description,medical_specialty,sample_name,transcription,keywords
 A 23-year-old white female presents with complaint of allergies., Allergy / Immunology, Allergic Rhinitis ,"SUBJECTIVE:,  This 23-year-old white female presents with complaint of allergies.  She used to have allergies when she lived in Seattle but she thinks they are worse here.  In the past, she has tried Claritin, and Zyrtec.  Both worked for short time but then seemed to lose effectiveness.  She has used Allegra also.  She used that last summer and she began using it again two weeks ago.  It does not appear to be working very well.  She has used over-the-counter sprays but no prescription nasal sprays.  She does have asthma but doest not require daily medication for this and does not think it is flaring up.,MEDICATIONS: , Her only medication currently is Ortho Tri-Cyclen and the Allegra.,ALLERGIES: , She has no known medicine allergies.,OBJECTIVE:,Vitals:  Weight was 130 pounds and blood pressure 124/78.,HEENT:  Her throat was mildly erythematous without exudate.  Nasal mucosa was erythematous and swollen.  Only clear drainage was seen.  TMs were clear.,Neck:  Supple without adenopathy.,Lungs:  Clear.,ASSESSMENT:,  Allergic rhinitis.,PLAN:,1.  She will try Zyrtec instead of Allegra again.  Another option will be to use loratadine.  She does not think she has prescription coverage so that might be cheaper.,2.  Samples of Nasonex two sprays in each nostril given for three weeks.  A prescription was written as well.","allergy / immunology, allergic rhinitis, allergies, asthma, nasal sprays, rhinitis, nasal, erythematous, allegra, sprays, allergic,"
 Consult for laparoscopic gastric bypass., Bariatrics, Laparoscopic Gastric Bypass Consult - 2 ,"PAST MEDICAL HISTORY:, He has difficulty climbing stairs, difficulty with airline seats, tying shoes, used to public seating, and lifting objects off the floor.  He exercises three times a week at home and does cardio.  He has difficulty walking two blocks or five flights of stairs.  Difficulty with snoring.  He has muscle and joint pains including knee pain, back pain, foot and ankle pain, and swelling.  He has gastroesophageal reflux disease.,PAST SURGICAL HISTORY:, Includes reconstructive surgery on his right hand 13 years ago.  ,SOCIAL HISTORY:, He is currently single.  He has about ten drinks a year.  He had smoked significantly up until several months ago.  He now smokes less than three cigarettes a day.,FAMILY HISTORY:, Heart disease in both grandfathers, grandmother with stroke, and a grandmother with diabetes.  Denies obesity and hypertension in other family members.,CURRENT MEDICATIONS:, None.,ALLERGIES:,  He is allergic to Penicillin.,MISCELLANEOUS/EATING HISTORY:, He has been going to support groups for seven months with Lynn Holmberg in Greenwich and he is from Eastchester, New York and he feels that we are the appropriate program.  He had a poor experience with the Greenwich program.  Eating history, he is not an emotional eater.  Does not like sweets.  He likes big portions and carbohydrates.  He likes chicken and not steak.  He currently weighs 312 pounds.  Ideal body weight would be 170 pounds.  He is 142 pounds overweight.  If ,he lost 60% of his excess body weight that would be 84 pounds and he should weigh about 228.,REVIEW OF SYSTEMS: ,Negative for head, neck, heart, lungs, GI, GU, orthopedic, and skin.  Specifically denies chest pain, heart attack, coronary artery disease, congestive heart failure, arrhythmia, atrial fibrillation, pacemaker, high cholesterol, pulmonary embolism, high blood pressure, CVA, venous insufficiency, thrombophlebitis, asthma, shortness of breath, COPD, emphysema, sleep apnea, diabetes, leg and foot swelling, osteoarthritis, rheumatoid arthritis, hiatal hernia, peptic ulcer disease, gallstones, infected gallbladder, pancreatitis, fatty liver, hepatitis, hemorrhoids, rectal bleeding, polyps, incontinence of stool, urinary stress incontinence, or cancer.  Denies cellulitis, pseudotumor cerebri, meningitis, or encephalitis.,PHYSICAL EXAMINATION:, He is alert and oriented x 3.  Cranial nerves II-XII are intact.  Afebrile.  Vital Signs are stable.","bariatrics, laparoscopic gastric bypass, weight loss programs, gastric bypass, atkin's diet, weight watcher's, body weight, laparoscopic gastric, weight loss, pounds, months, weight, laparoscopic, band, loss, diets, overweight, lost"
 Consult for laparoscopic gastric bypass., Bariatrics, Laparoscopic Gastric Bypass Consult - 1 ,"HISTORY OF PRESENT ILLNESS: , I have seen ABC today.  He is a very pleasant gentleman who is 42 years old, 344 pounds.  He is 5'9"".  He has a BMI of 51.  He has been overweight for ten years since the age of 33, at his highest he was 358 pounds, at his lowest 260.  He is pursuing surgical attempts of weight loss to feel good, get healthy, and begin to exercise again.  He wants to be able to exercise and play volleyball.  Physically, he is sluggish.  He gets tired quickly.  He does not go out often.  When he loses weight he always regains it and he gains back more than he lost.  His biggest weight loss is 25 pounds and it was three months before he gained it back.  He did six months of not drinking alcohol and not taking in many calories.  He has been on multiple commercial weight loss programs including Slim Fast for one month one year ago and Atkin's Diet for one month two years ago.,PAST MEDICAL HISTORY: , He has difficulty climbing stairs, difficulty with airline seats, tying shoes, used to public seating, difficulty walking, high cholesterol, and high blood pressure.  He has asthma and difficulty walking two blocks or going eight to ten steps.  He has sleep apnea and snoring.  He is a diabetic, on medication.  He has joint pain, knee pain, back pain, foot and ankle pain, leg and foot swelling.  He has hemorrhoids.,PAST SURGICAL HISTORY: , Includes orthopedic or knee surgery.,SOCIAL HISTORY: , He is currently single.  He drinks alcohol ten to twelve drinks a week, but does not drink five days a week and then will binge drink.  He smokes one and a half pack a day for 15 years, but he has recently stopped smoking for the past two weeks.,FAMILY HISTORY: , Obesity, heart disease, and diabetes.  Family history is negative for hypertension and stroke.,CURRENT MEDICATIONS:,  Include Diovan, Crestor, and Tricor.,MISCELLANEOUS/EATING HISTORY:  ,He says a couple of friends of his have had heart attacks and have had died.  He used to drink everyday, but stopped two years ago.  He now only drinks on weekends.  He is on his second week of Chantix, which is a medication to come off smoking completely.  Eating, he eats bad food.  He is single.  He eats things like bacon, eggs, and cheese, cheeseburgers, fast food, eats four times a day, seven in the morning, at noon, 9 p.m., and 2 a.m.  He currently weighs 344 pounds and 5'9"".  His ideal body weight is 160 pounds.  He is 184 pounds overweight.  If he lost 70% of his excess body weight that would be 129 pounds and that would get him down to 215.,REVIEW OF SYSTEMS: , Negative for head, neck, heart, lungs, GI, GU, orthopedic, or skin.  He also is positive for gout.  He denies chest pain, heart attack, coronary artery disease, congestive heart failure, arrhythmia, atrial fibrillation, pacemaker, pulmonary embolism, or CVA.  He denies venous insufficiency or thrombophlebitis.  Denies shortness of breath, COPD, or emphysema.  Denies thyroid problems, hip pain, osteoarthritis, rheumatoid arthritis, GERD, hiatal hernia, peptic ulcer disease, gallstones, infected gallbladder, pancreatitis, fatty liver, hepatitis, rectal bleeding, polyps, incontinence of stool, urinary stress incontinence, or cancer.  He denies cellulitis, pseudotumor cerebri, meningitis, or encephalitis.,PHYSICAL EXAMINATION:  ,He is alert and oriented x 3.  Cranial nerves II-XII are intact.  Neck is soft and supple.  Lungs:  He has positive wheezing bilaterally.  Heart is regular rhythm and rate.  His abdomen is soft.  Extremities:  He has 1+ pitting edema.,IMPRESSION/PLAN:,  I have explained to him the risks and potential complications of laparoscopic gastric bypass in detail and these include bleeding, infection, deep venous thrombosis, pulmonary embolism, leakage from the gastrojejuno-anastomosis, jejunojejuno-anastomosis, and possible bowel obstruction among other potential complications.  He understands.  He wants to proceed with workup and evaluation for laparoscopic Roux-en-Y gastric bypass.  He will need to get a letter of approval from Dr. XYZ.  He will need to see a nutritionist and mental health worker.  He will need an upper endoscopy by either Dr. XYZ.  He will need to go to Dr. XYZ as he previously had a sleep study.  We will need another sleep study.  He will need H. pylori testing, thyroid function tests, LFTs, glycosylated hemoglobin, and fasting blood sugar.  After this is performed, we will submit him for insurance approval.","bariatrics, laparoscopic gastric bypass, heart attacks, body weight, pulmonary embolism, potential complications, sleep study, weight loss, gastric bypass, anastomosis, loss, sleep, laparoscopic, gastric, bypass, heart, pounds, weight,"
 2-D M-Mode. Doppler.  , Cardiovascular / Pulmonary, 2-D Echocardiogram - 1 ,"2-D M-MODE: , ,1.  Left atrial enlargement with left atrial diameter of 4.7 cm.,2.  Normal size right and left ventricle.,3.  Normal LV systolic function with left ventricular ejection fraction of 51%.,4.  Normal LV diastolic function.,5.  No pericardial effusion.,6.  Normal morphology of aortic valve, mitral valve, tricuspid valve, and pulmonary valve.,7.  PA systolic pressure is 36 mmHg.,DOPPLER: , ,1.  Mild mitral and tricuspid regurgitation.,2.  Trace aortic and pulmonary regurgitation.","cardiovascular / pulmonary, 2-d m-mode, doppler, aortic valve, atrial enlargement, diastolic function, ejection fraction, mitral, mitral valve, pericardial effusion, pulmonary valve, regurgitation, systolic function, tricuspid, tricuspid valve, normal lv "
 2-D Echocardiogram, Cardiovascular / Pulmonary, 2-D Echocardiogram - 2 ,"1.  The left ventricular cavity size and wall thickness appear normal.  The wall motion and left ventricular systolic function appears hyperdynamic with estimated ejection fraction of 70% to 75%.  There is near-cavity obliteration seen.  There also appears to be increased left ventricular outflow tract gradient at the mid cavity level consistent with hyperdynamic left ventricular systolic function.  There is abnormal left ventricular relaxation pattern seen as well as elevated left atrial pressures seen by Doppler examination.,2.  The left atrium appears mildly dilated.,3.  The right atrium and right ventricle appear normal.,4.  The aortic root appears normal.,5.  The aortic valve appears calcified with mild aortic valve stenosis, calculated aortic valve area is 1.3 cm square with a maximum instantaneous gradient of 34 and a mean gradient of 19 mm.,6.  There is mitral annular calcification extending to leaflets and supportive structures with thickening of mitral valve leaflets with mild mitral regurgitation.,7.  The tricuspid valve appears normal with trace tricuspid regurgitation with moderate pulmonary artery hypertension.  Estimated pulmonary artery systolic pressure is 49 mmHg.  Estimated right atrial pressure of 10 mmHg.,8.  The pulmonary valve appears normal with trace pulmonary insufficiency.,9.  There is no pericardial effusion or intracardiac mass seen.,10.  There is a color Doppler suggestive of a patent foramen ovale with lipomatous hypertrophy of the interatrial septum.,11.  The study was somewhat technically limited and hence subtle abnormalities could be missed from the study.,","cardiovascular / pulmonary, 2-d, doppler, echocardiogram, annular, aortic root, aortic valve, atrial, atrium, calcification, cavity, ejection fraction, mitral, obliteration, outflow, regurgitation, relaxation pattern, stenosis, systolic function, tricuspid, valve, ventricular, ventricular cavity, wall motion, pulmonary artery"
" Morbid obesity.  Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis.  This is a 30-year-old female, who has been overweight for many years.  She has tried many different diets, but is unsuccessful. ", Bariatrics, Laparoscopic Gastric Bypass ,"PREOPERATIVE DIAGNOSIS: , Morbid obesity.,POSTOPERATIVE DIAGNOSIS:  ,Morbid obesity.,PROCEDURE: , Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis.,ANESTHESIA: , General with endotracheal intubation.,INDICATION FOR PROCEDURE: , This is a 30-year-old female, who has been overweight for many years.  She has tried many different diets, but is unsuccessful.  She has been to our Bariatric Surgery Seminar, received some handouts, and signed the consent.  The risks and benefits of the procedure have been explained to the patient.,PROCEDURE IN DETAIL:  ,The patient was taken to the operating room and placed supine on the operating room table.  All pressure points were carefully padded.  She was given general anesthesia with endotracheal intubation.  SCD stockings were placed on both legs.  Foley catheter was placed for bladder decompression.  The abdomen was then prepped and draped in standard sterile surgical fashion.  Marcaine was then injected through umbilicus.  A small incision was made.  A Veress needle was introduced into the abdomen.  CO2 insufflation was done to a maximum pressure of 15 mmHg.  A 12-mm VersaStep port was placed through the umbilicus.  I then placed a 5-mm port just anterior to the midaxillary line and just subcostal on the right side.  I placed another 5-mm port in the midclavicular line just subcostal on the right side, a few centimeters below and medial to that, I placed a 12-mm VersaStep port.  On the left side, just anterior to the midaxillary line and just subcostal, I placed a 5-mm port.  A few centimeters below and medial to that, I placed a 15-mm port.  I began by lifting up the omentum and identifying the transverse colon and lifting that up and thereby identifying my ligament of Treitz.  I ran the small bowel down approximately 40 cm and divided the small bowel with a white load GIA stapler.  I then divided the mesentery all the way down to the base of the mesentery with a LigaSure device.  I then ran the distal bowel down, approximately 100 cm, and at 100 cm, I made a hole at the antimesenteric portion of the Roux limb and a hole in the antimesenteric portion of the duodenogastric limb, and I passed a 45 white load stapler and fired a stapler creating a side-to-side anastomosis.  I reapproximated the edges of the defect.  I lifted it up and stapled across it with another white load stapler.  I then closed the mesenteric defect with interrupted Surgidac sutures.  I divided the omentum all the way down to the colon in order to create a passageway for my small bowel to go antecolic.  I then put the patient in reverse Trendelenburg.  I placed a liver retractor, identified, and dissected the angle of His.  I then dissected on the lesser curve, approximately 2.5 cm below the gastroesophageal junction, and got into a lesser space.  I fired transversely across the stomach with a 45 blue load stapler.  I then used two fires of the 60 blue load with SeamGuard to go up into my angle of His, thereby creating my gastric pouch.  I then made a hole at the base of the gastric pouch and had Anesthesia remove the bougie and place the OG tube connected to the anvil.  I pulled the anvil into place, and I then opened up my 15-mm port site and passed my EEA stapler.  I passed that in the end of my Roux limb and had the spike come out antimesenteric.  I joined the spike with the anvil and fired a stapler creating an end-to-side anastomosis, then divided across the redundant portion of my Roux limb with a white load GI stapler, and removed it with an Endocatch bag.  I put some additional 2-0 Vicryl sutures in the anastomosis for further security.  I then placed a bowel clamp across the bowel.  I went above and passed an EGD scope into the mouth down to the esophagus and into the gastric pouch.  I distended gastric pouch with air.  There was no air leak seen.  I could pass the scope easily through the anastomosis.  There was no bleeding seen through the scope.  We closed the 15-mm port site with interrupted 0 Vicryl suture utilizing Carter-Thomason.  I copiously irrigated out that incision with about 2 L of saline.  I then closed the skin of all incisions with running Monocryl.  Sponge, instrument, and needle counts were correct at the end of the case.  The patient tolerated the procedure well without any complications.","bariatrics, gastric bypass, eea anastomosis, roux-en-y, antegastric, antecolic, morbid obesity, roux limb, gastric pouch, intubation, laparoscopic, bypass, roux, endotracheal, anastomosis, gastric"
" Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.
", Bariatrics, Liposuction ,"PREOPERATIVE DIAGNOSES:,1.  Deformity, right breast reconstruction.,2.  Excess soft tissue, anterior abdomen and flank.,3.  Lipodystrophy of the abdomen.,POSTOPERATIVE DIAGNOSES:,1.  Deformity, right breast reconstruction.,2.  Excess soft tissue, anterior abdomen and flank.,3.  Lipodystrophy of the abdomen.,PROCEDURES:,1.  Revision, right breast reconstruction.,2.  Excision, soft tissue fullness of the lateral abdomen and flank.,3.  Liposuction of the supraumbilical abdomen.,ANESTHESIA: , General.,INDICATION FOR OPERATION:,  The patient is a 31-year-old white female who previously has undergone latissimus dorsi flap and implant, breast reconstruction.  She now had lateralization of the implant with loss of medial fullness for which she desired correction.  It was felt that mobilization of the implant medially would provide the patient significant improvement and this was discussed with the patient at length.  The patient also had a small dog ear in the flank area on the right from the latissimus flap harvest, which was to be corrected.  She had also had liposuction of the periumbilical and infraumbilical abdomen with desire to have great improvement superiorly, was felt to be a candidate for such.  The above-noted procedure was discussed with the patient in detail.  The risks, benefits and potential complications were discussed.  She was marked in the upright position and then taken to the operating room for the above-noted procedure.,OPERATIVE PROCEDURE: , The patient was taken to the operating room and placed in the supine position.  Following adequate induction of general LMA anesthesia, the chest and abdomen was prepped and draped in the usual sterile fashion.  The supraumbilical abdomen was then injected with a solution of 5% lidocaine with epinephrine, as was the dog ear.  At this time, the superior central scar was then excised, dissection continued through the subcutaneous tissue, the underlying latissimus muscle until the capsule of the implant was reached.  This was then opened.  The implant was removed and placed on the back table in antibiotic solution.  Using Bovie cautery, the medial capsule was released and undermining was then performed with release of the muscle to the level of the proposed medial projection of the breast.  The inframammary fold medially was secured with 2-0 PDS suture to create greater takeoff point at this level which in the upright position and using a sizer produced a good form.  The lateral pocket was diminished by series of 2-0 PDS suture to provide medialization of the implant.  The implant was then placed back into the submuscular pocket with much improved positioning and medial fullness.  With this completed, the implant was again removed, antibiotic irrigation was performed.  A drain was placed and brought out through a separate inferior stab wound incision and hemostasis was confirmed.  The implant was then replaced and the wound was then closed in layers using 2-0 PDS running suture on the muscle and 3-0 Monocryl Dermabond subcuticular sutures.  The 2.5 cm dog ear was then excised into and including the subcutaneous tissue, even contouring was achieved and this was closed with two layers using 3-0 Monocryl suture.  Using a #3 cannula, a superior umbilical incision, liposuction was carried out into the supraumbilical abdomen, removing approximately 40 to 50 mL of fat with improved supraumbilical contours.  This was closed with 6-0 Prolene suture.  The patient was placed in a compressive garment after treating the incision with Dermabond, Steri-Strips and antibiotic ointment around the drain site and umbilicus.  A Kerlix dressing and a surgical bra was placed to the chest area.  A compressive garment was placed.  The patient was then aroused from anesthesia, extubated, and taken to the recovery room in stable condition.  Sponge, needle, lap, instrument counts were all correct.  The patient tolerated the procedure well.  There were no complications.  The estimated blood loss was approximately 25 mL.","bariatrics, breast reconstruction, excess, lma anesthesia, lipodystrophy, liposuction, abdomen, drain site, flank, latissimus dorsi flap, soft tissue, supraumbilical, surgical bra, supraumbilical abdomen, reconstruction, breast, tissue, implant,"
 2-D Echocardiogram, Cardiovascular / Pulmonary, 2-D Echocardiogram - 3 ,"2-D ECHOCARDIOGRAM,Multiple views of the heart and great vessels reveal normal intracardiac and great vessel relationships.  Cardiac function is normal.  There is no significant chamber enlargement or hypertrophy.  There is no pericardial effusion or vegetations seen.  Doppler interrogation, including color flow imaging, reveals systemic venous return to the right atrium with normal tricuspid inflow.  Pulmonary outflow is normal at the valve.  Pulmonary venous return is to the left atrium.  The interatrial septum is intact.  Mitral inflow and ascending aorta flow are normal.  The aortic valve is trileaflet.  The coronary arteries appear to be normal in their origins.  The aortic arch is left-sided and patent with normal descending aorta pulsatility.","cardiovascular / pulmonary, 2-d echocardiogram, cardiac function, doppler, echocardiogram, multiple views, aortic valve, coronary arteries, descending aorta, great vessels, heart, hypertrophy, interatrial septum, intracardiac, pericardial effusion, tricuspid, vegetation, venous, pulmonaryNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Suction-assisted lipectomy - lipodystrophy of the abdomen and thighs., Bariatrics, Lipectomy - Abdomen/Thighs ,"PREOPERATIVE DIAGNOSIS: , Lipodystrophy of the abdomen and thighs.,POSTOPERATIVE DIAGNOSIS:,  Lipodystrophy of the abdomen and thighs.,OPERATION: , Suction-assisted lipectomy.,ANESTHESIA:,  General.,FINDINGS AND PROCEDURE:,  With the patient under satisfactory general endotracheal anesthesia, the entire abdomen, flanks, perineum, and thighs to the knees were prepped and draped circumferentially in sterile fashion.  After this had been completed, a #15 blade was used to make small stab wounds in the lateral hips, the pubic area, and upper edge of the umbilicus.  Through these small incisions, a cannula was used to infiltrate lactated Ringers with 1000 cc was infiltrated initially into the abdomen.  A 3 and 4-mm cannulas were then used to carry out the liposuction of the abdomen removing a total of 1100 cc of aspirate, which was mostly fat, little fluid, and blood.  Attention was then directed to the thighs both inner and outer.  A total of 1000 cc was infiltrated in both lateral thighs only about 50 cc in the medial thighs.  After this had been completed, 3 and 4-mm cannulas were used to suction 650 cc from each side, approximately 50 cc in the inner thigh and 600 on each lateral thigh.  The patient tolerated the procedure very well.  All of this aspirate was mostly fat with little fluid and very little blood.  Wounds were cleaned and steri-stripped and dressing of ABD pads and ***** was then applied.  The patient tolerated the procedure very well and was sent to the recovery room in good condition.","bariatrics, lipodystrophy, abd pads, suction-assisted lipectomy, abdomen, aspirate, lipectomy, perineum, steri-stripped, thighs, umbilicus, abdomen and thighs, abdomen/thighs, "
 Echocardiogram and Doppler, Cardiovascular / Pulmonary, 2-D Echocardiogram - 4 ,"DESCRIPTION:,1.  Normal cardiac chambers size.,2.  Normal left ventricular size.,3.  Normal LV systolic function.  Ejection fraction estimated around 60%.,4.  Aortic valve seen with good motion.,5.  Mitral valve seen with good motion.,6.  Tricuspid valve seen with good motion.,7.  No pericardial effusion or intracardiac masses.,DOPPLER:,1.  Trace mitral regurgitation.,2.  Trace tricuspid regurgitation.,IMPRESSION:,1.  Normal LV systolic function.,2.  Ejection fraction estimated around 60%.,","cardiovascular / pulmonary, ejection fraction, lv systolic function, cardiac chambers, regurgitation, tricuspid, normal lv systolic function, normal lv systolic, ejection fraction estimated, normal lv, lv systolic, systolic function, function ejection, echocardiogram, doppler, lv, systolic, ejection, mitral, valve"
" Morbid obesity.  Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy.", Bariatrics, Laparoscopic Gastric Bypass - 1 ,"PREOPERATIVE DIAGNOSIS: , Morbid obesity. ,POSTOPERATIVE DIAGNOSIS: , Morbid obesity. ,PROCEDURE:,  Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy. ,ANESTHESIA: , General with endotracheal intubation. ,INDICATIONS FOR PROCEDURE: , This is a 50-year-old male who has been overweight for many years and has tried multiple different weight loss diets and programs.  The patient has now begun to have comorbidities related to the obesity.  The patient has attended our bariatric seminar and met with our dietician and psychologist.  The patient has read through our comprehensive handout and understands the risks and benefits of bypass surgery as evidenced by the signing of our consent form.,PROCEDURE IN DETAIL: , The risks and benefits were explained to the patient.  Consent was obtained.  The patient was taken to the operating room and placed supine on the operating room table.  General anesthesia was administered with endotracheal intubation.  A Foley catheter was placed for bladder decompression.  All pressure points were carefully padded, and sequential compression devices were placed on the legs.  The abdomen was prepped and draped in standard, sterile, surgical fashion.  Marcaine was injected into the umbilicus.","bariatrics, morbid obesity, roux-en-y, gastric bypass, antecolic, antegastric, anastamosis, esophagogastroduodenoscopy, eea, surgidac sutures, roux limb, port, stapler, laparoscopic, intubation"
" Normal left ventricle, moderate biatrial enlargement, and mild tricuspid regurgitation, but only mild increase in right heart pressures.", Cardiovascular / Pulmonary, 2-D Doppler ,"2-D STUDY,1. Mild aortic stenosis, widely calcified, minimally restricted.,2. Mild left ventricular hypertrophy but normal systolic function.,3. Moderate biatrial enlargement.,4. Normal right ventricle.,5. Normal appearance of the tricuspid and mitral valves.,6. Normal left ventricle and left ventricular systolic function.,DOPPLER,1. There is 1 to 2+ aortic regurgitation easily seen, but no aortic stenosis.,2. Mild tricuspid regurgitation with only mild increase in right heart pressures, 30-35 mmHg maximum.,SUMMARY,1. Normal left ventricle.,2. Moderate biatrial enlargement.,3. Mild tricuspid regurgitation, but only mild increase in right heart pressures.","cardiovascular / pulmonary, 2-d study, doppler, tricuspid regurgitation, heart pressures, stenosis, ventricular, heart, ventricle, tricuspid, regurgitation,"
 Cerebral Angiogram - moyamoya disease., Neurology, Moyamoya Disease ,"CC:, Confusion and slurred speech.,HX , (primarily obtained from boyfriend): This 31 y/o RHF experienced a ""flu-like illness 6-8 weeks prior to presentation. 3-4 weeks prior to presentation, she was found ""passed out"" in bed, and when awoken appeared confused, and lethargic. She apparently recovered within 24 hours. For two weeks prior to presentation she demonstrated emotional lability, uncharacteristic of her ( outbursts of anger and inappropriate laughter). She left a stove on.,She began slurring her speech 2 days prior to admission. On the day of presentation she developed right facial weakness and began stumbling to the right. She denied any associated headache, nausea, vomiting, fever, chills, neck stiffness or visual change. There was no history of illicit drug/ETOH use or head trauma.,PMH:, Migraine Headache.,FHX: , Unremarkable.,SHX: ,Divorced. Lives with boyfriend. 3 children alive and well. Denied tobacco/illicit drug use. Rarely consumes ETOH.,ROS:, Irregular menses.,EXAM: ,BP118/66.  HR83. RR 20. T36.8C.,MS: Alert and oriented to name only. Perseverative thought processes. Utilized only one or two word answers/phrases. Non-fluent. Rarely followed commands. Impaired writing of name.,CN: Flattened right nasolabial fold only.,Motor: Mild weakness in RUE manifested by pronator drift. Other extremities were full strength.,Sensory: withdrew to noxious stimulation in all 4 extremities.,Coordination: difficult to assess.,Station: Right pronator drift.,Gait: unremarkable.,Reflexes: 2/2BUE, 3/3BLE, Plantars were flexor bilaterally.,General Exam: unremarkable.,INITIAL STUDIES:, CBC, GS, UA, PT, PTT, ESR, CRP, EKG were all unremarkable. Outside HCT showed hypodensities in the right putamen, left caudate, and at several subcortical locations (not specified).,COURSE: ,MRI Brian Scan, 2/11/92 revealed an old lacunar infarct in the right basal ganglia, edema within the head of the left caudate nucleus suggesting an acute ischemic event, and arterial enhancement of the left MCA distribution suggesting slow flow. The latter suggested a vasculopathy such as Moya Moya, or fibromuscular dysplasia. HIV, ANA, Anti-cardiolipin Antibody titer, Cardiac enzymes, TFTs, B12, and cholesterol studies were unremarkable.,She underwent a cerebral angiogram on 2/12/92. This revealed an occlusion of the left MCA just distal to its origin. The distal distribution of the left MCA filled on later films through collaterals from the left ACA. There was also an occlusion of the right MCA just distal to the temporal branch. Distal branches of the right MCA filled through collaterals from the right ACA. No other vascular abnormalities were noted. These findings were felt to be atypical but nevertheless suspicious of a large caliber vasculitis such as Moya Moya disease. She was subsequently given this diagnosis. Neuropsychologic testing revealed widespread cognitive dysfunction with particular impairment of language function. She had long latencies responding and understood only simple questions. Affect was blunted and there was distinct lack of concern regarding her condition. She was subsequently discharged home on no medications.,In 9/92 she was admitted for sudden onset right hemiparesis and mental status change. Exam revealed the hemiparesis and in addition she was found to have significant neck lymphadenopathy. OB/GYN exam including cervical biopsy, and abdominal/pelvic CT scanning revealed stage IV squamous cell cancer of the cervix. She died 9/24/92 of cervical cancer.",
 Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery. , Bariatrics, Gastric Bypass Discussion - 3 ,"PAST MEDICAL HISTORY:,  Significant for hypertension.  The patient takes hydrochlorothiazide for this.  She also suffers from high cholesterol and takes Crestor.  She also has dry eyes and uses Restasis for this.  She denies liver disease, kidney disease, cirrhosis, hepatitis, diabetes mellitus, thyroid disease, bleeding disorders, prior DVT, HIV and gout.  She also denies cardiac disease and prior history of cancer.,PAST SURGICAL HISTORY: , Significant for tubal ligation in 1993.  She had a hysterectomy done in 2000 and a gallbladder resection done in 2002.,MEDICATIONS: , Crestor 20 mg p.o. daily, hydrochlorothiazide 20 mg p.o. daily, Veramist spray 27.5 mcg daily, Restasis twice a day and ibuprofen two to three times a day.,ALLERGIES TO MEDICATIONS: , Bactrim which causes a rash.  The patient denies latex allergy.,SOCIAL HISTORY: , The patient is a life long nonsmoker.  She only drinks socially one to two drinks a month.  She is employed as a manager at the New York department of taxation.  She is married with four children.,FAMILY HISTORY: , Significant for type II diabetes on her mother's side as well as liver and heart failure.  She has one sibling that suffers from high cholesterol and high triglycerides.,REVIEW OF SYSTEMS: , Positive for hot flashes.  She also complains about snoring and occasional slight asthma.  She does complain about peripheral ankle swelling and heartburn.  She also gives a history of hemorrhoids and bladder infections in the past.  She has weight bearing joint pain as well as low back degenerating discs.  She denies obstructive sleep apnea, kidney stones, bloody bowel movements, ulcerative colitis, Crohn's disease, dark tarry stools and melena.,PHYSICAL EXAMINATION:  ,On examination temperature is 97.7, pulse 84, blood pressure 126/80, respiratory rate was 20.  Well nourished, well developed in no distress.  Eye exam, pupils equal round and reactive to light.  Extraocular motions intact.  Neuro exam deep tendon reflexes 1+ in the lower extremities.  No focal neuro deficits noted.  Neck exam nonpalpable thyroid, midline trachea, no cervical lymphadenopathy, no carotid bruit.  Lung exam clear breath sounds throughout without rhonchi or wheezes however diminished.  Cardiac exam regular rate and rhythm without murmur or bruit.  Abdominal exam positive bowel sounds, soft, nontender, obese, nondistended abdomen.  No palpable tenderness.  No right upper quadrant tenderness.  No organomegaly appreciated.  No obvious hernias noted.  Lower extremity exam +1 edema noted.  Positive dorsalis pedis pulses.,ASSESSMENT: , The patient is a 56-year-old female who presents to the bariatric surgery service with a body mass index of 41 with obesity related comorbidities.  The patient is interested in gastric bypass surgery.  The patient appears to be an excellent candidate and would benefit greatly in the management of her comorbidities.,PLAN: , In preparation for surgery will obtain the usual baseline laboratory values including baseline vitamin levels.  Will proceed with our usual work up with an upper GI series as well as consultations with the dietician and the psychologist preoperatively.  I have recommended six weeks of Medifast for the patient to obtain a 10% preoperative weight loss.","bariatrics, weight watchers, roux en y, atkins, medifast, meridia, south beach, cabbage, diets, laparoscopic roux en y gastric bypass surgery, rice, weight loss, six weeks of medifast, weight loss modalities, body mass index, gastric bypass surgery, bariatric surgery, gastric bypass,"
"  Surgical removal of completely bony impacted teeth #1, #16, #17, and #32.  Completely bony impacted teeth #1, #16, #17, and #32.", Dentistry, Bony Impacted Teeth Removal ,"PREOPERATIVE DIAGNOSIS:,  Completely bony impacted teeth #1, #16, #17, and #32.,POSTOPERATIVE DIAGNOSIS: , Completely bony impacted teeth #1, #16, #17, and #32.,PROCEDURE: , Surgical removal of completely bony impacted teeth #1, #16, #17, and #32.,ANESTHESIA: , General nasotracheal.,COMPLICATIONS: , None.,CONDITION:  ,Stable to PACU.,DESCRIPTION OF PROCEDURE: , Patient was brought to the operating room, placed on the table in a supine position, and after demonstration of an adequate plane of general anesthesia via the nasotracheal route, patient was prepped and draped in the usual fashion for an intraoral procedure.  A gauze throat pack was placed and local anesthetic was administered in all four quadrants, a total of 7.2 mL of lidocaine 2% with 1:100,000 epinephrine, and 3.6 mL of bupivacaine 0.5% with 1:200,000 epinephrine.  Beginning on the upper right tooth #1, incision was made with a #15 blade.  Envelope flap was raised with the periosteal elevator, and bone was removed on the buccal aspect with straight elevator.  Potts elevator was then used to luxate the tooth from the socket.  Remnants of the follicle were then removed with hemostat.  The area was irrigated and then closed with 3-0 gut suture.  On the lower right tooth #32, incision was made with a #15 blade.  Envelope flap was raised with the periosteal elevator, and bone was removed on the buccal and distal aspect with a high-speed drill with a round bur.  Tooth was then sectioned with the bur and removed in several pieces.  Remnants of the follicle were removed with a curved hemostat.  The area was irrigated with normal saline solution and closed with 3-0 gut sutures.  Moving to #16 on the upper left, incision was made with a #15 blade.  Envelope flap was raised with the periosteal elevator, and bone was removed on the buccal aspect with straight elevator.  Potts elevator was then used to luxate the tooth from the socket.  Remnants of the follicle were removed with a curved hemostat.  The area was irrigated with normal saline solution and closed with 3-0 gut sutures.  Moving to the lower left #17, incision was made with a #15 blade.  Envelope flap was  raised with the periosteal elevator, and bone was removed on the buccal and distal aspect with high-speed drill with a round bur.  Then the bur was used to section the tooth vertically.  Tooth was removed in several pieces followed by the removal of the remnants of the follicle.  The area was irrigated with normal saline solution and closed with 3-0 gut sutures.  Upon completion of the procedure, the throat pack was removed and the pharynx was suctioned.  An NG tube was then inserted and small amount of gastric contents were suctioned.  Patient was then awakened, extubated, and taken to the PACU in stable condition.","dentistry, intraoral, bony impacted teeth, throat pack, buccal aspect, saline solution, gut sutures, envelope flap, periosteal elevator,"
 Preoperative visit for weight management with laparoscopic gastric banding, Bariatrics, Laparoscopic Gastric Banding - Preop Visit  ,"HISTORY OF PRESENT ILLNESS: ,I have seen ABC today for her preoperative visit for weight management.  I have explained to her the need for Optifast for weight loss prior to these procedures to make it safer because of the large size of her liver.  She understands this.,IMPRESSION/PLAN:, We are going to put her on two weeks of Optifast at around 900 calories.  I have also explained the risks and potential complications of laparoscopic cholecystectomy to her in detail including bleeding, infection, deep venous thrombosis, pulmonary embolism, injury to the small intestine, stomach, liver, leak from the cystic duct, common bile duct, and possible need for ERCP and further surgery.  This surgery is going to be planned for October 6.  This is for cholelithiasis prior to her Lap-Banding procedure.,I have also reviewed with her the risks and potential complications of laparoscopic gastric banding including bleeding, infection, deep venous thrombosis, pulmonary embolism, slippage of the band, erosion of the band, injury to the esophagus, stomach, small intestine, large intestine, spleen, liver, injury to the band, port, or tubing necessitating replacement of the band, port, or tubing among other potential complications and she understands.  We are going to proceed for laparoscopic gastric banding.  I have reviewed her entire chart in detail.  I have also gone over with her the Fairfield County Bariatrics consent form for banding and all the risks.  She has also signed the St. Vincent's Hospital consent form for Lap-Banding.  She has taken the preoperative quiz for banding.  She has signed the preop and postop instructions, and understands them and we reviewed them.  She has taken the quiz and done fairly well.  We have reviewed with her any potential other issues and I have answered her questions.  She is planned for surgical intervention.,","bariatrics, laparoscopic gastric banding, pulmonary embolism, lap banding, potential complications, gastric banding, banding, stomach, gastric, laparoscopic, weightNOTE"
" Neck exploration; tracheostomy; urgent flexible bronchoscopy via tracheostomy site; removal of foreign body, tracheal metallic stent material; dilation distal trachea; placement of #8 Shiley single cannula tracheostomy tube.", Cardiovascular / Pulmonary, Tracheostomy ,"PREOPERATIVE DIAGNOSES,Airway obstruction secondary to severe subglottic tracheal stenosis with foreign body in the trachea.,POSTOPERATIVE DIAGNOSES,Airway obstruction secondary to severe subglottic tracheal stenosis with foreign body in the trachea.,OPERATION PERFORMED,Neck exploration; tracheostomy; urgent flexible bronchoscopy via tracheostomy site; removal of foreign body, tracheal metallic stent material; dilation distal trachea; placement of #8 Shiley single cannula tracheostomy tube.,INDICATIONS FOR SURGERY,The patient is a 50-year-old white male with history of progressive tracheomalacia treated in the National Tennessee, and several years ago he had a tracheal metallic stent placed with some temporary improvement.  However developed progressive problems and he had two additional stents placed with some initial improvement.  Subsequently, he developed progressive airway obstruction and came into the ABC Hospital critical airway service for further evaluation and was admitted on Month DD, YYYY.  He underwent bronchoscopy by Dr. W and found to have an extensive subglottic upper tracheal and distal tracheal stenosis secondary to metallic stent extensive granulation and inflammatory tissue changes.  The patient had some debridement and then was hospitalized and Laryngology and Thoracic Surgery services were consulted for further management.  Exploration of trachea, removal of foreign body stents constricting his airway, dilation and stabilization of his trachea were offered to the patient.  Nature of the proposed procedure including risks and complications of bleeding, infection, alteration of voice, speech, swallowing, voice changes permanently, possibility of tracheotomy temporarily or permanently to maintain his airway, loss of voice, cardiac risk factors, anesthetic risks, recurrence of problems, upon surgical intervention were all discussed at length.  The patient stated that he understood and wished to proceed.,DESCRIPTION OF PROCEDURE,The patient was taken to the operating room, placed in the supine position.  Following adequate monitoring by Anesthesia Service to maintain sedation, the patient's neck was prepped and draped in the sterile fashion.  The neck was then infiltrated with 1% Xylocaine and 1000 epinephrine.  A collar incision approximately 1 fingerbreadth above the clavicle, this was an outline incision, was carried out.  The skin, subcutaneous tissue, platysma, subplatysmal flaps elevated superiorly and inferiorly.  Strap muscles were separated in the midline, dissection carried down to visceral fascia.  Beneath the strap muscles, there was dense inflammation scarring obscuring palpable landmarks.  There appeared to be significant scarring fusion of soft tissue at the perichondrium and cartilage of the cricoid making the cricoid easily definable.  There was a markedly enlarged thyroid isthmus.  Thyroid isthmus was divided and dense inflammation, attachment of the thyroid isthmus, fusion of the thyroid gland to the capsule to the pretracheal fascia requiring extensive blunt sharp dissection.  Trachea was exposed from the cricoid to the fourth ring which entered down into the chest.  The trachea was incised between the second and third ring inferior limb in the midline and excision of small ridge of cartilage on each side sent for pathologic evaluation.  The tracheal cartilage externally had marked thickening and significant stiffness calcification, and the tracheal wall from the outside of the trachea to the mucosa measured 3 to 4 mm in thickness.  The trachea was entered and visualized with thickening of the mucosa and submucosa was noted.  The patient, however, was able to ventilate at this point a #6 Endo Tube was inserted and general anesthesia administered.  Once the airway was secured, we then proceeded working around the #6 Endo Tube as well as with the tube intake and out to explore the trachea with ridged fiberoptic scopes as well as flexible fiberoptic bronchoscopy to the trach site.  Examination revealed extrusion of metallic fragments from stent and multiple metallic fragments were removed from the stent in the upper trachea.  A careful examination of the subglottic area showed inflamed and thickened mucosa but patent subglottis.  After removal of the stents and granulation tissue, the upper trachea was widely patent.  The mid trachea had some marked narrowing secondary to granulation.  Stent material was removed from this area as well.  In the distal third of the trachea, a third stent was embedded within the mucosa, not encroaching on the lumen without significant obstruction distally and this was not disturbed at this time.  All visible stent material in the upper and mid trachea were removed.  Initial attempt to place a #16 Montgomery T tube showed the distal lumen of the T tube to be too short to stent the granulation narrowing of the trachea at the junction of the anterior two thirds and the distal third.  Also, this was removed and a #8 Shiley single cannula tracheostomy tube was placed after removal of the endotracheal tube.  A good ventilation was confirmed and the position of the tube confirmed it to be at the level just above the metallic stent which was embedded in the mucosa.  The distal trachea and mainstem bronchi were widely patent.  This secured his airway and no further manipulation felt to be needed at this time.  Neck wound was thoroughly irrigated and strap muscles were closed with interrupted 3-0 Vicryl.  The skin laterally to the trach site was closed with running 2-0 Prolene.  Tracheostomy tube was secured with interrupted 2-0 silk sutures and the patient was taken back to the Intensive Care Unit in satisfactory condition.  The patient tolerated the procedure well without complication.","cardiovascular / pulmonary, airway, laryngology, shiley, alteration of voice, bronchi, bronchoscopy, cannula, cartilage, cricoid, flexible, foreign body, mainstem, obstruction, perichondrium, stenosis, stent, subglottic, swallowing, trachea, tracheal, tracheal stenosis, tracheostomy, shiley single cannula tracheostomy, shiley single cannula, single cannula tracheostomy, thyroid isthmus, stent material, tracheostomy tube, tube, thyroid, "
 Patient status post lap band placement., Bariatrics, Lap Band Adjustment ,"REASON FOR VISIT:,  Lap band adjustment.,HISTORY OF PRESENT ILLNESS:,  Ms. A is status post lap band placement back in 01/09 and she is here on a band adjustment.  Apparently, she had some problems previously with her adjustments and apparently she has been under a lot of stress.  She was in a car accident a couple of weeks ago and she has problems, she does not feel full.  She states that she is not really hungry but she does not feel full and she states that she is finding when she is hungry at night, having difficulty waiting until the morning and that she did mention that she had a candy bar and that seemed to make her feel better.,PHYSICAL EXAMINATION: , On exam, her temperature is 98, pulse 76, weight 197.7 pounds, blood pressure 102/72, BMI is 38.5, she has lost 3.8 pounds since her last visit.  She was alert and oriented in no apparent distress.  ,PROCEDURE:  ,I was able to access her port.  She does have an AP standard low profile.  I aspirated 6 mL, I did add 1 mL, so she has got approximately 7 mL in her band, she did tolerate water postprocedure.,ASSESSMENT:,  The patient is status post lap band adjustments, doing well, has a total of 7 mL within her band, tolerated water postprocedure.  She will come back in two weeks for another adjustment as needed.,","bariatrics, lap band adjustment, lap band placement, lap band, "
 Fertile male with completed family.  Elective male sterilization via bilateral vasectomy., Urology, Vasectomy - 4 ,"PROCEDURE: , Elective male sterilization via bilateral vasectomy.,PREOPERATIVE DIAGNOSIS:  ,Fertile male with completed family.,POSTOPERATIVE DIAGNOSIS:,  Fertile male with completed family.,MEDICATIONS:  ,Anesthesia is local with conscious sedation.,COMPLICATIONS: , None.,BLOOD LOSS: , Minimal.,INDICATIONS:  ,This 34-year-old gentleman has come to the office requesting sterilization via bilateral vasectomy.  I discussed the indications and the need for procedure with the patient in detail, and he has given consent to proceed.  He has been given prophylactic antibiotics.,PROCEDURE NOTE: , Once satisfactory sedation have been obtained, the patient was placed in the supine position on the operating table.  Genitalia was shaved and then prepped with Betadine scrub and paint solution and were draped sterilely.  The procedure itself was started by grasping the right vas deferens in the scrotum, and bringing it up to the level of the skin.  The skin was infiltrated with 2% Xylocaine and punctured with a sharp hemostat to identify the vas beneath.  The vas was brought out of the incision carefully.  A 2-inch segment was isolated, and 1-inch segment was removed.  The free ends were cauterized and were tied with 2-0 silk sutures in such a fashion that the ends double back on themselves.  After securing hemostasis with a cautery, the ends were allowed to drop back into the incision, which was also cauterized.,Attention was now turned to the left side.  The vas was grasped and brought up to the level of the skin.  The skin was infiltrated with 2% Xylocaine and punctured with a sharp hemostat to identify the vas beneath.  The vas was brought out of the incision carefully.  A 2-inch segment was isolated, and 1-inch segment was removed.  The free ends were cauterized and tied with 2-0 silk sutures in such a fashion that the ends double back on themselves.  After securing hemostasis with the cautery, the ends were allowed to drop back into the incision, which was also cauterized.,Bacitracin ointment was applied as well as dry sterile dressing.  The patient was awakened and was returned to Recovery in satisfactory condition.","urology, sterilization, vas, fertile male, bilateral vasectomy, vasectomy, cauterized,"
" The patient is a 17-year-old female, who presents to the emergency room with foreign body and airway compromise and was taken to the operating room.  She was intubated and fishbone.", General Medicine, Airway Compromise & Foreign Body - ER Visit ,"HISTORY OF PRESENT ILLNESS:,  The patient is a 17-year-old female, who presents to the emergency room with foreign body and airway compromise and was taken to the operating room.  She was intubated and fishbone.,PAST MEDICAL HISTORY: , Significant for diabetes, hypertension, asthma, cholecystectomy, and total hysterectomy and cataract.,ALLERGIES:  ,No known drug allergies.,CURRENT MEDICATIONS: , Prevacid, Humulin, Diprivan, Proventil, Unasyn, and Solu-Medrol.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: , Negative for illicit drugs, alcohol, and tobacco.,PHYSICAL EXAMINATION:  ,Please see the hospital chart.,LABORATORY DATA: , Please see the hospital chart.,HOSPITAL COURSE: , The patient was taken to the operating room by Dr. X who is covering for ENT and noted that she had airway compromise and a rather large fishbone noted and that was removed.  The patient was intubated and it was felt that she should be observed to see if the airway would improve upon which she could be extubated.  If not she would require tracheostomy.  The patient was treated with IV antibiotics and ventilatory support and at the time of this dictation, she has recently been taken to the operating room where it was felt that the airway sufficient and she was extubated.  She was doing well with good p.o.s, good airway, good voice, and desiring to be discharged home.  So, the patient is being prepared for discharge at this point.  We will have Dr. X evaluate her before she leaves to make sure I do not have any problem with her going home.  Dr. Y feels she could be discharged today and will have her return to see him in a week.","general medicine, diabetes, hypertension, asthma, cholecystectomy, fishbone, foreign body, airway compromise, airway,"
 Whole body radionuclide bone scan due to prostate cancer., Urology, Whole Body Radionuclide Bone Scan ,"INDICATION:,  Prostate Cancer.,TECHNIQUE:,  3.5 hours following the intravenous administration of 26.5 mCi of Technetium 99m MDP, the skeleton was imaged in the anterior and posterior projections.,FINDINGS:,  There is a focus of abnormal increased tracer activity overlying the right parietal region of the skull.  The uptake in the remainder of the skeleton is within normal limits.  The kidneys image normally.  There is increased activity in the urinary bladder suggesting possible urinary retention.,CONCLUSION:,1.  Focus of abnormal increased tracer activity overlying the right parietal region of the skull.  CT scanning of magnetic resonance imaging of the skull and brain could be done for further assessment if it is clinically indicated.,2.  There is probably some degree of urinary retention.,","urology, prostate cancer, technetium, whole body, urinary retention, bone scan, radionuclide, "
 Patient discharged after laparoscopic Roux-en-Y gastric bypass., Bariatrics, Gastric Bypass Summary ,"FINAL DIAGNOSES,1.  Morbid obesity, status post laparoscopic Roux-en-Y gastric bypass. ,2.  Hypertension. ,3.  Obstructive sleep apnea, on CPAP.,OPERATION AND PROCEDURE: , Laparoscopic Roux-en-Y gastric bypass.,BRIEF HOSPITAL COURSE SUMMARY:  ,This is a 30-year-old male, who presented recently to the Bariatric Center for evaluation and treatment of longstanding morbid obesity and associated comorbidities.  Underwent standard bariatric evaluation, consults, diagnostics, and preop Medifast induced weight loss in anticipation of elective bariatric surgery. ,Taken to the OR via same day surgery process for elective gastric bypass, tolerated well, recovered in the PACU, and sent to the floor for routine postoperative care.  There, DVT prophylaxis was continued with subcu heparin, early and frequent mobilization, and SCDs.  PCA was utilized for pain control, efficaciously, he utilized the CPAP, was monitored, and had no new cardiopulmonary complaints.  Postop day #1, labs within normal limits, able to clinically start bariatric clear liquids at 2 ounces per hour, this was tolerated well.  He was ambulatory, had no cardiopulmonary complaints, no unusual fever or concerning symptoms.  By the second postoperative day, was able to advance to four ounces per hour, tolerated this well, and is able to discharge in stable and improved condition today.  He had his drains removed today as well.,DISCHARGE INSTRUCTIONS: , Include re-appointment in the office in the next week, call in the interim if any significant concerning complaints.  Scripts left in the chart for omeprazole and Lortab.  Med rec sheet completed (on no meds).  He will maintain bariatric clear liquids at home, goal 64 ounces per day, maintain activity at home, but no heavy lifting or straining.  Can shower starting tomorrow, drain site care and wound care reviewed.  He will re-appoint in the office in the next week, certainly call in the interim if any significant concerning complaints.","bariatrics, medifast, laparoscopic roux-en-y gastric bypass, roux-en-y, bariatric clear liquids, gastric bypass, laparoscopic, gastric, bariatric, bypass, "
 Normal vasectomy, Urology, Vasectomy - 1 ,"DESCRIPTION:,  The patient was placed in the supine position and was prepped and draped in the usual manner.  The left vas was grasped in between the fingers.  The skin and vas were anesthetized with local anesthesia.  The vas was grasped with an Allis clamp.  Skin was incised and the vas deferens was regrasped with another Allis clamp.  The sheath was incised with a scalpel and elevated using the iris scissors and clamps were used to ligate the vas deferens.  The portion in between the clamps was excised and the ends of the vas were clamped using hemoclips, two in the testicular side and one on the proximal side.  The incision was then inspected for hemostasis and closed with 3-0 chromic catgut interrupted fashion.,A similar procedure was carried out on the right side.  Dry sterile dressings were applied and the patient put on a scrotal supporter.  The procedure was then terminated.","urology, vasectomy, allis clamp, catgut, hemoclips, iris scissors, scrotal, scrotal supporter, testicular, vas, vas deferens, vas was grasped, deferens, clampsNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" Voluntary sterility.  Bilateral vasectomy.  The vas deferens was grasped with a vas clamp.  Next, the vas deferens was skeletonized.  It was clipped proximally and distally twice. ", Urology, Vasectomy ,"PREOPERATIVE DIAGNOSIS: , Voluntary sterility.,POSTOPERATIVE DIAGNOSIS: , Voluntary sterility.,OPERATIVE PROCEDURE:,  Bilateral vasectomy.,ANESTHESIA:,  Local.,INDICATIONS FOR PROCEDURE:  ,A gentleman who is here today requesting voluntary sterility.  Options were discussed for voluntary sterility and he has elected to proceed with a bilateral vasectomy.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room, and after appropriately identifying the patient, the patient was prepped and draped in the standard surgical fashion and placed in a supine position on the OR table.  Then, 0.25% Marcaine without epinephrine was used to anesthetize the scrotal skin.  A small incision was made in the right hemiscrotum.  The vas deferens was grasped with a vas clamp.  Next, the vas deferens was skeletonized.  It was clipped proximally and distally twice.  The cut edges were fulgurated.  Meticulous hemostasis was maintained.  Then, 4-0 chromic was used to close the scrotal skin on the right hemiscrotum.  Next, the attention was turned to the left hemiscrotum, and after the left hemiscrotum was anesthetized appropriately, a small incision was made in the left hemiscrotum.  The vas deferens was isolated.  It was skeletonized.  It was clipped proximally and distally twice.  The cut edges were fulgurated.  Meticulous hemostasis was maintained.  Then, 4-0 chromic was used to close the scrotal skin.  A jockstrap and sterile dressing were applied at the end of the case.  Sponge, needle, and instruments counts were correct.","urology, hemiscrotum, bilateral vasectomy, voluntary sterility, vas deferens, vasectomy, skeletonized, scrotal, sterility, deferens"
 Blood in urine - Transitional cell cancer of the bladder., Urology, Urology Consut - 1 ,"CHIEF COMPLAINT:,",
 Normal vasectomy, Urology, Vasectomy - 2 ,"DIAGNOSIS:,  Desires vasectomy.,NAME OF OPERATION: , Vasectomy.,ANESTHESIA:,  General.,HISTORY: , Patient, 37, desires a vasectomy.,PROCEDURE: , Through a midline scrotal incision, the right vas was identified and separated from the surrounding tissues, clamped, transected, and tied off with a 4-0 chromic.  No bleeding was identified.,Through the same incision the left side was identified, transected, tied off, and dropped back into the wound.  Again no bleeding was noted.,The wound was closed with 4-0 Vicryl times two.  He tolerated the procedure well.  A sterile dressing was applied.  He was awakened and transferred to the recovery room in stable condition.","urology, scrotal incision, right vas, bleeding, anesthesia, vasectomy"
 Hispanic male patient was admitted because of enlarged prostate and symptoms of bladder neck obstruction., Urology, Urology Discharge Summary ,"PROCEDURES:, Cystourethroscopy and transurethral resection of prostate.,COMPLICATIONS:, None.,ADMITTING DIAGNOSIS:, Difficulty voiding.,HISTORY:, This 67-year old Hispanic male patient was admitted because of enlarged prostate and symptoms of bladder neck obstruction.  Physical examination revealed normal heart and lungs.  Abdomen was negative for abnormal findings.  ,LABORATORY DATA:, BUN 19 and creatinine 1.1.  Blood group was A, Rh positive, Hemoglobin 13, Hematocrit 32.1, Prothrombin time 12.6 seconds, PTT 37.1.  Discharge  hemoglobin 11.4, and hematocrit 33.3.  Chest x-ray calcified old granulomatous disease, otherwise normal.  EKG was normal.  ,COURSE IN THE HOSPITAL:, The patient had a cysto and TUR of the prostate.  Postoperative course was uncomplicated. The pathology report is pending at the time of dictation.  He is being discharged in satisfactory condition with a good urinary stream, minimal hematuria, and on Bactrim DS one a day for ten days with a standard postprostatic surgery instruction sheet.  ,DISCHARGE DIAGNOSIS: , Enlarged prostate with benign bladder neck obstruction.  ,To be followed in my office in one week and by Dr. ABC next available as an outpatient.","urology, tur, bun, cystourethroscopy, difficulty voiding, bladder neck obstruction, creatinine, cysto, enlarged prostate, transurethral resection of prostate, urinary stream, bladder neck, neck obstruction, prostate"
" Umbilical hernia repair template.  The umbilical hernia carefully reduced back into the cavity, and the fascia was closed with interrupted vertical mattress sutures to approximate the fascia.", Urology, Umbilical Hernia Repair ,"PREOPERATIVE DIAGNOSIS: , Umbilical hernia.,POSTOPERATIVE DIAGNOSIS: , Umbilical hernia.,PROCEDURE PERFORMED: , Repair of umbilical hernia.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,PROCEDURE IN DETAIL:  ,The patient was prepped and draped in the sterile fashion.  An infraumbilical incision was formed and taken down to the fascia.  The umbilical hernia carefully reduced back into the cavity, and the fascia was closed with interrupted vertical mattress sutures to approximate the fascia, and then the wounds were infiltrated with 0.25% Marcaine.  The skin was reattached to the fascia with 2-0 Vicryls.  The skin was approximated with 2-0 Vicryl subcutaneous and then 4-0 Monocryl subcuticular stitches, dressed with Steri-Strips and 4 x 4's.  Patient was extubated and taken to the recovery area in stable condition.","urology, marcaine, steri-strips, mattress sutures, umbilical hernia, repair, umbilical, hernia,"
" Vasectomy 10 years ago, failed.  Azoospermic.  Reversal two years ago.  Interested in sperm harvesting and cryopreservation", Urology, Urology Letter ,"Sample Address,RE:  Sample Patient,Wife's name:  Sample Name,Dear Sample Doctor:,Mr. Sample Patient was seen on Month DD, YYYY, describing a vasectomy 10 years ago and a failed vasectomy reversal done almost two years ago at the University of Michigan.  He has remained azoospermic postoperatively.  The operative note suggests the presence of some sperm and sperm head on the right side at the time of the vasectomy reversal.,He states that he is interested in sperm harvesting and cryopreservation prior to the next attempted ovulation induction for his wife.  Apparently, several attempts at induction have been tried and due to some anatomic abnormality, they have been unsuccessful.,At the time that he left the office, he was asking for cryopreservation.  At the time of sperm harvesting, I recently received a phone call suggesting that he does not want to do this at all unless his wife's ovulation has been confirmed and it appears then that he may be interested in a fresh specimen harvest.  I look forward to hearing from you regarding the actual plan so that we can arrange our procedure appropriately.  At his initial request, Month DD, YYYY was picked as the date for scheduled harvesting, although this may change if you require fresh specimen.,Thank you very much for the opportunity to have seen him.,Sample Doctor, M.D.","urology, letter, urology letter, azoospermic, cryopreservation, specimen harvest, sperm harvesting, vasectomy, vasectomy reversal, fresh specimen, reversal, sperm,"
" Desire for sterility.  Vasectomy.  The vas was identified, skin was incised, and no scalpel instruments were used to dissect out the vas.", Urology, Vasectomy - 3 ,"PREOPERATIVE DIAGNOSIS:,  Desire for sterility.,POSTOPERATIVE DIAGNOSIS:,  Desire for sterility.,OPERATIVE PROCEDURES: , Vasectomy.,DESCRIPTION OF PROCEDURE: , The patient was brought to the suite, where after oral sedation, the scrotum was prepped and draped.  Then, 1% lidocaine was used for anesthesia.  The vas was identified, skin was incised, and no scalpel instruments were used to dissect out the vas.  A segment about 3 cm in length was dissected out.  It was clipped proximally and distally, and then the ends were cauterized after excising the segment.  Minimal bleeding was encountered and the scrotal skin was closed with 3-0 chromic.  The identical procedure was performed on the contralateral side.  He tolerated it well.  He was discharged from the surgical center in good condition with Tylenol with Codeine for pain.  He will use other forms of birth control until he has confirmed azoospermia with two consecutive semen analyses in the month ahead.  Call if there are questions or problems prior to that time.","urology, vas, contralateral, desire for sterility, scalpel, sterility, vasectomy"
" The patient noted for improving retention of urine, postop vaginal reconstruction, very concerned of possible vaginal prolapse.", Urology, Urinary Retention - Followup ,"HISTORY OF PRESENT ILLNESS: , The patient presents today for followup.  No dysuria, gross hematuria, fever, chills.  She continues to have urinary incontinence, especially while changing from sitting to standing position, as well as urge incontinence.  She is voiding daytime every 1 hour in the morning especially after taking Lasix, which tapers off in the afternoon, nocturia time 0.  No incontinence.  No straining to urinate.  Good stream, emptying well.  No bowel issues, however, she also indicates that while using her vaginal cream, she has difficulty doing this as she feels protrusion in the vagina, and very concerned if she has a prolapse.,IMPRESSION:  ,1.  The patient noted for improving retention of urine, postop vaginal reconstruction, very concerned of possible vaginal prolapse, especially while using the cream.,2.  Rule out ascites, with no GI issues other than lower extremity edema.,PLAN: , Following a detailed discussion with the patient, she elected to proceed with continued Flomax and will wean off the Urecholine to two times daily.  She will follow up next week, request Dr. X to do a pelvic exam, and in the meantime, she will obtain a CT of the abdomen and pelvis to further evaluate the cause of the abdominal distention.  All questions answered.","urology, urinary retention, dysuria, gross hematuria, postop vaginal reconstruction, vaginal reconstruction, vaginal prolapse, urinary, retention, prolapse, vaginal, incontinence,"
" This is a 66-year-old male with signs and symptoms of benign prostatic hypertrophy, who has had recurrent urinary retention since his kidney transplant.  He passed his fill and pull study and was thought to self-catheterize in the event that he does incur urinary retention again.", Urology, Urinary Retention ,"CHIEF COMPLAINT:,  Urinary retention.,HISTORY OF PRESENT ILLNESS: , This is a 66-year-old gentleman status post deceased donor kidney transplant in 12/07, who has had recurrent urinary retention issues since that time.  Most recently, he was hospitalized on 02/04/08 for acute renal insufficiency, which was probably secondary to dehydration.  He was seen by urology again at this visit for urinary retention.  He had been seen by urology during a previous hospitalization and he passed his voiding trial at the time of his stent removal on 01/22/08.  Cystoscopy showed at that time obstructive BPH.  He was started on Flomax at the time of discharge from the hospital.  During the most recent readmission on 02/04/08, he went back into urinary retention and he had had a Foley placed at the outside hospital.,REVIEW OF SYSTEMS:,  Positive for blurred vision, nasal congestion, and occasional constipation.  Denies chest pain, shortness of breath or any rashes or lesions.  All other systems were reviewed and found to be negative.,PAST MEDICAL HISTORY:,1.  End-stage renal disease, now status post deceased donor kidney transplant in 12/07.,2.  Hypertension.,3.  History of nephrolithiasis.,4.  Gout.,5.  BPH.,6.  DJD.,PAST SURGICAL HISTORY:,1.  Deceased donor kidney transplant in 12/07.,2.  Left forearm and left upper arm fistula placements.,FAMILY HISTORY:  ,Significant for mother with an unknown type of cancer, possibly colon cancer or lung and prostate problems on his father side of the family.  He does not know whether his father side of the family had any history of prostate cancer.,HOME MEDICATIONS:,1.  Norvasc.,2.  Toprol 50 mg.,3.  Clonidine 0.2 mg.,4.  Hydralazine.,5.  Flomax.,6.  Allopurinol.,7.  Sodium bicarbonate.,8.  Oxybutynin.,9.  Coumadin.,10.  Aspirin.,11.  Insulin 70/30.,12.  Omeprazole.,13.  Rapamune.,14.  CellCept.,15.  Prednisone.,16.  Ganciclovir.,17.  Nystatin swish and swallow.,18.  Dapsone.,19.  Finasteride.,ALLERGIES:,  No known drug allergies.,PHYSICAL EXAMINATION:,GENERAL:  This is a well-developed, well-nourished male, in no acute distress.  VITAL SIGNS:  Temperature 98, blood pressure 129/72, pulse 96, and weight 175.4 pounds.  LUNGS:  Clear to auscultation bilaterally.  CARDIOVASCULAR:  Regular rate and rhythm with a 3/6 systolic murmur.  ABDOMEN:  Right lower quadrant incision site scar well healed.  Nontender to palpation.  Liver and spleen not enlarged.  No hernias appreciated.  PENIS:  Normal male genitalia.  No lesions appreciated on the penis.  Previous DRE showed the prostate of approximately 40 grams and no nodules.  Foley in place and draining clear urine.,The patient underwent fill and pull study, in which his bladder tolerated 120 ml of sterile water passively filling his bladder.  He spontaneously voided without the Foley 110 mL.,ASSESSMENT AND PLAN:  ,This is a 66-year-old male with signs and symptoms of benign prostatic hypertrophy, who has had recurrent urinary retention since the kidney transplant in 12/07.  He passed his fill and pull study and was thought to self-catheterize in the event that he does incur urinary retention again.  We discussed with Mr. Barker that he has a urologist closer to his home and he lives approximately 3 hours away; however, he desires to continue follow up with the urology clinic at MCG and has been set up for followup in 6 weeks.  He was also given a prescription for 6 months of Flomax and Proscar.  He did not have a PSA drawn today as he had a catheter in place, therefore his PSA could be falsely elevated.  He will have PSA level drawn either just before his visit for followup.",
 Right distal ureteral calculus.  The patient had hematuria and a CT urogram showing a 1 cm non-obstructing calcification in the right distal ureter.  He had a KUB also showing a teardrop shaped calcification apparently in the right lower ureter.  , Urology, Ureteral Calculus - Consult ,"CHIEF COMPLAINT: , Right distal ureteral calculus.,HISTORY OF PRESENT ILLNESS:  ,The patient had hematuria and a CT urogram at ABC Radiology on 01/04/07 showing a 1 cm non-obstructing calcification in the right distal ureter.  He had a KUB also showing a teardrop shaped calcification apparently in the right lower ureter.  He comes in now for right ureteroscopy, Holmium laser lithotripsy, right ureteral stent placement.,PAST MEDICAL HISTORY:,1.  Prostatism.,2.  Coronary artery disease.,PAST SURGICAL HISTORY:,1.  Right spermatocelectomy.,2.  Left total knee replacement in 1987.,3.  Right knee in 2005.,MEDICATIONS:,1.  Coumadin 3 mg daily.,2.  Fosamax.,3.  Viagra p.r.n.,ALLERGIES: , NONE.,REVIEW OF SYSTEMS:,  CARDIOPULMONARY:  No shortness of breath or chest pain.  GI:  No nausea, vomiting, diarrhea or constipation.  GU:  Voids well.  MUSCULOSKELETAL:  No weakness or strokes.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL APPEARANCE:  An alert male in no distress.,HEENT:  Grossly normal.,NECK:  Supple.,LUNGS:  Clear.,HEART:  Normal sinus rhythm.  No murmur or gallop.,ABDOMEN:  Soft.  No masses.,GENITALIA:  Normal penis.  Testicles descended bilaterally.,RECTAL:  Examination benign.,EXTREMITIES:  No edema.,IMPRESSION: , Right distal ureteral calculus.,PLAN: , Right ureteroscopy, ureteral lithotripsy.  Risks and complications discussed with the patient.  He signed a true informed consent.  No guarantees or warrantees were given.",
" Umbilical hernia repair. A standard curvilinear umbilical incision was made, and dissection was carried down to the hernia sac using a combination of Metzenbaum scissors and Bovie electrocautery.  ", Urology, Umbilical Hernia Repair - 1 ,"PROCEDURE PERFORMED: , Umbilical hernia repair.,PROCEDURE:,  After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table.  The patient was sedated, and an adequate local anesthetic was administered using 1% lidocaine without epinephrine.  The patient was prepped and draped in the usual sterile manner.,A standard curvilinear umbilical incision was made, and dissection was carried down to the hernia sac using a combination of Metzenbaum scissors and Bovie electrocautery.  The sac was cleared of overlying adherent tissue, and the fascial defect was delineated.  The fascia was cleared of any adherent tissue for a distance of 1.5 cm from the defect.  The sac was then placed into the abdominal cavity and the defect was closed primarily using simple interrupted 0 Vicryl sutures.  The umbilicus was then re-formed using 4-0 Vicryl to tack the umbilical skin to the fascia.,The wound was then irrigated using sterile saline, and hemostasis was obtained using Bovie electrocautery.  The skin was approximated with 4-0 Vicryl in a subcuticular fashion.  The skin was prepped with benzoin, and Steri-Strips were applied.  A dressing was then applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.","urology, fascial defect, umbilical hernia repair, curvilinear umbilical, hernia sac, metzenbaum scissors, umbilical hernia, bovie electrocautery, electrocautery, hernia, incision, umbilical,"
" Persistent frequency and urgency, in a patient with a history of neurogenic bladder and history of stroke. ", Urology, Urinary Frequency & Urgency - Followup ,"HISTORY OF PRESENT ILLNESS:  ,This is a 55-year-old female with a history of stroke, who presents today for followup of frequency and urgency with urge incontinence.  This has been progressively worsening, and previously on VESIcare with no improvement.  She continues to take Enablex 50 mg and has not noted any improvement of her symptoms.  The nursing home did not do a voiding diary.  She is accompanied by her power of attorney.  No dysuria, gross hematuria, fever or chills.  No bowel issues and does use several Depends a day.,Recent urodynamics in April 2008, here in the office, revealed significant detrusor instability with involuntary urinary incontinence and low bladder volumes, and cystoscopy was unremarkable.,IMPRESSION:  ,Persistent frequency and urgency, in a patient with a history of neurogenic bladder and history of stroke.  This has not improved on VESIcare as well as Enablex.  Options are discussed.,We discussed other options of pelvic floor rehabilitation, InterStim by Dr. X, as well as more invasive procedure.  The patient and the power of attorney would like him to proceed with meeting Dr. X to discuss InterStim, which was briefly reviewed here today and brochure for this is provided today.  Prior to discussion, the nursing home will do an extensive voiding diary for one week, while she is on Enablex, and if this reveals no improvement, the patient will be started on Ventura twice daily and prescription is provided.  They will see Dr. X with a prior voiding diary, which is again discussed.  All questions answered.,PLAN:,  As above, the patient will be scheduled to meet with Dr. X to discuss option of InterStim, and will be accompanied by her power of attorney.  In the meantime, Sanctura prescription is provided, and voiding diaries are provided.  All questions answered.","urology, neurogenic bladder, urge incontinence, urgency, frequency, vesicare, enablex, persistent frequency and urgency, frequency and urgency, persistent frequency, voiding diary, voiding"
 Ultrasound examination of the scrotum due to scrotal pain.  Duplex and color flow imaging as well as real time gray-scale imaging of the scrotum and testicles was performed. , Urology, Ultrasound Scrotum ,"EXAM: , Ultrasound examination of the scrotum.,REASON FOR EXAM: , Scrotal pain.,FINDINGS:  ,Duplex and color flow imaging as well as real time gray-scale imaging of the scrotum and testicles was performed.  The left testicle measures 5.1 x 2.8 x 3.0 cm.  There is no evidence of intratesticular masses.  There is normal Doppler blood flow.  The left epididymis has an unremarkable appearance.  There is a trace hydrocele.,The right testicle measures 5.3 x 2.4 x 3.2 cm.  The epididymis has normal appearance.  There is a trace hydrocele.  No intratesticular masses or torsion is identified.  There is no significant scrotal wall thickening.,IMPRESSION:  ,Trace bilateral hydroceles, which are nonspecific, otherwise unremarkable examination.","urology, scrotal pain, epididymis, torsion, ultrasound examination, intratesticular masses, ultrasound, scrotal, testicles, scrotum,"
"  Transurethral resection of a medium bladder tumor (TURBT), left lateral wall.", Urology, Transurethral Resection Of Bladder Tumor  ,"PREOPERATIVE DIAGNOSIS: , Bladder tumor.,POSTOPERATIVE DIAGNOSIS: , Bladder tumor.,PROCEDURE PERFORMED: , Transurethral resection of a medium bladder tumor (TURBT), left lateral wall.,ANESTHESIA: , Spinal.,SPECIMEN TO PATHOLOGY: , Bladder tumor and specimen from base of bladder tumor.,DRAINS: , A 22-French 3-way Foley catheter, 30 mL balloon.,ESTIMATED BLOOD LOSS:,  Minimal.,INDICATIONS FOR PROCEDURE: , This is a 74-year-old male who presented with microscopic and an episode of gross hematuria.  He underwent an IVP, which demonstrated enlarged prostate and normal upper tracts.  Cystoscopy in the office demonstrated a 2.5- to 3-cm left lateral wall bladder tumor.  He is brought to the operating room for transurethral resection of that bladder tumor.,DESCRIPTION OF OPERATION: , After preoperative counseling of the patient and his wife, the patient was taken to the operating room and administered a spinal anesthetic.  He was placed in lithotomy position and prepped and draped in the usual fashion.  Using the visual obturator, the resectoscope was then inserted per urethra into the bladder.  The bladder was inspected confirming previous cystoscopic findings of a 2.5- to 3-cm left lateral wall bladder tumor away from the ureteral orifice.  Using the resectoscope loop, the tumor was then resected down to its base in a stepwise fashion.  Following completion of resection down to the base, the bladder was _______ free of tumor specimen.  The resectoscope was then reinserted and the base of the bladder tumor was then resected to get the base of the bladder tumor specimen, this was sent as a separate pathological specimen.  Hemostasis was assured with electrocautery.  The base of the tumor was then fulgurated again and into the periphery out in the normal mucosa surrounding the base of the bladder tumor.  Following completion of the fulguration, there was good hemostasis.  The remainder of the bladder was without evidence of significant abnormality.  Both ureteral orifices were visualized and noted to drain freely of clear urine.  The bladder was filled and the resectoscope was removed.  A 22-French 3-way Foley catheter was inserted per urethra into the bladder.  The balloon was inflated to 30 mL.  The catheter with sterile continuous irrigation and was noted to drain clear irrigant.  The patient was then removed from lithotomy position.  He was in stable condition.","urology, turbt, bladder tumor, cystoscopic, resectoscope, hemostasis, foley catheter, tumor, bladder, lithotomy, transurethral, resection, hematuria,"
 Transurethral electrosurgical resection of the prostate for benign prostatic hyperplasia., Urology, TURP ,"PREOPERATIVE DIAGNOSIS:,  Benign prostatic hyperplasia.,POSTOPERATIVE DIAGNOSIS:,  Benign prostatic hyperplasia.,OPERATION PERFORMED: , Transurethral electrosurgical resection of the prostate.,ANESTHESIA: , General.,COMPLICATIONS:,  None.,INDICATIONS FOR THE SURGERY:,  This is a 77-year-old man with severe benign prostatic hyperplasia.  He has had problem with urinary retention and bladder stones in the past.  He will need to have transurethral resection of prostate to alleviate the above-mentioned problems.  Potential complications include, but are not limited to:,1.  Infection.,2.  Bleeding.,3.  Incontinence.,4.  Impotence.,5.  Formation of urethral strictures.,PROCEDURE IN DETAIL: , The patient was identified, after which he was taken into the operating room.  General LMA anesthesia was then administered.  The patient was given prophylactic antibiotic in the preoperative holding area.  The patient was then positioned, prepped and draped.  Cystoscopy was then performed by using a #26-French continuous flow resectoscopic sheath and a visual obturator.  The prostatic urethra appeared to be moderately hypertrophied due to the lateral lobes and a large median lobe.  The anterior urethra was normal without strictures or lesions.  The bladder was severely trabeculated with multiple bladder diverticula.  There is a very bladder diverticula located in the right posterior bladder wall just proximal to the trigone.  Using the ***** resection apparatus and a right angle resection loop, the prostate was resected initially at the area of the median lobe.  Once the median lobe has completely resected, the left lateral lobe and then the right lateral lobes were taken down.  Once an adequate channel had been achieved, the prostatic specimen was retrieved from the bladder by using an Ellik evacuator.  A 3-mm bar electrode was then introduced into the prostate to achieve perfect hemostasis.  The sheath was then removed under direct vision and a #24-French Foley catheter was then inserted atraumatically with pinkish irrigation fluid obtained.  The patient tolerated the operation well.","urology, benign prostatic hyperplasia, cystoscopy, foley catheter, turp, transurethral, bladder, bladder diverticula, electrosurgical, obturator, prostate, resectoscopic, transurethral resection, urinary retention, resection of the prostate, transurethral electrosurgical resection, anesthesia, hyperplasia, resection, prostatic"
" Transurethral resection of the bladder tumor (TURBT), large.", Urology, TURBT - 1 ,"PREOPERATIVE DIAGNOSIS:  ,Bladder cancer.,POSTOPERATIVE DIAGNOSIS: , Bladder cancer.,OPERATION:  ,Transurethral resection of the bladder tumor (TURBT), large.,ANESTHESIA:,  General endotracheal.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY: , The patient is an 82-year-old male who presented to the hospital with renal insufficiency, syncopal episodes.  The patient was stabilized from cardiac standpoint on a renal ultrasound.  The patient was found to have a bladder mass.  The patient does have a history of bladder cancer.  Options were watchful waiting, resection of the bladder tumor were discussed.  Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE were discussed.  The patient understood all the risks, benefits, and options and wanted to proceed with the procedure.,DETAILS OF THE OR:  ,The patient was brought to the OR, anesthesia was applied.  The patient was placed in dorsal lithotomy position.  The patient was prepped and draped in the usual sterile fashion.  A 23-French scope was inserted inside the urethra into the bladder.  The entire bladder was visualized, which appeared to have a large tumor, lateral to the right ureteral opening.,There was a significant papillary superficial fluffiness around the left ________.  There was a periureteral diverticulum, lateral to the left ureteral opening.  There were moderate trabeculations throughout the bladder.  There were no stones.  Using a French cone tip catheter, bilateral pyelograms were obtained, which appeared normal.  Subsequently, using 24-French cutting loop resectoscope a resection of the bladder tumor was performed all the way up to the base.  Deep biopsies were sent separately.  Coagulation was performed around the periphery and at the base of the tumor.  All the tumors were removed and sent for path analysis.  There was an excellent hemostasis.  The rest of the bladder appeared normal.  There was no further evidence of tumor.  At the end of the procedure, a 22 three-way catheter was placed, and the patient was brought to the recovery in a stable condition.","urology, transurethral resection of the bladder tumor, transurethral resection, bladder cancer, bladder tumor, bladder, turbt, insufficiency, tumor"
 The patient has a possibly torsion detorsion versus other acute testicular problem. , Urology, Testicular Pain ,"CHIEF COMPLAINT: , Testicular pain.,HISTORY OF PRESENT ILLNESS:,  The patient is a 4-year-old boy with a history of abrupt onset of left testicular pain at 11:30 this morning.  He was unable to walk and would not stand upright, and had fairly significant discomfort, so the parents checked his panel because of it.  Because of this, they took him to Emergency Department, at which time, he had no swelling noted initially, but very painful.  He had no voiding or stooling problems.  No nausea, vomiting or fever.  Family denies trauma or dysuria.  At that time, he was going to get an ultrasound done, but the mother said that all of sudden the patient stated the pain had resolved.  He has had hot chocolate this morning at 10:30 in the morning and water around 2:30 in the morning.  He has not had any pain since but states that he has had pain in the past, not as long and states there was a twisting sensation.  He has no recent cold or flu, although he had rhinorrhea about 3 weeks ago.  He is on no medications and he is here for evaluation.,PAST MEDICAL HISTORY:,  The patient has no known allergies.  He is term delivery via spontaneous vaginal delivery.  He has had no problems or hospitalizations with circumcision.,PAST SURGICAL HISTORY: , He has had no previous surgeries.,REVIEW OF SYSTEMS:,  All 14-point review of systems were negative except for the above left testicular pain and the history of possible upper respiratory infection about 2 to 3 weeks ago.,IMMUNIZATIONS: , Up-to-date.,FAMILY HISTORY: , The patient lives at home with both parents who are Spanish speaking.  He is not in school.,MEDICATIONS:,  He is on no medications.,PHYSICAL EXAMINATION:,VITAL SIGNS:  On physical exam, weight is 15.9 kg.,GENERAL:  The patient is a cooperative little boy.,HEENT:  Normal head and neck exam.  No oral or nasal discharge.,NECK:  Without masses.,CHEST:  Without masses.,LUNGS:  Clear.,CARDIAC:  Without murmurs or gallops.,ABDOMEN:  Soft.  No masses or tenderness.  His scrotum did not have any swelling at the present time.  There was only minimal discomfort with palpation at the left inguinal area, but no masses were noted.  No palpable nodules such as appendix testis and no swelling was noted and he had mild epididymal swelling only.  His left testis was slightly harder than the right, but this was not very significant.,EXTREMITIES:  He had full range of motion in all 4 extremities.,SKIN:  Warm, pink, and dry.,NEUROLOGIC:  Grossly intact.,LABORATORY DATA: , Ultrasound was obtained today showing no blood flow or poor blood flow on the left except for increased blood flow to the epididymis on the study done at about 1330 hours, and second one done around 1630 hours was normal flow, possible increased flow on the left.  This is personally reviewed by me.  The right was normal.  No masses were appreciated.  There was some mild change in echotexture on the left on the initial study, which had apparently resolved on the second, but may be due to the technical aspects of the study.,ASSESSMENT/PLAN: , The patient has a possibly torsion detorsion versus other acute testicular problem.  If the patient has indeed testicular torsion, there is an increased possibility that it may reoccur again, actually within the first 24 to 36 hours and as such is recommended doing a left scrotal exploration with possible detorsion of left testis, possible orchiectomy if the testis is markedly abnormal or nonviable, which probably is not the case, and bilateral testes fixation if the torsion is found.  I discussed the pre and postsurgical care with the parents.  Procedure itself with potential complications, risks, benefits, and alternatives of surgery including that the torsion could occur again, although it is less likely after the surgical fixation procedure.  The parents understand and wished to proceed.  We will schedule this later today emergently.",
" Cystoscopy, transurethral resection of medium bladder tumor (4.0 cm in diameter), and direct bladder biopsy.", Urology, TURBT ,"PREOPERATIVE DIAGNOSIS:  ,Clinical stage Ta Nx Mx transitional cell carcinoma of the urinary bladder.,POSTOPERATIVE DIAGNOSIS: , Clinical stage Ta Nx Mx transitional cell carcinoma of the urinary bladder.,TITLE OF OPERATION: , Cystoscopy, transurethral resection of medium bladder tumor (4.0 cm in diameter), and direct bladder biopsy.,ANESTHESIA: , General laryngeal mask.,INDICATIONS: , This patient is a 59-year-old white male, who had an initial occurrence of a transitional cell carcinoma 5 years back.  He was found to have a new tumor last fall, and cystoscopy in November showed Ta papillary-appearing lesion inside the bladder neck anteriorly.  The patient had coronary artery disease and required revascularization, which occurred at the end of December prior to the tumor resection.  He is fully recovered and cleared by Cardiology and taken to the operating room at this time for TURBT.,FINDINGS: , Cystoscopy of the anterior and posterior urethra was within normal limits.  From 12 o'clock to 4 o'clock inside the bladder neck, there was a papillary tumor with some associated blood clot.  This was completely resected.  There was an abnormal dysplastic area in the left lateral wall that was biopsied, and the remainder of the bladder mucosa appeared normal.  The ureteral orifices were in the orthotopic location.  Prostate was 15 g and benign on rectal examination, and there was no induration of the bladder.,PROCEDURE IN DETAIL: , The patient was brought to the cystoscopy suite, and after adequate general laryngeal mask anesthesia obtained, placed in the dorsal lithotomy position and his perineum and genitalia were sterilely prepped and draped in usual fashion.  He had been given oral ciprofloxacin for prophylaxis.  Rectal bimanual examination was performed with the findings described.  Cystourethroscopy was performed with a #23-French ACMI panendoscope and 70-degree lens with the findings described.  A barbotage urine was obtained for cytology.  The cystoscope was removed and a #24-French continuous flow resectoscope sheath was introduced over visual obturator and cold cup biopsy forceps introduced.  Several biopsies were taken from the tumor and sent to the tumor bank.  I then introduced the Iglesias resectoscope element and resected all the exophytic tumor and the lamina propria.  Because of the Ta appearance, I did not intentionally dissect deeper into the muscle.  Complete hemostasis was obtained.  All the chips were removed with an Ellik evacuator.  Using the cold cup biopsy forceps, biopsy was taken from the dysplastic area in the left bladder and hemostasis achieved.  The irrigant was clear.  At the conclusion of the procedure, the resectoscope was removed and a #24-French Foley catheter was placed for efflux of clear irrigant.  The patient was then returned to the supine position, awakened, extubated, and taken on a stretcher to the recovery room in satisfactory condition.","urology, transitional cell carcinoma, urinary bladder, bladder tumor, cystoscopy, transurethral resection, acmi panendoscope, foley catheter, cold cup biopsy forceps, ta nx mx, cold cup biopsy, laryngeal mask, bladder neck, bladder, biopsy, tumor,"
 Left spermatocelectomy/epididymectomy and bilateral partial vasectomy.  Left spermatocele and family planning., Urology," Spermatocelectomy, Epididymectomy, & Vasectomy ","PREOPERATIVE DIAGNOSES:,1.  Left spermatocele.,2.  Family planning.,POSTOPERATIVE DIAGNOSES:,1.  Left spermatocele.,2.  Family planning.,PROCEDURE PERFORMED:,1.  Left spermatocelectomy/epididymectomy.,2.  Bilateral partial vasectomy.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS:,  Minimal.,SPECIMEN: , Left-sided spermatocele, epididymis, and bilateral partial vasectomy.,DISPOSITION:  ,To PACU in stable condition.,INDICATIONS AND FINDINGS: , This is a 48-year-old male with a history of a large left-sided spermatocele with significant discomfort.  The patient also has family status complete and desired infertility.  The patient was scheduled for elective left spermatocelectomy and bilateral partial vasectomy.,FINDINGS: , At this time of the surgery, significant left-sided spermatocele was noted encompassing almost the entirety of the left epididymis with only minimal amount of normal appearing epididymis remaining.,DESCRIPTION OF PROCEDURE:,  After informed consent was obtained, the patient was moved to the operating room.  A general anesthesia was induced by the Department of Anesthesia.,The patient was prepped and draped in the normal sterile fashion for a scrotal approach.  A #15 blade was used to make a transverse incision on the left hemiscrotum.  Electrocautery was used to carry the incision down into the tunica vaginalis and the testicle was delivered into the field.  The left testicle was examined.  A large spermatocele was noted.  Metzenbaum scissors were used to dissect the tissue around the left spermatocele.  Once the spermatocele was identified, as stated above, significant size was noted encompassing the entire left epididymis.  Metzenbaum scissors as well as electrocautery was used to dissect free the spermatocele from its testicular attachments and spermatocelectomy and left epididymectomy was completed with electrocautery.  Electrocautery was used to confirm excellent hemostasis.  Attention was then turned to the more proximal aspect of the cord.  The vas deferens was palpated and dissected free with Metzenbaum scissors.  Hemostats were placed on the two aspects of the cord, approximately 1 cm segment of cord was removed with Metzenbaum scissors and electrocautery was used to cauterize the lumen of the both ends of vas deferens and silk ties used to ligate the cut ends.  Testicle was placed back in the scrotum in appropriate anatomic position.  The dartos tissue was closed with running #3-0 Vicryl and the skin was closed in a horizontal interrupted mattress fashion with #4-0 chromic.  Attention was then turned to the right side.  The vas was palpated in the scrotum.  A small skin incision was made with a #15 blade and the vas was grasped with a small Allis clamp and brought into the surgical field.  A scalpel was used to excise the vas sheath and vas was freed from its attachments and grasped again with a hemostat.  Two ends were hemostated with hemostats and divided with Metzenbaum scissors.  Lumen was coagulated with electrocautery.  Silk ties used to ligate both cut ends of the vas deferens and placed back into the scrotum.  A #4-0 chromic suture was used in simple fashion to reapproximate the skin incision.  Scrotum was cleaned and bacitracin ointment, sterile dressing, fluffs, and supportive briefs applied.  The patient was sent to Recovery in stable condition.  He was given prescriptions for doxycycline 100 mg b.i.d., for five days and Vicodin ES 1 p.o. q.4h. p.r.n., pain, #30 for pain.  The patient is to followup with Dr. X in seven days.","urology, partial vasectomy, spermatocele, epididymis, family planning, vas deferens, metzenbaum scissors, vasectomy, spermatocelectomy, epididymectomy, testicle, deferens, hemostats, electrocautery, "
 Left testicular swelling for one day.  Testicular Ultrasound.  Hypervascularity of the left epididymis compatible with left epididymitis.  Bilateral hydroceles., Urology, Testicular Ultrasound ,"TESTICULAR ULTRASOUND,REASON FOR EXAM:  ,Left testicular swelling for one day.,FINDINGS:  ,The left testicle is normal in size and attenuation, it measures 3.2 x 1.7 x 2.3 cm.  The right epididymis measures up to 9 mm.  There is a hydrocele on the right side.  Normal flow is seen within the testicle and epididymis on the right.,The left testicle is normal in size and attenuation, it measures 3.9 x 2.1 x 2.6 cm.  The left testicle shows normal blood flow.  The left epididymis measures up to 9 mm and shows a markedly increased vascular flow.  There is mild scrotal wall thickening.  A hydrocele is seen on the left side.,IMPRESSION:,1.  Hypervascularity of the left epididymis compatible with left epididymitis.,2.  Bilateral hydroceles.","urology, hypervascularity, bilateral hydroceles, epididymis, epididymitis, testicular ultrasound, ultrasound, flow, hydroceles, testicle, testicular,"
" Salvage cystectomy (very difficult due to postradical prostatectomy and postradiation therapy to the pelvis), Indiana pouch continent cutaneous diversion, and omental pedicle flap to the pelvis.", Urology, Salvage Cystectomy ,"PREOPERATIVE DIAGNOSES:,1.  Radiation cystitis.,2.  Refractory voiding dysfunction.,3.  Status post radical retropubic prostatectomy and subsequent salvage radiation therapy.,POSTOPERATIVE DIAGNOSES:,1.  Radiation cystitis.,2.  Refractory voiding dysfunction.,3.  Status post radical retropubic prostatectomy and subsequent salvage radiation therapy.,TITLE OF OPERATION: , Salvage cystectomy (very difficult due to postradical prostatectomy and postradiation therapy to the pelvis), Indiana pouch continent cutaneous diversion, and omental pedicle flap to the pelvis.,ANESTHESIA: , General endotracheal with epidural.,INDICATIONS:  ,This patient is a 65-year-old white male who in 1998 had a radical prostatectomy.  He was initially dry without pads and then underwent salvage radiation therapy for rising PSA.  After that he began with episodes of incontinence as well as urinary retention requiring catheterization.  One year ago, he was unable to catheterize and was taken to the operative room and had cystoscopy.  He had retained staple removed and a diverticulum identified.  There were also bladder stones that were lasered and removed, and he had been incontinent ever since that time.  He wears 8 to 10 pads per day, and this has affected his quality of life significantly.  I took him to the operating room on January 16, 2008, and found diffuse radiation changes with a small capacity bladder and wide-open bladder neck.  We both felt that his lower urinary tract was not rehabilitatable and that a continent cutaneous diversion would solve the number of problems facing him.  I felt like if we could remove the bladder safely, then this would also provide a benefit.,FINDINGS: , At exploration, there were no gross lesions of the smaller or large bowel.  The bladder was predictably sucked into the pelvic sidewall both inferiorly and laterally.  The opened bladder, which we were able to remove completely, had a wide-open capacious diverticulum in its very distal segment.  Because of the previous radiation therapy and a dissection down to the pelvis, I elected to place an omental pedicle flap to provide additional blood supply for healing as well in the pelvis and also under the pubic bone which was exposed inferiorly due to previous surgery and treatment.,PROCEDURE IN DETAIL:  ,The patient was brought to the operative suite and after adequate general endotracheal and epidural anesthesia obtained, placed in the supine position, flexed over the anterosuperior iliac spine, and his abdomen and genitalia were sterilely prepped and draped in the usual fashion.  A nasogastric tube was placed as well as radial arterial line.  He was given intravenous antibiotics for prophylaxis.  A generous midline skin incision was made from the midepigastrium down to the symphysis pubis, deep into the rectus fascia, the rectus muscle separated in the midline, and exploration carried out with the findings described.  Moist wound towels and a Bookwalter retractor were placed for exposure.  We began by retracting the bowels by mobilizing the cecum and ascending colon and hepatic flexure and elevating the terminal ileum up to the second and third portion of the duodenum.  The ureter was identified as a crisis over the iliac vessels and dissected deep into pelvis and subsequently divided between clips.  An identical procedure was performed in the left side with similar findings and the bowels were packed cephalad.,We began then dissecting the bladder away from the pelvic side walls staying medial to both epigastric arteries.  This was quite challenging because of the previous radiation therapy and radical prostatectomy.  We essentially carved the bladder off of the pelvic sidewall inferiorly as best we could and then we were able to have enough freedom to identify the lateral pedicles, and these were taken between double clips approximately and clipped distally.  We then approached things posteriorly and carefully dissected between the __________ and posterior bladder.  There was some remnant seminal vesicle on the right as well as both remnant ejaculatory duct and we used this to dissect the longus safe plane anterior to the rectum.  We then entered the bladder anteriorly as distal as we could and remove the bladder and what we thought was a bladder neck and this appeared to end in a diverticulum.  We then peeled it off the remaining rectum and passed the specimen off the operative field.  Bladder was irrigated with warm sterile water and a meticulous inspection was made for hemostasis.,We then completely mobilized the omentum off of the proximal transverse colon.  This allowed a generous flap to be able to be laid into the pelvis without tension.,We then turned our attention to forming the Indiana pouch.  I completed the dissection of the right hepatic flexure and the proximal transverse colon and mobilized the omentum off of this portion of the colon.  The colon was divided proximal to the middle colic using a GIA-80 stapler.  I then divided the avascular plane of Treves along the terminal ileum and selected a point approximately 15 cm proximal to the ileocecal valve to divide the ileum.  The mesentery was then sealed with a LigaSure device and divided, and the bowel was divided with a GIA-60 stapler.  We then performed a side-to-side ileo-transverse colostomy using a GIA-80 stapler, closing the open end with a TA 60.  The angles were reinforced with silk sutures and the mesenteric closed with interrupted silk sutures.,We then removed the staple line along the terminal ileum, passed a 12-French Robinson catheter into the cecal segment, and plicated the ileum with 3 firings of the GIA-60 stapler.  The ileocecal valve was then reinforced with interrupted 3-0 silk sutures as described by Rowland, et al, and following this, passage of an 18-French Robinson catheter was associated with the characteristic ""pop,"" indicating that we had adequately plicated the ileocecal valve.,As the patient had had a previous appendectomy, we made an opening in the cecum in the area of the previous appendectomy.  We then removed the distal staple line along the transverse colon and aligned the cecal end and the distal middle colic end with two 3-0 Vicryl sutures.  The bowel segment was then folded over on itself and the reservoir formed with 3 successive applications of the SGIA Polysorb-75.  Between the staple lines, Vicryl sutures were placed and the defects closed with 3-0 Vicryl suture ligatures.,We then turned our attention to forming the ileocolonic anastomosis.  The left ureter was mobilized and brought underneath the sigmoid mesentery and brought through the mesentery of the terminal ileum and an end-to-side anastomosis performed with an open technique using interrupted 4-0 Vicryl sutures, and this was stented with a Cook 8.4-French ureteral stent, and this was secured to the bowel lumen with a 5-0 chromic suture.  The right ureter was brought underneath the pouch and placed in a stented fashion with an identical anastomosis.  We then brought the stents out through a separate incision cephalad in the pouch and they were secured with a 2-0 chromic suture.  A 24-French Malecot catheter was placed through the cecum and secured with a chromic suture.  The staple lines were then buried with a running 3-0 Vicryl two-layer suture and the open end of the pouch closed with a TA 60 Polysorb suture.  The pouch was filled to 240 cc and noted to be watertight, and the ureteral anastomoses were intact.,We then made a final inspection for hemostasis.  The cecostomy tube was then brought out to the right lower quadrant and secured to the skin with silk sutures.  We then matured our stoma through the umbilicus.  We removed the plug of skin through the umbilicus and delivered the ileal segment through this.  A portion of the ileum was removed and healthy, well-vascularized tissue was matured with interrupted 3-0 chromic sutures.  We left an 18-French Robinson through the stomag and secured this to the skin with silk sutures.  The Malecot and stents were also secured in a similar fashion.,We matured the stoma to the umbilicus with interrupted chromic stitches.  The stitch was brought out to the right upper quadrant and the Malecot to the left lower quadrant.  A Large JP drain was placed in the pelvis dependent to the omentum pedicle flap as well as the Indiana pouch.,The rectus fascia was closed with a buried #2 Prolene running stitch, tying a new figure-of-eight proximally and distally and meeting in the middle and tying it underneath the fascia.  Subcutaneous tissue was irrigated with saline and skin was closed with surgical clips.  The estimated blood loss was 450 mL, and the patient received no packed red blood cells.  The final sponge and needle count were reported to be correct.  The patient was awakened and extubated, and taken on stretcher to the recovery room in satisfactory condition.","urology, radiation cystitis, voiding dysfunction, retropubic prostatectomy, salvage radiation therapy, salvage cystectomy, indiana pouch continent cutaneous diversion, omental pedicle flap, ligasure, gia, stapler, gia stapler, vicryl sutures, radiation therapy, silk sutures, bladder, therapy, sutures, endotracheal, "
 Spermatocelectomy and orchidopexy, Urology, Spermatocelectomy ,"PREOPERATIVE DIAGNOSIS:,  Right spermatocele.,POSTOPERATIVE DIAGNOSIS:  ,Right spermatocele.,OPERATIONS PERFORMED:,1.  Right spermatocelectomy.,2.  Right orchidopexy.,ANESTHESIA: , Local MAC.,ESTIMATED BLOOD LOSS:,  Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY OF THE PATIENT:  ,The patient is a 77-year-old male who comes to the office with a large right spermatocele.  The patient says it does bother him on and off, has occasional pain and discomfort with it, has difficulty with putting clothes on etc. and wanted to remove.  Options such as watchful waiting, removal of the spermatocele or needle drainage were discussed.  Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE, risk of infection, scrotal pain, and testicular pain were discussed.  The patient was told that his scrotum may enlarge in the postoperative period for about a month and it will settle down.  The patient was told about the risk of recurrence of spermatocele.  The patient understood all the risks, benefits, and options and wanted to proceed with removal.,DETAILS OF THE PROCEDURE:  ,The patient was brought to the OR.  Anesthesia was applied.  The patient's scrotal area was shaved, prepped, and draped in the usual sterile fashion.  A midline scrotal incision was made measuring about 2 cm in size.  The incision was carried through the dartos through the scrotal sac and the spermatocele was identified.  All the layers of the spermatocele were removed.  Clear layer was visualized, was taken all the way up to the base, the base was tied.  Entire spermatocele sac was removed.  After removing the entire spermatocele sac, hemostasis was obtained.  The testicle was not in normal orientation.  The testis and epididymis was removed, which is a small appendage on the superior aspect of the testicle.  The testicle was placed in a normal orientation.  Careful attention was drawn not to twist the cord.  Orchidopexy was done to allow the testes to stay stable in the postoperative period using 4-0 Vicryl and was tied at 3 different locations.  Absorbable sutures were used, so that the patient does not feel the sutures in the postoperative period.  The dartos was closed using 2-0 Vicryl in running locking fashion.  There was excellent hemostasis.  The skin was closed using 4-0 Monocryl.  Dermabond was applied.  The patient tolerated the procedure well.  The patient was brought to the recovery room in stable condition.","urology, orchidopexy, spermatocele, spermatocelectomy, scrotal"
 SPARC suburethral sling due to stress urinary incontinence., Urology, Sling (SPARC Suburethral) ,"PREOPERATIVE DX: , Stress urinary incontinence.,POSTOPERATIVE DX: , Stress urinary incontinence.,OPERATIVE PROCEDURE: , SPARC suburethral sling.,ANESTHESIA: , General.,FINDINGS & INDICATIONS: , Outpatient evaluation was consistent with urethral hypermobility, stress urinary incontinence.  Intraoperatively, the bladder appeared normal with the exception of some minor trabeculations.  The ureteral orifices were normal bilaterally.,DESCRIPTION OF OPERATIVE PROCEDURE:,  This patient was brought to the operating room, a general anesthetic was administered.  She was placed in dorsal lithotomy position.  Her vulva, vagina, and perineum were prepped with Betadine scrubbed in solution.  She was draped in usual sterile fashion.  A Sims retractor was placed into the vagina and Foley catheter was inserted into the bladder.  Two Allis clamps were placed over the mid urethra.  This area was injected with 0.50% lidocaine containing 1:200,000 epinephrine solution.  Two areas suprapubically on either side of midline were injected with the same anesthetic solution.  The stab wound incisions were made in these locations and a sagittal incision was made over the mid urethra.  Metzenbaum scissors were used to dissect bilaterally to the level of the ischial pubic ramus.  The SPARC needles were then placed through the suprapubic incisions and then directed through the vaginal incision bilaterally.  The Foley catheter was removed.  A cystoscopy was performed using a 70-degree cystoscope.  There was noted to be no violation of the bladder.  The SPARC mesh was then snapped onto the needles, which were withdrawn through the stab wound incisions.  The mesh was snugged up against a Mayo scissor held under the mid urethra.  The overlying plastic sheaths were removed.  The mesh was cut below the surface of the skin.  The skin was closed with 4-0 Plain suture.  The vaginal vault was closed with a running 2-0 Vicryl stitch.  The blood loss was minimal.  The patient was awoken and she was brought to recovery in stable condition.","urology, stress urinary incontinence, foley catheter, metzenbaum scissor, sparc, sparc mesh, bladder, orifice, perineum, sling, suburethral, ureteral, urethral hypermobility, vagina, vaginal vault, vulva, cystoscopy, suburethral sling, stress urinary, urinary incontinence, incontinence"
" Left scrotal exploration with detorsion.  Already, de-torsed bilateral testes fixation and bilateral appendix testes cautery.", Urology, Scrotal Exploration ,"PREOPERATIVE DIAGNOSIS: , Left testicular torsion, possibly detorsion.,POSTOPERATIVE DIAGNOSIS: , Left testicular torsion, possibly detorsion.,PROCEDURE: , Left scrotal exploration with detorsion.  Already, de-torsed bilateral testes fixation and bilateral appendix testes cautery.,ANESTHETIC:,  A 0.25% Marcaine local wound insufflation per surgeon, 15 mL of Toradol.,FINDINGS:,  Congestion in the left testis and cord with a bell-clapper deformity on the right small appendix testes bilaterally.  No testis necrosis.,ESTIMATED BLOOD LOSS:,  5 mL.,FLUIDS RECEIVED: , 300 mL of crystalloid.,TUBES AND DRAINS:,  None.,SPECIMENS: , No tissues sent to pathology.,COUNTS:,  Sponges and needle counts were correct x2.,INDICATIONS OF OPERATION: , The patient is a 4-year-old boy with abrupt onset of left testicular pain.  He has had a history of similar onset.  Apparently, he had no full on one ultrasound and full on a second ultrasound, but because of possible torsion, detorsion, or incomplete detorsion, I recommended an exploration.,DESCRIPTION OF OPERATION:,  The patient was taken to the operating room, where surgical consent, operative site, and patient identification was verified.  Once he was anesthetized, he was placed in supine position and sterilely prepped and draped.  Superior scrotal incisions were then made with 15-blade knife and further extended up to the subcutaneous tissue and dartos fascia with electrocautery.  Electrocautery was used for hemostasis.  The subdartos pouch was created with curved tenotomy scissors.  The tunica vaginalis was then delivered, incised, and testis was delivered.  The testis itself with a bell-clapper deformity.  There was no actual torsion at the present time, there was some modest congestion and, however, the vasculature was markedly congested down the cord.  The penis fascia was cauterized and subdartos pouch was created.  The upper aspect of fascia was then closed with pursestring suture of 4-0 chromic.  The testis was then placed into the scrotum in a proper orientation.  No tacking sutures within the testis itself were used.  The tunica vaginalis; however, was wrapped perfectly behind the back of the testis.  A similar procedure was performed on the right side.  Again, an appendix testis was cauterized.  No torsion was seen.  He also had a bell-clapper deformity and similar dartos pouch was created and the testis was placed in the scrotum in the proper orientation and the upper aspect closed with #4-0 chromic suture.  The local anesthetic was then used for both as cord block, as well as a local wound insufflation bilaterally with 0.25% Marcaine.  The scrotal wall was then closed with subcuticular closure of #4-0 chromic.  Dermabond tissue adhesive was then used.  The patient tolerated the procedure well.  He was given IV Toradol and was taken to the recovery room in stable condition.","urology, de-torsed bilateral testes, testes fixation, bell clapper deformity, testicular torsion, subdartos pouch, tunica vaginalis, scrotal exploration, appendix testes, scrotal, testes, torsion, detorsion, insufflation, testis, "
" Cystoscopy under anesthesia, retrograde and antegrade pyeloureteroscopy, left ureteropelvic junction obstruction, difficult and open renal biopsy.", Urology, Pyeloureteroscopy ,"PREOPERATIVE DIAGNOSES: , Left obstructed renal ureteropelvic junction obstruction status post pyeloplasty, percutaneous procedure, and pyeloureteroscopy x2, and status post Pseudomonas pyelonephritis x6, renal insufficiency, and solitary kidney.,POSTOPERATIVE DIAGNOSES:,  Left obstructed renal ureteropelvic junction obstruction status post pyeloplasty, percutaneous procedure, and pyeloureteroscopy x2, and status post Pseudomonas pyelonephritis x6, renal insufficiency, and solitary kidney.,PROCEDURE:  ,Cystoscopy under anesthesia, retrograde and antegrade pyeloureteroscopy, left ureteropelvic junction obstruction, difficult and open renal biopsy.,ANESTHESIA:  ,General endotracheal anesthetic with a caudal block x2.,FLUIDS RECEIVED:  ,1000 mL crystalloid.,ESTIMATED BLOOD LOSS:  ,Less than 10 mL.,SPECIMENS: , Tissue sent to pathology is a renal biopsy.,ABNORMAL FINDINGS: , A stenotic scarred ureteropelvic junction with dilated ureter and dilated renal pelvis.,TUBES AND DRAINS:  ,A 10-French silicone Foley catheter with 3 mL in balloon and a 4.7-French ureteral double J-stent multilength.,INDICATIONS FOR OPERATION:  ,The patient is a 3-1/2-year-old boy, who has a solitary left kidney with renal insufficiency with creatinine of 1.2, who has had a ureteropelvic junction repair performed by Dr. Chang.  It was subsequently obstructed with multiple episodes of pyelonephritis, two percutaneous tube placements, ureteroscopy with balloon dilation of the system, and continued obstruction.  Plan is for co surgeons due to the complexity of the situation and the solitary kidney to do surgical procedure to correct the obstruction.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operative room.  Surgical consent, operative site, and patient identification were verified.  Dr. X and Dr. Y both agreed upon the procedures in advance.  Dr. Y then, once the patient was anesthetized, requested IV antibiotics with Fortaz, the patient had a caudal block placed, and he was then placed in lithotomy position.  Dr. Y then calibrated the urethra with the bougie a boule to 8, 10, and up to 12 French.  The 9.5-French cystoscope sheath was then placed within the patient's bladder with the offset scope, and his bladder had no evidence of cystitis.  I was able to locate the ureteral orifice bilaterally, although no urine coming from the right.  We then placed a 4-French ureteral catheter into the ureter as far as we could go.  An antegrade nephrostogram was then performed, which shows that the contrast filled the dilated pelvis, but did not go into the ureter.  A retrograde was performed, and it was found that there was a narrowed band across the two.  Upon draining the ureter allowing to drain to gravity, the pelvis which had been clamped and its nephrostomy tube did not drain at all.  Dr. Y then placed a 0.035 guidewire into the ureter after removing the 4-French catheter and then placed a 4.7-French double-J catheter into the ureter as far as it would go allowing it to coil in the bladder.  Once this was completed, we then removed the cystoscope and sheath, placed a 10-French Foley catheter, and the patient was positioned by Dr. X and Dr. Y into the flank position with the left flank up after adequate padding on the arms and legs as well as a brachial plexus roll.  He was then sterilely prepped and draped.  Dr. Y then incised the skin with a 15-blade knife through the old incision and then extended the incision with curved mosquito clamp and Dr. X performed cautery of the areas advanced to be excised.  Once this was then dissected, Dr. Y and Dr. X divided the lumbosacral fascia; at the latissimus dorsi fascia, posterior dorsal lumbotomy maneuver using the electrocautery; and then using curved mosquito clamps __________.  At this point, Dr. X used the cautery to enter the posterior retroperitoneal space through the posterior abdominal fascia.  Dr. Y then used the curved right angle clamp and dissected around towards the ureter, which was markedly adherent to the base of the retroperitoneum.  Dr. X and Dr. Y also needed dissection on the medial and lateral aspects with Dr. Y being on the lateral aspect of the area and Dr. X on the medial to get an adequate length of this.  The tissue was markedly inflamed and had significant adhesions noted.  The patient's spermatic vessels were also in the region as well as the renal vessels markedly scarred close to the ureteropelvic junction.  Ultimately, Dr. Y and Dr. X both with alternating dissection were able to dissect the renal pelvis to a position where Dr. Y put stay sutures and a 4-0 chromic to isolate the four quadrant area where we replaced the ureter.  Dr. X then divided the ureter and suture ligated the base, which was obstructed with a 3-0 chromic suture.  Dr. Y then spatulated the ureter for about 1.5 cm, and the stent was gently delivered in a normal location out of the ureter at the proximal and left alone in the bladder.  Dr. Y then incised the renal pelvis and dissected and opened it enough to allow the new ureteropelvic junction repair to be performed.  Dr. Y then placed interrupted sutures of 5-0 Monocryl at the apex to repair the most dependent portion of the renal pelvis, entered the lateral aspect, interrupted sutures of the repair.  Dr. X then was able to without much difficulty do interrupted sutures on the medial aspect.  The stent was then placed into the bladder in the proper orientation and alternating sutures by Dr. Y and Dr. X closed the ureteropelvic junction without any evidence of leakage.  Once this was complete, we removed the extra stay stitches and watched the ureter lay back into the retroperitoneum in a normal position without any kinking in apparently good position.  This opening was at least 1.5 cm wide.  Dr. Y then placed 2 stay sutures of 2-0 chromic in the lower pole of the kidney and then incised wedge biopsy and excised the biopsy with a 15-blade knife and curved iris scissors for renal biopsy for determination of renal tissue health.  Electrocautery was used on the base.  There was no bleeding, however, and the tissue was quite soft.  Dermabond and Gelfoam were placed, and then Dr. Y closed the biopsy site over with thrombin-Gelfoam using the 2-0 chromic stay sutures.  Dr. X then closed the fascial layers with running suture of 3-0 Vicryl in 3 layers.  Dr. Y closed the Scarpa fascia and the skin with 4-0 Vicryl and 4-0 Rapide respectively.  A 4-0 nylon suture was then placed by Dr. Y around the previous nephrostomy tube, which was again left clamped.  Dermabond tissue adhesive was placed over the incision and then a dry sterile dressing was placed by Dr. Y over the nephrostomy tube site, which was left clamped, and the patient then had a Foley catheter placed in the bladder.  The Foley catheter was then taped to his leg.  A second caudal block was placed for anesthesia, and he is in stable condition upon transfer to recovery room.","urology, cystoscopy, pyeloureteroscopy, ureteropelvic junction obstruction, pseudomonas pyelonephritis, renal insufficiency, fortaz, ureteropelvic junction repair, nephrostomy tube, renal biopsy, renal pelvis, foley catheter, ureteropelvic junction, renal, ureteropelvic,"
" Radical retropubic prostatectomy, robotic assisted and bladder suspension.  Adenocarcinoma of the prostate.", Urology, Prostatectomy - Robotic Radical Retropubic ,"PREOPERATIVE DIAGNOSIS: , Adenocarcinoma of the prostate.,POSTOPERATIVE DIAGNOSIS: , Adenocarcinoma of the prostate.,PROCEDURE,1.  Radical retropubic prostatectomy, robotic assisted.,2.  Bladder suspension.,ANESTHESIA:,  General by intubation.,The patient understands his diagnosis, grade, stage and prognosis.  He understands this procedure, options to it and potential benefits from it.  He strongly wishes to proceed.  He accepts all treatment-associated risks to include but not be limited to bleeding requiring transfusion; infection; sepsis; heart attack; stroke; bladder neck contractures; need to convert to an open procedure; urinary fistulae; impotence; incontinence; injury to bowel/rectum/bladder/ureters, etc.; small-bowel obstruction; abdominal hernia; osteitis pubis/chronic pelvic pain, etc.,DESCRIPTION OF THE CASE:  ,The patient was taken to the operating room, given a successful general anesthetic, placed in the lithotomy position, prepped with Betadine solutions and draped in the usual sterile fashion.  My camera ports were then placed in the standard fan array.  A camera port was placed in the midline above the umbilicus using the Hasson technique.  The balloon port was placed, the abdomen insufflated, and all other ports were placed under direct vision.  My assistant was on the right.  The patient was then placed in the steep Trendelenburg position, and the robot brought forward and appropriately docked.,I then proceeded to drop the bladder into the peritoneal cavity by incising between the right and left medial umbilical ligaments and carrying that dissection laterally along these ligaments deep into the pelvis.  This nicely exposed the space of Retzius.  I then defatted the anterior surface of the prostate and endopelvic fascia.,The endopelvic fascia was then opened bilaterally.  The levator ani muscles were carefully dissected free from the prostate and pushed laterally.  Dissection was continued posteriorly toward the bundles and caudally to the apex.  The puboprostatic ligaments were then transected.  A secure ligature of 0 Vicryl was placed around the dorsal venous complex.,I then approached the bladder neck.  The anterior bladder neck was transected down to the level of the Foley catheter, which was lifted anteriorly in the wound.  I then transected the posterior bladder neck down to the level of the ampullae of the vas.  The ampullae were mobilized and transected.  These were lifted anteriorly in the field, exposing the seminal vesicles, which were similarly mobilized.  Hemostasis was obtained using the bipolar Bovie.,I then identified the Denonvilliers fascia, and this was incised sharply.  Dissection was continued caudally along the anterior surface of the rectum and laterally toward the bundles.  I was able to then identify the pedicles over the seminal vesicles, which were hemoclipped and transected.,The field was then copiously irrigated with sterile water.  Hemostasis was found to be complete.  I then carried out a urethrovesical anastomosis.  This was accomplished with 3-0 Monocryl ligatures.  Two of these were tied together in the midline.  They were placed at the 6 o'clock position, and one was run in a clockwise and the other in a counterclockwise direction to the 12 o'clock position where they were securely tied.  A new Foley catheter was then easily delivered into the bladder and irrigated without extravasation.  The patient was given indigo carmine, and there was prompt blue urine in the Foley., ,I then carried out a bladder suspension.  This was done in hopes of obtaining early urinary control.  This was accomplished with 0 Vicryl ligatures.  One was placed at the bladder neck and through the dorsal venous complex and then the other along the anterior surface of the bladder to the posterior surface of the pubis.  This nicely re-retroperitonealized the bladder.,The prostate was then placed in an Endocatch bag and brought out through an extended camera port incision.  A JP drain was brought in through the 4th arm port and sutured to the skin with 2-0 silk.  The camera port fascia was closed with running 0 Vicryl.  The skin incisions were closed with a running, subcuticular 4-0 Monocryl.,The patient tolerated the procedure very well.  There were no complications.  Sponge and instrument counts were reported correct at the end of the case.","urology, adenocarcinoma, prostate, radical retropubic prostatectomy, robotic assisted, bladder, uspension, bladder neck, intubation, robotic, retropubic, prostatectomy"
" A 16-month-old with history of penile swelling for 4 days, had circumcision 1 week ago.", Urology, Pubic Cellulitis ,"DIAGNOSIS: , Pubic cellulitis.,HISTORY OF PRESENT ILLNESS:,  A 16-month-old with history of penile swelling for 4 days.  The patient was transferred for higher level of care.  This 16-month-old had circumcision 1 week ago and this is the third circumcision this patient underwent.  Apparently, the patient developed adhesions and the patient had surgery for 2 more occasions for removal of the adhesions.  This time, the patient developed fevers 3 days after the surgery with edema and erythema around the circumcision and it has spread to the pubic area.  The patient became febrile with 102 to 103 fever, treated with Tylenol with Codeine and topical antibiotics.  The patient was transferred to Children's Hospital for higher level of care.,REVIEW OF SYSTEMS: , ,ENT:  Denies any runny nose.  ,EYES:  No apparent discharge.  ,FEEDING:  Good feeding.  ,CARDIOVASCULAR:  There is no cyanosis or edema.  ,RESPIRATORY:  Denies any cough or wheezing.  ,GI:  Positive for constipation, no bowel movements for 2 days.  ,GU:  Positive dysuria for the last 2 days and penile discharge for the last 2 days with foul smelling.  ,NEUROLOGIC:  Denies any lethargy or seizure.  ,MUSCULOSKELETAL:  No pain or swelling.  ,SKIN:  Erythema and edema in the pubic area for the last 3 days.  All the rest of systems are negative except as noted above.,At the emergency room, the patient had a second dose of clindamycin.  The transfer labs are as follows:  15.7 for WBC, H&H 12.0 and 36.  One blood culture.  We will follow the results.  He is status post Rocephin and Cleocin.,PAST MEDICAL HISTORY: , Denied.  ,PAST SURGICAL HISTORY:,  The patient underwent 3 circumcisions since birth, the last 2 had been for possible removal of adhesions.,IMMUNIZATIONS: , He is behind with his immunizations.  He is due for his 16-month-old immunizations.,ACTIVITY: , NKDA.,BIRTH HISTORY: , Born to a 21-year-old, first baby, born NSVD, 8 pounds 10 ounces, no complications.,DEVELOPMENTAL:,  He is walking and speaking about 15 words.,FAMILY HISTORY: , Noncontributory.,MEDICATIONS: , Tylenol with Codeine q.6h.,SOCIAL HISTORY: , He lives with both parents and both of them smoke.  There are no pets.,SICK CONTACTS: , Mom has some upper respiratory infection.,DIET: , Regular diet.,PHYSICAL EXAMINATION: , ,VITAL SIGNS:  Temperature max at ER is 102, heart rate 153.,GENERAL:  This patient is alert, arousable, big boy.,HEENT:  Head:  Normocephalic, atraumatic.  Pupils are equal, round, and reactive to light.  Mucous membranes are moist.,NECK:  Supple.,CHEST:  Clear to auscultation bilaterally.  Good air exchange.,ABDOMEN:  Soft, nontender, nondistended.,EXTREMITIES:  Full range of movement.  No deformities.",
 Radical retropubic prostatectomy with pelvic lymph node dissection due to prostate cancer., Urology, Prostatectomy - Radical Retropubic ,"PREOPERATIVE DIAGNOSIS:,  Prostate cancer.,POSTOPERATIVE DIAGNOSIS: , Prostate cancer.,OPERATIVE PROCEDURE: , Radical retropubic prostatectomy with pelvic lymph node dissection.,ANESTHESIA:  ,General epidural,ESTIMATED BLOOD LOSS: , 800 cc.,COMPLICATIONS: , None.,INDICATIONS FOR SURGERY: , This is a 64-year-old man with adenocarcinoma of the prostate confirmed by needle biopsies.  He has elected to undergo radical retropubic prostatectomy with pelvic lymph node dissection.  Potential complications include, but are not limited to:,1.  Infection.,2.  Bleeding.,3.  Incontinence.,4.  Impotence.,5.  Deep venous thrombosis.,6.  Recurrence of the cancer.,PROCEDURE IN DETAIL: , Epidural anesthesia was administered by the anesthesiologist in the holding area.  Preoperative antibiotic was also given in the preoperative holding area.  The patient was then taken into the operating room after which general LMA anesthesia was administered.  The patient was shaved and then prepped using Betadine solution.  A sterile 16-French Foley catheter was inserted into the bladder with clear urine drain.  A midline infraumbilical incision was performed.  The rectus fascia was opened sharply.  The perivesical space and the retropubic space were developed bluntly.  Bookwalter retractor was then placed.  Bilateral obturator pelvic lymphadenectomy was performed.  The obturator nerve was identified and was untouched.  The margin for the resection of the lymph node bilaterally were the Cooper's ligament, the medial edge of the external iliac artery, the bifurcation of the common iliac vein, the obturator nerve, and the bladder.  Both hemostasis and lymphostasis was achieved by using silk ties and Hemo clips.  The lymph nodes were palpably normal and were set for permanent section.  The Bookwalter retractor was then repositioned and the endopelvic fascia was opened bilaterally using Metzenbaum scissors.  The puboprostatic ligament was taken down sharply.  The superficial dorsal vein complex over the prostate was bunched up by using the Allis clamp and then tied by using 2-0 silk sutures.  The deep dorsal vein complex was then bunched up by using the Allis over the membranous urethral area.  The dorsal vein complex was ligated by using 0 Vicryl suture on a CT-1 needle.  The Allis clamp was removed and the dorsal vein complex was transected by using Metzenbaum scissors.  The urethra was then identified and was dissected out.  The urethral opening was made just distal to the apex of the prostate by using Metzenbaum scissors.  This was extended circumferentially until the Foley catheter could be seen clearly.  2-0 Monocryl sutures were then placed on the urethral stump evenly spaced out for the anastomosis to be performed later.  The Foley catheter was removed and the posteriormost aspect of urethra and rectourethralis muscle was transected.  The lateral pelvic fascia was opened bilaterally to sweep the neurovascular bundles laterally on both sides.  The plane between Denonvilliers' fascia and the perirectal fat was developed sharply.  No tension was placed on the neurovascular bundle at any point in time.  The prostate dissected off the rectal wall easily.  Once the seminal vesicles were identified, the fascia covering over them were opened transversely.  The seminal vesicles were dissected out and the small bleeding vessels leading to them were clipped by using medium clips and then transected.  The bladder neck was then dissected out carefully to spare most of the bladder neck muscles.  Once all of the prostate had been dissected off the bladder neck circumferentially the mucosa lining the bladder neck was transected releasing the entire specimen.  The specimen was inspected and appeared to be completely intact.  It was sent for permanent section.  The bladder neck mucosa was then everted by using 4-0 chromic sutures.  Inspection at the prostatic bed revealed no bleeding vessels.  The sutures, which were placed previously onto the urethral stump, were then placed onto the bladder neck.  Once the posterior sutures had been placed, the Foley was placed into the urethra and into the bladder neck.  A 20-French Foley Catheter was used.  The anterior sutures were then placed.  The Foley was then inflated.  The bed was straightened and the sutures were tied down sequentially from anteriorly to posteriorly.  Mild traction of the Foley catheter was placed to assure the anastomosis was tight.  Two #19-French Blake drains were placed in the perivesical spaces.  These were anchored to the skin by using 2-0 silk sutures.  The instrument counts, lab counts, and sponge counts were verified to be correct, the patient was closed.  The fascia was closed in running fashion using #1 PDS.  Subcutaneous tissue was closed by using 2-0 Vicryl suture.  Skin was approximated by using metallic clips.  The patient tolerated the operation well.","urology, prostate cancer, foley catheter, metzenbaum scissors, prostate, adenocarcinoma, bladder, lymphadenectomy, pelvic lymph node dissection, perivesical, prostatectomy, retropubic, urethra, radical retropubic prostatectomy, lymph node dissection, dorsal vein complex, radical retropubic, lymph node, dorsal vein, vein complex, bladder neck, sutures, foley, urethral,"
 Radical retropubic nerve-sparing prostatectomy without lymph node dissection., Urology, Prostatectomy - Nerve Sparing ,"PREOPERATIVE DIAGNOSIS:  ,Prostate cancer.,POSTOPERATIVE DIAGNOSIS:,  Prostate cancer.,OPERATION PERFORMED:,  Radical retropubic nerve-sparing prostatectomy without lymph node dissection.,ESTIMATED BLOOD LOSS: , 450 mL.,REPLACEMENT:,  250 mL of Cell Saver and crystalloid.,COMPLICATIONS: , None.,INDICATIONS OF SURGERY: , This is a 67-year-old man with needle biopsy proven to be Gleason 6 adenocarcinoma in one solitary place on the right side of the prostate.  Due to him being healthy with no comorbid conditions, he has elected to undergo surgical treatment with radical retropubic prostatectomy.  Potential complications include, but are not limited to:,1.  Infection.,2.  Bleeding.,3.  Incontinence.,4.  Impotence.,5.  Injury to the adjacent viscera.,6.  Deep venous thrombosis.,PROCEDURE IN DETAIL: , Prophylactic antibiotic was given in the preoperative holding area, after which the patient was transferred to the operating room.  Epidural anesthesia and general endotracheal anesthesia were administered by Dr. A without any difficulty.  The patient was shaved, prepped, and draped using the usual sterile technique.  A sterile 16-French Foley catheter was then placed with clear urine drained.  A midline infraumbilical incision was performed by using a #10 scalpel blade.  The rectus fascia and the subcutaneous space were opened by using the Bovie.  Transversalis fascia was opened in the midline and the retropubic space and the paravesical space were developed bluntly.  A Bookwalter retractor was then placed.  The area of the obturator lymph nodes were carefully inspected and no suspicious adenopathy was detected.  Given this patient's low Gleason score and low PSA with a solitary core biopsy positive, the decision was made to not perform bilateral lymphadenectomy.  The endopelvic fascia was opened bilaterally by using the Metzenbaum scissors.  Opening was enlarged by using sharp dissection.  Small perforating veins from the prostate into the lateral pelvic wall were controlled by using bipolar coagulation device.  The dorsal aspect of the prostate was bunched up by using 2-0 silk sutures.  The deep dorsal vein complex was bunched up by using Allis also and ligated by using 0 Vicryl suture in a figure-of-eight fashion.  With the prostate retracted cephalad, the deep dorsal vein complex was transected superficially using the Bovie.  Deeper near the urethra, the dorsal vein complex was transected by using Metzenbaum scissors.  The urethra could then be easily identified.  Nearly two-third of the urethra from anteriorly to posteriorly was opened by using Metzenbaum scissors.  This exposed the blue Foley catheter.  Anastomotic sutures were then placed on to the urethral stump using 2-0 Monocryl suture.  Six of these were placed evenly spaced out anteriorly to posteriorly.  The Foley catheter was then removed.  This allowed for better traction of the prostate laterally.  Lateral pelvic fascia was opened bilaterally.  This effectively released the neurovascular bundle from the apex to the base of the prostate.  Continued dissection from the lateral pelvic fascia deeply opened up the plane into the perirectal fat.  The prostate was then dissected from laterally to medially from this opening in the perirectal fat.  The floor of the urethra posteriorly and the rectourethralis muscle was then transected just distal to the prostate.  Maximal length of ureteral stump was preserved.  The prostate was carefully lifted cephalad by using gentle traction with fine forceps.  The prostate was easily dissected off the perirectal fat using sharp dissection only.  Absolutely, no traction to the neurovascular bundle was evident at any point in time.  The dissection was carried out easily until the seminal vesicles could be visualized.  The prostate pedicles were controlled easily by using multiple medium clips in 4 to 5 separate small bundles on each side.  The bladder neck was then dissected out by using a bladder neck dissection method.  Unfortunately, most of the bladder neck fiber could not be preserved due to the patient's anatomy.  Once the prostate had been separated from the bladder in the area with the bladder neck, dissection was carried out posteriorly to develop a plane between the bladder and the seminal vesicles.  This was developed without any difficulty.  Both vas deferens were identified, hemoclipped and transected.  The seminal vesicles on both sides were quite large and a decision was made to not completely dissect the tip off, as it extended quite deeply into the pelvis.  About two-thirds of the seminal vesicles were able to be removed.  The tip was left behind.  Using the bipolar Gyrus coagulation device, the seminal vesicles were clamped at the tip sealed by cautery and then transected.  This was performed on the left side and then the right side.  This completely freed the prostate.  The prostate was sent for permanent section.  The opening in the bladder neck was reduced by using two separate 2-0 Vicryl sutures.  The mucosa of the bladder neck was everted by using 4-0 chromic sutures.  Small amount of bleeding around the area of the posterior bladder wall was controlled by using suture ligature.  The ureteral orifice could be seen easily from the bladder neck opening and was completely away from the everting sutures.  The previously placed anastomotic suture on the urethral stump was then placed on the corresponding position on the bladder neck.  This was performed by using a French ***** needle.  A 20-French Foley catheter was then inserted and the sutures were sequentially tied down.  A 15 mL of sterile water was inflated to balloon.  The bladder anastomosis to the urethra was performed without any difficulty.  A 19-French Blake Drain was placed in the left pelvis exiting the right inguinal region.  All instrument counts, lap counts, and latex were verified twice prior to the closure.  The rectus fascia was closed in running fashion using #1 PDS.  Subcutaneous space was closed by using 2-0 Vicryl sutures.  The skin was reapproximated by using metallic clips.  The patient tolerated the procedure well and was transferred to the recovery room in stable condition.","urology, prostate cancer, foley catheter, gleason, psa, prostate, adenocarcinoma, bladder neck, core biopsy, figure-of-eight, lymph node dissection, nerve-sparing, prostatectomy, rectus fascia, retropubic, bladder neck dissection, dorsal vein complex, nerve sparing, perirectal fat, seminal vesicles, sutures, bladder, urethra, posteriorly, seminal, vesicles, fascia, neck, dissection,"
 A 65-year-old man with chronic prostatitis returns for recheck., Urology, Prostatitis - Recheck ,"SUBJECTIVE:,  The patient is a 65-year-old man with chronic prostatitis who returns for recheck.  He follow with Dr. XYZ about every three to four months.  His last appointment was in May 2004.  Has had decreased libido since he has been on Proscar.  He had tried Viagra with some improvement.  He has not had any urinary tract infection since he has been on Proscar.  Has nocturia x 3 to 4.,PAST MEDICAL HISTORY/SURGERIES/HOSPITALIZATIONS:  ,Soon after birth for treatment of an inperforated anus and curvature of the penis.  At the age of 70 had another penile operation.  At the age of 27 and 28 he had repeat operations to correct this.  He did have complications of deep vein thrombosis and pulmonary embolism with one of those operations.  He has had procedures in the past for hypospadias, underwent an operation in 1988 to remove some tissue block in the anus.  In January of 1991 underwent cystoscopy.  He was hospitalized in 1970 for treatment of urinary tract infection.  In 2001, left rotator cuff repair with acromioplasty and distal clavicle resection.  In 2001, colonoscopy that was normal.  In 2001, prostate biopsy that showed chronic prostatitis.  In 2003, left inguinal hernia repair with MESH.,MEDICATIONS:,  Bactrim DS one pill a day, Proscar 5 mg a day, Flomax 0.4 mg daily.  He also uses Metamucil four times daily and stool softeners for bedtime.,ALLERGIES:,  Cipro.,FAMILY HISTORY:,  Father died from CA at the age of 79.  Mother died from postoperative infection at the age of 81.  Brother died from pancreatitis at the age of 40 and had a prior history of mental illness.  Father also had a prior history of lung cancer.  Mother had a history of breast cancer.  Father also had glaucoma.  He does not have any living siblings.  Friend died a year and half ago.,PERSONAL HISTORY:,  Negative for use of alcohol or tobacco.  He is a professor at College and teaches history and bible.,REVIEW OF SYSTEMS:,Eyes, nose and throat:  Wears eye glasses.  Has had some gradual decreased hearing ability.,Pulmonary:  Denies difficulty with cough or sputum production or hemoptysis.,Cardiac:  Denies palpitations, chest pain, orthopnea, nocturnal dyspnea, or edema.,Gastrointestinal:  Has had difficulty with constipation.  He denies any positive stools.  Denies peptic ulcer disease.  Denies reflux or melena.,Genitourinary:  As mentioned previously.,Neurologic:  Without symptoms.,Bones and Joints:  He has had occasional back pain.,Hematologic:  Occasionally has had some soreness in the right axillary region, but has not had known lymphadenopathy.,Endocrine:  He has not had a history of hypercholesterolemia or diabetes.,Dermatologic:  Without symptoms.,Immunization:  He had pneumococcal vaccination about three years ago.  Had an adult DT immunization five years ago.,PHYSICAL EXAMINATION:,Vital Signs:  Weight:  202.8 pounds.  Blood pressure:  126/72.  Pulse:  60.  Temperature:  96.8 degrees.,General Appearance:  He is a middle-aged man who is not in any acute distress.,HEENT:  Eyes:  Pupils are equally regular, round and reactive to light.  Extraocular movements are intact without nystagmus.  Visual fields were full to direct confrontation.  Funduscopic exam reveals middle size disc with sharp margins.  Ears:  Tympanic membranes are clear.  Mouth:  No oral mucosal lesions are seen.,Neck:  Without adenopathy or thyromegaly.,Chest:  Lungs are resonant to percussion.  Auscultation reveals normal breath sounds.,Heart:  Normal S1 and S2 without gallops or rubs.,Abdomen:  Without tenderness or masses to palpation.,Genitorectal exam:  Not repeated since these have been performed recently by Dr. Tandoc.,Extremities:  Without edema.,Neurologic:  Reflexes are +2 and symmetric throughout.  Babinski is negative and sensation is intact.  Cranial nerves are intact without localizing signs.  Cerebellar tension is normal.,IMPRESSION/PLAN:,1.  Chronic prostatitis.  He has been stable in this regard.,2.  Constipation.  He is encouraged to continue with his present measures.  Additionally, a TSH level will be obtained.,3.  Erectile dysfunction.  Testosterone level and comprehensive metabolic profile will be obtained.,4.  Anemia.  CBC will be rechecked.  Additional stools for occult blood will be rechecked.",
" Adenocarcinoma of the prostate, Erectile dysfunction - History & Physical", Urology, Prostate Adenocarcinoma - H&P ,"HISTORY OF PRESENT ILLNESS: , The patient is a 62-year old male with a Gleason score 8 adenocarcinoma of the prostate involving the left and right lobes.  He has a PSA of 3.1, with a prostate gland size of 41 grams.  This was initially found on rectal examination with a nodule on the right side of the prostate, showing enlargement relative to the left.  He has undergone evaluation with a bone scan that showed a right parietal lesion uptake and was seen by Dr. XXX and ultimately underwent an open biopsy that was not malignant.  Prior to this, he has also had a ProstaScint scan that was negative for any metastatic disease.  Again, he is being admitted to undergo a radical prostatectomy, the risks, benefits, and alternatives of which have been discussed, including that of bleeding, and a blood transfusion.,PAST MEDICAL HISTORY: , Coronary stenting.  History of high blood pressure, as well.  He has erectile dysfunction and has been treated with Viagra.,MEDICATIONS: , Lisinopril, Aspirin, Zocor, and Prilosec.,ALLERGIES:,  Penicillin.,SOCIAL HISTORY:,  He is not a smoker.  He does drink six beers a day.,REVIEW OF SYSTEMS: , Remarkable for his high blood pressure and drug allergies, but otherwise unremarkable, except for some obstructive urinary symptoms, with an AUA score of 19.,PHYSICAL EXAMINATION:,HEENT:  Examination unremarkable.,Breasts:  Examination deferred.,Chest:  Clear to auscultation.,Cardiac:  Regular rate and rhythm.,Abdomen:  Soft and nontender.  He has no hernias.,Genitourinary:  There is a normal-appearing phallus, prominence of the right side of prostate.,Extremities:  Examination unremarkable.,Neurologic:  Examination nonfocal.,IMPRESSION:,1.  Adenocarcinoma of the prostate.,2.  Erectile dysfunction.,PLAN:  ,The patient will undergo a bilateral pelvic lymphadenectomy and radical retropubic prostatectomy.  The risks, benefits, and alternatives of this have been discussed.  He understands and asks that I proceed ahead.  We also discussed bleeding and blood transfusions, and the risks, benefits and alternatives thereof.","urology, gleason score, gleason, prostate gland, prostascint, retropubic prostatectomy, adenocarcinoma of the prostate, erectile dysfunction, adenocarcinoma, radical, prostatectomy, erectile, dysfunction, prostate, "
 Prostate Brachytherapy - Prostate I-125 Implantation, Urology, Prostate Brachytherapy ,"PROSTATE BRACHYTHERAPY - PROSTATE I-125 IMPLANTATION,This patient will be treated to the prostate with ultrasound-guided I-125 seed implantation.  The original consultation and treatment planning will be separately performed.  At the time of the implantation, special coordination will be required.  Stepping ultrasound will be performed and utilized in the pre-planning process.  Some discrepancies are frequently identified, based on the positioning, edema, and/or change in the tumor since the pre-planning process.  Re-assessment is required at the time of surgery, evaluating the pre-plan and comparing to the stepping ultrasound.  Modifications will be made in real time to add or subtract needles and seeds as required.  This may be integrated with the loading of the seeds performed by the brachytherapist, as well as coordinated with the urologist, dosimetrist or physicist.,The brachytherapy must be customized to fit the individual's tumor and prostate.  Attention is given both preoperatively and intraoperatively to avoid overdosage of rectum and bladder.","urology, i-125 implantation, tumor, prostate, prostate brachytherapy, implantationNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" Right ureteropelvic junction obstruction.  Robotic-assisted pyeloplasty, anterograde right ureteral stent placement, transposition of anterior crossing vessels on the right, and nephrolithotomy.", Urology, Pyeloplasty - Robotic ,"PROCEDURES:,1.  Robotic-assisted pyeloplasty.,2.  Anterograde right ureteral stent placement.,3.  Transposition of anterior crossing vessels on the right.,4.  Nephrolithotomy.,DIAGNOSIS:,  Right ureteropelvic junction obstruction.,DRAINS:,1.  Jackson-Pratt drain times one from the right flank.,2.  Foley catheter times one.,ESTIMATED BLOOD LOSS: , Less than 30 cc.,COMPLICATIONS: , None.,SPECIMENS:,1.  Renal pelvis.,2.  Kidney stones.,INDICATIONS:  ,The patient is a 30-year-old Caucasian gentleman with history of hematuria subsequently found to have right renal stones and patulous right collecting system with notable two right crossing renal arteries.  Up on consideration of various modalities and therapy, the patient decided to undergo surgical therapy.,PROCEDURE IN DETAIL:  ,The patient was verified by armband and the procedure being robotic-assisted right pyeloplasty with nephrolithotomy was verified, and the procedure was carried out.  After institution of general endotracheal anesthesia and intravenous preoperative antibiotics, the patient was positioned into the right flank position with his right flank elevated.  Great care was taken to pad all pressure points and a right arm hanger was used.  The patient was flexed slightly, and a kidney rest was used.  Sequential compression devices were also placed.  Next, the patient was prepped and draped in normal sterile fashion with povidone-iodine.  Pneumoperitoneum was obtained by placing a Veress needle in the area of the umbilicus after it passed the water test.  A low pressure, high flow pneumoperitoneum was adequately obtained using CO2 gas.  Next, a 12-mm camera port was placed near the umbilicus.  The camera was inserted, and no bowel injury was seen.  Next, under direct vision flanking 8 mm camera ports, a 12 mm assist port, a 5 mm liver retraction port, and 5 mm assist port were placed.  The robot was docked and the instruments passed through respective checks.  Initial attention was directed to mobilizing the right colon from the abdominal wall totally medially.  Next, the right lateral duodenum was cauterized for further access to the right retroperitoneum.  At this point, the right kidney was in clear view, and the fascia was entered.  Initial attention was directed at careful dissection of the renal pelvis and proximal ureter which was done with a combination of electrocautery and blunt dissection.  It became readily apparent that there were two crossing vessels one in the medial inferior region of the kidney and another one in the most inferior portion of the lower pole.  These arteries were dissected carefully and vessel loops were applied.  Next, a small hole was then made in the renal pelvis using electrocautery and the contents of the renal pelvis were suctioned out.  The pyelotomy was extended so that the renal collecting system could be directly inspected.  Sequentially, each major calyx was inspected under direct vision and irrigated.  A total of four round kidney stones were extracted to be sent for analysis to being satisfied for the patient.  At this point, we directed our attention at the proximal right ureter which was dismembered from the remaining renal pelvis.  The proximal ureter was spatulated using cold scissors.  Next, redundant renal pelvis was excised using cold scissors and sent for permanent section.  We then identified the most inferior/dependent portion of the renal pelvis and placed a heel stitch at this for ureteral-renal pelvis anastomosis in a semi running fashion.  3-0 Monocryl sutures were used to re-anastomose the newly spatulated right ureter to the inferior portion of the renal pelvis.  Next, remainder of the pyelotomy was closed to itself also using 2-0 Monocryl sutures.  Before final stitches were placed, a 6x28 ureteral stent was placed anterograde.  This was accomplished by placing the stents over a guidewire, placing the guidewire under direct vision anterograde through the ureter.  This was done until the proximal end was in the renal pelvis, the guidewire was removed, and good proximal curl was verified by direct vision.  Then, the pyelotomy was completely closed again with 2-0 Monocryl sutures.  Next, attention was directed at transposition of the crossing renal artery by fixing it with Vicryl suture that would impinge less upon the renal pelvis.  Good pulsation was verified by direct vision proximal and distal to these pexy sutures.  Next, Gerota's fascia was reapproximated and closed with Vicryl sutures as was the right peritoneum.  Hemostasis appeared excellent at this point.  There was no obvious urine extravasation.  At this time, the procedure was terminated.  The robot was undocked.  Under direct visualization all 8 and 12 mm ports were closed at the level of the fascia with 0 Vicryl sutures in an interrupted fashion.  Then, all skin port sites were closed with 4-0 Monocryl in a subcuticular fashion and Dermabond and band-aids were applied over this.  Also, notably a Jackson-Pratt drain was placed in the area of the right kidney and additional right flank stab incision.  The patient tolerated the procedure well and no immediate perioperative complication was noted.,DISPOSITION: , The patient was discharged to Post Anesthesia Care Unit and subsequently to genitourinary floor to begin his recovery.","urology, pyeloplasty, ureteral stent placement, nephrolithotomy, ureteropelvic junction obstruction, jackson-pratt drain, foley catheter, renal pelvis, kidney stones, monocryl sutures, pelvis, renal, ureteropelvic, sutures, "
" Cystourethroscopy, right retrograde pyelogram, and right double-J stent placement 22 x 4.5 mm.  Right ureteropelvic junction calculus.", Urology, Retrograde Pyelogram & Cystourethroscopy ,"PREOPERATIVE DIAGNOSIS: , Right ureteral calculus.,POSTOPERATIVE DIAGNOSIS: , Right ureteropelvic junction calculus.,PROCEDURE PERFORMED:,1.  Cystourethroscopy.,2.  Right retrograde pyelogram.,3.  Right double-J stent placement 22 x 4.5 mm.,FIRST SECOND ANESTHESIA: , General.,SPECIMEN:,  Urine for culture and sensitivity.,DRAINS: , 22 x 4.5 mm right double-J ureteral stent.,PROCEDURE: , After consent was obtained, the patient was brought to operating room and placed in the supine position.  She was given general anesthesia and then placed in the dorsal lithotomy position.  A #21 French cystoscope was then passed through the urethra into the bladder.  There was noted to be some tightness of the urethra on passage.  On visualization of the bladder, there were no stones or any other debris within the bladder.  There were no abnormalities seen.  No masses, diverticuli, or other abnormal findings.  Attention was then turned to the right ureteral orifice and attempts to pass to a cone tip catheter, however, the ureteral orifice was noted to be also tight and we were unable to pass the cone tip catheter.  The cone tip catheter was removed and a glidewire was then passed without difficulty up into the renal pelvis.  An open-end ureteral catheter was then passed ________ into the distal right ureter.  Retrograde pyelogram was then performed.,There was noted to be an UPJ calculus with no noted hydronephrosis.  The wire was then passed back through the ureteral catheter.  The catheter was removed and a 22 x 4.5 mm double-J ureteral stent was then passed over the glidewire under fluoroscopic and cystoscopic guidance.  The stent was clear within the kidney as well as within the bladder.  The bladder was drained and the cystoscope was removed.  The patient tolerated the procedure well.  She will be discharged home.  She is to follow up with Dr. X for ESWL procedure.  She will be given prescription for Darvocet and will be asked to have a KUB x-ray done prior to her followup and to bring them with her to her appointment.","urology, ureteropelvic junction, calculus, cystourethroscopy, retrograde pyelogram, double-j stent placement, double j stent, cone tip catheter, ureteral stent, ureteral orifice, ureteral catheter, retrograde, pyelogram, catheter, ureteral"
 Open radical retropubic prostatectomy with bilateral lymph node dissection., Urology, Prostatectomy ,"PREOPERATIVE DIAGNOSIS:,  Prostate cancer, Gleason score 4+3 with 85% burden and 8/12 cores positive.,POSTOPERATIVE DIAGNOSIS:,  Prostate cancer, Gleason score 4+3 with 85% burden and 8/12 cores positive.,PROCEDURE DONE: , Open radical retropubic prostatectomy with bilateral lymph node dissection.,INDICATIONS:,  This is a 66-year-old gentleman who had an elevated PSA of 5.  His previous PSAs were in the 1 range.  TRUS biopsy revealed 4+3 Gleason score prostate cancer with a large tumor burden.  After extensive counseling, the patient elected for retropubic radical prostatectomy.  Given his disease burden, it was advised that an open prostatectomy is probably the standard of care to ensure entire excision.  The patient consented and agreed to proceed forward.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room here.  Time out was taken to properly identify the patient and procedure going to be done.  General anesthesia was induced.  The patient was placed in the supine position.  The bed was flexed distant to the pubic area.  The patient's lower abdominal area, pubic area, and penile and scrotal area were clipped, and then scrubbed with Hibiclens soap for three minutes.  The patient was then prepped and draped in normal sterile fashion.  Foley catheter was inserted sterilely in the field.  Preoperative antibiotics were given within 30 minutes of skin incision.  A 10 cm lower abdominal incision was made from the symphysis pubis towards the umbilicus.  Dissection was taken down through Scarpa's fascia to the level of the anterior rectus sheath.  The rectus sheath was then incised and the muscle was split in the middle.  Space of rectus sheath was then entered.  The Bookwalter ring was then applied to the belly, and the bladder was then retracted to the right side, thus exposing the left obturator area.  The lymph node packet on the left side was then dissected.  This was done in a split and roll fashion with the flimsy tissue, and the left external iliac vein was incised, and the tissues were then rolled over the left external iliac vein.  Dissection was carried down from the left external iliac vein to the obturator nerve and up to the level of the pelvic sidewall.  The proximal extent of dissection was the left hypogastric artery to the level of the node of Cloquet distally.  Care was taken to avoid injury to the nerves.  An accessory obturator vein was noted and was ligated.  The same procedure was done on the right side with dissection of the right obturator lymph node packet, which was sent for pathologic evaluation.  The bladder subsequently was retracted cephalad.  The prostate was then defatted up to the level of the endopelvic fascia.  The endopelvic fascia was then incised bilaterally, and the incision was then taken to the level of the puboprostatic ligaments.  Vicryl stitch was then applied at the level of the bladder neck in order to control the bladder back bleeders.  A Babcock was then applied around the dorsal venous complex over the urethra and the K-wire was then passed between the dorsal vein complex and the urethra by passing by the aid of a right angle.  A 0-Vicryl stitch was then applied over the dorsal venous complex, which was then tied down and cinched to the symphysis pubis.  Using a knife on a long handle, the dorsal venous complex was then incised using the K-wire as a guide.  Following the incision of the dorsal venous complex, the anterior urethra was then incised, thus exposing the Foley catheter.  The 3-0 Monocryl sutures were then applied going outside in on the anterior aspect of the urethra.  The lateral edges of the urethra were also then incised, and two lateral stitches were also applied going outside end.  The catheter was then drawn back at the level of membranous urethra, and a final posterior stitch was applied going outside end.  The urethra was subsequently divided in its entirety.  A Foley catheter was then taken out and was inserted directly into the bladder through the prostatic apex.  The prostate was then entered cephalad, and the prostatic pedicles were then systematically taken down with the right angle clips and cut.  Please note that throughout the case, the patient was noted to have significant oozing and bleeding partially from the dorsal venous complex, pelvic veins, and extensive vascularity that was noted in the patient's pelvic fatty tissue.  Throughout the case, the bleeding was controlled with the aid of a clips, Vicryl sutures, silk sutures, and ties, direct pressure packing, and FloSeal.  Following the excision of the prostatic pedicles, the posterior dissection at this point was almost complete.  Please note that the dissection was relatively technically challenging due to extensive adhesions between the prostate and Denonvilliers' fascia.  The seminal vesicle on the left side was dissected in its entirety; however, the seminal vesicle on the right side was adherently stuck to the Denonvilliers' fascia, which prompted the excision of most of the right seminal vesicle with the exception of the tip.  Care was taken throughout the posterior dissection to preserve the integrity of the ureters.  The anterior bladder neck was then cut anteriorly, and the bladder neck was separated from the prostate.  Following the dissection, the 5-French feeding tubes were inserted bilaterally into the ureters thus insuring their integrity.  Following the dissection of the bladder from the prostate, the prostate at this point was mobile and was sent for pathological evaluation.  The bladder neck was then repaired using Vicryl in a tennis racquet fashion.  The rest of the mucosa was then everted.  The ureteral orifices and ureters were protected throughout the procedure.  At this point, the initial sutures that were applied into the urethra were then applied into the corresponding position on the bladder neck, and the bladder neck was then cinched down and tied down after a new Foley catheter was inserted through the penile meatus and into the bladder pulling the bladder in position.  Hemostasis was then adequately obtained.  FloSeal was applied to the pelvis.  The bladder was then irrigated.  It was draining pink urine.  The wound was copiously irrigated.  The fascia was then closed using a #1 looped PDS.  The skin wound was then irrigated, and the skin was closed with a 4-0 Monocryl in subcuticular fashion.  At this point, the procedure was terminated with no complications.  The patient was then extubated in the operating room and taken in stable condition to the PACU.  Please note that during the case about 3600 mL of blood was noted.  This was due to the persistent continuous oozing from vascular fatty tissue and pelvic veins as previously noted in the dictation.","urology, bilateral lymph node dissection, retropubic prostatectomy, radical retropubic prostatectomy, gleason score, prostate cancer, trus, biopsy, bilateral lymph node, lymph node dissection, catheter was inserted, bilateral lymph, node dissection, vicryl stitch, prostatic pedicles, pelvic veins, external iliac, iliac vein, seminal vesicle, lymph node, foley catheter, dorsal venous, venous complex, bladder neck, dissection, prostatectomy, bladder, endopelvic, vicryl, catheter, vein, venous, fascia, dorsal, urethra, "
 The patient returns for followup evaluation 21 months after undergoing prostate fossa irradiation for recurrent Gleason 8 adenocarcinoma.    Concerning slow ongoing rise in PSA., Urology, Prostate Fossa Irradiation - Followup ,"HISTORY OF PRESENT ILLNESS: , The patient returns for followup evaluation 21 months after undergoing prostate fossa irradiation for recurrent Gleason 8 adenocarcinoma.  His urinary function had been stable until 2 days ago.  Over the past couple of days he has been waking every 1 to 1-1/2 hours and has had associated abdominal cramping, as well as a bit of sore throat (his wife has had a cold for about 2 weeks).  His libido remains intact (but he has not been sexually functional), but his erections have been dysfunctional.  The bowel function is stable with occasional irritative hemorrhoidal symptoms.  He has had no hematochezia.  The PSA has been slowly rising in recent months.  This month it reached 1.2.,PAIN ASSESSMENT: , Abdominal cramping in the past 2 days.  No more than 1 to 2 of 10 in intensity.,PERFORMANCE STATUS: , Karnofsky score 100.  He continues to work full-time.,NUTRITIONAL STATUS: , Appetite has been depressed over the past couple of days, and he has lost about 5 pounds.  (Per him, mostly this week.),PSYCHIATRIC: , Some stress regarding upcoming IRS audits of clients.,REVIEW OF SYSTEMS: , Otherwise noncontributory.,MEDICATIONS,1.  NyQuil.,2.  Timolol eye drops.,3.  Aspirin.,4.  Advil.,5.  Zinc.,PHYSICAL EXAMINATION,GENERAL:  Pleasant, well-developed, gentleman in no acute distress.  Weight is 197 pounds.,HEENT:  Sclerae and conjunctivae are clear.  Extraocular movement are intact.  Hearing is grossly intact.  The oral cavity is without thrush.  There is minor pharyngitis.,LYMPH NODES:  No palpable lymphadenopathy.,SKELETAL:  No focal skeletal tenderness.,LUNGS:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  Regular rate and rhythm.,ABDOMEN:  Soft, nontender without palpable mass or organomegaly.,DIGITAL RECTAL EXAMINATION:  There are external hemorrhoids.  The prostate fossa is flat without suspicious nodularity.  There is no blood on the examining glove.,EXTREMITIES:  Without clubbing, cyanosis, or edema.,NEUROLOGIC:  Without focal deficit.,IMPRESSION:,  Concerning slow ongoing rise in PSA.,PLAN: , Discussed significance of this in detail with the patient.  He understands the probability that there may be residual cancer although the location is unknown.  For now there is no good evidence that early management affects the ultimate prognosis.  Accordingly, he is comfortable with careful monitoring, and I have asked him to return here in 3 months with an updated PSA.  I also suggested that he reestablish contact with Dr. X at his convenience.",
" Prostate gland showing moderately differentiated infiltrating adenocarcinoma - Excised prostate including capsule, pelvic lymph nodes, seminal vesicles, and small portion of bladder neck.", Urology, Prostate Adenocarcinoma - 4 ,"PHYSICAL EXAMINATION:,  Patient is a 46-year-old white male seen for annual physical exam and had an incidental PSA elevation of 4.0.  All other systems were normal.,PROCEDURES:  ,Sextant biopsy of the prostate.,Radical prostatectomy:  Excised prostate including capsule, pelvic lymph nodes, seminal vesicles, and small portion of bladder neck.,PATHOLOGY:,Prostate biopsy:  Right lobe, negative.  Left lobe, small focus of adenocarcinoma, Gleason's 3 + 3 in approximately 5% of the tissue.,Radical prostatectomy:  Negative lymph nodes.  Prostate gland showing moderately differentiated infiltrating adenocarcinoma, Gleason 3 + 2 extending to the apex involving both lobes of the prostate, mainly right.  Tumor overall involved less than 5% of the tissue.  Surgical margin was reported and involved at the apex.  The capsule and seminal vesicles were free.,DISCHARGE NOTE:,  Patient has made good post-op recovery other than mild urgency incontinence.  His post-op PSA is 0.1 mg/ml.","urology, capsule, bladder neck, surgical margin, moderately differentiated infiltrating adenocarcinoma, pelvic lymph nodes, prostate gland, infiltrating adenocarcinoma, radical prostatectomy, seminal vesicles, gleason's, seminal, vesicles, adenocarcinoma, prostate, "
" Moderately differentiated adenocarcinoma, 1+ enlarged prostate with normal seminal vesicles.", Urology, Prostate Adenocarcinoma - 3 ,"PHYSICAL EXAMINATION: , The patient is a 63-year-old executive who was seen by his physician for a company physical.  He stated that he was in excellent health and led an active life.  His physical examination was normal for a man of his age.  Chest x-ray and chemical screening blood work were within normal limits.  His PSA was elevated.,IMAGING:,Chest x-ray:  Normal.,CT scan of abdomen and pelvis:  No abnormalities.,LABORATORY:,  PSA 14.6.,PROCEDURES: , Ultrasound guided sextant biopsy of prostate:  Digital rectal exam performed at the time of the biopsy showed a 1+ enlarged prostate with normal seminal vesicles.,PATHOLOGY:  ,Prostate biopsy:  Left apex:  adenocarcinoma, moderately differentiated, Gleason's score 3 + 4 = 7/10.  Maximum linear extent in apex of tumor was 6 mm.  Left mid region prostate:  moderately differentiated adenocarcinoma, Gleason's 3 + 2 = 5/10.  Left base, right apex, and right mid-region and right base:  negative for carcinoma.,TREATMENT:,  The patient opted for low dose rate interstitial prostatic implants of I-125.  It was performed as an outpatient on 8/10.","urology, sextant biopsy, vesicles, seminal, apex, interstitial prostatic implants, moderately differentiated adenocarcinoma, normal seminal vesicles, enlarged prostate, gleason's, moderately, differentiated, prostate, adenocarcinoma "
 Patient presents to the Emergency Department with complaint of a bleeding bump on his penis., Urology, Penile Mass - Emergency Visit ,"CHIEF COMPLAINT: , ""Bloody bump on penis."",HISTORY OF PRESENT ILLNESS: , This is a 29-year-old African-American male who presents to the Emergency Department today with complaint of a bleeding bump on his penis.  The patient states that he has had a large bump on the end of his penis for approximately a year and a half.  He states that it has never bled before.  It has never caused him any pain or has never been itchy.  The patient states that he is sexually active, but has been monogamous with the same person for the past 13 years.  He states that he believes that his sexual partner is monogamous as well and reciprocates in this practice.  The patient does state that last night he was ""trying to get some,"" meaning that he was engaging in sexual intercourse, at which time this bump bent backwards and ripped a portion of the skin on the tip of his penis.  The patient said that there is a large amount of blood from this injury.  This happened last night, but he was embarrassed to come to the Emergency Department yesterday when it was bleeding.  The patient has been able to get the bleeding to stop, but the large bump is still located on the end of his penis, and he is concerned that it will rip off, and does want it removed.  The patient denies any drainage or discharge from his penis.  He denies fevers or chills recently.  He also denies nausea or vomiting.  The patient has not had any discharge from his penis.  He has not had any other skin lesions on his penis that are new to him.  He states that he has had numerous bumps along the head of his penis and on the shaft of his penis for many years.  The patient has never had these checked out.  He denies fevers, chills, or night sweats.  He denies unintentional weight gain or loss.  He denies any other bumps, rashes, or lesions throughout the skin on his body.,PAST MEDICAL HISTORY:  ,No significant medical problems.,PAST SURGICAL HISTORY: , Surgery for excision of a bullet after being shot in the back.,SOCIAL HABITS: , The patient denies illicit drug usage.  He occasionally smokes tobacco and drinks alcohol.,MEDICATIONS: , None.,ALLERGIES: , No known medical allergies.,PHYSICAL EXAMINATION:  ,GENERAL:  This is an African-American male who appears his stated age of 29 years.  He is well nourished, well developed, in no acute distress.  The patient is pleasant.  He is sitting on a Emergency Department gurney.,VITAL SIGNS:  Temperature 98.4 degrees Fahrenheit, blood pressure of 139/78, pulse of 83, respiratory rate of 18, and pulse oximetry of 98% on room air.,HEART:  Regular rate and rhythm.  Clear S1, S2.  No murmur, rub, or gallop is appreciated.,LUNGS:  Clear to auscultation bilaterally.  No wheezes, rales, or rhonchi.,ABDOMEN:  Soft, nontender, nondistended, and positive bowel sounds throughout.,GENITOURINARY:  The patient's external genitalia is markedly abnormal.  There is a large pedunculated mass dangling from the glans of the penis at approximately the urethral meatus.  This pedunculated mass is approximately 1.5 x 2 cm in size and pedunculated by a stalk that is approximately 2 mm in diameter.  The patient appears to have condylomatous changes along the glans of the penis and on the shaft of the penis as well.  There are no open lesions at this point.  There is a small tear of the skin where the mass attaches to the glans near the urethral meatus.  Bleeding is currently stanch, and there is no sign of secondary infection at this time.  Bilateral testicles are descended and normal without pain or mass bilaterally.  There is no inguinal adenopathy.,EXTREMITIES:  No edema.,SKIN:  Warm, dry, and intact.  No rash or lesion.,DIAGNOSTIC STUDIES:  ,Non-emergency department courses.  It is thought that this patient should proceed directly with a referral to Urology for excision and biopsy of this mass.,ASSESSMENT AND PLAN: , Penile mass.  The patient does have a large pedunculated penile mass.  He will be referred to the urologist who is on-call today.  The patient will need this mass excised and biopsied.  The patient verbalized understanding the plan of followup and is discharged in satisfactory condition from the ER.,","urology, bump on penis, bleeding bump, glans, urethral meatus, penile mass, emergency department, penis, penile, pedunculated, bump, mass, "
 Ex-plantation of inflatable penile prosthesis and then placement of second inflatable penile prosthesis AMS700.  Nonfunctioning inflatable penile prosthesis and Peyronie's disease., Urology, Penile Prosthesis Replacement ,"PREOPERATIVE DIAGNOSES:,1.  Nonfunctioning inflatable penile prosthesis.,2.  Peyronie's disease.,POSTOPERATIVE DIAGNOSES:,1.  Nonfunctioning inflatable penile prosthesis.,2.  Peyronie's disease.,PROCEDURE PERFORMED: , Ex-plantation of inflatable penile prosthesis and then placement of second inflatable penile prosthesis AMS700.,ANESTHESIA:,  General LMA.,SPECIMEN: , Old triple component inflatable penile prosthesis.,PROCEDURE:  ,This is a 64-year-old male with prior history of Peyronie's disease and prior placement of a triple component inflatable penile prosthesis, which had worked for years for him, but has stopped working and subsequently has opted for ex-plantation and replacement of inflatable penile prosthesis.,OPERATIVE PROCEDURE: , After informed consent, the patient was brought to the operative suite and placed in the supine position.  General endotracheal intubation was performed by the Anesthesia Department and the perineum, scrotum, penis, and lower abdomen from the umbilicus down was prepped and draped in the sterile fashion in a 15-minute prep including iodine solution in the urethra.  The bladder was subsequently drained with a red Robinson catheter.  At that point, the patient was then draped in a sterile fashion and an infraumbilical midline incision was made and taken down through the subcutaneous space.  Care was maintained to avoid all bleeding as possible secondary to the fact that we could not use Bovie cautery secondary to the patient's pacemaker and monopolar was only source of hemostasis besides suture.  At that point, we got down to the fascia and the dorsal venous complex was easily identified as were both corporal bodies.  Attention was taken then to the tubing, going up to the reservoir in the right lower quadrant.  This was dissected out bluntly and sharply with Metzenbaum scissors and monopolar used for hemostasis.  At this point, as we tracked this proximally to the area of the rectus muscle, we found that the tubing was violated and this was likely the source of his malfunctioned inflatable penile prosthesis.  As we tried to remove the tubing and get to the reservoir, the tubing in fact completely broke as due to wire inside the tubing and the reservoir was left in its place secondary to risk of going after it and bleeding without the use of cautery.  At that point, this tubing was then tracked down to the pump, which was fairly easily removed from the dartos pouch in the right scrotum.  This was brought up into _________ incision and the two tubings going towards the two cylinders were subsequently tracked, first starting on the right side where a corporotomy incision was made at the placement of two #3-0 Prolene stay ties, staying lateral and anterior on the corporal body.  The corporal body was opened up and the cylinder was removed from the right side without difficulty.  However, we did have significant difficulty separating the tube connecting the pump to the right cylinder since this was surrounded by dense connective tissue and without the use of Bovie cautery, this was very difficult and was very time consuming, but we were able to do this and attention was then taken to the left side where the left proximal corporotomy was made after placement of two stick tie stay sutures.  This was done anterior and lateral staying away from the neurovascular bundle in the midline and this was done proximally on the corporal body.  The left cylinder was then subsequently explanted and this was very difficult as well trying to tract the tubing from the left cylinder across the midline back to the right pump since this was also densely scarred in and _________ a small amount of bleeding, which was controlled with monopolar and cautery was used on three different occasions, but just simple small burst under the guidance of anesthesia and there was no ectopy noted.  After removal of half of the pump, all the tubing, and both cylinders, these were passed off the table as specimen.  Both corporal bodies were then dilated with the Pratt dilators.  These were already fairly well dilated secondary to explantation of our cylinders and antibiotic irrigation was copiously used at this point and irrigated out both of our corporal spaces.  At this point, using the Farlow device, corporal bodies were measured first proximally then distally and they both measured out to be 9 cm proximally and 12 cm distally.  He had an 18 cm with rear tips in place, which were removed.  We decided to go ahead to and use another 18 cm inflatable penile prosthesis.  Confident with our size, we then placed rear tips, originally 3 cm rear tips, however, we had difficulty placing the rear tips into the left crest.  We felt that this was just a little bit too long and replaced both rear tips and down sized from 2 cm to 1 cm.  At this point, we went ahead and placed the right cylinder using the Farlow device and the Keith needle, which was brought out through the glans penis and hemostated and the posterior rear tip was subsequently placed proximally, entered the crest without difficulty.  Attention was then taken to the left side with the same thing was carried out, however, we did happen to dilate on two separate occasions both proximally and distally secondary to a very snug fit as well as buckling of the cylinders.  This then forced us to down size to the 1 cm rear tips, which slipping very easily with the Farlow device through the glans penis.  There was no crossover and no violation of the tunica albuginea.  The rear tips were then placed without difficulty and our corporotomies were closed with #2-0 PDS in a running fashion.  ________ starting on the patient's right side and then on the left side without difficulty and care was maintained to avoid damage or needle injury to the implants.  At that point, the wound was copiously irrigated and the device was inflated multiple times.  There was a very good fit and we had a very good result.  At that point, the pump was subsequently placed in the dartos pouch, which already has been created and was copiously irrigated with antibiotic solution.  This was held in place with a Babcock as well not to migrate proximally and attention was then taken to our connection from the reservoir to the pump.  Please also note that before placement of our pump, attention was then taken up to the left lower quadrant where an incision was then made in external oblique aponeurosis, approximately 3 cm dissection down underneath the rectus space was developed for our reservoir device, which was subsequently placed without difficulty and three simple interrupted sutures of #2-0 Vicryl used to close the defect in the rectus and at that point after placement of our pump, the connection was made between the pump and the reservoir without difficulty.  The entire system pump and corporal bodies were subsequently flushed and all air bubbles were evacuated.  After completion of the connection using a straight connector, the prosthesis was inflated and we had very good results with air inflation with good erection in both cylinders with a very slight deviation to the left, but this was able to be ________ with good cosmetic result.  At that point, after irrigation again of the space, the area was simply dry and hemostatic.  The soft tissue was reapproximated to separate the cylinder so as not to lie in rope against one another and the wound was closed in multiple layers.  The soft tissue and the skin was then reapproximated with staples.  Please also note that prior to the skin closure, a Jackson-Pratt drain was subsequently placed through the left skin and left lower quadrant and subsequently placed just over tubings, would be left in place for approximately 12 to 20 hours.  This was also sutured in place with nylon.  Sterile dressing was applied.  Light gauze was wrapped around the penis and/or sutures that begin at the tip of the glans penis were subsequently cut and removed in entirety bilaterally.  Coban was used then to wrap the penis and at the end of the case the patient was straight catheted, approximately 400 cc of amber-yellow urine.  No Foley catheter was used or placed.,The patient was awoken in the operative suite, extubated, and transferred to recovery room in stable condition.  He will be admitted overnight to the service of Dr. McDevitt.  Cardiology will be asked to consult with Dr. Stomel for a pacer placement and he will be placed on the Telemetry floor and kept on IV antibiotics.","urology, inflatable penile prosthesis, peyronie's disease, perineum, scrotum, penis, penile prosthesis, bovie cautery, corporal body, glans penis, pump, cylinders, penile, prosthesis, inflatable, corporal"
 Excision of penile skin bridges about 2 cm in size., Urology, Penile Skin Bridges Excision  ,"PREOPERATIVE DIAGNOSIS: , Penile skin bridges after circumcision.,POSTOPERATIVE DIAGNOSIS: , Penile skin bridges after circumcision.,PROCEDURE:  ,Excision of penile skin bridges about 2 cm in size.,ABNORMAL FINDINGS:  ,Same as above.,ANESTHESIA:  ,General inhalation anesthetic with caudal block.,FLUIDS RECEIVED: , 300 mL of crystalloids.,ESTIMATED BLOOD LOSS: , Less than 5 mL.,SPECIMENS: , No tissue sent to Pathology.,TUBES AND DRAINS:,  No tubes or drains were used.,COUNT: , Sponge and needle counts were correct x2.,INDICATIONS FOR OPERATION:  ,The patient is a 2-1/2-year-old boy with a history of newborn circumcision who developed multiple skin bridges after circumcision causing curvature with erection.  Plan is for repair.,DESCRIPTION OF PROCEDURE: , The patient is taken to the operating room, where surgical consent, operative site, and the patient's identification was verified.  Once he was anesthetized, the caudal block was placed and IV antibiotics were given.  He was then placed in a supine position and sterilely prepped and draped.  Once he was prepped and draped, we used a straight mosquito clamp and went under the bridges and crushed them, and then excised them with a curved iris and curved tenotomy scissors.  We removed the excessive skin on the shaft skin and on the glans itself.  We then on the ventrum excised the bridge and did a Heinecke-Mikulicz closure with interrupted figure-of-eight and interrupted suture of 5-0 chromic.  Electrocautery was used for hemostasis.  Once this was done, we then used Dermabond tissue adhesive and Surgicel to prevent the bridges from returning again.  IV Toradol was given at the end of procedure.  The patient tolerated the procedure well, was in stable condition upon transfer to the recovery room.","urology, heinecke-mikulicz, penile skin bridges, caudal block, penile skin, skin bridges, excision, circumcision, penile, "
" Adenocarcinoma of the prostate.  The patient underwent a transrectal ultrasound and biopsy and was found to have a Gleason 3+4 for a score of 7, 20% of the tissue removed from the left base. ", Urology, Prostate Adenocarcinoma ,"ADMISSION DIAGNOSIS:  ,Adenocarcinoma of the prostate.,HISTORY:,  The patient is a 71-year-old male whose personal physician, Dr. X identified a change in the patient's PSA from 7/2008 (4.2) to 4/2009 (10.5).  The patient underwent a transrectal ultrasound and biopsy and was found to have a Gleason 3+4 for a score of 7, 20% of the tissue removed from the left base.  The patient also had Gleason 6 in the right lobe, midportion, as well as the left apical portion.  He underwent a bone scan which was normal and cystoscopy which was normal and renal ultrasound that was normal.,SURGICAL HISTORY: , Appendectomy.,MEDICAL HISTORY:,  Atrial fibrillation.,MEDICATIONS:,  Coumadin and lisinopril.,SOCIAL HISTORY:  ,Smokes none.  Alcohol none.,ALLERGIES:,  NONE.,REVIEW OF SYSTEMS: , The patient relates no recent weight gain, weight loss, night sweats, fevers or chills.  Eyes:  No change in vision or diplopia.  Ears:  No tinnitus or vertigo.  Mouth:  No dysphagia.  Pulmonary:  No chronic cough or shortness of breath.  Cardiac:  No angina or palpitations.  GI:  No nausea, vomiting, diarrhea or constipation.  Musculoskeletal:  No arthritides or myalgias.  Hematopoietic:  No easy bleeding or bruising.  Skin:  No chronic ulcers or persistent itch.,PHYSICAL EXAMINATION:,GENERAL:  The patient is well developed and well nourished.,HEENT:  Head is normocephalic.  Eyes, pupils are equal.  Conjunctivae are pink.  Sclerae are anicteric.,NECK:  There is no adenopathy.,PULMONARY:  Respirations are unlabored.,HEART:  Regular rhythm.,ABDOMEN:  Liver, spleen, kidney, and bladder are not palpable.  There are no discernible masses.  There are no peritoneal signs.,GENITALIA:  The penis has no plaques.  Meatus is on the glans.  Scrotal skin is healthy.  Testicles are fair consistency.  Epididymides are nontender.,RECTAL:  The prostate is +1 to 2/4.  There are no areas that are suspicious for tumor.  Consistency is even.  Sidewalls are sharp.  Seminal vesicles are not palpable.,MUSCULOSKELETAL:  The upper and lower extremities are symmetric bilaterally.,NEUROLOGIC:  There are no gross focal neurologic abnormalities.,IMPRESSION:,1.  Adenocarcinoma of the prostate.,2.  Atrial fibrillation.,PLAN: , The patient's wife and I have discussed his treatment options, which include primarily radiation and surgery.  He has _________ surviving prostate cancer by Dr. Y.  He is aware of incontinency, both total and partial.  We discussed erectile dysfunction.  We have discussed bleeding, infection, injury to the rectum, injury to vessels and nerves, deep vein thrombosis, pulmonary embolus, MI, stroke, and death.  He had no questions at the conclusion of the conversation and he does know that in his age group, though a nerve-sparing procedure will be performed, preserving any erectile function is highly unlikely.  He had no questions at the conclusion of our last conversation.",
" Complete urinary obstruction, underwent a transurethral resection of the prostate - adenocarcinoma of the prostate.", Urology, Prostate Adenocarcinoma - 1 ,"HISTORY:,  This 75-year-old man was transferred from the nursing home where he lived to the hospital late at night on 4/11 through the Emergency Department in complete urinary obstruction.  After catheterization, the patient underwent cystoscopy on 4/13.  On 4/14 the patient underwent a transurethral resection of the prostate and was discharged back to the nursing home later that day with voiding improved.  Final diagnosis was adenocarcinoma of the prostate.  Because of his mental status and general debility, the patient's family declined additional treatment.,LABORATORY:,  None,PROCEDURES:,Cystoscopy:  Blockage of the urethra by a markedly enlarged prostate.,Transurethral resection of prostate:  45 grams of tissue were sent to the Pathology Department for analysis.,PATHOLOGY: , Well differentiated adenocarcinoma, microacinar type, in 1 of 25 chips of prostatic tissue.","urology, urinary obstruction, voiding, resection of the prostate, adenocarcinoma of the prostate, complete urinary obstruction, prostate adenocarcinoma, transurethral resection, cystoscopy, transurethral, resection, prostate, adenocarcinoma,"
 Moderate to poorly differentiated adenocarcinoma in the right lobe and poorly differentiated tubular adenocarcinoma in the left lobe of prostate., Urology, Prostate Adenocarcinoma - 2 ,"PHYSICAL EXAMINATION:,  This 71-year-old man went to his primary care physician for a routine physical.  His only complaints were nocturia times two and a gradual ""slowing down"" feeling.  The physical examination on 1/29 was within normal limits except for the digital rectal exam which revealed an asymmetric prostate gland with nodularity, R>L.  PSA was elevated.  The differential diagnosis for the visit was abnormal prostate, suggestive of CA.,IMAGING:  ,CT pelvis:  Irregular indentation of bladder.  Seminal vesicles enlarged.  Streaky densities in periprostatic fat consistent with transcapular spread to periprostatic plexus.  Impression:  prostatic malignancy with extracapsular extension and probable regional node metastasis.,Bone scan:  Negative for distant metastasis.,LABORATORY:,  PSA 32.1,PROCEDURES:,  Transrectal needle biopsy of prostate.  Pelvic lymphadenectomy and radical prostatectomy.,PATHOLOGY:  ,Prostate biopsy:  Moderate to poorly differentiated adenocarcinoma in the right lobe and poorly differentiated tubular adenocarcinoma in the left lobe of prostate.,Lymphadenectomy and prostatectomy:  Frozen section of removed pelvic lymph nodes demonstrated metastatic adenocarcinoma in one lymph node in the right obturator fossa.  Therefore, the radical prostatectomy was canceled.  ,Final pathology diagnosis:  Pelvic lymphadenectomy; left obturator fossa, single negative lymph node.  Right obturator fossa; metastatic adenocarcinoma in 1/5 lymph nodes.  Largest involved node 1.5 cm.,TREATMENT: , Patient began external beam radiation therapy to the pelvis.","urology, nocturia, asymmetric prostate gland, periprostatic, metastasis, poorly differentiated adenocarcinoma, differentiated adenocarcinoma, radical prostatectomy, metastatic adenocarcinoma, lymph nodes, prostatectomy, prostate, lymphadenectomy, adenocarcinoma"
" Penile discharge, infected-looking glans.  A 67-year-old male with multiple comorbidities with penile discharge and pale-appearing glans. It seems that the patient has had multiple catheterizations recently and has history of peripheral vascular disease. ", Urology, Penile Discharge ,"CHIEF COMPLAINT: , Penile discharge, infected-looking glans.,HISTORY OF PRESENT ILLNESS: , The patient is a 67-year-old African-American male, who was recently discharged from the hospital on July 21, 2008 after being admitted for altered mental status and before that after undergoing right above knee amputation for wet gangrene.  The patient was transferred to Nursing Home and presents today from the nursing home with complaints of bleeding from the right AKA stump and penile discharge.  As per the patient during his hospitalizations over here, he had indwelling Foley catheter for a few days and when he was discharged at the nursing home he was discharged without the catheter.  However, the patient was brought back to the ED today when he suffered fall yesterday and started bleeding from his stump.  While placing the catheter in the ED on retraction of foreskin purulent discharge was seen from the penis and the glans appeared infected, so urology consult was placed.,REVIEW OF SYSTEMS: , Negative except as in the HPI.,PAST MEDICAL HISTORY: , Significant for end-stage renal disease on dialysis, hypertension, peripheral vascular disease, coronary artery disease, congestive heart failure, diabetes, and hyperlipidemia.,PAST SURGICAL HISTORY:  ,Right AKA,MEDICATIONS:,  Novolin, Afrin, Nephro-Vite, Neurontin, lisinopril, furosemide, Tums, labetolol, Plavix, nitroglycerin, Aricept, omeprazole, oxycodone, Norvasc, Renagel, and morphine.,ALLERGIES: , PENICILLIN and ADHESIVE TAPE.,FAMILY HISTORY: , Significant for hypertension, hyperlipidemia, diabetes, chronic renal insufficiency, and myocardial infarction.,SOCIAL HISTORY: , The patient lives alone.  He is unemployed, disabled.  He has history of tobacco use in the past.  He denies alcohol or drug abuse.,PHYSICAL EXAMINATION:,GENERAL:  A well-appearing African-American male lying comfortably in bed, in acute distress.,NECK:  Supple.,LUNGS:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  S1 and S2, normal.,ABDOMEN:  Soft, nondistended, and nontender.,GENITOURINARY:  Penis is not circumcised.  Currently, indwelling Foley catheter in place.  On retraction of the foreskin, pale-looking glans tip with areas of yellow-white tissue.  The proximal glans appeared pink.  The patient currently has indwelling Foley catheter and glans slightly tender to touch.  However, no purulent discharge was seen on compression of the glans.  Otherwise on palpation, no other deformity noticed.  Bilateral testes descended.  No palpable abnormality.  No evidence of infection in his perineal area.,EXTREMITIES:  Right AKA.,NEUROLOGIC:  Awake, alert, and oriented.  No sensory or motor deficit.,LABORATORY DATA: , I independently reviewed the lab work done on the patient.  The patient had a UA done in the ED which showed few bacteria, white blood cells 6 to 12, and a few epithelial cells which were negative.  His basic metabolic panel with creatinine of 7.2 and potassium of 5, otherwise normal.  CBC with a white blood cell count of 11.5, hemoglobin of 9.5, and INR of 1.13.,IMPRESSION: , A 67-year-old male with multiple comorbidities with penile discharge and pale-appearing glans.  It seems that the patient has had multiple catheterizations recently and has history of peripheral vascular disease.  I think it is due to chronic ischemic changes.,RECOMMENDATIONS: , Our recommendation would be:,1.  To remove the Foley catheter.,2.  Local hygiene.,3.  Local application of bacitracin ointment.,4.  Antibiotic for urinary tract infection.,5.  Follow up as needed.  Of note, it was explained to the patient that the appearance of this glans may improve or may get worsened but at this point, there is no indication to operate on him.  If increased purulent discharge, the patient was asked to call us sooner, otherwise follow up as scheduled.",
 Penile injury and continuous bleeding from a penile laceration., Urology, Penile Injury ,"REASON FOR ADMISSION:,  Penile injury and continuous bleeding from a penile laceration.,HISTORY OF PRESENT ILLNESS:,  The patient is an 18-year-old detainee who was brought by police officers because of a penile injury and bleeding.  He is otherwise healthy.  He tried to insert a marble in his penis four days ago.  He told me that he grabbed the skin on the top of the penis and moved it away from the penis shaft and then using a toothbrush that he made in to a knife object he pierced the skin through from both sides and then kept moving the toothbrush to dilate and make a way for the marble.  Then he inserted a heart-shaped marble in one of the puncture wounds and inserted it under the skin and kept it there.  He was not significantly bleeding and essentially the bleeding stopped from both puncture wounds that he has.  Then today four days after that procedure, he was taking a bath today and he thinks because of the weight he felt a gush in his pants and he looked and he saw the bleeding come out.  He was bleeding so much that he started dripping to the sides of his legs.  So, he was brought to the hospital.  Actually after being seen by two nurses at the facility where he was at the detention center where he was at and they actually did the dressing twice and it was twice soaked with blood.  He came here and was continuously bleeding from that area that we had to change the dressing twice and he is actually still bleeding especially from one of the laceration, the one on the right side of the penis.  The marble also still can be felt underneath the skin.  There is no urethral bleeding.  He did urinate today without difficulty, without hematuria or dysuria.  There is pain in the lacerations.  No erythema in the skin or swelling in the penis and no other injuries.  He did this procedure for sexual pleasure as he said.,PAST MEDICAL HISTORY: , Unremarkable.,PAST SURGICAL HISTORY:  ,Tonsillectomy.,MEDICATION: , He took only ibuprofen.  No regular medication.,ALLERGIES: , None.,SOCIAL HISTORY:  ,He has been in detention for two months for immigration problems.  No drugs.  No alcohol.  No smoking.  He used to work in fast food chain.,FAMILY HISTORY: , Noncontributory to this illness.,REVIEW OF SYSTEMS: , Aside from the pain in the penis and continuous bleeding, he is basically asymptomatic and review of systems is unremarkable.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a young Hispanic male, lying in bed, appear comfortable in no apparent distress.,VITAL SIGNS:  Temperature 97.8, heart rate 99, respiratory rate 20, blood pressure 142/100, and saturation is 98% on room air.,ENT:  Sclerae nonicteric.  Pupils reactive to light.  Nostrils are normal.  Oral cavity is clear.,NECK:  Supple.  Trachea midline.  No JVD.,LUNGS:  Clear to auscultation bilaterally.,HEART:  Normal S1 and S2.  No murmurs or gallops.,ABDOMEN:  Soft, nontender, and nondistended.  Positive bowel sounds.,EXTREMITIES:  Pulses strong bilaterally.  No edema.,GENITAL:  Testicles appear normal.  The penis shaft has two lacerations on both sides, one of them is bleeding.  They measure about 5 to 6 mm on the right side, about 3 or 4 mm on the left side.  The one on the right side is bleeding much more than the other one.  There is a marble that can be felt and it is freely mobile underneath the skin of the dorsum of the penis.  There is no bleeding from the meatus or discharge and no other injuries were seen by inspection.,LABORATORY DATA:,  White count 11.1, hemoglobin 14.5, hematocrit 43.5, and platelets 303,000.  Coags unremarkable.  Glucose 106, creatinine 0.8, sodium 141, potassium 4, and calcium 9.7.  Urinalysis unremarkable.,IMPRESSION: , The patient with a penile laceration that is continuously bleeding from inserting a marble four days ago, which is still underneath the skin of the shaft of the penis.  No other injuries that can be seen and no other evidence of secondary bacterial infection at this time.  The patient is currently refusing removal of the marble and insisting on just repairing the laceration and he is having discussion with Dr. X.,PLAN:,1.  The patient will be admitted to the hospital and will follow Dr. X's recommendation.,2.  The patient was offered a repair of those lacerations, to stop the bleeding as well as the removal of the marble and he is currently considering that and discussing that with Dr. X.,3.  Prophylactic antibiotics to prevent infection.,4.  He has mild hypertension, which is likely due to stress and pain and also the leukocytosis probably can be explained by that.  This will be monitored.,5.  Monitor H&H to determine if he needs any transfusion at this time.  He does not need that.,6.  IV fluid for hydration and volume resuscitation at this time.,7.  Pain management.,8.  Topical care for the wound VAC after repair.,Time spent in evaluation and management of this patient including discussions about this procedure and the harm that can happen if he chooses to keep the penis including permanent damage and infection to the penis was 65 minutes.,I had clearly explained to the patient in detail about the possibility of permanent penile damage that could affect erection and future sexual functioning as well as significant infection if a foreign object was retained in the penis under the skin and he verbalized understanding of this.",
" The patient is a 16-month-old boy, who had a circumcision performed approximately 4 days before he developed penile swelling and fever and discharge. ", Urology, Penile Cellulitis ,"CHIEF COMPLAINT:  ,Penile cellulitis status post circumcision.,HISTORY OF PRESENT ILLNESS: , The patient is a 16-month-old boy, who had a circumcision performed approximately 4 days before he developed penile swelling and fever and discharge.  The child initially had a newborn circumcision at about 1 week of life and then developed a concealed or buried penis with extra skin and tightness of the skin.  He underwent a second circumcision with a general anesthetic approximately 8 to 9 days ago.  The mother states that on Thursday, he developed fairly significant swelling, scrotum was also swollen, the suprapubic region was swollen, and he was having a purulent discharge and a fairly significant fever to 102 to 103.  He was seen at Hospital, transferred to Children's Hospital for further care.  Since being hospitalized, his cultures apparently have grown Staph but is unknown yet whether it is methicillin-resistant.  He has been placed on clindamycin, and he is now currently afebrile and with marked improvement according to the mother.  I was requested a consultation by Dr. X because of the appearance of penis.  The patient has been voiding without difficulty throughout.,PAST MEDICAL HISTORY: , The patient has no known allergies.  He was a term delivery via vaginal delivery.  Surgeries; he has had 2 circumcisions.  No other hospitalizations.  He has had no heart murmurs, seizures, asthma, or bronchitis.,REVIEW OF SYSTEMS: , A 14-point review of systems was negative with the exception of the penile and scrotal cellulitis and the surgeries as mentioned.  He also had an ear infection about 1 to 2 weeks before his circumcision.,SOCIAL HISTORY: , The patient lives with both parents and no siblings.  There are smokers at home.,MEDICATIONS: , Clindamycin and bacitracin ointment.  Also Bactrim.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Weight is 14.9 kg.,GENERAL:  The patient was sleepy but easily arousable.,HEAD AND NECK:  Grossly normal.  His neck and chest are without masses.,NARES:  He had some crusted nares; otherwise, no other discharge.,LUNGS:  Clear.,CARDIAC:  Without murmurs or gallops.,ABDOMEN:  Soft without masses or tenderness.,GU:  He has a fairly prominent suprapubic fat pad, and he is quite a large child in any event; however, there were no signs of erythema.  There was some induration around the penis; however, there were no signs of active infection.  He has a buried appearance of the penis after recent circumcision with a normal appearing glans.  The tissue itself, however, was quite dull and is soft or readily retractable at this time.  The scrotum was normal, and there was no erythema, there was no tenderness.  Both testes were descended without hydroceles.,EXTREMITIES:  He has full range of motion of all 4 extremities.,SKIN:  Warm, pink, and dry.,NEUROLOGIC:  Grossly intact.,BACK:  Normal.,IMPRESSION/PLAN: , The patient had a recent circumcision with a fairly prominent suprapubic fat pad but also has a penile and suprapubic cellulitis.  This is being treated, but it is most likely Staph and pending sensitivities.  I talked to the mother and told her that at this point the swelling that is present is a mixture of the resolving cellulitis from a suprapubic fat pad.  I recommended that he be treated most likely with Bactrim for a 10-day course at home, bacitracin, or some antibiotics ointment to the penis with each diaper change for the next 2 to 3 weeks with sitz bath once or twice a day.  I told the mother that initially the tissues are going to be quite dull because of the infection and the recent surgery, but she ultimately will have to gently retract the skin to keep it from adhering again because of the prominent suprapubic fat pad, which makes it more likely.  Otherwise, it is a fairly healthy-appearing tissue at the present time and she knows the reasons that he cannot be discharged once the hospitalist service believes that it is appropriate to do so.  He has a scheduled followup appointment with his urologist  and he should keep that appointment or followup sooner if there is any other problem arising.","urology, newborn circumcision, suprapubic fat pad, penile cellulitis, penile swelling, cellulitis, penis, penile, suprapubic, circumcision, "
" He continues to have abdominal pain, and he had a diuretic renal scan, which indicates no evidence of obstruction and good differential function bilaterally. ", Urology, Pediatric Urology Letter ,"XYZ, M.D. ,Suite 123, ABC Avenue ,City, STATE 12345 ,RE:  XXXX, XXXX ,MR#:  0000000,Dear Dr. XYZ: ,XXXX was seen in followup in the Pediatric Urology Clinic.  I appreciate you speaking with me while he was in clinic.  He continues to have abdominal pain, and he had a diuretic renal scan, which indicates no evidence of obstruction and good differential function bilaterally. ,When I examined him, he seems to indicate that his pain is essentially in the lower abdomen in the suprapubic region; however, on actual physical examination, he seems to complain of pain through his entire right side.  His parents have brought up the question of whether this could be gastrointestinal in origin and that is certainly an appropriate consideration.  They also feel that since he has been on Detrol, his pain levels have been somewhat worse, and so, I have given them the option of stopping the Detrol initially.  I think he should stay on MiraLax for management of his bowels.  I would also suggest that he be referred to Pediatric Gastroenterology for evaluation.  If they do not find any abnormalities from a gastrointestinal perspective, then the next step would be to endoscope his bladder and then make sure that he does not have any evidence of bladder anatomic abnormalities that is leading to this pain. ,Thank you for following XXXX along with us in Pediatric Urology Clinic.  If you have any questions, please feel free to contact me. ,Sincerely yours,","urology, differential function, diuretic renal scan, abdominal pain, renal scan, pediatric urology, "
 Prostate adenocarcinoma and erectile dysfunction - Pathology report., Urology, Pathology - Prostate ,"SPECIMENS:,1.  Pelvis-right pelvic obturator node.,2.  Pelvis-left pelvic obturator node.,3.  Prostate.,POST-OPERATIVE DIAGNOSIS: , Adenocarcinoma of prostate, erectile dysfunction.,DIAGNOSTIC OPINION:,1.  Adenocarcinoma, Gleason score 9, with tumor extension to periprostatic tissue, margin involvement, and tumor invasion to seminal vesicle, prostate.,2.  No evidence of metastatic carcinoma, right pelvic obturator lymph node.,3.  Metastatic adenocarcinoma, left obturator lymph node; see description.,CLINICAL HISTORY: , None listed.,GROSS DESCRIPTION:,Specimen #1 labeled ""right pelvic obturator lymph nodes"" consists of two portions of adipose tissue measuring 2.5 x 1x 0.8 cm and 2.5 x 1x 0.5 cm.  There are two lymph nodes measuring 1 x 0.7 cm and 0.5 x 0.5 cm.  The entire specimen is cut into several portions and totally embedded.,Specimen #2 labeled ""left pelvic obturation lymph nodes"" consists of an adipose tissue measuring 4 x 2 x 1 cm.  There are two lymph nodes measuring 1.3 x 0.8 cm and 1 x 0.6 cm.  The entire specimen is cut into 1 cm.  The entire specimen is cut into several portions and totally embedded.,Specimen #3 labeled ""prostate"" consists of a prostate.  It measures 5 x 4.5 x 4 cm.  The external surface shows very small portion of seminal vesicles attached in both sides with tumor induration.  External surface also shows tumor induration especially in right side.  External surface is stained with green ink.  The cut surface shows diffuse tumor induration especially in right side.  The tumor appears to extend to excision margin.  Multiple representative sections are made.,MICROSCOPIC DESCRIPTION:,Section #1 reveals lymph node.  There is no evidence of metastatic carcinoma.,Section #2 reveals lymph node with tumor metastasis in section of large lymph node as well as section of small lymph node.,Section #3 reveals adenocarcinoma of prostate.  Gleason's score 9 (5+4).  The tumor shows extension to periprostatic tissue as well as margin involvement.  Seminal vesicle attached to prostate tissue shows tumor invasion.  Dr. XXX reviewed the above case.  His opinion agrees with the above diagnosis.,SUMMARY:,A.  Adenocarcinoma of prostate, Gleason's score 9, with both lobe involvement and seminal vesicle involvement (T3b).,B.  There is lymph node metastasis (N1).,C.  Distant metastasis cannot be assessed (MX).,D.  Excision margin is positive and there is tumor extension to periprostatic tissue.","urology, pelvic obturator node, erectile dysfunction, seminal vesicle, prostate, lymph node, specimen, section, adenocarcinoma of prostate, pelvic obturator, tumor, lymph, node, specimens, adenocarcinoma, "
 Right undescended testicle.  Orchiopexy & Herniorrhaphy., Urology, Orchiopexy & Herniorrhaphy - 1 ,"PREOPERATIVE DIAGNOSIS:,  Right undescended testicle.,POSTOPERATIVE DIAGNOSIS:,  Right undescended testicle.,OPERATIONS:,1.  Right orchiopexy.,2.  Right herniorrhaphy.,ANESTHESIA: , LMA.,ESTIMATED BLOOD LOSS: , Minimal.,SPECIMEN: , Sac.,BRIEF HISTORY: , This is a 10-year-old male who presented to us with his mom with consultation from Craig Connor at Cottonwood with right undescended testis.  The patient and mother had seen the testicle in the right hemiscrotum in the past, but the testicle seemed to be sliding.  The testis was identified right at the external inguinal ring.  The testis was unable to be brought down into the scrotal sac.  The patient could have had sliding testicle in the past and now the testis has become undescended as the child has grown.  Options such as watchful waiting and wait for puberty to stimulate the descent of the testicle, HCG stimulation, orchiopexy were discussed.  Risk of anesthesia, bleeding, infection, pain, hernia, etc. were discussed.  The patient and parents understood and wanted to proceed with right orchiopexy and herniorrhaphy.,PROCEDURE IN DETAIL: , The patient was brought to the OR, anesthesia was applied.  The patient was placed in supine position.  The patient was prepped and draped in the inguinal and scrotal area.  After the patient was prepped and draped, an inguinal incision was made on the right side about 1 cm away for the anterior superior iliac spine going towards the external ring over the inguinal canal.  The incision came through the subcutaneous tissue and external oblique fascia was identified.  The external oblique fascia was opened sharply and was taken all the way down towards the external ring.  The ilioinguinal nerve was identified right underneath the external oblique fascia, which was preserved and attention was drawn throughout the entire case to ensure that it was not under any tension or pinched or got hooked in the suture.  After dissecting proximally, the testis was identified in the distal end of the inguinal canal.  The testis was pulled up.  The cremasteric muscle was divided and dissection was carried all the way up to the internal inguinal ring.  There was very small hernia, which was removed and was tied at the base.  PDS suture was used to tie this hernia sac all the way up to the base.  There was a Y right at the vas and cord indicating there was enough length into the scrotal sac.  The testis was easily brought down into the scrotal sac.  One centimeter superior scrotal incision was made and a Dartos pouch was created.  The testicle was brought down into the pouch and was placed into the pouch.  Careful attention was done to ensure that there was no torsion of the cord.  The vas was medial all the way throughout and the cord was lateral all the way throughout.  The epididymis was in the posterolateral location.  The testicle was pexed using 4-0 Vicryl into the scrotal sac.  Skin was closed using 5-0 Monocryl.  The external oblique fascia was closed using 2-0 PDS.  Attention was drawn to re-create the external inguinal ring.  A small finger was easily placed in the external inguinal ring to ensure that there was no tightening of the cord.  Marcaine 0.25% was applied, about 15 mL worth of this was applied for local anesthesia.  After closing the external oblique fascia, the Scarpa was brought together using 4-0 Vicryl and the skin was closed using 5-0 Monocryl in subcuticular fashion.  Dermabond and Steri-Strips were applied.,The patient was brought to recovery room in stable condition at the end of the procedure.,Please note that the testicle was viable.  It was smaller than the other side, probably by 50%.  There were no palpable testicular masses.  Plan was for the patient to follow up with us in about 1 month.  The patient was told not to do any heavy lifting for at least 3 months, okay to shower in 48 hours.  No tub bath for 2 months.  The patient and family understood all the instructions.","urology, undescended testicle, orchiopexy & herniorrhaphy, external oblique fascia, inguinal ring, scrotal sac, oblique fascia, testicle, herniorrhaphy, orchiopexy, inguinal"
 Overactive bladder with microscopic hematuria., Urology, Overactive Bladder ,"REASON FOR VISIT: , Overactive bladder with microscopic hematuria.,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old noted to have microscopic hematuria with overactive bladder.  Her cystoscopy performed was unremarkable.  She continues to have some episodes of frequency and urgency mostly with episodes during the day and rare at night.  No gross hematuria, dysuria, pyuria, no other outlet obstructive and/or irritative voiding symptoms.  The patient had been previously on Ditropan and did not do nearly as well.  At this point, what we will try is a different medication.  Renal ultrasound is otherwise unremarkable, notes no evidence of any other disease.,IMPRESSION: , Overactive bladder with microscopic hematuria most likely some mild atrophic vaginitis is noted.  She has no other significant findings other than her overactive bladder, which had continued.  At this juncture what I would like to do is try a different anticholinergic medication.  She has never had any side effects from her medication.,PLAN: , The patient will discontinue Ditropan.  We will start Sanctura XR and we will follow up as scheduled.  Otherwise we will continue to follow her urinalysis over the next year or so.","urology, overactive bladder with microscopic hematuria, irritative voiding symptoms, anticholinergic, microscopic hematuria, overactive bladder, ditropan, microscopic, hematuria, bladder, overactive"
 Reduction of paraphimosis., Urology, Paraphimosis ,"PREOPERATIVE DIAGNOSIS: , Phimosis.,POSTOPERATIVE DIAGNOSIS: , Phimosis.,PROCEDURE: , Reduction of paraphimosis.,ANESTHESIA:  ,General inhalation anesthetic with 0.25% Marcaine, penile block and ring block about 20 mL given.,FLUIDS RECEIVED: , 100 mL.,SPECIMENS:,  No tissues sent to pathology.,COUNTS: , Sponge and needle counts were not necessary.,TUBES/DRAINS: , No tubes or drains were used.,FINDINGS: , Paraphimosis with moderate swelling.,INDICATIONS FOR OPERATION: , The patient is a 15-year-old boy who had acute alcohol intoxication had his foreskin retracted with a Foley catheter placed at another institution.  When they removed the catheter they forgot to reduce the foreskin and he developed paraphimosis.  The plan is for reduction.,DESCRIPTION OF OPERATION: , The patient was taken to the operating room where surgical consent, operative site, and patient identification were verified.  Once he was anesthetized, with manual pressure and mobilization of the shaft skin we were able to reduce the paraphimosis.  Using Betadine and alcohol cleanse, we then did a dorsal penile block and a ring block by surgeon with 0.25% Marcaine, 20 mL were given.  He did quite well after the procedure and was transferred to the recovery room in stable condition.","urology, dorsal penile block, reduction of paraphimosis, penile block, phimosis, paraphimosis,"
" Left inguinal hernia repair, left orchiopexy with 0.25% Marcaine, ilioinguinal nerve block and wound block at 0.5% Marcaine plain.", Urology, Orchiopexy & Hernia Repair ,"PREOPERATIVE DIAGNOSIS: , Left undescended testis.,POSTOPERATIVE DIAGNOSIS:,  Left undescended testis plus left inguinal hernia.,PROCEDURES:,  Left inguinal hernia repair, left orchiopexy with 0.25% Marcaine, ilioinguinal nerve block and wound block at 0.5% Marcaine plain.,ABNORMAL FINDINGS:,  A high left undescended testis with a type III epididymal attachment along with vas.,ESTIMATED BLOOD LOSS:,  Less than 5 mL.,FLUIDS RECEIVED:  ,1100 mL of crystalloid.,TUBES/DRAINS: , No tubes or drains were used.,COUNTS:,  Sponge and needle counts were correct x2.,SPECIMENS,:  No tissues sent to Pathology.,ANESTHESIA:,  General inhalational anesthetic.,INDICATIONS FOR OPERATION: , The patient is an 11-1/2-year-old boy with an undescended testis on the left.  The plan is for repair.,DESCRIPTION OF OPERATION:,  The patient was taken to the operating room, where surgical consent, operative site, and patient identification were verified.  Once he was anesthetized, he was then placed in a supine position, and sterilely prepped and draped.  A superior curvilinear scrotal incision was then made in the left hemiscrotum with a 15-blade knife and further extended with electrocautery into the subcutaneous tissue.  We then used the curved cryoclamp to dissect into the scrotal space and found the tunica vaginalis and dissected this up to the external ring.  We were able to dissect all the way up to the ring, but were unable to get the testis delivered.  We then made a left inguinal incision with a 15-blade knife, further extending with electrocautery through Scarpa fascia down to the external oblique fascia.  The testis again was not visualized in the external ring, so we brought the sac up from the scrotum into the inguinal incision and then incised the external oblique fascia with a 15-blade knife further extending with Metzenbaum scissors.  The testis itself was quite high up in the upper canal.  We then dissected the gubernacular structures off of the testis, and also, then opened the sac, and dissected the sac off and found that he had a communicating hernia hydrocele and dissected the sac off with curved and straight mosquitos and a straight Joseph scissors.  Once this was dissected off and up towards the internal ring, it was twisted upon itself and suture ligated with an 0 Vicryl suture.  We then dissected the lateral spermatic fascia, and then, using blunt dissection, dissected in the retroperitoneal space to get more cord length.  We also dissected the sac from the peritoneal reflection up into the abdomen once it had been tied off.  We then found that we had an adequate amount of cord length to get the testis in the mid-to-low scrotum.  The patient was found to have a type III epididymal attachment with a long looping vas, and we brought the testis into the scrotum in the proper orientation and tacked it to mid-to-low scrotum with a 4-0 chromic stay stitch.  The upper aspect of the subdartos pouch was closed with a 4-0 chromic pursestring suture.  The testis was then placed into the scrotum in the proper orientation.  We then placed the local anesthetic, and the ilioinguinal nerve block, and placed a small amount in both incisional areas as well.  We then closed the external oblique fascia with a running suture of 0-Vicryl ensuring that the ilioinguinal nerve and cord structures were not bottom closure.  The Scarpa fascia was closed with a 4-0 chromic suture, and the skin was closed with a 4-0 Rapide subcuticular closure.  Dermabond tissue adhesive was placed on the both incisions, and IV Toradol was given at the end of the procedure.  The patient tolerated the procedure well, was in a stable condition upon transfer to the recovery room.","urology, inguinal hernia repair, ilioinguinal nerve block, external oblique fascia, hernia repair, epididymal attachment, external ring, inguinal incision, scarpa fascia, cord length, inguinal hernia, nerve block, ilioinguinal nerve, undescended testis, testis, inguinal, fascia, hernia, dissected, "
 Right orchiopexy and right inguinal hernia repair., Urology, Orchiopexy & Hernia Repair - 1 ,"PREOPERATIVE DIAGNOSIS: , Right undescended testis (ectopic position).,POSTOPERATIVE DIAGNOSES:,  Right undescended testis (ectopic position), right inguinal hernia.,PROCEDURES: , Right orchiopexy and right inguinal hernia repair.,ANESTHESIA:,  General inhalational anesthetic with caudal block.,FLUIDS RECEIVED:  ,100 mL of crystalloids.,ESTIMATED BLOOD LOSS: , Less than 5 mL.,SPECIMENS:,  No tissues sent to pathology.,TUBES AND DRAINS: , No tubes or drains were used.,INDICATIONS FOR OPERATION:  ,The patient is an almost 4-year-old boy with an undescended testis on the right; plan is for repair.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operating room; surgical consent, operative site, and patient identification were verified.  Once he was anesthetized, a caudal block was placed.  He was then placed in the supine position and sterilely prepped and draped.  Since the testis was in the ectopic position, we did an upper curvilinear scrotal incision with a 15-blade knife and further extended it with electrocautery.  Electrocautery was also used for hemostasis.  A subdartos pouch was then created with a curved tenotomy scissors.  The tunica vaginalis was grasped with a curved mosquito clamp and then dissected from its gubernacular attachments.  As we were dissecting it, we then found the testis itself into the sac, and we opened the sac, and it was found to be slightly atrophic about 12 mm in length and had a type III epididymal attachment, not being attached to the top.  We then dissected the hernia sac off of the testis __________ some traction using the straight Joseph scissors and straight and curved mosquito clamps.  Once this was dissected off, we then twisted it upon itself, and then dissected it down towards the external ring, but on traction.  We then twisted it upon itself, suture ligated it with 3-0 Vicryl and released it, allowing it to spring back into the canal.  Once this was done, we then had adequate length of the testis into the scrotal sac.  Using a curved mosquito clamp, we grasped the base of the scrotum internally, and using the subcutaneous tissue, we tacked it to the base of the testis using a 4-0 chromic suture.  The testis was then placed into the scrotum in the proper orientation.  The upper aspect of the pouch was closed with a pursestring suture of 4-0 chromic.  The scrotal skin and dartos were then closed with subcutaneous closure of 4-0 chromic, and Dermabond tissue adhesive was used on the incision.  IV Toradol was given.  Both testes were well descended in the scrotum at the end of the procedure.","urology, ectopic position, inguinal hernia, inguinal hernia repair, hernia sac, tunica vaginalis, gubernacular attachments, testis ectopic position, curved mosquito clamp, caudal block, hernia repair, undescended testis, orchiopexy, dissected, hernia, inguinal, testis,"
 Bilateral orchiopexy.  This 8-year-old boy has been found to have a left inguinally situated undescended testes.  Ultrasound showed metastasis to be high in the left inguinal canal.  The right testis is located in the right inguinal canal on ultrasound and apparently ultrasound could not be displaced into the right hemiscrotum., Urology, Orchiopexy - Bilateral ,"PREOPERATIVE DIAGNOSIS:  ,Bilateral undescended testes.,POSTOPERATIVE DIAGNOSIS: , Bilateral undescended testes.,OPERATION PERFORMED: , Bilateral orchiopexy.,ANESTHESIA: , General.,HISTORY: , This 8-year-old boy has been found to have a left inguinally situated undescended testes.  Ultrasound showed metastasis to be high in the left inguinal canal.  The right testis is located in the right inguinal canal on ultrasound and apparently ultrasound could not be displaced into the right hemiscrotum.  Both testes appeared to be normal in size for the boy's age.,OPERATIVE FINDINGS: , As above, both testes appeared viable and normal in size, no masses.  There is a hernia on the left side.  The spermatic cord was quite short on the left and required Prentiss Maneuver to achieve adequate length for scrotal placement.,OPERATIVE PROCEDURE: , The boy was taken to the operating room, where he was placed on the operating table.  General anesthesia was administered by Dr. X, after which the boy's lower abdomen and genitalia were prepared with Betadine and draped aseptically.  A 0.25% Marcaine was infiltrated subcutaneously in the skin crease in the left groin in the area of the intended incision.  An inguinal incision was then made through this area, carried through the subcutaneous tissues to the anterior fascia.  External ring was exposed with dissection as well.  The fascia was opened in direction of its fibers exposing the testes, which lay high in the canal.  The testes were freed with dissection by removing cremasteric and spermatic fascia.  The hernia sac was separated from the cord, twisted and suture ligated at the internal ring.  Lateral investing bands of the spermatic cords were divided high into the inguinal internal ring.  However, this would only allow placement of the testes in the upper scrotum with some tension.,Therefore, the left inguinal canal was incised and the inferior epigastric artery and vein were ligated with #4-0 Vicryl and divided.  This maneuver allowed for placement of the testes in the upper scrotum without tension.,A sub dartos pouch was created by separating the abdominal fascia from the scrotal skin after making an incision in the left hemiscrotum in the direction of the vessel.  The testes were then brought into the pouch and anchored with interrupted #4-0 Vicryl sutures.  The skin was approximated with interrupted #5-0 chromic catgut sutures.  Inspection of the spermatic cord in the inguinal area revealed no twisting and the testicular cover was good.  Internal oblique muscle was approximated to the shelving edge and Poupart ligament with interrupted #4-0 Vicryl over the spermatic cord and the external oblique fascia was closed with running #4-0 Vicryl suture.  Additional 7 mL of Marcaine was infiltrated subfascially and the skin was closed with running #5-0 subcuticular after placing several #4-0 Vicryl approximating sutures in the subcutaneous tissues.,Attention was then turned to the opposite side, where an orchiopexy was performed in a similar fashion.  However, on this side, there was no inguinal hernia.  The testes were located in a superficial pouch of the inguinal canal and there was adequate length on the spermatic cord, so that the Prentiss maneuver was not required on this side.  The sub dartos pouch was created in a similar fashion and the wounds were closed similarly as well.,The inguinal and scrotal incisions were cleansed after completion of the procedure.  Steri-Strips and Tegaderm were applied to the inguinal incisions and collodion to the scrotal incision.  The child was then awakened and transported to post-anesthetic recovery area apparently in satisfactory condition.  Instrument and sponge counts were correct.  There were no apparent complications.  Estimated blood loss was less than 20 to 30 mL.","urology, bilateral orchiopexy, bilateral undescended testes, prentiss maneuver, subcutaneous tissues, internal ring, dartos pouch, scrotal incisions, undescended testes, spermatic cord, inguinal canal, testes, inguinally, orchiopexy, undescended, cord, vicryl, ultrasound, spermatic, canal,"
" Examination under anesthesia, diagnostic laparoscopy, right orchiectomy, and left testis fixation.", Urology, Orchiectomy & Testis Fixation ,"PREOPERATIVE DIAGNOSIS:,  Nonpalpable right undescended testis.,POSTOPERATIVE DIAGNOSIS: , Nonpalpable right undescended testis with atrophic right testis.,PROCEDURES: , Examination under anesthesia, diagnostic laparoscopy, right orchiectomy, and left testis fixation.,ANESTHESIA:  ,General inhalation anesthetic with caudal block.,FLUID RECEIVED:  ,250 mL of crystalloids.,ESTIMATED BLOOD LOSS: , Less than 5 mL.,SPECIMEN:,  The tissue sent to Pathology was right testicular remnant.,ABNORMAL FINDINGS:,  Closed ring on right with atrophic vessels going into the ring and there was obstruction at the shoulder of the ring.  Left had open appearing ring but the scrotum was not filled and vas and vessels going into the ring.,INDICATIONS FOR OPERATION: , The patient is a 2-year-old boy with a right nonpalpable undescended testis.  The plan is for evaluation and repair.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operating room, where surgical consent, operative site, and patient identification were verified.  Once he was anesthetized, a caudal block was placed.  The patient was placed in supine position and examined.  The left testis well within scrotum.  The right was again not palpable despite the patient being asleep with multiple attempts to check.,The patient was then sterilely prepped and draped.  An 8-French feeding tube was then placed within his bladder through the urethra and attached to the drainage.  We then incised the infraumbilical area once he was sterilely prepped and draped, with 15 blade knife, then using Hasson technique with stay stitches in the anterior and posterior rectus fascia sheath of 3-0 Monocryl.  We entered the peritoneum with the 5-mm one-step system.  We then used the short 0-degree lens for laparoscopy.  We then insufflated with carbon dioxide insufflation to pressure of 12 mmHg.  There was no bleeding noted upon evaluation of the abdomen and again the findings were as mentioned with closed ring with vas and vessels going to the left and vessels and absent vas on the right where the closed ring was found.  Because there was no testis found in the abdomen, we then evacuated the gas and closed the fascial sheath with the 3-0 Monocryl tacking sutures.  Then skin was closed with subcutaneous closure of 4-0 Rapide.  A curvilinear upper scrotal incision was made on the right with 15 blade knife and carried down through the subcutaneous tissue with electrocautery.  Electrocautery was used for hemostasis.  A curved tenotomy scissor was used to open the sac.  The tunica vaginalis was visualized and grasped and then dissected up towards external ring.  There was no apparent testicular tissue.  We did remove it, however, tying off the cord structure with a 4-0 Vicryl suture and putting a tagging suture at the base of the tissue sent.  We then closed the subdartos area with the subcutaneous closure of 4-0 chromic.  We then did a similar curvilinear incision on the left side for testicular fixation.  Delivered the testis into the field, which had a type III epididymal attachment and was indeed about 3 to 4 mL in size, which was larger than expected for the patient's age.  We then closed the upper aspect of the subdartos pouch with the 4-0 chromic pursestring suture and placed testis back into the scrotum in the proper orientation and closed the dartos, skin, and subcutaneous closure with 4-0 chromic on left hemiscrotum.  At the end of the procedure, the patient received IV Toradol and had Dermabond tissue adhesive placed on both incisions and left testis was well descended in the scrotum at the end of the procedure.  The patient tolerated procedure well, and was in stable condition upon transfer to the recovery room.","urology, diagnostic laparoscopy, caudal block, testis fixation, undescended testis, subcutaneous closure, testis, orchiectomy, laparoscopy, testicular, scrotum"
 Orchiopexy & inguinal herniorrhaphy., Urology, Orchiopexy & Herniorrhaphy ,"OPERATIVE NOTE:,  The patient was taken to the operating room and placed in the supine position on the operating room table.  The patient was prepped and draped in usual sterile fashion.  An incision was made in the groin crease overlying the internal ring.  This incision was about 1.5 cm in length.  The incision was carried down through the Scarpa's layer to the level of the external oblique.  This was opened along the direction of its fibers and carried down along the external spermatic fascia.  The cremasteric fascia was then incised and the internal spermatic fascia was grasped and pulled free.  A hernia sac was identified and the testicle was located.  Next the internal spermatic fascia was incised and the hernia sac was dissected free inside the internal ring.  This was performed by incising the transversalis fascia circumferentially.  The hernia sac was ligated with a 3-0 silk suture high and divided and was noted to retract into the abdominal cavity.  Care was taken not to injure the testicular vessels.  Next the abnormal attachments of the testicle were dissected free distally with care not to injure any long loop vas and these were divided beneath the testicle for a fair distance.  The lateral attachments tethering the cord vessels were freed from the sidewalls in the retroperitoneum high.  This gave excellent length and very adequate length to bring the testicle down into the anterior superior hemiscrotum.  The testicle was viable.  This was wrapped in a moist sponge.,Next a hemostat was passed down through the inguinal canal down into the scrotum.  A small 1 cm incision was made in the anterior superior scrotal wall.  Dissection was carried down through the dartos layer.  A subdartos pouch was formed with blunt dissection.  The hemostat was then pushed against the tissues and this tissue was divided.  The hemostat was then passed through the incision.  A Crile hemostat was passed back up into the inguinal canal.  The distal attachments of the sac were grasped and pulled down without twisting these structures through the incision.  The neck was then closed with a 4-0 Vicryl suture that was not too tight, but tight enough to prevent retraction of the testicle.  The testicle was then tucked down in its proper orientation into the subdartos pouch and the subcuticular tissue was closed with a running 4-0 chromic and the skin was closed with a running 6-0 subcuticular chromic suture.  Benzoin and a Steri-Strip were placed.  Next the transversus abdominis arch was reapproximated to the iliopubic tract over the top of the cord vessels to tighten up the ring slightly.  This was done with 2 to 3 interrupted 3-0 silk sutures.  The external oblique was then closed with interrupted 3-0 silk suture.  The Scarpa's layer was closed with a running 4-0 chromic and the skin was then closed with a running 4-0 Vicryl intracuticular stitch.  Benzoin and Steri-Strip were applied.  The testicle was in good position in the dependent portion of the hemiscrotum and the patient had a caudal block, was awakened, and was returned to the recovery room in stable condition.","urology, orchiopexy, benzoin, crile hemostat, scarpa's layer, caudal block, cremasteric fascia, groin crease, hemiscrotum, iliopubic tract, inguinal canal, inguinal herniorrhaphy, intracuticular stitch, retroperitoneum, spermatic fascia, testicle, hernia sac, inguinal, incisionNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Bilateral scrotal orchiectomy, Urology, Orchiectomy ,"BILATERAL SCROTAL ORCHECTOMY,PROCEDURE:,:  The patient is placed in the supine position, prepped and draped in the usual manner.  Under satisfactory general anesthesia, the scrotum was approached and through a transverse mid scrotal incision, the right testicle was delivered through the incision.  Hemostasis was obtained with the Bovie and the spermatic cord was identified.  It was clamped, suture ligated with 0 chromic catgut and the cord above was infiltrated with 0.25% Marcaine for postoperative pain relief.  The left testicle was delivered through the same incision.  The spermatic cord was identified, clamped, suture ligated and that cord was also injected with 0.25% percent Marcaine.  The incision was injected with the same material and then closed in two layers using 4-0 chromic catgut continuous for the dartos and interrupted for the skin.  A dry sterile dressing fluff and scrotal support applied over that.  The patient was sent to the Recovery Room in stable condition.","urology, scrotum, hemostasis, marcaine, catgut, incision, scrotal orchiectomy, spermatic cord, sterile dressing, testicle, transverse, suture ligated, chromic catgut, orchiectomy, scrotal, cordNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" A 6-mm left intrarenal stone, nonobstructing, by ultrasound and IVP. ", Urology, Microhematuria - Consult ,"HISTORY OF PRESENT ILLNESS: , The patient presents today as a consultation from Dr. ABC's office regarding the above.  He was seen a few weeks ago for routine followup, and he was noted for microhematuria.  Due to his history of kidney stone, renal ultrasound as well as IVP was done.  He presents today for followup.  He denies any dysuria, gross hematuria or flank pain issues.  Last stone episode was over a year ago.  No history of smoking.  Daytime frequency 3 to 4 and nocturia 1 to 2, good stream, empties well with no incontinence.,Creatinine 1.0 on June 25, 2008, UA at that time was noted for 5-9 RBCs, renal ultrasound of 07/24/2008 revealed 6 mm left intrarenal stone, with no hydronephrosis.  IVP same day revealed a calcification over the left kidney, but without bilateral hydronephrosis.  The calcification previously noted on the ureter appears to be outside the course of the ureter.  Otherwise unremarkable.  This is discussed.,IMPRESSION:  ,1.  A 6-mm left intrarenal stone, nonobstructing, by ultrasound and IVP.  The patient is asymptomatic.  We have discussed surgical intervention versus observation.  He indicates that this stone is not bothersome, prefers observation, need for hydration with a goal of making over 2 liters of urine within 24 hours is discussed.,2.  Microhematuria, we discussed possible etiologies of this, and the patient is agreeable to cystoscopy in the near future.  Urine sent for culture and sensitivity.,PLAN: , As above.  The patient will follow up for cystoscopy, urine sent for cytology, continue hydration.  Call if any concern.  The patient is seen and evaluated by myself.","urology, intrarenal stone, ivp, ultrasound, microhematuria, hydration, kidney stone, renal ultrasound"
 Stage I and II neuromodulator., Urology, Neuromodulator ,"PREOPERATIVE DIAGNOSIS:,  Refractory urgency and frequency.,POSTOPERATIVE DIAGNOSIS: , Refractory urgency and frequency.,OPERATION: , Stage I and II neuromodulator.,ANESTHESIA: , Local MAC.,ESTIMATED BLOOD LOSS:,  Minimal.,FLUIDS: , Crystalloid.  The patient was given Ancef preop antibiotic.  Ancef irrigation was used throughout the procedure.,BRIEF HISTORY: , The patient is a 63-year-old female who presented to us with urgency and frequency on physical exam.  There was no evidence of cystocele or rectocele.  On urodyanamcis, the patient has significant overactivity of the bladder.  The patient was tried on over three to four different anticholinergic agents such as Detrol, Ditropan, Sanctura, and VESIcare for at least one month each.  The patient had pretty much failure from each of the procedure.  The patient had less than 20% improvement with anticholinergics.  Options such as continuously trying anticholinergics, continuation of the Kegel exercises, and trial of InterStim were discussed.  The patient was interested in the trial.  The patient had percutaneous InterStim trial in the office with over 70% to 80% improvement in her urgency, frequency, and urge incontinence.  The patient was significantly satisfied with the results and wanted to proceed with stage I and II neuromodulator.  Risks of anesthesia, bleeding, infection, pain, MI, DVT, and PE were discussed.  Risk of failure of the procedure in the future was discussed.,Risk of lead migration that the treatment may or may not work in the long-term basis and data on the long term were not clear were discussed with the patient.  The patient understood and wanted to proceed with stage I and II neuromodulator.  Consent was obtained.,DETAILS OF THE OPERATION: , The patient was brought to the OR.  The patient was placed in prone position.  A pillow was placed underneath her pelvis area to slightly lift the pelvis up.  The patient was awake, was given some MAC anesthesia through the IV, but the patient was talking and understanding and was able to verbalize issues.  The patient's back was prepped and draped in the usual sterile fashion.  Lidocaine 1% was applied on the right side near the S3 foramen.  Under fluoroscopy, the needle placement was confirmed.  The patient felt stimulation in the vaginal area, which was tapping in nature.  The patient also had a pressure feeling in the vaginal area.  The patient had no back sensation or superficial sensation.  There was no sensation down the leg.  The patient did have __________, which turned in slide bellows response indicating the proper positioning of the needle.  A wire was placed.  The tract was dilated and lead was placed.  The patient felt tapping in the vaginal area, which is an indication that the lead is in its proper position.  Most of the leads had very low amplitude and stimulation.  Lead was tunneled under the skin and was brought out through an incision on the left upper buttocks.  Please note that the lidocaine was injected prior to the tunneling.  A pouch was created about 1 cm beneath the subcutaneous tissue over the muscle where the actual unit was connected to the lead.  Screws were turned and they were dropped.  Attention was made to ensure that the lead was all the way in into the InterStim.  Irrigation was performed after placing the main unit in the pouch.  Impedance was checked.  Irrigation was again performed with antibiotic irrigation solution.  The needle site was closed using 4-0 Monocryl.  The pouch was closed using 4-0 Vicryl and the subcutaneous tissue with 4-0 Monocryl.  Dermabond was applied.,The patient was brought to recovery in a stable condition.","urology, refractory urgency, urgency, frequency, neuromodulator, subcutaneous tissue, interstim,"
 Mini-laparotomy radical retropubic prostatectomy with bilateral pelvic lymph node dissection with Cavermap.  Adenocarcinoma of the prostate., Urology, Mini Laparotomy & Radical Retropubic Prostatectomy ,"PREOPERATIVE DIAGNOSIS:,  Adenocarcinoma of the prostate.,POSTOPERATIVE DIAGNOSIS:,  Adenocarcinoma of the prostate.,TITLE OF OPERATION:,  Mini-laparotomy radical retropubic prostatectomy with bilateral pelvic lymph node dissection with Cavermap.,ANESTHESIA: , General by intubation.,Informed consent was obtained for the procedure.  The patient understands the treatment options and wishes to proceed.  He accepts the risks to include bleeding requiring transfusion, infection, sepsis, incontinence, impotence, bladder neck constricture, heart attack, stroke, pulmonary emboli, phlebitis, injury to the bladder, rectum, or ureter, etcetera.,OPERATIVE PROCEDURE IN DETAIL: , The patient was taken to the Operating Room and placed in the supine position, prepped with Betadine solution and draped in the usual sterile fashion.  A 20- French Foley catheter was inserted into the penis and into the bladder and placed to dependent drainage.  The table was then placed in minimal flexed position.  A midline skin incision was then made from the umbilicus to the symphysis pubis.  It was carried down to the anterior rectus fascia into the pelvis proper.  Both obturator fossae were exposed.  Standard bilateral pelvic lymph node dissections were carried out.  The left side was approached first by myself.  The limits of my dissection were from the external iliac vein laterally to the obturator nerve medially, and from the bifurcation of the common iliac vein proximally to Cooper's ligament distally.  Meticulous lymphostasis and hemostasis was obtained using hemoclips and 2-0 silk ligatures.  The obturator nerve was visualized throughout and was not injured.  The right side was carried out by my assistant under my direct and constant supervision.  Again, the obturator nerve was visualized throughout and it was not injured.  Both packets were sent to Pathology where no evidence of carcinoma was found.,My attention was then directed to the prostate itself.  The  endopelvic fascia was opened bilaterally.  Using gentle dissection with a Kitner, I swept the levator muscles off the prostate and exposed the apical portion of the prostate.  A back bleeding control suture of 0 Vicryl was placed at the mid-prostate level.  A sternal wire was then placed behind the dorsal vein complex which was sharply transected.  The proximal and distal portions of this complex were then oversewn with 2-0 Vicryl in a running fashion.  When I was satisfied that hemostasis was complete, my attention was then turned to the neurovascular bundles.,The urethra was then sharply transected and six sutures of 2-0 Monocryl placed at the 1, 3, 5, 7, 9 and 11 o'clock positions.  The prostate was then lifted retrograde in the field and was swept from the anterior surface of the rectum and the posterior layer of Denonvilliers' fascia was incised distally, swept off the rectum and incorporated with the prostate specimen.  The lateral pedicles over the seminal vesicles were then mobilized, hemoclipped and transected.  The seminal vesicles themselves were then mobilized and hemostasis obtained using hemoclips.  Ampullae of the vas were mobilized, hemoclipped and transected.  The bladder neck was then developed using careful blunt and sharp dissection.  The prostate was then transected at the level of the bladder neck and sent for permanent specimen.  The bladder neck was reevaluated and the ureteral orifices were found to be placed well back from the edge.  The bladder neck was reconstructed in standard fashion.  It was closed using a running 2-0 Vicryl.  The mucosa was everted over the edge of the bladder neck using interrupted 3-0 Vicryl suture.  At the end of this portion of the case, the new bladder neck had a stoma-like appearance and would accommodate easily my small finger.  The field was then re-evaluated for hemostasis which was further obtained using hemoclips, Bovie apparatus and 3-0 chromic ligatures.  When I was satisfied that hemostasis was complete, the aforementioned Monocryl sutures were then placed at the corresponding positions in the bladder neck.  A new 20-French Foley catheter was brought in through the urethra into the bladder.  A safety suture of 0 Prolene was brought through the end of this and out through a separate stab wound in the bladder and through the left lateral quadrant.  The table was taken out of flexion and the bladder was then brought into approximation to the urethra and the Monocryl sutures were ligated.  The bladder was then copiously irrigated with sterile water and the anastomosis was found to be watertight.  The pelvis was also copiously irrigated with 2 liters of sterile water.  A 10-French Jackson-Pratt drain was placed in the pelvis and brought out through the right lower quadrant and sutured in place with a 2-0 silk ligature.,The wound was then closed in layers.  The muscle was closed with a running 0 chromic, the fascia with a running 1-0 Vicryl, the subcutaneous tissue with 3-0 plain, and the skin with a running 4-0 Vicryl subcuticular.  Steri-Strips were applied and a sterile dressing.,The patient was taken to the Recovery Room in good condition.  There were no complications.  Sponge and instrument counts were reported correct at the end of the case.","urology, mini-laparotomy, radical retropubic prostatectomy, pelvic lymph, pelvic lymph node dissection, cavermap, mini laparotomy, prostatectomy, bladder, intubation, adenocarcinoma, endopelvic, hemostasis, neck"
 An example/template for meatotomy., Urology, Meatotomy Template ,"OPERATIVE NOTE:  ,The patient was taken to the operating room and was placed in the supine position on the operating room table.  A general inhalation anesthetic was administered.  The patient was prepped and draped in the usual sterile fashion.  The urethral meatus was calibrated with a small mosquito hemostat and was gently dilated.  Next a midline ventral type incision was made opening the meatus.  This was done after clamping the tissue to control bleeding.  The meatus was opened for about 3 mm.  Next the meatus was calibrated and easily calibrated from 8 to 12 French with bougie sounds.  Next the mucosal edges were everted and reapproximated to the glans skin edges with approximately five interrupted 6-0 Vicryl sutures.  The meatus still calibrated between 10 and 12 French.  Antibiotic ointment was applied.  The procedure was terminated.  The patient was awakened and returned to the recovery room in stable condition.","urology, urethral meatus, mosquito hemostat, meatus, mucosal edges, glans, meatotomyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Neurogenic bladder, in a patient catheterizing himself 3 times a day, changing his catheter 3 times a week", Urology, Neurogenic Bladder - Consult ,"HISTORY OF PRESENT ILLNESS: , The patient presents today as a consultation from Dr. ABC's office regarding the above.  He has history of neurogenic bladder, and on intermittent self-catheterization 3 times a day.  However, June 24, 2008, he was seen in the ER, and with fever, weakness, possible urosepsis.  He had a blood culture, which was positive for Staphylococcus epidermidis, as well as urine culture noted for same bacteria.  He was treated on IV antibiotics, Dr. XYZ also saw the patient.  Discharged home.  Not taking any antibiotics.  Today in the office, the patient denies any dysuria, gross hematuria, fever, chills.  He is catheterizing 3 times a day, changing his catheter weekly.  Does have history of renal transplant, which has been followed by Dr. X and is on chronic steroids.  Renal ultrasound, June 23, 2008, was noted for mild hydronephrosis of renal transplant with fluid in the pericapsular space.  Creatinine, July 7, 2008 was 2.0, BUN 36, and patient tells me this is being followed by Dr. X.  No interval complaints today, no issues with catheterization or any gross hematuria.,IMPRESSION:  ,1.  Neurogenic bladder, in a patient catheterizing himself 3 times a day, changing his catheter 3 times a week, we again reviewed the technique of catheterization, and he has no issues with this.,2.  Recurrent urinary tract infection, in a patient who has been hospitalized twice within the last few months, he is on steroids for renal transplant, which has most likely been overall reducing his immune system.  He is asymptomatic today.  No complaints today.,PLAN:,  Following a detailed discussion with the patient, we elected to proceed with intermittent self-catheterization, changing catheter weekly, and technique has been discussed as above.  Based on the recent culture, we will place him on Keflex nighttime prophylaxis, for the next three months or so.  He will call if any concerns.  Follow up as previously scheduled in September for re-assessment.  All questions answered.  The patient is seen and evaluated by myself.","urology, neurogenic bladder, catheterizing, catheter, urinary tract infection, self-catheterization, intermittent self catheterization, renal transplant, catheterization,"
" Left orchiectomy, scrotal exploration, right orchidopexy.", Urology, Left Orchiectomy & Right Orchidopexy ,"PREOPERATIVE DIAGNOSIS: , Left testicular torsion.,POSTOPERATIVE DIAGNOSES:  ,1.  Left testicular torsion.,2.  Left testicular abscess.,3.  Necrotic testes.,SURGERY:,  Left orchiectomy, scrotal exploration, right orchidopexy.,DRAINS:,  Penrose drain on the left hemiscrotum.,The patient was given vancomycin, Zosyn, and Levaquin preop.,BRIEF HISTORY:  ,The patient is a 49-year-old male who came into the emergency room with 2-week history of left testicular pain, scrotal swelling, elevated white count of 39,000.  The patient had significant scrotal swelling and pain.  Ultrasound revealed necrotic testicle.  Options such as watchful waiting and removal of the testicle were discussed.  Due to elevated white count, the patient was told that he must have the testicle removed due to the infection and possible early signs of urosepsis.  The risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, scrotal issues, other complications were discussed.  The patient was told about the morbidity and mortality of the procedure and wanted to proceed.,PROCEDURE IN DETAIL: , The patient was brought to the OR.  Anesthesia was applied.  The patient was prepped and draped in usual sterile fashion.  A midline scrotal incision was made.  There was very, very thick scrotal skin.  There was no necrotic skin.  As soon as the left hemiscrotum was entered, significant amount of pus poured out of the left hemiscrotum.  The testicle was completely filled with pus and had completely disintegrated with pus.  The pus just poured out of the left testicle.  The left testicle was completely removed.  Debridement was done of the scrotal wall to remove any necrotic tissue.  Over 2 L of antibiotic irrigation solution was used to irrigate the left hemiscrotum.  There was good tissue left after all the irrigation and debridement.  A Penrose drain was placed in the bottom of the left hemiscrotum.  I worried about the patient may have torsed and then the testicle became necrotic, so the plan was to pex the right testicle, plus the right side also appeared very abnormal.  So, the right hemiscrotum was opened.  The testicle had significant amount of swelling and scrotal wall was very thick.  The testicle appeared normal.  There was no pus coming out of the right hemiscrotum.  At this time, a decision was made to place 4-0 Prolene nonabsorbable stitches in 3 different quadrants to prevent it from torsion.  The hemiscrotum was closed using 2-0 Vicryl in interrupted stitches and the skin was closed using 2-0 PDS in horizontal mattress.  There was very minimal pus left behind and the skin was very healthy.  Decision was made to close it to help the patient heal better in the long run.  The patient was brought to the recovery in stable condition.","urology, testicular abscess, necrotic testes, orchiectomy, scrotal exploration, orchidopexy, hemiscrotum, testicular torsion, penrose drain, scrotal swelling, scrotal wall, testicle, torsion"
" Left orchiopexy.  Ectopic left testis.   The patient did have an MRI, which confirmed ectopic testis located near the pubic tubercle.", Urology, Orchiopexy ,"PREOPERATIVE DIAGNOSIS:,  Ectopic left testis.,POSTOPERATIVE DIAGNOSIS: , Ectopic left testis.,PROCEDURE PERFORMED: , Left orchiopexy.,ANESTHESIA: , General.  The patient did receive Ancef.,INDICATIONS AND CONSENT: , This is a 16-year-old African-American male who had an ectopic left testis that severed approximately one-and-a-half years ago.  The patient did have an MRI, which confirmed ectopic testis located near the pubic tubercle.  The risks, benefits, and alternatives of the proposed procedure were discussed with the patient.  Informed consent was on the chart at the time of procedure.,PROCEDURE DETAILS:  ,The patient did receive Ancef antibiotics prior to the procedure.  He was then wheeled to the operative suite where a general anesthetic was administered.  He was prepped and draped in the usual sterile fashion and shaved in the area of the intended procedure.  Next, with a #15 blade scalpel, an oblique skin incision was made over the spermatic cord region.  The fascia was then dissected down both bluntly and sharply and hemostasis was maintained with Bovie electrocautery.  The fascia of the external oblique, creating the external ring was then encountered and that was grasped in two areas with hemostats and sized with Metzenbaum scissors.  This was then continued to open the external ring and was then carried cephalad to further open the external ring, exposing the spermatic cord.  With this accomplished, the testis was then identified.  It was located over the left pubic tubercle region and soft tissue was then meticulously dissected and cared to avoid all vascular and testicular structures.,The cord length was then achieved by applying some tension to the testis and further dissecting any of the fascial adhesions along the spermatic cord.  Once again, meticulous care was maintained not to involve any neurovascular or contents of the testis or vas deferens.  Weitlaner retractor was placed to provide further exposure.  There was a small vein encountered posterior to the testis and this was then hemostated into place and cut with Metzenbaum scissors and doubly ligated with #3-0 Vicryl.  Again hemostasis was maintained with ligation and Bovie electrocautery with adequate mobilization of the spermatic cord and testis.  Next, bluntly a tunnel was created through the subcutaneous tissue into the left empty scrotal compartment.  This was taken down to approximately the two-thirds length of the left scrotal compartment.  Once this tunnel has been created, a #15 blade scalpel was then used to make transverse incision.  A skin incision through the scrotal skin and once again the skin edges were grasped with Allis forceps and the dartos was then entered with the Bovie electrocautery exposing the scrotal compartment.  Once this was achieved, the apices of the dartos were then grasped with hemostats and supra-dartos pouch was then created using the Iris scissors.  A dartos pouch was created between the skin and the supra-dartos, both cephalad and caudad to the level of the scrotal incision.  A hemostat was then placed from inferior to superior through the created tunnel and the testis was pulled through the created supra-dartos pouch ensuring that anatomic position was in place, maintaining the epididymis posterolateral without any rotation of the cord.  With this accomplished, #3-0 Prolene was then used to tack both the medial and lateral aspects of the testis to the remaining dartos into the tunica vaginalis.  The sutures were then tied creating the orchiopexy.  The remaining body of the testicle was then tucked into the supra-dartos pouch and the skin was then approximated with #4-0 undyed Monocryl in a horizontal mattress fashion interrupted sutures.  Once again hemostasis was maintained with Bovie electrocautery.  Finally the attention was made towards the inguinal incision and this was then copiously irrigated and any remaining bleeders were then fulgurated with Bovie electrocautery to make sure to avoid any neurovascular spermatic structures.  External ring was then recreated and grasped on each side with hemostats and approximated with #3-0 Vicryl in a running fashion cephalad to caudad.  Once this was created, the created ring was inspected and there was adequate room for the cord.  There appeared to be no evidence of compression.  Finally, subcutaneous layer with sutures of #4-0 interrupted chromic was placed and then the skin was then closed with #4-0 undyed Vicryl in a running subcuticular fashion.  The patient had been injected with bupivacaine prior to closing the skin.  Finally, the patient was cleansed.,The scrotal support was placed and plan will the for the patient to take Keflex one tablet q.i.d. x7 days as well as Tylenol #3 for severe pain and Motrin for moderate pain as well as applying ice packs to scrotum.  He will follow up with Dr. X in 10 to 14 days.  Appointment will be made.","urology, pubic tubercle, ectopic testis, ectopic left testis, metzenbaum scissors, dartos pouch, bovie electrocautery, testis, orchiopexy, ectopic, scrotal, cord, dartos,"
 Examination under anesthesia and laparoscopic right orchiopexy., Urology, Laparoscopic Orchiopexy ,"PREOPERATIVE DIAGNOSIS: , Bilateral undescended testes.,POSTOPERATIVE DIAGNOSIS: , Bilateral undescended testes, bilateral intraabdominal testes.,PROCEDURE: , Examination under anesthesia and laparoscopic right orchiopexy.,ESTIMATED BLOOD LOSS:,  Less than 5 mL.,FLUIDS RECEIVED:  ,110 mL of crystalloid.,INTRAOPERATIVE FINDINGS: , Atrophic bilateral testes, right is larger than left.  The left had atrophic or dysplastic vas and epididymis.,TUBES AND DRAINS: , No tubes or drains were used.,INDICATIONS FOR OPERATION:  ,The patient is a 7-1/2-month-old boy with bilateral nonpalpable testes.  Plan is for exploration, possible orchiopexy.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operating room where surgical consent, operative site, and patient identification were verified.  Once he was anesthetized, he was then palpated and again both testes were nonpalpable.  Because of this, a laparoscopic approach was then elected.  We then sterilely prepped and draped the patient, put an 8-French feeding tube in the urethra, attached to bulb grenade for drainage.  We then made an infraumbilical incision with a 15-blade knife and then further extended with electrocautery and with curved mosquito clamps down to the rectus fascia where we made stay sutures of 3-0 Monocryl on the anterior and posterior sheaths and then opened up the fascia with the curved Metzenbaum scissors.  Once we got into the peritoneum, we placed a 5-mm port with 0-degree short lens.  Insufflation was then done with carbon dioxide up to 10 to 12 mmHg.  We then evaluated.  There was no bleeding noted.  He had a closed ring on the left with a small testis that was evaluated and found to have short vessels as well as atrophic or dysplastic vas, which was barely visualized.  The right side was also intraabdominal, but slightly larger, had better vessels, had much more recognizable vas, and it was closer to the internal ring.  So, we elected to do an orchiopexy on the right side.  Using the laparoscopic 3- and 5-mm dissecting scissors, we then opened up the window at the internal ring through the peritoneal tissue, then dissected it medially and laterally along the line of the vas and along the line of the vessels up towards the kidney, mid way up the abdomen, and across towards the bladder for the vas.  We then used the Maryland dissector to gently tease this tissue once it was incised.  The gubernaculum was then divided with electrocautery and the laparoscopic scissors.  We were able to dissect with the hook dissector in addition to the scissors the peritoneal shunts with the vessels and the vas to the point where we could actually stretch and bring the testis across to the other side, left side of the ring.  We then made a curvilinear incision on the upper aspect of the scrotum on the right with a 15-blade knife and extended down the subcutaneous tissue with electrocautery.  We used the curved tenotomy scissors to make a subdartos pouch.  Using a mosquito clamp, we were able to go in through the previous internal ring opening, grasped the testis, and then pulled it through in a proper orientation.  Using the hook electrode, we were able to dissect some more of the internal ring tissue to relax the vessels and the vas, so there was no much traction.  Using 2 stay sutures of 4-0 chromic, we tacked the testis to the base of scrotum into the middle portion of the testis.  We then closed the upper aspect of the subdartos pouch with a 4-0 chromic and then closed the subdartos pouch and the skin with subcutaneous 4-0 chromic.  We again evaluated the left side and found again that the vessels were quite short.  The testis was more atrophic, and the vas was virtually nonexistent.  We will go back at a later date to try to bring this down, but it will be quite difficult and has a higher risk for atrophy because of the tissue that is present.  We then removed the ports, closed the fascial defects with figure-of-eight suture of 3-0 Monocryl, closed the infraumbilical incision with two Monocryl stay sutures to close the fascial sheath, and then used 4-0 Rapide to close the skin defects, and then using Dermabond tissue adhesives, we covered all incisions.  At the end of the procedure, the right testis was well descended within the scrotum, and the feeding tube was removed.  The patient had IV Toradol and was in stable condition upon transfer to recovery room.","urology, laparoscopic right orchiopexy, undescended testes, orchiopexy, bilateral undescended testes, mosquito clamps, subdartos pouch, internal ring, laparoscopic,"
 An example/template for meatoplasty., Urology, Meatoplasty Template ,"OPERATIVE NOTE:  ,The patient was placed in the supine position under general anesthesia, and prepped and draped in the usual manner.  The penis was inspected.  The meatus was inspected and an incision was made in the dorsal portion of the meatus up towards the tip of the penis connecting this with the ventral urethral groove.  This was incised longitudinally and closed transversely with 5-0 chromic catgut sutures.  The meatus was calibrated and accepted the calibrating instrument without difficulty, and there was no stenosis.  An incision was made transversely below the meatus in a circumferential way around the shaft of the penis, bringing up the skin of the penis from the corpora.  The glans was undermined with sharp dissection and hemostasis was obtained with a Bovie.  Using a skin hook, the meatus was elevated ventrally and the glans flaps were reapproximated using 5-0 chromic catgut, creating a new ventral portion of the glans using the flaps of skin.  There was good viability of the skin.  The incision around the base of the penis was performed, separating the foreskin that was going to be removed from the coronal skin.  This was removed and hemostasis was obtained with a Bovie.  0.25% Marcaine was infiltrated at the base of the penis for post-op pain relief, and the coronal and penile skin was reanastomosed using 4-0 chromic catgut.  At the conclusion of the procedure, Vaseline gauze was wrapped around the penis.  There was good hemostasis and the patient was sent to the recovery room in stable condition.","urology, penis, meatus, urethral groove, corpora, glans, meatoplasty, bovie, chromic, catgut, hemostasisNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Laparoscopic lysis of adhesions, attempted laparoscopic pyeloplasty, and open laparoscopic pyeloplasty.  Right ureteropelvic junction obstruction, severe intraabdominal adhesions, and retroperitoneal fibrosis.", Urology, Laparoscopic Pyeloplasty ,"PREOPERATIVE DIAGNOSIS:  ,Right ureteropelvic junction obstruction.,POSTOPERATIVE DIAGNOSES:,1.  Right ureteropelvic junction obstruction.,2.  Severe intraabdominal adhesions.,3.  Retroperitoneal fibrosis.,PROCEDURES PERFORMED:,1.  Laparoscopic lysis of adhesions.,2.  Attempted laparoscopic pyeloplasty.,3.  Open laparoscopic pyeloplasty.,ANESTHESIA:,  General.,INDICATION FOR PROCEDURE:  ,This is a 62-year-old female with a history of right ureteropelvic junction obstruction with chronic indwelling double-J ureteral stent.  The patient presents for laparoscopic pyeloplasty.,PROCEDURE: , After informed consent was obtained, the patient was taken to the operative suite and administered general anesthetic.  The patient was sterilely prepped and draped in the supine fashion after building up the right side of the OR table to aid in the patient's positioning for bowel retraction.  Hassan technique was performed for the initial trocar placement in the periumbilical region.  Abdominal insufflation was performed.  There were significant adhesions noted.  A second 12 mm port was placed in the right midclavicular line at the level of the umbilicus and a Harmonic scalpel was placed through this and adhesiolysis was performed for approximately two-and-half hours, also an additional port was placed 12 mm in the midline between the xiphoid process and the umbilicus, an additional 5 mm port in the right upper quadrant subcostal and midclavicular.  After adhesions were taken down, the ascending colon was mobilized by incising the white line of Toldt and mobilizing this medially.  The kidney was able to be palpated within Gerota's fascia.  The psoas muscle caudate to the inferior pole of the kidney was identified and the tissue overlying this was dissected to the level of the ureter.  The uterus was grasped with a Babcock through a trocar port and carried up to the level of the ureteropelvic junction obstruction.  The renal pelvis was also identified and dissected free.  There was significant fibrosis and scar tissue around the ureteropelvic junction obliterating the tissue planes.  We were unable to dissect through this mass of fibrotic tissue safely and therefore the decision was made to abort the laparoscopic procedure and perform the pyeloplasty open.  An incision was made from the right upper quadrant port extending towards the midline.  This was carried down through the subcutaneous tissue, anterior fascia, muscle layers, posterior fascia, and peritoneum.  A Bookwalter retractor was placed.  The renal pelvis and the ureter were again identified.  Fibrotic tissue was able to be dissected away at this time utilizing right angle clamps and Bovie cautery.  The tissue was sent down to Pathology for analysis.  Please note that upon entering the abdomen, all of the above which was taken down from the adhesions to the abdominal wall were carefully inspected and no evidence of bowel injury was noted.  Ureter was divided just distal to the ureteropelvic junction obstruction and stent was maintained in place.  The renal pelvis was then opened in a longitudinal manner and excessive pelvis was removed reducing the redundant tissue.  At this point, the indwelling double-J ureteral stent was removed.  At this time, the ureter was spatulated laterally and at the apex of this spatulation a #4-0 Vicryl suture was placed.  This was brought up to the deepened portion of the pyelotomy and cystic structures were approximated.  The back wall of the ureteropelvic anastomosis was then approximated with running #4-0 Vicryl suture.  At this point, a double-J stent was placed with a guidewire down into the bladder.  The anterior wall of the uteropelvic anastomosis was then closed again with a #4-0 running Vicryl suture.  Renal sinus fat was then placed around the anastomosis and sutured in place.  Please note in the inferior pole of the kidney, there was approximately 2 cm laceration which was identified during the dissection of the fibrotic tissue.  This was repaired with horizontal mattress sutures #2-0 Vicryl.  FloSeal was placed over this and the renal capsule was placed over this.  A good hemostasis was noted.  A #10 Blake drain was placed through one of the previous trocar sites and placed into the perirenal space away from the anastomosis.  The initial trocar incision was closed with #0 Vicryl suture.  The abdominal incision was also then closed with running #0 Vicryl suture incorporating all layers of muscle and fascia.  The Scarpa's fascia was then closed with interrupted #3-0 Vicryl suture.  The skin edges were then closed with staples.  Please note that all port sites were inspected prior to closing and hemostasis was noted at all sites and the fascia was noted to be reapproximated as these trocar sites were placed with the ________ obturator.  We placed the patient on IV antibiotics and pain medications.  We will obtain KUB and x-rays for stent placement.  Further recommendations to follow.","urology, retroperitoneal, fibrosis, pyeloplasty, laparoscopic, lysis of adhesions, ureteropelvic junction obstruction, laparoscopic pyeloplasty, ureteropelvic junction, junction, ureteropelvic, intraabdominal, adhesions,"
" Bassini inguinal herniorrhaphy.  A standard inguinal incision was made, and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery. ", Urology, Inguinal Herniorrhaphy - 2 ,"PROCEDURE PERFORMED: , Bassini inguinal herniorrhaphy.,ANESTHESIA: , Local with MAC anesthesia.,PROCEDURE: , After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table.  The patient was sedated and an adequate local anesthetic was administered using 1% lidocaine without epinephrine.  The patient was prepped and draped in the usual sterile manner.,A standard inguinal incision was made, and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery.  The external oblique aponeurosis was cleared of overlying adherent tissue, and the external ring was delineated.  The external oblique was then incised with a scalpel and this incision was carried out to the external ring using Metzenbaum scissors.  Care was taken not to injure the ilioinguinal nerve.  Having exposed the inguinal canal, the cord structures were separated from the canal using blunt dissection, and a Penrose drain was then used to retract the cord structures as needed.  Adherent cremasteric muscle was dissected free from the cord using Bovie electrocautery.,The cord was then explored using a combination of sharp and blunt dissection, and the sac was found anteromedially to the cord structures.  The sac was dissected free from the cord structures using a combination of blunt dissection and Bovie electrocautery.,Once preperitoneal fat was encountered, the dissection stopped and the sac was suture ligated at the level of the preperitoneal fat using a 2-0 silk suture ligature.  The sac was excised and sent to Pathology.  The stump was examined and no bleeding was noted.  The ends of the suture were then cut, and the stump retracted back into the abdomen.,The floor of the inguinal canal was then strengthened by suturing the shelving edge of Poupart's ligament to the conjoined tendon using a 2-0 Prolene, starting at the pubic tubercle and running towards the internal ring.  In this manner, an internal ring was created that admitted just the tip of my smallest finger.,The Penrose drain was removed.  The wound was then irrigated using sterile saline, and hemostasis was obtained using Bovie electrocautery.  The incision in the external oblique was approximated using a 2-0 Vicryl in a running fashion, thus reforming the external ring.  Marcaine 0.5% was injected 1 fingerbreadth anterior to the anterior and superior iliac spine and around the wound for postanesthetic pain control.  The skin incision was approximated with skin staples.  A dressing was then applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.","urology, ilioinguinal nerve, adherent cremasteric muscle, bassini inguinal herniorrhaphy, external oblique aponeurosis, inguinal herniorrhaphy, metzenbaum scissors, external ring, blunt dissection, cord structures, bovie electrocautery, inguinal, electrocautery"
" Laparoscopic right inguinal herniorrhaphy with mesh, as well as a circumcision.   Recurrent right inguinal hernia, as well as phimosis.", Urology, Inguinal Herniorrhaphy & Circumcision ,"PREOPERATIVE DIAGNOSIS: , Recurrent right inguinal hernia, as well as phimosis.,POSTOPERATIVE DIAGNOSIS:,  Recurrent right inguinal hernia, as well as phimosis.,PROCEDURE PERFORMED: , Laparoscopic right inguinal herniorrhaphy with mesh, as well as a circumcision.,ANESTHESIA: , General endotracheal.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well and was transferred to recovery room in stable condition.,SPECIMEN: , Foreskin.,BRIEF HISTORY: , This patient is a 66-year-old African-American male who presented to Dr. Y's office with recurrent right inguinal hernia for the second time requesting hernia repair.  The procedure was discussed with the patient and the patient opted for laparoscopic repair due to multiple attempts at the open inguinal repair on the right.  The patient also is requesting circumcision with phimosis at the same operating time setting.,INTRAOPERATIVE FINDINGS: , The patient was found to have a right inguinal hernia with omentum and bowel within the hernia, which was easily reduced.  The patient was also found to have a phimosis, which was easily removed.,PROCEDURE:,  After informed consent, the risks and benefits of the procedure were explained to the patient.  The patient was brought to operating suite, after general endotracheal intubation, prepped and draped in the normal sterile fashion.  An infraumbilical incision was made with a #15 Bard-Parker scalpel.  The umbilical skin was elevated with a towel clip and the Veress needle was inserted without difficulty.  Saline drop test proved entrance into the abdominal cavity and then the abdomen was insufflated to sufficient pressure of 15 mmHg.  Next, the Veress was removed and #10 bladed trocar was inserted without difficulty.  The 30-degree camera laparoscope was then inserted and the abdomen was explored.  There was evidence of a large right inguinal hernia, which had omentum as well as bowel within it, easily reducible.  Attention was next made to placing a #12 port in the right upper quadrant, four fingerbreadths from the umbilicus.  Again, a skin was made with a #15 blade scalpel and the #12 port was inserted under direct visualization.  A #5 port was inserted in the left upper quadrant in similar fashion without difficulty under direct visualization.  Next, a grasper with blunt dissector was used to reduce the hernia and withdraw the sac and using an Endoshears, the peritoneum was scored towards the midline and towards the medial umbilical ligament and lateral.  The peritoneum was then spread using the blunt dissector, opening up and identifying the iliopubic tract, which was identified without difficulty.  Dissection was carried out, freeing up the hernia sac from the peritoneum.  This was done without difficulty reducing the hernia in its entirety.  Attention was next made to placing a piece of Prolene mesh, it was placed through the #12 port and placed into the desired position, stapled into place in its medial aspect via the 4 mm staples along the iliopubic tract.  The 4.8 mm staples were then used to staple the superior edge of the mesh just below the peritoneum and then the patient was re-peritonealized, re-approximating edge of the perineum with the 4.8 mm staples.  This was done without difficulty.  All three ports were removed under direct visualization.  No evidence of bleeding and the #10 and #12 mm ports were closed with #0-Vicryl and UR6 needle.  Skin was closed with running subcuticular #4-0 undyed Vicryl.  Steri-Strips and sterile dressings were applied.  Attention was next made to carrying out the circumcision.  The foreskin was retracted back over the penis head.  The desired amount of removing foreskin was marked out with a skin marker.  The foreskin was then put on tension using a clamp to protect the penis head.  A #15 blade scalpel was used to remove the foreskin and sending off as specimen.  This was done without difficulty.  Next, the remaining edges were retracted, hemostasis was obtained with Bovie electrocautery and the skin edges were re-approximated with #2-0 plain gut in simple interrupted fashion and circumferentially.  This was done without difficulty maintaining hemostasis.,A petroleum jelly was applied with a Coban dressing.  The patient tolerated this procedure well and was well and was transferred to recovery after extubation in stable condition.","urology, herniorrhaphy with mesh, laparoscopic, blunt dissector, inguinal herniorrhaphy, inguinal hernia, hernia, inguinal, peritoneum, circumcision, phimosis, foreskin"
" Left inguinal herniorrhaphy, modified Bassini.  Left inguinal hernia, direct.", Urology, Inguinal Herniorrhaphy - 3 ,"PREOPERATIVE DIAGNOSIS:,  Left inguinal hernia.,POSTOPERATIVE DIAGNOSIS: , Left inguinal hernia, direct.,PROCEDURE: , Left inguinal herniorrhaphy, modified Bassini.,DESCRIPTION OF PROCEDURE:  ,The patient was electively taken to the operating room.  In same day surgery, Dr. X applied a magnet to the pacemaker defibrillator that the patient has to change it into a fixed mode and to protect the device from the action of the cautery.  Informed consent was obtained, and the patient was transferred to the operating room where a time-out process was followed and the patient under general endotracheal anesthesia was prepped and draped in the usual fashion.  Local anesthesia was used as a field block and then an incision was made in the left inguinal area and carried down to the external oblique aponeurosis, which was opened.  The cord was isolated and protected.  It was dissected out.  The lipoma of the cord was removed and the sac was high ligated.  The main hernia was a direct hernia due to weakness of the floor.  A Bassini repair was performed.  We used a number of interrupted sutures of 2-0 Tevdek __________ in the conjoint tendon and the ilioinguinal ligament.,The external oblique muscle was approximated same as the soft tissue with Vicryl and then the skin was closed with subcuticular suture of Monocryl.  The dressing was applied and the patient tolerated the procedure well, estimated blood loss was minimal, was transferred to recovery room in satisfactory condition.","urology, inguinal herniorrhaphy, modified bassini, herniorrhaphy modified bassini, hernia direct, inguinal hernia, inguinal, bassini,"
 Cystopyelogram and laser vaporization of the prostate., Urology, Laser Vaporization of Prostate ,"PREOPERATIVE DIAGNOSIS: , Benign prostatic hypertrophy.,POSTOPERATIVE DIAGNOSIS: , Benign prostatic hypertrophy.,SURGERY:  ,Cystopyelogram and laser vaporization of the prostate.,ANESTHESIA: , Spinal.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY: , The patient is a 67-year-old male with a history of TURP, presented to us with urgency, frequency, and dribbling.  The patient was started on alpha-blockers with some help, but had nocturia q.1h.  The patient was given anticholinergics with minimal to no help.  The patient had a cystoscopy done, which showed enlargement of the left lateral lobes of the prostate.  At this point, options were discussed such as watchful waiting and laser vaporization to open up the prostate to get a better stream.  Continuation of alpha-blockers and adding another anti-cholinergic at night to prevent bladder overactivity were discussed.  The patient was told that his symptoms may be related to the mild-to-moderate trabeculation in the bladder, which can cause poor compliance.,The patient understood and wanted to proceed with laser vaporization to see if it would help improve his stream, which in turn might help improve emptying of the bladder and might help his overactivity of the bladder.  The patient was told that he may need anticholinergics.  There could be increased risk of incontinence, stricture, erectile dysfunction, other complications and the consent was obtained.,PROCEDURE IN DETAIL:  ,The patient was brought to the OR and anesthesia was applied.  The patient was placed in dorsal lithotomy position.  The patient was given preoperative antibiotics.  The patient was prepped and draped in the usual sterile fashion.  A #23-French scope was inserted inside the urethra into the bladder under direct vision.  Bilateral pyelograms were normal.  The rest of the bladder appeared normal except for some moderate trabeculations throughout the bladder.  There was enlargement of the lateral lobes of the prostate.  The old TUR scar was visualized right at the bladder neck.  Using diode side-firing fiber, the lateral lobes were taken down.  The verumontanum, the external sphincter, and the ureteral openings were all intact at the end of the procedure.  Pictures were taken and were shown to the family.  At the end of the procedure, there was good hemostasis.  A total of about 15 to 20 minutes of lasering time was used.  A #22 3-way catheter was placed.  At the end of the procedure, the patient was brought to recovery in stable condition.  Plan was for removal of the Foley catheter in 48 hours and continuation of use of anticholinergics at night.","urology, laser vaporization of the prostate, cystopyelogram, benign prostatic hypertroph, benign prostatic hypertrophy, alpha blockers, laser vaporization, anticholinergics, laser, vaporization, prostate, bladder"
" Direct inguinal hernia.  Rutkow direct inguinal herniorrhaphy.  A standard inguinal incision was made, and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery.  ", Urology, Inguinal Herniorrhaphy - 1 ,"PREOPERATIVE DIAGNOSIS: , Inguinal hernia.,POSTOPERATIVE DIAGNOSIS: , Direct inguinal hernia.,PROCEDURE PERFORMED:,  Rutkow direct inguinal herniorrhaphy.,ANESTHESIA: , General endotracheal.,DESCRIPTION OF PROCEDURE:  ,After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table.  General endotracheal anesthesia was induced without incident.  Preoperative antibiotics were given for prophylaxis against surgical infection.  The patient was prepped and draped in the usual sterile fashion.,A standard inguinal incision was made, and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery.  The external oblique aponeurosis was cleared of overlying adherent tissue, and the external ring was delineated.  The external oblique was then incised with a scalpel and this incision was carried out to the external ring using Metzenbaum scissors.  Having exposed the inguinal canal, the cord structures were separated from the canal using blunt dissection, and a Penrose drain was placed around the cord structures at the level of the pubic tubercle.  This Penrose drain was then used to retract the cord structures as needed.  Adherent cremasteric muscle was dissected free from the cord using Bovie electrocautery.,The cord was then explored using a combination of sharp and blunt dissection, and no sac was found.  The hernia was found coming from the floor of the inguinal canal medial to the inferior epigastric vessels.  This was dissected back to the hernia opening.  The hernia was inverted back into the abdominal cavity and a large PerFix plug inserted into the ring.  The plug was secured to the ring by interrupted 2-0 Prolene sutures.,The PerFix onlay patch was then placed on the floor of the inguinal canal and secured in place using interrupted 2-0 Prolene sutures.  By reinforcing the floor with the onlay patch, a new internal ring was thus formed.,The Penrose drain was removed.  The wound was then irrigated using sterile saline, and hemostasis was obtained using Bovie electrocautery.  The incision in the external oblique was approximated using a 2-0 Vicryl in a running fashion, thus reforming the external ring.  The skin incision was approximated with 4-0 Monocryl in a subcuticular fashion.  The skin was prepped with benzoin, and Steri-Strips were applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.","urology, cremasteric muscle, pubic tubercle, external oblique aponeurosis, inguinal herniorrhaphy, inguinal hernia, cord structures, penrose drain, bovie electrocautery, inguinal, herniorrhaphy, metzenbaum, bovie, electrocautery, cord, hernia"
 Inguinal herniorrhaphy.  A standard inguinal incision was made and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery. , Urology, Inguinal Herniorrhaphy ,"PROCEDURE PERFORMED: , Inguinal herniorrhaphy.,PROCEDURE: , After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table.  General endotracheal anesthesia was induced without incident.  The patient was prepped and draped in the usual sterile manner.,A standard inguinal incision was made and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery.  The external oblique aponeurosis was cleared of overlying adherent tissue, and the external ring was delineated.  The external oblique was then incised with a scalpel, and this incision was carried out to the external ring using Metzenbaum scissors.  Having exposed the inguinal canal, the cord structures were separated from the canal using blunt dissection, and a Penrose drain was placed around the cord structures at the level of the pubic tubercle.  This Penrose drain was then used to retract the cord structures as needed.  Adherent cremasteric muscle was dissected free from the cord using Bovie electrocautery.,The cord was then explored using a combination of sharp and blunt dissection, and the sac was found anteromedially to the cord structures.  The sac was dissected free from the cord structures using a combination of blunt dissection and Bovie electrocautery.  Once preperitoneal fat was encountered, the dissection stopped and the sac was suture ligated at the level of the preperitoneal fat using a 2-0 silk suture ligature.  The sac was excised and went to  Pathology.  The ends of the suture were then cut and the stump retracted back into the abdomen.,The Penrose drain was removed.  The wound was then irrigated using sterile saline, and hemostasis was obtained using Bovie electrocautery.  The incision in the external oblique was approximated using a 3-0 Vicryl in a running fashion, thus reforming the external ring.  The skin incision was approximated with 4-0 Vicryl in a subcuticular fashion.  The skin was prepped and draped with benzoin, and Steri-Strips were applied.  A dressing consisting of a 2 x 2 and OpSite was then applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition.","urology, inguinal canal, cremasteric muscle, pubic tubercl, inguinal herniorrhaphy, blunt dissection, penrose drain, bovie electrocautery, cord structures, inguinal, electrocautery, cord"
 Inguinal orchiopexy procedure., Urology, Inguinal orchiopexy ,,"urology, inguinal orchiopexy, keith needles, aponeurosis, bolster, catgut, dartos pouch, external oblique, hernia sac, inguinal ring, orchiopexy, scrotal wall, spermatic cord, spermatic vessels, testicle, transverse inguinal skin crease incision, chromic catgut, inguinal, chromic, spermatic, scrotal, incisionNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Bilateral inguinal hernia.  Bilateral direct inguinal hernia repair utilizing PHS system and placement of On-Q pain pump. , Urology, Inguinal Hernia Repair - 3 ,"PREOPERATIVE DIAGNOSIS:,  Bilateral inguinal hernia. ,POSTOPERATIVE DIAGNOSIS: , Bilateral inguinal hernia. ,PROCEDURE: , Bilateral direct inguinal hernia repair utilizing PHS system and placement of On-Q pain pump. ,ANESTHESIA: , General with endotracheal intubation. ,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating room table.  General anesthesia was administered with endotracheal intubation and the abdomen and groins were prepped and draped in standard, sterile surgical fashion.  I did an ilioinguinal nerve block on both sides, injecting Marcaine 1 fingerbreadth anterior and 1 fingerbreadth superior to the anterior superior iliac spine on both sides.","urology, phs system, on-q, pump, on-q pain pump, inguinal hernia repair, bilateral inguinal hernia, anterior superior iliac, direct inguinal hernia, subcutaneous tissue, scarpa's fascia, cord structures, phs mesh, ilioinguinal nerve, external oblique, inguinal hernia, hernia, oblique, inguinal, mesh,"
 Direct right inguinal hernia.  Marlex repair of right inguinal hernia., Urology, Inguinal Hernia Repair - 5 ,"PREOPERATIVE DIAGNOSIS: , Right inguinal hernia.,POSTOPERATIVE DIAGNOSIS: , Direct right inguinal hernia.,TITLE OF PROCEDURE: , Marlex repair of right inguinal hernia.,ANESTHESIA:,  Spinal.,PROCEDURE IN DETAIL:,  The patient was taken to the operative suite, placed on the table in the supine position, and given a spinal anesthetic.  The right inguinal region was shaved and prepped and draped in a routine sterile fashion.  The patient received 1 gm of Ancef IV push.,Transverse incision was made in the intraabdominal crease and carried through skin and subcutaneous tissue.  The external oblique fascia was exposed and incised down to and through the external inguinal ring.  The spermatic cord and hernia sac were dissected bluntly off the undersurface of the external oblique fascia exposing the attenuated floor of the inguinal canal.  The cord was surrounded with a Penrose drain.  The hernia sac was separated from the cord structures.  The floor of the inguinal canal, which consisted of attenuated transversalis fascia, was imbricated upon itself with a running locked suture of 2-0 Prolene.  Marlex patch 1 x 4 in dimension was trimmed to an appropriate shape with a defect to accommodate the cord.  It was placed around the cord and sutured to itself with 2-0 Prolene.  The patch was then sutured medially to the pubic tubercle, inferiorly to Cooper's ligament and inguinal ligaments, and superiorly to conjoined tendon using 2-0 Prolene.  The area was irrigated with saline solution, and 0.5% Marcaine with epinephrine was injected to provide prolonged postoperative pain relief.  The cord was returned to its position.  External oblique fascia was closed with a running 2-0 PDS, subcu with 2-0 Vicryl, and skin with running subdermal 4-0 Vicryl and Steri-Strips.  Sponge and needle counts were correct.  Sterile dressing was applied.","urology, marlex repair, inguinal region, external oblique fascia, inguinal ring, direct right inguinal hernia, inguinal hernia, inguinal, repair, marlex, oblique, fascia, hernia, "
 Right inguinal hernia.    Right direct inguinal hernia repair with PHS mesh system.  The Right groin and abdomen were prepped and draped in the standard sterile surgical fashion.  An incision was made approximately 1 fingerbreadth above the pubic tubercle and in a skin crease. , Urology, Inguinal Hernia Repair - 4 ,"PREOPERATIVE DIAGNOSIS: , Right inguinal hernia. ,POSTOPERATIVE DIAGNOSIS:,  Right direct inguinal hernia. ,PROCEDURE:,  Right direct inguinal hernia repair with PHS mesh system. ,ANESTHESIA:,  General with endotracheal intubation. ,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating table.  General anesthesia was administered with endotracheal intubation.  The Right groin and abdomen were prepped and draped in the standard sterile surgical fashion.  An incision was made approximately 1 fingerbreadth above the pubic tubercle and in a skin crease.  Dissection was taken down through the skin and subcutaneous tissue.  Scarpa's fascia was divided, and the external ring was located.  The external oblique was divided from the external ring up towards the anterior superior iliac spine.  The cord structures were then encircled.  Careful inspection of the cord structures did not reveal any indirect sac along the cord structures.  I did, however, feel a direct sac with a direct defect.  I opened the floor of the inguinal canal and dissected out the preperitoneal space at the direct sac and cut out the direct sac.  Once I cleared out the preperitoneal space, I placed a PHS mesh system with a posterior mesh into the preperitoneal space, and I made sure that it laid flat along Cooper's ligament and covered the myopectineal orifice.  I then tucked the extended portion of the anterior mesh underneath the external oblique between the external oblique and the internal oblique, and I then tacked the medial portion of the mesh to the pubic tubercle with a 0 Ethibond suture.  I tacked the superior portion of the mesh to the internal oblique and the inferior portion of the mesh to the shelving edge of the inguinal ligament.  I cut a hole in the mesh in order to incorporate the cord structures and recreated the internal ring, making sure that it was not too tight so that it did not strangulate the cord structures.  I then closed the external oblique with a running 3-0 Vicryl.  I closed the Scarpa's with interrupted 3-0 Vicryl, and I closed the skin with a running Monocril.  Sponge, instrument and needle counts were correct at the end of the case.  The patient tolerated the procedure well and without any complications.","urology, groin, phs mesh, inguinal hernia repair, direct inguinal hernia, preperitoneal space, external oblique, cord structures, inguinal hernia, inguinal, hernia, external, oblique, mesh, "
" A 9-year-old boy with a history of intermittent swelling of the right inguinal area consistent with a right inguinal hernia, taken to the operating room for inguinal hernia repair.", Urology, Inguinal Hernia Repair - 1 ,"PREOPERATIVE DIAGNOSIS:,  Right inguinal hernia.,POSTOPERATIVE DIAGNOSIS:,  Right inguinal hernia.,PROCEDURE:,  Right inguinal hernia repair.,INDICATIONS FOR PROCEDURE: , This patient is a 9-year-old boy with a history of intermittent swelling of the right inguinal area consistent with a right inguinal hernia.  The patient is being taken to the operating room for inguinal hernia repair.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine, put under general endotracheal anesthesia.  The patient's inguinal and scrotal area were prepped and draped in the usual sterile fashion.  An incision was made in the right inguinal skin crease.  The incision was taken down to the level of the aponeurosis of the external oblique, which was incised up to the level of the external ring.  The hernia sac was verified and dissected at the level of the internal ring and a high ligation performed.  The distal remnant was taken to its end and excised.  The testicle and cord structures were placed back in their native positions.  The aponeurosis of the external oblique was reapproximated with 3-0 Vicryl as well as the Scarpa's, the skin closed with 5-0 Monocryl and dressed with Steri-Strips.  The patient was extubated in the operating room and taken back to the recovery room.  The patient tolerated the procedure well.","urology, inguinal skin crease, inguinal hernia repair, external oblique, hernia repair, inguinal hernia, inguinal, hernia, "
" Repair of left inguinal hernia indirect.  The patient states that she noticed there this bulge and pain for approximately six days prior to arrival.  Upon examination in the office, the patient was found to have a left inguinal hernia consistent with tear, which was scheduled as an outpatient surgery.", Urology, Inguinal Hernia Repair - Indirect ,"PREOPERATIVE DIAGNOSIS: , Left inguinal hernia.,POSTOPERATIVE DIAGNOSIS:, Left indirect inguinal hernia.,PROCEDURE PERFORMED:, Repair of left inguinal hernia indirect.,ANESTHESIA: , Spinal with local.,COMPLICATIONS:,  None.,DISPOSITION,:  The patient tolerated the procedure well, was transferred to recovery in stable condition.,SPECIMEN: , Hernia sac.,BRIEF HISTORY: , The patient is a 60-year-old female that presented to Dr. X's office with complaints of a bulge in the left groin.  The patient states that she noticed there this bulge and pain for approximately six days prior to arrival.  Upon examination in the office, the patient was found to have a left inguinal hernia consistent with tear, which was scheduled as an outpatient surgery.,INTRAOPERATIVE FINDINGS: , The patient was found to have a left indirect inguinal hernia.,PROCEDURE: , After informed consent was obtained, risks and benefits of the procedure were explained to the patient.  The patient was brought to the operating suite.  After spinal anesthesia and sedation given, the patient was prepped and draped in normal sterile fashion.  In the area of the left inguinal region just superior to the left inguinal ligament tract, the skin was anesthetized with 0.25% Marcaine.  Next, a skin incision was made with a #10 blade scalpel.  Using Bovie electrocautery, dissection was carried down to Scarpa's fascia until the external oblique was noted.  Along the side of the external oblique in the direction of the external ring, incision was made on both sides of the external oblique and then grasped with a hemostat.  Next, the hernia and hernia sac was circumferentially grasped and elevated along with the round ligament.  Attention was next made to ligating the hernia sac at its base for removal.  The hernia sac was opened prior grasping with hemostats.  It was a sliding indirect hernia.  The bowel contents were returned to abdomen using a #0 Vicryl stick tie pursestring suture at its base.  The hernia sac was ligated and then cut above with the Metzenbaum scissors returning it to the abdomen.  This was then sutured at the apex of the repair down to the conjoint tendon.  Next, attention was made to completely removing the round ligament hernia sac which was again ligated at its base with an #0 Vicryl suture and removed as specimen.  Attention was next made to reapproximate it at floor with a modified ______ repair.  Using a #2-0 Ethibond suture in simple interrupted fashion, the conjoint tendon was approximated to the ilioinguinal ligament capturing a little bit of the floor of the transversalis fascia.  Once this was done, the external oblique was closed over, reapproximated again with a #2-0 Ethibond suture catching each hump in between each repair from the prior floor repair.  This was done in simple interrupted fashion as well.  Next Scarpa's fascia was reapproximated with #3-0 Vicryl suture.  The skin was closed with running subcuticular #4-0 undyed Vicryl suture.  Steri-Strips and sterile dressings were applied.  The patient tolerated the procedure very well and he was transferred to Recovery in stable condition.  The patient had an abnormal chest x-ray in preop and is going for a CT of the chest in Recovery.","urology, bulge, groin, ethibond suture, vicryl suture, external oblique, inguinal hernia, hernia, inguinal, ligament, oblique, vicryl, indirect, sac, suture, repair,"
" Right inguinal hernia.   Right inguinal hernia repair.  The patient is a 4-year-old boy with a right inguinal bulge, which comes and goes with Valsalva standing and some increased physical activity.", Urology, Inguinal Hernia Repair - 6 ,"PREOPERATIVE DIAGNOSIS:,  Right inguinal hernia.,POSTOPERATIVE DIAGNOSIS: , Right inguinal hernia.,ANESTHESIA: , General.,PROCEDURE:  ,Right inguinal hernia repair.,INDICATIONS: , The patient is a 4-year-old boy with a right inguinal bulge, which comes and goes with Valsalva standing and some increased physical activity.  He had an inguinal hernia on physical exam in the Pediatric Surgery Clinic and is here now for elective repair.  We met with his parents and explained the surgical technique, risks, and talked to them about trying to perform a diagnostic laparoscopic look at the contralateral side to rule out an occult hernia.  All their questions have been answered and they agreed with the plan.,OPERATIVE FINDINGS:  ,The patient had a well developed, but rather thin walled hernia sac on the right.  The thinness of hernia sac made it difficult to safely cannulate through the sac for the laparoscopy.  Therefore, high ligation was performed, and we aborted the plan for laparoscopic view of the left side.,DESCRIPTION OF PROCEDURE: , The patient came to operating room and had an uneventful induction of general anesthesia.  Surgical time-out was conducted while we were preparing and draping his abdomen with chlorhexidine based prep solution.  During our time-out, we reiterated the patient's name, medical record number, weight, allergies status, and planned operative procedure.  I then infiltrated 0.25% Marcaine with dilute epinephrine in the soft tissues around the inguinal crease in the right lower abdomen chosen for hernia incision.  An additional aliquot of Marcaine was injected deep to the external oblique fascia performing the ilioinguinal and iliohypogastric nerve block.  A curvilinear incision was made with a scalpel and a combination of electrocautery and some blunt dissection and scissor dissection was used to clear the tissue layers through Scarpa fascia and expose the external oblique.  After the oblique layers were opened, the cord structure were identified and elevated.  The hernia sac was carefully separated from the spermatic cord structures and control of the sac was obtained.  Dissection of the hernia sac back to the peritoneal reflection at the level of deep inguinal ring was performed.  I attempted to gently pass a 3-mm trocar through the hernia sac, but it was rather difficult and I became fearful that the sac would be torn in proximal control and mass ligation would be less effective.  I aborted the laparoscopic approach and performed a high ligation using transfixing and a simple mass ligature of 3-0 Vicryl.  The excess sac was trimmed and the spermatic cord structures were replaced.  The external oblique fascia and Scarpa layers were closed with interrupted 3-0 Vicryl and skin was closed with subcuticular 5-0 Monocryl and Steri-Strips.  The patient tolerated the operation well.  Blood loss was less than 5 mL.  The hernia sac was submitted for specimen, and he was then taken to the recovery room in good condition.","urology, laparoscopic, external oblique fascia, oblique fascia, spermatic cord, cord structures, external oblique, hernia sac, inguinal hernia, sac, hernia, inguinal, fascia, repair, oblique,"
 Bilateral inguinal hernia and bilateral hydrocele repair with an ilioinguinal nerve block bilaterally., Urology, Inguinal Hernia Repair ,"PREOPERATIVE DIAGNOSES:,  Bilateral inguinal hernia, bilateral hydroceles.,POSTOPERATIVE DIAGNOSES:,  Bilateral inguinal hernia, bilateral hydroceles.,PROCEDURES: , Bilateral inguinal hernia and bilateral hydrocele repair with an ilioinguinal nerve block bilaterally by surgeon 20 mL given.,ANESTHESIA: , General inhalational anesthetic.,ABNORMAL FINDINGS:,  Same as above.,ESTIMATED BLOOD LOSS: , Less than 5 mL.,FLUIDS RECEIVED: , 400 mL of Crystalloid.,DRAINS: , No tubes or drains were used.,COUNT: , Sponge and needle counts were correct x2.,INDICATIONS FOR PROCEDURE:  ,The patient is a 7-year-old boy with the history of fairly sizeable right inguinal hernia and hydrocele, was found to have a second smaller one on evaluation with ultrasound and physical exam.  Plan is for repair of both.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operating room, where surgical consent, operative site and the patient's identification was verified.  Once he was anesthetized, he was then placed in a supine position and sterilely prepped and draped.  A right inguinal incision was then made with 15 blade knife and further extended with electrocautery down to the subcutaneous tissue and electrocautery was also used for hemostasis.  The external oblique fascia was then visualized and incised with 15 blade knife and further extended with curved tenotomy scissors.  Using a curved mosquito clamp, we gently dissected into the inguinal canal until we got the hernia sac and dissected it out of the canal.  The cord structures were then dissected off the sac and then the sac itself was divided in the midline, twisted upon itself and suture ligated up at the peritoneal reflection with 3-0 Vicryl suture.  This was done twice.  The distal end where a large hydrocele noted, was gently milked into the lower aspect of the incision.  The hydrocele sac was then opened and drained and then the testis was delivered into the field.  The sac was then opened completely around the testis.  The appendix testis was cauterized.  We wrapped the sac around the back of the testis and tacked into place using the Lord maneuver using 4-0 Vicryl as a figure-of-eight suture.  Once this was done, the testis was then placed back into the scrotum in the proper orientation.  Ilioinguinal nerve block and wound instillation was then done with 10 mL of 0.25% Marcaine.  A similar procedure was done on the left side, also finding a small hernia, which was divided and ligated with the 3-0 Vicryl as on the right side and distally the hydrocele sac was also wrapped around the back of the testis in a Lord maneuver after opening the sac completely.  Again both testes were placed into the scrotum after the hydroceles were treated and then the external oblique fascia was closed on both sides with a running suture of 3-0 Vicryl ensuring that the ilioinguinal nerve and the cord structures not involved in the closure.  Scarpa fascia was closed with 4-0 chromic suture on each side and the skin was closed with 4-0 Rapide subcuticular closure.  Dermabond tissue adhesive was placed on both incisions.  IV Toradol was given at the end of the procedure and both testes were well descended within the scrotum at the end of the procedure.  The patient tolerated the procedure and was in stable condition upon transfer to the recovery room.","urology, bilateral hydrocele repair, bilateral inguinal hernia, external oblique fascia, ilioinguinal nerve block, bilateral hydroceles, external oblique, oblique fascia, cord structures, hydrocele sac, lord maneuver, nerve block, bilateral inguinal, ilioinguinal nerve, inguinal hernia, hernia, inguinal, hydrocele, bilateral, sac,"
 Left direct and indirect inguinal hernia.  Repair of left inguinal hernia with Prolene mesh.  The patient was found to have a left inguinal hernia increasing over the past several months.  The patient has a history of multiple abdominal surgeries and opted for an open left inguinal hernial repair with Prolene mesh., Urology, Inguinal Hernia Repair - 2 ,"PREOPERATIVE DIAGNOSIS:,  Left inguinal hernia.,POSTOPERATIVE DIAGNOSIS:, Left direct and indirect inguinal hernia.,PROCEDURE PERFORMED:, Repair of left inguinal hernia with Prolene mesh.,ANESTHESIA: , IV sedation with local.,COMPLICATIONS:,  None.,DISPOSITION:  ,The patient tolerated the procedure well and was transferred to Recovery in stable condition.,SPECIMEN: , Hernia sac, as well as turbid fluid with gram stain, which came back with no organisms from the hernia sac.,BRIEF HISTORY:  ,This is a 53-year-old male who presented to Dr. Y's office with a bulge in the left groin and was found to have a left inguinal hernia increasing over the past several months.  The patient has a history of multiple abdominal surgeries and opted for an open left inguinal hernial repair with Prolene mesh.,INTRAOPERATIVE FINDINGS: , The patient was found to have a direct as well as an indirect component to the left inguinal hernia with a large sac.  The patient was also found to have some turbid fluid within the hernia sac, which was sent down for gram stain and turned out to be negative with no organisms.,PROCEDURE: , After informed consent, risks and benefits of the procedure were explained to the patient, the patient was brought to the operative suite, prepped and draped in the normal sterile fashion.  The left inguinal ligament was identified from the pubic tubercle to the ASIS.  Two fingerbreadths above the pubic tubercle, a transverse incision was made.  First, the skin was anesthetized with 1% lidocaine and then an incision was made with a #15 blade scalpel, approximately 6 cm in length.  Dissection was then carried down with electro Bovie cautery through Scarpa's fascia maintaining hemostasis.  Once the external oblique was identified, external oblique was incised in the length of its fibers with a #15 blade scalpel.  Metzenbaum scissors were then used to extend the incision in both directions opening up the external oblique down to the external ring.  Next, the external oblique was grasped with Ochsner on both sides.  The cord, cord structures as well as hernia sac were freed up circumferentially and a Penrose drain was placed around it.  Next, the hernia sac was identified and the anteromedial portion of the hernia sac was stripped down, grasped with two hemostats.  A Metzenbaum scissor was then used to open the hernia sac and the hernia sac was explored.  There was some turbid fluid within the hernia sac, which was sent down for cultures.  Gram stain was negative for organisms.  Next, the hernia sac was to be ligated at its base and transected.  A peon was used at the base.  Metzenbaum scissor was used to cut the hernia sac and sending it off as a specimen.  An #0 Vicryl stick suture was used with #0 Vicryl loop suture to suture ligate the hernia sac at its base.,Next, attention was made to placing a Prolene mesh to cover the floor.  The mesh was sutured to the pubic tubercle medially along the ilioinguinal ligament inferiorly and along the conjoint tendon superiorly making a slit for the cord and cord structures.  Attention was made to salvaging the ilioinguinal nerve, which was left above the repair of the mesh and below the external oblique once closed and appeared to be intact.  Attention was next made after suturing the mesh with the #2-0 Polydek suture.  The external oblique was then closed over the roof with a running #0 Vicryl suture, taking care not to strangulate the cord and to recreate the external ring.  After injecting the external oblique and cord structures with Marcaine for anesthetic, the Scarpa's fascia was approximated with interrupted #3-0 Vicryl sutures.  The skin was closed with a running subcuticular #4-0 undyed Vicryl suture.  Steri-Strip with sterile dressings were applied.,The patient tolerated the procedure well and was transferred to Recovery in stable condition.","urology, left inguinal hernia, prolene mesh, hernia sac, gram stain, inguinal hernia repair, inguinal hernial repair, metzenbaum scissors, cord structures, inguinal hernia, sac, inguinal, hernia, metzenbaum, prolene, vicryl, cord, suture, oblique, mesh,"
" Right inguinal exploration, left inguinal hernia repair, bilateral hydrocele repair, and excision of right appendix testis.", Urology, Inguinal Exploration ,"PREOPERATIVE DIAGNOSES:,  Bilateral inguinal hernias with bilateral hydroceles after right inguinal hernia repair, cerebral palsy, asthma, seizure disorder, developmental delay, and gastroesophageal reflux disease.,POSTOPERATIVE DIAGNOSES: , Left inguinal hernia, bilateral hydroceles, and right torsed appendix testis.,PROCEDURE: , Right inguinal exploration, left inguinal hernia repair, bilateral hydrocele repair, and excision of right appendix testis.,FLUIDS RECEIVED:  ,700 mL of crystalloid.,ESTIMATED BLOOD LOSS:  ,10 mL.,SPECIMENS:,  Tissue sent to pathology is calcified right appendix testis.,TUBES/DRAINS: , No tubes or drains were used.,COUNTS:  ,Sponge and needle counts were correct x2.,ANESTHESIA: , General inhalational anesthetic and 0.25% Marcaine ilioinguinal nerve block, 30 mL given per surgeon.,INDICATIONS FOR OPERATION:  ,The patient is a 14-1/2-year-old boy with multiple medical problems, primarily due to cerebral palsy, asthma, seizures, gastroesophageal reflux disease, and developmental delay.  He had a hernia repair done on the right in the past, but developed a new hernia on the right and a smaller on the left.  The plan is for repair.,DESCRIPTION OF OPERATION: , The patient was taken to the operating room, where surgical consent, operative site, and patient identification were verified.  Once he was anesthetized, he was then placed in the supine position.  IV antibiotics were given.  He was then sterilely prepped and draped.  A right inguinal incision was made in the previous incisional site with a 15-blade knife, extended down through the subcutaneous tissue and Scarpa fascia with electrocautery.  Electrocautery was used for hemostasis.,The external oblique fascia was then visualized and incised.  There was a moderate amount of scar tissue noted, but we were able to incise that and go down into the right inguinal canal.  Upon dissection there, we did not find any hernias; however, he did have a fairly sizable hydrocele.  We went down towards the external ring and found that this was indeed tight without any hernias.,We then closed up the external oblique fascia and made an incision after doing a shave on the right and left scrotum into the upper scrotal sac with a curvilinear incision with a 15-blade knife.  We then extended down to the subcutaneous tissue.  Electrocautery was used for hemostasis.  The hydrocele sac was visualized and then drained after incising into it with a curved Metzenbaum scissors.  The testis was then delivered and found to have a moderate amount of scar tissue with a calcified appendix testis, which was then excised and sent to pathology.  We then checked the upper aspect of the tunica vaginalis pouch and found that there was indeed no other connection, was up above, so we then wrapped the sac around the back of the testis, and closed it with a 4-0 chromic suture in a Lord maneuver.  We then closed the upper aspect of the subdartos pouch with a pursestring suture of 4-0 chromic and placed the testis into the scrotum in the proper orientation.  We then used an ilioinguinal nerve block and wound instillation on both incisional areas with 0.25% Marcaine without epinephrine; 15 mL was given.,We performed a similar procedure on the left, incising it at the scrotal area first, rather than below, and found this tunica vaginalis, and dissected it in a similar fashion and cauterized the appendix testis, which was not torsed.  This was a smaller hydrocele, but because of the __________ shunt, we went up above and found that there was a very small connection, which was then dissected off the cord structures gently, twisted upon itself, suture ligated with a 2-0 Vicryl suture.,The ilioinguinal nerve block and other wound instillations again with 15 mL total of 0.25% Marcaine were then done by the surgeon as well.  The external oblique fascia was closed on both sides with a running suture of 2-0 Vicryl.  4-0 chromic was then used to close the Scarpa fascia.  The skin was closed with a 4-0 Rapide subcuticular closure.  The scrotal incisions were closed with a subcutaneous and dartos closure using 4-0 chromic.  IV Toradol was given at the end of the procedure.  Dermabond tissue adhesive was placed on all 4 incisions.  The patient tolerated the procedure well and was in a stable condition upon transfer to the recovery room.","urology, inguinal exploration, inguinal hernia repair, hydrocele repair, appendix testis, ilioinguinal nerve block, external oblique fascia, tunica vaginalis, ilioinguinal nerve, inguinal hernia, hernia repair, hernia, torsed, inguinal, hydrocele, appendix, testis, "
" Left communicating hydrocele.  Left inguinal hernia and hydrocele repair.  The patient is a 5-year-old young man with fluid collection in the tunica vaginalis and peritesticular space on the left side consistent with a communicating hydrocele. 
", Urology, Inguinal Hernia & Hydrocele Repair ,"PREOPERATIVE DIAGNOSIS:  ,Left communicating hydrocele.,POSTOPERATIVE DIAGNOSIS: , Left communicating hydrocele.,ANESTHESIA: , General.,PROCEDURE:  ,Left inguinal hernia and hydrocele repair.,INDICATIONS: , The patient is a 5-year-old young man with fluid collection in the tunica vaginalis and peritesticular space on the left side consistent with a communicating hydrocele.  The fluid size tends to fluctuate with time but has been relatively persistent for the past year.  I met with the patient's mom and also spoke with his father by phone in the past couple of months and explained the diagnosis of patent processus vaginalis for communicating hydrocele and talked to them about the surgical treatment and options.  All their questions have been answered and the patient is fit for operation today.,OPERATIVE FINDINGS:  ,The patient had a very thin patent processus vaginalis leading to a rather sizeable hydrocele sac in the left hemiscrotum.  We probably drained around 10 to 15 mL of fluid from the hydrocele sac.  The processus vaginalis was clearly seen back to the peritoneal reflection where a high ligation was successfully performed.  There were no other abnormalities noted in the inguinal scrotal region.,DESCRIPTION OF OPERATION: , The patient came to the operating room and had an uneventful induction of inhalation anesthetic.  A peripheral IV was placed, and we conducted a surgical time-out to reiterate all of The patient's important identifying information and to confirm that we were indeed going to perform a left inguinal hernia and hydrocele repair.  After preparation and draping was done with chlorhexidine based prep solution, a local infiltration block as well as an ilioinguinal and iliohypogastric nerve block was performed with 0.25% Marcaine with dilute epinephrine.  A curvilinear incision was made low in the left inguinal area along one of prominent skin folds.  Soft tissue dissection was carried down through Scarpa's layer to the external oblique fascia, which was then opened to expose the underlying spermatic cord structures.  The processus vaginalis was dissected free from the spermatic cord structures, and the distal hydrocele sac was widely opened and drained of its fluid contents.  The processus vaginalis was cleared back to peritoneal reflection at the deep inguinal ring and a high ligation was performed there using both the transfixing and a mass ligature of 3-0 Vicryl.  After the excess hydrocele and processus vaginalis tissue was excised, the spermatic cord structures were replaced and the external oblique and Scarpa's layers were closed with interrupted 3-0 Vicryl sutures.  Subcuticular 5-0 Monocryl and Steri-Strips were used for the final skin closure.  The patient tolerated the operation well.  He was awakened and taken to the recovery room in good condition.  Blood loss was minimal.  No specimen was submitted.,","urology, hydrocele, hydrocele repair, hernia, inguinal, fluid collection, tunica vaginalis, peritesticular space, hydrocele sac, spermatic cord, cord structures, inguinal hernia, communicating hydrocele, fluid, vaginalis"
" Incision and drainage of the penoscrotal abscess, packing, penile biopsy, cystoscopy, and urethral dilation.", Urology, I&D - Penoscrotal Abscess ,"PREOPERATIVE DIAGNOSIS: , Penoscrotal abscess.,POSTOPERATIVE DIAGNOSIS:,  Penoscrotal abscess.,OPERATION: , Incision and drainage of the penoscrotal abscess, packing, penile biopsy, cystoscopy, and urethral dilation.,BRIEF HISTORY: , The patient is a 75-year-old male presented with penoscrotal abscess.  Options such as watchful waiting, drainage, and antibiotics were discussed.  Risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, completely the infection turning into necrotizing fascitis, Fournier's gangrene were discussed.  The patient already had significant phimotic changes and disfigurement of the penis.  For further debridement the patient was told that his penis is not going to be viable, he may need a total or partial penectomy now or in the future.  Risks of decreased penile sensation, pain, Foley, other unexpected issues were discussed.  The patient understood all the complications and wanted to proceed with the procedure.,DETAIL OF THE OPERATION:  ,The patient was brought to the OR.  The patient was placed in dorsal lithotomy position.  The patient was prepped and draped in the usual fashion.  Pictures were taken prior to starting the procedure for documentation.  The patient had an open sore on the right side of the penis measuring about 1 cm in size with pouring pus out using blunt dissection.  The penile area was opened up distally to allow the pus to come out.  The dissection around the proximal scrotum was done to make sure there are no other pus pockets.  The corporal body was intact, but the distal part of the corpora was completely eroded and had a fungating mass, which was biopsied and sent for permanent pathology analysis.,Urethra was identified at the distal tip, which was dilated and using 23-French cystoscope cystoscopy was done, which showed some urethral narrowing in the distal part of the urethra.  The rest of the bladder appeared normal.  The prostatic urethra was slightly enlarged.  There are no stones or tumors inside the bladder.  There were moderate trabeculations inside the bladder.  Otherwise, the bladder and the urethra appeared normal.  There was a significantly fungating mass involving the distal part of the urethra almost possibility to have including the fungating wart or fungating squamous cell carcinoma.  Again biopsies were sent for pathology analysis.  Prior to urine irrigation anaerobic aerobic cultures were sent, irrigation with over 2 L of fluid was performed.  After irrigation, packing was done with Kerlix.  The patient was brought to recovery in a stable condition.  Please note that 18-French Foley was kept in place.  Electrocautery was used at the end of the procedure to obtain hemostasis as much as possible, but there was fungating mass with slight bleeding packing was done and tight scrotal Kling was applied.  The patient was brought to Recovery in a stable condition after applying 0.5% Marcaine about 20 mL were injected around for local anesthesia.","urology, i&d, penoscrotal, penile biopsy, cystoscopy, urethral dilation, incision and drainage, fungating mass, penoscrotal abscess, abscess, urethral, "
 Hypospadias repair (TIP) with tissue flap relocation and chordee release (Nesbit tuck)., Urology, Hypospadias Repair & Chordee Release - 1 ,"PREOPERATIVE DIAGNOSES: , Coronal hypospadias with chordee and asthma.,POSTOPERATIVE DIAGNOSES:,  Coronal hypospadias with chordee and asthma.,PROCEDURE: , Hypospadias repair (TIP) with tissue flap relocation and chordee release (Nesbit tuck).,ANESTHETIC: , General inhalational anesthetic with a caudal block.,FLUIDS RECEIVED:  ,300 mL of crystalloid.,ESTIMATED BLOOD LOSS:  ,20 mL.,TUBES/DRAINS:  ,An 8-French Zaontz catheter.,INDICATIONS FOR OPERATION:  ,The patient is a 17-month-old boy with hypospadias abnormality.  The plan is for repair.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operating room, where surgical consent, operative site, and patient identification were verified.  Once he was anesthetized, a caudal block was placed.  IV antibiotics were given.  He was then placed in the supine position.  The foreskin was retracted and cleansed.  He was then sterilely prepped and draped.  A stay stitch of 4-0 Prolene was then placed on the glans.  The urethra was calibrated with the lacrimal duct probes to an 8-French.  We then marked out the coronal cuff, the penile shaft skin as well as the glanular plate for future surgery with a marking pen.,We then used a 15-blade knife to circumscribe the penis around the coronal cuff.  We then degloved the penis using the curved tenotomy scissors, and electrocautery was used for hemostasis.  The patient had some splaying of the spongiosum tissue, which was also incised laterally and rotated to make a secondary flap.  Once the penis was degloved, and the excessive chordee tissue was released, we then placed a vessel loop tourniquet around the base of the penis and using IV grade saline injected the penis for an artifical erection.  He was still noted to have chordee, so a midline incision through the Buck fascia was made with a 15-blade knife and Heineke-Mikulicz closure using 5-0 Prolene was then used for the chordee Nesbit tuck.  We repeated the artificial erection and the penis was straight.  We then incised the urethral plate with an ophthalmic blade in the midline, and then elevated the glanular wings using a 15-blade knife to elevate and then incise them.  Using the curved iris scissors, we then also further mobilized the glanular wings.  The 8-French Zaontz was then placed while the tourniquet was still in place into the urethral plate.  The upper aspect of the distal meatus was then closed with an interrupted suture of 7-0 Vicryl, and then using a running subcuticular closure, we closed the urethral plates over the Zaontz catheter.  We then mobilized subcutaneous tissue from the penile shaft skin, and the inner perpetual skin on the dorsum, and then buttonholed the flap, placed it over the head of the penis, and then, used it to cover of the hypospadias repair with tacking sutures of 7-0 Vicryl.  We then rolled the spongiosum flap to cover the distal urethra that was also somewhat dysplastic; 7-0 Vicryl was used for that as well.  5-0 Vicryl was used to roll the glans with 2 deep sutures, and then, horizontal mattress sutures of 7-0 Vicryl were used to reconstitute the glans.  Interrupted sutures of 7-0 Vicryl were used to approximate the urethral meatus to the glans.  Once this was done, we then excised the excessive penile shaft skin, and used the interrupted sutures of 6-0 chromic to attach the penile shaft skin to the coronal cuff.  On the ventrum itself, we used horizontal mattress sutures to close the defect.,At the end of the procedure, the Zaontz catheter was sutured into place with a 4-0 Prolene suture, Dermabond tissue adhesive, and Surgicel was used as a dressing and a second layer of Telfa and clear eye tape was then used to tape it into place.  IV Toradol was given at the procedure.  The patient tolerated the procedure well and was in a stable condition upon transfer to the recovery room.","urology, coronal hypospadias with chordee, coronal hypospadias, tissue flap relocation, nesbit tuck, hypospadias with chordee, horizontal mattress sutures, chordee release, zaontz catheter, coronal cuff, hypospadias repair, penile shaft, zaontz, glans, urethral, repair, coronal, hypospadias, penis, chordee,"
" Pelvic tumor, cystocele, rectocele, and uterine fibroid.  Total abdominal hysterectomy, bilateral salpingooophorectomy, repair of bladder laceration, appendectomy, Marshall-Marchetti-Krantz cystourethropexy, and posterior colpoperineoplasty. She had a recent D&C and laparoscopy, and enlarged mass was noted and could not be determined if it was from the ovary or the uterus. ", Urology," Hysterectomy, BSO, & Appendectomy. ","1.  Pelvic tumor.,2.  Cystocele.,3.  Rectocele.,POSTOPERATIVE DIAGNOSES:,1.  Degenerated joint.,2.  Uterine fibroid.,3.  Cystocele.,4.  Rectocele.,PROCEDURE PERFORMED:  ,1.  Total abdominal hysterectomy.,2.  Bilateral salpingooophorectomy.,3.  Repair of bladder laceration.,4.  Appendectomy.,5.  Marshall-Marchetti-Krantz cystourethropexy.,6.  Posterior colpoperineoplasty.,GROSS FINDINGS:  The patient had a history of a rapidly growing mass on the abdomen, extending from the pelvis over the past two to three months.  She had a recent D&C and laparoscopy, and enlarged mass was noted and could not be determined if it was from the ovary or the uterus.  Curettings were negative for malignancy.  The patient did have a large cystocele and rectocele, and a collapsed anterior and posterior vaginal wall.,Upon laparotomy, there was a giant uterine tumor extending from the pelvis up to the above the umbilicus compatible with approximately four to five-month pregnancy.  The ovaries appeared to be within normal limits.  There was marked adherence between the bladder and the giant uterus and mass with edema and inflammation, and during dissection, a laceration inadvertently occurred and it was immediately recognized.  No other pathology noted from the abdominal cavity or adhesions.  The upper right quadrant of the abdomen compatible with a previous gallbladder surgery.  The appendix is in its normal anatomic position.  The ileum was within normal limits with no Meckel's diverticulum seen and no other gross pathology evident.  There was no evidence of metastasis or tumors in the left lobe of the liver.,Upon frozen section, diagnosis of initial and partial is that of a degenerating uterine fibroid rather than a malignancy.,OPERATIVE PROCEDURE:  The patient was taken to the Operating Room, prepped and draped in the low lithotomy position under general anesthesia.  A midline incision was made around the umbilicus down to the lower abdomen.  With a #10 Bard Parker blade knife, the incision was carried down through the fascia.  The fascia was incised in the midline, muscle fibers were splint in the midline, the peritoneum was grasped with hemostats and with a #10 Bard Parker blade after incision was made with Mayo scissors.  A Balfour retractor was placed into the wound.  This giant uterus was soft and compatible with a possible leiomyosarcoma or degenerating fibroid was handled with care.  The infundibular ligament on the right side was isolated and ligated with #0 Vicryl suture brought to an avascular area, doubly clamped and divided from the ovary and the ligament again re-ligated with #0 Vicryl suture.  The right round ligament was ligated with #0 Vicryl suture, brought to an avascular space within the broad ligament and divided from the uterus.  The infundibulopelvic ligament on the left side was treated in a similar fashion as well as the round ligament.  An attempt was made to dissect the bladder flap from the anterior surface of the uterus and this was remarkably edematous and difficult to do, and during dissection the bladder was inadvertently entered.  After this was immediately recognized, the bladder flap was wiped away from the anterior surface of the uterus.  The bladder was then repaired with a running locking stitch #0 Vicryl suture incorporating serosal muscularis mucosa and then the second layer of overlapping seromuscular sutures were used to make a two-layer closure of #0 Vicryl suture.  After removing the uterus, the bladder was tested with approximately 400 cc of sterile water and there appeared to be no leak.  Progressing and removing of the uterus was then carried out and the broad ligament was clamped bilaterally with a straight Ochsner forceps and divided from the uterus with Mayo scissors, and the straight Ochsner was placed by #0 Vicryl suture thus controlling the uterine blood supply.  The cardinal ligaments containing the cervical blood supply was serially clamped bilaterally with a curved Ochsner forceps, divided from the uterus with #10 Bard Parker blade knife and a curved Ochsner was placed by #0 Vicryl suture.  The cervix was again grasped with a Lahey tenaculum and pubovesicocervical ligament was entered and was divided using #10 Bard Parker blade knife and then the vaginal vault and with a double pointed sharp scissors.  A single-toothed tenaculum was placed on the cervix and then the uterus was removed from the vagina using hysterectomy scissors.  The vaginal cuff was then closed using a running #0 Vicryl suture in locking stitch incorporating all layers of the vagina, the cardinal ligaments of the lateral aspect and uterosacral ligaments on the posterior aspect.  The round ligaments were approximated to the vaginal cuff with #0 Vicryl suture and the bladder flap approximated to the round ligaments with #000 Vicryl suture.  The ______ was re-peritonealized with #000 Vicryl suture and then the cecum brought into the incision.  The pelvis was irrigated with approximately 500 cc of water.  The appendix was grasped with Babcock forceps.  The mesoappendix was doubly clamped with curved hemostats and divided with Metzenbaum scissors.  The curved hemostats were placed with #00 Vicryl suture.  The base of the appendix was ligated with #0 plain gut suture, doubly clamped and divided from the distal appendix with #10 Bard Parker blade knife, and the base inverted with a pursestring suture with #00 Vicryl.  No bleeding was noted.  Sponge, instrument, and needle counts were found to be correct.  All packs and retractors were removed.  The peritoneum muscle fascia was closed in single-layer closure using running looped #1 PDS, but prior to closure, a Marshall-Marchetti-Krantz cystourethropexy was carried out by dissecting the space of Retzius identifying the urethra in the vesical junction approximating the periurethral connective tissue to the symphysis pubis with interrupted #0 Vicryl suture.  Following this, the abdominal wall was closed as previously described and the skin was closed using skin staples.  Attention was then turned to the vagina, where the introitus of the vagina was grasped with an Allis forceps at the level of the Bartholin glands.  An incision was made between the mucous and the cutaneous junction and then a midline incision was made at the posterior vaginal mucosa in a tunneling fashion with Metzenbaum scissors.  The flaps were created bilaterally by making an incision in the posterior connective tissue of the vagina and wiping the rectum away from the posterior vaginal mucosa, and flaps were created bilaterally.  In this fashion, the rectocele was reduced and the levator ani muscles were approximated in the midline with interrupted #0 Vicryl suture.  Excess vaginal mucosa was excised and the vaginal mucosa closed with running #00 Vicryl suture.  The bulbocavernosus and transverse perinei muscles were approximated in the midline with interrupted #00 Vicryl suture.  The skin was closed with a running #000 plain gut subcuticular stitch.  The vaginal vault was packed with a Betadine-soaked Kling gauze sponge.  Sterile dressing was applied.  The patient was sent to recovery room in stable condition.","urology, marshall-marchetti-krantz cystourethropexy, pelvic tumor, cystocele, rectocele, uterine fibroid, hysterectomy, salpingooophorectomy, bladder laceration, appendectomy, colpoperineoplasty, marshall marchetti krantz cystourethropexy, bard parker blade knife, vicryl suture, vaginal mucosa, uterus, vaginal, uterine, mucosa, scissors, ligament, bladder"
 Hypospadias repair (TIT and tissue flap relocation) and Nesbit tuck chordee release., Urology, Hypospadias Repair & Chordee Release ,"PREOPERATIVE DIAGNOSIS:,  Penoscrotal hypospadias with chordee.,POSTOPERATIVE DIAGNOSIS: , Penoscrotal hypospadias with chordee.,PROCEDURE:,  Hypospadias repair (TIT and tissue flap relocation) and Nesbit tuck chordee release.,ANESTHESIA: , General inhalation anesthetic with a caudal block.,FLUIDS RECEIVED: , 300 mL of crystalloids.,ESTIMATED BLOOD LOSS: , 15 mL.,SPECIMENS: , No tissue sent to Pathology.,TUBES AND DRAINS: , An 8-French Zaontz catheter.,INDICATIONS FOR OPERATION: , The patient is a 1-1/2-year-old boy with penoscrotal hypospadias; plan is for repair.,DESCRIPTION OF PROCEDURE:  ,The patient was taken to the operating room, where surgical consent, operative site and the patient's identification was verified.  Once he was anesthetized, a caudal block was placed.  IV antibiotic was given.  The dorsal hood was retracted and the patient was then sterilely prepped and draped.  A stay stitch of 4-0 Prolene was then placed in the glans for traction.  His urethra was calibrated, it was quite thin, to a 10-French with the straight sounds.  We then marked the coronal cuff and the urethral plate as well as the penile shaft skin with marking pen and incised the coronal cuff circumferentially and then around the urethral plate with the 15 blade knife and then degloved the penis with a curved tenotomy scissors.  Electrocautery was used for hemostasis.  The ventral chordee tissue was removed.  We then placed a vessel loop tourniquet around the base of the penis and using IV grade saline did an artificial erection test, which showed that he had a persistent chordee.  In the midline a 15 blade knife was used to incise Buck fascia after marking the area of chordee with the marking pen.  We then used a Heinecke-Mikulicz Nesbit tuck with 5-0 Prolene to straighten the penis.  Artificial erection again performed showed the penis was straight.  The knot was buried with figure-of-eight suture of 7-0 Vicryl in Buck fascia above it.  We then left the tourniquet in place and then after marking the urethral plate incised it and enlarged it with Beaver blade and a 15 blade.  We then elevated the glanular wings as well in the similar fashion.  An 8-French Zaontz catheter was then placed and the urethral plate was then closed over this with a distal interrupted sutures of 7-0 Vicryl and then a running subcuticular closure of 7-0 Vicryl to close the defect.  We then put the stay sutures in the inter-preputial skin with 7-0 Vicryl and then rotated a flap using the subcutaneous tissue after dissecting it down to the pubis at the base of the penile shaft on the dorsum using the curved iris scissors.  We buttonholed the flap and then placed it through the penis as a sleeve.  Interrupted sutures of 7-0 Vicryl then used to reapproximate and to tack this flap and place over the urethroplasty.  Once this was done, a two 5-0 Vicryl deep sutures were placed in the glans to rotate the glans and allow for hemostasis.  Interrupted sutures of 7-0 Vicryl were then used to create the neomeatus and horizontal mattress sutures of 7-0 Vicryl used to reconstitute the glans.  We then removed the excessive preputial skin and using tacking sutures of 6-0 chromic tacked the penile shaft skin to the coronal cuff and on the ventrum we dropped a portion of the skin down on the left side of the penis to reconstitute the penoscrotal junction using horizontal mattress sutures.  We then closed the ventral defect.  Once this was done, the stay suture in the glans was used to keep the Zaontz catheter to tack it into place.  We then used Surgicel, Dermabond, and Telfa dressing with Mastisol and an eye tape to keep the dressing in place.  IV Toradol was given at the end of the procedure.  The patient was in stable condition upon transfer to the recovery room.","urology, tissue flap relocation, penoscrotal hypospadias, urethra, nesbit tuck chordee release, horizontal mattress sutures, hypospadias repair, chordee release, zaontz catheter, urethral plate, glans, hypospadias, penis, chordee,"
 Hypospadias repair. Urethroplasty plate incision with tissue flap relocation and chordee release., Urology, Hypospadias Repair ,"PREOPERATIVE DIAGNOSIS: , Coronal hypospadias with chordee.,POSTOPERATIVE DIAGNOSIS: , Coronal hypospadias with chordee.,PROCEDURE: , Hypospadias repair (urethroplasty plate incision with tissue flap relocation and chordee release).,ANESTHESIA: , General inhalation anesthetic with a 0.25% Marcaine dorsal block and ring block per surgeon, 7 mL given.,TUBES AND DRAINS: , An 8-French Zaontz catheter.,ESTIMATED BLOOD LOSS:  ,10 mL.,FLUIDS RECEIVED:,  300 mL.,INDICATIONS FOR OPERATION: , The patient is a 6-month-old boy with the history of coronal hypospadias with chordee.  Plan is for repair.,DESCRIPTION OF OPERATION: , The patient was taken to the operating room with surgical consent, operative site, and the patient identification were verified.  Once he was anesthetized, IV antibiotics were given.  The dorsal hood was retracted and cleansed.  He was then sterilely prepped and draped.  Stay suture of #4-0 Prolene was then placed in the glans.  His urethra was calibrated to 10-French bougie-a-boule.  We then marked the coronal cuff and the penile shaft skin, as well as the periurethral meatal area on the ventrum.  Byers flaps were also marked.  Once this was done, the skin was then incised around the coronal cuff with 15-blade knife and further extended with the curved tenotomy scissors to deglove the penis.  On the ventrum, the chordee tissue was removed and dissected up towards the urethral plate to use as secondary tissue flap coverage.  Once this was done, an electrocautery was used for hemostasis were then used.  A vessel loop tourniquet and IV grade saline was used for achieve artificial erection and chordee.  We then incised Buck fascia at the area of chordee in the ventrum and then used the #5-0 Prolene as a Heinecke-Mikulicz advancement suture.  Sutures were placed burying the knot and then artificial erection was again performed showing the penis was straight.  We then left the tourniquet in place, although loosened it slightly and then marked out the transurethral incision plate with demarcation for the glans and the ventral midline of the plate.  We then incised it with the ophthalmic micro lancet blade in the midline and along the __________ to elevate the glanular wings.  Using the curved iris scissors, we then elevated the wings even further.  Again, electrocautery was used for hemostasis.  An 8-French Zaontz catheter was then placed into the urethral plate and then interrupted suture of #7-0 Vicryl was used to mark the distal most extent of the urethral meatus and then the urethral plate was rolled using a subcutaneous closure using the #7-0 Vicryl suture.  There were two areas of coverage with the tissue flap relocation from the glanular wings.  The tissue flap that was rolled with the Byers flap was used to cover this, as well as the chordee tissue with interrupted sutures of #7-0 Vicryl.  Once this was completed, the glans itself had been rolled using two deep sutures of #5-0 Vicryl.  Interrupted sutures of #7-0 Vicryl were used to create the neomeatus and then horizontal mattress sutures of #7-0 Vicryl used to roll the glans in the midline.  The extra dorsal hood tissue of preputial skin was then excised.  An interrupted sutures of #6-0 chromic were then used to approximate penile shaft skin to the coronal cuff and on the ventrum around the midline.  The patient's scrotum was slightly asymmetric; however, this was due to the tissue configuration of the scrotum itself.  At the end of the procedure, stay suture of #4-0 Prolene was used to tack the drain into place and a Dermabond and Surgicel were used for dressing.  Telfa and the surgical eye tape was then used for the final dressing.  IV Toradol was given.  The patient tolerated the procedure well and was in stable condition upon transfer to recovery room.","urology, tissue flap relocation, urethroplasty plate incision, penile shaft skin, chordee release, zaontz catheter, penile shaft, hypospadias repair, flap relocation, coronal cuff, urethral plate, tissue flap, hypospadias, flap, chordee,"
" Left hydrocelectomy.   This is a 67-year-old male with pain, left scrotum.  He has had an elevated PSA and also has erectile dysfunction.  He comes in now for a left hydrocelectomy.  Physical exam confirmed obvious hydrocele, left scrotum.", Urology, Hydrocelectomy. ,"PREOPERATIVE DIAGNOSIS: , Left hydrocele.,OPERATION: , Left hydrocelectomy.,POSTOPERATIVE DIAGNOSIS: , Left hydrocele.,ANESTHESIA: , General,INDICATIONS AND STUDIES: , This is a 67-year-old male with pain, left scrotum.  He has had an elevated PSA and also has erectile dysfunction.  He comes in now for a left hydrocelectomy.  Physical exam confirmed obvious hydrocele, left scrotum, approximately 8 cm.  Laboratory data included a hematocrit of 43.5, hemoglobin of 15.0, and white count 4700.  Creatinine 1.3, sodium 141, and potassium 4.0.  Calcium 8.6.  Chest x-ray was unremarkable.  EKG was normal.,PROCEDURE: , The patient was satisfactorily given general anesthesia, prepped and draped in supine position, and left scrotal incision was made, carried down to the tunica vaginalis forming the hydrocele.  This was dissected free from the scrotal wall back to the base of the testicle and then excised back to the spermatic cord.  In the fashion, the hydrocele was excised and fluid drained.,Cord was infiltrated with 5 mL of 0.25% Marcaine.  The edges of the tunica vaginalis adjacent to the spermatic cord were oversewn with interrupted 3-0 Vicryl sutures for hemostasis.  The left testicle was replaced into the left scrotal compartment and affixed to the overlying Dartos fascia with a 3-0 Vicryl suture through the edge of the tunica vaginalis and the overlying Dartos fascia.,The left scrotal incision was closed, first closing the Dartos fascia with interrupted 3-0 Vicryl sutures.  Skin was closed with an interrupted running 4-0 chromic suture.  A sterile dressing was applied.  The patient was sent to the recovery room in good condition, upon awakening from general anesthesia.  Plan is to discharge the patient and see him back in the office in a week or 2 in followup.  Further plans will depend upon how he does.","urology, hydrocele, erectile dysfunction, spermatic cord, tunica vaginalis, vicryl sutures, dartos fascia, hydrocelectomy, psa, testicle, scrotum, scrotal,"
" Left hydrocelectomy, cystopyelogram, bladder biopsy, and fulguration for hemostasis.", Urology, Hydrocelectomy - 1 ,"PREOPERATIVE DIAGNOSES:,  Bladder cancer and left hydrocele.,POSTOPERATIVE DIAGNOSES: , Bladder cancer and left hydrocele.,OPERATION:  ,Left hydrocelectomy, cystopyelogram, bladder biopsy, and fulguration for hemostasis.,ANESTHESIA:,  Spinal.,ESTIMATED BLOOD LOSS:  ,Minimal.,FLUIDS:,  Crystalloid.,BRIEF HISTORY:  ,The patient is a 66-year-old male with history of smoking and hematuria, had bladder tumor, which was dissected.  He has received BCG.  The patient is doing well.  The patient was supposed to come to the OR for surveillance biopsy and pyelograms.  The patient had a large left hydrocele, which was increasingly getting worse and was making it very difficult for the patient to sit to void or put clothes on, etc.  Options such as watchful waiting, drainage in the office, and hydrocelectomy were discussed.  Risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, infection in the scrotum, enlargement of the scrotum, recurrence, and pain were discussed.  The patient understood all the options and wanted to proceed with the procedure.,PROCEDURE IN DETAIL: , The patient was brought to the OR.  Anesthesia was applied.  The patient was placed in dorsal lithotomy position.  The patient was prepped and draped in usual sterile fashion.,A transverse scrotal incision was made over the hydrocele sac and the hydrocele fluid was withdrawn.  The sac was turned upside down and sutures were placed.  Careful attention was made to ensure that the cord was open.  The testicle was in normal orientation throughout the entire procedure.  The testicle was placed back into the scrotal sac and was pexed with 4-0 Vicryl to the outside dartos to ensure that there was no risk of torsion.  Orchiopexy was done at 3 different locations.  Hemostasis was obtained using electrocautery.  The sac was closed using 4-0 Vicryl.  The sac was turned upside down so that when it heals, the fluid would not recollect.  The dartos was closed using 2-0 Vicryl and the skin was closed using 4-0 Monocryl and Dermabond was applied.  Incision measured about 2 cm in size.  Subsequently using ACMI cystoscope, a cystoscopy was performed.  The urethra appeared normal.  There was some scarring at the bulbar urethra, but the scope went in through that area very easily into the bladder.  There was a short prostatic fossa.  The bladder appeared normal.  There was some moderate trabeculation throughout the bladder, some inflammatory changes in the bag part, but nothing of much significance.  There were no papillary tumors or stones inside the bladder.  Bilateral pyelograms were obtained using 8-French cone-tip catheter, which appeared normal.  A cold cup biopsy of the bladder was done and was fulgurated for hemostasis.  The patient tolerated the procedure well.  The patient was brought to recovery at the end of the procedure after emptying the bladder.,The patient was given antibiotics and was told to take it easy.  No heavy lifting, pushing, or pulling.  Plan was to follow up in about 2 months.","urology, hydrocele, fulguration, bladder biopsy, hydrocelectomy, cystopyelogram, cystopyelogram bladder, bladder cancer, bladder,"
" Bilateral scrotal hydrocelectomies, large for both, and 0.5% Marcaine wound instillation, 30 mL given.", Urology, Hydrocelectomy ,"PREOPERATIVE DIAGNOSIS:,  Bilateral hydroceles.,POSTOPERATIVE DIAGNOSIS:,  Bilateral hydroceles.,PROCEDURE: , Bilateral scrotal hydrocelectomies, large for both, and 0.5% Marcaine wound instillation, 30 mL given.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,FLUIDS RECEIVED: , 800 mL.,TUBES AND DRAINS: , A 0.25-inch Penrose drains x4.,INDICATIONS FOR OPERATION:  ,The patient is a 17-year-old boy, who has had fairly large hydroceles noted for some time.  Finally, he has decided to have them get repaired.  Plan is for surgical repair.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operating room where surgical consent, operative site, and patient identification were verified.  Once he was anesthetized, he was then shaved, prepped, and then sterilely prepped and draped.  IV antibiotics were given.  Ancef 1 g given.  A scrotal incision was then made in the right hemiscrotum with a 15-blade knife and further extended with electrocautery.  Electrocautery was used for hemostasis.  Once we got to the hydrocele sac itself, we then opened and delivered the testis, drained clear fluid.  There was moderate amount of scarring on the testis itself from the tunica vaginalis.  It was then wrapped around the back and sutured in place with a running suture of 4-0 chromic in a Lord maneuver.  Once this was done, a drain was placed in the base of the scrotum and then the testis was placed back into the scrotum in the proper orientation.  A similar procedure was performed on the left, which has also had a hydrocele of the cord, which were both addressed and closed with Lord maneuver similarly.  This testis also was normal but had moderate amount of scarring on the tunic vaginalis from this.  A similar drain was placed.  The testes were then placed back into the scrotum in a proper orientation, and the local wound instillation and wound block was then placed using 30 mL of 0.5% Marcaine without epinephrine.  IV Toradol was given at the end of the procedure.  The skin was then sutured with a running interlocking suture of 3-0 Vicryl and the drains were sutured to place with 3-0 Vicryl.  Bacitracin dressing, ABD dressing, and jock strap were placed.  The patient was in stable condition upon transfer to the recovery room.","urology, bilateral scrotal hydrocelectomies, bilateral hydroceles, lord maneuver, hydrocelectomy, hydroceles,"
 Inguinal hernia hydrocele repair., Urology, Hydrocele Repair ,,"urology, inguinal hernia, external oblique, hernia sac, hydrocele, hydrocele repair, ilioinguinal nerve, inguinal skin crease, oblique aponeurosis, scrotum, spermatic cord, testicle appendix, transverse inguinal skin crease incision, hernia, anesthesia, inguinalNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Presents to the ER with hematuria that began while sleeping last night.   He denies any pain, nausea, vomiting or diarrhea.", Urology, Hematuria - ER Visit ,"HISTORY OF PRESENT ILLNESS:,  The patient is an 85-year-old gentleman who follows as an outpatient with Dr. A.  He is known to us from his last admission.  At that time, he was admitted with a difficulty voiding and constipation.  His urine cultures ended up being negative.  He was seen by Dr. B and discharged home on Levaquin for five days.,He presents to the ER today with hematuria that began while he was sleeping last night.  He denies any pain, nausea, vomiting or diarrhea.  In the ER, a Foley catheter was placed and was irrigated with saline.  White count was 7.6, H and H are 10.8 and 38.7, and BUN and creatinine are of 27 and 1.9.  Urine culture is pending.  Chest x-ray is pending.  His UA did show lots of red cells.  The patient currently is comfortable.  CBI is running.  His urine is clear.,PAST MEDICAL HISTORY:,1.  Hypertension.,2.  High cholesterol.,3.  Bladder cancer.,4.  Bilateral total knee replacements.,5.  Cataracts.,6.  Enlarged prostate.,ALLERGIES:,  SULFA.,MEDICATIONS AT HOME:,1.  Atenolol.,2.  Cardura.,3.  Zegerid.,4.  Flomax.,5.  Levaquin.,6.  Proscar.,7.  Vicodin.,8.  Morphine.,9.  Phenergan.,10.  Ativan.,11.  Zocor.,12.  Prinivil.,13.  Hydrochlorothiazide.,14.  Folic acid.,15.  Digoxin.,16.  Vitamin B12.,17.  Multivitamin.,SOCIAL HISTORY: , The patient lives at home with his daughter.  He does not smoke, occasionally drinks alcohol.  He is independent with his activities of daily living.,REVIEW OF SYSTEMS:,  Not additionally rewarding.,PHYSICAL EXAMINATION:,GENERAL:  An awake and alert 85-year-old gentleman who is afebrile.,VITAL SIGNS:  BP of 162/60 and pulse oximetry of 98% on room air.,HEENT:  Pink conjunctivae.  Anicteric sclerae.  Oral mucosa is moist.,NECK:  Supple.,CHEST:  Clear to auscultation.,HEART:  Regular S1 and S2.,ABDOMEN:  Soft and nontender to palpation.,EXTREMITIES:  Without edema.,He has a Foley catheter in place.  His urine is clear.,LABORATORY DATA:,  Reviewed.,IMPRESSION:,1.  Hematuria.",
" The patient had hematuria, and unable to void.  The patient had a Foley catheter, which was not in the urethra, possibly inflated in the prostatic urethra, which was removed. ", Urology, Hematuria & Urinary Retention ,"REASON FOR CONSULTATION:,  Hematuria and urinary retention.,BRIEF HISTORY: , The patient is an 82-year-old, who was admitted with the history of diabetes, hypertension, hyperlipidemia, coronary artery disease, presented with urinary retention and pneumonia.  The patient had hematuria, and unable to void.  The patient had a Foley catheter, which was not in the urethra, possibly inflated in the prostatic urethra, which was removed.  Foley catheter was repositioned 18 Coude was used.  About over a liter of fluids of urine was obtained with light pink urine, which was irrigated.  The bladder and the suprapubic area returned to normal after the Foley placement.  The patient had some evidence of clots upon irrigation.  The patient has had a chest CT, which showed possible atelectasis versus pneumonia.,PAST MEDICAL HISTORY:  ,Coronary artery disease, diabetes, hypertension, hyperlipidemia, Parkinson's, and CHF.,FAMILY HISTORY:  ,Noncontributory.,SOCIAL HISTORY: , Married and lives with wife.,HABITS:,  No smoking or drinking.,REVIEW OF SYSTEMS: , Denies any chest pain, denies any seizure disorder, denies any nausea, vomiting.  Does have suprapubic tenderness and difficulty voiding.  The patient denies any prior history of hematuria, dysuria, burning, or pain.,PHYSICAL EXAMINATION:,VITAL SIGNS:  The patient is afebrile.  Vitals are stable.,GENERAL:  The patient is a thin gentleman,GENITOURINARY:  Suprapubic area was distended and bladder was palpated very easily.  Prostate was 1+.  Testes are normal.,LABORATORY DATA: , The patient's white counts are 20,000.  Creatinine is normal.,ASSESSMENT AND PLAN:,1.  Pneumonia.,2.  Dehydration.,3.  Retention.,4.  BPH.,5.  Diabetes.,6.  Hyperlipidemia.,7.  Parkinson's.,8.  Congestive heart failure.,About 30 minutes were spent during the procedure and the Foley catheter was placed, Foley was irrigated and significant amount of clots were obtained.  Plan is for urine culture, antibiotics.  Plan is for renal ultrasound to rule out any pathology.  The patient will need cystoscopy and evaluation of the prostate.  Apparently, the patient's PSA is 0.45, so the patient is at low to no risk of prostate cancer at this time.  Continued Foley catheter at this point.  We will think about starting the patient on alpha-blockers once the patient's over all medical condition is improved and stable.",
 Patient presents with gross hematuria that started this morning., Urology, Hematuria - Consult ,"HISTORY OF PRESENT ILLNESS:,  This is a 77-year-old male, who presents with gross hematuria that started this morning.  The patient is a difficult historian, does have a speech impediment, slow to answer questions, but daughter was able to answer lot of questions too.  He is complaining of no other pain.  He denies any abdominal pain.  Denies any bleeding anywhere else.  Denies any bruising.  He had an episode similar to this a year ago where it began the same with hematuria.  He was discharged after a workup in the hospital, in the emergency room, with Levaquin.  Three days later, he returned with a very large hematoma to his left neck and a coagulopathy with significant bleeding.  His H and H was down in the 6 level.  He received blood transfusions.  He was diagnosed with a malignancy, coagulopathy, and sounds like was in critical condition.  Family actually states that they were told that he was unlikely to live through that event, but he did.  Since then, he has had no bleeding.  The patient has had no fever.  No cough.  No chest pain or shortness of breath.  No bleeding gums.  No blurred vision.  No headache.  No recent falls or trauma.  He has had no nausea or vomiting.  No diarrhea.  No blood in the stool or melena.  No leg or calf pain.  No joint pain.  No rashes.  No swollen glands.  He has no numbness, weakness or tingling to his extremities.  No acute anxiety or depression.,PAST MEDICAL HISTORY: , Has prostate cancer.,MEDICATION: , He is receiving Lupron injection by Dr. Y. The only other medication that he takes is Tramadol.,SOCIAL HISTORY: , He does not smoke or drink.,PHYSICAL EXAMINATION:,Vital Signs:  Are all reviewed on triage.,General:  He is alert.  Answers slowly with a speech impediment, but answers appropriately.,HEENT:  Pupils equal, round, and reactive to light.  Normal extraocular muscles.  Nonicteric sclerae.  Conjunctivae are not pale.  His oropharynx is clear.  His mucous membranes are moist.,Heart:  Regular rate and rhythm, with no murmurs.,Lungs:  Clear.,Abdomen:  Soft, nontender, nondistended.  Normal bowel sounds.  No organomegaly or mass.,Extremities:  No calf tenderness, erythema or warmth.  He has no bruises noted.,Neurological:  Cranial nerves II through XII are intact.  He has 5/5 strength throughout.  ,GU:  Normal.,LABORATORY DATA:  ,The patient did on urinalysis have few red blood cells.  His urine was also grossly red, although no blood clots or gross blood was noted.  It was more of a red fluid.  He had a mild decrease in H and H at 12.1 and 34.6.  His white count was normal at 7.2.  His PT was elevated at 15.9.  PTT elevated at 36.4.  INR is 1.4.  His comprehensive metabolic profile is normal except for BUN of 19.,CONDITION: , The patient is stable at this time, although because of the history of the same happening and the patient beginning in the same fashion his history of coagulopathy, the patient is discussed with Dr. X and he is admitted for orders.  Also we will consult Dr. Y, see orders for further.","urology, prostate cancer, bleeding, gross hematuria, speech impediment, hematuria, coagulopathy, blood,"
 Likely molluscum contagiosum (genital warts) caused by HPV.  It is not clear where this came from but it is most likely sexually transmitted., Urology, HPV Consult ,"He has no voiding complaints and no history of sexually transmitted diseases.,PAST MEDICAL HISTORY: , None.,PAST SURGICAL HISTORY: , Back surgery with a fusion of L5-S1.,MEDICATIONS: , He does take occasional Percocet for his back discomfort.,ALLERGIES:,  HE HAS NO ALLERGIES.,SOCIAL HISTORY:,  He is a smoker.  He takes rare alcohol.  His employment is that he does dynamite work and actually putting in the dynamite in large holes for destroying ground to that pipeline can be laid.  He travels to anywhere for his work.  He is married with one son.,FAMILY HISTORY: , Negative for prostate cancer, kidney cancer, bladder cancer, enlarged prostate or kidney disease.,REVIEW OF SYSTEMS:,  Negative for tremors, headaches, dizzy spells, numbness, tingling, feeling hot or cold, tired or sluggishness, abdominal pain, nausea or vomiting, indigestion, heartburn, fevers, chills, weight loss, wheezing, frequent cough, shortness of breath, chest pain, varicose veins, high blood pressure, skin rash, joint pain, ear infections, sore throat, sinus problems, hay fever, blood clotting problems, depressive affect or eye problems.,PHYSICAL EXAMINATION,GENERAL:  The patient is afebrile.  His vital signs are stable.  He is 177 pounds, 5 feet, 8 inches.  Blood pressure 144/66.  He is healthy appearing.  He is alert and oriented x 3.,HEART:  Regular rate and rhythm.,LUNGS:  Clear to auscultation.,ABDOMEN:  Soft and nontender.  His penis is circumcised.  He has a pedunculated cauliflower-like lesion on the dorsum of the penis at approximately 12 o'clock.  It is very obvious and apparent.  He also has a mildly raised brown lesion that the patient states has been there ever since he can remember and has not changed in size or caliber.  His testicles are descended bilaterally.  There are no masses.,ASSESSMENT AND PLAN: , This is likely molluscum contagiosum (genital warts) caused by HPV.  I did state to the patient that this is likely a viral infection that could have had a long incubation period.  It is not clear where this came from but it is most likely sexually transmitted.  He is instructed that he should use protected sex from this point on in order to try and limit the transmission.  Regarding the actual lesion itself, I did mention that we could apply a cream of Condylox, which could take up to a month to work.  I also offered him C02 laser therapy for the genital warts, which is an outpatient procedure.  The patient is very interested in something quick and effective such as a CO2 laser procedure.  I did state that the recurrence rate is significant and somewhere as high as 20% despite enucleating these lesions.  The patient understood this and still wished to proceed.  There is minimal risk otherwise except for those inherent in laser injury and accidental injury.  The patient understood and wished to proceed.","urology, sexually transmitted, molluscum contagiosum, genital warts, hpv,"
" Follow up consultation, second opinion, foreskin.", Urology, Foreskin - Followup ,"REASON FOR VISIT: , Follow up consultation, second opinion, foreskin.,HISTORY OF PRESENT ILLNESS: , A 2-week-old who at this point has otherwise been doing well.  He has a relatively unremarkable foreskin.  At this point in time, he otherwise seems to be doing reasonably well.  The question is about the foreskin.  He otherwise has no other significant issues.  Severity low, ongoing since birth two weeks.  Thank you for allowing me to see this patient in consultation.,PHYSICAL EXAMINATION:,  Male exam.  Normal and under the penis, report normal uncircumcised 2-week-old.  He has a slightly insertion on the penile shaft from the median raphe of the scrotum.,IMPRESSION: , Slightly high insertion of the median raphe.  I see no reason he cannot be circumcised as long as they are careful and do a very complete Gomco circumcision.  This kid should otherwise do reasonably well.,PLAN:  ,Follow up as needed.  But my other recommendation is that this kid as I went over with the mother may actually do somewhat better if he simply has a formal circumcision at one year of age, but may do well with a person who is very accomplished doing a Gomco circumcision.","urology, formal circumcision, median raphe, penis, gomco circumcision, gomco, circumcision, foreskin, "
 Foul-smelling urine and stomach pain after meals., Urology, Foul-Smelling Urine ,"CHIEF COMPLAINT:,  Foul-smelling urine and stomach pain after meals.,HISTORY OF PRESENT ILLNESS:,  Stomach pain with most meals x one and a half years and urinary symptoms for same amount of time.  She was prescribed Reglan, Prilosec, Pepcid, and Carafate at ED for her GI symptoms and Bactrim for UTI.  This visit was in July 2010.,REVIEW OF SYSTEMS:,  HEENT:  No headaches.  No visual disturbances, no eye irritation.  No nose drainage or allergic symptoms.  No sore throat or masses.  Respiratory:  No shortness of breath.  No cough or wheeze.  No pain.  Cardiac:  No palpitations or pain.  Gastrointestinal:  Pain and cramping.  Denies nausea, vomiting, or diarrhea.  Has some regurgitation with gas after meals.  Genitourinary:  ""Smelly"" urine.  Musculoskeletal:  No swelling, pain, or numbness.,MEDICATION ALLERGIES:,  No known drug allergies.,PHYSICAL EXAMINATION:,General:  Unremarkable.,HEENT:  PERRLA.  Gaze conjugate.,Neck:  No nodes.  No thyromegaly.  No masses.,Lungs:  Clear.,Heart:  Regular rate without murmur.,Abdomen:  Soft, without organomegaly, without guarding or tenderness.,Back:  Straight.  No paraspinal spasm.,Extremities:  Full range of motion.  No edema.,Neurologic:  Cranial nerves II-XII intact.  Deep tendon reflexes 2+ bilaterally.,Skin:  Unremarkable.,LABORATORY STUDIES:,  Urinalysis was done, which showed blood due to her period and moderate leukocytes.,ASSESSMENT:,1.  UTI.,2.  GERD.,3.  Dysphagia.,4.  Contraception consult.,PLAN:,1.  Cipro 500 mg b.i.d. x five days.  Ordered BMP, CBC, and urinalysis with microscopy.,2.  Omeprazole 20 mg daily and famotidine 20 mg b.i.d.,3.  Prescriptions same as #2.  Also referred her for a barium swallow series to rule out a stricture.,4.  Ortho Tri-Cyclen Lo.,",
 Cystoscopy and removal of foreign objects from the urethra., Urology, Foreign Object Removal - Urethra ,"PREOPERATIVE DIAGNOSIS: , Prostate cancer.,POSTOPERATIVE DIAGNOSIS: , Prostate cancer.,OPERATION: , Cystoscopy and removal of foreign objects from the urethra.,BRACHYTHERAPY:,  Iodine 125.,ANESTHESIA: , General endotracheal.  The patient was given Levaquin 500 mg IV preoperatively.,Total seeds were 59.  Activity of 0.439, 30 seeds in the periphery with 10 needles and total of 8 seeds at the anterior of the fold, 4 needles.  Please note that the total needles placed on the top were actually 38 seeds and 22 seeds were returned back.,BRIEF HISTORY: , This is a 72-year-old male who presented to us with elevated PSA and prostate biopsy with Gleason 6 cancer on the right apex.  Options such as watchful waiting, brachytherapy, radical prostatectomy, cryotherapy, and external beam radiation were discussed.  Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE, incontinence, erectile dysfunction, urethral stricture, dysuria, burning pain, hematuria, future procedures, and failure of the procedure were all discussed.  The patient understood all the risks, benefits, and options and wanted to proceed with the procedure.  The patient wanted to wait until he came back from his summer vacations, so a one dose of Zoladex was given.  Prostate size measured about 15 g in the OR and about 22 g about two months ago.  Consent was obtained.,DETAILS OF THE OPERATION:  ,The patient was brought to the OR and anesthesia was applied.  The patient was placed in dorsal lithotomy position.  The patient had a Foley catheter placed sterilely.  The scrotum was taped up using Ioban.  Transrectal ultrasound was done.  The prostate was measured 15 g.  Multiple images were taken.  A volume study was done.  This was given to the physicist, Dr. X was present who is radiation oncologist who helped with implanting of the seeds.  Total of 38 seeds were placed in the patient with 10 peripheral needles and then 4 internal needles.  Total of 30 seeds were placed in the periphery and total of 8 seeds were placed in the inside.  They were done directly under transrectal ultrasound vision.  The seeds were placed directly under ultrasound guidance.  There was a nice distribution of the seeds.  A couple of more seeds were placed on the right side due to the location of the prostate cancer.  Subsequently at the end of the procedure, fluoroscopy was done.  Couple of images were obtained.  Cystoscopy was done at the end of the procedure where a seed was visualized right in the urethra, which was grasped and pulled out using grasper, which was difficult to get the seed off of the spacers, which was actually pulled out.  There were no further seeds visualized in the bladder.  The bladder appeared normal.  At the end of the procedure, a Foley catheter was kept in place of 18 French and the patient was brought to recovery in stable condition.","urology, foreign objects, foley catheter, transrectal ultrasound, prostate cancer, cystoscopy, ultrasound, urethra, endotracheal, prostate"
" Recurring bladder infections with frequency and urge incontinence, not helped with Detrol LA.  Normal cystoscopy with atrophic vaginitis.", Urology, Flexible Cystoscopy - Atrophic Vaginitis ,"PREOPERATIVE DIAGNOSIS:,  Recurring bladder infections with frequency and urge incontinence, not helped with Detrol LA.,POSTOPERATIVE DIAGNOSIS: , Normal cystoscopy with atrophic vaginitis.,PROCEDURE PERFORMED: , Flexible cystoscopy.,FINDINGS:,  Atrophic vaginitis.,PROCEDURE:  ,The patient was brought in to the procedure suite, prepped and draped in the dorsal lithotomy position.  The patient then had flexible scope placed through the urethral meatus and into the bladder.  Bladder was systematically scanned noting no suspicious areas of erythema, tumor or foreign body.  Significant atrophic vaginitis is noted.,IMPRESSION: , Atrophic vaginitis with overactive bladder with urge incontinence.,PLAN: , The patient will try VESIcare 5 mg with Estrace and follow up in approximately 4 weeks.","urology, urge incontinence, frequency, overactive bladder, vesicare, flexible cystoscopy, bladder infections, atrophic vaginitis, incontinence, cystoscopy, vaginitis,"
" Microscopic hematuria with lateral lobe obstruction, mild.", Urology, Flexible Cystoscopy - BPH ,"PREOPERATIVE DIAGNOSIS: , Microscopic hematuria.,POSTOPERATIVE DIAGNOSIS:,  Microscopic hematuria with lateral lobe obstruction, mild.,PROCEDURE PERFORMED: , Flexible cystoscopy.,COMPLICATIONS: , None.,CONDITION: , Stable.,PROCEDURE: , The patient was placed in the supine position and sterilely prepped and draped in the usual fashion.  After 2% lidocaine was instilled, the anterior urethra is normal.  The prostatic urethra reveals mild lateral lobe obstruction.  There are no bladder tumors noted.,IMPRESSION:,  The patient has some mild benign prostatic hyperplasia.  At this point in time, we will continue with conservative observation.,PLAN: , The patient will follow up as needed.","urology, benign prostatic hyperplasia, urethra, lateral lobe obstruction, flexible cystoscopy, microscopic hematuria, cystoscopy, hematuria, obstruction,"
 Epididymectomy, Urology, Epididymectomy ,"EPIDIDYMECTOMY,OPERATIVE NOTE:  ,The patient was placed in the supine position and prepped and draped in the usual manner.  A transverse scrotal incision was made and carried down to the tunica vaginalis, which was opened.  A small amount of clear fluid was expressed.  The tunica vaginalis was opened and the testicle was brought out through this incision.  The epididymis was separated off the surface of the testicle using a scalpel.  With blunt and sharp dissection, the epididymis was dissected off the testicle.  Bovie was used for hemostasis.  The vessels going to the testicle were preserved without any obvious injury, and a nice viable testicle was present after the epididymis was removed from this.  The blood supply to the epididymis was cauterized using a Bovie and the vas was divided with cautery also.  There was no obvious bleeding.  The cord was infiltrated with 0.25% Marcaine, as was the dartos tissue in the scrotum.  The testicle was replaced in the scrotum.  Skin was closed in two layers using 3-0 chromic catgut for the dartos and a subcuticular closure with the same material.  A dry sterile dressing and compression were applied, and he was sent to the recovery room in stable condition.","urology, scrotal incision, 0.25% marcaine, bovie, epididymectomy, chromic catgut, epididymis, fluid, scalpel, scrotum, sterile dressing, testicle, tunica vaginalisNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Common Excretory Urogram - IVP template, Urology, Excretory Urogram - IVP  ,"There is normal and symmetrical filling of the caliceal system.  Subsequent films demonstrate that the kidneys are of normal size and contour bilaterally.  The caliceal system and ureters are in their usual position and show no signs of obstruction or intraluminal defects. The postvoid films demonstrate normal emptying of the collecting system, including the urinary bladder.,IMPRESSION:,  Negative intravenous urogram.,","urology, intravenous urogram, caliceal system, urinary bladder, excretory urogram, collecting systems, ivp, urogram, intravenousNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Left flank pain and unable to urinate., Urology, Flank Pain - Consult ,"CHIEF COMPLAINT: , Left flank pain and unable to urinate.,HISTORY: , The patient is a 46-year-old female who presented to the emergency room with left flank pain and difficulty urinating.  Details are in the history and physical.  She does have a vague history of a bruised left kidney in a motor vehicle accident.  She feels much better today.  I was consulted by Dr. X.,MEDICATIONS:,  Ritalin 50 a day.,ALLERGIES: , To penicillin.,PAST MEDICAL HISTORY: , ADHD.,SOCIAL HISTORY:,  No smoking, alcohol, or drug abuse.,PHYSICAL EXAMINATION: , She is awake, alert, and quite comfortable.  Abdomen is benign.  She points to her left flank, where she was feeling the pain.,DIAGNOSTIC DATA: , Her CAT scan showed a focal ileus in left upper quadrant, but no thickening, no obstruction, no free air, normal appendix, and no kidney stones.,LABORATORY WORK: , Showed white count 6200, hematocrit 44.7.  Liver function tests and amylase were normal.  Urinalysis 3+ bacteria.,IMPRESSION:,1.  Left flank pain, question etiology.,2.  No evidence of surgical pathology.,3.  Rule out urinary tract infection.,PLAN:,1.  No further intervention from my point of view.,2.  Agree with discharge and followup as an outpatient.  Further intervention will depend on how she does clinically.  She fully understood and agreed.","urology, flank pain, unable to urinate, urinary tract infection, flank, "
 Recurrent urinary tract infection in a patient recently noted for another Escherichia coli urinary tract infection., Urology, E. Coli UTI - Followup ,"HISTORY OF PRESENT ILLNESS:,  The patient presents today for followup, recently noted for E. coli urinary tract infection.  She was treated with Macrobid for 7 days, and only took one nighttime prophylaxis.  She discontinued this medication to due to skin rash as well as hives.  Since then, this had resolved.  Does not have any dysuria, gross hematuria, fever, chills.  Daytime frequency every two to three hours, nocturia times one, no incontinence, improving stress urinary incontinence after Prometheus pelvic rehabilitation.,Renal ultrasound, August 5, 2008, reviewed, no evidence of hydronephrosis, bladder mass or stone.  Discussed.,Previous urine cultures have shown E. coli, November 2007, May 7, 2008 and July 7, 2008.,CATHETERIZED URINE: , Discussed, agreeable done using standard procedure.  A total of 30 mL obtained.,IMPRESSION: , Recurrent urinary tract infection in a patient recently noted for another Escherichia coli urinary tract infection, completed the therapeutic dose, but stopped the prophylactic Macrodantin due to hives.  This has resolved.,PLAN: , We will send the urine for culture and sensitivity, if no infection, patient will call results on Monday, and she will be placed on Keflex nighttime prophylaxis, otherwise followup as previously scheduled for a diagnostic cystoscopy with Dr. X.  All questions answered.","urology, urinary tract infection, escherichia coli, prophylactic macrodantin, e. coli, infection, "
" Abnormal serum PSA of 16 ng/ml, dribbling urine, inability to empty bladder, nocturia, urinary hesitancy and slow urine stream.", Urology, Elevated PSA - H&P ,"CHIEF COMPLAINT:, This 61-year-old male presents today with recent finding of abnormal serum PSA of 16 ng/ml. Associated signs and symptoms: Associated signs and symptoms include dribbling urine, inability to empty bladder, nocturia, urinary hesitancy and urine stream is slow.  Timing (onset/frequency): Onset was 6 months ago. Patient denies fever and chills and denies flank pain.,ALLERGIES: ,Patient admits allergies to adhesive tape resulting in severe rash. Patient denies an allergy to anesthesia.,MEDICATION HISTORY:, Patient is not currently taking any medications.,PAST MEDICAL HISTORY:, Childhood Illnesses: (+) asthma, Cardiovascular Hx: (-) angina, Renal / Urinary Hx: (-) kidney problems.,PAST SURGICAL HISTORY:, Patient admits past surgical history of appendectomy in 1992.,SOCIAL HISTORY:, Patient admits alcohol use, Drinking is described as heavy, Patient denies illegal drug use, Patient denies STD history, Patient denies tobacco use.,FAMILY HISTORY:, Patient admits a family history of gout attacks associated with father.,REVIEW OF SYSTEMS:, Unremarkable with exception of chief complaint.,PHYSICAL EXAM: ,BP Sitting: 120/80 Resp: 20 HR: 72 Temp: 98.6,The patient is a pleasant, 61-year-old male in no apparent distress who looks his given age, is well-developed and nourished with good attention to hygiene and body habitus.,Neck: Neck is normal and symmetrical, without swelling or tenderness. Thyroid is smooth and symmetric with no enlargement, tenderness or masses noted.,Respiratory: Respirations are even without use of accessory muscles and no intercostal retractions noted. Breathing is not labored, diaphragmatic, or abdominal. Lungs clear to auscultation with no rales, rhonchi, wheezes, or rubs noted.,Cardiovascular: Normal S1 and S2 without murmurs, gallop, rubs or clicks.  Peripheral pulses full to palpation, no varicosities, extremities warm with no edema or tenderness.,Gastrointestinal: Abdominal organs, bladder, kidney: No abnormalities, without masses, tenderness, or rigidity. Hernia: absent; no inguinal, femoral, or ventral hernias noted. Liver and/or Spleen: no abnormalities, tenderness, or masses noted. Stool specimen not indicated.,Genitourinary: Anus and perineum: no abnormalities. No fissures, edema, dimples, or tenderness noted.,Scrotum: no abnormalities. No lesions, rash, or sebaceous cyst noted.,Epididymides: no abnormalities, masses, or spermatocele, without enlargement, induration, or tenderness.,Testes: symmetrical; no abnormalities, tenderness, hydrocele, or masses noted.,Urethral Meatus: no abnormalities; no hypospadias, lesions, polyps, or discharge noted.,Penis: no abnormalities; circumcised; no phimosis, Peyronie's, condylomata, or lumps noted.,Prostate: size 60 gr, RT>LT and firm.,Seminal Vesicles: no abnormalities; symmetrical; no tenderness, induration, or nodules noted.,Sphincter tone: no abnormalities; good tone; without hemorrhoids or masses.,Skin/Extremities: Skin is warm and dry with normal turgor and there is no icterus. No skin rash, subcutaneous nodules, lesions or ulcers observed.,Neurological/Psychiatric: Oriented to person, place and time. Mood and affect normal, appropriate to situation, without depression, anxiety, or agitation.,TEST RESULTS:, No tests to report at this time.,IMPRESSION: ,Elevated prostate specific antigen (PSA).,PLAN:, Cystoscopy in the office.,DIAGNOSTIC & LAB ORDERS:, Ordered serum creatinine. Urinalysis and C & S ordered using clean-catch specimen. Ordered free prostate specific antigen (PSA). Ordered ultrasound of prostate.,I have discussed the findings of this follow-up evaluation with the patient. The discussion included a complete verbal explanation of any changes in the examination results, diagnosis and current treatment plan. Discussed the possibility of a TURP surgical procedure; risks, complications, benefits, and alternative measures discussed. There are no activity restrictions . Instructed Ben to avoid caffeinated or alcoholic beverages and excessively spiced foods. Questions answered. If any questions should arise after returning home I have encouraged the patient to feel free to call the office at 327-8850.,PRESCRIPTIONS: , Proscar Dosage: 5 mg tablet Sig: once daily Dispense: 30 Refills: 0 Allow Generic: No,PATIENT INSTRUCTIONS:,  Patient completed benign prostatic hypertrophy questionnaire.",
" Left flank pain, ureteral stone.", Urology, Flank Pain - Consult - 1 ,"REASON FOR CONSULTATION: , Left flank pain, ureteral stone.,BRIEF HISTORY: , The patient is a 76-year-old female who was referred to us from Dr. X for left flank pain.  The patient was found to have a left ureteral stone measuring about 1.3 cm in size per the patient's history.  The patient has had pain in the abdomen and across the back for the last four to five days.  The patient has some nausea and vomiting.  The patient wants something done for the stone.  The patient denies any hematuria, dysuria, burning or pain.  The patient denies any fevers.,PAST MEDICAL HISTORY: , Negative.,PAST SURGICAL HISTORY:  ,Years ago she had surgery that she does not recall.,MEDICATIONS: , None.,ALLERGIES: , None.,REVIEW OF SYSTEMS: , Denies any seizure disorder, chest pain, denies any shortness of breath, denies any dysuria, burning or pain, denies any nausea or vomiting at this time.  The patient does have a history of nausea and vomiting, but is doing better.,PHYSICAL EXAMINATION:,VITAL SIGNS:  The patient is afebrile.  Vitals are stable.,HEART:  Regular rate and rhythm.,ABDOMEN:  Soft, left-sided flank pain and left lower abdominal pain.,The rest of the exam is benign.,LABORATORY DATA: , White count of 7.8, hemoglobin 13.8, and platelets 234,000.  The patient's creatinine is 0.92.,ASSESSMENT:,1.  Left flank pain.,2.  Left ureteral stone.,3.  Nausea and vomiting.,PLAN: , Plan for laser lithotripsy tomorrow.  Options such as watchful waiting, laser lithotripsy, and shockwave lithotripsy were discussed.  The patient has a pretty enlarged stone.  Failure of the procedure if the stone is significantly impacted into the ureteral wall was discussed.  The patient understood that the success of the surgery may be or may not be 100%, that she may require shockwave lithotripsy if we are unable to get the entire stone out in one sitting.  The patient understood all the risk, benefits of the procedure and wanted to proceed.  Need for stent was also discussed with the patient.  The patient will be scheduled for surgery tomorrow.  Plan for continuation of the antibiotics, obtain urinalysis and culture, and plan for KUB to evaluate for the exact location of the stone prior to surgery tomorrow.","urology, flank pain, ureteral stone, shockwave lithotripsy, shockwave, nausea, vomiting, lithotripsy, ureteral, stone, "
" Solitary left kidney with obstruction and hypertension and chronic renal insufficiency, plus a Pseudomonas urinary tract infection.", Urology, Discharge Summary - Urology & Nephrology  ,"ADMITTING DIAGNOSES:,  Solitary left kidney with obstruction, and hypertension, and chronic renal insufficiency.,DISCHARGE DIAGNOSES: , Solitary left kidney with obstruction and hypertension and chronic renal insufficiency, plus a Pseudomonas urinary tract infection.,PROCEDURES: , Cystoscopy under anesthesia, ureteroscopy, an attempted tube placement, stent removal with retrograde pyelography, percutaneous tube placement, and nephrostomy by Radiology.,PERTINENT LABORATORIES: , Creatinine of 1.4.  During the hospitalization it was decreased to 0.8 and Pseudomonas urinary tract infection, positive culture sensitive to ceftazidime and ciprofloxacin.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 3-1/2-year-old boy with a solitary kidney, had a ureteropelvic junction repair performed by Dr. Y, in the past, unfortunately, it was thought still be obstructed.  A stent was placed approximately 6 weeks ago after urethroscopic placement with some difficulty.  Plan was to remove the stent.  At the time of removal, we were unable to place another tube within the collecting system, and the patient was admitted for percutaneous nephrostomy placement.  He has had no recent cold or flu.  He has problems with hypertension for which he is on enalapril at home in addition to his Macrodantin prophylaxis.,PAST MEDICAL HISTORY: , The patient has no known allergies.  Multiple urinary tract infection, solitary kidney, and previous surgeries as mentioned above.,REVIEW OF SYSTEMS:,  A 14-organ system review of systems is negative except for the history of present illness.  He also has history of being a 34-week preemie twin.,ALLERGIES: , No known allergies.,FAMILY HISTORY: , Unremarkable without any bleeding or anesthetic problems.,SOCIAL HISTORY: , The patient lives at home with his parents, 2 brothers, and a sister.,IMMUNIZATIONS:,  Up-to-date.,MEDICATIONS: , On admission was Macrodantin, hydralazine, and enalapril.,PHYSICAL EXAMINATION:,GENERAL:  The patient is an active little boy.,HEENT:  The head and neck exam was grossly normal.  He had no oral, ocular, or nasal discharge.,LUNGS:  Exam was normal without wheezing.,HEART:  Without murmur or gallops.,ABDOMEN:  Soft, without mass or tenderness with a well-healed flank incision.,GU:  Uncircumcised male with bilaterally descended testes.,EXTREMITIES:  He has full range of motion in all 4 extremities.,SKIN:  Warm, pink, and dry.,NEUROLOGIC:  Grossly intact.,BACK:  He has normal back.  Normal gait.,HOSPITAL COURSE: , The patient was admitted to the hospital after inability to place a ureteral stent via ureteroscopy and cystoscopy.  He was made NPO.  He had a fever at first time with elevated creatinine.  He was also evaluated and treated by Dr. X, for fluid management, hypertensive management, and gave him some hydralazine and Lasix to improve his urine output, in addition to manage his blood pressure.  Once the percutaneous tube was placed, we found that his urine culture grew Pseudomonas, so he was kept on Fortaz, and was switched over to ciprofloxacin without difficulty.  He, otherwise, did well with continuing decrease his creatinine at the time of discharge to home.,The patient was discharged home in stable condition with ciprofloxacin, enalapril, and recommendation for followup in Urology in 1 to 2 weeks for the surgical correction in 2 to 3 weeks of repeat pyeloplasty or possible ureterocalicostomy.  The patient had draining nephrostomy tube without difficulty.,",
 Elevated PSA with nocturia and occasional daytime frequency., Urology, Elevated PSA - Chart Note ,"REASON FOR VISIT:  ,Elevated PSA with nocturia and occasional daytime frequency.,HISTORY: , A 68-year-old male with a history of frequency and some outlet obstructive issues along with irritative issues.  The patient has had history of an elevated PSA and PSA in 2004 was 5.5.  In 2003, he had undergone a biopsy by Dr. X, which was negative for adenocarcinoma of the prostate.  The patient has had PSAs as high as noted above.  His PSAs have been as low as 1.6, but those were on Proscar.  He otherwise appears to be doing reasonably well, off the Proscar, otherwise does have some irritative symptoms.  This has been ongoing for greater than five years.  No other associated symptoms or modifying factors.  Severity is moderate.  PSA relatively stable over time.,IMPRESSION: , Stable PSA over time, although he does have some irritative symptoms.  After our discussion, it does appear that if he is not drinking close to going to bed, he notes that his nocturia has significantly decreased.  At this juncture what I would like to do is to start with behavior modification.  There were no other associated symptoms or modifying factors.,PLAN: , The patient will discontinue all caffeinated and carbonated beverages and any fluids three hours prior to going to bed.  He already knows that this does decrease his nocturia.  He will do this without medications to see how well he does and hopefully he may need no other additional medications other than may be changing his alpha-blocker to something of more efficacious.","urology, daytime frequency, psa, irritative symptoms, elevated psa, frequency, nocturia"
" Cystoscopy, TUR, and electrofulguration of recurrent bladder tumors.", Urology, Electrofulguration - Bladder Tumor ,"PREOPERATIVE DIAGNOSIS: , Recurrent bladder tumors.,POSTOPERATIVE DIAGNOSIS:,  Recurrent bladder tumors.,OPERATION: , Cystoscopy, TUR, and electrofulguration of recurrent bladder tumors.,ANESTHESIA:,  General.,INDICATIONS: , A 79-year-old woman with recurrent bladder tumors of the bladder neck.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room, prepped and draped in lithotomy position under satisfactory general anesthesia.  A #21-French cystourethroscope was inserted into the bladder.  Examination of the bladder showed approximately a 3-cm area of erythema and recurrent papillomatosis just above and lateral to the left ureteral orifice.  No other lesions were noted.  Using a cold punch biopsy forceps, a random biopsy was obtained.  The entire area was electrofulgurated using the Bugbee electrode.  The patient tolerated the procedure well and left the operating room in satisfactory condition.","urology, bladder neck, bladder tumors, cystoscopy, tur, electrofulguration, bladder"
" Cystourethroscopy, urethral dilation, and bladder biopsy and fulguration.  Urinary hesitancy and weak stream, urethral narrowing, mild posterior wall erythema.", Urology, Cystourethroscopy & Urethral Dilation ,"PREOPERATIVE DIAGNOSIS:  ,Urinary hesitancy and weak stream.,POSTOPERATIVE DIAGNOSES:,1.  Urinary hesitancy and weak stream.,2.  Urethral narrowing.,3.  Mild posterior wall erythema.,PROCEDURE PERFORMED:,1.  Cystourethroscopy.,2.  Urethral dilation.,3.  Bladder biopsy and fulguration.,ANESTHESIA:  ,General.,SPECIMEN:  ,Urine culture sensitivity and cytology and bladder biopsy x1.,DISPOSITION: , To PACU in stable condition.,INDICATIONS AND FINDINGS:  ,This is a 76-year-old female with history of weak stream and history of intermittent catheterization secondary to hypotonic bladder in the past, last cystoscopy approximately two years ago.,FINDINGS AT TIME OF SURGERY:,  Cystourethroscopy revealed some mild narrowing of the urethra, which was easily dilated to #23 French.  A midureteral polyp was noted.  Cystoscopy revealed multiple cellules and mild trabeculation of the bladder.  Posterior wall revealed some mild erythema with some distorted architecture of the bladder mucosa.  No obvious raised bladder tumor was noted.  No foreign bodies were noted.  The ureteral orifices were noted on the trigone just proximal to the bladder neck.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained, the patient was moved to the operating room, general anesthesia was induced by the Department of Anesthesia.  The patient was prepped and draped in normal sterile fashion and urethral sounds used to dilate the urethra to accommodate #23 French cystoscope.  Cystoscopy was performed in its entirety with the above findings.  The small area of erythema on the posterior wall was biopsied using a flexible biopsy forceps and Bovie cautery was used to cauterize and fulgurate this area.  The bladder was drained, cystoscope was removed, scope was reinserted and bladder was again reexamined.  No evidence of active bleeding noted.  The bladder was drained, cystoscope was removed, and the patient was cleaned and sent to recovery room in stable condition to followup with Dr. X in two weeks.  She is given prescription for Levaquin and Pyridium and given discharge instructions.","urology, bladder biopsy, fulguration, urethral dilation, weak stream, bladder, cystoscopy, cystoscope, cystourethroscopy, biopsy, urethral,"
" Cystourethroscopy and tTransurethral resection of prostate (TURP).  Urinary retention and benign prostate hypertrophy.  This is a 62-year-old male with a history of urinary retention and progressive obstructive voiding symptoms and enlarged prostate 60 g on ultrasound, office cystoscopy confirmed this.", Urology, Cystourethroscopy & TURP - 1 ,"PREOPERATIVE DIAGNOSES:,1.  Urinary retention.,2.  Benign prostate hypertrophy.,POSTOPERATIVE DIAGNOSES:,1.  Urinary retention.,2.  Benign prostate hypertrophy.,PROCEDURES PERFORMED:,1.  Cystourethroscopy.,2.  Transurethral resection of prostate (TURP).,ANESTHESIA:,  Spinal.,RESECTION TIME:,  Less than one hour.,INDICATION FOR PROCEDURE:  ,This is a 62-year-old male with a history of urinary retention and progressive obstructive voiding symptoms and enlarged prostate 60 g on ultrasound, office cystoscopy confirmed this.,PROCEDURE:  PROCEDURE: , Informed written consent was obtained.  The patient was taken to the operative suite, administered spinal anesthetic and placed in dorsal lithotomy position.  She was sterilely prepped and draped in normal fashion.  A #27-French resectoscope was inserted utilizing the visual obturator blanching the bladder.  The bladder was visualized in all quadrants, no bladder tumors or stones were noted.  Ureteral orifices were visualized and did appear to be near the enlarged median lobe.  Prostate showed trilobar prostatic enlargement.  There were some cellules and tuberculations noted.  The visual obturator was removed.  The resectoscope was then inserted utilizing the #26 French resectoscope loop.  Resection was performed initiating at the bladder neck and at the median lobe.,This was taken down to the circular capsular fibers.  Attention was then turned to the left lateral lobe and this was resected from 12 o'clock to 3 o'clock down to the capsular fibers maintaining hemostasis along the way and taking care not to resect beyond the level of the verumontanum.  Ureteral orifices were kept out of harm's way throughout the case.  Resection was then performed from the 3 o'clock position to the 6 o'clock position in similar fashion.  Attention was then turned to the right lateral lobe and this was resected again in a similar fashion maintaining hemostasis along the way.  The resectoscope was then moved to the level of the proximal external sphincter and trimming of the apex was performed.  Open prostatic fossa was noted.  All chips were evacuated via Ellik evacuator and #24 French three-way Foley catheter was inserted and irrigated.  Clear return was noted.  The patient was then hooked up to better irrigation.  The patient was cleaned, reversed for anesthetic, and transferred to recovery room in stable condition.,PLAN:  ,We will admit with antibiotics, pain control, and bladder irrigation possible void trial in the morning.","urology, urinary retention, transurethral resection of prostate, prostate, enlarged, obstructive voiding symptoms, benign prostate hypertrophy, ureteral orifices, prostate hypertrophy, cystourethroscopy, turp, hypertrophy, resectoscope, urinary, bladder, resection,"
" Some improvement of erectile dysfunction, on low dose of Cialis, with no side effects.  ", Urology, Erectile Dysfunction - Followup ,"HISTORY OF PRESENT ILLNESS: , The patient presents today for followup, history of erectile dysfunction, last visit started on Cialis 10 mg.  He indicates that he has noticed some mild improvement of his symptoms, with no side effect.  On this dose, he is having firm erection, able to penetrate, lasting for about 10 or so minutes.  No chest pain, no nitroglycerin usage, no fever, no chills.  No dysuria, gross hematuria, fever, chills.  Daytime frequency every three hours, nocturia times 0, good stream.  He does have a history of elevated PSA and biopsy June of this year was noted for high grade PIN, mid left biopsy, with two specimens being too small to evaluate.  PSA 11.6.  Dr. X's notes are reviewed.,IMPRESSION:  ,1.  Some improvement of erectile dysfunction, on low dose of Cialis, with no side effects.  The patient has multiple risk factors, but denies using any nitroglycerin or any cardiac issues at this time.  We reviewed options of increasing the medication, versus trying other medications, options of penile prosthesis, Caverject injection use as well as working pump is reviewed.,2.  Elevated PSA in a patient with a recent biopsy showing high-grade PIN, as well as two specimens not being large enough to evaluate.  The patient tells me he has met with his primary care physician and after discussion, he is in consideration of repeating a prostate ultrasound and biopsy.  However, he would like to meet with Dr. X to discuss these prior to biopsy.,PLAN: , Following detailed discussion, the patient wishes to proceed with Cialis 20 mg, samples are provided as well as Levitra 10 mg, may increase this to 20 mg and understand administration of each and contraindication as well as potential side effects are reviewed.  The patient not to use them at the same time.  Will call if any other concern.  In the meantime, he is scheduled to meet with Dr. X, with a prior PSA in consideration of a possible repeating prostate ultrasound and biopsy.  He declined scheduling this at this time.  All questions answered.","urology, improvement of erectile dysfunction, erectile dysfunction, erectile, dysfunction, cialis, psa, biopsy,"
" Right hydronephrosis, right flank pain, atypical/dysplastic urine cytology, extrarenal pelvis on the right, no evidence of obstruction or ureteral/bladder lesions.  Cystoscopy, bilateral retrograde ureteropyelograms, right ureteral barbotage for urine cytology, and right ureterorenoscopy.", Urology," Cystoscopy, Ureteropyelogram, & Ureteral Barbotage ","PREOPERATIVE DIAGNOSES:,1.  Right hydronephrosis.,2.  Right flank pain.,3.  Atypical/dysplastic urine cytology.,POSTOPERATIVE DIAGNOSES:,1.  Right hydronephrosis.,2.  Right flank pain.,3.  Atypical/dysplastic urine cytology.,4.  Extrarenal pelvis on the right.,5.  No evidence of obstruction or ureteral/bladder lesions.,PROCEDURE PERFORMED:,1.  Cystoscopy.,2.  Bilateral retrograde ureteropyelograms.,3.  Right ureteral barbotage for urine cytology.,4.  Right ureterorenoscopy, diagnostic.,ANESTHESIA: , Spinal.,SPECIMEN TO PATHOLOGY: , Urine and saline wash barbotage from right ureter through the ureteral catheter.,ESTIMATED BLOOD LOSS:  ,Minimal.,INDICATIONS FOR PROCEDURE: , This is a 70-year-old female who reports progressive intermittent right flank pain associated with significant discomfort and disability.  She presented to the emergency room where she was found to have significant hydronephrosis on the right without evidence of a stone.  She has some ureteral thickening in her distal right ureter.  She has persistent microscopic hematuria and her urine cytology and cytomolecular diagnosis significant for urothelial dysplasia with neoplasia-associated karyotypic profile.  She was brought to the operating room for further evaluation and treatment.,DESCRIPTION OF OPERATION: , After preoperative counseling, the patient was taken to the operating room and administered a spinal anesthesia.  She was placed in the lithotomy position, prepped and draped in the usual sterile fashion.  The 21-French cystoscope was inserted per urethra into the bladder.  The bladder was inspected and found to be without evidence of intravesical tumors, stones or mucosal abnormalities.  The right ureteral orifice was visualized and cannulated with an open-ended ureteral catheter.  This was gently advanced to the mid ureter.  Urine was collected for cytology.  Retrograde injection of saline through the ureteral catheter was then also used to enhance collection of the specimen.  This too was collected and sent for a pooled urine cytology as specimen from the right renal pelvis and ureter.  An 0.038 guidewire was then passed up through the open-ended ureteral catheter.  The open-ended ureteral catheter and cystoscope were removed, and over the guidewire the flexible ureteroscope was passed up to the level of the renal pelvis.  Using direct vision and fluoroscopy to confirm location, the entire renal pelvis and calyces were inspected.  The renal pelvis demonstrated an extrarenal pelvis, but no evidence of obstruction at the renal UPJ level.  There were no intrapelvic or calyceal stones.  The ureter demonstrated no significant mucosal abnormalities, no visible tumors, and no areas of apparent constriction on multiple passes of the ureteroscope through the ureter to evaluate.  The ureteroscope was then removed.  The cystoscope was reinserted.  Once again, retrograde injection of contrast through an open-ended ureteral catheter was undertaken in the right ureter and collecting system.  No evidence of extravasation or significant change in anatomy was visualized.  The left ureteral orifice was then visualized and cannulated with an open-ended ureteral catheter, and retrograde injection of contrast demonstrated a normal left ureter and collecting system.  The cystoscope was removed.  Foley catheter was inserted.  The patient was placed in the supine position and transferred to the recovery room in satisfactory condition.","urology, hydronephrosis, ureteropyelogram, ureterorenoscopy, flank pain, renal pelvis, urine cytology, ureteral, cystoscopy, barbotage, cystoscope, retrograde, urine, "
" Discharge Summary of a patient with hematuria, benign prostatic hyperplasia, complex renal cyst versus renal cell carcinoma, and osteoarthritis.", Urology, Discharge Summary - Urology ,"ADMITTING DIAGNOSES:,1. Hematuria.,2. Benign prostatic hyperplasia.,3. Osteoarthritis.,DISCHARGE DIAGNOSES:,1. Hematuria, resolved.,2. Benign prostatic hyperplasia.,3. Complex renal cyst versus renal cell carcinoma or other tumor.,4. Osteoarthritis.,HOSPITAL COURSE:, This is a 77-year-old African-American male who was previously well until he began having gross hematuria and clots passing through his urethra on the day of admission. He stated that he never had blood in his urine before, however, he does have a past history of BPH and he had a transurethral resection of prostate more than 10 years ago. He was admitted to a regular bed. Dr. G of Urology was consulted for evaluation of his hematuria. During the workup for this, he had a CT of the abdomen and pelvis with and without contrast with early and late-phase imaging for evaluation of the kidneys and collecting system. At that time, he was shown to have multiple bilateral renal cysts with one that did not meet classification as a simple cyst and ultrasound was recommended.,He had an ultrasound done of the cyst which showed a 2.1 x 2.7 cm mass arising from the right kidney which, again, did not fit ultrasound criteria for a simple cyst and they recommended further evaluation by an MRI as this could be a hemorrhagic cyst or a solid mass or tumor, so an MRI was scheduled on the day of discharge for further evaluation of this. The report was not back at discharge. The patient had a cystoscopy and transurethral resection of prostate as well with entire resection of the prostate gland. Pathology on this specimen showed multiple portions of prostatic tissue which was primarily fibromuscular, and he was diagnosed with nonprostatic hyperplasia. His urine slowly cleared. He tolerated a regular diet with no difficulties in his activities of daily living, and his Foley was removed on the day of discharge.,He was started on ciprofloxacin, Colace, and Lasix after the transurethral resection and continued these for a short course. He is asked to continue the Colace as an outpatient for stool softening for comfort.,DISCHARGE MEDICATIONS:, Colace 100 mg 1 b.i.d.,DISCHARGE FOLLOWUP PLANNING:, The patient is to follow up with his primary care physician at ABCD, Dr. B or Dr. J, the patient is unsure of which, in the next couple weeks. He is to follow up with Dr. G of  Urology in the next week by phone in regards to the patient's MRI and plans for a laparoscopic partial renal resection biopsy. This is scheduled for the week after discharge potentially by Dr. G, and the patient will discuss the exact time later this week. The patient is to return to the emergency room or to our clinic if he has worsening hematuria again or no urine output.","urology, discharge summary, bph, benign prostatic hyperplasia, hematuria, osteoarthritis, clots, cystoscopy, gross hematuria, kidney, renal cell carcinoma, renal cyst, simple cyst, prostatic hyperplasia, transurethral resection, discharge, summary, transurethral, prostate, prostatic, hyperplasia, gross, benign, renal, cyst"
" Cystourethroscopy, right retrograde pyelogram, right ureteral pyeloscopy, right renal biopsy, and right double-J 4.5 x 26 mm ureteral stent placement.  Right renal mass and ureteropelvic junction obstruction and hematuria.", Urology, Cystourethroscopy & Retrograde Pyelogram - 1 ,"PREOPERATIVE DIAGNOSES:,1.  Right renal mass.,2.  Hematuria.,POSTOPERATIVE DIAGNOSES:,1.  Right renal mass.,2.  Right ureteropelvic junction obstruction.,PROCEDURES PERFORMED:,1.  Cystourethroscopy.,2.  Right retrograde pyelogram.,3.  Right ureteral pyeloscopy.,4.  Right renal biopsy.,5.  Right double-J 4.5 x 26 mm ureteral stent placement.,ANESTHESIA: , Sedation.,SPECIMEN: , Urine for cytology and culture sensitivity, right renal pelvis urine for cytology, and right upper pole biopsies.,INDICATION:,  The patient is a 74-year-old male who was initially seen in the office with hematuria.  He was then brought to the hospital for other medical problems and found to still have hematuria.  He has a CAT scan with abnormal appearing right kidney and it was felt that he will benefit from cystoscope evaluation.,PROCEDURE: ,After consent was obtained, the patient was brought to the operating room and placed in the supine position.  He was given IV sedation and placed in dorsal lithotomy position.  He was then prepped and draped in the standard fashion.  A #21 French cystoscope was then passed through his ureter on which patient was noted to have a hypospadias and passed through across the ends of the bladder.  The patient was noted to have mildly enlarged prostate, however, it was non-obstructing.,Upon visualization of the bladder, the patient was noted to have some tuberculation to the bladder.  There were no masses or any other abnormalities noted other than the tuberculation.  Attention was then turned to the right ureteral orifice and an open-end of the catheter was then passed into the right ureteral orifice.  A retrograde pyelogram was performed.  Upon visualization, there was no visualization of the upper collecting system on the right side.  At this point, a guidewire was then passed through the open-end of the ureteral catheter and the catheter was removed.  The bladder was drained and the cystoscope was removed.  The rigid ureteroscope was then passed into the bladder and into the right ureteral orifice with the assistance of a second glidewire.  The ureteroscope was taken all the way through the proximal ureter just below the UPJ and there were noted to be no gross abnormalities.  The ureteroscope was removed and an Amplatz wire then passed through the scope up into the collecting system along the side of the previous wire.  The ureteroscope was removed and a ureteral dilating sheath was passed over the Amplatz wire into the right ureter under fluoroscopic guidance.  The Amplatz wire was then removed and the flexible ureteroscope was passed through the sheath into the ureter.  The ureteroscope was passed up to the UPJ at which point there was noted to be difficulty entering the ureter due to UPJ obstruction.  The wire was then again passed through the flexible scope and the flexible scope was removed.  A balloon dilator was then passed over the wire and the UPJ was dilated with balloon dilation.  The dilator was then removed and again the cystoscope was passed back up into the right ureter and was able to enter the collecting system.  Upon visualization of the collecting system of the upper portion, there was noted to be papillary mass within the collecting system.  The ________ biopsy forceps were then passed through the scope and two biopsies were taken of the papillary mass.  Once this was done, the wire was left in place and the ureteroscope was removed.  The cystoscope was then placed back into the bladder and a 26 x 4.5 mm ureteral stent was passed over the wire under fluoroscopic and cystoscopic guidance into the right renal pelvis.  The stent was noted to be clear within the right renal pelvis as well as in the bladder.  The bladder was drained and the cystoscope was removed.  The patient tolerated the procedure well.  He will be transferred to the recovery room and back to his room.  It has been discussed with his primary physician that the patient will likely need a nephrectomy.  He will be scheduled for an echocardiogram tomorrow and then decision will be made where the patient will be stable for possible nephrectomy on Wednesday.","urology, renal mass, hematuria, ureteropelvic junction obstruction, cystourethroscopy, retrograde, pyelogram, ureteral pyeloscopy, renal biopsy, double-j, ureteral stent placement, ureteropelvic junction, flexible scope, papillary mass, ureteral stent, renal pelvis, ureteral orifice, amplatz wire, retrograde pyelogram, ureteral, cystoscope, ureteroscope, renal, bladder"
 Cystoscopy.  Transurethral resection of the prostate., Urology, Cystoscopy & TURP ,"PREOPERATIVE DIAGNOSES:,1.  Ta grade III TIS transitional cell carcinoma of the urinary bladder.,2.  Lower tract outlet obstructive symptoms secondary to benign prostatic hypertrophy.,3.  Inability to pass a Foley catheter x3.,POSTOPERATIVE DIAGNOSES:,1.  Ta grade III TIS transitional cell carcinoma of the urinary bladder.,2.  Lower tract outlet obstructive symptoms secondary to benign prostatic hypertrophy.,3.  Inability to pass a Foley catheter x3.,PROCEDURES:,1.  Cystoscopy.,2.  Transurethral resection of the prostate (TURP).,ANESTHESIA: , General laryngeal mask.,INDICATIONS: , This patient is a 61-year-old white male who has been treated at the VA in Houston for a bladder cancer.  His history dates back to 2003 when he had a non-muscle invasive bladder cancer.  He had multiple cystoscopies and followups since that time with no evidence of recurrence.  However, on recent cystoscopy, he had what appeared to be a recurrent tumor and was taken to the operating room and had this resected with findings of a Ta grade III transitional cell carcinoma associated with carcinoma in situ.  Retrograde pyelograms were suspicious on the right and cleared with ureteroscopy and the left renal pelvic washing was positive but this may represent contamination from the lower urinary tract as radiographically, there were no abnormalities.  I had cystoscoped the patient in the office showed during the period of time when he had significant irritative burning symptoms, and there were still healing biopsy sites.  We elected to allow his bladder to recover before starting the BCG.  We were ready to do that last week but two doctors and a nurse including myself were unable to pass Foley catheter.  I repeated a cystoscopy in the office with findings of a high bladder neck and BPH.  After a lengthy discussion with the patient and his wife, we elected to proceed with TURP after a full informed consent.,FINDINGS: , At cystoscopy, there was bilobular prostatic hyperplasia and a very high riding bladder neck, which may have been the predominant cause of his difficulty catheterizing and obstructive symptoms.  There were mucosal changes on the left posterior wall in the midline suspicious for carcinoma in situ.,PROCEDURE IN DETAIL: , The patient was brought to the cystoscopy suite and after adequate general laryngeal mask anesthesia obtained and placed in the dorsal lithotomy position, his perineum and genitalia were sterilely prepped and draped in the usual fashion.  A cystourethroscopy was performed with a #23 French ACMI panendoscope and 70-degree lens with the findings as described.  We removed the cystoscope and passed a #28 French continuous flow resectoscope sheath under visual obturator after dilating the meatus to #32 French with van Buren sounds.  Inspection of bladder again was made noting the location of the ureteral orifices relative to the bladder neck.  The groove was cut at 6 o'clock to open the bladder neck to verumontanum and then the left lobe was resected from 1 o'clock to 5 o'clock.  Hemostasis was achieved, and then a similar procedure performed in the right side.  We resected the anterior stromal tissue and the apical tissue and then obtained complete hemostasis.  Chips were removed with Ellik evacuator.  There was no bleeding at the conclusion of the procedure, and the resectoscope was removed.  A #24 French three-way Foley catheter was placed with efflux of clear irrigant.  The patient was returned to the supine position, awakened, extubated, and taken on a stretcher to the recovery room in satisfactory condition.","urology, urinary bladder, benign prostatic hypertrophy, transurethral resection of the prostate, turp, acmi panendoscope, van buren sounds, transitional cell carcinoma, foley catheter, bladder neck, bladder, carcinoma, cystoscopy"
" Cystourethroscopy, bilateral retrograde pyelogram, and transurethral resection of bladder tumor of 1.5 cm in size.  Recurrent bladder tumor and history of bladder carcinoma.", Urology, Cystourethroscopy & Retrograde Pyelogram ,"PREOPERATIVE DIAGNOSES:,1.  Recurrent bladder tumor.,2.  History of bladder carcinoma.,POSTOPERATIVE DIAGNOSIS:,","urology, recurrent bladder tumor, bladder carcinoma, bilateral retrograde pyelogram, transurethral resection of bladder tumor, lateral wall bladder tumor, transurethral resection, retrograde pyelogram, tumor, bladder, cystourethroscopy, pyelogram,"
" Cystoscopy under anesthesia, bilateral HIT/STING with Deflux under general anesthetic.", Urology, Cystoscopy ,"PREOPERATIVE DIAGNOSIS: , Bilateral vesicoureteral reflux with right reflux nephropathy after Deflux injection.,POSTOPERATIVE DIAGNOSIS: , Bilateral vesicoureteral reflux with right reflux nephropathy after Deflux injection.,PROCEDURE:,  Cystoscopy under anesthesia, bilateral HIT/STING with Deflux under general anesthetic.,ANESTHESIA: , General inhalational anesthetic.,FLUIDS RECEIVED: , 250 mL crystalloids.,ESTIMATED BLOOD LOSS:,  Less than 5 mL.,SPECIMENS:,  Urine sent for culture.,ABNORMAL FINDINGS:  ,Gaping ureteral orifices, right greater than left, with Deflux not in or near the ureteral orifices.  Right ureteral orifice was HIT with 1.5 mL of Deflux and left with 1.2 mL of Deflux.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 4-1/2-year-old boy with history of reflux nephropathy and voiding and bowel dysfunction.  He has had a STING procedure performed but continues to have reflux bilaterally.  Plan is for another injection.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operating room where surgical consent, operative site, and patient identification were verified.  Once he was anesthetized, IV antibiotics were given.  He was then placed in a lithotomy position with adequate padding of his arms and legs.  His urethra was calibrated to 12-French with a bougie a boule.  A 9.5-French cystoscope was used and the offset system was then used.  His urethra was normal without valves or strictures.  His bladder was fairly normal with minimal trabeculations but no cystitis noted.  Upon evaluation, the patient's right ureteral orifice was found to be remarkably gaping and the Deflux that was present was not in or near ureteral orifice but it was inferior to it below the trigone.  This was similarly found on the left side where the Deflux was not close to the orifice as well.  It was slightly more difficult because of the amount impacted upon our angle for injection.  We were able to ultimately get the Deflux to go ahead with HIT technique on the right into the ureter itself to inject a total of 1.5 mL to include the HIT technique as well as the ureteral orifice itself on the right and left sides and some on the uppermost aspect.  Once we injected this, we ran the irrigant over the orifice and it no longer fluttered and there was no bleeding.  Similar procedure was done on the left.  This was actually more difficult as the Deflux injection from before displaced the ureter slightly more laterally but again HIT technique was performed.  There was some mild bleeding and Deflux was used to stop this as well and again no evidence of fluttering of the ureteral orifice after injection.  At the end of the procedure, the irrigant was drained and 2% lidocaine jelly was instilled in the urethra.  The patient tolerated the procedure well and was in stable condition upon transfer to Recovery.  A low-dose of IV Toradol was given at the end of the procedure as well.","urology, bilateral vesicoureteral reflux, deflux, sting procedure, hit technique, cystoscopy under anesthesia, hit/sting with deflux, vesicoureteral reflux, ureteral orifices, vesicoureteral, cystoscopy, urethra, hit/sting, ureteral,"
 Benign prostatic hypertrophy and urinary retention.  Cystourethroscopy and transurethral resection of prostate (TURP)., Urology, Cystourethroscopy & TURP ,"PREOPERATIVE DIAGNOSES:,1.  Benign prostatic hypertrophy.,2.  Urinary retention.,POSTOPERATIVE DIAGNOSES:,1.  Benign prostatic hypertrophy.,2.  Urinary retention.,PROCEDURE PERFORMED:,1.  Cystourethroscopy.,2.  Transurethral resection of prostate (TURP).,ANESTHESIA:  ,Spinal.,DRAIN: , A #24 French three-way Foley catheter.,SPECIMENS: , Prostatic resection chips.,ESTIMATED BLOOD LOSS:  ,150 cc.,DISPOSITION:  ,The patient was transferred to the PACU in stable condition.,INDICATIONS AND FINDINGS:  ,This is an 84-year-old male with history of BPH and subsequent urinary retention with failure of trial of void, scheduled for elective TURP procedure.,FINDINGS: , At the time of surgery, cystourethroscopy revealed trilobar enlargement of the prostate with prostatic varices of the median lobe.  Cystoscopy showed a few cellules of the bladder with no obvious bladder tumors noted.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained, the patient was moved to operating room and spinal anesthesia was induced by the Department of Anesthesia.  The patient was prepped and draped in the normal sterile fashion and a #21 French cystoscope inserted into urethra and into the bladder.  Cystoscopy performed with the above findings.  Cystoscope was removed.  A #27 French resectoscope with a #26 cutting loop was inserted into the bladder.  Verumontanum was identified as a landmark and systematic transurethral resection of the prostate tissue was undertaken in an circumferential fashion with good resection of tissue completed.  ________ irrigator was used to evacuate the bladder of prostatic chips.  Resectoscope was then inserted and any residual chips were removed in piecemeal fashion with a resectoscope loop.  Any obvious bleeding from the prostatic fossa was controlled with electrocautery.  Resectoscope was removed.  A #24 French three-way Foley catheter inserted into the urethra and into the bladder.  Bladder was irrigated and connected to three-way irrigation.  The patient was cleaned and sent to recovery in stable condition to be admitted overnight for continuous bladder irrigation and postop monitoring.","urology, urinary retention, cystourethroscopy, transurethral resection of prostate, foley catheter, bph, cystoscopy, bladder, benign prostatic hypertrophy, turp, "
" Cystopyelogram, clot evacuation, transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder.", Urology, Cystopyelogram - 1 ,"PREOPERATIVE DIAGNOSIS: , Gross hematuria.,POSTOPERATIVE DIAGNOSIS:  ,Gross hematuria.,OPERATIONS:  ,Cystopyelogram, clot evacuation, transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder.,ANESTHESIA: , Spinal.,FINDINGS:  ,Significant amount of bladder clots measuring about 150 to 200 mL, two cupful of clots were removed.  There was papillary tumor on the left wall right at the bladder neck and one on the right dome near the bladder neck on the right side.  The right ureteral opening was difficult to visualize, the left one was normal.,BRIEF HISTORY: , The patient is a 78-year-old male with history of gross hematuria and recurrent UTIs.  The patient had hematuria.  Cystoscopy revealed atypical biopsy.  The patient came in again with gross hematuria.  The first biopsy was done about a month ago.  The patient was to come back and have repeat biopsies done, but before that came into the hospital with gross hematuria.  The options of watchful waiting, removal of the clots and biopsies were discussed.  Risk of anesthesia, bleeding, infection, pain, MI, DVT and PE were discussed.  Morbidity and mortality of the procedure were discussed.  Consent was obtained from the daughter-in-law who has the power of attorney in Florida.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the OR.  Anesthesia was applied.  The patient was placed in the dorsal lithotomy position.  The patient was prepped and draped in the usual sterile fashion.  The patient had been off of the Coumadin for about 4 days and INR had been reversed.  The patient has significant amount of clot upon entering the bladder.  There was a tight bladder neck contracture.  The prostate was not enlarged.  Using ACMI 24-French sheath, using Ellick irrigation about 2 cupful of clots were removed.  It took about half an hour to just remove the clots.  After removing the clots, using 24-French cutting loop resectoscope, tumor on the left upper wall near the dome or near the 2 o'clock position was resected.  This was lateral to the left ureteral opening.  The base was coagulated for hemostasis.  Same thing was done at 10 o'clock on the right side where there was some tumor that was visualized.  The back wall and the rest of the bladder appeared normal.  Using 8-French cone-tip catheter, left-sided pyelogram was normal.  The right-sided pyelogram was very difficult to obtain and there was some mucosal irritation from the clots.  The contrast did go up to what appeared to be the right ureteral opening, but the mucosa seemed to be very much irritated and it was very difficult to actually visualize the opening.  A little bit of contrast went out, but the force was not made just to avoid any secondary stricture formation.  The patient did have CT with contrast, which showed that the kidneys were normal.  At this time, a #24 three-way irrigation was started.  The patient was brought to Recovery room in stable condition.","urology, clot evacuation, transurethral resection, bladder tumor, bladder neck, gross hematuria, bladder, cystopyelogram, hematuria, clots,"
 Cystoscopy and Bladder biopsy with fulguration.   History of bladder tumor with abnormal cytology and areas of erythema., Urology, Cystoscopy & Bladder Biopsy ,"PREOPERATIVE DIAGNOSIS:,  History of bladder tumor with abnormal cytology and areas of erythema.,POSTOPERATIVE DIAGNOSIS: , History of bladder tumor with abnormal cytology and areas of erythema.,PROCEDURE PERFORMED:,1.  Cystoscopy.,2.  Bladder biopsy with fulguration.,ANESTHESIA: , IV sedation with local.,SPECIMEN: , Urine cytology and right lateral wall biopsies.,PROCEDURE:,  After the consent was obtained, the patient was brought to the operating room and given IV sedation.  He was then placed in dorsal lithotomy position and prepped and draped in standard fashion.  A #21 French cystoscope was then used to visualized the entire urethra and bladder.  There was noted to be a narrowing of the proximal urethra, however, the scope was able to pass through.  The patient was noted to have a previously resected prostate.  On visualization of the bladder, the patient did have areas of erythema on the right as well as the left lateral walls, more significant on the right side.  The patient did have increased vascularity throughout the bladder.  The ________ two biopsies of the right lateral wall and those were sent for pathology.  The Bovie cautery was then used to cauterize the entire area of the biopsy as well as surrounding erythema.  Bovie was also utilized to cauterize the areas of erythema on the left lateral wall.  No further bleeding was identified.  The bladder was drained and the cystoscope was removed.  The patient tolerated the procedure well and was transferred to the recovery room.,He will have his defibrillator restarted and will followup with Dr. X in approximately two weeks for the result.  He will be discharged home with antibiotics as well as pain medications.  He is to restart his Coumadin not before Sunday.","urology, bladder biopsy with fulguration, iv sedation, bladder biopsy, bladder tumor, abnormal cytology, bladder, cystoscopy, tumor, cytology, erythema,"
" Cystopyelogram, left ureteroscopy, laser lithotripsy, stone basket extraction, stent exchange with a string attached.", Urology, Cystopyelogram ,"PREOPERATIVE DIAGNOSIS: , Left distal ureteral stone.,POSTOPERATIVE DIAGNOSIS: , Left distal ureteral stone.,PROCEDURE PERFORMED: , Cystopyelogram, left ureteroscopy, laser lithotripsy, stone basket extraction, stent exchange with a string attached.,ANESTHESIA:,  LMA.,EBL: , Minimal.,FLUIDS: , Crystalloid.  The patient was given antibiotics, 1 g of Ancef and the patient was on oral antibiotics at home.,BRIEF HISTORY: , The patient is a 61-year-old female with history of recurrent uroseptic stones.  The patient had stones x2, 1 was already removed, second one came down, had recurrent episode of sepsis, stent was placed.  Options were given such as watchful waiting, laser lithotripsy, shockwave lithotripsy etc.  Risks of anesthesia, bleeding, infection, pain, need for stent, and removal of the stent were discussed.  The patient understood and wanted to proceed with the procedure.,DETAILS OF THE PROCEDURE: , The patient was brought to the OR.  Anesthesia was applied.  The patient was placed in dorsal lithotomy position.  The patient was prepped and draped in usual sterile fashion.  A 0.035 glidewire was placed in the left system.  Using graspers, left-sided stent was removed.  A semirigid ureteroscopy was done.  A stone was visualized in the mid to upper ureter.  Using laser, the stone was broken into 5 to 6 small pieces.  Using basket extraction, all the pieces were removed.  Ureteroscopy all the way up to the UPJ was done, which was negative.  There were no further stones.  Using pyelograms, the rest of the system appeared normal.  The entire ureter on the left side was open and patent.  There were no further stones.  Due to the edema and the surgery, plan was to leave the stent attached to the string and the patient was to pull the string in about 24 hours.  Over the 0.035 glidewire, a 26 double-J stent was placed.  There was a nice curl in the kidney and one in the bladder.  The patient tolerated the procedure well.  Please note that the string was kept in place and the patient was to remove the stent the next day.  The patient's family was instructed how to do so.  The patient had antibiotics and pain medications at home.  The patient was brought to recovery room in a stable condition.","urology, laser lithotripsy, shockwave lithotripsy, double-j stent, distal ureteral stone, ureteral stone, basket extraction, cystopyelogram, laser, lithotripsy, stones, string, ureteroscopy, stone, stent,"
" Holmium laser cystolithalopaxy.  A diabetic male in urinary retention with apparent neurogenic bladder and intermittent self-catheterization, recent urinary tract infections.  The cystoscopy showed a large bladder calculus, short but obstructing prostate.", Urology, Cystolithalopaxy ,"PREOPERATIVE DIAGNOSES:,1.  Prostatism.,2.  Bladder calculus.,OPERATION:,  Holmium laser cystolithalopaxy.,POSTOPERATIVE DIAGNOSES:,1.  Prostatism.,2.  Bladder calculus.,ANESTHESIA:  ,General.,INDICATIONS:,  This is a 62-year-old male diabetic and urinary retention with apparent neurogenic bladder and intermittent self-catheterization, recent urinary tract infections.  The cystoscopy showed a large bladder calculus, short but obstructing prostate.  He comes in now for transurethral resection of his prostate and holmium laser cystolithotripsy.,He is a diabetic with obesity.,LABORATORY DATA:  ,Includes urinalysis showing white cells too much to count, 3-5 red cells, occasional bacteria.  He had a serum creatinine of 1.2, sodium 138, potassium 4.6, glucose 190, calcium 9.1.  Hematocrit 40.5, hemoglobin 13.8, white count 7,900.,PROCEDURE: , The patient was satisfactorily given general anesthesia.  Prepped and draped in the dorsal lithotomy position.  A 27-French Olympus rectoscope was passed via the urethra into the bladder.  The bladder, prostate, and urethra were inspected.  He had an obstructing prostate.  He had marked catheter reaction in his bladder.  He had a lot of villous changes, impossible to tell from frank tumor.  He had a huge bladder calculus.  It was white and round.,I used the holmium laser with the largest fiber through the continuous flow resectoscope and sheath, and broke up the stone, breaking up approximately 40 grams of stone.  There was still stone left at the end of the procedure.  Most of the chips that could be irrigated out of the bladder were irrigated out using Ellik.,Then the scope was removed and a 24-French 3-way Foley catheter was passed via the urethra into the bladder.,The plan is to probably discharge the patient in the morning and then we will get a KUB.  We will probably bring him back for a second stage cystolithotripsy, and ultimately do a TURP.  We broke up the stone for over an hour, and my judgment continuing with litholapaxy transurethrally over an hour begins to markedly increase the risk to the patient.","urology, prostatism, holmium laser cystolithalopaxy, urinary tract infections, holmium laser, bladder calculus, bladder, cystolithalopaxy, diabetic, urethra, urinary, catheterization, stone, calculus, prostate,"
" Exploratory laparotomy, resection of small bowel lesion, biopsy of small bowel mesentery, bilateral extended pelvic and iliac lymphadenectomy (including preaortic and precaval, bilateral common iliac, presacral, bilateral external iliac lymph nodes), salvage radical cystoprostatectomy (very difficult due to previous chemotherapy and radiation therapy), and continent urinary diversion with an Indiana pouch.", Urology, Cystoprostatectomy ,"PREOPERATIVE DIAGNOSES:,1.  Clinical stage T2, NX, MX transitional cell carcinoma of the urinary bladder, status post chemotherapy and radiation therapy.,2.  New right hydronephrosis.,POSTOPERATIVE DIAGNOSES:,1.  Clinical stage T4a, N3, M1 transitional cell carcinoma of the urinary bladder, status post chemotherapy and radiation therapy.,2.  New right hydronephrosis.,3.  Carcinoid tumor of the small bowel.,TITLE OF OPERATION: , Exploratory laparotomy, resection of small bowel lesion, biopsy of small bowel mesentery, bilateral extended pelvic and iliac lymphadenectomy (including preaortic and precaval, bilateral common iliac, presacral, bilateral external iliac lymph nodes), salvage radical cystoprostatectomy (very difficult due to previous chemotherapy and radiation therapy), and continent urinary diversion with an Indiana pouch.,ANESTHESIA: , General endotracheal and epidural.,INDICATIONS: , This patient is a 65-year-old white male, who was diagnosed with a high-grade invasive bladder cancer in June 2005.  During the course of his workup of transurethral resection, he had a heart attack when he was taken off Plavix after having had a drug-eluting stent placed in.  He recovered from this and then underwent chemotherapy and radiation therapy with a brief response documented by cystoscopy and biopsy after which he had another ischemic event.  The patient has been followed regularly by myself and Dr. X and has been continuously free of diseases since that time.  In that interval, he had a coronary artery bypass graft and was taken off of Plavix.  Most recently, he had a PET CT, which showed new right hydronephrosis and a followup cystoscopy, which showed a new abnormality in the right side of his bladder where he previously had the tumor resected and treated.  I took him to the operating room and extensively resected this area with findings of a high-grade muscle invasive bladder cancer.  We could not identify the right ureteral orifice, and he had a right ureteral stent placed.  Metastatic workup was negative and Cardiology felt he was at satisfactory medical risk for surgery and he was taken to the operating room this time for planned salvage cystoprostatectomy.  He was interested in orthotopic neobladder, and I felt like that would be reasonable if resecting around the urethra indicated the tissue was healthier.  Therefore, we planned on an Indiana pouch continent cutaneous diversion.,OPERATIVE FINDINGS:  ,On exploration, there were multiple abnormalities outside the bladder as follows:  There were at least three small lesions within the distal small bowel, the predominant one measured about 1.5 cm in diameter with a white scar on the surface.  There were two much smaller lesions also with a small white scar, with very little palpable mass.  The larger of the two was resected and found to be a carcinoid tumor.  There also were changes in the small bowel mesentry that looked inflammatory and biopsies of this showed only fibrous tissue and histiocytes.  The small bowel mesentry was fairly thickened at the base, but no discrete abnormality noted.,Both common iliac and lymph node samples were very thickened and indurated, and frozen section of the left showed cancer cells that were somewhat degenerative suggesting a chemotherapy and radiation therapy effect; viability was unable to be determined.  There was a frozen section of the distal right external iliac lymph node that was negative.  The bladder was very thickened and abnormal suggesting extensive cancer penetrating just under the peritoneal surface.  The bladder was fairly stuck to the pelvic sidewall and anterior symphysis pubis requiring very meticulous resection in order to get it off of these structures.  The external iliac lymph nodes were resected on both sides of the obturator; the lymph packet, however, was very stuck and adherent to the pelvic sidewall, and I elected not to remove that.  The rest of the large bowel appeared normal.  There were no masses in the liver, and the gallbladder was surgically absent.  There was nasogastric tube in the stomach.,OPERATIVE PROCEDURE IN DETAIL: , The patient was brought to the operative suite, and after adequate general endotracheal and epidural anesthesia obtained, having placed in the supine position and flexed over the anterior superior iliac spine, his abdomen and genitalia were sterilely prepped and draped in usual fashion.  The radiologist placed a radial arterial line and an intravenous catheter.  Intravenous antibiotics were given for prophylaxis.  We made a generous midline skin incision from high end of the epigastrium down to the symphysis pubis, deepened through the rectus fascia, and the rectus muscles separated in the midline.  Exploration was carried out with the findings described.  The bladder was adherent and did appear immobile.  Moist wound towels and a Bookwalter retractor was placed for exposure.  We began by assessing the small and large bowel with the findings in the small bowel as described.  We subsequently resected the largest of the lesions by exogenous wedge resection and reanastomosed the small bowel with a two-layer running 4-0 Prolene suture.  We then mobilized the cecum and ascending colon and hepatic flexure after incising the white line of Toldt and mobilized the terminal ileal mesentery up to the second and third portion of the duodenum.  The ureters were carefully dissected out and down deep in the true pelvis.  The right ureter was thickened and hydronephrotic with a stent in place and the left was of normal caliber.  I kept the ureters intact until we were moving the bladder off as described above.  At that point, we then ligated the ureters with the RP-45 vascular load and divided it.,We then established the proximal ____________ laterally to both genitofemoral nerves and resected the precaval and periaortic lymph nodes.  The common iliac lymph nodes remained stuck to the ureter.  Frozen section with the findings described on the left.,I then began the dissection over the right external iliac artery and vein and had a great deal of difficulty dissecting distally.  I was, however, able to establish the distal plane of dissection and a large lymph node was present in the distal external iliac vessels.  Clips were used to control the lymphatics distally.  These lymph nodes were sent for frozen section, which was negative.  We made no attempt to circumferentially mobilize the vessels, but essentially, swept the tissue off of the anterior surface and towards the bladder and then removed it.  The obturator nerve on the right side was sucked into the pelvic sidewall, and I elected not to remove those.  On the left side, things were a little bit more mobile in terms of the lymph nodes, but still the obturator lymph nodes were left intact.,We then worked on the lateral pedicles on both sides and essentially determined that I can take these down.  I then mobilized the later half of the symphysis pubis and pubic ramus to get distal to the apical prostate.  At this point, I scrubbed out of the operation, talked to the family, and indicated that I felt the cystectomy was more palliative than therapeutic, and I reiterated his desire to be free of any external appliance.,I then proceeded to take down the lateral pedicles with an RP-45 stapler on the right and clips distally.  The endopelvic fascia was incised.  I then turned my attention posteriorly and incised the peritoneum overlying the anterior rectal wall and ramus very meticulously dissected the rectum away from the posterior Denonvilliers fascia.  I intentionally picked down those two pedicles lateral to the rectum between the clips and then turned my attention retropubically.  I was able to pass a 0 Vicryl suture along the dorsal venous complex, tied this, and then, sealed and divided the complex with a LigaSure and oversewed it distally with 2-0 Vicryl figure-of-eight stitch.  I then divided the urethra distal to the apex of the prostate, divided the Foley catheter between the clamps and then the posterior urethra.  I then was able to take down the remaining distal attachments of the apex and took the dissection off the rectum, and the specimen was then free of all attachments and handed off the operative field.  The bivalved prostate appeared normal.  We then carefully inspected the rectal wall and noted to be intact.  The wound was irrigated with 1 L of warm sterile water and a meticulous inspection made for hemostasis and a dry pack placed in the pelvis.,We then turned our attention to forming the Indiana pouch.  I completed the dissection of the right hepatic flexure and the proximal transverse colon and mobilized the omentum off of this portion of the colon.  The colon was divided proximal to the middle colic using a GIA-80 stapler.  I then divided the avascular plane of Treves along the terminal ileum and selected a point approximately 15 cm proximal to the ileocecal valve to divide the ileum.  The mesentery was then sealed with a LigaSure device and divided, and the bowel was divided with a GIA-60 stapler.  We then performed a side-to-side ileo-transverse colostomy using a GIA-80 stapler, closing the open end with a TA 60.  The angles were reinforced with silk sutures and the mesenteric closed with interrupted silk sutures.,We then removed the staple line along the terminal ileum, passed a 12-French Robinson catheter into the cecal segment, and plicated the ileum with 3 firings of the GIA-60 stapler.  The ileocecal valve was then reinforced with interrupted 3-0 silk sutures as described by Rowland, et al, and following this, passage of an 18-French Robinson catheter was associated with the characteristic ""pop,"" indicating that we had adequately plicated the ileocecal valve.,As the patient had had a previous appendectomy, we made an opening in the cecum in the area of the previous appendectomy.  We then removed the distal staple line along the transverse colon and aligned the cecal end and the distal middle colic end with two 3-0 Vicryl sutures.  The bowel segment was then folded over on itself and the reservoir formed with 3 successive applications of the SGIA Polysorb-75.  Between the staple lines, Vicryl sutures were placed and the defects closed with 3-0 Vicryl suture ligatures.,We then turned our attention to forming the ileocolonic anastomosis.  The left ureter was mobilized and brought underneath the sigmoid mesentery and brought through the mesentery of the terminal ileum and an end-to-side anastomosis performed with an open technique using interrupted 4-0 Vicryl sutures, and this was stented with a Cook 8.4-French ureteral stent, and this was secured to the bowel lumen with a 5-0 chromic suture.  The right ureter was brought underneath the pouch and placed in a stented fashion with an identical anastomosis.  We then brought the stents out through a separate incision cephalad in the pouch and they were secured with a 2-0 chromic suture.  A 24-French Malecot catheter was placed through the cecum and secured with a chromic suture.  The staple lines were then buried with a running 3-0 Vicryl two-layer suture and the open end of the pouch closed with a TA 60 Polysorb suture.  The pouch was filled to 240 cc and noted to be watertight, and the ureteral anastomoses were intact.,We then made a final inspection for hemostasis.  The cecostomy tube was then brought out to the right lower quadrant and secured to the skin with silk sutures.  We then matured our stoma through the umbilicus.  We removed the plug of skin through the umbilicus and delivered the ileal segment through this.  A portion of the ileum was removed and healthy, well-vascularized tissue was matured with interrupted 3-0 chromic sutures.  We left an 18-French Robinson through the stoma and secured this to the skin with silk sutures.  The Malecot and stents were also secured in a similar fashion.,The stoma was returned to the umbilicus after resecting the terminal ileum.,We then placed a large JP drain into both obturator fossae and brought it up the right lower quadrant.  Rectus fascia was closed with buried #2 Prolene stitch anchoring a new figure of 8 at each end tying the two stitches above and in the middle and underneath the fascia.  Interrupted stitches were placed as well.  The subcutaneous tissue was irrigated and skin closed with surgical clips.  The estimated blood loss was 2500 mL.  The patient received 5 units of packed red blood cells and 4 units of FFP.  The patient was then awakened, extubated, and taken on a stretcher to the recovery room in satisfactory condition.", 
 Cystoscopy & Visual urethrotomy procedure, Urology, Cystoscopy & Visual Urethrotomy ,"CYSTOSCOPY & VISUAL URETHROTOMY,OPERATIVE NOTE:,  The patient was placed in the dorsal lithotomy position and prepped and draped in the usual manner under satisfactory general anesthesia.  A Storz urethrotome sheath was inserted into the urethra under direct vision.  Visualization revealed a stricture in the bulbous urethra.  This was intubated with a 0.038 Teflon-coated guidewire, and using the straight cold urethrotomy knife, it was incised to 12:00 to allow free passage of the scope into the bladder.  Visualization revealed no other lesions in the bulbous or membranous urethra.  Prostatic urethra was normal for age.  No foreign bodies, tumors or stones were seen within the bladder.  Over the guidewire, a #16-French Foley catheter with a hole cut in the tip with a Cook cutter was threaded over the guidewire and inserted into the bladder and inflated with 10 mL of sterile water.,He was sent to the recovery room in stable condition.","urology, cystoscopy, foley catheter, storz urethrotome sheath, teflon-coated guidewire, urethrotomy, bladder, bulbous urethra, dorsal lithotomy position, knife, membranous urethra, cystoscopy & visual urethrotomy, visual urethrotomyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Newborn circumcision.  The penile foreskin was removed using Gomco. , Urology, Circumcision - Newborn  ,"PROCEDURE: , Newborn circumcision.,INDICATIONS: , Parental preference.,ANESTHESIA:,  Dorsal penile nerve block.,DESCRIPTION OF PROCEDURE:,  The baby was prepared and draped in a sterile manner.  Lidocaine 1% 4 mL without epinephrine was instilled into the base of the penis at 2 o'clock and 10 o'clock.  The penile foreskin was removed using a XXX Gomco.  Hemostasis was achieved with minimal blood loss.  There was no sign of infection.  The baby tolerated the procedure well.  Vaseline was applied to the penis, and the baby was diapered by nursing staff.","urology, nerve block, newborn circumcision, foreskin, gomco, penis, circumcision, newborn, penile"
 Circumcision.  Normal male phallus.   The infant is without evidence of hypospadias or chordee prior to the procedure., Urology, Circumcision - Infant ,"PROCEDURE: , Circumcision.,PRE-PROCEDURE DIAGNOSIS: , Normal male phallus.,POST-PROCEDURE DIAGNOSIS: , Normal male phallus.,ANESTHESIA:  ,1% lidocaine without epinephrine.,INDICATIONS: , The risks and benefits of the procedure were discussed with the parents.  The risks are infection, hemorrhage, and meatal stenosis.  The benefits are ease of care and cleanliness and fewer urinary tract infections.  The parents understand this and have signed a permit.,FINDINGS: , The infant is without evidence of hypospadias or chordee prior to the procedure.,TECHNIQUE:  ,The infant was given a dorsal penile block with 1% lidocaine without epinephrine using a tuberculin syringe and 0.5 cc of lidocaine was delivered subcutaneously at 10:30 and at 1:30 o'clock at the dorsal base of the penis.,The infant was prepped then with Betadine and draped with a sterile towel in the usual manner.  Clamps were placed at 10 o'clock and 2 o'clock and the adhesions between the glans and mucosa were instrumentally lysed.  Dorsal hemostasis was established and a dorsal slit was made.  The foreskin was fully retracted and remaining adhesions between the glans and mucosa were manually lysed.  The infant was fitted with a XX-cm Plastibell.  The foreskin was retracted around the Plastibell and circumferential hemostasis was established.  The excess foreskin was removed with scissors and the infant tolerated the procedure well with a minimum amount of blood loss.  Instructions for continuing care are to watch for any evidence of hemorrhage or urination and the parents are instructed in the care of the circumcised penis.","urology, dorsal slit, hypospadias, chordee, epinephrine, hemorrhage, penis, adhesions, circumcision, phallus, lidocaine, foreskin, infant"
 Circumcision.  The child appeared to tolerate the procedure well.  Care instructions were given to the parents., Urology, Circumcision - Child  ,"PROCEDURE: , Circumcision.,Signed informed consent was obtained and the procedure explained.,The child was placed in a Circumstraint board and restrained in the usual fashion.  The area of the penis and scrotum were prepared with povidone iodine solution.  The area was draped with sterile drapes, and the remainder of the procedure was done with sterile procedure.  A dorsal penile block was done using 2 injections of 0.3 cc each, 1% plain lidocaine.  A dorsal slit was made, and the prepuce was dissected away from the glans penis.  A ** Gomco clamp was properly placed for 5 minutes.  During this time, the foreskin was sharply excised using a #10 blade.  With removal of the clamp, there was a good cosmetic outcome and no bleeding.  The child appeared to tolerate the procedure well.  Care instructions were given to the parents.","urology, circumstraint, dorsal slit, gomco clamp, circumcision, childNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Consult for prostate cancer, Urology, Consult - Prostate Cancer ,"CONSULT FOR PROSTATE CANCER,The patient returned for consultation for his newly diagnosed prostate cancer.  The options including radical prostatectomy with or without nerve sparing were discussed with him with the risks of bleeding, infection, rectal injury, impotence, and incontinence.  These were discussed at length.  Alternative therapies including radiation therapy; either radioactive seed placement, conformal radiation therapy, or the HDR radiation treatments were discussed with the risks of bladder, bowel, and rectal injury and possible impotence were discussed also.  There is a risk of rectal fistula.  Hormonal therapy is usually added to the radiation therapy options and this has the risk of osteoporosis, gynecomastia, hot flashes and impotency.  Potency may not recover after the hormone therapy has been completed.  Cryosurgery was discussed with the risks of urinary retention, stricture formation, incontinence and impotency.  There is a risk of rectal fistula.  He would need to have a suprapubic catheter for about two weeks and may need to learn self-intermittent catheterization if he cannot void adequately.  Prostate surgery to relieve obstruction and retention after radioactive seeds or cryosurgery has a higher risk of urinary incontinence.  Observation therapy was discussed with him in addition.  I answered all questions that were put to me and I think he understands the options that are available.  I spoke with the patient for over 60 minutes concerning these options.","urology, prostate cancer, cryosurgery, hdr radiation, prostate surgery, bladder, bleeding, bowel, consultation, impotence, incontinence, infection, prostatectomy, radiation therapy, radical, rectal, rectal fistula, rectal injury, prostate cancer consult, cancer, radiation, prostateNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Cystoscopy, cryosurgical ablation of the prostate.", Urology, Cryosurgical Ablation of Prostate ,"PREOPERATIVE DIAGNOSIS:  ,Carcinoma of the prostate, clinical stage T1C.,POSTOPERATIVE DIAGNOSIS: , Carcinoma of the prostate, clinical stage T1C.,TITLE OF OPERATION: , Cystoscopy, cryosurgical ablation of the prostate.,FINDINGS:  ,After measurement of the prostate, we decided to place 5 rows of needles--row #1 had 3 needles, row #2 at the level of the mid-prostate had 4 needles, row #3 had 2 needles in the right lateral peripheral zone, row #4 was a single needle directly the urethra, and in row #5 were 2 needles placed in the left lateral peripheral zone.  Because of the length of the prostate, a pull-back was performed, pulling row #2 approximately 3 mm and rows #3, #4 and #5 approximately 1 cm back before refreezing.,OPERATION IN DETAIL: , The patient was brought to the operating room and placed in the supine position.  After adequate general endotracheal anesthesia was obtained, the patient was positioned in the dorsal lithotomy position.  Full bowel prep had been obtained prior to the procedure.  After performing flexible cystoscopy, a Foley catheter was placed per urethra into the bladder.  Next, the ultrasound probe was placed into the stabilizer and advanced into the rectum.  An excellent ultrasound image was visualized of the entire prostate, which was re-measured.  Next, the probe template was positioned over the perineum and the template guide brought up on the ultrasound screen in order to guide needle placement.  Then 17-gauge needles were serially placed into the prostate, from an anterior to posterior direction into the prostate.  Ultrasound guidance demonstrated that these needles, numbering approximately 14 to 15 needles, were well placed and spaced throughout the prostate to obtain excellent freezing of the entire gland while sparing the urethra.  Repeat cystoscopy demonstrated a single needle passing through the urethra; and due to the high anterior location of this needle, it was removed.  The CMS urethral warmer was then passed per urethra into the bladder, and flow instituted.  After placing these 17-gauge needles, the prostate was then frozen down to minus 150 degrees for 10 minutes in sequential fashion from anterior to posterior.  The ice ball was monitored and was seen to extend through the capsule of the prostate toward the rectum but not through the rectal wall itself.  Active warming was then performed before refreezing the prostate again and then passively warming it back to room temperature.  The urethral warmer was left on after the needles were removed and the patient brought to the recovery room.  The patient tolerated the procedure well and left the operating room in stable condition.","urology, carcinoma of the prostate, ablation, cystoscopy, cryosurgical ablation, prostate, ultrasound, cryosurgical, urethra, "
 Followup circumcision.  The patient had a pretty significant phimosis and his operative course was smooth.  Satisfactory course after circumcision for severe phimosis with no perioperative complications., Urology, Circumcision Followup ,"REASON FOR VISIT: , Followup circumcision.,HISTORY OF PRESENT ILLNESS: , The patient had his circumcision performed on 09/16/2007 here at Children's Hospital.  The patient had a pretty significant phimosis and his operative course was smooth.  He did have a little bit of bleeding when he woke in recovery room, which required placement of some additional sutures, but after that, his recovery has been complete.  His mom did note that she had to him a couple of days of oral analgesics, but he seems to be back to normal and pain free now.  He is having no difficulty urinating, and his bowel function remains normal.,PHYSICAL EXAMINATION:  ,Today, The patient looks healthy and happy.  We examined his circumcision site.  His Monocryl sutures are still in place.  The healing is excellent, and there is only a mild amount of residual postoperative swelling.  There was one area where he had some recurrent adhesions at the coronal sulcus, and I gently lysed this today and applied antibiotic ointment showing this to mom had to especially lubricate this area until the healing is completed.,IMPRESSION: , Satisfactory course after circumcision for severe phimosis with no perioperative complications.,PLAN:  ,The patient came in followup for his routine care with Dr. X, but should not need any further routine surgical followup unless he develops any type of difficulty with this surgical wound.  If that does occur, we will be happy to see him back at any time.,","urology, circumcision, adhesions, followup circumcision, sutures, phimosis, "
 Right lower pole renal stone and possibly infected stent.  Cysto stent removal., Urology, Cysto Stent Removal ,"PREOPERATIVE DIAGNOSIS: , Right lower pole renal stone and possibly infected stent.,POSTOPERATIVE DIAGNOSIS: , Right lower pole renal stone and possibly infected stent.,OPERATION:,  Cysto stent removal.,ANESTHESIA:,  Local MAC.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid.,MEDICATIONS: , The patient was on vancomycin and Levaquin was given x1 dose.  The patient was on vancomycin for the last 5 days.,BRIEF HISTORY:  ,The patient is a 53-year-old female who presented with Enterococcus urosepsis.  CT scan showed a lower pole stone with a stent in place.  The stent was placed about 2 months ago, but when patient came in with a possibly UPJ stone with fevers of unknown etiology.  The patient had a stent placed at that time due to the fevers, thinking that this was an urospetic stone.  There was some pus that came out.  The patient was cultured; actually it was negative at that time.  The patient subsequently was found to have lower extremity DVT and then was started on Coumadin.  The patient cannot be taken off Coumadin for the next 6 months due to the significant swelling and high risk for PE.  The repeat films were taken which showed the stone had migrated into the pole.,The stent was intact.  The patient subsequently developed recurrent UTIs and Enterococcus in the urine with fevers.  The patient was admitted for IV antibiotics since the patient could not really tolerate penicillin due to allergy and due to patient being on Coumadin, Cipro, and Levaquin where treatment was little bit more complicated.  Due to drug interaction, the patient was admitted for IV antibiotic treatment.  The thinking was that either the stone or the stent is infected, since the stone is pretty small in size, the stent is very likely possibility that it could have been infected and now it needs to be removed.  Since the stone is not obstructing, there is no reason to replace the stent at this time.  We are unable to do the ureteroscopy or the shock-wave lithotripsy when the patient is fully anticoagulated.  So, the best option at this time is to probably wait and perform the ureteroscopic laser lithotripsy when the patient is allowed to off her Coumadin, which would be probably about 4 months down the road.,Plan is to get rid of the stent and improve patient's urinary symptoms and to get rid of the infection and we will worry about the stone at later point.,DETAILS OF THE OR: , Consent had been obtained from the patient.  Risks, benefits, and options were discussed.  Risk of anesthesia, bleeding, infection, pain, MI, DVT, and PE were discussed.  The patient understood all the risks and benefits of removing the stent and wanted to proceed.  The patient was brought to the OR.  The patient was placed in dorsal lithotomy position.  The patient was given some IV pain meds.  The patient had received vancomycin and Levaquin preop.  Cystoscopy was performed using graspers.  The stent was removed without difficulty.  Plan was for repeat cultures and continuation of the IV antibiotics.","urology, infected stent, cysto stent removal, cysto stent, renal stone, lower pole, infected, stone, stent, cysto,"
 Circumcision and release of ventral chordee., Urology, Circumcision & Chordee Release ,"PREOPERATIVE DIAGNOSES: , Phimosis and adhesions.,POSTOPERATIVE DIAGNOSES:  ,Phimosis and adhesions.,PROCEDURES PERFORMED: , Circumcision and release of ventral chordee.,ANESTHESIA:  ,Local MAC.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid.  The patient was given antibiotics preop.,BRIEF HISTORY: , This is a 43-year-old male who presented to us with significant phimosis, difficulty retracting the foreskin.  The patient had buried penis with significant obesity issues in the suprapubic area.  Options such as watchful waiting, continuation of slowly retracting the skin, applying betamethasone cream, and circumcision were discussed.  Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE, and CVA risks were discussed.  The patient had discussed this issue with Dr Khan and had been approved to get off of the Plavix.  Consent had been obtained.  Risk of scarring, decrease in penile sensation, and unexpected complications were discussed.  The patient was told about removing the dressing tomorrow morning, okay to shower after 48 hours, etc.  Consent was obtained.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the OR.  Anesthesia was applied.  The patient was placed in supine position.  The patient was prepped and draped in usual sterile fashion.  Local MAC anesthesia was applied.  After draping, 17 mL of mixture of 0.25% Marcaine and 1% lidocaine plain were applied around the dorsal aspect of the penis for dorsal block.  The patient had significant phimosis and slight ventral chordee.  Using marking pen, the excess foreskin was marked off.  Using a knife, the ventral chordee was released.  The urethra was intact.  The excess foreskin was removed.  Hemostasis was obtained using electrocautery.  A 5-0 Monocryl stitches were used for 4 interrupted stitches and horizontal mattresses were done.  The patient tolerated the procedure well.  There was excellent hemostasis.  The penis was straight.  Vaseline gauze and Kerlix were applied.  The patient was brought to the recovery in stable condition.  Plan was for removal of the dressing tomorrow.  Okay to shower after 48 hours.","urology, phimosis, adhesions, release of ventral chordee, ventral chordee, circumcision, penis, chordee, foreskin,"
 Normal penis.  The foreskin was normal in appearance and measured 1.6 cm.  There was no bleeding at the circumcision site., Urology, Circumcision - 7 ,"PROCEDURE:,  Circumcision.,ANESTHESIA: , EMLA.,FINDINGS: , Normal penis.  The foreskin was normal in appearance and measured 1.6 cm.  There was no bleeding at the circumcision site.,PROCEDURE:,  Patient was placed on the circumcision restraint board.  EMLA had been applied approximately 90 minutes before.  A time-out was completed satisfactorily per protocol.  The area was prepped with Betadine.  The foreskin was grasped with sterile clamps and was dissected away from the corona and the glans penis with blunt dissection.  A Mogen clamp was applied to the cervix.  The excess foreskin was excised with the scalpel.  The clamp was removed.  At this point, the procedure was terminated.  Sterile Vaseline and gauze was applied to the glans penis.  There were no complications.  There was minimal blood loss.","urology, mogen clamp, glans penis, emla, penis, foreskin, circumcision"
 Circumcision procedure (neotal), Urology, Circumcision - 2 ,"CIRCUMCISION - NEONATAL,PROCEDURE:,:  The procedure, risks and benefits were explained to the patient's mom, and a consent form was signed.  She is aware of the risk of bleeding, infection, meatal stenosis, excess or too little foreskin removed and the possible need for revision in the future.  The infant was placed on the papoose board.  The external genitalia were prepped with Betadine.  A penile block was performed with a 30-gauge needle and 1.5 mL of Nesacaine without epinephrine.,Next, the foreskin was clamped at the 12 o'clock position back to the appropriate proximal extent of the circumcision on the dorsum of the penis.  The incision was made.  Next, all the adhesions of the inner preputial skin were broken down.  The appropriate size bell was obtained and placed over the glans penis.  The Gomco clamp was then configured, and the foreskin was pulled through the opening of the Gomco.  The bell was then placed and tightened down.  Prior to do this, the penis was viewed circumferentially, and there was no excess of skin gathered, particularly in the area of the ventrum.  A blade was used to incise circumferentially around the bell.  The bell was removed.  There was no significant bleeding, and a good cosmetic result was evident with the appropriate amount of skin removed.,Vaseline gauze was then placed.  The little boy was given back to his mom.,PLAN:,  They have a new baby checkup in the near future with their primary care physician.  I will see them back on a p.r.n. basis if there are any problems with the circumcision.","urology, neonatal, circumcision, gomco, gomco clamp, external genitalia, foreskin, glans, glans penis, infant, meatal stenosis, penile block, penis, preputial skin, circumferentially, infection, bell,"
 Circumcision procedure in a baby, Urology, Circumcision - 3 ,"CIRCUMCISION,After informed consent was obtained the baby was placed on the circumcision tray.  He was prepped in a sterile fashion times 3 with Betadine and then draped in a sterile fashion.  Then 0.2 mL of 1% lidocaine was injected at 10 and 2 o'clock.  A ring block was also done using another 0.3 mL of lidocaine.  Glucose water is also used for anesthesia.  After several minutes the curved clamp was attached at 9 o'clock with care being taken to avoid the meatus.  The blunt probe was then introduced again with care taken to avoid the meatus.  After initial adhesions were taken down the straight clamp was introduced to break down further adhesions.  Care was taken to avoid the frenulum.  The clamps where then repositioned at 12 and 6 o'clock.  The Mogen clamp was then applied with a dorsal tilt.  After the clamp was applied for 1 minute the foreskin was trimmed.  After an additional minute the clamp was removed and the final adhesions were taken down.  Patient tolerated the procedure well with minimal bleeding noted.  Patient to remain for 20 minutes after procedure to insure no further bleeding is noted.,Routine care discussed with the family.  Need to clean the area with just water initially and later with soap and water or diaper wipes once healed.","urology, circumcision, 1% lidocaine, betadine, glucose water, adhesions, circumcision tray, diaper wipes, foreskin, frenulum, meatus, straight clamp, sterile fashion, clampNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Circumcision in an older person, Urology, Circumcision - 1 ,"CIRCUMCISION - OLDER PERSON,OPERATIVE NOTE:,  The patient was taken to the operating room and placed in the supine position on the operating table.  General endotracheal anesthesia was administered.  The patient was prepped and draped in the usual sterile fashion.  A 4-0 silk suture is used as a stay-stitch of the glans penis.  Next, incision line was marked circumferentially on the outer skin 3 mm below the corona.  The incision was then carried through the skin and subcutaneous tissues down to within a layer of * fascia.  Next, the foreskin was retracted.  Another circumferential incision was made 3 mm proximal to the corona.  The intervening foreskin was excised.  Meticulous hemostasis was obtained with electrocautery.  Next, the skin was reapproximated at the frenulum with a U stitch of 5-0 chromic followed by stitches at 12, 3, and 9 o'clock.  The stitches were placed equal distance among these to reapproximate all the skin edges.  Next, good cosmetic result was noted with no bleeding at the end of the procedure.  Vaseline gauze, Telfa, and Elastoplast dressing was applied.  The stay-stitch was removed and pressure held until bleeding stopped.  The patient tolerated the procedure well and was returned to the recovery room in stable condition.","urology, circumcision, elastoplast, meticulous hemostasis, telfa, vaseline gauze, circumferential incision, corona, cosmetic result, endotracheal anesthesia, foreskin, glans penis, hemostasis, stay stitch, circumferentially, stitchNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Refractory priapism.  Cavernosaphenous shunt.   The patient presented with priapism x48 hours on this visit.  The patient underwent corporal aspiration and Winter's shunt both of which failed, Urology, Cavernosaphenous Shunt - Priapism ,"PREOPERATIVE DIAGNOSIS:,  Refractory priapism.,POSTOPERATIVE DIAGNOSIS:,  Refractory priapism.,PROCEDURE PERFORMED: , Cavernosaphenous shunt.,ANESTHESIA:,  General.,ESTIMATED BLOOD LOSS:  ,400 cc.,FLUIDS: , IV fluids 1600 crystalloids, one liter packed red blood cells.,INDICATIONS FOR PROCEDURE:  ,This is a 34-year-old African-American male who is known to our service with a history of recurrent priapism.  The patient presented with priapism x48 hours on this visit.  The patient underwent corporal aspiration and Winter's shunt both of which failed and then subsequently underwent _______ procedure.  The patient's priapism did return following this and he was scheduled for cavernosaphenous shunt.,PROCEDURE:,  Informed written consent was obtained.  The patient was taken to the operative suite and administered anesthetic.  The patient was sterilely prepped and draped in the supine fashion.  A #15 French Foley catheter was inserted under sterile conditions.  Incision was made in the left base of the penile shaft on the lateral aspect, approximately 3 cm in length.  Tissue was dissected down to the level of the corpora cavernosum and corpora spongiosum.  The fascia was incised in elliptical fashion for approximately 2 cm.  A #14 gauge Angiocath was inserted into the corpora cavernosum to the glans of the penis and the corpora was irrigated copiously until all of the old clotted blood was removed and fresher irrigation was noted.,Attention was then turned to the left groin and the superficial saphenous vein was harvested.  Due to incisions brought up into the initial incision after gauging enough length, this was then spatulated with Potts scissors for approximately 2 cm.  Vein was irrigated.  One branching vessel was noted to be leaking, this was tied off and repeat injection with heparinized saline showed no additional leaks.  Tunnel was then created from the superior most groin region to the incision in the penile shaft.  Saphenous vein was then passed through this tunnel with the aid of a hemostat.  Anastomosis was performed using #5-0 Prolene suture in a running fashion from proximal to distal.  There were no leaks noted.  There was good flow noted within the saphenous vein graft.  Penis was noted to be in a flaccid state.  All incisions were irrigated copiously and closed in several layers.  Sterile dressings were applied.  The patient was cleaned, transferred to recovery room in stable condition.,PLAN:  ,We will continue with antibiotics for pain control, maintain Foley catheter.  Further recommendations to follow.","urology, corporal aspiration, winter's shunt, foley catheter, corpora cavernosum, refractory priapism, saphenous vein, cavernosaphenous shunt, corporal, priapism, aspiration"
 The patient had spraying of urine and ballooning of the foreskin with voiding., Urology, Circumcision ,"PREOPERATIVE DIAGNOSIS:,  Phimosis.,POSTOPERATIVE DIAGNOSES:,  Phimosis.,OPERATIONS:,  Circumcision.,ANESTHESIA: , LMA.,EBL:,  Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY: , This is a 3-year-old male, who was referred to us from Dr. X's office with phimosis.  The patient had spraying of urine and ballooning of the foreskin with voiding.  The urine seemed to have collected underneath the foreskin and then would slowly drip out.  Options such as dorsal slit, circumcision, watchful waiting by gently pulling the foreskin back were discussed.  Risk of anesthesia, bleeding, infection, pain, scarring, and expected complications were discussed.  The patient's family understood all the complications and wanted to proceed with the procedure.  Consent was obtained using interpreter.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the OR and anesthesia was applied.  The patient was placed in supine position.  The patient was prepped and draped in usual sterile fashion.  All the penile adhesions were released prior to the prepping.  The extra foreskin was marked off, 1 x 3 Gamco clamp was used.  Hemostasis was obtained after removing the extra foreskin using the Gamco clamp.,Using 5-0 Monocryl, 4 quadrant stitches were placed and horizontal mattress suturing was done.  There was excellent hemostasis.  Dermabond was applied.  The patient was brought to recovery at the end of the procedure in stable condition.","urology, ballooning of the foreskin, spraying of urine, gamco clamp, spraying, ballooning, circumcision, urine, phimosis, foreskin"
" Brachytherapy, iodine-125 seed implantation, and cystoscopy.", Urology, Brachytherapy ,"PREOPERATIVE DIAGNOSIS:,  Prostate cancer.,POSTOPERATIVE DIAGNOSIS:,  Prostate cancer.,OPERATIONS: , Brachytherapy, iodine-125 seed implantation, and cystoscopy.,ANESTHESIA:,  LMA.,ESTIMATED BLOOD LOSS: , Minimal.,Total number of seeds placed, 63.  Needles, 24.,BRIEF HISTORY OF THE PATIENT: , This is a 57-year-old male who was seen by us for elevated PSA.  The patient had a prostate biopsy with T2b disease, Gleason 6.  Options such as watchful waiting, robotic prostatectomy, seed implantation with and without radiation were discussed.  Risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, incontinence, rectal dysfunction, voiding issues, burning pain, unexpected complications such as fistula, rectal injury, urgency, frequency, bladder issues, need for chronic Foley for six months, etc., were discussed.  The patient understood all the risks, benefits, and options, and wanted to proceed with the procedure.  The patient was told that there could be other unexpected complications.  The patient has history of urethral stricture.  The patient was told about the risk of worsening of the stricture with radiation.  Consent was obtained.,DETAILS OF THE OPERATION: , The patient was brought to the OR.  Anesthesia was applied.  The patient was placed in the dorsal lithotomy position.  The patient had SCDs on.  The patient was given preop antibiotics.  The patient had done bowel prep the day before.  Transrectal ultrasound was performed.  The prostate was measured at about 32 gm.  The images were transmitted to the computer system for radiation oncologist to determine the dosing etc.  Based on the computer analysis, the grid was placed.  Careful attention was drawn to keep the grid away from the patient.  There was a centimeter distance between the skin and the grid.  Under ultrasound guidance, the needles were placed, first in the periphery of the prostate, a total of 63 seeds were placed throughout the prostate.  A total of 24 needles was used.  Careful attention was drawn to stay away from the urethra.  Under longitudinal ultrasound guidance, all the seeds were placed.  There were no seeds visualized in the bladder under ultrasound.  There was only one needle where the seeds kind of dragged as the needle was coming out on the left side and were dropped out of position.  Other than that, all the seeds were very well distributed throughout the prostate under fluoroscopy.  Please note that the Foley catheter was in place throughout the procedure.  Prior to the seed placement, the Foley was attempted to be placed, but we had to do it using a Glidewire to get the Foley in and we used a Councill-tip catheter.  The patient has had history of bulbar urethral stricture.  Pictures were taken of the strictures in the pre-seed placement cysto time frame.  We needed to do the cystoscopy and Glidewire to be able to get the Foley catheter in.  At the end of the procedure, again cystoscopy was done, the entire bladder was visualized.  The stricture was wide open.  The prostate was slightly enlarged.  The bladder appeared normal.  There was no sheath inside the urethra or in the bladder.  The cysto was done using 30-degree and 70-degree lens.  At the end of the procedure, a Glidewire was placed, and 18 Councill-tip catheter was placed.  The plan was for Foley to be left in place overnight since the patient has history of urethral strictures.  The patient is to follow up tomorrow to have the Foley removed.  The patient could also be shown to have it removed at home.,The patient was brought to Recovery in stable condition at the end of the procedure.  The patient tolerated the procedure well.","urology, iodine-125 seed implantation, seed implantation, prostate cancer, cystoscopy, brachytherapy, councill tip catheter, brachytherapy iodine, ultrasound, catheter, urethral, prostate,"
 Normal Circumcision, Urology, Circumcision - 4 ,The patient tolerated the procedure well and was sent to the Recovery Room in stable condition.,"urology, circumcision, circumferential proximal incisions, hemostasis, vaseline soaked gauze, catgut, foreskin, needlepoint bovie, pain block, shaft of the penis, supine position, penisNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" Release of ventral chordee, circumcision, and repair of partial duplication of urethral meatus.", Urology, Circumcision - 5 ,"PROCEDURES:,1.  Release of ventral chordee.,2.  Circumcision.,3.  Repair of partial duplication of urethral meatus.,INDICATIONS: , The patient is an 11-month-old baby boy who presented for evaluation of a duplicated urethral meatus as well as ventral chordee and dorsal prepuce hooding.  He is here electively for surgical correction.,DESCRIPTION OF PROCEDURE: , The patient was brought back into operating room 35.  After successful induction of general endotracheal anesthetic, giving the patient, preoperative antibiotics and after completing a preoperative time out, the patient was prepped and draped in the usual sterile fashion.,A holding stitch was placed in the glans penis.  At this point, we probed both urethral meatus.  Using the Crede maneuver, we could see urine clearly coming out of the lower, the more ventral meatus.  At this point, we cannulated this with a 6-French hypospadias catheter.  We attempted to cannulate the dorsal opening, however, we were unsuccessful.  We then attempted to place lacrimal probes and were also unsuccessful indicating this was incomplete duplication.  At this point, we identified the band connecting both the urethral meatus and incised it with tenotomy scissors.  We sutured both meatus together such that there was one meatus at the normal position at the tip of the glans.,At this point, we made a circumcising incision around the penis and degloved the penis in its entirety relieving all chordee.  Once all the chordee had been adequately released, we turned our attention to the circumcision.  Excessive dorsal foreskin was removed from the skin and glans.  Mucosal cuts were reapproximated with interrupted 5-0 chromic suture.  Dermabond was placed over this and bacitracin was placed on this once dry.  This ended the procedure.  ,DRAINS:,  None.,ESTIMATED BLOOD LOSS: , Minimal.,URINE OUTPUT:  ,Unrecorded.,COMPLICATIONS: , None apparent.,DISPOSITION:  ,The patient will now go under the care of Dr. XYZ, Plastic Surgery, for excision of scalp hemangioma.","urology, release of ventral chordee, repair of partial duplication, partial duplication, ventral chordee, urethral meatus, glans, penis, circumcision, ventral, chordee, urethral, meatus,"
" Circumcision.   A dorsal slit was made, and the prepuce was dissected away from the glans penis.", Urology, Circumcision - 6 ,"PROCEDURE: , Circumcision.,Signed informed consent was obtained and the procedure explained.,DETAILS OF PROCEDURE: ,The child was placed in a Circumstraint board and restrained in the usual fashion.  The area of the penis and scrotum were prepared with povidone iodine solution.  The area was draped with sterile drapes, and the remainder of the procedure was done with sterile procedure.  A dorsal penile block was done using 2 injections of 0.3 cc each, 1% plain lidocaine.  A dorsal slit was made, and the prepuce was dissected away from the glans penis.  A Gomco clamp was properly placed for 5 minutes.  During this time, the foreskin was sharply excised using a #10 blade.  With removal of the clamp, there was a good cosmetic outcome and no bleeding.  The child appeared to tolerate the procedure well.  Care instructions were given to the parents.","urology, gomco clamp, dorsal slit, glans penis, slit, circumcision, penisNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" Closure of bladder laceration, during cesarean section.", Urology, Bladder Laceration Closure ,"PREOPERATIVE DIAGNOSES: , Bladder laceration.,POSTOPERATIVE DIAGNOSES:,  Bladder laceration.,NAME OF OPERATION: , Closure of bladder laceration.,FINDINGS:,  The patient was undergoing a cesarean section for twins.  During the course of the procedure, a bladder laceration was notices and urology was consulted.  Findings were a laceration on the dome of the bladder.,PROCEDURE: , Initially there as a mucosal layer of suture already placed.  This was done with 3-0 chromic catgut.  The bladder was distended and, while the bladder was distended with physiologic saline, a second layer of 3-0 chromic catgut created a watertight closure.  The second layer included the mucosa an dinner layer of the detrusor muscle.  A third layer of 2-0 Dexon was used.  Each of these were placed in a continuous running-locked suture technique.  There was complete watertight closure of the bladder.  Hemostasis was assured and a Jackson-Pratt drain was brought out through a separate stab wound.  The remaining portion of the operation, both the cesarean section and the wound closure, will be dictated by Dr. Redmond.","urology, mucosal layer, closure of bladder laceration, watertight closure, cesarean section, bladder laceration, bladder, cesarean, closure, laceration, "
 Recurrent bladder tumor.  The patient on recent followup cystoscopy for transitional cell carcinomas of the bladder neck was found to have a 5-cm area of papillomatosis just above the left ureteric orifice., Urology, Bladder Tumor ,"CHIEF COMPLAINT:,  Recurrent bladder tumor.,HISTORY OF PRESENT ILLNESS: , The patient is a 79-year-old woman, the patient of Dr. X, who on recent followup cystoscopy for transitional cell carcinomas of the bladder neck was found to have a 5-cm area of papillomatosis just above the left ureteric orifice.  The patient underwent TUR of several transitional cell carcinomas of the bladder on the bladder neck in 2006.  This was followed by bladder instillation of BCG.  At this time, the patient denies any voiding symptoms or hematuria.  The patient opting for TUR and electrofulguration of the recurrent tumors.,ALLERGIES: , None known.,MEDICATIONS: , Atenolol 5 mg daily.,OPERATIONS: , Status post bilateral knee replacements and status post TUR of bladder tumors.,REVIEW OF SYSTEMS: , Other than some mild hypertension, the patient is in very, very good health.  No history of diabetes, shortness of breath or chest pain.,PHYSICAL EXAMINATION: , Well-developed and well-nourished woman, alert and oriented.  Her lungs are clear.  Heart, regular sinus rhythm.  Back, no CVA tenderness.  Abdomen, soft and nontender.  No palpable masses.,IMPRESSION: , Recurrent bladder tumors.,PLAN: , The patient to have CBC, chem-6, PT, PTT, EKG, and chest x-ray beforehand.","urology, bladder neck, voiding symptoms, hematuria, transitional cell carcinomas, ureteric orifice, bladder tumor, bladder, cystoscopy, papillomatosis, transitional, carcinomas, orifice,"
 Patient has prostate cancer with metastatic disease to his bladder.  The patient has had problems with hematuria in the past.  The patient was encouraged to drink extra water and was given discharge instructions on hematuria., Urology, Blood in Urine - ER Visit ,"CHIEF COMPLAINT: , Blood in urine.,HISTORY OF PRESENT ILLNESS:  ,This is a 78-year-old male who has prostate cancer with metastatic disease to his bladder and in several locations throughout the skeletal system including the spine and shoulder.  The patient has had problems with hematuria in the past, but the patient noted that this episode began yesterday, and today he has been passing principally blood with very little urine.  The patient states that there is no change in his chronic lower back pain and denies any incontinence of urine or stool.  The patient has not had any fever.  There is no abdominal pain and the patient is still able to pass urine.  The patient has not had any melena or hematochezia.  There is no nausea or vomiting.  The patient has already completed chemotherapy and is beyond treatment for his cancer at this time.  The patient is receiving radiation therapy, but it is targeted to the bones and intended to give symptomatic relief of his skeletal pain and not intended to treat and cure the cancer.  The patient is not enlisted in hospice, but the principle around the patient's current treatment management is focusing on comfort care measures.,REVIEW OF SYSTEMS: , CONSTITUTIONAL:  No fever or chills.  The patient does report generalized fatigue and weakness over the past several days.  HEENT:  No headache, no neck pain, no rhinorrhea, no sore throat.  CARDIOVASCULAR:  No chest pain.  RESPIRATIONS:  No shortness of breath or cough, although the patient does get easily winded with exertion over these past few days.  GASTROINTESTINAL:  The patient denies any abdominal pain.  No nausea or vomiting.  No changes in the bowel movement.  No melena or hematochezia.  GENITOURINARY:  A gross hematuria since yesterday as previously described.  The patient is still able to pass urine without difficulty.  The patient denies any groin pain.  The patient denies any other changes to the genital region.  MUSCULOSKELETAL:  The chronic lower back pain which has not changed over these past few days.  The patient does have multiple other joints, which cause him discomfort, but there have been no recent changes in these either.  SKIN:  No rashes or lesions.  No easy bruising.  NEUROLOGIC:  No focal weakness or numbness.  No incontinence of urine or stool.  No saddle paresthesia.  No dizziness, syncope or near-syncope.  ENDOCRINE:  No polyuria or polydipsia.  No heat or cold intolerance.  HEMATOLOGIC/LYMPHATIC:  The patient does not have a history of easy bruising or bleeding, but the patient has had previous episodes of hematuria.,PAST MEDICAL HISTORY: , Prostate cancer with metastatic disease as previously described.,PAST SURGICAL HISTORY: , TURP.,CURRENT MEDICATIONS:,  Morphine, Darvocet, Flomax, Avodart and ibuprofen.,ALLERGIES: , VICODIN.,SOCIAL HISTORY: , The patient is a nonsmoker.  Denies any alcohol or illicit drug use.  The patient does live with his family.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Temperature is 98.8 oral, blood pressure is 108/65, pulse is 109, respirations 16, oxygen saturation is 97% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished, well developed.  The patient appears to be pale, but otherwise looks well.  The patient is calm, comfortable.  The patient is pleasant and cooperative.  HEENT:  Eyes normal with clear conjunctivae and corneas.  Nose is normal without rhinorrhea or audible congestion.  Mouth and oropharynx normal without any sign of infection.  Mucous membranes are moist.  NECK:  Supple.  Full range of motion.  No JVD.  CARDIOVASCULAR:  Heart is mildly tachycardic with regular rhythm without murmur, rub or gallop.  Peripheral pulses are +2.  RESPIRATIONS:  Clear to auscultation bilaterally.  No shortness of breath.  No wheezes, rales or rhonchi.  Good air movement bilaterally.  GASTROINTESTINAL:  Abdomen is soft, nontender, nondistended.  No rebound or guarding.  No hepatosplenomegaly.  Normal bowel sounds.  No bruit.  No masses or pulsatile masses.  GENITOURINARY:  The patient has normal male genitalia, uncircumcised.  There is no active bleeding from the penis at this time.  There is no swelling of the testicles.  There are no masses palpated to the testicles, scrotum or the penis.  There are no lesions or rashes noted.  There is no inguinal lymphadenopathy.  Normal male exam.  MUSCULOSKELETAL:  Back is normal and nontender.  There are no abnormalities noted to the arms or legs.  The patient has normal use of the extremities.  SKIN:  The patient appears to be pale, but otherwise the skin is normal.  There are no rashes or lesions.  NEUROLOGIC:  Motor and sensory are intact to the extremities.  The patient has normal speech.  PSYCHIATRIC:  The patient is alert and oriented x4.  Normal mood and affect.  HEMATOLOGIC/LYMPHATIC:  There is no evidence of bruising noted to the body.  No lymphadenitis is palpated.,EMERGENCY DEPARTMENT TESTING:,  CBC was done, which had a hemoglobin of 7.7 and hematocrit of 22.6.  Neutrophils were 81%.  The RDW was 18.5, and the rest of the values were all within normal limits and unremarkable.  Chemistry had a sodium of 134, a glucose of 132, calcium is 8.2, and rest of the values are unremarkable.  Alkaline phosphatase was 770 and albumin was 2.4.  Rest of the values all are within normal limits of the LFTs.  Urinalysis was grossly bloody with a large amount of blood and greater than 50 rbc's.  The patient also had greater than 300 of the protein reading, moderate leukocytes, 30-50 white blood cells, but no bacteria were seen.  Coagulation profile study had a PT of 15.9, PTT of 43 and INR of 1.3.,EMERGENCY DEPARTMENT COURSE: , The patient was given normal saline 2 liters over 1 hour without any adverse effect.  The patient was given multiple doses of morphine to maintain his comfort while here in the emergency room without any adverse effect.  The patient was given Levaquin 500 mg by mouth as well as 2 doses of Phenergan over the course of his stay here in the emergency department.  The patient did not have an adverse reaction to these medicines either.  Phenergan resolved his nausea and morphine did relieve his pain and make him pain free.  I spoke with Dr. X, the patient's urologist, about most appropriate step for the patient, and Dr. X said he would be happy to care for the patient in the hospital and do urologic scopes if necessary and surgery if necessary and blood transfusion.  It was all a matter of what the patient wished to do given the advanced stage of his cancer.  Dr. X was willing to assist in any way the patient wished him to.  I spoke with the patient and his son about what he would like to do and what the options were from doing nothing from keeping him comfortable with pain medicines to admitting him to the hospital with the possibility of scopes and even surgery being done as well as the blood transfusion.  The patient decided to choose a middle ground in which he would be transfused with 2 units of blood here in the emergency room and go home tonight.  The patient's son felt comfortable with his father's choice.  This was done.  The patient was transfused 2 units of packed red blood cells after appropriately typed and match.  The patient did not have any adverse reaction at any point with his transfusion.  There was no fever, no shortness of breath, and at the time of disposition, the patient stated he felt a little better and felt like he had a little more strength.  Over the course of the patient's several-hour stay in the emergency room, the patient did end up developing enough problems with clotted blood in his bladder that he had a urinary obstruction.  Foley catheter was placed, which produced bloody urine and relieved the developing discomfort of a full bladder.  The patient was given a leg bag and the Foley catheter was left in place.,DIAGNOSES,1.  HEMATURIA.,2.  PROSTATE CANCER WITH BONE AND BLADDER METASTATIC DISEASE.,3.  SIGNIFICANT ANEMIA.,4.  URINARY OBSTRUCTION.,CONDITION ON DISPOSITION:  ,Fair, but improved.,DISPOSITION: , To home with his son.,PLAN: , We will have the patient follow up with Dr. X in his office in 2 days for reevaluation.  The patient was given a prescription for Levaquin and Phenergan tablets to take home with him tonight.  The patient was encouraged to drink extra water.  The patient was given discharge instructions on hematuria and asked to return to the emergency room should he have any worsening of his condition or develop any other problems or symptoms of concern.",
 Bladder instillation for chronic interstitial cystitis., Urology, Bladder Instillation ,"CHIEF COMPLAINT:,  The patient comes for bladder instillation for chronic interstitial cystitis.,SUBJECTIVE:,  The patient is crying today when she arrives in the office saying that she has a lot of discomfort.  These bladder instillations do not seem to be helping her.  She feels anxious and worried.  She does not think she can take any more pain.  She is debating whether or not to go back to Dr. XYZ and ask for the nerve block or some treatment modality to stop the pain because she just cannot function on a daily basis and care for her children unless she gets something done about this, and she fears these bladder instillations because they do not seem to help.  They seem to be intensifying her pain.  She has the extra burden of each time she comes needing to have pain medication one way or another, thus then we would not allow her to drive under the influence of the pain medicine.  So, she has to have somebody come with her and that is kind of troublesome to her.  We discussed this at length.  I did suggest that it was completely appropriate for her to decide.  She will terminate these if they are that uncomfortable and do not seem to be giving her any relief, although I did tell her that occasionally people do have discomfort with them and then after the completion of the instillations, they do better and we have also had some people who have had to terminate the instillations because they were too uncomfortable and they could not stand it and they went on to have some other treatment modality.  She had Hysterectomy in the past.,MEDICATIONS: , Premarin 1.25 mg daily, Elmiron 100 mg t.i.d., Elavil 50 mg at bedtime, OxyContin 10 mg three tablets three times a day, Toprol XL 25 mg daily.,ALLERGIES:,  Compazine and Allegra.,OBJECTIVE:,Vital Signs:  Weight:  140 pounds.  Blood pressure:  132/90.  Pulse:  102.  Respirations:  18.  Age:  27.,PLAN:,  We discussed going for another evaluation by Dr. XYZ and seeking his opinion.  She said that she called him on the phone the other day and told him how miserable she was and he told her that he really thought she needed to complete.  The instillations give that a full trial and then he would be willing to see her back.  As we discussed these options and she was encouraged to think it over and decide what she would like to do for I could not makeup her mind for her.  She said she thought that it was unreasonable to quit now when she only had two or three more treatments to go, but she did indicate that the holiday weekend coming made her fearful and if she was uncomfortable after today’s instillation which she did choose to take then she would choose to cancel Friday’s appointment, also that she would not feel too badly over the holiday weekend.  I thought that was reasonable and agreed that that would work out.,PROCEDURE:,:  She was then given 10 mg of morphine subcutaneously because she did not feel she could tolerate the discomfort in the instillation without pain medicine.  We waited about 20 minutes.  The bladder was then instilled and the urethra was instilled with lidocaine gel which she tolerated and then after a 10-minute wait, the bladder was instilled with DMSO, Kenalog, heparin, and sodium bicarbonate, and the catheter was removed.  The patient retained the solution for one hour, changing position every 15 minutes and then voided to empty the bladder.  She seemed to tolerate it moderately well.  She is to call and let me know what she wishes to do about the Friday scheduled bladder instillation if she tolerated this then she is going to consider trying it.  If not, she will cancel and will start over next week or she will see Dr. Friesen.","urology, urethra, dmso, bladder, chronic interstitial cystitis, interstitial cystitis, bladder instillation, instillation, instillations,"
" Cystoscopy, bladder biopsies, and fulguration.  Bladder lesions with history of previous transitional cell bladder carcinoma, pathology pending.", Urology, Bladder Biopsies & Fulguration ,"PREOPERATIVE DIAGNOSIS:,  Bladder lesions with history of previous transitional cell bladder carcinoma.,POSTOPERATIVE DIAGNOSIS: , Bladder lesions with history of previous transitional cell bladder carcinoma, pathology pending.,OPERATION PERFORMED:  ,Cystoscopy, bladder biopsies, and fulguration.,ANESTHESIA: , General.,INDICATION FOR OPERATION: , This is a 73-year-old gentleman who was recently noted to have some erythematous, somewhat raised bladder lesions in the bladder mucosa at cystoscopy.  He was treated for a large transitional cell carcinoma of the bladder with TURBT in 2002 and subsequently underwent chemotherapy because of pulmonary nodules.  He has had some low grade noninvasive small tumor recurrences on one or two occasions over the past 18 months.  Recent cystoscopy raises suspicion of another recurrence.,OPERATIVE FINDINGS: , The entire bladder was actually somewhat erythematous with mucosa looking somewhat hyperplastic particularly in the right dome and lateral wall of the bladder.  Scarring was noted along the base of the bladder from the patient's previous cysto TURBT.  Ureteral orifice on the right side was not able to be identified.  The left side was unremarkable.,DESCRIPTION OF OPERATION: , The patient was taken to the operating room.  He was placed on the operating table.  General anesthesia was administered after which the patient was placed in the dorsal lithotomy position.  The genitalia and lower abdomen were prepared with Betadine and draped subsequently.  The urethra and bladder were inspected under video urology equipment (25 French panendoscope) with the findings as noted above.  Cup biopsies were taken in two areas from the right lateral wall of the bladder, the posterior wall of bladder, and the bladder neck area.  Each of these biopsy sites were fulgurated with Bugbee electrodes.  Inspection of the sites after completing the procedure revealed no bleeding and bladder irrigant was clear.  The patient's bladder was then emptied.  Cystoscope removed and the patient was awakened and transferred to the postanesthetic recovery area.  There were no apparent complications, and the patient appeared to tolerate the procedure well.  Estimated blood loss was less than 15 mL.","urology, cystoscope, carcinoma, transitional cell bladder carcinoma, bladder lesions, bladder, fulguration, biopsies, cystoscopy,"
" Austin & Youngswick bunionectomy with Biopro implant.  Screw fixation, left foot.", Surgery, Youngswick Bunionectomy ,"PREOPERATIVE DIAGNOSES:,1.  Hallux rigidus, left foot.,2.  Elevated first metatarsal, left foot.,POSTOPERATIVE DIAGNOSES:,1.  Hallux rigidus, left foot.,2.  Elevated first metatarsal, left foot.,PROCEDURE PERFORMED:,1.  Austin/Youngswick bunionectomy with Biopro implant.,2.  Screw fixation, left foot.,HISTORY: , This 51-year-old male presents to ABCD General Hospital with the above chief complaint.  The patient states that he has had degenerative joint disease in his left first MPJ for many years that has been progressively getting worse and more painful over time.  The patient desires surgical treatment.,PROCEDURE IN DETAIL: , An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported from the operating room and placed on the operating room table in the supine position with the safety belt across his lap.  Copious amount of Webril was placed around the left ankle followed by a blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 7 cc of 0.5% Marcaine plain was injected in a Mayo-type block.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was elevated from the operating table and exsanguinated with an Esmarch bandage.  The pneumatic ankle tourniquet was then inflated to 250 mmHg.  The foot was lowered to the operating table, the stockinet was reflected, and the foot was cleansed with wet and dry sponge.,Attention was then directed to the left first metatarsophalangeal joint.  Approximately a 6 cm dorsomedial incision was created over the first metatarsophalangeal joint, just medial to the extensor hallucis longus tendon.  The incision was then deepened with a #15 blade.  All vessels encountered were ligated for hemostasis.  The skin and subcutaneous tissue was undermined medially, off of the joint capsule.  A dorsal linear capsular incision was then made.  Care was taken to identify and preserve the extensor hallucis longus tendon.  The capsule and periosteum were then reflected off of the head of the first metatarsal as well as the base of the proximal phalanx.  There was noted to be a significant degenerative joint disease.  There was little to no remaining healthy articular cartilage left on the head of the first metatarsal.  There was significant osteophytic formation medially, dorsally, and laterally in the first metatarsal head as well as at the base of the proximal phalanx.  A sagittal saw was then used to resect the base of the proximal phalanx.  Care was taken to ensure that the resection was parallel to the nail.  After the bone was removed in toto, the area was inspected and the flexor tendon was noted to be intact.  The sagittal saw was then used to resect the osteophytic formation medially, dorsally, and laterally on the first metatarsal.  The first metatarsal was then re-modelled and smoothed in a more rounded position with a reciprocating rasp.  The sizers were then inserted for the Biopro implant.  A large was noted to be of the best size.  There was noted to be some hypertrophic bone laterally in the base of the proximal phalanx.  Following inspection, the sagittal saw was used to clean both the medial and lateral sides of the base.  A small bar drill was then used to pre-drill for the Biopro sizer.  The bone was noted to be significantly hardened.  The sizer was placed and a large Biopro was deemed to be the correct size implant.  The sizer was removed and bar drill was then again used to ream the medullary canal.  The hand reamer with a Biopro set was then used to complete the process.  The Biopro implant was then inserted and tamped with a hammer and rubber mallet to ensure tight fit.  There was noted to be distally increased range of motion after insertion of the implant.,Attention was then directed to the first metatarsal.  A long dorsal arm Austin osteotomy was then created.  A second osteotomy was then created just plantar and parallel to the first osteotomy site.  The wedge was then removed in toto.  The area was feathered to ensure high compression of the osteotomy site.  The head was noted to be in a more plantar flexed position.  The capital fragment was then temporarily fixated with two 0.45 K-wires.  A 2.7 x 16 mm screw was then inserted in the standard AO fashion.  A second more proximal 2.7 x 60 mm screw was also inserted in a standard AO fashion.  With both screws, there was noted to be tight compression at the osteotomy sites.,The K-wires were removed and the areas were then smoothed with reciprocating rash.  A screw driver was then used to check and ensure screw tightness.  The area was then flushed with copious amounts of sterile saline.  Subchondral drilling was performed with a 1.5 drill bit.  The area was then flushed with copious amounts of sterile saline.  Closure consisted of capsular closure with #3-0 Vicryl followed by subcutaneous closure with #4-0 Vicryl, followed by running subcuticular stitch of #5-0 Vicryl.  Dressings consisted of Steri-Strips, Owen silk, 4x4s, Kling, Kerlix, and Coban.  A total of 10 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain was injected intraoperatively for further anesthesia.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot.  The patient tolerated the above procedure and anesthesia well.  The patient was transported to PACU with vital signs stable and vascular status intact to the right foot.  The patient was given postoperative pain prescription for Vicodin ES and instructed to take 1 q.  4-6h. p.o. p.r.n. pain.  The patient was instructed to ice and elevate his left lower extremity as much as possible to help decrease postoperative edema.  The patient is to follow up with Dr. X in his office as directed.","surgery, hallux rigidus, metatarsal, youngswick, bunionectomy, screw fixation, ankle tourniquet, metatarsophalangeal joint, biopro implant, proximal phalanx, foot, austin, anesthesia, osteotomy, screw,"
" Patient with a history of gross hematuria.  CT scan was performed, which demonstrated no hydronephrosis or upper tract process; however, there was significant thickening of the left and posterior bladder wall.", Urology, Bladder Cancer ,"CHIEF COMPLAINT: , Bladder cancer.,HISTORY OF PRESENT ILLNESS:,  The patient is a 68-year-old Caucasian male with a history of gross hematuria.  The patient presented to the emergency room near his hometown on 12/24/2007 for evaluation of this gross hematuria.  CT scan was performed, which demonstrated no hydronephrosis or upper tract process; however, there was significant thickening of the left and posterior bladder wall.  Urology referral was initiated and the patient was sent to be evaluated by Dr. X. He eventually underwent a bladder biopsy on 01/18/08, which demonstrated high-grade transitional cell carcinoma without any muscularis propria in the specimen.  Additionally, the patient underwent workup for a right adrenal lesion, which was noted on the initial CT scan.  This workup involved serum cortisol analysis as well as potassium and aldosterone and ACTH level measurement.  All of this workup was found to be grossly negative.  Secondary to the absence of muscle in the specimen, the patient was taken back to the operating room on 02/27/08 by Dr. X and the tumor was noted to be very large with significant tumor burden as well as possible involvement of the bladder neck.  At that time, the referring urologist determined the tumor to be too large and risky for local resection, and the patient was referred to ABCD Urology for management and diagnosis.  The patient presents today for evaluation by Dr. Y.,PAST MEDICAL HISTORY: , Includes condyloma, hypertension, diabetes mellitus, hyperlipidemia, undiagnosed COPD, peripheral vascular disease, and claudication.  The patient denies coronary artery disease.,PAST SURGICAL HISTORY:,  Includes bladder biopsy on 01/18/08 without muscularis propria in the high-grade TCC specimen and a gun shot wound in 1984 followed by exploratory laparotomy x2.  The patient denies any bowel resection or GU injury at that time; however, he is unsure.,CURRENT MEDICATIONS:,1.  Metoprolol 100 mg b.i.d.,2.  Diltiazem 120 mg daily.,3.  Hydrocodone 10/500 mg p.r.n.,4.  Pravastatin 40 mg daily.,5.  Lisinopril 20 mg daily.,6.  Hydrochlorothiazide 25 mg daily.,FAMILY HISTORY: , Negative for any GU cancer, stones or other complaints.  The patient states he has one uncle who died of lung cancer.  He denies any other family history.,SOCIAL HISTORY: , The patient smokes approximately 2 packs per day times greater than 40 years.  He does drink occasional alcohol approximately 5 to 6 alcoholic drinks per month.  He denies any drug use.  He is a retired liquor store owner.,PHYSICAL EXAMINATION:,GENERAL:  He is a well-developed, well-nourished Caucasian male, who appears slightly older than stated age.  VITAL SIGNS:  Temperature is 96.7, blood pressure is 108/57, pulse is 75, and weight of 193.8 pounds.  HEAD AND NECK:  Normocephalic atraumatic.  LUNGS:  Demonstrate decreased breath sounds globally with small rhonchi in the inferior right lung, which is clear somewhat with cough.  HEART:  Regular rate and rhythm.  ABDOMEN:  Soft and nontender.  The liver and spleen are not palpably enlarged.  There is a large midline defect covered by skin, of which the fascia has numerous holes poking through.  These small hernias are of approximately 2 cm in diameter at the largest and are nontender.  GU:  The penis is circumcised and there are no lesions, plaques, masses or deformities.  There is some tenderness to palpation near the meatus where 20-French Foley catheter is in place.  Testes are bilaterally descended and there are no masses or tenderness.  There is bilateral mild atrophy.  Epididymidis are grossly within normal limits bilaterally.  Spermatic cords are grossly within normal limits.  There are no palpable inguinal hernias.  RECTAL:  The prostate is mildly enlarged with a small focal firm area in the midline near the apex.  There is however no other focal nodules.  The prostate is grossly approximately 35 to 40 g and is globally firm.  Rectal sphincter tone is grossly within normal limits and there is stool in the rectal vault.  EXTREMITIES:  Demonstrate no cyanosis, clubbing or edema.  There is dark red urine in the Foley bag collection.,LABORATORY EXAM:,  Review of laboratory from outside facility demonstrates creatinine of 2.38 with BUN of 42.  Additionally, laboratory exam demonstrates a grossly normal serum cortisol, ACTH, potassium, aldosterone level during lesion workup.  CT scan was reviewed from outside facility, report states there is left kidney atrophy without hydro or stones and there is thickened left bladder wall and posterior margins with a balloon inflated in the prostate at the time of the exam.  There is a 3.1 cm right heterogeneous adrenal nodule and there are no upper tract lesions or stones noted.,IMPRESSION:,  Bladder cancer.,PLAN:  ,The patient will undergo a completion TURBT on 03/20/08 with bilateral retrograde pyelograms at the time of surgery.  Preoperative workup and laboratory as well as paper work were performed in clinic today with Dr. Y. The patient will be scheduled for anesthesia preop.  The patient will have urine culture redrawn from his Foley or penis at the time of preoperative evaluation with anesthesia.  The patient was counseled extensively approximately 45 minutes on the nature of his disease and basic prognostic indicators and need for additional workup and staging.  The patient understands these instructions and also agrees to quit smoking prior to his next visit.  This patient was seen in evaluation with Dr. Y who agrees with the impression and plan.","urology, retrograde pyelogram, bladder biopsy, muscularis propria, bladder cancer, gross hematuria, bladder wall, ct scan, bladder, hematuria, "
 Bilateral vasovasostomy surgery sample., Urology, Bilateral Vasovasostomy ,"Initially a small incision was made in the right superior hemiscrotum and the incision was carried down to the vas deferens.  This incision was carried down to the area of the previous vasectomy.  A towel clip was placed around this.  Next the scarred area was dissected free back to normal vas proximally and distally.  Approximately 4 cm of vas was freed up.  Next the vas was amputated above and below the scar tissue.  Fine hemostats were used to grasp the adventitial tissue on each side of the vas, both the proximal and distal ends.  Both ends were then dilated very carefully with lacrimal duct probes up to a #2 successfully.  After accomplishing this, fluid could be milked from the proximal vas which was encouraging.,Next the reanastomosis was performed.  Three 7-0 Prolene were used and full thickness bites were taken through the muscle layer of the vas deferens and into the lumen.  This was all done with 3.5 loupe magnification.  Next the vas ends were pulled together by tying the sutures.  A good reapproximation was noted.  Next in between each of these sutures two to three of the 7-0 Prolenes were used to reapproximate the muscularis layer further in an attempt to make this fluid-tight.,There was no tension on the anastomosis and the vas was delivered back into the right hemiscrotum.  The subcuticular layers were closed with a running 3-0 chromic and the skin was closed with three interrupted 3-0 chromic sutures.,Next an identical procedure was done on the left side.,The patient tolerated the procedure well and was awakened and returned to the recovery room in stable condition.  Antibiotic ointment, fluffs, and a scrotal support were placed.","urology, vasovasostomy, adventitial tissue, anastomosis, fluffs, hemiscrotum, loupe magnification, lumen, muscle layer, scrotal support, subcuticular, vas deferens, vas ends, bilateral vasovasostomy, chromic, suturesNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" This patient has undergone cataract surgery, and vision is reduced in the operated eye due to presence of a secondary capsular membrane.  The patient is being brought in for YAG capsular discission.", Surgery, YAG Laser Capsulotomy - 1 ,"PREOPERATIVE DIAGNOSIS: , Secondary capsular membrane, right eye.,POSTOPERATIVE DIAGNOSIS: , Secondary capsular membrane, right eye.,PROCEDURE PERFORMED: , YAG laser capsulotomy, right eye.,INDICATIONS: , This patient has undergone cataract surgery, and vision is reduced in the operated eye due to presence of a secondary capsular membrane.  The patient is being brought in for YAG capsular discission.,PROCEDURE: , The patient was seated at the YAG laser, the pupil having been dilated with 1%  Mydriacyl, and Iopidine was instilled.  The Abraham capsulotomy lens was then positioned and applications of laser energy in the pattern indicated on the outpatient note were applied.  A total of","surgery, abraham capsulotomy, yag, yag laser capsulotomy, capsulotomy, laser, membrane, eye, capsular, "
" Cystoscopy, cystocele repair, BioArc midurethral sling.", Urology, BioArc Midurethral Sling ,"PREOPERATIVE DIAGNOSIS:,  Stress urinary incontinence, intrinsic sphincter deficiency.,POSTOPERATIVE DIAGNOSES: , Stress urinary incontinence, intrinsic sphincter deficiency.,OPERATIONS: , Cystoscopy, cystocele repair, BioArc midurethral sling.,ANESTHESIA:,  Spinal.,EBL: , Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY:  ,The patient is a 69-year-old female with a history of hysterectomy, complained of urgency, frequency, and stress urinary incontinence.  The patient had urodynamics done and a cystoscopy, which revealed intrinsic sphincter deficiency.  Options such as watchful waiting, Kegel exercises, broad-based sling to help with ISD versus Coaptite bulking agents were discussed.  Risks and benefits of all the procedures were discussed.  The patient understood and wanted to proceed with BioArc.  Risk of failure of the procedure, recurrence of incontinence due to urgency, mesh erosion, exposure, etc., were discussed.  Risk of MI, DVT, PE, and bleeding etc., were discussed.  The patient understood the risk of infection and wanted to proceed with the procedure.  The patient was told that due to the intrinsic sphincter deficiency, we will try to make the sling little bit tighter to allow better urethral closure, which may put her a high risk of retention versus if we make it too loose, then she may leak afterwards.,The patient understood and wanted to proceed with the procedure.,DETAILS OF THE OPERATION: , The patient was brought to the OR and anesthesia was applied.  The patient was placed in dorsal lithotomy position.  The patient was prepped and draped in usual sterile fashion.  A Foley catheter was placed.  Bladder was emptied.  Two Allis clamps were placed on the anterior vaginal mucosa.  Lidocaine 1% with epinephrine was applied, and hydrodissection was done.  Incision was made.  A bladder was lifted off of the vaginal mucosa.  The bladder cystocele was reduced.  Two stab incisions were placed on the lateral thigh over the medial aspect of the obturator canal.  Using BioArc needle, the needles were passed through under direct palpation through the vaginal incision from the lateral thigh to the vaginal incision.  The mesh arms were attached and arms were pulled back the outer plastic sheath and the excess mesh was removed.  The mesh was right at the bladder neck to the mid-urethra, completely covering over the entire urethra.,The sling was kept little tight, even though the right angle was easily placed between the urethra and the BioArc material.  The urethra was coapted very nicely.  At the end of the procedure, cystoscopy was done and there was no injury to the bladder.  There was good efflux of urine with indigo carmine coming through from both the ureteral openings.  The urethra was normal, seemed to have closed up very nicely with the repair.  The vaginal mucosa was closed using 0 Vicryl in interrupted fashion.  The lateral thigh incisions were closed using Dermabond.  Please note that the irrigation with antibiotic solution was done prior to the BioArc mesh placement.  The mesh was placed in antibiotic solution prior to the placement in the body.  The patient tolerated the procedure well.  After closure, Premarin cream was applied.  The patient was told to use Premarin cream postop.  The patient was brought to Recovery in stable condition.,The patient was told not to do any heavy lifting, pushing, pulling, and no tub bath, etc., for at least 2 months.  The patient understood.  The patient was to follow up as an outpatient.","urology, cystoscopy, cystocele repair, bioarc midurethral sling, sphincter, urinary incontinence, stress urinary incontinence, intrinsic sphincter deficiency, intrinsic sphincter, sphincter deficiency, incontinence, mesh, urethral, bioarc"
 Youngswick osteotomy with internal screw fixation of the first right metatarsophalangeal joint of the right foot., Surgery, Youngswick Osteotomy ,"TITLE OF OPERATION: , Youngswick osteotomy with internal screw fixation of the first right metatarsophalangeal joint of the right foot.,PREOPERATIVE DIAGNOSIS: , Hallux limitus deformity of the right foot.,POSTOPERATIVE DIAGNOSIS: , Hallux limitus deformity of the right foot.,ANESTHESIA:,  Monitored anesthesia care with 15 mL of 1:1 mixture of 0.5% Marcaine and 1% lidocaine plain.,ESTIMATED BLOOD LOSS:,  Less than 10 mL.,HEMOSTASIS:,  Right ankle tourniquet set at 250 mmHg for 35 minutes.,MATERIALS USED: , 3-0 Vicryl, 4-0 Vicryl, and two partially threaded cannulated screws from 3.0 OsteoMed System for internal fixation.,INJECTABLES:  ,Ancef 1 g IV 30 minutes preoperatively.,DESCRIPTION OF THE PROCEDURE: , The patient was brought to the operating room and placed on the operating table in the supine position.  After adequate sedation was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's right foot to anesthetize the future surgical site.  The right ankle was then covered with cast padding and an 18-inch ankle tourniquet was placed around the right ankle and set at 250 mmHg.  The right ankle tourniquet was then inflated.  The right foot was prepped, scrubbed, and draped in normal sterile technique.  Attention was then directed on the dorsal aspect of the first right metatarsophalangeal joint where a 6-cm linear incision was placed just parallel and medial to the course of the extensor hallucis longus to the right great toe.  The incision was deepened through the subcutaneous tissues.  All the bleeders were identified, cut, clamped, and cauterized.  The incision was deepened to the level of the capsule and the periosteum of the first right metatarsophalangeal joint.  All the tendinous and neurovascular structures were identified and retracted from the site to be preserved.  Using sharp and dull dissection, all the capsular and periosteal attachments were mobilized from the base of the proximal phalanx of the right great toe and head of the first right metatarsal.  Once the base of the proximal phalanx of the right great toe and the first right metatarsal head were adequately exposed, multiple osteophytes were encountered.  Gouty tophi were encountered both intraarticularly and periarticularly for the first right metatarsophalangeal joint, which were consistent with a medical history that is positive for gout for this patient.,Using sharp and dull dissection, all the ligamentous and soft tissue attachments were mobilized and the right first metatarsophalangeal joint was freed from all adhesions.  Using the sagittal saw, all the osteophytes were removed from the dorsal, medial, and lateral aspect of the first right metatarsal head as well as the dorsal, medial, and lateral aspect of the base of the proximal phalanx of the right great toe.  Although some improvement of the range of motion was encountered after the removal of the osteophytes, some tightness and restriction was still present.  The decision was thus made to perform a Youngswick-type osteotomy on the head of the first right metatarsal.  The osteotomy consistent of two dorsal cuts and a plantar cut in a V-pattern with the apex of the osteotomy distal and the base of the osteotomy proximal.  The two dorsal cuts were longer than the plantar cut in order to accommodate for the future internal fixation.  The wedge of bone that was formed between the two dorsal cuts was resected and passed off to Pathology for further examination.  The head of the first right metatarsal was then impacted on the shaft of the first right metatarsal and provisionally stabilized with two wires from the OsteoMed System.  The wires were inserted from a dorsal distal to plantar proximal direction through the dorsal osteotomy.  The wires were also used as guidewires for the insertion of two 16-mm proximally threaded cannulated screws from the OsteoMed System.  The 2 screws were inserted using AO technique.  Upon insertion of the screws, the two wires were removed.  Fixation of the osteotomy on the table was found to be excellent.  The area was copiously flushed with saline and range of motion was reevaluated and was found to be much improved from the preoperative levels without any significant restriction.  The cartilaginous surfaces on the base of the first right metatarsal and the base of the proximal phalanx were also fenestrated in order to induce some cartilaginous formation.  The capsule and periosteal tissues were then reapproximated with 3-0 Vicryl suture material, 4-0 Vicryl was used to approximate the subcutaneous tissues.  Steri-Strips were used to approximate and reinforce the skin edges.  At this time, the right ankle tourniquet was deflated.  Immediate hyperemia was noted in the entire right lower extremity upon deflation of the cuff.  The patient's surgical site was then covered with Xeroform, copious amounts of fluff and Kling, stockinette, and Ace bandage.  The patient's right foot was placed in a surgical shoe and the patient was then transferred to the recovery room under the care of the anesthesia team with her vital signs stable and neurovascular status at appropriate levels.  The patient was given instructions and education on how to continue caring for her right foot surgery at home.  The patient was also given pain medication instructions on how to control her postoperative pain.  The patient was eventually discharged from Hospital according to nursing protocol and was advised to follow up with Dr. X's office in one week's time for her first postoperative appointment.","surgery, hallux limitus deformity, metatarsophalangeal joint, plantar cut, youngswick osteotomy, dorsal cuts, ankle tourniquet, proximal phalanx, anesthesia, tourniquet, youngswick, phalanx, metatarsophalangeal, proximal, metatarsal, dorsal, osteotomy"
 Laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair.  Patient with a 5.5-cm diameter nonfunctioning mass in his right adrenal., Urology, Adrenalectomy & Umbilical Hernia Repair ,"PREOPERATIVE DIAGNOSES,1.  Adrenal mass, right sided.,2.  Umbilical hernia.,POSTOPERATIVE DIAGNOSES,1.  Adrenal mass, right sided.,2.  Umbilical hernia.,OPERATION PERFORMED: , Laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair.,ANESTHESIA:  ,General.,CLINICAL NOTE: , This is a 52-year-old inmate with a 5.5 cm diameter nonfunctioning mass in his right adrenal.  Procedure was explained including risks of infection, bleeding, possibility of transfusion, possibility of further treatments being required.  Alternative of fully laparoscopic are open surgery or watching the lesion.,DESCRIPTION OF OPERATION:  ,In the right flank-up position, table was flexed.  He had a Foley catheter in place.  Incision was made from just above the umbilicus, about 5.5 cm in diameter.  The umbilical hernia was taken down.  An 11 mm trocar was placed in the midline, superior to the GelPort and a 5 mm trocar placed in the midaxillary line below the costal margin.  A liver retractor was placed to this.,The colon was reflected medially by incising the white line of Toldt.  The liver attachments to the adrenal kidney were divided and the liver was reflected superiorly.  The vena cava was identified.  The main renal vein was identified.  Coming superior to the main renal vein, staying right on the vena cava, all small vessels were clipped and then divided.  Coming along the superior pole of the kidney, the tumor was dissected free from top of the kidney with clips and Bovie.  The harmonic scalpel was utilized superiorly and laterally.  Posterior attachments were divided between clips and once the whole adrenal was mobilized, the adrenal vein and one large adrenal artery were noted, doubly clipped, and divided.  Specimen was placed in a collection bag, removed intact.,Hemostasis was excellent.,The umbilical hernia had been completely taken down.  The edges were freshened up.  Vicryl #1 was utilized to close the incision and 2-0 Vicryl was used to close the fascia of the trocar.,Skin closed with clips.,He tolerated the procedure well.  All sponge and instrument counts were correct.  Estimated blood loss less than 100 mL.,The patient was awakened, extubated, and returned to recovery room in satisfactory condition.","urology, adrenalectomy, laparoscopic hand-assisted, umbilical hernia repair, vena cava, renal vein, hernia repair, laparoscopic, umbilical, hernia,"
" Wound debridement with removal of Surgisis xenograft and debridement of skin and subcutaneous tissue, secondary closure of wound, and VAC insertion.", Surgery, Wound Debridement ,"PREOPERATIVE DIAGNOSES,1.  Open wound from right axilla to abdomen with a prosthetic vascular graft, possibly infected.,2.  Diabetes.,3.  Peripheral vascular disease.,POSTOPERATIVE DIAGNOSES,1.  Open wound from right axilla to abdomen with a prosthetic vascular graft, possibly infected.,2.  Diabetes.,3.  Peripheral vascular disease.,OPERATIONS,1.  Wound debridement with removal of Surgisis xenograft and debridement of skin and subcutaneous tissue.,2.  Secondary closure of wound, complicated.,3.  VAC insertion.,DESCRIPTION OF PROCEDURE:,  After obtaining an informed consent, the patient was brought to the operating room where a general anesthetic was given.  A time-out process was followed.  All the staples holding the xenograft were removed as well as all the dressings and the area was prepped with Betadine soap and then painted with Betadine solution and draped in usual fashion.,The xenograft was not adhered at all and was easily removed.  There was some, what appeared to be a seropurulent exudate at the bottom of the incision.  This was towards the abdominal end, under the xenograft.,The graft was fully exposed and it was pulsatile.  We then proceeded to use a pulse spray with bacitracin clindamycin solution to clean up the graft.  A few areas of necrotic skin and subcutaneous tissue were debrided.  Prior to this, samples were taken for aerobic and anaerobic cultures.,Normal saline 3000 cc was used for the irrigation and at the end of that the wound appeared much cleaner and we proceeded to insert the sponges to put a VAC system to it.  There was a separate incision, which was bridged __________ to the incision of the abdomen, which we also put a sponge in it after irrigating it and we put the VAC in the main wound and we created a bridge to the second and more minor wound.  Prior to that, I had inserted a number of Vesseloops through the edges of the skin and I proceeded to approximate those on top of the VAC sponge.  Multiple layers were applied to seal the system, which was suctioned and appeared to be working satisfactorily.,The patient tolerated the procedure well and was sent to the ICU for recovery.","surgery, open wound, prosthetic vascular graft, closure of wound, surgisis, peripheral vascular disease, wound debridement, subcutaneous tissue, vac insertion, wound, betadine, debridement, xenograft, insertion,"
" Visually significant posterior capsule opacity, right eye.  YAG laser posterior capsulotomy, right eye.", Surgery, YAG Laser Capsulotomy ,"PREOPERATIVE DIAGNOSIS:,  Visually significant posterior capsule opacity, right eye.,POSTOPERATIVE DIAGNOSIS:,  Visually significant posterior capsule opacity, right eye.,OPERATIVE PROCEDURES:  ,YAG laser posterior capsulotomy, right eye.,ANESTHESIA: , Topical anesthesia using tetracaine ophthalmic drops.,INDICATIONS FOR SURGERY: , This patient was found to have a visually significant posterior capsule opacity in the right eye.  The patient has had a mild decrease in visual acuity, which has been a gradual change.  The posterior capsule opacity was felt to be related to the decline in vision.  The risks, benefits, and alternatives (including observation) were discussed.  I feel the patient had a good understanding of the proposed procedure and informed consent was obtained.,DESCRIPTION OF PROCEDURE: , The patient was identified and the procedure was verified.  Pupil was dilated per protocol.  Patient was positioned at the YAG laser.  Then, *** of energy were used to perform a circular posterior laser capsulotomy through the visual axis.  A total of ** shots were used.  Total energy was **.  The patient tolerated the procedure well and there were no complications.  The lens remained well centered and stable.  Postoperative instructions were provided.  Alphagan P ophthalmic drops times two were instilled prior to his dismissal.,Post-laser intraocular pressure measured ** mmHg.  Postoperative instructions were provided and the patient had no further questions.","surgery, capsule opacity, yag, ophthalmic, yag laser posterior capsulotomy, capsulotomy, opacity, laser, visually, eye, anesthesia "
" A complex closure and debridement of wound.  The patient is a 26-year-old female with a long history of shunt and hydrocephalus presenting with a draining wound in the right upper quadrant, just below the costal margin that was lanced by General Surgery and resolved; however, it continued to drain.", Surgery, Wound Closure & Debridement - Hydrocephalus ,"TITLE OF OPERATION:,  A complex closure and debridement of wound.,INDICATION FOR SURGERY:,  The patient is a 26-year-old female with a long history of shunt and hydrocephalus presenting with a draining wound in the right upper quadrant, just below the costal margin that was lanced by General Surgery and resolved; however, it continued to drain.  There is no evidence of fevers.  CRP was normal.  Shunt CT were all normal.  The thought was he has insidious fistula versus tract where recommendation was for excision of this tract.,PREOP DIAGNOSIS: , Possible cerebrospinal fluid versus wound fistula.,POSTOP DIAGNOSIS: , Possible cerebrospinal fluid versus wound fistula.,PROCEDURE DETAIL: , The patient was brought to the operating room and willing to be inducted with a laryngeal mask airway, positioned supine and the right side was prepped and draped in the usual sterile fashion.  Next, working on the fistula, this was elliptically excised.  Once this was excised, this was followed down to the fistulous tract, which was completely removed.  There was no CSF drainage.  The catheter was visualized, although not adequately properly.  Once this was excised, it was irrigated and then closed in multiple layers using 3-0 Vicryl for the deep layers and 4-0 Caprosyn and Indermil with a dry sterile dressing applied.  The patient was reversed, extubated and transferred to the recovery room in stable condition.  Multiple cultures were sent as well as the tracts sent to Pathology.  All sponge and needle counts were correct.","surgery, debridement of wound, shunt, costal margin, cerebrospinal fluid, cerebrospinal, closure, debridement, hydrocephalus, draining, fistula, wound, "
" Excision of dorsal wrist ganglion.  Made a transverse incision directly over the ganglion.  Dissection was carried down through the extensor retinaculum, identifying the 3rd and the 4th compartments and retracting them.", Surgery, Wrist Ganglion Excision ,"PREOPERATIVE DIAGNOSIS: , Wrist ganglion.,POSTOPERATIVE DIAGNOSIS: , Wrist ganglion.,TITLE OF PROCEDURE: , Excision of dorsal wrist ganglion.,PROCEDURE: , After administering appropriate antibiotics and general anesthesia, the upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with an Esmarch and tourniquet inflated to 250 mmHg.  I made a transverse incision directly over the ganglion.  Dissection was carried down through the extensor retinaculum, identifying the 3rd and the 4th compartments and retracting them.  I then excised the ganglion and its stalk.  In addition, approximately a square centimeter of the dorsal capsule was removed at the origin of stalk, leaving enough of a defect to prevent formation of a one-way valve.  We then identified the scapholunate ligament, which was uninjured.  I irrigated and closed in layers and injected Marcaine with epinephrine.  I dressed and splinted the wound.  The patient was sent to the recovery room in good condition, having tolerated the procedure well.","surgery, origin of stalk, extensor retinaculum, wrist ganglion, incision, excision, dorsal, tourniquet, wrist, ganglion"
 Placement of right new ventriculoperitoneal (VP) shunts Strata valve and to removal of right frontal Ommaya reservoir., Surgery, VP Shunt Placement ,"TITLE OF OPERATION: , Placement of right new ventriculoperitoneal (VP) shunts Strata valve and to removal of right frontal Ommaya reservoir.,INDICATION FOR SURGERY: , The patient is a 2-month-old infant, born premature with intraventricular hemorrhage and Ommaya reservoir recommendation for removal and replacement with a new VP shunt.,PREOP DIAGNOSIS: , Hydrocephalus.,POSTOP DIAGNOSIS: , Hydrocephalus.,PROCEDURE DETAIL: , The patient was brought to the operating room, underwent induction of general endotracheal airway, positioned supine, head turned towards left.  The right side prepped and draped in the usual sterile fashion.  Next, using a 15 blade scalpel, two incisions were made, one in the parietooccipital region and.  The second just lateral to the umbilicus.  Once this was clear, the Bactiseal catheter was then tunneled.  This was connected to a Strata valve.  The Strata valve was programmed to a setting of 1.01 and this was ensured.  The small burr hole was then created.  The area was then coagulated.  Once this was completed, new Bactiseal catheter was then inserted.  It was connected to the Strata valve.  There was good distal flow.  The distal end was then inserted into the peritoneal region via trocar.  Once this was insured, all the wounds were irrigated copiously and closed with 3-0 Vicryl and 4-0 Caprosyn as well as Indermil glue.  The right frontal incision was then opened.  The Ommaya reservoir identified and removed.  The wound was then also closed with an inverted 3-0 Vicryl and 4-0 Caprosyn.  Once all the wounds were completed, dry sterile dressings were applied.  The patient was then transported back to the ICU in stable condition intubated.  Blood loss minimal.  All sponge and needle counts were correct.","surgery, ommaya reservoir, frontal, strata valve, intraventricular hemorrhage, vp shunt, ventriculoperitoneal, hydrocephalus, "
 Vitrectomy under local anesthesia., Surgery, Vitrectomy - Local Anesthesia ,"DESCRIPTION OF PROCEDURE:,  After appropriate operative consent was obtained the patient was brought supine to the operating room and placed on the operating room table.  After intravenous sedation was administered a retrobulbar block consisting of 2% Xylocaine with 0.75% Marcaine and Wydase was administered to the right eye without difficulty.  The patient's right eye was prepped and draped in sterile ophthalmic fashion and the procedure begun.  A wire lid speculum was inserted into the right eye and a limited conjunctival peritomy performed at the limbus temporally and superonasally.  Infusion line was set up in the inferotemporal quadrant and two additional sclerotomies were made in the superonasal and superotemporal quadrants.  A lens ring was secured to the eye using 7-0 Vicryl suture.","surgery, lid speculum, conjunctival, peritomy, vitrectomy, operating, superonasally, anesthesiaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Vitrectomy under general anesthesia, Surgery, Vitrectomy - General Anesthesia ,"DESCRIPTION OF PROCEDURE: , After appropriate operative consent was obtained the patient was brought supine to the operating room and placed on the operating room table.  Induction of general anesthesia via endotracheal intubation was then accomplished without difficulty.  The patient's right eye was prepped and draped in sterile ophthalmic fashion and the procedure begun.  A wire lid speculum was inserted into the right eye and a limited conjunctival peritomy performed at the limbus temporally and superonasally.  Infusion line was set up in the inferotemporal quadrant and two additional sclerotomies were made in the superonasal and superotemporal quadrants.  A lens ring was secured to the eye using 7-0 Vicryl suture.","surgery, ophthalmic fashion, vitrectomy, operating, superonasally, anesthesiaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Vitrectomy opening.  A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and separately the supratemporal and inferotemporal quadrants. , Surgery, Vitrectomy Opening ,"VITRECTOMY OPENING,The patient was brought to the operating room and appropriately identified.  General anesthesia was induced by the anesthesiologist.  The patient was prepped and draped in the usual sterile fashion.  A lid speculum was used to provide exposure to the right eye.  A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and separately the supratemporal and inferotemporal quadrants.  Hemostasis was maintained with wet-field cautery.  Calipers were set at XX mm and the mark was made XX mm posterior to the limbus in the inferotemporal quadrant.  A 5-0 nylon suture was passed through partial-thickness sclera on either side of this mark.  The MVR blade was used to make a sclerotomy between the preplaced sutures.  An 8-0 nylon suture was then preplaced for a later sclerotomy closure.  The infusion cannula was inspected and found to be in good working order.  The infusion cannula was placed into the vitreous cavity and secured with the preplaced suture.  The tip of the infusion cannula was directly visualized and found to be free of any overlying tissue and the infusion was turned on.  Additional sclerotomies were made XX mm posterior to the limbus in the supranasal and supratemporal quadrants.","surgery, westcott scissors, inferotemporal quadrants, conjunctival, peritomy, sclerotomy, vitrectomy, supranasal, supratemporal, cannula, inferotemporalNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Pars plana vitrectomy, membrane peel, 23-gauge, right eye.", Surgery, Vitrectomy - 2 ,"PREOPERATIVE DIAGNOSES: , Epiretinal membrane, right eye.  CME, right eye.,POSTOPERATIVE DIAGNOSES: , Epiretinal membrane, right eye.  CME, right eye.,PROCEDURES: , Pars plana vitrectomy, membrane peel, 23-gauge, right eye.,PREOPERATIVE FINDINGS:,  The patient had epiretinal membrane causing cystoid macular edema.  Options were discussed with the patient stressing that the visual outcome was guarded.  Especially since this membrane was of chronic duration there is no guarantee of visual outcome.,DESCRIPTION OF PROCEDURE: , The patient was wheeled to the OR table.  Local anesthesia was delivered using a retrobulbar needle in an atraumatic fashion 5 cc of Xylocaine and Marcaine was delivered to retrobulbar area and massaged and verified.  Preparation was made for 23-gauge vitrectomy, using the trocar inferotemporal cannula was placed 3.5 mm from the limbus and verified.  The fluid was run.  Then superior sclerotomies were created using the trocars and 3.5 mm from the limbus at 10 o'clock and 2 o'clock.  Vitrectomy commenced and carried on as far anteriorly as possible using intraocular forceps, ILM forceps, the membrane was peeled off in its entirety.  There were no complications.  DVT precautions were in place.  I, as attending, was present in the entire case.","surgery, epiretinal membrane, pars plana vitrectomy, membrane peel, macular edema, cystoid, eye, retrobulbar, epiretinal, vitrectomy, membrane, "
 Unilateral transpedicular T11 vertebroplasty., Surgery, Vertebroplasty ,"PREOPERATIVE DIAGNOSIS:,  T11 compression fracture with intractable pain.,POSTOPERATIVE DIAGNOSIS:,  T11 compression fracture with intractable pain.,OPERATION PERFORMED:,  Unilateral transpedicular T11 vertebroplasty.,ANESTHESIA:,  Local with IV sedation.,COMPLICATIONS:,  None.,SUMMARY: , The patient in the operating room in the prone position with the back prepped and draped in the sterile fashion.  The patient was given sedation and monitored.  Using AP and lateral fluoroscopic projections the T11 compression fracture was identified.  Starting from the left side local anesthetic was used for skin wheal just lateral superior to the 10 o'clock position of the lateral aspect of the T11 pedicle on the left.  The 13-gauge needle and trocar were then taken and placed to 10 o'clock position on the pedicle.  At this point using AP and lateral fluoroscopic views, the needle and trocar were advanced into the vertebral body using the fluoroscopic images and making sure that the needle was lateral to the medial wall of the pedicle of the pedicle at all times.  Once the vertebral body was entered then using lateral fluoroscopic views, the needle was advanced to the junction of the anterior one third and posterior two thirds of the body.  At this point polymethylmethacrylate was mixed for 60 seconds.  Once the consistency had hardened and the __________ was gone, incremental dose of the cement were injected into the vertebral body.  It was immediately seen that the cement was going cephalad into the vertebral body and was exiting through the crack in the vertebra.  A total 1.2 cc of cement was injected.  On lateral view, the cement crushed to the right side as well.  There was some dye infiltration into the disk space.  There was no dye taken whatsoever into the posterior aspect of the epidural space or intrathecal canal.,At this point, as the needle was slowly withdrawn under lateral fluoroscopic images, visualization was maintained to ensure that none of the cement was withdrawn posteriorly into the epidural space.  Once the needle was withdrawn safely pressure was held over the site for three minutes.  There were no complications.  The patient was taken back to the recovery area in stable condition and kept flat for one hour.  Should be followed up the next morning.","surgery, transpedicular, vertebroplasty, fluoroscopic views, fluoroscopic images, epidural space, compression fracture, vertebral body, compression, pedicle, fluoroscopic, vertebral, needle "
 Insertion of a VVIR permanent pacemaker.  This is an 87-year-old Caucasian female with critical aortic stenosis with an aortic valve area of 0.5 cm square and recurrent congestive heart failure symptoms mostly refractory to tachybrady arrhythmias, Surgery, VVIR Permanent Pacemaker Insertion ,"PROCEDURE PERFORMED:,  Insertion of a VVIR permanent pacemaker.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , Minimal.,SITE:,  Left subclavian vein access.,INDICATION: , This is an 87-year-old Caucasian female with critical aortic stenosis with an aortic valve area of 0.5 cm square and recurrent congestive heart failure symptoms mostly refractory to tachybrady arrhythmias and therefore, this is indicated so that we can give better control of heart rate and to maintain beta-blocker therapy in the order of treatment.  It is overall a Class-II indication for permanent pacemaker insertion.,PROCEDURE:,  The risks, benefits, and alternative of the procedure were all discussed with the patient and the patient's family in detail at great length.  Overall options and precautions of the pacemaker and indications were all discussed.  They agreed to the pacemaker.  The consent was signed and placed in the chart.  The patient was taken to the Cardiac Catheterization Lab, where she was monitored throughout the whole procedure.  The patient was sterilely prepped and draped in the usual manner for permanent pacemaker insertion.  Myself and Dr. Wildes spoke for approximately 8 minutes before insertion for the procedure.  Using a lidocaine with epinephrine, the area of the left subclavian vein and left pectodeltoid region was anesthetized locally.,IV sedation, increments, and analgesics were given.  Using a #18 gauge needle, the left subclavian vein access was cannulated without difficulty.  A guidewire was then passed through the Cook needle and the Cook needle was then removed.  The wire was secured in place with the hemostat.  Using a #10 and #15 scalpel blade, a 5 cm horizontal incision was made in the left pectoral deltoid region where the skin was dissected and blunted down into the pectoris major muscle fascia.  The skin was then undermined used to make a pocket for the pacemaker.  The guidewire was then tunneled through the pacer pocket.  Cordis sheath was then inserted through the guidewire.  The guidewire and dilator were removed.  ___ cordis sheath was in placed within.  This was used for insertion of the ventricular screw and steroid diluted leads where under fluoroscopy.  It was placed into the apex.  Cordis sheath was then split apart and removed and after the ventricular lead was placed in its appropriate position and good thresholds were obtained, the lead was then sutured in place with #1-0 silk suture to the pectoris major muscle.  The lead was then connected on pulse generator.  The pocket was then irrigated and cleansed.  Pulse generator and the wire was then inserted into the ____ pocket.  The skin was then closed with gut suture.  The skin was then closed with #4-0 Poly___ sutures using a subcuticular uninterrupted technique.  The area was then cleansed and dried.  Steri-Strips and pressure dressing was then applied.  The patient tolerated the procedure well. there was no complications.,These are the settings on the pacemaker:,IMPLANT DEVICE: , Pulse Generator Model Name:  Sigma, model #:  12345, serial #:  123456.,VENTRICLE LEAD:,  Model #:  12345, the ventricular lead serial #:  123456.,Ventricle lead was a screw and steroid diluted lead placed into the right ventricle apex.,BRADY PARAMETER SETTINGS ARE AS FOLLOWS:,  Amplitude was set at 3.5 volts with a pulse of 0.4, sensitivity of 2.8.  The pacing mode was set at VVIR, lower rate of 60 and upper rate of 120.,STIMULATION THRESHOLDS:  ,The right ventricular lead and bipolar, threshold voltage is 0.6 volts, 1 milliapms current, 600 Ohms resistance, R-wave sensing 11 millivolts.,The patient tolerated the procedure well.  There was no complications.  The patient went to recovery in stable condition.  Chest x-ray will be ordered.  She will be placed on IV antibiotics and continue therapy for congestive heart failure and tachybrady arrhythmia.,Thank you for allowing me to participate in her care.  If you have any questions or concerns, please feel free to contact.","surgery, aortic stenosis, vvir permanent pacemaker, permanent pacemaker insertion, congestive heart failure, tachybrady arrhythmias, subclavian vein, cordis sheath, ventricular lead, pulse generator, permanent pacemaker, insertion, ventricle, vvir, ventricular, permanent, pacemaker, leads, "
" Vitrectomy. A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and, separately, the supratemporal and inferotemporal quadrants.  ", Surgery, Vitrectomy - 3 ,"DESCRIPTION OF OPERATION:,  The patient was brought to the operating room and appropriately identified.  Local anesthesia was obtained with a 50/50 mixture of 2% lidocaine and 0.75% bupivacaine given as a peribulbar block.  The patient was prepped and draped in the usual sterile fashion.  A lid speculum was used to provide exposure to the right eye.,A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and, separately, the supratemporal and inferotemporal quadrants.  Calipers were set at 3.5 mm and a mark was made 3.5 mm posterior to the limbus in the inferotemporal quadrant.,A 5-0 nylon suture was passed through partial-thickness sclera on either side of this mark.  The MVR blade was used to make a sclerotomy between the pre-placed sutures.  An 8-0 nylon suture was then pre-placed for later sclerotomy closure.  The infusion cannula was inspected and found to be in good working order.  The infusion cannula was placed in the vitreous cavity and secured with the pre-placed sutures.  The tip of the infusion cannula was directly visualized and found to be free of any overlying tissue and the infusion was turned on.,Additional sclerotomies were made 3.5 mm posterior to the limbus in the supranasal and supratemporal quadrants.  The light pipe and vitrectomy handpieces were then placed in the vitreous cavity and a vitrectomy was performed.  There was moderately severe vitreous hemorrhage, which was removed.  Once a view of the posterior pole could be obtained, there were some diabetic membranes emanating along the arcades.  These were dissected with curved scissors and judicious use of the vitrectomy cutter.  There was some bleeding from the inferotemporal frond.  This was managed by raising the intraocular pressure and using intraocular cautery.  The surgical view became cloudy and the corneal epithelium was removed with a beaver blade.  This improved the view.  There is an area suspicious for retinal break near where the severe traction was inferotemporally.  The Endo laser was used to treat in a panretinal scatter fashion to areas that had not received previous treatment.  The indirect ophthalmoscope was used to examine the retinal peripheral for 360 degrees and no tears, holes or dialyses were seen.  There was some residual hemorrhagic vitreous skirt seen.  The soft-tip cannula was then used to perform an air-fluid exchange.  Additional laser was placed around the suspicious area inferotemporally.  The sclerotomies were then closed with 8-0 nylon suture in an X-fashion, the infusion cannula was removed and it sclerotomy closed with the pre-existing 8-0 nylon suture.,The conjunctiva was closed with 6-0 plain gut.  A subconjunctival injection of Ancef and Decadron were given and a drop of atropine was instilled over the eye.  The lid speculum was removed.  Maxitrol ointment was instilled over the eye and the eye was patched.  The patient was brought to the recovery room in stable condition.","surgery, conjunctival peritomy, westcott scissors, lid speculum, inferotemporal quadrants, inferotemporal, conjunctival, scissors, supranasal, supratemporal, sclerotomy, eye, vitreous, vitrectomy, infusion, cannulaNOTE"
" Combined closed vitrectomy with membrane peeling, fluid-air exchange, and endolaser, right eye.", Surgery, Vitrectomy - 1 ,"PREOPERATIVE DIAGNOSIS: , Vitreous hemorrhage and retinal detachment, right eye.,POSTOPERATIVE DIAGNOSIS:,  Vitreous hemorrhage and retinal detachment, right eye.,NAME OF PROCEDURE: , Combined closed vitrectomy with membrane peeling, fluid-air exchange, and endolaser, right eye.,ANESTHESIA: , Local with standby.,PROCEDURE:  ,The patient was brought to the operating room, and an equal mixture of Marcaine 0.5% and lidocaine 2% was injected in a retrobulbar fashion.  As soon as satisfactory anesthesia and akinesia had been achieved, the patient was prepped and draped in the usual manner for sterile ophthalmic surgery.  A wire lid speculum was inserted.  Three modified sclerotomies were selected at 9, 10, and 1 o'clock.  At the 9 o'clock position, the Accurus infusion line was put in place and tied with a preplaced #7-0 Vicryl suture.  The two superior sites at 10 and 1 were opened up where the operating microscope with the optical illuminating system was brought into position, and closed vitrectomy was begun.  Initially formed core vitrectomy was performed and formed anterior vitreous was removed.  After this was completed, attention was placed in the posterior segment.  Several broad areas of vitreoretinal traction were noted over the posterior pole out of the equator where the previously noted retinal tears were noted.  These were carefully lifted and dissected off the edges of the flap tears and trimmed to the ora serrata.  After all the vitreous had been removed and the membranes released, the retina was completely mobilized.  Total fluid-air exchange was carried out with complete settling of the retina.  Endolaser was applied around the margins of the retinal tears, and altogether several 100 applications were placed in the periphery.  Good reaction was achieved.  The eye was inspected with an indirect ophthalmoscope.  The retina was noted to be completely attached.  The instruments were removed from the eye.  The sclerotomy sites were closed with #7-0 Vicryl suture.  The infusion line was removed from the eye and tied with a #7-0 Vicryl suture.  The conjunctivae and Tenon's were closed with #6-0 plain gut suture.  A collagen shield soaked with Tobrex placed over the surface of the globe, and a pressure bandage was put in place.  The patient left the operating room in a good condition.","surgery, vitreous hemorrhage, retinal detachment, combined closed vitrectomy, vitrectomy, membrane peeling, fluid-air exchange, endolaser, vitrectomy with membrane peeling, membrane, peeling, hemorrhage, detachment, vicryl, eye, retinal, "
 Placement of left ventriculostomy via twist drill.  Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure., Surgery, Ventriculostomy Placement ,"PROCEDURE: , Placement of left ventriculostomy via twist drill.,PREOPERATIVE DIAGNOSIS:,  Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,POSTOPERATIVE DIAGNOSIS: , Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,INDICATIONS FOR PROCEDURE:  ,The patient is a man with a history of massive intracranial hemorrhage and hydrocephalus with intraventricular hemorrhage.  His condition is felt to be critical.  In a desperate attempt to relieve increased intracranial pressure, we have proposed placing a ventriculostomy.  I have discussed this with patient's wife who agrees and asked that we proceed emergently.,After a sterile prep, drape, and shaving of the hair over the left frontal area, this area is infiltrated with local anesthetic.  Subsequently a 1 cm incision was made over Kocher's point.  Hemostasis was obtained.  Then a twist drill was made over this area.  Bones strips were irrigated away.  The dura was perforated with a spinal needle.,A Camino monitor was connected and zeroed.  This was then passed into the left lateral ventricle on the first pass.  Excellent aggressive very bloody CSF under pressure was noted.  This stopped, slowed, and some clots were noted.  This was irrigated and then CSF continued.  Initial opening pressures were 30, but soon arose to 80 or a 100.,The patient tolerated the procedure well.  The wound was stitched shut and the ventricular drain was then connected to a drainage bag.,Platelets and FFP as well as vitamin K have been administered and ordered simultaneously with the placement of this device to help prevent further clotting or bleeding.","surgery, intraventricular hemorrhage, hydrocephalus, intracranial pressure, camino monitor, twist drill, ventriculostomy, hemorrhage, intracranial, pressure, intraventricular"
" Chronic venous hypertension with painful varicosities, lower extremities, bilaterally.  Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, bilaterally.", Surgery, Vein Stripping ,"PREOPERATIVE DIAGNOSIS: , Chronic venous hypertension with painful varicosities, lower extremities, bilaterally.,POSTOPERATIVE DIAGNOSIS: , Chronic venous hypertension with painful varicosities, lower extremities, bilaterally.,PROCEDURES,1.  Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, right leg.,2.  Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, left leg.,PROCEDURE DETAIL: , After obtaining the informed consent, the patient was taken to the operating room where she underwent a general endotracheal anesthesia.  A time-out process was followed and antibiotics were given.,Then, both legs were prepped and draped in the usual fashion with the patient was in the supine position.  An incision was made in the right groin and the greater saphenous vein at its junction with the femoral vein was dissected out and all branches were ligated and divided.  Then, an incision was made just below the knee where the greater saphenous vein was also found and connection to varices from the calf were seen.  A third incision was made in the distal third of the right thigh in the area where there was a communication with large branch varicosities.  Then, a vein stripper was passed from the right calf up to the groin and the greater saphenous vein, which was divided, was stripped without any difficultly.  Several minutes of compression was used for hemostasis.  Then, the exposed branch varicosities both in the lower third of the thigh and in the calf were dissected out and then many stabs were performed to do stab phlebectomies at the level of the thigh and the level of the calf as much as the position would allow us to do.,Then in the left thigh, a groin incision was made and the greater saphenous vein was dissected out in the same way as was on the other side.  Also, an incision was made in the level of the knee and the saphenous vein was isolated there.  The saphenous vein was stripped and a several minutes of local compression was performed for hemostasis.  Then, a number of stabs to perform phlebectomy were performed at the level of the calf to excise branch varicosities to the extent that the patient's position would allow us.  Then, all incisions were closed in layers with Vicryl and staples.,Then, the patient was placed in the prone position and the stab phlebectomies of the right thigh and calf and left thigh and calf were performed using 10 to 20 stabs in each leg.  The stab phlebectomies were performed with a hook and they were very satisfactory.  Hemostasis achieved with compression and then staples were applied to the skin.,Then, the patient was rolled onto a stretcher where both legs were wrapped with the Kerlix, fluffs, and Ace bandages.,Estimated blood loss probably was about 150 mL.  The patient tolerated the procedure well and was sent to recovery room in satisfactory condition.  The patient is to be observed, so a decision will be made whether she needs to stay overnight or be able to go home.","surgery, chronic venous hypertension, varicosities, stab phlebectomies, greater saphenous vein stripping, lower extremities, vein stripping, saphenous vein, vein, incisions, hemostasis, stripping, branches, phlebectomies, thigh, calf, saphenous,"
 Fertile male with completed family.  Elective male sterilization via bilateral vasectomy., Surgery, Vasectomy - 4 ,"PROCEDURE: , Elective male sterilization via bilateral vasectomy.,PREOPERATIVE DIAGNOSIS:  ,Fertile male with completed family.,POSTOPERATIVE DIAGNOSIS:,  Fertile male with completed family.,MEDICATIONS:  ,Anesthesia is local with conscious sedation.,COMPLICATIONS: , None.,BLOOD LOSS: , Minimal.,INDICATIONS:  ,This 34-year-old gentleman has come to the office requesting sterilization via bilateral vasectomy.  I discussed the indications and the need for procedure with the patient in detail, and he has given consent to proceed.  He has been given prophylactic antibiotics.,PROCEDURE NOTE: , Once satisfactory sedation have been obtained, the patient was placed in the supine position on the operating table.  Genitalia was shaved and then prepped with Betadine scrub and paint solution and were draped sterilely.  The procedure itself was started by grasping the right vas deferens in the scrotum, and bringing it up to the level of the skin.  The skin was infiltrated with 2% Xylocaine and punctured with a sharp hemostat to identify the vas beneath.  The vas was brought out of the incision carefully.  A 2-inch segment was isolated, and 1-inch segment was removed.  The free ends were cauterized and were tied with 2-0 silk sutures in such a fashion that the ends double back on themselves.  After securing hemostasis with a cautery, the ends were allowed to drop back into the incision, which was also cauterized.,Attention was now turned to the left side.  The vas was grasped and brought up to the level of the skin.  The skin was infiltrated with 2% Xylocaine and punctured with a sharp hemostat to identify the vas beneath.  The vas was brought out of the incision carefully.  A 2-inch segment was isolated, and 1-inch segment was removed.  The free ends were cauterized and tied with 2-0 silk sutures in such a fashion that the ends double back on themselves.  After securing hemostasis with the cautery, the ends were allowed to drop back into the incision, which was also cauterized.,Bacitracin ointment was applied as well as dry sterile dressing.  The patient was awakened and was returned to Recovery in satisfactory condition.","surgery, sterilization, vas, fertile male, bilateral vasectomy, vasectomy, cauterized,"
" Desire for sterility.  Vasectomy.  The vas was identified, skin was incised, and no scalpel instruments were used to dissect out the vas.", Surgery, Vasectomy - 3 ,"PREOPERATIVE DIAGNOSIS:,  Desire for sterility.,POSTOPERATIVE DIAGNOSIS:,  Desire for sterility.,OPERATIVE PROCEDURES: , Vasectomy.,DESCRIPTION OF PROCEDURE: , The patient was brought to the suite, where after oral sedation, the scrotum was prepped and draped.  Then, 1% lidocaine was used for anesthesia.  The vas was identified, skin was incised, and no scalpel instruments were used to dissect out the vas.  A segment about 3 cm in length was dissected out.  It was clipped proximally and distally, and then the ends were cauterized after excising the segment.  Minimal bleeding was encountered and the scrotal skin was closed with 3-0 chromic.  The identical procedure was performed on the contralateral side.  He tolerated it well.  He was discharged from the surgical center in good condition with Tylenol with Codeine for pain.  He will use other forms of birth control until he has confirmed azoospermia with two consecutive semen analyses in the month ahead.  Call if there are questions or problems prior to that time.","surgery, vas, contralateral, desire for sterility, scalpel, sterility, vasectomy"
 Endoscopic third ventriculostomy., Surgery, Ventriculostomy ,"PREOPERATIVE DIAGNOSIS: , Aqueductal stenosis.,POSTOPERATIVE DIAGNOSIS:,  Aqueductal stenosis.,TITLE OF PROCEDURE:  ,Endoscopic third ventriculostomy.,ANESTHESIA: , General endotracheal tube anesthesia.,DEVICES:,  Bactiseal ventricular catheter with an Aesculap burr hole port.,SKIN PREPARATION:  ,ChloraPrep.,COMPLICATIONS: , None.,SPECIMENS: , CSF for routine studies.,INDICATIONS FOR OPERATION:  ,Triventricular hydrocephalus most consistent with aqueductal stenosis.  The patient having a long history of some intermittent headaches, macrocephaly.,OPERATIVE PROCEDURE: , After satisfactory general endotracheal tube anesthesia was administered, the patient was positioned on the operating table in supine position with the head neutral.  The right frontal area was shaven and then the head was prepped and draped in a standard routine manner.  The area of the proposed scalp incision was infiltrated with 0.25% Marcaine with 1:200,000 epinephrine.  A curvilinear scalp incision was made extending from just posterior to bregma curving up in the midline and then going off to the right anterior to the coronal suture.  Two Weitlaner were used to hold the scalp open.  A burr hole was made just anterior to the coronal suture and then the dura was opened in a cruciate manner and the pia was coagulated.  Neuropen was introduced directly through the parenchyma into the ventricular system, which was quite large and dilated.  CSF was collected for routine studies.  We saw the total absence of __________  consistent with the congenital form of aqueductal stenosis and a markedly thinned down floor of the third ventricle.  I could bend the ventricular catheter and look back and see the aqueduct, which was quite stenotic with a little bit of chorioplexus near its opening.  The NeuroPEN was then introduced through the midline of the floor of the third ventricle anterior to the mamillary bodies in front of the basilar artery and then was gently enlarged using NeuroPEN __________  various motions.  We went through the membrane of Liliequist.  We could see the basilar artery and the clivus, and there was no significant bleeding from the edges.  The Bactiseal catheter was then left to 7 cm of length because of her macrocephaly and secured to a burr hole port with a 2-0 Ethibond suture.  The wound was irrigated out with bacitracin and closed using 3-0 Vicryl for the deep layer and a Monocryl suture for the scalp followed by Mastisol and Steri-Strips.  The patient tolerated the procedure well.","surgery, aqueductal stenosis, ventriculostomy, triventricular hydrocephalus, neuropen, endoscopic third ventriculostomy, endotracheal tube anesthesia, burr hole port, aqueductal,"
 Burr hole and insertion of external ventricular drain catheter., Surgery, Ventricular Drain Catheter Insertion ,"PREOPERATIVE DIAGNOSES:,  Increased intracranial pressure and cerebral edema due to severe brain injury.,POSTOPERATIVE DIAGNOSES: , Increased intracranial pressure and cerebral edema due to severe brain injury.,PROCEDURE:,  Burr hole and insertion of external ventricular drain catheter.,ANESTHESIA: , Just bedside sedation.,PROCEDURE: , Scalp was clipped.  He was prepped with ChloraPrep and Betadine.  Incisions are infiltrated with 1% Xylocaine with epinephrine 1:200000.  He did receive antibiotics post procedure.  He was draped in a sterile manner.,Incision made just to the right of the right mid pupillary line 10 cm behind the nasion.  A self-retaining retractor was placed.  Burr hole was drilled with the cranial twist drill.  The dura was punctured with a twist drill.  A brain needle was used to localize the ventricle that took 3 passes to localize the ventricle.  The pressure was initially high.  The CSF was clear and colorless.  The CSF drainage rapidly tapered off because of the brain swelling.  With two tries, the ventricular catheter was then able to be placed into the ventricle and then brought out through a separate stab wound, the depth of catheter is 7 cm from the outer table of the skull.  There was intermittent drainage of CSF after that.  The catheter was secured to the scalp with #2-0 silk suture and the incision was closed with Ethilon suture.  The patient tolerated the procedure well.  No complications.  Sponge and needle counts were correct.  Blood loss is minimal.  None replaced.","surgery, intracranial pressure, cerebral edema, external ventricular drain catheter, ventricular drain catheter, brain injury, burr hole, ventricular, brain, catheter, "
" Vitreous hemorrhage, right eye.  Vitrectomy, right eye.  A Lancaster lid speculum was applied and the conjunctiva was opened 4 mm posterior to the limbus.", Surgery, Vitrectomy ,"PREOPERATIVE DIAGNOSIS:,  Vitreous hemorrhage, right eye.,POSTOPERATIVE DIAGNOSIS: , Vitreous hemorrhage, right eye.,PROCEDURE:  ,Vitrectomy, right eye.,PROCEDURE IN DETAIL:  ,The patient was prepared and draped in the usual manner for a vitrectomy procedure under local anesthesia.  Initially, a 5 cc retrobulbar injection was performed with 2% Xylocaine during monitored anesthesia control.  A Lancaster lid speculum was applied and the conjunctiva was opened 4 mm posterior to the limbus.  MVR incisions were made 4 mm posterior to the limbus in the *** and *** o'clock meridians following which the infusion apparatus was positioned in the *** o'clock site and secured with a 5-0 Vicryl suture.  Then, under indirect ophthalmoscopic control, the vitrector was introduced through the *** o'clock site and a complete vitrectomy was performed.  All strands of significance were removed.  Tractional detachment foci were apparent posteriorly along the temporal arcades.  Next, endolaser coagulation was applied to ischemic sites and to neovascular foci under indirect ophthalmoscopic control.  Finally, an air exchange procedure was performed, also under indirect ophthalmoscopic control.  The intraocular pressure was within the normal range.  The globe was irrigated with a topical antibiotic.  The MVR incisions were closed with 7-0 Vicryl.  No further manipulations were necessary.  The conjunctiva was closed with 6-0 plain catgut.  An eye patch was applied and the patient was sent to the recovery area in good condition.","surgery, ophthalmoscopic, vitrectomy, endolaser, lancaster lid speculum, vitreous hemorrhage, vitreous, hemorrhage, conjunctiva"
 Normal vasectomy, Surgery, Vasectomy - 2 ,"DIAGNOSIS:,  Desires vasectomy.,NAME OF OPERATION: , Vasectomy.,ANESTHESIA:,  General.,HISTORY: , Patient, 37, desires a vasectomy.,PROCEDURE: , Through a midline scrotal incision, the right vas was identified and separated from the surrounding tissues, clamped, transected, and tied off with a 4-0 chromic.  No bleeding was identified.,Through the same incision the left side was identified, transected, tied off, and dropped back into the wound.  Again no bleeding was noted.,The wound was closed with 4-0 Vicryl times two.  He tolerated the procedure well.  A sterile dressing was applied.  He was awakened and transferred to the recovery room in stable condition.","surgery, scrotal incision, right vas, bleeding, anesthesia, vasectomy"
 Normal vasectomy, Surgery, Vasectomy - 1 ,"DESCRIPTION:,  The patient was placed in the supine position and was prepped and draped in the usual manner.  The left vas was grasped in between the fingers.  The skin and vas were anesthetized with local anesthesia.  The vas was grasped with an Allis clamp.  Skin was incised and the vas deferens was regrasped with another Allis clamp.  The sheath was incised with a scalpel and elevated using the iris scissors and clamps were used to ligate the vas deferens.  The portion in between the clamps was excised and the ends of the vas were clamped using hemoclips, two in the testicular side and one on the proximal side.  The incision was then inspected for hemostasis and closed with 3-0 chromic catgut interrupted fashion.,A similar procedure was carried out on the right side.  Dry sterile dressings were applied and the patient put on a scrotal supporter.  The procedure was then terminated.","surgery, vasectomy, allis clamp, catgut, hemoclips, iris scissors, scrotal, scrotal supporter, testicular, vas, vas deferens, vas was grasped, deferens, clampsNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" Voluntary sterility.  Bilateral vasectomy.  The vas deferens was grasped with a vas clamp.  Next, the vas deferens was skeletonized.  It was clipped proximally and distally twice. ", Surgery, Vasectomy ,"PREOPERATIVE DIAGNOSIS: , Voluntary sterility.,POSTOPERATIVE DIAGNOSIS: , Voluntary sterility.,OPERATIVE PROCEDURE:,  Bilateral vasectomy.,ANESTHESIA:,  Local.,INDICATIONS FOR PROCEDURE:  ,A gentleman who is here today requesting voluntary sterility.  Options were discussed for voluntary sterility and he has elected to proceed with a bilateral vasectomy.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room, and after appropriately identifying the patient, the patient was prepped and draped in the standard surgical fashion and placed in a supine position on the OR table.  Then, 0.25% Marcaine without epinephrine was used to anesthetize the scrotal skin.  A small incision was made in the right hemiscrotum.  The vas deferens was grasped with a vas clamp.  Next, the vas deferens was skeletonized.  It was clipped proximally and distally twice.  The cut edges were fulgurated.  Meticulous hemostasis was maintained.  Then, 4-0 chromic was used to close the scrotal skin on the right hemiscrotum.  Next, the attention was turned to the left hemiscrotum, and after the left hemiscrotum was anesthetized appropriately, a small incision was made in the left hemiscrotum.  The vas deferens was isolated.  It was skeletonized.  It was clipped proximally and distally twice.  The cut edges were fulgurated.  Meticulous hemostasis was maintained.  Then, 4-0 chromic was used to close the scrotal skin.  A jockstrap and sterile dressing were applied at the end of the case.  Sponge, needle, and instruments counts were correct.","surgery, hemiscrotum, bilateral vasectomy, voluntary sterility, vas deferens, vasectomy, skeletonized, scrotal, sterility, deferens"
 Laparoscopic-assisted vaginal hysterectomy.  Abnormal uterine bleeding.  Uterine fibroids., Surgery, Vaginal Hysterectomy - Laparoscopic-Assisted ,"PREOPERATIVE DIAGNOSES,1.  Abnormal uterine bleeding.,2.  Uterine fibroids.,POSTOPERATIVE DIAGNOSES,1.  Abnormal uterine bleeding.,2.  Uterine fibroids.,OPERATION PERFORMED: , Laparoscopic-assisted vaginal hysterectomy.,ANESTHESIA: , General endotracheal anesthesia.,DESCRIPTION OF PROCEDURE:  ,After adequate general endotracheal anesthesia, the patient was placed in dorsal lithotomy position, prepped and draped in the usual manner for a laparoscopic procedure.  A speculum was placed into the vagina.  A single tooth tenaculum was utilized to grasp the anterior lip of the uterine cervix.  The uterus was sounded to 10.5 cm.  A #10 RUMI cannula was utilized and attached for uterine manipulation.  The single-tooth tenaculum and speculum were removed from the vagina.  At this time, the infraumbilical area was injected with 0.25% Marcaine with epinephrine and infraumbilical vertical skin incision was made through which a Veress needle was inserted into the abdominal cavity.  Aspiration was negative; therefore the abdomen was insufflated with carbon dioxide.  After adequate insufflation, Veress needle was removed and an 11-mm separator trocar was introduced through the infraumbilical incision into the abdominal cavity.  Through the trocar sheath, the laparoscope was inserted and adequate visualization of the pelvic structures was noted.  At this time, the suprapubic area was injected with 0.25% Marcaine with epinephrine.  A 5-mm skin incision was made and a 5-mm trocar was introduced into the abdominal cavity for instrumentation.  Evaluation of the pelvis revealed the uterus to be slightly enlarged and irregular.  The fallopian tubes have been previously interrupted surgically.  The ovaries appeared normal bilaterally.  The cul-de-sac was clean without evidence of endometriosis, scarring or adhesions.  The ureters were noted to be deep in the pelvis.  At this time, the right cornu was grasped and the right fallopian tube, uteroovarian ligament, and round ligaments were doubly coagulated with bipolar electrocautery and transected without difficulty.  The remainder of the uterine vessels and anterior and posterior leaves of the broad ligament, as well as the cardinal ligament was coagulated and transected in a serial fashion down to level of the uterine artery.  The uterine artery was identified.  It was doubly coagulated with bipolar electrocautery and transected.  A similar procedure was carried out on the left with the left uterine cornu identified.  The left fallopian tube, uteroovarian ligament, and round ligaments were doubly coagulated with bipolar electrocautery and transected.  The remainder of the cardinal ligament, uterine vessels, anterior, and posterior sheaths of the broad ligament were coagulated and transected in a serial manner to the level of the uterine artery.  The uterine artery was identified.  It was doubly coagulated with bipolar electrocautery and transected.  The anterior leaf of the broad ligament was then dissected to the midline bilaterally, establishing a bladder flap with a combination of blunt and sharp dissection.  At this time, attention was made to the vaginal hysterectomy.  The laparoscope was removed and attention was made to the vaginal hysterectomy.  The RUMI cannula was removed and the anterior and posterior leafs of the cervix were grasped with Lahey tenaculum.  A circumferential injection with 0.25% Marcaine with epinephrine was made at the cervicovaginal portio.  A circumferential incision was then made at the cervicovaginal portio.  The anterior and posterior colpotomies were accomplished with a combination of blunt and sharp dissection without difficulty.  The right uterosacral ligament was clamped, transected, and ligated with #0 Vicryl sutures.  The left uterosacral ligament was clamped, transected, and ligated with #0 Vicryl suture.  The parametrial tissue was then clamped bilaterally, transected, and ligated with #0 Vicryl suture bilaterally.  The uterus was then removed and passed off the operative field.  Laparotomy pack was placed into the pelvis.  The pedicles were evaluated.  There was no bleeding noted; therefore, the laparotomy pack was removed.  The uterosacral ligaments were suture fixated into the vaginal cuff angles with #0 Vicryl sutures.  The vaginal cuff was then closed in a running fashion with #0 Vicryl suture.  Hemostasis was noted throughout.  At this time, the laparoscope was reinserted into the abdomen.  The abdomen was reinsufflated.  Evaluation revealed no further bleeding.  Irrigation with sterile water was performed and again no bleeding was noted.  The suprapubic trocar sheath was then removed under laparoscopic visualization.  The laparoscope was removed.  The carbon dioxide was allowed to escape from the abdomen and the infraumbilical trocar sheath was then removed.  The skin incisions were closed with #4-0 Vicryl in subcuticular fashion.  Neosporin and Band-Aid were applied for dressing and the patient was taken to the recovery room in satisfactory condition.  Estimated blood loss was approximately 100 mL.  There were no complications.  The instrument, sponge, and needle counts were correct.","surgery, abnormal uterine bleeding, laparoscopic-assisted vaginal hysterectomy, uterine fibroids, bipolar electrocautery, vaginal hysterectomy, vicryl sutures, tooth, uterine, uterosacral, laparoscope, electrocautery, hysterectomy, laparoscopic, coagulated, vaginal, ligament, transected"
 Vaginal Hysterectomy.  A weighted speculum was placed in the posterior vaginal vault.  The cervix was grasped with a Massachusetts clamp on both its anterior and posterior lips., Surgery, Vaginal Hysterectomy ,,"surgery, omentum, massachusetts, vaginal hysterectomy, vaginal vault, vaginal mucosa, vicryl suture, hysterectomy, ligaments, speculum, ligated, vaginal, sutureNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Vacuum-assisted vaginal delivery of a third-degree midline laceration and right vaginal side wall laceration and repair of the third-degree midline laceration lasting for 25 minutes., Surgery, Vaginal Delivery - Vacuum-Assisted ,"PREOPERATIVE DIAGNOSES,1.  A 40 weeks 6 days intrauterine pregnancy.,2.  History of positive serology for HSV with no evidence of active lesions.,3.  Non-reassuring fetal heart tones.,POST OPERATIVE DIAGNOSES,1.  A 40 weeks 6 days intrauterine pregnancy.,2.  History of positive serology for HSV with no evidence of active lesions.,3.  Non-reassuring fetal heart tones.,PROCEDURES,1.  Vacuum-assisted vaginal delivery of a third-degree midline laceration and right vaginal side wall laceration.,2.  Repair of the third-degree midline laceration lasting for 25 minutes.,ANESTHESIA: , Local.,ESTIMATED BLOOD LOSS: , 300 mL.,COMPLICATIONS:  ,None.,FINDINGS,1.  Live male infant with Apgars of 9 and 9.,2.  Placenta delivered spontaneously intact with a three-vessel cord.,DISPOSITION:  ,The patient and baby remain in the LDR in stable condition.,SUMMARY: , This is a 36-year-old G1 woman who was pregnant since 40 weeks 6 days when she was admitted for induction of labor for post dates with favorable cervix.  When she was admitted, her cervix was 2.5 cm dilated with 80% effacement.  The baby had a -2 station.  She had no regular contractions.  Fetal heart tones were 120s and reactive.  She was started on Pitocin for labor induction and labored quite rapidly.  She had spontaneous rupture of membranes with a clear fluid.  She had planned on an epidural; however, she had sudden rapid cervical change and was unable to get the epidural.  With the rapid cervical change and descent of fetal head, there were some variable decelerations.  The baby was at a +1 station when the patient began pushing.  I had her push to get the baby to a +2 station.  During pushing, the fetal heart tones were in the 80s and did not recover in between contractions.  Because of this, I recommended a vacuum delivery for the baby.  The patient agreed.,The baby's head was confirmed to be in the right occiput anterior presentation.  The perineum was injected with 1% lidocaine.  The bladder was drained.  The vacuum was placed and the correct placement in front of the posterior fontanelle was confirmed digitally.  With the patient's next contraction, the vacuum was inflated and a gentle downward pressure was used to assist with brining the baby's head to a +3 station.  The contraction ended.  The vacuum was released and the fetal heart tones remained in the, at this time, 90s to 100s.  With the patient's next contraction, the vacuum was reapplied and the baby's head was delivered to a +4 station.  A modified Ritgen maneuver was used to stabilize the fetal head.  The vacuum was deflated and removed.  The baby's head then delivered atraumatically.  There was no nuchal cord.  The baby's anterior shoulder delivered after a less than 30 second delay.  No additional maneuvers were required to deliver the anterior shoulder.  The posterior shoulder and remainder of the body delivered easily.  The baby's mouth and nose were bulb suctioned.  The cord was clamped x2 and cut.  The infant was handed to the respiratory therapist.,Pitocin was added to the patient's IV fluids.  The placenta delivered spontaneously, was intact and had a three-vessel cord.  A vaginal inspection revealed a third-degree midline laceration as well as a right vaginal side wall laceration.  The right side wall laceration was repaired with #3-0 Vicryl suture in a running fashion with local anesthesia.  The third-degree laceration was also repaired with #3-0 Vicryl sutures.  Local anesthesia was used.  The capsule was visible, but did not appear to be injured at all.  It was reinforced with three separate interrupted sutures and then the remainder of the incision was closed with #3-0 Vicryl in the typical fashion.,The patient tolerated the procedure very well.  She remains in the LDR with the baby.  The baby is vigorous, crying and moving all extremities.  He will go to the new born nursery when ready.  The total time for repair of the laceration was 25 minutes.","surgery, intrauterine pregnancy, non-reassuring fetal heart tones, vacuum-assisted vaginal delivery, vaginal side wall laceration, fetal heart tones, vaginal delivery, vacuum assisted, laceration, intrauterine, tones, contractions, "
" Umbilical hernia repair template.  The umbilical hernia carefully reduced back into the cavity, and the fascia was closed with interrupted vertical mattress sutures to approximate the fascia.", Surgery, Umbilical Hernia Repair ,"PREOPERATIVE DIAGNOSIS: , Umbilical hernia.,POSTOPERATIVE DIAGNOSIS: , Umbilical hernia.,PROCEDURE PERFORMED: , Repair of umbilical hernia.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,PROCEDURE IN DETAIL:  ,The patient was prepped and draped in the sterile fashion.  An infraumbilical incision was formed and taken down to the fascia.  The umbilical hernia carefully reduced back into the cavity, and the fascia was closed with interrupted vertical mattress sutures to approximate the fascia, and then the wounds were infiltrated with 0.25% Marcaine.  The skin was reattached to the fascia with 2-0 Vicryls.  The skin was approximated with 2-0 Vicryl subcutaneous and then 4-0 Monocryl subcuticular stitches, dressed with Steri-Strips and 4 x 4's.  Patient was extubated and taken to the recovery area in stable condition.","surgery, marcaine, steri-strips, mattress sutures, umbilical hernia, repair, umbilical, hernia,"
 Upper endoscopy with removal of food impaction., Surgery, Upper Endoscopy  ,"PROCEDURE:,  Upper endoscopy with removal of food impaction.,HISTORY OF PRESENT ILLNESS: , A 92-year-old lady with history of dysphagia on and off for two years.  She comes in this morning with complaints of inability to swallow anything including her saliva.  This started almost a day earlier.  She was eating lunch and had beef stew and suddenly noticed inability to finish her meal and since then has not been able to eat anything.  She is on Coumadin and her INR is 2.5.,OPERATIVE NOTE: , Informed consent was obtained from patient.  The risks of aspiration, bleeding, perforation, infection, and serious risk including need for surgery and ICU stay particularly in view of food impaction for almost a day was discussed.  Daughter was also informed about the procedure and risks.  Conscious sedation initially was administered with Versed 2 mg and fentanyl 50 mcg.  The scope was advanced into the esophagus and showed liquid and solid particles from mid esophagus all the way to the distal esophagus.  There was a meat bolus in the distal esophagus.  This was visualized after clearing the liquid material and small particles of what appeared to be carrots.  The patient, however, was not tolerating the conscious sedation.  Hence, Dr. X was consulted and we continued the procedure with propofol sedation.,The scope was reintroduced into the esophagus after propofol sedation.  Initially a Roth net was used and some small amounts of soft food in the distal esophagus was removed with the Roth net.  Then, a snare was used to cut the meat bolus into pieces, as it was very soft.  Small pieces were grabbed with the snare and pulled out.  Thereafter, the residual soft meat bolus was passed into the stomach along with the scope, which was passed between the bolus and the esophageal wall carefully.  The patient had severe bruising and submucosal hemorrhage in the esophagus possibly due to longstanding bolus impaction and Coumadin therapy.  No active bleeding was seen.  There was a distal esophageal stricture, which caused slight resistance to the passage of the scope into the stomach.  As this area was extremely inflamed, a dilatation was not attempted.,IMPRESSION: , Distal esophageal stricture with food impaction.  Treated as described above.,RECOMMENDATIONS:,  IV Protonix 40 mg q.12h.  Clear liquid diet for 24 hours.  If the patient is stable, thereafter she may take soft pureed diet only until next endoscopy, which will be scheduled in three to four weeks.  She should take Prevacid SoluTab 30 mg b.i.d. on discharge.","surgery, dysphagia, removal of food impaction, distal esophagus, stomach, distal esophageal, esophageal stricture, upper endoscopy, food impaction, endoscopy, aspiration, sedation, bolus, impaction, esophagus, "
" Exam under anesthesia with uterine suction curettage.  A 10-1/2 week pregnancy, spontaneous, incomplete abortion.", Surgery, Uterine Suction Curettage ,"PREOPERATIVE DIAGNOSIS: , A 10-1/2 week pregnancy, spontaneous, incomplete abortion.,POSTOPERATIVE DIAGNOSIS:,  A 10-1/2 week pregnancy, spontaneous, incomplete abortion.,PROCEDURE: , Exam under anesthesia with uterine suction curettage.,ANESTHESIA: , Spinal.,ESTIMATED BLOOD LOSS: , Less than 10 cc.,COMPLICATIONS:,  None.,DRAINS:,  None.,CONDITION:,  Stable.,INDICATIONS:  ,The patient is a 29-year-old gravida 5, para 1-0-3-1, with an LMP at 12/18/05.  The patient was estimated to be approximately 10-1/2 weeks so long in her pregnancy.  She began to have heavy vaginal bleeding and intense lower pelvic cramping.  She was seen in the emergency room where she was found to be hemodynamically stable.  On pelvic exam, her cervix was noted to be 1 to 2 cm dilated and approximately 90% effaced.  There were bulging membranes protruding through the dilated cervix.  These symptoms were consistent with the patient's prior experience of spontaneous miscarriages.  These findings were reviewed with her and options for treatment discussed.  She elected to proceed with an exam under anesthesia with uterine suction curettage.  The risks and benefits of the surgery were discussed with her and knowing these, she gave informed consent.,PROCEDURE:  ,The patient was taken to the operating room where she was placed in the seated position.  A spinal anesthetic was successfully administered.  She was then moved to a dorsal lithotomy position.  She was prepped and draped in the usual fashion for the procedure.  After adequate spinal level was confirmed, a bimanual exam was again performed.  This revealed the uterus to be anteverted to axial and approximately 10 to 11 weeks in size.  The previously noted cervical exam was confirmed.  The weighted vaginal speculum was then inserted and the vaginal vault flooded with povidone solution.  This solution was then removed approximately 10 minutes later with dry sterile gauze sponge.  The anterior cervical lip was then attached with a ring clamp.  The tissue and membranes protruding through the os were then gently grasped with a ring clamp and traction applied.  The tissue dislodged revealing fluid mixed with blood as well as an apparent 10-week fetus.  The placental tissue was then gently tractioned out as well.  A size 9 curved suction curette was then gently inserted through the dilated os and into the endometrial cavity.  With the vacuum tubing applied in rotary motion, a moderate amount of tissue consistent with products of conception was evacuated.  The sharp curette was then utilized to probe the endometrial surface.  A small amount of additional tissue was then felt in the posterior uterine wall.  This was curetted free.  A second pass was then made with a vacuum curette.  Again, the endometrial cavity was probed with a sharp curette and no significant additional tissue was encountered.  A final pass was then made with a suction curette.,The ring clamp was then removed from the anterior cervical lip.  There was only a small amount of bleeding following the curettage.  The weighted speculum was then removed as well.  The bimanual exam was repeated and good involution was noted.  The patient was taken down from the dorsal lithotomy position.  She was transferred to the recovery room in stable condition.  The sponge and instrument count was performed and found to be correct.  The specimen of products of conception and 10-week fetus were submitted to Pathology for further evaluation.  The estimated blood loss for the procedure is less than 10 mL.","surgery, spontaneous, incomplete abortion, uterine suction curettage, fetus, anterior cervical lip, spontaneous incomplete abortion, bimanual exam, ring clamp, suction curettage, uterine, curettage, suction"
 Urgent cardiac catheterization with coronary angiogram., Surgery, Urgent Cardiac Cath ,"PROCEDURE: , Urgent cardiac catheterization with coronary angiogram.,PROCEDURE IN DETAIL: , The patient was brought urgently to the cardiac cath lab from the emergency room with the patient being intubated with an abnormal EKG and a cardiac arrest.  The right groin was prepped and draped in usual manner.  Under 2% lidocaine anesthesia, the right femoral artery was entered.  A 6-French sheath was placed.  The patient was already on anticoagulation.  Selective coronary angiograms were then performed using a left and a 3DRC catheter.  The catheters were reviewed.  The catheters were then removed and an Angio-Seal was placed.  There was some hematoma at the cath site.,RESULTS,1.  The left main was free of disease.,2.  The left anterior descending and its branches were free of disease.,3.  The circumflex was free of disease.,4.  The right coronary artery was free of disease.  There was no gradient across the aortic valve.,IMPRESSION: , Normal coronary angiogram.,","surgery, cardiac catheterization, coronary angiogram, angiogram"
" Uvulopalatopharyngoplasty and tonsillectomy.   The patient with a history of obstructive sleep apnea who has been using CPAP, however, he was not tolerating used of the machine and requested a surgical procedure for correction of his apnea.", Surgery, Uvulopalatopharyngoplasty & Tonsillectomy ,"PREOPERATIVE DIAGNOSIS:,  Obstructive sleep apnea.,POSTOPERATIVE DIAGNOSIS:  ,Obstructive sleep apnea.,PROCEDURE PERFORMED:,1.  Tonsillectomy.,2.  Uvulopalatopharyngoplasty.,ANESTHESIA:,  General endotracheal tube.,BLOOD LOSS: , Approximately 50 cc.,INDICATIONS: , The patient is a 41-year-old gentleman with a history of obstructive sleep apnea who has been using CPAP, however, he was not tolerating used of the machine and requested a surgical procedure for correction of his apnea.,PROCEDURE: , After all risks, benefits, and alternatives have been discussed with the patient, informed consent was obtained.  The patient was brought to the operative suite where he was placed in supine position and general endotracheal tube intubation was delivered by the Department of Anesthesia.  The patient was rotated 90 degrees away and a shoulder roll was placed and a McIvor mouthgag was inserted into the oral cavity.  Correct inspection and palpation did not reveal evidence of a bifid uvula or submucosal clots.  Attention was directed first to the right tonsil in which a curved Allis forceps was applied to the superior pole.  The needle-tip Bovie cautery was used to incise the mucosa of the anterior tonsillar pillar.  Once the tonsillar pillar was identified and the superior pole was released, the curved forceps with a straight Allis forceps and the dissection was carried down inferiorly, dissecting the tonsil free from all fascial attachments.  Once the tonsil was delivered from the oral cavity, hemostasis was obtained within the tonsillar fossa utilizing suction cautery.,Attention was then directed over to the left tonsil in which a similar procedure was performed.  Once all bleeding was controlled, the mucosa of both the hard and soft palate was anesthetized with a mixture of 1% lidocaine and 1:50000 epinephrine solution.  Now attention was directed to the posterior pillars.  A hemostat was used to clamp the posterior pillar, which was then taken down with Metzenbaum scissors.  The posterior pillar was then approximated to the anterior pillar with the use of #3-0 PDS suture so as to create a box shaped soft palate.  Now, the uvula was reflected onto the soft palate and #12 blade scalpel was used to incise the mucosa of the soft palate extending down onto the uvula.  The mucosa was dissected off with the use of Potts scissors.  Now the uvula was reflected onto the soft palate and sutured down in place with use of #3-0 PDS suture approximated with deep muscle layers.  Now the mucosa of the soft palate and the uvula were approximated with interrupted #3-0 PDS sutures.  Finally, #4-0 Vicryl sutures were placed intermittently between the PDS to further secure the uvula, which had been reflected onto the soft palate.  A final #3-0 PDS suture was used to further approximate the anterior and posterior tonsil pillars.  Final inspection did not reveal any further bleeding.  The mouth was then irrigated with saline and suctioned.  At this point, the procedure was complete.  He was awakened and taken to recovery room in stable condition.  He will be admitted as an observation patient to the Telemetry Floor for routine postoperative management.  Of note, IV Decadron was administered during the procedure.","surgery, endotracheal, metzenbaum, soft palate, obstructive sleep apnea, tonsillectomy, uvulopalatopharyngoplasty, obstructive, mucosa, uvula, palate,"
" Umbilical hernia repair. A standard curvilinear umbilical incision was made, and dissection was carried down to the hernia sac using a combination of Metzenbaum scissors and Bovie electrocautery.  ", Surgery, Umbilical Hernia Repair - 1 ,"PROCEDURE PERFORMED: , Umbilical hernia repair.,PROCEDURE:,  After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table.  The patient was sedated, and an adequate local anesthetic was administered using 1% lidocaine without epinephrine.  The patient was prepped and draped in the usual sterile manner.,A standard curvilinear umbilical incision was made, and dissection was carried down to the hernia sac using a combination of Metzenbaum scissors and Bovie electrocautery.  The sac was cleared of overlying adherent tissue, and the fascial defect was delineated.  The fascia was cleared of any adherent tissue for a distance of 1.5 cm from the defect.  The sac was then placed into the abdominal cavity and the defect was closed primarily using simple interrupted 0 Vicryl sutures.  The umbilicus was then re-formed using 4-0 Vicryl to tack the umbilical skin to the fascia.,The wound was then irrigated using sterile saline, and hemostasis was obtained using Bovie electrocautery.  The skin was approximated with 4-0 Vicryl in a subcuticular fashion.  The skin was prepped with benzoin, and Steri-Strips were applied.  A dressing was then applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.","surgery, fascial defect, umbilical hernia repair, curvilinear umbilical, hernia sac, metzenbaum scissors, umbilical hernia, bovie electrocautery, electrocautery, hernia, incision, umbilical,"
 A 21-year-old female was having severe cramping and was noted to have a blighted ovum with her first ultrasound in the office., Surgery, Vacuum D&C ,"PREOPERATIVE DIAGNOSIS: , Blighted ovum, severe cramping.,POSTOPERATIVE DIAGNOSIS:,  Blighted ovum, severe cramping.,OPERATION PERFORMED: , Vacuum D&C.,DRAINS: , None.,ANESTHESIA: , General.,HISTORY: , This 21-year-old white female gravida 1, para 0 who was having severe cramping and was noted to have a blighted ovum with her first ultrasound in the office.  Due to the severe cramping, a decision to undergo vacuum D&C was made.  At the time of the procedure, moderate amount of tissue was obtained.,PROCEDURE:  ,The patient was taken to the operating room and placed in a supine position, at which time a general form of anesthesia was administered by the anesthesia department.  The patient was then repositioned in a modified dorsal lithotomy position and then prepped and draped in the usual fashion.  A weighted vaginal speculum was placed in the posterior vaginal vault.  Anterior lip of the cervix was grasped with single tooth tenaculum, and the cervix was dilated to approximately 8 mm straight.  Plastic curette was placed into the uterine cavity and suction was applied at 60 mmHg to remove the tissue.  This was followed by gentle curetting of the lining as well as followed by suction curetting and then another gentle curetting and a final suction.  Methargen 0.2 mg was given IM and Pitocin 40 units and a 1000 was also started at the time of the procedure.  Once the procedure was completed, the single tooth tenaculum was removed from the vaginal vault with some _____ remaining blood and the weighted speculum was also removed.  The patient was repositioned to supine position and taken to recovery room in stable condition.","surgery, pitocin, single tooth tenaculum, vaginal vault, vacuum d&c, blighted ovum, speculum, tenaculum, curetting, blighted, cramping,"
" Subcutaneous ulnar nerve transposition.  A curvilinear incision was made over the medial elbow, starting proximally at the medial intermuscular septum, curving posterior to the medial epicondyle, then curving anteriorly along the path of the ulnar nerve.  Dissection was carried down to the ulnar nerve. ", Surgery, Ulnar Nerve Transposition ,"PROCEDURE:,  Subcutaneous ulnar nerve transposition.,PROCEDURE IN DETAIL: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A curvilinear incision was made over the medial elbow, starting proximally at the medial intermuscular septum, curving posterior to the medial epicondyle, then curving anteriorly along the path of the ulnar nerve.  Dissection was carried down to the ulnar nerve.  Branches of the medial antebrachial and the medial brachial cutaneous nerves were identified and protected.,Osborne's fascia was released, an ulnar neurolysis performed, and the ulnar nerve was mobilized.  Six cm of the medial intermuscular septum was excised, and the deep periosteal origin of the flexor carpi ulnaris was released to avoid kinking of the nerve as it was moved anteriorly.,The subcutaneous plane just superficial to the flexor-pronator mass was developed.  Meticulous hemostasis was maintained with bipolar electrocautery.  The nerve was transposed anteriorly, superficial to the flexor-pronator mass.  Motor branches were dissected proximally and distally to avoid tethering or kinking the ulnar nerve.,A semicircular medially based flap of flexor-pronator fascia was raised and sutured to the subcutaneous tissue in such a way as to prevent the nerve from relocating.  The subcutaneous tissue and skin were closed with simple interrupted sutures.  Marcaine with epinephrine was injected into the wound.  The elbow was dressed and splinted.  The patient was awakened and sent to the recovery room in good condition, having tolerated the procedure well.","surgery, neurolysis, ulnar, periosteal, flexor-pronator mass, ulnar nerve transposition, medial intermuscular septum, nerve transposition, intermuscular septum, flexor pronator, ulnar nerve, nerve"
 Upper endoscopy with foreign body removal (Penny in proximal esophagus)., Surgery, Upper Endoscopy - Foreign Body Removal ,"PROCEDURE:, Upper endoscopy with foreign body removal.,PREOPERATIVE DIAGNOSIS (ES):, Esophageal foreign body.,POSTOPERATIVE DIAGNOSIS (ES):, Penny in proximal esophagus.,ESTIMATED BLOOD LOSS:, None.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: ,After informed consent was obtained, the patient was taken to the pediatric endoscopy suite. After appropriate sedation by the anesthesia staff and intubation, an upper endoscope was inserted into the mouth, over the tongue, into the esophagus, at which time the foreign body was encountered. It was grasped with a coin removal forcep and removed with an endoscope. At that time, the endoscope was reinserted, advanced to the level of the stomach and stomach was evaluated and was normal. The esophagus was normal with the exception of some mild erythema, where the coin had been sitting. There were no erosions. The stomach was decompressed of air and fluid. The scope was removed without difficulty.,SUMMARY:, The patient underwent endoscopic removal of esophageal foreign body.,PLAN:, To discharge home, follow up as needed.","surgery, upper endoscopy, endoscopy, endoscopy suite, esophagus, foreign body, foreign body removal, esophageal foreign body, stomach,"
 Bilateral tympanostomy with myringotomy tube placement.    The patient is a 1-year-old male with a history of chronic otitis media with effusion and conductive hearing loss refractory to outpatient medical therapy. , Surgery, Tympanostomy & Myringotomy Tube Placement ,"PREOPERATIVE DIAGNOSES:,1.  Chronic otitis media with effusion.,2.  Conductive hearing loss.,POSTOPERATIVE DIAGNOSES:,1.  Chronic otitis media with effusion.,2.  Conductive hearing loss.,PROCEDURE PERFORMED: , Bilateral tympanostomy with myringotomy tube placement _______ split tube 1.0 mm.,ANESTHESIA:  ,Total IV general mask airway.,ESTIMATED BLOOD LOSS:  ,None.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE:,  The patient is a 1-year-old male with a history of chronic otitis media with effusion and conductive hearing loss refractory to outpatient medical therapy.  After risks, complications, consequences, and questions were addressed with the family, a written consent was obtained for the procedure.,PROCEDURE:,  The patient was brought to the operative suite by Anesthesia.  The patient was placed on the operating table in supine position.  After this, the patient was then placed under general mask airway and the patient's head was then turned to the left.,The Zeiss operative microscope and medium-sized ear speculum were placed and the cerumen from the external auditory canals were removed with a cerumen loop to #5 suction.  After this, the tympanic membrane is then brought into direct visualization with no signs of any gross retracted pockets or cholesteatoma.  A myringotomy incision was then made within the posterior inferior quadrant and the middle ear was then suctioned with a #5 suction demonstrating dry contents.  A _____ split tube 1.0 mm was then placed in the myringotomy incision utilizing a alligator forcep.  Cortisporin Otic drops were placed followed by cotton balls.  Attention was then drawn to the left ear with the head turned to the right and the medium sized ear speculum placed.  The external auditory canal was removed off of its cerumen with a #5 suction which led to the direct visualization of the tympanic membrane.  The tympanic membrane appeared with no signs of retraction pockets, cholesteatoma or air fluid levels.  A myringotomy incision was then made within the posterior inferior quadrant with a myringotomy blade after which a _________ split tube 1.0 mm was then placed with an alligator forcep.  After this, the patient had Cortisporin Otic drops followed by cotton balls placed.  The patient was then turned back to Anesthesia and transferred to recovery room in stable condition and tolerated the procedure very well.  The patient will be followed up approximately in one week and was sent home with a prescription for Ciloxan ear drops to be used as directed and with instructions not to get any water in the ears.","surgery, chronic otitis media with effusion, conductive hearing loss, bilateral tympanostomy, myringotomy tube placement, cortisporin otic drops, otitis media, tympanostomy, tympanic, membrane, otitis, media, effusion, conductive, hearing, ear, tube, myringotomy"
 Adenotonsillar hypertrophy and chronic otitis media.  Tympanostomy and tube placement and adenoidectomy., Surgery, Tympanostomy ,"PREOPERATIVE DIAGNOSIS: , Adenotonsillar hypertrophy and chronic otitis media.,POSTOPERATIVE DIAGNOSIS:,  Adenotonsillar hypertrophy and chronic otitis media.,PROCEDURE PERFORMED:,1.  Tympanostomy and tube placement.,2.  Adenoidectomy.,ANESTHESIA:  ,General endotracheal.,DESCRIPTION OF PROCEDURE:  ,The patient was taken to the operating room, prepped and draped in the usual fashion.  After induction of general endotracheal anesthesia, the McIvor mouth gag was placed in the oral cavity and a tongue depressor applied.  Two #12-French red rubber Robinson catheters were placed, 1 in each nasal passage, and brought out through the oral cavity and clamped over a dental gauze roll placed on the upper lip to provide soft palate retraction.,Attention was directed to the nasopharynx.  With the Bovie set at 50 coag and the suction Bovie tip on the suction hose, the adenoid bed was fulgurated by beginning at the posterosuperior aspect of the nasopharynx at the apex of the choana placing the tip of the suction cautery deep at the root of the adenoids next to the roof of the nasopharynx and then in a linear fashion making serial passages through the base of the adenoid fossa in parallel lines until the entire nasopharynx and adenoid bed had been fulgurated moving from posterior to anterior.  The McIvor was relaxed and attention was then directed to the ears.,The left external auditory canal was examined under the operating microscope and cleaned of ceruminous debris.,An anteroinferior quadrant tympanostomy incision was made.  Fluid was suctioned from the middle ear space, and a tympanostomy tube was placed at the level of the incision and pushed into position with the Rosen needle.  Cortisporin ear drops were instilled into the canal, and a cotton ball was placed in the external meatus.,By a similar procedure, the opposite tympanostomy and tube placement were accomplished.,The patient tolerated the procedure well and left the operating room in good condition.","surgery, robinson catheters, palate, tongue, tympanostomy, adenoidectomy, chronic otitis media, oral cavity, adenotonsillar hypertrophy, tube placement, hypertrophy, nasopharynx, adenotonsillar,"
" Transurethral resection of the bladder tumor (TURBT), large.", Surgery, TURBT - 1 ,"PREOPERATIVE DIAGNOSIS:  ,Bladder cancer.,POSTOPERATIVE DIAGNOSIS: , Bladder cancer.,OPERATION:  ,Transurethral resection of the bladder tumor (TURBT), large.,ANESTHESIA:,  General endotracheal.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY: , The patient is an 82-year-old male who presented to the hospital with renal insufficiency, syncopal episodes.  The patient was stabilized from cardiac standpoint on a renal ultrasound.  The patient was found to have a bladder mass.  The patient does have a history of bladder cancer.  Options were watchful waiting, resection of the bladder tumor were discussed.  Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE were discussed.  The patient understood all the risks, benefits, and options and wanted to proceed with the procedure.,DETAILS OF THE OR:  ,The patient was brought to the OR, anesthesia was applied.  The patient was placed in dorsal lithotomy position.  The patient was prepped and draped in the usual sterile fashion.  A 23-French scope was inserted inside the urethra into the bladder.  The entire bladder was visualized, which appeared to have a large tumor, lateral to the right ureteral opening.,There was a significant papillary superficial fluffiness around the left ________.  There was a periureteral diverticulum, lateral to the left ureteral opening.  There were moderate trabeculations throughout the bladder.  There were no stones.  Using a French cone tip catheter, bilateral pyelograms were obtained, which appeared normal.  Subsequently, using 24-French cutting loop resectoscope a resection of the bladder tumor was performed all the way up to the base.  Deep biopsies were sent separately.  Coagulation was performed around the periphery and at the base of the tumor.  All the tumors were removed and sent for path analysis.  There was an excellent hemostasis.  The rest of the bladder appeared normal.  There was no further evidence of tumor.  At the end of the procedure, a 22 three-way catheter was placed, and the patient was brought to the recovery in a stable condition.","surgery, transurethral resection of the bladder tumor, transurethral resection, bladder cancer, bladder tumor, bladder, turbt, insufficiency, tumor"
" Decompression of the ulnar nerve, left elbow.  Left cubital tunnel syndrome and ulnar nerve entrapment.", Surgery, Ulnar Nerve Decompression ,"PREOPERATIVE DIAGNOSES: , Left cubital tunnel syndrome and ulnar nerve entrapment.,POSTOPERATIVE DIAGNOSES: , Left cubital tunnel syndrome and ulnar nerve entrapment.,PROCEDURE PERFORMED: , Decompression of the ulnar nerve, left elbow.,ANESTHESIA: , General.,FINDINGS OF THE OPERATION:,  The ulnar nerve appeared to be significantly constricted as it passed through the cubital tunnel.  There was presence of hourglass constriction of the ulnar nerve.,PROCEDURE: , The patient was brought to the operating room and once an adequate general anesthesia was achieved, his left upper extremity was prepped and draped in standard sterile fashion.  A sterile tourniquet was positioned and tourniquet was inflated at 250 mmHg.  Perioperative antibiotics were infused.  Time-out procedure was called.  The medial epicondyle and the olecranon tip were well palpated.  The incision was initiated at equidistant between the olecranon and the medial epicondyle extending 3-4 cm proximally and 6-8 cm distally.  The ulnar nerve was identified proximally.  It was mobilized with a blunt and a sharp dissection proximally to the arcade of Struthers, which was released sharply.  The roof of the cubital tunnel was then incised and the nerve was mobilized distally to its motor branches.  The ulnar nerve was well-isolated before it entered the cubital tunnel.  The arch of the FCU was well defined.  The fascia was elevated from the nerve and both the FCU fascia and the Osborne fascia were divided protecting the nerve under direct visualization.  Distally, the dissection was carried between the 2 heads of the FCU.  Decompression of the nerve was performed between the heads of the FCU.  The muscular branches were well protected.  Similarly, the cutaneous branches in the arm and forearm were well protected.  The venous plexus proximally and distally were well protected.  The nerve was well mobilized from the cubital tunnel preserving the small longitudinal vessels accompanying it.  Proximally, multiple vascular leashes were defined near the incision of the septum into the medial epicondyle, which were also protected.  Once the in situ decompression of the ulnar nerve was performed proximally and distally, the elbow was flexed and extended.  There was no evidence of any subluxation.  Satisfactory decompression was performed.  Tourniquet was released.  Hemostasis was achieved.  Subcutaneous layer was closed with 2-0 Vicryl and skin was approximated with staples.  A well-padded dressing was applied.  The patient was then extubated and transferred to the recovery room in stable condition.  There were no intraoperative complications noted.  The patient tolerated the procedure very well.","surgery, ulnar nerve entrapment, ulnar nerve, ulnar nerve decompression, cubital tunnel syndrome, ulnar, nerve, fascia, decompression, cubital, tunnel"
 Transurethral electrosurgical resection of the prostate for benign prostatic hyperplasia., Surgery, TURP ,"PREOPERATIVE DIAGNOSIS:,  Benign prostatic hyperplasia.,POSTOPERATIVE DIAGNOSIS:,  Benign prostatic hyperplasia.,OPERATION PERFORMED: , Transurethral electrosurgical resection of the prostate.,ANESTHESIA: , General.,COMPLICATIONS:,  None.,INDICATIONS FOR THE SURGERY:,  This is a 77-year-old man with severe benign prostatic hyperplasia.  He has had problem with urinary retention and bladder stones in the past.  He will need to have transurethral resection of prostate to alleviate the above-mentioned problems.  Potential complications include, but are not limited to:,1.  Infection.,2.  Bleeding.,3.  Incontinence.,4.  Impotence.,5.  Formation of urethral strictures.,PROCEDURE IN DETAIL: , The patient was identified, after which he was taken into the operating room.  General LMA anesthesia was then administered.  The patient was given prophylactic antibiotic in the preoperative holding area.  The patient was then positioned, prepped and draped.  Cystoscopy was then performed by using a #26-French continuous flow resectoscopic sheath and a visual obturator.  The prostatic urethra appeared to be moderately hypertrophied due to the lateral lobes and a large median lobe.  The anterior urethra was normal without strictures or lesions.  The bladder was severely trabeculated with multiple bladder diverticula.  There is a very bladder diverticula located in the right posterior bladder wall just proximal to the trigone.  Using the ***** resection apparatus and a right angle resection loop, the prostate was resected initially at the area of the median lobe.  Once the median lobe has completely resected, the left lateral lobe and then the right lateral lobes were taken down.  Once an adequate channel had been achieved, the prostatic specimen was retrieved from the bladder by using an Ellik evacuator.  A 3-mm bar electrode was then introduced into the prostate to achieve perfect hemostasis.  The sheath was then removed under direct vision and a #24-French Foley catheter was then inserted atraumatically with pinkish irrigation fluid obtained.  The patient tolerated the operation well.","surgery, benign prostatic hyperplasia, cystoscopy, foley catheter, turp, transurethral, bladder, bladder diverticula, electrosurgical, obturator, prostate, resectoscopic, transurethral resection, urinary retention, resection of the prostate, transurethral electrosurgical resection, anesthesia, hyperplasia, resection, prostatic"
 Tube Shunt  - Ahmed valve model S2 implant with pericardial reinforcement - Sample/Template., Surgery, Tube Shunt - Ahmed Valve Implant ,"PREOPERATIVE DIAGNOSIS: ,Open angle glaucoma OX,POSTOPERATIVE DIAGNOSIS:, Open angle glaucoma OX,PROCEDURE:, Ahmed valve model S2 implant with pericardial reinforcement XXX eye,INDICATIONS: ,This is a XX-year-old (wo)man with glaucoma in the OX eye, uncontrolled by maximum tolerated medical therapy.,PROCEDURE: ,The risks and benefits of glaucoma surgery were discussed at length with the patient including bleeding, infection, reoperation, retinal detachment, diplopia, ptosis, loss of vision, and loss of the eye, corneal hemorrhage, hypotony, elevated pressure, worsening of glaucoma, and corneal edema. Informed consent was obtained. Patient received several sets of drops in his/her XXX eye including Ocuflox and Ocular. (S)He was taken to the operating room where monitored anesthetic care was initiated. Retrobulbar anesthesia was then administered to the XXX eye using a 50:50 mixture of 2% plain lidocaine and 0.05% Marcaine. The XXX eye was then prepped and draped in the usual sterile ophthalmic fashion. A speculum was placed on the eyelids and microscope was brought into position. A #7-0 Vicryl suture was passed through the superotemporal limbus and traction suture was placed at the superotemporal limbus and the eye was rotated infranasally so as to expose the superotemporal conjunctiva. At this point, smooth forceps and Westcott scissors were used to create a 100-degree superotemporal conjunctival peritomy, approximately 2 mm posterior to the superotemporal limbus. This was then dissected anteriorly to the limbus edge and then posteriorly. Steven scissors were then dissected in a superotemporal quadrant between the superior and lateral rectus muscles to provide good exposure. At this point, we primed the Ahmed valve with a #27 gauge cannula using BSS and it was noted to be patent. We then placed Ahmed valve in the superotemporal subconjunctival recess underneath the subtenon space and this was pushed posteriorly. We then measured with calipers so that it was positioned 9 mm posterior to the limbus. The Ahmed valve was then tacked down with #8-0 nylon suture through both fenestrations. We then applied light cautery to the superotemporal episcleral bed. We placed a paracentesis at the temporal position and inflated the anterior chamber with a small amount of Healon. We then used a #23 gauge needle and entered the superotemporal sclera, approximately 1 mm posterior to the limbus into the anterior chamber away from iris and away from cornea. We then trimmed the tube, beveled up in a 30 degree fashion with Vannas scissors, and introduced the tube through the #23 gauge tract into the anterior chamber so that approximately 2-3 mm of tube was extending into the anterior chamber. We burped some of the Healon out of the anterior chamber and filled it with BSS and we felt that the tube was in good position away from the lens, away from the cornea, and away from the iris. We then tacked down the tubes to the sclera with #8-0 Vicryl suture in a figure-of- eight fashion. The pericardium was soaked in gentamicin. We then folded the pericardium 1x1 cm piece onto itself and then placed it over the tube and this was tacked down in all four quadrants to the sclera with #8-0 nylon suture. At this point, we then re-approximated the conjunctiva to its original position and we closed it with an #8-0 Vicryl suture on a TG needle in a running fashion with interrupted locking bites. We then removed the traction suture. At the end of the case, the pupil was round, the chamber was deep, the tube appeared to be well positioned. The remaining portion of the Healon was burped out of the anterior chamber with BSS and the pressure was felt to be adequate. The speculum was removed. Ocuflox and Maxitrol ointment were placed over the eye. Then, an eye patch and shield were placed over the eye. The patient was awakened and taken to the recovery room in stable condition.","surgery, tube shunt, ahmed valve, healon, maxitrol ointment, ocuflox, open angle, anterior chamber, bleeding, conjunctival peritomy, cornea, corneal edema, corneal hemorrhage, diplopia, elevated pressure, glaucoma, hypotony, infection, loss of the eye, loss of vision, ophthalmic fashion, ptosis, reoperation, retinal detachment, sclera, superotemporal, worsening of glaucoma, ahmed valve model, superotemporal limbus, eye, ahmed, implant, bss, valve, limbus, "
" Laparoscopic tubal sterilization, tubal coagulation.  ", Surgery, Tubal Sterilization & Coagulation ,"PROCEDURE:  ,Laparoscopic tubal sterilization, tubal coagulation.,PREOPERATIVE DIAGNOSIS: , Request tubal coagulation.,POSTOPERATIVE DIAGNOSIS: , Request tubal coagulation.,PROCEDURE:  ,Under general anesthesia, the patient was prepped and draped in the usual manner.  Manipulating probe placed on the cervix, changed gloves.  Small cervical stab incision was made, Veress needle was inserted without problem.  A 3 L of carbon dioxide was insufflated.  The incision was enlarged.  A 5-mm trocar placed through the incision without problem.  Laparoscope placed through the trocar.  Pelvic contents visualized.  A 2nd puncture was made 2 fingerbreadths above the symphysis pubis in the midline.  Under direct vision, the trocar was placed in the abdominal cavity.  Uterus, tubes, and ovaries were all normal.  There were no pelvic adhesions, no evidence of endometriosis.  Uterus was anteverted and the right adnexa was placed on a stretch.  The tube was grasped 1 cm from the cornual region, care being taken to have the bipolar forceps completely across the tube and the tube was coagulated using amp meter for total desiccation.  The tube was grasped again and the procedure was repeated for a separate coagulation, so that 1.5 cm of the tube was coagulated.  The structure was confirmed to be tube by looking at fimbriated end.  The left adnexa was then placed on a stretch and the procedure was repeated again grasping the tube 1 cm from the cornual region and coagulating it.  Under traction, the amp meter was grasped 3 more times so that a total of 1.5 cm of tube was coagulated again.  Tube was confirmed by fimbriated end.  Gas was lend out of the abdomen.  Both punctures repaired with 4-0 Vicryl and punctures were injected with 0.5% Marcaine 10 mL.  The patient went to the recovery room in good condition.","surgery, cervix, cervical stab incision, laparoscopic tubal sterilization, tubal sterilization, tubal coagulation, sterilization, laparoscopic, endometriosis"
" Right ulnar nerve transposition, right carpal tunnel release, and right excision of olecranon bursa.  Right cubital tunnel syndrom, carpal tunnel syndrome, and olecranon bursitis.", Surgery, Ulnar Nerve Transposition & Olecranon Bursa Excision ,"PREOPERATIVE DIAGNOSIS:  ,1.  Right cubital tunnel syndrome.,2.  Right carpal tunnel syndrome.,3.  Right olecranon bursitis.,POSTOPERATIVE DIAGNOSIS:,  ,1.  Right cubital tunnel syndrome.,2.  Right carpal tunnel syndrome.,3.  Right olecranon bursitis.,PROCEDURES:,  ,1.  Right ulnar nerve transposition.,2.  Right carpal tunnel release.,3.  Right excision of olecranon bursa.,ANESTHESIA:,  General.,BLOOD LOSS:,  Minimal.,COMPLICATIONS:,  None.,FINDINGS: , Thickened transverse carpal ligament and partially subluxed ulnar nerve.,SUMMARY: , After informed consent was obtained and verified, the patient was brought to the operating room and placed supine on the operating table.  After uneventful general anesthesia was obtained, his right arm was sterilely prepped and draped in normal fashion.  After elevation and exsanguination with an Esmarch, the tourniquet was inflated.  The carpal tunnel was performed first with longitudinal incision in the palm carried down through the skin and subcutaneous tissues.  The palmar fascia was divided exposing the transverse carpal ligament, which was incised longitudinally.  A Freer was then inserted beneath the ligament, and dissection was carried out proximally and distally.,After adequate release has been formed, the wound was irrigated and closed with nylon.  The medial approach to the elbow was then performed and the skin was opened and subcutaneous tissues were dissected.  A medial antebrachial cutaneous nerve was identified and protected throughout the case.  The ulnar nerve was noted to be subluxing over the superior aspect of the medial epicondyle and flattened and inflamed.  The ulnar nerve was freed proximally and distally.  The medial intramuscular septum was excised and the flexor carpi ulnaris fascia was divided.  The intraarticular branch and the first branch to the SCU were transected; and then the nerve was transposed, it did not appear to have any significant tension or sharp turns.  The fascial sling was made from the medial epicondyle and sewn to the subcutaneous tissues and the nerve had good translation with flexion and extension of the elbow and not too tight.  The wound was irrigated.  The tourniquet was deflated and the wound had excellent hemostasis.  The subcutaneous tissues were closed with #2-0 Vicryl and the skin was closed with staples.  Prior to the tourniquet being deflated, the subcutaneous dissection was carried out over to the olecranon bursa, where the loose fragments were excised with a rongeurs as well as abrading the ulnar cortex and excision of hypertrophic bursa.  A posterior splint was applied.  Marcaine was injected into the incisions and the splint was reinforced with tape.  He was awakened from the anesthesia and taken to recovery room in a stable condition.  Final needle, instrument, and sponge counts were correct.","surgery, cubital tunnel syndrome, carpal tunnel syndrome, olecranon bursitis, ulnar nerve transposition, carpal tunnel release, excision of olecranon bursa, transposition, ligament, tourniquet, excision, bursa, syndrome, subcutaneous, ulnar, olecranon, carpal, nerve, tunnel, "
" Left canal wall down tympanomastoidectomy with ossicular chain reconstruction, microdissection, NIM facial nerve monitoring for three hours.", Surgery, Tympanomastoidectomy ,"PREOPERATIVE DIAGNOSIS: , Left canal cholesteatoma.,POSTOPERATIVE DIAGNOSIS: , Left canal cholesteatoma.,OPERATIVE PROCEDURE:,1.  Left canal wall down tympanomastoidectomy with ossicular chain reconstruction.,2.  Microdissection.,3.  NIM facial nerve monitoring for three hours.,COMPLICATIONS:  ,None.,FINDINGS:,  There is an extremely large canal cholesteatoma, which eroded most of the posterior and superior canal wall.  There was a significant amount of myringosclerosis and tympanosclerosis.  There is some mild erosion of the lenticular process of the incus.  The facial nerve was normal.  We removed the incus, removed the head of the malleus, and placed a titanium-PORP from the stapes capitulum to a cartilage graft.,PROCEDURE: , The patient was taken to the operating room, placed under general anesthetic and intubated without difficulty.  The NIM facial nerve monitoring electrodes were positioned and monitoring was performed throughout the procedure.  There was no abnormal activity during this case.  We inspected the ear canal, identified the huge defect, which was completely filled with cerumen.  Through the ear canal, we removed as much as we could and then infiltrated the canal and postauricular area with 1:100,000 of epinephrine.,We prepped and draped the ear in a sterile fashion.  We reopened the previously used postauricular incision and dissected down the mastoid cortex.  We reflected the soft tissues anteriorly to the level of the ear canal and identified where the ear canal skin entered the defect in the mastoid bone.  A #6 cutting bur was used to drill down the mastoid cortex and identified this cholesteatoma which was then carefully dissected out.  We went all the way to the mastoid antrum.  We finished a complete mastoidectomy with identification of the tegmen, sigmoid sinus.  We removed the lateral aspect of the mastoid tip.  We lowered the facial ridge.  The incudostapedial joint was already membranous in nature, we went ahead and used the joint knife and removed the incus.  We separated the incus from the stapes and then removed it.  We used a malleus head nipper to remove the head of the malleus and then we continued to saucerize the entire mastoid cavity.,There was no cholesteatoma within the middle ear space, but there was roughly 40% surface area perforation.  The remaining portion of the tympanic membrane was extremely calcified and myringosclerotic; this was removed.  There was also a large focus of tympanosclerosis between the stapes crura, which was impinging the ability of the stapes to move.  We carefully dissected this out.  This did seem to improve the mobility of the stapes somewhat.  At this point, there was a near total perforation.  There was only a minimal amount of anterior remnant of the drum left.  We tried to go ahead and harvest the temporalis fascia, but there was really only wisps of this fascia in place.  He had already had a previous tympanoplasty, but even outside the areas where the graft was taken, the temporalis muscle was quite atrophied and lumpy, and I suspect this was due to his chronic disease and long history of corticosteroid usage.  We harvested a few pieces as best as we could.  We went ahead and did a meatoplasty by making a canal incision in the 6 o'clock and 12 o'clock positions.  We excised cartilage posteriorly and inferiorly to enlarge the meatus.  This cartilage was thin and used for cartilage tympanoplasty.  We placed some Gelfoam in the middle ear space and placed the cartilage on the top of it.  We did cut a titanium-PORP of the proper side and placed on top of the stapes capitulum to interface with the cartilage cap.  A few other small pieces of temporalis fascia were used to bulge through the surrounding edges of the cartilage and make sure that it was medial to any remnant of ear canal and tympanic membrane remnants.  We placed a layer of Gelfoam lateral to the graft, closed the postauricular incision in layers and put 2 Merocel packs in the ear.  Glasscock dressing was applied.  The patient was awakened from anesthesia and taken to the recovery room in stable condition.  He will be given antibiotics and pain medicines and he will be given instructions to follow up with me in one week.","surgery, cholesteatoma, gelfoam, glasscock dressing, microdissection, nim, canal, canal wall, cerumen, facial nerve, incus, myringosclerosis, ossicular chain reconstruction, titanium-porp, tympanomastoidectomy, tympanosclerosis, facial nerve monitoring, ear canal, cartilage, ear,"
" Desires permanent sterilization.  Laparoscopic tubal ligation, Falope ring method.  Normal appearing uterus and adnexa bilaterally.", Surgery, Tubal Ligation - Laparoscopic ,"PREOPERATIVE DIAGNOSIS:,  Desires permanent sterilization.,POSTOPERATIVE DIAGNOSIS: , Desires permanent sterilization.,PROCEDURE: , Laparoscopic tubal ligation, Falope ring method.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , 10 mL.,COMPLICATIONS: , None.,INDICATIONS FOR SURGERY:  ,A 35-year-old female, P4-0-0-4, who desires permanent sterilization.  The risks of bleeding, infection, damage to other organs, and subsequent ectopic pregnancy was explained.  Informed consent was obtained.,OPERATIVE FINDINGS: , Normal appearing uterus and adnexa bilaterally.,DESCRIPTION OF PROCEDURE: , After administration of general anesthesia, the patient was placed in the dorsal lithotomy position, and prepped and draped in the usual sterile fashion.  The speculum was placed in the vagina, the cervix was grasped with the tenaculum, and a uterine manipulator inserted.  This area was then draped off the remainder of the operative field.,A 5-mm incision was made umbilically after injecting 0.25% Marcaine, 2 mL.  A Veress needle was inserted to confirm an opening pressure of 2 mmHg.  Approximately 4 liters of CO2 gas was insufflated into the abdominal cavity.  The Veress needle was removed, and a 5-mm port placed.  Position was confirmed using a laparoscope.  A second port was placed under direct visualization, 3 fingerbreadths suprapubically, 7 mm in diameter, after 2 mL of 0.25% Marcaine was injected.  This was done under direct visualization.  The pelvic cavity was examined with the findings as noted above.  The Falope rings were then applied to each tube bilaterally.  Good segments were noted to be ligated.  The accessory port was removed.  The abdomen was deflated.  The laparoscope and sheath was removed.  The skin edges were approximated with 5-0 Monocryl suture in subcuticular fashion.  The instruments were removed from the vagina.  The patient was returned to the supine position, recalled from anesthesia, and transferred to the recovery room in satisfactory condition.  Sponge and needle counts correct at the conclusion of the case.  Estimated blood loss was minimal.","surgery, tenaculum, uterine manipulator, veress needle, tubal ligation, permanent sterilization, uterus, adnexa, cavity, laparoscope, laparoscopic, needle, sterilization"
" Cystoscopy, transurethral resection of medium bladder tumor (4.0 cm in diameter), and direct bladder biopsy.", Surgery, TURBT ,"PREOPERATIVE DIAGNOSIS:  ,Clinical stage Ta Nx Mx transitional cell carcinoma of the urinary bladder.,POSTOPERATIVE DIAGNOSIS: , Clinical stage Ta Nx Mx transitional cell carcinoma of the urinary bladder.,TITLE OF OPERATION: , Cystoscopy, transurethral resection of medium bladder tumor (4.0 cm in diameter), and direct bladder biopsy.,ANESTHESIA: , General laryngeal mask.,INDICATIONS: , This patient is a 59-year-old white male, who had an initial occurrence of a transitional cell carcinoma 5 years back.  He was found to have a new tumor last fall, and cystoscopy in November showed Ta papillary-appearing lesion inside the bladder neck anteriorly.  The patient had coronary artery disease and required revascularization, which occurred at the end of December prior to the tumor resection.  He is fully recovered and cleared by Cardiology and taken to the operating room at this time for TURBT.,FINDINGS: , Cystoscopy of the anterior and posterior urethra was within normal limits.  From 12 o'clock to 4 o'clock inside the bladder neck, there was a papillary tumor with some associated blood clot.  This was completely resected.  There was an abnormal dysplastic area in the left lateral wall that was biopsied, and the remainder of the bladder mucosa appeared normal.  The ureteral orifices were in the orthotopic location.  Prostate was 15 g and benign on rectal examination, and there was no induration of the bladder.,PROCEDURE IN DETAIL: , The patient was brought to the cystoscopy suite, and after adequate general laryngeal mask anesthesia obtained, placed in the dorsal lithotomy position and his perineum and genitalia were sterilely prepped and draped in usual fashion.  He had been given oral ciprofloxacin for prophylaxis.  Rectal bimanual examination was performed with the findings described.  Cystourethroscopy was performed with a #23-French ACMI panendoscope and 70-degree lens with the findings described.  A barbotage urine was obtained for cytology.  The cystoscope was removed and a #24-French continuous flow resectoscope sheath was introduced over visual obturator and cold cup biopsy forceps introduced.  Several biopsies were taken from the tumor and sent to the tumor bank.  I then introduced the Iglesias resectoscope element and resected all the exophytic tumor and the lamina propria.  Because of the Ta appearance, I did not intentionally dissect deeper into the muscle.  Complete hemostasis was obtained.  All the chips were removed with an Ellik evacuator.  Using the cold cup biopsy forceps, biopsy was taken from the dysplastic area in the left bladder and hemostasis achieved.  The irrigant was clear.  At the conclusion of the procedure, the resectoscope was removed and a #24-French Foley catheter was placed for efflux of clear irrigant.  The patient was then returned to the supine position, awakened, extubated, and taken on a stretcher to the recovery room in satisfactory condition.","surgery, transitional cell carcinoma, urinary bladder, bladder tumor, cystoscopy, transurethral resection, acmi panendoscope, foley catheter, cold cup biopsy forceps, ta nx mx, cold cup biopsy, laryngeal mask, bladder neck, bladder, biopsy, tumor,"
" True cut needle biopsy of the breast.  This 65-year-old female on exam was noted to have dimpling and puckering of the skin associated with nipple discharge.  On exam, she has a noticeable carcinoma of the left breast with dimpling, puckering, and erosion through the skin.", Surgery, True Cut Needle Biopsy - Breast ,"PREOPERATIVE DIAGNOSIS:,  Carcinoma of the left breast.,POSTOPERATIVE DIAGNOSIS:,  Carcinoma of the left breast.,PROCEDURE PERFORMED: , True cut needle biopsy of the breast.,GROSS FINDINGS:  ,This 65-year-old female on exam was noted to have dimpling and puckering of the skin associated with nipple discharge.  On exam, she has a noticeable carcinoma of the left breast with dimpling, puckering, and erosion through the skin.  At this time, a true cut needle biopsy was performed.,PROCEDURE: , The patient was taken to operating room, is laid in the supine position, sterilely prepped and draped in the usual fashion.  The area over the left breast was infiltrated with 1:1 mixture of 0.25% Marcaine and 1% Xylocaine.  Using a #18 gauge automatic true cut needle core biopsy, five biopsies were taken of the left breast in core fashion.  Hemostasis was controlled with pressure.  The patient tolerated the procedure well, pending the results of biopsy.","surgery, carcinoma, true cut needle biopsy, nipple, discharge, dimpling, puckering, breast, "
 Nerve root decompression at L45 on the left side.  Tun-L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left.  Interpretation of radiograph., Surgery, Tun-L Catheter Placement ,"PREOPERATIVE DIAGNOSIS:,  Low Back Syndrome - Low back pain with left greater than right lower extremity radiculopathy.,POSTOPERATIVE DIAGNOSIS:,  Same.,PROCEDURE:,1.  Nerve root decompression at L45 on the left side.,2.  Tun-L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left.,3.  Interpretation of radiograph.,ANESTHESIA: , IV sedation with Versed and Fentanyl.,ESTIMATED BLOOD LOSS:,  None.,COMPLICATIONS:,  None.,INDICATION FOR PROCEDURE: , Severe and excruciating pain in the lumbar spine and lower extremity.  MRI shows disc pathology as well as facet arthrosis.,SUMMARY OF PROCEDURE: , The patient was admitted to the operating room, consent was obtained and signed.  The patient was taken to the Operating room and was placed in the prone position.  Monitors were placed, including EKG, pulse oximeter and blood pressure monitoring.  After adequate IV sedation with Versed and Fentanyl the procedure was begun.,The lumbar sacral region was prepped and draped in sterile fashion with Betadine and four sterile towels.  After the towels were places then sterile drapes were placed on top of that.,After which time the Epimed catheter was then placed, this was done by first repositioning the C-Arm to visualize the lumbar spine and the vertebral bodies were then counted beginning at L5, verifying the sacral hiatus.  The skin over the sacral hiatus was then injected with 1% Lidocaine and an #18-gauge needle was used for skin puncture.  The #18-gauge needle was inserted off of midline.  A #16-gauge RK needle was then placed into the skin puncture and using the paramedian approach and loss-of-resistance technique the needle was placed.  Negative aspiration was carefully performed.  Omnipaque 240 dye was then injected through the #16-gauge RK needle.  The classical run off was noted.  A filling defect was noted @ L45 nerve root on the left side.  After which time 10 cc of 0.25% Marcaine/Triamcinolone (9/1 mixture) was then infused through the 16 R-K Needle.  Some additional lyses of adhesions were visualized as the local anesthetic displaced the Omnipaque 240 dye using this barbotage technique.,An Epimed Tun-L catheter was then inserted through the #16-gauage R-K needle and threaded up to the L45 interspace under continuous fluoroscopic guidance.  As the catheter was threaded up under continuous fluoroscopic visualization lyses of adhesions were visualized.  The tip of the catheter was noted to be @ L45 level on the left side.  After this the #16-gauge RK needle was then removed under fluoroscopic guidance verifying that the tip of the catheter did not migrate from the L45 nerve root region on the left side.  After this was successfully done, the catheter was then secured in place; this was done with Neosporin ointment, a Split 2x2, Op site and Hypofix tape.  The catheter was then checked with negative aspiration and the Omnipaque 240 dye was then injected.  The classical run off was noted in the lumbar region.  Some lyses of adhesions were also visualized at this time with barbotage technique.  Good dye spread was noted to extend one level above and one level below the L45 nerve root and bilateral spread was noted.  Nerve root decompression was visualized as dye spread into the nerve root whereas prior this was a filling defect.  After which time negative aspiration was again performed through the Epimed® Tun-L catheter and then 10 cc of solution was then infused through the catheter, this was done over a 10-minute period with initial 3 cc test dose.  Approximately 3 minutes elapsed and then the remaining 7 cc were infused (Solution consisting of 8 cc of 0.25% Marcaine, 2 cc of Triamcinolone and 1 cc of Wydase.)  The catheter was then capped with a bacterial filter.  The patient was noted to have tolerated the procedure well without any complications.,Interpretation of radiograph revealed nerve root adhesions present with lysis of these adhesions as the procedure was performed.  A filling defect was seen at the L45 nerve root and this filling defect being significant of fibrosis and adhesions in this region was noted to be lysed with the insertion of the catheter as well as the barbotage procedure.  This verified positive nerve root decompression.  The tip of the Epimed Tun L catheter was noted to be at L45 level on the left side.  Positive myelogram without dural puncture was noted during this procedure; no sub-dural spread of Omnipaque 240 dye was noted.  This patient did not report any problems and reported pain reduction.","surgery, low back syndrome, low back pain, nerve root decompression, steroid solution, c-arm, epimed, tun l catheter, nerve root, negative aspiration, omnipaque dye, filling defect, nerve, root, catheter, adhesions, injection, needle,"
 Postpartum tubal ligation and removal of upper abdominal skin wall mass., Surgery, Tubal Ligation - Postpartum ,"PREOPERATIVE DIAGNOSES:,  Multiparity requested sterilization and upper abdominal wall skin mass., ,POSTOPERATIVE DIAGNOSES:  ,Multiparity requested sterilization and upper abdominal wall skin mass.,OPERATION PERFORMED: , Postpartum tubal ligation and removal of upper abdominal skin wall mass.,ESTIMATED BLOOD LOSS:,  Less than 5 mL.,DRAINS: , None.,ANESTHESIA: , Spinal.,INDICATION: , This is a 35-year-old white female gravida 6, para 3, 0-3-3 who is status post delivery on 09/18/2007.  The patient was requesting postpartum tubal ligation and removal of a large mole at the junction of her abdomen and left lower rib cage at the skin level.,PROCEDURE IN DETAIL:,  The patient was taken to the operating room, placed in a seated position with spinal form of anesthesia administered by anesthesia department.  The patient was then repositioned in a supine position and then prepped and draped in the usual fashion for postpartum tubal ligation.  Subumbilical ridge was created using two Ellis and first knife was used to make a transverse incision.  The Ellis were removed and used to be grasped incisional edges and both blunt and sharp dissection down to the level of the fascia was then completed.  The fascia grasped with two Kocher's and then sharply incised and then peritoneum was entered with use of blunt dissection.  Two Army-Navy retractors were put in place and a vein retractor was used to grasp the left fallopian tube and then regrasped with Babcock's and followed to the fimbriated end.  A modified Pomeroy technique was completed with double tying of with 0 chromic, then upper portion was sharply incised and the cut fallopian tube edges were then cauterized.  Adequate hemostasis was noted.  This tube was placed back in its anatomic position.  The right fallopian tube was grasped followed to its fimbriated end and then regrasped with a Babcock and a modified Pomeroy technique was also completed on the right side, and upper portion was then sharply incised and the cut edges re-cauterized with adequate hemostasis and this was placed back in its anatomic position.  The peritoneum as well as fascia was reapproximated with 0-Vicryl.  The subcutaneous tissues reapproximated with 3-0 Vicryl and skin edges reapproximated with 4-0 Vicryl as well in a subcuticular stitch.  Pressure dressings were applied.  Marcaine 10 mL was used prior to making an incision.  Sterile dressing was applied.  The large mole-like lesion was grasped with Allis.  It was approximately 1 cm x 0.5 cm in size and an elliptical incision was made around the mass and cut edges were cauterized and 4-0 Vicryl was used to reapproximate the skin edges and pressure dressing was also applied.  Instrument count, needle count, and sponge counts were all correct, and the patient was taken to recovery room in stable condition.","surgery, sterilization, fallopian tube, tubal ligation, postpartum"
 Laparoscopic tubal fulguration., Surgery, Tubal Fulguration - Laparoscopic  ,"A 1 cm infraumbilical skin incision was made.  Through this a Veress needle was inserted into the abdominal cavity.  The abdomen was filled with approximately 2 liters of CO2 gas.  The Veress needle was withdrawn.  A trocar sleeve was placed through the incision into the abdominal cavity.  The trocar was withdrawn and replaced with the laparoscope.  A 1 cm suprapubic skin incision was made.  Through this a second trocar sleeve was placed into the abdominal cavity using direct observation with the laparoscope.  The trocar was withdrawn and replaced with a probe.,The patient was placed in Trendelenburg position, and the bowel was pushed out of the pelvis.  Upon visualization of the pelvis organs, the uterus, fallopian tubes and ovaries were all normal.  The probe was withdrawn and replaced with the bipolar cautery instrument.  The right fallopian tube was grasped approximately 1 cm distal to the cornual region of the uterus.  Electrical current was applied to the tube at this point and fulgurated.  The tube was then regrasped just distal to this and refulgurated.  It was then regrasped just distal to the lateral point and refulgurated again.  The same procedure was then carried out on the opposite tube.  The bipolar cautery instrument was withdrawn and replaced with the probe.  The fallopian tubes were again traced to their fimbriated ends to confirm the burn points on the tubes.  The upper abdomen was visualized, and the liver surface was normal.  The gas was allowed to escape from the abdomen, and the instruments were removed.  The skin incisions were repaired.  The instruments were removed from the vagina.,There were no complications to the procedure.  Blood loss was minimal.  The patient went to the postanesthesia recovery room in stable condition.","surgery, tubal fulguration, cohen cannula, laparoscopic, trendelenburg position, veress needle, abdominal cavity, bipolar cautery, dorsal lithotomy, fallopian tubes, fimbriated ends, fulgurated, laparoscope, uterus, distal, trocar, tubesNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Laparoscopic bilateral tubal ligation with Falope rings., Surgery, Tubal Ligation ,"DIAGNOSIS: , Multiparous female, desires permanent sterilization.,NAME OF OPERATION: , Laparoscopic bilateral tubal ligation with Falope rings.,ANESTHESIA: , General, ET tube.,COMPLICATIONS:,  None.,FINDINGS:  ,Normal female anatomy except for mild clitoromegaly and a posterior uterine fibroid.,PROCEDURE: , The patient was taken to the operating room and placed on the table in the supine position.  After adequate general anesthesia was obtained, she was placed in the lithotomy position and examined.  She was found to have an anteverted uterus and no adnexal mass.  She was prepped and draped in the usual fashion.  The Foley catheter was placed.  A Hulka cannula was inserted into the cervix and attached to the anterior lip of the cervix.,An infraumbilical incision was made with the knife.  A Veress needle was inserted into the abdomen.  Intraperitoneal location was verified with approximately 10 cc of sterile solution.  A pneumoperitoneum was created.  The Veress needle was then removed, and a trocar was inserted directly without difficulty.  Intraperitoneal location was verified visually with the laparoscope.  There was no evidence of any intra-abdominal trauma.,Each fallopian tube was elevated with a Falope ring applicator, and a Falope ring was placed on each tube with a 1-cm to 1.5-cm portion of the tube above the Falope ring.,The pneumoperitoneum was evacuated, and the trocar was removed under direct visualization.  An attempt was made to close the fascia with a figure-of-eight suture.  However, this was felt to be more subcutaneous.  The skin was closed in a subcuticular fashion, and the patient was taken to the recovery room awake with vital signs stable.","surgery, sterilization, laparoscopic bilateral tubal ligation with falope rings, falope ring applicator, laparoscopic bilateral tubal ligation, bilateral tubal ligation, veress needle, tubal ligation, falope rings, anesthesia, tubal, ligation, falope"
" Insertion of a triple-lumen central line through the right subclavian vein by the percutaneous technique.  This lady has a bowel obstruction.  She was being fed through a central line, which as per the patient was just put yesterday and this slipped out. ", Surgery, Ttriple-Lumen Central Line ,"PREOPERATIVE DIAGNOSES,1.  Bowel obstruction.,2.  Central line fell off.,POSTOPERATIVE DIAGNOSES,1.  Bowel obstruction.,2.  Central line fell off.,PROCEDURE: , Insertion of a triple-lumen central line through the right subclavian vein by the percutaneous technique.,PROCEDURE DETAIL: , This lady has a bowel obstruction.  She was being fed through a central line, which as per the patient was just put yesterday and this slipped out.  At the patient's bedside after obtaining an informed consent, the patient's right deltopectoral area was prepped and draped in the usual fashion.  Xylocaine 1% was infiltrated and with the patient in Trendelenburg position, she had her right subclavian vein percutaneously cannulated without any difficulty.  A Seldinger technique was used and a triple-lumen catheter was inserted.  There was a good flow through all three ports, which were irrigated with saline prior to connection to the IV solutions.,The catheter was affixed to the skin with sutures and then a dressing was applied.,The postprocedure chest x-ray revealed that there were no complications to the procedure and that the catheter was in good place.","surgery, central line, triple lumen central line, subclavian vein, bowel obstruction, lumen, percutaneous, bowel, obstruction"
" Trigger thumb release.  Right trigger thumb.  The A-1 pulley was divided along its radial border, completely freeing the stenosing tenosynovitis (trigger release). ", Surgery, Trigger Thumb Release - 1 ,"PREOPERATIVE DIAGNOSIS:  ,Right trigger thumb.,POSTOPERATIVE DIAGNOSIS:,  Right trigger thumb.,OPERATIONS PERFORMED:,  Trigger thumb release.,ANESTHESIA:,  Monitored anesthesia care with regional anesthesia applied by surgeon with local.,COMPLICATIONS:,","surgery, trigger thumb, trigger thumb release, tenosynovitis trigger, tenosynovitis, release, thumb, tourniquet, trigger,"
 Foraminal disc herniation of left L3-L4.  Enlarged dorsal root ganglia of the left L3 nerve root.  Transpedicular decompression of the left L3-L4 with discectomy., Surgery, Transpedicular Decompression ,"PREOPERATIVE DIAGNOSIS: , Foraminal disc herniation of left L3-L4.,POSTOPERATIVE DIAGNOSES:,1.  Foraminal disc herniation of left L3-L4.,2.  Enlarged dorsal root ganglia of the left L3 nerve root.,PROCEDURE PERFORMED:, Transpedicular decompression of the left L3-L4 with discectomy.,ANESTHESIA:,  General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,SPECIMEN: , None.,HISTORY: , This is a 55-year-old female with a four-month history of left thigh pain.  An MRI of the lumbar spine has demonstrated a mass in the left L3 foramen displacing the nerve root, which appears to be a foraminal disc herniation effacing the L3 nerve root.  Upon exploration of the nerve root, it appears that there was a small disc herniation in the foramen, but more impressive was the abnormal size of the dorsal root ganglia that was enlarged more medially than laterally.  There was no erosion into the bone surrounding the area rather in the pedicle above or below or into the vertebral body, so otherwise the surrounding anatomy is normal.  I was prepared to do a discectomy and had not consented the patient for a biopsy of the nerve root.  But because of the sequela of cutting into a nerve root with residual weakness and persistent pain that the patient would suffer, at this point I was not able to perform this biopsy without prior consent from the patient.  So, surgery ended decompressing the L3 foramen and providing a discectomy with idea that we will obtain contrasted MRIs in the near future and I will discuss the findings with the patient and make further recommendations.,OPERATIVE PROCEDURE: , The patient was taken to OR #5 at ABCD General Hospital in a gurney.  Department of Anesthesia administered general anesthetic.  Endotracheal intubation followed.  The patient received the Foley catheter.  She was then placed in a prone position on a Jackson table.  Bony prominences were well padded.  Localizing x-rays were obtained at this time and the back was prepped and draped in the usual sterile fashion.  A midline incision was made over the L3-L4 disc space taking through subcutaneous tissues sharply, dissection was then carried out to the left of the midline with lumbodorsal fascia incised and the musculature was elevated in a supraperiosteal fashion from the level of L3.  Retractors were placed into the wound to retract the musculature.  At this point, the pars interarticularis was identified and the facet joint of L2-L3 was identified.  A marker was placed over the pedicle of L3 and confirmed radiographically.  Next, a microscope was brought onto the field.  The remainder of the procedure was noted with microscopic visualization.  A high-speed drill was used to remove the small portions of the lateral aspects of the pars interarticularis.  At this point, soft tissue was removed with a Kerrison rongeur and the nerve root was clearly identified in the foramen.  As the disc space of L3-L4 is identified, there is a small prominence of the disc, but not as impressive as I would expect on the MRI.  A discectomy was performed at this time removing only small portions of the lateral aspect of the disc.  Next, the nerve root was clearly dissected out and visualized, the lateral aspect of the nerve root appears to be normal in structural appearance.  The medial aspect with the axilla of the nerve root appears to be enlarged.  The color of the tissue was consistent with a nerve root tissue.  There was no identifiable plane and this is a gentle enlargement of the nerve root.  There are no circumscribed lesions or masses that can easily be separated from the nerve root.  As I described in the initial paragraph, since I was not prepared to perform a biopsy on the nerve and the patient had not been consented, I do not think it is reasonable to take the patient to this procedure, because she will have persistent weakness and pain in the leg following this procedure.  So, at this point there is no further decompression.  A nerve fork was passed both ventral and dorsal to the nerve root and there was no compression for lateral.  The pedicle was palpated inferiorly and medially and there was no compression, as the nerve root can be easily moved medially.  The wound was then irrigated copiously and suctioned dry.  A concoction of Duramorph and ______ was then placed over the nerve root for pain control.  The retractors were removed at this point.  The fascia was reapproximated with #1 Vicryl sutures, subcutaneous tissues with #2 Vicryl sutures, and Steri-Strips covering the incision.  The patient transferred to the hospital gurney, extubated by Anesthesia, and subsequently transferred to Postanesthesia Care Unit in stable condition.","surgery, dorsal root ganglia, nerve root, discectomy, foraminal disc herniation, transpedicular decompression, lateral aspects, disc herniation, nerve, anesthesia, foraminal"
" Insertion of a right brachial artery arterial catheter and a right subclavian vein triple lumen catheter.  Hyperpyrexia/leukocytosis, ventilator-dependent respiratory failure, and acute pancreatitis.", Surgery, Triple Lumen Catheter Insertion ,"PREOPERATIVE DIAGNOSES:,1.  Hyperpyrexia/leukocytosis.,2.  Ventilator-dependent respiratory failure.,3.  Acute pancreatitis.,POSTOPERATIVE DIAGNOSES:,1.  Hyperpyrexia/leukocytosis.,2.  Ventilator-dependent respiratory failure.,3.  Acute pancreatitis.,PROCEDURE PERFORMED:,1.  Insertion of a right brachial artery arterial catheter.,2.  Insertion of a right subclavian vein triple lumen catheter.,ANESTHESIA: , Local, 1% lidocaine.,BLOOD LOSS:,  Less than 5 cc.,COMPLICATIONS: , None.,INDICATIONS: , The patient is a 46-year-old Caucasian female admitted with severe pancreatitis.  She was severely dehydrated and necessitated some fluid boluses.  The patient became hypotensive, required many fluid boluses, became very anasarcic and had difficulty with breathing and became hypoxic.  She required intubation and has been ventilator-dependent in the Intensive Care since that time.  The patient developed very high temperatures as well as leukocytosis.  Her lines required being changed.,PROCEDURE:,1.  RIGHT BRACHIAL ARTERIAL LINE:  ,The patient's right arm was prepped and draped in the usual sterile fashion.  There was a good brachial pulse palpated.  The artery was cannulated with the provided needle and the kit.  There was good arterial blood return noted immediately.  On the first stick, the Seldinger wire was inserted through the needle to cannulate the right brachial artery without difficulty.  The needle was removed and a catheter was inserted over the Seldinger wire to cannulate the brachial artery.  The femoral catheter was used in this case secondary to the patient's severe edema and anasarca.  We did not feel that the shorter catheter would provide enough length.  The catheter was connected to the system and flushed without difficulty.  A good waveform was noted.  The catheter was sutured into place with #3-0 silk suture and OpSite dressing was placed over this.,2.  RIGHT SUBCLAVIAN TRIPLE LUMEN CATHETER:  ,The patient was prepped and draped in the usual sterile fashion.  1% Xylocaine was used to anesthetize an area just inferior and lateral to the angle of the clavicle.  Using the anesthetic needle, we checked down to the soft tissues anesthetizing, as we proceeded to the angle of the clavicle, this was also anesthetized.  Next, a #18 gauge thin walled needle was used following the same track to the angle of clavicle.  We roughed the needle down off the clavicle and directed it towards the sternal notch.  There was good venous return noted immediately.  The syringe was removed and a Seldinger guidewire was inserted through the needle to cannulate the vein.  The needle was then removed.  A small skin nick was made with a #11 blade scalpel and the provided dilator was used to dilate the skin, soft tissue and vein.  Next, the triple lumen catheter was inserted over the guidewire without difficulty.  The guidewire was removed.  All the ports aspirated and flushed without difficulty.  The catheter was sutured into place with #3-0 silk suture and a sterile OpSite dressing was also applied.  The patient tolerated the above procedures well.  A chest x-ray has been ordered, however, it has not been completed at this time, this will be checked and documented in the progress notes.","surgery, hyperpyrexia, leukocytosis, ventilator-dependen, respiratory failure, pancreatitis, brachial artery, arterial catheter, subclavian vein, triple lumen catheter, catheter, brachial, needle, "
" Need for intravenous access.  Insertion of a right femoral triple lumen catheter.  he patient is also ventilator-dependent, respiratory failure with tracheostomy in place and dependent on parenteral nutrition secondary to dysphagia and also has history of protein-calorie malnutrition and the patient needs to receive total parenteral nutrition and therefore needs central venous access.", Surgery, Triple Lumen Catheter Insertion - 1 ,"PREOPERATIVE DIAGNOSIS: , Need for intravenous access.,POSTOPERATIVE DIAGNOSIS: , Need for intravenous access.,PROCEDURE PERFORMED:  ,Insertion of a right femoral triple lumen catheter.,ANESTHESIA: , Includes 4 cc of 1% lidocaine locally.,ESTIMATED BLOOD LOSS: , Minimum.,INDICATIONS:,  The patient is an 86-year-old Caucasian female who presented to ABCD General Hospital secondary to drainage of an old percutaneous endoscopic gastrostomy site.  The patient is also ventilator-dependent, respiratory failure with tracheostomy in place and dependent on parenteral nutrition secondary to dysphagia and also has history of protein-calorie malnutrition and the patient needs to receive total parenteral nutrition and therefore needs central venous access.,PROCEDURE:,  The patient's legal guardian was talked to.  All questions were answered and consent was obtained.  The patient was sterilely prepped and draped.  Approximately 4 cc of 1% lidocaine was injected into the inguinal site.  A strong femoral artery pulse was felt and triple lumen catheter Angiocath was inserted at 30-degree angle cephalad and aspirated until a dark venous blood was aspirated.  A guidewire was then placed through the needle.  The needle was then removed.  The skin was ________ at the base of the wire and a dilator was placed over the wire.  The triple lumen catheters were then flushed with bacteriostatic saline.  The dilator was then removed from the guidewire and a triple lumen catheter was then inserted over the guidewire with the guidewire held at all times.,The wire was then carefully removed.  Each port of the lumen catheter was aspirated with 10 cc syringe with normal saline till dark red blood was expressed and then flushed with bacteriostatic normal saline and repeated on the remaining two ports.  Each port was closed off and also kept off.  Straight needle suture was then used to suture the triple lumen catheter down to the skin.  Peristatic agent was then placed at the site of the lumen catheter insertion and a Tegaderm was then placed over the site.  The surgical site was then sterilely cleaned.  The patient tolerated the full procedure well.  There were no complications.  The nurse was then contacted to allow for access of the triple lumen catheter.","surgery, intravenous access, catheter, femoral triple lumen catheter, triple lumen catheter, lumen, ventilator, respiratory, guidewire"
" Trigger finger release.  A longitudinal incision was made over the digit's A1 pulley.  Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles.  The sheath was opened under direct vision with a scalpel, and then a scissor was used to release it under direct vision from the proximal extent of the A1 pulley to just proximal to the proximal digital crease. ", Surgery, Trigger Finger Release ,"PROCEDURE: , Trigger finger release.,PROCEDURE IN DETAIL: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A longitudinal incision was made over the digit's A1 pulley.  Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles.  The sheath was opened under direct vision with a scalpel, and then a scissor was used to release it under direct vision from the proximal extent of the A1 pulley to just proximal to the proximal digital crease.  Meticulous hemostasis was maintained with bipolar electrocautery.,The tendons were identified and atraumatically pulled to ensure that no triggering remained.  The patient then actively moved the digit, and no triggering was noted.,After irrigating out the wound with copious amounts of sterile saline, the skin was closed with 5-0 nylon simple interrupted sutures.,The wound was dressed and the patient was sent to the recovery room in good condition, having tolerated the procedure well.","surgery, a1 pulley, neurovascular bundles, trigger finger release, proximal digital, digital crease, trigger finger, trigger, finger, sheath, incision"
 Trigger thumb release.  A transverse incision was made over the MPJ crease of the thumb.  Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles.  , Surgery, Trigger Thumb Release ,"PROCEDURE:  ,Trigger thumb release.,PROCEDURE IN DETAIL: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual sterile fashion.  The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A transverse incision was made over the MPJ crease of the thumb.  Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles.  The flexor sheath was opened under direct vision with a scalpel, and then a scissor was used to release the A1 pulley under direct vision on the radial side, from its proximal extent to its distal extent at the junction of the proximal and middle thirds of the proximal phalanx.  Meticulous hemostasis was maintained with bipolar electrocautery.,The flexor pollicis longus tendon was identified and atraumatically pulled to ensure that no triggering remained.  The patient then actively moved the thumb and no triggering was noted.,After irrigating out the wound with copious amounts of sterile saline, the skin was closed with 5-0 nylon simple interrupted sutures.,The wound was dressed and the patient was sent to the recovery room in good condition, having tolerated the procedure well.","surgery, neurovascular, a1 pulley, trigger thumb release, mpj crease, trigger thumb, flexor sheath, triggering, sheath, proximal, incision"
 Insertion of transesophageal echocardiography probe and unsuccessful insertion of arterial venous lines., Surgery, Transesophageal Echocardiography Probe ,"INDICATIONS FOR PROCEDURE:,  Impending open heart surgery for closure of ventricular septal defect in a 4-month-old girl.,Procedures were done under general anesthesia.  The patient was already in the operating room under general anesthesia.  Antibiotic prophylaxis with cefazolin and gentamicin was already given prior to beginning the procedures.,PROCEDURE #1:,  Insertion of transesophageal echocardiography probe.,DESCRIPTION OF PROCEDURE #1: , The probe was well lubricated and with digital manipulation, was passed into the esophagus without resistance.  The probe was placed so that the larger diameter was in the anterior-posterior position during insertion.  The probe was used by the pediatric cardiologist for preoperative and postoperative diagnostic echocardiography.  At the end, it was removed without trauma and there was no blood tingeing.  It is to be noted that approximately 30 minutes after removing the cannula, I inserted a 14-French suction tube to empty the stomach and there were a few mL of blood secretions that were suctioned.  There was no overt bleeding.,PROCEDURE #2: , Attempted and unsuccessful insertion of arterial venous lines.,DESCRIPTION OF PROCEDURE #2:,  Both groins were prepped and draped.  The patient was placed at 10 degrees head-up position.  A Cook 4-French double-lumen 8-cm catheter kit was opened.  Using the 21-gauge needle that comes with the kit, several attempts were made to insert central venous and then an arterial line in the left groin.  There were several successful punctures of these vessels, but I was unable to advance Seldinger wire.  After removal of the needles, the area was compressed digitally for approximately 5 minutes.  There was a small hematoma that was not growing.  Initially, the left leg was mildly mottled with prolonged capillary refill of approximately 3 seconds.  Using 1% lidocaine, I infiltrated the vessels of the groin both medial and lateral to the vascular sheath.  Further observation, the capillary refill and circulation of the left leg became more than adequate.  The O2 saturation monitor that was on the left toe functioned well throughout the procedures, from the beginning to the end.  At the end of the procedure, the circulation of the leg was intact.,","surgery, impending open heart surgery, ventricular septal defect, antibiotic prophylaxis, cefazolin, transesophageal echocardiography probe, arterial venous lines, groin, transesophageal echocardiography, echocardiography probe, insertion, transesophageal, arterial, venous, groins, echocardiography, probe"
"  Transurethral resection of a medium bladder tumor (TURBT), left lateral wall.", Surgery, Transurethral Resection Of Bladder Tumor  ,"PREOPERATIVE DIAGNOSIS: , Bladder tumor.,POSTOPERATIVE DIAGNOSIS: , Bladder tumor.,PROCEDURE PERFORMED: , Transurethral resection of a medium bladder tumor (TURBT), left lateral wall.,ANESTHESIA: , Spinal.,SPECIMEN TO PATHOLOGY: , Bladder tumor and specimen from base of bladder tumor.,DRAINS: , A 22-French 3-way Foley catheter, 30 mL balloon.,ESTIMATED BLOOD LOSS:,  Minimal.,INDICATIONS FOR PROCEDURE: , This is a 74-year-old male who presented with microscopic and an episode of gross hematuria.  He underwent an IVP, which demonstrated enlarged prostate and normal upper tracts.  Cystoscopy in the office demonstrated a 2.5- to 3-cm left lateral wall bladder tumor.  He is brought to the operating room for transurethral resection of that bladder tumor.,DESCRIPTION OF OPERATION: , After preoperative counseling of the patient and his wife, the patient was taken to the operating room and administered a spinal anesthetic.  He was placed in lithotomy position and prepped and draped in the usual fashion.  Using the visual obturator, the resectoscope was then inserted per urethra into the bladder.  The bladder was inspected confirming previous cystoscopic findings of a 2.5- to 3-cm left lateral wall bladder tumor away from the ureteral orifice.  Using the resectoscope loop, the tumor was then resected down to its base in a stepwise fashion.  Following completion of resection down to the base, the bladder was _______ free of tumor specimen.  The resectoscope was then reinserted and the base of the bladder tumor was then resected to get the base of the bladder tumor specimen, this was sent as a separate pathological specimen.  Hemostasis was assured with electrocautery.  The base of the tumor was then fulgurated again and into the periphery out in the normal mucosa surrounding the base of the bladder tumor.  Following completion of the fulguration, there was good hemostasis.  The remainder of the bladder was without evidence of significant abnormality.  Both ureteral orifices were visualized and noted to drain freely of clear urine.  The bladder was filled and the resectoscope was removed.  A 22-French 3-way Foley catheter was inserted per urethra into the bladder.  The balloon was inflated to 30 mL.  The catheter with sterile continuous irrigation and was noted to drain clear irrigant.  The patient was then removed from lithotomy position.  He was in stable condition.","surgery, turbt, bladder tumor, cystoscopic, resectoscope, hemostasis, foley catheter, tumor, bladder, lithotomy, transurethral, resection, hematuria,"
 Tracheotomy for patient with respiratory failure., Surgery, Tracheotomy - 1 ,"PREOPERATIVE DIAGNOSIS: , Respiratory failure.,POSTOPERATIVE DIAGNOSIS:  ,Respiratory failure.,OPERATIVE PROCEDURE: , Tracheotomy.,ANESTHESIA:  ,General inhalational.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine on the operating table.  General inhalational anesthesia was administered through the patient's existing 4.0 endotracheal tube.  The neck was extended and secured with tape and incision in the midline of the neck approximately 2 fingerbreadths above the sternal notch was outlined.  The incision measured approximately 1 cm and was just below the palpable cricoid cartilage and first tracheal ring.  The incision area was infiltrated with 1% Xylocaine with epinephrine 1:100,000.  A #67 blade was used to perform the incision.  Electrocautery was used to remove excess fat tissue to expose the strap muscles.  The strap muscles were grasped and divided in the midline with a cutting electrocautery.  Sharp dissection was used to expose the anterior trachea and cricoid cartilage.  The thyroid isthmus was identified crossing just below the cricoid cartilage.  This was divided in the midline with electrocautery.  Blunt dissection was used to expose adequate cartilaginous rings.  A 4.0 silk was used for stay sutures to the midline of the cricoid.  Additional stay sutures were placed on each side of the third tracheal ring.  Thin DuoDerm was placed around the stoma.  The tracheal incision was performed with a #11 blade through the second, third, and fourth tracheal rings.  The cartilaginous edges were secured to the skin edges with interrupted #4-0 Monocryl.  A 4.5 PED tight-to-shaft cuffed Bivona tube was placed and secured with Velcro ties.  A flexible scope was passed through the tracheotomy tube.  The carina was visualized approximately 1.5 cm distal to the distal end of the tracheotomy tube.  Ventilation was confirmed.  There was good chest rise and no appreciable leak.  The procedure was terminated.  The patient was in stable condition.  Bleeding was negligible and she was transferred back to the Pediatric intensive care unit in stable condition.","surgery, bivona tube, duoderm, tracheotomy tube, respiratory failure, cricoid cartilage, tracheotomy, tracheal, "
 Trabeculectomy with mitomycin C - Sample/Template., Surgery, Trabeculectomy ,"PREOPERATIVE DIAGNOSIS:, Open angle glaucoma OX,POSTOPERATIVE DIAGNOSIS:, Open angle glaucoma OX,PROCEDURE:, Trabeculectomy with mitomycin C, XXX eye 0.3 c per mg times three minutes.,INDICATIONS: ,This is a XX-year-old (wo)man with glaucoma in the OX eye, uncontrolled by maximum tolerated medical therapy.,PROCEDURE: ,The risks and benefits of glaucoma surgery were discussed at length with the patient including bleeding, infection, reoperation, retinal detachment, diplopia, ptosis, loss of vision, and loss of the eye, corneal hemorrhage hypotony, elevated pressure, worsening of glaucoma, and corneal edema. Informed consent was obtained. Patient received several sets of drops in his/her XXX eye including Ocuflox, Ocular, and pilocarpine. (S)He was taken to the operating room where monitored anesthetic care was initiated. Retrobulbar anesthesia was then administered to the XXX eye using a 50:50 mixture of 2% plain lidocaine and 0.05% Marcaine. The XXX eye was then prepped and draped in the usual sterile ophthalmic fashion and the microscope was brought in position. A Lieberman lid speculum was used to provide exposure. Vannas scissors and smooth forceps were used to create a 6 mm limbal peritomy superiorly. This was dissected posteriorly with Vannas scissors to produce a fornix based conjunctival flap. Residual episcleral vessels were cauterized with Eraser-tip cautery. Sponges soaked in mitomycin C 0.3 mm per cc were then placed underneath the conjunctival flap and allowed to sit there for 3 minutes checked against the clock. Sponges were removed and area was copiously irrigated with balanced salt solution. A Super blade was then used to fashion a partial thickness limbal based trapezoidal scleral flap. This was dissected anteriorly with a crescent blade to clear cornea. A temporal paracentesis was then made. Scleral flap was lifted and a Super blade was used to enter the anterior chamber. A Kelly-Descemet punch was used to remove a block of limbal tissue. DeWecker scissors were used to perform a surgical iridectomy. The iris was then carefully reposited back into place and the iridectomy was visible through the clear cornea. A scleral flap was then re- approximated back on the bed. One end of the scleral flap was closed with a #10-0 nylon suture in interrupted fashion and the knot was buried. The other end of the scleral flap was closed with #10-0 nylon suture in interrupted fashion and the knot was buried. The anterior chamber was then refilled with balanced salt solution and a small amount of fluid was noted to trickle out of the scleral flap with slow shallowing of the chamber. Therefore it was felt that another #10-0 nylon suture should be placed and it was therefore placed in interrupted fashion half way between each of the end sutures previously placed. The anterior chamber was then again refilled with balanced salt solution and it was noted that there was a small amount of fluid tricking out of the scleral flap and the pressure was felt to be adequate in the anterior chamber. Conjunctiva was then re-approximated to the limbus and closed with #9-0 Vicryl suture on a TG needle at each of the peritomy ends. Then a horizontal mattress style #9-0 Vicryl suture was placed at the center of the conjunctival peritomy. The conjunctival peritomy was checked for any leaks and was noted to be watertight using Weck- cel sponge. The anterior chamber was inflated and there was noted that the superior bleb was well formed. At the end of the case, the pupil was round, the chamber was formed and the pressure was felt to be adequate. Speculum and drapes were carefully removed. Ocuflox and Maxitrol ointment were placed over the eye. Atropine was also placed over the eye. Then an eye patch and eye shield were placed over the eye. The patient was taken to the recovery room in good condition. There were no complications.","surgery, trabeculectomy, kelly-descemet punch, maxitrol ointment, open angle glaucoma, tg needle, bleeding, corneal edema, corneal hemorrhage hypotony, diplopia, elevated pressure, glaucoma, infection, iridectomy, loss of the eye, loss of vision, mitomycin c, ptosis, reoperation, retinal detachment, temporal paracentesis, worsening of glaucoma, balanced salt solution, anterior chamber, scleral flap, eye, angle, mitomycin, conjunctival, chamber, flap, "
 Tracheostomy and thyroid isthmusectomy.  Ventilator-dependent respiratory failure and multiple strokes., Surgery, Tracheostomy & Thyroid Isthmusectomy ,"PREOPERATIVE DIAGNOSES:,1.  Ventilator-dependent respiratory failure.,2.  Multiple strokes.,POSTOPERATIVE DIAGNOSES:,1.  Ventilator-dependent respiratory failure.,2.  Multiple strokes.,PROCEDURES PERFORMED:,1.  Tracheostomy.,2.  Thyroid isthmusectomy.,ANESTHESIA: , General endotracheal tube.,BLOOD LOSS: , Minimal, less than 25 cc.,INDICATIONS:,  The patient is a 50-year-old gentleman who presented to the Emergency Department who had had multiple massive strokes.  He had required ventilator assistance and was transported to the ICU setting.  Because of the numerous deficits from the stroke, he is expected to have a prolonged ventilatory course and he will be requiring long-term care.,PROCEDURE: , After all risks, benefits, and alternatives were discussed with multiple family members in detail, informed consent was obtained.  The patient was brought to the Operative Suite where he was placed in supine position and general anesthesia was delivered through the existing endotracheal tube.  The neck was then palpated and marked appropriately in the cricoid cartilage sternal notch and thyroid cartilage marked appropriately with felt-tip marker.  The skin was then anesthetized with a mixture of 1% lidocaine and 1:100,000 epinephrine solution.  The patient was prepped and draped in usual fashion.  The surgeons were gowned and gloved.  A vertical skin incision was then made with a #15 blade scalpel extending from approximately two fingerbreadths above the level of the sternum approximately 1 cm above the cricoid cartilage.  Blunt dissection was then carried down until the fascia overlying the strap muscles were identified.  At this point, the midline raphe was identified and the strap muscles were separated utilizing the Bovie cautery.  Once the strap muscles have been identified, palpation was performed to identify any arterial aberration.  A high-riding innominate was not identified.  At this point, it was recognized that the thyroid gland was overlying the trachea could not be mobilized.  Therefore, dissection was carried down through to the cricoid cartilage at which point hemostat was advanced underneath the thyroid gland, which was then doubly clamped and ligated with Bovie cautery.  Suture ligation with #3-0 Vicryl was then performed on the thyroid gland in a double interlocking fashion.  This cleared a significant portion of the trachea.  The overlying pretracheal fascia was then cleared with use of pressured forceps as well as Bovie cautery.  Now, a tracheal hook was placed underneath the cricoid cartilage in order to stabilize the trachea.  The second tracheal ring was identified.  The Bovie cautery reduced to create a tracheal window beneath the second tracheal ring that was inferiorly based.  At this point, the anesthetist was appropriately alerted to deflate the endotracheal tube cuff.  The airway was entered and inferior to the base, window was created.  The anesthetist then withdrew the endotracheal tube until the tip of the tube was identified.  At this point, a #8 Shiley tracheostomy tube was inserted freely into the tracheal lumen.  The balloon was inflated and the ventilator was attached.  He was immediately noted to have return of the CO2 waveform and was ventilating appropriately according to the anesthetist.  Now, all surgical retractors were removed.  The baseplate of the tracheostomy tube was sutured to the patient's skin with #2-0 nylon suture.  The tube was further secured around the patient's neck with IV tubing.  Finally, a drain sponge was placed.  At this point, procedure was felt to be complete.  The patient was returned to the ICU setting in stable condition where a chest x-ray is pending.","surgery, ventilator-dependent respiratory failure, multiple strokes, thyroid, thyroid isthmusectomy, ventilator dependent, respiratory failure, strap muscles, thyroid gland, endotracheal tube, cricoid cartilage, bovie cautery, tracheostomy, ventilator, strokes, cartilage, tracheal, isthmusectomy"
 Tracheostomy change.  A #6 Shiley with proximal extension was changed to a #6 Shiley with proximal extension.  Ventilator-dependent respiratory failure and laryngeal edema., Surgery, Tracheostomy Change ,"PREOPERATIVE DIAGNOSES:,1.  Ventilator-dependent respiratory failure.,2.  Laryngeal edema.,POSTOPERATIVE DIAGNOSES:,1.  Ventilator-dependent respiratory failure.,2.  Laryngeal edema.,PROCEDURE PERFORMED: , Tracheostomy change.  A #6 Shiley with proximal extension was changed to a #6 Shiley with proximal extension.,INDICATIONS: , The patient is a 60-year-old Caucasian female who presented to ABCD General Hospital with exacerbation of COPD and CHF.  The patient had subsequently been taken to the operating room by Department of Otolaryngology and a direct laryngoscope was performed.  The patient was noted at that time to have transglottic edema.  Biopsies were taken.  At the time of surgery, it was decided that the patient required a tracheostomy for maintenance of continued ventilation and airway protection.  The patient is currently postop day #6 and appears to be unable to be weaned from ventilator at this time and may require prolonged ventricular support.  A decision was made to perform tracheostomy change.,DESCRIPTION OF PROCEDURE: , The patient was seen in the Intensive Care Unit.  The patient was placed in a supine position.  The neck was then extended.  The sutures that were previously in place in the #6 Shiley with proximal extension were removed.  The patient was preoxygenated to 100%.  After several minutes, the patient was noted to have a pulse oximetry of 100%.  The IV tubing that was supporting the patient's trache was then cut.  The tracheostomy tube was then suctioned.,The inner cannula was then removed from the tracheostomy and a nasogastric tube was placed down the lumen of the tracheostomy tube as a guidewire.  The tracheostomy tube was then removed over the nasogastric tube and the operative field was suctioned.  With the guidewire in place and with adequate visualization, a new #6 Shiley with proximal extension was then passed over the nasogastric tube guidewire and carefully inserted into the trachea.  The guidewire was then removed and the inner cannula was then placed into the tracheostomy.  The patient was then reconnected to the ventilator and was noted to have normal tidal volumes.  The patient had a tidal volume of 500 and was returning 500 cc to 510 cc.  The patient continued to saturate well with saturations 99%.  The patient appeared comfortable and her vital signs were stable.  A soft trache collar was then connected to the trachesotomy.  A drain sponge was then inserted underneath the new trache site.  The patient was observed for several minutes and was found to be in no distress and continued to maintain adequate saturations and continued to return normal tidal volumes.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well.  0.25% acetic acid soaks were ordered to the drain sponge every shift.","surgery, shiley, proximal extension, ventilator-dependent, respiratory failure, laryngeal edema, tracheostomy, cannula, respiratory, laryngeal, nasogastric, edema, ventilator"
" Neck exploration; tracheostomy; urgent flexible bronchoscopy via tracheostomy site; removal of foreign body, tracheal metallic stent material; dilation distal trachea; placement of #8 Shiley single cannula tracheostomy tube.", Surgery, Tracheostomy ,"PREOPERATIVE DIAGNOSES,Airway obstruction secondary to severe subglottic tracheal stenosis with foreign body in the trachea.,POSTOPERATIVE DIAGNOSES,Airway obstruction secondary to severe subglottic tracheal stenosis with foreign body in the trachea.,OPERATION PERFORMED,Neck exploration; tracheostomy; urgent flexible bronchoscopy via tracheostomy site; removal of foreign body, tracheal metallic stent material; dilation distal trachea; placement of #8 Shiley single cannula tracheostomy tube.,INDICATIONS FOR SURGERY,The patient is a 50-year-old white male with history of progressive tracheomalacia treated in the National Tennessee, and several years ago he had a tracheal metallic stent placed with some temporary improvement.  However developed progressive problems and he had two additional stents placed with some initial improvement.  Subsequently, he developed progressive airway obstruction and came into the ABC Hospital critical airway service for further evaluation and was admitted on Month DD, YYYY.  He underwent bronchoscopy by Dr. W and found to have an extensive subglottic upper tracheal and distal tracheal stenosis secondary to metallic stent extensive granulation and inflammatory tissue changes.  The patient had some debridement and then was hospitalized and Laryngology and Thoracic Surgery services were consulted for further management.  Exploration of trachea, removal of foreign body stents constricting his airway, dilation and stabilization of his trachea were offered to the patient.  Nature of the proposed procedure including risks and complications of bleeding, infection, alteration of voice, speech, swallowing, voice changes permanently, possibility of tracheotomy temporarily or permanently to maintain his airway, loss of voice, cardiac risk factors, anesthetic risks, recurrence of problems, upon surgical intervention were all discussed at length.  The patient stated that he understood and wished to proceed.,DESCRIPTION OF PROCEDURE,The patient was taken to the operating room, placed in the supine position.  Following adequate monitoring by Anesthesia Service to maintain sedation, the patient's neck was prepped and draped in the sterile fashion.  The neck was then infiltrated with 1% Xylocaine and 1000 epinephrine.  A collar incision approximately 1 fingerbreadth above the clavicle, this was an outline incision, was carried out.  The skin, subcutaneous tissue, platysma, subplatysmal flaps elevated superiorly and inferiorly.  Strap muscles were separated in the midline, dissection carried down to visceral fascia.  Beneath the strap muscles, there was dense inflammation scarring obscuring palpable landmarks.  There appeared to be significant scarring fusion of soft tissue at the perichondrium and cartilage of the cricoid making the cricoid easily definable.  There was a markedly enlarged thyroid isthmus.  Thyroid isthmus was divided and dense inflammation, attachment of the thyroid isthmus, fusion of the thyroid gland to the capsule to the pretracheal fascia requiring extensive blunt sharp dissection.  Trachea was exposed from the cricoid to the fourth ring which entered down into the chest.  The trachea was incised between the second and third ring inferior limb in the midline and excision of small ridge of cartilage on each side sent for pathologic evaluation.  The tracheal cartilage externally had marked thickening and significant stiffness calcification, and the tracheal wall from the outside of the trachea to the mucosa measured 3 to 4 mm in thickness.  The trachea was entered and visualized with thickening of the mucosa and submucosa was noted.  The patient, however, was able to ventilate at this point a #6 Endo Tube was inserted and general anesthesia administered.  Once the airway was secured, we then proceeded working around the #6 Endo Tube as well as with the tube intake and out to explore the trachea with ridged fiberoptic scopes as well as flexible fiberoptic bronchoscopy to the trach site.  Examination revealed extrusion of metallic fragments from stent and multiple metallic fragments were removed from the stent in the upper trachea.  A careful examination of the subglottic area showed inflamed and thickened mucosa but patent subglottis.  After removal of the stents and granulation tissue, the upper trachea was widely patent.  The mid trachea had some marked narrowing secondary to granulation.  Stent material was removed from this area as well.  In the distal third of the trachea, a third stent was embedded within the mucosa, not encroaching on the lumen without significant obstruction distally and this was not disturbed at this time.  All visible stent material in the upper and mid trachea were removed.  Initial attempt to place a #16 Montgomery T tube showed the distal lumen of the T tube to be too short to stent the granulation narrowing of the trachea at the junction of the anterior two thirds and the distal third.  Also, this was removed and a #8 Shiley single cannula tracheostomy tube was placed after removal of the endotracheal tube.  A good ventilation was confirmed and the position of the tube confirmed it to be at the level just above the metallic stent which was embedded in the mucosa.  The distal trachea and mainstem bronchi were widely patent.  This secured his airway and no further manipulation felt to be needed at this time.  Neck wound was thoroughly irrigated and strap muscles were closed with interrupted 3-0 Vicryl.  The skin laterally to the trach site was closed with running 2-0 Prolene.  Tracheostomy tube was secured with interrupted 2-0 silk sutures and the patient was taken back to the Intensive Care Unit in satisfactory condition.  The patient tolerated the procedure well without complication.","surgery, airway, laryngology, shiley, alteration of voice, bronchi, bronchoscopy, cannula, cartilage, cricoid, flexible, foreign body, mainstem, obstruction, perichondrium, stenosis, stent, subglottic, swallowing, trachea, tracheal, tracheal stenosis, tracheostomy, shiley single cannula tracheostomy, shiley single cannula, single cannula tracheostomy, thyroid isthmus, stent material, tracheostomy tube, tube, thyroid, "
 Total thyroidectomy with removal of substernal extension on the left.  Thyroid goiter with substernal extension on the left., Surgery, Total Thyroidectomy ,"PREOPERATIVE DIAGNOSIS:  ,Thyroid goiter with substernal extension on the left.,POSTOPERATIVE DIAGNOSIS:,  Thyroid goiter with substernal extension on the left.,PROCEDURE PERFORMED:,  Total thyroidectomy with removal of substernal extension on the left.,THIRD ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , Approximately 200 cc.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE:,  The patient is a 54-year-old Caucasian male with a history of an enlarged thyroid gland who presented to the office initially with complaints of dysphagia and some difficulty in breathing while lying supine.  The patient subsequently then had a CT scan which demonstrated a very large thyroid gland, especially on the left side with substernal extension down to the level of the aortic arch.  The patient was then immediately set up for surgery.  After risks, complications, consequences, and questions were addressed with the patient, a written consent was obtained.,PROCEDURE:,  The patient was brought to the operative suite by Anesthesia and placed on the operative table in the supine position.  The patient was then placed under general endotracheal intubation anesthesia and the patient then had a shoulder roll placed.  After this, the patient then had the area marked initially.  The preoperative setting was then localized with 1% lidocaine and epinephrine 1:100,000 approximately 10 cc total.  After this, the patient was then prepped and draped in the usual sterile fashion.  A #15 Bard-Parker was then utilized to make a skin incision horizontally, approximately 5 cm on either side from midline.  After this, a blunt dissection was then utilized to dissect the subcutaneous fat from the platysmal muscle.  There appeared to be a natural dehiscence of the platysma in the midline.  A sub-platysmal dissection was then performed in the superior, inferior, and lateral directions with the help of a bear claw, Metzenbaum scissors and DeBakey forceps.  Any bleeding was controlled with monopolar cauterization.  After this, the two anterior large jugular veins were noted and resected laterally.  The patient's trachea appeared to be slightly deviated to the right with identification finally of the midline raphe, off midline to the right.  This was grasped on either side with a DeBakey forceps and dissected with monopolar cauterization and dissected with a Metzenbaum scissors.  After this was dissected, the sternohyoid muscles were resected laterally and separated from the sternothyroid muscles.  The sternothyroid muscles were then bluntly freed and dissected from the right thyroid gland.  After this, attention was then drawn to the left gland, where the sternothyroid muscle was dissected bluntly on this side utilizing finger dissection and Kitners.  The left thyroid gland was freed initially superiorly and worked inferiorly and laterally until the gland was pulled from the substernal region by blunt dissection and reflected and pulled anteriorly.  After this, the superior and inferior parathyroid glands were noted.  The dissection was carried very close to the thyroid gland to try to select these parathyroids posteriorly.  After this, the superior pole was then identified and the superior laryngeal artery and vein were cross clamped and tied with __________ undyed Vicryl tie.  The superior pole was finally freed and a small little feeding branched vessels from this area were cauterized with the bipolar cautery and cut with Metzenbaum scissors.  After this, the thyroid gland was further freed down to the level of the Berry's ligament inferiorly and the dissection was carried once again more superiorly.  The fine stats were then utilized to dissect along the superior aspect of the recurrent laryngeal nerve on the left side with freeing of the connective Berry's ligament tissue from the gland with the bipolar cauterization and the fine stat.  Finally, attention was then drawn back to the patient's right side where the gland was rotated more anteriorly with fine dissection utilizing a fine stat to reflect the superior and inferior parathyroid glands laterally and posteriorly.  The recurrent laryngeal nerve on this side was identified and further dissection was carried superiorly and anteriorly through this nerve to finally free the right side of the gland to Berry's ligament.  The middle thyroid vein and inferior thyroid arteries were cross clamped and tied with #2-0 undyed Vicryl ties and also bipolared with the bipolar cauterization bilaterally.  The Berry's ligament was then finally freed and the gland was then passed to scrub tech and passed off the field to Pathology.  The neck was then thoroughly irrigated with normal saline solution and further bleeding was controlled with bipolar cauterization.  After this, Surgicel was then placed in the bilateral neck regions and a #10 Jackson-Pratt drain was then placed within the left neck region with some extension over to the right neck region.  This was brought out through the inferior skin incision and secured to the skin with a #2-0 nylon suture.  The strap muscles were then reapproximated with a running #3-0 Vicryl suture followed by reapproximation of the platysma and subcutaneous tissue with a #4-0 undyed Vicryl.  The skin was then reapproximated with a #5-0 Prolene subcuticular along with a #6-0 fast over the top.  After this, Mastisol Steri-Strips and Bacitracin along with a sterile dressing and a __________ dressing were then placed.  The patient intraoperatively did have approximately 50 cc of bloody drainage from this area within the JP drain.  The patient was then turned back to Anesthesia, extubated in the operating room and transferred to Recovery in stable condition.  The patient tolerated the procedure well and remained stable throughout.","surgery, thyroid goiter, goiter, thyroid, total thyroidectomy, berry's ligament, dissection, gland, thyroidectomy, anesthesia, berry's, ligament, cauterization, extension, substernal,"
" Left thyroid mass.  Left total thyroid lumpectomy.  The patient with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole.", Surgery, Total Thyroid Lumpectomy ,"PREOPERATIVE DIAGNOSIS:,  Left thyroid mass.,POSTOPERATIVE DIAGNOSIS:,  Left thyroid mass.,PROCEDURE PERFORMED:,  Left total thyroid lumpectomy.,ANESTHESIA,:  General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,COMPLICATIONS:,  None.,INDICATIONS FOR PROCEDURE:,  The patient is a 76-year-old Caucasian female with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole.  The patient was then discussed the risks, complications, and consequences of a surgical procedure and a written consent was obtained.,PROCEDURE:  ,The patient is brought to the operative suite by Anesthesia.  The patient was placed on the operative table in supine position.  After this, the patient was placed under general endotracheal intubation anesthesia and the patient was then placed upon a shoulder roll.  After this, the skin incision was marked approximately two fingerbreadths above the sternal notch.  It was then localized with 1% lidocaine with epinephrine 1:1000 approximately 7 cc total.,After this, the patient was then prepped and draped in the usual sterile fashion and a #10 blade was then utilized to make a skin incision.  The subcutaneous tissue was then bluntly dissected utilizing a Ray-Tec sponge and a bear claw was then utilized to retract the upper incisional skin with counter retraction performed to allow a subplatysmal plane of skin flaps to be performed in superior and inferolateral directions.  After this, the midline was then identified and grasped on either side with a DeBakey forceps.  The raphe was noted and Bovie cauterization was utilized to cut down into this region.  The fine stats were utilized to further open this area with exposure and bisection of the sternothyroid muscle.  It was separated on the left side from the patient's sternothyroid muscle.  After this, the sternothyroid muscle was identified, grasped with the DeBakey forceps and infiltrated initially through its fascial plane with the Metzenbaum scissors.  Blunt dissection was then utilized to free the sternothyroid muscle from the thyroid gland in superior and inferior directions and laterally with the help of Kitners.  After this, the plane was rotated more anteriorly with the superior and inferior parathyroid glands identified.  The fat cap was noted to be attached on the superior parathyroid to the posterior aspect of the thyroid itself.  It was freed from the thyroid gland and reflected laterally and posteriorly.  The inferior parathyroid gland actually appeared to be attached also to the inferior aspect of the thyroid itself and was reflected laterally.  After this, the patient's thyroid gland was palpated noting a thyroid nodule in the posterior inferior aspect along with the calcification laterally.  The nodule appeared to be sort of rubbery in consistency and approximately 1 cm diameter.  As the gland was rotated more anteriorly, the recurrent laryngeal nerve on the left side was identified and further dissection along Berry's ligament on the medial aspect was performed.  The middle thyroid vein and inferior thyroid artery were both cauterized with a bipolar cautery and bisected.  After this, the gland was easily rotated anteriorly with further dissection carried up to the superior pole.  The superior pole was exposed with the help of a Richardson and Army-Navy retractors with cross-clamping and tying of the superior laryngeal artery and vein.  Further, the small bleeding vessels were identified and bipolared, and cut with the Metzenbaum scissors.  The superior pole was finally freed and the gland was rotated more anteriorly onto the anterior aspect of the trachea.  Berry's ligament was finally freed and the gland was cross-clamped on the opposing thyroid isthmus with a mosquito.  After this, the gland was cut with a Metzenbaum scissors and tied with a #3-0 undyed Vicryl tie.  The defect on the neck now was thoroughly irrigated with normal saline solution and further bleeding was controlled with bipolar cauterization.  Surgicel was then cut in small strips and three replaced in the lateral part of the neck.,The opposing side of the thyroid gland on the right was palpated with no noticeable nodules or masses.  The strap muscles were then reapproximated with #3-0 Vicryl on a SH, followed by reapproximation of the subcutaneous tissue with #4-0 Vicryl, followed by reapproximation of the skin by running subcuticular #5-0 Prolene and a #6-0 fast absorbing gut.  Mastisol, Steri-Strips, and bacitracin were placed followed by a sterile 4 x 4 dressing.  The patient was then turned back to Anesthesia, extubated in the operating room, and transferred to Recovery in stable condition.  The patient tolerated the procedure well and will be admitted to hospital for 23-hour observation and will be followed up in one week afterwards.","surgery, thyroid lumpectomy, thyroid uptake scan, thyroid mass nodule, total thyroid lumpectomy, parathyroid glands, berry's ligament, metzenbaum scissors, thyroid gland, thyroid mass, gland, thyroid, total,"
" Total knee replacement.  A midline incision was made, centered over the patella.  Dissection was sharply carried down through the subcutaneous tissues.  A median parapatellar arthrotomy was performed.", Surgery, Total Knee Replacement - 1 ,"PROCEDURES: , Total knee replacement.,PROCEDURE DESCRIPTION:,  The patient was bought to the operating room and placed in the supine position.  After induction of anesthesia, a tourniquet was placed on the upper thigh.  Sterile prepping and draping proceeded.  The tourniquet was inflated to 300 mmHg.  A midline incision was made, centered over the patella.  Dissection was sharply carried down through the subcutaneous tissues.  A median parapatellar arthrotomy was performed.  The lateral patellar retinacular ligaments were released and the patella was retracted laterally.  Proximal medial tibia was denuded, with mild release of medial soft tissues.  The ACL and PCL were released.  The medial and lateral menisci and suprapatellar fat pad were removed.  These releases allowed for anterior subluxation of tibia.  An extramedullary tibial cutting jig was pinned to the proximal tibia in the appropriate alignment and flush cut was made along tibial plateau, perpendicular to the axis of the tibia.  Its alignment was checked with the rod and found to be adequate.  The tibia was then allowed to relocate under the femur.,An intramedullary hole was drilled into the femur and a femoral rod attached to the anterior cutting block was inserted, and the block was pinned in appropriate position, judging correct rotation using a variety of techniques.  An anterior rough cut was made.  The distal cutting jig was placed atop this cut surface and pinned to the distal femur, and the rod was removed.  The distal cut was performed.,A spacer block was placed, and adequate balance in extension was adjusted and confirmed, as was knee alignment.  Femoral sizing was performed with the sizer, and the appropriate size femoral 4-in-1 chamfer-cutting block was pinned in place and the cuts were made.  The notch-cutting block was pinned to the cut surface, slightly laterally, and the notch cut was then made.  The trial femoral component was impacted onto the distal femur and found to have an excellent fit.  A trial tibial plate and polyethylene were inserted, and stability was judged and found to be adequate in all planes.  Appropriate rotation of the tibial component was identified and marked.  The trials were removed and the tibia was brought forward again.  The tibial plate size was checked and the plate was pinned to plateau.  A keel guide was placed and the keel was then made.  The femoral intramedullary hole was plugged with bone from the tibia.  The trial tibial component and poly placed; and, after placement of the femoral component, range of motion and stability were checked and found to be adequate in various ranges of flexion and extension.,The patella was held in a slightly everted position with knee in extension.  Patellar width was checked with calipers.  A free-hand cut of the patellar articular surface was performed and checked to ensure symmetry with the calipers.  Sizing was then performed and 3 lug holes were drilled with the jig in place, taking care to medialize and superiorize the component as much as possible, given bony anatomy.  Any excess lateral patellar bone was recessed.  The trial patellar component was placed and found to have adequate tracking.  The trials were removed; and as the cement was mixed, all cut surfaces were thoroughly washed and dried.  The cement was applied to the components and the cut surfaces with digital pressurization, and then the components were impacted.  The excess cement was removed from the gutters and anterior and posterior parts of the knee.  The knee was brought into full extension with the trial polyethylene and further axially pressurized as cement hardened.  Once the cement had hardened, the tourniquet was deflated.  The knee was dislocated again, and any excess cement was removed with an osteotome.  Thorough irrigation and hemostasis were performed.  The real polyethylene component was placed and pinned.  Further vigorous power irrigation was performed, and adequate hemostasis was obtained and confirmed.  The arthrotomy was closed using 0 Ethibond and Vicryl sutures.  The subcutaneous tissues were closed after further irrigation with 2-0 Vicryl and Monocryl sutures.  The skin was sealed with staples.  Xeroform and a sterile dressing were applied followed by a cold-pack and Ace wrap.  The patient was transferred to the recovery room in stable condition, having tolerated the procedure well.","surgery, proximal medial tibia, total knee replacement, parapatellar arthrotomy, subcutaneous tissues, tibial plateau, incision, cutting, patella, femur, femoral, component, knee,"
" Short flap trabeculectomy with lysis of conjunctival scarring, tenonectomy, peripheral iridectomy, paracentesis, watertight conjunctival closure, and 0.5 mg/mL mitomycin x2 minutes, left eye.  Uncontrolled open angle glaucoma and conjunctival scarring, left eye.  ", Surgery, Trabeculectomy & Tenonectomy ,"PREOPERATIVE DIAGNOSES,1.  Uncontrolled open angle glaucoma, left eye.,2.  Conjunctival scarring, left eye.,POSTOPERATIVE DIAGNOSES,1.  Uncontrolled open angle glaucoma, left eye.,2.  Conjunctival scarring, left eye.,PROCEDURES: , Short flap trabeculectomy with lysis of conjunctival scarring, tenonectomy, peripheral iridectomy, paracentesis, watertight conjunctival closure, and 0.5 mg/mL mitomycin x2 minutes, left eye.,ANESTHESIA: ,Retrobulbar block with monitored anesthesia care.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  Negligible.,DESCRIPTION OF PROCEDURE:,  The patient was brought to the operating suite where the Anesthesia team established a peripheral IV as well as monitoring lines.  In the preoperative area, the patient received pilocarpine drops.  The patient received IV propofol and once somnolent from this, a retrobulbar block was administered consisting of 2% Xylocaine plain.  Approximately 3 mL were given.  The operative eye then underwent a Betadine prep with respect to the face, lids, lashes, and eye.  During the draping process, care was taken to isolate the lashes.  A screw type speculum was inserted to maintain patency of lids.  A 6-0 Vicryl suture was placed through the superior cornea, and the eye was reflected downward to expose the superior conjunctiva.  A peritomy was performed approximately 8 to 10 mm posterior to the limbus and this flap was dissected forward to the cornea.  All Tenons were removed from the overlying sclera and the area was treated with wet-field cautery to achieve hemostasis.  A 2 mm x 3 mm scleral flap was then outlined with a Micro-Sharp blade.  This was approximately one-half scleral depth in thickness.  A crescent blade was then used to dissect forward the clear cornea.  Hemostasis was again achieved with wet-field cautery.  A Weck-Cel sponge tip soaked in mitomycin was then placed under the conjunctival and tenon flap and left there for two minutes.  The site was then profusely irrigated with balanced salt solution.  A paracentesis wound was made temporarily and then the Micro-Sharp blade was used to enter the anterior chamber at the anterior most margin of the trabeculectomy bed.  A Kelly-Descemet punch was then inserted, and a trabeculectomy was performed.  Iris was withdrawn through the trabeculectomy site and a peripheral iridectomy was performed using Vannas scissors and 0.12 forceps.  The iris was then repositioned into the eye and the anterior chamber was inflated with BSS.  The scleral flap was sutured in place with two 10-0 nylon sutures with knots trimmed, rotated, and buried.  The overlying conjunctiva was then closed with a running 8-0 Vicryl suture on a BV needle.  BSS was irrigated in the anterior chamber and the blood was noted to elevate nicely without leakage.  Antibiotic and steroid drops were placed in the eye as was homatropine 5%.  The antibiotic consisted of Vigamox and the steroid was Econopred Plus.  A patch and shield were placed over the eye after the drape was removed.  The patient was taken to the recovery room in good condition.  She will be seen in followup in the office tomorrow.","surgery, uncontrolled open angle glaucoma, open angle, conjunctival, scarring, trabeculectomy, tenonectomy, iridectomy, paracentesis, watertight conjunctival closure, conjunctival scarring, eye, glaucoma, cornea, scleral,"
 Tracheostomy with skin flaps and SCOOP procedure FastTract.  Oxygen dependency of approximately 5 liters nasal cannula at home and chronic obstructive pulmonary disease. , Surgery, Tracheostomy & SCOOP Procedure ,"PREOPERATIVE DIAGNOSES:,1.  Oxygen dependency.,2.  Chronic obstructive pulmonary disease.,POSTOPERATIVE DIAGNOSES:,1.  Oxygen dependency.,2.  Chronic obstructive pulmonary disease.,PROCEDURES PERFORMED:,1.  Tracheostomy with skin flaps.,2.  SCOOP procedure FastTract.,ANESTHESIA: , Total IV anesthesia.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS:  ,None.,INDICATIONS FOR PROCEDURE: , The patient is a 55-year-old Caucasian male with a history of chronic obstructive pulmonary disease and O2 dependency of approximately 5 liters nasal cannula at home.  The patient with extensive smoking history who presents after risks, complications, and consequences of the SCOOP FastTract procedure were explained.,PROCEDURE:,  The patient was brought to operating suite by Anesthesia and placed on the operating table in the supine position.  After this, the patient was then placed under total IV anesthesia and the operating bed was then placed in reverse Trendelenburg.  The patient's sternal notch along with cricoid and thyroid cartilages were noted and palpated and a sternal marker was utilized to mark the cricoid cartilage in the sternal notch.  The midline was also marked and 1% lidocaine with epinephrine 1:100,000 at approximately 4 cc total was then utilized to localize the neck.  After this, the patient was then prepped and draped with Hibiclens.  A skin incision was then made in the midline with a #15 Bard-Parker in a vertical fashion.  After this, the skin was retracted laterally and a small anterior jugular branch was clamped and cross clamped and tied with #2-0 undyed Vicryl ties.  Further bleeding was controlled with monopolar cauterization and attention was then drawn down on to the strap muscles.  The patient's sternohyoid muscle was identified and grasped on either side and the midline raphe was identified.  Cauterization was then utilized to take down the midline raphe and further dissection was utilized with the skin hook and stat clamps.  The anterior aspect of the thyroid isthmus was identified and palpation on the cricoid cartilage was performed.  The cricoid cauterization over the cricoid cartilage was obtained with the monopolar cauterization and blunt dissection then was carried along the posterior aspect of the thyroid isthmus.  Stats were then placed on either side of the thyroid isthmus and the mid portion was bisected with the monopolar cauterization.  After this, the patient's anterior trachea was then identified and cleaned with pusher.  After this, the cricoid cartilage along the first and second tracheal rings was identified.  The cricoid hook was placed and the trachea was brought more anteriorly and superiorly.  After this, the patient's head incision was placed below the second tracheal ring with a #15 Bard-Parker.  After this, the patient had a tracheal punch with the SCOOP FastTract kit to create a small 4 mm punch within the tracheal cartilage.  After this, the patient then had a tracheal stent placed within the tracheal punched lumen and the patient was then had the tracheal stent secured to the neck with a Vicryl strap.  After this, the cricoid hook was removed and the patient then had FiO2 on the monitor noted with pulse oximetry of 100%.  The patient was then turned back to the anesthesia and transferred to the recovery room in stable condition.  The patient tolerated the procedure well and will stay in the hospital for approximately 23 hours.  The patient will have the stent guidewire removed with a scoop catheter 11 cm placed.","surgery, oxygen dependency, chronic obstructive pulmonary disease, tracheostomy, scoop procedure, nasal cannula, scoop procedure fasttract, thyroid isthmus, cricoid cartilage, isthmus, oxygen, dependency, scoop, cartilages"
" Right total knee arthroplasty - Osteoarthritis, right knee.", Surgery, Total Knee Arthroplasty - Right ,"PREOPERATIVE DIAGNOSIS (ES):, Osteoarthritis, right knee.,POSTOPERATIVE DIAGNOSIS (ES):, Osteoarthritis, right knee.,PROCEDURE:, Right total knee arthroplasty.,DESCRIPTION OF THE OPERATION:, The patient was brought to the Operating Room and after the successful placement of an epidural, as well as general anesthesia, administration 1 gm of Ancef preoperatively, the patient's right thigh, knee and leg were scrubbed, prepped and draped in the usual sterile fashion. The leg was exsanguinated by gravity and pneumatic tourniquet was inflated to 300 mmHg.,A straight anterior incision was carried down through the skin and subcutaneous tissue. Unilateral flaps were developed and a median retinacular parapatellar incision was made. The extensor mechanism was partially divided and the patella was everted. Some of the femoral bone spurs were resected using an osteotome and a rongeur. Ascending drill hole was made in the distal femur and the distal femoral cut, anterior and posterior and chamfer cuts were accomplished for a 67.5 femoral component.,At this point the ACL was resected. Some of the fat pad and synovium were resected, as well as both medial and lateral menisci. A posterior cruciate retractor was utilized, the tibia brought forward and a centering drill hole made in the tibia. The intramedullary guide was used for cutting the tibia. It was set at 8 mm. An additional 2 mm was resected because of a moderate defect medially.,A trial reduction was done with a 71 tibial baseplate. This was pinned and drilled and then trial reduction done with a 10-mm insert.,This gave good stability and a full range of motion.,The patella was measured with the calibers and 9 mm of bone was resected with an oscillating saw. A 34-mm component was drilled for.,A further trial reduction was done and two liters of pulse lavage were used to clean the bony surfaces. A packet of cement was hand mixed, pressurized with a spatula into the proximal tibia. Multiple drill holes were made on the medial side of the tibia where the bone was somewhat sclerotic. The tibia baseplate was secured and the patella was inserted, held with a clamp. The extraneous cement was removed. At this point the tibial baseplate was locked into place and the femoral component also seated solidly.,The knee was extended, held in this position for another 5-6 minutes until the cement was cured. Further extraneous cement was removed. The pneumatic tourniquet was released, hemostasis was obtained with electrocoagulation.,Retinaculum, quadriceps and extensor were repaired with multiple figure-of-eight #1 Vicryl sutures, the subcutaneous tissue with 2-0 and the skin with skin staples. A sterile, bulky compression dressing was placed. The patient was stable on operative release.","surgery, osteoarthritis, arthroplasty, knee, patella, retinacular parapatellar, total knee arthroplasty, total knee, knee arthroplasty, baseplate, femoral, tibia,"
" Total left knee replacement.  Degenerative arthritis of the left knee.  Degenerative ware of three compartments of the trochlea, the medial, as well as the lateral femoral condyles as well was the plateau.  ", Surgery, Total Knee Replacement ,"PREOPERATIVE DIAGNOSIS: ,Degenerative arthritis of the left knee.,POSTOPERATIVE DIAGNOSIS:, Degenerative arthritis of the left knee.,PROCEDURE PERFORMED: , Total left knee replacement on 08/19/03.  The patient also underwent a bilateral right total knee replacement in the same sitting and that will be dictated by Dr. X.,TOURNIQUET TIME: , 76 minutes.,BLOOD LOSS: , 150 cc.,ANESTHESIA:  ,General.,IMPLANT USED FOR PROCEDURE:,  NexGen size F femur on the left with #8 size peg tibial tray, a #12 mm polyethylene insert and this a cruciate retaining component.  The patella on the left was not resurfaced.,GROSS INTRAOPERATIVE FINDINGS: , Degenerative ware of three compartments of the trochlea, the medial, as well as the lateral femoral condyles as well was the plateau.  The surface of the patella was with a minimal ware and minimal osteophytes and we decided not to resurface the patellar component.,HISTORY:  ,This is a 69-year-old male with complaints of bilateral knee pain for several years and increased intensity in the past several months where it has affected his activities of daily living.  He attempted conservative treatment, which includes anti-inflammatory medications as well as cortisone and Synvisc.  This has only provided him with temporary relief.  It is for that reason, he is elected to undergo the above-named procedure.,All risks as well as complications were discussed with the patient, which include, but are not limited to infection, deep vein thrombosis, pulmonary embolism, need for further surgery, and further pain.  He has agreed to undergo this procedure and a consent was obtained preoperatively.,PROCEDURE: , The patient was wheeled back to operating room #2 at ABCD General Hospital on 08/19/03 and was placed supine on the operating room table.  At this time, a nonsterile tourniquet was placed on the left upper thigh, but not inflated.  An Esmarch was then used to exsanguinate the extremity and the left extremity was then prepped and draped in the usual sterile fashion for this procedure.  The tourniquet was then inflated to 325 mmHg.  At this time, a standard midline incision was made towards the total knee.  We did discuss preoperatively for a possible unicompartmental knee replacement for this patient, but he did have radiographic evidence of chondrocalcinosis of the lateral meniscus.  We did start off with a small midline skin incision in case we were going to do a unicompartmental.  Once we exposed the medial parapatellar mini-arthrotomy and visualized the lateral femoral condyle, we decided that this patient would not be an optimal candidate for unicompartmental knee replacement.  It is for this reason that we extended the incision and underwent with the total knee replacement.  Once the full medial parapatellar arthrotomy was performed with the subperiosteal dissection of the proximal tibia in order to evert the patella.  Once the patella was everted, we then used a drill to cannulate the distal femoral canal in order to place the intramedullary guide.  A Charnley awl was then used to remove all the intramedullary contents and they were removed from the knee.  At this time, a femoral sizer was then placed with reference to the posterior condyles and we measured a size F. Once this was performed, three degrees of external rotation was then drilled into the condyle in alignment with the epicondyles of the femur.  At this time, the intramedullary guide was then inserted and placed in three degrees of external rotation.  Our anterior cutting guide was then placed and an anterior cut was performed with careful protection of the soft tissues.  Next, this was removed and the distal femoral cutting guide was then placed in five degrees of valgus.  This was pinned to the distal femur and with careful protection of the collateral ligaments, a distal femoral cut was performed.  At this time, the intramedullary guide was removed and a final cutting block was placed.  This was placed in the center on the distal femur with 1 mm to 2 mm laterally translated for better patellar tracking.  At this time, the block was pinned and screwed in place with spring pins with careful protection of the soft tissues.  An oscillating saw was then used to resect the posterior and anterior cutting blocks with anterior and posterior chamfer as well as the notch cut.  Peg holes were then drilled.,The block was then removed and an osteotome was then used to remove all the bony cut pieces.  At this time with a better exposure of the proximal tibia, we placed external tibial guide.  This was placed with longitudinal axis of the tibia and carefully positioned in order to obtain an optimal cut for the proximal tibia.  At this time with careful soft tissue retraction and protection, an oscillating saw was used to make a proximal tibial osteotomy.  Prior to the osteotomy, the cut was checked with a depth gauge in order to assure appropriate bony resection.  At this time, a _blunt Kocher and Bovie cautery were used to remove the proximal tibial cut, which had soft tissue attachments.  Once this was removed, we then implanted our trial components of size F to the femur and a size 8 mm tibial tray with 12 mm plastic articulating surface.  The knee was taken through range of motion and revealed excellent femorotibial articulation.  The patella did tend to sublux somewhat laterally with extremes of flexion and it was for this reason, we performed a minimal small incision lateral retinacular release.  Distal lateral patella was tracked more uniformly within the patellar groove of the prosthesis.  At this time, an intraoperative x-ray was performed, which revealed excellent alignment with no varus angulation especially of the whole femur and tibial alignment and tibial cut.  At this time, the prosthesis was removed.  A McGill retractor was then reinserted and replaced peg tibial tray in order to peg the proximal tibia.  Once the drill holes were performed, we then copiously irrigated the wound and then suctioned it dry to get ready and prepped for cementation of the drilled components.  At this time, polymethyl methacrylate cement was then mixed.  The cement was placed on the tibial surface as well as the underneath surface of the component.  The component was then placed and impacted with excess cement removed.  In a similar fashion, the femoral component was also placed.  A 12 mm plastic tray was then placed and the leg held in full extension and compression in order to obtain adequate bony cement content.  Once the cement was fully hardened, the knee was flexed and a small osteotome was used to remove any extruding cement from around the prosthesis of the bone.  Once this was performed, copious irrigation was used to irrigate the wound and the wound was then suctioned dry.  The knee was again taken through range of motion with a 12 mm plastic as well as #14.  The #14 appeared to be a bit too tight especially in extremes of flexion.  We decided to go with a #12 mm polyethylene tray.  At this time, this was placed to the tibial articulation and then left in place.  This was rechecked with careful attention to detail with checking no soft tissue interpositioned between the polyethylene tray and the metal tray of the tibia.  The knee was again taken through range of motion and revealed excellent tracking of the patella with good femur and tibial contact.  A drain was placed and cut to length.,At this time, the knee was irrigated and copiously suction dried.  #1-0 Ethibond suture was then used to approximate the medial parapatellar arthrotomy in figure-of-eight fashion.  A tight capsular closure was performed.  This was reinforced with a #1-0 running Vicryl suture.  At this time, the knee was again taken through range of motion to assure tight capsular closure.  At this time, copious irrigation was used to irrigate the superficial wound.  #2-0 Vicryl was used to approximate the wound with figure-of-eight inverted suture.  The skin was then approximated with staples.  The leg was then cleansed.  Sterile dressing consisting of Adaptic, 4x4, ABDs, and Kerlix roll were then applied.  At this time, the patient was extubated and transferred to recovery in stable condition.  Prognosis is good for this patient.","surgery, degenerative arthritis, nexgen, polyethylene, cruciate, total knee replacement, proximal tibia, knee replacement, femoral, cutting, tibial, knee, arthritis, femur, cementation, "
 NexGen left total knee replacement.  Degenerative arthritis of left knee.  The patient is a 72-year-old female with a history of bilateral knee pain for years progressively worse and decreasing quality of life and ADLs., Surgery, Total Knee Replacement - NexGen ,"PREOPERATIVE DIAGNOSIS: , Degenerative arthritis of left knee.,POSTOPERATIVE DIAGNOSIS:,  Degenerative arthritis of left knee.,PROCEDURE PERFORMED: , NexGen left total knee replacement.,ANESTHESIA: , Spinal.,TOURNIQUET TIME:  Approximately 66 minutes.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , Approximately 50 cc.,COMPONENTS: , A NexGen stemmed tibial component size 5 was used, 10 mm cruciate retaining polyethylene surface, a NexGen cruciate retaining size E femoral component, and a size 38 9.5 mm thickness All-Poly Patella.,BRIEF HISTORY:,  The patient is a 72-year-old female with a history of bilateral knee pain for years progressively worse and decreasing quality of life and ADLs.  She wishes to proceed with arthroplasty at this time.,PROCEDURE:  ,The patient was taken to the Operative Suite at ABCD General Hospital on 09/11/03.  She was placed on the operating table.  Department of Anesthesia administered a spinal anesthetic.  Once adequately anesthetized, the left lower extremity was prepped and draped in the usual sterile fashion.  An Esmarch was applied and a tourniquet was inflated to 325 mmHg on the left thigh.  A longitudinal incision was made over the anterior portion of the knee and this was taken down through the subcutaneous tissue to the level of the patella retinaculum.  A medial peripatellar arthrotomy was then made and taken down to the level of the tibial tubercle.  Care was then ensured that the patellar tendon was not violated.  The proximal tibia was then skeletonized both medially and laterally to the level of the axis through the joint line.  Again care was ensured that the patellar tendon was not avulsed from the insertion on the tibia.  The intramedullary canal was then opened using a drill and the anterior sizing guide was then placed.  Rongeur was used to take out any osteophytes and the size of approximately size E. At this point, the epicondyle axis guide was then inserted and aligned in a proper orientation.  The anterior cutting guide was then placed.  Care was checked for the amount of resection that the femur would be notched and the oscillating saw was used to cut the anterior portion of the femur.  After this was performed, this was removed and the distal femoral cutting guide was then placed.  The left knee placed in 5 degrees of valgus, guide was then placed, and a standard distal cut was then taken.  After the cuts were ensured further to be leveled and they were, and we proceeded to place the finishing guide size E and distal femur.  This was placed slightly in lateral position and secured in position with spring tense and head lift tense.  Once adequately secured and placed in the appropriate orientation, the alignment was again verified with the epicondyle axis and appeared to be externally rotated appropriately.  The chamfer cuts and anterior and posterior cuts were then made as well as the notch cut using the reciprocating and oscillating saws.  After this was performed, the guide was removed and all bony fragments were then removed.  Attention was then directed to the tibia.  The external tibial alignment guide was then placed and pinned to the proximal tibia in a proper position.  Care was ensured if it is was a varus or valgus and the appropriate.  The femur gauge was then used to provide us appropriate amount of bony resection.  This was then pinned and secured into place.  Ligament retractors were used to protect the collateral ligaments and the tip proximal tibial cut was then made.  This bony portion was then removed and remaining meniscal fragments were removed as well as the ACL till adequate exposure was obtained.  Trial components were then inserted into position and taken the range of motion and found to have good and full excellent range of motion stability.  The trial components were then removed.  The tibia was then stemmed in standard fashion after the tibial plate was placed in some degree of external rotation with appropriate alignment.  After it was stemmed and broached, these were removed and the patella was then incised, a size 41 patella reamer blade was then used and was taken down, a size 38 patella button was then placed intact.  Again the trial components were placed back into position.  Patella button was placed and the tracking was evaluated.  They tracked centrally with no touch technique.  Again, all components were now removed and the knee was then copiously irrigated and suctioned dry.  Once adequately suctioned dry, the tibial portion was cemented and packed into place.  Also excess cement was removed.  The femoral component was then cemented into position.  All excess cement was removed.  A size 12 poly was then inserted in trial to provide compression at cement adhered.  The patella was then cemented and held into place.  All components were held under compression until cement had adequately adhered all excess cement was then removed.  The knee was then taken through range of motion and size 12 felt to be slightly too big, this was removed and the size 10 trial was replaced, and again had excellent varus and valgus stability with full range of motion and felt to be the articulate surface of choice.  The knee was again copiously irrigated and suctioned dry.  One last check in the posterior aspect of the knee for any loose bony fragments or osteophytes was performed, there were none found and a final articulating surface was impacted and locked into place.  After this, the knee was taken again for final range of motion and found to have excellent position, stability, and good alignment of the components.  The knee was once again copiously irrigated, and the tourniquet was deflated.  Bovie cautery was used to cauterize the knee bleeding that was seen until good hemostasis obtained.  A drain was then placed deep to the retinaculum and the retinaculum repair was performed using #2-0 Ethibond and oversewn with a #1 Vicryl.  This was flexed and the repair was found held securely.  At this point, the knee was again copiously irrigated and suctioned dry.  The subcutaneous tissue was closed with #2-0 Vicryl, and the skin was approximated with skin staples.  Sterile dressing with Adaptic, 4x4s, ABDs, and Kerlix rolls was then applied.  The patient was then transferred back to the gurney in a supine position.,DISPOSITION: , The patient tolerated well with no complications, to PACU in satisfactory condition.","surgery, degenerative arthritis, nexgen stemmed tibial component, all-poly patella, nexgen cruciate, total knee replacement, patellar tendon, proximal tibia, epicondyle axis, bony fragments, patella button, tibial, knee, arthritis, nexgen, patella"
" Right total knee arthroplasty using a Biomet cemented components, 62.5-mm right cruciate-retaining femoral component, 71-mm Maxim tibial component, and 12-mm polyethylene insert with 31-mm patella.  All components were cemented with Cobalt G.", Surgery, Total Knee Arthoplasty - Right - 1 ,"PREOPERATIVE DIAGNOSIS:,  Severe degenerative joint disease of the right knee.,POSTOPERATIVE DIAGNOSIS: , Severe degenerative joint disease of the right knee.,PROCEDURE:,  Right total knee arthroplasty using a Biomet cemented components, 62.5-mm right cruciate-retaining femoral component, 71-mm Maxim tibial component, and 12-mm polyethylene insert with 31-mm patella.  All components were cemented with Cobalt G.,ANESTHESIA:,  Spinal.,ESTIMATED BLOOD LOSS: , Minimal.,TOURNIQUET TIME: , Less than 60 minutes.,The patient was taken to the Postanesthesia Care Unit in stable condition.  The patient tolerated the procedure well.,INDICATIONS:  ,The patient is a 51-year-old female complaining of worsening right knee pain.  The patient had failed conservative measures and having difficulties with her activities of daily living as well as recurrent knee pain and swelling.  The patient requested surgical intervention and need for total knee replacement.,All risks, benefits, expectations, and complications of surgery were explained to her in great detail and she signed informed consent.  All risks including nerve and vessel damage, infection, and revision of surgery as well as component failure were explained to the patient and she did sign informed consent.  The patient was given antibiotics preoperatively.,PROCEDURE DETAIL:  ,The patient was taken to the operating suite and placed in supine position on the operating table.  She was placed in the seated position and a spinal anesthetic was placed, which the patient tolerated well.  The patient was then moved to supine position again and a well-padded tourniquet was placed on the right thigh.  Right lower extremity was prepped and draped in sterile fashion.  All extremities were padded prior to this.,The right lower extremity, after being prepped and draped in the sterile fashion, the tourniquet was elevated and maintained for less than 60 minutes in this case.  A midline incision was made over the right knee and medial parapatellar arthrotomy was performed.  Patella was everted.  The infrapatellar fat pad was incised and medial and lateral meniscectomy was performed and the anterior cruciate ligament was removed.  The posterior cruciate ligament was intact.,There was severe osteoarthritis of the lateral compartment on the lateral femoral condyle as well as mild-to-moderate osteoarthritis in the medial femoral compartment as well severe osteoarthritis along the patellofemoral compartment.  The medial periosteal tissue on the proximal tibia was elevated to the medial collateral ligament and medial collateral ligament was left intact throughout the entirety of the case.,At the extramedullary tibial guide, an extended cut was made adjusting for her alignment.  Once this was performed, excess bone was removed.  The reamer was placed along on the femoral canal, after which a 6-degree valgus distal cut was made along the distal femur.  Once this was performed, the distal femoral size in 3 degrees external rotation, 62.5-mm cutting block was placed in 3 degrees external rotation with anterior and posterior cuts as well as anterior and posterior Chamfer cuts remained in the standard fashion.  Excess bone was removed.,Next, the tibia was brought anterior and excised to 71 mm.  It was then punched in standard fashion adjusting for appropriate rotation along the alignment of the tibia.  Once this was performed, a 71-mm tibial trial was placed as well as a 62.5-mm femoral trial was placed with a 12-mm polyethylene insert.,Next, the patella was cut in the standard fashion measuring 31 mm and a patella bed was placed.  The knee was taken for range of motion; had excellent flexion and extension as well as adequate varus and valgus stability.  There was no loosening appreciated.  There is no laxity appreciated along the posterior cruciate ligament.,Once this was performed, the trial components were removed.  The knee was irrigated with fluid and antibiotics, after which the cement was put on the back table, this being Cobalt G, it was placed on the tibia.  The tibial components were tagged in position and placed on the femur.  The femoral components were tagged into position.  All excess cement was removed ___ placement of patella.  It was tagged in position.  A 12-mm polyethylene insert was placed; knee was held in extension and all excess cement was removed.  The cement hardened with the knee in full extension, after which any extra cement was removed.,The wounds were copiously irrigated with saline and antibiotics, and medial parapatellar arthrotomy was closed with #2 Vicryl.  Subcutaneous tissue was approximated with #2-0 Vicryl and the skin was closed with staples.  The patient was awakened from general anesthetic, transferred to the gurney, and taken into postanesthesia care unit in stable condition.  The patient tolerated the procedure well.","surgery, degenerative joint disease, knee, total knee arthroplasty, biomet, cemented, cobalt g, arthoplasty, osteoarthritis, polyethylene, cruciate, ligament, patella, femoral, tibial, "
" Infected right hip bipolar arthroplasty, status post excision and placement of antibiotic spacer.  Removal of antibiotic spacer and revision total hip arthroplasty.", Surgery, Total Hip Arthroplasty - Revision ,"PREOPERATIVE DIAGNOSIS: , Infected right hip bipolar arthroplasty, status post excision and placement of antibiotic spacer.,POSTOPERATIVE DIAGNOSIS:,  Infected right hip bipolar arthroplasty, status post excision and placement of antibiotic spacer.,PROCEDURES:,1.  Removal of antibiotic spacer.,2.  Revision total hip arthroplasty.,IMPLANTS,1.  Hold the Zimmer trabecular metal 50 mm acetabular shell with two 6.5 x 30 mm screws.,2.  Zimmer femoral component, 13.5 x 220 mm with a size AA femoral body.,3.  A 32-mm femoral head with a +0 neck length.,ANESTHESIA:  ,Regional.,ESTIMATED BLOOD LOSS: , 500 cc.,COMPLICATIONS:,  None.,DRAINS: , Hemovac times one and incisional VAC times one.,INDICATIONS:,  The patient is a 66-year-old female with a history of previous right bipolar hemiarthroplasty for trauma.  This subsequently became infected.  She has undergone removal of this prosthesis and placement of antibiotic spacer.  She currently presents for stage II reconstruction with removal of antibiotic spacer and placement of a revision total hip.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room by anesthesia personnel.  She was placed supine on the operating table.  A Foley catheter was inserted.  A formal time out was obtained in identifying the correct patient, operative site.  Preoperative antibiotics were held for intraoperative cultures.  The patient was placed into the lateral decubitus position with the right side up.  The previous surgical incision was identified.  The right lower extremity was prepped and draped in standard fashion.  The old surgical incision was reopened along its proximal extent.  Immediately encountered was a large amount of fibrous scar tissue.  Dissection was carried sharply down through this scar tissue.  Soft tissue plains were extremely difficult to visualize due to all the scarring.  There was no native tissue to orient oneself with.  We carried our dissection down through the scar tissue to what seemed to be a fascial layer.  We incised through the fascial layer down to some scarred gluteus maximus muscle and down over what was initially felt to be the greater trochanter.  Dissection was carried down through soft tissue and the distal located antibiotic spacer was exposed.  This was used as a landmark to orient remainder of the dissection.  The antibiotic spacer was exposed and followed distally to expose the proximal femur.  Dissection was continued posteriorly and proximally to expose the acetabulum.  A cobra retractor was able to be inserted across the superior aspect of the acetabulum to enhance exposure.  Once improved visualization was obtained, the antibiotic spacer was removed from the femur.  This allowed further improved visualization of the acetabulum.  The acetabulum was filled with soft tissue debris and scar tissue.  This was removed with sharp excision with a knife as well as with a rongeur and a Bovie.  Once soft tissue was removed, the acetabulum was reamed.  Reaming was started with a 46-mm reamer and carried up sequentially to prepare for 50-mm shell.  The 50 mm shell was trialed and had good stability and fit.  Attention was then turned to continue preparation of the femur.  The canal was then debrided with femoral canal curettes.  Some fibrous tissue was removed from the canal.  The length of the femoral stem was then checked with this canal curette in place.  Following x-rays, we prepared to begin reaming the femur.  This femur was reamed over a guide rod using flexible reaming rods.  The canal was reamed up to 13.5 mm distally in preparation for 14 mm stem.  The stem was selected and initially size A body was placed in trial.  The body was too tight proximally to fit.  The proximal canal was then reamed for a size AA body.  A longer stem with an anterior bow was selected and a size AA trial was assembled.  This fit nicely in the canal and had good fit and fill.  Intraoperative radiographs were obtained to determine component position.  Intraoperative radiographs revealed satisfactory length of the component past the distal of fractures in the femur.  The remainder of the trial was then assembled and the hip was relocated and trialed.  Initially, it was found to be unstable posteriorly.  We changed from a 10 degree lip liner to 20 degree lip liner.  Again, the hip was trialed and found to be unstable posteriorly.  This was due to reversion of the femoral component.  As we attempted to seat the prosthesis, the stent continued to attempt to turn in retroversion.  The stem was extracted and retrialed.  Improved stability was obtained and we decided to proceed with the real components.  A 20 degree liner was inserted into the acetabular shell.  The real femoral components were assembled and inserted into the femoral canal.  Again, the hip was trialed.  The components were found to be in relative retroversion.  The real components were then backed down and the neck was placed in the more anteversion and reinserted.  Again, the stem attempted to follow in the relative retroversion.  Along with this time, however, it was improved from previous attempts.  The femoral head trial was placed back on the components and the hip relocated.  It was taken to a range of motion and found to have improved stability compared to previous trialing.  Decision was made to accept the component position.  The real femoral head was selected and implanted.  The hip was then taken again to a range of motion.  It was stable at 90 degrees of flexion with 20 degrees of adduction and 40 degrees of internal rotation.  The patient reached full extension and had no instability anteriorly.,The wound was then irrigated again with pulsatile lavage.  Six liters of pulsatile lavage was used during the procedure.,The wound was then closed in a layered fashion.  A Hemovac drain was placed deep to the fascial layer.  The subcutaneous tissues were closed with #1 PDS, 2-0 PDS, and staples in the skin.  An incisional VAC was then placed over the wound as well.  Sponge and needle counts were correct at the close of the case.,DISPOSITION:,  The patient will be weightbearing as tolerated with posterior hip precautions.","surgery, infected, bipolar arthroplasty, antibiotic spacer, revision, placement of antibiotic spacer, total hip arthroplasty, scar tissue, soft tissue, antibiotic, spacer, femoral, hip, arthroplasty, total, acetabulum, femur, "
"  Right knee total arthroplasty.  Degenerative osteoarthritis, right knee.", Surgery, Total Knee Arthroplasty ,"PREOPERATIVE DIAGNOSIS:,  Degenerative osteoarthritis, right knee.,POSTOPERATIVE DIAGNOSIS: , Degenerative osteoarthritis, right knee.,PROCEDURE PERFORMED: ,Right knee total arthroplasty.,ANESTHESIA: , The procedure was done under a subarachnoid block anesthetic in the supine position with a tourniquet utilized.,TOTAL TOURNIQUET TIME: , Approximately 90 minutes.,SPECIFICATIONS: , The entire procedure is done in the inpatient operating suite in the Room #1 at ABCD General Hospital.  The following sizes of NexGen system were utilized:  E on right femur, cemented; 5 tibial stem tray with a 10 mm polyethylene insert, and a 32 mm patellar button.,HISTORY AND GROSS FINDINGS: , This is a 58-year-old white female suffering increasing right knee pain for number of years prior to surgical intervention.  She was completely refractory to conservative outpatient therapy.  She had undergone two knee arthroscopies in the years preceding this.  They were performed by myself.  She ultimately failed this treatment and developed a collapsing-type valgus degenerative osteoarthritis with complete collapse and ware of the lateral compartment and degenerative changes noted to the femoral sulcus that were proved live.  Medial compartment had minor changes present.  There was no contracture of the lateral collateral ligament, but instead mild laxity on both sides.  There was no significant flexion contracture preoperatively.,OPERATIVE PROCEDURE:  ,The patient was laid supine upon the operating table after receiving a subarachnoid block anesthetic by the Anesthesia Department.  Thigh tourniquet was placed upon the patient's right leg.  She was prepped and draped in the usual sterile manner.  The limb was elevated and exsanguinated and tourniquet placed 325 mmHg for the above noted time.  A straight incision was carried down through the skin and subcutaneous tissue.  Hemostasis was controlled with electrocoagulation.  Medial parapatellar arthrotomy was created and the knee cap was everted.  The ligaments were balanced.  A portion of the fat pad was removed and the ACL was completely removed.  Drill hole was made in the distal femur.  The size to an E, right.  Care was taken to make up for the severe loss of articular cartilage on the posterior condyle in the lateral side.  This was checked with the epicondylar abscess and with three degrees of external rotation, drill holes were made.  Intramedullary guide was then placed, pegged, and anterior cut carried out.  There was excellent resection.  It was flat.  Distal cutting guide was then placed in five degrees of valgus.  Appropriate cuts were carried out.  The standard cut was utilized.,The finishing guide for E was held with pins as well as screws.  Cutting was carried out posterior to anterior, then posterior chamfer and anterior chamfer, femoral sulcus cut was carried out and drill holes for pegs were made.  The cutting guide was then removed.  The bone was removed.  Excess bone was taken out posteriorly.  The posterior capsule was loosened up.  There were two different fabellas in the posterolateral compartment and they were loosened.  Posterolateral corner was then anchored with osteotome and was taken around the posterolateral corner.  An extramedullary tibial cutting guide was then placed, pinned, and held.  A cut was carried out parallel to the foot.  Hard copy ________ was obtained, deemed to be satisfactory after evening up the edges.  Trial range of motion was satisfactory.  It was necessary to perform a lateral retinacular release to the patella.  The patella was isolated.  Approximately 10 mm to 11 mm were reamed off.  The size to 32 mm button and drill hole guide was placed, impacted, and drilled.  Trial range of motion was satisfactory.  The tibial guide was then pinned.  Drill hole was placed, broached, and utilized.  Copious irrigation was carried out.  Methylmethacrylate was mixed and was sequentially placed from the femur to the tibia to the patella.  The implants were sequentially placed in tibia to femur to patella.  Once excess methylmethacrylate was removed and cured, 10 mm Poly was placed.  There was excellent ligament balancing.  A separate portal was utilized for subcutaneous drain.  Tourniquet was deflated and hemostasis was controlled with electrocoagulation.  Interrupted #1 Ethibond suture was utilized for parapatellar closure, running #1 Vicryl suture was utilized for overstitch.,Trial range of motion was satisfactory.  Interrupted #2-0 Vicryl was utilized for subcutaneous fat closure and skin staples were placed to the skin.  Adaptic, 4x4s, ABDs, and Webril were placed for compression dressing.  Digits were pink and warm with brawny pulses distally at the end of the case.  The patient was then transferred to PACU in apparent satisfactory condition.  Expected surgical prognosis on this patient is fair.","surgery, arthroplasty, knee, degenerative osteoarthritis, subcutaneous, osteoarthritis, degenerative, tourniquet, drill,"
" Total hip arthroplasty on the left.  Left hip degenerative arthritis.  Severe degenerative changes within the femoral head as well as the acetabulum, anterior as well as posterior osteophytes. ", Surgery, Total Hip Arthroplasty ,"PREOPERATIVE DIAGNOSIS: , Left hip degenerative arthritis.,POSTOPERATIVE DIAGNOSIS: , Left hip degenerative arthritis.,PROCEDURE PERFORMED:  ,Total hip arthroplasty on the left.,ANESTHESIA:  ,General.,BLOOD LOSS: , 800 cc.,The patient was positioned with the left hip exposed on the beanbag.,IMPLANT SPECIFICATION: , A 54 mm Trilogy cup with cluster holes 3 x 50 mm diameter with a appropriate liner, a 28 mm cobalt-chrome head with a zero neck length head, and a 12 mm porous proximal collared femoral component.,GROSS INTRAOPERATIVE FINDINGS:  ,Severe degenerative changes within the femoral head as well as the acetabulum, anterior as well as posterior osteophytes.  The patient also had a rent in the attachment of the hip abductors and a partial rent in the vastus lateralis.  This was revealed once we removed the trochanteric bursa.,HISTORY:  ,This is a 56-year-old obese female with a history of bilateral degenerative hip arthritis.  She underwent a right total hip arthroplasty by Dr. X in the year of 2000, and over the past three years, the symptoms in her left hip had increased tremendously especially in the past few months.,Because of the increased amount of pain as well as severe effect on her activities of daily living and uncontrollable pain with narcotic medication, the patient has elected to undergo the above-named procedure.  All risks as well complications were discussed with the patient including but not limited to infection, scar, dislocation, need for further surgery, risk of anesthesia, deep vein thrombosis, and implant failure.  The patient understood all these risks and was willing to continue further on with the procedure.,PROCEDURE: , The patient was wheeled back to the Operating Room #2 at ABCD General Hospital on 08/27/03.  The general anesthetic was first performed by the Department of Anesthesia.  The patient was then positioned with the left hip exposed on the beanbag in the lateral position.  Kidney rests were also used because of the patient's size.  An axillary roll was also inserted for comfort in addition to a Foley catheter, which was inserted by the OR nurse.  All her bony prominences were well padded.  At this time, the left hip and left lower extremity was then prepped and draped in the usual sterile fashion for this procedure.  At this time, an anterolateral approach was then performed, first incising through the skin in approximately 5 to 6 inches of subcutaneous fat.  The tensor fascia lata was then identified.  A self-retainer was then inserted to expose the operative field.  Bovie cautery was used for hemostasis.  At this time, a fresh blade was then used to incise the tensor fascia lata over the posterior one-third of the greater trochanter.  At this time, a blunt dissection was taken proximally.  The tensor fascia lata was occluded with a hip retractor.  At this time, after hemostasis was obtained, Bovie cautery was used to incise the proximal end of the vastus lateralis and removing the partial portion of the hip abductor, the gluteus medius.  At this time, a periosteal elevator was used to expose anterior hip capsule.  A ________ was then inserted over the femoral head purchasing of the acetabulum underneath the reflected head of the quadriceps muscle.  Once this was performed, Homan retractors were then inserted superiorly and inferiorly underneath the femoral neck.  At this time, a capsulotomy was then performed using a Bovie cautery and the capsulotomy was ________ and then edged over the acetabulum.  At this point, a large bone hook was then inserted over the neck and with gentle traction and external rotation, the femoral head was dislocated out of the acetabulum.  At this time, we had an exposure of the femoral head, which did reveal degenerative changes of the femoral head and once the acetabulum was visualized, we did see degenerative changes within the acetabulum as well as osteophyte formation around the rim of the acetabulum.  At this time, a femoral stem guide was then used to measure proximal femoral neck cut.  We made a cut approximately a fingerbreadth above the lesser trochanter.  At this time, with protection of the soft tissues an oscillating saw was used to make femoral neck cut.,The femoral head was then removed.  At this time, we removed the leg out of the bag and Homan retractors were then used to expose the acetabulum.  A long-handle knife was used to cut through the remainder of the capsule and remove the glenoid labrum around the rim of the acetabulum.  With better exposure of the acetabulum, we started reaming the acetabulum.  We started with a size #44 and progressively reamed to a size #50.  At the size #50 mm reamer, we obtained excellent bony bleeding with good remainder of bone stalk both anteriorly and posteriorly as well as superiorly within the acetabulum.  We then reamed up to size #52 in order to get bony bleeding around the rim as well as anterior and posterior within the acetabulum.  A size 54 mm Trilogy cup was then implanted with excellent approaches approximately 45 degrees of abduction and 10 to 15 degrees of anteversion dialed in.  Once the cup was impacted in place, we did visualize that the cup was well seated on to the internal portion of the acetabulum.  At this time, two screws were the placed within the superior table for better approaches securing the acetabular cup.  At this time, a plastic liner was then inserted for protection.  The leg was then placed back in the bag.  A Bennett retractor was used to retract the tensor fascia lata and femoral elevator was used to elevate the femur for better exposure and at this time, we began working on the femur.  A rongeur was used to lateralize over the greater trochanter.  A Box osteotome was used to remove the cancellous portion of the femoral neck.  A Charnley awl was then used to cannulate through the proximal femoral canal.  A power reamer was then used to ream the lateral aspect of the greater trochanter in order to provide maximal lateralization and prevent varus implantation of our stem.  At this time, we began broaching.  We started with a size #10 and progressively worked up to a size #12 mm broach.  Once the 12 mm broach was inserted in place, it was seated approximately 1 mm below the calcar.  A calcar reamer was then placed and the calcar was reamed smoothly.  A standard neck as well as a 28 mm plastic head was then placed and a trial reduction was then performed.  Once this was performed, the hip was taken to range of motion with external rotation, longitudinal traction as well as flexion and revealed good stability with no impingement or dislocation.  At this time, we removed 12 mm broach and proceeded with implanting our polyethylene liner within the acetabulum.  This was impacted and placed and checked to assure that it was well seated with no loosening.  Once this was performed, we then exposed the proximal femur one more time.  We copiously irrigated within the canal and then suctioned it dry.  At this time, a 12 mm porous proximal collared stem, a femoral component was then impacted in place.  Once it was well seated on the calcar, we double checked to assure that there was no evidence of calcar fractures, which there were none.  The 28 mm zero neck length cobalt-chrome femoral head was then impacted in place and the Morse taper assured that this was well fixed by ________.,Next, the hip was then reduced within the acetabulum and again we checked range of motion as well as ligamentous stability with gentle traction, external rotation, as well as hip flexion.  We were satisfied with components as well as the alignment of the components.  Copious irrigation was then used to irrigate the wound.  #1 Ethibond was then used to approximate the anterior hip capsule.  #1 Ethibond in interrupted fashion was used to approximate the vastus lateralis as well as the gluteus medius attachment over the partial gluteus medius attachment which was resected off the greater trochanter.  Next, a #1 Ethibond was then used to approximate the tensor fascia lata with figure-of-eight closure.  A tight closure was performed.  Since the patient did have a lot of subcutaneous fat, multiple #2-0 Vicryl sutures were then used to approximate the bed space and then #2-0 Vicryl for the subcutaneous skin.  Staples were then used for skin closure.  The patient's hip was then cleansed.  Sterile dressings consisting of Adaptic, 4 x 4, ABDs, and foam tape were then placed.  A drain was placed prior to wound closure for postoperative drainage.  After the dressing was applied, the patient was extubated safely and transferred to recovery in stable condition.  Prognosis is good.","surgery, degenerative arthritis, total hip arthroplasty, tensor fascia lata, vastus lateralis, gluteus medius, femoral neck, femoral head, head, femoral, acetabulum, hip, attachment, arthroplasty,"
" Total hip replacement.  An incision was made, centered over the greater trochanter.  Dissection was sharply carried down through the subcutaneous tissues. ", Surgery, Total Hip Replacement - 1 ,"PROCEDURE:,  Total hip replacement.,PROCEDURE DESCRIPTION:,  The patient was bought to the operating room and placed in the supine position.  After induction of anesthesia, the patient was turned on the side and secured in the hip table.  An incision was made, centered over the greater trochanter.  Dissection was sharply carried down through the subcutaneous tissues.  The gluteus maximus was incised and split proximally.  The piriformis and external rotators were identified.  These were removed from their insertions on the greater trochanter as a sleeve with the hip capsule.  The hip was dislocated.  A femoral neck cut was made using the guidance of preoperative templating.  The femoral head was removed.  Extensive degenerative disease was found on the femoral head as well as in the acetabulum.,Baseline leg-length measurements were taken.  The femur was retracted anteriorly and a complete labrectomy was performed.  Reaming of the acetabulum was then performed until adequate bleeding subchondral bone was identified in the key areas.  The trial shell was placed and found to have an excellent fit.  The real shell was opened and impacted into position in the appropriate amount of anteversion and abduction.  Screws were placed by drilling into the pelvis, measuring, and placing the appropriate length screw.  Excellent purchase was obtained.  The trial liner was placed.,The femur was then flexed and internally rotated.  The extra trochanteric bone was removed, as was any leftover lateral soft tissue at the piriformis insertion.  An intramedullary hole was drilled into the femur to define the canal.  Reaming was performed until the appropriate size was reached.  The broaches were then used to prepare the femur with the appropriate amount of version.  Once the appropriate size broach was reached, it was used as a trial with head and neck placement.  Hip range-of-motion was checked in all planes, including flexion-internal rotation, the position of sleep, and extension-external rotation.  The hip was found to have excellent stability with the final chosen head-neck combination.  Leg length measurements were taken and found to be within acceptable range, given the necessity for stability.,The real stem was opened and impacted into position.  The real head was impacted atop the stem.  If cement was used, the canal was thoroughly washed and dried and plugged with a restrictor, and then the cement was injected and pressurized and the stem was implanted in the appropriate version.  Excess cement was removed from the edges of the component.  Range of motion and stability were once again checked and found to be excellent.  Adequate hemostasis was obtained.  Vigorous power irrigation was used to remove all debris from the joint prior to final reduction.,The arthrotomy and rotators were closed using #1 Ethibond through drill holes in the bone, recreating the posterior hip structural anatomy.  The gluteus maximus was repaired using 0 Ethibond and 0 Vicryl.  The subcutaneous tissues were closed after further irrigation with 2-0 Vicryl and Monocryl sutures.  The skin was closed with nylon.  Xeroform and a sterile dressing were applied followed by a cold pack and Ace wrap.  The patient was transferred to the recovery room in stable condition, having tolerated the procedure well.","surgery, range-of-motion, hip, total hip replacement, gluteus maximus, femoral head, subcutaneous tissues, incision, ethibond, trochanter, subcutaneous, acetabulum, femur"
 Right hip osteoarthritis.  Total hip replacement on the right side., Surgery, Total Hip Replacement  ,"PREOPERATIVE DIAGNOSIS: , Right hip osteoarthritis.,POSTOPERATIVE DIAGNOSIS: , Right hip osteoarthritis.,PROCEDURES PERFORMED: , Total hip replacement on the right side using the following components:,1.  Zimmer trilogy acetabular system 10-degree elevated rim located at the 12 o'clock position.,2.  Trabecular metal modular acetabular system 48 mm in diameter.,3.  Femoral head 32 mm diameter +0 mm neck length.,4.  Alloclassic SL offset stem uncemented for taper.,ANESTHESIA: , Spinal.,DESCRIPTION OF PROCEDURE IN DETAIL:,  The patient was brought into the operating room and was placed on the operative table in a lateral decubitus position with the right side up.  After review of allergies, antibiotics were administered and time out was performed.  The right lower extremity was prepped and draped in a sterile fashion.  A 15 cm to 25 cm in length, an incision was made over the greater trochanter.  This was angled posteriorly.  Access to the tensor fascia lata was performed.  This was incised with the use of scissors.  Gluteus maximus was separated.  The bursa around the hip was identified, and the bleeders were coagulated with the use of Bovie.  Hemostasis was achieved.  The piriformis fossa was identified, and the piriformis fossa tendon was elevated with the use of a Cobb.  It was detached from the piriformis fossa and tagged with 2-0 Vicryl.  Access to the capsule was performed.  The capsule was excised from the posterior and superior aspects.  It was released also in the front with the use of a Mayo scissors.  The hip was then dislocated.  With the use of an oscillating saw, the femoral neck cut was performed.  The acetabulum was then visualized and debrided from soft tissues and osteophytes.  Reaming was initiated and completed for a 48 mm diameter cap without complications.  The trial component was put in place and was found to be stable in an anatomic position.  The actual component was then impacted in the acetabulum.  A 10-degree lip polyethylene was also placed in the acetabular cap.  Our attention was then focused to the femur.  With the use of a cookie cutter, the femoral canal was accessed.  The broaching process was initiated for No.4 trial component.  Trialing of the hip with the hip flexed at 90 degrees and internally rotated to 30 degrees did not demonstrate any obvious instability or dislocation.  In addition, in full extension and external rotation, there was no dislocation.  The actual component was inserted in place and hemostasis was achieved again.  The wound was irrigated with normal saline.  The wound was then closed in layers.  Before performing that the medium-sized Hemovac drain was placed in the wound.  The tensor fascia lata was closed with 0 PDS and the wound was closed with 2-0 Monocryl.  Staples were used for the skin.  The patient recovered from anesthesia without complications.,EBL: , 50 mL.,IV FLUIDS: , 2 liters.,DRAINS: , One medium-sized Hemovac.,COMPLICATIONS: , None.,DISPOSITION: , The patient was transferred to the PACU in stable condition.  She will be weightbearing as tolerated to the right lower extremity with posterior hip precautions.  We will start the DVT prophylaxis after the removal of the epidural catheter.","surgery, total hip replacement, epidural catheter, tensor fascia lata, hemostasis was achieved, medium sized hemovac, tensor fascia, fascia lata, trial component, medium sized, sized hemovac, total hip, hip replacement, hip osteoarthritis, piriformis fossa, total, hip, acetabular, extremity, tensor, fascia, hemostasis, acetabulum, dislocation, hemovac, replacement, osteoarthritis, femoral, piriformis, fossa, components, anesthesia, "
 Total abdominal hysterectomy (TAH) with a uterosacral vault suspension.   Enlarged fibroid uterus and abnormal uterine bleeding. , Surgery, Total Abdominal Hysterectomy - 3 ,"PREOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Abnormal uterine bleeding.,POSTOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Abnormal uterine bleeding.,PROCEDURE PERFORMED: , Total abdominal hysterectomy with a uterosacral vault suspension.,ANESTHESIA: , General with endotracheal tube as well as spinal with Astramorph.,ESTIMATED BLOOD LOSS: , 150 cc.,URINE OUTPUT:  ,250 cc of clear urine at the end of the procedure.,FLUIDS:,  2000 cc of crystalloids.,COMPLICATIONS: , None.,TUBES: , None.,DRAINS:  ,Foley to gravity.,PATHOLOGY: , Uterus, cervix, and multiple fibroids were sent to pathology for review.,FINDINGS:  ,On exam, under anesthesia, normal appearing vulva and vagina, a massively enlarged uterus approximately 20 weeks' in size with irregular contours suggestive of fibroids.,Operative findings demonstrated a large fibroid uterus with multiple subserosal and intramural fibroids as well as there were some filmy adnexal adhesions bilaterally.  The appendix was normal appearing.  The bowel and omentum were normal appearing.  There was no evidence of endometriosis.  Peritoneal surfaces and vesicouterine peritoneum as well as appendix and cul-de-sac were all free of any evidence of endometriosis.,PROCEDURE:,  After informed consent was obtained and all questions were answered to the patient's satisfaction in layman's terms, she was taken to the Operating Room where first a spinal anesthesia with Astramorph was obtained without any difficulty.  She then underwent a general anesthesia with endotracheal tube also without any difficulty.  She was then examined under anesthesia with noted findings as above.  The patient was then placed in dorsal supine position and prepped and draped in the usual sterile fashion..  A vertical skin incision was made 1 cm below the umbilicus extending down to 2 cm above the pubic symphysis.  This was made with a first knife and then carried down to the underlying layer of the fascia with the second knife.  Fascia was excised in the midline and extended superiorly and inferiorly with the Mayo scissors.  The rectus muscle was then separated in the midline.  The peritoneum identified and entered bluntly.  The peritoneal incision was then extended superiorly and inferiorly with external visualization of the bladder.  The uterus was markedly evident upon entering the peritoneal cavity.  The uterus was then exteriorized and noted to have the findings as above.  At this point, approximately 10 cc of vasopressin 20 units and 30 cc was injected into the uterine fundus and multiple fibroids were removed by using the incision with the Bovie and then using a blunt and the sharp dissection and grasping with Lahey clamps.  Once the debulking of the uterus was felt appropriate to proceed with the hysterectomy, the uterus was then reapproximated with a few #0 Vicryl sutures in a figure-of-eight fashion.  The round ligaments were identified bilaterally and clamped with the hemostats and transacted with the Metzenbaum scissors.  The round ligaments were then bilaterally tied with the #0 tie and noted to be hemostatic.  The uterovarian vessels bilaterally were then isolated through a vascular window created from taking down the round ligaments.  The uterovarian vessels bilaterally were #0 tied and then doubly clamped with straight Ochsner clamps and transacted and suture tied with a Heaney hand stitch fashion, and both uterine and ovarian vessels were noted to be hemostatic.  At this time, the attention was then turned to the vesicouterine peritoneum, which was tented up with Allis clamps and the bladder flap was then created sharply with Russian pickups and the Metzenbaum scissors.  Then the bladder was bluntly dissected off the underlying cervix with a moist Ray-Tec sponge down to the level of the cervix.,At this point, the uterus was pulled on traction and the uterosacral ligaments were easily visualized.  Using #2-0 PDS suture, the suture was placed through both uterosacral ligaments distally with a backhand stitch fashion throwing the sutures from lateral to medial.  These sutures were then tagged and saved for later.  The uterine vessels were then identified bilaterally and skeletonized, then clamped with straight Ochsner clamps balancing off the cervix, and the uterine vessels were then transacted and suture ligated with #0 Vicryl and noted to be hemostatic.  In a similar fashion, the broad ligament down to the level of the cardinal ligaments was clamped with curved Ochsner and transacted and suture ligated and noted to be hemostatic.  At this point, the Lahey clamp was placed on the cervix and the cervix was tented up.  The pubocervical vesical fascia was transacted with long knife.  Then while protecting posteriorly, using the double-pointed scissors, the vagina was entered with double-pointed scissors at the level of the cervix and was grasped with a straight Ochsner clamp.  The uterus and cervix were then amputated using the Jorgenson scissors and the cuff was outlined with Ochsner clamps.  The cuff was then copiously painted with Betadine soaked sponge.  The Betadine-soaked sponge was placed in the patient's vagina.  Then the cuff was then closed with a #0 Vicryl in a running locked fashion to make sure to bring the ipsilateral cardinal ligaments into the vaginal cuff.  This was accomplished with one #0 Vicryl running stitch and then an Allis clamp was placed in the midsection portion of the cuff and tented up and a #0 Vicryl figure-of-eight was placed in the midsection portion of the cuff.  At this time, the uterosacral ligaments previously tagged needle was brought through the cardinal ligament and the uterosacral ligament on the ipsilateral side.  The needle was cut off and these were then tagged with the hemostats.  The cuff was then closed by taking the running suture and bringing back through the posterior peritoneum, grabbing part of the uterosacral and midsection portion of the posterior peritoneum of the uterosacral and then tying the cuff down to bunch and cuff together.  The suture in the midportion of the cuff was then used to tie down the round ligaments bilaterally to the cuff.  The abdomen was copiously irrigated with warm normal saline.  All areas were noted to be hemostatic.  Then the previously tagged uterosacral sutures were then tied bringing the vaginal cuff angles down to the uterosacral ligaments.  The abdomen was then once again copiously irrigated with warm normal saline.  All areas were noted to be hemostatic.  The sigmoid colon was replaced back into the hollow of the sacrum.  Then the omentum was pulled over the bowel.  After the myomectomy was performed, the GYN Balfour was placed into the patient's abdomen and the bowel was packed away with moist laparotomy sponges.  The GYN Balfour was then removed.  Packing sponges were removed and the fascia was then closed in an interrupted figure-of-eight fashion with #0 Vicryl.,Skin was closed with staples.  The patient tolerated the procedure well.  The sponge, lap, and needle counts were correct x2.  The sponge from the patient's vagina was removed and the vagina was noted to be hemostatic.  The patient would be followed throughout her hospital stay.",
" Aortic stenosis.   Insertion of a Toronto stentless porcine valve, cardiopulmonary bypass, and cold cardioplegia arrest of the heart.", Surgery, Toronto Porcine Valve Insertion ,"PREOPERATIVE DIAGNOSIS:,  Aortic stenosis.,POSTOPERATIVE DIAGNOSIS:  ,Aortic stenosis.,PROCEDURES PERFORMED,1.  Insertion of a **-mm Toronto stentless porcine valve.,2.  Cardiopulmonary bypass.,3.  Cold cardioplegia arrest of the heart.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS:  , 300 cc.,INTRAVENOUS FLUIDS:  , 1200 cc of crystalloid.,URINE OUTPUT:  , 250 cc.,AORTIC CROSS-CLAMP TIME: , **,CARDIOPULMONARY BYPASS TIME TOTAL: , **,PROCEDURE IN DETAIL:,  After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and general endotracheal anesthesia was administered.  Next the neck, chest and legs were prepped and draped in the standard surgical fashion.  We used a #10-blade scalpel to make a midline median sternotomy incision.  Dissection was carried down to the left of the sternum using Bovie electrocautery.  The sternum was opened with a sternal saw.  The chest retractor was positioned.  Next, full-dose heparin was given.  The pericardium was opened.  Pericardial stay sutures were positioned.  After obtaining adequate ACT, we prepared to place the patient on cardiopulmonary bypass.  A 2-0 double pursestring of Ethibond suture was placed in the ascending aorta.  Through this was passed an aortic cannula connected to the arterial side of the cardiopulmonary bypass machine.  Next a 3-0 Prolene pursestring was placed in the right atrial appendage.  Through this was passed our venous cannula connected to the venous portion of the cardiopulmonary bypass machine.  A 4-0 U-stitch was placed in the right atrium.  A retrograde cardioplegia catheter was positioned at this site.  Next, scissors were used to dissect out the right upper pulmonary vein.  A 4-0 Prolene pursestring was placed in the right upper pulmonary vein.  Next, a right-angle sump was placed at this position.  We then connected our retrograde cardioplegia catheter to the cardioplegia solution circuit.  Bovie electrocautery was used to dissect the interface between the aorta and pulmonary artery.  The aorta was completely encircled.  Next, an antegrade cardioplegia needle and associated sump were placed in the ascending aorta.  We then prepared to cross-clamp the aorta.  We went down on our flows and cross-clamped the aorta.  We backed up our flows.  We then gave antegrade and retrograde cold blood cardioplegia solution circuit so as to arrest the heart.  The patient had some aortic insufficiency so we elected, after initially arresting the heart, to open the aorta and transect it and then give direct ostial infusion of cardioplegia solution circuit.  Next, after obtaining complete diastolic arrest of the heart, we turned our attention to exposing the aortic valve, and 4-0 Tycron sutures were placed in the commissures.  In addition, a 2-0 Prolene suture was placed in the aortic wall so as to bring the aortic wall and root up into view.  Next, scissors were used to excise the diseased aortic valve leaflets.  Care was taken to remove all the calcium from the aortic annulus.  We then sized up the aortic annulus which came out to be a **-mm stentless porcine Toronto valve.  We prepared the valve.  Next, we placed our proximal suture line of interrupted 4-0 Tycron sutures for the annulus.  We started with our individual commissural stitches.  They were connected to our valve sewing ring.  Next, we placed 5 interrupted 4-0 Tycron sutures in a subannular fashion at each commissural position.  After doing so, we passed 1 end of the suture through the sewing portion of the Toronto stentless porcine valve.  The valve was lowered into place and all of the sutures were tied.  Next, we gave another round of cold blood antegrade and retrograde cardioplegia.  Next, we sewed our distal suture line.  We began with the left coronary cusp of the valve.  We ran a 5-0 RB needle up both sides of the valve.  Care was taken to avoid the left coronary ostia.  This procedure was repeated on the right cusp of the stentless porcine valve.  Again, care was taken to avoid any injury to the coronary ostia.  Lastly, we sewed our non-coronary cusp.  This was done without difficulty.  At this point we inspected our aortic valve.  There was good coaptation of the leaflets, and it was noted that both the left and the right coronary ostia were open.  We gave another round of cold blood antegrade and retrograde cardioplegia.  The antegrade portion was given in a direct ostial fashion once again.  We now turned our attention to closing the aorta.  A 4-0 Prolene double row of suture was used to close the aorta in a running fashion.  Just prior to closing, we de-aired the heart and gave a warm shot of antegrade and retrograde cardioplegia.  At this point, we removed our aortic cross-clamp.  The heart gradually regained its electromechanical activity.  We placed 2 atrial and 2 ventricular pacing wires.  We removed our aortic vent and oversewed that site with another 4-0 Prolene on an SH needle.  We removed our retrograde cardioplegia catheter.  We oversewed that site with a 5-0 Prolene.  By now, the heart was de-aired and resumed normal electromechanical activity.  We began to wean the patient from cardiopulmonary bypass.  We then removed our venous cannula and suture ligated that site with a #2 silk.  We then gave full-dose protamine.  After knowing that there was no evidence of a protamine reaction, we removed the aortic cannula.  We buttressed that site with a 4-0 Prolene on an SH needle.  We placed a mediastinal chest tube and brought it out through the skin.  We also placed 2 Blake drains, 1 in the left chest and 1 in the right chest, as the patient had some bilateral pleural effusions.  They were brought out through the skin.  The sternum was closed with #7 wires in an interrupted figure-of-eight fashion.  The fascia was closed with #1 Vicryl.  We closed the subcu tissue with 2-0 Vicryl and the skin with 4-0 PDS.","surgery, cardioplegia, toronto stentless porcine valve, tycron sutures, coronary ostia, porcine valve, retrograde cardioplegia, cardiopulmonary bypass, sutures, valve, insertion, toronto, aortic, stentless, chest, coronary, porcine, cardiopulmonary, prolene, atrial, bypass, heart, aorta,"
" Total abdominal hysterectomy..  Severe menometrorrhagia unresponsive to medical therapy, anemia, and symptomatic fibroid uterus.", Surgery, Total Abdominal Hysterectomy - 1 ,"PREOPERATIVE DIAGNOSES:,1.  Severe menometrorrhagia unresponsive to medical therapy.,2.  Anemia.,3.  Symptomatic fibroid uterus.,POSTOPERATIVE DIAGNOSES:,1.  Severe menometrorrhagia unresponsive to medical therapy.,2.  Anemia.,3.  Symptomatic fibroid uterus.,PROCEDURE: , Total abdominal hysterectomy.,ANESTHESIA:  ,General.,ESTIMATED BLOOD LOSS: , 150 mL.,COMPLICATIONS: , None.,FINDING:  ,Large fibroid uterus.,PROCEDURE IN DETAIL:  ,The patient was prepped and draped in the usual sterile fashion for an abdominal procedure.  A scalpel was used to make a Pfannenstiel skin incision, which was carried down sharply through the subcutaneous tissue to the fascia.  The fascia was nicked in the midline and incision was carried laterally bilaterally with curved Mayo scissors.  The fascia was then bluntly and sharply dissected free from the underlying rectus abdominis muscles.  The rectus abdominis muscles were then bluntly dissected in the midline and this incision was carried forward inferiorly and superiorly with care taken to avoid bladder and bowel.  The peritoneum was then bluntly entered and this incision was carried forward inferiorly and superiorly with care taken to avoid bladder and bowel.  The O'Connor-O'Sullivan instrument was then placed without difficulty.  The uterus was grasped with a thyroid clamp and the entire pelvis was then visualized without difficulty.  The GIA stapling instrument was then used to separate the infundibulopelvic ligament in a ligated fashion from the body of the uterus.  This was performed on the left infundibulopelvic ligament and the right infundibulopelvic ligament without difficulty.  Hemostasis was noted at this point of the procedure.  The bladder flap was then developed free from the uterus without difficulty.  Careful dissection of the uterus from the pedicle with the uterine arteries and cardinal ligaments was then performed using #1 chromic suture ligature in an interrupted fashion on the left and right side.  This was done without difficulty.  The uterine fundus was then separated from the uterine cervix without difficulty.  This specimen was sent to pathology for identification.  The cervix was then developed with careful dissection.  Jorgenson scissors were then used to remove the cervix from the vaginal cuff.  This was sent to pathology for identification.  Hemostasis was noted at this point of the procedure.  A #1 chromic suture ligature was then used in running fashion at the angles and along the cuff.  Hemostasis was again noted.  Figure-of-eight sutures were then used in an interrupted fashion to close the cuff.  Hemostasis was again noted.  The entire pelvis was washed.  Hemostasis was noted.  The peritoneum was then closed using 2-0 chromic suture ligature in running pursestring fashion.  The rectus abdominis muscles were approximated using #1 chromic suture ligature in an interrupted fashion.  The fascia was closed using 0 Vicryl in interlocking running fashion.  Foundation sutures were then placed in an interrupted fashion for further closing the fascia.  The skin was closed with staple gun.  Sponge and needle counts were noted to be correct x2 at the end of the procedure.  Instrument count was noted to be correct x2 at the end of the procedure.  Hemostasis was noted at each level of closure.  The patient tolerated the procedure well and went to recovery room in good condition.","surgery, menometrorrhagia, fibroid, uterus, total abdominal hysterectomy, rectus abdominis muscles, fibroid uterus, suture ligature, therapy, hemostasis, anemia, abdominal,"
" Total Abdominal Hysterectomy (TAH).  An incision was made into the abdomen down through the subcutaneous tissue, muscular fascia and peritoneum.  Once inside the abdominal cavity, a self-retaining retractor was placed to expose the pelvic cavity with 3 lap sponges. ", Surgery, Total Abdominal Hysterectomy ,,"surgery, fundus, double-toothed tenaculum, muscular fascia, total abdominal hysterectomy, vicryl suture, abdominal, incision, hysterectomy, uterine, cavity, uterus, ligaments, peritoneum, vicrylNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Total abdominal hysterectomy.  Enlarged fibroid uterus, pelvic pain, and pelvic endometriosis.  On laparotomy, the uterus did have multiple pedunculated fibroids.", Surgery, Total Abdominal Hysterectomy - 2 ,"PREOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Pelvic pain.,POSTOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Pelvic pain.,3.  Pelvic endometriosis.,PROCEDURE PERFORMED: ,Total abdominal hysterectomy.,ANESTHESIA: , General endotracheal and spinal with Astramorph.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , 200 cc.,FLUIDS:  ,2400 cc of crystalloids.,URINE OUTPUT: , 100 cc of clear urine.,INDICATIONS:,  This is a 40-year-old female gravida-0 with a history of longstanding enlarged fibroid uterus.  On ultrasound, the uterus measured 14 cm x 6.5 cm x 7.8 cm.  She had received two dosage of Lupron to help shrink the fibroid.  Her most recent Pap smear was normal.,FINDINGS: , On a manual exam, the uterus is enlarged approximately 14 to 16 weeks size with multiple fibroids palpated.  On laparotomy, the uterus did have multiple pedunculated fibroids, the largest being approximately 7 cm.  The bilateral tubes and ovaries appeared normal.,There was evidence of endometriosis on the posterior wall of the uterus as well as the bilateral infundibulopelvic ligament.  There was some adhesions of the bowel to the left ovary and infundibulopelvic ligament and as well as to the right infundibulopelvic ligament.,PROCEDURE:,  After consent was obtained, the patient was taken to the operating room where spinal anesthetic was first administered and then general anesthetic.  The patient was placed in the dorsal supine position and prepped and draped in normal sterile fashion.  A Pfannenstiel skin incision was made and carried to the underlying Mayo fashion using the second knife.  The fascia was incised in midline and the incision extended laterally using Mayo scissors.  The superior aspect of the fascial incision was grasped with Kocher clamps, tented up, and dissected off the underlying rectus muscle both bluntly and sharply with Mayo scissors.  Attention was then turned to the inferior aspect of the incision, which in a similar fashion was grasped with Kocher clamps, tented up and dissected off the underlying rectus muscles.  The rectus muscles were separated in the midline and the peritoneum was identified, grasped with hemostat, and entered sharply with Metzenbaum scissors.  This incision was extended superiorly and inferiorly with good visualization of the bladder.  The uterus was then brought up out of the incision.  The bowel adhesions were carefully taken down using Metzenbaum scissors.  Good hemostasis was noted at this point.  The self-retaining retractor was then placed.  The bladder blade was placed.  The bowel was gently packed with moist laparotomy sponges and held in place with the blade on the GYN extension.  The uterus was then grasped with a Lahey clamp and brought up out of the incision.  The left round ligament was identified and grasped with Allis clamp and tented up.  A hemostat was passed in the avascular area beneath the round ligament.  A suture #0 Vicryl was used to suture ligate the round ligament.  Two hemostats were placed across the round ligament proximal to the previously placed suture and the Mayo scissors were used to transect the round ligament.  An avascular area of the broad ligament was then identified and entered bluntly.  The suture of #0 Vicryl was then used to suture ligate the left uterovarian ligament.  Two straight Ochsner's were placed across the uterovarian ligament proximal to the previous suture.  The ligament was then transected and suture ligated with #0 Vicryl.  Attention was then turned to the right round ligament, which in a similar fashion was tented up with an Allis clamp.  An avascular area was entered beneath the round ligament using a hemostat and the round ligament was suture ligated and transected.  An avascular area of the broad ligament was then entered bluntly and the right uterovarian ligament was then suture ligated with #0 Vicryl.,Two straight Ochsner's were placed across the ligament proximal to previous suture.  This was then transected and suture ligated again with #0 Vicryl.  The left uterine peritoneum was then identified and grasped with Allis clamps.  The vesicouterine peritoneum was then transected and then entered using Metzenbaum scissors.  This incision was extended across the anterior portion of the uterus and the bladder flap was taken down.  It was sharply advanced with Metzenbaum scissors and then bluntly using a moist Ray-Tec.  The Ray-Tec was left in place at this point to ensure that the bladder was below the level of the cervix.  The bilateral uterine arteries then were skeletonized with Metzenbaum scissors and clamped bilaterally using straight Ochsner's.  Each were then transected and suture ligated with #0 Vicryl.  A curved Ochsner was then placed on either side of the cervix.  The tissue was transected using a long knife and suture ligated with #0 Vicryl.  Incidentally, prior to taking down the round ligaments, a pedunculated fibroid and the right fundal portion of the uterus was injected with Vasopressin and removed using a Bovie.  The cervix was then grasped with a Lahey clamp.  The cervicovaginal fascia was then taken down first using the long-handed knife and then a back handle of the knife to bring the fascia down below the level of the cervix.  A double-pointed scissors were used to enter the vaginal vault below the level of the cervix.  A straight Ochsner was placed on the vaginal vault.  The Jorgenson scissors were used to amputate the cervix and the uterus off of the underlying vaginal tissue.  The vaginal cuff was then reapproximated with #0 Vicryl in a running locked fashion and the pelvis was copiously irrigated.  There was a small area of bleeding noted on the underside of the bladder.  The bladder was tented up using an Allis clamp and a figure-of-eight suture of #3-0 Vicryl was placed with excellent hemostasis noted at this point.  The uterosacral ligaments were then incorporated into the vaginal cuff and the cuff was synched down.  A figure-of-eight suture of #0 Vicryl was placed in the midline of the vaginal cuff in attempt to incorporate the bilateral round ligament.  The round ligament was too short.  It would be a maximal amount of stretch to incorporate, therefore, only the left round ligament was incorporated into the vaginal cuff.  The bilateral adnexal areas were then re-peritonealized with #3-0 Vicryl in a running fashion.  The bladder flap was reapproximated to the vaginal cuff using one interrupted suture.  The pelvis was again irrigated at this point with excellent hemostasis noted.  Approximately 200 cc of saline with methylene blue was placed into the Foley to inflate the bladder.  There was no spillage of blue fluid into the abdomen.  The fluid again was allowed to drain.  All sponges were then removed and the bowel was allowed to return to its anatomical position.  The peritoneum was then reapproximated with #0 Vicryl in a running fashion.  The fascia was reapproximated also with #0 Vicryl in a running fashion.  The skin was then closed with staples.,A previously placed Betadine soaked Ray-Tec was removed from the patient's vagina and sponge stick was used to assess any bleeding in the vaginal vault.  There was no appreciable bleeding.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2.  The patient was taken to the recovery room in satisfactory condition.  She will be followed immediately postoperatively within the hospital.","surgery, pelvic pain, pelvic endometriosis, astramorph, total abdominal hysterectomy, enlarged fibroid, metzenbaum scissors, vaginal cuff, scissors, vaginal, uterus, ligament, hysterectomy, endometriosis, pedunculated, fibroids, infundibulopelvic, uterovarian, abdominal, laparotomy, peritoneum, "
 Tonsillectomy and adenoidectomy.  Chronic adenotonsillitis.  The patient is a 9-year-old Caucasian male with history of recurrent episodes of adenotonsillitis that has been refractory to outpatient antibiotic therapy. , Surgery, Tonsillectomy & Adenoidectomy - 5 ,"POSTOPERATIVE DIAGNOSIS:,  Chronic adenotonsillitis.,PROCEDURE PERFORMED: , Tonsillectomy and adenoidectomy.,ANESTHESIA:  ,General endotracheal tube.,ESTIMATED BLOOD LOSS:,  Minimum, less than 5 cc.,SPECIMENS:,  Right and left tonsils 2+, adenoid pad 1+.  There was no adenoid specimen.,COMPLICATIONS: , None.,HISTORY: , The patient is a 9-year-old Caucasian male with history of recurrent episodes of adenotonsillitis that has been refractory to outpatient antibiotic therapy.  The patient has had approximately four to five episodes of adenotonsillitis per year for the last three to four years.,PROCEDURE: , Informed consent was properly obtained from the patient's parents and the patient was taken to the operating room #3 and was placed in a supine position.  He was placed under general endotracheal tube anesthesia by the Department of Anesthesia.  The bed was then rolled away from Department of Anesthesia.  A shoulder roll was then placed beneath the shoulder blades and a blue towel was then fashioned as a turban wrap.  The McIvor mouth gag was carefully positioned into the patient's mouth with attention to avoid the teeth.,The retractor was then opened and the oropharynx was visualized.  The adenoid pad was then visualized with a laryngeal mirror.  The adenoids appeared to be 1+ and non-obstructing.  There was no evidence of submucosal cleft palate palpable.  There was no evidence of bifid uvula.  A curved Allis clamp was then used to grasp the superior pole of the right tonsil.  The tonsil was then retracted inferiorly and medially.  Bovie cautery was used to make an incision on the mucosa of the right anterior tonsillar pillar to find the appropriate plane of dissection.  The tonsil was then dissected out within this plane using a Bovie.  Tonsillar sponge was re-applied to the tonsillar fossa.  Suction cautery was then used to adequately obtain hemostasis with the tonsillar fossa.  Attention was then directed to the left tonsil.  The curved Allis was used to grasp the superior pole of the left tonsil and it was retracted inferiorly and medially.  Bovie cautery was used to make an incision in the mucosa of the left anterior tonsillar pillar and define the appropriate plane of dissection.  The tonsil was then dissected out within this plane using the Bovie.  Next, complete hemostasis was achieved within the tonsillar fossae using suction cautery.  After adequate hemostasis was obtained, attention was directed towards the adenoid pad.  The adenoid pad was again visualized and appeared 1+ and was non-obstructing.  Decision was made to use suction cautery to cauterize the adenoids.  Using a laryngeal mirror under direct visualization, the adenoid pad was then cauterized with care to avoid the eustachian tube orifices as well as the soft palate and inferior turbinates.  After cauterization was complete, the nasopharynx was again visualized and tonsillar sponge was applied.  Adequate hemostasis was achieved.  The tonsillar fossae were again visualized and no evidence of bleeding was evident.  The throat pack was removed from the oropharynx and the oropharynx was suctioned.  There was no evidence of any further bleeding.  A flexible suction catheter was then used to suction out the nasopharynx to the oropharynx.  The suction catheter was also used to suction up the stomach.  Final look revealed no evidence of further bleeding and 10 mg of Decadron was given intraoperatively.,DISPOSITION:  ,The patient tolerated the procedure well and the patient was transported to the recovery room in stable condition.","surgery, chronic adenotonsillitis, tonsillectomy, adenoidectomy, adenoid, tonsils, tonsillar fossa, tonsillar fossae, suction cautery, adenotonsillitis, oropharynx, hemostasis, cautery, suction, tonsillar"
 Tonsillectomy and adenoidectomy and Left superficial nasal cauterization.  Recurrent tonsillitis.  Deeply cryptic hypertrophic tonsils with numerous tonsillolith.  Residual adenoid hypertrophy and recurrent epistaxis., Surgery, Tonsillectomy & Adenoidectomy - 4 ,"PREOPERATIVE DIAGNOSES,1.  Recurrent tonsillitis.,2.  Deeply cryptic hypertrophic tonsils with numerous tonsillolith.,3.  Residual adenoid hypertrophy and recurrent epistaxis.,POSTOPERATIVE DIAGNOSES,1.  Recurrent tonsillitis.,2.  Deeply cryptic hypertrophic tonsils with numerous tonsillolith.,3.  Residual adenoid hypertrophy and recurrent epistaxis.,FINAL DIAGNOSES,1.  Recurrent tonsillitis.,2.  Deeply cryptic hypertrophic tonsils with numerous tonsillolith.,3.  Residual adenoid hypertrophy and recurrent epistaxis.,OPERATION PERFORMED,1.  Tonsillectomy and adenoidectomy.,2.  Left superficial nasal cauterization.,DESCRIPTION OF OPERATION:,  The patient was brought to the operating room.  Endotracheal intubation carried out by Dr. X. The McIvor mouth gag was inserted and gently suspended.  Afrin was instilled in both sides of the nose and allowed to take effect for a period of time.  The hypertrophic tonsils were then removed by the suction and snare.  Deeply cryptic changes as expected were evident.  Bleeding was minimal and controlled with packing followed by electrocautery followed by extensive additional irrigation.  An inspection of the nasopharynx confirmed that the adenoids were in fact hypertrophic rubbery cryptic and obstructive.  They were shaved back, flushed with prevertebral fascia with curette.  Hemostasis established with packing followed by electrocautery.  In light of his history of recurring nosebleeds, both sides of the nose were carefully inspected.  A nasal endoscope was used to identify the plexus of bleeding, which was predominantly on the left mid portion of the septum that was controlled with broad superficial cauterization using a suction cautery device.  The bleeding was admittedly a bit of a annoyance.  An additional control was established by infiltrating slowly with a 1% Xylocaine with epinephrine around the perimeter of the bleeding site and then cauterizing the bleeding site itself.  No additional bleeding was then evident.  The oropharynx was reinspected, clots removed, the patient was extubated, taken to the recovery room in stable condition.  Discharge will be anticipated later in the day on Lortab plus amoxicillin plus Ponaris nose drops.  Office recheck anticipated if stable and doing well in three to four weeks.","surgery, tonsillitis, cryptic hypertrophic tonsils, tonsillolith, nasal cauterization, adenoid hypertrophy, hypertrophic tonsils, adenoidectomy, nasal, cauterization, hypertrophy, epistaxis, tonsils, hypertrophic, intubation, tonsillectomy"
 Tonsillectomy and adenoidectomy.  Obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis., Surgery, Tonsillectomy & Adenoidectomy - 3 ,"PREOPERATIVE DIAGNOSIS:,  Obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis.,POSTOPERATIVE DIAGNOSIS: , Obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis.,SURGICAL PROCEDURE PERFORMED: , Tonsillectomy and adenoidectomy.,ANESTHESIA: , General endotracheal technique.,SURGICAL FINDINGS:  ,A 4+/4+ cryptic and hypertrophic tonsils with 2+/3+ hypertrophic adenoid pads.,INDICATIONS: , We were requested to evaluate the patient for complaints of enlarged tonsils, which cause difficulty swallowing, recurrent pharyngitis, and sleep-induced respiratory disturbance.  She was evaluated and scheduled for an elective procedure.,DESCRIPTION OF SURGERY:  ,The patient was brought to the operative suite and placed supine on the operating room table.  General anesthetic was administered.  Once appropriate anesthetic findings were achieved, the patient was intubated and prepped and draped in the usual sterile manner for a tonsillectomy.  He was placed in semi-Rose ___ position and a Crowe Davis-type mouth gag was introduced into the oropharynx.  Under an operating headlight, the oropharynx was clearly visualized.  The right tonsil was grasped with the fossa triangularis and using electrocautery enucleation technique, was removed from its fossa.  This followed placing the patient in a suspension position using a McIvor-type mouth gag and a red rubber Robinson catheter via the right naris.  Once the right tonsil was removed, the left tonsil was removed in a similar manner, once again using a needle point Bovie dissection at 20 watts.  With the tonsils removed, it was possible to visualize the adenoid pads.  The oropharynx was irrigated and the adenoid pad evaluated with an indirect mirror technique.  The adenoid pad was greater than 2+/4 and hypertrophic.  It was removed with successive passes of electrocautery suction.  The tonsillar fossa was then once again hemostased with suction cautery, injected with 0.5% ropivacaine with 1:100,000 adrenal solution and then closed with 2-0 Monocryl on an SH needle.  The redundant soft tissue of the uvula was removed posteriorly and cauterized with electrocautery to prevent swelling of the uvula in the postoperative period.  The patient's oropharynx and nasopharynx were irrigated with copious amounts of normal saline contained with small amount of iodine, and she was recovered from her general endotracheal anesthetic.  She was extubated and left the operating room in good condition to the postoperative recovery room area.,Estimated blood loss was minimal.  There were no complications.  Specimens produced were right and left tonsils.  The adenoid pad was ablated with electrocautery.","surgery, obstructive adenotonsillar hypertrophy, pharyngitis, tonsillectomy, adenoidectomy, uvula, obstructive, adenotonsillar, hypertrophy, hypertrophic, fossa, tonsils, oropharynx, electrocautery, pads"
"  Tonsillectomy and adenoidectomy.  McIvor mouth gag was placed in the oral cavity, and a tongue depressor applied.", Surgery, Tonsillectomy & Adenoidectomy - 1  ,"PROCEDURE PERFORMED: , Tonsillectomy and adenoidectomy.,ANESTHESIA:,  General endotracheal.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and prepped and draped in the usual fashion after induction of general endotracheal anesthesia.  The McIvor mouth gag was placed in the oral cavity, and a tongue depressor applied.  Two #12-French red rubber Robinson catheters were placed, 1 in each nasal passage, and brought out through the oral cavity and clamped over a dental gauze roll placed on the upper lip to provide soft palate retraction.,The nasopharynx was inspected with a laryngeal mirror.  The adenoid tissue was fulgurated with the suction Bovie set at 35.  The catheters and the dental gauze roll were then removed.  The anterior tonsillar pillars were infiltrated with 0.5% Marcaine and epinephrine.  Using the radiofrequency wand, the tonsils were ablated bilaterally.  If bleeding occurred, it was treated with the wand on coag mode using a coag mode of 3 and an ablation mode of 9.  The tonsillectomy was completed.,The nasopharynx and nasal passages were suctioned free of debris, and the procedure was terminated.,The patient tolerated the procedure well and left the operating room in good condition.","surgery, tongue, nasal passage, palate, mcivor mouth gag, gauze roll, nasopharynx, tonsillectomy, adenoidectomy,"
" Tonsillectomy, uvulopalatopharyngoplasty, and septoplasty for obstructive sleep apnea syndrome with hypertrophy of tonsils and of uvula and soft palate with deviation of nasal septum", Surgery, Tonsillectomy and Septoplasty ,"PREOPERATIVE DIAGNOSIS:,  Obstructive sleep apnea syndrome with hypertrophy of tonsils and of uvula and soft palate.,POSTOPERATIVE DIAGNOSIS:,  Obstructive sleep apnea syndrome with hypertrophy of tonsils and of uvula and soft palate with deviation of nasal septum.,OPERATION:,  Tonsillectomy, uvulopalatopharyngoplasty, and septoplasty.,ANESTHESIA:,  General anesthetics.,HISTORY: , This is a 51-year-old gentleman here with his wife.  She confirms the history of loud snoring at night with witnessed apnea.  The result of the sleep study was reviewed.  This showed moderate sleep apnea with significant desaturation.  The patient was unable to tolerate treatment with CPAP.  At the office, we observed large tonsils and elongation and thickening of the uvula as well as redundant soft tissue of the palate.  A tortuous appearance of the septum also was observed.  This morning, I talked to the patient and his wife about the findings.  I reviewed the CT images.  He has no history of sinus infections and does not recall a history of nasal trauma.  We discussed the removal of tonsils and uvula and soft palate tissue and the hope that this would help with his airway.  Depending on the findings of surgery, I explained that I might remove that bone spur that we are seeing within the nasal passage.  I will get the best look at it when he is asleep.  We discussed recovery as well.  He visited with Dr. XYZ about the anesthetic produce.,PROCEDURE:,:  General tracheal anesthetic was administered by Dr. XYZ and Mr. Radke.  Afrin drops were placed in both nostrils and a cottonoid soaked with Afrin was placed in each side of the nose.  A Crowe-Davis mouth gag was placed.  The tonsils were very large and touched the uvula.  The uvula was relatively long and very thick and there were redundant folds of soft palate mucosa and prominent posterior and anterior tonsillar pillars.  Also, there was a cryptic appearance of the tonsils but there was no acute redness or exudate.  Retraction of the soft palate permitted evaluation of the nasopharynx with the mirror and the choanae were patent and there was no adenoid tissue present.  A very crowded pharynx was appreciated.  The tonsils were first removed using electrodissection technique.  Hemostasis was achieved with the electrocautery and with sutures of 0 plain catgut.  The tonsil fossae were injected with 0.25% Marcaine with 1:200,000 epinephrine.  There already was more room in the pharynx, but the posterior pharyngeal wall was still obscured by the soft palate and uvula.  The uvula was grasped with the Alice clamp.  I palpated the posterior edge of the hard palate and calculated removal of about a third of the length of the soft palate.  We switched over from the Bayonet cautery to the blunt needle tip electrocautery.  The planned anterior soft palate incision was marked out with the electrocautery from the left anterior tonsillar pillar rising upwards and then extending horizontally across the soft palate to include all of the uvula and a portion of the soft palate, and the incision then extended across the midline and then inferiorly to meet the right anterior tonsillar pillar.  This incision was then deepened with the electrocautery on a cutting current.  The uvular artery just to the right of the midline was controlled with the suction electrocautery.  The posterior soft palate incision was made parallel to the anterior soft palate incision but was made leaving a longer length of mucosa to permit closure of the palatoplasty.  A portion of the redundant soft palate mucosa tissue also was included with the resection specimen and the tissue including the soft palate and uvula was included with the surgical specimen as the tonsils were sent to pathology.  The tonsil fossae were injected with 0.25% Marcaine with 1:200,000 epinephrine.  The soft palate was also injected with 0.25% Marcaine with 1:200,000 epinephrine.  The posterior tonsillar pillars were then brought forward to close to the anterior tonsillar pillars and these were sutured down to the tonsil bed with interrupted 0 plain catgut sutures.  The posterior soft palate mucosa was advanced forward and brought up to the anterior soft palate incision and closure of the soft palate wound was then accomplished with interrupted 3-0 chromic catgut sutures.  A much improved appearance of the oropharynx with a greatly improved airway was appreciated.  A moist tonsil sponge was placed into the nasopharynx and the mouth gag was removed.  I removed the cottonoids from both nostrils.  Speculum exam showed the inferior turbinates were large, the septum was tortuous and it angulated to the right and then sharply bent back to the left.  The septum was injected with 0.25% Marcaine with 1:200,000 epinephrine using a separate syringe and needle.  A #15 blade was used to make a left cheilion incision.,Mucoperichondrium and mucoperiosteum were elevated with the Cottle elevator.  When we reached the deflected portion of the vomer, this was separated from the septal cartilage with a Freer elevator.  The right-sided mucoperiosteum was elevated with the Freer elevator and then with Takahashi forceps and with the 4 mm osteotome, the deflected portion of the septal bone from the vomer was resected.  This tissue also was sent as a separate specimen to pathology.  The intraseptal space was irrigated with saline and suctioned.  The nasal septal mucosal flaps were then sutured together with a quilting suture of 4-0 plain catgut.  I observed no evidence of purulent secretion or polyp formation within the nostrils.  The inferior turbinates were then both outfractured using a knife handle, and now there was a much more patent nasal airway on both sides.  There was good support for the nasal tip and the dorsum and there was good hemostasis within the nose.  No packing was used in the nostrils.  Polysporin ointment was introduced into both nostrils.  The mouth gag was reintroduced and the pack removed from the nasopharynx.  The nose and throat were irrigated with saline and suctioned.  An orogastric tube was placed and a moderate amount of clear fluid suctioned from the stomach and this tube was removed.  Sponge and needle count were reported correct.  The mouth gag having been withdrawn, the patient was then awakened and returned to recovery room in a satisfactory condition.  He tolerated the operation excellently.  Estimated blood loss was about 15-20 cc.  In the recovery room, I observed that he was moving air well and I spoke with his wife about the findings of surgery.","surgery, obstructive sleep apnea syndrome, afrin drops, bayonet cautery, cpap, cottle elevator, crowe-davis, freer elevator, obstructive sleep apnea, tonsillectomy, hypertrophy, mouth gag, nasal, nasal passage, nasal septum, nasopharynx, nostrils, palate, pharynx, septal cartilage, septoplasty, sleep apnea, soft palate, tonsils, uvula, uvulopalatopharyngoplasty, hypertrophy of tonsils, anterior tonsillar pillars, soft palate incision, palate incision, tonsillar pillars, incision "
 Tonsillectomy.  Chronic tonsillitis., Surgery, Tonsillectomy - 1 ,"PREOPERATIVE DIAGNOSIS:,  Chronic tonsillitis.,POSTOPERATIVE DIAGNOSIS: , Chronic tonsillitis.,PROCEDURE:  ,Tonsillectomy.,DESCRIPTION OF PROCEDURE: , Under general orotracheal anesthesia, a Crowe-Davis mouth gag was inserted and suspended.  Tonsils were removed by electrocautery dissection and the tonsillar beds were injected with Marcaine 0.25% plain.  A catheter was inserted in the nose and brought out from mouth.  The throat was irrigated with saline.  There was no further bleeding.  The patient was awakened and extubated and moved to the recovery room in satisfactory condition.","surgery, crowe-davis, mouth gag, chronic tonsillitis, tonsillitis, anesthesia, tonsillectomy"
 Tonsillectomy.   Tonsillitis.  McIvor mouth gag was placed in the oral cavity and a tongue depressor applied. , Surgery, Tonsillectomy ,"PREOPERATIVE DIAGNOSIS: , Tonsillitis.,POSTOPERATIVE DIAGNOSIS:  ,Tonsillitis.,PROCEDURE PERFORMED:  ,Tonsillectomy.,ANESTHESIA: , General endotracheal.,DESCRIPTION OF PROCEDURE:  ,The patient was taken to the operating room and prepped and draped in the usual fashion.  After induction of general endotracheal anesthesia, the McIvor mouth gag was placed in the oral cavity and a tongue depressor applied.  Two #12-French red rubber Robinson catheters were placed, 1 in each nasal passage, and brought out through the oral cavity and clamped over a dental gauze roll on the upper lip to provide soft palate retraction.  The nasopharynx was inspected with the laryngeal mirror.,Attention was then directed to the right tonsil.  The anterior tonsillar pillar was infiltrated with 1.5 cc of 1% Xylocaine with 1:100,000 epinephrine, as was the left tonsillar pillar.  The right tonsil was grasped with the tenaculum and retracted out of its fossa.  The anterior tonsillar pillar was incised with the #12 knife blade.  The plica semilunaris was incised with the Metzenbaum scissors.  Using the Metzenbaum scissors and the Fisher knife, the tonsil was dissected free of its fossa onto an inferior pedicle around which the tonsillar snare was placed and applied.  The tonsil was removed from the fossa and the fossa packed with a cherry gauze sponge as previously described.  By a similar procedure, the opposite tonsillectomy was performed and the fossa was packed.,Attention was re-directed to the right tonsil.  The pack was removed and bleeding was controlled with the suction Bovie unit.  Bleeding was then similarly controlled in the left tonsillar fossa and the nasopharynx after removal of the packs.  The catheters were then removed.  The nasal passages and oropharynx were suctioned free of debris.  The procedure was terminated.,The patient tolerated the procedure well and left the operating room in good condition.","surgery, tongue, palate, mcivor mouth gag, anterior tonsillar, metzenbaum scissors, oral cavity, tonsillar pillar, tonsillectomy, metzenbaum, tonsillitis, pillar, tonsillar, fossa "
" Tonsillectomy, adenoidectomy, and removal of foreign body (rock) from right ear.", Surgery, Tonsillectomy & Adenoidectomy ,"PREOPERATIVE DIAGNOSES:,  Hypertrophy of tonsils and adenoids, and also foreign body of right ear.,POSTOPERATIVE DIAGNOSES:,  Hypertrophy of tonsils and adenoids, and also foreign body of right ear.,OPERATIONS:,  Tonsillectomy, adenoidectomy, and removal of foreign body (rock) from right ear.,ANESTHESIA:,  General.,HISTORY: , The patient is 5-1/2 years old.  She is here this morning with her Mom.  She has very large tonsils and she snores at night and gets up frequently at night and does not sleep well.  At the office we saw the tonsils were very big.  There was a rock in the right ear and it was very deep in the canal, near the drum.  We will remove the foreign body under the same anesthetic.,PROCEDURE:,:  Natalie was placed under general anesthetic by the orotracheal route of administration, under Dr. XYZ and Ms. B.  I looked into the left ear under the microscope, took out a little wax and observed a normal eardrum.  On the right side, I took out some impacted wax and removed the rock with a large suction.  It was actually resting on the surface of the drum but had not scarred or damaged the drum.  The drum was intact with no evidence of middle ear fluid.  The microscope was set aside.  Afrin drops were placed in both nostrils.  The neck was gently extended and the Crowe-Davis mouth gag inserted.  The tonsils and adenoids were very large.  The uvula was intact.  Adenoidectomy was performed using the adenoid curette with a tonsil sponge placed into the nasopharynx.  Tonsillectomy accomplished by sharp and blunt dissection.  Hemostasis achieved with electrocautery and the tonsils beds injected with 0.25% Marcaine with 1:200,000 epinephrine.  Sutures of zero plain catgut next were used to re-approximate the posterior to the anterior tonsillar pillars, suturing these down to the tonsillar beds.  Sponge is removed from the nasopharynx.  The suction electrocautery was used for pinpoint hemostasis on the adenoid bed.  We made sure the cautery tip did not come into the contact with the soft palate or the eustachian tube orifices.  The nose and throat were then irrigated with saline and suctioned.  Excellent hemostasis was observed.  An orogastric tube was placed.  The stomach found to be empty.  The tube was removed, as was the mouth gag.  Sponge and needle count were reported correct.  The child was then awakened and prepared for her to return to the recovery room.  She tolerated the operation excellently.","surgery, tonsillectomy, afrin drops, crowe-davis, hypertrophy, adenoid bed, adenoidectomy, adenoids, canal, catgut, dissection, drum, ear, foreign body, middle ear, mouth gag, nasopharynx, orotracheal, suction electrocautery, throat, tonsils, uvula, wax, tonsils and adenoids"
 Tonsillectomy & adenoidectomy.  Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy.  , Surgery, Tonsillectomy & Adenoidectomy - 2 ,"PREOPERATIVE DIAGNOSIS: , Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy.,POSTOPERATIVE DIAGNOSIS: , Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy.,OPERATION PERFORMED: , Tonsillectomy & adenoidectomy.,ANESTHESIA: , General endotracheal.,FINDINGS: , The tonsils were 3+ enlarged and cryptic.,DESCRIPTION OF OPERATION:,  Under general anesthesia with an endotracheal tube, the patient was placed in supine position.  A mouth gag was inserted and suspended from Mayo stand.  Red rubber catheter was placed through the nose and pulled up through the mouth with elevation of the palate.  The adenoid area was inspected.  The adenoids were small.  The left tonsil was grasped with a tonsil tenaculum.  The tonsil was removed with the Gold laser.  The apposite tonsil was removed in a similar manner.  Hemostasis was secured with electrocautery.  Both tonsillar fossae were injected with 0.25% Marcaine with adrenaline.  The patient tolerated the procedure well and left the operating room in good condition.","surgery, tonsil, gold laser, adenoids, chronic tonsillitis, adenoid hypertrophy, tonsillectomy, adenoidectomy, endotracheal, tonsillitis, symptomatic, hypertrophy"
" Total thyroidectomy.  The patient is a female with a history of Graves disease.  Suppression was attempted, however, unsuccessful.  She presents today with her thyroid goiter. ", Surgery, Thyroidectomy - 1 ,"PREOPERATIVE DIAGNOSIS: , Thyroid goiter.,POSTOPERATIVE DIAGNOSIS:  ,Thyroid goiter.,PROCEDURE PERFORMED: , Total thyroidectomy.,ANESTHESIA:,1.  General endotracheal anesthesia.,2.  9 cc of 1% lidocaine with 1:100,000 epinephrine.,COMPLICATIONS:,  None.,PATHOLOGY: , Thyroid.,INDICATIONS:  ,The patient is a female with a history of Graves disease.  Suppression was attempted, however, unsuccessful.  She presents today with her thyroid goiter.  A thyroidectomy was indicated at this time secondary to the patient's chronic condition.  Indications, alternatives, risks, consequences, benefits, and details of the procedure including specifically the risk of recurrent laryngeal nerve paresis or paralysis or vocal cord dysfunction and possible trach were discussed with the patient in detail.  She agreed to proceed.  A full informed consent was obtained.,PROCEDURE: , The patient presented to ABCD General Hospital on 09/04/2003 with the history was reviewed and physical examinations was evaluated.  The patient was brought by the Department of Anesthesiology, brought back to surgical suite and given IV access and general endotracheal anesthesia.  A 9 cc of 1% lidocaine with 1:100,000 of epinephrine was infiltrated into the area of pre-demarcated above the suprasternal notch.  Time is allowed for full hemostasis to be achieved.  The patient was then prepped and draped in the normal sterile fashion.  A #10 blade was then utilized to make an incision in the pre-demarcated and anesthetized area.  Unipolar electrocautery was utilized for hemostasis.  Finger dissection was carried out in the superior and inferior planes.  Platysma was identified and dissected and a subplatysmal plane was created in the superior and inferior, medial and lateral directions using hemostat, Metzenbaum, and blunt dissection.  The strap muscles were identified.  The midline raphe was not easily identifiable at this time.  An incision was made through what appeared to be in the midline raphe and dissection was carried down to the thyroid.  Sternohyoid and sternothyroid muscles were identified and separated on the patient's right side and then subsequently on the left side.  It was noted at this time that the thyroid lobule on the right side is a bi-lobule.  Kitner blunt dissection was utilized to bluntly dissect the overlying thyroid fascia as well as strap muscles off the thyroid, force in the lateral direction.  This was carried down to the inferior and superior areas.  The superior pole of the right lobule was then identified.  A hemostat was placed in the cricothyroid groove and a Kitner was placed in this area.  A second Kitner was placed on lateral aspect of the superior pole and the superior pole of the right thyroid was retracted inferiorly.  Careful dissection was then carried out in a very meticulous fashion in the superior lobe and identified the appropriate vessels and cauterized with bipolar or ligated with the suture ligature.  This was carried out until the superior pole was identified.  Careful attention was made to avoid nerve injury in this area.  Dissection was then carried down again bluntly separating the inferior and superior lobes.  The bilobed right thyroid was then retracted medially.  The recurrent laryngeal nerve was then identified and tracked to its insertion.  The overlying vessels of the middle thyroid vein as well as the associated structures were then identified and great attention was made to perform a right careful meticulous dissection to remove the fascial attachments superficial to the recurrent laryngeal nerve off the thyroid.  When it was completed, this lobule was then removed from Berry's ligament.  There was noted to be no isthmus at this time and the entire right lobule was then sent to the Pathology for further evaluation.  Attention was then diverted to the patient's left side.  In a similar fashion, the sternohyoid and sternothyroid muscles were already separated.  Army-Navy as well as femoral retractors were utilized to lateralize the appropriate musculature.  The middle thyroid vein was identified.  Blunt dissection was carried out laterally to superiorly once again.  A hemostat was utilized to make an opening in the cricothyroid groove and a Kitner was then placed in this area.  Another Kitner was placed on the lateral aspect of the superior lobe of the left thyroid and retracted inferiorly.  Once again, a careful meticulous dissection was utilized to identify the appropriate structures in the superior pole of the left thyroid and suture ligature as well as bipolar cautery was utilized for hemostasis.  Once again, a careful attention was made not to injure the nerve in this area.  The superior pole was then freed appropriately and blunt dissection was carried down to lateral and inferior aspects.  The inferior aspect was then identified.  The inferior thyroid artery and vein were then identified and ligated.  The left thyroid was then medialized and the recurrent laryngeal nerve has been identified.  A careful dissection was then carried out to remove the fascial attachments superficial to the recurrent laryngeal nerve on the side as close to the thyroid gland as possible.  The thyroid was then removed from the Berry's ligament and it was then sent to Pathology for further evaluation.  Evaluation of the visceral space did not reveal any bleeding at this time.  This was irrigated and pinpoint areas were bipolored as necessary.  Surgicel was then placed bilaterally.  The strap muscles as well as the appropriate fascial attachments were then approximated with a #3-0 Vicryl suture in the midline.  The platysma was identified and approximated with a #4-0 Vicryl suture and the subdermal plane was approximated with a #4-0 Vicryl suture.  A running suture consisting of #5-0 Prolene suture was then placed and fast absorbing #6-0 was then placed in a running fashion.  Steri-Strips, Tincoban, bacitracin and a pressure gauze was then placed.  The patient was then admitted for further evaluation and supportive care.  The patient tolerated the procedure well.  The patient was transferred to Postanesthesia Care Unit in stable condition.","surgery, thyroid goiter, graves disease, thyroidectomy, total thyroidectomy, dissection, superior, kitner"
" Thromboendarterectomy of right common, external, and internal carotid artery utilizing internal shunt and Dacron patch angioplasty closure.  Coronary artery bypass grafting x3 utilizing left internal mammary artery to left anterior descending, and reverse autogenous saphenous vein graft to the obtuse marginal, posterior descending branch of the right coronary artery.", Surgery, Thromboendarterectomy ,"OPERATIVE PROCEDURE,1.  Thromboendarterectomy of right common, external, and internal carotid artery utilizing internal shunt and Dacron patch angioplasty closure.,2.  Coronary artery bypass grafting x3 utilizing left internal mammary artery to left anterior descending, and reverse autogenous saphenous vein graft to the obtuse marginal, posterior descending branch of the right coronary artery.  Total cardiopulmonary bypass,cold blood potassium cardioplegia, antegrade and retrograde, for myocardial protection, placement of temporary pacing wires.,DESCRIPTION:,  The patient was brought to the operating room, placed in supine position.  Adequate general endotracheal anesthesia was induced.  Appropriate monitoring lines were placed.  The chest, abdomen and legs were prepped and draped in a sterile fashion.  The greater saphenous vein was harvested from the right upper leg through interrupted skin incisions and was prepared by ligating all branches with 4-0 silk and flushing with vein solution.  The leg was closed with running 3-0 Dexon subcu, and running 4-0 Dexon subcuticular on the skin, and later wrapped.  A median sternotomy incision was made and the left internal mammary artery was dissected free from its takeoff at the subclavian to its bifurcation at the diaphragm and surrounded with papaverine-soaked gauze.  The sternum was closed.  A right carotid incision was made along the anterior border of the sternocleidomastoid muscle and carried down to and through the platysma.  The deep fascia was divided.  The facial vein was divided between clamps and tied with 2-0 silk.  The common carotid artery, takeoff of the external and internal carotid arteries were dissected free, with care taken to identify and preserve the hypoglossal and vagus nerves.  The common carotid artery was double-looped with umbilical tape, takeoff of the external was looped with a heavy silk, distal internal was double-looped with a heavy silk.  Shunts were prepared.  A patch was prepared.  Heparin 50 mg was given IV.  Clamp was placed on the beginning of the takeoff of the external and the proximal common carotid artery.  Distal internal was held with a forceps.  Internal carotid artery was opened with 11-blade.  Potts scissors were then used to extend the aortotomy through the lesion into good internal carotid artery beyond.  The shunt was placed and proximal and distal snares were tightened.  Endarterectomy was carried out under direct vision in the common carotid artery and the internal reaching a fine, feathery distal edge using eversion on the external.  All loose debris was removed and Dacron patch was then sutured in place with running 6-0 Prolene suture, removing the shunt just prior to completing the suture line.  Suture line was completed and the neck was packed.,The pericardium was opened.  A pericardial cradle was created.  The patient was heparinized for cardiopulmonary bypass, cannulated with a single aortic and single venous cannula.  A retrograde cardioplegia cannula was placed with a pursestring of 4-0 Prolene into the coronary sinus, and secured to a Rumel tourniquet.  An antegrade cardioplegia needle sump was placed in the ascending aorta and cardiopulmonary bypass was instituted.  The ascending aorta was cross-clamped and cold blood potassium cardioplegia was given antegrade, a total of 5 cc per kg.  This was followed sumping of the ascending aorta and retrograde cardioplegia, a total of 5 cc per kg to the coronary sinus.  The obtuse marginal 1 coronary was identified and opened, and an end-to-side anastomosis was then performed with running 7-0 Prolene suture.  The vein was cut to length.  Antegrade and retrograde cold blood potassium cardioplegia was given.  The obtuse marginal 2 was not felt to be suitable for bypass, therefore, the posterior descending of the right coronary was identified and opened, and an end-to-side anastomosis was then performed with running 7-0 Prolene suture to reverse autogenous saphenous vein.  The vein was cut to length.  The mammary was clipped distally, divided and spatulated for anastomosis.  Antegrade and retrograde cold blood potassium cardioplegia was given.  The anterior descending was identified and opened. the mammary was then sutured to this with running 8-0 Prolene suture.  Warm blood potassium cardioplegia was given, and the cross-clamp was removed.  A partial-occlusion clamp was placed.  Two aortotomies were made.  The veins were cut to fit these and sutured in place with running 5-0 Prolene suture.  The partial- occlusion clamp was removed.  All anastomoses were inspected and noted to be patent and dry.  Atrial and ventricular pacing wires were placed.  Ventilation was commenced.  The patient was fully warmed.  The patient was weaned from cardiopulmonary bypass and de-cannulated in a routine fashion.  Protamine was given.  Good hemostasis was noted.  A single mediastinal chest tube and bilateral pleural Blake drains were placed.  The sternum was closed with figure-of-eight stainless steel wire, the linea alba with figure-of-eight #1 Vicryl, the sternal fascia with running #1 Vicryl, the subcu with running 2-0 Dexon and the skin with a running 4-0 Dexon subcuticular stitch.","surgery, cabg, thromboendarterectomy, carotid artery, coronary artery bypass, mammary, obtuse, papaverine-soaked, running prolene suture, cardiopulmonary bypass, internal carotid, running prolene, prolene suture, carotid, sutured, artery, prolene, coronary, bypass, veinNOTE"
" Excisional biopsy with primary closure of a 4 mm right lateral base of tongue lesion.  Right lateral base of tongue lesion, probable cancer.", Surgery, Tongue Lesion Biopsy ,"PREOPERATIVE DIAGNOSIS: , Right lateral base of tongue lesion, probable cancer.,POSTOPERATIVE DIAGNOSIS: , Right lateral base of tongue lesion, probable cancer.,PROCEDURE PERFORMED:  ,Excisional biopsy with primary closure of a 4 mm right lateral base of tongue lesion.,ANESTHESIA: , General.,FINDINGS: , An ulceration in the right lateral base of tongue region.  This was completely excised.,ESTIMATED BLOOD LOSS:,  Less than 5 mL.,FLUIDS: , Crystalloid only.,COMPLICATIONS:,  None.,DRAINS:,  None.,CONDITION:,  Stable.,PROCEDURE:  ,The patient placed supine in position under general anesthesia.  First a Sweetheart gag was placed in the patient's mouth and the mouth was elevated.  The lesion in the tongue could be seen.  Then, it was injected with 1% lidocaine and 1:100,00 epinephrine.  After 5 minutes of waiting, then an elliptical incision was made around this mass with electrocautery and then it was sharply dissected off the muscular layer and removed in total.  Suction cautery was used for hemostasis.  Then, 3 simple interrupted #4-0 Vicryl sutures were used to close the wound and procedure was then terminated at that time.","surgery, excisional biopsy, tongue lesion, mouth, biopsy,"
" Transforaminal lumbar interbody fusion, placement of intervertebral prosthetic device.", Surgery, TLIF ,"PREOPERATIVE DIAGNOSIS (ES):, L4-L5 and L5-S1 degenerative disk disease/disk protrusions/spondylosis with radiculopathy.,POSTOPERATIVE DIAGNOSIS (ES):, L4-L5 and L5-S1 degenerative disk disease/disk protrusions/spondylosis with radiculopathy.,PROCEDURE:,1. Left L4-L5 and L5-S1 Transforaminal Lumbar Interbody Fusion (TLIF).,2. L4 to S1 fixation (Danek M8 system).,3. Right posterolateral L4 to S1 fusion.,4. Placement of intervertebral prosthetic device (Danek Capstone spacers L4-L5 and L5-S1).,5. Vertebral autograft plus bone morphogenetic protein (BMP).,COMPLICATIONS:, None.,ANESTHESIA:, General endotracheal.,SPECIMENS:, Portions of excised L4-L5 and L5-S1 disks.,ESTIMATED BLOOD LOSS:, 300 mL.,FLUIDS GIVEN:, IV crystalloid.,OPERATIVE INDICATIONS:, The patient is a 37-year-old male presenting with a history of chronic, persistent low back pain as well as left lower extremity of radicular character were recalcitrant to conservative management. Preoperative imaging studies revealed the above-noted abnormalities. After a detailed review of management considerations with the patient and his wife, he was elected to proceed as noted above.,Operative indications, methods, potential benefits, risks and alternatives were reviewed. The patient and his wife expressed understanding and consented to proceed as above.,OPERATIVE FINDINGS:, L4-L5 and L5-S1 disk protrusion with configuration as anticipated from preoperative imaging studies. Pedicle screw placement appeared satisfactory with satisfactory purchase and positioning noted at all sites as well as satisfactory findings upon probing of the pedicular tracts at each site. In addition, all pedicle screws were stimulated with findings of above threshold noted at all sites. Spacer snugness and positioning appeared satisfactory. Electrophysiological monitoring was carried out throughout the procedure and remained stable with no undue changes reported.,DESCRIPTION OF THE OPERATION:, After obtaining proper patient identification and appropriate preoperative informed consent, the patient was taken to the operating room on a hospital stretcher in the supine position. After the induction of satisfactory general endotracheal anesthesia and placement of appropriate monitoring equipment by Anesthesiology as well as placement of electrophysiological monitoring equipment by the Neurology team, the patient was carefully turned to the prone position and placed upon the padded Jackson table with appropriate additional padding placed as needed. The patient's posterior lumbosacral region was thoroughly cleansed and shaved. The patient was then scrubbed, prepped and draped in the usual manner. After local infiltration with 1% lidocaine with 1: 200,000 epinephrine solution, a posterior midline skin incision was made extending from approximately L3 to the inferior aspect of the sacrum. Dissection was continued in the midline to the level of the posterior fascia. Self-retaining retractors were placed and subsequently readjusted as needed. The fascia was opened in the midline, and the standard subperiosteal dissection was then carried out to expose the posterior and posterolateral elements from L3-L4 to the sacrum bilaterally with lateral exposure carried out to the lateral aspect of the transverse processes of L4 and L5 as well as the sacral alae bilaterally. _____ by completing the exposure, pedicle screw fixation was carried out in the following manner. Screws were placed in systematic caudal in a cranial fashion. The pedicle screw entry sites were chosen using standard dorsal landmarks and fluoroscopic guidance as needed. Cortical openings were created at these sites using a small burr. The pedicular tracts were then preliminarily prepared using a Lenke pedicle finder. They were then probed and subsequently tapped employing fluoroscopic guidance as needed. Each site was ""under tapped"" and reprobed with satisfactory findings noted as above. Screws in the following dimensions were placed. 6.5-mm diameter screws were placed at all sites. At S1, 40-mm length screws were placed bilaterally. At L5, 40-mm length screws were placed bilaterally, and at L4, 40-mm length screws were placed bilaterally with findings as noted above. The rod was then contoured to span from the L4 to the S1 screws on the right. The distraction was placed across the L4-L5 interspace, and the connections were temporarily secured. Using a matchstick burr, a trough was then carefully created slightly off the midline of the left lamina extending from its caudal aspect to its more cranial aspect at the foraminal level. This was longitudinally oriented. A transverse trough was similarly carefully created from the cranial point of the longitudinal trough out to the lateral aspect of the pars against the foraminal level that is slightly caudal to the L4 pedicle. This trough was completed to the level of the ligamentum flavum using small angled curettes and Kerrison rongeurs, and this portion of the lamina along with the inferior L4 articular process was then removed as a unit using rongeurs and curettes. The cranial aspect of the left L5 superior articular process was then removed using a small burr and angled curettes and Kerrison rongeurs. A superior laminotomy was performed from the left L5 lamina and flavectomy was then carried out across this region of decompression, working from caudally to cranially and medially to laterally, again using curettes and Kerrison rongeurs under direct visualization. In this manner, the left lateral aspect of the thecal sac passing left L5 spinal nerve and exiting left L4 spinal nerve along with posterolateral aspect of disk space was exposed. Local epidural veins were coagulated with bipolar and divided. Gelfoam was then placed in this area. This process was then repeated in similar fashion; thereby, exposing the posterolateral aspect of the left L5-S1 disk space. As noted, distraction had previously been placed at L4-L5, this was released. Distraction was placed across the L5-S1 interspace. After completing satisfactory exposure as noted, a annulotomy was made in the posterolateral left aspect of the L5-S1 disk space. Intermittent neural retraction was employed with due caution afforded to the neural elements throughout the procedure. The disk space was entered, and diskectomy was carried out in routine fashion using pituitary rongeurs followed by the incremental sized disk space shavers as well as straight and then angled TLIF curettes to prepare the front plate. Herniated portions of the disk were also removed in routine fashion. The diskectomy and endplate preparation were carried out working progressively from the left towards the right aspect of the disk across the midline in routine fashion. After completing this disk space preparation, Gelfoam was again placed. The decompression was assessed and appeared to be satisfactory. The distraction was released, and attention was redirected at L4-L5, where again, distraction was placed and diskectomy and endplate preparation was carried out at this interspace again in similar fashion. After completing the disk space preparation, attention was redirected to L5-S1. Distraction was released at L4-L5 and again, reapplied at L5-S1, incrementally increasing size. Trial spaces were used, and a 10-mm height by 26-mm length spacer was chosen. A medium BMP kit was appropriately reconstituted. A BMP sponge containing morcellated vertebral autograft was then placed into the anterior aspect of the disk space. The spacer was then carefully impacted into position. The distraction was released. The spacer was checked with satisfactory snugness and positioning noted. This process was then repeated in similar fashion at L4-L5, again with placement of a 10-mm height by 26-mm length Capstone spacer, again containing BMP and again with initial placement of a BMP sponge with vertebral autograft anteriorly within the interspace. This spacer was also checked again with satisfactory snugness and positioning noted. The prior placement of the spacers and BMP, the wound was thoroughly irrigated and dried with satisfactory hemostasis noted. Surgicel was placed over the exposed dura and disk space. The distraction was released on the right and compression plates across the L5-S1 and L4-L5 interspaces and the connections fully tightened in routine fashion. The posterolateral elements on the right from L4 to S1 were prepared for fusion in routine fashion, and BMP sponges with supplemental vertebral autograft was placed in the posterolateral fusion bed as well as the vertebral autograft in the dorsal aspect of the L4-L5 and L5-S1 facets on the right in a routine fashion. A left-sided rod was appropriated contoured and placed to span between the L4 to S1 screws. Again compression was placed across the L4-L5 and L5-S1 segments, and these connections were fully secured. Thorough hemostasis was ascertained after checking the construct closely and fluoroscopically. The wound was closed using multiple simple interrupted 0-Vicryl sutures to reapproximate the deep paraspinal musculature in the midline. The superficial paraspinal musculature in posterior fashion was closed in the midline using multiple simple interrupted 0-Vicryl sutures. The suprafascial subcutaneous layers were closed using multiple simple interrupted #0 and 2-0 Vicryl sutures. The skin was then closed using staples. Sterile dressings were then applied and secured in place. The patient tolerated the procedure well and was to the recovery room in satisfactory condition.","surgery, degenerative disk disease, disk protrusions, spondylosis, radiculopathy, tlif, transforaminal lumbar interbody fusio, danek m8, intervertebral prosthetic device, danek capstone, matchstick burr, capstone, bmp, vertebral autograft, screws were placed bilaterally, pedicle screw, kerrison rongeurs, disk space, disk, spacers, kerrison, interbody, rongeurs, pedicle, lumbar, screws, "
 Total thyroidectomy for goiter.  Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration., Surgery, Thyroidectomy  ,"TITLE OF OPERATION:  ,Total thyroidectomy for goiter.,INDICATION FOR SURGERY:  ,This is a 41-year-old woman who notes that compressive thyroid goiter and symptoms related to such who wishes to undergo surgery.  Risks, benefits, alternatives of the procedures were discussed in great detail with the patient.  Risks include but were not limited to anesthesia, bleeding, infection, injury to nerve, vocal fold paralysis, hoarseness, low calcium, need for calcium supplementation, tumor recurrence, need for additional treatment, need for thyroid medication, cosmetic deformity, and other.  The patient understood all these issues and they wished to proceed.,PREOP DIAGNOSIS: , Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,POSTOP DIAGNOSIS: , Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,ANESTHESIA: , General endotracheal.,PROCEDURE DETAIL: , After identifying the patient, the patient was placed supine in a operating room table.  After establishing general anesthesia via oral endotracheal intubation with a 6 Nerve Integrity monitoring system endotracheal tube.  The eyes were then tacked with Tegaderm.  The Nerve Integrity monitoring system, endotracheal tube was confirmed to be working adequately.  Essentially a 7 cm incision was employed in the lower skin crease of the neck.  A 1% lidocaine with 1:100,000 epinephrine were given.  Shoulder roll was applied.  The patient prepped and draped in a sterile fashion.  A 15-blade was used to make the incision.  Subplatysmal flaps were raised to the thyroid notch and sternal respectively.  The strap muscles were separated in the midline.  As we then turned to the left side where the sternohyoid muscle was separated from the sternothyroid muscle there was a very dense and firm thyroid mass on the left side.  The sternothyroid muscle was transected horizontally.  Similar procedure was performed on the right side.,Attention was then turned to identify the trachea in the midline.  Veins in this area and the pretracheal region were ligated with a harmonic scalpel.  Subsequently, attention was turned to dissecting the capsule off of the left thyroid lobe.  Again this was very firm in nature.  The superior thyroid pole was dissected in the superior third artery, vein, and the individual vessels were ligated with a harmonic scalpel.  The inferior and superior parathyroid glands were protected.  Recurrent laryngeal nerve was identified in the tracheoesophageal groove.  This had arborized early as a course underneath the inferior thyroid artery to a very small tiny anterior motor branch.  This was followed superiorly.  The level of cricothyroid membrane upon complete visualization of the entire nerve, Berry's ligament was transected and the nerve protected and then the thyroid gland was dissected over the trachea.  A prominent pyramidal level was also appreciated and dissected as well.,Attention was then turned to the right side.  There was significant amount of thyroid tissue that was very firm.  Multiple nodules were appreciated.  In a similar fashion, the capsule was dissected.  The superior and inferior parathyroid glands protected and preserved.  The superior thyroid artery and vein were individually ligated with the harmonic scalpel and the inferior thyroid artery was then ligated close to the thyroid gland capsule.  Once the recurrent laryngeal nerve was identified again on this side, the nerve had arborized early prior to the coursing underneath the inferior thyroid artery.  The anterior motor branch was then very fine, almost filamentous and stimulated at 0.5 milliamps, completely dissected toward the cricothyroid membrane with complete visualization.  A small amount of tissue was left at the Berry's ligament as the remainder of thyroid level was dissected over the trachea.  The entire thyroid specimen was then removed, marked with a stitch upon the superior pole.  The wound was copiously irrigated, Valsalva maneuver was given, bleeding points controlled.  The parathyroid glands appeared to be viable.  Both the anterior motor branches that were tiny were stimulated at 5 milliamps and confirmed to be working with the Nerve Integrity monitoring system.,Attention was then turned to burying the Surgicel on the wound bed on both sides.  The strap muscles were reapproximated in the midline using a 3-0 Vicryl suture of the sternothyroid horizontal transection and the strap muscles in the midline were then reapproximated.  The 1/8th inch Hemovac drain was placed and secured with a 3-0 nylon.  The incision was then closed with interrupted 3-0 Vicryl and Indermil for the skin.  The patient has a history of keloid formation and approximately 1 cubic centimeter of 40 mg per cubic centimeter Kenalog was injected into the incisional line using a tuberculin syringe and 25-gauge needle.  The patient tolerated the procedure well, was extubated in the operating room table, and sent to postanesthesia care unit in a good condition.  Upon completion of the case, fiberoptic laryngoscopy revealed intact bilateral true vocal fold mobility.","surgery, total thyroidectomy, goiter, multinodular thyroid goiter, multinodular, thyroid nodules, parathyroid glands, thyroid goiter, thyroid artery, thyroidectomy"
" History of compartment syndrome, right lower extremity, status post 4 compartments fasciotomy, to do incision for compartment fasciotomy. Wound debridement x2, including skin, subcutaneous, and muscle.  Insertion of tissue expander to the medial and lateral wound.", Surgery, Tissue Expander Insertion ,"PREOPERATIVE DIAGNOSES: , History of compartment syndrome, right lower extremity, status post 4 compartments fasciotomy, to do incision for compartment fasciotomy.,POSTOPERATIVE DIAGNOSES: , History of compartment syndrome, right lower extremity, status post 4 compartments fasciotomy, to do incision for compartment fasciotomy.,OPERATIONS:,1.  Wound debridement x2, including skin, subcutaneous, and muscle.,2.  Insertion of tissue expander to the medial wound.,3.  Insertion of tissue expander to the lateral wound.,COMPLICATIONS: , None.,TOURNIQUET: , None.,ANESTHESIA:  ,General.,INDICATIONS: , This patient developed a compartment syndrome.  She underwent 4 compartment fasciotomy with dual incision on medial and lateral aspect of the right lower leg.  She was doing very well and was obviously improving.,The swelling was reduced.  A compartment pressure had obviously improved based on examination.  She was therefore indicated for placement of tissue expander for ventral wound closure.  The risks of procedure as well as alternatives of this procedure were discussed at length with the patient and he understood them well.  Risks and benefits were all discussed, risk of bleeding, infection, damage to blood vessels, damage to nerve roots, need for further surgery, chronic pain with range of motion, risk of continued discomfort, risk of need for further reconstructive procedures, risk of blood clots, pulmonary embolism, myocardial infarction, and risk of death were discussed.  She understood them well.  All questions were answered, and she signed the consent for the procedure as described.,DESCRIPTION OF THE PROCEDURE:,  The patient was placed on the operating table and general anesthesia was achieved.  The medial wound was noted to be approximately 10.5 cm in length x 4 cm.  The lateral wound was noted in approximately 14 cm in length x 5 x 5 cm in width.  Both wounds were then thoroughly debrided.  The debridement of both wounds included skin and subcutaneous tissue and nonviable muscle portion.  This involve very small portion of muscle as well as skin edge and the subcutaneous tissue did require debridement on both sides.  At this point adequate debridement was performed and healthy tissue did appear to be present.  Initially on the medial wound I did place the DermaClose RC continuous external tissue expander.  On the medial wound the 5 skin anchors were placed on each side of the wound and separated appropriately.  I then did place the line loop from the tension controller in a lace like manner through the skin anchors and the tension controller was attached to the middle anchor.  I then did place adequate tension on the sutures.  Continued tension will be noted after engaging the tension controller.  At this point I performed the similar procedure to the lateral wound.  The skin anchors were placed separately and appropriately on either side of the skin margin.  The line loop from the tension controller was placed in lace like manner through the skin anchors.  The tension controller was then attached to the mid anchor and appropriate tension was applied.,It must be noted I did undermine the skin edges both sides of flap from both incision site prior to placement of the skin anchor and adequate mobilization was obtained.  Adequate tension was placed in this region.  A non thick dressing was then applied to the open-wound region and sterile dressing was then applied.  No complications were encountered throughout the procedure and the patient tolerated the procedure well.  The patient was taken to recovery room in stable condition.","surgery, fasciotomy, subcutaneous, muscle, wound debridement, insertion of tissue expander, compartment syndrome, compartment fasciotomy, lateral wound, medial wound, tension controller, tissue expander, wound, tissue, compartment,"
" Thrombectomy AV shunt, left forearm and patch angioplasty of the venous anastomosis.  Thrombosed arteriovenous shunt, left forearm with venous anastomotic stenosis.", Surgery, Thrombectomy AV Shunt ,"PREOPERATIVE DIAGNOSIS: , Thrombosed arteriovenous shunt left forearm.,POSTOPERATIVE DIAGNOSIS:  ,Thrombosed arteriovenous shunt, left forearm with venous anastomotic stenosis.,PROCEDURE:  ,Thrombectomy AV shunt, left forearm and patch angioplasty of the venous anastomosis.,ANESTHESIA: , Local.,SKIN PREP: , Betadine.,DRAINS: , None.,PROCEDURE TECHNIQUE:  ,The left arm was prepped and draped.  Xylocaine 1% was administered and a transverse antecubital incision was made over the venous limb of the graft, which was dissected out and encircled with a vessel loop.  The runoff vein was dissected out and encircled with the vessel loop as well.  A longitudinal incision was made over the venous anastomosis.  There was a narrowing in the area and slightly the incision was extended more proximally.  There was good back bleeding from the vein as well as bleeding from the more distal vein.  These were occluded with noncrushing DeBakey clamps and the patient was given 5000 units of heparin intravenously.  A #4 Fogarty was used to extract thrombus from the graft systematically until the arterial plug was removed and excellent inflow was established.  There was a narrowing in the mid portion of the venous limb of the graft, which was dilated with a #5 coronary dilator.  The Fogarty catheter was then passed up the vein, but no clot was obtained.  A patch PTFE material was fashioned and was sutured over the graftotomy with running 6-0 Gore-Tex suture.  Clamps were removed and flow established.  A thrill was easily palpable.  Hemostasis was achieved and the wound was irrigated and closed with 3-0 Vicryl subcutaneous suture followed by 4-0 nylon on the skin.  A sterile dressing was applied.  The patient was taken to the recovery room in satisfactory condition having tolerated the procedure well.  Sponge, instrument and needle counts were reported as correct.","surgery, angioplasty, venous, anastomosis, patch angioplasty, av shunt, venous anastomosis, av, thrombectomy, thrombosed, arteriovenous, vein, forearm, shunt,"
" Left thoracotomy with drainage of pleural fluid collection, esophageal exploration and repair of esophageal perforation, diagnostic laparoscopy and gastrostomy, and radiographic gastrostomy tube study with gastric contrast, interpretation.", Surgery, Thoracotomy & Esophageal Exploration ,"PREOPERATIVE DIAGNOSIS:  ,Esophageal rupture.,POSTOPERATIVE DIAGNOSIS:,  Esophageal rupture.,OPERATION PERFORMED,1.  Left thoracotomy with drainage of pleural fluid collection.,2.  Esophageal exploration and repair of esophageal perforation.,3.  Diagnostic laparoscopy and gastrostomy.,4.  Radiographic gastrostomy tube study with gastric contrast, interpretation.,ANESTHESIA: , General anesthesia.,INDICATIONS OF THE PROCEDURE: , The patient is a 47-year-old male with a history of chronic esophageal stricture who is admitted with food sticking and retching.  He has esophageal rupture on CT scan and comes now for a thoracotomy and gastrostomy.,DETAILS OF THE PROCEDURE: , After an extensive informed consent discussion process, the patient was brought to the operating room.  He was placed in a supine position on the operating table.  After induction of general anesthesia and placement of a double lumen endotracheal tube, he was turned and placed in a right lateral decubitus position on a beanbag with appropriate padding and axillary roll.  Left chest was prepped and draped in a usual sterile fashion.  After administration of intravenous antibiotics, a left thoracotomy incision was made, dissection was carried down to the subcutaneous tissues, muscle layers down to the fifth interspace.  The left lung was deflated and the pleural cavity entered.  The Finochietto retractor was used to help provide exposure.  The sixth rib was shingled in the posterior position and a careful expiration of the left pleural cavity was performed.,Immediately encountered was left pleural fluid including some purulent fluid.  Cultures of this were sampled and sent for microbiology analysis.  The left pleural space was then copiously irrigated.  A careful expiration demonstrated that the rupture appeared to be sealed.  There was crepitus within the mediastinal cavity.  The mediastinum was opened and explored and the esophagus was explored.  The tissues of the esophagus appeared to show some friability and an area of the rupture in the distal esophagus.  It was not possible to place any stitches in this tissue and instead a small intercostal flap was developed and placed to cover the area.  The area was copiously irrigated, this provided nice coverage and repair.  After final irrigation and inspection, two chest tubes were placed including a #36 French right angled tube at the diaphragm and a posterior straight #36 French.  These were secured at the left axillary line region at the skin level with #0-silk.,The intercostal sutures were used to close the chest wall with a #2 Vicryl sutures.  Muscle layers were closed with running #1 Vicryl sutures.  The wound was irrigated and the skin was closed with skin staples.,The patient was then turned and placed in a supine position.  A laparoscopic gastrostomy was performed and then a diagnostic laparoscopy performed.  A Veress needle was carefully inserted into the abdomen, pneumoperitoneum was established in the usual fashion, a bladeless 5-mm separator trocar was introduced.  The laparoscope was introduced.  A single additional left-sided separator trocar was introduced.  It was not possible to safely pass a nasogastric or orogastric tube, pass the stricture and perforation and so the nasogastric tube was left right at the level where there was some stricture or narrowing or resistance.  The stomach however did have some air insufflation and we were able to place our T-fasteners through the anterior abdominal wall and through the anterior gastric wall safely.  The skin incision was made and the gastric lumen was then accessed with the Seldinger technique.  Guide wire was introduced into the stomach lumen and series of dilators was then passed over the guide wire.  #18 French Gastrostomy was then passed into the stomach lumen and the balloon was inflated.  We confirmed that we were in the gastric lumen and the balloon was pulled up, creating apposition of the gastric wall and the anterior abdominal wall.  The T-fasteners were all crimped and secured into position.  As was in the plan, the gastrostomy was secured to the skin and into the tube.  Sterile dressing was applied.  Aspiration demonstrated gastric content.,Gastrostomy tube study, with interpretation.  Radiographic gastrostomy tube study with gastric contrast, with","surgery, esophageal rupture, thoracotomy, drainage of pleural fluid, esophageal perforation, esophageal exploration, laparoscopy, gastrostomy, pleural fluid, diagnostic laparoscopy, radiographic gastrostomy, gastric lumen, gastrostomy tube, gastric contrast, gastric, interpretation, abdominal, pleural, lumen, esophageal, tube, "
" Empyema.  Right thoracotomy, total decortication and intraoperative bronchoscopy.  A thoracostomy tube was placed at the bedside with only partial resolution of the pleural effusion.  On CT scan evaluation, there is evidence of an entrapped right lower lobe with loculations.", Surgery, Thoracotomy & Bronchoscopy ,"PREOPERATIVE DIAGNOSIS:,  Empyema.,POSTOPERATIVE DIAGNOSIS: , Empyema.,PROCEDURE PERFORMED:,1.  Right thoracotomy, total decortication.,2.  Intraoperative bronchoscopy.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  300 cc.,FLUIDS: , 2600 cc IV crystalloid.,URINE: , 300 cc intraoperatively.,INDICATIONS FOR PROCEDURE:  ,The patient is a 46-year-old Caucasian male who was admitted to ABCD Hospital since 08/14/03 with acute diagnosis of right pleural effusion.  A thoracostomy tube was placed at the bedside with only partial resolution of the pleural effusion.  On CT scan evaluation, there is evidence of an entrapped right lower lobe with loculations.  Decision was made to proceed with surgical intervention for a complete decortication and the patient understands the need for surgery and signed the preoperative informed consent.,OPERATIVE PROCEDURE: , The patient was taken to the operative suite and placed in the supine position under general anesthesia per Anesthesia Department.  Intraoperative bronchoscopy was performed by Dr. Y and evaluation of carina, left upper and lower lobes with segmental evidence of diffuse mucous, thick secretions which were thoroughly lavaged with sterile saline lavage.  Samples were obtained from both the left and the right subbronchiole segments for Gram stain cultures and ASP evaluation.  The right bronchus lower, middle, and upper were also examined and subsegmental bronchiole areas were thoroughly examined with no evidence of masses, lesions, or suspicious extrinsic compressions on the bronchi.  At this point, all mucous secretions were thoroughly irrigated and aspirated until the airways were clear.  Bronchoscope was then removed.  Vital signs remained stable throughout this portion of the procedure.  The patient was re-intubated by Anesthesia with a double lumen endotracheal tube.  At this point, the patient was repositioned in the left lateral decubitus position with protection of all pressure points and the table was extended in customary fashion.  At this point, the right chest was prepped and draped in the usual sterile fashion.  The chest tube was removed before prepping the patient and the prior thoracostomy site was cleansed thoroughly with Betadine.  The first port was placed through this incision intrathoracically.  A bronchoscope was placed for inspection of the intrathoracic cavity.  Pictures were taken.  There is extensive fibrinous exudate noted under parietal and visceral pleura, encompassing the lung surface, diaphragm, and the posterolateral aspect of the right thorax.  At this point, a second port site anteriorly was placed under direct visualization.  With the aid of the thoracoscopic view, a Yankauer resection device was placed in the thorax and blunt decortication was performed and aspiration of reminder of the pleural fluid.  Due to the gelatinous nature of the fibrinous exudate, there were areas of right upper lobe that adhered to the chest wall and the middle and lower lobes appeared entrapped.  Due to the extensive nature of the disease, decision was made to open the chest in a formal right thoracotomy fashion.  Incision was made.  The subcutaneous tissues were then electrocauterized down to the level of the latissimus dorsi, which was separated with electrocautery down to the anterior 6th rib space.  The chest cavity was entered with the right lung deflated per Anesthesia at our request.  Once the intrathoracic cavity was accessed, a thorough decortication was performed in meticulous systematic fashion starting with the right upper lobe, middle, and the right lower lobe.  With the expansion of the lung and reduction of the pleural surface fibrinous extubate, warm irrigation was used and the lungs allowed to re-expand.  There was no evidence of gross leakage or bleeding at the conclusion of surgery.,Full lung re-expansion was noted upon re-inflation of the lung.  Two #32 French thoracostomy tubes were placed, one anteriorly straight and one posteriorly on the diaphragmatic sulcus.  The chest tubes were secured in place with #0-silk sutures and placed on Pneumovac suction.  Next, the ribs were reapproximated with five interrupted CTX sutures and latissimus dorsi was then reapproximated with a running #2-0 Vicryl suture.  Next, subcutaneous skin was closed sequentially with a cosmetic layered subcutaneous closure.  Steri-Strips were applied along with sterile occlusive dressings.  The patient was awakened from anesthesia without difficulty and extubated in the operating room.  The chest tubes were maintained on Pleur-Evac suction for full re-expansion of the lung.  The patient was transported to the recovery with vital signs stable.  Stat portable chest x-ray is pending.  The patient will be admitted to the Intensive Care Unit for close monitoring overnight.","surgery, empyema, total decortication, intraoperative bronchoscopy, intrathoracic cavity, fibrinous exudate, latissimus dorsi, chest tubes, pleural effusion, bronchoscopy, thoracostomy, thoracotomy, decortication, anesthesia, pleural,"
" A 26-mm Dacron graft replacement of type 4 thoracoabdominal aneurysm from T10 to the bifurcation of the aorta, re-implanting the celiac, superior mesenteric artery and right renal as an island and the left renal as a 8-mm interposition Dacron graft, utilizing left heart bypass and cerebrospinal fluid drainage.", Surgery, Thoracoabdominal Aneurysm ,"POSTOPERATIVE DIAGNOSIS: , Type 4 thoracoabdominal aneurysm.,OPERATION/PROCEDURE: , A 26-mm Dacron graft replacement of type 4 thoracoabdominal aneurysm from T10 to the bifurcation of the aorta, re-implanting the celiac, superior mesenteric artery and right renal as an island and the left renal as a 8-mm interposition Dacron graft, utilizing left heart bypass and cerebrospinal fluid drainage.,DESCRIPTION OF PROCEDURE IN DETAIL: , Patient was brought to the operating room and put in supine position, and general endotracheal anesthesia was induced through a double-lumen endotracheal tube.  Patient was placed in the thoracoabdominal position with the left chest up and the hips back to a 30-degree angle.  The left groin, abdominal and chest were prepped and draped in a sterile fashion.  A thoracoabdominal incision was made.  The 8th interspace was entered.  The costal margin was divided.  The retroperitoneal space was entered and bluntly dissected free to the psoas, bringing all the peritoneal contents to the midline, exposing the aorta.  The inferior pulmonary ligament was then taken down so the aorta could be dissected free at the T10 level just above the diaphragm.  It was dissected free circumferentially.  The aortic bifurcation was dissected free, dissecting free both iliac arteries.  The left inferior pulmonary vein was then dissected free, and a pursestring of 4-0 Prolene was placed on this.  The patient was heparinized.  Through a stab wound in the center of this, a right-angle venous cannula was then placed at the left atrium and secured to a Rumel tourniquet.  This was hooked to a venous inflow of left heart bypass machine.  A pursestring of 4-0 Prolene was placed on the aneurysm and through a stab wound in the center of this, an arterial cannula was placed and hooked to outflow.  Bypass was instituted.  The aneurysm was cross clamped just above T10 and also, cross clamped just below the diaphragm.  The area was divided at this point.  A 26-mm graft was then sutured in place with running 3-0 Prolene suture.  The graft was brought into the diaphragm.  Clamps were then placed on the iliacs, and the pump was shut off.  The aorta was opened longitudinally, going posterior between the left and right renal arteries, and it was completely transected at its bifurcation.  The SMA, celiac and right renal artery were then dissected free as a complete island, and the left renal was dissected free as a complete Carrell patch.  The island was laid in the graft for the visceral liner, and it was sutured in place with running 4-0 Prolene suture with pledgetted 4-0 Prolene sutures around the circumference.  The clamp was then moved below the visceral vessels, and the clamp on the chest was removed, re-establishing flow to the visceral vessels.  The graft was cut to fit the bifurcation and sutured in place with running 3-0 Prolene suture.  All clamps were removed, and flow was re-established.  An 8-mm graft was sutured end-to-end to the Carrell patch and to the left renal.  A partial-occlusion clamp was placed.  An area of graft was removed.  The end of the graft was cut to fit this and sutured in place with running Prolene suture.  The partial-occlusion clamp was removed.  Protamine was given.  Good hemostasis was noted.  The arterial cannula, of course, had been removed when that part of the aneurysm was removed.  The venous cannula was removed and oversewn with a 4-0 Prolene suture.  Good hemostasis was noted.  A 36 French posterior and a 32 French anterior chest tube were placed.  The ribs were closed with figure-of-eight #2 Vicryl.  The fascial layer was closed with running #1 Prolene, subcu with running 2-0 Dexon and the skin with running 4-0 Dexon subcuticular stitch.  Patient tolerated the procedure well.","surgery, dacron graft, thoracoabdominal, cerebrospinal, thoracoabdominal aneurysm, running prolene, prolene suture, dissected free, graft, interposition, aneurysm, dacron, cannula, bifurcation, aorta, endotracheal, proleneNOTE"
" Left thoracotomy with total pulmonary decortication and parietal pleurectomy.  Empyema of the chest, left.", Surgery, Thoracotomy & Pleurectomy ,"PREOPERATIVE DIAGNOSIS: , Empyema of the chest, left.,POSTOPERATIVE DIAGNOSIS: , Empyema of the chest, left.,PROCEDURE: , Left thoracotomy with total pulmonary decortication and parietal pleurectomy.,PROCEDURE DETAIL: , After obtaining the informed consent, the patient was brought to the operating room, where he underwent a general endotracheal anesthetic using a double-lumen endotracheal tube.  A time-out process had been followed and preoperative antibiotics were given.,The patient was positioned with the left side up for a left thoracotomy.  The patient was prepped and draped in the usual fashion.  A posterolateral thoracotomy was performed.  It included the previous incision.  The chest was entered through the fifth intercostal space.  Actually, there was a very strong and hard parietal pleura, which initially did not allow us to obtain a good exposure, and actually the layer was so tough that the pin of the chest retractor broke.  Thanks to Dr. X's ingenuity, we were able to reuse the chest retractor and opened the chest after I incised the thickened parietal pleura resulting in an explosion of gas and pus from a cavity that was obviously welled off by the parietal pleura.  We aspirated an abundant amount of pus from this cavity.  The sample was taken for culture and sensitivity.,Then, at least half an hour was spent trying to excise the parietal pleura and finally we were able to accomplish that up to the apex and back to the aorta __________ towards the heart including his diaphragm.  Once we accomplished that, we proceeded to remove the solid exudate that was adhered to the lung.  Further samples for culture and sensitivity were sent.,Then, we were left with the trapped lung.  It was trapped by thickened visceral pleura.  This was the most difficult part of the operation and it was very difficult to remove the parietal pleura without injuring the lung extensively.  Finally, we were able to achieve this and after the corresponding lumen of the endotracheal tube was opened, we were able to inflate both the left upper and lower lobes of the lung satisfactorily.  There was only one area towards the mediastinum that apparently I was not able to fill.  This area, of course, was very rigid but any surgery in the direction __________ would have caused __________ injury, so I restrained from doing that.  Two large chest tubes were placed.  The cavity had been abundantly irrigated with warm saline.  Then, the thoracotomy was closed in layers using heavy stitches of Vicryl as pericostal sutures and then several figure-of-eight interrupted sutures to the muscle layers and a combination of nylon stitches and staples to the skin.,The chest tubes were affixed to the skin with heavy sutures of silk.  Dressings were applied and the patient was put back in the supine position and after a few minutes of observation and evaluation, he was able to be extubated in the operating room.,Estimated blood loss was about 500 mL.  The patient tolerated the procedure very well and was sent to the ICU in a satisfactory condition.","surgery, total pulmonary decortication, pulmonary decortication, parietal pleurectomy, endotracheal tube, chest retractor, chest tubes, parietal pleura, pleurectomy, empyema, endotracheal, thoracotomy, pleura, chest "
" Left mesothelioma, focal.  Left anterior pleural-based nodule, which was on a thin pleural pedicle with no invasion into the chest wall.", Surgery, Thoracoscopy & Thoracotomy - Mesothelioma ,"PREOPERATIVE DIAGNOSIS: , Left mesothelioma, focal.,POSTOPERATIVE DIAGNOSIS: , Left pleural-based nodule.,PROCEDURES PERFORMED:,1.  Left thoracoscopy.,2.  Left mini thoracotomy with resection of left pleural-based mass.,FINDINGS:,  Left anterior pleural-based nodule, which was on a thin pleural pedicle with no invasion into the chest wall.,FLUIDS: , 800 mL of crystalloid.,ESTIMATED BLOOD LOSS: , Minimal.,DRAINS, TUBES, CATHETERS: , 24-French chest tube in the left thorax plus Foley catheter.,SPECIMENS: , Left pleural-based nodule.,INDICATION FOR OPERATION:  ,The patient is a 59-year-old female with previous history of follicular thyroid cancer, approximately 40 years ago, status post resection with recurrence in the 1980s, who had a left pleural-based mass identified on chest x-ray.  Preoperative evaluation included a CT scan, which showed focal mass.  CT and PET confirmed anterior lesion.  Therefore the patient was seen in our thoracic tumor board where it was recommended to have resection performed with chest wall reconstruction.  In the outpatient setting, the patient was willing to proceed.,PROCEDURE PERFORMED IN DETAIL: , After informed consent was obtained, the patient identified correctly.  She was taken to the operating room where an epidural catheter was placed by Anesthesia without difficulty.  She was sedated and intubated with double-lumen endotracheal tube without difficulty.  She was positioned with left side up.  Appropriate pressure points were padded.  The left chest was prepped and draped in the standard surgical fashion.  The skin incision was made in the posterior axillary line, approximately 7th intercostal space with #10 blade, taken down through tissues and Bovie electrocautery.,Pleura was entered.  There was good deflation of the left lung.  __________ port was placed, followed by the 0-degree 10-mm scope with appropriate patient positioning.  Posteriorly a pedunculated 2.5 x 3-cm pleural-based mass was identified on the anterior chest wall.  There were thin adhesions to the pleura, but no invasion of the chest wall that could be identified.  The tumor was very mobile and was on a pedunculated stalk, approximately 1.5 cm.  It was felt that this could be resected without the need of chest wall reconstruction because of the narrow stalk.,Therefore a 2nd port was placed in the anterior axillary line approximately 8th intercostal space in the usual fashion.  Camera was placed through this port.  Laparoscopic scissors were placed through the posterior port, but it was necessary to have another instrument to provide more tension than just gravity.  Therefore because of the need to bring the specimen through the chest wall, a small 3-cm thoracotomy was made, which incorporated the posterior port site.  This was taken down to the subcutaneous tissue with Bovie electrocautery.  Periosteal elevator was used to lift the intercostal muscle off.  The ribs were not spread.  Through this 3-cm incision, both the laparoscopic scissors as well as Prestige graspers could be placed.  Prestige graspers were used to pull the specimen from the chest wall.  Care was taken not to injure the capsule.  The laparoscopic scissors on cautery were used to resect the parietal pleural off of the chest wall.  Care was taken not to transect the stalk.  Specimen came off the chest wall very easily.  There was good hemostasis.,At this point, the EndoCatch bag was placed through the incision.  Specimen was placed in the bag and then removed from the field.  There was good hemostasis.  Camera was removed.  A 24-French chest tube was placed through the anterior port and secured with 2-0 silk suture.  The posterior port site was closed 1st with 2-0 Vicryl in a running fashion for the intercostal muscle layer, followed by 2-0 closure of the latissimus fascia as well as subdermal suture, 4-0 Monocryl was used for the skin, followed by Steri-Strips and sterile drapes.  The patient tolerated the procedure well, was extubated in the operating room and returned to the recovery room in stable condition.","surgery, mini thoracotomy, pleural based mass, pleural based nodule, chest wall, mesothelioma focal, pleural, chest, thoracotomy, mesothelioma, laparoscopic, thoracoscopy, "
" Thrombosed left forearm loop fistula graft, chronic renal failure, and hyperkalemia.  Thrombectomy of the left forearm loop graft.  The venous outflow was good.  There was stenosis in the mid-venous limb of the graft.", Surgery, Thrombectomy ,"PREOPERATIVE DIAGNOSES:,1.  Thrombosed left forearm loop fistula graft.,2.  Chronic renal failure.,3.  Hyperkalemia.,POSTOPERATIVE DIAGNOSES:,1.  Thrombosed left forearm loop fistula graft.,2.  Chronic renal failure.,3.  Hyperkalemia.,PROCEDURE PERFORMED: , Thrombectomy of the left forearm loop graft.,ANESTHESIA: , Local with sedation.,ESTIMATED BLOOD LOSS: , Less than 5 cc.,COMPLICATIONS:, None.,OPERATIVE FINDINGS:,  The venous outflow was good.  There was stenosis in the mid-venous limb of the graft.,INDICATIONS: , The patient is an 81-year-old African-American female who presents with an occluded left forearm loop graft.  She was not able to have her dialysis as routine.  Her potassium was dramatically elevated at 7 the initial evening of anticipated surgery.  Both Surgery and Anesthesia thought this would be too risky to do.  Thus, she was given medications to decrease her potassium and a temporary hemodialysis catheter was placed in the femoral vein noted for her to have dialysis that night as well as this morning.  This morning her predialysis potassium was 6, and thus she was scheduled for surgery after her dialysis.,PROCEDURE: , The patient was taken to the operative suite and prepped and draped in the usual sterile fashion.  A transverse incision was made at the region of the venous anastomosis of the graft.  Further dissection was carried down to the catheter.  The vein appeared to be soft and without thrombus.  This outflow did not appear to be significantly impaired.  A transverse incision was made with a #11 blade on the venous limb of the graft near the anastomosis.  Next, a thrombectomy was done using a #4 Fogarty catheter.  Some of the clot and thrombus was removed from the venous limb.  The balloon did hang up in the multiple places along the venous limb signifying some degree of stenosis.  Once removing most of the clots from the venous limb prior to removing the plug, dilators were passed down the venous limb also indicating the area of stenosis.  At this point, we felt the patient would benefit from a curettage of the venous limb of the graft.  This was done and subsequent passes with the dilator and the balloon were then very easy and smooth following the curettage.  The Fogarty balloon was then passed beyond the clot and the plug.  The plug was visualized and inspected.  This also gave a good brisk bleeding from the graft.  The patient was heparinized and hep saline solution was injected into the venous limb and the angle vascular clamp was applied to the venous limb.  Attention was directed up to its anastomosis and the vein.  Fogarty balloon and thrombectomy was also performed well enough into this way.  There was good venous back bleeding following this.  The area was checked for any stenosis with the dilators and none was present.  Next, a #6-0 Prolene suture was used in a running fashion to close the graft.  Just prior to tying the suture, the graft was allowed to flush to move any debris or air.  The suture was also checked at that point for augmentation, which was good.  The suture was tied down and the wound was irrigated with antibiotic solution.  Next, a #3-0 Vicryl was used to approximate the subcutaneous tissues and a #4-0 undyed Vicryl was used in a running subcuticular fashion to approximate the skin edges.  Steri-Strips were applied and the patient was taken to recovery in stable condition.  She tolerated the procedure well.  She will be discharged from recovery when stable.  She is to resume her regular dialysis schedule and present for dialysis tomorrow.","surgery, thrombosed, hyperkalemia, thrombectomy, forearm loop graft, venous outflow, chronic renal failure, venous limb, loop graft, forearm loop, limb, forearm, graft, venous, anastomosis, stenosis,"
" Left thoracoscopy and left thoracotomy with declaudication and drainage of lung abscesses, and multiple biopsies of pleura and lung.", Surgery, Thoracoscopy/Thoracotomy ,"PREOPERATIVE DIAGNOSES:,  Empyema of the left chest and consolidation of the left lung.,POSTOPERATIVE DIAGNOSES:,  Empyema of the left chest, consolidation of the left lung, lung abscesses of the left upper lobe and left lower lobe.,OPERATIVE PROCEDURE: , Left thoracoscopy and left thoracotomy with declaudication and drainage of lung abscesses, and multiple biopsies of pleura and lung.,ANESTHESIA:,  General.,FINDINGS: , The patient has a complex history, which goes back about four months ago when she started having respiratory symptoms and one week ago she was admitted to another hospital with hemoptysis and on her evaluation there which included two CAT scans of chest she was found to have marked consolidation of the left lung with a questionable lung abscess or cavity with hydropneumothorax.  There was also noted to be some mild infiltrates of the right lung.  The patient had a 30-year history of cigarette smoking.  A chest tube was placed at the other hospital, which produced some brownish fluid that had foul odor, actually what was thought to be a fecal-like odor.  Then an abdominal CT scan was done, which did not suggest any communication of the bowel into the pleural cavity or any other significant abnormalities in the abdomen on the abdominal CT.  The patient was started on antibiotics and was then taken to the operating room, where there was to be a thoracoscopy performed.  The patient had a flexible fiberoptic bronchoscopy that showed no endobronchial lesions, but there was bloody mucous in the left main stem bronchus and this was suctioned out.  This was suctioned out with the addition of the use of saline ***** in the bronchus.  Following the bronchoscopy, a double lumen tube was placed, but it was not possible to secure the double lumen to the place so we did not proceed with the thoracoscopy on that day.,The patient was transferred for continued evaluation and treatment.  Today, the double lumen tube was placed and there was some erythema of the mucosa noted in the airways in the bronchi and also remarkably bloody secretions were also noted.  These were suctioned, but it was enough to produce a temporary obstruction of the left mainstem bronchus.  Eventually, the double lumen tube was secured and an attempt at a left thoracoscopy was performed after the chest tube was removed and digital dissection was carried out through that.  The chest tube tract, which was about in the sixth or seventh intercostal space, but it was not possible to dissect enough down to get a acceptable visualization through this tract.  A second incision for thoracoscopy was made about on the sixth intercostal space in the midaxillary line and again some digital dissection was carried out but it was not enough to be able to achieve an opening or space for satisfactory inspection of the pleural cavity.  Therefore the chest was opened and remarkable findings included a very dense consolidation of the entire lung such that it was very hard and firm throughout.  Remarkably, the surface of the lower lobe laterally was not completely covered with a fibrotic line, but it was more the line anterior and posterior and more of it over the left upper lobe.  There were many pockets of purulent material, which had a gray-white appearance to it.  There was quite a bit of whitish fibrotic fibrinous deposit on the parietal pleura of the lung especially the upper lobe.  The adhesions were taken down and they were quite bloody in some areas indicating that the process had been present for some time.  There seemed to be an abscess that was about 3 cm in dimension, all the lateral basilar segment of the lower lobe near the area where the chest tube was placed.  Many cultures were taken from several areas.  The most remarkable finding was a large cavity, which was probably about 11 cm in dimension, containing grayish pus and also caseous-like material, it was thought to be perhaps necrotic lung tissue, perhaps a deposit related to tuberculosis in the cavity.,The apex of the lung was quite densely adhered to the parietal pleura there and the adhesions were quite thickened and firm.,PROCEDURE AND TECHNIQUE:,  With the patient lying with the right side down on the operating table the left chest was prepped and draped in sterile manner.  The chest tube had been removed and initially a blunt dissection was carried out through the old chest tube tract, but then it was necessary to enlarge it slightly in order to get the Thoracoport in place and this was done and as mentioned above we could not achieve the satisfactory visualization through this.  Therefore, the next incision for Thoracoport and thoracoscopy insertion through the port was over the sixth intercostal space and a little bit better visualization was achieved, but it was clear that we would be unable to complete the procedure by thoracoscopy.  Therefore posterolateral thoracotomy incision was made, entering the pleural space and what is probably the sixth intercostal space.  Quite a bit of blunt and sharp and electrocautery dissection was performed to take down adhesions to the set of the fibrinous deposit on the pleural cavity.  Specimens for culture were taken and specimens for permanent histology were taken and a frozen section of one of the most quite dense.  Suture ligatures of Prolene were required.  When the cavity was encountered it was due to some compression and dissection of some of the fibrinous deposit in the upper lobe laterally and anterior and this became identified as a very thin layer in one area over this abscess and when it was opened it was quite large and we unroofed it completely and there was bleeding down in the depths of the cavity, which appeared to be from pulmonary veins and these were sutured with a ""tissue pledget"" of what was probably intercostal nozzle and endothoracic fascia with Prolene sutures.,Also as the upper lobe was retracted in caudal direction the tissue was quite dense and the superior branch of the pulmonary artery on the left side was torn and for hemostasis a 14-French Foley catheter was passed into the area of the tear and the balloon was inflated, which helped establish hemostasis and suturing was carried out again with utilizing a small pledget what was probably intercostal muscle and endothoracic fascia and this was sutured in place and the Foley catheter was removed.  The patch was sutured onto the pulmonary artery tear.  A similar maneuver was utilized on the pulmonary vein bleeding site down deep in the cavity.  Also on the pulmonary artery repair some ***** material was used and also thrombin, Gelfoam and Surgicel.  After reasonably good hemostasis was established pleural cavity was irrigated with saline.  As mentioned, biopsies were taken from multiple sites on the pleura and on the edge and on the lung.  Then two #24 Blake chest tubes were placed, one through a stab wound above the incision anteriorly and one below and one in the inferior pleural space and tubes were brought out through stab wounds necked into the skin with 0 silk.  One was positioned posteriorly and the other anteriorly and in the cephalad direction of the apex.  These were later connected to water-seal suction at 40 cm of water with negative pressure.,Good hemostasis was observed.  Sponge count was reported as being correct.  Intercostal nerve blocks at probably the fifth, sixth, and seventh intercostal nerves was carried out.  Then the sixth rib had been broken and with retraction the fractured ends were resected and rongeur used to smooth out the end fragments of this rib.  Metallic clip was passed through the rib to facilitate passage of an intracostal suture, but the bone was partially fractured inferiorly and it was very difficult to get the suture out through the inner cortical table, so that pericostal sutures were used with #1 Vicryl.  The chest wall was closed with running #1 Vicryl and then 2-0 Vicryl subcutaneous and staples on the skin.  The chest tubes were connected to water-seal drainage with 40 cm of water negative pressure.  Sterile dressings were applied.  The patient tolerated the procedure well and was turned in the supine position where the double lumen endotracheal tube was switched out with single lumen.  The patient tolerated the procedure well and was taken to the intensive care unit in satisfactory condition.","surgery, empyema, biopsies, bronchus, declaudication, endothoracic, hydropneumothorax, left lower lobe, left lung, left upper lobe, mainstem, pleura, thoracoscopy, thoracotomy, thoracotomy with declaudication, declaudication and drainage, double lumen tube, sixth intercostal space, lung abscesses, pleural cavity, intercostal space, upper lobe, double lumen, chest tube, cavity, tube, chest, lung, pulmonary, pleural, intercostal,"
 Thoracic right-sided discectomy at T8-T9.   The patient is a 53-year-old female with a history of right thoracic rib pain related to a herniated nucleus pulposus at T8-T9.  , Surgery, Thoracic Discectomy ,"PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus T8-T9.,POSTOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus T8-T9.,OPERATION PERFORMED: , Thoracic right-sided discectomy at T8-T9.,BRIEF HISTORY AND INDICATION FOR OPERATION: , The patient is a 53-year-old female with a history of right thoracic rib pain related to a herniated nucleus pulposus at T8-T9.  She has failed conservative measures and sought operative intervention for relief of her symptoms.  For details of workup, please see the dictated operative report.,DESCRIPTION OF OPERATION:  ,Appropriate informed consent was obtained and the patient was taken to the operating room and placed under general anesthetic.  She was placed in a position of comfort on the operating table with all bony prominences and soft tissues well padded and protected.  Second check was made prior to prepping and draping.  Following this, we did needle localization with reviews of AP and lateral multiple times to make sure we had the T8-T9 level.  We then made an approach through a midline incision and came out over the pars.  We dissected down carefully to identify the pars.  We then went on the outside of the pars and identified the foramen and then we took another series of x-rays to confirm the T8-T9 level.  We did this under live fluoroscopy.  We confirmed T8-T9 and then went ahead and took a Midas Rex and removed the superior portion of the pedicle overlying the outside of the disc and then worked our way downward removing portion of the transverse process as well.  We found the edge of the disc and then worked our way and we were able to remove some of the disc material but then decided to go ahead and take down the pars.  The pars was then drilled out.  We identified the disc even further and found the disc herniation material that was under the spinal cord.  We then took a combination of small pituitaries and removed the disc material without difficulty.  Once we had disc material out, we went ahead and made a small cruciate incision in the disc space and entered the disc space in earnest removing more disc material making sure there is nothing free to herniate further.  Once we had done that, we inspected up by the nerve root, found some more disc material there and removed that as well.  We could trace the nerve root out freely and easily.  We made sure there was no evidence of further disc material.  We used an Epstein curette and placed a nerve hook under the nerve root.  The Epstein curette removed some more disc material.  Once we had done this, we were satisfied with the decompression.  We irrigated the wound copiously to make sure there is no further disc material and then ready for closure.  We did place some steroid over the nerve root and readied for closure.  Hemostasis was meticulous.  The wound was closed with #1 Vicryl suture for the fascial layer, 2 Vicryl suture for the skin, and Monocryl and Steri-Strips applied.  Dressing was applied.  The patient was awoken from anesthesia and taken to the recovery room in stable condition.,ESTIMATED BLOOD LOSS:,  150 mL.,COMPLICATIONS: , None.,DISPOSITION:,  To PACU in stable condition having tolerated the procedure well, to mobilize routinely when she is comfortable to go to her home.","surgery, thoracic right-sided discectomy, herniated nucleus pulposus, discectomy, thoracic, herniated,"
 Bilateral temporal artery biopsy.  Rule out temporal arteritis., Surgery, Temporal Artery Biopsy ,"PREOPERATIVE DIAGNOSIS:,  Rule out temporal arteritis.,POSTOPERATIVE DIAGNOSIS:  ,Rule out temporal arteritis.,PROCEDURE:,  Bilateral temporal artery biopsy.,ANESTHESIA:,  Local anesthesia 1% Xylocaine with epinephrine.,INDICATIONS:,  I was consulted by Dr. X for this patient with bilateral temporal headaches to rule out temporal arteritis.  I explained fully the procedure to the patient.,PROCEDURE: , Both sides were done exactly the same way.  After 1% Xylocaine infiltration, a 2 to 3-cm incision was made over the temporal artery.  The temporal artery was identified and was grossly normal on both sides.  Proximal and distal were ligated with both of 3-0 silk suture and Hemoccult.  The specimen of temporal artery was taken from both sides measuring at least 2 to 3 cm.  They were sent as separate specimens, right and left labeled.  The wound was then closed with interrupted 3-0 Monocryl subcuticular sutures and Dermabond.  She tolerated the procedure well.","surgery, headaches, bilateral temporal artery, temporal artery biopsy, temporal arteritis, temporal artery, temporal, biopsy, arteritis"
" Thoracentesis, left.   Malignant pleural effusion, left, with dyspnea.", Surgery, Thoracentesis - 1 ,"PREOPERATIVE DIAGNOSIS: , Malignant pleural effusion, left, with dyspnea.,POSTOPERATIVE DIAGNOSIS: , Malignant pleural effusion, left, with dyspnea.,PROCEDURE:  ,Thoracentesis, left.,DESCRIPTION OF PROCEDURE: , The patient was brought to the recovery area of the operating room.  After obtaining the informed consent, the patient's posterior left chest wall was prepped and draped in usual fashion.  Xylocaine 1% was infiltrated above the seventh intercostal space in the midscapular line.  Initially, I tried to use the thoracentesis set after 1% Xylocaine had been infiltrated, but the needle of the system was just too short to reach the pleural cavity due to the patient's very thick chest wall.  Therefore, I had to use a #18 spinal needle, which I had to use almost in its entire length to reach the fluid.  From then on, I proceeded manually to withdraw 2000 mL of a light milky fluid.,The patient tolerated the procedure fairly well, but almost at the end of it she said that she was feeling like fainting and therefore we carefully withdrew the needle.  At that time, it was getting difficult to withdraw fluid anyway and we allowed her to lie down and after a few minutes the patient was feeling fine.  At any rate, we gave her bolus of 250 mL of normal saline and the patient returned to her room for additional hours of observation.  We then thought that if she was doing fine, then we will send her home.,A chest x-ray was performed after the procedure which showed a dramatic reduction of the amount of pleural fluid and then there was no pneumothorax or no other obvious complications of her procedure.,","surgery, malignant pleural effusion, chest wall, pleural effusion, dyspnea, thoracentesis, fluid, pleural, "
 Insertion of a left subclavian Tesio hemodialysis catheter and surgeon-interpreted fluoroscopy., Surgery, Tesio Hemodialysis Catheter Insertion ,"OPERATION,1.  Insertion of a left subclavian Tesio hemodialysis catheter.,2.  Surgeon-interpreted fluoroscopy.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and MAC anesthesia was administered.  Next, the patient's chest and neck were prepped and draped in the standard surgical fashion.  Lidocaine 1% was used to infiltrate the skin in the region of the procedure.  Next a #18-gauge finder needle was used to locate the left subclavian vein.  After aspiration of venous blood, Seldinger technique was used to thread a J wire through the needle.  This process was repeated.  The 2 J wires and their distal tips were confirmed to be in adequate position with surgeon-interpreted fluoroscopy.  Next, the subcutaneous tunnel was created.  The distal tips of the individual Tesio hemodialysis catheters were pulled through to the level of the cuff.  A dilator and sheath were passed over the individual J wires.  The dilator and wire were removed, and the distal tip of the Tesio hemodialysis catheter was threaded through the sheath, which was simultaneously withdrawn.  The process was repeated.  Both distal tips were noted to be in good position.  The Tesio hemodialysis catheters were flushed and aspirated without difficulty.  The catheters were secured at the cuff level with a 2-0 nylon.  The skin was closed with 4-0 Monocryl.  Sterile dressing was applied.  The patient tolerated the procedure well and was transferred to the PACU in good condition.","surgery, needle, tesio hemodialysis catheter, hemodialysis catheter, fluoroscopy, catheters, catheter, tesio, hemodialysisNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" Headaches, question of temporal arteritis.  Bilateral temporal artery biopsies.", Surgery, Temporal Artery Biopsy - 1 ,"PREOPERATIVE DIAGNOSIS:,  Headaches, question of temporal arteritis.,POSTOPERATIVE DIAGNOSIS:,  Headaches, question of temporal arteritis.,PROCEDURE:,  Bilateral temporal artery biopsies.,DESCRIPTION OF PROCEDURE: , After obtaining an informed consent, the patient was brought to the operating room where her right temporal area was prepped and draped in the usual fashion.  Xylocaine 1% was utilized and then an incision was made in front of the right ear and deepened anteriorly.  The temporal artery was found and exposed in an extension of about 2 cm.  The artery was proximally and distally ligated with 6-0 Prolene and also a side branch and a sample was sent for pathology.  Hemostasis achieved with a cautery and the incision was closed with a subcuticular suture of Monocryl.,Then, the patient was turned and her left temporal area was prepped and draped in the usual fashion.  A similar procedure was performed with 1% Xylocaine and exposed her temporal artery, which was excised in an extent to about 2 cm.  This was also proximally and distally ligated with 6-0 Prolene and also side branch.  Hemostasis was achieved with a cautery and the skin was closed with a subcuticular suture of Monocryl.,Dressings were applied to both areas.,The patient tolerated the procedure well.  Estimated blood loss was negligible, and the patient went back to Same Day Surgery for recovery.","surgery, temporal arteritis, temporal artery, temporal, artery, biopsies, hemostasis, subcuticular, headaches, arteritis, "
 Extraction of tooth #T and incision and drainage (I&D) of right buccal space infection.  Right buccal space infection and abscess tooth #T., Surgery, Teeth Extraction & I&D - 2 ,"PREOPERATIVE DIAGNOSIS:,  Right buccal space infection and abscess tooth #T.,POSTOPERATIVE DIAGNOSIS: , Right buccal space infection and abscess tooth #T.,PROCEDURE:,  Extraction of tooth #T and incision and drainage (I&D) of right buccal space infection.,ANESTHESIA:,  General, oral endotracheal tube.,COMPLICATIONS: , None.,SPECIMENS:,  Aerobic and anaerobic cultures were sent.,IV FLUID: , 150 mL.,ESTIMATED BLOOD LOSS:,  10 mL.,PROCEDURE: , The patient was brought to the operating room, placed on the table in a supine position, and after demonstration of an adequate plane of general anesthesia via the oral endotracheal route, the patient was prepped and draped in the usual fashion for an intraoral procedure.  Gauze throat pack was placed and the right buccal vestibule was palpated and area of the abscess was located.  The abscess cavity was aspirated using a 5 mL syringe with an 18-gauge needle.  Approximately 1 mL of purulent material was aspirated that was placed on aerobic and anaerobic cultures.  Culture swabs and the tooth sent to the laboratory for culture and sensitivity testing.,The area in the buccal vestibule was then opened with approximately 1-cm incision.  Blunt dissection was then used to open up the abscess cavity and explore the abscess cavity.  A small amount of additional purulence was drained from it, approximately 1 mL and at this point, tooth #T was extracted by forceps extraction.  Periosteal elevator was used to explore the area near the extraction site.  This was continuous with abscess cavity, so the abscess cavity was allowed to drain into the extraction site.  No drain was placed.  Upon completion of the procedure, the throat pack was removed.  The pharynx was suctioned.  The stomach was also suctioned and the patient was then awakened, extubated, and taken to the recovery room in stable condition.","surgery, buccal space, incision and drainage, throat pack, extraction site, tooth, i&d, drainage, infection, cavity, extraction, incision, buccal, abscess"
 Insertion of right internal jugular Tessio catheter and placement of left wrist primary submental arteriovenous fistula., Surgery, Tessio Catheter Insertion ,"OPERATIONS/PROCEDURES,1.  Insertion of right internal jugular Tessio catheter.,2.  Placement of left wrist primary submental arteriovenous fistula.,PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed in the supine position.  Adequate general endotracheal anesthesia was induced.  Appropriate monitoring lines were placed.  The right neck, chest and left arm were prepped and draped in a sterile fashion.  A small incision was made at the top of the anterior jugular triangle in the right neck.  Through this small incision, the right internal jugular vein was punctured and a guidewire was placed.  It was punctured a 2nd time, and a 2nd guidewire was placed.  The Tessio catheters were assembled.  They were measured for length.  Counter-incisions were made on the right chest.  They were then tunneled through these lateral chest wall incisions to the neck incision, burying the Dacron cuffs.  They were flushed with saline.  A suture was placed through the guidewire, and the guidewire and dilator were removed.  The arterial catheter was then placed through this, and the tear-away introducer was removed.  The catheter aspirated and bled easily.  It was flushed with saline and capped.  This was repeated with the venous line.  It also aspirated easily and was flushed with saline and capped.  The neck incision was closed with a 4-0 Tycron, and the catheters were sutured at the exit sites with 4-0 nylon.  Dressings were applied.  An incision was then made at the left wrist.  The basilic vein was dissected free, as was the radial artery.  Heparin was given, 50 mg.  The radial artery was clamped proximally and distally with a bulldog.  It was opened with a #11 blade and Potts scissors, and stay sutures of 5-0 Prolene were placed.  The vein was clipped distally, divided and spatulated for anastomosis.  It was sutured to the radial artery with a running 7-0 Prolene suture.  The clamps were removed.  Good flow was noted through the artery.  Protamine was given, and the wound was closed with interrupted 3-0 Dexon subcutaneous and a running 4-0 Dexon subcuticular on the skin.  The patient tolerated the procedure well.","surgery, internal jugular tessio catheter, arteriovenous, fistula, submental, tunneled, tessio catheter, internal jugular, radial artery, tessio, jugular, artery, catheterNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Thoracentesis.  Left pleural effusion.  Left hemothorax., Surgery, Thoracentesis ,"PREOPERATIVE DIAGNOSIS:,  Left pleural effusion.,POSTOPERATIVE DIAGNOSIS:,  Left hemothorax.,PROCEDURE: , Thoracentesis.,PROCEDURE IN DETAIL:,  After obtaining informed consent and having explained the procedure to the patient, he was sat at the side of a stretcher in the emergency department.  His left back was prepped and draped in the usual fashion.  Xylocaine 1% was used to infiltrate his chest wall and the chest entered upon the ninth intercostal space in the midscapular line and the thoracentesis catheter was used and placed, and then we proceed to draw by hand about 1200 mL blood.  This blood was nonclotting and it was tested twice.  Halfway during the procedure, the patient felt that he was getting dizzy and his pressure at that time had dropped to the 80s.  Therefore, we laid him off his right side while keeping the chest catheter in place.  At that time, I proceeded to continuously draw fluids slowly and then when the patient recovered we sat him up again and we proceed to complete the procedure.,Overall besides the described episode, the patient tolerated the procedure well and afterwards, we took another chest x-ray that showed much improvement in the pleural effusion and at that particular time, with all the history we proceeded to admit the patient for observation and with an idea to obtain a CT in the morning to see whether the patient would need an pigtail intrapleural catheter or not.","surgery, pleural effusion, hemothorax, thoracentesis, chest,"
 Extraction of teeth #2 and #19 and incision and drainage (I&D) of intraoral and extraoral of left mandibular dental abscess., Surgery, Teeth Extraction & I&D - 1 ,"PREOPERATIVE DIAGNOSES: , Carious teeth #2 and #19 and left mandibular dental abscess.,POSTOPERATIVE DIAGNOSES:,  Carious teeth #2 and #19 and left mandibular dental abscess.,PROCEDURES:,  Extraction of teeth #2 and #19 and incision and drainage of intraoral and extraoral of left mandibular dental abscess.,ANESTHESIA: , General, oral endotracheal.,COMPLICATIONS: , None.,DRAINS: , Penrose 0.25 inch intraoral and vestibule and extraoral.,CONDITION:,  Stable to PACU.,DESCRIPTION OF PROCEDURE:,  Patient was brought to the operating room, placed on the table in the supine position and after demonstration of an adequate plane of general anesthesia via the oral endotracheal route, patient was prepped and draped in the usual fashion for an intraoral procedure.  In addition, the extraoral area on the left neck was prepped with Betadine and draped accordingly.  Gauze throat pack was placed and local anesthetic was administered in the left lower quadrant, total of 3.4 mL of lidocaine 2% with 1:100,000 epinephrine and Marcaine 1.7 mL of 0.5% with 1:200,000 epinephrine.  An incision was made with #15 blade in the left submandibular area through the skin and blunt dissection was accomplished with curved mosquito hemostat to the inferior border of the mandible.  No purulent drainage was obtained.  The 0.25 inch Penrose drain was then placed in the extraoral incision and it was secured with 3-0 silk suture.  Moving to the intraoral area, periosteal elevator was used to elevate the periosteum from the buccal aspect of tooth #19.  The area did not drain any purulent material.  The carious tooth #19 was then extracted by elevator and forceps extraction.  After the tooth was removed, the 0.25 inch Penrose drain was placed in a subperiosteal fashion adjacent to the extraction site and secured with 3-0 silk suture.  The tube was then repositioned to the left side allowing access to the upper right quadrant where tooth #2 was then extracted by routine elevator and forceps extraction.  After the extraction, the throat pack was removed.  An orogastric tube was then placed by Dr. X, and stomach contents were suctioned.  The pharynx was then suctioned with the Yankauer suction.  The patient was awakened, extubated, and taken to the PACU in stable condition.","surgery, yankauer suction, orogastric tube, carious teeth, penrose drain, forceps extraction, dental abscess, incision, elevator, mandibular, dental, abscess, teeth, intraoral, extraction, drainage,"
" Left carpal tunnel release with flexor tenosynovectomy; cortisone injection of trigger fingers, left third and fourth fingers; injection of Dupuytren's nodule, left palm.", Surgery, Tenosynovectomy & Cortisone Injection ,"PREOPERATIVE DIAGNOSES,1.  EMG-proven left carpal tunnel syndrome.,2.  Tenosynovitis of the left third and fourth fingers at the A1 and A2 pulley level.,3.  Dupuytren's nodule in the palm.,POSTOPERATIVE DIAGNOSES,1.  EMG-proven left carpal tunnel syndrome.,2.  Tenosynovitis of the left third and fourth fingers at the A1 and A2 pulley level.,3.  Dupuytren's nodule in the palm.,PROCEDURE: , Left carpal tunnel release with flexor tenosynovectomy; cortisone injection of trigger fingers, left third and fourth fingers; injection of Dupuytren's nodule, left palm.,ANESTHESIA: , Local plus IV sedation (MAC).,ESTIMATED BLOOD LOSS:  ,Zero.,SPECIMENS:  ,None.,DRAINS: , None.,PROCEDURE DETAIL: , Patient brought to the operating room.  After induction of IV sedation the left hand was anesthetized suitable for carpal tunnel release; 10 cc of a mixture of 1% Xylocaine and 0.5% Marcaine was injected in the distal forearm and proximal palm suitable for carpal tunnel surgery.  Routine prep and drape was employed.  Arm was exsanguinated by means of elevation of Esmarch elastic tourniquet and tourniquet inflated to 250 mmHg pressure.  Hand was positioned palm up in the lead hand-holder.  A short curvilinear incision about the base of the thenar eminence was made.  Skin was sharply incised.  Sharp dissection was carried down to the transverse carpal ligament and this was carefully incised longitudinally along its ulnar margin.  Care was taken to divide the entire length of the transverse retinaculum including its distal insertion into deep palmar fascia in the midpalm.  Proximally the antebrachial fascia was released for a distance of 2-3 cm proximal to the wrist crease to insure complete decompression of the median nerve.  Retinacular flap was retracted radially to expose the contents of the carpal canal.  Median nerve was identified, seen to be locally compressed with moderate erythema and mild narrowing.  Locally adherent tenosynovium was present and this was carefully dissected free.  Additional tenosynovium was dissected from the flexor tendons, individually stripping and peeling each tendon in sequential order so as to debulk the contents of the carpal canal.  Epineurotomy and partial epineurectomy were carried out on the nerve in the area of mild constriction to relieve local external scarring of the epineurium.  When this was complete retinacular flap was laid loosely in place over the contents of the carpal canal and skin only was closed with interrupted 5-0 nylon horizontal mattress sutures.  A syringe with 3 cc of Kenalog-10 and 3 cc of 1% Xylocaine using a 25 gauge short needle was then selected; 1 cc of this mixture was injected into the third finger A1 and A2 pulley tendon sheaths using standard trigger finger injection technique; 1 cc was injected into the fourth finger A1/A2 pulley tendon sheath using standard tendon sheath injection technique; 1 cc was injected into the Dupuytren's nodule in the midpalm to relieve local discomfort.  Routine postoperative hand dressing with well-padded, well-molded volar plaster splint and lightly compressive Ace wrap was applied.  Tourniquet was deflated.  Good vascular color and capillary refill were seen to return to the tips of all digits.  Patient discharged to the ambulatory recovery area and from there discharged home.  Discharge medication is Darvocet-N 100, 30 tablets, one to two PO q.4h. p.r.n.  Patient asked to begin gentle active flexion, extension and passive nerve glide exercises beginning 24-48 hours after surgery.  She was asked to keep the dressings clean, dry and intact and follow up in my office.","surgery, carpal tunnel syndrome, pulley, dupuytren's, tenosynovitis, tenosynovectomy, carpal tunnel release, flexor tenosynovectomy, cortisone injection, dupuytren's nodule, injection, cortisone,"
" Painful enlarged navicula, right foot.  Osteochondroma of right fifth metatarsal. Partial tarsectomy navicula and partial metatarsectomy, right foot.", Surgery, Tarsectomy ,"PREOPERATIVE DIAGNOSES:,1.  Painful enlarged navicula, right foot.,2.  Osteochondroma of right fifth metatarsal.,POSTOPERATIVE DIAGNOSES:,1.  Painful enlarged navicula, right foot.,2.  Osteochondroma of right fifth metatarsal.,PROCEDURE PERFORMED:,1.  Partial tarsectomy navicula, right foot.,2.  Partial metatarsectomy, right foot.,HISTORY:  ,This 41-year-old Caucasian female who presents to ABCD General Hospital with the above chief complaint.  The patient states that she has extreme pain over the navicular bone with shoe gear as well as history of multiple osteochondromas of unknown origin.  She states that she has been diagnosed with hereditary osteochondromas.  She has had previous dissection of osteochondromas in the past and currently has not been diagnosed in her feet as well as spine and back.  The patient desires surgical treatment at this time.,PROCEDURE:  ,An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported to the operating room and placed on operating table in the supine position with a safety belt across her lap.  Copious amounts of Webril were placed on the left ankle followed by a blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 5 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain were injected in the diamond block type fashion around the navicular bone as well as the fifth metatarsal.  Foot was then prepped and draped in the usual sterile orthopedic fashion.,Foot was elevated from the operating table and exsanguinated with an Esmarch bandage.  The pneumatic ankle tourniquet was then inflated to 250 mmHg.  The foot was lowered as well as the operating table.  The sterile stockinet was reflected and the foot was cleansed with wet and dry sponge.  Attention was then directed to the navicular region on the right foot.  The area was palpated until the bony prominence was noted.  A curvilinear incision was made over the area of bony prominence.  At that time, a total of 10 cc with addition of 1% additional lidocaine plain was injected into the surgical site.  The incision was then deepened with #15 blade.  All vessels encountered were ligated for hemostasis.  The dissection was carried down to the level of the capsule and periosteum.  A linear incision was made over the navicular bone obliquely from proximal dorsal to distal plantar over the navicular bone.  The periosteum and the capsule were then reflected from the navicular bone at this time.  A bony prominence was noted both medially and plantarly to the navicular bone.  An osteotome and mallet were then used to resect the enlarged portion of the navicular bone.  After resection with an osteotome there was noted to be a large plantar shelf.  The surrounding soft tissues were then freed from this plantar area.  Care was taken to protect the attachments of the posterior tibial tendon as much as possible.  Only minimal resection of its attachment to the fiber was performed in order to expose the bone.  Sagittal saw was then used to resect the remaining plantar medial prominent bone.  The area was then smoothed with reciprocating rasp until no sharp edges were noted.  The area was flushed with copious amount of sterile saline at which time there was noted to be a palpable ________ where the previous bony prominence had been noted.  The area was then again flushed with copious amounts of sterile saline and the capsule and periosteum were then reapproximated with #3-0 Vicryl.  The subcutaneous tissues were then reapproximated with #4-0 Vicryl to reduce tension from the incision and running #5-0 Vicryl subcuticular stitch was performed.,Attention was then directed to the fifth metatarsal.  There was noted to be a palpable bony prominence dorsally with fifth metatarsal head as well as radiographic evidence laterally of an osteochondroma at the neck of the fifth metatarsal.  Approximately 7 cm incision was made dorsolaterally over the fifth metatarsal.  The incision was then deepened with #15 blade.  Care was taken to preserve the extensor tendon.  The incision was then created over the capsule and periosteum of the fifth metatarsal head.  Capsule and periosteum were reflected both dorsally, laterally, and plantarly.  At that time, there was noted to be a visible osteochondroma on the plantar lateral aspect of the fifth metatarsal neck as well as on the dorsal aspect of the head of the fifth metatarsal.  A sagittal saw was used to resect both of these osteal prominences.,All remaining sharp edges were then smoothed with reciprocating rasp.  The area was inspected for the remaining bony prominences and none was noted.  The area was flushed with copious amounts of sterile saline.  The capsule and periosteum were then reapproximated with #3-0 Vicryl.  Subcutaneous closure was then performed with #4-0 Vicryl in order to reduce tension around the incision line.  Running #5-0 subcutaneous stitch was then performed.  Steri-Strips were applied to both surgical sites.  Dressings consisted of Adaptic, soaked in Betadine, 4x4s, Kling, Kerlix, and Coban.  The pneumatic ankle tourniquet was released and the hyperemic flush was noted to all five digits of the right foot.,The patient tolerated the above procedure and anesthesia well without complications.  The patient was transferred to the PACU with vital signs stable and vascular status intact.  The patient was given postoperative pain prescription and instructed to be partially weightbearing with crutches as tolerated.  The patient is to follow-up with Dr. X in his office as directed or sooner if any problems or questions arise.","surgery, navicula, metatarsal, osteochondroma, tarsectomy, metatarsectomy, painful enlarged navicula, navicular bone, foot, bony, capsule, periosteum, navicular, incision, bone"
 Extraction of teeth.  Incision and drainage (I&D) of left mandibular vestibular abscess adjacent to teeth #18 and #19., Surgery, Teeth Extraction & I&D ,"PREOPERATIVE DIAGNOSES,1.  Carious teeth #2, #5, #12, #15, #18, #19, and #31.,2.  Left mandibular vestibular abscess.,POSTOPERATIVE DIAGNOSES,1.  Carious teeth #2, #5, #12, #15, #18, #19, and #31.,2.  Left mandibular vestibular abscess.,PROCEDURE,1.  Extraction of teeth #2.  #5, #12, #15, #18, #19, #31.,2.  Incision and drainage (I&D) of left mandibular vestibular abscess adjacent to teeth #18 and #19.,ANESTHESIA:,  General nasotracheal.,COMPLICATIONS: , None.,DRAIN:,  Quarter-inch Penrose drain place in left mandibular vestibule adjacent to teeth #18 and #19, secured with 3-0 silk suture.,CONDITION:,  The patient was taken to the PACU in stable condition.,INDICATION:,  Patient is a 32-year-old female who was admitted yesterday 03/04/10 with left facial swelling and a number of carious teeth which were also abscessed particularly those on the lower left and this morning, the patient was brought to the operating room for extraction of the carious teeth and incision and drainage of left vestibular abscess.,DESCRIPTION OF PROCEDURE:,  Patient was brought to the operating room, placed on the table in a supine position, and after demonstration of an adequate plane of general anesthesia via the nasotracheal route, patient was prepped and draped in the usual fashion for an intraoral procedure.  A gauze throat pack was placed and local anesthetic was administered in all four quadrants, a total of 6.8 mL of lidocaine 2% with 1:100,000 epinephrine, and 3.6 mL of Marcaine 0.5% with 1:200,000 epinephrine.  The area in the left vestibular area adjacent to the teeth #18 and #19 was aspirated with 5 cc syringe with an 18-guage needle and approximately 1 mL of purulent material was aspirated.  This was placed on the culture medium in the aerobic and anaerobic culture tubes and the tubes were then sent to the lab.  An incision was then made in the left mandibular vestibule adjacent to teeth #18 and #19.  The area was bluntly dissected with a curved hemostat and a small amount of approximately 3 mL of purulent material was drained.  Penrose drain was then placed using a curved hemostat.  The drain was secured with 3-0 silk suture.  The extraction of the teeth was then begun on the left side removing teeth #12, #15, #18 and #19 with forceps extraction, then moving to the right side teeth #2, #5, and #31 were removed with forceps extraction uneventfully.  After completion of the procedure, the throat pack was removed, the pharynx was suctioned.  The anesthesiologist then placed an orogastric tube and suctioned approximately 10 cc of stomach contents with the nasogastric tube.  The nasogastric tube was then removed.  Patient was then extubated and taken to the PACU in stable condition.","surgery, mandibular, vestibular, abscess, throat pack, purulent material, forceps extraction, nasogastric tube, carious teeth, incision, teeth, nasogastric, carious, extraction"
" Removal of cystic lesion, removal of teeth, modified Le Fort I osteotomy.
", Surgery, Teeth Extraction ,"PREOPERATIVE DIAGNOSES,1.  Basal cell nevus syndrome.,2.  Cystic lesion, left posterior mandible.,3.  Corrected dentition.,4.  Impacted teeth 1 and 16.,5.  Maxillary transverse hyperplasia.,POSTOPERATIVE DIAGNOSES,1.  Basal cell nevus syndrome.,2.  Cystic lesion, left posterior mandible.,3.  Corrected dentition.,4.  Impacted teeth 1 and 16.,5.  Maxillary transverse hyperplasia.,PROCEDURE,1.  Removal of cystic lesion, left posterior mandible.,2.  Removal of teeth numbers 4, 13, 20, and 29.,3.  Removal of teeth numbers 1 and 16.,4.  Modified Le Fort I osteotomy.,INDICATIONS FOR THE PROCEDURE:, The patient has undergone previous surgical treatment and had a diagnosis of basal cell nevus syndrome.  Currently our plan is to remove the impacted third molar teeth, to remove a cystic lesion left posterior mandible, to remove 4 second bicuspid teeth as requested by her orthodontist, and to weaken and her maxilla to allow expansion by a modified Le Fort osteotomy.,PROCEDURE IN DETAIL:, The patient was brought into the operating room, placed on the operating table in supine position.  Following treatment under adequate general anesthesia via the orotracheal route, the patient was prepped and draped in a manner consistent with intraoral surgical procedures.  The oral cavity was suctioned, was drained of fluid and a throat pack was placed.  General anesthesia nursing service was notified and which was removed at the end of the procedure.  Lidocaine 1% with epinephrine concentration in 1:100,000 was injected into the labial vestibule of the maxilla bilaterally as well as the lateral areas associated with the extractions sites in lower jaw and the left posterior mandible for a total of 11 mL.  A Bovie electrocautery was utilized to make a vestibular incision, beginning in the second molar region of the maxilla superior to the mucogingival junction extending to the area of the cuspid teeth.  Subperiosteal dissection revealed lateral aspect of the maxilla immediately posterior to the second molar tooth where the third molar tooth was identified and was bony crypt.  Following use of Cerebromaxillary osteotome, elevated, and underwent complete removal of the dental follicle.  Secondly, tooth number 4 was removed.  Tooth number 13 was removed, and the opposite third molar tooth was removed through an identical incision on the opposite side.  Surgeon then utilized a #15 saw to make a horizontal osteotomy through the lateral aspect of the maxilla from the target plates, anteriorly to the area of the buttress region cross the anterior maxilla to a point adjacent to the piriform rim, 5 mm superior to the nasal floor, bilaterally Cerebromaxillary osteotome utilized to separate the maxilla from the target placed posteriorly and a 5 mm Tessier osteotome through a vertical incision anteriorly between roots of teeth numbers 8 and 9.  This resulted in the alternate mobilization of the two halves of the maxilla, or to allow expansion.  These wounds were all irrigated with copious amounts of normal saline and with antibiotic containing solution, closed with 3-0 chromic suture in running fashion for watertight closure.  Attention was directed to the mandible where the left posterior mandible was approached through a lateral vestibular incision overlying the external oblique ridge and brought anteriorly in an old scar.  The surgeons utilized cautery osteotome to identify a cystic lesion associated with the left posterior mandible, which was approximately 1 cm in width and 2.5 to 3 cm in vertical dimension immediately adjacent to the neurovascular bundle.  This wound was then irrigated with copious amounts of normal saline and concentrated solution of clindamycin.  Closed primarily with a 3-0 Vicryl suture in running fashion for a watertight closure.  Teeth number 20 and 29 where removed and 3-0 chromic suture placed.  This concluded the procedure.  All cottonoids and other sponges, throat pack were removed.  No complications were encountered.  The aforementioned cystic lesion was sent with specimen no drains were placed.  The blood loss from this procedure was approximately 100 mL.,The patient was returned over the care of the anesthesia where she was extubated in the operating room, taken from the operating room to the recovery room with stable vital signs and spontaneous respirations.","surgery, nevus syndrome, basal cell, mandible, teeth, hyperplasia, cystic lesion, osteotomy, le fort, le fort osteotomy, orotracheal route, bony crypt, watertight, removal of cystic lesion, le fort i osteotomy, aspect of the maxilla, modified le fort, molar tooth, posterior mandible, maxillary, molar, tooth,"
 Full-mouth extraction of teeth and alveoloplasty in all four quadrants., Surgery, Teeth (full-mouth) Extraction ,"PREOPERATIVE DIAGNOSIS:, Nonrestorable teeth.,POSTOPERATIVE DIAGNOSIS:, Nonrestorable teeth.,PROCEDURE:, Full-mouth extraction of tooth #3,5,6, 7, 8, 9, 10, 11, 12, 13, 14, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 31, and alveoloplasty in all four quadrants.,ANESTHESIA:,  Nasotracheal general anesthesia.,IV FLUIDS:, A 700 mL of crystalloid.,EBL:, Minimum.,URINE:, Not recorded.,COMPLICATIONS:, None.,CONDITION:, Good.,DISPOSITION:,  The patient was extubated in OR, transferred to PACU for recovery and will be transferred for 23-hour observation and discharged on subsequent day.,BRIEF HISTORY OF THE PATIENT:, Indicated the patient for surgery.  The patient is a 41-year-old white female with multiple grossly decaying nonrestorable teeth.  After discussing treatment options, she decided she will like to have extraction of remaining teeth with subsequent placement of upper and lower complete dentures.,PAST MEDICAL HISTORY:, Positive for a narcotic abuse, presently on methadone treatment, hepatitis C, and headaches.,PAST SURGICAL HISTORY:, C-section x2.,MEDICATIONS,Right now include:,1.  Methadone.,2.  Beta-blocker.,3.  Xanax.,4.  Norco.,5.  Clindamycin.,ALLERGIES:, THE PATIENT IS ALLERGIC TO PENICILLIN.,PROCEDURE IN DETAIL:, The patient was greeted in preoperative holding area, subsequently transferred to OR #17 where the patient was intubated with anesthesia staff present.  The patient was prepped and draped in sterile fashion.  Local anesthesia consisting of 1% lidocaine and 1:100,000 epinephrine, total 15 mL were injected into the maxillomandible.  Throat pack was placed in the mouth after a thorough suction.,A full-thickness mucoperiosteal flap was reflected from the upper right to the upper left, tooth number 3,5,6,7,8,9,10,11,12,13, and 14 and were elevated and delivered.  Extraction sites were thoroughly curettaged and irrigated.  Bony undercuts were removed then smoothed with rongeurs and bone saw.  After thorough irrigation, the postsurgical site closed in a running fashion with 3-0 chromic sutures.  Subsequently, a full-thickness mucoperiosteal flap was reflected in the mandible, tooth numbers 31, 28, 27, 26, 25, 24, 23, 22, 21, 20, and 19 were elevated and delivered with simple forceps extractions.  Bony undercuts were removed with rongeurs and smoothed with bone saw.,Extraction sites were thoroughly irrigated and curettaged.  Wound was closed in continuous fashion 3-0 chromic.  After adequate hematosis was achieved, 0.5% Marcaine and 1:200,000 epinephrine was injected in the maxillomandible thus to heal to aid in hematosis and pain control.  Total of 8 mL were used.  Throat pack was subsequently removed.  Orogastric tube was passed to suction out the stomach.,The patient was subsequently extubated in OR and transferred to PACU for recovery.  The patient would be placed in 23-hour observation.",
 Total abdominal hysterectomy (TAH) with a right salpingo-oophorectomy., Surgery, TAH & Salpingo-oophorectomy - 1 ,"PREOPERATIVE DIAGNOSIS:  ,Persistent abnormal uterine bleeding after endometrial ablation.,POSTOPERATIVE DIAGNOSIS: , Persistent abnormal uterine bleeding after endometrial ablation.,PROCEDURE PERFORMED: , Total abdominal hysterectomy (TAH) with a right salpingo-oophorectomy.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , 250 cc.,FLUIDS:  ,1500 cc of crystalloids.,URINE: , 125 cc of clear urine at the end of the procedure.,FINDINGS: , On exam, under anesthesia, an obese female with an enlarged fibroid uterus freely movable on the pelvis.  Operative findings demonstrated the same with normal appearing tubes bilaterally.  The right ovary contained a right ovarian cyst.  The left ovary appeared to be within normal limits.  The peritoneal surfaces were noted to be within normal limits.  The bowel was also noted to be within normal limits.,INDICATIONS FOR THIS PROCEDURE: , The patient is a 44-year-old female who had an endometrial ablation done in May, which showed submucosal fibroids.  She had history of anemia and has been on iron therapy.  She started having bleeding three weeks ago with intermittent bouts of flooding.,She desired permanent and definitive therapy and therefore it was felt very appropriate to take the patient for a total abdominal hysterectomy.  The uterus, cervix, and right tube and ovary was sent to pathology for review.,PROCEDURE: , After informed consent was obtained, all questions were answered to the patient's satisfaction in layman's term.  She was taken to the operating room where a general anesthesia was obtained without any difficulty.  She was examined under anesthesia with noted findings above.  She was placed in a dorsal supine position and prepped and draped in the usual sterile fashion.  The Pfannenstiel skin incision was made with the first knife and was then carried down to the underlying layer of the fascia.  With the second knife, the fascia was excised in the midline and extended laterally with the Mayo scissors.  The superior aspect of the fascial incision was then tented up with the Ochsner clamps and the underlying rectus muscle was dissected off sharply as well as bluntly.  Attention was then turned to the inferior aspect of the fascial incision, which in a similar fashion was tented up and the underlying rectus muscle was dissected off sharply as well as bluntly.  The rectus muscle was then separated in the midline, the peritoneum was identified, entered bluntly and digitally.  Then the peritoneal incision was then extended superior and inferiorly with excellent visualization of the bladder.  The GYN Balfour was then placed.  A Lahey clamp was placed on the fundus of the uterus to pull the uterus into the operative field and the bowel was packed away with moist laparotomy sponges.  Attention was then turned to the round ligaments bilaterally, which were tented up with Allis clamps and then a hemostat was poked through the avascular portion underneath the round ligament and the #O-tie was passed through and then tied down.  Then the round ligament was transected and suture ligated and noted to be hemostatic.  The round ligaments were then skeletonized to create a window in the broad ligament.  The right infundibulopelvic ligament was isolated through the window created from the round ligaments and then the infundibular ligament on the right was loop tied and then doubly clamped with straight Ochsner clamps and then transected and suture ligated with a #0 Vicryl in a Heaney stitch fashion.  It was noted to be hemostatic.  Attention was then turned to the left side, in which the uterovarian vessel was isolated and then tied with an #O-tie and then doubly clamped with straight Ochsner clamps, transected and suture ligated with a #0 Vicryl in a Heaney stitch fashion and noted to be hemostatic.  The vesicouterine peritoneum was then identified, tented up with Allis clamps, and then the bladder flap was created sharply with a Russian and Metzenbaum scissors.  Then the bladder was deflected off of the underlying cervix with blunt dissection with a moist Ray-Tec sponge down to the level of the cervix.,The uterine vessels were skeletonized bilaterally and then clamped with straight Ochsner clamps and transected and suture ligated and noted to be hemostatic.  In the similar fashion, the broad ligament down to the level of the caudal ligament, the uterosacral ligaments was clamped with curved Ochsner clamps and transected and suture ligated, and noted to be hemostatic.  The second Lahey clamp was then placed on the cervix.  The cervix was tented up and the pubocervical vesical fascia was transected with a long knife and then the vagina was entered with a double pointed scissors poked through well protecting posteriorly with a large malleable.  The cuff was then outlined.  The vaginal cuff was grasped with a Ochsner clamp and then the cervix, uterus, and the right tube and ovary were transected using the Jorgenson scissors.  The cuff outlined with Ochsner clamps.  The cuff was then painted with a Betadine soaked Ray-Tec sponge and the sponge was placed over the vagina.  The vaginal cuff was then closed with a #0 Vicryl in a running locked fashion holding on to the beginning end on the right side as well as incorporating the ipsilateral cardinal ligaments into the cuff angles.  A long Allis was then used to grasp the mid portion of the cuff and a #0 Vicryl figure-of-eight stitch was placed in the mid portion of the cuff and tied down.  At this time, the abdomen was copiously irrigated with warm normal saline and noted to be hemostatic.  The suture that was used to close the cuff was then used to come back through the posterior peritoneum grabbing the uterosacral ligaments and the mid portion of the cuff, and then tied down to bring the cuff close and together.  Then, the right round ligament was pulled into the cuff and tied down with the #0 Vicryl that was used as a figure-of-eight stitch in the middle of the cuff.  The left round ligament was too small to reach the cuff.  The abdomen was then again copiously irrigated with warm normal saline and noted to be hemostatic.  The peritoneum was then re-peritonealized with a #3-0 Vicryl in a running fashion.  The GYN Balfour and all packing sponges were removed from the abdomen.  Then the abdomen was then once again copiously irrigated and the cuff and incision sites were once again reinspected and noted to be hemostatic.  The ______ was placed back into the hollow of the sacrum.  The omentum was then pulled over to top of the bowel and then the peritoneum was then closed with a #3-0 Vicryl in a running fashion and then the fascia was closed with #0 Vicryl in a running fashion.  The skin was closed with staples and dressing applied.  The patient was then examined at the end of the procedure.  The Betadine-soaked sponge was removed from the vagina.  The cuff was noted to be intact without bleeding and the patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2 and she was taken to the recovery in stable condition.  The patient will be followed throughout her hospital stay.","surgery, tah, salpingo-oophorectomy, total abdominal hysterectomy, abnormal uterine bleeding, endometrial ablatio, ochsner clamps, round ligaments, clamps, ligaments, cuff, salpingo, oophorectomy, hysterectomy, uterine, ablation, tubes, abdominal, anesthesia,"
 Total abdominal hysterectomy (TAH) with bilateral salpingooophorectomy and uterosacral ligament vault suspension.  Cervical intraepithelial neoplasia grade-III postconization.  Recurrent dysplasia.  Uterine procidentia grade II-III.  Mild vaginal vault prolapse., Surgery, TAH & Salpingooophorectomy ,"PREOPERATIVE DIAGNOSES:,1.  Cervical intraepithelial neoplasia grade-III status post conization with poor margins.,2.  Recurrent dysplasia.,3.  Unable to follow in office.,4.  Uterine procidentia grade II-III.,POSTOPERATIVE DIAGNOSES:,1.  Cervical intraepithelial neoplasia grade-III postconization.,2.  Poor margins.,3.  Recurrent dysplasia.,4.  Uterine procidentia grade II-III.,5.  Mild vaginal vault prolapse.,PROCEDURES PERFORMED:,1.  Total abdominal hysterectomy (TAH) with bilateral salpingooophorectomy.,2.  Uterosacral ligament vault suspension.,ANESTHESIA: , General and spinal with Astramorph for postoperative pain.,ESTIMATED BLOOD LOSS: , Less than 100 cc.,FLUIDS:  ,2400 cc.,URINE: , 200 cc of clear urine output.,INDICATIONS:  ,This patient is a 57-year-old nulliparous female who desires definitive hysterectomy for history of cervical intraepithelial neoplasia after conization and found to have poor margins.,FINDINGS:  ,On bimanual examination, the uterus was found to be small.  There were no adnexal masses appreciated.  Intraabdominal findings revealed a small uterus approximately 2 cm in size.  The ovaries were atrophic consistent with menopause.  The liver margins and stomach were palpated and found to be normal.,PROCEDURE IN DETAIL: , After informed consent was obtained, the patient was taken back to the operating suite and administered a spinal anesthesia for postoperative pain control.  She was then placed in the dorsal lithotomy position and administered general anesthesia.  She was then prepped and draped in the sterile fashion and an indwelling Foley catheter was placed in her bladder.  At this point, the patient was evaluated for a possible vaginal hysterectomy.  She was nulliparous and the pelvis was narrow.  After the anesthesia was administered, the patient was repeatedly stooling and therefore because of these two reasons, the decision was made to do an abdominal hysterectomy.  After the patient was prepped and draped, a Pfannenstiel skin incision was made approximately 2 cm above the pubic symphysis.  The second scalpel was used to dissect out to the underlying layer of fascia.  The fascia was incised in the midline and extended laterally using the Mayo scissors.  The superior aspect of the rectus fascia was grasped with Ochsners, tented up and underlying layer of rectus muscle was dissected off bluntly as well as with Mayo scissors.  In a similar fashion, the inferior portion of the rectus fascia was tented up, dissected off bluntly as well as with Mayo scissors.  The rectus muscle was then separated bluntly in the midline and the peritoneum was identified and entered with the Metzenbaum.  The peritoneal incision was extended superiorly and inferiorly with good visualization of the bladder.  At this point, the above findings were noted and the GYN Balfour retractor was placed.  Moist laparotomy sponges were used to pack the bowel out of the operative field.  The bladder blade and the extension for the retractor were then placed.  An Allis was used on the uterus for retraction.  The round ligaments were then identified, clamped with two hemostats and transected and then suture ligated.  The anterior portion of the broad ligament was dissected along vesicouterine resection.  The bladder was then dissected off the anterior cervix and vagina without difficulty.  The infundibulopelvic ligaments on both sides were then doubly clamped using hemostats, transected and suture ligated with #0 Vicryl suture.  The uterine vessels on both sides were skeletonized and clamped with two hemostats and transected and suture ligated with #0 Vicryl.  Good hemostasis was assured.  The cardinal ligaments on both sides were clamped using a curved hemostat, transected and suture ligated with #0 Vicryl.  Good hemostasis was obtained.  Two hemostats were then placed just under the cervix meeting in the midline.  The uterus and cervix were then _______ off using a scalpel.  This was handed and sent to Pathology for evaluation.  Using #0 Vicryl suture, the right vaginal cuff angle was closed and affixed to the ipsilateral cardinal ligament.  A baseball stitch was then used to close the cuff to the midline.  The same was done to the left vaginal cuff angle, which was affixed to the ipsilateral and cardinal ligaments.  The baseball stitch was used to close the cuff to the midline.  The hemostats were removed and the cuff was closed and good hemostasis was noted.  The uterosacral ligaments were also transfixed to the cuff and brought out for good support by using a #0 Vicryl suture through each uterosacral ligament and incorporating this into the vaginal cuff.  The pelvis was then copiously irrigated with warm normal saline.  Good support and hemostasis was noted.  The bowel packing was then removed and the GYN Balfour retractor was moved.  The peritoneum was then repaired with #0 Vicryl in a running fashion.  The fascia was then closed using #0 Vicryl in a running fashion, marking the first stitch and first last stitch in a lateral to medial fashion.  The skin was then closed with #4-0 undyed Vicryl in a subcuticular closure and an Op-Site was placed over this.  The patient was then brought out of general anesthesia and extubated.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2.  She will follow up postoperatively as an inpatient.","surgery, cervical intraepithelial neoplasia, vaginal vault prolapse, uterosacral ligament vault suspension, total abdominal hysterectomy, bilateral salpingooophorectomy, abdominal hysterectomy, uterosacral ligament, recurrent dysplasia, uterine procidentia, suture ligated, abdominal, intraepithelial, tah, salpingooophorectomy, hysterectomy, ligament, hemostats, vaginal, "
" Total abdominal hysterectomy (TAH), left salpingo-oophorectomy, lysis of interloop bowel adhesions.  Chronic pelvic pain, endometriosis, prior right salpingo-oophorectomy, history of intrauterine device perforation and exploratory surgery.", Surgery, TAH & Salpingo-oophorectomy & Lysis of Adhesions ,"PREOPERATIVE DIAGNOSES:,1.  Chronic pelvic pain.,2.  Endometriosis.,3.  Prior right salpingo-oophorectomy.,4.  History of intrauterine device perforation and exploratory surgery.,POSTOPERATIVE DIAGNOSES:,1.  Endometriosis.,2.  Interloop bowel adhesions.,PROCEDURE PERFORMED:,1.  Total abdominal hysterectomy (TAH).,2.  Left salpingo-oophorectomy.,3.  Lysis of interloop bowel adhesions.,ANESTHESIA:,  General.,ESTIMATED BLOOD LOSS:  ,400 cc.,FLUIDS: , 2300 cc of lactated Ringers, as well as lactated Ringers for intraoperative irrigation.,URINE: , 500 cc of clear urine output.,INTRAOPERATIVE FINDINGS: , The vulva and perineum are without lesions.  On bimanual exam, the uterus was enlarged, movable, and anteverted.  The intraabdominal findings revealed normal liver margin, kidneys, and stomach upon palpation.  The uterus was found to be normal in size with evidence of endometriosis on the uterus.  The right ovary and fallopian tube were absent.  The left fallopian tube and ovary appeared normal with evidence of a small functional cyst.  There was evidence of left adnexal adhesion to the pelvic side wall which was filmy, unable to be bluntly dissected.  There were multiple interloop bowel adhesions that were filmy in nature noted.,The appendix was absent.  There did appear to be old suture in a portion of the bowel most likely from a prior procedure.,INDICATIONS: , This patient is a 45-year-old African-American gravida7, para3-0-0-3, who is here for definitive treatment of chronic pelvic pain with a history of endometriosis.  She did have a laparoscopic ablation of endometriosis on a laparoscopy and also has a history of right salpingo-oophorectomy.  She has tried Lupron and did stop secondary to the side effects.,PROCEDURE IN DETAIL: , After informed consent was obtained in layman's terms, the patient was taken back to the Operating Suite and placed under general anesthesia.  She was then prepped and draped in the sterile fashion and placed in the dorsal supine position.  An indwelling Foley catheter was placed.  With the skin knife, an incision was made removing the old cicatrix.  A Bovie was used to carry the tissue through to the underlying layer of the fascia which was incised in the midline and extended with the Bovie.  The rectus muscle was then sharply and bluntly dissected off the superior aspect of the rectus fascia in the superior as well as the inferior aspect using the Bovie.  The rectus muscle was then separated in the midline using a hemostat and the peritoneum was entered bluntly.  The peritoneal incision was then extended superiorly and inferiorly with Metzenbaum scissors with careful visualization of the bladder.  At this point, the intraabdominal cavity was manually explored and the above findings were noted.  A Lahey clamp was then placed on the fundus of the uterus and the uterus was brought to the surgical field.  The bowel was then packed with moist laparotomy sponges.  Prior to this, the filmy adhesions leftover were taken down.  At this point, the left round ligament was identified, grasped with two hemostats, transected, and suture ligated with #0 Vicryl.  At this point, the broad ligament was dissected down and the lost portion of the bladder flap was created.  The posterior aspect of the peritoneum was also dissected.  At this point, the infundibulopelvic ligament was isolated and three tie of #0 Vicryl was used to isolate the pedicle.  Two hemostats were then placed across the pedicle and this was transected with the scalpel.  This was then suture ligated in Heaney fashion.  The right round ligament was then identified and in the similar fashion, two hemostats were placed across the round ligament and using the Mayo scissors the round ligament was transected and dissected down the broad ligament to create the bladder flap anteriorly as well as dissect the posterior peritoneum and isolate the round ligament.  This was then ligated with three tie of #0 Vicryl.  Also incorporated in this was the remnant from the previous right salpingo-oophorectomy.  At this point, the bladder flap was further created with sharp dissection as well as the moist Ray-Tech to push the bladder down off the anterior portion of the cervix.,The left uterine artery was then skeletonized and a straight Heaney was placed.  In a similar fashion, the contralateral uterine artery was skeletonized and straight Heaney clamp was placed.  These ligaments bilaterally were transected and suture ligated in a left Heaney stitch.  At this point, curved Masterson was used to incorporate the cardinal ligament complex, thus was transected and suture ligated.  Straight Masterson was then used to incorporate the uterosacrals bilaterally and this was also transected and suture ligated.  Prior to ligating the uterine arteries, the uterosacral arteries were tagged bilaterally with #0 Vicryl.  At this point, the roticulator was placed across the vaginal cuff and snug underneath the entire cervix.  The roticulator was then clamped and removed and the staple line was in place.  This was found to be hemostatic.  A suture was then placed through each cuff angle bilaterally and cardinal ligament complex was found to be fixed to each apex bilaterally.  At this point, McCall culdoplasty was performed with an #0 Vicryl incorporating each uterosacral as well as the posterior peritoneum.  There did appear to be good support on palpation.  Prior to this, the specimen was handed off and sent to pathology.  At this point, there did appear to be small amount of oozing at the right peritoneum.  Hemostasis was obtained using a #0 Vicryl in two single stitches.  Good hemostasis was then obtained on the cuff as well as the pedicles.  Copious irrigation was performed at this point with lactate Ringers.  The round ligaments were then incorporated into the cuff bilaterally.  Again, copious amount of irrigation was performed and good hemostasis was obtained.  At this point, the peritoneum was reapproximated in a single interrupted stitch on the left and right lateral aspects to cover each pedicle bilaterally.  At this point, the bowel packing as well as moist Ray-Tech was removed and while re-approximating the bowel it was noted that there were multiple interloop bowel adhesions which were taken down using the Metzenbaum scissors with good visualization of the underlying bowel.  Good hemostasis was obtained of these sites as well.  The sigmoid colon was then returned to its anatomic position and the omentum as well.  The rectus muscle was then reapproximated with two interrupted sutures of #2-0 Vicryl.  The fascia was then reapproximated with #0 Vicryl in a running fashion from lateral to medial meeting in the midline.  The Scarpa's fascia was then closed with #3-0 plain in a running suture.  The skin was then re-approximated with #4-0 undyed Vicryl in a subcuticular closure.  This was dressed with an Op-Site.  The patient tolerated the procedure well.  The sponge, lap, and needle were correct x2.  After the procedure, the patient was extubated and brought out of general anesthesia.  She will go to the floor where she will be followed postoperatively in the hospital.","surgery, chronic pelvic pain, endometriosis, intrauterine device, exploratory, abdominal hysterectomy, tah, total abdominal hysterectomy, lysis of interloop bowel adhesions, salpingo oophorectomy, bowel, ligament, adhesions, interloop, hemostasis, uterus, salpingo, oophorectomy, "
 Arthroscopic irrigation and debridement of same with partial synovectomy.  Septic left total knee arthroplasty., Surgery, Synovectomy - Partial ,"PREOPERATIVE DIAGNOSIS: , Septic left total knee arthroplasty.,POSTOPERATIVE DIAGNOSIS: , Septic left total knee arthroplasty.,OPERATION PERFORMED: , Arthroscopic irrigation and debridement of same with partial synovectomy.,ANESTHESIA:,  LMA.,ESTIMATED BLOOD LOSS:,  Minimal.,COMPLICATIONS: , None.,DRAINS:,  None.,INDICATIONS:,  The patient is an 81-year-old female, who is approximately 10 years status post total knee replacement performed in another state, who presented a couple of days ago to the office with worsening pain without injury and whose symptoms have been present for approximately a month following a possible urinary tract infection.  The patient' knee was aspirated in the office and cultures were positive for Escherichia coli.  She presents for operative therapy.,DESCRIPTION OF OPERATION: , After obtaining informed consent and the administration of antibiotics since her cultures had already been obtained, the patient was taken to the operating room and following satisfactory induction and the patient was placed on the table in supine position.  The left upper extremity was prepped and draped without a tourniquet.  The knee was injected with 30 mL of normal saline and standard arthroscopy portals were created.  The arthroscopy was inserted and a complete diagnostic was performed.  Arthroscopic pictures were taken throughout the procedure.  The knee was copiously irrigated with 9 L of irrigant.  A partial synovectomy was performed in all compartments.  Minimal amount of polyethylene wear was noted.  The total knee components were identified arthroscopically for future revision surgery.  The knee was then drained and the arthroscopic instruments were removed.  The portals were closed with 4-0 nylon and local anesthetic was injected.  A sterile dressing was applied and the patient was placed in a knee immobilizer, awakened from anesthesia and transported to the recovery room in stable condition and tolerated the procedure well.","surgery, total knee arthroplasty, arthroscopic irrigation, debridement, partial synovectomy, knee, arthroscopic, irrigation, arthroscopy, synovectomy,"
" Tailor bunionectomy, right foot, Weil-type with screw fixation.  Hallux abductovalgus deformity and tailor bunion deformity, right foot.", Surgery, Tailor Bunionectomy with Screw Fixation ,"PREOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus deformity, right foot.,2.  Tailor bunion deformity, right foot.,POSTOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus deformity, right foot.,2.  Tailor bunion deformity, right foot.,PROCEDURES PERFORMED:  ,Tailor bunionectomy, right foot, Weil-type with screw fixation.,ANESTHESIA: , Local with MAC, local consisting of 20 mL of 0.5% Marcaine plain.,HEMOSTASIS:,  Pneumatic ankle tourniquet at 200 mmHg.,INJECTABLES:,  A 10 mL of 0.5% Marcaine plain and 1 mL of dexamethasone phosphate.,MATERIAL: , A 2.4 x 14 mm, 2.4 x 16 mm, and 2.0 x 10 mm OsteoMed noncannulated screw.  A 2-0 Vicryl, 3-0 Vicryl, 4-0 Vicryl, and 5-0 nylon.,COMPLICATIONS: , None.,SPECIMENS: , None.,ESTIMATED BLOOD LOSS:,  Minimal.,PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed on the operating table in the usual supine position.  At this time, a pneumatic ankle tourniquet was placed on the patient's right ankle for the purpose of maintaining hemostasis.  Number of the anesthesias was obtained and then induced mild sedation and local anesthetic as described above was infiltrated about the surgical site.  The right foot was then scrubbed, prepped, and draped in the usual aseptic manner.  An Esmarch bandage was then used to exsanguinate the patient's right foot, and the pneumatic ankle tourniquet inflated to 200 mmHg.  Attention was then directed to dorsal aspect of the first metatarsophalangeal joint where a linear longitudinal incision measuring approximately a 3.5 cm in length was made.  The incision was carried deep utilizing both sharp and blunt dissections.  All major neurovascular structures were avoided.  At this time, through the original skin incision, attention was directed to the first intermetatarsal space where utilizing both sharp and blunt dissection the deep transverse intermetatarsal ligament was identified.  This was then incised fully exposing the tendon and the abductor hallucis muscle.  This was then resected from his osseous attachments and a small tenotomy was performed.  At this time, a small lateral capsulotomy was also performed.  Lateral contractures were once again reevaluated and noted to be grossly reduced.,Attention was then directed to the dorsal aspect of the first metatarsal phalangeal joint where linear longitudinal and periosteal and capsular incisions were made following the first metatarsal joint and following the original shape of the skin incision.  The periosteal capsular layers were then reflected both medially and laterally from the head of the first metatarsal and a utilizing an oscillating bone saw, the head of the first metatarsal and medial eminence was resected and passed from the operative field.  A 0.045 inch K-wire was then driven across the first metatarsal head in order to act as an access dye.  The patient was then placed in the frog-leg position, and two osteotomy cuts were made, one from the access guide to the plantar proximal position and one from the access guide to the dorsal proximal position.  The dorsal arm was made longer than the plantar arm to accommodate for fixation.  At this time, the capital fragment was resected and shifted laterally into a more corrected position.  At this time, three portions of the 0.045-inch K-wire were placed across the osteotomy site in order to access temporary forms of fixation.  Two of the three of these K-wires were removed in sequence and following the standard AO technique two 3.4 x 15 mm and one 2.4 x 14 mm OsteoMed noncannulated screws were placed across the osteotomy site.  Compression was noted to be excellent.  All guide wires and 0.045-inch K-wires were then removed.  Utilizing an oscillating bone saw, the overhanging wedge of the bone on the medial side of the first metatarsal was resected and passed from the operating field.  The wound was then once again flushed with copious amounts of sterile normal saline.  At this time, utilizing both 2-0 and 3-0 Vicryl, the periosteal and capsular layers were then reapproximated.  At this time, the skin was then closed in layers utilizing 4-0 Vicryl and 4-0 nylon.  At this time, attention was directed to the dorsal aspect of the right fifth metatarsal where a linear longitudinal incision was made over the metatarsophalangeal joint just lateral to the extensor digitorum longus tension.  Incision was carried deep utilizing both sharp and blunt dissections and all major neurovascular structures were avoided.,A periosteal and capsular incision was then made on the lateral aspect of the extensor digitorum longus tendon and periosteum and capsular layers were then reflected medially and laterally from the head of the fifth metatarsal.  Utilizing an oscillating bone saw, the lateral eminence was resected and passed from the operative field.  Utilizing the sagittal saw, a Weil-type osteotomy was made at the fifth metatarsal head.  The head was then shifted medially into a more corrected position.  A 0.045-inch K-wire was then used as a temporary fixation, and a 2.0 x 10 mm OsteoMed noncannulated screw was placed across the osteotomy site.  This was noted to be in correct position and compression was noted to be excellent.  Utilizing a small bone rongeur, the overhanging wedge of the bone on the dorsal aspect of the fifth metatarsal was resected and passed from the operative field.  The wound was once again flushed with copious amounts of sterile normal saline.  The periosteal and capsular layers were reapproximated utilizing 3-0 Vicryl, and the skin was then closed utilizing 4-0 Vicryl and 4-0 nylon.  At this time, 10 mL of 0.5% Marcaine plain and 1 mL of dexamethasone phosphate were infiltrated about the surgical site.  The right foot was then dressed with Xeroform gauze, fluffs, Kling, and Ace wrap, all applied in mild compressive fashion.  The pneumatic ankle tourniquet was then deflated and a prompt hyperemic response was noted to all digits of the right foot.  The patient was then transported from the operating room to the recovery room with vital sings stable and neurovascular status grossly intact to the right foot.  After a brief period of postoperative monitoring, the patient was discharged to home with proper written and verbal discharge instructions, which included to keep dressing clean, dry, and intact and to follow up with Dr. A.  The patient is to be nonweightbearing to the right foot.  The patient was given a prescription for pain medications on nonsteroidal anti-inflammatory drugs and was educated on these.  The patient tolerated the procedure and anesthesia well.  Dr. A was present throughout the entire case.","surgery, tailor bunionectomy, weil-type, screw fixation, hallux, abductovalgus, bunion, tailor, deformity, metatarsal, phalangeal, capsulotomy, abductor, hallucis, "
" Total abdominal hysterectomy (TAH) and left salpingo-oophorectomy.  Hypermenorrhea, uterine fibroids, pelvic pain, left adnexal mass, and pelvic adhesions.", Surgery, TAH & Salpingo-oophorectomy ,"PREOPERATIVE DIAGNOSES:,1.  Hypermenorrhea.,2.  Uterine fibroids.,3.  Pelvic pain.,4.  Left adnexal mass.,5.  Pelvic adhesions.,POSTOPERATIVE DIAGNOSES:,1.  Hypermenorrhea.,2.  Uterine fibroids.,3.  Pelvic pain.,4.  Left adnexal mass.,5.  Pelvic adhesions.,PROCEDURE PERFORMED:,1.  Total abdominal hysterectomy (TAH).,2.  Left salpingo-oophorectomy.,ANESTHESIA:,  General endotracheal.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , Less than 100 cc.,INDICATIONS: , The patient is a 47-year-old Caucasian female with complaints of hypermenorrhea and pelvic pain, noted to have a left ovarian mass 7 cm at the time of laparoscopy in July of 2003.  The patient with continued symptoms of pelvic pain and hypermenorrhea and desired definitive surgical treatment.,FINDINGS AT THE TIME OF SURGERY: , Uterus is anteverted and boggy with a very narrow introitus with a palpable left adnexal mass.,On laparotomy, the uterus was noted to be slightly enlarged with fibroid change as well as a hemorrhagic appearing left adnexal mass.  The bowel, omentum, and appendix had a normal appearance.,PROCEDURE: , The patient was taken to the operative suite where anesthesia was found to be adequate.  She was then prepared and draped in normal sterile fashion.  A Pfannenstiel skin incision was made with a scalpel and carried through the underlying layer of fascia with the second scalpel.  The fascia was then incised in the midline.  The fascial incision was then extended laterally with Mayo scissors.  The superior aspect of the fascial incision was grasped with Kochers with the underlying rectus muscle dissected off bluntly and sharply with Mayo scissors.  Attention was then turned to the inferior aspect of this incision, which in a similar fashion was tented up with the underlying rectus muscle and dissected off bluntly and sharply with Mayo scissors.  The rectus muscle was then separated in the midline.  The peritoneum was identified, tented up with hemostats and entered sharply with Metzenbaum scissors.  The peritoneal incision was then extended superiorly and inferiorly with good visualization of the bladder.  The uterus and left adnexa were then palpated and brought out into the surgical field.  The fundus of the uterus was grasped with a Lahey clamp.  The GYN/Balfour retractor was placed.  The bladder blade was placed.  The bowel was packed away with moist laparotomy sponges and the extension through GYN/Balfour retractor was placed.  At this time, the patient's anatomy was surveyed and there was found to be a left hemorrhagic appearing adnexal mass.  Attention was first turned to the right round ligament, which was tented up with a Babcock and a small window was made beneath the round ligament with a hemostat.  It was then suture ligated with #0 Vicryl suture, transected with the broad ligament being skeletonized on both sides.  Next, the right ________ was isolated bluntly as the patient had a previous RSO.  This was then suture ligated with #0 Vicryl suture, doubly clamped with Kocher clamps, transected, and suture ligated with #0 Vicryl suture with a Heaney stitch.  Attention was then turned to the left round ligament, which was tented up with the Babcock.  Small window was made beneath it and the broad ligament with hemostat was then suture ligated with #0 Vicryl suture, transected, and skeletonized with the aid of Metzenbaums.  The left infundibulopelvic ligament was then bluntly isolated.  It was then suture ligated with #0 Vicryl suture, doubly clamped with Kocher clamps, and transected and suture ligated with #0 Vicryl suture with a Heaney stitch.  The bladder flap was then placed on tension with Allis clamps.  It was then dissected off of the lower uterine segment with the aid of Metzenbaum scissors and Russians.  It was then gently pushed off of lower uterine segment with the aid of a moist Ray-Tec.  The uterine arteries were then skeletonized bilaterally.,They were then clamped with straight Kocher clamps, transected, and suture ligated with #0 Vicryl suture.  The cardinal ligament and uterosacral complexes on both sides were then clamped with curved Kocher clamps.  These were then transected and suture ligated with #0 Vicryl suture.  The lower uterine segment was then grasped with Lahey clamps, at which time the cervix was already visible.  It was then entered with the last transection.  The cervix was grasped with a single-toothed tenaculum and the uterus, cervix, and left adnexa were amputated off the vagina with the aid of Jorgenson scissors.  The angles of the vaginal cuff were then grasped with Kocher clamps.  A Betadine-soaked Ray-Tec was then pushed into the vagina and the vaginal cuff was closed with #0 Vicryl suture in a running lock fashion with care taken to transect the ipsilateral cardinal ligament, at which time the suction tip was changed and copious suction irrigation was performed.  Good hemostasis was appreciated.  A figure-of-eight suture in the center of the vaginal cuff was placed with #0 Vicryl.  This was tagged for later use.  The uterosacrals on both sides were incorporated into the vaginal cuff with the aid of #0 Vicryl suture.  The round ligaments were then pulled into the vaginal cuff using the figure-of-eight suture placed in the center of the vaginal cuff and these were tied in place.  The pelvis was then again copiously suctioned irrigated and hemostasis was appreciated.  The peritoneal surfaces were then reapproximated with the aid of #3-0 Vicryl suture in a running fashion.  The GYN/Balfour retractor and bladder blade were then removed.  The bowel was then packed.  Again copious suction irrigation was performed with hemostasis appreciated.  The peritoneum was then reapproximated with #2-0 Vicryl suture in a running fashion.  The fascia was then reapproximated with #0 Vicryl suture in a running fashion.  The Scarpa's  fascia was then reapproximated with #3-0 plain gut in a running fashion and the skin was closed with #4-0 undyed Vicryl in a subcuticular fashion.  Steri-Strips were placed.  At the end of the procedure, the sponge that was pushed into the vagina previously was removed and hemostasis was appreciated vaginally.  The patient tolerated the procedure well and was taken to Recovery in stable condition.  Sponge, lap, and needle counts were correct x2.  Specimens include uterus, cervix, left fallopian tube, and ovary.", 
 Placement of SynchroMed infusion pump and tunneling of SynchroMed infusion pump catheter.  Anchoring of the intrathecal catheter and connecting of the right lower quadrant SynchroMed pump catheter to the intrathecal catheter., Surgery, SynchroMed Pump Placement ,"PROCEDURES:,1.  Placement of SynchroMed infusion pump.,2.  Tunneling of SynchroMed infusion pump catheter,3.  Anchoring of the intrathecal catheter and connecting of the right lower quadrant SynchroMed pump catheter to the intrathecal catheter.,DESCRIPTION OF PROCEDURE: , Under general endotracheal anesthesia, the patient was placed in a lateral decubitus position.  The patient was prepped and draped in a sterile manner.  The intrathecal catheter was placed via a percutaneous approach by the pain management specialist at which point an incision was made adjacent to the needle containing the intrathecal catheter.  This incision was carried down through the skin and subcutaneous tissue to the paraspinous muscle fascia which was cleared around the entry point of the intrathecal catheter needle.  A pursestring suture of 3-0 Prolene was placed around the needle in the paraspinous muscle.  The needle was withdrawn.  The pursestring suture was tied to snug the tissues around the catheter and prevent cerebrospinal fluid leak.  The catheter demonstrated free flow of cerebrospinal fluid,throughout the RV procedure.  The catheter was anchored to the paraspinous muscle with an anchoring device using interrupted sutures of 3-0 Prolene.  Antibiotic irrigation and antibiotic soak sponge were placed into the wound, and the catheter was clamped to prevent persistent leakage of cerebrospinal fluid while the SynchroMed-pump pocket was created.  Then, I turned my attention to the anterior abdominal wall where an oblique incision was made and carried down through the skin and subcutaneous tissue to the external oblique fascia, which was freed from attachments to the overlying subcutaneous tissue utilizing blunt and sharp dissection with electrocautery.  A pocket was created that would encompass the SynchroMed fusion pump.  A tunneling device was then passed through the subcutaneous tissue from the back incision to the abdominal incision, and a SynchroMed pump catheter was placed to the tunneling device.  The tunneling device was then removed leaving the SynchroMed pump catheter extending from the anterior abdominal wall incision to the posterior back incision.  The intrathecal catheter was trimmed.  A clear plastic boot was placed over the intrathecal catheter, and the connecting device was advanced from the SynchroMed pump catheter into the intrathecal catheter connecting the 2 catheters together.  The clear plastic boot was then placed over the connection, and it was anchored in place with 0-silk ties.  Good CSF was then demonstrated flowing through the SynchroMed pump catheter.  The SynchroMed pump catheter was connected to the SynchroMed pump and anchored in place with a 0-silk tie.  Excess catheter was coiled and placed behind the pump.  The pump was placed into the subcutaneous pocket created for it on the anterior abdominal wall.  The pump was anchored to the anterior abdominal wall fascia with interrupted sutures of 2-0 Prolene; 4 of the sutures were placed.  The subcutaneous tissues were irrigated with normal saline.  The subcutaneous tissue of both wounds was closed with running suture of 3-0 Vicryl.  The skin of both wounds was closed with staples.  Antibiotic ointment and a sterile dressing were applied.  The patient was awake and taken to the recovery room.  The patient tolerated the procedure well and was stable at the completion of the procedure.  All sponge and lap, needle and instrument counts were correct at the completion of the procedure.","surgery, intrathecal, catheter, paraspinous, cerebrospinal, synchromed infusion pump, synchromed pump catheter, synchromed pump, paraspinous muscle, cerebrospinal fluid, tunneling device, infusion pump, subcutaneous tissue, infusion, synchromed, pump, incision,"
 Total abdominal hysterectomy and bilateral salpingo-oophorectomy., Surgery, TAH & BSO ,"PREOPERATIVE DIAGNOSES:,1.  Chronic pelvic pain.,2.  Dysmenorrhea.,3.  Dyspareunia.,4.  Endometriosis.,5.  Enlarged uterus.,6.  Menorrhagia.,POSTOPERATIVE DIAGNOSES:,1.  Chronic pelvic pain.,2.  Dysmenorrhea.,3.  Dyspareunia.,4.  Endometriosis.,5.  Enlarged uterus.,6.  Menorrhagia.,PROCEDURE: , Total abdominal hysterectomy and bilateral salpingo-oophorectomy.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,DRAINS: , Foley.,ANESTHESIA:,  General.,This 28-year-old white female who presented to undergo TAH-BSO secondary to chronic pelvic pain and a diagnosis of endometriosis.,At the time of the procedure, once entering into the abdominal cavity, there was no gross evidence of abnormalities of the uterus, ovaries or fallopian tube.  All endometriosis had been identified laparoscopically from a previous surgery.  At the time of the surgery, all the tissue was quite thick and difficult to cut as well around the bladder flap and the uterus itself.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and placed in supine position, at which time general form of anesthesia was administered by the anesthesia department.  The patient was then prepped and draped in the usual fashion for a low transverse incision.  Approximately two fingerbreadths above the pubic symphysis, a first knife was used to make a low transverse incision.  This was extended down to the level of the fascia.  The fascia was nicked in the center and extended in a transverse fashion.  The edges of the fascia were grasped with Kocher.  Both blunt and sharp dissection both caudally and cephalic was then completed consistent with Pfannenstiel technique.  The abdominal rectus muscle was divided in the midline and extended in a vertical fashion.  Perineum was entered at the high point and extended in a vertical fashion as well.  An O'Connor-O'Sullivan retractor was put in place on either side.  A bladder blade was put in place as well.  Uterus was grasped with a double-tooth tenaculum and large and small colon were packed away cephalically and held in place with free wet lap packs and a superior blade.  The bladder flap was released with Metzenbaum scissors and then dissected away caudally.  EndoGIA were placed down both sides of the uterus in two bites on each side with the staples reinforced with a medium Endoclip.  Two Heaney were placed on either side of the uterus at the level of cardinal ligaments.  These were sharply incised and both pedicles were tied off with 1 Vicryl suture.  Two _____ were placed from either side of the uterus at the level just inferior to the cervix across the superior part of the vaginal vault.  A long sharp knife was used to transect the uterus at the level of Merz forceps and the uterus and cervix were removed intact.  From there, the corners of the vaginal cuff were reinforced with figure-of-eight stitches.  Betadine soaked sponge was placed in the vaginal vault and a continuous locking stitch of 0 Vicryl was used to re-approximate the edges with a second layer used to reinforce the first.  Bladder flap was created with the use of 3-0 Vicryl and Gelfoam was placed underneath.  The EndoGIA was used to transect both the fallopian tube and ovaries at the infundibulopelvic ligament and each one was reinforced with medium clips.  The entire area was then re-peritonized and copious amounts of saline were used to irrigate the pelvic cavity.  Once this was completed, Gelfoam was placed into the cul-de-sac and the O'Connor-O'Sullivan retractor was removed as well as all the wet lap pack.  Edges of the peritoneum were grasped in 3 quadrants with hemostat and a continuous locking stitch of 2-0 Vicryl was used to re-approximate the peritoneum as well as abdominal rectus muscle.  The edges of the fascia were grasped at both corners and a continuous locking stitch of 1 Vicryl was used to re-approximate the fascia with overlapping in the center.  The subcutaneous tissue was irrigated.  Cautery was used to create adequate hemostasis and 3-0 Vicryl was used to re-approximate the tissue and the skin edges were re-approximated with sterile staples.  Sterile dressing was applied and Betadine soaked sponge was removed from the vaginal vault and the vaginal vault was wiped clean of any remaining blood.  The patient was taken to recovery room in stable condition.  Instrument count, needle count, and sponge counts were all correct.","surgery, tah, bso, total abdominal hysterectomy, bilateral salpingo-oophorectomy, hysterectomy, pelvic pai, dysmenorrhea, dyspareunia, endometriosis, uterus, menorrhagia, betadine soaked sponge, bladder flap, vaginal vault, abdominal, fascia, rectus, "
" Missed abortion.  Suction, dilation, and curettage.", Surgery," Suction, Dilation, & Curettage ","PREOPERATIVE DIAGNOSIS: , Missed abortion.,POSTOPERATIVE DIAGNOSIS:  ,Missed abortion.,PROCEDURE PERFORMED: , Suction, dilation, and curettage.,ANESTHESIA: , Spinal.,ESTIMATED BLOOD LOSS:,  50 mL.,COMPLICATIONS: , None.,FINDINGS: , Products of conception consistent with a 6-week intrauterine pregnancy.,INDICATIONS: , The patient is a 28-year-old gravida 4, para 3 female at 13 weeks by her last menstrual period and 6 weeks by an ultrasound today in the emergency room who presents with heavy bleeding starting today.  A workup done in the emergency room revealed a beta-quant level of 1931 and an ultrasound showing an intrauterine pregnancy with a crown-rump length consistent with a 6-week and 2-day pregnancy.  No heart tones were visible.  On examination in the emergency room, a moderate amount of bleeding was noted.,Additionally, the cervix was noted to be 1 cm dilated.  These findings were discussed with the patient and options including surgical management via dilation and curettage versus management with misoprostol versus expected management were discussed with the patient.  After discussion of these options, the patient opted for a suction, dilation, and curettage.  The patient was described to the patient in detail including risks of infection, bleeding, injury to surrounding organs including risk of perforation.  Informed consent was obtained prior to proceeding with the procedure.,PROCEDURE NOTE:  ,The patient was taken to the operating room where spinal anesthesia was administered without difficulty.  The patient was prepped and draped in usual sterile fashion in lithotomy position.  A weighted speculum was placed.  The anterior lip of the cervix was grasped with a single tooth tenaculum.  At this time, a 7-mm suction curettage was advanced into the uterine cavity without difficulty and was used to suction contents of the uterus.  Following removal of the products of conception, a sharp curette was advanced into the uterine cavity and was used to scrape the four walls of the uterus until a gritty texture was noted.  At this time, the suction curette was advanced one additional time to suction any remaining products.  All instruments were removed.  Hemostasis was visualized.  The patient was stable at the completion of the procedure.  Sponge, lap, and instrument counts were correct.","surgery, missed abortion, intrauterine pregnancy, dilation, curettage, suction, intrauterine"
" Excision of mass, left second toe and distal Symes amputation, left hallux with excisional biopsy.  Mass, left second toe.  Tumor.  Left hallux bone invasion of the distal phalanx.", Surgery, Symes Amputation - Hallux ,"PREOPERATIVE DIAGNOSES:,1.  Mass, left second toe.,2.  Tumor.,3.  Left hallux bone invasion of the distal phalanx.,POSTOPERATIVE DIAGNOSES:,1.  Mass, left second toe.,2.  Tumor.,3.  Left hallux with bone invasion of the distal phalanx.,PROCEDURE PERFORMED:,1.  Excision of mass, left second toe.,2.  Distal Syme's amputation, left hallux with excisional biopsy.,HISTORY: , This 47-year-old Caucasian male presents to ABCD General Hospital with a history of tissue mass on his left foot.  The patient states that the mass has been present for approximately two weeks and has been rapidly growing in size.  The patient also has history of shave biopsy in the past.  The patient does state that he desires surgical excision at this time.,PROCEDURE IN DETAIL:,  An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported from the operating room and placed on the operating room table in the supine position with the safety belt across his lap.  Copious amount of Webril was placed around the left ankle followed by a blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 6 cc mixed with 1% lidocaine plain with 0.5% Marcaine plain was injected in a digital block fashion at the base of the left hallux as well as the left second toe.,The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was elevated from the operating table and exsanguinated with an Esmarch bandage.  Care was taken with the exsanguination to perform exsanguination below the level of the digits so as not to rupture the masses.  The foot was lowered to the operating table.  The stockinet was reflected and the foot was cleansed with wet and dry sponge.  A distal Syme's incision was planned over the distal aspect of the left hallux.  The incision was performed with a #10 blade and deepened with #15 down to the level of bone.  The dorsal skin flap was removed and dissected in toto off of the distal phalanx.  There was noted to be in growth of the soft tissue mass into the dorsal cortex with erosion in the dorsal cortex and exposure of cortical bone at the distal phalanx.  The tissue was sent to Pathology where Dr. Green stated that a frozen sample would be of less use for examining for cancer.  Dr. Green did state that he felt that there was an adequate incomplete excision of the soft tissue for specimen.  At this time, a sagittal saw was then used to resect all ends of bone of the distal phalanx.  The area was inspected for any remaining suspicious tissues.  Any suspicious tissue was removed.  The area was then flushed with copious amounts of sterile saline.  The skin was then reapproximated with #4-0 nylon with a combination of simple and vertical mattress sutures.,Attention was then directed to the left second toe.  There was noted to be a dorsolateral mass over the dorsal distal aspect of the left second toe.  A linear incision was made just medial to the tissue mass.  The mass was then dissected from the overlying skin and off of the underlying capsule.  This tissue mass was hard, round, and pearly-gray in appearance.  It does not invade into any other surrounding tissues.  The area was then flushed with copious amounts of sterile saline and the skin was closed with #4-0 nylon.  Dressings consisted of Owen silk soaked in Betadine, 4x4s, Kling, Kerlix, and an Ace wrap.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot.  The patient tolerated the above procedure and anesthesia well without complications.  The patient was transported to PACU with vital signs stable and vascular status intact.  The patient was given postoperative pain prescription for Vicodin and instructed to follow up with Dr. Bonnani in his office as directed.  The patient will be contacted immediately pending the results of pathology.  Cultures obtained in the case were aerobic and anaerobic gram stain, Silver stain, and a CBC.","surgery, distal phalanx, mass, tumor., hallux bone, phalanx, symes amputation, excisional biopsy, distal, amputation, invasion, toe, symes, incision, flushed, excision, tissue, hallux"
 Closure of gastrostomy placed due to feeding difficulties. , Surgery, Surgical Closure of Gastrostomy ,"PREOPERATIVE DIAGNOSIS: , Gastrostomy (gastrocutaneous fistula).,POSTOPERATIVE DIAGNOSIS: , Gastrostomy (gastrocutaneous fistula).,OPERATION PERFORMED: , Surgical closure of gastrostomy.,ANESTHESIA: , General.,INDICATIONS: , This 1-year-old child had a gastrostomy placed due to feeding difficulties.  Since then, he has reached a point where he is now eating completely by mouth and no longer needed the gastrostomy.  The tube was, therefore, removed, but the tract has not shown signs of spontaneous closure.  He, therefore, comes to the operating room today for surgical closure of his gastrostomy.,OPERATIVE PROCEDURE: , After the induction of general anesthetic, the abdomen was prepped and draped in the usual manner.  An elliptical incision was made around the gastrostomy site and carried down through skin and subcutaneous tissue with sharp dissection.  The tract and the stomach were freed.  Stay sutures were then placed on either side of the tract.  The tract was amputated.  The intervening stomach was then closed with interrupted #4-0 Lembert, Nurolon sutures.  The fascia was then closed over the stomach using #3-0 Vicryl sutures.  The skin was closed with #5-0 subcuticular Monocryl.  A dressing was applied, and the child was awakened and taken to the recovery room in satisfactory condition.","surgery, gastrocutaneous fistula, nurolon, closure of gastrostomy, feeding difficulties, surgical closure, gastrostomy"
 Subxiphoid pericardial window.   A #10-blade scalpel was used to make an incision in the area of the xiphoid process.  Dissection was carried down to the level of the fascia using Bovie electrocautery. , Surgery, Subxiphoid Pericardial Window - 1 ,"OPERATION: , Subxiphoid pericardial window.,ANESTHESIA: , General endotracheal anesthesia.,OPERATIVE PROCEDURE IN DETAIL:  ,After obtaining informed consent from the patient's family, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and general endotracheal anesthesia was administered.  Next, the neck and chest were prepped and draped in the standard surgical fashion.  A #10-blade scalpel was used to make an incision in the area of the xiphoid process.  Dissection was carried down to the level of the fascia using Bovie electrocautery.  The xiphoid process was elevated, and the diaphragmatic attachments to it were dissected free.  Next the pericardium was identified.,The pericardium was opened with Bovie electrocautery.  Upon entering the pericardium, serous fluid was expressed.  In total, ** cc of fluid was drained.  A pericardial biopsy was obtained.  The fluid was sent off for cytologic examination as well as for culture.  A #24 Blake chest drain was brought out through the skin and placed in the posterior pericardium.  The fascia was closed with #1 Vicryl followed by 2-0 Vicryl followed by 4-0 PDS in a running subcuticular fashion.  Sterile dressing was applied.","surgery, xiphoid process, pericardium, subxiphoid pericardial window, endotracheal anesthesia, bovie electrocautery, subxiphoid pericardial, bovie, electrocautery, subxiphoid, window, pericardial,"
" Right buccal and canine's base infection from necrotic teeth.  ICD9 CODE:  528.3.   Incision and drainage of multiple facial spaces; CPT Code:  40801.  Surgical removal of the following teeth.  The teeth numbers 1, 2, 3, 4, and 5.  CPT code:  41899 and dental code 7210.", Surgery, Surgical Removal of Teeth ,"PREOPERATIVE DIAGNOSIS:,  Right buccal and canine's base infection from necrotic teeth.  ICD9 CODE:  528.3.,POSTOPERATIVE DIAGNOSIS: , Right buccal and canine's base infection from necrotic teeth.  ICD9 Code:  528.3.,PROCEDURE: , Incision and drainage of multiple facial spaces; CPT Code:  40801.  Surgical removal of the following teeth.  The teeth numbers 1, 2, 3, 4, and 5.  CPT code:  41899 and dental code 7210.,SPECIMENS: , Cultures and sensitivities were taken and sent for aerobic and anaerobic to the micro lab.,DRAINS:  ,A 1.5 inch Penrose drain placed in the right buccal and canine space.,ESTIMATED BLOOD LOSS:,  40 Ml.,FLUID:  ,700 mL of crystalloid.,COMPLICATIONS:  ,None.,CONDITION:  ,The patient was extubated breathing spontaneously to the PACU in good condition.,INDICATION FOR PROCEDURE:  ,The patient is a 41-year-old that has a recent history of toothache and tooth pain.  She saw her dentist in Sacaton before Thanksgiving who placed her on antibiotics and told her to return to the clinic for multiple teeth extractions.  The patient neglected to return to the dentist until this weekend for IV antibiotics and definitive treatment.  She noticed on Friday that her face was starting to swell up a little bit and it progressively got worse.  The patient was admitted to the hospital on Monday for IV antibiotics.  Oral surgery was consulted today to aid in the management of the increased facial swelling and tooth pain.  The patient was worked up preoperatively by anesthesia and Oromaxillary Facial Surgery.  It was determined that she would benefit from being having multiple teeth removed and drainage of the facial abscess under general anesthesia.  Risks, benefits, and alternatives of treatment were thoroughly discussed with the patient and consent was obtained.,DESCRIPTION OF PROCEDURE:,  The patient was taken to the operating room and laid on the operating room table on supine fashion.  ASA monitors were attached as stated.  General anesthesia was induced with IV anesthetic and maintained with a nasal endotracheal intubation and inhalation of anesthetics.  The patient was prepped and draped in usual oromaxillary facial surgery fashion.,An 18-gauze needle of 20 mL syringe was used to aspirate the pus out of the right buccal space.  This pus was then cultured and sent to micro lab for cultures and sensitivities.  Approximately 7 mL of 1% lidocaine with 1:1000 epinephrine was injected in the maxillary vestibule and palate.  After waiting appropriate time for local anesthesia to take affect a moist latex sponge was placed in the posterior oropharynx to throat pack throughout the case.  Mouth rinse was then poured into the oral cavity.  The mucosa was scrubbed with a tooth brush and peridex was evacuated with suction.  Using a #15 blade a clavicular incision from tooth #5 back to 1 with tuberosity release was performed.,A full thickness mucoperiosteal flap was developed and approximately 6 mL of pus was instantly drained from the buccal space.  It was noted on exam that the tooth #1 was fractured off to the gum line with gross decay.  Tooth #2, 3, 4, and 5 had pus leaking from the clavicular epithelium and had rampant decay on tooth #2 and 3 and some mobility on teeth #4 and 5.  It was decided that teeth #1 through 5 would be surgically removed to ensure that all potential teeth causing the abscess were removed.  Using a rongeur both buccal bone and the tooth 1, 2, 3, 4, and 5 were surgically removed.  The extraction sites were curetted with curettes and the bone was smoothed with the rongeur and the bone file.  Dissection was then carried further up in the canine space and the face was palpated extra orally from the temporalis muscle down to the infraorbital rim and more pus was expressed.  This site was then irrigated with copious amounts of sterile water.  There was still noted to be induration in the buccal mucosa so #15 blade was used anterior to Stensen duct.  A 2 cm incision was made and using a Hemostat blunt dissection in to the buccal mucosa was performed.  A little-to-no pus was received.  Using a half-inch Penrose the drain was placed up on the anterior border of the maxilla and zygoma and sutured in place with 2-0 Ethilon suture.  Remainder of the flap was left open to drain.  Further examination of the floor of mouth was soft.  The lateral pharynx was nonindurated or swollen.  At this point, the throat pack was removed and OG tube was placed and the stomach contents were evacuated.  The procedure was then determined to be over.  The patient was extubated, breathing spontaneously, and transferred to the PACU in excellent condition.","surgery, cultures, buccal, teeth, canine, pacu, teeth extractions, oromaxillary facial, facial surgery, buccal space, throat pack, buccal mucosa, surgical removal, canine's base, necrotic teeth, cpt code, infection, oral, mucosa, anesthesia, facial, pus, toothache, "
" Subxiphoid pericardiotomy.  Symptomatic pericardial effusion.  The patient had the appropriate inflammatory workup for pericardial effusion, however, it was nondiagnostic.", Surgery, Subxiphoid Pericardiotomy ,"PREOPERATIVE DIAGNOSIS: , Symptomatic pericardial effusion.,POSTOPERATIVE DIAGNOSIS: , Symptomatic pericardial effusion.,PROCEDURE PERFORMED:,  Subxiphoid pericardiotomy.,ANESTHESIA:,  General via ET tube.,ESTIMATED BLOOD LOSS: , 50 cc.,FINDINGS:,  This is a 70-year-old black female who underwent a transhiatal esophagectomy in November of 2003.  She subsequently had repeat chest x-rays and CT scans and was found to have a moderate pericardial effusion.  She had the appropriate inflammatory workup for pericardial effusion, however, it was nondiagnostic.  Also, during that time, she had become significantly more short of breath.  A dobutamine stress echocardiogram was performed, which was negative with the exception of the pericardial effusions.  She had no tamponade physiology.,INDICATION FOR THE PROCEDURE: , For therapeutic and diagnostic management of this symptomatic pericardial effusion.  Risks, benefits, and alternative measures were discussed with the patient.  Consent was obtained for the above procedure.,PROCEDURE: , The patient was prepped and draped in the usual sterile fashion.  A 4 cm incision was created in the midline above the xiphoid.  Dissection was carried down through the fascia and the xiphoid was resected.  The sternum was retracted superiorly the pericardium was identified and pericardial fat was cleared off the pericardium.  An #0 silk suture was then placed into the pericardium with care taken not to enter the underlying heart.,This suture was used to retract the pericardium and the pericardium was nicked with #15 blade under direct visualization.  Serous fluid exited through the pericardium and was sent for culture, cytology, and cell count etc.  A section of pericardium was taken approximately 2 cm x 2 cm x 2 cm and was removed.  The heart was visualized and appeared to be contracting well with no evidence of injury to the heart.  The pericardium was then palpated.  There was no evidence of studding.  A right angle chest tube was then placed in the pericardium along the diaphragmatic of the pericardium and then brought out though a small skin incision in the epigastrium.  It was sewn into place with #0 silk suture.  There was some air leak of the left pleural cavity, so a right angle chest tube was placed in the left pleural cavity and brought out through a skin nick in the epigastrium.  It was sewn in the similar way to the other chest tube.  Once again, the area was inspected and found to be hemostatic and then closed with #0 Vicryl suture for fascial stitch, then #3-0 Vicryl suture in the subcutaneous fat, and then #4-0 undyed Vicryl in a running subcuticular fashion.  The patient tolerated the procedure well.  Chest tubes were placed on 20 cm of water suction.  The patient was taken to PACU in stable condition.","surgery, subxiphoid pericardiotomy, symptomatic pericardial effusion, chest x-rays, echocardiogram, dobutamine, pleural cavity, chest tube, pericardial effusion, pericardium, inflammatory, subxiphoid, pericardiotomy, heart, chest, effusion, pericardial"
 Superior labrum anterior and posterior lesion repair., Surgery, Superior Labrum Lesions Repair ,"PROCEDURE IN DETAIL:,  After written consent was obtained from the patient, the patient was brought back into the operating room and identified.  The patient was placed on the operating room table in supine position and given anesthetic.,Once adequate anesthesia had been achieved, a careful examination of the shoulder was performed.  It revealed no patholigamentous laxity.  We then placed the patient into a beach-chair position, maintaining a neutral alignment of the head, neck, and thorax.  The shoulder was then prepped and draped in the usual sterile fashion.  We then injected the glenohumeral joint with 60 cc of sterile saline solution.  A small stab incision was made 2 cm inferior and 2 cm medial to the posterolateral angle of the acromion.  Through this incision, a blunt trocar was placed.,We then placed the camera through this cannula and the shoulder was insufflated with sterile saline solution.  An anterior portal was made just below the subscapularis and then we began to inspect the shoulder joint.,We found that the articular surface was in good condition.  The biceps was found to be intact.  There was a SLAP tear noted just posterior to the biceps.  Pictures were taken.  No Bankart or Hill-Sachs lesions were noted.  The rotator cuff was examined and there were no undersurface tears.  Pictures were again taken.,We then made a lateral portal going through the muscle belly of the rotator cuff.  A drill hole was made and then knotless suture anchor was placed to repair this.  Pictures were taken.  We then washed out the joint with copious amounts of sterile saline solution.  It was drained.  Our 3 incisions were closed using 3-0 nylon suture.  A pain pump catheter was introduced into the shoulder joint.  Xeroform, 4 x 4s, ABDs, tape, and sling were placed.,The patient was successfully taken out of the beach-chair position, extubated and brought to the recovery room in stable condition.  I then went out and spoke with the patient's family, going over the case, postoperative instructions, and followup care.","surgery, laxity, patholigamentous, superior labrum, saline solution, anterior, superior, lesions, repair, sterile, joint, shoulder,"
"  Suction dilation and curettage for incomplete abortion.  On bimanual exam, the patient has approximately 15-week anteverted, mobile uterus with the cervix that is dilated to approximately 2 cm with multiple blood colts in the vagina.  There was a large amount of tissue obtained on the procedure.", Surgery," Suction, Dilation, & Curettage - 1 ","PREOPERATIVE DIAGNOSIS: ,Incomplete abortion.,POSTOPERATIVE DIAGNOSIS: ,Incomplete abortion.,PROCEDURE PERFORMED:, Suction dilation and curettage.,ANESTHESIA:  ,General and nonendotracheal by Dr. X.,ESTIMATED BLOOD LOSS: , Less than 200 cc.,SPECIMENS: , Endometrial curettings.,DRAINS: , None.,FINDINGS:  ,On bimanual exam, the patient has approximately 15-week anteverted, mobile uterus with the cervix that is dilated to approximately 2 cm with multiple blood colts in the vagina.  There was a large amount of tissue obtained on the procedure.,PROCEDURE:  ,The patient was taken to the operating room where a general anesthetic was administered.  She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion.  Once the anesthetic was found to be adequate, a bimanual exam was performed under anesthetic.  Next, a weighted speculum was placed in the vagina.  The anterior lip of cervix was grasped with the vulsellum tenaculum and due to the patient already being dilated approximately 2 cm, no cervical dilation was needed.  A size 12 straight suction curette was used and connected to the suction and was placed in the cervix and a suction curettage was performed.  Two passes were made with the suction curettage.  Next, a sharp curettage was performed obtaining a small amount of tissue and this was followed by third suction curettage and then a final sharp curettage was performed, which revealed a good uterine cry on all sides of the uterus.  After the procedure, the vulsellum tenaculum was removed.  The cervix was seemed to be hemostatic.  The weighted speculum was removed.  The patient was given 0.25 mg of Methergine IM approximately half-way through the procedure.  After the procedure, a second bimanual exam was performed and the patient's uterus had significantly decreased in size.  It is now approximately eight to ten-week size.  The patient was taken from the operating room in stable condition after she was cleaned.  She will be discharged on today.  She was given Methergine, Motrin, and doxycycline for her postoperative care.  She will follow-up in one week in the office.","surgery, uterus, anteverted, dorsal lithotomy position, weighted speculum, mobile uterus, vulsellum tenaculum, bimanual exam, vagina, tenaculum, dilation, bimanual, cervix, suction, curettage,"
 Subcutaneous transposition of the right ulnar nerve.  Right carpal tunnel syndrome and right cubital tunnel syndrome., Surgery, Subcutaneous Transposition of Ulnar Nerve ,"PREOPERATIVE DIAGNOSIS:  ,1.  Right carpal tunnel syndrome.,2.","surgery, subcutaneous transposition, ulnar nerve, carpal tunnel syndrome, cubital tunnel syndrome, tourniquet, subcutaneous, epicondyle, antebrachial, syndrome, cubital, ulnar, nerve, tunnel"
 Right suboccipital craniectomy for resection of tumor using the microscope modifier 22 and cranioplasty., Surgery, Suboccipital Craniectomy  ,"TITLE OF OPERATION: , Right suboccipital craniectomy for resection of tumor using the microscope modifier 22 and cranioplasty.,INDICATION FOR SURGERY: , The patient with a large 3.5 cm acoustic neuroma.  The patient is having surgery for resection.  There was significant cerebellar peduncle compression.  The tumor was very difficult due to its size as well as its adherence to the brainstem and the nerve complex.  The case took 12 hours.  This was more difficult and took longer than the usual acoustic neuroma.,PREOP DIAGNOSIS: , Right acoustic neuroma.,POSTOP DIAGNOSIS: , Right acoustic neuroma.,PROCEDURE:,  The patient was brought to the operating room.  General anesthesia was induced in the usual fashion.  After appropriate lines were placed, the patient was placed in Mayfield 3-point head fixation, hold into a right park bench position to expose the right suboccipital area.  A time-out was settled with nursing and anesthesia, and the head was shaved, prescrubbed with chlorhexidine, prepped and draped in the usual fashion.  The incision was made and cautery was used to expose the suboccipital bone.  Once the suboccipital bone was exposed under the foramen magnum, the high speed drill was used to thin out the suboccipital bone and the craniectomy carried out with Leksell and insertion with Kerrison punches down to the rim of the foramen magnum as well as laterally to the edge of the sigmoid sinus and superiorly to the edge of the transverse sinus.  The dura was then opened in a cruciate fashion, the cisterna magna was drained, which nicely relaxed the cerebellum.  The dura leaves were held back with the 4-0 Nurolon.  The microscope was then brought into the field, and under the microscope, the cerebellar hemisphere was elevated.  Laterally, the arachnoid was very thick.  This was opened with bipolar and microscissors and this allowed for the cerebellum to be further mobilized until the tumor was identified.  The tumor was quite large and filled up the entire lateral aspect of the right posterior fossa.  Initially two retractors were used, one on the tentorium and one inferiorly.  The arachnoid was taken down off the tumor.  There were multiple blood vessels on the surface, which were bipolared.  The tumor surface was then opened with microscissors and the Cavitron was used to began debulking the lesion.  This was a very difficult resection due to the extreme stickiness and adherence to the cerebellar peduncle and the lateral cerebellum; however, as the tumor was able to be debulked, the edge began to be mobilized.  The redundant capsule was bipolared and cut out to get further access to the center of the tumor.  Working inferiorly and then superiorly, the tumor was taken down off the tentorium as well as out the 9th, 10th or 11th nerve complex.  It was very difficult to identify the 7th nerve complex.  The brainstem was identified above the complex.  Similarly, inferiorly the brainstem was able to be identified and cotton balls were placed to maintain this plain.  Attention was then taken to try identify the 7th nerve complex.  There were multitude of veins including the lateral pontine vein, which were coming right into this area.  The lateral pontine vein was maintained.  Microscissors and bipolar were used to develop the plain, and then working inferiorly, the 7th nerve was identified coming off the brainstem.  A number 1 and number 2 microinstruments were then used to began to develop the plane.  This then allowed for the further appropriate plane medially to be identified and cotton balls were then placed.  A number 11 and number 1 microinstrument continued to be used to free up the tumor from the widely spread out 7th nerve.  Cavitron was used to debulk the lesion and then further dissection was carried out.  The nerve stimulated beautifully at the brainstem level throughout this.  The tumor continued to be mobilized off the lateral pontine vein until it was completely off.  The Cavitron was used to debulk the lesion out back laterally towards the area of the porus.  The tumor was debulked and the capsule continued to be separated with number 11microinstrument as well as the number 1 microinstrument to roll the tumor laterally up towards the porus.  At this point, the capsule was so redundant, it was felt to isolate the nerve in the porus.  There was minimal bulk remaining intracranially.  All the cotton balls were removed and the nerve again stimulated beautifully at the brainstem.  Dr. X then came in and scrubbed into the case to drill out the porus and remove the piece of the tumor that was left in the porus and coming out of the porus.,I then scrubbed back into case once Dr. X had completed removing this portion of the tumor.  There was no tumor remaining at this point.  I placed some Norian in the porus to seal any air cells, although there were no palpated.  An intradural space was then irrigated thoroughly.  There was no bleeding.  The nerve was attempted to be stimulated at the brainstem level, but it did not stimulate at this time.  The dura was then closed with 4-0 Nurolons in interrupted fashion.  A muscle plug was used over one area.  Duragen was laid and strips over the suture line followed by Hemaseel.  Gelfoam was set over this and then a titanium cranioplasty was carried out.  The wound was then irrigated thoroughly.  O Vicryls were used to close the deep muscle and fascia, 3-0 Vicryl for subcutaneous tissue, and 3-0 nylon on the skin.,The patient was extubated and taken to the ICU in stable condition.","surgery, suboccipital, craniectomy, microscope, cranioplasty, acoustic neuroma, cerebellar peduncle, nerve complex, brainstem, nurolon, cavitron, kerrison, leksell, lateral pontine vein, suboccipital craniectomy, nerve, tumor"
" Emergent subxiphoid pericardial window, transesophageal echocardiogram.", Surgery, Subxiphoid Pericardial Window ,"PREOPERATIVE DIAGNOSIS (ES):,1. Endocarditis.,2. Status post aortic valve replacement with St. Jude mechanical valve.,3. Pericardial tamponade.,POSTOPERATIVE DIAGNOSIS (ES):,1. Endocarditis.,2. Status post aortic valve replacement with St. Jude mechanical valve.,3. Pericardial tamponade.,PROCEDURE:,1. Emergent subxiphoid pericardial window.,2. Transesophageal echocardiogram.,ANESTHESIA:, General endotracheal.,FINDINGS:, The patient was noted to have 600 mL of dark bloody fluid around the pericardium. We could see the effusion resolve on echocardiogram. The aortic valve appeared to have good movement in the leaflets with no perivalvular leaks. There was no evidence of endocarditis. The mitral valve leaflets moved normally with some mild mitral insufficiency.,DESCRIPTION OF THE OPERATION:, The patient was brought to the operating room emergently. After adequate general endotracheal anesthesia, his chest was prepped and draped in the routine sterile fashion. A small incision was made at the bottom of the previous sternotomy incision. The subcutaneous sutures were removed. The dissection was carried down into the pericardial space. Blood was evacuated without any difficulty. Pericardial Blake drain was then placed. The fascia was then reclosed with interrupted Vicryl sutures. The subcutaneous tissues were closed with a running Monocryl suture. A subdermal PDS followed by a subcuticular Monocryl suture were all performed. The wound was closed with Dermabond dressing. The procedure was terminated at this point. The patient tolerated the procedure well and was returned back to the intensive care unit in stable condition.","surgery, endocarditis, valve replacement, st. jude, echocardiogram, transesophageal, pericardium, blake drain, st jude mechanical valve, subxiphoid pericardial window, pericardial window, aortic valve, tamponade, subxiphoid, valve, pericardial, aortic"
 Repeat irrigation and debridement of Right distal femoral subperiosteal abscess., Surgery, Subperiosteal Abscess Debridement ,"PREOPERATIVE DIAGNOSIS: , Right distal femoral, subperiosteal abscess.,POSTOPERATIVE DIAGNOSIS: , Right distal femoral, subperiosteal abscess.,OPERATION:,  Repeat irrigation and debridement of above.,ANESTHESIA: , General.,BLOOD LOSS:,  Minimal.,FLUID: , Per anesthesia.,DRAINS: , Hemovac times two.,COMPLICATIONS: , None apparent.,SPECIMENS:,  To microbiology.,INDICATIONS: , She is a 10-year-old girl who has history of burns and has developed a subperiosteal abscess at her right distal femur.  I am bringing her back to the operating room for another exploration of this area and washout.  This will be the third procedure for this.  At the last time, there was gross purulence that was encountered.  Since that time, the patient has defervesced.  Her white count is slowly coming down.  Her C-reactive protein is slowly coming down.,PROCEDURE IN DETAIL:,  After informed consent was obtained, operative site marked, and after preoperative antibiotics were given, the patient was brought back to the operating room and placed supine on the operating table, where Anesthesia induced general anesthesia.  The patient's right lower extremity was prepped and draped in normal sterile fashion.  Surgical timeout occurred verifying the patient's identification, surgical site, surgical procedure, and administration of antibiotics.  The patient's previous incision sites had the sutures removed.  We bluntly dissected down through to the IT band.  These deep stitches were then removed.  We exposed the area of the subperiosteal abscess.  The tissue looked much better than at the last surgery.  We irrigated this area with three liters of saline containing bacitracin.  Next, we made our small medial window to assist with washout of the joint itself.  We put another three liters of saline containing bacitracin through the knee joint.  Lastly, we did another three liters into the area of the distal femur with three liters of plain saline.  We then placed two Hemovac drains, one in the metaphysis and one superficially.  We closed the deep fascia with #1 PDS.  Subcutaneous layers with 2-0 Monocryl and closed the skin with 2-0 nylon.  We placed a sterile dressing.  We then turned the case over to Dr. Petty for dressing change and skin graft.,PLAN:  ,Our plan will be to pull the drains in 48 hours.  We will then continue to watch the patient's fever curve and follow her white count to see how she is responding to the operative and medical therapies.,","surgery, repeat irrigation and debridement, repeat irrigation, distal femur, distal femoral, femoral subperiosteal, subperiosteal abscess, hemovac, femur, debridement, irrigation, saline, anesthesia, distal, subperiosteal, abscess, "
" Insertion of right subclavian central venous catheter.   Need for intravenous access, status post fall, and status post incision and drainage of left lower extremity.", Surgery, Subclavian Central Venous Catheter Insertion ,"PREOPERATIVE DIAGNOSES:,1.  Need for intravenous access.,2.  Status post fall.,3.  Status post incision and drainage of left lower extremity.,POSTOPERATIVE DIAGNOSES:,1.  Need for intravenous access.,2.  Status post fall.,3.  Status post incision and drainage of left lower extremity.,PROCEDURE PERFORMED: , Insertion of right subclavian central venous catheter.,SECOND ANESTHESIA: , Approximately 10 cc of 1% lidocaine.,ESTIMATED BLOOD LOSS: , Minimal.,INDICATIONS FOR PROCEDURE:  ,The patient is a 74-year-old white female who presents to ABCD General Hospital after falling down flight of eleven stairs and sustained numerous injuries.  The patient went to OR today for an I&D of left lower extremity degloving injury.  Orthopedics was planning on taking the patient back for serial debridements and need for reliable IV access is requested.,PROCEDURE: , Informed consent was obtained by the patient and her daughter.  All risks and benefits of the procedure were explained and all questions were answered.  The patient was prepped and draped in the normal sterile fashion.  After landmarks were identified, approximately 5 cc of 1% lidocaine were injected into the skin and subcuticular tissues and the right neck posterior head of the sternocleidomastoid.  Locator needle was used to correctly cannulate the right internal jugular vein.  Multiple attempts were made and the right internal jugular vein was unable to be cannulized.,Therefore, we prepared for a right subclavian approach.  The angle of the clavicle was found and a #22 gauge needle was used to anesthetize approximately 5 cc of 1% lidocaine in skin and subcuticular tissues along with the periosteum of the clavicle.  A Cook catheter needle was then placed and ________ the clavicle in the orientation aimed toward the sternal notch.  The right subclavian vein was then accessed.  A guidewire was placed with a Cook needle and then the needle was subsequently removed and a #11 blade scalpel was used to nick the skin.  A dilator sheath was placed over the guidewire and subsequently removed.  The triple lumen catheter was then placed over the guidewire and advanced to 14 cm.  All ports aspirated and flushed.  Good blood return was noted and all ports were flushed well.  The triple lumen catheter was then secured at 14 cm using #0 silk suture.  A sterile dressing was then applied.  A stat portable chest x-ray was ordered to check line placement.  The patient tolerated the procedure well and there were no complications.","surgery, intravenous access, incision and drainage, subclavian central venous catheter, central venous catheter, lower extremity, venous, intravenous, lidocaine, subclavian, needle, catheter, insertion"
" Open Stamm gastrotomy tube, lysis of adhesions, and closure of incidental colotomy", Surgery, Stamm Gastrostomy Tube Placement ,"PREOPERATIVE DIAGNOSES:,1. Squamous cell carcinoma of the head and neck.,2. Ethanol and alcohol abuse.,POSTOPERATIVE DIAGNOSES:,1. Squamous cell carcinoma of the head and neck.,2. Ethanol and alcohol abuse.,PROCEDURE:,1. Failed percutaneous endoscopic gastrostomy tube placement.,2. Open Stamm gastrotomy tube.,3. Lysis of adhesions.,4. Closure of incidental colotomy.,ANESTHESIA:, General endotracheal anesthesia.,IV FLUIDS:, Crystalloid 1400 ml.,ESTIMATED BLOOD LOSS:, Thirty ml.,DRAINS:, Gastrostomy tube was placed to Foley.,SPECIMENS:, None.,FINDINGS:, Stomach located high in the peritoneal cavity. Multiple adhesions around the stomach to the diaphragm and liver.,HISTORY: ,The patient is a 59-year-old black male who is indigent, an ethanol and tobacco abuse. He presented initially to the emergency room with throat and bleeding. Following evaluation by ENT and biopsy, it was determined to be squamous cell carcinoma of the right tonsil and soft palate, The patient is to undergo radiation therapy and possibly chemotherapy and will need prolonged enteral feeding with a bypass route from the mouth. The malignancy was not obstructing. Following obtaining informed consent for percutaneous endoscopic gastrostomy tube with possible conversion to open procedure, we elected to proceed following diagnosis of squamous cell carcinoma and election for radiation therapy.,DESCRIPTION OF PROCEDURE:, The patient was placed in the supine position and general endotracheal anesthesia was induced. Preoperatively, 1 gram of Ancef was given. The abdomen was prepped and draped in the usual sterile fashion. After anesthesia was achieved, an endoscope was placed down into the stomach, and no abnormalities were noted. The stomach was insufflated with air and the endoscope was positioned in the midportion and directed towards the anterior abdominal wall. With the room darkened and intensity turned up on the endoscope, a light reflex was noted on the skin of the abdominal wall in the left upper quadrant at approximately 2 fingerbreadths inferior from the most inferior rib. Finger pressure was applied to the light reflex with adequate indentation on the stomach wall on endoscopy. A 21-gauge 1-1/2 inch needle was initially placed at the margin of the light reflex, and this was done twice. Both times it was not visualized on the endoscopy. At this point, repositioning was made and, again, what was felt to be adequate light reflex was obtained, and the 14-gauge angio catheter was placed. Again, after two attempts, we were unable to visualize the needle in the stomach endoscopically. At this point, decision was made to convert the procedure to an open Stamm gastrostomy.,OPEN STAMM GASTROSTOMY: ,A short upper midline incision was made and deepened through the subcutaneous tissues. Hemostasis was achieved with electrocautery. The linea alba was identified and incised, and the peritoneal cavity was entered. The abdomen was explored. Adhesions were lysed with electrocautery under direct vision. The stomach was identified, and a location on the anterior wall near the greater curvature was selected. After lysis of adhesions was confirmed, we sufficiently moved the original chosen site without tension. A pursestring suture of #3-0 silk was placed on the interior surface of the stomach, and a second #3-0 pursestring silk stitch was placed exterior to that pursestring suture. An incision was then made at the location of the anterior wall which was near the greater curvature and was dissected down to the anterior abdominal wall. A Vanderbilt was used to pass through the abdominal wall in through the skin and then returned to the level of the skin and pulled the Bard feeding tube through the anterior wall into the field. An incision in the center of the pursestring suture on the anterior surface of the stomach was then made with electrocautery. The interior pursestring suture was sutured into place in such a manner as to inkwell the stomach around the catheter. The second outer concentric pursestring suture was then secured as well and tied to further inkwell the stomach. The stomach was then tacked to the anterior abdominal wall at the catheter entrance site with four #2-0 silk sutures in such a manner as to prevent leakage or torsion. The catheter was then secured to the skin with two #2-0 silk sutures. Hemostasis was checked and the peritoneal cavity was washed out and brought to the surgical field. Prior to the initiation of the gastrotomy, the bowel was run and at that time there was noted to be one incidental colotomy. This was oversewn with three #4-0 silk Lembert sutures. At the completion of the operation, the fascia was closed with #1 interrupted Vicryl suture, and the skin was closed with staples. The patient tolerated the procedure well and was taken to the postanesthesia care unit in stable condition.", 
" Successful stenting of the left anterior descending.  Angina pectoris, tight lesion in left anterior descending.", Surgery, Stenting ,"NAME OF PROCEDURE:,  Successful stenting of the left anterior descending.,DESCRIPTION OF PROCEDURE:,  Angina pectoris, tight lesion in left anterior descending.,TECHNIQUE OF PROCEDURE:,  Standard Judkins, right groin.,CATHETERS USED: , 6 French Judkins, right; wire, 14 BMW; balloon for predilatation, 25 x 15 CrossSail; stent 2.5 x 18 Cypher drug-eluting stent.,ANTICOAGULATION:  ,The patient was on aspirin and Plavix, received 3000 of heparin and was begun on Integrilin.,COMPLICATIONS: , None.,INFORMED CONSENT: , I reviewed with the patient the pros, cons, alternatives and risks of catheter and sedation exactly as I had done before during his diagnostic catheterization, plus I reviewed the risks of intervention including lack of success, need for emergency surgery, need for later restenosis and further procedures.,HEMODYNAMIC DATA: , The aortic pressure was in the physiologic range.,ANGIOGRAPHIC DATA: , Left coronary artery:  The left main coronary artery showed insignificant disease.  The left anterior descending showed fairly extensive calcification.  There was 90% stenosis in the proximal to midportion of the vessel.  Insignificant disease in the circumflex.,SUCCESSFUL STENTING: , A wire crossed the lesion.  We first predilated with a balloon, then advanced, deployed and post dilated the stent.  Final angiography showed 0% stenosis, no tears or thrombi, excellent intimal appearance.,PHYSICAL EXAMINATION,VITAL SIGNS:  Blood pressure 160/88, temperature 98.6, pulse 83, respirations 30.  He is saturating at 96% on 4 L nonrebreather.,GENERAL:  The patient is a 74 year-old white male who is cooperative with the examination and alert and oriented x3.  The patient cannot speak and communicates through writing.,HEENT:  Very small moles on face.  However, pupils equal, round and regular and reactive to light and accommodation.  Extraocular movements are intact.  Oropharynx is moist.,NECK:  Supple.  Tracheostomy site is clean without blood or discharge.,HEART:  Regular rate and rhythm.  No gallop, murmur or rub.,CHEST:  Respirations congested.  Mild crackles in the left lower quadrant and left lower base.,ABDOMEN:  Soft, nontender and nondistended.  Positive bowel sounds.,EXTREMITIES:  No clubbing, cyanosis or edema.,NEUROLOGIC:  Cranial nerves II-XII grossly intact.  No focal deficit.,GENITALIA:  The patient does have a right scrotal swelling, very much larger than the other side, not reproducible and mobile to touch.,CONCLUSIONS,1. Successful stenting of the left anterior descending.  Initially, there was 90% stenosis.  After stenting with a drug-eluting stent, there was 0% residual.,2. Insignificant disease in the other coronaries.,PLAN:,  The patient will be treated with aspirin, Plavix, Integrilin, beta blockers and statins.  I have discussed this with him, and I have answered his questions.",
" Spontaneous vaginal delivery.  Male infant, cephalic presentation, ROA.  Apgars 2 and 7.  Weight 8 pounds and 1 ounce.  Intact placenta.  Three-vessel cord.  Third degree midline tear.", Surgery, Spontaneous Vaginal Delivery - 1 ,"PREOPERATIVE DIAGNOSES,1.  Intrauterine pregnancy at 39 plus weeks gestation.,2.  Gestational hypertension.,3.  Thick meconium.,4.  Failed vacuum attempted delivery.,POSTOPERATIVE DIAGNOSES,1.  Intrauterine pregnancy at 39 plus weeks gestation.,2.  Gestational hypertension.,3.  Thick meconium.,4.  Failed vacuum attempted delivery.,OPERATION PERFORMED: , Spontaneous vaginal delivery.,ANESTHESIA: , Epidural was placed x2.,ESTIMATED BLOOD LOSS:,  500 mL.,COMPLICATIONS: , Thick meconium.  Severe variables, Apgars were 2 and 7.  Respiratory therapy and ICN nurse at delivery.  Baby went to Newborn Nursery.,FINDINGS: , Male infant, cephalic presentation, ROA.  Apgars 2 and 7.  Weight 8 pounds and 1 ounce.  Intact placenta.  Three-vessel cord.  Third degree midline tear.,DESCRIPTION OF OPERATION: , The patient was admitted this morning for induction of labor secondary to elevated blood pressure, especially for the last three weeks.  She was already 3 cm dilated.  She had artificial rupture of membranes.  Pitocin was started and she actually went to complete dilation.  While pushing, there was sudden onset of thick meconium, and she was having some severe variables and several late decelerations.  When she was complete +2, vacuum attempted delivery, three pop-offs were done.  The vacuum was then no longer used after the three pop-offs.  The patient pushed for a little bit longer and had a delivery, ROA, of a male infant, cephalic, over a third-degree midline tear.  Secondary to the thick meconium, DeLee suctioned nose and mouth before the anterior shoulder was delivered and again after delivery.  Baby was delivered floppy.  Cord was clamped x2 and cut, and the baby was handed off to awaiting ICN nurse and respiratory therapist.  Delivery of intact placenta and three-vessel cord.  Third-degree midline tear was repaired with Vicryl without any complications.  Baby initially did well and went to Newborn Nursery, where they are observing him a little bit longer there.  Again, mother and baby are both doing well.  Mother will go to Postpartum and baby is already in Newborn Nursery.","surgery, thick meconium, cephalic presentation, intrauterine pregnancy, gestational hypertension, spontaneous vaginal delivery, delivery, vaginal, placenta, newborn, meconium, apgars,"
" Spontaneous vaginal delivery.   Term pregnancy at 40 and 3/7th weeks.  On evaluation of triage, she was noted to be contracting approximately every five minutes and did have discomfort with her contractions.", Surgery, Spontaneous Vaginal Delivery ,"PREOPERATIVE DIAGNOSIS: , Term pregnancy at 40 and 3/7th weeks.,PROCEDURE PERFORMED: , Spontaneous vaginal delivery.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 36-year-old African-American female who is a G-2, P-2-0-0-2 with an EDC of 08/30/2003.  She is blood type AB -ve with antibody screen negative and is also rubella immune, VDRL nonreactive, hepatitis B surface antigen negative, and HIV nonreactive.  She does have a history of sickle cell trait.  She presented to Labor and Delivery Triage at 40 and 3/7th weeks gestation with complaint of contractions every ten minutes.  She also stated that she has lost her mucous plug.  She did have fetal movement, noted no leak of fluid, did have some spotting.  On evaluation of triage, she was noted to be contracting approximately every five minutes and did have discomfort with her contractions.  She was evaluated by sterile vaginal exam and was noted to be 4 cm dilated, 70% effaced, and -3 station.  This was a change from her last office exam, at which she was 1 cm to 2 cm dilated.,PROCEDURE DETAILS:,  The patient was admitted to Labor and Delivery for expected management of labor and AROM was performed and the amniotic fluid was noted to be meconium stained.  After her membranes were ruptured, contractions did increase to every two to three minutes as well as the intensity increased.  She was given Nubain for discomfort with good result.,She had a spontaneous vaginal delivery of a live born female at 11:37 with meconium stained fluid as noted from ROA position.  After controlled delivery of the head, tight nuchal cord was noted, which was quickly double clamped and cut and the shoulders and body were delivered without difficulty.  The infant was taken to the awaiting pediatrician.  Weight was 2870 gm, length was 51 cm.  The Apgars were 6 at 1 minute and 9 at 5 minutes.  There was initial neonatal depression, which was treated by positive pressure ventilation and the administration of Narcan.,Spontaneous delivery of an intact placenta with a three-vessel cord was noted at 11:45.  On examination, there were no noted perineal abrasions or lacerations.  On vaginal exam, there were no noted cervical or vaginal sidewall lacerations.  Estimated blood loss was less than 250 cc.  Mother and infant are in recovery doing well at this time.","surgery, roa position, arom, labor and delivery, spontaneous vaginal delivery, term pregnancy, contracting, meconium, lacerations, pregnancy, contractions, vaginal, "
" Stab wound, left posterolateral chest.   Closure of stab wound.", Surgery, Stab Wound Closure ,"PREPROCEDURE DIAGNOSIS:,  Stab wound, left posterolateral chest.,POST PROCEDURE DIAGNOSIS: , Stab wound, left posterolateral chest.,PROCEDURE PERFORMED: , Closure of stab wound.,ANESTHESIA: , 1% lidocaine with epinephrine by local infiltration.,NARRATIVE:  ,The wound was irrigated copiously with 500 mL of irrigation and closed in 1 layer with staples after locally anesthetizing with 1% lidocaine with epinephrine.  The patient tolerated the procedure well without apparent complications.","surgery, posterolateral chest, stab wound, lidocaine, epinephrine, infiltration, closure, "
 Right argon laser assisted stapedectomy.  Bilateral conductive hearing losses with right stapedial fixation secondary to otosclerosis., Surgery, Stapedectomy - Argon Lasor Assisted ,"PREOPERATIVE DIAGNOSIS: , Bilateral progressive conductive hearing losses with probable otosclerosis.,POSTOPERATIVE DIAGNOSIS: , Bilateral conductive hearing losses with right stapedial fixation secondary to otosclerosis.,OPERATION PERFORMED: , Right argon laser assisted stapedectomy.,DESCRIPTION OF OPERATION:  ,The patient was brought to the operating room.  Endotracheal intubation carried out by Dr. X. The patient's right ear was carefully prepped and then draped in the usual sterile fashion.  Slow infiltration of the external canal accomplished with 1% Xylocaine with epinephrine.  The earlobe was also infiltrated with the same solution.  A limited incision was made in the earlobe harvesting a small bit of fat from the earlobe that was diced and the donor site closed with interrupted sutures of 5-0 nylon.  This could later be removed in bishop.  A reinspection of the ear canal was accomplished.  A 65 Beaver blade was used to make incision both at 12 o'clock and at 6 o'clock.  Jordan round knife was used to incise the tympanomeatal flap with an adequate cuff for later reapproximation.  Elevation was carried down to the fibrous annulus.  An annulus elevator was used to complete the elevation beneath the annular ligament.  The tympanic membrane and the associated flap rotated anteriorly exposing the ossicular chain.  Palpation of the malleus revealed good mobility of both it and incus, but no movement of the stapes was identified.  Palpation with a fine curved needle on the stapes itself revealed no movement.  A house curette was used to takedown portions of the scutum with extreme care to avoid any inadvertent trauma to the chorda tympani.  The nerve was later hydrated with a small curved needle and an additional fluid to try to avoid inadvertent desiccation of it as well.  The self-retaining speculum holder was used to get secure visibility and argon laser then used to create rosette on the posterior cruse.  The stapes superstructure anteriorly was mobilized with a right angle hook at the incostapedial joint and the superstructure could then be downfractured.  The fenestration created in the footplate was nearly perfect for placement of the piston and therefore additional laser vaporization was not required in this particular situation.  A small bit of additional footplate was removed with a right angle hook to accommodate the 0.6 mm piston.  The measuring device was used and a 4.25 mm slim shaft wire Teflon piston chosen.  It was placed in the middle ear atraumatically with a small alligator forceps and was directed towards the fenestration in the footplate.  The hook was placed over the incus and measurement appeared to be appropriate.  A downbiting crimper was then used to complete the attachment of the prosthesis to the incus.  Prosthesis is once again checked for location and centering and appeared to be in ideal position.  Small pledgets of fat were placed around the perimeter of the piston in an attempt to avoid any postoperative drainage of perilymph.  A small pledget of fat was also placed on the top of the incudo-prosthesis junction.  The mobility appeared excellent.  The flap was placed back in its normal anatomic position.  The external canal packed with small pledgets of Gelfoam and antibiotic ointment.  She was then awakened and taken to the recovery room in a stable condition with discharge anticipated later this day to Bishop.  Sutures will be out in a week and a recheck in Reno in four to five weeks from now.","surgery, bilateral progressive conductive hearing loss, argon laser assisted, conductive hearing losses, intubation, argon, stapedectomy, otosclerosis, canal, earlobe, prosthesis, pledgets, laser"
" Spinal Manipulation under Anesthesia - Sacro-iliitis, lumbo-sacral segmental dysfunction, thoraco-lumbar segmental dysfunction, associated with myalgia/fibromyositis.", Surgery, Spinal Manipulation ,"PREOPERATIVE DIAGNOSIS: , Sacro-iliitis (720.2), lumbo-sacral segmental dysfunction (739.3), thoraco-lumbar segmental dysfunction (739.2), associated with myalgia/fibromyositis (729.1).,POSTOPERATIVE DIAGNOSIS: , Sacro-iliitis (720.2), lumbo-sacral segmental dysfunction (739.3), thoraco-lumbar segmental dysfunction (739.2), associated with myalgia/fibromyositis (729.1).,ANESTHESIA: , Conscious Sedation.,INFORMED CONSENT: , After adequate explanation of the medical surgical and procedural options, this patient has decided to proceed with the recommended spinal Manipulation under Anesthesia (MUA).  The patient has been informed that more than one procedure may be necessary to achieve the satisfactory results.,INDICATION:,  This patient has failed extended conservative care of condition/dysfunction by means of aggressive physical medical and pharmacological intervention.,COMMENTS: , This patient understands the essence of the diagnosis and the reasons for the MUA- The associated risks of the procedure, including anesthesia complications, fracture, vascular accidents, disc herniation and post-procedure discomfort, were thoroughly discussed with the patient.  Alternatives to the procedure, including the course of the condition without MUA, were discussed.  The patient understands the chances of success from undergoing MUA and that no guarantees are made or implied regarding outcome.  The patient has given both verbal and written informed consent for the listed procedure.,PROCEDURE IN DETAIL: , The patient was draped in the appropriate gowning and accompanied to the operative area.  Following their sacral block injection, they were asked to lie supine on the operative table and they were placed on the appropriate monitors for this procedure.  When the patient and I were ready, the anesthesiologist administered the appropriate medications to assist the patient into the twilight sedation using medication which allows the stretching, mobilization, and adjustments necessary for the completion of the outcome I desired.,THORACIC SPINE: , With the patient in the supine position on the operative table, the upper extremities were flexed at the elbow and crossed over the patient's chest to achieve maximum traction to the patient's thoracic spine.  The first assistant held the patient's arms in the proper position and assisted in rolling the patient for the adjusting procedure.  With the help of the first assist, the patient was rolled to their right side, selection was made for the contact point and the patient was rolled back over the doctor's hand.  The elastic barrier of resistance was found, and a low velocity thrust was achieved using a specific closed reduction anterior to posterior/superior manipulative procedure.  The procedure was completed at the level of TI-TI2.  Cavitation was achieved.,LUMBAR SPINE/SACRO-ILIAC JOINTS:,  With the patient supine on the procedure table, the primary physician addressed the patient's lower extremities which were elevated alternatively in a straight leg raising manner to approximately 90 degrees from the horizontal.  Linear force was used to increase the hip flexion gradually during this maneuver.  Simultaneously, the first assist physician applied a myofascial release technique to the calf and posterior thigh musculature.  Each lower extremity was independently bent at the knee and tractioned cephalad in a neutral sagittal plane, lateral oblique cephalad traction, and medial oblique cephalad traction maneuver.  The primary physician then approximated the opposite single knee from his position from neutral to medial slightly beyond the elastic barrier of resistance. (a piriformis myofascial release was accomplished at this time).  This was repeated with the opposite lower extremity.  Following this, a Patrick-Fabere maneuver was performed up to and slightly beyond the elastic barrier of resistance.,With the assisting physician stabling the pelvis and femoral head (as necessary), the primary physician extended the right lower extremity in the sagittal plane, and while applying controlled traction gradually stretched the para-articular holding elements of the right hip by means gradually describing an approximately 30-35 degree horizontal arc.  The lower extremity was then tractioned, and straight caudal and internal rotation was accomplished.  Using traction, the lower extremity was gradually stretched into a horizontal arch to approximately 30 degrees.  This procedure was then repeated using external rotation to stretch the para-articular holding elements of the hips bilaterally.  These procedures were then repeated on the opposite lower extremity.,By approximating the patient's knees to the abdomen in a knee-chest fashion (ankles crossed), the lumbo-pelvic musculature was stretched in the sagittal plane, by both the primary and first assist, contacting the base of the sacrum and raising the lower torso cephalad, resulting in passive flexion of the entire lumbar spine and its holding elements beyond the elastic barrier of resistance","surgery, fibromyositis, myalgia, segmental dysfunction, sacro-iliitis, spinal manipulation under anesthesia, lumbar segmental dysfunction, informed consent, iliac joints, spinal manipulation, sacro iliitis, lower extremity, spinal, mua, cephalad, dysfunction, segmental, lumbar, "
" Excision of volar radial wrist mass (inflammatory synovitis) and radial styloidectomy, right wrist.  Right wrist pain with an x-ray showing a scapholunate arthritic collapse pattern arthritis with osteophytic spurring of the radial styloid and a volar radial wrist mass suspected of being a volar radial ganglion.", Surgery, Styloidectomy ,"PREOPERATIVE DIAGNOSIS: , Right wrist pain with an x-ray showing a scapholunate arthritic collapse pattern arthritis with osteophytic spurring of the radial styloid and a volar radial wrist mass suspected of being a volar radial ganglion.,POSTOPERATIVE DIAGNOSIS: , Right wrist pain with an x-ray showing a scapholunate arthritic collapse pattern arthritis with osteophytic spurring of the radial styloid and a volar radial wrist mass suspected of being a volar radial ganglion; finding of volar radial wrist mass of bulging inflammatory tenosynovitis from the volar radial wrist joint rather than a true ganglion cyst; synovitis was debrided and removed.,PROCEDURE: , Excision of volar radial wrist mass (inflammatory synovitis) and radial styloidectomy, right wrist.,ANESTHESIA:,  Axillary block plus IV sedation.,ESTIMATED BLOOD LOSS:,  Zero.,SPECIMENS,1.  Inflammatory synovitis from the volar radial wrist area.,2.  Inflammatory synovitis from the dorsal wrist area.,DRAINS:,  None.,PROCEDURE DETAIL: , Patient brought to the operating room.  After induction of IV sedation a right upper extremity axillary block anesthetic was performed by anesthesia staff.  Routine prep and drape was employed.  Patient received 1 gm of IV Ancef preoperatively.  Arm was exsanguinated by means of elevation of Esmarch elastic tourniquet.  Tourniquet inflated to 250 mmHg pressure.  Hand positioned palm up in a lead hand-holder.  A longitudinal zigzag incision over the volar radial wrist mass was made.  Skin was sharply incised.  Careful blunt dissection was used in the subcutaneous tissue.  Antebrachial fascia was bluntly dissected and incised to reveal the radial artery.  Radial artery was mobilized preserving its dorsal and palmar branches.  Small transverse concomitant vein branches were divided to facilitate mobilization of the radial artery.  Wrist mass was exposed by blunt dissection.  This appeared to be an inflammatory arthritic mass from the volar radial wrist capsule.  This was debrided down to the wrist capsule with visualization of the joint through a small capsular window.  After complete volar synovectomy the capsular window was closed with 4-0 Mersilene figure-of-eight suture.  Subcutaneous tissue was closed with 4-0 PDS and the skin was closed with a running subcuticular 4-0 Prolene.  Forearm was pronated and C-arm image intensifier was used to confirm localization of the radial styloid for marking of the skin incision.  An oblique incision overlying the radial styloid centered on the second extensor compartment was made.  Skin was sharply incised.  Blunt dissection was used in the subcutaneous tissue.  Care was taken to identify and protect the superficial radial nerve.  Blunt dissection was carried out in the extensor retinaculum.  This was incised longitudinally over the second extensor compartment.  EPL tendon was identified, mobilized and released to facilitate retraction and prevent injury.  The interval between the ECRL and the ECRB was developed down to bone.  Dorsal capsulotomy was made and local synovitis was identified.  This was debrided and sent as second pathologic specimen.  Articular surface of the scaphoid was identified and seen to be completely devoid of articular cartilage with hard, eburnated subchondral bone consistent with a SLAC pattern arthritis.  Radial styloid had extensive spurring and was exposed subperiosteally and osteotomized in a dorsal oblique fashion preserving the volar cortex as the attachment point of the deep volar carpal ligament layer.  Dorsally the styloidectomy was beveled smooth and contoured with a rongeur.  Final x-rays documenting the styloidectomy were obtained.  Local synovitis beneath the joint capsule was debrided.  Remnants of the scapholunate interosseous which was completely deteriorated were debrided.  The joint capsule was closed anatomically with 4-0 PDS and extensor retinaculum was closed with 4-0 PDS.  Subcutaneous tissues closed with 4-0 Vicryl.  Skin was closed with running subcuticular 4-0 Prolene.  Steri-Strips were applied to wound edge closure; 10 cc of 0.5% plain Marcaine was infiltrated into the areas of the surgical incisions and radial styloidectomy for postoperative analgesia.  A bulky gently compressive wrist and forearm bandage incorporating an EBI cooling pad were applied.  Tourniquet was deflated.  Good vascular color and capillary refill were seen to return to the tips of all digits.  Patient discharged to the ambulatory recovery area and from there discharged home.,DISCHARGE PRESCRIPTIONS:,1.  Keflex 500 mg tablets, #20, one PO q.6h. x 5 days.,2.  Vicodin, 40 tablets, one to two PO q.4h. p.r.n.,3.  Percocet, #20 tablets, one to two PO q.3-4h. p.r.n. severe pain.","surgery, osteophytic, spurring, ganglion, synovitis, volar radial wrist mass, excision, inflammatory synovitis, radial styloidectomy, inflammatory, styloidectomy, volar, wrist, radial, mass"
 Posterior spinal fusion and spinal instrumentation.  Posterior osteotomy; posterior elements to include laminotomy-foraminotomy and decompression of the nerve roots., Surgery, Spinal Fusion & Instrumentation ,"PREOPERATIVE DIAGNOSIS: , Severe scoliosis.,ANESTHESIA: , General.  Lines were placed by Anesthesia to include an A line.,PROCEDURES: ,1.  Posterior spinal fusion from T2-L2.,2.  Posterior spinal instrumentation from T2-L2.,3.  A posterior osteotomy through T7-T8 and T8-T9.  Posterior elements to include laminotomy-foraminotomy and decompression of the nerve roots.,IMPLANT: , Sofamor Danek (Medtronic) Legacy 5.5 Titanium system.,MONITORING: , SSEPs, and the EPs were available.,INDICATIONS: , The patient is a 12-year-old female, who has had a very dysmorphic scoliosis.  She had undergone a workup with an MRI, which showed no evidence of cord abnormalities.  Therefore, the risks, benefits, and alternatives were discussed with Surgery with the mother, to include infections, bleeding, nerve injuries, vascular injuries, spinal cord injury with catastrophic loss of motor function and bowel and bladder control.  I also discussed ___________ and need for revision surgery.  The mom understood all this and wished to proceed.,PROCEDURE: , The patient was taken to the operating room and underwent general anesthetic.  She then had lines placed, and was then placed in a prone position.  Monitoring was then set up, and it was then noted that we could not obtain motor-evoked potentials.  The SSEPs were clear and were compatible with the preoperative, but no preoperative motors had been done, and there was a concern that possibly this could be from the result of the positioning.  It was then determined at that time, that we would go ahead and proceed to wake her up, and make sure she could move her feet.  She was then lightened under anesthesia, and she could indeed dorsiflex and plantarflex her feet, so therefore, it was determined to go ahead and proceed with only monitoring with the SSEPs.,The patient after being prepped and draped sterilely, a midline incision was made, and dissection was carried down.  The dissection utilized a combination of hand instruments and electrocautery and dissected out along the laminae and up to the transverse processes.  This occurred from T2-L2.  Fluoroscopy was brought in to verify positions and levels.  Once this was done, and all bleeding was controlled, retractors were then placed.  Attention was then turned towards placing screws first on the left side.  Lumbar screws were placed at the junction of the transverse process and the facets under fluoroscopic guidance.  The area was opened with a high speed burr, and then the track was defined with a blunt probe, and a ball-tipped feeler was then utilized to verify all walls were intact.  They were then tapped, and then screws were then placed.  This technique was used at L1 and L2, both the right and left.  At T12, a direct straight-ahead technique was utilized, where the facet was removed, and then the position was chosen under the fluoroscopy, and then it was spurred, the track was defined and then probed and tapped, and it was felt to be in good position.  Two screws, in the right and left were placed at T12 as well, reduction screws on the left.  The same technique was used for T11, where right and left screws were placed as well as T10 on the left.  At T9, a screw was placed on the left, and this was a reduction screw.  On the left at T8, a screw could not be placed due to the dysmorphic nature of the pedicle.  It was not felt to be intact; therefore, a screw was left out of this.  On the right, a thoracic screw was placed as well as at 7 and 6.  This was the dysmorphic portion of this.  Screws were attempted to be placed up, they could not be placed, so attention was then turned towards placing pedicle hooks.  Pedicle hooks were done by first making a box out of the pedicle, removing the complete pedicle, feeling the undersurface of the pedicle with a probe, and then seating the hook.  Upgoing pedicle hooks were placed at T3, T4, and T5.  A downgoing laminar hook was placed at the T7 level.  Screws had been placed at T6 and T7 on the right.  An upgoing pedicle hook was also placed at T3 on the right, and then, downgoing laminar hooks were placed at T2.  This was done by first using a transverse process, lamina finders to go around the transverse process and then ___________ laminar hooks.  Once all hooks were in place, spinal osteotomies were performed at T7-T8 and T8-T9.  This was the level of the kyphosis, to bring her back out of her kyphoscoliosis.  First the ligamentum flavum was resected using a large Kerrisons.  Next, the laminotomy was performed, and then a Kerrison was used to remove the ligamentum flavum at the level of the facet.  Once this was accomplished, a laminotomy was performed by removing more of the lamina, and to create a small wedge that could be closed down later to correct the kyphosis.  This was then brought out with resection of bone out to the foramen, doing a foraminotomy to free up the foramen on both sides.  This was done also between the T8-T9.  Once this was completed, Gelfoam was then placed.  Next, we observed, and measured and contoured.  The rods were then seated on the left, and then a derotation maneuver was performed.  Hooks had come loose, so the rod was removed on the left.  The hooks were then replaced, and the rod was reseated.  Again, it was derotated to give excellent correction.  Hooks were then well seated underneath, and therefore, they were then locked.  A second rod was then chosen on the right, and was measured, contoured, and then seated.  Next, once this was done, the rods were locked in the midsubstance, and then the downgoing pedicle hook, which had been placed at T7 was then helped to compress T8 as was the pedicle screw, and then this compressed the osteotomy sites quite nicely.  Next, distraction was then utilized to further correct at the spine, and to correct on the left, the left concave curve, which gave excellent correction.  On the right, compression was used to bring it down, and then, in the lower lumbar areas, distraction and compression were used to level out L2.  Once this was done, all screws were tightened.  Fluoroscopy was then brought in to verify L1 was level, and the first ribs were also level, and it gave a nice balanced spine.  Everything was copiously irrigated, ___________.  Next, a wake-up test was performed, and the patient was then noted to flex and extend the knees as well as dorsiflex and plantar flex both the feet.  The patient was then again sedated and brought back under general anesthesia.  Next, a high-speed burr was used for decortication.  After final tightening had been accomplished, and then allograft bone and autograft bone were mixed together with 10 mL of iliac crest aspirate and were placed into the wound.  The open canal areas had been protected with Gelfoam.  Once this was accomplished, the deep fascia was closed with multiple figure-of-eight #1's, oversewn with a running #1, _________ were then placed in the subcutaneous spaces which were then closed with 3-0 Vicryl, and then the skin was closed with 3-0 Monocryl and Dermabond.  Sterile dressing was applied.  Drains had been placed in the subcutaneous layer x2.  The patient during the case had no changes in the SSEPs, had a normal wake-up test, and had received Ancef and clindamycin during the case.  She was taken from the operating room in good condition.","surgery, osteotomy, laminotomy-foraminotomy, sofamor danek, sseps, spinal fusion, transverse processes, pedicle hooks, pedicle, laminotomy, hooks, screws, instrumentation, decompression, scoliosis, sofamor, foraminotomy, spinal"
" Anterior spine fusion from T11-L3.  Posterior spine fusion from T3-L5.  Posterior spine segmental instrumentation from T3-L5, placement of morcellized autograft and allograft.", Surgery, Spine Fusion ,"PREOPERATIVE DIAGNOSIS: , Severe neurologic or neurogenic scoliosis.,POSTOPERATIVE DIAGNOSIS: , Severe neurologic or neurogenic scoliosis.,PROCEDURES:  ,1.  Anterior spine fusion from T11-L3.,2.  Posterior spine fusion from T3-L5.,3.  Posterior spine segmental instrumentation from T3-L5, placement of morcellized autograft and allograft.,ESTIMATED BLOOD LOSS: , 500 mL.,FINDINGS: , The patient was found to have a severe scoliosis.  This was found to be moderately corrected.  Hardware was found to be in good positions on AP and lateral projections using fluoroscopy.,INDICATIONS: , The patient has a history of severe neurogenic scoliosis.  He was indicated for anterior and posterior spinal fusion to allow for correction of the curvature as well as prevention of further progression.  Risks and benefits were discussed at length with the family over many visits.  They wished to proceed.,PROCEDURE:,  The patient was brought to the operating room and placed on the operating table in the supine position.  General anesthesia was induced without incident.  He was given a weight-adjusted dose of antibiotics.  Appropriate lines were then placed.  He had a neuromonitoring performed as well.,He was then initially placed in the lateral decubitus position with his left side down and right side up.  An oblique incision was then made over the flank overlying the 10th rib.  Underlying soft tissues were incised down at the skin incision.  The rib was then identified and subperiosteal dissection was performed.  The rib was then removed and used for autograft placement later.,The underlying pleura was then split longitudinally.  This allowed for entry into the pleural space.  The lung was then packed superiorly with wet lap.  The diaphragm was then identified and this was split to allow for access to the thoracolumbar spine.,Once the spine was achieved, subperiosteal dissection was performed over the visualized vertebral bodies.  This required cauterization of the segmental vessels.  Once the subperiosteal dissection was performed to the posterior and anterior extents possible, the diskectomies were performed.  These were performed from T11-L3.  This was over 5 levels.  Disks and endplates were then removed.  Once this was performed, morcellized rib autograft was placed into the spaces.  The table had been previously bent to allow for easier access of the spine.  This was then straightened to allow for compression and some correction of the curvature.,The diaphragm was then repaired as was the pleura overlying the thoracic cavity.  The ribs were held together with #1 Vicryl sutures.  Muscle layers were then repaired using a running #2-0 PDS sutures and the skin was closed using running inverted #2-0 PDS suture as well.  Skin was closed as needed with running #4-0 Monocryl.  This was dressed with Xeroform dry sterile dressings and tape.,The patient was then rotated into a prone position.  The spine was prepped and draped in a standard fashion.,Longitudinal incision was made from T2-L5.  The underlying soft tissues were incised down at the skin incision.  Electrocautery was then used to maintain hemostasis.  The spinous processes were then identified and the overlying apophyses were split.  This allowed for subperiosteal dissection over the spinous processes, lamina, facet joints, and transverse processes.  Once this was completed, the C-arm was brought in, which allowed for easy placement of screws in the lumbar spine.  These were placed at L4 and L5.  The interspaces between the spinous processes were then cleared of soft tissue and ligamentum flavum.  This was done using a rongeur as well as a Kerrison rongeur.  Spinous processes were then harvested for morcellized autograft.,Once all the interspaces were prepared, Songer wires were then passed.  These were placed from L3-T3.,Once the wires were placed, a unit rod was then positioned.  This was secured initially at the screws distally on both the left and right side.  The wires were then tightened in sequence from the superior extent to the inferior extent, first on the left-sided spine where I was operating and then on the right side spine.  This allowed for excellent correction of the scoliotic curvature.,Decortication was then performed and placement of a morcellized autograft and allograft was then performed after thoroughly irrigating the wound with 4 liters of normal saline mixed with bacitracin.  This was done using pulsed lavage.,The wound was then closed in layers.  The deep fascia was closed using running #1 PDS suture, subcutaneous tissue was closed using running inverted #2-0 PDS suture, the skin was closed using #4-0 Monocryl as needed.  The wound was then dressed with Steri-Strips, Xeroform dry sterile dressings, and tape.  The patient was awakened from anesthesia and taken to the intensive care unit in stable condition.  All instrument, sponge, and needle counts were correct at the end of the case.,The patient will be managed in the ICU and then on the floor as indicated.","surgery, anterior spine fusion, posterior spine fusion, spine segmental instrumentation, dry sterile dressings, autograft and allograft, pds sutures, spinous processes, spine fusion, spine, instrumentation, morcellized, allograft, fusion, autograft, "
 Spermatocelectomy and orchidopexy, Surgery, Spermatocelectomy ,"PREOPERATIVE DIAGNOSIS:,  Right spermatocele.,POSTOPERATIVE DIAGNOSIS:  ,Right spermatocele.,OPERATIONS PERFORMED:,1.  Right spermatocelectomy.,2.  Right orchidopexy.,ANESTHESIA: , Local MAC.,ESTIMATED BLOOD LOSS:,  Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY OF THE PATIENT:  ,The patient is a 77-year-old male who comes to the office with a large right spermatocele.  The patient says it does bother him on and off, has occasional pain and discomfort with it, has difficulty with putting clothes on etc. and wanted to remove.  Options such as watchful waiting, removal of the spermatocele or needle drainage were discussed.  Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE, risk of infection, scrotal pain, and testicular pain were discussed.  The patient was told that his scrotum may enlarge in the postoperative period for about a month and it will settle down.  The patient was told about the risk of recurrence of spermatocele.  The patient understood all the risks, benefits, and options and wanted to proceed with removal.,DETAILS OF THE PROCEDURE:  ,The patient was brought to the OR.  Anesthesia was applied.  The patient's scrotal area was shaved, prepped, and draped in the usual sterile fashion.  A midline scrotal incision was made measuring about 2 cm in size.  The incision was carried through the dartos through the scrotal sac and the spermatocele was identified.  All the layers of the spermatocele were removed.  Clear layer was visualized, was taken all the way up to the base, the base was tied.  Entire spermatocele sac was removed.  After removing the entire spermatocele sac, hemostasis was obtained.  The testicle was not in normal orientation.  The testis and epididymis was removed, which is a small appendage on the superior aspect of the testicle.  The testicle was placed in a normal orientation.  Careful attention was drawn not to twist the cord.  Orchidopexy was done to allow the testes to stay stable in the postoperative period using 4-0 Vicryl and was tied at 3 different locations.  Absorbable sutures were used, so that the patient does not feel the sutures in the postoperative period.  The dartos was closed using 2-0 Vicryl in running locking fashion.  There was excellent hemostasis.  The skin was closed using 4-0 Monocryl.  Dermabond was applied.  The patient tolerated the procedure well.  The patient was brought to the recovery room in stable condition.","surgery, orchidopexy, spermatocele, spermatocelectomy, scrotal"
 Consult and Spinal fluid evaluation in a 15-day-old, Surgery, Spinal fluid evaluation ,"HISTORY:  ,This 15-day-old female presents to Children's Hospital and transferred from Hospital Emergency Department for further evaluation.  Information is obtained in discussion with the mother and the grandmother in review of previous medical records.  This patient had the onset on the day of presentation of a jelly-like red-brown stool started on Tuesday morning.  Then, the patient was noted to vomit after feeds.  The patient was evaluated at Hospital with further evaluation with laboratory data showing a white blood cell count elevated at 22.2; hemoglobin 14.1; sodium 138; potassium 7.2, possibly hemolyzed; chloride 107; CO2 23; BUN 17; creatinine 1.2; and glucose of 50, which was repeated and found to be stable in that range.  The patient underwent a barium enema, which was read by the radiologist as negative.  The patient was transferred to Children's Hospital for further evaluation after being given doses of ampicillin, cefotaxime, and Rocephin.,PAST MEDICAL HISTORY: , Further, the patient was born in Hospital.  Birth weight was 6 pounds 4 ounces.  There was maternal hypertension.  Mother denies group B strep or herpes.  Otherwise, no past medical history.,IMMUNIZATIONS: , None today.,MEDICATIONS: , Thrush medicine identified as nystatin.,ALLERGIES: , Denied.,PAST SURGICAL HISTORY: , Denied.,SOCIAL HISTORY:  ,Here with mother and grandmother, lives at home.  There is no smoking at home.,FAMILY HISTORY: , None noted exposures.,REVIEW OF SYSTEMS:  ,The patient is fed Enfamil, bottle-fed.  Has had decreased feeding, has had vomiting, has had diarrhea, otherwise negative on the 10 plus systems reviewed.,PHYSICAL EXAMINATION:,VITAL SIGNS/GENERAL:  On physical examination, the initial temperature 97.5, pulse 140, respirations 48 on this 2 kg 15-day-old female who is small, well-developed female, age appropriate.,HEENT: Head is atraumatic and normocephalic with a soft and flat anterior fontanelle.  Pupils are equal, round, and reactive to light.  Grossly conjugate.  Bilateral red reflex appreciated bilaterally.  Clear TMs, nose, and oropharynx.  There is a kind of abundant thrush and white patches on the tongue.,NECK:  Supple, full, painless, and nontender range of motion.,CHEST:  Clear to auscultation, equal, and stable.,HEART:  Regular without rubs or murmurs, and femoral pulses are appreciated bilaterally.,ABDOMEN:  Soft and nontender.  No hepatosplenomegaly or masses.,GENITALIA:  Female genitalia is present on a visual examination.,SKIN:  No significant bruising, lesions, or rash.,EXTREMITIES:  Moves all extremities, and nontender.  No deformity.,NEUROLOGICALLY:  Eyes open, moves all extremities, grossly age appropriate.,MEDICAL DECISION MAKING: , The differential entertained on this patient includes upper respiratory infection, gastroenteritis, urinary tract infection, dehydration, acidosis, and viral syndrome.  The patient is evaluated in the emergency department laboratory data, which shows a white blood cell count of 13.1, hemoglobin 14.0, platelets 267,000, 7 stabs, 68 segs, 15 lymphs, and 9 monos.  Serum electrolytes not normal.  Sodium 138, potassium 5.0, chloride 107, CO2 acidotic at 18, glucose normal at 88, and BUN markedly elevated at 22 as is the creatinine of 1.4.  AST and ALT were elevated as well at 412 and 180 respectively.  A cath urinalysis showing no signs of infection.  Spinal fluid evaluation, please see procedure note below.  White count 0, red count 2060.  Gram stain negative.,PROCEDURE NOTE: , After discussion of the risks, benefits, and indications, and obtaining informed consent with the family and their agreement to proceed, this patient was placed in the left lateral position and using aseptic Betadine preparation, sterile draping, and sterile technique pursued throughout, this patient's L4- L5 interspace was anesthetized with the 1% lidocaine solution following the above sterile preparation, entered with a 22-gauge styletted spinal needle of approximately 0.5 mL clear CSF, they were very slow to obtain.  The fluid was obtained, the needle was removed, and sterile bandage was placed.  The fluid was sent to laboratory for further evaluation (aunt and grandmother) were present throughout the period of time during this procedure and the procedure was tolerated well.  An i-STAT initially obtained showed somewhat of an acidosis with a base excess of -12.  A repeat i-STAT after a bolus of normal saline and a second bolus of normal saline, her maintenance rate of D5 half showed a base excess of -11, which is slowly improving, but not very fast.  Based on the above having this patient consulted to the Hospitalist Service at 2326 hours of request, this patient was consulted to PICU with the plan that the patient need to have continued IV fluids.  Showing signs of dehydration, a third bolus of normal saline was provided, twice maintenance D5 half was continued.  The patient was admitted to the Hospitalist Service for continued IV fluids.  The patient maintains to have clear lungs, has been feeding well here in the department, took virtually a whole small bottle of the appropriate formula.  She has not had any vomiting, is burping.  The patient is admitted for continued close observation and rehydration due to the working diagnoses of gastroenteritis, metabolic acidosis, and dehydration.  Critical care time on this patient is less than 30 minutes, exclusive, otherwise time has been spent evaluating this patient according to this patient's care and admission to the Hospitalist Service.",
 Split-thickness skin grafting a total area of approximately 15 x 18 cm on the right leg and 15 x 15 cm on the left leg., Surgery, Skin Graft ,"DIAGNOSIS:,  Stasis ulcers of the lower extremities,OPERATION:,  Split-thickness skin grafting a total area of approximately 15 x 18 cm on the right leg and 15 x 15 cm on the left leg.,INDICATIONS:,  This 84-year old female presented recently with large ulcers of the lower extremities.  These were representing on the order of 50% or more of the circumference of her lower leg.  They were in a distribution to be consistent with stasis ulcers.  They were granulating nicely and she was scheduled for surgery.,FINDINGS:,  Large ulcers of lower extremities with size as described above.  These are irregular in shape and posterior and laterally on the lower legs.  There was no evidence of infection.  The ultimate skin grafting was quite satisfactory.,PROCEDURE: , Having obtained adequate general endotracheal anesthesia, the patient was prepped from the pubis to the toes.  The legs were examined and the wounds were Pulsavaced bilaterally with 3 liters of saline with Bacitracin.  The wounds were then inspected and there was adequate hemostasis and there was only minimal fibrinous debris that needed to be removed.  Once this was accomplished, the skin was harvested from the right thigh at approximately 0.013 inch.  This was meshed 1:1.5 and then stapled into position on the wounds.  The wounds were then dressed with a fine mesh gauze that was stapled into position as well as Kerlix soaked in Sulfamylon solution.,She was then dressed in additional Kerlix, followed by Webril, and splints were fashioned in a spiral fashion that avoided foot drop and stabilized them, and at the same time did not put pressure across the heels.  The donor site was dressed with Op-Site.  The patient tolerated the procedure well and returned to the recovery room in satisfactory condition.","surgery, skin graft, lower extremities, split thickness skin grafting, skin grafting, kerlix, grafting, extremities, ulcers, leg, "
 SPARC suburethral sling due to stress urinary incontinence., Surgery, Sling (SPARC Suburethral) ,"PREOPERATIVE DX: , Stress urinary incontinence.,POSTOPERATIVE DX: , Stress urinary incontinence.,OPERATIVE PROCEDURE: , SPARC suburethral sling.,ANESTHESIA: , General.,FINDINGS & INDICATIONS: , Outpatient evaluation was consistent with urethral hypermobility, stress urinary incontinence.  Intraoperatively, the bladder appeared normal with the exception of some minor trabeculations.  The ureteral orifices were normal bilaterally.,DESCRIPTION OF OPERATIVE PROCEDURE:,  This patient was brought to the operating room, a general anesthetic was administered.  She was placed in dorsal lithotomy position.  Her vulva, vagina, and perineum were prepped with Betadine scrubbed in solution.  She was draped in usual sterile fashion.  A Sims retractor was placed into the vagina and Foley catheter was inserted into the bladder.  Two Allis clamps were placed over the mid urethra.  This area was injected with 0.50% lidocaine containing 1:200,000 epinephrine solution.  Two areas suprapubically on either side of midline were injected with the same anesthetic solution.  The stab wound incisions were made in these locations and a sagittal incision was made over the mid urethra.  Metzenbaum scissors were used to dissect bilaterally to the level of the ischial pubic ramus.  The SPARC needles were then placed through the suprapubic incisions and then directed through the vaginal incision bilaterally.  The Foley catheter was removed.  A cystoscopy was performed using a 70-degree cystoscope.  There was noted to be no violation of the bladder.  The SPARC mesh was then snapped onto the needles, which were withdrawn through the stab wound incisions.  The mesh was snugged up against a Mayo scissor held under the mid urethra.  The overlying plastic sheaths were removed.  The mesh was cut below the surface of the skin.  The skin was closed with 4-0 Plain suture.  The vaginal vault was closed with a running 2-0 Vicryl stitch.  The blood loss was minimal.  The patient was awoken and she was brought to recovery in stable condition.","surgery, stress urinary incontinence, foley catheter, metzenbaum scissor, sparc, sparc mesh, bladder, orifice, perineum, sling, suburethral, ureteral, urethral hypermobility, vagina, vaginal vault, vulva, cystoscopy, suburethral sling, stress urinary, urinary incontinence, incontinence"
 Squamous cell carcinoma of right temporal bone/middle ear space.  Right temporal bone resection; rectus abdominis myocutaneous free flap for reconstruction of skull base defect; right selective neck dissection zones 2 and 3., Surgery, Skull Base Reconstruction ,"PREOPERATIVE DIAGNOSIS:,  Squamous cell carcinoma of right temporal bone/middle ear space.,POSTOPERATIVE DIAGNOSIS: , Squamous cell carcinoma of right temporal bone/middle ear space.,PROCEDURE: , Right temporal bone resection; rectus abdominis myocutaneous free flap for reconstruction of skull base defect; right selective neck dissection zones 2 and 3.,ANESTHESIA: , General endotracheal.,DESCRIPTION OF PROCEDURE:  ,The patient was brought into the operating room, placed on the table in supine position.  General endotracheal anesthesia was obtained in the usual fashion.  The Neurosurgery team placed the patient in pins and after they positioned the patient the right lateral scalp was prepped with Betadine after shave as well as the abdomen.  The neck was prepped as well.  After this was performed, I made a wide ellipse of the conchal bowl with the Bovie and cutting current down through the cartilage of the conchal bowl.  A wide postauricular incision well beyond the mastoid tip extending into the right neck was then incised with the Bovie with the cutting current and a postauricular skin flap developed leaving the excise conchal bowl in place as the auricle was reflected over anterior to the condyle.  After this was performed, I used the Bovie to incise the soft tissue around the temporal bone away from the tumor on to the mandible.  The condyle was skeletonized so that it could be easily seen.  The anterior border of the sternocleidomastoid was dissected out and the spinal accessory nerve was identified and spared.  The neck contents to the hyoid were dissected out.  The hypoglossal nerve, vagus nerve, and spinal accessory nerve were dissected towards the jugular foramen.  The neck contents were removed as a separate specimen.  The external carotid artery was identified and tied off as it entered the parotid and tied with a Hemoclip distally for the future anastomosis.  A large posterior facial vein was identified and likewise clipped for later use.  I then used the cutting and diamond burs to incise the skull above the external auditory canal so as to expose the dura underneath this and extended it posteriorly to the sigmoid sinus, dissecting or exposing the dura to the level of the jugular bulb.  It became evident there was two tumor extending down the eustachian tube medial to the condyle and therefore I did use the router, I mean the side cutting bur to resect the condyle and the glenoid fossa to expose the medial extent of the eustachian tube.  The internal carotid artery was dissected out of the parapharyngeal space into the carotid canal and I drilled carotid canal up until it made.  I dissected the vertical segment of the carotid out as it entered the temporal bone until it made us turn to the horizontal portion.  Once this was dissected out, Dr. X entered the procedure for completion of the resection with the craniotomy.  For details, please see his operative note.,After Dr. X had completed the resection, I then harvested the rectus free flap.  A skin paddle was drawn out next to the umbilicus about 4 x 4 cm.  The skin paddle was incised with the Bovie and down to the anterior rectus sheath.  Sagittal incisions were made up superiorly and inferiorly to the skin paddle and the anterior rectus sheath dissected out above and below the skin paddle.  The sheath was incised to the midline and a small ellipse was made around the fascia to provide blood supply to the overlying skin.  The skin paddle was then sutured to the fascia and muscle with interrupted 3-0 Vicryl.  The anterior rectus sheath was then reflected off the rectus muscle, which was then divided superiorly with the Bovie and reflected out of the rectus sheath to an inferior direction.  The vascular pedicle could be seen entering the muscle in usual fashion.  The muscle was divided inferior to the pedicle and then the pedicle was dissected to the groin to the external iliac artery and vein where it was ligated with two large Hemoclips on each vessel.  The wound was then packed with saline impregnated sponges.  The rectus muscle with attached skin paddle was then transferred into the neck.  The inferior epigastric artery was sutured to the end of the external carotid with interrupted 9-0 Ethilon with standard microvascular technique.  Ischemia time was less than 10 minutes.  Likewise, the inferior epigastric vein was sutured to the end of the posterior facial vein with interrupted 9-0 Ethilon as well.  There was excellent blood flow through the flap and there were no or any issues with the vascular pedicle throughout the remainder of the case.  The wound was irrigated with copious amounts of saline.  The eustachian tube was obstructed with bone wax.  The muscle was then laid into position with the skin paddle underneath the conchal bowl.  I removed most the skin of the conchal bowl de-epithelializing and leaving the fat in place.  The wound was closed in layers overlying the muscle, which was secured superiorly to the muscle overlying the temporal skull.  The subcutaneous tissues were closed with interrupted 3-0 Vicryl.  The skin was closed with skin staples.  There was small incision made in the postauricular skin where the muscle could be seen and the skin edges were sewn directly to the muscle as to the rectus muscle itself.  The skin paddle was closed with interrupted 4-0 Prolene to the edges of the conchal bowl.,The abdomen was irrigated with copious amounts of saline and the rectus sheath was closed with #1 Prolene with the more running suture, taking care to avoid injury to the posterior rectus sheath by the use of ribbon retractors.  The subcutaneous tissues were closed with interrupted 2-0 Vicryl and skin was closed with skin staples.  The patient was then turned over to the Neurosurgery team for awakening after the patient was appropriately awakened.  The patient was then transferred to the PACU in stable condition with spontaneous respirations, having tolerated the procedure well.","surgery, rectus abdominis myocutaneous, skull base defect, squamous cell carcinoma, skull base, squamous cell, rectus sheath, abdominis, muscle, rectus, sheath"
" The skin biopsy was performed on the right ankle and right thigh.  The patient was consented for skin biopsy.  The complications, instructions as to how the procedure will be performed, and postoperative instructions were given to the patient. ", Surgery, Skin Biopsy ,"PROCEDURE:  ,The site was cleaned with antiseptic.  A local anesthetic (2% lidocaine) was given at each site.  A 3 mm punch biopsy was performed in the left calf and left thigh, above the knee.  The site was then checked for bleeding.  Once hemostasis was achieved, a local antibiotic was placed and the site was bandaged.,The patient was not on any anticoagulant medications.  There were also no other medications which would affect the ability to conduct the skin biopsy.  The patient was further instructed to keep the site completely dry for the next 24 hours, after which a new Band-Aid and antibiotic ointment should be applied to the area.  They were further instructed to avoid getting the site dirty or infected.  The patient completed the procedure without any complications and was discharged home.,The biopsy will be sent for analysis.,The patient will follow up with Dr. X within the next two weeks to review her results.","surgery, antiseptic, local anesthetic, hemostasis, punch biopsy, band-aid, skin biopsyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" Functional endoscopic sinus surgery, excision of nasopharyngeal mass via endoscopic technique, and excision of right upper lid skin lesion 1 cm in diameter with adjacent tissue transfer closure.", Surgery, Sinus Surgery - Endoscopic ,"PREOPERATIVE DIAGNOSES:,1.  Nasopharyngeal mass.,2.  Right upper lid skin lesion.,POSTOPERATIVE DIAGNOSES:,1.  Nasopharyngeal tube mass.,2.  Right upper lid skin lesion.,PROCEDURES PERFORMED:,1.  Functional endoscopic sinus surgery.,2.  Excision of nasopharyngeal mass via endoscopic technique.,3.  Excision of right upper lid skin lesion 1 cm in diameter with adjacent tissue transfer closure.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 30 cc.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE: , The patient is a 51-year-old Caucasian female with a history of a nasopharyngeal mass discovered with patient's chief complaint of nasal congestion and chronic ear disease.  The patient had a fiberoptic nasopharyngoscopy performed in the office which demonstrated the mass and confirmed also on CT scan.  The patient also has had this right upper lid skin lesion which appears to be a cholesterol granuloma for numerous months.  It appears to be growing in size and is irregularly bordered.  After risks, complications, consequences, and questions were addressed to the patient, a written consent was obtained for the procedure.,PROCEDURE: , The patient was brought to the operating suite by Anesthesia and placed on the operating table in supine position.  After this, the patient was turned to 90 degrees by the Department of Anesthesia.  The right upper eyelid skin lesion was injected with 1% lidocaine with epinephrine 1:100,000 approximately 1 cc total.  After this, the patient's bilateral nasal passages were then packed with cocaine-soaked cottonoids of 10% solution of 4 cc total.  The patient was then prepped and draped in usual sterile fashion and the right upper lid skin was then first cut around the skin lesion utilizing a Superblade.  After this, the skin lesion was then grasped with a ________ in the  superior aspect and the skin lesion was cut and removed in the subcutaneous plane utilizing Westcott scissors.  After this, the ________ was then hemostatically controlled with monopolar cauterization.  The patient's skin was then reapproximated with a running #6-0 Prolene suture.  A Mastisol along with a single Steri-Strip was in place followed Maxitrol ointment.  Attention then was drawn to the nasopharynx.  The cocaine-soaked cottonoids were removed from the nasal passages bilaterally and zero-degree otoscope was placed all the way to the patient's nasopharynx.  The patient had a severely deviated nasal septum more so to the right than the left.  There appeared to be a spur on the left inferior aspect and also on the right posterior aspect.  The nasopharyngeal mass appeared polypoid in nature almost lymphoid tissue looking.  It was then localized with 1% lidocaine with epinephrine 1:100,000 of approximately 3 cc total.  After this, the lesion was then removed on the right side with the XPS blade.  The torus tubarius was noted on the left side with the polypoid lymphoid tissue involving this area completely.  This area was taken down with the XPS blade.  Prior to taking down this lesion with the XPS, multiple biopsies were taken with a straight biter.  After this, a cocaine-soaked cottonoid was placed back in the patient's left nasal passage region and the nasopharynx and the attention was then drawn to the right side.  The zero-degree otoscope was placed in the patient's right nasal passage and all the way to the nasopharynx.  Again, the XPS was then utilized to take down the nasopharyngeal mass in its entirety with some involvement overlying the torus tubarius.  After this, the patient was then hemostatically controlled with suctioned Bovie cauterization.  A FloSeal was then placed followed by bilateral Merocels and bacitracin-coated ointment.  The patient's Meroceles were then tied together to the patient's forehead and the patient was then turned back to the Anesthesia.  The patient was extubated in the operating room and was transferred to the recovery room in stable condition.  The patient tolerated the procedure well and sent home and with instructions to followup approximately in one week.  The patient will be sent home with a prescription for Keflex 500 mg one p.o. b.i.d, and Tylenol #3 one to two p.o. q.4-6h. pain #30.","surgery, nasopharyngeal tube mass, lymphoid tissue, torus tubarius, sinus surgery, nasal passages, nasopharyngeal mass, skin lesion, lesion, nasopharynx, endoscopic, nasopharyngeal,"
" Open reduction and internal plate and screw fixation of depressed anterior table right frontal sinus, transconjunctival exploration of orbital floor, open reduction of nasal septum and nasal pyramid fracture with osteotomy.", Surgery, Sinus Fractures Repairs ,"PREOPERATIVE DIAGNOSES:,1.  Depressed anterior table frontal sinus fracture on the right side.,2.  Right nasoorbital ethmoid fracture.,3.  Right orbital blowout fracture with entrapped periorbita.,4.  Nasal septal and nasal pyramid fracture with nasal airway obstruction.,POSTOPERATIVE DIAGNOSES:,1.  Depressed anterior table frontal sinus fracture on the right side.,2.  Right nasoorbital ethmoid fracture.,3.  Right orbital blowout fracture with entrapped periorbita.,4.  Nasal septal and nasal pyramid fracture with nasal airway obstruction.,OPERATION:,1.  Open reduction and internal plate and screw fixation of depressed anterior table right frontal sinus.,2.  Transconjunctival exploration of right orbital floor with release of entrapped periorbita.,3.  Open reduction of nasal septum and nasal pyramid fracture with osteotomy.,ANESTHESIA:,  General endotracheal anesthesia.,PROCEDURE: , The patient was placed in the supine position.  Under affects of general endotracheal anesthesia, head and neck were prepped and draped with pHisoHex solution and draped in the appropriate sterile fashion.  A gull-wing incision was drawn over the forehead scalp.  Hair was removed along the suture line and incision was made to skin and subcutaneous tissue of the scalp down to, but not including the pericranium.  An inferiorly based forehead flap was then elevated to the superior orbital rim.  The depression of the anterior table of the frontal sinus was noted.  An incision was made more posterior creating an inferiorly based pericranial flap.  The supraorbital nerve was axing from the supraorbital foramen and the supraorbital foramen was converted to a groove in order to allow further inferior displacement and positioning of the forehead flap.  These allowed exposure of the medial orbital wall on the right side.  The displaced fractures of the right medial orbital wall were repositioned through coronal approach.  ,Further reduction of the nose intranasally also allowed the ethmoid fracture to be aligned more appropriately in the medial wall.  The anterior table fracture was satisfactorily reduced.  Multiple 1.3-mm screws and plate fixation were utilized to recontour the anterior forehead.  A mucocele was removed from the frontal sinus and there was no significant destruction of the posterior wall.  A sinus seeker was utilized and passed into the nasofrontal duct without difficulty.  It was felt that the frontal sinus obliteration would not be necessary.,At this point, the pericranial flap was folded in a fan-folded fashion on top of the plate and screw and hardware and fixed in position with the sutures to remain better contour of the forehead.  At this point, the nose was significantly shifted to the left and an open reduction of the nasal fracture was performed by osteotomies, which were made medially, laterally, and percutaneous transverse osteotomy of the nasal bone on the right side.  There is significant depression of the nasal bone on the left side.  A medial osteotomy was performed on the left side mobilizing nasal pyramid satisfactorily.  There is a high septal deviation, which would not allow complete correction of the deviation.  It was felt that this would best be left for a later date.  Open reduction rhinoplasty could be performed with spread of cartilage grafting in order to straighten the septum high dorsally.  Local infiltration anesthesia 1% Xylocaine with 1:100,000 epinephrine was infiltrated in the conjunctival fornix of the right lower eyelid as well as the inferior orbital rim.  An incision was made in the palpebral conjunctiva and capsular palpebral fascia beneath the tarsal plate preseptal approach to the inferior orbital rim was performed in this fashion.  Dissection proceeded down to the inferior orbital rim and subperiosteal dissection was performed over the orbital floor.  Hemostasis was achieved with electrocautery.  There was entrapped periorbita, which was released to the fractures, which were repositioned, but not fixed in position.  The forced ductions were performed, which demonstrated release of the periorbit satisfactorily.  The conjunctival incision was closed with an interrupted simple 6-0 plain gut suture.  The nasal pyramid was satisfactorily mobilized as well as the nasal septum and brought back to midline position with the help of a Boies elevator for the septum.  The coronal incision was closed with interrupted 3-0 PDS suture for the galea and deep subcutaneous tissue and the skin closed with interrupted surgical staples.  Nose was dressed with Steri-Strips.  Mastisol Orthoplast splint was prepared after the Doyle splints were placed in the nose and secured with 3-0 Prolene suture and the nose packed with two Kennedy Merocel sponges.  A supportive mildly compressive dressing with fluffs, Kerlix, and 4-inch Ace were applied.  The patient tolerated the procedure well and was returned to recovery room in satisfactory condition.","surgery, frontal sinus, nasal septal, transconjunctival, anterior table, ethmoid, ethmoid fracture, gull-wing incision, nasal airway obstruction, nasal pyramid, nasoorbital, osteotomy, phisohex, periorbita, depressed anterior table, nasal pyramid fracture, sinus fractures, inferior orbital, pyramid fracture, entrapped periorbita, orbital, fractures, nasal, frontal, forehead, sinus,"
 Left spermatocelectomy/epididymectomy and bilateral partial vasectomy.  Left spermatocele and family planning., Surgery," Spermatocelectomy, Epididymectomy, & Vasectomy ","PREOPERATIVE DIAGNOSES:,1.  Left spermatocele.,2.  Family planning.,POSTOPERATIVE DIAGNOSES:,1.  Left spermatocele.,2.  Family planning.,PROCEDURE PERFORMED:,1.  Left spermatocelectomy/epididymectomy.,2.  Bilateral partial vasectomy.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS:,  Minimal.,SPECIMEN: , Left-sided spermatocele, epididymis, and bilateral partial vasectomy.,DISPOSITION:  ,To PACU in stable condition.,INDICATIONS AND FINDINGS: , This is a 48-year-old male with a history of a large left-sided spermatocele with significant discomfort.  The patient also has family status complete and desired infertility.  The patient was scheduled for elective left spermatocelectomy and bilateral partial vasectomy.,FINDINGS: , At this time of the surgery, significant left-sided spermatocele was noted encompassing almost the entirety of the left epididymis with only minimal amount of normal appearing epididymis remaining.,DESCRIPTION OF PROCEDURE:,  After informed consent was obtained, the patient was moved to the operating room.  A general anesthesia was induced by the Department of Anesthesia.,The patient was prepped and draped in the normal sterile fashion for a scrotal approach.  A #15 blade was used to make a transverse incision on the left hemiscrotum.  Electrocautery was used to carry the incision down into the tunica vaginalis and the testicle was delivered into the field.  The left testicle was examined.  A large spermatocele was noted.  Metzenbaum scissors were used to dissect the tissue around the left spermatocele.  Once the spermatocele was identified, as stated above, significant size was noted encompassing the entire left epididymis.  Metzenbaum scissors as well as electrocautery was used to dissect free the spermatocele from its testicular attachments and spermatocelectomy and left epididymectomy was completed with electrocautery.  Electrocautery was used to confirm excellent hemostasis.  Attention was then turned to the more proximal aspect of the cord.  The vas deferens was palpated and dissected free with Metzenbaum scissors.  Hemostats were placed on the two aspects of the cord, approximately 1 cm segment of cord was removed with Metzenbaum scissors and electrocautery was used to cauterize the lumen of the both ends of vas deferens and silk ties used to ligate the cut ends.  Testicle was placed back in the scrotum in appropriate anatomic position.  The dartos tissue was closed with running #3-0 Vicryl and the skin was closed in a horizontal interrupted mattress fashion with #4-0 chromic.  Attention was then turned to the right side.  The vas was palpated in the scrotum.  A small skin incision was made with a #15 blade and the vas was grasped with a small Allis clamp and brought into the surgical field.  A scalpel was used to excise the vas sheath and vas was freed from its attachments and grasped again with a hemostat.  Two ends were hemostated with hemostats and divided with Metzenbaum scissors.  Lumen was coagulated with electrocautery.  Silk ties used to ligate both cut ends of the vas deferens and placed back into the scrotum.  A #4-0 chromic suture was used in simple fashion to reapproximate the skin incision.  Scrotum was cleaned and bacitracin ointment, sterile dressing, fluffs, and supportive briefs applied.  The patient was sent to Recovery in stable condition.  He was given prescriptions for doxycycline 100 mg b.i.d., for five days and Vicodin ES 1 p.o. q.4h. p.r.n., pain, #30 for pain.  The patient is to followup with Dr. X in seven days.","surgery, partial vasectomy, spermatocele, epididymis, family planning, vas deferens, metzenbaum scissors, vasectomy, spermatocelectomy, epididymectomy, testicle, deferens, hemostats, electrocautery, "
 Ventriculoperitoneal shunt revision with replacement of ventricular catheter and flushing of the distal end., Surgery, Shunt Revision - 3 ,"PREOPERATIVE DIAGNOSIS:,  Blocked ventriculoperitoneal shunt.,POSTOPERATIVE DIAGNOSIS:,  Blocked ventriculoperitoneal shunt.,PROCEDURE: , Ventriculoperitoneal shunt revision with replacement of ventricular catheter and flushing of the distal end.,ANESTHESIA: , General.,HISTORY: , The patient is nonverbal.  He is almost 3 years old.  He presented with 2 months of irritability, vomiting, and increasing seizures.  CT scan was not conclusive, but shuntogram shows no flow through the shunt.,DESCRIPTION OF PROCEDURE: , After induction of general anesthesia, the patient was placed supine on the operating room table with his head turned to the left.  Scalp was clipped.  He was prepped on the head, neck, chest and abdomen with ChloraPrep.  Incisions were infiltrated with 0.5% Xylocaine with epinephrine 1:200,000.  He received oxacillin.,He was then reprepped and draped in a sterile manner.,The frontal incision was reopened and extended along the valve.  Subcutaneous sharp dissection with Bovie cautery was done to expose the shunt parts.  I separated the ventricular catheter from the valve, and this was a medium pressure small contour Medtronic valve.  There was some flow from the ventricular catheter, but not as much as I would expect.  I removed the right-angled clip with a curette and then pulled out the ventricular catheter, and there was gushing of CSF under high pressure.  So, I do believe that the catheter was obstructed, although inspection of the old catheter holes did not show any specific obstructions.  A new Codman BACTISEAL catheter was placed through the same hole.  I replaced it several times because I wanted to be sure it was in the cavity.  It entered easily and there was still just intermittent flow of CSF.  The catheter irrigated very well and seemed to be patent.,I tested the distal system with an irrigation filled feeding tube, and there was excellent flow through the distal valve and catheter.  So I did not think it was necessary to replace those at this time.  The new catheter was trimmed to a total length of 8 cm and attached to the proximal end of the valve.  The valve connection was secured to the pericranium with a #2-0 Ethibond suture.  The wound was irrigated with bacitracin irrigation.  The shunt pumped and refilled well.  The wound was then closed with #4-0 Vicryl interrupted galeal suture and Steri-Strips on the skin.  It was uncertain whether this will correct the problem or not, but we will continue to evaluate.  If his abdominal pressure is too high, then he may need a different valve.  This will be determined over time, but at this time, the shunt seemed to empty and refill easily.  The patient tolerated the procedure well.  No complications.  Sponge and needle counts were correct.  Blood loss was minimal.  None replaced.","surgery, bactiseal, bactiseal catheter, codman bactiseal, blocked ventriculoperitoneal shunt, ventriculoperitoneal shunt revision, ventricular catheter, shunt revision, ventriculoperitoneal shunt, catheter, ventriculoperitoneal, ventricular, shunt"
" Right shockwave lithotripsy, cystoscopy, and stent removal x2.", Surgery, Shockwave Lithotripsy ,"PREOPERATIVE DIAGNOSIS:,  Right renal stone.,POSTOPERATIVE DIAGNOSIS:  ,Right renal stone.,PROCEDURE: , Right shockwave lithotripsy, cystoscopy, and stent removal x2.,ANESTHESIA: , LMA.,ESTIMATED BLOOD LOSS:,  Minimal.  The patient was given antibiotics preoperatively.,HISTORY: , This is a 47-year-old male who presented with right renal stone and right UPJ stone.  The right UPJ stone was removed using ureteroscopy and laser lithotripsy and the stone in the kidney.  The plan was for shockwave lithotripsy.  The patient had duplicated system on the right side.  Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE was discussed.  Options such as watchful waiting, passing the stone on its own, and shockwave lithotripsy were discussed.  The patient wanted to proceed with the shockwave to break the stone into small pieces as possible to allow the stones to pass easily.  Consent was obtained.,DETAILS OF THE OPERATION:  ,The patient was brought to the OR.  Anesthesia was applied.  The patient was placed in the supine position.  Using Dornier lithotriptor total of 2500 shocks were applied.  Energy levels were slowly started at O2 increased up to 7; gradually the stone seem to have broken into smaller pieces as the number of shocks went up.  The shocks were started at 60 per minute and slowly increased up to 90 per minute.  The patient's heart rate and blood pressure were stable throughout the entire procedure.,After the end of the shockwave lithotripsy the patient was placed in dorsal lithotomy position.  The patient was prepped and draped in usual sterile fashion and cystoscopy was done.  Using graspers, the stent was grasped x2 and pulled out, both stents were removed.  The patient tolerated the procedure well.  The patient was brought to recovery in stable condition.  The plan was for the patient to follow up with us and plan for KUB in about two to three months.","surgery, renal stone, stent removal, upj stone, shockwave lithotripsy, cystoscopy, stent, renal, shocks, upj, shockwave, lithotripsy, stone"
 Endoscopic proximal and distal shunt revision with removal of old valve and insertion of new., Surgery, Shunt Revision - 2 ,"PREOPERATIVE DIAGNOSIS: , Shunt malfunction.,POSTOPERATIVE DIAGNOSIS: , Partial proximal obstruction, patent distal system.,TITLE OF OPERATION: , Endoscopic proximal and distal shunt revision with removal of old valve and insertion of new.,SPECIMENS:  ,None.,COMPLICATIONS:,  None.,ANESTHESIA:,  General.,SKIN PREPARATION:  ,Chloraprep.,INDICATIONS FOR OPERATION: , Headaches, irritability, slight increase in ventricle size.  Preoperatively patient improved with Diamox.,BRIEF NARRATIVE OF OPERATIVE PROCEDURE: , After satisfactory general endotracheal tube anesthesia was administered, the patient was positioned on the operating table in the supine position with the head rotated towards the left.  The right frontal area and right retroauricular area was shaved and then the head, neck, chest and abdomen were prepped and draped out in the routine manner.  The old scalp incision was opened with a Colorado needle tip and the old catheter was identified as we took the Colorado needle tip over the existing ventricular catheter, right over the sleeve on top of it and when that was entered, the CSF poured out around the ventricular catheter.  The ventricular catheter was then disconnected from the reservoir and endoscopically explored.  We saw it was blocked up proximally.  The catheter was a little adherent and required some freeing up with coagulation and on twisting of the ventricular catheter, I was able to free up the ventricular catheter, and endoscopically inserted a new Bactiseal ventricular catheter.  The catheter went down to the septum and I could see both the right and left lateral ventricles and elected to pass it into the right lateral ventricle.  It irrigated out well.  There was minimal amount of bleeding, but not significant.  The distal catheter system was tested.  There was good distal run off.  Therefore, a linear skin incision was made in the retroauricular area.  Tunneling was performed between the two incisions and a ProGAV valve set to an opening pressure of 10 with a 1-5 shunt assist was brought through the subgaleal tissue, connected to the distal catheter and a flushing reservoir was interposed between the burr hole site ventricular catheter and the ProGAV valve.  All connections were secured with 2-0 Ethibond sutures.  Careful attention was made to make sure that the ProGAV was in the right orientation.  The wounds were irrigated out with Bacitracin, closed in a routine manner using Vicryl for the deep layers and Monocryl for the skin, followed by Mastisol and Steri-Strips.  The patient tolerated the procedure well.  He was awakened, extubated and taken to recovery room in satisfactory condition.","surgery, chloraprep, distal shunt revision, colorado needle tip, colorado needle, progav valve, shunt revision, ventricular catheter, catheter, shunt, ventricular,"
" Right shoulder hemi-resurfacing using a size 5 Biomet Copeland humeral head component, noncemented.  Severe degenerative joint disease of the right shoulder.", Surgery, Shoulder Hemi-resurfacing ,"PREOPERATIVE DIAGNOSIS: , Severe degenerative joint disease of the right shoulder.,POSTOPERATIVE DIAGNOSIS:,  Severe degenerative joint disease of the right shoulder.,PROCEDURE: , Right shoulder hemi-resurfacing using a size 5 Biomet Copeland humeral head component, noncemented.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,COMPLICATIONS:,  None.  The patient was taken to Postanesthesia Care Unit in stable condition.  The patient tolerated the procedure well.,INDICATIONS: , The patient is a 55-year-old female who has had increased pain in to her right shoulder.  X-rays as well as an MRI showed a severe arthritic presentation of the humeral head with mild arthrosis of the glenoid.  She had an intact rotator cuff being at a young age and with potential of glenoid thus it was felt that a hemi-resurfacing was appropriate for her right shoulder focusing in the humeral head.  All risks, benefits, expectations and complications of surgery were explained to her in detail including nerve and vessel damage, infection, potential for hardware failure, the need for revision surgery with potential of some problems even with surgical intervention.  The patient still wanted to proceed forward with surgical intervention.  The patient did receive 1 g of Ancef preoperatively.,PROCEDURE: , The patient was taken to the operating suite, placed in supine position on the operating table.  The Department of anesthesia administered a general endotracheal anesthetic, which the patient tolerated well.  The patient was moved to a beach chair position.  All extremities were well padded.  Her head was well padded to the table.  Her right upper extremity was draped in sterile fashion.  A saber incision was made from the coracoid down to the axilla.  Skin was incised down to the subcutaneous tissue, the cephalic vein was retracted as well as all neurovascular structures were retracted in the case.  Dissecting through the deltopectoral groove, the subscapularis tendon was found as well as the bicipital tendon, 1 finger breadth medial to the bicipital tendon an incision was made.  Subscapularis tendon was released.  The humeral head was brought in to; there were large osteophytes that were removed with an osteotome.  The glenoid then was evaluated and noted to just have mild arthrosis, but there was no need for surgical intervention in this region.  A sizer was placed.  It was felt that size 5 was appropriate for this patient, after which the guide was used to place the stem and pin.  This was placed, after which a reamer was placed along the humeral head and reamed to a size 5.  All extra osteophytes were excised.  The supraspinatus and infraspinatus tendons were intact.  Next, the excess bone was removed and irrigated after which reaming of the central portion of the humeral head was performed of which a trial was placed and showed that there was adequate fit and appropriate fixation.  The arm had excellent range of motion.  There are no signs of gross dislocation.  Drill holes were made into the humeral head after which a size 5 Copeland hemi-resurfacing component was placed into the humeral head, kept down in appropriate position, had excellent fixation into the humeral head.  Excess bone that had been reamed was placed into the Copeland metal component, after which this was tapped into position.  After which the wound site was copiously irrigated with saline and antibiotics and the humeral head was reduced and taken through range of motion; had adequate range of motion, full internal and external rotation as well as forward flexion and abduction.  There was no gross sign of dislocation.  Wound site once again it was copiously irrigated with saline antibiotics.  The subscapularis tendon was approximated back into position with #2 Ethibond after which the bicipital tendon did have significant tear to it; therefore it was tenodesed in to the pectoralis major tendon.  After which, the wound site again was irrigated with saline antibiotics after which subcutaneous tissue was approximated with 2-0 Vicryl.  The skin was closed with staples.  A sterile dressing was placed.  The patient was awakened from general anesthetic and transferred to hospital gurney to the postanesthesia care unit in stable condition.","surgery, degenerative joint disease, hemi-resurfacing, biomet copeland, shoulder hemi resurfacing, humeral, head, degenerative, glenoid, subscapularis, antibiotics, resurfacing, tendon, shoulder,"
 Endoscopic proximal shunt revision., Surgery, Shunt Revision - 1 ,"PREOPERATIVE DIAGNOSIS: , Shunt malfunction.  The patient with a ventriculoatrial shunt.,POSTOPERATIVE DIAGNOSIS:,  Shunt malfunction.  The patient with a ventriculoatrial shunt.,ANESTHESIA: , General endotracheal tube anesthesia.,INDICATIONS FOR OPERATION: , Headaches, fluid accumulating along shunt tract.,FINDINGS: , Partial proximal shunt obstruction.,TITLE OF OPERATION:,  Endoscopic proximal shunt revision.,SPECIMENS: , None.,COMPLICATIONS:,  None.,DEVICES: , Portnoy ventricular catheter.,OPERATIVE PROCEDURE:,  After satisfactory general endotracheal tube anesthesia was administered, the patient positioned on the operating table in supine position with the right frontal area shaved and the head was prepped and draped in a routine manner.  The old right frontal scalp incision was reopened in a curvilinear manner, and the Bactiseal ventricular catheter was identified as it went into the right frontal horn.  The distal end of the VA shunt was flushed and tested with heparinized saline, found to be patent, and it was then clamped.  Endoscopically, the proximal end was explored and we found debris within the lumen, and then we were able to freely move the catheter around.  We could see along the tract that the tip of the catheter had gone into the surrounding tissue and appeared to have prongs or extensions in the tract, which were going into the catheter consistent with partial proximal obstruction.  A Portnoy ventricular catheter was endoscopically introduced and then the endoscope was bend so that the catheter tip did not go into the same location where it was before, but would take a gentle curve going into the right lateral ventricle.  It flushed in quite well, was left at about 6.5 cm to 7 cm and connected to the existing straight connector and secured with 2-0 Ethibond sutures.  The wounds were irrigated out with Bacitracin and closed in a routine manner using two 3-0 Vicryl for the galea and a 4-0 running Monocryl for the scalp followed by Mastisol and Steri-Strips.  The patient was awakened and extubated having tolerated the procedure well without complications.  It should be noted that the when we were irrigating through the ventricular catheter, fluid easily came out around the catheter indicating that the patient had partial proximal obstruction so that we could probably flow around the old shunt tract and perhaps this was leading to some of the symptomatology or findings of fluid along the chest.","surgery, ventriculoatrial shunt, endoscopic proximal shunt revision, endoscopic proximal shunt, portnoy ventricular catheter, shunt malfunction, shunt revision, ventricular catheter, shunt, endoscopic, ventricular, proximal, catheter,"
 Bilateral endoscopic proximal shunt revision and a distal shunt revision., Surgery, Shunt Revision ,"TITLE OF OPERATION:,  Bilateral endoscopic proximal shunt revision and a distal shunt revision.,INDICATIONS FOR OPERATION:,  Headaches, full subtemporal site.,PREOPERATIVE DIAGNOSIS: , Slit ventricle syndrome.,POSTOPERATIVE DIAGNOSIS: , Slit ventricle syndrome.,FINDINGS:,  Coaptation of ventricles against proximal end of ventricular catheter.,ANESTHESIA: , General endotracheal tube anesthesia.,DEVICES: , A Codman Hakim programmable valve with Portnoy ventricular catheter, a 0/20 proGAV valve with a shunt assist of 20 cm dual right-angled connector, and a flushing reservoir.,BRIEF NARRATIVE OF OPERATIVE PROCEDURE:,  After satisfactory general endotracheal tube anesthesia was administered, the patient was positioned on the operating table in the prone position with the head held on a soft foam padding.  The occipital area was shaven bilaterally and then the areas of the prior scalp incisions were infiltrated with 0.25% Marcaine with 1:200,000 epinephrine after routine prepping and draping.  Both U-shaped scalp incisions were opened exposing both the left and the right ventricular catheters as well as the old low pressure reservoir, which might have been leading to the coaptation of the ventricles.  The patient also had a right subtemporal depression, which was full preoperatively.  The entire old apparatus was dissected out.  We then cut both the ventricular catheters and secured them with sutures so that __________ could be inserted.  They were both inspected.  No definite debris were seen.  After removing the ventricular catheters, the old tracts were inspected and we could see where there was coaptation of the ventricles against the ventricular catheter.  On the right side, we elected to insert the Portnoy ventricular catheter and on the left a new Bactiseal catheter was inserted underneath the corpus callosum in a different location.  The old valve was dissected out and the proGAV valve with a 2-0 shunt assist was inserted and secured with a 2-0 Ethibond suture.  The proGAV valve was then connected to a Bactiseal distal tubing, which was looped in a cephalad way and then curved towards the left burr hole site and then the Portnoy catheter on the right was secured with a right-angled sleeve and then interposed between it and the left burr hole site with a flushing reservoir.  All connections secured with 2-0 Ethibond suture and a small piece of Bactiseal tubing between the flushing reservoir and the connector, which secured the left Bactiseal tubing to the two other Bactiseal tubings one being the distal Bactiseal tubing going towards the proGAV valve, which was set to an opening pressure of 8 and the other one being the Bactiseal tubing, which was going towards the flushing reservoir.,All the wounds were irrigated out with bacitracin and then closed in a routine manner using Vicryl for the deep layers and Monocryl for the skin, followed by Mastisol and Steri-Strips.  The patient tolerated the procedure well without complications.  CSF was not sent off.","surgery, codman hakim, portnoy, slit ventricle syndrome, shunt revision, bilateral endoscopic proximal shunt, coaptation of the ventricles, portnoy ventricular catheter, ventricular catheter, progav valve, flushing reservoir, bactiseal tubing, shunt, ventricular, bactiseal"
" Sigmoidoscopy performed for evaluation of anemia, gastrointestinal Bleeding.", Surgery, Sigmoidoscopy - 1 ,"PROCEDURE: , Sigmoidoscopy.,INDICATIONS:,  Performed for evaluation of anemia, gastrointestinal Bleeding.,MEDICATIONS: , Fentanyl (Sublazine) 0.1 mg IV Versed (midazolam) 1 mg IV,BIOPSIES: , No BRUSHINGS:,PROCEDURE:,  A history and physical examination were performed.  The procedure, indications, potential complications (bleeding, perforation, infection, adverse medication reaction), and alternative available were explained to the patient who appeared to understand and indicated this.  Opportunity for questions was provided and informed consent obtained.  After placing the patient in the left lateral decubitus position, the sigmoidoscope was inserted into the rectum and under direct visualization advanced to 25 cm.  Careful inspection was made as the sigmoidoscope was withdrawn.  The quality of the prep was good.  The procedure was stopped due to patient discomfort.  The patient otherwise tolerated the procedure well.  There were no complications.,FINDINGS: , Was unable to pass scope beyond 25 cm because of stricture vs very short bends secondary to multiple previous surgeries.  Retroflexed examination of the rectum revealed small hemorrhoids.  External hemorrhoids were found.  Other than the findings noted above, the visualized colonic segments were normal.,IMPRESSION: , Internal hemorrhoids  External hemorrhoids  Unable to pass scope beyond 25 cm due either to stricture or very sharp bend secondary to multiple surgeries.  Unsuccessful Sigmoidoscopy.  Otherwise Normal Sigmoidoscopy to 25 cm.  External hemorrhoids were found.","surgery, gastrointestinal bleeding, gastrointestinal, sigmoidoscope, rectum, anemia, bleeding, sigmoidoscopy, hemorrhoids,"
  Insertion of a #8 Shiley tracheostomy tube.  A #10-blade scalpel was used to make an incision approximately 1 fingerbreadth above the sternal notch.  Dissection was carried down using Bovie electrocautery to the level of the trachea., Surgery, Shiley Tracheostomy Tube Insertion ,"OPERATION: , Insertion of a #8 Shiley tracheostomy tube.,ANESTHESIA: , General endotracheal anesthesia.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient's family, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered.,Next, a #10-blade scalpel was used to make an incision approximately 1 fingerbreadth above the sternal notch.  Dissection was carried down using Bovie electrocautery to the level of the trachea.  The 2nd tracheal ring was identified.  Next, a #11-blade scalpel was used to make a trap door in the trachea.  The endotracheal tube was backed out.  A #8 Shiley tracheostomy tube was inserted, and tidal CO2 was confirmed when it was connected to the circuit.  We then secured it in place using 0 silk suture.  A sterile dressing was applied.  The patient tolerated the procedure well.","surgery, tracheostomy, shiley tracheostomy tube, sternal notch, bovie electrocautery, tracheostomy tube, electrocautery, endotracheal, shiley, tube,"
" Excision of sebaceous cyst, right lateral eyebrow.", Surgery, Sebaceous Cyst Excision ,"PREOPERATIVE DIAGNOSIS: , Sebaceous cyst, right lateral eyebrow.,POSTOPERATIVE DIAGNOSIS:,  Sebaceous cyst, right lateral eyebrow.,PROCEDURE PERFORMED: , Excision of sebaceous cyst, right lateral eyebrow.,ASSISTANT: , None.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,ANESTHESIA: , General endotracheal anesthesia.,CONDITION OF THE PATIENT AT THE END OF THE PROCEDURE: , Stable.  Transferred to the recovery room.,INDICATIONS FOR PROCEDURE: , The patient is a 4-year-old with a history of sebaceous cyst.  The patient is undergoing PE tubes by Dr. X and I was asked to remove the cyst on the right lateral eyebrow.  I saw the patient in my clinic.  I explained to the mother in Spanish the risk and benefits.  Risk included but not limited to risk of bleeding, infection, dehiscence, scarring, need for future revision surgery.  We will proceed with the surgery.,PROCEDURE IN DETAIL: , The patient was taken into the operating room, placed in the supine position.  General anesthetic was administered.  A prophylactic dose of antibiotic was given.  The patient was prepped and draped in a usual manner.  The procedure began by infiltrating lidocaine with epinephrine around the cyst area.  Then, I proceeded with the help of a 15C blade to make an incision and remove a small wedge of tissue that includes a comedo point.  The incision was done superiorly then inferiorly to a full thickness and to the skin down to the cyst.  The cyst was detached of the surrounding structure with the help of blunt dissection.  Hemostasis was achieved with electrocautery.  The wound was closed with 5-0 Vicryl deep dermal interrupted stitches and Dermabond.  The patient tolerated the procedure well without complications and transferred to recovery room in stable condition.  I was present and participated in all aspects of the procedure.  Sponge, needle, and instrument counts were completed at the end of the procedure.","surgery, lateral eyebrow, excision of sebaceous cyst, sebaceous cyst, cyst, eyebrow, sebaceous,"
 Open septorhinoplasty with placement of bilateral spreader grafts.  Bilateral lateral osteotomies., Surgery, Septorhinoplasty ,"PREOPERATIVE DIAGNOSIS: , Acquired nasal septal deformity.,POSTOPERATIVE DIAGNOSIS: , Acquired nasal septal deformity.,PROCEDURES:,1.  Open septorhinoplasty with placement of bilateral spreader grafts.,2.  Placement of a radiated rib tip graft.,3.  Placement of a morcellized autogenous cartilage dorsal onlay graft.,4.  Placement of endogen, radiated collagen dorsal onlay graft.,5.  Placement of autogenous cartilage columellar strut graft.,6.  Bilateral lateral osteotomies.,7.  Takedown of the dorsal hump with repair of the bony and cartilaginous open roof deformities.,8.  Fracture of right upper lateral cartilage.,ANESTHESIA:  ,General endotracheal tube anesthesia.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:  ,100 mL.,URINE OUTPUT:,  Not recorded.,SPECIMENS:,  None.,DRAINS: , None.,FINDINGS:  ,1.  The patient had a marked dorsal hump, which was both bony and cartilaginous in nature.,2.  The patient had marked hypertrophy of his nasalis muscle bilaterally contributing to the soft tissue dorsal hump.,3.  The patient had a C-shaped deformity to the left before he had tip ptosis.,INDICATIONS FOR PROCEDURE: , The patient is a 22-year-old Hispanic male who is status post blunt trauma to the nose approximately 9 months with the second episode 2 weeks following and suffered a marked dorsal deformity.  The patient was evaluated, but did not complain of nasal obstruction, and his main complaint was his cosmetic deformity.  He was found to have a C-shaped deformity to the left as well as some tip ptosis.  The patient was recommended to undergo an open septorhinoplasty to repair of this cosmetic defect.,OPERATION IN DETAIL: , After obtaining a full consent from the patient, identified the patient, prepped with Betadine, brought to the operating room and placed in the supine position on the operating table.  The appropriate Esmarch was placed; and after adequate sedation, the patient was subsequently intubated without difficulty.  The endotracheal tube was then secured, and the table was then turned clockwise to 90 degrees.  Three Afrin-soaked cottonoids were then placed in nasal cavity bilaterally.  The septum was then injected with 3 mL of 1% lidocaine with 1:100,000 epinephrine in the subperichondrial plane bilaterally.  Then, 50 additional mL of 1% lidocaine with 1:100,000 epinephrine was then injected into the nose in preparation for an open rhinoplasty.,Procedure was begun by first marking a columellar incision.  This incision was made using a #15 blade.  A lateral transfixion incision was then made bilaterally using a #15 blade, and then, the columellar incision was completed using iris scissors with care not to injure the medial crura.  However, there was a dissection injury to the left medial crura.  Dissection was then taken in the subperichondrial plane over the lower lateral cartilages and then on to the upper lateral cartilage.  Once we reached the nasal bone, a Freer was used to elevate the tissue overlying the nasal bone in a subperiosteal fashion.  Once we had completed exposure of the bony cartilaginous structures, we appreciated a very large dorsal hump, which was made up of both a cartilaginous and bony portions.  There was also an obvious fracture of the right upper lateral cartilage.  There was also marked hypertrophy what appeared to be in the nasalis muscle in the area of the dorsal hump.  The skin was contributing to the patient's cosmetic deformity.  In addition, we noted what appeared to be a small mucocele coming from the area of the fractured cartilage on the right upper lateral cartilage.  This mucocele was attempted to be dissected free, most of which was removed via dissection.  We then proceeded to remove takedown of the dorsal hump using a Rubin osteotome.  The dorsal hump was taken down and passed off the table.  Examination of the specimen revealed the marking amount of scar tissue at the junction of the bone and cartilage.  This was passed off to use later for possible onlay grafts.  There was now a marked open roof deformity of the cartilage and bony sprue.  A septoplasty was then performed throughout and a Kelly incision on the right side.  Subperichondrial planes were elevated on the right side, and then, a cartilage was incised using a caudal and subperichondrial plane elevated on the left side.  A 2 x 3-cm piece of the cardinal cartilage was then removed with care to leave at least 1 cm dorsal and caudal septal strut.  This cartilage was passed down the table and then 2 columellar strut grafts measuring approximately 15 mm in length were then used and placed to close the bony and cartilaginous open roof deformities.  The spreader grafts were sewn in place using three interrupted 5-0 PDS sutures placed in the horizontal fashion bilaterally.  Once these were placed, we then proceeded to work on the bony open roof.  Lateral osteotomies were made with 2-mm osteotomes bilaterally.  The nasal bones were then fashioned medially to close the open roof deformity, and this reduced the width of the bony nasal dorsum.  We then proceeded to the tip.  A cartilaginous strut was then fashioned from the cartilaginous septum.  It was approximately 15 mm long.  This was placed, and a pocket was just formed between the medial crura.  This pocket was taken down to the nasal spine, and then, the strut graft was placed.  The intradermal sutures were then placed using interrupted 5-0 PDS suture to help to provide more tip projection and definition.  The intradermal sutures were then placed to help to align the nasal tip.  The cartilage strut was then sutured in place to the medial crura after elevating the vestibular skin off the medial crura in the area of the plane suturing.  Prior to the intradermal suturing, the vestibular skin was also taken off in the area of the dome.,The columellar strut was then sutured in place using interrupted 5-0 PDS suture placed in a horizontal mattress fashion with care to help repair the left medial crural foot.  The patient had good tip support after this maneuver.  We then proceeded to repair the septal deformity created by taking down the dorsal hump with the Rubin osteotome.  This was done by crushing the remaining cartilage in the morcellizer and then wrapping this crushed cartilage in endogen, which is a radiated collagen.  The autogenous cartilage was wrapped in endogen in a sandwich fashion, and then, a 4-0 chromic suture was placed through this to help with placement of the dorsal onlay graft.,The dorsal onlay was then sewn into position, and then, the 4-0 chromic suture was brought out through this externally to help the superior placement of the dorsal onlay graft.  Once we were happy with the position of the dorsal onlay graft, the graft was then sutured in place using two interrupted 4-0 fast-absorbing sutures inferiorly just above the superior edge of the lower lateral cartilages.  Once we were happy with the placement of this, we did need to take down some of the bony dorsal hump laterally, and this was done using a #6 and then followed with a #3 push grafts.  This wrapping was performed prior to placement of the dorsal onlay graft.,I went through content with the dorsal onlay graft and the closure of the roof deformities as well as placement of the columellar strut, we then felt the patient could use a bit more tip projection; and therefore, we fashioned a radiated rib into a small octagon; and this was sutured in place over the tip using two interrupted 5-0 PDS sutures.,At this point, we were happy with the test results, although the patient did have significant amount of fullness in the dorsal hump area due to soft tissue thick and fullness.  There do not appear to be any other pathology causing the patient dorsal hump and therefore, we felt we have achieved the best cosmetic result at this point.  The septum was reapproximated using a fast-absorbing 4-0 suture and a Keith needle placed in the mattress fashion.  The Kelly incision was closed using two interrupted 4-0 fast-absorbing gut suture.  Doyle splints were then placed within the nasal cavity and secured to the inferior septum using a 3-0 monofilament suture.  The columellar skin was reapproximated using interrupted 6-0 nylon sutures, and the marginal incision of the vestibular skin was closed using interrupted 4-0 chromic sutures.,At the end of the procedure, all sponge, needle, and instrument counts were correct.  A Denver external splint was then applied.  The patient was awakened, extubated, and transported to Anesthesia Care Unit in good condition.",
" Left scrotal exploration with detorsion.  Already, de-torsed bilateral testes fixation and bilateral appendix testes cautery.", Surgery, Scrotal Exploration ,"PREOPERATIVE DIAGNOSIS: , Left testicular torsion, possibly detorsion.,POSTOPERATIVE DIAGNOSIS: , Left testicular torsion, possibly detorsion.,PROCEDURE: , Left scrotal exploration with detorsion.  Already, de-torsed bilateral testes fixation and bilateral appendix testes cautery.,ANESTHETIC:,  A 0.25% Marcaine local wound insufflation per surgeon, 15 mL of Toradol.,FINDINGS:,  Congestion in the left testis and cord with a bell-clapper deformity on the right small appendix testes bilaterally.  No testis necrosis.,ESTIMATED BLOOD LOSS:,  5 mL.,FLUIDS RECEIVED: , 300 mL of crystalloid.,TUBES AND DRAINS:,  None.,SPECIMENS: , No tissues sent to pathology.,COUNTS:,  Sponges and needle counts were correct x2.,INDICATIONS OF OPERATION: , The patient is a 4-year-old boy with abrupt onset of left testicular pain.  He has had a history of similar onset.  Apparently, he had no full on one ultrasound and full on a second ultrasound, but because of possible torsion, detorsion, or incomplete detorsion, I recommended an exploration.,DESCRIPTION OF OPERATION:,  The patient was taken to the operating room, where surgical consent, operative site, and patient identification was verified.  Once he was anesthetized, he was placed in supine position and sterilely prepped and draped.  Superior scrotal incisions were then made with 15-blade knife and further extended up to the subcutaneous tissue and dartos fascia with electrocautery.  Electrocautery was used for hemostasis.  The subdartos pouch was created with curved tenotomy scissors.  The tunica vaginalis was then delivered, incised, and testis was delivered.  The testis itself with a bell-clapper deformity.  There was no actual torsion at the present time, there was some modest congestion and, however, the vasculature was markedly congested down the cord.  The penis fascia was cauterized and subdartos pouch was created.  The upper aspect of fascia was then closed with pursestring suture of 4-0 chromic.  The testis was then placed into the scrotum in a proper orientation.  No tacking sutures within the testis itself were used.  The tunica vaginalis; however, was wrapped perfectly behind the back of the testis.  A similar procedure was performed on the right side.  Again, an appendix testis was cauterized.  No torsion was seen.  He also had a bell-clapper deformity and similar dartos pouch was created and the testis was placed in the scrotum in the proper orientation and the upper aspect closed with #4-0 chromic suture.  The local anesthetic was then used for both as cord block, as well as a local wound insufflation bilaterally with 0.25% Marcaine.  The scrotal wall was then closed with subcuticular closure of #4-0 chromic.  Dermabond tissue adhesive was then used.  The patient tolerated the procedure well.  He was given IV Toradol and was taken to the recovery room in stable condition.","surgery, de-torsed bilateral testes, testes fixation, bell clapper deformity, testicular torsion, subdartos pouch, tunica vaginalis, scrotal exploration, appendix testes, scrotal, testes, torsion, detorsion, insufflation, testis, "
 Scleral buckle opening under local anesthesia., Surgery, Scleral Buckle Opening - Local Anesthesia ,"PROCEDURE IN DETAIL:,  After appropriate operative consent was obtained, the patient was brought supine to the operating room and placed on the operating room table.  After intravenous sedation was administered a retrobulbar block consisting of 2% Xylocaine with 0.75% Marcaine and Wydase was administered to the right eye without difficulty.  The patient's right eye was prepped and draped in a sterile ophthalmic fashion and the procedure begun.  A wire lid speculum was inserted into the right eye and a 360-degree conjunctival peritomy was performed at the limbus.  The 4 rectus muscles were looped and isolated using 2-0 silk suture.  The retinal periphery was then inspected via indirect ophthalmoscopy.,","surgery, retinal periphery, ophthalmoscopy, scleral, buckle, operating, anesthesiaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" Selective coronary angiography, coronary angioplasty.  Acute non-ST-elevation MI.", Surgery, Selective Coronary Angiography & Angioplasty ,"PREOPERATIVE DIAGNOSIS AND INDICATIONS:,  Acute non-ST-elevation MI.,POSTOPERATIVE DIAGNOSIS AND SUMMARY:,  The patient presented with an acute non-ST-elevation MI.  Despite medical therapy, she continued to have intermittent angina.  Angiography demonstrated the severe LAD as the culprit lesion.  This was treated as noted above with angioplasty alone as the stent could not be safely advanced.  She has residual lesions of 75% in the proximal right coronary and 60% proximal circumflex, and the other residual LAD lesions as noted above.  She will be continued on her medical therapy.  At age 90, she is not a good candidate for aortic valve replacement and coronary bypass grafting.,PROCEDURE PERFORMED: , Selective coronary angiography, coronary angioplasty.,PROCEDURE IN DETAIL:,  After informed consent was obtained, the patient was taken to the cath lab, placed on the table in the supine position.  The area of the right femoral artery was prepped and draped in a sterile fashion.  Using the percutaneous technique, a 6-French sheath was placed in the right femoral artery under fluoroscopic guidance.  With the guidewire in place, a 5-French JL-4 catheter was used to selectively angiogram the left coronary system.  The catheter was removed.  The sheath flushed.  The 5-French 3DRC catheter was then used to selectively angiogram the right coronary artery.  The cath removed, the sheath flushed.,It was decided that intervention was needed in the severe lesions in the LAD, which appeared to be the culprit lesions for the non-ST elevation-MI.  The patient was given a bolus of heparin and an ACT of approximately 50 seconds was obtained, we rebolused and the ACT was slightly lower.  We repeated the level and it was slightly higher.  We administered 500 more units of heparin and then proceeded with an ACT of approximately 270 seconds prior to the 500 units of heparin IV.  Additionally, the patient had been given 300 mg of Plavix orally during the procedure and Integrilin IV bolus and then maintenance drip was started.,A 6-French CLS 3.5 left coronary guide catheter was used to cannulate the left main and HEW guidewire was positioned in the distal LAD and another HEW guidewire in the relatively large third diagonal.  An Apex 2.5 x 15 mm balloon was positioned in the distal portion of the mid LAD stenosis and inflated to 6 atmospheres for 15 seconds and then deflated.  Angiography was then performed, demonstrated marked improvement in the stenosis and this image was used for sizing the last of the needed stent.  The balloon was pulled more proximally and then inflated again at 6 atmospheres for approximately 20 seconds, with the proximal end of the balloon positioned distal to the origin of the third diagonal so as to not compromise the ostium.  The balloon was inflated and removed, repeat angiography performed.  We attempted to advance a Driver 2.5 x 24 mm bare metal stent, but I could not advance it beyond the proximal LAD, where there was significant calcification.  The stent was removed.  Attempts to advance the same 2.5 x 15 mm Apex balloon that was previously used were unsuccessful.  It was removed, a new Apex 2.5 x 15 mm balloon was then positioned in the proximal LAD and inflated to 6 atmospheres for 15 seconds and then deflated and advanced slightly with the distal tip of the balloon proximal to the third diagonal ostium and it was inflated to 6 atmospheres for 15 seconds and then deflated and removed.  Repeat angiography demonstrated no evidence of dissection.  One more attempt was made to advance the Driver 2.5 x 24 mm bare metal stent, but again I could not advance it beyond the calcified plaque in the proximal LAD and this was despite the presence of the buddy wire in the diagonal.  I felt that further attempts in this calcified vessel in a 90-year-old with severe aortic stenosis and severe aortic insufficiency would likely result in complications of dissection, so the stent was removed.  The guidewires and guide cath were removed.  The sheath flushed and sutured into position.  The patient moved to ICU in stable condition with no chest discomfort at all.,CONTRAST: , Isovue-370, 120 mL.,FLUORO TIME: , 9.4 minutes.,ESTIMATED BLOOD LOSS: , 30 mL.,HEMODYNAMICS:,  Aorta 185/54.,Left ventriculography was not performed.  I did not make an attempt to cross this severely stenotic aortic valve.,The left main is a large vessel, giving rise to LAD and circumflex vessels.  The left main has no significant disease other than calcification in the walls.,The LAD is a moderate-to-large vessel, giving rise to small diagonals and then a moderate-to-large third diagonal, and then a small fourth diagonal.  The LAD has significant calcification proximally.  There is a 50% stenosis between the first and second diagonals that we treated with angioplasty alone in an attempt to be able to advance the stent.  This resulted in a 30% residual, mostly eccentric calcified plaque.  Following this, there was a 50% stenosis in the LAD just after the takeoff of the third diagonal.  This was not ballooned.  Beyond this is an 80% stenosis prior to the fourth diagonal and then a 99% stenosis after the fourth diagonal.  These 2 lesions were dilated with 10% residual prior to the fourth diagonal and 25% residual distal to the fourth diagonal.  As noted above, this area was not stented because I could not safely advance the stent.  Note, there was also a 50% stenosis at the origin of the moderate-to-large third diagonal that did not change with angioplasty.,The circumflex is a large, nondominant vessel consisting of a large obtuse marginal with multiple branches.  The proximal circumflex has an eccentric 60% stenosis prior to the takeoff of the obtuse marginal.  The remainder of the vessel was without significant disease.,The right coronary was a large, dominant vessel giving rise to a large posterior descending artery and small-to-moderate first posterolateral, small second posterolateral, and a small-to-moderate third posterolateral branch.  The right coronary has an eccentric smooth 75% stenosis beginning about a centimeter after the origin of the vessel and prior to the acute marginal branch.  The remainder of the right coronary and its branches were without significant disease.","surgery, non-st-elevation mi, selective coronary angiography, coronary angioplasty, calcified plaque, coronary angiography, st elevation, stenosis, lad, coronary, selective, angiography, angioplasty, balloon, vessel, stent, "
" Revision septoplasty, repair of internal nasal valve collapse using auricular cartilage, repair of bilateral external nasal valve collapse using auricular cartilage, harvest of right auricular cartilage.", Surgery, Septoplasty ,"PREOPERATIVE DIAGNOSES:,1.  Nasal septal deviation.,2.  Bilateral internal nasal valve collapse.,3.  Bilateral external nasal valve collapse.,POSTOPERATIVE DIAGNOSES:,1.  Nasal septal deviation.,2.  Bilateral internal nasal valve collapse.,3.  Bilateral external nasal valve collapse.,PROCEDURES:,1.  Revision septoplasty.,2.  Repair of internal nasal valve collapse using auricular cartilage.,3.  Repair of bilateral external nasal valve collapse using auricular cartilage.,4.  Harvest of right auricular cartilage.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , Approximately 20 mL.,IV FLUIDS: , Include a liter of crystalloid fluid.,URINE OUTPUT: , None.,FINDINGS: , Include that of significantly deviated septum with postoperative changes and a significant septal spur along the floor.  There is also evidence of bilateral internal as well as external nasal valve collapse.,INDICATIONS:  ,The patient is a pleasant 49-year-old gentleman who had undergone a previous septorhinoplasty after significant trauma in his 20s.  He now presents with significant upper airway resistance and nasal obstruction and is unable to tolerate a CPAP machine.  Therefore, for repair of the above-mentioned deformities including the internal and external nasal valve collapse as well as straightening of the deviated septum, the risks and benefits of the procedure were discussed with him included but not limited to bleeding, infection, septal perforation, need for further surgeries, external deformity, and he desired to proceed with surgery.,DESCRIPTION OF THE PROCEDURE IN DETAIL:  ,The patient was taken to the operating room and laid supine upon the OR table.  After the induction of general endotracheal anesthesia, the nose was decongested using Afrin-soaked pledgets followed by the injection of % lidocaine with 1:100,000 epinephrine in the submucoperichondrial planes bilaterally.  Examination revealed significant deviation of the nasal septum and the bony cartilaginous junction as well as the large septal spur along the floor.  The caudal septum appeared to be now in adequate position.  There was evidence that there had been a previous caudal septal graft on the right nares and it was decided to leave this in place.  Following the evaluation of the nose, a hemitransfixion incision was made on the left revealing a large septal spur consisting primarily down on the floor of the left nostril creating nearly a picture of the vestibular stenosis on the side.  Very carefully, the mucoperichondrial flaps were elevated over this, and it was excised using an osteotome taking care to preserve the 1.5 cm dorsal and caudal strap of the nasal septum and keep it attached to the nasal spine.  Very carefully, the bony cartilaginous junction was identified and a small piece of the bone, where the spur was, was carefully removed.  Following this, it was noted that the cartilaginous region was satisfactory in quantity as well as quality to perform adequate grafting procedures.  Therefore, attention was turned to harvesting the right-sided auricular cartilage, which was done after the region had adequately been prepped and draped in a sterile fashion.  Postauricular incision using a #15 blade, the area of the submucoperichondrial plane was elevated in order to preserve the nice lining and identifiable portion of the cartilage taking care to preserve the ridge of the helix at all times.  This was very carefully harvested.  This area had been injected previously with 1% lidocaine and 1:100,000 epinephrine.  Following this, the cartilage was removed.  It was placed in saline, noted to be fashioned in the bilateral spreader graft and alar rim graft as well as a small piece of crush which was used to be placed along the top of the dorsal irregularity.  The spreader grafts were sutured in place using submucoperichondrial pockets.  After an external septorhinoplasty approach had been performed and reflection of the skin and soft tissue envelope had been performed, adequately revealing straight septum with significant narrowing with what appeared to be detached perhaps from his ipsilateral cartilages rather from his previous surgery.  These were secured in place in the pockets using a 5-0 PDS suture in a mattress fashion in two places.  Following this, attention was turned to placing the alar rim grafts where pockets were created along the caudal aspect of the lower lateral cartilage and just along the alar margin.  Subsequently, the alar rim grafts were placed and extended all the way to the piriform aperture.  This was sutured in place using a 5-0 self-absorbing gut suture.  The lower lateral cartilage has had some inherent asymmetry.  This may have been related to his previous surgery with some asymmetry of the dome; however, this was left in place as he did not desire any changes in the tip region, and there was adequate support.  An endodermal suture was placed just to reenforce the region using a 5-0 PDS suture.  Following all this, the area was closed using a mattress 4-0 plain gut on a Keith needle followed by the application of ***** 5-0 fast-absorbing gut to close the hemitransfixion incision.  Very carefully, the skin and subcutaneous tissue envelopes were reflected.  The curvilinear incision was closed using a Vicryl followed by interrupted 6-0 Prolene sutures.  The marginal incisions were then closed using 5-0 fast-absorbing gut.  Doyle splints were placed and secured down using a nylon suture.  They had ointment also placed on them.  Following this, nasopharynx was suctioned.  There were no further abnormalities noted and everything appeared to be in nice position.  Therefore, an external splint was placed after the application of Steri-Strips.  The patient tolerated the procedure well.  He was awakened in the operating room.  He was extubated and taken to the recovery room in stable condition.","surgery, nasal septal deviation, nasal septal, auricular cartilage, nasal, nasal obstruction, nasal valve, septoplasty, submucoperichondrial, upper airway, internal nasal valve, external nasal valve, hemitransfixion incision, revision septoplasty, septal spur, valve collapse, auricular, cartilage, collapse, septum, valve, "
" Placement of Scott cannula, right lateral ventricle", Surgery, Scott Cannula ,"PROCEDURE:, Placement of Scott cannula, right lateral ventricle.,DESCRIPTION OF THE OPERATION:, The right side of the head was shaved and the area was then prepped using Betadine prep. Following an injection with Xylocaine with epinephrine, a small 1.5 cm linear incision was made paralleling the midline, lateral to the midline, at the region of the coronal suture. A twist drill was made with the hand drill through the dura. A Scott cannula was placed on the first pass into the right lateral ventricle with egress initially of bloody and the clear CSF. The Scott cannula was secured to the skin using 3-0 silk sutures. This will be connected to external drainage set at 10 cm of water.","surgery, coronal suture, twist drill, lateral ventricle, csf, placement of scott cannula, scott cannula, scott, cannulaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Septoplasty with partial inferior middle turbinectomy with KTP laser, sinus endoscopy with maxillary antrostomies, removal of tissue, with septoplasty and partial ethmoidectomy bilaterally.", Surgery, Septoplasty & Turbinectomy ,"OPERATIVE DIAGNOSES: , Chronic sinusitis with deviated nasal septum and nasal obstruction and hypertrophied turbinates.,OPERATIONS PERFORMED: , Septoplasty with partial inferior middle turbinectomy with KTP laser, sinus endoscopy with maxillary antrostomies, removal of tissue, with septoplasty and partial ethmoidectomy bilaterally.,OPERATION: , The patient was taken to the operating room.  After adequate anesthesia via endotracheal intubation, the nose was prepped with Afrin nasal spray.  After this was done, 1% Xylocaine with 100,000 epinephrine was infiltrated in both sides of the septum and the mucoperichondrium.  After this, the sinus endoscope at 25-degrees was then used to examine the nasal cavity in the left nasal cavity and staying lateral to the middle turbinate.  A 45-degree forceps then used to open up the maxillary sinus.  There was some prominent tissue and just superior to this, the anterior ethmoid was opened.  The 45-degree forceps was then used to open the maxillary sinus ostium.  This was enlarged with backbiting rongeur.  After this was done, the tissue found in the ethmoid and maxillary sinus were removed and sent to pathology and labeled as left maxillary sinus mucosa.  After this was done, attention was then turned to the right nasal cavity staying laterally to the middle turbinate.  There was noted to have prominence in the anterior ethmoidal area.  This was then opened with 45-degree forceps.  This mucosa was then removed from the anterior area.  The maxillary sinus ostium was then opened with 45-degree forceps.  Tissue was removed from this area.  This was sent as right maxillary mucosa.  After this, the backbiting rongeur was then used to open up the ostium and enlarge the ostium on the right maxillary sinus.  Protecting the eyes with wet gauze and using KTP laser at 10 watts, the sinus endoscope was used for observation and the submucosal resection was done of both inferior turbinates as well as anterior portion of the middle turbinates bilaterally.  This was to open up to expose the maxillary ostium as well as other sinus ostium to minimize swelling and obstruction.  After this was completed, a septoplasty was performed.  The incision was made with a #15 blade Bard-Parker knife.  The flap was then elevated, overlying the spur that was protruding into the right nasal cavity.  This was excised with a #15 blade Bard-Parker knife.  The tissue was then laid back in position.  After this was laid back in position, the nasal cavity was irrigated with saline solution, suctioned well as well as the oropharynx.  , ,Surgicel with antibiotic ointment was placed in each nostril and sutured outside the nose with 3-0 nylon.  The patient was then awakened and taken to recovery room in good condition.","surgery, sinusitis, ktp laser, septoplasty, deviated, endoscopy, ethmoidectomy, hypertrophied, maxillary, nasal obstruction, nasal septum, sinus, turbinates, turbinectomy, partial ethmoidectomy, parker knife, sinus ostium, nasal cavity, maxillary sinus, ktp, mucosa, cavity, forceps, antrostomies, ostium, nasal"
" Repair of total anomalous pulmonary venous connection, ligation of patent ductus arteriosus, repair secundum type atrial septal defect (autologous pericardial patch), subtotal thymectomy, and insertion of peritoneal dialysis catheter.", Surgery, Septal Defect Repair ,"TITLE OF OPERATION:,1.  Repair of total anomalous pulmonary venous connection.,2.  Ligation of patent ductus arteriosus.,3.  Repair secundum type atrial septal defect (autologous pericardial patch).,4.  Subtotal thymectomy.,5.  Insertion of peritoneal dialysis catheter.,INDICATION FOR SURGERY: , This neonatal was diagnosed postnatally with total anomalous pulmonary venous connection.  Following initial stabilization, she was transferred to the Hospital for complete correction.,PREOP DIAGNOSIS:  ,1.  Total anomalous pulmonary venous connection.,2.  Atrial septal defect.,3.  Patent ductus arteriosus.,4.  Operative weight less than 4 kilograms (3.2 kilograms).,COMPLICATIONS: , None.,CROSS-CLAMP TIME: , 63 minutes.,CARDIOPULMONARY BYPASS TIME MONITOR:,  35 minutes, profound hypothermic circulatory arrest time (4 plus 19) equals 23 minutes.  Low flow perfusion 32 minutes.,FINDINGS:,  Horizontal pulmonary venous confluence with right upper and middle with two veins entering the confluence on the right and multiple entry sites for left-sided veins.  Large patulous anastomosis between posterior aspect of the left atrium and anterior aspect of the pulmonary venous confluence.  Nonobstructed ascending vein ligated.  Patent ductus arteriosus diminutive left atrium with posterior atrial septal defect with deficient inferior margin.  At completion of the procedure, right ventricular pressure approximating one-half of systemic, normal sinus rhythm, good biventricular function by visual inspection.,PROCEDURE: , After the informed consent, the patient was brought to the operating room and placed on the operating room table in supine position.  Upon induction of general endotracheal anesthesia and placement of indwelling arterial and venous monitoring lines.  The patient was prepped and draped in the usual sterile fashion from chin to groins.  A median sternotomy incision was performed.  Dissection was carried through the deeper planes until the sternum was scored and divided with an oscillating saw.  A subtotal thymectomy was performed.  Systemic heparinization was achieved and the pericardium was entered and fashioned until cradle.  A small portion of the anterior pericardium was procured and fixed in glutaraldehyde for patch closure of segment of the atrial septal defect during the procedure.  Pursestrings were deployed on the ascending aorta on the right.  Atrial appendage.  The aorta was then cannulated with an 8-French aorta cannula and the right atrium with an 18-French Polystan right-angle cannula.  With an ACT greater than 400, greater pulmonary bypass was commenced with excellent cardiac decompression and the patent ductus arteriosus was ligated with a 2-0 silk tie.  Systemic cooling was started and the head was packed  and iced and systemic steroids were administered.  During cooling, traction suture was placed in the apex of the left ventricle.  After 25 minutes of cooling, the aorta was cross-clamped and the heart arrested by administration of 30 cubic centimeter/kilogram of cold-blood cardioplegia delivered directly within the aortic root following the aorta cross-clamping.  Following successful cardioplegic arrest, a period of low flow perfusion was started and a 10-French catheter was inserted into the right atrial appendage substituting the 18-French Polystan venous cannula.  The heart was then rotated to the right side and the venous confluence was exposed.  It was incised and enlarged and a corresponding incision in the dorsal and posterior aspect of the left atrium was performed.  The two openings were then anastomosed in an end-to-side fashion with several interlocking sutures to avoid pursestring effect with a running 7-0 PDS suture.  Following completion of the anastomosis, the heart was returned into the chest and the patient's blood volume was drained into the reservoir.  A right atriotomy was then performed during the period of circulatory arrest.  The atrial septal defect was very difficult to expose, but it was sealed with an autologous pericardial patch was secured in place with a running 6-0 Prolene suture.  The usual deairing maneuvers were carried out and lining was administered and the right atriotomy was closed in two layers with a running 6-0 Prolene sutures.  The venous cannula was reinserted.  Cardiopulmonary bypass restarted and the aorta cross-clamp was released.  The patient returned to normal sinus rhythm spontaneously and started regaining satisfactory hemodynamics which, following a prolonged period of rewarming, allow for us to wean her from cardiopulmonary bypass successfully and moderate inotropic support and sinus rhythm.  Modified ultrafiltration was carried out and two sets of atrial and ventricular pacing wires were placed as well as the peritoneal dialysis catheter and two 15-French Blake drains.  Venous decannulation was followed by aortic decannulation and administration of protamine sulfate.  All cannulation sites were oversewn with 6-0 Prolene sutures and the anastomotic sites noticed to be hemostatic.  With good hemodynamics and hemostasis, the sternum was then smeared with vancomycin, placing closure with stainless steel wires.  The subcutaneous tissues were closed in layers with the reabsorbable monofilament sutures.  Sponge and needle counts were correct times 2 at the end of the procedure.  The patient was transferred in very stable condition to the pediatric intensive care unit .,I was the surgical attending present in the operating room and in charge of the surgical procedure throughout the entire length of the case.  Given the magnitude of the operation, the unavailability of an appropriate level, cardiac surgical resident, Mrs. X (attending pediatric cardiac surgery at the Hospital) participated during the cross-clamp time of the procedure in quality of first assistant.","surgery, total anomalous pulmonary venous connection, patent ductus arteriosus, ligation, secundum type atrial septal defect, atrial septal defect, subtotal thymectomy, peritoneal dialysis catheter, cross clamp, cardiopulmonary bypass, pulmonary venous, atrial septal, septal defect, anomalous, venous, atrial, arteriosus, patent, ductus, septal, aorta, pulmonary, "
" Removal of infected sebaceous cyst, right neck.", Surgery, Sebaceous Cyst Removal ,"PREOPERATIVE DIAGNOSIS:,  Infected sebaceous cyst, right neck.,POSTOPERATIVE DIAGNOSIS:,  Infected sebaceous cyst, right neck.,PROCEDURE: , The patient was electively taken to the operating room after obtaining an informed consent.  With a combination of intravenous sedation and local infiltration anesthesia, a time-out process was followed and then the patient was prepped and draped in the usual fashion.  The elliptical incision was performed around the draining tract.  Immediately we fell in to an abscess cavity with a lot of pus and necrotic tissue.  All the necrotic tissue was excised together with an ellipse of skin.  Hemostasis was achieved with a cautery.  The cavity was irrigated with normal saline.  At the end of procedure, there was a good size around cavity that was packed with iodoform gauze.  One skin suture was grazed for approximation.,A bulky dressing was applied.,The patient tolerated the procedure well.  Estimated blood loss was negligible and the patient was sent to Same Day Surgery for recovery.","surgery, infected sebaceous cyst, necrotic tissue, sebaceous cyst, infected"
" Skin biopsy, scalp mole.  Darkened mole status post punch biopsy, scalp lesion.  Rule out malignant melanoma with pulmonary metastasis.", Surgery, Scalp Mole Skin Biopsy ,"PROCEDURE: , Skin biopsy, scalp mole.,INDICATION:  ,A 66-year-old female with pulmonary pneumonia, effusion, rule out metastatic melanoma to lung.,PROCEDURE NOTE: , The patient's scalp hair was removed with:,1.  K-Y jelly.,2.  Betadine prep locally.,3.  A 1% lidocaine with epinephrine local instilled.,4.  A 3 mm punch biopsy used to obtain biopsy specimen, which was sent to the lab.  To control bleeding, two 4-0 P3 nylon sutures were applied, antibiotic ointment on the wound.  Hemostasis was controlled.  The patient tolerated the procedure.,IMPRESSION:,  Darkened mole status post punch biopsy, scalp lesion, rule out malignant melanoma with pulmonary metastasis.,PLAN: , The patient will have sutures removed in 10 days.","surgery, k-y jelly, darkened mole, scalp mole, skin biopsy, punch biopsy, melanoma,"
 Scleral buckle opening.  The 4 scleral quadrants were inspected and found to be free of scleral thinning or staphyloma., Surgery, Scleral Buckle Opening ,"SCLERAL BUCKLE OPENING,The patient was brought to the operating room and appropriately identified.  General anesthesia was induced by the anesthesiologist.  The patient was prepped and draped in the usual sterile fashion.  A lid speculum was used to provide exposure to the right eye.  A 360-degree limbal conjunctival peritomy was created with Westcott scissors.  Curved tenotomy scissors were used to enter each of the intermuscular quadrants.  The inferior rectus muscle was isolated with a muscle hook, freed of its Tenon's attachment and tied with a 2-0 silk suture.  The 3 other rectus muscles were isolated in a similar fashion.  The 4 scleral quadrants were inspected and found to be free of scleral thinning or staphyloma.","surgery, tenotomy, scleral quadrants, scleral thinning, scleral buckle, staphylomaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Ligation and stripping of left greater saphenous vein to the level of the knee.  Stripping of multiple left lower extremity varicose veins.  Varicose veins., Surgery, Saphenous Vein - Ligation & Stripping ,"PREOPERATIVE DIAGNOSIS:,  Varicose veins.,POSTOPERATIVE DIAGNOSIS: , Varicose veins.,PROCEDURE PERFORMED:,1.  Ligation and stripping of left greater saphenous vein to the level of the knee.,2.  Stripping of multiple left lower extremity varicose veins.,ANESTHESIA:,  General endotracheal.,ESTIMATED BLOOD LOSS: , Approximately 150 mL.,SPECIMENS: , Multiple veins.,COMPLICATIONS:,  None.,BRIEF HISTORY:,  This is a 30-year-old Caucasian male who presented for elective evaluation from Dr. X's office for evaluation of intractable pain from the left lower extremity.  The patient has had painful varicose veins for number of years.  He has failed conservative measures and has felt more aggressive treatment to alleviate his pain secondary to his varicose veins.  It was recommended that the patient undergo a saphenous vein ligation and stripping.  He was explained the risks, benefits, and complications of the procedure including intractable pain.  He gave informed consent to proceed.,OPERATIVE FINDINGS:,  The left greater saphenous vein femoral junction was identified and multiple tributaries were ligated surrounding this region.,The vein was stripped from the saphenofemoral junction to the level of the knee.  Multiple tributaries of the greater saphenous vein and varicose veins from the left lower extremity were ligated and stripped accordingly.  Additionally, there were noted to be multiple regions within these veins that were friable and edematous consistent with acute and chronic inflammatory changes making stripping of these varicose veins extremely difficult.,OPERATIVE PROCEDURE:  ,The patient was marked preoperatively in the Preanesthesia Care Unit.  The patient was brought to the operating suite, placed in the supine position.  The patient underwent general endotracheal intubation.  After adequate anesthesia was obtained, the left lower extremity was prepped and draped circumferentially from the foot all the way to the distal section of the left lower quadrant and just right of midline.  A diagonal incision was created in the direction of the inguinal crease on the left.  A self-retaining retractor was placed and the incision was carried down through the subcutaneous tissues until the greater saphenous vein was identified.  The vein was isolated with a right angle.  The vein was followed proximally until a multiple tributary branches were identified.  These were ligated with #3-0 silk suture.  The dissection was then carried to the femorosaphenous vein junction.  This was identified and #0 silk suture was placed proximally and distally and ligated in between.  The proximal suture was tied down.  Distal suture was retracted and a vein stripping device was placed within the greater saphenous vein.  An incision was created at the level of the knee.  The distal segment of the greater saphenous vein was identified and the left foot was encircled with #0 silk suture and tied proximally and then ligated.  The distal end of the vein stripping device was then passed through at its most proximal location.  The device was attached to the vein stripping section and the greater saphenous vein was then stripped free from its canal within the left lower extremity.  Next, attention was made towards the multiple tributaries of the varicose vein within the left lower leg.  Multiple incisions were created with a #15 blade scalpel.  The incisions were carried down with electrocautery.  Next, utilizing sharp dissection with a hemostat, the tissue was spread until the vein was identified.  The vein was then followed to T3 and in all these locations intersecting segments of varicose veins were identified and removed.  Additionally, some segments were removed.  The stripping approach would be vein stripping device.  Multiple branches of the saphenous vein were then ligated and/or removed.  Occasionally, dissection was unable to be performed as the vein was too friable and would tear from the hemostat.  Bleeding was controlled with direct pressure.  All incisions were then closed with interrupted #3-0 Vicryl sutures and/or #4-0 Vicryl sutures.,The femoral incision was closed with interrupted multiple #3-0 Vicryl sutures and closed with a running #4-0 subcuticular suture.  The leg was then cleaned, dried, and then Steri-Strips were placed over the incisions.  The leg was then wrapped with a sterile Kerlix.  Once the Kerlix was achieved, an Ace wrap was placed over the left lower extremity for compression.  The patient tolerated the procedure well and was transferred to Postanesthesia Care Unit extubated in stable condition.  He will undergo evaluation postoperatively and will be seen shortly in the postanesthesia care unit.","surgery, varicose veins, saphenous vein, stripping, ligation, vein stripping, lower extremity, saphenous, varicose, vein, ligated, "
 Scarf bunionectomy procedure of the first metatarsal of the left foot.  Hallux abductovalgus deformity with bunion of the left foot., Surgery, Scarf Bunionectomy ,"PREOPERATIVE DIAGNOSIS: , Hallux abductovalgus deformity with bunion of the left foot.,POSTOPERATIVE DIAGNOSIS: , Hallux abductovalgus deformity with bunion of the left foot.,PROCEDURE PERFORMED: , Scarf bunionectomy procedure of the first metatarsal of the left foot.,ANESTHESIA:,  IV sedation with local.,HISTORY: , This patient is a 55-year-old female who presents to ABCD preoperative holding area after keeping herself n.p.o., since mid night for surgery for her painful left bunion.  The patient has had increasing pain over time and is having difficulty ambulating and wearing shoes.  The patient has failed to conservative treatment and desires surgical correction at this time.  Risks versus benefits of the procedure have been explained in detail by Dr. X, and consent is available on the chart for review.,PROCEDURE IN DETAIL:,  After an IV established by the Department of Anesthesia, the patient was given preoperatively 600 mg of clindamycin intravenously.  The patient was then taken to the Operating Suite via cart and was placed on the operating table in a supine position and a safety strap was placed across her waist for protection.  Next, a pneumatic ankle tourniquet was applied over her left ankle with copious amounts of Webril for the patient's protection.  After adequate IV sedation was applied, the patient was given a local injection consisting of 17 cc of 4.5 cc 1% lidocaine plain, 4.5 cc of 0.5% Marcaine plain, and 1.0 cc of Solu-Medrol mixture in the standard Mayo block to the left foot.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was then elevated, the Esmarch was applied and the tourniquet was inflated to 250 mmHg.  The foot was then lowered to the operating field.,A sterile stockinet was reflected and the attention was directed to the first metatarsophalangeal joint of the left foot.  After sufficient anesthesia, using a #10 blade a linear incision was made approximately 5 to 6 cm in length over the first metatarsophalangeal joint dorsally, just near to the extensor hallucis longus tendon.  Then using a fresh #15 blade, this incision was deepened through the skin into the subcutaneous layer after all small traversing veins were ligated and cauterized with electrocautery.  A neurovascular bundle was identified and reflected medially.  Laterally the extensor hallucis longus tendon was identified and protected with retraction as well.  Care was then taken to undermine the medial and lateral margins of the first metatarsophalangeal joint carefully.  The first metatarsophalangeal joint capsule was then identified and using a #15 blade, a linear incision made down to the bone through the joint capsule.  The periosteum was reflected and elevated off of its bone and the metatarsal head as well as the base of the proximal phalanx to a small degree.  Noted was a large hypertrophic bone spur on the dorsal medial aspect of the first metatarsal head as well as some small osteophytes along the medial portion of the proximal phalanx.  Care was then taken to reflect and dissect the periosteum off of the shaft of the first metatarsal proximally into the proximal portion of the metatarsal close to the first metatarsocuneiform joint.  The bone cortex was noted to be intact and in good condition.  Following this, using a sagittal saw with a #138 blade, the attention was directed to the medial hypertrophic bone of the first metatarsal head.  In the sagittal plane with the blade angulated from dorsolateral to proximal medial, the medial eminence of bone was resected.  Plantarly it was noted that the tibial sesamoid groove was intact and the sesamoid apparatus was intact as well.  Following this bone cut, 0.45 K-wire was inserted from medial to lateral through the medial portion of the first metatarsal head directed in the dorsal third of the metatarsal head.  Then using the Reese osteotomy guide, the guide was directed from the distal portion of the metatarsal head proximally to the proximal portion of the first metatarsal.  A second 0.45 K-wire was inserted proximally as well.  Following this, using the sagittal saw with the #138 blade a transverse linear osteotomy cut was made through the first metatarsal from medial to lateral.  After reaching the distal as well as the proximal portions of the bone and ensuring that cortex was cut on both the medial as well as lateral side, the Reese osteotomy guide was removed and the dorsal and plantar incision cuts were made.  This began with the dorsal distal cut, which extended from medial to lateral with the dorsal portion of the blade angled proximally about five degrees through the dorsal third of the distal first metatarsal.  Following this, attention was directed proximally and an incision osteotomy cut through the bone was made, directed medially to laterally with the inferior portion of the blade angled distally to transect the cortex of the bone.  Following this, the distal portion of the osteotomy cut was freely movable and was able to be translocated medially.  The head was then slit medially several millimeters until it was noted to be in good position and no chopping was present in the medullary canal of the bone.  Following this, the bone was stabilized using a 0.45 K-wire distally as well as proximally directed from dorsal to planar direction.  Next using the normal AO manner, the distal cortex was drilled from dorsal to plantar with a 2.0 mm drill bit and then over drilled proximally with the cortex using a 2.7 mm drill bit.  The proximal cortex was then _________ and then the drill hole was measured and it was determined to be 18 mm in length from dorsal to plantar cortex.  Then using 2.7 mm tap, the thread holes were placed and using an 18 x 2.7 mm screw ___________ was achieved and good apposition of the bone and tightness were achieved.  Intramedullary sludge was noted to exit from the osteotomy cut.  Following this, attention was directed proximally and the 0.45 K-wire was removed and the holes were predrilled using a 2.0 mm screw then over-drilled using 2.7 mm screw and counter sucked.  Following this, the holes were measured, found to 20 mm in length and the drill hole was tapped using a 2.7 mm tap.  Following this, a 20 mm full threaded screw was inserted and tightened.  Good intramedullary sludge was noted and compression was achieved.  Attention was then directed to the distal screw where it was once again tightened and found to be in good position with good bite.  Following this, range of motion was performed on the first metatarsophalangeal joint and some lateral deviation of the hallux was noted.  Based on this, a lateral release was performed.  The extensor hallucis longus tendon was identified and was transected medially and a linear incision was placed down using a #15 blade into the first interspace.  The incision was then deepened with sharp and blunt dissection and using a curved hemostat, the transverse as well as the oblique fibers of the abductor hallucis tendon were identified and transected.  Care was taken to perform lateral release around the fibular sesamoid through these suspensory ligaments as well as the transverse metatarsal ligament and the collateral ligament.  Upon completion of this, the hallux was noted to be in a rectus position with good alignment.  The area was then flushed and irrigated with copious amounts of sterile saline.  After this, attention was directed back to the medial capsule and a medial capsulorrhaphy was performed and the capsule was closed using #3-0 Vicryl suture.  Subcutaneous tissues were closed using #3-0 and #4-0 Vicryl sutures to close in layers.  The skin was then reapproximated and closed using #5-0 Monocryl suture.  Following this, the incisions were dressed and bandaged in the normal manner using Owen silk, 4x4s, Kling, and Kerlix as well as Coban dressing.  The tourniquet was then dropped with a total tourniquet time of 99 minutes at 250 mmHg.  The patient followed the procedure and the anesthesia well and vascular status was intact as noted by immediate hyperemia to digits one through five of the left foot.  The patient was then transferred back to the cart and escorted on the cart to the Postanesthesia Care Unit.  Following this, the patient was given prescription for Vicoprofen total #20 to be taken one every six hours as necessary for moderate to severe pain.  The patient was also given prescription for clindamycin to be taken 300 mg four times a day.  The patient was given surgical shoe and was placed in a posterior sling.  The patient was given crutches and instructed to use them for ambulation.  The patient was instructed to keep her foot iced and elevated and to remain nonweightbearing over the weekend.  The patient will follow up with Dr. X on Tuesday morning at 11'o clock in his Livonia office.  The patient was concerned about any possible allergic reaction to medication and was placed on codeine and antibiotics due to that.  The patient has Dr. X's pager and will contact him over this weekend if she has any problems or complaints or return to Emergency Department if any difficulty should arise.  X-rays were taken and the patient was discharged home upon completion of this.","surgery, hallux abductovalgus deformity, scarf bunionectomy, metatarsal, bunion, hallux abductovalgus, metatarsophalangeal joint, dorsally, foot, bone, abductovalgus "
 Scleral Buckle opening under general anesthesia., Surgery, Scleral Buckle Opening - General Anesthesia ,"PROCEDURE IN DETAIL:,  After appropriate operative consent was obtained, the patient was brought supine to the operating room and placed on the operating room table.  Induction of general anesthesia via endotracheal intubation was then accomplished without difficulty.  The patient's right eye was prepped and draped in a sterile ophthalmic fashion and the procedure begun.  A wire lid speculum was inserted into the right eye and a 360-degree conjunctival peritomy was performed at the limbus.  The 4 rectus muscles were looped and isolated using 2-0 silk suture.  The retinal periphery was then inspected via indirect ophthalmoscopy.","surgery, retinal periphery, conjunctival peritomy, ophthalmoscopy, scleral, buckle, operating, anesthesiaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Sterilization candidate.  Cervical dilatation and laparoscopic bilateral partial salpingectomy.  A 30-year-old female gravida 4, para-3-0-1-3 who desires permanent sterilization.", Surgery, Salpingectomy & Cervical Dilatation ,"PREOPERATIVE DIAGNOSIS:,  Sterilization candidate.,POSTOPERATIVE DIAGNOSIS:,  Sterilization candidate.,PROCEDURE PERFORMED:,1.  Cervical dilatation.,2.  Laparoscopic bilateral partial salpingectomy.,ANESTHESIA: , General endotracheal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:  ,Less than 50 cc.,SPECIMEN: , Portions of bilateral fallopian tubes.,INDICATIONS:,  This is a 30-year-old female gravida 4, para-3-0-1-3 who desires permanent sterilization.,FINDINGS: , On bimanual exam, the uterus is small, anteverted, and freely mobile.  There are no adnexal masses appreciated.  On laparoscopic exam, the uterus, bilateral tubes and ovaries appeared normal.  The liver margin and bowel appeared normal.,PROCEDURE: , After consent was obtained, the patient was taken to the operating room where general anesthetic was administered.  The patient was placed in dorsal lithotomy position and prepped and draped in the normal sterile fashion.  A sterile speculum was placed in the patient's vagina and the anterior lip of the cervix was grasped with a vulsellum tenaculum.  The uterus was then sounded to 7 cm.,The cervix was serially dilated with Hank dilators.  A #20 Hank dilator was left in place.  The sterile speculum was then removed.  Gloves were changed.  Attention was then turned to the abdomen where approximately a 10 mm transverse infraumbilical incision was made through the patient's previous scar.  The Veress needle was placed and gas was turned on.  When good flow and low abdominal pressures were noted, the gas was turned up and the abdomen was allowed to insufflate.  A 11 mm trocar was then placed through this incision and the camera was placed with the above findings noted.  Two 5 mm step trocars were placed, one 2 cm superior to the pubic bone along the midline and the other approximately 7 cm to 8 cm to the left at the level of the umbilicus.  The Endoloop was placed through the left-sided port.  A grasper was placed in the suprapubic port and put through the Endoloop and then a portion of the left tube was identified and grasped with a grasper.  A knuckle of tube was brought up with the grasper and a #0 Vicryl Endoloop synched down across this knuckle of tube.  The suture was then cut using the endoscopic shears.  The portion of tube that was tied off was removed using a Harmonic scalpel.  This was then removed from the abdomen and sent to Pathology.  The right tube was then identified and in a similar fashion, the grasper was placed through the loop of the #0 Vicryl Endoloop and the right tube was grasped with the grasper and the knuckle of tube was brought up into the loop.  The loop was then synched down.  The Endoshears were used to cut the suture.  The Harmonic scalpel was then used to remove that portion of tube.  The portion of the tube that was removed from the abdomen was sent to Pathology.  Both tubes were examined and found to have excellent hemostasis.  All instruments were then removed.  The 5 mm ports were removed with good hemostasis noted.  The camera was removed and the abdomen was allowed to desufflate.  The 11 mm trocar introducer was replaced and the trocar was removed.  The fascia of the infraumbilical incision was reapproximated with an interrupted suture of #3-0 Vicryl.  The skin was then closed with #4-0 undyed Vicryl in a subcuticular fashion.  Approximately 10 cc of Marcaine was injected at the incision site.  The vulsellum tenaculum and cervical dilator were then removed from the patient's cervix with excellent hemostasis noted.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct at the end of the procedure.  The patient was taken to the recovery room in satisfactory condition.  She will be discharged home with a prescription for Vicodin for pain and was instructed to follow up in the office in two weeks.","surgery, cervical dilatation, partial salpingectomy, permanent sterilization, vulsellum tenaculum, hank dilators, infraumbilical incision, vicryl endoloop, salpingectomy, dilatation, hemostasis, cervical, laparoscopic, endoloop, sterilization,"
 Stage IV necrotic sacral decubitus.  Debridement of stage IV necrotic sacral decubitus., Surgery, Sacral Decubitus Debridement  ,"PREOPERATIVE DIAGNOSIS:,  Stage IV necrotic sacral decubitus.,POSTOPERATIVE DIAGNOSIS:,  Stage IV necrotic sacral decubitus.,PROCEDURE PERFORMED:,  Debridement of stage IV necrotic sacral decubitus.,GROSS FINDINGS: , This is a 92-year-old African-American female who was brought into the office 48 hours earlier with a chief complaint of necrotic foul-smelling wound in the sacral region and upon examination was found to have absolutely necrosis of the fat and subcutaneous tissue in the sacral region approximately 15 cm x 15 cm.  A long discussion with the family ensued that it needs to be debrided and then cleaned and then if she cannot keep the stool out of the wound that she will probably need a diverting colostomy.,OPERATIVE PROCEDURE:  ,The patient was properly prepped and draped under local sedation.  A 0.25% Marcaine was injected circumferentially around the necrotic decubitus.  A wide excision and debridement of the necrotic decubitus taken down to the presacral fascia and all necrotic tissue was electrocauterized and removed.  All bleeding was cauterized with electrocautery and then a Kerlix stack was then placed and a pressure dressing applied.  The patient was sent to recovery in satisfactory condition.","surgery, diverting colostomy, sacral decubitus debridement, necrotic sacral decubitus, wound, tissue, debridement, sacral, decubitus, necrotic, "
 Repair of ruptured globe with repositing of uveal tissue - Sample/Template., Surgery, Ruptured Globe Repair - Sclera and Limbus ,"PREOPERATIVE DIAGNOSIS: , Ruptured globe with uveal prolapse OX.,POSTOPERATIVE DIAGNOSIS:,  Ruptured globe with uveal prolapse OX.,PROCEDURE:  ,Repair of ruptured globe with repositing of uveal tissue OX.,ANESTHESIA: ,General,SPECIMENS:,  None.,COMPLICATIONS:,  None.,INDICATIONS: , This is a XX-year-old (wo)man with a ruptured globe of the XXX eye.,PROCEDURE: ,  The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, re-operation, loss of vision, and loss of the eye. Informed consent was obtained. The patient received IV antibiotics including Ancef and Levaeuin prior to surgery. The patient was brought to the operating room and placud in the supine position, where (s)he wad prepped and draped in the routine fashion. A wire lid speculum was carefully placed to provide exposure. A two-armed 7 mm scleral laceration was seen in the supranasal quadrant. The laceration involved the sclera and the limbus in this area. There was a small amount of iris tissue prolapsed in the wound. The Westcott scissors and 0.12 forceps were used to carefully dissect the conjunctiva away from the wound to provide exposure. A cyclodialysis spatula was used to carefully reposit the prolapsed iris tissue back into the anterior chamber. The anterior chamber remained formed and the iris tissue easily resumed its normal position. The pupil appeared round. An 8-0 nylon suture was used to close the scleral portion of the laceration. Three sutures were placed using the 8-0 nylon suture. Then 9-0 nylon suture was used to close the limbal portion of the wound. After the wound appeared closed, a Superblade was used to create a paracentesis at approximately 2 o'clock. BSS was injected through the paracentesis to fill the anterior chamber. The wound was checked and found to be watertight. No leaks were observed. An 8-0 Vicryl suture was used to reposition the conjunctiva and close the wound. Three 8-0 Vicryl sutures were placed in the conjunctiva. All scleral sutures were completely covered. The anterior chamber remained formed and the pupil remained round and appeared so at the end of the case. Subconjunctival injections of Ancef and dexamethasone were given at the end of the case as well as Tobradex ointment. The lid speculum was carefully removed. The drapes were carefully removed. Sterile saline was used to clean around the XXX eye as well as the rest of the face. The area was carefully dried and an eye patch and shield were taped over the XXX eye. The patient was awakened from general anesthesia without difficulty. (S)he was taken to the recovery area in good condition. There were no complications.","surgery, ruptured globe, bss, subconjunctival, bleeding, conjunctiva, eye patch, infection, limbus, loss of the eye, loss of vision, re-operation, scleral laceration, supranasal quadrant, uveal prolapse, wire lid speculum, iris tissue, anterior chamber, laceration, iris, chamber, ruptured, globe, eye,"
 Laparoscopic right salpingooophorectomy.  Right pelvic pain and ovarian mass.  Right ovarian cyst with ovarian torsion., Surgery, Salpingooophorectomy - Laparoscopic ,"PREOPERATIVE DIAGNOSES:,1.  Right pelvic pain.,2.  Right ovarian mass.,POSTOPERATIVE DIAGNOSES:,1.  Right pelvic pain.,2.  Right ovarian mass.,3.  8 cm x 10 cm right ovarian cyst with ovarian torsion.,PROCEDURE PERFORMED:  ,Laparoscopic right salpingooophorectomy.,ANESTHESIA:  ,General with endotracheal tube.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,TUBES: , None.,DRAINS:,  None.,PATHOLOGY: , The right tube and ovary sent to pathology for review.,FINDINGS: , On exam under anesthesia, a normal-appearing vulva and vagina and normally palpated cervix, a uterus that was normal size, and a large right adnexal mass.  Laparoscopic findings demonstrated a 8 cm x 10 cm smooth right ovarian cyst that was noted to be torsed twice.  Otherwise, the uterus, left tube and ovary, bowel, liver margins, appendix, and gallbladder were noted all to be within normal limits.  There was no noted blood in the pelvis.,INDICATIONS FOR THIS PROCEDURE:,  The patient is a 26-year-old G1 P1 who presented to ABCD General Emergency Room with complaint of right lower quadrant pain since last night, which has been increasing in intensity.  The pain persisted despite multiple pain medications given in the Emergency Room.  The patient reports positive nausea and vomiting.  There was no vaginal bleeding or discharge.  There was no fevers or chills.  Her cultures done in the Emergency Room were pending.  The patient did have an ultrasound that demonstrated an 8 cm right ovarian cyst, questionable hemorrhagic.  The uterus and left ovary were within normal limits.  There was a positive flow noted to bilateral ovaries on ultrasound.  Therefore, it was felt appropriate to take the patient for a diagnostic laparoscopy with a possible oophorectomy.,PROCEDURE:,  After informed consent was obtained, and all questions were answered to the patient's satisfaction in layman's terms, she was taken to the operating room where general anesthesia was obtained without any difficulty.  She was placed in dorsal lithotomy position with the use of Allis strips and prepped and draped in the usual sterile fashion.  Her bladder was drained with a red Robinson catheter and she was examined under anesthesia and was noted to have the findings as above.  She was prepped and draped in the usual sterile fashion.  A weighted speculum was placed in the patient's vagina with excellent visualization of the cervix.  The cervix was grasped at 12 o'clock position with a single-toothed tenaculum and pulled into the operative field.  The uterus was then sounded to approximately 3.5 inches and then a uterine elevator was placed.  The vulsellum tenaculum was removed.  The weighted speculum was removed.  Attention was then turned to the abdomen where 1 cm infraumbilical incision was made in the infraumbilical fold.  The Veress step needle was then placed into the abdomen while the abdomen was being tented up with towel clamp.  The CO2 was then turned on with unoccluded flow and excellent pressures.  This was continued till a normal symmetrical pneumoperitoneum was obtained.  Then, a #11 mm step trocar and sleeve were placed into the infraumbilical port without any difficulty and placement was confirmed by laparoscope.  Laparoscopic findings are as noted above.  A suprapubic incision was made with the knife and then a #12 mm step trocar and sleeve were placed in the suprapubic region under direct visualization.  Then, a grasper was used to untorse the ovary.  Then, a #12 mm port was placed in the right flank region under direct visualization using a LigaSure vessel sealing system.  The right tube and ovary were amputated and noted to be hemostatic.  The EndoCatch bag was then placed through the suprapubic port and the ovary was placed into the bag.  The ovary was too large to fit completely into the bag.  Therefore, a laparoscopic needle with a 60 cc syringe was used to aspirate the contents of the ovary while it was still inside the bag.,There was approximately 200 cc of fluid aspirated from the cyst.  This was a clear yellow fluid.  Then, the bag was closed and the ovary was removed from the suprapubic port.  The suprapubic port did have to be extended somewhat to allow for the removal of the ovary.  The trocar and sleeve were then placed back into the port.  The abdomen was copiously irrigated with warm normal saline using the Nezhat-Dorsey suction irrigator and the incision site was noted to be hemostatic.  The pelvis was clear and clean.  ,Pictures were obtained.  The suprapubic port was then removed under direct visualization and then using a #0-vicyrl and UR6.  Two figure-of-eight sutures were placed in the fascia of suprapubic port and fascia was closed and the pneumoperitoneum was maintained after the sutures were placed.  Therefore, the peritoneal surface was noted to be hemostatic.  Therefore, the camera was removed.  All instruments were removed.  The abdomen was allowed to completely deflate and then the trocars were placed back through the sleeves of the right flank #12 port and the infraumbilical port and these were removed.  The infraumbilical port was examined and noted to have a small fascial defect which was repaired with #0-Vicryl and UR6.  The right flank area was palpated and there was no facial defect noted.  The skin was then closed with #4-0 undyed Vicryl in subcuticular fashion.  Dressings were changed.  The weighted speculum was removed from the patient's cervix.  The cervix noted to be hemostatic.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2 and the patient was taken to the Recovery in stable condition.", 
" Salvage cystectomy (very difficult due to postradical prostatectomy and postradiation therapy to the pelvis), Indiana pouch continent cutaneous diversion, and omental pedicle flap to the pelvis.", Surgery, Salvage Cystectomy ,"PREOPERATIVE DIAGNOSES:,1.  Radiation cystitis.,2.  Refractory voiding dysfunction.,3.  Status post radical retropubic prostatectomy and subsequent salvage radiation therapy.,POSTOPERATIVE DIAGNOSES:,1.  Radiation cystitis.,2.  Refractory voiding dysfunction.,3.  Status post radical retropubic prostatectomy and subsequent salvage radiation therapy.,TITLE OF OPERATION: , Salvage cystectomy (very difficult due to postradical prostatectomy and postradiation therapy to the pelvis), Indiana pouch continent cutaneous diversion, and omental pedicle flap to the pelvis.,ANESTHESIA: , General endotracheal with epidural.,INDICATIONS:  ,This patient is a 65-year-old white male who in 1998 had a radical prostatectomy.  He was initially dry without pads and then underwent salvage radiation therapy for rising PSA.  After that he began with episodes of incontinence as well as urinary retention requiring catheterization.  One year ago, he was unable to catheterize and was taken to the operative room and had cystoscopy.  He had retained staple removed and a diverticulum identified.  There were also bladder stones that were lasered and removed, and he had been incontinent ever since that time.  He wears 8 to 10 pads per day, and this has affected his quality of life significantly.  I took him to the operating room on January 16, 2008, and found diffuse radiation changes with a small capacity bladder and wide-open bladder neck.  We both felt that his lower urinary tract was not rehabilitatable and that a continent cutaneous diversion would solve the number of problems facing him.  I felt like if we could remove the bladder safely, then this would also provide a benefit.,FINDINGS: , At exploration, there were no gross lesions of the smaller or large bowel.  The bladder was predictably sucked into the pelvic sidewall both inferiorly and laterally.  The opened bladder, which we were able to remove completely, had a wide-open capacious diverticulum in its very distal segment.  Because of the previous radiation therapy and a dissection down to the pelvis, I elected to place an omental pedicle flap to provide additional blood supply for healing as well in the pelvis and also under the pubic bone which was exposed inferiorly due to previous surgery and treatment.,PROCEDURE IN DETAIL:  ,The patient was brought to the operative suite and after adequate general endotracheal and epidural anesthesia obtained, placed in the supine position, flexed over the anterosuperior iliac spine, and his abdomen and genitalia were sterilely prepped and draped in the usual fashion.  A nasogastric tube was placed as well as radial arterial line.  He was given intravenous antibiotics for prophylaxis.  A generous midline skin incision was made from the midepigastrium down to the symphysis pubis, deep into the rectus fascia, the rectus muscle separated in the midline, and exploration carried out with the findings described.  Moist wound towels and a Bookwalter retractor were placed for exposure.  We began by retracting the bowels by mobilizing the cecum and ascending colon and hepatic flexure and elevating the terminal ileum up to the second and third portion of the duodenum.  The ureter was identified as a crisis over the iliac vessels and dissected deep into pelvis and subsequently divided between clips.  An identical procedure was performed in the left side with similar findings and the bowels were packed cephalad.,We began then dissecting the bladder away from the pelvic side walls staying medial to both epigastric arteries.  This was quite challenging because of the previous radiation therapy and radical prostatectomy.  We essentially carved the bladder off of the pelvic sidewall inferiorly as best we could and then we were able to have enough freedom to identify the lateral pedicles, and these were taken between double clips approximately and clipped distally.  We then approached things posteriorly and carefully dissected between the __________ and posterior bladder.  There was some remnant seminal vesicle on the right as well as both remnant ejaculatory duct and we used this to dissect the longus safe plane anterior to the rectum.  We then entered the bladder anteriorly as distal as we could and remove the bladder and what we thought was a bladder neck and this appeared to end in a diverticulum.  We then peeled it off the remaining rectum and passed the specimen off the operative field.  Bladder was irrigated with warm sterile water and a meticulous inspection was made for hemostasis.,We then completely mobilized the omentum off of the proximal transverse colon.  This allowed a generous flap to be able to be laid into the pelvis without tension.,We then turned our attention to forming the Indiana pouch.  I completed the dissection of the right hepatic flexure and the proximal transverse colon and mobilized the omentum off of this portion of the colon.  The colon was divided proximal to the middle colic using a GIA-80 stapler.  I then divided the avascular plane of Treves along the terminal ileum and selected a point approximately 15 cm proximal to the ileocecal valve to divide the ileum.  The mesentery was then sealed with a LigaSure device and divided, and the bowel was divided with a GIA-60 stapler.  We then performed a side-to-side ileo-transverse colostomy using a GIA-80 stapler, closing the open end with a TA 60.  The angles were reinforced with silk sutures and the mesenteric closed with interrupted silk sutures.,We then removed the staple line along the terminal ileum, passed a 12-French Robinson catheter into the cecal segment, and plicated the ileum with 3 firings of the GIA-60 stapler.  The ileocecal valve was then reinforced with interrupted 3-0 silk sutures as described by Rowland, et al, and following this, passage of an 18-French Robinson catheter was associated with the characteristic ""pop,"" indicating that we had adequately plicated the ileocecal valve.,As the patient had had a previous appendectomy, we made an opening in the cecum in the area of the previous appendectomy.  We then removed the distal staple line along the transverse colon and aligned the cecal end and the distal middle colic end with two 3-0 Vicryl sutures.  The bowel segment was then folded over on itself and the reservoir formed with 3 successive applications of the SGIA Polysorb-75.  Between the staple lines, Vicryl sutures were placed and the defects closed with 3-0 Vicryl suture ligatures.,We then turned our attention to forming the ileocolonic anastomosis.  The left ureter was mobilized and brought underneath the sigmoid mesentery and brought through the mesentery of the terminal ileum and an end-to-side anastomosis performed with an open technique using interrupted 4-0 Vicryl sutures, and this was stented with a Cook 8.4-French ureteral stent, and this was secured to the bowel lumen with a 5-0 chromic suture.  The right ureter was brought underneath the pouch and placed in a stented fashion with an identical anastomosis.  We then brought the stents out through a separate incision cephalad in the pouch and they were secured with a 2-0 chromic suture.  A 24-French Malecot catheter was placed through the cecum and secured with a chromic suture.  The staple lines were then buried with a running 3-0 Vicryl two-layer suture and the open end of the pouch closed with a TA 60 Polysorb suture.  The pouch was filled to 240 cc and noted to be watertight, and the ureteral anastomoses were intact.,We then made a final inspection for hemostasis.  The cecostomy tube was then brought out to the right lower quadrant and secured to the skin with silk sutures.  We then matured our stoma through the umbilicus.  We removed the plug of skin through the umbilicus and delivered the ileal segment through this.  A portion of the ileum was removed and healthy, well-vascularized tissue was matured with interrupted 3-0 chromic sutures.  We left an 18-French Robinson through the stomag and secured this to the skin with silk sutures.  The Malecot and stents were also secured in a similar fashion.,We matured the stoma to the umbilicus with interrupted chromic stitches.  The stitch was brought out to the right upper quadrant and the Malecot to the left lower quadrant.  A Large JP drain was placed in the pelvis dependent to the omentum pedicle flap as well as the Indiana pouch.,The rectus fascia was closed with a buried #2 Prolene running stitch, tying a new figure-of-eight proximally and distally and meeting in the middle and tying it underneath the fascia.  Subcutaneous tissue was irrigated with saline and skin was closed with surgical clips.  The estimated blood loss was 450 mL, and the patient received no packed red blood cells.  The final sponge and needle count were reported to be correct.  The patient was awakened and extubated, and taken on stretcher to the recovery room in satisfactory condition.","surgery, radiation cystitis, voiding dysfunction, retropubic prostatectomy, salvage radiation therapy, salvage cystectomy, indiana pouch continent cutaneous diversion, omental pedicle flap, ligasure, gia, stapler, gia stapler, vicryl sutures, radiation therapy, silk sutures, bladder, therapy, sutures, endotracheal, "
 Repair of ruptured globe involving posterior sclera - Sample/Template. , Surgery, Ruptured Globe Repair - Posterior Sclera ,"PREOPERATIVE DIAGNOSIS: , Ruptured globe OX.,POSTOPERATIVE DIAGNOSIS:,  Ruptured globe OX.,PROCEDURE: , Repair of ruptured globe OX.,ANESTHESIA:, General,SPECIMENS:,  None.,COMPLICATIONS: ,None.,INDICATIONS:, This is a XX-year-old (wo)man with a ruptured globe of the XXX eye.,PROCEDURE:, The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, re-operation, loss of vision, and loss of the eye. Informed consent was obtained. The patient received IV antibiotics including Ancef and Levaeuin prior to surgery. The patient was brought to the operating room and placud in the supine position, where (s)he wad prepped and draped in the routine fashion. A wire lid speculum was placed to provide exposure.,Upon examination and dissection of the conjunctiva superiorly, a scleral rupture was found. The rupture extended approximately 15 mm in length superior to the cornea, approximately 2 mm from the limbus in a horizontal fashion. There was also a rupture at the limbus, near the middle of this laceration, causing the anterior chamber to be flat. There was a large blood clot filling the anterior chamber. An attempt was made to wash out the anterior chamber with BSS on a cannula. The BSS was injected through the limbal rupture, which communicated with the anterior chamber. The blood clot did not move. It was extremely adherent to the iris.,At that time, the rupture that involved the limbus from approximately 10:30 until 12 o'clock was closed using 1 suture of 10-0 nylon. The scleral laceration was then closed using 10 interrupted sutures with 9-0 Vicryl. At that time, the anterior chamber was formed and appeared to be fairly deep. The wounds were checked and found to be watertight. The knots were rotated posteriorly and the conjunctiva was draped up over the sutures and sewn into position at the limbus using four 7-0 Vicryl sutures, 2 nasally and 2 temporally. All suture knots were buried.  ,Gentamicin 0.5 cc was injected subconjunctivally. Then, the speculum was removed. The drapes were removed. Several drops of Ocuflox and Maxitrol ointment were placed in the XXX eye. An eye patch and shield were placed over the eye. The patient was awakened from general anesthesia without difficulty and taken to the recovery room in good condition.","surgery, ruptured globe, ancef, bss, maxitrol ointment, ocuflox, anterior chamber, bleeding, conjunctiva, infection, limbus, loss of the eye, loss of vision, re-operation, scleral laceration, scleral rupture, wire lid speculum, repair of ruptured globe, ruptured, anterior, chamber, globe"
" Cervical facial rhytidectomy.  Quadrilateral blepharoplasty.  Autologous fat injection to the upper lip - donor site, abdomen.", Surgery, Rhytidectomy & Blepharoplasty ,"PREOPERATIVE DIAGNOSIS:,  Ageing face.,POSTOPERATIVE DIAGNOSIS: , Ageing face.,OPERATIVE PROCEDURE:,1.  Cervical facial rhytidectomy.,2.  Quadrilateral blepharoplasty.,3.  Autologous fat injection to the upper lip.,OPERATIONS PERFORMED:,1.  Cervical facial rhytidectomy.,2.  Quadrilateral blepharoplasty.,3.  Autologous fat injection to the upper lip - donor site, abdomen.,INDICATION:  ,This is a 62-year-old female for the above-planned procedure.  She was seen in the preoperative holding area where the surgery was discussed accordingly and markings were applied.  Full informed consent noted and chemistries were on her chart and preoperative evaluation was negative.,PROCEDURE: , The patient was brought to the operative room under satisfaction, and she was placed supine on the OR table.  Administered general endotracheal anesthesia followed by sterile prep and drape at the patient's face and abdomen.  This included the neck accordingly.,Two platysmal sling application and operating headlight were utilized.  Hemostasis was controlled with the pinpoint cautery along with suction Bovie cautery.,The first procedure was performed was that of a quadrilateral blepharoplasty.  Markers were applied to both upper lids in symmetrical fashion.  The skin was excised from the right upper lid first followed by appropriate muscle resection.  Minimal fat removed from the medial upper portion of the eyelid.  Hemostasis was controlled with the quadrilateral tip needle; closure with a running 7-0 nylon suture.  Attention was then turned to the lower lid.  A classic skin muscle flap was created accordingly.  Fat was resected from the middle, medial, and lateral quadrant.  The fat was allowed to open drain the arcus marginalis for appropriate contour.  Hemostasis was controlled with the pinpoint cautery accordingly.  Skin was redraped with a conservative amount resected.  Running closure with 7-0 nylon was accomplished without difficulty.  The exact same procedure was repeated on the left upper and lower lid.,After completion of this portion of the procedure, the lag lid was again placed in the eyes.  Eye mass was likewise clamped.  Attention was turned to her face with plans for cervical facial rhytidectomy portion of the procedure.  The right face was first operated.  It was injected with a 0.25% Marcaine 1:200,000 adrenaline.  A submental incision was created followed by suction lipectomy and very minimal amounts of ***** in 3 mm and 2-mm suction cannula.  She had minimal subcutaneous extra fat as noted.  Attention was then turned to the incision which was in the temporal hairline in curvilinear fashion following the pretragal incision to the postauricular sulcus and into and along the post-occipital hairline.  The flap was elevated without difficulty with various facelift scissors.  Hemostasis was controlled again with a pinpoint cautery as well as suction Bovie cautery.,The exact same elevation of skin flap was accomplished on the left face followed by the anterosuperior submental space with approximately 4-cm incision.  Rectus plication in the midline with a running 4-0 Mersilene was followed by some transaction of the platysma above the hairline with coagulation, cutting, and cautery.  The submental incision was closed with a running 7-0 nylon over 5-0 Monocryl.,Attention was then turned to closure of the bilateral facelift incisions after appropriate SMAS plication.  The left side of face was first closed followed by interrupted SMAS plication utilizing 4-0 wide Mersilene.  The skin was draped appropriately and appropriate tissue was resected.  A 7-mm 9-0 French drain was utilized accordingly prior to closure of the skin with interrupted 4-0 Monocryl in the post-occipital region followed by running 5-0 nylon in the postauricular surface.  Preauricular interrupted 5-0 Monocryl was followed by running 7-0 nylon.  The hairline temporal incision was closed with running 5-0 nylon.  The exact same closure was accomplished on the right side of the face with a same size 7-mm French drain.,The patient's dressing consisted of Adaptic Polysporin ointment followed by Kerlix wrap with a 3-inch Ace.,The lips and mouth were sterilely prepped and draped accordingly after application of the head drape dressing as described.  Suction lipectomy was followed in the abdomen with sterile conditions were prepped and draped accordingly.  Approximately 2.5 to 3 cc of autologous fat was injected into the upper lip of the remaining cutaneous line with blunt tip dissector after having washed the fat with saline accordingly.  Tuberculin syringes were utilized on the injection utilizing a larger blunt tip needle for the actual injection procedure.  The incision site was closed with 7-0 nylon.,The patient tolerated the procedure well and was transferred to the recovery room in stable condition with Foley catheter in position.,The patient will be admitted for overnight short stay through the cosmetic package procedure.  She will be discharged in the morning.,Estimated blood loss was less than 75 cc.  No complications noted, and the patient tolerated the procedure well.","surgery, ageing face, adaptic polysporin ointment, autologous fat injection, bovie cautery, kerlix wrap, smas plication, arcus marginalis, blepharoplasty, facelift, platysmal sling, quadrilateral, rhytidectomy, right upper lid, cervical facial rhytidectomy, pinpoint cautery, facial rhytidectomy, quadrilateral blepharoplasty, running nylon, autologous, "
 Right shoulder hemiarthroplasty.   Right shoulder rotator cuff tear.  Glenohumeral rotator cuff arthroscopy.  Degenerative joint disease., Surgery, Right Shoulder Hemiarthroplasty ,"PREOPERATIVE DIAGNOSES:,1.  Right shoulder rotator cuff tear.,2.  Glenohumeral rotator cuff arthroscopy.,3.  Degenerative joint disease.,POSTOPERATIVE DIAGNOSES:,1.  Right shoulder rotator cuff tear.,2.  Glenohumeral rotator cuff arthroscopy.,3.  Degenerative joint disease.,PROCEDURE PERFORMED: ,Right shoulder hemiarthroplasty.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Approximately 125 cc.,COMPLICATIONS:,  None.,COMPONENTS: , A DePuy 10 mm global shoulder system stem was used cemented and a DePuy 44 x 21 mm articulating head was used.,BRIEF HISTORY:  ,The patient is an 82-year-old right-hand dominant female who presents for shoulder pain for many years now and affecting her daily living and function and pain is becoming unbearable failing conservative treatment.,PROCEDURE: , The patient was taken to the operative suite, placed on the operative field.  Department of Anesthesia administered general anesthetic.  Once adequately sedated, the patient was placed in the beach chair position.  Care was ensured that she was well positioned, adequately secured and padded.  At this point, the right upper extremity was then prepped and draped in the usual sterile fashion.  A deltopectoral approach was used and taken down to the skin with a #15 blade scalpel.,At this point, blunt dissection with Mayo scissors was used to come to the overlying subscapular tendon and bursal tissue.  Any perforating bleeders were cauterized with Bovie to obtain hemostasis.  Once the bursa was seen, it was removed with a Rongeur and subscapular tendon could be easily visualized.  At this point, the rotator cuff in the subacromial region was evaluated.  There was noted to be a large rotator cuff, which was irreparable.  There was eburnated bone on the greater tuberosity noted.  The articular surface could be visualized.  The biceps tendon was intact.  There was noted to be diffuse discolored synovium around this as well as some fraying of the tendon in the intraarticular surface.  The under surface of the acromion, it was felt there was mild ware on this as well.  At this point, the subscapular tendon was then taken off using Bovie cautery and Metzenbaum scissors that was tied with Metzenbaum suture.  It was separated from the capsule to have a two layered repair at closure.  The capsule was also reflected posterior.  At this point, the glenoid surface could be easily visualized.  It was evaluated and had good cartilage contact and appeared to be intact.  The humeral head was evaluated.  There was noted to be ware of the cartilage and eburnated bone particularly in the central portion of the humeral head.  At this point, decision was made to proceed with the arthroplasty, since the rotator cuff tear was irreparable and there was significant ware of the humoral head.  The arm was adequately positioned.  An oscillating saw was used to make the head articular cut.  This was done at the margin of the articular surface with the anatomic neck.  This was taken down to appropriate level until this articular surface was adequately removed.  At this point, the intramedullary canal and cancellous bone could be easily visualized.  The opening hand reamers were then used and this was advanced to a size #10.  Under direct visualization, this was performed easily.  At this point, the 10 x 10 proximal flange cutter was then inserted and impacted into place to cut grooves for the fins.  This was then removed.  A trial component was then impacted into place, which did fit well and trial heads were then sampled and it was felt that a size 44 x 21 mm head gave us the best fit and appeared adequately secured.  It did not appear overstuffed with evidence of excellent range of motion and no impingement.  At this point, the trial component was removed.  Wound was copiously irrigated and suctioned dry.  Cement was then placed with a cement gun into the canal and taken up to the level of the cut.  The prosthesis was then inserted into place and held under direct visualization.  All excess cement was removed and care was ensured that no cement was left in the posterior aspect of the joint itself.  This _______ cement was adequately hard at this point.  The final component of the head was impacted into place, secured on the Morris taper and checked, and this was reduced.,The final component was then taken through range of motion and found to have excellent stability and was satisfied with its position.  The wound was again copiously irrigated and suctioned dry.  At this point, the capsule was then reattached to its insertion site in the anterior portion.  Once adequately sutured with #1-Vicryl, attention was directed to the subscapular.  The subscapular was advanced superiorly and anchored not only to the biceps tendon region, but also to the top anterior portion of the greater tuberosity.  This was opened to allow some type of coverage points of the massive rotator cuff tear.  This was secured to the tissue and interosseous sutures with size #2 fiber wire.  After this was adequately secured, the wound was again copiously irrigated and suctioned dry.  The deltoid fascial split was then repaired using interrupted #2-0 Vicryl, subcutaneous tissue was then approximated using interrupted #24-0 Vicryl, skin was approximated using a running #4-0 Vicryl.  Steri-Strips and Adaptic, 4 x 4s, and ABDs were then applied.  The patient was then placed in a sling and transferred back to the gurney, reversed by Department of Anesthesia.,DISPOSITION: , The patient tolerated well and transferred to Postanesthesia Care Unit in satisfactory condition.","surgery, glenohumeral rotator cuff, arthroscopy, degenerative joint disease, shoulder hemiarthroplasty, rotator, cuff, subscapular, shoulder, "
 Arthroscopic subacromial decompression and repair of rotator cuff through mini-arthrotomy., Surgery, Rotator Cuff Repair ,"PREOPERATIVE DIAGNOSIS: , Rotator cuff tear, left.,POSTOPERATIVE DIAGNOSES:,1.  Sixty-percent rotator cuff tear, joint side.,2.  Impingement syndrome.,ANESTHESIA: , General,NAME OF OPERATION:,1.  Arthroscopic subacromial decompression.,2.  Repair of rotator cuff through mini-arthrotomy.,FINDINGS AT OPERATION: , The patient's glenohumeral joint was completely clear, other than obvious tear of the rotator cuff.  The midportion of this appeared to be complete, but for the most part, this was about a 60% rupture of the tendon.  This was confirmed later when the bursal side was opened up.  Note, the patient also had abrasion of the coracoacromial ligament under the anterolateral edge of the acromion.  He did not have any acromioclavicular joint pain or acromioclavicular joint disease noted.,PROCEDURE:,  He was given an anesthetic, examined, prepped, and draped in a sterile fashion in a beach-chair position.  The shoulder was instilled with fluid from posteriorly, followed by the arthroscope.  The shoulder was instilled with fluid from posteriorly, followed by the arthroscope.  Arthroscopy was then carried out in standard fashion using a 30-degree Dionic scope.  With the scope in the posterior portal, the above findings were noted, and an anterior portal was established.  A curved shaver was placed for debridement of the tear.  I established this was about a 60-70% tear with a probable complete area of tear which was very small.  There were no problems at the biceps or the rest of the joint.  The subacromial space showed findings, as noted above, and a thorough subacromial decompression was carried out with a Bovie, rotary shaver, and bur.  I did not debride the acromioclavicular joint.  The lateral portal was then extended to a mini-arthrotomy, and subacromial space was entered by blunt dissection through the deltoid.  The area of weakness of the tendon was found, and was transversely cut, and findings were confirmed.  The diseased tissue was removed, and the greater tuberosity was abraded with a rongeur.  Tendon-to-tendon repair was then carried out with buried sutures of 2-0 Ethibond, giving a very nice repair.  The shoulder was carried through a range of motion.  I could see no evidence of impingement.  Copious irrigation was carried out.  The deltoid deep fascia was anatomically closed, as was the superficial fascia.  The subcutaneous tissue and skin were closed in layers.  A sterile dressing was applied.  The patient appeared to tolerate the procedure well.","surgery, rotator cuff tear, mini-arthrotomy, repair of rotator cuff, arthroscopic subacromial decompression, arthroscopic subacromial, cuff tear, subacromial space, subacromial decompression, mini arthrotomy, acromioclavicular joint, rotator cuff, arthroscopic, decompression, acromioclavicular, impingement, rotator, cuff,"
 Ruptured globe with full-thickness corneal laceration repair - Sample/Template., Surgery, Ruptured Globe Repair - Cornea ,"PREOPERATIVE DIAGNOSIS:,  Ruptured globe with full-thickness corneal laceration OX.,POSTOPERATIVE DIAGNOSIS: , Ruptured globe with full-thickness corneal laceration OX.,PROCEDURE:  ,Ruptured globe with full-thickness corneal laceration repair OX.,ANESTHESIA:, General,SPECIMENS:,  None.,COMPLICATIONS:, None.,INDICATIONS:, This is a XX-year-old (wo)man with a ruptured globe with full-thickness corneal laceration of the XXX eye.,PROCEDURE:, The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, astigmatism, cataract, re-operation, loss of vision, and loss of the eye. Informed consent was obtained. The patient received IV antibiotics including Ancef and Levaeuin prior to surgery. The patient was brought to the operating room and placud in the supine position, where (s)he wad prepped and draped in the routine fashion. A wire lid speculum was placed to provide exposure and 0.12 forceps and a Superblade were used to create a paracentesis at approximately 11 o'clock. Viscoat was injected through the paracentesis to fill the anterior chamber. The Viscoat cannula was used to sweep the incarcerated iris tissue from the wound. More Viscoat was injected to deepen the anterior chamber. A 10-0 nylon suture was used to place four sutures to close the corneal laceration. BSS was then injected to fill the anterior chamber and a small leak was noted at the inferior end of the wound. A fifth 10-0 nylon suture was then placed. The wound was packed and found to be watertight. The sutures were rotated, the wound was again checked and found to be watertight. A small amount of Viscoat was, again, injected to deepen the anterior chamber and the wound was swept to be sure there was no incarcerated uveal tissue. Several drops were placed in the XXX eye including Ocuflox, Pred Forte, Timolol 0.5%, Alphagan and Trusopt. An eye patch and shield were taped over the XXX eye. The patient was awakened from general anesthesia. (S)he was taken to the recovery area in good condition. There were no complications.","surgery, ruptured globe, alphagan, bss, ocuflox, pred forte, superblade, timolol, viscoat cannula, anterior chamber, astigmatism, bleeding, cataract, corneal laceration, full-thickness corneal laceration, infection, laceration repair, loss of the eye, loss of vision, paracentesis, re-operation, wire lid speculum, viscoat, corneal, laceration,"
" Cystourethroscopy, right retrograde pyelogram, and right double-J stent placement 22 x 4.5 mm.  Right ureteropelvic junction calculus.", Surgery, Retrograde Pyelogram & Cystourethroscopy ,"PREOPERATIVE DIAGNOSIS: , Right ureteral calculus.,POSTOPERATIVE DIAGNOSIS: , Right ureteropelvic junction calculus.,PROCEDURE PERFORMED:,1.  Cystourethroscopy.,2.  Right retrograde pyelogram.,3.  Right double-J stent placement 22 x 4.5 mm.,FIRST SECOND ANESTHESIA: , General.,SPECIMEN:,  Urine for culture and sensitivity.,DRAINS: , 22 x 4.5 mm right double-J ureteral stent.,PROCEDURE: , After consent was obtained, the patient was brought to operating room and placed in the supine position.  She was given general anesthesia and then placed in the dorsal lithotomy position.  A #21 French cystoscope was then passed through the urethra into the bladder.  There was noted to be some tightness of the urethra on passage.  On visualization of the bladder, there were no stones or any other debris within the bladder.  There were no abnormalities seen.  No masses, diverticuli, or other abnormal findings.  Attention was then turned to the right ureteral orifice and attempts to pass to a cone tip catheter, however, the ureteral orifice was noted to be also tight and we were unable to pass the cone tip catheter.  The cone tip catheter was removed and a glidewire was then passed without difficulty up into the renal pelvis.  An open-end ureteral catheter was then passed ________ into the distal right ureter.  Retrograde pyelogram was then performed.,There was noted to be an UPJ calculus with no noted hydronephrosis.  The wire was then passed back through the ureteral catheter.  The catheter was removed and a 22 x 4.5 mm double-J ureteral stent was then passed over the glidewire under fluoroscopic and cystoscopic guidance.  The stent was clear within the kidney as well as within the bladder.  The bladder was drained and the cystoscope was removed.  The patient tolerated the procedure well.  She will be discharged home.  She is to follow up with Dr. X for ESWL procedure.  She will be given prescription for Darvocet and will be asked to have a KUB x-ray done prior to her followup and to bring them with her to her appointment.","surgery, ureteropelvic junction, calculus, cystourethroscopy, retrograde pyelogram, double-j stent placement, double j stent, cone tip catheter, ureteral stent, ureteral orifice, ureteral catheter, retrograde, pyelogram, catheter, ureteral"
 Revision rhinoplasty and left conchal cartilage harvest to correct nasal deformity., Surgery, Revision Rhinoplasty. ,"PREOPERATIVE DIAGNOSIS: , Nasal deformity, status post rhinoplasty.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE:,  Revision rhinoplasty (CPT 30450).  Left conchal cartilage harvest (CPT 21235).,ANESTHESIA: , General.,INDICATIONS FOR THE PROCEDURE: , This patient is an otherwise healthy male who had a previous nasal fracture.  During his healing, perioperatively he did sustain a hockey puck to the nose resulting in a saddle-nose deformity with septal hematoma.  The patient healed status post rhinoplasty as a result but was left with a persistent saddle-nose dorsal defect.  The patient was consented for the above-stated procedure.  The risks, benefits, and alternatives were discussed.,DESCRIPTION OF PROCEDURE: ,The patient was prepped and draped in the usual sterile fashion.  The patient did have approximately 12 mL of Lidocaine with epinephrine 1% with 1:100,000 infiltrated into the nasal soft tissues.  In addition to this, cocaine pledgets were placed to assist with hemostasis.,At this point, attention was turned to the left ear.  Approximately 3 mL of 1% Lidocaine with 1:100,000 epinephrine was infiltrated into the subcutaneous tissues of the conchal bulb.  Betadine was utilized for preparation.  A 15 blade was used to incise along the posterior conchal area and a Freer elevator was utilized to lift the soft tissues off the conchal cartilage in a submucoperichondrial plane.  I then completed this along the posterior aspect of the conchal cartilage, was transected in the concha cavum and concha cymba, both were harvested.  These were placed aside in saline.  Hemostasis was obtained with bipolar electrocauterization.  Bovie electrocauterization was also employed as needed.  The entire length of the wound was then closed with 5-0 plain running locking suture.  The patient then had a Telfa placed both anterior and posterior to the conchal defect and placed in a sandwich dressing utilizing a 2-0 Prolene suture.  Antibiotic ointment was applied generously.,Next, attention was turned to opening and lifting the soft tissues of the nose.  A typical external columella inverted V gull-wing incision was placed on the columella and trailed into a marginal incision.  The soft tissues of the nose were then elevated using curved sharp scissors and Metzenbaums.  Soft tissues were elevated over the lower lateral cartilages, upper lateral cartilages onto the nasal dorsum.  At this point, attention was turned to osteotomies and examination of the external cartilages.,The patient did have very broad lower lateral cartilages leading to a bulbous tip.  The lower lateral cartilages were trimmed in a symmetrical fashion leaving at least 8 mm of lower lateral cartilage bilaterally along the lateral aspect.  Having completed this, the patient had medial and lateral osteotomies performed with a 2-mm osteotome.  These were done transmucosally after elevating the tract using a Cottle elevator.  Direct hemostasis pressure was applied to assist with bruising.,Next, attention was turned to tip mechanisms.  The patient had a series of double-dome sutures placed into the nasal tip.  Then, 5-0 Dexon was employed for intradomal suturing, 5-0 clear Prolene was used for interdomal suturing.  Having completed this, a 5-0 clear Prolene alar spanning suture was employed to narrow the superior tip area.,Next, attention was turned to dorsal augmentation.  A Gore-Tex small implant had been selected, previously incised.  This was taken to the back table and carved under sterile conditions.  The patient then had the implant placed into the super-tip area to assist with support of the nasal dorsum.  It was placed into a precise pocket and remained in the midline.,Next, attention was turned to performing a columella strut.  The cartilage from the concha was shaped into a strut and placed into a precision pocket between the medial footplate of the lower lateral cartilage.  This was fixed into position utilizing a 5-0 Dexon suture.,Having completed placement of all augmentation grafts, the patient was examined for hemostasis.  The external columella inverted gull-wing incision along the nasal tip was closed with a series of interrupted everting 6-0 black nylon sutures.  The entire marginal incisions for cosmetic rhinoplasty were closed utilizing a series of 5-0 plain interrupted sutures.,At the termination of the case, the ear was inspected and the position of the conchal cartilage harvest was hemostatic.  There was no evidence of hematoma, and the patient had a series of brown Steri-Strips and Aquaplast cast placed over the nasal dorsum.  The inner nasal area was then examined at the termination of the case and it seemed to be hemostatic as well.,The patient was transferred to the PACU in stable condition.  He was charged to home on antibiotics to prevent infection both from the left ear conchal cartilage harvest and also the Gore-Tex implant area.  He was asked to follow up in 4 days for removal of the bolster overlying the conchal cartilage harvest.","surgery, nasal deformity, rhinoplasty, conchal cartilage harvest, conchal bulb, conchal, submucoperichondrial, gull-wing incision, gore-tex, gull wing incision, lower lateral cartilages, revision rhinoplasty, nasal dorsum, cartilage harvest, conchal cartilage, cartilage, nasal, deformity, hemostasis, columella, harvest, cartilages"
" Nasal endoscopy and partial rhinectomy due to squamous cell carcinoma, left nasal cavity.", Surgery, Rhinectomy & Nasal Endoscopy ,"PREOPERATIVE DIAGNOSIS: , Squamous cell carcinoma, left nasal cavity.,POSTOPERATIVE DIAGNOSIS:,  Squamous cell carcinoma, left nasal cavity.,OPERATIONS PERFORMED:,1.  Nasal endoscopy.,2.  Partial rhinectomy.,ANESTHESIA:,  General endotracheal.,INDICATIONS: , This is an 81-year-old gentleman who underwent septorhinoplasty many years ago.  He also has a history of a skin lesion, which was removed from the nasal ala many years ago, the details of which he does not recall.  He has been complaining of tenderness and induration of his nasal tip for approximately two years and has been treated unsuccessfully for folliculitis and cellulitis of the nasal tip.  He was evaluated by Dr. A, who performed the septorhinoplasty, and underwent an intranasal biopsy, which showed histologic evidence of invasive squamous cell carcinoma.  The preoperative examination shows induration of the nasal tip without significant erythema.  There is focal tenderness just cephalad to the alar crease.  There is no lesion either externally or intranasally.,PROCEDURE AND FINDINGS: , The patient was taken to the operating room and placed in supine position.  Following induction of adequate general endotracheal anesthesia, the left nose was decongested with Afrin.  He was prepped and draped in standard fashion.  The left nasal cavity was examined by anterior rhinoscopy.  The septum was midline.  There was slight asymmetry of the nares.  No lesion was seen within the nasal cavity either in the area of the intercartilaginous area, which was biopsied by Dr. A, the septum, the lateral nasal wall, and the floor.  The 0-degree nasal endoscope was then used to examine the nasal cavity more completely.  No lesion was detectable.  A left intercartilaginous incision was made with a #15 blade since this was the area of previous biopsy by Dr. A.  The submucosal tissue was thickened diffusely, but there was no identifiable distinct or circumscribed lesion present.  Random biopsies of the submucosal tissue were taken and submitted to pathology for frozen section.  A diagnosis of diffuse invasive squamous cell carcinoma was rendered.  An alar incision was made with a #15 blade and the full-thickness incision was completed with the electrocautery.  The incision was carried more cephalad through the lower lateral cartilage up to the area of the upper lateral cartilage at the superior margin.  The full unit of the left nasal tip was excised completely and submitted to pathology after tagging and labeling it.  Frozen section examination again revealed diffuse squamous cell carcinoma throughout the soft tissues involving all margins.  Additional soft tissue was then taken from all margins tagging them for the pathologist.  The inferior margins were noted to be clear on the next frozen section report, but there was still disease present in the region of the upper lateral cartilage at its insertion with the nasal bone.  A Joseph elevator was used to elevate the periosteum off the maxillary process and off the inferior aspect of the nasal bone.  Additional soft tissue was taken in these regions along the superior margin.  The frozen section examination revealed persistent disease medially and additional soft tissue was taken and submitted to pathology.  Once all margins had been cleared histologically, additional soft tissue was taken from the entire wound.  A 5-mm chisel was used to take down the inferior aspect of the nasal bone and the medial-most aspect of the maxilla.  This was all submitted to pathology for routine permanent examination.  Xeroform gauze was then fashioned to cover the defect and was sutured along the periphery of the wound with interrupted 6-0 nylon suture to provide a barrier and moisture.  The anesthetic was then discontinued as the patient was extubated and transferred to the PACU in good condition having tolerated the procedure well.  Sponge and needle counts were correct.","surgery, nasal cavity, joseph elevator, squamous cell carcinoma, endoscopy, intranasally, maxilla, nasal ala, nasal tip, rhinectomy, septorhinoplasty, nasal endoscopy, lateral cartilage, frozen section, additional soft, squamous cell, cell carcinoma, nasal, cartilage, squamous, carcinoma, cavity, tissue "
 Repair of one-half full-thickness left lower lid defect by tarsoconjunctival pedicle flap from left upper lid to left lower lid and repair of left upper and lateral canthal defect by primary approximation to lateral canthal tendon remnant., Surgery, Repair of Canthal & Lid Defect  ,"PREOPERATIVE DIAGNOSIS: , Status post Mohs resection epithelial skin malignancy left lower lid, left lateral canthus, and left upper lid.,POSTOPERATIVE DIAGNOSIS: , Status post Mohs resection epithelial skin malignancy left lower lid, left lateral canthus, and left upper lid.,PROCEDURES:,1.  Repair of one-half full-thickness left lower lid defect by tarsoconjunctival pedicle flap from left upper lid to left lower lid.,2.  Repair of left upper and lateral canthal defect by primary approximation to lateral canthal tendon remnant.,ASSISTANT: , None.,ANESTHESIA: , Attended local by Strickland and Associates.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed in supine position.  Dressing was removed from the left eye, which revealed the defect as noted above.  After systemic administration of alfentanil, local anesthetic was infiltrated into the left upper lid, left lateral canthus, and left lower eyelid.  The patient was prepped and draped in the usual ophthalmic fashion.  Protective scleral shell was placed in the left eye.  A 4-0 silk traction sutures placed through the upper eyelid margin.  The medial aspect of the remaining lower eyelid was freshened with straight iris scissors and fibrin was removed from the inferior aspect of the wound.  The eyelid was everted and a tarsoconjunctival pedicle flap was developed by incision of the tarsus approximately 3-1/2-4 mm from the lid margin the full width of the eyelid.  Relaxing incisions were made both medially and laterally and Mueller's muscle was subsequently dissected free from the superior tarsal border.  The tarsoconjunctival pedicle was then anchored to the lateral orbital rim with two interrupted 6-0 Vicryl sutures and one 4-0 Vicryl suture.  The protective scleral shell was removed from the eye.  The medial aspect of the eyelid was advanced temporally.  The tarsoconjunctival pedicle was then cut to size and the tarsus was anchored to the medial aspect of the eyelid with multiple interrupted 6-0 Vicryl sutures.  The conjunctiva and lower lid retractors were attached to the advanced tarsal edge with a running 7-0 Vicryl suture.  The upper eyelid wound was present.  It was advanced to the advanced tarsoconjunctival pedicle temporally.  The conjunctival pedicle was slightly trimmed to make a lateral canthal tendon and the upper eyelid was advanced to the tarsoconjunctival pedicle temporally with an interrupted 6-0 Vicryl suture, it was then secured to the lateral orbital rim with two interrupted 6-0 Vicryl sutures.  Skin muscle flap was then elevated, was draped superiorly and nasally and was anchored to the medial aspect of the eyelid with interrupted 7-0 Vicryl sutures.  Burrows triangle was removed as was necessary to create smooth wound closure, which was closed with interrupted 7-0 Vicryl suture.  Temporally the orbicularis was resuspended from the advanced skin muscle flap with interrupted 6-0 Vicryl suture to the periosteum overlying the lateral orbital rim.  The skin muscle flap was secured to the underlying tarsoconjunctival pedicle with vertical mattress sutures of 7-0 Vicryl followed by wound closure temporally with interrupted 7-0 Vicryl suture with removal of a burrow's triangle as was necessary to create smooth wound closure.  Erythromycin ointment was then applied to the eye and to the wound followed by multiple eye pads with moderate pressure.  The patient tolerated the procedure well and left the operating room in excellent condition.  There were no apparent complications.","surgery, mohs resection epithelial skin, lid left lateral canthus, lateral canthal defect, tarsoconjunctival pedicle flap, lateral canthal tendon, skin muscle flap, interrupted vicryl sutures, canthal defect, mohs resection, lid defect, pedicle flap, canthal tendon, lateral canthus, upper eyelid, lateral orbital, eyelid, vicryl, sutures, repair, eye, canthal, defect, tarsoconjunctival, pedicle"
 Repeat cesarean section and bilateral tubal ligation., Surgery, Repeat C-section ,"PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 39 weeks.,2.  History of previous cesarean section x2.  The patient desires a repeat section.,3.  Chronic hypertension.,4.  Undesired future fertility.  The patient desires permanent sterilization.,POSTOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 39 weeks.,2.  History of previous cesarean section x2.  The patient desires a repeat section.,3.  Chronic hypertension.,4.  Undesired future fertility.  The patient desires permanent sterilization.,PROCEDURE PERFORMED:  ,Repeat cesarean section and bilateral tubal ligation.,ANESTHESIA: , Spinal.,ESTIMATED BLOOD LOSS:,  800 mL.,COMPLICATIONS:  ,None.,FINDINGS: , Male infant in cephalic presentation with anteflexed head, Apgars were 2 at 1 minute and 9 at 5 minutes, 9 at 10 minutes, and weight 7 pounds 8 ounces.  Normal uterus, tubes, and ovaries were noted.,INDICATIONS:  ,The patient is a 31-year-old gravida 5, para 4 female, who presented to repeat cesarean section at term.  The patient has a history of 2 previous cesarean sections and she desires a repeat cesarean section, additionally she desires permanent fertilization.  The procedure was described to the patient in detail including possible risks of bleeding, infection, injury to surrounding organs, and the possible need for further surgery and informed consent was obtained.,PROCEDURE NOTE: , The patient was taken to the operating room where spinal anesthesia was administered without difficulty.  The patient was prepped and draped in the usual sterile fashion in the dorsal supine position with a leftward tilt.  A Pfannenstiel skin incision was made with the scalpel and carried through to the underlying layer of fascia using the Bovie.  The fascia was incised in the midline and extended laterally using Mayo scissors.  Kocher clamps were used to elevate the superior aspect of the fascial incision, which was elevated, and the underlying rectus muscles were dissected off bluntly and using Mayo scissors.  Attention was then turned to the inferior aspect of the fascial incision, which in similar fashion was grasped with Kocher clamps, elevated, and the underlying rectus muscles were dissected off bluntly and using the Bovie.  The rectus muscles were dissected in the midline.,The peritoneum was identified and entered using Metzenbaum scissors; this incision was extended superiorly and inferiorly with good visualization of the bladder.  The bladder blade was inserted.  The vesicouterine peritoneum was identified and entered sharply using Metzenbaum scissors.  This incision was extended laterally and the bladder flap was created digitally.  The bladder blade was reinserted.  The lower uterine segment was incised in a transverse fashion using the scalpel and extended using bandage scissors as well as manual traction.,Clear fluid was noted.  The infant was subsequently delivered using a Kelly vacuum due to anteflexed head and difficulty in delivering the infant's head without the Kelly.  The nose and mouth were bulb suctioned.  The cord was clamped and cut.  The infant was subsequently handed to the awaiting nursery nurse.  The placenta was delivered spontaneously intact with a three-vessel cord noted.  The uterus was exteriorized and cleared of all clots and debris.  The uterine incision was repaired in 2 layers using 0 chromic sutures.  Hemostasis was visualized.  Attention was turned to the right fallopian tube, which was grasped with Babcock clamp using a modified Pomeroy method, a 2 cm of segment of tube ligated x2, transected and specimen was sent to pathology.  Attention was then turned to the left fallopian tube, which was grasped with Babcock clamp again using a modified Pomeroy method, a 2 cm segment of tube was ligated x2 and transected.  Hemostasis was visualized bilaterally.  The uterus was returned to the abdomen, both fallopian tubes were visualized and were noted to be hemostatic.  The uterine incision was reexamined and it was noted to be hemostatic.  The pelvis was copiously irrigated.  The rectus muscles were reapproximated in the midline using 3-0 Vicryl.  The fascia was closed with 0 Vicryl suture, the subcutaneous layer was closed with 3-0 plain gut, and the skin was closed with staples.  Sponge, lap, and instrument counts were correct x2.  The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition.","surgery, bilateral tubal ligation, permanent sterilization, undesired future fertility, repeat cesarean section, intrauterine pregnancy, mayo scissors, kocher clamps, metzenbaum scissors, fallopian tube, babcock clamp, pomeroy method, rectus muscles, cesarean section, intrauterine, cesarean, "
 Cadaveric renal transplant to right pelvis - endstage renal disease., Surgery, Renal Transplant - Cadaveric ,"HISTORY OF PRESENT ILLNESS:  ,The patient is a 50-year-old African American female with past medical history significant for hypertension and endstage renal disease, on hemodialysis secondary to endstage renal disease, last hemodialysis was on June 22, 2007.  The patient presents with no complaints for cadaveric renal transplant.  After appropriate cross match and workup of HLA typing of both recipient and cadaveric kidneys, the patient was deemed appropriate for operative intervention and transplantation of kidney.,PREOPERATIVE DIAGNOSIS:,  Endstage renal disease.,POSTOPERATIVE DIAGNOSIS: , Endstage renal disease.,PROCEDURE:,  Cadaveric renal transplant to right pelvis.,ESTIMATED BLOOD LOSS: , 400 mL.,FLUIDS:  ,One liter of normal saline and one liter of 5% of albumin.,ANESTHESIA:  ,General endotracheal.,SPECIMEN:  ,None.,DRAIN: , None.,COMPLICATIONS: , None.,The patient tolerated the procedure without any complication.,PROCEDURE IN DETAIL:  ,The patient was brought to the operating room, prepped and draped in sterile fashion.  After adequate anesthesia was achieved, a curvilinear incision was made in the right pelvic fossa approximately 9 cm in length extending from the 1.5 cm medial of the ASIS down to the suprapubic space.  After this was taken down with a #10 blade, electrocautery was used to take down tissue down to the layer of the subcutaneous fat.  Camper's and Scarpa's were dissected with electrocautery.  Hemostasis was achieved throughout the tissue plains with electrocautery.  The external oblique aponeurosis was identified with musculature and was entered with electrocautery.  Then hemostats were entered in and dissection continued down with electrocautery down through the external internal obliques and the transversalis fascia.  Additionally, the rectus sheath was entered in a linear fashion.  After these planes were entered using electrocautery, the retroperitoneum was dissected free from the transversalis fascia using blunt dissection.  After the peritoneum and peritoneal structures were moved medially and superiorly by blunt dissection, the dissection continued down bluntly throughout the tissue planes removing some alveolar tissue over the right iliac artery.  Upon entering through the transversalis fascia, the epigastric vessels were identified and doubly ligated and tied with #0 silk ties.  After the ligation of the epigastric vessels, the peritoneum was bluntly dissected and all peritoneal structures were bluntly dissected to a superior and medial plane.  This was done without any complication and without entering the peritoneum grossly.  The round ligament was identified and doubly ligated at this time with #0 silk ties as well.  The dissection continued down now to layer of the alveolar tissue covering the right iliac artery.  This alveolar tissue was cleared using blunt dissection as well as electrocautery.  After the external iliac artery was identified, it was cleared circumferentially all the way around and noted to have good flow and had good arterial texture.  The right iliac vein was then identified, and this was cleared again using electrocautery and blunt dissection.  After the right iliac vein was identified and cleared off all the alveolar tissue, it was circumferentially cleared as well.  An additional perforating branch was noted at the inferior pole of the right iliac vein.  This was tied with a #0 silk tie and secured.  Hemostasis was achieved at this time and the tie had adequate control.  The dissection continued down and identified all other vital structures in this area.  Careful preservation of all vital structures was carried out throughout the dissection.  At this time, Satinsky clamp was placed over the right iliac vein.  This was then opened using a #11 blade, approximately 1 cm in length.  The heparinized saline was placed and irrigated throughout the inside of the vein, and the kidney was pulled into the abdominal field still covered in its protective socking with the superior pole marked.  The renal vein was then elevated and identified in this area.  A 5-0 double-ended Prolene stitch was used to secure the renal vein, both superiorly and inferiorly, and after appropriately being secured with 5-0 Prolene, these were tied down and secured.  The renal vein was then anastomosed to the right iliac vein in a circumferential manner in a running fashion until secured at both superior and inferior poles.  The dissection then continued down and the iliac artery was then anastomosed to the renal artery at this time using a similar method with 5-0 Prolene securing both superior and inferior poles.  After such time the 5-0 Prolene was run around in a circumferential manner until secured in both superior and inferior poles once again.  After this was done and the artery was secured, the Satinsky clamp was removed and a bulldog placed over.  The flow was then opened on the arterial side and then opened on the venous side to allow for proper flow.  The bulldog was then placed back on the renal vein and allowed for the hyperperfusion of the kidney.  The kidney pinked up nicely and had a good appearance to it and had appearance of good blood flow.  At this time, all Satinsky clamps were removed and all bulldog clamps were removed.  The dissection then continued down to the layer of the bladder at which time the bladder was identified.  Appropriate area on the dome the bladder was identified for entry.  This was entered using electrocautery and approximately 1 cm length after appropriately sizing and incising of the ureter using the Metzenbaum scissors in a linear fashion.  Before this was done, #0 chromic catgut stitches were placed and secured laterally and inferiorly on the dome of the bladder to elevate the area of the bladder and then the bladder was entered using the electrocautery approximately 1 cm in length.  At this time, a renal stent was placed into the ureter and secured superiorly and the stent was then placed into the bladder and secured as well.  Subsequently, the superior and inferior pole stitches with 5-0 Prolene were used to secure the ureter to the bladder.  This was then run mucosa-to-mucosa in a circumferential manner until secured in both superior and inferior poles once again.  Good flow was noted from the ureter at the time of operation.  Additional Vicryl stitches were used to overlay the musculature in a seromuscular stitch over the dome of the bladder and over the ureter itself.  At this time, an Ethibond stitch was used to make an additional seromuscular closure and rolling of the bladder musculature over the dome and over the anastomosis once again.  This was inspected and noted for proper control.  Irrigation of the bladder revealed that the bladder was appropriately filled and there were no flows and no defects.  At this time, the anastomoses were all inspected, hemostasis was achieved and good closure of the anastomosis was noted at this time.  The kidney was then placed back into its new position in the right pelvic fossa, and the area was once again inspected for hemostasis which was achieved.  A 1-0 Prolene stitch was then used for mass closure of the external, internal, and transversalis fascias and musculature in a running fashion from superior to inferior.  This was secured and knots were dumped.  Subsequently, the area was then checked and inspected for hemostasis which was achieved with electrocautery, and the skin was closed with 4-0 running Monocryl.  The patient tolerated procedure well without evidence of complication, transferred to the Dunn ICU where he was noted to be stable.  Dr. A was present and scrubbed through the entire procedure.","surgery, endstage renal disease, ethibond, satinsky clamp, aponeurosis, cadaveric, cross match, curvilinear incision, hemodialysis, iliac vein, pelvic fossa, peritoneum, recipient, renal transplant, transplant, transversalis fascia, superior and inferior poles, endstage renal, renal disease, vein, electrocautery, bladder, renal, intervention, "
" Acute lymphocytic leukemia in remission, removal of venous port.", Surgery, Removal of Venous Port ,"PREOPERATIVE DIAGNOSIS: , Acute lymphocytic leukemia in remission.,POSTOPERATIVE DIAGNOSIS: , Acute lymphocytic leukemia in remission.,OPERATION PERFORMED:  ,Removal of venous port.,ANESTHESIA: , General.,INDICATIONS: , This 9-year-old young lady presented with ALL in Orange County and had a port placed at that time.  She subsequently has now undergone chemotherapy here and is now off therapy.  She no longer needs her venous port so, comes to the operating room today for its removal.,OPERATIVE PROCEDURE: , After the induction of general anesthetic, the exit site was prepped and draped in usual manner.  The previous incision was opened by excising the old scar.  The port pocket was then opened and the port was removed from the pocket.  There was a resistance to the catheter being removed and so therefore, we began following the catheter along its path opening the tract until finally the catheter seemed to come free and could be pulled out without difficulty.  The port pocket was then closed using a #3-0 Vicryl in subcutaneous tissue, #5-0 subcuticular Monocryl in the skin.  Sterile dressing was applied.  Young lady was awakened and taken to the recovery room in satisfactory condition.","surgery, removal of venous port, acute lymphocytic leukemia, venous port, lymphocytic, leukemia, venous"
" Radical resection of tumor of the scalp, excision of tumor from the skull with debridement of the superficial cortex with diamond bur, and advancement flap closure.", Surgery, Resection of Tumor of Scalp ,"PREOPERATIVE DIAGNOSIS: , Squamous cell carcinoma of the scalp.,POSTOPERATIVE DIAGNOSIS:,  Same.,OPERATION PERFORMED: , Radical resection of tumor of the scalp (CPT 11643).  Excision of tumor from the skull with debridement of the superficial cortex with diamond bur.  Advancement flap closure, with total undermined area 18 centimeters by 16 centimeters (CPT 14300).,ANESTHESIA:,  General endotracheal anesthesia.,INDICATIONS:  ,This is an 81-year-old male who has a large exophytic 7cm lesion of the anterior midline scalp which is biopsy-positive for skin malignancy, specifically, squamous call carcinoma.  This appears to be affixed to the underlying scalp.,PLAN: , Radical resection with frozen sections to clear margins thereafter, with planned reconstruction.,CONSENT:,  I have discussed with the patient the possible risks of bleeding, infection, renal problems, scar formation, injury to muscle, nerves, and possible need for additional surgery with possible recurrence of the patient's carcinoma, with review of detailed informed consent with the patient, who understood, and wished to proceed.,FINDINGS: , The patient had a 7cm large exophytic lesion which appeared to be invasive into the superficial table of the skull.  The final periosteal margin which centrally appeared was positive for carcinoma.  The final margins peripherally were all negative.,DESCRIPTION OF PROCEDURE IN DETAIL: , The patient was taken to the operating room and there was placed supine on the operating room table.,General endotracheal anesthesia was administered after endotracheal tube intubation was performed by the Anesthesia Service personnel.  The patient was thereafter prepped and draped in the usual sterile manner using Betadine Scrub and Betadine paint.  Thereafter, the local anesthesia was injected into the area around the tumor.  A **** type excision was planned down to the periosteum.  A supraperiosteal radical resection was performed.,It was obvious that there was tumor at the deep margin, involving the periosteum.  The edges were marked along the four quadrants, at the 12 o'clock, 3 o'clock, 6 o'clock, and the 9 o'clock positions, and these were sent for frozen section evaluation.  Frozen section revealed positive margins at one end of the resection.  Therefore, an additional circumferential resection was performed and the final margins were all negative.,Following completion, the deep periosteal margin was resected.  The circumferential periosteal margins were noted to be negative; however, centrally, there was a small area which showed tumor eroding into the superficial cortex of the skull.  Therefore, the Midas Rex drill was utilized to resect approximately 1-2 mm of the superficial cortex of the bone at the area where the positive margin was located.  Healthy bone was obtained; however, it did not enter the diploic or marrow-containing bone in the area.  Therefore, no bong margin was taken.  However, at the end of the procedure, it did not appear that the residual bone had any residual changes consistent with carcinoma.,Following completion of the bony resection, the area was irrigated with copious amounts of saline.  Thereafter, advancement flaps were created, both on the left and the right side of the scalp, with the total undermined area being approximately 18cm by 16cm.  The galea was incised in multiple areas, to provide for additional mobilization of the tissue.  The tissue was closed under tension with 3-0 Vicryl suture deep in the galea and surgical staples superficially.,The patient was awakened from anesthetic, was extubated and was taken to the recovery room in stable condition.,DISPOSITION:,  The patient was discharged to home with antibiotics and analgesics, to follow-up in approximately one week.,NOTE: , The final margins of both periosteal, as well as skin were negative circumferentially, around the tumor.  The only positive margin was deep, which was a periosteal margin and bone underlying it was partially resected, as was indicated above.","surgery, squamous cell carcinoma of the scalp, squamous cell carcinoma, radical resection, margin, midas rex drill, radical resection of tumor, resection of tumor, endotracheal anesthesia, superficial cortex, margins, periosteum, skull, cortex, periosteal, scalp, resection, tumor, "
 Complex Regional Pain Syndrome Type I.  Stellate ganglion RFTC (radiofrequency thermocoagulation)  left side and interpretation of Radiograph., Surgery, Radiofrequency Thermocoagulation - 2 ,"PREOPERATIVE DIAGNOSIS:,  Complex Regional Pain Syndrome Type I.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE:,1.  Stellate ganglion RFTC (radiofrequency thermocoagulation)  left side.,2.  Interpretation of Radiograph.,ANESTHESIA:  ,IV Sedation with Versed and Fentanyl.,ESTIMATED BLOOD LOSS:,  None.,COMPLICATIONS:,  None.,INDICATIONS: , Patient with reflex sympathetic dystrophy, left side.  Positive for allodynia, pain, mottled appearance, skin changes upper extremities as well as swelling.,SUMMARY OF PROCEDURE: , Patient is admitted to the Operating Room.  Monitors placed, including EKG, Pulse oximeter, and BP cuff.  Patient had a pillow placed under the shoulder blades.  The head and neck was allowed to fall back into hyperextension.  The neck region was prepped and draped in sterile fashion with Betadine and alcohol.  Four sterile towels were placed.  The cricothyroid membrane was palpated, then going one finger's breadth lateral from the cricothyroid membrane and one finger's breadth inferior, the carotid pulse was palpated and the sheath was retracted laterally.  A 22 gauge SMK 5-mm bare tipped needle was then introduced in between the cricothyroid membrane and the carotid sheath and directed inferiomedially.  The needle is advanced prudently through the tissues, avoiding the carotid artery laterally.  The tip of the needle is perceived to intersect with the vertebral body of Cervical #7 and this was visualized by fluoroscopy.  Aspiration was cautiously performed after the needle was retracted approximately 1 mm and held steady with left hand.  No venous or arterial blood return is noted.  No cerebral spinal fluid is noted.  Positive sensory stimulation was elicited using the Radionics unit at 50 Hz from 0-0.1 volts and negative motor stimulation was elicited from 1-10 volts at 2 Hz.  After negative aspiration through the 22 gauge SMK 5mm bare tipped needle is absolutely confirmed, 5 cc of solution (solution consisting of 5 cc of 0.5% Marcaine, 1 cc of triamcinolone) was then injected into the stellate ganglion region.  This was done with intermittent aspiration vigilantly verifying negative aspiration.  The stylet was then promptly replaced and neurolysis (nerve decompression) was then carried out for 60 seconds at 80 degrees centigrade.  This exact same procedure using the exact same protocol was repeated one more time to complete the two lesions of the stellate ganglion.  The patient was immediately placed in the sitting position to reduce any side effect from the stellate ganglion block associated with cephalad spread of the solution.  Pressure was placed over the puncture site for approximately five minutes to eliminate any hemorrhage from blood vessels that may have been punctured and a Band-Aid was placed over the puncture site.  Patient was monitored for an additional ten to fifteen minutes and was noted to have tolerated the procedure well without any adverse sequelae.  Significant temperature elevation was noted on the affected side verifying neurolysis of the ganglion.  ,Interpretation of radiograph reveals placement of the 22-gauge SMK 5-mm bare tipped needle in the region of the stellate ganglion on the affected side.  Four lesions were carried out.","surgery, sheath, vertebral body, regional pain syndrome, radiofrequency thermocoagulation, stellate ganglion, rftc, radiofrequency, radiograph, cricothyroid, thermocoagulation, ganglion,"
 Cosmetic rhinoplasty.  Request for cosmetic change in the external appearance of the nose., Surgery, Rhinoplasty ,"PREOPERATIVE DIAGNOSES:,1.  Nasal obstruction secondary to deviated nasal septum.,2.  Bilateral turbinate hypertrophy.,PROCEDURE:,  Cosmetic rhinoplasty.  Request for cosmetic change in the external appearance of the nose.,ANESTHESIA: , General via endotracheal tube.,INDICATIONS FOR OPERATION:  ,The patient is a 26-year-old white female with longstanding nasal obstruction.  She also has concerns with regard to the external appearance of her nose and is requesting changes in the external appearance of her nose.  From her functional standpoint, she has severe left-sided nasal septal deviation with compensatory inferior turbinate hypertrophy.  From the aesthetic standpoint, the nose is over projected, lacks rotation, and has a large dorsal hump.  First we are going to straighten the nasal septum and reduce the size of the turbinates and then we will also take down the hump, rotate the tip of the nose, and de-project the nasal tip.  I explained to her the risks, benefits, alternatives, and complications for postsurgical procedure.  She had her questions asked and answered and requested that we proceed with surgery as outlined above.,PROCEDURE DETAILS: , The patient was taken to the operating room and placed in supine position.  The appropriate level of general endotracheal anesthesia was induced.  The face, head, and neck were sterilely prepped and draped.  The nose was anesthetized and vasoconstricted in the usual fashion.  Procedure began with a left hemitransfixion incision, which was brought down into the left intercartilaginous incision.  Right intercartilaginous incision was also made and the dorsum of the nose was elevated in the submucoperichondrial and subperiosteal plane.  Intact bilateral septomucoperichondrial flaps were elevated and a severe left-sided nasal septal deviation was corrected by detachment of the caudal nasal septum from the maxillary crest in a swinging door fashion and placing it back into the midline.  Posterior vomerine spur was divided superiorly and inferiorly and a large spur was removed.  Anterior and inferior one-third of each inferior turbinate was clamped, cut, and resected.  The upper lateral cartilages were divided from their attachments to the dorsal nasal septum and the cartilaginous septum was lowered by approximately 2 mm.  The bony hump of the nose was lowered with a straight osteotome by 4 mm.  Fading medial osteotomies were carried out and lateral osteotomies were then created in order to narrow the bony width of the nose.  The tip of the nose was then addressed via a retrograde dissection and removal of cephalic caudal semicircle cartilage medially at the tip.  The caudal septum was shortened by 2 mm in an angle in order to enhance rotation.  Medial crural footplates were reattached to the caudal nasal septum with a projection rotation control suture of #3-0 chromic.  The upper lateral cartilages were rejoined to the dorsal septum with a #4-0 plain gut suture.  No middle valves or bone grafts were necessary.  Intact mucoperichondrial flaps were closed with 4-0 plain gut suture and Doyle nasal splints were placed on either side of the nasal septum.  The middle meatus was filled with Surgicel and Cortisporin otic and external Denver splint was applied with sterile tape and Mastisol.  Excellent aesthetic and functional results were thus obtained and the patient was awakened in the operating room, taken to the recovery room in good condition.","surgery, nasal obstruction, cosmetic, dorsal hump, endotracheal tube, hemitransfixion incision, hypertrophy, intercartilaginous, intercartilaginous incision, nasal septum, nasal tip, septomucoperichondrial, submucoperichondrial, subperiosteal, turbinate, vomerine, spur, nasal septal, nasal, rhinoplasty, septum, "
" Release of A1 pulley, right thumb.   Stenosing tendinosis, right thumb (trigger finger).  There was noted to be thickening of the A1 pulley.  There was a fibrous nodule noted within the flexor tendon of the thumb, which caused triggering sensation to the thumb.", Surgery, Release of A1 Pulley - 1 ,"PREOPERATIVE DIAGNOSIS: , Stenosing tendinosis, right thumb (trigger finger).,POSTOPERATIVE DIAGNOSIS: , Stenosing tendinosis, right thumb (trigger finger).,PROCEDURE PERFORMED:,  Release of A1 pulley, right thumb.,ANESTHESIA:,  IV regional with sedation.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,TOURNIQUET TIME: , Approximately 20 minutes at 250 mmHg.,INTRAOPERATIVE FINDINGS: , There was noted to be thickening of the A1 pulley.  There was a fibrous nodule noted within the flexor tendon of the thumb, which caused triggering sensation to the thumb.,HISTORY:  ,This is a 51-year-old right hand dominant female with a longstanding history of pain as well as locking sensation to her right thumb.  She was actually able to spontaneously trigger the thumb.  She was diagnosed with stenosing tendinosis and wishes to proceed with release of A1 pulley.  All risks and benefits of the surgery was discussed with her at length.  She was in agreement with the above treatment plan.,PROCEDURE:  ,On 08/21/03, she was taken to operating room at ABCD General Hospital and placed supine on the operating table.  A regional anesthetic was applied by the Anesthesia Department.  Tourniquet was placed on her proximal arm.  The upper extremity was sterilely prepped and draped in the usual fashion.,An incision was made over the proximal crease of the thumb.  Subcuticular tissues were carefully dissected.  Hemostasis was controlled with electrocautery.  The nerves were identified and retracted throughout the entire procedure.  The fibers of the A1 pulley were identified.  They were sharply dissected to release the tendon.  The tendon was then pulled up into the wound and inspected.  There was no evidence of gross tear noted.  Fibrous nodule was noted within the tendon itself.  There was no evidence of continuous locking.  Once release of the pulley had been performed, the wound was copiously irrigated.  It was then reapproximated using #5-0 nylon simple interrupted and horizontal mattress sutures.  Sterile dressing was applied to the upper extremity.  Tourniquet was deflated.  It was noted that the thumb was warm and pink with good capillary refill.  The patient was transferred to Recovery in apparent stable and satisfactory condition.  Prognosis is fair.","surgery, release of a1 pulley, tendinosis, thumb, flexor tendon, trigger finger, fibrous nodule, stenosing tendinosis, tourniquet, stenosing, tendon, release, pulley"
" Bilateral rectus recession with the microscopic control, 8 mm, both eyes.", Surgery, Rectus Recession ,"PREOPERATIVE DIAGNOSIS:,  Congenital bilateral esotropia, 42 prism diopters.,PROCEDURE:,  Bilateral rectus recession with the microscopic control, 8 mm, both eyes.,POSTOPERATIVE DIAGNOSIS: , Congenital bilateral esotropia, 42 prism diopters.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL: , The patient was taken to the Surgery Room and placed in the supine position.  The general anesthesia was achieved with intubation with no problems.  Both eyes were prepped and draped in usual manner.  The attention was turned the right eye and a hole was made in the drape and a self-retaining eye speculum was placed ensuring eyelash in the eye drape.  The microscope was focused on the palpebral limbus and the eyeball was rotated medially and laterally with no problem.  The eyeball rotated medially and upwards by holding the limbus at 7 o'clock position.  Inferior fornix conjunctival incision was made and Tenons capsule buttonholed.  The lateral rectus muscle was engaged over the muscle hook and the Tenons capsule was retracted with the tip of the muscle hook.  The Tenons capsule was buttonholed.  The tip of the muscle hook and Tenons capsule was cleaned from the insertion of the muscle.  __________ extension of the muscle was excised.  The 7-0 Vicryl sutures were placed at the insertion of the muscle and double locked at the upper and lower borders.  The muscle was disinserted from original insertion.  The suture was passed 8 mm posterior to the insertion of the muscle in double sewed fashion.  The suture was pulled, tied, and cut.  The muscle was in good position.  The conjunctiva was closed with 7-0 Vicryl suture in running fashion.  The suture was pulled, tied, and cut.  The eye speculum was taken out.,Similar procedure performed on the left rectus muscle and it was recessed by 8 mm from its original insertion.  The suture was pulled, tied and cut.  The eye speculum was taken out after the conjunctiva was sewed up and the suture was cut.  TobraDex eye drops were instilled in both eyes and the patient extubated and was in good condition.  To be seen in the office in 1 week.","surgery, congenital bilateral esotropia, esotropia, tenons capsule, rectus muscle, bilateral rectus recession, rectus recession, eye speculum, muscle hook, eyes, muscle, rectus, "
 The patient was found to have limitations to extension at the IP joint to the right thumb and he had full extension after release of A1 pulley., Surgery, Release of A1 Pulley ,"PREOPERATIVE DIAGNOSIS: , Right trigger thumb.,POSTOPERATIVE DIAGNOSIS:,  Right trigger thumb.,SURGERY: , Release of A1 pulley, CPT code 26055.,ANESTHESIA:,  General LMA.,TOURNIQUET TIME:  ,9 minutes at 200 torr.,FINDINGS:,  The patient was found to have limitations to extension at the IP joint to the right thumb.  He was found to have full extension after release of A1 pulley.,INDICATIONS:,  The patient is 2-1/2-year-old.  He has a history of a trigger thumb.  This was evaluated in the office.  He was indicated for release of A1 pulley to allow for full excursion.  Risks and benefits including recurrence, infection, and problems with anesthesia were discussed at length with the family.  They wanted to proceed.,PROCEDURE:,  The patient was brought into the operating room and placed on the operating table in supine position.  General anesthesia was induced without incident.  He was given a weight-adjusted dose of antibiotics.  The right upper extremity was then prepped and draped in a standard fashion.  Limb was exsanguinated with an Esmarch bandage.  Tourniquet was raised to 200 torr.  Transverse incision was then made at the base of thumb.  The underlying soft tissues were carefully spread in line longitudinally.  The underlying tendon was then identified.  The accompanied A1 pulley was also identified.  This was incised longitudinally using #11 blade.  Inspection of the entire tendon then demonstrated good motion both in flexion and extension.  The leaflets of the pulley were easily identified.,The wound was then irrigated and closed.  The skin was closed using interrupted #4-0 Monocryl simple sutures.  The area was injected with 5 mL of 0.25% Marcaine.  The wound was dressed with Xeroform, dry sterile dressings, hand dressing, Kerlix, and Coban.  The patient was awakened from anesthesia and taken to the recovery room in good condition.  There were no complications.  All instrument, sponge, needle counts were correct at the end of case.,PLAN: , The patient will be discharged home.  He will return in 1-1/2 weeks for wound inspection.","surgery, a1 pulley, release of a1 pulley, trigger thumb, limitations to extension, ip joint"
" Radioactive plaque macular edema.  Removal of radioactive plaque, right eye with lateral canthotomy.  A lid speculum was applied and the conjunctiva was opened 4 mm from the limbus.  A 2-0 traction suture was passed around the insertion of the lateral rectus and the temporal one-half of the globe was exposed.", Surgery, Radioactive Plaque - Removal ,"PREOPERATIVE DIAGNOSIS: , Radioactive plaque macular edema.,POSTOPERATIVE DIAGNOSIS:,  Radioactive plaque macular edema.,TITLE OF OPERATION:,  Removal of radioactive plaque, right eye with lateral canthotomy.,OPERATIVE PROCEDURE IN DETAIL: , The patient was prepped and draped in the usual manner for a local eye procedure.  Then a retrobulbar injection of 2% Xylocaine was performed.  A lid speculum was applied and the conjunctiva was opened 4 mm from the limbus.  A 2-0 traction suture was passed around the insertion of the lateral rectus and the temporal one-half of the globe was exposed.  Next, the plaque was identified and the two scleral sutures were removed.  The plaque was gently extracted and the conjunctiva was re-sutured with 6-0 catgut, following removal of the traction suture.  The fundus was inspected with direct ophthalmoscopy.  An eye patch was applied following Neosporin solution irrigation.  The patient was sent to the recovery room in good condition.  A lateral canthotomy had been done.","surgery, conjunctiva, eye patch, ophthalmoscopy, radioactive plaque, traction, suture, eye, radioactive, plaque"
" Closure of rectovaginal fistula, transperineal approach", Surgery, Rectovaginal Fistula Closure ,"PREOPERATIVE DIAGNOSIS (ES):, Rectovaginal fistula.,POSTOPERATIVE DIAGNOSIS (ES):, Rectovaginal fistula.,PROCEDURE:, CPT code 57307 - Closure of rectovaginal fistula, transperineal approach.,MATERIAL FORWARDED TO THE LABORATORY FOR EXAMINATION:, Includes fistula tract.,ESTIMATED BLOOD LOSS:, 25 mL.,INDICATIONS:, The patient is a 27-year-old morbidly obese gravida three, para one, who was seen in consultation from Dr. M's office, in the office of Chattanooga GYN Oncology on 01/12/06 regarding an obstetrically related rectovaginal fistula, dating from 1998. She had an episioproctotomy associated with the birth of her seven pound son in 1998 and immediately noted the spontaneous loss of gas and stool. She had her fistula repaired by Dr. R in 2000 and did well for approximately one year, without complaint, when she again noted the spontaneous loss of stool and gas from her vagina. She has partial control if her stools are formed, but she has no control of her gas. She is a type 2 diabetic, with poorly controlled blood sugars at times, however, her diabetes has been fairly well controlled of late.,FINDINGS AT THE TIME OF SURGERY:, She had a 1 cm fistulous tract, approximately 4 cm proximal to the vaginal introitus. This communicated directly with the low rectal vault. She had good rectal sphincter tone and a very thin perineal body. The fistulous tract was excised completely and intact. The underlying rectal mucosa was closed with chromic and the perineal body was reinforced and reconstructed. At the completion of the procedure, the repair is watertight, there were no other defects.,DESCRIPTION OF THE OPERATION:, The patient was taken to the operating room where she underwent general endotracheal anesthesia. She was then placed in the lithotomy position using candy-cane stirrups. The vulva and vagina were prepped and the patient was draped. A lacrimal duct probe was used to define the fistulous tract and a transperineal incision was made. The rectovaginal septum was developed and with an index finger in the rectum, the rectovaginal septum was easily defined. The fistulous tract was isolated and using the lacrimal duct probe, it was completely isolated. Using electrocautery dissection on the pure cut mode, the rectal mucosa was entered in a circumferential fashion as was the vaginal mucosa. This allowed for removal of the fistulous tract intact, with both epithelial layers preserved. The perineum and rectum were irrigated vigorously and then the rectal mucosa was reapproximated with a running stitch of number 4-0 chromic. The rectal vault was distended with saline and the repair was watertight. The defect was irrigated, suctioned, inspected and found to be free of clot, blood or debris. The perineal body was reconstructed with reapproximation of the levator muscles, using a series of interrupted horizontal mattress stitches of number 2-0 Vicryl. This allowed for excellent restoration of the perineal body. After this was accomplished, the defect was once again irrigated, suctioned, inspected, and found to be free of clot, blood or debris. The vaginal defect was closed with a running locking stitch of number 2-0 Vicryl and the perineal incision was closed with a subcuticular stitch of number 2-0 Vicryl. The patient was awakened and taken to the recovery room in stable condition, after having tolerated the procedure well.","surgery, transperineal approach, fistula tract, fistula, rectovaginal, septum, lacrimal duct, probe, candy-cane, perineal, closure of rectovaginal fistula, rectal mucosa, perineal body, fistulous tract, rectovaginal fistula, transperineal, fistulous, rectal,"
 Right sacral alar notch and sacroiliac joint/posterior rami radiofrequency thermocoagulation., Surgery, Radiofrequency Thermocoagulation ,"PROCEDURE: , Right sacral alar notch and sacroiliac joint/posterior rami radiofrequency thermocoagulation.,ANESTHESIA:  ,Local sedation.,VITAL SIGNS: , See nurse's notes.,COMPLICATIONS: , None.,DETAILS OF PROCEDURE: , INT was placed.  The patient was in the operating room in the prone position.  The back prepped with Betadine.  The patient was given sedation and monitored.  Under fluoroscopy, the right sacral alar notch was identified.  After placement of a 20-gauge, 10 cm SMK needle into the notch, a positive sensory, negative motor stimulation was obtained.  Following negative aspiration, 5 cc of 0.5% of Marcaine and 20 mg of Depo-Medrol were injected.  Coagulation was then carried out at 90oC for 90 seconds.  The SMK needle was then moved to the mid-inferior third of the right sacroiliac joint.  Again the steps dictated above were repeated.,The above was repeated for the posterior primary ramus branch right at S2 and S3 by stimulating along the superior lateral wall of the foramen; then followed by steroid injected and coagulation as above.,There were no complications.  The patient was returned to outpatient recovery in stable condition.","surgery, posterior rami, sacroiliac joint, sacral alar notch, radiofrequency thermocoagulation, thermocoagulation, radiofrequency, sacroiliac, sacral, alar, notch"
 Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain., Surgery, Radiofrequency Thermocoagulation - 1 ,"PROCEDURE: , Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain.,ANESTHESIA: , Local sedation.,VITAL SIGNS: , See nurse's notes.,COMPLICATIONS: , None.,DETAILS OF PROCEDURE:  ,INT was placed.  The patient was in the operating room in the prone position with the back prepped and draped in a sterile fashion.  The patient was given sedation and monitored.  Lidocaine 1.5% for skin wheal was made 10 cm from the midline to the bilateral L2 distal vertebral body.  A 20-gauge, 15 cm SMK needle was then directed using AP and fluoroscopic guidance so that the tip of the needle was noted to be along the distal one-third and anterior border on the lateral view and on the AP view the tip of the needle was inside the lateral third of the border of the vertebral body.  At this time a negative motor stimulation was obtained.  Injection of 10 cc of 0.5% Marcaine plus 10 mg of Depo-Medrol was performed. Coagulation was then carried out for 90oC for 90 seconds.  At the conclusion of this, the needle under fluoroscopic guidance was withdrawn approximately 5 mm where again a negative motor stimulation was obtained and the sequence of injection and coagulation was repeated.  This was repeated one more time with a 5 mm withdrawal and coagulation.,At that time, attention was directed to the L3 body where the needle was placed to the upper one-third/distal two-thirds junction and the sequence of injection, coagulation, and negative motor stimulation with needle withdrawal one time of a 5 mm distance was repeated.  There were no compilations from this.  The patient was discharged to operating room recovery in stable condition.","surgery, lumbar sympathetic chain, vertebral body, radiofrequency thermocoagulation, motor stimulation, thermocoagulation, radiofrequency, coagulation, needle, "
" Bilateral L5, S1, S2, and S3 radiofrequency ablation for sacroiliac joint pain.  Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.", Surgery, Radiofrequency Ablation ,"PROCEDURE: , Bilateral L5, S1, S2, and S3 radiofrequency ablation.,INDICATION: , Sacroiliac joint pain.,INFORMED CONSENT: , The risks, benefits and alternatives of the procedure were discussed with the patient.  The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible of vascular entry of medications.  I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing.  The patient understood the informed consent and desired to have the procedure performed.,PROCEDURE: , Oxygen saturation and vital signs were monitored continuously throughout the procedure.  The patient remained awake throughout the procedure in order to interact and give feedback.  The x-ray technician was supervised and instructed to operate the fluoroscopy machine.,The patient was placed in a prone position on the treatment table with a pillow under the chest and head rotated.  The skin over and surrounding the treatment area was cleaned with Betadine.  The area was covered with sterile drapes, leaving a small window opening for needle placement.  Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.,With fluoroscopy, a 20 gauge 10-mm bent Teflon coated needle was gently guided into the groove between the SAP and the sacrum for the dorsal ramus of L5 and the lateral border of the posterior sacral foramen, for the lateral branches of S1, S2, and S3.  Also, fluoroscopic views were used to ensure proper needle placement.,The following technique was used to confirm correct placement.  Motor stimulation was applied at 2 Hz with 1 millisecond duration.  No extremity movement was noted at less than 2 volts.  Following this, the needle trocar was removed and a syringe containing 1% lidocaine was attached.  At each level, after syringe aspiration with no blood return, 0.5 mL of 1% lidocaine was injected to anesthetize the lateral branch and the surrounding tissue.  After completion, a lesion was created at that level with a temperature of 80 degrees for 90 seconds.,All injected medications were preservative free.  Sterile technique was used throughout the procedure.,ADDITIONAL DETAILS:  ,None.,COMPLICATIONS: , None.,DISCUSSION: , Post-procedure vital signs and oximetry were stable.  The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day.  The patient was told to resume all medications.  The patient was told to be in relative rest for 1 day but then could resume all normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes, or changes in bowel or bladder function.,Follow up appointment was made at PM&R Spine Clinic in approximately one to two weeks.","surgery, sacroiliac joint pain, sacroiliac, teflon coated needle, fluoroscopy, needle placement, radiofrequency ablation, ablation, tissue, lidocaine, needle,"
 Modified radical mastectomy.  An elliptical incision was made to incorporate the nipple-areolar complex and the previous biopsy site.  The skin incision was carried down to the subcutaneous fat but no further. , Surgery, Radical Mastectomy - 1 ,"PROCEDURE PERFORMED: , Modified radical mastectomy.,ANESTHESIA: , General endotracheal tube.,PROCEDURE:  ,After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating room table.  General endotracheal anesthesia was induced without incident.  The patient was prepped and draped in the usual sterile manner.  Care was taken to ensure that the arm was placed in a relaxed manner away from the body to facilitate exposure and to avoid nerve injury.,An elliptical incision was made to incorporate the nipple-areolar complex and the previous biopsy site.  The skin incision was carried down to the subcutaneous fat but no further.  Using traction and counter-traction, the upper flap was dissected from the chest wall medially to the sternal border, superiorly to the clavicle, laterally to the anterior border of the latissimus dorsi muscle, and superolaterally to the insertion of the pectoralis major muscle.  The lower flap was dissected in a similar manner down to the insertion of the pectoralis fascia overlying the fifth rib medially and laterally out to the latissimus dorsi.  Bovie electrocautery was used for the majority of the dissection and hemostasis tying only the large vessels with 2-0 Vicryl.  The breast was dissected from the pectoralis muscle beginning medially and progressing laterally removing the pectoralis fascia entirely.  Once the lateral border of the pectoralis major muscle was identified, the pectoralis muscle was retracted medially and the interpectoral fat was removed with the specimen.,The axillary dissection was then begun by incising the fascia overlying axilla proper allowing visualization of the axillary vein.  The highest point of axillary dissection was then marked with a long stitch for identification by the surgical pathologist.  The axilla was then cleared of its contents by sharp dissection.  Small vessels entering the axillary vein were clipped and divided.  The axilla was cleared down to the chest wall, and dissection was continued laterally to the subscapular vein.  The long thoracic nerve was cleared identified lying against the chest and was carefully preserved.  The long thoracic nerve represented the posterior most aspect of the dissection.  As the axillary contents were dissected in the posterolateral axilla, the thoracodorsal nerve was identified and carefully preserved.  The dissection continued caudally until the entire specimen was freed and delivered from the operative field.  Copious water lavage was used to remove any debris, and hemostasis was obtained with Bovie electrocautery.,Two Jackson-Pratt drains were inserted through separate stab incisions below the initial incision and cut to fit.  The most posterior of the 2 was directed into the axilla and the other directed anteriorly across the pectoralis major.  These were secured to the skin using 2-0 silk, which was Roman-sandaled around the drain.,The skin incision was approximated with skin staples.  A dressing was applied.  The drains were placed on ""grenade"" suction.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition.","surgery, latissimus dorsi muscle, pectoralis major muscle, pectoralis fascia, axillary vein, thoracic nerve, radical mastectomy, pectoralis major, axillary, incision, mastectomy, fascia, muscle, pectoralis, "
 Invasive carcinoma of left breast. Left modified radical mastectomy., Surgery, Radical Mastectomy ,"PREOPERATIVE DIAGNOSIS:,  Invasive carcinoma of left breast.,POSTOPERATIVE DIAGNOSIS:,  Invasive carcinoma of left breast.,OPERATION PERFORMED:,  Left modified radical mastectomy.,ANESTHESIA: , General endotracheal.,INDICATION FOR THE PROCEDURE:  ,The patient is a 52-year-old female who recently underwent a left breast biopsy and was found to have invasive carcinoma of the left breast.  The patient was elected to have a left modified radical mastectomy, she was not interested in a partial mastectomy.  She is aware of the risks and complications of surgery, and wished to proceed.,DESCRIPTION OF PROCEDURE:  ,The patient was taken to the operating room.  She underwent general endotracheal anesthetic.  The TED stockings and venous compression devices were placed on both lower extremities and they were functioning well.  The patient's left anterior chest wall, neck, axilla, and left arm were prepped and draped in the usual sterile manner.  The recent biopsy site was located in the upper and outer quadrant of left breast.  The plain incision was marked along the skin.  Tissues and the flaps were injected with 0.25% Marcaine with epinephrine solution and then a transverse elliptical incision was made in the breast of the skin to include nipple areolar complex as well as the recent biopsy site.  The flaps were raised superiorly and just below the clavicle medially to the sternum, laterally towards the latissimus dorsi, rectus abdominus fascia.  Following this, the breast tissue along with the pectoralis major fascia were dissected off the pectoralis major muscle.  The dissection was started medially and extended laterally towards the left axilla.  The breast was removed and then the axillary contents were dissected out.  Left axillary vein and artery were identified and preserved as well as the lung _____.  The patient had several clinically palpable lymph nodes, they were removed with the axillary dissection.  Care was taken to avoid injury to any of the above mentioned neurovascular structures.  After the tissues were irrigated, we made sure there were no signs of bleeding.  Hemostasis had been achieved with Hemoclips.  Hemovac drains x2 were then brought in and placed under the left axilla as well as in the superior and inferior breast flaps.  The subcu was then approximated with interrupted 4-0 Vicryl sutures and skin with clips.  The drains were sutured to the chest wall with 3-0 nylon sutures.  Dressing was applied and the procedure was completed.  The patient went to the recovery room in stable condition.","surgery, invasive carcinoma, chest wall, neck, axilla, modified radical mastectomy, radical mastectomy, invasive, carcinoma, mastectomy"
" Cystoscopy under anesthesia, retrograde and antegrade pyeloureteroscopy, left ureteropelvic junction obstruction, difficult and open renal biopsy.", Surgery, Pyeloureteroscopy ,"PREOPERATIVE DIAGNOSES: , Left obstructed renal ureteropelvic junction obstruction status post pyeloplasty, percutaneous procedure, and pyeloureteroscopy x2, and status post Pseudomonas pyelonephritis x6, renal insufficiency, and solitary kidney.,POSTOPERATIVE DIAGNOSES:,  Left obstructed renal ureteropelvic junction obstruction status post pyeloplasty, percutaneous procedure, and pyeloureteroscopy x2, and status post Pseudomonas pyelonephritis x6, renal insufficiency, and solitary kidney.,PROCEDURE:  ,Cystoscopy under anesthesia, retrograde and antegrade pyeloureteroscopy, left ureteropelvic junction obstruction, difficult and open renal biopsy.,ANESTHESIA:  ,General endotracheal anesthetic with a caudal block x2.,FLUIDS RECEIVED:  ,1000 mL crystalloid.,ESTIMATED BLOOD LOSS:  ,Less than 10 mL.,SPECIMENS: , Tissue sent to pathology is a renal biopsy.,ABNORMAL FINDINGS: , A stenotic scarred ureteropelvic junction with dilated ureter and dilated renal pelvis.,TUBES AND DRAINS:  ,A 10-French silicone Foley catheter with 3 mL in balloon and a 4.7-French ureteral double J-stent multilength.,INDICATIONS FOR OPERATION:  ,The patient is a 3-1/2-year-old boy, who has a solitary left kidney with renal insufficiency with creatinine of 1.2, who has had a ureteropelvic junction repair performed by Dr. Chang.  It was subsequently obstructed with multiple episodes of pyelonephritis, two percutaneous tube placements, ureteroscopy with balloon dilation of the system, and continued obstruction.  Plan is for co surgeons due to the complexity of the situation and the solitary kidney to do surgical procedure to correct the obstruction.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operative room.  Surgical consent, operative site, and patient identification were verified.  Dr. X and Dr. Y both agreed upon the procedures in advance.  Dr. Y then, once the patient was anesthetized, requested IV antibiotics with Fortaz, the patient had a caudal block placed, and he was then placed in lithotomy position.  Dr. Y then calibrated the urethra with the bougie a boule to 8, 10, and up to 12 French.  The 9.5-French cystoscope sheath was then placed within the patient's bladder with the offset scope, and his bladder had no evidence of cystitis.  I was able to locate the ureteral orifice bilaterally, although no urine coming from the right.  We then placed a 4-French ureteral catheter into the ureter as far as we could go.  An antegrade nephrostogram was then performed, which shows that the contrast filled the dilated pelvis, but did not go into the ureter.  A retrograde was performed, and it was found that there was a narrowed band across the two.  Upon draining the ureter allowing to drain to gravity, the pelvis which had been clamped and its nephrostomy tube did not drain at all.  Dr. Y then placed a 0.035 guidewire into the ureter after removing the 4-French catheter and then placed a 4.7-French double-J catheter into the ureter as far as it would go allowing it to coil in the bladder.  Once this was completed, we then removed the cystoscope and sheath, placed a 10-French Foley catheter, and the patient was positioned by Dr. X and Dr. Y into the flank position with the left flank up after adequate padding on the arms and legs as well as a brachial plexus roll.  He was then sterilely prepped and draped.  Dr. Y then incised the skin with a 15-blade knife through the old incision and then extended the incision with curved mosquito clamp and Dr. X performed cautery of the areas advanced to be excised.  Once this was then dissected, Dr. Y and Dr. X divided the lumbosacral fascia; at the latissimus dorsi fascia, posterior dorsal lumbotomy maneuver using the electrocautery; and then using curved mosquito clamps __________.  At this point, Dr. X used the cautery to enter the posterior retroperitoneal space through the posterior abdominal fascia.  Dr. Y then used the curved right angle clamp and dissected around towards the ureter, which was markedly adherent to the base of the retroperitoneum.  Dr. X and Dr. Y also needed dissection on the medial and lateral aspects with Dr. Y being on the lateral aspect of the area and Dr. X on the medial to get an adequate length of this.  The tissue was markedly inflamed and had significant adhesions noted.  The patient's spermatic vessels were also in the region as well as the renal vessels markedly scarred close to the ureteropelvic junction.  Ultimately, Dr. Y and Dr. X both with alternating dissection were able to dissect the renal pelvis to a position where Dr. Y put stay sutures and a 4-0 chromic to isolate the four quadrant area where we replaced the ureter.  Dr. X then divided the ureter and suture ligated the base, which was obstructed with a 3-0 chromic suture.  Dr. Y then spatulated the ureter for about 1.5 cm, and the stent was gently delivered in a normal location out of the ureter at the proximal and left alone in the bladder.  Dr. Y then incised the renal pelvis and dissected and opened it enough to allow the new ureteropelvic junction repair to be performed.  Dr. Y then placed interrupted sutures of 5-0 Monocryl at the apex to repair the most dependent portion of the renal pelvis, entered the lateral aspect, interrupted sutures of the repair.  Dr. X then was able to without much difficulty do interrupted sutures on the medial aspect.  The stent was then placed into the bladder in the proper orientation and alternating sutures by Dr. Y and Dr. X closed the ureteropelvic junction without any evidence of leakage.  Once this was complete, we removed the extra stay stitches and watched the ureter lay back into the retroperitoneum in a normal position without any kinking in apparently good position.  This opening was at least 1.5 cm wide.  Dr. Y then placed 2 stay sutures of 2-0 chromic in the lower pole of the kidney and then incised wedge biopsy and excised the biopsy with a 15-blade knife and curved iris scissors for renal biopsy for determination of renal tissue health.  Electrocautery was used on the base.  There was no bleeding, however, and the tissue was quite soft.  Dermabond and Gelfoam were placed, and then Dr. Y closed the biopsy site over with thrombin-Gelfoam using the 2-0 chromic stay sutures.  Dr. X then closed the fascial layers with running suture of 3-0 Vicryl in 3 layers.  Dr. Y closed the Scarpa fascia and the skin with 4-0 Vicryl and 4-0 Rapide respectively.  A 4-0 nylon suture was then placed by Dr. Y around the previous nephrostomy tube, which was again left clamped.  Dermabond tissue adhesive was placed over the incision and then a dry sterile dressing was placed by Dr. Y over the nephrostomy tube site, which was left clamped, and the patient then had a Foley catheter placed in the bladder.  The Foley catheter was then taped to his leg.  A second caudal block was placed for anesthesia, and he is in stable condition upon transfer to recovery room.","surgery, cystoscopy, pyeloureteroscopy, ureteropelvic junction obstruction, pseudomonas pyelonephritis, renal insufficiency, fortaz, ureteropelvic junction repair, nephrostomy tube, renal biopsy, renal pelvis, foley catheter, ureteropelvic junction, renal, ureteropelvic,"
" Radical vulvectomy (complete), bilateral inguinal lymphadenectomy (superficial and deep).", Surgery, Radical Vulvectomy ,"PREOPERATIVE DIAGNOSIS: , Clinical stage III squamous cell carcinoma of the vulva.,POSTOPERATIVE DIAGNOSIS: , Clinical stage III squamous cell carcinoma of the vulva.,OPERATION PERFORMED:,  Radical vulvectomy (complete), bilateral inguinal lymphadenectomy (superficial and deep).,ANESTHESIA: , General, endotracheal tube.,SPECIMENS: , Radical vulvectomy, right and left superficial and deep inguinal lymph nodes. ,INDICATIONS FOR PROCEDURE: , The patient recently presented with a new vaginal nodule. Biopsy was obtained and revealed squamous carcinoma.  The lesion extended slightly above the hymeneal ring and because of vaginal involvement was classified as a T3/Nx/Mx on clinical examination.  Of note, past history is significant for pelvic radiation for cervical cancer many years previously.,FINDINGS: , The examination under anesthesia revealed a 1.5 cm nodule of disease extending slightly above the hymeneal ring.  There was no palpable lymphadenopathy in either inguinal node region.  There were no other nodules, ulcerations, or other lesions.  At the completion of the procedure there was no clinical evidence of residual disease.,PROCEDURE:,  The patient was brought to the Operating Room with an IV in place.  She was placed in the low anterior lithotomy position after adequate anesthesia had been induced.  Examination under anesthesia was performed with findings as noted, after which she was prepped and draped.  The femoral triangles were marked and a 10 cm skin incision was made parallel to the inguinal ligament approximately 3 cm below the ligament.  Camper's fascia was divided and skin flaps were elevated with sharp dissection and ligation of vessels where necessary.  The lymph node bundles were mobilized by incising the loose areolar tissue attachments to the fascia of the rectus abdominis.  The fascia around the sartorius muscle was divided and the specimen was reflected from lateral to medial.  The cribriform fascia was isolated and dissected with preservation of the femoral nerve.  The femoral sheath containing artery and vein was opened and vessels were stripped of their lymphatic attachments.  The medial lymph node bundle was isolated, and Cloquet's node was clamped, divided, and ligated bilaterally.  The saphenous vessels were identified and preserved bilaterally.  The inferior margin of the specimen was ligated, divided, and removed.  Inguinal node sites were irrigated and excellent hemostasis was noted.  Jackson-Pratt drains were placed and Camper's fascia was approximated with simple interrupted stitches.  The skin was closed with running subcuticular stitches using 4-0 Monocryl suture.,Attention was turned to the radical vulvectomy specimen.  A marking pen was used to outline the margins of resection allowing 15-20 mm of margin on the inferior, lateral, and anterior margins.  The medial margin extended into the vagina and was approximately 5-8 mm.  The skin was incised and underlying adipose tissue was divided with electrocautery.  Vascular bundles were isolated, divided, and ligated.  After removal of the specimen, additional margin was obtained from the right vaginal side wall adjacent to the tumor site.  Margins were submitted on the right posterior, middle, and anterior vaginal side walls.  After removal of the vaginal margins, the perineum was irrigated with four liters of normal saline and deep tissues were approximated with simple interrupted stitches of 2-0 Vicryl suture.  The skin was closed with interrupted horizontal mattress stitches using 3-0 Vicryl suture.  The final sponge, needle, and instrument counts were correct at the completion of the procedure.  The patient was then awakened from her anesthetic and taken to the Post Anesthesia Care Unit in stable condition.","surgery, squamous cell carcinoma, vulvectomy, radical vulvectomy, bilateral inguinal lymphadenectomy, hymeneal ring, camper's fascia, carcinoma of the vulva, inguinal lymphadenectomy, lymph nodes, inguinal, vulva, squamous, carcinoma, radical, lymphadenectomy, fascia, vaginal, nodes"
 Worrisome skin lesion.  A punch biopsy of the worrisome skin lesion was obtained.  Lesion was removed., Surgery, Punch Biopsy - 2 ,"PREOPERATIVE DIAGNOSIS:,  Worrisome skin lesion, left hand.,POSTPROCEDURE DIAGNOSIS:,  Worrisome skin lesion, left hand.,PROCEDURE:,  The patient gave informed consent for his procedure.  After informed consent was obtained, attention was turned toward the area of interest, which was prepped and draped in the usual sterile fashion.,Local anesthetic medication was infiltrated around and into the area of interest.  There was an obvious skin lesion there and this gentleman has a history of squamous cell carcinoma.  A punch biopsy of the worrisome skin lesion was obtained with a portion of the normal tissue included.  The predominant portion of the biopsy was of the lesion itself.,Lesion was removed.  Attention was turned toward the area.  Pressure was held and the area was hemostatic.,The skin and the area were closed with 5-0 nylon suture.  All counts were correct.  The procedure was closed.  A sterile dressing was applied.  There were no complications.  The patient had no neurovascular deficits, etc., after this minor punch biopsy procedure.,","surgery, skin lesion, squamous cell carcinoma, punch biopsy, "
" Pulmonary valve stenosis, supple pulmonic narrowing, and static encephalopathy", Surgery, Pulmonary Valve Stenosis ,"HISTORY: , The patient is a 19-year-old boy with a membranous pulmonary atresia, underwent initial repair 12/04/1987 consisting of pulmonary valvotomy and placement of 4 mm Gore-Tex shunt between the ascending aorta and pulmonary artery with a snare.  This was complicated by shunt thrombosis __________ utilizing a 10-mm balloon.  Resulting in significant hypoxic brain injury where he has been left with static encephalopathy and cerebral palsy.  On 04/07/1988, he underwent heart catheterization and balloon pulmonary valvuloplasty utilizing a 10-mm balloon.  He has been followed conservatively since that time.  A recent echocardiogram demonstrated possibly a significant right ventricle outflow tract obstruction with tricuspid valve regurgitation velocity predicting a right ventricular systolic pressure in excess of 180 mmHg.  Right coronary artery to pulmonary artery fistula was also appreciated.  The patient underwent cardiac catheterization to assess hemodynamics associated with his current state of repair.,PROCEDURE:,  The patient was placed under general endotracheal anesthesia breathing on 30% oxygen throughout the case.  Cardiac catheterization was performed as outlined in the attached continuation sheets.  Vascular entry was by percutaneous technique, and the patient was heparinized.  Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a 7-French sheath, a 6-French wedge catheter was inserted.  The right femoral vein advanced through the right heart structures out to the branch pulmonary arteries.  This catheter was then exchanged over wire for a 5-French marker pigtail catheter, which was directed into the main pulmonary artery.,Using a 5-French sheath, a 5-French pigtail catheter was inserted in the right femoral artery and advanced retrograde to the descending aorta, ascending aorta, and left ventricle.  This catheter was then exchanged for a Judkins right coronary catheter for selective cannulation of the right coronary artery.,Flows were calculated by the Fick technique using a measured assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with injection of the main pulmonary artery and right coronary artery.,After angiography, two normal-appearing renal collecting systems were visualized.  The catheters and sheaths were removed and topical pressure applied for hemostasis.  The patient was returned to the recovery room in satisfactory condition.  There were no complications.,DISCUSSION:,  Oxygen consumption was assumed to be normal.  Mixed venous saturation was normal with no evidence of intracardiac shunt.  Left-sided heart was fully saturated.  Phasic right atrial pressures were normal with an A-wave similar to the normal right ventricular end-diastolic pressure.  Right ventricular systolic pressure was mildly elevated at 45% systemic level.  There was a 25 mmHg peak systolic gradient across the outflow tract to the main branch pulmonary arteries.  Phasic branch pulmonary artery pressures were normal.  Right-to-left pulmonary artery capillary wedge pressures were normal with an A-wave similar to the normal left ventricular end-diastolic pressure of 12 mmHg.  Left ventricular systolic pressure was systemic with no outflow obstruction to the ascending aorta.  Phasic ascending and descending pressures were similar and normal.  The calculated systemic and pulmonary flows were equal and normal.  Vascular resistances were normal.  Angiogram with contrast injection in the main pulmonary artery showed catheter induced pulmonary insufficiency.  The right ventricle appeared mildly hypoplastic with a good contractility and mild tricuspid valve regurgitation.  There is dynamic narrowing of the infundibulum with hypoplastic pulmonary annulus.  The pulmonary valve appeared to be thin and moved well.  The median branch pulmonary arteries were of good size with normal distal arborization.  Angiogram with contrast injection in the right coronary artery showed a non-dominant coronary with a small fistula arising from the proximal right coronary artery coursing over the infundibulum and entering the left facing sinus of the main pulmonary artery.,INITIAL DIAGNOSES:,1.  Membranous pulmonary atresia.,2.  Atrial septal defect.,3.  Right coronary artery to pulmonary artery fistula.,SURGERIES (INTERVENTIONS):  ,1.  Pulmonary valvotomy surgical.,2.  Aortopulmonary artery central shunt.,3.  Balloon pulmonary valvuloplasty.,CURRENT DIAGNOSES:  ,1.  Pulmonary valve stenosis supplemented to hypoplastic pulmonary annulus.,2.  Mild right ventricle outflow tract obstruction due to supple pulmonic narrowing.,3.  Small right coronary artery to main pulmonary fistula.,4.  Static encephalopathy.,5.  Cerebral palsy.,MANAGEMENT: , The case to be discussed with combined Cardiology/Cardiothoracic Surgery case conference.  Given the mild degree of outflow tract obstruction in this sedentary patient, aggressive intervention is not indicated.  Conservative outpatient management is to be recommended.  Further patient care will be directed by Dr. X.","surgery, membranous pulmonary atresia, atrial septal defect, pulmonary artery fistula, pulmonary valvotomy, central shunt, pulmonary valvuloplasty, static encephalopathy, cerebral palsy, hypoplastic pulmonary annulus, pulmonary valve stenosis, outflow tract obstruction, ventricular systolic pressure, branch pulmonary arteries, systolic pressure, pulmonary arteries, pulmonary valve, branch pulmonary, coronary artery, catheterization, artery, pulmonary, pressures, coronary, "
" Exploratory laparotomy, radical hysterectomy, bilateral ovarian transposition, pelvic and obturator lymphadenectomy.", Surgery, Radical Hysterectomy ,"PREOPERATIVE DIAGNOSIS:,  Cervical adenocarcinoma, stage I.,POSTOPERATIVE DIAGNOSIS: , Cervical adenocarcinoma, stage I.,OPERATION PERFORMED:,  Exploratory laparotomy, radical hysterectomy, bilateral ovarian transposition, pelvic and obturator lymphadenectomy.,ANESTHESIA: , General, endotracheal tube.,SPECIMENS: , Uterus with attached parametrium and upper vagina, right and left pelvic and obturator lymph nodes.,INDICATIONS FOR PROCEDURE:,  The patient recently underwent a cone biopsy at which time invasive adenocarcinoma of the cervix was noted.  She was advised regarding treatment options including radical hysterectomy versus radiation and the former was recommended. ,FINDINGS: , During the examination under anesthesia, the cervix was noted to be healing well from recent cone biopsy and no nodularity was noted in the supporting ligaments.  During the exploratory laparotomy, there was no evidence of disease extension into the broad ligament or bladder flap.  There was no evidence of intraperitoneal spread or lymphadenopathy.  ,OPERATIVE PROCEDURE:  ,The patient was brought to the Operating Room with an IV in place.  Anesthetic was administered after which she was examined under anesthesia.  The vagina was then prepped and a Foley catheter was placed.  She was prepped and draped.  A Pfannenstiel incision was made three centimeters above the symphysis pubis.  The peritoneum was entered and the abdomen was explored with findings as noted.  The Bookwalter retractor was placed, and bowel was packed.  Clamps were placed on the broad ligament for traction.  The retroperitoneum was opened by incising lateral and parallel to the infundibulopelvic ligaments.  The round ligaments were isolated, divided and ligated.  The peritoneum overlying the vesicouterine fold was incised, and the bladder was mobilized using sharp dissection.  The pararectal and paravesical spaces were opened, and the broad ligament was palpated with no evidence of suspicious findings or disease extension.  The utero-ovarian ligaments were then isolated, divided and doubly ligated.  Tubes and ovaries were mobilized.  The ureters were dissected free from the medial leaf of the peritoneum.  When the crossover of the uterine artery was reached, and the artery was isolated at its origin, divided and ligated.  The uterine artery pedicle was dissected anteriorly over the ureter.  The ureter was tunneled through the broad ligament using right angle clamps for tunneling after which each pedicle was divided and ligated.  This was continued until the insertion point of the ureter into the bladder trigone.  The peritoneum across the cul-de-sac was divided, and the rectovaginal space was opened.  Clamps were placed on the uterosacral ligaments at their point of origin.  Tissues were divided and suture ligated.  Clamps were placed on the paravaginal tissues, which were then divided, and suture ligated.  The vagina was then clamped and divided at the junction between the middle and upper third.  The vaginal vault was closed with interrupted figure-of-eight stitches.  Excellent hemostasis was noted.,Retractors were repositioned in the retroperitoneum for the lymphadenectomy.  The borders of dissection included the bifurcation of the common iliac artery superiorly, the crossover of the deep circumflex iliac vein over the external iliac artery inferiorly, the psoas muscle laterally and the anterior division of the hypogastric artery medially.  The obturator nerves were carefully isolated and preserved bilaterally and served as the posterior border of dissection.  Ligaclips were applied where necessary.  After removal of the lymph node specimens, the pelvis was irrigated.  The ovaries were transposed above the pelvic brim using running stitches.  Packs and retractors were removed, and peritoneum was closed with a running stitch.  Subcutaneous tissues were irrigated, and fascia was closed with a running mass stitch using delayed absorbable suture.  Subcutaneous adipose was irrigated, and Scarpa's fascia was closed with a running stitch.  Skin was closed with a running subcuticular stitch.  Final sponge, needle, and instrument counts were correct at the completion of the procedure.  The patient was awakened from the anesthetic and taken to the Post Anesthesia Care Unit in stable condition.","surgery, cervical adenocarcinoma, radical hysterectomy, exploratory laparotomy, bilateral ovarian transposition, lymphadenectomy, parametrium, cervix, pelvic and obturator lymphadenectomy, pelvic and obturator, obturator lymphadenectomy, laparotomy, ovarian, adenocarcinoma, radical, hysterectomy, pelvic, obturator, peritoneum, nodes, ligaments"
" Right ureteropelvic junction obstruction.  Robotic-assisted pyeloplasty, anterograde right ureteral stent placement, transposition of anterior crossing vessels on the right, and nephrolithotomy.", Surgery, Pyeloplasty - Robotic ,"PROCEDURES:,1.  Robotic-assisted pyeloplasty.,2.  Anterograde right ureteral stent placement.,3.  Transposition of anterior crossing vessels on the right.,4.  Nephrolithotomy.,DIAGNOSIS:,  Right ureteropelvic junction obstruction.,DRAINS:,1.  Jackson-Pratt drain times one from the right flank.,2.  Foley catheter times one.,ESTIMATED BLOOD LOSS: , Less than 30 cc.,COMPLICATIONS: , None.,SPECIMENS:,1.  Renal pelvis.,2.  Kidney stones.,INDICATIONS:  ,The patient is a 30-year-old Caucasian gentleman with history of hematuria subsequently found to have right renal stones and patulous right collecting system with notable two right crossing renal arteries.  Up on consideration of various modalities and therapy, the patient decided to undergo surgical therapy.,PROCEDURE IN DETAIL:  ,The patient was verified by armband and the procedure being robotic-assisted right pyeloplasty with nephrolithotomy was verified, and the procedure was carried out.  After institution of general endotracheal anesthesia and intravenous preoperative antibiotics, the patient was positioned into the right flank position with his right flank elevated.  Great care was taken to pad all pressure points and a right arm hanger was used.  The patient was flexed slightly, and a kidney rest was used.  Sequential compression devices were also placed.  Next, the patient was prepped and draped in normal sterile fashion with povidone-iodine.  Pneumoperitoneum was obtained by placing a Veress needle in the area of the umbilicus after it passed the water test.  A low pressure, high flow pneumoperitoneum was adequately obtained using CO2 gas.  Next, a 12-mm camera port was placed near the umbilicus.  The camera was inserted, and no bowel injury was seen.  Next, under direct vision flanking 8 mm camera ports, a 12 mm assist port, a 5 mm liver retraction port, and 5 mm assist port were placed.  The robot was docked and the instruments passed through respective checks.  Initial attention was directed to mobilizing the right colon from the abdominal wall totally medially.  Next, the right lateral duodenum was cauterized for further access to the right retroperitoneum.  At this point, the right kidney was in clear view, and the fascia was entered.  Initial attention was directed at careful dissection of the renal pelvis and proximal ureter which was done with a combination of electrocautery and blunt dissection.  It became readily apparent that there were two crossing vessels one in the medial inferior region of the kidney and another one in the most inferior portion of the lower pole.  These arteries were dissected carefully and vessel loops were applied.  Next, a small hole was then made in the renal pelvis using electrocautery and the contents of the renal pelvis were suctioned out.  The pyelotomy was extended so that the renal collecting system could be directly inspected.  Sequentially, each major calyx was inspected under direct vision and irrigated.  A total of four round kidney stones were extracted to be sent for analysis to being satisfied for the patient.  At this point, we directed our attention at the proximal right ureter which was dismembered from the remaining renal pelvis.  The proximal ureter was spatulated using cold scissors.  Next, redundant renal pelvis was excised using cold scissors and sent for permanent section.  We then identified the most inferior/dependent portion of the renal pelvis and placed a heel stitch at this for ureteral-renal pelvis anastomosis in a semi running fashion.  3-0 Monocryl sutures were used to re-anastomose the newly spatulated right ureter to the inferior portion of the renal pelvis.  Next, remainder of the pyelotomy was closed to itself also using 2-0 Monocryl sutures.  Before final stitches were placed, a 6x28 ureteral stent was placed anterograde.  This was accomplished by placing the stents over a guidewire, placing the guidewire under direct vision anterograde through the ureter.  This was done until the proximal end was in the renal pelvis, the guidewire was removed, and good proximal curl was verified by direct vision.  Then, the pyelotomy was completely closed again with 2-0 Monocryl sutures.  Next, attention was directed at transposition of the crossing renal artery by fixing it with Vicryl suture that would impinge less upon the renal pelvis.  Good pulsation was verified by direct vision proximal and distal to these pexy sutures.  Next, Gerota's fascia was reapproximated and closed with Vicryl sutures as was the right peritoneum.  Hemostasis appeared excellent at this point.  There was no obvious urine extravasation.  At this time, the procedure was terminated.  The robot was undocked.  Under direct visualization all 8 and 12 mm ports were closed at the level of the fascia with 0 Vicryl sutures in an interrupted fashion.  Then, all skin port sites were closed with 4-0 Monocryl in a subcuticular fashion and Dermabond and band-aids were applied over this.  Also, notably a Jackson-Pratt drain was placed in the area of the right kidney and additional right flank stab incision.  The patient tolerated the procedure well and no immediate perioperative complication was noted.,DISPOSITION: , The patient was discharged to Post Anesthesia Care Unit and subsequently to genitourinary floor to begin his recovery.","surgery, pyeloplasty, ureteral stent placement, nephrolithotomy, ureteropelvic junction obstruction, jackson-pratt drain, foley catheter, renal pelvis, kidney stones, monocryl sutures, pelvis, renal, ureteropelvic, sutures, "
 Punch biopsy of right upper chest skin lesion., Surgery, Punch Biopsy - 1 ,"PROCEDURE:,  Punch biopsy of right upper chest skin lesion.,ESTIMATED BLOOD LOSS:,  Minimal.,FLUIDS: , Minimal.,COMPLICATIONS:,  None.,PROCEDURE:,  The area around the lesion was anesthetized after she gave consent for her procedure.  Punch biopsy including some portion of lesion and normal tissue was performed.  Hemostasis was completed with pressure holding.  The biopsy site was approximated with non-dissolvable suture.  The area was hemostatic.  All counts were correct and there were no complications.  The patient tolerated the procedure well.  She will see us back in approximately five days.,","surgery, punch biopsy, skin lesion, "
" Macular edema, right eye.  Insertion of radioactive plaque, right eye with lateral canthotomy.  The plaque was positioned on the scleral surface immediately behind the macula and secured with two sutures of 5-0 Dacron.  The placement was confirmed with indirect ophthalmoscopy. ", Surgery, Radioactive Plaque - Insertion ,"PREOPERATIVE DIAGNOSIS:,  Macular edema, right eye.,POSTOPERATIVE DIAGNOSIS:  ,Macular edema, right eye.,TITLE OF OPERATION: , Insertion of radioactive plaque, right eye with lateral canthotomy.,OPERATIVE PROCEDURE IN DETAIL:  ,The patient was prepped and draped in the usual manner for a local eye procedure.  Initially, a 5 cc retrobulbar injection of 2% Xylocaine was done.  Then, a lid speculum was inserted and the conjunctiva was incised 4 mm posterior to the limbus.  A 2-0 silk traction suture was placed around the insertion of the lateral rectus muscle and, with gentle traction, the temporal one-half of the globe was exposed.  The plaque was positioned on the scleral surface immediately behind the macula and secured with two sutures of 5-0 Dacron.  The placement was confirmed with indirect ophthalmoscopy.  Next, the eye was irrigated with Neosporin and the conjunctiva was closed with 6-0 plain catgut.  The intraocular pressure was found to be within normal limits.  An eye patch was applied and the patient was sent to the Recovery Room in good condition.  A lateral canthotomy had been done.","surgery, canthotomy, ophthalmoscopy, radioactive plaque, scleral surface, macular edema, lateral canthotomy, macular"
" Radical retropubic prostatectomy, robotic assisted and bladder suspension.  Adenocarcinoma of the prostate.", Surgery, Prostatectomy - Robotic Radical Retropubic ,"PREOPERATIVE DIAGNOSIS: , Adenocarcinoma of the prostate.,POSTOPERATIVE DIAGNOSIS: , Adenocarcinoma of the prostate.,PROCEDURE,1.  Radical retropubic prostatectomy, robotic assisted.,2.  Bladder suspension.,ANESTHESIA:,  General by intubation.,The patient understands his diagnosis, grade, stage and prognosis.  He understands this procedure, options to it and potential benefits from it.  He strongly wishes to proceed.  He accepts all treatment-associated risks to include but not be limited to bleeding requiring transfusion; infection; sepsis; heart attack; stroke; bladder neck contractures; need to convert to an open procedure; urinary fistulae; impotence; incontinence; injury to bowel/rectum/bladder/ureters, etc.; small-bowel obstruction; abdominal hernia; osteitis pubis/chronic pelvic pain, etc.,DESCRIPTION OF THE CASE:  ,The patient was taken to the operating room, given a successful general anesthetic, placed in the lithotomy position, prepped with Betadine solutions and draped in the usual sterile fashion.  My camera ports were then placed in the standard fan array.  A camera port was placed in the midline above the umbilicus using the Hasson technique.  The balloon port was placed, the abdomen insufflated, and all other ports were placed under direct vision.  My assistant was on the right.  The patient was then placed in the steep Trendelenburg position, and the robot brought forward and appropriately docked.,I then proceeded to drop the bladder into the peritoneal cavity by incising between the right and left medial umbilical ligaments and carrying that dissection laterally along these ligaments deep into the pelvis.  This nicely exposed the space of Retzius.  I then defatted the anterior surface of the prostate and endopelvic fascia.,The endopelvic fascia was then opened bilaterally.  The levator ani muscles were carefully dissected free from the prostate and pushed laterally.  Dissection was continued posteriorly toward the bundles and caudally to the apex.  The puboprostatic ligaments were then transected.  A secure ligature of 0 Vicryl was placed around the dorsal venous complex.,I then approached the bladder neck.  The anterior bladder neck was transected down to the level of the Foley catheter, which was lifted anteriorly in the wound.  I then transected the posterior bladder neck down to the level of the ampullae of the vas.  The ampullae were mobilized and transected.  These were lifted anteriorly in the field, exposing the seminal vesicles, which were similarly mobilized.  Hemostasis was obtained using the bipolar Bovie.,I then identified the Denonvilliers fascia, and this was incised sharply.  Dissection was continued caudally along the anterior surface of the rectum and laterally toward the bundles.  I was able to then identify the pedicles over the seminal vesicles, which were hemoclipped and transected.,The field was then copiously irrigated with sterile water.  Hemostasis was found to be complete.  I then carried out a urethrovesical anastomosis.  This was accomplished with 3-0 Monocryl ligatures.  Two of these were tied together in the midline.  They were placed at the 6 o'clock position, and one was run in a clockwise and the other in a counterclockwise direction to the 12 o'clock position where they were securely tied.  A new Foley catheter was then easily delivered into the bladder and irrigated without extravasation.  The patient was given indigo carmine, and there was prompt blue urine in the Foley., ,I then carried out a bladder suspension.  This was done in hopes of obtaining early urinary control.  This was accomplished with 0 Vicryl ligatures.  One was placed at the bladder neck and through the dorsal venous complex and then the other along the anterior surface of the bladder to the posterior surface of the pubis.  This nicely re-retroperitonealized the bladder.,The prostate was then placed in an Endocatch bag and brought out through an extended camera port incision.  A JP drain was brought in through the 4th arm port and sutured to the skin with 2-0 silk.  The camera port fascia was closed with running 0 Vicryl.  The skin incisions were closed with a running, subcuticular 4-0 Monocryl.,The patient tolerated the procedure very well.  There were no complications.  Sponge and instrument counts were reported correct at the end of the case.","surgery, adenocarcinoma, prostate, radical retropubic prostatectomy, robotic assisted, bladder, uspension, bladder neck, intubation, robotic, retropubic, prostatectomy"
 Open radical retropubic prostatectomy with bilateral lymph node dissection., Surgery, Prostatectomy ,"PREOPERATIVE DIAGNOSIS:,  Prostate cancer, Gleason score 4+3 with 85% burden and 8/12 cores positive.,POSTOPERATIVE DIAGNOSIS:,  Prostate cancer, Gleason score 4+3 with 85% burden and 8/12 cores positive.,PROCEDURE DONE: , Open radical retropubic prostatectomy with bilateral lymph node dissection.,INDICATIONS:,  This is a 66-year-old gentleman who had an elevated PSA of 5.  His previous PSAs were in the 1 range.  TRUS biopsy revealed 4+3 Gleason score prostate cancer with a large tumor burden.  After extensive counseling, the patient elected for retropubic radical prostatectomy.  Given his disease burden, it was advised that an open prostatectomy is probably the standard of care to ensure entire excision.  The patient consented and agreed to proceed forward.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room here.  Time out was taken to properly identify the patient and procedure going to be done.  General anesthesia was induced.  The patient was placed in the supine position.  The bed was flexed distant to the pubic area.  The patient's lower abdominal area, pubic area, and penile and scrotal area were clipped, and then scrubbed with Hibiclens soap for three minutes.  The patient was then prepped and draped in normal sterile fashion.  Foley catheter was inserted sterilely in the field.  Preoperative antibiotics were given within 30 minutes of skin incision.  A 10 cm lower abdominal incision was made from the symphysis pubis towards the umbilicus.  Dissection was taken down through Scarpa's fascia to the level of the anterior rectus sheath.  The rectus sheath was then incised and the muscle was split in the middle.  Space of rectus sheath was then entered.  The Bookwalter ring was then applied to the belly, and the bladder was then retracted to the right side, thus exposing the left obturator area.  The lymph node packet on the left side was then dissected.  This was done in a split and roll fashion with the flimsy tissue, and the left external iliac vein was incised, and the tissues were then rolled over the left external iliac vein.  Dissection was carried down from the left external iliac vein to the obturator nerve and up to the level of the pelvic sidewall.  The proximal extent of dissection was the left hypogastric artery to the level of the node of Cloquet distally.  Care was taken to avoid injury to the nerves.  An accessory obturator vein was noted and was ligated.  The same procedure was done on the right side with dissection of the right obturator lymph node packet, which was sent for pathologic evaluation.  The bladder subsequently was retracted cephalad.  The prostate was then defatted up to the level of the endopelvic fascia.  The endopelvic fascia was then incised bilaterally, and the incision was then taken to the level of the puboprostatic ligaments.  Vicryl stitch was then applied at the level of the bladder neck in order to control the bladder back bleeders.  A Babcock was then applied around the dorsal venous complex over the urethra and the K-wire was then passed between the dorsal vein complex and the urethra by passing by the aid of a right angle.  A 0-Vicryl stitch was then applied over the dorsal venous complex, which was then tied down and cinched to the symphysis pubis.  Using a knife on a long handle, the dorsal venous complex was then incised using the K-wire as a guide.  Following the incision of the dorsal venous complex, the anterior urethra was then incised, thus exposing the Foley catheter.  The 3-0 Monocryl sutures were then applied going outside in on the anterior aspect of the urethra.  The lateral edges of the urethra were also then incised, and two lateral stitches were also applied going outside end.  The catheter was then drawn back at the level of membranous urethra, and a final posterior stitch was applied going outside end.  The urethra was subsequently divided in its entirety.  A Foley catheter was then taken out and was inserted directly into the bladder through the prostatic apex.  The prostate was then entered cephalad, and the prostatic pedicles were then systematically taken down with the right angle clips and cut.  Please note that throughout the case, the patient was noted to have significant oozing and bleeding partially from the dorsal venous complex, pelvic veins, and extensive vascularity that was noted in the patient's pelvic fatty tissue.  Throughout the case, the bleeding was controlled with the aid of a clips, Vicryl sutures, silk sutures, and ties, direct pressure packing, and FloSeal.  Following the excision of the prostatic pedicles, the posterior dissection at this point was almost complete.  Please note that the dissection was relatively technically challenging due to extensive adhesions between the prostate and Denonvilliers' fascia.  The seminal vesicle on the left side was dissected in its entirety; however, the seminal vesicle on the right side was adherently stuck to the Denonvilliers' fascia, which prompted the excision of most of the right seminal vesicle with the exception of the tip.  Care was taken throughout the posterior dissection to preserve the integrity of the ureters.  The anterior bladder neck was then cut anteriorly, and the bladder neck was separated from the prostate.  Following the dissection, the 5-French feeding tubes were inserted bilaterally into the ureters thus insuring their integrity.  Following the dissection of the bladder from the prostate, the prostate at this point was mobile and was sent for pathological evaluation.  The bladder neck was then repaired using Vicryl in a tennis racquet fashion.  The rest of the mucosa was then everted.  The ureteral orifices and ureters were protected throughout the procedure.  At this point, the initial sutures that were applied into the urethra were then applied into the corresponding position on the bladder neck, and the bladder neck was then cinched down and tied down after a new Foley catheter was inserted through the penile meatus and into the bladder pulling the bladder in position.  Hemostasis was then adequately obtained.  FloSeal was applied to the pelvis.  The bladder was then irrigated.  It was draining pink urine.  The wound was copiously irrigated.  The fascia was then closed using a #1 looped PDS.  The skin wound was then irrigated, and the skin was closed with a 4-0 Monocryl in subcuticular fashion.  At this point, the procedure was terminated with no complications.  The patient was then extubated in the operating room and taken in stable condition to the PACU.  Please note that during the case about 3600 mL of blood was noted.  This was due to the persistent continuous oozing from vascular fatty tissue and pelvic veins as previously noted in the dictation.","surgery, bilateral lymph node dissection, retropubic prostatectomy, radical retropubic prostatectomy, gleason score, prostate cancer, trus, biopsy, bilateral lymph node, lymph node dissection, catheter was inserted, bilateral lymph, node dissection, vicryl stitch, prostatic pedicles, pelvic veins, external iliac, iliac vein, seminal vesicle, lymph node, foley catheter, dorsal venous, venous complex, bladder neck, dissection, prostatectomy, bladder, endopelvic, vicryl, catheter, vein, venous, fascia, dorsal, urethra, "
 Radical retropubic nerve-sparing prostatectomy without lymph node dissection., Surgery, Prostatectomy - Nerve Sparing ,"PREOPERATIVE DIAGNOSIS:  ,Prostate cancer.,POSTOPERATIVE DIAGNOSIS:,  Prostate cancer.,OPERATION PERFORMED:,  Radical retropubic nerve-sparing prostatectomy without lymph node dissection.,ESTIMATED BLOOD LOSS: , 450 mL.,REPLACEMENT:,  250 mL of Cell Saver and crystalloid.,COMPLICATIONS: , None.,INDICATIONS OF SURGERY: , This is a 67-year-old man with needle biopsy proven to be Gleason 6 adenocarcinoma in one solitary place on the right side of the prostate.  Due to him being healthy with no comorbid conditions, he has elected to undergo surgical treatment with radical retropubic prostatectomy.  Potential complications include, but are not limited to:,1.  Infection.,2.  Bleeding.,3.  Incontinence.,4.  Impotence.,5.  Injury to the adjacent viscera.,6.  Deep venous thrombosis.,PROCEDURE IN DETAIL: , Prophylactic antibiotic was given in the preoperative holding area, after which the patient was transferred to the operating room.  Epidural anesthesia and general endotracheal anesthesia were administered by Dr. A without any difficulty.  The patient was shaved, prepped, and draped using the usual sterile technique.  A sterile 16-French Foley catheter was then placed with clear urine drained.  A midline infraumbilical incision was performed by using a #10 scalpel blade.  The rectus fascia and the subcutaneous space were opened by using the Bovie.  Transversalis fascia was opened in the midline and the retropubic space and the paravesical space were developed bluntly.  A Bookwalter retractor was then placed.  The area of the obturator lymph nodes were carefully inspected and no suspicious adenopathy was detected.  Given this patient's low Gleason score and low PSA with a solitary core biopsy positive, the decision was made to not perform bilateral lymphadenectomy.  The endopelvic fascia was opened bilaterally by using the Metzenbaum scissors.  Opening was enlarged by using sharp dissection.  Small perforating veins from the prostate into the lateral pelvic wall were controlled by using bipolar coagulation device.  The dorsal aspect of the prostate was bunched up by using 2-0 silk sutures.  The deep dorsal vein complex was bunched up by using Allis also and ligated by using 0 Vicryl suture in a figure-of-eight fashion.  With the prostate retracted cephalad, the deep dorsal vein complex was transected superficially using the Bovie.  Deeper near the urethra, the dorsal vein complex was transected by using Metzenbaum scissors.  The urethra could then be easily identified.  Nearly two-third of the urethra from anteriorly to posteriorly was opened by using Metzenbaum scissors.  This exposed the blue Foley catheter.  Anastomotic sutures were then placed on to the urethral stump using 2-0 Monocryl suture.  Six of these were placed evenly spaced out anteriorly to posteriorly.  The Foley catheter was then removed.  This allowed for better traction of the prostate laterally.  Lateral pelvic fascia was opened bilaterally.  This effectively released the neurovascular bundle from the apex to the base of the prostate.  Continued dissection from the lateral pelvic fascia deeply opened up the plane into the perirectal fat.  The prostate was then dissected from laterally to medially from this opening in the perirectal fat.  The floor of the urethra posteriorly and the rectourethralis muscle was then transected just distal to the prostate.  Maximal length of ureteral stump was preserved.  The prostate was carefully lifted cephalad by using gentle traction with fine forceps.  The prostate was easily dissected off the perirectal fat using sharp dissection only.  Absolutely, no traction to the neurovascular bundle was evident at any point in time.  The dissection was carried out easily until the seminal vesicles could be visualized.  The prostate pedicles were controlled easily by using multiple medium clips in 4 to 5 separate small bundles on each side.  The bladder neck was then dissected out by using a bladder neck dissection method.  Unfortunately, most of the bladder neck fiber could not be preserved due to the patient's anatomy.  Once the prostate had been separated from the bladder in the area with the bladder neck, dissection was carried out posteriorly to develop a plane between the bladder and the seminal vesicles.  This was developed without any difficulty.  Both vas deferens were identified, hemoclipped and transected.  The seminal vesicles on both sides were quite large and a decision was made to not completely dissect the tip off, as it extended quite deeply into the pelvis.  About two-thirds of the seminal vesicles were able to be removed.  The tip was left behind.  Using the bipolar Gyrus coagulation device, the seminal vesicles were clamped at the tip sealed by cautery and then transected.  This was performed on the left side and then the right side.  This completely freed the prostate.  The prostate was sent for permanent section.  The opening in the bladder neck was reduced by using two separate 2-0 Vicryl sutures.  The mucosa of the bladder neck was everted by using 4-0 chromic sutures.  Small amount of bleeding around the area of the posterior bladder wall was controlled by using suture ligature.  The ureteral orifice could be seen easily from the bladder neck opening and was completely away from the everting sutures.  The previously placed anastomotic suture on the urethral stump was then placed on the corresponding position on the bladder neck.  This was performed by using a French ***** needle.  A 20-French Foley catheter was then inserted and the sutures were sequentially tied down.  A 15 mL of sterile water was inflated to balloon.  The bladder anastomosis to the urethra was performed without any difficulty.  A 19-French Blake Drain was placed in the left pelvis exiting the right inguinal region.  All instrument counts, lap counts, and latex were verified twice prior to the closure.  The rectus fascia was closed in running fashion using #1 PDS.  Subcutaneous space was closed by using 2-0 Vicryl sutures.  The skin was reapproximated by using metallic clips.  The patient tolerated the procedure well and was transferred to the recovery room in stable condition.","surgery, prostate cancer, foley catheter, gleason, psa, prostate, adenocarcinoma, bladder neck, core biopsy, figure-of-eight, lymph node dissection, nerve-sparing, prostatectomy, rectus fascia, retropubic, bladder neck dissection, dorsal vein complex, nerve sparing, perirectal fat, seminal vesicles, sutures, bladder, urethra, posteriorly, seminal, vesicles, fascia, neck, dissection,"
 Radical retropubic prostatectomy with pelvic lymph node dissection due to prostate cancer., Surgery, Prostatectomy - Radical Retropubic ,"PREOPERATIVE DIAGNOSIS:,  Prostate cancer.,POSTOPERATIVE DIAGNOSIS: , Prostate cancer.,OPERATIVE PROCEDURE: , Radical retropubic prostatectomy with pelvic lymph node dissection.,ANESTHESIA:  ,General epidural,ESTIMATED BLOOD LOSS: , 800 cc.,COMPLICATIONS: , None.,INDICATIONS FOR SURGERY: , This is a 64-year-old man with adenocarcinoma of the prostate confirmed by needle biopsies.  He has elected to undergo radical retropubic prostatectomy with pelvic lymph node dissection.  Potential complications include, but are not limited to:,1.  Infection.,2.  Bleeding.,3.  Incontinence.,4.  Impotence.,5.  Deep venous thrombosis.,6.  Recurrence of the cancer.,PROCEDURE IN DETAIL: , Epidural anesthesia was administered by the anesthesiologist in the holding area.  Preoperative antibiotic was also given in the preoperative holding area.  The patient was then taken into the operating room after which general LMA anesthesia was administered.  The patient was shaved and then prepped using Betadine solution.  A sterile 16-French Foley catheter was inserted into the bladder with clear urine drain.  A midline infraumbilical incision was performed.  The rectus fascia was opened sharply.  The perivesical space and the retropubic space were developed bluntly.  Bookwalter retractor was then placed.  Bilateral obturator pelvic lymphadenectomy was performed.  The obturator nerve was identified and was untouched.  The margin for the resection of the lymph node bilaterally were the Cooper's ligament, the medial edge of the external iliac artery, the bifurcation of the common iliac vein, the obturator nerve, and the bladder.  Both hemostasis and lymphostasis was achieved by using silk ties and Hemo clips.  The lymph nodes were palpably normal and were set for permanent section.  The Bookwalter retractor was then repositioned and the endopelvic fascia was opened bilaterally using Metzenbaum scissors.  The puboprostatic ligament was taken down sharply.  The superficial dorsal vein complex over the prostate was bunched up by using the Allis clamp and then tied by using 2-0 silk sutures.  The deep dorsal vein complex was then bunched up by using the Allis over the membranous urethral area.  The dorsal vein complex was ligated by using 0 Vicryl suture on a CT-1 needle.  The Allis clamp was removed and the dorsal vein complex was transected by using Metzenbaum scissors.  The urethra was then identified and was dissected out.  The urethral opening was made just distal to the apex of the prostate by using Metzenbaum scissors.  This was extended circumferentially until the Foley catheter could be seen clearly.  2-0 Monocryl sutures were then placed on the urethral stump evenly spaced out for the anastomosis to be performed later.  The Foley catheter was removed and the posteriormost aspect of urethra and rectourethralis muscle was transected.  The lateral pelvic fascia was opened bilaterally to sweep the neurovascular bundles laterally on both sides.  The plane between Denonvilliers' fascia and the perirectal fat was developed sharply.  No tension was placed on the neurovascular bundle at any point in time.  The prostate dissected off the rectal wall easily.  Once the seminal vesicles were identified, the fascia covering over them were opened transversely.  The seminal vesicles were dissected out and the small bleeding vessels leading to them were clipped by using medium clips and then transected.  The bladder neck was then dissected out carefully to spare most of the bladder neck muscles.  Once all of the prostate had been dissected off the bladder neck circumferentially the mucosa lining the bladder neck was transected releasing the entire specimen.  The specimen was inspected and appeared to be completely intact.  It was sent for permanent section.  The bladder neck mucosa was then everted by using 4-0 chromic sutures.  Inspection at the prostatic bed revealed no bleeding vessels.  The sutures, which were placed previously onto the urethral stump, were then placed onto the bladder neck.  Once the posterior sutures had been placed, the Foley was placed into the urethra and into the bladder neck.  A 20-French Foley Catheter was used.  The anterior sutures were then placed.  The Foley was then inflated.  The bed was straightened and the sutures were tied down sequentially from anteriorly to posteriorly.  Mild traction of the Foley catheter was placed to assure the anastomosis was tight.  Two #19-French Blake drains were placed in the perivesical spaces.  These were anchored to the skin by using 2-0 silk sutures.  The instrument counts, lab counts, and sponge counts were verified to be correct, the patient was closed.  The fascia was closed in running fashion using #1 PDS.  Subcutaneous tissue was closed by using 2-0 Vicryl suture.  Skin was approximated by using metallic clips.  The patient tolerated the operation well.","surgery, prostate cancer, foley catheter, metzenbaum scissors, prostate, adenocarcinoma, bladder, lymphadenectomy, pelvic lymph node dissection, perivesical, prostatectomy, retropubic, urethra, radical retropubic prostatectomy, lymph node dissection, dorsal vein complex, radical retropubic, lymph node, dorsal vein, vein complex, bladder neck, sutures, foley, urethral,"
" The patient is a 9-year-old born with pulmonary atresia, intact ventricular septum with coronary sinusoids.", Surgery, Pulmonary Atresia ,"HISTORY: , The patient is a 9-year-old born with pulmonary atresia, intact ventricular septum with coronary sinusoids.  He also has VACTERL association with hydrocephalus.  As an infant, he underwent placement of a right modified central shunt.  On 05/26/1999, he underwent placement of a bidirectional Glenn shunt, pulmonary artery angioplasty, takedown of the central shunt, PDA ligation, and placement of a 4 mm left-sided central shunt.  On 08/01/2006, he underwent cardiac catheterization and coil embolization of the central shunt.  A repeat catheterization on 09/25/2001 demonstrated elevated Glenn pressures and significant collateral vessels for which he underwent embolization.  He then underwent repeat catheterization on 11/20/2003 and further embolization of residual collateral vessels.  Blood pressures were found to be 13 mmHg with the pulmonary vascular resistance of 2.6-3.1 Wood units.  On 03/22/2004, he returned to the operating room and underwent successful 20 mm extracardiac Fontan with placement of an 8-mm fenestration and main pulmonary artery ligation.  A repeat catheterization on 09/07/2006, demonstrated mildly elevated Fontan pressures in the context of a widely patent Fontan fenestration and intolerance of Fontan fenestration occlusion.  The patient then followed conservatively since that time.  The patient is undergoing a repeat evaluation to assess his candidacy for a Fontan fenestration occlusion, as well as consideration for a tricuspid valvuloplasty in attempt to relieve right ventricular hypertension and associated membranous ventricular aneurysm protruding into the left ventricular outflow tract.,PROCEDURE:,  After sedation and local Xylocaine anesthesia, the patient was placed under general endotracheal anesthesia, the patient was prepped and draped.  Cardiac catheterization was performed as outlined in the attached continuation sheets.  Vascular entry was by percutaneous technique, and the patient was heparinized.  Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a 7-French sheath, a 6-French wedge catheter was inserted in the right femoral vein and advanced from the inferior vena cava along the Fontan conduit into the main left pulmonary artery, as well as the superior vena cava.  This catheter was then exchanged for a 5-French VS catheter of a distal wire.  Apposition of the right pulmonary artery over, which the wedge catheter was advanced.  The wedge catheter could then be easily advanced across the Fontan fenestration into the right atrium and guidewire manipulation allowed access across the atrial septal defect to the pulmonary veins, left atrium, and left ventricle.,Using a 5-French sheath, a 5-French pigtail catheter was inserted into the right femoral artery and advanced retrograde to the descending aorta, ascending aorta, and left ventricle.  Attempt was then made to cross the tricuspid valve from the right atrium and guidewire persisted to prolapse through the membranous ventricular septum into the left ventricle.  The catheter distal wire position was finally achieved across what appeared to be the posterior aspect of the tricuspid valve, both angiographically as well as equal guidance.  Left ventricular pressure was found to be suprasystemic.  A balloon valvoplasty was performed using a Ranger 4 x 2 cm balloon catheter with no waste at minimal inflation pressure.  Echocardiogram, which showed no significant change in the appearance of a tricuspid valve and persistence of aneurysmal membranous ventricular septum.  Further angioplasty was then performed first utilizing a 6 mm cutting balloon directed through 7-French flexor sheath positioned within the right atrium.  There was a disappearance of a mild waist prior to spontaneous tear of the balloon.  The balloon catheter was then removed in its entirety.,Echocardiogram again demonstrated no change in the appearance of the tricuspid valve.  A final angioplasty was performed utilizing a 80 mm cutting balloon with the disappearance of a distinctive waste.  Echocardiogram; however, demonstrated no change and intact appearing tricuspid valve and no decompression of the right ventricle.  Further attempts to cross tricuspid valve were thus abandoned.  Attention was then directed to a Fontan fenestration.  A balloon occlusion then demonstrated minimal increase in Fontan pressures from 12 mmHg to 15 mmHg.  With less than 10% fall in calculated cardiac index.  The angiogram in the inferior vena cava demonstrated a large fenestration measuring 6.6 mm in diameter with a length of 8 mm.  A 7-French flexor sheath was again advanced cross the fenestration.  A 10-mm Amplatzer muscular ventricular septal defect occluder was loaded on delivery catheter and advanced through the sheath where the distal disk was allowed to be figured in the right atrium.  Entire system was then brought into the fenestration and withdrawal of the sheath allowed reconfiguration of the proximal disk.  Once the stable device configuration was confirmed, device was released from the delivery catheter.  Hemodynamic assessment and the angiograms were then repeated.,Flows were calculated by the Fick technique using an assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Angiograms with injection in the right coronary artery, left coronary artery, superior vena cava, inferior vena cava, and right ventricle.,After angiography, two normal-appearing renal collecting systems were visualized.  The catheters and sheaths were removed and topical pressure applied for hemostasis.  The patient was returned to the recovery room in satisfactory condition.  There were no complications.,DISCUSSION: , Oxygen consumption was assumed to be normal.  Mixed venous saturation was low due to systemic arterial desaturation.  There was modest increased saturation of the branch pulmonary arteries due to the presumed aortopulmonary collateral flow.  The right pulmonary veins were fully saturated.  Left pulmonary veins were not entered.  There was a fall in saturation within the left ventricle and descending aorta due to a right to left shunt across the Fontan fenestration.  Mean Fontan pressures were 12 mmHg with a 1 mmHg fall in mean pressure into the distal left pulmonary artery.  Right and left pulmonary capillary wedge pressures were similar to left atrial phasic pressure with an A-wave similar to the normal left ventricular end-diastolic pressure of 11 mmHg.  Left ventricular systolic pressure was normal with at most 5 mmHg systolic gradient pressure pull-back to the ascending aorta.  Phasic ascending and descending aortic pressures were similar and normal.  The calculated systemic flow was normal.  Pulmonary flow was reduced to the QT-QS ratio of 0.7621.  Pulmonary vascular resistance was normal at 1 Wood units.,Angiogram with injection in the right coronary artery demonstrated diminutive coronary with an extensive sinusoidal communication to the rudimentary right ventricle.  The left coronary angiogram showed a left dominant system with a brisk flow to the left anterior descending and left circumflex coronary arteries.  There was communication to the right-sided coronary sinusoidal communication to the rudimentary right ventricle.  Angiogram with injection in the superior vena cava showed patent right bidirectional Glenn shunt with mild narrowing of the proximal right pulmonary artery, as well as the central pulmonary artery, diameter of which was augmented by the Glenn anastomosis and the Fontan anastomosis.  There was symmetric contrast flow to both pulmonary arteries.  A large degree of contrast flowed retrograde into the Fontan and shunting into the right atrium across the fenestration.  There is competitive flow to the upper lobes presumably due to aortopulmonary collateral flow.  The branch pulmonaries appeared mildly hypoplastic.  Levo phase contrast returned into the heart, appeared unobstructed demonstrating good left ventricular contractility.  Angiogram with injection in the Fontan showed a widely patent anastomosis with the inferior vena cava.  Majority of the contrast flowing across the fenestration into the right atrium with a positive flow to the branch pulmonary arteries.,Following the device occlusion of Fontan fenestration, the Fontan and mean pressure increased to 15 mmHg with a 3 mmHg, a mean gradient in the distal left pulmonary artery and no gradient into the right pulmonary artery.  There was an increase in the systemic arterial pressures.  Mixed venous saturation increased from the resting state as with increase in systemic arterial saturation to 95%.  The calculated systemic flow increased slightly from the resting state and pulmonary flow was similar with a QT-QS ratio of 0.921.  Angiogram with injection in the inferior vena cava showed a stable device configuration with a good disk apposition to the anterior surface of the Fontan with no protrusion into the Fontan and no residual shunt and no obstruction to a Fontan flow.  An ascending aortogram that showed a left aortic arch with trace aortic insufficiency and multiple small residual aortopulmonary collateral vessels arising from the intercostal arteries.  A small degree of contrast returned to the heart.,INITIAL DIAGNOSES:  ,1.  Pulmonary atresia.,2.  VACTERL association.,3.  Persistent sinusoidal right ventricle to the coronary communications.,4.  Hydrocephalus.,PRIOR SURGERIES AND INTERVENTIONS:  ,1.  Systemic to pulmonary shunts.,2.  Right bidirectional Glenn shunt.,3.  Revision of the central shunt.,4.  Ligation and division of patent ductus arteriosus.,5.  Occlusion of venovenous and arterial aortopulmonary collateral vessels.,6.  Extracardiac Fontan with the fenestration.,CURRENT DIAGNOSES:  ,1.  Favorable Fontan hemodynamics.,2.  Hypertensive right ventricle.,3.  Aneurysm membranous ventricular septum with mild left ventricle outflow tract obstruction.,4.  Patent Fontan fenestration.,CURRENT INTERVENTION:  ,1.  Balloon dilation tricuspid valve attempted and failed.,2.  Occlusion of a Fontan fenestration.,MANAGEMENT:  ,He will be discussed at Combined Cardiology/Cardiothoracic Surgery case conference.  A careful monitoring of ventricle outflow tract will be instituted with consideration for a surgical repair.  Further cardiologic care will be directed by Dr. X.",
 Insertion of a Port-A-Catheter via the left subclavian vein approach under fluoroscopic guidance in a patient with ovarian cancer., Surgery, Port-A-Cath Insertion - 4 ,"PREOPERATIVE DIAGNOSIS: , Ovarian cancer.,POSTOPERATIVE DIAGNOSIS:,  Ovarian cancer.,OPERATION PERFORMED:,  Insertion of a Port-A-Catheter via the left subclavian vein approach under fluoroscopic guidance.,DETAILED OPERATIVE NOTE:,  The patient was placed on the operating table and placed under LMA general anesthesia in preparation for insertion of a Port-A-Catheter.  The chest was prepped and draped in the routine fashion for insertion of a Port-A-Catheter.  The left subclavian vein was punctured with a single stick and a guidewire threaded through the needle into the superior vena cava under fluoroscopic guidance.  The needle was removed.  An incision was made over the guidewire for entrance of the dilator with sheath.  A second counter incision was made transversally on the chest wall about an inch and half below the puncture site with a #15 blade.  Hemostasis was effective to electrocautery, and a pocket was fashioned subcutaneously for positioning of the reservoir.  The Port-A-Catheter reservoir tubing was attached to the reservoir in the routine fashion.  The reservoir was placed in the pocket and sutured to the anterior chest wall muscle with three interrupted 4-0 Prolene sutures for stability.  Next, a catheter passer was passed from the pocket exiting through the skin at the puncture site, previously placed for the guidewire, and the Port-A-Catheter was pulled from the reservoir exiting on the skin.  It was placed on the chest, measured, and cut to the appropriate length.  This having been done, the dilator with sheath attached was passed over the guidewire into the superior vena cava under fluoroscopic guidance.  The guidewire and dilator were removed, and the Port-A-Catheter was threaded through the sheath into the superior vena cava, and the sheath removed under fluoroscopic guidance.  Fluoroscopy revealed the Port-A-Catheter to be in excellent position.  The Port-A-Catheter was accessed with a butterfly 90-degree needle percutaneously that drew blood well and flushed easily.  It was flushed with heparinized saline connected in cath.  This having been done, the puncture site was closed with a circumferential subcutaneous 3-0 Vicryl suture, and the skin was closed with a percutaneous circumferential subcuticular suture.  This having been done, attention was applied to the reservoir incision.  It was closed with two layers of continuous 3-0 Vicryl suture, and the skin was closed with a continuous 3-0 Monocryl subcuticular stitch.  A dry sterile dressing was applied, and the patient having tolerated the procedure was transferred to the recovery room for postoperative care.","surgery, ovarian cancer, insertion, port-a-catheter, circumferential, counter incision, fluoroscopic, fluoroscopic guidance, guidewire, subclavian, superior vena cava, port a catheter, port, catheter, subcutaneously, vein"
 Right pterional craniotomy with obliteration of medial temporal arteriovenous malformation and associated aneurysm and evacuation of frontotemporal intracerebral hematoma., Surgery, Pterional Craniotomy ,"PREOPERATIVE DIAGNOSIS:  ,Status post spontaneous hemorrhage from medial temporal arteriovenous malformation with arteriographic evidence of associated aneurysm.,POSTOPERATIVE DIAGNOSIS: , Status post spontaneous hemorrhage from medial temporal arteriovenous malformation with arteriographic evidence of associated aneurysm.,OPERATION: , Right pterional craniotomy with obliteration of medial temporal arteriovenous malformation and associated aneurysm and evacuation of frontotemporal intracerebral hematoma.,ANESTHESIA: , Endotracheal.,ESTIMATED BLOOD LOSS: , 250 mL,REPLACEMENTS:  ,3 units of packed cells.,DRAINS:,  None.,COMPLICATIONS: , None.,PROCEDURE:  ,With the patient prepped and draped in the routine fashion in the supine position with the head in a Mayfield headrest, turned 45 degrees to the patient's left and a small roll placed under her right shoulder and hip, the previously made pterional incision was reopened and extended along its posterior inferior limb to the patient's zygoma.  Additional aspect of the temporalis muscle and fascia were incised with cutting Bovie current with effort made to preserve the posterior limb of the external carotid artery.  The scalp and temporalis muscle were then retracted anteroinferiorly with 0 silk sutures, attached rubber bands and Allis clamps and similar retraction of the posterior aspect of temporalis was retracted with 0 silk suture, attached with rubber bands and Allis clamps.  The bone flap, which had not been fixed in place was removed.  An additional portion of the temporofrontal bone based at the zygoma was removed with a B1 dissecting tool, B1 attached to the Midas Rex instrumentation.  Further bone removal was accomplished with Leksell rongeur, and hemostasis controlled with the use of bone wax.,At this point, a retractor was placed along the frontal lobe for visualization of the perichiasmatic cistern with visualization made of the optic nerve and carotid artery.  It should be noted that cottonoid paddies were placed over the brain to protect the cortical surface of the brain both underneath the retractor and the remainder of the exposed cortex.  The sylvian fissure was then dissected with the dissection description being dictated by Dr. X.,Following successful splitting of the sylvian fissure to its apparent midplate, attention was next turned to the temporal tip where the approximate location of the cerebral aneurysm noted on CT angio, as well as conventional arteriography was noted and a peel incision was made extending from the temporal tip approximately 3 cm posterior.  This was enlarged with bipolar coagulation and aspiration and inferior dissection accomplished under the operating microscope until the dome of, what appeared to be, an aneurysm could be visualized.,Dissection around the dome with bipolar coagulation and aspiration revealed a number of abnormal vessels, which appeared to be involved with the aneurysm at its base and these were removed with bipolar coagulation.  Until circumferential dissection revealed 1 major arterial supply to the base of the aneurysm, this was felt to be able to be handled with bipolar coagulation, which was done and the vessel then cut with microscissors and the aneurysm removed in toto.,Attention was next turned to the apparent nidus of the arteriovenous malformation, which was somewhat medial and inferior to the aneurysm and the nidus was then dissected with the use of bipolar coagulation and aspiration microscissors as further described by Dr. X. With removal of the arteriovenous malformation, attention was then turned to the previous frontal cortical incision, which was the site of partial decompression of the patient's intracerebral hematoma on the day of her admission.  Self-retaining retractors were placed within this cortical incision, and the hematoma cavity entered with additional hematoma removed with general aspiration and irrigation.  Following removal of additional hematoma, the bed of the hematoma site was lined with Surgicel.  Irrigation revealed no further active bleeding, and it was felt that at this time both the arteriovenous malformation, associated aneurysm, and intracerebral hematoma had been sequentially dealt with.,The cortical surface was then covered with Surgicel and the dura placed over the surface of the brain after coagulation of the dural edges, the freeze dried fascia, which had been used at the time of the 1st surgery was replaced over the surface of the brain with additional areas of cortical exposure covered with a DuraGuard.  The 2nd bone flap from the inferior frontotemporal region centered along the zygoma was reattached to the initial bone flap at 3 sites using a small 2-holed plate and 3-mm screws and the portable minidriver.,With this, return of the inferior plate accomplished, it was possible to reposition the bone flaps into their initial configuration, and attachments were secured anterior and posterior with somewhat longer 2-holed plates and 3-mm screws to the frontal and posterior temporal parietal region.  The wound was then closed.  It should be noted that a pledget of Gelfoam had been placed over the entire dural complex prior to returning the bone flap.  The wound was then closed by approximating the temporalis muscle with 2-0 Vicryl suture, the fascia was closed with 2-0 Vicryl suture, and the galea was closed with 2-0 interrupted suture, and the skin approximated with staples.  The patient appeared to tolerate the procedure well without complications.","surgery, hemorrhage, arteriovenous malformation, aneurysm, pterional craniotomy, bone flap, bipolar coagulation, arteriovenous, pterional, malformation, hematoma, intracerebral, "
 Insertion of Port-A-Cath via left subclavian vein using fluoroscopy in a patient with renal cell carcinoma., Surgery, Port-A-Cath Insertion - 3 ,"TITLE OF PROCEDURE: , Insertion of Port-A-Cath via left subclavian vein using fluoroscopy.,PREOPERATIVE DIAGNOSIS:  ,Metastatic renal cell carcinoma.,POSTOPERATIVE DIAGNOSIS: , Metastatic renal cell carcinoma.,PROCEDURE IN DETAIL:,  This is a 49-year-old gentleman was referred by Dr. A.  The patient underwent a left nephrectomy for renal cell carcinoma in 1999 in Philadelphia.  He has developed recurrence with metastases to the lung and to bone.,The patient is on dialysis via a right internal jugular PermCath that was placed elsewhere.,In the operating room under monitored anesthesia care with intravenous sedation, the patient was prepped and draped suitably.  Lidocaine 1% with epinephrine was used for local anesthesia and the left subclavian vein was punctured at the first pass without difficulty.  A J-wire was guided into place under fluoroscopic control.  A 7.2-French vortex titanium Port-A-Cath was now anchored in the subcutaneous pocket made just below using 3-0 Prolene.  The attached catheter tunneled, cut to the appropriate length and placed through the sheath that was then peeled away.  Fluoroscopy showed good catheter disposition in the superior vena cava.  The catheter was accessed with a butterfly Huber needle, blood was aspirated easily and the system was then flushed using heparinized saline.  The pocket was irrigated using antibiotic saline and closed with absorbable suture.  The port was left accessed with the butterfly needle after dressings were applied and the patient is to report to Dr. A's office later today for the commencement of chemotherapy.  There were no complications.","surgery, port-a-cath, french vortex, huber, metastatic, permcath, butterfly needle, catheter, fluoroscopy, jugular, nephrectomy, renal cell carcinoma, subclavian vein, vena cava, port a cath, cell carcinoma, insertion, subclavian, carcinoma, port"
 Insertion of subclavian dual-port Port-A-Cath and surgeon-interpreted fluoroscopy., Surgery, Port-A-Cath Insertion - 5 ,"PROCEDURES PERFORMED,1.  Insertion of subclavian dual-port Port-A-Cath.,2.  Surgeon-interpreted fluoroscopy.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and general endotracheal anesthesia was administered.  Next, the chest was prepped and draped in a standard surgical fashion.  A #18-gauge spinal needle was used to aspirate blood from the subclavian vein.  After aspiration of venous blood, Seldinger technique was used to thread a J wire.  The distal tip of the J wire was confirmed to be in adequate position with surgeon-interpreted fluoroscopy.  Next a #15-blade scalpel was used to make an incision in the skin.  Dissection was carried down to the level of the pectoralis muscle.  A pocket was created.  A dual-port Port-A-Cath was lowered into the pocket and secured with #2-0 Prolene.  Both ports were flushed.  The distal tip was pulled through to the wire exit site with a Kelly clamp.  It was cut to the appropriate length.  Next a dilator and sheath were threaded over the J wire.  The J wire and dilator were removed, and the distal tip of the dual-port Port-A-Cath was threaded over the sheath, which was simultaneously withdrawn.  Both ports of the dual-port Port-A-Cath were flushed and aspirated without difficulty.  The distal tip was confirmed to be in adequate position with surgeon-interpreted fluoroscopy.  The wire access site was closed with a 4-0 Monocryl.  The port pocket was closed in 2 layers with 2-0 Vicryl followed by 4-0 Monocryl in a running subcuticular fashion.  Sterile dressing was applied.  The patient tolerated the procedure well and was transferred to the PACU in good condition","surgery, surgeon-interpreted fluoroscopy, j wire, dual-port port-a-cath, port a cath, subclavian, fluoroscopy, cathNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Right subclavian Port-a-Cath insertion in a patient with bilateral breast carcinoma. , Surgery, Port-A-Cath Insertion - 1 ,"PREOPERATIVE DIAGNOSES: ,1.  Bilateral breast carcinoma.,2.  Chemotherapy required.,POSTOPERATIVE DIAGNOSES:,1.  Bilateral breast carcinoma.,2.  Chemotherapy required.,OPERATION: , Right subclavian Port-a-Cath insertion.,FINDINGS AND PROCEDURE:  ,With the patient under satisfactory general orotracheal anesthesia and in the supine position, the right upper anterior chest, neck, and arm were prepared with Betadine in the usual fashion.  The skin, subcutaneous tissue, and fascia of the pectoralis major muscle medially beneath the inferior third of the right clavicle was infiltrated with 0.5% Marcaine with epinephrine.  An incision transverse, parallel, and inferior to the middle third of the right clavicle was performed.  A subcutaneous pocket on the surface of the pectoralis major muscle was created.  The muscular fascia was also infiltrated with 0.5% Marcaine with epinephrine.  With the patient in the Trendelenburg position, utilizing the provided introducer needle, the right subclavian vein was cannulated.  A guidewire was passed without difficulty and the needle was removed.  Fluoroscopy confirmed satisfactory position of the guidewire in the right atrium.  A dilator and sheath was passed over the guidewire.  The guidewire and dilator were removed and a provided catheter was inserted through the sheath and the sheath was carefully withdrawn.  Fluoroscopy again confirmed satisfactory position of the catheter and the catheter under fluoroscopic guidance was retracted into the superior vena cava.  The catheter had been preflushed with dilute heparin solution (100 units/mL).  The port, which had been preflushed with saline, was attached to the catheter at approximately 13 cm level.  The locking cap had been placed on the catheter.  The port was connected to the catheter and the locking cap was secured.  The port was again flushed with dilute heparin solution and placed within the subcutaneous pocket.  Fluoroscopy again confirmed satisfactory position.  A hard copy of the fluoroscopy was obtained.  The catheter and port were secured to the pectoralis fascia in four locations with 2-0 Prolene suture.  Site was irrigated with saline.  Hemostasis was verified.  The subcutaneous tissue was approximated with interrupted 2-0 Vicryl suture.  The subcutaneous and dermis were closed with a running subcuticular 3-0 Vicryl suture.  A 0.25-inch Steri-Strips were applied.  The provided needle and butterfly attachment was flushed with saline, passed through the skin into the port, and then flushed again with dilute heparin solution thus confirmed satisfactory.  The site was dressed with Tegaderm type dressing and the needle catheters were covered with 4x4's and paper tape.  Estimated blood loss was less than 15 mL.  The patient tolerated the procedure well and left the operating room in good condition.","surgery, carcinoma, bilateral breast carcinoma, chemotherapy, fluoroscopy, port-a-cath, catheter, insertion, pectoralis fascia, subclavian, subclavian port a cath, port a cath insertion, port a cath, cath insertion, heparin, "
 Bleeding after transanal excision five days ago.  Exam under anesthesia with control of bleeding via cautery.  The patient is a 42-year-old gentleman who is five days out from transanal excision of a benign anterior base lesion.  He presents today with diarrhea and bleeding., Surgery, Postop Transanal Excision ,"PREOPERATIVE DIAGNOSIS: , Bleeding after transanal excision five days ago.,POSTOPERATIVE DIAGNOSIS: , Bleeding after transanal excision five days ago.,PROCEDURE:,  Exam under anesthesia with control of bleeding via cautery.,ANESTHESIA:,  General endotracheal.,INDICATION: , The patient is a 42-year-old gentleman who is five days out from transanal excision of a benign anterior base lesion.  He presents today with diarrhea and bleeding.  Digital exam reveals bright red blood on the finger.  He is for exam under anesthesia and control of hemorrhage at this time.,FINDINGS: , There was an ulcer where most of the polypoid lesion had been excised before.  In a near total fashion the wound had opened and again there was a raw ulcer surface in between the edges of the mucosa.  There were a few discrete sites of mild oozing, which were treated with cautery and #1 suture.  No other obvious bleeding was seen.,TECHNIQUE: , The patient was taken to the operating room and placed on the operative table in supine position.  After adequate general anesthesia was induced, the patient was then placed in modified prone position.  His buttocks were taped, prepped and draped in a sterile fashion.  The anterior rectal wall was exposed using a Parks anal retractor.  The entire wound was visualized with a few rotations of the retractor and a few sites along the edges were seen to be oozing and were touched up with cautery.  There was one spot in the corner that was oozing and this may have been from simply opening the retractor enough to see well.  This was controlled with a 3-0 Monocryl figure-of-eight suture.  At the completion, there was no bleeding, no oozing, it was completely dry, and we removed our retractor, and the patient was then turned and extubated and taken to the recovery room in stable condition.","surgery, diarrhea, anterior base lesion, polypoid lesion, transanal excision, transanal, anesthesia, bleeding,"
" The patient with left completion hemithyroidectomy and reimplantation of the left parathyroid and left sternocleidomastoid region in the inferior 1/3rd region.  Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.", Surgery, Post Hemithyroidectomy ,"PREOPERATIVE DIAGNOSES: , Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.,POSTOPERATIVE DIAGNOSES: , Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.,PROCEDURE:  ,The patient with left completion hemithyroidectomy and reimplantation of the left parathyroid and left sternocleidomastoid region in the inferior 1/3rd region.,FINDINGS: , Normal-appearing thyroid gland with a possible lump in the inferior aspect, there was a parathyroid gland that by frozen section _________  was not thyroid, it was reimplanted to the left lower sternocleidomastoid region.,ESTIMATED BLOOD LOSS:  ,Approximately 10 mL.,FLUIDS: , Crystalloid only.,COMPLICATIONS: , None.,DRAINS: , Rubber band drain in the neck.,CONDITION:,  Stable.,PROCEDURE:  ,The patient placed supine under general anesthesia.  First, a shoulder roll was placed, 1% lidocaine and 1:100,000 epinephrine was injected into the old scar, natural skin fold, and Betadine prep.  Sterile dressing was placed.  The laryngeal monitoring was noted to be working fine.  Then, an incision was made in this area in a curvilinear fashion through the old scar, taken through the fat and the platysma level.  The strap muscles were found and there was scar tissue along the trachea and the strap muscles were elevated off of the left thyroid, the thyroid gland was then found.  Then, using bipolar cautery and a Coblation dissector, the thyroid gland inferiorly was dissected off and the parathyroid gland was left inferiorly and there was scar tissue that was released and laterally, the thyroid gland was released, then came into the Berry ligaments.  The Berry ligament was dissected off and the gland came off all the way to the superior and inferior thyroid vessels, which were crossed with the Harmonic scalpel and removed.  No bleeding was seen.  There was a small nick in the external jugular vein that was tied with a 4-0 Vicryl suture ligature.  After this was completed, on examining the specimen, there appeared to be a lobule on it and it was sent off as possibly parathyroid, therefore it was reimplanted in the left lower sternocleidomastoid region using the silk suture ligature.  After this was completed, no bleeding was seen.  The laryngeal nerve could be seen and intact and then Rubber band  drain was placed throughout the neck along the thyroid bed and 4-0 Vicryl was used to close the strap muscles in an interrupted fashion along with the platysma region and subcutaneous region and a running 5-0 nylon was used to close the skin and Mastisol and Steri-Strips were placed along the skin edges and then on awakening, both laryngeal nerves were working normally.  Procedure was then terminated at that time.","surgery, thyroid, rubber band drain, berry ligaments, papillary carcinoma, follicular variant, strap muscles, thyroid gland, sternocleidomastoid, parathyroid, hemithyroidectomy,"
 Placement of a Port-A-Cath under fluoroscopic guidancein a patient with anal cancer., Surgery, Port-A-Cath Insertion - 2 ,"PREOPERATIVE DIAGNOSIS:,1.  Anal cancer.,2.  Need for IV access.,POSTOPERATIVE DIAGNOSIS:,1.  Anal cancer.,2.  Need for IV access.,OPERATIVE PROCEDURE:,1.  Placement of a Port-A-Cath.,2.  Fluoroscopic guidance.,ANESTHESIA:,  General LMA.,ESTIMATED BLOOD LOSS:,  Minimum.,IV FLUIDS: , Per anesthesia.,RECURRENT COMPLICATIONS: , None.,FINDINGS: , Good port placement on C-arm.,INDICATIONS AND PROCEDURE IN DETAIL: , This is a 55-year-old female who presents with anal cancer, who is beginning chemoradiation and needs IV access for chemotherapy.  Risks and benefits of the procedure explained, the patient appeared to understand, and agreed to proceed.  The patient was taken to the operating room, placed in supine position.  General LMA anesthesia was administered.  She is prepped and draped in the usual sterile fashion.  She was placed in the Trendelenburg position and the left subclavian vein was cannulated and a guide wire placed through the wire.  Fluoroscopy was used to confirm appropriate guide wire location in the subclavian vein to the superior vena cava.  The incision was then made around the guide wire, taken to the subcutaneous tissues with electric Bovie cautery.  A pocket was made in the subcutaneous tissue of adequate size for the port which was cut at 16 cm for appropriate locationing which was cut at 16 cm based on superficial measurements.  The 2-0 Vicryl sutures were used to secure the port in place and the sheath introducer was placed over the guide wire and the guide wire removed with a Port catheter being placed into the sheath introducer.  Fluoroscopy was used to confirm appropriate positioning of the catheter and the skin was closed using interrupted 3-0 Vicryl followed by running 4-0 Vicryl subcuticular stitch.  Heparin flush was used to flush the port.  Steri-Strips were applied and the patient was awakened and extubated in the OR taken to the PACU in good condition.  All counts were reported as correct and I was present for the entire procedure.","surgery, anal cancer, fluoroscopic, fluoroscopy, iv access, port-a-cath, trendelenburg position, chemotherapy, subclavian vein, port a cath, subcutaneous tissues, insertion, subclavian"
 Port insertion through the right subclavian vein percutaneously under radiological guidance.  Metastatic carcinoma of the bladder and bowel obstruction., Surgery, Port Insertion ,"PREOPERATIVE DIAGNOSES,1.  Metastatic carcinoma of the bladder.,2.  Bowel obstruction.,POSTOPERATIVE DIAGNOSES,1.  Metastatic carcinoma of the bladder.,2.  Bowel obstruction.,PROCEDURE: , Port insertion through the right subclavian vein percutaneously under radiological guidance.,PROCEDURE DETAIL:  ,The patient was electively taken to the operating room after obtaining an informed consent.  A time-out process was followed.  Antibiotics were given.  Then, the patient's right deltopectoral area was prepped and draped in the usual fashion.  Xylocaine 1% was infiltrated.  The right subclavian vein was percutaneously cannulated without any difficulty.  Then using the Seldinger technique, the catheter part of the port, which was a single-lumen port, was passed through the introducer under x-ray guidance and placed in the junction of the superior vena cava and the right atrium.,A pocket had been fashioned and a single-lumen drum of the port was connected to the catheter, which had been trimmed and affixed to the pectoralis fascia with couple of sutures of Vicryl.  Then, the fascia was closed using subcuticular suture of Monocryl.  The drum was aspirated and irrigated with heparinized saline and then was put in the pocket and the skin was closed.  A dressing was applied including the needle and the port with the catheter so that the floor could use the catheter right away.,The patient tolerated the procedure well and was sent to recovery room in satisfactory condition.  A chest x-ray was performed that showed that there were no complications of procedure and that the catheter was in right place.","surgery, metastatic carcinoma of the bladder, percutaneously, subclavian vein, port insertion, metastatic carcinoma, bowel obstruction, catheter"
" Port-A-Cath insertion template.  Catheter was inserted after subcutaneous pocket was created, the sheath dilators were advanced, and the wire and dilator were removed.", Surgery, Port-A-Cath Insertion ,"PROCEDURE PERFORMED: , Port-A-Cath insertion.,ANESTHESIA: , MAC.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:  ,Minimal.,PROCEDURE IN DETAIL:  ,Patient was prepped and draped in sterile fashion.  The left subclavian vein was cannulated with a wire.  Fluoroscopic confirmation of the wire in appropriate position was performed.  Then catheter was inserted after subcutaneous pocket was created, the sheath dilators were advanced, and the wire and dilator were removed.  Once the catheter was advanced through the sheath, the sheath was peeled away.  Catheter was left in place, which was attached to hub, placed in the subcutaneous pocket, sewn in place with 2-0 silk sutures, and then all hemostasis was further reconfirmed.  No hemorrhage was identified.  The port was in appropriate position with fluoroscopic confirmation.  The wound was closed in 2 layers, the 1st layer being 3-0 Vicryl, the 2nd layer being 4-0 Monocryl subcuticular stitch.  Dressed with Steri-Strips and 4 x 4's.  Port was checked.  Had good blood return, flushed readily with heparinized saline.","surgery, hemostasis, port a cath insertion, fluoroscopic confirmation, cath insertion, insertion, fluoroscopic, subcutaneous, catheter, sheath, dilators, wire, "
 Transnasal transsphenoidal approach in resection of pituitary tumor.   The patient is a 17-year-old girl who presented with headaches and was found to have a prolactin of 200 and pituitary tumor., Surgery, Pituitary Tumor Resection ,"TITLE OF OPERATION: , Transnasal transsphenoidal approach in resection of pituitary tumor.,INDICATION FOR SURGERY: , The patient is a 17-year-old girl who presented with headaches and was found to have a prolactin of 200 and pituitary tumor.  She was started on Dostinex with increasing dosages.  The most recent MRI demonstrated an increased growth with hemorrhage.  This was then discontinued.  Most recent prolactin was at 70, although normalized, the recommendation was surgical resection given the size of the sellar lesion.  All the risks, benefits, and alternatives were explained in great detail via translator.,PREOP DIAGNOSIS: , Pituitary tumor.,POSTOP DIAGNOSIS: , Pituitary tumor.,PROCEDURE DETAIL:  ,The patient brought to the operating room, positioned on the horseshoe headrest in a neutral position supine.  The fluoroscope was then positioned.  The approach will be dictated by Dr. X. Once the operating microscope and the endoscope were then used to approach it through transnasal, this was complicated and complex secondary to the drilling within the sinus.  Once this was ensured, the tumor was identified, separated from the pituitary gland, it was isolated and then removed.  It appeared to be hemorrhagic and a necrotic pituitary, several sections were sent.  Once this was ensured and completed and hemostasis obtained, the wound was irrigated.  There might have been a small CSF leak with Valsalva, so the recommendation was for a reconstruction, Dr. X will dictate.  The fat graft was harvested from the left lower quadrant and closed primarily, this was soaked in fat and used to close the closure.  All sponge and needle counts were correct.  The patient was extubated and transported to the recovery room in stable condition.  Blood loss was minimal.","surgery, transnasal transsphenoidal approach, resection, pituitary tumor, transsphenoidal, transnasal, prolactin, tumor, pituitary, "
" Application of PMT large halo crown and vest.  Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion.", Surgery, PMT Halo Crown & Vest ,"PREOPERATIVE DIAGNOSES: , Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion.,POSTOPERATIVE DIAGNOSES: , Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion, and potentially unstable cervical spine.,OPERATIVE PROCEDURE:  ,Application of PMT large halo crown and vest.,ESTIMATED BLOOD LOSS: , None.,ANESTHESIA:  ,Local, conscious sedation with Morphine and Versed.,COMPLICATIONS: , None.  Post-fixation x-rays, nonalignment, no new changes.  Post-fixation neurologic examination normal.,CLINICAL HISTORY:  ,The patient is a 41-year-old female who presented to me with severe cervical spondylosis and myelopathy.  She was referred to me by Dr. X.  The patient underwent a complicated anterior cervical discectomy, 2-level corpectomy, spinal cord decompression and fusion with fibular strut and machine allograft in the large cervical plate.  Surgery had gone well, and the patient has done well in the last 2 days.  She is neurologically improved and is moving all four extremities.  No airway issues.  It was felt that the patient was now a candidate for a halo vest placement given that chance of going to the OR were much smaller.  She was consented for the procedure, and I sought the help of ABC and felt that a PMT halo would be preferable to a Bremer halo vest.  The patient had this procedure done at the bedside, in the SICU room #1.  I used a combination of some morphine 1 mg and Versed 2 mg for this procedure.  I also used local anesthetic, with 1% Xylocaine and epinephrine a total of 15 to 20 cc.,PROCEDURE DETAILS:,  The patient's head was positioned on some towels, the retroauricular region was shaved, and the forehead and the posterolateral periauricular regions were prepped with Betadine.  A large PMT crown was brought in and fixed to the skull with pins under local anesthetic.  Excellent fixation achieved.  It was lateral to the supraorbital nerves and 1 fingerbreadth above the brows and the ear pinnae.,I then put the vest on, by sitting the patient up, stabilizing her neck.  The vest was brought in from the front as well and connected.  Head was tilted appropriately, slightly extended, and in the midline.  All connections were secured and pins were torqued and tightened.,During the procedure, the patient did fine with no significant pain.,Post-procedure, she is neurologically intact and she remained intact throughout.  X-rays of the cervical spine AP, lateral, and swimmer views showed excellent alignment of the hardware construct in the graft with no new changes.,The patient will be subjected to a CT scan to further define the alignment, and barring any problems, she will be ambulating with the halo on.,The patient will undergo pin site care as per protocol, and likely she will go in the next 2 to 3 days.  Her prognosis indeed is excellent, and she is already about 90% or so better from her surgery.  She is also on a short course of Decadron, which we will wean off in due course.,The matter was discussed with the patient and the patient's family.","surgery, cervical spondylosis, anterior cervical discectomy, corpectomy, decompression, fusion, pmt, crown, vest, pmt halo, cervical,"
 Ultrasound-guided right pleurocentesis for right pleural effusion with respiratory failure and dyspnea., Surgery, Pleurocentesis ,"PREOPERATIVE DIAGNOSIS: , Right pleural effusion with respiratory failure and dyspnea.,POSTOPERATIVE DIAGNOSIS: , Right pleural effusion with respiratory failure and dyspnea.,PROCEDURE: , Ultrasound-guided right pleurocentesis.,ANESTHESIA: , Local with lidocaine.,TECHNIQUE IN DETAIL: , After informed consent was obtained from the patient and his mother, the chest was scanned with portable ultrasound.  Findings revealed a normal right hemidiaphragm, a moderate right pleural effusion without septation or debris, and no gliding sign of the lung on the right.  Using sterile technique and with ultrasound as a guide, a pleural catheter was inserted and serosanguinous fluid was withdrawn, a total of 1 L.  The patient tolerated the procedure well.  Portable x-ray is pending.","surgery, pleural effusion, dyspnea, gliding sign, hemidiaphragm, pleural catheter, pleurocentesis, respiratory, serosanguinous fluid, ultrasound, pleural, "
 Closed reduction and pinning of the right ulna with placement of a long-arm cast., Surgery, Pinning - Ulna ,"PREOPERATIVE DIAGNOSIS:,  Right both bone forearm refracture.,POSTOPERATIVE DIAGNOSIS: , Right both bone forearm refracture.,PROCEDURE:,  Closed reduction and pinning of the right ulna with placement of a long-arm cast.,ANESTHESIA: , Surgery performed under general anesthesia.  Local anesthetic was 10 mL of 0.25% Marcaine plain.,COMPLICATIONS: , No intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,HARDWARE:  ,Hardware was 0.79 K-wire.,HISTORY AND PHYSICAL: , The patient is a 5-year-old male who sustained refracture of his right forearm on 12/05/2007.  The patient was seen in the emergency room.  The patient had a complete fracture of both bones with shortening bayonet apposition.  Treatment options were offered to the family including casting versus closed reduction and pinning.  The parents opted for the latter.  Risks and benefits of surgery were discussed.  Risks of surgery included risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, and need for later hardware removal, cast tightness.  All questions were answered, and the parents agreed to the above plan.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating room table.  General anesthesia was then administered.  The patient received Ancef preoperatively.  The right upper extremity was then prepped and draped in standard surgical fashion.  A small incision was made at the tip of the olecranon.  Initially, a 1.11 guidewire was placed, but this was noted to be too wide for this canal.  This was changed for a 0.79 K-wire.  This was driven up to the fracture site.  The fracture was manually reduced and then the K-wire passed through the distal segment.  This demonstrated adequate fixation and reduction of both bones.  The pin was then cut short.  The fracture site and pin site was infiltrated with 0.25% Marcaine.  The incision was closed using 4-0 Monocryl.  The wounds were cleaned and dried.  Dressed with Xeroform, 4 x 4.  The patient was then placed in a well-moulded long-arm cast.  He tolerated the procedure well.  He was subsequently taken to Recovery in stable condition.,POSTOPERATIVE PLAN: , The patient will be maintain current pin, and long-arm cast for 4 weeks at which time he will return for cast removal.  X-rays of the right forearm will be taken.  The patient may need additional mobilization time.  Once the fracture has healed, we will take the pin out, usually at the earliest 3 to 4 months.  Intraoperative findings were relayed to the parents.  All questions were answered.","surgery, closed reduction, pinning, forearm refracture, fracture site, arm cast,"
" Plantar fascitis, left foot.  Partial plantar fasciotomy.", Surgery, Plantar Fasciotomy ,"PREOPERATIVE DIAGNOSIS:,  Plantar fascitis, left foot.,POSTOPERATIVE DIAGNOSIS: , Plantar fascitis, left foot.,PROCEDURE PERFORMED: , Partial plantar fasciotomy, left foot.,ANESTHESIA:,  10 cc of 0.5% Marcaine plain with TIVA.,HISTORY:  ,This 35-year-old Caucasian female presents to ABCD General Hospital with above chief complaint.  The patient states she has extreme pain with plantar fascitis in her left foot and has attempted conservative treatment including orthotics without long-term relief of symptoms and desires surgical treatment.  The patient has been NPO since mid night.  Consent is signed and in the chart.  No known drug allergies.,Details Of Procedure:  An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported to the operating room and placed on the operating table in supine position with a safety belt across the stomach.  Copious amounts of Webril were placed on the left ankle followed by blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 10 cc of 0.5% Marcaine plain was injected into the surgical site both medially and laterally across the plantar fascia.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  An Esmarch bandage was applied for exsanguination and the pneumatic ankle tourniquet was inflated to 250 mmHg.  The foot was then reflected on the operating, stockinet reflected, and the foot cleansed with a wet and dry sponge.  Attention was then directed to the plantar medial aspect of the left heel.  An approximately 0.75 cm incision was then created in the plantar fat pad over the area of maximal tenderness.,The incision was then deepened with a combination of sharp and blunt dissection until the plantar fascia was palpated.  A #15 blade was then used to transect the medial and central bands of the plantar fascia.  Care was taken to preserve the lateral fibroids.  The foot was dorsiflexed against resistance as the fibers were released and there was noted to be increased laxity after release of the fibers on the plantar aspect of the foot indicating that plantar fascia has in fact been transacted.  The air was then flushed with copious amounts of sterile saline.  The skin incision was then closed with #3-0 nylon in simple interrupted fashion.  Dressings consisted of #0-1 silk, 4 x 4s, Kling, Kerlix, and Coban.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted throughout all digits of the left foot.  The patient tolerated the above procedure and anesthesia well without complications.  The patient was transported to the PACU with vital signs stable and vascular status intact to the left foot.  Intraoperatively, an additional 80 cc of 1% lidocaine was injected for additional anesthesia in the case.  The patient is to be nonweightbearing on the left lower extremity with crutches.  The patient is given postoperative pain prescriptions for Vicodin ES, one q3-4h. p.o. p.r.n. for pain as well as Celebrex 200 mg one p.o. b.i.d.  The patient is to follow-up with Dr. X as directed.","surgery, foot, plantar fasciotomy, plantar fascitis, plantar fascia, plantar, fasciotomy, ankle, medially, fascitis, fascia"
 Chest tube talc pleurodesis of the right chest., Surgery, Pleurodesis ,"PREOPERATIVE DIAGNOSIS:,  Large recurrent right pleural effusion.,POSTOPERATIVE DIAGNOSIS:,  Large recurrent right pleural effusion.,PROCEDURE:,1.  Conscious sedation.,2.  Chest tube talc pleurodesis of the right chest.,INDICATIONS: , The patient is a 65-year-old lady with a history of cirrhosis who has developed a recurrent large right pleural effusion.  Chest catheter had been placed previously, and she had been draining up to 1.5 liters of serous fluid a day.  Eventually, this has decreased and a talc pleurodesis is being done to see her pleural effusion does not recur.,SPECIMENS:,  None.,ESTIMATED BLOOD LOSS: , Zero.,NARRATIVE:,  After obtaining informed consent from the patient and her daughter, the patient was assessed and found to be in good condition and a good candidate for conscious sedation.  Vital signs were taken.  These were stable, so the patient was then given initially 0.5 mg of Versed and 2 mg of morphine IV.  After a couple of minutes, she was assessed and found to be awake but calm, so then the chest tube was clamped and then through the chest tube a solution of 120 mL of normal saline containing 5 g of talc and 40 mg of lidocaine were then put into her right chest taking care that no air would go in to create a pneumothorax.  She was then laid on her left lateral decubitus position for 5 minutes and then turned into the right lateral decubitus position for 5 minutes and then the chest tube was unclamped.  The patient was given additional 0.5 mg of Versed and 0.5 mg of Dilaudid IV achieving a state where the patient was comfortable but readily responsive.  The patient tolerated the procedure well.  She did complain of up to a 7/10 pain, but quickly this was brought under control.  The chest tube was unclamped.  Now, the patient will be left to rest and she will get a chest x-ray in the morning.","surgery, chest tube talc pleurodesis, lateral decubitus position, decubitus position, talc pleurodesis, pleural effusion, chest tube, chest, pleurodesis, talc, recurrent, pleural, effusion, tube"
 Endoscopic-assisted transsphenoidal exploration and radical excision of pituitary adenoma.  Endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus., Surgery, Pituitary Adenomectomy ,"PREOPERATIVE DIAGNOSIS: , Large and invasive recurrent pituitary adenoma.,POSTOPERATIVE DIAGNOSIS:,  Large and invasive recurrent pituitary adenoma.,OPERATION PERFORMED: , Endoscopic-assisted transsphenoidal exploration and radical excision of pituitary adenoma, endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus, harvesting of dermal fascia abdominal fat graft, placement of abdominal fat graft into sella turcica, reconstruction of sellar floor using autologous nasal bone creating a cranioplasty of less than 5 cm, repair of nasal septal deviation, using the operating microscope and microdissection technique, and placement of lumbar subarachnoid catheter connected to reservoir for aspiration and infusion.,INDICATIONS FOR PROCEDURE: , This man has undergone one craniotomy and 2 previous transsphenoidal resections of his tumor, which is known to be an invasive pituitary adenoma.  He did not return for followup or radiotherapy as instructed, and the tumor has regrown.  For this reason, he is admitted for transsphenoidal reoperation with an attempt to remove as much tumor as possible.  The high-risk nature of the procedure and the fact that postoperative radiation is mandatory was made clear to him.  Many risks including CSF leak and blindness were discussed in detail.  After clear understanding of all the same, he elected to proceed ahead with surgery.,PROCEDURE:  ,The patient was placed on the operating table, and after adequate induction of general anesthesia, he was placed in the left lateral decubitus position.  Care was taken to pad all pressure points appropriately.  The back was prepped and draped in usual sterile manner.,A 14-gauge Tuohy needle was introduced into the lumbar subarachnoid space.  Clear and colorless CSF issued forth.  A catheter was inserted to a distance of 40 cm, and the needle was removed.  The catheter was then connected to a closed drainage system for aspiration and infusion.,This no-touch technique is now a standard of care for treatment of patients with large invasive adenomas.  Via injections through the lumbar drain, one increases intracranial pressure and produces gentle migration of the tumor.  This improves outcome and reduces complications by atraumatically dissecting the tumor away from the optic apparatus.,The patient was then placed supine, and the 3-point headrest was affixed.  He was placed in the semi-sitting position with the head turned to the right and a roll placed under the left shoulder.  Care was taken to pad all pressure points appropriately.  The fluoroscope C-arm unit was then positioned so as to afford an excellent view of the sella and sphenoid sinus in the lateral projection.  The metallic arm was then connected to the table for the use of the endoscope.  The oropharynx, nasopharynx, and abdominal areas were then prepped and draped in the usual sterile manner.,A transverse incision was made in the abdominal region, and several large pieces of fat were harvested for later use.  Hemostasis was obtained.  The wound was carefully closed in layers.,I then advanced a 0-degree endoscope up the left nostril.  The middle turbinate was identified and reflected laterally exposing the sphenoid sinus ostium.  Needle Bovie electrocautery was used to clear mucosa away from the ostium.  The perpendicular plate of the ethmoid had already been separated from the sphenoid.  I entered into the sphenoid.,There was a tremendous amount of dense fibrous scar tissue present, and I slowly and carefully worked through all this.  I identified a previous sellar opening and widely opened the bone, which had largely regrown out to the cavernous sinus laterally on the left, which was very well exposed, and the cavernous sinus on the right, which I exposed the very medial portion of.  The opening was wide until I had the horizontal portion of the floor to the tuberculum sella present.,The operating microscope was then utilized.  Working under magnification, I used hypophysectomy placed in the nostril.,The dura was then carefully opened in the midline, and I immediately encountered tissue consistent with pituitary adenoma.  A frozen section was obtained, which confirmed this diagnosis without malignant features.,Slowly and meticulously, I worked to remove the tumor.  I used the suction apparatus as well as the bipolar coagulating forceps and ring and cup curette to begin to dissect tumor free.  The tumor was moderately vascular and very fibrotic.,Slowly and carefully, I systematically entered the sellar contents until I could see the cavernous sinus wall on the left and on the right.  There appeared to be cavernous sinus invasion on the left.  It was consistent with what we saw on the MRI imaging.,The portion working into the suprasellar cistern was slowly dissected down by injecting saline into the lumbar subarachnoid catheter.  A large amount of this was removed.  There was a CSF leak, as the tumor was removed for the upper surface of it was very adherent to the arachnoid and could not be separated free.,Under high magnification, I actually worked up into this cavity and performed a very radical excision of tumor.  While there may be a small amount of tumor remaining, it appeared that a radical excision had been created with decompression of the optic apparatus.  In fact, I reinserted the endoscope and could see the optic chiasm well.,I reasoned that I had therefore achieved the goal with that is of a radical excision and decompression.  Attention was therefore turned to closure.,The wound was copiously irrigated with Bacitracin solution, and meticulous hemostasis was obtained.  I asked Anesthesiology to perform a Valsalva maneuver, and there was no evidence of bleeding.,Attention was turned to closure and reconstruction.  I placed a very large piece of fat in the sella to seal the leak and verified that there was no fat in the suprasellar cistern by using fluoroscopy and looking at the pattern of the air.  Using a polypropylene insert, I reconstructed the sellar floor with this implant making a nice tight sling and creating a cranioplasty of less than 5 cm.,DuraSeal was placed over this, and the sphenoid sinus was carefully packed with fat and DuraSeal.,I inspected the nasal passages and restored the septum precisely to the midline repairing a previous septal deviation.  The middle turbinates were then restored to their anatomic position.  There was no significant intranasal bleeding, and for this reason, an open nasal packing was required.  Sterile dressings were applied, and the operation was terminated.,The patient tolerated the procedure well and left to the recovery room in excellent condition.  The sponge and needle counts were reported as correct, and there were no intraoperative complications.,Specimens were sent to Pathology consisting of tumor.", 
" A 44-year-old, 250-pound male presents with extreme pain in his left heel.", Surgery, Plantar Fasciitis ,"S -, A 44-year-old, 250-pound male presents with extreme pain in his left heel.  This is his chief complaint.  He says that he has had this pain for about two weeks.  He works on concrete floors.  He says that in the mornings when he gets up or after sitting, he has extreme pain and great difficulty in walking.  He also has a macular blotching of skin on his arms, face, legs, feet and the rest of his body that he says is a pigment disorder that he has had since he was 17 years old.  He also has redness and infection of the right toes.,O -, The patient apparently has a pigmentation disorder, which may or may not change with time, on his arms, legs and other parts of his body, including his face.  He has an erythematous moccasin-pattern tinea pedis of the plantar aspects of both feet.  He has redness of the right toes 2, 3 and 4.  Extreme exquisite pain can be produced by direct pressure on the plantar aspect of his left heel.,A -, 1.  Plantar fasciitis.,","surgery, plantar fasciitis, tinea pedis, tinea purpura, heel, fasciitis, plantar, "
" External fixation of left pilon fracture and closed reduction of left great toe, T1 fracture.  Due to the comminuted nature of her tibia fracture as well as soft tissue swelling, the patient is in need of a staged surgery with the 1st stage external fixation followed by open treatment and definitive plate and screw fixation.  ", Surgery, Pilon Fracture External Fixation ,"PREOP DIAGNOSES:,1.  Left pilon fracture.,2.  Left great toe proximal phalanx fracture.,POSTOP DIAGNOSES:,1.  Left pilon fracture.,2.  Left great toe proximal phalanx fracture.,OPERATION PERFORMED:,1.  External fixation of left pilon fracture.,2.  Closed reduction of left great toe, T1 fracture.,ANESTHESIA:  ,General.,BLOOD LOSS:  ,Less than 10 mL.,Needle, instrument, and sponge counts were done and correct.,DRAINS AND TUBES: , None.,SPECIMENS:,  None.,INDICATION FOR OPERATION:  ,The patient is a 58-year-old female who was involved in an auto versus a tree accident on 6/15/2009.  The patient suffered a fracture of a distal tibia and fibula as well as her great toe on the left side at that time.  The patient was evaluated by the emergency room and did undergo further evaluation due to loss of consciousness.  She underwent a provisional reduction and splinting in the emergency room followed by further evaluation for her heart and brain by the Medicine Service following this and she was appropriate for surgical intervention.  Due to the comminuted nature of her tibia fracture as well as soft tissue swelling, the patient is in need of a staged surgery with the 1st stage external fixation followed by open treatment and definitive plate and screw fixation.  The patient had swollen lower extremities, however, compartments were soft and she had no sign of compartment syndrome.  Risks and benefits of procedure were discussed in detail with the patient and her husband.  All questions were answered, and consent was obtained.  The risks including damage to blood vessels and nerves with painful neuroma or numbness, limb altered function, loss of range of motion, need for further surgery, infection, complex regional pain syndrome and deep vein thrombosis were all discussed as potential risks of the surgery.,FINDINGS:,1.  There was a comminuted distal tibia fracture with a fibular shaft fracture.  Following traction, there was adequate coronal and sagittal alignment of the fracture fragments and based on the length of the fibula, the fracture fragments were out to length.,2.  The base of her proximal phalanx fracture was assessed and reduced with essentially no articular step-off and approximately 1-mm displacement.  As the reduction was stable with buddy taping, no pinning was performed.,3.  Her compartments were full, but not firm nor did she have any sign of compartment syndrome and no compartment releases were performed.,OPERATIVE REPORT IN DETAIL:  ,The patient was identified in the preoperative holding area.  The left leg was identified and marked at the surgical site of the patient.  She was then taken to the operating room where she was transferred to the operating room in the supine position, placed under general anesthesia by the anesthesiology team.  She received Ancef for antibiotic prophylaxis.  A time-out was then undertaken verifying the correct patient, extremity, visibility of preoperative markings, availability of equipment, and administration of preoperative antibiotics.  When all was verified by the surgeon, anesthesia and circulating personnel left lower extremity was prepped and draped in the usual fashion.  At this point, intraoperative fluoroscopy was used to identify the fracture site as well as the appropriate starting point both in the calcaneus for a transcalcaneal cross stent and in the proximal tibia with care taken to leave enough room for later plate fixation without contaminating the future operative site.  A single centrally threaded calcaneal cross tunnel was then placed across the calcaneus parallel to the joint surface followed by placement of 2 Schantz pins in the tibia and a frame type external fixator was then applied in traction with attempts to get the fracture fragments out to length, but not overly distract the fracture and restore coronal and sagittal alignment as much as able.  When this was adequate, the fixator apparatus was locked in place, and x-ray images were taken verifying correct placement of the hardware and adequate alignment of the fracture.  Attention was then turned to the left great toe, where a reduction of the proximal phalanx fracture was performed and buddy taping as this provided good stability and was least invasive.  X-rays were taken showing good reduction of the base of the proximal phalanx of the great toe fracture.  At this point, the pins were cut short and capped to protect the sharp ends.  The stab wounds for the Schantz pin and cross pin were covered with gauze with Betadine followed by dry gauze, and the patient was then awakened from anesthesia and transferred to the progressive care unit in stable condition.  Please note there was no break in sterile technique throughout the case.,PLAN:  ,The patient will require definitive surgical treatment in approximately 2 weeks when the soft tissues are amenable to plate and screw fixation with decreased risk of wound complication.  She will maintain her buddy taping in regards to her great toe fracture.","surgery, phalanx fracture, schantz pins, toe fracture, tibia fracture, pilon fracture, external fixation, proximal phalanx, fracture, toe, pilon, phalanx, reduction, tibia, proximal, fixation, "
 Pilonidal cyst with abscess formation.  Excision of infected pilonidal cyst., Surgery, Pilonidal Cyst Excision ,"PREOPERATIVE DIAGNOSIS: , Pilonidal cyst with abscess formation.,POSTOPERATIVE DIAGNOSIS:,  Pilonidal cyst with abscess formation.,OPERATION: , Excision of infected pilonidal cyst.,PROCEDURE: , After obtaining informed consent, the patient underwent a spinal anesthetic and was placed in the prone position in the operating room.  A time-out process was followed.  Antibiotics were given and then the patient was prepped and draped in the usual fashion.  It appeared to me that the abscess had drained somewhat during the night, as it was much smaller than I was anticipating.  An elliptical excision of all infected tissues down to the coccyx was performed.  Hemostasis was achieved with a cautery.  The wound was irrigated with normal saline and it was packed open with iodoform gauze and an absorptive dressing.,The patient was sent to recovery room in satisfactory condition.  Estimated blood loss was minimal.  The patient tolerated the procedure well.","surgery, hemostasis, excision, pilonidal cyst, cyst, abscess, infected,"
 Revision and in situ pinning of the right hip., Surgery, Pinning - Hip ,"PREOPERATIVE DIAGNOSIS: , Right acute on chronic slipped capital femoral epiphysis.,POSTOPERATIVE DIAGNOSIS: , Right acute on chronic slipped capital femoral epiphysis.,PROCEDURE: , Revision and in situ pinning of the right hip.,ANESTHESIA: , Surgery performed under general anesthesia.,COMPLICATIONS:  ,There were no intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,LOCAL:  ,10 mL of 0.50% Marcaine local anesthetic.,HISTORY AND PHYSICAL: , The patient is a 13-year-old girl who presented in November with an acute on chronic right slipped capital femoral epiphysis.  She underwent in situ pinning.  The patient on followup; however, noted to have intraarticular protrusion of her screw.  This was not noted intraoperatively on previous fluoroscopic views.  Given this finding, I explained to the father and especially the mother that this can cause further joint damage and that the screw would need to be exchanged for a shorter one.  Risks and benefits of surgery were discussed.  Risks of surgery include risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, failure to remove the screw, possible continued joint stiffness or damage.  All questions were answered and parents agreed to above plan.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating table.  General anesthesia was then administered.  The patient received Ancef preoperatively.  A small bump was placed underneath her right buttock.  The right upper thigh was then prepped and draped in standard surgical fashion.  The upper aspect of the incision was reincised.  The dissection was carried down to the crew, which was easily found.  A guidewire was placed inside the screw with subsequent removal of the previous screw.  The previous screw measured 65 mm.  A 60 mm screw was then placed under direct visualization with fluoroscopy.  The hip was taken through full range of motion to check on the length of the screw, which demonstrated no intraarticular protrusion.  The guidewire was removed.  The wound was then irrigated and closed using 2-0 Vicryl in the fascial layer as well as the subcutaneous fat.  The skin was closed with 4-0 Monocryl.  The wound was cleaned and dried, dressed with Steri-Strips, Xeroform, 4 x 4s, and tape.  The area was infiltrated with total 10 mL of 0.5% Marcaine local anesthetic.,POSTOPERATIVE PLAN: , The patient will be discharged on the day of surgery.  She should continue toe touch weightbearing on her leg.  The wound may be wet in approximately 5 days.  The patient should follow up in clinic in about 10 days.  The patient is given Vicodin for pain.  Intraoperative findings were relayed to the mother.","surgery, guidewire, capital femoral epiphysis, intraarticular protrusion, femoral epiphysis, pinning, screw,"
" Left hemothorax, rule out empyema.  Insertion of a 12-French pigtail catheter in the left pleural space.", Surgery, Pigtail Catheter Insertion ,"PREOPERATIVE DIAGNOSIS:  ,Left hemothorax, rule out empyema.,POSTOPERATIVE DIAGNOSIS: , Left hemothorax rule out empyema.,PROCEDURE: , Insertion of a 12-French pigtail catheter in the left pleural space.,PROCEDURE DETAIL:  ,After obtaining informed consent, the patient was taken to the minor OR in the Same Day Surgery where his posterior left chest was prepped and draped in a usual fashion.  Xylocaine 1% was injected and then a 12-French pigtail catheter was inserted in the medial scapular line about the eighth intercostal space.  It was difficult to draw fluid by syringe, but we connected the system to a plastic bag and by gravity started draining at least 400 mL while we were in the minor OR.  Samples were sent for culture and sensitivity, aerobic and anaerobic.,The patient and I decided to admit him for a period of observation at least overnight.,He tolerated the procedure well and the postprocedure chest x-ray showed no complications.","surgery, chest, pleural space, pigtail catheter, insertion, empyema, hemothorax, "
" Botulinum toxin injection bilateral rectus femoris, medial hamstrings, and gastrocnemius soleus muscles, phenol neurolysis of bilateral obturator nerves, application of bilateral short leg fiberglass casts.", Surgery, Phenol Neurolysis & Botulinum Toxin Injection - 3 ,"PROCEDURE CODES:  64640 times two, 64614 time two, 95873 times two, 29405 times two.,PREOPERATIVE DIAGNOSIS:  Spastic diplegic cerebral palsy, 343.0.,POSTOPERATIVE DIAGNOSIS:  Spastic diplegic cerebral palsy, 343.0.,ANESTHESIA:  MAC.,COMPLICATIONS:  None.,DESCRIPTION OF TECHNIQUE:  Informed consent was obtained from the patient's mom.  The patient was brought to minor procedures and sedated per their protocol.  The patient was positioned lying supine.  Skin overlying all areas injected was prepped with chlorhexidine.,The obturator nerves were identified lateral to the adductor longus tendon origin and below the femoral pulse with active EMG stimulation.  Approximately 4 mL of 5% phenol was injected in this location bilaterally.  Phenol injections were done at the site of maximum hip adduction contraction with least amount of stimulus.  Negative drawback for blood was done prior to each injection of phenol.,Muscles injected with botulinum toxin were identified with active EMG stimulation.  Approximately 50 units was injected in the rectus femoris bilaterally, 75 units in the medial hamstrings bilaterally and 100 units in the gastrocnemius soleus muscles bilaterally.  Total amount of botulinum toxin injected was 450 units diluted 25 units to 1 mL.  After injections were performed, bilateral short leg fiberglass casts were applied.  The patient tolerated the procedure well and no complications were encountered.","surgery, botulinum toxin injection bilateral, toxin injection bilateral rectus, neurolysis of bilateral obturator, short leg fiberglass casts, muscles phenol neurolysis, botulinum toxin injection, gastrocnemius soleus muscles, short leg fiberglass, femoris medial, cerebral palsy, active emg, emg stimulation, phenol neurolysis, toxin injection, rectus femoris, gastrocnemius soleus, soleus muscles, obturator nerves, leg fiberglass, fiberglass casts, botulinum toxin, hamstrings, gastrocnemius, obturator, nerves, fiberglass, casts, muscles, botulinum, phenol, bilateral, injection, toxin"
" Phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves.  Botulinum toxin injection left pectoralis major, left wrist flexors, and bilateral knee extensors.", Surgery, Phenol Neurolysis & Botulinum Toxin Injection - 1 ,"PROCEDURES PERFORMED:,  Phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves.  Botulinum toxin injection left pectoralis major, left wrist flexors, and bilateral knee extensors.,PROCEDURE CODES: , 64640 times three, 64614 times four, 95873 times four.,PREOPERATIVE DIAGNOSIS: , Spastic quadriparesis secondary to traumatic brain injury, 907.0.,POSTOPERATIVE DIAGNOSIS:,  Spastic quadriparesis secondary to traumatic brain injury, 907.0.,ANESTHESIA:,  MAC.,COMPLICATIONS: , None.,DESCRIPTION OF TECHNIQUE: , Informed consent was obtained from the patient's brother.  The patient was brought to the minor procedure area and sedated per their protocol.  The patient was positioned lying supine.  Skin overlying all areas injected was prepped with chlorhexidine.  The obturator nerves were identified lateral to the adductor longus tendon origin and below the femoral pulse using active EMG stimulation.  Approximately 7 mL was injected on the right side and 5 mL on the left side.  At all sites of phenol injections in this area injections were done at the site of maximum hip adduction contraction with least amount of stimulus.  Negative drawback for blood was done prior to each injection of phenol.  The musculocutaneous nerve was identified in the left upper extremity above the brachial pulse using active EMG stimulation.  Approximately 5 mL of 5% phenol was injected in this location.  Injections in this area were done at the site of maximum elbow flexion contraction with least amount of stimulus.  Negative drawback for blood was done prior to each injection of phenol.,Muscles injected with botulinum toxin were identified using active EMG stimulation.  Approximately 150 units was injected in the knee extensors bilaterally, 100 units in the left pectoralis major, and 50 units in the left wrist flexors.  Total amount of botulinum toxin injected was 450 units diluted 25 units to 1 mL.  The patient tolerated the procedure well and no complications were encountered.","surgery, spastic quadriparesis, emg stimulation, emg, botulinum toxin injection, traumatic brain, brain injury, phenol neurolysis, toxin injection, musculocutaneous nerve, obturator nerves, pectoralis major, wrist flexors, knee extensors, active emg, botulinum toxin, toxin, injection, stimulus, neurolysis, musculocutaneous, extensors, botulinum, phenol"
" Right phacoemulsification of cataract with intraocular lens implantation - Cataract, right eye.", Surgery, Phacoemulsification of Cataract ,"PREOPERATIVE DIAGNOSIS (ES):, Cataract, right eye.,POSTOPERATIVE DIAGNOSIS (ES):, Cataract, right eye.,PROCEDURE:, Right phacoemulsification of cataract with intraocular lens implantation.,DESCRIPTION OF THE OPERATION:, Under topical anesthesia with monitored anesthesia care, the patient was prepped, draped and positioned under the operating microscope. A lid speculum was applied to the right eye, and a stab incision into the anterior chamber was done close to the limbus at about the 1 o'clock position with a Superblade, and Xylocaine 1% preservative free 0.25 mL was injected into the anterior chamber, which was then followed by Healon to deepen the anterior chamber. Using a keratome, another stab incision was done close to the limbus at about the 9 o'clock position and with the Utrata forceps, anterior capsulorrhexis was performed, and the torn anterior capsule was totally removed. Hydrodissection and hydrodelineation were performed with the tuberculin syringe filled with BSS. The tip of the phaco unit was introduced into the anterior chamber, and anterior sculpting of the nucleus was performed until about more than two-thirds of the nucleus was removed. Using the phaco tip and the Drysdale hook, the nucleus was broken up into 4 pieces and then phacoemulsified.,The phaco tip was then exchanged for the aspiration/irrigation tip, and cortical materials were aspirated. Posterior capsule was polished with a curette polisher, and Healon was injected into the capsular bag. Using the Monarch intraocular lens inserter, the posterior chamber intraocular lens model SN60WF power +19.50 was placed into the inserter after applying some Healon, and the tip of the inserter was gently introduced through the cornea tunnel wound, into the capsular bag and then the intraocular lens was then inserted inferior haptic first into the back and the superior haptic was placed into the bag with the same instrument. Intraocular lens was then rotated about half a turn with a collar button hook. Healon was removed with the aspiration/irrigation tip, and balanced salt solution was injected through the side port to deepen the anterior chamber. It was found that there was no leakage of fluid through the cornea tunnel wound. For this reason, no suture was applied. Vigamox, Econopred and Nevanac eye drops were instilled and the eye was covered with a perforated shield. The patient tolerated the procedure well. There were no complications.","surgery, cataract, implantation, intraocular, intraocular lens, lens implantation, phacoemulsification, capsular bag, capsule, intraocular lens implantation, cornea tunnel wound, phacoemulsification of cataract, cornea tunnel, anterior chamber, anesthesia, cornea, lens, chamber,"
" Phenol neurolysis right obturator nerve, botulinum toxin injection right rectus femoris and vastus medialis intermedius and right pectoralis major muscles.", Surgery, Phenol Neurolysis & Botulinum Toxin Injection - 2 ,"PROCEDURES PERFORMED: , Phenol neurolysis right obturator nerve, botulinum toxin injection right rectus femoris and vastus medialis intermedius and right pectoralis major muscles.,PROCEDURE CODES: , 64640 times one, 64614 times two, 95873 times two.,PREOPERATIVE DIAGNOSIS: , Spastic right hemiparetic cerebral palsy, 343.1.,POSTOPERATIVE DIAGNOSIS:,  Spastic right hemiparetic cerebral palsy, 343.1.,ANESTHESIA:,  MAC.,COMPLICATIONS: , None.,DESCRIPTION OF TECHNIQUE: , Informed consent was obtained from the patient.  She was brought to the minor procedure area and sedated per their protocol.  The patient was positioned lying supine.  Skin overlying all areas injected was prepped with chlorhexidine.  The right obturator nerve was identified using active EMG stimulation lateral to the adductor longus tendon origin and below the femoral pulse.  Approximately 6 mL of 5% phenol was injected in this location.  At all sites of phenol injections, injections were done at the site of maximum hip adduction contraction with least amount of stimulus.  Negative drawback for blood was done prior to each injection of phenol.,Muscles injected with botulinum toxin were identified with active EMG stimulation.  Approximately 100 units was injected in the right pectoralis major and 100 units in the right rectus femoris and vastus intermedius muscles.  Total amount of botulinum toxin injected was 200 units diluted 25 units to 1 mL.  The patient tolerated the procedure well and no complications were encountered.","surgery, femoris and vastus medialis, intermedius and right pectoralis, rectus femoris and vastus, vastus medialis intermedius, botulinum toxin injection, medialis intermedius, major muscles, cerebral palsy, active emg, emg stimulation, phenol neurolysis, toxin injection, obturator nerve, rectus femoris, pectoralis major, botulinum toxin, pectoralis, botulinum, phenol, injection, toxin"
" Cataract, right eye.  Phacoemulsification of cataract with posterior chamber intraocular lens, right eye.", Surgery, Phacoemulsification Of Cataract - 2 ,"PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:,  Cataract, right eye.,PROCEDURE:  ,Phacoemulsification of cataract with posterior chamber intraocular lens, right eye.,ANESTHESIA:  ,Topical.,COMPLICATIONS:  ,None.,PROCEDURE IN DETAIL:  ,The patient was identified.  The operative eye was treated with tetracaine 1% topically in the preoperative holding area.  The patient was taken to the operating room and prepped and draped in the usual sterile fashion for ophthalmic surgery.,Attention was turned to the left/right eye.  The lashes were tapped using Steri-Strips to prevent blinking.  A lid speculum was placed to prevent lid closure.  Anesthesia was verified.  Then, a 3.5-mm groove was created with a diamond blade temporarily.  This was beveled with a crescent blade, and the anterior chamber was entered with a 3.2-mm keratome in the iris plane.  A 1% nonpreserved lidocaine was injected intracamerally and followed with Viscoat.  A paracentesis was made.  A round capsulorrhexis was performed.  The anterior capsular flap was removed.  Hydrodelineation and dissection were followed by phacoemulsification of the cataract using a chop technique.  The irrigating-aspirating machine was used to clear residual cortex.  The Provisc was instilled.  An SN60WS diopter intraocular lens was inserted into the capsular bag, and the position was verified.  The viscoelastic was removed.  Intraocular lens remained well centered.  The incision was hydrated, and the anterior chamber pressure was checked with tactile pressure and found to be normal.  The anterior chamber remained deep, and there was no wound leak.  The patient tolerated the procedure well.  The eye was dressed with Maxitrol ointment.  A tight patch and Fox shield were placed.  The patient returned to the recovery room in excellent condition with stable vital signs and no eye pain.","surgery, cataract, posterior chamber, intraocular lens, hydrodelineation, phacoemulsification of cataract, phacoemulsification, lens, anterior, chamber, eye, intraocular "
 PICC line insertion, Surgery, PICC line insertion ,"PROCEDURE PERFORMED:,  PICC line insertion.,DESCRIPTION OF PROCEDURE:,  The patient was identified by myself on presentation to the angiography suite.  His right arm was prepped and draped in sterile fashion from the antecubital fossa up.  Under ultrasound guidance, a #21-gauge needle was placed into his right cephalic vein.  A guidewire was then threaded through the vein and advanced without difficulty.  An introducer was then placed over the guidewire.  We attempted to manipulate the guidewire to the superior vena cava; however, we could not pass the point of the subclavian vein and we tried several maneuvers and then opted to do a venogram.  What we did was we injected approximately 4 mL of Visipaque 320 contrast material through the introducer and did a mapping venogram and it turned out that the cephalic vein was joining into the subclavian vein.  It was very tortuous area.  We made several more attempts using the mapping system to pass the glide over that area, but we were unable to do that.  Decision was made at that point then to just do a midline catheter.  The catheter was cut to 20 cm, then we inserted back to the introducer.  The introducer was removed.  The catheter was secured by two #3-0 silk sutures.  Appropriate imaging was then taken.  Sterile dressing was applied.  The patient tolerated the procedure nicely and was discharged from Angiography in satisfactory condition back to the general floor.  We may make another attempt in the near future using a different approach.,","surgery, picc, picc line, angiography, guidewire, superior vena cava, subclavian vein, venogramNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Phacoemulsification with posterior chamber intraocular lens implant in the right eye., Surgery, Phacoemulsification & Lens Implantation - 7 ,"TITLE OF OPERATION: , Phacoemulsification with posterior chamber intraocular lens implant in the right eye.,INDICATION FOR SURGERY: , The patient is a 27-year-old male who sustained an open globe injury as a child.  He subsequently developed a retinal detachment in 2005 and now has silicone oil in the anterior chamber of the right eye as well as a dense cataract.  He is undergoing silicone oil removal as well as concurrent cataract extraction with lens implant in the right eye.,PREOP DIAGNOSIS:,1.  History of open globe to the right eye.,2.  History of retinal detachment status post repair in the right eye.,3.  Silicone oil in anterior chamber.,4.  Dense silicone oil cataract in the right eye obscuring the view of the posterior pole.,POSTOP DIAGNOSIS:,1.  History of open globe to the right eye.,2.  History of retinal detachment status post repair in the right eye.,3.  Silicone oil in anterior chamber.,4.  Dense silicone oil cataract in the right eye obscuring the view of the posterior pole.,ANESTHESIA: , General.,PROS DEV IMPLANT: , ABC Laboratories posterior chamber intraocular lens, 21.0 diopters, serial number 123456.,NARRATIVE: , Informed consent was obtained.  All questions were answered.  The patient was brought to preoperative holding area where the operative right eye was marked.  He was brought to the operating room and placed in the supine position.  EKG leads were placed.  General anesthesia was induced by the anesthesia service.  A time-out was called to confirm the procedure and operative eye.  The right operative eye was disinfected and draped in a standard fashion for eye surgery.  A lid speculum was placed.  The vitreoretinal team placed the infusion cannula after performing a peritomy.  At this point in the case, the patient was turned over to the cornea service with Mrs. Jun.  A paracentesis was made at the approximately 3 o'clock position.  Healon was placed into the anterior chamber.  The diamond keratome was used to make a vertical groove incision just inside the limbus at the 108-degree axis.  This incision was then shelved anteriorly and used to enter the anterior chamber.  The Utrata forceps were used to complete a continuous circular capsulorrhexis after incision of the capsule with the cystotome.  Hydrodissection was performed.  The lens nucleus was removed using phacoemulsification and irrigation and aspiration.  Lens cortex also was removed using irrigation and aspiration.  Viscoelastic was placed to inflate the capsular remnant.  The diamond knife was used to enlarge the phaco incision.  Intraocular lens was selected from preoperative calculations, placed in the injector system, and inserted into the capsule without difficulty.  The trailing haptic was placed using the Sheets forceps and the Barraquer sweep to push the IOL optic posteriorly as the trailing haptic was placed.  The anterior cornea wound was sutured along with the paracentesis after irrigation and aspiration was performed to remove remaining viscoelastic from the anterior chamber.  This was done without difficulty.  The anterior chamber was secured and watertight at the end of the procedure.  Intraocular pressure was satisfactory.  The patient tolerated the procedure well and then was turned over to the retina service in good condition.  They will dictate a separate note.","surgery, phacoemulsification, intraocular lens implant, posterior chamber, chamber, eye, intraocular, lens,"
" Phacoemulsification of cataract, extraocular lens implant in left eye.", Surgery, Phacoemulsification of Cataract - 1 ,"PREOPERATIVE DIAGNOSES:,1.  Senile nuclear cataract, left eye.,2.  Senile cortical cataract, left eye., ,POSTOPERATIVE DIAGNOSES:,1.  Senile nuclear cataract, left eye.,2.  Senile cortical cataract, left eye., ,PROCEDURES: , Phacoemulsification of cataract, extraocular lens implant in left eye., ,LENS IMPLANT USED:,  Alcon, model SN60WF, power of 22.5 diopters., ,PHACOEMULSIFICATION TIME:,  1 minute 41 seconds at 44.4% power., ,INDICATIONS FOR PROCEDURE: , This patient has a visually significant cataract in the affected eye with the best corrected visual acuity under moderate glare conditions worse than 20/40.  The patient complains of difficulties with glare in performing activities of daily living.,INFORMED CONSENT:,  The risks, benefits and alternatives of the procedure were discussed with the patient in the office prior to scheduling surgery.  All questions from the patient were answered after the surgical procedure was explained in detail.  The risks of the procedure as explained to the patient include, but are not limited to, pain, infection, bleeding, loss of vision, retinal detachment, need for further surgery, loss of lens nucleus, double vision, etc.  Alternative of the procedure is to do nothing or seek a second opinion.  Informed consent for this procedure was obtained from the patient.,OPERATIVE TECHNIQUE: , The patient was brought to the holding area.  Previously, an intravenous infusion was begun at a keep vein open rate.  After adequate sedation by the anesthesia department (under monitored anesthesia care conditions), a peribulbar and retrobulbar block was given around the operative eye.  A total of 10 mL mixture with a 70/30 mixture of 2% Xylocaine without epinephrine and 0.75% bupivacaine without epinephrine.  An adequate amount of anesthetic was infused around the eye without giving excessive tension to the eye or excessive chemosis to the periorbital area.  Manual pressure and a Honan balloon were placed over the eye for approximately 2 minutes after injection and adequate akinesia and anesthesia was noted.  Vital sign monitors were detached from the patient.  The patient was moved to the operative suite and the same monitors were reattached.  The periocular area was cleansed, dried, prepped and draped in the usual sterile manner for ocular surgery.  The speculum was set into place and the operative microscope was brought over the eye.  The eye was examined.  Adequate mydriasis was observed and a visually significant cataract was noted on the visual axis.,A temporal clear corneal incision was begun using a crescent blade with an initial groove incision made partial thickness through the temporal clear cornea.  Then a pocket incision was created without entering the anterior chamber of the eye.  Two peripheral paracentesis ports were created on each side of the initial incision site.  Viscoelastic was used to deepen the anterior chamber of the eye.  A 2.65 mm keratome was then used to complete the corneal valve incision.  A cystitome was bent and created using a tuberculin syringe needle.  It was placed in the anterior chamber of the eye.  A continuous curvilinear capsulorrhexis was begun.  It was completed using O'Gawa Utrata forceps.  A balanced salt solution on the irrigating cannula was placed through the paracentesis port of the eye to affect hydrodissection and hydrodelineation of the lens nucleus.  The lens nucleus was noted to be freely mobile in the bag.,The phacoemulsification tip was placed into the anterior chamber of the eye.  The lens nucleus was phacoemulsified and aspirated in a divide-and-conquer technique.  All remaining cortical elements were removed from the eye using irrigation and aspiration using a bimanual technique through the paracentesis ports.  The posterior capsule remained intact throughout the entire procedure.  Provisc was used to deepen the anterior chamber of the eye.  A crescent blade was used to expand the internal aspect of the wound.  The lens was taken from its container and inspected.  No defects were found.  The lens power selected was compared with the surgery worksheet from Dr. X's office.  The lens was placed in an inserter under Provisc.  It was placed through the wound, into the capsular bag and extruded gently from the inserter.  It was noted to be adequately centered in the capsular bag using a Sinskey hook.  The remaining viscoelastic was removed from the eye with irrigation an aspiration through the paracentesis side ports using a bimanual technique.  The eye was noted to be inflated without overinflation.  The wounds were tested for leaks, none were found.  Five drops dilute Betadine solution was placed over the eye.  The eye was irrigated.  The speculum was removed.  The drapes were removed.  The periocular area was cleaned and dried.  Maxitrol ophthalmic ointment was placed into the interpalpebral space.  A semi-pressure patch and shield was placed over the eye.  The patient was taken to the floor in stable and satisfactory condition, was given detailed written instructions and asked to follow up with Dr. X tomorrow morning in the office.","surgery, senile nuclear cataract, senile, phacoemulsification, phacoemulsification of cataract, lens implant, lens nucleus, anterior chamber, lens, alcon, eye, cataract, "
 Phacoemulsification with posterior chamber intraocular lens insertion., Surgery, Phacoemulsification & Lens Implantation - 6 ,"PROCEDURE: , Phacoemulsification with posterior chamber intraocular lens insertion.,INTRAOCULAR LENS: , Allergan Medical Optics model S140MB XXX diopter chamber lens.,PHACO TIME:,  Not known.,ANESTHESIA: , Retrobulbar block with local minimal anesthesia care.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS:,  None.,DESCRIPTION OF PROCEDURE: , While the patient was in the holding area, the operative eye was dilated with four sets of drops.  The drops consisted of Cyclogyl 1%, Acular, and Neo-Synephrine 2.5 %.  Additionally, a peripheral IV was established by the anesthesia team.  Once the eye was dilated, the patient was wheeled to the operating suite.,Inside the operating suite, central monitoring lines were established.  Through the peripheral IV, the patient received intravenous sedation consisting of Propofol and once somnolent from this, retrobulbar block was administered consisting of 2 cc's of 2% Xylocaine  plain with 150 units of Wydase.  The block was administered in a retrobulbar fashion using an Atkinson needle and a good block was obtained.  Digital pressure was applied for approximately five minutes.,The patient was then prepped and draped in the usual sterile fashion for ophthalmological surgery.  A Betadine prep was carried out of the face, lids, and eye.  During the draping process, care was taken to isolate the lashes.  A wire lid speculum was inserted to maintain patency of the lids.  With benefit of the operating microscope, a diamond blade was used to place a groove temporally.  A paracentesis wound was also placed temporally using the same blade.  Viscoelastic was then instilled into the anterior chamber through the paracentesis site and a 2.8 mm. diamond keratome was used to enter the anterior chamber through the previously placed groove.  The cystotome was then inserted into the eye and circular capsulorhexis was performed without difficulty.  The capsular remnant was withdrawn from the eye using long angled McPherson forceps.  Balanced salt solution with a blunt cannula was then inserted into the eye and hydrodissection was performed.  The lens was noted to rotate freely within the capsular bag.  The phaco instrument was then inserted into the eye using the Kelman tip.  The lens nucleus was grooved and broken into two halves.  One of the halves was in turn broken into quarters.  Each of the quarters was removed from the eye using the memory 2 settings and phacoemulsification.  Attention was then turned toward the remaining half of the nucleus and this, in turn, was removed as well, with the splitting maneuver.  Once the nucleus had been removed from the eye, the irrigating and aspirating tip was inserted and the cortical material was stripped out in sections.  Once the cortical material had been completely removed, a diamond dusted cannula was inserted into the eye and the posterior capsule was polished.  Viscoelastic was again instilled into the capsular bag as well as the anterior chamber.  The wound was enlarged slightly using the diamond keratome.  The above described intraocular lens was folded outside the eye using a mustache fold and inserted using folding forceps.  Once inside the eye, the lens was unfolded into the capsular bag in a single maneuver.  It was noted to be centered nicely.  The viscoelastic was then withdrawn from the eye using the irrigating and aspirating tip of the phaco machine.,Next, Miostat was instilled into the operative eye and the wound was checked for water tightness.  It was found to be such.  After removing the drapes and speculum, TobraDex drops were instilled into the operative eye and a gauze patch and Fox protective shield were placed over the eye.,The patient tolerated the procedure extremely well and was taken to the recovery area in good condition.  The patient is scheduled to be seen in follow-up in the office tomorrow, but should any complications arise this evening, the patient is to contact me immediately.","surgery, diopter, intraocular lens insertio, phacoemulsification, posterior chamber, diamond keratome, anterior chamber, capsular bag, intraocular lens, intraocular, allergan, eye, capsular, chamber, lens,"
" Amputation distal phalanx and partial proximal phalanx, right hallux.   Osteomyelitis, right hallux.", Surgery, Phalanx Amputation ,"PREOPERATIVE DIAGNOSIS:,  Osteomyelitis, right hallux.,POSTOPERATIVE DIAGNOSIS: , Osteomyelitis, right hallux.,PROCEDURE PERFORMED:,  Amputation distal phalanx and partial proximal phalanx, right hallux.,ANESTHESIA:,  TIVA/local.,HISTORY:,  This 44-year-old male patient was admitted to ABCD General Hospital on 09/02/2003 with a diagnosis of osteomyelitis of the right hallux and cellulitis of the right lower extremity.  The patient has a history of diabetes and has had a chronic ulceration to the right hallux and has been on outpatient antibiotics, which he failed.  The patient after a multiple conservative treatments such as wound care antibiotics, the patient was given the option of amputation as a treatment for the chronic resistant osteomyelitis.  The patient desires to attempt a surgical correction.  The risks versus benefits of the procedure were discussed with the patient in detail by Dr. X.  The consent was available on the chart for review.,PROCEDURE IN DETAIL: , After patient was taken to the operating room via cart and placed on the operating table in the supine position, a safety strap was placed across his waist.  Adequate IV sedation was administered by the Department of Anesthesia and a total of 3.5 cc of 1:1 mixture 1% lidocaine and 0.5% Marcaine plain were injected into the right hallux as a digital block.  The foot was prepped and draped in the usual aseptic fashion lowering the operative field.,Attention was directed to the hallux where there was a full-thickness ulceration to the distal tip of the hallux measuring 0.5 cm x 0.5 cm.  There was a ________ tract, which probed through the distal phalanx and along the sides of the proximal phalanx laterally.  The toe was 2.5 times to the normal size.  There were superficial ulcerations in the medial arch of both feet secondary to history of a burn, which were not infected.  The patient had dorsalis pedis and posterior tibial pulses that were found to be +2/4 bilaterally preoperatively.  X-ray revealed complete distraction of the distal phalanx and questionable distraction of the lateral aspect of the proximal phalanx.  A #10 blade was used to make an incision down the bone in a transverse fashion just proximal to the head of the proximal phalanx.  The incision was carried mediolaterally and plantarly encompassing the toe leaving a large amount of plantar skin intact.  Next, the distal phalanx was disarticulated at the interphalangeal joint and removed.  The distal toe was amputated and sent to laboratory for bone culture and sensitivity as well as tissue pathology.  Next, the head of the proximal phalanx was inspected and found to be soft on the distal lateral portion as suspected.  Therefore, a sagittal saw was used to resect approximately 0.75 cm of the distal aspect of head of the proximal phalanx.  This bone was also sent off for culture and was labeled proximal margin.  Next, the flexor hallucis longus tendon was identified and retracted as far as possible distally and transected.  The flexor tendon distally was gray discolored and was not viable.  A hemostat was used to inspect the flexor sheath to ensure no infection tracking up the sheath proximally.  None was found.  No purulent drainage or abscess was found.  The proximal margin of the surgical site tissue was viable and healthy.  There was no malodor.  Anaerobic and aerobic cultures were taken and passed this as a specimen to microbiology.  Next, copious amounts of gentamicin and impregnated saline were instilled into the wound.,A #3-0 Vicryl was used to reapproximate the deep subcutaneous layer to release skin tension.  The plantar flap was viable and was debulked with Metzenbaum scissors.  The flap was folded dorsally and reapproximated carefully with #3-0 nylon with a combination of simple interrupted and vertical mattress sutures.  Iris scissors were used to modify and remodel the plantar flap.  An excellent cosmetic result was achieved.  No tourniquet was used in this case.  The patient tolerated the above anesthesia and surgery without apparent complications.  A standard postoperative dressing was applied consisting of saline-soaked Owen silk, 4x4s, Kerlix, and Coban.  The patient was transported via cart to Postanesthesia Care Unit with vital signs able and vascular status intact to right foot.  He will be readmitted to Dr. Katzman where we will continue to monitor his blood pressure and regulate his medications.  Plan is to continue the antibiotics until further IV recommendations.,He will be nonweightbearing to the right foot and use crutches.  He will elevate his right foot and rest the foot, keep it clean and dry.  He is to follow up with Dr. X on Monday or Tuesday of next week.","surgery, osteomyelitis, phalanx, phalanx amputation, proximal margin, plantar flap, distal phalanx, proximal phalanx, proximal, hallux, amputation, foot, plantarly, distal"
" Phacoemulsification with IOL, right eye.  Cataract, right eye.  A lid speculum was placed in the right eye after which a supersharp was used to make a stab incision at the 4 o'clock position through which 2% preservative-free Xylocaine was injected followed by Viscoat.", Surgery, Phacoemulsification & Lens Implantation - 5 ,"PREOPERATIVE DIAGNOSIS:,  Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:,  Cataract, right eye.,OPERATION PERFORMED: , Phacoemulsification with IOL, right eye.,ANESTHESIA:,  Topical with MAC.,COMPLICATIONS,:  None.,ESTIMATED BLOOD LOSS: , None.,PROCEDURE IN DETAIL:  After appropriate consent was obtained, the patient was brought to the operating room and then prepared and draped in the usual sterile fashion per Ophthalmology.  A lid speculum was placed in the right eye after which a supersharp was used to make a stab incision at the 4 o'clock position through which 2% preservative-free Xylocaine was injected followed by Viscoat.  A 2.75-mm keratome then made a stab incision at the 2 o'clock position through which an anterior capsulorrhexis was performed using cystotome and Utrata.  BSS on blunt cannula, hydrodissector, and spun the nucleus after which phacoemulsification divided the nucleus in 3 quadrants each was subsequently cracked and removed through phacoemulsification I&A.  Healon was injected into the posterior capsule and a XXX lens was then placed with a shooter into the posterior capsule and rotated into position with I&A, which then removed all remaining cortex as well as viscoelastic material.  BSS on blunt cannula hydrated all wounds, which were noted to be free of leak and lid speculum was removed.  Under microscope, the anterior chamber being soft and well formed.  Pred Forte, Vigamox, and Iopidine were placed in the eye.  A shield was placed over the eye.  The patient was followed to recovery where he was noted to be in good condition.","surgery, lid speculum, lens, iol, viscoat, posterior, capsule, cataract, speculum, incision, phacoemulsification "
" Phacoemulsification of cataract and posterior chamber lens implant, right eye.", Surgery, Phacoemulsification & Lens Implantation - 4 ,"OPERATION PERFORMED:, Phacoemulsification of cataract and posterior chamber lens implant, right eye., ,ANESTHESIA:, Retrobulbar nerve block, right eye, ,DESCRIPTION OF OPERATION: ,The patient was brought to the operating room where local anesthetic was administered to the right eye followed by a dilute drop of Betadine and a Honan balloon.  Once anesthesia was achieved, the right eye was prepped with Betadine, rinsed with saline, and draped in a sterile fashion.  A lid speculum was placed and 4-0 silk sutures passed under the superior and inferior rectus muscles stabilizing the globe.  A fornix-based conjunctival flap was prepared superiorly from 10 to 12 o'clock and episcleral vessels were cauterized using a wet-field.  A surgical groove was applied with a 69 Beaver blade 1 mm posterior to the limbus in a frown configuration in the 10 to 12 o'clock position.  A lamellar dissection was carried anteriorly to clear cornea using a crescent knife.  A stab incision was applied with a Superblade at the 2 o'clock position at the limbus.  The chamber was also entered through the lamellar groove using a 3-mm keratome in a beveled fashion.  Viscoat was injected into the chamber and an anterior capsulorrhexis performed.  Hydrodissection was used to delineate the nucleus and the phacoemulsification tip was inserted into the chamber.  A deep linear groove was dissected through the nucleus vertically and the nucleus was rotated 90 degrees with the assistance of a spatula through the side-port incision.  A second groove was dissected perpendicular to the first and the nucleus was fractured into quadrants.  Each quadrant was emulsified under burst power within the capsular bag.  The epinuclear bowl was manipulated with vacuum, flipped into the iris plane, and emulsified under pulse power.  I&A was used to aspirate cortex from the capsular bag.  A scratcher was used to polish the capsule, and Viscoat was injected inflating the capsular bag and chamber.  The wound was enlarged with a shortcut blade to 5.5 mm.  The intraocular lens was examined, found to be adequate, irrigated with balanced salt, and inserted into the capsular bag.  The lens centralized nicely and Viscoat was removed using the I&A.  Balanced salt was injected through the side-port incision.  The wound was tested, found to be secure, and a single 10-0 nylon suture was applied to the wound with the knot buried within the sclera.  The conjunctiva was pulled over the suture, and Ancef 50 mg and Decadron 4 mg were injected sub-Tenon in the inferonasal and inferotemporal quadrants.  Maxitrol ointment was applied topically followed by an eye pad and shield.  The patient tolerated the procedure and was taken from the operating room in good condition.","surgery, retrobulbar nerve block, posterior chamber lens implant, phacoemulsification of cataract, lens implantation, capsular bag, cataract, phacoemulsification, nucleus, capsular, lens, eye"
" Cataract, right eye.  Phacoemulsification with intraocular lens placement, right eye.", Surgery, Phacoemulsification & Lens Implantation - 3 ,"PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:,  Cataract, right eye.,PROCEDURE:,  Phacoemulsification with intraocular lens placement, right eye.,ANESTHESIA: , Monitored anesthesia care,ESTIMATED BLOOD LOSS: , None,COMPLICATIONS:,  None,SPECIMENS:,  None,PROCEDURE IN DETAIL: , The patient had previously been examined in the clinic and was found to have a visually significant cataract in the right eye.  The patient had the risks and benefits of surgery discussed.  After discussion, the patient decided to proceed and the consent was signed.,On the day of surgery, the patient was taken from the holding area to the operating suite by the anesthesiologist and monitors were placed.  Following this, the patient was sterilely prepped and draped in the usual fashion.  After this, a lid speculum was placed, preservative-free lidocaine drops were placed, and the SuperSharp blade was used to make an anterior chamber paracentesis.  Preservative-free lidocaine was instilled into the anterior chamber, and then Viscoat was instilled into the eye.,The 3.0 diamond keratome was then used to make a clear corneal temporal incision.  Following this, the cystotome was used to make a continuous tear-type capsulotomy.  After this, BSS was used to hydrodissect and hydrodelineate the lens.  The phacoemulsification unit was used to remove the cataract.  The I&A unit was used to remove the residual cortical material.  Following this, Provisc was used to inflate the bag.  The lens, a model SA60AT of ABCD diopters, serial #1234, was inserted into the bag and rotated into position using the Lester pusher.,After this, the residual Provisc was removed.  Michol was instilled and then the corneal wound was hydrated with BSS, and the wound was found to be watertight.  The lid speculum was removed.  Acular and Vigamox drops were placed.  The patient tolerated the procedure well without complications and will be followed up in the office tomorrow.","surgery, capsulotomy, diopters, intraocular lens placement, lid speculum, anterior chamber, phacoemulsification, lens, cataract, intraocular"
" Cataract extraction with phacoemulsification and posterior chamber intraocular lens implantation.  Cataract, right eye.", Surgery, Phacoemulsification & Cataract Extraction - 4 ,"PREOPERATIVE DIAGNOSIS:  ,Cataract, right eye.,POSTOPERATIVE DIAGNOSIS: , Cataract, right eye.,PROCEDURE: , Cataract extraction with phacoemulsification and posterior chamber intraocular lens implantation.  ME 30, AC 25.0 diopter lens was used.,COMPLICATIONS:  ,None.,ANESTHESIA: , Local 2%, peribulbar lidocaine.,PROCEDURE NOTE:  ,Right eye was prepped and draped in the normal sterile fashion.  Lid speculum placed in his right eye.  Paracentesis made supratemporally.  Viscoat injected into the anterior chamber.  A 2.8 mm metal keratome blade was then used to fashion a clear corneal beveled incision temporally.  This was followed by circular capsulorrhexis and hydrodissection of the nucleus would be assessed.  Nuclear material removed via phacoemulsification.  Residual cortex removed via irrigation and aspiration.  The posterior capsule was clear and intact.  Capsular bag was then filled with Provisc solution.  The wound was enlarged to 3.5 mm with the keratoma.  The lens was folded in place into the capsular bag.  Residual Provisc was irrigated from the eye.  The wound was secured with one 10-0 nylon suture.  The lid speculum was removed.  One drop of 5% povidone-iodine prep was placed into the eye as well as a drop of Vigamox and TobraDex ointment.  He had a patch placed on it.  The patient was transported to the recovery room in stable condition.","surgery, provisc, intraocular lens implantation, intraocular lens, lens implantation, lid speculum, capsular bag, cataract extraction, phacoemulsification, cataract, intraocular"
 Phacoemulsification with intraocular lens placement.  A wire speculum was placed in the eye and then a clear corneal paracentesis site was made inferiorly with a 15-degree blade. , Surgery, Phacoemulsification & Lens Implantation - 2 ,"PROCEDURE PERFORMED: , Phacoemulsification with intraocular lens placement.,ANESTHESIA TYPE:  ,Topical.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room after the eye was dilated with topical Mydriacyl and Neo-Synephrine eye drops.  Topical anesthetic drops were applied to the eye just prior to entering the operating room.  The eye was then prepped with a 5% Betadine solution injected in the usual sterile fashion.  A wire speculum was placed in the eye and then a clear corneal paracentesis site was made inferiorly with a 15-degree blade.  Lidocaine 1% preservative-free, 0.1 cc, was instilled into the anterior chamber through the clear corneal paracentesis site and this was followed with viscoelastic to fill the chamber.  A 2.8-mm keratome was used to create a self-sealing corneal incision temporally and then a bent capsulotomy needle was used to create an anterior capsular flap.  The Utrata forceps were used to complete a continuous tear capsulorrhexis, and hydrodissection and hydrodelineation of the nucleus was performed with BSS on a cannula.  Phacoemulsification in a quartering and cracking technique was used to remove the nucleus, and then the residual cortex was removed with the irrigation and aspiration unit.  Gentle vacuuming of the central posterior capsule was performed with the irrigation and aspiration unit.  The capsular bag was re-expanded with viscoelastic, and then the wound was opened to a 3.4-mm size to accommodate the intraocular lens insertion using an additional keratome blade.,The lens was folded, inserted into the capsular bag and then unfolded.  The trailing haptic was tucked underneath the anterior capsular rim.  The lens was shown to center very well.  The viscoelastic was removed with the irrigation and aspiration unit and one 10-0 nylon suture was placed across the incision after Miochol was injected into the anterior chamber to cause pupillary constriction.  The wound was shown to be watertight.  Therefore, TobraDex ointment was applied to the eye, an eye pad loosely applied, and a Fox shield taped firmly in place over the eye.,The patient tolerated the procedure well and left the operating room in good condition.","surgery, keratome, phacoemulsification, cortex, tobradex, intraocular lens, aspiration unit, topical, chamber, viscoelastic, corneal, capsular, lens, intraocular, eye, "
" Cataract, right eye.  Phacoemulsification with intraocular lens insertion, right eye.  A wire lid speculum was inserted to keep the eye open and the eye rotated downward.", Surgery, Phacoemulsification & Cataract Extraction - 3 ,"PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:,  Cataract, right eye.,TITLE OF OPERATION:  ,Phacoemulsification with intraocular lens insertion, right eye.,ANESTHESIA: , Retrobulbar block.,COMPLICATIONS: , None.,PROCEDURE IN DETAIL:  ,The patient was brought to the operating room where retrobulbar anesthesia was induced.  The patient was then prepped and draped using standard procedure.  A wire lid speculum was inserted to keep the eye open and the eye rotated downward with a 0.12.  The anterior chamber was entered by making a small superior limbal incision with a crescent blade and then entering the anterior chamber with a keratome.  The chamber was then filled with viscoelastic and a continuous-tear capsulorrhexis performed.  The phacoemulsification was then instilled in the eye and a linear incision made in the lens.  The lens was then cracked with a McPherson forceps, and the remaining lens material removed with the phacoemulsification tip.  The remaining cortex was removed with an I&A.  The capsular bag was then inflated with viscoelastic and the wound extended slightly with the keratome.  The folding posterior chamber lens was then inserted in the capsular bag and rotated into position.  The remaining viscoelastic was removed from the eye with the I&A.  The wound was checked for watertightness and found to be watertight.  Tobramycin drops were instilled in the eye and a shield placed over it.  The patient tolerated the procedure well.","surgery, tobramycin, limbal, lid speculum, intraocular lens, capsular bag, eye, phacoemulsification, lens, intraocular"
 Cataract extraction via phacoemulsification with posterior chamber intraocular lens implantation.  An Alcon MA30BA lens was used.   A lid speculum was placed into the right eye.  Paracentesis was made at the infratemporal quadrant. , Surgery, Phacoemulsification & Cataract Extraction - 5 ,"PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:  ,Cataract, right eye.,PROCEDURE PERFORMED:  ,Cataract extraction via phacoemulsification with posterior chamber intraocular lens implantation.  An Alcon MA30BA lens was used, * diopters, #*.,ANESTHESIA: ,Topical 4% lidocaine with 1% nonpreserved intracameral lidocaine.,COMPLICATIONS:, None.,PROCEDURE: , Prior to surgery, the patient was counseled as to the risks, benefits and alternatives of the procedure with risks including, but not limited to, bleeding, infection, loss of vision, loss of the eye, need for a second surgery, retinal detachment and retinal swelling.  The patient understood the risks clearly and wished to proceed.,The patient was brought into the operating suite after being given dilating drops.  Topical 4% lidocaine drops were used.  The patient was prepped and draped in the normal sterile fashion.  A lid speculum was placed into the right eye.  Paracentesis was made at the infratemporal quadrant.  This was followed by 1% nonpreservative lidocaine into the anterior chamber, roughly 250 microliters.  This was exchanged for Viscoat solution.  Next, a crescent blade was used to create a partial-thickness linear groove at the temporal limbus.  This was followed by a clear corneal bevel incision with a 3 mm metal keratome blade.  Circular capsulorrhexis was initiated with a cystitome and completed with Utrata forceps.  Balanced salt solution was used to hydrodissect the nucleus.  Nuclear material was removed via phacoemulsification with divide-and-conquer technique.  The residual cortex was removed via irrigation and aspiration.  The capsular bag was then filled with Provisc solution.  The wound was slightly enlarged.  The lens was folded and inserted into the capsular bag.,Residual Provisc solution was irrigated out of the eye.  The wound was stromally hydrated and noted to be completely self-sealing.,At the end of the case, the posterior capsule was intact.  The lens was well centered in the capsular bag.  The anterior chamber was deep.  The wound was self sealed and subconjunctival injections of Ancef, dexamethasone and lidocaine were given inferiorly.  Maxitrol ointment was placed into the eye.  The eye was patched with a shield.,The patient was transported to the recovery room in stable condition to follow up the following morning.","surgery, alcon, phacoemulsification, cataract extraction, cataract, intraocular lens implantation, anterior chamber, provisc solution, capsular bag, topical, intraocular,"
" Visually significant nuclear sclerotic cataract, right eye.  Phacoemulsification with posterior chamber intraocular lens implantation, right eye.", Surgery, Phacoemulsification & Lens Implantation - 1 ,"PREOPERATIVE DIAGNOSIS:,  Visually significant nuclear sclerotic cataract, right eye.,POSTOPERATIVE DIAGNOSIS: , Visually significant nuclear sclerotic cataract, right eye.,OPERATIVE PROCEDURES: , Phacoemulsification with posterior chamber intraocular lens implantation, right eye.,ANESTHESIA:,  Monitored anesthesia care with retrobulbar block consisting of 2% lidocaine in an equal mixture with 0.75% Marcaine and Amphadase.,INDICATIONS FOR SURGERY:,  This patient has been experiencing difficulty with eyesight regarding activities of daily living.  There has been a progressive and gradual decline in the visual acuity.  The cataract was believed related to her decline in vision.  The risks, benefits, and alternatives (including with observation or spectacles) were discussed in detail.  The risks as explained included, but are not limited to pain, bleeding, infection, decreased or loss of vision/loss of eye, retinal detachment requiring further surgery, and possible consultation out of town, swelling of the back part of the eye/retina, need for prolonged eye drop use or injections, instability of the lens, and loss of corneal clarity necessitating long-term drop use or further surgery.  The possibility of needing intraocular lens exchange or incorrect lens power was discussed.  Anesthesia option and risks associated with anesthesia and retrobulbar anesthesia were discussed.  It was explained that some or all of these complications might arise at the time of or months to years after surgery.  The patient had a good understanding of the risks with the proposed, elective eye surgery.  The patient accepted these risks and elected to proceed with cataract surgery.  All questions were answered and informed consent was signed and placed in the chart.,DESCRIPTION OF PROCEDURE: , The patient was identified and the procedure was verified.  The pupil was dilated per protocol.  The patient was taken to the operating room and placed in the supine position.  After intravenous sedation, the retrobulbar block was injected followed by several minutes of digital massage.  No signs of orbital tenseness or retrobulbar hemorrhage were present.,The patient was prepped and draped in the usual ophthalmic sterile fashion.  An eyelid speculum was used to separate the eyelids.  A crescent blade was used to make a clear corneal temporally located incision.  A 1-mm Dual-Bevel blade was used to make a paracentesis site.  The anterior chamber was filled with viscoelastic (Viscoat).  The crescent blade was then used to make an approximate 2-mm long clear corneal tunnel through the temporal incision.  A 2.85-mm keratome blade was then used to penetrate into the anterior chamber through the temporal tunneled incision.  A 25-gauge pre-bent cystotome used to begin a capsulorrhexis.  The capsulorrhexis was completed with the Utrata forceps.  A 27-guage needle was used for hydrodissection and three full and complete fluid waves were noted.  The lens was able to be freely rotated within the capsular bag.  Divide-and-conquer ultrasound was used for phacoemulsification.  After four sculpted grooves were made, a bimanual approach with the phacoemulsification tip and Koch spatula was used to separate and crack each grooved segment.  Each of the four nuclear quadrants was phacoemulsified.  Aspiration was used to remove all remaining cortex.  Viscoelastic was used to re-inflate the capsular bag.  An AMO model SI40NB posterior chamber intraocular lens with power *** diopters and serial number *** was injected into the capsular bag.  The trailing haptic was placed with the Sinskey hook.  The lens was made well centered and stable.  Viscoelastic was aspirated.  BSS was used to re-inflate the anterior chamber to an adequate estimated intraocular pressure.  A Weck-Cel sponge was used to check both incision sites for leaks and none were identified.  The incision sites remained well approximated and dry with a well-formed anterior chamber and eccentric posterior chamber intraocular lens.  The eyelid speculum was removed and the patient was cleaned free of Betadine.  Vigamox and Econopred drops were applied.  A soft eye patch followed by a firm eye shield was taped over the operative eye.  The patient was then taken to the Postanesthesia Recovery Unit in good condition having tolerated the procedure well.,Discharge instructions regarding activity restrictions, eye drop use, eye shield/patch wearing, and driving restrictions were discussed.  All questions were answered.  The discharge instructions were also reviewed with the patient by the discharging nurse.  The patient was comfortable and was discharged with followup in 24 hours.  Complications none.","surgery, retrobulbar block, posterior chamber intraocular lens, nuclear sclerotic cataract, cataract, lens implantation, posterior chamber, anterior chamber, intraocular lens, lens, eye, intraocular, anesthesia, phacoemulsification, retrobulbar,"
" Cataract, right eye.  Phacoemulsification with intraocular lens insertion, right eye.  The patient was then prepped and draped using standard procedure.  An additional drop of tetracaine was instilled in the eye, and then a lid speculum was inserted.", Surgery, Phacoemulsification & Cataract Extraction - 2 ,"PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS: , Cataract, right eye.,TITLE OF OPERATION: , Phacoemulsification with intraocular lens insertion, right eye.,ANESTHESIA: , Topical.,COMPLICATIONS: , None.,PROCEDURE IN DETAIL:  ,The patient was brought to the operating room where tetracaine drops were instilled in the eye.  The patient was then prepped and draped using standard procedure.  An additional drop of tetracaine was instilled in the eye, and then a lid speculum was inserted.,The eye was rotated downward and a crescent blade used to make an incision at the limbus.  This was then dissected forward approximately 1 mm, and then a keratome was used to enter the anterior chamber.  The anterior chamber was filled with 1% preservative-free lidocaine and the lidocaine was then replaced with Provisc.  A cystotome was used to make a continuous-tear capsulorrhexis, and then the capsular flap was removed with the Utrata forceps.  The lens nucleus was hydrodissected using BSS on a cannula and then removed using the phaco.  This was aided by cracking the lens nucleus with McPherson forceps.  The remaining cortex was removed from the eye with the I&A.  The capsular bag was then polished with the I&A on capsular bag.  The bag was inflated using viscoelastic and then the wound extended slightly with a keratome.  A folding posterior chamber lens was inserted and rotated into position using McPherson forceps.  The I&A was then placed in the eye again and the remaining viscoelastic removed.  The wound was checked for watertightness and found to be watertight.  TobraDex drops were instilled in the eye and a shield was placed over it.,The patient tolerated the procedure well and was brought to recovery in good condition.","surgery, tetracaine, intraocular lens, lid speculum, mcpherson forceps, capsular bag, eye, phacoemulsification, cataract, lens, intraocular,"
" Visually significant cataract, left eye.  Phacoemulsification cataract extraction with intraocular lens implantation, left eye.  The patient was found to have a visually-significant cataract and, after discussion of the risks, benefits and alternatives to surgery, she elected to proceed with cataract extraction and lens implantation in this eye in efforts to improve her vision.", Surgery, Phacoemulsification & Cataract Extraction - 1 ,"PREOPERATIVE DIAGNOSIS: , Visually significant cataract, left eye.,POSTOPERATIVE DIAGNOSIS: , Visually significant cataract, left eye.,ANESTHESIA: , Topical/MAC.,PROCEDURE: , Phacoemulsification cataract extraction with intraocular lens implantation, left eye (Alcon AcrySof, SN60AT, 23.0 D, serial #***).,COMPLICATIONS: , None.,INDICATIONS FOR SURGERY:  ,The patient is a 74-year-old woman with complaints of painless progressive loss of vision in her left eye.  She was found to have a visually-significant cataract and, after discussion of the risks, benefits and alternatives to surgery, she elected to proceed with cataract extraction and lens implantation in this eye in efforts to improve her vision.,PROCEDURE IN DETAIL:  ,The patient was verified in the preoperative holding area and the informed consent was reviewed and verified to be on the chart.  They were transported to the operative suite, accompanied by the anesthesia service, where appropriate cardiopulmonary monitoring was established.  MAC anesthesia was achieved, which was followed by topical anesthesia using 1% preservative-free tetracaine eye drops.  The patient was prepped and draped in the usual fashion for sterile ophthalmic surgery and a lid speculum was placed.,Two stab-incision paracenteses were made in the cornea using the MVR blade, and the anterior chamber was irrigated with 1% preservative-free lidocaine for intracameral anesthesia.  The anterior chamber was filled with viscoelastic and a shelved, temporal, clear corneal incision was made using the diamond groove knife and steel keratome.  A continuous curvilinear capsulorrhexis was made in the anterior capsule using the bent-needle cystotome.  The lens nucleus was hydrodissected and hydrodelineated using balanced saline solution (BSS) on a Chang cannula until it rotated freely.,The phacoemulsification handpiece was introduced into the anterior chamber, and the lens nucleus was sculpted into 2 halves.  Each half was further subdivided with chopping and removed with phacoemulsification.  The remaining cortical material was removed with the irrigation and aspiration (I&A) handpiece.  The capsular bag was inflated with viscoelastic and the intraocular lens was injected into the capsule without difficulty.  The remaining viscoelastic was removed with the I&A handpiece, and the anterior chamber was filled to an appropriate intraocular pressure with BSS.  The corneal wounds were hydrated and verified to be water-tight.  Antibiotic ointment was placed, followed by a patch and shield.  The patient was transported to the PACU in good/stable condition.  There were no complications.  Followup is scheduled for tomorrow morning in the eye clinic.,A single interrupted 10-0 nylon suture was placed through the inferotemporal paracentesis to ensure that it was watertight at the end of the case.","surgery, intraocular lens implantation, eye, intraocular lens, lens implantation, cataract extraction, cataract, intraocular, viscoelastic, handpiece, implantation, chamber, phacoemulsification, extraction, visually, anterior, lens"
"  Cataract, nuclear sclerotic, right eye.  Phacoemulsification with intraocular lens implantation, right eye.", Surgery, Phacoemulsification & Lens Implantation ,"PREOPERATIVE DIAGNOSIS:,  Cataract, nuclear sclerotic, right eye.,POSTOPERATIVE DIAGNOSIS:,  Cataract, nuclear sclerotic, right eye.,OPERATIVE PROCEDURES: , Phacoemulsification with intraocular lens implantation, right eye.,ANESTHESIA: , Topical tetracaine, intracameral lidocaine, monitored anesthesia care.,IOL: , AMO Model SI40 NB, power *** diopters.,INDICATIONS FOR SURGERY: , This patient has been experiencing difficulty with eyesight regarding activities in their daily life.  There has been a progressive and gradual decline in the visual acuity.  By examination, this was found to be related to cataracts.  The risks, benefits, and alternatives (including observation or spectacles) were discussed in detail.  The patient accepted these risks and elected to proceed with cataract surgery.  All questions were answered and informed consent was obtained.,Questions were answered in personal conference with the patient to ensure that the patient had a good grasp of the operative goals, risks, and alternatives involved as well as the postoperative instructions.  A preoperative surgical history and physical examination was done to ensure that the patient was in optimal general health for cataract surgery.  To minimize and decrease the chance of bacterial infection, the patient was started on a course of antibiotic drops for two days prior to surgery.,DESCRIPTION OF PROCEDURE:  ,The patient was identified and the procedure was verified.  The pupil was dilated per protocol.  The patient was taken to the operating room and placed in a comfortable supine position.  The operative table was placed in Trendelenburg head-up tilt to decrease orbital congestion and posterior vitreous pressure.  The patient was prepped and draped in the usual ophthalmic sterile fashion.  The lids and periorbita were prepped with full-strength Betadine solution with care taken to concentrate on sterilizing the eyelid margins.  The conjunctival cul-de-sac was also prepped in dilute Betadine solution.  The fornices were also prepped.  The drape was done meticulously to ensure complete eyelash inclusion.,An eyelid speculum was placed to separate the eyelids.  A paracentesis site was made.  Intracameral preservative-free lidocaine was injected.  Amvisc Plus was then used to stabilize the anterior chamber.  A 3-mm diamond blade was then used to carefully construct a clear corneal incision in the temporal location.  A 25-gauge pre-bent cystotome was used to begin a capsulorrhexis.  The capsular flap was removed.  A 27-gauge blunt cannula was used for hydrodissection.  The lens was able to be freely rotated within the capsular bag.  Divide-and-conquer technique was used for phacoemulsification.  After four sculpted grooves were made, a bimanual approach with the phacoemulsification tip and Koch spatula was used to separate and crack each grooved segment.  Each of the four nuclear quadrants was phacoemulsified.  Aspiration was used to remove remaining cortex with the I/A handpiece.  Viscoelastic was used to re-inflate the capsular bag.  The intraocular lens was injected into the capsular bag.  The lens was then dialed into position.  The lens was well-centered and stable.  Viscoelastic was aspirated.  BSS was used to re-inflate the anterior chamber to an adequate estimated intraocular pressure along with stromal hydration.  A Weck-Cel sponge was used to check both incision sites for leaks and none were identified.  The incision sites remained well approximated and dry with a well-formed anterior chamber and well-centered intraocular lens.  The eyelid speculum was removed and the patient was cleaned free of Betadine.  Zymar and Pred Forte drops were applied.  A firm eye shield was taped over the operative eye.  The patient was then taken to the Postanesthesia Recovery Unit in good condition having tolerated the procedure well.,Discharge instructions regarding activity restrictions, eye drop use, eye shield/patch wearing, and driving restrictions were discussed.  All questions were answered.  The discharge instructions were also reviewed with the patient by the discharging nurse.  The patient was comfortable and was discharged with followup in 24 hours.","surgery, nuclear sclerotic, diopters, viscoelastic, capsulorrhexis, amvisc plus, lens implantation, intraocular lens, intraocular, topical, cataract, phacoemulsification, lens"
" Phacoemulsification and extracapsular cataract extraction with intraocular lens implantation, right eye.", Surgery, Phacoemulsification & Cataract Extraction ,"DIAGNOSIS:,  Nuclear sclerotic and cortical cataract, right eye.,OPERATION:,  Phacoemulsification and extracapsular cataract extraction with intraocular lens implantation, right eye.,PROCEDURE:,  The patient was taken to the operating room and placed on the table in the supine position.  Cardiac monitor and oxygen at 5 liters per minute were connected by the nursing staff.  Local anesthesia was obtained using 2% lidocaine, 0/75% Marcaine, 0.5 cc Wydase with 6 cc of this solution used in a paribulbar injection, followed by ten minutes of digital massage.  The patient was then prepped and draped in the usual sterile fashion for eye surgery.  With the Zeiss operating microscopy in position, a lid speculum was inserted and a 4-0 black silk bridal suture placed in the superior rectus muscle.  With Westcott scissors, a fornix-based conjunctival flap was made.  The surgical limbus was identified and hemostasis obtained with wet-field cautery.  With a 57-Beaver blade, a corneoscleral groove was made and shelved into clear cornea.  A stab incision was made at 2 o'clock with a 15-degree blade.  With a 3.0 mm keratome, the shelved groove was attended into the anterior chamber.  Viscoelastic was inserted into the anterior chamber and anterior capsulotomy was performed in a continuous-tear technique.  Hydrodissection was performed with Balanced Salt Solution.  Phacoemulsification was performed in a two-headed nuclear fracture technique.  The remaining cortical material was removed with irrigation and aspiration handpiece.  The posterior capsule remained intact and vacuumed with minimal suction.  The posterior chamber intraocular lens was obtained.  It was inspected, irrigated, inserted into the posterior chamber without difficulty.  Inspection revealed the intraocular lens to be in good position with intact capsule and well-approximated wound.  There was no aqueous leak even with digital pressure.  The conjunctiva was pulled back into position with wet-field cautery.  A subconjunctival injection with 20 mg Gatamycine and 0.5 cc Celestone was given.  Tobradex ointment was instilled into the eye, which was patched and shielded appropriately, after removing the lid speculum and bridle suture.  The patient tolerated the procedure well and was sent to the recovery room in good condition, to be followed in attending physician office the next day.","surgery, extracapsular cataract extraction, phacoemulsification, nuclear sclerotic, cortical cataract, extraction with intraocular lens, cataract extraction, intraocular lens, intraocular, extracapsular, implantation, conjunctival, cataract, chamberNOTE"
 Perlane injection for the nasolabial fold.  Restylane injection for the glabellar fold., Surgery, Perlane & Restylane Injection ,"PREOPERATIVE DIAGNOSES:  ,1.  Nasolabial mesiolabial fold.,2.  Mid glabellar fold.,POSTOPERATIVE DIAGNOSES:  ,1.  Nasolabial mesiolabial fold.,2.  Mid glabellar fold.,TITLE OF PROCEDURES:  ,1.  Perlane injection for the nasolabial fold.,2.  Restylane injection for the glabellar fold.,ANESTHESIA:  ,Topical with Lasercaine.,COMPLICATIONS: , None.,PROCEDURE: , The patient was evaluated preop and noted to be in stable condition.  Chart and informed consent were all reviewed preop.  All risks, benefits, and alternatives regarding the procedure have been reviewed in detail with the patient.  This includes risk of bleeding, infection, scarring, need for further procedure, etc.  The patient did sign the informed consent form regarding the Perlane and Restylane.  She is aware of the potential risk of bruising.  The patient has had Cosmederm in the past and had had a minimal response with this.  Please note Lasercaine had to be applied 30 minutes prior to the procedure.  The excess Lasercaine was removed with a sterile alcohol swab.,Using the linear threading technique, I injected the deep nasolabial fold.  We used 2 mL of the Perlane for injection of the nasolabial mesiolabial fold.  They were carefully massaged into good position at the end of the procedure.  She did have some mild erythema noted.,I then used approximately 0.4 mL of the Restylane for injection of the mid glabellar site.  She has a resting line of the mid glabella that did not respond with previous Botox injection.  Once this was filled, the Restylane was massaged into the proper tissue plane.  Cold compressors were applied afterwards.  She is scheduled for a recheck in the next one to two weeks, and we will make further recommendations at that time.  Post Restylane and Perlane precautions have been reviewed with the patient as well.","surgery, lasercaine, nasolabial mesiolabial fold, mid glabellar fold, perlane injection, restylane injection, nasolabial fold, mesiolabial fold, glabellar fold, injection, perlane, nasolabial, glabellar, restylane"
 Ex-plantation of inflatable penile prosthesis and then placement of second inflatable penile prosthesis AMS700.  Nonfunctioning inflatable penile prosthesis and Peyronie's disease., Surgery, Penile Prosthesis Replacement ,"PREOPERATIVE DIAGNOSES:,1.  Nonfunctioning inflatable penile prosthesis.,2.  Peyronie's disease.,POSTOPERATIVE DIAGNOSES:,1.  Nonfunctioning inflatable penile prosthesis.,2.  Peyronie's disease.,PROCEDURE PERFORMED: , Ex-plantation of inflatable penile prosthesis and then placement of second inflatable penile prosthesis AMS700.,ANESTHESIA:,  General LMA.,SPECIMEN: , Old triple component inflatable penile prosthesis.,PROCEDURE:  ,This is a 64-year-old male with prior history of Peyronie's disease and prior placement of a triple component inflatable penile prosthesis, which had worked for years for him, but has stopped working and subsequently has opted for ex-plantation and replacement of inflatable penile prosthesis.,OPERATIVE PROCEDURE: , After informed consent, the patient was brought to the operative suite and placed in the supine position.  General endotracheal intubation was performed by the Anesthesia Department and the perineum, scrotum, penis, and lower abdomen from the umbilicus down was prepped and draped in the sterile fashion in a 15-minute prep including iodine solution in the urethra.  The bladder was subsequently drained with a red Robinson catheter.  At that point, the patient was then draped in a sterile fashion and an infraumbilical midline incision was made and taken down through the subcutaneous space.  Care was maintained to avoid all bleeding as possible secondary to the fact that we could not use Bovie cautery secondary to the patient's pacemaker and monopolar was only source of hemostasis besides suture.  At that point, we got down to the fascia and the dorsal venous complex was easily identified as were both corporal bodies.  Attention was taken then to the tubing, going up to the reservoir in the right lower quadrant.  This was dissected out bluntly and sharply with Metzenbaum scissors and monopolar used for hemostasis.  At this point, as we tracked this proximally to the area of the rectus muscle, we found that the tubing was violated and this was likely the source of his malfunctioned inflatable penile prosthesis.  As we tried to remove the tubing and get to the reservoir, the tubing in fact completely broke as due to wire inside the tubing and the reservoir was left in its place secondary to risk of going after it and bleeding without the use of cautery.  At that point, this tubing was then tracked down to the pump, which was fairly easily removed from the dartos pouch in the right scrotum.  This was brought up into _________ incision and the two tubings going towards the two cylinders were subsequently tracked, first starting on the right side where a corporotomy incision was made at the placement of two #3-0 Prolene stay ties, staying lateral and anterior on the corporal body.  The corporal body was opened up and the cylinder was removed from the right side without difficulty.  However, we did have significant difficulty separating the tube connecting the pump to the right cylinder since this was surrounded by dense connective tissue and without the use of Bovie cautery, this was very difficult and was very time consuming, but we were able to do this and attention was then taken to the left side where the left proximal corporotomy was made after placement of two stick tie stay sutures.  This was done anterior and lateral staying away from the neurovascular bundle in the midline and this was done proximally on the corporal body.  The left cylinder was then subsequently explanted and this was very difficult as well trying to tract the tubing from the left cylinder across the midline back to the right pump since this was also densely scarred in and _________ a small amount of bleeding, which was controlled with monopolar and cautery was used on three different occasions, but just simple small burst under the guidance of anesthesia and there was no ectopy noted.  After removal of half of the pump, all the tubing, and both cylinders, these were passed off the table as specimen.  Both corporal bodies were then dilated with the Pratt dilators.  These were already fairly well dilated secondary to explantation of our cylinders and antibiotic irrigation was copiously used at this point and irrigated out both of our corporal spaces.  At this point, using the Farlow device, corporal bodies were measured first proximally then distally and they both measured out to be 9 cm proximally and 12 cm distally.  He had an 18 cm with rear tips in place, which were removed.  We decided to go ahead to and use another 18 cm inflatable penile prosthesis.  Confident with our size, we then placed rear tips, originally 3 cm rear tips, however, we had difficulty placing the rear tips into the left crest.  We felt that this was just a little bit too long and replaced both rear tips and down sized from 2 cm to 1 cm.  At this point, we went ahead and placed the right cylinder using the Farlow device and the Keith needle, which was brought out through the glans penis and hemostated and the posterior rear tip was subsequently placed proximally, entered the crest without difficulty.  Attention was then taken to the left side with the same thing was carried out, however, we did happen to dilate on two separate occasions both proximally and distally secondary to a very snug fit as well as buckling of the cylinders.  This then forced us to down size to the 1 cm rear tips, which slipping very easily with the Farlow device through the glans penis.  There was no crossover and no violation of the tunica albuginea.  The rear tips were then placed without difficulty and our corporotomies were closed with #2-0 PDS in a running fashion.  ________ starting on the patient's right side and then on the left side without difficulty and care was maintained to avoid damage or needle injury to the implants.  At that point, the wound was copiously irrigated and the device was inflated multiple times.  There was a very good fit and we had a very good result.  At that point, the pump was subsequently placed in the dartos pouch, which already has been created and was copiously irrigated with antibiotic solution.  This was held in place with a Babcock as well not to migrate proximally and attention was then taken to our connection from the reservoir to the pump.  Please also note that before placement of our pump, attention was then taken up to the left lower quadrant where an incision was then made in external oblique aponeurosis, approximately 3 cm dissection down underneath the rectus space was developed for our reservoir device, which was subsequently placed without difficulty and three simple interrupted sutures of #2-0 Vicryl used to close the defect in the rectus and at that point after placement of our pump, the connection was made between the pump and the reservoir without difficulty.  The entire system pump and corporal bodies were subsequently flushed and all air bubbles were evacuated.  After completion of the connection using a straight connector, the prosthesis was inflated and we had very good results with air inflation with good erection in both cylinders with a very slight deviation to the left, but this was able to be ________ with good cosmetic result.  At that point, after irrigation again of the space, the area was simply dry and hemostatic.  The soft tissue was reapproximated to separate the cylinder so as not to lie in rope against one another and the wound was closed in multiple layers.  The soft tissue and the skin was then reapproximated with staples.  Please also note that prior to the skin closure, a Jackson-Pratt drain was subsequently placed through the left skin and left lower quadrant and subsequently placed just over tubings, would be left in place for approximately 12 to 20 hours.  This was also sutured in place with nylon.  Sterile dressing was applied.  Light gauze was wrapped around the penis and/or sutures that begin at the tip of the glans penis were subsequently cut and removed in entirety bilaterally.  Coban was used then to wrap the penis and at the end of the case the patient was straight catheted, approximately 400 cc of amber-yellow urine.  No Foley catheter was used or placed.,The patient was awoken in the operative suite, extubated, and transferred to recovery room in stable condition.  He will be admitted overnight to the service of Dr. McDevitt.  Cardiology will be asked to consult with Dr. Stomel for a pacer placement and he will be placed on the Telemetry floor and kept on IV antibiotics.","surgery, inflatable penile prosthesis, peyronie's disease, perineum, scrotum, penis, penile prosthesis, bovie cautery, corporal body, glans penis, pump, cylinders, penile, prosthesis, inflatable, corporal"
 A 14-year-old young lady is in the renal failure and in need of dialysis., Surgery, Peritoneal Dialysis Catheter Insertion ,"PREOPERATIVE DIAGNOSIS: , Renal failure.,POSTOPERATIVE DIAGNOSIS:,  Renal failure.,OPERATION PERFORMED: , Insertion of peritoneal dialysis catheter.,ANESTHESIA: , General.,INDICATIONS:  ,This 14-year-old young lady is in the renal failure and in need of dialysis.  She had had a previous PD catheter placed, but it became infected and had to be removed.  She, therefore, comes back to the operating room for a new PD catheter.,OPERATIVE PROCEDURE:  ,After the induction of general anesthetic, the abdomen was prepped and draped in the usual manner.  A small transverse right upper quadrant incision was made and carried down through the skin and subcutaneous tissue with sharp dissection.  The fascia was divided and the posterior fascia and peritoneum were identified.  A hole was made in the posterior fascia through the peritoneum and into the peritoneal cavity.  The omentum came up through the hole and so therefore the omentum was actually brought up and a small portion of it removed, which could easily be brought up through the incision.  A PD catheter was then placed into the pelvis over a guidewire.  At this point, the peritoneum and posterior fascia was closed around the catheter.  The anterior fascia was then closed over the top of the cuff leaving the cuff buried in the fascia.  The second incision was then made lateral and the catheter brought out through a second incision and the subcutaneous cuff then positioned at that site.  The catheter was then connected and two runs of a 150 mL of fluid were made with a good inflow and a good clear return.  The skin was closed with 5-0 subcuticular Monocryl.  Sterile dressings were applied and the young lady awakened and taken to the recovery room in satisfactory condition.","surgery, pd catheter, catheter, omentum, peritoneal dialysis catheter, peritoneal dialysis, renal failure, peritoneal, dialysis, renal"
 Permacath placement - renal failure., Surgery, Permacath Placement ,"PROCEDURE:,  Permacath placement.,INDICATION: , Renal failure.,IMPRESSION: , Status post successful placement of a #4-French Permacath dialysis catheter.,DISCUSSION:,  After informed consent was obtained at the request of Dr. Xyz, Permacath placement was performed.,The right neck and anterior chest were sterilely cleansed and draped.  Lidocaine 1% buffered with sodium bicarbonate was used as a local anesthetic.  Using ultrasound guidance, a micropuncture needle was advanced into the internal jugular vein.  The wire was then advanced with fluoroscopic guidance.  A dilator was placed.  An incision was then made at the puncture site for approximately 1 cm in the neck.  A 1 cm incision was also made in the anterior chest.  The catheter was tunneled subcutaneously from the incision on the anterior chest, out the incision of the neck.  Following this, over the wire, the tract into the internal jugular vein was dilated and a peel-away sheath was placed.  The catheter was then advanced through the peel-away sheath.  The peel-away sheath was removed.  The catheter was examined under fluoroscopic imaging and was in satisfactory position.  Both ports were aspirated and flushed easily.  Following this, the incision on the neck was closed with 2 #3-0 silk sutures.  The incision on the anterior chest was also closed 2 #3-0 silk sutures.,The patient tolerated the procedure well.  No complications occurred during or immediately after the procedure.  The patient was returned to her room in satisfactory condition.","surgery, permacath placement, permacath, renal failure, anterior chest, catheter, dialysis, fluoroscopic, fluoroscopic guidance, internal jugular vein, micropuncture, needle, sheath, sutures, ultrasound guidance, internal jugular, jugular vein, placement, "
 Phacoemulsification with posterior chamber intraocular lens - Sample/Template., Surgery, Phacoemulsification ,"PREOPERATIVE DIAGNOSIS:, Senile cataract OX,POSTOPERATIVE DIAGNOSIS: ,Senile cataract OX,PROCEDURE: ,Phacoemulsification with posterior chamber intraocular lens OX, model SN60AT (for Acrysof natural lens), XXX diopters.,INDICATIONS: ,This is a XX-year-old (wo)man with decreased vision OX.,PROCEDURE:, The risks and benefits of cataract surgery were discussed at length with the patient, including bleeding, infection, retinal detachment, re-operation, diplopia, ptosis, loss of vision, and loss of the eye. Informed consent was obtained. On the day of surgery, (s)he received several sets of drops in the XXX eye including 2.5% phenylephrine, 1% Mydriacyl, 1% Cyclogyl, Ocuflox and Acular. (S)he was taken to the operating room and sedated via IV sedation. 2% lidocaine jelly was placed in the XXX eye (or, retrobulbar anesthesia was performed using a 50/50 mixture of 2% lidocaine and 0.75% marcaine). The XXX eye was prepped using a 10% Betadine solution. (S)he was covered in sterile drapes leaving only the XXX eye exposed. A Lieberman lid speculum was placed to provide exposure. The Thornton fixation ring and a Superblade were used to create a paracentesis at approximately 2 (or 11 depending upon side and handedness, and assuming superior incision) o'clock. Then 1% lidocaine was injected through the paracentesis. After the nonpreserved lidocaine was injected, Viscoat was injected through the paracentesis to fill the anterior chamber. The Thornton fixation ring and a 2.75 mm keratome blade were used to create a two-step full-thickness clear corneal incision superiorly. The cystitome and Utrata forceps were used to create a continuous capsulorrhexis in the anterior lens capsule. BSS on a hydrodissection cannula was used to perform gentle hydrodissection. Phacoemulsification was then performed to remove the nucleus. I & A was performed to remove the remaining cortical material. Provisc was injected to fill the capsular bag and anterior chamber. A XXX diopter SN60AT (for Acrysof natural lens) intraocular lens was injected into the capsular bag. The Kuglen hook was used to rotate it into proper position in the capsular bag. I & A was performed to remove the remaining Viscoelastic material from the eye. BSS on the 30-gauge cannula was used to hydrate the wound. The wounds were checked and found to be watertight. The lid speculum and drapes were carefully removed. Several drops of Ocuflox were placed in the XXX eye. The eye was covered with an eye shield. The patient was taken to the recovery area in a good condition. There were no complications.","surgery, phacoemulsification, acrysof, acrysof natural lens, acular, kuglen hook, ocuflox, provisc, sn60at, senile cataract, thornton fixation ring, bleeding, capsular bag, decreased vision, diopters, diplopia, infection, loss of the eye, loss of vision, ptosis, retinal detachment, lid speculum, thornton fixation, anterior chamber, intraocular lens, intraocular, chamber, lidocaine, "
" Nuclear sclerotic cataract, right eye.  Kelman phacoemulsification with posterior chamber intraocular lens, right eye.", Surgery, Phacoemulsification - Kelman ,"PREOPERATIVE DIAGNOSIS:,  Nuclear sclerotic cataract, right eye.,POSTOPERATIVE DIAGNOSIS:,  Nuclear sclerotic cataract, right eye.,OPERATIVE PROCEDURES:,  Kelman phacoemulsification with posterior chamber intraocular lens, right eye.,ANESTHESIA:,  Topical.,COMPLICATIONS:,  None.,INDICATION: , This is a 40-year-old male, who has been noticing problems with blurry vision.  They were found to have a visually significant cataract.  The risks, benefits, and alternatives of cataract surgery to the right eye were discussed and they did agree to proceed.,DESCRIPTION OF PROCEDURE:,  After informed consent was obtained, the patient was taken to the operating room.  A drop of tetracaine was instilled in the right eye and the right eye was prepped and draped in the usual sterile ophthalmic fashion.  A paracentesis was created at ** o'clock.  The anterior chamber was filled with Viscoat.  A clear corneal incision was made at ** o'clock with the 3-mm diamond blade.  A continuous curvilinear capsulorrhexis was begun with a cystotome and completed with Utrata forceps.  The lens was hydrodissected with a syringe filled with 2% Xylocaine and found to rotate freely within the capsular bag.  The nucleus was removed with the phacoemulsification handpiece in a stop and chop fashion.  The residual cortex was removed with the irrigation/aspiration handpiece.  The capsular bag was filled with Provisc and a model SI40, 15.0 diopter, posterior chamber intraocular lens was inserted into the capsular bag without complications and was found to rotate and center well.  The residual Provisc was removed with the irrigation/aspiration handpiece.  The wounds were hydrated and the eye was filled to suitable intraocular pressure with balanced salt solution.  The wounds were found to be free from leak.  Zymar and Pred Forte were instilled postoperatively.  The eye was covered with the shield.,The patient tolerated the procedure well and there were no complications.  He will follow up with us in one day.","surgery, nuclear sclerotic cataract, intraocular lens, cataract, kelman phacoemulsification, sclerotic cataract, posterior chamber, capsular bag, eye, anesthesia, phacoemulsification"
 Excision of penile skin bridges about 2 cm in size., Surgery, Penile Skin Bridges Excision  ,"PREOPERATIVE DIAGNOSIS: , Penile skin bridges after circumcision.,POSTOPERATIVE DIAGNOSIS: , Penile skin bridges after circumcision.,PROCEDURE:  ,Excision of penile skin bridges about 2 cm in size.,ABNORMAL FINDINGS:  ,Same as above.,ANESTHESIA:  ,General inhalation anesthetic with caudal block.,FLUIDS RECEIVED: , 300 mL of crystalloids.,ESTIMATED BLOOD LOSS: , Less than 5 mL.,SPECIMENS: , No tissue sent to Pathology.,TUBES AND DRAINS:,  No tubes or drains were used.,COUNT: , Sponge and needle counts were correct x2.,INDICATIONS FOR OPERATION:  ,The patient is a 2-1/2-year-old boy with a history of newborn circumcision who developed multiple skin bridges after circumcision causing curvature with erection.  Plan is for repair.,DESCRIPTION OF PROCEDURE: , The patient is taken to the operating room, where surgical consent, operative site, and the patient's identification was verified.  Once he was anesthetized, the caudal block was placed and IV antibiotics were given.  He was then placed in a supine position and sterilely prepped and draped.  Once he was prepped and draped, we used a straight mosquito clamp and went under the bridges and crushed them, and then excised them with a curved iris and curved tenotomy scissors.  We removed the excessive skin on the shaft skin and on the glans itself.  We then on the ventrum excised the bridge and did a Heinecke-Mikulicz closure with interrupted figure-of-eight and interrupted suture of 5-0 chromic.  Electrocautery was used for hemostasis.  Once this was done, we then used Dermabond tissue adhesive and Surgicel to prevent the bridges from returning again.  IV Toradol was given at the end of procedure.  The patient tolerated the procedure well, was in stable condition upon transfer to the recovery room.","surgery, heinecke-mikulicz, penile skin bridges, caudal block, penile skin, skin bridges, excision, circumcision, penile, "
 Parotidectomy procedure, Surgery, Parotidectomy ,,"surgery, parotidectomy, mixter clamp, auditory canal, buccal, buccinator, curved clamp, earlobe, fascia, fat layer, frontotemporal, mandibular, mastoid process, parotid, parotid duct, parotid gland, preauricular, preauricular incision, sternocleidomastoid, suction drain, temporoparotid, tied with vicryl sutures, vicryl, gland, nerve, sutures, incisionNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Pelvic laparotomy, lysis of pelvic adhesions, and left salpingooophorectomy with insertion of Pain-Buster Pain Management System.", Surgery, Pelvic Laparotomy ,"PREOPERATIVE DIAGNOSIS: , Large left adnexal mass, 8 cm in diameter.,POSTOPERATIVE DIAGNOSIS: , Pelvic adhesions, 6 cm ovarian cyst.,PROCEDURES PERFORMED:  ,1.  Pelvic laparotomy.,2.  Lysis of pelvic adhesions.,3.  Left salpingooophorectomy with insertion of Pain-Buster Pain Management System by Dr. X.,GROSS FINDINGS:  ,There was a transabdominal mass palpable in the lower left quadrant.  An ultrasound suggestive with a mass of 8 cm, did not respond to suppression with norethindrone acetate and on repeat ultrasound following the medical treatment, the ovarian neoplasm persisted and did not decreased in size.,PROCEDURE:  ,Under general anesthesia, the patient was placed in lithotomy position, prepped and draped.  A low transverse incision was made down to and through to the rectus sheath.  The rectus sheath was put laterally.  The inferior epigastric arteries were identified bilaterally, doubly clamped and tied with #0 Vicryl sutures.  The rectus muscle was then split transversally and the peritoneum was split transversally as well.  The left adnexal mass was identified and large bowel was attached to the mass and Dr. Zuba from General Surgery dissected the large bowel adhesions and separated them from the adnexal mass.  The ureter was then traced and found to be free of the mass and free of the infundibulopelvic ligament.  The infundibulopelvic ligament was isolated, entered via blunt dissection.  A #0 Vicryl suture was put into place, doubly clamped with curved Heaney clamps, cut with curved Mayo scissors and #0 Vicryl fixation suture put into place.  Curved Heaney clamps were then used to remove the remaining portion of the ovary from its attachment to the uterus and then #0 Vicryl suture was put into place.  Pathology was called to evaluate the mass for potential malignancy and the pathology's verbal report at the time of surgery was that this was a benign lesion.  Irrigation was used.  Minimal blood loss at the time of surgery was noted.  Sigmoid colon was inspected in place in physiologic position of the cul-de-sac as well as small bowel omentum.  Instrument, needle, and sponge counts were called for and found to be correct.  The peritoneum was closed with #0 Vicryl continuous running locking suture.  The rectus sheath was closed with #0 Vicryl continuous running locking suture.  A DonJoy Pain-Buster Pain Management System was placed through the skin into the subcutaneous space and the skin was closed with staples.  Final instrument needle counts were called for and found to be correct.  The patient tolerated the procedure well with minimal blood loss and transferred to recovery area in satisfactory condition.","surgery, lysis of pelvic adhesions, salpingooophorectomy, pain-buster pain management system, adnexal mass, pelvic laparotomy, pelvic adhesions, rectus sheath, vicryl sutures, adhesions, pelvic"
" Percutaneous endoscopic gastrostomy tube.  Protein-calorie malnutrition.  The patient was unable to sustain enough caloric intake and had markedly decreased albumin stores.  After discussion with the patient and the son, they agreed to place a PEG tube for nutritional supplementation.", Surgery, PEG Tube ,"PREOPERATIVE DIAGNOSIS:,  Protein-calorie malnutrition.,POSTOPERATIVE DIAGNOSIS: , Protein-calorie malnutrition.,PROCEDURE PERFORMED:, Percutaneous endoscopic gastrostomy (PEG) tube.,ANESTHESIA: , Conscious sedation per Anesthesia.,SPECIMEN: , None.,COMPLICATIONS: , None.,HISTORY:  ,The patient is a 73-year-old male who was admitted to the hospital with some mentation changes.  He was unable to sustain enough caloric intake and had markedly decreased albumin stores.  After discussion with the patient and the son, they agreed to place a PEG tube for nutritional supplementation.,PROCEDURE: , After informed consent was obtained, the patient was brought to the endoscopy suite.  He was placed in the supine position and was given IV sedation by the Anesthesia Department.  An EGD was performed from above by Dr. X.  The stomach was transilluminated and an optimal position for the PEG tube was identified using the single poke method.  The skin was infiltrated with local and the needle and sheath were inserted through the abdomen into the stomach under direct visualization.  The needle was removed and a guidewire was inserted through the sheath.  The guidewire was grasped from above with a snare by the endoscopist.  It was removed completely and the Ponsky PEG tube was secured to the guidewire.,The guidewire and PEG tube were then pulled through the mouth and esophagus and snug to the abdominal wall.  There was no evidence of bleeding.  Photos were taken.  The Bolster was placed on the PEG site.  A complete dictation for the EGD will be done separately by Dr. X.  The patient tolerated the procedure well and was transferred to recovery room in stable condition.  He will be started on tube feedings in 6 hours with aspiration precautions and dietary to determine his nutritional goal.","surgery, percutaneous endoscopic gastrostomy tube, protein calorie malnutrition, peg tube, malnutrition, nutritional"
" Pars plana vitrectomy, pars plana lensectomy, exploration of exit wound, closure of perforating corneal scleral laceration involving uveal tissue, air-fluid exchange, C3F8 gas, and scleral buckling, right eye.", Surgery, Pars Plana Vitrectomy & Lensectomy ,"TITLE OF OPERATION:,1.  Pars plana vitrectomy.,2.  Pars plana lensectomy.,3.  Exploration of exit wound.,4.  Closure of perforating corneal scleral laceration involving uveal tissue.,5.  Air-fluid exchange.,6.  C3F8 gas.,7.  Scleral buckling, right eye.,INDICATION FOR SURGERY: , The patient was hammering and a piece of metal entered his eye 1 day prior to the procedure giving him a traumatic cataract corneal laceration and the metallic intraocular foreign body was lodged in the posterior eye wall.  He undergoes repair of the open globe today.,PREOP DIAGNOSIS: , Perforating corneal scleral laceration involving uveal tissue with traumatic cataract and metallic foreign body lodged in the posterior eye wall, right eye.,POSTOP DIAGNOSIS: , Perforating corneal scleral laceration involving uveal tissue with traumatic cataract and metallic foreign body lodged in the posterior eye wall, right eye.,ANESTHESIA:,  General.,SPECIMEN:,  None.,IMPLANTS:,1.  Style number XXX silicone band reference XXX , lot number XXX , exploration 11/13.,2.  Style number XXX Watzke sleeve reference XXX , lot number XXX , exploration 04/14.,PROCEDURE: , The risk, benefits, and alternatives to the procedure were reviewed with the patient and his wife.  All of their questions were answered.  Informed consent was signed.  The patient was brought into the operating room.  A surgical time-out was performed during which all members of the operating room staff agreed upon the patient's name, operation to be performed, and correct operative eye.  After administration of general anesthesia, the patient was intubated without incident.,The right eye was prepared and draped in the usual fashion for ophthalmic surgery.  A wire lid speculum was used to separate the eyelids of the left eye.  A 9 o'clock anterior chamber paracentesis was created with Supersharp blade and the anterior chamber was filled with Healon.  The clear corneal incision was superior to the visual axis and was closed with three interrupted 10-0 nylon sutures with the knots buried.  A standard three-port pars plana vitrectomy __________ was initiated by performing partial conjunctival peritomies in the superonasal, superotemporal, and inferotemporal quadrants with Westcott scissors.  Hemostasis was achieved with bipolar cautery.  A 7-0 Vicryl suture was preplaced in the mattress fashion, 3 mm posterior to the surgical limbus in the inferotemporal quadrant.  A microvitreoretinal blade was used to create a sclerotomy at this site and a 4-mm infusion cannula was introduced through the sclerotomy and tied in place with the aforementioned suture.  The presence of the tip of the cannula was confirmed to be within the vitreous cavity prior to initiation of posterior infusion.  Two additional sclerotomies were created superonasally and superotemporally, 3 mm posterior to the surgical limbus with microvitreoretinal blade.,The vitreous cutter was used to perform the pars plana lens actively preserving peripheral anterior capsule.  The pars plana vitrectomy was performed with the assistance of the BIOM non-contact lens indirect viewing system using the light pipe illuminator and the vitreous cutter.  The vitreous was trimmed to the vitreous base.  A posterior vitreous detachment was created and extended 360 degrees with the assistance of triamcinolone for staining.,The foreign body appeared to exit the posterior pole along the superotemporal arcade and apparently severed a branched retinal artery resulting in an area of macular ischemia with retinal whitening along its course.  The exit wound was explored.  No intraocular foreign body or mural foreign body was observed with the assistance of intraocular forceps.  The intraocular magnet was then inserted through the sclerotomy and no foreign body was again identified.,An air-fluid exchange was performed with the assistance of the soft-tip extrusion cannula and the retinal periphery was examined with scleral depression.  No retinal breaks or defects were noted in the periphery.  The plugs were placed in the sclerotomies and the conjunctival peritomy was extended at 360 degrees.  Each of the rectus muscles was isolated on a 2-0 silk suture and a #XXX band was threaded beneath each of the rectus muscle and fixed to itself in the inferonasal quadrant with the Watzke sleeve.  The buckle was sutured to the eye wall with 5-0 Mersilene sutures in each quadrant in a mattress fashion.  The buckle was trimmed and the height of the buckle was inspected internally and noted to be adequate.,Residual intraocular fluid was removed with a soft-tip extrusion cannula and the sclerotomies were closed with 7-0 Vicryl sutures.  A 12% concentration of C3F8 gas was flushed through the eye.  The infusion cannula was removed and the sclerotomy was closed with the preplaced 7-0 Vicryl suture.  All of the sclerotomies were noted to be airtight.  The intraocular pressure following injection of 0.05 mL each of vancomycin (0.5 mg) and ceftazidime (1 mg) were injected through the superotemporal pars plana, 30-gauge needles.,The conjunctiva was closed with 6-0 plain gut sutures with the knots buried.  Subconjunctival injections of Ancef and Decadron were delivered inferotemporally.  The lid speculum was removed.  Pred-G ointment and atropine solution were applied to the ocular surface.  The eye was patched and shielded, and the patient was returned to the recovery room in stable condition, having tolerated the procedure well.  There were no complications.,I was the attending surgeon, was present and scrubbed for the entirety of the procedure.",
" Open repair of right pectoralis major tendon.   Right pectoralis major tendon rupture.  On MRI evaluation, a complete rupture of a portion of the pectoralis major tendon was noted.", Surgery, Pectoralis Tendon Repair ,"PREOPERATIVE DIAGNOSIS: , Right pectoralis major tendon rupture.,POSTOPERATIVE DIAGNOSIS: , Right pectoralis major tendon rupture.,OPERATION PERFORMED: , Open repair of right pectoralis major tendon.,ANESTHESIA:,  General with an interscalene block.,COMPLICATIONS:,  None.,Needle and sponge counts were done and correct.,INDICATION FOR OPERATION:  ,The patient is a 26-year-old right hand dominant male who works in sales, who was performing heavy bench press exercises when he felt a tearing burning pain severe in his right shoulder.  The patient presented with mild bruising over the proximal arm of the right side with x-ray showing no fracture.  Over concerns for pectoralis tendon tear, he was sent for MRI evaluation where a complete rupture of a portion of the pectoralis major tendon was noted.  Due to the patient's young age and active lifestyle surgical treatment was recommended in order to obtain best result.  The risks and benefits of the procedure were discussed in detail with the patient including, but not limited to scarring, infection, damage to blood vessels and nerves, re-rupture, need further surgery, loss of range of motion, inability to return to heavy activity such as weight lifting, complex usual pain syndrome, and deep vein thrombosis as well as anesthetic risks.  Understanding all risks and benefits, the patient desires to proceed with surgery as planned.,FINDINGS:,1.  Following deltopectoral approach to the right shoulder, the pectoralis major tendon was encountered.  The clavicular head was noted to be intact.  There was noted to be complete rupture of the sternal head of the pectoralis major tendon with an oblique-type tear having some remaining cuff on the humerus and some tendon attached to the retracted portion.,2.  Following freeing of adhesions using tracks and sutures, the pectoralis major tendon was able to reapproximated to its insertion site on the humerus just lateral to the biceps.,3.  A soft tissue repair was performed with #5 FiberWire suture and a single suture anchor of 5 x 5 bioabsorbable anchor was placed in order to decrease tension at the repair site.  Following repair of soft tissue and using the bone anchor, there was noted to be good apposition of the tendon with edges and a solid repair.,OPERATIVE REPORT IN DETAIL: , The patient was identified in the preop holding area.  His right shoulder was identified, marked his appropriate surgical site after verification with the patient.  He was then taken to the operating room where he was transferred to the operative table in supine position and placed under general anesthesia by anesthesiology team.  He then received prophylactic antibiotics.  A time-out was then undertaken verifying the correct patient, extremity, surgery performed, administration of antibiotics, and the availability of equipment.  At this point, the patient was placed to a modified beech chair position with care taken to ensure all appropriate pressure points were padded and there was no pressure over the eyes.  The right upper extremity was then prepped and draped in the usual sterile fashion.  Preoperative markings were still visible at this point.  A deltopectoral incision was made utilizing the inferior portion.  Dissection was carried down.  The deltoid was retracted laterally.  The clavicular head of the pectoralis major was noted to be intact with the absence of the sternal insertion.  There was a small cuff of tissue left on the proximal humerus associated with the clavicular head.  Gentle probing medially revealed the end of the sternal retracted portion, traction sutures of #5 Ethibond were used in this to allow for retraction and freeing from light adhesion.  This allowed reapproximation of the retracted tendon to the tendon stump.  At this point, a repair using #5 FiberWire was then performed of the pectoralis major tendon back to stump on the proximal humerus noting good apposition of the tendon edges and no gapping of the repair site.  At this point, a single metal suture anchor was attempted to be implanted just lateral to the insertion of the pectoralis in order to remove tension off the repair site; however, the inserted device attached to the metal anchor broke during insertion due to significant hardness of the bone.  For this reason, the starting hole was tapped and a 5x5 bioabsorbable anchor was placed, doubly loaded.  The sutures were then weaved through the lateral aspect of the torn tendon and a modified Krackow type performed and sutured thereby relieving tension off the soft tissue repair.  At this point, there was noted to be excellent apposition of the soft tissue ends and a solid repair to gentle manipulation.  Aggressive external rotation was not performed.  The wound was then copiously irrigated.  The cephalic vein was not injured during the case.  The skin was then closed using a 2-0 Vicryl followed by a 3-0 subcuticular Prolene suture with Steri-Strips.  Sterile dressing was then placed.  Anesthesia was then performed, interscalene block.  The patient was then awakened from anesthesia and transported to postanesthesia care in stable condition in a shoulder immobilizer with the arm adducted and internally rotated.,Plan for this patient, the patient will remain in the shoulder immobilizer until followup visit in approximately 10 days.  We will then start a gentle Codman type exercises and having limited motion until the 4-6 week point based on the patient's progression.","surgery, tendon rupture, interscalene block, pectoralis major tendon rupture, pectoralis major tendon, repair, pectoralis, interscalene, tendon, rupture, sutures,"
 Ligation (clip interruption) of patent ductus arteriosus.  This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch. , Surgery, Patent Ductus Arteriosus Ligation ,"TITLE OF OPERATION: , Ligation (clip interruption) of patent ductus arteriosus.,INDICATION FOR SURGERY: , This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch.  She has now been put forward for operative intervention.,PREOP DIAGNOSIS:  ,1.  Patent ductus arteriosus.,2.  Severe prematurity.,3.  Operative weight less than 4 kg (600 grams).,COMPLICATIONS: , None.,FINDINGS: , Large patent ductus arteriosus with evidence of pulmonary over circulation.  After completion of the procedure, left recurrent laryngeal nerve visualized and preserved.  Substantial rise in diastolic blood pressure.,DETAILS OF THE PROCEDURE: , After obtaining information consent, the patient was positioned in the neonatal intensive care unit, cribbed in the right lateral decubitus, and general endotracheal anesthesia was induced.  The left chest was then prepped and draped in the usual sterile fashion and a posterolateral thoracotomy incision was performed.  Dissection was carried through the deeper planes until the second intercostal space was entered freely with no damage to the underlying lung parenchyma.  The lung was quite edematous and was retracted anteriorly exposing the area of the isthmus.  The pleura overlying the ductus arteriosus was inside and the duct dissected in a nearly circumferential fashion.  It was then test occluded and then interrupted with a medium titanium clip.  There was preserved pulsatile flow in the descending aorta.  The left recurrent laryngeal nerve was identified and preserved.  With excellent hemostasis, the intercostal space was closed with 4-0 Vicryl sutures and the muscular planes were reapproximated with 5-0 Caprosyn running suture in two layers.  The skin was closed with a running 6-0 Caprosyn suture.  A sterile dressing was placed.  Sponge and needle counts were correct times 2 at the end of the procedure.  The patient was returned to the supine position in which palpable bilateral femoral pulses were noted.,I was the surgical attending present in the neonatal intensive care unit and in-charge of the surgical procedure throughout the entire length of the case.","surgery, clip interruption, ligation, patent ductus arteriosus, premature baby, intercostal space, arteriosus, interruption, pulmonary, circulation"
" Sinus bradycardia, sick-sinus syndrome, poor threshold on the ventricular lead and chronic lead.  Right ventricular pacemaker lead placement and lead revision.", Surgery, Pacemaker Lead Placement & Rrevision. ,"PROCEDURE: , Right ventricular pacemaker lead placement and lead revision.,INDICATIONS:,  Sinus bradycardia, sick-sinus syndrome, poor threshold on the ventricular lead and chronic lead.,EQUIPMENT: , A new lead is a Medtronic model #12345, threshold sensing at 5.7, impedance of 1032, threshold of 0.3, atrial threshold is 0.3, 531, and sensing at 4.1.  The original chronic ventricular lead had a threshold of 3.5 and 6 on the can.,ESTIMATED BLOOD LOSS: , 5 mL.,PROCEDURE DESCRIPTION:  ,Conscious sedation with Versed and fentanyl over left subclavicular area with pacemaker pocket was anesthetized with local anesthetic with epinephrine.  The patient received a venogram documenting patency of the subclavian vein.  Skin incision with blunt and sharp dissection.  Electrocautery for hemostasis.  The pocket was opened and the pacemaker was removed from the pocket and disconnected from the leads.  The leads were sequentially checked.  Through the pocket a puncture of the vein with a thin wall needle was made and a long sheath was used to help carry it along the tortuosity of the proximal subclavian and innominate superior vena cava.  Ultimately, a ventricular lead was placed in apex of the right ventricle, secured to base pocket with 2-0 silk suture.  Pocket was irrigated with antibiotic solution.  The pocket was packed with bacitracin-soaked gauze.  This was removed during the case and then irrigated once again.  The generator was attached to the leads, placed in the pocket, secured with 2-0 silk suture and the pocket was closed with a three layer of 4-0 Monocryl.,CONCLUSION:  , Successful replacement of a right ventricular lead secondary to poor lead thresholds in a chronic lead and placement of the previous Vitatron pulse generator model # 12345.","surgery, medtronic, atrial, subclavian, sick sinus syndrome, pacemaker lead placement, ventricular pacemaker, ventricular lead, lead, bradycardia, pacemaker, threshold, ventricular"
 Coil embolization of patent ductus arteriosus., Surgery, Patent Ductus Arteriosus ,"HISTORY: , The patient is a 5-1/2-year-old, who recently presented with a cardiac murmur diagnosed due to a patent ductus arteriosus.  An echocardiogram from 09/13/2007 demonstrated a 3.8-mm patent ductus arteriosus with restrictive left-to-right shunt.  There is mild left atrial chamber enlargement with an LA/AO ratio of 1.821.  An electrocardiogram demonstrated normal sinus rhythm with possible left atrial enlargement and left ventricular hypertrophy.  The patient underwent cardiac catheterization for device closure of a ductus arteriosus.,PROCEDURE:  ,After sedation and local Xylocaine anesthesia, the patient was prepped and draped.  Cardiac catheterization was performed as outlined in the attached continuation sheets.  Vascular entry was by percutaneous technique, and the patient was heparinized.  Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a 5-French sheath, a 5-French wedge catheter was inserted into the right femoral vein and advanced through the right heart structures up to the branch pulmonary arteries.  The atrial septum was not probe patent.,Using a 4-French sheath, a 4-French marker pigtail catheter was inserted into the right femoral artery advanced retrograde to the descending aorta, ascending aorta, and left ventricle.  A descending aortogram demonstrated a small, type A patent ductus arteriosus with a small left-to-right angiographic shunt.  Minimal diameter was approximately 1.6 mm with ampulla diameter of 5.8 mm and length of 6.2 mm.  The wedge catheter could be directed from the main pulmonary artery across the ductus arteriosus to the descending aorta.  This catheter exchanged over wire for a 5-French nit-occlude delivery catheter through which a nit-occlude 6/5 flex coil that was advanced and allowed to reconfigure the descending aorta.  Entire system was then brought into the ductal ampulla or one loop of coil was delivered in the main pulmonary artery.  Once the stable device configuration was confirmed by fluoroscopy, device was released from the delivery catheter.  Hemodynamic measurements and angiogram in the descending aorta were then repeated approximately 10 minutes following device implantation.,Flows were calculated by the Fick technique using a measured assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with injection in the descending aorta.,After angiography, two normal-appearing renal collecting systems were visualized.  The catheters and sheaths were removed and topical pressure applied for hemostasis.  The patient was returned to the recovery room in satisfactory condition.  There were no complications.,DISCUSSION: , Oxygen consumption was assumed to be normal.  Mixed venous saturation was normal with a slight increased saturation of the branch pulmonary arteries due to left-to-right shunt through the ductus arteriosus.  The left-sided heart was fully saturated.  The phasic right-sided and left-sided pressures were normal.  The calculated systemic flow was normal and pulmonary flow was slightly increased with a QP:QS ratio of 1:1.  Vascular resistances were normal.  A cineangiogram with contrast injection in the descending aorta showed a small conical shaped ductus arteriosus with a small left-to-right angiographic shunt.  The branch pulmonary arteries appeared normal.  There is otherwise a normal left aortic arch.,Following coil embolization of the ductus arteriosus, there is no change in mixed venous saturation.  No evidence of residual left-to-right shunt.  There is no change in right-sided pressures.  There is a slight increase in the left-sided phasic pressures.  Calculated systemic flow was unchanged from the resting state and pulmonary flow was similar with a QP:QS ratio of 1:1.  Final angiogram with injection in the descending aorta showed a majority of coil mass to be within the ductal ampulla with minimal protrusion in the descending aorta as well as the coil in the main pulmonary artery.  There is a trace residual shunt through the center of coil mass.,INITIAL DIAGNOSES:, Patent ductus arteriosus.,SURGERIES (INTERVENTIONS):  ,Coil embolization of patent ductus arteriosus.,MANAGEMENT:  ,The case to be discussed at Combined Cardiology/Cardiothoracic Surgery case conference.  The patient will require a cardiologic followup in 6 months and 1 year's time including clinical evaluation and echocardiogram.  Further patient care be directed by Dr. X.,","surgery, cardiac murmur, coil embolization, cineangiograms, patent ductus arteriosus, pulmonary artery, patent ductus, descending aorta, ductus, arteriosus, catheterization"
" Patellar tendon and medial and lateral retinaculum repair, right knee.   Patellar tendon retinaculum ruptures, right knee.", Surgery, Patellar Tendon & Retinaculum Repair ,"PREOPERATIVE DIAGNOSIS:  , Patellar tendon retinaculum ruptures, right knee.,POSTOPERATIVE DIAGNOSIS: , Patellar tendon retinaculum ruptures, right knee.,PROCEDURE PERFORMED: , Patellar tendon and medial and lateral retinaculum repair, right knee.,SPECIFICATIONS:  ,Intraoperative procedure done at Inpatient Operative Suite, room #2 of ABCD Hospital.  This was done under subarachnoid block anesthetic in supine position.,HISTORY AND GROSS FINDINGS: , The patient is a 45-year-old African-American male who suffered acute rupture of his patellar tendon diagnosed both by exam as well as x-ray the evening before surgical intervention.  He did this while playing basketball.,He had a massive deficit at the inferior pole of his patella on exam.  Once opened, he had complete rupture of this patellar tendon as well as a complete rupture of his medial lateral retinaculum.  Minimal cartilaginous pieces were at the patellar tendon.  He had grade II changes to his femoral sulcus as well as grade I-II changes to the undersurface of the patella.,OPERATIVE PROCEDURE: , The patient was laid supine on the operative table receiving a subarachnoid block anesthetic by Anesthesia Department.  A thigh high tourniquet was placed.  He is prepped and draped in the usual sterile manner.  Limb was elevated, exsanguinated and tourniquet placed at 325 mmHg for approximately 30 to 40 minutes.  Straight incision is carried down through skin and subcutaneous tissue anteriorly.  Hemostasis was controlled via electrocoagulation.  Patellar tendon was isolated along with the patella itself.,A 6 mm Dacron tape x2 was placed with a modified Kessler tendon stitch with a single limb both medially and laterally and a central limb with subsequent shared tape.  The inferior pole was freshened up.  Drill bit was utilized to make holes x3 longitudinally across the patella and the limbs strutted up through the patella with a suture passer.  This was tied over the bony bridge superiorly.  There was excellent reduction of the tendon to the patella.  Interrupted running #1-Vicryl suture was utilized for over silk.  A running #2-0 Vicryl for synovial closure medial and laterally as well as #1-Vicryl medial and lateral retinaculum.  There was excellent repair.  Copious irrigation was carried out.  Tourniquet was dropped and hemostasis controlled via electrocoagulation.  Interrupted #2-0 Vicryl was utilized for subcutaneous fat closure and skin staples were placed through the skin.  Adaptic, 4 x 4s, ABDs, and sterile Webril were placed for compression dressing.  Digits were warm and no brawny pulses present at the end of the case.  The patient's leg was placed in a Don-Joy brace 0 to 20 degrees of flexion.  He will leave this until seen in the office.,Expected surgical prognosis on this patient is fair.","surgery, subarachnoid, patellar tendon retinaculum, tendon, patellar, tourniquet, knee, ruptures, retinaculum"
" Excision of right superior parathyroid adenoma, seen on sestamibi parathyroid scan and an ultrasound.", Surgery, Parathyroid Adenoma Excision ,"PREOPERATIVE DIAGNOSIS:,  Right superior parathyroid adenoma.,POSTOPERATIVE DIAGNOSIS:,  Right superior parathyroid adenoma.,PROCEDURE: , Excision of right superior parathyroid adenoma.,ANESTHESIA:,  Local with 1% Xylocaine and anesthesia standby with sedation.,CLINICAL HISTORY:,  This 80-year-old woman has had some mild dementia.  She was begun on Aricept but could not tolerate that because of strange thoughts and hallucinations.  She was found to be hypercalcemic.  Intact PTH was mildly elevated.  A sestamibi parathyroid scan and an ultrasound showed evidence of a right superior parathyroid adenoma.,FINDINGS AND PROCEDURE:,  The patient was placed on the operating table in the supine position.  A time out was taken so that the anesthesia personnel, nursing personnel, surgical team, and patient could confirm the patient's identity, operative site and operative plan.  The electronic medical record was reviewed as was the ultrasound.  The patient was sedated.  A small roll was placed behind the shoulders to moderately hyperextend the neck.  The head was supported in a foam head cradle.  The neck and chest were prepped with chlorhexidine and isolated with sterile drapes.  After infiltration with 1% Xylocaine with epinephrine along the planned incision, a transverse incision was made in the skin crease a couple of centimeters above the clavicular heads and carried down through the skin, subcutaneous tissue, and platysma.  The larger anterior neck veins were divided between 4-0 silk ligatures.  Superior and inferior flaps were developed in the subplatysmal plane using electrocautery and blunt dissection.  The sternohyoid muscles were separated in the midline, and the right sternohyoid muscle was retracted laterally.  The right sternothyroid muscle was divided transversely with the cautery.  The right middle thyroid vein was divided between 4-0 silk ligatures.  The right thyroid lobe was rotated leftward.  Posterior to the mid portion of the left thyroid lobe, a right superior parathyroid adenoma of moderate size was identified.  This was freed up and its pedicle was ligated with small Hemoclips and divided and the gland was removed.  It was sent for weight and frozen section.  It weighed 960 mg and on frozen section was consistent with a parathyroid adenoma.,Prior to the procedure, a peripheral blood sample had been obtained and placed in a purple top tube labeled ""pre-excision.""  It was our intention to monitor intraoperative intact parathyroid hormone 10 minutes after removal of this parathyroid adenoma.  However, we could not obtain 3 cc of blood from either the left foot or the left arm after multiple attempts, and therefore, we decided that the chance of cure of hyperparathyroidism by removal of this parathyroid adenoma was high enough and the improvement in that chance of cure marginal enough that we would terminate the procedure without monitoring PTH.  The neck was irrigated with saline and hemostasis found to be satisfactory.  The sternohyoid muscles were reapproximated with interrupted 4-0 Vicryl.  The platysma was closed with interrupted 4-0 Vicryl, and the skin was closed with subcuticular 5-0 Monocryl and Dermabond.  The patient was awakened and taken to the recovery area in satisfactory condition having tolerated the procedure well.","surgery, parathyroid adenoma, superior parathyroid adenoma, excision, sestamibi parathyroid scan, sestamibi parathyroid, parathyroid scan, sternohyoid muscles, superior parathyroid, parathyroid, sestamibi, platysma, adenoma, ultrasound, sternohyoid, thyroid, muscles "
" Paracentesis.  A large abdominal mass, which was cystic in nature and the radiologist inserted a pigtail catheter in the emergency room. ", Surgery, Paracentesis ,"PREOPERATIVE DIAGNOSIS: , Abdominal mass.,POSTOPERATIVE DIAGNOSIS: , Abdominal mass.,PROCEDURE:,  Paracentesis.,DESCRIPTION OF PROCEDURE:  ,This 64-year-old female has stage II endometrial carcinoma, which had been resected before and treated with chemotherapy and radiation.  At the present time, the patient is under radiation treatment.  Two weeks ago or so, she developed a large abdominal mass, which was cystic in nature and the radiologist inserted a pigtail catheter in the emergency room.  We proceeded to admit the patient and drained a significant amount of clear fluid in the subsequent days.  The cytology of the fluid was negative and the culture was also negative.  Eventually, the patient was sent home with the pigtail shut off and the patient a week later underwent a repeat CAT scan of the abdomen and pelvis.,The CAT scan showed accumulation of the fluid and the mass almost achieving 80% of the previous size.  Therefore, I called the patient home and she came to the emergency department where the service was provided.  At that time, I proceeded to work on the pigtail catheter after obtaining an informed consent and preparing and draping the area in the usual fashion.  Unfortunately, the catheter was open.  I did not have a drainage system at that time.  So, I withdrew directly with a syringe 700 mL of clear fluid.  The system was connected to the draining bag, and the patient was instructed to keep a log and how to use equipment.  She was given an appointment to see me in the office next Monday, which is three days from now.","surgery, abdominal mass, clear fluid, cat scan, pigtail catheter, paracentesis,"
 Ultrasound-Guided Paracentesis for Ascites, Surgery, Paracentesis - Ultrasound-Guided ,"EXAM:,  Ultrasound-guided paracentesis,HISTORY: , Ascites.,TECHNIQUE AND FINDINGS:  ,Informed consent was obtained from the patient after the risks and benefits of the procedure were thoroughly explained.  Ultrasound demonstrates free fluid in the abdomen.  The area of interest was localized with ultrasonography.  The region was sterilely prepped and draped in the usual manner.  Local anesthetic was administered.  A 5-French Yueh catheter needle combination was taken.  Upon crossing into the peritoneal space and aspiration of fluid, the catheter was advanced out over the needle.  A total of approximately 5500 mL of serous fluid was obtained.  The catheter was then removed.  The patient tolerated the procedure well with no immediate postprocedure complications.,IMPRESSION: , Ultrasound-guided paracentesis as above.","surgery, yueh catheter, aspiration of fluid, ultrasound guided paracentesis, ultrasound guided, needle, catheter, paracentesis, ultrasound, ascites"
 Reduction of paraphimosis., Surgery, Paraphimosis ,"PREOPERATIVE DIAGNOSIS: , Phimosis.,POSTOPERATIVE DIAGNOSIS: , Phimosis.,PROCEDURE: , Reduction of paraphimosis.,ANESTHESIA:  ,General inhalation anesthetic with 0.25% Marcaine, penile block and ring block about 20 mL given.,FLUIDS RECEIVED: , 100 mL.,SPECIMENS:,  No tissues sent to pathology.,COUNTS: , Sponge and needle counts were not necessary.,TUBES/DRAINS: , No tubes or drains were used.,FINDINGS: , Paraphimosis with moderate swelling.,INDICATIONS FOR OPERATION: , The patient is a 15-year-old boy who had acute alcohol intoxication had his foreskin retracted with a Foley catheter placed at another institution.  When they removed the catheter they forgot to reduce the foreskin and he developed paraphimosis.  The plan is for reduction.,DESCRIPTION OF OPERATION: , The patient was taken to the operating room where surgical consent, operative site, and patient identification were verified.  Once he was anesthetized, with manual pressure and mobilization of the shaft skin we were able to reduce the paraphimosis.  Using Betadine and alcohol cleanse, we then did a dorsal penile block and a ring block by surgeon with 0.25% Marcaine, 20 mL were given.  He did quite well after the procedure and was transferred to the recovery room in stable condition.","surgery, dorsal penile block, reduction of paraphimosis, penile block, phimosis, paraphimosis,"
 DDDR permanent pacemaker.   Tachybrady syndrome.  A ventricular pacemaker lead was advanced through the sheath and into the vascular lumen and under fluoroscopic guidance guided down into the right atrium. , Surgery, Pacemaker - DDDR  ,"PROCEDURE PERFORMED:  ,DDDR permanent pacemaker.,INDICATION: , Tachybrady syndrome.,PROCEDURE:,  After all risks, benefits, and alternatives of the procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing.  The patient was taken to the Cardiac Catheterization Suite where the right subclavian region was prepped and draped in the usual sterile fashion.  1% lidocaine solution was used to infiltrate the skin overlying the left subclavian vein.  Once adequate anesthesia had been obtained, a thin-walled #18-gauze Argon needle was used to cannulate the left subclavian vein.  A steel guidewire was inserted through the needle into the vascular lumen without resistance.  The needle was then removed over the guidewire and the guidewire was secured to the field.  A second #18 gauze Argon needle was used to cannulate the left subclavian vein and once again a steel guidewire was inserted through the needle into the vascular lumen.  Likewise, the needle was removed over the guidewire and the guidewire was then secured to the field.  Next, a #15-knife blade was used to make a 1 to 1.5 inch linear incision over the area.  A #11-knife blade was used to make a deeper incision.  Hemostasis was made complete.  The edges of the incision were grasped and retracted.  Using Metzenbaum scissors, dissection was carried down to the pectoralis muscle fascial plane.  Digital blunt dissection was used to make a pacemaker pocket large enough to accommodate the pacemaker generator.  Metzenbaum scissors were then used to dissect cephalad to expose the guide wires.  The guidewires were then pulled through the pacemaker pocket.  One guidewire was secured to the field.,A bloodless introducer sheath was then advanced over a guidewire into the vascular lumen under fluoroscopic guidance.  The guidewire and dilator were then removed.  Next, a ventricular pacemaker lead was advanced through the sheath and into the vascular lumen and under fluoroscopic guidance guided down into the right atrium.  The pacemaker lead was then placed in the appropriate position in the right ventricle.  Pacing and sensing thresholds were obtained.  The lead was sewn at the pectoralis muscle plane using #2-0 silk suture in an interrupted stitch fashion around the ________.  Pacing and sensing threshold were then reconfirmed.  Next, a second bloodless introducer sheath was advanced over the second guidewire into the vascular lumen.  The guidewire and dilator were then removed.  Under fluoroscopic guidance, the atrial lead was passed into the right atrium.  The sheath was then turned away in standard fashion.  Using fluoroscopic guidance, the atrial lead was then placed in the appropriate position.  Pacing and sensing thresholds were obtained.  The lead was sewn to the pectoralis muscle facial plane utilizing #2-0 silk suture around the ________.  Sensing and pacing thresholds were then reconfirmed.  The leads were wiped free of blood and placed into the pacemaker generator.  The pacemaker generator leads were then placed into pocket with the leads posteriorly.  The deep tissues were closed utilizing #2-0 Chromic suture in an interrupted stitch fashion.  A #4-0 undyed Vicryl was then used to close the subcutaneous tissue in a continuous subcuticular stitch.  Steri-Strips overlaid.  A sterile gauge dressing was placed over the site.  The patient tolerated the procedure well and was transferred to the Cardiac Catheterization Room in stable and satisfactory condition.,PACEMAKER DATA (GENERATOR DATA):,Manufacturer:  Medtronics.,Model:  Sigma.,Model #:  1234.,Serial #:  123456789.,LEAD INFORMATION:,Right Atrial Lead:,Manufacturer:  Medtronics.,Model #:  1234.,Serial #:  123456789.,VENTRICULAR LEAD:,Manufacturer:  Medtronics.,Model #:  1234.,Serial #:  123456789.,PACING AND SENSING THRESHOLDS:,Right Atrial Bipolar Lead:  Pulse width 0.50 milliseconds, impedance 518 ohms, P-wave sensing 2.2 millivolts, polarity is bipolar.,Ventricular Bipolar Lead:  Pulse width 0.50 milliseconds, voltage 0.7 volts, current 1.5 milliamps, impedance 655 ohms, R-wave sensing 9.7 millivolts, polarity is bipolar.,PARAMETER SETTINGS:,  Pacing mode DDDR:  Mode switch is on, low rate 60, upper 120, ________ is 33.0 milliseconds.,IMPRESSION:,  Successful implantation of DDDR permanent pacemaker.,PLAN:,1.  The patient will be monitored on telemetry for 24 hours to ensure adequate pacemaker function.,2.  The patient will be placed on antibiotics for five days to avoid pacemaker infection.",
 Insertion of transvenous pacemaker for tachybrady syndrome, Surgery, Pacemaker Insertion ,"PREOPERATIVE DIAGNOSIS:, Tachybrady syndrome.,POSTOPERATIVE DIAGNOSIS:, Tachybrady syndrome.,OPERATIVE PROCEDURE:, Insertion of transvenous pacemaker.,ANESTHESIA:, Local,PROCEDURE AND GROSS FINDINGS:, The patient's chest was prepped with Betadine solution and a small amount of Lidocaine infiltrated.  In the left subclavian region, a subclavian stick was performed without difficulty, and a wire was inserted. Fluoroscopy confirmed the presence of the wire in the superior vena cava.  An introducer was then placed over the wire.  The wire was removed and replace by a ventricular lead that was seated under Fluoroscopy. Following calibration, the lead was attached to a pacemaker generator that was inserted in a subcutaneous pocket in the left subclavian area.  ,The subcutaneous tissues were irrigated and closed with Interrupted 4-O Vicryl, and the skin was closed with staples.  Sterile dressings were placed, and the patient was returned to the ICU in good condition.","surgery, insertion of transvenous pacemaker, fluoroscopy, tachybrady, tachybrady syndrome, chest, pacemaker, subclavian, subcutaneous, superior vena cava, syndrome, transvenous pacemaker, wire, insertion, "
 Pacemaker ICD interrogation.  Severe nonischemic cardiomyopathy with prior ventricular tachycardia., Surgery, Pacemaker Interrogation ,"PROCEDURE NOTE: , Pacemaker ICD interrogation.,HISTORY OF PRESENT ILLNESS: , The patient is a 67-year-old gentleman who was admitted to the hospital.  He has had ICD pacemaker implantation.  This is a St. Jude Medical model current DRRS, 12345 pacemaker.,DIAGNOSIS: , Severe nonischemic cardiomyopathy with prior ventricular tachycardia.,FINDINGS: , The patient is a DDD mode base rate of 60, max tracking rate of 110 beats per minute, atrial lead is set at 2.5 volts with a pulse width of 0.5 msec, ventricular lead set at 2.5 volts with a pulse width of 0.5 msec.  Interrogation of the pacemaker shows that atrial capture is at 0.75 volts at 0.5 msec, ventricular capture 0.5 volts at 0.5 msec, sensing in the atrium is 5.34 to 5.8 millivolts, R sensing is 12-12.0 millivolts, atrial lead impendence 590 ohms, ventricular lead impendence 750 ohms.  The defibrillator portion is set at VT1 at 139 beats per minute with SVT discrimination on therapy is monitor only.  VT2 detection criteria is 169 beats per minute with SVT discrimination on therapy of ATP times 3 followed by 25 joules, followed by 36 joules, followed by 36 joules times 2.  VF detection criteria set at 187 beats per minute with therapy of 25 joules, followed by 36 joules times 5.  The patient is in normal sinus rhythm.,IMPRESSION:  ,Normally functioning pacemaker ICD post implant day number 1.","surgery, cardiomyopathy, ventricular, tachycardia, pacemaker icd interrogation, millivolts, impendence, interrogation, pacemaker, "
 Implantation of a dual-chamber pacemaker and fluoroscopic guidance for implantation of a dual-chamber pacemaker., Surgery, Pacemaker (Dual Chamber) - 1 ,"PREPROCEDURE DIAGNOSIS: , Complete heart block.,POSTPROCEDURE DIAGNOSIS:  ,Complete heart block.,PROCEDURES PLANNED AND PERFORMED,1.  Implantation of a dual-chamber pacemaker.,2.  Fluoroscopic guidance for implantation of a dual-chamber pacemaker.,FLUOROSCOPY TIME: , 2.6 minutes.,MEDICATIONS AT THE TIME OF STUDY,1.  Versed 2.5 mg.,2.  Fentanyl 150 mcg.,3.  Benadryl 50 mg.,CLINICAL HISTORY: , the patient is a pleasant 80-year-old female who presented to the hospital with complete heart block.  She has been referred for a pacemaker implantation.,RISKS AND BENEFITS: , Risks, benefits, and alternatives to implantation of a dual-chamber pacemaker were discussed with the patient.  The patient agreed both verbally and via written consent.,DESCRIPTION OF PROCEDURE: , The patient was transported to the cardiac catheterization laboratory in the fasting state.  The region of the left deltopectoral groove was prepped and draped in the usual sterile manner.  Lidocaine 1% (20 mL) was administered to the area.  After achieving appropriate anesthesia, percutaneous access of the left axillary vein was then performed under fluoroscopy.  A guide wire was advanced into the vein.  Following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath.  Hemostasis was achieved with electrocautery.  Lidocaine 1% (10 mL) was then administered to the medial aspect of the incision.  A pocket was then fashioned in the medial direction.  Using the previously placed wire, a 7-French side-arm sheath was advanced over the wire into the left axillary vein.  The dilator was then removed over the wire.  A second wire was then advanced into the sheath into the left axillary vein.  The sheath was then removed over the top of the two wires.  One wire was then pinned to the drape.  Using the remaining wire, a 7 French side-arm sheath was advanced back into the left axillary vein.  The dilator and wire were removed.  A passive pacing lead was then advanced down into the right atrium.  The peel-away sheath was removed.  The lead was then passed across the tricuspid valve and positioned in the apical location.  Adequate pacing and sensing functions were established.  Suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue.  With the remaining wire, a 7-French side-arm sheath was advanced over the wire into the axillary vein.  The wire and dilating sheaths were removed.  An active pacing lead was then advanced down into the right atrium.  The peel-away sheath was removed.  Preformed J stylet was then advanced into the lead.  The lead was positioned in the appendage location.  Lead body was then turned, and the active fix screw was fixed to the tissue.  Adequate pacing and sensing function were established.  Suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue.  The pocket was then washed with antibiotic-impregnated saline.  Pulse generator was obtained and connected securely to the leads.  The leads were then carefully wrapped behind the pulse generator, and the entire system was placed in the pocket.  The pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using a running mattress stitch.  Sponge and needle counts were correct at the end of the procedure.  No acute complications were noted.,DEVICE DATA,1.  Pulse generator, manufacturer Boston Scientific, model # 12345, serial #1234.,2.  Right atrial lead, manufacturer Guidant, model #12345, serial #1234.,3.  Right ventricular lead, manufacturer Guidant, model #12345, serial #1234.,MEASURED INTRAOPERATIVE DATA,1.  Right atrial lead impedance 534 ohms.  P waves measured at 1.2 millivolts.  Pacing threshold 1.0 volt at 0.5 milliseconds.,2.  Right ventricular lead impedance 900 ohms.  R-waves measured 6.0 millivolts.  Pacing threshold 1.0 volt at 0.5 milliseconds.,DEVICE SETTINGS: , DDD 60 to 130.,CONCLUSIONS,1.  Successful implantation of a dual-chamber pacemaker with adequate pacing and sensing function.,2.  No acute complications.,PLAN,1.  The patient will be taken back to her room for continued observation.  She can be dismissed in 24 hours provided no acute complications at the discretion of the primary service.,2.  Chest x-ray to rule out pneumothorax and verified lead position.,3.  Completion of the course of antibiotics.,4.  Home dismissal instructions provided in written format.,5.  Device interrogation in the morning.,6.  Wound check in 7 to 10 days.,7.  Enrollment in device clinic.",
 Single chamber pacemaker implantation.  Successful single-chamber pacemaker implantation with left subclavian approach and venogram to assess the subclavian access site and the right atrial or right ventricle with asystole that resolved spontaneously during the procedure., Surgery, Pacemaker (Single Chamber) ,"SINGLE CHAMBER PACEMAKER IMPLANTATION,PREOPERATIVE DIAGNOSIS: , Mobitz type II block with AV dissociation and syncope.,POSTOPERATIVE DIAGNOSIS: , Mobitz type II block, status post single chamber pacemaker implantation, Boston Scientific Altrua 60, serial number 123456.,PROCEDURES:,1.  Left subclavian access under fluoroscopic guidance.,2.  Left subclavian venogram under fluoroscopic evaluation.,3.  Insertion of ventricular lead through left subclavian approach and ventricular lead is Boston Scientific Dextrose model 12345, serial number 123456.,4.  Insertion of single-chamber pacemaker implantation, Altrua, serial number 123456.,5.  Closure of the pocket after formation of pocket for pacemaker.,PROCEDURE IN DETAIL:  ,The procedure was explained to the patient with risks and benefits.  The patient agreed and signed the consent form.  The patient was brought to the cath lab, draped and prepped in the usual sterile fashion, received 1.5 mg of versed and 25 mg of Benadryl for conscious sedation.,Access to the right subclavian was successful after the second attempt.  The first attempt accessed the left subclavian artery.  The needle was removed and manual compression applied for five minutes followed by re-accessing the subclavian vein successfully.  The J-wire was introduced into the left subclavian vein.,The anterior wall chest was anesthetized with lidocaine 2%, 2-inch incision using a #10 blade was used.,The pocket was formed using blunt dissection as he was using the Bovie cautery for hemostasis.  The patient went asystole during the procedure.  The transcutaneous pacer was used.  The patient was oxygenating well.  The patient had several compression applied by the nurse.  However, her own rhythm resolved spontaneously and the percutaneous pacer was kept on standby.,After that, the J-wire was tunneled into the pocket and then used to put the #7-French sheath into the left subclavian vein.  The lead from the Boston Scientific Dextrose model 12345, serial number 12345 was inserted through the left subclavian to the right atrium; however, it was difficult to really enter the right ventricle; and while the lead was in place, the side port of the sheath was used to inject 15 mL of contrast to assess the subclavian and the right atrium.  The findings were showing different anatomy, may be consistent with persistent left superior vena cava, and the angle to the right ventricle was different.  At that point, the lead stylet was reshaped and was able to cross the tricuspid valve in a position consistent with the mid septal place.,At that point, the lead was actively fixated.  The stylet was removed.  The R-wave measured at 40 millivolts.  The impedance was 580 and the threshold was 1.3 volt.  The numbers were accepted and because of the patient's fragility and the different anatomy noticed in the right atrium, concern about putting a second lead with re-access of the subclavian was high.  I decided to proceed with a single-chamber pacemaker as a backup system.,After that, the lead sleeve was used to actively fixate the lead in the anterior chest with two Ethibond sutures in the usual fashion.,The lead was attached to the pacemaker in the header.  The pacemaker was single-chamber pacemaker Altura 60, serial number 123456.  After that, the pacemaker was put in the pocket.  Pocket was irrigated with normal saline and was closed into two layers, deep interrupted #3-0 Vicryl and surface as continuous #4-0 Vicryl continuous.,The pacemaker was programmed as VVI 60, and with history is 10 to 50 beats per minute.  The lead position will be evaluated with chest x-ray.,No significant bleeding noticed.,CONCLUSION:  ,Successful single-chamber pacemaker implantation with left subclavian approach and venogram to assess the subclavian access site and the right atrial or right ventricle with asystole that resolved spontaneously during the procedure.  No significant bleed.","surgery, mobitz, av dissociation, syncope, mobitz type ii block, boston scientific altrua, subclavian, venogram, ventricular, single chamber pacemaker implantation, single chamber pacemaker, pacemaker implantation, pacemaker, vein, chest, atrium, ventricle, atrial, implantation, chamber, "
 Implantation of a dual chamber permanent pacemaker, Surgery, Pacemaker (Dual Chamber) ,"CLINICAL HISTORY: ,This 78-year-old black woman has a history of hypertension, but no other cardiac problems. She noted complaints of fatigue, lightheadedness, and severe dyspnea on exertion. She was evaluated by her PCP on January 31st and her ECG showed sinus bradycardia with a rate of 37 beats per minute. She has had intermittent severe sinus bradycardia alternating with a normal sinus rhythm, consistent with sinoatrial exit block, and she is on no medications known to cause bradycardia. An echocardiogram showed an ejection fraction of 70% without significant valvular heart disease.,PROCEDURE:, Implantation of a dual chamber permanent pacemaker.,APPROACH:, Left cephalic vein.,LEADS IMPLANTED: ,Medtronic model 12345 in the right atrium, serial number 12345. Medtronic 12345 in the right ventricle, serial number 12345.,DEVICE IMPLANTED: ,Medtronic EnRhythm model 12345, serial number 12345.,LEAD PERFORMANCE: ,Atrial threshold less than 1.3 volts at 0.5 milliseconds. P wave 3.3 millivolts. Impedance 572 ohms. Right ventricle threshold 0.9 volts at 0.5 milliseconds. R wave 10.3. Impedance 855.,ESTIMATED BLOOD LOSS:, 20 mL.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the electrophysiology laboratory in a fasting state and intravenous sedation was provided as needed with Versed and fentanyl. The left neck and chest were prepped and draped in the usual manner and the skin and subcutaneous tissues below the left clavicle were infiltrated with 1% lidocaine for local anesthesia. A 2-1/2-inch incision was made below the left clavicle and electrocautery was used for hemostasis. Dissection was carried out to the level of the pectoralis fascia and extended caudally to create a pocket for the pulse generator. The deltopectoral groove was explored and a medium-sized cephalic vein was identified. The distal end of the vein was ligated and a venotomy was performed. Two guide wires were advanced to the superior vena cava and peel-away introducer sheaths were used to insert the two pacing leads. The venous pressures were elevated and there was a fair amount of back-bleeding from the vein, so a 3-0 Monocryl figure-of-eight stitch was placed around the tissue surrounding the vein for hemostasis. The right ventricular lead was placed in the high RV septum and the right atrial lead was placed in the right atrial appendage. The leads were tested with a pacing systems analyzer and the results are noted above. The leads were then anchored in place with #0-silk around their suture sleeve and connected to the pulse generator. The pacemaker was noted to function appropriately. The pocket was then irrigated with antibiotic solution and the pacemaker system was placed in the pocket. The incision was closed with two layers of 3-0 Monocryl and a subcuticular closure of 4-0 Monocryl. The incision was dressed with Steri-Strips and a sterile bandage and the patient was returned to her room in good condition.,IMPRESSION: ,Successful implantation of a dual chamber permanent pacemaker via the left cephalic vein. The patient will be observed overnight and will go home in the morning.","surgery, medtronic enrhythm, cephalic vein, dual chamber, dual chamber permanent pacemaker, dyspnea on exertion, echocardiogram, fatigue, hypertension, lightheadedness, normal sinus rhythm, pacemaker, permanent pacemaker, sinoatrial exit block, sinus bradycardia, valvular heart disease, bradycardia, medtronic, atrial,"
  Implantation of a single-chamber pacemaker.  Fluoroscopic guidance for implantation of single-chamber pacemaker., Surgery, Pacemaker (Single Chamber) - 1 ,"REFERRAL INDICATION,1.  Tachybrady syndrome.,2.  Chronic atrial fibrillation.,PROCEDURES PLANNED AND PERFORMED,1.  Implantation of a single-chamber pacemaker.,2.  Fluoroscopic guidance for implantation of single-chamber pacemaker.,FLUOROSCOPY TIME:  ,1.2 minutes.,MEDICATIONS AT THE TIME OF STUDY,1.  Ancef 1 g.,2.  Benadryl 50 mg.,3.  Versed 3 mg.,4.  Fentanyl 150 mcg.,CLINICAL HISTORY: , The patient is a pleasant 73-year-old female with chronic atrial fibrillation.  She has been found to have tachybrady syndrome, has been referred for pacemaker implantation.,RISKS AND BENEFITS: , Risks, benefits, and alternatives of implantation of a single-chamber pacemaker were discussed with the patient.  The patient agreed both verbally and via written consent.  Risks that were discussed included but were not limited to bleeding, infection, vascular injury, cardiac perforation, stroke, myocardial infarction, need for urgent cardiovascular surgery, and death were discussed with the patient.  The patient agreed both verbally and via written consent.,DESCRIPTION OF PROCEDURE: , The patient was transported to the cardiac catheterization laboratory in a fasting state.  The region of the left deltopectoral groove was prepped and draped in the usual sterile manner.  Lidocaine 1% (20 mL) was administered to the area.  Percutaneous access of the left axillary vein was then performed.  A wire was then advanced in the left axillary vein using fluoroscopy.  Following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath.  Lidocaine 1% (10 mL) was then administered to the medial aspect of the incision and a pocket was fashioned in the medial direction.  Using the previously placed guidewire, a 7-French sidearm sheath was advanced over the wire into the vein.  The dilator and wire were removed.  An active pacing lead was then advanced down in the right atrium.  The peel-away sheath was removed.  Lead was passed across the tricuspid valve and positioned in an apical septal location.  This was an active fixed lead and the screw was deployed.  Adequate pacing and sensing function were established.  The suture sleeve was then advanced to the entry point of the tissue and connected securely to the tissue.  The pocket was washed with antibiotic-impregnated saline.  A pulse generator was obtained and connected securely to the lead.  The lead was then carefully wrapped behind the pulse generator, and the entire system was placed in the pocket.  Pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using a running mattress stitch.  No acute complications were noted.,DEVICE DATA,1.  Pulse generator, manufacturer St. Jude model 12345, serial #123456.,2.  Right ventricular lead, manufacturer St. Jude model 12345, serial #ABCD123456.,MEASURED INTRAOPERATIVE DATA:,  Right ventricular lead impedance 630 ohms.  R wave measures 17.5 mV.  Pacing threshold of 0.8 V at 0.5 msec.,DEVICE SETTINGS: , VVI 70 to 120.,CONCLUSIONS,1.  Successful implantation of the single-chamber pacemaker with adequate pacing and sensing function.,2.  No acute complications.,PLAN,1.  The patient will be admitted for overnight observation and dismissed at the discretion of primary service.,2.  Chest x-ray to rule out pneumothorax and verify lead position.,3.  Completion of course of antibiotics.,4.  Device interrogation in the morning.,5.  Home dismissal instructions provided in a written format.,6.  Wound check in 7 to 10 days.,7.  Enrollment in Device Clinic.",
" Plantar flex third metatarsal and talus bunion, right foot.  Third metatarsal osteotomy, talus bunionectomy, and application of short-leg cast, right foot.  Patient has tried conservative methods such as wide shoes and serial debridement and accommodative padding, all of which provided inadequate relief.  At this time she desires to attempt a surgical correction. ", Surgery, Osteotomy & Bunionectomy - 1 ,"PREOPERATIVE DIAGNOSES:,1.  Plantar flex third metatarsal, right foot.,2.  Talus bunion, right foot.,POSTOPERATIVE DIAGNOSES:,1.  Plantar flex third metatarsal, right foot.,2.  Talus bunion, right foot.,PROCEDURE PERFORMED:,1.  Third metatarsal osteotomy, right foot.,2.  Talus bunionectomy, right foot.,3.  Application of short-leg cast, right foot.,ANESTHESIA: , TIVA/local.,HISTORY:  ,This 31-year-old female presents to ABCD Preoperative Holding Area after keeping herself n.p.o., since mid night for surgery on her painful right third plantar flex metatarsal.  In addition, she complains of a painful right talus bunion to the right foot.  She has tried conservative methods such as wide shoes and serial debridement and accommodative padding, all of which provided inadequate relief.  At this time she desires to attempt a surgical correction.  The risks versus benefits of the procedure have been explained to the patient by Dr. X and the consent is available on the chart for review.,PROCEDURE IN DETAIL:  ,After IV was established by the Department Of Anesthesia, the patient was taken to the operating room via cart.  She was placed on the operating table in supine position and a safety strap was placed across her waist for retraction.  Next, copious amounts of Webril were applied around the right ankle and a pneumatic ankle tourniquet was applied.,Next, after adequate IV sedation was administered by the Department Of Anesthesia, a total of 10 cc mixture of 4.5 cc of 1% lidocaine/4.5 cc of 0.5% Marcaine/1 cc of Kenalog was injected into the right foot in an infiltrative type block.  Next, the foot was prepped and draped in the usual aseptic fashion.  An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg.  Next, the foot was lowered in the operative field and attention was directed to the dorsal third metatarsal area.  There was a plantar hyperkeratotic lesion and a plantar flex palpable third metatarsal head.  A previous cicatrix was noted with slight hypertrophic scarring.  Using a #10 blade, a lazy S-type incision was created over the dorsal aspect of the third metatarsal, approximately 3.5 cm in length.  Two semi-elliptical converging incisions were made over the hypertrophic scar and it was removed and passed off as a specimen.  Next, the #15 blade was used to deepen the incision down to the subcutaneous tissue.  Any small traversing veins were ligated with electrocautery.  Next, a combination of blunt and sharp dissection were used to undermine the long extensor tendon, which was tacked down with a moderate amount of fibrosis and fibrotic scar tissue.  Next, the extensor tendon was retracted laterally and the deep fascia over the metatarsals was identified.  A linear incision down to bone was made with a #15 blade to the capsuloperiosteal tissues.  Next, the capsuloperiosteal tissues were elevated using a sharp dissection with a #15 blade, off of the third metatarsal.  McGlamry elevator was carefully inserted around the head of the metatarsal and freed and all the plantar adhesions were freed.  A moderate amount of plantar adhesions were encountered.  The third toe was plantar flex and the third metatarsal was delivered into the wound.  Next, a V-shaped osteotomy with an apex distally was created using a sagittal saw.  The metatarsal head was allowed to float.  The wound was flushed with copious amounts of sterile saline.  #3-0 Vicryl was used to close the capsuloperiosteal tissues, which kept the metatarsal head contained.  Next, #4-0 Vicryl was used to close the subcutaneous layer in a simple interrupted suture technique.  Next, #4-0 nylon was used to close the skin in a simple interrupted technique.,Attention was directed to the right fifth metatarsal.  There was a large palpable hypertrophic prominence, which is the area of maximal pain, which the patient complained of preoperatively.  A #10 blade was used to make a 3 cm incision through the skin.  Next, a #15 blade was used to deepen the incision through the subcutaneous tissue.  Next, the medial and lateral aspects were undermined.  The abductor tendon was identified and retracted.  A capsuloperiosteal incision was made with a #15 blade in a linear fashion down to the bone.  The capsuloperiosteal tissues were elevated off the bone with a Freer elevator and a #15 blade.,Next, the sagittal saw was used to resect the large hypertrophic dorsal exostosis.  A reciprocating rasp was used to smooth all bony prominences.  The wound was flushed with copious amount of sterile saline.  #3-0 Vicryl was used to close the capsuloperiosteal tissues.  #4-0 Vicryl was used to close subcutaneous layer with a simple interrupted suture.  Next, #4-0 nylon was used to close the skin in a simple interrupted technique.  Next, attention was directed to the plantar aspect of the third metatarsal where a bursal sac was felt to be palpated under the plantar flex third metatarsal head.  A #15 blade was used to make a small linear incision under the third metatarsal head.  The incision was deepened through the dermal layer and curved hemostats and Metzenbaum scissors were used to undermine the skin from the underlying bursa.  The wound was flushed and two simple interrupted sutures with #4-0 nylon were applied.,Standard postoperative dressing was applied consisting of Xeroform, 4x4s, Kerlix, Kling, and Coban.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to the digits.,A sterile stockinet was placed on the toes just below the knee.  Copious amounts of Webril were placed on all bony prominences.  3 inch and 4 inch fiberglass cast tape was used to create a below the knee well-padded, well-moulded cast.  One was able to insert two fingers to the distal and proximal aspects of the _cast.  The capillary refill time to the digits was less than three seconds after cast application.  The patient tolerated the above anesthesia and procedures without complications.  She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot.  She was given standard postoperative instructions to rest, ice and elevate her right foot.  She was counseled on smoking cessation.  She was given Vicoprofen #30 1 p.o. q.4-6h p.r.n., pain.  She was given Keflex #30 1 p.o. t.i.d.  She is to follow up with Dr. X on Monday.  She is to be full weightbearing with a cast boot.  She was given emergency contact numbers to call us if problem arises.","surgery, plantar flex, talus bunion, talus bunionectomy, metatarsal osteotomy, osteotomy, short-leg cast, hypertrophic scarring, subcutaneous tissue, sharp dissection, linear incision, foot talus, pneumatic ankle, capsuloperiosteal tissues, plantar, foot, metatarsal, capsuloperiosteal, bunionectomy"
 Open reduction and internal fixation of left distal radius., Surgery, ORIF of Left Distal Radius ,"PREOPERATIVE DIAGNOSIS: , Left distal radius fracture, metaphyseal extraarticular.,POSTOPERATIVE DIAGNOSIS: , Left distal radius fracture, metaphyseal extraarticular.,PROCEDURE: , Open reduction and internal fixation of left distal radius.,IMPLANTS:  ,Wright Medical Micronail size 2.,ANESTHESIA: , LMA.,TOURNIQUET TIME: , 49 minutes.,BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,PATHOLOGY: , None.,TIME OUT: , Time out was performed before the procedure started.,INDICATIONS:,  The patient was a 42-year-old female who fell and sustained a displaced left metaphyseal distal radius fracture indicated for osteosynthesis.  The patient was in early stage of gestation.  Benefits and risks including radiation exposure were discussed with the patient and consulted her primary care doctor.,DESCRIPTION OF PROCEDURE: , Supine position, LMA anesthesia, well-padded arm, tourniquet, Hibiclens, alcohol prep, and sterile drape.,Exsanguination achieved, tourniquet inflated to 250 mmHg.  First, under fluoroscopy the fracture was reduced.  A 0.045 K-wire was inserted from dorsal ulnar corner of the distal radius and crossing fracture line to maintain the reduction.  A 2-cm radial incision, superficial radial nerve was exposed and protected.  Dissecting between the first and second dorsal extensor retinaculum, the second dorsal extensor compartment was elevated off from the distal radius.  The guidewire was inserted under fluoroscopy.  A cannulated drill was used to drill antral hole.  Antral awl was inserted.  Then we reamed the canal to size 2.  Size 2 Micronail was inserted to the medullary canal.  Using distal locking guide, three locking screws were inserted distally.  The second dorsal incision was made.  The deep radial dorsal surface was exposed.  Using locking guide, two proximal shaft screws were inserted and locked the nail to the radius.  Fluoroscopic imaging was taken and showing restoration of the height, tilt, and inclination of the radius.  At this point, tourniquet was deflated, hemostasis achieved, wounds irrigated and closed in layers.  Sterile dressing applied.  The patient then was extubated and transferred to the recovery room under stable condition.,Postoperatively, the patient will see a therapist within five days.  We will immobilize wrist for two weeks and then starting flexion-extension and prosupination exercises.","surgery, distal radius fracture, dorsal extensor, locking guide, radius fracture, extraarticular, metaphyseal, guidewire, fracture, dorsal, distal, "
 OssaTron extracorporeal shockwave therapy to right lateral epicondyle.  Right lateral epicondylitis., Surgery, OssaTron Extracorporeal Shockwave Therapy ,"PREOPERATIVE DIAGNOSIS:,  Right lateral epicondylitis.,POSTOPERATIVE DIAGNOSIS:,  Right lateral epicondylitis.,OPERATION PERFORMED:,  OssaTron extracorporeal shockwave therapy to right lateral epicondyle.,ANESTHESIA:,  Bier block.,DESCRIPTION OF PROCEDURE: , With the patient under adequate Bier block anesthesia, the patient was positioned for extracorporeal shockwave therapy.  The OssaTron equipment was brought into the field and the nose piece for treatment was placed against the lateral epicondyle targeting the area previously determined with the patient's input of maximum pain.  Then using standard extracorporeal shockwave protocol, the OssaTron treatment was applied to the lateral epicondyle of the elbow.  After completion of the treatment, the tourniquet was deflated, and the patient was returned to the holding area in satisfactory condition having tolerated the procedure well.","surgery, epicondylitis, ossatron extracorporeal shockwave therapy, bier block, epicondyle, ossatron, extracorporeal, shockwave, "
 Open reduction and internal fixation (ORIF) of the right wrist using an Acumed locking plate.  Closed displaced angulated fracture of the right distal radius., Surgery, ORIF Wrist - Acumed Locking Plate ,"PREOPERATIVE DIAGNOSIS:  ,Closed displaced angulated fracture of the right distal radius.,POSTOPERATIVE DIAGNOSIS: , Closed displaced angulated fracture of the right distal radius.,PROCEDURE: , Open reduction and internal fixation (ORIF) of the right wrist using an Acumed locking plate.,ANESTHESIA: , General laryngeal mask airway.,ESTIMATED BLOOD LOSS: , Minimal.,TOURNIQUET TIME: , 40 minutes.,COMPLICATIONS: , None.,The patient was taken to the postanesthesia care unit in stable condition.  The patient tolerated the procedure well.,INDICATIONS:  ,The patient is a 23-year-old gentleman who was involved in a crush injury to his right wrist.  He was placed into a well-molded splint after reduction was performed in the emergency department.  Further x-rays showed further distal fragment dorsal angulation that progressively worsened and it was felt that surgical intervention was warranted.  All risks, benefits, expectations, and complications of the surgery were explained to the patient in detail, and he signed the informed consent for ORIF of the right wrist.,PROCEDURE: , The patient was taken to the operating suite, placed in supine position on the operative table.  The Department of anesthesia administered a general endotracheal anesthetic, which the patient tolerated well.  The right upper extremity had a well-padded tourniquet placed on the right arm, which was insufflated and maintained for 40 minutes at 250 mmHg pressure.  The right upper extremity was prepped and draped in a sterile fashion.  A 5-cm incision was made over the flexor carpi radialis of the right wrist.  The skin was incised down to the subcutaneous tissue, the deep tissue was retracted, blunt dissection was performed down to the pronator quadratus.  Sharp dissection was performed through the pronator quadratus after which a tissue elevator was used to elevate this tissue.  Next, a reduction was performed placing the distal fragment into appropriate alignment.  This was checked under fluoroscopy, and was noted to be adequately reduced and in appropriate position.  An Acumed Accu-lock plate was placed along the volar aspect of the distal radius.  This was checked under AP and lateral views with C-arm, noted to be in appropriate alignment.  A 3.5-mm cortical screw was placed through the proximal aspect of the plate, positioned it into position.  Two distal locking screws were placed along the plate itself.  The screws were checked under AP and lateral views noting the fracture fragment was well aligned and appropriately reduced with the 2 screws being placed into appropriate position with the appropriate length as well as not being intraarticular.  Four more screws were placed along the distal aspect of the plate and 2 more proximal along the plate.  All locking screws placed into position and had excellent purchase into the bone or had excellent fixation into the plate and maintained the alignment of the fracture.  AP and lateral views were taken of these screw placements again.  None of these screws were into the joint and all had appropriate length into the dorsal cortex.  Two more 3.5 fully threaded cortical screws were placed along the proximal aspect of the plate and had excellent bicortical purchase.  AP and lateral views were taken of the wrist once again showing that this was appropriate reduction of the fracture as well as appropriate placement of the screws.  Bicortical purchase was appreciated and no screws were placed into the joint.  The wound itself was copiously irrigated with saline and Kantrex after which the subcutaneous tissue was approximated with 2-0 Vicryl, and the skin was closed with running 4-0 nylon stitch; 10 mL of 0.5% Marcaine plain was injected into the wound site after which sterile dressing was placed as well as the volar splint.  The patient was awakened from general anesthetic, transferred to the hospital gurney and taken to the postanesthesia care unit in stable condition.  The patient tolerated the procedure well.","surgery, open reduction, angulated fracture, distal radius, acumed locking plate, internal fixation, tourniquet, acumed, orif, reduction, fracture, wrist"
" Acetabular fracture on the left posterior column/transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip.  Osteosynthesis of acetabular fracture on the left, complex variety and total hip replacement.", Surgery, Osteosynthesis ,"PREOPERATIVE DIAGNOSIS:,  Acetabular fracture on the left posterior column/transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip.,POSTOPERATIVE DIAGNOSIS:,  Acetabular fracture on the left posterior column/transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip.,PROCEDURES:,1.  Osteosynthesis of acetabular fracture on the left, complex variety.,2.  Total hip replacement.,ANESTHESIA: , General.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE: , The patient in the left side up lateral position under adequate general endotracheal anesthesia, the patient's left lower extremity and buttock area were prepped with iodine and alcohol in the usual fashion, draped with sterile towels and drapes so as to create a sterile field.  Kocher Langenbeck variety incision was utilized and carried down through the fascia lata with the split fibers of the gluteus maximus in line.  The femoral insertion of gluteus maximus was tenotomized close to its femoral insertion.  The piriformis and obturator internus tendons and adjacent gemelli were tenotomized close to their femoral insertion, tagged, and retractor was placed in the lesser notch as well as a malleable retractor in the greater notch enabling the exposure of the posterior column.  The major transverse fracture was freed of infolded soft tissue, clotted blood, and lavaged copiously with sterile saline solution and then reduced anatomically with the aid of bone hook in the notch and provisionally stabilized utilizing a tenaculum clamp and definitively stabilized utilizing a 7-hole 3.5 mm reconstruction plate with the montage including two interfragmentary screws.  It should be mentioned that prior to reduction and stabilization of the acetabular fracture its femoral head component was removed from the joint enabling direct visualization of the articular surface.  Once a stable fixation of the reduced fracture of the acetabulum was accomplished, it should be mentioned that in the process of doing this, the posterior wall fragment was hinged on its soft tissue attachments and a capsulotomy was made in the capsule in line with the rent at the level of the posterior wall.  Once this was accomplished, the procedure was turned over to Dr. X and his team, who proceeded with placement of cup and femoral components as well and cup was preceded by placement of a trabecular metal tray for the cup with screw fixation of same.  This will be dictated in separate note.  The patient tolerated the procedure well.  The sciatic nerve was well protected and directly visualized to the level of the notch.","surgery, hip replacement, osteosynthesis, intertrochanteric variety, femoral insertion, acetabular fracture, fracture, acetabular, intertrochanteric, femoral "
 Open reduction and internal fixation of the left medial epicondyle fracture with placement in a long-arm posterior well-molded splint and closed reduction casting of the right forearm., Surgery, ORIF & Closed Reduction ,"PREOPERATIVE DIAGNOSES: , Left elbow fracture dislocation with incarceration of the medial epicondyle with ulnar nerve paresthesias status post closed reduction, attempts 2, right radial shaft fracture with volar apex angulation.,POSTOPERATIVE DIAGNOSES:,  Left elbow fracture dislocation with incarceration of the medial epicondyle with ulnar nerve paresthesias status post closed reduction, attempts 2, right radial shaft fracture with volar apex angulation.,PROCEDURES:  ,1.  Open reduction internal fixation of the left medial epicondyle fracture with placement in a long-arm posterior well-molded splint.,2.  Closed reduction casting of the right forearm.,ANESTHESIA: , Surgery performed under general anesthesia.  Local anesthetic was 10 mL of 0.5% Marcaine.,TOURNIQUET TIME: , On the left was 29 minutes.,COMPLICATIONS:  ,There were no intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,HISTORY AND PHYSICAL:  ,The patient is a 13-year-old right-hand dominant girl, who fell off a swing at school around 1:30 today.  The patient was initially seen at an outside facility and brought here by her father, given findings on x-ray, a closed reduction was attempted on the left elbow.  After the attempted reduction, the patient was noted to have an incarcerated medial epicondyle fracture as well as increasing ulnar paresthesias that were not present prior to the procedure.  Given this finding, the patient needed urgent open reduction and internal fixation to relieve the pressure on the ulnar nerve.  At that same time, the patient's mildly angulated radial shaft fracture will be reduced.  This was explained to the father.  The risks of surgery included the risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, need for later hardware removal, and possible continuous nerve symptoms.  All questions were answered.  The father agreed to the above plan.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating room table.  General anesthesia was then administered.  The patient received Ancef preoperatively.  The left upper extremity was then prepped and draped in the standard surgical fashion.  Attempts to remove the incarcerated medial epicondyle with supination, valgus stress, and with extension were unsuccessful.  It was decided at this time that she would need open reduction.  The arm was wrapped in Esmarch prior to inflation of the tourniquet to 250 mmHg.  The Esmarch was then removed.  An incision was then made.  Care was taken to avoid any injury to the ulnar nerve.  The medial epicondyle fracture was found incarcerated into the anterior aspect of the joint.  This was easily removed.  The ulnar nerve was also identified, and appeared to be intact.  The medial epicondyle was then transfixed using a guidewire into its anatomic position with the outer cortex over drilled with a 3.2 drill bit, and subsequently a 44-mm 4.5 partially threaded cannulated screw was then placed with a washer to hold the medial epicondyle in place.  After fixation of the fragment, the ulnar nerve was visualized as it traveled around the medial epicondyle fracture with no signs of impingement.  The wound was then irrigated with normal saline and closed using 2-0 Vicryl and 4-0 Monocryl.  The wound was clean and dry, dressed with Steri-Strips and Xeroform.  The area was infiltrated with 0.5% Marcaine.  The patient was then placed in a long-arm posterior well-molded splint with 90 degrees of flexion and neutral rotation.  The tourniquet was released at 30 minutes prior to placement of the dressing, showed no significant bleeding.  Attention was then turned to right side, the arm was then manipulated and a well-molded long-arm cast placed.  The final position in the cast revealed a very small residual volar apex angulation, which is quite acceptable in this age.  The patient tolerated the procedure well, was subsequently extubated and taken to recovery in a stable condition.,POSTOPERATIVE PLAN: , The patient will be hospitalized for pain control and neurovascular testing for the next 1 to 2 days.  The father was made aware of the intraoperative findings.  All questions answered.","surgery, orif, elbow fracture, dislocation, open reduction internal fixation, closed reduction, left medial epicondyle fracture, long-arm posterior well-molded splint, splint, radial shaft fracture, volar apex angulation, medial epicondyle fracture, medial epicondyle, internal fixation, epicondyle fracture, ulnar nerve, epicondyle, fracture, reduction, tourniquet, ulnar, nerve, "
" Distal metaphyseal osteotomy and bunionectomy with internal screw fixation, right foot.  Reposition osteotomy with internal screw fixation to correct angulation deformity of proximal phalanx, right foot.", Surgery, Osteotomy & Bunionectomy ,"PREOPERATIVE DIAGNOSES:,1.  Metatarsus primus varus with bunion deformity, right foot.,2.  Hallux abductovalgus with angulation deformity, right foot.,POSTOPERATIVE DIAGNOSES:,1.  Metatarsus primus varus with bunion deformity, right foot.,2.  Hallux abductovalgus with angulation deformity, right foot.,PROCEDURES:,1.  Distal metaphyseal osteotomy and bunionectomy with internal screw fixation, right foot.,2.  Reposition osteotomy with internal screw fixation to correct angulation deformity of proximal phalanx, right foot.,ANESTHESIA:,Local infiltrate with IV sedation.,INDICATION FOR SURGERY: , The patient has had a longstanding history of foot problems.  The foot problem has been progressive in nature and has not been responsive to conservative treatment.  The preoperative discussion with the patient included the alternative treatment options.,The procedure was explained in detail and risk factors such as infection, swelling, scarred tissue; numbness, continued pain, recurrence, and postoperative management were explained in detail.  The patient has been advised, although no guaranty for success could be given, most patients have improved function and less pain.  All questions were thoroughly answered.  The patient requested surgical repair since the problem has reached a point that interferes with her normal daily activities.  The purpose of the surgery is to alleviate the pain and discomfort.,DETAILS OF PROCEDURE:  ,The patient was brought to the operating room and placed in a supine position.  No tourniquet was utilized.  IV sedation was administered and during that time local anesthetic consisting of approximately 10 mL total in a 1:1 mixture of 0.25% Marcaine and 1% lidocaine with epinephrine was locally infiltrated proximal to the operative site.  The lower extremity was prepped and draped in the usual sterile manner.  Balanced anesthesia was obtained.,PROCEDURE #1: , Distal metaphyseal osteotomy with internal screw fixation with bunionectomy, right foot.  A dorsal curvilinear incision medial to the extensor hallucis longus tendon was made, extending from the distal third of the shaft of the first metatarsal to a point midway on the shaft of the proximal phalanx.  Care was taken to identify and retract the vital structures and when necessary, vessels were ligated via electrocautery.  Sharp and blunt dissection was carried down through the subcutaneous tissue, superficial fascia, and then down to the capsular and periosteal layer, which was visualized.  A linear periosteal capsular incision was made in line with the skin incision.  The capsular tissue and periosteal layer were underscored, free from its underlying osseous attachments, and they refracted to expose the osseous surface.  Inspection revealed increased first intermetatarsal angle and hypertrophic changes to the first metatarsal head.  The head of the first metatarsal was dissected free from its attachment medially and dorsally, delivered dorsally and may be into the wound.,Inspection revealed the first metatarsophalangeal joint surface appeared to be in satisfactory condition.  The sesamoid was in satisfactory condition.  An oscillating saw was utilized to resect the hypertrophic portion of the first metatarsal head to remove the normal and functional configuration.  Care was taken to preserve the sagittal groove.  The rough edges were then smoothed with a rasp.,Attention was then focused on the medial mid portion of the first metatarsal head where a K-wire access guide was positioned to define the apex and direction of displacement for the capital fragment.  The access guide was noted to be in good position.  A horizontally placed, through-and-through osteotomy with the apex distal and the base proximal was completed.  The short plantar arm was from the access guide to proximal plantar and the long dorsal arm was from the access guide to proximal dorsal.  The capital fragment was distracted off the first metatarsal, moved laterally to decrease the intermetatarsal angle to create a more anatomical and functional position of the first metatarsal head.  The capital fragment was impacted upon the metatarsal.,Inspection revealed satisfactory reduction of the intermetatarsal angle and good alignment of the capital fragment.  It was then fixated with 1 screw.  A guide pin was directed from the dorsal aspect of the capital fragment to the plantar aspect of the shaft and first metatarsal in a distal dorsal to proximal plantar direction.  The length was measured, __________ mm cannulated cortical screw was placed over the guide pin and secured in position.  Compression and fixation were noted to be satisfactory.  Inspection revealed good fixation and alignment at the operative site.  Attention was then directed to the medial portion of the distal third of the shaft of the first metatarsal where an oscillating saw was used to resect the small portion of the bone that was created by shifting the capital fragment laterally.  All rough edges were rasped smooth.  Examination revealed there was still lateral deviation of the hallux.  A second procedure, the reposition osteotomy of the proximal phalanx with internal screw fixation to correct angulation deformity was indicated., ,PROCEDURE #2:,  Reposition osteotomy with internal screw fixation to correct angulation deformity, proximal phalanx, right hallux.  The original skin incision was extended from the point just distal to the interphalangeal joint.  All vital structures were identified and retracted.  Sharp and blunt dissection was carried down through the subcutaneous tissue, superficial fascia, and down to the periosteal layer, which was underscored, free from its underlying osseous attachments and reflected to expose the osseous surface.  The focus of the deformity was noted to be more distal on the hallux.  Utilizing an oscillating saw, a more distal, wedge-shaped transverse oblique osteotomy was made with the apex being proximal and lateral and the base medial distal was affected.  The proximal phalanx was then placed in appropriate alignment and stabilized with a guide pin, which was then measured, __________ 14 mm cannulated cortical screw was placed over the guide pin and secured into position.,Inspection revealed good fixation and alignment at the osteotomy site.  The alignment and contour of the first way was now satisfactorily improved.  The entire surgical wound was flushed with copious amounts of sterile normal saline irrigation.  The periosteal and capsular layer was closed with running sutures of #3-0 Vicryl.  The subcutaneous tissue was closed with #4-0 Vicryl and the skin edges coapted well with #4-0 nylon with running simples, reinforced with Steri-Strips.,Approximately 6 mL total in a 1:1 mixture of 0.25% Marcaine and 1% lidocaine plain was locally infiltrated proximal to the operative site for postoperative anesthesia.  A dressing consisting of Adaptic and 4 x 4 was applied to the wound making sure the hallux was carefully splinted, followed by confirming bandages and an ACE wrap to provide mild compression.  The patient tolerated the procedure and anesthesia well and left the operating room to recovery room in good postoperative condition with vital signs stable and arterial perfusion intact as evident by the normal capillary fill time.,A walker boot was dispensed and applied.  The patient should wear it when walking or standing., ,The next office visit will be in 4 days.  The patient was given prescriptions for Percocet 5 mg #40 one p.o. q.4-6h. p.r.n. pain, along with written and oral home instructions.  The patient was discharged home with vital signs stable in no acute distress.", 
" Open reduction and internal fixation of left atrophic mandibular fracture, removal of failed dental implant from the left mandible.  The patient fell following an episode of syncope and sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in fracture. ", Surgery, ORIF Mandibular Fracture & Dental Implant Removal ,"PREOPERATIVE DIAGNOSES: , Open, displaced, infected left atrophic mandibular fracture; failed dental implant.,POSTOPERATIVE DIAGNOSES: , Open, displaced, infected left atrophic mandibular fracture; failed dental implant.,PROCEDURE PERFORMED: , Open reduction and internal fixation (ORIF) of left atrophic mandibular fracture, removal of failed dental implant from the left mandible.,ANESTHESIA: , General nasotracheal.,ESTIMATED BLOOD LOSS: , 125 mL.,FLUIDS GIVEN: , 1 L of crystalloids.,SPECIMEN: , Soft tissue from the fracture site sent for histologic diagnosis.,CULTURES: , Also sent for Gram stain, aerobic and anaerobic, culture and sensitivity.,INDICATIONS FOR THE PROCEDURE: , The patient is a 79-year-old male, who fell in his hometown, following an episode of syncope.  He sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in the above-mentioned fracture.  He was admitted to hospital in Harleton, Texas, where his initial evaluation showed the rib fractures have also showed a nodule on his right upper lobe as well as a mediastinal mass.  His mandible fracture was not noted initially.  The patient also has a history of prostate cancer and a renal cell carcinoma.  The patient at that point underwent a bronchoscopy with a biopsy of the mediastinal mass and the results of that biopsy are still pending.  The patient later saw a local oral surgeon.  He diagnosed his mandible fracture and advised him to seek treatment in Houston.  He presented to my office for evaluation on January 18, 2010, and he was found to have an extremely atrophic mandible with a fracture in the left parasymphysis region involving a failed dental implant, which had been placed approximately 15 years ago.  The patient had significant discomfort and could eat foods and drink fluids with difficulty.  Due to the nature of his fracture and the complex medical history, he was sent to the hospital for admission and following cardiac clearance, he was scheduled for surgery today.,PROCEDURE IN DETAIL: , The patient was taken to the operating room, and placed in a supine position.  Following a nasal intubation and induction of general anesthesia, the surgeon then scrubbed, gowned, and gloved in the normal sterile fashion.  The patient was then prepped and draped in a manner consistent with sterile procedures.  A marking pen was first used to outline the incision in the submental region and it was extended from the left mandibular body to the right mandibular body region, approximately 1.5 cm medial to the inferior border of the mandible.  A 1 mL of lidocaine 1% with 1:100,000 epinephrine was then infiltrated along the incision and then a 15-blade was used to incise through the skin and subcutaneous tissue.  A combination of sharp and blunt dissection was then used to carry the dissection superiorly to the inferior border of the mandible.  Electrocautery as well as 4.0 silk ties were used for hemostasis.  A 15-blade was then used to incise the periosteum along the inferior border of the mandible and it was reflected exposing the mandible as well as the fracture site.  The fracture site was slightly distracted allowing access to the dental implant within the bone and it was easily removed from the wound.  Cultures of this site were also obtained and then the granulation tissue from the wound was also curetted free of the wound and sent for a histologic diagnosis.  Manipulation of the mandible was then used to achieve an anatomic reduction and then an 11-hole Synthes reconstruction plate was then used to stand on the fracture site.  Since there was an area of weakness in the right parasymphysis region, in the location of another dental implant, the bone plate was extended posterior to that site.  When the plate was adapted to the mandible, it was then secured to the bone with 9 screws, each being 2 mm in diameter and each screw was placed bicortically.  All the screws were also locking screws.  Following placement of the screws, there was felt to be excellent stability of the fracture, so the wound was irrigated with a copious amount of normal saline.  The incision was closed in multiple layers with 4.0 Vicryl in the muscular and subcutaneous layers and 5.0 nylon in the skin.  A sterile dressing was then placed over the incision.  The patient tolerated the procedure well and was taken to the recovery room with spontaneous respirations and stable vital signs.  Estimated blood loss is 125 mL.","surgery, atrophic mandibular fracture, dental implant, open reduction and internal fixation, orif, mandibular fracture, mandible, atrophic, mandibular, dental, implant,"
 Open reduction internal fixation (ORIF) with irrigation and debridement of open fracture.  Closed reduction and screw fixation of right femoral neck fracture.  Retrograde femoral nail using a striker T2 retrograde nail.  Irrigation and debridement of knee and elbow abrasions., Surgery," ORIF, Closed Reduction, Screw Fixation, Etc. ","TITLE OF OPERATION:,1.  Open reduction internal fixation (ORIF) with irrigation and debridement of open fracture including skin, muscle, and bone using a Synthes 3.5 mm locking plate on the lateral malleolus and two Synthes 4.5 mm cannulated screws medial malleolus.,2.  Closed reduction and screw fixation of right femoral neck fracture using one striker Asnis 8.0 mm cannulated screw and two 6.5 mm cannulated screws.,3.  Retrograde femoral nail using a striker T2 retrograde nail 10 x 340 with a 10 mm INCAP and two 5 mm distal locking screws and two 5 mm proximal locking screws.,4.  Irrigation and debridement of right knee.,5.  Irrigation and debridement of right elbow abrasions.,PREOP DIAGNOSIS:,1.  Right open ankle fracture.,2.  Right femoral shaft fracture.,3.  Right femoral neck fracture.,4.  Right open knee.,5.  Right elbow abrasions.,POSTOP DIAGNOSIS:,1.  Right open ankle fracture.,2.  Right femoral shaft fracture.,3.  Right femoral neck fracture.,4.  Right open knee.,5.  Right elbow abrasions.,INTRAVENOUS FLUIDS: , 650 packed red blood cells.,TOURNIQUET TIME: , 2 hours.,URINE OUTPUT:  ,1600 cubic centimeters.,ESTIMATED BLOOD LOSS: , 250 cubic centimeters.,COMPLICATIONS:,  None.,PLAN:,  non-weightbearing right lower extremity, clindamycin x 48 hours.,OPERATIVE NARRATIVE:,  The patient is a 53-year-old female who is a pedestrian struck, in a motor vehicle accident and sustained numerous injuries.  She sustained a right open ankle fracture, right femur fracture, right femoral neck fracture, right open knee, and right elbow abrasions.  Given the emergent nature of the right femoral neck fracture and her young age as well as the open fracture, it was decided to proceed with an urgent operative intervention.  The risks of surgery were discussed in detail and the consents were signed.  The operative site was marked.  The patient was taken to the operating room where she was given preoperative clindamycin.  The patient had then general anesthetic performed by anesthesia.,A well-padded side tourniquet was placed.  Attention was turned to the right ankle first.  The large medical laceration was extended and the tissues were debrided.  All dirty of the all injured bone, muscle, and tissues were debrided.  Wound was then copiously irrigated with 8 liters of normal saline.  At this point, the medial malleolus fracture was identified and was reduced.  This was then fixed in with two 4.5 mm cannulated Synthes screws.,Next, the attention was turned to lateral malleolus.  Incision was made over the distal fibula.  It was carried down sharply through the skin in the subcutaneous issues.  Care was taken to preserve the superficial peroneal nerve.  The fracture was identified, and there was noted to be very comminuted distal fibula fracture.  The fracture was reduced and confirmed with fluoroscopy.  A 7 hole Synthes 3.5 mm locking plate was placed.  This was placed in a bridging fashion with three screws above and three screws below the fracture.  Appropriate reduction was confirmed under fluoroscopy.  A cotton test was performed, and the ankle did not open up.  Therefore, it was decided not to proceed with syndesmotic screw.,Next, the patient was then placed in the fracture table and all extremities were well padded.  All prominences were padded.  The right leg was then prepped and draped in usual sterile fashion.  A 2-cm incision was made just distal to the greater trochanter.  This was carried down sharply through the skin to the fascia.  The femur was identified.  The guidewire for a striker Asnis 6.5 mm screw was placed in the appropriate position.  The triangle guide was then used to ensure appropriate triangular formation of the remainder of the screws.  A reduction of the fracture was performed prior to placing all the guide wires.  A single 8 mm Asnis screw was placed inferiorly followed by two 6.5 mm screws superiorly.,Next, the abrasions on the right elbow were copiously irrigated.  The necrotic and dead tissue was removed.  The abrasions did not appear to enter the joints.  They were wrapped with Xeroform 4 x 4 x 4 Kerlix and Ace wrap.,Next, the lacerations of the anterior knee were connected and were extended in the midline.  They were carried down sharply to the skin and the retinacular issues to the joint.  The intercondylar notch was identified.  A guide wire for the striker T2 retrograde nail was placed and localized with fluoroscopy.  The opening reamer was used following the bolted guide wire was then passed.  The femur was then sequentially reamed using the flexible reamers.  A T2 retrograde nail 10 x 340 was then passed.  Two 5 mm distal locking screws and two 5 mm proximal locking screws were then placed.,Prior to reaming and passing the retrograde nail, the knee was copiously irrigated with 8 liters of normal saline.  Any dead tissues in the knee were identified and were debrided using rongeurs and curettes.,The patient was placed in the AO splints for the right ankle.  The wounds were dressed with Xeroform 4 x 4 x 4s and IO band.  The care was then transferred for the patient to Halstead Service.,The plan will be non-weightbearing right lower extremity and antibiotics for 48 hours.,Dr. X was present and scrubbed for the entirety of the procedure.",
" Open reduction and internal fixation (ORIF) of comminuted C2 fracture.  Posterior spinal instrumentation C1-C3, using Synthes system.  Posterior cervical fusion C1-C3.  Insertion of morselized allograft at C1to C3.", Surgery, ORIF & Cervical Fusion ,"PREOPERATIVE DIAGNOSIS: , Fracture dislocation, C2.,POSTOPERATIVE DIAGNOSIS:  ,Fracture dislocation, C2.,OPERATION PERFORMED,1.  Open reduction and internal fixation (ORIF) of comminuted C2 fracture.,2.  Posterior spinal instrumentation C1-C3, using Synthes system.,3.  Posterior cervical fusion C1-C3.,4.  Insertion of morselized allograft at C1to C3.,ANESTHESIA:,  GETA.,ESTIMATED BLOOD LOSS:,  100 mL.,COMPLICATIONS: , None.,DRAINS: , Hemovac x1.,Spinal cord monitoring is stable throughout the entire case.,DISPOSITION:,  Vital signs are stable, extubated and taken back to the ICU in a satisfactory and stable condition.,INDICATIONS FOR OPERATION:,  The patient is a middle-aged female, who has had a significantly displaced C2 comminuted fracture.  This is secondary to a motor vehicle accident and it was translated appropriately 1 cm.  Risks and benefits have been conferred with the patient as well as the family, they wish to proceed.  The patient was taken to the operating room for a C1-C3 posterior cervical fusion, instrumentation, open reduction and internal fixation.,OPERATION IN DETAIL: , After appropriate consent was obtained from the patient, the patient was wheeled back to the operating theater room #5.  The patient was placed in the usual supine position and intubated and under general anesthesia without any difficulties.  Spinal cord monitoring was induced.  No changes were seen from the beginning to the end of the case.,Mayfield tongues were placed appropriately.  This was placed in line with the pinna of the ear as well as a cm above the tip of the earlobes.  The patient was subsequently rolled onto the fluoroscopic OSI table in the usual prone position with chest rolls.  The patient's Mayfield tongue was fixated in the usual standard fashion.  The patient was subsequently prepped and draped in the usual sterile fashion.  Midline incision was extended from the base of the skull down to the C4 spinous process.  Full thickness skin fascia developed.  The fascia was incised at midline and the posterior elements at C1, C2, C3, as well as the inferior aspect of the occiput was exposed.  Intraoperative x-ray confirmed the level to be C2.,Translaminar screws were placed at C2 bilaterally.  Trajectory was completed with a hand drill and sounded in all four quadrants to make sure there was no violation of pedicles and once this was done, two 3.5 mm translaminar screws were placed bilaterally at C2.  Good placement was seen both in the AP and lateral planes using fluoroscopy.  Facet screws were then placed at C3.  Using standard technique of Magerl, starting in the inferomedial quadrant 14 mm trajectories in the 25-degree caudad-cephalad direction as well as 25 degrees in the medial lateral direction was made.  This was subsequently sounded in all four quadrants to make sure that there is no elevation of the trajectory.  A 14 x 3.5 mm screws were then placed appropriately.  Lateral masteries at C1 endplate were placed appropriately.  The medial and lateral borders were demarcated with a Penfield.  The great occipital nerve was retracted out the way.  Starting point was made with a high-speed power bur and midline and lateral mass bilaterally.  Using a 20-degree caudad-cephalad trajectory as well as 10-degree lateral-to-medial direction, the trajectory was completed in 8 mm increments, this was subsequently sounded in all four quadrants to make sure that there was no violation of the pedicle wall of the trajectory.  Once this was done, 24 x 3.5 mm smooth Schanz screws were placed appropriately.  Precontoured titanium rods were then placed between the screws at the C1, C2, C3 and casts were placed appropriately.  Once this was done, all end caps were appropriately torqued.  This completed the open reduction and internal fixation of the C2 fracture, which showed perfect alignment.  It must be noted that the reduction was partially performed on the table using lateral fluoroscopy prior to the instrumentation, almost reducing the posterior vertebral margin of the odontoid fracture with the base of the C2 access.  Once the screws were torqued bilaterally, good alignment was seen both in the AP and lateral planes using fluoroscopy, this completed instrumentation as well as open reduction and internal fixation of C2.  The cervical fusion was completed by decorticating the posterior elements of C1, C2, and C3.  Once this was done, the morselized allograft 30 mL of cortical cancellous bone chips with 10 mL of demineralized bone matrix was placed over the decorticated elements.  The fascia was closed using interrupted #1 Vicryl suture figure-of-8.  Superficial drain was placed appropriately.  Good alignment of the instrumentation as well as of the fracture was seen both in the AP and lateral planes.  The subcutaneous tissues were closed using a #2-0 Vicryl suture.  The dermal edges were approximated using staples.  The wound was then dressed sterilely using Bacitracin ointment, Xeroform, 4x4s, and tape, and the drain was connected appropriately.  The patient was subsequently released with a Mayfield contraption and rolled on to the stretcher in the usual supine position.  Mayfield tongues were subsequently released.  No significant bleeding was appreciated.  The patient was subsequently extubated uneventfully and taken back to the recovery room in satisfactory and stable condition.  No complications arose.","surgery, fracture dislocation, spinal instrumentatio, comminuted, fracture, morselized, allograft, vicryl suture, mayfield tongues, cervical fusion, internal fixation, orif, cervical, fusion, fixation, spinal, reduction, instrumentation, "
 Fractured right fifth metatarsal.  Open reduction and internal screw fixation right fifth metatarsal.  Application of short leg splint., Surgery, ORIF - Fifth Metatarsal ,"PREOPERATIVE DIAGNOSIS: , Fractured right fifth metatarsal.,POSTOPERATIVE DIAGNOSIS: , Fractured right fifth metatarsal.,PROCEDURE PERFORMED:,1.  Open reduction and internal screw fixation right fifth metatarsal.,2.  Application of short leg splint.,ANESTHESIA:,  TIVA/local.,HISTORY: , This 32-year-old female presents to Preoperative Holding Area after keeping herself n.p.o., since mid night for open reduction and internal fixation of a fractured right fifth metatarsal.  The patient relates that approximately in mid-June that she was working as a machinist at Detroit Diesel and dropped a large set of tools on her right foot.  She continued to walk on the foot and found nothing was wrong despite the pain.  She was recently seen by Dr. X and was referred to Dr. Y for surgery.  The risks versus benefits of the procedure had been explained to the patient in detail by Dr. Y.  The consent is available on the chart for review.  The urine beta was taken in the preoperative area and was negative.,PROCEDURE IN DETAIL:  ,After IV was established by the Department of Anesthesia, the patient was taken to the operating room via cart and placed on the operating table in the supine position.  A safety strap was placed across her waist for her protection.  Copious amounts of Webril were applied about the right ankle and a pneumatic ankle tourniquet was applied.  After adequate IV sedation was administered by the Department of Anesthesia, a total of 10 cc of 0.5% Marcaine plain was used to perform an infiltrative type block to the right fifth metatarsal area of the right foot.  Next, the foot was prepped and draped in the usual aseptic fashion.  An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg.  The foot was lowered in the operative field and a sterile stocking was reflected.  Attention was directed to the right fifth metatarsal base.  The Xi-scan and fluoroscopic unit was used to visualize the fractured fifth metatarsal.  An avulsion fracture of the right fifth metatarsal base was visualized.  The fracture was linear in nature from distal lateral to proximal medial.  There appeared to be a pseudoarthrosis on the lateral view.  A skin scrub was used to carefully mark out all the landmarks including the peroneus longus and brevis tendons in the fifth metatarsal and the sural nerve.  A linear incision was created with a #10 blade.  A #15 blade was used to deepen the incision through the subcutaneous tissue.  All small veins traversing the subcutaneous tissue were ligated with electrocautery.  Next, using combination of sharp and blunt dissection, the deep fascia was reached.  Next a linear capsuloperiosteal incision was made down to the bone using a #15 blade.  Next, using a periosteal elevator and a #15 blade, the capsuloperiosteal tissues were stripped from the bone.  The fracture site was not clearly visualized due to bony callus.  A #25 gauge needle was introduced into the fracture site under fluoroscopy.  The fracture site was easily found.  An osteotome was used to separate the pseudoarthrosis.,A curette was used to remove the hypertrophic excessive pseudoarthrotic bone.  Next, a small ball burr was used to resect the remaining hypertrophic bone.  Next, a #1.0 drill bit was used to drill the subchondral bone on either side of the fracture site and a good healthy bleeding bone.  Next, a bone clamp was applied and the fracture was reduced.  Next, a threaded K-wire was thrown from the proximal base of the fifth metatarsal across the fracture site distally.  A #4-0 mm Synthes partially threaded, cannulated 50 mm screw was thrown using standard AO technique from the proximal fifth metatarsal base down the shaft and the fracture site was fixated rigidly.  All this was done under fluoroscopy.  Next, the wound was flushed with copious amounts of sterile saline.  The fracture site was found to have rigid compression.  The hypertrophic bone on the lateral aspect of the metatarsal was reduced with a ball burr and the wound was again flushed.  Next, the capsuloperiosteal tissues were closed with #3-0 Vicryl in a simple interrupted fashion.  A few fibers of the peroneus brevis tendon that were stripped from the base of the proximal phalanx were reattached carefully with Vicryl.  Next, the subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted suture technique.  Next, the skin was closed with #5-0 Prolene in a horizontal mattress technique.  A postoperative fluoroscopic x-ray was taken and the bony alignment was found to be intact and the screw placement had excellent appearance.  A dressing consisting of Owen silk, 4x4s, fluff, and Kerlix were applied.,A sterile stockinet was applied over the foot.  Next, copious amounts of Webril were applied to pad all bony prominences.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all digits.  Next, 4-inch, pre-moulded, well-padded posterior splint was applied.  The capillary refill time of the digits was less than three seconds.  The patient tolerated the above anesthesia and procedure without complications.  After anesthesia was reversed, she was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot.  She was given Vicodin 5/500 mg #30 1-2 p.o. q.4-6h. p.r.n., pain, Naprosyn 500 mg p.o. b.i.d. p.c., Keflex 500 mg #30 one p.o. t.i.d., till gone.  She was given standard postoperative instructions to be non-weightbearing and was dispensed with crutches.  She will rest, ice, and elevate her right leg.  She is to follow up in the clinic on 08/26/03 at 10:30 a.m..  She was given emergency contact numbers and will call or return if problems arise earlier.","surgery, metatarsal, internal screw fixation, leg splint, fractured right fifth metatarsal, pneumatic ankle tourniquet, ankle tourniquet, metatarsal base, fracture site, fractured, hypertrophic, bernstein, orif"
 Open reduction and internal fixation of left lateral malleolus.  Left lateral malleolus fracture., Surgery, ORIF - Malleolus ,"PREOPERATIVE DIAGNOSIS: , Left lateral malleolus fracture.,POSTOPERATIVE DIAGNOSIS:,  Left lateral malleolus fracture.,PROCEDURE PERFORMED: , Open reduction and internal fixation of left lateral malleolus.,ANESTHESIA:  ,General.,TOURNIQUET TIME: , 59 minutes.,COMPLICATIONS: , None.,BLOOD LOSS: , Negligible.,CLOSURE: , 2-0 Vicryl and staples.,INDICATIONS FOR SURGERY:,  This is a young gentleman with soccer injury to his left ankle and an x-ray showed displaced lateral malleolus fracture with widening of the mortise now for ORIF.  The risks and perceivable complications of the surgeries were discussed with the patient via a translator as well as nonsurgical treatment options and this was scheduled emergently.,OPERATIVE PROCEDURE: , The patient was taken to the operative room where general anesthesia was successfully introduced.  The right ankle was prepped and draped in standard fashion.  The tourniquet was applied about the right upper thigh.  An Esmarch tourniquet was used to exsanguinate the ankle.  The tourniquet was insufflated to a pressure 325 mm for approximately 59 minutes.  An approximately 6 inch longitudinal incision was made just over the lateral malleolus.  Care was taken to spare overlying nerves and vessels.  An elevator was used to expose the fracture.  The fracture was freed of old hematoma and reduced with a reducing clamp.  An interfragmentary cortical screw was placed of 28 mm with excellent purchase.  The intraoperative image showed excellent reduction.  A 5-hole semitubular plate was then contoured to the lateral malleolus and fixed with 3 cortical screws proximally and 2 cancellous screws distally.  Excellent stability of fracture was achieved.  Final fluoroscopy showed a reduction to be anatomic in 2 planes.  The wound was irrigated with copious amounts of normal saline.  Deep tissue was closed with 2-0 Vicryl.  The skin was approximated with 2-0 Vicryl and closed with staples.  Dry sterile dressing was applied.,The patient tolerated the procedure, was awakened and taken to the recovery room in stable condition.","surgery, open reduction and internal fixation, esmarch, internal fixation, malleolus fracture, lateral malleolus, tourniquet, orif, fixation, ankle, reduction, fracture, malleolus"
" Open left angle comminuted angle of mandible, 802.35, and open symphysis of mandible, 802.36.  Open reduction, internal fixation (ORIF) of bilateral mandible fractures with multiple approaches, CPT code 21470, and surgical extraction of teeth #17, CPT code 41899.", Surgery, ORIF - Mandible Fracture ,"PREOPERATIVE DIAGNOSIS:,  Open left angle comminuted angle of mandible, 802.35, and open symphysis of mandible, 802.36.,POSTOPERATIVE DIAGNOSIS:,  Open left angle comminuted angle of mandible, 802.35, and open symphysis of mandible, 802.36.,PROCEDURE:,  Open reduction, internal fixation (ORIF) of bilateral mandible fractures with multiple approaches, CPT code 21470, and surgical extraction of teeth #17, CPT code 41899.,ANESTHESIA: , General anesthesia via nasal endotracheal intubation.,FLUIDS: , 1800 mL of LR.,ESTIMATED BLOOD LOSS: , 150 mL.,HARDWARE:  ,A 2.3 titanium locking reconstruction plate from Leibinger on the symphysis and a 2.0 reconstruction plate on the left angle.,SPECIMEN: , None.,COMPLICATIONS: , None.,CONDITION: , The patient was extubated to the PACU, breathing spontaneously in excellent good condition.,INDICATIONS FOR THE PROCEDURE: , The patient is a 55-year-old male that he is 12 hour status post interpersonal violence in which he sustained bilateral mandible fractures and positive loss of consciousness.  He reported to the Hospital the day after his altercation complaining of mall occlusion and sore left shoulder.  He was worked up by the emergency department.  His head CT was cleared and his left shoulder was clear of any fractures or soft tissue damage.  Oral maxillary facial surgery was consulted to manage the mandible fracture.  After review of the CT and examination it was determined that the patient would benefit from open reduction, internal fixation of bilateral mandible fractures.  Risks, benefits, and alternative to treatment were thoroughly discussed with the patient and consent was obtained.,DESCRIPTION OF PROCEDURE:, The patient was brought to the operating room #2 at Hospital.  He was laid in supine position on the operating room table.  ASA monitors were attached and stated general anesthesia was induced with IV anesthetic and maintained with nasal endotracheal intubation and inflation anesthetics.,The patient was prepped and draped in the usual oral maxillofacial surgery fashion.  The surgeon approached the operating room table in a sterile fashion.  Approximately 10 mL of 1% lidocaine with 1:100,000 epinephrine was injected into oral vestibule in a nerve block fashion.  Erich arch bars were adapted to the maxilla and mandible, secured in the posterior teeth with 24-gauge surgical steel wire and 26-gauge surgical steel wire in the anterior.  This was done from second molar to second molar on both the maxilla and the mandible secondary to the patient missing multiple teeth.  The patient was manipulated up into maximum intercuspation.  He has a malocclusion with severe bruxism and so wear facets were lined up.  This was secured with 26-gauge surgical steel wire.  Attention was then directed to the symphysis extraorally.  Approximately 5 mL of 1% lidocaine with epinephrine was injected into the area of incision which paralleled the inferior border of the mandible 2 cm below the inferior border of the mandible.,After waiting appropriate time for local anesthesia using a 15 blade, a skin and platysma incision was made.  Then using a series of blunt and sharp dissections, the dissection was carried to the inferior border of the mandible.  The periosteum was incised and reflected with the periosteal elevator.  The fracture was noted and it was displaced.  Manipulation of the segments and checking with the occlusion intraorally, the fracture was aligned.  This was secured with 7-hole 2.3 titanium locking reconstruction plate with bicortical screws.  The wound was then packed with moist Ray-Tec and attention was directed intraorally to the left angle fracture.  Approximately 5 mL of 1% lidocaine with 1:100,000 epinephrine was injected into the left vestibule.  After waiting appropriate time for local anesthesia to take effect, using Bovie electrocautery, a sagittal split incision was made and the fracture was identified.  It was noted that the fracture went through tooth #17 and this needed to be extracted.  Taking a round bur, a buckle trough was made and the tooth was elevated and removed both distal and mesial roots.  The fracture was then reduced and lateral superior border plate 2-0 4 whole with monocortical screws was placed.  The fracture was noted to be well reduced.  The wound was then irrigated with copious amount of sterile water.  The patient was released for excellent intercuspation.  He was then manipulated up into the occlusion easily.  Wound was then closed with running 3-0 chromic gut suture.  Attention was then directed extraorally.  This was irrigated with copious amount of sterile water and closed in a layer fashion with 3-0 Vicryl, 4-0 Vicryl, and 5-0 Prolene on skin.  Attention was then again directed into the mouth.  The throat pack was removed and orogastric tube was placed and stomach content was evacuated.  The patient was then manipulated back up to maximum intercuspation and secured with interdental elastics and a pressure dressing was applied to the extraoral incisions.  At this point, the procedure was then determined to be over.,The patient was extubated and breathing spontaneously, transported to the PACU in excellent condition.","surgery, mandible, endotracheal, leibinger, pacu, oral maxillary facial surgery, maxillofacial, buckle, round bur, lidocaine with epinephrine, surgical steel wire, bilateral mandible fractures, mandible fracture, orif, symphysis, fracture, "
 Open reduction and internal fixation of left tibia., Surgery, ORIF - Left Tibia ,"PREOPERATIVE DIAGNOSIS: , Left tibial tubercle avulsion fracture.,POSTOPERATIVE DIAGNOSIS:,  Comminuted left tibial tubercle avulsion fracture with intraarticular extension.,PROCEDURE:,  Open reduction and internal fixation of left tibia.,ANESTHESIA: , General.  The patient received 10 ml of 0.5% Marcaine local anesthetic.,TOURNIQUET TIME: , 80 minutes.,ESTIMATED BLOOD LOSS:,  Minimal.,DRAINS: , One JP drain was placed.,COMPLICATIONS: , No intraoperative complications or specimens.  Hardware consisted of two 4-5 K-wires, One 6.5, 60 mm partially threaded cancellous screw and one 45, 60 mm partially threaded cortical screw and 2 washers.,HISTORY AND PHYSICAL:,  The patient is a 14-year-old male who reported having knee pain for 1 month.  Apparently while he was playing basketball on 12/22/2007 when he had gone up for a jump, he felt a pop in his knee.  The patient was seen at an outside facility where he was splinted and subsequently referred to Children's for definitive care.  Radiographs confirmed comminuted tibial tubercle avulsion fracture with patella alta.  Surgery is recommended to the grandmother and subsequently to the father by phone.  Surgery would consist of open reduction and internal fixation with subsequent need for later hardware removal.  Risks of surgery include the risks of  anesthesia, infection, bleeding, changes on sensation in most of the extremity, hardware failure, need for later hardware removal, failure to restore extensor mechanism tension, and need for postoperative rehab.  All questions were answered, and father and grandmother agreed to the above plan.,PROCEDURE: , The patient was taken to the operating and placed supine on the operating table.  General anesthesia was then administered.  The patient was given Ancef preoperatively.  A nonsterile tourniquet was placed on the upper aspect of the patient's left thigh.  The patient's extremity was then prepped and draped in the standard surgical fashion.  Midline incision was marked on the skin extending from the tibial tubercle proximally and extremities wrapped in Esmarch.  Finally, the patient had tourniquet that turned in 75 mmHg.  Esmarch was then removed.  The incision was then made.  The patient had significant  tearing of the posterior retinaculum medially with proximal migration of the tibial tubercle which was located in the joint there was a significant comminution and intraarticular involvement.  We were able to see the underside of the anterior horn of both medial and lateral meniscus.  The intraarticular cartilage was restored using two 45 K-wires.  Final position was checked via fluoroscopy and the corners were buried in the cartilage.  There was a large free floating metaphyseal piece that included parts of proximal tibial physis.  This was placed back in an anatomic location and fixed using a 45 cortical screw with a washer.  The avulsed fragment with the patellar tendon was then fixed distally to this area using a 6.5, 60 mm cancellous screw with a washer.  The cortical screw did not provide good compression and fixation at this distal fragment.  Retinaculum was repaired using 0 Vicryl suture as best as possible.  The hematoma was evacuated at the beginning of the case as well as the end.  The knee was copiously irrigated with normal saline.  The subcutaneous tissue was re-approximated using 2-0 Vicryl and the skin with 4-0 Monocryl.  The wound was cleaned, dried, and dressed with Steri-Strips, Xeroform, and 4 x4s.  Tourniquet was released at 80 minutes.  JP drain was placed on the medium gutter.  The extremity was then wrapped in Ace wrap from the proximal thigh down to the toes.  The patient was then placed in a knee mobilizer.  The patient tolerated the procedure well.  Subsequently extubated and taken to the recovery in stable condition.,POSTOP PLAN:  ,The patient hospitalized overnight to decrease swelling and as well as manage his pain.  He may weightbear as tolerated using knee mobilizer.  Postoperative findings relayed to the grandmother.  The patient will need subsequent hardware removal.  The patient also was given local anesthetic at the end of the case.","surgery, intraarticular extension, tibial tubercle avulsion fracture, tubercle avulsion fracture, jp drain, cortical screw, hardware removal, tibial tubercle, tourniquet, orif, tubercle, tibial,"
" Hawkins IV talus fracture.  Open reduction internal fixation of the talus, medial malleolus osteotomy, and repair of deltoid ligament.", Surgery, ORIF - Talus ,"PREOPERATIVE DIAGNOSIS:, Hawkins IV talus fracture.,POSTOPERATIVE DIAGNOSIS: , Hawkins IV talus fracture.,PROCEDURE PERFORMED:,1.  Open reduction internal fixation of the talus.,2.  Medial malleolus osteotomy.,3.  Repair of deltoid ligament.,ANESTHESIA: , Spinal.,TOURNIQUET TIME: , 90 min.,BLOOD LOSS:,  50 cc.,The patient is in the semilateral position on the beanbag.,INTRAOPERATIVE FINDINGS:,  A comminuted Hawkins IV talus fracture with an incomplete rupture of the deltoid ligament.  There was no evidence of osteochondral defects of the talar dome.,HISTORY:  ,This is a 50-year-old male who presented to ABCD General Hospital Emergency Department with complaints of left ankle pain and disfigurement.  There was no open injury.  The patient fell approximately 10 feet off his liner, landing on his left foot.  There was evidence of gross deformity of the ankle.  An x-ray was performed in the Emergency Room, which revealed a grade IV Hawkins classification talus fracture.  He was distal neurovascularly intact.  The patient denied any other complaints besides pain in the ankle.,It was for this reason, we elected to undergo the above-named procedure in order to reduce and restore the blood supply to the talus body.  Because of its tenuous blood supply, the patient is at risk for avascular necrosis.  The patient has agreed to undergo the above-named procedure and consent was obtained.  All risks as well as complications were discussed.,PROCEDURE: , The patient was brought back to operative room #4 of ABCD General Hospital on 08/20/03.  A spinal anesthetic was administered.  A nonsterile tourniquet was placed on the left upper thigh, but not inflated.  He was then positioned on the beanbag.  The extremity was then prepped and draped in the usual sterile fashion for this procedure.  An Esmarch was then used to exsanguinate the extremity and the tourniquet was then inflated to 325 mmHg.  At this time, an anteromedial incision was made in order to perform a medial malleolus osteotomy to best localize the fracture region in order to be able to bone graft the comminuted fracture site.  At this time, a #15 blade was used to make approximately 10 cm incision over the medial malleolus.  This was curved anteromedial along the root of the saphenous vein.  The saphenous vein was located.  Its tributaries going plantar were cauterized and the vein was retracted anterolaterally.  At this time, we identified the medial malleolus.  There was evidence of approximately 80% avulsion, rupture of the deltoid ligament off of the medial malleolus.  This was a major blood feeder to the medial malleolus and we were concerned, once we were going to do the osteotomy, that this would later create healing problem.  It is for this reason that the pedicle, which was attached to the medial malleolus, was left intact.  This pedicle was the anterior portion of the deltoid ligament.  At this time, a MicroChoice saw was then used to make a box osteotomy of the medial malleolus.  Once this was performed, the medial malleolus was retracted anterolaterally with its remaining pedicle intact for later blood supply.  This provided us with excellent exposure to the fracture site of the medial side.  At this time, any loose comminuted pieces were removed.  The dome of the talus was also checked and did not reveal any osteochondral defects.  There was some comminution on the dorsal aspect of the complete talus fracture and we were concerned that once we place the screw, this would tend to extend the fracture site.  It is for this reason, we did the medial malleolar osteotomy to prevent this from happening in order to best expose the fracture site.  At this time, a reduction was performed.  The #7-0 partially threaded cannulated screws were used in order to fix the fracture.  At this time, a 3.2 mm guidewire was placed going from posterolateral to anteromedial.,This was placed slightly lateral to the Achilles tendon, percutaneously inserted, and then drilled in the according fashion across the fracture site.  Once this was performed, a skin knife was then used to incise over the percutaneous insertion in order to accommodate the screw going in.  A depth gauze was then used to measure screw length.  A cannulated drill was then used to drill across the fracture site to allow the entrance of the screw.  A 55 mm partially threaded #7-0 cannulated screw was then placed with excellent compression at the fracture site.  Once this was obtained, we checked the reduction again using intraoperative Xi-Scan in the AP and lateral direction.  This projection gave us excellent view of our screw placement and excellent compression across the fracture site.  At this time, we bone grafted the area of comminution using 1 cc of DynaGraft with crushed cancellous allograft.  This was placed using a freer elevator into the fracture site where the comminution was.  At this time, we copiously irrigated the wound.  The osteotomy site was then repaired, first clamped using two large tenaculum reduction clamps.  Two partially threaded #4-0 cannulated screws were then used to fix the osteotomy site and anatomical reduction was performed with excellent compression across the osteotomy site with the two screws.  Next, a #1-0 Vicryl was then used to repair the deltoid ligament, which was ruptured via the injury.  A tight repair was performed of the deltoid ligament.  At this time, again copious irrigation was used to irrigate the wound.  A #2-0 Vicryl was then used to approximate the subcutaneous skin and staples for the skin incision.  At this time, the leg was cleansed, Adaptic, 4 x 4, and Kerlix roll were then applied.  The patient was then placed in a plaster splint for mobilization.  The tourniquet was then released.  The patient was then transferred off the operating table to recovery in stable condition.  The prognosis for this fracture is guarded.  There is a high rate of avascular necrosis of the talar body, approximately anywhere from 40-60% risk.  The patient is aware of this and he will be followed as an outpatient for this problem.","surgery, deltoid ligament, medial malleolus osteotomy, open reduction internal fixation of the talus, hawkins iv talus fracture, medial malleolus, fracture site, malleolus, talus, medial, fracture, tourniquet, ligament, osteotomy, "
 Orchiopexy & inguinal herniorrhaphy., Surgery, Orchiopexy & Herniorrhaphy ,"OPERATIVE NOTE:,  The patient was taken to the operating room and placed in the supine position on the operating room table.  The patient was prepped and draped in usual sterile fashion.  An incision was made in the groin crease overlying the internal ring.  This incision was about 1.5 cm in length.  The incision was carried down through the Scarpa's layer to the level of the external oblique.  This was opened along the direction of its fibers and carried down along the external spermatic fascia.  The cremasteric fascia was then incised and the internal spermatic fascia was grasped and pulled free.  A hernia sac was identified and the testicle was located.  Next the internal spermatic fascia was incised and the hernia sac was dissected free inside the internal ring.  This was performed by incising the transversalis fascia circumferentially.  The hernia sac was ligated with a 3-0 silk suture high and divided and was noted to retract into the abdominal cavity.  Care was taken not to injure the testicular vessels.  Next the abnormal attachments of the testicle were dissected free distally with care not to injure any long loop vas and these were divided beneath the testicle for a fair distance.  The lateral attachments tethering the cord vessels were freed from the sidewalls in the retroperitoneum high.  This gave excellent length and very adequate length to bring the testicle down into the anterior superior hemiscrotum.  The testicle was viable.  This was wrapped in a moist sponge.,Next a hemostat was passed down through the inguinal canal down into the scrotum.  A small 1 cm incision was made in the anterior superior scrotal wall.  Dissection was carried down through the dartos layer.  A subdartos pouch was formed with blunt dissection.  The hemostat was then pushed against the tissues and this tissue was divided.  The hemostat was then passed through the incision.  A Crile hemostat was passed back up into the inguinal canal.  The distal attachments of the sac were grasped and pulled down without twisting these structures through the incision.  The neck was then closed with a 4-0 Vicryl suture that was not too tight, but tight enough to prevent retraction of the testicle.  The testicle was then tucked down in its proper orientation into the subdartos pouch and the subcuticular tissue was closed with a running 4-0 chromic and the skin was closed with a running 6-0 subcuticular chromic suture.  Benzoin and a Steri-Strip were placed.  Next the transversus abdominis arch was reapproximated to the iliopubic tract over the top of the cord vessels to tighten up the ring slightly.  This was done with 2 to 3 interrupted 3-0 silk sutures.  The external oblique was then closed with interrupted 3-0 silk suture.  The Scarpa's layer was closed with a running 4-0 chromic and the skin was then closed with a running 4-0 Vicryl intracuticular stitch.  Benzoin and Steri-Strip were applied.  The testicle was in good position in the dependent portion of the hemiscrotum and the patient had a caudal block, was awakened, and was returned to the recovery room in stable condition.","surgery, orchiopexy, benzoin, crile hemostat, scarpa's layer, caudal block, cremasteric fascia, groin crease, hemiscrotum, iliopubic tract, inguinal canal, inguinal herniorrhaphy, intracuticular stitch, retroperitoneum, spermatic fascia, testicle, hernia sac, inguinal, incisionNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Open reduction and internal fixation of right distal radius fracture - intraarticular four piece fracture and right carpal tunnel release., Surgery, ORIF - 1 ,"PREOPERATIVE DIAGNOSES:,1.  Displaced intraarticular fracture, right distal radius.,2.  Right carpal tunnel syndrome.,PREOPERATIVE DIAGNOSES:,1.  Displaced intraarticular fracture, right distal radius.,2.  Right carpal tunnel syndrome.,OPERATIONS PERFORMED:,1.  Open reduction and internal fixation of right distal radius fracture - intraarticular four piece fracture.,2.  Right carpal tunnel release.,ANESTHESIA: , General.,CLINICAL SUMMARY: , The patient is a 37-year-old right-hand dominant Hispanic female who sustained a severe fracture to the right wrist approximately one week ago.  This was an intraarticular four-part fracture that was displaced dorsally.  In addition, the patient previously undergone a carpal tunnel release, but had symptoms of carpal tunnel preop.  She is admitted for reconstructive operation.  The symptoms of carpal tunnel were present preop and worsened after the injury.,OPERATION:,  The patient was brought from the ambulatory care unit and placed on the operating table in a supine position and administered general anesthetic by Anesthesia.  Once adequate anesthesia had been obtained, the right upper extremity was prepped and draped in the usual sterile manner.  Tourniquet was placed around the right upper extremity.  The upper extremity was then elevated and exsanguinated using an Esmarch dressing.  The tourniquet was elevated to 250 mmHg.  The entire operation was performed with 4.5 loop magnification.  At this time an approximately 8 cm longitudinal incision was then made overlying the right flexor carpi radialis tendon from the flexion crease to the wrist proximally.  This was carried down to the flexor carpi radialis, which was then retracted ulnarly.  The floor of the flexor carpi radialis was then incised exposing the flexor pronator muscles.  The flexor pollicis longus was retracted ulnarly and the pronator quadratus was longitudinally incised 1 cm from its origin.  It was then elevated off of the fracture site exposing the fracture site, which was dorsally displaced.  This was an intraarticular four-part fracture.  Under image control, the two volar pieces and dorsal pieces were then carefully manipulated and reduced.  Then, 2.06 two-inch K-wires were drilled radial into the volar ulnar fragment and then a second K-wire was then drilled from the dorsal radial to the dorsal ulnar piece.  A third K-wire was then drilled from the volar radial to the dorsal ulnar piece.  The fracture was then manipulated.  The fracture ends were copiously irrigated with normal saline and curetted and then the fracture was reduced in the usual fashion by recreating the defect and distracting it.  Further K-wires were then placed through the radial styloid into the proximal fragment.  A Hand Innovations DVR plate of regular size for the right wrist was then fashioned over and placed over the distal radius and secured with two K-wires.  At this time, the distal screws were then placed.  The distal screws were the small screws.  These were non-locking screws, all eight screws were placed.  They were placed in the usual fashion by drilling with a small drill bit removing the small introducers and then using its depth.  Again, these were 18-20 mm screws.  After placing three of the screws it was necessary to remove the K-wires.  There was excellent reduction of the fragments and the fracture; excellent reduction of the intraarticular component and the fracture.  After the distal screws were placed, the fracture was reduced and held in place with K-wires, which were replaced and the proximal screws were drilled with the drill guide and the larger drill bit.  The screws were then placed.  These were 12 mm screws.  They were placed 4 in number.  The K-wires were then removed.  Finally, a 3 cm intrathenar incision was made beginning 1 cm distal to the flexor crease of the wrist.  This was carried down to the transverse carpal ligament, which was divided throughout the length of the incision, upon entering the carpal canal, the median nerve was found to be adherent to the undersurface of the structure.  It was dissected free from the structure out to its trifurcation.  The motor branches seen entering the thenar fascia and obstructed.  The nerve was then retracted dorsally and the patient had a great deal of scar tissue in the area of the volar flexion crease to the wrist where she had a previous incision that extended from the volar flexion crease of the wrist overlying the palmaris longus proximally for 1 cm.  In this area, careful dissection was performed in order to move the nerve from the surrounding structures and the most proximal aspect of the transverse carpal ligament, the more proximally located volar carpal ligament was then divided 5 cm into the distal forearm on the ulnar side of the palmaris longus tendon.  Incisions were then copiously irrigated with normal saline.  Homeostasis was maintained with electrocautery.  The pronator quadratus was closed with 3-0 Vicryl and the above skin incisions were closed proximally with 4-0 nylon and palmar incision with 5-0 nylon in the horizontal mattress fashion.  A large bulky dressing was then applied with a volar short-arm splint maintaining the wrist in neutral position.  The tourniquet was let down.  The fingers were immediately pink.  The patient was awakened and taken to the recovery room in good condition.  There were no operative complications.  The patient tolerated the procedure well.","surgery, intraarticular fracture, esmarch, k-wires, open reduction and internal fixation, tourniquet, carpal tunnel release, carpal tunnel syndrome, flexor carpi radialis, flexor pronator muscles, intraarticular, right distal radius, transverse carpal ligament, volar flexion crease, pronator quadratus, flexor carpi, carpi radialis, flexion crease, carpal ligament, carpal tunnel, carpal, volar"
 Bilateral orchiopexy.  This 8-year-old boy has been found to have a left inguinally situated undescended testes.  Ultrasound showed metastasis to be high in the left inguinal canal.  The right testis is located in the right inguinal canal on ultrasound and apparently ultrasound could not be displaced into the right hemiscrotum., Surgery, Orchiopexy - Bilateral ,"PREOPERATIVE DIAGNOSIS:  ,Bilateral undescended testes.,POSTOPERATIVE DIAGNOSIS: , Bilateral undescended testes.,OPERATION PERFORMED: , Bilateral orchiopexy.,ANESTHESIA: , General.,HISTORY: , This 8-year-old boy has been found to have a left inguinally situated undescended testes.  Ultrasound showed metastasis to be high in the left inguinal canal.  The right testis is located in the right inguinal canal on ultrasound and apparently ultrasound could not be displaced into the right hemiscrotum.  Both testes appeared to be normal in size for the boy's age.,OPERATIVE FINDINGS: , As above, both testes appeared viable and normal in size, no masses.  There is a hernia on the left side.  The spermatic cord was quite short on the left and required Prentiss Maneuver to achieve adequate length for scrotal placement.,OPERATIVE PROCEDURE: , The boy was taken to the operating room, where he was placed on the operating table.  General anesthesia was administered by Dr. X, after which the boy's lower abdomen and genitalia were prepared with Betadine and draped aseptically.  A 0.25% Marcaine was infiltrated subcutaneously in the skin crease in the left groin in the area of the intended incision.  An inguinal incision was then made through this area, carried through the subcutaneous tissues to the anterior fascia.  External ring was exposed with dissection as well.  The fascia was opened in direction of its fibers exposing the testes, which lay high in the canal.  The testes were freed with dissection by removing cremasteric and spermatic fascia.  The hernia sac was separated from the cord, twisted and suture ligated at the internal ring.  Lateral investing bands of the spermatic cords were divided high into the inguinal internal ring.  However, this would only allow placement of the testes in the upper scrotum with some tension.,Therefore, the left inguinal canal was incised and the inferior epigastric artery and vein were ligated with #4-0 Vicryl and divided.  This maneuver allowed for placement of the testes in the upper scrotum without tension.,A sub dartos pouch was created by separating the abdominal fascia from the scrotal skin after making an incision in the left hemiscrotum in the direction of the vessel.  The testes were then brought into the pouch and anchored with interrupted #4-0 Vicryl sutures.  The skin was approximated with interrupted #5-0 chromic catgut sutures.  Inspection of the spermatic cord in the inguinal area revealed no twisting and the testicular cover was good.  Internal oblique muscle was approximated to the shelving edge and Poupart ligament with interrupted #4-0 Vicryl over the spermatic cord and the external oblique fascia was closed with running #4-0 Vicryl suture.  Additional 7 mL of Marcaine was infiltrated subfascially and the skin was closed with running #5-0 subcuticular after placing several #4-0 Vicryl approximating sutures in the subcutaneous tissues.,Attention was then turned to the opposite side, where an orchiopexy was performed in a similar fashion.  However, on this side, there was no inguinal hernia.  The testes were located in a superficial pouch of the inguinal canal and there was adequate length on the spermatic cord, so that the Prentiss maneuver was not required on this side.  The sub dartos pouch was created in a similar fashion and the wounds were closed similarly as well.,The inguinal and scrotal incisions were cleansed after completion of the procedure.  Steri-Strips and Tegaderm were applied to the inguinal incisions and collodion to the scrotal incision.  The child was then awakened and transported to post-anesthetic recovery area apparently in satisfactory condition.  Instrument and sponge counts were correct.  There were no apparent complications.  Estimated blood loss was less than 20 to 30 mL.","surgery, bilateral orchiopexy, bilateral undescended testes, prentiss maneuver, subcutaneous tissues, internal ring, dartos pouch, scrotal incisions, undescended testes, spermatic cord, inguinal canal, testes, inguinally, orchiopexy, undescended, cord, vicryl, ultrasound, spermatic, canal,"
" Open reduction and internal fixation, high grade Frykman VIII distal radius fracture.", Surgery, ORIF - 2 ,"PREOPERATIVE DIAGNOSIS: , Severely comminuted fracture of the distal radius, left.,POSTOPERATIVE DIAGNOSIS: , Severely comminuted fracture of the distal radius, left.,OPERATIVE PROCEDURE:  ,Open reduction and internal fixation, high grade Frykman VIII distal radius fracture.,ANESTHESIA: , General endotracheal.,PREOPERATIVE INDICATIONS: , This is a 52-year-old patient of mine who I have repaired both shoulder rotator cuffs, the most recent one in the calendar year 2007.  While he was climbing a ladder recently in the immediate postop stage, he fell suffering the aforementioned heavily comminuted Frykman fracture.  This fracture had a fragment that extended in the distal radial ulnar joint, a die-punch fragment in the center of the radius.  The ulnar styloid and the radial styloid were off and there were severe dorsal comminutions.  He presented to my office the morning of April 3, 2007, having had a left reduction done elsewhere a day ago.  The reduction, although adequate, had allowed for the fragments to settle and I discussed with him the severity of the injury on a scale of 1-8, this was essentially an 8.  The best results have been either with external fixation or internal fixation, most recently volar plating of a locking variety has been popular, and I felt that this would be appropriate in his case.,Risks and benefits otherwise described were bleeding, infection, need to do operative revise or removal of hardware.  He is taking a job out of state in the next couple of months.  Hence I felt that even with close followup, this is a particularly difficult fracture as far as the morbidity of the injury proceeds.,OPERATIVE NOTE: , After adequate general endotracheal anesthesia was obtained, one gram of Ancef was given intravenously.  The left upper extremity was prepped and draped in supine position with the left hand in the arm table, magnification was used throughout.  The time out procedure was done to the satisfaction of all present that this was indeed the appropriate extremity on the appropriate patient.  A small C-arm was brought in to help guide the incision which was a volar curvilinear incision that included as part of this due to the fracture blisters eminent compartment syndrome and numbness in fingers.  A carpal tunnel release was done with the transverse carpal ligament being protected with a Freer elevator.  The usual amount of dissection of the pronator quadratus was necessary to view the distal radial fragment.  The pronator quadratus actually grasped several of the fragments itself which had to be dissected free from them, specifically the distal radial ulnar joint and die-punch fragment.  At this point, a locking Synthes distal radius plate from the modular handset was selected that had five articular screws as well as five locking shaft screws.  The ulnar styloid was not affixed in any portion of this repair.  The plate was viewed under the image intensification device, i.e., x-ray and the screws were placed in this order.  The most proximal shaft screw was placed to allow the remainder of the plate to form a buttress to then rearrange the fragments around the locking screws and a locking plate having been selected from the volar approach, a locking 12-mm screw through 16-mm screws were placed in the following order.  Most proximal on the radial shaft of the plate, then the radial styloid, i.e., the most distal and lateral screw, the next most proximal shaft screw followed by the distal radial ulnar joint screw.  Three screws were locking across the die-punch fragment.  The remaining two screws were placed into the radial shaft.  All of these were locking screws of 2 mm in diameter and as the construct was created, the relative motion of the intra-articular fragment in dorsal comminution all diminished greatly, although the exposure as well as the amount of reduction force used was substantial.  The tourniquet time was 1.5 hours.  At this point, the tourniquet was let down.  The entire construct was irrigated with copious amounts of bacitracin and normal saline.  Closure was affected with 0 Vicryl underneath the skin surface followed by 3-0 Prolene in interrupted sutures in the volar wound.  Several image intensification x-rays were taken at the conclusion of the case to check screw length.  Screw lengths were changed out during the case as needed based on the x-ray findings.  The wound was injected with Marcaine, lidocaine, Depo-Medrol, and Kantrex.  A very heavily padded fluffy cotton Jones-type dressing was applied with a volar splint.  Estimated blood loss was 10 mL.  There were no specimens.  Tourniquet time was 1.5 hours.","surgery, distal radius, c-arm, depo-medrol, frykman, jones-type dressing, kantrex, marcaine, open reduction and internal fixation, die-punch, intra-articular, lidocaine, pronator quadratus, radial styloid, ulnar styloid, distal radial ulnar joint, radial ulnar joint, distal, screws, orif, fracture, radial "
" Open reduction internal fixation of the left supracondylar, intercondylar distal femur fracture.", Surgery, ORIF - 3 ,"PREOPERATIVE DIAGNOSIS (ES):, Left supracondylar, intercondylar distal femur fracture.,POSTOPERATIVE DIAGNOSIS (ES):, Left supracondylar, intercondylar distal femur fracture.,PROCEDURE:, Open reduction internal fixation of the left supracondylar, intercondylar distal femur fracture (27513).,OPERATIVE FINDINGS:, He had intercondylar split, and then he had a medial Hoffa fracture. He also had some comminution of the medial femoral condyle which prohibited an anatomic key between the two segments of the medial condyle.,IMPLANTS:, We used 2.4 and 3.5 cortical screws, as well as a LISS Synthes femoral locking plate.,COMPLICATIONS:, None.,IV FLUIDS:, 2000,ANESTHESIA:, General endotracheal.,ESTIMATED BLOOD LOSS:, 40 mL,URINE OUTPUT:, 650,HISTORY: ,This 45-year-old male had a ground-level fall, sustaining this injury. He was admitted for definitive operative fixation. Risks and benefits were discussed, he agreed to go ahead with the procedure.,DESCRIPTION OF THE OPERATION:, The patient was identified in preop holding, then taken to the operating room. Once adequate anesthesia was obtained, his left lower extremity was prepped and draped in a routine sterile fashion. He was given antibiotics. He placed a traction pin through his proximal tibia, and pulled weight off the end of the bed. I made a midline approach and then did the lateral parapatellar arthrotomy. We excised some of the fat pad to give us better visibility into the notch. We excised a good bit of his synovium and synovial pouch. At this time we were able to identify the fracture fragments. Again, there was an intercondylar split and then two free pieces of the medial condyle. The femur fracture was very distal through the metaphysis. At this time we thoroughly cleaned out all the clot between all the fracture fragments and cleaned the cortical margins.,Next we began the reduction. There was no reduction key between the two segments of the Hoffa fracture. Therefore, we reduced the anterior portion of the medial condyle to the lateral condyle, held it with point-of-reduction clamp and K-wires, and then secured it with 2.4 mini fragment lag screws. Next, with this medial anterior piece in place, we had some contour over the notch with which we were able to reduce the posterior medial Hoffa fragment. This gave us a nice notch contour. Again, there was some comminution laterally so that the fracture between the Hoffa segments did not have a perfect key. Once we had it reduced, based on the notch reduction, we then held it with K-wires. We secured it with two 3.5 cortical screws from the lateral condyle into this posterior segment. We then secured it with 2.4 cortical screws from the anterior medial to the posterior medial segment just subchondral. Then, finally, we secured it with a 3.5 cortical screw from the anterior medial to the posterior medial piece. All screws ran between and out of the notch.,With the condyle now well reduced, we reduced it to the metaphysis. We slid a 13-hole LISS plate submuscularly. We checked on AP and lateral views that showed we had good reduction of the fracture and appropriate plate placement. We placed the tip threaded guidewire through the A-hole of the plate jig and got it parallel to the joint. We then clamped the plate down to the bone. Proximally, we made a stab incision for the trocar at the 13-hole position, placed our tip threaded guidewire in the lateral aspect of the femur, checked it on lateral view, and had it in good position.,With the jig in appropriate position and clamped, we then proceeded to fill the distal locking screws to get purchase into the condyles. We then placed multiple unicortical locking screws in the shaft and metaphyseal segment. Our most proximal screw was proximal to the tip of the prosthesis.,At this time we took the jig off and put the final screw into the A-hole of the plate. We then took final C-arm views which showed we had a good reduction on AP and lateral views, the plate was in good position, we had full range of motion of the knee, and good reduction clinically and radiographically. We then pulse lavaged the knee with 3 liters of fluid. We closed the quad tendon and lateral retinaculum with interrupted 0 Vicryl over a Hemovac drain. Subdermal tissue was closed with 2-0 Vicryl, skin with staples. Sterile dressing and a hinged knee brace were applied. The patient was awakened from anesthesia and taken to Recovery in stable condition.,PLAN:,1. Nonweightbearing for 3 months.,2. CPM for 0 to 90 degrees as tolerated.",
 Right orchiopexy and right inguinal hernia repair., Surgery, Orchiopexy & Hernia Repair - 1 ,"PREOPERATIVE DIAGNOSIS: , Right undescended testis (ectopic position).,POSTOPERATIVE DIAGNOSES:,  Right undescended testis (ectopic position), right inguinal hernia.,PROCEDURES: , Right orchiopexy and right inguinal hernia repair.,ANESTHESIA:,  General inhalational anesthetic with caudal block.,FLUIDS RECEIVED:  ,100 mL of crystalloids.,ESTIMATED BLOOD LOSS: , Less than 5 mL.,SPECIMENS:,  No tissues sent to pathology.,TUBES AND DRAINS: , No tubes or drains were used.,INDICATIONS FOR OPERATION:  ,The patient is an almost 4-year-old boy with an undescended testis on the right; plan is for repair.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operating room; surgical consent, operative site, and patient identification were verified.  Once he was anesthetized, a caudal block was placed.  He was then placed in the supine position and sterilely prepped and draped.  Since the testis was in the ectopic position, we did an upper curvilinear scrotal incision with a 15-blade knife and further extended it with electrocautery.  Electrocautery was also used for hemostasis.  A subdartos pouch was then created with a curved tenotomy scissors.  The tunica vaginalis was grasped with a curved mosquito clamp and then dissected from its gubernacular attachments.  As we were dissecting it, we then found the testis itself into the sac, and we opened the sac, and it was found to be slightly atrophic about 12 mm in length and had a type III epididymal attachment, not being attached to the top.  We then dissected the hernia sac off of the testis __________ some traction using the straight Joseph scissors and straight and curved mosquito clamps.  Once this was dissected off, we then twisted it upon itself, and then dissected it down towards the external ring, but on traction.  We then twisted it upon itself, suture ligated it with 3-0 Vicryl and released it, allowing it to spring back into the canal.  Once this was done, we then had adequate length of the testis into the scrotal sac.  Using a curved mosquito clamp, we grasped the base of the scrotum internally, and using the subcutaneous tissue, we tacked it to the base of the testis using a 4-0 chromic suture.  The testis was then placed into the scrotum in the proper orientation.  The upper aspect of the pouch was closed with a pursestring suture of 4-0 chromic.  The scrotal skin and dartos were then closed with subcutaneous closure of 4-0 chromic, and Dermabond tissue adhesive was used on the incision.  IV Toradol was given.  Both testes were well descended in the scrotum at the end of the procedure.","surgery, ectopic position, inguinal hernia, inguinal hernia repair, hernia sac, tunica vaginalis, gubernacular attachments, testis ectopic position, curved mosquito clamp, caudal block, hernia repair, undescended testis, orchiopexy, dissected, hernia, inguinal, testis,"
" Left inguinal hernia repair, left orchiopexy with 0.25% Marcaine, ilioinguinal nerve block and wound block at 0.5% Marcaine plain.", Surgery, Orchiopexy & Hernia Repair ,"PREOPERATIVE DIAGNOSIS: , Left undescended testis.,POSTOPERATIVE DIAGNOSIS:,  Left undescended testis plus left inguinal hernia.,PROCEDURES:,  Left inguinal hernia repair, left orchiopexy with 0.25% Marcaine, ilioinguinal nerve block and wound block at 0.5% Marcaine plain.,ABNORMAL FINDINGS:,  A high left undescended testis with a type III epididymal attachment along with vas.,ESTIMATED BLOOD LOSS:,  Less than 5 mL.,FLUIDS RECEIVED:  ,1100 mL of crystalloid.,TUBES/DRAINS: , No tubes or drains were used.,COUNTS:,  Sponge and needle counts were correct x2.,SPECIMENS,:  No tissues sent to Pathology.,ANESTHESIA:,  General inhalational anesthetic.,INDICATIONS FOR OPERATION: , The patient is an 11-1/2-year-old boy with an undescended testis on the left.  The plan is for repair.,DESCRIPTION OF OPERATION:,  The patient was taken to the operating room, where surgical consent, operative site, and patient identification were verified.  Once he was anesthetized, he was then placed in a supine position, and sterilely prepped and draped.  A superior curvilinear scrotal incision was then made in the left hemiscrotum with a 15-blade knife and further extended with electrocautery into the subcutaneous tissue.  We then used the curved cryoclamp to dissect into the scrotal space and found the tunica vaginalis and dissected this up to the external ring.  We were able to dissect all the way up to the ring, but were unable to get the testis delivered.  We then made a left inguinal incision with a 15-blade knife, further extending with electrocautery through Scarpa fascia down to the external oblique fascia.  The testis again was not visualized in the external ring, so we brought the sac up from the scrotum into the inguinal incision and then incised the external oblique fascia with a 15-blade knife further extending with Metzenbaum scissors.  The testis itself was quite high up in the upper canal.  We then dissected the gubernacular structures off of the testis, and also, then opened the sac, and dissected the sac off and found that he had a communicating hernia hydrocele and dissected the sac off with curved and straight mosquitos and a straight Joseph scissors.  Once this was dissected off and up towards the internal ring, it was twisted upon itself and suture ligated with an 0 Vicryl suture.  We then dissected the lateral spermatic fascia, and then, using blunt dissection, dissected in the retroperitoneal space to get more cord length.  We also dissected the sac from the peritoneal reflection up into the abdomen once it had been tied off.  We then found that we had an adequate amount of cord length to get the testis in the mid-to-low scrotum.  The patient was found to have a type III epididymal attachment with a long looping vas, and we brought the testis into the scrotum in the proper orientation and tacked it to mid-to-low scrotum with a 4-0 chromic stay stitch.  The upper aspect of the subdartos pouch was closed with a 4-0 chromic pursestring suture.  The testis was then placed into the scrotum in the proper orientation.  We then placed the local anesthetic, and the ilioinguinal nerve block, and placed a small amount in both incisional areas as well.  We then closed the external oblique fascia with a running suture of 0-Vicryl ensuring that the ilioinguinal nerve and cord structures were not bottom closure.  The Scarpa fascia was closed with a 4-0 chromic suture, and the skin was closed with a 4-0 Rapide subcuticular closure.  Dermabond tissue adhesive was placed on the both incisions, and IV Toradol was given at the end of the procedure.  The patient tolerated the procedure well, was in a stable condition upon transfer to the recovery room.","surgery, inguinal hernia repair, ilioinguinal nerve block, external oblique fascia, hernia repair, epididymal attachment, external ring, inguinal incision, scarpa fascia, cord length, inguinal hernia, nerve block, ilioinguinal nerve, undescended testis, testis, inguinal, fascia, hernia, dissected, "
 Right undescended testicle.  Orchiopexy & Herniorrhaphy., Surgery, Orchiopexy & Herniorrhaphy - 1 ,"PREOPERATIVE DIAGNOSIS:,  Right undescended testicle.,POSTOPERATIVE DIAGNOSIS:,  Right undescended testicle.,OPERATIONS:,1.  Right orchiopexy.,2.  Right herniorrhaphy.,ANESTHESIA: , LMA.,ESTIMATED BLOOD LOSS: , Minimal.,SPECIMEN: , Sac.,BRIEF HISTORY: , This is a 10-year-old male who presented to us with his mom with consultation from Craig Connor at Cottonwood with right undescended testis.  The patient and mother had seen the testicle in the right hemiscrotum in the past, but the testicle seemed to be sliding.  The testis was identified right at the external inguinal ring.  The testis was unable to be brought down into the scrotal sac.  The patient could have had sliding testicle in the past and now the testis has become undescended as the child has grown.  Options such as watchful waiting and wait for puberty to stimulate the descent of the testicle, HCG stimulation, orchiopexy were discussed.  Risk of anesthesia, bleeding, infection, pain, hernia, etc. were discussed.  The patient and parents understood and wanted to proceed with right orchiopexy and herniorrhaphy.,PROCEDURE IN DETAIL: , The patient was brought to the OR, anesthesia was applied.  The patient was placed in supine position.  The patient was prepped and draped in the inguinal and scrotal area.  After the patient was prepped and draped, an inguinal incision was made on the right side about 1 cm away for the anterior superior iliac spine going towards the external ring over the inguinal canal.  The incision came through the subcutaneous tissue and external oblique fascia was identified.  The external oblique fascia was opened sharply and was taken all the way down towards the external ring.  The ilioinguinal nerve was identified right underneath the external oblique fascia, which was preserved and attention was drawn throughout the entire case to ensure that it was not under any tension or pinched or got hooked in the suture.  After dissecting proximally, the testis was identified in the distal end of the inguinal canal.  The testis was pulled up.  The cremasteric muscle was divided and dissection was carried all the way up to the internal inguinal ring.  There was very small hernia, which was removed and was tied at the base.  PDS suture was used to tie this hernia sac all the way up to the base.  There was a Y right at the vas and cord indicating there was enough length into the scrotal sac.  The testis was easily brought down into the scrotal sac.  One centimeter superior scrotal incision was made and a Dartos pouch was created.  The testicle was brought down into the pouch and was placed into the pouch.  Careful attention was done to ensure that there was no torsion of the cord.  The vas was medial all the way throughout and the cord was lateral all the way throughout.  The epididymis was in the posterolateral location.  The testicle was pexed using 4-0 Vicryl into the scrotal sac.  Skin was closed using 5-0 Monocryl.  The external oblique fascia was closed using 2-0 PDS.  Attention was drawn to re-create the external inguinal ring.  A small finger was easily placed in the external inguinal ring to ensure that there was no tightening of the cord.  Marcaine 0.25% was applied, about 15 mL worth of this was applied for local anesthesia.  After closing the external oblique fascia, the Scarpa was brought together using 4-0 Vicryl and the skin was closed using 5-0 Monocryl in subcuticular fashion.  Dermabond and Steri-Strips were applied.,The patient was brought to recovery room in stable condition at the end of the procedure.,Please note that the testicle was viable.  It was smaller than the other side, probably by 50%.  There were no palpable testicular masses.  Plan was for the patient to follow up with us in about 1 month.  The patient was told not to do any heavy lifting for at least 3 months, okay to shower in 48 hours.  No tub bath for 2 months.  The patient and family understood all the instructions.","surgery, undescended testicle, orchiopexy & herniorrhaphy, external oblique fascia, inguinal ring, scrotal sac, oblique fascia, testicle, herniorrhaphy, orchiopexy, inguinal"
 Left facial cellulitis and possible odontogenic abscess.  Attempted incision and drainage (I&D) of odontogenic abscess., Surgery, Odontogenic Abscess I&D ,"PREOPERATIVE DIAGNOSES:,1.  Left facial cellulitis.,2.  Possible odontogenic abscess of the #18, #19, and #20.,POSTOPERATIVE DIAGNOSES:,1.  Left facial cellulitis.,2.  Possible odontogenic abscess of the #18, #19, and #20.,PROCEDURE PERFORMED: , Attempted incision and drainage (I&D) of odontogenic abscess.,ANESTHESIA:  ,1% lidocaine plain approximately 5 cc total.,COMPLICATIONS: , The patient is very noncompliant with attempted procedure refusing further exam and treatment after localization and attempted FNA.  The attempted FNA was without any purulent aspirate although limited in the area of attempted examination.,INDICATIONS FOR THE PROCEDURE: , The patient is a 39-year-old Caucasian female who was admitted to ABCD General Hospital on 08/21/03 secondary to acute left facial cellulitis suspected to be secondary to odontogenic etiology.  The patient states that this was started approximately 24 hours ago.  The patient subsequently presented to ABCD General Hospital Emergency Room secondary to worsening of left face swelling and increasing in pain.  The patient admits to poor dental hygiene.  Denies any recent or dental abscesses in the past.  The patient is a substance abuser, does admit to smoking cocaine approximately three days ago.  The patient did have a CT scan of the face obtained with contrast demonstrated no signs of any acute abscess although a profuse amount of cellulitis was noted.  After risks, complications, consequences, and questions were discussed with the patient, a written consent was obtained for an I&D of a possible odontogenic abscess ________ on the CT scan.,PROCEDURE:  ,The patient was brought in upright and supine position.  Approximately 5 cc of 1% lidocaine without epinephrine was injected in the localized area along the buccogingival sulcus of the left side.  This was done at the base of #18, #19, and #20 teeth.  After this, the patient did have approximately 2 more mg of morphine given through the IV for pain control.  After this, the #18 gauge needle on a ________ syringe was then utilized to attempt a FNA at the base of #18 tooth and #19 with one stick placed.  There were no signs of any purulent drainage, although at this time the patient became very irate and noncompliant and refusing further examination.  The patient understood consequences of her actions.  Does state that she does not care at this time and just wants to be left alone.  At this time, the bed was actually placed back in its normal position and the patient will be continued on clindamycin 900 mg IV q.6h. along with pain control utilizing Toradol, morphine, and Vicodin.  The patient will also be started on Peridex oral rinse of 10 cc p.o. swish and spit t.i.d. and a K-pad to the left face.","surgery, odontogenic, facial cellulitis, incision and drainage, fna, buccogingival, odontogenic abscess, abscess, drainage, i&d, cellulitis,"
" Examination under anesthesia, diagnostic laparoscopy, right orchiectomy, and left testis fixation.", Surgery, Orchiectomy & Testis Fixation ,"PREOPERATIVE DIAGNOSIS:,  Nonpalpable right undescended testis.,POSTOPERATIVE DIAGNOSIS: , Nonpalpable right undescended testis with atrophic right testis.,PROCEDURES: , Examination under anesthesia, diagnostic laparoscopy, right orchiectomy, and left testis fixation.,ANESTHESIA:  ,General inhalation anesthetic with caudal block.,FLUID RECEIVED:  ,250 mL of crystalloids.,ESTIMATED BLOOD LOSS: , Less than 5 mL.,SPECIMEN:,  The tissue sent to Pathology was right testicular remnant.,ABNORMAL FINDINGS:,  Closed ring on right with atrophic vessels going into the ring and there was obstruction at the shoulder of the ring.  Left had open appearing ring but the scrotum was not filled and vas and vessels going into the ring.,INDICATIONS FOR OPERATION: , The patient is a 2-year-old boy with a right nonpalpable undescended testis.  The plan is for evaluation and repair.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operating room, where surgical consent, operative site, and patient identification were verified.  Once he was anesthetized, a caudal block was placed.  The patient was placed in supine position and examined.  The left testis well within scrotum.  The right was again not palpable despite the patient being asleep with multiple attempts to check.,The patient was then sterilely prepped and draped.  An 8-French feeding tube was then placed within his bladder through the urethra and attached to the drainage.  We then incised the infraumbilical area once he was sterilely prepped and draped, with 15 blade knife, then using Hasson technique with stay stitches in the anterior and posterior rectus fascia sheath of 3-0 Monocryl.  We entered the peritoneum with the 5-mm one-step system.  We then used the short 0-degree lens for laparoscopy.  We then insufflated with carbon dioxide insufflation to pressure of 12 mmHg.  There was no bleeding noted upon evaluation of the abdomen and again the findings were as mentioned with closed ring with vas and vessels going to the left and vessels and absent vas on the right where the closed ring was found.  Because there was no testis found in the abdomen, we then evacuated the gas and closed the fascial sheath with the 3-0 Monocryl tacking sutures.  Then skin was closed with subcutaneous closure of 4-0 Rapide.  A curvilinear upper scrotal incision was made on the right with 15 blade knife and carried down through the subcutaneous tissue with electrocautery.  Electrocautery was used for hemostasis.  A curved tenotomy scissor was used to open the sac.  The tunica vaginalis was visualized and grasped and then dissected up towards external ring.  There was no apparent testicular tissue.  We did remove it, however, tying off the cord structure with a 4-0 Vicryl suture and putting a tagging suture at the base of the tissue sent.  We then closed the subdartos area with the subcutaneous closure of 4-0 chromic.  We then did a similar curvilinear incision on the left side for testicular fixation.  Delivered the testis into the field, which had a type III epididymal attachment and was indeed about 3 to 4 mL in size, which was larger than expected for the patient's age.  We then closed the upper aspect of the subdartos pouch with the 4-0 chromic pursestring suture and placed testis back into the scrotum in the proper orientation and closed the dartos, skin, and subcutaneous closure with 4-0 chromic on left hemiscrotum.  At the end of the procedure, the patient received IV Toradol and had Dermabond tissue adhesive placed on both incisions and left testis was well descended in the scrotum at the end of the procedure.  The patient tolerated procedure well, and was in stable condition upon transfer to the recovery room.","surgery, diagnostic laparoscopy, caudal block, testis fixation, undescended testis, subcutaneous closure, testis, orchiectomy, laparoscopy, testicular, scrotum"
" Leukemic meningitis.   Right frontal side-inlet Ommaya reservoir.  The patient is a 49-year-old gentleman with leukemia and meningeal involvement, who was undergoing intrathecal chemotherapy. ", Surgery, Ommaya reservoir ,"TITLE OF OPERATION: , Right frontal side-inlet Ommaya reservoir.,INDICATION FOR SURGERY: , The patient is a 49-year-old gentleman with leukemia and meningeal involvement, who was undergoing intrathecal chemotherapy.  Recommendation was for an Ommaya reservoir.  Risks and benefits have been explained.  They agreed to proceed.,PREOP DIAGNOSIS: , Leukemic meningitis.,POSTOP DIAGNOSIS:  ,Leukemic meningitis.,PROCEDURE DETAIL: , The patient was brought to the operating room, underwent induction of laryngeal mask airway, positioned supine on a horseshoe headrest.  The right frontal region was prepped and draped in the usual sterile fashion.  Next, a curvilinear incision was made just anterior to the coronal suture 7 cm from the middle pupillary line.  Once this was completed, a burr hole was then created with a high-speed burr.  The dura was then coagulated and opened.  The Ommaya reservoir catheter was inserted up to 6.5 cm.  There was good flow.  This was connected to the side inlet, flat-bottom Ommaya and this was then placed in a subcutaneous pocket posterior to the incision.  This was then cut and __________.  It was then tapped percutaneously with 4 cubic centimeters and sent for routine studies.  Wound was then irrigated copiously with __________ irrigation, closed using 3-0 Vicryl for the deep layers and 4-0 Caprosyn for the skin.  The connection was made with a 3-0 silk suture and was a right-angle intermediate to hold the catheter in place.","surgery, caprosyn, leukemic meningitis, ommaya reservoir, leukemia, meningeal, intrathecal, chemotherapy, leukemic, meningitis, ommaya, "
" Left orchiopexy.  Ectopic left testis.   The patient did have an MRI, which confirmed ectopic testis located near the pubic tubercle.", Surgery, Orchiopexy ,"PREOPERATIVE DIAGNOSIS:,  Ectopic left testis.,POSTOPERATIVE DIAGNOSIS: , Ectopic left testis.,PROCEDURE PERFORMED: , Left orchiopexy.,ANESTHESIA: , General.  The patient did receive Ancef.,INDICATIONS AND CONSENT: , This is a 16-year-old African-American male who had an ectopic left testis that severed approximately one-and-a-half years ago.  The patient did have an MRI, which confirmed ectopic testis located near the pubic tubercle.  The risks, benefits, and alternatives of the proposed procedure were discussed with the patient.  Informed consent was on the chart at the time of procedure.,PROCEDURE DETAILS:  ,The patient did receive Ancef antibiotics prior to the procedure.  He was then wheeled to the operative suite where a general anesthetic was administered.  He was prepped and draped in the usual sterile fashion and shaved in the area of the intended procedure.  Next, with a #15 blade scalpel, an oblique skin incision was made over the spermatic cord region.  The fascia was then dissected down both bluntly and sharply and hemostasis was maintained with Bovie electrocautery.  The fascia of the external oblique, creating the external ring was then encountered and that was grasped in two areas with hemostats and sized with Metzenbaum scissors.  This was then continued to open the external ring and was then carried cephalad to further open the external ring, exposing the spermatic cord.  With this accomplished, the testis was then identified.  It was located over the left pubic tubercle region and soft tissue was then meticulously dissected and cared to avoid all vascular and testicular structures.,The cord length was then achieved by applying some tension to the testis and further dissecting any of the fascial adhesions along the spermatic cord.  Once again, meticulous care was maintained not to involve any neurovascular or contents of the testis or vas deferens.  Weitlaner retractor was placed to provide further exposure.  There was a small vein encountered posterior to the testis and this was then hemostated into place and cut with Metzenbaum scissors and doubly ligated with #3-0 Vicryl.  Again hemostasis was maintained with ligation and Bovie electrocautery with adequate mobilization of the spermatic cord and testis.  Next, bluntly a tunnel was created through the subcutaneous tissue into the left empty scrotal compartment.  This was taken down to approximately the two-thirds length of the left scrotal compartment.  Once this tunnel has been created, a #15 blade scalpel was then used to make transverse incision.  A skin incision through the scrotal skin and once again the skin edges were grasped with Allis forceps and the dartos was then entered with the Bovie electrocautery exposing the scrotal compartment.  Once this was achieved, the apices of the dartos were then grasped with hemostats and supra-dartos pouch was then created using the Iris scissors.  A dartos pouch was created between the skin and the supra-dartos, both cephalad and caudad to the level of the scrotal incision.  A hemostat was then placed from inferior to superior through the created tunnel and the testis was pulled through the created supra-dartos pouch ensuring that anatomic position was in place, maintaining the epididymis posterolateral without any rotation of the cord.  With this accomplished, #3-0 Prolene was then used to tack both the medial and lateral aspects of the testis to the remaining dartos into the tunica vaginalis.  The sutures were then tied creating the orchiopexy.  The remaining body of the testicle was then tucked into the supra-dartos pouch and the skin was then approximated with #4-0 undyed Monocryl in a horizontal mattress fashion interrupted sutures.  Once again hemostasis was maintained with Bovie electrocautery.  Finally the attention was made towards the inguinal incision and this was then copiously irrigated and any remaining bleeders were then fulgurated with Bovie electrocautery to make sure to avoid any neurovascular spermatic structures.  External ring was then recreated and grasped on each side with hemostats and approximated with #3-0 Vicryl in a running fashion cephalad to caudad.  Once this was created, the created ring was inspected and there was adequate room for the cord.  There appeared to be no evidence of compression.  Finally, subcutaneous layer with sutures of #4-0 interrupted chromic was placed and then the skin was then closed with #4-0 undyed Vicryl in a running subcuticular fashion.  The patient had been injected with bupivacaine prior to closing the skin.  Finally, the patient was cleansed.,The scrotal support was placed and plan will the for the patient to take Keflex one tablet q.i.d. x7 days as well as Tylenol #3 for severe pain and Motrin for moderate pain as well as applying ice packs to scrotum.  He will follow up with Dr. X in 10 to 14 days.  Appointment will be made.","surgery, pubic tubercle, ectopic testis, ectopic left testis, metzenbaum scissors, dartos pouch, bovie electrocautery, testis, orchiopexy, ectopic, scrotal, cord, dartos,"
 Bilateral scrotal orchiectomy, Surgery, Orchiectomy ,"BILATERAL SCROTAL ORCHECTOMY,PROCEDURE:,:  The patient is placed in the supine position, prepped and draped in the usual manner.  Under satisfactory general anesthesia, the scrotum was approached and through a transverse mid scrotal incision, the right testicle was delivered through the incision.  Hemostasis was obtained with the Bovie and the spermatic cord was identified.  It was clamped, suture ligated with 0 chromic catgut and the cord above was infiltrated with 0.25% Marcaine for postoperative pain relief.  The left testicle was delivered through the same incision.  The spermatic cord was identified, clamped, suture ligated and that cord was also injected with 0.25% percent Marcaine.  The incision was injected with the same material and then closed in two layers using 4-0 chromic catgut continuous for the dartos and interrupted for the skin.  A dry sterile dressing fluff and scrotal support applied over that.  The patient was sent to the Recovery Room in stable condition.","surgery, scrotum, hemostasis, marcaine, catgut, incision, scrotal orchiectomy, spermatic cord, sterile dressing, testicle, transverse, suture ligated, chromic catgut, orchiectomy, scrotal, cordNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" Incision and drainage and excision of the olecranon bursa, left elbow.  Acute infected olecranon bursitis, left elbow.", Surgery, Olecranon Bursa - Excision ,"PREOPERATIVE DIAGNOSIS: , Acute infected olecranon bursitis, left elbow.,POSTOPERATIVE DIAGNOSIS: , Infection, left olecranon bursitis.,PROCEDURE PERFORMED:,1.  Incision and drainage, left elbow.,2.  Excision of the olecranon bursa, left elbow.,ANESTHESIA: , Local with sedation.,COMPLICATIONS: , None.,NEEDLE AND SPONGE COUNT: , Correct.,SPECIMENS: , Excised bursa and culture specimens sent to the microbiology.,INDICATION:  ,The patient is a 77-year-old male who presented with 10-day history of pain on the left elbow with an open wound and drainage purulent pus followed by serous drainage.  He was then scheduled for I&D and excision of the bursa.  Risks and benefits were discussed.  No guarantees were made or implied.,PROCEDURE: , The patient was brought to the operating room and once an adequate sedation was achieved, the left elbow was injected with 0.25% plain Marcaine.  The left upper extremity was prepped and draped in standard sterile fashion.  On examination of the left elbow, there was presence of thickening of the bursal sac.  There was a couple of millimeter opening of skin breakdown from where the serous drainage was noted.  An incision was made midline of the olecranon bursa with an elliptical incision around the open wound, which was excised with skin.  The incision was carried proximally and distally.  The olecranon bursa was significantly thickened and scarred.  Excision of the olecranon bursa was performed.  There was significant evidence of thickening of the bursa with some evidence of adhesions.  Satisfactory olecranon bursectomy was performed.  The wound margins were debrided.  The wound was thoroughly irrigated with Pulsavac irrigation lavage system mixed with antibiotic solution.  There was no evidence of a loose body.  There was no bleeding or drainage.  After completion of the bursectomy and I&D, the skin margins, which were excised were approximated with 2-0 nylon in horizontal mattress fashion.  The open area of the skin, which was excised was left _________ and was dressed with 0.25-inch iodoform packing.  Sterile dressings were placed including Xeroform, 4x4, ABD, and Bias.  The patient tolerated the procedure very well.  He was then extubated and transferred to the recovery room in a stable condition.  There were no intraoperative complications noticed.","surgery, incision and drainage, infected olecranon, olecranon bursitis, olecranon bursa, olecranon, wound, excision, drainage, elbow, bursa"
" Chronic plantar fasciitis, right foot.  Open plantar fasciotomy, right foot.", Surgery, Open Plantar Fasciotomy ,"PREOPERATIVE DIAGNOSIS: , Chronic plantar fasciitis, right foot.,POSTOPERATIVE DIAGNOSIS:,  Chronic plantar fasciitis, right foot.,PROCEDURE: , Open plantar fasciotomy, right foot.,ANESTHESIA: , Local infiltrate with IV sedation.,INDICATIONS FOR SURGERY:,  The patient has had a longstanding history of foot problems.  The foot problem has been progressive in nature and has not been responsive to conservative care despite multiple attempts at conservative care.  The preoperative discussion with the patient including alternative treatment options, the procedure itself was explained, and risk factors such as infection, swelling, scar tissue, numbness, continued pain, recurrence, falling arch, digital contracture, and the postoperative management were discussed.  The patient has been advised, although no guarantee for success could be given, most of the patients have improved function and less pain.  All questions were thoroughly answered.  The patient requested for surgical repair since the problem has reached a point to interfere with normal daily activities.  The purpose of the surgery is to alleviate the pain and discomfort.,DETAILS OF THE PROCEDURE:  ,The patient was given 1 g Ancef for antibiotic prophylaxis 30 minutes prior to the procedure.  The patient was brought to the operating room and placed in the supine position.  Following a light IV sedation, a posterior tibial nerve block and local infiltrate of the operative site was performed with 10 mL, and a 1:1 mixture of 1% lidocaine with epinephrine, and 0.25% Marcaine was affected.  The lower extremity was prepped and draped in the usual sterile manner.  Balance anesthesia was obtained.,PROCEDURE:, Plantar fasciotomy, right foot.  The plantar medial tubercle of the calcaneus was palpated and a vertical oblique incision, 2 cm in length with the distal aspect overlying the calcaneal tubercle was affected. Blunt dissection was carried out to expose the deep fascia overlying the abductor hallucis muscle belly and the medial plantar fascial band.  A periosteal elevator did advance laterally across the inferior aspect of the medial and central plantar fascial bands, creating a small and narrow soft tissue tunnel.  Utilizing a Metzenbaum scissor, transection of the medial two-third of the plantar fascia band began at the junction of the deep fascia of the abductor hallucis muscle belly and medial plantar fascial band, extending to the lateral two-thirds of the band.  The lateral plantar fascial band was left intact.  Visualization and finger probe confirmed adequate transection.  The surgical site was flushed with normal saline irrigation.,The deep layer was closed with 3-0 Vicryl and the skin edges coapted with combination of 1 horizontal mattress and simples.  The dressing consisted of Adaptic, 4 x 4, conforming bandages, and an ACE wrap to provide mild compression.  The patient tolerated the procedure and anesthesia well, and left the operating room to recovery room in good postoperative condition with vital signs stable and arterial perfusion intact.  A walker boot was dispensed and applied.  The patient will be allowed to be full weightbearing to tolerance, in the boot to encourage physiological lengthening of the release of plantar fascial band.,The next office visit will be in 4 days.  The patient was given prescriptions for Keflex 500 mg 1 p.o. three times a day x10 days and Lortab 5 mg #40, 1 to 2 p.o. q.4-6 h. p.r.n. pain, 2 refills, along with written and oral home instructions.  After a short recuperative period, the patient was discharged home with vital signs stable and in no acute distress.","surgery, plantar fascial band, plantar fasciitis, plantar fasciotomy, plantar fascial, anesthesia, plantar, fascia, fasciotomy, fascial, band, foot,"
 Acute acalculous cholecystitis.  Open cholecystectomy.  The patient's gallbladder had some patchy and necrosis areas.  There were particular changes on the serosal surface as well as on the mucosal surface with multiple clots within the gallbladder., Surgery, Open Cholecystectomy ,"PREOPERATIVE DIAGNOSIS: , Acute acalculous cholecystitis.,POSTOPERATIVE DIAGNOSIS:,  Acute hemorrhagic cholecystitis.,PROCEDURE PERFORMED: , Open cholecystectomy.,ANESTHESIA: , Epidural with local.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well and was transferred to recovery in stable condition.,SPECIMEN:  ,Gallbladder.,BRIEF HISTORY:  ,The patient is a 73-year-old female who presented to ABCD General Hospital on 07/23/2003 secondary to a fall at home from which the patient suffered a right shoulder as well as hip fracture.  The patient subsequently went to the operating room on 07/25/2003 for a right hip hemiarthroplasty per the Orthopedics Department.  Subsequently, the patient was doing well postoperatively, however, the patient does have severe O2 and steroid-dependent COPD and at an extreme risk for any procedure.  The patient began developing abdominal pain over the course of the next several days and a consultation was requested on 08/07/2003 for surgical evaluation for upper abdominal pain.  During the evaluation, the patient was found to have an acute acalculous cholecystitis in which nonoperative management was opted for and on 08/08/03, the patient underwent a percutaneous cholecystostomy tube placement to drain the gallbladder.  The patient did well postdrainage.  The patient's laboratory values and biliary values returned to normal and the patient was planned for a removal of the tube with 48 hours of the tubing clamp.  However, once the tube was removed, the patient re-obstructed with recurrent symptoms and a second tube was needed to be placed; this was done on 08/16/2003.  A HIDA scan had been performed, which showed no cystic duct obstruction.  A tube cholecystogram was performed, which showed no cystic or common duct obstruction.  There was abnormal appearance of the gallbladder, however, the pathway was patent.  Thus after failure of two nonoperative management therapies, extensive discussions were made with the family and the patient's only option was to undergo a cholecystectomy.  Initial thoughts were to do a laparoscopic cholecystectomy, however, with the patient's severe COPD and risk for ventilator management, the options were an epidural and an open cholecystectomy under local was made and to be performed.,INTRAOPERATIVE FINDINGS:  ,The patient's gallbladder had some patchy and necrosis areas.  There were particular changes on the serosal surface as well as on the mucosal surface with multiple clots within the gallbladder.  The patient also had no plane between the gallbladder and the liver bed.,OPERATIVE PROCEDURE: , After informed written consent, risks and benefits of the procedure were explained to the patient and discussed with the patient's family.  The patient was brought to the operating room after an epidural was performed per anesthesia.  Local anesthesia was given with 1% lidocaine.  A paramedian incision was made approximately 5 cm in length with a #15 blade scalpel.  Next, hemostasis was obtained using electro Bovie cautery.  Dissection was carried down transrectus in the midline to the posterior rectus fascia, which was grasped with hemostats and entered with a #10 blade scalpel.  Next, Metzenbaum scissors were used to extend the incision and the abdomen was entered .  The gallbladder was immediately visualized and brought up into view, grasped with two ring clamps elevating the biliary tree into view.  Dissection with a ______ was made to identify the cystic artery and cystic duct, which were both easily identified.  The cystic artery was clipped, two distal and one proximal to the gallbladder cutting between with Metzenbaum scissors.  The cystic duct was identified.  A silk tie #3-0 silk was placed one distal and one proximal with #3-0 silk and then cutting in between with a Metzenbaum scissors.  The gallbladder was then removed from the liver bed using electro Bovie cautery.  A plane was created.  The hemostasis was obtained using the electro Bovie cautery as well as some Surgicel.  The gallbladder was then removed as specimen, sent to pathology for frozen sections for diagnosis, of which the hemorrhagic cholecystitis was diagnosed on frozen sections.  Permanent sections are still pending.  The remainder of the fossa was hemostatic with the Surgicel and attention was next made to closing the abdomen.  The peritoneum as well as posterior rectus fascia was approximated with a running #0 Vicryl suture and then the anterior rectus fascia was closed in interrupted figure-of-eight #0 Vicryl sutures.  Skin staples were used on the skin and sterile dressings were applied and the patient was transferred to recovery in stable condition.","surgery, open cholecystectomy, hemorrhagic, gallbladder, serosal, liver bed, acute acalculous, acalculous cholecystitis, cystic duct, bovie cautery, rectus fascia, metzenbaum scissors, fascia, cholecystitis, cholecystectomy, cystic,"
 Nissen fundoplication.   A 2 cm midline incision was made at the junction of the upper two-thirds and lower one-third between the umbilicus and the xiphoid process. , Surgery, Nissen Fundoplication ,"PROCEDURE PERFORMED: , Nissen fundoplication.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained detailing the risks of infection, bleeding, esophageal perforation and death, the patient was brought to the operative suite and placed supine on the operating room table.  General endotracheal anesthesia was induced without incident.  The patient was then placed in a modified lithotomy position taking great care to pad all extremities.  TEDs and Venodynes were placed as prophylaxis against deep venous thrombosis.  Antibiotics were given for prophylaxis against surgical infection.,A 52-French bougie was placed in the proximal esophagus by Anesthesia, above the cardioesophageal junction.  A 2 cm midline incision was made at the junction of the upper two-thirds and lower one-third between the umbilicus and the xiphoid process.  The fascia was then cleared of subcutaneous tissue using a tonsil clamp.  A 1-2 cm incision was then made in the fascia gaining entry into the abdominal cavity without incident.  Two sutures of 0 Vicryl were then placed superiorly and inferiorly in the fascia, and then tied to the special 12 mm Hasson trocar fitted with a funnel-shaped adaptor in order to occlude the fascial opening.  Pneumoperitoneum was then established using carbon dioxide insufflation to a steady state of pressure of 16 mmHg.  A 30-degree laparoscope was inserted through this port and used to guide the remaining trocars.,The remaining trocars were then placed into the abdomen taking care to make the incisions along Langer's line, spreading the subcutaneous tissue with a tonsil clamp, and confirming the entry site by depressing the abdominal wall prior to insertion of the trocar.  A total of 4 other 10/11 mm trocars were placed.  Under direct vision 1 was inserted in the right upper quadrant at the midclavicular line, at a right supraumbilical position; another at the left upper quadrant at the midclavicular line, at a left supraumbilical position; 1 under the right costal margin in the anterior axillary line; and another laterally under the left costal margin on the anterior axillary line.  All of the trocars were placed without difficulty.  The patient was then placed in reverse Trendelenburg position.,The triangular ligament was taken down sharply, and the left lobe of the liver was retracted superolaterally using a fan retractor placed through the right lateral cannula.  The gastrohepatic ligament was then identified and incised in an avascular plane.  The dissection was carried anteromedially onto the phrenoesophageal membrane.  The phrenoesophageal membrane was divided on the anterior aspect of the hiatal orifice.  This incision was extended to the right to allow identification of the right crus.  Then along the inner side of the crus, the right esophageal wall was freed by dissecting the cleavage plane.,The liberation of the posterior aspect of the esophagus was started by extending the dissection the length of the right diaphragmatic crus.  The pars flaccida of the lesser omentum was opened, preserving the hepatic branches of the vagus nerve.  This allowed free access to the crura, left and right, and the right posterior aspect of the esophagus, and the posterior vagus nerve.,Attention was next turned to the left anterolateral aspect of the esophagus.  At its left border, the left crus was identified.  The dissection plane between it and the left aspect of the esophagus was freed.  The gastrophrenic ligament was incised, beginning the mobilization of the gastric pouch.  By dissecting the intramediastinal portion of the esophagus, we elongated the intra-abdominal segment of the esophagus and reduced the hiatal hernia.,The next step consisted of mobilization of the gastric pouch.  This required ligation and division of the gastrosplenic ligament and several short gastric vessels using the harmonic scalpel.  This dissection started on the stomach at the point where the vessels of the greater curvature turned towards the spleen, away from the gastroepiploic arcade.  The esophagus was lifted by a Babcock inserted through the left upper quadrant port.  Careful dissection of the mesoesophagus and the left crus revealed a cleavage plane between the crus and the posterior gastric wall.  Confirmation of having opened the correct plane was obtained by visualizing the spleen behind the esophagus.  A one-half inch Penrose drain was inserted around the esophagus and sewn to itself in order to facilitate retraction of the distal esophagus.  The retroesophageal channel was enlarged to allow easy passage of the antireflux valve.,The 52-French bougie was then carefully lowered into the proximal stomach, and the hiatal orifice was repaired.  Two interrupted 0 silk sutures were placed in the diaphragmatic crura to close the orifice.,The last part of the operation consisted of the passage and fixation of the antireflux valve.  With anterior retraction on the esophagus using the Penrose drain, a Babcock was passed behind the esophagus, from right to left.  It was used to grab the gastric pouch to the left of the esophagus and to pull it behind, forming the wrap.  The,52-French bougie was used to calibrate the external ring.  Marcaine 0.5% was injected 1 fingerbreadth anterior to the anterior superior iliac spine and around the wound for postanesthetic pain control.  The skin incision was approximated with skin staples.  A dressing was then applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.","surgery, umbilicus, insufflation, phrenoesophageal membrane, nissen fundoplication, gastric pouch, esophagus, penrose, antireflux, nissen, fundoplication, trocars, ligament,"
 Nipple areolar reconstruction utilizing a full-thickness skin graft and mastopexy, Surgery, Nipple Reconstruction ,"PREOPERATIVE DIAGNOSES,1.  Surgical absence of left nipple areola with personal history of breast cancer.,2.  Breast asymmetry.,POSTOPERATIVE DIAGNOSES,1.  Surgical absence of left nipple areola with personal history of breast cancer.,2.  Breast asymmetry.,PROCEDURE,1.  Left nipple areolar reconstruction utilizing a full-thickness skin graft from the left groin.,2.  Redo right mastopexy.,ANESTHESIA,General endotracheal.,COMPLICATIONS,None.,DESCRIPTION OF PROCEDURE IN DETAIL,The patient was brought to the operating room and placed on the table in the supine position and after suitable induction of general endotracheal anesthesia, the patient was placed in a frog-leg position and prepped and draped in usual fashion for the above-noted procedure.  The initial portion of the procedure was harvesting a full-thickness skin graft from the left groin region.  This was accomplished by ellipsing out a 42-mm diameter circle of skin just below the thigh, peroneal crease.  The defect was then closed with 3-0 Vicryl followed by 3-0 chromic suture in a running locked fashion.  The area was dressed with antibiotic ointment and then a Peri-Pad.  The patient's legs were brought out frog-leg back to the midline and sterile towels were placed over the opening in the drapes.  Surgical team's gloves were changed and then attention was turned to the planning of the left nipple flap.,A maltese cross pattern was employed with a 1-cm diameter nipple and a 42-mm diameter nipple areolar complex.  Once the maltese cross had been designed on the breast at the point where the nipple was to be placed, the areas of the portion of flap were de-epithelialized.  Then, when this had been completed, the dermis about the maltese cross was incised full thickness to allow mobilization of the flap to form the neonipple.  At this point, a Bovie electrocautery was used to control bleeding points and then 4-0 chromic suture was used to suture the arms of the flap together creating the nipple.  When this had been completed, the skin graft, which had been harvested from the left groin was brought onto the field where it was prepared by removing all subcutaneous tissue from the posterior aspect of the graft and carefully removing the hair follicles encountered within the graft.  At this point, the graft was sutured into position in the defect using 3-0 chromic in an interrupted fashion and then trimming the ellipse to an appropriate circle to fill the areola.  At this point, 4-0 chromic was used to run around the perimeter of the full-thickness skin graft and then at this point the nipple was delivered through a cruciate incision in the middle of the skin graft and then inset appropriately with 4-0 chromic.  The areolar skin graft was pie crusted.  Then, at this point, the area of areola was dressed with silicone gel sheeting.  A silo was placed over the neonipple with 3-0 nylon through the apex of the neonipple to support the nipple in an erect position.  Mastisol and Steri-Strips were then applied.,At this point, attention was turned to the right breast where a 2-cm wide ellipse transversely oriented and with its inferior most aspect just inferior to the transverse mastopexy incision line was made.  The skin was removed from the area and then a layered closure of 3-0 Vicryl followed by 3-0 PDS in a running subcuticular fashion was carried out.  When this had been completed, the Mastisol and Steri-Strips were applied to the transverse right breast incision.  Fluff dressings were applied to the right breast as well as the area around the silo on the left breast around the reconstructed nipple areola.  The patient was then placed in Surgi-Bra and then was taken from the operating room to the recovery room in good condition.","surgery, nipple areola, breast asymmetry, general endotracheal, peri-pad, surgi-bra, breast cancer, frog-leg position, full-thickness skin graft, general endotracheal anesthesia, mastopexy, nipple areolar complex, nipple areolar reconstruction, nipple flap, prepped and draped, transverse mastopexy, areolar reconstruction, skin graft, graft, nipple, areolar, breast"
 Right radical nephrectomy and assisted laparoscopic approach., Surgery, Nephrectomy - Radical ,"PREOPERATIVE DIAGNOSIS: , Right renal mass.,POSTOPERATIVE DIAGNOSIS: , Right renal mass.,PROCEDURE: , Right radical nephrectomy and assisted laparoscopic approach.,ANESTHESIA:  ,General.,PROCEDURE IN DETAIL:  ,The patient underwent general anesthesia with endotracheal intubation.  An orogastric was placed and a Foley catheter placed.  He was placed in a modified flank position with the hips rotated to 45 degrees.  Pillow was used to prevent any pressure points.  He was widely shaved, prepped, and draped.  A marking pen was used to delineate a site for the Pneumo sleeve in the right lower quadrant and for the trocar sites in the midline just above the umbilicus and halfway between the xiphoid and the umbilicus.  The incision was made through the premarked site through the skin and subcutaneous tissue.  The aponeurosis of the external oblique was incised in the direction of its fibers.  Muscle-splitting incision was made in the internal oblique and transversus abdominis.  The peritoneum was opened and the Pneumo sleeve was placed in the usual fashion being sure that no bowel was trapped inside the ring.  Then, abdominal insufflation was carried out through the Pneumo sleeve and the scope was passed through the Pneumo sleeve to visualize placement of the trocars in the other two positions.  Once this had been completed, the scope was placed in the usual port and dissection begun by taking down the white line of Toldt, so that the colon could be retracted medially.  This exposed the duodenum, which was gently swept off the inferior vena cava and dissection easily disclosed the takeoff of the right renal vein off the cava.  Next, attention was directed inferiorly and the ureter was divided between clips and the inferior tongue of Gerota fascia was taken down, so that the psoas muscle was exposed.  The attachments lateral to the kidney was taken down, so that the kidney could be flipped anteriorly and medially, and this helped in exposing the renal artery.  The renal artery had been previously noticed on the CT scan to branch early and so each branch was separately ligated and divided using the stapler device.  After the arteries had been divided, the renal vein was divided again using a stapling device.  The remaining attachments superior to the kidney were divided with the Harmonic scalpel and also utilized the stapler, and the specimen was removed.  Reexamination of the renal fossa at low pressures showed a minimal degree of oozing from the adrenal gland, which was controlled with Surgicel.  Next, the port sites were closed with 0 Vicryl utilizing the passer and doing it over the hand to prevent injury to the bowel and the right lower quadrant incision for the hand port was closed in the usual fashion.  The estimated blood loss was negligible.  There were no complications.  The patient tolerated the procedure well and left the operating room in satisfactory condition.","surgery, renal mass, foley catheter, gerota fascia, muscle-splitting incision, pneumo sleeve, endotracheal, laparoscopic, nephrectomy, orogastric, renal fossa, right lower quadrant, trocar, umbilicus, vena cava, renal, pneumo, radical, "
 Transplant nephrectomy after rejection of renal transplant, Surgery, Nephrectomy - Transplant ,"PREOPERATIVE DIAGNOSIS: , Rejection of renal transplant.,POSTOPERATIVE DIAGNOSIS: , Rejection of renal transplant.,OPERATIVE PROCEDURE: , Transplant nephrectomy.,DESCRIPTION OF PROCEDURE: , The patient has had rapid deterioration of her kidney function since her transplant at ABCD one year ago.  The patient was recently thought to have obstruction to the transplant and a stent was placed in to the transplant percutaneously, but the ureter was wide open and there was no evidence of obstruction.  Because the kidney was felt to be irretrievably lost and immunosuppression had been withdrawn, it was elected to go ahead and remove the kidney and hopes that her fever and toxic course could be arrested.,With the patient in the supine position, the previously placed nephrostomy tube was removed.  The patient then after adequate prepping and draping, and placing of a small roll under the right hip, underwent an incision in the direction of the transplant incision down through and through all muscle layers and into the preperitoneal space.  The kidney was encountered and kidney was dissected free of its attachments through the retroperitoneal space.  During the course of dissection, the iliac artery and vein were identified as was the native ureter and the patient's ilioinguinal nerve; all these were preserved.  The individual vessels in the kidney were identified, ligated, and incised, and the kidney was removed.  The ureter was encountered during the course of resection, but was not ligated.  The patient's retroperitoneal space was irrigated with antibiotic solution and #19 Blake drain was placed into the retroperitoneal space, and the patient returned to the recovery room in good condition.,ESTIMATED BLOOD LOSS:  900 mL.","surgery, renal transplant, blake drain, rejection, iliac artery, ilioinguinal, immunosuppression, kidney function, nephrectomy, nephrostomy tube, retroperitoneal space, toxic, ureter, vein, transplant, renal, retroperitoneal, kidney, "
 Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection., Surgery, Neuroplasty ,"PREOPERATIVE DIAGNOSES:,  ,1.  Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2.  Epidural fibrosis with nerve root entrapment.,POSTOPERATIVE DIAGNOSES:,  ,1.  Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2.  Epidural fibrosis with nerve root entrapment.,OPERATION PERFORMED:,  Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,ANESTHESIA:,  Local/IV sedation.,COMPLICATIONS:,  None.,SUMMARY:  ,The patient in the operating room, status post transforaminal epidurogram (see operative note for further details).  Using AP and lateral fluoroscopic views to confirm the needle location the superior most being in the left L4 neural foramen and the inferior most in the left L5 neural foramen, 375 units of Wydase was injected through each needle.  After two minutes, 3.5 cc of 0.5% Marcaine and 80 mg of Depo-Medrol was injected through each needle.  These needles were removed and the patient was discharged in stable condition.","surgery, nerve root decompression, discectomy, epidural fibrosis, nerve root entrapment, transforaminal neuroplasty, neural foramen, nerve root, foramen, neuroplasty, transforaminal, needle, epidural,"
" Repair of nerve and tendon, right ring finger and exploration of digital laceration.  Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis and 25% laceration to the flexor digitorum profundus of the right ring finger and laceration 100% of the ulnar digital nerve to the right ring finger.", Surgery, Nerve & Tendon Repair - Finger ,"PREOPERATIVE DIAGNOSIS:,  Volar laceration to right ring finger with possible digital nerve injury with possible flexor tendon injury.,POSTOPERATIVE DIAGNOSES:,1.  Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis.,2.  25% laceration to the flexor digitorum profundus of the right ring finger and laceration 100% of the ulnar digital nerve to the right ring finger.,PROCEDURE PERFORMED:,1.  Repair of nerve and tendon, right ring finger.,2.  Exploration of digital laceration.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 10 cc.,TOTAL TOURNIQUET TIME:  ,57 minutes.,COMPLICATIONS: , None.,DISPOSITION:  ,To PACU in stable condition.,BRIEF HISTORY OF PRESENT ILLNESS: , This is a 13-year-old male who had sustained a laceration from glass and had described numbness and tingling in his right ring finger.,GROSS OPERATIVE FINDINGS: , After wound exploration, it was found there was a 100% laceration to the ulnar digital neurovascular bundle.  The FDS had a partial ulnar slip laceration and the FDP had a 25% transverse laceration as well.  The radial neurovascular bundle was found to be completely intact.,OPERATIVE PROCEDURE:  ,The patient was taken to the operating room and placed in the supine position.  All bony prominences were adequately padded.  Tourniquet was placed on the right upper extremity after being packed with Webril, but not inflated at this time.  The right upper extremity was prepped and draped in the usual sterile fashion.  The hand was inspected.  Palmar surface revealed approximally 0.5 cm laceration at the base of the right ring finger at the base of proximal phalanx, which was approximated with nylon suture.  The sutures were removed and the wound was explored.  It was found that the ulnar digital neurovascular bundle was 100% transected.  The radial neurovascular bundle on the right ring finger was found to be completely intact.  We explored the flexor tendon and found that there was a partial laceration of the ulnar slip of the FDS and a 25% laceration in a transverse fashion to the FDP.  We copiously irrigated the wound.  Repair was undertaken of the FDS with #3-0 undyed Ethibond suture.  The laceration of the FDP was not felt that it need to repair due to majority of the substance in the FDP was still intact.  Attention during our repair at the flexor tendon, the A1 pulley was incised for better visualization as well as better tendon excursion after repair.  Attention was then drawn to the ulnar digital bundle which has been transected prior during the injury.  The digital nerve was dissected proximally and distally to likely visualize the nerve.  The nerve was then approximated using microvascular technique with #8-0 nylon suture.  The hands were well approximated.  The nerve was not under undue tension.  The wound was then copiously irrigated and the skin was closed with #4-0 nylon interrupted horizontal mattress alternating with simple suture.  Sterile dressing was placed and a dorsal extension Box splint was placed.  The patient was transferred off of the bed and placed back on a gurney and taken to PACU in stable condition.  Overall prognosis is good.","surgery, laceration, flexor tendon, volar laceration, digital laceration, ulnar slip, flexor digitorum, neurovascular bundle, nerve, injury, ring, finger, neurovascular, fds, bundle, tendon, repair, flexor, digital, ulnar, "
 Laparoscopic right partial nephrectomy due to right renal mass., Surgery, Nephrectomy - Partial (Laparoscopic ) ,"PREOPERATIVE DIAGNOSIS: , Right renal mass.,POSTOPERATIVE DIAGNOSIS: , Right renal mass.,PROCEDURE PERFORMED: , Laparoscopic right partial nephrectomy.,ESTIMATED BLOOD LOSS:,  250 mL.,X-RAYS: , None.,SPECIMENS: , Included right renal mass as well as biopsies from the base of the resection.,ANESTHESIA:,  General endotracheal.,COMPLICATIONS: , None.,DRAINS: , Included a JP drain in the right flank as well as a #16-French Foley catheter per urethra.,BRIEF HISTORY: , The patient is a 60-year-old gentleman with a history of an enhancing right renal mass approximately 2 cm in diameter.  I had a long discussion with him concerning variety of options.  We talked in particular about extirpated versus ablative surgery.  Based on his young age and excellent state of health, decision was made at this point to proceed to a right partial nephrectomy laparoscopically.  All questions were answered, and he wished to proceed with surgery as planned.  Note that the patient does have a positive family history of renal cell carcinoma.,PROCEDURE IN DETAIL: , After acquisition of proper informed consent and administration of perioperative antibiotics, the patient was taken to the operating room and placed supine on the operating table.  After institution of adequate general anesthetic via endotracheal rod, he was placed into the right anterior flank position with his right side elevated on a roll and his right arm across his chest.  All pressure points were carefully padded, and he was securely taped to the table.  Note that sequential compression devices were in place on both lower extremities and were activated prior to induction of anesthesia.  His abdomen was then prepped and draped in a standard surgical fashion.  Note that a #16-French Foley catheter was in place per urethra as well as an orogastric tube.  The abdomen was insufflated at the right lateral abdomen using the Veress needle to a pressure of 15 without incident.  We then placed a Visiport 10 x 12 trocar in the right lateral abdomen.  With the trocar in place, we were able to place the remaining trocars under direct laparoscopic visualization.  We placed three additional trocars.  An 11 mm screw type trocar at the umbilicus, a 6 screw type trocar 7 cm in the midline above the umbilicus, and a 10 x 12 trocar to serve as a retractor port approximately 8 cm inferior in the midline.,The procedure was begun by reflecting the right colon by incising the white line of Toldt.  The colon was reflected medially, and the retroperitoneum was exposed on that side.  This was a fairly superficial lesion, so decision was made in advance to potentially not perform vascular clamping, however, I did feel it important to get high level control prior to proceeding to the partial.  With the colon reflected, the duodenum was identified, and it was reflected medially under Kocher maneuver.  The ureter and gonadal vein were identified on the right side and elevated.  The space between the ureter and the gonadal vein was then developed, and the gonadal vein was dropped elevating only the ureter, and carrying this plane dissection up towards the renal hilum.  Once we got up to the renal hilum, we were able to skeletonize the renal hilar vessels partially, and in particular, we did develop some of the upper pole dissection above the level of the hilum to provide for access for a Satinsky clamp or bulldogs.  The remainder of the kidney was then freed off its lateral and superior attachments primarily using the Harmonic scalpel and the LigaSure device.,With the kidney free and the hilum prepared, the Gerota fascia was taken down overlying the kidney exposing the renal parenchyma, and using this approach, we were able to identify the 2-cm, right renal mass located in the lower pole laterally.  A cap of fat was left overlying this mass.  Based on the position of the mass, we performed intraoperative laparoscopic ultrasound, which showed the mass to be somewhat deeper than initially anticipated.  Based on this finding, I decided to go ahead and clamp the renal hilum during resection.  A Satinsky clamp was introduced through the lower most trocar site and used to clamp the renal hilum en bloc.  Note that the patient had been receiving renal protection protocol including fenoldopam and mannitol throughout the procedure, and he also received Lasix prior to clamping the renal hilum.  With the renal hilum clamped, we did resect the tumor using cold scissors.  There was somewhat more bleeding than would be expected based on the hilar clamping; however, we were able to successfully resect this lesion.  We also took a biopsy at the base of the resection and passed off the table as a specimen for frozen section.  With the tumor resected, the base of the resection was then cauterized using the Argon beam coagulator, and several bleeding vessels were oversewn using figure-of-eight 3-0 Vicryl sutures with lap ties for tensioning.  We then placed a FloSeal into the wound and covered it with a Surgicel and held the pressure.  We then released the vascular clamp.  Total clamp time was 11 minutes.  There was minimal bleeding and occlusion of this maneuver, and after unclamping the kidney, the kidney pinked up appropriately and appeared well perfused after removal of the clamp.  We then replaced the kidney within its Gerota envelope and closed that with 3-0 Vicryl using lap ties for tensioning.  A JP drain was introduced through the right flank and placed adjacent to the kidney and sutured the skin with 2-0 nylon.  The specimen was placed into a 10-mm Endocatch bag and extracted from the lower most trocar site after extending it approximately 1 cm.  It was evaluated on the table and passed off the table for Pathology to evaluate.  They stated that the tumor was close to the margin, but there appeared to be 1-2 mm normal parenchyma around the tumor.  In addition, the frozen section biopsies from the base of the resection were negative for renal cell carcinoma.  Based on these findings, the lower most trocar site was closed using a running 0 Vicryl suture in the fascia.  We then re-insufflated the abdomen and carefully evaluated the entire intraoperative field for hemostasis.  Any bleeding points were controlled primarily using bipolar cautery or hemoclips.  The area was copiously irrigated with normal saline.  The colon was then replaced into its normal anatomic position.  The mesentry was evaluated.  There were no defects noted.  We closed the 10 x 12 lateral most trocar site using a Carter-Thompson closure device with 0-Vicryl.  All trocars were removed under direct visualization, and the abdomen was desufflated prior to removal of the last trocar.  The skin incisions were irrigated with normal saline and infiltrated with 0.25% Marcaine, and the skin was closed using a running 4-0 Monocryl in subcuticular fashion.  Benzoin and Steri-Strips were placed.  The patient was returned in supine position and awoken from general anesthetic without incident.  He was then transferred to hospital gurney and taken to the postanesthesia care unit for postoperative monitoring.  At the end of the case, sponge, instrument, and needle counts were correct.  I was scrubbed and present throughout the entire case.","surgery, renal mass, foley catheter, gerota fascia, jp drain, kocher maneuver, laparoscopic, ligasure device, satinsky clamp, toldt, bulldogs, nephrectomy, renal parenchyma, resection, urethra, vicryl sutures, partial nephrectomy, gonadal vein, renal hilum, satinsky, renal, kidney, hilum, foley, endotracheal, "
 Laparoscopic right radical nephrectomy due to right renal mass., Surgery, Nephrectomy - Radical (Laparoscopic) ,"PREOPERATIVE DIAGNOSIS:,  Right renal mass.,POSTOP DIAGNOSIS: , Right renal mass.,PROCEDURE PERFORMED:,  Laparoscopic right radical nephrectomy.,ESTIMATED BLOOD LOSS:,  100 mL.,X-RAYS: , None.,SPECIMENS: , Right radical nephrectomy specimen.,COMPLICATIONS: , None.,ANESTHESIA:  ,General endotracheal.,DRAINS:,  16-French Foley catheter per urethra.,BRIEF HISTORY: , The patient is a 71-year-old woman recently diagnosed with 6.5 cm right upper pole renal mass.  This is an enhancing lesion suspicious for renal cell carcinoma versus oncocytoma.  I discussed a variety of options with her, and she opted to proceed with a laparoscopic right radical nephrectomy.  All questions were answered, and she wished to proceed with surgery as planned.,PROCEDURE IN DETAIL:,  After acquisition of appropriate written and informed consent and administration of perioperative antibiotics, the patient was taken to the operating room and placed supine on the operating table.  Note that, sequential compression devices were placed on both lower extremities and were activated per induction of anesthesia.  After institution of adequate general anesthetic via the endotracheal route, she was placed into the right anterior flank position with the right side elevated in a roll and the right arm across her chest.  All pressure points were carefully padded, and she was securely taped to the table to prevent shifting during the procedure.  Her abdomen was then prepped and draped in the standard surgical fashion after placing a 16-French Foley catheter per urethra to gravity drainage.  The abdomen was insufflated in the right outer quadrant.  Note that, the patient had had previous surgery which complicated accesses somewhat and that she had a previous hysterectomy.  The abdomen was insufflated into the right lateral abdomen with Veress needle to 50 mm of pressure without incident.  We then placed a 10/12 Visiport trocar approximately 7 cm lateral to the umbilicus.  Once this had entered into the peritoneal cavity without incident, the remaining trocars were all placed.  Under direct laparoscopic visualization, we placed three additional trocars; an 11-mm screw-type trocar in the umbilicus, a 6-mm screw-type trocar in the upper midline approximately 7 cm above the umbilicus, and 10/12 trocar in the lower midline about 7 cm below the umbilicus within and over the old hysterectomy scar.  There were some adhesions of omentum to the underside of that scar, and these were taken down sharply using laparoscopic scissors.,We began nephrectomy procedure by reflecting the right colon, by incising the white line of Toldt.  This exposed the retroperitoneum on the right side.  The duodenum was identified and reflected medially in a Kocher maneuver using sharp dissection only.  We then identified the ureter and gonadal vein in the retroperitoneum.  The gonadal vein was left down along the vena cava, and the plane underneath the ureter was elevated and this plane was carried up towards the renal hilum.  Sequential packets of tissue were taken using primarily the LigaSure Atlas device.  Once we got to the renal hilum, it became apparent that this patient had two sets of renal arteries and veins.  We proceeded then and skeletonized the structures into four individual packets.  We then proceeded to perform the upper pole dissection and developing the plane above the kidney and between the kidney and adrenal gland.  The adrenal was spared during this procedure.  There was no contiguous connection between the renal mass and a right adrenal gland.  This plane of dissection was taken down primarily using the LigaSure device.  We then sequentially took the four vessels going to the kidney initially taking two renal arteries with the endo GI stapler and then to renal veins again with endo GI stapler sequential flaring.  Once this was completed, the kidney was free except for its attachment to the ureter and lateral attachments.  The lateral attachments of the kidney were taken down using the LigaSure Atlas device, and then the ureter was doubly clipped and transected.  The kidney was then freed within the retroperitoneum.  A 50-mm EndoCatch bag was introduced through the lower most trocar site, and the kidney was placed into this bag for subsequent extraction.  We extended the lower most trocar site approximately 6 cm to facilitate extraction.  The kidney was removed and passed off the table as a specimen for pathology.  This was bivalved by pathology, and we reviewed the specimen.","surgery, renal mass, carter-thomason, endocatch bag, foley catheter, gi stapler, laparoscopic, ligasure, toldt, laparoscopic scissors, nephrectomy, radical nephrectomy, screw-type trocar, umbilicus, upper pole, urethra, carter thomason closure device, laparoscopic right radical nephrectomy, carter thomason closure, carter thomason, renal hilum, kidney, abdomen, endotracheal, radical, oncocytoma, renal, "
" Excision of neuroma, third interspace, left foot.  Morton's neuroma, third interspace, left foot.", Surgery, Neuroma Excision ,"PREOPERATIVE DIAGNOSIS: , Morton's neuroma, third interspace, left foot.,POSTOPERATIVE DIAGNOSIS:,  Morton's neuroma, third interspace, left foot.,OPERATION PERFORMED: , Excision of neuroma, third interspace, left foot.,ANESTHESIA: , General (local was confirmed by surgeon).,HEMOSTASIS: , Ankle pneumatic tourniquet 225 mmHg.,TOURNIQUET TIME: , 18 minutes.  Electrocautery was necessary.,INJECTABLES: , 50:50 mixture of 0.5% Marcaine and 1% Xylocaine, both plain.  Also, 0.5 mL dexamethasone phosphate (4 mg/mL).,INDICATIONS: , Please see dictated H&P for specifics.,PROCEDURE:  ,After proper identification was made, the patient was brought to the operating room and placed on the table in supine position.  The patient was then placed under general anesthesia.  A local block was then injected into the third ray of the left foot.  The left foot was then prepped with chlorhexidine gluconate and then draped in the usual sterile technique.  The left foot was then exsanguinated with an Esmarch bandage and elevated and an ankle pneumatic tourniquet was then inflated.  Attention was then directed to the third interspace where a longitudinal incision was placed just proximal to the webspace.  The incision was deepened via sharp and blunt dissection with care taken to protect all vital structures.  Identification of the neuroma was made following plantar flexion of the digits.  It was grasped with a hemostat and it was dissected in toto and removed.  It was then sent to pathology.  The area was then flushed with copious amounts of sterile saline.  Closure was with 4-0 Vicryl in the subcutaneous tissue and then running subcuticular 4-0 nylon suture in the skin.  Steri-Strips were then placed over that area.  A sterile compressive dressing consisting of saline-soaked gauze, ABD, Kling, Coban was placed over the foot.  The tourniquet was then released.  Good flow was noted to return to all digits.  The patient did tolerate the procedure well.  He left the operating room with all vital signs stable and neurovascular status intact.  The patient went to the recovery.  The patient previously had been given both oral and written preoperative as well as postoperative instructions and a prescription for pain.  The patient will follow up with me in approximately 4 days for dressing change.","surgery, interspace, ankle pneumatic, pneumatic tourniquet, morton's neuroma, tourniquet, neuroma, foot, anesthesia,"
" Needle-localized excisional biopsy, left breast.  The patient is a 71-year-old black female who had a routine mammogram, which demonstrated suspicious microcalcifications in the left breast.  She had no palpable mass on physical exam.  She does have significant family history with two daughters having breast cancer.", Surgery, Needle-Localized Excisional Biopsy - Breast ,"PREOPERATIVE DIAGNOSIS:,  Suspicious microcalcifications, left breast.,POSTOPERATIVE DIAGNOSIS:,  Suspicious microcalcifications, left breast.,PROCEDURE PERFORMED:,  Needle-localized excisional biopsy, left breast.,ANESTHESIA:,  Local with sedation.,SPECIMEN:  ,Left breast with specimen mammogram.,COMPLICATIONS:,  None.,HISTORY: , The patient is a 71-year-old black female who had a routine mammogram, which demonstrated suspicious microcalcifications in the left breast.  She had no palpable mass on physical exam.  She does have significant family history with two daughters having breast cancer.  The patient also has a history of colon cancer.  A surgical biopsy was recommended and she was scheduled electively.,PROCEDURE:,  After proper informed consent was obtained, she was placed in the operative suite.  This occurred after undergoing preoperative needle localization.  She was placed in the operating room in the supine position.  She was given sedation by the Anesthesia Department.  The left breast was prepped and draped in the usual sterile fashion.  The skin was infiltrated with local and a curvilinear incision was made in the left lower outer quadrant.  The breast tissue was grasped with Allis clamps and a core of tissue was removed around the localization wire.  There were some fibrocystic changes noted.  The specimen was then completely removed and was sent to Radiology for mammogram.  The calcifications were seen in specimen per Dr. X.  Meticulous hemostasis was achieved with electrocautery.  The area was irrigated and suctioned.,The aspirant was clear.  The skin was then reapproximated using #4-0 undyed Vicryl in a running subcuticular fashion.  Steri-Strips and sterile dressing on the patient's bra were applied.  The patient tolerated the procedure well and was transferred to recovery room in stable condition.","surgery, suspicious microcalcifications, needle-localized excisional biopsy, needle localized excisional biopsy, routine mammogram, breast cancer, excisional biopsy, breast, needle, biopsy, mammogram, microcalcifications"
 Stage I and II neuromodulator., Surgery, Neuromodulator ,"PREOPERATIVE DIAGNOSIS:,  Refractory urgency and frequency.,POSTOPERATIVE DIAGNOSIS: , Refractory urgency and frequency.,OPERATION: , Stage I and II neuromodulator.,ANESTHESIA: , Local MAC.,ESTIMATED BLOOD LOSS:,  Minimal.,FLUIDS: , Crystalloid.  The patient was given Ancef preop antibiotic.  Ancef irrigation was used throughout the procedure.,BRIEF HISTORY: , The patient is a 63-year-old female who presented to us with urgency and frequency on physical exam.  There was no evidence of cystocele or rectocele.  On urodyanamcis, the patient has significant overactivity of the bladder.  The patient was tried on over three to four different anticholinergic agents such as Detrol, Ditropan, Sanctura, and VESIcare for at least one month each.  The patient had pretty much failure from each of the procedure.  The patient had less than 20% improvement with anticholinergics.  Options such as continuously trying anticholinergics, continuation of the Kegel exercises, and trial of InterStim were discussed.  The patient was interested in the trial.  The patient had percutaneous InterStim trial in the office with over 70% to 80% improvement in her urgency, frequency, and urge incontinence.  The patient was significantly satisfied with the results and wanted to proceed with stage I and II neuromodulator.  Risks of anesthesia, bleeding, infection, pain, MI, DVT, and PE were discussed.  Risk of failure of the procedure in the future was discussed.,Risk of lead migration that the treatment may or may not work in the long-term basis and data on the long term were not clear were discussed with the patient.  The patient understood and wanted to proceed with stage I and II neuromodulator.  Consent was obtained.,DETAILS OF THE OPERATION: , The patient was brought to the OR.  The patient was placed in prone position.  A pillow was placed underneath her pelvis area to slightly lift the pelvis up.  The patient was awake, was given some MAC anesthesia through the IV, but the patient was talking and understanding and was able to verbalize issues.  The patient's back was prepped and draped in the usual sterile fashion.  Lidocaine 1% was applied on the right side near the S3 foramen.  Under fluoroscopy, the needle placement was confirmed.  The patient felt stimulation in the vaginal area, which was tapping in nature.  The patient also had a pressure feeling in the vaginal area.  The patient had no back sensation or superficial sensation.  There was no sensation down the leg.  The patient did have __________, which turned in slide bellows response indicating the proper positioning of the needle.  A wire was placed.  The tract was dilated and lead was placed.  The patient felt tapping in the vaginal area, which is an indication that the lead is in its proper position.  Most of the leads had very low amplitude and stimulation.  Lead was tunneled under the skin and was brought out through an incision on the left upper buttocks.  Please note that the lidocaine was injected prior to the tunneling.  A pouch was created about 1 cm beneath the subcutaneous tissue over the muscle where the actual unit was connected to the lead.  Screws were turned and they were dropped.  Attention was made to ensure that the lead was all the way in into the InterStim.  Irrigation was performed after placing the main unit in the pouch.  Impedance was checked.  Irrigation was again performed with antibiotic irrigation solution.  The needle site was closed using 4-0 Monocryl.  The pouch was closed using 4-0 Vicryl and the subcutaneous tissue with 4-0 Monocryl.  Dermabond was applied.,The patient was brought to recovery in a stable condition.","surgery, refractory urgency, urgency, frequency, neuromodulator, subcutaneous tissue, interstim,"
" Needle-localized excisional biopsy of the left breast.  Left breast mass with abnormal mammogram.  The patient had a nonpalpable left breast mass, which was excised and sent to Radiology with confirmation that the mass is in the specimen.", Surgery, Needle-Localized Excisional Biopsy - Breast - 1 ,"PREOPERATIVE DIAGNOSIS: ,Left breast mass with abnormal mammogram.,POSTOPERATIVE DIAGNOSIS:,  Left breast mass with abnormal mammogram.,PROCEDURE PERFORMED:,  Needle-localized excisional biopsy of the left breast.,ANESTHESIA:,  Local with sedation.,COMPLICATIONS: , None.,SPECIMEN: , Breast mass.,DISPOSITION: , The patient tolerated the procedure well and was transferred to recovery in stable condition.,INTRAOPERATIVE FINDINGS: , The patient had a nonpalpable left breast mass, which was excised and sent to Radiology with confirmation that the mass is in the specimen.,BRIEF HISTORY:,  The patient is a 62-year-old female who presented to Dr. X's office with an abnormal mammogram showing a suspicious area on the left breast with microcalcifications and a nonpalpable mass.  So the patient was scheduled for a needle-localized left breast biopsy.,PROCEDURE:,  After informed consent, the risks and benefits of the procedure were explained to the patient.  The patient was brought to the operating suite.  After IV sedation was given, the patient was prepped and draped in normal sterile fashion.  Next, a curvilinear incision was made.,After anesthetizing the skin with 0.25% Marcaine and 1% lidocaine mixture, an incision was made with a #10 blade scalpel.  The lesion with needle was then grasped with an Allis clamp.  Using #10 blade scalpel, the specimen was colonized out and sent to Radiology for confirmation.  Next, hemostasis was obtained using electrobovie cautery.  The skin was then closed with #4-0 Monocryl suture in running subcuticular fashion.  Steri-Strips and sterile dressings were applied.  The patient tolerated the procedure well and was sent to Recovery in stable condition.","surgery, needle localized excisional biopsy, excisional biopsy, abnormal mammogram, breast mass, breast, radiology, biopsy, mammogram, needle"
 Left partial nephrectomy due to left renal mass., Surgery, Nephrectomy - Partial ,"PREOPERATIVE DIAGNOSIS:,  Left renal mass, 5 cm in diameter.,POSTOPERATIVE DIAGNOSIS:,  Left renal mass, 5 cm in diameter.,OPERATION PERFORMED: , Left partial nephrectomy.,ANESTHESIA: , General with epidural.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , About 350 mL.,REPLACEMENT: , Crystalloid and Cell Savers from the case.,INDICATIONS FOR SURGERY:  ,This is a 64-year-old man with a left renal mass that was confirmed to be renal cell carcinoma by needle biopsy.  Due to the peripheral nature of the tumor located in the mid to lower pole laterally, he has elected to undergo a partial nephrectomy.  Potential complications include but are not limited to,,1.  Infection.,2.  Bleeding.,3.  Postoperative pain.,4.  Herniation from the incision.,PROCEDURE IN DETAIL:,  Epidural anesthesia was administered in the holding area, after which the patient was transferred into the operating room.  General endotracheal anesthesia was administered, after which the patient was positioned in the flank standard position.  A left flank incision was made over the area of the twelfth rib.  The subcutaneous space was opened by using the Bovie.  The ribs were palpated clearly and the fascia overlying the intercostal space between the eleventh and twelfth rib was opened by using the Bovie.  The fascial layer covering of the intercostal space was opened completely until the retroperitoneum was entered.  Once the retroperitoneum had been entered, the incision was extended until the peritoneal envelope could be identified.  The peritoneum was swept medially.  The Finochietto retractor was then placed for exposure.  The kidney was readily identified and was mobilized from outside Gerota's fascia.  The ureter was dissected out easily and was separated with a vessel loop.  The superior aspect of the kidney was mobilized from the superior attachment.  The pedicle of the left kidney was completely dissected revealing the vein and the artery.  The artery was a single artery and was dissected easily by using a right-angle clamp.  A vessel loop was placed around the renal artery.  The tumor could be easily palpated in the lateral lower pole to mid pole of the left kidney.  The Gerota's fascia overlying that portion of the kidney was opened in the area circumferential to the tumor.  Once the renal capsule had been identified, the capsule was scored using a Bovie about 0.5 cm lateral to the border of the tumor.  Bulldog clamp was then placed on the renal artery.  The tumor was then bluntly dissected off of the kidney with a thin rim of a normal renal cortex.  This was performed by using the blunted end of the scalpel.  The tumor was removed easily.  The argon beam coagulation device was then utilized to coagulate the base of the resection.  The visible larger bleeding vessels were oversewn by using 4-0 Vicryl suture.  The edges of the kidney were then reapproximated by using 2-0 Vicryl suture with pledgets at the ends of the sutures to prevent the sutures from pulling through.  Two horizontal mattress sutures were placed and were tied down.  The Gerota's fascia was then also closed by using 2-0 Vicryl suture.  The area of the kidney at the base was covered with Surgicel prior to tying the sutures.  The bulldog clamp was removed and perfect hemostasis was evident.  There was no evidence of violation into the calyceal system.  A 19-French Blake drain was placed in the inferior aspect of the kidney exiting the left flank inferior to the incision.  The drain was anchored by using silk sutures.  The flank fascial layers were closed in three separate layers in the more medial aspect.  The lateral posterior aspect was closed in two separate layers using Vicryl sutures.  The skin was finally reapproximated by using metallic clips.  The patient tolerated the procedure well.","surgery, renal mass, bovie, finochietto retractor, gerota's fascia, herniation, bulldog clamp, needle biopsy, nephrectomy, partial nephrectomy, renal cell carcinoma, retroperitoneum, vicryl suture, gerota's, kidney, partial, renal, sutures, vicryl,"
 Left laparoscopic hand-assisted nephrectomy., Surgery, Nephrectomy ,"PREOPERATIVE DIAGNOSIS: , Left renal mass, left renal bleed.,POSTOPERATIVE DIAGNOSIS:  ,Left renal mass, left renal bleed.,PROCEDURE PERFORMED: , Left laparoscopic hand-assisted nephrectomy.,ANESTHESIA:,  General endotracheal.,EBL: , 100 mL.,The patient had a triple-lumen catheter A-line placed.,BRIEF HISTORY:,  The patient is a 54-year-old female with history of diabetic nephropathy, diabetes, hypertension, left BKA, who presented with abdominal pain with left renal bleed.  The patient was found to have a complex mass in the upper pole and the lower pole of the kidney.  MRI and CAT scan showed questionable renal mass, which could be malignant.  Initial plan was to let the patient stabilize for 2 weeks and perform the nephrectomy.  At this point, the patient was unable to go home.  The patient continually complained of pain.  The patient required about 3 to 4 units of blood transfusions prior.  The patient initially came in with hemoglobin less than 5.  The hemoglobin prior to surgery was 10.,Risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, respiratory failure, morbidity and mortality of the procedure due to her low ejection fraction were discussed.  Cardiac clearance was obtained.  The patient was high risk, family and the patient knew about the risk.  The recommendation from the pulmonologist, cardiologist, and medical team was to get the kidney out at this point because the patient and the family stated that they would not do well at home without any intervention.  The patient and family understood all the risks and benefits in order to proceed with the surgery.,DETAILS OF THE PROCEDURE:,  The patient was brought to the OR.  Anesthesia was applied.  The patient had A-line triple-lumen catheter.  The patient was placed in left side up, right side down oblique position.  All the pressure points were well padded.  The right fistula was carefully padded completely around it.  Axilla was protected.  The fistula was checked throughout the procedure to ensure that it was stable.  The arms, ankles, knees, and joints were all padded with foam.  The patient was taped to the table using 2-inch wide tape.  OG and a Foley catheter were in place.  A supraumbilical incision was made about 6 cm in size and incision was carried through the subcutaneous tissue and through the fascia and peritoneum was entered sharply.  There were some adhesions where the omentum was into the umbilical hernia, which was completely stuck.  The omentum was released out of that just so we could obtain pneumoperitoneum.  Pneumoperitoneum was obtained after using GelPort.  Two 12-mm ports were placed in the left anterior axillary line, and mid clavicular line.  The colon was reflected medially.  Kidney was dissected laterally behind and inferiorly.  There was large hematoma visualized with significant amount of old blood, which was irrigated out.  Dissection was carried superiorly and the spleen was reflected medially.  The spleen and colon were all intact at the end of the procedure.  They were stable all throughout.  Using endovascular GIA stapler, all the medial and lateral dissection was carried through the stapler to ensure that the patient had minimal bleeding due to low cardiac reserve.  Hemostasis was obtained.  The renal vein and the renal artery were stapled and there was excellent hemostasis.,The dissection was carried lateral to the adrenal and medial to the right kidney.  The adrenal was preserved.  The entire kidney was removed through the hand port.  Irrigation was performed.  There was excellent hemostasis at the end of the nephrectomy.  Fibrin glue and Surgicel were applied just in case the patient had delayed DIC.  The colon was placed back and 12-mm ports were closed under direct palpation using 0 Vicryl.  The fascia was closed using loop #1 PDS in a running fashion and was tied in the middle.  Please note that prior to the fascial closure, the peritoneum was closed using 0 Vicryl in running fashion.  The subcuticular tissue was brought together using 4-0 Vicryl.  The skin was closed using 4-0 Monocryl.  Dermabond was applied.  The patient was brought to the recovery in a stable condition.","surgery, laparoscopic, nephrectomy, laparoscopic hand assisted nephrectomy, triple lumen catheter, lumen catheter, running fashion, renal mass, renal bleed, dissection, hemostasis, kidney, renal"
" Malignant mass of the left neck, squamous cell carcinoma.  Left neck mass biopsy and selective surgical neck dissection, left.", Surgery, Neck Mass Biopsy ,"PREOPERATIVE DIAGNOSIS: , Malignant mass of the left neck.,POSTOPERATIVE DIAGNOSIS:,  Malignant mass of the left neck, squamous cell carcinoma.,PROCEDURES,1.  Left neck mass biopsy.,2.  Selective surgical neck dissection, left.,DESCRIPTION OF PROCEDURE:,  After obtaining an informed, the patient was taken to the operating room where a time-out process was followed.  Preoperative antibiotic was given and Dr. X proceeded to intubate the patient after a detailed anesthetic preparation that started in the Same Day Surgery and followed in the operating room.  Finally, a 5.5-French endotracheal tube was inserted and the patient was able to tolerate that and did have stable vital signs and a proper oxygenation.,Then, the patient was positioned with the neck slightly distended and turned toward the opposite side of the operation.  The neck was prepped and draped in the usual fashion.  I proceeded to mark the site of the mass and then also to mark the proposed site for the creation of a flap.  Then, I performed an extensive anesthetic block of the area.,Then, an incision was made along the area marked for development of the flap, but in a very limited extent, just to expose the cervical mass.  The cervical mass, which was about 4 cm in diameter and very firm and rubbery, was found lodged between the sternocleidomastoid muscle and the internal jugular vein in the area III of the neck.  A wedge sample was sent to Pathology for frozen section.  At the same time, we waited for the result and the initial report was not clear in the sense that a lot of lymphoepithelial reaction was seen.  Therefore, a larger sample was sent to Pathology and at that particular time, the fresh frozen was reported as having squamous elements.  This was not totally clear in my mind and therefore I proceeded to excise the full mass, which luckily was not attached to any structures except in the very deep surface.  There, there were some attachments to branches of the external carotid artery, which had to be suture ligated.  At any rate, the whole specimen was to the lab and finally the diagnosis was that of a metastatic squamous cell carcinoma.,With that information in hand, we proceeded to continue with a neck dissection and proceeded to make an incision along the previously marked sites of the flap, which basically involved a reverse U shape on the left neck.  This worked out quite nicely.  The external jugular vein was out of the way, so initially we did not deal with it.  We proceeded to tackle the area III and extended into II-A.  When we excised the mass, the upper end was in intimate relationship with the parotid gland, which was relatively large in this patient, but it looked normal otherwise.  Also, I felt that the submaxillary gland was enlarged.  At any rate, we decided to clean up the areas III and IV and a few nodes from II-A that were removed, and then we went into the posterior triangle where we identified the spinal accessory nerve, which we protected, actually did not even dissect close to it.,The same nerve had been already identified anterior to the internal jugular vein, very proximally behind the digastric and the sternocleidomastoid muscle.  At any rate, there were large nodes in the posterior triangle, in areas V-A and V-B, which were excised and sent to Pathology for examination.  Also, there was a remnant of a capsule of the main mass that we proceeded to excise and sent to Pathology as an extra specimen.  Hemostasis was revised and found to be adequate.  The flaps had been protected by folding it to the chest and protected by wet sponges on both sides of the flap.  The flap was replaced in its position.  A soft Jackson-Pratt catheter was left in the area, and then we proceeded to approximate the flap with a number of subcutaneous sutures of Vicryl and then running sutures of subcuticular Monocryl to the skin.  I would like to mention that also the facial vein was excised and the external jugular vein was ligated.  It was in very lateral location and it was on the site of the drain, so we ligated that but did not excise it.  A pressure dressing was applied.,The patient tolerated the procedure well.  Estimated blood loss was no more than 100 mL.  The patient was extubated in the operating room and sent for recovery.","surgery, neck mass biopsy, surgical neck dissection, internal jugular vein, external jugular vein, squamous cell carcinoma, neck mass, malignant mass, neck dissection, mass, neck, wedge, vein,"
" Nasal septoplasty, bilateral submucous resection of the inferior turbinates, and tonsillectomy and resection of soft palate.  Nasal septal deviation with bilateral inferior turbinate hypertrophy.  Tonsillitis with hypertrophy.  Edema to the uvula and soft palate.", Surgery, Nasal Septoplasty & Tonsillectomy ,"PREOPERATIVE DIAGNOSES,1.  Nasal septal deviation with bilateral inferior turbinate hypertrophy.,2.  Tonsillitis with hypertrophy.,3.  Edema to the uvula and soft palate.,POSTOPERATIVE DIAGNOSES,1.  Nasal septal deviation with bilateral inferior turbinate hypertrophy.,2.  Tonsillitis with hypertrophy.,3.  Edema to the uvula and soft palate.,OPERATION PERFORMED,1.  Nasal septoplasty.,2.  Bilateral submucous resection of the inferior turbinates.,3.  Tonsillectomy and resection of soft palate.,ANESTHESIA: , General endotracheal.,INDICATIONS: , Chris is a very nice 38-year-old male with nasal septal deviation and bilateral inferior turbinate hypertrophy causing nasal obstruction.  He also has persistent tonsillitis with hypertrophy and tonsillolith and halitosis.  He also has developed tremendous edema to his posterior palate and uvula, which is causing choking.  Correction of these mechanical abnormalities is indicated.,DESCRIPTION OF OPERATION:  ,The patient was placed on the operating room table in the supine position.  After adequate general endotracheal anesthesia was administered, the right and left nasal septal mucosa and right and left inferior turbinates were anesthetized with 1% lidocaine with 1:100,000 epinephrine using approximately 10 mL.  Afrin-soaked pledgets were placed in the nasal cavity bilaterally.  The face was prepped with pHisoHex and draped in a sterile fashion.  A hemitransfixion incision was performed on the left with a #15 blade and submucoperichondrial and mucoperiosteal flap was raised with the Cottle elevator.  Anterior to the septal deflection, the septal cartilage was incised and an opposite-sided submucoperichondrial and mucoperiosteal flap was raised with the Cottle elevator.  The deviated portion of the nasal septal cartilage and bone was removed with a Takahashi forceps, and a large inferior septal spur was removed with a V-chisel.  Once the septum was reduced in the midline, the hemitransfixion incision was closed with a 4-0 Vicryl in an interrupted fashion.  The right and left inferior turbinates were trimmed in a submucous fashion using straight and curved turbinate scissors under direct visualization with a 4 mm 0 degree Storz endoscope.  Hemostasis was acquired by using suction electrocautery.  The turbinates were then covered with bacitracin ointment after cauterizing them and bacitracin ointment soaked Doyle splints were placed in the right and left nares and secured anteriorly to the columella with a 3-0 nylon suture.  The table was then turned.  A shoulder roll placed under the shoulders and the face was draped in a clean fashion.  A McIvor mouth gag was applied.  The tongue was retracted and the McIvor was gently suspended from the Mayo stand.  The left tonsil was grasped with a curved Allis forceps, retracted medially, and the anterior tonsillar pillar was incised with Bovie electrocautery.  The tonsil was removed from the superior pole to inferior pole using a Bovie electrocautery in its entirety in a subcapsular fashion.  The right tonsil was grasped in a similar fashion, retracted medially, and the anterior tonsillar pillar was incised with Bovie electrocautery.  The tonsil was removed from the superior pole to inferior pole using Bovie electrocautery in its entirety in a subcapsular fashion.  The inferior, middle, and superior pole vessels were further cauterized with suction electrocautery.  The extremely edematous portion of soft palate was resected using a right angle clamp and right angle scissor and was closed with 3-0 Vicryl in a figure-of-eight interrupted fashion.  Copious saline irrigation of the oral cavity was then performed.  There was no further identifiable bleeding at the termination of the procedure.  The estimated blood loss was less than 10 mL.  The patient was extubated in the operating room, brought to the recovery room in satisfactory condition.  There were no intraoperative complications.","surgery, nasal septal deviation, turbinate hypertrophy, nasal septoplasty, submucous resection, resection of soft palate, tonsillectomy, bilateral inferior turbinate, bovie electrocautery, nasal septal, inferior turbinates, turbinates, nasal, tonsillitis, electrocautery, hypertrophy,"
 Left midface elevation with nasolabial fold elevation and nasolabial fold z-plasty and right symmetrization midface elevation., Surgery, Nasolabial Fold Elevation ,"PREOPERATIVE DIAGNOSIS:,  Left nasolabial fold scar deformity with effacement of alar crease.,POSTOPERATIVE DIAGNOSIS:,  Left nasolabial fold scar deformity with effacement of alar crease.,PROCEDURES PERFORMED:,1.  Left midface elevation with nasolabial fold elevation.,2.  Left nasolabial fold z-plasty and right symmetrization midface elevation.,ANESTHESIA: , General endotracheal intubation.,ESTIMATED BLOOD LOSS: , Less than 25 mL.,FLUIDS: , Crystalloid,CULTURES TAKEN: , None.,PATIENT'S CONDITION: , Stable.,IMPLANTS: , Coapt Endotine Midface B 4.5 bioabsorbable implants, reference #CFD0200197, lot #01447 used on the right and used on the left side.,IDENTIFICATION: , This patient is well known to the Stanford Plastic Surgery Service.  The patient is status post resection of the dorsal nasal sidewall skin cancer with nasolabial flap reconstruction with subsequent deformity.  In particular, the patient has had effacement of his alar crease with deepening of his nasolabial fold and notable asymmetry.  The patient was seen in consultation and felt to be a surgical candidate for improvement.  Risks and benefits of the operation were described to the patient in detail including, but not limited to bleeding, infection, scarring, possible damage to surrounding structures including neurovascular structures, need for revision of surgery, continued asymmetry, and anesthetic complication.  The patient understood these risks and benefits and consented to the operation.,PROCEDURE IN DETAIL: , The patient was taken to OR and placed supine on the operating table.  Dose of antibiotics was given to the patient.  Compression devices were placed on the lower extremities to prevent the knee embolic events.  The patient was turned to 180 degrees.  The ETT tube was secured and the area was then prepped and draped in usual sterile fashion.  A head wrap was then placed on the position and we then began our local.  Of note, the patient had previous incisions just lateral to his lateral canthus bilaterally and that were used for access.  Local consisting a 50:50 mix of 0.25% Marcaine with epinephrine and 1% lidocaine with epinephrine was then injected into the subperiosteal plane taking care to prevent injury to the infraorbital nerves.  This was done bilaterally.  We then marked the nasolabial fold and began with the elevation of the left midface.,We began with a lateral canthal-type incision extending out over his previous incision down to subcutaneous tissue.  We continued down to the lateral orbital rim until we identified periosteum.  We then pulled in a periosteal elevator and elevated the midface down over the zygoma elevating some lateral mesenteric attachments down over the buccal region until we felt we had reached pass the nasolabial folds medially.  Care was taken to preserve the infraorbital nerve and that was visualized after elevation.  We then released the periosteum distally and retracted up on the periosteum and noted improved contour of the nasolabial fold with increased bulk over the midface region over the zygoma.,We then used our Endotine Coapt device to engage the periosteum at the desired location and then elevated the midface and secured into position using the Coapt bioabsorbable screw.  After this was then carried out, we then clipped and cut as well as the end of the screw.  Satisfied with this, we then elevated the periosteum and secured it to reinforce our midface elevation to the lateral orbital rim and this was done using 3-0 Monocryl.  Several sutures were then used to anchor the orbicularis and deeper tissue to create additional symmetry.  Excess skin along the incision was then removed as well the skin from just lateral to the canthus.  Care was taken to leave the orbicularis muscle down.  We then continued closing our incision using absorbable plain gut 5-0 sutures for the subciliary-type incision and then continuing with interrupted 6-0 Prolenes lateral to the canthus.,We then turned our attention to performing the z-plasty portion of the case.  A z-plasty was designed along the previous scar where it was padding to the notable scar deformity and effacement of crease and the z-plasty was then designed to lengthen along the scar to improve the contour.  This was carried out using a 15 blade down to subcutaneous tissue.  The flaps were debulked slightly to reduce the amount of fullness and then transposed and sutured into place using chromic suture.  At this point, we then noted that he had improvement of the nasal fold but continued asymmetry with regards to improved bulk on the left side and less bulk on the right and it was felt that a symmetrization procedure was required to make more symmetry with the midface bilaterally and nasolabial folds bilaterally.  As such, we then carried out the dissection after injecting local as noted and we used a 15 blade scalpel to create our incision along the lateral canthus along its preexisting incision.  We carried this down to the lateral orbital rim again elevating the periosteum taking care to preserve infraorbital nerve.,At this point, we then released the periosteum distally just at the level of the nasolabial fold and placed our Endotine midface implant into the desired area and then elevated slightly just for symmetry only.  This was then secured in place using the bioabsorbable screw and then resected a very marginal amount of tissue just for removal of the dog ear deformity and closed the deeper layers of tissue using 3-0 PDS and then closing the extension to the subciliary area using 5-0 plain gut and then 6-0 Prolene lateral to the canthus.,At this point, we felt that we had achieved improved contour, improved symmetry, and decreased effacement of the nasolabial fold and alar crease.  Satisfied with our procedures, we then placed cool compresses on to the eyes.,The patient was then extubated and brought to the PACU in stable condition.,Dr. X was present and scrubbed for the entire case and actively participated during all key elements.  Dr. Y was available and participated in the portions of the case as well.",
" Left neck dissection.   Metastatic papillary cancer, left neck.  The patient had thyroid cancer, papillary cell type, removed with a total thyroidectomy and then subsequently recurrent disease was removed with a paratracheal dissection.", Surgery, Neck Dissection ,"PREOPERATIVE DIAGNOSIS: , Metastatic papillary cancer, left neck.,POSTOPERATIVE DIAGNOSIS: , Metastatic papillary cancer, left neck.,OPERATION PERFORMED: , Left neck dissection.,ANESTHESIA:  ,General endotracheal.,INDICATIONS: , The patient is a very nice gentleman, who has had thyroid cancer, papillary cell type, removed with a total thyroidectomy and then subsequently recurrent disease was removed with a paratracheal dissection.  He now has evidence of lesion in the left mid neck and the left superior neck on ultrasound, which are suspicious for recurrent cancer.  Left neck dissection is indicated.,DESCRIPTION OF OPERATION: , The patient was placed on the operating room table in the supine position.  After adequate general endotracheal anesthesia was administered, the table was then turned.  A shoulder roll placed under the shoulders and the face was placed in an extended fashion.  The left neck, chest, and face were prepped with Betadine and draped in a sterile fashion.  A hockey stick skin incision was performed, extending a previous incision line superiorly towards the mastoid cortex through skin, subcutaneous tissue and platysma with Bovie electrocautery on cut mode.  Subplatysmal superior and inferior flaps were raised.  The dissection was left lateral neck dissection encompassing zones 1, 2A, 2B, 3, and the superior portion of 4.  The sternocleidomastoid muscle was unwrapped at its fascial attachment and this was taken back posterior to the XI cranial nerve into the superior posterior most triangle of the neck.  This was carried forward off of the deep rooted muscles including the splenius capitis and anterior and middle scalenes taken medially off of these muscles including the fascia of the muscles, stripped from the carotid artery, the X cranial nerve, the internal jugular vein and then carried anteriorly to the lateral most extent of the dissection previously done by Dr. X in the paratracheal region.  The submandibular gland was removed as well.  The X, XI, and XII cranial nerves were preserved.  The internal jugular vein and carotid artery were preserved as well.  Copious irrigation of the wound bed showed no identifiable bleeding at the termination of the procedure.  There were two obviously positive nodes in this neck dissection.  One was left medial neck just lateral to the previous tracheal dissection and one was in the mid region of zone 2.  A #10 flat fluted Blake drain was placed through a separate stab incision and it was secured to the skin with a 2-0 silk ligature.  The wound was closed in layers using a 3-0 Vicryl in a buried knot interrupted fashion for the subcutaneous tissue and the skin was closed with staples.  A fluff and Kling pressure dressing was then applied.  The patient was extubated in the operating room, brought to the recovery room in satisfactory condition.  There were no intraoperative complications.","surgery, metastatic papillary cancer, thyroidectomy, thyroid cancer, papillary cell type, dissection, neck, metastatic, paratracheal, papillary, cancer"
" Nonpalpable neoplasm, right breast.  Needle localized wide excision of nonpalpable neoplasm, right breast.", Surgery, Needle Localized Excision - Breast Neoplasm ,"PREOPERATIVE DIAGNOSIS: , Nonpalpable neoplasm, right breast.,POSTOPERATIVE DIAGNOSIS: , Deferred for Pathology.,PROCEDURE PERFORMED:  ,Needle localized wide excision of nonpalpable neoplasm, right breast.,SPECIMEN: , Mammography.,GROSS FINDINGS:  ,This 53-year-old Caucasian female who had a nonpalpable neoplasm detected by mammography in the right breast.  After excision of neoplasm, there was a separate 1 x 2 cm nodule palpated within the cavity.  This too was excised.,OPERATIVE PROCEDURE:  ,The patient was taken to the operating room, placed in supine position in the operating table.  Intravenous sedation was administered by the Anesthesia Department.  The Kopans wire was trimmed to an appropriate length.  The patient was sterilely prepped and draped in the usual manner.  Local anesthetic consisting of 1% lidocaine and 0.5% Marcaine was injected into the proposed line of incision.  A curvilinear circumareolar incision was then made with a #15 scalpel blade close to the wire.  The wire was stabilized and brought to protrude through the incision.  Skin flaps were then generated with electrocautery.  A generous core tissue was grasped with Allis forceps and excised with electrocautery.  Prior to complete excision, the superior margin was marked with a #2-0 Vicryl suture, which was tied and cut short.  The lateral margin was marked with a #2-0 Vicryl suture, which was tied and cut along.  The posterior margin was marked with a #2-0 Polydek suture, which was tied and cut.,The specimen was then completely excised and sent off the operative field as specimen where specimen mammography confirmed the excision of the mammographically detected neoplasm.  On palpation of the cavity, there was felt to be a second nodule further medial and this was grasped with an Allis forceps and excised with electrocautery and sent off the field as a separate specimen.  Hemostasis was obtained with electrocautery.  Good hemostasis was obtained.  The incision was closed in two layers.  The first layer consisting of a subcuticular inverted interrupted sutures of #4-0 undyed Vicryl.  The second layer consisted of Steri-Strips on the epidermis.  A pressure dressing of fluff, 4x4s, ABDs, and Elastic bandage was applied.  The patient tolerated the surgery well.","surgery, neoplasm, needle localized wide excision, needle localized, nonpalpable neoplasm, needle, incision, electrocautery, excision, breast "
" Nasal septal reconstruction, bilateral submucous resection of the inferior turbinates, and bilateral outfracture of the inferior turbinates.  Chronic nasal obstruction secondary to deviated nasal septum and inferior turbinate hypertrophy.", Surgery, Nasal Septal Reconstruction ,"PREOPERATIVE DIAGNOSES:,1.  Chronic nasal obstruction secondary to deviated nasal septum.,2.  Inferior turbinate hypertrophy.,POSTOPERATIVE DIAGNOSES:,1.  Chronic nasal obstruction secondary to deviated nasal septum.,2.  Inferior turbinate hypertrophy.,PROCEDURE PERFORMED:,1.  Nasal septal reconstruction.,2.  Bilateral submucous resection of the inferior turbinates.,3.  Bilateral outfracture of the inferior turbinates.,ANESTHESIA:,  General endotracheal tube.,BLOOD LOSS: , Minimal less than 25 cc.,INDICATIONS: , The patient is a 51-year-old female with a history of chronic nasal obstruction.  On physical examination, she was derived to have a severely deviated septum with an S-shape deformity as well as turbinate hypertrophy present along the inferior turbinates contributing to the obstruction.,PROCEDURE:  ,After all risks, benefits, and alternatives have been discussed with the patient in detail, informed consent was obtained.  The patient was brought to the Operating Suite where she was placed in the supine position and general endotracheal intubation was delivered by the Department of Anesthesia.  The patient was rotated 90 degrees away.  Nasal pledgets saturated with 4 cc of 10% cocaine solution were inserted into the nasal cavities.  These were then removed and the nasal septum as well as the turbinates were localized with the mixture of 1% lidocaine with 1:100000 epinephrine solution.  The nasal pledgets were then reinserted as the patient was prepped in the usual fashion.  The nasal pledgets were again removed and the turbinates as well as an infraorbital nerve block was performed with 0.25% Marcaine solution.  The nasal vestibules were then cleansed with a pHisoHex solution.  A #15 blade scalpel was then used to make an incision along the length of the caudal septum.  The mucoperichondrial junction was then identified with the aid of cotton-tipped applicator as well as the stitch scissor.  Once the plane was identified, the mucosal flap on the left side of the septum was elevated with the aid of a Cottle.  At this point it should be mentioned that the patient's septum was significantly deviated with a large S-shape deformity obstructing both the right and left nasal cavity with the convex portion present in the left nasal cavity.  Again, the Cottle elevator was used to raise the mucosal flap down to the level of the septal spur.  At this point, the septal knife was used to make a crossover incision through the cartilage just anterior to the septal spur.  Again, the mucosal flap was elevated in the right nasal septum.  Now Knight scissors were used to remove the ascending portion of the nasal cartilage, which was then removed with a Takahashi forceps.  A Cottle elevator was used to further elevate the mucosal flap off the septal spur on the left side.  Removal of the spur was performed with the aid of the septal knife as well as a 3 mm straight chisel.  Once all ascending cartilage has been removed, inspection of the nasal cavity revealed patent passages with the exception of inferior turbinates that were very hypertrophied and was felt to be contributing to the patient's symptoms.  Therefore, the turbinates were again localized and a #15 blade scalpel was used to make a vertical incision dissected down to the chondral bone.  The XPS microdebrider with the inferior turbinate blade was then inserted through the incision and a submucous resection was performed by passing the microdebrider along the length of the bone.  Once the submucosal tissue had been resected, an outfracture procedure was performed so as to fully open the nasal passages.  Inspection revealed very patent and nonobstructive nasal passages.  Now the caudal incision was reapproximated with #4-0 chromic suture.  Finally, a #4-0 fast absorbing plain gut suture was used to approximate the mucosal surface of the septum in a running whipstitch fashion.  Finally, Merocel packing was placed and the patient was retuned to the Department of Anesthesia for awakening and taken to the recovery room without incident.","surgery, chronic nasal obstruction, nasal septum, inferior turbinate hypertrophy, nasal septal reconstruction, submucous resection, inferior turbinates, outfracture, nasal septal, nasal pledgets, nasal cavity, nasal obstruction, turbinate hypertrophy, mucosal flap, septal, septum, turbinates, nasal, cavity, chronic, hypertrophy, obstruction, mucosal,"
" Bilateral nasolacrimal probing.   Tearing, eyelash encrustation with probable tear duct obstruction bilateral.  Distal nasolacrimal duct stenosis with obstruction, left and right eye", Surgery, Nasolacrimal Probing ,"PREOPERATIVE DIAGNOSES:,  Tearing, eyelash encrustation with probable tear duct obstruction bilateral.,POSTOPERATIVE DIAGNOSES:  ,1.  Distal nasolacrimal duct stenosis with obstruction, left eye.,2.  Distal nasolacrimal duct stenosis with obstruction, right eye.,OPERATIVE PROCEDURE: , Bilateral nasolacrimal probing.,ANESTHESIA: , Monitored anesthesia care along with mask sedation.,INDICATIONS FOR SURGERY: , This young infant is a 19-month-old who has had persistent tearing and mild eyelash encrustation of each eye for many months.  Conservative measures at home have failed to completely resolve the symptoms.  He has been placed on previous antibiotics treatment for presumed conjunctivitis.  Please refer to clinic note for more details.  Conservative measures at home have failed to resolve the symptoms.  A nasolacrimal probing was offered as an elective procedure.  Procedure as well as inherent risks, expected outcomes, benefits, and alternatives (including continued observation) were discussed with his mother prior to scheduling surgery.  Again, a description of procedure as well as diagram instruction was provided to mother and father in the morning of the procedure.  The risks as explained included, but were not limited to temporary bleeding, persistent symptoms, recurrence need for further procedure, possible need for future stent placement or repeat probing, and anesthesia risk were all discussed.  Also a rare possibility of errant passage of the nasolacrimal probe was discussed.  Preoperative evaluation and explanation include drying of the nasolacrimal system with an explanation expected outcome/result from surgery.  No guarantees were offered.  Informed consent was signed and placed on the chart.,DESCRIPTION OF PROCEDURE:  ,The patient was identified and the procedure was verified.  Procedure as well as inherent risks were again discussed with parents prior to the procedure.  After anesthesia was induced in the operating room, tetracaine drops were applied to each eye and the pressure of the eyes were checked with Tono-Pen.  The pressure on the right was 17 mmHg and on the left was 16 mmHg.,A punctal dilator was then used to dilate the left superior puncta.  A size 00 Bowman probe was used to navigate the superior puncta and canaliculus with traction of the eyelid temporally.  The probe was advanced until a firm stop of the lacrimal bone was felt.  The probe was rotated in a superior and medial fashion along the brow to allow for navigation through the nasolacrimal sac and duct.  A mild resistance was felt at the distal aspect of the nasolacrimal duct consistent with a location of the valve.  There was also some mild stenosis distally, but not felt significant.  The probe was used to navigate through this mild resistance.  A second Bowman probe was then placed through the left naris and metal on metal contact was felt confirming patency.  Both probes were removed.  The 00 Bowman probe was then used to navigate the inferior puncta canaliculus system.  Patency was confirmed.  The left upper lid was everted and inspected and was found to be normal.,Attention was then turned to the right side where the similar procedure through the right superior puncta was performed.  A punctal dilator was used to dilate the puncta followed by a size 00 Bowman probe.  Again on this side, a size 0 Bowman probe was unable to be placed initially to the superior puncta.  The probe was used to navigate the superior puncta, canaliculus, and then the probe was rotated superomedially and the probe was advanced.  Similar amount of distal stenosis and distal nasolacrimal duct obstruction was felt.  The mild resistance was over come at the approximate location of the valve.  Metal-on-metal feel confirmed patency through the right naris with a second metal probe.  At the completion of the procedure all probes were removed.  Awakened and taken to the postanesthesia recovery unit in good condition having tolerated the procedure well.,Postoperative instructions were provided to the parents by me, and the discharging nurse.  I did advised nasolacrimal massage for the next 7 to 10 days on each side two to three times daily.  Technique explained and demonstrated.  Erythromycin ointment to both eyes twice daily for three days.  Follow up was arranged and he may call with any further questions or concerns.","surgery, tearing, eyelash encrustation, tear duct obstruction, nasolacrimal duct stenosis, nasolacrimal, bowman probe, distal nasolacrimal duct, nasolacrimal probing, nasolacrimal duct, superior puncta, probe, obstruction, eyelash, duct, punctal,"
 Bilateral myringotomies with insertion of Santa Barbara T-tube., Surgery, Myringotomy/Tube Insertion - 2 ,"PREOPERATIVE DIAGNOSES:  ,Tympanic membrane atelectasis and chronic eustachian tube dysfunction.,POSTOPERATIVE DIAGNOSES: , Tympanic membrane atelectasis and chronic eustachian tube dysfunction.,OPERATIVE PROCEDURE: , Bilateral myringotomies with insertion of Santa Barbara T-tube.,ANESTHESIA: , General mask.,FINDINGS:,  The patient is an 8-year-old white female with chronic eustachian tube dysfunction and TM atelectasis, was taken to the operating room for tubes.  At the time of surgery, she has had an extruding right Santa Barbara T-tube and severe left TM atelectasis with retraction.  There was a scant amount of fluid in both middle ear clefts.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed in supine position, and general mask anesthesia was established.  The right ear was draped in normal sterile fashion.  Cerumen was removed from the external canal.  The extruding Santa Barbara T-tube was identified and atraumatically removed.  A fresh Santa Barbara T-tube was atraumatically inserted and Ciloxan drops applied.,The attention was then directed to the left side where severe TM atelectasis was identified.  With a mask anesthetic, the eardrum elevated.  A radial incision was made in the inferior aspect of the tympanic membrane and middle ear fluid aspirated.  A Santa Barbara T-tube was then inserted without difficulty and 5 drops Ciloxan solution applied.  Anesthesia was then reversed and the patient taken to recovery room in satisfactory condition.","surgery, tympanic membrane, cerumen, ciloxan, santa barbara t-tube, tm atelectasis, atelectasis, eardrum, eustachian tube, eustachian tube dysfunction, middle ear, middle ear fluid, myringotomies, atelectasis and chronic eustachian, santa barbara t tube, myringotomies with insertion, chronic eustachian tube, barbara t tube, santa barbara, insertion, tube, tympanic "
" Open reduction, nasal fracture with nasal septoplasty.", Surgery, Nasal Septoplasty ,"PREOPERATIVE DIAGNOSES: , Nasal fracture and deviated nasal septum with obstruction.,POSTOPERATIVE DIAGNOSES: , Nasal fracture and deviated nasal septum with obstruction.,OPERATION:,  Open reduction, nasal fracture with nasal septoplasty.,ANESTHESIA: , General.,HISTORY: , This 16-year-old male fractured his nose playing basketball.  He has a left nasal obstruction and depressed left nasal bone.,DESCRIPTION OF PROCEDURE: , The patient was given general endotracheal anesthesia and monitored with pulse oximetry, EKG, and CO2 monitors.,The face was prepped with Betadine soap and solution and draped in a sterile fashion.  Nasal mucosa was decongested using Afrin pledgets as well as 1% Xylocaine, 1:100,000 epinephrine was injected into bilateral nasal septal mucoperichondrium and the nasal dorsum, lateral osteotomy sites.,Inspection revealed caudal portion of the cartilaginous septum lying crosswise across the nasal spine area and columella causing obstruction of the left nasal valve.  Further up, the cartilaginous septum was displaced to the left of the maxillary crest.  There was a large maxillary crest and supramaxillary crest had a large spur with the vomer bone touching the inferior turbinate.,There was a large deep groove horizontally on the right side corresponding to the left maxillary crest.,A left hemitransfixion incision was made.  Mucoperichondrium was elevated from left side of the cartilaginous septum and mucoperiosteum was elevated from the ethmoid plate.  Vomer and inferior tunnel was created at the floor of the left side of the nose to connect the anterior and inferior tunnels, which was rather difficult at the area of the vomerine spur, which was very sharp and touching the inferior turbinate.,The caudal cartilaginous septum, which was lying crosswise, was separated from the main cartilage leaving approximately 1 cm strut.  The right side mucoperichondrium was released from the cartilaginous septum as well as ethmoid plate and the maxillary crest area.,The caudal cartilaginous strut was sutured to the columella with interrupted #4-0 chromic catgut suture to bring it into the midline.,Further back, the cartilaginous septum anterior to the ethmoid plate was deviated to the left side, so it was freed from the maxillary crest, nasal dorsum, from the ethmoid plate, and was sutured in the midline with a transfixion #4-0 plain catgut sutures.,Further posteriorly, the ethmoid plate was deviated to the left side and portion of it was removed with Jansen-Middleton punch forceps.,The main deviation was also caused by the vomerine crest and the maxillary crest and supramaxillary cartilaginous cartilage.,This area was freed from the perichondrium on both sides.  The maxillary crest was removed with a gouge.  Vomer was partially removed with a gouge and the rest of the vomer was displaced back into the midline.,Thus, the deviated septum was corrected.  Left hemitransfixion incisions were closed with interrupted #4-0 chromic catgut sutures.  The septum was also filtered with #4-0 plain catgut sutures.,By valve, septal splints were tied to the septum bilaterally with a transfixion #5-0 nylon suture.,Next, the nasal bone suture deviated to the left side were corrected.  The right nasal bone was depressed and left nasal bone was wide.  Therefore, the nasal bones were refractured back into the midline by compressing the left nasal bone and elevating the right nasal bone with the nasal bone elevator through the nasal cavities.  The left intercartilaginous incision was made and the nasal bones were disimpacted subperiosteally and they were molded back into the midline.,Steri-Strips were applied to the nasal dorsal skin and a Denver type of splint was applied to the nasal dorsal to stabilize the nasal bones.,Nasal cavities were packed with Telfa gauze rolled on both sides with bacitracin ointment.  Approximate blood loss was 10 to 20 mL.","surgery, nasal fracture, deviated nasal septum, nasal septoplasty, nasal bones, ethmoid plate, cartilaginous septum, nasal bone, maxillary crest, septum, nasal, fracture, maxillary, cartilaginous, crest, "
 Bilateral myringotomies and insertion of Shepard grommet draining tubes., Surgery, Myringotomy/Tube Insertion - 1 ,"PREOPERATIVE DIAGNOSIS: , Bilateral chronic serous otitis media.,POSTOPERATIVE DIAGNOSIS: , Bilateral chronic serous otitis media.,OPERATION PERFORMED:,1.  Bilateral myringotomies.,2.  Insertion of Shepard grommet draining tubes.,ANESTHESIA: , General, by mask.,ESTIMATED BLOOD LOSS: , Less than 1 mL.,COMPLICATIONS:,  None.,FINDINGS:  ,The patient had a long history of persistent recurrent infections and was placed on antibiotics for the same.  At this point in time, he had a small amount of thick mucoid material in both middle ear spaces with middle ear mucosa somewhat inflamed, but no active acute infection at this point in time.,PROCEDURE:,  With the patient under adequate general anesthesia with the mask delivery of anesthesia, he had his ear canals cleaned utilizing an operating microscope and all foul cerumen had been removed from both sides.  Bilateral inferior radial myringotomies were performed, first on the right and then on the left.  Middle ear spaces were suctioned of small amount of thick mucoid material on both sides and then Shepard grommet draining tubes were inserted on either side.  Floxin drops were then instilled bilaterally to decrease any clotting within the tubes, and then cotton ball was placed in the external meatus bilaterally.  At this point, the patient was awakened and returned to the recovery room, satisfactory, with no difficulty encountered.","surgery, serous otitis media, floxin drops, shepard grommet, cerumen, cotton ball, middle ear, mucoid, myringotomies, tubes, shepard grommet draining tubes, serous otitis, shepard, grommet, insertion"
 Removal of the old right pressure equalizing tube.  Myringotomy with placement of a left pressure equalizing tube., Surgery, Myringotomy/Tube Insertion - 3 ,"PREOPERATIVE DIAGNOSES: ,1.  Chronic eustachian tube dysfunction.,2.  Retained right pressure equalization tube.,3.  Retracted left tympanic membrane.,4.  Dizziness.,POSTOPERATIVE DIAGNOSES:,1.  Chronic eustachian tube dysfunction.,2.  Retained right pressure equalization tube.,3.  Retracted left tympanic membrane.,4.  Dizziness.,PROCEDURE:,1.  Removal of the old right pressure equalizing tube with placement of a tube.  Tube used was Santa Barbara.,2.  Myringotomy with placement of a left pressure equalizing tube.  The tube used was Santa Barbara.,ANESTHESIA:,  General.,INDICATION: , This is a 98-year-old female whom I have known for several years.  She has a marginal hearing.  With the additional conductive loss secondary to the retraction of the tympanic membrane, her hearing aid and function deteriorated significantly.  So, we have kept sets of tubes in her ears at all times.  The major problem is that she has got small ear canals and a very sensitive external auditory canal; therefore it cannot tolerate even the wax cleaning in the clinic awake.,The patient was seen in the OR and tubes were placed.  There were no significant findings.,PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, she was brought to the neurosensory OR, placed under general anesthesia.  Mask airway was used.  IV had already been started.,On the right side, we removed the old tube and then cleaned the cerumen and found that it was larger than the side of the tube in perfection or perforation in tympanic membrane in the anterior inferior quadrant.  In the same area, a small Santa Barbara tube was placed.  This T-tube was cut to 80% of its original length for comfort and then positioned to point straight out and treated.  Three drops of ciprofloxacin eyedrops was placed in the ear canal.,On the left side, the tympanic membrane adhered and it was retracted and has some myringosclerosis.  Anterior, inferior incision was made.  Tympanic membrane bounced back to neutral position.  A Santa Barbara tube was cut to the 80% of the original length and placed in the hole.  Ciprofloxacin drops were placed in the ear.  Procedure completed.,ESTIMATED BLOOD LOSS: , None.,COMPLICATION: , None.,SPECIMEN:,  None.,DISPOSITION:,  To PACU in a stable condition.",
 Multiple stent placements with Impella circulatory assist device., Surgery, Multiple Stent Placements ,"PROCEDURE PERFORMED:,1.  Left heart catheterization, left ventriculogram, aortogram, coronary angiogram.,2.  PCI of the LAD and left main coronary artery with Impella assist device.,INDICATIONS FOR PROCEDURE: , Unstable angina and congestive heart failure with impaired LV function.,TECHNIQUE OF PROCEDURE: , After obtaining informed consent, the patient was brought to the cardiac catheterization suite in postabsorptive and nonsedated state.  The right groin was prepped and draped in the usual sterile manner.  Lidocaine 2% was used for infiltration anesthesia.  Using modified Seldinger technique, a 7-French sheath was introduced into the right common femoral artery and a 6-French sheath was introduced into the right common femoral vein.  Through the arterial sheath, angiography of the right common femoral artery was obtained.  Thereafter, 6-French pigtail catheter was advanced to the level of the distal aorta where angiography of the distal aorta and the bifurcation of the right and left common iliac arteries was obtained.  Thereafter, a 4-French sheath was introduced into the left common femoral artery using modified Seldinger technique.  Thereafter, the pigtail catheter was advanced over an 0.035-inch J-wire into the left ventricle and LV-gram was performed in RAO view and after pullback, an aortogram was performed in the LAO view.  Therefore, a 6-French JL4 and JR4 guiding catheters were used to engage the left and right coronary arteries respectively and multiple orthogonal views of the coronary arteries were obtained.,ANGIOGRAPHIC FINDINGS:  ,1.  LV-gram:  LVEDP was 15 mmHg.  LV ejection fraction 10% to 15% with global hypokinesis.  Only anterior wall is contracting.  There was no mitral regurgitation.  There was no gradient across the aortic valve upon pullback, and on aortography, there was no evidence of aortic dissection or aortic regurgitation.,2.  The right coronary artery is a dominant vessels with a mid 50% to 70% stenosis which was not treated.  The left main coronary artery calcified vessel with disease.,2.  The left anterior descending artery had an 80% to 90% mid-stenosis.  First diagonal branch had a more than 90% stenosis.,3.  The circumflex coronary artery had a patent stent.,INTERVENTION: , After reviewing the angiographic images, we elected to proceed with intervention of the left anterior descending artery.  The 4-French sheath in the left common femoral artery was upsized to a 12-French Impella sheath through which an Amplatz wire and a 6-French multipurpose catheter were advanced into the left ventricle.  The Amplatz wire was exchanged for an Impella 0.018-inch stiff wire.  The multipurpose catheter was removed, and the Impella was advanced into the left ventricle and a performance level of 8 was achieved with a cardiac output of 2 to 2.5 l/min.  Thereafter, a 7-French JL4 guiding catheter was used to engage the left coronary artery and an Asahi soft 0.014-inch wire was advanced into the left anterior descending artery and a second 0.014-inch Asahi soft wire was advanced into the diagonal branch.  The diagonal branch was predilated with a 2.5 x 30-mm Sprinter balloon at nominal atmospheres and thereafter a 2.5 x 24 Endeavor stent was successfully deployed in the mid-LAD and a 3.0 x 15-mm Endeavor stent was deployed in the proximal LAD.  The stent delivery balloon was used to post-dilate the overlapping segment.  The LAD, the diagonal was rewires with an 0.014-inch Asahi soft wire and a 3.0 x 20-mm Maverick balloon was advanced into the LAD for post-dilatation and a 2.0 x 30-mm Sprinter balloon was advanced into the diagonal for kissing inflations which were performed at nominal atmospheres.  At this point, it was noted that the left main had a retrograde dissection.  A 3.5 x 18-mm Endeavor stent was successfully deployed in the left main coronary artery.  The Asahi soft wire in the diagonal was removed and placed into the circumflex coronary artery.  Kissing inflations of the LAD and the circumflex coronary artery were performed using 3.0 x 20 Maverick balloons x2 balloons, inflated at high atmospheres of 14.,RESULTS: , Lesion reduction in the LAD FROM 90% to 0% and TIMI 3 flow obtained.  Lesion reduction in the diagonal from 90% to less than 60% and TIMI 3 flow obtained.  Lesion reduction in the left maintained coronary artery from 50% to 0% and TIMI 3 flow obtained.,The patient tolerated the procedure well and the inflations well with no evidence of any hemodynamic instability.  The Impella device was gradually decreased from performance level of 8 to performance level of 1 at which point it was removed into the aorta and it was turned off and the Impella was removed from the body and the 2 Perclose sutures were tightened.  From the right common femoral artery, a 6-French IMA catheter was advanced and an 0.035-inch wire down into the left common femoral and superficial femoral artery, over which an 8 x 40 balloon was advanced and tamponade of the arteriotomy site of the left common femoral artery was performed from within the artery at 3 atmospheres for a total of 20 minutes.  The right common femoral artery and vein sheaths were both sutured in place for further observation.  Of note, the patient received Angiomax during the procedure and an ACT above 300 was maintained.,IMPRESSION:,1.  Left ventricular dysfunction with ejection fraction of 10% to 15%.,2.  High complex percutaneous coronary intervention of the left main coronary artery, left anterior descending artery, and diagonal with Impella circulatory support.,COMPLICATIONS: , None.,The patient tolerated the procedure well with no complications.  The estimated blood loss was 200 ml.  Estimated dye used was 200 ml of Visipaque.  The patient remained hemodynamically stable with no hypotension and no hematomas in the groins.,PLAN:  ,1.  Aspirin, Plavix, statins, beta blockers, ACE inhibitors as tolerated.,2.  Hydration.,3.  The patient will be observed over night for any hemodynamic instability or ischemia.  If she remains stable, the right common femoral artery and vein sheaths will be removed and manual pressure will be applied for hemostasis.","surgery, impella circulatory assist device, impella assist device, unstable angina, congestive heart failure, heart catheterization, ventriculogram, aortogram, angiogram, ventricular dysfunction, pigtail catheter was advanced, femoral artery and vein, artery and vein, asahi soft wire, circumflex coronary artery, common femoral artery, modified seldinger technique, multiple stent placements, timi flow, multiple stent, impella circulatory, french sheath, femoral artery, endeavor stent, descending artery, coronary artery, common femoral, asahi soft, anterior descending, femoral, coronary, artery, impella, catheterization, "
" Bilateral myringotomies, insertion of PE tubes, and pharyngeal anesthesia.", Surgery, Myringotomy/Tube Insertion ,"PREOPERATIVE DIAGNOSES:,  Chronic otitis media with effusion, conductive hearing loss, and recurrent acute otitis media.,POSTOPERATIVE DIAGNOSES:,  Chronic otitis media with effusion, conductive hearing loss, and recurrent acute otitis media.,OPERATION: , Bilateral myringotomies, insertion of PE tubes, and pharyngeal anesthesia.,ANESTHESIA:  ,General via facemask.,ESTIMATED BLOOD LOSS: , None.,COMPLICATIONS: , None.,INDICATIONS:  ,The patient is a one-year-old with history of chronic and recurrent episodes of otitis media with persistent middle ear effusions resistant to medical therapy.,PROCEDURE: , The patient was brought to the operating room, was placed in supine position.  General anesthesia was begun via face mask technique.  Once an adequate level of anesthesia was obtained, the operating microscope was brought, positioned and visualized the right ear canal.  A small amount of wax was removed with a loop.  A 4-mm operating speculum was then introduced.  An anteroinferior quadrant radial myringotomy was then performed.  A large amount of mucoid middle ear effusion was aspirated from the middle ear cleft.  Reuter bobbin PE tube was then inserted, followed by Floxin otic drops and a cotton ball in the external meatus.  Head was then turned to the opposite side, where similar procedure was performed.  Once again, the middle ear cleft had a mucoid effusion.  A tube was inserted to an anteroinferior quadrant radial myringotomy.,Anesthesia was then reversed and the patient was transported to the recovery room having tolerated the procedure well with stable signs.","surgery, bilateral myringotomies, insertion of pe tubes, chronic otitis media, conductive hearing loss, recurrent acute otitis media, reuter bobbin, radial myringotomy, ear cleft, pe tubes, middle ear, otitis media, effusion, otitis, media, ear, anesthesia"
 Mohs Micrographic Surgery for basal cell CA at mid parietal scalp., Surgery, Mohs Micrographic Surgery - 1 ,"PREOP DIAGNOSIS: , Basal Cell CA.,POSTOP DIAGNOSIS:,  Basal Cell CA.,LOCATION: , Mid parietal scalp.,PREOP SIZE:,  1.5 x 2.9 cm,POSTOP SIZE:,  2.7 x 2.9 cm,INDICATION:,  Poorly defined borders.,COMPLICATIONS:,  None.,HEMOSTASIS:, Electrodessication.,PLANNED RECONSTRUCTION:,  Simple Linear Closure.,DESCRIPTION OF PROCEDURE:,  Prior to each surgical stage, the surgical site was tested for anesthesia and reanesthetized as needed, after which it was prepped and draped in a sterile fashion.,The clinically-apparent tumor was carefully defined and debulked prior to the first stage, determining the extent of the surgical excision.  With each stage, a thin layer of tumor-laden tissue was excised with a narrow margin of normal appearing skin, using the Mohs fresh tissue technique.  A map was prepared to correspond to the area of skin from which it was excised.  The tissue was prepared for the cryostat and sectioned.  Each section was coded, cut and stained for microscopic examination.  The entire base and margins of the excised piece of tissue were examined by the surgeon.  Areas noted to be positive on the previous stage (if applicable) were removed with the Mohs technique and processed for analysis.,No tumor was identified after the final stage of microscopically controlled surgery.  The patient tolerated the procedure well without any complication.  After discussion with the patient regarding the various options, the best closure option for each defect was selected for optimal functional and cosmetic results.","surgery, basal cell ca, basal cell, mohs technique, mohs, tumor-laden tissue, mohs fresh tissue technique, mohs micrographic surgery, micrographic surgery, parietal scalp, micrographic, basal, cell, ca, surgical, tumor, tissue, stage,"
 Mitral valve repair using a quadrangular resection of the P2 segment of the posterior leaflet.  Mitral valve posterior annuloplasty using a Cosgrove Galloway Medtronic fuser band.  Posterior leaflet abscess resection., Surgery, Mitral Valve Repair & Annuloplasty ,"OPERATIONS,1.  Mitral valve repair using a quadrangular resection of the P2 segment of the posterior leaflet.,2.  Mitral valve posterior annuloplasty using a Cosgrove Galloway Medtronic fuser band.,3.  Posterior leaflet abscess resection.,ANESTHESIA:  ,General endotracheal anesthesia,TIMES:  ,Aortic cross-clamp time was ** minutes.  Cardiopulmonary bypass time total was ** minutes.,PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered.  Next, the patient's chest and legs were prepped and draped in standard surgical fashion.  A #10-blade scalpel was used to make a midline median sternotomy incision.  Dissection was carried down to the level of the sternum using Bovie electrocautery.  The sternum was opened with a sternal saw, and full-dose heparinization was given.  Next, the chest retractor was positioned.  The pericardium was opened with Bovie electrocautery and pericardial stay sutures were positioned.  We then prepared to place the patient on cardiopulmonary bypass.  A 2-0 Ethibond double pursestring was placed in the ascending aorta.  Through this was passed our aortic cannula and connected to the arterial side of the cardiopulmonary bypass machine.  Next, double cannulation with venous cannulas was instituted.  A 3-0 Prolene pursestring was placed in the right atrial appendage.  Through this was passed our SEC cannula.  This was connected to the venous portion of the cardiopulmonary bypass machine in a Y-shaped circuit.  Next, a 3-0 Prolene pursestring was placed in the lower border of the right atrium.  Through this was passed our inferior vena cava cannula.  This was likewise connected to the Y connection of our venous cannula portion.  We then used a 4-0 U-stitch in the right atrium for our retrograde cardioplegia catheter, which was inserted.  Cardiopulmonary bypass was instituted.  Metzenbaum scissors were used to dissect out the SVC and IVC, which were subsequently encircled with umbilical tape.  Sondergaard's groove was taken down.  Next, an antegrade cardioplegia needle and associated sump were placed in the ascending aorta.  This was connected appropriately as was the retrograde cardioplegia catheter.  Next, the aorta was cross-clamped, and antegrade and retrograde cardioplegia was infused so as to arrest the heart in diastole.  Next a #15-blade scalpel was used to open the left atrium.  The left atrium was decompressed with pump sucker.  Next, our self-retaining retractor was positioned so as to bring the mitral valve up into view.  Of note was the fact that the mitral valve P2 segment of the posterior leaflet had an abscess associated with it.  The borders of the P2 segment abscess were defined by using a right angle to define the chordae which were encircled with a 4-0 silk.  After doing so, the P2 segment of the posterior leaflet was excised with a #11-blade scalpel.  Given the laxity of the posterior leaflet, it was decided to reconstruct it with a 2-0 Ethibond pledgeted suture.  This was done so as to reconstruct the posterior annular portion.  Prior to doing so, care was taken to remove any debris and abscess-type material.  The pledgeted stitch was lowered into place and tied.  Next, the more anterior portion of the P2 segment was reconstructed by running a 4-0 Prolene stitch so as to reconstruct it.  This was done without difficulty.  The apposition of the anterior and posterior leaflet was confirmed by infusing solution into the left ventricle.  There was noted to be a small amount of central regurgitation.  It was felt that this would be corrected with our annuloplasty portion of the procedure.  Next, 2-0 non-pledgeted Ethibond sutures were placed in the posterior portion of the annulus from trigone to trigone in interrupted fashion.  Care was taken to go from trigone to trigone.  Prior to placing these sutures, the annulus was sized and noted to be a *** size for the Cosgrove-Galloway suture band ring from Medtronic.  After, as mentioned, we placed our interrupted sutures in the annulus, and they were passed through the CG suture band.  The suture band was lowered into position and tied in place.  We then tested our repair and noted that there was very mild regurgitation.  We subsequently removed our self-retaining retractor.  We closed our left atriotomy using 4-0 Prolene in a running fashion.  This was done without difficulty.  We de-aired the heart.  We then gave another round of antegrade and retrograde cardioplegia in warm fashion.  The aortic cross-clamp was removed, and the heart gradually resumed electromechanical activity.  We then removed our retrograde cardioplegia catheter from the coronary sinus and buttressed this site with a 5-0 Prolene.  We placed 2 ventricular and 2 atrial pacing leads which were brought out through the skin.  The patient was gradually weaned off cardiopulmonary bypass and our venous cannulas were removed.  We then gave full-dose protamine; and after noting that there was no evidence of a protamine reaction, we removed our aortic cannula.  This site was buttressed with a 4-0 Prolene on an SH needle.  The patient tolerated the procedure well.  We placed a mediastinal #32-French chest tube as well as a right chest Blake drain.  The mediastinum was inspected for any signs of bleeding.  There were none.  We closed the sternum with #7 sternal wires in interrupted figure-of-eight fashion.  The fascia was closed with a #1 Vicryl followed by a 2-0 Vicryl, followed by 3-0 Vicryl in a running subcuticular fashion.  The instrument and sponge count was correct at the end of the case.  The patient tolerated the procedure well and was transferred to the intensive care unit in good condition.","surgery, mitral valve repair, mitral valve, abscess resection, leaflet abscess, cosgrove galloway medtronic, bovie electrocautery, cannulation, bypass, annuloplasty, cardioplegia, mitral"
 Mohs Micrographic Surgery for basal cell CA at medial right inferior helix., Surgery, Mohs Micrographic Surgery - 2 ,"PREOP DIAGNOSIS: , Basal Cell CA.,POSTOP DIAGNOSIS:,  Basal Cell CA.,LOCATION:  ,Medial right inferior helix.,PREOP SIZE:,  1.4 x 1 cm,POSTOP SIZE: , 2.7 x 2 cm,INDICATION: , Poorly defined borders.,COMPLICATIONS: , None.,HEMOSTASIS: , Electrodessication.,PLANNED RECONSTRUCTION: , Wedge resection advancement flap.,DESCRIPTION OF PROCEDURE: , Prior to each surgical stage, the surgical site was tested for anesthesia and reanesthetized as needed, after which it was prepped and draped in a sterile fashion.,The clinically-apparent tumor was carefully defined and debulked prior to the first stage, determining the extent of the surgical excision.  With each stage, a thin layer of tumor-laden tissue was excised with a narrow margin of normal appearing skin, using the Mohs fresh tissue technique.  A map was prepared to correspond to the area of skin from which it was excised.  The tissue was prepared for the cryostat and sectioned.  Each section was coded, cut and stained for microscopic examination.  The entire base and margins of the excised piece of tissue were examined by the surgeon.  Areas noted to be positive on the previous stage (if applicable) were removed with the Mohs technique and processed for analysis.,No tumor was identified after the final stage of microscopically controlled surgery.  The patient tolerated the procedure well without any complication.  After discussion with the patient regarding the various options, the best closure option for each defect was selected for optimal functional and cosmetic results.","surgery, medial right inferior helix, wedge resection advancement flap, tumor-laden tissue, mohs fresh tissue technique, mohs technique, mohs micrographic surgery, basal cell ca, micrographic surgery, basal cell, micrographic, helix, basal, cell, ca, mohs, tissue, stage,"
" Arthroscopy with arthroscopic rotator cuff debridement, anterior acromioplasty, and Mumford procedure left shoulder.  Partial rotator cuff tear with impingement syndrome.  Degenerative osteoarthritis of acromioclavicular joint, left shoulder, rule out slap lesion.", Surgery, Mumford Procedure & Acromioplasty ,"PREOPERATIVE DIAGNOSES:,1.  Partial rotator cuff tear with impingement syndrome.,2.  Degenerative osteoarthritis of acromioclavicular joint, left shoulder, rule out slap lesion.,POSTOPERATIVE DIAGNOSES:,1.  Partial rotator cuff tear with impingement syndrome.,2.  Degenerative osteoarthritis of acromioclavicular joint, left shoulder.,PROCEDURE PERFORMED:,1.  Arthroscopy with arthroscopic rotator cuff debridement.,2.  Anterior acromioplasty.,3.  Mumford procedure left shoulder.,SPECIFICATIONS: , The entire operative procedure was done in Inpatient Operative Suite, Room #1 at ABCD General Hospital.  This was done in a modified beach chair position with interscalene and subsequent general anesthetic.,HISTORY AND GROSS FINDINGS: , This is a 38-year-old morbidly obese white male suffering increasing pain in his left shoulder for a number of months prior to surgical intervention.  He was refractory to conservative outpatient therapy.  He had injection of his AC joint, which removed symptoms but was not long lasting.  After discussing the alternatives of the care as well as advantages and disadvantages, risks, complications, and expectations, he elected to undergo the above-stated procedure on this date.,Intraarticular viewing of the joint revealed a partial rotator cuff tear on the supraspinatus insertion on the joint side.  All else was noted to be intact including the glenohumeral joint, the long head of the biceps, and the labrum.  The remainder of the rotator cuff observed was noted to be intact.  Subacromially, the patient was noted to have increased synovitis.  Degenerative changes were noted upon observation of the distal clavicle.,OPERATIVE PROCEDURE: , The patient was laid supine upon the operative table.  After receiving interscalene block anesthetic by Anesthesia Department, the patient was placed in modified beach chair position.  He was prepped and draped in the usual sterile manner.  Portals were created posteriorly and anteriorly from outside to in.  A full and complete diagnostic intraarticular arthroscopy was carried out.  Debridement was carried out through a 3.5 meniscal shaver to the 4.2 meniscal shaver to the undersurface of the partial tear of the rotator cuff.  Retrospectively it was approximately 25% of the generalized thickness.,Attention was then turned to the subacromial region.  The scope was directed subacromially.  A portal was created laterally.  Ultimately, the patient needed a general anesthetic once we were closer to the distal clavicle.  Gross bursectomy was carried out with a 4.2 meniscal shaver.  #18-gauge spinal needles have been placed to outline the anterior acromion prior to this.,It was difficult to control the patient's blood pressure with systolics ranging anywhere from 165 or 170 up to 200.  Because of this and difficulties with his anesthetic, it was elected to change to an open procedure.  Thus, the patient was anesthetized safely and secured.  An oblique incision was carried at the cross Langer's line across the outlet of the shoulder through the skin and subcutaneous tissue.  Hemostasis was controlled via electrocoagulation.  Flaps were created.  Anterior deltoid was reflected inferiorly.  Anterior acromioplasty was carried out with a saw then a Micro-Aire and then a beaver-tail rasp.  An excellent decompression was present.  CA ligament had been previously resected.  We then took the incision over the distal clavicle.  The end of the distal clavicle approximately 12 mm to 14 mm was isolated and removed with the Micro-Aire saw.  The beaver-tail rasp was utilized to smooth off the edges.  Pain buster catheter was placed deep to closure of the AC capsule and then to the deltoid with interrupted #1 Vicryl.  Transosseous sutures were placed across the acromion and the deltoid was elevated and closed with the same.  A superficial running #2-0 Vicryl suture was utilized for deltoid closure distally.  Interrupted #2-0 Vicryl was utilized to subcutaneous fat closure, running #4-0 subcuticular stitch for skin closure and Adaptic, 4x4s, ABDs, and Elastoplast tape placed for compression dressing.  0.25% Marcaine was flooded into the joint prior to the skin closure.  Pain buster catheter was hooked up.  The patient's arm was placed in arm sling.  He was safely transferred to the PACU in apparent satisfactory condition.  Expected surgical prognosis on this patient is fair.","surgery, slap lesion, acromioclavicular joint, impingement syndrome, mumford procedure, acromioplasty, arthroscopy, arthroscopic, arthroscopic rotator cuff debridement, anterior acromioplasty, rotator cuff tear, arthroscopic rotator, meniscal shaver, cuff tear, rotator cuff, debridement, osteoarthritis, acromioclavicular, clavicle, deltoid, rotator, cuff, shoulder, joint"
 Endoscopic subperiosteal midface lift using the endotine midface suspension device.  Transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad., Surgery, Midface Lift & Blepharoplasty ,"PREOPERATIVE DIAGNOSES:,1.  Request for cosmetic surgery.,2.  Facial asymmetry following motor vehicle accident.,POSTOPERATIVE DIAGNOSES:,1.  Request for cosmetic surgery.,2.  Facial asymmetry following motor vehicle accident.,PROCEDURES:,1.  Endoscopic subperiosteal midface lift using the endotine midface suspension device.,2.  Transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad.,ANESTHESIA: , General via endotracheal tube.,INDICATIONS FOR OPERATION: , The patient is a 28-year-old country and western performer who was involved in a motor vehicle accident over a year ago.  Since that time, she is felt to have facial asymmetry, which is apparent in publicity photographs for her record promotions.  She had requested a procedure to bring about further facial asymmetry.  She was seen preoperatively by psychiatrist specializing in body dysmorphic disorder as well as analysis of the patient's requesting cosmetic surgery and was felt to be a psychiatrically good candidate.  She did have facial asymmetry with the bit of more fullness in higher cheekbone on the right as compared to the left.  Preoperative workup including CT scan failed to show any skeletal trauma.  The patient was counseled with regard to the risks, benefits, alternatives, and complications of the postsurgical procedure including but not limited to bleeding, infection, unacceptable cosmetic appearance, numbness of the face, change in sensation of the face, facial nerve paralysis, need for further surgery, need for revision, hair loss, etc., and informed consent was obtained.,PROCEDURE:,  The patient was taken to the operating room, placed in supine position after having been marked in the upright position while awake.  General endotracheal anesthesia was induced with a #6 endotracheal tube.  All appropriate measures were taken to preserve the vocal cords in a professional singer.  Local anesthesia consisting of 5/6th 1% lidocaine with 1:100,000 units of epinephrine in 1/6th 0.25% Marcaine was mixed and then injected in a regional field block fashion in the subperiosteal plane via the gingivobuccal sulcus injection on either side as well as into the temporal fossa at the level of the true temporal fascia.  The upper eyelids were injected with 1 cc of 1% Xylocaine with 1:100,000 units of epinephrine.  Adequate time for vasoconstriction and anesthesia was allowed to be obtained.  The patient was prepped and draped in the usual sterile fashion.  A 4-0 silk suture was placed in the right lower lid.  For traction, it was brought anteriorly.  The conjunctiva was incised with the needle tip Bovie with Jaeger lid plate protecting the cornea and globe.  A Q-Tip was then used to separate the orbicularis oculi muscle from the fat pad beneath and carried down to the bone.  The middle and medial fat pads were identified and a small amount of fat was removed from each to take care of the pseudofat herniation, which was present.  The inferior oblique muscle was identified, preserved, and protected throughout the procedure.  The transconjunctival incision was then closed with buried knots of 6-0 fast absorbing gut.  Contralateral side was treated in similar fashion with like results and throughout the procedure.  Lacri-Lube was in the eyes in order to maintain hydration.  Attention was next turned to the midface, where a temporal incision was made parallel to the nasojugal folds.  Dissection was carried out with the hemostat down to the true temporal fascia and the endoscopic temporal dissection dissector was used to elevate the true temporal fascia.  A 30-degree endoscope was used to visualize the fat pads, so that we knew we are in the proper plane.  Subperiosteal dissection was carried out over the zygomatic arch and Whitnall's tubercle and the temporal dissection was completed.,Next, bilateral gingivobuccal sulcus incisions were made and a Joseph elevator was used to elevate the periosteum of the midface and anterior face of the maxilla from the tendon of the masseter muscle up to Whitnall's tubercle.  The two dissection planes within joint in the subperiosteal fashion and dissection proceeded laterally out to the zygomatic neurovascular bundle.  It was bipolar electrocauteried and the tunnel was further dissected free and opened.  The endotine 4.5 soft tissue suspension device was then inserted through the temporal incision, brought down into the subperiosteal midface plane of dissection.  The guard was removed and the suspension spikes were engaged into the soft tissues.  The spikes were elevated superiorly such that a symmetrical midface elevation was carried out bilaterally.  The endotine device was then secured to the true temporal fascia with three sutures of 3-0 PDS suture.  Contralateral side was treated in similar fashion with like results in order to achieve facial symmetry and symmetry was obtained.  The gingivobuccal sulcus incisions were closed with interrupted 4-0 chromic and the scalp incision was closed with staples.  The sterile dressing was applied.  The patient was awakened in the operating room and taken to the recovery room in good condition.","surgery, cosmetic surgery, jaeger lid plate, lacri-lube, q-tip, blepharoplasty, conjunctiva, facial asymmetry, fat pad, lower lid, midface lift, regional field block, temporal fascia, temporal fossa, vasoconstriction, true temporal fascia, gingivobuccal sulcus, gingivobuccal,"
 Right middle ear exploration with a Goldenberg TORP reconstruction., Surgery, Middle Ear Exploration ,"PREOPERATIVE DIAGNOSIS: , Right profound mixed sensorineural conductive hearing loss.,POSTOPERATIVE DIAGNOSIS:,  Right profound mixed sensorineural conductive hearing loss.,PROCEDURE PERFORMED:,  Right middle ear exploration with a Goldenberg TORP reconstruction.,ANESTHESIA:,  General ,ESTIMATED BLOOD LOSS:,  Less than 5 cc.,COMPLICATIONS:,  None.,DESCRIPTION OF FINDINGS:,  The patient consented to revision surgery because of the profound hearing loss in her right ear.  It was unclear from her previous operative records and CT scan as to whether or not she was a reconstruction candidate.  She had reports of stapes fixation as well as otosclerosis on her CT scan.,At surgery, she was found to have a mobile malleus handle, but her stapes was fixed by otosclerosis.  There was no incus.  There was no specific round window niche.  There was a very minute crevice; however, exploration of this area did not reveal a niche to a round window membrane.  The patient had a type of TORP prosthesis, which had tilted off the footplate anteriorly underneath the malleus handle.,DESCRIPTION OF THE PROCEDURE:,  The patient was brought to the operative room and placed in supine position.  The right face, ear, and neck prepped with ***** alcohol solution.  The right ear was draped in the sterile field.  External auditory canal was injected with 1% Xylocaine with 1:50,000 epinephrine.  A Fisch indwelling incision was made and a tympanomeatal flap was developed in a 12 o'clock to the 7 o'clock position.  Meatal skin was elevated, middle ear was entered.  This exposure included the oval window, round window areas.  There was a good cartilage graft in place and incorporated into the posterior superior ***** of the drum.  The previous prosthesis was found out of position as it had tilted out of position anteriorly, and there was no contact with the footplate.  The prosthesis was removed without difficulty.  The patient's stapes had an arch, but the ***** was atrophied.  Malleus handle was mobile.  The footplate was fixed.  Consideration have been given to performing a stapedectomy with a tissue seal and then returning later for prosthesis insertion; however, upon inspection of the round window area, there was found to be no definable round window niche, no round window membrane.  The patient was felt to have obliterated otosclerosis of this area along with the stapes fixation.  She is not considered to be a reconstruction candidate under the current circumstances.  No attempt was made to remove bone from the round window area.  A different style of Goldenberg TORP was placed on the footplate underneath the cartilage support in hopes of transferring some sound conduction from the tympanic membrane to the footplate.  The fit was secure and supported with Gelfoam in the middle ear.  The tympanomeatal flap was returned to anatomic position supported with Gelfoam saturated Ciprodex.  The incision was closed with #4-0 Vicryl and individual #5-0 nylon to the skin, and a sterile dressing was applied.","surgery, conductive hearing loss, goldenberg, meatal skin, torp, torp reconstruction, ear, ear exploration, handle, malleus, otosclerosis, sensorineural, stapedectomy, tympanomeatal, middle ear exploration, hearing loss, malleus handle, middle ear, middle"
 Mini-laparotomy radical retropubic prostatectomy with bilateral pelvic lymph node dissection with Cavermap.  Adenocarcinoma of the prostate., Surgery, Mini Laparotomy & Radical Retropubic Prostatectomy ,"PREOPERATIVE DIAGNOSIS:,  Adenocarcinoma of the prostate.,POSTOPERATIVE DIAGNOSIS:,  Adenocarcinoma of the prostate.,TITLE OF OPERATION:,  Mini-laparotomy radical retropubic prostatectomy with bilateral pelvic lymph node dissection with Cavermap.,ANESTHESIA: , General by intubation.,Informed consent was obtained for the procedure.  The patient understands the treatment options and wishes to proceed.  He accepts the risks to include bleeding requiring transfusion, infection, sepsis, incontinence, impotence, bladder neck constricture, heart attack, stroke, pulmonary emboli, phlebitis, injury to the bladder, rectum, or ureter, etcetera.,OPERATIVE PROCEDURE IN DETAIL: , The patient was taken to the Operating Room and placed in the supine position, prepped with Betadine solution and draped in the usual sterile fashion.  A 20- French Foley catheter was inserted into the penis and into the bladder and placed to dependent drainage.  The table was then placed in minimal flexed position.  A midline skin incision was then made from the umbilicus to the symphysis pubis.  It was carried down to the anterior rectus fascia into the pelvis proper.  Both obturator fossae were exposed.  Standard bilateral pelvic lymph node dissections were carried out.  The left side was approached first by myself.  The limits of my dissection were from the external iliac vein laterally to the obturator nerve medially, and from the bifurcation of the common iliac vein proximally to Cooper's ligament distally.  Meticulous lymphostasis and hemostasis was obtained using hemoclips and 2-0 silk ligatures.  The obturator nerve was visualized throughout and was not injured.  The right side was carried out by my assistant under my direct and constant supervision.  Again, the obturator nerve was visualized throughout and it was not injured.  Both packets were sent to Pathology where no evidence of carcinoma was found.,My attention was then directed to the prostate itself.  The  endopelvic fascia was opened bilaterally.  Using gentle dissection with a Kitner, I swept the levator muscles off the prostate and exposed the apical portion of the prostate.  A back bleeding control suture of 0 Vicryl was placed at the mid-prostate level.  A sternal wire was then placed behind the dorsal vein complex which was sharply transected.  The proximal and distal portions of this complex were then oversewn with 2-0 Vicryl in a running fashion.  When I was satisfied that hemostasis was complete, my attention was then turned to the neurovascular bundles.,The urethra was then sharply transected and six sutures of 2-0 Monocryl placed at the 1, 3, 5, 7, 9 and 11 o'clock positions.  The prostate was then lifted retrograde in the field and was swept from the anterior surface of the rectum and the posterior layer of Denonvilliers' fascia was incised distally, swept off the rectum and incorporated with the prostate specimen.  The lateral pedicles over the seminal vesicles were then mobilized, hemoclipped and transected.  The seminal vesicles themselves were then mobilized and hemostasis obtained using hemoclips.  Ampullae of the vas were mobilized, hemoclipped and transected.  The bladder neck was then developed using careful blunt and sharp dissection.  The prostate was then transected at the level of the bladder neck and sent for permanent specimen.  The bladder neck was reevaluated and the ureteral orifices were found to be placed well back from the edge.  The bladder neck was reconstructed in standard fashion.  It was closed using a running 2-0 Vicryl.  The mucosa was everted over the edge of the bladder neck using interrupted 3-0 Vicryl suture.  At the end of this portion of the case, the new bladder neck had a stoma-like appearance and would accommodate easily my small finger.  The field was then re-evaluated for hemostasis which was further obtained using hemoclips, Bovie apparatus and 3-0 chromic ligatures.  When I was satisfied that hemostasis was complete, the aforementioned Monocryl sutures were then placed at the corresponding positions in the bladder neck.  A new 20-French Foley catheter was brought in through the urethra into the bladder.  A safety suture of 0 Prolene was brought through the end of this and out through a separate stab wound in the bladder and through the left lateral quadrant.  The table was taken out of flexion and the bladder was then brought into approximation to the urethra and the Monocryl sutures were ligated.  The bladder was then copiously irrigated with sterile water and the anastomosis was found to be watertight.  The pelvis was also copiously irrigated with 2 liters of sterile water.  A 10-French Jackson-Pratt drain was placed in the pelvis and brought out through the right lower quadrant and sutured in place with a 2-0 silk ligature.,The wound was then closed in layers.  The muscle was closed with a running 0 chromic, the fascia with a running 1-0 Vicryl, the subcutaneous tissue with 3-0 plain, and the skin with a running 4-0 Vicryl subcuticular.  Steri-Strips were applied and a sterile dressing.,The patient was taken to the Recovery Room in good condition.  There were no complications.  Sponge and instrument counts were reported correct at the end of the case.","surgery, mini-laparotomy, radical retropubic prostatectomy, pelvic lymph, pelvic lymph node dissection, cavermap, mini laparotomy, prostatectomy, bladder, intubation, adenocarcinoma, endopelvic, hemostasis, neck"
" Biopsy-proven mesothelioma - Placement of Port-A-Cath, left subclavian vein with fluoroscopy.", Surgery, Mesothelioma - Port-A-Cath Insertion ,"PREOPERATIVE DIAGNOSIS: , Mesothelioma.,POSTOPERATIVE DIAGNOSIS:,  Mesothelioma.,OPERATIVE PROCEDURE: , Placement of Port-A-Cath, left subclavian vein with fluoroscopy.,ASSISTANT:,  None.,ANESTHESIA: , General endotracheal.,COMPLICATIONS:,  None.,DESCRIPTION OF PROCEDURE: , The patient is a 74-year-old gentleman who underwent right thoracoscopy and was found to have biopsy-proven mesothelioma.  He was brought to the operating room now for Port-A-Cath placement for chemotherapy.  After informed consent was obtained with the patient, the patient was taken to the operating room, placed in supine position.  After induction of general endotracheal anesthesia, routine prep and drape of the left chest, left subclavian vein was cannulated with #18 gauze needle, and guidewire was inserted.  Needle was removed.  Small incision was made large enough to harbor the port.  Dilator and introducers were then placed over the guidewire.  Guidewire and dilator were removed, and a Port-A-Cath was introduced in the subclavian vein through the introducers.  Introducers were peeled away without difficulty.  He measured with fluoroscopy and cut to the appropriate length.  The tip of the catheter was noted to be at the junction of the superior vena cava and right atrium.  It was then connected to the hub of the port.  Port was then aspirated for patency and flushed with heparinized saline and summoned to the chest wall.  Wounds were then closed.  Needle count, sponge count, and instrument counts were all correct.","surgery, biopsy-proven mesothelioma, placement of port-a-cath, port a cath, subclavian vein, fluoroscopy, mesothelioma,"
 Rhabdomyosarcoma of the left orbit.  Left subclavian vein MediPort placement.  Needs chemotherapy., Surgery, MediPort Placement ,"PREOPERATIVE DIAGNOSIS:,  Rhabdomyosarcoma of the left orbit.,POSTOPERATIVE DIAGNOSIS:,  Rhabdomyosarcoma of the left orbit.,PROCEDURE: , Left subclavian vein MediPort placement (7.5-French single-lumen).,INDICATIONS FOR PROCEDURE: , This patient is a 16-year-old girl, with newly diagnosed rhabdomyosarcoma of the left orbit.  The patient is being taken to the operating room for MediPort placement.  She needs chemotherapy.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine, put under general endotracheal anesthesia.  The patient's neck, chest, and shoulders were prepped and draped in usual sterile fashion.  An incision was made on the left shoulder area.  The left subclavian vein was cannulated.  The wire was passed, which was in good position under fluoro, using Seldinger Technique.  Near wire incision site made a pocket above the fascia and sutured in a size 7.5-French single-lumen MediPort into the pocket in 4 places using 3-0 Nurolon.  I then sized the catheter under fluoro and placed introducer and dilator over the wire, removed the wire and dilator, placed the catheter through the introducer and removed the introducer.  The line tip was in good position under fluoro.  It withdrew and flushed well.  I then closed the incision using 4-0 Vicryl, 5-0 Monocryl for the skin, and dressed with Steri-Strips.  Accessed the ports with a 1-inch 20-gauge Huber needle, and it withdrew and flushed well with final heparin flush.  We secured this with Tegaderm.  The patient is then to undergo bilateral bone marrow biopsy and lumbar puncture by Oncology.","surgery, rhabdomyosarcoma of the left orbit, single lumen, subclavian vein, mediport placement, chemotherapy, rhabdomyosarcoma, mediport, "
 Right nodular malignant mesothelioma., Surgery, Mesothelioma - Thoracotomy & Lobectomy ,"PREOPERATIVE DIAGNOSIS:,  Right mesothelioma.,POSTOPERATIVE DIAGNOSIS: , Right lung mass invading diaphragm and liver.,FINDINGS: , Right lower lobe lung mass invading diaphragm and liver.,PROCEDURES:,1.  Right thoracotomy.,2.  Right lower lobectomy with en bloc resection of diaphragm and portion of liver.,SPECIMENS: , Right lower lobectomy with en bloc resection of diaphragm and portion of liver.,BLOOD LOSS: , 600 mL.,FLUIDS: , Crystalloid 2.7 L and 1 unit packed red blood cells.,ANESTHESIA: , Double-lumen endotracheal tube.,CONDITION:,  Stable, extubated, to PACU.,PROCEDURE IN DETAIL:,  Briefly, this is a gentleman who was diagnosed with a B-cell lymphoma and then subsequently on workup noted to have a right-sided mass seeming to arise from the right diaphragm.  He was presented at Tumor Board where it was thought upon review that day that he had a right nodular malignant mesothelioma.  Thus, he was offered a right thoracotomy and excision of mass with possible reconstruction of the diaphragm.  He was explained the risks, benefits, and alternatives to this procedure.  He wished to proceed, so he was brought to the operating room.,An epidural catheter was placed.  He was put in a supine position where SCDs and Foley catheter were placed.  He was put under general endotracheal anesthesia with a double-lumen endotracheal tube.  He was given preoperative antibiotics, then he was placed in the left decubitus position, and the area was prepped and draped in the usual fashion.,A low thoracotomy in the 7th interspace was made using the skin knife and then Bovie cautery onto the middle of the rib and then with the Alexander instrument, the chest was entered.  Upon entering the chest, the chest wall retractor was inserted and the cavity inspected.  It appeared that the mass actually arose more from the right lower lobe and was involving the diaphragm.  He also had some marked lymphadenopathy.  With these findings, which were thought at that time to be more consistent with a bronchogenic carcinoma, we proceeded with the intent to perform a right lower lobectomy and en bloc diaphragmatic resection.  Thus, we mobilized the inferior pulmonary ligament and made our way around the hilum anteriorly and posteriorly.  We also worked to open the fissure and tried to identify the arteries going to the superior portion of the right lower lobe and basilar arteries as well as the artery going to the right middle lobe.  The posterior portion of the fissure ultimately divided with the single firing of a GIA stapler with a blue load and with the final portion being divided between 2-0 ties.  Once we had clearly delineated the arterial anatomy, we were able to pass a right angle around the artery going to the superior segment.  This was ligated in continuity with an additional stick tie in the proximal portion of 3-0 silk.  This was divided thus revealing a branched artery going to the basilar portion of the right lower lobe.  This was also ligated in continuity and actually doubly ligated.  Care was taken to preserve the artery to the right and middle lobe.,We then turned our attention once again to the hilum to dissect out the inferior pulmonary vein.  The superior pulmonary vein was visualized as well.  The right angle was passed around the inferior pulmonary vein, and this was ligated in continuity with 2-0 silk and a 3-0 stick tie.  Upon division of this portion, the specimen site had some bleeding, which was eventually controlled using several 3-0 silk sutures.  The bronchial anatomy was defined.  Next, we identified the bronchus going to the right lower lobe as well as the right middle lobe.  A TA-30 4.8 stapler was then closed.  The lung insufflated.  The right middle lobe and right upper lobe were noted to inflate well.  The stapler was fired, and the bronchus was cut with a 10-blade.,We then turned our attention to the diaphragm.  There was a small portion of the diaphragm of approximately 4 to 5 cm has involved with tumor, and we bovied around this with at least 1 cm margin.  Upon going through the diaphragm, it became clear that the tumor was also involving the dome of the liver, so after going around the diaphragm in its entirety, we proceeded to wedge out the portion of liver that was involved.  It seemed that it would be a mucoid shallow portion.  The Bovie was set to high cautery.  The capsule was entered, and then using Bovie cautery, we wedged out the remaining portion of the tumor with a margin of normal liver.  It did leave quite a shallow defect in the liver.  Hemostasis was achieved with Bovie cautery and gentle pressure.  The specimen was then taken off the table and sent to Pathology for permanent.  The area was inspected for hemostasis.  A 10-flat JP was placed in the abdomen at the portion of the wedge resection, and 0 Prolene was used to close the diaphragmatic defect, which was under very little tension.  A single 32 straight chest tube was also placed.  The lung was seen to expand.  We also noted that the incomplete fissure between the middle and upper lobes would prevent torsion of the right middle lobe.  Hemostasis was observed at the end of the case.  The chest tube was irrigated with sterile water, and there was no air leak observed from the bronchial stump.  The chest was then closed with Vicryl at the level of the intercostal muscles, staying above the ribs.  The 2-0 Vicryl was used for the latissimus dorsi layer and the subcutaneous layer, and 4-0 Monocryl was used to close the skin.  The patient was then brought to supine position, extubated, and brought to the recovery room in stable condition.,Dr. X was present for the entirety of the procedure, which was a right thoracotomy, right lower lobectomy with en bloc resection of diaphragm and a portion of liver.","surgery, double lumen endotracheal, en bloc resection, malignant mesothelioma, lung mass, endotracheal tube, chest tube, bovie cautery, en bloc, diaphragm, lobectomy, mesothelioma, thoracotomy, "
 Microsuspension direct laryngoscopy with biopsy.  Fullness in right base of the tongue and chronic right ear otalgia., Surgery, Microsuspension Direct Laryngoscopy & Biopsy ,"PREOPERATIVE DIAGNOSES:,1.  Fullness in right base of the tongue.,2.  Chronic right ear otalgia.,POSTOPERATIVE DIAGNOSIS: , Pending pathology.,PROCEDURE PERFORMED: , Microsuspension direct laryngoscopy with biopsy.,ANESTHESIA: , General.,INDICATION:,  This is a 50-year-old female who presents to the office with a chief complaint of ear pain on the right side.  Exact etiology of her ear pain had not been identified.  A fiberoptic examination had been performed in the office.  Upon examination, she was noted to have fullness in the right base of her tongue.  She was counseled on the risks, benefits, and alternatives to surgery and consented to such.,PROCEDURE: , After informed consent was obtained, the patient was brought to the Operative Suite where she was placed in supine position.  General endotracheal tube intubation was delivered by the Department of Anesthesia.  The patient was rotated 90 degrees away where a shoulder roll was placed.  A tooth guard was then placed to protect the upper dentition.  The Dedo laryngoscope was then inserted into the oral cavity.  It was advanced on the right lateral pharyngeal wall until the epiglottis was brought into view.  At this point, it was advanced underneath the epiglottis until the vocal cords were seen.  At this point, it was suspended via the Lewy suspension arm from the Mayo stand.  At this point, the Zeiss microscope with a 400 mm lens was brought into the surgical field.  Inspection of the vocal cords underneath the microscope revealed them to be white and glistening without any mucosal abnormalities.  It should be mentioned that the right vocal cord did appear to be slightly more hyperemic, however, there were no mucosal abnormalities identified.  This was confirmed with a laryngeal probe as well as use of mirror evaluated in the subglottic portion as well as the ventricle.  At this point, the scope was desuspended and the microscope was removed.  The scope was withdrawn through the vallecular region.  Inspection of the vallecula revealed a fullness on the right side with a papillomatous type growth that appeared very friable.  Biopsies were obtained with straight-biting cup forceps.  Once hemostasis was achieved, the scope was advanced into the piriform sinuses.  Again in the right piriform sinus, there was noted to be studding along the right lateral wall of the piriform sinus.  Again, biopsies were performed and once hemostasis was achieved, the scope was further withdrawn down the lateral pharyngeal wall.  There were no mucosal abnormalities identified within the oropharynx.  The scope was then completely removed and a bimanual examination was performed.  No neck masses were identified.  At this point, the procedure was complete.  The mouth guard was removed and the patient was returned to Anesthesia for awakening and taken to the recovery room without incident.","surgery, microsuspension, laryngoscopy, otalgia, ear pain, fiberoptic, dedo laryngoscope, epiglottis, direct laryngoscopy, piriform sinuses, tongue, microscope, mucosal, abnormalities, fullness, ear, scope "
 Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck.   Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side.  Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field., Surgery, Metastatic Lymphadenopathy & Thyroid Tissue Removal ,"TITLE OF OPERATION: , Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck.  Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side.  Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,INDICATION FOR SURGERY: , The patient is a 37-year-old gentleman well known to me with a history of medullary thyroid cancer sporadic in nature having undergone surgery in 04/07 with final pathology revealing extrafocal, extrathyroidal extension, and extranodal extension in the soft tissues of his medullary thyroid cancer.  The patient had been followed for a period of time and underwent rapid development of a left and right infraclavicular lymphadenopathy and central neck lymphadenopathy also with imaging studies to suggest superior mediastinal disease.  Fine-needle aspiration of the left and right infraclavicular lymph nodes revealed persistent medullary thyroid cancer.  Risks, benefits, and alternatives of the procedures discussed with in detail and the patient elected to proceed with surgery as discussed.  The risks included, but not limited to anesthesia, bleeding, infection, injury to nerve, lip, tongue, shoulder, weakness, tongue numbness, droopy eyelid, tumor comes back, need for additional treatment, diaphragm weakness, pneumothorax, need for chest tube, others.  The patient understood all these issues and did wish to proceed.,PROCEDURE DETAIL:  ,After identifying the patient, the patient was placed supine on the operating room table.  The patient was intubated with a number 7 nerve integrity monitor system endotracheal tube.  The eyes were protected with Tegaderm.  The patient was rotated to 180 degrees towards the operating surgeon.  The Foley catheter was placed into the bladder with good return of urine.  Attention then was turned to securing the nerve integrity monitor system endotracheal tube and this was confirmed to be working adequately.  A previous apron incision was incorporated and advanced over onto the right side to the mastoid tip.  The incision then was planned around the old scar to be excised.  A 1% lidocaine with 1 to 100,000 epinephrine was injected.  A shoulder roll was applied.  The incision was made, the apron flap was raised to the level of the mandible and mastoid tip bilaterally all the way down to the clavicle and sternal notch inferiorly.  Attention was then turned to performing the level 1 dissection on the left.  Subsequently the marginal mandibular nerve was identified over the facial notch of the mandible.  The facial artery and vein were individually ligated and marginal mandibular nerve traced superiorly and perifascial lymph nodes freed from the marginal mandibular nerve.  Level 1A lymph nodes of the submental region were dissected off the mylohyoid and digastric.  The submandibular gland was appreciated and retracted laterally.  The mylohyoid muscle appreciated.  The lingual nerve was appreciated and the submandibular ganglion was ligated.  The hypoglossal nerve was appreciated and protected and digastric tunnel was then made posteriorly and the lymph nodes posterior along the marginal mandibular nerve and into the parotid gland were then dissected and incorporated into the specimen for histopathologic analysis.  The marginal mandibular nerve stimulated at the completion of this portion of the procedure.  Attention was then turned to incising the fascia along the clavicle on the left side.  Dissection then ensued along the floor of the neck palpating a very large bulky lymph node before the neck was identified.  The brachial plexus and phrenic nerve were identified.  The internal jugular vein identified and the mass was freed from the floor of the neck with careful dissection and suture ligation of vessels.  Attention was then turned to the central neck.  The strap muscles were appreciated in the midline.  There was a large firm mass measuring approximately 3 cm that appeared to be superior to the strap musculature.  A careful dissection with incorporation of a portion of the sternal hyoid muscle in this area for a margin was then performed.  Attention was then turned to identify the carotid artery and the internal jugular vein on the left side.  This was traced inferiorly, internal jugular vein to the brachiocephalic vein.  Palpation deep to this area into the mediastinum and up against the trachea revealed a 1.5 cm lymph node mass.  Subsequently this was carefully dissected preserving the brachiocephalic vein and also the integrity of the trachea and the carotid artery and these lymph nodes were removed in full and sent for histopathologic analysis.  Attention was then turned to the right neck dissection.  A posterior flap on the right was raised to the anterior border of the trapezius.  The accessory nerve was identified in the posterior triangle and traced superiorly and inferiorly.  Attention was then turned to identifying the submandibular gland.  A digastric tunnel was performed back to the sternocleidomastoid muscle.  The fascia overlying the sternocleidomastoid muscle on the right side was incised and the omohyoid muscle was appreciated.  The omohyoid muscle was retracted inferiorly.  Penrose drain was placed around the inferior aspect of the sternocleidomastoid muscle.  Subsequently the internal jugular vein was identified.  The external jugular vein ligated about 1 cm above the clavicle.  Palpation in this area and the infraclavicular region on the right revealed a firm irregular lymph node complex.  Dissection along the floor of the neck then was performed to allow for mobilization.  The transverse cervical artery and vein were individually ligated to allow full mobilization of this mass.  Tissue between the phrenic nerve and the internal jugular vein was clamped and suture ligated.  The tissue was then brought posteriorly from the trapezius muscle to the internal jugular vein and traced superiorly.  The cervical rootlets were transected after the contribution, so the phrenic nerve all the way superiorly to the skull base.  The hypoglossal nerve was identified and protected as the lymph node packet was dissected over the internal jugular vein.  The wound was copiously irrigated.  Valsalva maneuver was given.  No bleeding points identified.  The wound was then prepared for closure.  Two number 10 JPs were placed through the left supraclavicular fossa in the previous drain sites and secured with 3-0 nylon.  The wound was closed  with interrupted 3-0 Vicryl for platysma, subsequently a 4-0 running Biosyn for the skin, and Indermil.  The patient tolerated the procedure well, was extubated on the operating room table, and sent to the postanesthesia care unit in good condition.","surgery, lymphadenopathy, thyroid, infraclavicular, fossa, lymph nodes, dissection, pretracheal, internal jugular vein, infraclavicular lymphadenopathy, metastatic lymphadenopathy, mandibular nerve, vein, nodes, neck, nerve, muscle, jugularNOTE"
" Arthroscopy, medial meniscoplasty, lateral meniscoplasty, medial femoral chondroplasty, and medical femoral microfracture, right knee.  Patellar chondroplasty.  Lateral femoral chondroplasty.   Meniscal tear, osteochondral lesion, degenerative joint disease, and chondromalacia,", Surgery, Meniscoplasty & Chondroplasty ,"PREOPERATIVE DIAGNOSIS:,  Medial meniscal tear of the right knee.,POSTOPERATIVE DIAGNOSES:,1.  Medial meniscal tear, right knee.,2.  Lateral meniscal tear, right knee.,3.  Osteochondral lesion, medial femoral condyle, right knee.,4.  Degenerative joint disease, right knee.,5.  Patella grade-II chondromalacia.,6.  Lateral femoral condyle grade II-III chondromalacia.,PROCEDURE PERFORMED:,1.  Arthroscopy, right knee.,2.  Medial meniscoplasty, right knee.,3.  Lateral meniscoplasty, right knee.,4.  Medial femoral chondroplasty, right knee.,5.  Medical femoral microfracture, right knee.,6.  Patellar chondroplasty.,7.  Lateral femoral chondroplasty.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS:,  None.,BRIEF HISTORY AND INDICATION FOR PROCEDURE: , The patient is a 47-year-old female who has knee pain since 03/10/03 after falling on ice.  The patient states she has had inability to bear significant weight and had swelling, popping, and giving away, failing conservative treatment and underwent an operative procedure.,PROCEDURE:,  The patient was taken to the Operative Suite at ABCD General Hospital on 09/08/03, placed on the operative table in supine position.  Department of Anesthesia administered general anesthetic.  Once adequately anesthetized, the right lower extremity was placed in a Johnson knee holder.  Care was ensured that all bony prominences were well padded and she was positioned and secured.  After adequately positioned, the right lower extremity was prepped and draped in the usual sterile fashion.  Attention was then directed to creation of the arthroscopic portals, both medial and lateral portal were made for arthroscope and instrumentation respectively.  The arthroscope was advanced through the inferolateral portal taking in a suprapatellar pouch.  All compartments were then examined in sequential order with photodocumentation of each compartment.  The patella was noted to have grade-II changes of the inferior surface, otherwise appeared to track within the trochlear groove.  There was mild grooving of the trochlear cartilage.  The medial gutter was visualized.  There was no evidence of loose body.  The medial compartment was then entered.  There was noted to be a large defect on the medial femoral condyle grade III-IV chondromalacia changes with exposed bone in evidence of osteochondral displaced fragment.  There was also noted to be a degenerative meniscal tear of the posterior horn of the medial meniscus.  The arthroscopic probe was then introduced and the meniscus and chondral surfaces were probed throughout its entirety and photos were taken.  At this point, a meniscal shaver was then introduced and the chondral surfaces were debrided as well as any loose bodies removed.  This gave a smooth shoulder to the chondral lesion.  After this, the meniscus was debrided until it had been smooth over the frayed edges.  At this point, the shaver was removed.  The meniscal binder was then introduced and the meniscus was further debrided until the tear was adequately contained at this point.  The shaver was reintroduced and all particles were again removed and the meniscus was smoothed over the edge.  The probe was then reintroduced and the shaver removed, the meniscus was probed ___________ and now found to be stable.  At this point, attention was directed to the rest of the knee.  The ACL was examined.  It was intact and stable.  The lateral compartment was then entered.  There was noted to be a grade II-III changes of the lateral femoral condyle.  Again, with the edge of some friability at the shoulder of this cartilage lesion.  There was noted to be some mild degenerative fraying of the posterior horn of the lateral meniscus.  The probe was introduced and the remaining meniscus appeared stable.  This was then removed and the stapler was introduced.  A chondroplasty and meniscoplasty were then performed until adequately debrided and smoothed over.  The lateral gutter was then visualized.  There was no evidence of loose bodies.  Attention was then redirected back to the medial and femoral condyles.,At this point, a 0.62 K-wire was then placed in through the initial portal, medial portal, as well as an additional poke hole, so we can gain access and proper orientation to the medial femoral lesion.  Microfacial technique was then used to introduce the K-wire into the subchondral bone in multiple areas until we had evidence of some bleeding to allow ___________ of this lesion.  After this was performed, the shaver was then reintroduced and the loose bodies and loose fragments were further debrided.  At this point, the shaver was then moved to the suprapatellar pouch and the patellar chondroplasty was then performed until adequately debrided.  Again, all compartments were then re-visualized and there was no further evidence of other pathology or loose bodies.  The knee was then copiously irrigated and suctioned dry.  All instrumentation was removed.  Approximately 20 cc of 0.25% plain Marcaine was injected into the portal site and the remaining portion intraarticular.  Sterile dressings of Adaptic, 4x4s, ABDs, and Webril were then applied.  The patient was then transferred back to the gurney in supine position.,DISPOSITION:  The patient tolerated the procedure well with no complications.  The patient was transferred to PACU in satisfactory condition.", 
 Right pleural effusion and suspected malignant mesothelioma., Surgery, Mesothelioma - Pleural Biopsy ,"PREOPERATIVE DIAGNOSIS: , Right pleural effusion and suspected malignant mesothelioma.,POSTOPERATIVE DIAGNOSIS:,  Right pleural effusion, suspected malignant mesothelioma.,PROCEDURE: , Right VATS pleurodesis and pleural biopsy.,ANESTHESIA:,  General double-lumen endotracheal.,DESCRIPTION OF FINDINGS: , Right pleural effusion, firm nodules, diffuse scattered throughout the right pleura and diaphragmatic surface.,SPECIMEN: , Pleural biopsies for pathology and microbiology.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid 1.2 L and 1.9 L of pleural effusion drained.,INDICATIONS: , Briefly, this is a 66-year-old gentleman who has been transferred from an outside hospital after a pleural effusion had been drained and biopsies taken from the right chest that were thought to be consistent with mesothelioma.  Upon transfer, he had a right pleural effusion demonstrated on x-ray as well as some shortness of breath and dyspnea on exertion.  The risks, benefits, and alternatives to right VATS pleurodesis and pleural biopsy were discussed with the patient and his family and they wished to proceed.,PROCEDURE IN DETAIL:  ,After informed consent was obtained, the patient was brought to the operating room and placed in supine position.  A double-lumen endotracheal tube was placed.  SCDs were also placed and he was given preoperative Kefzol.  The patient was then brought into the right side up, left decubitus position, and the area was prepped and draped in the usual fashion.  A needle was inserted in the axillary line to determine position of the effusion.  At this time, a 10-mm port was placed using the knife and Bovie cautery.  The effusion was drained by placing a sucker into this port site.  Upon feeling the surface of the pleura, there were multiple firm nodules.  An additional anterior port was then placed in similar fashion.  The effusion was then drained with a sucker.  Multiple pleural biopsies were taken with the biopsy device in all areas of the pleura.  Of note, feeling the diaphragmatic surface, it appeared that it was quite nodular, but these nodules felt as though they were on the other side of the diaphragm and not on the pleural surface of the diaphragm concerning for a possibly metastatic disease.  This will be worked up with further imaging study later in his hospitalization.  After the effusion had been drained, 2 cans of talc pleurodesis aerosol were used to cover the lung and pleural surface with talc.  The lungs were then inflated and noted to inflate well.  A 32 curved chest tube chest tube was placed and secured with nylon.  The other port site was closed at the level of the fascia with 2-0 Vicryl and then 4-0 Monocryl for the skin.  The patient was then brought in the supine position and extubated and brought to recovery room in stable condition.,Dr. X was present for the entire procedure which was right VATS pleurodesis and pleural biopsies.,The counts were correct x2 at the end of the case.","surgery, double-lumen, endotracheal, pleural surface, chest tube, pleural biopsy, malignant mesothelioma, vats pleurodesis, pleural biopsies, pleural effusion, pleural, vats, pleurodesis, mesothelioma,"
 Left metastasectomy of metastatic renal cell carcinoma with additional mediastinal lymph node dissection and additional fiberoptic bronchoscopy., Surgery, Metastasectomy & Bronchoscopy ,"PREOPERATIVE DIAGNOSIS:  ,Metastatic renal cell carcinoma.,POSTOPERATIVE DIAGNOSIS:,  Metastatic renal cell carcinoma.,PROCEDURE PERFORMED:,  Left metastasectomy of metastatic renal cell carcinoma with additional mediastinal lymph node dissection and additional fiberoptic bronchoscopy used to confirm adequate placement of the double-lumen endotracheal tube with a tube thoracostomy, which was used to drain the left chest after the procedure.,ANESTHESIA:,  General endotracheal anesthesia with double-lumen endotracheal tube.,FINDINGS:,  Multiple pleural surface seeding, many sub-millimeter suspicious looking lesions.,DISPOSITION OF SPECIMENS:,To Pathology for permanent analysis as well as tissue banking.  The lesions sent for pathologic analysis were the following,,1.  Level 8 lymph node.,2.  Level 9 lymph node.,3.  Wedge, left upper lobe apex, which was also sent to the tissue bank and possible multiple lesions within this wedge.,4.  Wedge, left upper lobe posterior.,5.  Wedge, left upper lobe anterior.,6.  Wedge, left lower lobe superior segment.,7.  Wedge, left lower lobe diaphragmatic surface, anterolateral.,8.  Wedge, left lower lobe, anterolateral.,9.  Wedge, left lower lobe lateral adjacent to fissure.,10.  Wedge, left upper lobe, apex anterior.,11.  Lymph node package, additional level 8 lymph node.,ESTIMATED BLOOD LOSS:,  Less than 100 mL.,CONDITION OF THE PATIENT AFTER SURGERY: , Stable.,HISTORY OF PROCEDURE: , The patient was given preoperative informed consent for the procedure as well as for the clinical trial he was enrolled into.  The patient agreed based on the risks and the benefits of the procedure, which were presented to him and was taken to the operating room.  A correct time out procedure was performed.  The patient was placed into the supine position.  He was given general anesthesia, was endotracheally intubated without incident with a double-lumen endotracheal tube.  Fiberoptic bronchoscopy was used to perform confirmation of adequate placement of the double-lumen tube.  Following this, the decision was made to proceed with the surgery.  The patient was rolled into the right lateral decubitus position with the left side up.  All pressure points were padded.  The patient had a sterile DuraPrep preparation to the left chest.  A sterile drape around that was applied.  Also, the patient had Marcaine infused into the incision area.  Following this, the patient had a posterolateral thoracotomy incision, which was a muscle-sparing incision with a posterior approach just over the ausculatory triangle.  The incision was approximately 10 cm in size.  This was created with a 10-blade scalpel.  Bovie electrocautery was used to dissect the subcutaneous tissues.  The auscultatory triangle was opened.  The posterior aspect of the latissimus muscle was divided from the adjacent tissue and retracted anteriorly.  The muscle was not divided.  After the latissimus muscle was retracted anteriorly, the ribs were counted, and the sixth rib was identified.  The superior surface of the sixth rib was incised with Bovie electrocautery and the sixth rib was divided with rib shears.  Following this, the patient had the entire intercostal muscle separated from the superior aspect of the sixth rib on the left as far as the Bovie would reach.  The left lung was allowed to collapse and meticulous inspection of the left lung identified the lesions, which were taken out with stapled wedge resections via a TA30 green load stapler for all of the wedges.  The patient tolerated the procedure well without any complications.  The largest lesion was the left upper lobe apex lesion, which was possibly multiple lesions, which was taken in one large wedge segment, and this was also adjacent to another area of the wedges.  The patient had multiple pleural abnormalities, which were identified on the surface of the lung.  These were small white spotty looking lesions and were not confirmed to be tumor implants, but were suspicious to be multiple areas of tumor.  Based on this, the wedges of the tumors that were easily palpable were excised with complete excision of all palpable lesions.  Following this, the patient had a 32-French chest tube placed in the anteroapical position.  A 19-French Blake was placed in the posterior apical position.  The patient had the intercostal space reapproximated with #2-0 Vicryl suture, and the lung was allowed to be re-expanded under direct visualization.  Following this, the chest tubes were placed to Pleur-evac suction and the auscultatory triangle was closed with 2-0 Vicryl sutures.  The deeper tissue was closed with 3-0 Vicryl suture, and the skin was closed with running 4-0 Monocryl suture in a subcuticular fashion.  The patient tolerated the procedure well and had no complications.", 
 Posterior mediastinal mass with possible neural foraminal involvement (benign nerve sheath tumor by frozen section).  Left thoracotomy with resection of posterior mediastinal mass., Surgery, Mediastinal Mass Resection ,"PREOPERATIVE DIAGNOSIS:,  Posterior mediastinal mass with possible neural foraminal involvement.,POSTOPERATIVE DIAGNOSIS: , Posterior mediastinal mass with possible neural foraminal involvement (benign nerve sheath tumor by frozen section).,OPERATION PERFORMED:,  Left thoracotomy with resection of posterior mediastinal mass.,INDICATIONS FOR PROCEDURE:  ,The patient is a 23-year-old woman who recently presented with a posterior mediastinal mass and on CT and MRI there were some evidence of potential widening of one of the neural foramina.  For this reason, Dr. X and I agreed to operate on this patient together.  Please note that two surgeons were required for this case due to the complexity of it.  The indications and risks of the procedure were explained and the patient gave her informed consent.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating suite and placed in the supine position.  General endotracheal anesthesia was given with a double lumen tube.  The patient was positioned for a left thoracotomy.  All pressure points were carefully padded.  The patient was prepped and draped in usual sterile fashion.  A muscle sparing incision was created several centimeters anterior to the tip of the scapula.  The serratus and latissimus muscles were retracted.  The intercostal space was opened.  We then created a thoracoscopy port inferiorly through which we placed a camera for lighting and for visualization.  Through our small anterior thoracotomy and with the video-assisted scope placed inferiorly we had good visualization of the posterior mediastinum mass.  This was in the upper portion of the mediastinum just posterior to the subclavian artery and aorta.  The lung was deflated and allowed to retract anteriorly.  With a combination of blunt and sharp dissection and with attention paid to hemostasis, we were able to completely resect the posterior mediastinal mass.  We began by opening the tumor and taking a very wide large biopsy.  This was sent for frozen section, which revealed a benign nerve sheath tumor.  Then, using the occluder device Dr. X was able to _____ the inferior portions of the mass.  This left the external surface of the mass much more malleable and easier to retract.  Using a bipolar cautery and endoscopic scissors we were then able to completely resect it.  Once the tumor was resected, it was then sent for permanent sections.  The entire hemithorax was copiously irrigated and hemostasis was complete.  In order to prevent any lymph leak, we used 2 cc of Evicel and sprayed this directly on to the raw surface of the pleural space.  A single chest tube was inserted through our thoracoscopy port and tunneled up one interspace.  The wounds were then closed in multiple layers.  A #2 Vicryl was used to approximate the ribs.  The muscles of the chest wall were allowed to return to their normal anatomic position.  A 19 Blake was placed in the subcutaneous tissues.  Subcutaneous tissues and skin were closed with running absorbable sutures.  The patient was then rolled in the supine position where she was awakened from general endotracheal anesthesia and taken to the recovery room in stable condition.","surgery, posterior mediastinal mass, neural foraminal, nerve sheath tumor, frozen section, thoracotomy, mediastinal mass, foraminal, neural, sheath, mediastinal, "
 The patient had undergone mitral valve repair about seven days ago. , Surgery, Mediastinal Exploration & Right Atrium Repair ,"PREOPERATIVE DIAGNOSES:,1.  Cardiac tamponade.,2.  Status post mitral valve repair.,POSTOPERATIVE DIAGNOSES:,1.  Cardiac tamponade.,2.  Status post mitral valve repair.,PROCEDURE PERFORMED: , Mediastinal exploration with repair of right atrium.,ANESTHESIA: , General endotracheal.,INDICATIONS: , The patient had undergone mitral valve repair about seven days ago.  He had epicardial pacing wires removed at the bedside.  Shortly afterwards, he began to feel lightheaded and became pale and diaphoretic.  He was immediately rushed to the operating room for cardiac tamponade following removal of epicardial pacing wires.  He was transported immediately and emergently and remained awake and alert throughout the time period inspite of hypotension with the systolic pressure in the 60s-70s.,DETAILS OF PROCEDURE:  ,The patient was taken emergently to the operating room and placed supine on the operating room table.  His chest was prepped and draped prior to induction under general anesthesia.  Incision was made through the previous median sternotomy chest incision.  Wires were removed in the usual manner and the sternum was retracted.  There were large amounts of dark blood filling the mediastinal chest cavity.  Large amounts of clot were also removed from the pericardial well and chest.  Systematic exploration of the mediastinum and pericardial well revealed bleeding from the right atrial appendix at the site of the previous cannulation.  This was repaired with two horizontal mattress pledgeted #5-0 Prolene sutures.  An additional #0 silk tie was also placed around the base of the atrial appendage for further hemostasis.  No other sites of bleeding were identified.  The mediastinum was then irrigated with copious amounts of antibiotic saline solution.  Two chest tubes were then placed including an angled chest tube into the pericardial well on the inferior border of the heart, as well as straight mediastinal chest tube.  The sternum was then reapproximated with stainless steel wires in the usual manner and the subcutaneous tissue was closed in multiple layers with running Vicryl sutures.  The skin was then closed with a running subcuticular stitch.  The patient was then taken to the Intensive Care Unit in a critical but stable condition.","surgery, mitral valve repair, exploration, median sternotomy chest incision, pericardial, mediastinal exploration, pacing wires, cardiac tamponade, chest tubes, mitral valve, valve repair, mediastinal, mitral, wires, atrium, repair,"
 Mediastinal exploration and delayed primary chest closure.  The patient is a 12-day-old infant who has undergone a modified stage I Norwood procedure with a Sano modification. , Surgery, Mediastinal Exploration ,"TITLE OF OPERATION:,  Mediastinal exploration and delayed primary chest closure.,INDICATION FOR SURGERY:,  The patient is a 12-day-old infant who has undergone a modified stage I Norwood procedure with a Sano modification.  The patient experienced an unexplained cardiac arrest at the completion of the procedure, which required institution of extracorporeal membrane oxygenation for more than two hours following discontinuation of cardiopulmonary bypass.  The patient has been successfully resuscitated with extracorporeal membrane oxygenation and was decannulated 48 hours ago.  She did not meet the criteria for delayed primary chest closure.,PREOP DIAGNOSIS: , Open chest status post modified stage I Norwood procedure.,POSTOP DIAGNOSIS: , Open chest status post modified stage I Norwood procedure.,ANESTHESIA:,  General endotracheal.,COMPLICATIONS:,  None.,FINDINGS: , No evidence of intramediastinal purulence or hematoma.  At completion of the procedure no major changes in hemodynamic performance.,DETAILS OF THE PROCEDURE: , After obtaining informed consent, the patient was brought to the room, placed on the operating room table in supine position.  Following the administration of general endotracheal anesthesia, the chest was prepped and draped in the usual sterile fashion and all the chest drains were removed.  The chest was then prepped and draped in the usual sterile fashion and previously placed segmental AlloDerm was removed.  The mediastinum was then thoroughly irrigated with diluted antibiotic irrigation and both pleural cavities suctioned.  Through a separate incision and another 15-French Blake drain was inserted and small titanium clips were utilized to mark the rightward aspect of the RV-PA connection as well as inferior most aspect of the ventriculotomy.  The pleural spaces were opened widely and the sternum was then spilled with vancomycin paste and closed the sternum with steel wires.  The subcutaneous tissue and skin were closed in layers.  There was no evidence of significant increase in central venous pressure or desaturation.  The patient tolerated the procedure well.  Sponge and needle counts were correct times 2 at the end of the procedure.  The patient was transferred to the Pediatric Intensive Care Unit shortly thereafter in critical but stable condition.,I was the surgical attending present in the operating room in charge of the surgical  procedure throughout the entire length of the case.","surgery, mediastinal exploration, delayed primary chest closure, extracorporeal membrane oxygenation, stage i norwood procedure, sano modification, chest closure, infant, mediastinal, exploration, closure, endotracheal, chest"
" Medial branch rhizotomy, lumbosacral.  Fluoroscopy was used to identify the boney landmarks of the spine and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.", Surgery, Medial Branch Rhizotomy ,"PROCEDURE: , Medial branch rhizotomy, lumbosacral.,INFORMED CONSENT:,  The risks, benefits and alternatives of the procedure were discussed with the patient.  The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible of vascular entry of medications.  I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing.  The patient understood the informed consent and desired to have the procedure performed.,SEDATION: , The patient was given conscious sedation and monitored throughout the procedure.  Oxygenation was given.  The patient's oxygenation and vital signs were closely followed to ensure the safety of the administration of the drugs.,PROCEDURE:  ,The patient remained awake throughout the procedure in order to interact and give feedback.  The x-ray technician was supervised and instructed to operate the fluoroscopy machine.  The patient was placed in the prone position on the treatment table with a pillow under the abdomen to reduce the natural lumbar lordosis.  The skin over and surrounding the treatment area was cleaned with Betadine.  The area was covered with sterile drapes, leaving a small window opening for needle placement.  Fluoroscopy was used to identify the boney landmarks of the spine and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.  With fluoroscopy, a Teflon coated needle, ***, was gently guided into the region of the Medial Branch nerves from the Dorsal Ramus of ***.  Specifically, each needle tip was inserted to the bone at the groove between the transverse process and superior articular process on lumbar vertebra, or for sacral vertebrae at the lateral-superior border of the posterior sacral foramen.  Needle localization was confirmed with AP and lateral radiographs.,The following technique was used to confirm placement at the Medial Branch nerves.  Sensory stimulation was applied to each level at 50 Hz; paresthesias were noted at,*** volts.  Motor stimulation was applied at 2 Hz with 1 millisecond duration; corresponding paraspinal muscle twitching without extremity movement was noted at *** volts.,Following this, the needle Trocar was removed and a syringe containing 1% lidocaine was attached.  At each level, after syringe aspiration with no blood return, 1cc 1% lidocaine was injected to anesthetize the Medial Branch nerve and surrounding tissue.  After completion of each nerve block a lesion was created at that level with a temperature of 85 degrees Celsius for 90 seconds.  All injected medications were preservative free.  Sterile technique was used throughout the procedure.,COMPLICATIONS:,  None.  No complications.,The patient tolerated the procedure well and was sent to the recovery room in good condition.,DISCUSSION: , Post-procedure vital signs and oximetry were stable.  The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day.  The patient was told to resume all medications.  The patient was told to be in relative rest for 1 day but then could resume all normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes, or changes in bowel or bladder function.,Follow up appointment was made in approximately 1 week.","surgery, lumbosacral, medial branch rhizotomy, medial branch nerves, rhizotomy, fluoroscopy,"
" Excision of soft tissue mass, right foot.  The patient is a 51-year-old female with complaints of soft tissue mass over the dorsum of the right foot.", Surgery, Mass Excision - Foot ,"PREOPERATIVE DIAGNOSIS: , Soft tissue mass, right foot.,POSTOPERATIVE DIAGNOSIS: , Soft tissue mass, right foot.,PROCEDURE PERFORMED: , Excision of soft tissue mass, right foot.,HISTORY:  ,The patient is a 51-year-old female with complaints of soft tissue mass over the dorsum of the right foot.  The patient has had previous injections to the site which have caused the mass to decrease in size, however, the mass continues to be present and is irritated and painful with shoes.  The patient has requested surgical intervention at this time.,PROCEDURE:  ,After an IV was instituted by the Department of Anesthesia, the patient was escorted from the preoperative holding area to the operating room.  The patient was then placed on the operating room table in the supine position and a towel was placed around the patient's abdomen and secured her to the table.  Using copious amounts of Webril, a pneumatic ankle tourniquet was applied to her right ankle.  Using a Skin Skribe, the area of the soft tissue mass was outlined over the dorsum of her foot.  After adequate amount of anesthesia was provided by the Department of Anesthesia, a local ankle block was given using 10 cc of 4.5 mL of 1% lidocaine plain, 4.5 mL of 0.5% Marcaine plain and 1.0 mL of Solu-Medrol and the foot was scrubbed and prepped in a normal sterile orthopedic manner.  Following this, the ankle was elevated and Esmarch bandage applied to exsanguinate the foot and the ankle tourniquet was inflated to 250 mmHg.  The foot was then brought back down to the table using bandage scissors.  The stockinette was reflected and the right foot was exposed.  Using a fresh #10 blade, a curvilinear incision was performed over the dorsum of the right foot.  Then using a #15 blade, the incision was deepened with care taken to identify and avoid or cauterize any bleeders which were noted.  Following this, the incision was deepened using a combination of sharp and blunt dissection and the muscle belly of the extensor digitorum brevis muscle was identified.  Further dissection was then performed in the medial direction in the area of the soft tissue mass.  The intermediate dorsal cutaneous nerve was identified and gently retracted laterally.  Large amounts of adipose tissue were noted medial to the belly of the extensor digitorum brevis muscle.  Using careful dissection, adipose tissue in this area was removed and saved for pathology.  Following removal of adipose tissue in this area and identification of no more adipose tissue, attention was directed lateral to the belly of the extensor digitorum brevis muscle, which was also noted to have large amounts of adipose tissue in this area as well.  Using careful dissection, from the lateral border of the foot as much adipose tissue as possible was removed from this area as well and saved for pathology.  There was noted to be no other fluid-filled masses or lesions identifiable in this area then between the slits of the extensor digitorum brevis muscle, careful dissection was performed to examine the underside of the belly of the muscle as well as structures beneath and no abnormal structures were identified here as well.  Following this, feeling adequately that no other mass remained in the area, the incision was flushed using copious amounts of sterile saline.  The wound was then reinspected and all remaining tissues appeared healthy including the subcutaneous tissue.  The tendon and muscle belly of the extensor digitorum brevis muscle, the nerves of the intermediate dorsal cutaneous nerve and also the medial dorsal cutaneous nerve which were identified medially, all appeared intact.  No deficits were noted.  No abnormal appearing tissue was present within the surgical site.  Following this, the skin edges were reapproximated using #4-0 Vicryl deep closure of the subcutaneous layer was performed.  Then, using #4-0 nylon and simple interrupted suture, the skin was reapproximated and closed with care taken to ensure eversion of the skin edges and good approximation of the borders.  The patient was also given 7 cc of 1% lidocaine plain throughout the procedure to augment local anesthesia.  Following this, the wound was dressed using Xeroform gauze and 4x4s and was dressed using two ABD pads, dorsal and plantar for compression and using Kling, Kerlix and Coban.  The patient then had the ankle tourniquet deflated with a total tourniquet time of 55 minutes at 250 mmHg and immediate hyperemia was noted to digits one through five of the right foot.  The patient tolerated the procedure and anesthesia well and was noted to have vascular status intact.  The patient was then escorted to the Postanesthesia Care Unit where she was placed in a surgical shoe.  The patient was then given postoperative instructions to include ice and elevation to her right foot.  The patient was cleared for ambulation as tolerated, but was instructed that with increased ambulation will come increased swelling and pain.  The patient will follow up with Dr. X in his office on Tuesday, 08/26/03 for further follow up.  The patient was given prescription for Vicoprofen #25 taken one tablet q.4h. p.r.n., moderate to severe pain and also prescription for Keflex #20 500 mg tablets to be taken b.i.d. x10 days.  The patient was given a number for the Emergency Room and instructed to return if any sign or symptom of infection should present and the patient was educated as to the nature of these.  The patient had no further questions and recovered without any complications in the Postanesthesia Care Unit.","surgery, excision, digitorum brevis muscle, soft tissue mass, adipose tissue, soft tissue, mass, injections, foot, tissue, xeroform, dorsum, belly, extensor, digitorum, brevis, ankle, adipose, muscle, "
 An example/template for meatotomy., Surgery, Meatotomy Template ,"OPERATIVE NOTE:  ,The patient was taken to the operating room and was placed in the supine position on the operating room table.  A general inhalation anesthetic was administered.  The patient was prepped and draped in the usual sterile fashion.  The urethral meatus was calibrated with a small mosquito hemostat and was gently dilated.  Next a midline ventral type incision was made opening the meatus.  This was done after clamping the tissue to control bleeding.  The meatus was opened for about 3 mm.  Next the meatus was calibrated and easily calibrated from 8 to 12 French with bougie sounds.  Next the mucosal edges were everted and reapproximated to the glans skin edges with approximately five interrupted 6-0 Vicryl sutures.  The meatus still calibrated between 10 and 12 French.  Antibiotic ointment was applied.  The procedure was terminated.  The patient was awakened and returned to the recovery room in stable condition.","surgery, urethral meatus, mosquito hemostat, meatus, mucosal edges, glans, meatotomyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Closed reduction of mandible fractures with Erich arch bars and elastic fixation.  Left angle and right body mandible fractures., Surgery, Mandible Fractures Closed Reduction ,"HISTORY OF PRESENT ILLNESS: , The patient is a 22-year-old male who sustained a mandible fracture and was seen in the emergency department at Hospital.  He was seen in my office today and scheduled for surgery today for closed reduction of the mandible fractures.,PREOPERATIVE DIAGNOSES: , Left angle and right body mandible fractures.,POSTOPERATIVE DIAGNOSES: , Left angle and right body mandible fractures.,PROCEDURE: , Closed reduction of mandible fractures with Erich arch bars and elastic fixation.,ANESTHESIA:,  General nasotracheal.,COMPLICATIONS:,  None.,CONDITION:,  Stable to PACU.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room and placed on the table in a supine position and after demonstration of an adequate plane of general anesthesia via the nasotracheal route, the patient was prepped and draped in the usual fashion for placement of arch bars.  Gauze throat pack was placed and upper and lower arch bars were placed on the maxillary and mandibular dentition with a 25-gauge circumdental wires.  After the placement of the arch bars, the occlusion was checked and found to be satisfactory and stable.  The throat pack was then removed.  An NG tube was then passed and approximately 50 cc of stomach contents were suctioned out.,The elastic fixation was then placed on the arch bars holding the patient in maxillomandibular fixation and at this point, the procedure was terminated and the patient was then awakened, extubated, and taken to the PACU in stable condition.","surgery, closed reduction of mandible fractures, erich arch bars, elastic fixation, throat pack, arch bars, arch, erich, mandible, fractures"
 Bilateral reduction mammoplasty for bilateral macromastia, Surgery, Mammoplasty - 1 ,"PREOPERATIVE DIAGNOSIS,Bilateral macromastia.,POSTOPERATIVE DIAGNOSIS,Bilateral macromastia.,OPERATION,Bilateral reduction mammoplasty.,ANESTHESIA,General.,FINDINGS,The patient had large ptotic breasts bilaterally and had had chronic difficulty with pain in the back and shoulder.  Right breast was slightly larger than the left this was repaired with a basic wise pattern reduction mammoplasty with anterior pedicle.,PROCEDURE,With the patient under satisfactory general endotracheal anesthesia, the entire chest was prepped and draped in usual sterile fashion.  A previously placed mark to identify the neo-nipple site was re-identified and carefully measured for asymmetry and appeared to be satisfactory.  A keyhole wire ring was then used to outline the basic wise pattern with 6-cm lamps inferiorly.  This was then carefully checked for symmetry and appeared to be satisfactory.  All marks were then completed and lightly incised on both breasts.  The right breast was approached first.  The neo-nipple site was de-epithelialized superiorly and then the inferior pedicle was de-epithelialized using cutting cautery.  After this had been completed, cutting cautery was used to carry down an incision along the inferior aspect of the periosteum starting immediately.  This was taken down to the prepectoral fashion dissected for short distance superiorly, and then blunt dissection was used to mobilize under the superior portion of the breast tissues to the lateral edge of the pectoral muscle.  There was very little bleeding with this procedure.  After this had been completed, attention was directed to the lateral side, and the inferior incision was made and taken down to the serratus.  Cautery dissection was then used to carry this up superiorly over the lateral edge of the pectoral muscle to communicate with the previous pocket.  After this had been completed, cutting cautery was used to cut around the inferior pedicle completely freeing the superior breast from the inferior breast.  Hemostasis was obtained with electrocautery.  After this had been completed, cutting cautery was used to cut along the superior edge of the redundant tissue and this was tapered under the superior flaps.  On the right side, there was a small palpable lobule, which had shown up on mammogram, but nothing except some fat density was identified.  This site had been previously marked carefully, and there were no unusual findings and the superior tissue was then sent out separately for pathology.  After this had been completed, final hemostasis obtained, and the wound was irrigated and a tagging suture placed to approximate the tissues.  The breast cleared and the nipple appeared good.,Attention was then directed to the left breast, which was completed in the similar manner.  After this had been completed, the patient was placed in a near upright position, and symmetry appeared good, but it was a bit poor on the lateral aspect of the right side, which was little larger and some suction lipectomy was carried out in this area.  After completion of this, 1860 grams had been removed from the right and 1505 grams was removed from the left.  Through separate stab wounds on the lateral aspect, 10-mm flat Blake drains were brought out and sutures were then placed **** and irrigated.  The wounds were then closed with interrupted 4-0 Monocryl on the deep dermis and running intradermal 4-0 Monocryl on the skin, packing sutures and staples were removed as they were approached.  The nipple was sutured with running intradermal 4-0 Monocryl.  Vascularity appeared good throughout.  After this had been completed, all wounds were cleaned and Steri-Stripped.  The patient tolerated the procedure well.  All counts were correct.  Estimated blood loss was less than 150 mL, and she was sent to recovery room in good condition.","surgery, macromastia, estimated blood loss, monocryl, steri-stripped, dermis, inferior breast, mammoplasty, neo-nipple, prepped and draped, ptotic breasts, recovery room in good condition, reduction mammoplasty, superior breast, upright position, bilateral macromastia, incision, superiorly, breasts "
 An example/template for meatoplasty., Surgery, Meatoplasty Template ,"OPERATIVE NOTE:  ,The patient was placed in the supine position under general anesthesia, and prepped and draped in the usual manner.  The penis was inspected.  The meatus was inspected and an incision was made in the dorsal portion of the meatus up towards the tip of the penis connecting this with the ventral urethral groove.  This was incised longitudinally and closed transversely with 5-0 chromic catgut sutures.  The meatus was calibrated and accepted the calibrating instrument without difficulty, and there was no stenosis.  An incision was made transversely below the meatus in a circumferential way around the shaft of the penis, bringing up the skin of the penis from the corpora.  The glans was undermined with sharp dissection and hemostasis was obtained with a Bovie.  Using a skin hook, the meatus was elevated ventrally and the glans flaps were reapproximated using 5-0 chromic catgut, creating a new ventral portion of the glans using the flaps of skin.  There was good viability of the skin.  The incision around the base of the penis was performed, separating the foreskin that was going to be removed from the coronal skin.  This was removed and hemostasis was obtained with a Bovie.  0.25% Marcaine was infiltrated at the base of the penis for post-op pain relief, and the coronal and penile skin was reanastomosed using 4-0 chromic catgut.  At the conclusion of the procedure, Vaseline gauze was wrapped around the penis.  There was good hemostasis and the patient was sent to the recovery room in stable condition.","surgery, penis, meatus, urethral groove, corpora, glans, meatoplasty, bovie, chromic, catgut, hemostasisNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
  Right hallux abductovalgus deformity.  Right McBride bunionectomy.  Right basilar wedge osteotomy with OrthoPro screw fixation., Surgery, McBride Bunionectomy & Wedge Osteotomy ,"PREOPERATIVE DIAGNOSIS:,  Right hallux abductovalgus deformity.,POSTOPERATIVE DIAGNOSIS:,  Right hallux abductovalgus deformity.,PROCEDURES PERFORMED:,1.  Right McBride bunionectomy.,2.  Right basilar wedge osteotomy with OrthoPro screw fixation.,ANESTHESIA: , Local with IV sedation.,HEMOSTASIS: , With pneumatic ankle cuff.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room and placed in a supine position.  The right foot was prepared and draped in usual sterile manner.  Anesthesia was achieved utilizing a 50:50 mixture of 2% lidocaine plain with 0.5 Marcaine plain infiltrated just proximal to the first metatarsocuneiform joint.  Hemostasis was achieved utilizing a pneumatic ankle Tourniquet placed above the right ankle and inflated to a pressure of 225 mmHg.  At this time, attention was directed to the dorsal aspect of the right first metatarsophalangeal joint where dorsal linear incision approximately 3 cm in length was made.  The incision was deepened within the same plain taking care of the Bovie and retracted all superficial nerves and vessels as necessary.  The incision was then carried down to the underlying capsular structure once again taking care of the Bovie and retracted all superficial nerves and vessels as necessary.  The capsular incision following the same outline as the skin incision was made and carried down to the underlying bony structure.  The capsule was then freed from the underling bony structure utilizing sharp and blunt dissection.  Using a microsagittal saw, the medial and dorsal very prominent bony eminence were removed and the area was inspected for any remaining bony prominences following resection of bone and those noted were removed using a hand rasp.  At this time, attention was directed to the first inner space using sharp and blunt dissection.  Dissection was carried down to the underling level of the adductor hallucis tendon, which was isolated and freed from its phalangeal, sesamoidal, and metatarsal attachments.  The tendon was noted to lap the length and integrity for transfer and at this time was tenotomized taking out resection of approximately 0.5 cm to help prevent any re-fibrous attachment.  At this time, the lateral release was stressed and was found to be complete.  The extensor hallucis brevis tendon was then isolated using blunt dissection and was tenotomized as well taking out approximately 0.5-cm resection.  The entire area was copiously flushed 3 times using a sterile saline solution and was inspected for any bony prominences remaining and it was noted that the base of the proximal phalanx on the medial side due to the removal of the extensive buildup of the metatarsal head was going to be very prominent in nature and at this time was removed using a microsagittal saw.  The area was again copiously flushed and inspected for any abnormalities and/or prominences and none were noted.  At this time, attention was directed to the base of the first metatarsal where a second incision was made approximately 4 cm in length.  The incision was deepened within the same plain taking care of Bovie and retracted all superficial nerves and vessels as necessary.  The incision was then carried down to the level of the metatarsal and using sharp and blunt dissection periosteal capsule structures were freed from the base of the metatarsal and taking care to retract the long extensive tendon and any neurovascular structures to avoid any disruption.  At this time, there was a measurement made of 1 cm just distal to the metatarsocuneiform joint on the medial side and 2 cm distal to the metatarsocuneiform joint from the lateral aspect of the joint.  At this time, 0.5 cm was measured distal to that lateral measurement and using microsagittal saw, a wedge osteotomy was taken from the base with the apex of the osteotomy being medial, taking care to keep the medial cortex intact as a hinge.  The osteotomy site was feathered down until the osteotomy site could be closed with little tension on it and at this time using an OrthoPro screw 3.0 x 22 mm.  The screw was placed following proper technique.  The osteotomy site was found to be fixated with absolutely no movement and good stability upon manual testing.  A very tiny gap on the lateral aspect of the osteotomy site was found and this was filled in packing it with the cancellous bone that was left over from the wedge osteotomy.  The packing of the cancellous bone was held in place with bone wax.  The entire area was copiously flushed 3 times using a sterile saline solution and was inspected and tested again for any movement of the osteotomy site or any gapping and then removed.  At this time, a deep closure was achieved utilizing #2-0 Vicryl suture, subcuticular closure was achieved using #4-0 Vicryl suture, and skin repair was achieved at both surgical sites with #5-0 nylon suture in a running interlocking fashion.  The hallux was found to have excellent movement upon completion of the osteotomy and the second procedure of the McBride bunionectomy and the metatarsal was found to stay in excellent alignment with good stability at the proximal osteotomy site.  At this time, the surgical site was postoperatively injected with 0.5 Marcaine plain as well as dexamethasone 4 mg primarily.  The surgical sites were then dressed with sterile Xeroform, sterile 4x4s, cascading, and Kling with a final protective layer of fiberglass in a nonweightbearing cast fashion.  The tourniquet was dropped and color and temperature of all digits returned to normal.  The patient tolerated the anesthesia and the procedure well and left the operating room in stable condition.,The patient has been given written and verbal postoperative instructions and has been instructed to call if she has any questions, problems, or concerns at any time with the numbers provided.  The patient has also been warned a number of times the importance of elevation and no weightbearing on the surgical foot.,","surgery, hallux, abductovalgus, bunionectomy, mcbride, basilar, wedge, osteotomy, orthopro, screw, fixation, wedge osteotomy"
 Bilateral reduction mammoplasty with superior and inferiorly based dermal parenchymal pedicle with transposition of the nipple-areolar complex., Surgery, Mammoplasty - 3 ,"PREOPERATIVE DIAGNOSES:,  Bilateral mammary hypertrophy with breast asymmetry, right breast larger than left.,POSTOPERATIVE DIAGNOSES:,  Bilateral mammary hypertrophy with breast asymmetry, right breast larger than left.,OPERATION:,  Bilateral reduction mammoplasty with superior and inferiorly based dermal parenchymal pedicle with transposition of the nipple-areolar complex with resection of 947 g in the larger right breast and 758 g in the smaller left breast.,ANESTHESIA:  ,General endotracheal anesthesia.,PROCEDURE IN DETAIL:  ,The patient was placed in the supine position under the effects of general endotracheal anesthesia.  The breasts were prepped and draped with DuraPrep and iodine solution and then draped in appropriate sterile fashion.  Markings were then made in the standing position preoperatively.  The nipple areolar complex was drawn at the level of the anterior projection of the inframammary fold along the central margin of the breast.  A McKissock ring was utilized as a pattern.  It was centered over the new nipple position and the medial and lateral flaps were drawn tangential to the pigmented areola at a 40-degree angle.  Medial and lateral flaps were drawn 8 cm in length.  At the most medial and lateral extremity inframammary folds, a line was drawn to the lower level at the medial and lateral flaps.  On the left side, the epithelialization was performed about the 45-mm nipple-areolar complex within the confines of the superior-medially based dermal parenchymal pedicle.  Resection of the skin, subcutaneous tissue, and glandular tissue was performed along the inframammary fold, and then cut was made medially and laterally.  The resection medially was perpendicular to the chest wall down to the areolar tissue overlying the pectoralis major muscle, and laterally, the resection was performed tangential to the chest wall, skin, subcutaneous tissue, and glandular tissue towards the axillary tail.  The pedicle was thinned as well, so it was 2-cm thick beneath the nipple-areolar complex and they were medially 4-cm thick at its base.  On the right side, 947 g of breast tissue was removed.  Hemostasis was achieved with electrocautery.  Identical procedure was performed on the opposite left side, again with a superiorly and inferiorly based dermal parenchymal pedicle with deepithelialization about the 45-mm diameter nipple-areolar complex.  Resection of the skin, subcutaneous tissue, and glandular tissue was performed medially down to the chest overlying the pectoralis major muscle and laterally tangential to the chest wall towards the axillary tail setting the pedicle as well beneath the nipple areolar complex.  Hemostasis was achieved with electrocautery.  With pedicle on the left, the breast issue on the left side was weighed at 758 g.  Hemostasis was achieved with cautery.  The patient was placed in the sitting position with wound partially closed and there appeared to be excellent symmetry between the right and left sides.  The nipple-areolar complex was transposed within the position and the medial and lateral flaps were brought together beneath the transposed nipple-areolar complex.  Closure was performed with interrupted 3-0 PDS suture for deep subcutaneous tissue and dermis.  Skin was closed with running subcuticular 4-0 Monocryl suture.  A Jackson-Pratt drain had been placed prior to final closure and secured with a 4-0 silk suture.  The wound had been irrigated prior to final closure as well with bacitracin irrigation solution prior to final cauterization.  Closure was performed with an anchor-shaped closure around the nipple-areolar complex, vertically of inframammary folds and across the inframammary folds.  Dressing was applied.  The suture line was treated with Dermabond.  The patient returned to the recovery room with 2 Jackson-Pratt drains, 1 on each side and IV Foley catheter with instructions to be seen in my office in 2 days.  The patient tolerated the procedure well and returned to the recovery room in satisfactory condition.","surgery, bilateral mammary hypertrophy, duraprep, general endotracheal anesthesia, jackson-pratt drains, breast asymmetry, hypertrophy, inframammary folds, mammary, mammoplasty, nipple areolar complex, nipple-areolar complex, parenchymal, pedicle, prepped and draped, reduction mammoplasty, transposition, medial and lateral, based dermal, dermal parenchymal, parenchymal pedicle, subcutaneous tissue, nipple, areolar, inferiorly, subcutaneous, inframammary, breast, tissue, "
" Bilateral augmentation mammoplasty, breast implant, TCA peel to lesions, vein stripping.", Surgery, Mammoplasty - 2 ,"PREOPERATIVE DIAGNOSES,Breast hypoplasia, melasma to the face, and varicose veins to the posterior aspect of the right distal thigh/popliteal fossa area.,PROCEDURES,1.  Bilateral augmentation mammoplasty, subglandular with a mammary gel silicone breast implant, 435 cc each.,2.  TCA peel to two lesions of the face and vein stripping to the right posterior thigh and popliteal fossa area.,ANESTHESIA,General endotracheal.,EBL,100 cc.,IV FLUIDS,2L.,URINE OUTPUT,Per Anesthesia.,INDICATION FOR SURGERY,The patient is a 48-year-old female who was seen in clinic by Dr. W and where she was evaluated for her small breasts as well as dark areas on her face and varicose veins to the back and posterior aspect of her right lower extremity.  She requested that surgical procedures to be performed for correction of these abnormalities.  As such, complications were explained to the patient including infection, bleeding, poor wound healing, and need for additional surgery.  The patient subsequently signed the consent and requested that Dr. W and associates to perform the procedure.,TECHNIQUE,The patient was brought to the operating room in supine position.  General anesthesia was induced and then the patient was placed on the operating table in a prone position.  The posterior thigh of the right lower extremity was prepped and draped in a sterile fashion.  First, multiple serial small incisions less than 1 cm in length were made to the posterior aspect of the right thigh and sequential stripping of the varicose veins was performed.  Once these varicose veins had been completely stripped and avulsed, then next the wounds were then irrigated and were cleaned with wet and dry, and all the incisions were closed with the use of 5-0 Monocryl buried interrupted sutures.  The incisions were then dressed with Mastisol, Steri-Strips, ABDs and a TED hose.  Next, the patient was then flipped back over onto the stretcher and placed on the operating table in a supine position.  The anterior chest was then prepped and draped in a sterile fashion.  Next, a 10 blade was placed through previous circumareolar incisions from a previous augmentation mammoplasty.  Dissection was carried out with a 10 blade and Bovie cautery until the pectoralis fascia was identified to both breasts.  Once the pectoralis muscle and fascia were identified, then a surgical plane was created in a subglandular layer.  The hemostasis was obtained to both breast pockets with the Bovie cautery and suction and irrigation was performed to bilateral breast pockets as well.  A sizer was used to identify the appropriate size of the silicone implant to be used.  This was determined to be approximately 435 cc bilaterally.  As such, two mammary gel silicone breast implants were placed in a subglandular muscle.  Additional dissection of the breast pockets were performed bilaterally and the patient was sequentially placed in the upright sitting position for evaluation of appropriate placement of the mammary gel silicone implants.  Once it was determined that the implants were appropriately selected and placed with the 435 cc silicon gel implant, the circumareolar incisions were closed in approximately 4-layered fashion closing the fascia, subcutaneous tissue, deep dermis, and a running dermal subcuticular for final skin closure.  This was performed with 3-0 Monocryl and then 4-0 Monocryl for running subcuticular.  The incisions were then dressed with Mastisol, Steri-Strips, and Xeroform and dressed with sample Kerlix.  Next, our attention was paid to the face where 25% TCA solution was applied to two locations; one on the left cheek and the other one on the right cheek, where a hyperpigmentation/melasma.  Several applications of the TCA peel was performed, and at the end of this, the frosting was noted to both spots.  At the end of the case, needle and instrument counts were correct.  Dr. W was present and scrubbed for the entire procedure.  The patient was extubated in the operating room and taken to the PACU in stable condition.","surgery, breast hypoplasia, monocryl, pacu, tca, tca peel, ted hose, augmentation mammoplasty, breast implant, melasma, poor wound healing, popliteal fossa area, prepped and draped, silicone, varicose vein, vein stripping, mastisol steri strips, steri strips, circumareolar incisions, mammary gel, varicose veins, augmentation, breast, circumareolar, incisions, mammoplasty, mastisol, strips"
 Bilateral transaxillary subpectoral mammoplasty with saline-filled implants., Surgery, Mammoplasty - 4 ,"DIAGNOSIS: , Bilateral hypomastia.,NAME OF OPERATION:,  Bilateral transaxillary subpectoral mammoplasty with saline-filled implants.,ANESTHESIA:,  General.,PROCEDURE: , After first obtaining a suitable level of general anesthesia with the patient in the supine position, the breasts were prepped with Betadine scrub and solution.  Sterile towels, sheets, and drapes were placed in the usual fashion for surgery of the breasts.  Following prepping and draping, the anterior axillary folds and the inframammary folds were infiltrated with a total of 20 cc of 0.5% Xylocaine with 1:200,000 units of epinephrine.,After a suitable hemostatic waiting period, transaxillary incisions were made, and dissection was carried down to the edge of the pectoralis fascia.  Blunt dissection was then used to form a bilateral subpectoral pocket.  Through the subpectoral pocket a sterile suction tip was introduced, and copious irrigation with sterile saline solution was used until the irrigant was clear.,Following completion of irrigation, 350-cc saline-filled implants were introduced.  They were first filled with 60 cc of saline and checked for gross leakage; none was evident.  They were over filled to 400 cc of saline each.  The patient was then placed in the seated position, and the left breast needed 10 cc of additional fluid for symmetry.,Following completion of the filling of the implants and checking the breasts for symmetry, the patient's wounds were closed with interrupted vertical mattress sutures of 4-0 Prolene.  Flexan dressings were applied followed by the patient's bra.,She seemed to tolerate the procedure well.","surgery, bilateral transaxillary subpectoral mammoplasty, saline filled implants, subpectoral mammoplasty, mammoplasty, transaxillary, subpectoral, implants, breasts, saline, anesthesia"
 Lysis of pelvic adhesions.  The patient had an 8 cm left ovarian mass.   The mass was palpable on physical examination and was tender.  She was scheduled for an elective pelvic laparotomy with left salpingooophorectomy., Surgery, Lysis of Pelvic Adhesions ,"PREOPERATIVE DIAGNOSIS: , Multiple pelvic adhesions.,POSTOPERATIVE DIAGNOSIS: , Multiple pelvic adhesions.,PROCEDURE PERFORMED: ,Lysis of pelvic adhesions.,ANESTHESIA: , General with local.,SPECIMEN: , None.,COMPLICATIONS: , None.,HISTORY: , The patient is a 32-year-old female who had an 8 cm left ovarian mass, which was evaluated by Dr. X.  She had a ultrasound, which demonstrated the same.  The mass was palpable on physical examination and was tender.  She was scheduled for an elective pelvic laparotomy with left salpingooophorectomy.  During the surgery, there were multiple pelvic adhesions between the left ovarian cyst and the sigmoid colon.  These adhesions were taken down sharply with Metzenbaum scissors.,PROCEDURE: , A pelvic laparotomy had been performed by Dr. X.  Upon exploration of the abdomen, multiple pelvic adhesions were noted as previously stated.  A 6 cm left ovarian cyst was noted with adhesions to the sigmoid colon and mesentery.  These adhesions were taken down sharply with Metzenbaum scissors until the sigmoid colon was completely freed from the ovarian cyst.  The ureter had been identified and isolated prior to the adhesiolysis.  There was no evidence of bleeding.  The remainder of the case was performed by Dr. X and this will be found in a separate operative report.","surgery, lysis of pelvic adhesions, pelvic adhesions, pelvic, adhesions, salpingooophorectomy, lysis, laparotomy, sigmoid, colon, mass, ovarian,"
 Sentinel lymph node biopsy.  Ultrasound-guided lumpectomy with intraoperative ultrasound., Surgery, Lumpectomy & Lymph Node Biopsy ,"PREOPERATIVE DIAGNOSIS,Left breast ductal carcinoma in situ.,POSTOPERATIVE DIAGNOSIS,Left breast ductal carcinoma in situ.,PROCEDURES PERFORMED,1.  Sentinel lymph node biopsy.,2.  Ultrasound-guided lumpectomy with intraoperative ultrasound.,ANESTHESIA,General LMA anesthesia.,ESTIMATED BLOOD LOSS,Minimum.,IV FLUIDS,Per anesthesia record.,COMPLICATIONS,None.,FINDINGS,Clip well localized within the specimen.,INDICATION,This is a 65-year-old female who presents with abnormal mammogram who underwent stereotactic biopsy at an outside facility, which showed atypical ductal hyperplasia with central necrosis.  On reviewing this pathology, it is mostly likely DCIS.  The risks and benefits of the procedure were explained to the patient who appeared to understand and agreed to proceed.  The patient desired MammoSite Radiation Therapy; therefore, the sentinel lymph node biopsy was incorporated into the procedure.,PROCEDURE IN DETAIL,The patient was taken to the operating room, placed in supine position, and general LMA anesthesia was administered.  She was prepped and draped in the usual sterile fashion.  Prior to the procedure, she underwent nuclear medicine injection with technetium-99 and methylene blue.  Incision was made of the area of great uptake and the axilla and taken through the subcutaneous tissue with electric Bovie cautery.  Two sentinel lymph nodes were identified, one was blue and hot and the other was just hot.  These were sent to Pathology for touch prep.  Adequate hemostasis was obtained.  The wound was packed and attention was turned to the left breast.  Ultrasound was used to identify the marker and the mass within the breast and create an adequate anterior skin flap.  An elliptical incision was made roughly at approximately the 3 o'clock position secondary to subcutaneous tissues with electric Bovie cautery.  The mass was dissected off the surrounding tissue using Bovie cautery down to the level of the pectoralis fascia, which was incorporated within the specimen.  The specimen was completely removed and marked **** double deep, and a mini C-arm was used to confirm this.  The marker was well localized within the center of the specimen.  The fascia was then elevated off of the pectoralis muscle and closed loosely with the interrupted 2-0 Vicryl sutures to create a nice spherical cavity for the MammoSite radiation catheter.  The wound was then closed with a deep layer of interrupted 3-0 Vicryl followed by 3-0 Vicryl subcuticular stitch and 4-0 running Monocryl.  The axillary wound was closed with interrupted 3-0 Vicryl and a running 4-0 Monocryl.  Steri-Strips were applied.  The patient was awakened and extubated in the OR and taken to PACU in stable condition.  All counts were reported as correct.  I was present for the entire procedure.","surgery, carcinoma in situ, dcis, lma, mammosite radiation therapy, monocryl, pacu, sentinel, steri-strips, central necrosis, ductal carcinoma, ductal hyperplasia, lumpectomy, lymph node biopsy, node biopsy, stereotactic biopsy, sentinel lymph node biopsy, electric bovie, lymph node, sentinel lymph, intraoperative, anesthesia, lymph, biopsy, ultrasound"
 Left axillary lymph node excisional biopsy.  Left axillary adenopathy., Surgery, Lymph Node Excisional Biopsy ,"PREOPERATIVE DIAGNOSIS: , Left axillary adenopathy.,POSTOPERATIVE DIAGNOSIS: , Left axillary adenopathy.,PROCEDURE: , Left axillary lymph node excisional biopsy.,ANESTHESIA:,  LMA.,INDICATIONS: , Patient is a very pleasant woman who in 2006 had breast conservation therapy with radiation only.  Note, she refused her CMF adjuvant therapy and this was for a triple-negative infiltrating ductal carcinoma of the breast.  Patient has been following with Dr. Diener and Dr. Wilmot.  I believe that genetic counseling had been recommended to her and obviously the CMF was recommended, but she declined both.  She presented to the office with left axillary adenopathy in view of the high-risk nature of her lesion.  I recommended that she have this lymph node removed.  The procedure, purpose, risk, expected benefits, potential complications, alternative forms of therapy were discussed with her and she was agreeable to surgery.,TECHNIQUE: , Patient was identified, then taken into the operating room where after induction of appropriate anesthesia, her left chest, neck, axilla, and arm were prepped with Betadine solution, draped in a sterile fashion.  An incision was made at the hairline, carried down by sharp dissection through the clavipectoral fascia.  I was able to easily palpate the lymph node and grasp it with a figure-of-eight 2-0 silk suture and by sharp dissection, was carried to hemoclip all attached structures.  The lymph node was excised in its entirety.  The wound was irrigated.  The lymph node sent to pathology.  The wound was then closed.  Hemostasis was assured and the patient was taken to recovery room in stable condition.","surgery, axillary lymph node excisional biopsy, sharp dissection, excisional biopsy, lymph node, axillary, excisional, biopsy"
" Lumbar discogram L2-3, L3-4, L4-5, and L5-S1.  Low back pain.", Surgery, Lumbar Discogram ,"PREOPERATIVE DIAGNOSIS: , Low back pain.,POSTOPERATIVE DIAGNOSIS: , Low back pain.,PROCEDURE PERFORMED:,1.  Lumbar discogram L2-3.,2.  Lumbar discogram L3-4.,3.  Lumbar discogram L4-5.,4.  Lumbar discogram L5-S1.,ANESTHESIA:  ,IV sedation.,PROCEDURE IN DETAIL:  ,The patient was brought to the Radiology Suite and placed prone onto a radiolucent table.  The C-arm was brought into the operative field and AP, left right oblique and lateral fluoroscopic images of the L1-2 through L5-S1 levels were obtained.  We then proceeded to prepare the low back with a Betadine solution and draped sterile.  Using an oblique approach to the spine, the L5-S1 level was addressed using an oblique projection angled C-arm in order to allow for perpendicular penetration of the disc space.  A metallic marker was then placed laterally and a needle entrance point was determined.  A skin wheal was raised with 1% Xylocaine and an #18-gauge needle was advanced up to the level of the disc space using AP, oblique and lateral fluoroscopic projections.  A second needle, #22-gauge 6-inch needle was then introduced into the disc space and with AP and lateral fluoroscopic projections, was placed into the center of the nucleus.  We then proceeded to perform a similar placement of needles at the L4-5, L3-4 and L2-3 levels.,A solution of Isovue 300 with 1 gm of Ancef was then drawn into a 10 cc syringe and without informing the patient of our injecting, we then proceeded to inject the disc spaces sequentially.","surgery, back pain, c-arm, fluoroscopic projections, disc space, lumbar discogram, fluoroscopic, needle,"
" Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left.  Herniated nucleus pulposus of L5-S1 on the left.
  ", Surgery, Lumbar Laminotomy & Discectomy ,"PREOPERATIVE DIAGNOSIS:,  Herniated nucleus pulposus of L5-S1 on the left.,POSTOPERATIVE DIAGNOSIS: ,Herniated nucleus pulposus of L5-S1 on the left.,PROCEDURE PERFORMED:, Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left.,ANESTHESIA: , General via endotracheal tube.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,SPECIMENS: , Disc that was not sent to the lab.,DRAINS: , None.,COMPLICATIONS: , None.,SURGICAL PROGNOSIS: , Remains guarded due to her ongoing pain condition and Tarlov cyst at the L5 nerve root distally.,SURGICAL INDICATIONS: , The patient is a 51-year-old female who has had unrelenting low back pain that radiated down her left leg for the past several months.  The symptoms were unrelieved by conservative modalities.  The symptoms were interfering with all aspects of daily living and inability to perform any significant work endeavors.  She is understanding the risks, benefits, potential complications, as well as all treatment alternatives.  She wished to proceed with the aforementioned surgery due to her persistent symptoms.  Informed consent was obtained.,OPERATIVE TECHNIQUE: , The patient was taken to OR room #5 where she was given general anesthetic by the Department of Anesthesia.  She was subsequently placed on the Jackson spinal table with the Wilson attachment in the prone position.  Palpation did reveal the iliac crest and suspected L5-S1 interspace.  Thereafter the lumbar spine was serially prepped and draped.  A midline incision was carried over the spinal process of L5 to S1.  Skin and subcutaneous tissue were divided sharply.  Electrocautery provided hemostasis.  Electrocautery was then utilized to dissect through the subcutaneous tissues to the lumbar fascia.  Lumbar fascia was identified and the decussation of fibers was identified at the L5-S1 interspace.  On the left side, superior aspect dissection was carried out with the Cobb elevator and electrocautery.  This revealed the interspace of suspect level of L5-S1 on the left.  A Kocher clamp was placed between the spinous processes of the suspect level of L5-S1.  X-ray did confirm the L5-S1 interval.  Angled curet was utilized to detach the ligamentum flavum from its bony attachments at the superior edge of S1 lamina and the inferior edge of the L5 lamina.  Meticulous dissection was undertaken and the ligamentum flavum was removed.  Laminotomy was created with Kerrison rongeur, both proximally and distally.  The microscope was positioned and the dura was inspected.  A blunt Penfield elevator was then utilized to dissect and identify the L5-S1 nerve root on the left.  It was noted to be tented over a disc extrusion.  The nerve root was protected and medialized.  It was retracted with a nerve root retractor.  This did reveal a subligamentous disc herniation at approximately the L5-S1 disc space and neuroforaminal area.  A #15 Bard-Parker blade was utilized to create an annulotomy.  Medially, disc material was extruding through this annulotomy.  Two tier rongeur was then utilized to grasp the disc material and the disc was removed from the interspace.  Additional disc material was then removed, both to the right and left of the annulotomy.  Up and downbiting pituitary rongeurs were utilized to remove any other loose disc pieces.  Once this was completed, the wound was copiously irrigated with antibiotic solution and suctioned dry.  The Penfield elevator was placed in the disc space of L5-S1 and a crosstable x-ray did confirm this level.  Nerve root was again expected exhibiting the foramina.  A foraminotomy was created with a Kerrison rongeur.  Once this was created, the nerve root was again inspected and deemed free of tension.  It was mobile within the neural foramina.  The wound was again copiously irrigated with antibiotic solution and suctioned dry.  A free fat graft was then harvested from the subcutaneous tissues and placed over the exposed dura.  Lumbar fascia was then approximated with #1 Vicryl interrupted fashion, subcutaneous tissue with #2-0 Vicryl interrupted fashion, and #4-0 undyed Vicryl was utilized to approximate the skin.  Compression dressing was applied.  The patient was turned, awoken, and noted to be moving all four extremities without apparent deficits.  She was taken to the recovery room in apparent satisfactory condition.  Expected surgical prognosis remains guarded due to her ongoing pain syndrome that has been requiring significant narcotic medications.","surgery, lumbar laminotomy with discectomy, microscopic assisted, herniated nucleus pulposus, subcutaneous tissue, ligamentum flavum, kerrison rongeur, penfield elevator, lumbar laminotomy, lumbar fascia, nerve root, discectomy, lumbar, laminotomy, herniated,"
 Possible CSF malignancy.  This is an 83-year-old woman referred for diagnostic lumbar puncture for possible malignancy by Dr. X.   The patient has gradually stopped walking even with her walker and her left arm has become gradually less functional.  She is not able to use the walker because her left arm is so weak. , Surgery, Lumbar Puncture ,"REASON FOR VISIT:  ,This is an 83-year-old woman referred for diagnostic lumbar puncture for possible malignancy by Dr. X. She is accompanied by her daughter.,HISTORY OF PRESENT ILLNESS:,  The patient' daughter tells me that over the last month the patient has gradually stopped walking even with her walker and her left arm has become gradually less functional.  She is not able to use the walker because her left arm is so weak.  She has not been having any headaches.  She has had a significant decrease in appetite.  She is known to have lung cancer, but Ms. Wilson does not know what kind.  According to her followup notes, it is presumed non-small cell lung cancer of the left upper lobe of the lung.  The last note I have to evaluate is from October 2008.  CT scan from 12/01/2009 shows atrophy and small vessel ischemic change, otherwise a normal head CT, no mass lesion.  I also reviewed the MRI from September 2009, which does not suggest normal pressure hydrocephalus and shows no mass lesion.,Blood tests from 11/18/2009 demonstrate platelet count at 132 and INR of 1.0.,MAJOR FINDINGS: , The patient is a pleasant and cooperative woman who answers the questions the best she can and has difficulty moving her left arm and hand.  She also has pain in her left arm and hand at a level of 8-9/10.,VITAL SIGNS: , Blood pressure 126/88, heart rate 70, respiratory rate 16, and weight 95 pounds.,I screened the patient with questions to determine whether it is likely she has abnormal CSF pressure and she does not have any of the signs that would suggest this, so we performed the procedure in the upright position.,PROCEDURE:,  Lumbar puncture, diagnostic (CPT 62270).,PREOPERATIVE DIAGNOSIS: , Possible CSF malignancy.,POSTOPERATIVE DIAGNOSIS:  ,To be determined after CSF evaluation.,PROCEDURE PERFORMED: , Lumbar puncture.,ANESTHESIA: , Local with 2% lidocaine at the L4-L5 level.,SPECIMEN REMOVED:  ,15 cc of clear CSF.,ESTIMATED BLOOD LOSS: , None.,DESCRIPTION OF THE PROCEDURE:  ,I explained the procedure, its rationale, risks, benefits, and alternatives to the patient and her daughter.  The patient' daughter remained present throughout the procedure.  The patient provided written consent and her daughter signed as witness to the consent.,I located the iliac crest and spinous processes before the procedure and determined the level I planned for the puncture.  During the procedure, I spoke constantly with the patient to explain what was happening and to warn when there might be pain or discomfort.  The skin was prepped with chlorhexidine solution with the patient seated on the chair leaning forward with her face resting on the exam table.  Using local anesthetic and aseptic technique, I inserted a 20-gauge spinal needle at the L4-L5 interspace and 15 cc of CSF was collected without difficulty.,The patient tolerated the procedure well.,ASSESSMENT:  ,White blood cells 1, red blood cells 54, glucose 59, protein 51, Gram stain negative, bacterial culture negative after three days, and remaining tests pending.",
 Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation., Surgery, Lumbar Re-exploration ,"PREOPERATIVE DIAGNOSIS: , Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.,POSTOPERATIVE DIAGNOSIS: , Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.,PROCEDURE: , Lumbar re-exploration for removal of fractured internal fixation plate from T11 through L2 followed by a repositioning of the L2 pedicle screws and evaluation of the fusion from T11 through L2 followed by a bilateral hemilaminectomy and diskectomy for decompression at L4-5 and L5-S1 with posterior lumbar interbody fusion using morselized autograft bone and the synthetic spacers from the Capstone system at L4-5 and L5-S1 followed by placement of the pedicle screw fixation devices at L3, L4, L5, and S1 and insertion of a 20 cm fixation plate that range from the T11 through S1 levels and then subsequent onlay fusion using morselized autograft bone and bone morphogenetic soaked sponge at L1-2 and then at L3-L4, L4-L5, and L5-S1 bilaterally.,DESCRIPTION OF PROCEDURE:  ,This is a 68-year-old lady who presents with a history of osteomyelitis associated with the percutaneous vertebroplasty that was actually treated several months ago with removal of the infected vertebral augmentation and placement of a posterior pedicle screw plate fixation device from T11 through L2.  She subsequently actually done reasonably well until about a month ago when she developed progressive severe intractable pain.  Imaging study showed that the distal hardware at the plate itself had fractured consistent with incomplete fusion across her osteomyelitis area.  There was no evidence of infection on the imaging or with her laboratory studies.  In addition, she developed a pretty profound stenosis at L4-L5 and L5-S1 that appeared to be recurrent as well.  She now presents for revision of her hardware, extension of fusion, and decompression.,The patient was brought to the operating room, placed under satisfactory general endotracheal anesthesia.  She was placed on the operative table in the prone position.  Back was prepared with Betadine, iodine, and alcohol.  We elliptically excised her old incision and extended this caudally so that we had access from the existing hardware fixation all the way down to her sacrum.  The locking nuts were removed from the screw post and both plates refractured or significantly weakened and had a crease in it.  After these were removed, it was obvious that the bottom screws were somewhat loosened in the pedicle zone so we actually tightened one up and that fit good snugly into the nail when we redirected so that it actually reamed up into the upper aspect of the vertebral body in much more secure purchase.  We then dressed the L4-L5 and L5-S1 levels which were profoundly stenotic.  This was a combination of scar and overgrown bone.  She had previously undergone bilateral hemilaminectomies at L4-5 so we removed scar bone and actually cleaned and significantly decompressed the dura at both of these levels.  After completing this, we inserted the Capstone interbody spacer filled with morselized autograft bone and some BMP sponge into the disk space at both levels.  We used 10 x 32 mm spacers at both L4-L5 and L5-S1.  This corrected the deformity and helped to preserve the correction of the stenosis and then after we cannulated the pedicles of L4, L5 and S1 tightened the pedicle screws in L3.  This allowed us to actually seat a 20 cm plate contoured to the lumbar lordosis onto the pedicle screws all the way from S1 up to the T11 level.  Once we placed the plate onto the screws and locked them in position, we then packed the remaining BMP sponge and morselized autograft bone through the plate around the incomplete fracture healing at the L1 level and then dorsolaterally at L4-L5 and L5-S1 and L3-L4, again the goal being to create a dorsal fusion and enhance the interbody fusion as well.  The wound was then irrigated copiously with bacitracin solution and then we closed in layers using #1 Vicryl in muscle and fascia, 3-0 in subcutaneous tissue and approximated staples in the skin.  Prior to closing the skin, we confirmed correct sponge and needle count.  We placed a drain in the extrafascial space and then confirmed that there were no other foreign bodies.  The Cell Saver blood was recycled and she was given two units of packed red blood cells as well.  I was present for and performed the entire procedure myself or supervised.","surgery, degenerative spondylolisthesis, spondylolisthesis, stenosis, lumbar re-exploration, internal fixation plate, hemilaminectomy, diskectomy, synthetic spacers, pedicle screws, fusion, lumbar, pedicle, fixation, hardware,"
" Lumbar puncture.  A 20-gauge spinal needle was then inserted into the L3-L4 space.  Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained. ", Surgery, Lumbar Puncture - 2 ,"PROCEDURE PERFORMED:,  Lumbar puncture.,The procedure, benefits, risks including possible risks of infection were explained to the patient and his father, who is signing the consent form.  Alternatives were explained.  They agreed to proceed with the lumbar puncture.  Permit was signed and is on the chart.  The indication was to rule out toxoplasmosis or any other CNS infection. ,DESCRIPTION: , The area was prepped and draped in a sterile fashion.  Lidocaine 1% of 5 mL was applied to the L3-L4 spinal space after the area had been prepped with Betadine three times.  A 20-gauge spinal needle was then inserted into the L3-L4 space.  Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained.  The spinal needle was then withdrawn and the area cleaned and dried and a Band-Aid applied to the clean, dry area.,COMPLICATIONS:,  None.  The patient was resting comfortably and tolerated the procedure well.,ESTIMATED BLOOD LOSS: , None.,DISPOSITION: , The patient was resting comfortably with nonlabored breathing and the incision was clean, dry, and intact.  Labs and cultures were sent for the usual in addition to some extra tests that had been ordered.,The opening pressure was 292, the closing pressure was 190.","surgery, spinal needle, lumbar puncture, lumbar, gauge, csf"
" Injection for myelogram and microscopic-assisted lumbar laminectomy with discectomy at L5-S1 on the left.  Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.", Surgery, Lumbar Laminectomy & Discectomy ,"PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.,POSTOPERATIVE DIAGNOSIS:,  Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.,PROCEDURE PERFORMED:,1.  Injection for myelogram.,2.  Microscopic-assisted lumbar laminectomy with discectomy at L5-S1 on the left on 08/28/03.,BLOOD LOSS: , Approximately 25 cc.,ANESTHESIA: , General.,POSITION:,  Prone on the Jackson table.,INTRAOPERATIVE FINDINGS:,  Extruded nucleus pulposus at the level of L5-S1.,HISTORY: , This is a 34-year-old male with history of back pain with radiation into the left leg in the S1 nerve root distribution.  The patient was lifting at work on 08/27/03 and felt immediate sharp pain from his back down to the left lower extremity.  He denied any previous history of back pain or back surgeries.  Because of his intractable pain as well as severe weakness in the S1 nerve root distribution, the patient was aware of all risks as well as possible complications of this type of surgery and he has agreed to pursue on.  After an informed consent was obtained, all risks as well as complications were discussed with the patient.  ,PROCEDURE DETAIL:  ,He was wheeled back to Operating Room #5 at ABCD General Hospital on 08/28/03.  After a general anesthetic was administered, a Foley catheter was inserted.,The patient was then turned prone on the Jackson table.  All of his bony prominences were well-padded.  At this time, a myelogram was then performed.  After the lumbar spine was prepped, a #20 gauge needle was then used to perform a myelogram.  The needle was localized to the level of L3-L4 region.  Once inserted into the thecal sac, we immediately got cerebrospinal fluid through the spinal needle.  At this time, approximately 10 cc of Conray injected into the thecal sac.  The patient was then placed in the reversed Trendelenburg position in order to assist with distal migration of the contrast.  The myelogram did reveal that there was some space occupying lesion, most likely disc at the level of L5-S1 on the left.  There was a lack of space filling defect on the left evident on both the AP and the lateral projections using C-arm fluoroscopy.  At this point, the patient was then fully prepped and draped in the usual sterile fashion for this procedure for a microdiscectomy.  A long spinal needle was then inserted into region of surgery on the right.  The surgery was going to be on the left.  Once the spinal needle was inserted, a localizing fluoroscopy was then used to assure appropriate location and this did confirm that we were at the L5-S1 nerve root region.  At this time, an approximately 2 cm skin incision was made over the lumbar region, dissected down to the deep lumbar fascia.  At this time, a Weitlaner was inserted.  Bovie cautery was used to obtain hemostasis.  We further continued through the deep lumbar fascia and dissected off the short lumbar muscles off of the spinous process and the lamina.  A Cobb elevator was then used to elevate subperiosteally off of all the inserting short lumbar muscles off of the spinous process as well as the lamina on the left-hand side.  At this time, a Taylor retractor was then inserted and held there for retraction.  Suction as well as Bovie cautery was used to obtain hemostasis.  At this time, a small Kerrison Rongeur was used to make a small lumbar laminotomy to expose our window for the nerve root decompression.  Once the laminotomy was performed, a small _______ curette was used to elevate the ligamentum flavum off of the thecal sac as well as the adjoining nerve roots.  Once the ligamentum flavum was removed, we immediately identified a piece of disc material floating around outside of the disc space over the S1 nerve root, which was compressive.  We removed the extruded disc with further freeing up of the S1 nerve root.  A nerve root retractor was then placed.  Identification of disc space was then performed.  A #15 blade was then inserted and small a key hole into the disc space was then performed with a #15 blade.  A small pituitary was then inserted within the disc space and more disc material was freed and removed.  The part of the annulus fibrosis were also removed in addition to the loose intranuclear pieces of disc.  Once this was performed, we removed the retraction off the nerve root and the nerve root appeared to be free with pulsatile visualization of the vasculature indicating that the nerve root was essentially free.,At this time, copious irrigation was used to irrigate the wound.  We then performed another look to see if any loose pieces of disc were extruding from the disc space and only small pieces were evident and they were then removed with the pituitary rongeur.  At this time, a small piece of Gelfoam was then used to cover the exposed nerve root.  We did not have any dural leaks during this case.  #1-0 Vicryl was then used to approximate the deep lumbar fascia, #2-0 Vicryl was used to approximate the superficial lumbar fascia, and #4-0 running Vicryl for the subcutaneous skin.  Sterile dressings were then applied.  The patient was then carefully slipped over into the supine position, extubated and transferred to Recovery in stable condition.  At this time, we are still waiting to assess the patient postoperatively to assure no neurological sequela postsurgically are found and also to assess his pain level.","surgery, microscopic-assisted lumbar laminectomy, discectomy, nerve root, lumbar laminectomy, herniated nucleus, thecal sac, spinal needle, nucleus pulposus, disc space, root, nerve, weakness, lumbar, laminectomy, nucleus, pulposus, myelogram"
 Lumbar puncture with moderate sedation., Surgery, Lumbar Puncture - 1 ,"PROCEDURE: , Lumbar puncture with moderate sedation.,INDICATION: , The patient is a 2-year, 2-month-old little girl who presented to the hospital with severe anemia, hemoglobin 5.8, elevated total bilirubin consistent with hemolysis and weak positive direct Coombs test.  She was transfused with packed red blood cells.  Her hemolysis seemed to slow down.  She also on presentation had indications of urinary tract infection with urinalysis significant for 2+ leukocytes, positive nitrites, 3+ protein, 3+ blood, 25 to 100 white cells, 10 to 25 bacteria, 10 to 25 epithelial cells on clean catch specimen.  Culture subsequently grew out no organisms; however, the child had been pretreated with amoxicillin about x3 doses prior to presentation to the hospital.  She had a blood culture, which was also negative.  She was empirically started on presentation with the cefotaxime intravenously.  Her white count on presentation was significantly elevated at 20,800, subsequently increased to 24.7 and then decreased to 16.6 while on antibiotics.  After antibiotics were discontinued, she increased over the next 2 days to an elevated white count of 31,000 with significant bandemia, metamyelocytes and myelocytes present.  She also had three episodes of vomiting and thus she is being taken to the procedure room today for a lumbar puncture to rule out meningitis that may being inadvertently treated in treating her UTI.,I discussed with The patient's parents prior to the procedure the lumbar puncture and moderate sedation procedures.  The risks, benefits, alternatives, complications including, but not limited to bleeding, infection, respiratory depression.  Questions were answered to their satisfaction.  They would like to proceed.,PROCEDURE IN DETAIL: , After ""time out"" procedure was obtained, the child was given appropriate monitoring equipment including appropriate vital signs were obtained.  She was then given Versed 1 mg intravenously by myself.  She subsequently became sleepy, the respiratory monitors, end-tidal, cardiopulmonary and pulse oximetry were applied.  She was then given 20 mcg of fentanyl intravenously by myself.  She was placed in the left lateral decubitus position.  Dr. X cleansed the patient's back in a normal sterile fashion with Betadine solution.  She inserted a 22-gauge x 1.5-inch spinal needle in the patient's L3-L4 interspace that was carefully identified under my direct supervision.  Clear fluid was not obtained initially, needle was withdrawn intact.  The patient was slightly repositioned by the nurse and Dr. X reinserted the needle in the L3-L4 interspace position, the needle was able to obtain clear fluid, approximately 3 mL was obtained.  The stylette was replaced and the needle was withdrawn intact and bandage was applied.  Betadine solution was cleansed from the patient's back.,During the procedure, there were no untoward complications, the end-tidal CO2, pulse oximetry, and other vitals remained stable.  Of note, EMLA cream had also been applied prior procedure, this was removed prior to cleansing of the back.,Fluid will be sent for a routine cell count, Gram stain culture, protein, and glucose.,DISPOSITION: , The child returned to room on the medical floor in satisfactory condition.","surgery, moderate sedation, lumbar puncture, needle, lumbar, "
" Lumbar laminectomy for decompression with foraminotomies L3-L4, L4-L5, L5-S1 microtechniques and repair of CSF fistula, microtechniques L5-S1, application of DuraSeal.  Lumbar stenosis and cerebrospinal fluid fistula.", Surgery, Lumbar Laminectomy ,"PREOPERATIVE DIAGNOSIS: , Lumbar stenosis.,POSTOPERATIVE DIAGNOSES:,  Lumbar stenosis and cerebrospinal fluid fistula.,TITLE OF THE OPERATION,1.  Lumbar laminectomy for decompression with foraminotomies L3-L4, L4-L5, L5-S1 microtechniques.,2.  Repair of CSF fistula, microtechniques L5-S1, application of DuraSeal.,INDICATIONS:,  The patient is an 82-year-old woman who has about a four-month history now of urinary incontinence and numbness in her legs and hands, and difficulty ambulating.  She was evaluated with an MRI scan, which showed a very high-grade stenosis in her lumbar spine, and subsequent evaluation included a myelogram, which demonstrated cervical stenosis at C4-C5, C5-C6, and C6-C7 as well as a complete block of the contrast at L4-L5 and no contrast at L5-S1 either and stenosis at L3-L4 and all the way up, but worse at L3-L4, L4-L5, and L5-S1.  Yesterday, she underwent an anterior cervical discectomy and fusions C4-C5, C5-C6, C6-C7 and had some improvement of her symptoms and increased strength, even in the recovery room.  She was kept in the ICU because of her age and the need to bring her back to the operating room today for decompressive lumbar laminectomy.  The rationale for putting the surgery is close together that she is normally on Coumadin for atrial fibrillation, though she has been cardioverted.  She and her son understand the nature, indications, and risks of the surgery, and agreed to go ahead.,PROCEDURE: , The patient was brought from the Neuro ICU to the operating room, where general endotracheal anesthesia was obtained.  She was rolled in a prone position on the Wilson frame.  The back was prepared in the usual manner with Betadine soak, followed by Betadine paint.  Markings were applied.  Sterile drapes were applied.  Using the usual anatomical landmarks, linear midline incision was made presumed over L4-L5 and L5-S1.  Sharp dissection was carried down into subcutaneous tissue, then Bovie electrocautery was used to isolate the spinous processes.  A Kocher clamp was placed in the anterior spinous ligament and this turned out to be L5-S1.  The incision was extended rostrally and deep Gelpi's were inserted to expose the spinous processes and lamina of L3, L4, L5, and S1.  Using the Leksell rongeur, the spinous processes of L4 and L5 were removed completely, and the caudal part of L3.  A high-speed drill was then used to thin the caudal lamina of L3, all of the lamina of L4 and of L5.  Then using various Kerrison punches, I proceeded to perform a laminectomy.  Removing the L5 lamina, there was a dural band attached to the ligamentum flavum and this caused about a 3-mm tear in the dura.  There was CSF leak.  The lamina removal was continued, ligamentum flavum was removed to expose all the dura.  Then using 4-0 Nurolon suture, a running-locking suture was used to close the approximate 3-mm long dural fistula.  There was no CSF leak with Valsalva.,I then continued the laminectomy removing all of the lamina of L5 and of L4, removing the ligamentum flavum between L3-L4, L4-L5 and L5-S1.  Foraminotomies were accomplished bilaterally.  The caudal aspect of the lamina of L3 also was removed.  The dura came up quite nicely.  I explored out along the L4, L5, and S1 nerve roots after completing the foraminotomies, the roots were quite free.  Further more, the thecal sac came up quite nicely.  In order to ensure no CSF leak, we would follow the patient out of the operating room.  The dural closure was covered with a small piece of fat.  This was all then covered with DuraSeal glue.  Gelfoam was placed on top of this, then the muscle was closed with interrupted 0 Ethibond.  The lumbodorsal fascia was closed with multiple sutures of interrupted 0 Ethibond in a watertight fashion.  Scarpa's fascia was closed with a running 0 Vicryl, and finally the skin was closed with a running-locking 3-0 nylon.  The wound was blocked with 0.5% plain Marcaine.,ESTIMATED BLOOD LOSS:  Estimated blood loss for the case was about 100 mL.,SPONGE AND NEEDLE COUNTS:  Correct.,FINDINGS:  A very tight high-grade stenosis at L3-L4, L4-L5, and L5-S1.  There were adhesions between the dura and the ligamentum flavum owing to the severity and length of the stenosis.,The patient tolerated the procedure well with stable vitals throughout.","surgery, microtechniques, fistula, duraseal, foraminotomies, lumbar, stenosis, cerebrospinal, lumbar laminectomy, ligamentum flavum, csf, laminectomy, lamina,"
" Microscopic lumbar discectomy, left L5-S1.   Extruded herniated disc, left L5-S1.  Left S1 radiculopathy (acute). Morbid obesity.", Surgery, Lumbar Discectomy - Microscopic ,"PREOPERATIVE DIAGNOSES:,1.  Extruded herniated disc, left L5-S1.,2.  Left S1 radiculopathy (acute).,3.  Morbid obesity.,POSTOPERATIVE DIAGNOSES:,1.  Extruded herniated disc, left L5-S1.,2.  Left S1 radiculopathy (acute).,3.  Morbid obesity.,PROCEDURE PERFORMED: , Microscopic lumbar discectomy, left L5-S1.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:  ,50 cc.,HISTORY: , This is a 40-year-old female with severe intractable left leg pain from a large extruded herniated disc at L5-S1.  She has been dealing with these symptoms for greater than three months.  She comes to my office with severe pain, left my office and reported to the Emergency Room where she was admitted for pain control one day before surgery.  I have discussed the MRI findings with the patient and the potential risks and complications.  She was scheduled to go to surgery through my office, but because of her severe symptoms, she was unable to keep that appointment and reported right to the Emergency Room.  We discussed the diagnosis and the operative procedure in detail.  I have reviewed the potential risks and complications and she had agreed to proceed with the surgery.  Due to the patient's weight which exceeds 340 lb, there was some concern about her operative table being able to support her weight and also my standard microlumbar discectomy incision is not ________ in this situation just because of the enormous size of the patient's back and abdomen and I have discussed this with her.  She is aware that she will have a much larger incision than what is standard and has agreed to accept this.,OPERATIVE PROCEDURE:  ,The patient was taken to OR #5 at ABCD General Hospital.  While in the hospital gurney, Department of Anesthesia administered general anesthetic, endotracheal intubation was followed.  A Jackson table was prepared for the patient and was reinforced replacing struts under table to prevent the table from collapsing.  The table reportedly does have a limit of 500 lb, but the table has never been stressed above 275 lb.  Once the table was reinforced, the patient was carefully rolled in a prone position on the Jackson table with the bony prominences being well padded.  A marker was placed in from the back at this time and an x-ray was obtained for incision localization.  The back is now prepped and draped in the usual sterile fashion.  A midline incision was made over the L5-S1 disc space taking through subcutaneous tissue sharply with a #10 Bard-Parker scalpel.  The lumbar dorsal fascia was then encountered and incised to the left of midline.  In the subperiosteal fashion, the musculature was elevated off the lamina at L5 and S1 after facet joint, but not disturbing the capsule.  A second marker was now placed and an intraoperative x-ray confirms our location at the L5-S1 disc space.  The microscope was brought into the field at this point and the remainder of the procedure done with microscopic visualization and illumination.  A high speed drill was used to perform a laminotomy by removing small portion of the superior edge of the S1 lamina and the inferior edge of the L5 lamina.  Ligaments and fragments were encountered and removed at this time.  The epidural space was now encountered.  The S1 nerve root was now visualized and found to be displaced dorsally as a result of a large disc herniation while the nerve was carefully protected with a Penfield.  A small stab incision was made into the disc fragment and probably a large portion of disc extrudes from the opening.  This disc fragment was removed and the nerve root was much more supple, it was carefully retracted.  The nerve root was now retracted and using a series of downgoing curettes, additional disc material was removed from around the disc space and from behind the body of S1 and L5.  At this point, all disc fragments were removed from the epidural space.  Murphy ball was passed anterior to the thecal sac in the epidural space and there was no additional compression that I can identify.  The disc space was now encountered and loose disc fragments were removed from within the disc space.  The disc space was then irrigated.  The nerve root was then reassessed and found to be quite supple.  At this point, the Murphy ball was passed into the foramen of L5 and this was patent and also into the foramen of S1 by passing ventral and dorsal to the nerve root and there were no obstructions in the passage of the device.  At this point, the wound was irrigated copiously and suctioned dry.  Gelfoam was used to cover the epidural space.  The retractors were removed at this point.  The fascia was reapproximated with #1 Vicryl suture, subcutaneous tissue with #2-0 Vicryl suture and Steri-Strips for curved incision.  The patient was transferred to the hospital gurney in supine position and extubated by Anesthesia, subsequently transferred to Postanesthesia Care Unit in stable condition.","surgery, extruded herniated disc, radiculopathy, microscopic, lumbar, discectomy, lumbar discectomy, morbid obesity, herniated disc, epidural space, nerve root, disc space, space, intractable, lamina, epidural, incision, nerve, herniated,"
" Repeat low transverse cesarean section and bilateral tubal ligation (BTL).   Intrauterine pregnancy at 30 and 4/7th weeks, previous cesarean section x2, multiparity, request for permanent sterilization, and breach presentation in the delivery of a liveborn female neonate.", Surgery, Low-Transverse C-Section & BTL - 1 ,"PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 30 and 4/7th weeks.,2.  Previous cesarean section x2.,3.  Multiparity.,4.  Request for permanent sterilization.,POSTOPERATIVE DIAGNOSIS:,1.  Intrauterine pregnancy at 30 and 4/7th weeks.,2.  Previous cesarean section x2.,3.  Multiparity.,4.  Request for permanent sterilization.,5.  Breach presentation in the delivery of a liveborn female neonate.,PROCEDURES PERFORMED:,1.  Repeat low transverse cesarean section.,2.  Bilateral tubal ligation (BTL).,TUBES: , None.,DRAINS: , Foley to gravity.,ESTIMATED BLOOD LOSS: , 600 cc.,FLUIDS:,  200 cc of crystalloids.,URINE OUTPUT:,  300 cc of clear urine at the end of the procedure.,FINDINGS:,  Operative findings demonstrated a wire mesh through the anterior abdominal wall and the anterior fascia.  There were bowel adhesions noted through the anterior abdominal wall.  The uterus was noted to be within normal limits.  The tubes and ovaries bilaterally were noted to be within normal limits.  The baby was delivered from the right sacral anterior position without any difficulty.  Apgars 8 and 9.  Weight was 7.5 lb.,INDICATIONS FOR THIS PROCEDURE:  ,The patient is a 23-year-old G3 P 2-0-0-2 with reported 30 and 4/7th weeks' for a scheduled cesarean section secondary to repeat x2.  She had her first C-section because of congenial hip problems.  In her second C-section, baby was breached, therefore, she is scheduled for a third C-section.  The patient also requests sterilization.  Therefore, she requested a tubal ligation.,PROCEDURE: , After informed consent was obtained and all questions were answered to the patient's satisfaction in layman's terms, she was taken to the operating room where a spinal with Astramorph anesthesia was obtained without any difficulty.  She was placed in the dorsal supine position with a leftward tilt and prepped and draped in the usual sterile fashion.  A Pfannenstiel skin incision was made removing the old scar with a first knife and then carried down to the underlying layer of fascia with a second knife.  The fascia was excised in the midline extended laterally with the Mayo scissors.  The superior aspect of the fascial incision was then tented up with Ochsner clamps and the underlying rectus muscle dissected off sharply with the Metzenbaum scissors.  There was noted dense adhesions at this point as well as a wire mesh was noted.  The anterior aspect of the fascial incision was then tented up with Ochsner clamps and the underlying rectus muscle dissected off sharply as well as bluntly.  The rectus muscle superiorly was opened with a hemostat.  The peritoneum was identified and entered bluntly digitally.  The peritoneal incision was then extended superiorly up to the level of the mesh.  Then, inferiorly using the knife, the adhesions were taken down and the bladder was identified and the peritoneum incision extended inferiorly to the level of the bladder.  The bladder blade was inserted and vesicouterine peritoneum was identified and tented up with Allis clamps and bladder flap was created sharply with the Metzenbaum scissors digitally.  The bladder blade was then reinserted to protect the bladder and the uterine incision was made with a first knife and then extended laterally with the Bandage scissors.  The amniotic fluid was noted to be clear.  At this point, upon examining the intrauterine contents, the baby was noted to be breached.  The right foot was identified and then the baby was delivered from the double footling breach position without any difficulty.  The cord was clamped and the baby was then handed off to awaiting pediatricians.  The placenta cord gases were obtained and the placenta was then manually extracted from the uterus.  The uterus was exteriorized and cleared of all clots and debris.  Then, the uterine incision was then closed with #0 Vicryl in a double closure stitch fashion, first layer in locking stitch fashion and the second layer an imbricating layer.  Attention at this time was turned to the tubes bilaterally.,Both tubes were isolated and followed all the way to the fimbriated end and tented up with the Babcock clamp.  The hemostat was probed through the mesosalpinx in the avascular area and then a section of tube was clamped off with two hemostats and then transected with the Metzenbaum scissors.  The ends was then burned with the cautery and then using a #2-0 Vicryl suture tied down.  Both tube sections were noted to be hemostatic and the tubes were then sent to pathology for review.  The uterus was then replaced back into the abdomen.  The gutters were cleared of all clots and debris.  The uterine incision was then once again inspected and noted to be hemostatic.  The bladder flap was then replaced back into the uterus with #3-0 interrupted sutures.  The peritoneum was then closed with #3-0 Vicryl in a running fashion.  Then, the area at the fascia where the mesh had been cut and approximately 0.5 cm portion was repaired with #3-0 Vicryl in a simple stitch fashion.  The fascia was then closed with #0 Vicryl in a running fashion.  The subcutaneous layer and Scarpa's fascia were repaired with a #3-0 Vicryl.  Then, the skin edges were reapproximated using sterile clips.  The dressing was placed.  The uterus was then cleared of all clots and debris manually.  Then, the patient tolerated the procedure well.  Sponge, lap, and needle, counts were correct x2.  The patient was taken to recovery in sable condition.  She will be followed up throughout her hospital stay.",
"  Primary low transverse cervical cesarean section.  Intrauterine pregnancy at 38 weeks and malpresentation.  A viable male neonate in the left occiput transverse position with Apgars of 9 and 9 at 1 and 5 minutes respectively, weighing 3030 g.  No nuchal cord.  No meconium.  Normal uterus, fallopian tubes, and ovaries.", Surgery, Low-Transverse C-Section - 5 ,"PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 38 weeks.,2.  Malpresentation.,POSTOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 38 weeks.,2.  Malpresentation.,3.  Delivery of a viable male neonate.,PROCEDURE PERFORMED: , Primary low transverse cervical cesarean section.,ANESTHESIA: , Spinal with Astramorph.,ESTIMATED BLOOD LOSS: , 300 cc.,URINE OUTPUT:,  80 cc of clear urine.,FLUIDS: , 2000 cc of crystalloids.,COMPLICATIONS: , None.,FINDINGS: , A viable male neonate in the left occiput transverse position with Apgars of 9 and 9 at 1 and 5 minutes respectively, weighing 3030 g.  No nuchal cord.  No meconium.  Normal uterus, fallopian tubes, and ovaries.,INDICATIONS: , This patient is a 21-year-old gravida 3, para 1-0-1-1 Caucasian female who presented to Labor and Delivery in labor.  Her cervix did make some cervical chains.  She did progress to 75% and -2, however, there was a raised lobular area palpated on the fetal head.  However, on exam unable to delineate the facial structures, but definite fetal malpresentation.  The fetal heart tones did start and it continued to have variable decelerations with contractions overall are reassuring.  The contraction pattern was inadequate.  It was discussed with the patient's family that in light of the physical exam and with the fetal malpresentation that a cesarean section will be recommended.  All the questions were answered.,PROCEDURE IN DETAIL: , After informed consent was obtained in layman's terms, the patient was taken back to the operating suite and placed in the dorsal lithotomy position with a leftward tilt.  Prior to this, the spinal anesthesia was administered.  The patient was then prepped and draped.  A Pfannenstiel skin incision was made with the first scalpel and carried through to the underlying layer of fascia with the second scalpel.  The fascia was then incised in the midline and extended laterally using Mayo scissors.  The superior aspect of the rectus fascia was then grasped with Ochsners, tented up and the underlying layer of rectus muscle was dissected up bluntly as well as with Mayo scissors.  The superior portion and inferior portion of the rectus fascia was identified, tented up and the underlying layer of rectus muscle was dissected up bluntly as well as with Mayo scissors.  The rectus muscle was then separated in the midline.  The peritoneum was then identified, tented up with hemostats and entered sharply with Metzenbaum scissors.  The peritoneum was then gently stretched.  The vesicouterine peritoneum was then identified, tented up with an Allis and the bladder flap was created bluntly as well as using Metzenbaum scissors.  The uterus was entered with the second scalpel and large transverse incision.  This was then extended in upward and lateral fashion bluntly.  The infant was then delivered atraumatically.  The nose and mouth were suctioned.  The cord was then clamped and cut.  The infant was handed off to the awaiting pediatrician.  The placenta was then manually extracted.  The uterus was exteriorized and cleared of all clots and debris.  The uterine incision was then repaired using #0 chromic in a running fashion marking a U stitch.  A second layer of the same suture was used in an imbricating fashion to obtain excellent hemostasis.  The uterus was then returned to the anatomical position.  The abdomen and the gutters were cleared of all clots.  Again, the incision was found to be hemostatic.  The rectus muscle was then reapproximated with #2-0 Vicryl in a single interrupted stitch.  The rectus fascia was then repaired with #0 Vicryl in a running fashion locking the first stitch and first last stitch in a lateral to medial fashion.  This was palpated and the patient was found to be without defect and intact.  The skin was then closed with staples.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2.  She will be followed up as an inpatient with Dr. X.","surgery, low transverse cervical cesarean section, cesarean section, pregnancy, neonate, metzenbaum scissors, intrauterine pregnancy, rectus fascia, rectus muscle, intrauterine, peritoneum, malpresentation, transverse, astramorph, "
 Primary low transverse cesarean section by Pfannenstiel skin incision with bilateral tubal sterilization.   Intrauterine pregnancy at 35-1/7.  Rh isoimmunization.  Suspected fetal anemia.  Desires permanent sterilization., Surgery, Low-Transverse C-Section - 8 ,"PREOPERATIVE DIAGNOSES,1.  Intrauterine pregnancy at 35-1/7.,2.  Rh isoimmunization.,3.  Suspected fetal anemia.,4.  Desires permanent sterilization.,POSTOPERATIVE DIAGNOSES,1.  Intrauterine pregnancy at 35-1/7.,2.  Rh isoimmunization.,3.  Suspected fetal anemia.,4.  Desires permanent sterilization.,OPERATION PERFORMED: , Primary low transverse cesarean section by Pfannenstiel skin incision with bilateral tubal sterilization.,ANESTHESIA:,  Spinal anesthesia.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS:  ,500 mL.,INTRAOPERATIVE FLUIDS: , 1000 mL crystalloids.,URINE OUTPUT: , 300 mL clear urine at the end of procedure.,SPECIMENS:,  Cord gases, hematocrit on cord blood, placenta, and bilateral tubal segments.,INTRAOPERATIVE FINDINGS: , Male infant, vertex position, very bright yellow amniotic fluid.  Apgars 7 and 8 at 1 and 5 minutes respectively.  Weight pending at this time.  His name is Kasson as well as umbilical cord and placenta stained yellow.  Otherwise normal appearing uterus and bilateral tubes and ovaries.,DESCRIPTION OF OPERATION:,  After informed consent was obtained, the patient was taken to the operating room where spinal anesthesia was obtained by Dr. X without difficulties.  The patient was placed in supine position with leftward tilt.  Fetal heart tones were checked and were 140s, and she was prepped and draped in a normal sterile fashion.  At this time, a Pfannenstiel skin incision made with a scalpel and carried down to the underlying fascia with electrocautery.  The fascia was nicked sharply in the midline.  The fascial incision was extended laterally with Mayo scissors.  The inferior aspect of the fascial incision was grasped with Kocher x2, elevated, and rectus muscles dissected sharply with the use of Mayo scissors.  Attention was then turned to the superior aspect of the fascial incision.  Fascia was grasped, elevated, and rectus muscles dissected off sharply.  The rectus muscles were separated in the midline bluntly.  The peritoneum was identified, grasped, and entered sharply and the peritoneal incision extended inferiorly and superiorly with good visualization of bladder.  Bladder blade was inserted.  Vesicouterine peritoneum was tented up and a bladder flap was created using Metzenbaum scissors.  Bladder blade was reinserted to effectively protect the bladder from the operative field and the lower uterine segment incised in a transverse U-shaped fashion with the scalpel.  Uterine incision was extended laterally and manually.  Membranes were ruptured and bright yellow clear amniotic fluid was noted.  Infant's head was in a floating position, able to flex the head, push against the incision, and then easily brought it to the field vertex.  Nares and mouth were suctioned with bulb suction.  Remainder of the infant was delivered atraumatically.  The infant was very pale upon delivery.  Cord was doubly clamped and cut and immediately handed to the awaiting intensive care nursery team.  An 8 cm segment of the tube was doubly clamped and transected.  Cord gases were obtained.  Cord was then cleansed, laid on a clean laparotomy sponge, and cord blood was drawn for hematocrit measurements.  At this time, it was noted that the cord was significantly yellow stained as well as the placenta.  At this time, the placenta was delivered via gentle traction on the cord and exterior uterine massage.  Uterus was exteriorized and cleared off all clots and debris with dry laparotomy sponge and the lower uterine segment was closed with 1-0 chromic in a running locked fashion.  Two areas of oozing were noted and separate figure-of-eight sutures were placed to obtain hemostasis.  At this time, the uterine incision was hemostatic.  The bladder was examined and found to be well below the level of the incision repair.  Tubes and ovaries were examined and found to be normal.  The patient was again asked if she desires permanent sterilization of which she agrees and therefore the right fallopian tube was identified and followed out to the fimbriated end and grasped at the mid portion with a Babcock clamp.  Mesosalpinx was divided with electrocautery and a 4-cm segment of tube was doubly tied and transected with a 3-cm segment of tube removed.  Hemostasis was noted.  Then, attention was turned to the left fallopian tube which in similar fashion was grasped and brought out through the fimbriated end and grasped the midline portion with Babcock clamp.  Mesosalpinx was incised and 3-4 cm tube doubly tied, transected, and excised and excellent hemostasis was noted.  Attention was returned to the uterine incision which is seemed to be hemostatic and uterus was returned to the abdomen.  Gutters were cleared off all clots and debris.  Lower uterine segments were again re-inspected and found to be hemostatic.  Sites of tubal sterilization were also visualized and were hemostatic.  At this time, the peritoneum was grasped with Kelly clamps x3 and closed with running 3-0 Vicryl suture.  Copious irrigation was used.  Rectus muscle belly was examined and found to be hemostatic and tacked and well approximated in the midline.  At this time, the fascia was closed using 0 Vicryl in a running fashion.  Manual palpation confirms thorough and adequate closure of the fascial layer.  Copious irrigation was again used.  Hemostasis noted, and skin was closed with staples.  The patient tolerated the procedure well.  Sponge, lap, needle, and instrument counts were correct x3 and the patient was sent to the recovery room awake and stable condition.  Infant assumed the care of the intensive care nursery team and being followed and workup up for isoimmunization and fetal anemia.  The patient will be followed for her severe right upper quadrant pain post delivery.  If she continues to have pain, may need a surgical consult for gallbladder and/or angiogram for evaluation of right kidney and questionable venous plexus.  This all will be relayed to Dr. Y, her primary obstetrician who was on call starting this morning at 7 a.m. through the weekend.","surgery, intrauterine pregnancy, rh isoimmunization, primary low transverse cesarean section, bilateral tubal sterilization, pfannenstiel skin incision, fascial incision, uterine incision, fetal anemia, permanent sterilization, rectus muscles, incision, tubes, cord, "
" Primary low-transverse C-section.  Postdates pregnancy, failure to progress, meconium stained amniotic fluid.", Surgery, Low-Transverse C-Section - 4 ,"PREOPERATIVE DIAGNOSES:,1.  Postdates pregnancy.,2.  Failure to progress.,3.  Meconium stained amniotic fluid.,POSTOPERATIVE DIAGNOSES:,1.  Postdates pregnancy.,2.  Failure to progress.,3.  Meconium stained amniotic fluid.,OPERATION:,  Primary low-transverse C-section.,ANESTHESIA:,  Epidural.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operating room and under epidural anesthesia, she was prepped and draped in the usual manner.  Anesthesia was tested and found to be adequate.  Incision was made, Pfannenstiel, approximately 1.5 fingerbreadths above the symphysis pubis and carried sharply through subcutaneous and fascial layers without difficulty; the fascia being incised laterally.  Bleeders were bovied.  Rectus muscles were separated from the overlying fascia with blunt and sharp dissection.  Muscles were separated in the midline.  Peritoneum was entered sharply and incision was carried out laterally in each direction.  Bladder blade was placed and bladder flap developed with blunt and sharp dissection.  A horizontal _______ incision was made in the lower uterine segment and carried laterally in each direction.  Allis was placed in the incision, and an uncomplicated extraction of a 7 pound 4 ounce, Apgar 9 female was accomplished and given to the pediatric service in attendance.  Infant was carefully suctioned after delivery of the head and body.  Cord blood was collected.  _______ and endometrial cavity was wiped free of membranes and clots.  Lower segment incision was inspected.  There were some extensive adhesions on the left side and a figure-of-eight suture of 1 chromic was placed on both lateral cuff borders and the cuff was closed with two interlocking layers of 1 chromic.  Bleeding near the left cuff required an additional suture of 1 chromic after which hemostasis was present.  Cul-de-sac was suctioned free of blood and clots and irrigated.  Fundus was delivered back into the abdominal cavity and lateral gutters were suctioned free of blood and clots and irrigated.  Lower segment incision was again inspected and found to be hemostatic.  The abdominal wall was then closed in layers, 2-0 chromic on the peritoneum, 0 Maxon on the fascia, 3-0 plain on the subcutaneous and staples on the skin.  Hemostasis was present between all layers.  The area was gently irrigated across the peritoneum and fascial layers.  There were no intraoperative complications except blood loss.  The patient was taken to the recovery room in satisfactory condition.","surgery, pregnancy, meconium stained amniotic fluid, low transverse c section, amniotic fluid, meconium, peritoneum, blood, chromic, fascial, amniotic, incision,"
" Repeat low-transverse C-section, lysis of omental adhesions, lysis of uterine adhesions with repair of uterine defect, and bilateral tubal ligation.", Surgery, Low-Transverse C-Section - 3 ,"PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 33 weeks, twin gestation.,2.  Active preterm labor.,3.  Advanced dilation.,4.  Multiparity.,5.  Requested sterilization.,POSTOPERATIVE DIAGNOSIS:,1.  Intrauterine pregnancy at 33 weeks, twin gestation.,2.  Active preterm labor.,3.  Advanced dilation.,4.  Multiparity.,5.  Requested sterilization.,6.  Delivery of a viable female A weighing 4 pounds 7 ounces, Apgars were 8 and 9 at 1 and 5 minutes respectively and female B weighing 4 pounds 9 ounces, Apgars 6 and 7 at 1 and 5 minutes respectively.,7.  Uterine adhesions and omentum adhesions.,OPERATION PERFORMED: , Repeat low-transverse C-section, lysis of omental adhesions, lysis of uterine adhesions with repair of uterine defect, and bilateral tubal ligation.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , 500 mL.,DRAINS:,  Foley.,This is a 25-year-old white female gravida 3, para 2-0-0-2 with twin gestation at 33 weeks and previous C-section.  The patient presents to Labor and Delivery in active preterm labor and dilated approximately 4 to 6 cm.  The decision for C-section was made.,PROCEDURE:,  The patient was taken to the operating room and placed in a supine position with a slight left lateral tilt and she was then prepped and draped in usual fashion for a low transverse incision.  The patient was then given general anesthesia and once this was completed, first knife was used to make a low transverse incision extending down to the level of the fascia.  The fascia was nicked in the center and extended in a transverse fashion with the use of curved Mayo scissors.  The edges of the fascia were grasped with Kocher and both blunt and sharp dissection was then completed both caudally and cephalically.  The abdominal rectus muscle was divided in the center and extended in a vertical fashion.  Peritoneum was entered at a high point and extended in a vertical fashion as well.  The bladder blade was put in place.  The bladder flap was created with the use of Metzenbaum scissors and dissected away caudally.  The second knife was used to make a low transverse incision with care being taken to avoid the presenting part of the fetus.  The first fetus was vertex.  The fluid was clear.  The head was delivered followed by the remaining portion of the body.  The cord was doubly clamped and cut.  The newborn handed off to waiting pediatrician and nursery personnel.  The second fluid was ruptured.  It was the clear fluid as well.  The presenting part was brought down to be vertex.  The head was delivered followed by the rest of the body and the cord was doubly clamped and cut, and newborn handed off to waiting pediatrician in addition of the nursery personnel.  Cord pH blood and cord blood was obtained from both of the cords with careful identification of A and B. Once this was completed, the placenta was delivered and handed off for further inspection by Pathology.  At this time, it was noted at the uterus was adhered to the abdominal wall by approximately of 3 cm x 3 cm thick uterine adhesion and this was needed to be released by sharp dissection.  Then, there were multiple omental adhesions on the surface of the uterus itself.  This needed to be released as well as on the abdominal wall and then the uterus could be externalized.  The lining was wiped clean of any remaining blood and placental fragments and the edges of the uterus were grasped in four quadrants with Kocher and continuous locking stitch of 0 chromic was used to re-approximate the uterine incision, with the second layer used to imbricate the first.  The bladder flap was re-approximated with 3-0 Vicryl and Gelfoam underneath.  The right fallopian tube was grasped with a Babcock, it was doubly tied off with 0 chromic and the knuckle portion was then sharply incised and cauterized.  The same technique was completed on the left side with the knuckle portion cut off and cauterized as well.  The defect on the uterine surface was reinforced with 0 Vicryl in a baseball stitch to create adequate Hemostasis.  Interceed was placed over this area as well.  The abdominal cavity was irrigated with copious amounts of saline and the uterus was placed back in its anatomical position.  The gutters were wiped clean of any remaining blood.  The edges of the peritoneum were grasped with hemostats and a continuous locking stitch was used to re-approximate abdominal rectus muscles as well as the peritoneal edges.  The abdominal rectus muscle was irrigated.  The corners of the fascia grasped with hemostats and continuous locking stitch of 0 Vicryl started on both corners and overlapped on the center.  The subcutaneous tissue was irrigated.  Cautery was used to create adequate hemostasis and 3-0 Vicryl was used to re-approximate the subcutaneous tissue.  Skin edges were re-approximated with sterile staples.  Sterile dressing was applied.  Uterus was evacuated of any remaining blood vaginally.  The patient was taken to the recovery room in stable condition.  Instrument count, needle count, and sponge counts were all correct.","surgery, intrauterine pregnancy, gestation, preterm labor, omentum adhesions, low transverse c section, uterine adhesions, intrauterine, adhesions, abdominal, uterus, uterine, "
 Repeat low transverse cesarean section and bilateral tubal ligation (BTL).  Intrauterine pregnancy at term with previous cesarean section.  Desires permanent sterilization.  Macrosomia., Surgery, Low-Transverse C-Section & BTL ,"PREOPERATIVE DIAGNOSIS: , Intrauterine pregnancy at term with previous cesarean section.,SECONDARY DIAGNOSES,1.  Desires permanent sterilization.,2.  Macrosomia.,POSTOPERATIVE DIAGNOSES,1.  Desires permanent sterilization.,2.  Macrosomia.,3.  Status post repeat low transverse cesarean and bilateral tubal ligation.,PROCEDURES,1.  Repeat low transverse cesarean section.,2.  Bilateral tubal ligation (BTL).,ANESTHESIA: , Spinal.,FINDINGS:,  A viable female infant weighing 7 pounds 10 ounces, assigned Apgars of 9 and 9.  There was normal pelvic anatomy, normal tubes.  The placenta was normal in appearance with a three-vessel cord.,DESCRIPTION OF PROCEDURE:,  Patient was brought to the operating room with an IV running and a Foley catheter in place, satisfactory spinal anesthesia was administered following which a wedge was placed under the right hip.  The abdomen was prepped and draped in a sterile fashion.  A Pfannenstiel incision was made and carried sharply down to the level of fascia.  The fascia was incised transversely.  The fascia was dissected away from the underlying rectus muscles.  With sharp and blunt dissection, rectus muscles were divided in midline.  The perineum was entered bluntly.  The incision was carried vertically with scissors.  Transverse incision was made across the bladder peritoneum.  The bladder was dissected away from the underlying lower uterine segment.  Bladder retractor was placed to protect the bladder.  The lower uterine segment was entered sharply with a scalpel.  Incision was carried transversely with bandage scissors.  Clear amniotic fluids were encountered.  The infant was out of the pelvis and was in oblique vertex presentation.  The head was brought down into the incision and delivered easily as were the shoulders and body.  The mouth and oropharynx were suctioned vigorously.  The cord was clamped and cut.  The infant was passed off to the waiting pediatrician in satisfactory condition.  Cord bloods were taken.,Placenta was delivered spontaneously and found to be intact.  Uterus was explored and found to be empty.  Uterus was delivered through the abdominal incision and massaged vigorously.  Intravenous Pitocin was administered.  T clamps were placed about the margins of the uterine incision, which was closed primarily with a running locking stitch of 0 Vicryl with adequate hemostasis.  Secondary running locking stitch was placed for extra strength to the wound.  At this point, attention was diverted to the patient's tubes, a Babcock clamp grasped the isthmic portion of each tube and approximately 1-cm knuckle on either side was tied off with two lengths of 0 plain catgut.  Intervening knuckle was excised and passed off the field.  The proximal end of the tubal mucosa was cauterized.  Cul-de-sac and gutters were suctioned vigorously.  The uterus was returned to its proper anatomic position in the abdomen.  The fascia was closed with a simple running stitch of 0 PDS.,The skin was closed with running subcuticular of 4-0 Monocryl.  Uterus was expressed of its contents.  Patient was brought to the recovery room in satisfactory condition.  There were no complications.  There was 600 cc of blood loss.  All sponge, needle, and instrument counts were reported to be correct.,SPECIMEN: , Tubal segments.,DRAIN: , Foley catheter draining clear yellow urine.","surgery, placenta, low transverse cesarean section, bilateral tubal ligation, permanent sterilization, cesarean section, intrauterine, btl, sterilization, macrosomia, uterine, "
" Repeat low-transverse cesarean section via Pfannenstiel incision.  Intrauterine pregnancy at 39 and 1/7th weeks.  Previous cesarean section, refuses trial of labor.  Fibroid uterus, oligohydramnios, and nonreassuring fetal heart tones.", Surgery, Low-Transverse C-Section - 7 ,"PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 39 and 1/7th weeks.,2.  Previous cesarean section, refuses trial of labor.,3.  Fibroid uterus.,4.  Oligohydramnios.,5.  Nonreassuring fetal heart tones.,POSTOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 39 and 1/7th weeks.,2.  Previous cesarean section, refuses trial of labor.,3.  Fibroid uterus.,4.  Oligohydramnios.,5.  Nonreassuring fetal heart tones.,PROCEDURE PERFORMED:,  Repeat low-transverse cesarean section via Pfannenstiel incision.,ANESTHESIA:,  General.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS:,  1200 cc.,FLUIDS:,  2700 cc.,URINE:,  400 cc clear at the end of the procedure.,DRAINS: , Foley catheter.,SPECIMENS:  ,Placenta, cord gases and cord blood.,INDICATIONS:  ,The patient is a G5 P1 Caucasian female at 39 and 1/7th weeks with a history of previous cesarean section for failure to progress and is scheduled cesarean section for later this day who presents to ABCD Hospital complaining of contractions.  She was found to not be in labor, but had nonreassuring heart tones with a subtle late decelerations and AFOF of approximately 40 mm.  A decision was made to take her for a C-section early.,FINDINGS: , The patient had an enlarged fibroid uterus with a large anterior fibroid with large varicosities, normal appearing tubes and ovaries bilaterally.  There was a live male infant in the ROA position with Apgars of 9 at 1 minute and 9 at 5 minutes and a weight of 5 lb 4 oz.,PROCEDURE: , Prior to the procedure, an informed consent was obtained.  The patient who previously been interested in a tubal ligation refused the tubal ligation prior to surgery.  She states that she and her husband are fully disgusted and that they changed their mind and they were adamant about this.  After informed consent was obtained, the patient was taken to the operating room where spinal anesthetic with Astramorph was administered.  She was then prepped and draped in the normal sterile fashion.  Once the anesthetic was tested, it was found to be inadequate and a general anesthetic was administered.  Once the general anesthetic was administered and the patient was asleep, the previous incision was removed with the skin knife and this incision was then carried through an underlying layer of fascia with a second knife.  The fascia was incised in the midline with a second knife.  This incision was then extended laterally in both directions with the Mayo scissors.  The superior aspect of this fascial incision was then dissected off to the underlying rectus muscle bluntly without using Ochsner clamps.  It was then dissected in the midline with Mayo scissors.  The inferior aspect of this incision was then addressed in a similar manner.  The rectus muscles were then separated in the midline with a hemostat.  The rectus muscles were separated further in the midline with Mayo scissors superiorly and inferiorly.  Next, the peritoneum was grasped with two hemostats, tented up and entered sharply with the Metzenbaum scissors.  This incision was extended inferiorly with the Metzenbaum scissors, being careful to avoid the bladder and the peritoneal incision was extended bluntly.  Next, the bladder blade was placed.  The vesicouterine peritoneum was identified, tenting up with Allis clamps and entered sharply with the Metzenbaum scissors.  This incision was extended laterally in both directions and a bladder flap was created digitally.  The bladder blade was then reinserted.  Next, the uterine incision was made with a second knife and the uterus was entered with the blunt end of the knife.  Next, the uterine incision was extended laterally in both directions with the banded scissors.  Next, the infant's head and body were delivered without difficulty.  There was multiple section on the abdomen.  The cord was clamped and cut.  Section of cord was collected for gases and the cord blood was collected.  Next, the placenta was manually extracted.  The uterus was exteriorized and cleared of all clots and debris.  The edges of the uterine incision were then identified with Allis _______ clamps.  The uterine incision was reapproximated with #0 chromic in a running locked fashion and a second layer of the same suture was used to obtain excellent hemostasis.  One figure-of-eight with #0 chromic was used in one area to prevent a questionable hematoma from expanding along the varicosity for the anterior fibroid.  After several minutes of observation, the hematoma was seem to be non-expanding.  The uterus was replaced in the abdomen.  The uterine incision was reexamined and seem to be continuing to be hemostatic.  The pelvic gutters were then cleared of all clots and debris.  The vesicouterine peritoneum was then reapproximated with #3-0 Vicryl in a running fashion.  The peritoneum was then closed with #0 Vicryl in a running fashion.  The rectus muscles reapproximated with #0 Vicryl in a single interrupted stitch.  The fascia was closed with #0 Vicryl in a running locked fashion and the skin was closed with staples.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x3.  The patient was then taken to Recovery in stable condition and she will be followed for immediate postoperative course in the hospital.",
" Primary low transverse cervical cesarean section.   Intrauterine pregnancy of 39 weeks, Herpes simplex virus positive by history, hepatitis C positive by history with low elevation of transaminases, cephalopelvic disproportion, asynclitism, postpartum macrosomia, and delivery of viable 9 lb female neonate.", Surgery, Low-Transverse C-Section - 9 ,"PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy of 39 weeks.,2.  Herpes simplex virus, positive by history.,3.  Hepatitis C, positive by history with low elevation of transaminases.,4.  Cephalopelvic disproportion.,5.  Asynclitism.,6.  Postpartum macrosomia.,POSTOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy of 39 weeks.,2.  Herpes simplex virus, positive by history.,3.  Hepatitis C, positive by history with low elevation of transaminases.,4.  Cephalopelvic disproportion.,5.  Asynclitism.,6.  Postpartum macrosomia.,7.  Delivery of viable 9 lb female neonate.,PROCEDURE PERFORMED: , Primary low transverse cervical cesarean section.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , About 600 cc.,Baby is doing well.  The patient's uterus is intact, bladder is intact.,HISTORY: , The patient is an approximately 25-year-old Caucasian female with gravida-4, para-1-0-2-1.  The patient's last menstrual period was in December of 2002 with a foreseeable due date on 09/16/03 confirmed by ultrasound.,The patient has a history of herpes simplex virus to which there is no active prodromal and no evidence of lesions.  The patient has a history of IVDA and contracted hepatitis C with slightly elevated liver transaminases.  The patient had been seen through our office for prenatal care.  The patient is on Valtrex.  The patient was found to be 3 cm about 40%, 0 to 9 engaged.  Bag of waters was ruptured.  She was on Pitocin.  She was contracting appropriately for a couple of hours or so with appropriate ________.  There was no cervical change noted.  Most probably because there was a sink vertex and that the head was too large to descend into the pelvis.  The patient was advised of this and we recommended cesarean section.  She agreed.  We discussed the surgery, foreseeable risks and complications, alternative treatment, the procedure itself, and recovery in layman's terms.  The patient's questions were answered.  I personally made sure that she understood every aspect of the consent and that she was comfortable with the understanding of what would transpire.,PROCEDURE:  ,The patient was then taken back to operative suite.  She was given anesthetic and sterilely prepped and draped.  Pfannenstiel incision was used.  A second knife was used to carry the incision down to the anterior rectus fascia.  Anterior rectus fascia was incised in the midline and carried bilaterally and the fascia was lifted off the underlying musculature.  The rectus muscles were separated.  The patient's peritoneum tented up towards the umbilicus and we entered the abdominal cavity.  There was a very thin lower uterine segment.  There seemed to be quite a large baby.  The patient had a small nick in the uterus.  Following the blunt end of the bladder knife going through the innermost layer of the myometrium and into the endometrial cavity, clear amniotic fluid was obtained.  A blunt low transverse cervical incision was made.  Following this, we placed a ________ on the very large fetal head.  The head was delivered following which we were able to deliver a large baby girl, 9 lb, good at tone and cry.  The patient then underwent removal of the placenta after the cord blood and ABG were taken.  The patient's uterus was examined.  There appeared to be no retained products.  The patient's uterine incision was reapproximated and sutured with #0 Vicryl in a running non-interlocking fashion, the second imbricating over the first.  The patient's uterus was hemostatic.  Bladder flap was reapproximated with #0 Vicryl.  The patient then underwent an irrigation at every level of closure and the patient was quite hemostatic.  We reapproximated the rectus musculature with care being taken not to incorporate any underlying structures.  The patient had three interrupted sutures of this.  The fascia was reapproximated with two stitches of #0 Vicryl going from each apex towards the midline.  The Scarpa's fascia was reapproximated with #0 gut.  There was noted no fascial defects and the skin was closed with #0 Vicryl.,Prior to closing the abdominal cavity, the uterus appeared to be intact and bladder appeared to have clear urine and appeared to be intact.  The patient was hemostatic.  All counts were correct and the patient tolerated the procedure well.  We will see her back in recovery.","surgery, intrauterine pregnancy, herpes simplex virus, hepatitis c, cephalopelvic disproportion, asynclitism, postpartum, macrosomia, low transverse cervical cesarean section, rectus fascia, cesarean section, intrauterine, transaminases, herpes, uterus, fascia, "
" Primary low transverse cesarean section via Pfannenstiel incision.  Pregnancy at 40 weeks, failure to progress, premature prolonged rupture of membranes, group B strep colonization, and delivery of viable male neonate.", Surgery, Low-Transverse C-Section - 6 ,"PREOPERATIVE DIAGNOSES:,1.  Pregnancy at 40 weeks.,2.  Failure to progress.,3.  Premature prolonged rupture of membranes.,4.  Group B strep colonization.,POSTOPERATIVE DIAGNOSIS:,1.  Pregnancy at 40 weeks.,2.  Failure to progress.,3.  Premature prolonged rupture of membranes.,4.  Group B strep colonization.,5.  Delivery of viable male neonate.,PROCEDURE PERFORMED: , Primary low transverse cesarean section via Pfannenstiel incision.,ANESTHESIA:  ,Spinal.,ESTIMATED BLOOD LOSS: , 1000 cc.,FLUID REPLACEMENT: , 2700 cc crystalloid.,URINE:,  500 cc clear yellow urine in the Foley catheter.,INTRAOPERATIVE FINDINGS:  ,Normal appearing uterus, tubes, and ovaries.  A viable male neonate with Apgars of 9 and 9 at 1 and 5 minutes respectively.  Infant weight equaled to 4140 gm with clear amniotic fluid.  The umbilical cord was wrapped around the leg tightly x1.  Infant was in a vertex, right occiput anterior position.,INDICATIONS FOR PROCEDURE:  ,The patient is a 19-year-old G1 P0 at 41 and 1/7th weeks' intrauterine pregnancy.  She presented at mid night on 08/22/03 complaining of spontaneous rupture of membranes, which was confirmed in Labor and Delivery.  The patient had a positive group beta strep colonization culture and was started on penicillin.  The patient was also started on Pitocin protocol at that time.  The patient was monitored throughout the morning showing some irregular contractions every 5 to 6 minutes and then eventually no contractions on the monitor.  IUPC was placed without difficulty and contractions appeared to be regular, however, they were inadequate amount of the daily units.  The patient was given a rest from the Pitocin.  She walked and had a short shower.  The patient was then placed back on Pitocin with IUPC in place and we were unable to achieve adequate contractions.  Maximum cervical dilation was 5 cm, 80% effaced, negative 2 station, and cephalic position.  At the time of C-section, the patient had been ruptured for over 24 hours and it was determined that she would not progress in her cervical dilation, as there was suspected macrosomia on ultrasound.  Options were discussed with the patient and family and it was determined that we will take her for C-section today.  Consent was signed.  All questions were answered with Dr. X present.,PROCEDURE: , The patient was taken to the operative suite where a spinal anesthetic was placed.  She was placed in the dorsal supine position with left upward tilt.  She was prepped and draped in the normal sterile fashion and her spinal anesthetic was found to adequate.  A Pfannenstiel incision was made with a first scalpel and carried through the underlying layer of fascia with a second scalpel.  The fascia was incised in the midline and extended laterally using curved Mayo scissors.  The superior aspect of the fascial incision was grasped with Ochsner and Kocher clamps and elevated off the rectus muscles.  Attention was then turned to the inferior aspect of the incision where Kocher clamps were used to elevate the fascia off the underlying rectus muscle.  The rectus muscle was separated in the midline bluntly.  The underlying peritoneum was tented up with Allis clamps and incised using Metzenbaum scissors.  The peritoneum was then bluntly stretched.  The bladder blade was placed.  The vesicouterine peritoneum was identified, tented up with Allis' and entered sharply with Metzenbaum scissors.  The incision was extended laterally and the bladder flap created digitally.  The bladder blade was then reinserted in the lower uterine segment.  A low transverse uterine incision was made with a second scalpel.  The uterine incision was extended laterally bluntly.  The bladder blade was removed and the infant's head was delivered with the assistance of a vacuum.  Infant's nose and mouth were bulb suctioned and the body was delivered atraumatically.  There was, of note, an umbilical cord around the leg tightly x1.,Cord was clamped and cut.  Infant was handed to the waiting pediatrician.  Cord gas was sent for pH as well as blood typing.  The placenta was manually removed and the uterus was exteriorized and cleared of all clots and debris.  The uterine incision was grasped circumferentially with Alfred clamps and closed with #0-Chromic in a running locked fashion.  A second layer of imbricating stitch was performed using #0-Chromic suture to obtain excellent hemostasis.  The uterus was returned to the abdomen.  The gutters were cleared of all clots and debris.  The rectus muscle was loosely approximated with #0-Vicryl suture in a single interrupted fashion.  The fascia was reapproximated with #0-Vicryl suture in a running fashion.  The subcutaneous Scarpa's fascia was then closed with #2-0 plain gut.  The skin was then closed with staples.  The incision was dressed with sterile dressing and bandage.  Blood clots were evacuated from the vagina.  The patient tolerated the procedure well.  The sponge, lap, and needle counts were correct x2.  The mother was taken to the recovery room in stable and satisfactory condition.","surgery, c-section, cesarean section, low transverse, pregnancy, rupture of membranes, cervical dilation, kocher clamps, metzenbaum scissors, vicryl suture, pfannenstiel incision, uterine incision, rectus muscles, incision, transverse, colonization, rectus, muscles, bladder, uterine, section, fascia, "
" Intrauterine pregnancy at 37 plus weeks, nonreassuring fetal heart rate.", Surgery, Low-Transverse C-Section - 2 ,"PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 37 plus weeks, nonreassuring fetal heart rate.,2.  Protein S low.,3.  Oligohydramnios.,POSTOPERATIVE:,1.  Intrauterine pregnancy at 37 plus weeks, nonreassuring fetal heart rate.,2.  Protein S low.,3.  Oligohydramnios.,4.  Delivery of a viable female, weight 5 pound, 14 ounces.  Apgars of 9 and 9 at 1 and 5 minutes respectively and cord pH is 7.314.,OPERATION PERFORMED:,  Low transverse C-section.,ESTIMATED BLOOD LOSS: , 500 mL.,DRAINS: , Foley.,ANESTHESIA: , Spinal with Duramorph.,HISTORY OF PRESENT ILLNESS:  ,This is a 21-year-old white female gravida 1, para 0, who had presented to the hospital at 37-3/7 weeks for induction.  The patient had oligohydramnios and also when placed on the monitor had nonreassuring fetal heart rate with late deceleration.  Due to the IUGR as well a decision for a C-section was made.,PROCEDURE: , The patient was taken to the operating room and placed in a seated position with standard spinal form of anesthesia administered by the Anesthesia Department.  The patient was then repositioned, prepped and draped in a slight left lateral tilt.  Once this was completed first knife was used to make a low transverse skin incision approximately two fingerbreadths above the pubic symphysis.  This was extended down to the level of the fascia.  The fascia was nicked in the center and extended in transverse fashion.  Edges of the fascia were grasped with Kocher and both blunt and sharp dissection both caudally and cephalic was completed consistent with the Pfannenstiel technique.  The abdominal rectus muscle was divided in the center, extended in vertical fashion and the peritoneum was entered at a high point and extended in vertical fashion.  Bladder blade was put in place and a bladder flap was created with the use of Metzenbaum and pickups and then bluntly dissected via cautery and reincorporated in the bladder blade.  Second knife was used to make a low transverse uterine incision with care being taken to avoid the presenting part of fetus.  Presenting part was vertex, the head was delivered, followed by the remaining portion of the body.  The mouth and nose were suctioned through bulb syringe and the cord was doubly clamped and cut and then the newborn handed off to waiting nursing personnel.  Cord pH blood and cord blood was obtained.  The placenta was delivered manually and the uterus was externalized and the lining was cleaned off any remaining placental fragments and blood and the incisional edges were reapproximated with 0-chromic and a continuous locking stitch with a second layer used to imbricate the first.  The bladder flap was re-peritonized with Gelfoam underneath and abdomen was irrigated with copious amounts of saline and the uterus was placed back in its anatomical position.  The gutters were wiped clean of any remaining blood and fluid and the edges of the perineum grasped with hemostats and continuous locking stitches of 2-0 Vicryl was used to reapproximate the abdominal rectus muscle as well as the perineum.  This area was then irrigated.  Cautery was used for adequate hemostasis, corners of the fascia grasped with hemostats and continuous locking stitch of 1-Vicryl was started at both corners and overlapped in the center.  Subcutaneous tissue was irrigated with saline and reapproximated with 3-0 Vicryl.  Skin edges reapproximated with sterile staples.  Sterile dressing was applied.  The uterus was evacuated of any remaining clots vaginally.  The patient was taken to recovery room in stable condition.  Instrument count, needle count, and sponge counts were all correct.","surgery, apgars, low transverse c section, fetal heart rate, bladder blade, intrauterine pregnancy, intrauterine"
" Primary cesarean section by low-transverse incision.  Term pregnancy, nonreassuring fetal heart tracing.", Surgery, Low-Transverse C-Section - 1 ,"PREOPERATIVE DIAGNOSES: , Term pregnancy, nonreassuring fetal heart tracing.,POSTOPERATIVE DIAGNOSES: , Term pregnancy, nonreassuring fetal heart tracing.,OPERATION:,  Primary cesarean section by low-transverse incision.,ANESTHESIA:,  Epidural.,ESTIMATED BLOOD LOSS: , 450 mL.,COMPLICATIONS: , None.,CONDITION: , Stable.,DRAINS:  ,Foley catheter.,INDICATIONS: , The patient is a 39-year-old, G4, para 0-0-3-0, with an EDC of 03/08/2009.  The patient began having prodromal symptoms 2 to 3 days prior to presentation.  She was seen on 03/09/2007 and a nonstress test was performed.  This revealed some spontaneous variable-appearing decelerations.  She was given IV hydration.  A biophysical profile was obtained, which provided a score of 0/8 with only a 1 cm fluid pocket found.  Therefore, she was admitted for further fetal monitoring and evaluation.  She had changed her cervix from closed 2 days prior to presentation to 1 cm dilated.  She was having somewhat irregular contractions, but with stronger contractions, continued to have decelerations to 50 to 60 beats per minute.  Due to these findings, a scalp electrode was placed as well as an IUPC for an amnioinfusion.  This relieved the decelerations somewhat.  However, over a period of time with strong contractions, she still had bradycardia 40 to 50 beats per minute and developed a late component on the return of the decelerations.  Due to this finding, it was evident that the fetal state would not support labor in order to accomplish a vaginal delivery.  These findings were reviewed with the patient and recommendation was made for cesarean section delivery.  The risks and benefits of this surgery were reviewed, and knowing these facts, the patient gave informed consent.,PROCEDURE: , The patient was taken to the operating room where her epidural anesthesia was reinforced.  She was prepped and draped in the usual fashion for the procedure.  After adequate epidural level was confirmed, the scalp was utilized to make a transverse incision in the patient's lower abdominal wall.  This incision was carried down to the level of the fascia, which was also transversely incised.  After adequate hemostasis, the fascia was bluntly and sharply separated up from the underlying rectus muscle.  The rectus muscle was separated in midline exposing the peritoneum.  The peritoneum was carefully grasped and elevated with hemostats.  It was entered in an up and down fashion with Metzenbaum scissors.  The bladder blade was placed in the lower pole of the incision to protect the bladder.,The uterus was palpated and inspected.  A thin lower uterine segment was noted.  The vertex presentation was confirmed.  The scalp was then utilized to make a transverse or Kerr incision in the lower uterine wall.  Clear fluid was noted upon entering into the amniotic space.  At 05:27, a term viable female infant was delivered up through the incision.  She had spontaneous respirations.  She was given bulb suctioning for clear fluid.  Her cord was clamped and cut and she was delivered off the field to Dr. X who was attending.  The baby girl was subsequently signed Apgars of 8 at one minute and 9 at five minutes.  Her birth weight was found to be 5 pounds and 5 ounces.,The placenta was manually extracted from the endometrial cavity.  A ring clamp and two Allis clamps were placed around the margin of the uterine incision for hemostasis.  The uterus was delivered up into the operative field.  The endometrial cavity was swiped clean with a moist laparotomy pad.  The uterine incision was then closed in a two-layered fashion with 0 Vicryl suture, the first layer interlocking and the second layer imbricating.  Two additional stitches of 3-0 Vicryl suture were utilized for hemostasis.  The uterine incision was noted to be hemostatic upon closure.  The uterus was rotated forward, normal tubes and ovaries were noted on both sides.  The uterus was then returned to its normal position of the abdominal cavity.  The sponge and instrument count was performed for the first time at this point and found to be correct.  The pelvis and anterior uterine space was then irrigated with saline solution.  It was suctioned dry.  A final check of the uterine incision confirmed hemostasis.  The rectus muscle was stabilized across the midline with two simple stitches of 0 Vicryl suture.  The subcutaneous tissue was then exposed, and the fascia closed with two running lengths of 0 Vicryl suture, beginning in lateral margins and overlapping the midline.  The subcutaneous tissue was then irrigated and inspected.  No active bleeding was noted.  It was closed with a running length of 3-0 plain catgut suture.  The skin was then approximated with surgical steel staples.  The incision was infiltrated with a 0.5% solution of Marcaine local anesthetic.  The incision was cleansed and sterilely dressed.,The patient was transferred to the recovery room in stable condition.  The estimated blood loss through the procedure was 450 mL.  The sponge and instrument counts were performed two more times during closure and found to be correct each time.","surgery, low-transverse incision, edc, para, amnioinfusion, nonreassuring fetal heart tracing, primary cesarean section, fetal heart tracing, low transverse, term pregnancy, fetal heart, heart tracing, rectus muscle, uterine incision, vicryl suture, incision, transverse, fetal, suture, uterine, "
" A repeat low transverse cervical cesarean section, Lysis of adhesions, Dissection of the bladder of the anterior abdominal wall and away from the fascia, and the patient also underwent a bilateral tubal occlusion via Hulka clips.", Surgery, Low-Transverse C-Section - 10 ,"PREOPERATIVE DIAGNOSES:,1.  36th and 4/7th week, intrauterine growth rate.,2.  Charcot-Marie-Tooth disease.,3.  Previous amniocentesis showing positive fetal lung maturity, family planning complete.,4.  Previous spinal fusion.,5.  Two previous C-sections.  The patient refuses trial labor.  The patient is with regular contractions dilated to 3, possibly an early labor, contractions are getting more and more painful.,POSTOPERATIVE DIAGNOSES:,1.  36th and 4/7th week, intrauterine growth rate.,2.  Charcot-Marie-Tooth disease.,3.  Previous amniocentesis showing positive fetal lung maturity, family planning complete.,4.  Previous spinal effusion.,5.  Two previous C-section.  The patient refuses trial labor.  The patient is with regular contractions dilated to 3, possibly an early labor, contractions are getting more and more painful.,6.  Adhesions of bladder.,7.  Poor fascia quality.,8.  Delivery of a viable female neonate.,PROCEDURE PERFORMED:,1.  A repeat low transverse cervical cesarean section.,2.  Lysis of adhesions.,3.  Dissection of the bladder of the anterior abdominal wall and away from the fascia.,4.  The patient also underwent a bilateral tubal occlusion via Hulka clips.,COMPLICATIONS: , None.,BLOOD LOSS:,  600 cc.,HISTORY AND INDICATIONS:  ,Indigo Carmine dye bladder test in which the bladder was filled, showed that there was no defects in the bladder of the uterus.  The uterus appeared to be intact.  This patient is a 26-year-old Caucasian female.  The patient is well known to the OB/GYN clinic.  The patient had two previous C-sections.  She appears to be in probably early labor.  She had an amniocentesis early today.  She is contracting regularly about every three minutes.  The contractions are painful and getting much more so since the amniocentesis.  The patient had fetal lung maturity noted.  The patient also has probable IUGR as none of her babies have been over 4 lb.  The patient's baby appears to be somewhat small.  The patient suffers from Charcot-Marie-Tooth disease, which has left her wheelchair bound.  The patient has had a spinal fusion, however, family planning is definitely complete per the patient.  The patient refuses trial labor.  The patient and I discussed the consent.  She understands the foreseeable risks and complications, alternative treatment of the procedure itself, and recovery.  Her questions were answered.  The patient also understands that when we occlude her tube that she is at risk for failure of this part of the procedure, which would result in either an intrauterine or ectopic pregnancy.  The patient understands this and would like to try our best.,PROCEDURE:  ,The patient was taken back to the operative suite.  She was given general anesthetic by Department of Anesthesiology.  Once again, in layman's terms, the patient understands the risks.  The patient had the informed consent reviewed and understood.  The patient has had a Pfannenstiel incision, which was slightly bent towards the right side favoring the right side.  The patient had the first knife went through this incision.  The second knife was used to go to the level of fascia.  The fascia was very thin, ruddy in appearance, and with abundant scar tissue.  The fascia was incised.  Following this, we were able to see the peritoneum.  There was really no obvious rectus abdominal muscles noted.  They were very weak, atrophic, and thin.  The patient has the peritoneum tented up.  We entered the abdominal cavity.  The bladder flap was then entered into the anterior abdominal wall and to the underlying area of the fascia.  The bladder flap was then entered into the uterus as well.  There are some bladder adhesions.  We removed these adhesions and we removed the bladder of the fascia.  We dissected the bladder of the lower segment.  We made a small nick on the lower segment.  We were able to utilize the blunt end of the knife to enter into the uterine cavity.  The baby was in occiput transverse position with the ear being cocked at such a position as well.  The patient's baby was delivered without difficulty.  It was a 4 lb and 10 oz baby girl who vigorously cried well.  There was a prolapse of the umbilical cord just below the chin as well and this may be attributed to the decelerations we caught on the monitor strip right before we decided to have her undergo resection.  The patient's placenta was delivered.  There was no retained placenta.  The uterine incision was closed with two layers of #0 Vicryl, the second layer imbricating over the first.  The patient on the right side had the inferior epigastric artery and the vein just underneath the peritoneum easily visualized.  Then we ligated this as there was bleeding and oozing.  The patient had the Indigo Carmine instilled into the bladder with some saline about 300 cc.  The 400 cc was instilled.  The bladder appears to be intact.  The bladder did require extensive dissection of the fascia in order to be able to get a proper fascial edges for closure and dissection of the lower uterine segment.  There was some oozing around the area of the bladder.  We placed an Avitene there.  The two Hulka clips were placed perpendicular to going across each fallopian tube into the mesosalpinx.  The patient has two clips on each side.  There was excellent tubal occlusion and placement.  The uterus was placed back into the abdominal cavity.  We rechecked again.  The tubal placement was excellent.  It did not involve the round ligaments, uterosacral ligaments, the uteroovarian ligaments, and the tube into the mesosalpinx.  The patient then underwent further examination.  Hemostasis appeared to be good.  The fascia was reapproximated with short running intervals of #0 Vicryl across the fascia.  We took care not to get into any bleeders and to make sure that the fascia was indeed closed as best as it was possible.  The Scarpa's fascia was reapproximated with #0 gut.  The skin was reapproximated then as well via subcutaneous closure.  The patient's sponge and needle counts found to be correct.  Uterus appeared to be normal prior to closure.  Bladder appeared to be normal.  The patient's blood loss is 600 cc.","surgery, intrauterine growth rate, charcot-marie-tooth disease, amniocentesis, c-sections, trial labor, low transverse cervical cesarean section, lysis of adhesions, dissection, bladder, abdominal wall, fascia, hulka clips, bilateral tubal occlusion, intrauterine, transverse, uterus, abdominal, "
 Primary low-transverse cesarean section., Surgery, Low-Transverse C-Section ,"PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at term.,2.  Arrest of dilation. ,POSTOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at term.,2.  Arrest of dilation.,PROCEDURE PERFORMED:,  Primary low-transverse cesarean section.,ANESTHESIA: , Epidural.,ESTIMATED BLOOD LOSS: , 1000 mL.,COMPLICATIONS: , None.,FINDINGS:  ,Female infant in cephalic presentation, OP position, weight 9 pounds 8 ounces.  Apgars were 9 at 1 minute and 9 at 5 minutes.  Normal uterus, tubes, and ovaries were noted.,INDICATIONS:  ,The patient is a 20-year-old gravida 1, para 0 female, who presented to labor and delivery in early active labor at 40 and 6/7 weeks gestation.  The patient progressed to 8 cm, at which time, Pitocin was started.  She subsequently progressed to 9 cm, but despite adequate contractions, arrested dilation at 9 cm.  A decision was made to proceed with a primary low transverse cesarean section.,The procedure was described to the patient in detail including possible risks of bleeding, infection, injury to surrounding organs, and possible need for further surgery.  Informed consent was obtained prior to proceeding with the procedure.,PROCEDURE NOTE:  ,The patient was taken to the operating room where epidural anesthesia was found to be adequate.  The patient was prepped and draped in the usual sterile fashion in the dorsal supine position with a left-ward tilt.  A Pfannenstiel skin incision was made with the scalpel and carried through to the underlying layer of fascia using the Bovie.  The fascia was incised in the midline and extended laterally using Mayo scissors.  Kocher clamps were used to elevate the superior aspect of the fascial incision, which was elevated, and the underlying rectus muscles were dissected off bluntly and using Mayo scissors.  Attention was then turned to the inferior aspect of the fascial incision, which in similar fashion was grasped with Kocher clamps, elevated, and the underlying rectus muscles were dissected off bluntly and using Mayo scissors.  The rectus muscles were dissected in the midline.,The peritoneum was bluntly dissected, entered, and extended superiorly and inferiorly with good visualization of the bladder.  The bladder blade was inserted.  The vesicouterine peritoneum was identified with pickups and entered sharply using Metzenbaum scissors.  This incision was extended laterally and the bladder flap was created digitally.  The bladder blade was reinserted.  The lower uterine segment was incised in a transverse fashion using the scalpel and extended using manual traction.  Clear fluid was noted.  The infant was subsequently delivered atraumatically.  The nose and mouth were bulb suctioned.  The cord was clamped and cut.  The infant was subsequently handed to the awaiting nursery nurse.  Next, cord blood was obtained per the patient's request for cord blood donation, which took several minutes to perform.  Subsequent to the collection of this blood, the placenta was removed spontaneously intact with a 3-vessel cord noted.  The uterus was exteriorized and cleared of all clots and debris.  The uterine incision was repaired in 2 layers using 0 chromic suture.  Hemostasis was visualized.  The uterus was returned to the abdomen.,The pelvis was copiously irrigated.  The uterine incision was reexamined and was noted to be hemostatic.  The rectus muscles were reapproximated in the midline using 3-0 Vicryl.  The fascia was closed with 0 Vicryl, the subcutaneous layer was closed with 3-0 plain gut, and the skin was closed with staples.  Sponge, lap, and instrument counts were correct x2.  The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition.","surgery, intrauterine pregnancy at term, arrest of dilation, cephalic presentation, low transverse cesarean section, cesarean section, rectus muscles, intrauterine, "
" VATS right middle lobectomy, fiberoptic bronchoscopy, mediastinal lymph node sampling, tube thoracostomy x2, multiple chest wall biopsies and excision of margin on anterior chest wall adjacent to adherent tumor.", Surgery, Lobectomy - VATS ,"PREOPERATIVE DIAGNOSIS:,  Right middle lobe lung cancer.,POSTOPERATIVE DIAGNOSIS: , Right middle lobe lung cancer.,PROCEDURES PERFORMED:,1.  VATS right middle lobectomy.,2.  Fiberoptic bronchoscopy thus before and after the procedure.,3.  Mediastinal lymph node sampling including levels 4R and 7.,4.  Tube thoracostomy x2 including a 19-French Blake and a 32-French chest tube.,5.  Multiple chest wall biopsies and excision of margin on anterior chest wall adjacent to adherent tumor.,ANESTHESIA:  ,General endotracheal anesthesia with double-lumen endotracheal tube.,DISPOSITION OF SPECIMENS: , To pathology both for frozen and permanent analysis.,FINDINGS:,  The right middle lobe tumor was adherent to the anterior chest wall.  The adhesion was taken down, and the entire pleural surface along the edge of the adhesion was sent for pathologic analysis.  The final frozen pathology on this entire area returned as negative for tumor.  Additional chest wall abnormalities were biopsied and sent for pathologic analysis, and these all returned separately as negative for tumor and only fibrotic tissue.  Several other biopsies were taken and sent for permanent analysis of the chest wall.  All of the biopsy sites were additionally marked with Hemoclips.  The right middle lobe lesion was accompanied with distal pneumonitis and otherwise no direct involvement of the right upper lobe or right lower lobe.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,CONDITION OF THE PATIENT AFTER SURGERY: , Stable.,HISTORY OF PROCEDURE:,  This patient is well known to our service.  He was admitted the night before surgery and given hemodialysis and had close blood sugar monitoring in control.  The patient was subsequently taken to the operating room on April 4, 2007, was given general anesthesia and was endotracheally intubated without incident.  Although, he had markedly difficult airway, the patient had fiberoptic bronchoscopy performed all the way down to the level of the subsegmental bronchi.  No abnormalities were noted in the entire tracheobronchial tree, and based on this, the decision was made to proceed with the surgery.  The patient was kept in the supine position, and the single-lumen endotracheal tube was removed and a double-lumen tube was placed.  Following this, the patient was placed into the left lateral decubitus position with the right side up and all pressure points were padded.  Sterile DuraPrep preparation on the right chest was placed.  A sterile drape around that was also placed.  The table was flexed to open up the intercostal spaces.  A second bronchoscopy was performed to confirm placement of the double-lumen endotracheal tube.  Marcaine was infused into all incision areas prior to making an incision.  The incisions for the VATS right middle lobectomy included a small 1-cm incision for the auscultatory incision approximately 4 cm inferior to the inferior tip of the scapula.  The camera port was in the posterior axillary line in the eighth intercostal space through which a 5-mm 30-degree scope was used.  Third incision was an anterior port, which was approximately 2 cm inferior to the inframammary crease and the midclavicular line in the anterior sixth intercostal space, and the third incision was a utility port, which was a 4 cm long incision, which was approximately one rib space below the superior pulmonary vein.  All of these incisions were eventually created during the procedure.  The initial incision was the camera port through which, under direct visualization, an additional small 5-mm port was created just inferior to the anterior port.  These two ports were used to identify the chest wall lesions, which were initially thought to be metastatic lesions.  Multiple biopsies of the chest wall lesions were taken, and the decision was made to also insert the auscultatory incision port.  Through these three incisions, the initial working of the diagnostic portion of the chest wall lesion was performed.  Multiple biopsies were taken of the entire chest wall offers and specimens came back as negative.  The right middle lobe was noted to be adherent to the anterior chest wall.  This area was taken down and the entire pleural surface along this area was taken down and sent for frozen pathologic analysis.  This also returned as negative with only fibrotic tissue and a few lymphocytes within the fibrotic tissue, but no tumor cells.  Based on this, the decision was made to not proceed with chest wall resection and continue with right middle lobectomy.  Following this, the anterior port was increased in size and the utility port was made and meticulous dissection from an anterior to posterior direction was performed.  The middle lobe branch of the right superior pulmonary vein was initially dissected and stapled with vascular load 45-mm EndoGIA stapler.  Following division of the right superior pulmonary vein, the right middle lobe bronchus was easily identified.  Initially, this was thought to be the main right middle lobe bronchus, but in fact it was the medial branch of the right middle lobe bronchus.  This was encircled and divided with a blue load stapler with a 45-mm EndoGIA.  Following division of this, the pulmonary artery was easily identified.  Two branches of the pulmonary artery were noted to be going into the right middle lobe.  These were individually divided with a vascular load after encircling with a right angle clamp.  The vascular staple load completely divided these arterial branches successfully from the main pulmonary artery trunk, and following this, an additional branch of the bronchus was noted to be going to the right middle lobe.  A fiberoptic bronchoscopy was performed intraoperatively and confirmed that this was in fact the lateral branch of the right middle lobe bronchus.  This was divided with a blue load stapler 45 mm EndoGIA.  Following division of this, the minor and major fissures were completed along the edges of the right middle lobe separating the right upper lobe from the right middle lobe as well as the right middle lobe from the right lower lobe.  Following complete division of the fissure, the lobe was put into an EndoGIA bag and taken out through the utility port.  Following removal of the right middle lobe, a meticulous lymph node dissection sampling was performed excising the lymph node package in the 4R area as well as the 7 lymph node package.  Node station 8 or 9 nodes were easily identified, therefore none were taken.  The patient was allowed to ventilate under water on the right lung with no obvious air leaking noted.  A 19-French Blake was placed into the posterior apical position and a 32-French chest tube was placed in the anteroapical position.  Following this, the patient's lung was allowed to reexpand fully, and the patient was checked for air leaking once again.  Following this, all the ports were closed with 2-0 Vicryl suture used for the deeper tissue, and 3-0 Vicryl suture was used to reapproximate the subcutaneous tissue and 4-0 Monocryl suture was used to close the skin in a running subcuticular fashion.  The patient tolerated the procedure well, was extubated in the operating room and taken to the recovery room in stable condition.","surgery, middle lobe, endogia, fiberoptic, mediastinal lymph node, vats, bronchoscopy, chest tube, chest wall, endotracheal tube, endotracheally, lobectomy, lung cancer, pneumonitis, sampling, thoracostomy, utility port, lumen endotracheal tube, superior pulmonary vein, chest wall lesions, anterior chest wall, middle lobectomy, fiberoptic bronchoscopy, anterior chest, lymph node, node, port, chest, bronchus, tumor, pulmonary, incision,"
" Right lower lobectomy, right thoracotomy, extensive lysis of adhesions, mediastinal lymphadenectomy.", Surgery, Lobectomy & Lymphadenectomy ,"PREOPERATIVE DIAGNOSIS:  ,Right lower lobe mass, possible cancer.,POSTOPERATIVE DIAGNOSIS: , Non-small cell carcinoma of the right lower lobe.,PROCEDURES:,1.  Right thoracotomy.,2.  Extensive lysis of adhesions.,3.  Right lower lobectomy.,4.  Mediastinal lymphadenectomy.,ANESTHESIA: , General.,DESCRIPTION OF THE PROCEDURE: , The patient was taken to the operating room and placed on the operating table in the supine position.  After an adequate general anesthesia was given, she was placed in the left lateral decubitus and the right chest was prepped and draped in the sterile fashion.  Lateral thoracotomy was performed on the right side anterior to the tip of the scapula, and this was carried down through the subcutaneous tissue.  The latissimus dorsi muscle was partially transected and then the serratus was reflected anteriorly.  The chest was entered through the fifth intercostal space.  A retractor was placed and then extensive number of adhesions between the lung and the pleura were lysed carefully with sharp and blunt dissection.  The right lower lobe was identified.  There was a large mass in the superior segment of the lobe, which was very close to the right upper lobe, and because of the adhesions, it could not be told if the tumor was extending into the right upper lobe, but it appeared that it did not.  Dissection was then performed at the lower lobe of the fissure, and a GIA stapler was placed through here to separate the tumor from the upper lobe including a small segment of the upper lobe with the lower lobe.  Then, dissection of the hilum was performed, and the branches of the pulmonary artery to the lower lobe were ligated with #2-0 silk freehand ties proximally and distally and #3-0 silk transfixion stitches and then transected.  The inferior pulmonary vein was dissected after dividing the ligament, and it was stapled proximally and distally with a TA30 stapler and then transected.  Further dissection of the fissure allowed for its completion with a GIA stapler and then the bronchus was identified and dissected.  The bronchus was stapled with a TA30 bronchial stapler and then transected, and the specimen was removed and sent to the Pathology Department for frozen section diagnosis.  The frozen section diagnosis was that of non-small cell carcinoma, bronchial margins free and pleural margins free.  The mediastinum was then explored.  No nodes were identified around the pulmonary ligament or around the esophagus.  Subcarinal nodes were dissected, and hemostasis was obtained with clips.  The space below and above the osseous was opened, and the station R4 nodes were dissected.  Hemostasis was obtained with clips and with electrocautery.  All nodal tissue were sent to Pathology as permanent specimen.  Following this, the chest was thoroughly irrigated and aspirated.  Careful hemostasis was obtained and a couple of air leaks were controlled with #6-0 Prolene sutures.  Then, two #28 French chest tubes were placed in the chest, one posteriorly and one anteriorly, and secured to the skin with #2-0 nylon stitches.  The incision was then closed with interrupted #2-0 Vicryl pericostal stitches.  A running #1 PDS on the muscle layer, a running 2-0 PDS in the subcutaneous tissue, and staples on the skin.  A sterile dressing was applied, and the patient was then awakened and transferred to the following Intensive Care Unit in stable and satisfactory condition.,ESTIMATED BLOOD LOSS: , 100 mL.,TRANSFUSIONS:,  None.,COMPLICATIONS:,  None.,CONDITION: , Condition of the patient on arrival to the intensive care unit was satisfactory.","surgery, right lower lobe, gia stapler, mediastinal, non-small cell carcinoma, cancer, frozen section, hilum, lobectomy, lymphadenectomy, lysis of adhesions, pleura, thoracotomy, upper lobe, lower lobectomy, adhesions, chest"
 Primary low segment cesarean section., Surgery, Low -Segment C-Section ,"PREOPERATIVE DIAGNOSIS:  ,Pregnancy at 42 weeks, nonreassuring fetal testing, and failed induction.,POSTOPERATIVE DIAGNOSIS: , Pregnancy at 42 weeks, nonreassuring fetal testing, and failed induction.,PROCEDURE: , Primary low segment cesarean section.  The patient was placed in the supine position under spinal anesthesia with a Foley catheter in place and she was prepped and draped in the usual manner.  A low abdominal transverse skin incision was constructed and carried down through the subcutaneous tissue through the anterior rectus fascia.  Bleeding points were snapped and coagulated along the way.  The fascia was opened transversally and was dissected sharply and bluntly from the underlying rectus muscles.  These were divided in the midline revealing the peritoneum, which was opened vertically.  The uterus was in mid position.  The bladder flap was incised elliptically and reflected caudad.  A low transverse hysterotomy incision was then constructed and extended bluntly.  Amniotomy revealed clear amniotic fluid.  A live born vigorous male infant was then delivered from the right occiput transverse position.  The infant breathed and cried spontaneously.  The nares and pharynx were suctioned.  The umbilical cord was clamped and divided and the infant was passed to the waiting neonatal team.  Cord blood samples were obtained.  The placenta was manually removed and the uterus was eventrated for closure.  The edges of the uterine incision were grasped with Pennington clamps and closure was carried out in standard two-layer technique using 0 Vicryl suture with the second layer imbricating the first.  Hemostasis was completed with an additional figure-of-eight suture of 0 Vicryl.  The cornual sac and gutters were irrigated.  The uterus was returned to the abdominal cavity.  The adnexa were inspected and were normal.  The abdomen was then closed in layers.  Fascia was closed with running 0 Vicryl sutures, subcutaneous tissue with running 3-0 plain Catgut, and skin with 3-0 Monocryl subcuticular suture and Steri-Strips.  Blood loss was estimated at 700 mL.  All counts were correct.,The patient tolerated the procedure well and left the operating room in excellent condition.","surgery, nonreassuring fetal testing, anterior rectus fascia, pennington clamps, fetal testing, low segment, induction, suture,"
 Right upper lung lobectomy.  Mediastinal lymph node dissection, Surgery, Lobectomy & Lymph Node Dissection ,"OPERATION,1.  Right upper lung lobectomy.,2.  Mediastinal lymph node dissection.,ANESTHESIA,1.  General endotracheal anesthesia with dual-lumen tube.,2.  Thoracic epidural.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room, and general endotracheal anesthesia was administered with a dual-lumen tube.  Next, the patient was placed in the left lateral decubitus position, and his right chest was prepped and draped in the standard surgical fashion.  We used a #10-blade scalpel to make an incision in the skin approximately 1 fingerbreadth below the angle of the scapula.  Dissection was carried down in a muscle-sparing fashion using Bovie electrocautery.  The 5th rib was counted, and the 6th interspace was entered.  The lung was deflated.  We identified the major fissure.  We then began by freeing up the inferior pulmonary ligament, which was done with Bovie electrocautery.  Next, we used Bovie electrocautery to dissect the pleura off the lung.  The pulmonary artery branches to the right upper lobe of the lung were identified.  Of note was the fact that there was a visible, approximately 4 x 4-cm mass in the right upper lobe of the lung without any other metastatic disease palpable.  As mentioned, a combination of Bovie electrocautery and sharp dissection was used to identify the pulmonary artery branches to the right upper lobe of the lung.  Next, we began by ligating the pulmonary artery branches of the right upper lobe of the lung.  This was done with suture ligature in combination with clips.  After taking the pulmonary artery branches of the right upper lobe of the lung, we used a combination of blunt dissection and sharp dissection with Metzenbaum scissors to separate out the pulmonary vein branch of the right upper lobe of the lung.  This likewise was ligated with a 0 silk.  It was stick-tied with a 2-0 silk.  It was then divided.  Next we dissected out the bronchial branch to the right upper lobe of the lung.  A curved Glover was placed around the bronchus.  Next a TA-30 stapler was fired across the bronchus.  The bronchus was divided with a #10-blade scalpel.  The specimen was handed off.  We next performed a mediastinal lymph node dissection.  Clips were applied to the base of the feeding vessels to the lymph nodes.  We inspected for any signs of bleeding.  There was minimal bleeding.  We placed a #32-French anterior chest tube, and a #32-French posterior chest tube.  The rib space was closed with #2 Vicryl in an interrupted figure-of-eight fashion.  A flat Jackson-Pratt drain, #10 in size, was placed in the subcutaneous flap.  The muscle layer was closed with a combination of 2-0 Vicryl followed by 2-0 Vicryl, followed by 4-0 Monocryl in a running subcuticular fashion.  Sterile dressing was applied.  The instrument and sponge count was correct at the end of the case.  The patient tolerated the procedure well and was transferred to the PACU in good condition.","surgery, mediastinal, thoracic, epidural, lymph node dissection, lymph node, artery branches, lobectomy, lung, anesthesia, bovie, electrocautery, lymph, pulmonary, branches"
 Left lower lobectomy., Surgery, Lobectomy - Left Lower ,"OPERATION: , Left lower lobectomy.,OPERATIVE PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed in the supine position.  After general endotracheal anesthesia was induced, the appropriate monitoring devices were placed.  The patient was placed in the right lateral decubitus position.  The left chest and back were prepped and draped in a sterile fashion.  A right lateral thoracotomy incision was made.  Subcutaneous flaps were raised.  The anterior border of the latissimus dorsi was freed up, and the muscle was retracted posteriorly.  The posterior border of the pectoralis was freed up and it was retracted anteriorly.  The 5th intercostal space was entered.,The inferior pulmonary ligament was then taken down with electrocautery.  The major fissure was then taken down and arteries identified.  The artery was dissected free and it was divided with an Endo GIA stapler.  The vein was then dissected free and divided with an Endo GIA stapler.  The bronchus was then cleaned of all nodal tissue.  A TA-30 green loaded stapler was then placed across this, fired, and main bronchus divided distal to the stapler.,Then the lobe was removed and sent to pathology where margins were found to be free of tumor.  Level 9, level 13, level 11, and level 6 nodes were taken for permanent cell specimen.  Hemostasis noted.  Posterior 28-French and anterior 24-French chest tubes were placed.,The wounds were closed with #2 Vicryl.  A subcutaneous drain was placed.  Subcutaneous tissue was closed with running 3-0 Dexon, skin with running 4-0 Dexon subcuticular stitch.","surgery, lower lobectomy, electrocautery, endo gia stapler, subcutaneous drain, endotracheal, subcutaneous, lobectomy,"
" Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.
", Surgery, Liposuction ,"PREOPERATIVE DIAGNOSES:,1.  Deformity, right breast reconstruction.,2.  Excess soft tissue, anterior abdomen and flank.,3.  Lipodystrophy of the abdomen.,POSTOPERATIVE DIAGNOSES:,1.  Deformity, right breast reconstruction.,2.  Excess soft tissue, anterior abdomen and flank.,3.  Lipodystrophy of the abdomen.,PROCEDURES:,1.  Revision, right breast reconstruction.,2.  Excision, soft tissue fullness of the lateral abdomen and flank.,3.  Liposuction of the supraumbilical abdomen.,ANESTHESIA: , General.,INDICATION FOR OPERATION:,  The patient is a 31-year-old white female who previously has undergone latissimus dorsi flap and implant, breast reconstruction.  She now had lateralization of the implant with loss of medial fullness for which she desired correction.  It was felt that mobilization of the implant medially would provide the patient significant improvement and this was discussed with the patient at length.  The patient also had a small dog ear in the flank area on the right from the latissimus flap harvest, which was to be corrected.  She had also had liposuction of the periumbilical and infraumbilical abdomen with desire to have great improvement superiorly, was felt to be a candidate for such.  The above-noted procedure was discussed with the patient in detail.  The risks, benefits and potential complications were discussed.  She was marked in the upright position and then taken to the operating room for the above-noted procedure.,OPERATIVE PROCEDURE: , The patient was taken to the operating room and placed in the supine position.  Following adequate induction of general LMA anesthesia, the chest and abdomen was prepped and draped in the usual sterile fashion.  The supraumbilical abdomen was then injected with a solution of 5% lidocaine with epinephrine, as was the dog ear.  At this time, the superior central scar was then excised, dissection continued through the subcutaneous tissue, the underlying latissimus muscle until the capsule of the implant was reached.  This was then opened.  The implant was removed and placed on the back table in antibiotic solution.  Using Bovie cautery, the medial capsule was released and undermining was then performed with release of the muscle to the level of the proposed medial projection of the breast.  The inframammary fold medially was secured with 2-0 PDS suture to create greater takeoff point at this level which in the upright position and using a sizer produced a good form.  The lateral pocket was diminished by series of 2-0 PDS suture to provide medialization of the implant.  The implant was then placed back into the submuscular pocket with much improved positioning and medial fullness.  With this completed, the implant was again removed, antibiotic irrigation was performed.  A drain was placed and brought out through a separate inferior stab wound incision and hemostasis was confirmed.  The implant was then replaced and the wound was then closed in layers using 2-0 PDS running suture on the muscle and 3-0 Monocryl Dermabond subcuticular sutures.  The 2.5 cm dog ear was then excised into and including the subcutaneous tissue, even contouring was achieved and this was closed with two layers using 3-0 Monocryl suture.  Using a #3 cannula, a superior umbilical incision, liposuction was carried out into the supraumbilical abdomen, removing approximately 40 to 50 mL of fat with improved supraumbilical contours.  This was closed with 6-0 Prolene suture.  The patient was placed in a compressive garment after treating the incision with Dermabond, Steri-Strips and antibiotic ointment around the drain site and umbilicus.  A Kerlix dressing and a surgical bra was placed to the chest area.  A compressive garment was placed.  The patient was then aroused from anesthesia, extubated, and taken to the recovery room in stable condition.  Sponge, needle, lap, instrument counts were all correct.  The patient tolerated the procedure well.  There were no complications.  The estimated blood loss was approximately 25 mL.","surgery, breast reconstruction, excess, lma anesthesia, lipodystrophy, liposuction, abdomen, drain site, flank, latissimus dorsi flap, soft tissue, supraumbilical, surgical bra, supraumbilical abdomen, reconstruction, breast, tissue, implant,"
 Closed reduction and placement of long-arm cast., Surgery, Long-Arm Cast ,"PREOPERATIVE DIAGNOSIS:,  Left distal radius fracture displaced.,POSTOPERATIVE DIAGNOSIS: , Left distal radius fracture displaced.,SURGERY:  ,Closed reduction and placement of long-arm cast, CPT code 25605.,ANESTHESIA:  ,General LMA.,FINDINGS:  ,The patient was found to have a displaced fracture.  She was found to be in perfect alignment after closed reduction and placement of cast.  The radial deviation was well corrected.,INDICATIONS: , The patient is 5 years old.  She was seen in our office today 1 week after being placed into a cast for a displaced fracture.  She was noted to have significant loss of alignment especially on the lateral view.  She was indicated for closed reduction and placed of the long-arm cast.  Risks and benefits were discussed at length with the family.  They wished to proceed.,PROCEDURE:  ,The patient was brought to the operating room and placed on the operating table in supine position.  General anesthesia was induced without incident.  Previous cast was previously removed.  An arm was approached and a closed reduction was performed.  This was checked under AP and lateral projection and was found to be in adequate alignment.  There was very mild residual dorsiflexion deformity noted.,A long-arm cast was then placed with plaster and molding.  Repeat x-rays demonstrated adequate alignment on both views.,The cast was then reinforced with fiberglass.  The patient was awakened from anesthesia and taken to recovery room in good condition.  There were no complications.  All instruments, sponge, and needle counts were correct at the end of case.,PLAN:  ,The patient will be discharged home.  She will return in 3 weeks for cast removal and clinical examination.  She would likely be placed into a wrist-guard at that time.  She has a prescription for Tylenol with codeine elixir.,","surgery, long-arm cast, closed reduction, displaced fracture, radial deviation, distal radius fracture, arm cast"
" Excision of lipoma, left knee.  A 4 cm mass of adipose tissue most likely representing a lipoma was found in the patient's anteromedial left knee.", Surgery, Lipoma Excision - 1 ,"PREOPERATIVE DIAGNOSIS:,  Mass, left knee.,POSTOPERATIVE DIAGNOSIS: , Lipoma, left knee.,PROCEDURE PERFORMED: ,Excision of lipoma, left knee.,ANESTHESIA: , Local with sedation.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS: , Minimal.,GROSS FINDINGS: , A 4 cm mass of adipose tissue most likely representing a lipoma was found in the patient's anteromedial left knee.,HISTORY:,  The patient is a 35-year-old female with history of lump on her right knee for the past, what she reports to be six years.  She states it had grow in size over the last six months, rarely causes her any discomfort or pain, denies any neurovascular complaints of her right lower extremity.  She denies any other lumps or bumps on her body.  She wishes to have this removed for cosmetic reasons.,PROCEDURE: , After all potential risks, benefits, and complications of the procedure were discussed with the patient, informed consent was obtained.  She was transferred from the Preoperative Care Unit to Operating Suite #1.  She was transferred from the gurney to the operating table.  All bony prominences were well padded.  A well padded tourniquet was applied to her right thigh.  Anesthesia then administered some sedation, which she tolerated well.  Her right lower extremity was then sterilely prepped and draped in normal fashion.  Next, a rubber Esmarch was used to exsanguinate her right lower extremity.,Next, approximately 20 cc of 0.25% Marcaine with 1% lidocaine were used to locally anesthetize her anterior medial right knee in location of the mass.  Next, a #15 blade Bard-Parker scalpel was utilized to make an approximately 3 cm vertical incision over the soft tissue mass upon incising the skin and the subcutaneous tissue readily and there was the aforementioned fatty tissue mass.  This was easily excised with blunt dissection.  Examination of the wound then revealed a second piece of fatty tissue, which resembled a lipoma measuring approximately 1.5 cm x 2 cm.  This was then also excised utilizing Littler scissors.  Hemostasis was obtained.  The wound was then copiously irrigated after this all the underlying bone tissue was removed.  #2-0 Vicryl interrupted subcutaneous sutures were then placed and the skin was reapproximated utilizing #4-0 horizontal mattress nylon sutures.  Sterile dressings was applied of Adaptic, 4x4s, and Kerlix as well as an Ace wrap.  Sedation was reversed.  Tourniquet was deflated.  The patient was transferred from the operating table to the gurney and to the Postoperative Care Unit in stable condition.  Her prognosis for this is good.","surgery, excision of lipoma, adipose tissue, fatty tissue, lipoma, tissue, knee"
 Suction-assisted lipectomy of the breast with removal of 350 cc of breast tissue from both sides and two mastopexies., Surgery, Lipectomy - Breast ,"PREOPERATIVE DIAGNOSIS,Mammary hypertrophy with breast ptosis.,POSTOPERATIVE DIAGNOSIS,Mammary hypertrophy with breast ptosis.,OPERATION,Suction-assisted lipectomy of the breast with removal of 350 cc of breast tissue from both sides and two mastopexies.,ANESTHESIA,General endotracheal anesthesia.,PROCEDURE,The patient was placed in the supine position.  Under effects of general endotracheal anesthesia, markings were made preoperatively for the mastopexy.  An eccentric circle was drawn around the nipple and a wedge drawn from the inferior border of the areola to the inframammary fold.  A stab incision was made bilaterally and tumescent infiltration of anesthesia, lactated ringers with 1 cc of epinephrine to 1000 cc of lactated ringers was infused with a tumescent blunt needle.  200 cc was infiltrated on each side.  This was followed by power-assisted liposuction and manual liposuction with removal of 350 cc of supernatant fat from both sides utilizing a radial tunneling technique with a 4-mm cannula.  This was followed by the epithelialization of skin between the inner circle corresponding to the diameter of the areola 4 cm diameter and the outer eccentric circle with a tangent at the 6 o'clock position.  This would result in an elevation of the nipple-areolar complex with transposition.  The epithelialization of the wedge inferiorly equalized the circumference distance between the inner circle and the outer circle.  Hemostasis was achieved with electrocautery.  After the epithelialization was performed on both sides, nipple-areolar complex was transposed to new nipple position and the wedge was closed with transposition of the nipple-areolar complex beneath the transposed nipple.  Closure was performed with interrupted 3-0 PDS suture on deep subcutaneous tissue and dermal skin closure with running subcuticular 4-0 Monocryl suture.  Dermabond was applied followed by Adaptic and Kerlix in the suturing spaces supportive mildly compressive dressing.  The patient tolerated the procedure well.  The patient was returned to recovery room in satisfactory condition.","surgery, breast ptosis, dermabond, mammary hypertrophy, monocryl, anesthesia, breast tissue, endotracheal anesthesia, lipectomy, mastopexies, mastopexy, nipple, nipple-areolar complex, suction assisted lipectomy, nipple areolar complex, lactated ringers, nipple areolar, areolar complex, epithelialization, areolar, breast, "
" Intramuscular lipoma, right upper extremity.  Excision of intramuscular lipoma with flap closure.", Surgery, Lipoma Excision ,"PREOPERATIVE DIAGNOSIS:,  Mass lesion, right upper extremity.,POSTOPERATIVE DIAGNOSIS: , Intramuscular lipoma, right arm, approximately 4 cm.,PROCEDURE PERFORMED:  ,Excision of intramuscular lipoma with flap closure by Dr. Y.,INDICATIONS FOR PROCEDURE:  ,This is a 77-year-old African-American female who presents as an outpatient to the General Surgical Service with a mass in the anterior aspect of the mid-biceps region of the right upper extremity.  The mass has been increasing in size and symptoms according to the patient.  The risks and benefits of the surgical excision were discussed.  The patient gave informed consent for surgical removal.,GROSS FINDINGS: , At the time of surgery, the patient was found to have intramuscular lipoma within the head of the biceps.  It was removed in its entirety and submitted to Pathology for appropriate analysis.,PROCEDURE: , The patient was taken to the operating room.  She was given intravenous sedation and the arm area was sterilely prepped and draped in the usual fashion.  Xylocaine was utilized as local anesthetic and a longitudinal incision was made in the axis of the extremity.  The skin and subcutaneous tissue were incised as well as the muscular fascia.  The fibers of the biceps were divided bluntly and retracted.  The lipoma was grasped with an Allis clamp and blunt and sharp dissection was utilized to remove the mass without inuring the underlying neurovascular structures.  The mass was submitted to Pathology.  Good hemostasis was seen.  The wound was irrigated and closed in layers.  The deep muscular fascia was reapproximated with #2-0 Vicryl suture.,The subcutaneous tissues were reapproximated with #3-0 Vicryl suture and the deep dermis was reapproximated with #3-0 Vicryl suture.  Re-approximated wound flaps without tension and the skin was closed with #4-0 undyed Vicryl in running subcuticular fashion.  The patient was given wound care instructions and will follow up again in my office in one week.  Overall prognosis is good.","surgery, excision, mass lesion, intramuscular, muscular fascia, vicryl suture, intramuscular lipoma, suture, mass, lipoma "
" Percutaneous liver biopsy.   With the patient lying in the supine position and the right hand underneath the head, an area of maximal dullness was identified in the mid-axillary location by percussion.", Surgery, Liver Biopsy ,"TITLE OF PROCEDURE: , Percutaneous liver biopsy.,ANALGESIA: , 2% Lidocaine.,ALLERGIES: , The patient denied any allergy to iodine, lidocaine or codeine.,PROCEDURE IN DETAIL:  ,The procedure was described in detail to the patient at a previous clinic visit and by the medical staff today.  The patient was told of complications which might occur consisting of bleeding, bile peritonitis, bowel perforation, pneumothorax, or death.  The risks and benefits of the procedure were understood, and the patient signed the consent form freely.,With the patient lying in the supine position and the right hand underneath the head, an area of maximal dullness was identified in the mid-axillary location by percussion.  The area was prepped and cleaned with povidone iodine following which the skin, subcutaneous tissue, and serosal surfaces were infiltrated with 2% lidocaine down to the capsule of the liver.  Next, a small incision was made with a Bard-Parker #11 scalpel.  A 16-gauge modified Klatskin needle was inserted through the incision and into the liver on one occasion with the patient in deep expiration.  Liver cores measuring *** cm were obtained and will be sent to Pathology for routine histologic study.,POST-PROCEDURE COURSE AND DISPOSITION: , The patient will remain under close observation in the medical treatment room for four to six hours and then be discharged home without medication.  Normal activities can be resumed tomorrow.  The patient is to contact me if severe abdominal or chest pain, fever, melena, light-headedness or any unusual symptoms develop.  An appointment will be made for the patient to see me in the clinic in the next few weeks to discuss the results of the liver biopsy so that management decisions can be made.,COMPLICATIONS:,  None.,RECOMMENDATIONS: , Prior to discharge, hepatitis A and B vaccines will be recommended.  Risks and benefits for vaccination have been addressed and the patient will consider this option.","surgery, bile peritonitis, bowel perforation, pneumothorax, klatskin needle, mid axillary, liver biopsy, percutaneous, lidocaine, biopsy, liver"
 Suction-assisted lipectomy - lipodystrophy of the abdomen and thighs., Surgery, Lipectomy - Abdomen/Thighs ,"PREOPERATIVE DIAGNOSIS: , Lipodystrophy of the abdomen and thighs.,POSTOPERATIVE DIAGNOSIS:,  Lipodystrophy of the abdomen and thighs.,OPERATION: , Suction-assisted lipectomy.,ANESTHESIA:,  General.,FINDINGS AND PROCEDURE:,  With the patient under satisfactory general endotracheal anesthesia, the entire abdomen, flanks, perineum, and thighs to the knees were prepped and draped circumferentially in sterile fashion.  After this had been completed, a #15 blade was used to make small stab wounds in the lateral hips, the pubic area, and upper edge of the umbilicus.  Through these small incisions, a cannula was used to infiltrate lactated Ringers with 1000 cc was infiltrated initially into the abdomen.  A 3 and 4-mm cannulas were then used to carry out the liposuction of the abdomen removing a total of 1100 cc of aspirate, which was mostly fat, little fluid, and blood.  Attention was then directed to the thighs both inner and outer.  A total of 1000 cc was infiltrated in both lateral thighs only about 50 cc in the medial thighs.  After this had been completed, 3 and 4-mm cannulas were used to suction 650 cc from each side, approximately 50 cc in the inner thigh and 600 on each lateral thigh.  The patient tolerated the procedure very well.  All of this aspirate was mostly fat with little fluid and very little blood.  Wounds were cleaned and steri-stripped and dressing of ABD pads and ***** was then applied.  The patient tolerated the procedure very well and was sent to the recovery room in good condition.","surgery, lipodystrophy, abd pads, suction-assisted lipectomy, abdomen, aspirate, lipectomy, perineum, steri-stripped, thighs, umbilicus, abdomen and thighs, abdomen/thighs, "
" Diagnostic operative arthroscopy with repair and reconstruction of anterior cruciate ligament using autologous hamstring tendon, a 40 mm bioabsorbable femoral pin, and a 9 mm bioabsorbable tibial pin.  Repair of lateral meniscus using two fast fixed meniscal repair sutures.  Partial medial meniscectomy.  Partial chondroplasty of patella.  Lateral retinacular release.  Open medial plication as well of the right knee.", Surgery, Ligament Reconstruction & Meniscus Repair ,"PREOPERATIVE DIAGNOSES:,1.  Torn anterior cruciate ligament, right knee.,2.  Patellofemoral instability, right knee.,3.  Possible torn medial meniscus.,POSTOPERATIVE DIAGNOSES:,1.  Complete tear anterior cruciate ligament, right knee.,2.  Complex tear of the posterior horn lateral meniscus.,3.  Tear of posterior horn medial meniscus.,4.  Patellofemoral instability.,5.  Chondromalacia patella.,PROCEDURES PERFORMED:,1.  Diagnostic operative arthroscopy with repair and reconstruction of anterior cruciate ligament using autologous hamstring tendon, a 40 mm bioabsorbable femoral pin, and a 9 mm bioabsorbable tibial pin.,2.  Repair of lateral meniscus using two fast fixed meniscal repair sutures.,3.  Partial medial meniscectomy.,4.  Partial chondroplasty of patella.,5.  Lateral retinacular release.,6.  Open medial plication as well of the right knee.,ANESTHESIA:,  General.,COMPLICATIONS:,  None.,TOURNIQUET TIME:,  130 minutes at 325 mmHg.,INTRAOPERATIVE FINDINGS: , There was noted to be a grade-II chondromalacia patellofemoral joint.  The patella was noted to be situated laterally past the lateral femoral condyle.  There was a tear to the posterior horn of the medial meniscus within the white zone.  There was a complex tear involving a horizontal cleavage component to the posterior horn of the lateral meniscus as well in the entire meniscus.  There was a complete tear of the anterior cruciate ligament.  The posterior cruciate ligament appeared intact.  Preoperatively, she had a positive Lachman with a positive pivot shift test as well as increased patellofemoral instability.,HISTORY: , This is a 39-year-old female who has sustained a twisting injury to her knee while on trampoline in late August.  She was diagnosed per MRI.  An MRI confirmed the clinical diagnosis of anterior cruciate ligament tear.  She states she has had multiple episodes of instability to the patellofemoral joint throughout the years with multiple dislocations.  She elected to proceed with surgery to repair the anterior cruciate ligament as well as possibly plicate the medial retinaculum to help prevent further dislocations of the patellofemoral joint.  All risks and benefits of surgery were discussed with her at length.  She was in agreement with the treatment plan.,PROCEDURE:  ,On 09/11/03, she was taken to the operating room at ABCD General Hospital.  She was placed supine on the operating table.  General anesthetic was applied by the Anesthesiology Department.  Tourniquet was placed on the proximal thigh and it was then placed in a knee holder.  She was sterilely prepped and draped in the usual fashion.  An Esmarch was used to exsanguinate the lower extremity.  Tourniquet was inflated to 325 mmHg.  Longitudinal incision was made just medial to the tibial tubercle.  The subcutaneous tissue was carefully dissected.  Hemostasis was controlled with electrocautery.  The tendons of gracilis and semitendinosus were identified and isolated, and then stripped off the musculotendinous junction.  They were taken on the back table.  The soft tissue debris was removed from the tendons.  The ends of the tendons were sewn together using #5 Tycron whip type sutures.  The tendons were measured on back table and found to be 8 mm as the most adequate size, they were then placed under tension on the back table.  Stab incision was made in the inferolateral parapatellar region, through this camera was placed in the knee.  The knee was inflated with saline solution and operative pictures were obtained.  The above findings were noted.  A second port site was initiated in the inferomedial parapatellar region.  Through this, a probe was placed.  Tear in the posterior horn medial meniscus was identified.  It was resected using a meniscal resector.  It was then further contoured using arthroscopic shaver.  Attention was then taken to the lateral compartment.  A partial meniscectomy was performed using the resector and the shaver.  The posterior periphery of the lateral meniscus was also noticed to be unstable.  A repair was then performed using two fasting fixed meniscal repair sutures to help anchor the meniscus around the popliteus tendon.  There was noted to be excellent fixation.  The shaver was then taken into the intrachondral notch.  First a partial chondroplasty was performed on the patella to remove the loose articular debris as well as a partial synovectomy to the medial aspect of the patellar femoral joint.  Next, the remnant of the anterior cruciate ligament was removed using the arthroscopic shaver and arthroplasty was then performed on the medial aspect of the lateral femoral condyle.  Next, a tibial guide was placed through the anterior medial portal.  A ___ pin was then placed up through the anterior incision entering the tibial eminence just anterior to the posterior cruciate ligament.  This tibial tunnel was then drilled using 8 mm cannulated drill.  Next, an over-the-top guide was then placed at approximately the 11:30 position.  A ____ pin was then placed into the femur and 8 mm drill was then used to drill this femoral tunnel approximately 35 mm.  Next the U shape guide was placed through tibial tunnel into the femur.  A pin was then placed through the distal femur from lateral to medial, through the U-shaped guide a puller wire was then passed through the distal femur.  It was then pulled out through the tibial tunnel using the You-shaped guide.  The tendon was then placed around the wire.  The wire was pulled back up through the tibial into the femoral tunnel.  A 40 mm bioabsorbable pin was then placed through the femoral tunnel securing the hamstring tendons.  Attention was then pulled through the tibial tunnel.  The knee was cycled approximately 20 times.  A 9 mm bioabsorbable screw was then placed through the tibial tunnel fixating the distal aspect of the graft.  There was noted definite fixation of the graft.  There was no evidence of impingement either in full flexion or full extension.  The knee was copiously irrigated and it was then suctioned dry.  A longitudinal incision was made just medial to the patellofemoral joint.  Soft tissues were carefully dissected and the medial retinaculum was incised along with the incision.  Following this, a release of lateral retinaculum was performed using a knife to further release the patellofemoral joint and allow further medial plication.  The medial retinaculum was then plicated using #1 Ethibond sutures and then oversewn with #0 Vicryl suture.  The subcuticular tissues were reapproximated with #2-0 Vicryl simple interrupted sutures followed by a #4-0 PDS running subcuticular stitch.  She was placed in a DonJoy knee immobilizer.  The tourniquet was deflated.  It was noted the lower extremity was warm and pink with good capillary refill.  She was transferred to the recovery room in apparent stable and satisfactory condition.  Prognosis for this patient is guarded.  She will be full weightbearing on the lower extremity using the knee immobilizer locked in extension.  She may remove her dressing two to three days, however, follow back in the office in 10 to 14 days for suture removal.  She will require one to two more physical therapy to help regain motion and strength to the lower extremity.", 
 Ligament reconstruction and tendon interposition arthroplasty of right wrist., Surgery, Ligament Reconstruction & Tendon Interposition Arthroplasty ,"OPERATION PERFORMED:,  Ligament reconstruction and tendon interposition arthroplasty of right wrist.,DESCRIPTION OF PROCEDURE: , With the patient under adequate anesthesia, the right upper extremity was prepped and draped in a sterile manner.,Attention was turned to the base of the thumb where a longitudinal incision was made over the anatomic snuffbox and extended out onto the carpometacarpal joint.  Using blunt dissection radial sensory nerve was dissected and retracted out of the operative field.  Further blunt dissection exposed the radial artery, which was dissected and retracted off the trapezium.  An incision was then made across the scaphotrapezial joint distally onto the trapezium and out onto the carpometacarpal joint.  Sharp dissection exposed the trapezium, which was then morselized and removed in toto with care taken to protect the underlying flexor carpi radialis tendon.  The radial beak of the trapezoid was then osteotomized off the head of the scaphoid.  The proximal metacarpal was then fenestrated with a 4.5-mm drill bit.  Four fingers proximal to the flexion crease of the wrist a small incision was made over the FCR tendon and blunt dissection delivered the FCR tendon into this incision.  The FCR tendon was divided and this incision was closed with 4-0 nylon sutures.  Attention was returned to the trapezial wound where longitudinal traction on the FCR tendon delivered the FCR tendon into the wound.,The FCR tendon was then threaded through the fenestration in the metacarpal.  A bone anchor was then placed distal to the metacarpal fenestration.  The FCR tendon was then pulled distally and the metacarpal reduced to an anatomic position.  The FCR tendon was then sutured to the metacarpal using the previously placed bone anchor.  Remaining FCR tendon was then anchovied and placed into the scaphotrapezoidal and trapezial defect.  The MP joint was brought into extension and the capsule closed using interrupted 3-0 Tycron sutures.,Attention was turned to the MCP joint where the MP joint was brought in to 15 degrees of flexion and pinned with a single 0.035 Kirschner wire.  The pin was cut at the level of the skin.,All incisions were closed with running 3-0 Prolene subcuticular stitch.,Sterile dressings were then applied.  The tourniquet was deflated.  The patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well.","surgery, arthroplasty, ligament, tendon, fcr, tendon interposition arthroplasty, ligament reconstruction, reconstruction, trapezium, metacarpal, joint, interposition,"
 Repair of upper lid canalicular laceration - Sample/Template., Surgery, Lid Laceration Repair ,"PREOPERATIVE DIAGNOSES:,1. XXX upper lid laceration.,2. XXX upper lid canalicular laceration.,POSTOPERATIVE DIAGNOSES:,1. XXX upper lid laceration.,2. XXX upper lid canalicular laceration.,PROCEDURES:,1. Repair of XXX upper lid laceration.,2. Repair of XXX upper lid canalicular laceration.,ANESTHESIA:, General,SPECIMENS:,  None.,COMPLICATIONS:, None.,INDICATIONS:, This is a XX-year-old (wo)man with XXX eye upper eyelid laceration involving the canaliculus.,PROCEDURE:, The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, re-operation, loss of vision, and loss of the eye. Informed consent was obtained. The patient was brought to the operating room and placed in the supine position, where (s)he was prepped and draped in the routine fashion for general ophthalmic plastic reconstructive surgery, once the appropriate cardiac and respiratory monitoring was placed on him/her, and once general endotracheal anesthetic had been administered. The patient then had the wound freshened up with Westcott scissors and cotton-tip applications. Hemostasis was achieved with a high-temp disposable cautery. Once this had been done, the proximal end of the XXX upper lid canalicular system was intubated with a Monoka tube on a Prolene. The proximal end was then found and this was intubated with the same tubing system. Then, two 6-0 Vicryl sutures were used to reapproximate the medial canthal tendon. Once this had been done, the skin was reapproximated with interrupted 6-0 Vicryl sutures and interrupted 6-0 plain gut sutures. To ensure that the punctum was in the correct position and in the Monoka tube was seated with a seater, and the tube was cut short. The patient's nose was suctioned of blood, and (s)he was awakened from general endotracheal anesthesia and did well. (S)he left the operating room in good condition.","surgery, laceration, monoka tube, westcott scissors, bleeding, canalicular laceration, canthal tendon, cotton-tip, infection, lid, lid canalicular system, lid laceration, loss of the eye, loss of vision, ophthalmic plastic reconstructive surgery, re-operation, upper lid, lid laceration repair, laceration repair, lid canalicular, canalicular"
" Microscopic suspension direct laryngoscopy with biopsy of left true vocal cord stripping.  Hoarseness, bilateral true vocal cord lesions, and leukoplakia.", Surgery, Laryngoscopy & Vocal Cord Biopsy ,"PREOPERATIVE DIAGNOSES:,1.  Hoarseness.,2.  Bilateral true vocal cord lesions.,3.  Leukoplakia.,POSTOPERATIVE DIAGNOSES:,1.  Hoarseness.,2.  Bilateral true vocal cord lesions.,3.  Leukoplakia.,PROCEDURE PERFORMED:  ,Microscopic suspension direct laryngoscopy with biopsy of left true vocal cord stripping.,ANESTHESIA:,  General endotracheal.,ESTIMATED BLOOD LOSS:,  Minimal.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE:  The patient is a 33-year-old Caucasian male with a history of chronic hoarseness and bilateral true vocal cord lesions, and leukoplakia discovered on a fiberoptic nasal laryngoscopy in the office.  Discussed risks, complications, and consequences of a surgical biopsy of the left true vocal cord and consent was obtained.,PROCEDURE: , The patient was brought to operative suite by anesthesia, placed on the operating table in supine position.  After this, the patient was placed under general endotracheal intubation anesthesia and the operative table was turned 90 degrees by the Department of Anesthesia.  A shoulder roll was then placed followed by the patient being placed in reverse Trendelenburg.,After this, a mouthguard was placed in the upper teeth and a Dedo laryngoscope was placed in the patient's oral cavity and advanced through the oral cavity in the oropharynx down into the hypopharynx.  The patient's larynx was then brought into view with the true vocal cords hidden underneath what appeared to be redundant false vocal cords.  The left true vocal cord was then first addressed and appeared to have an extensive area of leukoplakia extending from the posterior one-third up to the anterior third.  The false vocal cord also appeared to be very full on the left side along with fullness in the subglottic region.  The patient's anterior commissure appeared to be clear.  The false cord on the right side also appeared to be very redundant and overshadowing the true vocal cord.  Once the true vocal cord was retracted laterally, there was revealed a second area of leukoplakia involving the right true vocal cord in the anterior one-third aspect.  The patient's subglottic region was very edematous and with redundant mucosal tissue.  The areas of leukoplakia appeared to be cobblestoned in appearance, irregularly bordered, and very hard to the touch.  The left true vocal cord was then first addressed, was stripped from posteriorly to anteriorly utilizing a #45 laryngeal forceps.  After this, the patient had pressure placed upon this area with tropical adrenaline and a rectal swab to maintain hemostasis.  The specimen was passed off the field and was sent to Pathology for evaluation.  Hemostasis was maintained on the left side.  Prior to taking this biopsy, the Louie arm was attached to the laryngoscope and then suspended on the Mayo stand.  The Zeiss operating microscope was then brought into view to directly visualize the vocal cords.  The biopsies were taken under direct visualization utilizing the Zeiss operating microscope.  After the specimen was taken and the laryngoscope was desuspended from the Mayo stand and Louie arm was removed, the scope was then pulled more cephalad and the piriform sinuses, valecula, and base of the tongue were all directly visualized, which appeared normal except for the left base of tongue appeared to be full.  This area was biopsied multiple times with a straight laryngeal forceps and passed off the field and sent to Pathology as specimen.  The scope was then pulled back into the superior aspect of hypopharynx into the oropharynx and the oral cavity demonstrated no signs of any gross lesions.  A bimanual examination was then performed, which again demonstrated a fullness on the left base of tongue region with no signs of any other gross lesions.  There were no signs of any palpable cervical lymphadenopathy.  The tooth guard was removed and the patient was then turned back to anesthesia.  The patient did receive intraoperatively 10 mg of Decadron.  The patient tolerated the procedure well and was extubated in the operating room.,The patient was transferred to recovery room in stable condition and tolerated the procedure well.  The patient will be sent home with prescriptions for Medrol DOSEPAK, Tylenol with Codeine, Elixir, and amoxicillin 250 mg per 5 cc.","surgery, direct laryngoscopy, zeiss operating microscope, vocal cord lesions, vocal cord, cord, vocal, microscopic, laryngoscopy, hoarseness, biopsy, leukoplakia"
 Lateral release with lengthening of the ECRB tendon.  Lateral epicondylitis.   , Surgery, Lateral Epicondylitis Release ,"PREOPERATIVE DIAGNOSIS:  ,Lateral epicondylitis.","surgery, lateral release, ecrb tendon, ecrl, lateral epicondylitis, tourniquet, aponeurosis, epicondyle, antebrachial, epicondylitis, dissection, extensor, ecrb "
 The patient needing to be reintubated due to a leaking ET tube.  The patient is recently postoperative. , Surgery, Leaking ET tube ,"ASSESSMENT:  ,The patient needed reintubation due to a leaking tube.  I explained to the patient the procedure that I was going to do and he nodded in seeming understanding of the procedure.,Using Versed and succinylcholine, we were able to sedate and paralyze him to perform the procedure.  His potassium this morning was normal.  Using an 8.5 ET tube under direct visualization, the tube was passed through the cords.  The patient tolerated the procedure extremely well.  Auscultation of the lungs revealed bilateral equal breath sounds.  Chest x-ray is pending.  CO2 monitor was positive.","surgery, et tube, reintubated, postoperative, leakingNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Cystopyelogram and laser vaporization of the prostate., Surgery, Laser Vaporization of Prostate ,"PREOPERATIVE DIAGNOSIS: , Benign prostatic hypertrophy.,POSTOPERATIVE DIAGNOSIS: , Benign prostatic hypertrophy.,SURGERY:  ,Cystopyelogram and laser vaporization of the prostate.,ANESTHESIA: , Spinal.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY: , The patient is a 67-year-old male with a history of TURP, presented to us with urgency, frequency, and dribbling.  The patient was started on alpha-blockers with some help, but had nocturia q.1h.  The patient was given anticholinergics with minimal to no help.  The patient had a cystoscopy done, which showed enlargement of the left lateral lobes of the prostate.  At this point, options were discussed such as watchful waiting and laser vaporization to open up the prostate to get a better stream.  Continuation of alpha-blockers and adding another anti-cholinergic at night to prevent bladder overactivity were discussed.  The patient was told that his symptoms may be related to the mild-to-moderate trabeculation in the bladder, which can cause poor compliance.,The patient understood and wanted to proceed with laser vaporization to see if it would help improve his stream, which in turn might help improve emptying of the bladder and might help his overactivity of the bladder.  The patient was told that he may need anticholinergics.  There could be increased risk of incontinence, stricture, erectile dysfunction, other complications and the consent was obtained.,PROCEDURE IN DETAIL:  ,The patient was brought to the OR and anesthesia was applied.  The patient was placed in dorsal lithotomy position.  The patient was given preoperative antibiotics.  The patient was prepped and draped in the usual sterile fashion.  A #23-French scope was inserted inside the urethra into the bladder under direct vision.  Bilateral pyelograms were normal.  The rest of the bladder appeared normal except for some moderate trabeculations throughout the bladder.  There was enlargement of the lateral lobes of the prostate.  The old TUR scar was visualized right at the bladder neck.  Using diode side-firing fiber, the lateral lobes were taken down.  The verumontanum, the external sphincter, and the ureteral openings were all intact at the end of the procedure.  Pictures were taken and were shown to the family.  At the end of the procedure, there was good hemostasis.  A total of about 15 to 20 minutes of lasering time was used.  A #22 3-way catheter was placed.  At the end of the procedure, the patient was brought to recovery in stable condition.  Plan was for removal of the Foley catheter in 48 hours and continuation of use of anticholinergics at night.","surgery, laser vaporization of the prostate, cystopyelogram, benign prostatic hypertroph, benign prostatic hypertrophy, alpha blockers, laser vaporization, anticholinergics, laser, vaporization, prostate, bladder"
" Direct laryngoscopy, rigid bronchoscopy and dilation of subglottic upper tracheal stenosis.", Surgery, Laryngoscopy ,"PREOPERATIVE DIAGNOSIS,Subglottic upper tracheal stenosis.,POSTOPERATIVE DIAGNOSIS,Subglottic upper tracheal stenosis.,OPERATION PREFORMED,Direct laryngoscopy, rigid bronchoscopy and dilation of subglottic upper tracheal stenosis.,INDICATIONS FOR THE SURGERY,The patient is a 76-year-old white female with a history of subglottic upper tracheal stenosis.  She has had undergone multiple previous endoscopic procedures in the past; last procedure was in January 2007.  She returns with some increasing shortness of breath and dyspnea on exertion.  Endoscopic reevaluation is offered to her.  The patient has been considering laryngotracheal reconstruction; however, due to a recent death in the family, she has postponed this, but she has been having increasing symptoms.  An endoscopic treatment was offered to her.  Nature of the proposed procedure including risks and complications involving bleeding, infection, alteration of voice, speech, or swallowing, hoarseness changing permanently, recurrence of stenosis despite a surgical intervention, airway obstruction necessitating a tracheostomy now or in the future, cardiorespiratory, and anesthetic risks were all discussed in length.  The patient states she understood and wished to proceed.,DESCRIPTION OF THE OPERATION,The patient was taken to the operating room, placed on table in supine position.  Following adequate general anesthesia, the patient was prepared for endoscopy.  The top sliding laryngoscope was then inserted in the oral cavity, pharynx, and larynx examined. In the oral cavity, she had good dentition.  Tongue and buccal cavity mucosa were without ulcers, masses, or lesions.  The oropharynx was clear.  The larynx was then manually suspended.  Epiglottis area, epiglottic folds, false cords, true vocal folds with some mild edema, but otherwise, without ulcers, masses, or lesions, and the supraglottic and glottic airway were widely patent.  The larynx was manually suspended and a 5 x 30 pediatric rigid bronchoscope was passed through the vocal folds.  At the base of the subglottis, there was a narrowing and in the upper trachea, restenosis had occurred.  Moderate amount of mucoid secretions, these were suctioned, following which the area of stenosis was dilated.  Remainder of the bronchi was then examined.  The mid and distal trachea were widely patent.  Pale pink mucosa takeoff from mainstem bronchi were widely patent without ulcers, lesions, or evidence of scarring.  The scope was pulled back and removed and following this, a 6 x 30 pediatric rigid bronchoscope was passed through the larynx and further dilatation carried out.  Once this had been completed, dramatic improvement in the subglottic upper tracheal airway accomplished.  Instrumentation was removed and a #6 endotracheal tube, uncuffed, was placed to allow smooth emerge from anesthesia.  The patient tolerated the procedure well without complication.","surgery, stenosis, epiglottis, subglottic, bronchoscope, bronchoscopy, endoscopic, laryngoscopy, laryngotracheal reconstruction, larynx, oral cavity, pharynx, tracheal, true vocal folds, vocal, upper tracheal stenosis, subglottic upper tracheal, subglottic upper, upper tracheal, airway, cavity, patent, "
" Left orchiectomy, scrotal exploration, right orchidopexy.", Surgery, Left Orchiectomy & Right Orchidopexy ,"PREOPERATIVE DIAGNOSIS: , Left testicular torsion.,POSTOPERATIVE DIAGNOSES:  ,1.  Left testicular torsion.,2.  Left testicular abscess.,3.  Necrotic testes.,SURGERY:,  Left orchiectomy, scrotal exploration, right orchidopexy.,DRAINS:,  Penrose drain on the left hemiscrotum.,The patient was given vancomycin, Zosyn, and Levaquin preop.,BRIEF HISTORY:  ,The patient is a 49-year-old male who came into the emergency room with 2-week history of left testicular pain, scrotal swelling, elevated white count of 39,000.  The patient had significant scrotal swelling and pain.  Ultrasound revealed necrotic testicle.  Options such as watchful waiting and removal of the testicle were discussed.  Due to elevated white count, the patient was told that he must have the testicle removed due to the infection and possible early signs of urosepsis.  The risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, scrotal issues, other complications were discussed.  The patient was told about the morbidity and mortality of the procedure and wanted to proceed.,PROCEDURE IN DETAIL: , The patient was brought to the OR.  Anesthesia was applied.  The patient was prepped and draped in usual sterile fashion.  A midline scrotal incision was made.  There was very, very thick scrotal skin.  There was no necrotic skin.  As soon as the left hemiscrotum was entered, significant amount of pus poured out of the left hemiscrotum.  The testicle was completely filled with pus and had completely disintegrated with pus.  The pus just poured out of the left testicle.  The left testicle was completely removed.  Debridement was done of the scrotal wall to remove any necrotic tissue.  Over 2 L of antibiotic irrigation solution was used to irrigate the left hemiscrotum.  There was good tissue left after all the irrigation and debridement.  A Penrose drain was placed in the bottom of the left hemiscrotum.  I worried about the patient may have torsed and then the testicle became necrotic, so the plan was to pex the right testicle, plus the right side also appeared very abnormal.  So, the right hemiscrotum was opened.  The testicle had significant amount of swelling and scrotal wall was very thick.  The testicle appeared normal.  There was no pus coming out of the right hemiscrotum.  At this time, a decision was made to place 4-0 Prolene nonabsorbable stitches in 3 different quadrants to prevent it from torsion.  The hemiscrotum was closed using 2-0 Vicryl in interrupted stitches and the skin was closed using 2-0 PDS in horizontal mattress.  There was very minimal pus left behind and the skin was very healthy.  Decision was made to close it to help the patient heal better in the long run.  The patient was brought to the recovery in stable condition.","surgery, testicular abscess, necrotic testes, orchiectomy, scrotal exploration, orchidopexy, hemiscrotum, testicular torsion, penrose drain, scrotal swelling, scrotal wall, testicle, torsion"
 Carbon dioxide laser photo-ablation due to recurrent dysplasia of vulva., Surgery, Laser of Vulva ,"PREOPERATIVE DIAGNOSIS: , Recurrent dysplasia of vulva.,POSTOPERATIVE DIAGNOSIS:,  Same.,OPERATION PERFORMED:,  Carbon dioxide laser photo-ablation.,ANESTHESIA: , General, laryngeal mask.,INDICATIONS FOR PROCEDURE: , The patient has a past history of recurrent vulvar dysplasia.  She has had multiple prior procedures for treatment.  She was counseled to undergo laser photo-ablation.,FINDINGS:,  Examination under anesthesia revealed several slightly raised and pigmented lesions, predominantly on the left labia and perianal regions.  After staining with acetic acid, several additional areas of acetowhite epithelium were seen on both sides and in the perianal region.,PROCEDURE:  ,The patient was brought to the operating room with an IV in place.  Anesthetic was administered, after which she was placed in the lithotomy position.  Examination under anesthesia was performed, after which she was prepped and draped.  Acetic acid was applied and marking pen was utilized to outline the extent of the dysplastic lesion.  The carbon dioxide laser was then used to ablate the lesion to the third surgical plane as defined Reid.  Setting was 25 watts using a 6 mm pattern size with the silk-touch hand piece in the paint mode.  Excellent hemostasis was noted and Bacitracin was applied prophylactically.  The patient was awakened from her anesthetic and taken to the Post Anesthesia Care Unit in stable condition.","surgery, laser of vulva, recurrent dysplasia, carbon dioxide laser photo-ablation, recurrent dysplasia of vulva, dysplasia of vulva, carbon dioxide laser, photo ablation, carbon, dysplasia, laser, ablation,"
 LEEP procedure of endocervical polyp and Electrical excision of pigmented mole of inner right thigh., Surgery, LEEP ,"DIAGNOSIS:,1.  Broad-based endocervical poly.,2.  Broad- based pigmented, raised nevus, right thigh.,OPERATION:,1.  LEEP procedure of endocervical polyp.,2.  Electrical excision of pigmented mole of inner right thigh.,FINDINGS: , There was a 1.5 x 1.5 cm broad-based pigmented nevus on the inner thigh that was excised with a wire loop.  Also, there was a butt-based, 1-cm long endocervical polyp off the posterior lip of the cervix slightly up in the canal.,PROCEDURE: , With the patient in the supine position, general anesthesia was administered.  The patient was put in the dorsal lithotomy position and prepped and draped for dilatation and curettage in a routine fashion.,An insulated posterior weighted retractor was put in.  Using the LEEP tenaculum, we were able to grasp the anterior lip of the cervix with a large wire loop at 35 cutting, 30 coagulation.  The endocervical polyp on the posterior lip of the cervix was excised.,Then changing from a 50 of coagulation and 5 cutting, the base of the polyp was electrocoagulated, which controlled all the bleeding.  The wire loop was attached, and the pigmented raised nevus on the inner thigh was excised with the wire loop.  Cautery of the base was done, and then it was closed with figure-of-eight 3-0 Vicryl sutures.  A band-aid was applied over this.,Rechecking the cervix, no bleeding was noted.  The patient was laid flat on the table, awakened, and moved to the recovery room bed and sent to the recovery room in satisfactory condition.","surgery, endocervical polyp, pigmented mole, polyp, leep tenaculum, leep, cervix, endocervical, pigmented "
" Squamous cell carcinoma of the larynx.  Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.", Surgery, Laryngectomy & Thyroid Lobectomy ,"TITLE OF OPERATION:,  Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.,INDICATION FOR SURGERY: , A 58-year-old gentleman who has had a history of a T3 squamous cell carcinoma of his glottic larynx having elected to undergo a laser excision procedure in late 06/07.  Subsequently, biopsy confirmed tumor persistence in the right glottic region.  Risks, benefits, and alternatives of the surgical intervention versus possibility of chemoradiation therapy were discussed with the patient in detail.  Also concerned for a CT scan finding of possible cartilaginous invasion at the cricoid level.  The patient understood the issues regarding surgical intervention and wished to undergo a surgical intervention despite a clear understanding of risks, benefits, and alternatives.  He was accompanied by his wife and daughter.  Risks included, but were not limited to anesthesia, bleeding, infection, injury of the nerves including lower lip weakness, tongue weakness, tongue numbness, shoulder weakness, need for physical therapy, possibility of total laryngectomy, possibility of inability to speak or swallow, difficulty eating, wound care issues, failure to heal, need for additional treatment, and the patient understood all of these issues and they wished to proceed.,PREOP DIAGNOSIS: , Squamous cell carcinoma of the larynx.,POSTOP DIAGNOSIS: , Squamous cell carcinoma of the larynx.,PROCEDURE DETAIL: , After identifying the patient, the patient was placed supine on the operating room table.  After the establishment of the general anesthesia via oral endotracheal intubation, the patient had his eyes protected with Tegaderm.  A #6 endotracheal tube was placed initially.  Direct laryngoscopy was performed with a Lindholm laryngoscope.  A 0-degree endoscope was used to take pictures of what was apparently a recurrence of tumor along the right true vocal fold extending into the anterior arytenoid area and extending about 1 cm below into the subglottis.  Subsequently, a decision was then made to go ahead and perform the surgical intervention.  A hemi-apron incision was employed, and 1% lidocaine with 1:100,000 epinephrine was injected.  A shoulder roll was applied after the patient was prepped and draped in a sterile fashion.  Subsequently, a hemi-apron incision was performed.  Subplatysmal flaps were raised at the hyoid bone into the clavicle.  Attention was then turned to the right side, where a level 2, 3, 4 neck dissection was performed.  Submandibular fascia was appreciated inferiorly along the submandibular gland, this was incised allowing for identification of the digastric muscle.  Digastric tunnel was performed posteriorly to the level of the sternocleidomastoid muscle.  The fascia along the sternocleidomastoid muscle was then dissected along the anterior aspect until the cranial nerve XI was identified.  Level 2A contents were then dissected off the floor of the neck including levels 3 and 4.  Preservation of the phrenic nerve was obtained by identification, and subsequently cross-clamping fibrofatty tissue and lymph nodes just adjacent to the jugular vein inferiorly at level 4.  The specimen was then mobilized over the internal jugular vein with preservation of hypoglossal nerve.  Levels 2, 3, 4 neck dissection specimens were then labeled appropriately, attached with staples, and sent for histopathological evaluation.,Attention was then turned to attempting to perform a partial laryngectomy up front with a possibility of total laryngectomy as discussed.  Subsequently, the strap muscles were separated in the midline.  The trachea was identified in the midline.  The thyroid isthmus was plicated using the Harmonic scalpel, and attention was then turned to transecting the strap muscles at the superior aspect of the thyroid cartilage.  Once this was performed, sinuses were mobilized from the thyroid cartilage both on the right and left side respectively.  The cricothyroid joint was then freed on the left side and then on the right side with noting on the right side that this cartilage was a bit more irregular.  Attention was then turned to performing a cricothyrotomy.  Upon performing this, it was obvious that there was tumor just above the level of the cricothyrotomy incision.  A #7 anode tube was then placed in this area and secured.  Attention was then turned to performing the laryngotomy at the level of the petiole of epiglottis.  Subsequently, the cuts were made on the left side with visualization of the vocalis process and coming down to the level of the cricoid cartilage, and the thyroid cartilage was then intentionally fractured along the anterior spine.  It was evident that this tumor had extended more than 1 cm into the subglottic region.  Careful dissection of larynx from an inferior margin and portion of cricoid cartilage resection then was performed posteriorly, though it was evident that the cricoid cartilage was invaded.  Frozen section biopsy then confirmed this finding as read by Dr. X of Surgical Pathology.,In light of this finding with cartilaginous invasion and inability to preserve the cricoid cartilage, the patient's case was then converted into a total laryngectomy.  Subsequently, the trachea was transected at the level 3, 4 tracheal ring into cartilaginous space and anterior tracheal stoma was fashioned using 3-0 vertical mattress sutures for the skin.  A W-plasty was also performed to allow for enlargement of the stoma.  Attention was then turned to identifying the common parting wall of the trachea and the esophagus.  Attention was then turned to resecting the hyoid bone.  The remainder of the specimen cuts were made superior from sinus preserving a modest amount of pharyngeal mechanism.  The wound was copiously irrigated.  Subsequently, a tracheoesophageal puncture site was performed using a right-angled hemostat at about approximately 1 cm from the posterior tracheal wall superior aspect.  Once this was performed, a running 3-0 canal stitch was used to close the pharynx.  Subsequently, interrupted 4-0 chromic stitches were then used as reinforcement line from superior to inferior, and fibrin glue was applied.  Two #10 JP drains were placed on the right side and one on the left side and secured appropriately with 3-0 nylon.  The wound was then closed using interrupted 3-0 Vicryl for the platysma and staples for the skin.  The patient tolerated the procedure well and was brought to the Weinberg Intensive Care Unit with the endotracheal tube still in place to be decannulated later.","surgery, laryngectomy, neck dissection, tracheoesophageal, cricopharyngeal myotomy, thyroid lobectomy, squamous cell carcinoma, larynx, thyroid cartilage, cricoid cartilage, total laryngectomy, thyroid, cartilage"
 Exploratory laparotomy and right salpingectomy., Surgery, Laparotomy & Salpingectomy ,"PREOPERATIVE DIAGNOSES:,1.  Right ectopic pregnancy.,2.  Severe abdominal pain.,3.  Tachycardia.,POSTOPERATIVE DIAGNOSES:,1.  Right ectopic pregnancy.,2.  Severe abdominal pain.,3.  Tachycardia.,PROCEDURE PERFORMED:,  Exploratory laparotomy and right salpingectomy.,ANESTHESIA:  ,General endotracheal.,ESTIMATED BLOOD LOSS: , 200 mL.,COMPLICATIONS:  ,None.,FINDINGS: , Right ectopic pregnancy with brisk active bleeding approximately 1L of blood found in the abdomen cavity.  Normal-appearing ovaries bilaterally, normal-appearing left fallopian tube, and normal-appearing uterus.,INDICATIONS:  ,The patient is a 23-year-old gravida P2, P0 at approximately who presented to ER at approximately 8 weeks gestational age with vaginal bleeding and severe abdominal pain.  The patient states she is significant for a previous right ectopic pregnancy diagnosed in 08/08 and treated appropriately and adequately with methotrexate.  Evaluation in the emergency room reveals a second right ectopic pregnancy.  Her beta quant was found to be approximately 13,000.  The ultrasound showed right adnexal mass with crown-rump length measuring consistent with an 8 weeks gestation and a moderate free fluid in the abdominal cavity.  Given these findings as well as physical examination findings a recommendation was made proceed with an exploratory laparotomy and right salpingectomy.  The procedure was discussed with the patient in detail including risks of bleeding, infection, injury to surrounding organs and possible need for further surgery.  Informed consult was obtained prior to proceeding with the procedure.,PROCEDURE NOTE:  ,The patient was taken to the operating room where general anesthesia was administered without difficulty.  The patient was prepped and draped in the usual sterile fashion.  A Pfannenstiel skin incision was made with scalpel and carried through to the underlying layer of fascia using the Bovie.  The fascia was incised in the midline and extended laterally using Mayo scissors.  Kocher clamps were used to grasp the superior aspect of the fascial incision, which was elevated and the underlying rectus muscles were dissected off bluntly using Mayo scissors, attention was then turned to the inferior aspect, which was grasped with Kocher clamps, elevated and the underlying rectus muscles dissected up bluntly using Mayo scissors.  The rectus muscles were dissected in the midline.  The peritoneum was identified using blunt dissection and entered in this manner and extended superiorly and inferiorly with good visualization of the bladder.  At this time, the blood found in the abdomen was suctioned.  The bowel was packed with moist laparotomy sponge.  The right ectopic pregnancy was identified.  The fallopian tube was clamped x2, excised, and ligated x2 using 0-Vicryl suture.  Hemostasis was visualized.  At this time, the left tube and ovary were examined and were found to be normal in appearance.  The pelvis was cleared off clots and was copiously irrigated.  The fallopian tube was reexamined and it was noted to be hemostatic.,At this time, the laparotomy sponges were removed.  The rectus muscles were reapproximated using 3-0 Vicryl.  The fascia was reapproximated with #0 Vicryl sutures.  The subcutaneous layer was closed with 3-0 plain gut.  The skin was closed with 4-0 Monocryl.  Sponge, lap, and instrument counts were correct x2.  The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition.","surgery, ectopic pregnancy, salpingectomy, exploratory laparotomy, fallopian tube, mayo scissors, rectus muscles, "
" Diagnostic laparoscopy and rigid sigmoidoscopy.  Acute pain, fever postoperatively, hemostatic uterine perforation, no bowel or vascular trauma.", Surgery, Laparoscopy & Sigmoidoscopy ,"PREOPERATIVE DIAGNOSES:,1.  Acute pain.,2.  Fever postoperatively.,POSTOPERATIVE DIAGNOSIS:,1.  Acute pain.,2.  Fever postoperatively.,3.  Hemostatic uterine perforation.,4.  No bowel or vascular trauma.,PROCEDURE PERFORMED:,1.  Diagnostic laparoscopy.,2.  Rigid sigmoidoscopy by Dr. X.,ANESTHESIA: , General endotracheal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Scant.,SPECIMEN:,  None.,INDICATIONS:  ,This is a 17-year-old African-American female, gravida-1, para-1, and had a hysteroscopy and dilation curettage on 09/05/03.  The patient presented later that evening after having increasing abdominal pain, fever and chills at home with a temperature up to 101.2.  The patient denied any nausea, vomiting or diarrhea.  She does complain of some frequent urination.  Her vaginal bleeding is minimal.,FINDINGS: , On bimanual exam, the uterus is approximately 6-week size, anteverted, and freely mobile with no adnexal masses appreciated.  On laparoscopic exam, there is a small hemostatic perforation noted on the left posterior aspect of the uterus.  There is approximately 40 cc of serosanguineous fluid in the posterior cul-de-sac.  The bilateral tubes and ovaries appeared normal.  There is no evidence of endometriosis in the posterior cul-de-sac or along the bladder flap.  There is no evidence of injury to the bowel or pelvic sidewall.  The liver margin, gallbladder and remainder of the bowel including the appendix appeared normal.,PROCEDURE: , After consent was obtained, the patient was taken to the Operating Room where general anesthetic was administered.  The patient was placed in the dorsal lithotomy position and prepped and draped in the normal sterile fashion.  A sterile speculum was placed in the patient's vagina and the anterior lip of the cervix was grasped with a vulsellum tenaculum.  The uterine manipulator was then placed into the patient's cervix and the vulsellum tenaculum and sterile speculum were removed.  Gloves were changed and attention was then turned to the abdomen where approximately 10 mm transverse infraumbilical incision was made.  Veress needle was placed through this incision and the gas turned on.  When good flow and low abdominal pressures were noted, the gas was turned up and the abdomen was allowed to insufflate.  A 11 mm trocar was then placed through this incision.  The camera was placed with the above findings noted.  A 5 mm step trocar was placed 2 cm superior to the pubic bone and along the midline.  A blunt probe was placed through this trocar to help for visualization of the pelvic and abdominal organs.  The serosanguineous fluid of the cul-de-sac was aspirated and the pelvis was copiously irrigated with sterile saline.  At this point, Dr. X was consulted.  He performed a rigid sigmoidoscopy, please see his dictation for further details.  There does not appear to be any evidence of colonic injury.  The saline in the pelvis was then suctioned out using Nezhat-Dorsey.  All instruments were removed.  The 5 mm trocar was removed under direct visualization with excellent hemostasis noted.  The camera was removed and the abdomen was allowed to desufflate.  The 11 mm trocar introducer was replaced and the trocar removed.  The skin was then closed with #4-0 undyed Vicryl in a subcuticular fashion.  Approximately 10 cc of 0.25% Marcaine was injected into the incision sites for postoperative pain relief.  Steri-Strips were then placed across the incision.  The uterine manipulator was then removed from the patient's cervix with excellent hemostasis noted.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct at the end of the procedure.  The patient was taken to the recovery room in satisfactory condition.,She will be followed immediately postoperatively within the hospital and started on IV antibiotics.","surgery, uterine perforation, vascular, bowel, diagnostic laparoscopy, vulsellum tenaculum, uterine manipulator, excellent hemostasis, rigid sigmoidoscopy, laparoscopy, sigmoidoscopy, postoperatively, trocar, "
" Laparoscopy, laparotomy, cholecystectomy with operative cholangiogram, choledocholithotomy with operative choledochoscopy and T-tube drainage of the common bile duct.", Surgery," Laparoscopy, Laparotomy, & Cholecystectomy  ","PREOPERATIVE DIAGNOSES: , Cholelithiasis, cholecystitis, and recurrent biliary colic.,POSTOPERATIVE DIAGNOSES: , Severe cholecystitis, cholelithiasis, choledocholithiasis, and morbid obesity.,PROCEDURES PERFORMED: , Laparoscopy, laparotomy, cholecystectomy with operative cholangiogram, choledocholithotomy with operative choledochoscopy and T-tube drainage of the common bile duct.,ANESTHESIA: , General.,INDICATIONS: , This is a 63-year-old white male patient with multiple medical problems including hypertension, diabetes, end-stage renal disease, coronary artery disease, and the patient is on hemodialysis, who has had recurrent episodes of epigastric right upper quadrant pain.  The patient was found to have cholelithiasis on last admission.  He was being worked up for this including cardiac clearance.  However, in the interim, he returned again with another episode of same pain.  The patient had a HIDA scan done yesterday, which shows nonvisualization of the gallbladder consistent with cystic duct obstruction.  Because of these, laparoscopic cholecystectomy was advised with cholangiogram.  Possibility of open laparotomy and open procedure was also explained to the patient.  The procedure, indications, risks, and alternatives were discussed with the patient in detail and informed consent was obtained.,DESCRIPTION OF PROCEDURE: , The patient was put in supine position on the operating table under satisfactory general anesthesia.  The entire abdomen was prepped and draped.  A small transverse incision was made about 2-1/2 inches above the umbilicus in the midline under local anesthesia.  The patient has a rather long torso.  Fascia was opened vertically and stay sutures were placed in the fascia.  Peritoneal cavity was carefully entered.  Hasson cannula was inserted into the peritoneal cavity and it was insufflated with CO2.  Laparoscopic camera was inserted and examination at this time showed difficult visualization with a part of omentum and hepatic flexure of the colon stuck in the subhepatic area.  The patient was placed in reverse Trendelenburg and rotated to the left.  An 11-mm trocar was placed in the subxiphoid space and two 5-mm in the right subcostal region.  Slowly, the dissection was carried out in the right subhepatic area.  Initially, I was able to dissect some of the omentum and hepatic flexure off the undersurface of the liver.  Then, some inflammatory changes were noted with some fatty necrosis type of changes and it was not quite clear whether this was part of the gallbladder or it was just pericholecystic infection/inflammation.  The visualization was extremely difficult because of the patient's obesity and a lot of fat intra-abdominally, although his abdominal wall is not that thick.  After evaluating this for a little while, we decided that there was no way that this could be done laparoscopically and proceeded with formal laparotomy.  The trocars were removed.,A right subcostal incision was made and peritoneal cavity was entered.  A Bookwalter retractor was put in place.  The dissection was then carried out on the undersurface of the liver.  Eventually, the gallbladder was identified, which was markedly scarred down and shrunk and appeared to have palpable stone in it.  Dissection was further carried down to what was felt to be the common bile duct, which appeared to be somewhat larger than normal about a centimeter in size.  The duodenum was kocherized.  The gallbladder was partly intrahepatic.  Because of this, I decided not to dig it out of the liver bed causing further bleeding and problem.  The inferior wall of the gallbladder was opened and two large stones, one was about 3 cm long and another one about 1.5 x 2 cm long, were taken out of the gallbladder.,It was difficult to tell where the cystic duct was.  Eventually after probing near the neck of the gallbladder, I did find the cystic duct, which was relatively very short.  Intraoperative cystic duct cholangiogram was done using C-arm fluoroscopy.  This showed a rounded density at the lower end of the bile duct consistent with the stone.  At this time, a decision was made to proceed with common duct exploration.  The common duct was opened between stay sutures of 4-0 Vicryl and immediately essentially clear bile came out.  After some pressing over the head of the pancreas through a kocherized maneuver, the stone did fall into the opening in the common bile duct.  So, it was about a 1-cm size stone, which was removed.  Following this, a 10-French red rubber catheter was passed into the common bile duct both proximally and distally and irrigated generously.  No further stones were obtained.  The catheter went easily into the duodenum through the ampulla of Vater.  At this point, a choledochoscope was inserted and proximally, I did not see any evidence of any common duct stones or proximally into the biliary tree.  However, a stone was found distally still floating around.  This was removed with stone forceps.  The bile ducts were irrigated again.  No further stones were removed.  A 16-French T-tube was then placed into the bile duct and the bile duct was repaired around the T-tube using 4-0 Vicryl interrupted sutures obtaining watertight closure.  A completion T-tube cholangiogram was done at this time, which showed slight narrowing and possibly a filling defect proximally below the confluence of the right and left hepatic duct, although externally, I was unable to see anything or palpate anything in this area.  Because of this, the T-tube was removed, and I passed the choledochoscope proximally again, and I was unable to see any evidence of any lesion or any stone in this area.  I felt at this time this was most likely an impression from the outside, which was still left over a gallbladder where the stone was stuck and it was impressing on the bile duct.  The bile duct lumen was widely open.  T-tube was again replaced into the bile duct and closed again and a completion T-tube cholangiogram appeared to be more satisfactory at this time.  The cystic duct opening through which I had done earlier a cystic duct cholangiogram, this was closed with a figure-of-eight suture of 2-0 Vicryl, and this was actually done earlier and completion cholangiogram did not show any leak from this area.,The remaining gallbladder bed, which was left in situ, was cauterized both for hemostasis and to burn off the mucosal lining.  Subhepatic and subdiaphragmatic spaces were irrigated with sterile saline solution.  Hemostasis was good.  A 10-mm Jackson-Pratt drain was left in the foramen of Winslow and brought out through the lateral 5-mm port site.  The T-tube was brought out through the middle 5-mm port site, which was just above the incision.  Abdominal incision was then closed in layers using 0 Vicryl running suture for the peritoneal layer and #1 Novafil running suture for the fascia.  Subcutaneous tissue was closed with 3-0 Vicryl running sutures in two layers.  Subfascial and subcutaneous tissues were injected with a total of 20 mL of 0.25% Marcaine with epinephrine for postoperative pain control.  The umbilical incision was closed with 0 Vicryl figure-of-eight sutures for the fascia, 2-0 Vicryl for the subcutaneous tissues, and staples for the skin.  Sterile dressing was applied, and the patient transferred to recovery room in stable condition.","surgery, cholelithiasis, cholecystitis, biliary colic, choledocholithiasis, laparoscopy, laparotomy, cholecystectomy, cholangiogram, choledocholithotomy, choledochoscopy, t-tube drainage, cystic duct cholangiogram, common bile duct, peritoneal cavity, gallbladder"
" Laparotomy and myomectomy.   Enlarged fibroid uterus and blood loss anemia.  On bimanual exam, the patient has an enlarged, approximately 14-week sized uterus that is freely mobile and anteverted with no adnexal masses.  Surgically, the patient has an enlarged fibroid uterus with a large fundal/anterior fibroids.", Surgery, Laparotomy & Myomectomy ,"PREOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Blood loss anemia.,POSTOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Blood loss anemia.,PROCEDURE PERFORMED:,1.  Laparotomy.,2.  Myomectomy.,ANESTHESIA:  ,General.,ESTIMATED BLOOD LOSS: , Less than a 100 cc.,URINE OUTPUT: , 110 cc, clear at the end of the procedure.,FLUIDS: , 500 cc during the procedure.,SPECIMENS: , Four uterine fibroids.,DRAINS:  ,Foley catheter to gravity.,COMPLICATIONS: , None.,FINDINGS: , On bimanual exam, the patient has an enlarged, approximately 14-week sized uterus that is freely mobile and anteverted with no adnexal masses.  Surgically, the patient has an enlarged fibroid uterus with a large fundal/anterior fibroids, which is approximately 6+ cm and several small submucosal fibroids within the endometrium.  Both ovaries and tubes appeared within normal limits.,PROCEDURE: , The patient was taken to the operating room where she was prepped and draped in the normal sterile fashion in the dorsal supine position.  After the general anesthetic was found to be adequate, a Pfannenstiel skin incision was made with the first knife.  This was carried through the underlying layer of fascia with a second knife.  The fascia was incised in the midline with the second knife and the fascial incision was then extended laterally in both directions with the Mayo scissors.  The superior aspect of the fascial incision was then grasped with Ochsner clamps, tented up, and dissected off the underlying layer of rectus muscle bluntly.  It was then dissected in the middle with the Mayo scissors.  The inferior aspect of this incision was addressed in a similar manner.  The rectus muscles were separated in the midline bluntly.  The peritoneum was identified with hemostat clamps, tented up, and entered sharply with the Metzenbaum scissors.  The peritoneal incision was then extended superiorly and inferiorly with the Metzenbaum scissors and then extended bluntly.  Next, the uterus was grasped bluntly and removed from the abdomen.  The fundal fibroid was identified.  It was then injected with vasopressin, 20 units mixed in 30 cc of normal saline along the serosal surface and careful to aspirate to avoid any blood vessels.  15 cc was injected.  Next, the point tip was used with the cautery _______ cutting to cut the linear incision along the top of the _______ fibroid until fibroid fibers were seen.  The edges of the myometrium was grasped with Allis clamps, tented up, and a hemostat was used to bluntly dissect around the fibroid followed by blunt dissection with a finger.  The fibroid was easily and bluntly dissected out.  It was also grasped with Lahey clamp to prevent traction.  Once the blunt dissection of the large fibroid was complete, it was handed off to the scrub nurse.  The large fibroid traversed the whole myometrium down to the mucosal surface and the endometrial cavity was largely entered when this fibroid was removed.  At this point, several smaller fibroids were noticed along the endometrial surface of the uterus.  Three of these were removed just by bluntly grasping with the Lahey clamp and twisting, all three of these were approximately 1 cm to 2 cm in size.  These were also handed to the scrub tech.  Next, the uterine incision was then closed with first two interrupted layers of #0 chromic in an interrupted figure-of-eight fashion and then with a #0 Vicryl in a running baseball stitch.  The uterus was seen to be completely hemostatic after closure.  Next, a 3 x 4 inch piece of Interceed was placed over the incision and dampened with normal saline.  The uterus was then carefully returned to the abdomen and being careful not to disturb the Interceed.  Next, the greater omentum was replaced over the uterus.,The rectus muscles were then reapproximated with a single interrupted suture of #0 Vicryl in the midline.  Then the fascia was closed with #0 Vicryl in a running fashion.  Next, the Scarpa's fascia was closed with #3-0 plain gut in a running fashion and the skin was closed with #4-0 undyed Vicryl in a running subcuticular fashion.  The incision was then dressed with 0.5-inch Steri-Strips and bandaged appropriately.  After the patient was cleaned, she was taken to Recovery in stable condition and she will be followed for her immediate postoperative period during the hospital.","surgery, enlarged fibroid uterus, blood loss anemia, laparotomy, myomectomy, metzenbaum scissors, uterus, fibroid, rectus, fascia, scissors, fashion, clamps, enlarged, incision, bluntly, "
" Attempted laparoscopy, open laparoscopy and fulguration of endometrial implant.   Chronic pelvic pain, probably secondary to endometriosis.", Surgery, Laparoscopy - 3 ,"PREOPERATIVE DIAGNOSIS: , Chronic pelvic pain, probably secondary to endometriosis.,POSTOPERATIVE DIAGNOSIS:,  Mild pelvic endometriosis.,PROCEDURE:,1.  Attempted laparoscopy.,2.  Open laparoscopy.,3.  Fulguration of endometrial implant.,ANESTHESIA: , General endotracheal.,BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,INDICATIONS:  ,The patient is a 21-year-old single female with chronic recurrent pelvic pain unresponsive to both estrogen and progesterone-containing birth control pills, either cyclically or daily as well as progestational medication only, who had a negative GI workup recently including colonoscopy, and desired definitive operative evaluation and diagnosis prior to initiation of a 6-month course of Depo-Lupron.,PROCEDURE: , After an adequate plane of general anesthesia had been obtained, the patient was placed in a dorsal lithotomy position.  She was prepped and draped in the usual sterile fashion for pelviolabdominal surgery.  Bimanual examination revealed a mid position normal-sized uterus with benign adnexal area.,In the high lithotomy position, a weighted speculum was placed into the posterior vaginal wall.  The anterior lip of the cervix was grasped with a single-tooth tenaculum.  A Hulka tenaculum was placed transcervically.  The other instruments were removed.  A Foley catheter was placed transurethrally to drain the bladder intraoperatively.,In the low lithotomy position and in steep Trendelenburg, attention was turned to the infraumbilical region.  Here, a stab wound incision was made through which the 120 mm Veress needle was placed and approximately 3 L of carbon dioxide used to create a pneumoperitoneum.  The needle was removed, the incision minimally enlarged, and the #5 trocar and cannula were placed.  The trocar was removed and the scope placed confirming a preperitoneal insufflation.,The space was drained off the insufflated gas and 2 more attempts were made, which failed due to the patient's adiposity.  Attention was turned back to the vaginal area where in the high lithotomy position, attempts were made at a posterior vaginal apical insertion.  The Hulka tenaculum was removed, the posterior lip of the cervix grasped with a single-tooth tenaculum, and the long Allis clamp used to grasp the posterior fornix on which was placed traction.  The first short and subsequently 15 cm Veress needles were attempted to be placed, but after several passes, no good pneumoperitoneum could be established via this route also.  It was elected not to do a transcervical intentional uterine perforation, but to return to the umbilical area.  The 15 cm Veress needle was inserted several times, but again a pneumo was preperitoneal.,Finally, an open laparoscopic approach was undertaken.  The skin incision was expanded with a knife blade.  Blunt dissection was used to carry the dissection down to the fascia.  This was grasped with Kocher clamps, entered sharply and opened transversely.  Four 0 Vicryl sutures were placed as stay sutures and tagged with hemostats and needles were cutoff.  Dissection continued between the rectus muscle and finally the anterior peritoneum was reached, grasped, elevated, and entered.,At this juncture, the Hasson cannula was placed and tied snugly with the above stay sutures while the pneumoperitoneum was being created, a #10 scope was placed confirming the intraperitoneal positioning.,Under direct visualization, a suprapubic 5 mm cannula and manipulative probe were placed.  Clockwise inspection of the pelvis revealed a benign vesicouterine pouch, normal uterus and fundus, normal right tube and ovary.  In the cul-de-sac, there were 3 clusters of 3 to 5 carbon charred type endometrial implants and those more distally in the greatest depth had created puckering and tenting.  The left tube and ovary were normal.  There were no adhesions.  There was no evidence of acute pelvic inflammatory disease.,The Endoshears and subsequently cautery on a hook were placed and the implants fulgurated.  Pictures were taken for confirmation both before and after the burn.,The carbon chars were irrigated and aspirated.  The smoke plume was removed without difficulty.  Approximately 50 mL of irrigant was left in the pelvis.  Due to the difficulty in placing and maintaining the Hasson cannula, no attempts were made to view the upper abdominal quadrant, specifically the liver and gallbladder.,The suprapubic cannula was removed under direct visualization, the pneumo released, the scope removed, the stay sutures cut, and the Hasson cannula removed.  The residual sutures were then tied together to completely occlude the fascial opening so that there will be no future hernia at this site.  Finally, the skin incisions were approximated with 3-0 Dexon subcuticularly.  They had been preincisionally injected with bupivacaine to which the patient said she had no known allergies.  The vaginal instruments were removed.  All counts were correct.  The patient tolerated the procedure well and was taken to the recovery room in stable condition.","surgery, endometriosis, fulguration, endometrial, single tooth tenaculum, endometrial implant, hulka tenaculum, veress needle, hasson cannula, pneumoperitoneum, laparoscopy, cannula, "
" Laparoscopy with ablation of endometriosis.  Allen-Masters window in the upper left portion of the cul-de-sac, bronze lesions of endometriosis in the central portion of the cul-de-sac as well as both the left uterosacral ligament, flame lesions of the right uterosacral ligament approximately 5 mL of blood tinged fluid in the cul-de-sac.", Surgery, Laparoscopy - 4 ,"PROCEDURE: , Laparoscopy with ablation of endometriosis.,DIAGNOSIS: , Endometriosis.,ANESTHESIA:,  General.,ESTIMATED BLOOD LOSS: , None.,FINDINGS: , Allen-Masters window in the upper left portion of the cul-de-sac, bronze lesions of endometriosis in the central portion of the cul-de-sac as well as both the left uterosacral ligament, flame lesions of the right uterosacral ligament approximately 5 mL of blood tinged fluid in the cul-de-sac.  Normal tubes and ovaries, normal gallbladder, smooth liver edge.,PROCEDURE:  ,The patient was taken to the operating room and placed under general anesthesia.  She was put in the dorsal lithotomy position, and the perineum and abdomen were prepped and draped in a sterile manner.  Subumbilical area was injected with Marcaine, and a Veress needle was placed subumbilically through which approximately 2 L of CO2 were inflated.  Scalpel was used to make a subumbilical incision through which a 5-mm trocar was placed.  Laparoscope was inserted through the cannula and the pelvis was visualized.  Under direct visualization, two 5-mm trocars were placed in the right and left suprapubic midline.  Incision sites were transilluminated and injected with Marcaine prior to cutting.  Hulka manipulator was placed on the cervix.  Pelvis was inspected and blood tinged fluid was aspirated from the cul-de-sac.  The beginnings of an Allen-Masters window in the left side of the cul-de-sac were visualized along with bronze lesions of endometriosis.  Some more lesions were noted above the left uterosacral ligament.  Flame lesions were noted above the right uterosacral ligament.  Tubes and ovaries were normal bilaterally with the presence of a few small paratubal cysts on the left tube.  There was a somewhat leathery appearance to the ovaries.  The lesions of endometriosis were ablated with the argon beam coagulator, as was a region of the Allen-Masters window.  Pelvis was irrigated and all operative sites were hemostatic.  No other abnormalities were visualized and all instruments were moved under direct visualization.  Approximately 200 mL of fluid remained in the abdominal cavity.  All counts were correct and the skin incisions were closed with 2-0 Vicryl after all CO2 was allowed to escape.  The patient was taken to the recovery in stable condition.","surgery, ablation of endometriosis, allen-masters window, uterosacral ligament, endometriosis, cul de sac, laparoscopy, lesions, ablation"
 Laparoscopic supracervical hysterectomy.  A female with a history of severe dysmenorrhea and menorrhagia unimproved with medical management., Surgery, Laparoscopic Supracervical Hysterectomy.   ,"PREOPERATIVE DIAGNOSIS,1.  Dysmenorrhea.,2.  Menorrhagia.,POSTOPERATIVE DIAGNOSIS,1.  Dysmenorrhea.,2.  Menorrhagia.,PROCEDURE:,  Laparoscopic supracervical hysterectomy.,ESTIMATED BLOOD LOSS:,  30 cc.,COMPLICATIONS:,  None.,INDICATIONS FOR SURGERY: , A female with a history of severe dysmenorrhea and menorrhagia unimproved with medical management.  Please see clinic notes.  Risks of bleeding, infection, damage to other organs have been explained.  Informed consent was obtained.,OPERATIVE FINDINGS:,  Slightly enlarged but otherwise normal-appearing uterus.  Normal-appearing adnexa bilaterally.,OPERATIVE PROCEDURE IN DETAIL: , After administration of general anesthesia the patient was placed in dorsal lithotomy position, prepped and draped in the usual sterile fashion.  Uterine manipulator was inserted as well as a Foley catheter and this was then draped off from the remainder of the abdominal field.  A 5 mm incision was made umbilically after injecting 0.25% Marcaine; 0.25% Marcaine was injected in all the incisional sites.  Veress needle was inserted, position confirmed using the saline drop method.  After confirming an opening pressure of 4 mmHg of CO2 gas, approximately four liters was insufflated in the abdominal cavity.  Veress needle was removed and a 5 mm port placed and position confirmed using the laparoscope.  A 5 mm port was placed three fingerbreadths suprapubically and on the left and right side.  All these were placed under direct visualization.  Pelvic cavity was examined with findings as noted above.  The left utero-ovarian ligament was grasped and cauterized using the Gyrus.  Part of the superior aspect of the broad ligament was then cauterized as well.  Following this the anterior peritoneum over the bladder flap was incised and the bladder flap bluntly resected off the lower uterine segment.  The remainder of the broad and cardinal ligament was then cauterized and excised.  A similar procedure was performed on the right side.  The cardinal ligament was resected all the way down to 1 cm above the uterosacral ligament.  After assuring that the bladder was well out of the way of the operative field, bipolar cautery was used to incise the cervix at a level just above the uterosacral ligaments.  The area was irrigated extensively and cautery used to assure hemostasis.  A 15 mm probe was then placed on the right side and the uterine morcellator was used to remove the specimen and submitted to pathology for examination.  Hemostasis was again confirmed under low pressure.  Using Carter-Thomason the fascia was closed in the 15 mm port site with 0 Vicryl suture.  The accessory ports were removed and abdomen deflated and skin edges reapproximated with 5-0 Monocryl suture.  Instruments removed from vagina.  Patient returned to supine position, recalled from general anesthesia and transferred to recovery in satisfactory condition.  Sponge and needle counts correct at the conclusion of the case.  Estimated blood loss was 30 cc.  There were no complications.","surgery, adnexa, uterus, laparoscopic supracervical hysterectomy, veress needle, bladder flap, cardinal ligament, uterine, cauterized, dysmenorrhea, menorrhagia,"
" Diagnostic laparoscopy and laparoscopic appendectomy.  Right lower quadrant abdominal pain, rule out acute appendicitis.", Surgery, Laparoscopy & Laparoscopic Appendectomy ,"PREOPERATIVE DIAGNOSIS: , Right lower quadrant abdominal pain, rule out acute appendicitis.,POSTOPERATIVE DIAGNOSIS:,  Acute suppurative appendicitis.,PROCEDURE PERFORMED:,1.  Diagnostic laparoscopy.,2.  Laparoscopic appendectomy.,ANESTHESIA: , General endotracheal and injectable 1% lidocaine and 0.25% Marcaine.,ESTIMATED BLOOD LOSS: , Minimal.,SPECIMEN: , Appendix.,COMPLICATIONS: , None.,BRIEF HISTORY: , This is a 37-year-old Caucasian female presented to ABCD General Hospital with progressively worsening suprapubic and right lower quadrant abdominal pain, which progressed throughout its course starting approximately 12 hours prior to presentation.  She admits to some nausea associated with it.  There have been no fevers, chills, and/or genitourinary symptoms.  The patient had right lower quadrant tenderness with rebound and percussion tenderness in the right lower quadrant.  She had a leukocytosis of 12.8.  She did undergo a CT of the abdomen and pelvis, which was non diagnostic for an acute appendicitis.  Given the severity of her abdominal examination and her persistence of her symptoms, we recommend the patient undergo diagnostic laparoscopy with probable need for laparoscopic appendectomy and possible open appendectomy.  The risks, benefits, complications of the procedure, she gave us informed consent to proceed.,OPERATIVE FINDINGS:  ,Exploration of the abdomen via laparoscopy revealed an appendix with suppurative fluid surrounding it, it was slightly enlarged.  The left ovary revealed some follicular cysts.  There was no evidence of adnexal masses and/or torsion of the fallopian tubes.  The uterus revealed no evidence of mass and/or fibroid tumors.  The remainder of the abdomen was unremarkable.,OPERATIVE PROCEDURE: , The patient was brought to the operative suite, placed in the supine position.  The abdomen was prepped and draped in the normal sterile fashion with Betadine solution.  The patient underwent general endotracheal anesthesia.  The patient also received a preoperative dose of Ancef 1 gram IV.  After adequate sedation was achieved, a #10 blade scalpel was used to make an infraumbilical transverse incision utilizing a Veress needle.  Veress needle was inserted into the abdomen and the abdomen was insufflated approximately 15 mmHg.  Once the abdomen was sufficiently insufflated, a 10 mm bladed trocar was inserted into the abdomen without difficulty.  A video laparoscope was inserted into the infraumbilical trocar site and the abdomen was explored.  Next, a 5 mm port was inserted in the midclavicular line of the right upper quadrant region.  This was inserted under direct visualization.  Finally, a suprapubic 12 mm portal was created.  This was performed with #10 blade scalpel to create a transverse incision.  A bladed trocar was inserted into the suprapubic region.  This was done again under direct visualization.  Maryland dissector was inserted into the suprapubic region and a window was created between the appendix and mesoappendix at the base of the cecum.  This was done while the 5 mm trocar was used to grasp the middle portion of the appendix and retracted anteriorly.  Utilizing a endovascular stapling device, the appendix was transected and doubly stapled with this device.  Next, the mesoappendix was doubly stapled and transected with the endovascular stapling device.  The staple line was visualized and there was no evidence of bleeding.  The abdomen was fully irrigated with copious amounts of normal saline.  The abdomen was then aspirated.  There was no evidence of bleeding.  All ports were removed under direct visualization.  No evidence of bleeding from the port sites.  The infraumbilical and suprapubic ports were then closed.  The fascias were then closed with #0-Vicryl suture on a UR6 needle.  Once the fascias were closed, all incisions were closed with #4-0 undyed Vicryl.  The areas were cleaned, Steri-Strips were placed across the wound.  Sterile dressing was applied.,The patient tolerated the procedure well.  She was extubated following the procedure, returned to Postanesthesia Care Unit in stable condition.  She will be admitted to General Medical Floor and she will be followed closely in the early postoperative course.","surgery, lower quadrant, diagnostic laparoscopy, acute appendicitis, laparoscopic appendectomy, abdomen, appendectomy, laparoscopy, appendix, suprapubic,"
 Laparoscopy.  The cervix was grasped with a single-tooth tenaculum.  The uterus was gently sounded and a manipulator was inserted for movement of the uterus throughout the case. , Surgery, Laparoscopy - 1 ,,"surgery, uterus, cervix, vaginal, single tooth tenaculum, trocar sites, laparoscopy, bladder, laparoscopic, abdominal, cavity, trocar, toothNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,Home"
" Pelvic pain, pelvic endometriosis, and pelvic adhesions.  Laparoscopy, Harmonic scalpel ablation of endometriosis, lysis of adhesions, and cervical dilation.  Laparoscopically, the patient has large omental to anterior abdominal wall adhesions along the left side of the abdomen extending down to the left adnexa. ", Surgery, Laparoscopy ,"PREOPERATIVE DIAGNOSIS:,  Pelvic pain.,POSTOPERATIVE DIAGNOSES:,1.  Pelvic pain.,2.  Pelvic endometriosis.,3.  Pelvic adhesions.,PROCEDURE PERFORMED:,1.  Laparoscopy.,2.  Harmonic scalpel ablation of endometriosis.,3.  Lysis of adhesions.,4.  Cervical dilation.,ANESTHESIA:  ,General.,SPECIMEN:  ,Peritoneal biopsy.,ESTIMATED BLOOD LOSS:,  Scant.,COMPLICATIONS: , None.,FINDINGS: , On bimanual exam, the patient has a small, anteverted, and freely mobile uterus with no adnexal masses.  Laparoscopically, the patient has large omental to anterior abdominal wall adhesions along the left side of the abdomen extending down to the left adnexa.  There are adhesions involving the right ovary to the anterior abdominal wall and the bowel.  There are also adhesions from the omentum to the anterior abdominal wall near the liver.  The uterus and ovaries appear within normal limits other than the adhesions.  The left fallopian tube grossly appeared within normal limits.  The right fallopian tube was not well visualized but appeared grossly scarred and no tubal end was visualized.  There was a large area of endometriosis, approximately 1 cm wide in the left ovarian fossa and there was a small spot of endometriosis in the posterior cul-de-sac.  There was also vesicular appearing endometriosis lesion in the posterior cul-de-sac.,PROCEDURE:  ,The patient was taken in the operating room and generalized anesthetic was administered.  She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion.  After exam under anesthetic, weighted speculum was placed in the vagina.  The anterior lip of the cervix was grasped with vulsellum tenaculum.  The uterus was sounded and then was serially dilated with Hank dilators to a size 10 Hank, then the uterine manipulator was inserted and attached to the anterior lip of the cervix.  At this point, the vulsellum tenaculum was removed along with the weighted speculum and attention was turned towards the abdomen.  An approximately 2 cm incision was made immediately inferior to the umbilicus with the skin knife.  The superior aspect of the umbilicus was grasped with a towel clamp.  The abdomen was tented up and a Veress needle inserted through this incision.  When the Veress needle was felt to be in place, deep position was checked by placing saline in the needle.  This was seen to freely drop in the abdomen so it was connected to CO2 gas.  Again, this was started at the lowest setting, was seen to flow freely, so it was advanced to the high setting.  The abdomen was then insufflated to an adequate distention.  Once an adequate distention was reached, the CO2 gas was disconnected.  The Veress needle was removed and a size #11 step trocar was placed.  Next, the laparoscope was inserted through this port.  The medial port was connected to CO2 gas.  Next, a 1 cm incision was made in the midline approximately 2 fingerbreadths above the pubic symphysis.  Through this, a Veress needle was inserted followed by size #5 step trocar and this procedure was repeated under direct visualization on the right upper quadrant lateral to the umbilicus and a size #5 trocar was also placed.  Next, a grasper was placed through the suprapubic port.  This was used to grasp the bowel that was adhesed to the right ovary and the Harmonic scalpel was then used to lyse these adhesions.  Bowel was carefully examined afterwards and no injuries or bleeding were seen.  Next, the adhesions touching the right ovary and anterior abdominal wall were lysed with the Harmonic scalpel and this was done without difficulty.  There was a small amount of bleeding from the anterior abdominal wall peritoneum.  This was ablated with the Harmonic scalpel.  The Harmonic scalpel was used to lyse and ablate the endometriosis in the left ovarian fossa and the posterior cul-de-sac.  Both of these areas were seen to be hemostatic.  Next, a grasper was placed and was used to bluntly remove the vesicular lesion from the posterior cul-de-sac.  This was sent to pathology.  Next, the pelvis was copiously irrigated with the Nezhat dorsi suction irrigator and the irrigator was removed.  It was seen to be completely hemostatic.  Next, the two size #5 ports were removed under direct visualization.  The camera was removed.  The abdomen was desufflated.  The size #11 introducer was replaced and the #11 port was removed.,Next, all the ports were closed with #4-0 undyed Vicryl in a subcuticular interrupted fashion.  The incisions were dressed with Steri-Strips and bandaged appropriately and the patient was taken to recovery in stable condition and she will be discharged home today with Darvocet for pain and she will follow-up in one week in the clinic for pathology results and to have a postoperative check.","surgery, pelvic pain, endometriosis, pelvic adhesions, laparoscopy, scalpel ablation, lysis of adhesions, cervical dilation, peritoneal biopsy, harmonic scalpel, adhesions, harmonic, scalpel, abdominal, pelvic, abdomen, anterior, "
 Diagnostic laparoscopy and drainage of cyst., Surgery, Laparoscopy - Drainage of Cyst ,"PREOPERATIVE DIAGNOSIS:,  Ovarian cyst, persistent.,POSTOPERATIVE DIAGNOSIS: , Ovarian cyst.,ANESTHESIA:,  General,NAME OF OPERATION:,  Diagnostic laparoscopy and drainage of cyst.,PROCEDURE:,  The patient was taken to the operating room, prepped and draped in the usual manner, and adequate anesthesia was induced.  An infraumbilical incision was made, and Veress needle placed without difficulty.  Gas was entered into the abdomen at two liters.  The laparoscope was entered, and the abdomen was visualized.  The second puncture site was made, and the second trocar placed without difficulty.  The cyst was noted on the left, a 3-cm, ovarian cyst.  This was needled, and a hole cut in it with the scissors.  Hemostasis was intact.  Instruments were removed.  The patient was awakened and taken to the recovery room in good condition.","surgery, ovarian cyst, infraumbilical incision, drainage of cyst, diagnostic laparoscopy, laparoscopy, drainage, ovarian, "
 Examination under anesthesia and laparoscopic right orchiopexy., Surgery, Laparoscopic Orchiopexy ,"PREOPERATIVE DIAGNOSIS: , Bilateral undescended testes.,POSTOPERATIVE DIAGNOSIS: , Bilateral undescended testes, bilateral intraabdominal testes.,PROCEDURE: , Examination under anesthesia and laparoscopic right orchiopexy.,ESTIMATED BLOOD LOSS:,  Less than 5 mL.,FLUIDS RECEIVED:  ,110 mL of crystalloid.,INTRAOPERATIVE FINDINGS: , Atrophic bilateral testes, right is larger than left.  The left had atrophic or dysplastic vas and epididymis.,TUBES AND DRAINS: , No tubes or drains were used.,INDICATIONS FOR OPERATION:  ,The patient is a 7-1/2-month-old boy with bilateral nonpalpable testes.  Plan is for exploration, possible orchiopexy.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operating room where surgical consent, operative site, and patient identification were verified.  Once he was anesthetized, he was then palpated and again both testes were nonpalpable.  Because of this, a laparoscopic approach was then elected.  We then sterilely prepped and draped the patient, put an 8-French feeding tube in the urethra, attached to bulb grenade for drainage.  We then made an infraumbilical incision with a 15-blade knife and then further extended with electrocautery and with curved mosquito clamps down to the rectus fascia where we made stay sutures of 3-0 Monocryl on the anterior and posterior sheaths and then opened up the fascia with the curved Metzenbaum scissors.  Once we got into the peritoneum, we placed a 5-mm port with 0-degree short lens.  Insufflation was then done with carbon dioxide up to 10 to 12 mmHg.  We then evaluated.  There was no bleeding noted.  He had a closed ring on the left with a small testis that was evaluated and found to have short vessels as well as atrophic or dysplastic vas, which was barely visualized.  The right side was also intraabdominal, but slightly larger, had better vessels, had much more recognizable vas, and it was closer to the internal ring.  So, we elected to do an orchiopexy on the right side.  Using the laparoscopic 3- and 5-mm dissecting scissors, we then opened up the window at the internal ring through the peritoneal tissue, then dissected it medially and laterally along the line of the vas and along the line of the vessels up towards the kidney, mid way up the abdomen, and across towards the bladder for the vas.  We then used the Maryland dissector to gently tease this tissue once it was incised.  The gubernaculum was then divided with electrocautery and the laparoscopic scissors.  We were able to dissect with the hook dissector in addition to the scissors the peritoneal shunts with the vessels and the vas to the point where we could actually stretch and bring the testis across to the other side, left side of the ring.  We then made a curvilinear incision on the upper aspect of the scrotum on the right with a 15-blade knife and extended down the subcutaneous tissue with electrocautery.  We used the curved tenotomy scissors to make a subdartos pouch.  Using a mosquito clamp, we were able to go in through the previous internal ring opening, grasped the testis, and then pulled it through in a proper orientation.  Using the hook electrode, we were able to dissect some more of the internal ring tissue to relax the vessels and the vas, so there was no much traction.  Using 2 stay sutures of 4-0 chromic, we tacked the testis to the base of scrotum into the middle portion of the testis.  We then closed the upper aspect of the subdartos pouch with a 4-0 chromic and then closed the subdartos pouch and the skin with subcutaneous 4-0 chromic.  We again evaluated the left side and found again that the vessels were quite short.  The testis was more atrophic, and the vas was virtually nonexistent.  We will go back at a later date to try to bring this down, but it will be quite difficult and has a higher risk for atrophy because of the tissue that is present.  We then removed the ports, closed the fascial defects with figure-of-eight suture of 3-0 Monocryl, closed the infraumbilical incision with two Monocryl stay sutures to close the fascial sheath, and then used 4-0 Rapide to close the skin defects, and then using Dermabond tissue adhesives, we covered all incisions.  At the end of the procedure, the right testis was well descended within the scrotum, and the feeding tube was removed.  The patient had IV Toradol and was in stable condition upon transfer to recovery room.","surgery, laparoscopic right orchiopexy, undescended testes, orchiopexy, bilateral undescended testes, mosquito clamps, subdartos pouch, internal ring, laparoscopic,"
" Laparoscopy with left salpingo-oophorectomy.  Left adnexal mass/ovarian lesion.  The labia and perineum were within normal limits.  The hymen was found to be intact.  Laparoscopic findings revealed a 4 cm left adnexal mass, which appeared fluid filled.  ", Surgery, Laparoscopy & Salpingo-oophorectomy ,"PREOPERATIVE DIAGNOSIS:,  Left adnexal mass.,POSTOPERATIVE DIAGNOSIS:,  Left ovarian lesion.,PROCEDURE PERFORMED:  ,Laparoscopy with left salpingo-oophorectomy.,ANESTHESIA:,  General.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,COMPLICATIONS:,  None.,FINDINGS:,  The labia and perineum were within normal limits.  The hymen was found to be intact.  Laparoscopic findings revealed a 4 cm left adnexal mass, which appeared fluid filled.  There were a few calcifications on the surface of the mass.  The right ovary and fallopian tube appeared normal.  There was no evidence of endometriosis.  The uterus appeared normal in size.  There were no pelvic adhesions noted.,INDICATIONS: , The patient is a 55-year-old gravida 0, para 0 Caucasian female who presents with a left adnexal mass on ultrasound which is 5.3 cm.  She does complain of minimal discomfort.  Bimanual exam was not able to be performed secondary to the vaginal stenosis and completely intact hymen.,PROCEDURE IN DETAIL: , After informed consent was obtained, the patient was taken back to the Operative Suite, prepped and draped, and placed in the dorsal lithotomy position.  A 1 cm skin incision was made in the infraumbilical vault.  While tenting up the abdominal wall, the Veress needle was inserted without difficulty and the abdomen was insufflated.  This was done using appropriate flow and volume of CO2.  The #11 step trocar was then placed without difficulty.  The above findings were confirmed.  A #12 mm port was then placed approximately 2 cm above the pubic symphysis under direct visualization.  Two additional ports were placed, one on the left lateral aspect of the abdominal wall and one on the right lateral aspect of the abdominal wall.  Both #12 step ports were done under direct visualization.  Using a grasper, the mass was tented up at the inferior pelvic ligament and the LigaSure was placed across this and several bites were taken with good visualization while ligating.  The left ovary was then placed in an Endocatch bag and removed through the suprapubic incision.  The skin was extended around this incision and the fascia was extended using the Mayo scissors.  The specimen was removed intact in the Endocatch bag through this site.  Prior to desufflation of the abdomen, the site where the left adnexa was removed was visualized to be hemostatic.  All the port sites were hemostatic as well.  The fascia of the suprapubic incision was then repaired using a running #0 Vicryl stitch on a UR6 needle.  The skin was then closed with #4-0 undyed Vicryl in a subcuticular fashion.  The remaining incisions were also closed with #4-0 undyed Vicryl in a running fashion after all instruments were removed and the abdomen was completely desufflated.  Steri-Strips were placed on each of the incisions.  The patient tolerated the procedure well.  Sponge, lap, and needle count were x2.  She will go home on Vicodin for pain and followup postoperatively in the office where we will review path report with her.","surgery, salpingo-oophorectomy, ovarian lesion, adnexal mass, salpingo oophorectomy, abdominal wall, intact, adnexal, laparoscopy, mass,"
"  Total laparoscopic hysterectomy with laparoscopic staging, including paraaortic lymphadenectomy, bilateral pelvic and obturator lymphadenectomy, and washings.", Surgery, Laparoscopic Hysterectomy ,"PREOPERATIVE DIAGNOSIS:,  Endometrial carcinoma.,POSTOPERATIVE DIAGNOSIS: , Endometrial carcinoma.,PROCEDURE PERFORMED:,  Total laparoscopic hysterectomy with laparoscopic staging, including paraaortic lymphadenectomy, bilateral pelvic and obturator lymphadenectomy, and washings.,ANESTHESIA: , General, endotracheal tube.,SPECIMENS: , Pelvic washings for cytology; uterus with attached right tube and ovary; pelvic and paraaortic lymph node dissection; obturator lymph node dissection.,INDICATIONS FOR PROCEDURE: , The patient was recently found to have a grade II endometrial cancer.  She was counseled to undergo laparoscopic staging.,FINDINGS:,  During the laparoscopy, the uterus was noted to be upper limits of normal size, with a normal-appearing right fallopian tubes and ovaries.  No ascites was present.  On assessment of the upper abdomen, the stomach, diaphragm, liver, gallbladder, spleen, omentum, and peritoneal surfaces of the bowel, were all unremarkable in appearance.,PROCEDURE: , The patient was brought into the operating room with an intravenous line in placed, and anesthetic was administered.  She was placed in a low anterior lithotomy position using Allen stirrups.  The vaginal portion of the procedure included placement of a ZUMI uterine manipulator with a Koh colpotomy ring and a vaginal occluder balloon.,The laparoscopic port sites were anesthetized with intradermal injection of 0.25% Marcaine.  There were five ports placed, including a 3-mm left subcostal port, a 10-mm umbilical port, a 10-mm suprapubic port, and 5-mm right and left lower quadrant ports.  The Veress needle was placed through a small incision at the base of the umbilicus, and a pneumoperitoneum was insufflated without difficulty.  The 3-mm port was then placed in the left subcostal position without difficulty, and a 3-mm scope was placed.  There were no adhesions underlying the previous vertical midline scar.  The 10-mm port was placed in the umbilicus, and the laparoscope was inserted.  Remaining ports were placed under direct laparoscopic guidance.  Washings were obtained from the pelvis, and the abdomen was explored with the laparoscope, with findings as noted.,Attention was then turned to lymphadenectomy.  An incision in the retroperitoneum was made over the right common iliac artery, extending up the aorta to the retroperitoneal duodenum.  The lymph node bundle was elevated from the aorta and the anterior vena cava until the retroperitoneal duodenum had been reached.  Pedicles were sealed and divided with bipolar cutting forceps.  Excellent hemostasis was noted.  Boundaries of dissection included the ureters laterally, common ileac arteries at uterine crossover inferiorly, and the retroperitoneal duodenum superiorly with careful preservation of the inferior mesenteric artery.  Right and left pelvic retroperitoneal spaces were then opened by incising lateral and parallel to the infundibulopelvic ligament with the bipolar cutting forceps.  The retroperitoneal space was then opened and the lymph nodes were dissected, with boundaries of dissection being the bifurcation of the common iliac artery superiorly, psoas muscle laterally, inguinal ligament inferiorly, and the anterior division of the hypogastric artery medially.  The posterior boundary was the obturator nerve, which was carefully identified and preserved bilaterally.  The left common iliac lymph node was elevated and removed using the same technique.,Attention was then turned to the laparoscopic hysterectomy.  The right infundibulopelvic ligament was divided using the bipolar cutting forceps.  The mesovarium was skeletonized.  A bladder flap was mobilized by dividing the round ligaments using the bipolar cutting forceps, and the peritoneum on the vesicouterine fold was incised to mobilize the bladder.  Once the Koh colpotomy ring was skeletonized and in position, the uterine arteries were sealed using the bipolar forceps at the level of the colpotomy ring.  The vagina was transected using a monopolar hook (or bipolar spatula), resulting in separation of the uterus and attached tubes and ovaries.  The uterus, tubes, and ovaries were then delivered through the vagina, and the pneumo-occluder balloon was reinserted to maintain pneumoperitoneum.  The vaginal vault was closed with interrupted figure-of-eight stitches of 0-Vicryl using the Endo-Stitch device.  The abdomen was irrigated, and excellent hemostasis was noted.,The insufflation pressure was reduced, and no evidence of bleeding was seen.  The suprapubic port was then removed, and the fascia was closed with a Carter-Thomason device and 0-Vicryl suture.  The remaining ports were removed under direct laparoscopic guidance, and the pneumoperitoneum was released.  The umbilical port was removed using laparoscopic guidance.  The umbilical fascia was closed with an interrupted figure-of-eight stitch using 2-0 Vicryl.  The skin was closed with interrupted subcuticular stitches using 4-0 Monocryl suture.  The final sponge, needle, and instrument counts were correct at the completion of the procedure.  The patient was awakened and taken to the post anesthesia care unit in stable condition.","surgery, endometrial carcinoma, laparoscopic hysterectomy, total laparoscopic hysterectomy, laparoscopic staging, lymphadenectomy, pelvic, obturator, lymph node dissection, direct laparoscopic guidance, tubes and ovaries, bipolar cutting forceps, node dissection, koh colpotomy, iliac artery, infundibulopelvic ligament, laparoscopic guidance, retroperitoneal duodenum, lymph node, laparoscopic, hysterectomy, endometrial, pneumoperitoneum, washings, vaginal, retroperitoneal, forceps, bipolar,"
" Laparoscopy.  An incision was made in the umbilicus, allowing us to insert a micro-laparoscopic trocar.  We then insufflated the abdomen with approximately 3 liters of carbon dioxide gas and inserted the micro-laparoscopic instrument.", Surgery, Laparoscopy - 2 ,,"surgery, umbilicus, trocar, falope, laparoscopy, abdomen, suprapubic, laparoscopicNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Laparoscopic lysis of adhesions, attempted laparoscopic pyeloplasty, and open laparoscopic pyeloplasty.  Right ureteropelvic junction obstruction, severe intraabdominal adhesions, and retroperitoneal fibrosis.", Surgery, Laparoscopic Pyeloplasty ,"PREOPERATIVE DIAGNOSIS:  ,Right ureteropelvic junction obstruction.,POSTOPERATIVE DIAGNOSES:,1.  Right ureteropelvic junction obstruction.,2.  Severe intraabdominal adhesions.,3.  Retroperitoneal fibrosis.,PROCEDURES PERFORMED:,1.  Laparoscopic lysis of adhesions.,2.  Attempted laparoscopic pyeloplasty.,3.  Open laparoscopic pyeloplasty.,ANESTHESIA:,  General.,INDICATION FOR PROCEDURE:  ,This is a 62-year-old female with a history of right ureteropelvic junction obstruction with chronic indwelling double-J ureteral stent.  The patient presents for laparoscopic pyeloplasty.,PROCEDURE: , After informed consent was obtained, the patient was taken to the operative suite and administered general anesthetic.  The patient was sterilely prepped and draped in the supine fashion after building up the right side of the OR table to aid in the patient's positioning for bowel retraction.  Hassan technique was performed for the initial trocar placement in the periumbilical region.  Abdominal insufflation was performed.  There were significant adhesions noted.  A second 12 mm port was placed in the right midclavicular line at the level of the umbilicus and a Harmonic scalpel was placed through this and adhesiolysis was performed for approximately two-and-half hours, also an additional port was placed 12 mm in the midline between the xiphoid process and the umbilicus, an additional 5 mm port in the right upper quadrant subcostal and midclavicular.  After adhesions were taken down, the ascending colon was mobilized by incising the white line of Toldt and mobilizing this medially.  The kidney was able to be palpated within Gerota's fascia.  The psoas muscle caudate to the inferior pole of the kidney was identified and the tissue overlying this was dissected to the level of the ureter.  The uterus was grasped with a Babcock through a trocar port and carried up to the level of the ureteropelvic junction obstruction.  The renal pelvis was also identified and dissected free.  There was significant fibrosis and scar tissue around the ureteropelvic junction obliterating the tissue planes.  We were unable to dissect through this mass of fibrotic tissue safely and therefore the decision was made to abort the laparoscopic procedure and perform the pyeloplasty open.  An incision was made from the right upper quadrant port extending towards the midline.  This was carried down through the subcutaneous tissue, anterior fascia, muscle layers, posterior fascia, and peritoneum.  A Bookwalter retractor was placed.  The renal pelvis and the ureter were again identified.  Fibrotic tissue was able to be dissected away at this time utilizing right angle clamps and Bovie cautery.  The tissue was sent down to Pathology for analysis.  Please note that upon entering the abdomen, all of the above which was taken down from the adhesions to the abdominal wall were carefully inspected and no evidence of bowel injury was noted.  Ureter was divided just distal to the ureteropelvic junction obstruction and stent was maintained in place.  The renal pelvis was then opened in a longitudinal manner and excessive pelvis was removed reducing the redundant tissue.  At this point, the indwelling double-J ureteral stent was removed.  At this time, the ureter was spatulated laterally and at the apex of this spatulation a #4-0 Vicryl suture was placed.  This was brought up to the deepened portion of the pyelotomy and cystic structures were approximated.  The back wall of the ureteropelvic anastomosis was then approximated with running #4-0 Vicryl suture.  At this point, a double-J stent was placed with a guidewire down into the bladder.  The anterior wall of the uteropelvic anastomosis was then closed again with a #4-0 running Vicryl suture.  Renal sinus fat was then placed around the anastomosis and sutured in place.  Please note in the inferior pole of the kidney, there was approximately 2 cm laceration which was identified during the dissection of the fibrotic tissue.  This was repaired with horizontal mattress sutures #2-0 Vicryl.  FloSeal was placed over this and the renal capsule was placed over this.  A good hemostasis was noted.  A #10 Blake drain was placed through one of the previous trocar sites and placed into the perirenal space away from the anastomosis.  The initial trocar incision was closed with #0 Vicryl suture.  The abdominal incision was also then closed with running #0 Vicryl suture incorporating all layers of muscle and fascia.  The Scarpa's fascia was then closed with interrupted #3-0 Vicryl suture.  The skin edges were then closed with staples.  Please note that all port sites were inspected prior to closing and hemostasis was noted at all sites and the fascia was noted to be reapproximated as these trocar sites were placed with the ________ obturator.  We placed the patient on IV antibiotics and pain medications.  We will obtain KUB and x-rays for stent placement.  Further recommendations to follow.","surgery, retroperitoneal, fibrosis, pyeloplasty, laparoscopic, lysis of adhesions, ureteropelvic junction obstruction, laparoscopic pyeloplasty, ureteropelvic junction, junction, ureteropelvic, intraabdominal, adhesions,"
" Morbid obesity.  Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis.  This is a 30-year-old female, who has been overweight for many years.  She has tried many different diets, but is unsuccessful. ", Surgery, Laparoscopic Gastric Bypass ,"PREOPERATIVE DIAGNOSIS: , Morbid obesity.,POSTOPERATIVE DIAGNOSIS:  ,Morbid obesity.,PROCEDURE: , Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis.,ANESTHESIA: , General with endotracheal intubation.,INDICATION FOR PROCEDURE: , This is a 30-year-old female, who has been overweight for many years.  She has tried many different diets, but is unsuccessful.  She has been to our Bariatric Surgery Seminar, received some handouts, and signed the consent.  The risks and benefits of the procedure have been explained to the patient.,PROCEDURE IN DETAIL:  ,The patient was taken to the operating room and placed supine on the operating room table.  All pressure points were carefully padded.  She was given general anesthesia with endotracheal intubation.  SCD stockings were placed on both legs.  Foley catheter was placed for bladder decompression.  The abdomen was then prepped and draped in standard sterile surgical fashion.  Marcaine was then injected through umbilicus.  A small incision was made.  A Veress needle was introduced into the abdomen.  CO2 insufflation was done to a maximum pressure of 15 mmHg.  A 12-mm VersaStep port was placed through the umbilicus.  I then placed a 5-mm port just anterior to the midaxillary line and just subcostal on the right side.  I placed another 5-mm port in the midclavicular line just subcostal on the right side, a few centimeters below and medial to that, I placed a 12-mm VersaStep port.  On the left side, just anterior to the midaxillary line and just subcostal, I placed a 5-mm port.  A few centimeters below and medial to that, I placed a 15-mm port.  I began by lifting up the omentum and identifying the transverse colon and lifting that up and thereby identifying my ligament of Treitz.  I ran the small bowel down approximately 40 cm and divided the small bowel with a white load GIA stapler.  I then divided the mesentery all the way down to the base of the mesentery with a LigaSure device.  I then ran the distal bowel down, approximately 100 cm, and at 100 cm, I made a hole at the antimesenteric portion of the Roux limb and a hole in the antimesenteric portion of the duodenogastric limb, and I passed a 45 white load stapler and fired a stapler creating a side-to-side anastomosis.  I reapproximated the edges of the defect.  I lifted it up and stapled across it with another white load stapler.  I then closed the mesenteric defect with interrupted Surgidac sutures.  I divided the omentum all the way down to the colon in order to create a passageway for my small bowel to go antecolic.  I then put the patient in reverse Trendelenburg.  I placed a liver retractor, identified, and dissected the angle of His.  I then dissected on the lesser curve, approximately 2.5 cm below the gastroesophageal junction, and got into a lesser space.  I fired transversely across the stomach with a 45 blue load stapler.  I then used two fires of the 60 blue load with SeamGuard to go up into my angle of His, thereby creating my gastric pouch.  I then made a hole at the base of the gastric pouch and had Anesthesia remove the bougie and place the OG tube connected to the anvil.  I pulled the anvil into place, and I then opened up my 15-mm port site and passed my EEA stapler.  I passed that in the end of my Roux limb and had the spike come out antimesenteric.  I joined the spike with the anvil and fired a stapler creating an end-to-side anastomosis, then divided across the redundant portion of my Roux limb with a white load GI stapler, and removed it with an Endocatch bag.  I put some additional 2-0 Vicryl sutures in the anastomosis for further security.  I then placed a bowel clamp across the bowel.  I went above and passed an EGD scope into the mouth down to the esophagus and into the gastric pouch.  I distended gastric pouch with air.  There was no air leak seen.  I could pass the scope easily through the anastomosis.  There was no bleeding seen through the scope.  We closed the 15-mm port site with interrupted 0 Vicryl suture utilizing Carter-Thomason.  I copiously irrigated out that incision with about 2 L of saline.  I then closed the skin of all incisions with running Monocryl.  Sponge, instrument, and needle counts were correct at the end of the case.  The patient tolerated the procedure well without any complications.","surgery, gastric bypass, eea anastomosis, roux-en-y, antegastric, antecolic, morbid obesity, roux limb, gastric pouch, intubation, laparoscopic, bypass, roux, endotracheal, anastomosis, gastric"
 Right hand-assisted laparoscopic cryoablation of renal lesions x2.  Lysis of adhesions and renal biopsy., Surgery, Laparoscopic Cryoablation ,"PREOPERATIVE DIAGNOSIS: , Bilateral renal mass.,POSTOPERATIVE DIAGNOSIS:,  Bilateral renal mass.,OPERATION: , Right hand-assisted laparoscopic cryoablation of renal lesions x2.  Lysis of adhesions and renal biopsy.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:,  100 Ml.,FLUIDS: , Crystalloid.,The patient was bowel prepped and was given preoperative antibiotics.,BRIEF HISTORY: , The patient is a 73-year-old male, who presented to us with a referral from Dr. X's office with bilateral renal mass and renal insufficiency.  The patient's baseline creatinine was around 1.6 to 1.7.  The patient was found to have a 3 to 4-cm exophytic right renal mass, 1-cm renal mass inferior to that, and about 2-cm left renal mass.  Since the patient had bilateral renal disease and the patient had renal insufficiency, the best option at this time had been cryoprocedure for the kidney versus partial nephrectomy, one kidney at a time.  The patient understood all his options, had done some research on cryotherapy and wanted to proceed with the procedure.  The patient had a renal biopsy done, which showed a possibility of an oncocytoma, which also would indicate that if this is not truly a cancerous lesion, but there is an associated risk of renal cell carcinoma that the patient will benefit from a cryo of the kidney.,Risk of anesthesia, bleeding, infection, pain, hernia, bowel obstruction, ileus, injury to bowel, postoperative bleeding, etc., were discussed.  The patient understood the risk of delayed bleeding, the needing for nephrectomy, renal failure, renal insufficiency, etc., and wanted to proceed with the procedure.,DETAILS OF THE OR:  ,The patient was brought to the OR.  Anesthesia was applied.  The patient was given preoperative antibiotics.  The patient was bowel prepped.  The patient was placed in right side up, left side down, semiflank, with kidney rest up.  All the pressure points are very well padded using foam and towels.  The left knee was bent and the right knee was straight.  There was no tension on any of the joints.  All pressure points were well padded.  The patient was taped to the table using 2-inch wide tape all the way around.  A Foley catheter and OG tube were in place prior to prepping and draping the patient.  A periumbilical incision measuring about 6 cm was made.  The incision was carried through the subcutaneous tissue through the fascia using sharp dissection.  The peritoneum was open.  Abdomen was entered.  There were some adhesions on the right side of the abdomen, which were released using metz.  Two 12-mm ports were placed in the anteroaxillary line and one in the midclavicular line.  A gel porter was placed.  Pneumoperitoneum was obtained.  All ports were placed under direct vision, and the right colon was reflected medially.  Duodenum was cauterized.  Minimal dissection was done on the hilum and the Gerota's was opened laterally, and the renal masses were clearly visualized all the way around.  Pictures were taken.  Superficial biopsies were taken of 2 renal lesions using 3 different probes.  The 2 lesions were frozen.  The 2 probes were 2.4 mm and the other one was 3.1 mm in diameter.  So the R3.8 and R2.4 long probes were used.  Freezing/thawing, two cycles were done.  The temperatures were -131, -137, -150 and the freezing time was 5 and 10 minutes each and passive sign was done.  The exact times or exact temperatures are on the chart.  There was a nice ice ball with each freezing and with passive sign.  The probes were removed.,The probes were placed directly percutaneously through the skin into the renal lesions.,After freezing/thawing, the probes were removed and to seal with Surgicel were placed.  Pictures were taken after following total of 20 minutes were spent looking at the renal mass to make sure that there was no delayed bleeding.  From the time the probes were removed, until the time the laparoscope was removed, was total of 30 minutes.  So the masses were visualized for a total of 30 minutes without any pneumoperitoneum.  Pneumoperitoneum was obtained again.  Fibrin glue was placed over it just for precautionary measure.  There was about a total of 100 mL of blood loss overall with the entire procedure.  Please note that towels were used to prep off the colon and the liver to ensure there was no freezing of any other organ.  The kidney was kept in the left hand at all times.  Careful attention was drawn to make sure that the probe was deep enough, at least 3.5 to 4 cm in, to get the medial aspect of the tumors frozen.  The laparoscopic vacuum ultrasound showed that there was complete resolution of these lesions.  At the end of the procedure, after freezing/thawing and putting the fibrin glue, Surgicel, and EndoSeal, the colon was reflected medially.  Please note that the perirenal fat was placed over the lesion to ensure that the frozen area of the kidney was not exposed to the bowel.  Lap count was correct.  Please note that renal biopsy for permanent section was performed on the superficial aspect of the lesions.  No deeper biopsies were done to minimize the risk of bleeding.  The 12-mm ports were closed using 0-Vicryl and the middle incision.  The hand-port incision was closed using looped #1 PDS from both sides and was tied in the middle.  Please note that the pneumoperitoneum was closed using 0-Vicryl in running fashion.  After closing the abdomen, 4-0 Monocryl was used to close the skin and Dermabond was applied.,The patient was brought to recovery in a stable condition.","surgery, hand-assisted laparoscopic cryoablation, laparoscopic, cryoablation, bilateral renal mass, fibrin glue, laparoscopic cryoablation, renal insufficiency, renal lesions, renal biopsy, renal mass, insufficiency, renal, freezing/thawing, lesions"
" Chronic cholecystitis, cholelithiasis, and liver cyst.  Laparoscopic cholecystectomy and excision of liver cyst.  Exploration of the abdomen revealed multiple adhesions of omentum overlying the posterior aspect of the gallbladder. ", Surgery, Laparoscopic Cholecystectomy & Liver Cyst Excision ,"PREOPERATIVE DIAGNOSES:,1.  Chronic cholecystitis.,2.  Cholelithiasis.,POSTOPERATIVE DIAGNOSES:,1.  Chronic cholecystitis.,2.  Cholelithiasis.,3.  Liver cyst.,PROCEDURES PERFORMED:,1.  Laparoscopic cholecystectomy.,2.  Excision of liver cyst.,ANESTHESIA:  ,General endotracheal and injectable 0.25% Marcaine with 1% lidocaine.,SPECIMENS: , Include,1.  Gallbladder.,2.  Liver cyst.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,OPERATIVE FINDINGS:,  Exploration of the abdomen revealed multiple adhesions of omentum overlying the posterior aspect of the gallbladder.  Additionally, there was a notable liver cyst.  The remainder of the abdomen remained free of any adhesions.,BRIEF HISTORY: , This is a 66-year-old Caucasian female who presented to ABCD General Hospital for an elective cholecystectomy.  The patient complained of intractable nausea, vomiting, and abdominal bloating after eating fatty foods.  She had had multiple attacks in the past of these complaints.  She was discovered to have had right upper quadrant pain on examination.  Additionally, she had an ultrasound performed on 08/04/2003, which revealed cholelithiasis.  The patient was recommended to undergo laparoscopic cholecystectomy for her recurrent symptoms.  She was explained the risks, benefits, and complications of the procedure and she gave informed consent to proceed.,OPERATIVE PROCEDURE:  ,The patient was brought to the operative suite and placed in the supine position.  The patient received preoperative antibiotics with Kefzol.  The abdomen was prepped and draped in the normal sterile fashion with Betadine solution.  The patient did undergo general endotracheal anesthesia.  Once the adequate sedation was achieved, a supraumbilical transverse incision was created with a #10 blade scalpel.  Utilizing a Veress needle, the Veress needle was inserted intra-abdominally and was hooked to the CO2 insufflation.  The abdomen was insufflated to 15 mmHg.  After adequate insufflation was achieved, the laparoscopic camera was inserted into the abdomen and to visualize a distended gallbladder as well as omental adhesion adjacent to the gallbladder.  Decision to proceed with laparoscopic cystectomy was decided.  A subxiphoid transverse incision was created with a #10 blade scalpel and utilizing a bladed 12 mm trocar, the trocar was inserted under direct visualization into the abdomen.  Two 5 mm ports were placed, one at the midclavicular line 2 cm below the costal margin and a second at the axillary line, one hand length approximately below the costal margin.  All ports were inserted with bladed 5 mm trocar then under direct visualization.  After all trocars were inserted, the gallbladder was grasped at the fundus and retracted superiorly and towards the left shoulder.  Adhesions adjacent were taken down with a Maryland dissector.  Once this was performed, the infundibulum of the gallbladder was grasped and retracted laterally and anteriorly.  This helped to better delineate the cystic duct as well as the cystic artery.  Utilizing Maryland dissector, careful dissection of the cystic duct and cystic artery were created posteriorly behind each one.  Utilizing Endoclips, clips were placed on the cystic duct and cystic artery, one proximal to the gallbladder and two distally.  Utilizing endoscissors, the cystic duct and cystic artery were ligated.  Next, utilizing electrocautery, the gallbladder was carefully dissected off the liver bed.  Electrocautery was used to stop any bleeding encountered along the way.  The gallbladder was punctured during dissection and cleared, biliary contents did drained into the abdomen.  No evidence of stones were visualized.  Once the gallbladder was completely excised from the liver bed, an EndoCatch was placed and the gallbladder was inserted into EndoCatch and removed from the subxiphoid port.  This was sent off as an specimen, a gallstone was identified within the gallbladder.  Next, utilizing copious amounts of irrigation, the abdomen was irrigated.  A small liver cyst that have been identified upon initial aspiration was grasped with a grasper and utilizing electrocautery was completely excised off the left lobe of the liver.  This was also taken and sent off as specimen.  The abdomen was then copiously irrigated until clear irrigation was identified.  All laparoscopic ports were removed under direct visualization.  The abdomen was de-insufflated.  Utilizing #0 Vicryl suture, the abdominal fascia was approximated with a figure-of-eight suture in the supraumbilical and subxiphoid region.  All incisions were then closed with #4-0 undyed Vicryl.  Two midline incisions were closed with a running subcuticular stitch and the lateral ports were closed with interrupted sutures.  The areas were cleaned and dried.  Steri-Strips were placed.  On the incisions, sterile dressing was applied.  The patient tolerated the procedure well.  She was extubated following procedure.  She is seen to tolerate the procedure well and she will follow up with Dr. X within one week for a follow-up evaluation.","surgery, excision of liver cyst, gallbladder, omentum, cystic artery, gallstone, laparoscopic cholecystectomy, cystic duct, liver cyst, liver, abdomen, electrocautery, cholelithiasis, cholecystectomy, adhesions, laparoscopic, cyst, cystic, "
" Morbid obesity.  Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy.", Surgery, Laparoscopic Gastric Bypass - 1 ,"PREOPERATIVE DIAGNOSIS: , Morbid obesity. ,POSTOPERATIVE DIAGNOSIS: , Morbid obesity. ,PROCEDURE:,  Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy. ,ANESTHESIA: , General with endotracheal intubation. ,INDICATIONS FOR PROCEDURE: , This is a 50-year-old male who has been overweight for many years and has tried multiple different weight loss diets and programs.  The patient has now begun to have comorbidities related to the obesity.  The patient has attended our bariatric seminar and met with our dietician and psychologist.  The patient has read through our comprehensive handout and understands the risks and benefits of bypass surgery as evidenced by the signing of our consent form.,PROCEDURE IN DETAIL: , The risks and benefits were explained to the patient.  Consent was obtained.  The patient was taken to the operating room and placed supine on the operating room table.  General anesthesia was administered with endotracheal intubation.  A Foley catheter was placed for bladder decompression.  All pressure points were carefully padded, and sequential compression devices were placed on the legs.  The abdomen was prepped and draped in standard, sterile, surgical fashion.  Marcaine was injected into the umbilicus.","surgery, morbid obesity, roux-en-y, gastric bypass, antecolic, antegastric, anastamosis, esophagogastroduodenoscopy, eea, surgidac sutures, roux limb, port, stapler, laparoscopic, intubation"
" Symptomatic cholelithiasis.  Laparoscopic cholecystectomy and appendectomy (CPT 47563, 44970).  The patient requested appendectomy because of the concern of future diagnostic dilemma with pain crisis.  Laparoscopic cholecystectomy and appendectomy were recommended to her. ", Surgery, Laparoscopic Cholecystectomy & Appendectomy ,"PREOPERATIVE DIAGNOSIS: , Symptomatic cholelithiasis.,POSTOPERATIVE DIAGNOSIS: , Symptomatic cholelithiasis.,PROCEDURE: , Laparoscopic cholecystectomy and appendectomy (CPT 47563, 44970).,ANESTHESIA: , General endotracheal.,INDICATIONS:  ,This is an 18-year-old girl with sickle cell anemia who has had symptomatic cholelithiasis.  She requested appendectomy because of the concern of future diagnostic dilemma with pain crisis.  Laparoscopic cholecystectomy and appendectomy were recommended to her.  The procedure was explained in detail including the risks of bleeding, infection, biliary injury, retained common duct stones.  After answering her questions, she wished to proceed and gave informed consent.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine on the operating table.  She was positively identified and the correct surgical site and procedure reviewed.  After successful administration of general endotracheal anesthesia, the skin of the abdomen was prepped with chlorhexidine solution and sterilely draped.,The infraumbilical skin was infiltrated with 0.25% bupivacaine with epinephrine and horizontal incision created.  The linea alba was grasped with a hemostat and Veress needle was placed into the peritoneal cavity and used to insufflate carbon dioxide gas to a pressure of 15 mmHg.  A 12-mm expandable disposable trocar was placed and through this a 30 degree laparoscope was used to inspect the peritoneal cavity.  Upper abdominal anatomy was normal.  Pelvic laparoscopy revealed bilaterally closed internal inguinal rings.  Additional trocars were placed under direct vision including a 5-mm reusable in the right lateral _____.  There was a 12-mm expandable disposable in the right upper quadrant and a 5-mm reusable in the subxiphoid region.  Using these, the gallbladder was grasped and retraced cephalad.  Adhesions were taken down over the cystic duct and the duct was circumferentially dissected and clipped at the gallbladder cystic duct junction.  A small ductotomy was created.  Reddick cholangiogram catheter was then placed within the duct and the balloon inflated.  Continuous fluoroscopy was used to instill contrast material.  This showed normal common bile duct which entered the duodenum without obstruction.  There was no evidence of common bile duct stones.  The cholangiogram catheter was removed.  The duct was doubly clipped and divided.  The artery was divided and cauterized.  The gallbladder was taken out of the gallbladder fossa.  It was then placed in Endocatch bag and left in the abdomen.  Attention was then paid to the appendix.  The appendix was identified and window was made in the mesoappendix at the base.  This was amputated with an Endo-GIA stapler.  The mesoappendix was divided with an Endo-GIA vascular stapler.  This was placed in another Endocatch bag.  The abdomen was then irrigated.  Hemostasis was satisfactory.  Both the appendix and gallbladder were removed and sent for pathology.  All trocars were removed.  The 12-mm port sites were closed with 2-0 PDS figure-of-eight fascial sutures.  The umbilical skin was reapproximated with interrupted 5-0 Vicryl Rapide.  The remaining skin incisions were closed with 5-0 Monocryl subcuticular suture.  The skin was cleaned.  Mastisol, Steri-Strips and band-aids were applied.  The patient was awakened, extubated in the operating room, transferred to the recovery room in stable condition.","surgery, endo-gia, endocatch bag, symptomatic cholelithiasis, laparoscopic cholecystectomy, appendectomy, cholangiogram, mesoappendix, abdomen, appendix, cholelithiasis, endotracheal, laparoscopic, cholecystectomy, gallbladder, duct "
 Laparoscopic cholecystectomy.  A 2 cm infraumbilical midline incision was made.  The fascia was then cleared of subcutaneous tissue using a tonsil clamp., Surgery, Laparoscopic Cholecystectomy - 9 ,"PROCEDURE PERFORMED: , Laparoscopic cholecystectomy.,PROCEDURE:  ,After informed consent was obtained, the patient was brought to the operating room and placed supine on the operating room table.  General endotracheal anesthesia was induced without incident.  The patient was prepped and draped in the usual sterile manner.,A 2 cm infraumbilical midline incision was made.  The fascia was then cleared of subcutaneous tissue using a tonsil clamp.  A 1-2 cm incision was then made in the fascia, gaining entry into the abdominal cavity without incident.  Two sutures of 0 Vicryl were then placed superiorly and inferiorly in the fascia, and then tied to the special 12 mm Hasson trocar fitted with a funnel-shaped adapter in order to occlude the fascial opening.  Pneumoperitoneum was then established using carbon dioxide insufflation to a steady pressure of 16 mmHg.,The remaining trocars were then placed into the abdomen under direct vision of the 30 degree laparoscope taking care to make the incisions along Langer's lines, spreading the subcutaneous tissues with a tonsil clamp, and confirming the entry site by depressing the abdominal wall prior to insertion of the trocar.  A total of 3 other trocars were placed.  The first was a 10/11 mm trocar in the upper midline position.  The second was a 5 mm trocar placed in the anterior iliac spine.  The third was a 5 mm trocar placed to bisect the distance between the second and upper midline trocars.  All of the trocars were placed without difficulty.,The patient was then placed in reverse Trendelenburg position and was rotated slightly to the left.  The gallbladder was then grasped through the second and third trocars and retracted cephalad toward the right shoulder.  A laparoscopic dissector was then placed through the upper midline cannula, fitted with a reducer, and the structures within the triangle of Calot were meticulously dissected free.,A laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic duct proximally and distally.  The duct was divided between the clips.  The clips were carefully placed to avoid occluding the juncture with the common bile duct.  The cystic artery was found medially and slightly posterior to the cystic duct.  It was carefully dissected free from its surrounding tissues.  A laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic artery proximally and distally.  The artery was divided between the clips.  The 2 midline port sites were injected with 5% Marcaine.,After the complete detachment of the gallbladder from the liver, the video laparoscope was removed and placed through the upper 10/11 mm cannula.  The neck of the gallbladder was grasped with a large penetrating forceps placed through the umbilical 12 mm Hasson cannula.  As the gallbladder was pulled through the umbilical fascial defect, the entire sheath and forceps were removed from the abdomen.  The neck of the gallbladder was removed from the abdomen.  Following gallbladder removal, the remaining carbon dioxide was expelled from the abdomen.,Both midline fascial defects were then approximated using 0 Vicryl suture.  All skin incisions were approximated with 4-0 Vicryl in a subcuticular fashion.  The skin was prepped with benzoin, and Steri-Strips were applied.  Dressings were applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition.","surgery, langer's lines, laparoscope, cystic duct, cystic artery, laparoscopic cholecystectomy, midline cannula, infraumbilical, tonsil, cholecystectomy, fascia, abdomen, trocars, cannula, laparoscopic, gallbladder, "
 Laparoscopic cholecystectomy with attempted intraoperative cholangiogram.  A 2 cm infraumbilical midline incision was made.  The fascia was then cleared of subcutaneous tissue using a tonsil clamp., Surgery, Laparoscopic Cholecystectomy & Cholangiogram - 1 ,"PROCEDURE PERFORMED:,  Laparoscopic cholecystectomy with attempted intraoperative cholangiogram.,PROCEDURE: , After informed consent was obtained, the patient was brought to the operating room and placed supine on the operating room table.  General endotracheal anesthesia was induced without incident.  The patient was prepped and draped in the usual sterile manner.,A 2 cm infraumbilical midline incision was made.  The fascia was then cleared of subcutaneous tissue using a tonsil clamp.  A 1-2 cm incision was then made in the fascia, gaining entry into the abdominal cavity without incident.  Two sutures of 0 Vicryl were then placed superiorly and inferiorly in the fascia, and then tied to the special 12 mm Hasson trocar fitted with a funnel-shaped adapter in order to occlude the fascial opening.  Pneumoperitoneum was then established using carbon dioxide insufflation to a steady pressure of 16 mmHg.,The remaining trocars were then placed into the abdomen under direct vision of the 30 degree laparoscope taking care to make the incisions along Langer's lines, spreading the subcutaneous tissues with a tonsil clamp, and confirming the entry site by depressing the abdominal wall prior to insertion of the trocar.  A total of 3 other trocars were placed.  The first was a 10/11 mm trocar in the upper midline position.  The second was a 5 mm trocar placed in the anterior axillary line approximately 3 cm above the anterior superior iliac spine.  The third was a 5 mm trocar placed to bisect the distance between the second and upper midline trocars.  All of the trocars were placed without difficulty.,The patient was then placed in reverse Trendelenburg position and was rotated slightly to the left.  The gallbladder was then grasped through the second and third trocars and retracted cephalad toward the right shoulder.  A laparoscopic dissector was then placed through the upper midline cannula, fitted with a reducer, and the structures within the triangle of Calot were meticulously dissected free.,A laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic duct close to the gallbladder.  The gallbladder was then grasped through the upper midline cannula and a fine-tipped scissors introduced through the third cannula and used to make a small ductotomy in the cystic duct near the clips.  Several attempts at passing the cholangiocatheter into the ductotomy were made.  Despite numerous attempts at several angles, the cholangiocatheter could not be inserted into the cystic duct.  After several such attempts, and due to the fact that the anatomy was clear, we aborted any further attempts at cholangiography.  The distal cystic duct was doubly clipped.  The duct was divided between the clips.  The clips were carefully placed to avoid occluding the juncture with the common bile duct.  The port sites were injected with 0.5% Marcaine.,The cystic artery was found medially and slightly posteriorly to the cystic duct.  It was carefully dissected free from its surrounding tissues.  A laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic artery proximally and distally.  The artery was divided between the clips.  The port sites were injected with 0.5% Marcaine.,After the cystic duct and artery were transected, the gallbladder was dissected from the liver bed using Bovie electrocautery.  Prior to complete dissection of the gallbladder from the liver, the peritoneal cavity was copiously irrigated with saline and the operative field was examined for persistent blood or bile leaks of which there were none.,After the complete detachment of the gallbladder from the liver, the video laparoscope was removed and placed through the upper 10/11 mm cannula.  The neck of the gallbladder was grasped with a large penetrating forceps placed through the umbilical 12 mm Hasson cannula.  As the gallbladder was pulled through the umbilical fascial defect, the entire sheath and forceps were removed from the abdomen.  The neck of the gallbladder was then secured with a Kocher clamp, and the gallbladder was removed from the abdomen.,Following gallbladder removal, the remaining carbon dioxide was expelled from the abdomen.,Both midline fascial defects were then approximated using 0 Vicryl suture.  All skin incisions were approximated with 4-0 Vicryl in a subcuticular fashion.  The skin was prepped with benzoin, and Steri-Strips were applied.  Dressings were applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition.","surgery, intraoperative cholangiogram, cystic artery, laparoscopic cholecystectomy, cystic duct, gallbladder, tonsil, cholecystectomy, cholangiogram, abdomen, laparoscopic, cannula,"
 Laparoscopic cholecystectomy with cholangiogram.  Acute gangrenous cholecystitis with cholelithiasis.  The patient had essentially a dead gallbladder with stones and positive wide bile/pus coming from the gallbladder., Surgery, Laparoscopic Cholecystectomy & Cholangiogram ,"PREOPERATIVE DIAGNOSIS:,  Acute cholecystitis.,POSTOPERATIVE DIAGNOSIS:,  Acute gangrenous cholecystitis with cholelithiasis.,OPERATION PERFORMED: , Laparoscopic cholecystectomy with cholangiogram.,FINDINGS:  ,The patient had essentially a dead gallbladder with stones and positive wide bile/pus coming from the gallbladder.,COMPLICATIONS:  ,None.,EBL: , Scant.,SPECIMEN REMOVED: , Gallbladder with stones.,DESCRIPTION OF PROCEDURE:  ,The patient was prepped and draped in the usual sterile fashion under general anesthesia.  A curvilinear incision was made below the umbilicus.  Through this incision, the camera port was able to be placed into the peritoneal cavity under direct visualization.  Once this complete, insufflation was begun.  Once insufflation was adequate, additional ports were placed in the epigastrium as well as right upper quadrant.  Once all four ports were placed, the right upper quadrant was then explored.  The patient had significant adhesions of omentum and colon to the liver, the gallbladder constituting definitely an acute cholecystitis.  This was taken down using Bovie cautery to free up visualization of the gallbladder.  The gallbladder was very thick and edematous and had frank necrosis of most of the anterior gallbladder wall.  Adhesions were further taken down between the omentum, the colon, and the gallbladder slowly starting superiorly and working inferiorly towards the cystic duct area.  Once the adhesions were fully removed, the cholangiogram was done which did not show any evidence of any common bile duct dilatation or obstruction.  At this point, due to the patient's gallbladder being very necrotic, it was deemed that the patient should have a drain placed.  The cystic duct and cystic artery were serially clipped and transected.  The gallbladder was removed from the gallbladder fossa removing the entire gallbladder.  Adequate hemostasis with Bovie cautery was achieved.  The gallbladder was then placed into a bag and removed from the peritoneal cavity through the camera port.  A JP drain was then run through the anterior port and out of one of the trochar sites and secured to the skin using 3-0 nylon suture.  Next, the right upper quadrant was copiously irrigated out using the suction irrigator.  Once this was complete, the additional ports were able to be removed.  The fascial opening at the umbilicus was reinforced by closing it using a 0 Vicryl suture in a figure-of-8 fashion.  All skin incisions were injected using Marcaine 1/4 percent plain.  The skin was reapproximated further using 4-0 Monocryl sutures in a subcuticular technique.  The patient tolerated the procedure well and was able to be transferred to the recovery room in stable condition.","surgery, acute cholecystitis, cholangiogram, cholelithiasis, cholecystitis, gallbladder, gangrenous cholecystitis, bovie cautery, cystic duct, laparoscopic cholecystectomy, laparoscopic, cholecystectomy, cystic, duct,"
 Cholecystitis and cholelithiasis.  Laparoscopic cholecystectomy and intraoperative cholangiogram.  The patient received 1 gm of IV Ancef intravenously piggyback.  The abdomen was prepared and draped in routine sterile fashion., Surgery, Laparoscopic Cholecystectomy - 7 ,"PREOPERATIVE DIAGNOSIS: , Cholecystitis and cholelithiasis.,POSTOPERATIVE DIAGNOSIS:  ,Cholecystitis and cholelithiasis.,TITLE OF PROCEDURE,1.  Laparoscopic cholecystectomy.,2.  Intraoperative cholangiogram.,ANESTHESIA:  ,General.,PROCEDURE IN DETAIL:  ,The patient was taken to the operative suite and placed in the supine position under general endotracheal anesthetic.  The patient received 1 gm of IV Ancef intravenously piggyback.  The abdomen was prepared and draped in routine sterile fashion.,A 1-cm incision was made at the umbilicus and a Veress needle was inserted.  Saline test was performed.  Satisfactory pneumoperitoneum was achieved by insufflation of CO2 to a pressure of 14 mmHg.  The Veress needle was removed.  A 10- to 11-mm cannula was inserted.  Inspection of the peritoneal cavity revealed a gallbladder that was soft and without adhesions to it.  It was largely mobile.  The liver had a normal appearance as did the peritoneal cavity.  A 5-mm cannula was inserted in the right upper quadrant anterior axillary line.  A second 5-mm cannula was inserted in the subcostal space.  A 10- to 11-mm cannula was inserted into the upper midline.,The gallbladder was reflected in a cephalad direction.  The gallbladder was punctured with the aspirating needle, and under C-arm fluoroscopy was filled with contrast, filling the intra- and extrahepatic biliary trees, which appeared normal.  Extra contrast was aspirated and the aspirating needle was removed.  The ampulla was grasped with a second grasper, opening the triangle of Calot.  The cystic duct was dissected and exposed at its junction with the ampulla, was controlled with a hemoclip, digitally controlled with two clips and divided.  This was done while the common duct was in full visualization.  The cystic artery was similarly controlled and divided.  The gallbladder was dissected from its bed and separated from the liver, brought to the outside through the upper midline cannula and removed.,The subhepatic and subphrenic spaces were irrigated thoroughly with saline solution.  There was oozing and bleeding from the lateral 5-mm cannula site, but this stopped spontaneously with removal of the cannula.  The subphrenic and subhepatic spaces were again irrigated thoroughly with saline until clear.  Hemostasis was excellent.  CO2 was evacuated and the camera removed.  The umbilical fascia was closed with 2-0 Vicryl, the subcu with 3-0 Vicryl, and the skin was closed with 4-0 nylon.  Sterile dressings were applied.  Sponge and needle counts were correct.","surgery, cholangiogram, cholecystitis, cholelithiasis, ancef, endotracheal, umbilicus, veress needle, c-arm fluoroscopy, intraoperative cholangiogram, laparoscopic cholecystectomy, laparoscopic, cholecystectomy, gallbladder, cannula,"
" Chronic cholecystitis.   Laparoscopic cholecystectomy.  Patient with increasingly severe more frequent right upper quadrant abdominal pain, more after meals, had a positive ultrasound for significant biliary sludge.", Surgery, Laparoscopic Cholecystectomy - 8 ,"PREOPERATIVE DIAGNOSIS: , Chronic cholecystitis.,POSTOPERATIVE DIAGNOSIS:  ,Chronic cholecystitis.,PROCEDURE PERFORMED:  ,Laparoscopic cholecystectomy.,BLOOD LOSS: , Minimal.,ANESTHESIA: , General endotracheal anesthesia.,COMPLICATIONS: , None.,CONDITION: , Stable.,DRAINS: , None.,DISPOSITION:  ,To recovery room and to home.,FLUIDS:  ,Crystalloid.,FINDINGS: , Consistent with chronic cholecystitis.  Final pathology is pending.,INDICATIONS FOR THE PROCEDURE:  ,Briefly, the patient is a 38-year-old male referred with increasingly severe more frequent right upper quadrant abdominal pain, more after meals, had a positive ultrasound for significant biliary sludge.  He presented now after informed consent for the above procedure.,PROCEDURE IN DETAIL:  ,The patient was identified in the preanesthesia area, then taken to the operating room, placed in the supine position on the operating table, and induced under general endotracheal anesthesia.  The patient was correctly positioned, padded at all pressure points, had antiembolic TED hose and Flowtrons in the lower extremities.  The anterior abdomen was then prepared and draped in a sterile fashion.  Preemptive local anesthetic was infiltrated with 1% lidocaine and 0.5% ropivacaine.  The initial incision was made sharply at the umbilicus with a #15-scalpel blade and carried down through deeper tissues with Bovie cautery, down to the midline fascia with a #15 scalpel blade.  The blunt-tipped Hasson introducer cannula was placed into the abdominal cavity under direct vision where it was insufflated using carbon dioxide gas to a pressure of 15 mmHg.  The epigastric and right subcostal trocars were placed under direct vision.  The right upper quadrant was well visualized.  The gallbladder was noted to be significantly distended with surrounding dense adhesions.  The fundus of the gallbladder was grasped and retracted anteriorly and superiorly, and the surrounding adhesions were then taken down off the gallbladder using a combination of the bullet-nose Bovie dissector and the blunt Kittner peanut dissector.  Further dissection allowed identification of the infundibulum and cystic duct junction where the cystic duct was identified and dissected out further using a right-angle clamp.  The cystic duct was clipped x3 and then divided.  The cystic artery was dissected out in like fashion, clipped x3, and then divided.  The gallbladder was then taken off the liver bed in a retrograde fashion using the hook-tip Bovie cautery with good hemostasis.  Prior to removal of the gallbladder, all irrigation fluid was clear.  No active bleeding or oozing was seen.  All clips were noted to be secured and intact and in place.  The gallbladder was placed in a specimen pouch after placing the camera in the epigastric port.  The gallbladder was retrieved through the umbilical fascial defect and submitted to Pathology.  The camera was placed back once again into the abdominal cavity through the umbilical port, and all areas remained clean and dry and the trocar was removed under direct visualization.  The insufflation was allowed to escape.  The umbilical fascia was closed using interrupted #1 Vicryl sutures.  Finally, the skin was closed in a layered subcuticular fashion with interrupted 3-0 and 4-0 Monocryl.  Sterile dressings were applied.  The patient tolerated the procedure well.,","surgery, abdomen, bovie cautery, endotracheal anesthesia, laparoscopic cholecystectomy, cystic duct, chronic cholecystitis, abdominal, laparoscopic, cholecystectomy, cholecystitis, gallbladder, "
" Cholelithiasis; possible choledocholithiasis.  Laparoscopic cholecystectomy and intraoperative cholangiogram.  A small incision was made in the umbilicus, and a Veress needle was introduced into the abdomen.  CO2 insufflation was done to a maximum pressure of 15 mmHg, and a 12-mm VersaStep port was placed into the umbilicus.", Surgery, Laparoscopic Cholecystectomy - 6 ,"PREOPERATIVE DIAGNOSIS:,  Cholelithiasis; possible choledocholithiasis.","surgery, choledocholithiasis, cholangiogram, co2 insufflation, umbilicus, common bile duct, bile duct, laparoscopic cholecystectomy, cystic duct, intraoperative, laparoscopic, cholecystectomy, cholelithiasis, endotracheal, gallbladder, cystic, duct"
" Laparoscopic cholecystectomy.  Biliary colic and biliary dyskinesia.  The patient had a workup for her gallbladder, which showed evidence of biliary dyskinesia.", Surgery, Laparoscopic Cholecystectomy - 10 ,"PREOPERATIVE DIAGNOSIS: , Biliary colic and biliary dyskinesia.,POSTOPERATIVE DIAGNOSIS:,  Biliary colic and biliary dyskinesia.,PROCEDURE PERFORMED:,  Laparoscopic cholecystectomy.,ANESTHESIA: , General endotracheal.,COMPLICATIONS:,  None.,DISPOSITION:  ,The patient tolerated the procedure well and was transferred to recovery in stable condition.,BRIEF HISTORY:  ,This patient is a 42-year-old female who presented to Dr. X's office with complaints of upper abdominal and back pain, which was sudden onset for couple of weeks.  The patient is also diabetic.  The patient had a workup for her gallbladder, which showed evidence of biliary dyskinesia.  The patient was then scheduled for laparoscopic cholecystectomy for biliary colic and biliary dyskinesia.,INTRAOPERATIVE FINDINGS: , The patient's abdomen was explored.  There was no evidence of any peritoneal studding or masses.  The abdomen was otherwise within normal limits.  The gallbladder was easily visualized.  There was an intrahepatic gallbladder.  There was no evidence of any inflammatory change.,PROCEDURE:,  After informed written consent, the risks and benefits of the procedure were explained to the patient.  The patient was brought into the operating suite.,After general endotracheal intubation, the patient was prepped and draped in normal sterile fashion.  Next, an infraumbilical incision was made with a #10 scalpel.  The skin was elevated with towel clips and a Veress needle was inserted.  The abdomen was then insufflated to 15 mmHg of pressure.  The Veress needle was removed and a #10 blade trocar was inserted without difficulty.  The laparoscope was then inserted through this #10 port and the abdomen was explored.  There was no evidence of any peritoneal studding.  The peritoneum was smooth.  The gallbladder was intrahepatic somewhat.  No evidence of any inflammatory change.  There were no other abnormalities noted in the abdomen.  Next, attention was made to placing the epigastric #10 port, which again was placed under direct visualization without difficulty.  The two #5 ports were placed, one in the midclavicular and one in the anterior axillary line again in similar fashion under direct visualization.  The gallbladder was then grasped out at its fundus, elevated to patient's left shoulder.  Using a curved dissector, the cystic duct was identified and freed up circumferentially.  Next, an Endoclip was used to distal and proximal to the gallbladder, Endoshears were used in between to transect the cystic duct.  The cystic artery was transected in similar fashion.  Attention was next made in removing the gallbladder from the liver bed using electrobovie cautery and spatulated tip.  It was done without difficulty.  The gallbladder was then grasped via the epigastric port and removed without difficulty and sent to pathology.  Hemostasis was maintained using electrobovie cautery.  The liver bed was then copiously irrigated and aspirated.  All the fluid and air was then aspirated and then all ports were removed under direct visualization.  The two #10 ports were then closed in the fascia with #0 Vicryl and a UR6 needle.  The skin was closed with a running subcuticular #4-0 undyed Vicryl.  0.25% Marcaine was injected and Steri-Strips and sterile dressings were applied.  The patient tolerated the procedure well and was transferred to Recovery in stable condition.","surgery, electrobovie cautery, laparoscopic cholecystectomy, biliary colic, biliary dyskinesia, biliary, laparoscopic, cholecystectomy, colic, abdomen, dyskinesia, gallbladder"
 Standard Laparoscopic Cholecystectomy Operative Note., Surgery, Laparoscopic Cholecystectomy ,"The patient's abdomen was prepped and draped in the usual sterile fashion.  A subumbilical skin incision was made.  The Veress needle was inserted, and the patient's abdominal cavity was insufflated with moderate pressure all times.  A subumbilical trocar was inserted.  The camera was inserted in the panoramic view.  The abdomen demonstrated some inflammation around the gallbladder.  A 10-mm midepigastric trocar was inserted.  A. 2 mm and 5 mm trocars were inserted.  The most lateral trocar grasping forceps was inserted and grasped the fundus of the gallbladder and placed in tension at liver edge.,Using the dissector, the cystic duct was identified and double Hemoclips were invited well away from the cystic-common duct junction.  The cystic artery was identified and double Hemoclips applied.  The gallbladder was taken down from the liver bed using Endoshears and electrocautery.  Hemostasis was obtained.  The gallbladder was removed from the midepigastric trocar site without difficulty.  The trocars were removed and the skin incisions were reapproximated using 4-0 Monocryl.  Steri-Strips and sterile dressing were placed.  The patient tolerated the procedure well and was taken to the recovery room in stable condition.","surgery, gallbladder, laparoscopic cholecystectomy, midepigastric trocar, double hemoclips, laparoscopic, cholecystectomy, midepigastric, trocars, hemoclips, trocarNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Biliary colic.   Laparoscopic cholecystectomy.  Laparoscopic examination showed no injury from entry.  Marcaine was then injected just subxiphoid, and a 5-mm port was placed under direct visualization for the laparoscope. ", Surgery, Laparoscopic Cholecystectomy - 5 ,"PREOPERATIVE DIAGNOSIS: , Biliary colic.","surgery, veress needle, gallbladder, laparoscope, laparoscopic examination, endotracheal intubation, laparoscopic cholecystectomy, biliary colic, abdomen, cholecystectomy, endotracheal, umbilicus, laparoscopic, "
 Acute cholecystitis.  Laparoscopic cholecystectomy.  The abdominal area was prepped and draped in the usual sterile fashion.  A small skin incision was made below the umbilicus.  It was carried down in the transverse direction on the side of her old incision.  It was carried down to the fascia., Surgery, Laparoscopic Cholecystectomy - 4 ,"PREOPERATIVE DIAGNOSIS: , Acute cholecystitis.,POSTOPERATIVE DIAGNOSIS:,  Acute cholecystitis.,PROCEDURE PERFORMED:,  Laparoscopic cholecystectomy.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS:,  Zero.,COMPLICATIONS: , None.,PROCEDURE:  ,The patient was taken to the operating room, and after obtaining adequate general anesthesia, the patient was placed in the supine position.  The abdominal area was prepped and draped in the usual sterile fashion.  A small skin incision was made below the umbilicus.  It was carried down in the transverse direction on the side of her old incision.  It was carried down to the fascia.  An open pneumoperitoneum was created with Hasson technique.  Three additional ports were placed in the usual fashion.  The gallbladder was found to be acutely inflamed, distended, and with some necrotic areas.  It was carefully retracted from the isthmus, and the cystic structure was then carefully identified, dissected, and divided between double clips.  The gallbladder was then taken down from the gallbladder fossa with electrocautery.  There was some bleeding from the gallbladder fossa that was meticulously controlled with a Bovie.  The gallbladder was then finally removed via the umbilical port with some difficulty because of the size of the gallbladder and size of the stones.  The fascia had to be opened.  The gallbladder had to be opened, and the stones had to be extracted carefully.  When it was completed, I went back to the abdomen and achieved complete hemostasis.  The ports were then removed under direct vision with the scope.  The fascia of the umbilical wound was closed with a figure-of-eight 0 Vicryl.  All the incisions were injected with 0.25% Marcaine, closed with 4-0 Monocryl, Steri-Strips, and sterile dressing.,The patient tolerated the procedure satisfactorily and was transferred to the recovery room in stable condition.","surgery, laparoscopic, cholecystectomy, cholecystitis, gallbladder fossa, laparoscopic cholecystectomy, acute cholecystitis, gallbladder"
 Chronic cholecystitis without cholelithiasis., Surgery, Laparoscopic Cholecystectomy - 3 ,"PREOPERATIVE DIAGNOSIS: , Chronic cholecystitis without cholelithiasis.,POSTOPERATIVE DIAGNOSIS:  ,Chronic cholecystitis without cholelithiasis.,PROCEDURE: , Laparoscopic cholecystectomy.,BRIEF DESCRIPTION: , The patient was brought to the operating room and anesthesia was induced.  The abdomen was prepped and draped and ports were placed.  The gallbladder was grasped and retracted.  The cystic duct and cystic artery were circumferentially dissected and a critical view was obtained.  The cystic duct and cystic artery were then doubly clipped and divided and the gallbladder was dissected off the liver bed with electrocautery and placed in an endo catch bag.  The gallbladder fossa and clips were examined and looked good with no evidence of bleeding or bile leak.  The ports were removed under direct vision with good hemostasis.  The Hasson was removed.  The abdomen was desufflated.  The gallbladder in its endo catch bag was removed.  The ports were closed.  The patient tolerated the procedure well.  Please see full hospital dictation.","surgery, chronic cholecystitis without cholelithiasis, laparoscopic cholecystectomy, cystic duct, cystic artery, endo catch, chronic cholecystitis, laparoscopic, cholecystectomy, abdomen, cholecystitis, cholelithiasis, gallbladder, cystic"
 Laparoscopic cholecystectomy due to chronic cholecystitis and cholelithiasis., Surgery, Laparoscopic Cholecystectomy - 2 ,"PREOPERATIVE DIAGNOSIS:,1.  Cholelithiasis.,2.  Chronic cholecystitis.,POSTOPERATIVE DIAGNOSIS:,1.  Cholelithiasis.,2.  Chronic cholecystitis.,NAME OF OPERATION: , Laparoscopic cholecystectomy.,ANESTHESIA:,  General.,FINDINGS:,  The gallbladder was thickened and showed evidence of chronic cholecystitis.  There was a great deal of inflammatory reaction around the cystic duct.  The cystic duct was slightly larger.  There was a stone impacted in the cystic duct with the gallbladder.  The gallbladder contained numerous stones which were small.  With the stone impacted in the cystic duct, it was felt that probably none were within the common duct.  Other than rather marked obesity, no other significant findings were noted on limited exploration of the abdomen.,PROCEDURE:,  Under general anesthesia after routine prepping and draping, the abdomen was insufflated with the Veress needle, and the standard four trocars were inserted uneventfully.  Inspection was made for any entry problems, and none were encountered.,After limited exploration, the gallbladder was then retracted superiorly and laterally, and the cystic duct was dissected out.  This was done with some difficulty due to the fibrosis around the cystic duct, but care was taken to avoid injury to the duct and to the common duct.  In this manner, the cystic duct and cystic artery were dissected out.  Care was taken to be sure that the duct that was identified went into the gallbladder and was the cystic duct.  The cystic duct and cystic artery were then doubly clipped and divided, taking care to avoid injury to the common duct.  The gallbladder was then dissected free from the gallbladder bed.  Again, the gallbladder was somewhat adherent to the gallbladder bed due to previous inflammatory reaction.  The gallbladder was dissected free from the gallbladder bed utilizing the endo shears and the cautery to control bleeding.  The gallbladder was extracted through the operating trocar site, and the trocar was reinserted.  Inspection was made of the gallbladder bed.  One or two bleeding areas were fulgurated, and bleeding was well controlled.","surgery, cholelithiasis chronic, inflammatory reaction, cystic artery, laparoscopic cholecystectomy, common duct, chronic cholecystitis, gallbladder bed, cystic duct, cystic, gallbladder, duct, inflammatory"
 Laparoscopic cholecystectomy., Surgery, Laparoscopic Cholecystectomy - 1 ,"PROCEDURE:,:  After informed consent was obtained, the patient was brought to the operating room and placed supine on the operating room table.  General endotracheal anesthesia was induced.  The patient was then prepped and draped in the usual sterile fashion.  An #11 blade scalpel was used to make a small infraumbilical skin incision in the midline.  The fascia was elevated between two Ochsner clamps and then incised.  A figure-of-eight stitch of 2-0 Vicryl was placed through the fascial edges.  The 11-mm port without the trocar engaged was then placed into the abdomen.  A pneumoperitoneum was established.  After an adequate pneumoperitoneum had been established, the laparoscope was inserted.  Three additional ports were placed all under direct vision.  An 11-mm port was placed in the epigastric area.  Two 5-mm ports were placed in the right upper quadrant.  The patient was placed in reverse Trendelenburg position and slightly rotated to the left.  The fundus of the gallbladder was retracted superiorly and laterally.  The infundibulum was retracted inferiorly and laterally.  Electrocautery was used to carefully begin dissection of the peritoneum down around the base of the gallbladder.  The triangle of Calot was carefully opened up.  The cystic duct was identified heading up into the base of the gallbladder.  The cystic artery was also identified within the triangle of Calot.  After the triangle of Calot had been carefully dissected, a clip was then placed high up on the cystic duct near its junction with the gallbladder.  The cystic artery was clipped twice proximally and once distally.  Scissors were then introduced and used to make a small ductotomy in the cystic duct, and the cystic artery was divided.  An intraoperative cholangiogram was obtained.  This revealed good flow through the cystic duct and into the common bile duct.  There was good flow into the duodenum without any filling defects.  The hepatic radicals were clearly visualized.  The cholangiocatheter was removed, and two clips were then placed distal to the ductotomy on the cystic duct.  The cystic duct was then divided using scissors.  The gallbladder was then removed up away from the liver bed using electrocautery.  The gallbladder was easily removed through the epigastric port site.  The liver bed was then irrigated and suctioned.  All dissection areas were inspected.  They were hemostatic.  There was not any bile leakage.  All clips were in place.  The right gutter up over the edge of the liver was likewise irrigated and suctioned until dry.  All ports were then removed under direct vision.  The abdominal cavity was allowed to deflate.  The fascia at the epigastric port site was closed with a stitch of 2-0 Vicryl.  The fascia at the umbilical port was closed by tying the previously placed stitch.  All skin incisions were then closed with subcuticular sutures of 4-0 Monocryl and 0.25% Marcaine with epinephrine was infiltrated into all port sites.  The patient tolerated the procedure well.  The patient is currently being aroused from general endotracheal anesthesia.  I was present during the entire case.","surgery, laparoscopic, calot, ochsner clamps, additional ports, cholangiogram, cholecystectomy, cystic duct, duodenum, epigastric, fascia, gallbladder, infraumbilical skin incision, infundibulum, pneumoperitoneum, triangle of calot, laparoscopic cholecystectomy, liver bed, epigastric port, port site, cystic artery, triangle, port, duct, cysticNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Appendicitis.  Laparoscopic appendectomy. Infraumbilical incision was performed and taken down to the fascia.  The fascia was incised.  The peritoneal cavity was carefully entered.  Two other ports were placed in the right and left lower quadrants., Surgery, Laparoscopic Appendectomy - 2 ,"PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS:,  Appendicitis.,PROCEDURE PERFORMED: , Laparoscopic appendectomy.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  Minimal.,PROCEDURE IN DETAIL: , The patient was prepped and draped in sterile fashion.  Infraumbilical incision was performed and taken down to the fascia.  The fascia was incised.  The peritoneal cavity was carefully entered.  Two other ports were placed in the right and left lower quadrants.  The appendix was readily identified, and the base of the appendix as well as the mesoappendix was divided with the Endo GIA stapler and brought out through the umbilical wound with the Endocatch bag.,All hemostasis was further reconfirmed.  No leakage of enteral contents was noted.  All trocars were removed under direct visualization.  The umbilical fascia was closed with interrupted 0 Vicryl sutures.  The skin was closed with 4-0 Monocryl subcuticular stitch and dressed with Steri-Strips and 4 x 4's.  The patient was extubated and taken to the recovery area in stable condition.  The patient tolerated the procedure well.","surgery, mesoappendix, endocatch, laparoscopic appendectomy, appendix, umbilical, laparoscopic, appendectomy, appendicitis, fascia, infraumbilical"
" Dilatation and curettage (D&C) and Laparoscopic ablation of endometrial implants.  Pelvic pain, hypermenorrhea, and mild pelvic endometriosis.", Surgery, Laparoscopic Ablation of Eendometrial Implants ,"PREOPERATIVE DIAGNOSES:,1.  Pelvic pain.,2.  Hypermenorrhea.,POSTOPERATIVE DIAGNOSES:,1.  Pelvic pain.,2.  Hypermenorrhea.,3.  Mild pelvic endometriosis.,PROCEDURE PERFORMED:,1.  Dilatation and curettage (D&C).,2.  Laparoscopic ablation of endometrial implants.,ANESTHESIA:  ,General endotracheal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,SPECIMEN: , Endometrial curettings.,INDICATIONS: , This is a 26-year-old female with a history of approximately one year of heavy painful menses.  She did complain of some dyspareunia and wants a definitive diagnosis.,FINDINGS: , On bimanual exam, the uterus is small and anteverted with mildly decreased mobility on the left side.  There are no adnexal masses appreciated.  On laparoscopic exam, the uterus is normal appearing but slightly compressible.  The bilateral tubes and ovaries appear normal.  There is evidence of endometriosis on the left pelvic sidewall in the posterior cul-de-sac.  There was no endometriosis in the right pelvic sidewall or along the bladder flap.,There were some adhesions on the right abdominal sidewall from the previous appendectomy.  The liver margin, gallbladder, and bowel appeared normal.  The uterus was sounded to 9 cm.,PROCEDURE: , After consent was obtained, the patient was taken to the operating room and general anesthetic was administered.  The patient was placed in dorsal lithotomy position and prepped and draped in normal sterile fashion.  Sterile speculum was placed in the patient's vagina.  The anterior lip of the cervix was grasped with vulsellum tenaculum.  The uterus was sounded to 9 cm.  The cervix was then serially dilated with Hank dilators.  A sharp curettage was performed until a gritty texture was noted in all aspects of the endometrium.  The moderate amount of tissue that was obtained was sent to Pathology.  The #20 Hank dilator was then replaced and the sterile speculum was removed.  Gloves were changed and attention was then turned to the abdomen where approximately 10 mm transverse infraumbilical incision was made.  The Veress needle was placed into this incision and the gas was turned on.  When good flow and low abdominal pressures were noted, the gas was turned up and the abdomen was allowed to insufflate.  The #11 mm trocar was then placed through this incision and a camera was placed with the above findings noted.  A Bierman needle was placed 2 cm superior to the pubic bone and along the midline to allow a better visualization of the pelvic organs.  A 5 mm port was placed approximately 7 cm to 8 cm to the right of the umbilicus and approximately 3 cm inferior.  The harmonic scalpel was placed through this port and the areas of endometriosis were ablated using the harmonic scalpel.  A syringe was placed on to the Bierman needle and a small amount of fluid in the posterior cul-de-sac was removed to allow better visualization of the posterior cul-de-sac.  The lesions in the posterior cul-de-sac were then ablated using the Harmonic scalpel.  All instruments were then removed.  The Bierman needle and 5 mm port was removed under direct visualization with excellent hemostasis noted.  The camera was removed and the abdomen was allowed to desufflate.  The 11 mm trocar introducer was replaced and the trocar was removed.  The skin was closed with #4-0 undyed Vicryl in subcuticular fashion.  ,Approximately 10 cc of 0.25% Marcaine was placed in the incision sites.  The dilator and vulsellum tenaculum were removed from the patient's cervix with excellent hemostasis noted.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct at the end of procedure.  The patient was taken to the recovery room in satisfactory condition.  She will be discharged home with a prescription for Darvocet for pain and is instructed to follow up in the office in two weeks with further treatment will be discussed including approximately six months of continuous monophasic oral contraceptives.","surgery, pelvic pain, hypermenorrhea, endometriosis, dilatation and curettage, d&c, endometrial implants, ablation, cul de sac, vulsellum tenaculum, hank dilators, laparoscopic ablation, bierman needle, pelvic, "
 Laparoscopic appendectomy.  The patient is a 42-year-old female who presented with right lower quadrant pain.  She was evaluated and found to have a CT evidence of appendicitis., Surgery, Laparoscopic Appendectomy - 5 ,"PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS: , Appendicitis.,PROCEDURE PERFORMED: , Laparoscopic appendectomy.,ANESTHESIA: , General endotracheal.,INDICATION FOR OPERATION: , The patient is a 42-year-old female who presented with right lower quadrant pain.  She was evaluated and found to have a CT evidence of appendicitis.  She was subsequently consented for a laparoscopic appendectomy.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained, the patient was brought to the operating room, placed supine on the table.  The abdomen was prepared and draped in usual sterile fashion.  After the induction of satisfactory general endotracheal anesthesia, supraumbilical incision was made.  A Veress needle was inserted.  Abdomen was insufflated to 15 mmHg.  A 5-mm port and camera placed.  The abdomen was visually explored.  There were no obvious abnormalities.  A 15-mm port was placed in the suprapubic position in addition of 5 mm was placed in between the 1st two.  Blunt dissection was used to isolate the appendix.  Appendix was separated from surrounding structures.  A window was created between the appendix and the mesoappendix.  GIA stapler was tossed across it and fired.  Mesoappendix was then taken with 2 fires of the vascular load on the GIA stapler.  Appendix was placed in an Endobag and removed from the patient.  Right lower quadrant was copiously irrigated.  All irrigation fluids were removed.  Hemostasis was verified.  The 15-mm port was removed and the port site closed with 0-Vicryl in the Endoclose device.  All other ports were irrigated, infiltrated with 0.25% Marcaine and closed with 4-0 Vicryl subcuticular sutures.  Steri-Strips and sterile dressings were applied.  Overall, the patient tolerated this well, was awakened and returned to recovery in good condition.","surgery, gia stapler, laparoscopic appendectomy, appendectomy, endotracheal, mesoappendix, laparoscopic, appendicitis, appendix"
" Laparoscopic lysis of adhesions and Laparoscopic left adrenalectomy.  Left adrenal mass, 5.5 cm and intraabdominal adhesions.", Surgery, Laparoscopic Adrenalectomy ,"PREOPERATIVE DIAGNOSIS: , Left adrenal mass, 5.5 cm.,POSTOPERATIVE DIAGNOSES:,1.  Left adrenal mass, 5.5 cm.,2.  Intraabdominal adhesions.,PROCEDURE PERFORMED:,1.  Laparoscopic lysis of adhesions.,2.  Laparoscopic left adrenalectomy.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS:,  Less than 100 cc.,FLUIDS: , 3500 cc crystalloids.,DRAINS:,  None.,DISPOSITION:,  The patient was taken to recovery room in stable condition.  Sponge, needle, and instrument counts were correct per OR staff.,HISTORY:,  This is a 57-year-old female who was found to have a large left adrenal mass, approximately 5.5 cm in size.  She had undergone workup previously with my associate, Dr. X as well as by Endocrinology, and showed this to be a nonfunctioning mass.  Due to the size, the patient was advised to undergo an adrenalectomy and she chose the laparoscopic approach due to her multiple pulmonary comorbidities.,INTRAOPERATIVE FINDINGS: , Showed multiple intraabdominal adhesions in the anterior abdominal wall.  The spleen and liver were unremarkable.  The gallbladder was surgically absent.,There was large amount of omentum and bowel in the pelvis, therefore the gynecological organs were not visualized.  There was no evidence of peritoneal studding or masses.  The stomach was well decompressed as well as the bladder.,PROCEDURE DETAILS: , After informed consent was obtained from the patient, she was taken to the operating room and given general anesthesia.  She was placed on a bean bag and secured to the table.  The table was rotated to the right to allow gravity to aid in our retraction of the bowel.,Prep was performed.  Sterile drapes were applied.  Using the Hassan technique, we placed a primary laparoscopy port approximately 3 cm lateral to the umbilicus on the left.  Laparoscopy was performed with ___________.  At this point, we had a second trocar, which was 10 mm to 11 mm port.  Using the non-cutting trocar in the anterior axillary line and using Harmonic scalpel, we did massive lysis of adhesions from the anterior abdominal wall from the length of the prior abdominal incision, the entire length of the abdominal incision from the xiphoid process to the umbilicus.  The adhesions were taken down off the entire anterior abdominal wall.,At this point, secondary and tertiary ports were placed.  We had one near the midline in the subcostal region and to the left midline and one at the midclavicular line, which were also 10 and 11 ports using a non-cutting blade.,At this point, using the Harmonic scalpel, we opened the white line of Toldt on the left and reflected the colon medially, off the anterior aspect of the Gerota's fascia.  Blunt and sharp dissection was used to isolate the upper pole of the kidney, taking down some adhesions from the spleen.  The colon was further mobilized medially again using gravity to aid in our retraction.  After isolating the upper pole of the kidney using blunt and sharp dissection as well as the Harmonic scalpel, we were able to dissect the plane between the upper pole of the kidney and lower aspect of the adrenal gland.  We were able to isolate the adrenal vein, dumping into the renal vein, this was doubly clipped and transected.  There was also noted to be vascular structure of the upper pole, which was also doubly clipped and transected.  Using the Harmonic scalpel, we were able to continue free the remainder of the adrenal glands from its attachments medially, posteriorly, cephalad, and laterally.,At this point, using the EndoCatch bag, we removed the adrenal gland through the primary port in the periumbilical region and sent the flap for analysis.  Repeat laparoscopy showed no additional findings.  The bowel was unremarkable, no evidence of bowel injury, no evidence of any bleeding from the operative site.,The operative site was irrigated copiously with saline and reinspected and again there was no evidence of bleeding.  The abdominal cavity was desufflated and was reinspected.  There was no evidence of bleeding.,At this point, the camera was switched to one of the subcostal ports and the primary port in the periumbilical region was closed under direct vision using #0 Vicryl suture.  At this point, each of the other ports were removed and then with palpation of each of these ports, this indicated that the non-cutting ports did close and there was no evidence of fascial defects.,At this point, the procedure was terminated.  The abdominal cavity was desufflated as stated.  The patient was sent to Recovery in stable condition.  Postoperative orders were written.  The procedure was discussed with the patient's family at length.",
" Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots.  Right L4-L5 and right L5-S1 laminotomies, medial facetectomies, and foraminotomies, decompression of right L5 and S1 nerve roots.  Right L4-S1 posterolateral fusion with local bone graft.  Left L4 through S1 segmental pedicle screw instrumentation.  Preparation harvesting of local bone graft.", Surgery," Laminotomy, Facetectomy & Foraminotomy ","PREOPERATIVE DIAGNOSES: , Right lumbosacral radiculopathy secondary to lumbar spondylolysis.,POSTOPERATIVE DIAGNOSES: , Right lumbosacral radiculopathy secondary to lumbar spondylolysis.,OPERATION PERFORMED:,1.  Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots.,2.  Right L4-L5 and right L5-S1 laminotomies, medial facetectomies, and foraminotomies, decompression of right L5 and S1 nerve roots.,3.  Right L4-S1 posterolateral fusion with local bone graft.,4.  Left L4 through S1 segmental pedicle screw instrumentation.,5.  Preparation harvesting of local bone graft.,ANESTHESIA: , General endotracheal.,PREPARATION:,  Povidone-iodine.,INDICATION: , This is a gentleman with right-sided lumbosacral radiculopathy, MRI disclosed and lateral recess stenosis at the L4-5, L5-S1 foraminal narrowing in L4 and L5 roots.  The patient was felt to be a candidate for decompression stabilization pulling distraction between the screws to relieve radicular pain.  The patient understood major risks and complications such as death and paralysis seemingly rare, main concern is a 10 to 15% of failure rate to respond to surgery for which further surgery may or may not be indicated, small risk of wound infection, spinal fluid leak.  The patient is understanding and agreed to proceed and signed the consent.,PROCEDURE: , The patient was brought to the operating room, peripheral venous lines were placed.  General anesthesia was induced.  The patient was intubated.  Foley catheter was in place.  The patient laid prone onto the OSI table using 6-post, pressure points were carefully padded; the back was shaved, sterilely prepped and draped.  A previous incision was infiltrated with local and incised with a scalpel.  The posterior spine on the right side was exposed in routine fashion along with transverse processes in L4-L5 in the sacral ala.  Laminotomies were then performed at L4-L5 and L5-S1 in a similar fashion using Midas Rex drill with AM8 bit, inferior portion of lamina below and superior portion of lamina above, and the medial facet was drilled down to the thin shelf of bone.  The thin shelf of bone along the ligamentum flavum moved in a piecemeal fashion with 2 and 3 mm Kerrison, bone was harvested throughout to be used for bone grafting.  The L5 and S1 roots were completely unroofed in the lateral recess working lateral to the markedly hypertrophied facet joints.  Transpedicular approaches were carried out for both L4 and L5 roots working lateral to medial and medial to lateral with foraminotomies, L4-L5 roots were extensively decompressed.  Pars interarticularis were maintained.  Using angled 2-mm Kerrisons hypertrophied ligamentum flavum, the superior facet of S1 and L5 was resected increasing the dimensions for the foramen passed lateral to medial and medial to lateral without further compromise.  Pedicle screws were placed L4-L5 and S1 on the right side.  Initial hole began with Midas Rex drill, deepened with a gear shift and with 4.5 mm tap, palpating with pedicle probe.  It showed no penetration outside the pedicle vertebral body.  At L4-L5 5.5 x 45 mm screws were placed and at S1 5.5 x 40 mm screw was placed.  Good bone purchase was obtained.  Gelfoam was placed over the roots laterally, corticated transverse processes lateral facet joints were prepared, small infuse sponge was placed posterolaterally on the right side, then the local bone graft from L4 to S1.  Traction was applied between the L4-L5, L5-S1 screws locking notes were tightened out, heads were rotated fractured off about 2-3 mm traction were applied at each side, further opening the foramen for the exiting roots.  Prior to placement of BMP, the wound was irrigated with antibiotic irrigation.  Medium Hemovac drain was placed in the depth of wound, brought out through a separate stab incision.  Deep fascia was closed with #1 Vicryl, subcutaneous fascia with #1 Vicryl, and subcuticular with 2-0 Vicryl.  Skin was stapled.  The drain was sutured in place with 2-0 Vicryl and connected to closed drain system.  The patient was laid supine on the bed, extubated, and taken to recovery room in satisfactory condition.  The patient tolerated the procedure well without apparent complication.  Final sponge and needle counts are correct.  Estimated blood loss 600 mL.,The patient received 200 mL of cell saver blood back.","surgery, lumbosacral radiculopathy, lumbar spondylolysis, laminotomies, medial facetectomies, foraminotomies, decompression, nerve roots, fusion, bone graft, segmental, pedicle screw, transverse processes, bone, facetectomies, transpedicular, graft, pedicle"
 Ruptured appendicitis., Surgery, Laparoscopic Appendectomy - 1 ,"PREOPERATIVE DIAGNOSIS:,  Acute appendicitis.,POSTOPERATIVE DIAGNOSIS:,  Ruptured appendicitis.,PROCEDURE:,  Laparoscopic appendectomy.,INDICATIONS FOR PROCEDURE:,  This patient is a 4-year-old boy with less than 24-hour history of apparent right lower quadrant abdominal pain associated with vomiting and fevers.  The patient has elevated white count on exam and CT scan consistent with acute appendicitis.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine, put under general endotracheal anesthesia.  The patient's abdomen was prepped and draped in usual sterile fashion.  A periumbilical incision was made.  The fascia was incised.  Peritoneal cavity entered bluntly.  A 10-mm trocar and scope was passed.  Peritoneal cavity was insufflated.  Five-mm ports placed in left lower and hypogastric areas.  On visualization of the right lower quadrant, appendix was visualized stuck against the right anterior abdominal wall, there is obvious site of perforation and leakage of content and pus.  We proceeded to take the mesoappendix down to the base, and once the base was free, we placed GIA stapler across the base, fired the stapler, removed the appendix through the periumbilical port site.  We irrigated and suctioned out the right lower and pelvic areas.  We then removed the ports under direct visualization, closed the periumbilical port site fascia with 0 Vicryl, all skin incisions with 5-0 Monocryl, and dressed with Steri-Strips.  The patient was extubated in the operating table and taken back to recovery room.  The patient tolerated the procedure well.","surgery, ruptured appendicitis, acute appendicitis, laparoscopic appendectomy, laparoscopic, ruptured, abdominal, peritoneal, periumbilical, appendicitis, appendectomy, "
 Laparoscopic appendectomy.  Acute appendicitis., Surgery, Laparoscopic Appendectomy ,"PREOPERATIVE DIAGNOSIS: , Acute appendicitis.,POSTOPERATIVE DIAGNOSIS: , Acute appendicitis.,OPERATIVE PROCEDURE:,  Laparoscopic appendectomy.,INTRAOPERATIVE FINDINGS: , Include inflamed, non-perforated appendix.,OPERATIVE NOTE:  ,The patient was seen by me in the preoperative holding area.  The risks of the procedure were explained.  She was taken to the operating room and given perioperative antibiotics prior to coming to the surgery.  General anesthesia was carried out without difficulty and a Foley catheter was inserted.  The left arm was tucked and the abdomen was prepped with Betadine and draped in sterile fashion.  A 5-mm blunt port was inserted infra-umbilically at the level of the umbilicus under direct vision of a 5-mm 0-degree laparoscope.  Once we were inside the abdominal cavity, CO2 was instilled to attain an adequate pneumoperitoneum.  A left lower quadrant 5-mm port was placed under direct vision and a 12-mm port in the suprapubic region.  The 5-mm scope was introduced at the umbilical port and the appendix was easily visualized.  The base of the cecum was acutely inflamed but not perforated.  I then was easily able to grasp the mesoappendix and create a window between the base of the mesoappendix and the base of the appendix.  The window is big enough to get an Endo GIA blue cartridge through it and fired across the base of the mesoappendix without difficulty.  I reloaded with a red vascular cartridge, came across the mesoappendix without difficulty.  I then placed the appendix in an Endobag and brought out through the suprapubic port without difficulty.  I reinserted the suprapubic port and irrigated out the right lower quadrant until dry.  One final inspection revealed no bleeding from the staple line.  We then removed all ports under direct vision, and there was no bleeding from the abdominal trocar sites.  The pneumoperitoneum was then deflated and the suprapubic fascial defect was closed with 0-Vicryl suture.  The skin incision was injected with 0.25% Marcaine and closed with 4-0 Monocryl suture.  Steri-strips and sterile dressings were applied.  No complications.  Minimal blood loss.  Specimen is the appendix.  Brought to the recovery room in stable condition.","surgery, appendix, endobag, laparoscopic appendectomy, acute appendicitis, appendectomy, umbilically, abdominal, pneumoperitoneum, laparoscopic, appendicitis, suprapubic, mesoappendix, "
" Microscopic-assisted revision of bilateral decompressive lumbar laminectomies and foraminotomies at the levels of L3-L4, L4-L5, and L5-S1.  Posterior spinal fusion at the level of L4-L5 and L5-S1 utilizing local bone graft, allograft and segmental instrumentation.  Posterior lumbar interbody arthrodesis utilizing cage instrumentation at L4-L5 with local bone graft and allograft.  All procedures were performed under SSEP, EMG, and neurophysiologic monitoring.", Surgery, Laminectomy & Foraminotomy Revision ,"PREOPERATIVE DIAGNOSES:,1.  Recurrent spinal stenosis at L3-L4, L4-L5, and L5-S1.,2.  Spondylolisthesis, which is unstable at L4-L5.,3.  Recurrent herniated nucleus pulposus at L4-L5 bilaterally.,POSTOPERATIVE DIAGNOSES:,1.  Recurrent spinal stenosis at L3-L4, L4-L5, and L5-S1.,2.  Spondylolisthesis, which is unstable at L4-L5.,3.  Recurrent herniated nucleus pulposus at L4-L5 bilaterally.,PROCEDURE PERFORMED:,1.  Microscopic-assisted revision of bilateral decompressive lumbar laminectomies and foraminotomies at the levels of L3-L4, L4-L5, and L5-S1.,2.  Posterior spinal fusion at the level of L4-L5 and L5-S1 utilizing local bone graft, allograft and segmental instrumentation.,3.  Posterior lumbar interbody arthrodesis utilizing cage instrumentation at L4-L5 with local bone graft and allograft.  All procedures were performed under SSEP, EMG, and neurophysiologic monitoring.,ANESTHESIA: , General via endotracheal tube.,ESTIMATED BLOOD LOSS:  ,Approximately 1000 cc.,CELL SAVER RETURNED:  ,Approximately 550 cc.,SPECIMENS: , None.,COMPLICATIONS: , None.,DRAIN: , 8-inch Hemovac.,SURGICAL INDICATIONS: , The patient is a 59-year-old male who had severe disabling low back pain.  He had previous lumbar laminectomy at L4-L5.  He was noted to have an isthmic spondylolisthesis.,Previous lumbar laminectomy exacerbated this condition and made it further unstable.  He is suffering from neurogenic claudication.  He was unresponsive to extensive conservative treatment.  He has understanding of the risks, benefits, potential complications, treatment alternatives and provided informed consent.,OPERATIVE TECHNIQUE: , The patient was taken to OR #5 where he was given general anesthetic by the Department of Anesthesia.  He was subsequently placed prone on the Jackson's spinal table with all bony prominences well padded.  His lumbar spine was then sterilely prepped and draped in the usual fashion.  A previous midline incision was extended from approximate level of L3 to S1.  This was in the midline.  Skin and subcutaneous tissue were debrided sharply.  Electrocautery provided hemostasis.  ,Electrocautery was utilized to dissect through subcutaneous tissue of lumbar fascia.  The lumbar fascia was identified and split in the midline.  Subperiosteal dissection was then carried out with electrocautery and ______ elevated from the suspected levels of L3-S1.  Once this was exposed, the transverse processes, a Kocher clamp was placed and a localizing cross-table x-ray confirmed the interspace between the spinous processes of L3-L4.  Once this was completed, a self-retaining retractor was then placed.  With palpation of the spinous processes, the L4 posterior elements were noted to be significantly loosened and unstable.  These were readily mobile with digital palpation.  A rongeur was then utilized to resect the spinous processes from the inferior half of L3 to the superior half of S1.  This bone was morcellized and placed on the back table for utilization for bone grafting.  The rongeur was also utilized to thin the laminas from the inferior half of L3 to superior half of S1.  Once this was undertaken, the unstable posterior elements of L4 were meticulously dissected free until wide decompression was obtained.  Additional decompression was extended from the level of the inferior half of L3 to the superior half of S1.  The microscope was utilized during this portion of procedure for visualization.  There was noted to be no changes during the decompression portion or throughout the remainder of the surgical procedure.  Once decompression was deemed satisfactory, the nerve roots were individually inspected and due to the unstable spondylolisthesis, there was noted to be tension on the L4 and L5 nerve roots crossing the disc space at L4-L5.  Once this was identified, foraminotomies were created to allow additional mobility.  The wound was then copiously irrigated with antibiotic solution and suctioned dry.  Working type screws, provisional titanium screws were then placed at L4-l5.  This was to allow distraction and reduction of the spondylolisthesis.  These were placed in the pedicles of L4 and L5 under direct intensification.  The position of the screws were visualized, both AP and lateral images.  They were deemed satisfactory.,Once this was completed, a provisional plate was applied to the screws and distraction applied across L4-L5.  This allowed for additional decompression of the L5 and L4 nerve roots.  Once this was completed, the L5 nerve root was traced and deemed satisfactory exiting neural foramen after additional dissection and discectomy were performed.  Utilizing a series of interbody spacers, a size 8 mm spacer was placed within the L4-L5 interval.  This was taken in sequence up to a 13 mm space.  This was then reduced to a 11 mm as it was much more anatomic in nature.  Once this was completed, the spacers were then placed on the left side and distraction obtained.  Once the distraction was obtained to 11 mm, the interbody shavers were utilized to decorticate the interbody portion of L4 and L5 bilaterally.  Once this was taken to 11 mm bilaterally, the wound was copiously irrigated with antibiotic solution and suction dried.  A 11 mm height x 9 mm width x 25 mm length carbon fiber cages were packed with local bone graft and Allograft.  There were impacted at the interspace of L4-L5 under direct image intensification.  Once these were deemed satisfactory, the wound was copiously irrigated with antibiotic solution and suction dried.  The provisional screws and plates were removed.  This allowed for additional compression along L4-L5 with the cage instrumentation.  Permanent screws were then placed at L4, L5, and S1 bilaterally.  This was performed under direct image intensification.  The position was verified in both AP and lateral images.  Once this was completed, the posterolateral gutters were decorticated with an AM2 Midas Rex burr down to bleeding subchondral bone.  The wound was then copiously irrigated with antibiotic solution and suction dried.  The morcellized Allograft and local bone graft were mixed and packed copiously from the transverse processes of L4-S1 bilaterally.  A 0.25 inch titanium rod was contoured of appropriate length to span from L4-S1.  Appropriate cross connecters were applied and the construct was placed over the pedicle screws.  They were tightened and sequenced to allow additional posterior reduction of the L4 vertebra.  Once this was completed, final images in the image intensification unit were reviewed and were deemed satisfactory.  All connections were tightened and retightened in Torque 2 specifications.  The wound was then copiously irrigated with antibiotic solution and suction dried.  The dura was inspected and noted to be free of tension.  At the conclusion of the procedure, there was noted to be no changes on the SSEP, EMG, and neurophysiologic monitors.  An 8-inch Hemovac drain was placed exiting the wound.  The lumbar fascia was then approximated with #1 Vicryl in interrupted fashion, the subcutaneous tissue with #2-0 Vicryl interrupted fashion, surgical stainless steel clips were used to approximate the skin.  The remainder of the Hemovac was assembled.  Bulky compression dressing utilizing Adaptic, 4x4, and ABDs was then affixed to the lumbar spine with Microfoam tape.  He was turned and taken to the recovery room in apparent satisfactory condition.  Expected surgical prognosis remains guarded.",
 Acute appendicitis with perforation.  Laparoscopic appendectomy.   A CT scan of abdomen showed evidence of appendicitis with perforation. , Surgery, Laparoscopic Appendectomy - 4 ,"PREOPERATIVE DIAGNOSIS:,  Acute appendicitis with perforation.,POSTOPERATIVE DIAGNOSIS:  ,Acute appendicitis with perforation.,ANESTHESIA:,  General.,PROCEDURE: , Laparoscopic appendectomy.,INDICATIONS FOR PROCEDURE: , The patient is a 4-year-old little boy, who has been sick for several days and was seen in our Emergency Department yesterday where a diagnosis of possible constipation was made, but he was sent home with a prescription for polyethylene glycol but became more acutely ill and returned today with tachycardia, high fever and signs of peritonitis.  A CT scan of his abdomen showed evidence of appendicitis with perforation.  He was evaluated in the Emergency Department and placed on the appendicitis critical pathway for this acute appendicitis process.  He required several boluses of fluid for tachycardia and evidence of dehydration.,I met with Carlos' parents and talked to them about the diagnosis of appendicis and surgical risks, benefits, and alternative treatment options.  All their questions have been answered and they agree with the surgical plan.,OPERATIVE FINDINGS: , The patient had acute perforated appendicitis with diffuse suppurative peritonitis including multiple intraloop abscesses and purulent debris in all quadrants of the abdomen including the perihepatic and subphrenic recesses as well.,DESCRIPTION OF PROCEDURE: , The patient came to the operating room and had an uneventful induction of general anesthesia.  A Foley catheter was placed for decompression, and his abdomen was prepared and draped in a standard fashion.  A 0.25% Marcaine was infiltrated in the soft tissues around his umbilicus and in the suprapubic and left lower quadrant locations chosen for trocar insertion.  We conducted our surgical timeout and reiterated all of Carlos' unique and important identifying information and confirmed the diagnosis of appendicitis and planned laparoscopic appendectomy as the procedure.  A 1-cm vertical infraumbilical incision was made and an open technique was used to place a 12-mm Step trocar through the umbilical fascia.  CO2 was insufflated to a pressure of 15 mmHg and then two additional 5-mm working ports were placed in areas that had been previously anesthetized.,There was a lot of diffuse purulent debris and adhesions between the omentum and adjacent surfaces of the bowel and the parietal peritoneum.  After these were gently separated, we began to identify the appendix.  In the __________ due to the large amount of small bowel dilatation and distension, I used the hook cautery with the lowest intraperitoneal __________ profile to coagulate the mesoappendix.  The base of the appendix was then ligated with 2-0 PDS Endoloops, and the appendix was amputated and withdrawn through the umbilical port.  I spent the next 10 minutes irrigating purulent fluid and debris from the peritoneal cavity using 2 L of sterile crystalloid solution and a suction power irrigation system.  When this was complete, the CO2 was released one final time and as much of the fluid was drained from the peritoneal cavity as possible.  The umbilical fascia was closed with figure-of-eight suture of 0 Monocryl and the skin incisions were closed with subcuticular 5-0 Monocryl and Steri-Strips.  The patient tolerated the operation well.  He was awakened and taken to the recovery room in satisfactory condition.  His blood loss was less than 10 mL, and he received only crystalloid fluid during the procedure.","surgery, adhesions, peritoneum, purulent debris, umbilical fascia, peritoneal cavity, laparoscopic appendectomy, appendectomy, constipation, purulent, debris, umbilical, appendix, abdomen, laparoscopic, perforation, appendicitis,"
 Appendicitis.  Laparoscopic appendectomy.   CO2 insufflation was done to a maximum pressure of 15 mmHg and a 12-mm VersaStep port was placed through his umbilicus., Surgery, Laparoscopic Appendectomy - 3 ,"PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS:,  Appendicitis. ,PROCEDURE: , Laparoscopic appendectomy. ,ANESTHESIA: , General with endotracheal intubation. ,PROCEDURE IN DETAIL:  ,The patient was taken to the operating room and placed supine on the operating room table.  General anesthesia was administered with endotracheal intubation.  His abdomen was prepped and draped in a standard, sterile surgical fashion.  A Foley catheter was placed for bladder decompression.  Marcaine was injected into his umbilicus.  A small incision was made.  A Veress needle was introduced in his abdomen.  CO2 insufflation was done to a maximum pressure of 15 mmHg and a 12-mm VersaStep port was placed through his umbilicus.  A 5-mm port was then placed just to the right side of the umbilicus.  Another 5-mm port was placed just suprapubic in the midline.  Upon inspection of the cecum, I was able find an inflamed and indurated appendix.  I was able to clear the mesentery at the base of the appendix between the appendix and the cecum.  I fired a white load stapler across the appendix at its base and fired a grey load stapler across the mesentery, and thereby divided the mesentery and freed the appendix.  I put the appendix in an Endocatch bag and removed it through the umbilicus.  I irrigated out the abdomen.  I then closed the fascia of the umbilicus with interrupted 0 Vicryl suture utilizing Carter-Thomason and closed the skin of all incisions with a running Monocryl.  Sponge, instrument, and needle counts were correct at the end of the case.  The patient tolerated the procedure well without any complications.","surgery, foley catheter, co2 insufflation, endotracheal intubation, laparoscopic appendectomy, appendectomy, intubation, cecum, laparoscopic, appendicitis, endotracheal, abdomen, mesentery, umbilicus, appendix, "
 Patient status post lap band placement., Surgery, Lap Band Adjustment ,"REASON FOR VISIT:,  Lap band adjustment.,HISTORY OF PRESENT ILLNESS:,  Ms. A is status post lap band placement back in 01/09 and she is here on a band adjustment.  Apparently, she had some problems previously with her adjustments and apparently she has been under a lot of stress.  She was in a car accident a couple of weeks ago and she has problems, she does not feel full.  She states that she is not really hungry but she does not feel full and she states that she is finding when she is hungry at night, having difficulty waiting until the morning and that she did mention that she had a candy bar and that seemed to make her feel better.,PHYSICAL EXAMINATION: , On exam, her temperature is 98, pulse 76, weight 197.7 pounds, blood pressure 102/72, BMI is 38.5, she has lost 3.8 pounds since her last visit.  She was alert and oriented in no apparent distress.  ,PROCEDURE:  ,I was able to access her port.  She does have an AP standard low profile.  I aspirated 6 mL, I did add 1 mL, so she has got approximately 7 mL in her band, she did tolerate water postprocedure.,ASSESSMENT:,  The patient is status post lap band adjustments, doing well, has a total of 7 mL within her band, tolerated water postprocedure.  She will come back in two weeks for another adjustment as needed.,","surgery, lap band adjustment, lap band placement, lap band, "
 Decompressive left lumbar laminectomy C4-C5 and C5-C6 with neural foraminotomy. Posterior cervical fusion C4-C5.  Songer wire.  Right iliac bone graft., Surgery, Laminectomy & Foraminotomy & Cervical Fusion ,"PREOPERATIVE DIAGNOSES,1.  Post anterior cervical discectomy and fusion at C4-C5 and C5-C6 with possible pseudoarthrosis at C4-C5.,2.  Cervical radiculopathy involving the left arm.,3.  Disc degeneration at C3-C4 and C6-C7.,POSTOPERATIVE DIAGNOSES,1.  Post anterior cervical discectomy and fusion at C4-C5 and C5-C6 with possible pseudoarthrosis at C4-C5.,2.  Cervical radiculopathy involving the left arm.,3.  Disc degeneration at C3-C4 and C6-C7.,OPERATIVE PROCEDURES,1.  Decompressive left lumbar laminectomy C4-C5 and C5-C6 with neural foraminotomy.,2.  Posterior cervical fusion C4-C5.,3.  Songer wire.,4.  Right iliac bone graft.,TECHNIQUE:  ,The patient was brought to the operating room.  Preoperative evaluations included previous cervical spine surgery.  The patient initially had some relief; however, his left arm pain did recur and gradually got worse.  Repeat studies including myelogram and postspinal CTs revealed some blunting of the nerve root at C4-C5 and C5-C6.  There was also noted to be some annular bulges at C3-C4, and C6-C7.  The CT scan in March revealed that the fusion was not fully solid.  X-rays were done in November including flexion and extension views, it appeared that the fusion was solid.,The patient had been on pain medication.  The patient had undergone several nonoperative treatments.  He was given the option of surgical intervention.  We discussed Botox, I discussed with the patient and posterior cervical decompression.  I explained to the patient this will leave a larger scar on his neck, and that no guarantee would help, there would be more bleeding and more pain from the posterior surgery than it was from the anterior surgery.  If at the time of surgery there was some motion of the C4-C5 level, I would recommend a fusion.  The patient was a smoker and had been advised to quit smoking but has not quit smoking.  I have therefore recommended that he use iliac bone graft.  I explained to the patient that this would give him a scar over the back of the right pelvis and could be a source of chronic pain for the patient for the rest of his life.  Even if this type of bone graft was used, there was no guarantee that it will fuse and he should stop smoking completely.,The patient also was advised that if I did a fusion, I would also use post instrumentation, which was a wire.  The wire would be left permanently.,Even with all these procedures, there was no guarantee that his symptoms would improve.  His numbness, tingling, and weakness could get worse rather than better, his neck pain and arm pain could persist.  He still had some residual bursitis in his left shoulder and this would not be cured by this procedure.  Other procedures may be necessary later.  There is still with a danger of becoming quadriplegic or losing total control of bowel or bladder function.  He could lose total control of his arms or legs and end up in the bed for the rest of his life.  He could develop chronic regional pain syndromes.  He could get difficulty swallowing or eating.  He could have substantial weakness in the arm.  He was advised that he should not undergo the surgery unless the pain is persistent, severe, and unremitting.,He was also offered his records if he would like any other pain medications or seek other treatments, he was advised that Dr. X would continue to prescribe pain medication if he did not wish to proceed with surgery.,He stated he understood all the risks.  He did not wish to get any other treatments.  He said the pain has reached the point that he wished to proceed with surgery.,PROCEDURE IN DETAIL: , In the operating room, he was given general endotracheal anesthesia.,I then carefully rolled the patient on thoracic rolls.  His head was controlled by a horseshoe holder.  The anesthesiologist checked the eye positions to make sure there was no pressure on the orbits and the anesthesiologist continued to check them every 15 minutes.  The arms, the right hip, and the neck was then prepped and draped.  Care was taken to position both arms and both legs.  Pulses were checked.,A midline incision was made through the skin and subcutaneous tissue on the cervical spine.  A loupe magnification and headlamp illumination was used.  Bleeding vessels were cauterized.  Meticulous hemostasis was carried out throughout the procedure.  Gradually and carefully I exposed the spinous process of the C6, C5, and C4.  A lateral view was done after an instrument in place.  This revealed the C6-C7 level.  I therefore did a small laminotomy opening at C4-C5.  I placed an instrument and x-rays confirmed C4-C5 level.,I stripped the muscles from the lamina and then moved them laterally and held with a self-retaining retractor.,Once I identified the level, I then used a bur to thin the lamina of C5.  I used a 1-mm, followed by a 2-mm Kerrison rongeur to carefully remove the lamina off C5 on the left.  I removed some of the superior lamina of C6 and some of the inferior lamina of C4.  This allowed me to visualize the dura and the nerve roots and gradually do neural foraminotomies for both the C5 and C6 nerve roots.  There was some bleeding from the epidural veins and a bipolar cautery was used.  Absolutely no retractors were ever placed in the canal.  There was no retraction.  I was able to place a small probe underneath the nerve root and check the disc spaces to make sure there was no fragments of disc or herniation disc and none were found.,At the end of the procedure, the neuroforamen were widely patent.  The nerve roots had been fully decompressed.,I then checked stability.  There was micromotion at the C4-C5 level.  I therefore elected to proceed with a fusion.,I debrided the interspinous ligament between C4 and C5.  I used a bur to roughen up the surface of the superior portion of the spinous process of C5 and the inferior portion of C4.  Using a small drill, I opened the facet at C4-C5.  I then used a very small curette to clean up the articular cartilage.  I used a bur then to roughen up the lamina at C4-C5.,Attention was turned to the right and left hip, which was also prepped.  An incision made over the iliac crest.  Bleeding vessels were cauterized.  I exposed just the posterior aspect of the crest.  I removed some of the bone and then used the curette to remove cancellous bone.,I placed the Songer wire through the base of the spinous process of C4 and C5.  Drill holes made with a clip.  I then packed cancellous bone between the decorticated spinous process.  I then tightened the Songer wire to the appropriate tension and then cut off the excess wire.,Prior to tightening the wire, I also packed cancellous bone with facet at C4-C5.  I then laid bone upon the decorticated lamina of C4 and C5.,The hip wound was irrigated with bacitracin and Kantrex.  Deep structures were closed with #1 Vicryl, subcutaneous suture and subcuticular tissue was closed.,No drain was placed in the hip.,A drain was left in the posterior cervical spine.  The deep tissues were closed with 0 Vicryl, subcutaneous tissue and skin were then closed.  The patient was taken to the recovery room in good condition.",
"  L1 laminotomy, microdissection, retrieval of foreign body (retained lumbar spinal catheter), attempted insertion of new external lumbar drain, and fluoroscopy.", Surgery, Laminotomy & Microdissection ,"PREOPERATIVE DIAGNOSES:  ,1.  Fractured and retained lumbar subarachnoid spinal catheter.,2.  Pseudotumor cerebri (benign intracranial hypertension).,PROCEDURES:  ,1.  L1 laminotomy.,2.  Microdissection.,3.  Retrieval of foreign body (retained lumbar spinal catheter).,4.  Attempted insertion of new external lumbar drain.,5.  Fluoroscopy.,ANESTHESIA: , General.,HISTORY:  ,The patient had a lumbar subarachnoid drain placed yesterday.  All went well with the surgery.  The catheter stopped draining and on pulling back the catheter, it fractured and CT scan showed that the remaining fragment is deep to the lamina.  The patient continues to have right eye blindness and headaches, presumably from the pseudotumor cerebri.,DESCRIPTION OF PROCEDURE:  ,After induction of general anesthesia, the patient was placed prone on the operating room table resting on chest rolls.  Her face was resting in a pink foam headrest.  Extreme care was taken positioning her because she weighs 92 kg.  There was a lot of extra padding for her limbs and her limbs were positioned comfortably.  The arms were not hyperextended.  Great care was taken with positioning of the head and making sure there was no pressure on her eyes especially since she already has visual disturbance.  A Foley catheter was in place.  She received IV Cipro 400 mg because she is allergic to most antibiotics.,Fluoroscopy was used to locate the lower end of the fractured catheter and the skin was marked.  It was also marked where we would try to insert the new catheter at the L4 or L3 interspinous space.,The patient was then prepped and draped in a sterile manner.,A 7-cm incision was made over the L1 lamina.  The incision was carried down through the fascia all the way down to the spinous processes.  A self-retaining McCullough retractor was placed.  The laminae were quite deep.  The microscope was brought in and using the Midas Rex drill with the AM-8 bit and removing some of the spinous process of L1-L2 with double-action rongeurs, the laminotomy was then done using the drill and great care was taken and using a 2-mm rongeur, the last layer of lamina was removed exposing the epidural fat and dura.  The opening in the bone was 1.5 x 1.5 cm.,Occasionally, bipolar cautery was used for bleeding of epidural veins, but this cautery was kept to a minimum.,Under high magnification, the dura was opened with an 11 blade and microscissors.  At first, there was a linear incision vertically to the left of midline, and I then needed to make a horizontal incision more towards the right.  The upper aspect of the cauda equina was visualized and perhaps the lower end of the conus.  Microdissection under high magnification did not expose the catheter.  The fluoroscope was brought in 2 more times including getting a lateral view and the fluoroscope appeared to show that the catheter should be in this location.,I persisted with intensive microdissection and finally we could see the catheter deep to the nerves and I was able to pull it out with the microforceps.,The wound was irrigated with bacitracin irrigation.,At this point, I then attempted lumbar puncture by making a small incision with an 11 blade in the L4 interspinous space and then later in the L3 interspinous space and attempted to puncture the dural sac with the Tuohy needle.  Dr. Y also tried.  Despite using the fluoroscope and our best attempts, we were not able to convincingly puncture the lumbar subarachnoid space and so the attempted placement of the new lumbar catheter had to be abandoned.  It will be done at a later date.,I felt it was unsafe to place a new catheter at this existing laminotomy site because it was very high up near the conus.  The potential for complications involving her spinal cord was greater and we have already had a complication of the catheter now and I just did not think it was safe to put in this location.,Under high magnification, the dura was closed with #6-0 PDS interrupted sutures.,After the dura was closed, a piece of Gelfoam was placed over the dura.  The paraspinous muscles were closed with 0 Vicryl interrupted sutures.  The subcutaneous fascia was also closed with 0 Vicryl interrupted suture.  The subcutaneous layer was closed with #2-0 Vicryl interrupted suture and the skin with #4-0 Vicryl Rapide.  The 4-0 Vicryl Rapide sutures were also used at the lumbar puncture sites to close the skin.,The patient was then turned carefully on to her bed after sterile dressings were applied and then taken to the recovery room.  The patient tolerated procedure well.  No complications.  Sponge and needle counts correct.  Blood loss minimal, none replaced.  This procedure took 5 hours.  This case was also extremely difficult due to patient's size and the difficulty of locating the catheter deep to the cauda equina.","surgery, laminotomy, microdissection, lumbar spinal catheter, external lumbar drain, fluoroscopy, lumbar subarachnoid, spinal catheter, intracranial hypertension, vicryl interrupted sutures, lumbar, catheter, "
  Fracture reduction with insertion of prosthetic device at T8 with kyphoplasty.   Vertebroplasties at T7 and T9 with insertion of prosthetic device.   Fracture of the T8 vertebra and T9 vertebra., Surgery, Kyphoplasty & Vertebroplasty ,"PREOPERATIVE DIAGNOSES:,1.  Pathologic insufficiency.,2.  Fracture of the T8 vertebrae and T9 vertebrae.,POSTOPERATIVE DIAGNOSES:,1.  Pathologic insufficiency.,2.  Fracture of the T8 vertebra and T9 vertebra.,PROCEDURE PERFORMED:,1.  Fracture reduction with insertion of prosthetic device at T8 with kyphoplasty.,2.  Vertebroplasties at T7 and T9 with insertion of prosthetic device.,ANESTHESIA: , Local with sedation.,SPECIMEN: , Bone from the T8 vertebra.,COMPLICATIONS:,  None.,SURGICAL INDICATIONS:,  The patient is an 80-year-old female who had previous history of compression fractures.  She had recently undergone an additional compression fracture of the T8 vertebrae.  She was in extreme pain.  This pain interfered with activities of daily living and was unimproved with conservative treatment modalities.  She is understanding the risks, benefits, and potential complications as well as all treatment alternatives.  The patient provided informed consent.,OPERATIVE TECHNIQUE: , The patient was taken to OR #2 where she was placed prone on the Jackson spinal table.  She was given sedative.  The thoracodorsal spine was then sterilely prepped and draped in the usual fashion.  Biplanar image intensification was utilized to localize the T8, T7, and T9 vertebrae.  Local anesthetic of 1% Marcaine with epinephrine and lidocaine were 50:50 mixed.,Approximately 7 cc was instilled on the left side.  This was directly over the posterior aspect of the pedicle on the left.  Once this was localized, the right side was localized as well.  Stab incisions were then created over the pedicles of T8 bilaterally.  Jamshidi needles were then placed percutaneously.  Their position was verified in both AP and lateral images.  They were advanced slowly under direct image intensification in biplanar fashion.  Once these were satisfactorily placed, the inner trocar was removed and a guidewire was inserted into the depths of the T7 vertebrae.  The Jamshidi needles were then removed.  A biopsy was then harvested with a biopsy trocar placed into the T8 vertebrae.  This bone was then removed and sent to the lab.  The injection cannulas were then placed over the guidewires and their position was verified in both AP and lateral images.  Once this was completed, a second Jamshidi needle was placed at the T7 vertebrae on the left at the entrance of the pedicle.  This was advanced under direct image intensification in a biplanar fashion.  Once this was deemed satisfactory, it was impacted.  The inner trocar was removed and a guidewire was then placed.  An injection cannula was then placed over the guidewire into the body of T7.  In a similar fashion, T9 was dressed on the left side as well.  A guidewire was then placed through the Jamshidi needle, which was verified in both AP and lateral images.  The cement injection cannula was then placed over this entering the T9 vertebrae body.  Attention was then turned to the kyphoplasty portion of the procedure at the T8 vertebrae.  The balloons were inserted bilaterally.  The balloons were then inflated under direct image intensification and pressurized to approximately 200 mmHg.  These were allowed to expand and reduce the fracture.  Once this was completed, the balloons were deflated and removed.  The inner cannulas of all four entrance holes were removed and approximately 1.5 cc of cement was injected in each of the cannulas.  This was done directly under image intensification.  Once this was completed, additional cement was injected into T9 as there was a larger vertebra.  The cement was allowed to cure.  The cannula was removed and final radiographs were obtained.  The stab incisions were then cleansed with water and antibiotic irrigation.  The wounds were then approximated with #4-0 Nylon in interrupted fashion.  Compression dressings were applied and fixed with tape.  She was aroused and moved to her inpatient bed.  She was moving all four extremities without deficit.  She had no significant pain.","surgery, pathologic insufficiency, vertebrae, fracture, fracture reduction, vertebroplasties, kyphoplasty, prosthetic device, jamshidi needles, insertion, prosthetic,"
" Complete laminectomy, L4. and facetectomy, L3-L4 level.  A dural repair, right sided, on the lateral sheath, subarticular recess at the L4 pedicle level.  Posterior spinal instrumentation, L4 to S1, using Synthes Pangea System.  Posterior spinal fusion, L4 to S1.  Insertion of morselized autograft, L4 to S1.  ", Surgery, Laminectomy & Facetectomy ,"PREOPERATIVE DIAGNOSIS:,  Dural tear, postoperative laminectomy, L4-L5.,POSTOPERATIVE DIAGNOSES,1.  Dural tear, postoperative laminectomy, L4-L5.,2.  Laterolisthesis, L4-L5.,3.  Spinal instability, L4-L5.,OPERATIONS PERFORMED,1.  Complete laminectomy, L4.,2.  Complete laminectomy plus facetectomy, L3-L4 level.,3.  A dural repair, right sided, on the lateral sheath, subarticular recess at the L4 pedicle level.,4.  Posterior spinal instrumentation, L4 to S1, using Synthes Pangea System.,5.  Posterior spinal fusion, L4 to S1.,6.  Insertion of morselized autograft, L4 to S1.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , 500 mL.,COMPLICATIONS: , None.,DRAINS:  ,Hemovac x1.,DISPOSITION: , Vital signs stable, taken to the recovery room in a satisfactory condition, extubated.,INDICATIONS FOR OPERATION: , The patient is a 48-year-old gentleman who has had a prior decompression several weeks ago.  He presented several days later with headaches as well as a draining wound.  He was subsequently taken back for a dural repair.  For the last 10 to 11 days, he has been okay except for the last two days he has had increasing headaches, has nausea, vomiting, as well as positional migraines.  He has fullness in the back of his wound.  The patient's risks and benefits have been conferred him due to the fact that he does have persistent spinal leak.  The patient was taken to the operating room for exploration of his wound with dural repair with possible stabilization pending what we find intraoperatively.,PROCEDURE IN DETAIL:,  After appropriate consent was obtained from the patient, the patient was wheeled back to the operating theater room #7.  The patient was placed in the usual supine position and intubated under general anesthesia without any difficulties.  The patient was given intraoperative antibiotics.  The patient was rolled onto the OSI table in usual prone position and prepped and draped in usual sterile fashion.,Initially, a midline incision was made from the cephalad to caudad level.  Full-thickness skin flaps were developed.  It was seen immediately that there was large amount of copious fluid emanating from the wound, clear-like fluid, which was the cerebrospinal fluid.  Cultures were taken, aerobic, anaerobic, AFB, fungal.  Once this was done, the paraspinal muscles were affected from the posterior elements.  It was seen that there were no facet complexes on the right side at L4-L5 and L5-S1.  It was seen that the spine was listhesed at L5 and that the dural sac was pinched at the L4-5 level from the listhesis.  Once this was done; however, the fluid emanating from the dura could not be seen appropriately.  Complete laminectomy at L4 was performed as well extending the L5 laminectomy more to the left.  Complete laminectomy at L3 was done.  Once this was done within the subarticular recess on the right side at the L4 pedicle level, a rent in the dura was seen.  Once this was appropriately cleaned, the dural edges were approximated using a running 6-0 Prolene suture.  A Valsalva confirmed no significant lead after the repair was made.  There was a significant laterolisthesis at L4-L5 and due to the fact that there were no facet complexes at L5-S1 and L4-L5 on the right side as well as there was a significant concavity on the right L4-L5 disk space which was demonstrated from intraoperative x-rays and compared to preoperative x-rays, it was decided from an instrumentation.  The lateral pedicle screws were placed at L4, L5, and S1 using the standard technique of Magerl.  After this the standard starting point was made.  Trajectory was completed with gearshift and sounded in all four quadrants to make sure there was no violation of the pedicle wall.  Once this was done, this was undertapped at 1 mm and resounded in all four quadrants to make sure that there was no violation of the pedicle wall.  The screws were subsequently placed.  Tricortical purchase was obtained at S1 ________ appropriate size screws.  Precontoured titanium rod was then appropriately planned and placed between the screws at L4, L5, and S1.  This was done on the right side first.  The screw was torqued at S1 appropriately and subsequently at L5.  Minimal compression was then placed between L5 and L4 to correct the concavity as well as laterolisthesis and the screw appropriately torqued at L4.  Neutral compression distraction was obtained on the left side.  Screws were torqued at L4, L5, and S1 appropriately.  Good placement was seen both in AP and lateral planes using fluoroscopy.  Laterolisthesis corrected appropriately at L4 and L5.,Posterior spinal fusion was completed by decorticating the posterior elements at L4-L5 and the sacral ala with a curette.  Once good bleeding subchondral bone was appreciated, the morselized bone from the laminectomy was morselized with corticocancellous bone chips together with demineralized bone matrix.  This was placed in the posterior lateral gutters.  DuraGen was then placed over the dural repair, and after this, fibrin glue was placed appropriately.  Deep retractors then removed from the confines of the wound.  Fascia was closed using interrupted Prolene running suture #1.  Once this was done, suprafascial drain was placed appropriately.  Subcutaneous tissues were opposed using a 2-0 Prolene suture.  The dermal edges were approximated using staples.  Wound was dressed sterilely using bacitracin ointment, Xeroform, 4 x 4's, and tape.  The drain was connected appropriately.  The patient was rolled on stretcher in usual supine position, extubated uneventfully, and taken back to the recovery room in a satisfactory stable condition.  No complications arose.", 
  Left knee arthroscopy with lateral capsular release., Surgery, Knee Arthroscopy ,"PREOPERATIVE DIAGNOSIS: , Left patellar chondromalacia.,POSTOPERATIVE DIAGNOSIS:,  Left patellar chondromalacia with tight lateral structures.,PROCEDURE:,  Left knee arthroscopy with lateral capsular release.,ANESTHESIA: , Surgery performed under general anesthesia.,TOURNIQUET TIME:  ,47 minutes.,MEDICATION:  ,The patient received 0.5% Marcaine local anesthetic 32 mL.,COMPLICATIONS: , No intraoperative complications.,DRAINS AND SPECIMENS: , None.,HISTORY AND PHYSICAL:  ,The patient is a 14-year-old girl who started having left knee pain in the fall of 2007.  She was not seen in Orthopedic Clinic until November 2007.  The patient had an outside MRI performed that demonstrated left patellar chondromalacia only.  The patient was referred to physical therapy for patellar tracking exercises.  She was also given a brace.  The patient reported increasing pain with physical therapy and mother strongly desired other treatment.  It was explained to the mother in detail that this is a difficult problem to treat although majority of the patients get better with physical therapy.  Her failure with nonoperative treatment is below the standard 6-month trial; however, given her symptoms and severe pain, lateral capsular release was offered.  Risk and benefits of surgery were discussed.  Risks of surgery including risk of anesthesia, infection, bleeding, changes in sensation and motion extremity, failure of procedure to relieve pain, need for postoperative rehab, and significant postoperative swelling.  All questions were answered, and mother and daughter agreed to the above plans.,PROCEDURE NOTE: , The patient was taken to the operating room and placed on the operating table.  General anesthesia was then administered.  The patient received Ancef preoperatively.  A nonsterile tourniquet was placed on the upper aspect of left thigh.  The extremity was then prepped and draped in the standard surgical fashion.  A medial suprapatellar portal was marked on the skin as well as anteromedial and anterolateral joint line.  The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg.  Esmarch was then removed.  Incisions were then made.  Camera was initially inserted into the lateral joint line.  Visualization of patellofemoral joint revealed type 2 chondromalacia with slight lateral subluxation.  The patient did have congruent articulation about 30 degrees of knee flexion.  Visualization of the medial joint line revealed no loose bodies.  There was a small plica.  Visualization of the medial joint line revealed no significant chondromalacia.  Menisci was probed and tested with no signs of tears and instability.  ACL was noted to be intact.  The intercondylar notch and lateral joint line also revealed no significant chondromalacia or meniscal pathology.  Lateral gutter also demonstrated no loose bodies or plica.  The camera was then removed and inserted into the anteromedial portal using two 18-gauge needles.  The extent of lateral capsular release was marked using a monopolar coblator, lateral capsular release was performed.  The patient had significant improvement in anteromedial translation from 25% to 50%.  At the end of the case, all instruments were removed.  The knee was injected with 32 mL of 0.5% Marcaine with additional epinephrine.  Please note, the patient received 30 mL of 1:500,000 dilution epinephrine at the beginning of the case.  The portals were then closed using 4-0 Monocryl.  The wound was clean and dry, and dressed with Steri-Strips, Xeroform, and 4 x 4s.  The kneecap was translated medially under pressure and a bias placed.  The tourniquet was released at 47 minutes.  The patient was then placed in the knee immobilizer.  The patient tolerated the procedure well and was subsequently extubated and taken to the recovery in stable condition.,POSTOPERATIVE PLAN: , The patient will weightbear as tolerated in the knee immobilizer.  She will start physical therapy within 1 to 2 weeks to work on patella mobilization as well as reconditioning and strengthening.  Intraoperative findings were relayed to the mother.  All questions were answered.","surgery, knee arthroscopy, lateral capsular release, chondromalacia, patellar, lateral joint line, medial joint line, lateral joint, medial joint, capsular release, joint line, arthroscopy, tourniquet, knee,"
" Arthroscopy of the left knee with medial meniscoplasty.  Internal derangement, left knee. Displaced bucket-handle tear of medial meniscus, left knee.", Surgery, Knee Arthroscopy & Medial Meniscoplasty ,"PREOPERATIVE DIAGNOSIS: , Internal derangement, left knee.,POSTOPERATIVE DIAGNOSIS: , Internal derangement, left knee.,PROCEDURE PERFORMED:,  Arthroscopy of the left knee with medial meniscoplasty.,ANESTHESIA:  ,LMA.,GROSS FINDINGS: , Displaced bucket-handle tear of medial meniscus, left knee.,PROCEDURE: , After informed consent was obtained, the patient was taken to ABCD General Hospital Operating Room #1 where anesthesia was administered by the Department of Anesthesiology.  The patient was then transferred to the operating room table in supine position with Johnson knee holder well-padded.  Tourniquet was placed around the left upper thigh.  The limb was then prepped and draped in usual sterile fashion.  Standard anteromedial and anterolateral arthroscopy portals were obtained and a systematic examination of the knee was then performed.  Patellofemoral joint showed frequent chondromalacia.  Examination of the medial compartment showed a displaced bucket-handle tear of the medial meniscus involving the entire posterior, parietal, and portion of his anterior portion of the medial meniscus.  The medial femoral condyle and medial tibial plateau were unaffected.  Intercondylar notch examination revealed an intact ACL and PCL stable to drawer testing and probing and the lateral compartment showed an intact lateral meniscus.  The femoral condyle and tibial plateau were all stable to probing.  Attention was then directed back to the medial compartment where the detached portion of the meniscus was excised using arthroscopy scissors.  A shaver was then used to smooth all the edges until the margins were stable to probing.,The knee was then flushed with normal saline and suctioned dry.  20 cc of 0.25% Marcaine was injected into the knee and into the arthroscopy portals.  A dressing consisting of Adaptic, 4x4s, ABDs, and Webril were applied followed by a TED hose.  The patient was then transferred to the recovery room in stable condition.","surgery, arthroscopy, meniscoplasty, derangement, internal derangement, knee, displaced bucket handle tear, femoral condyle, tibial plateau, medial meniscoplasty, medial meniscus, medial "
 Left medial compartment osteoarthritis of the knee.  Left unicompartmental knee replacement., Surgery, Knee Replacement ,"PREOPERATIVE DIAGNOSIS: , Left medial compartment osteoarthritis of the knee.,POSTOPERATIVE DIAGNOSIS:,  Left medial compartment osteoarthritis of the knee.,PROCEDURE  PERFORMED:,  Left unicompartmental knee replacement.,COMPONENTS USED:,  Biomet size medium femoral component size B tibial tray and a 3 mm polyethylene component.,COMPLICATIONS:,  None.,TOURNIQUET TIME: , 59 minutes.,BLOOD LOSS: , Minimal.,INDICATIONS FOR PROCEDURE: , A 55-year-old female who had previously undergone a Biomet Oxford unicompartmental knee replacement on the right side.  She has done quite well with this.  She now has had worsening left knee pain predominantly on the inside of her knee and has consented for unicompartmental knee replacement on the left.,DESCRIPTION OF PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed supine on the operating room table.  After appropriate anesthesia, the left lower extremity was identified with a time out procedure.  Preoperative antibiotics were given.  Left lower extremity was then prepped and draped in usual sterile fashion after applying a thigh tourniquet.  The tourniquet was insufflated after elevation of the limb, and a standard medial parapatellar incision was used.  Soft tissue dissection was carried down the retinaculum, was opened sharply to expose the joint, meniscus that was visible along the tibia was removed.  The anterior fat pad was removed.  The knee was then examined.  The ACL was found to be intact.  The lateral compartment had very minimal arthritis.  There were some osteoarthritic changes of the patellofemoral joint, but these were felt to be mild.  Following this, the tibial external alignment guide was placed and pinned into place in the appropriate place.  Tibial bone cut was made and checked with a feeler gauge and felt to be an adequate resection.  Following this resection, the femoral intramedullary guide was placed without difficulty.  The femoral cutting guide was then placed and referenced off of this femoral intramedullary guide.  Once in the appropriate position, it was pinned and drilled.  This was removed, and the posterior cutting block was inserted.  It was impacted into place.  Posterior bone cut was made for the medium femoral component.  Next, a zero spigot was used and the distal femur was reamed.  Following this, the check of the extension and flexion gaps revealed that an additional 1 mm needed to be reamed, so 1 spigot was used and this was reamed as well.  Next, trial components were placed into the knee and the knee was taken through range of motion and felt to come out to full extension with a 3 mm poly with a good fit.  Next, the tibia was prepared.  The tibial tray was pinned into place, and the cuts for the keel of the tibia were made.  These were removed with a small osteotome from the set.  Following this, a trial tibial with the keel was placed and it did fit nicely.  After this, all trial components were removed.  The knee was copiously irrigated.  Cement was begun mixing.  Drill holes were used along the femur for cement interdigitation.  The wound was cleaned and dried.  Cement was placed on the tibia.  Tibial tray was impacted into place.  Excess cement was removed.  Tibia was placed in the femur.  Femoral component was impacted into place.  Excess cement was removed.  It was held with a 4 mm trial insert and approximately 30 degrees of knee flexion until the cement had hardened.  Following this, it was again trialed with a meniscal bearing implant and it was felt that 3 mm would be the appropriate size.  A 3 mm polyethylene was chosen and inserted in the knee without difficulty, taken through range of motion and found to come out to full extension with no impingement and full flexion.  The intramedullary rod removed from the femur.  The wound was irrigated with normal saline.  The retinaculum was closed with #1 PDS, 2-0 Monocryl was used for the subcutaneous tissue and staples used for the skin.  A sterile dressing was placed.  Tourniquet was then desufflated.  Sponge and needle counts were correct at the end of the procedure.  Dr. Jinnah was present for the surgery.  The patient was transferred to the recovery room in stable condition.  She will be weightbearing as tolerated in the left lower extremity and will be maintained on Lovenox for DVT prophylaxis.  Prior to closure, the posterior capsule was injected with the joint cocktail.","surgery, knee replacement, osteoarthritis, osteoarthritis of the knee, excess cement was removed, medium femoral component, medial compartment osteoarthritis, unicompartmental knee replacement, medium femoral, femoral intramedullary, intramedullary guide, medial compartment, femoral component, tibial tray, lower extremity, unicompartmental knee, tibial, knee, tourniquet, intramedullary, extension, flexion, compartment, unicompartmental, replacement, femoral, cement,"
 Bilateral knee degenerative arthritis.  Bilateral knee arthroplasty.  The Zimmer NexGen total knee system was utilized., Surgery, Knee Arthroplasty - Bilateral ,"PREOPERATIVE DIAGNOSIS: , Bilateral knee degenerative arthritis.,POSTOPERATIVE DIAGNOSIS: , Bilateral knee degenerative arthritis.,PROCEDURE PERFORMED: , Bilateral knee arthroplasty.,Please note this procedure was done by Dr. X for the left total knee and Dr. Y for the right total knee.  This operative note will discuss the right total knee arthroplasty.,ANESTHESIA:  ,General.,COMPLICATIONS: , None.,BLOOD LOSS: , Approximately 150 cc.,HISTORY:,  This is a 79-year-old female who has disabling bilateral knee degenerative arthritis.  She has been unresponsive to conservative measures.  All risks, complications, anticipated benefits, and postoperative course were discussed.  The patient has agreed to proceed with surgery as described below.,GROSS FINDINGS: , There was noted to be eburnation and wear along the patellofemoral joint and femoral tibial articulation medially and laterally with osteophyte formation and sclerosis.,SPECIFICATIONS: , The Zimmer NexGen total knee system was utilized.,PROCEDURE: , The patient was taken to the operating room #2 and placed in supine position on the operating room table.  She was administered spinal anesthetic by Dr. Z.,The tourniquet was placed about the proximal aspect of the right lower extremity.  The right lower extremity was then sterilely prepped and draped in the usual fashion.  An Esmarch bandage was used to exsanguinate the right lower extremity and the tourniquet was inflated to 325 mmHg.  Longitudinal incision was made over the anterior aspect of the right knee.  Subcutaneous tissue was carefully dissected.  A medial parapatellar retinacular incision was made.  The patella was then everted and the above noted gross findings were appreciated.  A drill hole was placed in the distal aspect of the femur and the distal femoral cutting guides were positioned in place.  The appropriate cuts were made at the distal femur as well as with use of the chamfer guide.  The trial femoral component was then positioned in place and noted to have good fit.  Attention was then directed to proximal tibia, the external tibial alignment guide was positioned in place and the proximal tibial cut was made demonstrating satisfactory cut.  The medial and lateral collateral ligaments remained intact throughout the procedure as well as the posterior cruciate ligaments.  The remnants of the anterior cruciate ligament and menisci were resected.  The tibial trial was positioned in place.  Intraoperative radiographs were taken, demonstrating satisfactory alignment of the tibial cut.  The tibial holes were then drilled.  The patella was then addressed with the Bovie used to remove the soft tissue around the perimeter of the patella.  The patellar cutting guide was positioned in place and the posterior aspect of the patella was resected to the appropriate thickness.  Three drill holes were made within the patella after it was determined that 35 mm patella would be most appropriate.  The knee was placed through range of motion with the trial components marked and then the appropriate components obtained.  The tibial tray was inserted with cement, backed it into place, excess methylmethacrylate was removed.  The femoral component was inserted with methylmethacrylate.  Any excessive methylmethacrylate and bony debris were removed from the joint.  Trial Poly was positioned in place and the knee was held in full extension while the methylmethacrylate became firm.  The methylmethacrylate was also used at the patella.  The prosthesis was positioned in place.  The patellar clamp held securely till the methylmethacrylate was firm.  After all three components were in place, the knee was then again in placed range of motion and there appeared to be some torsion to the proximal tibial component and concerned regarding the alignment.  This component was removed and revised to a stemmed component with better alignment and position.  The previous component removed, the methylmethacrylate was removed.  Further irrigation was performed and then a stemmed template was positioned in place with the intramedullary alignment guide positioned and the tibia drilled and broached.  The trial tibial stemmed component was positioned in place.  Knee was placed through range of motion and the tracking was better.  Actual component was then obtained, methyl methacrylate was placed within the tibia.  The stemmed tibial component was impacted into place with good fit.  The Poly was then positioned in place.  Knee held in full extension with compression longitudinally after methylmethacrylate was solidified.  The trial Poly was removed.  Wound was irrigated and the joint was inspected.  There was no debris.  Collateral ligaments and posterior cruciate ligaments remained intact.  Soft tissue balancing was done and a 17 mm Poly was then inserted with the knee and tibial and femoral components with good tracking as well as the patellar component.  The tourniquet was deflated.  Hemostasis was satisfactory.  A drain was placed into the depths of the wound.  The medial retinacular incision was closed with one Ethibond suture in interrupted fashion.  The knee was placed through range of motion and there was no undue tissue tension, good patellar tracking, no excessive soft tissue laxity or constrain.  The subcutaneous tissue was closed with #2-0 undyed Vicryl in interrupted fashion.  The skin was closed with surgical clips.  The exterior of the wound was cleansed as well padded dressing ABDs and ace wrap over the right lower extremity.  At the completion of the procedure, distal pulses were intact.  Toes were pink, warm, with good capillary refill.  Distal neurovascular status was intact.  Postoperative x-ray demonstrated satisfactory alignment of the prosthesis.  Prognosis is good in this 79-year-old female with a significant degenerative arthritis.","surgery, patellofemoral, eburnation, osteophyte, articulation, tibial, femoral, bilateral knee arthroplasty, knee degenerative arthritis, zimmer nexgen, lower extremity, arthroplasty, patella, methylmethacrylate,"
 Revision right total knee arthroplasty.  Right failed total knee arthroplasty., Surgery, Knee Arthroplasty - Revision ,"PREOPERATIVE DIAGNOSIS: , Right failed total knee arthroplasty.,POSTOPERATIVE DIAGNOSIS:  ,Right failed total knee arthroplasty.,PROCEDURE PERFORMED: ,  Revision right total knee arthroplasty.,FIRST ANESTHESIA: , Spinal.,ESTIMATED BLOOD LOSS: , Approximately 75 cc.,TOURNIQUET TIME: , 123 minutes.  Then it was let down for approximately 15 minutes and then reinflated for another 26 minutes for a total of 149 minutes.,COMPONENTS: , A Zimmer NexGen Legacy knee size D right stemmed femoral component was used.  A NexGen femoral component with a distal femoral augmented block, size 5 mm.  A NexGen tibial component, size 3 mm was used.  A size 14 mm constrained polyethylene surface was used as well.  Original patellar component that the patient had was maintained.,COMPLICATIONS:  ,None.,BRIEF HISTORY:,  The patient is a 68-year-old female with a history of knee pain for 13 years.  She had previous total knee arthroplasty and revision at an outside facility.  She had continued pain, snapping, malalignment, difficulty with ambulation, and giving away and wished to undergo additional revision surgery.,PROCEDURE:,  The patient was taken to the operative suite and placed on the operating table.  Department of Anesthesia administered the spinal anesthetic.  Once adequately anesthetized, the patient was placed in a supine position.  Care was ensured and she was adequately secured and well padded in position.  Once this was obtained, the right lower extremity was prepped and draped in the usual sterile fashion.  Tourniquet was inflated to approximately 325 mmHg on the right thigh.  At this point, an incision was made over her anterior previous knee scar taking this down to the subcutaneous tissue of the overlying retinaculum.  A medial parapatellar arthrotomy was then made by using a second knife and this was taken both distally and proximally to allow us to sublux the patella on the lateral aspect to allow exposure to the joint surface.  There was noted to be no evidence of purulence or gross clinical appearance of infection, however, intraoperative cultures were taken to asses this as well.  At this point, the previous articular surface was then removed using an osteotome until this was left free and then removed.  This was done without difficulty.  Attention was then directed removing the femoral component.  Osteotome was taken around each of the edges until this was gently lifted up and then a femoral extractor was placed around it and this was back flapped until this was easily removed.  After this was performed, attention was then directed to the tibial component.  An osteotome was again inserted around the surface and this was easily pried loose.  There was noted to be minimal difficulty with this and did not appear to have adequate cement fixation.  This was evaluated.  The bone stalk appeared to be adequate, however, there were noted to be some deficits where we need to trim cement, so we elected to proceed with stemmed component.  The attention was first directed to the femur and the femoral canal was opened up and superficially reamed up to a size 18 mm proximal portion for the Zimmer stemmed component.  At this point, the distal femoral cut was evaluated with a intramedullary guide and this was noted to be cut in a varus cut leaving us a large deficit of the medial femoral cut.  We elected because of this large amount of retic to take off the medial condyle to correct this varus cut to a six degree valgus cut.  We elected to augment the medial aspect and take only 5 mm off of the lateral condyle instead of a full 10 to 12.  At this point, the distal femoral cutting guide based on the intramedullary head was then placed.  Care was ensured that this was aligned in proper rotation with the external epicondylar axis.  Once this was pinned in position, approximately a six degree valgus cut was then made.  This allowed a portion of the medial condyle to be removed distally.  The anterior cut was checked next using the intramedullary guide.  The anterior surface cutting block was then placed.  This aligned us to anterior cutting block.,We ensured again that rotation was aligned with the epicondylar axis.  Once this was adequately aligned with this and gave us some external rotation, this was pinned in position and new anterior cut was made.  It was noted that minimal bone was taken off the surface, only a slight portion on the medial anterior surface.  _______ was then removed and the chamfer cutting guide was then placed on.  This allowed us to make a box cut and recut some of the angled cuts of the distal femur.  Once this was placed and pinned in position.  Care was then again taken to check that this was in proper rotation and then the chamfer cuts were recut.  It was noted that the anterior chamfers did not need to be cut, take off no bone.  The posterior chamfers did remove some bony aspects.  This was also taken off some of the posterior aspects of the condyles and then the ossicle saw and reciprocal saw were used to take off a notch cut to open up a constrained component.  After all these cuts were taken, the guides were then removed and the trial component with a medial 5 mm augment was then placed.  This appeared to have an adequate fit and then packed in position.  It appeared to be satisfactory.  At this point, this was removed and attention was then directed to the tibia.  The intramedullary canal was again opened up using a proximal drill and this was reamed to the appropriate size until good _______ was obtained.  At this point, the intramedullary guide was used to evaluate a tibial cut.  This appeared to be adequate, however, we elected to remove 2 mm of bone to give us a new fresh bony surface.  The cutting guide was placed in adequate alignment and checked both the with intramedullary guide and an external alignment rod, which allowed us to ensure that we had proper external rotation of this tibial component.  At this point, this was pinned in position and the tibial cut was made to remove an extra 2 mm of bone.  This was again removed and a trial tibial stemmed component was then placed as well as the trial augmented stemmed femoral component.  This was placed in a proper position.  A 10 mm articular surface was placed in the knee and this was taken through range of motion.  This was found to have better alignment and satisfactory position.  We elected to take an intraoperative x-ray at this point, to evaluate our cut.  The intraoperative x-ray demonstrates satisfactory cuts and alignment of the prosthesis.  At this point, all trials were removed.  The patella was then examined.  The rongeur was used to remove the surrounding synovium.  The patella was evaluated and found to have mild wear on the lateral aspect of the inferior butt, however, this was very mild and overall had a good position and was well fixed to the bone.  It was elected at this time to maintain this anatomic patella that was previously placed.  At this point, the joint again was reevaluated and any bone loose fragments removed.  There was noted to be some posterior tightness and mild osteophytes.  These were removed with a rongeur.,At this time, while preparing the canals, the tourniquet was deflated due to it being 123 minutes.  Approximately 10 minutes did get by, as the knee was copiously irrigated and suctioned dried.  The tourniquet was then reinflated.  The canals were prepped for cementing.  They were suction-dried and cleaned.  The tibial component was cemented and then impacted into position and ensured it was adequately aligned in proper external rotation and alignment that was previously tried with the trial.  Once this was fixed and secured, all extra cement was removed and attention was directed to the femoral component.  The stemmed femoral component was then impacted in position and cemented.  Again care was ensured that it was in adequate position and proper rotation.  A size 14 mm poly was then inserted in between to provide compression.  This was then taken through extension and held until cement cured.  This was then removed and the components were evaluated.  All excess cement was removed and they were well fixed.  Size 14 mm trial Poly was then placed and this was taken through range of motion.  This was found to have excellent range of motion and good stability.  It was elected at this time that we would go with the size 14 mm Poly.  This gave us extra Poly for ware and then provide excellent contact throughout the range of motion.  The final articular surface was then placed and tightened into position to allow to _______ secured.  The knee was then reduced and the knee was taken through range of motion.  The patella was tracking with no-touch technique and adequately positioned.  At this point, the tourniquet was deflated for second time and then the knee was copiously irrigated and suctioned dry.  All bleeding was cauterized using a Bovie cautery.  The retinaculum was then repaired using #1 Ethibond in a figure-of-eight fashion.  This was reinforced with a running #2-0 Vicryl.  The knee was then flexed and noted that the patella was tracking with good alignment.  The wound was again copiously irrigated and suctioned dry.  A drain was placed prior to retinaculum repair deep to this to provide adequate drainage.  At this point, the subcutaneous tissue was closed with #2-0 Vicryl.  Skin was approximated with skin clips.  Sterile dressing of Adaptic, 4x4, Webril, and ABDs were then placed.  A large Dupre dressing was then placed up the entire lower extremity.  The patient was then transferred back to recovery in supine position.,DISPOSITION: , The patient tolerated the procedure well with no complications and transferred to PACU in satisfactory condition.","surgery, knee arthroplasty, revision, zimmer nexgen, distal femoral, intramedullary guide, femoral component, femoral, knee, arthroplasty, intramedullary, patellar, medial, tibial, "
 KYPHON Balloon Kyphoplasty at T12 and L1evels Insertion of KYPHON HV-R bone cement under low pressure at T12 and L1 levels and bone biopsy., Surgery, Kyphoplasty ,"PRE-OP DIAGNOSIS:,  Osteoporosis, pathologic fractures T12- L2 with severe kyphosis.,POST-OP DIAGNOSIS:,  Osteoporosis, pathologic fractures T12- L2 with severe kyphosis.,PROCEDURE:,1.  KYPHON Balloon Kyphoplasty at T12 and L1evels Insertion of KYPHON HV-R bone cement under low pressure at T12 and L1 levels.,2.  Bone biopsy (medically necessary).,ANESTHESIA:, General,COMPLICATIONS:, None,BLOOD LOSS:, Minimal,INDICATIONS:,  Mrs. Smith is a 75-year-old female who has had severe back pain that began approximately three months ago and is debilitating.  She has been unresponsive to nonoperative treatment modalities including bed rest and analgesics.  She presents with and is on medication therapy for COPD, diabetes and hypertension (other co-morbidities may be present upon admission and should be documented in the operative note).,Radiographic imaging including MRI confirms multiple compression fractures of the thoracolumbar spine including T12, L1 and L2.  In addition to the fractures, she presents with kyphotic posture.  Films on 1/04 demonstrated L1 and L2 osteoporotic fractures.  Films on 2/04 demonstrated increased loss of height at L1.  Films on 3/04 demonstrated a new compression fracture at T12 and further collapse of L1.  The L2 fracture is documented on radiographic studies as being chronic and a year or more old.  The T12 fracture has the most significant kyphotic deformity.  Based on these findings, we have decided to perform KYPHON Balloon Kyphoplasty on the L1 and T12 fractures.,PROCEDURE:,  The patient was brought to the operating room/radiology suite and general anesthesia/local sedation with endotracheal intubation was performed.  The patient was positioned prone on the Jackson table.  The back was prepped and draped.  The image intensifier (C-arm) was brought into position and the T12 pedicles were identified and marked with a skin marker.  In view of the collapse of T12, a transpedicular approach to the vertebral body was appropriate.  An 11-gauge needle was advanced through the T12 pedicle to the junction of the pedicle and vertebral body on the right side.  Positioning was confirmed on the AP and lateral plane.  Following satisfactory placement of the needle, the stylet was removed.  A guide pin was inserted through the 11g to a point 3mm from the anterior cortex.  AP and lateral images were taken to verify position and trajectory.  Alongside of the guide pin a 1-cm paramedian incision was made.  The needle was then removed leaving the guide pin in place.  The osteointroducer was placed over the guide pin and advanced through the pedicle.  Once I was at the junction of the pedicle and the vertebral body, a lateral image was taken to insure that the cannula was positioned approximately 1cm past the vertebral body wall.  Through the cannula, a drill was advanced into the vertebral body under fluoroscopic guidance toward the anterior cortex, creating a channel.  The anterior cortex was probed with the guide pin to ensure no perforations in the anterior cortex.  After completing the entry into the vertebral body, a 15 mm inflatable bone tamp was inserted through the cannula and advanced under fluoroscopic guidance into the vertebral body near the anterior cortex.  The radiopaque marker bands on the bone tamp were identified using AP and lateral images.  The above sequence of instrument placement was then repeated on the left side of the T12 vertebral body.  Once both bone tamps were in position, they were inflated to 0.5 cc and 50 psi.  Expansion of the bone tamps was done sequentially in increments of 0.25 to 0.5 cc of contrast, with careful attention being paid to the inflation pressures and balloon position.  The inflation was monitored with AP and lateral imaging.  The final balloon volume was 3.5 cc on the right side and 3 cc on the left.  There was no breach of the lateral wall or anterior cortex of the vertebral body.  Direct reduction of the fracture was achieved, end plate movement was noted and approximately 5 mm of height restoration was achieved.  Under fluoroscopic imaging, and the use of the bone void fillers, internal fixation was achieved through a low-pressure injection of KYPHON HV-R bone cement.  The cavity was filled with a total volume of 3.5 cc on the right side and 3 cc on the left side.  Once the bone cement had hardened, the cannulas were then removed.,At this time, we proceeded to perform a balloon kyphoplasty at L1 using the same sequence of steps as on T12.  An entry needle was placed bilaterally through the pedicle into the vertebral body, a cortical window was created, inflation of the bone tamps directly reduced the fracture, the bone tamps were removed, and internal fixation by bone void filler insertion was achieved.  Throughout the procedure, AP and lateral imaging monitored positioning.,Post-procedure, all incisions were closed with sutures.  The patient was kept in the prone position for approximately 10 minutes post cement injection.  She was then turned supine, monitored briefly and returned to the floor.  She was moving both her lower extremities at this time.,Throughout the procedure, there were no intraoperative complications.  Estimated blood loss was minimal.","surgery, osteoporosis, pathologic fractures, kyphosis, bone cement, balloon kyphoplasty, kyphon balloon kyphoplasty, bone biopsy, kyphon, insertion of kyphon, ap and lateral, vertebral body, kyphon balloon, anterior cortex, vertebral, body, fractures, insertion, bone, kyphoplasty, guide, balloon, pedicles, cortex, positioned, therapy"
 Arthroscopic procedure of the knee., Surgery, Knee Arthroscopy - 1 ,"PROCEDURE IN DETAIL: , After written consent was obtained from the patient, the patient was brought back into the operating room and identified.  The patient was placed in the operating room table in supine position and given general anesthetic.,Ancef 1 g was given for infectious prophylaxis.  Once the patient was under general anesthesia, the knee was prepped and draped in usual sterile fashion.  Once the knee was fully prepped and draped, then we made 2 standard portals medial and lateral.  Through the lateral portal, the camera was placed.  Through the medial portal, tools were placed.  We proceeded to examine scarring of the patellofemoral joint.  Then we probed the patellofemoral joint.  A chondroplasty was performed using a shaver.  Then we moved down to the lateral gutter.  Some loose bodies were found using a shaver and dissection.  We moved down the medial gutter.  No plica was found.,We moved into the medial joint; we found that the medial meniscus was intact.  We moved to the lateral joint and found that the lateral meniscus was intact.  Pictures were taken.  We drained the knee and washed out the knee with copious amounts of sterile saline solution.  The instruments were removed.  The 2 portals were closed using 3-0 nylon suture.  Xeroform, 4 x 4s, Kerlix x2, and TED stocking were placed.  The patient was successfully extubated and brought to the recovery room in stable condition.  I then spoke with the family going over the case, postoperative instructions, and followup care.","surgery, chondroplasty, knee, meniscus, patellofemoral, arthroscopy, portals, jointNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Revision laminectomy L5-S1, discectomy L5-S1, right medial facetectomy, preparation of disk space and arthrodesis with interbody graft with BMP.  Status post previous lumbar surgery for herniated disk with severe recurrence of axial back pain, failed conservative therapy.", Surgery, Laminectomy & Discectomy & Facetectomy ,"TITLE OF OPERATION: , Revision laminectomy L5-S1, discectomy L5-S1, right medial facetectomy, preparation of disk space and arthrodesis with interbody graft with BMP.,INDICATIONS FOR SURGERY:  ,Please refer to medical record, but in short, the patient is a 43-year-old male known to me, status post previous lumbar surgery for herniated disk with severe recurrence of axial back pain, failed conservative therapy.  Risks and benefits of surgery were explained in detail including risk of bleeding, infection, stroke, heart attack, paralysis, need for further surgery, hardware failure, persistent symptoms, and death.  This list was inclusive, but not exclusive.  An informed consent was obtained after all patient's questions were answered.,PREOPERATIVE DIAGNOSIS:  ,Severe lumbar spondylosis L5-S1, collapsed disk space, hypermobility, and herniated disk posteriorly.,POSTOPERATIVE DIAGNOSIS: , Severe lumbar spondylosis L5-S1, collapsed disk space, hypermobility, and herniated disk posteriorly.,ANESTHESIA: , General anesthesia and endotracheal tube intubation.,DISPOSITION: , The patient to PACU with stable vital signs.,PROCEDURE IN DETAIL:  ,The patient was taken to the operating room.  After adequate general anesthesia with endotracheal tube intubation was obtained, the patient was placed prone on the Jackson table.  Lumbar spine was shaved, prepped, and draped in the usual sterile fashion.  An incision was carried out from L4 to S1.  Hemostasis was obtained with bipolar and Bovie cauterization.  A Weitlaner was placed in the wound and a subperiosteal dissection was carried out identifying the lamina of L4, L5, and sacrum.  At this time, laminectomy was carried out of L5-S1.  Thecal sac was retracted rightward and the foramen was opened and unilateral medial facetectomy was carried out in the disk space.  At this time, the disk was entered with a #15 blade and bipolar.  The disk was entered with straight up and down-biting pituitaries, curettes, and the high speed drill and we were able to takedown calcified herniated disk.  We were able to reestablish the disk space, it was very difficult, required meticulous dissection and then drilling with a diamond bur in the disk space underneath the spinal canal, very carefully holding the spinal canal out of harm's way as well as the exiting nerve root.  Once this was done, we used rasps to remove more disk material anteriorly and under the midline to the left side and then we put in interbody graft of BMP 8 mm graft from Medtronic.  At this time, Dr. X will dictate the posterolateral fusion, pedicle screw fixation to L4 to S1 with compression and will dictate the closure of the wound.  There were no complications.","surgery, revision laminectomy, discectomy, facetectomy, arthrodesis, lumbar spondylosis, hypermobility, collapsed disk space, medial facetectomy, interbody graft, herniated disk, interbody, laminectomy, disk, therapy, lumbar, herniated, space,"
 Procedure note on Keller Bunionectomy, Surgery, Keller Bunionectomy ,"PROCEDURE: , Keller Bunionectomy.,For informed consent, the more common risks, benefits, and alternatives to the procedure were thoroughly discussed with the patient.  An appropriate consent form was signed, indicating that the patient understands the procedure and its possible complications.,This 59 year-old female was brought to the operating room and placed on the surgical table in a supine position.  Following anesthesia, the surgical site was prepped and draped in the normal sterile fashion.,Attention was then directed to the right foot where, utilizing a # 15 blade, a 6 cm. linear incision was made over the 1st metatarsal head, taking care to identify and retract all vital structures.  The incision was medial to and parallel to the extensor hallucis longus tendon.  The incision was deepened through subcutaneous underscored, retracted medially and laterally - thus exposing the capsular structures below, which were incised in a linear longitudinal manner, approximately the length of the skin incision.  The capsular structures were sharply underscored off the underlying osseous attachments, retracted medially and laterally.,Utilizing an osteotome and mallet, the exostosis was removed, and the head was remodeled with the Liston bone forceps and the bell rasp.  The surgical site was then flushed with saline.  The base of the proximal phalanx of the great toe was osteotomized approximately 1 cm. distal to the base and excised to toto from the surgical site.,Superficial closure was accomplished using Vicryl 5-0 in a running subcuticular fashion.  Site was dressed with a light compressive dressing.  The tourniquet was released.  Excellent capillary refill to all the digits was observed without excessive bleeding noted.,ANESTHESIA: , local.,HEMOSTASIS: , Accomplished with pinpoint electrocoagulation.,ESTIMATED BLOOD LOSS: , 10 cc.,MATERIALS:,  None.,INJECTABLES:,  Agent used for local anesthesia was Lidocaine 2% without epi.,PATHOLOGY:,  Sent no specimen.,DRESSINGS: , Site was dressed with a light compressive dressing.,CONDITION: , Patient tolerated procedure and anesthesia well.  Vital signs stable.  Vascular status intact to all digits.  Patient recovered in the operating room.,SCHEDULING: , Return to clinic in 2 week (s).","surgery, keller bunionectomy, metatarsal head, incision, capsular, osteotome, compressive dressing, keller, bunionectomy, "
" Left below-the-knee amputation.  Dressing change, right foot.", Surgery, Knee Amputation ,"PREOPERATIVE DIAGNOSES:,1.  Left diabetic foot abscess and infection.,2.  Left calcaneus fracture with infection.,3.  Right first ray amputation.,POSTOP DIAGNOSES:,1.  Left diabetic foot abscess and infection.,2.  Left calcaneus fracture with infection.,3.  Right first ray amputation.,OPERATION AND PROCEDURE:,1.  Left below-the-knee amputation.,2.  Dressing change, right foot.,ANESTHESIA: , General.,BLOOD LOSS: , Less than 100 mL.,TOURNIQUET TIME:,  24 minutes on the left, 300 mmHg.,COMPLICATIONS:,  None.,DRAINS: , A one-eighth-inch Hemovac.,INDICATIONS FOR SURGERY: , The patient is a 62 years of age with diabetes.  He developed left heel abscess.  He had previous debridements, developed a calcaneal fracture and has now had several debridement with placement of the antibiotic beads.  After re-inspecting the wound last week, the plan was for possible debridement and he desired below-the-knee amputation.  We are going to change the dressing on the right side also.  The risks, benefits, and alternatives of surgery were discussed.  The risks of bleeding, infection, damage to nerves and blood vessels, persistent wound healing problems, and the need for future surgery.  He understood all the risks and desired operative treatment.,OPERATIVE PROCEDURE IN DETAIL: , After appropriate informed consent obtained, the patient was taken to the operating room and placed in the supine position.  General anesthesia induced.  Once adequate anesthesia had been achieved, cast padding placed on the left proximal thigh and tourniquet was applied.  The right leg was redressed.  I took the dressing down.  There was a small bit of central drainage, but it was healing nicely.  Adaptic and new sterile dressings were applied.,The left lower extremity was then prepped and draped in usual sterile fashion.,A transverse incision made about the mid shaft of the tibia.  A long posterior flap was created.  It was taken to the subcutaneous tissues with electrocautery.  Please note that tourniquet had been inflated after exsanguination of the limb.  Superficial peroneal nerve identified, clamped, and cut.  Anterior compartment was divided.  The anterior neurovascular bundle identified, clamped, and cut.  The plane was taken between the deep and superficial compartments.  The superficial compartment was reflected posteriorly.  Tibial nerve identified, clamped, and cut.  Tibial vessels identified, clamped, and cut.,Periosteum of the tibia elevated proximally along with the fibula.  The tibia was then cut with Gigli saw.  It was beveled anteriorly and smoothed down with a rasp.  The fibula was cut about a cm and a half proximal to this using a large bone cutter.  The remaining posterior compartment was divided.  The peroneal bundle identified, clamped, and cut.  The leg was then passed off of the field.  Each vascular bundle was then doubly ligated with 0 silk stick tie and 0 silk free tie.  The nerves were each pulled at length, injected with 0.25% Marcaine with epinephrine, cut, and later retracted proximally.  The tourniquet was released.  Good bleeding from the tissues and hemostasis obtained with electrocautery.  Copious irrigation performed using antibiotic-impregnated solution.  A one-eighth-inch Hemovac drain placed in the depth of wound adhering on the medial side.  A gastroc soleus fascia brought up and attached to the anterior fascia and periosteum with #1 Vicryl in an interrupted fashion.  The remaining fascia was closed with #1 Vicryl.  Subcutaneous tissues were then closed with 2-0 PDS suture using 2-0 Monocryl suture in interrupted fashion.  Skin closed with skin staples.  Xeroform gauze, 4 x 4, and a padded soft dressing applied.  He was placed in a well-padded anterior and posterior slab splint with the knee in extension.  He was then awakened, extubated, and taken to recovery in stable condition.  There were no immediate operative complications, and he tolerated the procedure well.","surgery, infection, adaptic, gigli saw, hemovac, abscess, amputation, below-the-knee amputation, calcaneus fracture, debridement, diabetic foot, ray amputation, tourniquet, transverse incision, knee amputation, knee, dressing, clamped, "
 Exam under anesthesia.  Removal of intrauterine clots.  Postpartum hemorrhage, Surgery, Intrauterine Clots Removal ,"PREOPERATIVE DIAGNOSIS: , Postpartum hemorrhage.,POSTOPERATIVE DIAGNOSIS: , Postpartum hemorrhage.,PROCEDURE:,  Exam under anesthesia.  Removal of intrauterine clots.,ANESTHESIA: , Conscious sedation.,ESTIMATED BLOOD LOSS:,  Approximately 200 mL during the procedure, but at least 500 mL prior to that and probably more like 1500 mL prior to that.,COMPLICATIONS: , None.,INDICATIONS AND CONCERNS: , This is a 19-year-old G1, P1 female, status post vaginal delivery, who was being evaluated by the nurse on labor and delivery approximately four hours after her delivery.  I was called for persistent bleeding and passing large clots.  I examined the patient and found her to have at least 500 mL of clots in her uterus.  She was unable to tolerate exam any further than that because of concerns of the amount of bleeding that she had already had and inability to adequately evaluate her.  I did advise her that I would recommend they came under anesthesia and dilation and curettage.  Risks and benefits of this procedure were discussed with Misty, all of her questions were adequately answered and informed consent was obtained.,PROCEDURE: , The patient was taken to the operating room where satisfactory conscious sedation was performed.  She was placed in the dorsal lithotomy position, prepped and draped in the usual fashion.  Bimanual exam revealed moderate amount of clot in the uterus.  I was able to remove most of the clots with my hands and an attempt at short curettage was performed, but because of contraction of the uterus this was unable to be adequately performed.  I was able to thoroughly examine the uterine cavity with my hand and no remaining clots or placental tissue or membranes were found.  At this point, the procedure was terminated.  Bleeding at this time was minimal.  Preop H&H were 8.3 and 24.2.  The patient tolerated the procedure well and was taken to the recovery room in good condition.","surgery, uterus, intrauterine clots, postpartum hemorrhage, intrauterine, curettage, hemorrhage, bleeding, postpartum, clots,"
 Repair of juxtarenal abdominal aortic aneurysm with 14 mm Hemashield tube graft., Surgery, Juxtarenal Abdominal Aortic Aneurysm Repair ,"PREOPERATIVE DIAGNOSIS:  Large juxtarenal abdominal aortic aneurysm.,POSTOPERATIVE DIAGNOSIS:  Large juxtarenal abdominal aortic aneurysm.,ANESTHESIA:  General endotracheal anesthesia.,OPERATIVE TIME:  Three hours.,ANESTHESIA TIME:  Four hours.,DESCRIPTION OF PROCEDURE:  After thorough preoperative evaluation, the patient was brought to the operating room and placed on the operating table in supine position and after placement of upper extremity IV access and radial A-line, general endotracheal anesthesia was induced.  A Foley catheter was placed and a right internal jugular central line was placed.  The chest, abdomen, both groin, and perineum were prepped widely with Betadine and draped as a sterile field with an Ioban drape.  A long midline incision from xiphoid to pubis was created with a scalpel and the abdomen was carefully entered.  A sterile Omni-Tract was introduced into the field to retract the abdominal wall and gentle exploration of the abdomen was performed.  With the exception of the vascular findings to be described, there were no apparent intra-abdominal abnormalities.,The transverse colon retracted superiorly.  The small bowel was wrapped in moist green towel and retracted in the right upper quadrant.  The posterior peritoneum overlying the aneurysm was scribed mobilizing the ligament of Treitz thoroughly ligating and dividing the inferior mesenteric vein.  Dissection continued superiorly to identify the left renal vein and the right and left inferior renal arteries.  The mid left renal artery was likewise identified.  The perirenal aorta was prepared for clamp superior to the inferior left renal artery.  During this portion of the dissection, the patient was given multiple small doses of intravenous mannitol to establish an osmotic diuresis.  The distal dissection was then completed exposing each common iliac artery.  The arteries were suitable for control.,The patient was then given 8000 units of intravenous sodium heparin and systemic anticoagulation verified by activated clotting time.  The aneurysm was repaired.,First, the common carotid arteries were controlled with atraumatic clamps.  The inferior left renal artery was controlled with a microvascular clamp and a straight aortic clamp was used to control the aorta superior to this renal artery.  The aneurysm was opened on the right anterior lateral aspect and an endarterectomy of the aneurysm sac was performed.  There was a high-grade stenosis at the origin of the inferior mesenteric artery and an eversion endarterectomy was performed at this site.  The vessel was controlled with a microvascular clamp.  Two pairs of lumbar arteries were oversewn with 2-0 silk.  A 14 mm Hemashield tube graft was selected and sewn end-to-end fashion to the proximal aorta using a semi continuous 3-0 Prolene suture.  At the completion of anastomosis three patch stitches of 3-0 Prolene were required for hemostasis.  The graft was cut to appropriate length and sewn end-to-end at the iliac bifurcation using semi-continuous 3-0 Prolene suture.  Prior to completion of this anastomosis, the graft was flushed of air and debris and blood flow was reestablished slowly to the distal native circulation first to the pelvis with external compression on the femoral vessels and finally to the distal native circulation.  The distal anastomosis was competent without leak.,The patient was then given 70 mg of intravenous protamine and final hemostasis obtained using electrocoagulation.  The back bleeding from the inferior mesenteric artery was assessed and was pulsatile and vigorous.  The colon was normal in appearance and this vessel was oversewn using 2-0 silk.  The aneurysm sac was then closed about the grafts snuggly using 3-0 PDS in a vest-over-pants fashion.  The posterior peritoneum was reapproximated using running 3-0 PDS.  The entire large and small bowel were inspected and these structures were well perfused with a strong pulse within the SMA normal appearance of the entire viscera.  The NG tube was positioned in the fundus of the stomach and the viscera returned to their anatomic location.  The midline fascia was then reapproximated using running #1 PDS suture.  The subcutaneous tissues were irrigated with bacitracin and kanamycin solution.  The skin edges coapted using surgical staples.,At the conclusion of the case, sponge and needle counts were correct and a sterile occlusive compressive dressing was applied.","surgery, inferior left renal artery, semi continuous prolene suture, juxtarenal abdominal aortic aneurysm, inferior mesenteric artery, continuous prolene suture, abdominal aortic aneurysm, hemashield tube, inferior mesenteric, renal artery, aortic aneurysm, aneurysm, iliac, endarterectomy, viscera, hemashield, abdomen, prolene, arteries, juxtarenal, graft, aortic, endotracheal, renal, artery, "
" Bilateral degenerative arthritis of the knees.  Right total knee arthroplasty done in conjunction with a left total knee arthroplasty, which will be dictated separately.", Surgery, Knee Arthroplasty ,"PREOPERATIVE DIAGNOSIS: , Bilateral degenerative arthritis of the knees.,POSTOPERATIVE DIAGNOSIS: , Bilateral degenerative arthritis of the knees.,PROCEDURE PERFORMED: , Right total knee arthroplasty done in conjunction with a left total knee arthroplasty, which will be dictated separately.,ANESTHESIA: , General.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS: , Bilateral procedure was 400 cc.,TOTAL TOURNIQUET TIME:  ,75 minutes.,COMPONENTS: , Include the Zimmer NexGen complete knee solution system, which include a size F right cruciate retaining femoral component, a size #8 peg tibial component precoat, a All-Poly standard size 38, 9.5 mm thickness patellar component, and a prolonged highly cross-linked polyethylene NexGen cruciate retaining tibial articular surface size blue 12 mm height.,HISTORY OF PRESENT ILLNESS: , The patient is a 69-year-old male who presented to the office complaining of bilateral knee pain for a couple of years.  The patient complained of clicking noises and stiffness, which affected his daily activities of living.,PROCEDURE: , After all potential complications, risks as well as anticipated benefits of the above-named procedure was discussed at length, the patient's informed consent was obtained.,Operative extremities were then confirmed with the operating surgeons as well as the nursing staff, Department of Anesthesia, and the patient.  The patient was then transferred to preoperative area to operative suite #2 and placed on the operating room table in supine position.  All bony prominences were well padded at this time.  At this time, Department of Anesthesia administered general anesthetic to the patient.  The patient was allowed in DVT study and the right extremity was in the Esmarch study as well as the left.  The nonsterile tourniquet was then applied to the right upper thigh of the patient, but not inflated at this time.  The right lower extremity was sterilely prepped and draped in the usual sterile fashion.  The right upper extremity was then elevated and exsanguinated using an Esmarch and the tourniquet was inflated using 325 mmHg.  The patient was a consideration for a unicompartmental knee replacement.  So, after all bony and soft tissue landmarks were identified, a limited midline longitudinal incision was made directly over the patella.  A sharp dissection was then taken down to the level of the fascia in line with the patella as well as the quadriceps tendon.  Next, a medial parapatellar arthrotomy was performed using the #10 blade scalpel.  Upon viewing of the articular surfaces, there was significant ware in the trochlear groove as well as the medial femoral condyle and it was elected to proceed with total knee replacement.  At this time, the skin incisions as well as the deep incisions were extended proximally and distally in a midline fashion.  Total incision now measured approximately 25 cm.  Retractors were placed.  Next, attention was directed to establishing medial and lateral flaps of the proximal tibia.  Reciprocating osteal elevator was used to establish soft tissue plane and then an electrocautery was then used to subperiosteal strip medially and laterally on the proximal tibia.  At this time, the patella was then everted.  The knee was flexed up to 90 degrees.  Next, using the large drill bit, the femoral canal was then opened in appropriate position.  The intramedullary sizing guide was then placed and the knee was sized to a size F. At this time, the three degrees external rotation holes were then drilled after carefully assessing the epicondylar access as well as the white sideline.  The guide was then removed.  The intramedullary guide was then placed with nails holding the guide in three degrees of external rotation.  Next, the anterior femoral resection guide was then placed and clamped into place using a pointed _________________ was then used to confirm that there would no notching performed.  Next, soft tissue retractors were placed and an oscillating saw was used to make the anterior femoral cut.  Upon checking, it was noted to be flat with no oscillations.  The anterior guide was then removed and the distal femoral resection guide was placed in five degrees of valgus.  It was secured in place using nails.  The intramedullary guide was then removed and the standard distal femoral cut was then made using oscillating saw.,This was then removed and the size F distal finishing femoral guide was then placed on the femur in proper position.  Bony and soft tissue landmarks were confirmed and the resection guide was then held in place using nail as well as spring screws.  Again, the collateral ligament retractors were then placed and the oscillating saw was used to make each of the anterior and posterior as well as each chamfer cut.  A reciprocating saw was then used to cut the trochlear cut and the peg holes were drilled as well.  The distal finishing guide was then removed and osteotome was then used to remove all resected bone.  The oscillating saw was then used to complete the femoral notch cut.  Upon viewing, there appeared to be proper amount of bony resection and all bone was removed completely.  There was no posterior osteophytes noted and no fragments to the posterior aspect.  Next, attention was directed towards the tibia.  The external tibial guide was reflected.  This was placed on the anterior tibia and held in place using nails after confirming the proper varus and valgus position.  The resection guide was then checked and appeared to be sufficient amount of resection in both medial and lateral condyles of the tibia.  Next, collateral ligament retractors were placed as well as McGill retractors for the PCL.  Oscillating saw was then used to make the proximal tibial cut.  Osteotome was used to remove this excess resected bone.  The laminar spreader was then used to check the flexion and extension.  The gaps appeared to be equal.  The external guide was then removed and trial components were placed to a size F femoral component and a 12 mm tibial component on a size 8 tray.  The knee was taken through range of motion and had very good flexion as well as full extension.  There appeared to be good varus and valgus stability as well.  Next, attention was directed towards the patella.  There noted to be a sufficient ware and it was selected to replace the patella.  It was sized with caliper, pre-cut and noted to be 26 mm depth.  The sizing guide was then used and a size 51 resection guide selected.  A 51 mm reamer was then placed and sufficient amount of patella was then removed.  The calcar was then used to check again and there was noted to be 15 mm remaining.  The 38 mm patella guide was then placed on the patella.  It was noted to be in proper size and the three drill holes for the pegs were used.  A trial component was then placed.  The knee was taken through range of motion.  There was noted to be some subluxation lateral to the patellar component and a lateral release was performed.  After this, the component appeared to be tracking very well.  There remained a good range of motion in the knee and extension as well as flexion.  At this time, an AP x-ray of the knee was taken with the trial components in place.  Upon viewing this x-ray, it appeared that the tibial cut was in neutral, all components in proper positioning.  The knee was then copiously irrigated and dried.  The knee was then flexed ___________ placed, and the peg drill guide was placed on the tibia in proper position, held in place with nails.,The four peg holes were then drilled.  The knee again was copiously irrigated and suction dried.  The final components were then selected again consisting of size F femoral components.  A peg size 8 tibial component, a 12 mm height articular surface, size blue, and a 38 mm 9.5 mm thickness All-Poly patella.  Polymethyl methacrylate was then prepared at this time.  The proximal tibia was dried and the cement was then pressed into place.  The cement was then placed on the backside of the tibial component and the tibial component was then impacted into proper positioning.  Next, the proximal femur was cleaned and dried.  Polymethyl methacrylate was placed on the resected portions of the femur as well as the backside of the femoral components.  This was then impacted in place as well.  At this time, all excess cement was removed from both the tibial and femoral components.  A size 12 mm trial tibial articular surface was then put in place.  The knee was reduced and held in loading position throughout the remaining drying position of the cement.  Next, the resected patella was cleaned and dried.  The cement was placed on the patella as well as the backside of the patellar component.  The component was then put in proper positioning and held in place with a clamp.  All excess polymethyl methacrylate was removed from this area as well.  This was held until the cement had hardened sufficiently.  Next, the knee was examined.  All excess cement was then removed.  The knee was taken through range of motion with sufficient range of motion as well as stability.  The final 12 mm height polyethylene tibial component was then put into place and snapped down in proper position.  Again range of motion was noted to be sufficient.  The knee was copiously irrigated and suction dried once again.  A drain was then placed within the knee.  The wound was then closed first using #1 Ethibond to close the arthrotomy oversewn with a #1 Vicryl.  The knee was again copiously irrigated and dried.  The skin was closed using #2-0 Vicryl in subcuticular fashion followed by staples on the skin.  The ConstaVac was then _______ to the drain.  Sterile dressing was applied consisting of Adaptic, 4x4, ABDs, Kerlix, and a 6-inch Dupre roll from foot to thigh.  Department of Anesthesia then reversed the anesthetic.  The patient was transferred back to the hospital gurney to Postanesthesia Care Unit.  The patient tolerated the procedure well and there were no complications.","surgery, degenerative, arthritis, zimmer nexgen, all-poly, cruciate, patellar component, total knee arthroplasty, knee arthroplasty, tibial component, femoral, patellar, tibial, knee, arthroplasty, anesthesia, "
 Secondary scleral suture fixated posterior chamber intraocular lens implant with penetrating keratoplasty.  A concurrent vitrectomy and endolaser was performed by the vitreoretinal team., Surgery, Intraocular Lens Implant ,"TITLE OF OPERATION:  ,1.  Secondary scleral suture fixated posterior chamber intraocular lens implant with penetrating keratoplasty.,2.  A concurrent vitrectomy and endolaser was performed by the vitreoretinal team.,INDICATION FOR SURGERY:  ,The patient is a 62-year-old white male who underwent cataract surgery in 09/06.  This was complicated by posterior capsule rupture.  An intraocular lens implant was not attempted.  He developed corneal edema and a preretinal hemorrhage.  He is aware of the risks, benefits, and alternatives of the surgery and now wishes to proceed with secondary scleral suture fixated posterior chamber intraocular lens implant in the left eye, vitrectomy, endolaser, and penetrating keratoplasty.,PREOP DIAGNOSIS:  ,1.  Preretinal hemorrhage.,2.  Diabetic retinopathy.,3.  Aphakia.,4.  Corneal edema.,POSTOP DIAGNOSIS:  ,1.  Preretinal hemorrhage.,2.  Diabetic retinopathy.,3.  Aphakia.,4.  Corneal edema.,ANESTHESIA: , General.,SPECIMEN:  ,1.  Donor corneal swab sent to Microbiology.,2.  Donor corneal scar rim sent to Eye Pathology.,3.  The patient's cornea sent to Eye Pathology.,PROS DEV IMPLANT:  ,ABC Laboratories 16.0 diopter posterior chamber intraocular lens, serial number 123456.,NARRATIVE: , Informed consent was obtained, and all questions were answered.  The patient was brought to the preoperative holding area, where the operative left eye was marked.  He was brought to the operating room and placed in the supine position.  EKG leads were placed.  General anesthesia was induced.  The left ocular surface and periorbital skin were disinfected and draped in the standard fashion for eye surgery after a shield and tape were placed over the unoperated right eye.  A lid speculum was placed.  The posterior segment infusion was placed by the vitreoretinal service.  Peritomy was performed at the 3 and 9 o'clock limbal positions.  A large Flieringa ring was then sutured to the conjunctival surface using 8-0 silk sutures tied in an interrupted fashion.  The cornea was then measured and was found to accommodate a 7.5-mm trephine.  The center of the cornea was marked.  The keratoprosthesis was identified.,A 7.5-mm trephine blade was then used to incise the anterior corneal surface.  This was done after a paracentesis was placed at the 1 o'clock position and viscoelastic was used to dissect peripheral anterior synechiae.  Once the synechiae were freed, the above-mentioned trephination of the anterior cornea was performed.  Corneoscleral scissors were then used to excise completely the central cornea.  The keratoprosthesis was placed in position and was sutured with six interrupted 8-0 silk sutures.  This was done without difficulty.  At this point, the case was turned over to the vitreoretinal team, which will dictate under a separate note.  At the conclusion of the vitreoretinal procedure, the patient was brought under the care of the cornea service.  The 9-0 Prolene sutures double armed were then placed on each lens haptic loop.  The keratoprosthesis was removed.  Prior to this removal, scleral flaps were made, partial thickness at the 3 o'clock and 9 o'clock positions underneath the peritomies.  Wet-field cautery also was performed to achieve hemostasis.  The leading hepatic sutures were then passed through the bed of the scleral flap.  These were drawn out of the eye and then used to draw the trailing hepatic into the posterior segment of the eye followed by the optic.  The trailing hepatic was then placed into the posterior segment of the eye as well.  The trailing haptic sutures were then placed through the opposite scleral flap bed and were withdrawn.  These were tied securely into position with the IOL nicely centered.  At this point, the donor cornea punched at 8.25 mm was then brought into the field.  This was secured with four cardinal sutures.  The corneal button was then sutured in place using a 16-bite 10-0 nylon running suture.  The knot was secured and buried after adequate tension was adjusted.  The corneal graft was watertight.  Attention was then turned back to the IOL sutures, which were locked into position.  The ends were trimmed.  The flaps were secured with single 10-0 nylon sutures to the apex, and the knots were buried.  At this point, the case was then turned back over to the vitreoretinal service for further completion of the retinal procedure.  The patient tolerated the corneal portions of the surgery well and was turned over to the retina service in good condition, having tolerated the procedure well.  No complications were noted.  The attending surgeon, Dr. X, performed the entire procedure.  No complications of the procedure were noted.  The intraocular lens was selected from preoperative calculations.  No qualified resident was available to assist.","surgery, vitrectomy, endolaser, keratoplasty, intraocular lens implant, preretinal hemorrhage, scleral flaps, intraocular, keratoprosthesis, chamber, implant, scleral, vitreoretinal, lens, sutures, eye, "
 Debridement left ischial ulcer., Surgery, Ischial Ulcer Debridement ,"PREOPERATIVE DIAGNOSES: , Nonhealing decubitus ulcer, left ischial region? Osteomyelitis, paraplegia, and history of spina bifida.,POSTOPERATIVE DIAGNOSES: , Nonhealing decubitus ulcer, left ischial region? Osteomyelitis, paraplegia, and history of spina bifida.,PROCEDURE PERFORMED:  ,Debridement left ischial ulcer.,ANESTHESIA: ,Local MAC.,INDICATIONS:,  This is a 27-year-old white male patient, with a history of spina bifida who underwent spinal surgery about two years ago and subsequently he has been paraplegic.  The patient has a nonhealing decubitus ulcer in the left ischial region, which is quite deep.  It appears to be right down to the bone.  MRI shows findings suggestive of osteomyelitis.  The patient is being brought to operating room for debridement of this ulcer.  Procedure, indication, and risks were explained to the patient.  Consent obtained.,PROCEDURE IN DETAIL: ,The patient was put in right lateral position and left buttock and ischial region was prepped and draped.  Examination at this time showed fair amount of chronic granulation tissue and scarred tissue circumferentially as well as the base of this decubitus ulcer.  This was sharply excised until bleeding and healthy tissue was obtained circumferentially as well as the base.  The ulcer does not appear to be going into the bone itself as there was a covering on the bone, which appears to be quite healthy, normal and bone itself appeared solid.,I did not rongeur the bone.  The deeper portion of the excised tissue was also sent for tissue cultures.  Hemostasis was achieved with cautery and the wound was irrigated with sterile saline solution and then packed with medicated Kerlix.  Sterile dressing was applied.  The patient transferred to recovery room in stable condition.","surgery, debridement, ischial ulcer, ischial region, osteomyelitis, paraplegia, spina bifida, decubitus ulcer "
 Intramedullary nail fixation of the left tibia fracture with a Stryker T2 tibial nail.  Left tibial shaft fracture status post gunshot wound., Surgery, Intramedullary Nail Fixation ,"TITLE OF OPERATION: , Intramedullary nail fixation of the left tibia fracture with a Stryker T2 tibial nail, 10 x 390 with a one 5-mm proximal locking screw and three 5-mm distal locking screws (CPT code is 27759) (the ICD-9 code again is 823.2 for a tibial shaft fracture).,INDICATION FOR SURGERY:  ,The patient is a 19-year-old male, who sustained a gunshot wound to the left tibia with a distal tibial shaft fracture.  The patient was admitted and splinted and had compartment checks.  The risks of surgery were discussed in detail including, but not limited to infection, bleeding, injuries to nerves, or vital structures, nonunion or malunion, need for reoperation, compartment syndrome, and the risk of anesthesia.  The patient understood these risks and wished to proceed.,PREOP DIAGNOSIS: , Left tibial shaft fracture status post gunshot wound (CPT code 27759).,POSTOP DIAGNOSIS: , Left tibial shaft fracture status post gunshot wound (CPT code 27759).,ANESTHESIA: , General endotracheal.,INTRAVENOUS FLUID:,  900.,ESTIMATED BLOOD LOSS:  ,100.,COMPLICATIONS:,  None.,DISPOSITION: , Stable to PACU.,PROCEDURE DETAIL:  ,The patient was met in the preoperative holding area and operative site was marked.  The patient was brought to the operating room and given preoperative antibiotics.  Left leg was then prepped and draped in the usual sterile fashion.  A midline incision was made in the center of the knee and was carried down sharply to the retinacular tissue.  The starting guidewire was used to localize the correct starting point, which is on the medial aspect of the lateral tibial eminence.  This was advanced and confirmed on the AP and lateral fluoroscopic images.  The opening reamer was then used and the ball-tip guidewire was passed.  The reduction was obtained over a large radiolucent triangle.  After passing the guidewire and achieving appropriate reduction, the flexible reamers were then sequentially passed, starting at 9 mm up to 11.5 mm reamer.  At this point, a 10 x 390 mm was passed without difficulty.  The guide was used to the proximal locking screw and the appropriate circle technique was used to the distal locking screws.  The final images were taken with fluoroscopy and a 15-mm end-cap was placed.  The wounds were then irrigated and closed with 2-0 Vicryl followed by staples to the distal screws and 0 Vicryl followed 2-0 Vicryl and staples to the proximal incision.  The patient was placed in a short leg, well-padded splint, was awakened and taken to recovery in good condition.,The plan will be nonweightbearing left lower extremity.  He will be placed in a short leg splint and should be transitioned to a short leg cast for the next 4 weeks.","surgery, screw, stryker, tibia, intramedullary nail fixation, tibial shaft fracture, intramedullary, guidewire, nail, fracture, tibial"
 Displaced left subtrochanteric femur fracture.  Intramedullary rod in the left hip using the Synthes trochanteric fixation nail measuring 11 x 130 degrees with an 85-mm helical blade., Surgery, Intramedullary Rod ,"PREOPERATIVE DIAGNOSIS:,  Displaced left subtrochanteric femur fracture.,POSTOPERATIVE DIAGNOSIS:,  Displaced left subtrochanteric femur fracture.,OPERATION: , Intramedullary rod in the left hip using the Synthes trochanteric fixation nail measuring 11 x 130 degrees with an 85-mm helical blade.,COMPLICATIONS:,  None.,TOURNIQUET TIME:,  None.,ESTIMATED BLOOD LOSS:,  50 mL.,ANESTHESIA: , General.,INDICATIONS:  ,The patient suffered a fall at which time she was taken to the emergency room with pain in the lower extremities.  She was diagnosed with displaced left subcapital hip fracture, now was asked to consult.  With this diagnosis, she was indicated the above-noted procedure.  This procedure as well as alternatives to this procedure was discussed at length with the patient and her son, who has the power of attorney, and they understood them well.,Risks and benefits were also discussed.  Risks include bleeding, infection, damage to blood vessels, damage to nerves, risk of further surgery, chronic pain, restricted range of motion, risk of continued discomfort, risk of malunion, risk of nonunion, risk of need for further reconstructive procedures, risk of need for altered activities and altered gait, risk of blood clots, pulmonary embolism, myocardial infarction, and risk of death were discussed.  She understood these well and consented, and the son signed the consent for the procedure as described.,DESCRIPTION OF PROCEDURE: , The patient was placed on the operating table and general anesthesia was achieved.  The patient was then placed in fracture boots and manipulated under fluoroscopic control until we could obtain near anatomic alignment.  External positions were felt to be present.  At this point, the left hip and left lower extremity was then prepped and draped in the usual sterile manner.  A guidewire was then placed percutaneously into the tip of the greater trochanter and a small incision was made overlying the guidewire.  An overlying drill was inserted to the proper depths.  A Synthes 11 x 130 degrees trochanteric fixation that was chosen was placed into the intramedullary canal to the proper depth.  Proper rotation was obtained and the guide for the helical blade was inserted.  A small incision was made for this as well.  A guidewire was inserted and felt to be in proper position, in the posterior aspect of the femoral head, lateral, and the center position on AP.  This placed the proper depths and lengths better.  The outer cortex was enlarged and an 85-mm helical blade was attached to the proper depths and proper fixation was done.  Appropriate size screw was then tightened down.  At this point, a distal guide was then placed and drilled across both the cortices.  Length was better.  Appropriate size screw was then inserted.  Proper size and fit of the distal screw was also noted.  At this point, on fluoroscopic control, it was confirming in AP and lateral direction.  We did a near anatomical alignment to the fracture site and all hardware was properly fixed.  Proper size and fit was noted.  Excellent bony approximation was noted.  At this point, both wounds were thoroughly irrigated, hemostasis confirmed, and closure was then begun.,The fascial layers were then reapproximated using #1 Vicryl in a figure-of-eight manner, the subcutaneous tissues were reapproximated in layers using #1 and 2-0 Vicryl sutures, and the skin was reapproximated with staples.  The area was then infiltrated with a mixture of a 0.25% Marcaine with Epinephrine and 1% plain lidocaine.  Sterile dressing was then applied.  No complication was encountered throughout the procedure.  The patient tolerated the procedure well.  The patient was taken to the recovery room in stable condition.","surgery, displaced, femur fracture, subtrochanteric, hip, synthes, intramedullary rod, subtrochanteric femur, trochanteric fixation, helical blade, tourniquet, intramedullary, trochanteric, fixation, helical, blade, guidewire, fracture,"
 Inguinal orchiopexy procedure., Surgery, Inguinal orchiopexy ,,"surgery, inguinal orchiopexy, keith needles, aponeurosis, bolster, catgut, dartos pouch, external oblique, hernia sac, inguinal ring, orchiopexy, scrotal wall, spermatic cord, spermatic vessels, testicle, transverse inguinal skin crease incision, chromic catgut, inguinal, chromic, spermatic, scrotal, incisionNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Laparoscopic right inguinal herniorrhaphy with mesh, as well as a circumcision.   Recurrent right inguinal hernia, as well as phimosis.", Surgery, Inguinal Herniorrhaphy & Circumcision ,"PREOPERATIVE DIAGNOSIS: , Recurrent right inguinal hernia, as well as phimosis.,POSTOPERATIVE DIAGNOSIS:,  Recurrent right inguinal hernia, as well as phimosis.,PROCEDURE PERFORMED: , Laparoscopic right inguinal herniorrhaphy with mesh, as well as a circumcision.,ANESTHESIA: , General endotracheal.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well and was transferred to recovery room in stable condition.,SPECIMEN: , Foreskin.,BRIEF HISTORY: , This patient is a 66-year-old African-American male who presented to Dr. Y's office with recurrent right inguinal hernia for the second time requesting hernia repair.  The procedure was discussed with the patient and the patient opted for laparoscopic repair due to multiple attempts at the open inguinal repair on the right.  The patient also is requesting circumcision with phimosis at the same operating time setting.,INTRAOPERATIVE FINDINGS: , The patient was found to have a right inguinal hernia with omentum and bowel within the hernia, which was easily reduced.  The patient was also found to have a phimosis, which was easily removed.,PROCEDURE:,  After informed consent, the risks and benefits of the procedure were explained to the patient.  The patient was brought to operating suite, after general endotracheal intubation, prepped and draped in the normal sterile fashion.  An infraumbilical incision was made with a #15 Bard-Parker scalpel.  The umbilical skin was elevated with a towel clip and the Veress needle was inserted without difficulty.  Saline drop test proved entrance into the abdominal cavity and then the abdomen was insufflated to sufficient pressure of 15 mmHg.  Next, the Veress was removed and #10 bladed trocar was inserted without difficulty.  The 30-degree camera laparoscope was then inserted and the abdomen was explored.  There was evidence of a large right inguinal hernia, which had omentum as well as bowel within it, easily reducible.  Attention was next made to placing a #12 port in the right upper quadrant, four fingerbreadths from the umbilicus.  Again, a skin was made with a #15 blade scalpel and the #12 port was inserted under direct visualization.  A #5 port was inserted in the left upper quadrant in similar fashion without difficulty under direct visualization.  Next, a grasper with blunt dissector was used to reduce the hernia and withdraw the sac and using an Endoshears, the peritoneum was scored towards the midline and towards the medial umbilical ligament and lateral.  The peritoneum was then spread using the blunt dissector, opening up and identifying the iliopubic tract, which was identified without difficulty.  Dissection was carried out, freeing up the hernia sac from the peritoneum.  This was done without difficulty reducing the hernia in its entirety.  Attention was next made to placing a piece of Prolene mesh, it was placed through the #12 port and placed into the desired position, stapled into place in its medial aspect via the 4 mm staples along the iliopubic tract.  The 4.8 mm staples were then used to staple the superior edge of the mesh just below the peritoneum and then the patient was re-peritonealized, re-approximating edge of the perineum with the 4.8 mm staples.  This was done without difficulty.  All three ports were removed under direct visualization.  No evidence of bleeding and the #10 and #12 mm ports were closed with #0-Vicryl and UR6 needle.  Skin was closed with running subcuticular #4-0 undyed Vicryl.  Steri-Strips and sterile dressings were applied.  Attention was next made to carrying out the circumcision.  The foreskin was retracted back over the penis head.  The desired amount of removing foreskin was marked out with a skin marker.  The foreskin was then put on tension using a clamp to protect the penis head.  A #15 blade scalpel was used to remove the foreskin and sending off as specimen.  This was done without difficulty.  Next, the remaining edges were retracted, hemostasis was obtained with Bovie electrocautery and the skin edges were re-approximated with #2-0 plain gut in simple interrupted fashion and circumferentially.  This was done without difficulty maintaining hemostasis.,A petroleum jelly was applied with a Coban dressing.  The patient tolerated this procedure well and was well and was transferred to recovery after extubation in stable condition.","surgery, herniorrhaphy with mesh, laparoscopic, blunt dissector, inguinal herniorrhaphy, inguinal hernia, hernia, inguinal, peritoneum, circumcision, phimosis, foreskin"
 Acute on chronic renal failure and uremia.  Insertion of a right internal jugular vein hemodialysis catheter., Surgery, Internal Jugular Vein Catheter Insertion ,"PREOPERATIVE DIAGNOSES:,1.  Acute on chronic renal failure.,2.  Uremia.,POSTOPERATIVE DIAGNOSES:,1.  Acute on chronic renal failure.,2.  Uremia.,PROCEDURE PERFORMED:  ,Insertion of a right internal jugular vein hemodialysis catheter.,ANESTHESIA: , 1% local lidocaine.,BLOOD LOSS: , Less than 5 cc.,COMPLICATIONS: , None.,HISTORY: , The patient is a 74-year-old Caucasian male who presents via direct admission for acute on chronic renal failure with uremia.  The patient incidentally was in a car accident ten days ago and has been feeling pretty awful since that time.  He is slightly short of breath with mild difficulty in breathing.  A pre-procedure x-ray was obtained, which showed no pneumothorax.  He did have a significant right pleural effusion and a mild left pleural effusion.  We decided to insert the catheter on the right side.,PROCEDURE:  ,The patient was prepped and draped in the usual sterile fashion.  1% lidocaine was used to anesthetize the area two fingerbreadths above the clavicle just posterior to the right sternocleidomastoid muscle and below the external jugular vein.  Using the same anesthetic needle, the right internal jugular vein was used to cannulate with good venous blood return.  The tract was noted.,The needle was removed and a second #18 gauge thin-walled needle was used along same tract to cannulate the right internal jugular vein also without difficulty and good venous blood return.  The syringe was removed and a Seldinger guidewire was inserted through the needle to cannulate the vein also without difficulty.  The needle was removed and an #11 blade was used to make a small skin incision provided skin and vein dilators were used.  The circle-C 8-inch hemodialysis catheter was then inserted over the guidewire without difficulty.  The guidewire was removed.  Both of the ports were aspirated venous blood without difficulty and both flushed also without difficulty.  The ports were flushed with injectable normal saline secondary to the patient going for dialysis today.  Thus, he will not need heparinization of the lines.  Again, he tolerated the procedure well.  A postoperative x-ray would be obtained to check catheter placement and rule out pneumothorax.","surgery, uremia, internal jugular vein hemodialysis catheter, pneumothorax, jugular vein, dialysis, chronic renal failure, internal jugular vein, pleural effusion, hemodialysis catheter, renal failure, cannulate, guidewire, insertion, jugular, catheter, hemodialysis, vein"
" Bassini inguinal herniorrhaphy.  A standard inguinal incision was made, and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery. ", Surgery, Inguinal Herniorrhaphy - 2 ,"PROCEDURE PERFORMED: , Bassini inguinal herniorrhaphy.,ANESTHESIA: , Local with MAC anesthesia.,PROCEDURE: , After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table.  The patient was sedated and an adequate local anesthetic was administered using 1% lidocaine without epinephrine.  The patient was prepped and draped in the usual sterile manner.,A standard inguinal incision was made, and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery.  The external oblique aponeurosis was cleared of overlying adherent tissue, and the external ring was delineated.  The external oblique was then incised with a scalpel and this incision was carried out to the external ring using Metzenbaum scissors.  Care was taken not to injure the ilioinguinal nerve.  Having exposed the inguinal canal, the cord structures were separated from the canal using blunt dissection, and a Penrose drain was then used to retract the cord structures as needed.  Adherent cremasteric muscle was dissected free from the cord using Bovie electrocautery.,The cord was then explored using a combination of sharp and blunt dissection, and the sac was found anteromedially to the cord structures.  The sac was dissected free from the cord structures using a combination of blunt dissection and Bovie electrocautery.,Once preperitoneal fat was encountered, the dissection stopped and the sac was suture ligated at the level of the preperitoneal fat using a 2-0 silk suture ligature.  The sac was excised and sent to Pathology.  The stump was examined and no bleeding was noted.  The ends of the suture were then cut, and the stump retracted back into the abdomen.,The floor of the inguinal canal was then strengthened by suturing the shelving edge of Poupart's ligament to the conjoined tendon using a 2-0 Prolene, starting at the pubic tubercle and running towards the internal ring.  In this manner, an internal ring was created that admitted just the tip of my smallest finger.,The Penrose drain was removed.  The wound was then irrigated using sterile saline, and hemostasis was obtained using Bovie electrocautery.  The incision in the external oblique was approximated using a 2-0 Vicryl in a running fashion, thus reforming the external ring.  Marcaine 0.5% was injected 1 fingerbreadth anterior to the anterior and superior iliac spine and around the wound for postanesthetic pain control.  The skin incision was approximated with skin staples.  A dressing was then applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.","surgery, ilioinguinal nerve, adherent cremasteric muscle, bassini inguinal herniorrhaphy, external oblique aponeurosis, inguinal herniorrhaphy, metzenbaum scissors, external ring, blunt dissection, cord structures, bovie electrocautery, inguinal, electrocautery"
" Direct inguinal hernia.  Rutkow direct inguinal herniorrhaphy.  A standard inguinal incision was made, and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery.  ", Surgery, Inguinal Herniorrhaphy - 1 ,"PREOPERATIVE DIAGNOSIS: , Inguinal hernia.,POSTOPERATIVE DIAGNOSIS: , Direct inguinal hernia.,PROCEDURE PERFORMED:,  Rutkow direct inguinal herniorrhaphy.,ANESTHESIA: , General endotracheal.,DESCRIPTION OF PROCEDURE:  ,After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table.  General endotracheal anesthesia was induced without incident.  Preoperative antibiotics were given for prophylaxis against surgical infection.  The patient was prepped and draped in the usual sterile fashion.,A standard inguinal incision was made, and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery.  The external oblique aponeurosis was cleared of overlying adherent tissue, and the external ring was delineated.  The external oblique was then incised with a scalpel and this incision was carried out to the external ring using Metzenbaum scissors.  Having exposed the inguinal canal, the cord structures were separated from the canal using blunt dissection, and a Penrose drain was placed around the cord structures at the level of the pubic tubercle.  This Penrose drain was then used to retract the cord structures as needed.  Adherent cremasteric muscle was dissected free from the cord using Bovie electrocautery.,The cord was then explored using a combination of sharp and blunt dissection, and no sac was found.  The hernia was found coming from the floor of the inguinal canal medial to the inferior epigastric vessels.  This was dissected back to the hernia opening.  The hernia was inverted back into the abdominal cavity and a large PerFix plug inserted into the ring.  The plug was secured to the ring by interrupted 2-0 Prolene sutures.,The PerFix onlay patch was then placed on the floor of the inguinal canal and secured in place using interrupted 2-0 Prolene sutures.  By reinforcing the floor with the onlay patch, a new internal ring was thus formed.,The Penrose drain was removed.  The wound was then irrigated using sterile saline, and hemostasis was obtained using Bovie electrocautery.  The incision in the external oblique was approximated using a 2-0 Vicryl in a running fashion, thus reforming the external ring.  The skin incision was approximated with 4-0 Monocryl in a subcuticular fashion.  The skin was prepped with benzoin, and Steri-Strips were applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.","surgery, cremasteric muscle, pubic tubercle, external oblique aponeurosis, inguinal herniorrhaphy, inguinal hernia, cord structures, penrose drain, bovie electrocautery, inguinal, herniorrhaphy, metzenbaum, bovie, electrocautery, cord, hernia"
" Left inguinal herniorrhaphy, modified Bassini.  Left inguinal hernia, direct.", Surgery, Inguinal Herniorrhaphy - 3 ,"PREOPERATIVE DIAGNOSIS:,  Left inguinal hernia.,POSTOPERATIVE DIAGNOSIS: , Left inguinal hernia, direct.,PROCEDURE: , Left inguinal herniorrhaphy, modified Bassini.,DESCRIPTION OF PROCEDURE:  ,The patient was electively taken to the operating room.  In same day surgery, Dr. X applied a magnet to the pacemaker defibrillator that the patient has to change it into a fixed mode and to protect the device from the action of the cautery.  Informed consent was obtained, and the patient was transferred to the operating room where a time-out process was followed and the patient under general endotracheal anesthesia was prepped and draped in the usual fashion.  Local anesthesia was used as a field block and then an incision was made in the left inguinal area and carried down to the external oblique aponeurosis, which was opened.  The cord was isolated and protected.  It was dissected out.  The lipoma of the cord was removed and the sac was high ligated.  The main hernia was a direct hernia due to weakness of the floor.  A Bassini repair was performed.  We used a number of interrupted sutures of 2-0 Tevdek __________ in the conjoint tendon and the ilioinguinal ligament.,The external oblique muscle was approximated same as the soft tissue with Vicryl and then the skin was closed with subcuticular suture of Monocryl.  The dressing was applied and the patient tolerated the procedure well, estimated blood loss was minimal, was transferred to recovery room in satisfactory condition.","surgery, inguinal herniorrhaphy, modified bassini, herniorrhaphy modified bassini, hernia direct, inguinal hernia, inguinal, bassini,"
" Repair of left inguinal hernia indirect.  The patient states that she noticed there this bulge and pain for approximately six days prior to arrival.  Upon examination in the office, the patient was found to have a left inguinal hernia consistent with tear, which was scheduled as an outpatient surgery.", Surgery, Inguinal Hernia Repair - Indirect ,"PREOPERATIVE DIAGNOSIS: , Left inguinal hernia.,POSTOPERATIVE DIAGNOSIS:, Left indirect inguinal hernia.,PROCEDURE PERFORMED:, Repair of left inguinal hernia indirect.,ANESTHESIA: , Spinal with local.,COMPLICATIONS:,  None.,DISPOSITION,:  The patient tolerated the procedure well, was transferred to recovery in stable condition.,SPECIMEN: , Hernia sac.,BRIEF HISTORY: , The patient is a 60-year-old female that presented to Dr. X's office with complaints of a bulge in the left groin.  The patient states that she noticed there this bulge and pain for approximately six days prior to arrival.  Upon examination in the office, the patient was found to have a left inguinal hernia consistent with tear, which was scheduled as an outpatient surgery.,INTRAOPERATIVE FINDINGS: , The patient was found to have a left indirect inguinal hernia.,PROCEDURE: , After informed consent was obtained, risks and benefits of the procedure were explained to the patient.  The patient was brought to the operating suite.  After spinal anesthesia and sedation given, the patient was prepped and draped in normal sterile fashion.  In the area of the left inguinal region just superior to the left inguinal ligament tract, the skin was anesthetized with 0.25% Marcaine.  Next, a skin incision was made with a #10 blade scalpel.  Using Bovie electrocautery, dissection was carried down to Scarpa's fascia until the external oblique was noted.  Along the side of the external oblique in the direction of the external ring, incision was made on both sides of the external oblique and then grasped with a hemostat.  Next, the hernia and hernia sac was circumferentially grasped and elevated along with the round ligament.  Attention was next made to ligating the hernia sac at its base for removal.  The hernia sac was opened prior grasping with hemostats.  It was a sliding indirect hernia.  The bowel contents were returned to abdomen using a #0 Vicryl stick tie pursestring suture at its base.  The hernia sac was ligated and then cut above with the Metzenbaum scissors returning it to the abdomen.  This was then sutured at the apex of the repair down to the conjoint tendon.  Next, attention was made to completely removing the round ligament hernia sac which was again ligated at its base with an #0 Vicryl suture and removed as specimen.  Attention was next made to reapproximate it at floor with a modified ______ repair.  Using a #2-0 Ethibond suture in simple interrupted fashion, the conjoint tendon was approximated to the ilioinguinal ligament capturing a little bit of the floor of the transversalis fascia.  Once this was done, the external oblique was closed over, reapproximated again with a #2-0 Ethibond suture catching each hump in between each repair from the prior floor repair.  This was done in simple interrupted fashion as well.  Next Scarpa's fascia was reapproximated with #3-0 Vicryl suture.  The skin was closed with running subcuticular #4-0 undyed Vicryl suture.  Steri-Strips and sterile dressings were applied.  The patient tolerated the procedure very well and he was transferred to Recovery in stable condition.  The patient had an abnormal chest x-ray in preop and is going for a CT of the chest in Recovery.","surgery, bulge, groin, ethibond suture, vicryl suture, external oblique, inguinal hernia, hernia, inguinal, ligament, oblique, vicryl, indirect, sac, suture, repair,"
 Inguinal herniorrhaphy.  A standard inguinal incision was made and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery. , Surgery, Inguinal Herniorrhaphy ,"PROCEDURE PERFORMED: , Inguinal herniorrhaphy.,PROCEDURE: , After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table.  General endotracheal anesthesia was induced without incident.  The patient was prepped and draped in the usual sterile manner.,A standard inguinal incision was made and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery.  The external oblique aponeurosis was cleared of overlying adherent tissue, and the external ring was delineated.  The external oblique was then incised with a scalpel, and this incision was carried out to the external ring using Metzenbaum scissors.  Having exposed the inguinal canal, the cord structures were separated from the canal using blunt dissection, and a Penrose drain was placed around the cord structures at the level of the pubic tubercle.  This Penrose drain was then used to retract the cord structures as needed.  Adherent cremasteric muscle was dissected free from the cord using Bovie electrocautery.,The cord was then explored using a combination of sharp and blunt dissection, and the sac was found anteromedially to the cord structures.  The sac was dissected free from the cord structures using a combination of blunt dissection and Bovie electrocautery.  Once preperitoneal fat was encountered, the dissection stopped and the sac was suture ligated at the level of the preperitoneal fat using a 2-0 silk suture ligature.  The sac was excised and went to  Pathology.  The ends of the suture were then cut and the stump retracted back into the abdomen.,The Penrose drain was removed.  The wound was then irrigated using sterile saline, and hemostasis was obtained using Bovie electrocautery.  The incision in the external oblique was approximated using a 3-0 Vicryl in a running fashion, thus reforming the external ring.  The skin incision was approximated with 4-0 Vicryl in a subcuticular fashion.  The skin was prepped and draped with benzoin, and Steri-Strips were applied.  A dressing consisting of a 2 x 2 and OpSite was then applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition.","surgery, inguinal canal, cremasteric muscle, pubic tubercl, inguinal herniorrhaphy, blunt dissection, penrose drain, bovie electrocautery, cord structures, inguinal, electrocautery, cord"
 Left direct and indirect inguinal hernia.  Repair of left inguinal hernia with Prolene mesh.  The patient was found to have a left inguinal hernia increasing over the past several months.  The patient has a history of multiple abdominal surgeries and opted for an open left inguinal hernial repair with Prolene mesh., Surgery, Inguinal Hernia Repair - 2 ,"PREOPERATIVE DIAGNOSIS:,  Left inguinal hernia.,POSTOPERATIVE DIAGNOSIS:, Left direct and indirect inguinal hernia.,PROCEDURE PERFORMED:, Repair of left inguinal hernia with Prolene mesh.,ANESTHESIA: , IV sedation with local.,COMPLICATIONS:,  None.,DISPOSITION:  ,The patient tolerated the procedure well and was transferred to Recovery in stable condition.,SPECIMEN: , Hernia sac, as well as turbid fluid with gram stain, which came back with no organisms from the hernia sac.,BRIEF HISTORY:  ,This is a 53-year-old male who presented to Dr. Y's office with a bulge in the left groin and was found to have a left inguinal hernia increasing over the past several months.  The patient has a history of multiple abdominal surgeries and opted for an open left inguinal hernial repair with Prolene mesh.,INTRAOPERATIVE FINDINGS: , The patient was found to have a direct as well as an indirect component to the left inguinal hernia with a large sac.  The patient was also found to have some turbid fluid within the hernia sac, which was sent down for gram stain and turned out to be negative with no organisms.,PROCEDURE: , After informed consent, risks and benefits of the procedure were explained to the patient, the patient was brought to the operative suite, prepped and draped in the normal sterile fashion.  The left inguinal ligament was identified from the pubic tubercle to the ASIS.  Two fingerbreadths above the pubic tubercle, a transverse incision was made.  First, the skin was anesthetized with 1% lidocaine and then an incision was made with a #15 blade scalpel, approximately 6 cm in length.  Dissection was then carried down with electro Bovie cautery through Scarpa's fascia maintaining hemostasis.  Once the external oblique was identified, external oblique was incised in the length of its fibers with a #15 blade scalpel.  Metzenbaum scissors were then used to extend the incision in both directions opening up the external oblique down to the external ring.  Next, the external oblique was grasped with Ochsner on both sides.  The cord, cord structures as well as hernia sac were freed up circumferentially and a Penrose drain was placed around it.  Next, the hernia sac was identified and the anteromedial portion of the hernia sac was stripped down, grasped with two hemostats.  A Metzenbaum scissor was then used to open the hernia sac and the hernia sac was explored.  There was some turbid fluid within the hernia sac, which was sent down for cultures.  Gram stain was negative for organisms.  Next, the hernia sac was to be ligated at its base and transected.  A peon was used at the base.  Metzenbaum scissor was used to cut the hernia sac and sending it off as a specimen.  An #0 Vicryl stick suture was used with #0 Vicryl loop suture to suture ligate the hernia sac at its base.,Next, attention was made to placing a Prolene mesh to cover the floor.  The mesh was sutured to the pubic tubercle medially along the ilioinguinal ligament inferiorly and along the conjoint tendon superiorly making a slit for the cord and cord structures.  Attention was made to salvaging the ilioinguinal nerve, which was left above the repair of the mesh and below the external oblique once closed and appeared to be intact.  Attention was next made after suturing the mesh with the #2-0 Polydek suture.  The external oblique was then closed over the roof with a running #0 Vicryl suture, taking care not to strangulate the cord and to recreate the external ring.  After injecting the external oblique and cord structures with Marcaine for anesthetic, the Scarpa's fascia was approximated with interrupted #3-0 Vicryl sutures.  The skin was closed with a running subcuticular #4-0 undyed Vicryl suture.  Steri-Strip with sterile dressings were applied.,The patient tolerated the procedure well and was transferred to Recovery in stable condition.","surgery, left inguinal hernia, prolene mesh, hernia sac, gram stain, inguinal hernia repair, inguinal hernial repair, metzenbaum scissors, cord structures, inguinal hernia, sac, inguinal, hernia, metzenbaum, prolene, vicryl, cord, suture, oblique, mesh,"
" Right inguinal hernia.   Right inguinal hernia repair.  The patient is a 4-year-old boy with a right inguinal bulge, which comes and goes with Valsalva standing and some increased physical activity.", Surgery, Inguinal Hernia Repair - 6 ,"PREOPERATIVE DIAGNOSIS:,  Right inguinal hernia.,POSTOPERATIVE DIAGNOSIS: , Right inguinal hernia.,ANESTHESIA: , General.,PROCEDURE:  ,Right inguinal hernia repair.,INDICATIONS: , The patient is a 4-year-old boy with a right inguinal bulge, which comes and goes with Valsalva standing and some increased physical activity.  He had an inguinal hernia on physical exam in the Pediatric Surgery Clinic and is here now for elective repair.  We met with his parents and explained the surgical technique, risks, and talked to them about trying to perform a diagnostic laparoscopic look at the contralateral side to rule out an occult hernia.  All their questions have been answered and they agreed with the plan.,OPERATIVE FINDINGS:  ,The patient had a well developed, but rather thin walled hernia sac on the right.  The thinness of hernia sac made it difficult to safely cannulate through the sac for the laparoscopy.  Therefore, high ligation was performed, and we aborted the plan for laparoscopic view of the left side.,DESCRIPTION OF PROCEDURE: , The patient came to operating room and had an uneventful induction of general anesthesia.  Surgical time-out was conducted while we were preparing and draping his abdomen with chlorhexidine based prep solution.  During our time-out, we reiterated the patient's name, medical record number, weight, allergies status, and planned operative procedure.  I then infiltrated 0.25% Marcaine with dilute epinephrine in the soft tissues around the inguinal crease in the right lower abdomen chosen for hernia incision.  An additional aliquot of Marcaine was injected deep to the external oblique fascia performing the ilioinguinal and iliohypogastric nerve block.  A curvilinear incision was made with a scalpel and a combination of electrocautery and some blunt dissection and scissor dissection was used to clear the tissue layers through Scarpa fascia and expose the external oblique.  After the oblique layers were opened, the cord structure were identified and elevated.  The hernia sac was carefully separated from the spermatic cord structures and control of the sac was obtained.  Dissection of the hernia sac back to the peritoneal reflection at the level of deep inguinal ring was performed.  I attempted to gently pass a 3-mm trocar through the hernia sac, but it was rather difficult and I became fearful that the sac would be torn in proximal control and mass ligation would be less effective.  I aborted the laparoscopic approach and performed a high ligation using transfixing and a simple mass ligature of 3-0 Vicryl.  The excess sac was trimmed and the spermatic cord structures were replaced.  The external oblique fascia and Scarpa layers were closed with interrupted 3-0 Vicryl and skin was closed with subcuticular 5-0 Monocryl and Steri-Strips.  The patient tolerated the operation well.  Blood loss was less than 5 mL.  The hernia sac was submitted for specimen, and he was then taken to the recovery room in good condition.","surgery, laparoscopic, external oblique fascia, oblique fascia, spermatic cord, cord structures, external oblique, hernia sac, inguinal hernia, sac, hernia, inguinal, fascia, repair, oblique,"
 Direct right inguinal hernia.  Marlex repair of right inguinal hernia., Surgery, Inguinal Hernia Repair - 5 ,"PREOPERATIVE DIAGNOSIS: , Right inguinal hernia.,POSTOPERATIVE DIAGNOSIS: , Direct right inguinal hernia.,TITLE OF PROCEDURE: , Marlex repair of right inguinal hernia.,ANESTHESIA:,  Spinal.,PROCEDURE IN DETAIL:,  The patient was taken to the operative suite, placed on the table in the supine position, and given a spinal anesthetic.  The right inguinal region was shaved and prepped and draped in a routine sterile fashion.  The patient received 1 gm of Ancef IV push.,Transverse incision was made in the intraabdominal crease and carried through skin and subcutaneous tissue.  The external oblique fascia was exposed and incised down to and through the external inguinal ring.  The spermatic cord and hernia sac were dissected bluntly off the undersurface of the external oblique fascia exposing the attenuated floor of the inguinal canal.  The cord was surrounded with a Penrose drain.  The hernia sac was separated from the cord structures.  The floor of the inguinal canal, which consisted of attenuated transversalis fascia, was imbricated upon itself with a running locked suture of 2-0 Prolene.  Marlex patch 1 x 4 in dimension was trimmed to an appropriate shape with a defect to accommodate the cord.  It was placed around the cord and sutured to itself with 2-0 Prolene.  The patch was then sutured medially to the pubic tubercle, inferiorly to Cooper's ligament and inguinal ligaments, and superiorly to conjoined tendon using 2-0 Prolene.  The area was irrigated with saline solution, and 0.5% Marcaine with epinephrine was injected to provide prolonged postoperative pain relief.  The cord was returned to its position.  External oblique fascia was closed with a running 2-0 PDS, subcu with 2-0 Vicryl, and skin with running subdermal 4-0 Vicryl and Steri-Strips.  Sponge and needle counts were correct.  Sterile dressing was applied.","surgery, marlex repair, inguinal region, external oblique fascia, inguinal ring, direct right inguinal hernia, inguinal hernia, inguinal, repair, marlex, oblique, fascia, hernia, "
 Right inguinal hernia.    Right direct inguinal hernia repair with PHS mesh system.  The Right groin and abdomen were prepped and draped in the standard sterile surgical fashion.  An incision was made approximately 1 fingerbreadth above the pubic tubercle and in a skin crease. , Surgery, Inguinal Hernia Repair - 4 ,"PREOPERATIVE DIAGNOSIS: , Right inguinal hernia. ,POSTOPERATIVE DIAGNOSIS:,  Right direct inguinal hernia. ,PROCEDURE:,  Right direct inguinal hernia repair with PHS mesh system. ,ANESTHESIA:,  General with endotracheal intubation. ,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating table.  General anesthesia was administered with endotracheal intubation.  The Right groin and abdomen were prepped and draped in the standard sterile surgical fashion.  An incision was made approximately 1 fingerbreadth above the pubic tubercle and in a skin crease.  Dissection was taken down through the skin and subcutaneous tissue.  Scarpa's fascia was divided, and the external ring was located.  The external oblique was divided from the external ring up towards the anterior superior iliac spine.  The cord structures were then encircled.  Careful inspection of the cord structures did not reveal any indirect sac along the cord structures.  I did, however, feel a direct sac with a direct defect.  I opened the floor of the inguinal canal and dissected out the preperitoneal space at the direct sac and cut out the direct sac.  Once I cleared out the preperitoneal space, I placed a PHS mesh system with a posterior mesh into the preperitoneal space, and I made sure that it laid flat along Cooper's ligament and covered the myopectineal orifice.  I then tucked the extended portion of the anterior mesh underneath the external oblique between the external oblique and the internal oblique, and I then tacked the medial portion of the mesh to the pubic tubercle with a 0 Ethibond suture.  I tacked the superior portion of the mesh to the internal oblique and the inferior portion of the mesh to the shelving edge of the inguinal ligament.  I cut a hole in the mesh in order to incorporate the cord structures and recreated the internal ring, making sure that it was not too tight so that it did not strangulate the cord structures.  I then closed the external oblique with a running 3-0 Vicryl.  I closed the Scarpa's with interrupted 3-0 Vicryl, and I closed the skin with a running Monocril.  Sponge, instrument and needle counts were correct at the end of the case.  The patient tolerated the procedure well and without any complications.","surgery, groin, phs mesh, inguinal hernia repair, direct inguinal hernia, preperitoneal space, external oblique, cord structures, inguinal hernia, inguinal, hernia, external, oblique, mesh, "
" A 9-year-old boy with a history of intermittent swelling of the right inguinal area consistent with a right inguinal hernia, taken to the operating room for inguinal hernia repair.", Surgery, Inguinal Hernia Repair - 1 ,"PREOPERATIVE DIAGNOSIS:,  Right inguinal hernia.,POSTOPERATIVE DIAGNOSIS:,  Right inguinal hernia.,PROCEDURE:,  Right inguinal hernia repair.,INDICATIONS FOR PROCEDURE: , This patient is a 9-year-old boy with a history of intermittent swelling of the right inguinal area consistent with a right inguinal hernia.  The patient is being taken to the operating room for inguinal hernia repair.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine, put under general endotracheal anesthesia.  The patient's inguinal and scrotal area were prepped and draped in the usual sterile fashion.  An incision was made in the right inguinal skin crease.  The incision was taken down to the level of the aponeurosis of the external oblique, which was incised up to the level of the external ring.  The hernia sac was verified and dissected at the level of the internal ring and a high ligation performed.  The distal remnant was taken to its end and excised.  The testicle and cord structures were placed back in their native positions.  The aponeurosis of the external oblique was reapproximated with 3-0 Vicryl as well as the Scarpa's, the skin closed with 5-0 Monocryl and dressed with Steri-Strips.  The patient was extubated in the operating room and taken back to the recovery room.  The patient tolerated the procedure well.","surgery, inguinal skin crease, inguinal hernia repair, external oblique, hernia repair, inguinal hernia, inguinal, hernia, "
 Bilateral inguinal hernia.  Bilateral direct inguinal hernia repair utilizing PHS system and placement of On-Q pain pump. , Surgery, Inguinal Hernia Repair - 3 ,"PREOPERATIVE DIAGNOSIS:,  Bilateral inguinal hernia. ,POSTOPERATIVE DIAGNOSIS: , Bilateral inguinal hernia. ,PROCEDURE: , Bilateral direct inguinal hernia repair utilizing PHS system and placement of On-Q pain pump. ,ANESTHESIA: , General with endotracheal intubation. ,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating room table.  General anesthesia was administered with endotracheal intubation and the abdomen and groins were prepped and draped in standard, sterile surgical fashion.  I did an ilioinguinal nerve block on both sides, injecting Marcaine 1 fingerbreadth anterior and 1 fingerbreadth superior to the anterior superior iliac spine on both sides.","surgery, phs system, on-q, pump, on-q pain pump, inguinal hernia repair, bilateral inguinal hernia, anterior superior iliac, direct inguinal hernia, subcutaneous tissue, scarpa's fascia, cord structures, phs mesh, ilioinguinal nerve, external oblique, inguinal hernia, hernia, oblique, inguinal, mesh,"
 Bilateral inguinal hernia and bilateral hydrocele repair with an ilioinguinal nerve block bilaterally., Surgery, Inguinal Hernia Repair ,"PREOPERATIVE DIAGNOSES:,  Bilateral inguinal hernia, bilateral hydroceles.,POSTOPERATIVE DIAGNOSES:,  Bilateral inguinal hernia, bilateral hydroceles.,PROCEDURES: , Bilateral inguinal hernia and bilateral hydrocele repair with an ilioinguinal nerve block bilaterally by surgeon 20 mL given.,ANESTHESIA: , General inhalational anesthetic.,ABNORMAL FINDINGS:,  Same as above.,ESTIMATED BLOOD LOSS: , Less than 5 mL.,FLUIDS RECEIVED: , 400 mL of Crystalloid.,DRAINS: , No tubes or drains were used.,COUNT: , Sponge and needle counts were correct x2.,INDICATIONS FOR PROCEDURE:  ,The patient is a 7-year-old boy with the history of fairly sizeable right inguinal hernia and hydrocele, was found to have a second smaller one on evaluation with ultrasound and physical exam.  Plan is for repair of both.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operating room, where surgical consent, operative site and the patient's identification was verified.  Once he was anesthetized, he was then placed in a supine position and sterilely prepped and draped.  A right inguinal incision was then made with 15 blade knife and further extended with electrocautery down to the subcutaneous tissue and electrocautery was also used for hemostasis.  The external oblique fascia was then visualized and incised with 15 blade knife and further extended with curved tenotomy scissors.  Using a curved mosquito clamp, we gently dissected into the inguinal canal until we got the hernia sac and dissected it out of the canal.  The cord structures were then dissected off the sac and then the sac itself was divided in the midline, twisted upon itself and suture ligated up at the peritoneal reflection with 3-0 Vicryl suture.  This was done twice.  The distal end where a large hydrocele noted, was gently milked into the lower aspect of the incision.  The hydrocele sac was then opened and drained and then the testis was delivered into the field.  The sac was then opened completely around the testis.  The appendix testis was cauterized.  We wrapped the sac around the back of the testis and tacked into place using the Lord maneuver using 4-0 Vicryl as a figure-of-eight suture.  Once this was done, the testis was then placed back into the scrotum in the proper orientation.  Ilioinguinal nerve block and wound instillation was then done with 10 mL of 0.25% Marcaine.  A similar procedure was done on the left side, also finding a small hernia, which was divided and ligated with the 3-0 Vicryl as on the right side and distally the hydrocele sac was also wrapped around the back of the testis in a Lord maneuver after opening the sac completely.  Again both testes were placed into the scrotum after the hydroceles were treated and then the external oblique fascia was closed on both sides with a running suture of 3-0 Vicryl ensuring that the ilioinguinal nerve and the cord structures not involved in the closure.  Scarpa fascia was closed with 4-0 chromic suture on each side and the skin was closed with 4-0 Rapide subcuticular closure.  Dermabond tissue adhesive was placed on both incisions.  IV Toradol was given at the end of the procedure and both testes were well descended within the scrotum at the end of the procedure.  The patient tolerated the procedure and was in stable condition upon transfer to the recovery room.","surgery, bilateral hydrocele repair, bilateral inguinal hernia, external oblique fascia, ilioinguinal nerve block, bilateral hydroceles, external oblique, oblique fascia, cord structures, hydrocele sac, lord maneuver, nerve block, bilateral inguinal, ilioinguinal nerve, inguinal hernia, hernia, inguinal, hydrocele, bilateral, sac,"
" Left communicating hydrocele.  Left inguinal hernia and hydrocele repair.  The patient is a 5-year-old young man with fluid collection in the tunica vaginalis and peritesticular space on the left side consistent with a communicating hydrocele. 
", Surgery, Inguinal Hernia & Hydrocele Repair ,"PREOPERATIVE DIAGNOSIS:  ,Left communicating hydrocele.,POSTOPERATIVE DIAGNOSIS: , Left communicating hydrocele.,ANESTHESIA: , General.,PROCEDURE:  ,Left inguinal hernia and hydrocele repair.,INDICATIONS: , The patient is a 5-year-old young man with fluid collection in the tunica vaginalis and peritesticular space on the left side consistent with a communicating hydrocele.  The fluid size tends to fluctuate with time but has been relatively persistent for the past year.  I met with the patient's mom and also spoke with his father by phone in the past couple of months and explained the diagnosis of patent processus vaginalis for communicating hydrocele and talked to them about the surgical treatment and options.  All their questions have been answered and the patient is fit for operation today.,OPERATIVE FINDINGS:  ,The patient had a very thin patent processus vaginalis leading to a rather sizeable hydrocele sac in the left hemiscrotum.  We probably drained around 10 to 15 mL of fluid from the hydrocele sac.  The processus vaginalis was clearly seen back to the peritoneal reflection where a high ligation was successfully performed.  There were no other abnormalities noted in the inguinal scrotal region.,DESCRIPTION OF OPERATION: , The patient came to the operating room and had an uneventful induction of inhalation anesthetic.  A peripheral IV was placed, and we conducted a surgical time-out to reiterate all of The patient's important identifying information and to confirm that we were indeed going to perform a left inguinal hernia and hydrocele repair.  After preparation and draping was done with chlorhexidine based prep solution, a local infiltration block as well as an ilioinguinal and iliohypogastric nerve block was performed with 0.25% Marcaine with dilute epinephrine.  A curvilinear incision was made low in the left inguinal area along one of prominent skin folds.  Soft tissue dissection was carried down through Scarpa's layer to the external oblique fascia, which was then opened to expose the underlying spermatic cord structures.  The processus vaginalis was dissected free from the spermatic cord structures, and the distal hydrocele sac was widely opened and drained of its fluid contents.  The processus vaginalis was cleared back to peritoneal reflection at the deep inguinal ring and a high ligation was performed there using both the transfixing and a mass ligature of 3-0 Vicryl.  After the excess hydrocele and processus vaginalis tissue was excised, the spermatic cord structures were replaced and the external oblique and Scarpa's layers were closed with interrupted 3-0 Vicryl sutures.  Subcuticular 5-0 Monocryl and Steri-Strips were used for the final skin closure.  The patient tolerated the operation well.  He was awakened and taken to the recovery room in good condition.  Blood loss was minimal.  No specimen was submitted.,","surgery, hydrocele, hydrocele repair, hernia, inguinal, fluid collection, tunica vaginalis, peritesticular space, hydrocele sac, spermatic cord, cord structures, inguinal hernia, communicating hydrocele, fluid, vaginalis"
 This patient has reoccurring ingrown infected toenails., Surgery, Infected Toenails ,"S - ,This patient has reoccurring ingrown infected toenails.  He presents today for continued care.,O - ,On examination, the left great toenail is ingrown on the medial and lateral toenail border.  The right great toenail is ingrown on the lateral nail border only.  There is mild redness and granulation tissue growing on the borders of the toes.  One on the medial and one on the lateral aspect of the left great toe and one on the lateral aspect of the right great toe.  These lesions measure 0.5 cm in diameter each.  I really do not understand why this young man continues to develop ingrown nails and infections.,A - ,1.  Onychocryptosis.,","surgery, infected toenails, onychocryptosis, benign lesions, toenail border, left great toe, neosporin ointment, hemostasis was achieved, ointment and absorbent, toenails, ingrown, lesions, benign, infected,"
" Right inguinal exploration, left inguinal hernia repair, bilateral hydrocele repair, and excision of right appendix testis.", Surgery, Inguinal Exploration ,"PREOPERATIVE DIAGNOSES:,  Bilateral inguinal hernias with bilateral hydroceles after right inguinal hernia repair, cerebral palsy, asthma, seizure disorder, developmental delay, and gastroesophageal reflux disease.,POSTOPERATIVE DIAGNOSES: , Left inguinal hernia, bilateral hydroceles, and right torsed appendix testis.,PROCEDURE: , Right inguinal exploration, left inguinal hernia repair, bilateral hydrocele repair, and excision of right appendix testis.,FLUIDS RECEIVED:  ,700 mL of crystalloid.,ESTIMATED BLOOD LOSS:  ,10 mL.,SPECIMENS:,  Tissue sent to pathology is calcified right appendix testis.,TUBES/DRAINS: , No tubes or drains were used.,COUNTS:  ,Sponge and needle counts were correct x2.,ANESTHESIA: , General inhalational anesthetic and 0.25% Marcaine ilioinguinal nerve block, 30 mL given per surgeon.,INDICATIONS FOR OPERATION:  ,The patient is a 14-1/2-year-old boy with multiple medical problems, primarily due to cerebral palsy, asthma, seizures, gastroesophageal reflux disease, and developmental delay.  He had a hernia repair done on the right in the past, but developed a new hernia on the right and a smaller on the left.  The plan is for repair.,DESCRIPTION OF OPERATION: , The patient was taken to the operating room, where surgical consent, operative site, and patient identification were verified.  Once he was anesthetized, he was then placed in the supine position.  IV antibiotics were given.  He was then sterilely prepped and draped.  A right inguinal incision was made in the previous incisional site with a 15-blade knife, extended down through the subcutaneous tissue and Scarpa fascia with electrocautery.  Electrocautery was used for hemostasis.,The external oblique fascia was then visualized and incised.  There was a moderate amount of scar tissue noted, but we were able to incise that and go down into the right inguinal canal.  Upon dissection there, we did not find any hernias; however, he did have a fairly sizable hydrocele.  We went down towards the external ring and found that this was indeed tight without any hernias.,We then closed up the external oblique fascia and made an incision after doing a shave on the right and left scrotum into the upper scrotal sac with a curvilinear incision with a 15-blade knife.  We then extended down to the subcutaneous tissue.  Electrocautery was used for hemostasis.  The hydrocele sac was visualized and then drained after incising into it with a curved Metzenbaum scissors.  The testis was then delivered and found to have a moderate amount of scar tissue with a calcified appendix testis, which was then excised and sent to pathology.  We then checked the upper aspect of the tunica vaginalis pouch and found that there was indeed no other connection, was up above, so we then wrapped the sac around the back of the testis, and closed it with a 4-0 chromic suture in a Lord maneuver.  We then closed the upper aspect of the subdartos pouch with a pursestring suture of 4-0 chromic and placed the testis into the scrotum in the proper orientation.  We then used an ilioinguinal nerve block and wound instillation on both incisional areas with 0.25% Marcaine without epinephrine; 15 mL was given.,We performed a similar procedure on the left, incising it at the scrotal area first, rather than below, and found this tunica vaginalis, and dissected it in a similar fashion and cauterized the appendix testis, which was not torsed.  This was a smaller hydrocele, but because of the __________ shunt, we went up above and found that there was a very small connection, which was then dissected off the cord structures gently, twisted upon itself, suture ligated with a 2-0 Vicryl suture.,The ilioinguinal nerve block and other wound instillations again with 15 mL total of 0.25% Marcaine were then done by the surgeon as well.  The external oblique fascia was closed on both sides with a running suture of 2-0 Vicryl.  4-0 chromic was then used to close the Scarpa fascia.  The skin was closed with a 4-0 Rapide subcuticular closure.  The scrotal incisions were closed with a subcutaneous and dartos closure using 4-0 chromic.  IV Toradol was given at the end of the procedure.  Dermabond tissue adhesive was placed on all 4 incisions.  The patient tolerated the procedure well and was in a stable condition upon transfer to the recovery room.","surgery, inguinal exploration, inguinal hernia repair, hydrocele repair, appendix testis, ilioinguinal nerve block, external oblique fascia, tunica vaginalis, ilioinguinal nerve, inguinal hernia, hernia repair, hernia, torsed, inguinal, hydrocele, appendix, testis, "
" Painful ingrown toenail, left big toe.  Removal of an ingrown part of the left big toenail with excision of the nail matrix.", Surgery, Ingrown Toenail Removal ,"PREOPERATIVE DIAGNOSIS: , Painful ingrown toenail, left big toe.,POSTOPERATIVE DIAGNOSIS: , Painful ingrown toenail, left big toe.,OPERATION: , Removal of an ingrown part of the left big toenail with excision of the nail matrix.,DESCRIPTION OF PROCEDURE:  ,After obtaining informed consent, the patient was taken to the minor OR room and intravenous sedation with morphine and Versed was performed and the toe was blocked with 1% Xylocaine after having been prepped and draped in the usual fashion.  The ingrown part of the toenail was freed from its bed and removed, then a flap of skin had been made in the area of the matrix supplying the particular part of the toenail.  The matrix was excised down to the bone and then the skin flap was placed over it.  Hemostasis had been achieved with a cautery.  A tubular dressing was performed to provide a bulky dressing.,The patient tolerated the procedure well.  Estimated blood loss was negligible.  The patient was sent back to Same Day Surgery for recovery.","surgery, toenail, nail matrix, ingrown toenail, painful, ingrown,"
" Autologous iliac crest bone graft to maxilla and mandible under general anesthetic.  Maxillary atrophy, severe mandibular atrophy, acquired facial deformity, and masticatory dysfunction.", Surgery, Iliac Crest Bone Graft - Maxilla & Mandible ,"PREOPERATIVE DIAGNOSES:,1.  Maxillary atrophy.,2.  Severe mandibular atrophy.,3.  Acquired facial deformity.,4.  Masticatory dysfunction.,POSTOPERATIVE DIAGNOSES:,1.  Maxillary atrophy.,2.  Severe mandibular atrophy.,3.  Acquired facial deformity.,4.  Masticatory dysfunction.,PROCEDURE PERFORMED: , Autologous iliac crest bone graft to maxilla and mandible under general anesthetic.,Dr. X and company accompanied the patient to OR #6 at 7:30 a.m.  Nasal trachea intubation was performed per routine.  The bilateral iliac crest harvest was first performed by Dr. X and company under separate OR report.  Once the bone was harvested, surgical templets were used to recontour initially the maxillary graft and the mandibular graft.  Then, CAT scan models were used to find tune and adjust the bony contact regions for the maxillary tricortical block graft and the mandibular tricortical block graft.  Subsequent to the harvest of the bilateral ilium, the intraoral region was scrubbed per routine.  Surgical team scrubbed and gowned in usual fashion and the patient was draped.  Xylocaine 1%, 1:100,000 epinephrine 7 ml was infiltrated into the labial and palatal mucosa.  A primary incision was made in the maxilla starting on the patient's left tuberosity region along the crest of the residual ridge to the contralateral side in similar fashion.  Release incisions were made in the posterior region of the maxilla.,A full-thickness periosteal reflexion first exposed the palatal region.  The contents of the neurovascular canal from the greater palatine foramina were identified.  The hard palate was directly observed.  The facial tissues were then reflected exposing the lateral aspect of the maxilla, the zygomatic arch, the infraorbital nerve, artery and vein, the lateral piriform rim, the inferior piriform rim, and the remaining issue of the nasal spine.  Similar features were reflected on the contralateral side.  The area was re-contoured with rongeurs.  The block of bone, which was formed and harvested from the left ilium was then placed and found to be stable.  A surgical mallet then compressed this bone further into the region.  A series of five 2 mm diameter titanium screws measuring 14 mm to 16 mm long were then used to fixate the block of bone into the residual maxilla.  Particulate bone was then placed around the remaining block of bone.  A piece of AlloDerm mixed with Croften and patient's platelet-rich plasma, which was centrifuged from drawing 20 cc of blood was then mixed together and placed over the lateral aspect of the block.  The tissues were expanded then with a tissue Metzenbaum scissors and once the labial tissue was expanded, the tissues were approximated for primary closure without tension using interrupted and continuous sutures #3-0 Gore-Tex.  Attention was brought then to the mandible.  1% Xylocaine, 1:100,000 epinephrine was infiltrated in the labial mucosa 5 cc were given.  A primary incision was made between the mental foramina and the residual crest of the ridge and reflected first to the lingual area observing the superior genial tubercle in the facial area degloving the mentalis muscle and exposing the anterior body.  The anterior body was found to be approximately 3 mm in height.  A posterior tunnel was done first on the left side along the mylohyoid ridge and then under retromolar pad to the external oblique and the ridge was then degloved.  A tunnel was formed in the posterior region separating the mental nerve artery and vein from the flap and exposing that aspect of the body of the mandible.  A similar procedure was done on the contralateral side.  The tissues were stretched with tissue scissors and then a high speed instrumentation was used to decorticate the anterior mandible using a 1.6 mm twist drill and a pear shaped bur was used in the posterior region to begin original exploratory phenomenon of repair.  A block of bone was inserted between the mental foramina and fixative with three 16 cm screws first with a twist drill then followed with self-tapping 2 mm diameter titanium screws.  The block of bone was further re-contoured in situ.  Particulate bone was then injected into the posterior tunnels bilaterally.  A piece of AlloDerm was placed over those particulate segments.  The tissues were approximated for primary closure using #3-0 Gore-Tex suture both interrupted and horizontal mattress in form.  The tissues were compressed for about four minutes to allow platelet clots to form and to help adhere the flap.,The estimated blood loss in the harvest of the hip was 100 cc.  The estimated blood loss in the intraoral procedure was 220 cc.  Total blood loss for the procedure 320 cc.  The fluid administered 300 cc.  The urine out 180.  All sponges were counted encountered for as were sutures.  The patient was taken to Recovery at approximately 12 o'clock noon.","surgery, autologous iliac crest bone graft, to, mandible, mandibular atrophy, maxillary atrophy, facial deformity, masticatory dysfunction, iliac crest bone graft, mental foramina, iliac crest, bone, autologous, maxillary, mandibular, maxilla"
 Insertion of left femoral circle-C catheter (indwelling catheter).  Chronic renal failure.  The patient was discovered to have a MRSA bacteremia with elevated fever and had tenderness at the anterior chest wall where his Perm-A-Cath was situated., Surgery, Indwelling Catheter Insertion ,"PREOPERATIVE DIAGNOSIS: , Chronic renal failure.,POSTOPERATIVE DIAGNOSIS:  ,Chronic renal failure.,PROCEDURE PERFORMED:,  Insertion of left femoral circle-C catheter.,ANESTHESIA: , 1% lidocaine.,ESTIMATED BLOOD LOSS:,  Minimal.,COMPLICATIONS: , None.,HISTORY: , The patient is a 36-year-old African-American male presented to ABCD General Hospital on 08/30/2003 for evaluation of elevated temperature.  He was discovered to have a MRSA bacteremia with elevated fever and had tenderness at the anterior chest wall where his Perm-A-Cath was situated.  He did require a short-term of Levophed for hypotension.  He is felt to have an infected dialysis catheter, which was removed.  He was planned to undergo replacement of his Perm-A-Cath, dialysis catheter, however, this was not possible.  He will still require a dialysis and will require at least a temporary dialysis catheter until which time a long-term indwelling catheter can be established for dialysis.  He was explained the risks, benefits, and complications of the procedure previously.  He gave us informed consent to proceed.,OPERATIVE PROCEDURE: , The patient was placed in the supine position.  The left inguinal region was shaved.  His left groin was then prepped and draped in normal sterile fashion with Betadine solution.  Utilizing 1% lidocaine, the skin and subcutaneous tissue were anesthetized with 1% lidocaine.  Under direct aspiration technique, the left femoral vein was cannulated.  Next, utilizing an #18 gauge Cook needle, the left femoral vein was cannulated.  Sutures were removed, nonpulsatile flow was observed and a Seldinger guidewire was inserted within the catheter.  The needle was then removed.  Utilizing #11 blade scalpel, a small skin incision was made adjacent to the catheter.  Utilizing a #10 French dilator, the skin, subcutaneous tissue, and left femoral vein were dilated over the Seldinger guidewire.  Dilator was removed and a preflushed circle-C 8 inch catheter was inserted over the Seldinger guidewire.  The guidewire was retracted out from the blue distal port and grasped.  The catheter was then placed in the left femoral vessel _______.  This catheter was then fixed to the skin with #3-0 silk suture.  A mesenteric dressing was then placed over the catheter site.  The patient tolerated the procedure well.  He was turned to the upright position without difficulty.  He will undergo dialysis today per Nephrology.","surgery, chronic renal failure, femoral circle-c catheter, indwelling catheter, catheter, insertion, seldinger, guidewire, indwelling, femoral, dialysis,"
" Induction of vaginal delivery of viable male, Apgars 8 and 9.  Term pregnancy and oossible rupture of membranes, prolonged.", Surgery, Induction of Vaginal Delivery ,"DIAGNOSES,1.  Term pregnancy.,2.  Possible rupture of membranes, prolonged.,PROCEDURE:,  Induction of vaginal delivery of viable male, Apgars 8 and 9.,HOSPITAL COURSE:,  The patient is a 20-year-old female, gravida 4, para 0, who presented to the office.  She had small amount of leaking since last night.  On exam, she was positive Nitrazine, no ferning was noted.  On ultrasound, her AFI was about 4.7 cm.  Because of a variable cervix, oligohydramnios, and possible ruptured membranes, we recommended induction.,She was brought to the hospital and begun on Pitocin.  Once she was in her regular pattern, we ruptured her bag of water; fluid was clear.  She went rapidly to completion over the next hour and a half.  She then pushed for 2 hours delivering a viable male over an intact perineum in an OA presentation.  Upon delivery of the head, the anterior and posterior arms were delivered, and remainder of the baby without complications.  The baby was vigorous, moving all extremities.  The cord was clamped and cut.  The baby was handed off to mom with nurse present.  Apgars were 8 and 9.  Placenta was delivered spontaneously, intact.  Three-vessel cord with no retained placenta.  Estimated blood loss was about 150 mL.  There were no tears.","surgery, induction of vaginal delivery, vaginal delivery, viable male, pregnancy, placenta, vaginal, membranes, apgars"
 Perirectal abscess.  Incision and drainage (I&D) of perirectal abscess., Surgery, I&D - Perirectal Abscess ,"PREOPERATIVE DIAGNOSIS:,  Perirectal abscess.,POSTOPERATIVE DIAGNOSIS:,  Perirectal abscess.,PROCEDURE: , Incision and drainage (I&D) of perirectal abscess.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room after obtaining an informed consent.  A spinal anesthetic was given, and then the patient in the jackknife position had his gluteal area prepped and draped in the usual fashion.,Prior to prepping, I performed a digital rectal examination that showed no pathology and then I proceeded to insert an anoscope.  I found some small internal hemorrhoids and no fistulous tracts.,Then, the patient was prepped and draped in the usual fashion and the abscess area, which was in the left gluteal side, was incised with a cruciate incision and drained.  All necrotic tissue was debrided.  The cavity was digitally explored and found to have no communication to any deeper structures or to the colorectal area.  The cavity was irrigated with saline and then was packed with iodoform gauze and dressed.,Estimated blood loss was minimal.  The patient tolerated the procedure well and was sent for recovery in satisfactory condition.","surgery, hemorrhoids, incision and drainage, perirectal abscess, cavity, i&d, perirectal, "
"  Incision and drainage (I&D) with primary wound closure of scalp lacerations.  The patient is a middle-aged female, who has had significant lacerations to her head from a motor vehicle accident.  The patient was taken to the operating room for an I&D of the lacerations with wound closure.", Surgery, I&D & Wound Closure - Scalp Lacerations ,"PREOPERATIVE DIAGNOSIS: , Scalp lacerations.,POSTOPERATIVE DIAGNOSIS: , Scalp lacerations.,OPERATION PERFORMED: , Incision and drainage (I&D) with primary wound closure of scalp lacerations.,ANESTHESIA:,  GET.,EBL: , Minimal.,COMPLICATIONS: , None.,DRAINS: , None.,DISPOSITION: , Vital signs stable and taken to the recovery room in a satisfactory condition.,INDICATION FOR PROCEDURE:  ,The patient is a middle-aged female, who has had significant lacerations to her head from a motor vehicle accident.  The patient was taken to the operating room for an I&D of the lacerations with wound closure.,PROCEDURE IN DETAIL:  ,After appropriate consent was obtained from the patient, the patient was wheeled out to the operating theater room #5.  Before the neck instrumentation was performed, the patient's lacerations to her scalp were I&D'ed and closed.  It was noted that the head was significantly contaminated with blood as well as mangled.  It was decided at that time in order to repair the lacerations appropriately, the patient would undergo cutting of her hair.  This was shaved appropriately with shavers.  Once this was done, the scalp lacerations were copiously irrigated with a scrubbing brush, hexedine solution together with peroxide.  Once this was appropriately debrided with regards to the midline incision with the scalp going through the midline of her skull as well as the incision on the left aspect of her scalp, the wounds were significantly irrigated with normal saline.  No significant debris was appreciated.  Once this was done, staples were used to oppose the dermal edges together.  The patient was subsequently dressed sterilely using bacitracin ointment, Xeroform, 4x4s, and tape.  The neck procedure was subsequently performed.","surgery, drainage, incision, primary wound closure, lacerations, wound closure, scalp lacerations, scalp, i&d,"
" Postoperative wound infection, complicated.  Irrigation and debridement of postoperative wound infection.  Removal of foreign body.  Placement of vacuum-assisted closure.device.", Surgery, I&D - ORIF Wound ,"TITLE OF OPERATION:,1.  Irrigation and debridement of postoperative wound infection (CPT code 10180).,2.  Removal of foreign body, deep (CPT code 28192).,3.  Placement of vacuum-assisted closure device, less than 50 centimeter squared (CPT code 97605).,PREOP DIAGNOSIS: , Postoperative wound infection, complicated (ICD-9 code 998.59).,POSTOP DIAGNOSIS: , Postoperative wound infection, complicated (ICD-9 code 998.59).,PROCEDURE DETAIL:  ,The patient is a 59-year-old gentleman who is status post open reduction and internal fixation of bilateral calcanei.  He was admitted for a left wound breakdown with drainage.  He underwent an irrigation and debridement with VAC placement 72 hours prior to this operative visit.  It was decided to bring him back for a repeat irrigation and debridement and VAC change prior to Plastics doing a local flap.  The risks of surgery were discussed in detail including, but not limited to infection, bleeding, injuries to nerves and vital structures, need for reoperation, pain or stiffness, arthritis, fracture, the risk of anesthesia.  The patient understood these risks and wished to proceed.  The patient was admitted, and the operative site was marked.,The patient was brought to the operating room and given general anesthetic.  He was placed in the right lateral decubitus, and all bony prominences were well padded.  An axillary roll was placed.  A well-padded thigh tourniquet was placed on the left leg.  The patient then received antibiotics on the floor prior to coming down to the operating room which satisfied the preoperative requirement.  Left leg was then prepped and draped in usual sterile fashion.  The previous five antibiotic spacer beads were removed without difficulty.  The wound was then rongeured and curetted, and all bone was cleaned down to healthy bleeding bone.  The wound actually looked quite good with evidence of purulence or drainage.  Skin edges appeared to be viable.  Hardware all looked to be intact.  At this point, the wound was irrigated with 9 liters of bibiotic solution.  A VAC sponge was then placed over the wound, and the patient's leg was placed into a posterior splint.  The patient was awakened and then taken to recovery in good condition.,Dr. X was present for the timeouts and for all critical portions of the procedure.  He was immediately available for any questions during the case.,PLAN:,1.  A CAM walker boots.,2.  A VAC change on Sunday by the nurse.,3.  A flap per Plastic Surgery.","surgery, irrigation and debridement, removal of foreign body, vacuum-assisted closure device, foreign body, postoperative wound, wound infection, infection, wound, orif, debridement, vacuum,"
" Incision and drainage of the penoscrotal abscess, packing, penile biopsy, cystoscopy, and urethral dilation.", Surgery, I&D - Penoscrotal Abscess ,"PREOPERATIVE DIAGNOSIS: , Penoscrotal abscess.,POSTOPERATIVE DIAGNOSIS:,  Penoscrotal abscess.,OPERATION: , Incision and drainage of the penoscrotal abscess, packing, penile biopsy, cystoscopy, and urethral dilation.,BRIEF HISTORY: , The patient is a 75-year-old male presented with penoscrotal abscess.  Options such as watchful waiting, drainage, and antibiotics were discussed.  Risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, completely the infection turning into necrotizing fascitis, Fournier's gangrene were discussed.  The patient already had significant phimotic changes and disfigurement of the penis.  For further debridement the patient was told that his penis is not going to be viable, he may need a total or partial penectomy now or in the future.  Risks of decreased penile sensation, pain, Foley, other unexpected issues were discussed.  The patient understood all the complications and wanted to proceed with the procedure.,DETAIL OF THE OPERATION:  ,The patient was brought to the OR.  The patient was placed in dorsal lithotomy position.  The patient was prepped and draped in the usual fashion.  Pictures were taken prior to starting the procedure for documentation.  The patient had an open sore on the right side of the penis measuring about 1 cm in size with pouring pus out using blunt dissection.  The penile area was opened up distally to allow the pus to come out.  The dissection around the proximal scrotum was done to make sure there are no other pus pockets.  The corporal body was intact, but the distal part of the corpora was completely eroded and had a fungating mass, which was biopsied and sent for permanent pathology analysis.,Urethra was identified at the distal tip, which was dilated and using 23-French cystoscope cystoscopy was done, which showed some urethral narrowing in the distal part of the urethra.  The rest of the bladder appeared normal.  The prostatic urethra was slightly enlarged.  There are no stones or tumors inside the bladder.  There were moderate trabeculations inside the bladder.  Otherwise, the bladder and the urethra appeared normal.  There was a significantly fungating mass involving the distal part of the urethra almost possibility to have including the fungating wart or fungating squamous cell carcinoma.  Again biopsies were sent for pathology analysis.  Prior to urine irrigation anaerobic aerobic cultures were sent, irrigation with over 2 L of fluid was performed.  After irrigation, packing was done with Kerlix.  The patient was brought to recovery in a stable condition.  Please note that 18-French Foley was kept in place.  Electrocautery was used at the end of the procedure to obtain hemostasis as much as possible, but there was fungating mass with slight bleeding packing was done and tight scrotal Kling was applied.  The patient was brought to Recovery in a stable condition after applying 0.5% Marcaine about 20 mL were injected around for local anesthesia.","surgery, i&d, penoscrotal, penile biopsy, cystoscopy, urethral dilation, incision and drainage, fungating mass, penoscrotal abscess, abscess, urethral, "
 Incision and drainage of left neck abscess., Surgery, I&D - Neck Abscess ,"PREOPERATIVE DIAGNOSIS: , Left neck abscess.,POSTOPERATIVE DIAGNOSIS: , Left neck abscess.,OPERATIVE PROCEDURE: , Incision and drainage of left neck abscess.,ANESTHESIA:  ,General inhalational.,DESCRIPTION OF PROCEDURE: , The patient was taken to operating room and placed supine on the operating table.  General inhalational anesthesia was administered.  The patient was draped in usual fashion.  The prominent area of the left submandibular swelling was noted and a 1-cm incision was outlined with a marking pen and the area was infiltrated with 0.5 mL of local anesthetic using 1% Xylocaine with epinephrine 1:100,000.  The incision was performed with a #15 blade.  An 18-gauge needle and 10 mL syringe was used to evacuate a small amount of the purulence from the abscess cavity.  This was submitted for culture and sensitivity, anaerobic cultures and Gram stain.  The cavity was opened with a small hemostat and a great deal of grossly purulent material was evacuated.  The cavity was irrigated with peroxide and saline.  A 0.25-inch Penrose drain was placed and secured with a single #3-0 nylon suture.  A 4 x 4 dressing was applied.  Bleeding was negligible.  There were no untoward complications.  The patient tolerated the procedure well and was transferred to the recovery room in stable condition.","surgery, i&d, incision and drainage, neck abscess, drainage, cavity, incision, "
" Grade 1 compound fracture, right mid-shaft radius and ulna with complete displacement and shortening.   Irrigation and debridement of skin subcutaneous tissues, muscle, and bone, right forearm.  Open reduction, right both bone forearm fracture with placement of long-arm cast.", Surgery, I&D & Open Reduction - Forearm ,"PREOPERATIVE DIAGNOSIS:  ,Grade 1 compound fracture, right mid-shaft radius and ulna with complete displacement and shortening.,POSTOPERATIVE DIAGNOSIS: , Grade 1 compound fracture, right mid-shaft radius and ulna with complete displacement and shortening.,OPERATIONS:,1.  Irrigation and debridement of skin subcutaneous tissues, muscle, and bone, right forearm.,2.  Open reduction, right both bone forearm fracture with placement of long-arm cast.,COMPLICATIONS:,  None.,TOURNIQUET: , None.,ESTIMATED BLOOD LOSS:,  25 mL.,ANESTHESIA: , General.,INDICATIONS:  ,The patient suffered injury at which time he fell over a concrete bench.  He landed mostly on the right arm.  He noted some bleeding at the time of the injury and a small puncture wound.  He was taken to the emergency room and diagnosed a compound both bone forearm fracture, and based on this, he was seen for malalignment.,He was indicated the above-noted procedure.  This procedure as well as alternatives of this procedure was discussed at length with the patient's parents and they understood them well.  Risks and benefits were also discussed.  Risks such as bleeding, infection, damage to blood vessels, damage to nerve roots, need for further surgeries, chronic pain on full range of motion, risk of continued discomfort, risk of need for repeat debridement, risk of need for internal fixation, risk of blood clots, pulmonary embolism, myocardial infarction, and risk of death were discussed.  They understood these well.  All questions were answered and they signed the consent for procedure as described.,DESCRIPTION OF PROCEDURE:  ,The patient was placed on the operating table and general anesthesia was achieved.  The right forearm was inspected.  There was noted to be a 3-mm puncture-type wound over the volar aspect of the forearm in the middle one-third overlying the radial one-half.  There was bleeding in this region.  No gross contamination was seen.  At this point, under fluoroscopic control, I did attempt to see a fracture.  I was unable to do the forearm under the close reduction techniques.  At this point, the right upper extremity was then prepped and draped in the usual sterile manner.  An incision was made through the puncture wound site extending this proximally and distally.  There was noted to be some slight amount of nonviable tissue at the skin edge and debridement was required and performed.  I also did perform a light debridement of the nonviable subcutaneous tissue, muscle, and small bony fragments were also removed.  These were all completely debrided appropriately and then at this point, a thorough irrigation was performed of the radius, which I communicated through the puncture wound.  Both ends were clearly visualized, and thorough irrigation was performed using total of 6 L of antibiotic solution.  All nonviable gross contaminated tissue was removed.  At this point with the bones in direct visualization, I did reduce the bony ends to anatomic alignment with excellent bony approximation.  Proper alignment of tissue and angulation was confirmed.,At this point, under fluoroscopic control confirmed the radius and ulna in anatomic position, which will be completely displaced and shortened previously.  The ulna was now also noted to be in anatomic alignment.,At this point, the region was thoroughly irrigated.  Hemostasis confirmed and closure then begun.  The skin was reapproximated using 3-0 nylon suture.  The visual puncture wound region was left open and this was intact with the depth of the wound down the bone using 1.5-inch Nugauze with iodoform.  Sterile dressing applied and a long-arm cast with the forearm in neutral position was applied.  X-ray with fluoroscopic evaluation was performed, which confirmed.  They maintained excellent bony approximation and the anatomic alignment.  The long-arm cast was then completely mature.  No complications were encountered throughout the procedure.  The patient tolerated the procedure well.  The patient was then taken to the recovery room in stable condition.","surgery, compound fracture, mid-shaft radius, ulna, open reduction, irrigation and debridement, subcutaneous, tissues, muscle, bone, forearm, radius and ulna, forearm fracture, anatomic alignment, arm cast, puncture wound, tourniquet, i&d, fracture,"
 Incision and drainage (I&D) of gluteal abscess.  Removal of pigtail catheter.  Limited exploratory laparotomy with removal of foreign body and lysis of adhesions., Surgery, I&D - Gluteal Abscess ,"PREOPERATIVE DIAGNOSES,1.  Postoperative wound infection.,2.  Left gluteal abscess.,3.  Intraperitoneal pigtail catheter.,POSTOPERATIVE DIAGNOSES,1.  Postoperative wound infection.  There was an intraperitoneal foreign body.,2.  Left gluteal abscess.,3.  Intraperitoneal pigtail catheter.,PROCEDURES,1.  Incision and drainage (I&D) of gluteal abscess.,2.  Removal of pigtail catheter.,3.  Limited exploratory laparotomy with removal of foreign body and lysis of adhesions.,DESCRIPTION OF PROCEDURE: , After obtaining the informed consent, the patient was transferred to the operating room where a time-out process was followed.  Under general endotracheal anesthesia, first of all the patient was positioned in the left lateral decubitus and the left gluteal area was prepped and draped in the usual fashion.  The opening of the abscess was probed and there was a tract of about 20 cm going subcutaneously upward.  I proceeded to enlarge the drainage area and to some degree unroofing the tract partially and then the area was débrided and then packed with iodoform gauze and a temporary dressing was applied.,Then, the patient was placed in a supine position, and I proceeded to remove the pigtail catheter after dividing it to undo its locking mechanism.  It came out without any difficulty.  Then, the colostomy was protected and draped apart, and the patient's abdomen was prepped and draped in the usual fashion.  My initial idea was to just drain and debride the wound infection, which had a sinus tract at lower end of the midline incision.  I initially probed the wound with a hemostat and this had at least 12 cm long tract and I proceeded to excise the badly scarred skin that was on top of it and then continued the dissection to the fascia and I realized that the sinus tract was going through the fascia into the abdomen.  Very carefully, I started dividing the fascia.  Of course, there were several small bowel loops adhered to the area.  The dissection was quite tedious for a while.  Initially, I thought that may be there was an enterocutaneous fistula in the area, but then I realized that the tissue that was interpreted as an intestinal mucosa was actually a very smooth __________ tissue that was walling the sinus tract.  I made a laparotomy of about 10 cm and I carefully dissected the bowel of the fascia.  There was an area at the bottom which looked like a foreign body and initially I thought there was a mesh that can be used to close the abdomen, but later on this substance floated out by self and it was an elongated strip, maybe about 6 cm, which we sent to Pathology for examination.  Initially, I have obtained a sample for culture and sensitivity for aerobic and anaerobic organisms.,I was very happy that we were not really dealing with enterocutaneous fistula.  The area was irrigated generously with saline and then we closed the fascia with number of interrupted figure-of-eight sutures of heavy PPS.  The subcutaneous tissue and the skin were left open and packed with Betadine-soaked sponges.,A dressing was applied.  A small dressing was applied to the area where we removed the pigtail catheter and also we went down to the gluteal area and put a formal dressing in that area.  The patient tolerated the procedure well.  Estimated blood loss was minimal, and he was sent to the ICU and also made acute care because of the need for a laparotomy, which we were not anticipating.","surgery, intraperitoneal pigtail catheter, postoperative wound infection, foreign body, intraperitoneal, exploratory laparotomy, enterocutaneous fistula, wound infection, sinus tract, gluteal abscess, pigtail catheter, i&d, abscess, laparotomy, fascia, pigtail, catheter, gluteal, incision, foreign"
" Incision and drainage and removal of foreign body, right foot.  The patient has had previous I&D but continues to have to purulent drainage.  The patient's parents agreed to performing a surgical procedure to further clean the wound.", Surgery, I&D & Foreign Body Removal ,"PREOPERATIVE DIAGNOSIS:,  Foreign body, right foot.,POSTOPERATIVE DIAGNOSIS: , Foreign body, right foot.,PROCEDURE PERFORMED:,1.  Incision and drainage, right foot.,2.  Removal of foreign body, right foot.,HISTORY: , This 7-year-old Caucasian male is an inpatient at ABCD General Hospital with a history of falling off his bike and having a root ________ angle inside of his foot.  The patient has had previous I&D but continues to have to purulent drainage.  The patient's parents agreed to performing a surgical procedure to further clean the wound.,PROCEDURE:,  An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported to the operating room and placed on the operating table in a supine position with a safety strap across his lap.  General anesthesia was administered by the Department of Anesthesia.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  The stockinette was reflected and the foot was cleansed with wet and dry sponge.  There was noted to be some remaining periwound erythema.  There was noted to be some mild crepitation about 2 cm proximal from the entry wound.  The entry wound was noted to be over the third metatarsal head dorsally.  Upon inspection of the wound, there was noted to be hard foreign filling substance deep within the wound.  The entry site from the foreign body was extended proximally approximately about 0.5 cm.  At this time, a large wooden foreign body was visualized and removed with a straight stat.,The area was carefully inspected for any remaining piece of foreign body.  Several small pieces were noted and they were removed.  The area was palpated and there was no more remaining foreign body noted.  At this time, the wound was inspected thoroughly.  There was noted to be an area along the third metatarsal head more distally that did probe to the bone.  There was no purulent drainage expressed.  Area was flushed with copious amounts of sterile saline.  Pulse lavage was performed with 3 liters of plain sterile saline.  Wound cultures were obtained, aerobic and aerobic.  The wound was then again inspected for any remaining foreign body or purulent drainage.  None was noticed.  The wound was packed with sterile new gauze packing lately and dressings consisted of 4x4s, ABDs, Kling, and Kerlix.,The patient tolerated the above procedure and anesthesia well without complications.  The patient was transported to the PACU with vital signs stable and vascular status intact.  The patient is to be readministered to the pediatrics where daily dressing changes will be performed by podiatry.  The patient had a postoperative pain prescription written for Tylenol, Elixir with codeine as needed.","surgery, incision and drainage, removal of foreign body, purulent drainage, foreign body, metatarsal head, orthopedic, metatarsal, i&d, incision, drainage, foot "
 Incision and drainage of right buccal space abscess and teeth extraction., Surgery, I&D - Buccal Space Abscess ,"PREOPERATIVE DIAGNOSES,1.  Right buccal space abscess/cellulitis.,2.  Nonrestorable caries teeth #1, #29, and #32.,POSTOPERATIVE DIAGNOSES,1.  Right buccal space abscess/cellulitis.,2.  Nonrestorable caries teeth #1, #29, and #32.,PROCEDURE,1.  Incision and drainage of right buccal space abscess.,2.  Extraction of teeth #1, #29, and #32.,ANESTHESIA,GETA,EBL,20 mL.,IV FLUIDS,900 mL.,URINE OUTPUT,Not measured.,COMPLICATIONS,None.,SPECIMENS,1.  Aerobic culture was sent from the right buccal space abscess/cellulitis.,2.  Anaerobic culture from the same space was also obtained.,PROCEDURE IN DETAIL,The patient was identified in the appropriate holding area and transported to #13.  The patient was intubated by anesthesia orotracheally using a #7 ET tube.  The patient was induced in effective sleep using a propofol and gas inhalation anesthetics.  Following intubation, the patient's mouth was cleaned with chlorhexidine and a toothbrush following placement of a throat pack.  At that point, approximately 5 mL of 2% lidocaine with 1:20,000 epinephrine was injected for a right inferior alveolar block, as well as local infiltration in the right long buccal nerve area as well as the right cheek area.  Local infiltration also was done near the tooth #32.  At this point, a periosteal elevator was used to loosen up the gingival tissue of the teeth #1, #29, and #32; and all 3 teeth were extracted using simple extraction, using elevators and forceps.  In addition, the previous Penrose drain was removed by removing the suture, and the incision that was used for I&D on the previous day was extended laterally.  A hemostat was used to puncture through to the right buccal space.  Approximately, 2.5 to 3 mL of purulence was drained, and that was used for Gram stain and culture, as mentioned above.  Following copious irrigation of the area, following the extraction and following the incision and drainage, 2 quarter-inch Penrose drains were placed in the anterior as well as the posterior section of the incision into the buccal space.  At this point copious irrigation was done again, the throat pack was removed, and the procedure was ended.  Note that the patient was extubated without incident.  Dr. B was present for all critical aspects of patient care.","surgery, abscess, #7 et tube, aerobic culture, anaerobic culture, extraction of teeth, geta, alveolar block, buccal space, caries, cellulitis, copious irrigation, extraction, teeth, nonrestorable caries teeth, buccal space abscess, nonrestorable caries, caries teeth, throat pack, buccal, "
" Placement of right external iliac artery catheter via left femoral approach, arteriography of the right iliac arteries, primary open angioplasty of the right iliac artery using an 8 mm diameter x 3 cm length angioplasty balloon, open stent placement in the right external iliac artery for inadequate angiographic result of angioplasty alone.", Surgery," Iliac Artery Catheter & Stent Placement, Arteriography, Angioplasty ","PREOPERATIVE DIAGNOSIS: , External iliac artery stenosis supplying recently transplanted kidney with renovascular hypertension and impaired renal function.,POSTOPERATIVE DIAGNOSIS:,  External iliac artery stenosis supplying recently transplanted kidney with renovascular hypertension and impaired renal function.,PROCEDURES:,1.  Placement of right external iliac artery catheter via left femoral approach.,2.  Arteriography of the right iliac arteries.,3.  Primary open angioplasty of the right iliac artery using an 8 mm diameter x 3 cm length angioplasty balloon.,3.  Open stent placement in the right external iliac artery for inadequate angiographic result of angioplasty alone.,ANESTHESIA: , Local with intravenous sedation.,INDICATION FOR PROCEDURE:,  He is a 67-year-old white male who is well known to me.  He had severe peripheral vascular disease and recently underwent a kidney transplant.  He has had some troubles with increasing serum creatinine and hypertension.  Duplex suggests a high-grade iliac stenosis just proximal to his transplant kidney.  He is brought to the operating room for arteriography and potential treatment of this.,DESCRIPTION OF PROCEDURE: , The patient was brought to operating room #14.  A condom catheter was put in place.  Preoperative antibiotics were administered.  The patient's left arm was prepped and draped in the usual sterile fashion.  An incision was made over his brachial artery after anesthetizing the skin.  His brachial artery was dissected free and looped with vessel loops.  Under direct vision, it was punctured with an 18-gauge needle and a short 3J guidewire and 6-French sheath put in place.  A 3J guidewire was then introduced after the administration of intravenous heparin and advanced into the descending thoracic aorta.  This was then advanced down into the right common iliac artery.  The catheter was placed over this and arteriography performed.  After adjusting the image intensifier to unfold the origin of the renal artery from the iliac system.  We were able to demonstrate an approximately 60-70% stenosis of the external iliac artery.  Immediately preceding the origin of the artery for the transplant kidney, which appeared to be widely patent.  We elected to try and treat this.  With catheter support a magic torque guidewire was advanced through the stenosis and into the common femoral artery.  An 8 mm diameter x 3 cm length angioplasty balloon was positioned across the stenosis and inflated.  This inflation was held for one minute.  This was then deflated and a catheter positioned again in the proximal common iliac artery.  For this application, we used a guide catheter that would allow us to inject contrast without losing our wire purchase.  This showed an improvement in the stenosis, but a residual stenosis of at least 30% and we elected to stent this.  An 8 mm diameter x 3 cm length stent was chosen and placed just proximal to the origin of the renal artery.  After this was completed, the stent introduction balloon was removed and the catheter replaced.  Repeat angiography showed a widely patent segment with no evidence of any residual stenosis.  There was no evidence of any dissection or damage to the renal artery.  We interpreted this as satisfactory procedure.  Guidewires and sheaths were removed.  The brachial artery was repaired with two interrupted sutures of 7-0 Prolene.  The wound was irrigated and the subcutaneous tissue closed with a running suture of Vicryl.  The skin was reapproximated with a running intracuticular suture of Monocryl.  Steri-Strips and sterile occlusive dressing were applied and the patient was taken to the recovery room in stable condition.  Estimated blood loss for the procedure was less than 50 mL.  Total contrast employed was 37.5 mL.  Total fluoroscopy time was 12 minutes and 43 seconds.","surgery, external iliac artery catheter, catheter via left femoral, external iliac artery stenosis, impaired renal function, common iliac artery, iliac artery catheter, external iliac artery, iliac artery, femoral approach, iliac arteries, transplanted kidney, renovascular hypertension, widely patent, residual stenosis, stent placement, angioplasty balloon, brachial artery, renal artery, iliac, angioplasty, artery, guidewire, arteriography, kidney, renal, catheter, stenosis"
" Dilation and curettage (D&C), hysteroscopy, and laparoscopy with right salpingooophorectomy and aspiration of cyst fluid.  Thickened endometrium and tamoxifen therapy, adnexal cyst, endometrial polyp, and right ovarian cyst.", Surgery, Hysteroscopy & Laproscopy with Salpingooophorectomy ,"PREOPERATIVE DIAGNOSES:,1.  Thickened endometrium and tamoxifen therapy.,2.  Adnexal cyst.,POSTOPERATIVE DIAGNOSES:,1.  Thickened endometrium and tamoxifen therapy.,2.  Adnexal cyst.,3.  Endometrial polyp.,4.  Right ovarian cyst.,PROCEDURE PERFORMED:,1.  Dilation and curettage (D&C).,2.  Hysteroscopy.,3.  Laparoscopy with right salpingooophorectomy and aspiration of cyst fluid.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 20 cc.,COMPLICATIONS:,  None.,INDICATIONS: , This patient is a 44-year-old gravida 2, para 1-1-1-2 female who was diagnosed with breast cancer in December of 2002.  She has subsequently been on tamoxifen.  Ultrasound did show a thickened endometrial stripe as well as an adnexal cyst.  The above procedures were therefore performed.,FINDINGS:  ,On bimanual exam, the uterus was found to be slightly enlarged and anteverted.  The external genitalia was normal.  Hysteroscopic findings revealed both ostia well visualized and a large polyp on the anterolateral wall of the endometrium.  Laparoscopic findings revealed a normal-appearing uterus and normal left ovary.  There was no evidence of endometriosis on the ovaries bilaterally, the ovarian fossa, the cul-de-sac, or the vesicouterine peritoneum.  There was a cyst on the right ovary which appeared simple in nature.  The cyst was aspirated and the fluid was blood tinged.  Therefore, the decision to perform oophorectomy was made.  The liver margins appeared normal and there were no pelvic or abdominal adhesions noted.  The polyp removed from the hysteroscopic portion of the exam was found to be 4 cm in size.,PROCEDURE IN DETAIL: , After informed consent was obtained in layman's terms, the patient was taken back to the operating suite, prepped and draped and placed in the dorsal lithotomy position.  Her bladder was drained with a red Robinson catheter.  A bimanual exam was performed, which revealed the above findings.  A weighted speculum was then placed in the posterior vaginal vault in the 12 o'clock position and the cervix was grasped with vulsellum tenaculum.  The cervix was then sounded in the anteverted position to 10 cm.  The cervix was then serially dilated using Hank and Hegar dilators up to a Hank dilator of 20 and Hagar dilator of 10.  The hysteroscope was then inserted and the above findings were noted.  A sharp curette was then introduced and the 4 cm polyp was removed.  The hysteroscope was then reinserted and the polyp was found to be completely removed at this point.  The polyp was sent to Pathology for evaluation.  The uterine elevator was then placed as a means to manipulate the uterus.  The weighted speculum was removed.  Gloves were changed.  Attention was turned to the anterior abdominal wall where 1 cm infraumbilical skin incision was made.  While tenting up the abdominal wall, the Veress needle was inserted without difficulty.  Using a sterile saline drop test, appropriate placement was confirmed.  The abdomen was then insufflated with appropriate volume inflow of CO2.  The #11 step trocar was placed without difficulty.  The above findings were then visualized.  A 5 mm port was placed 2 cm above the pubic symphysis.  This was done under direct visualization and the grasper was inserted through this port for better visualization.  A 12 mm port was then made in the right lateral aspect of the abdominal wall and the Endo-GIA was inserted through this port and the fallopian tube and ovary were incorporated across the infundibulopelvic ligament.  Prior to this, the cyst was aspirated using 60 cc syringe on a needle.  Approximately, 20 cc of blood-tinged fluid was obtained.  After the ovary and fallopian tube were completely transected, this was placed in an EndoCatch bag and removed through the lateral port site.  The incision was found to be hemostatic.  The area was suction irrigated.  After adequate inspection, the port sites were removed from the patient's abdomen and the abdomen was desufflated.  The infraumbilical port site and laparoscope were also removed.  The incisions were then repaired with #4-0 undyed Vicryl and dressed with Steri-Strips.  10 cc of 0.25% Marcaine was then injected locally.  The patient tolerated the procedure well.  The sponge, lap, and needle counts were correct x2.  She will be followed up on an outpatient basis.","surgery, adnexal cyst, endometrial, ovarian cyst, dilation and curettage, d&c, hysteroscopy, laparoscopy, salpingooophorectomy, aspiration of cyst fluid, thickened endometrium, tamoxifen therapy, abdominal wall, cyst, ovarian, endometrium, "
 Incision and drainage (I&D) of buttock abscess.  , Surgery, I&D - Buttock Abscess ,"PRINCIPAL DIAGNOSIS: , Buttock abscess, ICD code 682.5.,PROCEDURE PERFORMED:,  Incision and drainage (I&D) of buttock abscess.,CPT CODE: , 10061.,DESCRIPTION OF PROCEDURE:  ,Under general anesthesia, skin was prepped and draped in usual fashion.  Two incisions were made along the right buttock approximately 5 mm diameter.  Purulent material was drained and irrigated with copious amounts of saline flush.  A Penrose drain was placed.  Penrose drain was ultimately sutured forming a circular drain.  The patient's drain will be kept in place for a period of 1 week and to be taken as an outpatient basis.  Anesthesia, general endotracheal anesthesia.  Estimated blood loss approximately 5 mL.  Intravenous fluids 100 mL.  Tissue collected.  Purulent material from buttock abscess sent for usual cultures and chemistries.  Culture and sensitivity Gram stain.  A single Penrose drain was placed and left in the patient.  Dr. X attending surgeon was present throughout the entire procedure.","surgery, incision and drainage, purulent material, penrose drain, buttock abscess, i&d, drainage"
" Total abdominal hysterectomy, right salpingoophorectomy, and extensive adhesiolysis and enterolysis.", Surgery, Hysterectomy & Salpingoophorectomy ,"PREOPERATIVE DIAGNOSES:,1.Stage IV endometriosis with severe pelvic pain.,2.Status post prior left salpingoophorectomy.,POSTOPERATIVE DIAGNOSES:,1.Stage IV endometriosis with severe pelvic pain.,2.Status post prior left salpingoophorectomy.,3.Severe adhesions.,TYPE OF ANESTHESIA: , General endotracheal tube.,TECHNICAL PROCEDURE: , Total abdominal hysterectomy, right salpingoophorectomy, and extensive adhesiolysis and enterolysis.,INDICATION FOR PROCEDURE: , The patient is a 42-year-old parous female who had a longstanding history of severe endometriosis unresponsive to hormonal medical therapy and pain medication.  She had severe dyspareunia and chronic suprapelvic pain.  The patient had had a prior left salpingoophorectomy laparoscopically in 2004 for same disease process.  Now, she presented with a recurrent right ovarian endometrioma and severe pelvic pain.  She desired surgical treatment.  She accepted risk of a complete hysterectomy and salpingoophorectomy, risk of injury to underlying organs.  The risks, benefits, and alternatives were clearly discussed with the patient as documented in the medical record.,DESCRIPTION OF FINDINGS: , Absent left adnexa.  Right ovary about 6 cm with chocolate cyst and severely adherent to the right pelvic side wall, uterus, and colon.  Careful dissection to free right ovary and remove it although it is likely that some ovarian tissue remains behind.  Ureter visualized and palpated on right and appears normal.  Indigo carmine given IV with no leaks intraperitoneally noted.  Sigmoid colon dissected free from back of uterus and from cul-de-sac.  Bowel free of lacerations or denudation.  Upon inspection, right tube with hydrosalpinx, appendix absent.  Omental adhesions to ensure abdominal wall was lysed.,TECHNICAL PROCEDURE: , After informed consent was obtained, the patient was taken to the operating room where she underwent smooth induction of general anesthesia.  She was placed in a supine position with a transurethral Foley in place and compression stockings in place.  The abdomen and vagina were thoroughly prepped and draped in the usual sterile fashion.,A Pfannenstiel skin incision was made with the scalpel and carried down sharply to the underlying layer of fascia and peritoneum.  The peritoneum was bluntly entered and the incision extended caudally and cephaladly with good visualization of underlying organs.  Next, exploration of the abdominal and pelvic organs revealed the above noted findings.  The uterus was enlarged and probably contained adenomyosis.  There were dense adhesions, and a large right endometrioma with a chocolate cyst-like material contained within.  The sigmoid colon was densely adhered to the cul-de-sac into the posterior aspect of the uterus.  A Bookwalter retractor was placed into the incision, and the bowel was packed away with moist laparotomy sponges.  Next, a sharp and blunt dissection was used to free the extensive adhesions, and enterolysis was performed with very careful attention not to injure or denude the bowel.  Next, the left round ligament and cornual region was divided, transected, and suture-ligated with 0 Polysorb.  The anterior and posterior leafs of the broad ligament were dissected and opened anteriorly to the level of the bladder.  The uterine arteries were skeletonized on the left, and these were suture-clamped and transected with 0 Polysorb with good hemostasis noted.  Next, the bladder flap was developed anteriorly, and the bladder peritoneum was sharply and bluntly dissected off of the lower uterus.,On the right, a similar procedure was performed.  The right round ligament was suture-ligated with 0 Polysorb.  It was transected and divided with electrocautery.  The anterior and posterior leafs of the broad ligament were dissected and developed anteriorly and posteriorly, and this area was relatively avascular.  The left infundibulopelvic ligament was identified.  It was cross-clamped and transected, suture-ligated with 0 Polysorb with good hemostasis noted.  Next, the uterine arteries were skeletonized on the right.  They were transected and suture-ligated with 0 Polysorb.  The uterosacral ligaments were taken bilaterally and transected and suture-ligated with 0 Polysorb.  The cardinal ligaments were taken near their insertion into the cervical and uterine tissue.  Pedicles were sharply developed and suture-ligated with 0 Polysorb.  Next, the electrocautery was used to dissect the cervix anteriorly from the underlying vagina.  Once entry into the vagina was made, the cervix and uterus were amputated with Jorgensen scissors.  The vaginal cuff angles were suture-ligated with 0 Polysorb and transfixed to the ipsilateral, cardinal, and uterosacral ligaments for vaginal support.  The remainder of the vagina was closed with figure-of-eight sutures in an interrupted fashion with good hemostasis noted.,Next, the right ovarian tissue was densely adherent to the colon.  It was sharply and bluntly dissected, and most of the right ovary and endometrioma was removed and dissected off completely; however, there is a quite possibility that small remnants of ovarian tissue were left behind.  The right ureter was seen and palpated.  It did not appear to be dilated and had good peristalsis noted.  Next, the retractors were removed.  The laparotomy sponges were removed from the abdomen.  The rectus fascia was closed with 0 Polysorb in a continuous running fashion with 2 sutures meeting in the midline.  The subcutaneous tissue was closed with 0 plain gut in an interrupted fashion.  The skin was closed with 4-0 Polysorb in a subcuticular fashion.  A thin layer of Dermabond was placed.,The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x 2.  Cefoxitin 2 g was given preoperatively.,INTRAOPERATIVE COMPLICATIONS:,  None.,DESCRIPTION OF SPECIMEN: , Uterus and right adnexa.,ESTIMATED BLOOD LOSS: , 1000 mL.,POSTOPERATIVE CONDITION: , Stable.,",
" Hysteroscopy, Essure, tubal occlusion, and ThermaChoice endometrial ablation.", Surgery, Hysteroscopy & Endometrial Ablation ,"PREOPERATIVE DX:,1.  Menorrhagia,2.  Desires permanent sterilization.,POSTOPERATIVE DX:,1.  Menorrhagia,2.  Desires permanent sterilization.,OPERATIVE PROCEDURE:,  Hysteroscopy, Essure, tubal occlusion, and ThermaChoice endometrial ablation.,ANESTHESIA: , General with paracervical block.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS:,  On hysteroscopy, 100 ml deficit of lactated Ringer's via IV, 850 ml of lactated Ringer's.,COMPLICATIONS: , None.,PATHOLOGY: , None.,DISPOSITION:  ,Stable to recovery room.,FINDINGS:,  A nulliparous cervix without lesions.  Uterine cavity sounding to 10 cm, normal appearing tubal ostia bilaterally, fluffy endometrium, normal appearing cavity without obvious polyps or fibroids.,PROCEDURE: , The patient was taken to the operating room, where general anesthesia was found to be adequate.  She was prepped and draped in the usual sterile fashion.  A speculum was placed into the vagina.  The anterior lip of the cervix was grasped with a single-tooth tenaculum and a paracervical block was performed using 20 ml of 0.50% lidocaine with 1:200,000 of epinephrine.,The cervical vaginal junction at the 4 o'clock position was injected and 5 ml was instilled.  The block was performed at 8 o'clock as well with 5 ml at 10 and 2 o'clock.  The lidocaine was injected into the cervix.  The cervix was minimally dilated with #17 Hanks dilator.  The 5-mm 30-degree hysteroscope was then inserted under direct visualization using lactated Ringer's as a distention medium.  The uterine cavity was viewed and the above normal findings were noted.  The Essure tubal occlusion was then inserted through the operative port and the tip of the Essure device easily slid into the right ostia.  The coil was advanced and easily placed and the device withdrawn.  There were three coils into the uterine cavity after removal of the insertion device.  The device was removed and reloaded.  The advice was to advance under direct visualization and the tip was inserted into the left ostia.  This passed easily and the device was inserted.  It was removed easily and three coils again were into the uterine cavity.  The hysteroscope was then removed and the ThermaChoice ablation was performed.  The uterus was then sounded to 9.5 to 10 cm.  The ThermaChoice balloon was primed and pressure was drawn to a negative 150.  The device was then moistened and inserted into the uterine cavity and the balloon was slowly filled with 40 ml of D5W.  The pressure was brought up to 170 and the cycle was initiated.  A full cycle of eight minutes was performed.  At no time there was a significant loss of pressure from the catheter balloon.  After the cycle was complete, the balloon was deflated and withdrawn.  The tenaculum was withdrawn.  No bleeding was noted.  The patient was then awakened, transferred, and taken to the recovery room in satisfactory condition.","surgery, menorrhagia, essure, hysteroscopy, thermachoice, uterine cavity, endometrial ablation, endometrium, fibroids, fluffy, lactated ringer, nulliparous, paracervical block, permanent sterilization, polyps, tubal occlusion, tubal ostia, lactated ringer's, ablation, uterine, "
 Incision and drainage with bolster dressing placement of right ear recurrent auricular hematoma., Surgery, I&D - Auricular Hematoma ,"PREOPERATIVE DIAGNOSIS: , Recurrent severe right auricular hematoma.,POSTOPERATIVE DIAGNOSIS: , Recurrent severe right auricular hematoma.,TITLE OF PROCEDURE:,  Incision and drainage with bolster dressing placement of right ear recurrent auricular hematoma.,ANESTHESIA: , Xylocaine 1% with 1:100,000 dilution of epinephrine totaling 2 mL.,COMPLICATIONS:,  None.,FINDINGS: , Approximately 5 mL of serosanguineous drainage.,PROCEDURE: , The patient underwent an incision and drainage procedure with stay suture placement on 05/28/2008 by me and also by Dr. X on 05/23/2008 for a large near 100% auricular hematoma.  She presents for suture removal; however, there is still fluid noted now at the antihelix fold above the concha bullosa below previous sutures placed by Dr. X.  It was recommended that this area be drained through the previous incision and drainage incision which has healed and wound care by the patient appears to be very poor if any at all being performed which may be complicating matters.  Consent was obtained.  The patient is aware that the complications with this ear area severe and auricular deformity is inevitable; however, quick prompt aggressive drainage addressing fluid collections offers a best chance for improvement from an already very difficult situation.,The area was prepped in the usual manner, localized and the previous incision was reopened with a curved hemostat and about 5 mL of serosanguineous drainage was noted.  A through-and-through Keith needle bolster dressing was applied with cottonoid pledget on both sides of the ear to help compression.  She tolerated this procedure very well.","surgery, bolster dressing placement, antihelix fold, incision and drainage, bolster dressing, auricular hematoma, auricular, hematoma, incision, drainage"
 Hypospadias repair (TIP) with tissue flap relocation and chordee release (Nesbit tuck)., Surgery, Hypospadias Repair & Chordee Release - 1 ,"PREOPERATIVE DIAGNOSES: , Coronal hypospadias with chordee and asthma.,POSTOPERATIVE DIAGNOSES:,  Coronal hypospadias with chordee and asthma.,PROCEDURE: , Hypospadias repair (TIP) with tissue flap relocation and chordee release (Nesbit tuck).,ANESTHETIC: , General inhalational anesthetic with a caudal block.,FLUIDS RECEIVED:  ,300 mL of crystalloid.,ESTIMATED BLOOD LOSS:  ,20 mL.,TUBES/DRAINS:  ,An 8-French Zaontz catheter.,INDICATIONS FOR OPERATION:  ,The patient is a 17-month-old boy with hypospadias abnormality.  The plan is for repair.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operating room, where surgical consent, operative site, and patient identification were verified.  Once he was anesthetized, a caudal block was placed.  IV antibiotics were given.  He was then placed in the supine position.  The foreskin was retracted and cleansed.  He was then sterilely prepped and draped.  A stay stitch of 4-0 Prolene was then placed on the glans.  The urethra was calibrated with the lacrimal duct probes to an 8-French.  We then marked out the coronal cuff, the penile shaft skin as well as the glanular plate for future surgery with a marking pen.,We then used a 15-blade knife to circumscribe the penis around the coronal cuff.  We then degloved the penis using the curved tenotomy scissors, and electrocautery was used for hemostasis.  The patient had some splaying of the spongiosum tissue, which was also incised laterally and rotated to make a secondary flap.  Once the penis was degloved, and the excessive chordee tissue was released, we then placed a vessel loop tourniquet around the base of the penis and using IV grade saline injected the penis for an artifical erection.  He was still noted to have chordee, so a midline incision through the Buck fascia was made with a 15-blade knife and Heineke-Mikulicz closure using 5-0 Prolene was then used for the chordee Nesbit tuck.  We repeated the artificial erection and the penis was straight.  We then incised the urethral plate with an ophthalmic blade in the midline, and then elevated the glanular wings using a 15-blade knife to elevate and then incise them.  Using the curved iris scissors, we then also further mobilized the glanular wings.  The 8-French Zaontz was then placed while the tourniquet was still in place into the urethral plate.  The upper aspect of the distal meatus was then closed with an interrupted suture of 7-0 Vicryl, and then using a running subcuticular closure, we closed the urethral plates over the Zaontz catheter.  We then mobilized subcutaneous tissue from the penile shaft skin, and the inner perpetual skin on the dorsum, and then buttonholed the flap, placed it over the head of the penis, and then, used it to cover of the hypospadias repair with tacking sutures of 7-0 Vicryl.  We then rolled the spongiosum flap to cover the distal urethra that was also somewhat dysplastic; 7-0 Vicryl was used for that as well.  5-0 Vicryl was used to roll the glans with 2 deep sutures, and then, horizontal mattress sutures of 7-0 Vicryl were used to reconstitute the glans.  Interrupted sutures of 7-0 Vicryl were used to approximate the urethral meatus to the glans.  Once this was done, we then excised the excessive penile shaft skin, and used the interrupted sutures of 6-0 chromic to attach the penile shaft skin to the coronal cuff.  On the ventrum itself, we used horizontal mattress sutures to close the defect.,At the end of the procedure, the Zaontz catheter was sutured into place with a 4-0 Prolene suture, Dermabond tissue adhesive, and Surgicel was used as a dressing and a second layer of Telfa and clear eye tape was then used to tape it into place.  IV Toradol was given at the procedure.  The patient tolerated the procedure well and was in a stable condition upon transfer to the recovery room.","surgery, coronal hypospadias with chordee, coronal hypospadias, tissue flap relocation, nesbit tuck, hypospadias with chordee, horizontal mattress sutures, chordee release, zaontz catheter, coronal cuff, hypospadias repair, penile shaft, zaontz, glans, urethral, repair, coronal, hypospadias, penis, chordee,"
" Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, right and left pelvic lymphadenectomy, common iliac lymphadenectomy, and endometrial cancer staging procedure.", Surgery, Hysterectomy (TAH - BSO) ,"PREOPERATIVE DIAGNOSIS: , Endometrial cancer.,POSTOPERATIVE DIAGNOSIS: , Same.,OPERATION PERFORMED:,  Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, right and left pelvic lymphadenectomy, common iliac lymphadenectomy, and endometrial cancer staging procedure.,ANESTHESIA:,  General, endotracheal tube.,SPECIMENS: , Pelvic washings for cytology, uterus with attached tubes and ovaries, right and left pelvic lymph nodes, para-aortic nodes.,INDICATIONS FOR PROCEDURE: , The patient recently presented with postmenopausal bleeding and was found to have a Grade II endometrial carcinoma on biopsy.  She was counseled to undergo staging laparotomy.,FINDINGS:,  Examination under anesthesia revealed a small uterus with no nodularity.  During the laparotomy, the uterus was small, mobile, and did not show any evidence of extrauterine spread of disease.  Other abdominal viscera, including the diaphragm, liver, spleen, omentum, small and large bowel, and peritoneal surfaces, were palpably normal.  There was no evidence of residual neoplasm after removal of the uterus.  The uterus itself showed no serosal abnormalities and the tubes and ovaries were unremarkable in appearance.,PROCEDURE: , The patient was brought to the Operating Room with an IV in place.  Anesthesia was induced, after which she was examined, prepped and draped.,A vertical midline incision was made and fascia was divided.  The peritoneum was entered without difficulty and washings were obtained.  The abdomen was explored with findings as noted.  A Bookwalter retractor was placed and bowel was packed.  Clamps were placed on the broad ligament for traction.  The retroperitoneal spaces were opened by incising lateral and parallel to the infundibulopelvic ligament.  The round ligaments were isolated, divided, and ligated.  The peritoneum overlying the vesicouterine fold was incised to mobilize the bladder.,Retroperitoneal spaces were then opened, allowing exposure of pelvic vessels and ureters.  The infundibulopelvic ligaments were isolated, divided, and doubly ligated.  The uterine artery pedicles were skeletonized, clamped, divided, and suture ligated.  Additional pedicles were developed on each side of the cervix, after which tissue was divided and suture ligated.  When the base of the cervix was reached, the vagina was cross-clamped and divided, allowing removal of the uterus with attached tubes and ovaries.  Angle stitches of o-Vicryl were placed, incorporating the uterosacral ligaments and the vaginal vault was closed with interrupted figure-of-eight stitches.  The pelvis was irrigated and excellent hemostasis was noted.,Retractors were repositioned to allow exposure for lymphadenectomy.  Metzenbaum scissors were used to incise lymphatic tissues.  Borders of the pelvic node dissection included the common iliac bifurcation superiorly, the psoas muscle laterally, the cross-over of the deep circumflex iliac vein over the external iliac artery inferiorly, and the anterior division of the hypogastric artery medially.  The posterior border of dissection was the obturator nerve, which was carefully identified and preserved bilaterally.  Ligaclips were applied where necessary.  After the lymphadenectomy was performed bilaterally, excellent hemostasis was noted.,Retractors were again repositioned to allow exposure of para-aortic nodes.  Lymph node tissue was mobilized, Ligaclips were applied, and the tissue was excised.  The pelvis was again irrigated and excellent hemostasis was noted.  The bowel was run and no evidence of disease was seen.,All packs and retractors were removed and the abdominal wall was closed using a running Smead-Jones closure with #1 permanent monofilament suture.  Subcutaneous tissues were irrigated and a Jackson-Pratt drain was placed.  Scarpa's fascia was closed with a running stitch and skin was closed with a running subcuticular stitch.  The final sponge, needle and instrument counts were correct at the completion of the procedure. ,The patient was then awakened from her anesthetic and taken to the Post Anesthesia Care Unit in stable condition.","surgery, tah, bso, lymphadenectomy, endometrial, total abdominal hysterectomy, bilateral salpingo oophorectomy, tubes and ovaries, salpingo oophorectomy, lymph nodes, endometrial cancer, abdominal, hysterectomy, oophorectomy, hemostasis, retractors, washings, laparotomy, ligated, pelvic, uterus, nodes,"
" Pelvic tumor, cystocele, rectocele, and uterine fibroid.  Total abdominal hysterectomy, bilateral salpingooophorectomy, repair of bladder laceration, appendectomy, Marshall-Marchetti-Krantz cystourethropexy, and posterior colpoperineoplasty. She had a recent D&C and laparoscopy, and enlarged mass was noted and could not be determined if it was from the ovary or the uterus. ", Surgery," Hysterectomy, BSO, & Appendectomy. ","1.  Pelvic tumor.,2.  Cystocele.,3.  Rectocele.,POSTOPERATIVE DIAGNOSES:,1.  Degenerated joint.,2.  Uterine fibroid.,3.  Cystocele.,4.  Rectocele.,PROCEDURE PERFORMED:  ,1.  Total abdominal hysterectomy.,2.  Bilateral salpingooophorectomy.,3.  Repair of bladder laceration.,4.  Appendectomy.,5.  Marshall-Marchetti-Krantz cystourethropexy.,6.  Posterior colpoperineoplasty.,GROSS FINDINGS:  The patient had a history of a rapidly growing mass on the abdomen, extending from the pelvis over the past two to three months.  She had a recent D&C and laparoscopy, and enlarged mass was noted and could not be determined if it was from the ovary or the uterus.  Curettings were negative for malignancy.  The patient did have a large cystocele and rectocele, and a collapsed anterior and posterior vaginal wall.,Upon laparotomy, there was a giant uterine tumor extending from the pelvis up to the above the umbilicus compatible with approximately four to five-month pregnancy.  The ovaries appeared to be within normal limits.  There was marked adherence between the bladder and the giant uterus and mass with edema and inflammation, and during dissection, a laceration inadvertently occurred and it was immediately recognized.  No other pathology noted from the abdominal cavity or adhesions.  The upper right quadrant of the abdomen compatible with a previous gallbladder surgery.  The appendix is in its normal anatomic position.  The ileum was within normal limits with no Meckel's diverticulum seen and no other gross pathology evident.  There was no evidence of metastasis or tumors in the left lobe of the liver.,Upon frozen section, diagnosis of initial and partial is that of a degenerating uterine fibroid rather than a malignancy.,OPERATIVE PROCEDURE:  The patient was taken to the Operating Room, prepped and draped in the low lithotomy position under general anesthesia.  A midline incision was made around the umbilicus down to the lower abdomen.  With a #10 Bard Parker blade knife, the incision was carried down through the fascia.  The fascia was incised in the midline, muscle fibers were splint in the midline, the peritoneum was grasped with hemostats and with a #10 Bard Parker blade after incision was made with Mayo scissors.  A Balfour retractor was placed into the wound.  This giant uterus was soft and compatible with a possible leiomyosarcoma or degenerating fibroid was handled with care.  The infundibular ligament on the right side was isolated and ligated with #0 Vicryl suture brought to an avascular area, doubly clamped and divided from the ovary and the ligament again re-ligated with #0 Vicryl suture.  The right round ligament was ligated with #0 Vicryl suture, brought to an avascular space within the broad ligament and divided from the uterus.  The infundibulopelvic ligament on the left side was treated in a similar fashion as well as the round ligament.  An attempt was made to dissect the bladder flap from the anterior surface of the uterus and this was remarkably edematous and difficult to do, and during dissection the bladder was inadvertently entered.  After this was immediately recognized, the bladder flap was wiped away from the anterior surface of the uterus.  The bladder was then repaired with a running locking stitch #0 Vicryl suture incorporating serosal muscularis mucosa and then the second layer of overlapping seromuscular sutures were used to make a two-layer closure of #0 Vicryl suture.  After removing the uterus, the bladder was tested with approximately 400 cc of sterile water and there appeared to be no leak.  Progressing and removing of the uterus was then carried out and the broad ligament was clamped bilaterally with a straight Ochsner forceps and divided from the uterus with Mayo scissors, and the straight Ochsner was placed by #0 Vicryl suture thus controlling the uterine blood supply.  The cardinal ligaments containing the cervical blood supply was serially clamped bilaterally with a curved Ochsner forceps, divided from the uterus with #10 Bard Parker blade knife and a curved Ochsner was placed by #0 Vicryl suture.  The cervix was again grasped with a Lahey tenaculum and pubovesicocervical ligament was entered and was divided using #10 Bard Parker blade knife and then the vaginal vault and with a double pointed sharp scissors.  A single-toothed tenaculum was placed on the cervix and then the uterus was removed from the vagina using hysterectomy scissors.  The vaginal cuff was then closed using a running #0 Vicryl suture in locking stitch incorporating all layers of the vagina, the cardinal ligaments of the lateral aspect and uterosacral ligaments on the posterior aspect.  The round ligaments were approximated to the vaginal cuff with #0 Vicryl suture and the bladder flap approximated to the round ligaments with #000 Vicryl suture.  The ______ was re-peritonealized with #000 Vicryl suture and then the cecum brought into the incision.  The pelvis was irrigated with approximately 500 cc of water.  The appendix was grasped with Babcock forceps.  The mesoappendix was doubly clamped with curved hemostats and divided with Metzenbaum scissors.  The curved hemostats were placed with #00 Vicryl suture.  The base of the appendix was ligated with #0 plain gut suture, doubly clamped and divided from the distal appendix with #10 Bard Parker blade knife, and the base inverted with a pursestring suture with #00 Vicryl.  No bleeding was noted.  Sponge, instrument, and needle counts were found to be correct.  All packs and retractors were removed.  The peritoneum muscle fascia was closed in single-layer closure using running looped #1 PDS, but prior to closure, a Marshall-Marchetti-Krantz cystourethropexy was carried out by dissecting the space of Retzius identifying the urethra in the vesical junction approximating the periurethral connective tissue to the symphysis pubis with interrupted #0 Vicryl suture.  Following this, the abdominal wall was closed as previously described and the skin was closed using skin staples.  Attention was then turned to the vagina, where the introitus of the vagina was grasped with an Allis forceps at the level of the Bartholin glands.  An incision was made between the mucous and the cutaneous junction and then a midline incision was made at the posterior vaginal mucosa in a tunneling fashion with Metzenbaum scissors.  The flaps were created bilaterally by making an incision in the posterior connective tissue of the vagina and wiping the rectum away from the posterior vaginal mucosa, and flaps were created bilaterally.  In this fashion, the rectocele was reduced and the levator ani muscles were approximated in the midline with interrupted #0 Vicryl suture.  Excess vaginal mucosa was excised and the vaginal mucosa closed with running #00 Vicryl suture.  The bulbocavernosus and transverse perinei muscles were approximated in the midline with interrupted #00 Vicryl suture.  The skin was closed with a running #000 plain gut subcuticular stitch.  The vaginal vault was packed with a Betadine-soaked Kling gauze sponge.  Sterile dressing was applied.  The patient was sent to recovery room in stable condition.","surgery, marshall-marchetti-krantz cystourethropexy, pelvic tumor, cystocele, rectocele, uterine fibroid, hysterectomy, salpingooophorectomy, bladder laceration, appendectomy, colpoperineoplasty, marshall marchetti krantz cystourethropexy, bard parker blade knife, vicryl suture, vaginal mucosa, uterus, vaginal, uterine, mucosa, scissors, ligament, bladder"
 Laparoscopic supracervical hysterectomy.  Menorrhagia and dysmenorrhea., Surgery, Hysterectomy - Laparoscopic Supracervical ,"PREOPERATIVE DIAGNOSES:,  Menorrhagia and dysmenorrhea.,POSTOPERATIVE DIAGNOSES: , Menorrhagia and dysmenorrhea.,PROCEDURE: , Laparoscopic supracervical hysterectomy.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , 100 mL.,FINDINGS: , An 8-10 cm anteverted uterus, right ovary with a 2 cm x 2 cm x 2 cm simple cyst containing straw colored fluid, a normal-appearing left ovary, and normal-appearing tubes bilaterally.,SPECIMENS:  ,Uterine fragments.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL: , The patient was brought to the OR where general endotracheal anesthesia was obtained without difficulty.  The patient was placed in dorsal lithotomy position.  Examination under anesthesia revealed an anteverted uterus and no adnexal masses.  The patient was prepped and draped in normal sterile fashion.  A Foley catheter was placed in the patient's bladder.  The patient's cervix was visualized with speculum.  A single-tooth tenaculum was placed on the anterior lip of the cervix.  A HUMI uterine manipulator was placed through the internal os of the cervix and the balloon was inflated.  The tenaculum and speculum were then removed from the vagina.  Attention was then turned to the patient's abdomen where a small infraumbilical incision was made with scalpel.  Veress needle was placed through this incision and the patient's abdomen was inflated to a pressure of 15 mmHg.  Veress needle was removed and then 5-mm trocar was placed through the umbilical incision.  Laparoscope was placed through this incision and the patient's abdominal contents were visualized.  A 2nd trocar incision was placed in the midline 2 cm above the symphysis pubis and a 5-mm trocar was placed through this incision on direct visualization for laparoscope.  A trocar incision was made in the right lower quadrant.  A 10-mm trocar was placed through this incision under direct visualization with the laparoscope.  A ___ trocar incision was made in the left lower quadrant and a 2nd 10-mm trocar was placed through this incision under direct visualization with the laparoscope.  The patient's abdominal and pelvic anatomy were again visualized with the assistance of a blunt probe.  The Gyrus cautery was used to cauterize and cut the right and left round ligaments.  The anterior leaf of the broad ligament was bluntly dissected and cauterized and cut in an inferior fashion towards lower uterine segment.  The right uteroovarian ligament was cauterized and cut using the Gyrus.  The uterine vessels were then bluntly dissected.  The Gyrus was then used to cauterize the right uterine vessels.  Gyrus was then used on the left side to cauterize and cut the left round ligament.  The anterior leaf of the broad ligament on the left side was bluntly dissected, cauterized, and cut.  Using the Gyrus, the left uteroovarian ligament was cauterized and cut and the left uterine vessels were then bluntly dissected.  The left uterine vessels were then cauterized and cut using the Gyrus.  At this point, as the uterine vessels had been cauterized on both sides, the uterine body exhibited blanching.  At this point, the Harmonic scalpel hook was used to amputate the uterine body from the cervix at the level just below the uterine vessels.  The HUMI manipulator was removed prior to amputation of the uterine body.  After the uterine body was detached from the cervical stump, morcellation of the uterine body was performed using the uterine morcellator.  The uterus was removed in a piecemeal fashion through the right lower quadrant trocar incision.  Once, all fragments of the uterus were removed from the abdominal cavity, the pelvis was irrigated.  The Harmonic scalpel was used to cauterize the remaining endocervical canal.  The cervical stump was also cauterized with the Harmonic scalpel and good hemostasis was noted at the cervical stump and also at the sites of all pedicles.  The Harmonic scalpel was then used to incise the right ovarian simple cyst.  The right ovarian cyst was then drained yielding straw-colored fluid.  The site of right ovarian cystotomy was noted to be hemostatic.  The pelvis was again inspected and noted to be hemostatic.  The ureters were identified on both sides and noted to be intact throughout the visualized course.  All instruments were then removed from the patient's abdomen and the abdomen was deflated.  The fascial defects at the 10-mm trocar sites were closed using figure-of-8 sutures of 0-Vicryl and skin incisions were closed with a 4-0 Vicryl in subcuticular fashion.  The cervix was then visualized with the speculum.  Good hemostasis at the site of tenaculum insertion was obtained using silver nitrate sticks.  All instruments were removed from the patient's vagina and the patient was placed in normal supine position.,Sponge, lap, needle, and instrument counts were correct x2.  The patient was awoken from anesthesia and then transferred to the recovery room in stable condition.","surgery, supracervical hysterectomy, incision, uterine, uteroovarian, hysterectomy, supracervical, menorrhagia, dysmenorrhea, cervical, laparoscopic, laparoscope, cervix, ligaments, trocar"
 Non-healing surgical wound to the left posterior thigh. Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg., Surgery, Hypergranulation - Consult ,"CHIEF COMPLAINT:,  Non-healing surgical wound to the left posterior thigh.,HISTORY OF PRESENT ILLNESS: , This is a 49-year-old white male who sustained a traumatic injury to his left posterior thighthis past year while in ABCD.  He sustained an injury from the patellar from a boat while in the water.  He was air lifted actually up to XYZ Hospital and underwent extensive surgery.  He still has an external fixation on it for the healing fractures in the leg and has undergone grafting and full thickness skin grafting closure to a large defect in his left posterior thigh, which is nearly healed right in the gluteal fold on that left area.  In several areas right along the graft site and low in the leg, the patient has several areas of hypergranulation tissue.  He has some drainage from these areas.  There are no signs and symptoms of infection.  He is referred to us to help him get those areas under control.,PAST MEDICAL HISTORY:,  Essentially negative other than he has had C. difficile in the recent past.,ALLERGIES:,  None.,MEDICATIONS: , Include Cipro and Flagyl.,PAST SURGICAL HISTORY: , Significant for his trauma surgery noted above.,FAMILY HISTORY: , His maternal grandmother had pancreatic cancer.  Father had prostate cancer.  There is heart disease in the father and diabetes in the father.,SOCIAL HISTORY:,  He is a non-cigarette smoker and non-ETOH user.  He is divorced.  He has three children.  He has an attorney.,REVIEW OF SYSTEMS:,CARDIAC:  He denies any chest pain or shortness of breath.,GI:  As noted above.,GU:  As noted above.,ENDOCRINE:  He denies any bleeding disorders.,PHYSICAL EXAMINATION:,GENERAL:  He presents as a well-developed, well-nourished 49-year-old white male who appears to be in no significant distress.,HEENT:  Unremarkable.,NECK:  Supple.  There is no mass, adenopathy, or bruit.,CHEST:  Normal excursion.,LUNGS:  Clear to auscultation and percussion.,COR:  Regular.  There is no S3, S4, or gallop.  There is no murmur.,ABDOMEN:  Soft.  It is nontender.  There is no mass or organomegaly.,GU:  Unremarkable.,RECTAL:  Deferred.,EXTREMITIES:  His right lower extremity is unremarkable.  Peripheral pulse is good.  His left lower extremity is significant for the split thickness skin graft closure of a large defect in the posterior thigh, which is nearly healed.  The open areas that are noted above __________ hypergranulation tissue both on his gluteal folds on the left side.  There is one small area right essentially within the graft site, and there is one small area down lower on the calf area.  The patient has an external fixation on that comes out laterally on his left thigh.  Those pin sites look clean.,NEUROLOGIC:  Without focal deficits.  The patient is alert and oriented.,IMPRESSION: , Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg.,PLAN:,  Plan would be for chemical cauterization of these areas.  Series of treatment with chemical cauterization till these are closed.",
 Hypospadias repair (TIT and tissue flap relocation) and Nesbit tuck chordee release., Surgery, Hypospadias Repair & Chordee Release ,"PREOPERATIVE DIAGNOSIS:,  Penoscrotal hypospadias with chordee.,POSTOPERATIVE DIAGNOSIS: , Penoscrotal hypospadias with chordee.,PROCEDURE:,  Hypospadias repair (TIT and tissue flap relocation) and Nesbit tuck chordee release.,ANESTHESIA: , General inhalation anesthetic with a caudal block.,FLUIDS RECEIVED: , 300 mL of crystalloids.,ESTIMATED BLOOD LOSS: , 15 mL.,SPECIMENS: , No tissue sent to Pathology.,TUBES AND DRAINS: , An 8-French Zaontz catheter.,INDICATIONS FOR OPERATION: , The patient is a 1-1/2-year-old boy with penoscrotal hypospadias; plan is for repair.,DESCRIPTION OF PROCEDURE:  ,The patient was taken to the operating room, where surgical consent, operative site and the patient's identification was verified.  Once he was anesthetized, a caudal block was placed.  IV antibiotic was given.  The dorsal hood was retracted and the patient was then sterilely prepped and draped.  A stay stitch of 4-0 Prolene was then placed in the glans for traction.  His urethra was calibrated, it was quite thin, to a 10-French with the straight sounds.  We then marked the coronal cuff and the urethral plate as well as the penile shaft skin with marking pen and incised the coronal cuff circumferentially and then around the urethral plate with the 15 blade knife and then degloved the penis with a curved tenotomy scissors.  Electrocautery was used for hemostasis.  The ventral chordee tissue was removed.  We then placed a vessel loop tourniquet around the base of the penis and using IV grade saline did an artificial erection test, which showed that he had a persistent chordee.  In the midline a 15 blade knife was used to incise Buck fascia after marking the area of chordee with the marking pen.  We then used a Heinecke-Mikulicz Nesbit tuck with 5-0 Prolene to straighten the penis.  Artificial erection again performed showed the penis was straight.  The knot was buried with figure-of-eight suture of 7-0 Vicryl in Buck fascia above it.  We then left the tourniquet in place and then after marking the urethral plate incised it and enlarged it with Beaver blade and a 15 blade.  We then elevated the glanular wings as well in the similar fashion.  An 8-French Zaontz catheter was then placed and the urethral plate was then closed over this with a distal interrupted sutures of 7-0 Vicryl and then a running subcuticular closure of 7-0 Vicryl to close the defect.  We then put the stay sutures in the inter-preputial skin with 7-0 Vicryl and then rotated a flap using the subcutaneous tissue after dissecting it down to the pubis at the base of the penile shaft on the dorsum using the curved iris scissors.  We buttonholed the flap and then placed it through the penis as a sleeve.  Interrupted sutures of 7-0 Vicryl then used to reapproximate and to tack this flap and place over the urethroplasty.  Once this was done, a two 5-0 Vicryl deep sutures were placed in the glans to rotate the glans and allow for hemostasis.  Interrupted sutures of 7-0 Vicryl were then used to create the neomeatus and horizontal mattress sutures of 7-0 Vicryl used to reconstitute the glans.  We then removed the excessive preputial skin and using tacking sutures of 6-0 chromic tacked the penile shaft skin to the coronal cuff and on the ventrum we dropped a portion of the skin down on the left side of the penis to reconstitute the penoscrotal junction using horizontal mattress sutures.  We then closed the ventral defect.  Once this was done, the stay suture in the glans was used to keep the Zaontz catheter to tack it into place.  We then used Surgicel, Dermabond, and Telfa dressing with Mastisol and an eye tape to keep the dressing in place.  IV Toradol was given at the end of the procedure.  The patient was in stable condition upon transfer to the recovery room.","surgery, tissue flap relocation, penoscrotal hypospadias, urethra, nesbit tuck chordee release, horizontal mattress sutures, hypospadias repair, chordee release, zaontz catheter, urethral plate, glans, hypospadias, penis, chordee,"
" Left hydrocelectomy, cystopyelogram, bladder biopsy, and fulguration for hemostasis.", Surgery, Hydrocelectomy - 1 ,"PREOPERATIVE DIAGNOSES:,  Bladder cancer and left hydrocele.,POSTOPERATIVE DIAGNOSES: , Bladder cancer and left hydrocele.,OPERATION:  ,Left hydrocelectomy, cystopyelogram, bladder biopsy, and fulguration for hemostasis.,ANESTHESIA:,  Spinal.,ESTIMATED BLOOD LOSS:  ,Minimal.,FLUIDS:,  Crystalloid.,BRIEF HISTORY:  ,The patient is a 66-year-old male with history of smoking and hematuria, had bladder tumor, which was dissected.  He has received BCG.  The patient is doing well.  The patient was supposed to come to the OR for surveillance biopsy and pyelograms.  The patient had a large left hydrocele, which was increasingly getting worse and was making it very difficult for the patient to sit to void or put clothes on, etc.  Options such as watchful waiting, drainage in the office, and hydrocelectomy were discussed.  Risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, infection in the scrotum, enlargement of the scrotum, recurrence, and pain were discussed.  The patient understood all the options and wanted to proceed with the procedure.,PROCEDURE IN DETAIL: , The patient was brought to the OR.  Anesthesia was applied.  The patient was placed in dorsal lithotomy position.  The patient was prepped and draped in usual sterile fashion.,A transverse scrotal incision was made over the hydrocele sac and the hydrocele fluid was withdrawn.  The sac was turned upside down and sutures were placed.  Careful attention was made to ensure that the cord was open.  The testicle was in normal orientation throughout the entire procedure.  The testicle was placed back into the scrotal sac and was pexed with 4-0 Vicryl to the outside dartos to ensure that there was no risk of torsion.  Orchiopexy was done at 3 different locations.  Hemostasis was obtained using electrocautery.  The sac was closed using 4-0 Vicryl.  The sac was turned upside down so that when it heals, the fluid would not recollect.  The dartos was closed using 2-0 Vicryl and the skin was closed using 4-0 Monocryl and Dermabond was applied.  Incision measured about 2 cm in size.  Subsequently using ACMI cystoscope, a cystoscopy was performed.  The urethra appeared normal.  There was some scarring at the bulbar urethra, but the scope went in through that area very easily into the bladder.  There was a short prostatic fossa.  The bladder appeared normal.  There was some moderate trabeculation throughout the bladder, some inflammatory changes in the bag part, but nothing of much significance.  There were no papillary tumors or stones inside the bladder.  Bilateral pyelograms were obtained using 8-French cone-tip catheter, which appeared normal.  A cold cup biopsy of the bladder was done and was fulgurated for hemostasis.  The patient tolerated the procedure well.  The patient was brought to recovery at the end of the procedure after emptying the bladder.,The patient was given antibiotics and was told to take it easy.  No heavy lifting, pushing, or pulling.  Plan was to follow up in about 2 months.","surgery, hydrocele, fulguration, bladder biopsy, hydrocelectomy, cystopyelogram, cystopyelogram bladder, bladder cancer, bladder,"
" Bilateral scrotal hydrocelectomies, large for both, and 0.5% Marcaine wound instillation, 30 mL given.", Surgery, Hydrocelectomy ,"PREOPERATIVE DIAGNOSIS:,  Bilateral hydroceles.,POSTOPERATIVE DIAGNOSIS:,  Bilateral hydroceles.,PROCEDURE: , Bilateral scrotal hydrocelectomies, large for both, and 0.5% Marcaine wound instillation, 30 mL given.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,FLUIDS RECEIVED: , 800 mL.,TUBES AND DRAINS: , A 0.25-inch Penrose drains x4.,INDICATIONS FOR OPERATION:  ,The patient is a 17-year-old boy, who has had fairly large hydroceles noted for some time.  Finally, he has decided to have them get repaired.  Plan is for surgical repair.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operating room where surgical consent, operative site, and patient identification were verified.  Once he was anesthetized, he was then shaved, prepped, and then sterilely prepped and draped.  IV antibiotics were given.  Ancef 1 g given.  A scrotal incision was then made in the right hemiscrotum with a 15-blade knife and further extended with electrocautery.  Electrocautery was used for hemostasis.  Once we got to the hydrocele sac itself, we then opened and delivered the testis, drained clear fluid.  There was moderate amount of scarring on the testis itself from the tunica vaginalis.  It was then wrapped around the back and sutured in place with a running suture of 4-0 chromic in a Lord maneuver.  Once this was done, a drain was placed in the base of the scrotum and then the testis was placed back into the scrotum in the proper orientation.  A similar procedure was performed on the left, which has also had a hydrocele of the cord, which were both addressed and closed with Lord maneuver similarly.  This testis also was normal but had moderate amount of scarring on the tunic vaginalis from this.  A similar drain was placed.  The testes were then placed back into the scrotum in a proper orientation, and the local wound instillation and wound block was then placed using 30 mL of 0.5% Marcaine without epinephrine.  IV Toradol was given at the end of the procedure.  The skin was then sutured with a running interlocking suture of 3-0 Vicryl and the drains were sutured to place with 3-0 Vicryl.  Bacitracin dressing, ABD dressing, and jock strap were placed.  The patient was in stable condition upon transfer to the recovery room.","surgery, bilateral scrotal hydrocelectomies, bilateral hydroceles, lord maneuver, hydrocelectomy, hydroceles,"
 Hypospadias repair. Urethroplasty plate incision with tissue flap relocation and chordee release., Surgery, Hypospadias Repair ,"PREOPERATIVE DIAGNOSIS: , Coronal hypospadias with chordee.,POSTOPERATIVE DIAGNOSIS: , Coronal hypospadias with chordee.,PROCEDURE: , Hypospadias repair (urethroplasty plate incision with tissue flap relocation and chordee release).,ANESTHESIA: , General inhalation anesthetic with a 0.25% Marcaine dorsal block and ring block per surgeon, 7 mL given.,TUBES AND DRAINS: , An 8-French Zaontz catheter.,ESTIMATED BLOOD LOSS:  ,10 mL.,FLUIDS RECEIVED:,  300 mL.,INDICATIONS FOR OPERATION: , The patient is a 6-month-old boy with the history of coronal hypospadias with chordee.  Plan is for repair.,DESCRIPTION OF OPERATION: , The patient was taken to the operating room with surgical consent, operative site, and the patient identification were verified.  Once he was anesthetized, IV antibiotics were given.  The dorsal hood was retracted and cleansed.  He was then sterilely prepped and draped.  Stay suture of #4-0 Prolene was then placed in the glans.  His urethra was calibrated to 10-French bougie-a-boule.  We then marked the coronal cuff and the penile shaft skin, as well as the periurethral meatal area on the ventrum.  Byers flaps were also marked.  Once this was done, the skin was then incised around the coronal cuff with 15-blade knife and further extended with the curved tenotomy scissors to deglove the penis.  On the ventrum, the chordee tissue was removed and dissected up towards the urethral plate to use as secondary tissue flap coverage.  Once this was done, an electrocautery was used for hemostasis were then used.  A vessel loop tourniquet and IV grade saline was used for achieve artificial erection and chordee.  We then incised Buck fascia at the area of chordee in the ventrum and then used the #5-0 Prolene as a Heinecke-Mikulicz advancement suture.  Sutures were placed burying the knot and then artificial erection was again performed showing the penis was straight.  We then left the tourniquet in place, although loosened it slightly and then marked out the transurethral incision plate with demarcation for the glans and the ventral midline of the plate.  We then incised it with the ophthalmic micro lancet blade in the midline and along the __________ to elevate the glanular wings.  Using the curved iris scissors, we then elevated the wings even further.  Again, electrocautery was used for hemostasis.  An 8-French Zaontz catheter was then placed into the urethral plate and then interrupted suture of #7-0 Vicryl was used to mark the distal most extent of the urethral meatus and then the urethral plate was rolled using a subcutaneous closure using the #7-0 Vicryl suture.  There were two areas of coverage with the tissue flap relocation from the glanular wings.  The tissue flap that was rolled with the Byers flap was used to cover this, as well as the chordee tissue with interrupted sutures of #7-0 Vicryl.  Once this was completed, the glans itself had been rolled using two deep sutures of #5-0 Vicryl.  Interrupted sutures of #7-0 Vicryl were used to create the neomeatus and then horizontal mattress sutures of #7-0 Vicryl used to roll the glans in the midline.  The extra dorsal hood tissue of preputial skin was then excised.  An interrupted sutures of #6-0 chromic were then used to approximate penile shaft skin to the coronal cuff and on the ventrum around the midline.  The patient's scrotum was slightly asymmetric; however, this was due to the tissue configuration of the scrotum itself.  At the end of the procedure, stay suture of #4-0 Prolene was used to tack the drain into place and a Dermabond and Surgicel were used for dressing.  Telfa and the surgical eye tape was then used for the final dressing.  IV Toradol was given.  The patient tolerated the procedure well and was in stable condition upon transfer to recovery room.","surgery, tissue flap relocation, urethroplasty plate incision, penile shaft skin, chordee release, zaontz catheter, penile shaft, hypospadias repair, flap relocation, coronal cuff, urethral plate, tissue flap, hypospadias, flap, chordee,"
 Wide Local Excision of the Vulva.  Radical anterior hemivulvectomy.  Posterior skinning vulvectomy., Surgery, Hemivulvectomy ,"PREOPERATIVE DIAGNOSIS: , Recurrent vulvar melanoma.,POSTOPERATIVE DIAGNOSIS: , Recurrent vulvar melanoma.,OPERATION PERFORMED: , Radical anterior hemivulvectomy.  Posterior skinning vulvectomy.,SPECIMENS: , Radical anterior hemivulvectomy, posterior skinning vulvectomy.,INDICATIONS FOR PROCEDURE: , The patient has a history of vulvar melanoma first diagnosed in November of 1995.  She had a surgical resection at that time and recently noted recurrence of an irritated nodule around the clitoris.  Biopsy obtained by The patient confirmed recurrence.  In addition, biopsies on the posterior labia (left side) demonstrated melanoma in situ.,FINDINGS: , During the examination under anesthesia, the biopsy sites were visible and a slightly pigmented irregular area of epithelium was seen near the clitoris.  No other obvious lesions were seen.  The room was darkened and a Woods lamp was used to inspect the epithelium.  A marking pen was used to outline all pigmented areas, which included several patches on both the right and left labia.,PROCEDURE: , The patient was prepped and draped and a scalpel was used to incise the skin on the anterior portion of the specimen.  The radical anterior hemivulvectomy was designed so that a 1.5-2.0 cm margin would be obtained and the depth was carried to the fascia of the urogenital diaphragm.  Subcutaneous adipose was divided with electrocautery and the specimen was mobilized from the periosteum.  After removal of the radical anterior portion, the skin on the posterior labia and perineal body was mobilized.  Skin was incised with a scalpel and electrocautery was used to undermine.  After removal of the specimen, the wounds were closed primarily with subcutaneous interrupted stitches of 3-0 Vicryl suture.  The final sponge, needle, and instrument counts were correct at the completion of the procedure.  The patient was then taken to the Post Anesthesia Care Unit in stable condition.","surgery, vulvar melanoma, wide local excision, radical anterior hemivulvectomy, posterior skinning vulvectomy, vulvectomy, hemivulvectomy, melanoma, woods lamp, recurrent vulvar melanoma, anterior hemivulvectomy, vulvar, labia, radical, skinning,"
 Laparoscopic left inguinal hernia repair., Surgery, Hernia Repair ,"PREOPERATIVE DIAGNOSIS:,  Left inguinal hernia.,POSTOPERATIVE DIAGNOSIS: , Left inguinal hernia.,ANESTHESIA:,  General; 0.25% Marcaine at trocar sites.,NAME OF OPERATION:,  Laparoscopic left inguinal hernia repair.,PROCEDURE: , A skin incision was placed at the umbilicus where the left rectus fascia was incised anteriorly.  The rectus muscle was retracted laterally.  Balloon dissector was passed below the muscle and above the peritoneum.  Insufflation and deinsufflation were done with the balloon removed.  The structural balloon was placed in the preperitoneal space and insufflated to 10 mmHg carbon dioxide.  The other trocars were placed in the lower midline times two.  The hernia sac was easily identified and was well defined.  It was dissected off the cord anteromedially.  It was an indirect sac.  It was taken back down and reduced into the peritoneal cavity.  Mesh was then tailored and placed overlying the defect, covering the femoral, indirect, and direct spaces, tacked into place.  After this was completed, there was good hemostasis.  The cord, structures, and vas were left intact.  The trocars were removed.  The wounds were closed with 0 Vicryl for the fascia, 4-0 for the skin.  Steri-Strips were applied.  The patient was awakened and carried to the recovery room in good condition, having tolerated the procedure well.","surgery, rectus fascia, hernia, laparoscopic left inguinal hernia, inguinal hernia repair, hernia repair, laparoscopic, rectus, fascia, repair, balloon, inguinal, "
 Placement of a subclavian single-lumen tunneled Hickman central venous catheter.  Surgeon-interpreted fluoroscopy., Surgery, Hickman Central Venous Catheter Placement ,"PROCEDURE PERFORMED,1.  Placement of a subclavian single-lumen tunneled Hickman central venous catheter.,2.  Surgeon-interpreted fluoroscopy.,OPERATION IN DETAIL:,  After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and anesthesia was administered.  Next, a #18-gauge needle was used to locate the subclavian vein.  After aspiration of venous blood, a J wire was inserted through the needle using Seldinger technique.  The needle was withdrawn.  The distal tip location of the J wire was confirmed to be in adequate position with surgeon-interpreted fluoroscopy.  Next, a separate stab incision was made approximately 3 fingerbreadths below the wire exit site.  A subcutaneous tunnel was created, and the distal tip of the Hickman catheter was pulled through the tunnel to the level of the cuff.  The catheter was cut to the appropriate length.  A dilator and sheath were passed over the J wire.  The dilator and J wire were removed, and the distal tip of the Hickman catheter was threaded through the sheath, which was simultaneously withdrawn.  The catheter was flushed and aspirated without difficulty.  The distal tip was confirmed to be in good location with surgeon-interpreted fluoroscopy.  A 2-0 nylon was used to secure the cuff down to the catheter at the skin level.  The skin stab site was closed with a 4-0 Monocryl.  The instrument and sponge count was correct at the end of the case.  The patient tolerated the procedure well and was transferred to the postanesthesia recovery area in good condition.","surgery, j wire, distal tip, stab incision, tunneled, hickman central venous catheter, subclavian, venous, fluoroscopy, hickman, catheterNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Inguinal hernia hydrocele repair., Surgery, Hydrocele Repair ,,"surgery, inguinal hernia, external oblique, hernia sac, hydrocele, hydrocele repair, ilioinguinal nerve, inguinal skin crease, oblique aponeurosis, scrotum, spermatic cord, testicle appendix, transverse inguinal skin crease incision, hernia, anesthesia, inguinalNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Left hydrocelectomy.   This is a 67-year-old male with pain, left scrotum.  He has had an elevated PSA and also has erectile dysfunction.  He comes in now for a left hydrocelectomy.  Physical exam confirmed obvious hydrocele, left scrotum.", Surgery, Hydrocelectomy. ,"PREOPERATIVE DIAGNOSIS: , Left hydrocele.,OPERATION: , Left hydrocelectomy.,POSTOPERATIVE DIAGNOSIS: , Left hydrocele.,ANESTHESIA: , General,INDICATIONS AND STUDIES: , This is a 67-year-old male with pain, left scrotum.  He has had an elevated PSA and also has erectile dysfunction.  He comes in now for a left hydrocelectomy.  Physical exam confirmed obvious hydrocele, left scrotum, approximately 8 cm.  Laboratory data included a hematocrit of 43.5, hemoglobin of 15.0, and white count 4700.  Creatinine 1.3, sodium 141, and potassium 4.0.  Calcium 8.6.  Chest x-ray was unremarkable.  EKG was normal.,PROCEDURE: , The patient was satisfactorily given general anesthesia, prepped and draped in supine position, and left scrotal incision was made, carried down to the tunica vaginalis forming the hydrocele.  This was dissected free from the scrotal wall back to the base of the testicle and then excised back to the spermatic cord.  In the fashion, the hydrocele was excised and fluid drained.,Cord was infiltrated with 5 mL of 0.25% Marcaine.  The edges of the tunica vaginalis adjacent to the spermatic cord were oversewn with interrupted 3-0 Vicryl sutures for hemostasis.  The left testicle was replaced into the left scrotal compartment and affixed to the overlying Dartos fascia with a 3-0 Vicryl suture through the edge of the tunica vaginalis and the overlying Dartos fascia.,The left scrotal incision was closed, first closing the Dartos fascia with interrupted 3-0 Vicryl sutures.  Skin was closed with an interrupted running 4-0 chromic suture.  A sterile dressing was applied.  The patient was sent to the recovery room in good condition, upon awakening from general anesthesia.  Plan is to discharge the patient and see him back in the office in a week or 2 in followup.  Further plans will depend upon how he does.","surgery, hydrocele, erectile dysfunction, spermatic cord, tunica vaginalis, vicryl sutures, dartos fascia, hydrocelectomy, psa, testicle, scrotum, scrotal,"
 Left C5-6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root., Surgery, Hemilaminotomy & Foraminotomy ,"PRE AND POSTOPERATIVE DIAGNOSIS:,  Left cervical radiculopathy at C5, C6,OPERATION: , Left C5-6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root.,After informed consent was obtained from the patient, he was taken to the OR.  After general anesthesia had been induced, Ted hose stockings and pneumatic compression stockings were placed on the patient and a Foley catheter was also inserted.  At this point, the patient's was placed in three point fixation with a Mayfield head holder and then the patient was placed on the operating table in a prone position.  The patient's posterior cervical area was then prepped and draped in the usual sterile fashion.  At this time the patient's incision site was infiltrated with 1 percent Lidocaine with epinephrine.  A scalpel was used to make an approximate 3 cm skin incision cephalad to the prominent C7 spinous processes, which could be palpated.  After dissection down to a spinous process using Bovie cautery, a clamp was placed on this spinous processes and cross table lateral x-ray was taken.  This showed the spinous process to be at the C4 level.  Therefore, further soft tissue dissection was carried out caudally to this level after the next spinous processes presumed to be C5 was identified.  After the muscle was dissected off the lamina laterally on the left side, self retaining retractors were placed and after hemostasis was achieved, a Penfield probe was placed in the interspace presumed to be C5-6 and another cross table lateral x-ray of the C spine was taken.  This film confirmed our position at C5-6 and therefore the operating microscope was brought onto the field at this time.  At the time the Kerrison rongeur was used to perform a hemilaminotomy by starting with the inferior margin of the superior lamina.  The superior margin of the inferior lamina of C6 was also taken with the Kerrison rongeur after the ligaments had been freed by using a Woodson probe.  This was then extended laterally to perform a medial facetectomy also using the Kerrison rongeur.  However, progress was limited because of thickness of the bone.  Therefore at this time the Midas-Rex drill, the AM8 bit was brought onto the field and this was used to thin out the bone around our laminotomy and medial facetectomy area.  After the bone had been thinned out, further bone was removed using the Kerrison rongeur.  At this point the nerve root was visually inspected and observed to be decompressed.  However, there was a layer of fibrous tissue overlying the exiting nerve root which was removed by placing a Woodson resector in a plane between the fibrous sheath and the nerve root and incising it with a 15 blade.  Hemostasis was then achieved by using Gelfoam as well as bipolar electrocautery.  After hemostasis was achieved, the surgical site was copiously irrigated with Bacitracin.  Closure was initiated by closing the muscle layer and the fascial layer with 0 Vicryl stitches.  The subcutaneous layer was then reapproximated using 000 Dexon.  The skin was reapproximated using a running 000 nylon.  Sterile dressings were applied.  The patient was then extubated in the OR and transferred to the Recovery room in stable condition.,ESTIMATED BLOOD LOSS:,  minimal.","surgery, foraminotomy with medial facetectomy, facetectomy for microscopic decompression, decompression of nerve root, hemilaminotomy and foraminotomy, decompression of nerve, microscopic decompression, medial facetectomy, kerrison rongeur, nerve root, spinous processes, facetectomy, kerrison, hemilaminotomy, foraminotomy,"
 Construction of right upper arm hemodialysis fistula with transposition of deep brachial vein.  End-stage renal disease with failing AV dialysis fistula., Surgery, Hemodialysis Fistula Construction ,"PREOPERATIVE DIAGNOSIS: , End-stage renal disease with failing AV dialysis fistula.,POSTOPERATIVE DIAGNOSIS: , End-stage renal disease with failing AV dialysis fistula.,PROCEDURE: , Construction of right upper arm hemodialysis fistula with transposition of deep brachial vein.,ANESTHESIA: , Endotracheal.,DESCRIPTION OF OPERATIVE PROCEDURE: , General endotracheal anesthesia was initiated without difficulty.  The right arm, axilla, and chest wall were prepped and draped in sterile fashion.  Longitudinal skin incision was made from the lower axilla distally down the medial aspect of the arm and the basilic vein was not apparent.  The draining veins are the deep brachial veins.  The primary vein was carefully dissected out and small tributaries clamped, divided, and ligated with #3-0 Vicryl suture.  A nice length of vein was obtained to the distal one third of the arm.  This appeared to be of adequate length to transpose the vein through the subcutaneous tissue to an old occluded fistula vein, which remains patent through a small collateral vein.  A transverse skin incision was made over the superior aspect of the old fistula vein.  This vein was carefully dissected out and encircled with vascular tapes.  The brachial vein was then tunneled in a gentle curve above the bicep to the level of the cephalic vein fistula.  The patient was sensible, was then systemically heparinized.  The existing fistula vein was clamped proximally and distally, incised longitudinally for about a centimeter.  The brachial vein end was spatulated.  Subsequently, a branchial vein to arterialized fistula vein anastomosis was then constructed using running #6-0 Prolene suture in routine fashion.  After the completion of the anastomosis, the fistula vein was forebled and the branchial vein backbled.  The anastomosis was completed.  A nice thrill could be palpated over the outflow brachial vein.  Hemostasis was noted.  A 8 mm Blake drain was placed in the wound and brought out through inferior skin stab incision and ___ the skin with #3-0 nylon suture.  The wounds were then closed using interrupted #4-0 Vicryl and deep subcutaneous tissue ___ staples closed the skin.  Sterile dressings were applied.  The patient was then x-ray'd and taken to Recovery in satisfactory condition.  Estimated blood loss 50 mL, drains 8 mm Blake.  Operative complication none apparent, final sponge, needle, and instrument counts reported as correct.","surgery, end-stage renal disease, av dialysis fistula, brachial vein, upper arm hemodialysis fistula, fistula, vein, hemodialysis, av, dialysis, anastomosis, brachial, "
 Left-sided large hemicraniectomy for traumatic brain injury and increased intracranial pressure.  She came in with severe traumatic brain injury and severe multiple fractures of the right side of the skull. , Surgery, Hemicraniectomy ,"TITLE OF OPERATION:,  Left-sided large hemicraniectomy for traumatic brain injury and increased intracranial pressure.,INDICATION FOR SURGERY: ,  The patient is a patient well known to my service.  She came in with severe traumatic brain injury and severe multiple fractures of the right side of the skull.  I took her to the operating a few days ago for a large right-sided hemicraniectomy to save her life.  I spoke with the family, the mom, especially about the risks, benefits, and alternatives of this procedure, most especially given the fact that she had undergone a very severe traumatic brain injury with a very poor GCS of 3 in some brainstem reflexes.  I discussed with them that this was a life-saving procedure and the family agreed to proceed with surgery as a level 1.  We went to the operating room at that time and we did a very large right-sided hemicraniectomy.  The patient was put in the intensive care unit.  We had placed also at that time a left-sided intracranial pressure monitor both which we took out a few days ago.  Over the last few days, the patient began to slowly deteriorate little bit on her clinical examination, that is, she was at first localizing briskly with the right side and that began to be less brisk.  We obtained a CT scan at this point, and we noted that she had a fair amount of swelling in the left hemisphere with about 1.5 cm of midline shift.  At this point, once again I discussed with the family the possibility of trying to save her life and go ahead and doing a left-sided very large hemicraniectomy with this __________  this was once again a life-saving procedure and we proceeded with the consent of mom to go ahead and do a level 1 hemicraniectomy of the left side.,PROCEDURE IN DETAIL: , The patient was taken to the operating room.  She was already intubated and under general anesthesia.  The head was put in a 3-pin Mayfield headholder with one pin in the forehead and two pins in the back to be able to put the patient with the right-hand side down and the left-hand side up since on the right-hand side, she did not have a bone flap which complicated matters a little bit, so we had to use a 3-pin Mayfield headholder.  The patient tolerated this well.  We sterilely prepped everything and we actually had already done a midline incision prior to this for the prior surgery, so we incorporated this incision into the new incision, and to be able to open the skin on the left side, we did a T-shaped incision with T vertical portion coming from anterior to the ear from the zygoma up towards the vertex of the skull towards the midline of the skin.  We connected this.  Prior to this, we brought in all surgical instrumentation under sterile and standard conditions.  We opened the skin as in opening a book and then we also did a myocutaneous flap.  We brought in the muscle with it.  We had a very good exposure of the skull.  We identified all the important landmarks including the zygoma inferiorly, the superior sagittal suture as well as posteriorly and anteriorly.  We had very good landmarks, so we went ahead and did one bur hole and the middle puncta right above the zygoma and then brought in the craniotome and did a very large bone flap that measured about 7 x 9 cm roughly, a very large decompression of the left side.  At this point, we opened the dura and the dura as soon as it was opened, there was a small subdural hematoma under a fair amount of pressure and cleaned this very nicely irrigated completely the brain and had a few contusions over the operculum as well as posteriorly.  All this was irrigated thoroughly.  Once we made sure we had absolutely great hemostasis without any complications, we went ahead and irrigated once again and we had controlled the meddle meningeal as well as the superior temporal artery very nicely.  We had absolutely good hemostasis.  We put a piece of Gelfoam over the brain.  We had opened the dura in a cruciate fashion, and the brain clearly bulging out despite of the fact that it was in the dependent position.  I went ahead and  irrigated everything thoroughly putting a piece of DuraGen as well as a piece of Gelfoam with very good hemostasis and proceeded to close the skin with running nylon in place.  This running nylon we put in place in order not to put any absorbables, although I put a few 0 popoffs just to approximate the skin nicely.  Once we had done this, irrigated thoroughly once again the skin.  We cleaned up everything and then we took the patient off __________ anesthesia and took the patient back to the intensive care unit.  The EBL was about 200 cubic centimeters.  Her hematocrit went down to about 21 and I ordered the patient to receive one unit of blood intraoperatively which they began to work on as we began to continue to do the work and the sponges and the needle counts were correct.  No complications.  The patient went back to the intensive care unit.","surgery, large hemicraniectomy, intracranial pressure, multiple fractures, skull, traumatic brain injury, mayfield headholder, injury, hemicraniectomyNOTE"
 Debulking of hemangioma of the nasal tip through an open rhinoplasty approach and rhinoplasty., Surgery, Hemangioma Debulking & Rhinoplasty ,"PREOPERATIVE DIAGNOSIS: , Hemangioma, nasal tip.,POSTOPERATIVE DIAGNOSIS:,  Hemangioma, nasal tip.,PROCEDURE PERFORMED:  ,1.  Debulking of hemangioma of the nasal tip through an open rhinoplasty approach.,2.  Rhinoplasty.,ESTIMATED BLOOD LOSS:  ,Minimal.,FINDINGS: , Large hemangioma involving the midline of the columella separated the lower lateral cartilages at a level of the columella and the nasal domes.,CONDITION:  ,Condition of the patient at end of the procedure stable, transferred to recovery room.,INDICATIONS FOR THE PROCEDURE: , The patient is a 2-year-old female with a history of a nasal tip hemangioma.  The hemangioma has involved at her upper tongue.  There has not been any change in the last 6 months.  We have discussed with the parents the situation and decided to proceed with the debulking of the nasal tip hemangioma.  They understand the nature of the incision, the nature of the surgery, and the possibility of future revision surgeries.  They understand the risk of bleeding, infection, dehiscence, scarring, need for future revision surgery, and minor asymmetry.  They wished to proceed with surgery.,Because of the procedure, informed consent is obtained.  The patient is taken to operating room and placed in the supine position.  General anesthetic is administrated to an oroendotracheal tube.  The face is prepped and draped in the usual manner.  The incision is designed to the lower aspect of the hemangioma, which corresponds to the columella and upper lip junction and then the remaining of the incision is designed as an open rhinoplasty with bilateral rim incisions.  The area is infiltrated with lidocaine with epinephrine.  We waited 7 minutes for the hemostatic effect and proceeded with the incision.  The incision was then done with a 15 C blade starting at the columella and then going laterally to the level of the rim and the double hook is placed at the level of the dome and the intracartilage incision is done through the mucosa, then extended laterally and upward to follow the lower lateral cartilage.  This is done in both sides.  Further incision is done.  A small tenotomy scissors is used and with the help of retraction of the lower lateral cartilage, the hemangioma is separated gently from the lower lateral cartilage on both sides and I proceeded to leave that the central part of the incision lifting up the entire columella to the level of the nasal tip.  The hemangioma is removed and is found to be involving the medial aspects of both medial crura.  This gently separated from the medial crura and from the soft tissue care is taken not to remove the entire hemangioma from the skin as the nose not to devascularize the distal columella portion.  Hemostasis is achieved with electrocautery.  Then, we proceed to place some interdomal stitches with the help of a 6-0 clear nylon and intercrural stitches are placed and then an interdomal stitch, a single one was placed.  The skin is redraped and the nose found to have satisfactory shape.  The columellar piece was tailored on the lateral aspect corresponding to rim incisions to match the newly created width of the columella.  Portions of skin and hemangioma are taken laterally on both sides of the columella distally.  The skin was closed with 6-0 mild chromic stitches, including the portion at the level of the columella and rim incisions medially.  The remaining of the internal incisions are closed with 5-0 chromic interrupted stitches.  The nose is irrigated and suctioned.  The patient tolerated the procedure without complications.  I was present and participated in all aspects of the procedure.  Sponge and instrument count were complete at the end of the procedure.","surgery, rhinoplasty approach, debulking of hemangioma, nasal domes, lower lateral cartilages, nasal tip, columella, hemangioma, debulking, cartilages, rhinoplasty, nasal,"
" Left heart catheterization, coronary angiography, and left ventriculogram.  No angiographic evidence of coronary artery disease.  Normal left ventricular systolic function.  Normal left ventricular end diastolic pressure.", Surgery," Heart Catheterization, Ventriculography, & Angiography - 8 ","PROCEDURES,1.  Left heart catheterization.,2.  Coronary angiography.,3.  Left ventriculogram.,PREPROCEDURE DIAGNOSIS:,  Atypical chest pain.,POSTPROCEDURE DIAGNOSES,1.  No angiographic evidence of coronary artery disease.,2.  Normal left ventricular systolic function.,3.  Normal left ventricular end diastolic pressure.,INDICATION:  ,The patient is a 58-year-old male with past medical history significant for polysubstance abuse, chronic tobacco abuse, chronic alcohol dependence with withdrawal, atrial flutter, history of ventricular tachycardia with AICD placement, and hepatitis C. The patient was admitted for atypical chest pain and scheduled for cardiac catheterization.,PROCEDURE IN DETAIL:,  After informed consent was signed by the patient, the patient was taken to the cardiac catheterization laboratory.  He was prepped and draped in the usual sterile manner.  The right inguinal area was anesthetized with 2% Xylocaine.  A 4-French sheath was inserted into the right femoral artery using the modified Seldinger technique.  JL4 and 3DRC catheters were used to cannulate the left and right coronary arteries respectively.  Coronary angiographies were performed.  These catheters were removed and exchanged for a 4-French pigtail catheter, which was positioned into the left ventricle.  Left ventriculography was performed.  The patient tolerated the procedure well.  At the end of the procedure, all catheters and sheaths were removed.  The patient was then transferred to telemetry in a stable condition.,HEMODYNAMIC DATA: , Hemodynamic data shows aortic pressures of 100/56 with mean of 70 mmHg and the LV 100/0 with LVEDP of 10 mmHg.,AORTIC VALVE:  ,There is no significant gradient across this valve noted.,LV GRAM: , A 10 mL of contrast were delivered for 3 seconds for a total of 30 mL.  Ejection fraction was calculated to be 69%.  There were no wall motion abnormalities noted.,ANGIOGRAM,LEFT MAIN CORONARY ARTERY: , Left main coronary artery is a moderate-caliber vessel free of disease and trifurcates.,LAD: , LAD is a long, tortuous vessel which wraps around the apex.  The LAD is small in caliber.  In addition, there is a long bifurcating small-caliber diagonal branch noted.  LAD and its branches are free of disease.,RAMUS INTERMEDIUS: , Ramus intermedius is a long small-caliber vessel free of disease.,LCX: , LCX is a nondominant small-caliber vessel with long bifurcating small-caliber distal OM branch.  LCX and its branches are free of disease.,RCA:,  RCA is a dominant small-caliber vessel with long small-caliber PDA branch.  RCA and its branches are free of disease.,IMPRESSION,1.  No angiographic evidence of coronary artery disease.,2.  Normal left ventricular systolic function.,3.  Normal left ventricular end diastolic pressure.,RECOMMENDATION: , Recommend to look for alternative causes of chest pain.",
" Austin-Moore bipolar hemiarthroplasty, left hip.  Subcapital left hip fracture.", Surgery, Hemiarthroplasty - Austin-Moore Bipolar ,"PREOPERATIVE DIAGNOSIS: , Subcapital left hip fracture.,POSTOPERATIVE DIAGNOSIS: , Subcapital left hip fracture.,PROCEDURE PERFORMED: , Austin-Moore bipolar hemiarthroplasty, left hip.,ANESTHESIA:  ,Spinal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:  ,Less than 100 cc.,HISTORY:  ,The patient is an 86-year-old female who was seen and evaluated in ABCD General Hospital Emergency Department on 08/30/03 after sustaining a fall at her friend's house.  The patient states that she was knocked over by her friend's dog.  She sustained a subcapital left hip fracture.  Prior to admission, she lived alone in Terrano, was ambulating with a walker.  All risks, benefits, and potential complications of the procedure were then discussed with the patient and informed consent was obtained.,HARDWARE SPECIFICATIONS: , A 28 mm medium head was used, a small cemented femoral stem was used, and a 28 x 46 cup was used.,PROCEDURE:  ,All risks, benefits, and potential complications of the procedure were discussed with the patient, informed consent was obtained.  She was then transferred from the preoperative care unit to operating suite #1.  Department of Anesthesia administered spinal anesthetic without complications.,After this, the patient was transferred to the operating table and positioned.  All bony prominences were well padded.  She was positioned on a beanbag in the right lateral decubitus position with the left hip facing upwards.  The left lower extremity was then sterilely prepped and draped in the normal fashion.  A skin maker was then used to mark all bony prominences.  Skin incision was then carried out extending from the greater trochanter in a curvilinear fashion posteriorly across the buttocks.  A #10 blade Bard-Parker scalpel was used to incise the skin through to the subcutaneous tissues.  A second #10 blade was then used to incise through the subcutaneous tissue down to the fascia lata.  This was then incised utilizing Metzenbaum scissors.  This was taken down to the bursa, which was removed utilizing a rongeur.  Utilizing a periosteal elevator as well as the sponge, the fat was then freed from the short external rotators of the left hip after these were placed and stretched.  The sciatic nerve was then visualized and retracted utilizing a Richardson retractor.  Bovie was used to remove the short external rotators from the greater trochanter, which revealed the joint capsule.  The capsule was cleared and incised utilizing a T-shape incision.  A fracture hematoma was noted upon entering the joint capsule as well as subcapital hip fracture.  A cork screw was then used to remove the fractured femoral head, which was given to the scrub tech which was sized on the back table.  All bony remnants were then removed from the acetabulum and surrounding soft tissue with a rongeur.  Acetabulum was then inspected and found to be clear.  Attention was then turned to the proximal femur where a cutting tunnel was used to mark the femur for the femoral neck cut.  An oscillating saw was then used to make the femoral cut.  Box osteotome was then used to remove the bone from proximal femur.  A Charnley awl was then used to open the femoral canal, paying close attention to keep the awl in the lateral position.  Next, attention was turned to broaching.  Initially, a small broach was placed, first making efforts to lateralize the broach then the femoral canal.  It was felt that the patient has less benefit from a cemented prosthesis and a small size was appropriate.  Next, the trial components were inserted consisting of the above-mentioned component sizes.  The hip was taken through range of motion and tested to adduction, internal and external rotations as well as with a shuck and a posterior directed force on a flexed tip.  It was noted that these size were stable through the range of motion.  Next, the trial components were removed and the femoral canal was copiously irrigated and suctioned dried utilizing Super sucker and __________ then inserted pressuring the femoral canal.  The femoral component was then inserted and then held under pressure.  Extruding cement was removed from the proximal femur.  After the cement had fully hardened and dried, the head and cup were applied.  The hip was subsequently reduced and taken again through range of motion, which was felt to be stable.,Next, the capsule was closed utilizing #1 Ethibond in figure-of-eight fashion.  Next, the fascia lata was repaired utilizing a figure-of-eight Ethibond sutures.  The most proximal region at the musculotendinous junction was repaired utilizing a running #1 Vicryl suture.  The wound was then copiously irrigated again to suction dry.  Next, the subcutaneous tissues were reapproximated using #2-0 Vicryl simple interrupted sutures.  The skin was then reapproximated utilizing skin clips.  Sterile dressing was applied consisting of Adaptic, 4x4s, ABDs as well as foam tape.  The patient was then transferred from the operating table to the gurney.  Leg lengths were checked, which were noted to be equal and abduction pillow was placed.  The patient was then transferred to the Postoperative Care Unit in stable condition.","surgery, austin-moore bipolar hemiarthroplasty, subcapital left hip fracture, hip fracture, austin moore bipolar hemiarthroplasty, subcutaneous tissues, hip, hemiarthroplasty, austin, cemented, femur, subcapital, fracture, femoral,"
 Right side craniotomy for temporal lobe intracerebral hematoma evacuation and resection of temporal lobe lesion.  Biopsy of dura., Surgery, Hematoma Evacuation ,"PREOPERATIVE DIAGNOSIS: , Right temporal lobe intracerebral hemorrhage.,POSTOPERATIVE DIAGNOSES:,1.  Right temporal lobe intracerebral hemorrhage.,2.  Possible tumor versus inflammatory/infectious lesion versus vascular lesion, pending final pathology and microbiology.,PROCEDURES:,1.  Emergency right side craniotomy for temporal lobe intracerebral hematoma evacuation and resection of temporal lobe lesion.,2.  Biopsy of dura.,3.  Microscopic dissection using intraoperative microscope.,SPECIMENS: , Temporal lobe lesion and dura as well as specimen for microbiology for culture.,DRAINS:,  Medium Hemovac drain.,FINDINGS: , Vascular hemorrhagic lesion including inflamed dura and edematous brain with significant mass effect, and intracerebral hematoma with a history of significant headache, probable seizures, nausea, and vomiting.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Per Anesthesia.,FLUIDS: , One unit of packed red blood cells given intraoperatively.,The patient was brought to the operating room emergently.  This is considered as a life threatening admission with a hemorrhage in the temporal lobe extending into the frontal lobe and with significant mass effect.,The patient apparently became hemiplegic suddenly today.  She also had an episode of incoherence and loss of consciousness as well as loss of bowel/urine.,She was brought to Emergency Room where a CT of the brain showed that she had significant hemorrhage of the right temporal lobe extending into the external capsule and across into the frontal lobe.  There is significant mass effect.  There is mixed density in the parenchyma of the temporal lobe.,She was originally scheduled for elective craniotomy for biopsy of the temporal lobe to find out why she was having spontaneous hemorrhages.  However, this event triggered her family to bring her to the emergency room, and this is considered a life threatening admission now with a significant mass effect, and thus we will proceed directly today for evacuation of ICH as well as biopsy of the temporal lobe as well as the dura.,PROCEDURE IN DETAIL: , The patient was anesthetized by the anesthesiology team.  Appropriate central line as well as arterial line, Foley catheter, TED, and SCDs were placed.  The patient was positioned supine with a three-point Mayfield head pin holder.  Her scalp was prepped and draped in a sterile manner.  Her former incisional scar was barely and faintly noticed; however, through the same scalp scar, the same incision was made and extended slightly inferiorly.  The scalp was resected anteriorly.  The subdural scar was noted, and hemostasis was achieved using Bovie cautery.  The temporalis muscle was reflected along with the scalp in a subperiosteal manner, and the titanium plating system was then exposed.,The titanium plating system was then removed in its entirety.  The bone appeared to be quite fused in multiple points, and there were significant granulation tissue through the burr hole covers.,The granulation tissue was quite hemorrhagic, and hemostasis was achieved using bipolar cautery as well as Bovie cautery.,The bone flap was then removed using Leksell rongeur, and the underlying dura was inspected.  It was quite full.  The 4-0 sutures from the previous durotomy closure was inspected, and more of the inferior temporal bone was resected using high-speed drill in combination with Leksell rongeur.  The sphenoid wing was also resected using a high-speed drill as well as angled rongeur.,Hemostasis was achieved on the fresh bony edges using bone wax.  The dura pack-up stitches were noted around the periphery from the previous craniotomy.  This was left in place.,The microscope was then brought in to use for the remainder of the procedure until closure.  Using a #15 blade, a new durotomy was then made.  Then, the durotomy was carried out using Metzenbaum scissors, then reflected the dura anteriorly in a horseshoe manner, placed anteriorly, and this was done under the operating microscope.  The underlying brain was quite edematous.,Along the temporal lobe there was a stain of xanthochromia along the surface.  Thus a corticectomy was then accomplished using bipolar cautery, and the temporal lobe at this level and the middle temporal gyrus was entered.  The parenchyma of the brain did not appear normal.  It was quite vascular.  Furthermore, there was a hematoma mixed in with the brain itself.  Thus a core biopsy was then performed in the temporal tip.  The overlying dura was inspected and it was quite thickened, approximately 0.25 cm thick, and it was also highly vascular, and thus a big section of the dura was also trimmed using bipolar cautery followed by scissors, and several pieces of this vascularized dura was resected for pathology.  Furthermore, sample of the temporal lobe was cultured.,Hemostasis after evacuation of the intracerebral hematoma using controlled suction as well as significant biopsy of the overlying dura as well as intraparenchymal lesion was accomplished.  No attempt was made to enter into the sylvian fissure.  Once hemostasis was meticulously achieved, the brain was inspected.  It still was quite swollen, known that there was still hematoma in the parenchyma of the brain.  However, at this time it was felt that since there is no diagnosis made intraoperatively, we would need to stage this surgery further should it be needed once the diagnosis is confirmed.  DuraGen was then used for duraplasty because of the resected dura.  The bone flap was then repositioned using Lorenz plating system.  Then a medium Hemovac drain was placed in subdural space.  Temporalis muscle was approximated using 2-0 Vicryl.  The galea was then reapproximated using inverted 2-0 Vicryl.  The scalp was then reapproximated using staples.  The head was then dressed and wrapped in a sterile fashion.,She was witnessed to be extubated in the operating room postoperatively, and she followed commands briskly.  The pupils are 3 mm bilaterally reactive to light.  I accompanied her and transported her to the ICU where I signed out to the ICU attending.",
" Left heart catheterization, coronary angiography, left ventriculography.  Severe complex left anterior descending and distal circumflex disease with borderline, probably moderate narrowing of a large obtuse marginal branch.", Surgery," Heart Catheterization, Ventriculography, & Angiography - 7 ","PROCEDURE: , Left heart catheterization, coronary angiography, left ventriculography.,COMPLICATIONS: , None.,PROCEDURE DETAIL: , The right femoral area was draped and prepped in the usual fashion after Xylocaine infiltration.  A 6-French arterial sheath was placed in the usual fashion.  Left and right coronary angiograms were then performed in various projections after heparin was given 2000 units intraaortic.  The right coronary artery was difficult to cannulate because of its high anterior takeoff.  This was nondominant.  Several catheters were used.  Ultimately, an AL1 diagnostic catheter was used.  A pigtail catheter was advanced across the aortic valve.  Left ventriculogram was then done in the RAO view using 30 mL of contrast.  Pullback gradient was obtained across the aortic valve.  Femoral angiogram was performed through the sheath which was above the bifurcation, was removed with a Perclose device with good results.  There were no complications.  He tolerated this procedure well and returned to his room in good condition.,FINDINGS,1.  Right coronary artery:  This has an unusual high anterior takeoff.  The vessel is nondominant, has diffuse mild-to-moderate disease.,2.  Left main trunk:  A 30% to 40% distal narrowing is present.,3.  Left anterior descending:  Just at the ostium of the vessel and up to and including the bifurcation of the first large diagonal branch, there is 80 to 90% narrowing.  The diagonal is a large vessel about 3 mm in size.,4.  Circumflex:  Dominant vessel, 50% narrowing at the origin of the obtuse marginal.  After this, there is 40% narrowing in the AV trunk.  The small posterior lateral branch has diffuse mild disease and then the vessel gives rise to a fairly large posterior ventricular branch, which has 70% ostial narrowing, and then after this the posterior descending has 80% narrowing at its origin.,5.  Left ventriculogram:  Normal volume in diastole and systole.  Normal systolic function is present.  There is no mitral insufficiency or left ventricular outflow obstruction.,DIAGNOSES,1.  Severe complex left anterior descending and distal circumflex disease with borderline, probably moderate narrowing of a large obtuse marginal branch.  Dominant circumflex system.  Severe disease of the posterior descending.  Mild left main trunk disease.,2.  Normal left ventricular systolic function.,Given the complex anatomy of the predominant problem which is the left anterior descending; given its ostial stenosis and involvement of the bifurcation of the diagonal, would recommend coronary bypass surgery.  The patient also has severe disease of the circumflex which is dominant.  This anatomy is not appropriate for percutaneous intervention.  The case will be reviewed with a cardiac surgeon.","surgery, heart catheterization, coronary angiography, left ventriculography, arterial sheath, coronary artery, obtuse marginal branch, angiography, catheterization,"
" Left heart catheterization, left ventriculography, selective coronary angiography.", Surgery," Heart Catheterization, Ventriculography, & Angiography - 9 ","PROCEDURE:,  Left heart catheterization, left ventriculography, selective coronary angiography.,INDICATION: , This lady with a previous left internal mammary graft to left anterior descending, saphenous vein graft to obtuse margin branch, saphenous vein graft to the diagonal branch, and saphenous vein graft to the right coronary artery presented with recurrent difficulties with breathing.  This was felt to be related largely to chronic obstructive lung disease.  She had dynamic T-wave changes in precordial leads.  Cardiac enzymes were indeterminate.  She was evaluated by Dr. X and given her previous history and multiple risk factors it was elected to proceed with cardiac catheterization and coronary angiography.,Risks of the procedure including risks of conscious sedation, death, cerebrovascular accident, dye reaction, need for emergency surgery, vascular access injury and/or infection, and risks of cath-based interventions were discussed in detail.  The patient understood and agreed to proceed.,DESCRIPTION OF THE PROCEDURE: , The patient was brought to the cardiac catheterization laboratory.  Under Versed and fentanyl sedation, the right groin was sterilely prepped and draped.  Local anesthesia was obtained with 2% Xylocaine.  The right femoral artery was entered using modified Seldinger technique and a 4-French introducer sheath placed in that vessel.  Through the indwelling femoral arterial sheath, a JL4 4-French catheter was advanced over the wire to the ascending aorta, appropriately aspirated and flushed.  Ascending aortic root pressures obtained.  This catheter was utilized in an attempt to cannulate the left coronary ostium.  This catheter was too small, was exchanged for a JL5 4-French catheter, which was advanced over the wire to the ascending aorta, the cath appropriately aspirated and flushed, and advanced to left coronary ostium and multiple views of left coronary artery obtained.,This catheter was then exchanged for a 4-French right coronary catheter, which was advanced over the wire to the ascending aorta.  The catheter appropriately aspirated and flushed.  The catheter was advanced in the right coronary artery.  Multiple views of that vessel were obtained.  The catheter was then sequentially advanced to the saphenous vein graft to the diagonal branch, saphenous vein graft to the obtuse marginal branch, and left internal mammary artery, left anterior descending coronary artery, and multiple views of those vessels were obtained.  This catheter was then exchanged for a 4-French pigtail catheter, which was advanced over the wire to the ascending aorta.  The catheter was appropriately aspirated and flushed and advanced to left ventricle, baseline left ventricular pressures obtained.,Following this, left ventriculography was performed in a 30-degree RAO projection using 30 mL of contrast injected over 3 seconds.  Post left ventriculography pressures were then obtained as was a pullback pressure across the aortic valve.  Videotapes were then reviewed.  It was elected to terminate the procedure at that point in time.,The vascular sheath was removed and manual compression carried out.  Excellent hemostasis was obtained.  The patient tolerated the procedure without complication.,RESULTS OF PROCEDURE,1.  ,HEMODYNAMICS:,  Left ventricular end-diastolic filling pressure was 24.  There was no gradient across the aortic valve.,2.  ,LEFT VENTRICULOGRAPHY: , Left ventriculography demonstrated well-preserved left ventricular systolic function.  Mild inferobasilar hypokinesis was noted.  No significant mitral regurgitation noted.  Ejection fraction was estimated at 60%.,3.  ,CORONARY ARTERIOGRAPHY,A.  ,LEFT MAIN CORONARY: , The left main coronary was patent.,B.  ,LEFT ANTERIOR DESCENDING CORONARY ARTERY:,  Left anterior descending coronary was occluded shortly after a very small first septal perforator was given.,C.  ,CIRCUMFLEX CORONARY ARTERY:,  Circumflex coronary artery was occluded at its origin.,D.  ,RIGHT CORONARY ARTERY,.  Right coronary artery was occluded in its mid portion.,4.  ,SAPHENOUS VEIN GRAFT ANGIOGRAPHY,A.  ,SAPHENOUS VEIN GRAFT TO THE DIAGONAL BRANCH: , The saphenous vein graft to diagonal branch was widely patent at its origin and insertion sites.  Excellent flow was noted in the diagonal system with some retrograde flow.,B.  There was retrograde flow as well in the left anterior descending system.,C.  ,SAPHENOUS VEIN GRAFT TO THE OBTUSE MARGINAL SYSTEM:,  Saphenous vein graft to the obtuse marginal system was widely patent at its origin and insertion sites.  There was no graft disease noted.  Excellent flow was noted in the bifurcating marginal system.,D.  ,SAPHENOUS VEIN GRAFT TO RIGHT CORONARY ARTERY:,  Saphenous vein graft to right coronary was widely patent with no graft disease.  Origin and insertion sites were free of disease.  Distal flow in the graft to the posterior descending was normal.,5.  ,LEFT INTERNAL MAMMARY ARTERY ANGIOGRAPHY: , Left internal mammary artery angiography demonstrated a widely patent left internal mammary at its origin and insertion sites.  There was no focal disease noted, inserted into the mid-to-distal LAD which was a small-caliber vessel.  Retrograde filling of a small septal system was noted.,SUMMARY OF RESULTS,1.  Elevated left ventricular end-diastolic filling pressure with normal left ventricular systolic function and mild hypokinesis of inferobasilar segment.",
" Exploratory laparotomy, lysis of adhesions, and right hemicolectomy.  Right colon cancer, ascites, and adhesions.", Surgery, Hemicolectomy ,"PREOPERATIVE DIAGNOSIS: , Right colon tumor.,POSTOPERATIVE DIAGNOSES:,1.  Right colon cancer.,2.  Ascites.,3.  Adhesions.,PROCEDURE PERFORMED:,1.  Exploratory laparotomy.,2.  Lysis of adhesions.,3.  Right hemicolectomy.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Less than 200 cc.,URINE OUTPUT: , 200 cc.,CRYSTALLOIDS GIVEN: , 2700 cc.,INDICATIONS FOR THIS PROCEDURE:  ,The patient is a 53-year-old African-American female who presented with near obstructing lesion at the hepatic flexure.  The patient underwent a colonoscopy which found this lesion and biopsies were taken proving invasive adenocarcinoma.  The patient was NG decompressed preoperatively and was prepared for surgery.  The need for removal of the colon cancer was explained at length.  The patient was agreeable to proceed with the surgery and signed preoperatively informed consent.,PROCEDURE: , The patient was taken to the Operative Suite and placed in the supine position under general anesthesia per Anesthesia Department and NG and Foley catheters were placed preoperatively.  She was given triple antibiotics IV.  Due to her near obstructive symptoms, a formal ________ was not performed.,The abdomen was prepped and draped in the usual sterile fashion.  A midline laparotomy incision was made with a #10 blade scalpel and subcutaneous tissues were separated with electrocautery down to the anterior abdominal fascia.  Once divided, the intraabdominal cavity was accessed and bowel was protected as the rest of the abdominal wall was opened in the midline.  Extensive fluid was seen upon entering the abdomen, ascites fluid, which was clear straw-colored and this was sampled for cytology.  Next, the small bowel was retracted with digital exploration and there was a evidence of hepatic flexure, colonic mass, which was adherent to the surrounding tissues.  With mobilization of the colon along the line of Toldt down to the right gutter, the entire ileocecal region up to the transverse colon was mobilized into the field.  Next, a window was made 5 inches from the ileocecal valve and a GIA-75 was fired across the ileum.  Next, a second GIA device was fired across the proximal transverse colon, just sparring the middle colic artery.  The dissection was then carried down along the mesentry, down to the root of the mesentry.  Several lymph nodes were sampled carefully, and small radiopaque clips were applied along the base of the mesentry.  The mesentry vessels are hemostated and tied with #0-Vicryl suture sequentially, ligated in between.  Once this specimen was submitted to pathology, the wound was inspected.  There was no evidence of bleeding from any of the suture sites.  Next, a side-by-side anastomosis was performed between the transverse colon and the terminal ileum.  A third GIA-75 was fired side-by-side and GIA-55 was used to close the anastomosis.  A patent anastomosis was palpated.  The anastomosis was then protected with a #2-0 Vicryl #0-muscular suture.  Next, the mesenteric root was closed with a running #0-Vicryl suture to prevent any chance of internal hernia.  The suture sites were inspected and there was no evidence of leakage.  Next, the intraabdominal cavity was thoroughly irrigated with sterile saline and the anastomosis was carried into the right lower gutter.  Omentum was used to cover the intestines which appeared dilated and indurated from the near obstruction.  Next, the abdominal wall was reapproximated and the fascial layer using a two running loop PDS sutures meeting in the middle with good approximation of both the abdominal fascia.  Additional sterile saline was used to irrigate the subcutaneous fat and then the skin was closed with sequential sterile staples.,Sterile dressing was applied and the skin was cleansed and the patient was awakened from anesthesia without difficulty and extubated in the Operating Room and she was transferred to Recovery Room in stable condition and will be continued to be monitored on the Telemetry Floor with triple antibiotics and NG decompression.,","surgery, colon tumor, ascites, adhesions, lysis of adhesions, exploratory laparotomy, colon cancer, transverse colon, hemicolectomy, laparotomy, "
" Hemiarthroplasty of left shoulder utilizing a global advantage system with an #8 mm cemented humeral stem and 48 x 21 mm modular head replacement.  Comminuted fracture, dislocation left proximal humerus.", Surgery, Hemiarthroplasty - Shoulder ,"PREOPERATIVE DIAGNOSIS:,  Comminuted fracture, dislocation left proximal humerus.,POSTOPERATIVE DIAGNOSIS:, Comminuted fracture, dislocation left proximal humerus.,PROCEDURE PERFORMED: , Hemiarthroplasty of left shoulder utilizing a global advantage system with an #8 mm cemented humeral stem and 48 x 21 mm modular head replacement.,PROCEDURE:  ,The patient was taken to OR #2, administered general anesthetic.  He was positioned in the modified beach chair position on the operative table utilizing the shoulder apparatus.  The left shoulder and upper extremities were then prepped and draped in the usual manner.  A longitudinal incision was made extending from a point just lateral to the coracoid down towards deltoid tuberosity of the humerus.  This incision was taken down through the skin and subcutaneous tissues were split utilizing the coag cautery.  Hemostasis was achieved with the cautery.  The deltoid fascia were identified, skin flaps were then created.  The deltopectoral interval was identified and the deltoid split just lateral to the cephalic vein.  The deltoid was then retracted.  There was marked hematoma and swelling within the subdeltoid bursa.  This area was removed with rongeurs.  The biceps tendon was identified which was the landmark for the rotator interval.  Mayo scissors was utilized to split the remaining portion of the rotator interval.  The greater tuberosity portion with the rotator cuff was identified.  Excess bone was removed from the greater tuberosity side to allow for closure later.  The lesser tuberosity portion with the subscapularis was still attached to the humeral head, therefore, osteotome was utilized to separate the lesser tuberosity from the humeral head fragment.,Excess bone was removed from the lesser tuberosity as well.  Both of these were tagged with Ethibond sutures for later.  The humeral head was delivered out of the wound.  It was localized to the area of the anteroinferior glenoid region.  The glenoid was then inspected, and noted to be intact.  The fracture was at the level of the surgical neck on the proximal humerus.  The canal was repaired with the broaches.  An #8 stem was chosen as it was going to be cemented into place.  The trial stem was impacted into position and the shaft of the bone marked with the cautery to the appropriate retroversion.  Trial reduction was performed.  The 48 x 21 mm head was the most appropriate size, matching the patient's as well as the soft tissue tension on the shoulder.  At this point, the wound was copiously irrigated with gentamycin solution.  The canal was copiously irrigated as well and suctioned dry.  Methyl methacrylate cement was mixed.  The cement gun was filled and the canal was filled with the cement.  The #8 stem was then impacted into place and held in the position in the appropriate retroversion until the cement had cured.  Excess cement was removed by sharp dissection.  Prior to cementation of the stem, a hole was drilled in the shaft of proximal humerus and #2 fiber wires were placed through this hole for closure later.  Once the cement was cured, the modular head was impacted on to the Morse taper.  It was stable and the shoulder was reduced.  The lesser tuberosity was then reapproximated back to the original site utilizing the #2 fiber wire suture that was placed in the humeral shaft as well as the holes in the humeral implant.  The greater tuberosity portion with rotator cuff was also attached to the implant as well as the shaft of the humerus utilizing #2 fiber wires as well.  The rotator interval was closed with #2 fiber wire in an interrupted fashion.  The biceps tendon was ________ within this closure.  The wound was copiously irrigated with gentamycin solution, suctioned dry.  The deltoid fascia was then approximated with interrupted #2-0 Vicryl suture.  Subcutaneous layer was approximated with interrupted #2-0 Vicryl and skin approximated with staples.  Subcutaneous tissues were infiltrated with 0.25% Marcaine solution.  A bulky dressing was applied to the wound followed by application of a large arm sling.  Circulatory status was intact in the extremity at the completion of the case.  The patient was then transferred to recovery room in apparent satisfactory condition.","surgery, dislocation, proximal humerus, comminuted fracture, rotator interval, tuberosity portion, hemiarthroplasty, fracture, wound, proximal, deltoid, rotator, stem, humeral, humerus, tuberosity, cemented,"
 Left heart catheterization with left ventriculography and selective coronary angiography.  A 50% distal left main and two-vessel coronary artery disease with normal left ventricular systolic function.  Frequent PVCs.  Metabolic syndrome., Surgery," Heart Catheterization, Ventriculography, & Angiography - 6 ","PREOPERATIVE DIAGNOSES,1.  Dyspnea on exertion with abnormal stress echocardiography.,2.  Frequent PVCs.,3.  Metabolic syndrome.,POSTOPERATIVE DIAGNOSES,1.  A 50% distal left main and two-vessel coronary artery disease with normal left ventricular systolic function.,2.  Frequent PVCs.,3.  Metabolic syndrome.,PROCEDURES,1.  Left heart catheterization with left ventriculography.,2.  Selective coronary angiography.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained, the patient was brought to the Cardiac Catheterization Laboratory in fasting state.  Both groins were prepped and draped in the usual sterile fashion.  Xylocaine 1% was used as local anesthetic.  Versed and fentanyl were used for conscious sedation.  Next, a #6-French sheath was placed in the right femoral artery using modified Seldinger technique.  Next, selective angiography of the left coronary artery was performed in multiple views using #6-French JL4 catheter.  Next, selective angiography of the right coronary artery was performed in multiple views using #6-French 3DRC catheter.  Next, a #6-French angle pigtail catheter was advanced into the left ventricle.  The left ventricular pressure was then recorded.  Left ventriculography was the performed using 36 mL of contrast injected over 3 seconds.  The left heart pull back was then performed.  The catheter was then removed.,Angiography of the right femoral artery was performed.  Hemostasis was obtained by Angio-Seal closure device.  The patient left the Cardiac Catheterization Laboratory in stable condition.,HEMODYNAMICS,1.  LV pressure was 163/0 with end-diastolic pressure of 17.  There was no significant gradient across the aortic valve.,2.  Left ventriculography showed old inferior wall hypokinesis.  Global left ventricular systolic function is normal.  Estimated ejection fraction was 58%.  There is no significant mitral regurgitation.,3.  Significant coronary artery disease.,4.  The left main is approximately 7 or 8 mm proximally.  It trifurcates into left anterior descending artery, ramus intermedius artery, and left circumflex artery.  The distal portion of the left main has an ulcerated excentric plaque, up to about 50% in severity.,5.  The left anterior descending artery is around 4 mm proximally.  It extends slightly beyond the apex into the inferior wall.  It gives rises to several medium size diagonal branches as well as small to medium size multiple septal perforators.  At the ostium of the left anterior descending artery, there was an eccentric plaque up to 70% to 80%, best seen in the shallow LAO with caudal angulation.,There was no other flow-limiting disease noted in the rest of the left anterior descending artery or its major branches.,The ramus intermedius artery is around 3 mm proximally, but shortly after its origin, it bifurcates into two medium size branches.  There was no significant disease noted in the ramus intermedius artery however.,The left circumflex artery is around 2.5 mm proximally.  It gave off a recurrent atrial branch and a small AV groove branch prior to terminating into a bifurcating medium size obtuse marginal branch.  The mid to distal circumflex has a moderate disease, which is relatively diffuse up to about 40% to 50%.,The right coronary artery is around 4 mm in diameter.  It gives off conus branch, two medium size acute marginal branches, relatively large posterior descending artery and a posterior lateral branch.  In the mid portion of the right coronary artery at the origin of the first acute marginal branch, there is a relatively discrete stenosis of about 80% to 90%.  Proximally, there is an area of eccentric plaque, but seem to be non-flow limiting, at best around 20% to 30%.  Additionally, there is what appears to be like a shell-like lesion in the proximal segment of the right coronary artery as well.  The posterior descending artery has an eccentric plaque of about 40% to 50% in its mid segment.,PLAN:  ,Plan to consult cardiovascular surgery for consideration of coronary artery bypass surgery.  Continue risk factor modification, aspirin, and beta blocker.","surgery, heart catheterization, ventriculography, coronary angiography, dyspnea, metabolic syndrome, two-vessel coronary artery disease, echocardiography, selective coronary angiography, anterior descending artery, branches, coronary, angiography, artery, catheterization, "
" Left heart catheterization, selective bilateral coronary angiography and left ventriculography.  Revascularization of the left anterior descending with angioplasty and implantation of a drug-eluting stent.  Right heart catheterization and Swan-Ganz catheter placement for monitoring.", Surgery," Heart Catheterization, Ventriculography, & Angiography - 5 ","PREOPERATIVE DIAGNOSES,1.  Acute coronary artery syndrome with ST segment elevation in anterior wall distribution.,2.  Documented coronary artery disease with previous angioplasty and stent in the left anterior descending artery and circumflex artery, last procedure in 2005.,3.  Primary malignant ventricular arrhythmia and necessitated ventricular fibrillation.  He is intubated and ventilated.,POSTOPERATIVE DIAGNOSES:,  Acute coronary artery syndrome with ST segment elevation in anterior wall distribution.  Primary ventricular arrhythmia.  Occluded left anterior descending artery, successfully re-canalized with angioplasty and implantation of the drug-eluting stent.  Previously stented circumflex with mild stenosis and previously documented occlusion of the right coronary artery, well collateralized.,PROCEDURES:,  Left heart catheterization, selective bilateral coronary angiography and left ventriculography.  Revascularization of the left anterior descending with angioplasty and implantation of a drug-eluting stent.  Right heart catheterization and Swan-Ganz catheter placement for monitoring.,DESCRIPTION OF PROCEDURE:  ,The patient arrived from the emergency room intubated and ventilated.  He is hemodynamically stable on heparin and Integrilin bolus and infusion was initiated.  The right femoral area was prepped and draped in usual sterile fashion.  Lidocaine 2 mL was then filled locally.  The right femoral artery was cannulated with an 18-guage needle followed by a 6-French vascular sheath.  A guiding catheter XB 3.5 was advanced in manipulated to cannulate the left coronary artery and angiography was obtained.  A confirmed occlusion of the left anterior descending artery with minimal collaterals and also occlusion of the right coronary artery, which is well collateralized.  An angioplasty wire with present wire was advanced into the left anterior descending artery, and could cross the area of occlusion within the stent.  An angioplasty balloon measuring 2.0 x 15 was advanced and three inflations were obtained.  It successfully re-canalized the artery.  There is evidence of residual stenosis within the distal aspect of the previous stents.  A drug-eluting stent Xience 2.75 x 15 was advanced and positioned within the area of stenosis with its distal marker adjacent to bifurcation with a diagonal branch and was deployed at 12 and 18 atmospheres.  The intermittent result was improved.  An additional inflation was obtained more proximally.  His blood pressure fluctuated and dropped in the 70s, correlating with additional sedation.  There is patency of the left anterior descending artery and good antegrade flow.  The guiding catheter was replaced with a 5-French Judkins right catheter manipulated to cannulate the right coronary artery and selective angiography was obtained.  The catheter was then advanced into the left ventricle and pressure measurement was obtained including pullback across the aortic valve.  The right femoral vein was cannulated with an 18-guage needle followed by an 8-French vascular sheath.  A 8-French Swan-Ganz catheter was then advanced under fluoroscopic and hemodynamic control and pressure stenting was obtained from the right ventricle, pulmonary artery, and pulmonary capillary wedge position.  Cardiac catheter was determined by thermal dilution.  The procedure was then concluded, well tolerated and without complications.  The vascular sheath was in secured in place and the patient return to the coronary care unit for further monitoring.  Fluoroscopy time was 8.2 minutes.  Total amount of contrast was 113 mL.,HEMODYNAMICS:,  The patient remained in sinus rhythm with intermittent ventricular bigeminy post revascularization.  His initial blood pressure was 96/70 with a mean of 83 and the left ventricular pressure was 17 mmHg.  There was no gradient across the aortic valve.  Closing pressure was 97/68 with a mean of 82.,Right heart catheterization with right atrial pressure at 13, right ventricle 31/9, pulmonary artery 33/19 with a mean of 25, and capillary wedge pressure of 19.  Cardiac output was 5.87 by thermal dilution.,CORONARIES:,  On fluoroscopy, there was evidence of previous coronary stent in the left anterior descending artery and circumflex distribution.,A.  Left main coronary:  The left main coronary artery is of good caliber and has no evidence of obstructive lesions.,B.  Left anterior descending artery:  The left anterior descending artery was initially occluded within the previously stented proximal-to-mid segment.  There is minimal collateral flow.,C.  Circumflex:  Circumflex is a nondominant circulation.  It supplies a first obtuse marginal branch on good caliber.  There is an outline of the stent in the midportion, which has mild 30% stenosis.  The rest of the vessel has no significant obstructive lesions.  It also supplies significant collaterals supplying the occluded right coronary artery.,D.  Right coronary artery:  The right coronary artery is a weekly dominant circulation.  The vessel is occluded in intermittent portion and has a minimal collateral flow distally.,ANGIOPLASTY: , The left anterior descending artery was the site of re-canalization by angioplasty and implantation of a drug-eluting stent (Xience 15 mm length deployed at 2.9 mm) final result is good with patency of the left anterior descending artery, good antegrade flow and no evidence of dissection.  The stent was deployed proximal to the bifurcation with a second diagonal branch, which has remained patent.  There is a septal branch overlapped by the stent, which is also patent, although presenting a proximal stenosis.  The distal left anterior descending artery trifurcates with two diagonal branches and apical left anterior descending artery.  There is good antegrade flow and no evidence of distal embolization.,CONCLUSION: , Acute coronary artery syndrome with ST-segment elevation in anterior wall distribution, complicated with primary ventricular malignant arrhythmia and required defibrillation along intubation and ventilatory support.,Previously documented coronary artery disease with remote angioplasty and stents in the left anterior descending artery and circumflex artery.,Acute coronary artery syndrome with ST-segment elevation in anterior wall distribution related to in-stent thrombosis of the left anterior descending artery, successfully re-canalized with angioplasty and a drug-eluting stent.  There is mild-to-moderate disease of the previously stented circumflex and clinic occlusion of the right coronary artery, well collateralized.,Right femoral arterial and venous vascular access.,RECOMMENDATION:,  Integrilin infusion is maintained until tomorrow.  He received aspirin and Plavix per nasogastric tube.  Titrated doses of beta-blockers and ACE inhibitors are initiated.  Additional revascularization therapy will be adjusted according to the clinical evaluation.","surgery, ventricular arrhythmia, coronary artery syndrome, st segment elevation, heart catheterization, selective bilateral coronary angiography, ventriculography, catheterization, swan-ganz catheter, anterior descending artery, drug eluting stent, coronary artery, angioplasty, stent, coronary, anterior, angiography, artery, heart, "
 Left heart catheterization with left ventriculography and selective coronary angiography.  Percutaneous transluminal coronary angioplasty and stent placement of the right coronary artery., Surgery," Heart Catheterization, Ventriculography, & Angiography - 4 ","NAME OF PROCEDURE,1.  Left heart catheterization with left ventriculography and selective coronary angiography.,2.  Percutaneous transluminal coronary angioplasty and stent placement of the right coronary artery.,HISTORY: , This is a 58-year-old male who presented with atypical chest discomfort.  The patient had elevated troponins which were suggestive of a myocardial infarction.  The patient is suspected of having significant obstructive coronary artery disease, therefore he is undergoing cardiac catheterization.,PROCEDURE DETAILS: , Informed consent was given prior to the patient was brought to the catheterization laboratory.  The patient was brought to the catheterization laboratory in postabsorptive state.  The patient was prepped and draped in the usual sterile fashion, 2% Xylocaine solution was used to anesthetize the right femoral region.  Using modified Seldinger technique, a 6-French arterial sheath was placed.  Then, the patient had already been on heparin.  Then, a Judkins left 4 catheter was intubated into the left main coronary artery.  Several projections were obtained and the catheter was removed.  A 3DRC catheter was intubated into the right coronary artery.  Several projections were obtained and the catheter was removed.  Then, a 3DRC guiding catheter was intubated into the right coronary artery.  Then, a universal wire was advanced across the lesion into the distal right coronary artery.  Integrilin was given.  Then, a 3.0 x 12 Voyager balloon was inflated at 13 atmospheres for 30 seconds.  Then, a projection was obtained.  Then, a 3.0 x 15 Vision stent was placed into the distal right coronary artery.  The stent was deployed at 15 atmospheres for 25 seconds.  Post stent, the patient was given intracoronary nitroglycerin after one projection.  Then, there was an attempt to place the intervention wire across the third posterolateral branch which was partially obstructed and this was not successful.  Then, a pilot 150 wire was advanced across the lesion.  Then, attempt to place the 2.0 x 8 power saver across the lesion was performed.  However, it was felt that there was adequate flow and no further intervention needed to be performed.  Then, the stent delivery system was removed.  A pigtail catheter was placed into the left ventricle.  Hemodynamics followed by left ventriculography was performed.  Then, a pullback gradient was performed and the catheter was removed.  Then, the right femoral artery was visualized and using angiography and then an Angio-Seal was applied.  The patient was transferred back to his room in good condition.,FINDINGS,1.  Hemodynamics:  The opening aortic pressure was 116/61 with a mean of 64.  The opening left ventricular pressure was 112 with end-diastolic pressure of 23.  LV pressure on pullback was 106 with end-diastolic pressure of 21.  Aortic pressure was 111/67 with a mean of 87.  The closing pressure was 110/67.,2.  Left ventriculography:  The left ventricle was of normal cavity, size, and wall thickness.  There is a mild anterolateral hypokinesis and moderate inferior and inferoapical hypokinesis.  The overall systolic function appeared to be mildly reduced with ejection fraction between 40% and 45%.  The mitral valve had no significant prolapse or regurgitation.  The aortic valve appeared to be trileaflet and moved normally.,3.  Coronary angiography:  The left main is a normal-caliber vessel.  This bifurcates into the left anterior descending and circumflex arteries.  The left main is free of any significant obstructive coronary artery disease.  The left anterior descending is a large vessel that extends to the apex.  It gives off approximately 10 septal perforators and 5 diagonal branches.  The first diagonal branch was large.  The left anterior descending had mild irregularities, but no high-grade disease.  The left circumflex is a nondominant vessel, which gives rise to two obtuse marginal branches.  The two obtuse marginal branches are large.  There is a relatively small left atrial branch.  The left circumflex had a 50% stenosis after the first obtuse marginal branch.  The rest of the vessel is moderately irregular, but no high-grade disease.  The right coronary artery appears to be a dominant vessel, which gives rise to three right ventricular branches, four posterior lateral branches, two right atrial branches, and two small conus branches.  The right coronary artery had moderate disease in its proximal segment with multiple areas of plaquing but no high-grade disease.  However, distal between the second and third posterolateral branch, there is a 90% stenosis.  The rest of the vessels had mild irregularities, but no high-grade disease.  Then percutaneous transluminal coronary angioplasty of the right coronary artery resulted in a 20% residual stenosis.  Then, after stent placement there was 0% residual stenosis; however, there was partial occlusion of the third posterolateral branch.  Then, a wire was advanced through this and there was improvement of flow.  There is improvement from TIMI grade 2 to TIMI grade 3 flow.,CLINICAL IMPRESSION,1.  Successful percutaneous transluminal angioplasty and stent placement of the right coronary artery.,2.  Two-vessel coronary artery disease.,3.  Elevated left ventricular end-diastolic pressure.,4.  Mild anterolateral and moderate inferoapical hypokinesis.,RECOMMENDATIONS,1.  Integrilin.,2.  Bed rest.,3.  Risk factor modification.,4.  Thallium scintigraphy in approximately six weeks.","surgery, heart catheterization, ventriculography, selective coronary angiography., angioplasty, stent placement, transluminal, percutaneous, coronary artery, coronary angiography, coronary angioplasty, diastolic pressure, obtuse marginal, percutaneous transluminal, catheterization, artery, coronary, angiography"
" Left heart catheterization, bilateral selective coronary angiography, saphenous vein graft angiography, left internal mammary artery angiography, and left ventriculography.", Surgery," Heart Catheterization, Ventriculography, & Angiography ","PROCEDURES PERFORMED:,1.  Left heart catheterization.,2.  Bilateral selective coronary angiography.,3.  Saphenous vein graft angiography.,4.  Left internal mammary artery angiography.,5.  Left ventriculography.,INDICATIONS: , Persistent chest pain on maximum medical therapy with known history of coronary artery disease, status post coronary artery bypass grafting in year 2000.,PROCEDURE: , After the risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient in detail, an informed consent was obtained both verbally and in writing.  The patient was taken to the Cardiac Catheterization Suite where the right femoral region was prepped and draped in the usual sterile fashion.  1% lidocaine solution was then used to infiltrate the skin overlying the right femoral artery.  Once adequate anesthesia had been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right femoral artery.  A steel guidewire was then inserted through the needle into the vascular lumen without resistance.  A small nick was then made in the skin and its pressure was held.  The needle was removed over the guidewire.  A #6 French sheath was then advanced over the guidewire into the vascular lumen without resistance.  The guidewire and dilator were then removed.  The sheath was then flushed.  Next, angulated pigtail catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of the guidewire.  The catheter was then advanced into the left ventricle.  The guidewire was then removed.  The catheter was connected to the manifold and flushed.  LVEDP was then measured and found to be favorable for a left ventriculogram.  The left ventriculogram was performed in the RAO position with a single power injection of non-ionic contrast material.  LVEDP was then remeasured.  Pullback was then performed, which failed to reveal an LVAO gradient.  The catheter was then removed.  Next, a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  Using hand injections of non-ionic contrast material, the left coronary system was evaluated in several different views.  Once adequate study has been performed, the catheter was removed.  Next, a Judkins right #4 catheter was then advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  The ostium of the saphenous vein graft was engaged using hand injections of non-ionic contrast material.  The saphenous vein graft was visualized in several different views.  The Judkins right catheter was then advanced and the native coronary artery was engaged using hand injections of non-ionic contrast material.  Right coronary system was evaluated in several different views.  Once adequate study has been performed, the catheter was retracted.  We were unable to engage the left subclavian artery thus the catheter was removed over an exchange wire.  Next, a multipurpose catheter was advanced over the exchange wire.  The wire was then easily passed into the left subclavian artery.  The multipurpose catheter was then removed.  LIMA catheter was then exchanged over the wire into the left subclavian artery.  The guidewire was removed and the catheter was connected to the manifold and flushed.  LIMA graft was then engaged using hand injections of non-ionic contrast material.  The LIMA graft was evaluated in several different views.  Once adequate study has been performed, the LIMA catheter was retracted under fluoroscopic guidance.  The sheath was flushed for the final time.  The patient was returned to the cardiac catheterization holding area in stable and satisfactory condition.,FINDINGS:,LEFT VENTRICULOGRAM: , There is no evidence of any wall motion abnormalities with an estimated ejection fraction of 60%.  Left ventricular end-diastolic pressure was 24 mmHg preinjection and 26 mmHg postinjection.  There is no mitral regurgitation.  There is no LVAO or pullback.,LEFT MAIN CORONARY ARTERY: , The left main is a moderate caliber vessel, which bifurcates into the left anterior descending and circumflex arteries.  There is no evidence of any hemodynamically significant stenosis.,LEFT ANTERIOR DESCENDING ARTERY: , The LAD is a small caliber vessel, which traverses through the intraventricular groove and wraps around the apex of the heart.  There are luminal irregularities from the mid to distal portion.  There is noted to be antegrade flow in the LIMA to LAD graft.  There are very small diagonal branches, which are diffusely diseased.,CIRCUMFLEX ARTERY: , The circumflex is a small caliber vessel, which traverses through the atrioventricular groove.  There are minor luminal irregularities throughout.  There are very small obtuse marginal branches, which are diffusely diseased.,RIGHT CORONARY ARTERY:,  The RCA is a small vessel with luminal irregularities throughout.  The RCA is the dominant coronary artery.,Left internal mammary artery graft to the left anterior descending artery failed to demonstrate any hemodynamically significant stenosis.  Saphenous vein graft to the obtuse marginal branches is a Y-graft, which bifurcates to the first obtuse marginal and the obtuse marginal branch.  The saphenous vein graft to the obtuse marginal branches is widely patent without any evidence of hemodynamically significant disease.,IMPRESSION:,1.  Diffusely diseased native vessels.,2.  Saphenous vein graft to the obtuse marginal branch is widely patent.,3.  Left internal mammary artery graft to the left anterior descending artery is patent.,4.  Normal left ventricular function with ejection fraction of 60%.,5.  Mildly elevated left-sided filling pressures.,PLAN:,1.  The patient is to continue on her current medical regimen, which includes beta-blocker, aspirin, statin, and Plavix.  The patient is unable to tolerate a long-acting nitrate, thus this will be discontinued.,2.  We will add Norvasc 5 mg daily as well as hydrochlorothiazide 25 mg daily.,3.  Risk factor modification was discussed with the patient including diet control as well as tobacco cessation.,4.  The patient will need to be monitored closely for close lipid control as well as blood pressure control.",
" Selective coronary angiography, left heart catheterization, and left ventriculography.  Severe stenosis at the origin of the large diagonal artery and subtotal stenosis in the mid segment of this diagonal branch.", Surgery," Heart Catheterization, Ventriculography, & Angiography - 11 ","NAME OF PROCEDURES,1.  Selective coronary angiography.,2.  Left heart catheterization.,3.  Left ventriculography.,PROCEDURE IN DETAIL:  ,The right groin was sterilely prepped and draped in the usual fashion.  The area of the right coronary artery was anesthetized with 2% lidocaine and a 4-French sheath was placed.  Conscious sedation was obtained using a combination of Versed 1 mg and fentanyl 50 mcg.  A left #4, 4-French, Judkins catheter was placed and advanced through the ostium of the left main coronary artery.  Because of difficulty positioning the catheter, the catheter was removed and a 6-French sheath was placed and a 6-French #4 left Judkins catheter was placed.  This was advanced through the ostium of the left main coronary artery where selective angiograms were performed.  Following this, the 4-French right Judkins catheter was placed and angiograms of the right coronary were performed.  A pigtail catheter was placed and a left heart catheterization was performed, followed by a left ventriculogram.  The left heart pullback was performed.  The catheter was removed and a small injection of contrast was given to the sheath.  The sheath was removed over a wire and an Angio-Seal was placed.  There were no complications.  Total contrast media was 200 mL of Optiray 350.  Fluoroscopy time 5.3 minutes.  Total x-ray dose is 1783 mGy.,HEMODYNAMICS:  ,Rhythm is sinus throughout the procedure.  LV pressure of 155/22 mmHg, aortic pressure of 160/80 mmHg.  LV pullback demonstrates no gradient.,The right coronary artery is a nondominant vessel and free of disease.  This also gives rise to the conus branch and two RV free wall branches.  The left main has minor plaquing in the inferior aspect measuring no more than 10% to 15%.  This vessel then bifurcates into the LAD and circumflex.  The circumflex is a large caliber vessel and is dominant.  This vessel gives rise to a large first marginal artery, a moderate sized second marginal branch, and additionally gives rise to a large third marginal artery and the PDA.  There was a very eccentric and severe stenosis in the proximal circumflex measuring approximately 90% in severity.  The origin of the first marginal artery has a severe stenosis measuring approximately 90% in severity.  The distal circumflex has a 60% lesion just prior to the origin of the third marginal branch and PDA.,The proximal LAD is ectatic.  The LAD gives rise to a large first diagonal artery that has a 90% lesion in its origin and a subtotal occlusion midway down the diagonal.  Distal to the origin of this diagonal branch, there is another area of ectasia in the LAD, followed by an area of stenosis that in some views is approximately 50% in severity.,The left ventriculogram demonstrates hypokinesis of the distal half of the inferior wall.  The overall ejection fraction is preserved.  There is moderate dilatation of the aortic root.  The calculated ejection fraction is 63%.,IMPRESSION,1.  Left ventricular dysfunction as evidenced by increased left ventricular end diastolic pressure and hypokinesis of the distal inferior wall.,2.  Coronary artery disease with high-grade and complex lesion in the proximal portion of the dominant large circumflex coronary artery.  There is subtotal stenosis at the origin of the first obtuse marginal artery.,3.  A 60% stenosis in the distal circumflex.,4.  Ectasia of the proximal left anterior descending with 50% stenosis in the mid left anterior descending.,5.  Severe stenosis at the origin of the large diagonal artery and subtotal stenosis in the mid segment of this diagonal branch.","surgery, coronary angiography, catheterization, ventriculography, heart catheterization, coronary artery, stenosis, artery, angiography"
" Left heart catheterization, left ventriculography, coronary angiography, and successful stenting of tight lesion in the distal circumflex and moderately tight lesion in the mid right coronary artery.", Surgery," Heart Catheterization, Ventriculography, & Angiography - 1 ","PROCEDURE:,  Left heart catheterization, left ventriculography, coronary angiography, and successful stenting of tight lesion in the distal circumflex and moderately tight lesion in the mid right coronary artery.  This gentleman has had a non-Q-wave, troponin-positive myocardial infarction, complicated by ventricular fibrillation.,PROCEDURE DETAILS:,  The patient was brought to the catheterization lab, the chart was reviewed, and informed consent was obtained.  Right groin was prepped and draped sterilely and infiltrated 2% Xylocaine.  Using the Seldinger technique, a #6-French sheath was placed in the right femoral artery.  ACT was checked and was low.  Additional heparin was given.  A #6-French pigtail catheter was passed.  Left ventriculography was performed.  The catheter was exchanged for a #6-French JL4 catheter.  Nitroglycerin was given in the left main.  Left coronary angiography was performed.  The catheter was exchanged for a #6-French __________ coronary catheter.  Nitroglycerin was given in the right main, and right coronary angiography was performed.  Films were closely reviewed, and it was felt that he had a significant lesion in the RCA and the distal left circumflex is basically an OM.  Considering his age and his course, it was elected to stent both these lesions.  ReoPro was started, and the catheter was exchanged for a #6-French JR4 guide.  ReoPro was given in the RCA to prevent no reflow.  A 0.014 Universal wire was passed.  The lesion was measured.  A 4.5 x 18-mm stent was passed and deployed to moderate pressures with an excellent result.  The catheter was removed and exchanged for a #6-French JL4 guide.  The same wire was passed down the circumflex and the lesion measured.  A 2.75 x 15-mm stent was deployed to a moderate pressure with an excellent result.  Plavix was given.  The catheter was removed and sheath was in place.  The results were explained to the patient and his wife.,FINDINGS,1.  Hemodynamics.  Please  see attached sheet for details.  ED was 20.  There is no gradient across the aortic valve.,2.  Left ventriculography revealed septum upper limits of normal size with borderline normal LV systolic function with borderline normal wall motion, in which there is a question of  diffuse, very minimal global hypokinesis.  There is mild MR noted.,3.  Coronary angiography.,a.  Left main normal.,b.  LAD.  Some very minimal luminal irregularities.  There is a 1st diagonal which has a branch that is 1.5 mm with a proximal 50% narrowing.,c.  Left circumflex is basically a marginal branch, in which distally there was a long 98% lesion.,d.  The RCA is large dominant and has a mid somewhat long 70% lesion.,4.  Stenting.,a.  The RCA revealed a lesion that went from 70% to a -5%.,B.  The circumflex went from 95% to -5%.,CONCLUSION,1.  Decreased left ventricular compliance.,2.  Borderline normal overall ejection fraction with mild mitral regurgitation.,3.  Triple-vessel coronary artery disease with a borderline lesion in a very small branch of the 1st diagonal and significant lesions in the mid dominant right coronary artery and the distal circumflex, which is basically old.,4.  Successful stenting of the right coronary artery and the circumflex.,RECOMMENDATION: , ReoPro/stent protocol, Plavix for at least 9 months, aggressive control of risk factors.  I have ordered Zocor and a fasting lipid panel.,AICD will be considered, realizing when this gentleman becomes ischemic he is at high risk for fibrillating.","surgery, heart catheterization, ventriculography, coronary angiography, stenting, distal circumflex, coronary artery, coronary, lesion, catheterization, cardiac, angiography, heart, rca, artery, circumflex, "
" Left heart catheterization, left ventriculography, selective coronary angiography, and right femoral artery approach.", Surgery," Heart Catheterization, Ventriculography, & Angiography - 12 ","PROCEDURE: , Cardiac catheterization by:,a.  Left heart catheterization.,b.  Left ventriculography.,c.  Selective coronary angiography.,d.  Right femoral artery approach.,COMPLICATIONS:,  None.,MEDICATIONS,1.  IV Versed.,2.  IV fentanyl.,3.  Intravenous fluid administration.,4.  Heparin 3000 units IV.,INDICATIONS: , This 70-year-old Asian-American presents with chest pain syndrome, abnormal EKG suggesting an acute ST elevation, anterior myocardial infarction, being taken urgently to cardiac catheterization laboratory with possible coronary intervention.,NARRATIVE: , After detailed informed consent had been obtained.  Usual benefits, alternatives, and risks of the procedure had been discussed with the patient, she was agreeable to proceed.  The patient was prepped, draped, and anesthetized in the usual manner.  Using modified Seldinger technique a 6 French introducer sheath inserted into the right femoral artery.  Next, 6 French 3D right coronary catheter was inserted and right coronary angiogram was obtained in various projections.  Next, a 6 French JL4.0 left coronary catheter was inserted and left coronary angiogram was obtained in various projections.  Next, 4 French pigtail catheter was inserted into left ventricle under fluoroscopic guidance.  Left ventricular angiogram was performed.  Pre and post angiogram LVEDP, LV, and aortic pressures were obtained.  At the end of the procedure catheters were removed and the introducer sheath was secured.  The patient was admitted to the TCU in stable condition.,FINDINGS,HEMODYNAMICS,LEFT HEART PRESSURES:,  LVEDP of 5, left ventricular systolic pressure of 81, central aortic pressure systolic 70, diastolic 20.,LEFT VENTRICULOGRAPHY: , Left ventricular chamber size is normal.  The distal half of the anterior wall of the entire apex and the distal half of the inferior wall are completely akinetic with hypercontractility of the basilar segments of the anterior and inferior wall.  Calculated ejection fraction of 51%, which probably overestimates the overall effective ejection fraction.  No LV thrombus or mitral regurgitation present.,CORONARY ARTERIOGRAPHY,1.  ,RIGHT CORONARY ARTERY: , The RCA gives rise to a posterior descending artery and a small posterolateral branch.  Angiographically the right coronary artery is normal.,2.  ,LEFT MAIN ARTERY:,  The left main vessel is angiographically normal, bifurcates into left anterior descending artery and circumflex system.,3.  ,LEFT ANTERIOR DESCENDING ARTERY: , The LAD gives rise to a normal complement of septal branches, diagonal branches, and extends around the apex.  Angiographically the mid left anterior descending artery and distal left anterior descending artery demonstrates systolic compression of the vessel lumen, consistent with myocardial bridging.  The degree of myocardial bridging appears moderate in the mid vessel and mild in the distal segment.  Otherwise, there is no evidence of atherosclerotic obstruction.,4.  ,CIRCUMFLEX ARTERY: , The circumflex gives rise to two large extremely tortuous marginal vessels that extend towards the apex.  Angiographically, the circumflex artery is normal.,CONCLUSION: , This is a 70-year-old female with above clinical and cardiovascular history, who has angiographic evidence of a large anterior apical and inferior apical wall motion abnormality with angiographically patent coronary arteries with two segments of myocardial bridging involving the mid and distal left anterior descending artery.  These angiographic findings are consistent with Takasubo syndrome, aka apical ballooning syndrome.  The patient will be treated medically.",
" Left heart catheterization, left and right coronary angiography, left ventricular angiography, and intercoronary stenting of the right coronary artery.", Surgery," Heart Catheterization, Ventriculography, & Angiography - 10 ","PROCEDURE: , Left heart catheterization, left and right coronary angiography, left ventricular angiography, and intercoronary stenting of the right coronary artery.,PROCEDURE IN DETAIL:  ,The patient was brought to the Catheterization Laboratory.  After informed consent, he was medicated with Versed and fentanyl.  The right groin was prepped and draped, and infiltrated with 2% Xylocaine.  Percutaneously, #6-French arterial sheath was placed.  Selective native left and right coronary angiography was performed followed by left ventricular angiography.  The patient had a totally occluded right coronary.  We initially started with a JR4 guide.  We were able to a sport wire through the total occlusion and saw a very tight stenosis.  We were able to get a 30 x 13 mm power saver balloon into the stenosis and dilated.  We then attempted to put a 30 x 12 mm stent across the stenosis, but we had very little guide support, the guide kept coming out.  We then switched to an AL1 guide and that too did not enable us to get anything to cross this lesion.  We finally had to go an AL2 guide, we were concerned that this could cause some proximal dissection.  That guided seated, we did have initial difficulty getting the wire back across the stenosis, and we did see a little staining suggesting we did have some tearing from the guide tip.  The surgeons were put on notice in case we could not get this vessel open, but we were able to re-cross with a sport wire.  We then re-dilated the area of stenosis and with good guide support, we were able to get a 30 x 23 mm Vision stent, where the lesion was and post-dilated it to 18 atmospheres.  Routine angiography did show that the distal posterolateral branch seems to be occluded, whether this was from distal wire dissection or distal thrombosis was unclear, but we were able to re-wire that area and get a 25 x12 Vision balloon and dilate the area and re-establish flow to the small segment.  We then came back because of the residual dissection proximal to the first stent and put a 30 x15 mm Vision stent at 18 atmospheres.  Final angiography showed resolution of the dissection.  We could see a little staining extrinsic to the stent.  No perforation and excellent flow.  During the intervention, we did give a bolus and drip of Angiomax.  At the end of the procedure, we stopped the Angiomax and gave 600 mg of Plavix.  We did a right femoral angiogram; however, the Angio-Seal plug could not take, so we used manual pressure and a Femostop.  We transported the patient to his room in stable condition.,ANGIOGRAPHIC DATA:,  Left main coronary is normal.  Left anterior descending artery has a fair amount of wall disease proximally about 50 to 60% stenosis of the LAD before it bifurcates into diagonal.  The diagonal does appear to have about 50% osteal stenosis.  There is a lot of plaquing further down the diagonal, but good flow.  The rest of the LAD looked good pass the proximal 60% stenosis and after the diagonal branch.  Circumflex artery was nondominant vessel, consisting of an obtuse marginal vessel.  The first obtuse marginal had a long 50% narrowing and then the AV groove branch was free of any disease.  Some mild collaterals to the right were seen.  Right coronary angiography revealed a total occlusion of the right coronary, just about 0.5 cm after its origin.  After we got a wire across the area of occlusion, we could see some thrombosis and a 99% stenosis just at the curve.  Following the balloon angioplasty, we established good flow down the distal vessel.  We still had about residual 70% stenosis.  When we had to go back with the AL2 guide, we could see a little bit of staining in the proximal portion of the vessel that we did not notice previously and we felt that the tip of the guide caused a little bit of intimal dissection.  We re-dilated and then deployed.  Repeat angiography now did show some hang up off dye distally.  We never did have the wire that far down, so this was probably felt to be due to distal embolization of some thrombus.  After deploying the stent, we had total resolution of the original lesion.  We then directed our attention to the posterolateral branch, which the remainder of the vessel was patent giving off a large PDA.  The posterolateral branch appeared to be occluded in its mid portion.  We got a wire through and dilated this.  We then came back and put a second stent in the proximal area of the right coronary proximal and abutting to the previous stent.  Repeat angiography now showed no significant dissection, a little bit of contrast getting extrinsic to the stent probably in a little subintimal pouch, but this was excluded by the stent.  There were no filling defects in the stent and excellent flow.  The distal posterolateral branch did open up, although it was little under-filled and there may have been some mild residual disease there.,IMPRESSION: , Atherosclerotic heart disease with total occlusion of right coronary, successfully stented to zero residual with repair of a small proximal dissection.  Minor distal disease of the posterolateral branch and 60% proximal left anterior descending coronary artery stenosis and 50% diagonal stenosis along with 50% stenosis of the first obtuse marginal branch.","surgery, heart catheterization, coronary angiography, ventricular angiography, intercoronary stenting, intercoronary, coronary, stenting, stenosis, angiography"
" Left heart catheterization with ventriculography, selective coronary angiography.  Standard Judkins, right groin.  Catheters used were a 6 French pigtail, 6 French JL4, 6 French JR4.", Surgery," Heart Catheterization, Ventriculography, & Angiography - 3 ","NAME OF PROCEDURE: , Left heart catheterization with ventriculography, selective coronary angiography.,INDICATIONS: , Acute coronary syndrome.,TECHNIQUE OF PROCEDURE: , Standard Judkins, right groin.  Catheters used were a 6 French pigtail, 6 French JL4, 6 French JR4.  ,ANTICOAGULATION:  ,The patient was on heparin at the time.,COMPLICATIONS: , None.,I reviewed with the patient the pros, cons, alternatives, risks of catheterization and sedation including myocardial infarction, stroke, death, damage to nerve, artery or vein in the leg, perforation of a cardiac chamber, dissection of an artery requiring countershock, infection, bleeding, ATN allergy, need for cardiac surgery.  All questions were answered, and the patient desired to proceed.,HEMODYNAMIC DATA:  ,Aortic pressure was in the physiologic range.  No significant gradient across the aortic valve.,ANGIOGRAPHIC DATA,1. Ventriculogram:  The left ventricle is of normal size and shape, normal wall motion, normal ejection fraction.,2. Right coronary artery:  Dominant.  There was insignificant disease in the system.,3. Left coronary:  Left main, left anterior descending and circumflex systems showed no significant disease.,CONCLUSIONS,1. Normal left ventricular systolic function.,2. Insignificant coronary disease.,PLAN: , Based upon this study, medical therapy is warranted.  Six-French Angio-Seal was used in the groin.","surgery, standard judkins, french pigtail, selective coronary angiography, heart catheterization, ventriculography, catheterization, angiography,"
" Left heart cath, selective coronary angiography, LV gram, right femoral arteriogram, and Mynx closure device.  Normal stress test.", Surgery, Heart Catheterization & Angiography - 1 ,"CLINICAL INDICATION:  ,Normal stress test.,PROCEDURES PERFORMED:,1.  Left heart cath.,2.  Selective coronary angiography.,3.  LV gram.,4.  Right femoral arteriogram.,5.  Mynx closure device.,PROCEDURE IN DETAIL: , The patient was explained about all the risks, benefits, and alternatives of this procedure.  The patient agreed to proceed and informed consent was signed.,Both groins were prepped and draped in the usual sterile fashion.  After local anesthesia with 2% lidocaine, a 6-French sheath was inserted in the right femoral artery.  Left and right coronary angiography was performed using 6-French JL4 and 6-French 3DRC catheters.  Then, LV gram was performed using 6-French pigtail catheter.  Post LV gram, LV-to-aortic gradient was obtained.  Then, the right femoral arteriogram was performed.  Then, the Mynx closure device was used for hemostasis.  There were no complications.,HEMODYNAMICS: , LVEDP was 9.  There was no LV-to-aortic gradient.,CORONARY ANGIOGRAPHY:,1.  Left main is normal.  It bifurcates into LAD and left circumflex.,2.  Proximal LAD at the origin of big diagonal, there is 50% to 60% calcified lesion present.  Rest of the LAD free of disease.,3.  Left circumflex is a large vessel and with minor plaque.,4.  Right coronary is dominant and also has proximal 40% stenosis.,SUMMARY:,1.  Nonobstructive coronary artery disease, LAD proximal at the origin of big diagonal has 50% to 60% stenosis, which is calcified.,2.  RCA has 40% proximal stenosis.,3.  Normal LV systolic function with LV ejection fraction of 60%.,PLAN: , We will treat with medical therapy.  If the patient becomes symptomatic, we will repeat stress test.  If there is ischemic event, the patient will need surgery for the LAD lesion.  For the time being, we will continue with the medical therapy.,","surgery, selective coronary angiography, lv gram, femoral, mynx, heart cath, mynx closure device, heart catheterization, femoral arteriogram, stress test, coronary angiography, heart, arteriogram, catheterization, lad, coronary, angiography, "
" Right and left heart catheterization, left ventriculogram, aortogram, and bilateral selective coronary angiography.  The patient is a 48-year-old female with severe mitral stenosis diagnosed by echocardiography, moderate aortic insufficiency and moderate to severe pulmonary hypertension who is being evaluated as a part of a preoperative workup for mitral and possible aortic valve repair or replacement. ", Surgery, Heart Catheterization & Ventriculogram ,"PROCEDURE PERFORMED:,1.  Right heart catheterization.,2.  Left heart catheterization.,3.  Left ventriculogram.,4.  Aortogram.,5.  Bilateral selective coronary angiography.,ANESTHESIA:,  1% lidocaine and IV sedation including Versed 1 mg.,INDICATION:,  The patient is a 48-year-old female with severe mitral stenosis diagnosed by echocardiography, moderate aortic insufficiency and moderate to severe pulmonary hypertension who is being evaluated as a part of a preoperative workup for mitral and possible aortic valve repair or replacement.  She has had atrial fibrillation and previous episodes of congestive heart failure.  She has dyspnea on exertion and occasionally orthopnea and paroxysmal nocturnal dyspnea.,PROCEDURE:,  After the risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient in detail, informed consent was obtained, both verbally and in writing.  The patient was taken to the Cardiac Catheterization Lab where the procedure was performed.  The right inguinal area was thoroughly cleansed with Betadine solution and the patient was draped in the usual manner.  1% lidocaine solution was used to anesthetize the right inguinal area.  Once adequate anesthesia had been attained, a thing wall Argon needle was used to cannulate the right femoral vein.  A guidewire was advanced into the lumen of the vein without resistance.  The needle was removed and the guidewire was secured to the sterile field.  The needle was flushed and then used to cannulate the right femoral artery.  A guidewire was advanced through the lumen of the needle without resistance.  A small nick was made in the skin and the needle was removed.  This pressure was held.  A #6 French arterial sheath was advanced over the guidewire without resistance.  The dilator and guidewire were removed.  FiO2 sample was obtained and the sheath was flushed.  An #8 French sheath was advanced over the guidewire into the femoral vein after which the dilator and guidewire were removed and the sheath was flushed.  A Swan-Ganz catheter was advanced through the venous sheath into a pulmonary capillary was positioned and the balloon was temporarily deflated.  An angulated pigtail catheter was advanced into the left ventricle under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to a manifold and flushed.  Left ventricular pressures were continuously measured and the balloon was re-inflated and pulmonary capillary wedge pressure was remeasured.  Using dual transducers together and the mitral valve radius was estimated.  The balloon was deflated and mixed venous sample was obtained.  Hemodynamics were measured.  The catheter was pulled back in to the pulmonary artery right ventricle and right atrium.  The right atrial sample was obtained and was negative for shunt.  The Swan-Ganz catheter was then removed and a left ventriculogram was performed in the RAO projection with a single power injection of non-ionic contrast material.  Pullback was then performed which revealed a minimal LV-AO gradient.  Since the patient had aortic insufficiency on her echocardiogram, an aortogram was performed in the LAO projection with a single power injection of non-ionic contrast material.  The pigtail catheter was then removed and a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  The ostium of the left main coronary artery was carefully engaged.  Using multiple hand injections of non-ionic contrast material, the left coronary system was evaluated in different views.  This catheter was then removed and a Judkins right #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  The ostium of the right coronary artery was then engaged and using hand injections of non-ionic contrast material, the right coronary system was evaluated in different views.  This catheter was removed.  The sheaths were flushed final time.  The patient was taken to the Postcatheterization Holding Area in stable condition.,FINDINGS:,HEMODYNAMICS: , Right atrial pressure 9 mmHg, right ventricular pressure is 53/14 mmHg, pulmonary artery pressure 62/33 mmHg with a mean of 46 mmHg.  Pulmonary capillary wedge pressure is 29 mmHg.  Left ventricular end diastolic pressure was 13 mmHg both pre and post left ventriculogram.  Cardiac index was 2.4 liters per minute/m2.  Cardiac output 4.0 liters per minute.  The mitral valve gradient was 24.5 and mitral valve area was calculated to be 0.67 cm2.  The aortic valve area is calculated to be 2.08 cm2.,LEFT VENTRICULOGRAM: , No segmental wall motion abnormalities were noted.  The left ventricle was somewhat hyperdynamic with an ejection fraction of 70%.  2+ to 3+ mitral regurgitation was noted.,AORTOGRAM: , There was 2+ to 3+ aortic insufficiency noted.  There was no evidence of aortic aneurysm or dissection.,LEFT MAIN CORONARY ARTERY: , This was a moderate caliber vessel and it is rather long.  It bifurcates into the LAD and left circumflex coronary artery.  No angiographically significant stenosis is noted.,LEFT ANTERIOR DESCENDING ARTERY:,  The LAD begins as a moderate caliber vessel ________ anteriorly in the intraventricular groove.  It tapers in its mid portion to become small caliber vessel.  Luminal irregularities are present, however, no angiographically significant stenosis is noted.,LEFT CIRCUMFLEX CORONARY ARTERY: , The left circumflex coronary artery begins as a moderate caliber vessel.  Small obtuse marginal branches are noted and this is the nondominant system.  Lumen irregularities are present throughout the circumflex system.  However no angiographically significant stenosis is noted.,RIGHT CORONARY ARTERY: , This is the moderate caliber vessel and it is the dominant system.  No angiographically significant stenosis is noted, however, mild luminal irregularities are noted throughout the vessel.,IMPRESSION:,1.  Nonobstructive coronary artery disease.,2.  Severe mitral stenosis.,3.  2+ to 3+ mitral regurgitation.,4.  2+ to 3+ aortic insufficiency.",
 Left heart catheterization and bilateral selective coronary angiography. Left ventriculogram was not performed., Surgery, Heart Catheterization & Angiography - 2 ,"PROCEDURES PERFORMED:,1.  Left heart catheterization.,2.  Bilateral selective coronary angiography.,3.  Left ventriculogram was not performed.,INDICATION: , Non-ST elevation MI.,PROCEDURE: , After risks, benefits, and alternatives of the above-mentioned procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing.  The patient was taken to cardiac catheterization suite where the right femoral region was prepped and draped in the usual sterile fashion.  1% lidocaine solution was used to infiltrate the skin overlying the right femoral artery.  Once adequate anesthesia had been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right femoral artery.  A steel guidewire was inserted through the needle into the vascular lumen without resistance.  A small nick was then made in the skin.  The pressure was held.  The needle was removed over the guidewire.  Next, a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  The ostium of the left main coronary artery was engaged.  Using hand injections of nonionic contrast material, the left coronary system was evaluated in several different views.  Once an adequate study had been performed, the catheter was removed from the ostium of the left main coronary artery and a steel guidewire was inserted through the catheter.  The catheter was then removed over the guidewire.,Next, a Judkins right #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to manifold and flushed.  The catheter did slip into the left ventricle.  During the rotation, the LVEDP was then measured.  The ostium of the right coronary artery was then engaged.  Using hand injections of nonionic contrast material, the right coronary system was evaluated in several different views.  Once adequate study has been performed, the catheter was then removed.  The sheath was lastly flushed for the final time.,FINDINGS:,LEFT MAIN CORONARY ARTERY: , The left main coronary artery is a moderate caliber vessel, which bifurcates into the left anterior descending and circumflex arteries.  There is no evidence of any hemodynamically significant stenosis.,LEFT ANTERIOR DESCENDING ARTERY: , The LAD is a moderate caliber vessel, which is subtotaled in its mid portion for approximately 1.5 cm to 1 cm with subsequent TIMI-I flow distally.  The distal portion was diffusely diseased.  The proximal portion otherwise shows minor luminal irregularities.  The first diagonal branch demonstrated minor luminal irregularities throughout.,CIRCUMFLEX ARTERY:  ,The circumflex is a moderate caliber vessel, which traverses through the atrioventricular groove.  There is a 60% proximal lesion and a 90% mid lesion prior to the takeoff of the first obtuse marginal branch.  The first obtuse marginal branch demonstrates minor luminal irregularities throughout.,RIGHT CORONARY ARTERY: , The RCA is a moderate caliber vessel, which demonstrates a 90% mid stenotic lesion.  The dominant coronary artery gives off the posterior descending artery and posterolateral artery.  The left ventricular end-diastolic pressure was approximately 22 mmHg.  It should be noted that during injection of the contrast agent that there was ST elevation in the inferior leads, which resolved after the injection was complete.,IMPRESSION:,1.  Three-vessel coronary artery disease involving a subtotaled left anterior descending artery with TIMI-I flow distally and 90% circumflex lesion and 90% right coronary artery lesion.,2.  Mildly elevated left-sided filling pressures.,PLAN:,1.  The patient will be transferred to Providence Hospital today for likely PCI of the mid LAD lesion with a surgical evaluation for a coronary artery bypass grafting.  These findings and plan were discussed in detail with the patient and the patient's family.  The patient is agreeable.,2.  The patient will be continued on aggressive medical therapy including beta-blocker, aspirin, ACE inhibitor, and statin therapy.  The patient will not be placed on Plavix secondary to the possibility for coronary bypass grafting.  In light of the patient's history of cranial aneurysmal bleed, the patient will be held off of Lovenox and Integrilin.","surgery, non-st elevation, coronary angiography, ventriculogram, heart catheterization, bypass grafting, catheterization, coronary, artery, angiography, luminal, branch, descending, circumflex, vessel, guidewire, "
" Left heart catheterization with ventriculography, selective coronary arteriographies, successful stenting of the left anterior descending diagonal.", Surgery," Heart Catheterization, Ventriculography, & Angiography - 2 ","NAME OF PROCEDURE: , Left heart catheterization with ventriculography, selective coronary arteriographies, successful stenting of the left anterior descending diagonal.,INDICATION:,  Recurrent angina.  History of coronary disease.,TECHNICAL PROCEDURE: , Standard Judkins, right groin.,CATHETERS USED:,  6-French pigtail, 6-French JL4, 6-French JR4.,ANTICOAGULATION: , 2000 of heparin, 300 of Plavix, was begun on Integrilin.,COMPLICATIONS: , None.,STENT: , For stenting we used a 6-French left Judkins guide.  Stent was a 275 x 13 Zeta.,DESCRIPTION OF PROCEDURE: , I reviewed with the patient the pros, cons, alternatives and risks of catheterization and sedation including myocardial infarction, stroke, death, damage to nerve, artery or vein in the leg, perforation of cardiac chamber, resection of an artery, arrhythmia requiring countershock, infection, bleeding, allergy, and need for vascular surgery.  All questions were answered and the patient decided to proceed.,HEMODYNAMIC DATA: , Aortic pressure was within physiologic range.  There was no significant gradient across the aortic valve.,ANGIOGRAPHIC DATA,1.  Ventriculogram:  Left ventricle was of normal size and shape with normal wall motion, normal ejection fraction.,2.  Right coronary artery:  Dominant.  There was a lesion in the proximal portion in the 60% range, insignificant disease distally.,3.  Left coronary artery:  The left main coronary artery showed insignificant disease.  The circumflex arose, showed about 30% proximally.  Left anterior descending arose and the previously placed stent was perfectly patent.  There was a large diagonal branch which showed 90% stenosis in its proximal portion.  There was a lesion in the 30% to 40% range even more proximal.,I reviewed with the patient the options of medical therapy, intervention on the culprit versus bypass surgery.  He desired that we intervene.,Successful stenting of the left anterior descending, diagonal.  The guide was placed in the left main.  We easily crossed the lesion in the diagonal branch of the left anterior descending.  We advanced, applied and post-dilated the 275 x 13 stent.  Final angiography showed 0% residual at the site of previous 90% stenosis.  The more proximal 30% to 40% lesion was unchanged.,CONCLUSION,1.  Successful stenting of the left anterior descending/diagonal.  Initially there was 90% in the diagonal after stenting.  There was 0% residual.  There was a lesion a bit more proximal in the 40% range.,2.  Left anterior descending stent remains patent.,3.  30% in the circumflex.,4.  60% in the right coronary.,5.  Ejection fraction and wall motion are normal.,PLAN: , We have stented the culprit lesion.  The patient will receive a course of aspirin, Plavix, Integrilin, and statin therapy.  We used 6-French Angio-Seal in the groin.  All questions have been answered.  I have discussed the possibility of restenosis, need for further procedures.",
" Left and right heart catheterization and selective coronary angiography.  Coronary artery disease, severe aortic stenosis by echo.", Surgery, Heart Catheterization & Angiography ,"INDICATION:,  Coronary artery disease, severe aortic stenosis by echo.,PROCEDURE PERFORMED:,1.  Left heart catheterization.,2.  Right heart catheterization.,3.  Selective coronary angiography.,PROCEDURE: , The patient was explained about all the risks, benefits and alternatives to the procedure.  The patient agreed to proceed and informed consent was signed.,Both groins were prepped and draped in usual sterile fashion.  After local anesthesia with 2% lidocaine, 6-French sheath was inserted in the right femoral artery and 7-French sheath was inserted in the right femoral vein.  Then right heart cath was performed using 7-French Swan-Ganz catheter.  Catheter was placed in the pulmonary capillary wedge position.  Pulmonary capillary wedge pressure, PA pressure was obtained, cardiac output was obtained, then RV, RA pressures were obtained.  The right heart catheter _______ pulled out.  Then selective coronary angiography was performed using 6-French JL4 and 6-French 3DRC catheter.  Then attempt was made to cross the aortic valve with 6-French pigtail catheter, but it was unsuccessful.  After the procedure, catheters were pulled out, sheath was pulled out and hemostasis was obtained by manual pressure.  The patient tolerated the procedure well.  There were no complications.,HEMODYNAMICS:,1.  Cardiac output was 4.9 per liter per minute.  Pulmonary capillary wedge pressure, mean was 7, PA pressure was 20/14, RV 26/5, RA mean pressure was 5.,2.  Coronary angiography, left main is calcified _______ dense complex.,3.  LAD proximal 70% calcified stenosis present and patent stent to the mid LAD and diagonal 1 is a moderate-size vessel, has 70% stenosis.  Left circumflex has diffuse luminal irregularities.  OM1 has 70% stenosis, is a moderate-size vessel.  Right coronary is dominant and has minimal luminal irregularities.,SUMMARY: , Three-vessel coronary artery disease with aortic stenosis by echo with normal pulmonary artery systolic pressure.,RECOMMENDATION: , Aortic valve replacement with coronary artery bypass surgery.","surgery, lad proximal, femoral artery, sheath, catheter, selective coronary angiography, coronary artery disease, pulmonary capillary wedge, capillary wedge, coronary angiography, coronary artery, heart catheterization, catheterization, heart, artery, stenosis, angiography, pressure, coronary"
 Right heart catheterization.   Refractory CHF to maximum medical therapy., Surgery, Heart Catheterization - 2 ,"PROCEDURE PERFORMED:,  Right heart catheterization.,INDICATION: , Refractory CHF to maximum medical therapy.,PROCEDURE: , After risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient and the patient's family in detail, informed consent was obtained both verbally and in writing.  The patient was taken to Cardiac Catheterization Suite where the right internal jugular region was prepped and draped in the usual sterile fashion.  1% lidocaine solution was used to infiltrate the skin overlying the right internal jugular vein.  Once adequate anesthesia has been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right internal jugular vein.  A steel guidewire was then inserted through the needle into the vessel without resistance.  Small nick was then made in the skin and the needle was removed.  An #8.5 French venous sheath was then advanced over the guidewire into the vascular lumen without resistance.  The guidewire and dilator were then removed.  The sheath was then flushed.  A Swan-Ganz catheter was inserted to 20 cm and the balloon was inflated.  Under fluoroscopic guidance, the catheter was advanced into the right atrium through the right ventricle and into the pulmonary artery wedge position.  Hemodynamics were measured along the way.  Pulmonary artery saturation was obtained.  The Swan was then kept in place for the patient to be transferred to the ICU for further medical titration.  The patient tolerated the procedure well.  The patient returned to the cardiac catheterization holding area in stable and satisfactory condition.,FINDINGS:,  Body surface area equals 2.04, hemoglobin equals 9.3, O2 is at 2 liters nasal cannula.  Pulmonary artery saturation equals 37.8.  Pulse oximetry on 2 liters nasal cannula equals 93%.  Right atrial pressure is 8, right ventricular pressure equals 59/9, pulmonary artery pressure equals 61/31 with mean of 43, pulmonary artery wedge pressure equals 21, cardiac output equals 3.3 by the Fick method, cardiac index is 1.6 by the Fick method, systemic vascular resistance equals 1821, and transpulmonic gradient equals 22.,IMPRESSION:  ,Exam and Swan findings consistent with low perfusion given that the mixed venous O2 is only 38% on current medical therapy as well as elevated right-sided filling pressures and a high systemic vascular resistance.,PLAN: , Given that the patient is unable to tolerate vasodilator therapy secondary to significant orthostasis and the fact that the patient will not respond to oral titration at this point due to lack of cardiac reserve, the patient will need to be discharged home on Primacor.  The patient is unable to continue with his dobutamine therapy secondary to nonsustained ventricular tachycardia.  At this time, we will transfer the patient to the Intensive Care Unit for titration of the Primacor therapy.  We will also increase his Lasix to 80 mg IV q.d.  We will increase his amiodarone to 400 mg daily.  We will also continue with his Coumadin therapy.  As stated previously, we will discontinue vasodilator therapy starting with the Isordil.","surgery, chf, cardiac, catheterization, swan-ganz, heart catheterization, internal jugular, pulmonary artery, heart, jugular, cannulate, vascular, needle, pulmonary, therapy"
" Removal of painful hardware, first left metatarsal.  Excision of nonunion, first left metatarsal.  Incorporation of corticocancellous bone graft with internal fixation consisting of screws and plates of the first left metatarsal.", Surgery, Hardware Removal - Metatarsal ,"TITLE OF OPERATION:,1.  Removal of painful hardware, first left metatarsal.,2.  Excision of nonunion, first left metatarsal.,3.  Incorporation of corticocancellous bone graft with internal fixation consisting of screws and plates of the first left metatarsal.,PREOPERATIVE DIAGNOSES:,1.  Nonunion of fractured first left metatarsal osteotomy.,2.  Painful hardware, first left metatarsal.,POSTOPERATIVE DIAGNOSES:,1.  Nonunion of fractured first left metatarsal osteotomy.,2.  Painful hardware, first left metatarsal.,ANESTHESIA:,  General anesthesia with local infiltration of 5 mL of 0.5% Marcaine and 1% lidocaine plain with 1:100,000 epinephrine preoperatively and 15 mL of 0.5% Marcaine postoperatively.,HEMOSTASIS: , Left ankle tourniquet set at 250 mmHg for 60 minutes.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,MATERIALS USED:,  2-0 Vicryl, 3-0 Vicryl, 4-0 Vicryl, 5-0 Prolene, as well as one corticocancellous allograft consisting of ASIS and one T-type plate prebent with six screw holes and five 3.0 partially threaded cannulated screws and a single 3.0 noncannulated screw from the OsteoMed and Synthes System respectively for the fixation of the bone graft and the plate on the first left metatarsal.,INJECTABLES: , 1 g Ancef IV 30 minutes preoperatively and the afore-mentioned lidocaine.,DESCRIPTION OF THE PROCEDURE:  ,The patient was brought to the operating room and placed on the operating table in the supine position.  After general anesthesia was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's left foot to anesthetize the future surgical sites.  The left ankle was covered with cast padding and an 18-inch ankle tourniquet was placed around the left ankle and set at 250 mmHg.  The left foot was then prepped, scrubbed, and draped in normal sterile technique.  The left ankle tourniquet was then inflated.  Attention was then directed on the dorsal aspect of the first left metatarsal shaft where an 8-cm linear incision was placed directly parallel and medial to the course of the extensor hallucis longus tendon.  The incision extended from the base of the first left metatarsal all the way to the first left metatarsophalangeal joint.  The incision was deepened through subcutaneous tissues.  All the bleeders were identified, cut, clamped, and cauterized.  The incision was deepened to the level of the periosteum of the first left metatarsal.  All the tendinous neurovascular structures were identified and retracted from the site to be preserved.  Using sharp and dull dissection, the periosteal tissues were mobilized from their attachments on the first left metatarsal shaft.  Dissection was carried down to the level of the lose screw fixation and the two screws were identified and removed intact.  The screws were sent to pathology for examination.  The nonunion was also identified closer to the base of the first left metatarsal and using the sagittal saw the nonunion and some of the healthy tissue on both ends of the previous osteotomy were resected and sent to pathology for identification.  The remaining two ends of the previous osteotomy were then fenestrated with the use of a 0.045 Kirschner wire to induce bleeding.  The corticocancellous bone graft was prepped according to the instructions in saline for at least 60 minutes and then interposed in the previous area of the osteotomy.  Provisional fixation with K-wires was achieved and also correction of the bunion deformity of the first left metatarsophalangeal joint was also accomplished.  The bone graft was then stabilized with the use of a T-type prebent plate with the use of fixed screws that were inserted using AO technique through the plate and the shaft of the first left metatarsal and compressed appropriately the graft.  Removal of the K-wires and examination of fixation and graft incorporation into the previous nonunion area was found to be excellent.  The area was flushed copiously flushed with saline.  The periosteal and capsular tissues were approximated with 3-0 Vicryl and 2-0 Vicryl suture material.  All the subcutaneous tissues were approximated with 4-0 Vicryl suture material and 5-0 Prolene was used to approximate the skin edges at this time.  The left ankle tourniquet was deflated.  Immediate hyperemia was noted to the entire left lower extremity upon deflation of the cuff.  The patient's incision was covered with Xeroform, copious amounts of fluff and Kling, stockinette, and Ace bandage.  The patient's left foot was placed in a surgical shoe.,The patient was then transferred to the postanesthesia care unit with his vital signs stable and the vascular status at appropriate levels.  The patient was given specific instructions and education on how to continue caring for his left foot surgery.  The patient was also given pain medications, instructions on how to control his postoperative pain.  The patient was eventually discharged from Hospital according to nursing protocol and was advised to follow up with Dr. X's office in one week's time for his first postoperative appointment.","surgery, hardware removal, metatarsal osteotomy, painful hardware, osteotomy, excision of nonunion, corticocancellous bone graft, internal fixation, subcutaneous tissues, previous osteotomy, vicryl suture, suture material, corticocancellous bone, ankle tourniquet, bone graft, metatarsal, tourniquet, allograft, fixation, plates, ankle, vicryl, nonunion, screws, "
 Left distal medial hamstring release., Surgery, Hamstring Release ,"PREOPERATIVE DIAGNOSIS: , Autism with bilateral knee flexion contractures.,POSTOPERATIVE DIAGNOSIS: , Autism with bilateral knee flexion contractures.,PROCEDURE: , Left distal medial hamstring release.,ANESTHESIA: , General anesthesia.  Local anesthetic 10 mL of 0.25% Marcaine local.,TOURNIQUET TIME: , 15 minutes.,ESTIMATED BLOOD LOSS:  ,Minimal.,COMPLICATIONS:  ,There were no intraoperative complications.,DRAIN:  ,None.,SPECIMENS:  ,None.,HISTORY AND PHYSICAL:  ,The patient is a 12-year-old boy born at a 32-week gestation and with drug exposure in utero.  The patient has diagnosis of autism as well.  The patient presented with bilateral knee flexion contractures, initially worse on right than left.  He had right distal medial hamstring release performed in February 2007 and has done quite well and has noted significant improvement in his gait and his ability to play.  The patient presents now with worsening left knee flexion contracture, and desires the same procedure to be performed.  Risks and benefits of the surgery were discussed.  The risks of surgery include risk of anesthesia, infection, bleeding, changes in sensation and motion of extremity, failure to restore normal anatomy, continued contracture, possible need for other procedures.  All questions were answered and mother and son agreed to above plan.,PROCEDURE NOTE:  ,The patient was taken to operating room and placed supine on operating table.  General anesthesia was administered.  The patient received Ancef preoperatively.  Nonsterile tourniquet was placed on the upper aspect of the patient's left thigh.  The extremity was then prepped and draped in standard surgical fashion.  The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg.  Esmarch was then removed.  A small 3 cm incision was made over the distal medial hamstring.  Hamstring tendons were isolated and released in order of semitendinosus, semimembranosus, and sartorius.  The wound was then irrigated with normal saline and closed used 2-0 Vicryl and then 4-0 Monocryl.  The wound was cleaned and dried and dressed with Steri-Strips.  The area was infiltrated with total 10 mL of 0.25% Marcaine.  The wound was then covered with Xeroform, 4 x 4s, and Bias.  Tourniquet was released at 15 minutes.  The patient was then placed in knee immobilizer.  The patient tolerated the procedure well and subsequently taken to recovery in stable condition.,POSTOPERATIVE PLAN: , The patient may weight bear as tolerated in his brace.  He will start physical therapy in another week or two.  The patient restricted from any PE for at least 6 week.  He may return to school on 01/04/2008.  He was given Vicodin for pain.","surgery, medial hamstring release, distal medial hamstring release, bilateral knee flexion contractures, bilateral knee, hamstring release, knee flexion, tourniquet, flexion, contractures, hamstring, "
" Right and left heart catheterization, coronary angiography, left ventriculography.", Surgery, Heart Catheterization ,"PROCEDURES:,1.  Right and left heart catheterization.,2.  Coronary angiography.,3.  Left ventriculography.,PROCEDURE IN DETAIL:,  After informed consent was obtained, the patient was taken to the cardiac catheterization laboratory.  Patient was prepped and draped in sterile fashion.  Via modified Seldinger technique, the right femoral vein was punctured and a 6-French sheath was placed over a guide wire.  Via modified Seldinger technique, right femoral artery was punctured and a 6-French sheath was placed over a guide wire.  The diagnostic procedure was performed using the JL-4, JR-4, and a 6-French pigtail catheter along with a Swan-Ganz catheter.  The patient tolerated the procedure well and there were immediate complications were noted.  Angio-Seal was used at the end of the procedure to obtain hemostasis.,CORONARY ARTERIES:,LEFT MAIN CORONARY ARTERY:  The left main coronary artery is of moderate size vessel with bifurcation into the left descending coronary artery and circumflex coronary artery.  No significant stenotic lesions were identified in the left main coronary artery.,LEFT ANTERIOR DESCENDING CORONARY ARTERY:  The left descending artery is a moderate sized vessel, which gives rise to multiple diagonals and perforating branches.  No significant stenotic lesions were identified in the left anterior descending coronary artery system.,CIRCUMFLEX ARTERY:  The circumflex artery is a moderate sized vessel.  The vessel is a stenotic lesion.  After the right coronary artery, the RCA is a moderate size vessel with no focal stenotic lesions.,HEMODYNAMIC DATA: , Capital wedge pressure was 22.  The aortic pressure was 52/24.  Right ventricular pressure was 58/14.  RA pressure was 14.  The aortic pressure was 127/73.  Left ventricular pressure was 127/15.  Cardiac output of 9.2.,LEFT VENTRICULOGRAM: , The left ventriculogram was performed in the RAO projection only.  In the RAO projection, the left ventriculogram revealed dilated left ventricle with mild global hypokinesis and estimated ejection fraction of 45 to 50%.  Severe mitral regurgitation was also noted.,IMPRESSION:,1.  Left ventricular dilatation with global hypokinesis and estimated ejection fraction of 45 to 50%.,2.  Severe mitral regurgitation.,3.  No significant coronary artery disease identified in the left main coronary artery, left anterior descending coronary artery, circumflex coronary artery or the right coronary artery.,","surgery, ventriculography, catheterization, seldinger, hypokinesis, estimated ejection fraction, severe mitral regurgitation, descending coronary artery, coronary artery, aortic pressure, heart catheterization, stenotic lesions, coronary, artery, heart, angiography, anterior, ventricular, ventriculogram, lesions"
" Resection of infected bone, left hallux, proximal phalanx, and distal phalanx.  Osteomyelitis, left hallux.", Surgery, Hallux Infected Bone Resection ,"PREOPERATIVE DIAGNOSIS: , Osteomyelitis, left hallux.,POSTOPERATIVE DIAGNOSIS: , Osteomyelitis, left hallux.,PROCEDURES PERFORMED: , Resection of infected bone, left hallux, proximal phalanx, and distal phalanx.,ANESTHESIA: , TIVA/Local.,HISTORY:,  This 77-year-old male presents to ABCD preoperative holding area after keeping himself NPO since mid night for surgery on his infected left hallux.  The patient has a history of chronic osteomyelitis and non-healing ulceration to the left hallux of almost 10 years' duration.  He has failed outpatient antibiotic therapy and conservative methods.  At this time, he desires to attempt surgical correction.  The patient is not interested in a hallux amputation at this time; however, he is consenting to removal of infected bone.  He was counseled preoperatively about the strong probability of the hallux being a ""floppy tail"" after the surgery and accepts the fact.  The risks versus benefits of the procedure were discussed with the patient in detail by Dr. X and the consent is available on the chart for review.,PROCEDURE IN DETAIL:  ,The patient's wound was debrided with a #15 blade and down to good healthy tissue preoperatively.  The wound was on the planar medial, distal and dorsal medial.  The wound's bases were fibrous.  They did not break the bone at this point.  They were each approximately 0.5 cm in diameter.  After IV was established by the Department of Anesthesia, the patient was taken to the operating room and placed on the operating table in supine position with safety straps placed across his waist for his protection.,Due to the patient's history of diabetes and marked calcifications on x-ray, a pneumatic ankle tourniquet was not applied.  Next, a total of 3 cc of a 1:1 mixture of 0.5% Marcaine plain and 1% lidocaine plain was used to infiltrate the left hallux and perform a digital block.  Next, the foot was prepped and draped in the usual aseptic fashion.  It was lowered in the operative field and attention was directed to the left hallux after the sterile stockinet was reflected.  Next, a #10 blade was used to make a linear incision approximately 3.5 cm in length along the dorsal aspect of the hallux from the base to just proximal to the eponychium.  Next, the incision was deepened through the subcutaneous tissue.  A heavy amount of bleeding was encountered.  Therefore, a Penrose drain was applied at the tourniquet, which failed.  Next, an Esmarch bandage was used to exsanguinate the distal toes and forefoot and was left in the forefoot to achieve hemostasis.  Any small veins crossing throughout the subcutaneous layer were ligated via electrocautery.  Next, the medial and lateral margins of the incision were under marked with a sharp dissection down to the level of the long extension tendon.  The long extensor tendon was thickened and overall exhibited signs of hypertrophy.  The transverse incision through the long extensor tendon was made with a #15 blade.  Immediately upon entering the joint, yellow discolored fluid was drained from the interphalangeal joint.  Next, the extensor tendon was peeled dorsally and distally off the bone.  Immediately the head of the proximal phalanx was found to be lytic, disease, friable, crumbly, and there were free fragments of the medial aspect of the bone, the head of the proximal phalanx.  This bone was removed with a sharp dissection.  Next, after adequate exposure was obtained and the collateral ligaments were released off the head of proximal phalanx, a sagittal saw was used to resect the approximately one-half of the proximal phalanx.  This was passed off as the infected bone specimen for microbiology and pathology.  Next, the base of the distal phalanx was exposed with sharp dissection and a rongeur was used to remove soft crumbly diseased medial and plantar aspect at the base of distal phalanx.  Next, there was diseased soft tissue envelope around the bone, which was also resected to good healthy tissue margins.  The pulse lavage was used to flush the wound with 1000 cc of gentamicin-impregnated saline.  Next, cleaned instruments were used to take a proximal section of proximal phalanx to label a clean margin.  This bone was found to be hard and healthy appearing.  The wound after irrigation was free of all debris and infected tissue.  Therefore anaerobic and aerobic cultures were taken and sent to microbiology.  Next, OsteoSet beads, tobramycin-impregnated, were placed.  Six beads were placed in the wound.  Next, the extensor tendon was re-approximated with #3-0 Vicryl.  The subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted technique.  Next, the skin was closed with #4-0 nylon in a horizontal mattress technique.,The Esmarch bandage was released and immediate hyperemic flush was noted at the digits.  A standard postoperative dressing was applied consisting of 4 x 4s, Betadine-soaked #0-1 silk, Kerlix, Kling, and a loosely applied Ace wrap.  The patient tolerated the above anesthesia and procedure without complications.  He was transported via a cart to the Postanesthesia Care Unit.  His vitals signs were stable and vascular status was intact.  He was given a medium postop shoe that was well-formed and fitting.  He is to elevate his foot, but not apply ice.  He is to follow up with Dr. X.  He was given emergency contact numbers.  He is to continue the Vicodin p.r.n. pain that he was taking previously for his shoulder pain and has enough of the medicine at home.  The patient was discharged in stable condition.","surgery, osteomyelitis, proximal phalanx, distal phalanx, infected bone, proximal, bone, phalanx, healing, hallux, infected, tissue, distal,"
 Hardware removal in the left elbow., Surgery, Hardware Removal - Elbow ,"PREOPERATIVE DIAGNOSIS: , Retained hardware in left elbow.,POSTOPERATIVE DIAGNOSIS:,  Retained hardware in left elbow.,PROCEDURE: , Hardware removal in the left elbow.,ANESTHESIA: , Procedure done under general anesthesia.  The patient also received 4 mL of 0.25% Marcaine of local anesthetic.,TOURNIQUET:  ,There is no tourniquet time.,ESTIMATED BLOOD LOSS:  ,Minimal.,COMPLICATIONS:  ,No intraoperative complications.,HISTORY AND PHYSICAL:  ,The patient is a 5-year, 8-month-old male who presented to me direct from ED with distracted left lateral condyle fracture.  He underwent screw compression for the fracture in October 2007.  The fracture has subsequently healed and the patient presents for hardware removal.  The risks and benefits of surgery were discussed.  The risks of surgery include the risk of anesthesia, infection, bleeding, changes in sensation and motion of extremity, failure of removal of hardware, failure to relieve pain or improved range of motion.  All questions were answered and the family agreed to the above plan.,PROCEDURE: , The patient was taken to the operating room, placed supine on the operating table.  General anesthesia was then administered.  The patient's left upper extremity was then prepped and draped in standard surgical fashion.  Using his previous incision, dissection was carried down through the screw.  A guide wire was placed inside the screw and the screw was removed without incident.  The patient had an extension lag of about 15 to 20 degrees.  Elbow is manipulated and his arm was able to be extended to zero degrees dorsiflex.  The washer was also removed without incident.  Wound was then irrigated and closed using #2-0 Vicryl and #4-0 Monocryl.  Wound was injected with 0.25% Marcaine.  The wound was then dressed with Steri-Strips, Xeroform, 4 x4 and bias.  The patient tolerated the procedure well and subsequently taken to the recovery in stable condition.,DISCHARGE NOTE: , The patient will be discharged on date of surgery.  He is to follow up in one week's time for a wound check.  This can be done at his primary care physician's office.  The patient should keep his postop dressing for about 4 to 5 days.  He may then wet the wound, but not scrub it.  The patient may resume regular activities in about 2 weeks.  The patient was given Tylenol with Codeine 10 mL p.o. every 3 to 4 hours p.r.n.","surgery, retained hardware, hardware removal, tourniquet, elbow, hardware,"
" Hardware removal, right ulnar", Surgery, Hardware Removal - Ulnar ,"PREOPERATIVE DIAGNOSIS: , Retained hardware, right ulnar.,POSTOPERATIVE DIAGNOSIS: , Retained hardware, right ulnar,PROCEDURE: , Hardware removal, right ulnar.,ANESTHESIA:,  The patient received 2.5 mL of 0.25% Marcaine and local anesthetic.,COMPLICATIONS: , No intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,HISTORY AND PHYSICAL:  ,The patient is a 5-year, 5-month-old male who sustained a both-bone forearm fracture in September 2007.  The fracture healed uneventfully, but then the patient subsequently suffered a refracture one month ago.  The patient had shortening in arms, noted in both bones.  The parents opted for surgical stabilization with nailing.  This was performed one month ago on return visit.  His ulnar nail was quite prominent underneath the skin.  It was decided to remove the ulnar nail early and place the patient in another cast for 3 weeks.,Risks and benefits of the surgery were discussed with the mother.  Risk of surgery incudes risks of anesthesia, infection, bleeding, changes in sensation in most of the extremity, need for longer casting.  All questions were answered and mother agreed to above plan.,PROCEDURE IN DETAIL:  ,The patient was seen in the operative room, placed supine on operating room table.  General anesthesia was then administered.  The patient was given Ancef preoperatively.  The left elbow was prepped and draped in a standard surgical fashion.  A small incision was made over the palm with K-wire.  This was removed without incident.  The wound was irrigated.  The bursitis was curetted.  Wounds closed using #4-0 Monocryl.  The wound was clean and dry, dressed with Xeroform 4 x 4s and Webril.  Please note the area infiltrated with 0.25% Marcaine.  The patient was then placed in a long-arm cast.  The patient tolerated the procedure well and was subsequently taken to the recovery room in stable condition.,POSTOPERATIVE PLAN:  ,The patient will maintain the cast for 3 more weeks.  Intraoperative nail was given to the mother.  The patient to take Tylenol with Codeine as needed.  All questions were answered.,","surgery, both-bone forearm fracture, retained hardware, hardware removal, hardware, forearm, ulnar,"
" Chest pain and non-Q-wave MI with elevation of troponin I only.  Left heart catheterization, left ventriculography, and left and right coronary arteriography.", Surgery, Heart Catheterization - 1 ,"PROCEDURES: , Left heart catheterization, left ventriculography, and left and right coronary arteriography.,INDICATIONS: , Chest pain and non-Q-wave MI with elevation of troponin I only.,TECHNIQUE:  ,The patient was brought to the procedure room in satisfactory condition.  The right groin was prepped and draped in routine fashion.  An arterial sheath was inserted into the right femoral artery.,Left and right coronary arteries were studied with a 6FL4 and 6FR4 Judkins catheters respectively.  Cine coronary angiograms were done in multiple views.,Left heart catheterization was done using the 6-French pigtail catheter.  Appropriate pressures were obtained before and after the left ventriculogram, which was done in the RAO view.,At the end of the procedure, the femoral catheter was removed and Angio-Seal was applied without any complications.,FINDINGS:,1.  LV is normal in size and shape with good contractility, EF of 60%.,2.  LMCA normal.,3.  LAD has 20% to 30% stenosis at the origin.,4.  LCX is normal.,5.  RCA is dominant and normal.,RECOMMENDATIONS: , Medical management, diet, and exercise.  Aspirin 81 mg p.o. daily, p.r.n. nitroglycerin for chest pain.  Follow up in the clinic.","surgery, arteriography, coronary arteriography, heart catheterization, ventriculography, angiograms"
 Left heart catheterization and bilateral selective coronary angiography.   The patient is a 65-year-old male with known moderate mitral regurgitation with partial flail of the P2 and P3 gallops who underwent outpatient evaluation for increasingly severed decreased functional capacity and retrosternal chest pain that was aggravated by exertion and decreased with rest., Surgery, Heart Cath & Coronary Angiography ,"PROCEDURE PERFORMED:,1.  Left heart catheterization.,2.  Bilateral selective coronary angiography.,ANESTHESIA: , 1% lidocaine and IV sedation, including fentanyl 25 mcg.,INDICATION: , The patient is a 65-year-old male with known moderate mitral regurgitation with partial flail of the P2 and P3 gallops who underwent outpatient evaluation for increasingly severed decreased functional capacity and retrosternal chest pain that was aggravated by exertion and decreased with rest.  It was accompanied by diaphoresis and shortness of breath.  The patient was felt to be a candidate for mitral valve repair versus mitral valve replacement and underwent a stress test as part of his evaluation for chest pain.  He underwent adenosine Cardiolite, which revealed 2 mm ST segment depression in leads II, III aVF, and V3, V4, and V5.  Stress images revealed left ventricular dilatations suggestive of multivessel disease.  He is undergoing evaluation today as a part of preoperative evaluation and because of the positive stress test.,PROCEDURE: , After risks, benefits, alternatives of the above mentioned procedure were explained to the patient in detail, informed consent was obtained both verbally and writing.  The patient was taken to the Cardiac Catheterization Laboratory where the procedure was performed.  The right inguinal area was sterilely cleansed with a Betadine solution and the patient was draped in the usual manner.  1% lidocaine solution was used to anesthetize the right inguinal area.  Once adequate anesthesia had been obtained, a thin-walled Argon needle was used to cannulate the right femoral artery.,The guidewire was then advanced through the lumen of the needle without resistance and a small nick was made in the skin.  The needle was removed and a pressure was held.  A #6 French arterial sheath was advanced over the guidewire without resistance.  The dilator and guidewire were removed and the sheath was flushed.  A Judkins left #4 catheter was advanced to the ascending aorta under direct fluoroscopic visualization with the use of the guidewire.  The guidewire was removed and the catheter was connected to the manifold and flushed.  The ostium of the left main coronary artery was carefully engaged and limited evaluation was performed after noticing that the patient had a significant left main coronary artery stenosis.  The catheter was withdrawn from the ostium of the left main coronary artery and the guidewire was inserted through the tip of the catheter.  The catheter was removed over guidewire and a Judkins right #4 catheter was advanced to the ascending aorta under direct fluoroscopic visualization with use of a guidewire.  The guidewire was removed and the catheter was connected to the manifold and flushed.  The ostium of the right coronary artery was carefully engaged and using hand injections of nonionic contrast material, the right coronary artery was evaluated in both diagonal views.  This catheter was removed.  The sheath was flushed the final time.  The patient was taken to the postcatheterization holding area in stable condition.,FINDINGS:,LEFT MAIN CORONARY ARTERY:,  This vessel is seen to be heavily calcified throughout its course.  Begins as a moderate caliber vessel.  There is a 60% stenosis in the distal portion with extension of the lesion to the ostium and proximal portions of the left anterior descending and left circumflex coronary artery.,LEFT ANTERIOR DESCENDING CORONARY ARTERY:,  This vessel is heavily calcified in its proximal portion.  It is of moderate caliber and seen post anteriorly in the intraventricular groove and wraps around the apex.  There is a 90% stenosis in the proximal portion and 90% ostial stenosis in the first and second anterolateral branches.  There is sequential 80% and 90% stenosis in the mid-portion of the vessel.  Otherwise, the LAD is seen to be diffusely diseased.,LEFT CIRCUMFLEX CORONARY ARTERY:  ,This vessel is also calcified in its proximal portion.  There is a greater than 90% ostial stenosis, which appears to be an extension of the lesion in the left main coronary artery.  There is a greater than 70% stenosis in the proximal portion of the first large obtuse marginal branch, otherwise, the circumflex system is seen to be diffusely diseased.,RIGHT CORONARY ARTERY: , This is a large caliber vessel and is the dominant system.  There is diffuse luminal irregularities throughout the vessel and a 80% to 90% stenosis at the bifurcation above the posterior descending artery and posterolateral branch.,IMPRESSION:,1.  Three-vessel coronary artery disease as described above.,2.  Moderate mitral regurgitation per TEE.,3.  Status post venous vein stripping of the left lower extremity and varicosities in both lower extremities.,4.  Long-standing history of phlebitis.,PLAN: , Consultation will be obtained with Cardiovascular and Thoracic Surgery for CABG and mitral valve repair versus replacement.","surgery, left heart catheterization, bilateral selective coronary angiography, regurgitation, gallops, diaphoresis, shortness of breath, coronary angiography, proximal portions, catheterization, artery, coronary, bilateral, selective, angiography, mitral, stenosis, vessel, guidewire, "
" Pyogenic granuloma, left lateral thigh.   Excision of recurrent pyogenic granuloma.", Surgery, Granuloma Excision ,"PREOPERATIVE DIAGNOSIS: , Pyogenic granuloma, left lateral thigh.,POSTOPERATIVE DIAGNOSIS: , Pyogenic granuloma, left lateral thigh.,ANESTHESIA:,  General.,PROCEDURE: , Excision of recurrent pyogenic granuloma.,INDICATIONS: , The patient is 12-year-old young lady, who has a hand-sized congenital vascular malformation on her left lateral thigh below the greater trochanter, which was described by her parents as a birthmark.  This congenital cutaneous vascular malformation faded substantially over the first years of her life and has regressed to a flat, slightly hyperpigmented lesion.  Although no isolated injury event can be recalled, the patient has developed a pyogenic granuloma next to the distal portion of this lesion on her mid thigh, and it has been treated with topical cautery in her primary care doctor's office, but with recurrence.  She is here today for excision.,OPERATIVE FINDINGS: , The patient had what appeared to be a classic pyogenic granuloma arising from this involuted vascular malformation.,DESCRIPTION OF OPERATION:  ,The patient came to the operating room, had an uneventful induction of general anesthesia.  We conducted a surgical time-out, reiterated her important and unique identifying information and confirmed that the excision of the left thigh pyogenic granuloma was the procedure planned for today.  Preparation and draping was __________ ensued with a chlorhexidine based prep solution.  The pyogenic granuloma was approximately 6 to 7 mm in greatest dimension and to remove it required creating an elliptical incision of about 1 to 1.2 cm.  This entire area was infiltrated with 0.25% Marcaine with dilute epinephrine to provide a wide local field block and then an elliptical incision was made with a #15 scalpel blade, excising the pyogenic granuloma, its base, and a small rim of surrounding normal skin.  Some of the abnormal vessels in the dermal and subdermal layer were cauterized with the needle-tip electrocautery pencil.  The wound was closed in layers with a deep dermal roll of 5-0 Monocryl stitches supplemented by 5-0 intradermal Monocryl and Steri-Strips for final skin closure.  The patient tolerated the procedure well.  This nodule was submitted to pathology for confirmation of its histology as a pyogenic granuloma.  Blood loss was less than 5 mL and there were no complications.","surgery, trochanter, granuloma, pyogenic granuloma, vascular malformation, pyogenic, vascular, malformation, thigh,"
 , Surgery, G-tube placement ,"PREOPERATIVE DIAGNOSIS:,  Neurologic devastation secondary to nonaccidental trauma.,POSTOPERATIVE DIAGNOSES: , Neurologic devastation secondary to nonaccidental trauma.,PROCEDURE: , Laparoscopic G-tube placement (14-French 1.2-cm MIC-Key).,INDICATIONS FOR PROCEDURE: , This patient is a 5-month-old baby boy who presented unfortunately because of nonaccidental trauma.  The patient suffered neurologic devastation.  In order to facilitate enteral feedings, the plan is to place a G-tube as the patient cannot take by mouth.  Consent was obtained by court order as the patient is a ward of the state.,DESCRIPTION OF PROCEDURE:  ,The patient was taken to the operating room, placed supine, put under general endotracheal anesthesia.  The patient's abdomen was prepped and draped in the usual sterile fashion.  An incision was made through the umbilicus.  Peritoneal cavity entered bluntly.  A 5-mm trocar was introduced.  Abdomen was insufflated with a 5-mm scope.  No obvious pathology noted.  We visualized the stomach.  We chose the spot in the left upper quadrant for future G-tube site.  I made a small incision on the skin there, put another 5-mm trocar at that site.  Using a Babcock, we grasped the stomach along the greater curvature site for further G-tube.  I pulled a knuckle of stomach through the incision and secured with 4-0 Vicryl.  I then used 3-0 Prolene sutures as tacking sutures on either side of the future G-tube site taking full-thickness abdominal wall through stomach and back out the abdominal wall.  I then pulled the knuckle of stomach back up through the incision, made a gastrotomy, and then put a 4-0 pursestring around the gastrotomy site, introduced the 14, 1.2- cm MIC-Key into the stomach.  The gastrotomy site insufflated with 5 mL of saline.  We then tied down the pursestring.  On the laparoscopy, the G-tube looked to be in good position.  I insufflated the stomach through the G-tube, which I did and removed air subsequently.  I then placed 2 x 2 underneath the G-tube and tied down tacking sutures around the G-tube itself, placed the G-tube to gravity, desufflated the abdomen, closed the umbilical port site fascia with 3-0 Vicryl, closed skin with 5-0 Monocryl, and dressed with bacitracin, 2 x 2, and Steri-Strips.  The patient was extubated in the operating room and taken back to recovery room.  The patient tolerated the procedure well.","surgery, neurologic devastation, g-tube placement, mic-key, laparoscopic g-tube placement, babcock, g-tube site, gastrotomy, mic key, abdominal wall, gastrotomy site, nonaccidental trauma, tube, stomach, "
" Gastroscopy.  A short-segment Barrett esophagus, hiatal hernia, and incidental fundic gland polyps in the gastric body; otherwise, normal upper endoscopy to the transverse duodenum.", Surgery, Gastroscopy - 3 ,"PROCEDURE: , Gastroscopy.,PREOPERATIVE DIAGNOSIS: , Gastroesophageal reflux disease.,POSTOPERATIVE DIAGNOSIS:,  Barrett esophagus.,MEDICATIONS: , MAC.,PROCEDURE: , The Olympus gastroscope was introduced into the oropharynx and passed carefully through the esophagus, stomach, and duodenum to the transverse duodenum.  The preparation was excellent and all surfaces were well seen.  The hypopharynx appeared normal.  The esophagus had a normal contour and normal mucosa throughout its distance, but at the distal end, there was a moderate-sized hiatal hernia noted.  The GE junction was seen at 40 cm and the hiatus was noted at 44 cm from the incisors.  Above the GE junction, there were three fingers of columnar epithelium extending cephalad, to a distance of about 2 cm.  This appears to be consistent with Barrett esophagus.  Multiple biopsies were taken from numerous areas in this region.  There was no active ulceration or inflammation and no stricture.  The hiatal hernia sac had normal mucosa except for one small erosion at the hiatus.  The gastric body had normal mucosa throughout.  Numerous small fundic gland polyps were noted, measuring 3 to 5 mm in size with an entirely benign appearance.  Biopsies were taken from the antrum to rule out Helicobacter pylori.  A retroflex view of the cardia and fundus confirmed the small hiatal hernia and demonstrated no additional lesions.  The scope was passed through the pylorus, which was patent and normal.  The mucosa throughout the duodenum in the first, second, and third portions was entirely normal.  The scope was withdrawn and the patient was sent to the recovery room.  He tolerated the procedure well.,FINAL DIAGNOSES:,1.  A short-segment Barrett esophagus.,2.  Hiatal hernia.,3.  Incidental fundic gland polyps in the gastric body.,4.  Otherwise, normal upper endoscopy to the transverse duodenum.,RECOMMENDATIONS:,1.  Follow up biopsy report.,2.  Continue PPI therapy.,3.  Follow up with Dr. X as needed.,4.  Surveillance endoscopy for Barrett in 3 years (if pathology confirms this diagnosis).","surgery, olympus, gastroscope, barrett, gastroesophageal reflux disease, transverse duodenum, barrett esophagus, hiatal hernia, gastroscopy, endoscopy, hiatal, duodenum, esophagus, hernia,"
" Gangrene osteomyelitis, right second toe.  The patient is a 58-year-old female with poorly controlled diabetes with severe lower extremity lymphedema.  The patient has history of previous right foot infection requiring first ray resection.", Surgery, Gangrene Surgery ,"PREOPERATIVE DIAGNOSIS: , Gangrene osteomyelitis, right second toe.,POSTOPERATIVE DIAGNOSIS: , Gangrene osteomyelitis, right second toe.,OPERATIVE REPORT:  ,The patient is a 58-year-old female with poorly controlled diabetes with severe lower extremity lymphedema.  The patient has history of previous right foot infection requiring first ray resection.  The patient has ulcerations of right second toe dorsally at the proximal interphalangeal joint, which has failed to respond to conservative treatment.  The patient now has exposed bone and osteomyelitis in the second toe.  The patient has been on IV antibiotics as an outpatient and has failed to respond to these and presents today for surgical intervention.,After an IV was started by the Department of Anesthesia, the patient was taken back to the operating room and placed on the operative table in the supine position.  A restraint belt was placed around the patient's waist using copious amounts of Webril and an ankle pneumatic tourniquet was placed around the patient's right ankle and the patient was made comfortable by the Department of Anesthesia.  After adequate amounts of sedation had been given to the patient, we administered a block of 10 cc of 0.5% Marcaine plain in proximal digital block around the second digit.  The foot and ankle were then prepped in the normal sterile orthopedic manner.  The foot was elevated and an Esmarch bandage applied to exsanguinate the foot.  The tourniquet was then inflated to 250 mmHg and the foot was brought back onto the table.  Using Band-Aid scissors, the stockinet was cut and reflected and using a wet and dry sponge, the foot was wiped, cleaned, and the second toe identified.,Using a skin scrape, a racket type incision was planned around the second toe to allow also remodelling of previous operative site.  Using a fresh #10 blade, skin incision was made circumferentially in the racket-shaped manner around the second digit.  Then, using a fresh #15 blade, the incision was deepened and was taken down to the level of the second metatarsophalangeal joint.  Care was taken to identify bleeders and cautery was used as necessary for hemostasis.  After cleaning up all the soft tissue attachments, the second digit was disarticulated down to the level of the metatarsophalangeal joint.  The head of the second metatarsal was inspected and was noted to have good glistening white cartilage with no areas of erosion evident by visual examination.  Attention was then directed to closure of the wound.  All remaining tissue was noted to be healthy and granular in appearance with no necrotic tissue evident.  Areas of subcutaneous tissue were then removed through a sharp dissection in order to allow better approximation of the skin edges.  Due to long-standing lower extremity lymphedema and postoperative changes on previous surgery, I thought that we were unable to close the incision in entirety.  Therefore, after copious amounts of irrigation using sterile saline, it was determined to use modified dental rolls using #4-0 gauze to remove tension from the skin.  Deep vertical mattress sutures were used in order to reapproximate more closely, the skin edges and bring the plantar flap of skin up to the dorsal skin.  This was obtained using #2-0 nylon suture.  Following this, the remaining exposed tissue from the wound was covered using moist to dry saline soaked 4 x 4 gauze.  The wound was then dressed using 4 x 4 gauze fluffed with abdominal pads, then using Kling and Kerlix and an ACE bandage to provide compression.  The tourniquet was deflated at 42 minutes' time and hemostasis was noted to be achieved.  The ACE bandage was extended up to just below the knee and no bleeding striking to the bandages was appreciated.  The patient tolerated the procedure well and was escorted to the Postanesthesia Care Unit with vital signs stable and vascular status intact, as was evidenced by capillary bleeding, which was present during the procedure.  Sedation was given postoperative introductions, which include to remain nonweightbearing to her right foot.  The patient was instructed to keep the foot elevated and to apply ice behind her knee as necessary, no more than 20 minutes each hour.  The patient was instructed to continue her regular medications.  The patient was to continue IV antibiotic course and was given prescription for Vicoprofen to be taken q.4h. p.r.n. for moderate to severe pain #30.  The patient will followup with Podiatry on Monday morning at 8:30 in the Podiatry Clinic for dressing change and evaluation of her foot at that time.,The patient was instructed as to signs and symptoms of infection, was instructed to return to the Emergency Department immediately if these should present.  The second digit was sent to Pathology for gross and micro.","surgery, dorsally, toe, ulcerations, foot infection, ray resection, metatarsophalangeal joint, ace bandage, gangrene osteomyelitis, foot, infection, gangrene, digital,"
" Esophagitis, minor stricture at the gastroesophageal junction, hiatal hernia.  Otherwise normal upper endoscopy to the transverse duodenum.", Surgery, Gastroscopy ,"PREOPERATIVE DIAGNOSES: , Dysphagia and esophageal spasm.,POSTOPERATIVE DIAGNOSES: , Esophagitis and esophageal stricture.,PROCEDURE:,  Gastroscopy.,MEDICATIONS:,  MAC.,DESCRIPTION OF PROCEDURE: , The Olympus gastroscope was introduced into the oropharynx and passed carefully through the esophagus, stomach, and duodenum, to the third portion of the duodenum.  The hypopharynx was normal and the upper esophageal sphincter was unremarkable.  The esophageal contour was normal, with the gastroesophageal junction located at 38 cm from the incisors.  At this point, there were several linear erosions and a sense of stricturing at 38 cm.  Below this, there was a small hiatal hernia with the hiatus noted at 42 cm from the incisors.  The mucosa within the hernia was normal.  The gastric lumen was normal with normal mucosa throughout.  The pylorus was patent permitting passage of the scope into the duodenum, which was normal through the third portion.  During withdrawal of the scope, additional views were obtained of the cardia, confirming the presence of a small hiatal hernia.  It was decided to attempt dilation of the strictured area, so an 18-mm TTS balloon was placed across the stricture and inflated to the recommended diameter.  When the balloon was fully inflated, the lumen appeared to be larger than 18 mm diameter, suggesting that the stricture was in fact not a significant one.  No stretching of the mucosa took place.  The balloon was deflated and the scope was withdrawn.  The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1.  Esophagitis.,2.  Minor stricture at the gastroesophageal junction.,3.  Hiatal hernia.,4.  Otherwise normal upper endoscopy to the transverse duodenum.,RECOMMENDATIONS:  ,Continue proton pump inhibitor therapy.","surgery, duodenum, esophagus, gastroscope, stomach, upper endoscopy, transverse duodenum, gastroesophageal junction, hiatal hernia, gastroscopy, endoscopy, esophagitis, gastroesophageal, hiatal, esophageal, hernia"
" Gastrostomy, a 6-week-old with feeding disorder and Down syndrome.", Surgery, Gastrostomy ,"PREOPERATIVE DIAGNOSES:,1.  Feeding disorder.,2.  Down syndrome.,3.  Congenital heart disease.,POSTOPERATIVE DIAGNOSES:,1.  Feeding disorder.,2.  Down syndrome.,3.  Congenital heart disease.,OPERATION PERFORMED: , Gastrostomy.,ANESTHESIA: , General.,INDICATIONS:  ,This 6-week-old female infant had been transferred to Children's Hospital because of Down syndrome and congenital heart disease.  She has not been able to feed well and in fact has to now be NG tube fed.  Her swallowing mechanism does not appear to be very functional, and therefore, it was felt that in order to aid in her home care that she would be better served with a gastrostomy.,OPERATIVE PROCEDURE:  ,After the induction of general anesthetic, the abdomen was prepped and draped in usual manner.  Transverse left upper quadrant incision was made and carried down through skin and subcutaneous tissue with sharp dissection.  The muscle was divided and the peritoneal cavity entered.  The greater curvature of the stomach was grasped with a Babcock clamp and brought into the operative field.  The site for gastrostomy was selected and a pursestring suture of #4-0 Nurolon placed in the gastric wall.  A 14-French 0.8 cm Mic-Key tubeless gastrostomy button was then placed into the stomach and the pursestring secured about the tube.  Following this, the stomach was returned to the abdominal cavity and the posterior fascia was closed using a #4-0 Nurolon affixing the stomach to the posterior fascia.  The anterior fascia was then closed with #3-0 Vicryl, subcutaneous tissue with the same, and the skin closed with #5-0 subcuticular Monocryl.  The balloon was inflated to the full 5 mL.  A sterile dressing was then applied and the child awakened and taken to the recovery room in satisfactory condition.,","surgery, feeding disorder, down syndrome, congenital heart disease, mic-key tubeless, nurolon, subcutaneous tissue, fascia, syndrome, stomach, gastrostomy"
 Full mouth dental rehabilitation in the operative room under general anesthesia., Surgery, Full Mouth Dental Rehabilitation - 2 ,"OPERATION PERFORMED:,  Full mouth dental rehabilitation in the operative room under general anesthesia.,PREOPERATIVE DIAGNOSIS: , Severe dental caries.,POSTOPERATIVE DIAGNOSES:,1.  Severe dental caries.,2.  Non-restorable teeth.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , Minimal.,DURATION OF SURGERY: , 43 minutes.,BRIEF HISTORY:  ,The patient was first seen by me on 04/26/2007.  She had a history of open heart surgery at 11 months' of age.  She presented with severe anterior caries with most likely dental extractions needed.  Due to her young age, I felt that she would be best served in the safety of the hospital operating room.  After consultation with the mother, she agreed to have her treated in the safety of the hospital operating room at Children's Hospital.,OPERATIVE PREPARATION:  ,This child was brought to Hospital Day Surgery and is accompanied by her mother.  There I met with them and discussed the needs of the child, types of restorations to be performed, the risks and benefits of the treatment as well as the options and alternatives of the treatment.  After all their questions and concerns were addressed, I gave the informed consent to proceed with the treatment.  The patient's history and physical examination was reviewed.  Once she was cleared by Anesthesia and the child was taken back to the operating room.,OPERATIVE PROCEDURE:  ,The patient was placed on the surgical table in the usual supine position with all extremities protected.  Anesthesia was induced by mask.  The patient was then intubated with a nasal endotracheal tube and the tube was stabilized.  The head was wrapped and the eyes were taped shut for protection.  An angiocatheter was placed in the left hand and an IV was started.  The head and neck were draped with sterile towels, and the body was covered with a lead apron and sterile sheath.  A moist continuous throat pack was placed beyond the tonsillar pillars.  Plastic lip and cheek retractors were then placed.  Preoperative clinical photographs were taken.  Two posterior bitewing radiographs and two anterior periapical films were taken in the operating room with digital radiography.  After the radiographs were taken, the lead shield was removed.  Prophylaxis was then performed using prophy cup and fluoridated prophy paste.  The teeth were then rinsed well and the patient's oral cavity was suctioned clean.  Clinical and radiographic examinations followed and areas of decay were noted.  During the restorative phase, these areas of decay were entered into and removed.  Entry was made to the level of the dental-enamel junction and beyond as necessary to remove it.  Final caries was removed and was confirmed upon reaching hard, firm sounding dentin.  Teeth restored with amalgam had a dentin tubular seal placed prior to amalgam placement.  Non-restorable primary teeth would be extracted.,Upon conclusion of the restorative phase, the oral cavity was aspirated and found to be free of blood, mucus, and other debris.  The original treatment plan was verified with the actual treatment provided.  Postoperative clinical photographs were then taken.  The continuous gauze throat pack was removed with continuous suction with visualization.  Topical fluoride was then placed on the teeth.,At the end of the procedure, the child was undraped, extubated, and awakened in the operating room and taken to the recovery room breathing spontaneously with stable vital signs.,FINDINGS:  ,This young patient presented with mild generalized marginal gingivitis secondary to light generalized plaque accumulation and fair oral hygiene.  All primary teeth were present.  Dental caries were present on the following teeth:  Tooth D, E, F, and G caries on all surfaces; teeth J, lingual caries.  The remainder of her teeth and soft tissues were within normal limits.  The following restorations and procedures were performed:  Tooth D, E, F, and G were extracted and four sutures were placed one at each extraction site and tooth J lingual amalgam.,CONCLUSION:  ,The mother was informed of the completion of the procedure.  She was given a synopsis of the treatment provided as well as written and verbal instructions for postoperative care.  They will contact to my office in the event of immediate postoperative complications.  After full recovery, she was discharged from the recovery room in the care of her mother.","surgery, full mouth dental rehabilitation, dental rehabilitation, full mouth, dental caries, non-restorable teeth, dental extractions, throat pack, oral cavity, restorative phase, primary teeth, dental, anesthesia, mouth, rehabilitation, prophylaxis, oral, amalgam, tooth, "
 Excision of ganglion of the left wrist.  A curved incision was made over the presenting ganglion over the dorsal aspect of the wrist. , Surgery, Ganglion Excision ,"PREOPERATIVE DIAGNOSIS: , Ganglion of the left wrist.,POSTOPERATIVE DIAGNOSIS: , Ganglion of the left wrist.,OPERATION: , Excision of ganglion.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 5 mL.,OPERATION: , After a successful anesthetic, the patient was positioned on the operating table.  A tourniquet applied to the upper arm.  The extremity was prepped in a usual manner for a surgical procedure and draped off.  The superficial vessels were exsanguinated with an elastic wrap and the tourniquet was then inflated to the usual arm pressure.  A curved incision was made over the presenting ganglion over the dorsal aspect of the wrist.  By blunt and sharp dissection, it was dissected out from underneath the extensor tendons and the stalk appeared to arise from the distal radiocapitellar joint and the dorsal capsule was excised along with the ganglion and the specimen was removed and submitted.  The small superficial vessels were electrocoagulated and instilled after closing the skin with 4-0 Prolene, into the area was approximately 6 to 7 mL of 0.25 Marcaine with epinephrine.  A Jackson-Pratt drain was inserted and then after the tourniquet was released, it was kept deflated until at least 5 to 10 minutes had passed and then it was activated and then removed in the recovery room.  The dressings applied to the hand were that of Xeroform, 4x4s, ABD, Kerlix, and elastic wrap over a volar fiberglass splint.  The tourniquet was released.  Circulation returned to the fingers.  The patient then was allowed to awaken and left the operating room in good condition.","surgery, curved incision, superficial vessels, tourniquet, excision, dorsal, wrist, ganglion"
 Full mouth dental rehabilitation in the operating room under general anesthesia., Surgery, Full Mouth Dental Rehabilitation - 1 ,"OPERATION PERFORMED:,  Full mouth dental rehabilitation in the operating room under general anesthesia.,PREOPERATIVE DIAGNOSES:  ,1.  Severe dental caries.,2.  Hemophilia.,POSTOPERATIVE DIAGNOSES:  ,1.  Severe dental caries.,2.  Hemophilia.,3.  Nonrestorable teeth.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,DURATION OF SURGERY:  ,1 hour and 22 minutes.,BRIEF HISTORY:  ,The patient was first seen by me on 08/23/2007, who is 4-year-old with hemophilia, who received infusion on Tuesdays and Thursdays and he has a MediPort.  Mom reported history of high fever after surgery and he has one seizure previously.  He has history of trauma to his front teeth and physician put him on antibiotics.  He was only cooperative for having me do a visual examination on his anterior teeth.  Visual examination revealed severe dental caries and dental abscess from tooth #E and his maxillary anterior teeth needed to be extracted.  Due to his young age and hemophilia, I felt that he would be best served to be taken to the hospital operating room.,OTHER PREPARATION:  ,The child was brought to the Hospital Day Surgery accompanied by his mother.  There, I met with her and discussed the needs of the child, types of restoration to be performed, and the risks, and benefits of the treatment as well as the options and alternatives of the treatment.  After all her questions and concerns were addressed, she gave her informed consent to proceed with treatment.  The patient's history and physical examination was reviewed.  He was given factor for appropriately for his hemophilia prior to being taken back to the operating room.  Once he was cleared by Anesthesia, the child was taken back to the operating room.,OPERATIVE PROCEDURE:  ,The patient was placed on the surgical table in the usual supine position with all extremities protected.  Anesthesia was induced by mask.  The patient was then intubated with an oral tube and the tube was stabilized.  The head was wrapped and IV was started.  The head and neck were draped with sterile towels and the body was covered with a lead apron and sterile sheath.  A moist continuous throat pack was placed beyond tonsillar pillars.  Plastic lip and cheek retractors were then placed.  Preoperative clinical photographs were taken.  Two posterior bitewing radiographs and two anterior periapical films were taken in the operating room with digital radiograph.  After the radiographs were taken, the lead shield was removed.,Prophylaxis was then performed using a prophy cup and fluoridated prophy paste.  The patient's teeth were rinsed well.  The patient's oral cavity was suctioned clean.  Clinical and radiographic examination followed and areas of decay were noted.  During the restorative phase, these areas of decay were incidentally removed.  Entry was made to the level of the dental-enamel junction and beyond as necessary to remove it.  Final caries removal was confirmed upon reaching hard, firm and sound dentin.,Teeth restored with composite ___________  bonded with a one-step bonding agent.  Teeth restored with amalgam had a dentin tubular seal placed prior to amalgam placement.  Non-restorable primary teeth would be extracted.  The caries were extensive and invaded the pulp tissues, pulp therapy was initiated using ViscoStat and then IRM pulpotomies.  Teeth treated in such a manner would then be crowned with stainless steel crowns.,Upon conclusion of the restorative phase, the oral cavity was aspirated and found to be free of blood, mucus, and other debris.  The original treatment plan was verified with the actual treatment provided.  Postoperative clinical photographs were then taken.  The continuous gauze throat pack was removed with continuous suction with visualization.  Topical fluoride was then placed on the teeth.  At the end of the procedure, the child was undraped, extubated, and awakened in the operating room, was taken to the recovery room, breathing spontaneously with stable vital signs.,FINDINGS: , This young patient presented with mild generalized marginal gingivitis, secondary to light generalized plaque accumulation and fair oral hygiene.  All primary teeth were present.  Dental carries were present on the following teeth:  Tooth B, OL caries, tooth C, M, L, S caries, tooth B, caries on all surfaces, tooth E caries on all surfaces, tooth F caries on all surfaces, tooth T caries on all surfaces, tooth H, lingual and facial caries, tooth I, caries on all surfaces, tooth L caries on all surfaces, and tooth S, all caries.  The remainder of his teeth and soft tissues were within normal limits.  The following restoration and procedures were performed.  Tooth B, OL amalgam, tooth C, M, L, S composite, tooth D, E, F, and G were extracted, tooth H, and L and separate F composite.  Tooth I is stainless steel crown, tooth L pulpotomy and stainless steel crown and tooth S no amalgam.  Sutures were also placed at extraction site D, E, S, and G.,CONCLUSION:  ,The mother was informed of the completion of the procedure.  She was given a synopsis of the treatment provided as well as written and verbal instructions for postoperative care.  She is to contact to myself with an event of immediate postoperative complications and after full recovery, he was discharged from recovery room in the care of his mother.  She was also given prescription for Tylenol with Codeine Elixir for postoperative pain control.,", 
" Dysphagia, possible stricture.  Retained gastric contents forming a partial bezoar, suggestive of gastroparesis.", Surgery, Gastroscopy - 1 ,"PROCEDURE: , Gastroscopy.,PREOPERATIVE DIAGNOSES: , Dysphagia, possible stricture.,POSTOPERATIVE DIAGNOSIS: , Gastroparesis.,MEDICATION: , MAC.,DESCRIPTION OF PROCEDURE: , The Olympus gastroscope was introduced into the hypopharynx and passed carefully through the esophagus, stomach, and duodenum.  The hypopharynx was normal.  The esophagus had a normal upper esophageal sphincter, normal contour throughout, and a normal gastroesophageal junction viewed at 39 cm from the incisors.  There was no evidence of stricturing or extrinsic narrowing from her previous hiatal hernia repair.  There was no sign of reflux esophagitis.  On entering the gastric lumen, a large bezoar of undigested food was seen occupying much of the gastric fundus and body.  It had 2 to 3 mm diameter.  This was broken up using a scope into smaller pieces.  There was no retained gastric liquid.  The antrum appeared normal and the pylorus was patent.  The scope passed easily into the duodenum, which was normal through the second portion.  On withdrawal of the scope, additional views of the cardia were obtained, and there was no evidence of any tumor or narrowing.  The scope was withdrawn.  The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1.  Normal postoperative hernia repair.,2.  Retained gastric contents forming a partial bezoar, suggestive of gastroparesis.,3.  Otherwise normal upper endoscopy to the descending duodenum.,RECOMMENDATIONS:,1.  Continue proton pump inhibitors.,2.  Use Reglan 10 mg three to four times a day.",surgery
 Gastroscopy.  Dysphagia and globus.  No evidence of inflammation or narrowing to explain her symptoms., Surgery, Gastroscopy - 2 ,"PROCEDURE:,  Gastroscopy.,PREOPERATIVE DIAGNOSIS:,  Dysphagia and globus.,POSTOPERATIVE DIAGNOSIS: , Normal.,MEDICATIONS:,  MAC.,DESCRIPTION OF PROCEDURE: , The Olympus gastroscope was introduced through the oropharynx and passed carefully through the esophagus and stomach, and then through the gastrojejunal anastomosis into the efferent jejunal loop.  The preparation was good and all surfaces were well seen.  The hypopharynx was normal with no evidence of inflammation.  The esophagus had a normal contour and normal mucosa throughout with no sign of stricturing or inflammation or exudate.  The GE junction was located at 39 cm from the incisors and appeared normal with no evidence of reflux, damage, or Barrett's.  Below this there was a small gastric pouch measuring 6 cm with intact mucosa and no retained food.  The gastrojejunal anastomosis was patent measuring about 12 mm, with no inflammation or ulceration.  Beyond this there was a side-to-side gastrojejunal anastomosis with a short afferent blind end and a normal efferent end with no sign of obstruction or inflammation.  The scope was withdrawn and the patient was sent to recovery room.  She tolerated the procedure well.,FINAL DIAGNOSES:,1.  Normal post-gastric bypass anatomy.,2.  No evidence of inflammation or narrowing to explain her symptoms.","surgery, olympus gastroscope, gastric pouch, gastrojejunal anastomosis, dysphagia, globus, esophagus, mucosa, gastric, gastroscopy, gastrojejunal, inflammation "
 Cystoscopy and removal of foreign objects from the urethra., Surgery, Foreign Object Removal - Urethra ,"PREOPERATIVE DIAGNOSIS: , Prostate cancer.,POSTOPERATIVE DIAGNOSIS: , Prostate cancer.,OPERATION: , Cystoscopy and removal of foreign objects from the urethra.,BRACHYTHERAPY:,  Iodine 125.,ANESTHESIA: , General endotracheal.  The patient was given Levaquin 500 mg IV preoperatively.,Total seeds were 59.  Activity of 0.439, 30 seeds in the periphery with 10 needles and total of 8 seeds at the anterior of the fold, 4 needles.  Please note that the total needles placed on the top were actually 38 seeds and 22 seeds were returned back.,BRIEF HISTORY: , This is a 72-year-old male who presented to us with elevated PSA and prostate biopsy with Gleason 6 cancer on the right apex.  Options such as watchful waiting, brachytherapy, radical prostatectomy, cryotherapy, and external beam radiation were discussed.  Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE, incontinence, erectile dysfunction, urethral stricture, dysuria, burning pain, hematuria, future procedures, and failure of the procedure were all discussed.  The patient understood all the risks, benefits, and options and wanted to proceed with the procedure.  The patient wanted to wait until he came back from his summer vacations, so a one dose of Zoladex was given.  Prostate size measured about 15 g in the OR and about 22 g about two months ago.  Consent was obtained.,DETAILS OF THE OPERATION:  ,The patient was brought to the OR and anesthesia was applied.  The patient was placed in dorsal lithotomy position.  The patient had a Foley catheter placed sterilely.  The scrotum was taped up using Ioban.  Transrectal ultrasound was done.  The prostate was measured 15 g.  Multiple images were taken.  A volume study was done.  This was given to the physicist, Dr. X was present who is radiation oncologist who helped with implanting of the seeds.  Total of 38 seeds were placed in the patient with 10 peripheral needles and then 4 internal needles.  Total of 30 seeds were placed in the periphery and total of 8 seeds were placed in the inside.  They were done directly under transrectal ultrasound vision.  The seeds were placed directly under ultrasound guidance.  There was a nice distribution of the seeds.  A couple of more seeds were placed on the right side due to the location of the prostate cancer.  Subsequently at the end of the procedure, fluoroscopy was done.  Couple of images were obtained.  Cystoscopy was done at the end of the procedure where a seed was visualized right in the urethra, which was grasped and pulled out using grasper, which was difficult to get the seed off of the spacers, which was actually pulled out.  There were no further seeds visualized in the bladder.  The bladder appeared normal.  At the end of the procedure, a Foley catheter was kept in place of 18 French and the patient was brought to recovery in stable condition.","surgery, foreign objects, foley catheter, transrectal ultrasound, prostate cancer, cystoscopy, ultrasound, urethra, endotracheal, prostate"
" Right frontotemporoparietal craniotomy, evacuation of acute subdural hematoma.   Acute subdural hematoma, right, with herniation syndrome.", Surgery, Frontotemporoparietal Craniotomy ,"PREOPERATIVE DIAGNOSES: , Acute subdural hematoma, right, with herniation syndrome.,POSTOPERATIVE DIAGNOSES: , Acute subdural hematoma, right, with herniation syndrome.,OPERATION PERFORMED:  ,Right frontotemporoparietal craniotomy, evacuation of acute subdural hematoma.,ANESTHESIA: , General endotracheal.,PREPARATION: , Povidone.,INDICATION:,  This is an 83-year-old male with herniation syndrome with large subdural hematoma 100%.  This procedure is being done as an emergency procedure in an attempt to save his life and maximize the potential for recovery.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room intubated.  The patient previously was given fresh frozen plasma plus recombinant activated factor VII.  The patient had a roll placed on his right shoulder, head was maintained three point fixation with a Mayfield headholder.  The right side of the head was shaved, thoroughly prepped and draped, a large ? scalp incision was marked, infiltrated with local and incised with a scalpel, Raney clips were applied to the scalp margins, hemostasis, temporalis muscle and fascia, pericranium opened and aligned with incision, flap was reflected anteriorly.  Burr holes are placed low in the temporal bone at the keyhole posteriorly and then superiorly with a perforator, then using Midas Rex drill with a B1 foot plate a free flap was turned.  The dura was opened in a cruciate fashion, acute subdural hematoma was evacuated.  There was a small arterial bleeder in the anterior parietal region, which was controlled with bipolar electrocautery.  Using suction and biopsy forceps, acute clot was resected from the frontotemporoparietal and occipital poles, subdural space was irrigated, no further bleeders were encountered.  Dura was closed with 4-0 Nurolon.  A subdural Camino ICP catheter was placed in the subdural space.  Bone flaps secured in place with neuro clips with 5 mm screws, central pack up suture was placed, dural tack up sutures were placed using 4-0 Nurolon prior to placement of the bone flap.  The wound was irrigated with saline, temporalis muscle and fascia closed with 2-0 Vicryl, subgaleal Hemovac was placed, galea was closed with 2-0 Vicryl, and scalp with staples.  ICP monitor and the Hemovac were sutured in place with 2-0 Vicryl.  The patient was taken out of the head holder, a sterile dressing placed.  The head was wrapped.  The patient was taken directly to ICU, still intubated in guarded condition.  Brain was nicely soft and pulsatile.  At the termination of the procedure, no significant contusion of the brain was identified.  Final sponge and needle counts are correct.  Estimated blood loss 400 cc.","surgery, subdural hematoma, craniotomy, herniation, subdural, temporalis, frontotemporoparietal, hematoma,"
 Patient with complaint of a very painful left foot because of the lesions on the bottom of the foot. , Surgery, Foot Lesions ,"S -, An 84-year-old diabetic female, 5'7-1/2"" tall, 148 pounds, history of hypertension and diabetes.  She presents today with complaint of a very painful left foot because of the lesions on the bottom of the foot.  She also has a left great toenail that is giving her problems as well.,O - ,Plantar to the left first metatarsal head is a very panful hyperkeratotic lesion that measures 1.1 cm in diameter.  There is a second lesion plantar to the fifth plantarflex metatarsal head which also measures 1.1 cm in diameter.  These lesions have become so painful that the patient is now having difficulty walking wearing shoes or even doing gardening.  The first and fifth metatarsal heads are plantarflexed.  Vibratory sensation appears to be absent.  Dorsal pedal pulses are nonpalpable.  Varicose veins are visible to the skin on the patient's feet that are very thin, almost transparent.  The medial aspect of the left great toenail has dried blood under the nail.  The nail itself is very opaque, loose from the nailbed almost rotten, opaque, discolored, hypertrophic.  All of the patient's toenails are elongated and discolored and opaque as well.  There is dried blood under the medial aspect of the left great toenail.,A - ,1.  Painful feet.,","surgery, painful left foot, lesions, plantar, metatarsal head, hyperkeratotic lesion, toenail, nail matrix, metatarsal, metatarsal heads, foot, painful"
" Excision of foreign body, right foot and surrounding tissue.  This 41-year-old male presents to preoperative holding area after keeping himself n.p.o., since mid night for removal of painful retained foreign body in his right foot.  The patient works in the Electronics/Robotics field and relates that he stepped on a wire at work, which somehow got into his shoe.  The wire entered his foot.", Surgery, Foreign Body Removal - Foot ,"PREOPERATIVE DIAGNOSIS: , Foreign body, right foot.,POSTOPERATIVE DIAGNOSIS: , Foreign body in the right foot.,PROCEDURE PERFORMED:,  Excision of foreign body, right foot and surrounding tissue.,ANESTHESIA: , TIVA and local.,HISTORY:,  This 41-year-old male presents to preoperative holding area after keeping himself n.p.o., since mid night for removal of painful retained foreign body in his right foot.  The patient works in the Electronics/Robotics field and relates that he stepped on a wire at work, which somehow got into his shoe.  The wire entered his foot.  His family physician attempted to remove the wire, but it only became deeper in the foot.  The wound eventually healed, but a scar tissue was formed.  The patient has had constant pain with ambulation intermittently since the incident occurred.  He desires attempted surgical removal of the wire.  The risks and benefits of the procedure have been explained to the patient in detail by Dr. X.  The consent is available on the chart for review.,PROCEDURE IN DETAIL: , After IV was established by the Department of Anesthesia, the patient was taken to the operating room via cart and placed on the operating table in a supine position with a safety strap placed across his waist for his protection.,A pneumatic ankle tourniquet was applied about the right ankle over copious amounts of Webril for the patient's protection.  After adequate IV sedation was administered by the Department of Anesthesia, a total of 12 cc of 0.5% Marcaine plain was used to administer an ankle block.  Next, the foot was prepped and draped in the usual aseptic fashion.  An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg.  The foot was lowered into the operative field and the sterile stockinet was reflected.  Attention was directed to the plantar aspect of the foot where approximately a 5 mm long cicatrix was palpated and visualized.  This was the origin and entry point of the previous puncture wound from the wire.  This cicatrix was found lateral to the plantar aspect of the first metatarsal between the first and second metatarsals in a nonweightbearing area.  Next, the Xi-scan was draped and brought into the operating room.  A #25 gauge needles under fluoroscopy were inserted into the plantar aspect of the foot and three planes to triangulate the wire.  Next, a #10 blade was used to make approximately a 3 cm curvilinear ""S""-shaped incision.  Next, the #15 blade was used to carry the incision through the subcutaneous tissue.  The medial and lateral margins of the incision were undermined.  Due to the small nature of the foreign body and the large amount of fat on the plantar aspect of the foot, the wires seemed to serve no benefit other then helping with the incision planning.  Therefore, they were removed.  Once the wound was opened, a hemostat was used to locate the wire very quickly and the wire was clamped.  A second hemostat was used to clamp the wire.  A #15 blade was used to carefully transect the fatty tissue around the tip of the hemostats, which were visualized in the base of the wound.  The wire quickly came into visualization.  It measured approximately 4 mm in length and was approximately 1 mm in diameter.  The wire was green colored and metallic in nature.  It was removed with the hemostat and passed off as a specimen to be sent to Pathology for identification.  The wire was found at the level of deep fascia at the capsular level just plantar to the deep transverse intermetatarsal ligament.  Next, copious amounts of sterile gentamicin impregnated saline was instilled in the wound for irrigation and the wound base was thoroughly cleaned and inspected.  Next, a #3-0 Vicryl was used to throw two simple interrupted deep sutures to remove the dead space.  Next, #4-0 Ethibond was used to close the skin in a combination of simple interrupted and horizontal mattress suture technique.  The standard postoperative dressing consisting of saline-soaked Owen silk, 4x4s, Kling, Kerlix, and Coban were applied.  The pneumatic ankle tourniquet was released.  There was immediate hyperemic flush to the digits noted.  The patient's anesthesia was reversed.  He tolerated the above anesthesia and procedure without complications.  The patient was transported via cart to the Postanesthesia Care Unit.,Vital signs were stable and vascular status was intact to the right foot.  He was given OrthoWedge shoe.  Ice was applied behind the knee and his right lower extremity was elevated on to pillows.  He was given standard postoperative instructions consisting of rest, ice and elevation to the right lower extremity.  He is to be non-weightbearing for three weeks, at which time, the wound will be evaluated and sutures will be removed.  He is to follow up with Dr. X on 08/22/2003 and was given emergency contact number to call if problems arise.  He was given a prescription for Tylenol #4, #30 one p.o. q.4-6h. p.r.n., pain as well as Celebrex 200 mg #30 take two p.o. q.d. p.c., with 200 mg 12 hours later as a rescue dose.  He was given crutches.  He was discharged in stable condition.","surgery, foreign body removal, excision of foreign body, ankle tourniquet, plantar aspect, foreign body, foot, ankle, plantar, wound,"
" Cellulitis with associated abscess and foreign body, right foot. Irrigation debridement and removal of foreign body of right foot.  Purulent material from the abscess located in the plantar aspect of the foot between the third and fourth metatarsal heads.", Surgery, Foreign Body Removal - Foot - 1 ,"PREOPERATIVE DIAGNOSES:,1.  Cellulitis with associated abscess, right foot.,2.  Foreign body, right foot.,POSTOPERATIVE DIAGNOSES:,1.  Cellulitis with associated abscess, right foot.,2.  Foreign body, right foot.,PROCEDURE PERFORMED:,1.  Irrigation debridement.,2.  Removal of foreign body of right foot.,ANESTHESIA:,  Spinal with sedation.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , Minimal.,GROSS FINDINGS: , Include purulent material from the abscess located in the plantar aspect of the foot between the third and fourth metatarsal heads.,HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old Caucasian male with a history of uncontrolled diabetes mellitus.  The patient states that he was working in his garage over the past few days when he noticed some redness and edema in his right foot.  He notes some itching as well as increasing pain and redness in the right foot and presented to ABCD General Hospital Emergency Room.  He was evaluated by the Emergency Room staff as well as the medical team and the Department of Orthopedics.  It was noted upon x-ray a foreign body in his foot and he had significant amount of cellulitis as well ________ right lower extremity.  After a long discussion held with the patient, it was elected to proceed with irrigation debridement and removal of the foreign body.,PROCEDURE: , After all potential complications, risks, as well as anticipated benefits of the above-named procedures were discussed at length with the patient, informed consent was obtained.  The operative extremity was then confirmed with the patient, operative surgeon, the Department of Anesthesia and nursing staff.  The patient was then transferred to preoperative area to Operative Suite #5 and placed on the operating table in supine position.  All bony prominences were well padded at this time.  The Department of Anesthesia was administered spinal anesthetic to the patient.  Once this anesthesia was obtained, the patient's right lower extremity was sterilely prepped and draped in the usual sterile fashion.  Upon viewing of the plantar aspect of the foot, there was noted to be a swollen ecchymotic area with a small hole in it, which purulent fluid was coming from.  At this time, after all bony and soft tissue landmarks were identified as well as the localization of the pus, a 2 cm longitudinal incision was made directly over this area, which was located between the second and third metatarsal heads.  Upon incising this, there was a foul smelling purulent fluid, which flowed from this region.  Aerobic and anaerobic cultures were taken as well as gram stain.  The area was explored and it ________ to the dorsum of the foot.  There was no obvious joint involvement.  After all loculations were broken, 3 liters antibiotic-impregnated fluid were pulse-evac through the wound.  The wound was again inspected with no more gross purulent or necrotic appearing tissue.  The wound was then packed with an iodoform gauge and a sterile dressing was applied consisting of 4x4s, floss, and Kerlix covered by an Ace bandage.  At this time, the Department of Anesthesia reversed the sedation.  The patient was transferred back to the hospital gurney to Postanesthesia Care Unit.  The patient tolerated the procedure well and there were no complications.,DISPOSITION:  ,The patient will be followed on a daily basis for possible repeat irrigation debridement.","surgery, removal of foreign body, purulent material, metatarsal, cellulitis, abscess, kerlix, foreign body, foot, irrigation, debridement, purulent, "
" Microscopic hematuria with lateral lobe obstruction, mild.", Surgery, Flexible Cystoscopy - BPH ,"PREOPERATIVE DIAGNOSIS: , Microscopic hematuria.,POSTOPERATIVE DIAGNOSIS:,  Microscopic hematuria with lateral lobe obstruction, mild.,PROCEDURE PERFORMED: , Flexible cystoscopy.,COMPLICATIONS: , None.,CONDITION: , Stable.,PROCEDURE: , The patient was placed in the supine position and sterilely prepped and draped in the usual fashion.  After 2% lidocaine was instilled, the anterior urethra is normal.  The prostatic urethra reveals mild lateral lobe obstruction.  There are no bladder tumors noted.,IMPRESSION:,  The patient has some mild benign prostatic hyperplasia.  At this point in time, we will continue with conservative observation.,PLAN: , The patient will follow up as needed.","surgery, benign prostatic hyperplasia, urethra, lateral lobe obstruction, flexible cystoscopy, microscopic hematuria, cystoscopy, hematuria, obstruction,"
" Flexible fiberoptic bronchoscopy with right lower lobe bronchoalveolar lavage and right upper lobe endobronchial biopsy.  Severe tracheobronchitis, mild venous engorgement with question varicosities associated pulmonary hypertension, right upper lobe submucosal hemorrhage without frank mass underneath it status post biopsy.", Surgery, Flexible Fiberoptic Bronchoscopy ,"PREOPERATIVE/POSTOPERATIVE DIAGNOSES:,1.  Severe tracheobronchitis.,2.  Mild venous engorgement with question varicosities associated pulmonary hypertension.,3.  Right upper lobe submucosal hemorrhage without frank mass underneath it status post biopsy.,PROCEDURE PERFORMED: , Flexible fiberoptic bronchoscopy with:,a.  Right lower lobe bronchoalveolar lavage.,b.  Right upper lobe endobronchial biopsy.,SAMPLES: , Bronchoalveolar lavage for cytology and for microbiology of the right lower lobe endobronchial biopsy of the right upper lobe.,INDICATIONS: , The patient with persistent hemoptysis of unclear etiology.,PROCEDURE: , After obtaining informed consent, the patient was brought to Bronchoscopy Suite.  The patient had previously been on Coumadin and then heparin.  Heparin was discontinued approximately one-and-a-half hours prior to the procedure.  The patient underwent topical anesthesia with 10 cc of 4% Xylocaine spray to the left nares and nasopharynx.  Blood pressure, EKG, and oximetry monitoring were applied and monitored continuously throughout the procedure.  Oxygen at two liters via nasal cannula was delivered with saturations in the 90% to 100% throughout the procedure.  The patient was premedicated with 50 mg of Demerol and 2 mg of Versed.  After conscious sedation was achieved, the bronchoscope was advanced through the left nares into the nasopharynx and oropharynx.  There was minimal redundant oral soft tissue in the oropharynx.  There was mild erythema.  Clear secretions were suctioned.,Additional topical anesthesia was applied to the larynx and then throughout the tracheobronchial tree for the procedure, a total of 16 cc of 2% Xylocaine was applied.  Vocal cord motion was normal.  The bronchoscope was then advanced through the larynx into the trachea.  There was evidence of moderate inflammation with prominent vascular markings and edema.  No frank blood was visualized.  The area was suction clear of copious amounts of clear white secretions.  Additional topical anesthesia was applied and the bronchoscope was advanced into the left main stem.  The bronchoscope was then sequentially advanced into each segment and sub-segment of the left upper lobe and left lower lobe.  There was significant amount of inflammation, induration, and vascular tortuosity in these regions.  No frank blood was identified.  No masses or lesions were identified.  There was senile bronchiectasis with slight narrowing and collapse during the exhalation.  The air was suctioned clear.  The bronchoscope was withdrawn and advanced into the right main stem.  Bronchoscope was introduced into the right upper lobe and each sub-segment was visualized.  Again significant amounts of tracheobronchitis was noted with vascular infiltration.  In the sub-carina of the anterior segment of the right upper lobe, there was evidence of a submucosal hematoma without frank mass underneath this.  The bronchoscope was removed and advanced into the right middle and right lower lobe.  There was marked injection and inflammation in these regions.  In addition, there was marked vascular engorgement with near frank varicosities identified throughout the region.  Again, white clear secretions were identified.  No masses or other processes were noted.  The area was suctioned clear.  A bronchoalveolar lavage was subsequently performed in the anterior segment of the right lower lobe.  The bronchoscope was then withdrawn and readvanced into the right upper lobe.  Endobronchial biopsies of the carina of the sub-segment and anterior segment of the right upper lobe were obtained.  Minimal hemorrhage occurred after the biopsy, which stopped after 1 cc of 1:1000 epinephrine.  The area remained clear.  No further hemorrhage was identified.  The bronchoscope was subsequently withdrawn.  The patient tolerated the procedure well and was stable throughout the procedure.  No further hemoptysis was identified.  The patient was sent to Recovery in good condition.","surgery, bronchoalveolar lavage, endobronchial biopsy, cytology, microbiology, tracheobronchitis, venous engorgement, varicosities, pulmonary hypertension, flexible fiberoptic bronchoscopy, fiberoptic bronchoscopy, lobe, bronchoalveolar, lavage, endobronchial, hemorrhage, oropharynx, vascular, bronchoscopy, biopsy, submucosal, bronchoscope"
" Removal of foreign body of right thigh.  Foreign body of the right thigh, sewing needle.", Surgery, Foreign Body Removal - Thigh ,"PREPROCEDURE DIAGNOSIS:,  Foreign body of the right thigh.,POSTOPERATIVE DIAGNOSIS: , Foreign body of the right thigh, sewing needle.,PROCEDURE:  ,Removal of foreign body of right thigh.,HISTORY:  ,This is a 71-year-old lady who has been referred because there is a mass in the right thigh.  The patient comes with an ultrasound and apparently was diagnosed with a blood clot.  On physical examination, blood pressure was 152/76 and temperature was 95.0.  The patient is 5 feet 1 inch and weighs 170.  On examination of her right thigh, there is a transverse area of ecchymosis in the upper third of the thigh.  There is a palpation of a very sharp object just under the skin.  The patient desires for this to be removed.,DESCRIPTION OF PROCEDURE: , After obtaining informed consent in our office, the area was prepped and draped in usual fashion.  Xylocaine 1% was infiltrated in the end of the object that was the sharpest and a small incision was made there and then I pushed the foreign body through partially and then grabbed it with a hemostat and took it out and it was a 1-1/2-inch sewing needle.,Compression was applied for a few minutes and then a Band-Aid was applied.,The patient was given a tetanus toxoid 0.5 cc IM shot injection and then she was dismissed with instructions of return if inflammatory signs develop.","surgery, removal of foreign body, sewing needle, foreign body"
" Flexor carpi radialis and palmaris longus repair.  Right wrist laceration with a flexor carpi radialis laceration and palmaris longus laceration 90%, suspected radial artery laceration.", Surgery, Flexor Carpi Radialis & Palmaris Longus Repair ,"PREOPERATIVE DIAGNOSIS:,  Right wrist laceration with a flexor carpi radialis laceration and palmaris longus laceration 90%, suspected radial artery laceration.,POSTOPERATIVE DIAGNOSIS:,  Right wrist laceration with a flexor carpi radialis laceration and palmaris longus laceration 90%, suspected radial artery laceration.,PROCEDURES PERFORMED:  ,1.  Repair flexor carpi radialis.,2.  Repair palmaris longus.,ANESTHETIC: , General.,TOURNIQUET TIME:  ,Less than 30 minutes.,CLINICAL NOTE:  ,The patient is a 21-year-old who sustained a clean laceration off a teapot last night.  She had lacerated her flexor carpi radialis completely and 90% of her palmaris longus.  Both were repaired proximal to the carpal tunnel.  The postoperative plans are for a dorsal splint and early range of motion passive and active assist.  The wrist will be at approximately 30 degrees of flexion.  The MPJ is at 30 degrees of flexion, the IP straight.  Splinting will be used until the 4-week postoperative point.,PROCEDURE: , Under satisfactory general anesthesia, the right upper extremity was prepped and draped in the usual fashion.  There were 2 transverse lacerations.  Through the first laceration, the flexor carpi radialis was completely severed.  The proximal end was found with a tendon retriever.  The distal end was just beneath the subcutaneous tissue.,A primary core stitch was used with a Kessler stitch.  This was with 4-0 FiberWire.  A second core stitch was placed, again using 4-0 FiberWire.  The repair was oversewn with locking, running, 6-0 Prolene stitch.  Through the second incision, the palmaris longus was seen to be approximately 90% severed.  It was an oblique laceration.  It was repaired with a 4-0 FiberWire core stitch and with a Kessler-type stitch.  A secure repair was obtained.  She was dorsiflexed to 75 degrees of wrist extension without rupture of the repair.  The fascia was released proximally and distally to give her more room for excursion of the repair.,The tourniquet was dropped, bleeders were cauterized.  Closure was routine with interrupted 5-0 nylon.  A bulky hand dressing as well as a dorsal splint with the wrist MPJ and IP as noted.  The splint was dorsal.  The patient was sent to the recovery room in good condition.","surgery, kessler stitch, flexor carpi radialis, palmaris longus, radialis, laceration, fiberwire, flexor, carpi, palmaris, longus, repair"
" Flexible nasal laryngoscopy.  Foreign body, left vallecula at the base of the tongue.   Airway is patent and stable.", Surgery, Flexible Nasal Laryngoscopy ,"PREOPERATIVE DIAGNOSIS:  ,Oropharyngeal foreign body.,POSTOPERATIVE DIAGNOSES:,1.  Foreign body, left vallecula at the base of the tongue.,2.  Airway is patent and stable.,PROCEDURE PERFORMED: , Flexible nasal laryngoscopy.,ANESTHESIA:,  ______ with viscous lidocaine nasal spray.,INDICATIONS: , The patient is a 39-year-old Caucasian male who presented to ABCD General Hospital Emergency Department with acute onset of odynophagia and globus sensation.  The patient stated his symptoms began around mid night after returning home _________ ingesting some chicken.  The patient felt that he had ingested a chicken bone, tried to dislodge this with fluids and other solid foods as well as sticking his finger down his throat without success.  The patient subsequently was seen in the Emergency Department where it was discovered that the patient had a left vallecular foreign body.  Department of Otolaryngology was asked to consult for further evaluation and treatment of this foreign body.,PROCEDURE: , After verbal informed consent was obtained, the patient was placed in the upright position.  The fiberoptic nasal laryngoscope was inserted in the patient's right naris and then the left naris.  There was visualized some bilateral caudal spurring of the septum.  The turbinates were within normal limits.  There was some posterior nasoseptal deviation to the left.  The nasal laryngoscope was then inserted back into the right naris and it was advanced along the floor of the nasal cavity.  The nasal mucous membranes were pink and moist.  There was no evidence of mass, ulceration, lesion, or obstruction.,The scope was further advanced to the level of the nasopharynx where the eustachian tubes were visualized bilaterally.  There was evidence of some mild erythema in the right fossa Rosenmüller.  There was no evidence of mass lesion or ulceration in this area, however.  The eustachian tubes were patent without obstruction.  The scope was further advanced to the level of the oropharynx where the base of the tongue, vallecula, and epiglottis were visualized.  There was evidence of a 1.5 cm left vallecular white foreign body.  The rest of the oropharynx was without abnormality.  The epiglottis was within normal limits and was noted to be omega in shape.  There was no edema or erythema to the epiglottis.  The scope was then further advanced to the level of the hypopharynx to the level of the true vocal cords.  There was no evidence of erythema or edema of the posterior commissure, arytenoid cartilage, or superior surface of the vocal cords.  The laryngeal surface of the epiglottis was within normal limits.  There was no evidence of mass lesion or nodularity of the vocal cords.  The patient was asked to Valsalva and the piriform sinuses were observed without evidence of foreign body or mass lesion.  The patient did have complete glottic closure upon phonation and the airway was patent and stable throughout the exam.  The glottic aperture was completely patent with inspiration.  The anterior commissure, epiglottic folds, false vocal cords, and piriform sinuses were all within normal limits.  The scope was then removed without difficulty.  The patient tolerated the procedure well and remained in stable condition.,FINDINGS:,1.  A 1.5 cm white foreign body consistent with a chicken bone at the left vallecular region.  There is no evidence of supraglottic or piriform sinuses foreign body.,2.  Mild erythema of the right nasopharynx in the region of the fossa Rosenmüller.  No mass is appreciated at this time.,PLAN:,  The patient is to go to the operating room for direct laryngoscopy/microscopic suspension direct laryngoscopy for removal of foreign body under anesthesia this a.m.  Airway precautions were instituted.  The patient currently remained in stable condition.","surgery, oropharyngeal foreign body, flexible nasal laryngoscopy, nasal spray, foreign body, tongue, laryngoscopy, erythema, epiglottis, nasal, oropharyngeal"
 CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking., Surgery, Frameless Stereotactic Radiosurgery ,"PREOPERATIVE DIAGNOSIS:,  Right occipital arteriovenous malformation.,POSTOPERATIVE DIAGNOSIS:,  Right occipital arteriovenous malformation.,PROCEDURE PERFORMED:,  CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking.,Please note no qualified resident was available to assist in the procedure.,INDICATION: , The patient is a 30-year-old male with a right occipital AVM.  He was referred for stereotactic radiosurgery.  The risks of the radiosurgical treatment were discussed with the patient including, but not limited to, failure to completely obliterate the AVM, need for additional therapy, radiation injury, radiation necrosis, headaches, seizures, visual loss, or other neurologic deficits.  The patient understands these risks and would like to proceed.,PROCEDURE IN DETAIL: , The patient arrived to Outpatient CyberKnife Suite one day prior to the treatment.  He was placed on the treatment table.  The Aquaplast mask was constructed.  Initial imaging was obtained by the CyberKnife system.  The patient was then transported over to the CT scanner at Stanford.  Under the supervision of Dr. X, 125 mL of Omnipaque 250 contrast was administered.  Dr. X then supervised the acquisition of 1.2-mm contiguous axial CT slices.  These images were uploaded over the hospital network to the treatment planning computer, and the patient was discharged home.,Treatment plan was then performed by me.  I outlined the tumor volume.  Inverse treatment planning was used to generate the treatment plan for this patient.  This resulted in a total dose of 20 Gy delivered to 84% isodose line using a 12.5 mm collimator.  The maximum dose within this center of treatment volume was 23.81 Gy.  The volume treated was 2.972 mL, and the treated lesion dimensions were 1.9 x 2.7 x 1.6 cm.  The volume treated at the reference dose was 98%.  The coverage isodose line was 79%.  The conformality index was 1.74 and modified conformality index was 1.55.  The treatment plan was reviewed by me and Dr. Y of Radiation Oncology, and the treatment plan was approved.,On the morning of May 14, 2004, the patient arrived at the Outpatient CyberKnife Suite.  He was placed on the treatment table.  The Aquaplast mask was applied.  Initial imaging was used to bring the patient into optimal position.  The patient underwent stereotactic radiosurgery to deliver the 20 Gy to the AVM margin.  He tolerated the procedure well.  He was given 8 mg of Decadron for prophylaxis and discharged home.,Followup will consist of an MRI scan in 6 months.  The patient will return to our clinic once that study is completed.,I was present and participated in the entire procedure on this patient consisting of CT-guided frameless stereotactic radiosurgery for the right occipital AVM.,Dr. X was present during the entire procedure and will be dictating his own operative note.","surgery, ct-guided, occipital, cyberknife, frameless stereotactic radiosurgery, occipital arteriovenous malformation, conformality index, arteriovenous malformation, malformation, avm, arteriovenous,"
" Fogarty thrombectomy, left forearm arteriovenous Gore-Tex bridge fistula and revision of distal anastomosis with 7 mm interposition Gore-Tex graft.  Chronic renal failure and thrombosed left forearm arteriovenous Gore-Tex bridge fistula.", Surgery, Fogarty Thrombectomy ,"PREOPERATIVE DIAGNOSES:,1.  Chronic renal failure.,2.  Thrombosed left forearm arteriovenous Gore-Tex bridge fistula.,POSTOPERATIVE DIAGNOSIS:,1.  Chronic renal failure.,2.  Thrombosed left forearm arteriovenous Gore-Tex bridge fistula.,PROCEDURE PERFORMED:,1.  Fogarty thrombectomy, left forearm arteriovenous Gore-Tex bridge fistula.,2.  Revision of distal anastomosis with 7 mm interposition Gore-Tex graft.,ANESTHESIA:,  General with controlled ventillation.,GROSS FINDINGS: , The patient is a 58-year-old black male with chronic renal failure.  He undergoes dialysis through the left forearm bridge fistula and has small pseudoaneurysms at the needle puncture sites level.  There is narrowing at the distal anastomosis due to intimal hypoplasia and the vein beyond it was of good quality.,OPERATIVE PROCEDURE: , The patient was taken to the OR suite, placed in supine position.  General anesthetic was administered.  Left arm was prepped and draped in appropriate manner.  A Pfannenstiel skin incision was created just below the antecubital crease just deeper to the subcutaneous tissue.  Utilizing both blunt and sharp dissections segment of the fistula was isolated ________ vessel loop.  Transverse graftotomy was created.  A #4 Fogarty catheter passed proximally and distally restoring inflow and meager inflow.  A fistulogram was performed and the above findings were noted.  In a retrograde fashion, the proximal anastomosis was patent.  There was no narrowing within the forearm graft.  Both veins were flushed with heparinized saline and controlled with a vascular clamp.  A longitudinal incision was then created in the upper arm just deep into the subcutaneous tissue fascia.  Utilizing both blunt and sharp dissection, the brachial vein as well as distal anastomosis was isolated.  The distal anastomosis amputated off the fistula and oversewn with continuous running #6-0 Prolene suture tied upon itself.  The vein was controlled with vascular clamps.  Longitudinal venotomy created along the anteromedial wall.  A 7 mm graft was brought on to the field and this was cut to shape and size.  This was sewed to the graft in an end-to-side fashion with U-clips anchoring the graft at the heel and toe with interrupted #6-0 Prolene sutures.  Good backflow bleeding was confirmed.  The vein flushed with heparinized saline and graft was controlled with vascular clamp.  The end of the insertion graft was cut to shape in length and sutured to the graft in an end-to-end fashion with continuous running #6-0 Prolene suture.  Good backflow bleeding was confirmed.  The graftotomy was then closed with interrupted #6-0 Prolene suture.  Flow through the fistula was permitted, a good flow passed.  The wound was copiously irrigated with antibiotic solution.  Sponge, needles, instrument counts were correct.  All surgical sites were inspected.  Good hemostasis was noted.  The incision was closed in layers with absorbable sutures.  Sterile dressing was applied.  The patient tolerated the procedure well and returned to the recovery room in apparent stable condition.","surgery, chronic renal failure, thrombosed, gore-tex bridge fistula, arteriovenous, fogarty, thrombectomy, anastomosis, gore tex bridge, fogarty thrombectomy, prolene suture, renal failure, distal anastomosis, bridge fistula, interposition, renal, prolene"
" Flexible fiberoptic bronchoscopy diagnostic with right middle and upper lobe lavage and lower lobe transbronchial biopsies.  Mild tracheobronchitis with history of granulomatous disease and TB, rule out active TB/miliary TB.", Surgery, Flexible Fiberoptic Bronchoscopy -1 ,"POSTOPERATIVE DIAGNOSIS:,  Mild tracheobronchitis with history of granulomatous disease and TB, rule out active TB/miliary TB.,PROCEDURE PERFORMED:,  Flexible fiberoptic bronchoscopy diagnostic with:,a.  Right middle lobe bronchoalveolar lavage.,b.  Right upper lobe bronchoalveolar lavage.,c.  Right lower lobe transbronchial biopsies.,COMPLICATIONS:,  None.,Samples include bronchoalveolar lavage of the right upper lobe and right middle lobe and transbronchial biopsies of the right lower lobe.,INDICATION:  ,The patient with a history of TB and caseating granulomata on open lung biopsy with evidence of interstitial lung disease and question tuberculosis.,PROCEDURE:,  After obtaining an informed consent, the patient was brought to the Bronchoscopy Suite with appropriate isolation related to ______ precautions.  The patient had appropriate oxygen, blood pressure, heart rate, and respiratory rate monitoring applied and monitored continuously throughout the procedure.  2 liters of oxygen via nasal cannula was applied to the nasopharynx with 100% saturations achieved.  Topical anesthesia with 10 cc of 4% Xylocaine was applied to the right nares and oropharynx.  Subsequent to this, the patient was premedicated with 50 mg of Demerol and then Versed 1 mg sequentially for a total of 2 mg.  With this, adequate consciousness sedation was achieved.  3 cc of 4% viscous Xylocaine was applied to the right nares.  The bronchoscope was then advanced through the right nares into the nasopharynx and oropharynx.,The oropharynx and larynx were well visualized and showed mild erythema, mild edema, otherwise negative.,There was normal vocal cord motion without masses or lesions.  Additional topical anesthesia with 2% Xylocaine was applied to the larynx and subsequently throughout the tracheobronchial tree for a total of 18 cc.  The bronchoscope was then advanced through the larynx into the trachea.  The trachea showed mild evidence of erythema and moderate amounts of clear frothy secretions.  These were suctioned clear.  The bronchoscope was then advanced through the carina, which was sharp.  Then advanced into the left main stem and each segment, subsegement in the left upper lingula and lower lobe was visualized.  There was mild tracheobronchitis with mild friability throughout.  There was modest amounts of white secretion.  There were no other findings including evidence of mass, anatomic distortions, or hemorrhage.  The bronchoscope was subsequently withdrawn and advanced into the right mainstem.  Again, each segment and subsegment was well visualized.  The right upper lobe anatomy showed some segmental distortion with dilation and irregularities both at the apical region as well as in the subsegments of the anteroapical and posterior segments.  No specific masses or other lesions were identified throughout the tracheobronchial tree on the right.  There was mild tracheal bronchitis with friability.  Upon coughing, there was punctate hemorrhage.  The bronchoscope was then advanced through the bronchus intermedius and the right middle lobe and right lower lobe.  These again had no other anatomic lesions identified.  The bronchoscope was then wedged in the right middle lobe and bronchoalveolar samples were obtained.  The bronchoscope was withdrawn and the area was suctioned clear.  The bronchoscope was then advanced into the apical segment of the right upper lobe and the bronchioalveolar lavage again performed.  Samples were taken and the bronchoscope was removed suctioned the area clear.  The bronchoscope was then re-advanced into the right lower lobe and multiple transbronchial biopsies were taken under fluoroscopic guidance in the posterior and lateral segments of the right lower lobe.  Minimal hemorrhage was identified and suctioned clear without difficulty.  The bronchoscope was then withdrawn to the mainstem.  The area was suctioned clear.  Fluoroscopy revealed no evidence of pneumothorax.  The bronchoscope was then withdrawn.  The patient tolerated the procedure well without evidence of desaturation or complications.","surgery, bronchoalveolar, lavage, lobe, tracheobronchitis, granulomatous, miliary tb, tb, flexible fiberoptic bronchoscopy, bronchoscope, flexible, fiberoptic, transbronchial, biopsies, bronchoscopy, oropharynx,"
" Recurring bladder infections with frequency and urge incontinence, not helped with Detrol LA.  Normal cystoscopy with atrophic vaginitis.", Surgery, Flexible Cystoscopy - Atrophic Vaginitis ,"PREOPERATIVE DIAGNOSIS:,  Recurring bladder infections with frequency and urge incontinence, not helped with Detrol LA.,POSTOPERATIVE DIAGNOSIS: , Normal cystoscopy with atrophic vaginitis.,PROCEDURE PERFORMED: , Flexible cystoscopy.,FINDINGS:,  Atrophic vaginitis.,PROCEDURE:  ,The patient was brought in to the procedure suite, prepped and draped in the dorsal lithotomy position.  The patient then had flexible scope placed through the urethral meatus and into the bladder.  Bladder was systematically scanned noting no suspicious areas of erythema, tumor or foreign body.  Significant atrophic vaginitis is noted.,IMPRESSION: , Atrophic vaginitis with overactive bladder with urge incontinence.,PLAN: , The patient will try VESIcare 5 mg with Estrace and follow up in approximately 4 weeks.","surgery, urge incontinence, frequency, overactive bladder, vesicare, flexible cystoscopy, bladder infections, atrophic vaginitis, incontinence, cystoscopy, vaginitis,"
" Breast flap revision, nipple reconstruction, reduction mammoplasty, breast medial lesion enclosure.", Surgery, Flap revision ,"PREOPERATIVE DIAGNOSES,1.  Acquired absence of bilateral breast status post previous bilateral DIEP flap reconstruction.,2.  Bilateral breast asymmetry.,3.  Right breast macromastia.,4.  Right abdominal scar deformity.,5.  Left abdominal scar deformity.,6.  A 1.3 cm lesion right inferior breast.,7.  Lesion measuring 0.5 cm right inferior breast lateral.,POSTOPERATIVE DIAGNOSES,1.  Acquired absence of bilateral breast status post previous bilateral DIEP flap reconstruction.,2.  Bilateral breast asymmetry.,3.  Right breast macromastia.,4.  Right abdominal scar deformity.,5.  Left abdominal scar deformity.,6.  A 1.3 cm lesion right inferior breast.,7.  Lesion measuring 0.5 cm right inferior breast lateral.,PROCEDURES,1.  Left breast flap revision.,2.  Right breast flap revision.,3.  Right breast reduction mammoplasty.,4.  Right nipple reconstruction.,5.  Left abdominal scar deformity.,6.  Right abdominal scar deformity.,7.  Excision of right breast medial lesion enclosure.,8.  Excision of right breast lateral lesion enclosure.,ANESTHESIA:,  General.,COMPLICATIONS:,  None.,DRAINS:,  None.,SPECIMENS:,  Right breast skin and lesions x2.,COMPLICATIONS:, None.,INDICATIONS:,  This patient is a 54-year-old white female who presents for a revision of her previous bilateral breast reconstruction.  The patient had asymmetry as well as right breast hypertrophy, and therefore, the procedures named above were indicated.  The patient was informed about the possible risks and complications of the above procedures and gave an informed consent.,PROCEDURE:,  The patient was brought to the operating room, placed supine on the operative table.  After adequate endotracheal anesthesia was established and IV prophylactic antibiotics were given, the chest and abdomen were prepped and draped in standard surgical fashion.,Attention was first turned to the left breast where liposuction was performed laterally to allow for better contour and minimize the outer quadrant.  The incision was made for this and was then closed with 5-0 Prolene interrupted suture.,Attention was then turned to the right breast where liposuction was also performed to reduce the medial superior and lateral quadrants.  Once this was performed, the vertical reduction mammoplasty was outlined.  Prior to that, the nipple reconstruction was performed with a keyhole pattern flap.  The flap was elevated with 15-blade and hemostasis was then obtained with the Bovie.  The flap was then sutured onto itself and secured with 5-0 Prolene interrupted sutures.  Then the lateral and medial limbs were undermined to close the defect and this was performed with 3-0 Monocryl interrupted sutures.  Subsequently, the reduction mastectomy skin was then excised sharply and passed up the table marked and sent to Pathology. ,Hemostasis was then obtained with the Bovie and then undermining was performed in the medial, superior, and lateral skin to allow for closure of the reduction incisions.  Once this was performed, a 3-0 Monocryl interrupted sutures were used to close the inferior limb.  Subsequently 2-0 PDS continuous suture was then placed in the periareolar area to close the defect, with a diameter that equaled the new nipple areolar complex.  Once this was performed, the remaining incision was then closed with 3-0 Monocryl followed by 4-0 Monocryl subcuticular sutures.  Subsequently, the 2 lesions were excised, the larger one which was medial and the lateral one that was smaller that were excised sharply, passed up the table and sent to Pathology.  They were closed in 2 layers using 3-0 Monocryl followed by 4-0 Monocryl subcuticular suture.,Attention was then turned to the abdominal scars where liposuction and tumescent solution of diluted epinephrine were used to minimize the amount of excision that was required.  Subsequently the extra skin was excised sharply in an elliptical fashion on the right side measuring approximately 10 x 3 cm, this was the superior and inferior skin, was when undermined and closure was performed after hemostasis was obtained with 3-0 Monocryl followed by 4-0 Monocryl subcuticular suture.,Attention was then turned to the contralateral left side where there was a larger defect.  There was a larger excision required measuring approximately 15 x 3 cm.  The superior and inferior edges of skin were undermined and closed primarily using 3-0 Monocryl followed by 4-0 Monocryl subcuticular sutures.  Steri-Strips were placed on all incisions followed by surgical bra.,The patient tolerated the procedure well and was extubated without complications and transferred to the recovery room in stable condition.  All instruments, needle counts, and sponges were correct at the end of the case.",
 Flexible sigmoidoscopy.  The Olympus video colonoscope then introduced into the rectum and passed by directed vision to the distal descending colon., Surgery, Flex Sig - 2 ,"PROCEDURE IN DETAIL: , Following a barium enema prep and lidocaine ointment to the rectal vault, perirectal inspection and rectal exam were normal.  The Olympus video colonoscope then introduced into the rectum and passed by directed vision to the distal descending colon.  Withdrawal notes an otherwise normal descending, rectosigmoid and rectum.  Retroflexion noted no abnormality of the internal ring.  No hemorrhoids were noted.  Withdrawal from the patient terminated the procedure.","surgery, flexible sigmoidoscopy, flex sig, colonoscope, olympus video colonoscope, rectumNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Flexible bronchoscopy  to evaluate the airway (chronic wheezing)., Surgery, Flexible Bronchoscopy ,"PROCEDURE:, Flexible bronchoscopy.,PREOPERATIVE DIAGNOSIS (ES):, Chronic wheezing.,INDICATIONS FOR PROCEDURE:, Evaluate the airway.,DESCRIPTION OF PROCEDURE: ,This was done in the pediatric endoscopy suite with the aid of Anesthesia. The patient was sedated with sevoflurane and propofol. One mL of 1% lidocaine was used for airway anesthesia. The 2.8-mm flexible pediatric bronchoscope was passed through the left naris. The upper airway was visualized. The epiglottis, arytenoids, and vocal cords were all normal. The scope was passed below the cords. The subglottic space was normal. The patient had normal tracheal rings and a normal membranous portion of the trachea. There was noted to be slight deviation of the trachea to the right. At the carina, the right and left mainstem were evaluated. The right upper lobe, right middle lobe, and right lower lobe were all anatomically normal. The scope was wedged in the right middle lobe, 10 mL of saline was infused, 10 was returned. This was sent for cell count, cytology, lipid index, and quantitative bacterial cultures. The left side was then evaluated and there was noted to be the normal cardiac pulsations on the left. There was also noted to be some dynamic collapse of the left mainstem during the respiratory cycle. The left upper lobe and left lower lobe were normal. The scope was withdrawn. The patient tolerated the procedure well.,ENDOSCOPIC DIAGNOSIS:, Left mainstem bronchomalacia.","surgery, flexible bronchoscopy, airway, arytenoids, bronchomalacia, bronchoscopy, endoscopy suite, epiglottis, mainstem, subglottic, vocal cords, wheezing, chronic wheezing, tracheal, lobe, "
 Flexible sigmoidoscopy due to rectal bleeding., Surgery, Flex Sig - 1 ,"INDICATION:  , Rectal bleeding.,PREMEDICATION:, See procedure nurse NCS form.,PROCEDURE:  ,","surgery, rectal bleeding, digital rectal exam, pentax video, anal verge, angiodysplasia, colonic mucosa, diverticula, endoscope, flexible, flexible sigmoidoscopy, hemorrhoids, masses, polyps, rectum, sigmoidoscopy, sphincter tone, internal hemorrhoids, bleeding, rectal "
" Fiberoptic flexible bronchoscopy with lavage, brushings, and endobronchial mucosal biopsies of the right bronchus intermedius/right lower lobe.  Right hyoid mass, rule out carcinomatosis.  Chronic obstructive pulmonary disease.  Changes consistent with acute and chronic bronchitis.", Surgery, Fiberoptic Flexible Bronchoscopy ,"PREOPERATIVE DIAGNOSES:,1.  Right hyoid mass, rule out carcinomatosis.,2.  Weight loss.,3.  Chronic obstructive pulmonary disease.,POSTOPERATIVE DIAGNOSES:,1.  Right hyoid mass, rule out carcinomatosis.,2.  Weight loss.,3.  Chronic obstructive pulmonary disease.,4.  Changes consistent with acute and chronic bronchitis.,5.  Severe mucosal irregularity with endobronchial narrowing of the right middle and lower lobes.,6.  Left vocal cord irregularity.,PROCEDURE PERFORMED:  ,Fiberoptic flexible bronchoscopy with lavage, brushings, and endobronchial mucosal biopsies of the right bronchus intermedius/right lower lobe.,ANESTHESIA: , Demerol 50 mg with Versed 3 mg as well as topical cocaine and lidocaine solution.,LOCATION OF PROCEDURE: , Endoscopy suite #4.,After informed consent was obtained and following the review of the procedure including procedure as well as possible risks and complications were explained and consent was previously obtained, the patient was sedated with the above stated medication and the patient was continuously monitored on pulse oximetry, noninvasive blood pressure, and EKG monitoring.  Prior to starting the procedure, the patient was noted to have a baseline oxygen saturation of 86% on room air.  Subsequently, she was given a bronchodilator treatment with Atrovent and albuterol and subsequent saturation increased to approximately 90% to 91% on room air.,The patient was placed on a supplemental oxygen as the patient was sedated with above-stated medication.  As this occurred, the bronchoscope was inserted into the right naris with good visualization of the nasopharynx and oropharynx.  The cords were noted to oppose bilaterally on phonation.  There was some slight mucosal irregularity noted on the vocal cord on the left side.  Additional topical lidocaine was instilled on the vocal cords, at which point the bronchoscope was introduced into the trachea, which was midline in nature.  The bronchoscope was then advanced to the distal trachea and additional lidocaine was instilled.  At this time, the bronchoscope was further advanced through the main stem and additional lidocaine was instilled.  Bronchoscope was then further advanced into the right upper lobe, which revealed no evidence of any endobronchial lesion.  The mucosa was diffusely friable throughout.  Bronchoscope was then slowly withdrawn into the right main stem and additional lidocaine was instilled.  At this point, the bronchoscope was then advanced to the right bronchus intermedius.  At this time, it was noted that there was severe mucosal irregularities of nodular in appearance significantly narrowing the right lower lobe and right middle lobe opening.  The mucosal area throughout this region was severely friable.  Additional lidocaine was instilled as well as topical epinephrine.  At this time, bronchoscope was maintained in this region and endobronchial biopsies were performed.  At the initial attempt of inserting biopsy forceps, some resistance was noted within the proximal channel at this time making advancement of the biopsy forceps out of the proximal channel impossible.  So the biopsy forceps was withdrawn and the bronchoscope was completely withdrawn and new bronchoscope was then utilized.  At this time, bronchoscope was then reinserted into the right naris and subsequently advanced to the vocal cords into the right bronchus intermedius without difficulty.  At this time, the biopsy forceps were easily passed and visualized in the right bronchus intermedius.  At this time, multiple mucosal biopsies were performed with some mild oozing noted.  Several aliquots of normal saline lavage followed.  After completion of multiple biopsies there was good hemostasis.  Cytology flushing was also performed in this region and subsequently several aliquots of additional normal saline lavage was followed.  Bronchoscope was unable to be passed distally to the base of the segment of the right lower lobe or distal to the further visualized endobronchial anatomy of the right middle lobe subsegments.  The bronchoscope was then withdrawn to the distal trachea.,At this time, bronchoscope was then advanced to the left main stem.  Additional lidocaine was instilled.  The bronchoscope was advanced to the left upper and lower lobe subsegments.  There was no endobronchial lesion visualized.  There is mild diffuse erythema and fibromucosa was noted throughout.  No endobronchial lesion was visualized in the left bronchial system.  The bronchoscope was then subsequently further withdrawn to the distal trachea and readvanced into the right bronchial system.  At this time, bronchoscope was readvanced into the right bronchus intermedius and additional aliquots of normal saline lavage until cleared.  There is no gross bleeding evidenced at this time or diffuse mucosal erythema and edema present throughout.  The bronchoscope was subsequently withdrawn and the patient was sent to recovery room.  During the bronchoscopy, the patient noted ________ have desaturation and required increasing FiO2 with subsequent increased saturation to 93% to 94%.  The patient remained at this level of saturation or greater throughout the remaining of the procedure.,The patient postprocedure relates having some intermittent hemoptysis prior to the procedure as well as moderate exertional dyspnea.  This was confirmed by her daughter and mother who were also present at the bedside postprocedure.  The patient did receive a nebulizer bronchodilator treatment immediately prebronchoscopy and postprocedure as well.  The patient also admitted to continued smoking in spite of all of the above.  The patient was extensively counseled regarding the continued smoking especially with her present symptoms.  She was advised regarding smoking cessation.  The patient was also placed on a prescription of prednisone 2 mg tablets starting at 40 mg a day decreasing every three days to continue to wean off.  The patient was also administered Solu-Medrol 60 mg IV x1 in recovery room.  There was no significant bronchospastic component noted, although because of the severity of the mucosal edema, erythema, and her complaints, short course of steroids will be instituted.  The patient was also advised to refrain from using any aspirin or other nonsteroidal anti-inflammatory medication because of her hemoptysis.  At this time, the patient was also advised that if hemoptysis were to continue or worsen or develop progressive dyspnea, to either contact myself, , or return to ABCD Emergency Room for evaluation of possible admission.  However, the above was reviewed with the patient in great detail as well as with her daughter and mother who were at the bedsite at this time as well.","surgery, carcinomatosis, chronic obstructive pulmonary disease, fiberoptic flexible bronchoscopy, lavage, brushings, endobronchial mucosal biopsies, mucosal, bronchoscope, atrovent, topical, fiberoptic, hemoptysis, bronchoscopy, endobronchial, oropharynx"
 Left arm fistulogram.  Percutaneous transluminal angioplasty of the proximal and distal cephalic vein.  Ultrasound-guided access of left upper arm brachiocephalic fistula., Surgery, Fistulogram & Angioplasty ,"PREPROCEDURE DIAGNOSIS: , End-stage renal disease.,POSTPROCEDURE DIAGNOSIS: , End-stage renal disease.,PROCEDURES PERFORMED,1.  Left arm fistulogram.,2.  Percutaneous transluminal angioplasty of the proximal and distal cephalic vein.,3.  Ultrasound-guided access of left upper arm brachiocephalic fistula.,ANESTHESIA:,  Sedation with local.,COMPLICATIONS:,  None.,CONDITION:,  Fair.,DISPOSITION:,  PACU.,ACCESS SITE:,  Left upper arm brachiocephalic fistula.,SHEATH SIZE: , 5 French.,CONTRAST TYPE: , JC PEG tube 70.,CONTRAST VOLUME: , 48 mL.,FLUOROSCOPY TIME: , 16 minutes.,INDICATION FOR PROCEDURE: , This is a 38-year-old female with a left upper arm brachiocephalic fistula which has been transposed.  The patient recently underwent a fistulogram with angioplasty at the proximal upper arm cephalic vein due to a stenosis detected on Duplex ultrasound.  The patient subsequently was noted to have poor flow to the fistula, and the fistula was difficult to palpate.  A repeat ultrasound was performed which demonstrated a high-grade stenosis involving the distal upper arm cephalic vein just distal to the brachial anastomosis.  The patient presents today for a left arm fistulogram with angioplasty.  The risks, benefits, and alternatives of the procedure were discussed with the patient and understands and in agreement to proceed.,PROCEDURE DETAILS:  ,The patient was brought to the angio suite and laid supine on the table.  After sedation was administered, the left arm was then prepped and draped in a standard surgical fashion.  Continuous pulse oximetry and cardiac monitoring were performed throughout the procedure.  The patient was given 1 g of IV Ancef prior to incision.,The left brachiocephalic fistula was visualized with bevel ultrasound.  The cephalic vein in the proximal upper arm region appeared to be of adequate caliber.  There was an area of stenosis at the proximal cephalic vein just distal to the brachial artery anastomosis.  The cephalic vein in the proximal forearm region was easily compressible.  The skin overlying the vessel was injected with 1% lidocaine solution.  A small incision was made with the #11 blade.  The cephalic vein then was cannulated with a 5 French micropuncture introducer sheath.  The sheath was advanced over the wire.  A fistulogram was performed which demonstrated a high-grade stenosis just distal to the brachial artery anastomosis.  The introducer sheath was then exchanged for a 5 French sheath over a 0.025 guide wire.  The sheath was aspirated and flushed with heparinized saline solution.  A 0.025 glidewire was then obtained and advanced, placed over the sheath and across the area of stenosis into the brachial artery.  A 5 French short Kumpe catheter was used to guide the wire into the distal brachial and radial artery.  After crossing the area of stenosis, a 5 x 20 mm standard angioplasty balloon was obtained and prepped from the back table.  This was placed over the glidewire into the area of stenosis and inflated to 14 mmHg pressure and then deflated.  The balloon was then removed over the wire and repeat fistulogram was performed which demonstrated significant improvement.  However, there is still a remainder of residual stenosis.  The 5-mm balloon was placed over the wire again and a repeat angioplasty was performed.  The balloon was then removed over the wire and a repeat angiogram was performed which demonstrated again an area of stenosis right at the anastomosis.  The glidewire was removed and a 0.014 guide wire was then obtained and placed through the sheath and across the brachial anastomosis and into the radial artery.  A 4 x 20 mm cutting balloon was obtained and prepped on the back table.  The 5 French sheath was then exchanged for a 6 French sheath.  The balloon was then placed over the 0.014 guide wire into the area of stenosis and then inflated to normal pressures at 8 mmHg.  The balloon was then deflated and removed over the wire.  A 5 mm x 20 mm balloon was obtained and prepped and placed over the wire into the area of stenosis and inflated to pressures of 14 mmHg.  A repeat fistulogram was performed after the removal of the balloon which demonstrated excellent results with no significant residual stenosis.  The patient actually had a nice palpable thrill at this point.  The fistulogram of the distal cephalic vein at the subclavian anastomosis was performed which demonstrated a mild area of stenosis.  The sheath was removed and blood pressure was held over the puncture site for approximately 10 minutes.,After hemostasis was achieved, the cephalic vein again was visualized with bevel ultrasound.  The proximal cephalic vein was then cannulated after injecting the skin overlying the vessel with a 1% lidocaine solution.  A 5 French micropuncture introducer sheath was then placed over the wire into the proximal cephalic vein.  A repeat fistulogram was performed which demonstrated an area of stenosis within the distal cephalic vein just prior to the subclavian vein confluence.  The 5 French introducer sheath was then exchanged for a 5 French sheath.  The 5 mm x 20 mm balloon was placed over a 0.035 glidewire across the area of stenosis.  The balloon was inflated to 14 mmHg.  The balloon was then deflated and a repeat fistulogram was performed through the sheath which demonstrated good results.  The sheath was then removed and blood pressure was held over the puncture site for approximately 10 minutes.  After adequate hemostasis was achieved, the area was cleansed in 2x2 and Tegaderm was applied.  The patient tolerated the procedure without any complications.  I was present for the entire case.  The sponge, instrument, and needle counts are correct at the end of the case.  The patient was subsequently taken to PACU in stable condition.,ANGIOGRAPHIC FINDINGS:,  The initial left arm brachiocephalic fistulogram demonstrated a stenosis at the brachial artery anastomosis and distally within the cephalic vein.  After standard balloon angioplasty, there was a mild improvement but some residual area of stenosis remained at the anastomosis.  Then postcutting balloon angioplasty, venogram demonstrated a significant improvement without any evidence of significant stenosis.,Fistulogram of the proximal cephalic vein demonstrated a stenosis just prior to the confluence with the left subclavian vein.  Postangioplasty demonstrated excellent results with the standard balloon.  There was no evidence of any contrast extravasation.,IMPRESSION,1.  High-grade stenosis involving the cephalic vein at the brachial artery anastomosis and distally.  Postcutting balloon and standard balloon angioplasty demonstrated excellent results without any evidence of contrast extravasation.,2.  A moderate grade stenosis within the distal cephalic vein just prior to the confluence to the left subclavian vein.  Poststandard balloon angioplasty demonstrated excellent results.  No evidence of contrast extravasation.",
" Fiberoptic nasolaryngoscopy.  Dysphagia with no signs of piriform sinus pooling or aspiration.  Right parapharyngeal lesion, likely thyroid cartilage, nonhemorrhagic.", Surgery, Fiberoptic Nasolaryngoscopy ,"PREOPERATIVE DIAGNOSES:,1.  Dysphagia.,2.  Right parapharyngeal hemorrhagic lesion.,POSTOPERATIVE DIAGNOSES:,1.  Dysphagia with no signs of piriform sinus pooling or aspiration.,2.  No parapharyngeal hemorrhagic lesion noted.,3.  Right parapharyngeal lesion, likely thyroid cartilage, nonhemorrhagic.,PROCEDURE PERFORMED: ,Fiberoptic nasolaryngoscopy.,ANESTHESIA: , None.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE: , The patient is a 93-year-old Caucasian male who was admitted to ABCD General Hospital on 08/07/2003 secondary to ischemic ulcer on the right foot.  ENT was asked to see the patient regarding postop dysphagia with findings at that time of the consultation on 08/17/03 with a fiberoptic nasolaryngoscopy, a right parapharyngeal hemorrhagic lesion possibly secondary to LMA intubation.  The patient subsequently resolved with his dysphagia and workup of Speech was obtained, which showed no aspiration, no pooling, minimal premature spillage with solids, but good protection of the airway.  This is a reevaluation of the right parapharyngeal hemorrhagic lesion that was noted prior.,PROCEDURE DETAILS: ,The patient was brought in the semi-Fowler's position, a fiberoptic nasal laryngoscope was then passed into the patient's right nasal passage, all the way to the nasopharynx.  The scope was then flexed caudally and advanced slowly through the nasopharynx into the oropharynx, and down to the hypopharynx.  The patient's oro and nasopharynx all appeared normal with no signs of any gross lesions, edema, or ecchymosis.,Within the hypopharynx although there was an area of fullness and on the right side around the level of the thyroid cartilage cornu that seemed to be prominent and within the lumen of the hypopharynx.  There were no signs of any obstruction.  The epiglottis, piriform sinuses, vallecula, and base of tongue all appeared normal with no signs of any gross lesions.  The patient with excellent phonation with good glottic closure upon phonation and no signs of any aspiration or pooling of secretions.  The scope was then pulled out and the patient tolerated the procedure well.  At this time, we will follow up as an outpatient and possibly there is a need for a microscopic suspension direct laryngoscopy for evaluation of this right parapharyngeal lesion.","surgery, parapharyngeal, dysphagia, sinus pooling, piriform, nasolaryngoscopy, fiberoptic, laryngoscope, nasopharynx, oropharynx, fiberoptic nasolaryngoscopy, hemorrhagic lesion, aspiration, cartilage, hypopharynx, lesion,"
" Flexible sigmoidoscopy.  Sigmoid and left colon diverticulosis; otherwise, normal flexible sigmoidoscopy to the proximal descending colon.", Surgery, Flex Sig - 3 ,"PROCEDURE: , Flexible sigmoidoscopy.,PREOPERATIVE DIAGNOSIS:,  Rectal bleeding.,POSTOPERATIVE DIAGNOSIS:  ,Diverticulosis.,MEDICATIONS: , None.,DESCRIPTION OF PROCEDURE:  ,The Olympus gastroscope was introduced through the rectum and advanced carefully through the colon for a distance of 90 cm, reaching the proximal descending colon.  At this point, stool occupied the lumen, preventing further passage.  The colon distal to this was well cleaned out and easily visualized.  The mucosa was normal throughout the regions examined.  Numerous diverticula were seen.  There was no blood or old blood or active bleeding.  A retroflexed view of the anorectal junction showed no hemorrhoids.  He tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1.  Sigmoid and left colon diverticulosis.,2.  Otherwise normal flexible sigmoidoscopy to the proximal descending colon.,3.  The bleeding was most likely from a diverticulum, given the self limited but moderately severe quantity that he described.,RECOMMENDATIONS:,1.  Follow up with Dr. X as needed.,2.  If there is further bleeding, a full colonoscopy is recommended.","surgery, olympus, gastroscope, rectal bleeding, flexible sigmoidoscopy, colon diverticulosis, descending colon, diverticulosis, hemorrhoids, flexible, sigmoidoscopy, colon"
 Flexible Sigmoidoscopy., Surgery, Flex Sig ,"MEDICATIONS:,  None.,DESCRIPTION OF THE PROCEDURE:,  After informed consent was obtained, the patient was placed in the left lateral decubitus position and the Olympus video colonoscope was inserted through the anus and advanced in retrograde fashion for a distance of *** cm to the proximal descending colon and then slowly withdrawn.  The mucosa appeared normal.  Retroflex examination of the rectum was normal.","surgery, flexible sigmoidoscopy, flex sig, olympus video colonoscope, colonoscopeNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Emergent fiberoptic bronchoscopy with lavage.   Status post multiple trauma/motor vehicle accident.  Acute respiratory failure.  Acute respiratory distress/ventilator asynchrony.  Hypoxemia.  Complete atelectasis of left lung.  Clots partially obstructing the endotracheal tube and completely obstructing the entire left main stem and entire left bronchial system., Surgery, Fiberoptic Bronchoscopy with Lavage ,"PREOPERATIVE DIAGNOSES:,1.  Status post multiple trauma/motor vehicle accident.,2.  Acute respiratory failure.,3.  Acute respiratory distress/ventilator asynchrony.,4.  Hypoxemia.,5.  Complete atelectasis of left lung.,POSTOPERATIVE DIAGNOSES:,1.  Status post multiple trauma/motor vehicle accident.,2.  Acute respiratory failure.,3.  Acute respiratory distress/ventilator asynchrony.,4.  Hypoxemia.,5.  Complete atelectasis of left lung.,6.  Clots partially obstructing the endotracheal tube and completely obstructing the entire left main stem and entire left bronchial system.,PROCEDURE PERFORMED: ,Emergent fiberoptic plus bronchoscopy with lavage.,LOCATION OF PROCEDURE:  ,ICU.  Room #164.,ANESTHESIA/SEDATION:,  Propofol drip, Brevital 75 mg, morphine 5 mg, and Versed 8 mg.,HISTORY,:  The patient is a 44-year-old male who was admitted to ABCD Hospital on 09/04/03 status post MVA with multiple trauma and subsequently diagnosed with multiple spine fractures as well as bilateral pulmonary contusions, requiring ventilatory assistance.  The patient was noted with acute respiratory distress on ventilator support with both ventilator asynchrony and progressive desaturation.  Chest x-ray as noted above revealed complete atelectasis of the left lung.  The patient was subsequently sedated and received one dose of paralytic as noted above followed by emergent fiberoptic flexible bronchoscopy.,PROCEDURE DETAIL,:  A bronchoscope was inserted through the oroendotracheal tube, which was partially obstructed with blood clots.  These were lavaged with several aliquots of normal saline until cleared.  The bronchoscope required removal because the tissue/clots were obstructing the bronchoscope.  The bronchoscope was reinserted on several occasions until cleared and advanced to the main carina.  The endotracheal tube was noted to be in good position.  The bronchoscope was advanced through the distal trachea.  There was a white tissue completely obstructing the left main stem at the carina.  The bronchoscope was advanced to this region and several aliquots of normal saline lavage were instilled and suctioned.  Again this partially obstructed the bronchoscope requiring several times removing the bronchoscope to clear the lumen.  The bronchoscope subsequently was advanced into the left mainstem and subsequently left upper and lower lobes.  There was diffuse mucus impactions/tissue as well as intermittent clots.  There was no evidence of any active bleeding noted.  Bronchoscope was adjusted and the left lung lavaged until no evidence of any endobronchial obstruction is noted.  Bronchoscope was then withdrawn to the main carina and advanced into the right bronchial system.  There is no plugging or obstruction of the right bronchial system.  The bronchoscope was then withdrawn to the main carina and slowly withdrawn as the position of endotracheal tube was verified, approximately 4 cm above the main carina.  The bronchoscope was then completely withdrawn as the patient was maintained on ventilator support during and postprocedure.  Throughout the procedure, pulse oximetry was greater than 95% throughout.  There is no hemodynamic instability or variability noted during the procedure.  Postprocedure chest x-ray is pending at this time.","surgery, multiple trauma, motor vehicle accident, acute respiratory failure, acute respiratory distress, ventilator asynchrony, hypoxemia, atelectasis, bronchoscopy, lavage, fiberoptic bronchoscopy, endotracheal tube, acute respiratory, asynchrony, bronchoscope, fiberoptic, endotracheal, bronchial, ventilatory, tube, respiratory, "
" Bilateral facet Arthrogram and injections at L34, L45, L5S1.  Interpretation of radiograph.  Low Back Syndrome - Low Back Pain.", Surgery, Facet Arthrogram & Injection ,"PREOPERATIVE DIAGNOSIS: , Low Back Syndrome - Low Back Pain.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE:,1.  Bilateral facet Arthrogram at L34, L45, L5S1.,2.  Bilateral facet injections at L34, L45, L5S1.,3.  Interpretation of radiograph.,ANESTHESIA:  ,IV sedation with Versed and Fentanyl.,ESTIMATED BLOOD LOSS: , None.,COMPLICATIONS:  ,None.,INDICATION: , Pain in the lumbar spine secondary to facet arthrosis that was demonstrated by physical examination and verified with x-ray studies and imaging scans.,SUMMARY OF PROCEDURE: , The patient was admitted to the OR, consent was obtained and signed.  The patient was taken to the Operating room and was placed in the prone position.  Monitors were placed, including EKG, pulse oximeter and blood pressure monitoring.  Prior to sedation vitals signs were obtained and were continuously monitored throughout the procedure for amount of pain or changes in pain, EKG, respiration and heart rate and at intervals of three minutes for blood pressure.  After adequate IV sedation with Versed and Fentanyl the procedure was begun.,The lumbar sacral regions were prepped and draped in sterile fashion with Betadine prep and four sterile towels.,The facets in the lumbar regions were visualized with Fluoroscopy using an anterior posterior view.  A skin wheal was placed with 1% Lidocaine at the L34 facet region on the left.  Under fluoroscopic guidance a 22 gauge spinal needle was then placed into the L34 facet on the left side.  This was performed using the oblique view under fluoroscopy to the enable the view of the ""Scotty Dog,"" After obtaining the ""Scotty Dog"" view the joints were easily seen.  Negative aspiration was carefully performed to verity that there was no venous, arterial or cerebral spinal fluid flow.  After negative aspiration was verified, 1/8th of a cc of Omnipaque 240 dye was then injected.  Negative aspiration was again performed and 1/2 cc of solution (Solution consisting of 9 cc of 0.5% Marcaine with 1 cc of Triamcinolone) was then injected into the joint.  The needle was then withdrawn out of the joint and 1.5 cc of this same solution was injected around the joint.  The 22-gauge needle was then removed.  Pressure was place over the puncture site for approximately one minute.  This exact same procedure was then repeated along the left-sided facets at L45, and L5S1.  This exact same procedure was then repeated on the right side.  At each level, vigilance was carried out during the aspiration of the needle to verify negative flow of blood or cerebral spinal fluid.,The patient was noted to have tolerated the procedure well without any complications.,Interpretation of the radiograph revealed placement of the 22-gauge spinal needles into the left-sided and right-sided facet joints at, L34, L45, and L5S1.  Visualizing the ""Scotty Dog"" technique under fluoroscopy facilitated this.  Dye spread into each joint space is visualized.  No venous or arterial run-off is noted.  No epidural run-off is noted.  The joints were noted to have chronic inflammatory changes noted characteristic of facet arthrosis.","surgery, low back syndrome, low back pain, facet injection, fluoroscopy, iv sedation, spinal fluid, facet arthrogram, aspiration, arthrogram, injection, facet,"
" Incompetent glottis.  Fat harvesting from the upper thigh, micro-laryngoscopy, fat injection thyroplasty.", Surgery, Fat Harvesting ,"PREOPERATIVE DIAGNOSIS: , Incompetent glottis.,POSTOPERATIVE DIAGNOSIS:,  Incompetent glottis.,OPERATION PERFORMED:,1.  Fat harvesting from the upper thigh.,2.  Micro-laryngoscopy.,3.  Fat injection thyroplasty.,FINDINGS AND PROCEDURE: , With the patient in the supine position under adequate general endotracheal anesthesia, the operative area was prepped and draped in a routine fashion.  A 1-cm incision was made in the upper thigh, and approximately 5 cc of fat was liposuctioned from the subcutaneous space.  After this had been accomplished, the wound was closed with an interrupted subcuticular suture of 4-0 chromic and a light compression dressing was applied.,Next, the fat was placed in a urine strainer and copiously washed using 100 cc of PhysioSol containing 100 units of regular insulin.  After this had been accomplished, it was placed in a 3-cc BD syringe and, thence, into the Stasney fat injector device.  Next, a Dedo laryngoscope was used to visualize the larynx, and approximately *** cc of fat was injected into the right TA muscle and *** cc of fat into the left TA muscle.,The patient tolerated the procedure well and was returned to the recovery room in satisfactory condition.  Estimated blood loss was negligible.","surgery, dedo laryngoscope, physiosol, micro laryngoscopy, fat injection, fat harvesting, incompetent glottis, laryngoscopy, thyroplasty, glottis, thigh"
" Right common femoral artery cannulation, cnscious sedation using IV Versed and IV fentanyl, retrograde bilateral coronary angiography, abdominal aortogram with pelvic runoff, left external iliac angiogram with runoff to the patient's left foot, left external iliac angiogram with runoff to the patient's right leg, right common femoral artery angiogram runoff to the patient's right leg.", Surgery, Femoral Artery Cannulation & Aortogram ,"PREOPERATIVE DIAGNOSES: , Angina with severe claudication, coronary artery disease, hypertension, dyslipidemia, heavy tobacco abuse, and PAD.,POSTOPERATIVE DIAGNOSES: , Angina with severe claudication, coronary artery disease, hypertension, dyslipidemia, heavy tobacco abuse, and PAD.  Significant coronary artery disease, very severe PAD.,PROCEDURES PERFORMED:,1.  Right common femoral artery cannulation.,2.  Conscious sedation using IV Versed and IV fentanyl.,3.  Retrograde bilateral coronary angiography.,4.  Abdominal aortogram with pelvic runoff.,5.  Left external iliac angiogram with runoff to the patient's left foot.,6.  Left external iliac angiogram with runoff to the patient's right leg.,7.  Right common femoral artery angiogram runoff to the patient's right leg.,PROCEDURE IN DETAIL:,  The patient was taken to the cardiac catheterization laboratory after having a valid consent.  He was prepped and draped in the usual sterile fashion.,After local infiltration with 2% Xylocaine, the right common femoral artery was entered percutaneously and a 4-French sheath was placed over the artery.  The arterial sheath was flushed throughout the procedure.,Conscious sedation was obtained using IV Versed and IV fentanyl.,With the help of a Wholey wire, a 4-French 4-curve Judkins right coronary artery catheter was advanced into the ascending aorta.  The wire was removed, the catheter was flushed.  The catheter was engaged in the left main.  Injections were performed at the left main in different views.  The catheter was then exchanged for an RCA catheter, 4-French 4-curve which was advanced into the ascending aorta with the help of a J-wire.  The wire was removed, the catheter was flushed.  The catheter was engaged in the RCA.  Injections were performed at the RCA in different views.,The catheter was then exchanged for a 5-French Omniflush catheter, which was advanced into the abdominal aorta with the help of a regular J-wire.  The wire was removed.  The catheter was flushed.  Abdominal aortogram was then performed with runoff to the patient's pelvis.,The Omniflush catheter was then retracted into the aortic bifurcation.  Through the Omniflush catheter, a Glidewire was then advanced distally into the left SFA.  The Omniflush was then removed.  Through the wire, a Royal Flush catheter was then advanced into the left external iliac.  The wire was removed.  Left external iliac angiogram was performed with runoff to the patient's left foot _______ was then performed.  The catheter was then retracted into the left common iliac.  Angiograms were performed of the left common iliac with runoff to the patient's left groin.  The catheter was then positioned at the level of the right common iliac.  Angiogram of the right common iliac with runoff to the patient's right leg was then performed.  The catheter was then removed with the help of a J-wire.  The J-wire was left in the abdominal aorta.  Hand injection was performed of the right common femoral artery in 2 locations with runoff to the patient's right leg.,The wire was then removed.  The arterial sheath was then removed after being flushed.  Hemostasis was obtained using hand compression.,The patient tolerated the procedure well and had no complications.  At the end of the procedure, palpable right common femoral pulses were noted as well as 1+ right PT pulse.,Hemodynamic Findings:,  Aortic pressure 140/70.,ANGIOGRAPHIC FINDINGS: , Left main with calcification 25% to 40% lesion.,The left main is very short.,LAD with calcification 25% to 40% proximal lesion.,D1 has 25% lesion.  No in-stent restenosis was noted in D1.,D2 and D3 are very small with luminal irregularities.,Circumflex artery was diseased throughout the vessel.  The circumflex artery has an ostium of 60% to 75% lesion distally and the circumflex has a 75% lesion.,OM1 has 25% to 40% lesion.  These OMs are small with luminal irregularities.,RCA has 25% to 50% lesion, distally, the RCA has luminal irregularities.,Left ventriculography was not done.,ABDOMINAL AORTOGRAM:,  Right renal artery with luminal irregularities.  Left renal artery with luminal irregularities.  The abdominal aorta has 25% lesion.,Right common iliac has a 25% to 50% lesion as well as a distal 75% lesion.,The right external iliac has a proximal 75% lesion.,The distal part of the right external iliac as well as the right common femoral appears to be occlusive by the 5-French sheath.,The right SFA was visualized, although not very well.,Left common iliac with 25% to 50% lesion.  Left external iliac with 25% to 40% lesion.  Left common femoral with 25% to 40% lesion.  Left SFA with 25% lesion.  Left popliteal with wall luminal irregularities.,Three-vessel runoff is noted at the level of the left knee and at the level of the left ankle.,Conclusions:  Severe coronary artery disease.  Very severe peripheral arterial disease.,PLAN: , Because of the anatomic distribution of the coronary artery disease, for now we will continue medical treatment for CAD.  We will proceed with revascularization of the right external iliac as well as right common femoral.  Discontinue tobacco.",
" Diagnostic fiberoptic bronchoscopy with biopsies and bronchoalveolar lavage.   Bilateral upper lobe cavitary lung masses.  Airway changes including narrowing of upper lobe segmental bronchi, apical and posterior on the right, and anterior on the left.  There are also changes of inflammation throughout.", Surgery, Fiberoptic Bronchoscopy ,"PREOPERATIVE DIAGNOSIS:,  Bilateral upper lobe cavitary lung masses.,POSTOPERATIVE DIAGNOSES:,1.  Bilateral upper lobe cavitary lung masses.,2.  Final pending pathology.,3.  Airway changes including narrowing of upper lobe segmental bronchi, apical and posterior on the right, and anterior on the left.  There are also changes of inflammation throughout.,PROCEDURE PERFORMED: , Diagnostic fiberoptic bronchoscopy with biopsies and bronchoalveolar lavage.,ANESTHESIA: , Conscious sedation was with Demerol 150 mg and Versed 4 mg IV.,OPERATIVE REPORT: , The patient is residing in the endoscopy suite.  After appropriate anesthesia and sedation, the bronchoscope was advanced transorally due to the patient's recent history of epistaxis.  Topical lidocaine was utilized for anesthesia.  Epiglottis and vocal cords demonstrated some mild asymmetry of the true cords with right true and false vocal cord appearing slightly more prominent.  This may be normal anatomic variant.  The scope was advanced into the trachea.  The main carina was sharp in appearance.  Right upper, middle, and lower segmental bronchi as well as left upper lobe and lower lobe segmental bronchi were serially visualized.  Immediately noted were some abnormalities including circumferential narrowing and probable edema involving the posterior and apical segmental bronchi on the right and to a lesser degree the anterior segmental bronchus on the left.  No specific intrinsic masses were noted.  Under direct visualization, the scope was utilized to lavage the posterior segmental bronchus in the right upper lobe.  Also cytologic brushings and protected bacteriologic brushing specimens were obtained.  Three biopsies were attempted within the cavitary lesion in the posterior segment of the right upper lobe.  During lavage, some caseous appearing debris appeared intermittently.  The specimens were collected and sent to the lab.  Procedure was terminated with hemostasis having been verified.  The patient tolerated the procedure well.,Throughout the procedure, the patient's vital signs and oximetry were monitored and remained within satisfactory limits.,The patient will be returned to her room with orders as per usual.","surgery, inflammation, lung masses, lobe cavitary, bronchoalveolar, biopsies, segmental bronchi, fiberoptic, bronchoscopy, lavage, cavitary, segmental, lobe,"
" Fiberoptic bronchoscopy, diagnostic.  Hemoptysis and history of lung cancer.  Tumor occluding right middle lobe with friability.", Surgery, Fiberoptic Bronchoscopy - 1 ,"PREOPERATIVE DIAGNOSIS:,1.  Hemoptysis.,2.  History of lung cancer.,POSTOPERATIVE DIAGNOSIS:,  Tumor occluding right middle lobe with friability.,PROCEDURE PERFORMED:,  Fiberoptic bronchoscopy, diagnostic.,LOCATION: , Endoscopy suite #4.,ANESTHESIA:,  General per Anesthesia Service.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE: , The patient presented to ABCD Hospital with a known history of lung cancer and acute hemoptysis with associated chest pain.  Due to her prior history, it was felt that she would benefit from diagnostic fiberoptic bronchoscopy to help determine the etiology of the hemoptysis.  She was brought to endoscopy suite #4 and informed consent was obtained.  ,PROCEDURE DETAILS:  ,The patient was placed in the supine position and intubated by the Anesthesia Service.  Intravenous sedation was given as per Anesthesia.  The fiberoptic scope was passed through the #8 endotracheal tube into the main trachea.  The right mainstem bronchus was examined.  The right upper lobe and subsegments appeared grossly within normal limits with no endobronchial lesions noted.  Upon examining the right middle lobe, there was a tumor noted occluding the lateral segment of the right middle lobe and a clot appreciated over the medial segment of the right middle lobe.,The clot was lavaged with normal saline and there was noted to be tumor behind this clot.  Tumor completely occluded both segments of the right middle lobe.  Scope was then passed to the subsegments of the right lower lobe, which were individually examined and noted to be grossly free of endobronchial lesions.  Scope was pulled back to the level of the midtrachea, passed into the left mainstem bronchus.  Left upper lobe and its subsegments were examined and noted to be grossly free of endobronchial lesions.  The lingula and left lower subsegments were all each individually examined and noted to be grossly free of endobronchial lesions.  There were some secretions noted throughout the left lung.  The scope was retracted and passed again to the right mainstem bronchus.  The area of the right middle lobe was reexamined.  The tumor was noted to be grossly friable with oozing noted from the tumor with minimal manipulation.  It did not appear as if a scope or cannula could be passed distal to the tumor.  Due to continued oozing, 1 cc of epinephrine was applied topically with adequate hemostasis obtained.  The area was examined for approximately one minute for assurance of adequate hemostasis.  The scope was then retracted and the patient was sent to the recovery room in stable condition.  She will be extubated as per the Anesthesia Service.  Cytology and cultures were not sent due to the patient's known diagnosis.  Further recommendations are pending at this time.","surgery, hemoptysis, lung cancer, tumor, fiberoptic, bronchoscopy, endoscopy suite, adequate hemostasis, fiberoptic bronchoscopy, endobronchial lesions, middle lobe, lobe,"
 External cephalic version.  A 39-week intrauterine pregnancy with complete breech presentation., Surgery, External Cephalic Version ,"PREOPERATIVE DIAGNOSIS: , A 39-week intrauterine pregnancy with complete breech presentation.,POSTOPERATIVE DIAGNOSIS:,  A 39-week intrauterine pregnancy in vertex presentation, status post successful external cephalic version.,PROCEDURE: , External cephalic version.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL:  ,The patient was brought to Labor and Delivery where a reactive fetal heart tracing was obtained.  The patient was noted to have irregular contractions.  She was given 1 dose of subcutaneous terbutaline which resolved her contraction.  A bedside ultrasound was performed which revealed single intrauterine pregnancy and complete breech presentation.  There was noted to be adequate fluid.  Using manual pressure, the breech was manipulated in a forward roll fashion until a vertex presentation was obtained.  Fetal heart tones were checked intermittently during the procedure and were noted to be reassuring.  Following successful external cephalic version, the patient was placed on continuous external fetal monitoring.  She was noted to have a reassuring and reactive tracing for 1 hour following the external cephalic version.  She did not have regular contractions and therefore she was felt to be stable for discharge to home.  She was given appropriate labor instructions.","surgery, intrauterine pregnancy, vertex presentation, complete breech presentation, external cephalic version, fetal, contractions, pregnancy, breech, intrauterine, "
 Left masticator space infection secondary to necrotic tooth #17.  Extraoral incision and drainage of facial space infection and extraction of necrotic tooth #17., Surgery, Extraoral I&D ,"PREOPERATIVE DIAGNOSIS:,  Left masticator space infection secondary to necrotic tooth #17.,POSTOPERATIVE DIAGNOSIS: , Left masticator space infection secondary to necrotic tooth #17.,SURGICAL PROCEDURE:,  Extraoral incision and drainage of facial space infection and extraction of necrotic tooth #17.,FLUIDS:  ,500 mL of crystalloid.,ESTIMATED BLOOD LOSS: , 60 mL.,SPECIMENS:,  Cultures and sensitivities, Aerobic and anaerobic were sent for micro studies.,DRAINS:,  One 0.25-inch Penrose placed in the medial aspect of the masticator space.,CONDITION: , Good, extubated, breathing spontaneously, to PACU.,INDICATIONS FOR PROCEDURE:  ,The patient is a 26-year-old Caucasian male with a 2-week history of a toothache and 5-day history of increasing swelling of his left submandibular region, presents to Clinic, complaining of difficulty swallowing and breathing.  Oral surgery was consulted to evaluate the patient.,After evaluation of the facial CT with tracheal deviation and abscess in the left muscular space, it was determined that the patient needed to be taken urgently to the operating room under general anesthesia and have the abscess incision and drainage and removal of tooth #17.  Risks, benefits, alternatives, treatments were thoroughly discussed with the patient and consent was obtained.,DESCRIPTION OF PROCEDURE:,  The patient was transported to operating room #4 at Clinic.  He was laid supine on the operating room table.  ASA monitors were attached and general anesthesia was induced with IV anesthetics and maintained with oral endotracheal intubation and inhalation of anesthetics.  The patient was prepped and draped in the usual oral and maxillofacial surgery fashion.,The surgeon approached the operating room table in sterile fashion.  Approximately 2 mL of 1% lidocaine with 1:100,000 epinephrine were injected into the left submandibular area in the area of the incision.  After waiting appropriate time for local anesthesia to take effect, an 18-gauge needle was introduced into the left masticator space and approximately 5 mL of pus was removed.  This was sent for aerobic and anaerobic micro.  Using a 15-blade, a 2-cm incision was made in the left submandibular region, then a hemostat was introduced in blunt dissection into the medial border of the mandible was performed.  The left masticator space was thoroughly explored as well as the left submandibular space and submental space.  Pus was drained from this site.  Copious amounts of sterile fluid were irrigated into the site.,Attention was then directed intraorally where a moistened Ray-Tec sponge was placed in the posterior oropharynx to act as a throat pack.  Approximately 4 mL of 1% lidocaine with 1:100,000 epinephrine were injected into the left inferior alveolar nerve block.  Using a 15-blade, a full-thickness mucoperiosteal flap was developed around tooth #17.  The tooth was elevated and delivered, and the lingual area of tooth #17 was explored and more pus was expressed.  This pus was evacuated intraorally __________ suction.  The extraction site and the left masticator space were irrigated, and it was noted that the irrigation was communicating with extraoral incision in the neck.,A 0.25-inch Penrose drain was placed in the lingual aspect of the mandible extraorally through the neck and secured with 2-0 silk suture.  A tack stitch intraorally with 3-0 chromic suture was placed.  The throat pack was then removed.  An orogastric tube was placed and removed all other stomach contents and then removed.  At this point, the procedure was then determined to be over.  The patient was extubated, breathing spontaneously, and transported to PACU in good condition.","surgery, masticator space infection, extraoral, incision and drainage, ray-tec sponge, submandibular, space infection, necrotic tooth, masticator space, space, drainage, necrotic, incision, masticator, tooth, "
" Bilateral C3-C4, C4-C5, C5-C6, and C6-C7 medial facetectomy and foraminotomy with technical difficulty, total laminectomy C3, C4, C5, and C6, excision of scar tissue, and repair of dural tear with Prolene 6-0 and Tisseel.", Surgery, Facetectomy & Foraminotomy ,"PREOPERATIVE DIAGNOSES,1.  Neck pain with bilateral upper extremity radiculopathy.,2.  Residual stenosis, C3-C4, C4-C5, C5-C6, and C6-C7 with probable instability.,POSTOPERATIVE DIAGNOSES,1.  Neck pain with bilateral upper extremity radiculopathy.,2.  Residual stenosis, C3-C4, C4-C5, C5-C6, and C6-C7 secondary to facet arthropathy with scar tissue.,3.  No evidence of instability.,OPERATIVE PROCEDURE PERFORMED,1.  Bilateral C3-C4, C4-C5, C5-C6, and C6-C7 medial facetectomy and foraminotomy with technical difficulty.,2.  Total laminectomy C3, C4, C5, and C6.,3.  Excision of scar tissue.,4.  Repair of dural tear with Prolene 6-0 and Tisseel.,FLUIDS:,  1500 cc of crystalloid.,URINE OUTPUT: , 200 cc.,DRAINS: , None.,SPECIMENS: , None.,COMPLICATIONS: , None.,ANESTHESIA:,  General endotracheal anesthesia.,ESTIMATED BLOOD LOSS:,  Less than 250 cc.,INDICATIONS FOR THE OPERATION:  ,This is the case of a very pleasant 41 year-old Caucasian male well known to me from previous anterior cervical discectomy and posterior decompression.  Last surgery consisted of four-level decompression on 08/28/06.  The patient continued to complain of posterior neck pain radiating to both trapezius.  Review of his MRI revealed the presence of what still appeared to be residual lateral recess stenosis.  It also raised the possibility of instability and based on this I recommended decompression and posterolateral spinal instrumention; however, intraoperatively, it appeared like there was no abnormal movement of any of the joint segments; however, there was still residual stenosis since the laminectomy that was done previously was partial.  Based on this, I did total decompression by removing the lamina of C3 through C6 and doing bilateral medial facetectomy and foraminotomy at C3-C4, C4-C5, C5-C6, and C6-C7 with no spinal instrumentation.  Operation and expected outcome risks and benefits were discussed with him prior to the surgery.  Risks include but not exclusive of bleeding and infection.  Infection can be superficial, but may also extend down to the epidural space, which may require return to the operating room and evacuation of the infection.  There is also the risk of bleeding that could be superficial but may also be in the epidural space resulting in compression of spinal cord.  This may result in weakness of all four extremities, numbness of all four extremities, and impairment of bowel and bladder function, which will require an urgent return to the operating room and evacuation of the hematoma.  There is also the risk of a dural tear with its attendant problems of CSF leak, headache, nausea, vomiting, photophobia, pseudomeningocele, and dural meningitis.  This too may require return to the operating room for evacuation of said pseudomeningocele and repair.  The patient understood the risk of the surgery.  I told him there is just a 30% chance that there will be no improvement with the surgery; he understands this and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room, awake, alert, not in any form of distress.  After smooth induction and intubation, a Foley catheter was inserted.  Monitoring leads were also placed by Premier Neurodiagnostics for both SSEP and EMG monitoring.  The SSEPs were normal, and the EMGs were silent during the entire case.  After completion of the placement of the monitoring leads, the patient was then positioned prone on a Wilson frame with the head supported on a foam facial support.  Shave was then carried out over the occipital and suboccipital region.  All pressure points were padded.  I proceeded to mark the hypertrophic scar for excision.  This was initially cleaned with alcohol and prepped with DuraPrep.,After sterile drapes were laid out, incision was made using a scalpel blade #10.  Wound edge bleeders were carefully controlled with bipolar coagulation and a hot knife was utilized to excise the hypertrophic scar.  Dissection was then carried down to the cervical fascia, and by careful dissection to the scar tissue, the spinous process of C2 was then identified.  There was absence of the spinous process of C3, C4, C5, and C6, but partial laminectomy was noted; removal of only 15% of the lamina.  With this completed, we proceeded to do a total laminectomy at C3, C4, C5, and C6, which was technically difficult due to the previous surgery.  There was also a dural tear on the right C3-C4 space that was exposed and repaired with Prolene 6-0 and later with Tisseel.  By careful dissection and the use of a -5 and 3 mm bur, total laminectomy was done as stated with bilateral medial facetectomy and foraminotomy done at C3-C4, C4-C5, C5-C6, and C6-C7.  There was significant epidural bleeding, which was carefully coagulated.  At two points, I had to pack this with small pieces of Gelfoam.  After repair of the dural tear, Valsalva maneuver showed no evidence of any CSF leakage.  Area was irrigated with saline and bacitracin and then lined with Tisseel.  The wound was then closed in layers with Vicryl 0 simple interrupted sutures to the fascia; Vicryl 2-0 inverted interrupted sutures to the dermis and a running nylon 2-0 continuous vertical mattress stitch.  The patient was extubated and transferred to recovery.",
 Left supraorbital deep complex facial laceration measuring 6x2 cm.  Plastic closure of deep complex facial laceration measuring 6x2 cm.  The patient is a 23-year-old male who was intoxicated and hit with an unknown object to his forehead.  The patient subjectively had loss of consciousness on the scene and minimal bleeding from the left supraorbital laceration site., Surgery, Facial Laceration Closure ,"PREOPERATIVE DIAGNOSIS:,  Left supraorbital deep complex facial laceration measuring 6x2 cm.,POSTOPERATIVE DIAGNOSIS: , Left supraorbital deep complex facial laceration measuring 6x2 cm.,PROCEDURE PERFORMED: , Plastic closure of deep complex facial laceration measuring 6x2 cm.,ANESTHESIA: , Local anesthesia with 1% lidocaine with 1:100,000 epinephrine, total of 2 cc were used.,SPECIMENS: , None.,FINDINGS: , Deep complex left forehead laceration.,HISTORY: , The patient is a 23-year-old male who was intoxicated and hit with an unknown object to his forehead.  The patient subjectively had loss of consciousness on the scene and minimal bleeding from the left supraorbital laceration site.  He was brought to the Emergency Room, where a CAT scan of the head and facial bumps was performed, which were negative.,Prior to performing surgery informed consent was obtained from the patient who was well aware of the risks, benefits, alternatives and complications of the surgery to include infection, bleeding, cosmetic deformity, significant scarring, need for possible scar revision.  The patient was allowed to ask all questions he wanted, and they were answered in a language he could understand.  He wished to pursue surgery and signed the informed consent.,PROCEDURE: , The patient was placed in the supine position.  The wound was copiously irrigated with normal saline on irrigating tip.  After one liter of irrigation, the wound was prepped and draped in the usual sterile fashion.  The incision was then localized with a solution of 1% lidocaine with 1:100,000 epinephrine, a total of less than 2 cc was used.  We then reapproximated the wound in double-layered fashion with deep sutures of #5-0 Vicryl, two interrupted sutures were used, and then the skin was closed with interrupted sutures of #5-0 nylon.  The wound came together very nicely.  Tincture of Benzoin was placed.  Steri-Strips were placed over the top and a small amount of bacitracin was placed over the Steri-Strips.  The patient tolerated the procedure well with no complications.","surgery, plastic closure, facial laceration, deep complex facial laceration, steri strips, closure, bleeding, sterile, sutures, forehead, wound, supraorbital, facial, laceration"
 Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid., Surgery, Eyelid Squamous Cell Carcinoma Excision ,"PREOPERATIVE DIAGNOSIS: , Right upper eyelid squamous cell carcinoma.,POSTOPERATIVE DIAGNOSIS: , Right upper eyelid squamous cell carcinoma.,PROCEDURE PERFORMED: , Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid.,COMPLICATIONS:  ,None.,BLOOD LOSS: , Minimal.,ANESTHESIA:,  Local with sedation.,INDICATION:,  The patient is a 65-year-old male with a large squamous cell carcinoma on his right upper eyelid, which had previous radiation.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, laid supine, administered intravenous sedation, and prepped and draped in a sterile fashion.  He was anesthetized with a combination of 2% lidocaine and 0.5% Marcaine with Epinephrine on both upper eyelids.  The area of obvious scar tissue from the radiation for the squamous cell carcinoma on the right upper eyelid was completely excised down to the eyelid margin including resection of a few of the upper eye lashes.  This was extended essentially from the punctum to the lateral commissure and extended up on to the upper eyelid.  The resection was carried down through the orbicularis muscle resecting the pretarsal orbicularis muscle and the inferior portion of the preseptal orbicularis muscle leaving the tarsus intact and leaving the orbital septum intact.  Following complete resection, the patient was easily able to open and close his eyes as the levator muscle insertion was left intact to the tarsal plate.  The specimen was sent to pathology, which revealed only fibrotic tissue and no evidence of any residual squamous cell carcinoma.  Meticulous hemostasis was obtained with Bovie cautery and a full-thickness skin graft was taken from the opposite upper eyelid in a fashion similar to a blepharoplasty of the appropriate size for the defect in the right upper eyelid.  The left upper eyelid incision was closed with 6-0 fast-absorbing gut interrupted sutures, and the skin graft was sutured in place with 6-0 fast-absorbing gut interrupted sutures.  An eye patch was placed on the right side, and the patient tolerated the procedure well and was taken to PACU in good condition.","surgery, frozen section, full-thickness skin grafting, squamous cell carcinoma, eyelid, orbicularis,"
" Exploratory laparotomy.  Extensive lysis of adhesions.  Right salpingo-oophorectomy.   Pelvic mass, suspected right ovarian cyst.", Surgery, Exploratory Laparotomy - 2 ,"PREOPERATIVE DIAGNOSES,1.  Pelvic mass.,2.  Suspected right ovarian cyst.,POSTOPERATIVE DIAGNOSES,1.  Pelvic mass.,2.  Suspected right ovarian cyst.,PROCEDURES,1.  Exploratory laparotomy.,2.  Extensive lysis of adhesions.,3.  Right salpingo-oophorectomy.,ANESTHESIA:,  General.,ESTIMATED BLOOD LOSS: , 200 mL,SPECIMENS:  ,Right tube and ovary.,COMPLICATIONS: , None.,FINDINGS: , Extensive adhesive disease with the omentum and bowel walling of the entire pelvis, which required more than 45 minutes of operating time in order to establish visualization and to clear the bowel and other important structures from the ovarian cyst, tube, and ovary in order to remove them.  The large and small bowels were completely enveloping a large right ovarian cystic mass.  Normal anatomy was difficult to see due to adhesions.  Cyst was ruptured incidentally intraoperatively with approximately 150 mL to 200 mL of turbid fluid.  Cyst wall, tube, and ovary were stripped away from the bowel.  Posterior peritoneum was also removed in order to completely remove the cyst wall ovary and tube.  There was excellent postoperative hemostasis.,PROCEDURE:  ,The patient was taken to the operating room, where general anesthesia was achieved without difficulty.  She was then placed in a dorsal supine position and prepped and draped in the usual sterile fashion.  A vertical midline incision was made from the umbilicus and extended to the symphysis pubis along the line of the patient's prior incision.  Incision was carried down carefully until the peritoneal cavity was reached.  Care was taken upon entry of the peritoneum to avoid injury of underlying structures.  At this point, the extensive adhesive disease was noted, again requiring greater than 45 minutes of dissection in order to visualize the intended anatomy for surgery.  The omentum was carefully stripped away from the patient's right side developing a window.  This was extended down along the inferior portion of the incision removing the omentum from its adhesions to the anterior peritoneum and what appears to be the vesicouterine peritoneum.  A large mass of bowel was noted to be adherent to itself causing a quite tortuous course.  Adhesiolysis was performed in order to free up the bowel in order to pack it out of the pelvis.  Excellent hemostasis was noted.  The bowel was then packed over of the pelvis allowing visualization of a matted mass of large and small bowel surrounding a large ovarian cyst.  Careful adhesive lysis and dissection enabled the colon to be separated from the posterior wall of the cyst.  Small bowel and portion of the colon were adherent anteriorly on the cyst and during the dissection of these to remove them from their attachment, the cyst was ruptured.  Large amount of turbid fluid was noted and was evacuated.  The cyst wall was then carefully placed under tension and stripped away from the patient's small and large bowel.  Once the bowel was freed, the remnants of round ligament was identified, elevated, and the peritoneum was incised opening the retroperitoneal space.,The retroperitoneal space was opened following the line of the ovarian vessels, which were identified and elevated and a window made inferior to the ovarian vessels, but superior to the course of the ureter.  This pedicle was doubly clamped, transected, and tied with a free tie of #2-0 Vicryl.  A suture ligature of #0 Vicryl was used to obtain hemostasis.  Excellent hemostasis was noted at this pedicle.  The posterior peritoneum and portion of the remaining broad ligament were carefully dissected and shelled out to remove the tube and ovary, which was still densely adherent to the peritoneum.  Care was taken at the side of the remnant of the uterine vessels.  However, a laceration of the uterine vessels did occur, which was clamped with a right-angle clamp, and carefully sutured ligated with excellent hemostasis noted.  Remainder of the specimen was then shelled out including portions of the posterior and sidewall peritoneum and removed.,The opposite tube and ovary were identified, were also matted behind a large amount of large bowel and completely enveloped and wrapped in the fallopian tube.  Minimal dissection was performed in order to ascertain and ensure that the ovary appeared completely normal.  It was then left in situ.  Hemostasis was achieved in the pelvis with the use of electrocautery.  The abdomen and pelvis were copiously irrigated with warm saline solution.  The peritoneal edges were inspected and found to have good hemostasis after the side of the uterine artery pedicle, and the ovarian vessel pedicle.  The areas of the bowel had previously been dissected and due to adhesive disease, it was carefully inspected and excellent hemostasis was noted.,All instruments and packs removed from the patient's abdomen.  The abdomen was closed with a running mattress closure of #0 PDS, beginning at the superior aspect of the incision, and extending inferiorly.  Excellent closure of the incision was noted.  The subcutaneous tissues were then copiously irrigated.  Hemostasis was achieved with the use of cautery.  Subcutaneous tissues were reapproximated to close the edge space with a several interrupted sutures of #0 plain gut suture.  The skin was closed with staples.,Incision was sterilely clean and dressed.  The patient was awakened from general anesthesia and taken to the recovery room in stable condition.  All counts were noted correct times three.","surgery, pelvic mass, ovarian cyst, exploratory laparotomy, lysis of adhesions, salpingo-oophorectomy, cyst, bowel, adhesions, uterine, abdomen, pelvis, ovary, peritoneum, ovarian, hemostasis, "
" Exploratory laparotomy, lysis of adhesions and removal, reversal of Hartmann's colostomy, flexible sigmoidoscopy, and cystoscopy with left ureteral stent.", Surgery, Exploratory Laparotomy - 1 ,"PREOPERATIVE DIAGNOSIS:,  History of perforated sigmoid diverticuli with Hartmann's procedure.,POSTOPERATIVE DIAGNOSES:  ,1.  History of perforated sigmoid diverticuli with Hartmann's procedure.,2.  Massive adhesions.,PROCEDURE PERFORMED:,1.  Exploratory laparotomy.,2.  Lysis of adhesions and removal.,3.  Reversal of Hartmann's colostomy.,4.  Flexible sigmoidoscopy.,5.  Cystoscopy with left ureteral stent.,ANESTHESIA: , General.,HISTORY: , This is a 55-year-old gentleman who had a previous perforated diverticula.  Recommendation for reversal of the colostomy was made after more than six months from the previous surgery for a sigmoid colon resection and Hartmann's colostomy.,PROCEDURE:  ,The patient was taken to the operating room placed into lithotomy position after being prepped and draped in the usual sterile fashion.  A cystoscope was introduced into the patient's urethra and to the bladder.  Immediately, no evidence of cystitis was seen and the scope was introduced superiorly, measuring the bladder and immediately a #5 French ____ was introduced within the left urethra.  The cystoscope was removed, a Foley was placed, and wide connection was placed attaching the left ureteral stent and Foley.  At this point, immediately the patient was re-prepped and draped and immediately after the ostomy was closed with a #2-0 Vicryl suture, immediately at this point, the abdominal wall was opened with a #10 blade Bard-Parker down with electrocautery for complete hemostasis through the midline.,The incision scar was cephalad due to the severe adhesions in the midline.  Once the abdomen was entered in the epigastric area, then massive lysis of adhesions was performed to separate the small bowel from the anterior abdominal wall.  Once the small bowel was completely free from the anterior abdominal wall, at this point, the ostomy was taken down with an elliptical incision with cautery and then meticulous dissection with Metzenbaum scissors and electrocautery down to the anterior abdominal wall, where a meticulous dissection was carried with Metzenbaum scissors to separate the entire ostomy from the abdominal wall.  Immediately at this point, the bowel was dropped within the abdominal cavity, and more lysis of adhesions was performed cleaning the left gutter area to mobilize the colon further down to have no tension in the anastomosis.  At this point, the rectal stump, where two previous sutures with Prolene were seen, were brought with hemostats.  The rectal stump was free in a 360 degree fashion and immediately at this point, a decision to perform the anastomosis was made.  First, a self-retaining retractor was introduced in the abdominal cavity and a bladder blade was introduced as well.  Blue towel was placed above the small bowel retracting the bowel to cephalad and at this point, immediately the rectal stump was well visualized, no evidence of bleeding was seen, and the towels were placed along the edges of the abdominal wound.  Immediately, the pursestring device was fired approximately 1 inch from the skin and on the descending colon, this was fired.  The remainder of the excess tissue was closed with Metzenbaum scissors and immediately after dilating #25 and #29 mushroom tip from the T8 Ethicon was placed within the colon and then #9-0 suture was tied.  Immediately from the anus, the dilator #25 and #29 was introduced dilating the rectum.  The #29 EEA was introduced all the way anteriorly to the staple line and this spike from the EEA was used to perforate the rectum and then the mushroom from the descending colon was attached to it.  The EEA was then fired.  Once it was fired and was removed, the pelvis was filled with fluid.  Immediately both doughnuts were ____ from the anastomosis.  A Doyen was placed in both the anastomosis.  Colonoscope was introduced.  No bubble or air was seen coming from the anastomosis.  There was no evidence of bleeding.  Pictures of the anastomosis were taken.  The scope then was removed from the patient's rectum.  Copious amount of irrigation was used within the peritoneal cavity.  Immediately at this point, all complete sponge and instrument count was performed.  First, the ostomy site was closed with interrupted figure-of-eight #0 Vicryl suture.  The peritoneum was closed with running #2-0 Vicryl suture.  Then, the midline incision was closed with a loop PDS in cephalad to caudad and caudad to cephalad tight in the middle.  Subq tissue was copiously irrigated and the staples on the skin.,The iodoform packing was placed within the old ostomy site and then the staples on the skin as well.  The patient did tolerate the procedure well and will be followed during the hospitalization.  The left ureteral stent was removed at the end of the procedure.  _____ were performed.  Lysis of adhesions were performed.  Reversal of colostomy and EEA anastomosis #29 Ethicon.","surgery, reversal of hartmann's colostomy, flexible sigmoidoscopy, cystoscopy, ureteral stent, lysis of adhesions, exploratory laparotomy, hartmann's colostomy, abdominal wall, immediately, adhesions, colostomy, sigmoidoscopy, bowel, anastomosis, abdominal"
 Left little finger extensor tendon laceration.  Repair of left little extensor tendon., Surgery, Extensor Tendon Repair ,"PREOPERATIVE DIAGNOSIS:,  Left little finger extensor tendon laceration.,POSTOPERATIVE DIAGNOSIS: , Left little finger extensor tendon laceration.,PROCEDURE PERFORMED:  ,Repair of left little extensor tendon.,COMPLICATIONS:,  None.,BLOOD LOSS: , Minimal.,ANESTHESIA: , Bier block.,INDICATIONS: , The patient is a 14-year-old right-hand dominant male who cut the back of his left little finger and had a small cut to his extensor tendon.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operative room, laid supine, administered intervenous sedation with Bier block and prepped and draped in a sterile fashion.  The old laceration was opened and the extensor tendon was identified and there was a small longitudinal laceration in the tendon, which is essentially in line with the tendon fibers.  This was just proximal to the PIP joint and on complete flexion of the PIP joint, I did separate just a little bit that was not thought to be significantly dynamically unstable.  It was sutured with a single 4-0 Prolene interrupted figure-of-eight suture and on dynamic motion it did not separate at all.  The wound was irrigated and closed with 5-0 nylon interrupted sutures.  The patient tolerated the procedure well and was taken to the PCU in good condition.","surgery, extensor tendon laceration, bier block, pip joint, extensor tendon, tendon, repair, finger, laceration, extensor,"
" Exploratory laparotomy, low anterior colon resection, flexible colonoscopy, and transverse loop colostomy and JP placement.  Colovesical fistula and intraperitoneal abscess.", Surgery, Exploratory Laparotomy & Colon Resection ,"PREOPERATIVE DIAGNOSIS: , Colovesical fistula.,POSTOPERATIVE DIAGNOSES:,1.  Colovesical fistula.,2.  Intraperitoneal abscess.,PROCEDURE PERFORMED:,1.  Exploratory laparotomy.,2.  Low anterior colon resection.,3.  Flexible colonoscopy.,4.  Transverse loop colostomy and JP placement.,ANESTHESIA: , General.,HISTORY:  ,This 74-year-old female who had a recent hip fracture and the patient was in rehab when she started having some stool coming out of the urethra.  The patient had retrograde cystogram, which revealed colovesical fistula.  Recommendation for a surgery was made.  The patient was explained the risks and benefits as well as the two sons and the daughter.  They understood that the patient can even die from this procedure.  All the three procedures were explained, without a colostomy, with Hartmann's colostomy, and with a transverse loop colostomy, and out of the three procedures, the patient's requested to have the loop colostomy and stated that the Hartmann's colostomy leaving the anastomosis with the risk of leaking.,PROCEDURE DETAILS: , The patient was taken to the operating room, prepped and draped in the sterile fashion and was given general anesthetic.  An incision was performed in the midline below the umbilicus to the pubis with a #10 blade Bard Parker.  Electrocautery was used for hemostasis down to the fascia.  The fascia was grasped with Ochsner's and then immediately the peritoneum was entered and the incision was carried cephalad and caudad with electrocautery.,Once within the peritoneum, adhesiolysis was performed to separate the small bowel from the attachment of the anterior abdominal wall.  At this point, immediately a small bowel was retracted cephalad.  The patient was taken to a slightly Trendelenburg position and the descending colon was seen.  The white line of Toldt was opened all the way down to the area of inflammation.  At this point, meticulous dissection was carried to separate the small bowel from the attachment to the abscess.  When the small bowel was completely freed of  abscess, bulk of the bladder was seen anteriorly to the uterus.  The abscess was cultured and sent it back to Bacteriology Department and immediately the opening into the bladder was visualized.  At this point, the entire sigmoid colon was separated posteriorly as well as laterally and it was all the way down to sigmoid down to the rectum.  At this point, decision to place a moist towel and retract old intestine superiorly as well as to place first self-retaining retractor in the abdominal cavity with a bladder blade was placed.  Immediately, a GIA was fired right across the descending colon and sigmoid colon junction and then with peons within the mesentery were placed all the way down to the rectosigmoid junction where a TA-55 balloon Roticulator was fired.  The specimen was cut with #10 blade Bard-Parker and sent it to Pathology.  Immediately copious amount of irrigation was used and the staple line in the descending colon was brought with Allis.  A pursestring device was fired.  The staple line was cut.  The dilators were used using #25 and #29, then _________ #29 EEA was placed and the suture was tied.  At this point, attention was directed down to the rectal stump where dilators #25 and #29 were passed from the anus into the rectum and then the #29 Ethicon GIA was introduced.  The spike came posteriorly through the staple line to avoid the inflammatory process anteriorly that was present in the area of the cul-de-sac as well as the uterine was present in this patient.  ,Immediately, the EEA was connected with a mushroom.  It was tied, fired, and a Doyen was placed above the anastomosis approximately four inches.  Fluid was placed within the _________ and immediately a colonoscope was introduced from the patient's anus insufflating air.  No air was seen evolving from the staple line.  All fluid was removed and pictures of the staple line were taken.  The scope was removed at this point.  The case was passed to Dr. X for repair of the vesicle fistula.  Dr. X did repair down the perforation of the bladder that was communicating with an abscess secondary to the perforated diverticulitis and the colon.  After this was performed, copious amount of irrigation was used again.  More lysis of adhesions were performed and decision to make a loop transverse colostomy was made to protect the anastomosis in a phase of a severe inflammatory process in the pelvis in the infected area.  The incision was performed in the right upper quadrant.,This incision was performed with cutting in the cautery, down into the fascia splitting the muscle and then the Penrose was passed under transverse colon, and was grasped on pulling the transverse colon at the level of the skin.  The wire was passed under the transverse colon.  It was left in place.  Moderate irrigation was used in the peritoneal cavity and in the right lower quadrant, a JP was placed in the pelvis posteriorly to the abscess cavity that was down on the pelvis.  At this point, immediately, yellow fluid was removed from the peritoneal cavity and the abdomen was closed with cephalad to caudad and caudad to cephalad with a loop PDS suture and then tied.  Electrocautery for hemostasis and the subcutaneous tissue.  Copious amount of irrigation was used.  The skin was approximated with staples.  At this point, immediately, the wound was covered with a moist towel and decision to mature the loop colostomy was made.  The colostomy was opened longitudinally and then matured with interrupted #3-0 Vicryl suture through the skin edge.  One it was completely matured, immediately the index finger was probed proximally and distally and both loops were completely opened.  As previously mentioned, the Penrose was removed and the Bard was secured with a #3-0 nylon suture.  The JP was secured with #3-0 nylon suture as well.  At this point, dressings were applied.  The patient tolerated the procedure well.  The stent from the left ureter was removed and the Foley was left in place.  The patient did tolerate the procedure well and will be followed up during the hospitalization.","surgery, intraperitoneal abscess, colovesical fistula, low anterior colon resection, flexible colonoscopy, transverse loop colostomy, jp placement, exploratory laparotomy, colon resection, descending colon, transverse colon, colostomy, colon, laparotomy, aparotomy, fistula"
" Exploratory laparotomy, release of small bowel obstruction, and repair of periumbilical hernia.  Acute small bowel obstruction and incarcerated umbilical Hernia.", Surgery, Exploratory Laparotomy & Hernia Repair ,"PREOPERATIVE DIAGNOSIS:,1.  Acute bowel obstruction.,2.  Umbilical hernia.,POSTOPERATIVE DIAGNOSIS:,1.  Acute small bowel obstruction.,2.  Incarcerated umbilical Hernia.,PROCEDURE PERFORMED:,1.  Exploratory laparotomy.,2.  Release of small bowel obstruction.,3.  Repair of periumbilical hernia.,ANESTHESIA: , General with endotracheal intubation.,COMPLICATIONS:,  None.,DISPOSITION: , The patient tolerated the procedure well and was transferred to recovery in stable condition.,SPECIMEN: , Hernia sac.,HISTORY:  ,The patient is a 98-year-old female who presents from nursing home extended care facility with an incarcerated umbilical hernia, intractable nausea and vomiting and a bowel obstruction.  Upon seeing the patient and discussing in extent with the family, it was decided the patient needed to go to the operating room for this nonreducible umbilical hernia and bowel obstruction and the family agreed with surgery.,INTRAOPERATIVE FINDINGS: , The patient was found to have an incarcerated umbilical hernia.  There was a loop of small bowel incarcerated within the hernia sac.  It showed signs of ecchymosis, however no signs of any ischemia or necrosis.  It was easily reduced once opening the abdomen and the rest of the small bowel was ran without any other defects or abnormalities.,PROCEDURE: , After informed written consent, risks and benefits of the procedure were explained to the patient and the patient's family.  The patient was brought to the operating suite.  After general endotracheal intubation, prepped and draped in normal sterile fashion.  A midline incision was made around the umbilical hernia defect with a #10 blade scalpel.  Dissection was then carried down to the fascia.  Using a sharp dissection, an incision was made above the defect superior to the defect entering the fascia.  The abdomen was entered under direct visualization.  The small bowel that was entrapped within the hernia sac was easily reduced and observed and appeared to be ecchymotic, however, no signs of ischemia were noted or necrosis.  The remaining of the fascia was then extended using Metzenbaum scissors.  The hernia sac was removed using Mayo scissors and sent off as specimen.  Next, the bowel was run from the ligament of Treitz to the ileocecal valve with no evidence of any other abnormalities.  The small bowel was then milked down removing all the fluid.  The bowel was decompressed distal to the obstruction.  Once returning the abdominal contents to the abdomen, attention was next made in closing the abdomen and using #1 Vicryl suture in the figure-of-eight fashion the fascia was closed.  The umbilicus was then reapproximated to its anatomical position with a #1 Vicryl suture.  A #3-0 Vicryl suture was then used to reapproximate the deep dermal layers and skin staples were used on the skin.  Sterile dressings were applied.  The patient tolerated the procedure well and was transferred to recovery in stable condition.","surgery, endotracheal intubation, acute bowel obstruction, umbilical hernia, exploratory laparotomy, release of small bowel obstruction, repair of periumbilical hernia, incarcerated umbilical hernia, incarcerated, bowel, hernia, exploratory, laparotomy, abdomen, umbilical, obstruction, "
 Excision of left upper cheek skin neoplasm and left lower cheek skin neoplasm with two-layer closure.  Shave excision of the right nasal ala skin neoplasm., Surgery, Excision - Skin Neoplasm  ,"PREOPERATIVE DIAGNOSES:,1.  Enlarging nevus of the left upper cheek.,2.  Enlarging nevus 0.5 x 1 cm, left lower cheek.,3.  Enlarging superficial nevus 0.5 x 1 cm, right nasal ala.,TITLE OF PROCEDURES:,1.  Excision of left upper cheek skin neoplasm 0.5 x 1 cm with two layer closure.,2.  Excision of the left lower cheek skin neoplasm 0.5 x 1 cm with a two layer plastic closure.,3.  Shave excision of the right nasal ala 0.5 x 1 cm skin neoplasm.,ANESTHESIA:  ,Local.  I used a total of 5 mL of 1% lidocaine with 1:100,000 epinephrine.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,COMPLICATIONS:,  None.,PROCEDURE: , The patient was evaluated preop and noted to be in stable condition.  Chart and informed consent were all reviewed preop.  All risks, benefits, and alternatives regarding the procedure have been reviewed in detail with the patient.  Risks including but not limited to bleeding, infection, scarring, recurrence of the lesion, need for further procedures have been all reviewed.  Each of these lesions appears to be benign nevi; however, they have been increasing in size.  The lesions involving the left upper and lower cheek appear to be deep.  These required standard excision with the smaller lesion of the right nasal ala being more superficial and amenable to a superficial shave excision.  Each of these lesions was marked.  The skin was cleaned with a sterile alcohol swab.  Local anesthetic was infiltrated.  Sterile prep and drape were then performed.,Began first excision of the left upper cheek skin lesion.  This was excised with the 15-blade full thickness.  Once it was removed in its entirety, undermining was performed, and the wound was closed with 5-0 myochromic for the deep subcutaneous, 5-0 nylon interrupted for the skin.,The lesion of the lower cheek was removed in a similar manner.  Again, it was excised with a 15 blade with two layer plastic closure.  Both these lesions appear to be fairly deep nevi.,The right nasal ala nevus was superficially shaved using the radiofrequency wave unit.  Each of these lesions was sent as separate specimens.  The patient was discharged from my office in stable condition.  He had minimal blood loss.  The patient tolerated the procedure very well.  Postop care instructions were reviewed in detail.  We have scheduled a recheck in one week and we will make further recommendations at that time.","surgery, enlarging nevus, nevus, skin neoplasm, nasal ala, cheek skin neoplasm, shave excision, superficial, lesions, neoplasm, excision, cheek"
" Re-excision of squamous cell carcinoma site, right hand.", Surgery, Excision of Squamous Cell Carcinoma ,"PREOPERATIVE DIAGNOSIS: , Squamous cell carcinoma on the right hand, incompletely excised.,POSTOPERATIVE DIAGNOSIS: , Squamous cell carcinoma on the right hand, incompletely excised.,NAME OF OPERATION: , Re-excision of squamous cell carcinoma site, right hand.,ANESTHESIA:,  Local with monitored anesthesia care.,INDICATIONS:,  Patient, 72,  status post excision of squamous cell carcinoma on the dorsum of the right hand at the base of the thumb.  The deep margin was positive.  Other margins were clear.  He was brought back for re-excision.,PROCEDURE:,  The patient was brought to the operating room and placed in the supine position.  He was given intravenous sedation.  The right hand was prepped and draped in the usual sterile fashion.  Three cubic centimeters of 1% Xylocaine mixed 50/50 with 0.5% Marcaine with epinephrine was instilled with local anesthetic around the site of the excision, and the site of the cancer was re-excised with an elliptical incision down to the extensor tendon sheath.  The tissue was passed off the field as a specimen.,The wound was irrigated with warm normal saline.  Hemostasis was assured with the electrocautery.  The wound was closed with running 3-0 nylon without complication.  The patient tolerated the procedure well and was taken to the recovery room in stable condition after a sterile dressing was applied.","surgery, monitored anesthesia care, elliptical incision, squamous cell carcinoma site, squamous cell carcinoma, squamous cell, excision, squamous, carcinoma "
 Excision of the left upper cheek actinic neoplasm and left lower cheek upper neck skin neoplasm with two-layer plastic closures, Surgery, Excision - Actinic Neoplasm ,"PREOPERATIVE DIAGNOSES:,1.  Enlarging skin neoplasm, actinic neoplasm, left upper cheek, measures 1 cm x 1.5 cm.,2.  Enlarging 0.5 cm x 1 cm nevus of the left lower cheek neck region.,3.  A 1 cm x 1 cm seborrheic keratosis of the mid neck.,4.  A 1 cm x 1.5 cm verrucous seborrheic keratosis of the right auricular rim.,5.  A 1 cm x 1 cm actinic keratosis of the right mid cheek.,POSTOPERATIVE DIAGNOSES:,1.  Enlarging skin neoplasm, actinic neoplasm, left upper cheek, measures 1 cm x 1.5 cm.,2.  Enlarging 0.5 cm x 1 cm nevus of the left lower cheek neck region.,3.  A 1 cm x 1 cm seborrheic keratosis of the mid neck.,4.  A 1 cm x 1.5 cm verrucous seborrheic keratosis of the right auricular rim.,5.  A 1 cm x 1 cm actinic keratosis of the right mid cheek.,TITLE OF PROCEDURES:,1.  Excision of the left upper cheek actinic neoplasm defect measuring 1.5 cm x 1.8 cm with two-layer plastic closure.,2.  Excision of the left lower cheek upper neck, 1 cm x 1.5 cm skin neoplasm with two-layer plastic closure.,3.  Shave excision of the mid neck seborrheic keratosis that measured 1 cm x 1.5 cm.,4.  Shave excision of the right superior pinna auricular rim, 1 cm x 1.5 cm verrucous keratotic neoplasm.,5.  A 50% trichloroacetic acid treatment of the right mid cheek, 1 cm x 1 cm actinic neoplasm.,ANESTHESIA: , Local.  I used a total of 6 mL of 1% lidocaine with 1:100,000 epinephrine.,ESTIMATED BLOOD LOSS:,  Less than 30 mL.,COMPLICATIONS: , None.,COUNTS:  ,Sponge and needle counts were all correct.,PROCEDURE:,  The patient was evaluated preop and noted to be in stable condition.  Chart and informed consent were all reviewed preop.  All risks, benefits, and alternatives regarding the procedure have been reviewed in detail with the patient.  She is aware of risks include but not limited to bleeding, infection, scarring, recurrence of the lesion, need for further procedures, etc.  The areas of concern were marked with the marking pen.  Local anesthetic was infiltrated.  Sterile prep and drape were then performed.,I began excising the left upper cheek and left lower cheek neck lesions as listed above.  These were excised with the #15 blade.  The left upper cheek lesion measures 1 cm x 1.5 cm, defect after excision is 1.5 cm x 1.8 cm.  A suture was placed at the 12 o'clock superior margin.  Clinically, this appears to be either actinic keratosis or possible basal cell carcinoma.  The healthy margin of healthy tissue around this lesion was removed.  Wide underminings were performed and the lesion was closed in a two-layered fashion using 5-0 myochromic for the deep subcutaneous and 5-0 nylon for the skin.,The left upper neck lesion was also removed in the similar manner.  This is dark and black, appears to be either an intradermal nevus or pigmented seborrheic keratosis.  It was excised using a #15 blade down the subcutaneous tissue with the defect 1 cm x 1.5 cm.  After wide underminings were performed, a two-layer plastic closure was performed with 5-0 myochromic for the deep subcutaneous and 5-0 nylon for the skin.,The lesion of the mid neck and the auricular rim were then shave excised for the upper dermal layer with the Ellman radiofrequency wave unit.  These appeared to be clinically seborrheic keratotic neoplasms.,Finally proceeded with the right cheek lesion, which was treated with the 50% TCA.  This was also an actinic keratosis.  It is new in onset, just within the last week.  Once a light frosting was obtained from the treatment site, bacitracin ointment was applied.  Postop care instructions have been reviewed in detail.  The patient is scheduled a recheck in one week for suture removal.  We will make further recommendations at that time.",
 Excision of the left temple keratotic neoplasm and left nasolabial fold defect and right temple keratotic neoplasm., Surgery, Excision - Keratotic Neoplasm ,"PREOPERATIVE DIAGNOSES:,1.  Enlarging dark keratotic lesion of the left temple measuring 1 x 1 cm.,2.  Enlarging keratotic neoplasm of the left nasolabial fold measuring 0.5 x 0.5 cm.,3.  Enlarging seborrheic keratotic neoplasm of the right temple measuring 1 x 1 cm.,POSTOPERATIVE DIAGNOSES:,1.  Enlarging dark keratotic lesion of the left temple measuring 1 x 1 cm.,2.  Enlarging keratotic neoplasm of the left nasolabial fold measuring 0.5 x 0.5 cm.,3.  Enlarging seborrheic keratotic neoplasm of the right temple measuring 1 x 1 cm.,TITLE OF PROCEDURES:,1.  Excision of the left temple keratotic neoplasm, final defect 1.8 x 1.5 cm with two layer plastic closure.,2.  Excision of the left nasolabial fold defect 0.5 x 0.5 cm with single layer closure.,3.  Excision of the right temple keratotic neoplasm, final defect measuring 1.5 x 1.5 cm with two layer plastic closure.,ANESTHESIA: , Local using 3 mL of 1% lidocaine with 1:100,000 epinephrine.,ESTIMATED BLOOD LOSS: , Less than 30 mL.,COMPLICATIONS:,  None.,PROCEDURE: , The patient was evaluated preoperatively and noted to be in stable condition.  Informed consent was obtained from the patient.  All risks, benefits and alternatives regarding the surgery have been reviewed in detail with the patient.  This includes risks of bleeding, infection, scarring, recurrence of lesion, need for further procedures, etc.  Each of the areas was cleaned with a sterile alcohol swab.  Planned excision site was marked with a marking pen.  Local anesthetic was infiltrated.  Sterile prep and drape were then performed.,We began first with excision of the left temple followed by the left nasolabial and right temple lesions.  The left temple lesion is noted to be a dark black what appears to be a keratotic or possible seborrheic keratotic neoplasm.  However, it is somewhat deeper than the standard seborrheic keratosis.  The incision for removal of this lesion was placed within the relaxed skin tension line of the left temple region.  Once this was removed, wide undermining was performed and the wound was closed in a two layer fashion using 5-0 myochromic for the deep subcutaneous and 5-0 nylon for the skin.,Excision of left cheek was a keratotic nevus.  It was excised with a defect 0.5 x 0.5 cm.  It was closed in a single layer fashion 5-0 nylon.,The lesion of the right temple also dark black keratotic neoplasm was excised with the incision placed within the relaxed skin tension.  Once it was excised full-thickness, the defect measure 1.5 x 1.5 cm.  Wide undermine was performed and it was closed in a two layer fashion using 5-0 myochromic for the deep subcutaneous, 5-0 nylon that was used to close skin.  Sterile dressing was applied afterwards.  The patient was discharged in stable condition.  Postop care instructions reviewed in detail.  She is scheduled with me in one week and we will make further recommendations at that time.","surgery, keratotic lesion, keratotic neoplasm, seborrheic keratotic neoplasm, seborrheic, keratotic, neoplasm, nasolabial, two layer plastic closure, nasolabial fold, excision, "
 Excision of soft tissue mass on the right flank.  This 54-year-old male was evaluated in the office with a large right flank mass.  He would like to have this removed., Surgery, Excision - Soft Tissue Mass ,"PREOPERATIVE DIAGNOSIS: , Right flank subcutaneous mass.,POSTOPERATIVE DIAGNOSIS: , Right flank subcutaneous mass.,PROCEDURE PERFORMED: , Excision of soft tissue mass on the right flank.,ANESTHESIA: , Sedation with local.,INDICATIONS FOR PROCEDURE:,  This 54-year-old male was evaluated in the office with a large right flank mass.  He would like to have this removed.,DESCRIPTION OF PROCEDURE:,  Consent was obtained after all risks and benefits were described.  The patient was brought back into the operating room.  The aforementioned anesthesia was given.  Once the patient was properly anesthetized, the area was prepped and draped in the sterile fashion.  With the area properly prepped and draped, a needle was used to localize the area directly above the mass on the patient's right flank.  Then a #10 blade scalpel was used to make the incision approximately 4 cm to 5 cm in length just above the mass.  The incision was extended down using electrocautery.  The excision then had a Allis clamp placed on it and was retracted using sharp dissection and electrocautery was used to dissect the mass off the muscle.  The mass was sent off to Pathology for investigation.  Hemostasis maintained with electrocautery and then the subcutaneous fascia was closed using a #3-0 Vicryl suture in interrupted fashion and the skin was reapproximated using a #4-0 undyed Vicryl suture in a running subcuticular fashion.  The patient's wound was cleaned.  Steri-Strips were placed and sterile dressings were placed on top of this.  The patient tolerated the procedure well and will reevaluate in the office in one week's time.","surgery, electrocautery, soft tissue mass, subcutaneous, excision"
 Leaking anastomosis from esophagogastrectomy.   Exploratory laparotomy and drainage of intra-abdominal abscesses with control of leakage. , Surgery, Exploratory Laparotomy ,"PREOPERATIVE DIAGNOSIS: , Leaking anastomosis from esophagogastrectomy. ,POSTOPERATIVE DIAGNOSIS: ,  Leaking anastomosis from esophagogastrectomy. ,PROCEDURE: ,  Exploratory laparotomy and drainage of intra-abdominal abscesses with control of leakage. ,COMPLICATIONS:,  None. ,ANESTHESIA: , General oroendotracheal intubation. ,PROCEDURE:  , After adequate general anesthesia was administered, the patient's abdomen was prepped and draped aseptically. Sutures and staples were removed. The abdomen was opened. The were some very early stage adhesions that were easy to separate. Dissection was carried up toward the upper abdomen where the patient was found to have a stool filled descended colon. This was retracted caudally to expose the stomach. There were a number of adhesions to the stomach. These were carefully dissected to expose initially the closure over the gastrotomy site. Initially this looked like this was leaking but it was actually found to be intact.  The pyloroplasty was identified and also found to be intact with no evidence of leakage. Further dissection up toward the hiatus revealed an abscess collection. This was sent for culture and sensitivity and was aspirated and lavaged. Cavity tracked up toward the hiatus. Stomach itself appeared viable, there was no necrotic sections. Upper apex of the stomach was felt to be viable also. I did not pull the stomach and esophagus down into the abdomen from the mediastinum, but placed a sucker up into the mediastinum where additional turbid fluid was identified. Carefully placed a 10 mm flat Jackson-Pratt drain into the mediastinum through the hiatus to control this area of leakage. Two additional Jackson-Pratt drains were placed essentially through the gastrohepatic omentum. This was the area that most of the drainage had collected in. As I had previously discussed with Dr. Sageman I did not feel that mobilizing the stomach to redo the anastomosis in the chest would be a recoverable situation for the patient. I therefore did not push to visualize any focal areas of the anastomosis with the intent of repair. Once the drains were secured, they were brought out through the anterior abdominal wall and secured with 3-0 silk sutures and secured to bulb suction. The midline fascia was then closed using running #2 Prolene sutures bolstered with retention sutures. Subcutaneous tissue was copiously lavaged and then the skin was closed with loosely approximated staples. Dry gauze dressing was placed. The patient tolerated the procedure well, there were no complications.","surgery, drainage, oroendotracheal, intubation, intra abdominal, abdominal abscesses, jackson pratt, exploratory laparotomy, anastomosis, esophagogastrectomy, mediastinum, abdomen, stomach"
" Functional endoscopic sinus surgery, bilateral maxillary antrostomy, bilateral total ethmoidectomy, bilateral nasal polypectomy, and right middle turbinate reduction. ", Surgery, Ethmoidectomy & Nasal Polypectomy ,"PROCEDURES PERFORMED:,1.  Functional endoscopic sinus surgery.,2.  Bilateral maxillary antrostomy.,3.  Bilateral total ethmoidectomy.,4.  Bilateral nasal polypectomy.,5.  Right middle turbinate reduction.,ANESTHESIA:,  General endotracheal tube.,BLOOD LOSS:,  Approximately 50 cc.,INDICATION: , This is a 48-year-old female with a history of chronic sinusitis as well as nasal polyposis that have been refractory to outpatient medical management.  She has underwent sinus surgery in the past approximately 12 years ago with the CT evaluation revealed evidence of chronic mucosal thickening within the maxillary and ethmoid sinuses as well as the presence of polyposis within the nasal cavities bilaterally.,PROCEDURE:  ,After all risks, benefits, and alternatives have been discussed with the patient in detail, informed consent was obtained.  The patient was brought to the operative suite where she was placed in supine position and general anesthesia was delivered by the Department of Anesthesia.  The patient was rotated 90 degrees away where cotton pledgets saturated with 4 cc of 10% cocaine solution were inserted into the nasal cavity.  The nasal septum, as well as the turbinates were then localized with a mixture of 1% lidocaine with 1:100,000 epinephrine solution.  The patient was then prepped and draped in the usual fashion.,Attention was directed first to the left nasal cavity.  A zero-degree sinus endoscope was inserted into the nasal cavity down to the level of the nasopharynx.  The initial examination revealed a gross polypoid disease emanating from the sphenoid sinuses as well as off the supreme turbinate.  There was also polypoid disease present within the left middle meatus.  Nasopharynx was visualized with a patent eustachian tube.  At this point, the XPS micro debrider was used to take down all the polyps emanating from the inferior surface of the left middle turbinate as well as from the supreme turbinate.  The ostium to the sphenoid sinus was visualized and was not entered.  At this point, the left middle turbinate was localized and then medialized with the use of a freer elevator.  A ball-tip probe was then used to localize the openings for the natural maxillary ostium.  Side-biting forceps were used to take down the uncinate process and was further taken down with the use of the microdebrider.  The opening of the maxillary sinus was visualized.  The posterior fontanelle was taken down with the use of straight line forceps.  It should be mentioned that tissue was very thick and polypoid with chronic inflammatory changes evident.  The maxillary sinus ostia was then suctioned with Olive-tip suction and maxillary wash was performed.  The remainder of the anterior ethmoid was then cleaned again removing excess polypoid tissue.  The basal lamella was visualized and the posterior ethmoid air cells were then entered with use of the microdebrider as the surgical assistant palpated the patient's eyes for any vibration.  All polypoid tissue was collected in the microdebrider and sent as a surgical specimen.  Once all polypoid tissue has been removed, the cocaine pledgets were reinserted into the ethmoid air cells for hemostatic purposes.  Attention was then directed to the right nasal cavity.  Again, a sinus endoscope was inserted.  Inspection revealed a grossly hypertrophied turbinate.  It was felt that this enlarged and polypoid turbinate was contributing the patient's symptoms.  Therefore, the turbinate was localized and a hemostat was used to crush the mid portion of the turbinate, which was then resected with use of side-biting scissors as well the Takahashi forceps.  Sinus endoscope was then inserted all the way down through the nasopharynx.  Again, the eustachian tube was visualized without any obstructing lesions or masses.  Upon retraction, there was again polypoid tissue noted within the ethmoid sinuses.  The ball-tip probe was again used to locate the right maxillary ostium.  The side-biting forceps was used further take down the uncinate process.  The maxillary ostium was then widened with use of a XPS microdebrider.  A maxillary sinus wash was then performed.  Now, the attention was directed to the ethmoid air cells.  It should be mentioned again that the tissue of the anterior ethmoid was very thickened and polypoid.  This was again taken down with the use of XPS microdebrider while the surgical assistant carefully palpated the patient's eye.,Once all polypoid tissue have been removed, some bleeding that was encountered was controlled with the use of suction cautery in a very conservative manner.  Once all bleeding has been controlled, all surgical instruments were removed and Merocel packing was placed in the bilateral nasal cavities with the intent to remove in the recovery room.  At this point, the procedure was felt to be complete.  The patient was awakened and taken to the recovery room without incident.","surgery, endoscopic sinus surgery, maxillary antrostomy, ethmoidectomy, nasal polypectomy, turbinate reduction, sinus surgery, sinus endoscope, maxillary sinus, nasal cavity, polypoid tissue, sinus, maxillary, turbinate, polypoid, nasal, total, ostium, microdebrider,"
" Esophagoscopy with removal of foreign body.   Esophageal foreign body, no associated comorbidities are noted.", Surgery, Esophagoscopy & Foreign Body Removal - 1 ,"PRIMARY DIAGNOSIS:,  Esophageal foreign body, no associated comorbidities are noted.,PROCEDURE:,  Esophagoscopy with removal of foreign body.,CPT CODE: , 43215.,PRINCIPAL DIAGNOSIS:,  Esophageal foreign body, ICD-9 code 935.1.,DESCRIPTION OF PROCEDURE: , Under general anesthesia, flexible EGD was performed.  Esophagus was visualized.  The quarter was visualized at the aortic knob, was removed with grasper.  Estimated blood loss 0.  Intravenous fluids during time of procedure 100 mL.  No tissues.  No complications.  The patient tolerated the procedure well.  Dr. X Pipkin attending pediatric surgeon was present throughout the entire procedure.  The patient was transferred from OR to PACU in stable condition.","surgery, esophagus, foreign body, esophagoscopy, esophageal, "
 Excision of bilateral chronic hydradenitis., Surgery, Excision - Hydradenitis ,"PREOPERATIVE DIAGNOSIS: , Bilateral hydradenitis, chronic.,POSTOPERATIVE DIAGNOSIS: , Bilateral hydradenitis, chronic.,NAME OF OPERATION: , Excision of bilateral chronic hydradenitis.,ANESTHESIA:,  Local.,FINDINGS: , This patient had previously had excision of hydradenitis.  However, she had residual disease in both axilla with chronic redraining of the cyst from hydradenitis.  This now is controlled and it was found to be suitable for excision.  There was an area in each axilla which needed to be excised.,PROCEDURE: , Under local infiltration and after routine prepping and draping, an elliptical incision was first made on the left side to encompass the area of chronic hydradenitis.  This wound was then irrigated with saline.  The deeper layers were closed using interrupted 3-0 Vicryl.  The skin was closed using interrupted 5-0 nylon.,Attention was then directed to the right side where a similar procedure was carried out encompassing the involved area with the closure being identical to the opposite side.  This appeared to encompass all of the active area of hydradenitis.,The needle counts were all correct.  No intraoperative complications were encountered.  Dressings were applied, and the patient was returned to the recovery room in satisfactory condition.","surgery, hydradenitis, elliptical incision, bilateral hydradenitis, chronic hydradenitis, axilla, excision, chronic,"
 Esophagogastroduodenoscopy with pseudo and esophageal biopsy.  Hiatal hernia and reflux esophagitis. The patient is a 52-year-old female morbidly obese black female who has a long history of reflux and GERD type symptoms including complications such as hoarseness and chronic cough., Surgery, Esophagogastroduodenoscopy with Biopsies -2 ,"PREOPERATIVE DIAGNOSIS: , Refractory dyspepsia.,POSTOPERATIVE DIAGNOSIS:,1.  Hiatal hernia.,2.  Reflux esophagitis.,PROCEDURE PERFORMED:,  Esophagogastroduodenoscopy with pseudo and esophageal biopsy.,ANESTHESIA:,  Conscious sedation with Demerol and Versed.,SPECIMEN: , Esophageal biopsy.,COMPLICATIONS: , None.,HISTORY:,  The patient is a 52-year-old female morbidly obese black female who has a long history of reflux and GERD type symptoms including complications such as hoarseness and chronic cough.  She has been on multiple medical regimens and continues with dyspeptic symptoms.,PROCEDURE: , After proper informed consent was obtained, the patient was brought to the endoscopy suite.  She was placed in the left lateral position and was given IV Demerol and Versed for sedation.  When adequate level of sedation achieved, the gastroscope was inserted into the hypopharynx and the esophagus was easily intubated.  At the GE junction, a hiatal hernia was present.  There were mild inflammatory changes consistent with reflux esophagitis.  The scope was then passed into the stomach.  It was insufflated and the scope was coursed along the greater curvature to the antrum.  The pylorus was patent.  There was evidence of bile reflux in the antrum.  The duodenal bulb and sweep were examined and were without evidence of mass, ulceration, or inflammation.  The scope was then brought back into the antrum.,A retroflexion was attempted multiple times, however, the patient was having difficulty holding the air and adequate retroflexion view was not visualized.  The gastroscope was then slowly withdrawn.  There were no other abnormalities noted in the fundus or body.  Once again at the GE junction, esophageal biopsy was taken.  The scope was then completely withdrawn.  The patient tolerated the procedure and was transferred to the recovery room in stable condition.  She will return to the General Medical Floor.  We will continue b.i.d proton-pump inhibitor therapy as well as dietary restrictions.  She should also attempt significant weight loss.","surgery, refractory dyspepsia, hiatal hernia, reflux esophagitis, esophagogastroduodenoscopy, esophageal, pseudo, esophageal biopsy, ge junction, hiatal, hernia, esophagitis, antrum, gerd,"
" Esophagogastroduodenoscopy with gastric biopsies.  Antral erythema; 2 cm polypoid pyloric channel tissue, questionable inflammatory polyp which was biopsied; duodenal erythema and erosion.", Surgery, Esophagogastroduodenoscopy with Biopsies - 1 ,"PROCEDURE: , Esophagogastroduodenoscopy with gastric biopsies.,INDICATION:,  Abdominal pain.,FINDINGS:,  Antral erythema; 2 cm polypoid pyloric channel tissue, questionable inflammatory polyp which was biopsied; duodenal erythema and erosion.,MEDICATIONS: , Fentanyl 200 mcg and versed 6 mg.,SCOPE: , GIF-Q180.,PROCEDURE DETAIL: , Following the preprocedure patient assessment the procedure, goals, risks including bleeding, perforation and side effects of medications and alternatives were reviewed.  Questions were answered.  Pause preprocedure was performed.,Following titrated intravenous sedation the flexible video endoscope was introduced into the esophagus and advanced to the second portion of the duodenum without difficulty.  The esophagus appeared to have normal motility and mucosa.  Regular Z line was located at 44 cm from incisors.  No erosion or ulceration.  No esophagitis.,Upon entering the stomach gastric mucosa was examined in detail including retroflexed views of cardia and fundus.  There was pyloric channel and antral erythema, but no visible erosion or ulceration.  There was a 2 cm polypoid pyloric channel tissue which was suspicious for inflammatory polyp.  This was biopsied and was placed separately in bottle #2.  Random gastric biopsies from antrum, incisura and body were obtained and placed in separate jar, bottle #1.  No active ulceration was found.,Upon entering the duodenal bulb there was extensive erythema and mild erosions, less than 3 mm in length, in first portion of duodenum, duodenal bulb and junction of first and second part of the duodenum.  Postbulbar duodenum looked normal.,The patient was assessed upon completion of the procedure.  Okay to discharge once criteria met.,Follow up with primary care physician.,I met with patient afterward and discussed with him avoiding any nonsteroidal anti-inflammatory medication.  Await biopsy results.","surgery, gastric biopsies, duodenal erythema, inflammatory polyp, pyloric channel tissue, pyloric channel, esophagogastroduodenoscopy, pyloric, duodenal, duodenum, polypoid,"
" Esophageal foreign body, US penny.  Esophagoscopy with foreign body removal.  The patient had a penny lodged in the proximal esophagus in the typical location. ", Surgery, Esophagoscopy & Foreign Body Removal ,"PREOPERATIVE DIAGNOSIS: , Esophageal foreign body.,POSTOPERATIVE DIAGNOSIS:,  Esophageal foreign body, US penny.,PROCEDURE: , Esophagoscopy with foreign body removal.,ANESTHESIA: , General.,INDICATIONS: , The patient is a 17-month-old baby girl with biliary atresia, who had a delayed diagnosis and a late attempted Kasai portoenterostomy, which failed.  The patient has progressive cholestatic jaundice and is on the liver transplant list at ABCD.  The patient is fed by mouth and also with nasogastric enteral feeding supplements.  She has had an __________ cough and relatively disinterested in oral intake for the past month.  She was recently in the GI Clinic and an x-ray was ordered to check her tube placement and an incidental finding of a coin in the proximal esophagus was noted.  Based on the history, it is quite possible this coin has been there close to a month.  She is brought to the operating room now for attempted removal.  I met with the parents and talked to them at length about the procedure and the increased risk in a child with a coin that has been in for a prolonged period of time.  Hopefully, there will be no coin migration or significant irrigation that would require prolonged hospitalization.,OPERATIVE FINDINGS: , The patient had a penny lodged in the proximal esophagus in the typical location.  There was no evidence of external migration and surrounding irritation was noted, but did not appear to be excessive.  The coin actually came out with relative ease after which endoscopically identified.,DESCRIPTION OF OPERATION: , The patient came to the operating room and had induction of general anesthesia.  She was slow to respond to the usual propofol and other inducing agents and may be has some difficulty with tolerance or __________ tolerance to these medications.  After her endotracheal tube was placed and securely taped to the left side of her mouth, I positioned the patient with a prominent shoulder roll and neck hyperextension and then used the laryngoscope to elevate the tiny glottic mechanism.  A rigid esophagoscope was then inserted into the proximal esophagus, and the scope was gradually advanced with the lumen directly in frontal view.  This was facilitated by the nasoenteric feeding tube that was in place, which I followed carefully until the edge of the coin could be seen.  At this location, there was quite a bit of surrounding mucosal inflammation, but the coin edge could be clearly seen and was secured with the coin grasping forceps.  I then withdrew the scope, forceps, and the coin as one unit, and it was easily retrieved.  The patient tolerated the procedure well.  There were no intraoperative complications.  There was only one single coin noted, and she was awakened and taken to the recovery room in good condition.","surgery, portoenterostomy, foreign body removal, proximal esophagus, coin, esophagoscopy, esophageal, esophagus,"
 Esophagogastroduodenoscopy with biopsy of one of the polyps and percutaneous endoscopic gastrostomy tube placement.  Malnutrition and dysphagia with two antral polyps and large hiatal hernia., Surgery, Esophagogastroduodenoscopy - 9 ,"PREOPERATIVE DIAGNOSES: , Malnutrition and dysphagia.,POSTOPERATIVE DIAGNOSES: , Malnutrition and dysphagia with two antral polyps and large hiatal hernia.,PROCEDURES: , Esophagogastroduodenoscopy with biopsy of one of the polyps and percutaneous endoscopic gastrostomy tube placement.,ANESTHESIA: , IV sedation, 1% Xylocaine locally.,CONDITION:,  Stable.,OPERATIVE NOTE IN DETAIL: , After risk of operation was explained to this patient's family, consent was obtained for surgery.  The patient was brought to the GI lab.  There, she was placed in partial left lateral decubitus position.  She was given IV sedation by Anesthesia.  Her abdomen was prepped with alcohol and then Betadine.  Flexible gastroscope was passed down the esophagus, through the stomach into the duodenum.  No lesions were noted in the duodenum.  There appeared to be a few polyps in the antral area, two in the antrum.  Actually, one appeared to be almost covering the pylorus.  The scope was withdrawn back into the antrum.  On retroflexion, we could see a large hiatal hernia.  No other lesions were noted.  Biopsy was taken of one of the polyps.  The scope was left in position.  Anterior abdominal wall was prepped with Betadine, 1% Xylocaine was injected in the left epigastric area.  A small stab incision was made and a large bore Angiocath was placed directly into the anterior abdominal wall, into the stomach, followed by a thread, was grasped with a snare using the gastroscope, brought out through the patient's mouth.  Tied to the gastrostomy tube, which was then pulled down and up through the anterior abdominal wall.  It was held in position with a dressing and a stent.  A connector was applied to the cut gastrostomy tube, held in place with a 2-0 silk ligature.  The patient tolerated the procedure well.  She was returned to the floor in stable condition.","surgery, antral, polyps, gastrostomy, endoscopic gastrostomy, hiatal hernia, abdominal wall, gastrostomy tube, esophagogastroduodenoscopy, malnutrition, dysphagia, abdominal"
 Esophagogastroduodenoscopy with photo.  Insertion of a percutaneous endoscopic gastrostomy tube.  Neuromuscular dysphagia.  Protein-calorie malnutrition., Surgery, Esophagogastroduodenoscopy & Gastrostomy Tube Insertion ,"PREOPERATIVE DIAGNOSES:,1.  Neuromuscular dysphagia.,2.  Protein-calorie malnutrition.,POSTOPERATIVE DIAGNOSES:,1.  Neuromuscular dysphagia.,2.  Protein-calorie malnutrition.,PROCEDURES PERFORMED:,1.  Esophagogastroduodenoscopy with photo.,2.  Insertion of a percutaneous endoscopic gastrostomy tube.,ANESTHESIA:,  IV sedation and local.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well without difficulty.,BRIEF HISTORY:  ,The patient is a 50-year-old African-American male who presented to ABCD General Hospital on 08/18/2003 secondary to right hemiparesis from a CVA.  The patient deteriorated with several CVAs and had became encephalopathic requiring a ventilator-dependency with respiratory failure.  The patient also had neuromuscular dysfunction.  After extended period of time, per the patient's family request and requested by the ICU staff, decision to place a feeding tube was decided and scheduled for today.,INTRAOPERATIVE FINDINGS: , The patient was found to have esophagitis as well as gastritis via EGD and was placed on Prevacid granules.,PROCEDURE: , After informed written consent, the risks and benefits of the procedure were explained to the patient and the patient's family.  First, the EGD was to be performed.,The Olympus endoscope was inserted through the mouth, oropharynx and into the esophagus.  Esophagitis was noted.  The scope was then passed through the esophagus into the stomach.  The cardia, fundus, body, and antrum of the stomach were visualized.  There was evidence of gastritis.  The scope was passed into the duodenal bulb and sweep via the pylorus and then removed from the duodenum retroflexing on itself in the stomach looking at the hiatus.  Next, attention was made to transilluminating the anterior abdominal wall for the PEG placement.  The skin was then anesthetized with 1% lidocaine.  The finder needle was then inserted under direct visualization.  The catheter was then grasped via the endoscope and the wire was pulled back up through the patient's mouth.  The Ponsky PEG tube was attached to the wire.  A skin nick was made with a #11 blade scalpel.  The wire was pulled back up through the abdominal wall point and Ponsky PEG back up through the abdominal wall and inserted into position.  The endoscope was then replaced confirming position.  Photograph was taken.  The Ponsky PEG tube was trimmed and the desired attachments were placed and the patient did tolerate the procedure well.  We will begin tube feeds later this afternoon.","surgery, neuromuscular dysphagia, protein-calorie malnutrition, esophagogastroduodenoscopy, endoscopic, gastrostomy, percutaneous, gastrostomy tube, percutaneous endoscopic gastrostomy tube, protein calorie malnutrition, abdominal wall, dysphagia, stomach, abdominal, neuromuscular, tube,"
" Positive peptic ulcer disease.  Gastritis.  Esophagogastroduodenoscopy with photography and biopsy.   The patient had a history of peptic ulcer disease, epigastric abdominal pain x2 months, being evaluated at this time for ulcer disease.", Surgery, Esophagogastroduodenoscopy - 7 ,"PREOPERATIVE DIAGNOSIS:,  Positive peptic ulcer disease.,POSTOPERATIVE DIAGNOSIS:,  Gastritis.,PROCEDURE PERFORMED: , Esophagogastroduodenoscopy with photography and biopsy.,GROSS FINDINGS:,  The patient had a history of peptic ulcer disease, epigastric abdominal pain x2 months, being evaluated at this time for ulcer disease.,Upon endoscopy, gastroesophageal junction was at 40 cm, no esophageal tumor, varices, strictures, masses, or no reflux esophagitis was noted.  Examination of the stomach reveals mild inflammation of the antrum of the stomach, no ulcers, erosions, tumors, or masses.  The profundus and the cardia of the stomach were unremarkable.  The pylorus was concentric.  The duodenal bulb and sweep with no inflammation, tumors, or masses.,OPERATIVE PROCEDURE: , The patient taken to the Endoscopy Suite, prepped and draped in the left lateral decubitus position.  She was given IV sedation using Demerol and Versed.  Olympus videoscope was inserted in the hypopharynx, upon deglutition passed into the esophagus.  Using air insufflation, the scope was advanced down through the esophagus into the stomach along the greater curvature of the stomach to the pylorus to the duodenal bulb and sweep.  The above gross findings noted.  The panendoscope was withdrawn back from the stomach, deflected upon itself.  The lesser curve fundus and cardiac were well visualized.  Upon examination of these areas, panendoscope was returned to midline.  Photographs and biopsies were obtained of the antrum of the stomach.  Air was aspirated from the stomach and panendoscope was slowly withdrawn carefully examining the lumen of the bowel.,Photographs and biopsies were obtained as appropriate.  The patient is sent to recovery room in stable condition.","surgery, antrum, esophageal tumor, varices, strictures, masses, duodenal bulb, peptic ulcer, duodenal, esophagus, esophagogastroduodenoscopy, panendoscope, peptic, inflammation, ulcer, disease, stomach"
" Esophagogastroduodenoscopy with biopsies.  Gastroesophageal reflux disease, chronic dyspepsia, alkaline reflux gastritis, gastroparesis, probable Billroth II anastomosis, and status post Whipple's pancreaticoduodenectomy.", Surgery, Esophagogastroduodenoscopy with Biopsies ,"PREOPERATIVE DIAGNOSES:,1.  Gastroesophageal reflux disease.,2.  Chronic dyspepsia.,POSTOPERATIVE DIAGNOSES:,1.  Gastroesophageal reflux disease.,2.  Chronic dyspepsia.,3.  Alkaline reflux gastritis.,4.  Gastroparesis.,5.  Probable Billroth II anastomosis.,6.  Status post Whipple's pancreaticoduodenectomy.,PROCEDURE PERFORMED:,  Esophagogastroduodenoscopy with biopsies.,INDICATIONS FOR PROCEDURE: , This is a 55-year-old African-American female who had undergone Whipple's procedure approximately five to six years ago for a benign pancreatic mass.  The patient has pancreatic insufficiency and is already on replacement.  She is currently using Nexium.  She has continued postprandial dyspepsia and reflux symptoms.  To evaluate this, the patient was boarded for EGD.  The patient gave informed consent for the procedure.,GROSS FINDINGS: , At the time of EGD, the patient was found to have alkaline reflux gastritis.  There was no evidence of distal esophagitis.  Gastroparesis was seen as there was retained fluid in the small intestine.  The patient had no evidence of anastomotic obstruction and appeared to have a Billroth II reconstruction by gastric jejunostomy.  Biopsies were taken and further recommendations will follow.,PROCEDURE:  ,The patient was taken to the Endoscopy Suite.  The heart and lungs examination were unremarkable.  The vital signs were monitored and found to be stable throughout the procedure.  The patient's oropharynx was anesthetized with Cetacaine spray.  She was placed in left lateral position.  The patient had the video Olympus GIF gastroscope model inserted per os and was advanced without difficulty through the hypopharynx.  GE junction was in normal position.  There was no evidence of any hiatal hernia.  There was no evidence of distal esophagitis.  The gastric remnant was entered.  It was noted to be inflamed with alkaline reflux gastritis.  The anastomosis was open and patent.  The small intestine was entered.  There was retained fluid material in the stomach and small intestine and _______ gastroparesis.  Biopsies were performed.  Insufflated air was removed with withdrawal of the scope.  The patient's diet will be adjusted to postgastrectomy-type diet.  Biopsies performed.  Diet will be reviewed.  The patient will have an upper GI series performed to rule out more distal type obstruction explaining the retained fluid versus gastroparesis.  Reglan will also be added.  Further recommendations will follow.","surgery, gastroesophageal reflux disease, chronic dyspepsia, alkaline reflux gastritis, gastroparesis, whipple's pancreaticoduodenectomy, billroth ii anastomosis, gastroesophageal reflux, alkaline reflux, reflux gastritis, gif, esophagogastroduodenoscopy, dyspepsia, gastritis, anastomosis, pancreaticoduodenectomy, biopsies, alkaline, reflux,"
" Chronic abdominal pain and heme positive stool, antral gastritis, and duodenal polyp.  Esophagogastroduodenoscopy with photos and antral biopsy.", Surgery, Esophagogastroduodenoscopy - 8 ,"PREOPERATIVE DIAGNOSIS:, Chronic abdominal pain and heme positive stool.,POSTOPERATIVE DIAGNOSES:,1.  Antral gastritis.,2.  Duodenal polyp.,PROCEDURE PERFORMED:,  Esophagogastroduodenoscopy with photos and antral biopsy.,ANESTHESIA: , Demerol and Versed.,DESCRIPTION OF PROCEDURE: , Consent was obtained after all risks and benefits were described.  The patient was brought back into the Endoscopy Suite.  The aforementioned anesthesia was given.  Once the patient was properly anesthetized, bite block was placed in the patient's mouth.  Then, the patient was given the aforementioned anesthesia.  Once he was properly anesthetized, the endoscope was placed in the patient's mouth that was brought down to the cricopharyngeus muscle into the esophagus and from the esophagus to his stomach.  The air was insufflated down.  The scope was passed down to the level of the antrum where there was some evidence of gastritis seen.  The scope was passed into the duodenum and then duodenal sweep where there was a polyp seen.  The scope was pulled back into the stomach in order to flex upon itself and straightened out.  Biopsies were taken for CLO and histology of the antrum.  The scope was pulled back.  The junction was visualized.  No other masses or lesions were seen.  The scope was removed.  The patient tolerated the procedure well.  We will recommend the patient be on some type of a H2 blocker.  Further recommendations to follow.","surgery, endoscopy, gastritis, clo, histology, antrum, heme positive stool, esophagogastroduodenoscopy, duodenal, polyp, antral, "
 Esophagogastroduodenoscopy.   The Olympus video gastroscope was then introduced into the upper esophagus and passed by direct vision to the descending duodenum., Surgery, Esophagogastroduodenoscopy - 6 ,"PROCEDURE IN DETAIL: , Following premedication with Vistaril 50 mg and Atropine 0.4 mg IM, the patient received Versed 5.0 mg intravenously after Cetacaine spray to the posterior palate.  The Olympus video gastroscope was then introduced into the upper esophagus and passed by direct vision to the descending duodenum.  The upper, mid and lower portions of the esophagus; the lesser and greater curves of the stomach; anterior and posterior walls; body and antrum; pylorus; duodenal bulb; and duodenum were all normal.  No evidence of friability, ulceration or tumor mass was encountered.  The instrument was withdrawn to the antrum, and biopsies taken for CLO testing, and then the instrument removed.","surgery, cetacaine, pylorus, antrum, duodenum, upper esophagus, esophagogastroduodenoscopy, descending, esophagusNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Esophagogastroduodenoscopy with biopsy and colonoscopy with biopsy., Surgery, Esophagogastroduodenoscopy - 4 ,"PROCEDURE: , Esophagogastroduodenoscopy with biopsy and colonoscopy with biopsy.,INDICATIONS FOR PROCEDURE: , A 17-year-old with history of 40-pound weight loss, abdominal pain, status post appendectomy with recurrent abscess formation and drainage.  Currently, he has a fistula from his anterior abdominal wall out.  It does not appear to connect to the gastrointestinal tract, but merely connect from the ventral surface of the rectus muscles out the abdominal wall.  CT scans show thickened terminal ileum, which suggest that we are dealing with Crohn's disease.  Endoscopy is being done to evaluate for Crohn's disease.,MEDICATIONS:  ,General anesthesia.,INSTRUMENT:,  Olympus GIF-160 and PCF-160.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  Less than 5 mL.,FINDINGS: , With the patient in the supine position, intubated under general anesthesia.  The endoscope was inserted without difficulty into the hypopharynx.  The scope was advanced down the esophagus, which had normal mucosal coloration and vascular pattern.  Lower esophageal sphincter was located at 40 cm from the central incisors.  It appeared normal and appeared to function normally.  The endoscope was advanced into the stomach, which was distended with excess air.  Rugal folds were flattened completely.  There were multiple superficial erosions scattered throughout the fundus, body, and antral portions consistent with Crohn's involvement of the stomach.  The endoscope was advanced through normal-appearing pyloric valve into the first, second, and third portion of the duodenum, which had normal mucosal coloration and fold pattern.  Biopsies were obtained x2 in the second portion of the duodenum, antrum, body, and distal esophagus at 37 cm from the central incisors for histology.  Two additional biopsies were obtained in the antrum for CLO testing.  Excess air was evacuated from the stomach.  The scope was removed from the patient who tolerated that part of the procedure well.,The patient was turned and scope was changed for colonoscopy.  Prior to colonoscopy, it was noted that there was a perianal fistula at 7 o'clock.  The colonoscope was then inserted into the anal verge.  The colonic clean out was excellent.  The scope was advanced without difficulty to the cecum.  The cecal area had multiple ulcers with exudate.  The ileocecal valve was markedly distorted.  Biopsies were obtained x2 in the cecal area and then the scope was withdrawn through the ascending, transverse, descending, sigmoid, and rectum.  The colonic mucosa in these areas was well seen and there were a few scattered aphthous ulcers in the ascending and descending colon.  Biopsies were obtained in the cecum at 65 cm, transverse colon 50 cm, rectosigmoid 20 cm, and rectum at 5 cm.  No fistulas were noted in the colon.  Excess air was evacuated from the colon.  The scope was removed.  The patient tolerated the procedure well and was taken to recovery in satisfactory condition.,IMPRESSION: , Normal esophagus and duodenum.  There were multiple superficial erosions or aphthous ulcers in the stomach along with a very few scattered aphthous ulcers in the colon with marked cecal involvement with large ulcers and a very irregular ileocecal valve.  All these findings are consistent with Crohn's disease.,PLAN:  ,Begin prednisone 30 mg p.o. daily.  Await PPD results and chest x-ray results, as well as cocci serology results.  If these are normal, then we would recommend Remicade 5 mg/kg IV infusion.  We would start Modulon 50 mL/h for 20 hours to reverse the malnutrition state of this boy.  Check CMP and phosphate every Monday, Wednesday, and Friday for receding syndrome noted by following potassium and phosphate.  We will discuss with Dr. X possibly repeating the CT fistulogram if the findings on the previous ones are inconclusive as far as the noting whether we can rule in or out an enterocutaneous fistula.  He will need an upper GI to rule out small intestinal strictures and involvement of the small intestine that cannot be seen with upper and lower endoscopy.  If he has no stricture formation in the small bowel, we would then recommend a video endoscopy capsule to further evaluate any mucosal lesions consistent with Crohn's in the small intestine that we cannot visualize with endoscopy.","surgery, olympus gif-160, pcf-160, endoscopy, crohn's disease, aphthous ulcers, esophagogastroduodenoscopy, endoscope, esophagus, duodenum, mucosal, stomach, biopsies, colonoscopy"
 Esophagogastroduodenoscopy.  The Olympus video panendoscope was advanced under direct vision into the esophagus.  The esophagus was normal in appearance and configuration.  The gastroesophageal junction was normal. , Surgery, Esophagogastroduodenoscopy - 5 ,"MEDICATIONS:,1.  Versed intravenously.,2.  Demerol intravenously.,DESCRIPTION OF THE PROCEDURE: , After informed consent, the patient was placed in the left lateral decubitus position and Cetacaine spray was applied to the posterior pharynx.  The patient was sedated with the above medications.  The Olympus video panendoscope was advanced under direct vision into the esophagus.  The esophagus was normal in appearance and configuration.  The gastroesophageal junction was normal.  The scope was advanced into the stomach, where the fundic pool was aspirated and the stomach was insufflated with air.  The gastric mucosa appeared normal.  The pylorus was normal.  The scope was advanced through the pylorus into the duodenal bulb, which was normal, then into the second part of the duodenum, which was normal as well.  The scope was pulled back into the stomach.  Retroflexed view showed a normal incisura, lesser curvature, cardia and fundus.  The scope was straightened out, the air removed and the scope withdrawn.  The patient tolerated the procedure well.  There were no apparent complications.,","surgery, duodenal bulb, gastric mucosa, olympus video, video panendoscope, gastroesophageal junction, esophagogastroduodenoscopy, gastroesophageal, pylorus, stomach, esophagus, scopeNOTE"
 Esophagogastroduodenoscopy performed in the emergency department., Surgery, Esophagogastroduodenoscopy - 13 ,"PROCEDURE PERFORMED: , Esophagogastroduodenoscopy performed in the emergency department.,INDICATION: , Melena, acute upper GI bleed, anemia, and history of cirrhosis and varices.,FINAL IMPRESSION,1.  Scope passage massive liquid in stomach with some fresh blood near the fundus, unable to identify source due to gastric contents.,2.  Endoscopy following erythromycin demonstrated grade I esophageal varices.  No stigmata of active bleeding.  Small amount of fresh blood within the hiatal hernia.  No definite source of bleeding seen.,PLAN,1.  Repeat EGD tomorrow morning following aggressive resuscitation and transfusion.,2.  Proton-pump inhibitor drip.,3.  Octreotide drip.,4.  ICU bed.,PROCEDURE DETAILS:  ,Prior to the procedure, physical exam was stable.  During the procedure, vital signs remained within normal limits.  Prior to sedation, informed consent was obtained.  Risks, benefits, and alternatives including, but not limited to risk of bleeding, infection, perforation, adverse reaction to medication, failure to identify pathology, pancreatitis, and death explained to the patient and his wife, who accepted all risks.  The patient was prepped in the left lateral position.  IV sedation was given to a total of fentanyl 100 mcg and midazolam 4 mg for the initial EGD.  An additional 50 mcg of fentanyl and 2 mg of midazolam were given following erythromycin.  Scope tip of the Olympus gastroscope was passed into the esophagus.  Proximal, middle, and distal thirds of the esophagus were well visualized.  There was fresh blood in the esophagus, which was washed thoroughly, but no source was seen.  No evidence of varices was seen.  The stomach was entered.  The stomach was filled with very large clot and fresh blood and liquid, which could not be suctioned due to the clot burden.  There was a small amount of bright red blood near the fundus, but a source could not be identified due to the clot burden.  Because of this, the gastroscope was withdrawn.  The patient was given 250 mg of erythromycin in the Emergency Department and 30 minutes later, the scope was repassed.  On the second look, the esophagus was cleared.  The liquid gastric contents were cleared.  There was still a moderate amount of clot burden in the stomach, but no active bleeding was seen.  There was a small grade I esophageal varices, but no stigmata of bleed.  There was also a small amount of fresh blood within the hiatal hernia, but no source of bleeding was identified.  The patient was hemodynamically stable; therefore, a decision was made for a second look in the morning.  The scope was withdrawn and air was suctioned.  The patient tolerated the procedure well and was sent to recovery without immediate complications.","surgery, gi bleed, anemia, cirrhosis, stomach, fundus, hiatal hernia, esophagogastroduodenoscopy, erythromycin, varices, esophagus,"
 Esophagogastroduodenoscopy and colonoscopy with biopsy and polypectomy., Surgery, Esophagogastroduodenoscopy - 3 ,"PROCEDURES:,  Esophagogastroduodenoscopy and colonoscopy with biopsy and polypectomy.,REASON FOR PROCEDURE: , Child with abdominal pain and rectal bleeding.  Rule out inflammatory bowel disease, allergic enterocolitis, rectal polyps, and rectal vascular malformations.,CONSENT:,  History and physical examination was performed.  The procedure, indications, alternatives available, and complications, i.e. bleeding, perforation, infection, adverse medication reaction, the possible need for blood transfusion, and surgery should a complication occur were discussed with the parents who understood and indicated this.  Opportunity for questions was provided and informed consent was obtained.,MEDICATION:  ,General anesthesia.,INSTRUMENT: , Olympus GIF-160.,COMPLICATIONS:,  None.,FINDINGS: , With the patient in the supine position and intubated, the endoscope was inserted without difficulty into the hypopharynx.  The esophageal mucosa and vascular pattern appeared normal.  The lower esophageal sphincter was located at 25 cm from the central incisors.  It appeared normal.  A Z-line was identified within the lower esophageal sphincter.  The endoscope was advanced into the stomach, which distended with excess air.  Rugal folds flattened completely.  Gastric mucosa appeared normal throughout.  No hiatal hernia was noted.  Pyloric valve appeared normal.  The endoscope was advanced into the first, second, and third portions of duodenum, which had normal mucosa, coloration, and fold pattern.  Biopsies were obtained x2 in the second portion of duodenum, antrum, and distal esophagus at 22 cm from the central incisors for histology.  Additional 2 biopsies were obtained for CLO testing in the antrum.  Excess air was evacuated from the stomach.  The scope was removed from the patient who tolerated that part of procedure well.  The patient was turned and the scope was advanced with some difficulty to the terminal ileum.  The terminal ileum mucosa and the colonic mucosa throughout was normal except at approximately 10 cm where a 1 x 1 cm pedunculated juvenile-appearing polyp was noted.  Biopsies were obtained x2 in the terminal ileum, cecum, ascending colon, transverse colon, descending colon, sigmoid, and rectum.  Then, the polyp was snared right at the base of the polyp on the stalk and 20 watts of pure coag was applied in 2-second bursts x3.  The polyp was severed.  There was no bleeding at the stalk after removal of the polyp head.  The polyp head was removed by suction.  Excess air was evacuated from the colon.  The patient tolerated that part of the procedure well and was taken to recovery in satisfactory condition.  Estimated blood loss approximately 5 mL.,IMPRESSION: , Normal esophagus, stomach, duodenum, and colon as well as terminal ileum except for a 1 x 1-cm rectal polyp, which was removed successfully by polypectomy snare.,PLAN:  ,Histologic evaluation and CLO testing.  I will contact the parents next week with biopsy results and further management plans will be discussed at that time.","surgery, esophagus, stomach, duodenum, rectal polyp, polypectomy snare, olympus gif-160, endoscope was advanced, clo testing, polyp head, terminal ileum, polypectomy, biopsies, esophagogastroduodenoscopy, ileum, mucosa, colonoscopy,"
 Esophagogastroduodenoscopy with biopsy., Surgery, Esophagogastroduodenoscopy - 2 ,"PROCEDURE:,  Esophagogastroduodenoscopy with biopsy.,REASON FOR PROCEDURE:,  The child with history of irritability and diarrhea with gastroesophageal reflux.  Rule out reflux esophagitis, allergic enteritis, and ulcer disease, as well as celiac disease.  He has been on Prevacid 7.5 mg p.o. b.i.d. with suboptimal control of this irritability.,Consent history and physical examinations were performed.  The procedure, indications, alternatives available, and complications i.e. bleeding, perforation, infection, adverse medication reactions, possible need for blood transfusion, and surgery associated complication occur were discussed with the mother who understood and indicated this.  Opportunity for questions was provided and informed consent was obtained.,MEDICATIONS:  ,General anesthesia.,INSTRUMENT: , Olympus GIF-XQ 160.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  Less than 5 mL.,FINDINGS: , With the patient in the supine position intubated under general anesthesia, the endoscope was inserted without difficulty into the hypopharynx.  The proximal, mid, and distal esophagus had normal mucosal coloration and vascular pattern.  Lower esophageal sphincter appeared normal and was located at 25 cm from the central incisors.  A Z-line was identified within the lower esophageal sphincter.  The endoscope was advanced into the stomach, which was distended with excess air.  The rugal folds flattened completely.  The gastric mucosa was entirely normal.  No hiatal hernia was seen and the pyloric valve appeared normal.  The endoscope was advanced into first, second, and third portion of the duodenum, which had normal mucosal coloration and fold pattern.  Ampule of Vater was identified and found to be normal.  Biopsies were obtained x2 in the second portion of duodenum, antrum, and distal esophagus at 22 cm from the central incisors for histology.  Additional two antral biopsies were obtained for CLO testing.  Excess air was evacuated from the stomach.  The scope was removed from the patient who tolerated the procedure well.  The patient was taken to recovery room in satisfactory condition.,IMPRESSION:,  Normal esophagus, stomach, and duodenum.,PLAN:,  Histologic evaluation and CLO testing.  Continue Prevacid 7.5 mg p.o. b.i.d.  I will contact the parents next week with biopsy results and further management plans will be discussed at that time.","surgery, olympus gif-xq 160, diarrhea, gastroesophageal, esophagitis, reflux, clo testing, esophagogastroduodenoscopy with biopsy, endoscope, esophagus, stomach, duodenum, esophagogastroduodenoscopy"
" Esophagogastroduodenoscopy, photography, and biopsy.  Gastroesophageal reflux disease, hiatal hernia, and enterogastritis.", Surgery, Esophagogastroduodenoscopy - 12 ,"PREOPERATIVE DIAGNOSES:,1.  Gastroesophageal reflux disease.,2.  Hiatal hernia.,POSTOPERATIVE DIAGNOSES:,1.  Gastroesophageal reflux disease.,2.  Hiatal hernia.,3.  Enterogastritis.,PROCEDURE PERFORMED:  ,Esophagogastroduodenoscopy, photography, and biopsy.,GROSS FINDINGS: , The patient has a history of epigastric abdominal pain, persistent in nature.  She has a history of severe gastroesophageal reflux disease, takes Pepcid frequently.  She has had a history of hiatal hernia.  She is being evaluated at this time for disease process.  She does not have much response from Protonix.,Upon endoscopy, the gastroesophageal junction is approximately 40 cm.  There appeared to be some inflammation at the gastroesophageal junction and a small 1 cm to 2 cm hiatal hernia.  There is no advancement of the gastric mucosa up into the lower one-third of the esophagus.  However there appeared to be inflammation as stated previously in the gastroesophageal junction.  There was some mild inflammation at the antrum of the stomach.  The fundus of the stomach was within normal limits.  The cardia showed some laxity to the lower esophageal sphincter.  The pylorus is concentric.  The duodenal bulb and sweep are within normal limits.  No ulcers or erosions.,OPERATIVE PROCEDURE: , The patient is taken to the Endoscopy Suite, prepped and draped in the left lateral decubitus position.  The patient was given IV sedation using Demerol and Versed.  Olympus videoscope was inserted into the hypopharynx and upon deglutition passed into the esophagus.  Using air insufflation, panendoscope was advanced down the esophagus into the stomach along the greater curvature of the stomach through the pylorus into the duodenal bulb and sweep and the above gross findings were noted.  Panendoscope was slowly withdrawn carefully examining the lumen of the bowel.  Photographs were taken with the pathology present.  Biopsy was obtained of the antrum of the stomach and also CLO test.  The biopsy is also obtained of the gastroesophageal junction at 12, 3, 6 and 9 o' clock positions to rule out occult Barrett's esophagitis.  Air was aspirated from the stomach and the panendoscope was removed.  The patient sent to recovery room in stable condition.","surgery, biopsy, gastroesophageal reflux, gastroesophageal reflux disease, duodenal bulb, gastroesophageal junction, hiatal hernia, enterogastritis, endoscopy, esophagogastroduodenoscopy, gastroesophageal,"
 Esophagogastroduodenoscopy with bile aspirate.  Recurrent right upper quadrant pain with failure of antacid medical therapy.  Normal esophageal gastroduodenoscopy., Surgery, Esophagogastroduodenoscopy - 11 ,"PREOPERATIVE DIAGNOSIS:,  Recurrent right upper quadrant pain with failure of antacid medical therapy.,POSTOPERATIVE DIAGNOSIS: , Normal esophageal gastroduodenoscopy.,PROCEDURE PERFORMED:,  Esophagogastroduodenoscopy with bile aspirate.,ANESTHESIA: , IV Demerol and Versed in titrated fashion.,INDICATIONS: , This 41-year-old female presents to surgical office with history of recurrent right upper quadrant abdominal pain.  Despite antacid therapy, the patient's pain has continued.  Additional findings were concerning with possibility of a biliary etiology.  The patient was explained the risks and benefits of an EGD as well as a Meltzer-Lyon test where upon bile aspiration was performed.  The patient agreed to the procedure and informed consent was obtained.,GROSS FINDINGS: , No evidence of neoplasia, mucosal change, or ulcer on examination.  Aspiration of the bile was done after the administration of 3 mcg of Kinevac.,PROCEDURE DETAILS: , The patient was placed in the supine position.  After appropriate anesthesia was obtained, an Olympus gastroscope inserted from the oropharynx through the second portion of duodenum.  Prior to this, 3 mcg of IV Kinevac was given to the patient to aid with the stimulation of bile.  At this time, the patient as well complained of epigastric discomfort and nausea.  This pain was similar to her previous pain.,Bile was aspirated with a trap to enable the collection of the fluid.  This fluid was then sent to lab for evaluation for crystals.  Next, photodocumentation obtained and retraction of the gastroscope through the antrum revealed no other evidence of disease, retroflexion revealed no evidence of hiatal hernia or other mass and after straightening the scope and aspiration ________, gastroscope was retracted.  The gastroesophageal junction was noted at 20 cm.  No other evidence of disease was appreciated here.  Retraction of the gastroscope backed through the esophagus, off the oropharynx, removed from the patient.  The patient tolerated the procedure well.  We will await evaluation of bile aspirate.","surgery, bile aspirate, esophageal, gastroduodenoscopy, kinevac, oropharynx, esophagogastroduodenoscopy, gastroscope"
" Esophagogastroduodenoscopy with biopsy, a 1-year-10-month-old with a history of dysphagia to solids.", Surgery, Esophagogastroduodenoscopy - 1 ,"PROCEDURE: , Esophagogastroduodenoscopy with biopsy.,PREOPERATIVE DIAGNOSIS: , A 1-year-10-month-old with a history of dysphagia to solids.  The procedure was done to rule out organic disease.,POSTOPERATIVE DIAGNOSES: , Loose lower esophageal sphincter and duodenal ulcers.,CONSENT: , The consent is signed.,MEDICATIONS:  ,The procedure was done under general anesthesia given by Dr. Marino Fernandez.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL:,  A history and physical examination were performed, and the procedure, indications, potential complications including bleeding, perforation, the need for surgery, infection, adverse medical reaction, risks, benefits, and alternatives available were explained to the parents, who stated good understanding and consented to go ahead with the procedure.  The opportunity for questions was provided, and informed consent was obtained.  Once the consent was obtained, the patient was sedated with IV medications and intubated by Dr. Fernandez and placed in the supine position.  Then, the tip of the XP-160 videoscope was introduced into the oropharynx, and under direct visualization, we could advance the endoscope into the upper, mid, and lower esophagus.  We did not find any strictures in the upper esophagus, but the patient had the lower esophageal sphincter totally loose.  Then the tip of the endoscope was advanced down into the stomach and guided into the pylorus, and then into the first portion of the duodenum.  We noticed that the patient had several ulcers in the first portion of the duodenum.  Then the tip of the endoscope was advanced down into the second portion of the duodenum, one biopsy was taken there, and then, the tip of the endoscope was brought back to the first portion, and two biopsies were taken there.  Then, the tip of the endoscope was brought back to the antrum, where two biopsies were taken, and one biopsy for CLOtest.  By retroflexed view, at the level of the body of the stomach, I could see that the patient had the lower esophageal sphincter loose.  Finally, the endoscope was unflexed and was brought back to the lower esophagus, where two biopsies were taken.  At the end, air was suctioned from the stomach, and the endoscope was removed out of the patient's mouth.  The patient tolerated the procedure well with no complications.,FINAL IMPRESSION:  ,1.  Duodenal ulcers.,2.  Loose lower esophageal sphincter.,PLAN:,1.  To start omeprazole 20 mg a day.,2.  To review the biopsies.,3.  To return the patient back to clinic in 1 to 2 weeks.","surgery, esophagogastroduodenoscopy, esophageal, biopsies, endoscope"
 Esophagogastroduodenoscopy with biopsy and snare polypectomy - Iron-deficiency anemia, Surgery, Esophagogastroduodenoscopy ,"PROCEDURE:, Esophagogastroduodenoscopy with biopsy and snare polypectomy.,INDICATION FOR THE PROCEDURE:, Iron-deficiency anemia.,MEDICATIONS:, MAC.,The risks of the procedure were made aware to the patient and consisted of medication reaction, bleeding, perforation, and aspiration.,PROCEDURE:, After informed consent and appropriate sedation, the upper endoscope was inserted into the oropharynx down into the stomach and beyond the pylorus and the second portion of the duodenum. The duodenal mucosa was completely normal. The pylorus was normal. In the stomach, there was evidence of diffuse atrophic-appearing nodular gastritis. Multiple biopsies were obtained. There also was a 1.5-cm adenomatous appearing polyp along the greater curvature at the junction of the body and antrum. There was mild ulceration on the tip of this polyp. It was decided to remove the polyp via snare polypectomy. Retroflexion was performed, and this revealed a small hiatal hernia in the distal esophagus. The Z-line was identified and was unremarkable. The esophageal mucosa was normal.,FINDINGS:,1. Hiatal hernia.,2. Diffuse nodular and atrophic appearing gastritis, biopsies taken.,3. A 1.5-cm polyp with ulceration along the greater curvature, removed.,RECOMMENDATIONS:,1. Follow up biopsies.,2. Continue PPI.,3. Hold Lovenox for 5 days.,4. Place SCDs.","surgery, esophagogastroduodenoscopy, iron-deficiency, iron-deficiency anemia, anemia, biopsy, endoscope, esophageal mucosa, esophagus, hiatal hernia, polypectomy, snare polypectomy, esophagogastroduodenoscopy with biopsy, iron deficiency anemia,"
" Ivor-Lewis esophagogastrectomy, feeding jejunostomy, placement of two right-sided 28 French chest tubes, and right thoracotomy.", Surgery," Esophagogastrectomy, Jejunostomy, & Chest Tubes ","OPERATION,1.  Ivor-Lewis esophagogastrectomy.,2.  Feeding jejunostomy.,3.  Placement of two right-sided #28-French chest tubes.,4.  Right thoracotomy.,ANESTHESIA:  ,General endotracheal anesthesia with a dual-lumen tube.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered.  Prior to administration of general anesthesia, the patient had an epidural anesthesia placed.  In addition, he had a dual-lumen endotracheal tube placed.  The patient was placed in the supine position to begin the procedure.  His abdomen and chest were prepped and draped in the standard surgical fashion.  After applying sterile dressings, a #10-blade scalpel was used to make an upper midline incision from the level of the xiphoid to just below the umbilicus.  Dissection was carried down through the linea using Bovie electrocautery.  The abdomen was opened.  Next, a Balfour retractor was positioned as well as a mechanical retractor.  Next, our attention was turned to freeing up the stomach.  In an attempt to do so, we identified the right gastroepiploic artery and arcade.  We incised the omentum and retracted it off the stomach and gastroepiploic arcade.  The omentum was divided using suture ligature with 2-0 silk.  We did this along the greater curvature and then moved to the lesser curvature where the short gastric arteries were taken down with ligation using 2-0 silk.  Next, we turned our attention to performing a Kocher maneuver.  This was done and the stomach was freed up.  We took down the falciform ligament as well as the caudate attachment to the diaphragm.  We enlarged the diaphragmatic hiatus so as to be able to place approximately 3 fingers into the chest.  We also did a portion of the esophageal dissection from the abdomen into the chest area.  The esophagus and the esophageal hiatus were identified in the abdomen.  We next turned our attention to the left gastric artery.  The left gastric artery was identified at the base of the stomach.  We first took the left gastric vein by ligating and dividing it using 0 silk ties.  The left gastric artery was next taken using suture ligature with silk ties followed by 2-0 stick tie reinforcement.  At this point the stomach was freely mobile.  We then turned our attention to performing our jejunostomy feeding tube.  A 2-0 Vicryl pursestring was placed in the jejunum approximately 20 cm distal to the ligament of Treitz.  We then used Bovie electrocautery to open the jejunum at this site.  We placed a 16-French red rubber catheter through this site.  We tied down in place.  We then used 3-0 silk sutures to perform a Witzel.  Next, the loop of jejunum was tacked up to the abdominal wall using 2-0 silk ties.  After doing so and pulling the feeding jejunostomy out through the skin and securing it appropriately, we turned our attention to closing the abdomen.  This was done with #1 Prolene.  We put in a 2nd layer of 2-0 Vicryl.  The skin was closed with 4-0 Monocryl.,Next, we turned our attention to performing the thoracic portion of the procedure.  The patient was placed in the left lateral decubitus position.  The right chest was prepped and draped appropriately.  We then used a #10 blade scalpel to make an incision in a posterolateral, non-muscle-sparing fashion.  Dissection was carried down to the level of the ribs with Bovie electrocautery.  Next, the ribs were counted and the 5th interspace was entered.  The lung was deflated.  We placed standard chest retractors.  Next, we incised the peritoneum over the esophagus.  We dissected the esophagus to just above the azygos vein.  The azygos vein, in fact, was taken with 0 silk ligatures and reinforced with 2-0 stick ties.  As mentioned, we dissected the esophagus both proximally and distally down to the level of the hiatus.  After doing this, we backed our NG tube out to above the level where we planned to perform our pursestring.  We used an automatic pursestring and applied.  We then transected the proximal portion of the stomach with Metzenbaum scissors.  We secured our pursestring and then placed a 28 anvil in the divided proximal portion of the esophagus.  The pursestring was then tied down without difficulty.  Next, we tabularized our stomach using a #80 GIA stapler.  After doing so, we chose a portion of the stomach more distally and opened it using Bovie electrocautery.  We placed our EEA stapler through it and then punched out through the gastric wall.  We connected our anvil to the EEA stapler.  This was then secured appropriately.  We checked to make sure that there was appropriate muscle apposition.  We then fired the stapler.  We obtained 2 complete rings, 1 of the esophagus and 1 of the stomach, which were sent for pathology.  We also sent the gastroesophageal specimen for pathology.  Of note was the fact that the frozen section showed no evidence of tumor and in the proximal distal margins.  We then turned our attention to closing the gastrostomy opening.  This was closed with 2-0 Vicryl in a running fashion.  We then buttressed this with serosal 3-0 Vicryl interrupted sutures.  We returned the newly constructed gastroesophageal anastomosis into the chest and covered it by covering the pleura over it.  Next, we placed two #28-French chest tubes, 1 anteriorly and 1 posteriorly, taking care not to place it near the anastomosis.  We then closed the chest with #2 Vicryl in an interrupted figure-of-eight fashion.  The lung was brought up.  We closed the muscle layers with #0 Vicryl followed by #0 Vicryl; then we closed the subcutaneous layer with 2-0 Vicryl and the skin with 4-0 Monocryl.  Sterile dressing was applied.  The instrument and sponge count was correct at the end of the case.  The patient tolerated the procedure well and was extubated in the operating room and transferred to the ICU in good condition.","surgery, ivor-lewis, esophagogastrectomy, jejunostomy, thoracotomy, dual-lumen tube, chest tubes, bovie electrocautery, chest, endotracheal, electrocautery, abdomen, gastric, esophagus, tubes, vicryl, stomach, "
 Direct laryngoscopy and esophagoscopy with removal of foreign body, Surgery, Esophageal Foreign Body Removal ,"PREOPERATIVE DIAGNOSIS: , Esophageal foreign body.,POSTOPERATIVE DIAGNOSIS:,  Esophageal foreign body.,PROCEDURES PERFORMED:,1.  Direct laryngoscopy with intubation by surgeon.,2.  Rigid tracheoscopy.,3.  Rigid esophagoscopy with removal of foreign body.,INDICATIONS: , The patient is an 8-month-old Hispanic male, who presented to the Emergency Department with approximately 12-hour history of choking event and presumed for esophageal foreign body.  When seen in the Emergency Department, he was having no difficulty managing his secretions or any signs of any airway compromise.  Imaging in the Emergency Department did demonstrate an esophageal foreign body at or above the level of the cricopharyngeus.  Due to this, the patient was consented and taken urgently to the operating room for removal of this foreign body.,OPERATIVE DETAILS:,  The patient was correctly identified in the preop holding area and brought to operating room #37.  After informed consent was reviewed, general anesthesia was induced, initially with propofol, the existing IV.  Following this after protective eye tape was placed, #9 Parson's laryngoscope was introduced transorally and used to perform a direct laryngoscopy.  Normal anatomy was visualized.  Following this, a 4-mm, 20-rigid endoscope was introduced through the Parson's laryngoscope and used to perform a direct tracheoscopy.  The patient's supraglottis, glottis, and subglottis down to the level of the mid trachea were found to be benign with no abnormal-appearing anatomy.  Following this, the rigid endoscope was removed and the patient was intubated with a 4-0 endotracheal tube cuffed without difficulty.  After confirming bilateral breath sounds and positive end tidal CO2, this was secured to the patient by the anesthesia staff.  Following this, the Parson's laryngoscope was removed and a size 4 rigid esophagoscope was inserted transorally and passed down to the level of the patient's cricopharyngeus were the foreign body was visualized.  At this point, the coin grasper device was connected to the camera system and inserted through the existing esophagoscope.  This was used to grasp the coin and the coin was removed under direct visualization and handed off as a separate specimen.  Following this, the 34 mm 0-degree scope was inserted through the esophagoscope once the esophagoscope was passed down to the patient's GE junction.  The entire esophageal mucosa was examined as the esophagoscope was backed out and there was only a minimal amount of superficial ulceration in the posterior wall of the esophagus near the level of the cricopharyngeus muscle.  There were no other lesions or signs of further esophageal damage.  Following this, all instrumentation was removed, and care of the patient was turned back to the anesthesia staff for stable wakeup.,FINDINGS:,1.  Normal supraglottic, glottic, and subglottic anatomy.,2.  Esophageal foreign body at the level of the cricopharyngeus.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS:,  None.,DISPOSITION: , Stable to the PACU and then home.","surgery, rigid tracheoscopy, rigid esophagoscopy, subglottic, supraglottic, glottic, removal of foreign body, level of the cricopharyngeus, esophageal foreign body, foreign body, rigid endoscope, direct laryngoscopy, emergency department, parson's laryngoscope, foreign, esophagoscopy, tracheoscopy, transorally, laryngoscopy, anesthesia, parson's, laryngoscope, endoscope, cricopharyngeus, esophagoscope, esophageal"
 Esophagogastroduodenoscopy with antral biopsies for H. pylori x2 with biopsy forceps.  Nausea and vomiting and upper abdominal pain., Surgery, Esophagogastroduodenoscopy - 10 ,"PREOPERATIVE DIAGNOSIS: , Nausea and vomiting and upper abdominal pain.,POST PROCEDURE DIAGNOSIS:  ,Normal upper endoscopy.,OPERATION: , Esophagogastroduodenoscopy with antral biopsies for H. pylori x2 with biopsy forceps.,ANESTHESIA:,  IV sedation 50 mg Demerol, 8 mg of Versed.,PROCEDURE: , The patient was taken to the endoscopy suite.  After adequate IV sedation with the above medications, hurricane was sprayed in the mouth as well as in the esophagus.  A bite block was placed and the gastroscope placed into the mouth and was passed into the esophagus and negotiated through the esophagus, stomach, and pylorus.  The first, second, and third portions of the duodenum were normal.  The scope was withdrawn into the antrum which was normal and two bites with the biopsy forceps were taken in separate spots for H. pylori.  The scope was retroflexed which showed a normal GE junction from the inside of the stomach and no evidence of pathology or paraesophageal hernia.  The scope was withdrawn at the GE junction which was in a normal position with a normal transition zone.  The scope was then removed throughout the esophagus which was normal.  The patient tolerated the procedure well.,The plan is to obtain a HIDA scan as the right upper quadrant ultrasound appeared to be normal, although previous ultrasounds several years ago showed a gallstone.","surgery, h. pylori, forceps, antral biopsies, ge junction, esophagogastroduodenoscopy, pylori, esophagus, antral, "
 Endoscopic retrograde cholangiopancreatography (ERCP) with brush cytology and biopsy., Surgery, ERCP ,"PROCEDURE:, Endoscopic retrograde cholangiopancreatography with brush cytology and biopsy.,INDICATION FOR THE PROCEDURE:, Patient with a history of chronic abdominal pain and CT showing evidence of chronic pancreatitis, with a recent upper endoscopy showing an abnormal-appearing ampulla.,MEDICATIONS:, General anesthesia.,The risks of the procedure were made aware to the patient and consisted of medication reaction, bleeding, perforation, aspiration, and post ERCP pancreatitis.,DESCRIPTION OF PROCEDURE: ,After informed consent and appropriate sedation, the duodenoscope was inserted into the oropharynx, down the esophagus, and into the stomach. The scope was then advanced through the pylorus to the ampulla. The ampulla had a markedly abnormal appearance, as it was enlarged and very prominent. It extended outward with an almost polypoid shape. It had what appeared to be adenomatous-appearing mucosa on the tip. There also was ulceration noted on the tip of this ampulla. The biliary and pancreatic orifices were identified. This was located not at the tip of the ampulla, but rather more towards the base. Cannulation was performed with a Wilson-Cooke TriTome sphincterotome with easy cannulation of the biliary tree. The common bile duct was mildly dilated, measuring approximately 12 mm. The intrahepatic ducts were minimally dilated. There were no filling defects identified. There was felt to be a possible stricture within the distal common bile duct, but this likely represented an anatomic variant given the abnormal shape of the ampulla. The patient has no evidence of obstruction based on lab work and clinically. Nevertheless, it was decided to proceed with brush cytology of this segment. This was done without any complications. There was adequate drainage of the biliary tree noted throughout the procedure. Multiple efforts were made to access the pancreatic ductal anatomy; however, because of the shape of the ampulla, this was unsuccessful. Efforts were made to proceed in a long scope position, but still were unsuccessful. Next, biopsies were obtained of the ampulla away from the biliary orifice. Four biopsies were taken. There was some minor oozing which had ceased by the end of the procedure. The stomach was then decompressed and the endoscope was withdrawn.,FINDINGS:,1. Abnormal papilla with bulging, polypoid appearance, and looks adenomatous with ulceration on the tip; biopsies taken.,2. Cholangiogram reveals mildly dilated common bile duct measuring 12 mm and possible distal CBD stricture, although I think this is likely an anatomic variant; brush cytology obtained.,3. Unable to access the pancreatic duct.,RECOMMENDATIONS:,1. NPO except ice chips today.,2. Will proceed with MRCP to better delineate pancreatic ductal anatomy.,3. Follow up biopsies and cytology.","surgery, endoscopic retrograde cholangiopancreatography, biopsy, brush cytology, cholangiopancreatography, pancreatitis, endoscopy, duodenoscope, wilson-cooke tritome, ampulla, common bile duct, ercp, endoscopic, biliary, pancreatic, duct, biopsies, cytology"
 Lateral escharotomy of right upper arm burn eschar and medial escharotomy of left upper extremity burns and eschar., Surgery, Escharotomy ,"PREOPERATIVE DIAGNOSES:,  32% total body surface area burn to the bilateral upper extremities and neck and anterior thorax with impending compartment syndrome of the right upper extremity.,POSTOPERATIVE DIAGNOSES: , 32% total body surface area burn to the bilateral upper extremities and neck and anterior thorax with impending compartment syndrome of the right upper extremity.,PROCEDURES  PERFORMED:,1.  Lateral escharotomy of right upper arm burn eschar.,2.  Medial escharotomy of left upper extremity burns and eschar.,ANESTHESIA:,  Propofol and Versed.,INDICATIONS FOR PROCEDURE: , The patient is a 72-year-old gentleman who was involved in a propane explosion where he sustained significant burns to his bilateral upper extremities, neck, and thorax.  The patient was transferred from outside facility and was found to have significant burns with impending compartment syndrome of the right upper extremity.  The patient had a _____ between his left and right upper extremity and very tight compartment of his right upper extremity.  It is felt the patient would need an escharotomy of his right upper extremity to maintain perfusion to his right arm and hand.,DESCRIPTION OF PROCEDURE:,  After appropriate time out was performed indicating the correct procedure, correct patient, and all parties involved, the patient's right upper extremity was placed in anatomical position.  An electrocautery device was readied and used to incise making make an incision on the lateral aspect of the patient's right upper extremity.  Starting just below the right humeral head, an incision was made through the burn eschar down to underlying subcutaneous tissue.  The incision was carried from the right humeral head down to just below the antecubital fossa on the right upper extremity.  All dermal bridging was taken down and was opened without any excessive bleeding.  Next, a medial incision was made starting at the axilla down to just below the medial epicondyle of the right upper extremity.  Again, the incision was carried through the entire of the eschar down to underlying subcutaneous tissue.  All bleeding was made hemostatic with electrocautery and all dermal abrasions were taken down.  At the completion of the procedure, the patient had improved right distal radial pulse and his compartment was much softer.  Silvadene cream was placed within the escharotomy incision and wrapped in Kerlix.  The patient tolerated the procedure well, and there were no adverse events during or after the procedure.","surgery, lateral escharotomy, medial escharotomy, eschar, anterior thorax, underlying subcutaneous tissue, bilateral upper extremities, impending compartment syndrome, arm burn, extremity burns, humeral head, burn eschar, compartment syndrome, escharotomy, humeral, burns "
 Epigastric herniorrhaphy.  Epigastric hernia., Surgery, Epigastric Herniorrhaphy ,"PREOPERATIVE DIAGNOSIS: , Epigastric hernia.,POSTOPERATIVE DIAGNOSIS: , Epigastric hernia.,OPERATIONS:,  Epigastric herniorrhaphy.,ANESTHESIA: , General inhalation.,PROCEDURE: , Following attainment of satisfactory anesthesia, the patient's abdomen was prepped with Hibiclens and draped sterilely.  The hernia mass had been marked preoperatively.  This area was anesthetized with a mixture of Marcaine and Xylocaine.  A transverse incision was made over the hernia and dissection carried down to the entrapped fat.  Sharp dissection was carried around the fat down to the fascial edge.  The preperitoneal fat could not be reduced; therefore, it is trimmed away and the small fascial defect then closed with interrupted 0-Ethibond sutures.  The fascial edges were injected with the local anesthetic mixture.  Subcutaneous tissues were then closed with interrupted 4-0 Vicryl and skin edges closed with running subcuticular 4-0 Vicryl.  Steri-Strips and a sterile dressing were applied to complete the closure.  The patient was then awakened and taken to the PACU in satisfactory condition.,ESTIMATED BLOOD LOSS: , 10 mL.,SPONGE AND NEEDLE COUNT: , Reported as correct.,COMPLICATIONS: , None.","surgery, hibiclens, epigastric herniorrhaphy, epigastric hernia, herniorrhaphy,"
 Epididymectomy, Surgery, Epididymectomy ,"EPIDIDYMECTOMY,OPERATIVE NOTE:  ,The patient was placed in the supine position and prepped and draped in the usual manner.  A transverse scrotal incision was made and carried down to the tunica vaginalis, which was opened.  A small amount of clear fluid was expressed.  The tunica vaginalis was opened and the testicle was brought out through this incision.  The epididymis was separated off the surface of the testicle using a scalpel.  With blunt and sharp dissection, the epididymis was dissected off the testicle.  Bovie was used for hemostasis.  The vessels going to the testicle were preserved without any obvious injury, and a nice viable testicle was present after the epididymis was removed from this.  The blood supply to the epididymis was cauterized using a Bovie and the vas was divided with cautery also.  There was no obvious bleeding.  The cord was infiltrated with 0.25% Marcaine, as was the dartos tissue in the scrotum.  The testicle was replaced in the scrotum.  Skin was closed in two layers using 3-0 chromic catgut for the dartos and a subcuticular closure with the same material.  A dry sterile dressing and compression were applied, and he was sent to the recovery room in stable condition.","surgery, scrotal incision, 0.25% marcaine, bovie, epididymectomy, chromic catgut, epididymis, fluid, scalpel, scrotum, sterile dressing, testicle, tunica vaginalisNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
  Endotracheal intubation.  The patient was intubated secondary to respiratory distress and increased work of breathing and falling saturation on 15 liters nonrebreather.  PCO2 was 29 and pO2 was 66 on the 15 liters., Surgery, Endotracheal Intubation - 1 ,"PROCEDURE PERFORMED: , Endotracheal intubation.,INDICATION FOR PROCEDURE:  ,The patient was intubated secondary to respiratory distress and increased work of breathing and falling saturation on 15 liters nonrebreather.  PCO2 was 29 and pO2 was 66 on the 15 liters.,NARRATIVE OF PROCEDURE: , The patient was given a total of 5 mg of Versed, 20 mg of etomidate, and 10 mg of vecuronium.  He was intubated in a single attempt.  Cords were well visualized, and a #8 endotracheal tube was passed using a curved blade.  Fiberoptically, a bronchoscope was passed for lavage and the tube was found to be in good position 3 cm above the main carina where it was kept there and the right lower lobe was lavaged with trap A lavage with 100 mL of normal sterile saline for cytology, AFB, and fungal smear and culture.  A separate trap B was then lavaged for bacterial C&S and Gram stain and was sent for those purposes.  The patient tolerated the procedure well.","surgery, nonrebreather, respiratory distress, falling saturation, endotracheal intubation, lavage, breathingNOTE"
" A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings.  Epidermal autograft on Integra to the back and application of allograft to areas of the lost Integra, not grafted on the back.", Surgery, Epidermal Autograft ,"PREOPERATIVE DIAGNOSIS:,  A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings.,POSTOPERATIVE DIAGNOSIS:,  A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings.,PROCEDURES PERFORMED:,1.  Epidermal autograft on Integra to the back (3520 cm2).,2.  Application of allograft to areas of the lost Integra, not grafted on the back (970 cm2).,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:,  Approximately 50 cc.,BLOOD PRODUCTS RECEIVED:,  One unit of packed red blood cells.,COMPLICATIONS: , None.,INDICATIONS: , The patient is a 26-year-old male, who sustained a 60% total body surface area flame burn involving the head, face, neck, chest, abdomen, back, bilateral upper extremities, hands, and bilateral lower extremities.  He has previously undergone total burn excision with placement of Integra and an initial round of epidermal autografting to the bilateral upper extremities and hands.  His donor sites have healed particularly over his buttocks and he returns for a second round of epidermal autografting over the Integra on his back utilizing the buttock donor sites, the extent they will provide coverage.,OPERATIVE FINDINGS:,1.  Variable take of Integra, particularly centrally and inferiorly on the back.  A fair amount of lost Integra over the upper back and shoulders.,2.  No evidence of infection.,3.  Healthy viable wound beds prior to grafting.,PROCEDURE IN DETAIL:,  The patient was brought to the operating room and positioned supine.  General endotracheal anesthesia was uneventfully induced and an appropriate time out was performed.  He was then repositioned prone and perioperative IV antibiotics were administered.  He was prepped and draped in the usual sterile manner.  All staples were removed from the Integra and the adherent areas of Silastic were removed.  The entire wound bed was further prepped with scrub brushes and more Betadine followed by a sulfamylon solution.  Hemostasis of the wound bed was ensured using epinephrine-soaked Telfa pads.  Following dermal tumescence of the buttocks, epidermal autografts were harvested 8 one-thousandths of an inch using the air Zimmer dermatome.  These grafts were passed to the back table where they were meshed 3:1.  The donor sites were hemostased using epinephrine-soaked Telfa and lap pads.  Once all the  grafts were meshed, we brought them back up onto the field, positioned them over the wounds beginning inferiorly and moving cephalad where we had best areas of Integra engraftment.  We were happy with the lie of the grafts and they were stapled into place.  The grafts were then overlaid with Conformant 2, which was also stapled into place.  Utilizing all of his buttocks skin, we did not have enough to cover his entire back, so we elected to apply allograft to the cephalad and a few areas on his flanks where we had had poor Integra engraftment.  Allograft was thawed and meshed 1:1.  It was then brought up onto the field, trimmed to fit and stapled into place over the wound.  Once the entirety of the posterior wounds on his back were covered out with epidermal autograft or allograft sulfamylon soaked dressings were applied.  Donor sites on his buttocks were dressed in Acticoat and secured with staples.  He was then repositioned supine and extubated in the operating room having tolerated the procedure without any apparent complications.  He was transported to PACU in stable condition.","surgery, flame burns, body surface area, epidermal autograft, autograft, integra, integra engraftment, wound, grafts, epidermal, allograft, "
" Evacuation of epidural hematoma and insertion of epidural drain.   Epidural hematoma, cervical spine.  Status post cervical laminectomy, C3 through C7 postop day #10.  Central cord syndrome and acute quadriplegia.", Surgery, Epidural Hematoma Evacuation ,"PREOPERATIVE DIAGNOSES:,1.  Epidural hematoma, cervical spine.,2.  Status post cervical laminectomy, C3 through C7 postop day #10.,3.  Central cord syndrome.,4.  Acute quadriplegia.,POSTOPERATIVE DIAGNOSES:,1.  Epidural hematoma, cervical spine.,2.  Status post cervical laminectomy, C3 through C7 postop day #10.,3.  Central cord syndrome.,4.  Acute quadriplegia.,PROCEDURE PERFORMED:,1.  Evacuation of epidural hematoma.,2.  Insertion of epidural drain.,ANESTHESIA: , General.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS:  ,200 cc.,HISTORY:  ,This is a 64-year-old female who has had an extensive medical history beginning with coronary artery bypass done on emergent basis while she was in Maryland in April of 2003 after having myocardial infarction.  She was then transferred to Beaumont Hospital, at which point, she developed a sternal abscess.  The patient was treated for the abscess in Beaumont and then subsequently transferred to some other type of facility near her home in Warren, Michigan at which point, she developed a second what was termed minor myocardial infarction.,The patient subsequently recovered in a Cardiac Rehab Facility and approximately two weeks later, brings us to the month of August, at which time she was at home ambulating with a walker or a cane, and then sustained a fall and at that point she was unable to walk and had acute progressive weakness and was identified as having a central cord syndrome based on an MRI, which showed record signal change.  The patient underwent cervical laminectomy and seemed to be improving subjectively in terms of neurologic recovery, but objectively there was not much improvement.  Approximately 10 days after the surgery, brings us to today's date, the health officer was notified of the patient's labored breathing.  When she examined the patient, she also noted that the patient was unable to move her extremities.  She was concerned and called the Orthopedic resident who identified the patient to be truly quadriplegic.  I was notified and ordered the operative crew to report immediately and recommended emergent decompression for the possibility of an epidural hematoma.  On clinical examination, there was swelling in the posterior aspect of the neck.  The patient has no active movement in the upper and lower extremity muscle groups.  Reflexes are absent in the upper and lower extremities.  Long track signs are absent.  Sensory level is at the C4 dermatome.  Rectal tone is absent.  I discussed the findings with the patient and also the daughter.  We discussed the possibility of this is permanent quadriplegia, but at this time, the compression of the epidural space was warranted and certainly for exploration reasons be sure that there is a hematoma there and they have agreed to proceed with surgery.  They are aware that it is possible she had known permanent neurologic status regardless of my intervention and they have agreed to accept this and has signed the consent form for surgery.,OPERATIVE PROCEDURE:  ,The patient was taken to OR #1 at ABCD General Hospital on a gurney.  Department of Anesthesia administered fiberoptic intubation and general anesthetic.  A Foley catheter was placed in the bladder.  The patient was log rolled in a prone position on the Jackson table.  Bony prominences were well padded.  The patient's head was placed in the prone view anesthesia head holder.  At this point, the wound was examined closely and there was hematoma at the caudal pole of the wound.  Next, the patient was prepped and draped in the usual sterile fashion.  The previous skin incision was reopened.  At this point, hematoma properly exits from the wound.  All sutures were removed and the epidural spaces were encountered at this time.  The self-retaining retractors were placed in the depth of the wound.  Consolidated hematoma was now removed from the wound.  Next, the epidural space was encountered.  There was no additional hematoma in the epidural space or on the thecal sac.  A curette was carefully used to scrape along the thecal sac and there was no film or lining covering the sac.  The inferior edge of the C2 lamina was explored and there was no compression at this level and the superior lamina of T1 was explored and again no compression was identified at this area as well.  Next, the wound was irrigated copiously with one liter of saline using a syringe.  The walls of the wound were explored.  There was no active bleeding.  Retractors were removed at this time and even without pressure on the musculature, there was no active bleeding.  A #19 French Hemovac drain was passed percutaneously at this point and placed into the epidural space.  Fascia was reapproximated with #1 Vicryl sutures, subcutaneous tissue with #3-0 Vicryl sutures.  Steri-Strips covered the incision and dressing was then applied over the incision.  The patient was then log rolled in the supine position on the hospital gurney.  She remained intubated for airway precautions and transferred to the recovery room in stable condition.  Once in the recovery room, she was alert.  She was following simple commands and using her head to nod, but she did not have any active movement of her upper or lower extremities.  Prognosis for this patient is guarded.","surgery, epidural hematoma, cervical spine, cervical laminectomy, central cord syndrome, acute quadriplegia, insertion of epidural drain, epidural drain, epidural space, hematoma, epidural, cervical, laminectomy, quadriplegia, "
 The patient was brought to the OR with the known 4 cm abdominal aortic aneurysm + 2.5 cm right common iliac artery aneurysm., Surgery, Endovascular Abdominal Aortic Aneurysm Repair ,"PREOPERATIVE DIAGNOSIS: , Abdominal aortic aneurysm.,POSTOPERATIVE DIAGNOSIS: , Abdominal aortic aneurysm.,OPERATION PERFORMED:,  Endovascular abdominal aortic aneurysm repair.,FINDINGS: , The patient was brought to the OR with the known 4 cm abdominal aortic aneurysm + 2.5 cm right common iliac artery aneurysm.  A Gore exclusive device was used 3 pieces were used to effect the repair.  We had to place an iliac extender down in to right external iliac artery to manage the right common iliac artery aneurysm.  The right hypogastric artery had been previously coiled off.  Left common femoral artery was used for the _____ side.  We had small type 2 leak right underneath the take off the renal arteries, this was not felt to be type I leak and this was very delayed filling and it was felt that this was highly indicative of type 2 leak from a lumbar artery, which commonly come off in this area.  It was felt that this would seal after reversal of the anticoagulation given sufficient time.,PROCEDURE: , With the patient supine position under general anesthesia, the abdomen and lower extremities were prepped and draped in a sterile fashion.,Bilateral groin incisions were made, and the common femoral arteries were dissected out bilaterally.  The patient was then heparinized.,The 7-French sheaths were then placed retrograde bilaterally.,A stiff Amplatz wires were then placed up the right femoral artery and a stiff Amplatz were placed left side a calibrated catheter was placed up the right side.  The calibrated aortogram was the done.  We marked the renal arteries aortic bifurcation and bifurcation, common iliac arteries.  We then preceded placement of the main trunk, by replacing the 7 French sheath in the left groin area with 18-french sheath and then deployed the trunk body just below the take off renal arteries.,Once the main trunk has been deployed within wired _____ then deployed an iliac limb down in to the right common iliac artery.  As noted above, we then had to place an iliac extension, down in the external iliac artery to exclude the right common iliac artery and resume completely.,Following completion of the above all arteries were ballooned appropriately.  A completion angiogram was done which showed late small type 2 leak just under the take off renal arteries.  The area was ballooned aggressively.  It was felt that this would dissolve as discussed above.,Following completion of the above all wire sheaths etc., were removed from both groin areas.  Both femoral arteries were repaired by primary suture technique.  Flow was then reestablished to the lower extremities, and protamine was given to reverse the heparin.,Both surgical sites were then irrigated thoroughly.  Meticulous hemostasis was achieved.  Both wounds were then closed in a routine layered fashion.,Sterile antibiotic dressings were applied.  Sponge and needle counts were reported as correct.  The patient tolerated the procedure well the patient was taken to the recovery room in satisfactory condition.","surgery, gore, common iliac artery aneurysm, abdominal aortic aneurysm repair, abdominal aortic aneurysm, common iliac, aortic aneurysm, iliac artery, artery, aneurysm, iliac, abdominal, aortic, arteries,"
 Endotracheal intubation.  Respiratory failure.  The patient is a 52-year-old male with metastatic osteogenic sarcoma.  He was admitted two days ago with small bowel obstruction., Surgery, Endotracheal Intubation ,"PROCEDURE: , Endotracheal intubation.,INDICATION: , Respiratory failure.,BRIEF HISTORY: , The patient is a 52-year-old male with metastatic osteogenic sarcoma.  He was admitted two days ago with small bowel obstruction.  He has been on Coumadin for previous PE and currently on heparin drip.  He became altered and subsequently deteriorated quite rapidly to the point where he is no longer breathing on his own and has minimal responsiveness.  A code blue was called.  On my arrival, the patient's vital signs are stable.  His blood pressure is systolically in 140s and heart rate 80s.  He however has 0 respiratory effort and is unresponsive to even painful stimuli.  The patient was given etomidate 20 mg.,DESCRIPTION OF PROCEDURE:  ,The patient positioned appropriate equipment at the bedside, given 20 mg of etomidate and 100 mg of succinylcholine.  Mac-4 blade was used.  A 7.5 ET tube placed to 24th teeth.  There is good color change on the capnographer with bilateral breath sounds.  Following intubation, the patient's blood pressure began to drop.  He was given 2 L of bolus.  I started him on dopamine drip at 10 mcg.  Dr. X was at the bedside, who is the primary caregiver, he assumed the care of the patient, will be transferred to the ICU.  Chest x-ray will be reviewed and Pulmonary will be consulted.","surgery, metastatic osteogenic sarcoma, respiratory failure, bowel obstruction, blood pressure, endotracheal intubation, endotracheal, sarcoma"
" Right L4, attempted L5, and S1 transforaminal epidurogram for neural mapping.", Surgery, Epidurogram ,"PREOPERATIVE DIAGNOSES:  ,1.  Right lower extremity radiculopathy with history of post laminectomy pain.,2.  Epidural fibrosis with nerve root entrapment.,POSTOPERATIVE DIAGNOSES:  ,1.  Right lower extremity radiculopathy with history of post laminectomy pain.,2.  Epidural fibrosis with nerve root entrapment.,OPERATION PERFORMED: , Right L4, attempted L5, and S1 transforaminal epidurogram for neural mapping.,ANESTHESIA:,  Local/IV sedation.,COMPLICATIONS: , None.,SUMMARY: , The patient in the operating room in the prone position with the back prepped and draped in the sterile fashion.  The patient was given sedation and monitored.  Local anesthetic was used to insufflate the skin and paraspinal tissues and the L5 disk level on the right was noted to be completely collapsed with no way whatsoever to get a needle to the neural foramen of the L5 root.  The left side was quite open; however, that was not the side of her problem.  At this point using a oblique fluoroscopic projection and gun-barrel technique, a 22-gauge 3.5 inch spinal needle was placed at the superior articular process of L5 on the right, stepped off laterally and redirected medially into the intervertebral foramen to the L4 nerve root.  A second needle was taken and placed at the S1 nerve foramen using AP and lateral fluoroscopic views to confirm location.  After negative aspiration, 2 cc of Omnipaque 240 dye was injected through each needle.,There was a defect flowing in the medial epidural space at both sides.  There were no complications.","surgery, laminectomy, radiculopathy, nerve root entrapment, epidural fibrosis, nerve root, epidurogram, neural, epidural, foramen, nerve, needle"
" Upper endoscopy with biopsy.   The patient admitted for coffee-ground emesis, which has been going on for the past several days.  An endoscopy is being done to evaluate for source of upper GI bleeding.", Surgery, Endoscopy With Biopsy ,"PROCEDURE:,  Upper endoscopy with biopsy.,PROCEDURE INDICATION: , This is a 44-year-old man who was admitted for coffee-ground emesis, which has been going on for the past several days.  An endoscopy is being done to evaluate for source of upper GI bleeding.,Informed consent was obtained.  Outlining the risks, benefits and alternatives of the procedure included, but not to risks of bleeding, infection, perforation, the patient agreed for the procedure.,MEDICATIONS: , Versed 4 mg IV push and fentanyl 75 mcg IV push given throughout the procedure in incremental fashion with careful monitoring of patient's pressures and vital signs.,PROCEDURE IN DETAIL:  ,The patient was placed in the left lateral decubitus position.  Medications were given.  After adequate sedation was achieved, the Olympus video endoscope was inserted into the mouth and advanced towards the duodenum.","surgery, coffee-ground emesis, gi bleeding, upper endoscopy, iv push, esophagus, duodenum, mucosa, stomach, endoscopy, biopsy,"
 Upper gastrointestinal endoscopy., Surgery, Endoscopy ,"PREOPERATIVE DIAGNOSIS: , Anemia.,PROCEDURE:,  Upper gastrointestinal endoscopy.,POSTOPERATIVE DIAGNOSES:,1.  Severe duodenitis.,2.  Gastroesophageal junction small ulceration seen.,3.  No major bleeding seen in the stomach.,PROCEDURE IN DETAIL: , The patient was put in left lateral position.  Olympus scope was inserted from the mouth, under direct visualization advanced to the upper part of the stomach, upper part of esophagus, middle of esophagus, GE junction, and some intermittent bleeding was seen at the GE junction.  Advanced into the upper part of the stomach into the antrum.  The duodenum showed extreme duodenitis and the scope was then brought back.  Retroflexion was performed, which was normal.  Scope was then brought back slowly.  Duodenitis was seen and a little bit of ulceration seen at GE junction.,FINDING: , Severe duodenitis, may be some source of bleeding from there, but no active bleeding at this time.","surgery, upper gastrointestinal endoscopy, ge junction, gastrointestinal, esophagus, endoscopy, stomach, duodenitis, bleeding"
 Normal upper GI endoscopy., Surgery, Endoscopy Template ,"INDICATIONS:,  Dysphagia.,PREMEDICATION:,  Topical Cetacaine spray and Versed IV.,PROCEDURE:,:  The scope was passed into the esophagus under direct vision.  The esophageal mucosa was all unremarkable.  There was no evidence of any narrowing present anywhere throughout the esophagus and no evidence of esophagitis.  The scope was passed on down into the stomach.  The gastric mucosa was all examined including a retroflexed view of the fundus and there were no abnormalities seen.  The scope was then passed into the duodenum and the duodenal bulb and second and third portions of the duodenum were unremarkable.  The scope was again slowly withdrawn through the esophagus and no evidence of narrowing was present.  The scope was then withdrawn.,IMPRESSION:,  Normal upper GI endoscopy without any evidence of anatomical narrowing.","surgery, dysphagia, cetacaine spray, esophagus, esophageal mucosa, duodenum, scope was passed, upper gi, gi endoscopy, gi, endoscopy, scope"
 Intermittent rectal bleeding with abdominal pain., Surgery, Endoscopy - 4 ,"PROCEDURE: , Endoscopy.,CLINICAL INDICATIONS: , Intermittent rectal bleeding with abdominal pain.,ANESTHESIA: , Fentanyl 100 mcg and 5 mg of IV Versed.,PROCEDURE:,  The patient was taken to the GI lab and placed in the left lateral supine position.  Continuous pulse oximetry and blood pressure monitoring were in place.  After informed consent was obtained, the video endoscope was inserted over the dorsum of the tongue without difficulty.  With swallowing, the scope was advanced down the esophagus into the body of the stomach.  The scope was further advanced down to the antrum and through the pylorus into the duodenum, which was visualized into its second portion.  It appeared free of stricture, neoplasm, or ulceration.  Samples were obtained from the antrum and prepyloric area to check for Helicobacter, rapid urease, and additional samples were sent to pathology.  Retroflexion view of the fundus of the stomach was normal without evidence of a hiatal hernia.  The scope was then slowly removed.  The distal esophagus appeared benign with a normal-appearing gastroesophageal sphincter and no esophagitis.  The remaining portion of the esophagus was normal.,IMPRESSION:,  Abdominal pain.  Symptoms most consistent with gastroesophageal reflux disease without endoscopic evidence of hiatal hernia.,RECOMMENDATIONS:,  Await results of CLO testing and biopsies.  Return to clinic with Dr. Spencer in 2 weeks for further discussion.","surgery, duodenum, stomach, hiatal hernia, endoscopy, antrum, hiatal, hernia, gastroesophageal, scope, esophagus, abdominal"
 Endoscopic carpal tunnel release.  Left carpal tunnel syndrome., Surgery, Endoscopic Carpal Tunnel Rlease ,"PREOPERATIVE DIAGNOSIS:,  Left carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:,  Left carpal tunnel syndrome.,OPERATIONS PERFORMED:,  Endoscopic carpal tunnel release.,ANESTHESIA:,  I.V. sedation and local (1% Lidocaine).,ESTIMATED BLOOD LOSS:,  Zero.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL: , With the patient under adequate anesthesia, the upper extremity was prepped and draped in a sterile manner.  The arm was exsanguinated.  The tourniquet was elevated at 290 mm/Hg.  Construction lines were made on the left palm to identify the ring ray.  A transverse incision was made in the wrist, between FCR and FCU, one fingerbreadth proximal to the interval between the glabrous skin of the palm and normal forearm skin.  Blunt dissection exposed the antebrachial fascia.  Hemostasis was obtained with bipolar cautery.  A distal-based window in the antebrachial fascia was then fashioned.  Care was taken to protect the underlying contents.  A proximal forearm fasciotomy was performed under direct vision.  A synovial elevator was used to palpate the undersurface of the transverse carpal ligament, and synovium was elevated off this undersurface.  Hamate sounds were then used to palpate the hook of hamate.  The endoscopic instrument was then inserted into the proximal incision.  The transverse carpal ligament was easily visualized through the portal.  Using palmar pressure, the transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end.,The distal end of the transverse carpal ligament was then identified in the window.  The blade was then elevated, and the endoscopic instrument was withdrawn, dividing the transverse carpal ligament under direct vision.  After complete division o the transverse carpal ligament, the instrument was reinserted.  Radial and ulnar edges of the transverse carpal ligament were identified, and complete release was confirmed.,The wound was then closed with running subcuticular stitch.  Steri-Strips were applied, and sterile dressing was applied over the Steri-Strips.  The tourniquet was deflated.  The patient was awakened from anesthesia and returned to the Recovery Room in satisfactory condition, having tolerated the procedure well.","surgery, fcr, fcu, antebrachial fascia, endoscopic carpal tunnel release, carpal tunnel release, carpal tunnel syndrome, carpal, endoscopic, ligament, tourniquet, transverse,"
" Upper endoscopy, patient with dysphagia.", Surgery, Endoscopy - 1 ,"PROCEDURE:,  Upper endoscopy.,PREOPERATIVE DIAGNOSIS: , Dysphagia.,POSTOPERATIVE DIAGNOSIS:,1.  GERD, biopsied.,2.  Distal esophageal reflux-induced stricture, dilated to 18 mm.,3.  Otherwise normal upper endoscopy.,MEDICATIONS: , Fentanyl 125 mcg and Versed 7 mg slow IV push.,INDICATIONS: , This is a 50-year-old white male with dysphagia, which has improved recently with Aciphex.,FINDINGS: , The patient was placed in the left lateral decubitus position and the above medications were administered.  The oropharynx was sprayed with Cetacaine.  The endoscope was passed, under direct visualization, into the esophagus.  The squamocolumnar junction was irregular and edematous.  Biopsies were obtained for histology.  There was a mild ring at the LES, which was dilated with a 15 to 18 mm balloon, with no resultant mucosal trauma.  The entire gastric mucosa was normal, including a retroflexed view of the fundus.  The entire duodenal mucosa was normal to the second portion.  The patient tolerated the procedure well without complication.,IMPRESSION:,1.  Gastroesophageal reflux disease, biopsied.,2.  Distal esophageal reflux-induced stricture, dilated to 18 mm.,3.  Otherwise normal upper endoscopy.,PLAN:,I will await the results of the biopsies.  The patient was told to continue maintenance Aciphex and anti-reflux precautions.  He will follow up with me on a p.r.n. basis.","surgery, lateral decubitus position, gastroesophageal reflux disease, gerd, normal upper endoscopy, mucosa was normal, esophageal reflux, stricture dilated, upper endoscopy, distal, esophageal, aciphex, biopsies, dysphagia, endoscopy, reflux,"
 Endoscopic carpal tunnel release and de Quervain's release. Left carpal tunnel syndrome and de Quervain's tenosynovitis., Surgery, Endoscopic Carpal Tunnel & de Quervain's Release ,"PREOPERATIVE DIAGNOSIS:  ,1.  Left carpal tunnel syndrome.,2.  de Quervain's tenosynovitis.,POSTOPERATIVE DIAGNOSIS:,  ,1.  Left carpal tunnel syndrome.,2.  de Quervain's tenosynovitis.,OPERATIONS PERFORMED:  ,1.  Endoscopic carpal tunnel release.,2.  de Quervain's release.,ANESTHESIA:,  I.V. sedation and local (1% Lidocaine).,ESTIMATED BLOOD LOSS:,  Zero.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL:  ,ENDOSCOPIC CARPAL TUNNEL RELEASE:,  With the patient under adequate anesthesia, the upper extremity was prepped and draped in a sterile manner.  The arm was exsanguinated.  The tourniquet was elevated at 290 mm/Hg.  Construction lines were made on the left palm to identify the ring ray.  A transverse incision was made in the wrist, between FCR and FCU, one fingerbreadth proximal to the interval between the glabrous skin of the palm and normal forearm skin.  Blunt dissection exposed the antebrachial fascia.  Hemostasis was obtained with bipolar cautery.  A distal-based window in the antebrachial fascia was then fashioned.  Care was taken to protect the underlying contents.  A proximal forearm fasciotomy was performed under direct vision.  A synovial elevator was used to palpate the undersurface of the transverse carpal ligament, and synovium was elevated off this undersurface.  Hamate sounds were then used to palpate the hook of hamate.  The endoscopic instrument was then inserted into the proximal incision.  The transverse carpal ligament was easily visualized through the portal.  Using palmar pressure, the transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end.,The distal end of the transverse carpal ligament was then identified in the window.  The blade was then elevated, and the endoscopic instrument was withdrawn, dividing the transverse carpal ligament under direct vision.  After complete division o the transverse carpal ligament, the instrument was reinserted.  Radial and ulnar edges of the transverse carpal ligament were identified, and complete release was confirmed.,The wound was then closed with running subcuticular stitch.  Steri-Strips were applied, and sterile dressing was applied over the Steri-Strips.  The tourniquet was deflated.  The patient was awakened from anesthesia and returned to the Recovery Room in satisfactory condition, having tolerated the procedure well.,DE QUERVAIN'S RELEASE: , With the patient under adequate regional anesthesia applied by surgeon using 1% plain Xylocaine, the upper extremity was prepped and draped in a sterile manner.  The arm was exsanguinated.  The tourniquet was elevated to 290 mm/Hg.  A transverse incision was then made over the radial aspect of the wrist overlying the first dorsal tunnel.  Using blunt dissection, the radial sensory nerve branches were dissected and retracted out of the operative field.  The first dorsal tunnel was then identified.  The first dorsal tunnel was incised along the dorsal ulnar border, completely freeing the stenosing tenosynovitis (de Quervain's release).  EPB and APL tendons were inspected and found to be completely free.  The radial sensory nerve was inspected and found to be without damage.,The skin was closed with a running 3-0 Prolene subcuticular stitch and Steri-Strips were applied and, over the Steri-Strips, a sterile dressing, and, over the sterile dressing, a volar splint with the hand in safe position.  The tourniquet was deflated.  The patient was returned to the holding area in satisfactory condition, having tolerated the procedure well.","surgery, de quervain's tenosynovitis, de quervain's release, carpal tunnel syndrome, carpal tunnel release, endoscopic carpal tunnel release, tunnel, transverse, carpal, tourniquet, endoscopic, "
 Patient with dysphagia., Surgery, Endoscopy - 3 ,"PROCEDURES PERFORMED: , Endoscopy.,INDICATIONS: , Dysphagia.,POSTOPERATIVE DIAGNOSIS:,  Esophageal ring and active reflux esophagitis.,PROCEDURE: , Informed consent was obtained prior to the procedure from the parents and patient.  The oral cavity is sprayed with lidocaine spray.  A bite block is placed.  Versed IV 5 mg and 100 mcg of IV fentanyl was given in cautious increments.  The GIF-160 diagnostic gastroscope used.  The patient was alert during the procedure.  The esophagus was intubated under direct visualization.  The scope was advanced toward the GE junction with active reflux esophagitis involving the distal one-third of the esophagus noted.  The stomach was unremarkable.  Retroflexed exam unremarkable.  Duodenum not intubated in order to minimize the time spent during the procedure.  The patient was alert although not combative.  A balloon was then inserted across the GE junction, 15 mm to 18 mm, and inflated to 3, 4.7, and 7 ATM, and left inflated at 18 mm for 45 seconds.  The balloon was then deflated.  The patient became uncomfortable and a good-size adequate distal esophageal tear was noted.  The scope and balloon were then withdrawn.  The patient left in good condition.,IMPRESSION: , Successful dilation of distal esophageal fracture in the setting of active reflux esophagitis albeit mild.,PLAN: , I will recommend that the patient be on lifelong proton pump inhibition and have repeat endoscopy performed as needed.  This has been discussed with the parents.  He was sent home with a prescription for omeprazole.","surgery, active reflux esophagitis, ge junction, distal esophageal, active reflux, reflux esophagitis, dysphagia, esophagus, scope, ge, junction, endoscopy, esophageal, reflux, esophagitis, distal, balloon"
" Cystoscopy, TUR, and electrofulguration of recurrent bladder tumors.", Surgery, Electrofulguration - Bladder Tumor ,"PREOPERATIVE DIAGNOSIS: , Recurrent bladder tumors.,POSTOPERATIVE DIAGNOSIS:,  Recurrent bladder tumors.,OPERATION: , Cystoscopy, TUR, and electrofulguration of recurrent bladder tumors.,ANESTHESIA:,  General.,INDICATIONS: , A 79-year-old woman with recurrent bladder tumors of the bladder neck.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room, prepped and draped in lithotomy position under satisfactory general anesthesia.  A #21-French cystourethroscope was inserted into the bladder.  Examination of the bladder showed approximately a 3-cm area of erythema and recurrent papillomatosis just above and lateral to the left ureteral orifice.  No other lesions were noted.  Using a cold punch biopsy forceps, a random biopsy was obtained.  The entire area was electrofulgurated using the Bugbee electrode.  The patient tolerated the procedure well and left the operating room in satisfactory condition.","surgery, bladder neck, bladder tumors, cystoscopy, tur, electrofulguration, bladder"
" Melena and solitary erosion over a fold at the GE junction, gastric side.", Surgery, Endoscopy - 2 ,"PREOPERATIVE DIAGNOSIS:,  Melena.,POSTOPERATIVE DIAGNOSIS:,  Solitary erosion over a fold at the GE junction, gastric side.,PREMEDICATIONS: , Versed 5 mg IV.,REPORTED PROCEDURE:,  The Olympus gastroscope was used.  The scope was placed in the upper esophagus under direct visit.  The esophageal mucosa was entirely normal.  There was no evidence of erosions or ulceration.  There was no evidence of varices.  The body and antrum of the stomach were normal.  They pylorus duodenum bulb and descending duodenum are normal.  There was no blood present within the stomach.,The scope was then brought back into the stomach and retroflexed in order to inspect the upper portion of the body of the stomach.  When this was done, a prominent fold was seen lying along side the GE junction along with gastric side and there was a solitary erosion over this fold.  The lesion was not bleeding.  If this fold were in any other location of the stomach, I would consider the fold, but at this location, one would have to consider that this would be an isolated gastric varix.  As such, the erosion may be more significant.  There was no bleeding.  Obviously, no manipulation of the lesion was undertaken.  The scope was then straightened, withdrawn, and the procedure terminated.,ENDOSCOPIC IMPRESSION:,1.  Solitary erosion overlying a prominent fold at the gastroesophageal junction, gastric side – may simply be an erosion or may be an erosion over a varix.,2.  Otherwise unremarkable endoscopy - no evidence of a bleeding lesion of the stomach.,PLAN:,1.  Liver profile today.,2.  Being Nexium 40 mg a day.,3.  Scheduled colonoscopy for next week.","surgery, ge junction, melena, olympus gastroscope, solitary erosion, descending duodenum, esophageal mucosa, esophagus, gastric side, pylorus duodenum bulb, stomach, liver profile, colonoscopy, ge junction gastric, junction gastric, endoscopy, duodenum, scope, solitary, junction, gastric, erosion,"
" Ethmoidectomy, antrostomy with polyp removal, turbinectomy, and septoplasty.", Surgery, Endoscopic Sinus Surgery ,"PREOPERATIVE DIAGNOSIS:,1.  Left chronic anterior and posterior ethmoiditis.,2.  Left chronic maxillary sinusitis with polyps.,3.  Left inferior turbinate hypertrophy.,4.  Right anterior and posterior chronic ethmoiditis.,5.  Right chronic maxillary sinusitis with polyps.,6.  Right chronic inferior turbinate hypertrophic.,7.  Intranasal deformity causing nasal obstruction due to septal deviation.,POSTOPERATIVE DIAGNOSIS:,1.  Left chronic anterior and posterior ethmoiditis.,2.  Left chronic maxillary sinusitis with polyps.,3.  Left inferior turbinate hypertrophy.,4.  Right anterior and posterior chronic ethmoiditis.,5.  Right chronic maxillary sinusitis with polyps.,6.  Right chronic inferior turbinate hypertrophic.,7.  Intranasal deformity causing nasal obstruction due to septal deviation.,NAME OF OPERATION: , Bilateral endoscopic sinus surgery, including left anterior and posterior ethmoidectomy, left maxillary antrostomy with polyp removal, left inferior partial turbinectomy, right anterior and posterior ethmoidectomy, right maxillary antrostomy and polyp removal, right partial inferior turbinectomy, and septoplasty.,ANESTHESIA:,  General endotracheal.,ESTIMATED BLOOD LOSS: , Approximately 20 cc.,HISTORY OF PRESENT ILLNESS: , The patient is a 55-year-old female who has had chronic nasal obstruction secondary to nasal polyps and chronic sinusitis.  She also has a septal deviation mid posterior to the left compromising greater than 70% of her nasal airway.,PROCEDURE:  ,The patient was brought to the operating room and placed in the supine position.  After adequate endotracheal anesthesia was obtained, the skin was prepped and draped in sterile fashion.  Lidocaine 1% with 1:100,000 epinephrine was injected into the region of the anterior portion of the nasal septum.  Approximately 10 cc total was used.,A #15 blade and the Freer elevator were used to help make a standard hemitransfixion incision.  A mucoperichondrial flap was carefully elevated, and the junction with the cartilaginous bony septum was separated with the Freer elevator.  The bony deflection was removed using Jansen-Middleton forceps.  The cartilaginous deflection was created by freeing up the inferior attachments to the cartilaginous septum, placing it more on the midline maxillary crest.  The initial incision was placed in its anatomical position and secured with a 4-0 nylon suture for stabilization effect.,Attention then was directed toward the left side.  Lidocaine 1% with 1:100,000 epinephrine was injected in the region of the anterior portion of the left middle turbinate and uncinate process and polyps.  Approximately 10 cc total was used.  The polyps were removed using the Richards essential shaver to help identify the middle turbinate and uncinate process better.  The uncinate process was removed systematically superiorly to inferiorly with back-biting forceps.  Next, the maxillary antrostomy was identified and expanded with the back-biting forceps and showed polypoid accumulation in the mucosal disease on its opening site.  The sinus linings were edematous but did not have any polyps in the inferior, lateral, or superior aspects.,The anterior and posterior ethmoid air cells were entered primarily and dissected with the Richards essential shaver followed by the use of a 30-degree endoscope and up-biting forceps for the superior and lateral dissection.  Bright mucosal disease and small polypoid accumulations were noted through the sinuses also.  The inferior turbinates had some polypoid changes on them also and showed marked mucosal irritation and hypertrophy.  The mucosal polypoid accumulations were cleared using the Richards essential shaver.  The turbinate was partially resected from mucosally but with good shape to it.  It was not desirable to remove it in its entirety.  Any obvious bleeding points along the edge were controlled with the suction Bovie apparatus.,The same procedure and findings were noted on the right side with 1% lidocaine with 1:100,000 epinephrine injected into the anterior portion of the right middle turbinate, polyps, and uncinate process; 10 cc total were used.  The polyps were removed.  The Richards essential shaver was used to allow better exposure of the uncinate process.  The uncinate process was removed superiorly to inferiorly with back-biting side-biting forceps.,Next, a maxillary antrostomy was identified and expanded with the back-biting and side-biting forceps and showed all plate accumulations there also.  The anterior and posterior ethmoid air cells were then entered primarily and dissected with Richards essential shaver followed by the use of the 30-degree scope and up-biting forceps for the superior and lateral resection.  The inferior turbinates showed mucosal disease, polypoid accumulations, and changes.  These were removed using the Richards essential shaver followed by a submucosal resection of the hypertrophied portion of the turbinate.,Any obvious bleeding points were controlled with the suction Bovie apparatus.  A thorough irrigation was then carried out in the nasal cavity, and Gelfilm packing was used to coat the linings in the middle meatal regions.  The patient tolerated the procedure well and returned to the recovery room in stable condition.",
 Left elbow manipulation and hardware removal of left elbow., Surgery, Elbow Manipulation ,"PREOPERATIVE DIAGNOSIS:,  Left elbow with retained hardware.,POSTOPERATIVE DIAGNOSIS: , Left elbow with retained hardware.,PROCEDURE: , ,1.  Left elbow manipulation.,2.  Hardware removal of left elbow.,ANESTHESIA:  ,Surgery was performed under general anesthesia.,COMPLICATIONS:,  There were no intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,INTRAOPERATIVE FINDING: , Preoperatively, the patient is 40 to 100 degrees range of motion with limited supination and pronation of about 20 degrees.  We increased his extension and flexion to about 20 to 120 degrees and the pronation and supination to about 40 degrees.,LOCAL ANESTHETIC:  ,10 mL of 0.25% Marcaine.,HISTORY AND PHYSICAL: , The patient is a 10-year-old right-hand dominant male, who threw himself off a quad on 10/10/2007.  The patient underwent open reduction and internal fixation of his left elbow fracture dislocation.  The patient also sustained a nondisplaced right glenoid neck fracture.  The patient's fracture has healed without incident, although he had significant postoperative stiffness for which he is undergoing physical therapy, as well as use of a Dynasplint.  The patient is neurologically intact distally.  Given the fact that his fracture has healed, surgery was recommended for hardware removal to decrease his irritation with elbow extension from the hardware.  Risks and benefits of the surgery were discussed.  The risks of surgery included the risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremities, failure to remove hardware, failure to relieve pain, continued postoperative stiffness.  All questions were answered and the parents agreed to the above plan.,PROCEDURE:  ,The patient was taken to the operating room and placed supine on the operating table.  General anesthesia was then administered.  The patient's left upper extremity was then prepped and draped in a standard surgical fashion.  Using fluoroscopy, the patient's K-wire was located.  An incision was made over his previous scar.  A subcutaneous dissection then took place in the plane between the subcutaneous fat and muscles.  The K-wires were easily palpable.  A small incision was made into the triceps, which allowed for visualization of the two pins, which were removed without incident.  The wound was then irrigated.  The triceps split was now closed using #2-0 Vicryl.  The subcutaneous tissue was also closed using #2-0 Vicryl and the skin with #4-0 Monocryl.  The wound was clean and dry and dressed with Steri-Strips, Xeroform, and 4 x 4s, as well as bias.  A total of 10 mL of 0.25% Marcaine was injected into the incision, as well as the joint line.  At the beginning of the case, prior to removal of the hardware, the arm was taken through some strenuous manipulations with improvement of his extension to 20 degrees, flexion to 130 degrees and pronation supination to about 40 degrees.,DIAGNOSTIC IMPRESSION:  ,The postoperative films demonstrated no fracture, no retained hardware.  The patient tolerated the procedure well and was subsequently taken to the recovery room in stable condition.,POSTOPERATIVE PLAN: , The patient will restart physical therapy and Dynasplint in 3 days.  The patient is to follow up in 1 week's time for a wound check.  The patient was given Tylenol No.  3 for pain.","surgery, k-wires, dynasplint, elbow manipulation, hardware removal, retained hardware, elbow, hardware, "
 Emergency cesarean section., Surgery, Emergency C-section. ,"PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at term.,2.  Nonreassuring fetal heart tones with a prolonged deceleration.,POSTOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at term.,2.  Nonreassuring fetal heart tones with a prolonged deceleration.,PROCEDURE PERFORMED: , Emergency cesarean section.,ANESTHESIA:  ,General and endotracheal as well as local anesthesia.,ESTIMATED BLOOD LOSS: , 800 mL.,COMPLICATIONS: , None.,FINDINGS:  ,Female infant in cephalic presentation in OP position.  Normal uterus, tubes and ovaries are noted.  Weight was 6 pounds and 3 ounces, Apgars were 6 at 1 minute and 7 at 5 minutes, and 9 at 10 minutes.  Normal uterus, tubes and ovaries were noted.,INDICATIONS:  ,The patient is a 21-year-old Gravida 1, para 0 female who present to labor and delivery at term with spontaneous rupture of membranes noted at 5 a.m. on the day of delivery.  The patient was admitted and cervix was found to be 1 cm dilated.  Pitocin augmentation of labor was started.  The patient was admitted by her primary obstetrician Dr. Salisbury and was managed through the day by him at approximately 5 p.m. at change of shift care was assumed by me.  At this time, the patient was noted to have variable decelerations down to the 90s lasting approximately 1 minute with good return to baseline, good variability was noted as well as accelerations, variable deceleration despite position change was occurring with almost every contraction, but was lasting for 60 to 90 seconds at the longest.  Vaginal exam was done.  Cervix was noted to be 4 cm dilated.,At this time IPC was placed and amnioinfusion was started in hopes to relieve the variable declarations.  At 19:20 fetal heart tones was noted to go down to the 60s and remained down in the 60s for 3 minutes at which time the patient was transferred from Labor And Delivery Room to the operating room for an emergency cesarean section.  Clock in the operating room is noted to be 2 minutes faster then the time on trace view.  The OR delivery time was 19:36.  Delivery of this infant was performed in 14 minutes from the onset of the deceleration.  Upon arrival to the operating room, while prepping the patient for surgery and awaiting the arrival of the anesthesiologist, heart tones were noted to be in 60s and slowly came up to the 80s.  Following the transfer of the patient to the operating room bed and prep of the abdomen, the decision was made to begin the surgery under local anesthesia, 2% lidocaine was obtained for this purpose.,PROCEDURE NOTE: , The patient was taken to the operating room she was quickly prepped and draped in the dorsal supine position with a leftward tilt.  2% lidocaine was obtained and the skin was anesthetized using approximately 15 mL of 2% lidocaine.  As the incision site was being injected, the anesthesiologist arrived.  The procedure was started prior to the patient being put under general anesthesia.,A Pfannenstiel skin incision was made with a scalpel and carried through the underlying layer of fascia using the Scalpel using __________ technique.  The rectus muscles were separated in midline.  The peritoneum was bluntly dissected.  The bladder blade was inserted.  The uterus has been incised in the transverse fashion using the scalpel and extended using manual traction.  The infant was subsequently delivered.  Immediately following delivery of the infant.  The infant was noted to be crying with good tones.  The cord was clammed and cut.  The infant was subsequently transferred or handed to the nursery nurse.  The placenta was delivered manually intact with a three-vessel cord noted.  The uterus was exteriorized and cleared of all clots and debris.  The uterine incision was repaired in 2 layers using 0 chromic sutures.  Hemostasis was visualized.  The uterus was returned to the abdomen.  The pelvis was copiously irrigated.  The rectus muscles were reapproximated in the midline using 3-0 Vicryl.  The fascia was reapproximated with 0 Vicryl suture.  The subcutaneous layer was closed with 2-0 plain gut.  The skin was closed in the subcuticular stitch using 4-0 Monocryl.  Steri-strips were applied.  Sponge, laps, and instrument counts were correct.  The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition.","surgery, intrauterine pregnancy at term, prolonged deceleration, apgars, emergency cesarean section, fetal heart tones, intrauterine,"
" Patient admitted because of recurrent nausea and vomiting, with displacement of the GEJ feeding tube.", Surgery, EGD with Biopsy - 1 ,"PROCEDURE PERFORMED: , EGD with biopsy.,INDICATION: , Mrs. ABC is a pleasant 45-year-old female with a history of severe diabetic gastroparesis, who had a gastrojejunal feeding tube placed radiologically approximately 2 months ago.  She was admitted because of recurrent nausea and vomiting, with displacement of the GEJ feeding tube.  A CT scan done yesterday revealed evidence of feeding tube remnant still seen within the stomach.  The endoscopy is done to confirm this and remove it, as well as determine if there are any other causes to account for her symptoms.  Physical examination done prior to the procedure was unremarkable, apart from upper abdominal tenderness.,MEDICATIONS: , Fentanyl 25 mcg, Versed 2 mg, 2% lidocaine spray to the pharynx.,INSTRUMENT: , GIF 160.,PROCEDURE REPORT:,  Informed consent was obtained from Mrs. ABC's sister, after the risks and benefits of the procedure were carefully explained, which included but were not limited to bleeding, infection, perforation, and allergic reaction to the medications.  Consent was not obtained from Mrs. Morales due to her recent narcotic administration.  Conscious sedation was achieved with the patient lying in the left lateral decubitus position.  The endoscope was then passed through the mouth, into the esophagus, the stomach, where retroflexion was performed, and it was advanced into the second portion of the duodenum.,FINDINGS:,1.  ESOPHAGUS:  There was evidence of grade C esophagitis, with multiple white-based ulcers seen from the distal to the proximal esophagus, at 12 cm in length.  Multiple biopsies were obtained from this region and placed in jar #1.,2.  STOMACH:  Small hiatal hernia was noted within the cardia of the stomach.  There was an indentation/scar from the placement of the previous PEG tube and there was suture material noted within the body and antrum of the stomach.  The remainder of the stomach examination was normal.  There was no feeding tube remnant seen within the stomach.,3.  DUODENUM:  This was normal.,COMPLICATIONS:,  None.,ASSESSMENT:,1.  Grade C esophagitis seen within the distal, mid, and proximal esophagus.,2.  Small hiatal hernia.,3.  Evidence of scarring at the site of the previous feeding tube, as well as suture line material seen in the body and antrum of the stomach.,PLAN: , Followup results of the biopsies and will have radiology replace her gastrojejunal feeding tube.","surgery, recurrent nausea and vomiting, egd with biopsy, nausea and vomiting, gastrojejunal feeding tube, feeding tube remnant, recurrent nausea, gej feeding, gastrojejunal feeding, proximal esophagus, hiatal hernia, feeding tube, egd, biopsy, nausea, vomiting, gej, gastrojejunal, duodenum, esophagitis, multiple, distal, biopsies, hiatal, hernia, antrum, esophagus, feeding, tube, stomach,"
" Esophagogastroduodenoscopy with biopsy.  Patient has had biliary colic-type symptoms for the past 3-1/2 weeks, characterized by severe pain, and brought on by eating greasy foods.", Surgery, EGD with Biopsy - 2 ,"TYPE OF PROCEDURE: , Esophagogastroduodenoscopy with biopsy.,PREOPERATIVE DIAGNOSIS:,  Abdominal pain.,POSTOPERATIVE DIAGNOSIS:,  Normal endoscopy.,PREMEDICATION: , Fentanyl 125 mcg IV, Versed 8 mg IV.,INDICATIONS:  ,This healthy 28-year-old woman has had biliary colic-type symptoms for the past 3-1/2 weeks, characterized by severe pain, and brought on by eating greasy foods.  She has had similar episodes couple of years ago and was told, at one point, that she had gallstones, but after her pregnancy, a repeat ultrasound was done, and apparently was normal, and nothing was done at that time.  She was evaluated in the emergency department recently, when she developed this recurrent pain, and laboratory studies were unrevealing.  Ultrasound was normal and a HIDA scan was done, which showed a low normal ejection fraction of 40%, and moderate reproduction of her pain.  Endoscopy was requested to make sure there is not upper GI source of her pain before considering cholecystectomy.,PROCEDURE: , The patient was premedicated and the Olympus GIF 160 video endoscope advanced to the distal duodenum.  Gastric biopsies were taken to rule out Helicobacter and the procedure was completed without complication.,IMPRESSION:  ,Normal endoscopy.,PLAN: , Refer to a general surgeon for consideration of cholecystectomy.","surgery, hida scan, endoscopy, gallstones, olympus, esophagogastroduodenoscopy with biopsy, biliary colic, colic type, greasy foods, normal endoscopy, esophagogastroduodenoscopy, biliary, colic, greasy, foods, cholecystectomy, biopsy,"
 Abnormal electronystagmogram demonstrating prominent nystagmus on position testing in the head hanging right position., Surgery, Electronystagmogram ,"PROCEDURE:  ,This tracing was obtained utilizing silver chloride biopotential electrodes placed at the medial and lateral canthi at both eyes and on the superior and inferior orbital margins of the left eye along a vertical line drawn through the middle of the pupil in the neutral forward gaze.  Simultaneous recordings were made in both eyes in the horizontal direction and the left eye in the vertical directions.  Caloric irrigations were performed using a closed loop irrigation system at 30 degrees and 44 degrees C into either ear.,FINDINGS: , Gaze testing did not reveal any evidence of nystagmus.  Saccadic movements did not reveal any evidence of dysmetria or overshoot.  Sinusoidal tracking was performed well for the patient's age.  Optokinetic nystagmus testing was performed poorly due to the patient's difficulty in following the commands.  Therefore adequate OKNs were not achieved.  The Dix-Hallpike maneuver in the head handing left position resulted in moderate intensity left beating nystagmus, which was converted to a right beating nystagmus when she sat up again.  The patient complained of severe dizziness in this position.  There was no clear-cut decremental response with repetition.  In the head hanging left position, no significant nystagmus was identified.  Positional testing in the supine, head hanging, head right, head left, right lateral decubitus, and left lateral decubitus positions did not reveal any evidence of nystagmus.,Caloric stimulation revealed a calculated unilateral weakness of 7.0% on the right (normal <20%) and left beating directional preponderance of 6.0% (normal <20-30%).,IMPRESSION: , Abnormal electronystagmogram demonstrating prominent nystagmus on position testing in the head hanging right position.  No other significant nystagmus was noted.  There was no evidence of clear-cut caloric stimulation abnormality.  This study would be most consistent with a right vestibular dysfunction.","surgery, silver chloride biopotential electrodes, inferior orbital margins, lateral canthi, vestibular dysfunction, prominent nystagmus, head hanging, electronystagmogram, eyes, nystagmus,"
 Common description of EGD, Surgery, EGD Template - 4 ,,"surgery, lateral supine position, stomach, duodenum, stricture, egd, advanced, scopeNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 EGD with dilation for dysphagia., Surgery, EGD with Dilation ,"INDICATION:  ,","surgery, egd, hurricaine spray, olympus endoscope, savary wire, cricopharyngeus, decubitus, dilator, duodenum, dysphagia, esophagus, hiatal hernia, peptic, pylorus, stomach, tortuosity, egd with dilation, tortuous, scope, hiatal, hernia,"
 Common description of EGD., Surgery, EGD Template - 2 ,"The patient was placed in the left lateral decubitus position, medicated with the above medications to achieve and maintain a conscious sedation.  Vital signs were monitored throughout the procedure without evidence of hemodynamic compromise or desaturation.,The Olympus single-channel endoscope was passed under direct visualization through the oral cavity and advanced to the second portion of the duodenum.,FINDINGS:,ESOPHAGUS:  Proximal and mid esophagus were without abnormalities.,STOMACH:  Insufflated and retroflexed visualization of the gastric cavity revealed,DUODENUM:  Normal.","surgery, gastric cavity, lateral decubitus position, endoscope, olympus, egd, visualization, cavity, duodenum, esophagusNOTE"
" EGD with photos and biopsies.  This is a 75-year-old female who presents with difficulty swallowing, occasional choking, and odynophagia.  She has a previous history of hiatal hernia.  She was on Prevacid currently. ", Surgery, EGD With Photos & Biopsies. ,"1.  Odynophagia.,2.  Dysphagia.,3.  Gastroesophageal reflux disease rule out stricture.,POSTOPERATIVE DIAGNOSES:,1.  Antral gastritis.,2.  Hiatal hernia.,PROCEDURE PERFORMED:  EGD with photos and biopsies.,GROSS FINDINGS:  This is a 75-year-old female who presents with difficulty swallowing, occasional choking, and odynophagia.  She has a previous history of hiatal hernia.  She was on Prevacid currently.  At this time, an EGD was performed to rule out stricture.  At the time of EGD, there was noted some antral gastritis and hiatal hernia.  There are no strictures, tumors, masses, or varices present.,OPERATIVE PROCEDURE:  The patient was taken to the Endoscopy Suite in the lateral decubitus position.  She was given sedation by the Department Of Anesthesia.  Once adequate sedation was reached, the Olympus gastroscope was inserted into oropharynx.  With air insufflation entered through the proximal esophagus to the GE junction.  The esophagus was without evidence of tumors, masses, ulcerations, esophagitis, strictures, or varices.  There was a hiatal hernia present.  The scope was passed through the hiatal hernia into the body of the stomach.  In the distal antrum, there was some erythema with patchy erythematous changes with small superficial erosions.  Multiple biopsies were obtained.  The scope was passed through the pylorus into the duodenal bulb and duodenal suite, they appeared within normal limits.  The scope was pulled back from the stomach, retroflexed upon itself, _____ fundus and GE junction.  As stated, multiple biopsies were obtained.,The scope was then slowly withdrawn.  The patient tolerated the procedure well and sent to recovery room in satisfactory condition.","surgery, odynophagia, dysphagia, gastroesophageal reflux disease, antral gastritis, hiatal hernia, difficulty swallowing, esophagus, stomach, duodenal, egd, biopsies, hiatal, hernia, "
" EGD with PEG tube placement using Russell technique.  Protein-calorie malnutrition, intractable nausea, vomiting, and dysphagia, and enterogastritis.", Surgery, EGD & PEG Tube Placement ,"PREOPERATIVE DIAGNOSES:,1.  protein-calorie malnutrition.,2.  Intractable nausea, vomiting, and dysphagia.,POSTOPERATIVE DIAGNOSES:,1.  Protein-calorie malnutrition.,2.  Intractable nausea, vomiting, and dysphagia.,3.  Enterogastritis.,PROCEDURE PERFORMED: , EGD with PEG tube placement using Russell technique.,ANESTHESIA: , IV sedation with 1% lidocaine for local.,ESTIMATED BLOOD LOSS:  ,None.,COMPLICATIONS:  ,None.,BRIEF HISTORY: , This is a 44-year-old African-American female who is well known to this service.  She has been hospitalized multiple times for intractable nausea and vomiting and dehydration.  She states that her decreased p.o. intake has been progressively worsening.  She was admitted to the service of Dr. Lang and was evaluated by Dr. Wickless as well all of whom agreed that the best option for supplemental nutrition for this patient was placement of a PEG tube.,PROCEDURE: , After risks, complications, and benefits were explained to the patient and informed consent was obtained, the patient was taken to the operating room.  She was placed in the supine position.  The area was prepped and draped in the sterile fashion.  After adequate IV sedation was obtained by anesthesia, esophagogastroduodenoscopy was performed.  The esophagus, stomach, and duodenum were visualized without difficulty.  There was no gross evidence of any malignancy.  There was some enterogastritis which was noted upon exam.  The appropriate location was noted on the anterior wall of the stomach.  This area was localized externally with 1% lidocaine.  Large gauge needle was used to enter the lumen of the stomach under visualization.  A guide wire was then passed again under visualization and the needle was subsequently removed.  A scalpel was used to make a small incision, next to the guidewire and ensuring that the underlying fascia was nicked as well.  A dilator with break-away sheath was then inserted over the guidewire and under direct visualization was seen to enter the lumen of the stomach without difficulty.  The guidewire and dilator were then removed again under visualization and the PEG tube was placed through the break-away sheath and visualized within the lumen of the stomach.  The balloon was then insufflated and the break-away sheath was then pulled away.  Proper placement of the tube was ensured through visualization with a scope.  The tube was then sutured into place using nylon suture.  Appropriate sterile dressing was applied.,DISPOSITION:  ,The patient was transferred to the recovery in a stable condition.  She was subsequently returned to her room on the General Medical Floor.  Previous orders will be resumed.  We will instruct the Nursing that the PEG tube can be used at 5 p.m. this evening for medications if necessary and bolus feedings.","surgery, protein-calorie malnutrition, nausea, vomiting, peg tube placement, russell technique, peg tube, egd, protein, dysphagia, malnutrition, enterogastritis"
 Common description of EGD., Surgery, EGD Template - 3 ,"without difficulty, into the upper GI tract.  The anatomy and mucosa of the esophagus, gastroesophageal junction, stomach, pylorus, and small bowel were all carefully inspected.  All structures were visually normal in appearance.  Biopsies of the distal duodenum, gastric antrum, and distal esophagus were taken and sent for pathological evaluation.  The endoscope and insufflated air were slowly removed from the upper GI tract.  A repeat look at the structures involved again showed no visible abnormalities, except for the biopsy sites.,The patient tolerated the procedure with excellent comfort and stable vital signs.  After a recovery period in the Endoscopy Suite, the patient is discharged to continue recovering in the family's care at home.  The family knows to follow up with me today if there are concerns about the patient's recovery,from the procedure.  They will follow up with me later this week for biopsy and CLO test results so that appropriate further diagnostic and therapeutic plans can be made.,","surgery, gastric antrum, distal duodenum, distal esophagus, esophagus, duodenum, clo test, upper gi tract, upper gi, gi tract, egd, endoscope, gi, tract, structures, distal, biopsyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" EGD and colonoscopy.  Blood loss anemia, normal colon with no evidence of bleeding, hiatal hernia, fundal gastritis with polyps, and antral mass.", Surgery, EGD & Colonoscopy ,"PREOPERATIVE DIAGNOSIS: , Blood loss anemia.,POSTOPERATIVE DIAGNOSES:,1.  Normal colon with no evidence of bleeding.,2.  Hiatal hernia.,3.  Fundal gastritis with polyps.,4.  Antral mass.,ANESTHESIA: , Conscious sedation with Demerol and Versed.,SPECIMEN:  ,Antrum and fundal polyps.,HISTORY: , The patient is a 66-year-old African-American female who presented to ABCD Hospital with mental status changes.  She has been anemic as well with no gross evidence of blood loss.  She has had a decreased appetite with weight loss greater than 20 lb over the past few months.  After discussion with the patient and her daughter, she was scheduled for EGD and colonoscopy for evaluation.,PROCEDURE: , After informed consent was obtained, the patient was brought to the endoscopy suite.  She was placed in the left lateral position and was given IV Demerol and Versed for sedation.  When adequate level of sedation was achieved, a digital rectal exam was performed, which demonstrated no masses and no hemorrhoids.  The colonoscope was inserted into the rectum and air was insufflated.  The scope was coursed through the rectum and sigmoid colon, descending colon, transverse colon, ascending colon to the level of the cecum.  There were no polyps, masses, diverticuli, or areas of inflammation.  The scope was then slowly withdrawn carefully examining all walls.  Air was aspirated.  Once in the rectum, the scope was retroflexed.  There was no evidence of perianal disease.  No source of the anemia was identified.,Attention was then taken for performing an EGD.  The gastroscope was inserted into the hypopharynx and was entered into the hypopharynx.  The esophagus was easily intubated and traversed.  There were no abnormalities of the esophagus.  The stomach was entered and was insufflated.  The scope was coursed along the greater curvature towards the antrum.  Adjacent to the pylorus, towards the anterior surface, was a mass like lesion with a central _______.  It was not clear if this represents a healing ulcer or neoplasm.  Several biopsies were taken.  The mass was soft.  The pylorus was then entered.  The duodenal bulb and sweep were examined.  There was no evidence of mass, ulceration, or bleeding.  The scope was then brought back into the antrum and was retroflexed.  In the fundus and body, there was evidence of streaking and inflammation.  There were also several small sessile polyps, which were removed with biopsy forceps.  Biopsy was also taken for CLO.  A hiatal hernia was present as well.  Air was aspirated.  The scope was slowly withdrawn.  The GE junction was unremarkable.  The scope was fully withdrawn.  The patient tolerated the procedure well and was transferred to recovery room in stable condition.  She will undergo a CAT scan of her abdomen and pelvis to further assess any possible adenopathy or gastric obstructional changes.  We will await the biopsy reports and further recommendations will follow.","surgery, esophagus, gastroscope, hypopharynx, rectum, fundal gastritis, antral mass, hiatal hernia, egd, hernia, polyps, colonoscopy,"
 Esophagogastroduodenoscopy and colonoscopy with polypectomy, Surgery, EGD - Colonoscopy - Polypectomy ,"PROCEDURES:,1.  Esophagogastroduodenoscopy.,2.  Colonoscopy with polypectomy.,PREOPERATIVE DIAGNOSES:,1.  History of esophageal cancer.,2.  History of colonic polyps.,POSTOPERATIVE FINDINGS:,1.  Intact surgical intervention for a history of esophageal cancer.,2.  Melanosis coli.,3.  Transverse colon polyps in the setting of surgical changes related to partial and transverse colectomy.,MEDICATIONS:,  Fentanyl 250 mcg and 9 mg of Versed.,INDICATIONS:,  The patient is a 55-year-old dentist presenting for surveillance upper endoscopy in the setting of a history of esophageal cancer with staging at T2N0M0.,He also has a history of adenomatous polyps and presents for surveillance of this process.,Informed consent was obtained after explanation of the procedures, as well as risk factors of bleeding, perforation, and adverse medication reaction.,ESOPHAGOGASTRODUODENOSCOPY:,  The patient was placed in the left lateral decubitus position and medicated with the above medications to achieve and maintain a conscious sedation.  Vital signs were monitored throughout the procedure without evidence of hemodynamic compromise or desaturation.  The Olympus single-channel endoscope was passed under direct visualization, through the oral cavity, and advanced to the second portion of the duodenum.,FINDINGS:,1.  ESOPHAGUS:  Anatomy consistent with esophagectomy with colonic transposition.,2.  STOMACH:  Revealed colonic transposition with normal mucosa.,3.  DUODENUM:  Normal.,IMPRESSION: , Intact surgical intervention with esophagectomy colonic transposition.,COLONOSCOPY: , The patient was then turned and a colonic 140-series colonoscope was passed under direct visualization through the anal verge and advanced to the cecum as identified by the appendiceal orifice.  Circumferential visualization the colonic mucosa revealed the following:,1.  Cecum revealed melanosis coli.,2.  Ascending, melanosis coli.,3.  Transverse revealed two diminutive sessile polyps, excised by cold forceps technique and submitted to histology as specimen #1 with surgical changes consistent with partial colectomy related to the colonic transposition.,4.  Descending, melanosis coli.,5.  Sigmoid, melanosis coli.,6.  Rectum, melanosis coli.,IMPRESSION: , Diffuse melanosis coli with incidental finding of transverse colon polyps.,RECOMMENDATION: , Follow-up histology.  Continue fiber with avoidance of stimulant laxatives.",
 Common description of EGD., Surgery, EGD Template - 1 ,,"surgery, duodenal mucosa, duodenal, esophageal mucosa, fundus, egd, entire, mucosaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Problems with dysphagia to solids and had food impacted in the lower esophagus.  Upper endoscopy to evaluate the esophagus., Surgery, EGD - 1 ,"HISTORY OF PRESENT ILLNESS:,  Briefly, this is a 17-year-old male, who has had problems with dysphagia to solids and recently had food impacted in the lower esophagus.  He is now having upper endoscopy to evaluate the esophagus after edema and inflammation from the food impaction has resolved, to look for any stricture that may need to be dilated, or any other mucosal abnormality.,PROCEDURE PERFORMED: , EGD.,PREP: , Cetacaine spray, 100 mcg of fentanyl IV, and 5 mg of Versed IV.,FINDINGS:,  The tip of the endoscope was introduced into the esophagus, and the entire length of the esophagus was dotted with numerous, white, punctate lesions, suggestive of eosinophilic esophagitis.  There were come concentric rings present.  There was no erosion or flame hemorrhage, but there was some friability in the distal esophagus.  Biopsies throughout the entire length of the esophagus from 25-40 cm were obtained to look for eosinophilic esophagitis.  There was no stricture or Barrett mucosa.  The bony and the antrum of the stomach are normal without any acute peptic lesions.  Retroflexion of the tip of the endoscope in the body of the stomach revealed a normal cardia.  There were no acute lesions and no evidence of ulcer, tumor, or polyp.  The pylorus was easily entered, and the first, second, and third portions of the duodenum are normal.  Adverse reactions:  None.,FINAL IMPRESSION:  ,Esophageal changes suggestive of eosinophilic esophagitis.  Biopsies throughout the length of the esophagus were obtained for microscopic analysis.  There was no evidence of stricture, Barrett, or other abnormalities in the upper GI tract.","surgery, length of the esophagus, food impacted, lower esophagus, upper endoscopy, entire length, eosinophilic esophagitis, egd, dysphagia, solids, impacted, endoscopy, mucosal, endoscope, biopsies, barrett, stomach, stricture, eosinophilic, esophagitis, esophagus, "
" Esophagogastroduodenoscopy, patient with dysphagia.", Surgery, EGD - 2 ,"PROCEDURES PERFORMED: , Esophagogastroduodenoscopy.,PREPROCEDURE DIAGNOSIS: , Dysphagia.,POSTPROCEDURE DIAGNOSIS: , Active reflux esophagitis, distal esophageal stricture, ring due to reflux esophagitis, dilated with balloon to 18 mm.,PROCEDURE: , Informed consent was obtained prior to the procedure with special attention to benefits, risks, alternatives.  Risks explained as bleeding, infection, bowel perforation, aspiration pneumonia, or reaction to the medications.  Vital signs were monitored by blood pressure, heart rate, and oxygen saturation.  Supplemental O2 given.  Specifics of the procedure discussed.  The procedure was discussed with father and mother as the patient is mentally challenged.  He has no complaints of dysphagia usually for solids, better with liquids, worsening over the last 6 months, although there is an emergency department report from last year.  He went to the emergency department yesterday with beef jerky.,All of this reviewed.  The patient is currently on Cortef, Synthroid, Tegretol, Norvasc, lisinopril, DDAVP.  He is being managed for extensive past history due to an astrocytoma, brain surgery, hypothyroidism, endocrine insufficiency.  He has not yet undergone significant workup.  He has not yet had an endoscopy or barium study performed.  He is developmentally delayed due to the surgery, panhypopituitarism.,His family history is significant for his father being of mine, also having reflux issues, without true heartburn, but distal esophageal stricture.  The patient does not smoke, does not drink.  He is living with his parents.  Since his emergency department visitation yesterday, no significant complaints.,Large male, no acute distress.  Vital signs monitored in the endoscopy suite.  Lungs clear.  Cardiac exam showed regular rhythm.  Abdomen obese but soft.  Extremity exam showed large hands.  He was a Mallampati score A, ASA classification type 2.,The procedure discussed with the patient, the patient's mother.  Risks, benefits, and alternatives discussed.  Potential alternatives for dysphagia, such as motility disorder, given his brain surgery, given the possibility of achalasia and similar discussed.  The potential need for a barium swallow, modified barium swallow, and similar discussed.  All questions answered.  At this point, the patient will undergo endoscopy for evaluation of dysphagia, with potential benefit of the possibility to dilate him should there be a stricture.  He may have reflux symptoms, without complaining of heartburn.  He may benefit from a trial of PPI.  All of this reviewed.  All questions answered.,","surgery, distal esophageal stricture, reflux esophagitis, distal esophageal, esophageal stricture, barium swallow, esophagogastroduodenoscopy, esophagitis, esophageal, heartburn, stricture, endoscopy, reflux, dysphagia "
" Repair of left ear laceration deformity Y-V plasty 2 cm.  Repair of right ear laceration deformity, complex repair 2 cm.", Surgery, Ear Laceration Repair ,"PREOPERATIVE DIAGNOSIS:,  Bilateral ear laceration deformities.,POSTOPERATIVE DIAGNOSIS:,  Bilateral ear laceration deformities.,PROCEDURE:,1.  Repair of left ear laceration deformity Y-V plasty 2 cm.,2.  Repair of right ear laceration deformity, complex repair 2 cm.,ANESTHESIA: , 1% Xylocaine, 1:100,000 epinephrine local.,BRIEF CLINICAL NOTE: , This patient was brought to the operating room today for the above procedure.,OPERATIVE NOTE: , The patient was laid in supine position, adequately anesthetized with the above anesthesia, sterilely prepped and draped.  The left ear laceration deformity was very close to the bottom of her ear and therefore it was transected through the centrifugal edge of the ear lobe and pared.  The marsupialized epithelialized tracts were pared to raw tissue.  They were pared in a fashion to create a Y-V plasty with de-epithelialization of the distal V and overlap of the undermined from the proximal cephalad edge.  The 5-0 chromic sutures were used to approximate anteriorly, posteriorly, and anterior centrifugal edge in the Y-V plasty fashion to decrease the risk of notching.  Bacitracin, Band-Aid was placed.  Next, attention was turned to the contralateral ear where an elongated laceration deformity was pared of the marsupialized epithelialized edges anteriorly, posteriorly to create raw edges.  This was not taken through the edge of the lobe to decrease the risk of notch deformity.  The laceration was repaired anteriorly and posteriorly in a pleated fashion to decrease length of the incision and to decrease any deformity toward the edge or any dog-ear deformity toward the edge.  The 5-0 chromic sutures were used in interrupted fashion for this.  The patient tolerated the procedure well.  Band-Aid and bacitracin were placed.  She left the operating room in stable condition.","surgery, bilateral ear laceration, dog-ear deformity, ear laceration deformity, band aid, laceration deformity, ear laceration, laceration, deformity, ear, repair "
 Right ear examination under anesthesia.  Right tympanic membrane perforation along with chronic otitis media., Surgery, Ear Examination ,"PREOPERATIVE DIAGNOSIS: , Right tympanic membrane perforation.,POSTOPERATIVE DIAGNOSIS: , Right tympanic membrane perforation along with chronic otitis media.,PROCEDURE: , Right ear examination under anesthesia.,INDICATIONS: , The patient is a 15-year-old child with history of a right tympanic membrane perforation following tube placement as well as right conductive hearing loss.  Exam in the office revealed a posterior superior right marginal tympanic perforation.  Risks and benefits of surgery including risk of bleeding, general anesthesia, hearing loss as well as recurrent perforation were discussed with the mother.  The mother wished to proceed with surgery.,FINDINGS:,  The patient was brought to the room, placed in supine position, given general endotracheal anesthesia.  The postauricular crease was then injected with 1% Xylocaine with 1:200,000 epinephrine along with external meatus.  An area of the scalp was shaved above the ear and then also 1% Xylocaine with 1:200,000 epinephrine injected, a total of 4 mL local anesthetic was used.  The ear was then prepped and draped in the usual sterile fashion.  The microscope was then brought into view and examining the marginal perforation, the patient was noted to have large granuloma under the tympanic membrane at the anterior border of the drum.  The granulation tissue was debrided as much as possible.  Decision was made to cancel the tympanoplasty after debriding the middle ear space as much as possible.  The middle ear space was filled with Floxin drops.  The patient woke up anesthesia, extubated, and brought to recovery room in stable condition.  There were no intraoperative complications.  Needle and sponge was correct.  Estimated blood loss minimal.","surgery, chronic otitis media, middle ear space, tympanic membrane perforation, otitis media, hearing loss, middle ear, ear space, ear examination, membrane perforation, tympanic membrane, anesthesia, membrane, tympanic, ear, perforation, "
"  Dual Chamber ICD Implantation, fluoroscopy,  defibrillation threshold testing, venography.", Surgery, Dual Chamber ICD Implantation ,"PROCEDURE:,1.  Implantation, dual chamber ICD.,2.  Fluoroscopy.,3.  Defibrillation threshold testing.,4.  Venography.,PROCEDURE NOTE: , After informed consent was obtained, the patient was taken to the operating room.  The patient was prepped and draped in a sterile fashion.  Using modified Seldinger technique, the left subclavian vein was attempted to be punctured but unsuccessfully.  Approximately 10 cc of intravenous contrast was injected into the left upper extremity peripheral vein.  Venogram was then performed.  Under fluoroscopy via modified Seldinger technique, the left subclavian vein was punctured and a guidewire was passed through the vein into the superior vena cava, then the right atrium and then into the inferior vena cava.  A second guidewire was placed in a similar fashion.  Approximately a 5 cm incision was made in the left upper anterior chest.  The skin and subcutaneous tissue was dissected out of the prepectoral fascia.  Both guide wires were brought into the pocket area.  A sheath was placed over the lateral guidewire and fluoroscopically guided to the vena cava.  The dilator and guidewire were removed.  A Fixation ventricular lead, under fluoroscopic guidance, was placed through the sheath into the superior vena cava, right atrium and then right ventricle.  Using straight and curved stylettes, it was placed in position and screwed into the right ventricular apex.  After pacing and sensing parameters were established in the lead, the collar on the lead was sutured to the pectoral muscle with Ethibond suture.  A guide sheath was placed over the guidewire and fluoroscopically placed in the superior vena cava.  The dilator and guidewire were removed.  An Active Fixation atrial lead was fluoroscopically passed through the sheath, into the superior vena cava and then the right atrium.  Using straight and J-shaped stylettes, it was placed in the appropriate position and screwed in the right atrial appendage area.  After significant pacing parameters were established in the lead, the collar on the lead was sutured to the pectoral muscles with Ethibond suture.  The tract was flushed with saline solution.  A Medtronic pulse generator was attached to both the leads and fixed to the pectoral muscle with Ethibond suture.  Deep and superficial layers were closed with 3-0 Vicryl in a running fashion.  Steri-strips were placed over the incision.  Tegaderm was placed over the Steri-strips.  Pressure dressing was applied to the pocket area.","surgery, venography, defibrillation threshold testing, venogram, dual chamber icd implantation, dual chamber icd, superior vena cava, seldinger technique, pectoral muscle, steri strips, dual chamber, ethibond suture, superior vena, vena cava, dual, chamber, icd, implantation, fluoroscopy, atrium, pectoral, vein, fluoroscopically, vena, cava, lead, guidewire,"
" Left ear cartilage graft, repair of nasal vestibular stenosis using an ear cartilage graft, cosmetic rhinoplasty, left inferior turbinectomy.", Surgery, Ear Cartilage Graft ,"PREOPERATIVE DIAGNOSES:  ,1.  Posttraumatic nasal deformity.,2.  Nasal obstruction.,3.  Nasal valve collapse.,4.  Request for cosmetic change with excellent appearance of nose.,POSTOPERATIVE DIAGNOSES:,1.  Posttraumatic nasal deformity.,2.  Nasal obstruction.,3.  Nasal valve collapse.,4.  Request for cosmetic change with excellent appearance of nose.,OPERATIVE PROCEDURES:,1.  Left ear cartilage graft.,2.  Repair of nasal vestibular stenosis using an ear cartilage graft.,3.  Cosmetic rhinoplasty.,4.  Left inferior turbinectomy.,ANESTHESIA: , General via endotracheal tube.,INDICATIONS FOR OPERATION: , The patient is with symptomatic nasal obstruction and fixed nasal valve collapse following a previous nasal fracture and attempted repair.  We discussed with the patient the indications, risks, benefits, alternatives, and complications of the proposed surgical procedure, she had her questions asked and answered.  Preoperative imaging was performed in consultation with regard to aesthetic results and communicated via the computerized imager.  The patient had questions asked and answered.  Informed consent was obtained.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed in supine position.  The appropriate level of general endotracheal anesthesia was induced.  The patient was converted to the lounge chair position, and the nose was anesthetized and vasoconstricted in the usual fashion.  Procedure began with an inverted going incision and elevation of the skin of the nose in the submucoperichondrial plane over the medial crural footplates and lower lateral cartilages and up over the dorsum.  The septal angle was approached and submucoperichondrial flaps were elevated.  Severe nasal septal deviation to the right hand side and evidence of an old fracture with a separate alignment of the cartilaginous nose from the bony nose was encountered.  The upper laterals were divided and medial and lateral osteotomies were carried out.  Inadequate septal cartilage was noted to be present for use as spreader graft; therefore, left postauricular incision was made, and the conchal bowl cartilage graft was harvested, and it was closed with 3-0 running locking chromic with a sterile cotton ball pressure dressing applied.  Ear cartilage graft was then placed to put two spreader grafts on the left and one the right.  The two on the left extended all the way up to the caudal tip, the one on the right just primarily the medial wall.  It was placed in such a way to correct a caudal dorsal deviation of the nasal tip septum.  The upper lateral cartilage was noted to be of the same width and length in size.  Yet, the left lower cartilage was scarred and adherent to the upper lateral cartilage.  The upper lateral cartilages were noted to be excessive of uneven length with the right being much taller than the left and that was shortened to the same length.  The scar bands were released in the lower lateral cartilages to the upper lateral cartilages to allow free mobilization of the lower lateral cartilages.  A middle crus stitch was used to unite the domes, and then the nose was projected by suturing the medial crural footplates of the caudal septum in deep projected fashion.  Crushed ear cartilage was then placed in the pockets above the spreader grafts in the area of the deficient dorsal nasal height and the lateral nasal sidewall height.  The spreader brought an excellent aesthetic appearance to the nose.  We left more than 1 cm of dorsal and caudal support for the nasal tip and dorsum height.  Mucoperichondrial flaps were closed with 4-0 plain gut suture.  The skin was closed with 5-0 chromic and 6-0 fast absorbing gut.  Doyle splints were placed on each side of nasal septum and secured with 3-0 nylon and a Denver splint was applied.  The patient was awakened in the operating room and taken to the recovery room in good condition.","surgery, nasal deformity, nasal obstruction, nasal valve, cartilage, cartilaginous, crural, graft, nasal fracture, postauricular, rhinoplasty, septal cartilage, submucoperichondrial, turbinectomy, vestibular, ear cartilage graft, posttraumatic nasal deformity, vestibular stenosis, ear cartilage, cartilage graft, cartilages, caudal, nasal, nose, obstruction, repair, stenosis"
" Dual chamber generator replacement.  The patient is a pleasant patient who presented to the office, recently was found to be at ERI and she has been referred for generator replacement.", Surgery, Dual Chamber Generator Replacement ,"REFERRAL INDICATIONS,1.  Pacemaker at ERI.,2.  History AV block.,PROCEDURES PLANNED AND PERFORMED:,  Dual chamber generator replacement.,FLUOROSCOPY TIME: , 0 minutes.,MEDICATION AT THE TIME OF STUDY,1.  Ancef 1 g.,2.  Versed 2 mg.,3.  Fentanyl 50 mcg.,CLINICAL HISTORY:  ,The patient is a pleasant patient who presented to the office, recently was found to be at ERI and she has been referred for generator replacement.,RISKS AND BENEFITS: , Risks, benefits, and alternatives to generator replacement have been discussed with the patient.  Risks including but not limited to bleeding, infection, vascular injury, and the need for pacemaker upgrade were discussed with the patient.  The patient agreed both verbally and via written consent.,DESCRIPTION OF OPERATION: , The patient was transported to the cardiac catheterization laboratory in a fasting state.  The region of the left dorsal pectoral groove was prepped and draped in a usual sterile manner.  Lidocaine 1% (20 mL) was administered to the area of the previous incision.  A transverse incision was made through the skin and subcutaneous tissue.  Hemostasis was achieved with electrocautery.  Using blunt dissection, pacemaker, and leads were removed from the pocket.  Leads were disconnected from the pulse generator and interrogated.  The pocket was washed with antibiotic impregnated saline.  The new pulse generator was obtained and connected securely to the leads and placed back in the pocket.  The pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using running stitch.  Sponge and needle counts were correct at the end of the procedure.  No acute complications were noted.,DEVICE DATA,1.  Explanted pulse generator Medronic, product # KDR601, serial # ABCD1234.,2.  New pulse generator Medronic, product # ADDR01, serial # ABCD1234.,3.  Right atrial lead, product # 4068, serial # ABCD1234.,4.  Right atrial lead, product # 4068, serial # ABCD1234.,MEASURED INTRAOPERATIVE DATA,1.  Right atrial lead impedance 572 ohms.  P wave measure 3.7 mV, pacing threshold 1.5 volts at 0.5 msec.,2.  Right ventricular lead impedance 365 ohms.  No R waves to measure, pacing threshold 0.9 volts at 0.5 msec.,CONCLUSIONS,1.  Successful dual chamber generator replacement.,2.  No acute complications.,PLAN,1.  She will be monitored for 3 hours and then dismissed home.,2.  Resume all medications.  Ex-home dismissal instructions.,3.  Doxycycline 100 mg one p.o. twice daily for 7 days.,4.  Wound check in 7-10 days.,5.  Continue followup in device clinic.",
" Bilateral L5 dorsal ramus block and bilateral S1, S2, and S3 lateral branch block for sacroiliac joint pain.  Fluoroscopic pillar view was used to identify the bony landmarks of the sacrum and sacroiliac joint and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.", Surgery, Dorsal Ramus & Branch Block ,"PROCEDURE: , Bilateral L5 dorsal ramus block and bilateral S1, S2, and S3 lateral branch block.,INDICATION: , Sacroiliac joint pain.,INFORMED CONSENT: , The risks, benefits and alternatives of the procedure were discussed with the patient.  The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible vascular entry of medications.  I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing.  The patient understood the informed consent and desired to have the procedure performed.,PROCEDURE:  ,Oxygen saturation and vital signs were monitored continuously throughout the procedure.  The patient remained awake throughout the procedure in order to interact and give feedback.  The X-ray technician was supervised and instructed to operate the fluoroscopy machine.,The patient was placed in the prone position on the treatment table, pillow under the chest, and head rotated contralateral to the side being treated.  The skin over and surrounding the treatment area was cleaned with Betadine.  The area was covered with sterile drapes, leaving a small window opening for needle placement.  Fluoroscopic pillar view was used to identify the bony landmarks of the sacrum and sacroiliac joint and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.,With fluoroscopy, a 25-gauge 3.5-inch spinal needle was gently guided into the groove between the SAP and sacrum through the dorsal ramus of the L5 and the lateral and superior border of the posterior sacral foramen with the lateral branches of S1, S2, and S3.  Multiple fluoroscopic views were used to ensure proper needle placement.  Approximately 0.25 mL of nonionic contrast agent was injected showing no concurrent vascular dye pattern.  Finally, the treatment solution, consisting of 0.5% of bupivacaine was injected to each area.  All injected medications were preservative free.  Sterile technique was used throughout the procedure.,ADDITIONAL DETAILS: , This was then repeated on the left side.,COMPLICATIONS: , None.,DISCUSSION:  ,Postprocedure vital signs and oximetry were stable.  The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day.  The patient was told to resume all medications.  The patient was told to resume normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes or changes in bowel or bladder function.,Follow up appointment was made at the PM&R Spine Clinic in approximately 1 week.","surgery, sacroiliac, lateral branch block, ramus block, branch block, sacroiliac joint, dorsal ramus, fluoroscopic, branch, dorsal, ramus, bilateral, needle, block,"
" Excision dorsal ganglion, right wrist.   The extensor retinaculum was then incised and the extensor tendon was dissected and retracted out of the operative field. ", Surgery, Dorsal Ganglion - Excision ,"PREOPERATIVE DIAGNOSIS:,  Dorsal ganglion, right wrist.,POSTOPERATIVE DIAGNOSIS:,  Dorsal ganglion, right wrist.,OPERATIONS PERFORMED:,  Excision dorsal ganglion, right wrist.,ANESTHESIA:,  Monitored anesthesia care with regional anesthesia applied by surgeon.,TOURNIQUET TIME:,  minutes.,DESCRIPTION OF PROCEDURE: , With the patient under adequate anesthesia, the upper extremity was prepped and draped in a sterile manner.  The arm was exsanguinated and the tourniquet was elevated to 290 mm/Hg.  A transverse incision was made over the dorsal ganglion.  Using blunt dissection the dorsal ulnar sensory nerve branches and radial sensory nerve branches were dissected and retracted out of the operative field.  The extensor retinaculum was then incised and the extensor tendon was dissected and retracted out of the operative field.  The ganglion was then further dissected to its origin from the dorsal distal scapholunate interosseus ligament and excised in toto.  Care was taken to protect ligament integrity.  Reactive synovium was then removed using soft tissue rongeur technique.  The wound was then infiltrated with 0.25% Marcaine.  The tendons were allowed to resume their normal anatomical position.  The skin was closed with 3-0 Prolene subcuticular stitch.  Sterile dressings were applied.  The tourniquet was deflated.  The patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well.","surgery, excision dorsal ganglion, extensor tendon, extensor retinaculum, dorsal ganglion, retinaculum, ganglion"
" Diagnostic laparotomy, exploratory laparotomy, Meckel's diverticulectomy, open incidental appendectomy, and peritoneal toilet.", Surgery, Diverticulectomy & Laparotomy ,"PREOPERATIVE DIAGNOSIS: , Acute appendicitis.,POSTOPERATIVE DIAGNOSIS: , Perforated Meckel's diverticulum.,PROCEDURES PERFORMED:,1.  Diagnostic laparotomy.,2.  Exploratory laparotomy.,3.  Meckel's diverticulectomy.,4.  Open incidental appendectomy.,5.  Peritoneal toilet.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:  ,300 ml.,URINE OUTPUT: , 200 ml.,TOTAL FLUID:,  1600 mL.,DRAIN:,  JP x1 right lower quadrant and anterior to the rectum.,TUBES:,  Include an NG and a Foley catheter.,SPECIMENS: , Include Meckel's diverticulum and appendix.,COMPLICATIONS: , Ventilator-dependent respiratory failure with hypoxemia following closure.,BRIEF HISTORY: , This is a 45-year-old Caucasian gentleman presented to ABCD General Hospital with acute onset of right lower quadrant pain that began 24 hours prior to this evaluation.,The pain was very vague and progressed in intensity.  The patient has had anorexia with decrease in appetite.  His physical examination revealed the patient to be febrile with the temperature of 102.4.  He had right lower quadrant and suprapubic tenderness with palpation with Rovsing sign and rebound consistent with acute surgical abdomen.  The patient was presumed acute appendicitis and was placed on IV antibiotics and recommended that he undergo diagnostic laparoscopy with possible open exploratory laparotomy.  He was explained the risks, benefits, and complications of the procedure and gave informed consent to proceed.,OPERATIVE FINDINGS: , Diagnostic laparoscopy revealed purulent drainage within the region of the right lower quadrant adjacent to the cecum and terminal ileum.  There was large amounts of purulent drainage.  The appendix was visualized, however, it was difficult to be visualized secondary to the acute inflammatory process, purulent drainage, and edema.  It was decided given the signs of perforation and purulent drainage within the abdomen that we would convert to an open exploratory laparotomy.  Upon exploration of the ileum, there was noted to be a ruptured Meckel's diverticulum, this was resected.  Additionally, the appendix appeared normal without evidence of perforation and/or edema and a decision to proceed with incidental appendectomy was performed.  The patient was irrigated with copious amounts of warmth normal saline approximately 2 to 3 liters.  The patient was closed and did develop some hypoxemia after closure.  He remained ventilated and was placed on a large amount of ________.  His hypoxia did resolve and he remained intubated and proceed to the Critical Care Complex or postop surgical care.,OPERATIVE PROCEDURE:,  The patient was brought to the operative suite and placed in the supine position.  He did receive preoperative IV antibiotics, sequential compression devices, NG tube placement with Foley catheter, and heparin subcutaneously.  The patient was intubated by the Anesthesia Department.  After adequate anesthesia was obtained, the abdomen was prepped and draped in the normal sterile fashion with Betadine solution.  Utilizing a #10 blade scalpel, an infraumbilical incision was created.  The Veress needle was inserted into the abdomen.  The abdomen was insufflated to approximately 15 mmHg.  A #10 mm ablated trocar was inserted into the abdomen and a video laparoscope was inserted and the abdomen was explored and the above findings were noted.  A right upper quadrant 5 mm port was inserted to help with manipulation of bowel and to visualize the appendix.  Decision was then made to convert to exploratory laparotomy given the signs of acute perforation.  The instruments were then removed.  The abdomen was then deflated.  Utilizing ________ #10 blade scalpel, a midline incision was created from the xiphoid down to level of the pubic symphysis.,The incision was carried down with a #10 blade scalpel and the bleeding was controlled along the way with electrocautery.  The posterior layer of the rectus fascia and peritoneum was opened carefully with the scissors as the peritoneum had already been penetrated during laparoscopy.  Incision was carried down to the midline within the linea alba.  Once the abdomen was opened, there was noted to be gross purulent drainage.  The ileum was explored and there was noted to be a perforated Meckel's diverticulum.  Decision to resect the diverticulum was performed.,The blood supply to the Meckel's diverticulum was carefully dissected free and a #3-0 Vicryl was used to tie off the blood supply to the Meckel's diverticulum.  Clamps were placed to the proximal supply to the Meckel's diverticulum was tied off with #3-0 Vicryl sutures.  The Meckel's diverticulum was noted to be completely free and was grasped anteriorly and utilizing a GIA stapling device, the diverticulum was transected.  There was noted to be a hemostatic region within the transection and staple line looked intact without evidence of perforation and/or leakage.  Next, decision was decided to go ahead and perform an appendectomy.  Mesoappendix was doubly clamped with hemostats and cut with Metzenbaum scissors.  The appendiceal artery was identified and was clamped between two hemostats and transected as well.  Once the appendix was completely freed of the surrounding inflammation and adhesion.  A plain gut was placed at the base of the appendix and tied down.  The appendix was milked distally with a straight stat and clamped approximately halfway.  A second piece of plain gut suture was used to ligate above and then was transected with a #10 blade scalpel.  The appendiceal stump was then inverted with a pursestring suture of #2-0 Vicryl suture.  Once the ________ was completed, decision to place a JP drain within the right lower quadrant was performed.  The drain was positioned within the right lower quadrant and anterior to the rectum and brought out through a separate site in the anterior abdominal wall.  It was sewn in place with a #3-0 nylon suture.  The abdomen was then irrigated with copious amounts of warmed normal saline.  The remainder of the abdomen was unremarkable for pathology.  The omentum was replaced over the bowel contents and utilizing #1-0 PDS suture, the abdominal wall, anterior and posterior rectus fascias were closed with a running suture.  Once the abdomen was completely closed, the subcutaneous tissue was irrigated with copious amounts of saline and the incision was closed with staples.  The previous laparoscopic sites were also closed with staples.  Sterile dressings were placed over the wound with Adaptic and 4x4s and covered with ABDs.  JPs replaced with bulb suction.  NG tube and Foley catheter were left in place.  The patient tolerated this procedure well with exception of hypoxemia which resolved by the conclusion of the case.,The patient will proceed to the Critical Care Complex where he will be closely evaluated and followed in his postoperative course.  To remain on IV antibiotics and we will manage ventilatory-dependency of the patient.",
" Excision of Dupuytren disease of the right hand extending out to the proximal interphalangeal joint of the little finger.  The patient is a 51-year-old male with left Dupuytren disease, which is causing contractions both at the metacarpophalangeal and the PIP joint as well as significant discomfort.", Surgery, Dupuytren Disease Excision ,"PREOPERATIVE DIAGNOSIS: , Right hand Dupuytren disease to the little finger.,POSTOPERATIVE DIAGNOSIS:  ,Right hand Dupuytren disease to the little finger.,PROCEDURE PERFORMED:  ,Excision of Dupuytren disease of the right hand extending out to the proximal interphalangeal joint of the little finger.,COMPLICATIONS:  ,None.,BLOOD LOSS: , Minimal.,ANESTHESIA: , Bier block.,INDICATIONS:  ,The patient is a 51-year-old male with left Dupuytren disease, which is causing contractions both at the metacarpophalangeal and the PIP joint as well as significant discomfort.,DESCRIPTION OF PROCEDURE:  ,The patient was taken to the operating room, laid supine, administered a bier block, and prepped and draped in the sterile fashion.  A zig-zag incision was made down the palmar surface of the little finger and under the palm up to the mid palm region.  Skin flaps were elevated carefully, dissecting Dupuytren contracture off the undersurface of the flaps.  Both neurovascular bundles were identified proximally in the hand and the Dupuytren disease fibrous band was divided proximally, which essentially returned to normal-appearing tissue.  The neurovascular bundles were then dissected distally resecting everything medial to the 2 neurovascular bundles and above the flexor tendon sheath all the way out to the PIP joint of the finger where the Dupuytren disease stopped.  The wound was irrigated.  The neurovascular bundles rechecked with no evidence of any injury and the neurovascular bundles were not significantly involved in the Dupuytren disease.  The incisions were closed with 5-0 nylon interrupted sutures.,The patient tolerated the procedure well and was taken to the PACU in good condition.","surgery, excision of dupuytren disease, proximal interphalangeal joint, dupuytren disease, bier block, pip joint, disease, dupuytren, contractions, metacarpophalangeal, neurovascular, bundles, interphalangeal, finger"
 Stenosing tenosynovitis first dorsal extensor compartment/de Quervain tendonitis.  Release of first dorsal extensor compartment., Surgery, Dorsal Extensor Compartment Release ,"PREOPERATIVE DIAGNOSIS: , Stenosing tenosynovitis first dorsal extensor compartment/de Quervain tendonitis.,POSTOPERATIVE DIAGNOSIS: , Stenosing tenosynovitis first dorsal extensor compartment/de Quervain tendonitis.,PROCEDURE PERFORMED:,  Release of first dorsal extensor compartment.,ASSISTANT: , None.,ANESTHESIA: , Bier block.,TOURNIQUET TIME: , 30 minutes.,COMPLICATIONS: , None.,INDICATIONS:  ,The above patient is a 47-year-old right hand dominant black female who has signs and symptomology of de Quervain's stenosing tenosynovitis.  She was treated conservatively with steroid injections, splinting, and nonsteroidal anti-inflammatory agents without relief.  She is presenting today for release of the first dorsal extensor compartment.  She is aware of the risks, benefits, alternatives and has consented to this operation.,PROCEDURE: , The patient was given intravenous prophylactic antibiotics.  She was taken to the operating suite under the auspices of Anesthesiology.  She was given a left upper extremity bier block.  Her left upper extremity was then prepped and draped in the normal fashion with Betadine solution.  Afterwards, a transverse incision was made over the extensor retinaculum of the first dorsal extensor compartment.  Dissection was carried down through the dermis into the subcutaneous tissue.  The dorsal radial sensory branches were kept out of harm's way.  They were retracted gently to the ulnar side of the wrist.  The retinaculum was incised with a #15 scalpel blade in the longitudinal fashion and the retinaculum was released completely both proximally and distally.  Both the extensor pollices brevis and abductor pollices longus tendons were identified.  There was no pathology noted within the first dorsal extensor compartment.  The wound was irrigated.  Hemostasis was obtained with bipolar cautery.  The wound was infiltrated with _0.25% Marcaine solution and then closure performed with #6-0 nylon suture utilizing a horizontal mattress stitch.  Sterile occlusive dressing was applied along with the thumb spica splint.  The tourniquet was released and the patient was transported to the recovery area in stable and satisfactory condition.","surgery, dorsal extensor compartment, de quervain tendonitis, dorsal, extensor, quervain, tendonitis, retinaculum, tenosynovitis, tourniquet,"
" Insertion of a double lumen port through the left femoral vein, radiological guidance.  Open exploration of the left subclavian and axillary vein.  Metastatic glossal carcinoma, needing chemotherapy and a port.", Surgery, Double Lumen Port Inserstion ,"PREOPERATIVE DIAGNOSIS:,  Metastatic glossal carcinoma, needing chemotherapy and a port.,POSTOPERATIVE DIAGNOSIS: , Metastatic glossal carcinoma, needing chemotherapy and a port.,PROCEDURES,1.  Open exploration of the left subclavian/axillary vein.,2.  Insertion of a double lumen port through the left femoral vein, radiological guidance.,DESCRIPTION OF PROCEDURE: , After obtaining the informed consent, the patient was electively taken to the operating room, where he underwent a general anesthetic through his tracheostomy.  The left deltopectoral and cervical areas were prepped and draped in the usual fashion.  Local anesthetic was infiltrated in the area.  There was some evidence that surgical procedure had happened in the area nearby and also there was collateral venous circulation under the skin, which made us suspicious that may be __________, but at any rate I tried to cannulate it subcutaneously and I was unsuccessful.  Therefore, I proceeded to make an incision and was able to isolate the vein, which would look very sclerotic.  I tried to cannulate it, but I could not advance the wire.,At that moment, I decided that there was no way we are going to put a port though that area.  I packed the incision and we prepped and redraped the patient including both groins.  Local anesthetic was infiltrated and then the left femoral vein was percutaneously cannulated without any difficulty.  The introducer was placed and then a wire and then the catheter of the double lumen port, which had been trimmed to position it near the heart.  It was done with radiological guidance.  Again, I was able to position the catheter in the junction of inferior vena cava and right atrium.  The catheter was looked upwards and the double lumen port was inserted subcutaneously towards the iliac area.  The port had been aspirated satisfactorily and irrigated with heparin solution.  The drain incision was closed in layers including subcuticular suture with Monocryl.  Then, we went up to the left shoulder and closed that incision in layers.  Dressings were applied.,The patient tolerated the procedure well and was sent back to recovery room in satisfactory condition.","surgery, axillary, vein, subclavian, double lumen port, femoral vein, radiological guidance, glossal carcinoma, port, inserstion, femoral, radiological, metastatic, carcinoma, chemotherapy, anesthetic, catheter, "
 Direct laryngoscopy and bronchoscopy., Surgery, Direct Laryngoscopy ,"PREOPERATIVE DIAGNOSIS:,  Subglottic stenosis.,POSTOPERATIVE DIAGNOSIS: , Subglottic stenosis.,OPERATIVE PROCEDURES: , Direct laryngoscopy and bronchoscopy.,ANESTHESIA:,  General inhalation.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and placed supine on the operative table.  General inhalational anesthesia was administered through the patient's tracheotomy tube.  The small Parsons laryngoscope was inserted and the 2.9-mm telescope was used to inspect the airway.  There was an estimated 60-70% circumferential mature subglottic stenosis that extended from just under the vocal folds to approximately 3 mm below the vocal folds.  The stoma showed some suprastomal fibroma.  The remaining tracheobronchial passages were clear.  The patient's 3.5 neonatal tracheostomy tube was repositioned and secured with Velcro ties.  Bleeding was negligible.  There were no untoward complications.  The patient tolerated the procedure well and was transferred to recovery room in stable condition.","surgery, laryngoscopy and bronchoscopy, direct laryngoscopy, subglottic stenosis, bronchoscopy, laryngoscopy, subglottic, stenosis, "
 Degenerative disk disease at L4-L5 and L5-S1.  Anterior exposure diskectomy and fusion at L4-L5 and L5-S1., Surgery, Diskectomy & Fusion ,"PREOPERATIVE DIAGNOSIS: , Degenerative disk disease at L4-L5 and L5-S1.,POSTOPERATIVE DIAGNOSIS:,  Degenerative disk disease at L4-L5 and L5-S1.,PROCEDURE PERFORMED:  ,Anterior exposure diskectomy and fusion at L4-L5 and L5-S1.,ANESTHESIA: , General.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , 150 mL.,PROCEDURE IN DETAIL:  ,Patient was prepped and draped in sterile fashion.  Left lower quadrant incision was performed and taken down to the preperitoneal space with the use of the Bovie, and then preperitoneal space was opened.  The iliac veins were carefully mobilized medially, and then the L4-L5 disk space was confirmed by fluoroscopy, and diskectomy fusion, which will be separately dictated by Dr. X, was performed after the adequate exposure was gained, and then after this L4-L5 disk space was fused and the L5-S1 disk space was carefully identified between the iliac vessels and the presacral veins and vessels were ligated with clips, disk was carefully exposed.  Diskectomy and fusion, which will be separately dictated by Dr. X, were performed.  Once this was completed, all hemostasis was confirmed.  The preperitoneal space was reduced.  X-ray confirmed adequate positioning and fusion.  Then the fascia was closed with #1 Vicryl sutures, and then the skin was closed in 2 layers, the first layer being 2-0 Vicryl subcutaneous tissues and then a 4-0 Monocryl subcuticular stitch, then dressed with Steri-Strips and 4 x 4's.  Then patient was placed in the prone position after vascular checks of the lower extremity confirmed patency of the arteries with warm bilateral lower extremities.","surgery, anterior exposure, degenerative disk disease, disk disease, disk space, diskectomy, fusion,"
 Traumatic injury to bilateral upper extremities.  Dressing change under anesthesia.  This 6 year old was involved in a traumatic accident.  She presents today for evaluation and dressing change., Surgery, Dressing Change ,"PREOPERATIVE DIAGNOSIS: , Traumatic injury to bilateral upper extremities.,POSTOPERATIVE DIAGNOSIS: , Traumatic injury to bilateral upper extremities.,PROCEDURE: , Dressing change under anesthesia.,PREOPERATIVE INDICATIONS:  ,This 6 year old was involved in a traumatic accident.  She presents today for evaluation and dressing change.,OPERATIVE PROCEDURE IN DETAIL: , The patient was brought to the operating room under the care of Dr. X.  He called us intraoperatively to evaluate the hand that had previously been repaired.  We were involved to that extent.  After removing the bandages, we recognized that more of the tissue had healed than was initially expected.  She had good perfusion although the distal aspect of her left long finger.  This was better than expected.  For this reason, no debridement was done at this time.  Dressings were reapplied to include Xeroform and a splint.  General Surgery and Orthopedic then carried on the rest of the operation.","surgery, bandages, traumatic injury, upper extremities, dressing change, traumatic, dressing, injury, "
 Fractional dilatation and curettage, Surgery, Dilatation & Curettage - D&C ,"PREOPERATIVE DIAGNOSIS: , Postmenopausal bleeding.,POSTOPERATIVE DIAGNOSIS: , Same.,OPERATION PERFORMED:  ,Fractional dilatation and curettage.,SPECIMENS: , Endocervical curettings, endometrial curettings.,INDICATIONS FOR PROCEDURE: , The patient recently presented with postmenopausal bleeding.  An office endometrial biopsy was unable to be performed secondary to a stenotic internal cervical os.,FINDINGS: , Examination under anesthesia revealed a retroverted, retroflexed uterus with fundal diameter of 6.5 cm.  The uterine cavity was smooth upon curettage.  Curettings were fairly copious.  Sounding depth was 8 cm.,PROCEDURE:,  The patient was brought to the Operating Room with an IV in place.  The patient was given a general anesthetic and was placed in the lithotomy position.  Examination under anesthesia was completed with findings as noted.  She was prepped and draped and a speculum was placed into the vagina.  ,Tenaculum was placed on the cervix.  The endocervical canal was curetted using a Kevorkian curette, and the sound was used to measure the overall depth of the uterus.  The endocervical canal was dilated without difficulty to a size 16 French dilator.  A small, sharp curette was passed into the uterine cavity and curettings were obtained.,After completion of the curettage, polyp forceps were passed into the uterine cavity.  No additional tissue was obtained.  Upon completion of the dilatation and curettage, minimum blood loss was noted.,The patient was awakened from her anesthetic, and taken to the post anesthesia care unit in stable condition.","surgery, postmenopausal bleeding, endometrial, fractional dilatation, fractional dilatation and curettage, endocervical, dilatation and curettage, endocervical canal, uterine cavity, curetted, dilatation, curettings, curettage"
" Anterior cervical discectomy, osteophytectomy, foraminotomies, spinal cord decompression, fusion with machined allografts, Eagle titanium plate, Jackson-Pratt drain placement, and intraoperative monitoring with EMGs and SSEPs", Surgery," Discectomy, Osteophytectomy, & Foraminotomy ","PREOPERATIVE DIAGNOSES:,  Cervical degenerative disc disease, spondylosis, severe myelopathy, spinal cord compression especially at C3-C4, C4-C5, and C5-C6, and progressive quadriparesis.,POSTOPERATIVE DIAGNOSES:,  Cervical degenerative disc disease, spondylosis, severe myelopathy, spinal cord compression especially at C3-C4, C4-C5, and C5-C6, progressive quadriparesis, and very poor bone quality as well as difficulty with hemostasis with the patient having been on aspirin.,OPERATIVE PROCEDURE,1.  Anterior cervical discectomy, osteophytectomy, foraminotomies, spinal cord decompression at C3-C4, C4-C5, and C5-C6.,2.  Microscope.,3.  Fusion with machined allografts at C3-C4, C4-C5, and C5-C6.,4.  Eagle titanium plate from C3 to C6.,5.  Jackson-Pratt drain placement.,6.  Intraoperative monitoring with EMGs and SSEPs.,ESTIMATED BLOOD LOSS: , 350 cc.,ANESTHESIA: , General endotracheal anesthesia.,COMPLICATIONS:  ,None.,COUNTS: , Correct.,SPECIMENS SENT:  ,None.,CLINICAL HISTORY:  ,The patient is a 77-year-old male who was admitted through the emergency room for progressive weakness and falling.  He was worked by the neurologist, Dr. X, and found to have cervical spondylosis with myelopathy.  I was consulted and elected to do a lumbar and cervical myelogram CT scan, which showed lumbar stenosis but also cervical stenosis with more pathology anteriorly than posteriorly.  The patient had worst disease at level C3-C4, C4-C5, and C5-C6.  The patient was significantly weak and almost quadriparetic, stronger on the right side than on the left side.  I thought that surgery was indicated to prevent progressive neurological deterioration, as well as to prevent a central cord syndrome if the patient were to get into a motor vehicle accident or simply fall.  Conservative management was not an option.  The patient was preoped and consented, and was medically cleared.  I discussed the indications, risks, and benefits of the surgery with the patient and the patient's family.  The risks of bleeding, hoarseness, swallowing difficulty, pseudoarthrosis as well as plate migration and hardware failure were all discussed with the patient.  An informed consent was obtained from the patient as such.  He was brought into the OR today for the operative procedure.,DESCRIPTION OF PROCEDURE:  ,The patient was brought into the OR, intubated, and given a general anesthetic.  Intubation was done under C-spine precautions.  The patient received preoperative vancomycin and Decadron.  He was hooked up to the SSEP apparatus and had poor baselines and delays.,With a large a shoulder roll, I extended the patient's neck, and landmark incision in crease in the right upper neck, and the area was then prepped and sterilely draped.  All the lines had been put in and the arms were padded.,Using a knife and cautery, I took the incision down through the skin and subcutaneous tissue and arrived at the cervical spine.  Prominent osteophyte at C5-C6 was noted, lesser at C4-C5.  Intraoperative x-ray confirmed our levels, and we were fully exposed from C3-C6.,Trimline retractors were put in, and I cut the discs out as well as removed the superficial hyperstatic bone and osteophytes.,With the drill, I performed a superficial discectomy and endplate resection, curetting the endplate as I went.  I then brought in the microscope, under the microscopic guidance, firmly removed the end plates and drilled through the posterior longitudinal ligament to decompress the spinal cord.  Worst findings at C3-C4 followed C5-C6 and then C4-C5.  Excellent thecal sac decompression was achieved and foraminal decompression was also achieved.  With change in intraoperative monitoring, a microscope was used for this decompressive procedure.,The patient was very oozy throughout this procedure, and during the decompression part, the oozing was constant.  This was partly due to the patient's cancellous bone, but he had been on aspirin which was stopped only 2 days ago, and the option was not available to wait 2 to 3 weeks which would have made this man worse simply over time.  I thus elected to give him DDAVP, platelets, and used Horsley bone wax for excellent hemostasis.  This took literally half-an-hour to an hour and added to the complexity and difficulty of this case.  Eventually, with blood pressure controlled and all the other parameters under control, bleeding was somewhat slow.,I then selected two 10 and one 9-mm cadaveric allograft, which had soaking in bacitracin solution.  These were trimmed to the desired dimensions, and under slight distraction, these were tapped into position.  Excellent graft alignment was achieved.,I now brought in a DePuy titanium eagle plate, and I fixed it to the spine from C3 to C6.  Fourteen millimeter screws were used; all the screws were tightened and torqued.  The patient's bone quality was poor, but the screws did torque appropriately.  I inspected the plate, controlled the hemostasis, assessed post-fixation x-ray, and was really happy with the screw length and the overall alignment.,The wound was irrigated with antibiotic solution; a Jackson-Pratt drain 10-French was put in with trocar.  Decision was made to start the closure.  So, I closed the platysma with 3-0 Vicryl and used staples for the skin.  A simple Primapore or Medpore dressing was applied.  The patient was extubated in the OR and taken to the PSU in stable medical condition.,When I saw the patient in the ICU, he was awake, alert, and moving all four extremities, somewhat weak on the left side.  He had done well from the surgery.  Blood loss was 350 cc.  All instrument, needle, and sponge counts were correct.  No complications, no change in intraoperative monitoring.  No specimens were sent.,The patient's wife was spoken to and fully appraised of the intraoperative findings and the expected prognosis.  The patient will be kept n.p.o. tonight and will gradually advance his diet, and also will gradually advance his activity.  I will keep him on Decadron and keep the collar on.  I do not think there is need for halo rest.  We will be obtaining formal C-spine films in the morning.  Prognosis is guarded but favorable at this time.",
" Dilation and evacuation.  12 week incomplete miscarriage.  The patient unlike her visit in the ER approximately 4 hours before had some tissue in the vagina protruding from the os, this was teased out and then a D&E was performed yielding significant amount of central tissue. ", Surgery, Dilation & Evacuation ,"PREOPERATIVE DIAGNOSIS:,  12 week incomplete miscarriage.,POSTOPERATIVE DIAGNOSIS: , 12 week incomplete miscarriage.,OPERATION PERFORMED: , Dilation and evacuation.,ANESTHESIA: , General.,OPERATIVE FINDINGS:  ,The patient unlike her visit in the ER approximately 4 hours before had some tissue in the vagina protruding from the os, this was teased out and then a D&E was performed yielding significant amount of central tissue.  The fetus of 12 week had been delivered previously by Dr. X in the ER.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,COMPLICATIONS:  ,None.,SPONGE AND NEEDLE COUNT: , Correct.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operating room placed in the operating table in supine position.  After adequate anesthesia, the patient was placed in dorsal lithotomy position.  The vagina was prepped.  The patient was then draped.  A speculum was placed in the vagina.  Previously mentioned products of conception were teased out with a ring forceps.  The anterior lip of the cervix was then grasped with a ring forceps as well and with a 10-mm suction curette multiple curettages were performed removing fairly large amount of tissue for a 12-week pregnancy.  A sharp curettage then was performed and followed by two repeat suction curettages.  The procedure was then terminated and the equipment removed from the vagina, as well as the speculum.  The patient tolerated the procedure well.  Blood type is Rh negative.  We will see the patient back in my office in 2 weeks.","surgery, incomplete miscarriage, dilation, evacuation, vagina protruding, protruding, speculum, miscarriage, forceps, curettages, vagina,"
" Redo L4-5 diskectomy, left - recurrent herniation L4-5 disk with left radiculopathy.", Surgery, Diskectomy ,"PREOPERATIVE DIAGNOSIS (ES):, Recurrent herniation L4-5 disk with left radiculopathy.,POSTOPERATIVE DIAGNOSIS (ES):, Recurrent herniation L4-5 disk with left radiculopathy.,PROCEDURE:, Redo L4-5 diskectomy left.,COMPLICATIONS:, None.,ANTIBIOTIC (S),: Vancomycin given preoperatively.,ANESTHESIA:, General endotracheal.,ESTIMATED BLOOD LOSS:, 10 mL.,BLOOD REPLACED:, None.,CRYSTALLOID GIVEN:, 800 mL.,DRAIN (S):, None.,DESCRIPTION OF THE OPERATION:, The patient was brought to the operating room in supine position. General endotracheal anesthesia was administered. He was turned into the prone position on the operating table and positioned in the modified knee-chest position with Andrews frame being used. Care was taken to protect pressure points. The back was shaved, scrubbed with Betadine scrub, rinsed with alcohol, and prepped with DuraPrep, and draped in the usual sterile fashion with Ioban drape being used. A midline skin incision was made, excising scar from previous surgery. Dissection was carried down through the subcutaneous tissue with electrocautery technique. The lumbosacral fascia was split to the left of the spinous process, and subperiosteal dissection of the spinous process and lamina, area of previous laminotomy was identified. Cross-table lateral was also made to confirm position. The scar was then loosened from the inferior portion of 4, superior of L5 lamina, and a portion of the lamina was removed. I did identify normal dura. The scar was then lysed from the medial wall. Dura and nerve root were identified and protected with nerve root retractor. The bulging disk fragment was still contained under the longitudinal ligament. A rent was made with the Penfield and a moderately large fragment was removed. The disk space was then entered with a cruciate cut in the annulus, with additional nuclear material being received. When no other fragments could be removed from the disk space, no other fragments were felt in the central canal under the longitudinal ligament, and a Murphy ball could be passed through the foramen without evidence of compression, the decompression was complete. Check was made for CSF leakage, and no evidence of significant epidural bleeding was present. The wound was irrigated with antibiotic solution. Twenty milligrams of Depo-Medrol was placed over the dura and nerve root. A free fat graft from the subcutaneous tissue was then placed over the dura. Closure was obtained with the lumbosacral fascia being reapproximated with #1, running, Vicryl suture. Subcutaneous closure was obtained in layers with 2-0, running, Vicryl suture. Skin closure was obtained with 3-0 Vicryl subcuticular suture. Proxi-Strips and sterile dressing was applied. The skin had been infiltrated with 8 mL of 0.5% Marcaine with epinephrine.,After a sterile dressing was applied, the patient was turned into the supine position on the waiting recovery room stretcher, brought from under the effects of anesthesia, and taken to the recovery room.","surgery, herniation, andrews frame, csf leakage, depo-medrol, l4-5, proxi-strips, diskectomy, endotracheal anesthesia, lumbosacral fascia, modified knee-chest position, radiculopathy, supine position, nerve root, duraprep, "
 She required augmentation with Pitocin to achieve a good active phase.  She achieved complete cervical dilation., Surgery, Delivery Note - 9 ,"DELIVERY NOTE:,  This G1, P0 with EDC 12/23/08 presented with SROM about 7.30 this morning.  Her prenatal care complicated by GBS screen positive and a transfer of care at 34 weeks from Idaho.  Exam upon arrival 2 to 3 cm, 100% effaced, -1 station and by report pool of fluid was positive for Nitrazine and positive ferning.,She required augmentation with Pitocin to achieve a good active phase.  She achieved complete cervical dilation at 1900  At this time, a bulging bag was noted, which ruptured and thick meconium was present.  At 1937 hours, she delivered a viable male infant, left occiput, anterior.  Mouth and nares suctioned well with a DeLee on the perineum.  No nuchal cord present.  Shoulders and body followed easily.  Infant re-suctioned with the bulb and cord clamped x2 and cut and was taken to the warmer where the RN and RT were in attendance.  Apgars 9 and 9.  Pitocin 15 units infused via pump protocol.  Placenta followed complete and intact with fundal massage and general traction on the cord.  Three vessels are noted.  She sustained a bilateral periurethral lax on the left side, this extended down to the labia minora, became a second degree in the inferior portion and did have some significant bleeding in this area.  Therefore, this was repaired with #3-0 Vicryl after 1% lidocaine infiltrated approximately 5 mL.  The remainder of the lacerations was not at all bleeding and no other lacerations present.  Fundus required bimanual massage in a couple of occasions for recurrent atony with several larger clots; however, as the Pitocin infused and massage continued, this improved significantly.  EBL was about 500 mL.  Bleeding appears much better; however, Cytotec 400 mcg was placed per rectum apparently prophylactically.  Mom and baby currently doing very well.","surgery, augmentation with pitocin, delivery, cervical, dilation, perineum, lacerations, pitocin, infantNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Dental restorations and extractions.  Dental caries.  He has had multiple severe carious lesions that warrant multiple extractions at this time., Surgery, Dental Restorations & Extractions ,"PREOPERATIVE DIAGNOSIS:,  Dental caries.,POSTOPERATIVE DIAGNOSIS: , Dental caries.,PROCEDURE: , Dental restorations and extractions.,CLINICAL HISTORY: , This 23-year-old male is a client of the ABC Center because of his disability, the nature of which is unclear to me at this time; however, he reportedly has several issues that qualify him as disabled.  He has had multiple severe carious lesions that warrant multiple extractions at this time.  It is also unclear to me as to how his prior or existing restorations were accomplished.  In any case, he has been cleared for the procedure today.  He has his history and physical in the chart.,PROCEDURE: , The patient was brought to the operating room at 11 o'clock and placed in the supine position.  Dr. X administered the general anesthetic, after which a throat pack was placed.  Available full mouth x-rays were reviewed.  These x-rays were taken at another location.  Teeth 2, 4, 10, 12, 13, 15, 18, 20, 27, and 31 were all in varying degrees of severe decay from complete destruction of the crowns to pulp exposures with periapical radiolucencies.  All of these aforementioned teeth were extracted using combinations of forceps and elevators.  Hemostasis in all of these sites was accomplished with direct pressure using gauze packs.  ,Tooth 5 had caries in the distal surface extending to the occlusal as well as another carious lesion in the buccal.  These carious lesions and his tooth were excavated, and the tooth was restored with amalgam involving these surfaces.  ,Tooth 6 had caries on the facial surface, which was excavated, and the tooth was restored with composite.  ,Tooth 7 had caries involving the distal surface.  ,Tooth 8 likewise had caries involving the distal surface, and both of these distal lesions extended into incisal area.  These carious lesions were excavated, and both of these teeth were restored with composite.  ,Tooth 9 had caries in a mesial surface and a buccal surface, which was excavated, and this tooth was restored with composite.  ,Tooth 28 caries in the mesial surface extending to the occlusal, which was excavated, and the tooth was restored with amalgam, and tooth 30 had carries in the buccal surface, which was excavated, and the tooth was restored with amalgam.  ,A prophylaxis was done, primarily using a rotating rubber cup and some minor scaling, and the mouth was irrigated and suctioned thoroughly.  The throat pack was removed, and the patient was awakened and brought to the recovery room in good condition at 1330 hours.  There was negligible blood loss.","surgery, extractions, multiple extractions, mesial surface, buccal surface, dental restorations, dental caries, distal surface, composite tooth, carious lesions, tooth, dental, caries"
 An 83-year-old diabetic female presents today stating that she would like diabetic foot care., Surgery, Diabetic Foot Care ,"S - ,An 83-year-old diabetic female presents today stating that she would like diabetic foot care.,O - ,On examination, the lateral aspect of her left great toenail is deeply ingrown.  Her toenails are thick and opaque.  Vibratory sensation appears to be intact.  Dorsal pedal pulses are 1/4.  There is no hair growth seen on her toes, feet or lower legs.  Her feet are warm to the touch.  All of her toenails are hypertrophic, opaque, elongated and discolored.,A - ,1.  Onychocryptosis.,","surgery, onychocryptosis, onychomycosis, great toenail, diabetic foot care, diabetic foot, foot, toenail, ingrown, toenails, diabetic, "
" Diagnostic laparoscopy.   Acute pelvic inflammatory disease and periappendicitis.  The patient appears to have a significant pain requiring surgical evaluation.  It did not appear that the pain was pelvic in nature, but more higher up in the abdomen, more towards the appendix.", Surgery, Diagnostic Laparoscopy - 1 ,"PREOPERATIVE DIAGNOSIS: , Acute abdominal pain, rule out appendicitis versus other.,POSTOPERATIVE DIAGNOSIS:,  Acute pelvic inflammatory disease and periappendicitis.,PROCEDURE PERFORMED: , Diagnostic laparoscopy.,COMPLICATIONS:,  None.,CULTURES:,  Intra-abdominally are done.,HISTORY:  ,The patient is a 31-year-old African-American female patient who complains of sudden onset of pain and has seen in the Emergency Room.  The pain has started in the umbilical area and radiated to McBurney's point.  The patient appears to have a significant pain requiring surgical evaluation.  It did not appear that the pain was pelvic in nature, but more higher up in the abdomen, more towards the appendix.  The patient was seen by Dr. Y at my request in the ER with me in attendance.  We went over the case.  He decided that she should go to the operating room for evaluation and to have appendix evaluated and probably removed.  The patient on ultrasound had a 0.9 cm ovarian cyst on the right side.  The patient's cyst was not completely simple and they are concerns over the possibility of an abnormality.  The patient states that she has had chlamydia in the past, but it was not a pelvic infection more vaginal infection.  The patient has had hospitalization for this.  The patient therefore signed informed in layman's terms with her understanding that perceivable risks and complications, the alternative treatment, the procedure itself and recovery.  All questions were answered.  ,PROCEDURE: ,The patient was seen in the Emergency Room.  In the Emergency Room, there is really no apparent vaginal discharge.  No odor or cervical motion tenderness.  Negative bladder sweep.  Adnexa were without abnormalities.  In the OR, we were able to perform pelvic examination showing a slightly enlarged fibroid uterus about 9 to 10-week size.  The patient had no adnexal fullness.  The patient then underwent an insertion of a uterine manipulator and Dr. X was in the case at that time and he started the laparoscopic process i.e., inserting the laparoscope.  We then observed under direct laparoscopic visualization with the aid of a camera that there was pus in and around the uterus.  The both fallopian tubes were seen.  There did not appear to be hydrosalpinx.  The ovaries were seen.  The left showed some adhesions into the ovarian fossa.  The cul-de-sac had a banded adhesions.  The patient on the right adnexa had a hemorrhagic ovarian cyst, where the cyst was only about a centimeter enlarged.  The ovary did not appear to have pus in it, but there was pus over the area of the bladder flap.  The patient's bowel was otherwise unremarkable.  The liver contained evidence of Fitz-Hugh-Curtis syndrome and prior PID.  The appendix was somewhat adherent into the retrocecal area and to the mid-quadrant abdominal sidewall on the right.  The case was then turned over to Dr. Y who was in the room at that time and Dr. X had left.  The patient's case was turned over to him.  Dr. Y was performed an appendectomy following which cultures and copious irrigation.  Dr. Y was then closed the case.  The patient was placed on antibiotics.  We await the results of the cultures and as well further ______ therapy.,PRIMARY DIAGNOSES:,1.  Periappendicitis.,2.  Pelvic inflammatory disease.,3.  Chronic adhesive disease.","surgery, periappendicitis, pelvic inflammatory disease, chronic adhesive disease, abdominal pain, appendicitis, diagnostic laparoscopy, laparoscopy, pelvic,"
 The patient is a 22-year-old woman with a possible ruptured ectopic pregnancy., Surgery, Diagnostic Laparoscopy ,"TITLE OF OPERATION:,  Diagnostic laparoscopy.,INDICATION FOR SURGERY: , The patient is a 22-year-old woman with a possible ruptured ectopic pregnancy.,PREOP DIAGNOSIS: , Possible ruptured ectopic pregnancy.,POSTOP DIAGNOSIS: , No evidence of ectopic pregnancy or ruptured ectopic pregnancy.,ANESTHESIA: , General endotracheal.,SPECIMEN: , Peritoneal fluid.,EBL: , Minimal.,FLUIDS:,  900 cubic centimeters crystalloids.,URINE OUTPUT: , 400 cubic centimeters.,FINDINGS: , Adhesed left ovary with dilated left fallopian tube, tortuous right fallopian tube with small 1 cm ovarian cyst noted on right ovary, perihepatic lesions consistent with history of PID, approximately 1-200 cubic centimeters of more serous than sanguineous fluid.  No evidence of ectopic pregnancy.,COMPLICATIONS: , None.,PROCEDURE:,  After obtaining informed consent, the patient was taken to the operating room where general endotracheal anesthesia was administered.  She was examined under anesthesia.  An 8-10 cm anteverted uterus was noted.  The patient was placed in the dorsal-lithotomy position and prepped and draped in the usual sterile fashion, a sponge on a sponge stick was used in the place of a HUMI in order to not instrument the uterus in the event that this was a viable intrauterine pregnancy and this may be a desired intrauterine pregnancy.  Attention was then turned to the patient's abdomen where a 5-mm incision was made in the inferior umbilicus.  The abdominal wall was tented and VersaStep needle was inserted into the peritoneal cavity.  Access into the intraperitoneal space was confirmed by a decrease in water level when the needle was filled with water.  No peritoneum was obtained without difficulty using 4 liters of CO2 gas.  The 5-mm trocar and sleeve were then advanced in to the intraabdominal cavity and access was confirmed with the laparoscope.,The above-noted findings were visualized.  A 5-mm skin incision was made approximately one-third of the way from the ASI to the umbilicus at McBurney's point.  Under direct visualization, the trocar and sleeve were advanced without difficulty.  A third incision was made in the left lower quadrant with advancement of the trocar into the abdomen in a similar fashion using the VersaStep.  The peritoneal fluid was aspirated and sent for culture and wash and cytology.  The abdomen and pelvis were surveyed with the above-noted findings.  No active bleeding was noted.  No evidence of ectopic pregnancy was noted.  The instruments were removed from the abdomen under good visualization with good hemostasis noted.  The sponge on a sponge stick was removed from the vagina.  The patient tolerated the procedure well and was taken to the recovery room in stable condition.,The attending, Dr. X, was present and scrubbed for the entire procedure.","surgery, peritoneal fluid, sanguineous fluid, ruptured ectopic pregnancy, diagnostic laparoscopy, intrauterine pregnancy, ectopic pregnancy, trocar, ruptured, ectopic, tortuous, pregnancy, "
 Dental restoration.    Dental caries.  Cavities have been noted by his parents and pediatrician that have been noted to be pretty severe. , Surgery, Dental Restoration ,"PREOPERATIVE DIAGNOSIS: , Dental caries.,POSTOPERATIVE DIAGNOSIS:,  Dental caries.,PROCEDURE: , Dental restoration.,CLINICAL HISTORY:  ,This 2-year, 10-month-old male has not had any prior dental treatment because of his unmanageable behavior in a routine dental office setting.  He was referred to me for that reason to be treated under general anesthesia for his dental work.  Cavities have been noted by his parents and pediatrician that have been noted to be pretty severe.  There are no contraindications to this procedure.  He is healthy.  His history and physical is in the chart.,PROCEDURE:  ,The patient was brought to the operating room at 10:15 and placed in the supine position.  Dr. X administered the general anesthetic after which 2 bite-wing and 2 periapical x-rays were exposed and developed and his teeth were examined.  A throat pack was then placed.  Tooth D had caries on the distal surface which was excavated and the tooth was restored with composite.  Teeth E and F had caries in the mesial and distal surfaces, these carious lesions were excavated and the teeth were restored with composite.  Tooth G had caries in the mesial surface which was excavated and the tooth was restored with composite.  Teeth I and L both had caries on the occlusal surfaces which were excavated and upon excavation of the caries in tooth I the pulp was perforated and a therapeutic pulpotomy was therefore necessary.  This was done using ferric sulfate and zinc oxide eugenol.  For final restorations, amalgam restorations were placed involving the occlusal surfaces both teeth I and L. A prophylaxis was done and topical fluoride applied and the excess was suctioned thoroughly.  The throat pack was removed and the patient was awakened and brought to the recovery room in good condition at 11:30.  There was no blood loss.","surgery, cavities, carious lesions, throat pack, composite teeth, occlusal surfaces, dental restoration, dental caries, dental, teeth, caries, "
 Dental prophylaxis under general anesthesia., Surgery, Dental Prophylaxis ,"OPERATION PERFORMED:  ,Dental prophylaxis under general anesthesia.,PREOPERATIVE DIAGNOSES:,1.  Impacted wisdom teeth.,2.  Moderate gingivitis.,POSTOPERATIVE DIAGNOSES:,1.  Impacted wisdom teeth.,2.  Moderate gingivitis.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS:  ,Minimal.,DURATION OF SURGERY:  ,One hour 17 minutes.,BRIEF HISTORY:  ,The patient was referred to me by Dr. X.  He contacted myself and stated that Angelica was going to have her wisdom teeth extracted in the setting of a hospital operating room at Hospital and he inquired if we could pair on the procedure and I could do her full mouth dental rehabilitation before the wisdom teeth were removed by him.  I agreed.  I saw her in my office and she was cooperative for full mouth set of radiographs in my office and a clinical examination.  This clinical and radiographic examination revealed no dental caries; however, she was in need of a good dental cleaning.,OPERATIVE PREPARATION:  ,The patient was brought to Hospital Day Surgery accompanied by her mother.  I met with them and discussed the needs of the child, types of restoration to be performed, and the risks and benefits of the treatment as well as the options and alternatives of the treatment.  After all their questions and concerns were addressed, they gave their informed consent to proceed with the treatment.  The patient's history and physical examination was reviewed.  Once she was cleared by Anesthesia, she was taken back to the operating room.,OPERATIVE PROCEDURE:  ,The patient was placed on the surgical table in the usual supine position with all extremities protected.  Anesthesia was induced by mask.  The patient was then intubated with a nasal endotracheal tube and the tube was stabilized.  The head was wrapped and the eyes were taped shut for protection.  An Angiocath was previously placed in preop.  The head and neck were draped in sterile towels, and the body was covered with lead apron and sterile sheath.  A moist continuous throat pack was placed beyond tonsillar pillars.  Plastic lip and cheek retractors were then placed.  Preoperative digital intraoral photographs were taken.  No digital radiographs were taken in the operating room, as I stated before I had a full set of digital radiographs taken in my office.  A prophylaxis was then performed using a Prophy cup and fluoridated Prophy paste after scaling and replaning was done.  She presented with moderate calculus on the buccal surfaces of her maxillary, first molars and lower molars.  She did not require any restorative dentistry.,Upon the conclusion of the restorative phase, the oral cavity was aspirated and found to be free of blood, mucus, and other debris.  The original treatment plan was verified with the actual treatment provided.  Postoperative clinical photographs were taken.  The continuous gauze throat pack was removed with continuous suction and visualization.  Topical fluoride was then placed on the teeth.,At the end of the procedure, the child was undraped, extubated, and awakened in the operating room, taken to the recovery room, breathing spontaneously with stable vital signs.,FINDINGS: , This patient presented in her permanent dentition.  Her teeth #1, 16, 17, and 32 were impacted and are going to be removed following my full mouth dental rehabilitation by Dr. Alexander.  Oral hygiene was fair.  There was generalized plaque and calculus throughout.  She did not have any caries, did not require any restorative dentistry.,CONCLUSION:,  Following my dental surgery, the patient continued to intubated and was prepped for oral surgery procedures by Dr. X and his associates.  There were no postop pain requirements.  I did not have any specific requirements for the patient or her mother and that will be handled by Dr. X and their instructions on soft foods, etc., and pain control will be managed by them.","surgery, dental prophylaxis, impacted wisdom teeth, gingivitis, wisdom teeth, moderate gingivitis, dental rehabilitation, throat pack, digital radiographs, restorative dentistry, impacted, anesthesia, restorative, wisdom, oral, prophylaxis, teeth, dental, "
" Torn rotator cuff and subacromial spur with impingement syndrome, right shoulder.  Diagnostic arthroscopy with subacromial decompression and open repair of rotator cuff using three Panalok suture anchors.", Surgery, Diagnostic Arthroscopy ,"PREOPERATIVE DIAGNOSIS:,  Torn rotator cuff, right shoulder.,POSTOPERATIVE DIAGNOSES:,1.  Torn rotator cuff, right shoulder.,2.  Subacromial spur with impingement syndrome, right shoulder.,PROCEDURE PERFORMED:,1.  Diagnostic arthroscopy with subacromial decompression.,2.  Open repair of rotator cuff using three Panalok suture anchors.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:  ,Approximately 200 cc.,INTRAOPERATIVE FINDINGS: , There was noted to be a full thickness tear to the supraspinatus tendon at the insertion of the greater tuberosity.  There is moderate amount of synovitis noted throughout the glenohumeral joint.  There is a small subacromial spur noted on the very anterolateral border of the acromion.,HISTORY: , This is a 62-year-old female who previously underwent a repair of rotator cuff.  She continued to have pain within the shoulder.  She had a repeat MRI performed, which confirmed the clinical diagnosis of re-tear of the rotator cuff.  She wished to proceed with a repair.  All risks and benefits of the surgery were discussed with her at length.  She was in agreement with the above treatment plan.,PROCEDURE: , On 08/21/03, she was taken to the Operative Room at ABCD General Hospital.  She was placed supine on the operating table.  General anesthesia was applied by the Anesthesiology Department.  She was placed in the modified beachchair position.  Her upper extremity was sterilely prepped and draped in usual fashion.  A stab incision was made in the posterior aspect of the glenohumeral joint.  A camera was placed in the joint and was insufflated with saline solution.  Intraoperative pictures were obtained and the above findings were noted.  A second port site was initiated anteriorly.  Through this a probe was placed and the intraarticular structures were palpated and found to be intact.  A tear of the inner surface of the rotator cuff was identified.  The camera was then taken to the subacromial space.  A straight lateral portal was also used and a shaver was placed into the subacromial space.  Further debridement of the anterolateral border of the acromion was performed to remove evidence of the subacromial spur, which had reformed.  The edges of the rotator cuff were then debrided.  The camera was then removed and the shoulder was suction and dried.  A lateral incision was made over the anterolateral border of the acromion.  Subcuticular tissues were carefully dissected.  Hemostasis was controlled with electrocautery.  The deltoid musculature was then incised and aligned with its fibers exposing the rotator cuff tear and the edges were further debrided using a rongeur.  A trough was then made in the greater tuberosity using the rongeur.  Two Panalok anchors were then placed within the trough and weaved through the suture and third Panalok anchor was placed medial to the trough and weaved through the rotator cuff.  The ends of the suture were tied down from the fixating the rotator cuff within the trough.  The rotator cuff was then further oversewed using the Panalok suture.  The wound was then copiously irrigated and it was then suction dried.  The deltoid muscle was reapproximated using #1 Vicryl.  A continuous infusion pump catheter was placed into the subacromial space to help with postoperative pain control.  The subcutaneous tissues were reapproximated with #2-0 Vicryl.  The skin was closed with #4-0 PDS running subcuticular stitch.  Sterile dressing was applied to the upper extremity.  She was then placed in a shoulder immobilizer.  She was transferred to the recovery room in apparent stable and satisfactory condition.  Prognosis for this patient was guarded.  She will begin pendulum exercises postoperative day #3.  She will follow back in the office in 10 to 14 days for reevaluation.  Physical therapy initiated approximately six weeks postoperatively.","surgery, subacromial decompression, panalok suture, repair of rotator cuff, torn rotator cuff, diagnostic arthroscopy, subacromial space, subacromial spur, arthroscopy, panalok, shoulder, subacromial,"
" Her cervix on admission was not ripe, so she was given a dose of Cytotec 25 mcg intravaginally and in the afternoon, she was having frequent contractions and fetal heart tracing was reassuring.  At a later time, Pitocin was started.", Surgery, Delivery Note - 8 ,"DELIVERY NOTE: , The patient is a very pleasant 22-year-old primigravida with prenatal care with both Dr. X and myself and her pregnancy has been uncomplicated except for the fact that she does live a significant distance away from the hospital.  The patient was admitted to labor and delivery on Tuesday, December 22, 2008 at 5:30 in the morning at 40 weeks and 1 day gestation for elective induction of labor since she lives a significant distance away from the hospital.  Her cervix on admission was not ripe, so she was given a dose of Cytotec 25 mcg intravaginally and in the afternoon, she was having frequent contractions and fetal heart tracing was reassuring.  At a later time, Pitocin was started.  The next day at about 9 o'clock in the morning, I checked her cervix and performed artifical rupture of membranes, which did reveal Meconium-stained amniotic fluid and so an intrauterine pressure catheter was placed and then MDL infusion started.  The patient did have labor epidural, which worked well.  It should be noted that the patient's recent vaginal culture for group B strep did come back negative for group B strep.  The patient went on to have a normal spontaneous vaginal delivery of a live-term male newborn with Apgar scores of 7 and 9 at 1 and 5 minutes respectively and a newborn weight of 7 pounds and 1.5 ounces at birth.  The intensive care nursery staff was present because of the presence of Meconium-stained amniotic fluid.  DeLee suctioning was performed at the perineum.  A second-degree midline episiotomy was repaired in layers in the usual fashion using 3-0 Vicryl.  The placenta was simply delivered and examined and found to be complete and bimanual vaginal exam was performed and revealed that the uterus was firm.,ESTIMATED BLOOD LOSS: , Approximately 300 mL.","surgery, amniotic fluid, contractions, pitocin, meconium, cervix, labor, vaginal, delivery, intravaginallyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Her pregnancy is complicated by preterm contractions.  She was on bedrest since her 34th week.  She was admitted here and labor was confirmed with rupture of membranes., Surgery, Delivery Note - 6 ,"DELIVERY NOTE: , This is an 18-year-old, G2, P0 at 35-4/7th weeks by a stated EDC of 01/21/09.  The patient is a patient of Dr. X's.  Her pregnancy is complicated by preterm contractions.  She was on bedrest since her 34th week.  She also has a history of tobacco abuse with asthma.  She was admitted here and labor was confirmed with rupture of membranes.  She was initially 5, 70%, -1.  Her bag was ruptured, IUPC was placed.  She received an epidural for pain control and Pitocin augmentation was performed.  She progressed for several hours to complete and to push, then pushed for approximately 15 minutes to deliver a vigorous female infant from OA presentation.  Delivery of the head was manual assisted.  The shoulders and the rest of body then followed without difficulty.  Baby was bulb suctioned, had a vigorous cry.  Cord was clamped twice and cut and the infant was handed to the awaiting nursing team.  Placenta then delivered spontaneously and intact, was noted to have a three-vessel cord.  The inspection of the perineum revealed it to be intact.  There was a hymenal remnant/skin tag that was protruding from the vaginal introitus.  I discussed this with the patient.  She opted to have it removed.  This was performed and I put a single interrupted suture 3-0 Vicryl for hemostasis.  Further inspection revealed bilateral superficial labial lacerations that were hemostatic and required no repair.  Overall EBL is 300 mL.  Mom and baby are currently doing well.  Cord gases are being sent due to prematurity.,","surgery, preterm, rupture of membranes, preterm contractions, contractions, pregnancy, deliveryNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Pitocin was started quickly to allow for delivery as quickly as possible.  Baby was delivered with a single maternal pushing effort with retraction by the forceps., Surgery, Delivery Note - 2 ,"Pitocin was started quickly to allow for delivery as quickly as possible and the patient rapidly became complete, and then as she began to push, there were additional decelerations of the baby's heart rate, which were suspicions of cord around the neck.  These were variable decelerations occurring late in the contraction phase.  The baby was in a +2 at a 3 station in an occiput anterior position, and so a low-forceps delivery was performed with Tucker forceps using gentle traction, and the baby was delivered with a single maternal pushing effort with retraction by the forceps.  The baby was a little bit depressed at birth because of the cord around the neck, and the cord had to be cut before the baby was delivered because of the tension, but she responded quickly to stimulus and was given an Apgar of 8 at 1 minute and 9 at 5 minutes.  The female infant seemed to weigh about 7.5 pounds, but has not been officially weighed yet.  Cord gases were sent and the placenta was sent to Pathology.  The cervix, the placenta, and the rectum all seemed to be intact.  The second-degree episiotomy was repaired with 2-O and 3-0 Vicryl.  Blood loss was about 400 mL.,Because of the hole in the dura, plan is to keep the patient horizontal through the day and a Foley catheter is left in place.  She is continuing to be attended to by the anesthesiologist who will manage the epidural catheter.  The baby's father was present for the delivery, as was one of the patient's sisters.  All are relieved and pleased with the good outcome.","surgery, labor, delivery, pitocin, tucker forceps, apnea, cerebrospinal fluid, contraction, epidural, episiotomy, fetal heart tones, baby was delivered, baby's heart rate, heart rate, catheter, placenta, cordNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Artificial rupture of membrane was performed for clear fluid.  She did receive epidural anesthesia.  She progressed to complete and pushing., Surgery, Delivery Note - 5 ,"DELIVERY NOTE: , This is a 30-year-old G7, P5 female at 39-4/7th weeks who presents to Labor and Delivery for induction for history of large babies and living far away.  She was admitted and started on Pitocin.  Her cervix is 3 cm, 50% effaced and -2 station.  Artificial rupture of membrane was performed for clear fluid.  She did receive epidural anesthesia.  She progressed to complete and pushing.  She pushed to approximately one contraction and delivered a live-born female infant at 1524 hours.  Apgars were 8 at 1 minute and 9 at 5 minutes.  Placenta was delivered intact with three-vessel cord.  The cervix was visualized.  No lacerations were noted.  Perineum remained intact.  Estimated blood loss is 300 mL.  Complications were none.  Mother and baby remained in the birthing room in good condition.","surgery, perineum, placenta, rupture of membrane, artificial rupture, cervix, delivery, inductionNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 The patient had ultrasound done on admission that showed gestational age of 38-2/7 weeks.  The patient progressed to a normal spontaneous vaginal delivery over an intact perineum., Surgery, Delivery Note - 10 ,"DELIVERY NOTE:  ,This is a 30-year-old G6, P5-0-0-5 with unknown LMP and no prenatal care, who came in complaining of contractions and active labor.  The patient had ultrasound done on admission that showed gestational age of 38-2/7 weeks.  The patient progressed to a normal spontaneous vaginal delivery over an intact perineum.  Rupture of membranes occurred on 12/25/08 at 2008 hours via artificial rupture of membranes.  No meconium was noted.  Infant was delivered on 12/25/08 at 2154 hours.  Two doses of ampicillin was given prior to rupture of membranes.  GBS status unknown.  Intrapartum events, no prenatal care.  The patient had epidural for anesthesia.  No observed abnormalities were noted on initial newborn exam.  Apgar scores were 9 and 9 at one and five minutes respectively.  There was a nuchal cord x1, nonreducible, which was cut with two clamps and scissors prior to delivery of body of child.  Placenta was delivered spontaneously and was normal and intact.  There was a three-vessel cord.  Baby was bulb suctioned and then sent to newborn nursery.  Mother and baby were in stable condition.  EBL was approximately 500 mL, NSVD with postpartum hemorrhage.  No active bleeding was noted upon deliverance of the placenta.  Dr. X attended the delivery with second year resident, Dr. X. Upon deliverance of the placenta, the uterus was massaged and there was good tone.  Pitocin was started following deliverance of the placenta.  Baby delivered vertex from OA position.  Mother following delivery had a temperature of 100.7, denied any specific complaints and was stable following delivery.","surgery, spontaneous vaginal delivery, rupture of membranes, gestational age, vaginal delivery, intact perineum, prenatal care, gestational, placentaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" The patient presented to Labor and Delivery with complaints of spontaneous rupture of membranes.   She was found to be positive for Nitrazine pull and fern.  At that time, she was not actually contracting.", Surgery, Delivery Note - 7 ,"DELIVERY NOTE:,  The patient is a 29-year-old gravida 6, para 2-1-2-3, who has had an estimated date of delivery at 01/05/2009.  The patient presented to Labor and Delivery with complaints of spontaneous rupture of membranes at 2000 hours on 12/26/2008.  She was found to be positive for Nitrazine pull and fern.  At that time, she was not actually contracting.  She was Group B Streptococcus positive, however, was 5 cm dilated.  The patient was started on Group B Streptococcus prophylaxis with ampicillin.  She received a total of three doses throughout her labor.  Her pregnancy was complicated by scanty prenatal care.  She would frequently miss visits.  At 37 weeks, she claims that she had a suspicious bump on her left labia.  There was apparently no fluid or blistering of the lesion.  Therefore, it was not cultured by the provider; however, the patient was sent for serum HSV antibody levels, which she tested positive for both HSV1 and HSV2.  I performed a bright light exam and found no lesions anywhere on the vulva or in the vault as per sterile speculum exam and consulted with Dr. X, who agreed that since the patient seems to have no active lesion that she likely has had a primary outbreak in the past and it is safe to proceed with the vaginal delivery.  The patient requested an epidural anesthetic, which she received with very good relief.  She had IV Pitocin augmentation of labor and became completely dilated per my just routine exam just after 6 o'clock and was set up for delivery and the patient pushed very effectively for about one and a half contractions.  She delivered a viable female infant on 12/27/2008 at 0626 hours delivering over an intact perineum.  The baby delivered in the occiput anterior position.  The baby was delivered to the mother's abdomen where she was warm, dry, and stimulated.  The umbilical cord was doubly clamped and then cut.  The baby's Apgars were 8 and 9.  The placenta was delivered spontaneously intact.  There was a three-vessel cord with normal insertion.  The fundus was massaged to firm and Pitocin was administered through the IV per unit protocol.  The perineum was inspected and was found to be fully intact.  Estimated blood loss was approximately 400 mL.  The patient's blood type is A+.  She is rubella immune and as previously mentioned, GBS positive and she received three doses of ampicillin.","surgery, nitrazine pull and fern, rupture of membranes, spontaneous, membranes, nitrazine, streptococcus, pitocin, perineum, hsv, laborNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Delivery was via spontaneous vaginal delivery.  Nuchal cord x1 were tight and reduced.  Infant was DeLee suctioned at perineum. , Surgery, Delivery Note - 3 ,"DELIVERY NOTE: , On 12/23/08 at 0235 hours, a 23-year-old G1, P0, white female, GBS negative, under epidural anesthesia, delivered a viable female infant with Apgar scores of 7 and 9.  Points taken of for muscle tone and skin color.  Weight and length are unknown at this time.  Delivery was via spontaneous vaginal delivery.  Nuchal cord x1 were tight and reduced.  Infant was DeLee suctioned at perineum.  Cord clamped and cut and infant handed to the awaiting nurse in attendance.  Cord blood sent for analysis, intact.  Meconium stained placenta with three-vessel cord was delivered spontaneously at 0243 hours.  A 15 units of Pitocin was started after delivery of the placenta.  Uterus, cervix, and vagina were explored and a mediolateral episiotomy was repaired with a 3-0 Vicryl in a normal fashion.  Estimated blood loss was approximately 400 mL.  The patient was taken to the recovery room in stable condition.  Infant was taken to Newborn Nursery in stable condition.  The patient tolerated the procedure well.  The only intrapartum event that occurred was thick meconium.  Otherwise, there were no other complications.  The patient tolerated the procedure well.","surgery, nuchal cord, spontaneous, nuchal, delee, delivered, meconium, placenta, vaginal, perineum, delivery, infantNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Spontaneous controlled sterile vaginal delivery performed without episiotomy., Surgery, Delivery Note - 1 ,"The patient presented in the early morning hours of February 12, 2007, with contractions.  The patient was found to be in false versus early labor and managed as an outpatient.  The patient returned to labor and delivery approximately 12 hours later with regular painful contractions.  There was minimal cervical dilation, but 80% effacement by nurse examination.  The patient was admitted.  Expected management was utilized initially.  Stadol was used for analgesia.  Examination did not reveal vulvar lesions.  Epidural was administered.  Membranes ruptured spontaneously.  Cervical dilation progressed.  Acceleration-deceleration complexes were seen.  Overall, fetal heart tones remained reassuring during the progress of labor.  The patient was allowed to ""labor down"" during second stage.  Early decelerations were seen as well as acceleration-deceleration complexes.  Overall, fetal heart tones were reassuring.  Good maternal pushing effort produced progressive descent.,Spontaneous controlled sterile vaginal delivery was performed without episiotomy and accomplished without difficulty.  Fetal arm was wrapped at the level of the neck with the fetal hand and also at the level of the neck.  There was no loop or coil of cord.  Infant was vigorous female sex.  Oropharynx was aggressively aspirated.  Cord blood was obtained.  Placenta delivered spontaneously.,Following delivery, uterus was explored without findings of significant tissue.  Examination of the cervix did not reveal lacerations.  Upper vaginal lacerations were not seen.  Multiple first-degree lacerations were present.  Specific locations included the vestibula at 5 o'clock, left labia minora with short extension up the left sulcus, right anterior labia minora at the vestibule, and midline of the vestibule.  All mucosal lacerations were reapproximated with interrupted simple sutures of 4-0 Vicryl with the knots being buried.  Post-approximation examination of the rectum showed smooth, intact mucosa.  Blood loss with the delivery was 400 mL.,Plans for postpartum care include routine postpartum orders.  Nursing personnel will be notified of Gilbert's syndrome.","surgery, delivery, gilbert's syndrome, membranes, cervical dilation, contractions, labia minora, labor, labor and delivery, trimester, uterus, vaginal delivery, vaginal lacerations, vulvar, fetal heart tones, fetal heart, heart tones, postpartum, vaginal, fetal, lacerationsNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Incision and drainage with extensive debridement, left shoulder.  Removal total shoulder arthroplasty (uncemented humeral Biomet component; cemented glenoid component).  Implantation of antibiotic beads, left shoulder.", Surgery, Debridement - Shoulder ,"TITLE OF OPERATION:  ,1.  Incision and drainage with extensive debridement, left shoulder.,2.  Removal total shoulder arthroplasty (uncemented humeral Biomet component; cemented glenoid component).,3.  Implantation of antibiotic beads, left shoulder.,INDICATION FOR SURGERY: , The patient was seen multiple times preoperatively and found to have findings consistent with a chronic and indolent infections.  Risks and benefits have been discussed with him and his family at length including but not exclusive of continued infection, nerve or artery damage, stiffness, loss of range of motion, incomplete relief of pain, incomplete return of function, fractures, loss of bone, medical complications, surgical complications, transfusion related complications, etc.  The patient understood and wished to proceed.,PREOP DIAGNOSIS: , Presumed infection, left total shoulder arthroplasty.,POSTOP DIAGNOSES:  ,1.  Deep extensive infection, left total shoulder arthroplasty.,2.  Biceps tenosynovitis.,3.  Massive rotator cuff tear in left shoulder (full thickness subscapularis tendon rupture 3 cm x 4 cm; supraspinatus tendon rupture 3 cm x 3 cm; infraspinatus tear 2 cm x 2 cm).,DESCRIPTION OF PROCEDURE:  ,The patient was anesthetized in the supine position, a Foley catheter was placed in his bladder.  He was then placed Beach chair position and all bony prominences were well padded.  Pillows were placed around his knees to protect his sciatic nerve.  He was brought to the side of the table and secured with towels and tape.  The head was placed in neutral position with no lateral bending or extension to protect the brachioplexus from any stretch.  Left upper extremity was then prepped and draped in usual sterile fashion.  Unfortunately, preoperative antibiotics were given prior to the procedure.  This occurred due to lack of communication between the surgical staff and the anesthesia staff.  The patient's extremity, however, was prepped a second time with a chlorhexidine prep after he had been draped.  Also, Ioban bandages were placed securely to the skin to prevent any further introduction of infection into his shoulder.,Deltopectoral incision was then made.  The patient's had a cephalic vein, it was identified and protected throughout the case.  It was retracted laterally and once this has been completed, the deltopectoral interval was developed as carefully as possible.  The patient did have significant scar from this point on and did bleed from many surfaces throughout the case.  As a result, he was transfused 1 unit postoperatively.  He did not have any problems during the case except for one small drop of blood pressure.  However this was due primarily because of the extensive scarring of his proximal humerus.  He had scar between the anterior capsular structures and the conjoint tendon.  Also there was significant scar between the deltoid and the proximal humerus.  The deltoid was very carefully and tediously removed from the proximal humerus in order not to damage the axillary nerve.  Once the plane between the deltoid and underlying tissue was found, the proximal humerus was discovered to have a large defect, approximately 4 x 3.  This was covered by rimmed fibrous tissue which was fairly compressible, which felt to be purulent, however, when the needle was stuck into this area, there was no return of fluid.  As a result, this was finally opened and found to have fibrinous exudates which appeared to be old congealed, purulent material.  There was some suggestion of a synovitis type reaction also inside this cystic area.  This was all debrided but was found to track all the way into the proximal humerus from the lateral femoral component and also tracked posteriorly through and around the posterior cortex of the proximal humerus indicating that the infraspinatus probably had some tearing and detachment.  This later proved to be the case and infraspinatus did indeed have a tear 2 cm x 2 cm.  All of the mucinous material and fibrinous material was removed from the proximal humerus.  This was fairly extensive debridement.  All of this was sent to pathology and also sent for culture and sensitivity.  It should be noted that Gram stain became as multiple white blood cells but no organism seen.  The pathology came back as fibrinous material with multiple white cells, also with signs of chronic inflammation consistent with an infection.,Attention was then directed towards the anterior structures to gain access to the joint so that we could dislocate the prosthesis and remove it.  There was also cystic area in the anterior aspect of the shoulder which was fairly fibrinous.  This was also removed.  Once this was removed, though the capsule was found to be very thin, there was essentially no subscapularis tendon whatsoever.  It should also noted the patient's proximal humerus was subluxed superiorly so that there was no supraspinatus tendon present whatsoever.  As a result, the biceps tendon was finally identified just below the pectoralis tendon insertion.  The upper 1 or 2 cm of the pectoralis insertion was released in order to find the biceps.  It was tracked proximally and transverse ligament released.  The biceps tendon was flat and somewhat erythematous.  As a result, it released and tagged with an 0 Vicryl suture.  It was later tenodesed to the conjoint tendon using 2-0 Prolene sutures.  The joint was then entered and noted significant synovitis throughout the entire glenoid.  This was all very carefully removed using a rongeur and sharp dissection.,Next, the humeral component was removed and this was done by attempting to remove it with the slap hammer and device which comes with the Biomet set.  Unfortunately, this device would not hold the proximal humerus and we could not get the component to release.  As a result, bone contact of the metal proximally was released using a straight osteotome.  Once this was completed, another attempt was made to remove the prosthesis but this only resulted in fracture of the proximal humerus through the areas of erosion of the infection and once this has been completed, we abandoned use of that particular device and using a __________ , we were able to hit the prosthesis lip from beneath and essentially remove it.  There was no cement.  There was exudate within the canal which was removed using a curette.,Using fluoroscopy, sequential reamers were placed to a size of 11 distally down the shaft to remove the exudate.  This was also thoroughly irrigated with irrigation antibiotic, and impregnated irrigation to decrease any risk of infection.  It should be noted that the reaming was done fluoroscopically to make sure that there was no penetration of the canal at any point.,The attention was then directed to the glenoid.  The glenoid component was very carefully dissected free and found to be very loose.  It was essentially removed with digital dissection.  There was no remaining cement in the cavity itself.  The patient's glenoid was very carefully debrided.  The glenoid itself was found to be very cup shaped with significant amount of bone loss in the central portion of the canal itself.  This was debrided using rongeurs and curette until there was no purulent exudate present anywhere in the glenoid itself.,Next, the entire wound was irrigated thoroughly with 9 liters of antibiotic impregnated irrigation.  Rather than place a spacer, it was elected to use antiobiotic beads.  This was with antibiotic impregnated cement with one package with 3 gram of vancomycin.  These beads were then connected using Prolene and placed into the glenoid cavity itself, also some were placed in the greater tuberosity region.  These three did not have a Prolene attached to them.  The ones placed down the canal did have a Prolene used as did the ones placed in the cavity of the glenoid itself.,The biceps tendon was then tenodesed under tension to the conjoint tendon.  There was essentially no capsule left purely to close over the proximal humerus.  It was electively the proximal humerus.  A portion of bone intact because it did have some bleeding surfaces.  Deltopectoral was then closed with 0-Vicryl sutures, the deep subcutaneous tissues with 0-Vicryl sutures, superficial subcutaneous tissues with 2-0 Vicryl sutures.  Skin was closed with staples.  A sterile bandage was applied along with a cold therapy device and shoulder immobilizer.  The patient was sent to recovery room in stable and satisfactory condition.,It should be noted that __________ is being requested for this case.  This was a significantly scarred patient which required extra dissection and attention.  Even though this was a standard revision case due to infection, there was a significant more decision making and technical challenges in this case and this was present for typical revision case.  Similarly, this case took approximately 30 to 40% more length of time due to bleeding and the attention to hemostasis.  The blood loss and operative findings indicates that this case was at least 30 to 40% more challenging than a standard total shoulder or revision case.  This is being dictated for insurance purposes only and reflects no inherent difficulties with the case whatsoever.","surgery, incision and drainage, shoulder arthroplasty, extensive debridement, uncemented humeral, biomet, cemented, antibiotic beads, biceps tenosynovitis, rotator cuff tear, total shoulder arthroplasty, proximal humerus, vicryl sutures, glenoid, tendon, proximal, humerus, beads, shoulder, incision,"
" Delayed open reduction internal fixation with plates and screws, 6-hole contoured distal fibular plate and screws reducing posterolateral malleolar fragment as well as medial malleolar fragment.", Surgery, Delayed ORIF ,"PREOPERATIVE DIAGNOSES:,1.  Right ankle trimalleolar fracture.,2.  Right distal tibia plafond fracture with comminuted posterolateral impacted fragment.,OPERATIVE PROCEDURE:  ,Delayed open reduction internal fixation with plates and screws, 6-hole contoured distal fibular plate and screws reducing posterolateral malleolar fragment, as well as medial malleolar fragment.,POSTOPERATIVE DIAGNOSES:,1.  Right ankle trimalleolar fracture.,2.  Right distal tibia plafond fracture with comminuted posterolateral impacted fragment.,TOURNIQUET TIME: , 80 minutes.,HISTORY: , This 50-year-old gentleman was from the area and riding his motorcycle in Kentucky.,The patient lost control of his motorcycle when he was traveling approximately 40 mile per hour.  He was on a curve and lost control.  He is unsure what exactly happened, but he thinks his right ankle was pinned underneath the motorcycle while he was sliding.  There were no other injuries.  He was treated in Kentucky.  A close reduction was performed and splint applied.  Orthopedic surgeon called myself with regards to this patient's fracture management and suggested a CT scan.  The patient returned to Ohio and his friend drove him all the way from Kentucky to Northwest Ohio overnight.  The patient showed up in the emergency department where a CT scan was asked to be performed.  This was performed and reviewed.  The patient, however, had significant amount of soft tissue swelling and therefore he was asked to follow up in 2 days.  At this time, he still had significant swelling, but because of the amount of swelling that he had particularly with the long car ride for many hours with his leg dependent, it was felt to be best to wait.,Indeed after 7 days, the patient started to develop fracture blisters on the posterior medial aspect of his ankle with large blisters measuring approximately 2 to 3 inches.  The patient was x-rayed in the office.  He had lost some of his reduction.  Therefore, he was re-reduced at approximately 7 days and then each time the patient had examination of tissues, he was re-reduced just to keep the pressure off the skin.,An x-ray showed the distal fibular fracture starting at the mortise region laterally.  It appeared as an abduction type injury with minimal rotation.  This was comminuted, fragmented, and impacted.,The medial malleolus fracture was an avulsion type.  The syndesmosis appeared to be intact.  This appeared as an AO type B fracture.  However, this was not a rotational injury.,There is a posterior malleolar fragment attached to the distal fibular fragment, which appeared to be avulsed as well, but comminuted.  CT scan revealed a more serious fracture with an anterior as well as posterior plafond fracture of an anterior fragment, which was undisplaced in the posterior medial corner.  A posterior Tillaux fragment appeared to be separate.  However, in this area, there was significant comminution in the mid portion of the ankle joint.,There were many fragments and defects in this region.,The medial mortise however appeared to be intact with regards to the tibial plafond even though there was an anterior undisplaced fragment.,We discussed delayed open reduction internal fixation with the patient.  He understood the risk of surgery including infection, decreased range of motion, stiffness, neurovascular injury, weakness, and numbness.  We discussed seriously the risk of osteoarthritis because of the comminution in the intraarticular surface shown on the CT scan.  We discussed deep vein thrombosis, pulmonary embolism, skin slough, skin necrosis, infection, and need for second surgery.  We discussed shortening, decreased strength, limited use, disability of operative extremity, malunion, nonunion, compartment syndrome, stiffness of the operative extremity, numbness, and weakness.  Examination of the patient revealed that he had slightly decreased sensation on the dorsum of his foot.,The patient was able to flex and extend his toes, had good capillary refill, good dorsalis pedis, and posterior tibial pulse.,The patient's tissues were edematous and we has waited approximately 10 days before performing the surgery when the skin could be wrinkled anteriorly.  We discussed his incision, the medial incision as well as lateral incision and the lateral incision would be more posterolateral to maintain a bridge of at least 6 to 8 cm between the 2 incisions.  We did discuss the skin slough as well as skin necrosis, particularly medially where the most skin pressure was because of displacement laterally.  He understood the posterolateral comminution of the tibial plafond, which would be reduced by aligning up the cortex posteriorly.,We discussed the posterolateral approach with reduction of the fibula.  We discussed that likely the distal fibula would not be removed completely to assess the articular surface as this would likely comminute the fibula, even more fragmentation would occur, and would not be able to obtain an anatomic reduction.  He understood this distal fibular fracture was comminuted and there were missing fragments of bone because they were impacted into intramedullary cancellous space.  With this, the patient understood that the hardware may necessitate removal as well in the future.  We discussed hardware irritation.  We also discussed risk of osteoarthritis, which was nearly 100% particularly because of comminution of this area posteriorly.  With these risks discussed and listed on the consent, the patient wanted the procedure.,OPERATIVE NOTE:,  The patient was brought to operating theater and given successful general anesthetic.  His right leg was prepped and draped in the usual fashion.  Before prep and drape was performed, a close reduction was tried to be obtained to see whether there was any obstruction to reduction.  It was felt that at one point the posterior tibialis tendon may be intraarticular.,The reduction appeared to line up.  However, there was significant gap of approximately 1.5 to 2 cm between the avulsed medial malleolus fragment and distal tibia.,A lateral incision was made over the fracture site approximately 8 cm long and was taken to subcutaneous tissue.  The superficial peroneal nerve was seen and this was avoided.  The incision was placed posterolateral to fibula.,This was to ensure good flap of tissue between the 2 incisions medial and laterally.  The fracture was seen.  The fracture was elevated and medialized and de-rotated.  The anterior portion of the distal fibula was significantly comminuted with defect.  The posterior aspect was still intact.  However, there were multiple fracture lines demonstrating a crush-type injury.  This was reduced manually.  At this point, dissection was performed bluntly behind the peroneal tendons in between this and flexor hallucis longus tendon.  No sharp dissection was performed.  The posterior malleolar fragment was palpated with the distal fibula reduced.  The posterior malleolar fragment appeared to be reduced as well.,X-ray views confirmed this.,An incision was made, standard incision, curvilinear, medially distal to the medial corner of the mortise and curving anterior and posteriorly around the tip of the medial malleolus.  This was taken only through subcutaneous tissue.  The saphenous vein was found, dissected out.  Its branches were cauterized.  Penrose drain was placed around this.,Dissection was undertaken.  The periosteal tissue was seen and was invaginated into the joint.,This was recovered and flipped back on both sides.  Next, the towel clip was used.  Ends were freshened up using irrigation.  The joint surface appeared to be congruent anteriorly and posteriorly medially.,Anatomic reduction was performed in the medial malleolus using 2 mm K-wires and exchanging these for a 35 mm and a 40 mm, anterior and posterior respectively, partially threaded cancellous screws.  Anatomic reduction was gained.  X-rays were taken showing excellent anatomic reduction.  Next, attention was drawn towards the fibula.  Standard 6-hole one-third tubular plate was applied to this.  Again, this was more of a transverse impacted fracture.  Therefore, interfragmentary screw on an angle could not be used.,The posterior cortex was used to assess anatomic reduction.  Screws were placed.  It was used as a spring plate pushing the distal fibular fragment medially.,Screw holes were filled.  They were double-checked.  Screws had excellent purchase and were tightened up.  At this point, lateral views were taken as well as palpation of posterior lateral fragment was performed in the plafond.  This appeared to show anatomic reduction and did not appear to be a step on the articular surface or the posterior cortex of the distal tibia.,The screw was then placed from anterior medial to posterior lateral into this comminuted fragment.,A 2 mm K-wire was used.  Finger was placed on this fragment and the pin was advanced even before the finger.  X-ray views could show the posterior cortex and location of the pin.  This was then exchanged for a 55 mm partially threaded cancellous screw after tapping was performed.  This was double checked to ensure good positioning and this was so.  On the lateral view, we could see this was not in the joint.  AP views and mortise views showed this was not in the joint.  One could palpate this as well.  The screw was placed slightly proximal to distal in the anteroposterior plane.  At the distal tip of it, it was just in the subchondral bone but not in the joint.  There was slight to excellent purchase of this posterior lateral fragment.  Wounds were copiously irrigated followed by closing using 2-0 Vicryl in inverted fashion followed by staples to skin.  Adaptic, 4 x 4s, abdominal pad was placed on wound, held in place with Kerlix followed by an extensor bandage.  Posterior splint was placed on the patient.  The patient's leg was placed in neutral position.  Significant amount of cast padding were used and large bulky trauma ABD type dressings.  The heel was padded and leg was padded with approximately 2 inches of padding.  Tourniquet was deflated.  The patient had good capillary refill, good pulses, and the patient returned to recovery room in stable condition with no complications.  Physician assistant assisted during the case with retracting as well as holding the medial malleolar fragment and fragments in position while placement screws were applied.  Positioning of the leg was accomplished by the physician assistant.  As well, physician assistant assisted in transport of patient to and from the recovery room, assisted in cautery as well as dissection and retraction of tissue.  The patient is expected to do well overall.  He does have an area of comminution shown on the CT scan.  However, by x-rays, it appears that there is anatomic reduction gained at this posterolateral fragment.  Nonetheless, this area was crushed and the patient will have degenerative changes in the future caused by this crushing area.",
 She progressed in labor throughout the day.  Finally getting the complete and began pushing.  Pushed for about an hour and a half when she was starting to crown., Surgery, Delivery Note - 4 ,"DELIVERY NOTE: , The patient came in around 0330 hours in the morning on this date 12/30/08 in early labor and from a closed cervix very posterior yesterday; she was 3 cm dilated.  Membranes ruptured this morning by me with some meconium.  An IUPC was placed.  Some Pitocin was started because the contractions were very weak.  She progressed in labor throughout the day.  Finally getting the complete at around 1530 hours and began pushing.  Pushed for about an hour and a half when she was starting to crown.  The Foley was already removed at some point during the pushing.  The epidural was turned down by the anesthesiologist because she was totally numb.  She pushed well and brought the head drown crowning, at which time I arrived and setting her up delivery with prepping and draping.  She pushed well delivering the head and DeLee suctioning was carried out on the perineum because of the meconium even though good amount of amnioinfusion throughout the day was completed.  With delivery of the head, I could see the perineum tear and after delivery of the baby and doubly clamping of the cord having baby off to RT in attendance.  Exam revealed a good second-degree tear ascended a little bit up higher in the vagina and a little off to the right side but rectum sphincter were intact, although I cannot see good fascia around the sphincter anteriorly.  The placenta separated with some bleeding seen and was assisted expressed and completely intact.  Uterus firmed up well with IV pit.  Repair of the tear with 2-0 Vicryl stitches and a 3-0 Vicryl in a subcuticular like area just above the rectum and the perineum was performed using a little local anesthesia to top up with the epidural.  Once this was complete, mom and baby doing well.  Baby was a female infant.  Apgars 8 and 9.","surgery, iupc, meconium, pitocin, epidural, rectum, sphincter, labor, perineum, pushed, deliveryNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Debridement of left lateral foot ulcer with excision of infected and infarcted interosseous space muscle tendons and fat.  Sharp excision of left distal foot plantar fascia., Surgery, Debridement - Foot Ulcer ,"PREOPERATIVE DIAGNOSES,1.  Left lateral fifth ray amputation site cellulitis with infected left fourth metatarsophalangeal joint.,2.  Osteomyelitis of left distal fifth metatarsal bone at left proximal fourth toe phalanx.,3.  Plantar fascitis of left distal lateral foot.,POSTOPERATIVE DIAGNOSES,1.  Left lateral fifth ray amputation site cellulitis with infected left fourth metatarsophalangeal joint.,2.  Osteomyelitis of left distal fifth metatarsal bone at left proximal fourth toe phalanx.,3.  Plantar fascitis of left distal lateral foot.,OPERATION PERFORMED,1.  Debridement of left lateral foot ulcer with excision of infected and infarcted interosseous space muscle tendons and fat.,2.  Sharp excision of left distal foot plantar fascia.,ANESTHESIA:,  None required.,INDICATIONS:,  The patient is a 51-year-old diabetic female with severe peripheral vascular disease, who has had angioplasties and single perineal artery runoff to the left leg who developed gangrene of her left fifth toe requiring left fifth ray amputation.  She has developed cellulitis of the lateral foot with osteomyelitis and now requires debridement of the local fascitis and necrotic tissue to evaluate for current infectious status and prepare for future amputation.,PROCEDURE IN DETAIL:,  The procedure was performed in the patient's room.  The dressing was removed exposing about a 4 cm x 2.5 cm left distal lateral foot fifth ray amputation open wound.  Distally, there is infarcted left fourth metatarsophalangeal joint capsule, as well as plantar fat below the joint.,She has neuropathy allowing debridement of the tissues.,Using sharp scissors and forceps all the necrotic fat and joint capsule area was easily debrided.  There was complete infarction of the lateral joint capsule and the head of the phalanx, as well as distal metatarsal head were chronically infected.,The wound was packed with 4x4 gauze pads and dry gauze pads were placed between the toes followed by Kerlix roll pad.,The patient suffered no complications from the procedure.","surgery, plantar fascia, foot ulcer, interosseous, metatarsal, cellulitis, amputation, osteomyelitis, plantar fascitis, joint capsule, ray amputation, debridement, plantar, foot"
 Delivery is a normal spontaneous vaginal delivery of an intrauterine fetal demise.  Fetal position is right occiput anterior., Surgery, Delivery Note ,"HISTORY: , This patient with prenatal care in my office who did have some preterm labor and was treated with nifedipine and was stable on nifedipine and bed rest; unfortunately, felt decreased fetal movement yesterday, 12/29/08, presented to the hospital for evaluation on the evening of 12/29/08.  At approximately 2030 hours and on admission, no cardiac activity was noted by my on-call partner, Dr. X.  This was confirmed by Dr. Y with ultrasound and the patient was admitted with a diagnosis of intrauterine fetal demise at 36 weeks' gestation.,SUMMARY:,  She was admitted.  She was 3 cm dilated on admission.  She desired induction of labor.  Therefore, Pitocin was started.  Epidural was placed for labor pain.  She did have a temperature of 100.7 and antibiotics were ordered including gentamicin and clindamycin secondary to penicillin allergy.  She remained febrile, approximately 100.3.  She then progressed.  On my initial exam at approximately 0730 hours, she was 3 to 4 cm dilated.  She had reported previously some mucous discharge with no ruptured membranes.  Upon my exam, no membranes were noted.  Attempted artificial rupture of membranes was performed.  No fluid noted and there was no fluid discharge noted all the way until the time of delivery.  Intrauterine pressure catheter was placed at that time to document there are adequate pressures on contraction secondary to induction of labor.  She progressed well and completely dilated, pushed approximately three times, and proceeded with delivery.,DELIVERY NOTE:,  Delivery is a normal spontaneous vaginal delivery of an intrauterine fetal demise.  Fetal position is right occiput anterior.,COMPLICATIONS: , Again, intrauterine fetal demise.  Placenta delivery spontaneous.  Condition was intact with a three-vessel cord.  Lacerations; she had a small right periurethral laceration as well as a small second-degree midline laceration.  These were both repaired postdelivery with 4-0 Vicryl on an SH and a 3-0 Vicryl on a CT-1 respectively.  Estimated blood loss was 200 mL.,Infant is a male infant, appears grossly morphologically normal.  Apgars were 0 and 0.  Weight pending at this time.,NARRATIVE OF DELIVERY:,  I was called.  This patient was completely dilated.  I arrived.  She pushed for three contractions.  She was very comfortable.  She delivered the fetal vertex in the right occiput anterior position followed by the remainder of the infant.  There was a tight nuchal cord x1 that was reduced after delivery of the fetus.  Cord was doubly clamped.  The infant was transferred to a bassinet cleaned by the nursing staff en route.  The placenta delivered spontaneously, was carefully examined, found to be intact.  No signs of abruption.  No signs of abnormal placentation or abnormal cord insertion.  The cord was examined and a three-vessel cord was confirmed.  At this time, IV Pitocin and bimanual massage.  Fundus firm as above with minimal postpartum bleeding.  The vagina and perineum were carefully inspected.  A small right periurethral laceration was noted, was repaired with a 4-0 Vicryl on an SH needle followed by a small second-degree midline laceration, was repaired in a normal running fashion with a 3-0 Vicryl suture.  At this time, the repair is intact.  She is hemostatic.  All instruments and sponges were removed from the vagina and the procedure was ended.,Father of the baby has seen the baby at this time and the mother is waiting to hold the baby at this time.  We have called pastor in to baptize the baby as well as calling social work.  They are deciding on a burial versus cremation, have decided against autopsy at this time.  She will be transferred to postpartum for her recovery.  She will be continued on antibiotics secondary to fever to eliminate endometritis and hopefully will be discharged home tomorrow morning.,All of the care and findings were discussed in detail with Christine and Bryan and at this time obviously they are very upset and grieving, but grieving appropriately and understanding the findings and the fact that there is not always a known cause for a term fetal demise.  I have discussed with her that we will do some blood workup postdelivery for infectious disease profile and clotting disorders.","surgery, decreased fetal movement, labor pain, preterm labor, delivery note, vaginal delivery, fetal position, fetal demise, intrauterine, delivery, spontaneous, dilated, lacerations, cord, fetal "
" Decompressive laminectomy at T12 with bilateral facetectomies, decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes ClickX System.", Surgery, Decompressive Laminectomy ,"PREOPERATIVE DIAGNOSIS: , T12 compression fracture with cauda equina syndrome and spinal cord compression.,POSTOPERATIVE DIAGNOSIS:,  T12 compression fracture with cauda equina syndrome and spinal cord compression.,OPERATION PERFORMED: , Decompressive laminectomy at T12 with bilateral facetectomies, decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes Click'X System using 6.5 mm diameter x 40 mm length T11 screws and L1 screws, 7 mm diameter x 45 mm length.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:,  400 mL, replaced 2 units of packed cells.,Preoperative hemoglobin was less than 10.,DRAINS:,  None.,COMPLICATIONS:,  None.,DESCRIPTION OF PROCEDURE: , With the patient prepped and draped in a routine fashion in the prone position on laminae support, an x-ray was taken and demonstrated a needle at the T12-L1 interspace.  An incision was made over the posterior spinous process of T10, T11, T12, L1, and L2.  A Weitlaner retractor was placed and cutting Bovie current was used to incise the fascia overlying the dorsal spinous process of T10, T11, T12, L1, and L2.  An additional muscular ligamentous attachment was dissected free bilaterally with cutting Bovie current osteotome and Cobb elevator.  The cerebellar retractors were placed in the wound and obvious deformation of the lamina particularly on the left side at T12 was apparent.  Initially, on the patient's left side, pedicle screws were placed in T11 and L1.  The inferior articular facet was removed at T11 and an awl placed at the proximal location of the pedicle.  Placement confirmed with biplanar coaxial fluoroscopy.  The awl was in appropriate location and using a pedicle finder under fluoroscopic control, the pedicle was probed to the mid portion of the body of T11.  A 40-mm Click'X screw, 6.5 mm diameter with rod holder was then threaded into the T11 vertebral body.,Attention was next turned to the L1 level on the left side and the junction of the transverse processes with the superior articular facet and intra-articular process was located using an AM-8 dissecting tool, AM attachment to the Midas Rex instrumentation.  The area was decorticated, an awl was placed, and under fluoroscopic biplanar imaging noted to be at the pedicle in L1.  Using a pedicle probe, the pedicle was then probed to the mid body of L1 and a 7-mm diameter 45-mm in length Click'X Synthes screw with rod holder was placed in the L1 vertebral body.,At this point, an elongated rod was placed on the left side for purposes of distraction should it be felt necessary in view of the MRI findings of significant compression on the patient's ventral canal on the right side.  Attention was next turned to the right side and it should be noted that the dissection above was carried out with operating room microscope and at this point, the intraspinous process ligament superior to the posterior spinous process at T12 was noted be completely disrupted on a traumatic basis.  The anteroposterior spinous process ligament superior to the T12 was incised with cutting Bovie current and the posterior spinous process at T12 removed with a Leksell rongeur.  It was necessary to remove portion of the posterior spinous process at T11 for a full visualization of the involved laminar fractures at T12.,At this point, a laminectomy was performed using 45-degree Kerrison rongeur, both 2 mm and 4 mm, and Leksell rongeur.  There was an epidural hematoma encountered to the midline and left side at the mid portion of the T12 laminectomy and this was extending superiorly to the T11-T12 interlaminar space.  Additionally, there was marked instability of the facets bilaterally at T12 and L1.  These facets were removed with 45-degree Kerrison rongeur and Leksell rongeur.  Bony compression both superiorly and laterally from fractured bony elements was removed with 45-degree Kerrison rongeur until the thecal sac was completely decompressed.  The exiting nerve roots at T11 and T12 were visualized and followed with Frazier dissectors, and these nerve roots were noted to be completely free.  Hemostasis was controlled with bipolar coagulation.,At this point, a Frazier dissector could be passed superiorly, inferiorly, medially, and laterally to the T11-T12 nerve roots bilaterally, and the thecal sac was noted to be decompressed both superiorly and inferiorly, and noted to be quite pulsatile.  A #4 Penfield was then used to probe the floor of the spinal canal, and no significant ventral compression remained on the thecal sac.  Copious antibiotic irrigation was used and at this point on the patient's right side, pedicle screws were placed at T11 and L1 using the technique described for a left-sided pedicle screw placement.  The anatomic landmarks being the transverse process at T11, the inferior articulating facet, and the lateral aspect of the superior articular facet for T11 and at L1, the transverse process, the junction of the intra-articular process and the facet joint.,With the screws placed on the left side, the elongated rod was removed from the patient's right side along with the locking caps, which had been placed.  It was felt that distraction was not necessary.  A 75-mm rod could be placed on the patient's left side with reattachment of the locking screw heads with the rod cap locker in place; however, it was necessary to cut a longer rod for the patient's right side with the screws slightly greater distance apart ultimately settling on a 90-mm rod.  The locking caps were placed on the right side and after all 4 locking caps were placed, the locking cap screws were tied to the cold weld.  Fluoroscopic examination demonstrated no evidence of asymmetry at the intervertebral space at T11-T12 or T12-L1 with excellent positioning of the rods and screws.  A crosslink approximately 60 mm in width was then placed between the right and left rods, and all 4 screws were tightened.,It should be noted that prior to the placement of the rods, the patient's autologous bone, which had been removed during laminectomy portion of the procedure and cleansed off soft tissue and morcellated was packed in the posterolateral space after decortication had been effected on the transverse processes at T11, T12, and L1 with AM-8 dissecting tool, AM attachment as well as the lateral aspects of the facet joints.  This was done bilaterally prior to placement of the rods.,Following placement of the rods as noted above, allograft bone chips were packed in addition on top of the patient's own allograft in these posterolateral gutters.  Gelfoam was used to cover the thecal sac and at this point, the wound was closed by approximating the deep muscle with 0 Vicryl suture.  The fascia was closed with interrupted 0 Vicryl suture, subcutaneous layer was closed with 2-0 Vicryl suture, subcuticular layer was closed with 2-0 inverted interrupted Vicryl suture, and the skin approximated with staples.  The patient appeared to tolerate the procedure well without complications.","surgery, facetectomies, decompression, posterolateral fusion, synthes click'x system, decompressive laminectomy, leksell rongeur, kerrison rongeur, transverse processes, thecal sac, nerve roots, pedicle screws, spinous process, pedicle, process, screws, rods, laminectomy, decompressive, spinous, "
 Debridement of the necrotic tissue of the left lower abdomen as well as the left peritoneal area.  Pannus and left peritoneal specimen sent to Pathology., Surgery, Debridement Necrotic Tissue ,"PREOPERATIVE DIAGNOSIS: , Necrotizing infection of the left lower abdomen and left peritoneal area.,POSTOPERATIVE DIAGNOSIS:,  Necrotizing infection of the left lower abdomen and left peritoneal area.,PROCEDURE PERFORMED:,  Debridement of the necrotic tissue of the left lower abdomen as well as the left peritoneal area.,ANESTHESIA:,  General.,FLUIDS:,  800 cc given.,ESTIMATED BLOOD LOSS:  ,350 cc.,SPECIMEN,:  Pannus and left peritoneal specimen sent to Pathology.,REASON FOR PROCEDURE:,  This is a 53-year-old white male who presented to ABCD General Hospital on 09/05/03 with a chief complaint of drainage from his left groin.  The patient is a diabetic who requires insulin, but has been noncompliant and states that his blood sugars have been out of control.  He has had a groin abdominal wound drained for about four days.  The patient states that there has been pus that has saturated his sheath.  He has had a possible fever at home that he did not chart with a thermometer.  He has had the same groin infection twice in the past with tunneling lesions.  The patient states that his wife noted there was a round scar on his abdomen and that was black and had crept up in the last day.  Bowel habits and eating were essentially normal.,Urinary habits were normal.  The patient is morbidly obese and is approximately 450 lb.  He has not been following a diabetic diet or using insulin secondary to lack of funds to put his medications.,PAST MEDICAL HISTORY:,  Diabetes, morbid obesity, and nephrolithiasis.,PAST SURGICAL HISTORY:,  Appendectomy and stone extraction.,PROCEDURE: , The patient was examined in the Emergency Room by Dr. X and was found to have multiple areas of erythematous tissue, which could potentially be consistent with a necrotizing fascitis texture.  The patient had a white count of 11.4 and a hemoglobin of 13.4.  Please note that the patient is a Jehovah's Witness and has adamantly refused receiving any blood products.  The risks and benefits of such were discussed with the patient at length prior to surgery and he was permitted to make sure not to receive blood and his wishes will be granted.  In the operative suite, he was prepped and draped in the usual sterile fashion.  The patient was placed in a lithotomy position to visualize the peritoneum as well as the abdomen.  Copious amounts of Betadine solution were used to cleanse the area and the wound was visualized.  Approximately, 10 cm x 5 cm elliptical incision was made on the lower left quadrant of the abdomen surrounding the area of necrosis.  Necrotic tissue comprised approximately 2 cm x 2 cm area and was indurated.  The abdomen appeared to have a large erythematous border, however, the true indurated tissue was approximately the size of a deck of cards.  The area was incised using a #10 blade scalpel and then Bovie cauterization was used to achieve good hemostasis.  The tissue was removed using an Allis forceps as well as a Bovie to double the incision down to the fascia.  The necrotic tissue was lifted out of the abdomen.  All bleeding was cauterized using the Bovie.  A solution of gentamicin and sterile saline was placed into a high-powered water pump device and the wound was copiously irrigated and suctioned.  A wet Kerlix dressing was passed into the wound and it will be left opened with wet-to-dry dressing.  The left groin area was also incised using an elliptical incision that was approximately 13 cm x 6 cm.  The tissue was incised to the muscle layer of the muscle.  There was a pus pocket that was visible with capsule as well and there was an area of the necrotic tissue as well.  There was a mild amount of pus that drained from the wound.  Cultures were taken from the groin wound and were sent to pathology.  The specimen was excised using traction with the Allis clamps as well as Bovie set on coag.  Once the tissue was excised from the ________, the area was fully irrigated using the gentamicin sterile saline solution in the high-powered water irrigation unit.  After the irrigation, the wound was packed using a wet Kerlix dressing and will be left open to heal.,It was determined at this time that both wounds will be left open to heal with the wet-to-dry dressings in place and we will come back and close the wounds at a later date.  The skin excised from the left lower abdominal quadrant as well as the left groin was sent to pathology.  The patient tolerated the procedure well and was taken to recovery in good condition.","surgery, debridement, abdomen, peritoneal, pannus, pathology, necrotizing infection, necrotic tissue, tissue, infection, necrotizing, groin, wound, "
" DDDR permanent pacemaker, insertion of a steroid-eluting screw in right atrial lead, insertion of a steroid-eluting screw in right ventricular apical lead, pulse generator insertion, model Sigma,", Surgery, DDDR Permanent Pacemaker ,"PROCEDURES PERFORMED:,1.  DDDR permanent pacemaker.,2.  Insertion of a steroid-eluting screw in right atrial lead.,3.  Insertion of a steroid-eluting screw in right ventricular apical lead.,4.  Pulse generator insertion, model Sigma.,SITE: , Left subclavian vein access.,INDICATION: , The patient is a 73-year-old African-American female with symptomatic bradycardia and chronotropic incompetence with recurrent heart failure and symptoms of hypoperfusion, and for a Class 2a indication for a permanent pacemaker was ascertained.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , Minimal.,Risks, benefits, and alternatives of the procedure were all explained in detail to the patient and the patient's family at length.  They all consented for the procedure, and the consent was signed and placed on the chart.,PROCEDURE: , The patient was taken to cardiac cath lab where she was monitored throughout all procedure.  The area of the left pectoral deltoid and subclavian area was sterilely prepped and draped in the usual manner.  We also scrubbed for approximately eight minutes.  Using lidocaine with epinephrine, the area of the left pectoral deltoid region and subclavian area was then fully anesthetized.  Using an #18 gauge Cook needle, the left subclavian vein was cannulated at two separate sites without difficulty, where two separate guidewires were inserted into the left subclavian vein.  The Cook needles were removed.  Then the guidewires were secured in place with hemostat.  Using a #10 and #15 scalpel blade, a 5 cm horizontal incision was made in the left pectodeltoid groove, where the skin was dissected and blunted on to the pectoralis major muscle.  The skin was then undermined making a pocket for the generator.  The guidewires were then tunneled through the performed pocket.  Subsequently, the atrial and ventricular leads were inserted through each one of the Cordis separately and respectively.  Initially, the ventricular lead was inserted, where a Cordis sheath was placed and the guidewire was removed.  After the thresholds and appropriate position was obtained for the ventricular lead, the Cordis sheath was then inserted for the atrial lead.  After the atrial lead was inserted and appropriately placed and thresholds were obtained, the Cordis was removed and then both leads were sutured in place with pectoralis major muscle with #1-0 silk suture.  The leads were then connected to a pulse generator.  The pocket was then irrigated and cleansed, where then the leads and the generators were inserted into that pocket.  The subcutaneous tissue was then closed with gut sutures and the skin was then closed with #4-0 polychrome sutures using a subcuticular uninterrupted technique.  The area was then cleansed and dry.  Steri-Strips and pressure dressing were applied.  The patient tolerated the procedure well.  There were no complications.,Information on the pacemaker:,The implanted device are as follows:,PULSE GENERATOR,Model Name:  Sigma.,Model #:  SDR203.,Serial #:  123456.,ATRIAL LEAD,Model #:  4568-45 cm.,Serial #:  123456.,RIGHT VENTRICULAR APICAL STEROID-eluting SCREW IN LEAD:,Model #:  4068-52 cm.,Serial #:  123456.,STIMULATION THRESHOLDS ARE AS FOLLOWS:,The right atrial chamber polarity is bipolar, pulse width is 0.50 milliseconds, 1.5 volts of voltage, 3.7 milliamps of current, 557 ohms of impedance, and P-wave sensing of 3.3 millivolts.,The right ventricular polarity is bipolar, pulse width is 0.50 milliseconds, 0.7 volts of voltage, 1.4 milliamps of current, impedance of 700 ohms, and R-wave sensing of 14 millivolts.,The brady parameter settings were set as follows:,The atrial and ventricular appendages were set at 3.5 volts with 0.4 milliseconds of pulse width, atrial sensitivity of 0.5 with 180 milliseconds of blanking.  Ventricular sensitivity was set at 2.8 with 28 milliseconds of blanking.  The pacing mode was DDDR, mode switch was on lower rate of 70 and upper rate of 130.,The patient tolerated the procedure well.  There were no complications.  The patient went to Recovery in satisfactory condition.  Family was updated.  Orders are all in the chart.  Please see orders.,Again, thank you for allowing to participate in this care.",
" Dilation and curettage (D&C), laparoscopy, right salpingectomy, lysis of adhesions, and evacuation of hemoperitoneum.  Pelvic pain, ectopic pregnancy, and hemoperitoneum.", Surgery," D&C, Laparoscopy, & Salpingectomy ","PREOPERATIVE DIAGNOSES:,1.  Pelvic pain.,2.  Ectopic pregnancy.,POSTOPERATIVE DIAGNOSES:,1.  Pelvic pain.,2.  Ectopic pregnancy.,3.  Hemoperitoneum.,PROCEDURES PERFORMED:,1.  Dilation and curettage (D&C).,2.  Laparoscopy.,3.  Right salpingectomy.,4.  Lysis of adhesions.,5.  Evacuation of hemoperitoneum.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , Scant from the operation, however, there was approximately 2 liters of clotted and old blood in the abdomen.,SPECIMENS:,  Endometrial curettings and right fallopian tube.,COMPLICATIONS: , None.,FINDINGS: , On bimanual exam, the patient has a small anteverted uterus, it is freely mobile.  No adnexal masses, however, were appreciated on the bimanual exam.  Laparoscopically, the patient had numerous omental adhesions to the vesicouterine peritoneum in the fundus of the uterus.  There were also adhesions to the left fallopian tube and the right fallopian tube.  There was a copious amount of blood in the abdomen approximately 2 liters of clotted and unclotted blood.  There was some questionable gestational tissue ________ on the left sacrospinous ligament.  There was an apparent rupture and bleeding ectopic pregnancy in the isthmus portion of the right fallopian tube.,PROCEDURE:,  After an informed consent was obtained, the patient was taken to the operating room and the general anesthetic was administered.  She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion.  Once the anesthetic was found to be adequate, a bimanual exam was performed under anesthetic.  A weighted speculum was then placed in the vagina.  The interior wall of vagina elevated with the uterine sound and the anterior lip of the cervix was grasped with the vulsellum tenaculum.  The cervix was then serially dilated with Hank dilators to a size #20 Hank and then a sharp curettage was performed obtaining a moderate amount of decidual appearing tissue and the tissue was then sent to pathology.  At this point, the uterine manipulator was placed in the cervix and attached to the anterior cervix and vulsellum tenaculum and weighted speculum were removed.  Next, attention was then turned to the abdomen.  The surgeons all are removed the dirty gloves in the previous portion of the case.  Next, a 2 cm incision was made immediately inferior to umbilicus.  The superior aspect of the umbilicus was grasped with a towel clamp and a Veress needle was inserted through this incision.  Next, a syringe was used to inject normal saline into the Veress needle.  The normal saline was seen to drop freely, so a Veress needle was connected to the CO2 gas which was started at its lowest setting.  The gas was seen to flow freely with normal resistance, so the CO2 gas was advanced to a higher setting.  The abdomen was insufflated to an adequate distension.  Once an adequate distention was reached, the CO2 gas was disconnected.  The Veress needle was removed and a size #11 step trocar was placed.  The introducer was removed and the trocar was connected to the CO2 gas and a camera was inserted.  Next, a 1 cm incision was made in the midline approximately two fingerbreadths below the pubic symphysis after transilluminating with the camera.  A Veress needle and a step sheath were inserted through this incision.  Next, the Veress needle was removed and a size #5 trocar was inserted under direct visualization.  Next a size #5 port was placed approximately five fingerbreadths to the left of the umbilicus in a similar fashion.  A size #12 port was placed in a similar fashion approximately six fingerbreadths to the right of the umbilicus and also under direct visualization.  The laparoscopic dissector was inserted through the suprapubic port and this was used to dissect the omental adhesions bluntly from the vesicouterine peritoneum and the bilateral fallopian tubes.  Next, the Dorsey suction irrigator was used to copiously irrigate the abdomen.  Approximate total of 3 liters of irrigation was used and the majority of all blood clots and free blood was removed from the abdomen.,Once the majority of blood was cleaned from the abdomen, the ectopic pregnancy was easily identified and the end of the fallopian tube was grasped with the grasper from the left upper quadrant and the LigaSure device was then inserted through the right upper quadrant with # 12 port.  Three bites with the LigaSure device were used to transect the mesosalpinx inferior to the fallopian tube and then transect the fallopian tube proximal to the ectopic pregnancy.  An EndoCatch bag was then placed to the size #12 port and this was used to remove the right fallopian tube and ectopic pregnancy.  This was then sent to the pathology.  Next, the right mesosalpinx and remains of the fallopian tube were examined again and they were seemed to be hemostatic.  The abdomen was further irrigated.  The liver was examined and appeared to be within normal limits.  At this point, the two size #5 ports and a size #12 port were removed under direct visualization.  The camera was then removed.  The CO2 gas was disconnected and the abdomen was desufflated.  The introducer was then replaced in a size #11 port and the whole port and introducer was removed as a single unit.  All laparoscopic incisions were closed with a #4-0 undyed Vicryl in a subcuticular interrupted fashion.  They were then steri-stripped and bandaged appropriately.  At the end of the procedure, the uterine manipulator was removed from the cervix and the patient was taken to Recovery in stable condition.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2.  She was discharged home with a postoperative hemoglobin of 8.9.  She was given iron 325 mg to be taken twice a day for five months and Darvocet-N 100 mg to be taken every four to six hours for pain.  She will follow up within a week in the OB resident clinic.","surgery, pelvic pain, ectopic pregnancy, hemoperitoneum, d&c, dilation, laparoscopy, curettage, salpingectomy, lysis of adhesions, bimanual exam, veress needle, fallopian tube, umbilicus, cervix, ectopic, pregnancy, abdomen, tube, "
" Debridement of wound, fasciotomies, debridement of muscle from the anterior compartment, and application of vacuum-assisted closure systems to fasciotomy wounds, as well as traumatic wound.", Surgery, Debridements ,"PREOPERATIVE DIAGNOSIS:,  Status post polytrauma of left lower extremity status post motorcycle accident with an open wound of the left ankle.,POSTOPERATIVE DIAGNOSIS:,  Status post polytrauma left lower extremity status post motorcycle accident with an open wound of the left ankle with elevated compartment pressure for the lateral as well as the medial compartments with necrotic muscle of the anterior compartment.,PROCEDURE: , Debridement of wound, fasciotomies, debridement of muscle from the anterior compartment, and application of vacuum-assisted closure systems to fasciotomy wounds, as well as traumatic wound.,ANESTHESIA: , General.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE: , The patient in the supine position under adequate general endotracheal anesthesia, the patient's left lower extremity was prepped with Hibiclens and alcohol in the usual fashion with sterile towels and drapes so as to create a sterile field.  The patient's traumatic wound was gently debrided and lavaged with a Pulsavac given the appearance of the patient's leg (there was some blistering of the skin).  The compartment pressures of the patient's four compartments were measured, for the anterior and lateral compartments the measurement was 32, for the posterior compartment superficial and deep, it was 34.  With this information, we proceeded with fasciotomy medially decompressing the superficial as well as the deep posterior compartments.  Muscle in these compartments was contractile.  Anterolateral incision was then made and carried down through the fascia anterolaterally with opening of the fascia on the anterior as well as the lateral compartment.  The lateral compartment appeared contractile.  The anterior compartment appeared necrotic for most of the muscle in the compartments.  What appeared viable was left intact.  A vacuum-assisted closure system was utilized on each fasciotomy wound.  Given the nature of the patient's foot, we proceeded with a fasciotomy of the patient's foot medially and good contractile muscle was found there.  This was included in the VAC seal, as well as the traumatic wound.  A good seal was obtained to through the fasciotomy wounds and traumatic wound, and the patient was placed in a posterior plaster splint, well padded.  He tolerated the procedure well, was taken to the recovery room in good condition.","surgery, left lower extremity, debridement of wound, fasciotomies, debridement of muscle, vacuum-assisted closure systems, status post motorcycle accident, vacuum assisted closure systems, vacuum assisted closure, assisted closure systems, wound fasciotomies, fasciotomies debridement, vacuum assisted, closure systems, lower extremity, lateral compartments, anterior compartment, fasciotomy wounds, traumatic wound, wound, anterior, polytrauma, motorcycle, accident, contractile, vacuum, debridements, traumatic, muscle, fasciotomy, compartment"
 Complex right lower quadrant mass with possible ectopic pregnancy.  Right ruptured tubal pregnancy and pelvic adhesions. Dilatation and curettage and laparoscopy with removal of tubal pregnancy and right partial salpingectomy., Surgery, D&C & Tubal Pregnancy Removal ,"PREOPERATIVE DIAGNOSIS: , Complex right lower quadrant mass with possible ectopic pregnancy.,POSTOPERATIVE DIAGNOSES:,1.  Right ruptured tubal pregnancy.,2.  Pelvic adhesions.,PROCEDURE PERFORMED:,1.  Dilatation and curettage.,2.  Laparoscopy with removal of tubal pregnancy and right partial salpingectomy.,ANESTHESIA:  ,General.,ESTIMATED BLOOD LOSS:  ,Less than 100 cc.,COMPLICATIONS: , None.,INDICATIONS: , The patient is a 25-year-old African-American female, gravida 7, para-1-0-5-1 with two prior spontaneous abortions with three terminations who presents with pelvic pain.  She does have a slowly increasing beta HCG starting at 500 to 849 and the max to 900.  Ultrasound showed a complex right lower quadrant mass with free fluid in the pelvis.  It was decided to perform a laparoscopy for the possibility of an ectopic pregnancy.,FINDINGS: , On bimanual exam, the uterus was approximately 10 weeks' in size, mobile, and anteverted.  There were no adnexal masses appreciated although there was some fullness in the right lower quadrant.  The cervical os appeared parous.,Laparoscopic findings revealed a right ectopic pregnancy, which was just distal to the right fallopian tube and attached to the fimbria as well as adherent to the right ovary.  There were some pelvic adhesions in the right abdominal wall as well.  The left fallopian tube and ovary and uterus appeared normal.  There was no evidence of endometriosis.  There was a small amount of blood in the posterior cul-de-sac.,PROCEDURE IN DETAIL: , After informed consent was obtained in layman's terms, the patient was taken back to the operating suite, prepped and draped, placed under general anesthesia, and placed in the dorsal lithotomy position.  The bimanual exam was performed, which revealed the above findings.  A weighted speculum was placed in the patient's posterior vaginal vault and the 12 o' clock position of the cervix was grasped with the vulsellum tenaculum.  The cervix was then serially dilated using Hank dilators up to a #10.  A sharp curette was then introduced and curettage was performed obtaining a mild amount of tissue.  The tissue was sent to pathology for evaluation.  The uterine elevator was then placed in the patient's cervix.  Gloves were changed.  The attention was turned to the anterior abdominal wall where a 1 cm infraumbilical skin incision was made.  While tenting up the abdominal wall, the Veress needle was placed without difficulty.  The abdomen was then insufflated with appropriate volume and flow of CO2.  The #11 step trocar was then placed without difficulty in abdominal wall.  The placement was confirmed with a laparoscope.  It was then decided to put a #5 step trocar approximately 2 cm above the pubis symphysis in order to manipulate the pelvic contents.  The above findings were then noted.  Because the tubal pregnancy was adherent to the ovary, an additional port was placed in the right lateral aspect of the patient's abdomen.  A #12 step trocar port was placed under direct visualization.  Using a grasper, Nezhat-Dorsey suction irrigator, the mass was hydro-dissected off of the right ovary and further shelled away with graspers.  This was removed with the gallbladder grasper through the right lateral port site.  There was a small amount of oozing at the distal portion of the fimbria where the mass has been attached.  Partial salpingectomy was therefore performed.  This was done using the LigaSure.  The LigaSure was clamped across the portion of the tube including distal tube and ligated and transected.  Good hemostasis was obtained in all of the right adnexal structures.  The pelvis was then copiously suction irrigated.  The area again was then visualized and again found to be hemostatic.  The instruments were then removed from the patient's abdomen under direct visualization.  The abdomen was then desufflated and the #11 step trocar was removed.  The incisions were then repaired with #4-0 undyed Vicryl and dressed with Steri-Strips.  The uterine elevator was removed from the patient's vagina.,The patient tolerated the procedure well.  The sponge, lap, and needle count were correct x2.  She will follow up postoperatively as an outpatient.","surgery, lower quadrant mass, tubal pregnancy, pelvic adhesions, laparoscopy, salpingectomy, ectopic pregnancy, abdominal wall, pregnancy,"
" Carpal tunnel syndrome and de Quervain's stenosing tenosynovitis.  Carpal tunnel release and de Quervain's release.  A longitudinal incision was made in line with the 4th ray, from Kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease.  The dissection was carried down to the superficial aponeurosis. ", Surgery, de Quervain Release - Carpal ,"PREOPERATIVE DIAGNOSIS,1.  Carpal tunnel syndrome.,2. de Quervain's stenosing tenosynovitis.,POSTOPERATIVE DIAGNOSIS,1.  Carpal tunnel syndrome.,2. de Quervain's stenosing tenosynovitis.,TITLE OF PROCEDURE,1.  Carpal tunnel release.,2. de Quervain's release.,ANESTHESIA: , MAC,COMPLICATIONS: , None.,PROCEDURE IN DETAIL:  ,After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with Esmarch and the tourniquet inflated to 250 mmHg.,A longitudinal incision was made in line with the 4th ray, from Kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease.  The dissection was carried down to the superficial aponeurosis.  The subcutaneous fat was dissected radially from 2-3 mm and the superficial aponeurosis cut on this side to leave a longer ulnar leaf.,The ulnar leaf of the cut superficial aponeurosis was dissected ulnarly, and the distal edge of the transverse carpal ligament was identified with a hemostat.  The hemostat was gently placed under the transverse carpal ligament to protect the contents of the carpal tunnel, and the ligament was cut on its ulnar side with a knife directly onto the hemostat.  The antebrachial fascia was cut proximally under direct vision with scissors.,After irrigating the wound with copious amounts of normal saline, the radial leaf of the cut transverse carpal ligament was repaired to the ulnar leaf of the cut superficial aponeurosis with 4-0 Vicryl.  Care was taken to avoid entrapping the motor branch of the median nerve in the suture.  A hemostat was placed under the repair to ensure that the median nerve was not compressed.  The skin was repaired with 5-0 nylon interrupted stitches.,The first dorsal compartment was addressed through a transverse incision at the level of the radial styloid tip.  Dissection was carried down with care taken to avoid and protect the superficial radial nerve branches.  I released the compartment in a separate subsheath for the EPB on the dorsal side.  Both ends of the sheath were released to lengthen them, and then these were repaired with 4-0 Vicryl.  It was checked to make sure that there was significant room remaining for the tendons.  This was done to prevent postoperative subluxation.,I then irrigated and closed the wounds in layers.  Marcaine with epinephrine was placed into all wounds, and dressings and splint were placed.  The patient was sent to the recovery room in good condition, having tolerated the procedure well.","surgery, de quervain's release, carpal tunnel syndrome, tenosynovitis, carpal, incision, aponeurosis, tunnel, cut,"
 Wrist de Quervain stenosing tenosynovitis.  de Quervain release.  Fascial lengthening flap of the 1st dorsal compartment., Surgery, de Quervain Release - Wrist ,"PREOPERATIVE DIAGNOSIS:,  Wrist de Quervain stenosing tenosynovitis.,POSTOPERATIVE DIAGNOSIS: , Wrist de Quervain stenosing tenosynovitis.,TITLE OF PROCEDURES,1. de Quervain release.,2.  Fascial lengthening flap of the 1st dorsal compartment.,ANESTHESIA:,  MAC.,COMPLICATIONS: , None.,PROCEDURE IN DETAIL: , After MAC anesthesia and appropriate antibiotics were administered, the upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with an Esmarch and the tourniquet inflated to 250 mmHg.,I made a transverse incision just distal to the radial styloid.  Dissection was carried down directly to the 1st dorsal compartment with the superficial radial nerve identified and protected.  Meticulous hemostasis was maintained with bipolar electrocautery.,I dissected the sheath superficially free of any other structures, specifically the superficial radial nerve.  I then incised it under direct vision dorsal to its axis and incised it both proximally and distally.  The EPB subsheath was likewise released.,I irrigated the wound thoroughly.  In order to prevent tendon subluxation, I then back-cut both the dorsal and volar leafs of the sheath so that I could close them in an extended and lengthened position.  I did this with 3-0 Vicryl.  I then passed an instrument underneath to check and make sure that the sheath was not too tight.  I then irrigated it and closed the skin, and then I dressed and splinted the wrist appropriately.  The patient was sent to the recovery room in good condition, having tolerated the procedure well.","surgery, de quervain, tenosynovitis, de quervain release, fascial lengthening flap, dorsal compartment, sheath, wrist, dorsal, tourniquet,"
" Dilation and curettage (D&C), laparoscopy, enterolysis, lysis of the pelvic adhesions, and left salpingo-oophorectomy.  Complex left ovarian cyst, bilateral complex adnexae, bilateral hydrosalpinx, chronic pelvic inflammatory disease, and massive pelvic adhesions.", Surgery, D&C & Laparoscopy - 2 ,"PREOPERATIVE DIAGNOSIS: , Incidental right adnexal mass on ultrasound.,POSTOPERATIVE DIAGNOSES:,1.  Complex left ovarian cyst.,2.  Bilateral complex adnexae.,3.  Bilateral hydrosalpinx.,4.  Chronic pelvic inflammatory disease.,5.  Massive pelvic adhesions.,PROCEDURE PERFORMED:,1.  Dilation and curettage (D&C).,2.  Laparoscopy.,3.  Enterolysis.,4.  Lysis of the pelvic adhesions.,5.  Left salpingo-oophorectomy.,ANESTHESIA:  ,General.,COMPLICATIONS: , None.,SPECIMENS: , Endometrial curettings and left ovarian mass.,ESTIMATED BLOOD LOSS: , Less than 100 cc.,DRAINS:,  None.,FINDINGS: , On bimanual exam, the patient has a slightly enlarged, anteverted, freely mobile uterus with an enlarged left adnexa.  Laparoscopically, the patient has massive pelvic adhesions with completely obliterated posterior cul-de-sac and adnexa.,No adnexal structures were initially able to be visualized until after the lysis of adhesions.  Eventually we found a normal appearing right ovary, severely scarred right and left fallopian tubes, and a enlarged complex cystic left ovary.  There was a normal-appearing appendix and liver, and the vesicouterine junction appeared within normal limits.  There were significant adhesions from the small bowel to the bilateral adnexa in the posterior surface of the uterus.,PROCEDURE:  ,The patient was taken to the operating room where a general anesthetic was administered.  She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion.  Once the anesthetic was found to be adequate, a bimanual exam was performed under anesthetic.  Next, a weighted speculum was placed in the vagina and anterior wall of the vagina was elevated with the uterine sound and the anterior lip of the cervix was grasped with a vulsellum tenaculum.  The uterus was then sounded to 12 cm.  The cervix was then serially dilated with Hank dilators to a size #20 Hank.  Next a Telfa pad was placed on the weighted speculum and a short curettage was performed obtaining a large amount of endometrial tissue.  Next, the uterine manipulator was placed in the cervix and attached to the anterior lip of the cervix.  At this point, the vulsellum tenaculum and weighted speculum were removed.  Next, attention was turned to the abdomen where an approximately 2 cm incision was made immediately inferior to the umbilicus.  The superior aspect of the umbilicus was grasped with a towel clamp and Veress needle was inserted through this incision.  Small amount of normal saline was injected into Veress needle and seemed to drop freely.  So, the Veress needle was connected to he CO2 gas, which was started at the lower setting.  It was seen to flow freely with a normal resistance so the gas was advanced to the higher setting.  The abdomen was then insufflated to an adequate distention.  Next, the Veress needle was removed and a size #11 step trocar was inserted.  Next, the introducer was removed from the trocar and the laparoscope was inserted through this port and the port was also connected to the CO2 gas.  At this point, the initial operative findings were seen.  Next, a size #5 step trocar was inserted approximately two fingerbreadths above the pubic symphysis in the midline.  This was done by making a 1 cm incision with the skin knife, introducing a Veress needle with Ethicon sheet, and the Veress needle was then removed and the #5 port was introduced under direct visualization.  A size #5 port was also placed approximately six fingerbreadths to the right of the umbilicus in a similar manner also under direct visualization.  A blunt probe was inserted suprapubically along with a grasper in the right upper quadrant.  These were used to see the above operative findings.  Next, a size #12 mm port was introduced approximately seven fingerbreadths to the left of the umbilicus under direct visualization.  Through this, a Harmonic scalpel was inserted.,The Harmonic scalpel along with the grasper was used to meticulously address the adhesions along the right adnexa in the posterior cul-de-sac.  Care was taken at all times to avoid the bowel and the ureters.  The fallopian tubes appeared massively scarred and completely obliterated from disease.  After the right adnexa had been freed to the point where we could visualize the ovary and the posterior cul-de-sac was clearing off then we could visualize the uterosacral ligaments.  Attention was turned to the left adnexa, which appeared to contain a cystic structure, but it was unclear at the beginning of the procedure what the structure was.  Adhesions were carefully taken down from the bowel to the left fallopian tube and ovary, and sidewall.  The adhesions were then carefully removed from the inferior aspect of the ovary also with the Harmonic scalpel.  At intermittent points throughout the procedure, the suction irrigator was used to irrigate and suck blood and irrigation out of the pelvis to watch for any bleeding.  At this point, the Harmonic scalpel was removed and another laparoscopic needle with a 60 cc syringe was inserted and this was used to aspirate approximately 30 cc of serosanguineous fluid from the cystic structure.  Next, the needle was removed and the ligature device was inserted.  This was used to clamp across the fallopian tube initially and then after the fallopian tube was ligated, the uterovarian ligament was clamped and ligated with the ligature device.  Next, the fallopian tube was removed from the ovary with the ligature device in approximately 3 clamping and ligations.  Then, the attention was turned to the inferior aspect of the ovary.  First the infundibulopelvic ligament was identified, clamped with a ligature device, and ligated.  Next, the ovary was bluntly dissected from the ovarian fossa with attention to the left ureter.  Next, the ligature device was used to clamp and ligate the broad ligament immediately inferior to the ovary across.  Then the ovary was completely bluntly dissected out of the ovarian fossa and completely separated from the pelvis.  This was grasped with a clamp.  The ligature device was removed from the #12 and a EndoCatch bag was inserted to the size #12 port.  The left ovary was placed in this EndoCatch bag, which was then removed along with the whole port from the left upper quadrant.  Next, the pelvis was copiously irrigated and suctioned of all blood and extra fluid.  At this point, the remaining two size #5 ports were removed under direct visualization.  The camera was removed and the abdomen was desufflated.  Next, an introducer was replaced on a #11 port.  The #11 port was removed.  Next, the fascia in the left upper quadrant port was identified and grasped with Ochsner clamps, tented up, and closed with a single interrupted suture of #0 Vicryl on a UR-6 needle.  Next, all skin incisions were closed with #4-0 undyed Vicryl in a subcuticular interrupted fashion.  The incisions were cleaned, injected with 0.25% Marcaine, and then adjusted with Steri-Strips and bandage appropriately.,The patient was taken from the operating room in stable condition and should be observed overnight in the hospital.",
" D&C and hysteroscopy.  Abnormal uterine bleeding, enlarged fibroid uterus, hypermenorrhea, intermenstrual spotting, and thickened endometrium per ultrasound of a 2 cm lining.
6.  Grade 1+ rectocele.", Surgery, D&C & Hysteroscopy Followup ,"PREOPERATIVE DIAGNOSES:,1.  Abnormal uterine bleeding.,2.  Enlarged fibroid uterus.,3.  Hypermenorrhea.,4.  Intermenstrual spotting.,5.  Thickened endometrium per ultrasound of a 2 cm lining.,POSTOPERATIVE DIAGNOSES:,1.  Abnormal uterine bleeding.,2.  Enlarged fibroid uterus.,3.  Hypermenorrhea.,4.  Intermenstrual spotting.,5.  Thickened endometrium per ultrasound of a 2 cm lining.,6.  Grade 1+ rectocele.,PROCEDURE PERFORMED:  ,D&C and hysteroscopy.,COMPLICATIONS: , None.,HISTORY: , The patient is a 48-year-old para 2, vaginal delivery.  She has heavy periods lasting 7 to 14 days with spotting in between her periods.  The patient's uterus is 12.2 x 6.2 x 5.3 cm.  Her endometrial thickness is 2 cm.  Her adnexa is within normal limits.  The patient and I had a long discussion.  Consent was reviewed in layman's terms.  The patient understood the foreseeable risks and complications, the alternative treatments and procedure itself and recovery.  Questions were answered.  The patient was taken back to the operative suite.  The patient underwent pelvic examination and then carefully placed in dorsal lithotomy position.  The patient had excellent femoral pulses and there was no excessive extension or hyperflexion of the lower extremities.  The patient's history is that she is at risk for development of condyloma.  The patient's husband was found to have a laryngeal papillomatosis.  She has had a laparotomy, which is an infraumbilical incision appendectomy, a laparoscopy, and bilateral tubal ligation.  Her uterus appears to be mobile by 12-week size.  There is a good descend.  There appears to be no adnexal abnormalities.  Uterus is 12-week sized and has fibroids, it is boggy and probably has a component of adenomyosis.  The patient's cervix was dilated without difficulty utilizing Circon ACMI hysteroscope with a 12-degree lens.  The patient underwent hysteroscopy.  The outflow valve was opened at all times.  The inflow valve was opened just to achieve appropriate distension.  The patient did have no evidence of trauma of the cervix.  No Trendelenburg as we were in room #9.  The patient also had the bag held two fingerbreadths above the level of the heart.  The patient was seen.  There is a 2 x 3 cm focal thickening of the posterior wall of the uterus' endometrial lining, a more of a polypoid nature.  The patient also has one in the fundal area.  The thickened tissue was removed via sharp curettage.  Therefore, we reinserted the hysteroscope.  It appeared that there was an appropriate curettage and that all areas of suspicion were indeed removed.  The patient's procedure was ended with specimen being obtained and sent to Department of Pathology.  We will follow her up in the office.","surgery, pelvic examinatio, abnormal uterine bleeding, enlarged fibroid uterus, hypermenorrhea, intermenstrual spotting, thickened endometrium, intermenstrual, d&c, uterine, bleeding, fibroid, endometrium, hysteroscopy, uterus"
" Dilation and curettage (D&C) and hysteroscopy.  A female presents 7 months status post spontaneous vaginal delivery, has had abnormal uterine bleeding since her delivery with an ultrasound showing a 6 cm x 6 cm fundal mass suspicious either for retained products or endometrial polyp.", Surgery, D&C & Hysteroscopy - 1 ,"PREOPERATIVE DIAGNOSES:,1.  Abnormal uterine bleeding.,2.  Status post spontaneous vaginal delivery.,POSTOPERATIVE DIAGNOSES:,1.  Abnormal uterine bleeding.,2.  Status post spontaneous vaginal delivery.,PROCEDURE PERFORMED:,1.  Dilation and curettage (D&C).,2.  Hysteroscopy.,ANESTHESIA: , IV sedation with paracervical block.,ESTIMATED BLOOD LOSS:,  Less than 10 cc.,INDICATIONS:  ,This is a 17-year-old African-American female that presents 7 months status post spontaneous vaginal delivery without complications at that time.  The patient has had abnormal uterine bleeding since her delivery with an ultrasound showing a 6 cm x 6 cm fundal mass suspicious either for retained products or endometrial polyp.,PROCEDURE:,  The patient was consented and seen in the preoperative suite.  She was taken to the operative suite, placed in a dorsal lithotomy position, and placed under IV sedation.  She was prepped and draped in the normal sterile fashion.  Her bladder was drained with the red Robinson catheter which produced approximately 100 cc of clear yellow urine.  A bimanual exam was done, was performed by Dr. X and Dr. Z.  The uterus was found to be anteverted, mobile, fully involuted to a pre-pregnancy stage.  The cervix and vagina were grossly normal with no obvious masses or deformities.  A weighted speculum was placed in the posterior aspect of the vagina and the anterior lip of the cervix was grasped with the vulsellum tenaculum.,The uterus was sounded to 8 cm.  The cervix was sterilely dilated with Hank dilator and then Hagar dilator.  At the time of blunt dilation, it was noticed that the dilator passed posteriorly with greater ease than it had previously.  The dilation was discontinued at that time because it was complete and the hysteroscope was placed into the uterus.  Under direct visualization, the ostia were within normal limits.  The endometrial lining was hyperplastic, however, there was no evidence of retained products or endometrial polyps.  The hyperplastic tissue did not appear to have calcification or other abnormalities.  There was a small area of the lower uterine segment posteriorly that was suspicious for endometrial perforation, however this area was hemostatic, no evidence of bowel involvement and was approximately 1 x 1 cm in nature.  The hysteroscope was removed and a sharp curette was placed intrauterine very carefully using a anterior wall for guidance.  Endometrial curettings were obtained and the posterior aspect suspicious for perforation was gently probed and seemed to have clamped down since the endometrial curetting.  The endometrial sampling was placed on Telfa pad and sent to Pathology for evaluation.  A rectal exam was performed at the end of the procedure which showed no hematoma formation in the posterior cul-de-sac.  There was a normal consistency of the cervix and the normal step-off.  The uterine curette was removed as well as the vulsellum tenaculum and the weighted speculum.  The cervix was found to be hemostatic.  The patient was taken off the dorsal lithotomy position and recovered from her IV sedation in the recovery room.  The patient will be sent home once stable from anesthesia.  She will be instructed to followup in the office in two weeks for discussion of the pathologic report of the endometrial curettings.  The patient is sent home on Tylenol #3 prescription as she is allergic to Motrin.  The patient is instructed to refrain from intercourse douching or using tampons for the next two weeks.  The patient is also instructed to contact us if she has any problems with further bleeding, fevers, or difficulty with urination.","surgery, dilation and curettage, hysteroscopy, abnormal uterine bleeding, spontaneous vaginal delivery, endometrial curettings, vaginal delivery, uterine bleeding, endometrial, d&c, cervix, vaginal, uterine, delivery,"
" Enlarged fibroid uterus, hypermenorrhea, and secondary anemia.  Dilatation and curettage and hysteroscopy.", Surgery, D&C & Hysteroscopy ,"PREOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Hypermenorrhea.,POSTOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Hypermenorrhea.,3.  Secondary anemia.,PROCEDURE PERFORMED:,1.  Dilatation and curettage.,2.  Hysteroscopy.,GROSS FINDINGS: , Uterus was anteverted, greatly enlarged, irregular and firm.  The cervix is patulous and nulliparous without lesions.  Adnexal examination was negative for masses.,PROCEDURE:  ,The patient was taken to the operating room where she was properly prepped and draped in sterile manner under general anesthesia.  After bimanual examination, the cervix was exposed with a weighted vaginal speculum and the anterior lip of the cervix grasped with a vulsellum tenaculum.  The uterus was sounded to a depth of 11 cm.  The endocervical canal was then progressively dilated with Hanks and Hegar dilators to a #10 Hegar.  The ACMI hysteroscope was then introduced into the uterine cavity using sterile saline solution as a distending media and with attached video camera.  The endometrial cavity was distended with fluids and the cavity visualized.  Multiple irregular areas of fibroid degeneration were noted throughout the cavity.  The coronal areas were visualized bilaterally with corresponding tubal ostia.  A moderate amount of proliferative appearing endometrium was noted.  There were no direct intraluminal lesions seen.  The patient tolerated the procedure well.  Several pictures were taken of the endometrial cavity and the hysteroscope removed from the cavity.,A large sharp curet was then used to obtain a moderate amount of tissue, which was the sent to pathologist for analysis.  The instrument was removed from the vaginal vault.  The patient was sent to recovery area in satisfactory postoperative condition.","surgery, dilatation and curettage, hysteroscopy, anemia, enlarged fibroid uterus, endometrial cavity, hypermenorrhea, fibroid, uterus"
" Cystourethroscopy and tTransurethral resection of prostate (TURP).  Urinary retention and benign prostate hypertrophy.  This is a 62-year-old male with a history of urinary retention and progressive obstructive voiding symptoms and enlarged prostate 60 g on ultrasound, office cystoscopy confirmed this.", Surgery, Cystourethroscopy & TURP - 1 ,"PREOPERATIVE DIAGNOSES:,1.  Urinary retention.,2.  Benign prostate hypertrophy.,POSTOPERATIVE DIAGNOSES:,1.  Urinary retention.,2.  Benign prostate hypertrophy.,PROCEDURES PERFORMED:,1.  Cystourethroscopy.,2.  Transurethral resection of prostate (TURP).,ANESTHESIA:,  Spinal.,RESECTION TIME:,  Less than one hour.,INDICATION FOR PROCEDURE:  ,This is a 62-year-old male with a history of urinary retention and progressive obstructive voiding symptoms and enlarged prostate 60 g on ultrasound, office cystoscopy confirmed this.,PROCEDURE:  PROCEDURE: , Informed written consent was obtained.  The patient was taken to the operative suite, administered spinal anesthetic and placed in dorsal lithotomy position.  She was sterilely prepped and draped in normal fashion.  A #27-French resectoscope was inserted utilizing the visual obturator blanching the bladder.  The bladder was visualized in all quadrants, no bladder tumors or stones were noted.  Ureteral orifices were visualized and did appear to be near the enlarged median lobe.  Prostate showed trilobar prostatic enlargement.  There were some cellules and tuberculations noted.  The visual obturator was removed.  The resectoscope was then inserted utilizing the #26 French resectoscope loop.  Resection was performed initiating at the bladder neck and at the median lobe.,This was taken down to the circular capsular fibers.  Attention was then turned to the left lateral lobe and this was resected from 12 o'clock to 3 o'clock down to the capsular fibers maintaining hemostasis along the way and taking care not to resect beyond the level of the verumontanum.  Ureteral orifices were kept out of harm's way throughout the case.  Resection was then performed from the 3 o'clock position to the 6 o'clock position in similar fashion.  Attention was then turned to the right lateral lobe and this was resected again in a similar fashion maintaining hemostasis along the way.  The resectoscope was then moved to the level of the proximal external sphincter and trimming of the apex was performed.  Open prostatic fossa was noted.  All chips were evacuated via Ellik evacuator and #24 French three-way Foley catheter was inserted and irrigated.  Clear return was noted.  The patient was then hooked up to better irrigation.  The patient was cleaned, reversed for anesthetic, and transferred to recovery room in stable condition.,PLAN:  ,We will admit with antibiotics, pain control, and bladder irrigation possible void trial in the morning.","surgery, urinary retention, transurethral resection of prostate, prostate, enlarged, obstructive voiding symptoms, benign prostate hypertrophy, ureteral orifices, prostate hypertrophy, cystourethroscopy, turp, hypertrophy, resectoscope, urinary, bladder, resection,"
" Enlarged fibroid uterus, infertility, pelvic pain, and probable bilateral tubal occlusion.  Dilatation and curettage and laparoscopy and injection of indigo carmine dye.", Surgery, D&C & Laparoscopy ,"PREOPERATIVE DIAGNOSES:,1.  Hypermenorrhea.,2.  Pelvic pain.,3.  Infertility.,POSTOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Infertility.,3.  Pelvic pain.,4.  Probable bilateral tubal occlusion.,PROCEDURE PERFORMED:,1.  Dilatation and curettage.,2.  Laparoscopy.,3.  Injection of indigo carmine dye.,GROSS FINDINGS: , The uterus was anteverted, firm, enlarged, irregular, and mobile.  The cervix is nulliparous without lesions.  Adnexal examination was negative for masses.,PROCEDURE:  ,The patient was placed in the lithotomy position, properly prepared and draped in sterile manner.  After bimanual examination, the cervix was exposed with a weighted vaginal speculum and the anterior lip of the cervix was grasped with vulsellum tenaculum.  Uterus sounded to a depth of 10.5 cm.  Endocervical canal was progressively dilated with Hanks dilators to #20-French.  A medium-sized sharp curet was used to obtain a moderated amount of tissue upon curettage, which was taken from all uterine quadrants and sent to the pathologist for analysis.  A ________ syringe was then introduced into the uterine cavity to a depth of 9 cm and the balloon insufflated with 10 cc of air.  A 20 cc syringe filled with dilute indigo carmine dye was attached to the end of the ________ syringe to use to inject at the time of laparoscopy.,A small subumbilical incision was then made with insertion of the step dilating sheath with a Veress needle into the peritoneal cavity.  The peritoneal cavity was insufflated with 3 liters of carbondioxide and a 12 mm trocar inserted.  The laparoscope was then inserted through the trocar with visualization of the pelvic contents.  In steep Trendelenburg position, the uterus was visualized and aided by use of a Bierman needle to displace bowel from visualized areas.  The fallopian tubes appeared normal bilaterally with good visualization of a normal appearing fimbria.  The ovaries also appeared normal bilaterally.  The uterus was greatly enlarged and distorted with large fibroids in multiple areas and especially on the right coronal area.  An attempt was made to inject the indigo carmine dye and in fact a three syringes of 20 cc were injected without any visualization of intraperitoneal dye still.  Both fallopian tubes apparently were blocked.  The upper abdomen was visually explored and found to be normal as was the bowel and area of the right ileum.  The patient tolerated the procedure well.  Instruments were removed from the vaginal vault and the abdomen.  Trocar was removed and the carbondioxide allowed to escape and the subumbilical wound repaired with two #4-0 undyed Vicryl sutures.  Sterile dressing was applied to the wound and the patient was sent to the recovery area in satisfactory postoperative condition.","surgery, dilatation and curettage, laparoscopy, pelvic pain, infertility, enlarged fibroid uterus, tubal occlusion, indigo carmine dye, fibroid uterus, uterus infertility, peritoneal cavity, fallopian tubes, indigo carmine, endocervical, uterine, pelvic, curettage, uterus,"
" Dilation and curettage (D&C), laparoscopy, and harmonic scalpel ablation of lesion which is suspicious for endometriosis.  Chronic pelvic pain, hypermenorrhea, desire for future fertility, failed conservative medical therapy, possible adenomyosis, left hydrosalpinx, and suspicion for endometriosis.", Surgery, D&C & Laparoscopy - 1 ,"PREOPERATIVE DIAGNOSES:,1.  Chronic pelvic pain.,2.  Hypermenorrhea.,3.  Desire for future fertility.,4.  Failed conservative medical therapy.,POSTOPERATIVE DIAGNOSES:,1.  Chronic pelvic pain.,2.  Hypermenorrhea.,3.  Desire for future fertility.,4.  Failed conservative medical therapy.,5.  Possible adenomyosis.,6.  Left hydrosalpinx.,7.  Suspicion for endometriosis.,PROCEDURES PERFORMED:,1.  Dilation and curettage (D&C).,2.  Laparoscopy.,3.  Harmonic scalpel ablation of lesion which is suspicious for endometriosis.,ANESTHESIA: , General with endotracheal tube.,ESTIMATED BLOOD LOSS: , Less than 20 cc.,COMPLICATIONS:,  None.,INDICATIONS: , This is a 35-year-old Caucasian female gravida 1, para 0-0-1-0 with a history of spontaneous abortion.  This patient had approximately greater than ten years of chronic pelvic pain with dysmenorrhea which has significantly affected her activities of daily living.  Symptoms have not improved with prescription of oral contraceptives.,The patient has had one prior surgery for a left ovarian cystectomy done by laparoscopy in 1996.  The cyst was not diagnosed as an endometrioma.  The patient does desire future fertility; however, would like a definitive diagnosis.  Conservative medical therapy was offered i.e.  Lupron or repeat oral contraceptives, but declined.,FINDINGS:,  Bimanual exam reveals a small retroverted uterus which is easily mobile.  There were no adnexal masses.  The cervix was normal on palpation.  A fibrotic band was noted at the internal os during dilation.  On laparoscopic exam, the uterus was found to be small with mild spongy texture.  On palpation, the right ovary and adnexa were grossly normal with no evidence of endometriosis.  The left ovary was grossly normal.  The left fallopian tube had a mild hydrosalpinx present.  The left uterosacral ligament had three to four 1 mm to 2 mm lesions that were vesicular in nature consistent with endometriosis.  The vesicouterine reflection in the anterior aspect of the uterus were within normal limits as were the posterior cul-de-sac.  The liver appeared grossly normal.  There were no obvious pelvic adhesions.  The left internal inguinal ring is somewhat patent, however, there is no bowel or viscera protruding through it.,PROCEDURE:  ,The patient was seen in the preop suite.  History was reviewed and all questions were answered.  The patient was then taken to the operative suite where she was placed under general anesthesia with endotracheal tube.  She was placed in a dorsal lithotomy position in Allen stirrups.  She was prepped and draped in the normal sterile fashion.  Her bladder was drained with a red Robinson catheter producing approximately 100 cc of clear yellow urine.  A bimanual exam was performed by Dr. X, Dr. Y, and Dr. Z with above findings noted.  A sterile weighted speculum was placed in posterior aspect of the vagina and the anterior aspect of the cervix was grasped with vulsellum tenaculum.  There was an attempt to place the uterine sound through the external and internal cervical os, however, secondary to a fibrotic band at the internal os that was impossible.  A #9 dilator was allowed to remain in the cervix for minimal manipulation while attention was then turned to the abdomen.  An infraumbilical incision was made using skin scalpel.  The Veress needle was placed and CO2 was insufflated.  It was immediately noticed that the pressures were inconsistent with intraabdominal insufflation and the CO2 was discontinued and Veress needle was completely removed.  A second attempt placement of the Veress needle into the abdomen was successful and CO2 was insufflated approximately 3 liters with minimal intraabdominal pressure.  The #12 port was placed and the laparoscope was inserted.  Attention was then turned back to the uterus and with the assistance of current hemostat to bluntly dissect the fibrotic band of the internal os.,Successful sounding of the uterus showed an 8-cm uterus that was in a retroverted position.  The cervix was serially dilated using Hank dilators to allow for introduction of the sharp curette.  A curettage was then performed and specimen of the endometrium was sent for pathologic evaluation.  This procedure was performed under direct laparoscopic visualization.  Laparoscopic evaluation of the pelvis was performed and the above findings noted.  A second abdominal incision was performed suprapubically using a skin scalpel and the Veress needle was placed through the incision successfully under direct visualization.  A #5 port was then placed through the sheath and the uterine manipulator was used to complete visualization.  The manipulator was then removed and the Harmonic scalpel was placed through the #5 port.  The Harmonic scalpel was used then to ablate the 1 mm vesicular lesions on the left uterosacral ligament.  The lesions were suspect for endometriosis, however, they were not diagnostic of endometriosis.  There was also present a 3 mm to 5 mm submucosal uterine fibroid on the right lower uterine segment.  The Harmonic scalpel was removed from the abdomen as was the #5 port.  The incision was internally found to be hemostatic.  The laparoscope was then removed from the abdomen.  The abdomen was desufflated.  The introducer was then replaced into the #12 port and the #12 port was removed from the abdomen.  The uterine manipulator was removed from the uterus and the cervix was found to be hemostatic.  The weighted speculum was then removed.  The patient taken out of dorsal lithotomy position.  She was recovered from general anesthesia and taken to the postoperative suite for complete recovery.  The patient's discharge instructions will include a followup in one to two weeks in Dr. X's office for discussion of pathology.  Her family was notified of the findings.  She will be instructed not to have intercourse or use tampons or douche for the next two weeks.  The patient will be sent home with a prescription for Darvocet for pain.",
 Benign prostatic hypertrophy and urinary retention.  Cystourethroscopy and transurethral resection of prostate (TURP)., Surgery, Cystourethroscopy & TURP ,"PREOPERATIVE DIAGNOSES:,1.  Benign prostatic hypertrophy.,2.  Urinary retention.,POSTOPERATIVE DIAGNOSES:,1.  Benign prostatic hypertrophy.,2.  Urinary retention.,PROCEDURE PERFORMED:,1.  Cystourethroscopy.,2.  Transurethral resection of prostate (TURP).,ANESTHESIA:  ,Spinal.,DRAIN: , A #24 French three-way Foley catheter.,SPECIMENS: , Prostatic resection chips.,ESTIMATED BLOOD LOSS:  ,150 cc.,DISPOSITION:  ,The patient was transferred to the PACU in stable condition.,INDICATIONS AND FINDINGS:  ,This is an 84-year-old male with history of BPH and subsequent urinary retention with failure of trial of void, scheduled for elective TURP procedure.,FINDINGS: , At the time of surgery, cystourethroscopy revealed trilobar enlargement of the prostate with prostatic varices of the median lobe.  Cystoscopy showed a few cellules of the bladder with no obvious bladder tumors noted.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained, the patient was moved to operating room and spinal anesthesia was induced by the Department of Anesthesia.  The patient was prepped and draped in the normal sterile fashion and a #21 French cystoscope inserted into urethra and into the bladder.  Cystoscopy performed with the above findings.  Cystoscope was removed.  A #27 French resectoscope with a #26 cutting loop was inserted into the bladder.  Verumontanum was identified as a landmark and systematic transurethral resection of the prostate tissue was undertaken in an circumferential fashion with good resection of tissue completed.  ________ irrigator was used to evacuate the bladder of prostatic chips.  Resectoscope was then inserted and any residual chips were removed in piecemeal fashion with a resectoscope loop.  Any obvious bleeding from the prostatic fossa was controlled with electrocautery.  Resectoscope was removed.  A #24 French three-way Foley catheter inserted into the urethra and into the bladder.  Bladder was irrigated and connected to three-way irrigation.  The patient was cleaned and sent to recovery in stable condition to be admitted overnight for continuous bladder irrigation and postop monitoring.","surgery, urinary retention, cystourethroscopy, transurethral resection of prostate, foley catheter, bph, cystoscopy, bladder, benign prostatic hypertrophy, turp, "
" Cystourethroscopy, urethral dilation, and bladder biopsy and fulguration.  Urinary hesitancy and weak stream, urethral narrowing, mild posterior wall erythema.", Surgery, Cystourethroscopy & Urethral Dilation ,"PREOPERATIVE DIAGNOSIS:  ,Urinary hesitancy and weak stream.,POSTOPERATIVE DIAGNOSES:,1.  Urinary hesitancy and weak stream.,2.  Urethral narrowing.,3.  Mild posterior wall erythema.,PROCEDURE PERFORMED:,1.  Cystourethroscopy.,2.  Urethral dilation.,3.  Bladder biopsy and fulguration.,ANESTHESIA:  ,General.,SPECIMEN:  ,Urine culture sensitivity and cytology and bladder biopsy x1.,DISPOSITION: , To PACU in stable condition.,INDICATIONS AND FINDINGS:  ,This is a 76-year-old female with history of weak stream and history of intermittent catheterization secondary to hypotonic bladder in the past, last cystoscopy approximately two years ago.,FINDINGS AT TIME OF SURGERY:,  Cystourethroscopy revealed some mild narrowing of the urethra, which was easily dilated to #23 French.  A midureteral polyp was noted.  Cystoscopy revealed multiple cellules and mild trabeculation of the bladder.  Posterior wall revealed some mild erythema with some distorted architecture of the bladder mucosa.  No obvious raised bladder tumor was noted.  No foreign bodies were noted.  The ureteral orifices were noted on the trigone just proximal to the bladder neck.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained, the patient was moved to the operating room, general anesthesia was induced by the Department of Anesthesia.  The patient was prepped and draped in normal sterile fashion and urethral sounds used to dilate the urethra to accommodate #23 French cystoscope.  Cystoscopy was performed in its entirety with the above findings.  The small area of erythema on the posterior wall was biopsied using a flexible biopsy forceps and Bovie cautery was used to cauterize and fulgurate this area.  The bladder was drained, cystoscope was removed, scope was reinserted and bladder was again reexamined.  No evidence of active bleeding noted.  The bladder was drained, cystoscope was removed, and the patient was cleaned and sent to recovery room in stable condition to followup with Dr. X in two weeks.  She is given prescription for Levaquin and Pyridium and given discharge instructions.","surgery, bladder biopsy, fulguration, urethral dilation, weak stream, bladder, cystoscopy, cystoscope, cystourethroscopy, biopsy, urethral,"
" Right hydronephrosis, right flank pain, atypical/dysplastic urine cytology, extrarenal pelvis on the right, no evidence of obstruction or ureteral/bladder lesions.  Cystoscopy, bilateral retrograde ureteropyelograms, right ureteral barbotage for urine cytology, and right ureterorenoscopy.", Surgery," Cystoscopy, Ureteropyelogram, & Ureteral Barbotage ","PREOPERATIVE DIAGNOSES:,1.  Right hydronephrosis.,2.  Right flank pain.,3.  Atypical/dysplastic urine cytology.,POSTOPERATIVE DIAGNOSES:,1.  Right hydronephrosis.,2.  Right flank pain.,3.  Atypical/dysplastic urine cytology.,4.  Extrarenal pelvis on the right.,5.  No evidence of obstruction or ureteral/bladder lesions.,PROCEDURE PERFORMED:,1.  Cystoscopy.,2.  Bilateral retrograde ureteropyelograms.,3.  Right ureteral barbotage for urine cytology.,4.  Right ureterorenoscopy, diagnostic.,ANESTHESIA: , Spinal.,SPECIMEN TO PATHOLOGY: , Urine and saline wash barbotage from right ureter through the ureteral catheter.,ESTIMATED BLOOD LOSS:  ,Minimal.,INDICATIONS FOR PROCEDURE: , This is a 70-year-old female who reports progressive intermittent right flank pain associated with significant discomfort and disability.  She presented to the emergency room where she was found to have significant hydronephrosis on the right without evidence of a stone.  She has some ureteral thickening in her distal right ureter.  She has persistent microscopic hematuria and her urine cytology and cytomolecular diagnosis significant for urothelial dysplasia with neoplasia-associated karyotypic profile.  She was brought to the operating room for further evaluation and treatment.,DESCRIPTION OF OPERATION: , After preoperative counseling, the patient was taken to the operating room and administered a spinal anesthesia.  She was placed in the lithotomy position, prepped and draped in the usual sterile fashion.  The 21-French cystoscope was inserted per urethra into the bladder.  The bladder was inspected and found to be without evidence of intravesical tumors, stones or mucosal abnormalities.  The right ureteral orifice was visualized and cannulated with an open-ended ureteral catheter.  This was gently advanced to the mid ureter.  Urine was collected for cytology.  Retrograde injection of saline through the ureteral catheter was then also used to enhance collection of the specimen.  This too was collected and sent for a pooled urine cytology as specimen from the right renal pelvis and ureter.  An 0.038 guidewire was then passed up through the open-ended ureteral catheter.  The open-ended ureteral catheter and cystoscope were removed, and over the guidewire the flexible ureteroscope was passed up to the level of the renal pelvis.  Using direct vision and fluoroscopy to confirm location, the entire renal pelvis and calyces were inspected.  The renal pelvis demonstrated an extrarenal pelvis, but no evidence of obstruction at the renal UPJ level.  There were no intrapelvic or calyceal stones.  The ureter demonstrated no significant mucosal abnormalities, no visible tumors, and no areas of apparent constriction on multiple passes of the ureteroscope through the ureter to evaluate.  The ureteroscope was then removed.  The cystoscope was reinserted.  Once again, retrograde injection of contrast through an open-ended ureteral catheter was undertaken in the right ureter and collecting system.  No evidence of extravasation or significant change in anatomy was visualized.  The left ureteral orifice was then visualized and cannulated with an open-ended ureteral catheter, and retrograde injection of contrast demonstrated a normal left ureter and collecting system.  The cystoscope was removed.  Foley catheter was inserted.  The patient was placed in the supine position and transferred to the recovery room in satisfactory condition.","surgery, hydronephrosis, ureteropyelogram, ureterorenoscopy, flank pain, renal pelvis, urine cytology, ureteral, cystoscopy, barbotage, cystoscope, retrograde, urine, "
" Cystourethroscopy, right retrograde pyelogram, right ureteral pyeloscopy, right renal biopsy, and right double-J 4.5 x 26 mm ureteral stent placement.  Right renal mass and ureteropelvic junction obstruction and hematuria.", Surgery, Cystourethroscopy & Retrograde Pyelogram - 1 ,"PREOPERATIVE DIAGNOSES:,1.  Right renal mass.,2.  Hematuria.,POSTOPERATIVE DIAGNOSES:,1.  Right renal mass.,2.  Right ureteropelvic junction obstruction.,PROCEDURES PERFORMED:,1.  Cystourethroscopy.,2.  Right retrograde pyelogram.,3.  Right ureteral pyeloscopy.,4.  Right renal biopsy.,5.  Right double-J 4.5 x 26 mm ureteral stent placement.,ANESTHESIA: , Sedation.,SPECIMEN: , Urine for cytology and culture sensitivity, right renal pelvis urine for cytology, and right upper pole biopsies.,INDICATION:,  The patient is a 74-year-old male who was initially seen in the office with hematuria.  He was then brought to the hospital for other medical problems and found to still have hematuria.  He has a CAT scan with abnormal appearing right kidney and it was felt that he will benefit from cystoscope evaluation.,PROCEDURE: ,After consent was obtained, the patient was brought to the operating room and placed in the supine position.  He was given IV sedation and placed in dorsal lithotomy position.  He was then prepped and draped in the standard fashion.  A #21 French cystoscope was then passed through his ureter on which patient was noted to have a hypospadias and passed through across the ends of the bladder.  The patient was noted to have mildly enlarged prostate, however, it was non-obstructing.,Upon visualization of the bladder, the patient was noted to have some tuberculation to the bladder.  There were no masses or any other abnormalities noted other than the tuberculation.  Attention was then turned to the right ureteral orifice and an open-end of the catheter was then passed into the right ureteral orifice.  A retrograde pyelogram was performed.  Upon visualization, there was no visualization of the upper collecting system on the right side.  At this point, a guidewire was then passed through the open-end of the ureteral catheter and the catheter was removed.  The bladder was drained and the cystoscope was removed.  The rigid ureteroscope was then passed into the bladder and into the right ureteral orifice with the assistance of a second glidewire.  The ureteroscope was taken all the way through the proximal ureter just below the UPJ and there were noted to be no gross abnormalities.  The ureteroscope was removed and an Amplatz wire then passed through the scope up into the collecting system along the side of the previous wire.  The ureteroscope was removed and a ureteral dilating sheath was passed over the Amplatz wire into the right ureter under fluoroscopic guidance.  The Amplatz wire was then removed and the flexible ureteroscope was passed through the sheath into the ureter.  The ureteroscope was passed up to the UPJ at which point there was noted to be difficulty entering the ureter due to UPJ obstruction.  The wire was then again passed through the flexible scope and the flexible scope was removed.  A balloon dilator was then passed over the wire and the UPJ was dilated with balloon dilation.  The dilator was then removed and again the cystoscope was passed back up into the right ureter and was able to enter the collecting system.  Upon visualization of the collecting system of the upper portion, there was noted to be papillary mass within the collecting system.  The ________ biopsy forceps were then passed through the scope and two biopsies were taken of the papillary mass.  Once this was done, the wire was left in place and the ureteroscope was removed.  The cystoscope was then placed back into the bladder and a 26 x 4.5 mm ureteral stent was passed over the wire under fluoroscopic and cystoscopic guidance into the right renal pelvis.  The stent was noted to be clear within the right renal pelvis as well as in the bladder.  The bladder was drained and the cystoscope was removed.  The patient tolerated the procedure well.  He will be transferred to the recovery room and back to his room.  It has been discussed with his primary physician that the patient will likely need a nephrectomy.  He will be scheduled for an echocardiogram tomorrow and then decision will be made where the patient will be stable for possible nephrectomy on Wednesday.","surgery, renal mass, hematuria, ureteropelvic junction obstruction, cystourethroscopy, retrograde, pyelogram, ureteral pyeloscopy, renal biopsy, double-j, ureteral stent placement, ureteropelvic junction, flexible scope, papillary mass, ureteral stent, renal pelvis, ureteral orifice, amplatz wire, retrograde pyelogram, ureteral, cystoscope, ureteroscope, renal, bladder"
" Cystourethroscopy, bilateral retrograde pyelogram, and transurethral resection of bladder tumor of 1.5 cm in size.  Recurrent bladder tumor and history of bladder carcinoma.", Surgery, Cystourethroscopy & Retrograde Pyelogram ,"PREOPERATIVE DIAGNOSES:,1.  Recurrent bladder tumor.,2.  History of bladder carcinoma.,POSTOPERATIVE DIAGNOSIS:,","surgery, recurrent bladder tumor, bladder carcinoma, bilateral retrograde pyelogram, transurethral resection of bladder tumor, lateral wall bladder tumor, transurethral resection, retrograde pyelogram, tumor, bladder, cystourethroscopy, pyelogram,"
 Cystoscopy & Visual urethrotomy procedure, Surgery, Cystoscopy & Visual Urethrotomy ,"CYSTOSCOPY & VISUAL URETHROTOMY,OPERATIVE NOTE:,  The patient was placed in the dorsal lithotomy position and prepped and draped in the usual manner under satisfactory general anesthesia.  A Storz urethrotome sheath was inserted into the urethra under direct vision.  Visualization revealed a stricture in the bulbous urethra.  This was intubated with a 0.038 Teflon-coated guidewire, and using the straight cold urethrotomy knife, it was incised to 12:00 to allow free passage of the scope into the bladder.  Visualization revealed no other lesions in the bulbous or membranous urethra.  Prostatic urethra was normal for age.  No foreign bodies, tumors or stones were seen within the bladder.  Over the guidewire, a #16-French Foley catheter with a hole cut in the tip with a Cook cutter was threaded over the guidewire and inserted into the bladder and inflated with 10 mL of sterile water.,He was sent to the recovery room in stable condition.","surgery, cystoscopy, foley catheter, storz urethrotome sheath, teflon-coated guidewire, urethrotomy, bladder, bulbous urethra, dorsal lithotomy position, knife, membranous urethra, cystoscopy & visual urethrotomy, visual urethrotomyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Cystoscopy.  Transurethral resection of the prostate., Surgery, Cystoscopy & TURP ,"PREOPERATIVE DIAGNOSES:,1.  Ta grade III TIS transitional cell carcinoma of the urinary bladder.,2.  Lower tract outlet obstructive symptoms secondary to benign prostatic hypertrophy.,3.  Inability to pass a Foley catheter x3.,POSTOPERATIVE DIAGNOSES:,1.  Ta grade III TIS transitional cell carcinoma of the urinary bladder.,2.  Lower tract outlet obstructive symptoms secondary to benign prostatic hypertrophy.,3.  Inability to pass a Foley catheter x3.,PROCEDURES:,1.  Cystoscopy.,2.  Transurethral resection of the prostate (TURP).,ANESTHESIA: , General laryngeal mask.,INDICATIONS: , This patient is a 61-year-old white male who has been treated at the VA in Houston for a bladder cancer.  His history dates back to 2003 when he had a non-muscle invasive bladder cancer.  He had multiple cystoscopies and followups since that time with no evidence of recurrence.  However, on recent cystoscopy, he had what appeared to be a recurrent tumor and was taken to the operating room and had this resected with findings of a Ta grade III transitional cell carcinoma associated with carcinoma in situ.  Retrograde pyelograms were suspicious on the right and cleared with ureteroscopy and the left renal pelvic washing was positive but this may represent contamination from the lower urinary tract as radiographically, there were no abnormalities.  I had cystoscoped the patient in the office showed during the period of time when he had significant irritative burning symptoms, and there were still healing biopsy sites.  We elected to allow his bladder to recover before starting the BCG.  We were ready to do that last week but two doctors and a nurse including myself were unable to pass Foley catheter.  I repeated a cystoscopy in the office with findings of a high bladder neck and BPH.  After a lengthy discussion with the patient and his wife, we elected to proceed with TURP after a full informed consent.,FINDINGS: , At cystoscopy, there was bilobular prostatic hyperplasia and a very high riding bladder neck, which may have been the predominant cause of his difficulty catheterizing and obstructive symptoms.  There were mucosal changes on the left posterior wall in the midline suspicious for carcinoma in situ.,PROCEDURE IN DETAIL: , The patient was brought to the cystoscopy suite and after adequate general laryngeal mask anesthesia obtained and placed in the dorsal lithotomy position, his perineum and genitalia were sterilely prepped and draped in the usual fashion.  A cystourethroscopy was performed with a #23 French ACMI panendoscope and 70-degree lens with the findings as described.  We removed the cystoscope and passed a #28 French continuous flow resectoscope sheath under visual obturator after dilating the meatus to #32 French with van Buren sounds.  Inspection of bladder again was made noting the location of the ureteral orifices relative to the bladder neck.  The groove was cut at 6 o'clock to open the bladder neck to verumontanum and then the left lobe was resected from 1 o'clock to 5 o'clock.  Hemostasis was achieved, and then a similar procedure performed in the right side.  We resected the anterior stromal tissue and the apical tissue and then obtained complete hemostasis.  Chips were removed with Ellik evacuator.  There was no bleeding at the conclusion of the procedure, and the resectoscope was removed.  A #24 French three-way Foley catheter was placed with efflux of clear irrigant.  The patient was returned to the supine position, awakened, extubated, and taken on a stretcher to the recovery room in satisfactory condition.","surgery, urinary bladder, benign prostatic hypertrophy, transurethral resection of the prostate, turp, acmi panendoscope, van buren sounds, transitional cell carcinoma, foley catheter, bladder neck, bladder, carcinoma, cystoscopy"
" Exploratory laparotomy, resection of small bowel lesion, biopsy of small bowel mesentery, bilateral extended pelvic and iliac lymphadenectomy (including preaortic and precaval, bilateral common iliac, presacral, bilateral external iliac lymph nodes), salvage radical cystoprostatectomy (very difficult due to previous chemotherapy and radiation therapy), and continent urinary diversion with an Indiana pouch.", Surgery, Cystoprostatectomy ,"PREOPERATIVE DIAGNOSES:,1.  Clinical stage T2, NX, MX transitional cell carcinoma of the urinary bladder, status post chemotherapy and radiation therapy.,2.  New right hydronephrosis.,POSTOPERATIVE DIAGNOSES:,1.  Clinical stage T4a, N3, M1 transitional cell carcinoma of the urinary bladder, status post chemotherapy and radiation therapy.,2.  New right hydronephrosis.,3.  Carcinoid tumor of the small bowel.,TITLE OF OPERATION: , Exploratory laparotomy, resection of small bowel lesion, biopsy of small bowel mesentery, bilateral extended pelvic and iliac lymphadenectomy (including preaortic and precaval, bilateral common iliac, presacral, bilateral external iliac lymph nodes), salvage radical cystoprostatectomy (very difficult due to previous chemotherapy and radiation therapy), and continent urinary diversion with an Indiana pouch.,ANESTHESIA: , General endotracheal and epidural.,INDICATIONS: , This patient is a 65-year-old white male, who was diagnosed with a high-grade invasive bladder cancer in June 2005.  During the course of his workup of transurethral resection, he had a heart attack when he was taken off Plavix after having had a drug-eluting stent placed in.  He recovered from this and then underwent chemotherapy and radiation therapy with a brief response documented by cystoscopy and biopsy after which he had another ischemic event.  The patient has been followed regularly by myself and Dr. X and has been continuously free of diseases since that time.  In that interval, he had a coronary artery bypass graft and was taken off of Plavix.  Most recently, he had a PET CT, which showed new right hydronephrosis and a followup cystoscopy, which showed a new abnormality in the right side of his bladder where he previously had the tumor resected and treated.  I took him to the operating room and extensively resected this area with findings of a high-grade muscle invasive bladder cancer.  We could not identify the right ureteral orifice, and he had a right ureteral stent placed.  Metastatic workup was negative and Cardiology felt he was at satisfactory medical risk for surgery and he was taken to the operating room this time for planned salvage cystoprostatectomy.  He was interested in orthotopic neobladder, and I felt like that would be reasonable if resecting around the urethra indicated the tissue was healthier.  Therefore, we planned on an Indiana pouch continent cutaneous diversion.,OPERATIVE FINDINGS:  ,On exploration, there were multiple abnormalities outside the bladder as follows:  There were at least three small lesions within the distal small bowel, the predominant one measured about 1.5 cm in diameter with a white scar on the surface.  There were two much smaller lesions also with a small white scar, with very little palpable mass.  The larger of the two was resected and found to be a carcinoid tumor.  There also were changes in the small bowel mesentry that looked inflammatory and biopsies of this showed only fibrous tissue and histiocytes.  The small bowel mesentry was fairly thickened at the base, but no discrete abnormality noted.,Both common iliac and lymph node samples were very thickened and indurated, and frozen section of the left showed cancer cells that were somewhat degenerative suggesting a chemotherapy and radiation therapy effect; viability was unable to be determined.  There was a frozen section of the distal right external iliac lymph node that was negative.  The bladder was very thickened and abnormal suggesting extensive cancer penetrating just under the peritoneal surface.  The bladder was fairly stuck to the pelvic sidewall and anterior symphysis pubis requiring very meticulous resection in order to get it off of these structures.  The external iliac lymph nodes were resected on both sides of the obturator; the lymph packet, however, was very stuck and adherent to the pelvic sidewall, and I elected not to remove that.  The rest of the large bowel appeared normal.  There were no masses in the liver, and the gallbladder was surgically absent.  There was nasogastric tube in the stomach.,OPERATIVE PROCEDURE IN DETAIL: , The patient was brought to the operative suite, and after adequate general endotracheal and epidural anesthesia obtained, having placed in the supine position and flexed over the anterior superior iliac spine, his abdomen and genitalia were sterilely prepped and draped in usual fashion.  The radiologist placed a radial arterial line and an intravenous catheter.  Intravenous antibiotics were given for prophylaxis.  We made a generous midline skin incision from high end of the epigastrium down to the symphysis pubis, deepened through the rectus fascia, and the rectus muscles separated in the midline.  Exploration was carried out with the findings described.  The bladder was adherent and did appear immobile.  Moist wound towels and a Bookwalter retractor was placed for exposure.  We began by assessing the small and large bowel with the findings in the small bowel as described.  We subsequently resected the largest of the lesions by exogenous wedge resection and reanastomosed the small bowel with a two-layer running 4-0 Prolene suture.  We then mobilized the cecum and ascending colon and hepatic flexure after incising the white line of Toldt and mobilized the terminal ileal mesentery up to the second and third portion of the duodenum.  The ureters were carefully dissected out and down deep in the true pelvis.  The right ureter was thickened and hydronephrotic with a stent in place and the left was of normal caliber.  I kept the ureters intact until we were moving the bladder off as described above.  At that point, we then ligated the ureters with the RP-45 vascular load and divided it.,We then established the proximal ____________ laterally to both genitofemoral nerves and resected the precaval and periaortic lymph nodes.  The common iliac lymph nodes remained stuck to the ureter.  Frozen section with the findings described on the left.,I then began the dissection over the right external iliac artery and vein and had a great deal of difficulty dissecting distally.  I was, however, able to establish the distal plane of dissection and a large lymph node was present in the distal external iliac vessels.  Clips were used to control the lymphatics distally.  These lymph nodes were sent for frozen section, which was negative.  We made no attempt to circumferentially mobilize the vessels, but essentially, swept the tissue off of the anterior surface and towards the bladder and then removed it.  The obturator nerve on the right side was sucked into the pelvic sidewall, and I elected not to remove those.  On the left side, things were a little bit more mobile in terms of the lymph nodes, but still the obturator lymph nodes were left intact.,We then worked on the lateral pedicles on both sides and essentially determined that I can take these down.  I then mobilized the later half of the symphysis pubis and pubic ramus to get distal to the apical prostate.  At this point, I scrubbed out of the operation, talked to the family, and indicated that I felt the cystectomy was more palliative than therapeutic, and I reiterated his desire to be free of any external appliance.,I then proceeded to take down the lateral pedicles with an RP-45 stapler on the right and clips distally.  The endopelvic fascia was incised.  I then turned my attention posteriorly and incised the peritoneum overlying the anterior rectal wall and ramus very meticulously dissected the rectum away from the posterior Denonvilliers fascia.  I intentionally picked down those two pedicles lateral to the rectum between the clips and then turned my attention retropubically.  I was able to pass a 0 Vicryl suture along the dorsal venous complex, tied this, and then, sealed and divided the complex with a LigaSure and oversewed it distally with 2-0 Vicryl figure-of-eight stitch.  I then divided the urethra distal to the apex of the prostate, divided the Foley catheter between the clamps and then the posterior urethra.  I then was able to take down the remaining distal attachments of the apex and took the dissection off the rectum, and the specimen was then free of all attachments and handed off the operative field.  The bivalved prostate appeared normal.  We then carefully inspected the rectal wall and noted to be intact.  The wound was irrigated with 1 L of warm sterile water and a meticulous inspection made for hemostasis and a dry pack placed in the pelvis.,We then turned our attention to forming the Indiana pouch.  I completed the dissection of the right hepatic flexure and the proximal transverse colon and mobilized the omentum off of this portion of the colon.  The colon was divided proximal to the middle colic using a GIA-80 stapler.  I then divided the avascular plane of Treves along the terminal ileum and selected a point approximately 15 cm proximal to the ileocecal valve to divide the ileum.  The mesentery was then sealed with a LigaSure device and divided, and the bowel was divided with a GIA-60 stapler.  We then performed a side-to-side ileo-transverse colostomy using a GIA-80 stapler, closing the open end with a TA 60.  The angles were reinforced with silk sutures and the mesenteric closed with interrupted silk sutures.,We then removed the staple line along the terminal ileum, passed a 12-French Robinson catheter into the cecal segment, and plicated the ileum with 3 firings of the GIA-60 stapler.  The ileocecal valve was then reinforced with interrupted 3-0 silk sutures as described by Rowland, et al, and following this, passage of an 18-French Robinson catheter was associated with the characteristic ""pop,"" indicating that we had adequately plicated the ileocecal valve.,As the patient had had a previous appendectomy, we made an opening in the cecum in the area of the previous appendectomy.  We then removed the distal staple line along the transverse colon and aligned the cecal end and the distal middle colic end with two 3-0 Vicryl sutures.  The bowel segment was then folded over on itself and the reservoir formed with 3 successive applications of the SGIA Polysorb-75.  Between the staple lines, Vicryl sutures were placed and the defects closed with 3-0 Vicryl suture ligatures.,We then turned our attention to forming the ileocolonic anastomosis.  The left ureter was mobilized and brought underneath the sigmoid mesentery and brought through the mesentery of the terminal ileum and an end-to-side anastomosis performed with an open technique using interrupted 4-0 Vicryl sutures, and this was stented with a Cook 8.4-French ureteral stent, and this was secured to the bowel lumen with a 5-0 chromic suture.  The right ureter was brought underneath the pouch and placed in a stented fashion with an identical anastomosis.  We then brought the stents out through a separate incision cephalad in the pouch and they were secured with a 2-0 chromic suture.  A 24-French Malecot catheter was placed through the cecum and secured with a chromic suture.  The staple lines were then buried with a running 3-0 Vicryl two-layer suture and the open end of the pouch closed with a TA 60 Polysorb suture.  The pouch was filled to 240 cc and noted to be watertight, and the ureteral anastomoses were intact.,We then made a final inspection for hemostasis.  The cecostomy tube was then brought out to the right lower quadrant and secured to the skin with silk sutures.  We then matured our stoma through the umbilicus.  We removed the plug of skin through the umbilicus and delivered the ileal segment through this.  A portion of the ileum was removed and healthy, well-vascularized tissue was matured with interrupted 3-0 chromic sutures.  We left an 18-French Robinson through the stoma and secured this to the skin with silk sutures.  The Malecot and stents were also secured in a similar fashion.,The stoma was returned to the umbilicus after resecting the terminal ileum.,We then placed a large JP drain into both obturator fossae and brought it up the right lower quadrant.  Rectus fascia was closed with buried #2 Prolene stitch anchoring a new figure of 8 at each end tying the two stitches above and in the middle and underneath the fascia.  Interrupted stitches were placed as well.  The subcutaneous tissue was irrigated and skin closed with surgical clips.  The estimated blood loss was 2500 mL.  The patient received 5 units of packed red blood cells and 4 units of FFP.  The patient was then awakened, extubated, and taken on a stretcher to the recovery room in satisfactory condition.", 
 Right lower pole renal stone and possibly infected stent.  Cysto stent removal., Surgery, Cysto Stent Removal ,"PREOPERATIVE DIAGNOSIS: , Right lower pole renal stone and possibly infected stent.,POSTOPERATIVE DIAGNOSIS: , Right lower pole renal stone and possibly infected stent.,OPERATION:,  Cysto stent removal.,ANESTHESIA:,  Local MAC.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid.,MEDICATIONS: , The patient was on vancomycin and Levaquin was given x1 dose.  The patient was on vancomycin for the last 5 days.,BRIEF HISTORY:  ,The patient is a 53-year-old female who presented with Enterococcus urosepsis.  CT scan showed a lower pole stone with a stent in place.  The stent was placed about 2 months ago, but when patient came in with a possibly UPJ stone with fevers of unknown etiology.  The patient had a stent placed at that time due to the fevers, thinking that this was an urospetic stone.  There was some pus that came out.  The patient was cultured; actually it was negative at that time.  The patient subsequently was found to have lower extremity DVT and then was started on Coumadin.  The patient cannot be taken off Coumadin for the next 6 months due to the significant swelling and high risk for PE.  The repeat films were taken which showed the stone had migrated into the pole.,The stent was intact.  The patient subsequently developed recurrent UTIs and Enterococcus in the urine with fevers.  The patient was admitted for IV antibiotics since the patient could not really tolerate penicillin due to allergy and due to patient being on Coumadin, Cipro, and Levaquin where treatment was little bit more complicated.  Due to drug interaction, the patient was admitted for IV antibiotic treatment.  The thinking was that either the stone or the stent is infected, since the stone is pretty small in size, the stent is very likely possibility that it could have been infected and now it needs to be removed.  Since the stone is not obstructing, there is no reason to replace the stent at this time.  We are unable to do the ureteroscopy or the shock-wave lithotripsy when the patient is fully anticoagulated.  So, the best option at this time is to probably wait and perform the ureteroscopic laser lithotripsy when the patient is allowed to off her Coumadin, which would be probably about 4 months down the road.,Plan is to get rid of the stent and improve patient's urinary symptoms and to get rid of the infection and we will worry about the stone at later point.,DETAILS OF THE OR: , Consent had been obtained from the patient.  Risks, benefits, and options were discussed.  Risk of anesthesia, bleeding, infection, pain, MI, DVT, and PE were discussed.  The patient understood all the risks and benefits of removing the stent and wanted to proceed.  The patient was brought to the OR.  The patient was placed in dorsal lithotomy position.  The patient was given some IV pain meds.  The patient had received vancomycin and Levaquin preop.  Cystoscopy was performed using graspers.  The stent was removed without difficulty.  Plan was for repeat cultures and continuation of the IV antibiotics.","surgery, infected stent, cysto stent removal, cysto stent, renal stone, lower pole, infected, stone, stent, cysto,"
" Residual stone status post right percutaneous nephrolithotomy, attempted second-look nephrolithotomy, cysto with insertion of 6-French variable length double-J stent.", Surgery, Cysto & Double-J Stent Insersion ,"PREOPERATIVE DIAGNOSIS:,  Residual stone, status post right percutaneous nephrolithotomy.,POSTOPERATIVE DIAGNOSES: , Residual stone status post right percutaneous nephrolithotomy, attempted second-look nephrolithotomy, cysto with insertion of 6-French variable length double-J stent.,ANESTHESIA:,  General via endotracheal tube.,BLOOD LOSS:,  Minimal.,DRAINS: , 16-French Foley, 6-French variable length double-J stent.,INTRAOPERATIVE COMPLICATIONS: , Unable to re-access the collecting system.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room and laid supine.  General anesthesia was accomplished.  A 16-French Foley was placed using aseptic technique.  The patient was then placed on the operating table prone.  His right flank was prepped and draped in a sterile fashion.  At this point, contrast was injected through his existing nephrostomy tube and there was no continuity with the collecting system and it was removed.  The 5-French Pollack catheter was used to pass a 0.38 super-stiff Amplatz wire.  The wire would not go down the ureter.  Multiple attempts were made using Pollack catheters and Cobra catheters and attempts were made to dilate the track, both with rigid dilator and the balloon dilator and access could not be obtained.  After multiple attempts, access was lost.  At this point, the tubes were left out of the kidney and sterile dressings were applied.  The patient was then placed on another operating table supine.  His genitalia were prepped and draped after removing his Foley catheter.  Flexible cystoscopy was performed and the right orifice identified, which was edematous and erythematous.  The wire was passed up to kidney and a 5-French Pollack catheter was then passed over to after the removing the scope.  The wire was removed.  Contrast injection with good placement in the collecting system.  The wire was replaced.  The Pollack catheter removed and 6-French variable length double-J stent was inserted using fluoroscopic guidance.  The wire was removed leaving the double-J stent in good position.  _______ 16-French Foley was reinserted and connected to close drains.,Procedure was terminated at this point and had been well tolerated.  The patient was awakened and taken to recovery room in satisfactory condition having tolerated the procedure well.","surgery, residual stone, percutaneous, cobra catheters, amplatz, double j stent, pollack catheter, cysto, catheter, nephrolithotomy, stent, french"
" Holmium laser cystolithalopaxy.  A diabetic male in urinary retention with apparent neurogenic bladder and intermittent self-catheterization, recent urinary tract infections.  The cystoscopy showed a large bladder calculus, short but obstructing prostate.", Surgery, Cystolithalopaxy ,"PREOPERATIVE DIAGNOSES:,1.  Prostatism.,2.  Bladder calculus.,OPERATION:,  Holmium laser cystolithalopaxy.,POSTOPERATIVE DIAGNOSES:,1.  Prostatism.,2.  Bladder calculus.,ANESTHESIA:  ,General.,INDICATIONS:,  This is a 62-year-old male diabetic and urinary retention with apparent neurogenic bladder and intermittent self-catheterization, recent urinary tract infections.  The cystoscopy showed a large bladder calculus, short but obstructing prostate.  He comes in now for transurethral resection of his prostate and holmium laser cystolithotripsy.,He is a diabetic with obesity.,LABORATORY DATA:  ,Includes urinalysis showing white cells too much to count, 3-5 red cells, occasional bacteria.  He had a serum creatinine of 1.2, sodium 138, potassium 4.6, glucose 190, calcium 9.1.  Hematocrit 40.5, hemoglobin 13.8, white count 7,900.,PROCEDURE: , The patient was satisfactorily given general anesthesia.  Prepped and draped in the dorsal lithotomy position.  A 27-French Olympus rectoscope was passed via the urethra into the bladder.  The bladder, prostate, and urethra were inspected.  He had an obstructing prostate.  He had marked catheter reaction in his bladder.  He had a lot of villous changes, impossible to tell from frank tumor.  He had a huge bladder calculus.  It was white and round.,I used the holmium laser with the largest fiber through the continuous flow resectoscope and sheath, and broke up the stone, breaking up approximately 40 grams of stone.  There was still stone left at the end of the procedure.  Most of the chips that could be irrigated out of the bladder were irrigated out using Ellik.,Then the scope was removed and a 24-French 3-way Foley catheter was passed via the urethra into the bladder.,The plan is to probably discharge the patient in the morning and then we will get a KUB.  We will probably bring him back for a second stage cystolithotripsy, and ultimately do a TURP.  We broke up the stone for over an hour, and my judgment continuing with litholapaxy transurethrally over an hour begins to markedly increase the risk to the patient.","surgery, prostatism, holmium laser cystolithalopaxy, urinary tract infections, holmium laser, bladder calculus, bladder, cystolithalopaxy, diabetic, urethra, urinary, catheterization, stone, calculus, prostate,"
 Cystoscopy and Bladder biopsy with fulguration.   History of bladder tumor with abnormal cytology and areas of erythema., Surgery, Cystoscopy & Bladder Biopsy ,"PREOPERATIVE DIAGNOSIS:,  History of bladder tumor with abnormal cytology and areas of erythema.,POSTOPERATIVE DIAGNOSIS: , History of bladder tumor with abnormal cytology and areas of erythema.,PROCEDURE PERFORMED:,1.  Cystoscopy.,2.  Bladder biopsy with fulguration.,ANESTHESIA: , IV sedation with local.,SPECIMEN: , Urine cytology and right lateral wall biopsies.,PROCEDURE:,  After the consent was obtained, the patient was brought to the operating room and given IV sedation.  He was then placed in dorsal lithotomy position and prepped and draped in standard fashion.  A #21 French cystoscope was then used to visualized the entire urethra and bladder.  There was noted to be a narrowing of the proximal urethra, however, the scope was able to pass through.  The patient was noted to have a previously resected prostate.  On visualization of the bladder, the patient did have areas of erythema on the right as well as the left lateral walls, more significant on the right side.  The patient did have increased vascularity throughout the bladder.  The ________ two biopsies of the right lateral wall and those were sent for pathology.  The Bovie cautery was then used to cauterize the entire area of the biopsy as well as surrounding erythema.  Bovie was also utilized to cauterize the areas of erythema on the left lateral wall.  No further bleeding was identified.  The bladder was drained and the cystoscope was removed.  The patient tolerated the procedure well and was transferred to the recovery room.,He will have his defibrillator restarted and will followup with Dr. X in approximately two weeks for the result.  He will be discharged home with antibiotics as well as pain medications.  He is to restart his Coumadin not before Sunday.","surgery, bladder biopsy with fulguration, iv sedation, bladder biopsy, bladder tumor, abnormal cytology, bladder, cystoscopy, tumor, cytology, erythema,"
" Cystoscopy under anesthesia, bilateral HIT/STING with Deflux under general anesthetic.", Surgery, Cystoscopy ,"PREOPERATIVE DIAGNOSIS: , Bilateral vesicoureteral reflux with right reflux nephropathy after Deflux injection.,POSTOPERATIVE DIAGNOSIS: , Bilateral vesicoureteral reflux with right reflux nephropathy after Deflux injection.,PROCEDURE:,  Cystoscopy under anesthesia, bilateral HIT/STING with Deflux under general anesthetic.,ANESTHESIA: , General inhalational anesthetic.,FLUIDS RECEIVED: , 250 mL crystalloids.,ESTIMATED BLOOD LOSS:,  Less than 5 mL.,SPECIMENS:,  Urine sent for culture.,ABNORMAL FINDINGS:  ,Gaping ureteral orifices, right greater than left, with Deflux not in or near the ureteral orifices.  Right ureteral orifice was HIT with 1.5 mL of Deflux and left with 1.2 mL of Deflux.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 4-1/2-year-old boy with history of reflux nephropathy and voiding and bowel dysfunction.  He has had a STING procedure performed but continues to have reflux bilaterally.  Plan is for another injection.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operating room where surgical consent, operative site, and patient identification were verified.  Once he was anesthetized, IV antibiotics were given.  He was then placed in a lithotomy position with adequate padding of his arms and legs.  His urethra was calibrated to 12-French with a bougie a boule.  A 9.5-French cystoscope was used and the offset system was then used.  His urethra was normal without valves or strictures.  His bladder was fairly normal with minimal trabeculations but no cystitis noted.  Upon evaluation, the patient's right ureteral orifice was found to be remarkably gaping and the Deflux that was present was not in or near ureteral orifice but it was inferior to it below the trigone.  This was similarly found on the left side where the Deflux was not close to the orifice as well.  It was slightly more difficult because of the amount impacted upon our angle for injection.  We were able to ultimately get the Deflux to go ahead with HIT technique on the right into the ureter itself to inject a total of 1.5 mL to include the HIT technique as well as the ureteral orifice itself on the right and left sides and some on the uppermost aspect.  Once we injected this, we ran the irrigant over the orifice and it no longer fluttered and there was no bleeding.  Similar procedure was done on the left.  This was actually more difficult as the Deflux injection from before displaced the ureter slightly more laterally but again HIT technique was performed.  There was some mild bleeding and Deflux was used to stop this as well and again no evidence of fluttering of the ureteral orifice after injection.  At the end of the procedure, the irrigant was drained and 2% lidocaine jelly was instilled in the urethra.  The patient tolerated the procedure well and was in stable condition upon transfer to Recovery.  A low-dose of IV Toradol was given at the end of the procedure as well.","surgery, bilateral vesicoureteral reflux, deflux, sting procedure, hit technique, cystoscopy under anesthesia, hit/sting with deflux, vesicoureteral reflux, ureteral orifices, vesicoureteral, cystoscopy, urethra, hit/sting, ureteral,"
" Cystopyelogram, left ureteroscopy, laser lithotripsy, stone basket extraction, stent exchange with a string attached.", Surgery, Cystopyelogram ,"PREOPERATIVE DIAGNOSIS: , Left distal ureteral stone.,POSTOPERATIVE DIAGNOSIS: , Left distal ureteral stone.,PROCEDURE PERFORMED: , Cystopyelogram, left ureteroscopy, laser lithotripsy, stone basket extraction, stent exchange with a string attached.,ANESTHESIA:,  LMA.,EBL: , Minimal.,FLUIDS: , Crystalloid.  The patient was given antibiotics, 1 g of Ancef and the patient was on oral antibiotics at home.,BRIEF HISTORY: , The patient is a 61-year-old female with history of recurrent uroseptic stones.  The patient had stones x2, 1 was already removed, second one came down, had recurrent episode of sepsis, stent was placed.  Options were given such as watchful waiting, laser lithotripsy, shockwave lithotripsy etc.  Risks of anesthesia, bleeding, infection, pain, need for stent, and removal of the stent were discussed.  The patient understood and wanted to proceed with the procedure.,DETAILS OF THE PROCEDURE: , The patient was brought to the OR.  Anesthesia was applied.  The patient was placed in dorsal lithotomy position.  The patient was prepped and draped in usual sterile fashion.  A 0.035 glidewire was placed in the left system.  Using graspers, left-sided stent was removed.  A semirigid ureteroscopy was done.  A stone was visualized in the mid to upper ureter.  Using laser, the stone was broken into 5 to 6 small pieces.  Using basket extraction, all the pieces were removed.  Ureteroscopy all the way up to the UPJ was done, which was negative.  There were no further stones.  Using pyelograms, the rest of the system appeared normal.  The entire ureter on the left side was open and patent.  There were no further stones.  Due to the edema and the surgery, plan was to leave the stent attached to the string and the patient was to pull the string in about 24 hours.  Over the 0.035 glidewire, a 26 double-J stent was placed.  There was a nice curl in the kidney and one in the bladder.  The patient tolerated the procedure well.  Please note that the string was kept in place and the patient was to remove the stent the next day.  The patient's family was instructed how to do so.  The patient had antibiotics and pain medications at home.  The patient was brought to recovery room in a stable condition.","surgery, laser lithotripsy, shockwave lithotripsy, double-j stent, distal ureteral stone, ureteral stone, basket extraction, cystopyelogram, laser, lithotripsy, stones, string, ureteroscopy, stone, stent,"
 CT of abdomen with and without contrast.  CT-guided needle placement biopsy., Surgery, CT-Guided Needle Placement Biopsy ,"EXAM: , CT of abdomen with and without contrast.  CT-guided needle placement biopsy.,HISTORY: , Left renal mass.,TECHNIQUE: , Pre and postcontrast enhanced images were acquired through the kidneys.,FINDINGS: , Comparison made to the prior MRI.  There is re-demonstration of multiple bilateral cystic renal lesions.  Several of these demonstrate high attenuation in the precontrast phase of the exam suggesting that they are hemorrhagic cysts.  There was however one cyst seen in the lower pole of the left kidney, which demonstrated apparent enhancement from 30 to 70 Hounsfield units post contrast administration.  This measured approximately 1.4 x 1.3 cm to the exophytic half of the lower pole.  No other enhancing renal masses were seen.  The visualized liver, spleen, pancreas, and adrenal glands were unremarkable.  There are changes of cholecystectomy.  Mild prominence of the common bile duct is likely secondary to cholecystectomy.  There is no abdominal lymphadenopathy, masses, fluid collection, or ascites.,Lung bases are clear.  No acute bony pathology was noted.,IMPRESSION: , Solitary apparently enhancing left renal mass in the lower pole as described.  Renal cell carcinoma cannot be excluded.,CT-GUIDED NEEDLE BIOPSY, LEFT KIDNEY MASS: , Following discussion of risks, benefits, and alternatives, the patient wished to proceed with CT-guided biopsy of left renal lesion.  The patient was placed in the decubitus position.  The region overlying the left renal mass of note was marked.  Area was prepped and draped in usual sterile fashion.  Local anesthesia was achieved with approximately 8 mL of 1% lidocaine with bicarbonate.  The Versed and fentanyl were given to achieve conscious sedation.  Utilizing an 18 x 15 gauge coaxial system, 3 core biopsies were obtained through the mass in question, and sent to pathology for analysis.  Following procedure, scans through the region demonstrate a small subcutaneous hematoma in the region of the superficial anesthesia.  No perinephric fluid/hematoma was identified.  The patient tolerated the procedure without immediate complications.,IMPRESSION: , Three core biopsies through the region of the left renal tumor as described.","surgery, ct, ct-guided, ct-guided biopsy, hounsfield units, mri, abdomen, biopsy, cholecystectomy, contrast, contrast administration, decubitus position, images, needle, postcontrast, renal lesions, renal mass, renal tumor, with and without, ct guided needle placement, ct of abdomen, needle placement, lower pole, ct guided, renal"
" Cystopyelogram, clot evacuation, transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder.", Surgery, Cystopyelogram - 1 ,"PREOPERATIVE DIAGNOSIS: , Gross hematuria.,POSTOPERATIVE DIAGNOSIS:  ,Gross hematuria.,OPERATIONS:  ,Cystopyelogram, clot evacuation, transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder.,ANESTHESIA: , Spinal.,FINDINGS:  ,Significant amount of bladder clots measuring about 150 to 200 mL, two cupful of clots were removed.  There was papillary tumor on the left wall right at the bladder neck and one on the right dome near the bladder neck on the right side.  The right ureteral opening was difficult to visualize, the left one was normal.,BRIEF HISTORY: , The patient is a 78-year-old male with history of gross hematuria and recurrent UTIs.  The patient had hematuria.  Cystoscopy revealed atypical biopsy.  The patient came in again with gross hematuria.  The first biopsy was done about a month ago.  The patient was to come back and have repeat biopsies done, but before that came into the hospital with gross hematuria.  The options of watchful waiting, removal of the clots and biopsies were discussed.  Risk of anesthesia, bleeding, infection, pain, MI, DVT and PE were discussed.  Morbidity and mortality of the procedure were discussed.  Consent was obtained from the daughter-in-law who has the power of attorney in Florida.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the OR.  Anesthesia was applied.  The patient was placed in the dorsal lithotomy position.  The patient was prepped and draped in the usual sterile fashion.  The patient had been off of the Coumadin for about 4 days and INR had been reversed.  The patient has significant amount of clot upon entering the bladder.  There was a tight bladder neck contracture.  The prostate was not enlarged.  Using ACMI 24-French sheath, using Ellick irrigation about 2 cupful of clots were removed.  It took about half an hour to just remove the clots.  After removing the clots, using 24-French cutting loop resectoscope, tumor on the left upper wall near the dome or near the 2 o'clock position was resected.  This was lateral to the left ureteral opening.  The base was coagulated for hemostasis.  Same thing was done at 10 o'clock on the right side where there was some tumor that was visualized.  The back wall and the rest of the bladder appeared normal.  Using 8-French cone-tip catheter, left-sided pyelogram was normal.  The right-sided pyelogram was very difficult to obtain and there was some mucosal irritation from the clots.  The contrast did go up to what appeared to be the right ureteral opening, but the mucosa seemed to be very much irritated and it was very difficult to actually visualize the opening.  A little bit of contrast went out, but the force was not made just to avoid any secondary stricture formation.  The patient did have CT with contrast, which showed that the kidneys were normal.  At this time, a #24 three-way irrigation was started.  The patient was brought to Recovery room in stable condition.","surgery, clot evacuation, transurethral resection, bladder tumor, bladder neck, gross hematuria, bladder, cystopyelogram, hematuria, clots,"
" Laparoscopic assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, culdoplasty, and cystoscopy.  Chronic pelvic inflammatory disease, pelvic adhesions, pelvic pain, fibroid uterus, and enterocele.", Surgery, Culdoplasty & Vaginal Hysterectomy ,"PREOPERATIVE DIAGNOSES:,1.  Chronic pelvic inflammatory disease.,2.  Pelvic adhesions.,3.  Pelvic pain.,4.  Fibroid uterus.,5.  Enterocele.,POSTOPERATIVE DIAGNOSES:,1.  Chronic pelvic inflammatory disease.,2.  Pelvic adhesions.,3.  Pelvic pain.,4.  Fibroid uterus.,5.  Enterocele.,PROCEDURE PERFORMED:,1.  Laparoscopic assisted vaginal hysterectomy, bilateral salpingo-oophorectomy.,2.  McCall's culdoplasty.,3.  Cystoscopy.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , 350 cc.,INDICATIONS:  ,The patient is a 45-year-old Caucasian female with complaints of long standing pelvic pain throughout the menstrual cycle and worse with menstruation, uncontrolled with Anaprox DS also with complaints of dyspareunia.  On laparoscopy in May of 2003, PID, adenomyosis, and uterine fibroids were demonstrated.  The patient desires definitive treatment.,FINDINGS AT THE TIME OF SURGERY:  ,Uterus was retroverted and somewhat boggy on bimanual examination without any palpable adnexal abnormalities.  On laparoscopic examination, the uterus was quite soft and boggy consistent with the uterine adenomyosis.  There was also evidence of fibroid change in the right fundal aspect of the uterus.  There was a white exudative material covering the uterus as well as bilateral ovaries and fallopian tubes.  There were filmy adhesions to the right pelvic side wall, as well as left pelvic side wall.,PROCEDURE: , The patient taken to the operative suite where anesthesia was found to be adequate.  She was then prepared and draped in the normal sterile fashion.  A Foley catheter was initially placed and was noted to be draining clear to yellow urine.  A weighted speculum was placed in the patient's vagina.  The bladder was elevated and the anterior lip of the cervix was grasped with a vulsellum tenaculum.  The uterus sounded to 7 cm and the cervix was then progressively dilated.  A #20 Hank dilator, which was left within the cervix used in conjunction with the vulsellum tenaculum as a uterine manipulator.  At this time, after the gloves were changed, attention was then turned to the patient's abdomen.  A small approximately 1 cm infraumbilical incision was made with the scalpel.  A Veress needle was then inserted through this incision and a pneumoperitoneum was created with CO2 gas with appropriate volumes and pressures.  A #10 mm step trocar was then inserted through this site and intraabdominal placing was confirmed with the laparoscope.  On entrance into the patient's abdomen and pelvis, survey of the abdomen and pelvis revealed the operative area to be relatively free of adhesions except for the right pelvic saddle in which there were filmy adhesions.  There was also white exudate noted covering the surface of the uterus and adnexa and the uterus had a quite boggy appearance.  At this time, under transillumination in the left anterior axillary line, a second incision was made with a scalpel and through this site a #12 mm step trocar was inserted under direct visualization by the laparoscope.  A third incision was made in the right anterior axillary line under transillumination and through this site a second #12 mm step trocar was placed under direct visualization by the laparoscope.  Then 2 cm above the pubic symphysis in the midline and fourth incision was made and a #5 mm step trocar was inserted through this site.  The uterus was elevated and deviated to the patient's right and infundibulopelvic ligament on the left was placed on tension with the aid of a grasper.  The Endo-GIA was placed through the left sided port and was fired was to cross the infundibulopelvic ligament and down passed to the level of the round ligament, transecting and stapling at the same time.  Attention was then turned to the right adnexa.,The uterus was brought over to the patient's left and the right infundibulopelvic ligament was placed on tension with the aid of a grasper.  An Endo-GIA was used to transect and staple this vasculature and down passed to the level of round ligament.  At this time, there was noted to be a small remnant of the round ligament on the right and a Harmonic scalpel was used to complete the transection and was found to be hemostatic.  In addition, on the left the same procedure was performed to completely transect the round ligament on the left and a good hemostasis was noted.  At this time, the uterus was dropped and the vesicouterine peritoneum was grasped with graspers.  The bladder was then dissected off of the lower uterine segment with the aid of a Harmonic scalpel and hemostasis was appreciated.  The anterior cervix of the uterus was scored in the midline up to the level of the fundus with the aid of a Harmonic scalpel and then out to the adnexa bilaterally to aid in orientation during the vaginal portion of the procedure.  At this time, copious suction irrigation was performed and the operative sites were found to be hemostatic.  The pneumoperitoneum was the evacuated and the attention was then turned to the vaginal portion of the procedure.  The weighted speculum was placed into the patient's vagina.  At this time, the Foley catheter was noted to have ________ and there was noted to be a small puncture site noted into the Foley bulb.  The Foley catheter was replaced and the bladder was to be filled at a later time with methylene blue to rule out any bladder injury during the laparoscopic part of the procedure.  The cervix was then grasped from right to left with a Lahey clamps and the anterior vaginal mucosa was placed on stretch with aid of Allis clamps.  The vaginal mucosa anteriorly was then incised with aid of a scalpel from the 9 o'clock position to 3 o'clock position.  The anterior vaginal mucosa and bladder were suctioned and were then dissected away from the lower uterine segment with the aid of Mayo scissors and blunt dissection until anteriorly the peritoneal cavity was entered at which time the peritoneal incision was extended bluntly.  Next, using Lahey clamps serially following the ________ placed by the Harmonic scalpel from above were followed up to the pubic uterine fundus until the uterus was delivered into the vagina anteriorly.  At this time, two curved Heaney clamps were placed across the uterine artery on the right.  This was then transected and suture ligated with #0 Vicryl suture.  The second clamp was advanced to incorporate the cardinal ligament complex and this was then transected and suture ligated with #0 Vicryl suture.  Attention was then turned to the left uterine artery which was again doubly clamped with curved Heaney clamps, transected and suture ligated with #0 Vicryl suture.  This second clamp was then advanced to capture the vasculature and the cardinal ligament complex.  This was again transected and suture ligated with #0 Vicryl suture.,Next, the uterosacral were clamped off with the curved Heaney clamps and this clamp was met in the midline by another clamp just underneath the cervix and clamping off of the vaginal cuff.  Next the uterus, ovaries and cervix were transected away from the vaginal cuff with the aid of double pointed scissors and this specimen was handed off to pathology.  At this time, the bladder was instilled with approximately 800 cc of methylene blue and there was no evidence of any leak of blue dye as could be seen from the prospective of the vaginal portion of the procedure.  Next, the posterior vaginal cuff and posterior peritoneum were incorporated in a running lock stitch of #0 Chromic beginning at the 9'o clock position over to the 3'o clock position.  Next, the anterior vaginal mucosa was grasped with the Allis clamp and the peritoneum was identified anteriorly.  The angles of the vaginal cuff were then closed with #0 Chromic suture figure-of-eight stitch with care taken to incorporate the anterior vaginal mucosa, the anterior peritoneum, and the previously closed posterior vaginal mucosa and the posterior peritoneum.  Two additional sutures medially were placed and these were tagged and not tied in place.  A #0 Vicryl suture on a UR6 needle was used to perform the McCall's culdoplasty type approximation with the vaginal cuff to open and the uterosacral ligament visualized.  This was then tied in place and the remainder of the vaginal cuff was closed with #0 Chromic suture with figure-of-eight stitches.  At this time, the gloves were changed and attention was returned to the laparoscopic portion of the procedure at which time the abdomen was re-insufflated and the patient was placed in Trendelenburg.  The bowel was moved out of the way and copious suction irrigation was performed and all operative areas were noted to be hemostatic.  The bladder was again filled with approximately 400 cc methylene blue and from the laparoscopic ________ point there was no evidence of leakage of blue dye at this time.  The pneumoperitoneum was then evacuated and a cystoscopy was performed filling the bladder with approximately 400 cc of normal saline and there was noted to be a pinpoint perforation right on bladder dome which was found to be hemostatic and was not found to have any leakage at this time.  The bladder was then drained and the Foley catheter was replaced and after gloves changed, attention was turned to the abdomen with the laparoscopic instruments removed from the patient's abdomen.  The skin incisions were closed with #4-0 undyed Vicryl in a subcuticular fashion.  Approximately 10 cc of 0.25% Marcaine in total were injected at incision site for additional analgesia.  The Steri-Strips were placed.  The patient tolerated the procedure well and taken to recovery in stable condition.  Sponge, lap, and needle counts were correct x2.  The specimens include the uterus, cervix, bilateral ovaries, and fallopian tubes.  The patient will have her Foley catheter maintained for approximately 7 to 10 days.","surgery, pelvic inflammatory disease, pelvic adhesions, pelvic pain, fibroid uterus, enterocele, salpingo-oophorectomy, mccall's culdoplasty, cystoscopy, laparoscopic assisted vaginal hysterectomy, foley catheter, vaginal mucosa, vaginal cuff, bladder, ligament, clamps, suture, pelvic, uterus, vaginal, inflammatory, laparoscopic, "
 Endoscopic and microsurgical transnasal resection of cystic suprasellar tumor.  , Surgery, Cystic Suprasellar Tumor Resection ,"TITLE OF OPERATION:,  Endoscopic and microsurgical transnasal resection of cystic suprasellar tumor.,INDICATION FOR SURGERY: , She is a 3-year-old girl who is known to have a head injury and CT in 2005 was normal, presented with headache.  All endocrine labs were normal.  Surgery was recommended.,PREOP DIAGNOSIS: , Cystic suprasellar tumor.,POSTOP DIAGNOSIS:,  Cystic suprasellar tumor.,PROCEDURE DETAIL: , The patient was brought to operating room, underwent smooth induction of general endotracheal anesthesia, head was placed in the horseshoe head rest and positioned supine with head turned slightly towards left and slightly extended.  The patient was then prepped and draped in the usual sterile fashion.  With the assistance of fluoro and mapping the localization, the right nostril was infiltrated.  Dr. X will dictate the procedure of the approach.  Once the dura was visualized, there was a complex procedure secondary to the small nasal naris as well as the bony drilling that would necessitate significant drilling.  Once the operating microscope was in the field, at this point, the drilling was completed.  The dura was opened in cruciate fashion revealing normal pituitary, which was displaced and the cystic tumor.  This was then opened and using microsurgical technique with the curette suctioned and the pituitary calcifications were removed, several Valsalva maneuvers were performed without any evidence of CSF leak and trying to pull the tumor further down.  Once this was completed, there was no evidence of any bleeding.  The endoscope was then used to remove any residual fragments __________ with the arachnoid.  Once this was completely ensured, small piece of Duragel was placed and the closure will be dictated by Dr. X.  She was reversed, extubated, and transported to the ICU in stable condition.  Blood loss, minimal.  All sponge, needle counts were correct.","surgery, microsurgical transnasal resection, cystic suprasellar tumor, transnasal resection, endoscopic, transnasal, microsurgical, suprasellar, cystic, tumor, "
" CT-guided needle placement, CT-guided biopsy of right renal mass, and embolization of biopsy tract with gelfoam.", Surgery, CT-Guided Biopsy - Kidney ,"REASON FOR EXAM:  This 60-year-old female who was found to have a solid indeterminate mass involving the inferior pole of the right kidney was referred for percutaneous biopsy under CT guidance at the request of Dr. X.,PROCEDURE:  The procedure risks and possible complications including, but not limited to severe hemorrhage which could result in emergent surgery, were explained to the patient.  The patient understood.  All questions were answered, and informed consent was obtained.  With the patient in the prone position, noncontrasted CT localization images were obtained through the kidney.  Conscious sedation was utilized with the patient being monitored.  The patient was administered divided dose of Versed and fentanyl intravenously.,Following sterile preparation and local anesthesia to the posterior aspect of the right flank, an 18-gauge co-axial Temno-type needle was directed into the inferior pole right renal mass from the posterior oblique approach.  Two biopsy specimens were obtained and placed in 10% formalin solution.  CT documented needle placement.  Following the biopsy, there was active bleeding through the stylet, as well as a small hematoma about the inferior aspect of the right kidney posteriorly.  I placed several torpedo pledgets of Gelfoam through the co-axial sheath into the site of bleeding.  The bleeding stopped.  The co-axial sheath was then removed.  Bandage was applied.  Hemostasis was obtained.  The patient was placed in the supine position.  Postbiopsy CT images were then obtained.  The patient's hematoma appeared stable.  The patient was without complaints of pain or discomfort.  The patient was then sent to her room with plans of observing for approximately 4 hours and then to be discharged, as stable.  The patient was instructed to remain at bedrest for the remaining portions of the day at home and patient is to followup with Dr. Fieldstone for the results and follow-up care.,FINDINGS:  Initial noncontrasted CT localization images reveals the presence of an approximately 2.1 cm cortical mass involving the posterior aspect of the inferior pole of the right kidney.  Images obtained during the biopsy reveals the cutting portion of the biopsy needle to extend through the mass.  Images obtained following the biopsy reveals the development of a small hematoma posterior to the right kidney in its inferior pole adjacent to the mass.  There are small droplets of air within the hematoma.  No hydronephrosis is identified.,CONCLUSION:,1.  Percutaneous biopsy of inferior pole right renal mass under computed tomography guidance with specimen sent to laboratory in 10% formalin solution.,2.  Development of a small hematoma adjacent to the inferior pole of the right kidney with active bleeding through the biopsy needle stopped by tract embolization with Gelfoam pledgets.","surgery, embolization, ct localization, gelfoam pledgets, ct guided needle placement, ct guided biopsy, needle placement, renal mass, ct guided, inferior pole, ct, biopsy, hematoma, kidney, mass,"
" Right frontotemporal craniotomy and evacuation of hematoma, biopsy of membranes, microtechniques.", Surgery, Craniotomy - Frontotemporal  ,"PREOPERATIVE DIAGNOSIS:,  Right frontotemporal chronic subacute subdural hematoma.,POSTOPERATIVE DIAGNOSIS:,  Right frontotemporal chronic subacute subdural hematoma.,TITLE OF THE OPERATION: , Right frontotemporal craniotomy and evacuation of hematoma, biopsy of membranes, microtechniques.,ASSISTANT: , None.,INDICATIONS: , The patient is a 75-year-old man with a 6-week history of decline following a head injury.  He was rendered unconscious by the head injury.  He underwent an extensive syncopal workup in Mississippi.  This workup was negative.  The patient does indeed have a heart pacemaker.  The patient was admitted to ABCD three days ago and yesterday underwent a CT scan, which showed a large appearance of subdural hematoma.  There is a history of some bladder tumors and so a scan with contrast was obtained that showed some enhancement in the membranes.  I decided to perform a craniotomy rather than burr hole drainage because of the enhancing membranes and the history of a bladder tumor undefined as well as layering of the blood within the cavity.  The patient and the family understood the nature, indications, and risk of the surgery and agreed to go ahead.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room where general and endotracheal anesthesia was obtained.  The head was turned over to the left side and was supported on a cushion.  There was a roll beneath the right shoulder.  The right calvarium was shaved and prepared in the usual manner with Betadine-soaked scrub followed by Betadine paint.  Markings were applied.  Sterile drapes were applied.  A linear incision was made more or less along the coronal suture extending from just above the ear up to near the midline.  Sharp dissection was carried down into subcutaneous tissue and Bovie electrocautery was used to divide the galea and the temporalis muscle and fascia.  Weitlaner retractors were inserted.  A single bur hole was placed underneath the temporalis muscle.  I placed the craniotomy a bit low in order to have better cosmesis.  A cookie cutter type craniotomy was then carried out in dimensions about 5 cm x 4 cm.  The bone was set aside.  The dura was clearly discolored and very tense.  The dura was opened in a cruciate fashion with a #15 blade.  There was immediate flow of a thin motor oil fluid under high pressure.  Literally the fluid shot out several inches with the first nick in the membranous cavity.  The dura was reflected back and biopsy of the membranes was taken and sent for permanent section.  The margins of the membrane were coagulated.  The microscope was brought in and it was apparent there were septations within the cavity and these septations were for the most part divided with bipolar electrocautery.  The wound was irrigated thoroughly and was inspected carefully for any sites of bleeding and there were none.  The dura was then closed in a watertight fashion using running locking 4-0 Nurolon.  Tack-up sutures had been placed at the beginning of the case and the bone flap was returned to the wound and fixed to the skull using the Lorenz plating system.  The wound was irrigated thoroughly once more and was closed in layers.  Muscle fascia and galea were closed in separate layers with interrupted inverted 2-0 Vicryl.  Finally, the skin was closed with running locking 3-0 nylon.,Estimated blood loss for the case was less than 30 mL.  Sponge and needle counts were correct.,FINDINGS: , Chronic subdural hematoma with multiple septations and thickened subdural membrane.,I might add that the arachnoid was not violated at all during this procedure.  Also, it was noted that there was no subarachnoid blood but only subdural blood.","surgery, frontotemporal, weitlaner, calvarium, cookie cutter type, craniotomy, dura, frontotemporal craniotomy, galea, hematoma, subdural, subdural hematoma, syncopal, temporalis, subacute subdural hematoma, temporalis muscle,"
 Left temporal craniotomy and removal of brain tumor., Surgery, Craniotomy - Temporal ,"PREOPERATIVE DIAGNOSIS:,  Brain tumor left temporal lobe.,POSTOPERATIVE DIAGNOSIS:,  Brain tumor left temporal lobe - glioblastoma multiforme.,OPERATIVE PROCEDURE:,1.  Left temporal craniotomy.,2.  Removal of brain tumor.,OPERATING MICROSCOPE: , Stealth.,PROCEDURE: , The patient was placed in the supine position, shoulder roll, and the head was turned to the right side.  The entire left scalp was prepped and draped in the usual fashion after having being placed in 2-point skeletal fixation.  Next, we made an inverted-U fashion base over the asterion over temporoparietal area of the skull.  A free flap was elevated after the scalp that was reflected using the burr hole and craniotome.  The bone flap was placed aside and soaked in the bacitracin solution.,The dura was then opened in an inverted-U fashion.  Using the Stealth, we could see that this large cystic mass was just below the cortex in the white matter just anterior to the trigone of the ventricle.  We head through the vein of Labbe, and we made great care to preserve this.  We saw where the tumor almost made to the surface.  Here we made a small corticectomy using the Stealth for guidance.  We left small corticectomy entered large cavity with approximately 15 cc of yellowish necrotic liquid.  This was submitted to pathology.  We biopsied this very abnormal tissue and submitted it to pathology.  They gave us a frozen section diagnosis of glioblastoma multiforme.  With the operating microscope and Greenwood bipolar forceps, we then systematically debulked this tumor.  It was very vascular and we really continued to remove this tumor until all visible tumors was removed.  We appeared to get two gliotic planes circumferentially.  We could see it through the ventricle.  After removing all visible tumor grossly, we then irrigated this cavity multiple times and obtained meticulous hemostasis and then closed the dura primarily with 4-0 Nurolon sutures with the piece of DuraGen placed over this in order to increase our chances for a good watertight seal.  The bone flap was then replaced and sutured with the Lorenz titanium plate system.  The muscle fascia galea was closed with interrupted 2-0 Vicryl sutures.  Skin staples were used for skin closure.  The blood loss of the operation was about 200 cc.  There were no complications of the surgery per se.  The needle count, sponge count, and the cottonoid count were correct.,COMMENT:  ,Operating microscope was quite helpful in this; as we could use the light as well as the magnification to help us delineate the brain tumor - gliotic interface and while it was vague at sometimes we could I think clearly get a good cleavage plane in most instances so that we got a gross total removal of this very large and necrotic-looking tumor of the brain.","surgery, temporal lobe, brain tumor, lorenz titanium plate, burr hole, cortex, corticectomy, craniotome, craniotomy, frozen section, glioblastoma multiforme, temporal craniotomy, temporoparietal, ventricle, white matter, tumor, temporal, brain,"
" Acute left subdural hematoma.  Left frontal temporal craniotomy for evacuation of acute subdural hematoma.  CT imaging reveals an acute left subdural hematoma, which is hemispheric.", Surgery, Craniotomy - Frontotemporal - 1 ,"PREOPERATIVE DIAGNOSIS:,  Acute left subdural hematoma.,POSTOPERATIVE DIAGNOSIS:,  Acute left subdural hematoma.,PROCEDURE:,  Left frontal temporal craniotomy for evacuation of acute subdural hematoma.,DESCRIPTION OF PROCEDURE: , This is a 76-year-old man who has a history of acute leukemia.  He is currently in the phase of his therapy where he has developed a profound thrombocytopenia and white cell deficiency.  He presents after a fall in the hospital in which he apparently struck his head and now has a progressive neurologic deterioration consistent with an intracerebral injury.  His CT imaging reveals an acute left subdural hematoma, which is hemispheric.,The patient was brought to the operating room, placed under satisfactory general endotracheal anesthesia.  He had previously been intubated and taken to the Intensive Care Unit and now is brought for emergency craniotomy.  The images were brought up on the electronic imaging and confirmed that this was a left-sided condition.  He was fixed in a three-point headrest.  His scalp was shaved and prepared with Betadine, iodine and alcohol.  We made a small curved incision over the temporal, parietal, frontal region.  The scalp was reflected.  A single bur hole was made at the frontoparietal junction and then a 4x6cm bur hole was created.  After completing the bur hole flap, the dura was opened and a gelatinous mass of subdural was peeled away from the brain.  The brain actually looked relatively relaxed; and after removal of the hematoma, the brain sort of slowly came back up.  We investigated the subdural space forward and backward as we could and yet careful not to disrupt any venous bleeding as we close to the midline.  After we felt that we had an adequate decompression, the dura was reapproximated and we filled the subdural space with saline.  We placed a small drain in the extra dural space and then replaced the bone flap and secured this with the bone plates.  The scalp was reapproximated, and the patient was awakened and taken to the CT scanner for a postoperative scan to ensure that there was no new hemorrhage or any other intracerebral pathology that warranted treatment.  Given that this actual skin looked good with apparent removal of about 80% of the subdural we elected to take patient to the Intensive Care Unit for further management.,I was present for the entire procedure and supervised this.  I confirmed prior to closing the skin that we had correct sponge and needle counts and the only foreign body was the drain.","surgery, subdural, hematoma, temporal craniotomy, craniotomy, subdural space, bur hole, subdural hematoma, "
" Bilateral orbital frontal zygomatic craniotomy (skull base approach), bilateral orbital advancement with (C-shaped osteotomies down to the inferior orbital rim) with bilateral orbital advancement with bone grafts, bilateral forehead reconstruction with autologous graft.", Surgery, Craniotomy - Frontal Zygomatic ,"PREOPERATIVE DIAGNOSIS:,  Metopic synostosis with trigonocephaly.,POSTOPERATIVE DIAGNOSIS:,  Metopic synostosis with trigonocephaly.,PROCEDURES:  ,1.  Bilateral orbital frontal zygomatic craniotomy (skull base approach).,2.  Bilateral orbital advancement with (C-shaped osteotomies down to the inferior orbital rim) with bilateral orbital advancement with bone grafts.,3.  Bilateral forehead reconstruction with autologous graft.,4.  Advancement of the temporalis muscle bilaterally.,5.  Barrel-stave osteotomies of the parietal bones.,ANESTHESIA: , General.,PROCEDURE: , After induction of general anesthesia, the patient was placed supine on the operating room table with a roll under his shoulders and his head resting on a foam doughnut.  Scalp was clipped.  He was prepped with ChloraPrep.  Incision was infiltrated with 0.5% Xylocaine with epinephrine 1:200,000 and he received antibiotics and he was then reprepped and draped in a sterile manner.,A bicoronal zigzag incision was made and Raney clips used for hemostasis.  Subcutaneous flaps were developed and reflected anteriorly and slightly posteriorly.  These were subgaleal flaps.  Bipolar and Bovie cautery were used for hemostasis.  The craniectomy was outlined with methylene blue.  The pericranium was incised exposing the bone along the outline of the craniotomy.,Paired bur holes were drilled anteriorly and posteriorly straddling the metopic suture.  One was just above the nasion and the other was near the bregma.  Also bilateral pterional bur holes were drilled.  There was a little bit of bleeding from a tributary of the sagittal sinus anteriorly and so bone wax was used for hemostasis in all the bur holes.,The dura was separated with a #4 Penfield dissector and then the craniotomies were fashioned or cut.  I should say with the Midas Rex drill using the V5 bit and the footplate attachment, the bilateral craniotomies were cut and then the midline piece was elevated separately.  Great care was taken when removing the bone from the midline.  Bipolar cautery was used for bleeding points on the dura and especially over the sagittal sinus and the bleeding was controlled.,The wound was irrigated with bacitracin irrigation.,The next step was to perform the orbital osteotomies with careful protection of the orbital contents.  Osteotomies were made with the Midas Rex drill using the V5 bit in the orbital roof bilaterally.  This was a very thick and vertically oriented orbital roof on each side.  Midas Rex drill and osteotomes and mallet were used to cut these osteotomies using retractors to protect the orbital contents and the dura.  The osteotomies were carried down through the tripod of the orbit and down through the lateral orbital rim and all the way down to the inferior orbital rim using the osteotome and mallet.  Bone wax was used for hemostasis.  It was necessary to score the undersurface of the bone at the midline because it was so thick and pointed.  So we were not going to be able to effect the orbital advancement without scoring the bone and thinning it out a bit.  This was done with the Midas Rex drill using B5 bit.  Also, the marked ridge just above the nasion was burred down with the Midas Rex drill.  The osteotomies were also carried down through the zygoma.  At this point, with a gentle rocking motion and sustained pressure using the osteotomes, it was then possible to carefully advance the orbital rims bilaterally, first on the right and then on the left again using just a careful rocking motion against the remaining bone to gently bend the orbital rims outward bilaterally.,Dr. X cut the bone grafts from the bone flaps and I fashioned a shelf to secure the bone graft by burring a ledge on the internal surface of the superior orbital rim.  This created a shelf for the notched bone graft to lean against basically anteriorly.  The posterior notch of the bone graft was able to be braced by the ledge of orbital roof posteriorly.,The left medial orbital rim greenstick fractured a bit, but the bone graft appeared to stay in place.,Holes were then cut in the supraorbital rim for advancement of the temporalis muscle and then a Synthes mesh was placed anteriorly using absorbable screw hardware and attached the mesh where the forehead bone flaps turned around and recontoured to make a nice bilateral forehead for Isaac.,At this point the undersurface of the temporalis muscle was scored using the Bovie cautery to allow advancement of the muscle anteriorly and we sutured it to the supraorbital rims bilaterally with #3-0 Vicryl suture.  This helped fill-in the indentation left by the orbital advancement at the temporal region.,Also, I separated the undersurface of the dura from the bone bilaterally and cut multiple barrel-stave osteotomies in the parietal bones and then greenstick fractured these barrel-staves outward to create a more normal contour of the bone slightly posteriorly.,At this point, Gelfoam had been used to protect the dura over the sagittal sinus during this part of the procedure.,The wound was then irrigated with bacitracin irrigation.  Bleeding had been controlled during the procedure with Bovie and bipolar electrocautery, even so the blood loss was fairly significant adding up to about 300 or 400 mL and he received that much in packed cells and he also received a unit of fresh frozen plasma.,At this point, the reconstruction looked good.  The advancement was about 1 cm and we were pleased with the results.  The wound was irrigated and then the Gelfoam over the midline dura was left in place and the galea was then closed with #4-0 and some #3-0 Vicryl interrupted suture and #5-0 mild chromic on the skin.  The patient tolerated procedure well.  No complications.  Sponge and needle counts were correct.  Again, blood loss was bout 300 to 400 mL and he received 2 units of blood and some fresh frozen plasma.","surgery, metopic synostosis, trigonocephaly, bilateral orbital frontal zygomatic craniotomy, skull base approach, orbital advancement, c-shaped osteotomies, forehead reconstruction, temporalis muscle, midas rex drill, frontal zygomatic, sagittal sinus, orbital roof, orbital rim, bone grafts, forehead, bone, orbital, craniotomy, osteotomies, "
 Left retrosigmoid craniotomy and excision of acoustic neuroma., Surgery, Craniotomy - Retrosigmoid  ,"PREOPERATIVE DIAGNOSIS: , Left acoustic neuroma.,POSTOPERATIVE DIAGNOSIS: , Left acoustic neuroma.,PROCEDURE PERFORMED: , Left retrosigmoid craniotomy and excision of acoustic neuroma.,ANESTHESIA:,  General.,OPERATIVE FINDINGS: , This patient had a 3-cm acoustic neuroma.  The tumor was incompletely excised leaving a remnant of the tumor along the cerebellopontine angle portion of the facial nerve.  The facial nerve was stimulated at the brainstem at 0.05 milliamperes at the conclusion of the dissections.,PROCEDURE IN DETAIL:  ,Following induction of adequate general anesthetic, the patient was positioned for surgery.  She was placed in a lateral position and her head was maintained with Mayfield pins.  The left periauricular area was shaved, prepped, and draped in the sterile fashion.  Transdermal electrodes for continuous facial nerve EMG monitoring were placed, and no response was verified.  The proposed incision was injected with 1% Xylocaine with epinephrine.  Next, T-shaped incision was made approximately 5 cm behind the postauricular crease.  The incision was undermined at the level of temporalis fascia, and the portion of the fascia was harvested for further use.,Incision was made along the inferior aspect of the temporalis muscle and then extended inferiorly over the mastoid tip.  Periosteal elevator was used to elevate periosteum in order to expose the mastoid and anterior aspect of the occipital bone.  Emissary veins posterior to the sigmoid sinus were controlled with electrocautery and bone wax.  Bergen retractors were used to maintain exposure.  Using a cutting bur with continuous suction and irrigation of craniotomy was performed.  The sigmoid sinus was identified anteriorly and the transverse sites were identified superiorly.  From these structures approximately 4 x 4 cm, a window of bone was removed.  Bone shavings were collected during the dissection and placed in Siloxane suspension for later use.  The bone flap was also left at the site for further use.  Dissection was extended along the inferior aspect of the sigmoid sinus to provide additional exposure of the skull base.  Bone wax was used to occlude air cells lateral to the sigmoid sinus.  There was extensively aerated temporal bone.  At this point, Dr. Trask entered the case in order to open the dura and expose the tumor.  The cerebellum was retracted away from the tumor, and the retractor was placed to help maintain exposure.  Once initial exposure was completed, attention was directed to the posterior aspect of the temporal bone.  The dura was excised from around the porous acusticus extending posteriorly along the bone.  Then, using diamond burs, the internal auditory canal was dissected out.  The bone was removed laterally for distance of approximately 8 mm.  There was considerable aeration around the internal auditory canal as well.  The dura was then incised over the internal auditory canal exposing the intracanalicular portion of the tumor.  The tumor extended all the way to the fundus such that initial exposure of the facial nerve around the tumor was difficult.  Therefore, Dr. Trask returned in order to further release the tumor from the brainstem and to debulk the central portions of the tumor.  With dissection, he released the tumor from the trigeminal nerve superiorly and elevated the tumor away from the dorsal brainstem.  The eighth nerve was identified and transected.  Tumor debulking allowed for retraction of the tumor capsule away from the brainstem.  The facial nerve was difficult to identify at the brainstem as well.  It was identified by using an electrical stimulator but dissection attempted at this time was the plane between the nerve and the tumor proximally but this was difficult to achieve.  Attention was then redirected to the internal auditory canal where this portion of the tumor was removed.  The superior and inferior vestibular nerves were evulsed laterally and dissection proceeded along the facial nerve to the porous acusticus.  At this point, plane of dissection was again indistinct.  The tumor had been released from the porous and could be rotated.  The tumor was further debulked and thinned, but could not crucially visualize the nerve on the anterior face of the tumor.  The nerve could be stimulated, but was quite splayed over the anterior face.  Further debulking of the tumor proceeded and additional attempts were made to establish point of dissection along the nerve, both proximally and distally.  However, the cerebellopontine angle portion of the nerve was not usually delineated.  However, the tumor was then thinned using CUSA down to fine sheath measuring only about 1 to 2 mm in thickness.  It was released from the brainstem ventrally.  The tumor was then cauterized with bipolar electrocautery.  The facial nerve was stimulated at the brainstem and stimulated easily at 0.05 milliamperes.  Overall, the remaining tumor volume would be of small percentage of the original volume.  At this point, Dr. Trask re-inspected the posterior fossa to ensure complete hemostasis.  The air cells around the internal auditory canal were packed off with muscle and bone wax.  A piece of fascia was then laid over the bone defect.  Next, the dura was closed with DuraGen and DuraSeal.  The bone flap and bone ***** were then placed in the bone defect.  Postauricular musculature was then reapproximated using interrupted 3-0 Vicryl sutures.  The skin was also closed using interrupted subdermal 3-0 Vicryl sutures.  Running 4-0 nylon suture was placed at the skin levels.  Sterile mastoid dressing was then placed.  The patient tolerated the procedure well and was transported to the PACU in a stable condition.  All counts were correct at the conclusion of the procedure.,ESTIMATED BLOOD LOSS:  ,100 mL.","surgery, neuroma, bergen retractors, emissary veins, mayfield pins, acoustic, acoustic neuroma, cerebellopontine, craniotomy, facial nerve, periauricular, retrosigmoid, retrosigmoid craniotomy, internal auditory canal, porous acusticus, sigmoid sinus, auditory canal, bone, brainstem, nerve, postauricular, tumor"
" Occipital craniotomy, removal of large tumor using the inner hemispheric approach, stealth system operating microscope and CUSA.", Surgery, Craniotomy - Occipital ,"PREOPERATIVE DIAGNOSIS: , Brain tumors, multiple.,POSTOPERATIVE DIAGNOSES:,  Brain tumors multiple - adenocarcinoma and metastasis from breast.,PROCEDURE:,  Occipital craniotomy, removal of large tumor using the inner hemispheric approach, stealth system operating microscope and CUSA.,PROCEDURE:,  The patient was placed in the prone position after general endotracheal anesthesia was administered.  The scalp was prepped and draped in the usual fashion.  The CUSA was brought in to supplement the use of operating microscope as well as the stealth, which was used to localize the tumor.  Following this, we then made a transverse linear incision, the scalp galea was reflected and the quadrilateral bone flap was removed after placing burr holes in the midline and over the parietal areas directly over the tumor.  The bone flap was elevated.  The ultrasound was then used.  The ultrasound showed the tumors directly I believe are in the interhemispheric fissure.  We noticed that the dura was quite tense despite that the patient had slight hyperventilation.  We gave 4 ounce of mannitol, the brain became more pulsatile.  We then used the stealth to perform a ventriculostomy.  Once this was done, the brain began to pulsate nicely.  We then entered the interhemispheric space after we incised the dura in an inverted U fashion based on the superior side of the sinus.  After having done this we then used operating microscope and slight self-retaining retraction was used.  We obtained access to the tumor.  We biopsied this and submitted it.  This was returned as a malignant brain tumor - metastatic tumor, adenocarcinoma compatible with breast cancer.,Following this we then debulked this tumor using CUSA and then removed it in total.  After gross total removal of this tumor, the irrigation was used to wash the tumor bed and a meticulous hemostasis was then obtained using bipolar cautery.  The next step was after removal of this tumor, closure of the wound, a large piece of Duragen was placed over the dural defect and the bone flap was reapproximated and held secured with Lorenz plates.  The tumors self extend into the ventricle and after we had removed the tumor, we could see our ventricular catheter in the occipital horn of the ventricle.  This being the case, we left this ventricular catheter in, brought it out through a separate incision and connected to sterile drainage.  The next step was to close the wound after reapproximating the bone flap.  The galea was closed with 2-0 Vicryl and the skin was closed with interrupted 3-0 nylon sutures inverted with mattress sutures.  The sterile dressings were applied to the scalp.  The patient returned to the recovery room in satisfactory condition.  Hemodynamically remained stable throughout the operation.,Once again, we performed occipital craniotomy, total removal of her large metastatic tumor involving the parietal lobe using a biparietal craniotomy.  The tumor was removed using the combination of CUSA, ultrasound, stealth guided-ventriculostomy and the patient will have a second operation today, we will perform a selective craniectomy to remove another large tumor in the posterior fossa.","surgery, brain tumor, cusa, occipital, adenocarcinoma, bone flap, craniotomy, malignant, metastatic, scalp galea, transverse linear incision, ventriculostomy, occipital craniotomy, tumor, stealth, brain, "
" Biparietal craniotomy, insertion of left lateral ventriculostomy, right suboccipital craniectomy and excision of tumor.", Surgery, Craniotomy - Biparietal  ,"PREOPERATIVE DIAGNOSES: , Multiple metastatic lesions to the brain, a subtentorial lesion on the left, greater than 3 cm, and an infratentorial lesion on the right, greater than 3 cm.,POSTOPERATIVE DIAGNOSES: , Multiple metastatic lesions to the brain, a subtentorial lesion on the left, greater than 3 cm, and an infratentorial lesion on the right, greater than 3 cm.,TITLE OF THE OPERATION:,1.  Biparietal craniotomy and excision of left parietooccipital metastasis from breast cancer.,2.  Insertion of left lateral ventriculostomy under Stealth stereotactic guidance.,3.  Right suboccipital craniectomy and excision of tumor.,4.  Microtechniques for all the above.,5.  Stealth stereotactic guidance for all of the above and intraoperative ultrasound.,INDICATIONS: , The patient is a 48-year-old woman with a diagnosis of breast cancer made five years ago.  A year ago, she was diagnosed with cranial metastases and underwent whole brain radiation.  She recently has deteriorated such that she came to my office, unable to ambulate in a wheelchair.  Metastatic workup does reveal multiple bone metastases, but no spinal cord compression.  She had a consult with Radiation-Oncology that decided they could radiate her metastases less than 3 cm with stereotactic radiosurgery, but the lesions greater than 3 cm needed to be removed.  Consequently, this operation is performed.,PROCEDURE IN DETAIL: , The patient underwent a planning MRI scan with Stealth protocol.  She was brought to the operating room with fiducial still on her scalp.  General endotracheal anesthesia was obtained.  She was placed on the Mayfield head holder and rolled into the prone position.  She was well padded, secured, and so forth.  The neck was flexed so as to expose the right suboccipital region as well as the left and right parietooccipital regions.  The posterior aspect of the calvarium was shaved and prepared in the usual manner with Betadine soak scrub followed by Betadine paint.  This was done only, of course, after fiducial were registered in planning and an excellent accuracy was obtained with the Stealth system.  Sterile drapes were applied and the accuracy of the system was confirmed.  A biparietal incision was performed.  A linear incision was chosen so as to increase her chances of successful wound healing and that she is status post whole brain radiation.  A biparietal craniotomy was carried out, carrying about 1 cm over toward the right side and about 4 cm over to the left side as guided by the Stealth stereotactic system.  The dura was opened and reflected back to the midline.  An inner hemispheric approach was used to reach the very large metastatic tumor.  This was very delicate removing the tumor and the co-surgeons switched off to spare one another during the more delicate parts of the operation to remove the tumor.  The tumor was wrapped around and included the choroidal vessels.  At least one choroidal vessel was sacrificed in order to obtain a gross total excision of the tumor on the parietal occipital region.  Bleeding was quite vigorous in some of the arteries and finally, however, was completely controlled.  Complete removal of the tumor was confirmed by intraoperative ultrasound.,Once the tumor had been removed and meticulous hemostasis was obtained, this wound was left opened and attention was turned to the right suboccipital area.  A linear incision was made just lateral to the greater occipital nerve.  Sharp dissection was carried down in the subcutaneous tissues and Bovie electrocautery was used to reach the skull.  A burr hole was placed down low using a craniotome.  A craniotomy was turned and then enlarged as a craniectomy to at least 4 cm in diameter.  It was carried caudally to the floor of the posterior fossa and rostrally to the transverse sinus.  Stealth and ultrasound were used to localize the very large tumor that was within the horizontal hemisphere of the cerebellum.  The ventriculostomy had been placed on the left side with the craniotomy and removal of the tumor, and this was draining CSF relieving pressure in the posterior fossa.  Upon opening the craniotomy in the parietal occipital region, the brain was noted to be extremely tight, thus necessitating placement of the ventriculostomy.,At the posterior fossa, a corticectomy was accomplished and the tumor was countered directly.  The tumor, as the one above, was removed, both piecemeal and with intraoperative Cavitron Ultrasonic Aspirator.  A gross total excision of this tumor was obtained as well.,I then explored underneath the cerebellum in hopes of finding another metastasis in the CP angle; however, this was just over the lower cranial nerves, and rather than risk paralysis of pharyngeal muscles and voice as well as possibly hearing loss, this lesion was left alone and to be radiated and that it is less than 3 cm in diameter.,Meticulous hemostasis was obtained for this wound as well.,The posterior fossa wound was then closed in layers.  The dura was closed with interrupted and running mattress of 4-0 Nurolon.  The dura was watertight, and it was covered with blue glue.  Gelfoam was placed over the dural closure.  Then, the muscle and fascia were closed in individual layers using #0 Ethibond.  Subcutaneous was closed with interrupted inverted 2-0 and 0 Vicryl, and the skin was closed with running locking 3-0 Nylon.,For the cranial incision, the ventriculostomy was brought out through a separate stab wound.  The bone flap was brought on to the field.  The dura was closed with running and interrupted 4-0 Nurolon.  At the beginning of the case, dural tack-ups had been made and these were still in place.  The sinuses, both the transverse sinus and sagittal sinus, were covered with thrombin-soaked Gelfoam to take care of any small bleeding areas in the sinuses.,Once the dura was closed, the bone flap was returned to the wound and held in place with the Lorenz microplates.  The wound was then closed in layers.  The galea was closed with multiple sutures of interrupted 2-0 Vicryl.  The skin was closed with a running locking 3-0 Nylon.,Estimated blood loss for the case was more than 1 L.  The patient received 2 units of packed red cells during the case as well as more than 1 L of Hespan and almost 3 L of crystalloid.,Nevertheless, her vitals remained stable throughout the case, and we hopefully helped her survival and her long-term neurologic status for this really nice lady.","surgery, metastatic lesion, biparietal, mayfield head holder, microtechniques, stealth, craniotomy, excision, fiducial, infratentorial, parietooccipital, stereotactic, suboccipital, subtentorial, ventriculostomy, lesions to the brain, removal of the tumor, parietal occipital region, running locking nylon, biparietal craniotomy, posterior fossa, tumor, brain, dura, lesions, "
" Cystoscopy, cryosurgical ablation of the prostate.", Surgery, Cryosurgical Ablation of Prostate ,"PREOPERATIVE DIAGNOSIS:  ,Carcinoma of the prostate, clinical stage T1C.,POSTOPERATIVE DIAGNOSIS: , Carcinoma of the prostate, clinical stage T1C.,TITLE OF OPERATION: , Cystoscopy, cryosurgical ablation of the prostate.,FINDINGS:  ,After measurement of the prostate, we decided to place 5 rows of needles--row #1 had 3 needles, row #2 at the level of the mid-prostate had 4 needles, row #3 had 2 needles in the right lateral peripheral zone, row #4 was a single needle directly the urethra, and in row #5 were 2 needles placed in the left lateral peripheral zone.  Because of the length of the prostate, a pull-back was performed, pulling row #2 approximately 3 mm and rows #3, #4 and #5 approximately 1 cm back before refreezing.,OPERATION IN DETAIL: , The patient was brought to the operating room and placed in the supine position.  After adequate general endotracheal anesthesia was obtained, the patient was positioned in the dorsal lithotomy position.  Full bowel prep had been obtained prior to the procedure.  After performing flexible cystoscopy, a Foley catheter was placed per urethra into the bladder.  Next, the ultrasound probe was placed into the stabilizer and advanced into the rectum.  An excellent ultrasound image was visualized of the entire prostate, which was re-measured.  Next, the probe template was positioned over the perineum and the template guide brought up on the ultrasound screen in order to guide needle placement.  Then 17-gauge needles were serially placed into the prostate, from an anterior to posterior direction into the prostate.  Ultrasound guidance demonstrated that these needles, numbering approximately 14 to 15 needles, were well placed and spaced throughout the prostate to obtain excellent freezing of the entire gland while sparing the urethra.  Repeat cystoscopy demonstrated a single needle passing through the urethra; and due to the high anterior location of this needle, it was removed.  The CMS urethral warmer was then passed per urethra into the bladder, and flow instituted.  After placing these 17-gauge needles, the prostate was then frozen down to minus 150 degrees for 10 minutes in sequential fashion from anterior to posterior.  The ice ball was monitored and was seen to extend through the capsule of the prostate toward the rectum but not through the rectal wall itself.  Active warming was then performed before refreezing the prostate again and then passively warming it back to room temperature.  The urethral warmer was left on after the needles were removed and the patient brought to the recovery room.  The patient tolerated the procedure well and left the operating room in stable condition.","surgery, carcinoma of the prostate, ablation, cystoscopy, cryosurgical ablation, prostate, ultrasound, cryosurgical, urethra, "
 Right frontal craniotomy with resection of right medial frontal brain tumor.  Stereotactic image-guided neuronavigation and  microdissection and micro-magnification for resection of brain tumor., Surgery, Craniotomy & Neuronavigation ,"PROCEDURES:,1.  Right frontal craniotomy with resection of right medial frontal brain tumor.,2.  Stereotactic image-guided neuronavigation for resection of tumor.,3.  Microdissection and micro-magnification for resection of brain tumor.,ANESTHESIA: , General via endotracheal tube.,INDICATIONS FOR THE PROCEDURE:  ,The patient is a 71-year-old female with a history of left-sided weakness and headaches.  She has a previous history of non-small cell carcinoma of the lung, treated 2 years ago.  An MRI was obtained which showed a large enhancing mass in the medial right frontal lobe consistent with a metastatic lesion or possible primary brain tumor.  After informed consent was obtained, the patient was brought to the operating room for surgery.,PREOPERATIVE DIAGNOSES: , Medial right frontal brain tumor with surrounding edema and mass effect and right to left brain shift.,POSTOPERATIVE DIAGNOSES: , Medial right frontal brain tumor with surrounding edema and mass effect and right to left brain shift, probable metastatic lung carcinoma.,DESCRIPTION OF THE PROCEDURE: , The patient was wheeled into the operating room and satisfactory general anesthesia was obtained via endotracheal tube.  She was positioned on the operating room table in the Sugita frame with the head secured.,Using the preoperative image-guided MRI, we carefully registered the fiducials and then obtained the stereotactic image-guided localization to guide us towards the tumor.  We marked external landmarks.  Then we shaved the head over the right medial frontal area.  This area was then sterilely prepped and draped.,Evoked potential monitoring and sensory potentials were carried out throughout the case and no changes were noted.,A horseshoe shaped flap was based on the right and then brought across to the midline.  This was opened and hemostasis obtained using Raney clips.  The skin flap was retracted medially.  Two burr holes were made and were carefully connected.  One was placed right over the sinus and we carefully then removed a rectangular shaped bone flap.  Hemostasis was obtained.  Using the neuronavigation, we identified where the tumor was.  The dura was then opened based on a horseshoe flap based on the medial sinus.  We retracted this medially and carefully identified the brain.  The brain surface was discolored and obviously irritated consistent with the tumor.,We used the stereotactic neuronavigation to identify the tumor margins.,Then we used a bipolar to coagulate a thin layer of brain over the tumor.  Subsequently, we entered the tumor.  The tumor itself was extremely hard.  Specimens were taken and send for frozen section analysis, which showed probable metastatic carcinoma.,We then carefully dissected around the tumor margins.,Using the microscope, we then brought microscopic magnification and dissection into the case.  We used paddies and carefully developed microdissection planes all around the margins of the tumor superiorly, medially, inferiorly, and laterally.,Then using the Cavitron, we cored out the central part of the tumor.  Then we collapsed the tumor on itself and removed it entirely.  In this fashion, microdissection and magnification resection of the tumor was carried out.  We resected the entire tumor.  Neuronavigation was used to confirm that no further tumor residual was remained.,Hemostasis was obtained using bipolar coagulation and Gelfoam.  We also lined the cavity with Surgicel.  The cavity was nicely dry and excellent hemostasis was obtained.,The dura was closed using multiple interrupted 4-0 Nurolon sutures in a watertight fashion.  Surgicel was placed over the dural closure.  The bone flap was repositioned and held in place using CranioFIX cranial fixators.  The galea was re-approximated and the skin was closed with staples.  The wound was dressed.  The patient was returned to the intensive care unit.  She was awake and moving extremities well.  No apparent complications were noted.  Needle and sponge counts were listed as correct at the end of the procedure.  Estimated intraoperative blood loss was approximately 150 mL and none was replaced.","surgery, stereotactic image-guided neuronavigation, micro-magnification, resection of brain tumor, frontal craniotomy, mass effect, brain shift, stereotactic image, brain tumor, brain, tumor, craniotomy, endotracheal, carcinoma, neuronavigation, microdissection, "
 Right-sided craniotomy for evacuation of a right frontal intracranial hemorrhage.  Status post orbitozygomatic resection of a pituitary tumor with a very large intracranial component basically a very large skull-based brain tumor., Surgery, Craniotomy ,"TITLE OF OPERATION: , Right-sided craniotomy for evacuation of a right frontal intracranial hemorrhage.,INDICATION FOR SURGERY: , The patient is very well known to our service.  In brief, the patient is status post orbitozygomatic resection of a pituitary tumor with a very large intracranial component basically a very large skull-based brain tumor.  He was taken to the operating room for the orbitozygomatic approach.  Intraoperatively, everything went well without any complications.  The brain at the end of the procedure was absolutely intact, but the patient developed a seizure in the Intensive Care Unit and then was taken to the CT scan, developed a second seizure.  He was given Ativan for this, and then began to identify a large component measuring about 3 x 3 cm of the right frontal lobe, what appeared to be a hemorrhagic conversion of potential venous infarct.  I had a long discussion immediately with Dr. X and Dr. Y.  We decided to take the patient immediately as a level 1 for evacuation of this hematoma with a small amount of a midline shift with an intraventricular component.  It worried me and I think that we needed to go ahead and take him to the operating room immediately.  The patient was taken as a level 1 immediately and emergently and into the operating room for this procedure.  The original plan was to do first a right-sided orbitozygomatic procedure and then stage it a few weeks later with an endonasal endoscopic procedure for resection of this pituitary tumor component.  He was taken to the operating room for evacuation of a right frontal intraparenchymal hematoma.,PREOP DIAGNOSIS:,  Pituitary tumor with a large intracranial component, status post resection and now development of an intracranial hemorrhage.,POSTOP DIAGNOSIS:,  Intracranial hemorrhage in the right frontal lobe with extension into the intraventricular space after resection of a pituitary tumor via orbitozygomatic approach.,ANESTHESIA: , General.,PROCEDURE IN DETAIL: , The patient was taken to the operating room.  In the supine position, his head was put in a horseshoe without any complications.  The patient tolerated this very well, and the prior incision was immediately opened.  The surgery had taken place a few hours prior to this, the original orbitozygomatic approach.  At this point, this was a life-saving procedure.  We went ahead, opened the old incision after everything was sterilely prepped, and all the surgical instrumentation was brought into place.  We went ahead and opened the incision and took out the pterional bone flap without any complications.  We immediately opened the dura expeditiously, and the brain was moderately under some pressure, but not really bulging out.  So I went ahead and identified an area over the right frontal lobe that was a little bit consistent with a hemorrhagic infarct and nonviable tissue.  So we went ahead and did a corticectomy right there and identified the actual clot immediately and went ahead, and over the next few hours, very meticulously began to evacuate these clots without any complication whatsoever.  We went all the way down to the ventricle and identified this clot in the ventricle and went ahead and removed this clot without any complications, and we had a very nice resection.  The brain was very relaxed.  We had a very good resection of the actual blood clot, and the brain was very relaxed.  We irrigated thoroughly.  We identified the ventricles.  We went ahead and did a very careful hemostasis with Avitene with thrombin and Gelfoam with thrombin over the next times in doing the procedure.  All this was done very well, and then we lined the cavity with Surgicel, and the Surgicel was only put at the edge and draping down as to not to leave any fragments potentially to communicate with the actual ventricle, and then after this, everything was good.  We went ahead and closed back the actual dura back.  We had done a pericranial flap.  This was also put back in place and the dura was closed with 4-0 Surgilons.  We reconstructed everything.  The frontal sinus was reconstructed thoroughly without any complications.  We went ahead and put once again a watertight closure and went ahead and put another piece of DuraGen with Hemaseel in place, and went ahead and put the bone flap back and reconstructed very nicely once again with self-tapping, self-drilling screws, low-profile plates.  Once everything was confirmed to be in place, we went ahead and closed the muscle flap and also the actual fat pad was put back into place and closed together with 0 pop-offs, and the skin with staples without any complications.  In summary, the procedure was going back to the operating room for evacuation of a right-sided intracranial hemorrhage, most likely a conversion of an intraparenchymal hematoma with extension into the ventricle without any complications.  So everything was stable.  Estimated blood loss was about 100 cubic centimeters.  The sponges and needle counts were correct.  No specimens were sent to pathology.,DISPOSITION: , The patient after this procedure was brought to the Neuro Intensive Care Unit for close observation.","surgery, orbitozygomatic, intracranial, brain tumor, intraparenchymal hematoma, orbitozygomatic approach, frontal lobe, intracranial hemorrhage, pituitary tumor, craniotomy, hemorrhage,"
 Right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain., Surgery, Craniotomy - Burr Hole  ,"PREOPERATIVE DIAGNOSIS: , Right chronic subdural hematoma.,POSTOPERATIVE DIAGNOSIS: ,Right chronic subdural hematoma.,TYPE OF OPERATION: , Right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , 100 cc.,OPERATIVE PROCEDURE:,  In preoperative identification, the patient was taken to the operating room and placed in supine position.  Following induction of satisfactory general endotracheal anesthesia, the patient was prepared for surgery.  Table was turned.  The right shoulder roll was placed.  The head was turned to the left and rested on a doughnut.  The scalp was shaved, and then prepped and draped in usual sterile fashion.  Incisions were marked along a putative right frontotemporal craniotomy frontally and over the parietal boss.  The parietal boss incision was opened.  It was about an inch and a half in length.  It was carried down to the skull.  Self-retaining retractor was placed.  A bur hole was now fashioned with the perforator.  This was widened with a 2-mm Kerrison punch.  The dura was now coagulated with bipolar electrocautery.  It was opened in a cruciate-type fashion.  The dural edges were coagulated back to the bony edges.  There was egress of a large amount of liquid.  Under pressure, we irrigated for quite sometime until irrigation was returning mostly clear.  A subdural drain was now inserted under direct vision into the subdural space and brought out through a separate stab incision.  It was secured with a 3-0 nylon suture.  The area was closed with interrupted inverted 2-0 Vicryl sutures.  The skin was closed with staples.  Sterile dressing was applied.  The patient was subsequently returned back to anesthesia.  He was extubated in the operating room, and transported to PACU in satisfactory condition.","surgery, hematoma, burr hole, craniotomy, frontotemporal, frontotemporal craniotomy, subdural, subdural drain, subdural hematoma, subdural space"
 Anterior cranial vault reconstruction with fronto-orbital bar advancement., Surgery, Cranial Vault Reconstruction ,"INDICATION FOR OPERATION:,  Right coronal synostosis with left frontal compensatory bossing causing plagiocephaly.,PREOPERATIVE DIAGNOSIS:,  Syndromic craniosynostosis.,POSTOPERATIVE DIAGNOSIS: , Syndromic craniosynostosis.,TITLE OF OPERATION: , Anterior cranial vault reconstruction with fronto-orbital bar advancement.,SPECIMENS: , None.,DRAINS: , One subgaleal drain exiting from the left posterior aspect of wound.,DESCRIPTION OF PROCEDURE:,  After satisfactory general endotracheal tube anesthesia was started, the patient was placed on the operating table in supine position with the head held on a horseshoe-shaped headrest and the head was prepped and draped down the routine manner.  Here, the proposed scalp incision was infiltrated with 1% Xylocaine and then a zigzag scalp incision was made from one ear to the other ear, posterior to the coronal suture.  Scalp incision was reflected anteriorly and then the periosteum was taken off of the bone and then the temporalis muscles were reflected anterolaterally until the anterior cranial vault was exposed and then the periorbital rim, nasion and orbital part of the zygomatic arch were all dissected out as well as the pterion.  Using a craniotome, several bur holes were made; two on the either side of the midline posteriorly and then two posterolaterally.  The two posterior bur holes were then connected with a punch over the superior sagittal sinus and then the craniotome was used to fashion a flap first on the left and then on the right, going paramedian along the superior sagittal sinus in the midline and then curving over the fronto-orbital bar.  We then dissected superior sagittal sinus off of the inner table of the right bundle flap and then connected the right bundle flap going across the pterion on the right, which was abnormal.  The pterion on the right was then run short down after removing both bone flaps and then the dura was dissected off from the orbital roofs.  On the right, the orbital roof was jagged and abnormal and we had to repair a CSF leak from where the dura was punctured by the orbital roof.  The orbital rim was then dissected out and then using the saw and chisels, we were able to make the releasing cuts to free up the orbital rims, zygomatic arch and then remove the orbital bar going posteriorly and then the distal bar was split in the middle and then reapproximated with a bone graft in the middle to move the orbits out a little bit and the orbital bar was held together using absorbable plate.  It was then replaced and advanced and then relaxing, barrel-staving incisions were made in the bone flaps and the orbital rim and it was held on the right side with an absorbable plate to fix it in the proper position.  The bone flaps were then reapproximated using absorbable plates and screws, as well as #2-0 Vicryl to secure back into place.  Some of the places were also secured in the midline posteriorly, as well as off to the right where the bony defects were in place.  The periosteum was then brought over the skull and fastened in place and the temporalis muscles were tacked up to the periosteum.  The wounds were irrigated out.  A drain was left in posteriorly and then the wounds were closed in a routine manner using Vicryl for the galea and fast-absorbing gut for the skin followed by sterile dressings.  The patient tolerated the procedure well and did receive blood transfusions.","surgery, coronal synostosis, syndromic craniosynostosis, craniosynostosis, plagiocephaly, fronto-orbital bar, cranial vault reconstruction, cranial vault, orbital bar, orbital, cranial,"
 Selective coronary angiography.  Placement of overlapping 3.0 x 18 and 3.0 x 8 mm Xience stents in the proximal right coronary artery.  Abdominal aortography., Surgery, Coronary Angiography & Abdominal Aortography ,"NAME OF PROCEDURE,1.  Selective coronary angiography.,2.  Placement of overlapping 3.0 x 18 and 3.0 x 8 mm Xience stents in the proximal right coronary artery.,3.  Abdominal aortography.,INDICATIONS:  ,The patient is a 65-year-old gentleman with a history of exertional dyspnea and a cramping-like chest pain.  Thallium scan has been negative.  He is undergoing angiography to determine if his symptoms are due to coronary artery disease.,NARRATIVE:  ,The right groin was sterilely prepped and draped in the usual fashion and the area of the right coronary artery anesthetized with 2% lidocaine.  Constant sedation was obtained using Versed 1 mg and fentanyl 50 mcg.  Received additional Versed and fentanyl during the procedure.  Please refer to the nurses' notes for dosages and timing.,The right femoral artery was entered and a 4-French sheath was placed.  Advancement of the guidewire demonstrated some obstruction at the level of abdominal aorta.  Via the right Judkins catheter, the guidewire was easily infiltrated to the thoracic aorta and over aortic arch.  The right Judkins catheter was advanced to the origin of the right coronary artery where selective angiograms were performed.  This revealed a very high-grade lesion at the proximal right coronary artery.  This catheter was exchanged for a left #4 Judkins catheter which was advanced to the ostium of the left main coronary artery where selective angiograms were performed.,The patient was found to have the above mentioned high-grade lesion in the right coronary artery and a coronary intervention was performed.  A 6-French sheath and a right Judkins guide was placed.  The patient was started on bivalarudin.  A BMW wire was easily placed across the lesion and into the distal right coronary artery.  A 3.0 x 15 mm Voyager balloon was placed and deployed at 10 atmospheres.  The intermediate result was improved with TIMI-3 flow to the terminus of the vessel.  Following this, a 3.0 x 18 mm Xience stent was placed across the lesion and deployed at 17 atmospheres.  This revealed excellent result however at the very distal of the stent there was an area of haziness but no definite dissection.  This was stented with a 3.0 x 8 mm Xience stent deployed again at 17 atmospheres.  Final angiograms revealed excellent result with TIMI-3 flow at the terminus of the right coronary artery and approximately 10% residual stenosis at the worst point of the narrowing.  The guiding catheter was withdrawn over wire and a pigtail was placed.  This was advanced to the abdominal aorta at the area of obstruction and small injection of contrast was given demonstrating that there was a small aneurysm versus a small retrograde dissection in that area with some dye hang up after injection.  The catheter was removed.  The bivalarudin was stopped at the termination of procedure.  A small injection of contrast given through arterial sheath and Angio-Seal was placed without incident.,It should also be noted that an 8-French sheath was placed in the right femoral vein.  This was placed initially as the patient was going to have a right heart catheterization as well because of the dyspnea.,Total contrast media, 205 mL, total fluoroscopy time was 7.5 minutes, X-ray dose, 2666 milligray.,HEMODYNAMICS: , Rhythm was sinus throughout the procedure.  Aortic pressure was 170/81 mmHg.,The right coronary artery is a dominant vessel.  This vessel gives rise to conus branch and two small RV free wall branches and PDA and a small left ventricular branch.  It should be noted that there was competitive flow in the posterior left ventricular branch and that the distal right coronary artery fills via left sided collaterals.  In the proximal right coronary artery, there is a large ulcerative plaque followed immediately by a severe stenosis that is subtotal in severity.  After intervention, there is TIMI-3 flow to the terminus of the right coronary with better fill into the distal right coronary artery and loss of competitive flow.  There was approximately 10% residual stenosis at the worst part of the previous stenosis.,The left main is without disease and trifurcates into a moderate-sized ramus intermedius, the LAD and the circumflex.  The ramus intermedius is free of disease.  The LAD terminates at the LV apex and has elongated area of mild stenosis at its mid segment.  This measures 25% to 30% at its worst point.  The circumflex is a large caliber vessel.  There is a proximal 15% to 20% stenosis and an area of ectasia in the proximal circumflex.  Distally, this circumflex gives rise to a large bifurcating marginal artery and beyond that point, the circumflex is a small vessel within the AV groove.,The aortogram demonstrates eccentric aneurysm formation.  This may represent a small retrograde dissection as well.  There was some dye hang up in the wall.,IMPRESSION,1.  Successful stenting of subtotal stenosis of the proximal coronary artery.,2.  Non-obstructive coronary artery disease in the mid left anterior descending as described above and ectasia of the proximal circumflex coronary artery.,3.  Left to right collateral filling noted prior to coronary intervention.,4.  Small area of eccentric aneurysm formation in the abdominal aorta.","surgery, xience stents, thallium scan, coronary artery, coronary angiography, abdominal aortography, artery, coronary, angiography, stents, flow, vessel, abdominal, catheter, circumflex, stenosis, proximal,"
 Postoperative hemorrhage. Examination under anesthesia with control of right parapharyngeal space hemorrhage.  The patient is a 35-year-old female with a history of a chronic pharyngitis and obstructive adenotonsillar hypertrophy. , Surgery, Control of Parapharyngeal Hemorrhage ,"PREOPERATIVE DIAGNOSIS: , Postoperative hemorrhage.,POSTOPERATIVE DIAGNOSIS:,  Postoperative hemorrhage.,SURGICAL PROCEDURE:  ,Examination under anesthesia with control of right parapharyngeal space hemorrhage.,ANESTHESIA:  ,General endotracheal technique.,SURGICAL FINDINGS: , Right lower pole bleeder cauterized with electrocautery with good hemostasis.,INDICATIONS FOR SURGERY: , The patient is a 35-year-old female with a history of a chronic pharyngitis and obstructive adenotonsillar hypertrophy.  Previously, in the day she had undergone a tonsillectomy with adenoidectomy and was recovering without difficulty.  However, in the PACU after a coughing spell she began bleeding from the right oropharynx, and was taken back to the operative suite for control of hemorrhage.,DESCRIPTION OF SURGERY:  ,The patient was placed supine on the operating room table and general anesthetic was administered, once appropriate anesthetic findings achieved the patient was intubated and then prepped and draped in usual sterile manner for a parapharyngeal space hemorrhage.  A Crowe-Davis type mouth gag was introduced in the oropharynx and under operating headlight the oropharynx was clearly visualized.  There was a small bleeder present at the inferior mid pole of the right oropharynx in the tonsillar fossa, this area was cauterized with suction cautery and irrigated.  There was no other bleeding noted.  The patient was repositioned and the mouth gag, the tongue was rotated to the left side of the mouth and the right parapharyngeal space carefully examined.  There was a small amount of oozing noted in the right tonsillar bed, and this was cauterized with suction cautery.  No other bleeding was noted and the patient was recovered from general anesthetic.  She was extubated and left the operating room in good condition to postoperative recovery room area.  Prior to extubation the patient's tonsillar fossa were injected with a 6 mL of 0.25% Marcaine with 1:100,000 adrenalin solution to facilitate postoperative analgesia and hemostasis.","surgery, obstructive adenotonsillar hypertrophy, tonsillar fossa, suction cautery, postoperative hemorrhage, parapharyngeal space, anesthesia, oropharynx, parapharyngeal, tonsillectomy, hemorrhage,"
" Lateral and plantar condylectomy, fifth left metatarsal.", Surgery, Condylectomy ,"TITLE OF OPERATION:,  Lateral and plantar condylectomy, fifth left metatarsal.,PREOPERATIVE DIAGNOSIS: , Prominent, lateral, and plantar condyle hypertrophy, fifth left metatarsal.,POSTOPERATIVE DIAGNOSIS: , Prominent, lateral, and plantar condyle hypertrophy, fifth left metatarsal.,ANESTHESIA:  ,Monitored anesthesia care with 10 mL of 1:1 mixture of both 0.5% Marcaine and 1% lidocaine plain.,HEMOSTASIS:,  30 minutes, left ankle tourniquet set at 250 mmHg.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,MATERIALS USED: , 3-0 Vicryl and 4-0 Vicryl.,INJECTABLES:,  Ancef 1 g IV 30 minutes preoperatively.,DESCRIPTION OF THE PROCEDURE: , The patient was brought to the operating room and placed on the operating table in a supine position.  After adequate sedation was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's left foot to anesthetize the future surgical sites.  The left ankle was covered with cast padding and an 18-inch ankle tourniquet was placed around the left ankle and set at 250 mmHg.  The left foot was then prepped, scrubbed, and draped in a normal sterile technique.  The left ankle tourniquet was inflated.  Attention was then directed on the dorsolateral aspect of the fifth left metatarsophalangeal joint where a 4-cm linear incision was placed over the fifth left metatarsophalangeal joint parallel and lateral to the course of the extensor digitorum longus to the fifth left toe.  The incision was deepened through the subcutaneous tissues.  All the bleeders were identified, cut, clamped, and cauterized.  The incision was deepened to the level of the capsule and the periosteum of the fifth left metatarsophalangeal joint.  All the tendinous and neurovascular structures were identified and retracted from the site to be preserved.  Using sharp and dull dissection, the soft tissue attachments through the fifth left metatarsal head were mobilized.  The lateral and plantar aspect of the fifth left metatarsal head were adequately exposed and using the sagittal saw a lateral and plantar condylectomy of the fifth left metatarsal head were then achieved.  The bony prominences were removed and passed off the operating table to be sent to pathology for identification.  The remaining sharp edges of the fifth left metatarsal head were then smoothened with the use of a dental rasp.  The area was copiously flushed with saline.  Then, 3-0 Vicryl and 4-0 Vicryl suture materials were used to approximate the periosteal, capsular, and subcutaneous tissues respectively.  The incision was reinforced with Steri-Strips.  Range of motion of the fifth left metatarsophalangeal joint was tested and was found to be excellent and uninhibited.  The patient's left ankle tourniquet at this time was deflated.  Immediate hyperemia was noted to the entire left lower extremity upon deflation of the cuff.  The patient's incision was covered with Xeroform, copious amounts of fluff and Kling, stockinette, and Ace bandage and the patient's left foot was placed in a surgical shoe.  The patient was then transferred to the recovery room under the care of the anesthesia team with her vital signs stable and her vascular status at appropriate levels.  The patient was given pain medications and instructions on how to control her postoperative course.  She was discharged from Hospital according to nursing protocol and was will follow up with Dr. X in one week's time for her first postoperative appointment.","surgery, plantar condyle hypertrophy, condyle hypertrophy, subcutaneous tissues, ankle tourniquet, metatarsophalangeal joint, metatarsal head, plantar condylectomy, tourniquet, condylectomy, plantar, ankle, metatarsal,"
" Selective coronary angiography, left heart catheterization with hemodynamics, LV gram with power injection, right femoral artery angiogram, closure of the right femoral artery using 6-French AngioSeal.", Surgery, Coronary Angiography ,"REASON FOR EXAM: , Dynamic ST-T changes with angina.,PROCEDURE:,1.  Selective coronary angiography.,2.  Left heart catheterization with hemodynamics.,3.  LV gram with power injection.,4.  Right femoral artery angiogram.,5.  Closure of the right femoral artery using 6-French AngioSeal.,Procedure explained to the patient, with risks and benefits.  The patient agreed and signed the consent form.,The patient received a total of 2 mg of Versed and 25 mcg of fentanyl for conscious sedation.  The patient was draped and dressed in the usual sterile fashion.  The right groin area infiltrated with lidocaine solution.  Access to the right femoral artery was successful, okayed with one attempt with anterior wall stick.  Over a J-wire, 6-French sheath was introduced using modified Seldinger technique.,Over the J-wire, a JL4 catheter was passed over the aortic arch.  The wire was removed.  Catheter was engaged into the left main.  Multiple pictures with RAO caudal, AP cranial, LAO cranial, shallow RAO, and LAO caudal views were all obtained.  Catheter disengaged and exchanged over J-wire into a JR4 catheter, the wire was removed.  Catheter with counter-clock was rotating to the RCA one shot with LAO, position was obtained.  The cath disengaged and exchanged over J-wire into a pigtail catheter.  Pigtail catheter across the aortic valve.  Hemodynamics obtained.  LV gram with power injection of 36 mL of contrast was obtained.,The LV gram assessed followed by pullback hemodynamics.,The catheter exchanged out and the right femoral artery angiogram completed to the end followed by the removal of the sheath and deployment of 6-French AngioSeal with no hematoma.  The patient tolerated the procedure well with no immediate postprocedure complication.,HEMODYNAMICS:  ,The aortic pressure was 117/61 with a mean pressure of 83.  The left ventricular pressure was 119/9 to 19 with left ventricular end-diastolic pressure of 17 to 19 mmHg.  The pullback across the aortic valve reveals zero gradient.,ANATOMY:  ,The left main showed minimal calcification as well as the proximal LAD.  No stenosis in the left main seen, the left main bifurcates in to the LAD and left circumflex.,The LAD was a large and a long vessel that wraps around the apex showed no focal stenosis or significant atheromatous plaque and the flow was TIMI 3 flow in the LAD.  The LAD gave off two early diagonal branches.  The second was the largest of the two and showed minimal lumen irregularities, but no focal stenosis.,Left circumflex was a dominant system supplying three obtuse marginal branches and distally supplying the PDA.  The left circumflex was large and patent, 6.0 mm in diameter.  All three obtuse marginal branches appeared to be with no significant stenosis.,The obtuse marginal branch, the third OM3 showed at the origin about 30 to 40% minimal narrowing, but no significant stenosis.  The PDA was wide, patent, with no focal stenosis.,The RCA was a small nondominant system with no focal stenosis and supplying the RV marginal.,LV gram showed that the LV EF is preserved with EF of 60%.  No mitral regurgitation identified.,IMPRESSION:,1.  Patent coronary arteries with normal left anterior descending, left circumflex, and dominant left circumflex system.,2.  Nondominant right, which is free of atheromatous plaque.,3.  Minimal plaque in the diagonal branch II, and the obtuse,marginal branch III, with no focal stenosis.,4.  Normal left ventricular function.,5.  Evaluation for noncardiac chest pain would be recommended.", 
 Cauterization of peri and intra-anal condylomas.  Extensive perianal and intra-anal condyloma which are likely represent condyloma acuminata., Surgery, Condyloma Cauterization ,"PREOPERATIVE DIAGNOSIS: , Extensive perianal and intra-anal condyloma.,POSTOPERATIVE DIAGNOSIS: , Extensive perianal and intra-anal condyloma.,PROCEDURE PERFORMED:,  Cauterization of peri and intra-anal condylomas.,ANESTHESIA:  ,IV sedation and local.,SPECIMEN: , Multiple condylomas were sent to pathology.,ESTIMATED BLOOD LOSS: , 10 cc.,BRIEF HISTORY: , This is a 22-year-old female, who presented to the office complaining of condylomas she had noted in her anal region.  She has noticed approximately three to four weeks ago.  She denies any pain but does state that there is some itching.  No other symptoms associated.,GROSS FINDINGS: , We found multiple extensive perianal and intra-anal condylomas, which are likely represent condyloma acuminata.,PROCEDURE: , After risks, benefits and complications were explained to the patient and a verbal consent was obtained, the patient was taken to the operating room.  After the area was prepped and draped, a local anesthesia was achieved with Marcaine.  Bovie electrocautery was then used to remove the condylomas taking care to achieve meticulous hemostasis throughout the course of the procedure.  The condylomas were removed 350 degrees from the perianal and intra-anal regions.  After all visible condylomas were removed, the area was again washed with acetic acid solution.  Any residual condylomas were then cauterized at this time.  The area was then examined again for any residual bleeding and there was none.,DISPOSITION: , The patient was taken to Recovery in stable condition.  She will be sent home with prescriptions for a topical lidocaine and Vicodin.  She will be instructed to do sitz bath b.i.d., and post-bowel movement.  She will follow up in the office next week.","surgery, intra-anal, perianal, acuminata, cauterization, condyloma, anal,"
" Cervical cone biopsy, dilatation & curettage", Surgery, Cone Biopsy ,"PREOPERATIVE DIAGNOSIS: , Cervical carcinoma in situ.,POSTOPERATIVE DIAGNOSIS: , Cervical carcinoma in situ.,OPERATION PERFORMED:,  Cervical cone biopsy, dilatation & curettage.,SPECIMENS:  ,Cone biopsy, endocervical curettings, endometrial curettings.,INDICATIONS FOR PROCEDURE: , The patient recently presented with a Pap smear showing probable adenocarcinoma in situ.  The patient was advised to have cone biopsy to fully assess endocervical glands.,FINDINGS: , During the examination, under anesthesia, the vulva, vagina, and cervix were grossly unremarkable.  The uterus was smooth with no palpable cervical nodularity and no adnexal masses were noted.,PROCEDURE: , The patient was brought to the Operating Room with an IV in place.  Anesthetic was administered and she was placed in the lithotomy position.  The patient was prepped and draped after which a weighted speculum was placed in the vagina and a tenaculum was placed on the cervix for traction.  Angle stitches of 0 Vicryl sutures were placed at 3 o'clock and 9 o'clock in the lateral vagina fornices.  The cervix was stained with Lugol's iodine solution. ,After the cervix was stained, a scalpel was used to excise a cone shaped biopsy circumferentially around the cervical os.  The specimen was removed intact, after which the uterine cavity was sounded to a depth of 8 cm.  A Kevorkian curette was used to obtain endocervical curettings.  The cone biopsy site was sutured using a running lock stitch of 0 Vicryl suture.  Upon completion of the suture placement, the endocervical canal was sounded to assure patency.  A prophylactic application of Monsel's solution completed the procedure.  ,The patient was awakened from her anesthetic and taken to the post anesthesia care unit in stable condition.  Final sponge, needle, and instrument counts were.","surgery, cervical carcinoma in situ, cervical cone biopsy, endometrial curettings, endocervical, endometrial, dilatation & curettage, carcinoma in situ, cone biopsy, dilatation, curettage, carcinoma, vicryl, curettings, vagina, sutures, cervix, cervical, cone, biopsy,"
 Colonoscopy with random biopsies and culture., Surgery, Colonoscopy with Biopsy - 4 ,"PREOPERATIVE DIAGNOSIS: , Antibiotic-associated diarrhea.  ,POSTOPERATIVE DIAGNOSIS:  ,Antibiotic-associated diarrhea.  ,OPERATION PERFORMED: , Colonoscopy with random biopsies and culture.,INDICATIONS: , The patient is a 50-year-old woman who underwent hemorrhoidectomy approximately one year ago.  She has been having difficulty since that time with intermittent diarrhea and abdominal pain.  She states this happens quite frequently and can even happen when she uses topical prednisone for her ears or for her eyes.  She presents today for screening colonoscopy, based on the same.,OPERATIVE COURSE:  , The risks and benefits of colonoscopy were explained to the patient in detail.  She provided her consent.  The morning of the operation, the patient was transported from the preoperative holding area to the endoscopy suite.  She was placed in the left lateral decubitus position.  In divided doses, she was given 7 mg of Versed and 125 mcg of fentanyl.  A digital rectal examination was performed, after which time the scope was intubated from the anus to the level of the hepatic flexure.  This was intubated fairly easily; however, the patient was clearly in some discomfort and was shouting out, despite the amount of anesthesia she was provided.  In truth, the pain she was experiencing was out of proportion to any maneuver or difficulty with the procedure.  While more medication could have been given, the patient is actually a fairly thin woman and diminutive and I was concerned that giving her any more sedation may lead to respiratory or cardiovascular collapse.  In addition, she was really having quite some difficulty staying still throughout the procedure and was putting us all at some risk.  For this reason, the procedure was aborted at the level of the hepatic flexure.  She was noted to have some pools of stool.  This was suctioned and sent to pathology for C difficile, ova and parasites, and fecal leukocytes.  Additionally, random biopsies were performed of the colon itself.  It is unfortunate we were unable to complete this procedure, as I would have liked to have taken biopsies of the terminal ileum.  However, given the degree of discomfort she had, again, coupled with the relative ease of the procedure itself, I am very suspicious of irritable bowel syndrome.  The patient tolerated the remainder of the procedure fairly well and was sent to the recovery room in stable condition, where it is anticipated she will be discharged to home.,PLAN:,  She needs to follow up with me in approximately 2 weeks' time, both to follow up with her biopsies and cultures.  She has been given a prescription for VSL3, a probiotic, to assist with reculturing the rectum.  She may also benefit from an antispasmodic and/or anxiolytic.  Lastly, it should be noted that when she next undergoes endoscopic procedure, propofol would be indicated.","surgery, colonoscopy with random biopsies, hepatic flexure, topical, culture, antibiotic, hepatic, flexure, diarrhea, biopsies, colonoscopy"
 Colpocleisis and rectocele repair., Surgery, Colpocleisis ,"PREOPERATIVE DIAGNOSES: , Vault prolapse and rectocele.,POSTOPERATIVE DIAGNOSES:,  Vault prolapse and rectocele.,OPERATION: , Colpocleisis and rectocele repair.,ANESTHESIA:  ,Spinal.,ESTIMATED BLOOD LOSS:,  Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY OF THE PATIENT: , This is an 85-year-old female who presented to us with a vaginal mass.  On physical exam, the patient was found to have grade 3 rectocele and poor apical support, and history of hysterectomy.  The patient had good anterior support at the bladder.  Options were discussed such as watchful waiting, pessary, repair with and without mesh, and closing of the vagina (colpocleisis) were discussed.  Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE, morbidity, and mortality of the procedure were discussed., ,Risk of infection and abscess formation were discussed.  The patient understood all the risks and benefits and wanted to proceed with the procedure.  Risk of retention and incontinence were discussed.  Consent was obtained through the family members.,DETAILS OF THE OR:,  The patient was brought to the OR.  Anesthesia was applied.  The patient was placed in dorsal lithotomy position.  The patient had a Foley catheter placed.  The posterior side of the rectocele was visualized with grade 3 rectocele and poor apical support.  A 1% lidocaine with epinephrine was applied for posterior hydrodissection, which was very difficult to do due to the significant scarring of the posterior part.  Attempts were made to lift the vaginal mucosa off of the rectum, which was very, very difficult to do at this point due to the patient's overall poor medical condition in terms of poor mobility and significant scarring.  Discussion was done with the family in the waiting area regarding simply closing the vagina and doing a colpocleisis since the patient is actually inactive.  Family agreed that she is not active and they rather not have any major invasive procedure especially in light of scarring and go ahead and perform the colpocleisis.  Oral consent was obtained from the family and her surgery was preceded.  The vaginal mucosa was denuded off using electrocautery and Metzenbaum scissors.  Using 0 Vicryl, 2 transverse longitudinal stitches were placed to bring the anterior and the posterior part of the vagina together and was started at the apex and was brought all the way out to the introitus.  The vaginal mucosa was pretty much completely closed off all the way up to the introitus.  Indigo carmine was given.  Cystoscopy revealed there was a good efflux of urine from both of the ureteral openings.  There was no injury to the bladder or kinking of the ureteral openings.  The bladder was normal.  Rectal exam was normal at the end of the colpocleisis repair.  There was good hemostasis., ,At the end of the procedure, Foley was removed and the patient was brought to recovery in a stable condition.","surgery, vault prolapse, rectocele repair, rectocele, vaginal mass, metzenbaum scissors, ureteral openings, vaginal mucosa, colpocleisis, vaginal, infection,"
 Completion thyroidectomy with limited right paratracheal node dissection., Surgery, Completion Thyroidectomy ,"TITLE OF OPERATION:,  Completion thyroidectomy with limited right paratracheal node dissection.,INDICATION FOR SURGERY:,  A 49-year-old woman with a history of a left dominant nodule in her thyroid gland, who subsequently underwent left thyroid lobectomy and isthmusectomy, was found to have multifocal papillary thyroid carcinoma throughout her left thyroid lobe and isthmus.  Consideration given to completion thyroidectomy.  Risks, benefits, and alternatives of this procedure was discussed with the patient in great detail.  Risks included but were not limited to anesthesia, bleeding, infection, injury to nerves including vocal fold paralysis, hoarseness, low calcium, scar, cosmetic deformity, need for thyroid hormone replacement, and also need for further management.  The patient understood all of this and then wished to proceed.,PREOP DIAGNOSIS:,  Multifocal thyroid carcinoma and previous left thyroid lobectomy resection specimen.,POSTOP DIAGNOSIS: , Multifocal thyroid carcinoma and previous left thyroid lobectomy resection specimen.,PROCEDURE DETAIL:,  After identifying the patient, the patient was placed supine in the operating room table.  After establishment of general anesthesia via orotracheal intubation with a number 6 nerve integrity monitoring system endotracheal tube, the eyes were protected with Tegaderm.  Nerve integrity monitoring system endotracheal tube was confirmed to be working adequately and secured.  The previous skin incision for a thyroidectomy was then planned, then incorporated into an ellipse.  The patient was prepped and draped in a sterile fashion.  Subsequently, the ellipse around the previous incision was deformed.  The scar was then excised.  Subplatysmal flaps were raised to the thyroid notch and sternal notch respectively.  Strap muscles were isolated in the midline and dissected and mobilized from the thyroid lobe on the right side.  There was some dense fibrosis and inflammation surrounding the right thyroid lobe.  Careful dissection along the thyroid lobe allowed for identification of the superior thyroid artery and vein which were individually ligated with a Harmonic scalpel.  The right inferior and superior parathyroid glands were identified and preserved and recurrent laryngeal nerve was identified and traced superiorly, then preserved.  Of note is that there were multiple lymph nodes in the paratracheal region on the right side.  These lymph nodes were carefully dissected away from the recurrent laryngeal nerve, trachea, and the carotid artery, and sent as a separate specimen labeled right paratracheal lymph nodes.  The wound was copiously irrigated.  Valsalva maneuver was given.  Surgicel was placed in the wound bed.  Strap muscles were reapproximated in the midline with 3-0 Vicryl and incision was then closed with interrupted 3-0 Vicryl and Indermil for the skin.  The patient was extubated in the operating room table, sent to the postanesthesia care unit in good condition.","surgery, multifocal thyroid carcinoma, thyroid lobectomy, thyroid, papillary, thyroid lobe, isthmus, completion thyroidectomy, thyroidectomy, paratracheal, lobectomy, "
" Colonoscopy with photos.  The patient is an 85-year-old female who was admitted to the hospital with a markedly decreased hemoglobin and blood loss anemia.  She underwent an EGD and attempted colonoscopy; however, due to a very poor prep, only a flexible sigmoidoscopy was performed at that time.  A coloscopy is now being performed for completion.", Surgery, Colonoscopy With Photos ,"PREOPERATIVE DIAGNOSIS: , Blood loss anemia.,POSTOPERATIVE DIAGNOSES:,1.  Diverticulosis coli.,2.  Internal hemorrhoids.,3.  Poor prep.,PROCEDURE PERFORMED:,  Colonoscopy with photos.,ANESTHESIA: , Conscious sedation per Anesthesia.,SPECIMENS:,  None.,HISTORY:,  The patient is an 85-year-old female who was admitted to the hospital with a markedly decreased hemoglobin and blood loss anemia.  She underwent an EGD and attempted colonoscopy; however, due to a very poor prep, only a flexible sigmoidoscopy was performed at that time.  A coloscopy is now being performed for completion.,PROCEDURE:,  After proper informed consent was obtained, the patient was brought to the Endoscopy Suite.  She was placed in the left lateral position and was given sedation by the Anesthesia Department.  A digital rectal exam was performed and there was no evidence of mass.  The colonoscope was then inserted into the rectum.  There was some solid stool encountered.  The scope was maneuvered around this.  There was relatively poor prep as the scope was advanced through the sigmoid colon and portions of the descending colon.  The scope was then passed through the transverse colon and ascending colon to the cecum.  No masses or polyps were noted.  Visualization of the portions of the colon was however somewhat limited.  There were scattered diverticuli noted in the sigmoid.,The scope was slowly withdrawn carefully examining all walls.  Once in the rectum, the scope was retroflexed and nonsurgical internal hemorrhoids were noted.  The scope was then completely withdrawn.  The patient tolerated the procedure well and was transferred to recovery room in stable condition.  She will be placed on a high-fiber diet and Colace and we will continue to monitor her hemoglobin.","surgery, blood loss anemia, diverticulosis coli, internal hemorrhoids, poor prep, colonoscopy, sigmoidoscopy, hemoglobin, coloscopy, colonoscopy with photos, attempted colonoscopy, flexible sigmoidoscopy, photos, anemia, scope"
" A 10-1/2-year-old born with asplenia syndrome with a complex cyanotic congenital heart disease characterized by dextrocardia bilateral superior vena cava, complete atrioventricular septal defect, a total anomalous pulmonary venous return to the right-sided atrium, and double-outlet to the right ventricle with malposed great vessels, the aorta being anterior with a severe pulmonary stenosis. ", Surgery, Complex Cyanotic Congenital Heart Disease ,"HISTORY:,  The patient is a 10-1/2-year-old born with asplenia syndrome with a complex cyanotic congenital heart disease characterized by dextrocardia bilateral superior vena cava, complete atrioventricular septal defect, a total anomalous pulmonary venous return to the right-sided atrium, and double-outlet to the right ventricle with malposed great vessels, the aorta being anterior with a severe pulmonary stenosis.  He had undergone staged repair beginning on 04/21/1997 with a right modified Blalock-Taussig shunt followed on 09/02/1999 with a bilateral bidirectional Glenn shunt, and left pulmonary artery to main pulmonary artery pericardial patch augmentation.  These procedures were performed at Medical College Hospital.  Family states that they moved to the United States.  Evaluation at the Children's Hospital earlier this year demonstrated complete occlusion of the right bidirectional Glenn shunt as well as occlusion of the proximal right pulmonary artery.  He was also found to have elevated Glenn pressures at 22 mmHg, transpulmonary gradient axis of 14 mmHg.  The QP:QS ratio of 0.6:1.  A large decompressing venous collateral was also appreciated.  The patient was brought back to cardiac catheterization in an attempt to reconstitute the right caval pulmonary anastomosis and to occlude the venous collateral vessel.,DESCRIPTION OF PROCEDURE: , After sedation and local Xylocaine anesthesia, the patient was prepped and draped.  Cardiac catheterization was performed as outlined in the attached continuation sheets.  Vascular entry was by percutaneous technique, and the patient was heparinized.  Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a 6-French sheath, a 6-French wedge catheter was inserted in the right femoral vein and advanced from the inferior vena cava into the right-sided atrium pulmonary veins and the right ventricle.,Using a 6-French sheath, a 5-French pigtail catheter was inserted into the right femoral artery and advanced retrograde to the descending aorta and ascending aorta.  A separate port of arterial access was obtained in the left femoral artery utilizing a 5-French sheath.,Percutaneous access into the right jugular vein was attempted, but unsuccessful.  Ultrasound on the right neck demonstrated a complete thrombosis of the right internal jugular vein.  Using percutaneous technique and a 5-French sheath, 5-French wedge catheter was inserted into the left internal jugular vein and advanced along the left superior vena cava across the left caval-pulmonary anastomosis into the main pulmonary artery and left pulmonary artery with aid of guidewire.  This catheter then also advanced into the bridging innominate vein.  The catheter was then exchanged over wire for a 4-French Bernstein catheter, which was advanced to the blind end of the right superior vena cava.  A balloon wedge angiogram of the right lower pulmonary vein demonstrated back filling of a small right lower pulmonary artery.  There was no vascular continuity to the stump of the right Glenn.  The jugular venous catheter and sheaths were exchanged over a wire for a 6-French flexor sheath, which was advanced to the proximal right superior vena cava.  The Bernstein catheter was then reintroduced using a Terumo guidewire.  Probing of the superior vena cava facilitated access into the right lower pulmonary artery.  The angiogram in the right pulmonary artery showed a diminutive right lower pulmonary artery and severe long segment proximal stenosis.  The distal pulmonary measured approximately 5.5 to 60 mm in diameter with a long segment stenosis measuring approximately 31 mm in length.  The length of the obstruction was balloon dilated using ultra-thin SD 4 x 2 cm balloon catheter with complete disappearance of the waist.  This facilitated advancement of a flexor sheath into the proximal portion of the stenosis.  A PG 2960 BPX Genesis stent premounted on a 6 mm OptiProbe.  A balloon catheter was advanced across the area of narrowing and inflated with a near-complete disappearance of proximal waist.  Angiogram demonstrated a good stent apposition to the caval wall.  Further angioplasty was then performed utilizing an ultra-thin SDS 8 x 3 cm balloon catheter inflated to 19 atmospheres pressure with complete disappearance of a distinct proximal waist.  Angiogram demonstrated wide patency of reconstituted right caval pulmonary anastomosis though there was no flow seen to the right upper pulmonary artery.  The balloon wedge angiograms were then obtained in the right upper pulmonary veins suggesting the presence of right upper pulmonary artery and not contiguous with the right lower pulmonary artery.  Bernstein catheter was advanced into the main pulmonary artery where a wire probing of the stump of the proximal right pulmonary artery facilitated access to the right upper pulmonary artery.  Angiogram demonstrated severe long segment stenosis of the proximal right pulmonary artery.  Angioplasty of the right pulmonary was then performed using the OptiProbe 6-mm balloon catheter inflated to 16 atmospheres pressure with disappearance of a distinct waist.  Repeat angiogram showed improvement in caliber of right upper pulmonary artery with filling defect of the proximal right pulmonary artery.  The proximal right pulmonary artery was then dilated and stent implanted using a PG 2980 BPX Genesis stent premounted on 8-mm OptiProbe balloon catheter and implanted with complete disappearance of the waist.  Distal right upper pulmonary artery was then dilated and stent implanted utilizing a PG 1870 BPX Genesis stent premounted on 7-mm OptiProbe balloon catheter.  Repeat angiograms were then performed.  Attention was then directed to the large venous collateral vessel arising from the left superior vena cava with a contrast filling of a left-sided azygos vein.  A selective angiogram demonstrated a large azygos vein of the midsection measuring approximately 9.4 mm in diameter.  An Amplatzer 12 mm vascular plug was loaded on the delivery catheter and advanced through the flexor sheath into the azygos vein.  Once stable device was confirmed, the device was released from the delivery catheter.  The 4-French Bernstein catheter was then reintroduced and 5 inch empirical 0.038 inch, 10 cm x 8 mm detachable coils were then implanted above the vascular plug filling the proximal azygos vein.  A pigtail catheter was then introduced into the left superior vena cava for final angiogram.,Flows were calculated by the Fick technique using an assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with injection of the coronary sinus of pulmonary veins, the innominate vein, superior vena cava, the main pulmonary artery, and azygos vein.,After angiography, two normal-appearing renal collecting systems were visualized.  The catheters and sheaths were removed and topical pressure applied for hemostasis.  The patient was returned to the recovery room in satisfactory condition.  There were no complications.,DISCUSSION:,  Oxygen consumption was assumed to be normal mixed venous saturation, but was low due to systemic arterial desaturation of 79%.  The pulmonary veins were fully saturated with partial pressure of oxygen ranging between 120 and 169 mmHg in 30% oxygen.  Remaining saturations reflected complete admixture.  There was increased saturation in the left pulmonary artery due to aortopulmonary collateral flow.  Phasic right atrial pressures were normal with an A-wave somewhat to the normal right ventricular end-diastolic pressure of 9 mmHg.  Left ventricular systolic pressure was systemic with no outflow obstruction to the ascending aorta.  Phasic ascending, descending pressures were similar and normal.  Mean Glenn pressures at initiation of the case were slightly elevated at 14 mmHg with a transpulmonary gradient of 9 mmHg.  The calculated systemic flow was a normal pulmonary flows reduced with a QP:QS ratio of 0.6:1.  The pulmonary vascular resistance was elevated at 4.4 Woods units.  Following stent implantation in the right caval pulmonary anastomosis and right pulmonary artery, there was a slight increase in the Glenn venous pressures to 16 mmHg.  Following embolization of the azygos vein, there was increase in systemic arterial saturation to 84% and increase in mixed venous saturation.  There was similar increase in Glenn pressures to 28 mmHg with a transpulmonary gradient of 14 mmHg.  There was an increase in arterial pressure.  The calculated systemic flow increased from 3.1 liters /minute/meter squared to 4.3 liters/minute/meter squared.  Angiogram within the innominate vein following stent implantation demonstrated appropriate stent position without significant distortion of the innominate vein or proximal cava.  There appeared unobstructed contrast flow to the right lower pulmonary artery of a 1-mmHg mean pressure gradient.  There was absence of contrast filling of the right middle and right upper pulmonary artery.  Final angiogram with a contrast injection in the left superior vena cava showed a forward flow through the right Glenn, a good contrast filling of the right lower pulmonary artery, and a widely patent left Glenn negative contrast washout of the proximal right pulmonary artery and left pulmonary artery presumably due to aortopulmonary collateral flow.  Contrast injection within the right upper pulmonary artery following the stent implantation demonstrated widely patent proximal right pulmonary artery along the length of the implanted stents though with retrograde contrast flow.,INITIAL DIAGNOSES:  ,1.  Asplenia syndrome.,2.  Dextrocardia bilateral superior vena cava.,3.  Atrioventricular septal defect.,4.  Total anomalous pulmonary venous return to the right-sided atrium.,5.  Double outlet right ventricle with malposed great vessels.,6.  Severe pulmonary stenosis.,7.  Separate hepatic venous drainage into the atria.,PRIOR SURGERIES AND INTERVENTIONS:  ,1.  Right modified Blalock-Taussig shunt.,2.  Bilateral bidirectional Glenn shunt.,3.  Patch augmentation of the main pulmonary to left pulmonary artery.,CURRENT DIAGNOSES:  ,1.  Obstructed right caval pulmonary anastomosis.,2.  Obstructed right proximal pulmonary artery.,3.  Venovenous collateral vessel.,CURRENT INTERVENTION:  ,1.  Balloon dilation of the right superior vena cava and stent implantation.,2.  Balloon dilation of the proximal right pulmonary artery, stent implantation.,3.  Embolization of venovenous collateral vessel.,MANAGEMENT: , The case will be discussed in Combined Cardiology Cardiothoracic Surgery case conference.  A repeat catheterization is recommended in 3 months to assess for right pulmonary artery growth and to assess candidacy for Fontan completion.  The patient will be maintained on anticoagulant medications of aspirin and Plavix.  Further cardiology care will be directed by Dr. X.",
" A woman referred for colonoscopy secondary to heme-positive stools.  Procedure done to rule out generalized diverticular change, colitis, and neoplasia.", Surgery, Colonoscopy with Biopsy ,"INDICATIONS FOR PROCEDURE: , A 79-year-old Filipino woman referred for colonoscopy secondary to heme-positive stools.  Procedure done to rule out generalized diverticular change, colitis, and neoplasia.,DESCRIPTION OF PROCEDURE: , The patient was explained the procedure in detail, possible complications including infection, perforation, adverse reaction of medication, and bleeding.  Informed consent was signed by the patient.,With the patient in left decubitus position, had received a cumulative dose of 4 mg of Versed and 75 mg of Demerol, using Olympus video colonoscope under direct visualization was advanced to the cecum.  Photodocumentation of appendiceal orifice and the ileocecal valve obtained.  Cecum was slightly obscured with stool but the colon itself was adequately prepped.  There was no evidence of overt colitis, telangiectasia, or overt neoplasia.  There was moderately severe diverticular change, which was present throughout the colon and photodocumented.  The rectal mucosa was normal and retroflexed with mild internal hemorrhoids.  The patient tolerated the procedure well without any complications.,IMPRESSION:,1.  Colonoscopy to the cecum with adequate preparation.,2.  Long tortuous spastic colon.,3.  Moderately severe diverticular changes present throughout.,4.  Mild internal hemorrhoids.,RECOMMENDATIONS:,1.  Clear liquid diet today.,2.  Follow up with primary care physician as scheduled from time to time.,3.  Increase fiber in diet, strongly consider fiber supplementation.","surgery, olympus video colonoscope, advanced to the cecum, heme-positive stools, diverticular change, colitis, colonoscopy to the cecum, spastic colon, colonoscopy with biopsy, liver disease, biopsy, hepatitis, chronic, liver, disease, mucosa, polyp, rectal, colonoscopy,"
 Small internal hemorrhoids and Ileal colonic anastomosis., Surgery, Colonoscopy with Biopsy - 2 ,"PROCEDURE PERFORMED: , Colonoscopy and biopsy.,INDICATIONS:,  The patient is a 50-year-old female who has had a history of a nonspecific colitis, who was admitted 3 months ago at Hospital because of severe right-sided abdominal pains, was found to have multiple ulcers within the right colon, and was then readmitted approximately 2 weeks later because of a cecal volvulus, and had a right hemicolectomy.  Since then, she has had persistent right abdominal pains, as well as diarrhea, with up to 2-4 bowel movements per day.  She has had problems with recurrent seizures and has been seen by Dr. XYZ, who started her recently on methadone.,MEDICATIONS: , Fentanyl 200 mcg, Versed 10 mg, Phenergan 25 mg intravenously given throughout the procedure.,INSTRUMENT: , PCF-160L.,PROCEDURE REPORT: , Informed consent was obtained from the patient, after the risks and benefits of the procedure were carefully explained, which included but were not limited to bleeding, infection, perforation, and allergic reaction to the medications, as well as the possibility of missing polyps within the colon.,A colonoscope was then passed through the rectum, all the way toward the ileal colonic anastomosis, seen within the proximal transverse colon.  The distal ileum was examined, which was normal in appearance.  Random biopsies were obtained from the ileum and placed in jar #1.  Random biopsies were obtained from the normal-appearing colon and placed in jar #2.  Small internal hemorrhoids were noted within the rectum on retroflexion.,COMPLICATIONS: , None.,ASSESSMENT:,1.  Small internal hemorrhoids.,2.  Ileal colonic anastomosis seen in the proximal transverse colon.,3.  Otherwise normal colonoscopy and ileum examination.,PLAN:, Followup results of biopsies.  If the biopsies are unremarkable, the patient may benefit from a trial of tricyclic antidepressants, if it's okay with Dr. XYZ, for treatment of her chronic abdominal pains.","surgery, proximal transverse, transverse colon, internal hemorrhoids, colonic anastomosis, biopsy, rectum, transverse, hemorrhoids, colonic, anastomosis, abdominal, ileum, biopsies, colonoscopy"
 The patient with a recent change in bowel function and hematochezia., Surgery, Colonoscopy with Biopsy - 1 ,"PREPROCEDURE DIAGNOSIS:,  Change in bowel function.,POSTPROCEDURE DIAGNOSIS:,  Proctosigmoiditis.,PROCEDURE PERFORMED:,  Colonoscopy with biopsy.,ANESTHESIA: , IV sedation.,POSTPROCEDURE CONDITION: , Stable.  ,INDICATIONS:,  The patient is a 33-year-old with a recent change in bowel function and hematochezia.  He is here for colonoscopy.  He understands the risks and wishes to proceed.  ,PROCEDURE: , The patient was brought to the endoscopy suite where he was placed in left lateral Sims position, underwent IV sedation.  Digital rectal examination was performed, which showed no masses, and a boggy prostate.  The colonoscope was placed in the rectum and advanced, under direct vision, to the cecum.  In the rectum and sigmoid, there were ulcerations, edema, mucosal abnormalities, and loss of vascular pattern consistent with proctosigmoiditis.  Multiple random biopsies were taken of the left and right colon to see if this was in fact pan colitis.,RECOMMENDATIONS: , Follow up with me in 2 weeks and we will begin Canasa suppositories.","surgery, change in bowel function, iv sedation, bowel function, proctosigmoiditis, sedation, rectum, bowel, function, colonoscopy, hematochezia,"
" Colonoscopy with multiple biopsies, including terminal ileum, cecum, hepatic flexure, and sigmoid colon.", Surgery, Colonoscopy with Biopsy - 3 ,"PREPROCEDURE DIAGNOSIS: , Abdominal pain, diarrhea, and fever.,POSTPROCEDURE DIAGNOSIS: , Pending pathology.,PROCEDURES PERFORMED: , Colonoscopy with multiple biopsies, including terminal ileum, cecum, hepatic flexure, and sigmoid colon.","surgery, colonoscopy with multiple biopsies, length of the colon, diarrhea and fever, terminal ileum cecum, multiple biopsies, ileum cecum, cecum hepatic, hepatic flexure, terminal ileum, sigmoid colon, colonoscopy, diarrhea, cecum, hepatic, flexure, inflammation, biopsies, terminal, ileum, sigmoid, scope, "
 Total colonoscopy with biopsy and snare polypectomy., Surgery, Colonoscopy & Polypectomy - 3 ,"PREOPERATIVE DIAGNOSIS:,  Alternating hard and soft stools.,POSTOPERATIVE DIAGNOSIS:,Sigmoid diverticulosis.,Sessile polyp of the sigmoid colon.,Pedunculated polyp of the sigmoid colon.,PROCEDURE: , Total colonoscopy with biopsy and snare polypectomy.,PREP:,  4/4.,DIFFICULTY:,  1/4.,PREMEDICATION AND SEDATION: , Fentanyl 100, midazolam 5.,INDICATION FOR PROCEDURE:,  A 64-year-old male who has developed alternating hard and soft stools.  He has one bowel movement a day.,FINDINGS: , There is extensive sigmoid diverticulosis, without evidence of inflammation or bleeding.  There was a small, sessile polyp in the sigmoid colon, and a larger pedunculated polyp in the sigmoid colon, both appeared adenomatous.,DESCRIPTION OF PROCEDURE: , Preoperative counseling, including an explicit discussion of the risk and treatment of perforation was provided.  Preoperative physical examination was performed.  Informed consent was obtained.  The patient was placed in the left lateral decubitus position.  Premedications were given slowly by intravenous push.  Rectal examination was performed, which was normal.  The scope was introduced and passed with minimal difficulty to the cecum.  This was verified anatomically and video photographs were taken of the ileocecal valve and appendiceal orifice.  The scope was slowly withdrawn, the mucosa carefully visualized.  It was normal in its entirety until reaching the sigmoid colon.  Sigmoid colon had extensive diverticular disease, small-mouth, without inflammation or bleeding.  In addition, there was a small sessile polyp, which was cold biopsied and recovered, and approximately an 8 mm pedunculated polyp.  A snare was placed on the stalk of the polyp and divided with electrocautery.  The polyp was recovered and sent for pathologic examination.  Examination of the stalk showed good hemostasis.  The scope was slowly withdrawn and the remainder of the examination was normal.,ASSESSMENT: , Diverticular disease.  A diverticular disease handout was given to the patient's wife and a high fiber diet was recommended.  In addition, 2 polyps, one of which is assuredly an adenoma.  Patient needs a repeat colonoscopy in 3 years.","surgery, total colonoscopy with biopsy, colonoscopy with biopsy, total colonoscopy, snare polypectomy, sigmoid diverticulosis, sessile polyp, pedunculated polyp, diverticular disease, sigmoid colon, colonoscopy, polypectomy, biopsy, diverticulosis, inflammation, adenomatous, sessile, sigmoid,"
 Common description of colonoscopy, Surgery, Colonoscopy Template - 1 ,,"surgery, decubitus position, cecum, colonic mucosa, ileocecal, rectum, colonoscopy, colonoscopeNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Common description of colonoscopy, Surgery, Colonoscopy Template - 3 ,,"surgery, left lateral sims position, cecum, mass, lesions, mucosal abnormalities, friability, polyps, endoscopy suite, endoscopyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Common description of colonoscopy, Surgery, Colonoscopy Template - 5 ,,"surgery, cecum, colonoscope, digital rectal examination, colonoscopyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Common description of colonoscopy, Surgery, Colonoscopy Template - 4 ,"A colonoscope was then passed through the rectum, all the way toward the cecum, which was identified by the presence of the appendiceal orifice and ileocecal valve.  This was done without difficulty and the bowel preparation was good.  The ileocecal valve was intubated and the distal 2 to 3 cm of terminal ileum was inspected and was normal.  The colonoscope was then slowly withdrawn and a careful examination of the mucosa was performed.,COMPLICATIONS: , None.","surgery, cecum, colonoscope, bleeding, infection, perforation, allergic reaction, ileocecal valve, informed, allergic, ileocecal, valve, colonoscopyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Common description of colonoscopy, Surgery, Colonoscopy Template - 2 ,,"surgery, cecum, retroflexion, colon, tumor, polyp, mass, ulceration, tip, endoscope, inserted, colonoscopyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Colonoscopy, conscious sedation, and snare polypectomy.", Surgery, Colonoscopy & Polypectomy - 2 ,"PREPROCEDURE DIAGNOSIS: , Colon cancer screening.,POSTPROCEDURE DIAGNOSIS:  ,Colon polyps, diverticulosis, hemorrhoids.,PROCEDURE PERFORMED: , Colonoscopy, conscious sedation, and snare polypectomy.  ,INDICATIONS:  ,The patient is a 63-year-old male who has myelodysplastic syndrome, who was referred for colonoscopy.  He has had previous colonoscopy.  There is no family history of bleeding, no current problems with his bowels.  On examination, he has internal hemorrhoids.  His prostate is enlarged and increased somewhat in firmness.  He has scattered diverticular disease of a moderate degree and he has two polyps, one 1 cm in the mid ascending colon, and one in the left transverse colon, which is also 1 cm.  These were removed with snare polypectomy technique.  I would recommend that the patient have an increased fiber diet and repeat colonoscopy in 5 years or sooner if he develops bowel habit change or bleeding.,PROCEDURE: , After explaining the operative procedure, the risks and potential complications of bleeding and perforation, the patient was given 175 mcg fentanyl, and 8 mg Versed intravenously for conscious sedation.  Blood pressure 115/60, pulse 98, respiration 18, and saturation 92%.  A rectal examination was done and then the colonoscope was inserted through the anorectum, rectosigmoid, descending, transverse, and ascending colon, to the ileocecal valve.  The scope was withdrawn to the mid ascending colon, where the polyp was encircled with a snare and removed with a mixture of cutting and coagulating current, then retrieved through the suction port.  The scope was withdrawn into the left transverse colon, where the second polyp was identified.  It was encircled with a snare and removed with a mixture of cutting and coagulating current, and then removed through the suction port as well.  The scope was then gradually withdrawn the remaining distance and removed.  The patient tolerated the procedure well.","surgery, colon polyps, diverticulosis, hemorrhoids, cutting and coagulating, transverse colon, snare polypectomy, ascending colon, colonoscopy, polyps, bowels, coagulating, sedation, scope, ascending, snare, polypectomy, "
 Patient with history of adenomas and irregular bowel habits., Surgery, Colonoscopy - 7 ,"PROCEDURE:,  Colonoscopy.,PREOPERATIVE DIAGNOSIS: , Follow up adenomas.,POSTOPERATIVE DIAGNOSES:,1.  Two colon polyps, removed.,2.  Small internal hemorrhoids.,3.  Otherwise normal examination of cecum.,MEDICATIONS: , Fentanyl 150 mcg and Versed 7 mg slow IV push.,INDICATIONS: , This is a 60-year-old white female with a history of adenomas.  She does have irregular bowel habits.,FINDINGS: , The patient was placed in the left lateral decubitus position and the above medications were administered.  The colonoscope was advanced to the cecum as identified by the ileocecal valve, appendiceal orifice, and blind pouch.  The colonoscope was slowly withdrawn and a careful examination of the colonic mucosa was made, including a retroflexed view of the rectum.  There was a 4 mm descending colon polyp, which was removed with jumbo forceps, and sent for histology in bottle one.  There was a 10 mm pale, flat polyp in the distal rectum, which was removed with jumbo forceps, and sent for histology in bottle 2.  There were small internal hemorrhoids.  The remainder of the examination was normal to the cecum.  The patient tolerated the procedure well without complication.,IMPRESSION:,1.  Two colon polyps, removed.,2.  Small internal hemorrhoids.,3.  Otherwise normal examination to cecum.,PLAN: , I will await the results of the colon polyp histology.  The patient was told the importance of daily fiber.","surgery, colon polyps, internal hemorrhoids, rectum, irregular bowel habits, colon polyps removed, irregular bowel, bowel habits, polyps removed, bowel, habits, colonoscope, hemorrhoids, cecum, forceps, polyps, colonoscopy, adenomas,"
" Colonoscopy to cecum with snare polypectomy and esophagogastroduodenoscopy with biopsies.  Hematochezia, refractory dyspepsia, colonic polyps at 35 cm and 15 cm, diverticulosis coli, and acute and chronic gastritis.
", Surgery, Colonoscopy & Esophagogastroduodenoscopy ,"PREOPERATIVE DIAGNOSES:,1.  Hematochezia.,2.  Refractory dyspepsia.,POSTOPERATIVE DIAGNOSES:,1.  Colonic polyps at 35 cm and 15 cm.,2.  Diverticulosis coli.,2.  Acute and chronic gastritis.,PROCEDURE PERFORMED:,1.  Colonoscopy to cecum with snare polypectomy.,2.  Esophagogastroduodenoscopy with biopsies.,INDICATIONS FOR PROCEDURES:  ,This is a 43-year-old white male who presents as an outpatient to the General Surgery Service with hematochezia with no explainable source at the anal verge.  He also had refractory dyspepsia despite b.i.d., Nexium therapy.  The patient does use alcohol and tobacco.  The patient gave informed consent for the procedure.,GROSS FINDINGS: , At the time of colonoscopy, the entire length of colon was visualized.  The patient was found to have a sigmoid diverticulosis.  He also was found to have some colonic polyps at 35 cm and 15 cm.  The polyps were large enough to be treated with snare cautery technique.  The polyps were achieved and submitted to pathology.  EGD did confirm acute and chronic gastritis.  The biopsies were performed for H&E and CLO testing.  The patient had no evidence of distal esophagitis or ulcers.  No mass lesions were seen.,PROCEDURE:  ,The patient was taken to the Endoscopy Suite with the heart and lungs examination unremarkable.  The vital signs were monitored and found to be stable throughout the procedure.  The patient was placed in the left lateral position where intravenous Demerol and Versed were given in a titrated fashion.,The video Olympus colonoscope was advanced per anus and without difficulty to the level of cecum.  Photographic documentation of the diverticulosis and polyps were obtained.  The patient's polyps were removed in a similar fashion, each removed with snare cautery.  The polyps were encircled at their stalk.  Increasing the tension and cautery was applied as coagulation and cutting blunt mode, 15/15 was utilized.  Good blanching was seen.  The polyp was retrieved with the suction port of the scope.  The patient was re-scoped to the polyp levels to confirm that there was no evidence of perforation or bleeding at the polypectomy site.  Diverticulosis coli was also noted.  With colonoscopy completed, the patient was then turned for EGD.  The oropharynx was previously anesthetized with Cetacaine spray and a biteblock was placed.  Video Olympus GIF gastroscope model was inserted per os and advanced without difficulty through the hypopharynx.  The esophagus revealed a GE junction at 39 cm.  The GE junction was grossly within normal limits.  The stomach was entered and distended with air.  Acute and chronic gastritis features as stated were appreciated.  The pylorus was traversed with normal duodenum.  The stomach was again reentered.  Retroflex maneuver of the scope confirmed that there was no evidence of hiatal hernia.  There were no ulcers or mass lesions seen.  The patient had biopsy performed of the antrum for H&E and CLO testing.  There was no evidence of untoward bleeding at biopsy sites.  Insufflated air was removed with withdrawal of the scope.  The patient will be placed on a reflux diet, given instruction and information on Nexium usage.  Additional recommendations will follow pending biopsy results.  He is to also abstain from alcohol and tobacco.  He will require follow-up colonoscopy again in three years for polyp disease.","surgery, endoscopy, olympus colonoscope, snare polypectomy, ge junction, refractory dyspepsia, colonic polyps, diverticulosis coli, chronic gastritis, esophagogastroduodenoscopy, snare, biopsies, dyspepsia, gastritis, diverticulosis, polypectomy, colonoscopy, hematochezia, polyps"
 Colonoscopy to screen for colon cancer, Surgery, Colonoscopy - 6 ,"INDICATIONS: , This is a 55-year-old female who is having a colonoscopy to screen for colon cancer.  There is no family history of colon cancer and there has been no blood in the stool.,PROCEDURE PERFORMED:  ,Colonoscopy.,PREP: , Fentanyl 100 mcg IV and 3 mg Versed IV.,PROCEDURE:,  The tip of the endoscope was introduced into the rectum.  Retroflexion of the tip of the endoscope failed to reveal any distal rectal lesions.  The rest of the colon through to the cecum was well visualized.  The cecal strap, ileocecal valve, and light reflex in the right lower quadrant were all identified.  There was no evidence of tumor, polyp, mass, ulceration, or other focus of inflammation.  Adverse reactions none.,IMPRESSION:,  Normal colonic mucosa through to the cecum.  There was no evidence of tumor or polyp.","surgery, versed iv, colon, tumor, polyp, mass, ulceration, focus of inflammation, tip of the endoscope, evidence of tumor, colon cancer, endoscope, cecum, cancer, colonoscopy, "
 Patient with history of polyps., Surgery, Colonoscopy - 9 ,"PREOPERATIVE DIAGNOSIS:,  Prior history of polyps.,POSTOPERATIVE DIAGNOSIS:,  Small polyps, no evidence of residual or recurrent polyp in the cecum.,PREMEDICATIONS: , Versed 5 mg, Demerol 100 mg IV.,REPORTED PROCEDURE:,  The rectal chamber revealed no external lesions.  Prostate was normal in size and consistency.,The colonoscope was inserted into the rectal ampulla and advanced under direct vision at all times until the tip of the scope was placed in the cecum.  The position of the scope within the cecum was verified by identification of the ileocecal valve.  Navigation was difficult because it seemed that the cecum took an upward turn at its final turn, but the examination was completed.,The cecum was extensively studied and no lesion was seen.  There was not even a scar representing the prior polyp.  I was able to see the area across from the ileocecal valve exactly where the polyp was two years ago, and I saw no lesion at all.  The scope was then slowly withdrawn.  In the mid transverse colon, was a small submucosal lesion, which appeared to be a lipoma.  It was freely mobile and very small with normal overlying mucosa.  There was a similar lesion in the descending colon.  Both of these appeared to be lipomatous, so no attempt was made to remove them.  There were diverticula present in the sigmoid colon.  In addition, there were two polyps in the sigmoid colon both of which were resected using electrocautery.  There was no bleeding.  The scope was then withdrawn.  The rectum was normal.  When the scope was retroflexed in the rectum, two very small polyps were noted just at the anorectal margin, and so these were obliterated using the electrocautery snare.  There was no specimen and there was no bleeding.  The scope was then straightened, withdrawn, and the procedure terminated.,ENDOSCOPIC IMPRESSION:,1.  Small polyps, sigmoid colon, resected them.,2.  Diverticulosis, sigmoid colon.,3.  Small rectal polyps, obliterated them.,4.  Submucosal lesions, consistent with lipomata as described.,5.  No evidence of residual or recurrent neoplasm in the cecum.","surgery, ileocecal valve, sigmoid colon, polyps, ileocecal, submucosal, electrocautery, bleeding, rectum, rectal, sigmoid, cecum, scope, colonoscopy,"
 Total colonoscopy and polypectomy, Surgery, Colonoscopy & Polypectomy - 1 ,"PREOPERATIVE DIAGNOSIS:,  History of colitis.,POSTOPERATIVE DIAGNOSIS: , Small left colon polyp.,PROCEDURE PERFORMED: , Total colonoscopy and polypectomy.,ANESTHESIA:,  IV Versed 8 mg and 175 mcg of IV fentanyl.,CLINICAL HISTORY: , This patient had a tough time with colitis 10 years ago and has intermittent problems with bleeding.  He has been admitted to the hospital now for colonoscopy and polyp surveillance.,PROCEDURE:  ,The patient was prepped and draped in a left lateral decubitus position.  The flexible 165 cm CF video Olympus colonoscope was inserted through the anus and passed under TV-directed monitor through the area of the rectum, sigmoid colon, left colon, transverse colon, right colon, and cecum.  He had an excellent prep.  He had a 2-3 mm polyp in the left colon that was removed with a jumbo biopsy forceps.  He tolerated the procedure well.  There was no other evidence of any cancer, growth, tumor, colitis, or problems throughout the entire colon.  His exam that he had in 1997 showed a small amount of colitis at that time and he has had some intermittent symptoms since.  Representative pictures were taken throughout the entire exam.  There was no other evidence any problems.  On withdrawal of the scope, the same findings were noted.,FINAL IMPRESSION: , Small, left colon polyp in a patient with intermittent colitis-like symptoms and bleeding.","surgery, anus, lateral decubitus position, colon, colonoscopy and polypectomy, total colonoscopy, colon polyp, colonoscopy, bleeding, colitis, polypectomy, intermittent,"
 Colonoscopy due to hematochezia and personal history of colonic polyps., Surgery, Colonoscopy - 5 ,"PROCEDURE: , Colonoscopy.,INDICATIONS: , Hematochezia, Personal history of colonic polyps.,MEDICATIONS:,  Midazolam 2 mg IV, Fentanyl 100 mcg IV,PROCEDURE:,  A History and Physical has been performed, and patient medication allergies have been reviewed.  The patient's tolerance of previous anesthesia has been reviewed.  The risks and benefits of the procedure and the sedation options and risks were discussed with the patient.  All questions were answered and informed consent was obtained.  Mental Status Examination:  alert and oriented.  Airway Examination:  normal oropharyngeal airway and neck mobility.  Respiratory Examination:  clear to auscultation.  CV Examination:  RRR, no murmurs, no S3 or S4.  ASA Grade Assessment:  P1 A normal healthy patient.  After reviewing the risks and benefits, the patient was deemed in satisfactory condition to undergo the procedure.  The anesthesia plan was to use conscious sedation.  Immediately prior to administration of medications, the patient was re-assessed for adequacy to receive sedatives.  The heart rate, respiratory rate, oxygen saturations, blood pressure, adequacy of pulmonary ventilation, and response to care were monitored throughout the procedure.  The physical status of the patient was re-assessed after the procedure.  After I obtained informed consent, the scope was passed under direct vision.  Throughout the procedure, the patient's blood pressure, pulse, and oxygen saturations were monitored continuously.  The colonoscope was introduced through the anus and advanced to the cecum, identified by appendiceal orifice & IC valve.  The quality of the prep was good.  The patient tolerated the procedure well.,FINDINGS:,1.  A sessile, non-bleeding polyp was found in the rectum.  The polyp was 5 mm in size.  Polypectomy was performed with a saline injection-lift technique using the snare.  Resection and retrieval were complete.  Estimated blood loss was minimal.,2.  One pedunculated, non-bleeding polyp was found in the sigmoid colon.  The polyp was 7 mm in size.  Polypectomy was performed with a hot forceps.  Resection and retrieval were complete.  Estimated blood loss was minimal.,3.  Multiple large-mouthed diverticula were found in the descending colon.,4.  Internal, non-bleeding, prolapsed with spontaneous reduction (grade II) hemorrhoids were found on retroflexion.,IMPRESSION:,1.  One 5 mm benign appearing polyp in the rectum.  Resected and retrieved.,2.  One 7 mm polyp in the sigmoid colon.  Resected and retrieved.,3.  Diverticulosis.,4.  Internal hemorrhoids were found.,RECOMMENDATION:,1.  High fiber diet.,2.  Await pathology results.,3.  Repeat colonoscopy for surveillance in 3 years.,4.  The findings and recommendations were discussed with the patient.,CPT CODE(S):,45385, Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare,technique.,45384, 59, Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot,biopsy forceps or bipolar cautery.,45381, 59, Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance.,ICD9 CODE(S):,211.4, Benign neoplasm of rectum and anal canal.,211.3, Benign neoplasm of colon.,562.10, Diverticulosis of colon (without mention of hemorrhage).,455.2, Internal hemorrhoids with other complication,578.1, Blood in stool.,v12.72, Personal history of colonic polyps.",
" Patient with active flare of Inflammatory Bowel Disease, not responsive to conventional therapy including sulfasalazine, cortisone, local therapy.", Surgery, Colonoscopy - 8 ,"PROCEDURES PERFORMED:,  Colonoscopy.,INDICATIONS:,  Renewed symptoms likely consistent with active flare of Inflammatory Bowel Disease, not responsive to conventional therapy including sulfasalazine, cortisone, local therapy.,PROCEDURE: , Informed consent was obtained prior to the procedure with special attention to benefits, risks, alternatives.  Risks explained as bleeding, infection, bowel perforation, aspiration pneumonia, or reaction to the medications.  Vital signs were monitored by blood pressure, heart rate, and oxygen saturation.  Supplemental O2 given.  Specifics discussed.  Preprocedure physical exam performed.  Stable vital signs.  Lungs clear.  Cardiac exam showed regular rhythm.  Abdomen soft.  Her past history, her past workup, her past visitation with me for Inflammatory Bowel Disease, well responsive to sulfasalazine reviewed.  She currently has a flare and is not responding, therefore, likely may require steroid taper.  At the same token, her symptoms are mild.  She has rectal bleeding, essentially only some rusty stools.  There is not significant diarrhea, just some lower stools.  No significant pain.  Therefore, it is possible that we are just dealing with a hemorrhoidal bleed, therefore, colonoscopy now needed.  Past history reviewed.  Specifics of workup, need for followup, and similar discussed.  All questions answered.,A normal digital rectal examination was performed.  The PCF-160 AL was inserted into the anus and advanced to the cecum without difficulty, as identified by the ileocecal valve, cecal stump, and appendical orifice.  All mucosal aspects thoroughly inspected, including a retroflexed examination.  Withdrawal time was greater than six minutes.  Unfortunately, the terminal ileum could not be intubated despite multiple attempts.,Findings were those of a normal cecum, right colon, transverse colon, descending colon.  A small cecal polyp was noted, this was biopsy-removed, placed in bottle #1.  Random biopsies from the cecum obtained, bottle #2; random biopsies from the transverse colon obtained, as well as descending colon obtained, bottle #3.  There was an area of inflammation in the proximal sigmoid colon, which was biopsied, placed in bottle #4.  There was an area of relative sparing, with normal sigmoid lining, placed in bottle #5, randomly biopsied, and then inflammation again in the distal sigmoid colon and rectum biopsied, bottle #6, suggesting that we may be dealing with Crohn disease, given the relative sparing of the sigmoid colon and junk lesion.  Retroflexed showed hemorrhoidal disease.  Scope was then withdrawn, patient left in good condition.  ,IMPRESSION:,  Active flare of Inflammatory Bowel Disease, question of Crohn disease.,PLAN: , I will have the patient follow up with me, will follow up on histology, follow up on the polyps.  She will be put on a steroid taper and make an appointment and hopefully steroids alone will do the job.  If not, she may be started on immune suppressive medication, such as azathioprine, or similar.  All of this has been reviewed with the patient.  All questions answered.","surgery, sulfasalazine cortisone local therapy, inflammatory bowel disease, cortisone local, local therapy, crohn disease, sigmoid colon, bowel disease, colonoscopy, inflammatory, rectal, sulfasalazine, cecum, sigmoid, bowel, disease"
" Colonoscopy - Diarrhea, suspected irritable bowel", Surgery, Colonoscopy - 4 ,"PREOPERATIVE DIAGNOSIS:,  Diarrhea, suspected irritable bowel.,POSTOPERATIVE DIAGNOSIS:,  Normal colonoscopy., PREMEDICATIONS: , Versed 5 mg, Demerol 75 mg IV.,REPORTED PROCEDURE:,  The rectal exam revealed no external lesions.  The prostate was normal in size and consistency.,The colonoscope was inserted into the cecum with ease.  The cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, sigmoid colon, and rectum were normal.  The scope was retroflexed in the rectum and no abnormality was seen, so the scope was straightened, withdrawn, and the procedure terminated.,ENDOSCOPIC IMPRESSION:,  Normal colonoscopy - no evidence of inflammatory disease, polyp, or other neoplasm.  These findings are certainly consistent with irritable bowel syndrome.","surgery, diarrhea, ascending colon, cecum, colonoscope, colonoscopy, descending colon, hepatic flexure, inflammatory disease, irritable bowel syndrome, irritable bowel., polyp, rectal exam, rectum, sigmoid colon, splenic flexure, transverse colon, normal colonoscopy, irritable bowel, flexure, irritable, bowel, "
 Colonoscopy to evaluate prior history of neoplastic polyps., Surgery, Colonoscopy - 3 ,"PREOPERATIVE DIAGNOSIS:,  Prior history of neoplastic polyps.,POSTOPERATIVE DIAGNOSIS:,  Small rectal polyps/removed and fulgurated.,PREMEDICATIONS:,  Prior to the colonoscopy, the patient complained of a sever headache and she was concerned that she might become ill.  I asked the nurse to give her 25 mg of Demerol IV.,Following the IV Demerol, she had a nausea reaction.  She was then given 25 mg of Phenergan IV.  Following this, her headache and nausea completely resolved.  She was then given a total of 7.5 mg of Versed with adequate sedation.  Rectal exam revealed no external lesions.  Digital exam revealed no mass.,REPORTED PROCEDURE:,  The P160 colonoscope was used.  The scope was placed in the rectal ampulla and advanced to the cecum.  Navigation through the sigmoid colon was difficult.  Beginning at 30 cm was a very tight bend.  With gentle maneuvering, the scope passed through and then entered the cecum.  The cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, and descending colon were normal.  The sigmoid colon was likewise normal.  There were five very small (punctate) polyps in the rectum.  One was resected using the electrocautery snare and the other four were ablated using the snare and cautery.  There was no specimen because the polyps were so small.  The scope was retroflexed in the rectum and no further abnormality was seen, so the scope was straightened, withdrawn, and the procedure terminated.,ENDOSCOPIC IMPRESSION:,1.  Five small polyps as described, all fulgurated.,2.  Otherwise unremarkable colonoscopy.","surgery, colonoscopy, demerol, phenergan, rectal exam, versed, ascending colon, cecum, colonoscope, descending colon, fulgurated, hepatic flexure, neoplastic, polyps, punctate, rectal ampulla, splenic flexure, transverse colon, scope"
" Colonoscopy and biopsies, epinephrine sclerotherapy, hot biopsy cautery, and snare polypectomy.  Colon cancer screening.  Family history of colon polyps.", Surgery, Colonoscopy - 21 ,"OPERATIVE PROCEDURES: , Colonoscopy and biopsies, epinephrine sclerotherapy, hot biopsy cautery, and snare polypectomy.,PREOPERATIVE DIAGNOSES:,1.  Colon cancer screening.,2.  Family history of colon polyps.,POSTOPERATIVE DIAGNOSES:,1.  Multiple colon polyps (5).,2.  Diverticulosis, sigmoid colon.,3.  Internal hemorrhoids.,ENDOSCOPE USED: , EC3870LK.,BIOPSIES:  ,Biopsies taken from all polyps.  Hot biopsy got applied to one.  Epinephrine sclerotherapy and snare polypectomy applied to four polyps.,ANESTHESIA: , Fentanyl 75 mcg, Versed 6 mg, and glucagon 1.5 units IV push in divided doses.  Also given epinephrine 1:20,000 total of 3 mL.,The patient tolerated the procedure well.,PROCEDURE:  ,The patient was placed in left lateral decubitus after appropriate sedation.  Digital rectal examination was done, which was normal.  Endoscope was introduced and passed through a rather spastic tortuous sigmoid colon with multiple diverticula seen all the way through transverse colon where about 1 cm x 1 cm sessile polyp was seen.  It was biopsied and then in piecemeal fashion removed using snare polypectomy after base was infiltrated with epinephrine.  Pedunculated polyp next to it was hard to see and there was a lot of peristalsis.  The scope then was advanced through rest of the transverse colon to ascending colon and cecum.  Terminal ileum was briefly reviewed, appeared normal and so did cecum after copious amount of fecal material was irrigated out.  Ascending colon was unremarkable.  At hepatic flexure may be proximal transverse colon, there was a sessile polyp about 1.2 cm x 1 cm that was removed in the same manner with a biopsy taken, base infiltrated with epinephrine and at least two passes of snare polypectomy and subsequent hot biopsy cautery removed to hold polypoid tissue, which could be seen.  In transverse colon on withdrawal and relaxation with epinephrine, an additional 1 mm to 2 mm sessile polyp was removed by hot biopsy.  Then in the transverse colon, additional larger polyp about 1.3 cm x 1.2 cm was removed in piecemeal fashion again with epinephrine, sclerotherapy, and snare polypectomy.  Subsequently pedunculated polyp in distal transverse colon near splenic flexure was removed with snare polypectomy.  The rest of the splenic flexure and descending colon were unremarkable.  Diverticulosis was again seen with almost constant spasm despite of glucagon.  Sigmoid colon did somewhat hinder the inspection of that area.  Rectum, retroflexion posterior anal canal showed internal hemorrhoids moderate to large.  Excess of air insufflated was removed.  The endoscope was withdrawn.,PLAN: , Await biopsy report.  Pending biopsy report, recommendation will be made when the next colonoscopy should be done at least three years perhaps sooner besides and due to multitude of the patient's polyps.","surgery, colon cancer, colon polyps, snare polypectomy, cautery, epinephrine sclerotherapy, transverse colon, polypectomy, colonoscopy, sigmoid, endoscope, sclerotherapy, epinephrine, biopsy,"
 Possible inflammatory bowel disease.  Polyp of the sigmoid colon..  Total colonoscopy with photography and polypectomy., Surgery, Colonoscopy - 18 ,"PREOPERATIVE DIAGNOSIS: , Possible inflammatory bowel disease.,POSTOPERATIVE DIAGNOSIS: , Polyp of the sigmoid colon.,PROCEDURE PERFORMED:  ,Total colonoscopy with photography and polypectomy.,GROSS FINDINGS: , The patient had a history of ischiorectal abscess.  He has been evaluated now for inflammatory bowel disease.  Upon endoscopy, the colon prep was good.  We were able to reach the cecum without difficulty.  There are no diverticluli, inflammatory bowel disease, strictures, or obstructing lesions.  There was a pedunculated polyp approximately 4.5 cm in size located in the sigmoid colon at approximately 35 cm.  This large polyp was removed using the snare technique.,OPERATIVE PROCEDURE:  ,The patient was taken to the endoscopy suite, prepped and draped in left lateral decubitus position.  IV sedation was given by Anesthesia Department.  The Olympus videoscope was inserted into anus.  Using air insufflation, the colonoscope was advanced through the anus to the rectum, sigmoid colon, descending colon, transverse colon, ascending colon and cecum, the above gross findings were noted.  The colonoscope was slowly withdrawn and carefully examined the lumen of the bowel.  When the polyp again was visualized, the snare was passed around the polyp.  It required at least two to three passes of the snare to remove the polyp in its totality.  There was a large stalk on the polyp.  ________ the polyp had been removed down to the junction of the polyp in the stalk, which appeared to be cauterized and no residual adenomatous tissue was present.  No bleeding was identified.  The colonoscope was then removed and patient was sent to recovery room in stable condition.","surgery, polypectomy, inflammatory bowel disease, sigmoid colon, rectum, descending colon, transverse colon, ascending colon, cecum, total colonoscopy, bowel disease, inflammatory, polyp, colonoscopy, colonoscope, bowel, "
 Mild-to-moderate diverticulosis.  She was referred for a screening colonoscopy.  There is no family history of colon cancer.  No evidence of polyps or malignancy., Surgery, Colonoscopy - 22 ,"PROCEDURE: , Colonoscopy.,PREOPERATIVE DIAGNOSES:,  The patient is a 56-year-old female.  She was referred for a screening colonoscopy.  The patient has bowel movements every other day.  There is no blood in the stool, no abdominal pain.  She has hypertension, dyslipidemia, and gastroesophageal reflux disease.  She has had cesarean section twice in the past.  Physical examination is unremarkable.  There is no family history of colon cancer.,POSTOPERATIVE DIAGNOSIS: , Diverticulosis.,PROCEDURE IN DETAIL: , Procedure and possible complications were explained to the patient.  Ample opportunity was provided to her to ask questions.  Informed consent was obtained.  She was placed in left lateral position.  Inspection of perianal area was normal.  Digital exam of the rectum was normal.,Video Olympus colonoscope was introduced into the rectum.  The sigmoid colon is very tortuous.  The instrument was advanced to the cecum after placing the patient in a supine position.  The patient was well prepared and a good examination was possible.  The cecum was identified by the ileocecal valve and the appendiceal orifice.  Images were taken.  The instrument was then gradually withdrawn while examining the colon again in a circumferential manner.  Few diverticula were encountered in the sigmoid and descending colon.  Retroflex view of the rectum was unremarkable.  No polyps or malignancy was identified.,After obtaining images, the air was suctioned.  Instrument was withdrawn from the patient.  The patient tolerated the procedure well.  There were no complications.,SUMMARY OF FINDINGS:  ,Colonoscopy was performed to cecum and demonstrates the following:,1.  Mild-to-moderate diverticulosis.,2.  ,RECOMMENDATION:,1.  The patient was provided information on diverticulosis including dietary advice.,2.  She was advised repeat colonoscopy after 10 years.","surgery, screening colonoscopy, colon cancer, colonoscopy, polyps, malignancy, sigmoid, rectum, cecum, diverticulosis"
" Colonoscopy.   Rectal bleeding and perirectal abscess.  Normal colonoscopy to the terminal ileum.  Opening in the skin at the external anal verge, consistent with drainage from a perianal abscess, with no palpable abscess at this time, and with no evidence of fistulous connection to the bowel lumen.", Surgery, Colonoscopy - 16 ,"PROCEDURE: , Colonoscopy.,PREOPERATIVE DIAGNOSES: , Rectal bleeding and perirectal abscess.,POSTOPERATIVE DIAGNOSIS: , Perianal abscess.,MEDICATIONS:,  MAC.,DESCRIPTION OF PROCEDURE:  ,The Olympus pediatric variable colonoscope was introduced through the rectum and advanced carefully through the colon into the cecum and then through the ileocecal valve into the terminal ileum.  The preparation was excellent and all surfaces were well seen.  The mucosa throughout the colon and in the terminal ileum was normal, with no evidence of colitis.  Special attention was paid to the rectum, including retroflexed views of the distal rectum and the anorectal junction.  There was no evidence of either inflammation or a fistulous opening.  The scope was withdrawn.  A careful exam of the anal canal and perianal area demonstrated a jagged 8-mm opening at the anorectal junction posteriorly (12 o'clock position).  Some purulent material could be expressed through the opening.  There was no suggestion of significant perianal reservoir of inflamed tissue or undrained material.  Specifically, the posterior wall of the distal rectum and anal canal were soft and unremarkable.  In addition, scars were noted in the perianal area.  The first was a small dimpled scar, 1 cm from the anal verge in the 11 o'clock position.  The second was a dimpled scar about 5 cm from the anal verge on the left buttock's cheek.  There were no other abnormalities noted.  The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1.  Normal colonoscopy to the terminal ileum.,2.  Opening in the skin at the external anal verge, consistent with drainage from a perianal abscess, with no palpable abscess at this time, and with no evidence of fistulous connection to the bowel lumen.,RECOMMENDATIONS:,1.  Continue antibiotics.,2.  Followup with Dr. X.,3.  If drainage persists, consider surgical drainage.","surgery, olympus, colonoscope, rectal bleeding, perianal abscess, terminal ileum, anal verge, anorectal, fistulous, ileum, verge, rectum, anal, perianal, colonoscopy, abscess"
 Universal diverticulosis and nonsurgical internal hemorrhoids. Total colonoscopy with photos.  The patient is a 62-year-old white male who presents to the office with a history of colon polyps and need for recheck., Surgery, Colonoscopy - 17 ,"PREOPERATIVE DIAGNOSIS: , Colon polyps.,POSTOPERATIVE DIAGNOSES:,1.  Universal diverticulosis.,2.  Nonsurgical internal hemorrhoids.,PROCEDURE PERFORMED:, Total colonoscopy with photos.,ANESTHESIA:,  Demerol 100 mg IV with Versed 3 mg IV.,SPECIMENS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,INDICATIONS FOR PROCEDURE:  ,The patient is a 62-year-old white male who presents to the office with a history of colon polyps and need for recheck.,PROCEDURE:,  Informed consent was obtained.  All risks and benefits of the procedure were explained and all questions were answered.  The patient was brought back to the Endoscopy Suite where he was connected to cardiopulmonary monitoring.  Demerol 100 mg IV and Versed 3 mg IV was given in a titrated fashion until appropriate anesthesia was obtained.  Upon appropriate anesthesia, a digital rectal exam was performed, which showed no masses.  The colonoscope was then placed into the anus and the air was insufflated.  The scope was then advanced under direct vision into the rectum, rectosigmoid colon, descending colon, transverse colon, ascending colon until it reached the cecum.  Upon entering the sigmoid colon and throughout the rest of the colon, there was noted diverticulosis.  After reaching the cecum, the scope was fully withdrawn visualizing all walls again noting universal diverticulosis.,Upon reaching the rectum, the scope was then retroflexed upon itself and there was noted to be nonsurgical internal hemorrhoids.  The scope was then subsequently removed.  The patient tolerated the procedure well and there were no complications.","surgery, endoscopy, rectum, rectosigmoid colon, descending colon, transverse colon, ascending colon, total colonoscopy, colon polyps, colonoscopy, cecum, polyps, diverticulosis, hemorrhoids,"
" History of polyps.  Total colonoscopy and photography.  Normal colonoscopy, left colonic diverticular disease.  3+ benign prostatic hypertrophy.", Surgery, Colonoscopy - 13 ,"PREOPERATIVE DIAGNOSIS: , History of polyps.,POSTOPERATIVE DIAGNOSES:,1.  Normal colonoscopy, left colonic diverticular disease.,2.  3+ benign prostatic hypertrophy.,PROCEDURE PERFORMED: , Total colonoscopy and photography.,GROSS FINDINGS: , This is a 74-year-old white male here for recheck colonoscopy for a history of polyps.  After signed informed consent, blood pressure monitoring, EKG monitoring, and pulse oximetry monitoring, he was brought to the Endoscopic Suite.  He was given 100 mg of Demerol, 3 mg of Versed IV push slowly.  Digital examination revealed a large prostate for which he is following up with his urologist.  No nodules.  3+ BPH.  Anorectal canal was within normal limits.  No stricture tumor or ulcer.  The Olympus CF 20L video endoscope was inserted per anus.  The anorectal canal was visualized, was normal.  The sigmoid, descending, splenic, and transverse showed scattered diverticula.  The hepatic, ascending, cecum, and ileocecal valve was visualized and was normal.  The colonoscope was removed.  The air was aspirated.  The patient was discharged with high-fiber, diverticular diet.  Recheck colonoscopy three years.","surgery, digital examination, benign prostatic hypertrophy, anorectal canal, diverticular disease, photography, anorectal, colonoscopy,"
 Colonoscopy.  The Olympus video colonoscope then was introduced into the rectum and passed by directed vision to the cecum and into the terminal ileum. , Surgery, Colonoscopy - 12 ,"PROCEDURE IN DETAIL: , Following instructions and completion of an oral colonoscopy prep, the patient, having been properly informed of, with signature consenting to total colonoscopy and indicated procedures, the patient received premedications of Vistaril 50 mg, Atropine 0.4 mg IM, and then intravenous medications of Demerol 50 mg and Versed 5 mg IV.  Perirectal inspection was normal.  The Olympus video colonoscope then was introduced into the rectum and passed by directed vision to the cecum and into the terminal ileum.  No abnormalities were seen of the terminal ileum, the ileocecal valve, cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, rectosigmoid and rectum.  Retroflexion exam in the rectum revealed no other abnormality and withdrawal terminated the procedure.","surgery, ileocecal valve, cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, rectosigmoid, rectum, terminal ileum, olympus video colonoscope, flexure, colonoscopyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Screening colonoscopy.  Tiny polyps.   If adenomatous, repeat exam in five years.  ", Surgery, Colonoscopy - 20 ,"PREOPERATIVE DIAGNOSIS: , Screening. ,POSTOPERATIVE DIAGNOSIS:,  Tiny Polyps.,PROCEDURE PERFORMED:  , Colonoscopy.,PROCEDURE:  , The procedure, indications, and risks were explained to the patient, who understood and agreed.  He was sedated with Versed 3 mg, Demerol 25 mg during the examination.  ,A digital rectal exam was performed and the Pentax Video Colonoscope was advanced over the examiner's finger into the rectum.  It was passed to the level of the cecum.  The ileocecal valve was identified, as was the appendiceal orifice.  ,Slowly withdrawal through the colon revealed a small polyp in the transverse colon.  This was approximately 3 mm in size and was completely removed using multiple bites with cold biopsy forceps.  In addition, there was a 2 mm polyp versus lymphoid aggregate in the descending colon.  This was also removed using the cold biopsy forceps.  Further detail failed to reveal any other lesions with the exception of small hemorrhoids.  ,IMPRESSION:  , Tiny polyps.  ,PLAN:  , If adenomatous, repeat exam in five years.  Otherwise, repeat exam in 10 years.,","surgery, pentax video colonoscope, biopsy forceps, tiny polyps, polyps, adenomatous, colonoscopy"
 Colonoscopy in a patient with prior history of anemia and abdominal bloating., Surgery, Colonoscopy - 2 ,"PREOPERATIVE DIAGNOSES:,  Prior history of anemia, abdominal bloating.,POSTOPERATIVE DIAGNOSIS:,  External hemorrhoids, otherwise unremarkable colonoscopy.,PREMEDICATIONS:,  Versed 5 mg, Demerol 50 mg IV.,REPORT OF PROCEDURE:,  Digital rectal exam revealed external hemorrhoids.  The colonoscope was inserted into the rectal ampulla and advanced to the cecum.  The position of the scope within the cecum was verified by identification of the appendiceal orifice.  The cecum, the ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, and rectum were normal.  The scope was retroflexed in the rectum and no abnormality was seen.  So the scope was straightened, withdrawn, and the procedure terminated.,ENDOSCOPIC IMPRESSION:,1.  Normal colonoscopy.,2.  External hemorrhoids.","surgery, colonoscopy, digital rectal exam, abdominal, anemia, ascending colon, bloating, cecum, colonoscope, descending colon, hemorrhoids, hepatic flexure, rectal ampulla, rectum, splenic flexure, transverse colon, external hemorrhoids, scope, "
" Colonoscopy.  The Olympus video colonoscope was inserted through the anus and was advanced in retrograde fashion through the sigmoid colon, descending colon, around the splenic flexure, into the transverse colon, around the hepatic flexure, down the ascending colon, into the cecum. ", Surgery, Colonoscopy - 11 ,"MEDICATIONS:,1.  Versed intravenously.,2.  Demerol intravenously.,DESCRIPTION OF THE PROCEDURE: , After informed consent was obtained, the patient was placed in the left lateral decubitus position and sedated with the above medications.  The Olympus video colonoscope was inserted through the anus and was advanced in retrograde fashion through the sigmoid colon, descending colon, around the splenic flexure, into the transverse colon, around the hepatic flexure, down the ascending colon, into the cecum.  The cecum was identified by the presence of the appendiceal orifice and the ileocecal valve.  The colonoscope was then advanced through the ileocecal valve into the terminal ileum, which was normal on examination.  The scope was then pulled back into the cecum and then slowly withdrawn.  The mucosa was examined in detail.  The mucosa was entirely normal.  Upon reaching the rectum, retroflex examination of the rectum was normal.  The scope was then straightened out, the air removed and the scope withdrawn.  The patient tolerated the procedure well.  There were no apparent complications.,","surgery, olympus, scope, sigmoid colon, descending colon, splenic flexure, transverse colon, hepatic flexure, ascending colon, ileocecal valve, ileocecal, mucosa, rectum, colonoscope, flexure, cecum, colonoscopyNOTE"
 Colonoscopy with terminal ileum examination.   Iron deficiency anemia.  Following titrated intravenous sedation the flexible video endoscope was introduced into the rectum and advanced to the cecum without difficulty. , Surgery, Colonoscopy - 19 ,"INDICATION: , Iron deficiency anemia.,PROCEDURE:  ,Colonoscopy with terminal ileum examination.,POSTOPERATIVE DIAGNOSIS:,  Normal examination.,WITHDRAWAL TIME: , 15 minutes.,SCOPE: , CF-H180AL.,MEDICATIONS: , Fentanyl 100 mcg and versed 10 mg.,PROCEDURE DETAIL:  ,Following the preprocedure patient assessment the procedure, goals, risks including bleeding, perforation, missed polyp rate as well as side effects of medications and alternatives were reviewed.  Questions were answered.  Pause preprocedure was performed.,Following titrated intravenous sedation the flexible video endoscope was introduced into the rectum and advanced to the cecum without difficulty.  The ileocecal valve looked normal.  Preparation was fair allowing examination of 85% of mucosa after washing and cleaning with tap water through the scope.  The terminal ileum was intubated through the ileocecal valve for a 5 cm extent.  Terminal ileum mucosa looked normal.,Then the scope was withdrawn while examining the mucosa carefully including the retroflexed views of the rectum.  No polyp, no diverticulum and no bleeding source was identified.,The patient was assessed upon completion of the procedure.  Okay to discharge once criteria met.  ,RECOMMENDATIONS:,  Follow up with primary care physician.","surgery, polyp, endoscope, mucosa, iron deficiency anemia, ileocecal valve, terminal ileum, colonoscopy, anemia, rectum, ileum"
 Colon cancer screening and family history of polyps.  Sigmoid diverticulosis and internal hemorrhoids., Surgery, Colonoscopy - 10 ,"PREOPERATIVE DIAGNOSES: , Colon cancer screening and family history of polyps.,POSTOPERATIVE DIAGNOSIS:,  Colonic polyps.,PROCEDURE:,  Colonoscopy.,ANESTHESIA:,  MAC,DESCRIPTION OF PROCEDURE:  ,The Olympus pediatric variable colonoscope was introduced into the rectum and advanced carefully through the colon into the cecum and then through the ileocecal valve into the terminal ileum.  The preparation was excellent and all surfaces were well seen.  The mucosa was normal throughout the colon and in the terminal ileum.  Two polyps were identified and were removed.  The first was a 7-mm sessile lesion in the mid transverse colon at 110 cm, removed with the snare without cautery and retrieved.  The second was a small 4-mm sessile lesion in the sigmoid colon at 20 cm also removed with the snare and retrieved.  No other lesions were identified.  Numerous diverticula were found in the sigmoid colon.  A retroflex through the anorectal junction showed moderate internal hemorrhoids.  The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1.  Sigmoid diverticulosis.,2.  Colonic polyps in the transverse colon and sigmoid colon, benign appearance, removed.,3.  Internal hemorrhoids.,4.  Otherwise normal colonoscopy to the terminal ileum.,RECOMMENDATIONS:,1.  Follow up biopsy report.,2.  Follow up with Dr. X as needed.,3.  Screening colonoscopy in 5 years.",surgery
 Colonoscopy.  Change in bowel habits and rectal prolapse.  Normal colonic mucosa to the cecum.  , Surgery, Colonoscopy - 15 ,"PROCEDURE:,  Colonoscopy.,PREOPERATIVE DIAGNOSES: , Change in bowel habits and rectal prolapse.,POSTOPERATIVE DIAGNOSIS: , Normal colonoscopy.,PROCEDURE:  ,The Olympus pediatric variable colonoscope was introduced through the rectum and advanced carefully through the colon to the cecum identified by the ileocecal valve and the appendiceal orifice.  The preparation was poor, but mucosa was visible after lavage and suction.  Small lesions might have been missed in certain places, but no large lesions are likely to have been missed.  The mucosa was normal, was visualized.  In particular, there was no mucosal abnormality in the rectum and distal sigmoid, which is reported to be prolapsing.  Biopsies were taken from the rectal wall to look for microscopic changes.  The anal sphincter was considerably relaxed, with no tone and a gaping opening.  The patient tolerated the procedure well and was sent to recovery room.,FINAL DIAGNOSIS: , Normal colonic mucosa to the cecum.  No contraindications to consideration of a repair of the prolapse.","surgery, olympus, colonoscope, bowel habits, colonic mucosa, colonic, rectum, rectal, cecum, mucosa, colonoscopy, "
" Colonoscopy. History of colon polyps and partial colon resection, right colon.  Mild diverticulosis of the sigmoid colon.  Hemorrhoids.", Surgery, Colonoscopy - 14 ,"PREPROCEDURE DIAGNOSIS: , History of colon polyps and partial colon resection, right colon.,POSTPROCEDURE DIAGNOSES:  ,1. Normal operative site.  ,2. Mild diverticulosis of the sigmoid colon.  ,3. Hemorrhoids.,PROCEDURE:  ,Total colonoscopy.,PROCEDURE IN DETAIL:  ,The patient is a 60-year-old of Dr. ABC's being evaluated for the above.  The patient also apparently had an x-ray done at the Hospital and it showed a dark spot, and because of this, a colonoscopy was felt to be needed.  She was prepped the night before and on the morning of the test with oral Fleet's, brought to the second floor and sedated with a total of 50 mg of Demerol and 3.75 mg of Versed IV push.  Digital rectal exam was done, unremarkable.  At that point, the Pentax video colonoscope was inserted.  The rectal vault appeared normal.  The sigmoid showed diverticula throughout, mild to moderate in nature.  The scope was then passed through the descending and transverse colon over to the hepatic flexure area and then the anastomosis site was visualized.  The scope was passed a short distance up the ileum, which appeared normal.  The scope was then withdrawn through the transverse, descending, sigmoid, and rectal vault area.  The scope was then retroflexed, and anal verge visualized showed some hemorrhoids.  The scope was then removed.  The patient tolerated the procedure well.,RECOMMENDATIONS:  ,Repeat colonoscopy in three years.","surgery, partial colon resection, diverticulosis, colon polyps, rectal vault, colonoscopy, polyps, hemorrhoids, sigmoid"
" Closing wedge osteotomy, fifth metatarsal with internal screw fixation, right foot.", Surgery, Closing Wedge Osteotomy ,"PREOPERATIVE DIAGNOSIS: , Tailor's bunion, right foot.,POSTOPERATIVE DIAGNOSIS: , Tailor's bunion, right foot.,PROCEDURE: , Closing wedge osteotomy, fifth metatarsal with internal screw fixation, right foot.,ANESTHESIA: , Local infiltrate with IV sedation.,INDICATIONS FOR SURGERY: , The patient has had a longstanding history of foot problems.  The problem has been progressive in nature.  The preoperative discussion with the patient included alternative treatment options, the procedure was explained, and the risk factors such as infection, swelling, scar tissue, numbness, continued pain, recurrence, and the postoperative management were discussed.  The patient has been advised, although no guarantee for success could be given, most of the patient have less pain and improved function, all questions were thoroughly answered.  The patient requested for surgical repair since the problem has reached a point that interfere with normal daily activity.  The purpose of the surgery is to alleviate pain and discomfort.,DETAILS OF PROCEDURE:  ,The patient was given 1 g of Ancef IV for antibiotic prophylaxis 30 minutes prior to the procedure.  The patient was brought to the operating room and placed in the supine position.  No tourniquet was utilized.  IV sedation was achieved followed by a local anesthetic consisting of approximately 10 mL total in 1:1 mixture of 0.25% Marcaine and 1% lidocaine with epinephrine was locally infiltrated proximal to the operative site.  The lower extremity was prepped and draped in the usual sterile manner.  Balanced anesthesia was obtained.,PROCEDURE:, Closing wedge osteotomy, fifth metatarsal with internal screw fixation, right foot.  A dorsal curvilinear incision was made extending from the base of the proximal phalanx fifth digit to a point 1.5 cm from the base of the fifth metatarsal.  Care was taken to identify and retract all vital structures and when necessary, vessels were ligated via electrocautery.  The extensor tendon was identified and retracted medially.  Sharp and blunt dissection was carried down through the subcutaneous tissue down to the periosteal layer.  A linear periosteal capsular incision was made in line with the skin incision.  The capsular tissue and periosteal layer was underscored, free from its underlying osseous attachment, and then reflected to expose the osseous surface.  Inspection of the fifth metatarsophalangeal joint revealed articular cartilage to be perverse and hypertrophic changes to the lateral and dorsolateral aspect of the fifth metatarsal head.  An oscillating saw was utilized to carefully resect the hypertrophic portion of the fifth metatarsal head to a more normal configuration.  The both edges were rasped smooth.,Attention was then focused on the fifth metatarsal.  The periosteal layer proximal to the fifth metatarsal head was underscored, free from its underlying attachment, and then reflected to expose the osseous surface.  An excess guide position perpendicular to the weightbearing surface was placed to define apex of the osteotomy.,Using an oscillating saw, a vertically placed, wedge-shaped oblique ostomy was made with the apex being proximal, lateral, and the base medial and distal.  Generous amounts of lateral cortex were preserved for the lateral hinge.  The wedge was removed from the surgical field.  The fifth metatarsal was placed in the appropriate position and stabilized with a guide pin, which was then countersunk and a 3-0 x 40 mm cannulated cortical screw was placed over the guide pin and secured into position.  Good purchase was noted at the osteotomy site.  Inspection revealed satisfactory reduction of the fourth intermetatarsal angle with the fifth metatarsal in good alignment and position.  The surgical site was flushed with copious amounts of normal saline irrigation.  The periosteal and capsular layers were closed with running sutures of 3-0 Vicryl.  The subcutaneous tissues were closed with 4-0 Vicryl, and the skin edges were closed with 4-0 nylon in a running interrupted fashion.  A dressing consisting of Adaptic, 4 x 4, confirming bandages, and ACE wrap to provide mild compression was applied.  The patient tolerated the procedure and anesthesia well and left the operating room to the recovery room in good postoperative condition with vital signs stable and arterial perfusion intact as evident by normal capillary refill time, and all digits were warm and pink.,A walker boot was dispensed and applied.  The patient should wear that all the time when standing or walking and be nonweightbearing with crutches and to clear by me.,Office visit will be in 4 days.  The patient was given prescriptions for Keflex 500 mg one p.o. t.i.d. for 10 days and Ultram ER, #15 one p.o. daily along with written and oral home instructions including a number on which I can be reached 24 hours a day if any problem arises.,After short recuperative period, the patient was discharged home with a vital sign stable in no acute distress.","surgery, internal screw fixation, osteotomy, closing wedge osteotomy, tailor's bunion, screw fixation, periosteal layer, metatarsal head, wedge osteotomy, metatarsal, anesthesia"
" Juxtaductal coarctation of the aorta, dilated cardiomyopathy, bicuspid aortic valve, patent foramen ovale.", Surgery, Coarctation of Aorta ,"HISTORY: , The patient is a 4-month-old who presented with respiratory distress and absent femoral pulses with subsequent evaluation including echocardiogram that demonstrated severe coarctation of the aorta with a peak gradient of 29 mmHg and associated dilated cardiomyopathy with fractional shortening of 16%.  A bicuspid aortic valve was also seen without insufficiency or stenosis.  The patient underwent cardiac catheterization for balloon angioplasty for coarctation of the aorta.,PROCEDURE:  ,After sedation and general endotracheal anesthesia, the patient was prepped and draped.  Cardiac catheterization was performed as outlined in the attached continuation sheets.  Vascular entry was by percutaneous technique, and the patient was heparinized.  Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a percutaneous technique a 4-French 8 cm long double lumen central venous catheter was inserted in the left femoral vein and sutured into place.  There was good blood return from both the ports.,Using a 4-French sheath a 4-French wedge catheter was inserted into the right femoral vein and advanced through the right heart structures out to the branch of pulmonary arteries.  The atrial septum was not probe patent.,Using a 4-French sheath a 4-French marker pigtail catheter was inserted into the left femoral artery and advanced retrograde to the descending aorta ,ascending aorta and left ventricle.  A descending aortogram demonstrated discrete coarctation of the aorta approximately 8 mm distal to the origin of the left subclavian artery.  The transverse arch measured 5 mm.  Isthmus measured 4.7 mm and coarctation measured 2.9 x 1.8 mm at the descending aorta level.  The diaphragm measured 5.6 mm.  The pigtail catheter was exchanged for a wedge catheter, which was then directed into the right innominate artery.  This catheter was exchanged over a wire for a Tyshak mini 6 x 2 cm balloon catheter which was advanced across the coarctation and inflated with complete disappearance of discrete waist.  Pressure pull-back following angioplasty, however, demonstrated a residual of 15-20 mmHg gradient.  Repeat angiogram showed mild improvement in degree of aortic narrowing.  The angioplasty was then performed using a Tyshak mini 7 x 2 cm balloon catheter with complete disappearance of mild waist.  The pigtail catheter was then reintroduced for a pressure pull-back measurement and final angiogram.,Flows were calculated by the Fick technique using an assumed oxygen consumption.,Cineangiograms were obtained with injection in the descending aorta.,After angiography, two normal-appearing renal collecting systems were visualized.  The catheters and sheaths were removed and topical pressure applied for hemostasis.  The patient was returned to the pediatric intensive care unit in satisfactory condition.  There were no complications.,DISCUSSION: , Oxygen consumption was assumed to be normal.  Mixed venous saturation was low due to mild systemic arterial desaturation and anemia.  There is no evidence of significant intracardiac shunt.  Further the heart was desaturated due to VQ mismatch.,Phasic right-sided pressures were normal as was the right pulmonary artery capillary wedge pressure with the A-wave similar to the normal left ventricular end-diastolic pressure of 12 mmHg.  Left ventricular systolic pressure was mildly increased with a 60 mmHg systolic gradient into the ascending aorta and a 29 mmHg systolic gradient on pressure pull-back to the descending aorta.  The calculated flows were mildly increased.  Vascular resistances were normal.  A cineangiogram with contrast injection in the descending aorta showed a normal left aortic arch with normal origins of the brachiocephalic vessels.  There is discrete juxtaductal coarctation of the aorta.  Flow within the intercostal arteries was retrograde.  Following balloon angioplasty of coarctation of the aorta, there was slight fall in the mixed venous saturation and an increase in systemic arterial saturation as the fall in left ventricular systolic pressure from 99 mmHg to 92 mmHg.  There remained a 4 mmHg systolic gradient into the ascending aorta and 9 mmHg systolic gradient pressure pull-back to the descending aorta.  The calculated systemic flow fell to normal values.  Final angiogram with injection in the descending aorta demonstrated improved caliber of coarctation of the aorta with mild intimal irregularity and a small left lateral filling defect consistent with a small intimal tear in the region of the ductus arteriosus.  There is brisk flow in the descending aorta and appropriate flow in the intercostal arteries.  The narrowest diameter of the aorta measured 4.9 x 4.2 mm.,DIAGNOSES:  ,1.  Juxtaductal coarctation of the aorta.,2.  Dilated cardiomyopathy.,3.  Bicuspid aortic valve.,4.  Patent foramen ovale.,INTERVENTION: , Balloon dilation of coarctation of the aorta.,MANAGEMENT: , The case will be discussed at combined Cardiology and Cardiothoracic Surgery Case Conference.  The patient will be allowed to recover from the current intervention with the hopes of complete left ventricular function recovery.  The patient will undoubtedly require formal coarctation of the aorta repair surgically in 4-6 months.  The further cardiologic care will be directed by Dr. X.","surgery, coarctation, juxtaductal, dilated cardiomyopathy, bicuspid aortic valve, patent foramen ovale, catheter was inserted, mmhg systolic gradient, mmhg systolic, systolic gradient, descending aorta, catheterization, mmhg, ventricular, aorta, aortic, foramen,"
" Closed reduction percutaneous pinning, left distal humerus.   Closed type-III supracondylar fracture, left distal humerus.  Tethered brachial artery, left elbow.", Surgery, Closed Reduction Percutaneous Pinning ,"PREOPERATIVE DIAGNOSIS: , Closed type-III supracondylar fracture, left distal humerus.,POSTOPERATIVE DIAGNOSES:,1.  Closed type-III supracondylar fracture, left distal humerus.,2.  Tethered brachial artery, left elbow.,PROCEDURE PERFORMED: , Closed reduction percutaneous pinning, left distal humerus.,SPECIFICATIONS: , The entire operative procedure was done in the inpatient operating suite, room #2 at ABCD General Hospital.  A portion of the procedure was done in consult with Dr. X with separate dictation by him.,HISTORY AND GROSS FINDINGS:  ,This is a 4-year-old white male, apparently dominantly right-handed who suffered a severe injury to his left distal humerus after jumping off of a swing.  He apparently had not had previous problems with his left arm.  He was seen in the Emergency with a grossly deformed left elbow.  His parents' were both present preoperatively.  His x-ray exam as well as physical exam was consistent with a closed type-III supracondylar fracture of the left distal humerus with rather severe puckering of the skin anteriorly with significant ecchymosis in the same region.  Gross neurologic exam revealed his ulnar, median, and radial nerves to be mostly intact, although a complete exam was impossible.  He did have a radial pulse palpable.,PROCEDURE: , After discussing the alternatives of the case as well as advantages and disadvantages, risks, complications, and expectations with the patient's parents including malunion, nonunion, gross deformity, growth arrest, infection, loss of elbow motions, stiffness, instability, need for surgery in the future, nerve problems, artery problems, and compartment syndrome, they elected to proceed.,The patient was laid supine upon operative table after receiving general anesthetic by Anesthesia Department.  Closed reduction was accomplished in a sequential manner.  Milking of the soft tissue envelope was carried out to try and reduce the shaft of the humerus back into its plane relative to the brachialis muscle and the neurovascular bundle anteriorly.  Then a slow longitudinal traction was carried out.  The elbow was hyperflexed.  Pressure placed upon the olecranon tip and two 0.045 K-wires placed first, one being on the lateral side and with this placement on the medial side of medial epicondyle with care taken to protect the ulnar nerve.  The close reduction was deemed to be acceptable once viewed on C-arm.,After this, pulse was attempted to be palpated distally.  Prior to the procedure, I talked to Dr. X of Vascular Surgery at ABCD Hospital.  He had scrubbed in to the case to follow up on the loss of the radial artery distally.  This was not present palpatory, but also by Doppler.  A weak ulnar artery pulse was present via Doppler.  Because of this, the severe displacement of the injury and the fact that the Doppler sound had an occlusion-type sound just above the fracture site or _______.  A long discussion was carried out with Dr. X and myself, and we decided to proceed with exploration of the brachial artery.  Prior to this, I went out to the waiting room to discuss with the patient's parents, the reasoning what we are going to do and the reasoning for this.  I then came back in and then we proceeded.  He was prepped and draped in the usual sterile manner.  Please see Dr. X's report for the discussion of the exploration and release of the brachial artery.  There was no indication that it was actually in the fracture site, the soft tissue had tethered in its right angle towards the fracture site, thus reducing its efficiency of providing blood distally.  Once it was released, both clinically on the table as well as by Doppler, the patient had bounding pulses.,We then proceeded to close utilizing a #4-0 Vicryl for subcutaneous fat closure and a running #5-0 Vicryl subcuticular stitch for skin closure.  Steri-Strips were placed.  The patient's arm was placed in just a slight degree of flexion with a neutral position.  He was splinted posteriorly.  Adaptic and fluffs have been placed around the patient's pin sites.  K-wires have been bent, cut, and pin caps placed.,Expected surgical prognosis on this patient is guarded for the obvious reasons noted above.  There is concern for growth plate disturbance.  He will be watched very closely for the potential development of re-perfusing compartment syndrome.,A full and complete neurologic exam will be impossible tonight, but will be carried on a sequential basis starting tomorrow morning.  There is always a potential for loss of elbow motion, overall cosmetic elbow alignment, and elbow function.","surgery, closed reduction, percutaneous pinning, distal humeru, supracondylar fracture, tethered brachial artery, artery, supracondylar, brachial, pinning, reduction, fracture, humerus, elbow,"
" Colonoscopy due to rectal bleeding, constipation, abnormal CT scan, rule out inflammatory bowel disease.", Surgery, Colonoscopy - 1 ,"INDICATION: ,  Rectal bleeding, constipation, abnormal CT scan, rule out inflammatory bowel disease.,PREMEDICATION: ,See procedure nurse NCS form.,PROCEDURE:  ,","surgery, bleeding, ct scan, digital rectal exam, pentax video, rectal, cecal strap, cecum, colonic mucosa, colonoscope, colonoscopy, constipation, hemorrhoids, ileocecal valve, inflammatory bowel disease, lateral position, bowel disease, internal hemorrhoids, inflammatory"
" Left upper extremity amputation.  This 3-year-old male suffered amputation of his left upper extremity with complications of injury.  He presents at this time for further attempts at closure.  Left abdominal flap 5 x 5 cm to left forearm, debridement of skin, subcutaneous tissue, muscle, and bone, closure of wounds, placement of VAC negative pressure wound dressing.", Surgery, Closure of Amputation Wounds ,"PREOPERATIVE DIAGNOSIS: , Left upper extremity amputation.,POSTOPERATIVE DIAGNOSIS: , Left upper extremity amputation.,PROCEDURES:,1.  Left abdominal flap 5 x 5 cm to left forearm.,2.  Debridement of skin, subcutaneous tissue, muscle, and bone.,3.  Closure of wounds, simple closure approximately 8 cm.,4.  Placement of VAC negative pressure wound dressing.,INDICATIONS: , This 3-year-old male suffered amputation of his left upper extremity with complications of injury.  He presents at this time for further attempts at closure.,OPERATIVE FINDINGS: , A clean wound to left upper extremity with partial dehiscence of previously closed wounds and also the closure was satisfactory.,DESCRIPTION OF PROCEDURE: , Under inhalational anesthesia, he was prepped and draped in usual fashion exposing left upper extremity and also exposing continuity of the left abdomen, chest, and groin.  He underwent systematic evaluation of his wound of his left upper extremity and we excised first the whole wound prior to doing some additional closure.  Some areas were dehisced and appeared to be because it was approximation of granulation tissue and as a result the edges were freshened up prior to approximating them.  In this fashion, simple closure was accomplished and its total length was approximately 8 cm.  It should be noted that prior to doing any procedure that appropriate timeout was performed and he received prophylactic antibiotics as indicated and did not require DVT prophylaxis.  At this time, once we accomplished debridement and simple closure removing skin, subcutaneous tissue, muscle and bone as well as closing the arm, we could design our flap for the abdomen.  The flap was designed as a slightly greater than 1:1 ellipse of skin from just below the costal margin.  This was elevated at the level of the external oblique and then laid on the left forearm.  The donor's site was closed using interrupted 4-0 Vicryl in the deep dermis and running subcuticular 4-0 Monocryl on the skin.  Steri-Strips were applied.  At this time, the flap was inset using again 4-0 Monocryl sutures and then ultimately the VAC negative pressure wound dressing was applied to help hold this in place and optimize the vascularization of the flap.  The patient tolerated the procedure well and he returned to the recovery room in satisfactory condition.","surgery, abdominal flap, debridement, skin, subcutaneous tissue, muscle, bone, closure of wounds, vac, vac negative, upper extremity, closure, wounds, flap, extremity, amputation"
 Collar Tubes technique, Surgery, Collar Tubes ,,"surgery, ototopical drops, tympanic, membrane, ear canals, cerumen, collar tubes, incision, myringotomy, collar, tubes, anesthesiaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Iron deficiency anemia.  Diverticulosis in the sigmoid., Surgery, Colonoscopy ,"PREOPERATIVE DIAGNOSIS:,  Iron deficiency anemia.,POSTOPERATIVE DIAGNOSIS:,  Diverticulosis.,PROCEDURE:,  Colonoscopy.,MEDICATIONS: , MAC.,PROCEDURE: , The Olympus pediatric variable colonoscope was introduced into the rectum and advanced carefully through the colon to the cecum identified by the ileocecal valve and the appendiceal orifice.  Preparation was good, although there was some residual material in the cecum that was difficult to clear completely.  The mucosa was normal throughout the colon.  No polyps or other lesions were identified, and no blood was noted.  Some diverticula were seen of the sigmoid colon with no luminal narrowing or evidence of inflammation.  A retroflex view of the anorectal junction showed no hemorrhoids.  The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1.  Diverticulosis in the sigmoid.,2.  Otherwise normal colonoscopy to the cecum.,RECOMMENDATIONS:,1.  Follow up with Dr. X as needed.,2.  Screening colonoscopy in 2 years.,3.  Additional evaluation for other causes of anemia may be appropriate.","surgery, olympus, colonoscope, iron deficiency anemia, diverticulosis, sigmoid, cecum, anemia, colonoscopy"
 Closure of multiple complex lacerations.  Multiple complex lacerations of the periorbital area., Surgery, Closure of Complex Lacerations ,"PREOPERATIVE DIAGNOSIS:,  Multiple complex lacerations of the periorbital area.,POSTOPERATIVE DIAGNOSIS:,  Multiple complex lacerations of the periorbital area.,PROCEDURE PERFORMED:,  Closure of multiple complex lacerations.,ANESTHESIA: , Local 1% with epinephrine.,ESTIMATED BLOOD LOSS: , Minimal.,SPECIMEN: , None.,COMPLICATIONS:,  None.,HISTORY:,  The patient is a 19-year-old Caucasian male who presented status post a bicycle versus MVA.  The patient obtained multiple complex lacerations of the right periorbital area.,PROCEDURE: , Informed consent was properly obtained from the patient and he was placed in a 45-degree angle.  Topical viscous lidocaine was applied for pain management and then 1% epinephrine was injected into the periorbital area for anesthetic effect.  A #5-0 Vicryl suture was used to close the deep layers and then #6-0 Prolene was used in interrupted fashion for superficial closure.  The patient was instructed to take Keflex antibiotic for 10 days.  He was also instructed and given prescription for erythromycin ophthalmic ointment to be applied to the periorbital areas t.i.d.  The patient is to ice the area and to follow up in one week for suture removal.  The patient tolerated the procedure well and he was discharged from the Emergency Room in stable condition.","surgery, vicryl suture, complex lacerations, epinephrine, closure, periorbital, lacerations,"
 Repair of bilateral cleft of the palate with vomer flaps., Surgery, Cleft Repair ,"PREOPERATIVE DIAGNOSES: , Bilateral cleft lip and bilateral cleft of the palate.,POSTOPERATIVE DIAGNOSES: , Bilateral cleft lip and bilateral cleft of the palate.,PROCEDURE PERFORMED: , Repair of bilateral cleft of the palate with vomer flaps.,ESTIMATED BLOOD LOSS: , 40 mL.,COMPLICATIONS: , None.,ANESTHESIA: , General endotracheal anesthesia.,CONDITION OF THE PATIENT AT THE END OF THE PROCEDURE:,  Stable, extubated, and transferred to the recovery room in stable condition.,INDICATIONS FOR PROCEDURE:  ,The patient is a 10-month-old baby with a history of a bilateral cleft of the lip and palate.  The patient has undergone cleft lip repair, and she is here today for her cleft palate operation.  We have discussed with the mother the nature of the procedure, risks, and benefits; the risks included but not limited to the risk of bleeding, infection, dehiscence, scarring, the need for future revision surgeries.  We will proceed with surgery.,DETAILS OF THE PROCEDURE:,  The patient was taken into the operating room, placed in the supine position, and general anesthetic was administered.  A prophylactic dose of antibiotics was given.  The patient proceeded to have bilateral PE tube placement by Dr. X, from Ear, Nose, and Throat Surgery.  After he was done with his procedure, the head of the bed was turned 90 degrees.  The patient was positioned with a shoulder roll and doughnut.  A Dingman retractor was placed.  The operative area was infiltrated with lidocaine with epinephrine 1:200,000, a total of 3 mL, and then, I proceeded with the prepping and draping.  The patient was prepped and draped.  I proceeded to do the palate repair.  The nature of the palate repair was done in the same way on the both sides.  I will describe one side.  The other side was done exactly in the same manner.  The 2 hemiuvulas are placed, holding from a single hook and infiltrated with lidocaine with epinephrine 1:200,000, triangle in the nasal mucosa was previously marked.  This triangle of nasal mucosa was removed and excised.  This was done on both uvulas.  Then, an incision was done at the level of the palatal cleft at the junction of the nasal and oral mucosa.  A 1-mm cuff of oral mucosa was used to be able to approximate the nasal mucosa better.  Once the incision was done up to the level of the hard palate, the muscle was dissected off the surrounding tissue, 2 mm from the nasal and the oral mucosa.  Then, I proceeded to place an incision at the alveolopalatal junction with the help of 15-blade.  The incision starts at the maxillary tuberosity posteriorly and comes anteriorly at the alveolopalatal junction through the full thickness of mucoperiosteal flap.  Then the flap was lifted up with the help of a freer, and then the remaining of the incision medially was completed.  Hemostasis was achieved with help of electrocautery and Surgicel.  The mucoperiosteal flap was retracted posteriorly with the help of a freer elevator.  The greater auricular foramen was exposed, and the pedicle skeletonized to allow medial retraction of the mucoperiosteal flap.  Then an osteotomy was done at the level of the greater auricular foramen to allow mobilization of the pedicle medially as well as a small incision was done in the periosteum around the pedicle.  The pedicle carefully dissected to allow better mobilization of the mucoperiosteal flap medially.  This procedure was done on both sides in the same manner, and then __________ dissection was done including dissection of the hard palate from the nasal mucosa, it was evident that the nasal mucosa would not reach medially to be placed together.  At this point, the decision was made to proceed with vomer flaps.  The flaps are __________ infiltrated the vomer with the help of lidocaine with epinephrine after an incision in the manner of an open book.  The incision was done with a 15C blade.  The vomer flaps were dissected, and the mucosa was moved laterally to approximate to the nasal mucosa of the hard palate.  This was approximated on both sides with 5-0 chromic running and interrupted stitches, and I proceeded to the remaining of the posterior aspect of the nasal mucosa with a 5-0 chromic and a 4-0 chromic.  Then 2 stitches of 4-0 Vicryl were applied to the soft palate in the Delaire manner through the full thickness of the mucosa and muscle on one side, on the other side, and then coming back on the mucosa to evert the edges of the soft palate.  The remaining part of the soft palate was placed together with 4-0 Vicryl and 4-0 chromic interrupted stitches.  The throat pack was removed.  The palate was cleaned.  The Dingman retractor was removed, and a single stitch after infiltration of lidocaine without epinephrine at the level of the midline of the tongue was applied with 2-0 silk to the dorsal aspect of the tongue and attached to the right cheek with a piece of Tegaderm.  The patient tolerated the procedure without complications.  BSS is applied to the eye after removing the Tegaderm.  I was present and participated in all aspects of the procedure.  The sponge, needle, and instrument count were completed at the end of the procedure.  The patient tolerated the procedure without complications and was transferred to the recovery room in a stable condition.","surgery, bilateral cleft, cleft lip, oral mucosa, hard palate, soft palate, vomer flaps, mucoperiosteal flap, nasal mucosa, flaps, cleft, mucosa, palate, mucoperiosteal, bilateral, nasal,"
" Trimalleolar ankle fracture and dislocation right ankle.  A comminuted fracture involving the lateral malleolus, as well as a medial and posterior malleolus fracture as well.  Closed open reduction and internal fixation of right ankle.  ", Surgery, Closed ORIF - Ankle ,"PREOPERATIVE DIAGNOSES:,1.  Trimalleolar ankle fracture.,2.  Dislocation right ankle.,POSTOPERATIVE DIAGNOSES:,1.  Trimalleolar ankle fracture.,2.  Dislocation right ankle.,PROCEDURE PERFORMED: , Closed open reduction and internal fixation of right ankle.,ANESTHESIA:  ,Spinal with sedation.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS:  ,Minimal.,TOTAL TOURNIQUET TIME:  ,75 minutes at 325 mmHg.,COMPONENTS: , Synthes small fragment set was used including a 2.5 mm drill bed.  A six hole one-third tibial plate, one 12 mm 3.5 mm cortical screw fully threaded and two 16 mm 3.5 mm cortical fully-threaded screws.  There were two 20 mm 4.0 cancellous screws and one 18 mm 4.0 cancellous screw placed.  There were two 4.0 cancellous partially-threaded screws placed.,GROSS FINDINGS:  ,Include a comminuted fracture involving the lateral malleolus as well as a medial and posterior malleolus fracture as well.,HISTORY OF PRESENT ILLNESS: , The patient is an 87-year-old Caucasian female who presented to ABCD General Hospital Emergency Room complaining of right ankle pain status post a trip and fall.  The patient noted while walking with a walker, apparently tripped and fell.  The patient had significant comorbidities, seen and evaluated by the Emergency Room Department as well as Department of Orthopedics while in the Emergency Room.  At that time, a closed reduction was performed and she was placed in a Robert-Jones splint.  After complete medical workup and clearance, we elected to take her to the operating room for definitive care.,PROCEDURE:  ,After all potential complications and risks as well as risks and benefits of the above-mentioned procedure was discussed at length with the patient and family, informed consent was obtained.  The upper extremity was then confirmed with the operating surgeon, the patient, the nursing staff and Department of Anesthesia.  The patient was then transferred to preoperative area in the Operative Suite #3 and placed on the operating room table in supine position.  At this time, the Department of Anesthesia administered spinal anesthetic to the patient as well as sedation.  All bony prominences were well padded at this time.  A nonsterile tourniquet was placed on the right upper thigh of the patient.  This was then removed and the right lower extremity was sterilely prepped and draped in the usual sterile fashion.  The right lower extremity was then elevated and exsanguinated using Esmarch and tourniquet was then placed to 325 mmHg and kept up to a total of 75 minutes.  Next, after all bony and soft tissue landmarks were identified, a 6 cm longitudinal incision was made directly over this vestibule on the right ankle.  A sharp dissection was carefully taken down to the level of bone taking care to protect the neurovascular structures.  Once the bone was reached, the fractured site was identified.  The bony ends were then opened and divided of all hematoma as well as excess periosteum within the fracture site.  The wound was copiously irrigated and dried.  Next, the fracture was then reduced in anatomic position.  There was noted to be quite a bit of comminution as well as soft overall status of the bone.  It was held in place with reduction forceps.  A six hole one-third tubular Synthes plate was then selected for instrumentation.  It was contoured using ________ and placed on the lateral aspect of the distal fibula.  Next, the three most proximal holes were sequentially drilled using a 2.5 mm drill bed, depth gauged and then a 3.5 mm fully threaded cortical screw was placed in each.  The most proximal was a 12 mm and the next two were 16 mm in length.  Next, the three most distal holes were sequentially drilled using a 2.5 mm drill bed, depth gauged, and a 4.0 cancellous screw was placed in each hole.  The most distal with a 20 mm and two most proximal were 18 mm in length.  Next the Xi-scan was used to visualize the hardware placement as well as the fracture reduction appeared to be in good anatomic position, all hardware was in good position.  There was no lateralization of the joints.  Attention was then directed towards the medial aspect of the ankle.  Again, after all bony and soft tissue landmarks were identified, a 4 cm longitudinal incision was made directly over the medial malleolus.  Again, the dissection was carefully taken down the level of the fracture site.  The retractors were then placed to protect all neurovascular structures.  Once the fracture site was identified, it was dried of all hematoma as well as excess periosteum.  The fracture site was then displaced and the ankle joint was visualized including the dome of the talus.  There appeared to be some minor degenerative changes of the talus, but no loose bodies.  Next, the wound was copiously irrigated and suctioned dry.  The medial malleolus was placed in reduced position and held in place with a 1.25 mm K-wire.  Next, the 2.5 mm drill bed was then used to sequentially drill holes to full depth and 4.0 cancellous screws were placed in each, each with a 45 mm in length.  These appeared to hold the fracture site securely in an anatomic position.  Again, Xi-scan was brought in to confirm placement of the screws.  They were in good overall position and there was no lateralization of the joint.  At this time, each wound was copiously irrigated and suctioned dry.  The wounds were then closed using #2-0 Vicryl suture in subcutaneous fashion followed by staples on the skin.  A sterile dressing was applied consistent with Adaptic, 4x4s, Kerlix, and Webril.  A Robert-Jones style splint was then placed on the right lower extremity.  This was covered by a 4-inch Depuy dressing.  At this time, the Department of Anesthesia reversed the sedation.  The patient was transferred back to the hospital gurney and to the Postanesthetic Care Unit.  The patient tolerated the procedure well.  There were no complications.","surgery, ankle fracture, dislocation, open reduction, internal fixation, orif, trimalleolar ankle fracture, cortical screw, cancellous screws, fracture site, fracture, ankle, malleolus, "
 Clear corneal temporal incision (no stitches).  A lid speculum was placed in the fissure of the right eye., Surgery, Clear Corneal Temporal Incision ,"CLEAR CORNEAL TEMPORAL INCISION (NO STITCHES),DESCRIPTION OF OPERATION: , Under satisfactory local anesthesia, the patient was appropriately prepped and draped.  A lid speculum was placed in the fissure of the right eye.,The secondary incision was then made through clear cornea using 1-mm diamond keratome at surgeon's 7:30 position and the anterior chamber re-formed using viscoelastic.  The primary incision was then made using a 3-mm diamond keratome at the surgeon's 5 o'clock position and additional viscoelastic injected into the anterior chamber as needed.  The capsulorrhexis was then performed in a standard circular tear fashion.  The nucleus was then separated from its cortical attachments by hydrodissection and emulsified in the capsular bag.  The residual cortex was then aspirated from the bag and the bag re-expanded using viscoelastic.  The posterior chamber intraocular lens was then inspected, irrigated, coated with Healon and folded, and then placed into the capsular bag under direct visualization.  The lens was noted to center well.  The residual viscoelastic was then removed from the eye and the eye re-formed using balanced salt solution.  The eye was then checked and found to be watertight; therefore, no suture was used.  The lid speculum and the drapes were then removed and the eye treated with Maxitrol ointment.,A shield was applied and the patient returned to the recovery room in good condition.","surgery, clear corneal temporal incision, intraocular lens, corneal temporal incision, lid speculum, incision, temporal, chamber, corneal, viscoelastic, eyeNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Right distal both-bone forearm fracture.  Closed reduction under conscious sedation and application of a splint was warranted., Surgery, Closed Reduction - 1 ,"PREOPERATIVE DIAGNOSIS: , Right distal both-bone forearm fracture.,POSTOPERATIVE DIAGNOSIS: , Right distal both-bone forearm fracture.,INDICATIONS:,  Mr. ABC is a 10-year-old boy who suffered a fall resulting in a right distal both-bone forearm fracture.  Upon evaluation by Orthopedic Surgery team in the emergency department, it was determined that a closed reduction under conscious sedation and application of a splint was warranted.  This was discussed with the parents who expressed verbal and written consent.,PROCEDURE:,  Conscious sedation was achieved via propofol via the emergency department staff.  Afterwards, traction with re-creation of the injury pattern was utilized to achieve reduction of the patient's fracture.  This was confirmed with image intensifier.  Subsequently, the patient was placed into a splint.  The patient was aroused from conscious sedation and at this time it was noted that he had full sensation throughout radial, median, and ulnar nerve distributions and positive extensor pollicis longus, flexor pollicis longus, dorsal and palmar interossei.,DISPOSITION:  ,Post-reduction x-rays revealed good alignment in the AP x-rays.  The lateral x-rays also revealed adequate reduction.  At this time, we will allow the patient to be discharged home and have him follow up with Dr. XYZ in one week.","surgery, closed reduction, distal both bone forearm, emergency department, pollicis longus, bone forearm, forearm fracture, conscious sedation, emergency, department, pollicis, longus, splint, distal, bone, forearm, conscious, sedation, fracture, reduction, "
 Left distal both-bone forearm fracture.  Closed reduction with splint application with use of image intensifier., Surgery, Closed Reduction - 2 ,"PREOPERATIVE DIAGNOSIS: , Left distal both-bone forearm fracture.,POSTOPERATIVE DIAGNOSIS: , Left distal both-bone forearm fracture.,PROCEDURE:,  Closed reduction with splint application with use of image intensifier.,INDICATIONS: , Mr. ABC is an 11-year-old boy who sustained a fall on 07/26/2008.  Evaluation in the emergency department revealed both-bone forearm fracture.  Considering the amount of angulation, it was determined that we should proceed with conscious sedation and closed reduction.  After discussion with parents, verbal and written consent was obtained.,DESCRIPTION OF PROCEDURE:  ,The patient was induced with propofol for conscious sedation via the emergency department staff.  After it was confirmed that appropriate sedation had been reached, a longitudinal traction in conjunction with re-creation of the injury maneuver was applied reducing the fracture.  Subsequently, this was confirmed with image intensification, a sugar-tong splint was applied and again reduction was confirmed with image intensifier.  The patient was aroused from anesthesia and tolerated the procedure well.  Post-reduction plain films revealed some anterior displacement of the distal fragment.  At this time, it was determined this fracture proved to be unstable.,DISPOSITION: , After review of the reduction films, it appears that there is some element of fracture causing displacement.  We will proceed to the operating room for open reduction and internal fixation versus closed reduction and percutaneous pinning as our operative schedule allows.,","surgery, closed reduction, reduction with splint application, distal both bone forearm, distal both bone, splint application, emergency department, conscious sedation, image intensifier, bone forearm, forearm fracture, reduction, emergency, department, conscious, displacement, splint, sedation, tong, distal, bone, image, intensifier, forearm, fracture "
" Bilateral open mandible fracture, open left angle and open symphysis fracture.  Closed reduction of mandible fracture with MMF.", Surgery, Closed Reduction - Mandible Fracture ,"PREOPERATIVE DIAGNOSIS: , Bilateral open mandible fracture, open left angle and open symphysis fracture.,POSTOPERATIVE DIAGNOSIS: , Bilateral open mandible fracture, open left angle and open symphysis fracture.,PROCEDURE:  ,Closed reduction of mandible fracture with MMF.,ANESTHESIA: , General anesthesia via nasal endotracheal intubation.,FLUIDS: , 2 L of crystalloid.,ESTIMATED BLOOD LOSS: , Minimal.,HARDWARE: , None.,SPECIMENS: , None.,COMPLICATIONS: , None.,CONDITION:  ,The patient was extubated to PACU in good condition.,INDICATIONS FOR PROCEDURE: , The patient is a 17-year-old female who is 2 days status post an altercation in which she sustained multiple blows to the face.  She was worked up on Friday night, 2 days earlier at Hospital, was given palliative treatment and discharged and instructed to follow up as an outpatient with an oral surgeon and given a phone number to call.  The patient was worked up initially.  On initial exam, it was noted that the patient had a left V3 paresthesia.  She had a gross malocclusion.  On the facial CT and panoramic x-ray, it was noted to be a displaced left angle fracture and nondisplaced symphysis fracture.  Alternatives were discussed with the patient and it was determined she would benefit from being taken to the operating room under general anesthesia to have a closed reduction of her fractures.  Risks, benefits, and alternatives of treatment were thoroughly discussed with the patient and informed consent was obtained with the patient's mother.,DESCRIPTION OF PROCEDURE:, The patient was taken to the operating room #4 at Hospital and laid in a supine position on the operating room table.  Monitor was attached and general anesthesia was induced with IV anesthetics and maintained with nasal endotracheal intubation and inhalation anesthetics.  The patient was prepped and draped in the usual oromaxillofacial surgery fashion.,Surgeon approached the operating table in a sterile fashion.  Approximately 10 mL of 2% lidocaine with 1:100,000 epinephrine was injected into the oral vestibule in a nerve block fashion.  A moistened Ray-Tec sponge was placed in the posterior oropharynx and the mouth was prepped with Peridex mouthrinse, scrubbed with a toothbrush.  The Peridex was evacuated with Yankauer suction.  Erich arch bars were adapted to the maxilla from the first molar to the contralateral first molar and secured with 24-gauge surgical steel wire on the posterior teeth and 26-gauge surgical steel wire on the anterior teeth.  Same was done on the mandible.  The patient was then manipulated up in the maximum intercuspation and noted to be reproducible.  The throat pack was then removed.,The patient was remanipulated up to the maximum intercuspation and secured with interdental elastics.  At this point in time, the procedure was then determined to be over.,The patient was extubated and transferred to the PACU in good condition.","surgery, open symphysis fracture, closed reduction, mmf, endotracheal, pacu, bilateral open mandible fracture, symphysis fracture, mandible fracture, fracture, intubation, angle, mandible, "
 Newborn circumcision.  The penile foreskin was removed using Gomco. , Surgery, Circumcision - Newborn  ,"PROCEDURE: , Newborn circumcision.,INDICATIONS: , Parental preference.,ANESTHESIA:,  Dorsal penile nerve block.,DESCRIPTION OF PROCEDURE:,  The baby was prepared and draped in a sterile manner.  Lidocaine 1% 4 mL without epinephrine was instilled into the base of the penis at 2 o'clock and 10 o'clock.  The penile foreskin was removed using a XXX Gomco.  Hemostasis was achieved with minimal blood loss.  There was no sign of infection.  The baby tolerated the procedure well.  Vaseline was applied to the penis, and the baby was diapered by nursing staff.","surgery, nerve block, newborn circumcision, foreskin, gomco, penis, circumcision, newborn, penile"
" Cleft soft palate.  Repair of cleft soft palate and excise accessory ear tag, right ear. ", Surgery, Cleft Repair - Soft Palate ,"PREOPERATIVE DIAGNOSIS: , Cleft soft palate.,POSTOPERATIVE DIAGNOSIS: , Cleft soft palate.,PROCEDURES:,1.  Repair of cleft soft palate, CPT 42200.,2.  Excise accessory ear tag, right ear.,ANESTHESIA: , General.,DESCRIPTION OF PROCEDURE: , The patient was placed supine on the operating room table.  After anesthesia was administered, time out was taken to ensure correct patient, procedure, and site.  The face was prepped and draped in a sterile fashion.  The right ear tag was examined first.  This was a small piece of skin and cartilaginous material protruding just from the tragus.  The lesion was excised and injected with 0.25% bupivacaine with epinephrine and then excised using an elliptical-style incision.  Dissection was carried down the subcutaneous tissue to remove any cartilaginous attachment to the tragus.  After this was done, the wound was cauterized and then closed using interrupted 5-0 Monocryl.  Attention was then turned towards the palate.  The Dingman mouthgag was inserted and the palate was injected with 0.25% bupivacaine with epinephrine.  After giving this 5 minutes to take effect, the palate was incised along its margins.  The anterior oral mucosa was lifted off and held demonstrating the underlying levator muscle.  Muscle was freed up from its attachments at the junction of the hard palate and swept down so that it will be approximated across the midline.  The Z-plasties were then designed, so there would be opposing Z-plasties from the nasal mucosa compared to the oral mucosa.  The nasal mucosa was sutured first using interrupted 4-0 Vicryl.  Next, the muscle was reapproximated using interrupted 4-0 Vicryl with an attempt to overlap the muscle in the midline.  In addition, the remnant of the uvula tissue was found and was sutured in such a place that it would add some extra bulk to the nasal surface of the palate.  Following this, the oral layer of mucosa was repaired using an opposing Z-plasty compared to the nasal layer.  This was also sutured in place using interrupted 4-0 Vicryl.  The anterior and posterior open edges of the palatal were sewn together.  The patient tolerated the procedure well.  Suction of blood and mucus performed at the end of the case.  The patient tolerated the procedure well.,IMMEDIATE COMPLICATIONS: , None.,DISPOSITION:,  In satisfactory condition to recovery.","surgery, repair, tragus, oral mucosa, nasal mucosa, ear tag, soft palate, palate, cleft, soft"
 Circumcision and release of ventral chordee., Surgery, Circumcision & Chordee Release ,"PREOPERATIVE DIAGNOSES: , Phimosis and adhesions.,POSTOPERATIVE DIAGNOSES:  ,Phimosis and adhesions.,PROCEDURES PERFORMED: , Circumcision and release of ventral chordee.,ANESTHESIA:  ,Local MAC.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid.  The patient was given antibiotics preop.,BRIEF HISTORY: , This is a 43-year-old male who presented to us with significant phimosis, difficulty retracting the foreskin.  The patient had buried penis with significant obesity issues in the suprapubic area.  Options such as watchful waiting, continuation of slowly retracting the skin, applying betamethasone cream, and circumcision were discussed.  Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE, and CVA risks were discussed.  The patient had discussed this issue with Dr Khan and had been approved to get off of the Plavix.  Consent had been obtained.  Risk of scarring, decrease in penile sensation, and unexpected complications were discussed.  The patient was told about removing the dressing tomorrow morning, okay to shower after 48 hours, etc.  Consent was obtained.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the OR.  Anesthesia was applied.  The patient was placed in supine position.  The patient was prepped and draped in usual sterile fashion.  Local MAC anesthesia was applied.  After draping, 17 mL of mixture of 0.25% Marcaine and 1% lidocaine plain were applied around the dorsal aspect of the penis for dorsal block.  The patient had significant phimosis and slight ventral chordee.  Using marking pen, the excess foreskin was marked off.  Using a knife, the ventral chordee was released.  The urethra was intact.  The excess foreskin was removed.  Hemostasis was obtained using electrocautery.  A 5-0 Monocryl stitches were used for 4 interrupted stitches and horizontal mattresses were done.  The patient tolerated the procedure well.  There was excellent hemostasis.  The penis was straight.  Vaseline gauze and Kerlix were applied.  The patient was brought to the recovery in stable condition.  Plan was for removal of the dressing tomorrow.  Okay to shower after 48 hours.","surgery, phimosis, adhesions, release of ventral chordee, ventral chordee, circumcision, penis, chordee, foreskin,"
 Normal penis.  The foreskin was normal in appearance and measured 1.6 cm.  There was no bleeding at the circumcision site., Surgery, Circumcision - 7 ,"PROCEDURE:,  Circumcision.,ANESTHESIA: , EMLA.,FINDINGS: , Normal penis.  The foreskin was normal in appearance and measured 1.6 cm.  There was no bleeding at the circumcision site.,PROCEDURE:,  Patient was placed on the circumcision restraint board.  EMLA had been applied approximately 90 minutes before.  A time-out was completed satisfactorily per protocol.  The area was prepped with Betadine.  The foreskin was grasped with sterile clamps and was dissected away from the corona and the glans penis with blunt dissection.  A Mogen clamp was applied to the cervix.  The excess foreskin was excised with the scalpel.  The clamp was removed.  At this point, the procedure was terminated.  Sterile Vaseline and gauze was applied to the glans penis.  There were no complications.  There was minimal blood loss.","surgery, mogen clamp, glans penis, emla, penis, foreskin, circumcision"
 Circumcision.  Normal male phallus.   The infant is without evidence of hypospadias or chordee prior to the procedure., Surgery, Circumcision - Infant ,"PROCEDURE: , Circumcision.,PRE-PROCEDURE DIAGNOSIS: , Normal male phallus.,POST-PROCEDURE DIAGNOSIS: , Normal male phallus.,ANESTHESIA:  ,1% lidocaine without epinephrine.,INDICATIONS: , The risks and benefits of the procedure were discussed with the parents.  The risks are infection, hemorrhage, and meatal stenosis.  The benefits are ease of care and cleanliness and fewer urinary tract infections.  The parents understand this and have signed a permit.,FINDINGS: , The infant is without evidence of hypospadias or chordee prior to the procedure.,TECHNIQUE:  ,The infant was given a dorsal penile block with 1% lidocaine without epinephrine using a tuberculin syringe and 0.5 cc of lidocaine was delivered subcutaneously at 10:30 and at 1:30 o'clock at the dorsal base of the penis.,The infant was prepped then with Betadine and draped with a sterile towel in the usual manner.  Clamps were placed at 10 o'clock and 2 o'clock and the adhesions between the glans and mucosa were instrumentally lysed.  Dorsal hemostasis was established and a dorsal slit was made.  The foreskin was fully retracted and remaining adhesions between the glans and mucosa were manually lysed.  The infant was fitted with a XX-cm Plastibell.  The foreskin was retracted around the Plastibell and circumferential hemostasis was established.  The excess foreskin was removed with scissors and the infant tolerated the procedure well with a minimum amount of blood loss.  Instructions for continuing care are to watch for any evidence of hemorrhage or urination and the parents are instructed in the care of the circumcised penis.","surgery, dorsal slit, hypospadias, chordee, epinephrine, hemorrhage, penis, adhesions, circumcision, phallus, lidocaine, foreskin, infant"
" Circumcision.   A dorsal slit was made, and the prepuce was dissected away from the glans penis.", Surgery, Circumcision - 6 ,"PROCEDURE: , Circumcision.,Signed informed consent was obtained and the procedure explained.,DETAILS OF PROCEDURE: ,The child was placed in a Circumstraint board and restrained in the usual fashion.  The area of the penis and scrotum were prepared with povidone iodine solution.  The area was draped with sterile drapes, and the remainder of the procedure was done with sterile procedure.  A dorsal penile block was done using 2 injections of 0.3 cc each, 1% plain lidocaine.  A dorsal slit was made, and the prepuce was dissected away from the glans penis.  A Gomco clamp was properly placed for 5 minutes.  During this time, the foreskin was sharply excised using a #10 blade.  With removal of the clamp, there was a good cosmetic outcome and no bleeding.  The child appeared to tolerate the procedure well.  Care instructions were given to the parents.","surgery, gomco clamp, dorsal slit, glans penis, slit, circumcision, penisNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" Release of ventral chordee, circumcision, and repair of partial duplication of urethral meatus.", Surgery, Circumcision - 5 ,"PROCEDURES:,1.  Release of ventral chordee.,2.  Circumcision.,3.  Repair of partial duplication of urethral meatus.,INDICATIONS: , The patient is an 11-month-old baby boy who presented for evaluation of a duplicated urethral meatus as well as ventral chordee and dorsal prepuce hooding.  He is here electively for surgical correction.,DESCRIPTION OF PROCEDURE: , The patient was brought back into operating room 35.  After successful induction of general endotracheal anesthetic, giving the patient, preoperative antibiotics and after completing a preoperative time out, the patient was prepped and draped in the usual sterile fashion.,A holding stitch was placed in the glans penis.  At this point, we probed both urethral meatus.  Using the Crede maneuver, we could see urine clearly coming out of the lower, the more ventral meatus.  At this point, we cannulated this with a 6-French hypospadias catheter.  We attempted to cannulate the dorsal opening, however, we were unsuccessful.  We then attempted to place lacrimal probes and were also unsuccessful indicating this was incomplete duplication.  At this point, we identified the band connecting both the urethral meatus and incised it with tenotomy scissors.  We sutured both meatus together such that there was one meatus at the normal position at the tip of the glans.,At this point, we made a circumcising incision around the penis and degloved the penis in its entirety relieving all chordee.  Once all the chordee had been adequately released, we turned our attention to the circumcision.  Excessive dorsal foreskin was removed from the skin and glans.  Mucosal cuts were reapproximated with interrupted 5-0 chromic suture.  Dermabond was placed over this and bacitracin was placed on this once dry.  This ended the procedure.  ,DRAINS:,  None.,ESTIMATED BLOOD LOSS: , Minimal.,URINE OUTPUT:  ,Unrecorded.,COMPLICATIONS: , None apparent.,DISPOSITION:  ,The patient will now go under the care of Dr. XYZ, Plastic Surgery, for excision of scalp hemangioma.","surgery, release of ventral chordee, repair of partial duplication, partial duplication, ventral chordee, urethral meatus, glans, penis, circumcision, ventral, chordee, urethral, meatus,"
 Circumcision procedure in a baby, Surgery, Circumcision - 3 ,"CIRCUMCISION,After informed consent was obtained the baby was placed on the circumcision tray.  He was prepped in a sterile fashion times 3 with Betadine and then draped in a sterile fashion.  Then 0.2 mL of 1% lidocaine was injected at 10 and 2 o'clock.  A ring block was also done using another 0.3 mL of lidocaine.  Glucose water is also used for anesthesia.  After several minutes the curved clamp was attached at 9 o'clock with care being taken to avoid the meatus.  The blunt probe was then introduced again with care taken to avoid the meatus.  After initial adhesions were taken down the straight clamp was introduced to break down further adhesions.  Care was taken to avoid the frenulum.  The clamps where then repositioned at 12 and 6 o'clock.  The Mogen clamp was then applied with a dorsal tilt.  After the clamp was applied for 1 minute the foreskin was trimmed.  After an additional minute the clamp was removed and the final adhesions were taken down.  Patient tolerated the procedure well with minimal bleeding noted.  Patient to remain for 20 minutes after procedure to insure no further bleeding is noted.,Routine care discussed with the family.  Need to clean the area with just water initially and later with soap and water or diaper wipes once healed.","surgery, circumcision, 1% lidocaine, betadine, glucose water, adhesions, circumcision tray, diaper wipes, foreskin, frenulum, meatus, straight clamp, sterile fashion, clampNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Circumcision in an older person, Surgery, Circumcision - 1 ,"CIRCUMCISION - OLDER PERSON,OPERATIVE NOTE:,  The patient was taken to the operating room and placed in the supine position on the operating table.  General endotracheal anesthesia was administered.  The patient was prepped and draped in the usual sterile fashion.  A 4-0 silk suture is used as a stay-stitch of the glans penis.  Next, incision line was marked circumferentially on the outer skin 3 mm below the corona.  The incision was then carried through the skin and subcutaneous tissues down to within a layer of * fascia.  Next, the foreskin was retracted.  Another circumferential incision was made 3 mm proximal to the corona.  The intervening foreskin was excised.  Meticulous hemostasis was obtained with electrocautery.  Next, the skin was reapproximated at the frenulum with a U stitch of 5-0 chromic followed by stitches at 12, 3, and 9 o'clock.  The stitches were placed equal distance among these to reapproximate all the skin edges.  Next, good cosmetic result was noted with no bleeding at the end of the procedure.  Vaseline gauze, Telfa, and Elastoplast dressing was applied.  The stay-stitch was removed and pressure held until bleeding stopped.  The patient tolerated the procedure well and was returned to the recovery room in stable condition.","surgery, circumcision, elastoplast, meticulous hemostasis, telfa, vaseline gauze, circumferential incision, corona, cosmetic result, endotracheal anesthesia, foreskin, glans penis, hemostasis, stay stitch, circumferentially, stitchNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Normal Circumcision, Surgery, Circumcision - 4 ,The patient tolerated the procedure well and was sent to the Recovery Room in stable condition.,"surgery, circumcision, circumferential proximal incisions, hemostasis, vaseline soaked gauze, catgut, foreskin, needlepoint bovie, pain block, shaft of the penis, supine position, penisNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" Left and right coronary system cineangiography.  Left ventriculogram.  PCI to the left circumflex with a 3.5 x 12 and a 3.5 x 8 mm Vision bare-metal stents postdilated with a 3.75-mm noncompliant balloon x2.
", Surgery, Cineangiography - 1 ,"REASON FOR CATHETERIZATION:,  ST-elevation myocardial infarction.,PROCEDURES UNDERTAKEN,1.  Left coronary system cineangiography.,2.  Right coronary system cineangiography.,3.  Left ventriculogram.,4.  PCI to the left circumflex with a 3.5 x 12 and a 3.5 x 8 mm Vision bare-metal stents postdilated with a 3.75-mm noncompliant balloon x2.,PROCEDURE: , After all risks and benefits were explained to the patient, informed consent was obtained.  The patient was brought to the cardiac cath suite.  Right groin was prepped in usual sterile fashion.  Right common femoral artery was cannulated with the modified Seldinger technique.  A 6-French sheath was introduced.  Next, Judkins right catheter was used to engage the right coronary artery and cineangiography was recorded in multiple views.  Next, an EBU 3.5 guide was used to engage the left coronary system.  Cineangiography was recorded in several views and it was noted to have a 99% proximal left circumflex stenosis.  Angiomax bolus and drip were started after checking an ACT, which was 180, and an Universal wire was advanced through the left circumflex beyond the lesion.  Next, a 3.0 x 12 mm balloon was used to pre-dilate the lesion.  Next a 3.5 x 12 mm Vision bare-metal stent was advanced to the area of stenosis and deployed at 12 atmospheres.  There was noted to be a plaque shift proximally at the edge of the stent.  Therefore, a 3.5 x 8 mm Vision bare-metal stent was advanced to cover the proximal margin of the first stent and deployed at 12 atmospheres.  Next, a 3.75 x 13 mm noncompliant balloon was advanced into the margin of the stent and two inflations at 20 atmospheres were done for 20 seconds.  Final images showed excellent results with initial 99% stenosis reduced to 0%.  The patient continues to have residual stenosis in the mid to distal in the OM branch.  At this point, wire was removed.  Final images confirmed initial stent results, no evidence of dissection, perforation, or complications.,Next, an angled pigtail catheter was advanced into the left ventricular cavity.  LV pressure was measured.  LV gram was done in both the LAO and RAO projections and a pullback gradient across the aortic valve was done and recorded.  Finally, all guides were removed.  Right femoral artery access site was imaged and Angio-Seal deployed to attain excellent hemostasis.  The patient tolerated the procedure very well without complications.,DIAGNOSTIC FINDINGS,1.  Left main:  Left main is a large-caliber vessel bifurcating in LAD and left circumflex with no significant disease.,2.  The LAD:  LAD is a large-caliber vessel, wraps around the apex, gives off multiple septal perforators, three small-to-medium caliber diagonal branches without any significant disease.,3.  Left circumflex:  Left circumflex is a large-caliber vessel, gives off a large distal PDA branch, has a 99% proximal lesion, 50% mid vessel lesion, and a 50% lesion in the OM, which is a distal branch.,4.  Right coronary artery:  Right coronary artery is a moderate-caliber vessel, dominant, bifurcates into PDA and PLV branches, has only mild disease.  Otherwise, no significant stenosis noted.,5.  LV:  The LVEF 50%.  Inferolateral wall hypokinesis.  No significant mitral regurgitation.  No gradient across the aortic valve on pullback.,ASSESSMENT AND PLAN: , ST-elevation myocardial infarction with a 99% stenosis of the proximal portion of the left circumflex treated with a 3.5 x 12 mm Vision bare-metal stent and a 3.5 x 8 mm Vision bare-metal stent.  Excellent results, 0% residual stenosis.  The patient continues to have some residual 50% stenosis in the left circumflex system, some mild disease throughout the other vessels.  Therefore, we will aggressively treat this patient medically with close followup as an outpatient.","surgery, ventriculogram, circumflex, bare-metal stents, myocardial infarction, st-elevation, coronary system cineangiography, infarction, stents, cineangiography, stenosis,"
" Left and right coronary system cineangiography, cineangiography of SVG to OM and LIMA to LAD.  Left ventriculogram and aortogram.  Percutaneous intervention of the left circumflex and obtuse marginal branch with plano balloon angioplasty unable to pass stent.", Surgery, Cineangiography ,"PROCEDURES UNDERTAKEN,1.  Left coronary system cineangiography.,2.  Right coronary system cineangiography.,3.  Cineangiography of SVG to OM.,4.  Cineangiography of LIMA to LAD.,5.  Left ventriculogram.,6.  Aortogram.,7.  Percutaneous intervention of the left circumflex and obtuse marginal branch with plano balloon angioplasty unable to pass stent.,NARRATIVE:,  After all risks and benefits were explained to the patient, informed consent was obtained.  The patient was brought to the cardiac catheterization suite.  The right groin was prepped in the usual sterile fashion.  Right common femoral artery was cannulated using a modified Seldinger technique and a long 6-French AO sheath was introduced secondary to tortuous aorta.  Next, Judkins left catheter was used to engage the left coronary system.  Cineangiography was recorded in multiple views.  Next, Judkins right catheter was used to engage the right coronary system.  Cineangiography was recorded in multiple views.  Next, the Judkins right catheter was used to engage the SVG to OM.  Cineangiography was recorded.  Next, the Judkins right was advanced into the left subclavian and exchanged over a long exchange length J-wire for a 4-French left internal mammary artery which was used to engage the LIMA graft to LAD and cineangiography was recorded in multiple views.  Next, an angled pigtail catheter was advanced into the left ventricular cavity.  LV pressures were measured.  LV gram was done and a pullback gradient across the aortic valve was done and recorded.  Next, an aortogram was done and recorded.  At this point, I decided to proceed with percutaneous intervention of the left circumflex.  Therefore, AVA 3.5 guide was used to engage the left coronary artery.  Angiomax bolus and drip was started.  Universal wire was advanced past the lesion and a 2.5-balloon was advanced first to the proximal lesions and predilations were done at 14 atmospheres and then to the distal lesion and predilatation was done at 12 atmospheres.  Next, we attempted to advance a 3.0 x 12 stent to the distal lesion; however, we were unable to pass the stent.  Next, second dilatations were done again with the 2.5 balloon at 18 atmospheres; however, we are unable to break the lesion.  We next attempted a cutting balloon.  Again, we are unable to cross the lesion, therefore a buddy wire technique was used with a PT choice support wire.  Again, we were unable to cross the lesion with the stent.  We then try to cross with a noncompliant balloon, which we were unsuccessful.  We also try to cutting balloon again, we were unsuccessful.  Despite multiple dilatations, we were unable to cross anything beyond the noncompliant balloon across the lesion; therefore, finally the procedure was aborted.  Final images showed no evidence of dissection, perforation, or further complication.  The right groin was filled after taking an image to confirm sheath placement above the bifurcation with excellent results.  The patient tolerated the procedure very well without complications, was taken off the operating table and transferred back to cardiac telemetry floor.,DIAGNOSTIC FINDINGS,1.  The LV.  LVEDP was 4.  LVES is approximately 50%-55% with inferobasal hypokinesis.  No significant MR. No gradient across the aortic valve.,2.  Aortogram.  The ascending aorta shows no significant dilatation or evidence of dissection.  The valve shows no significant aortic insufficiencies.  The abdominal aorta and distal aorta shows significant tortuosities.,3.  The left main.  The left main coronary artery is a large caliber vessel, bifurcating the LAD and left circumflex with some mild distal disease of about 10%-20%.,4.  Left circumflex.  The left circumflex vessel is a large caliber vessel gives off a distal branching obtuse marginal branch.  The upper pole of the OM shows retrograde filling of the distal graft and also at that point approximately a 70%-80% stenosis.  The mid left circumflex is a high-grade 80% diffuse tortuous stenosis.,5.  LAD.  The LAD is a totally 100% occluded vessel.  The LIMA to LAD is patent with only a small-to-moderate caliber LAD.  There is a large diagonal branch coming off the proximal portion of the LAD and that proximal LAD showed some diffuse disease upwards of 60%-70%.  The diagonal shows proximal 80% stenosis.,6.  The right coronary artery:  The right coronary artery is 100% occluded.  There are retrograde collaterals from left to right to the distal PDA and PLV branches.  The SVG to OM is 100% occluded at its take off.  The SVG to PDA is not found; however, presumed 100% occluded given that there is collateral flow to the distal right.,7.  LIMA to LAD is widely patent.,ASSESSMENT AND PLAN: , Attempted intervention to the left circumflex system, only able to perform plano balloon angioplasty, unable to pass stents, noncompliant balloons or cutting balloon.  Final images showed some improvement, however, continued residual stenosis.  At this point, the patient will be transferred back to telemetry floor and monitored.  We can attempt future intervention or continue aggressive medical management.  The patient continues to have residual stenosis in the diagonal; however, due to the length of this procedure, I did not attempt intervention to that diagonal branch.  Possible consideration would be a stress test as an outpatient depending on where patient shows ischemia, focus on treatment to that lesion.","surgery, coronary system cineangiography, svg to om, lima to lad, ventriculogram, aortogram, percutaneous intervention, circumflex, obtuse marginal branch, balloon angioplasty, coronary artery, balloon, cineangiography, lad,"
 Circumcision.  The child appeared to tolerate the procedure well.  Care instructions were given to the parents., Surgery, Circumcision - Child  ,"PROCEDURE: , Circumcision.,Signed informed consent was obtained and the procedure explained.,The child was placed in a Circumstraint board and restrained in the usual fashion.  The area of the penis and scrotum were prepared with povidone iodine solution.  The area was draped with sterile drapes, and the remainder of the procedure was done with sterile procedure.  A dorsal penile block was done using 2 injections of 0.3 cc each, 1% plain lidocaine.  A dorsal slit was made, and the prepuce was dissected away from the glans penis.  A ** Gomco clamp was properly placed for 5 minutes.  During this time, the foreskin was sharply excised using a #10 blade.  With removal of the clamp, there was a good cosmetic outcome and no bleeding.  The child appeared to tolerate the procedure well.  Care instructions were given to the parents.","surgery, circumstraint, dorsal slit, gomco clamp, circumcision, childNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Placement of cholecystostomy tube under ultrasound guidance.  Acute acalculous cholecystitis., Surgery, Cholecystostomy Tube Placement ,"PREOPERATIVE DIAGNOSIS:,  Acute acalculous cholecystitis.,POSTOPERATIVE DIAGNOSIS: , Acute acalculous cholecystitis.,PROCEDURE:,  Placement of cholecystostomy tube under ultrasound guidance.,ANESTHESIA: , Xylocaine 1% With Epinephrine.,INDICATIONS: , Patient is a pleasant 75-year-old gentleman who is about one week status post an acute MI who also has acute cholecystitis.  Because it is not safe to take him to the operating room for general anesthetic, I recommended he undergo the above-named procedure.  Procedure, purpose, risks, expected benefits, potential complications, and alternative forms of therapy were discussed with him and he was agreeable to surgery.,TECHNIQUE: , Patient was identified, then taken to the Radiology suite, where the area of interest was identified using ultrasound and prepped with Betadine solution, draped in sterile fashion.  After infiltration with 1% Xylocaine and after multiple attempts, the gallbladder was finally cannulated by Dr. Kindred using the Cook 18-French needle.  The guidewire was then placed and via Seldinger technique, a 10-French pigtail catheter was placed within the gallbladder, secured using the Cook catheter method, and dressings were applied and patient was taken to recovery room in stable condition.","surgery, under ultrasound guidance, cholecystostomy tube, acalculous cholecystitis, catheter, cholecystostomy, ultrasound, acalculous, cholecystitis"
 Circumcision procedure (neotal), Surgery, Circumcision - 2 ,"CIRCUMCISION - NEONATAL,PROCEDURE:,:  The procedure, risks and benefits were explained to the patient's mom, and a consent form was signed.  She is aware of the risk of bleeding, infection, meatal stenosis, excess or too little foreskin removed and the possible need for revision in the future.  The infant was placed on the papoose board.  The external genitalia were prepped with Betadine.  A penile block was performed with a 30-gauge needle and 1.5 mL of Nesacaine without epinephrine.,Next, the foreskin was clamped at the 12 o'clock position back to the appropriate proximal extent of the circumcision on the dorsum of the penis.  The incision was made.  Next, all the adhesions of the inner preputial skin were broken down.  The appropriate size bell was obtained and placed over the glans penis.  The Gomco clamp was then configured, and the foreskin was pulled through the opening of the Gomco.  The bell was then placed and tightened down.  Prior to do this, the penis was viewed circumferentially, and there was no excess of skin gathered, particularly in the area of the ventrum.  A blade was used to incise circumferentially around the bell.  The bell was removed.  There was no significant bleeding, and a good cosmetic result was evident with the appropriate amount of skin removed.,Vaseline gauze was then placed.  The little boy was given back to his mom.,PLAN:,  They have a new baby checkup in the near future with their primary care physician.  I will see them back on a p.r.n. basis if there are any problems with the circumcision.","surgery, neonatal, circumcision, gomco, gomco clamp, external genitalia, foreskin, glans, glans penis, infant, meatal stenosis, penile block, penis, preputial skin, circumferentially, infection, bell,"
 The patient had spraying of urine and ballooning of the foreskin with voiding., Surgery, Circumcision ,"PREOPERATIVE DIAGNOSIS:,  Phimosis.,POSTOPERATIVE DIAGNOSES:,  Phimosis.,OPERATIONS:,  Circumcision.,ANESTHESIA: , LMA.,EBL:,  Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY: , This is a 3-year-old male, who was referred to us from Dr. X's office with phimosis.  The patient had spraying of urine and ballooning of the foreskin with voiding.  The urine seemed to have collected underneath the foreskin and then would slowly drip out.  Options such as dorsal slit, circumcision, watchful waiting by gently pulling the foreskin back were discussed.  Risk of anesthesia, bleeding, infection, pain, scarring, and expected complications were discussed.  The patient's family understood all the complications and wanted to proceed with the procedure.  Consent was obtained using interpreter.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the OR and anesthesia was applied.  The patient was placed in supine position.  The patient was prepped and draped in usual sterile fashion.  All the penile adhesions were released prior to the prepping.  The extra foreskin was marked off, 1 x 3 Gamco clamp was used.  Hemostasis was obtained after removing the extra foreskin using the Gamco clamp.,Using 5-0 Monocryl, 4 quadrant stitches were placed and horizontal mattress suturing was done.  There was excellent hemostasis.  Dermabond was applied.  The patient was brought to recovery at the end of the procedure in stable condition.","surgery, ballooning of the foreskin, spraying of urine, gamco clamp, spraying, ballooning, circumcision, urine, phimosis, foreskin"
 Laparoscopic cholecystectomy.  Gallstone pancreatitis.  Video laparoscopy revealed dense omental adhesions surrounding the gallbladder circumferentially. , Surgery, Cholecystectomy Laparoscopic ,"PREOPERATIVE DIAGNOSIS: ,Gallstone pancreatitis.,POSTOPERATIVE DIAGNOSIS: , Gallstone pancreatitis.,PROCEDURE PERFORMED: , Laparoscopic cholecystectomy.,ANESTHESIA: , General endotracheal and local injectable Marcaine.,ESTIMATED BLOOD LOSS: , Minimal.,SPECIMEN: , Gallbladder.,COMPLICATIONS:  ,None.,OPERATIVE FINDINGS: , Video laparoscopy revealed dense omental adhesions surrounding the gallbladder circumferentially.  These dense adhesions were associated with chronic inflammatory edematous changes.  The cystic duct was easily identifiable and seen entering into the gallbladder and clipped two proximally and one distally.  The cystic artery was an anomalous branch that was anterior to the cystic duct and was identified, clipped with two clips proximally and one distally.  The remainder of the evaluation of the abdomen revealed no evidence of nodularity or masses in the liver.  There was no evidence of adhesions from the abdominal wall to the liver.  The remainder of the abdomen was unremarkable.,BRIEF HISTORY:  ,This is a 17-year-old African-American female who presented to ABCD General Hospital on 08/20/2003 with complaints of intractable right upper quadrant abdominal pain.  She had been asked to follow up and scheduled for surgery previously.  Her pain had now been intractable associated with anorexia.  She was noted on physical examination to be afebrile; however, she was having severe right upper quadrant pain with examination as well as a Murphy's sign and voluntary guarding with examination.  Her transaminases were markedly elevated.  She also developed pancreatitis secondary to gallstones.  Her common bile duct was dilated to 1 cm with no evidence of wall thickening, but evidence of cholelithiasis.  She was seen by the gastroenterologist and underwent a sphincterotomy with balloon extraction of gallstones secondary to choledocholithiasis.  Following this, she was scheduled for operative laparoscopic cholecystectomy.  Her parents were explained the risks, benefits, and complications of the procedure.  She gave us informed consent to proceed with surgery.,OPERATIVE PROCEDURE:  ,The patient brought to the operative suite and placed in the supine position.  Preoperatively, the patient received IV antibiotics of Ancef, sequential compression devices and subcutaneous heparin.  The abdomen was prepped and draped in the normal sterile fashion with Betadine solution.  Utilizing a #15 blade scalpel, a transverse infraumbilical incision was created.  Utilizing a Veress needle with anterior traction on the anterior abdominal wall with a towel clamp, the Veress needle was inserted without difficulty.  Hanging water drop test was performed with notable air aspiration through the Veress needle and the saline passed through the Veress needle without difficulty.  The abdomen was then insufflated to 15 mmHg with carbon-dioxide.  Once the abdomen was sufficiently insufflated, a #10 mm bladed trocar was inserted into the abdomen without difficulty.  Video laparoscope was inserted and the above notable findings were identified in the operative findings.  The patient to proceed with laparoscopic cholecystectomy was decided and a subxiphoid port was placed.  A #15 bladed scalpel was used to make a transverse incision in the subxiphoid region within the midline.  The trocar was then inserted into the abdomen under direct visualization with the video laparoscope and seen to go to the right of falciform ligament.  Next, two 5 mm trocars were inserted under direct visualization, one in the midclavicular and one in the anterior midaxillary line.  These were inserted without difficulty.  The liver edge was lifted and revealed a markedly edematous gallbladder with severe omental adhesions encapsulating the gallbladder.  Utilizing Endoshears scissor, a plane was created circumferentially to the dome of the gallbladder to allow assistance and dissection of these dense adhesions.  Next, the omental adhesions adjacent to the infundibulum were taken down and allowed to expose the cystic duct.  A small vessel was seen anterior to the cystic duct and this was clipped two proximally and one distally and noted to be an anomalous arterial branch.  This was transected with Endoshears scissor and visualized the pulsatile branch with two clips securely in place.  Next, the cystic duct was carefully dissected with Maryland dissectors and was visualized clearly both anterior and posteriorly.  Endoclips were placed two proximally and one distally and then the cystic duct was transected with Endoshears scissor.,Once the clips were noted to be in place, utilizing electrocautery another Dorsey dissector was used to carefully dissect the gallbladder off the liver bed wall.  The gallbladder was removed and the bleeding from the gallbladder wall was easily controlled with electrocautery.  The abdomen was then irrigated with copious amounts of normal saline.  The gallbladder was grasped with a gallbladder grasper and removed from the subxiphoid port.  There was noted to be gallstones within the gallbladder.  Once the abdomen was re-insufflated after removing the gallbladder and copious irrigation was performed, all ports were then removed under direct visualization with no evidence of bleeding from the anterior abdominal wall.  Utilizing #0 Vicryl suture, a figure-of-eight was placed to the subxiphoid and infraumbilical fascia and this was approximated without difficulty.  The subxiphoid port was irrigated with copious amounts of normal saline prior to closure of the fascia.  A #4-0 Vicryl suture was used to approximate all incisions.  The incisions were then injected with local injectable 0.25% Marcaine.  All ports were then cleaned dry.  Steri-Strips were placed across and sterile pressure dressings were placed on top of this.  The patient tolerated the entire procedure well.  She was transferred to the Postanesthesia Care Unit in stable condition.  She will be followed closely in the postoperative course in General Medical Floor.","surgery, gallstone, gallbladder, pancreatitis, anterior abdominal wall, video laparoscope, laparoscopic cholecystectomy, omental adhesions, veress needle, cystic duct, injectable, adhesions, cholecystectomy, laparoscopic, abdomen"
 Open cholecystectomy (attempted laparoscopic cholecystectomy)., Surgery, Cholecystectomy - Open ,"PREOPERATIVE DIAGNOSIS (ES):,1. Cholelithiasis.,2. Cholecystitis.,POSTOPERATIVE DIAGNOSIS (ES):,1. Acute perforated gangrenous cholecystitis.,2. Cholelithiasis.,PROCEDURE:,1. Attempted laparoscopic cholecystectomy.,2. Open cholecystectomy.,ANESTHESIA:, General endotracheal anesthesia.,COUNTS:, Correct.,COMPLICATIONS:, None apparent.,ESTIMATED BLOOD LOSS:, 275 mL.,SPECIMENS:,1. Gallbladder.,2. Lymph node.,DRAINS:, One 19-French round Blake.,DESCRIPTION OF THE OPERATION:, After consent was obtained and the patient was properly identified, the patient was transported to the operating room and after induction of general endotracheal anesthesia, the patient was prepped and draped in a normal sterile fashion.,After infiltration with local, a vertical incision was made at the umbilicus and utilizing graspers, the underlying fascia was incised and was divided sharply. Dissecting further, the peritoneal cavity was entered. Once this done, a Hasson trocar was secured with #1 Vicryl and the abdomen was insufflated without difficulty. A camera was placed into the abdomen and there was noted to be omentum overlying the subhepatic space. A second trocar was placed in the standard fashion in the subxiphoid area; this was a 10/12 mm non-bladed trocar. Once this was done, a grasper was used to try and mobilize the omentum and a second grasper was added in the right costal margin; this was a 5-mm port placed, it was non-bladed and placed in the usual fashion under direct visualization without difficulty. A grasper was used to mobilize free the omentum which was acutely friable and after a significant time-consuming effort was made to mobilize the omentum, it was clear that the gallbladder was well incorporated by the omentum and it would be unsafe to proceed with a laparoscopy procedure and then the procedure was converted to open.,The trocars were removed and a right subcostal incision was made incorporating the 10/12 subxiphoid port. The subcutaneous space was divided with electrocautery, as well as the muscles and fascia. The Bookwalter retraction system was then set up and retractors were placed to provide exposure to the right subhepatic space. Then utilizing a right-angle and electrocautery, the omentum was freed from the gallbladder. An ensuing retrograde cholecystectomy was performed, in which, electrocautery and blunt dissection were used to mobilize the gallbladder from the gallbladder fossa; this was done down to the infundibulum. After meticulous dissection, the cystic artery was identified and it was ligated between 3-0 silks. Several other small ties were placed on smaller bleeding vessels and the cystic duct was identified, was skeletonized, and a 3-0 stick tie was placed on the proximal portion of it. After it was divided, the gallbladder was freed from the field.,Once this was done, the liver bed was inspected for hemostasis and this was achieved with electrocautery. Copious irrigation was also used. A 19-French Blake drain was placed in Morrison's pouch lateral to the gallbladder fossa and was secured in place with 2-0 nylon; this was a 19-French round Blake. Once this was done, the umbilical port was closed with #1 Vicryl in an interrupted fashion and then the wound was closed in two layers with #1 Vicryl in an interrupted fashion. The skin was closed with and absorbable stitch.,The patient was then awakened from anesthesia, extubated, and transported to the recovery room in stable condition.","surgery, cholelithiasis, cholecystitis, gangrenous, cholecystectomy, laparoscopic, gallbladder, blake, omentum, hasson, electrocautery, gallbladder fossa, endotracheal, subhepatic, french, "
 Endoscopic retrograde cholangiopancreatography with brush cytology and biopsy., Surgery, Cholangiopancreatography (Endoscopic) ,"PROCEDURE:, Endoscopic retrograde cholangiopancreatography with brush cytology and biopsy.,INDICATION FOR THE PROCEDURE:, Patient with a history of chronic abdominal pain and CT showing evidence of chronic pancreatitis, with a recent upper endoscopy showing an abnormal-appearing ampulla.,MEDICATIONS:, General anesthesia.,The risks of the procedure were made aware to the patient and consisted of medication reaction, bleeding, perforation, aspiration, and post ERCP pancreatitis.,DESCRIPTION OF PROCEDURE:, After informed consent and appropriate sedation, the duodenoscope was inserted into the oropharynx, down the esophagus, and into the stomach. The scope was then advanced through the pylorus to the ampulla. The ampulla had a markedly abnormal appearance, as it was enlarged and very prominent. It extended outward with an almost polypoid shape. It had what appeared to be adenomatous-appearing mucosa on the tip. There also was ulceration noted on the tip of this ampulla. The biliary and pancreatic orifices were identified. This was located not at the tip of the ampulla, but rather more towards the base. Cannulation was performed with a Wilson-Cooke TriTome sphincterotome with easy cannulation of the biliary tree. The common bile duct was mildly dilated, measuring approximately 12 mm. The intrahepatic ducts were minimally dilated. There were no filling defects identified. There was felt to be a possible stricture within the distal common bile duct, but this likely represented an anatomic variant given the abnormal shape of the ampulla. The patient has no evidence of obstruction based on lab work and clinically. Nevertheless, it was decided to proceed with brush cytology of this segment. This was done without any complications. There was adequate drainage of the biliary tree noted throughout the procedure. Multiple efforts were made to access the pancreatic ductal anatomy; however, because of the shape of the ampulla, this was unsuccessful. Efforts were made to proceed in a long scope position, but still were unsuccessful. Next, biopsies were obtained of the ampulla away from the biliary orifice. Four biopsies were taken. There was some minor oozing which had ceased by the end of the procedure. The stomach was then decompressed and the endoscope was withdrawn.,FINDINGS:,1. Abnormal papilla with bulging, polypoid appearance, and looks adenomatous with ulceration on the tip; biopsies taken.,2. Cholangiogram reveals mildly dilated common bile duct measuring 12 mm and possible distal CBD stricture, although I think this is likely an anatomic variant; brush cytology obtained.,3. Unable to access the pancreatic duct.,RECOMMENDATIONS:,1. NPO except ice chips today.,2. Will proceed with MRCP to better delineate pancreatic ductal anatomy.,3. Follow up biopsies and cytology.","surgery, cholangiogram, ercp, endoscopic, endoscopic retrograde cholangiopancreatography, mrcp, wilson-cooke tritome sphincterotome, abdominal pain, ampulla, bile duct, brush cytology, cholangiopancreatography, pancreatitis, papilla, polypoid, retrograde cholangiopancreatography, cholangiopancreatography with brush cytology, brush cytology and biopsy, shape of the ampulla, pancreatic ductal anatomy, common bile duct, cannulation, brush, pancreatic, cytology"
" Resection of left chest wall tumor, partial resection of left diaphragm, left lower lobe lung wedge resection, left chest wall reconstruction with Gore-Tex mesh.", Surgery, Chest Wall Tumor Resection ,"PREOPERATIVE DIAGNOSIS: , Left chest wall tumor, spindle cell histology.,POSTOPERATIVE DIAGNOSIS: , Left chest wall tumor, spindle cell histology with pathology pending.,PROCEDURE:  ,Resection of left chest wall tumor, partial resection of left diaphragm, left lower lobe lung wedge resection, left chest wall reconstruction with Gore-Tex mesh.,ANESTHESIA: , General endotracheal.,SPECIMEN:,  Left chest wall with tumor and left lower lobe lung wedge resection to pathology.,INDICATIONS FOR PROCEDURE:,  The patient is a 79-year-old male who began to experience back pain approximately 2 years ago, which increased.  Chest x-ray and CT scan revealed a 3 cm x 4 cm mass abutting the left chest wall inferior to the left scapula with pleural thickening.  A biopsy was performed at an outside hospital (Kaiser) and pathology was consistent with mesothelioma.  The patient had a metastatic workup, which was negative including a brain MRI and bone scan.  The bone scan showed only signal positivity in the left 9th rib near the tumor.  The patient has a significant past medical history consisting of coronary artery disease, hypertension, non-insulin dependent diabetes, longstanding atrial fibrillation, anemia, and hypercholesterolemia.  He and his family were apprised of the high-risk nature of this surgery preoperatively and informed consent was obtained.,PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed in the supine position.  The patient was intubated with a double-lumen endotracheal tube.  Intravenous antibiotics were given.  A Foley catheter was placed.  The patient was placed in the right lateral decubitus position and the left chest was prepped and draped in the usual sterile fashion.  An incision approximately 8 inches long was made centered over the mass and extending slightly obliquely over the mass.  The skin and subcutaneous tissues were dissected sharply with the electrocautery.  Good hemostasis was obtained.  The tumor was easily palpable and clearly involving the 8th to 9th rib.  A thoracotomy was initially made above the mass in approximately the 7th intercostal space.  Inspection of the pleural cavity revealed multiple adhesions, which were taken down with a combination of blunt and sharp dissection.  The thoracotomy was extended anteriorly and posteriorly.  It was clear that in order to obtain an adequate resection of the tumor, approximately 4 rib segment of the chest wall would need to be resected.  The ribs of the chest wall were first cut at their anterior aspect.  The ribs 7, 8, 9, and 10 were serially transected after the interspaces were dissected with electrocautery.  Hemostasis was obtained with both electrocautery and clips.  The chest wall segment to be resected was retracted laterally and posteriorly.  It was clear that there were at least 2 areas where the tumor was invading the lung and a lengthy area of diaphragmatic involvement.  Inferiorly, the diaphragm was divided to provide a margin of at least 1 to 2 cm around the areas of tumor.  The spleen and the stomach were identified and were protected.  Inferiorly, the resection of the chest wall was continued in the 10th interspace.  The dissection was then carried posteriorly to the level of the spine.  The left lung at this point was further dissected out and multiple firings of the GIA 75 were used to perform a wedge resection of the left lower lobe, which provided a complete resection of all palpable and visible tumor in the lung.  A 2-0 silk tie was used to ligate the last remaining corner of lung parenchyma at the corner of the wedge resection.  Posteriorly, the chest wall segment was noted to have an area at the level of approximately T8 and T9, where the tumor involved the vertebral bodies.  The ribs were disarticulated, closed to or at their articulations with the spine.  Bleeding from the intercostal vessels was controlled with a combination of clips and electrocautery.  There was no disease grossly involving or encasing the aorta.,The posterior transection of the ribs was completed and the specimen was passed off of the field as a specimen to pathology for permanent section.  The specimen was oriented for the pathologist who came to the room.  Hemostasis was obtained.  The vent in the diaphragm was then closed primarily with a series of figure-of-8 #1 Ethibond sutures.  This produced a satisfactory diaphragmatic repair without undue tension.  A single 32-French chest tube was placed in the pleural cavity exiting the left hemithorax anteriorly.  This was secured with a #1 silk suture.  The Gore-Tex mesh was brought on to the field and was noted to be of adequate size to patch the resulting chest wall defect.  A series of #1 Prolene were placed in an interrupted horizontal mattress fashion circumferentially and tied down individually.  The resulting mesh closure was snug and deemed adequate.  The serratus muscle was reapproximated with figure-of-8 0 Vicryl.  The latissimus was reapproximated with a two #1 Vicryl placed in running fashion.  Of note, two #10 JP drains were placed over the mesh repair of the chest wall.  The subcutaneous tissues were closed with a running 3-0 Vicryl suture and the skin was closed with a 4-0 Monocryl.  The wounds were dressed.  The patient was brought from the operating room directly to the North ICU, intubated in stable condition.  All counts were correct.,","surgery, chest wall tumor resection, diaphragm, left lower lobe, lung wedge resection, chest wall reconstruction, chest wall segment, gore tex mesh, chest wall tumor, chest wall, pleural cavity, lower lobe, wedge resection, resection, tumor, wall, chest, anesthesia, electrocautery, wedge, mesh, lung,"
 Laparoscopic cholecystectomy with cholangiogram., Surgery, Cholecystectomy & Cholangiogram. ,"PREOPERATIVE DIAGNOSES:,1.  Cholelithiasis.,2.  Acute cholecystitis.,POSTOPERATIVE DIAGNOSES:,1.  Acute on chronic cholecystitis.,2.  Cholelithiasis.,PROCEDURE PERFORMED: , Laparoscopic cholecystectomy with cholangiogram.,ANESTHESIA: , General.,INDICATIONS: , This is a 38-year-old diabetic Hispanic female patient, with ongoing recurrent episodes of right upper quadrant pain, associated with nausea.  Ultrasound revealed cholelithiasis.  The patient also had somewhat thickened gallbladder wall.  The patient was admitted through emergency room last night with acute onset right upper quadrant pain.  Clinically, it was felt the patient had acute cholecystitis.  Laparoscopic cholecystectomy with cholangiogram was advised.  Procedure, indication, risk, and alternative were discussed with the patient in detail preoperatively and informed consent was obtained.,DESCRIPTION OF PROCEDURE: , The patient was put in supine position on the operating table under satisfactory general anesthesia, and abdomen was prepped and draped.  A small transverse incision was made just above the umbilicus under local anesthesia.  Fascia was opened vertically.  Stay sutures were placed in the fascia.  Peritoneal cavity was carefully entered.  Hasson cannula was inserted and peritoneal cavity was insufflated with CO2.,Laparoscopic camera was inserted, and the patient was placed in reverse Trendelenburg, rotated to the left.  A 11-mm trocar was placed in the subxiphoid space and two 5-mm in the right subcostal region.  Examination at this time showed no free fluid, no acute inflammatory changes.  Liver was grossly normal.  Gallbladder was noted to be thickened.  Gallbladder wall with a stone stuck in the neck of the gallbladder and pericholecystic edema, consistent with acute cholecystitis.,The fundus of the gallbladder was retracted superiorly, and dissection was carried at the neck of the gallbladder where a cystic duct was identified and isolated.  It was clipped distally and using C-arm fluoroscopy, intraoperative cystic duct cholangiogram was done, which was interpreted as normal.  There was slight dilatation noted at the junction of the right and left hepatic duct, but no filling defects or any other pathology was noted.  It was presumed that this was probably a congenital anomaly.  The cystic duct was clipped twice proximally and divided beyond the clips.  Cystic artery was identified, isolated, clipped twice proximally, once distally, and divided.,The gallbladder was then removed from its bed using cautery dissection and subsequently delivered through the umbilical port.  Specimen was sent for histopathology.  Subhepatic and subdiaphragmatic spaces were irrigated with sterile saline solution.  Hemostasis was good.  Trocars were removed under direct vision and peritoneal cavity was evacuated with CO2.  Umbilical area fascia was closed with 0-Vicryl figure-of-eight sutures, required extra sutures to close the fascial defect.  Some difficulty was encountered closing the fascia initially because of the patient's significant amount of subcutaneous fat.  In the end, the repair appears to be quite satisfactory.  Rest of the incisions closed with 3-0 Vicryl for the subcutaneous tissues and staples for the skin.  Sterile dressing was applied.,The patient transferred to recovery room in stable condition.","surgery, cholelithiasis, acute cholecystitis, laparoscopic, cholecystectomy, cholangiogram, laparoscopic cholecystectomy, gallbladder,"
" Left pleural effusion, parapneumonic, loculated.  Left chest tube placement.", Surgery, Chest Tube Placement ,"PREOPERATIVE DIAGNOSIS: , Left pleural effusion, parapneumonic, loculated.,POSTOPERATIVE DIAGNOSIS: , Left pleural effusion, parapneumonic, loculated.,OPERATION: , Left chest tube placement.,IV SEDATION: , 5 mg of Versed total given under pulse ox monitoring, 1% lidocaine local infiltration.,PROCEDURE: , With the patient semi recumbent and supine the left anterolateral chest was prepped and draped in the usual sterile fashion.  A 1% lidocaine was liberally infiltrated into the skin, subcutaneous tissue, deep fascia and the anterior axillary line just below the level of the nipple.  The incision was made and deepened through the different layers to reach the intercostal space.  The pleura was entered on top of the underlying rib and finger digital palpation was performed.  Multiple loculations were encountered.  Break up of loculations was performed posteriorly and a chest tube was directed posteriorly.  Only a small amount of fluid was noted to come out initially.  This was sent for various studies.  Soft adhesions were encountered.  The plan was to obtain a chest x-ray and start Activase installation.","surgery, activase, chest tube placement, pleural effusion, chest tube, lidocaine, infiltration, parapneumonic, loculated, pleural, chest, "
 Delayed primary chest closure.  Open chest status post modified stage 1 Norwood operation.  The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation., Surgery, Chest Closure ,"PROCEDURE:, Delayed primary chest closure.,INDICATIONS: , The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation.  Given the magnitude of the operation and the size of the patient (2.5 kg), we have elected to leave the chest open to facilitate postoperative management.  He is now taken back to the operative room for delayed primary chest closure.,PREOP DX: , Open chest status post modified stage 1 Norwood operation.,POSTOP DX:,  Open chest status post modified stage 1 Norwood operation.,ANESTHESIA: , General endotracheal.,COMPLICATIONS: , None.,FINDINGS:,  No evidence of intramediastinal purulence or hematoma.  He tolerated the procedure well.,DETAILS OF PROCEDURE: , The patient was brought to the operating room and placed on the operating table in the supine position.  Following general endotracheal anesthesia, the chest was prepped and draped in the usual sterile fashion.  The previously placed AlloDerm membrane was removed.  Mediastinal cultures were obtained, and the mediastinum was then profusely irrigated and suctioned.  Both cavities were also irrigated and suctioned.  The drains were flushed and repositioned.  Approximately 30 cubic centimeters of blood were drawn slowly from the right atrial line.  The sternum was then smeared with a vancomycin paste.  The proximal aspect of the 5 mm RV-PA conduit was marked with a small titanium clip at its inferior most aspect and with an additional one on its rightward inferior side.  The sternum was then closed with stainless steel wires followed by closure of subcutaneous tissues with interrupted monofilament stitches.  The skin was closed with interrupted nylon sutures and a sterile dressing was placed.  The peritoneal dialysis catheter, atrial and ventricular pacing wires were removed.  The patient was transferred to the pediatric intensive unit shortly thereafter in very stable condition.,I was the surgical attending present in the operating room and in charge of the surgical procedure throughout the entire length of the case.","surgery, open chest, stage 1 norwood operation, hypoplastic left heart syndrome, delayed primary chest closure, chest closure, norwood operation"
" Removal of chest wall mass.  The area of the mass, which was on the anterior lower ribs on the left side was marked and then a local anesthetic was injected.", Surgery, Chest Wall Mass Removal ,"PREOPERATIVE DIAGNOSIS:,  Chest wall mass, left.,POSTOPERATIVE DIAGNOSIS: , Chest wall mass, left.,PROCEDURE:,  Removal of chest wall mass.,DESCRIPTION OF PROCEDURE: , After obtaining the informed consent, the patient was brought to the operating room where he underwent a general endotracheal anesthetic.  The time-out process was followed and preoperative antibiotics were given.  The patient was in the supine position and was prepped and draped in the usual fashion.,The area of the mass, which was on the anterior lower ribs on the left side was marked and then a local anesthetic was injected.  An incision was made directly on the mass and carried down to the ribs.  This is where the several chondral cartilages of the lower ribs meet.  So I believe they were isolated in 9th rib anteriorly and I was able to encircle it.  The medial area was __________.  There was no way to perform same procedure there, so what I did, I took an electric saw and proceeded to divide the calcified cartilages of the sternum and also the attachments to the lower ribs.  There was also a separate sharp growth of the mass growing superiorly.  Apparently, I was able to excise the mass and actually it was much larger than it was palpated externally.  This may be due to an extension towards the inside of his chest.  Hemostasis was revised.  The internal mammary was intact and there was no obvious penetration of the pleural cavity.  The specimen was sent to Pathology and then we proceeded to close the defect.  Obviously, the space between the ribs cannot be approximated.  So what we did was approximate the pectoralis major operative defect and then the soft tissues and the skin with subcuticular suture of Monocryl.,The patient tolerated the procedure well.  Estimated blood loss was minimal and he was sent to the recovery room in satisfactory condition.","surgery, chest wall mass, local anesthetic, lower ribs, chest wall, mass, cartilages, wall, chest, ribs, "
 Chest tube insertion done by two physicians in ER - spontaneous pneumothorax secondary to barometric trauma., Surgery, Chest Tube Insertion in ER ,"PREOPERATIVE DIAGNOSES:,1.  Right spontaneous pneumothorax secondary to barometric trauma.,2.  Respiratory failure.,3.  Pneumonia with sepsis.,POSTOPERATIVE DIAGNOSES:,1.  Right spontaneous pneumothorax secondary to barometric trauma.,2.  Respiratory failure.,3.  Pneumonia with sepsis.,INFORMED CONSENT: , Not obtained.  This patient is obtunded, intubated, and septic.  This is an emergent procedure with 2-physician emergency consent signed and on the chart.,PROCEDURE: , The patient's right chest was prepped and draped in sterile fashion.  The site of insertion was anesthetized with 1% Xylocaine, and an incision was made.  Blunt dissection was carried out 2 intercostal spaces above the initial incision site.  The chest wall was opened, and a 32-French chest tube was placed into the thoracic cavity, after examination with the finger, making sure that the thoracic cavity had been entered correctly.  The chest tube was placed.,A postoperative chest x-ray is pending at this time.,The patient tolerated the procedure well and was taken to the recovery room in stable condition.,ESTIMATED BLOOD LOSS:,  10 mL,COMPLICATIONS:,  None.,SPONGE COUNT: , Correct x2.","surgery, spontaneous pneumothorax, barometric trauma, respiratory failure, sepsis, pneumonia, blunt dissection, chest wall, thoracic cavity, chest x-ray, chest tube insertion, chest tube, pneumothorax, tube, chest, insertion,"
 Right hemothorax.  Insertion of a #32 French chest tube on the right hemithorax.  This is a 54-year-old female with a newly diagnosed carcinoma of the cervix.  The patient is to have an Infuse-A-Port insertion., Surgery, Chest Tube Insertion ,"PREOPERATIVE DIAGNOSIS: , Right hemothorax.,POSTOPERATIVE DIAGNOSIS: , Right hemothorax.,PROCEDURE PERFORMED: , Insertion of a #32 French chest tube on the right hemithorax.,ANESTHESIA: , 1% Lidocaine and sedation.,INDICATIONS FOR PROCEDURE:,  This is a 54-year-old female with a newly diagnosed carcinoma of the cervix.  The patient is to have an Infuse-A-Port insertion today.  Postoperatively from that, she started having a blood tinged pink frothy sputum.  Chest x-ray was obtained and showed evidence of a hemothorax on the right hand side, opposite side of the Infuse-A-Port and a wider mediastinum.  The decision was made to place a chest tube in the right hemithorax to allow for the patient to be stable for transfer out of the operating room.,DESCRIPTION OF PROCEDURE: , The area was prepped and draped in the sterile fashion.  The area was anesthetized with 1% Lidocaine solution.  The patient was given sedation.  A #10 blade scalpel was used to make an incision approximately 1.5 cm long.  Then a curved scissor was used to dissect down to the level of the rib.  A blunt peon was then used to again enter into the right hemithorax.  Immediately a blood tinged effusion was released.  The chest tube was placed and directed in a posterior and superior direction.  The chest tube was hooked up to the Pleur-evac device which was ________ tip suction.  The chest tube was tied in with a #0 silk suture in a U-stitch fashion.  It was sutured in place with sterile dressing and silk tape.  The patient tolerated this procedure well.  We will obtain a chest x-ray in postop to ensure proper placement and continue to follow the patient very closely.","surgery, hemothorax, hemithorax, pleur-evac device, infuse-a-port insertion, chest tube, carcinoma"
 Bilateral pleural effusion.  Removal of bilateral #32 French chest tubes with closure of wound., Surgery, Chest Tube Removal ,"PREOPERATIVE DIAGNOSIS: , Bilateral pleural effusion.,POSTOPERATIVE DIAGNOSIS: , Bilateral pleural effusion.,PROCEDURE PERFORMED: ,Removal of bilateral #32-French chest tubes with closure of wound.,COMPLICATIONS:,  None.,INDICATIONS FOR PROCEDURE: , The patient is a 66-year-old African-American male who has been in the intensive care unit for over a month with bilateral chest tubes for chronic draining pleural effusions with serous drainage.  A decision was made to proceed with removal of these chest tubes and because of the fistulous tracts, this necessitated to close the wounds with sutures.  The patient was agreeable to proceed.,OPERATIVE PROCEDURE:  ,The patient was prepped and draped at the bedside over both chest tube sites.  The pressures applied over the sites and the skin was closed with interrupted #3-0 Ethilon sutures.  The skin was then cleansed and Vaseline occlusive dressing was applied over the sites.  The same procedure was performed on the other side.  The chest tubes were removed on full inspiration.  Vital signs remained stable throughout the procedure.  The patient will remain in the intensive care unit for continued monitoring.,","surgery, serous drainage, bilateral pleural effusion, pleural effusion, chest tubes, effusion, pleural, chest "
" Repeat low-transverse cesarean section, bilateral tubal ligation (BTL), extensive anterior abdominal wall/uterine/bladder adhesiolysis.  Term pregnancy and desires permanent sterilization.", Surgery, Cesarean Section & BTL ,"PREOPERATIVE DIAGNOSES:,1.  Term pregnancy.,2.  Desires permanent sterilization.,POSTOPERATIVE DIAGNOSES:,1.  Term pregnancy.,2.  Desires permanent sterilization.,PROCEDURE:,1.  Repeat low-transverse cesarean section.,2.  Bilateral tubal ligation.,3.  Extensive anterior abdominal wall/uterine/bladder adhesiolysis.,ANESTHESIA:,  Spinal/epidural with good effect.,FINDINGS:  ,Delivered vigorous male infant from cephalic presentation.  Apgars 9/9.  Birth weight 6 pounds 14 ounces.  Infant suctioned with a bulb upon delivery of the head and body.  Cord clamped and cut and infant passed to pediatric team present.  Complete placenta manually extracted intact with three vessel cord.  Extensive anterior abdominal wall adhesions with the anterior abdominal wall completely adhered to the anterior uterus throughout its entire length of the incision.  In addition, the bladder was involved in adhesion mass complex.  A window was developed surgically at the apical aspect of the incision enabling finger to pass to get behind the dense anterior abdominal wall adhesions.  These adhesions were surgically transected using Bovie cautery technique freeing up the anterior uterine attachment from the anterior abdominal wall.  Upon initial entry through the fibrous layer of the anterior abdominal wall _______ into the serosal and slightly muscular part of the anterior uterus due to the dense adhesion attachment that had occurred from previous surgeries.  Bilateral tubal ligation performed without difficulty via Parkland technique.,ESTIMATED BLOOD LOSS: , 500 mL.,COMPLICATIONS: , None.,URINE OUTPUT:  ,Per anesthesia records.  Urine cleared postoperatively.,IV FLUIDS:  ,Per anesthesia records.,The patient tolerated the procedure well and was taken to the recovery room in stable condition with stable vital signs.,OPERATIVE TECHNIQUE: , The patient was placed in a supine position after spinal/epidural anesthesia.  She was prepped and draped in the usual manner for repeat cesarean section.  A sharp knife was used to make a Pfannenstiel skin incision at the site of the previous scar.  This was carried through the subcutaneous tissue into the dense fibromuscular and fascial layer with a sharp knife.  This incision was extended laterally with Mayo scissors.  Dense fibromuscular layer was encountered from the patient's previous surgeries.  Upon entry, incision was entered into the serosal and partial muscular layer of the anterior uterus and there was no free area to enter into the peritoneal cavity due to dense fibromuscular adhesions of the entire uterus to the anterior abdominal wall at the length of the incision.  Fascia was previously separated superiorly and inferiorly from the muscular layer.  A surgical window was created at the apical aspect of the incision in the direction of the uterine fundus.  Finger was able to be passed and placed behind the dense adhesions between the uterus through anterior abdominal wall.  This adhesion complex was transacted via Bovie cautery its entire length circumferentially freeing the uterus from its attachment to anterior abdominal wall.  Inferiorly, difficulty was encountered with adhesion separation involving the bladder additionally to the uterus and the anterior abdominal wall.  These adhesions likewise were surgically transacted via sharp, blunt, and electrocautery dissection.  This was successfully done without anterior entry into the bladder.  Smooth pickups and Metzenbaum scissors were then used to do sharp dissection to separated the bladder from its attachment to the lower uterine segment enabling the vesicouterine peritoneal reflection for incision of the uterus.  The uterus was then incised using a sharp knife and low transverse incision.  This was extended with bandage scissors.  The infant was delivered easily from a cephalic presentation.  Bulb suction was done following delivery of the head and body.  The cord clamped and cut and the infant passed to pediatric team present.  Cord segment and cord blood was obtained.  Complete placenta manually extracted intact with three vessel cord.  Vigorous male infant, Apgars 9/9, weight 6 pounds 14 ounces.  Complete placenta with three vessels retrieved.  Uterus was exteriorized from the abdominal cavity.  Wet lap applied to the fundus and dry lap used to remove the remaining membranous tissue from the lining.  Pennington clamps placed at the uterine incision angles and the inferior incision lip.  A #1 chromic suture closed the uterus in running continuous interlocking closure.  Good hemostasis upon completion of the closure.  Laparotomy pads placed in the posterior cul-de-sac to remove any blood or clots.  The uterus was returned to the abdominal cavity, after using #1 chromic suture to close the anterior uterine incision, that was partial thickness through the serosal end of the muscular layer at midline adhesion.  This was closed with chromic suture in a running continuous interlocking closure with good hemostasis.  Attention was then focused on the bilateral tubal ligation.  Babcock clamp placed in the mid fallopian tube and elevated.  Cautery was used to make a window in the avascular segment of the mesosalpinx.  Proximal and distal #1 chromic suture ligation with mid fallopian tube transection performed.  The ligated proximal and distal stumps were then cauterized with Bovie cautery.  This tubal ligation procedure was done in a bilateral fashion.  Upon completion of tubal ligation, uterus was returned to the abdominal cavity.  Left and right gutters examined and found to be clean and dry.  Evaluation of the low uterine segment incision revealed continued hemostasis.  Oozing was encountered in the inferior bladder of dissection and 2-0 chromic suture in running continuous fashion, partial thickness of the bladder to control the oozing at this site was successfully done.  Interceed was then placed on the low uterine incision and the low anterior uterine aspect.  The midline rectus including peritoneum was re-approximated with simple interrupted chromic sutures.  Irrigation of the muscular layer with good hemostasis noted.  The fascia was closed with #1 Vicryl in a running continuous closure.  Subcutaneous tissue was irrigated, additional hemostasis with Bovie cautery.  The skin was closed with staples.","surgery, term pregnancy, sterilization, low-transverse cesarean section, bilateral tubal ligation, adhesiolysis, anterior uterus, abdominal cavity, cesarean section, chromic suture, tubal ligation, adhesions, uterus, abdominal, infant, anterior, cesarean, hemostasis, chromic, uterine, "
" Left total knee cemented arthroplasty.  Severe tricompartmental osteoarthritis, left knee with varus deformity.", Surgery, Cemented Arthroplasty ,"PREOPERATIVE DIAGNOSIS: , Severe tricompartmental osteoarthritis, left knee with varus deformity.,POSTOPERATIVE DIAGNOSIS:,  Severe tricompartmental osteoarthritis, left knee with varus deformity.,PROCEDURE PERFORMED:  ,Left total knee cemented arthroplasty.,ANESTHESIA: , Spinal with Duramorph.,ESTIMATED BLOOD LOSS:  ,50 mL.,NEEDLE AND SPONGE COUNT:,  Correct.,SPECIMENS: , None.,TOURNIQUET TIME:  ,Approximately 77 minutes.,IMPLANTS USED:,1.  Zimmer NexGen posterior stabilized LPS-Flex GSF femoral component size D, left.,2.  All-poly patella, size 32/8.5 mm thickness.,3.  Prolong highly cross-linked polyethylene 12 mm.,4.  Stemmed tibial component, size 2.,5.  Palacos cement with antibiotics x2 batches.,INDICATION: , The patient is an 84-year-old female with significant endstage osteoarthritis of the left knee, who has had rapid progression with pain and disability.  Surgery was indicated to relieve her pain and improve her functional ability.  Goal objectives and the procedure were discussed with the patient.  Risks and benefits were explained.  No guarantees have been made or implied.  Informed consent was obtained.,DESCRIPTION OF THE PROCEDURE:  ,The patient was taken to the operating room and once an adequate spinal anesthesia with Duramorph was achieved, her left lower extremity was prepped and draped in a standard sterile fashion.  A nonsterile tourniquet was placed proximally in the thigh.  Antibiotics were infused prior to Foley catheter insertion.  Time-out procedure was called.,A straight longitudinal anterior midline incision was made.  Dissection was carried down sharply down the skin, subcutaneous tissue and the fascia.  Deep fascia was exposed.  The tourniquet was inflated at 300 mmHg prior to the skin incision.  A standard medial parapatellar approach was made.  The quadriceps tendon was incised approximately 1 cm from the vastus medialis insertion.  Incision was then carried down distally and distal arthrotomy was completed.  Patellar tendon was well protected.  Retinaculum and capsule was incised approximately 5 mm from the medial border of the patella for later repair.  The knee was exposed very well.  Significant tricompartmental osteoarthritis was noted.  The osteophytes were removed with a rongeur.  Anterior and posterior cruciate ligaments were excised.  Medial and lateral meniscectomies were performed.  Medial dissection was performed subperiosteally along the medial aspect of the proximal tibia to address the varus deformity.  The medial compartment was more affected than lateral.  Medial ligaments were tied.  Retropatellar fat pad was excised.  Osteophytes were removed.  Using a Cobb elevator, the medial soft tissue periosteum envelope was well reflected.,Attention was placed for the preparation of the femur.  The trochlear notch was ossified.  A rongeur was utilized to identify the notch and then using an intramedullary drill guide, a starting hole was created slightly anterior to the PCL attachment.  The anterior portal was 1 cm anterior to the PCL attachment.  The anterior femoral sizer was positioned keeping 3 degrees of external rotation.  Rotation was also verified using the transepicondylar axis and Whiteside line.  The pins were positioned in the appropriate holes.  Anterior femoral cut was performed after placing the cutting guide.  Now, the distal cutting guide was attached to the alignment and 5 degrees of valgus cut was planned.  A distal femoral cut was made which was satisfactory.  A sizer was positioned which was noted to be D.  The 5-in-1 cutting block size D was secured with spring pins over the resected bone.  Using an oscillating saw, cuts were made in a sequential manner such as anterior condyle, posterior condyle, anterior chamfer, and posterior chamfer.  Then using a reciprocating saw, intercondylar base notch cut and side cuts were made.  Following this, the cutting block for High-Flex knee was positioned taking 2 mm of additional posterior condyle.  Using a reciprocating saw, the side cuts were made and bony intercondylar notch cut was completed.  The bone with its attached soft tissue was removed.  Once the femoral preparation was completed, attention was placed for the preparation of the tibia.  The medial and the lateral collateral ligaments were well protected with a retractor.  The PCL retractor was positioned and the tibia was translated anteriorly.  Osteophytes were removed.  The extramedullary tibial alignment guide was affixed to the tibia and appropriate amount of external rotation was considered reference to the medial 1/3rd of the tibial tubercle.  Similarly, horseshoe alignment guide was positioned and the alignment guide was well aligned to the distal 1/3rd of the crest of the tibia as well as the 2nd toe.  Once the alignment was verified in a coronal plane, the tibial EM guide was well secured and then posterior slope was also aligned keeping the alignment rod parallel to the tibial crest.  A built-in 7-degree posterior slope was considered with instrumentation.  Now, the 2 mm stylus arm was positioned over the cutting block medially, which was the most affected site.  Tibial osteotomy was completed 90 degrees to the mechanical axis in the coronal plane.  The resected thickness of the bone was satisfactory taken 2 mm from the most affected site.  The resected surface shows some sclerotic bone medially.  Now, attention was placed for the removal of the posterior osteophytes from the femoral condyle.  Using curved osteotome, angle curette, and a rongeur, the posterior osteophytes were removed.  Now, attention was placed for confirming the flexion-extension gap balance using a 10 mm spacer block in extension and 12 mm in flexion.  Rectangular gap was achieved with appropriate soft tissue balance in both flexion and extension.  The 12 mm spacer block was satisfactory with good stability in flexion and extension.,Attention was now placed for completion of the tibia.  Size 2 tibial trial plate was positioned.  Appropriate external rotation was maintained with the help of the horseshoe alignment rod.  Reference to the tibial crest distally and 2nd toe was considered as before.  The midpoint of the trial tray was collinear with the medial 1/3rd of the tibial tubercle.  The rotation of tibial plate was satisfactory as required and the preparation of the tibia was completed with intramedullary drill followed by broach impactor.  At this point, trial femoral and tibial components were reduced using a 12 mm trial liner.  The range of motion and stability in both flexion and extension was satisfactory.  No further soft tissue release was indicated.  I was able to achieve 0 degrees of extension and complete flexion of the knee.,Attention was now placed for the preparation of the patella.  Using a patellar caliper, the thickness was measured to be 21.5 mm.  This gives an ideal resection of 8.5 mm keeping 13 mm of bone intact.  Reaming was initiated with a patellar reamer reaming up to 13 mm with the reaming alignment guide.  Using a caliper, the resected patella was measured, which was noted to be 13 mm.  A 32 sizer was noted to accommodate the resected surface very well.  Drilling was completed and trial 32 button was inserted without any difficulty.  The tracking was satisfactory.  There was no evidence of any subluxation or dislocation of the patella.  The trial components position was satisfactory.  The alignment and the rotation of all 3 components were satisfactory.  All the trial components were removed and the wound was thoroughly irrigated with Pulsavac lavage irrigation mechanical system.  The resected surfaces were dried with a sponge.  Two batches of Palacos cement were mixed.  The cementing was initiated starting with tibia followed by femur and patella.  Excess peripheral cement were removed with the curette and knife.  The knee was positioned in extension with a 12 mm trial liner.  Patellar clamp was placed after cementing the all-poly patella.  Once the cement was set hard and cured, tourniquet was deflated.  Hemostasis was achieved.  The trial 12 mm liner was replaced with definitive Prolong highly cross-linked polyethylene liner.  Range of motion and stability was verified at 0 degrees and flexion of 120 degrees.  Anterior-posterior drawer test was satisfactory.  Medial and lateral stability was satisfactory.  Patellar tracking was satisfactory.  The wound was thoroughly irrigated.  Hemostasis was achieved.  A local cocktail was injected, which included the mixture of 0.25% plain Marcaine, 30 mg of Toradol, and 4 mg of morphine.  The quadriceps mechanism and distal arthrotomy was repaired with #1 Vicryl in figure-of-8 fashion.  The subcutaneous closure was performed in layers using 2-0 Vicryl and 0 Vicryl followed by 2-0 Vicryl proximally.  The skin was approximated with staples.  Sterile dressings were placed including Xeroform, 4x4, ABD, and Bias.  The patient was then transferred to the recovery room in a stable condition.  There were no intraoperative complications noted.  She tolerated the procedure very well.",
" Cesarean Section.  An incision was made as noted above in the findings and carried down through the subcutaneous tissue, muscular fascia and peritoneum. ", Surgery, Cesarean Section ,,"surgery, peritoneum, cesarean section, abdominal incision, subcutaneous tissue, bladder flap, incision, cesarean, fascia, flap, abdominalNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Laparoscopic resection of cecal polyp.  Local anesthetic was infiltrated into the right upper quadrant where a small incision was made.  Blunt dissection was carried down to the fascia which was grasped with Kocher clamps.  , Surgery, Cecal Polyp Resection ,"PREOPERATIVE DIAGNOSIS:,  Cecal polyp.,POSTOPERATIVE DIAGNOSIS: , Cecal polyp.,PROCEDURE: , Laparoscopic resection of cecal polyp.,COMPLICATIONS: , None., ,ANESTHESIA:  ,General oral endotracheal intubation.,PROCEDURE:,  After adequate general anesthesia was administered the patient's abdomen was prepped and draped aseptically.  Local anesthetic was infiltrated into the right upper quadrant where a small incision was made.  Blunt dissection was carried down to the fascia which was grasped with Kocher clamps.  A bladed 11-mm port was inserted without difficulty.  Pneumoperitoneum was obtained using C02.  Under direct vision 2 additional, non-bladed, 11-mm trocars were placed, one in the left lower quadrant and one in the right lower quadrant.  There was some adhesion noted to the anterior midline which was taken down using the harmonic scalpel.  The cecum was visualized and found to have tattoo located almost opposite the ileocecal valve.  This was in what appeared to be an appropriate location for removal of this using the Endo GIA stapler without impinging on the ileocecal valve or the appendiceal orifice.  The appendix was somewhat retrocecal in position but otherwise looked normal.  The patient was also found to have ink marks in the peritoneal cavity diffusely indicating possible extravasation of dye.  There was enough however in the wall to identify the location of the polyp.  The lesion was grasped with a Babcock clamp and an Endo GIA stapler used to fire across this transversely. The specimen was then removed through the 12-mm port and examined on the back table.  The lateral margin was found to be closely involved with the specimen so I did not feel that it was clear.  I therefore lifted the lateral apex of the previous staple line and created a new staple line extending more laterally around the colon.  This new staple line was then opened on the back table and examined.  There was some residual polypoid material noted but the margins this time appeared to be clear.  The peritoneal cavity was then lavaged with antibiotic solution.  There were a few small areas of bleeding along the staple line which were treated with pinpoint electrocautery.  The trocars were removed under direct vision.  No bleeding was noted.  The bladed trocar site was closed using a figure-of-eight O Vicryl suture.  All skin incisions were closed with running 4-0 Monocryl subcuticular sutures.  Mastisol and Steri-Strips were placed followed by sterile Tegaderm dressing.  The patient tolerated the procedure well without any complications.","surgery, polyp, laparoscopic resection, blunt dissection, kocher clamps, ileocecal valve, gia stapler, peritoneal cavity, cecal polyp, infiltrated, anesthetic "
 Left hip cemented hemiarthroplasty and biopsy of the tissue from the fracture site and resected femoral head sent to the pathology for further assessment., Surgery, Cemented Hemiarthroplasty & Biopsy ,"PREOPERATIVE DIAGNOSIS:,  Closed displaced probable pathological fracture, basicervical femoral neck, left hip.,POSTOPERATIVE DIAGNOSIS: , Closed displaced probable pathological fracture, basicervical femoral neck, left hip.,PROCEDURES PERFORMED:,1.  Left hip cemented hemiarthroplasty.,2.  Biopsy of the tissue from the fracture site and resected femoral head sent to the pathology for further assessment.,IMPLANTS USED:,1.  DePuy Ultima calcar stem, size 3 x 45.,2.  Bipolar head 28 x 43.,3.  Head with +0 neck length.,4.  Distal centralizer and cement restrictor.,5.  SmartSet antibiotic cement x2.,ANESTHESIA: , General.,NEEDLE AND SPONGE COUNT: , Correct.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS: , 300 mL.,SPECIMEN: , Resected femoral head and tissue from the fracture site as well as the marrow from the canal.,FINDINGS:  ,On exposure, the fracture was noted to be basicervical pattern with no presence of calcar about the lesser trochanter.  The lesser trochanter was intact.  The fracture site was noted to show abnormal pathological tissue with grayish discoloration.  The quality of the bone was also pathologically abnormal with soft trabecular bone.  The abnormal pathological tissues were sent along with the femoral head to pathology for assessment.  Articular cartilage of the acetabulum was intact and well preserved.,INDICATION: , The patient is a 53-year-old female with a history of malignant melanoma, who apparently had severe pain in her left lower extremity and was noted to have a basicervical femoral neck fracture.  She denied any history of fall or trauma.  The presentation was consistent with pathological fracture pending tissue assessment.  Indication, risks, and benefits were discussed.  Treatment options were reviewed.  No guarantees have been made or implied.,PROCEDURE:  ,The patient was brought to the operating room and once an adequate general anesthesia was achieved, she was positioned on a pegboard with the left side up.  The left lower extremity was prepped and draped in a standard sterile fashion.  Time-out procedure was called.  Antibiotics were infused.,A standard posterolateral approach was made.  Subcutaneous dissection was performed and the dissection was carried down to expose the fascia of the gluteus maximus.  This was then incised along the line of the incision.  Hemostasis was achieved.  Charnley retractor was positioned.  The trochanter was intact.  The gluteus medius was well protected with retractor.  The piriformis and minimus junction was identified.  The minimus was also reflected along with the medius.  Using Bovie and knife, the piriformis and external rotators were detached from its trochanteric insertion.  Similarly, L-shaped capsulotomy was performed.  A #5 Ethibond was utilized to tag the piriformis and the capsule for late repair.  Fracture site was exposed.  The femoral neck fracture was noted to be very low-lying basicervical type.  Femoral head was retrieved without any difficulty with the help of a corkscrew.  The head size was measured to be 43 mm.  Bony fragments were removed.  The acetabular socket was thoroughly irrigated.  A 43-mm bipolar trial head was inserted and this was noted to give a satisfactory fit with good stability.  The specimens submitted to pathology included the resected femoral head and the tissue at the fracture site, which was abnormal with grayish discoloration.  This was sent to the pathology.  The fracture was noted to be basicervical and preoperatively, decision was made to consider cemented calcar stem.  An L-shaped osteotomy was performed in order to accept the calcar prosthesis.  The basicervical fracture was noted to be just at the level of superior border of the lesser trochanter.  There was no calcar superior to the lesser trochanter.  The L-shaped osteotomy was performed to refine the bony edges and accept the calcar prosthesis.  Hemostasis was achieved.  Now, the medullary canal was entered with a canal finder.  The fracture site was well exposed.  Satisfactory lateralization was performed.  Attention was for the reaming process.  Using a size 1 reamer, the medullary canal was entered and reamed up to size 3, which gave us a satisfactory fit into the canal.  At this point, a trial prosthesis size 3 with 45 mm calcar body was inserted.  Appropriate anteversion was positioned.  The anteversion was marked with a Bovie to identify subsequent anteversion during implantation.  The bony edges were trimmed.  The calcar implant with 45 mm neck length was fit in the host femur very well.  There was no evidence of any subsidence.  At this point, trial reduction was performed using a bipolar trial head with 0 neck length.  The relationship between the central femoral head and the greater trochanter was satisfactory.  The hip was well reduced without any difficulty.  The stability and range of motion in extension and external rotation as well as flexion-adduction, internal rotation was satisfactory.  The shuck was less than 1 mm.  Leg length was satisfactory in reference to the contralateral leg.  Stability was satisfactory at 90 degrees of flexion and hip at 75-80 degrees of internal rotation.  Similarly, keeping the leg completely adducted, I was able to internally rotate the hip to 45 degrees.  After verifying the stability and range of motion in all direction, trial components were removed.  The canal was thoroughly irrigated and dry sponge was inserted and canal was dried completely.  At this point, 2 batches of SmartSet cement with antibiotics were mixed.  The definitive Ultima calcar stem size 3 with 45 mm calcar body was selected.  Centralizer was positioned.  The cement restrictor was inserted.  Retrograde cementing technique was applied once the canal was dried.  Using cement gun, retrograde cementing was performed.  The stem was then inserted into cemented canal with appropriate anteversion, which was maintained until the cement was set hard and cured.  The excess cement was removed with the help of a curette and Freer elevator.  All the cement debris was removed.,Attention was now placed for the insertion of the trial femoral head.  Once again, 0 neck length trial bipolar head was inserted over the trunnion.  It was reduced and range of motion and stability was satisfactory.  I also attempted with a -3 trial head, but the 0 gave us a satisfactory stability, range of motion, as well as the length and the shuck was also minimal.  The hip was raised to 90 degrees of flexion and 95 degrees of internal rotation.  There was no evidence of any impingement on extension and external rotation as well as flexion-adduction, internal rotation.  I also tested the hip at 90 degrees of flexion with 10 degrees adduction and internal rotation and further progressive flexion of the hip beyond 90 degrees, which was noted to be very stable.  At this point, a definitive component using +0 neck length and bipolar 43 head were placed over the trunnion and the hip was reduced.  Range of motion and stability was as above.  Now, the attention was placed for the repair of the capsule and the external rotators and the piriformis.  This was repaired to the trochanteric insertion using #5 Ethibond and suture plaster.  Satisfactory reinforcement was achieved with the #5 Ethibond.  The wound was thoroughly irrigated.  Hemostasis was achieved.  The fascia was closed with #1 Vicryl followed by subcutaneous closure using 2-0 Vicryl.  The wound was thoroughly washed and a local injection with mixture of morphine and Toradol was infiltrated including the capsule and the pericapsular structures.  Skin was approximated with staples.  Sterile dressings were placed.  Abduction pillow was positioned and the patient was then extubated and transferred to the recovery room in a stable condition.  There were no intraoperative complications noted.",
 Right subclavian triple lumen central line placement, Surgery, Central Line Placement ,"PREOPERATIVE DIAGNOSIS:,1. Severe chronic obstructive coronary disease.,2. Respiratory failure.,POSTOPERATIVE DIAGNOSIS:,1. Severe chronic obstructive coronary disease.,2. Respiratory failure.,OPERATION:,  Right subclavian triple lumen central line placement.,ANESTHESIA: , Local Xylocaine.,INDICATIONS FOR OPERATION:  ,This 50-year-old gentleman with severe respiratory failure is mechanically ventilated. He is currently requiring multiple intravenous drips, and Dr. X has kindly requested central line placement.,INFORMED CONSENT:  ,The patient was unable to provide his own consent, secondary to mechanical ventilation and sedation. No available family to provide conservator ship was located either.,PROCEDURE:  ,With the patient in his Intensive Care Unit bed, mechanically ventilated in the Trendelenburg position. The right neck was prepped and draped with Betadine in a sterile fashion. Single needle stick aspiration of the right subclavian vein was accomplished without difficulty, and the guide wire was advanced. The dilator was advanced over the wire. The triple lumen catheter was cannulated over the wire, and the wire then removed. No PVCs were encountered during the procedure. All three ports to the catheter aspirated and flushed blood easily, and they were all flushed with normal saline. The catheter was anchored to the chest wall with butterfly phalange using 3-0 silk suture. Betadine ointment and a sterile Op-Site dressing were applied. Stat upright chest x-ray was obtained at the completion of the procedure, and final results are pending.,FINDINGS/SPECIMENS REMOVED:, None,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS:, Nil.","surgery, respiratory failure, central line placement, chronic obstructive coronary disease, normal saline, subclavian, subclavian triple lumen central line placement, subclavian vein, triple lumen, triple lumen central line, lumen central line placement, central line, line placement, respiratory, xylocaine,"
 Insertion of central venous line and arterial line and transesophageal echocardiography probe., Surgery, Central Venous & Arterial  Line ,"INDICATIONS FOR PROCEDURES: , Impending open-heart surgery for atrial septectomy and bilateral bidirectional Glenn procedure.,The patient was already under general anesthesia in the operating room.  Antibiotic prophylaxis with cephazolin and gentamicin were already given.  A strict aseptic technique was used including use of gowns, mask, and gloves, etc.  The skin was cleansed with alcohol and then prepped with ChloraPrep solution.,PROCEDURE #1:,  Insertion of central venous line.,DESCRIPTION OF PROCEDURE #1: , Attention was directed to the right groin.  A Cook 4-French double-lumen 12-cm long central venous heparin-coated catheter kit was opened.  Using the 21-gauge needle that comes with this kit, the needle was inserted approximately 2 cm below the right inguinal ligament just medial to the pulsations of the femoral artery.  There was good venous blood return on the first try.  Using the Seldinger technique, the soft J-end of the wire was inserted through the needle without resistance approximately 15 cm.  It was then exchanged for a 5-French dilator followed by the 4-French double-lumen catheter and the wire was removed intact.  There was good blood return from both lumens, which were flushed with heparinized saline.  The catheter was sutured to the skin at three points with #4-0 silk for stabilization.,PROCEDURE #2:,  Insertion of arterial line.,DESCRIPTION OF PROCEDURE #2:,  Attention was directed to the left wrist, which was placed on wrist rest.  The Allen test was normal.  A Cook 2.5-French 5 cm long arterial catheter kit was opened.  A 22-gauge IV cannula was used to enter the artery, which was done on the first try with good pulsatile blood return.  Using the Seldinger technique, the catheter was exchanged for a 2.5-French catheter and the wire was removed intact.  There was pulsatile blood return and the catheter was flushed with heparinized saline solution.  It was sutured to the skin with #4-0 silk at three points for stabilization.,Both catheters functioned well throughout the procedure.  The distal circulation of the leg and the hand was intact immediately after insertion, approximately 20 minutes later, and at the end of the procedure.  There were no complications.,PROCEDURE #3: , Insertion of transesophageal echocardiography probe.,DESCRIPTION OF PROCEDURE #3: , The probe was inserted under direct vision because initially there was some resistance to insertion.  Under direct vision, using the #2 Miller blade, the upper esophageal opening was visualized and the probe was passed easily without resistance.  There was good visualization of the heart.  The probe was used by the pediatric cardiologist for preoperative and postoperative diagnostic echocardiography.  The probe was removed at the end.  There was no trauma and there was no blood tingeing.,","surgery, open-heart surgery, central venous line, arterial line, transesophageal echocardiography probe, glenn procedure, atrial septectomy, aseptic technique, pulsatile blood, central venous, blood return, arterial, central, probe, insertion, catheter"
 Central line insertion.  Empyema thoracis and need for intravenous antibiotics., Surgery, Central Line Insertion ,"PREOPERATIVE DIAGNOSES,1.  Empyema thoracis.,2.  Need for intravenous antibiotics.,POSTOPERATIVE DIAGNOSES,1.  Empyema thoracis.,2.  Need for intravenous antibiotics.,PROCEDURE:,  Central line insertion.,DESCRIPTION OF PROCEDURE: , With the patient in his room, after obtaining the informed consent, his left deltopectoral area was prepped and draped in the usual fashion.  Xylocaine 1% was infiltrated and with the patient in the Trendelenburg position, the left subclavian vein was subcutaneously cannulated without any difficulty.  The triple-lumen catheter was inserted and all ports were flushed out and were irrigated with normal saline.  The catheter was fixed to the skin with sutures.  The dressing was applied and then the chest x-ray was obtained which showed no complications of the procedure and good position of the catheter.","surgery, thoracis, intravenous, central line insertion, empyema, catheter, "
" Cauterization of epistaxis, left nasal septum.  Fiberoptic nasal laryngoscopy.  Atrophic dry nasal mucosa.  Epistaxis.  Atrophic laryngeal changes secondary to inhaled steroid use.", Surgery, Cauterization - Epistaxis ,"PREOPERATIVE DIAGNOSIS: , Epistaxis and chronic dysphonia.,POSTOPERATIVE DIAGNOSES:,1.  Atrophic dry nasal mucosa.,2.  Epistaxis.,3.  Atrophic laryngeal changes secondary to inhaled steroid use.,PROCEDURE PERFORMED:,1.  Cauterization of epistaxis, left nasal septum.,2.  Fiberoptic nasal laryngoscopy.,ANESTHESIA: , Neo-Synephrine with lidocaine nasal spray.,FINDINGS:,1.  Atrophic dry cracked nasal mucosa.,2.  Atrophic supraglottic and glottic changes likely secondary to inhaled steroids and recent endotracheal tube intubation.,INDICATIONS: , The patient is a 37-year-old African-American female who was admitted to ABCD General Hospital with a left wrist abscess.  The patient was taken to the operating room for incision and drainage.  Postoperatively, the patient was placed on nasal cannula oxygen and developed subsequent epistaxis.  Upon evaluating the patient, the patient complains of epistaxis from the left naris as well as some chronic dysphonia that had become exacerbated after surgery.  The patient does report of having endotracheal tube intubation during anesthesia.  The patient also gives a history of inhaled steroid use for her asthma.,The patient was extubated after surgery without difficulty, but continued to have some difficulty and the Department of Otolaryngology was asked to evaluate the patient regarding epistaxis and dysphonia.,PROCEDURE DETAILS:,  After the procedure was described, the patient was placed in the seated position.  The fiberoptic nasal laryngoscope was then inserted into the patient's left naris.  The nasal mucosal membranes were dry and atrophic throughout.  There was no evidence of any mass lesions.  The nasal laryngoscope was then advanced towards the posterior aspect of the nasal cavity.  There was no evidence of mass, ulceration, lesion, or obstruction.  The nasolaryngoscopy continued to be advanced into the oropharynx and the vallecula and the base of the tongue were evaluated and were without evidence of mass lesion or ulceration.,The fiberoptic scope was further advanced and visualization of the larynx revealed some atrophic, dry, supraglottic, and glottic changes.  There was no evidence of any local mass lesion, nodule, or ulcerations.  There was no evidence of any erythema.  Upon phonation, the vocal cords approximated completely and upon inspiration, the true vocal cords were abducted in a normal fashion and was symmetric.  The airway was stable and patent throughout the entire examination.  The nasal laryngoscope was then slowly withdrawn from the supraglottic region and the scope was further advanced into the oropharynx and nasopharynx.  The eustachian tube was completely visualized and was patent without obstruction.  The scope was then further removed without difficulty.  The patient tolerated the procedure well and remained in stable condition.,RECOMMENDATIONS AND PLAN: , The patient would benefit from Ocean nasal spray as well as bacitracin ointment applied to the anterior naris.  At this time, we were unable to discontinue the patient's inhaled steroids that she is using for her asthma.  If this becomes possible in the future, this may provide her some relief of her chronic dysphonia.  The patient is to follow up with Department of Otolaryngology after discharge from the hospital for further evaluation of these problems.","surgery, laryngeal, inhaled steroid use, dry nasal mucosa, fiberoptic nasal laryngoscopy, nasal mucosa, atrophic, cauterization, mucosa, supraglottic, laryngoscope, fiberoptic, dysphonia, lesions, epistaxis,"
" Ultrasound-guided placement of multilumen central venous line, left femoral vein.", Surgery, Catheter Placement ,"PROCEDURE PERFORMED: , Ultrasound-guided placement of multilumen central venous line, left femoral vein.,INDICATIONS:,  Need for venous access in a patient on a ventilator and on multiple IV drugs.,CONSENT: , Consent obtained from patient's sister.,PREOPERATIVE MEDICATIONS: , Local anesthesia with 1% plain lidocaine.,PROCEDURE IN DETAIL: , The ultrasound was used to localize the left femoral vein and to confirm it's patency and course.  The left inguinal area was then prepped and draped in a sterile manner.  The overlying soft tissues were anesthetized with 1% plain lidocaine.  Under direct ultrasound visualization, the femoral vein was cannulated without difficulty, and a guidewire advanced.  This was followed by a stab incision and the vein dilator in order to form a tract for the catheter itself.  Finally, the multilumen catheter itself was inserted over the guidewire.  Once the catheter was fully inserted, the guidewire was completely withdrawn.  Placement was confirmed by the withdrawal of dark venous blood from all ports; all ports were then flushed, the catheter sewn into place, and the dressing applied.  He tolerated the procedure very well, without complications.","surgery, plain lidocaine, femoral vein, ultrasound, venous, femoral, guidewire, placement, vein, catheter, access, "
" Temporal cheek-neck facelift  and submental suction assisted lipectomy to correct facial and neck skin ptosis and cheek, neck, and jowl lipotosis, and facial rhytides.", Surgery, Cheek-Neck Facelift ,"PREOPERATIVE DIAGNOSIS: , Facial and neck skin ptosis.  Cheek, neck, and jowl lipotosis. Facial rhytides.,POSTOPERATIVE DIAGNOSIS:,  Same.,PROCEDURE: , Temporal cheek-neck facelift (CPT 15825).  Submental suction assisted lipectomy (CPT 15876).,ANESTHESIA: , General.,DESCRIPTION OF PROCEDURE: , This patient is a 65-year-old female who has progressive aging changes of the face and neck.  The patient demonstrates the deformities described above and has requested surgical correction.  The procedure, risks, limitations, and alternatives in this individual case have been very carefully discussed with the patient.  The patient has consented to surgery.,The patient was brought into the operating room and placed in the supine position on the operating table.  An intravenous line was started and anesthesia was maintained throughout the case.  The patient was monitored for cardiac, blood pressure, and oxygen saturation continuously.,The hair was prepared and secured with rubber bands and micropore tape along the incision line.  A marking pen had been used to outline the area of the incisions, which included the preauricular area to the level of the tragus, the post-tragal region, the post auricular region and into the hairline.  In addition, the incision was marked in the temporal area in the event of a temporal lift, then across the coronal scalp for the forehead lift.  The incision was marked in the submental crease for the submental lipectomy and liposuction.  The incision in the post auricular area extended up on the posterior aspect of the ear and ended near the occipital hairline.,The areas to be operated on were injected with 1% Lidocaine containing 1:100,000 Epinephrine.  This provided local anesthesia and vasoconstriction.  The total of Lidocaine used throughout the procedure was maintained at no more than 500mg.,SUBMENTAL SUCTION ASSISTED LIPECTOMY: , The incision was made, as previously outlined, in the submental crease in a transverse direction, through the skin and subcutaneous tissue, and hemostasis was obtained with bipolar cautery.  A Metzenbaum scissors was used to elevate the area in the submental region for about 2 or 3cm and making radial tunnels from the angle of the mandible all the way to the next angle of the mandible.  4mm liopsuction cannula was then introduced along these previously outlined tunnels into the jowl on both sides and down top the anterior border of the sternocleidomastoid laterally and just past the thyroid notch interiorly.  The tunnels were enlarged with a 6mm flat liposuction cannula.,Then with the Wells-Johnson liposuction machine 27-29 inches of underwater mercury suction was accomplished in all tunnels.  Care was taken not to turn the opening of the suction cannula up to the dermis, but it was rotated in and out taking a symmetrical amount of fat from each area.  A similar procedure was performed with the 4 mm cannula cleaning the area.  Bilateral areas were palpated for symmetry, and any remaining fat was then suctioned directly.,A triangular wedge of anterior platysma border was cauterized and excised at the cervical mental angle.  A plication stitch of 3-0 Vicryl was placed.,When a satisfactory visible result had been accomplished from the liposuction, the inferior flap was then advanced over anteriorly and the overlying skin excised in an incremental fashion.  5-0 plain catgut was used for closure in a running interlocking fashion.  The wound was cleaned at the end, dried, and Mastisol applied.  Then tan micropore tape was placed for support to the entire area.,FACE LIFT: , After waiting approximately 10-15 minutes for adequate vasoconstriction the post auricular incision was started at the earlobe and continued up on the posterior aspect of the ear for approximately 2cm just superior to the external auditory canal.  A gentle curve was then made, and again the incision was carried down to and into the posterior hairline paralleling the hair follicles and directed posteriorly towards the occipital region.  A preauricular incision was carried into the natural crease superior to the tragus, curved posterior to the tragus bilaterally then brought out inferiorly in the natural crease between the lobule and preauricular skin.  The incision was made in the temporal area beveling parallel with the hair follicles.  (The incision had been designed with curve underneath the sideburn in order to maintain the sideburn hair locations and then curved posteriorly.),The plane of dissection in the hairbearing area was kept deep to the roots of the hair follicles and superficial to the fascia of the temporalis muscle and sternocleidomastoid.  The dissection over the temporalis muscle was continued anteriorly towards the anterior hairline and underneath the frontalis to the supraorbital rim.  At the superior level of the zygoma and at the level of the sideburn, dissection was brought more superficially in order to avoid the nerves and vessels in the areas, specifically the frontalis branch of the facial nerve.,The facial flaps were then elevated with both blunt and sharp dissection with the Kahn facelift dissecting scissors in the post auricular region to pass the angle of the mandible.  This area of undermining was connected with an area of undermining starting with the temporal region extending in the preauricular area of the cheek out to the jowl.  Great care was taken to direct the plane of dissecting superficial to the parotid fascia or SMAS.  The entire dissection was carried in a radial fashion from the ear for approximately 4cm at the lateral canthal area to 8-10cm in the neck region.  When the areas of dissection had been connected carefully, hemostasis was obtained and all areas inspected.  At no point were muscle fibers or major vessels or nerves encountered in the dissection.,The SMAS was sharply incised in a semilunar fashion in front of the ear and in front of the anterior border of the SCM.  The SMAS flap was then advanced posteriorly and superiorly.  The SMAS was split at the level of the earlobe, and the inferior portion was sutured to the mastoid periosteum.  The excess SMAS was trimmed and excised from the portion anterior to the auricle.  The SMAS was then imbricated with 2-0 Surgidak interrupted sutures.,The area was then inspected for any bleeding points and careful hemostasis obtained.  The flaps were then rotated and advanced posteriorly and then superiorly, and incremental cuts were made and the suspension points in the pre and post auricular area were done with 2-0 Tycron suture.  The excess and redundant amount of skin were then excised and trimmed cautiously so as not to cause any downward pull on the ear lobule or any stretching of the scars in the healing period.  Skin closure was accomplished in the hairbearing areas with 5-0 Nylon in the preauricular tuft and 4-0 Nylon interrupted in the post auricular area.  The pre auricular area was closed first with 5-0 Dexon at the ear lobules, and 6-0 Nylon at the lobules, and 5-0 plain catgut in a running interlocking fashion.  5-0 Plain catgut was used in the post auricular area as well, leaving ample room for serosanguinous drainage into the dressing.  The post tragal incisin was closed with interrupted and running interlocking 5-0 plain catgut.  The exact similar procedure was repeated on the left side.,At the end of this procedure, all flaps were inspected for adequate capillary filling or any evidence of hematoma formation.  Any small amount of fluid was expressed post-auricularly.  A fully perforated bulb suction drain was placed under the flap and exited posterior to the hairline on each side prior to the suture closure.  A Bacitracin impregnated nonstick dressing was cut to conform to the pre and post auricular area and placed over the incision lines.,ABD padding over 4X4 gauze was used to cover the pre and post auricular areas.  This was wrapped around the head in a vertical circumferential fashion and anchored with white micropore tape in a non-constricting but secured fashion.  The entire dressing complex was secured with a pre-formed elastic stretch wrap device.  All branches of the facial nerve were checked and appeared to be functioning normally.,The procedures were completed without complication and tolerated well.  The patient left the operating room in satisfactory condition.  A follow-up appointment was scheduled, routine post-op medications prescribed, and post-op instructions given to the responsible party.,The patient was released to home in satisfactory condition.","surgery, neck skin ptosis, lipotosis, rhytides, facelift, submental suction assisted lipectomy, pre and post auricular, cheek neck facelift, auricular region, neck facelift, cheek neck, post auricular, auricular, incision, postoperative, cheek, submental, dissection, neck, "
 Refractory priapism.  Cavernosaphenous shunt.   The patient presented with priapism x48 hours on this visit.  The patient underwent corporal aspiration and Winter's shunt both of which failed, Surgery, Cavernosaphenous Shunt - Priapism ,"PREOPERATIVE DIAGNOSIS:,  Refractory priapism.,POSTOPERATIVE DIAGNOSIS:,  Refractory priapism.,PROCEDURE PERFORMED: , Cavernosaphenous shunt.,ANESTHESIA:,  General.,ESTIMATED BLOOD LOSS:  ,400 cc.,FLUIDS: , IV fluids 1600 crystalloids, one liter packed red blood cells.,INDICATIONS FOR PROCEDURE:  ,This is a 34-year-old African-American male who is known to our service with a history of recurrent priapism.  The patient presented with priapism x48 hours on this visit.  The patient underwent corporal aspiration and Winter's shunt both of which failed and then subsequently underwent _______ procedure.  The patient's priapism did return following this and he was scheduled for cavernosaphenous shunt.,PROCEDURE:,  Informed written consent was obtained.  The patient was taken to the operative suite and administered anesthetic.  The patient was sterilely prepped and draped in the supine fashion.  A #15 French Foley catheter was inserted under sterile conditions.  Incision was made in the left base of the penile shaft on the lateral aspect, approximately 3 cm in length.  Tissue was dissected down to the level of the corpora cavernosum and corpora spongiosum.  The fascia was incised in elliptical fashion for approximately 2 cm.  A #14 gauge Angiocath was inserted into the corpora cavernosum to the glans of the penis and the corpora was irrigated copiously until all of the old clotted blood was removed and fresher irrigation was noted.,Attention was then turned to the left groin and the superficial saphenous vein was harvested.  Due to incisions brought up into the initial incision after gauging enough length, this was then spatulated with Potts scissors for approximately 2 cm.  Vein was irrigated.  One branching vessel was noted to be leaking, this was tied off and repeat injection with heparinized saline showed no additional leaks.  Tunnel was then created from the superior most groin region to the incision in the penile shaft.  Saphenous vein was then passed through this tunnel with the aid of a hemostat.  Anastomosis was performed using #5-0 Prolene suture in a running fashion from proximal to distal.  There were no leaks noted.  There was good flow noted within the saphenous vein graft.  Penis was noted to be in a flaccid state.  All incisions were irrigated copiously and closed in several layers.  Sterile dressings were applied.  The patient was cleaned, transferred to recovery room in stable condition.,PLAN:  ,We will continue with antibiotics for pain control, maintain Foley catheter.  Further recommendations to follow.","surgery, corporal aspiration, winter's shunt, foley catheter, corpora cavernosum, refractory priapism, saphenous vein, cavernosaphenous shunt, corporal, priapism, aspiration"
 Normal cataract surgery.  , Surgery, Cataract Surgery ,"NORMAL CATARACT SURGERY,PROCEDURE DETAILS: , The patient was taken to the operating room where the Rand-Stein anesthesia protocol was followed using alfentanil and Brevital.  Topical tetracaine drops were applied.  The operative eye was prepped and draped in the usual sterile fashion.  A lid speculum was inserted.,Under the Zeiss operating microscope, a lateral clear corneal approach was utilized.  A stab incision was made with a diamond blade to the right of the lateral limbus and the anterior chamber filled with intracameral lidocaine and viscoelastic.  A 3-mm single pass clear corneal incision was made just anterior to the vascular arcade of the temporal limbus using a diamond keratome.  A 5- to 5.5-mm anterior capsulorrhexis was created.  The nucleus was hydrodissected and hydrodelineated, and was freely movable in the capsular bag.  The nucleus was then phacoemulsified using a quadrantic divide-and-conquer technique.  Following the deep groove formation, the lens was split bimanually and the resultant quadrants and epicortex removed under high-vacuum burst-mode phacoemulsification.  Peripheral cortex was removed with the irrigation and aspiration handpiece.  The posterior capsule was polished.  The capsular bag was expanded with viscoelastic.  The implant was inspected under the microscope and found to be free of defects.  The implant was inserted into the cartridge system under viscoelastic and placed in the capsular bag.  The trailing haptic was positioned with the cartridge system.  Residual viscoelastic was removed from the anterior chamber and from behind the implant.  The corneal wound was hydrated with balanced salt solution.  The anterior chamber was fully re-formed through the side-port incision.  The wound was inspected and found to be watertight.  The intraocular pressure was adjusted as necessary.  The lid speculum was removed.  Topical Timoptic drops, Eserine and Dexacidin ointment were applied.  The eye was shielded.  The patient appeared to tolerate the procedure well and left the operating room in stable condition.  Followup appointment is with Dr. X on the first postoperative day.","surgery, zeiss, peripheral cortex, phacoemulsified, hydrodissected, rand-stein, lid speculum, anterior chamber, capsular bag, cataract, viscoelasticNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Extracapsular cataract extraction with phacoemulsification and implantation of a posterior chamber intraocular lens, left eye.", Surgery, Cataract Extraction - 2 ,"PREOPERATIVE DIAGNOSIS: , Cataract, left eye.,POSTOPERATIVE DIAGNOSIS:  ,Cataract, left eye.,PROCEDURE PERFORMED:  ,Extracapsular cataract extraction with phacoemulsification and implantation of a posterior chamber intraocular lens, left eye.,ANESTHESIA: , Topical.,COMPLICATIONS: , None.,PROCEDURE: , After the induction of topical anesthesia with 4% Xylocaine drops, the left eye was prepped and draped in the usual fashion.  A speculum was inserted, and the microscope was moved into position.,A 3.2-mm incision was made in clear cornea at the limbus with a diamond keratome at the 3 o'clock position, and 0.1 cc of 1% Xylocaine without preservative was instilled into the anterior chamber.  It was then filled with viscoelastic.  A stab incision was made into the anterior chamber at the limbus at 5 o'clock position with a microblade.,A cystitome was used to make a capsulotomy, and the capsulorrhexis forceps were used to complete a circular capsulorrhexis.  The nucleus was hydrodelineated and hydrodissected with balanced salt solution on a 26-gauge cannula, and the phacoemulsifier was used to phacoemulsify the nucleus using a bimanual technique with the nucleus rotator inserted through the keratotomy incision.  The irrigation-aspiration handpiece was used to systematically aspirate cortex 360 degrees.  The posterior capsule was vacuumed; it was clear and intact.,The capsular bag and the anterior chamber were filled with viscoelastic.  A model MA30AC lens, power 21.5 diopters, serial number 864414.095, was folded, grasped with the lens insertion forceps and inserted into the capsular bag.  The trailing loop was placed inside the bag.  The viscoelastic was removed with the irrigation-aspiration handpiece.  The lens centered well.  A single 10-0 nylon suture was placed to close the wound.  It was checked and ascertained to be watertight.  Decadron 0.25 cc, 0.25 cc of antibiotic and 0.25 cc of Xylocaine were injected subconjunctivally.  Dexacidin ointment was placed in the eye, and the procedure was terminated.,The procedure was well tolerated by the patient who was returned to the recovery room in good condition.","surgery, anterior chamber, keratome, limbus, intraocular lens, cataract extraction, extracapsular, phacoemulsification, capsular, cataract, chamber, intraocular,"
" Cataract to right eye.  Cataract extraction with intraocular lens implant of the right eye, anterior vitrectomy of the right eye.", Surgery, Cataract Extraction & Vitrectomy ,"PREOPERATIVE DIAGNOSIS: , Cataract to right eye.,POSTOPERATIVE DIAGNOSIS: , Cataract to right eye.,PROCEDURE PERFORMED:  ,Cataract extraction with intraocular lens implant of the right eye, anterior vitrectomy of the right eye.,LENS IMPLANT USED:  ,See below.,COMPLICATIONS: , Posterior capsular hole, vitreous prolapse.,ANESTHESIA:  ,Topical.,PROCEDURE IN DETAIL:  ,The patient was identified in the preoperative holding area before being escorted back to the operating room suite.  Hemodynamic monitoring was begun.  Time-out was called and the patient eye operated upon and lens implant intended were verbally verified.  Three drops of tetracaine were applied to the operative eye.  The patient was then prepped and draped in usual sterile fashion for intraocular surgery.  A lid speculum was placed.  Two paracentesis sites were created approximately 120 degrees apart straddling the temple using a slit knife.  The anterior chamber was irrigated with a dilute 0.25% solution of non-preserved lidocaine and filled with Viscoat.  The clear corneal temporal incision was fashioned.  The anterior chamber was entered by introducing a keratome.  The continuous tear capsulorrhexis was performed using the bent needle cystotome and completed with Utrata forceps.  The cataractous lens was then hydrodissected and phacoemulsified using a modified phaco-chop technique.  Following removal of the last nuclear quadrant, there was noted to be a posterior capsular hole nasally.  This area was tamponaded with Healon.  The anterior chamber was swept with a cyclodialysis spatula and there was noted to be vitreous prolapse.  An anterior vitrectomy was then performed bimanually until the vitreous was cleared from the anterior chamber area.  The sulcus area of the lens was then inflated using Healon and a V9002 16.0 diopter intraocular lens was unfolded and centered in the sulcus area with haptic secured in the sulcus.  There was noted to be good support.  Miostat was injected into the anterior chamber and viscoelastic agent rinsed out of the eye with Miostat.  Gentle bimanual irrigation, aspiration was performed to remove remaining viscoelastic agents anteriorly.  The pupil was noted to constrict symmetrically.  Wounds were checked with Weck-cels and found to be free of vitreous.  BSS was used to re-inflate the anterior chamber to normal depth as confirmed by tactile pressure at about 12.  All corneal wounds were then hydrated, checked and found to be watertight and free of vitreous.  A single 10-0 nylon suture was placed temporarily as prophylaxis and the knot buried.  Lid speculum was removed.  TobraDex ointment, light patch and a Soft Shield were applied.  The patient was taken to the recovery room, awake and comfortable.  We will follow up in the morning for postoperative check.  He will not be given Diamox due to his sulfa allergy.  The intraoperative course was discussed with both he and his wife.","surgery, intraocular lens implant, lid speculum, cataract extraction, anterior vitrectomy, anterior chamber, eye, intraocular, extraction, hemodynamic, implant, vitrectomy, vitreous, cataract, lens,"
 Right carpal tunnel release and right index and middle fingers release A1 pulley.  Right carpal tunnel syndrome and right index finger and middle fingers tenosynovitis., Surgery, Carpal Tunnel Release - 8 ,"PREOPERATIVE DIAGNOSES:,1.  Right carpal tunnel syndrome.,2.  Right index finger and middle fingers tenosynovitis.,POSTOPERATIVE DIAGNOSES:,1.  Right carpal tunnel syndrome.,2.  Right index finger and middle fingers tenosynovitis.,PROCEDURES PERFORMED:,1.  Right carpal tunnel release.,2.  Right index and middle fingers release A1 pulley.,TOURNIQUET TIME:  ,70 minutes.,BLOOD LOSS: , Minimal.,GROSS INTRAOPERATIVE FINDINGS:,1.  A compressed median nerve at the carpal tunnel, which was flattened.,2.  A stenosing tenosynovitis of the A1 pulley of the right index as well as middle fingers.  After the A1 pulley was released, there was evidence of some synovitis as well as some fraying of the flexor digitorum profundus as well as flexor digitorum superficialis tendons.,HISTORY:  ,This is a 78-year-old male who is complaining of right hand pain and numbness with decreased range of the middle index finger and right middle finger complaining of catching and locking.  The patient was diagnosed with carpal tunnel syndrome on bilateral hands the right being worse than the left.  He had positive EMG findings as well as clinical findings.  The patient did undergo an injection, which only provided him with temporary relief and is for this reason, he has consented to undergo the above-named procedure.,All risks as well as complications were discussed with the patient and consent was obtained.,PROCEDURE:  ,The patient was wheeled back to the operating room #1 at ABCD General Hospital on 08/29/03.  He was placed supine on the operating room table.  Next, a non-sterile tourniquet was placed on the right forearm, but not inflated.  At this time, 8 cc of 0.25% Marcaine with epinephrine was instilled into the carpal tunnel region of the volar aspect of the wrist for anesthesia.  In addition, an additional 2 cc were used on the superficial skin of the volar palm over the A1 pulley of the right index and right middle fingers.  At this time, the extremity was then prepped and draped in usual sterile fashion for this procedure.  First, we went for release of the carpal tunnel.  Approximately 2.5 cm incision was made over the volar aspect of the wrist over the carpal tunnel region.  First, dissection through the skin in the superficial fascia was performed with a self-retractor placed in addition to Ragnells retracting proximally and distally.  The palmaris brevis muscle was then identified and sharply transected.  At this time, we identified the transverse carpal tunnel ligament and a #15 blade was used to sharply and carefully release that fascia.  Once the fascia of the transverse carpal ligament was transected, the identification of the median nerve was visualized.  The resection of the ligament was taken both proximally and distally to assure complete release and it was checked thoroughly.  At this time, a neurolysis was performed and no evidence of space-occupying lesions were identified within the carpal tunnel.  At this time, copious irrigation was used to irrigate the wound.  The wound was suctioned dry.  At this time, we proceeded to the release of the A1 pulleys.  Approximately, a 1.5 cm incision was made over the A1 pulley in the volar aspect of the palm of the right index and right middle fingers.  First, we went for the index finger.  Once the skin incision was made, Metzenbaum scissor was used to longitudinally dissect the subcutaneous tissue and with Ragnell retractors we identified the A1 pulley.  A #15 blade was used to make a longitudinal slit along with A1 pulley and the Littler scissors were used to release the A1 pulley proximally as well as distally.  Once this was performed, a tendon hook was then used to wrap the tendon and release the tendons both proximally and distally and they were removed from the wound in order to check their integrity.  There was some evidence of synovitis in addition to some fraying of the both the profundus as well as superficialis tendons.  Once a thorough release was performed, copious irrigation was used to irrigate that wound.  In the similar fashion, a 1.5 cm incision was made over the volar aspect of the A1 pulley of the right middle finger.  A Littler scissor was used to bluntly dissect in the longitudinal fashion.  With the Ragnell retractors, we identified the A1 pulley of the right middle finger.,Using a #15 blade, the A1 pulley was scored with the #15 blade and the Litter scissor was used to complete the release of the A1 pulley distally and proximally.  We again placed the tendon hook around both the superficialis and the profundus tendons and they were extruded from the wound to check their integrity.  Again, there was evidence of some synovitis as well as fraying of both tendons.  The girth of both tendons and both wounds were within normal limits.  At this time, copious irrigation was used to irrigate the wound.  The patient was then asked to intraoperatively flex and extend his fingers and he was able to fully flex his fingers to make a close fit which he was not able to do preoperatively.  In addition, he was able to abduct his thumb indicating that the recurrent branch of the median nerve was intact.  At this time, #5-0 nylon was used to approximate in a vertical mattress type fashion both the carpal tunnel incision as well as the both A1 pulley incisions of the right middle finger and right index finger.  The wound closure took place after the tourniquet was released and hemostasis was obtained with Bovie cautery.  At this time, a short-arm splint was placed on the volar aspect of the wrist after it was wrapped in a sterile dressing consisting of Adaptic and Kerlix roll.  The patient was then carefully taken off of the operating room table to Recovery in stable condition.","surgery, compressed median nerve, stenosing tenosynovitis, carpal tunnel release, carpal tunnel syndrome, middle fingers, carpal tunnel, littler scissors, median nerve, copious irrigation, volar aspect, tunnel, pulley, carpal, fingers, index, tourniquet, ligament, tenosynovitis, superficialis, tendons,"
 Left knee arthroscopy with removal of the cartilage loose body and microfracture of the medial femoral condyle with chondroplasty., Surgery, Cartilage Loose Body Removal ,"PREOPERATIVE DIAGNOSIS: , Left knee medial femoral condyle osteochondritis dissecans.,POSTOPERATIVE DIAGNOSIS: , Left knee medial femoral condyle osteochondritis dissecans.,PROCEDURES:,  Left knee arthroscopy with removal of the cartilage loose body and microfracture of the medial femoral condyle with chondroplasty.,ANESTHESIA: , General.,TOURNIQUET TIME:  ,Thirty-seven minutes.,MEDICATIONS: , The patient also received 30 mL of 0.5% Marcaine local anesthetic at the end of the case.,COMPLICATIONS: , No intraoperative complications.,DRAINS AND SPECIMENS: , None.,INTRAOPERATIVE FINDINGS: , The patient had a loose body that was found in the suprapatellar pouch upon entry of the camera.  This loose body was then subsequently removed.  It measured 24 x 14 mm.  This was actually the OCD lesion seen on the MRI that had come from the weightbearing surface of just the lateral posterior aspect of the medial femoral condyle,HISTORY AND PHYSICAL: , The patient is 13-year-old male with persistent left knee pain.  He was initially seen at Sierra Pacific Orthopedic Group where an MRI demonstrated unstable OCD lesion of the left knee.  The patient presented here for a second opinion.  Surgery was recommended grossly due to the instability of the fragment.  Risks and benefits of surgery were discussed.  The risks of surgery include risk of anesthesia, infection, bleeding, changes in sensation and motion extremity, failure to relieve pain or restore the articular cartilage, possible need for other surgical procedures, and possible early arthritis.  All questions were answered and parents agreed to the above plan.,DESCRIPTION OF PROCEDURE:  ,The patient was taken to the operating room and placed supine on the operating table.  General anesthesia was then administered.  The patient received Ancef preoperatively.  A nonsterile tourniquet was placed on the upper aspect of the patient's left thigh.  The extremity was then prepped and draped in standard surgical fashion.  The standard portals were marked on the skin.  The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg.  The portal incisions were then made by an #11 blade.  Camera was inserted into the lateral joint line.  There was a noted large cartilage loose body in the suprapatellar pouch.  This was subsequently removed with extension of the anterolateral portal.  Visualization of the rest of the knee revealed significant synovitis.  The patient had a large cartilage defect in the posterolateral aspect of the medial femoral condyle.  The remainder of the knee demonstrated no other significant cartilage lesions, loose bodies, plica or meniscal pathology.  ACL was also visualized to be intact in the intracondylar notch.,Attention was then turned back to the large defect.  The loose cartilage was debrided using a shaver.  Microfracture technique was then performed to 4 mm depth at 2 to 3 mm distances.  Tourniquet was released at the end of the case to ensure that there was fat and bleeding at the microfracture sites.  All instruments were then removed.  The portals were closed using #4-0 Monocryl.  A total of 30 mL of 0.5% Marcaine was injected into the knee.  Wounds were then cleaned and dried, and dressed in Steri-Strips, Xeroform, 4 x 4s, and bias.  The patient was then placed in a knee immobilizer.  The patient tolerated the procedure well.  The tourniquet was released at 37 minutes.  He was taken to recovery in stable condition.,POSTOPERATIVE PLAN: , The loose cartilage fragment was given to the family.  The intraoperative findings were relayed with intraoperative photos.  There was a large deficit in the weightbearing portion of medial femoral condyle.  His prognosis is guarded given the fact of the fragile lesion and location, but in advantages of his age and his rehab potential down the road, if the patient still has symptoms, he may be a candidate for osteochondral autograft, a procedure which is not performed at Children's or possible cartilaginous transplant.  All questions were answered.  The patient will follow up in 10 days, may wet the wound in 5 days.","surgery, knee arthroscopy, chondroplasty, medial femoral condyle, cartilage loose body, loose cartilage, knee, arthroscopy, tourniquet, microfracture, orthopedic, femoral, cartilage, "
 Extracapsular cataract extraction with posterior chamber intraocular lens placement by phacoemulsification.  A peribulbar block was given to the eye using 8 cc of a mixture of 0.5% Marcaine without epinephrine mixed with Wydase plus one-half of 2% lidocaine without epinephrine., Surgery, Cataract Extraction - 1 ,"PROCEDURE PERFORMED: , Extracapsular cataract extraction with posterior chamber intraocular lens placement by phacoemulsification.,ANESTHESIA:,  Peribulbar.,COMPLICATIONS:,  None.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room after the eye was dilated with topical Mydriacyl and Neo-Synephrine drops.  A Honan balloon was placed over the eye for a period of 20 minutes at 10 mmHg.  A peribulbar block was given to the eye using 8 cc of a mixture of 0.5% Marcaine without epinephrine mixed with Wydase plus one-half of 2% lidocaine without epinephrine.  The Honan balloon was then re-placed over the eye for an additional 10 minutes at 20 mmHg.  The eye was prepped with a Betadine solution and draped in the usual sterile fashion.  A wire speculum was placed in the eye and then a clear corneal paracentesis site was made inferiorly with a 15-degree blade, followed by instillation of 0.1 cc of preservative-free lidocaine 1% into the anterior chamber, followed by viscoelastic.  A 2.8-mm keratome was used to create a self-sealing temporal corneal incision and then a bent capsulotomy needle was used to create an anterior capsular flap.  The Utrata forceps were used to complete a continuous tear capsulorrhexis, and hydrodissection and hydrodelineation of the nucleus was performed with BSS on a cannula.  Phacoemulsification in a quartering-and-cracking technique was used to remove the nucleus and then the residual cortex was removed with the irrigation and aspiration unit.  Gentle vacuuming of the central posterior capsule was performed.  The capsular bag was re-expanded with viscoelastic, and then the wound was opened to a 3.4-mm size with an additional keratome to allow insertion of the intraocular lens.,The intraocular lens was folded, inserted into the capsular bag and then un-folded.  The trailing haptic was tucked underneath the anterior capsular rim.  The lens was shown to center very well.  Therefore, the viscoelastic was removed with the irrigation and aspiration unit and one 10-0 nylon suture was placed across the incision after Miochol was injected into the anterior chamber to cause pupillary constriction.  The wound was shown to be watertight.  Therefore, TobraDex ointment was applied to the eye, an eye pad loosely applied and a Fox shield taped firmly in place.,The patient tolerated the procedure well and left the operating room in good condition.","surgery, phacoemulsification, hydrodissection, peribulbar block, irrigation and aspiration, honan balloon, anterior chamber, anterior capsular, aspiration unit, capsular bag, cataract extraction, intraocular lens, cataract, extraction, peribulbar, lidocaine, viscoelastic, chamber, epinephrine, anterior, capsular, lens, intraocular, eye, "
" Cataract extraction with lens implantation, right eye.  The lens was inspected and found to be free of defects, folded, and easily inserted into the capsular bag, and unfolded.", Surgery, Cataract Extraction ,"PROCEDURE PERFORMED:,  Cataract extraction with lens implantation, right eye.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room.  The patient was identified and the correct operative site was also identified.  A retrobulbar block using 5 ml of 2% lidocaine without epinephrine was done after adequate anesthetic was assured, and the eye was massaged to reduce risk of bleeding.  The patient was prepped and draped in the usual fashion.  A lid speculum was applied.,A groove incision at the 12 o'clock position was made with a 5700 blade.  This was beveled anteriorly in a lamellar fashion using the crescent knife.  Then the anterior chamber was entered with a slit knife.  The chamber was deepened with Viscoat.  Then a paracentesis at the 3 o'clock position was created using a super sharp blade.  A cystitome was used to nick the anterior capsule and then the capsulotomy was completed with capsulorrhexis forceps.  Hydrodissection was employed using BSS on a blunt 27-gauge needle.,The phaco tip was then introduced into the eye, and the eye was divided into 4 grooves.  Then a second instrument was used, a Sinskey hook, to crack these grooves, and the individual quadrants were brought into the central zone and phacoemulsified.  I/A proceeded without difficulty using the irrigation/aspiration cannula.  The capsule was felt to be clear and intact.  The capsular bag was then expanded with ProVisc.,The internal corneal wound was increased using the slit knife.  The lens was inspected and found to be free of defects, folded, and easily inserted into the capsular bag, and unfolded.  A corneal light shield was then used as the wound was sutured with a figure-of-eight 10-0 nylon suture.  Then the Viscoat was removed using I/A, and the suture drawn up and tied.,The 0.2 ml of gentamicin was injected subconjunctivally.  Maxitrol ointment was instilled into the conjunctival sac.  The eye was covered with a double patch and shield, and the patient was discharged.","surgery, lens implantation, anterior chamber, lid speculum, eye, sinskey hook, cataract extraction, capsular bag, cataract, capsular, knife, lens"
 Left carpal tunnel release.  Left carpal tunnel syndrome.  Severe compression of the median nerve on the left at the wrist., Surgery, Carpal Tunnel Release - 6 ,"PREOPERATIVE DIAGNOSIS: , Left carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:,  Left carpal tunnel syndrome.,OPERATIVE PROCEDURE PERFORMED:,  Left carpal tunnel release.,FINDINGS:,  Showed severe compression of the median nerve on the left at the wrist.,SPECIMENS:  ,None.,FLUIDS:,  500 mL of crystalloids.,URINE OUTPUT:,  No Foley catheter.,COMPLICATIONS: , None.,ANESTHESIA: , General through a laryngeal mask.,ESTIMATED BLOOD LOSS: , None.,CONDITION: , Resuscitated with stable vital signs.,INDICATION FOR THE OPERATION: , This is a case of a very pleasant 65-year-old forensic pathologist who I previously had performed initially a discectomy and removal of infection at 6-7, followed by anterior cervical discectomy with anterior interbody fusion at C5-6 and C6-7 with spinal instrumentation.  At the time of initial consultation, the patient was also found to have bilateral carpal tunnel and for which we are addressing the left side now.  Operation, expected outcome, risks, and benefits were discussed with him for most of the risk would be that of infection because of the patient's diabetes and a previous history of infection in the form of pneumonia.  There is also the possibility of bleeding as well as the possibility of injury to the median nerve on dissection.  He understood this risk and agreed to have the procedure performed.,DESCRIPTION OF THE PROCEDURE: , The patient was brought to the operating room, awake, alert, not in any form of distress.  After smooth induction of anesthesia and placement of a laryngeal mask, he remained supine on the operating table.  The left upper extremity was then prepped with Betadine soap and antiseptic solution.  After sterile drapes were laid out, an incision was made following inflation of blood pressure cuff to 250 mmHg.  Clamp time approximately 30 minutes.  An incision was then made right in the mid palm area between the thenar and hypothenar eminence.  Meticulous hemostasis of any bleeders were done.  The fat was identified.  The palmar aponeurosis was identified and cut and this was traced down to the wrist.  There was severe compression of the median nerve.  Additional removal of the aponeurosis was performed to allow for further decompression.  After this was all completed, the area was irrigated with saline and bacitracin solution and closed as a single layer using Prolene 4-0 as interrupted vertical mattress stitches.  Dressing was applied.  The patient was brought to the recovery.","surgery, compression, wrist, carpal tunnel release, carpal tunnel syndrome, median nerve, tunnel, carpal, "
" Carpal tunnel syndrome.  Open carpal tunnel release.  A longitudinal incision was made in line with the 4th ray.  The dissection was carried down to the superficial aponeurosis, which was cut.  The distal edge of the transverse carpal ligament was identified with a hemostat. ", Surgery, Carpal Tunnel Release - Open ,"PREOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome.,TITLE OF PROCEDURE:  ,Open carpal tunnel release.,COMPLICATIONS:  ,None.,PROCEDURE IN DETAIL:  ,After administering appropriate antibiotics and general anesthesia the Left upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A longitudinal incision was made in line with the 4th ray.  The dissection was carried down to the superficial aponeurosis, which was cut.  The distal edge of the transverse carpal ligament was identified with a hemostat.  The hemostat was gently placed under the transverse carpal ligament to protect the contents of the carpal tunnel, and the ligament was cut on its ulnar side with a knife directly onto the hemostat.  The antebrachial fascia was cut proximally under direct vision with scissors.,After irrigating the wound with copious amounts of normal saline, the skin was repaired with 4-0 nylon interrupted stitches.,Marcaine with epinephrine was injected into the wound, which was then dressed and splinted.  The patient was sent to the recovery room in good condition, having tolerated the procedure well.","surgery, carpal ligament, carpal tunnel release, carpal tunnel syndrome, transverse carpal ligament, transverse, ligament, hemostat, tunnel, incision "
 Right carpal tunnel release.  Right carpal tunnel syndrome.  This is a 54-year-old female who was complaining of right hand numbness and tingling of the median distribution and has elected to undergo carpal tunnel surgery secondary to failure of conservative management., Surgery, Carpal Tunnel Release - 9 ,"PREOPERATIVE DIAGNOSIS:,  Right carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:, Right carpal tunnel syndrome.,PROCEDURE:,  Right carpal tunnel release.,ANESTHESIA:,  Bier block to the right hand.,TOTAL TOURNIQUET TIME: , 20 minutes.,COMPLICATIONS: , None.,DISPOSITION: , Stable to PACU.,ESTIMATED BLOOD LOSS: , Less than 10 cc.,GROSS OPERATIVE FINDINGS:,  We did find a compressed right median nerve upon entering the carpal tunnel, otherwise, the structures of the carpal canal are otherwise unremarkable.  No evidence of tumor was found.,BRIEF HISTORY OF PRESENT ILLNESS:  ,This is a 54-year-old female who was complaining of right hand numbness and tingling of the median distribution and has elected to undergo carpal tunnel surgery secondary to failure of conservative management.,PROCEDURE: , The patient was taken to the operative room and placed in the supine position.  The patient underwent a Bier block by the Department of Anesthesia on the upper extremity.  The upper extremity was prepped and draped in usual sterile fashion and left free.  Attention was drawn then to the palm of the hand.  We did identify area of incision that we would make, which was located over the carpal tunnel.,Approximately, 1.5 cm incision was made using a #10 blade scalpel.  Dissection was carried through the skin and fascia over the palm down to the carpal tunnel taking care during dissection to avoid any branches of nerves.  Carpal tunnel was then entered and the rest of the transverse carpal ligament was incised sharply with a #10 scalpel.  We inspected the median nerve and found that it was flat and compressed from the transverse carpal ligament.  We found no evidence of tumor or space occupying lesion in the carpal tunnel.  We then irrigated copiously.  Tourniquet was taken down at that time and pressure was held.  There was no evidence of obvious bleeders.  We approximated the skin with nylon and placed a postoperative dressing with a volar splint.  The patient tolerated the procedure well.  She was placed back in the gurney and taken to PACU.","surgery, carpal tunnel release, carpal tunnel syndrome, median nerve, bier block, carpal ligament, tunnel, carpal, transverse, median, "
  Right carpal tunnel syndrome.  Right carpal tunnel release., Surgery, Carpal Tunnel Release - 7 ,"PREOPERATIVE DIAGNOSIS: , Right carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:,  Right carpal tunnel syndrome.,PROCEDURE PERFORMED: , Right carpal tunnel release.,PROCEDURE NOTE:  ,The right upper extremity was prepped and draped in the usual fashion.  IV sedation was supplied by the anesthesiologist.  A local block using 6 cc of 0.5% Marcaine was used at the transverse wrist crease using a 25 gauge needle, superficial to the transverse carpal ligament.,The upper extremity was exsanguinated with a 6 inch ace wrap.,Tourniquet time was less than 10 minutes at 250 mmHg.,An incision was used in line with the third web space just to the ulnar side of the thenar crease.  It was carried sharply down to the transverse wrist crease.  The transverse carpal ligament was identified and released under direct vision.  Proximal to the transverse wrist crease it was released subcutaneously.  During the entire procedure care was taken to avoid injury to the median nerve proper, the recurrent median, the palmar cutaneous branch, the ulnar neurovascular bundle and the superficial palmar arch.  The nerve appeared to be mildly constricted.  Closure was routine with running 5-0 nylon.  A bulky hand dressing as well as a volar splint was applied and the patient was sent to the outpatient surgery area in good condition.","surgery, superficial palmar arch, carpal tunnel release, carpal tunnel syndrome, transverse wrist crease, superficial, ligament, "
" Right open carpal tunnel release and cortisone injection, left carpal tunnel.", Surgery, Carpal Tunnel Release - 4 ,"PREOPERATIVE DIAGNOSIS:  ,Bilateral carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Bilateral carpal tunnel syndrome.,PROCEDURES:,1.  Right open carpal tunnel release.,2.  Cortisone injection, left carpal tunnel.,ANESTHESIA: , General LMA.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS:,  None.,INDICATIONS:,  This patient is a 50-year-old male with bilateral carpal tunnel syndrome, which is measured out as severe.  He is scheduled for the above-mentioned procedures.  The planned procedures were discussed with the patient including the associated risks.  The risks included but are not limited to bleeding, infection, nerve damage, failure to heal, possible need for reoperation, possible recurrence, or any associated risk of the anesthesia.  He voiced understanding and agreed to proceed as planned.,DESCRIPTION OF PROCEDURE: , The patient was identified in the holding area and correct operative site was identified by the surgeon's mark.  Informed consent was obtained.  The patient was then brought to the operating room and transferred to the operating table in supine position.  Time-out was then performed at which point the surgeon, nursing staff, and anesthesia staff all confirmed the correct identification.,After adequate general LMA anesthesia was obtained, a well-padded tourniquet was placed on the patient's right upper arm.  The right upper extremity was then prepped and draped in the usual sterile fashion.  Planned skin incision was marked along the base of the patient's right palm.  Right upper extremity was then exsanguinated using Esmarch.  The tourniquet was then inflated to 250 mmHg.  Skin incision was then made and dissection was carried down with scalpel to the level of the palmar fascia which was sharply divided by the skin incision.  Bleeding points were identified with electrocautery using bipolar electrocautery.  Retractors were then placed to allow visualization of the distal extent of the transverse carpal ligament, and this was then divided longitudinally under direct vision.  Baby Metzenbaum scissors were used to dissect distal to this area to confirm the absence of any remaining crossing obstructing fibrous band.  Retractors were then replaced proximally to allow visualization of proximal extent of the transverse carpal ligament and the release was continued proximally until complete release was performed.  This was confirmed by visually and palpably.  Next, baby Metzenbaum scissors were used to dissect anteroposterior adjacent antebrachial fascia, and this was divided longitudinally under direct vision using baby Metzenbaum scissors to a level of approximately 3 cm proximal to the proximal extent of the skin incision.  Carpal canal was then inspected.  The median nerve was flattened and injected.  No other abnormalities were noted.  Wounds were then irrigated with normal saline and antibiotic additive.  Decadron 4 mg was then placed adjacent to the median nerve.  Skin incision was then closed with interrupted 5-0 nylon suture.  The wound was then dressed with Adaptic, 4 x 4s, Kling, and Coban.  The tourniquet was then deflated.  Attention was then directed to the left side.  Using sterile technique, the left carpal canal was injected with a mixture of 40 mg of Depo-Medrol, 1 cc of 1% lidocaine, and 1 cc of 0.25% Marcaine.  Band-Aid was then placed over the injection site.  The patient was then awakened, extubated, and transferred over to his hospital bed.  He was transported to recovery room in stable condition.  There were no intraoperative or immediate postoperative complications.  All counts were reported as correct.","surgery, carpal tunnel syndrome, 4 x 4s, adaptic, carpal canal, coban, cortisone injection, esmarch, kling, metzenbaum, carpal tunnel release, electrocautery, fibrous band, palmar fascia, tourniquet, transverse carpal ligament, bilateral carpal tunnel, baby metzenbaum scissors, carpal ligament, bilateral carpal, metzenbaum scissors, carpal tunnel, carpal, tunnel,"
 Bilateral open carpal tunnel release., Surgery, Carpal Tunnel Release - 5 ,"PREOPERATIVE DIAGNOSIS:  ,Carpal tunnel syndrome, bilateral.,POSTOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome, bilateral.,ANESTHESIA:,  General,NAME OF OPERATION: , Bilateral open carpal tunnel release.,FINDINGS AT OPERATION: , The patient had identical, very thick, transverse carpal ligaments, with dull synovium.,PROCEDURE:  ,Under satisfactory anesthesia, the patient was prepped and draped in a routine manner on both upper extremities.  The right upper extremity was exsanguinated, and the tourniquet inflated.  A curved incision was made at the the ulnar base, carried through the subcutaneous tissue and superficial fascia, down to the transverse carpal ligament.  This was divided under direct vision along its ulnar border, and wound closed with interrupted nylon.  The wound was injected, and a dry, sterile dressing was applied.  An identical procedure was done to the opposite side.  The patient left the operating room in satisfactory condition.","surgery, bilateral open carpal tunnel, carpal tunnel syndrome, carpal tunnel release, carpal tunnel, release, tourniquet, bilateral, tunnel, carpal"
" Carpal tunnel syndrome.  Endoscopic carpal tunnel release.  After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion, the arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.", Surgery, Carpal Tunnel Release - Endoscopic ,"PREOPERATIVE DIAGNOSIS:,  Carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome.,TITLE OF PROCEDURE: , Endoscopic carpal tunnel release.,ANESTHESIA: , MAC,PROCEDURE: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion, the arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,I made a transverse incision one fingerbreadth proximal to the distal volar wrist crease.  Dissection was carried down to the antebrachial fascia, which was cut in a distally based fashion.  Bipolar electrocautery was used to maintain meticulous hemostasis.  I then performed an antebrachial fasciotomy proximally.  I entered the extra bursal space deep into the transverse carpal ligament and used the spatula probe and then the dilators and then the square probe to enlarge the area.  Great care was taken to feel the washboard undersurface of the transverse carpal ligament and the hamate on the ulnar side.  Great care was taken with placement.  A good plane was positively identified.  I then placed the endoscope in and definitely saw the transverse striations of the deep surface of the transverse carpal ligament.,Again, I felt the hook of the hamate ulnar to me.  I had my thumb on the distal aspect of the transverse carpal ligament.  I then partially deployed the blade, and starting 1 mm from the distal edge, the transverse carpal ligament was positively identified.  I pulled back and cut and partially tightened the transverse carpal ligament.  I then feathered through the distal ligament and performed a full-thickness incision through the distal half of the ligament.  I then checked to make sure this was properly performed and then cut the proximal aspect.  I then entered the carpal tunnel again and saw that the release was complete, meaning that the cut surfaces of the transverse carpal ligament were separated; and with the scope rotated, I could see only one in the field at a time.  Great care was taken and at no point was there any longitudinal structure cut.  Under direct vision through the incision, I made sure that the distal antebrachial fascia was cut.  Following this, I irrigated and closed the skin.  The patient was dressed and sent to the recovery room in good condition.","surgery, endoscopic, carpal tunnel syndrome, carpal tunnel release, carpal ligament, tourniquet, carpal, esmarch, tunnel, transverse, ligament"
" Left carpal tunnel release, left ulnar nerve anterior submuscular transposition at the elbow, lengthening of the flexor pronator muscle mass in the proximal forearm to accommodate the submuscular position of the ulnar nerve.", Surgery, Carpal Tunnel Release - 3 ,"PREOPERATIVE DIAGNOSES:,1.  Left carpal tunnel syndrome (354.0).,2.  Left ulnar nerve entrapment at the elbow (354.2).,POSTOPERATIVE DIAGNOSES:,1.  Left carpal tunnel syndrome (354.0).,2.  Left ulnar nerve entrapment at the elbow (354.2).,OPERATIONS PERFORMED:,1.  Left carpal tunnel release (64721).,2.  Left ulnar nerve anterior submuscular transposition at the elbow (64718).,3.  Lengthening of the flexor pronator muscle mass in the proximal forearm to accommodate the submuscular position of the ulnar nerve (25280).,ANESTHESIA: , General anesthesia with intubation.,INDICATIONS OF PROCEDURE: , This patient is insulin-dependant diabetic.  He is also has end-stage renal failure and has chronic hemodialysis.  Additionally, the patient has had prior heart transplantation.  He has been evaluated for ischemic problems to both lower extremities and also potentially to the left upper extremity.  However, it is our contention that this patient's prime problem of the left upper extremity is probably neuropathic ulcers from total lack of sensation along the ulnar border of the left little finger.  These started initially as unrecognized paper cuts.  Additionally, the patient appears to have a neurogenic pain affecting predominantly the areas innovated by the median nerve, but also to the little finger.  Finally, this patient does indeed have occlusive arterial disease to the left upper extremity in that he has a short segment radial artery occlusion and he does appear to have a narrowed segment in the ulnar artery, but the arteriogram shows distal perfusion down the ulnar border of the hand and into the little finger.  Thus, we have planned to proceed first with nerve entrapment releases and potentially at the later date do arterial reconstruction if deemed necessary.  Thirdly, this patient does have chronic distal ischemic problems with evidence of ""ping-pong ball sign"" due to fat atrophy at the finger tips and some periodic cracking and ulceration at the tips of the fingers.  However, this patient has no clinical sign at all of tissue necrosis at the finger tips at this time.,The patient has also previously had an arteriovenous shunt in the forearm, which has been deactivated within the last 3 weeks.  Thus, we planned to bring this patient to the operating room for left carpal tunnel release as well as anterior submuscular transposition of the ulnar nerve.  This patient had electro diagnostic studies performed, which showed severe involvement of both the ulnar nerve at the elbow and the medial nerve at the carpal tunnel.,DESCRIPTION OF PROCEDURE: , After general anesthesia being induced and the patient intubated, he is given intravenous Ancef.  The entire left upper extremity is prepped with Betadine all the way to the axilla and draped in a sterile fashion.  A sterile tourniquet and webril are placed higher on the arm.  The arm is then exsanguinated with Ace bandage and tourniquet inflated to 250 mmHg.  I started first at the carpal tunnel release and a longitudinal curvilinear incision is made parallel to the thenar crease and stopping short of the wrist flexion crease.  Dissection continued through subcutaneous tissue to the palmer aponeurosis, which is divided longitudinally from distal to proximal.  I next encountered the transverse carpal ligament, which in turn is also divided longitudinally from distal to proximal, and the proximal most division of the transverse carpal ligament is done under direct vision into the distal forearm.  Having confirmed a complete release of the transverse carpal ligament, I next evaluated the contents of the carpal tunnel.  The synovium was somewhat thickened, but not unduly so.  There was some erythema along the length of the median nerve, indicating chronic compression.  The motor branch of the median nerve was clearly identified.  The contents of the carpal canal were retracted in a radial direction and the floor of the canal evaluated and no other extrinsic compressive pathology was identified.  The wound was then irrigated with normal saline and wound edges were reapproximated with interrupted 5-0 nylon sutures.,I next turned my attention to the cubital tunnel problem and a longitudinal curvilinear incision is made on the medial aspect of the arm extending into the forearm with the incision passing directly between the olecranon and the medial epicondyle.  Dissection continues through fascia and then skin clamps are elevated to the level of the fascia on the flexor pronator muscle mass.  In the process of elevating this skin flap I elevated and deactivated shunt together with the skin flap.  I now gained access to the radial border of the flexor pronator muscle mass, dissected down the radial side, until I identified the median nerve.,I turned my attention back to the ulnar nerve and it is located immediately posterior to the medial intramuscular septum in the upper arm, and I dissected it all the way proximally until I encountered the location with ulnar the nerve passed from the anterior to the posterior compartments in the upper portion of the arm.  The entire medial intramuscular septum is now excised.  The ulnar nerve is mobilized between vessel loops and includes with it is accompanying vascular structures.  Larger penetrating vascular tributaries to the muscle ligated between hemoclips.  I continued to mobilize the nerve around the medial epicondyle and then took down the aponeurosis between the two heads of the flexor carpi ulnaris and continued to dissect the nerve between the FCU muscle fibers.  The nerve is now mobilized and I had retained the large muscular branches and dissected them out into the muscle and also proximally using microvascular surgical techniques.  In this way, the nerve was able to be mobilized between vessiloops and easily transposed anterior to the flexor pronator muscle mass in tension free manner.,I now made an oblique division of the entire flexor pronator muscle mass proximally in the forearm and the ulnar nerve was able to be transposed deep to the muscle in a nonkinking and tension-free manner.  Because of the oblique incision into the flexor pronator muscle mass the muscle edges were now able to slide on each other.  So that in effect a lengthening is performed.  Fascial repair is done with interrupted figure-of-eight 0-Ethibond sutures.  I now ranged the arm through the full range of flexion and extension at the elbow and there was no significant kinking on the nerve and there was a tension-free coverage of the muscle without any impingement on the nerve.  The entire arm is next wrapped with a Kerlix wrap and I released the tourniquet and after allowing the reactive hyperemia to subside, I then unwrap the arm and check for hemostasis.  Wound is copiously irrigated with normal saline and then a 15-French Round Blake drainage placed through a separate stab incision and laid along the length of the wound.  A layered wound closure is done with interrupted Vicryl subcutaneously, and a running subcuticular Monocryl to the skin.  A 0.25% plain Marcaine then used to infiltrate all the wound edges to help with post operative analgesia and dressings take the form of Adaptic impregnated Bacitracin ointment, followed by a well-fluffed gauze and a Kerlix dressing and confirming Kerlix and webril, and an above elbow sugar-tong splint is applied extending to the support of the wrist.  Fingers and femoral were free to move.  The splint is well padded with webril and is in turn held in place with Kerlix and Ace bandage.  Meanwhile the patient is awakened and extubated in the operating room and returned to the recovery room in good condition.  Sponge and needle counts reported as correct at the end of the procedure.","surgery, carpal tunnel syndrome, ace bandage, kerlix, carpal tunnel release, curvilinear incision, flexor pronator muscle, ping-pong ball sign, synovium, ulnar artery, ulnar nerve, ulnar nerve entrapment, pronator muscle mass, transverse carpal, carpal ligament, tunnel release, flexor pronator, pronator muscle, carpal tunnel, tunnel, carpal, nerve, pronator, forearm,"
 Endoscopic release of left transverse carpal ligament., Surgery, Carpal Ligament Release - 1 ,"PREOPERATIVE DIAGNOSIS:,  Carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:,  Carpal tunnel syndrome.,PROCEDURE: , Endoscopic release of left transverse carpal ligament.,ANESTHESIA:,  Monitored anesthesia care with regional anesthesia provided by surgeon.  ,TOURNIQUET TIME: , 12 minutes.,OPERATIVE PROCEDURE IN DETAIL: , With the patient under adequate monitored anesthesia, the left upper extremity was prepped and draped in a sterile manner.  The arm was exsanguinated.  The tourniquet was elevated at 290 mmHg.  Construction lines were made on the left palm to identify the ring ray.  A transverse incision was made in the palm between FCR and FCU, one finger breadth proximal to the interval between the glabrous skin of the palm and normal forearm skin.  Blunt dissection exposed the antebrachial fascia.  Hemostasis was obtained with bipolar cautery.  A distal based window in the antebrachial fascia was then fashioned.  Care was taken to protect the underlying contents.  A synovial elevator was used to palpate the undersurface of the transverse carpal ligament, and synovium was elevated off this undersurface.,Hamate sounds were then used to palpate the Hood of Hamate.  The Agee Inside Job was then inserted into the proximal incision.  The transverse carpal ligament was easily visualized through the portal.  Using palmar pressure, transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end.  The distal end of the transverse carpal ligament was then identified in the window.  The blade was then elevated, and the Agee Inside Job was withdrawn, dividing transverse carpal ligament under direct vision.  After complete division of transverse carpal ligament, the Agee Inside Job was reinserted.  Radial and ulnar edges of the transverse carpal ligament were identified and complete release was accomplished.  One cc of Celestone was then introduced into the carpal tunnel and irrigated free.  ,The wound was then closed with a running 3-0 Prolene subcuticular stitch.  Steri-strips were applied and a sterile dressing was applied over the Steri-strips.  The tourniquet was deflated.  The patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well.","surgery, carpal tunnel syndrome, antebrachial fascia, carpal, ligament, palmar, synovium, tourniquet, transverse carpal ligament, transverse incision, agee inside job, transverse carpal, carpal ligament, carpal tunnel, antebrachial, release, endoscopic,"
" Endoscopic release of left transverse carpal ligament.  Steroid injection, stenosing tenosynovitis of right middle finger.", Surgery, Carpal Ligament Release - 2 ,"PREOPERATIVE DIAGNOSES:,1.  Left carpal tunnel syndrome.,2.  Stenosing tenosynovitis of right middle finger (trigger finger).,POSTOPERATIVE DIAGNOSES:,1.  Left carpal tunnel syndrome.,2.  Stenosing tenosynovitis of right middle finger (trigger finger).,PROCEDURES:,1.  Endoscopic release of left transverse carpal ligament.,2.  Steroid injection, stenosing tenosynovitis of right middle finger.,ANESTHESIA:  ,Monitored anesthesia care with regional anesthesia applied by surgeon.,TOURNIQUET TIME: , Left upper extremity was 15 minutes.,OPERATIVE PROCEDURE IN DETAIL:,  With the patient under adequate monitored anesthesia, the left upper extremity was prepped and draped in a sterile manner.  The arm was exsanguinated.  The tourniquet was elevated at 290 mmHg.  Construction lines were made on the left palm to identify the ring ray.  A transverse incision was made in the palm between FCR and FCU, one finger breadth proximal to the interval between the glabrous skin of the palm and normal forearm skin.  Blunt dissection exposed the antebrachial fascia.  Hemostasis was obtained with bipolar cautery.  A distal based window in the antebrachial fascia was then fashioned.  Care was taken to protect the underlying contents.  A synovial elevator was used to palpate the undersurface of the transverse carpal ligament, and synovium was elevated off this undersurface.,Hamate sounds were then used to palpate the Hood of Hamate.  The Agee Inside Job was then inserted into the proximal incision.  The transverse carpal ligament was easily visualized through the portal.  Using palmar pressure, transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end.  The distal end of the transverse carpal ligament was then identified in the window.  The blade was then elevated, and the Agee Inside Job was withdrawn, dividing transverse carpal ligament under direct vision.  After complete division of transverse carpal ligament, the Agee Inside Job was reinserted.  Radial and ulnar edges of the transverse carpal ligament were identified and complete release was accomplished.  One mL of Celestone was then introduced into the carpal tunnel and irrigated free.  ,The wound was then closed with a running 3-0 Prolene subcuticular stitch.  Steri-strips were applied and a sterile dressing was applied over the Steri-strips.  The tourniquet was deflated.  The patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well.,Attention was turned to the right palm where after a sterile prep, the right middle finger flexor sheath was injected with 0.5 mL of 1% plain Xylocaine and 0.5 mL of Depo-Medrol 40 mg/mL.  A Band-Aid dressing was then applied.,The patient was then awakened from the anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well.","surgery, carpal tunnel syndrome, agee inside job, steroid injection, antebrachial fascia, forearm, ring ray, synovial elevator, tenosynovitis, tourniquet, transverse incision, trigger finger, tenosynovitis of right middle, transverse carpal ligament, transverse carpal, carpal ligament, steri strips, stenosing tenosynovitis, middle finger, ligament, carpal, endoscopic, finger"
 Left endoscopic carpal tunnel release and endotracheal fasciotomy., Surgery, Carpal Tunnel Release - 2 ,"PREOPERATIVE DIAGNOSIS: , Left carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Left carpal tunnel syndrome.,OPERATIVE PROCEDURE:,1.  Left endoscopic carpal tunnel release.,2.  Endotracheal fasciotomy.,ANESTHESIA:,  General.,COMPLICATIONS: , None.,INDICATION: , The patient is a 62-year-old lady with the aforementioned diagnosis refractory to nonoperative management.  All risks and benefits were explained.  Questions answered.  Options discussed.  No guarantees were made.  She wished to proceed with surgery.,PROCEDURE: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion, the arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,I made a transverse incision one fingerbreadth proximal to the distal volar wrist crease.  Dissection was carried down to the antebrachial fascia, which was cut in a distally based fashion.  Bipolar electrocautery was used to maintain meticulous hemostasis.  I then performed an antebrachial fasciotomy proximally.  I entered the extra bursal space deep into the transverse carpal ligament and used the spatula probe and then the dilators and then the square probe to enlarge the area.  Great care was taken to feel the washboard undersurface of the transverse carpal ligament and the hamate on the ulnar side.  Great care was taken with placement.  A good plane was positively identified.  I then placed the endoscope in and definitely saw the transverse striations of the deep surface of the transverse carpal ligament.,Again, I felt the hook of the hamate ulnar to me.  I had my thumb on the distal aspect of the transverse carpal ligament.  I then partially deployed the blade, and starting 1 mm from the distal edge, the transverse carpal ligament was positively identified.  I pulled back and cut and partially tightened the transverse carpal ligament.  I then feathered through the distal ligament and performed a full-thickness incision through the distal half of the ligament.  I then checked to make sure this was properly performed and then cut the proximal aspect.  I then entered the carpal tunnel again and saw that the release was complete, meaning that the cut surfaces of the transverse carpal ligament were separated; and with the scope rotated, I could see only one in the field at a time.  Great care was taken and at no point was there any longitudinal structure cut.  Under direct vision through the incision, I made sure that the distal antebrachial fascia was cut.  Following this, I irrigated and closed the skin.  The patient was dressed and sent to the recovery room in good condition.","surgery, carpal tunnel syndrome, antebrachial fascia, antebrachial fasciotomy, carpal tunnel release, electrocautery, fasciotomy, hamate, wrist crease, endoscopic carpal tunnel release, transverse carpal ligament, carpal tunnel, transverse carpal, carpal ligament, carpal, antebrachial, transverse, ligament"
" Right common carotid endarterectomy, internal carotid endarterectomy, external carotid endarterectomy, and Hemashield patch angioplasty of the right common, internal and external carotid arteries.", Surgery, Carotid Endarterectomy - 1 ,"PREOPERATIVE DIAGNOSIS:,  Right common, internal and external carotid artery stenosis.,POSTOPERATIVE DIAGNOSIS:,  Right common, internal and external carotid artery stenosis.,OPERATIONS,1.  Right common carotid endarterectomy.,2.  Right internal carotid endarterectomy.,3.  Right external carotid endarterectomy.,4.  Hemashield patch angioplasty of the right common, internal and external carotid arteries.,ANESTHESIA:,  General endotracheal anesthesia.,URINE OUTPUT: , Not recorded,OPERATION IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered.  Next the right neck was prepped and draped in the standard surgical fashion.  A #10-blade scalpel was used to make an incision at the anterior tip of the sternocleidomastoid muscle.  Dissection was carried down to the level of the carotid artery using Bovie electrocautery and sharp dissection with Metzenbaum scissors.  The common, internal and external carotid arteries were identified.  The facial vein was ligated with #3-0 silk.  The hypoglossal nerve was identified and preserved as it coursed across the carotid artery.  After dissecting out an adequate length of common, internal and external carotid artery, heparin was given.  Next, an umbilical tape was passed around the common carotid artery.  A #0 silk suture was passed around the internal and external carotid arteries.  The hypoglossal nerve was identified and preserved.  An appropriate sized Argyle shunt was chosen.  A Hemashield patch was cut to the appropriate size.  Next, vascular clamps were placed on the external carotid artery.  DeBakey pickups were used to control the internal carotid artery and common carotid artery.  A #11-blade scalpel was used to make an incision on the common carotid artery.  The arteriotomy was lengthened onto the internal carotid artery.  Next, the Argyle shunt was placed.  It was secured in place.  Next, an endarterectomy was performed; and this was done on the common, internal carotid and external carotid arteries.  An inversion technique was used on the external carotid artery.  The artery was irrigated and free debris was removed.  Next, we sewed the Hemashield patch onto the artery using #6-0 Prolene in a running fashion.  Prior to completion of our anastomosis, we removed our shunt.  We completed the anastomosis.  Next, we removed our clamp from the external carotid artery, followed by the common carotid artery, and lastly by the internal carotid artery.  There was no evidence of bleeding.  Full-dose protamine was given.  The incision was closed with #0 Vicryl, followed by #2-0 Vicryl, followed by #4-0 PDS in a running subcuticular fashion.  A sterile dressing was applied.","surgery, angioplasty, common carotid artery, external carotid artery, hemashield patch, common carotid, carotid endarterectomy, external, artery, carotid, hemashield, endarterectomy"
" Carpal tunnel release.  Nerve conduction study tests diagnostic of carpal tunnel syndrome.  The patient failed to improve satisfactorily on conservative care, including anti-inflammatory medications and night splints.", Surgery, Carpal Tunnel Release ,"PROCEDURE PERFORMED: , Carpal tunnel release.,INDICATIONS FOR SURGERY: , Nerve conduction study tests diagnostic of carpal tunnel syndrome.  The patient failed to improve satisfactorily on conservative care, including anti-inflammatory medications and night splints.,PROCEDURE:  ,The patient was brought to the operating room and, following a Bier block to the operative arm, the arm was prepped and draped in the usual manner.,Utilizing an incision that was laid out to extend not more distally than the thumb web space or proximally to a position short of crossing the most prominent base of the palm and in line with the longitudinal base of the thenar eminence in line with the fourth ray, the soft tissue dissection was carried down sharply through the skin and subcutaneous fat to the transverse carpal ligament.  It was identified at its distal edge.  Using a hemostat to probe the carpal tunnel, sharp dissection utilizing scalpel and iris scissors were used to release the carpal tunnel from a distal-to-proximal direction in its entirety.  The canal was probed with a small finger to verify no evidence of any bone prominences.  The nerve was examined for any irregularity.  There was slight hyperemia of the nerve and a slight hourglass deformity.  Following an irrigation, the skin was approximated using interrupted simple and horizontal mattress #5 nylon suture.  A sterile dressing was applied.,The patient was taken to the recovery room in satisfactory condition.,The time of the Bier block was 30 minutes.,COMPLICATIONS: , None noted.","surgery, carpal tunnel syndrome, carpal ligament, nerve conduction study, carpal tunnel release, bier block, carpal tunnel, tunnel, carpal, "
" Carpal tunnel release with transverse carpal ligament reconstruction.  A longitudinal incision was made in line with the fourth ray, from Kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease.  The dissection was carried down to the superficial aponeurosis.  ", Surgery, Carpal Ligament Reconstruction ,"PROCEDURE:,  Carpal tunnel release with transverse carpal ligament reconstruction.,PROCEDURE IN DETAIL: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A longitudinal incision was made in line with the fourth ray, from Kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease.  The dissection was carried down to the superficial aponeurosis.  The subcutaneous fat was dissected radially for 2-3 mm, and the superficial aponeurosis cut on this side to leave a longer ulnar leaf.,The ulnar leaf of the cut superficial aponeurosis was dissected ulnarly, and the distal edge of the transverse carpal ligament was identified with a hemostat.  The hemostat was gently placed under the transverse carpal ligament to protect the contents of the carpal tunnel, and the ligament was cut on its ulnar side with a knife directly onto the hemostat.  The antebrachial fascia was cut proximally under direct vision with a scissor.,After irrigating the wound with copious amounts of normal saline, the radial leaf of the cut transverse carpal ligament was repaired to the ulnar leaf of the cut superficial aponeurosis with 4-0 Vicryl.  Care was taken to avoid entrapping the motor branch of the median nerve in the suture.  A hemostat was placed under the repair to ensure that the median nerve was not compressed.  The skin was repaired with 5-0 nylon interrupted stitches.,Marcaine with epinephrine was injected into the wound, which was then dressed and splinted.  The patient was sent to the recovery room in good condition, having tolerated the procedure well.","surgery, carpal tunnel, carpal ligament reconstruction, transverse carpal ligament, ulnar, hemostat, transverse, superficial, ligament, carpal"
 Right carotid stenosis and prior cerebrovascular accident. Right carotid endarterectomy with patch angioplasty., Surgery, Carotid Endarterectomy  ,"PREOPERATIVE DIAGNOSES:,1.  Right carotid stenosis.,2.  Prior cerebrovascular accident.,POSTOPERATIVE DIAGNOSES:,1.  Right carotid stenosis.,2.  Prior cerebrovascular accident.,PROCEDURE PERFORMED:  ,Right carotid endarterectomy with patch angioplasty.,ESTIMATED BLOOD LOSS:  ,250 cc.,OPERATIVE FINDINGS: , The common and internal carotid arteries were opened.  A high-grade narrowing was present at the proximal internal carotid and this tapered well to a slightly small diameter internal carotid.  This was repaired with a Dacron patch and the patient tolerated this well under regional anesthetic without need for shunting.,PROCEDURE:  ,The patient was taken to the operating room, placed in supine position, prepped and draped in the usual sterile manner with Betadine solution.  Longitudinal incisions were made along the anterior border of the sternocleidomastoid, carried down through subcutaneous fat and fascia.  Hemostasis was obtained with electrocautery.  The platysmal muscle was divided.  The carotid sheath was identified and opened.  The vagus nerve, ansa cervicalis, and hypoglossal nerves were identified and avoided.  The common internal and external carotids were then freed from the surrounding tissue.  At this point, 10,000 units of aqueous heparin were administered and allowed to take effect.  The external and common carotids were then clamped.  The patient's neurological status was evaluated and found to be unchanged from preoperative levels.,Once sufficient time had lapsed, we proceeded with the procedure.  The carotid bulb was opened with a #11 blade and extended with Potts scissors through the very tight lesion into normal internal carotid.  The plaque was then sharply excised proximally and an eversion endarterectomy was performed successfully at the external.  The plaque tapered nicely on the internal and no tacking sutures were necessary.  Heparinized saline was injected and no evidence of flapping or other debris was noted.  The remaining carotid was examined under magnification, which showed no debris of flaps present.  At this point, a Dacron patch was brought on to the field, cut to appropriate length and size, and anastomosed to the artery using #6-0 Prolene in a running fashion.  Prior to the time of last stitch, the internal carotid was back-bled through this.  The last stitch was tied.  Hemostasis was excellent.  The internal was again gently occluded while flow was restored to the common and external carotids for several moments and then flow was restored to the entire system.  At this point, a total of 50 mg of Protamine was administered and allowed to take effect.  Hemostasis was excellent.  The wound was irrigated with antibiotic solution and closed in layers using #3-0 Vicryl and #4-0 undyed Vicryl.  The patient was then taken to the recovery room in satisfactory condition after tolerating the procedure well.  Sponge, needles, and instrument count were correct.  Estimated blood loss was 250 cc.","surgery, carotid stenosis, cerebrovascular, platysmal, dacron patch, carotid endarterectomy, cerebrovascular accident, internal carotid, carotid, stenosis, carotids, endarterectomy"
 Direct-current cardioversion.  This is a 53-year-old gentleman with history of paroxysmal atrial fibrillation for 3 years.  Successful DC cardioversion of atrial fibrillation., Surgery, Cardioversion - Direct Current - 1 ,"PROCEDURE:  ,Direct-current cardioversion.,BRIEF HISTORY:  ,This is a 53-year-old gentleman with history of paroxysmal atrial fibrillation for 3 years.  He had a wide area of circumferential ablation done on November 9th for atrial fibrillation.  He did develop recurrent atrial fibrillation the day before yesterday and this is persistent.  Therefore, he came in for cardioversion today.  He is still within the first 4 to 6 weeks post ablation where we would attempt early cardioversion.,The patient was in the SDI unit, attached to noninvasive monitoring devices.  After Brevital was brought by the anesthesia service a single 150 joule synchronized biphasic shock using AP paddles did restore him to sinus rhythm in the 80s.  He tolerated it well.  He will be observed for couple hours and discharged home later today.  He will continue on his current medications.  He will follow back up in two to three weeks in the Atrial Fibrillation Clinic and then again in a couple months with myself.,CONCLUSIONS / FINAL DIAGNOSES: , Successful DC cardioversion of atrial fibrillation.","surgery, direct-current cardioversion, circumferential ablation, paroxysmal atrial, dc cardioversion, direct current, atrial fibrillation, ablation, cardioversion,"
 Cardioversion.  Unsuccessful direct current cardioversion with permanent atrial fibrillation., Surgery, Cardioversion - Unsuccessful ,"REASON FOR EXAM: , Atrial flutter/cardioversion.,PROCEDURE IN DETAIL: , The procedure was explained to the patient with risks and benefits.  The patient agreed and signed the consent form.  The patient received sedation prior to the cardioversion with a transesophageal echo as dictated earlier with a total of 50 mcg of fentanyl and 6 mg of Versed.  The pads were applied in the anterior-posterior approach.  The synchronized cardioversion with biphasic energy delivered at 150 J. First attempt was unsuccessful.  Second attempt at 200 J with anterior-posterior approach.  With biphasic synchronized energy delivered was also unsuccessful with degeneration of the atrial flutter into atrial fibrillation.,The patient was decided to be on wave control and amiodarone and reattempted cardioversion after anticoagulation for four to six weeks and because of the reduced LV function, the success of the rate without antiarrhythmic may be low.,IMPRESSION: , Unsuccessful direct current cardioversion with permanent atrial fibrillation.","surgery, atrial flutter, cardioversion, anterior-posterior, transesophageal, atrial fibrillation, flutter/cardioversion, fibrillation, atrial,"
 Direct current cardioversion.  Successful direct current cardioversion with restoration of sinus rhythm from atrial fibrillation with no immediate complication. , Surgery, Cardioversion - Direct Current ,"PROCEDURE: , Direct current cardioversion.,REASON FOR PROCEDURE: , Atrial fibrillation.,PROCEDURE IN DETAIL:  ,The procedure was explained to the patient with risks and benefits including risk of stroke.  The patient understands as well as her husband.  The patient had already a transesophageal echocardiogram showing no left atrial appendage thrombus or thrombus in the left atrium.  There was spontaneous echocardiogram contrast noticed.  The patient was on anticoagulation with Lovenox, received already 3 mg of Versed and 25 mcg of fentanyl for the TEE followed by next 2 mg of Versed for total of 5 mg of Versed.  The pads applied in the anterior and posterior approach.  With synchronized biphasic waveform at 150 J, one shock was successful in restoring sinus rhythm.  The patient had some occasional PACs noticed with occasional sinus tachycardia.  The patient had no immediate post-procedure complications.  The rhythm was maintained and 12-lead EKG was requested.,IMPRESSION:  ,Successful direct current cardioversion with restoration of sinus rhythm from atrial fibrillation with no immediate complication.","surgery, thrombus, atrium, echocardiogram, transesophageal, direct current cardioversion, atrial fibrillation, sinus rhythm, sinus, rhythm, cardioversion"
" Left carotid endarterectomy with endovascular patch angioplasty.  Critical left carotid stenosis.  The external carotid artery was occluded at its origin.  When the endarterectomy was performed, the external carotid artery back-bled nicely.  The internal carotid artery had good backflow bleeding noted.", Surgery, Carotid Endarterectomy & Angioplasty. ,"PREOPERATIVE DIAGNOSIS:,  Critical left carotid stenosis.,POSTOPERATIVE DIAGNOSIS: , Critical left carotid stenosis.,PROCEDURE PERFORMED:,  Left carotid endarterectomy with endovascular patch angioplasty.,ANESTHESIA:,  Cervical block.,GROSS FINDINGS:  ,The patient is a 57-year-old black female with chronic renal failure.  She does have known critical carotid artery stenosis.  She wishes to undergo bilateral carotid endarterectomy, however, it was felt necessary by Dr. X to perform cardiac catheterization.  She was admitted to the hospital yesterday with chest pain.  She has been considered for coronary artery bypass grafting.  I have been asked to address the carotid stenosis, left being more severe, this was addressed first.  Intraoperatively, an atherosclerotic plaque was noted in the common carotid artery extending into the internal carotid artery.  The internal carotid artery is quite torturous.  The external carotid artery was occluded at its origin.  When the endarterectomy was performed, the external carotid artery back-bled nicely.  The internal carotid artery had good backflow bleeding noted.,OPERATIVE PROCEDURE: , The patient was taken to the OR suite and placed in the supine position.  Then neck, shoulder, and chest wall were prepped and draped in appropriate manner.  Longitudinal incision was created along the anterior border of the left sternocleidal mastoid muscle and this was taken through the subcutaneous tissue and platysmal muscle utilizing electrocautery.,Utilizing both blunt and sharp dissections, the common carotid artery, the internal carotid artery beyond the atherosclerotic back, the external carotid artery, and the superior thyroid artery were isolated and encircled with a umbilical tape.  During the dissection, facial veins were ligated with #4-0 silk ligature prior to dividing them.  Also during the dissection, ansa cervicalis, hypoglossal, and vagus nerve identified and preserved.  There was some inflammation above the carotid bulb, but this was not problematic.,The patient had been administered 5000 units of aqueous heparin after allowing adequate circulating time.  The internal carotid artery is controlled with Heifitz clip followed by the external carotid artery and the superior thyroid artery being controlled with Heifitz clips.  The common carotid artery was controlled with profunda clamp.  The patient remained neurologically intact.  A longitudinal arteriotomy was created along the posterior lateral border of the common carotid artery.  This was extended across the lobe on to the internal carotid artery.  An endarterectomy was then performed.  The ________ intima was cleared of all debris and the ________ was flushed with copious amounts of heparinized saline.  As mentioned before, the internal carotid artery is quite torturous.  This was shortened by imbricating the internal carotid artery with horizontal mattress stitches of #7-0 Prolene suture.,The wound was copiously irrigated, rather an endovascular patch was then brought on to the field.  This was cut to shape and length.  This was sutured in place with continuous running #6-0 Prolene suture.  The suture line began at both sites.  The suture was tied in the center along the anterior and posterior walls.  Prior to completing the closure, the common carotid artery was flushed.  The internal carotid artery permitted to back bleed.  The clamp was placed after completing the closure.  The clamp was placed at the origin of the internal carotid artery.  Flow was first directed into the external carotid artery then into the internal carotid artery.  The patient remained neurologically intact.  Topical ________ Gelfoam was utilized.  Of note, during the endarterectomy, the patient did receive an additional 7000 units of aqueous heparin.  The wound was copiously irrigated with antibiotic solution.  Sponge, needle, and all counts were correct.  All surgical sites were inspected.  Good hemostasis noted.  The incision was closed in layers with absorbable suture.  Stainless steel staples approximated skin.  Sterile dressings were applied.  The patient tolerated the procedure well, grossly neurologically intact.","surgery, carotid stenosis, carotid endarterectomy, endovascular patch angioplasty, cervical block, carotid artery, common carotid artery, external carotid artery, endovascular patch, common carotid, external carotid, angioplasty, artery, endovascular, neurologically, carotid, stenosis, endarterectomy"
" Patient with a history of atrial fibrillation in the past, more recently who has had atrial flutter.  The patient has noted some lightheadedness as well as chest discomfort and shortness of breath when atrial flutter recurred.", Surgery, Cardiac Consult & Cardioversion ,"HISTORY OF PRESENT ILLNESS: , Mr. A is a 50-year-old gentleman with a history of atrial fibrillation in the past, more recently who has had atrial flutter, who estimates he has had six cardioversions since 10/09, and estimates that he has had 12 to 24 in his life beginning in 2006 when the atrial fibrillation first emerged.  He, since 10:17 p.m. on 01/17/10, noted recurrence of his atrial fibrillation, called our office this morning, that is despite being on flecainide, atenolol, and he is maintained on Coumadin.,The patient has noted some lightheadedness as well as chest discomfort and shortness of breath when atrial flutter recurred and we see that on his 12-lead EKG here.  Otherwise, no chest pain.,PAST MEDICAL HISTORY: , Significant for atrial fibrillation/atrial flutter and again he had atrial fibrillation more persistently in 2006, but more recently it has been atrial flutter and that is despite use of antiarrhythmics including flecainide.  He completed a stress test in my office within the past several weeks that was normal without evidence of ischemia.  Other medical history is significant for hyperlipidemia.,MEDICATIONS:,As outpatient,,1.  Atenolol 25 mg once a day.,2.  Altace 2.5 mg once a day.,3.  Zocor 20 mg once a day.,4.  Flecainide 200 in the morning and 100 in the evening.,5.  Coumadin as directed by our office.,ALLERGIES: , TO MEDICATIONS ARE NONE.  HE DENIES SHRIMP, SEA FOOD OR DYE ALLERGY.,FAMILY HISTORY: , He has a nephew who was his sister's son who passed away at age 22 reportedly from an MI, but was reported to have hypertrophic cardiomyopathy as well.  The patient has previously met with the electrophysiologist, Dr. X, at General Hospital and it sounds like he had a negative EP study.,SOCIAL HISTORY: , The patient does not smoke cigarettes, abuse alcohol nor drink any caffeine.  No use of illicit drugs.  He has been married for 22 years and he is actually accompanied throughout today's cardiology consultation by his wife.  He is not participating in regular exercises now because he states since starting flecainide, he has gotten sluggish.  He is employed as an attorney and while he states that overall his mental stress is better, he has noted more recent mental stress this past weekend when he was taking his daughter back to college.,REVIEW OF SYSTEMS: , He denies any history of stroke, cancer, vomiting of blood, coughing up blood, bright red blood per rectum, bleeding stomach ulcers, renal calculi.  There are some questions especially as his wife has told me that he may have obstructive sleep apnea and not had a formal sleep study.,PHYSICAL EXAM: , Blood pressure 156/93, pulse is 100, respiratory rate 18.  On general exam, he is a pleasant overweight gentleman, in no acute distress.  HEENT:  Shows cranium is normocephalic and atraumatic.  He has moist mucosal membranes.  Neck veins are not distended.  There are no carotid bruits.  Visible skin warm and perfused.  Affect appropriate.  He is quite oriented and pleasant.  No significant kyphoscoliosis on recumbent back exam.  Lungs are clear to auscultation anteriorly.  No wheezes.  No egophony.  Cardiac Exam:  S1, S2.  Regular rate, controlled.  No significant murmurs, rubs or gallops.  PMI is nondisplaced.  Abdomen is soft, nondistended, appears benign.  Extremities without significant edema.  Pulses grossly intact.,DIAGNOSTIC STUDIES/LAB DATA:,  Initial ECG shows atrial flutter.,IMPRESSION: , Mr. A is a 50-year-old gentleman with a history of paroxysmal atrial fibrillation in the past, more recently is having breakthrough atrial flutter despite flecainide and we had performed a transesophageal echocardiogram-guided cardioversion for him in late 12/20/09, who now has another recurrence within the past 41 hours or so.  I have reviewed again with him in detail regarding risks, benefits, and alternatives of proceeding with cardioversion, which the patient is in favor of.  After in depth explanation of the procedure with him that there would be more definitive resumption of normal sinus rhythm by using electrocardioversion with less long-term side effects, past the acute procedure, alternatives being continued atrial flutter with potential for electrophysiologic consultation for ablation and/or heart rate control with anticoagulation, which the patient was not interested nor was I primarily recommending as the next step, and risks including, but not limited to and the patient was aware and this was all done in the presence of his wife that this is not an all-inclusive list, but the risks include but not limited to oversedation from conscious sedation, risk of aspiration pneumonia from regurgitation of stomach contents, which would be less likely as I did confirm with the patient that he had been n.p.o. for greater than 15 hours, risk of induction of other arrhythmias including tachyarrhythmias requiring further management including cardioversion or risk of bradyarrhythmias, in the past when we had a cardioverter with 150 joules, he did have a 5.5-second pause especially while he is on antiarrhythmic therapy, statistically less significant risk of CVA, although we cannot really make that null.  The patient expressed understanding of this risk, benefit, and alternative analysis.  I invited questions from him and his wife and once their questions were answered to their self-stated satisfaction, we planned to go forward with the procedure.,PROCEDURE NOTE:  ,The patient received a total of 7 mg of Versed and 50 micrograms of fentanyl utilizing titrate-down sedation with good effect and this was after the appropriate time-out procedure had been done as per the Medical Center universal protocol with appropriate identification of the patient, position, procedure documentation, procedure indication, and there were no questions.  The patient did actively participate in this time-out procedure.  After the universal protocol was done, he then received the cardioversion attempt with 50 joules using ""lollipop posterior patch"" with hands-driven paddle on the side, which was 50 joules of synchronized biphasic energy.  There was successful resumption of normal sinus rhythm, in fact this time there was not a significant pause as compared to when he had this done previously in late 12/09 and this sinus rhythm was confirmed by a 12-lead EKG.,IMPRESSION: , Cardioversion shows successful resumption of normal sinus rhythm from atrial flutter and that is while the patient has been maintained on Coumadin and his INR is 3.22.  We are going to watch him and discharge him from the Medical Center area on his current flecainide of 200 mg in the morning and 100 mg in the evening, atenolol 25 mg once a day, Coumadin _____ as currently being diagnosed.  I had previously discussed with the patient and he was agreeable with meeting with his electrophysiologist again, Dr. X, at Electrophysiology Unit at General Hospital and I will be planning to place a call for Dr. X myself.  Again, he has no ischemia on this most recent stress test and I suppose in the future it may be reasonable to get obstructive sleep apnea evaluation and that may be one issue promulgating his symptoms.,I had previously discussed the case with Dr. Y who is the patient's general cardiologist as well as updated his wife at the patient's bedside regarding our findings.",
 Left heart cardiac catheterization., Surgery, Cardiac Catheterization - 8 ,"PROCEDURE PERFORMED:,1.  Right femoral artery access.,2.  Selective right and left coronary angiogram.,3.  Left heart catheterization.,4.  Left ventriculogram.,INDICATIONS FOR PROCEDURE:,  A 50-year-old lady with known history of coronary artery disease with previous stenting to the left anterior descending artery presents with symptoms of shortness of breath.  The resting echocardiogram showed a severe decrease in her left ventricular systolic function with a reported LVEF of 20% to 25%.  This was a sharp decline from a previous LVEF of 50% to 55%.  We therefore, decided to proceed with coronary angiography.,TECHNIQUE: , After obtaining informed consent, the patient was brought to the cardiac catheterization suite in post-absorptive and non-sedated state.  The right groin was prepped and draped in the usual sterile manner.  2% Lidocaine was used for infiltration anesthesia.  Using modified Seldinger technique, a 6-French sheath was introduced into the right femoral artery.  6-French JL4 and JR4 diagnostic catheters were used to perform the left and right coronary angiogram.  A 6-French pigtail catheter was used to perform the LV-gram in the RAO projection.,HEMODYNAMIC DATA: , LVEDP of 11.  There was no gradient across the aortic valve upon pullback.,ANGIOGRAPHIC FINDINGS:,1.  The left main coronary artery is a very short vessel and immediately bifurcates into the left anterior descending artery and the left circumflex coronary artery.,2.  The left main coronary artery is free of any disease.,3.  The left circumflex coronary artery which is a nondominant vessel gives off 2 marginal branches.  The first marginal branch is very small in caliber and runs a fairly long course and is free of any disease.,4.  The second marginal branch which is actually a continuation of the left circumflex coronary artery gives off several secondary branches.  One of its secondary branches which is a small caliber has an ostial 70% stenosis.,5.  The left anterior descending artery has a patent stent in the proximal LAD.  The second stent which is overlapping the junction of the mid and distal left anterior descending artery has mild late luminal loss.  There appears to be 30% narrowing involving the distal cuff segment of the stent in the distal left anterior descending artery.  The diagonal branches are free of any disease.,6.  The right coronary artery is a dominant vessel and has mild luminal irregularities.  Its midsegment has a focal area of 30% narrowing as well.  The rest of the right coronary artery is free of any disease.,7.  The LV-gram performed in the RAO projection shows well preserved left ventricular systolic function with an estimated LVEF of 55%.,RECOMMENDATION: , Continue with optimum medical therapy.  Because of the discrepancy between the left ventriculogram EF assessment and the echocardiographic EF assessment, I have discussed this matter with Dr. XYZ and we have decided to proceed with a repeat 2D echocardiogram.  The mild disease in the distal left anterior descending artery with mild in-stent re-stenosis should be managed medically with optimum control of hypertension and hypercholesterolemia.","surgery, heart catheterization, ventriculogram, femoral artery access, coronary angiogram, lvef, distal left anterior descending, circumflex coronary artery, anterior descending artery, femoral artery, systolic function, cardiac catheterization, circumflex coronary, anterior descending, coronary artery, coronary, artery, catheterization, descending"
 Carious teeth and periodontal disease affecting all remaining teeth and partial bony impacted tooth #32. Extraction of teeth., Surgery, Carious Teeth Extraction ,"PREOPERATIVE DIAGNOSIS: , Carious teeth and periodontal disease affecting all remaining teeth.,POSTOPERATIVE DIAGNOSIS: , Carious teeth and periodontal disease affecting all remaining teeth and partial bony impacted tooth #32.,PROCEDURE: , Extraction of remaining teeth numbers 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, and 32.,ANESTHESIA:,  General, oral endotracheal.,COMPLICATIONS: , None.,CONDITION:,  Stable to PACU.,PROCEDURE:  Patient was brought to the operating room, placed on the table in the supine position and after demonstration of an adequate plane of general anesthesia, the patient was prepped and draped in the usual fashion for an intraoral procedure.  Gauze throat pack was placed and local anesthetic was administered in the upper and lower left quadrants and extraction of teeth was begun on the upper left quadrant teeth numbers 9, 10, 11, 12, 13, 14, 15, and 16 were removed with elevators and forceps extraction.  Moving to the lower quadrant on the left side, tooth numbers 17, 18, 19, 20, 21, 22, 23, and 24 were removed with elevators and routine forceps extraction.  The flaps were then closed with 3-0 gut sutures and upon completion of the two quadrants on the left side, the endotracheal tube was then relocated from the right side to the left side for access to the quadrants on the right.  Teeth numbers 2, 3, 4, 5, 7, and 8 were then removed with elevators and routine forceps extraction.  It was noted that tooth #6 was missing, could not be seen whether tooth #6 was palately impacted, but the tooth was not encountered.  On the lower right quadrant, teeth numbers 25, 26, 27, 28, 29, 30, and 31 were removed with elevators and routine forceps extraction.  Tooth #32 was partially bony impacted, but exposed, so it was removed by removing bone on buccal aspect with high-speed drill with a round bur.  Tooth was then luxated from the socket.  The flaps were then closed on both quadrants with 3-0 gut sutures.  The area was irrigated thoroughly with normal saline solution and a total of 8.5 mL of lidocaine 2% with 1:100, 000 epinephrine and 3.6 mL of bupivacaine 0.5% with epinephrine 1:200, 000.  Upon completion of the procedure, the throat pack was removed.  The pharynx was suctioned.  An oral gastric tube was passed and small amount of stomach contents were suctioned.  The patient was then extubated and taken to PACU in stable condition.","surgery, intraoral procedure, partial bony impacted tooth, teeth extraction, forceps extraction, periodontal disease, carious teeth, periodontal, carious "
 Right carpal tunnel release., Surgery, Carpal Tunnel Release - 1 ,"PREOPERATIVE DIAGNOSIS: , Right carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Right carpal tunnel syndrome.,TITLE OF THE PROCEDURE: , Right carpal tunnel release.,COMPLICATIONS:,  There were no complications during the procedure.,SPECIMEN:  ,The specimen was sent to pathology.,INSTRUMENTS: , All counts were correct at the end of the case and no complications were encountered.,INDICATIONS:  ,This is a 69-year-old female who have been complaining of right hand pain, which was steadily getting worse over a prolonged period of time.  The patient had tried nonoperative therapy, which did not assist the patient.  The patient had previous diagnosis of carpal tunnel and EMG showed compression of the right median nerve.  As a result of these findings, the patient was sent to my office presenting with this history and was carefully evaluated.  On initial evaluation, the patient had the symptomology of carpal tunnel syndrome.  The patient at the time had the risks, benefits, and alternatives thoroughly explained to her.  All questions were answered.  No guarantees were given.  The patient had agreed to the surgical procedure and the postoperative rehabilitation as needed.,DETAILS OF THE PROCEDURE:  ,The patient was brought to the operating room, placed supine on the operating room table, prepped and draped in the sterile fashion and was given sedation.  The patient was then given sedation.  Once this was complete, the area overlying the carpal ligament was carefully injected with 1% lidocaine with epinephrine.  The patient had this area carefully and thoroughly injected with approximately 10 mL of lidocaine with epinephrine and once this was complete, a 15-blade knife was then used to incise the skin opposite the radial aspect of the fourth ray.  Careful dissection under direct visualization was performed through the subcutaneous fat as well as through the palmar fascia.  A Weitlaner retractor was then used to retract the skin and careful dissection through the palmar fascia would then revealed the transverse carpal ligament.  This was then carefully incised using a 15-blade knife and once entry was again into the carpal canal, a Freer elevator was then inserted and under direct visualization, the carpal ligament was then released.  The transverse carpal ligament was carefully released first in the distal direction until palmar fat could be visualized and by palpation no further ligament could be felt.  The area was well hemostased with the 1% lidocaine with epinephrine and both proximal and distal dissection along the nerve was performed.  Visualization of the transverse carpal ligament was maintained with Weitlaner retractor as well as centric.  Both the centric and the Ragnell were used to retract both proximal and distal corners of the incision and the entirety of the area was under direct visualization at all times.  Palmar fascia was released both proximally and distally as well as the transverse carpal ligament.  Direct palpation of the carpal canal demonstrated a full and complete release.  Observation of the median nerve revealed an area of hyperemia in the distal two-thirds of the nerve, which demonstrated the likely area of compression.  Once this was complete, hemostasis was established using bipolar cautery and some small surface bleeders and irrigation of the area was performed and then the closure was achieved with 4-0 chromic suture in a horizontal mattress and interrupted stitch.  Xeroform was then applied to the incision.  A bulky dressing was then applied consisting of Kerlix and Ace wrap, and the patient was taken to the recovery room in stable condition without any complications.","surgery, carpal tunnel syndrome, ace wrap, emg, freer elevator, kerlix, weitlaner retractor, bulky dressing, carpal tunnel, carpal tunnel release, palmar fascia, subcutaneous fat, lidocaine with epinephrine, transverse carpal ligament, carpal ligament, carpal, tunnel, ligament,"
 Cardioversion.  An 86-year-old woman with a history of aortic valve replacement in the past with paroxysmal atrial fibrillation , Surgery, Cardioversion ,"HISTORY: , The patient is an 86-year-old woman with a history of aortic valve replacement in the past with paroxysmal atrial fibrillation who was admitted yesterday with the recurrence of such in a setting of hypokalemia, incomplete compliance with obstructive sleep apnea therapy with CPAP, chocolate/caffeine ingestion and significant mental stress.  Despite repletion of her electrolytes and maintenance with Diltiazem IV she has maintained atrial fibrillation.  I have discussed in detail with the patient regarding risks, benefits, and alternatives of the procedure.  After an in depth discussion of the procedure (please see my initial consultation for further details) I asked the patient this morning if she would like me to repeat that as that discussion had happened yesterday.  The patient declined.  I invited questions for her which she stated she had none and wanted to go forward with the cardioversion which seemed appropriate.,PROCEDURE NOTE: , The appropriate time-out procedure was performed as per Medical Center protocol including proper identification of the patient, physician, procedure, documentation, and there were no safety issues identified by myself nor the staff.  The patient participated actively in this.  She received a total of 4 mg of Versed then and 50 micrograms of fentanyl with utilizing titrated conscious sedation with good effect.  She was placed in the supine position and hands free patches had previously been placed in the AP position and she received one synchronized cardioversion attempt after Diltiazem drip had been turned off with successful resumption of normal sinus rhythm.  This was confirmed on 12 lead EKG.,IMPRESSION/PLAN: , Successful resumption of normal sinus rhythm from recurrent atrial fibrillation.  The patient's electrolytes are now normal and that will need close watching to avoid hypokalemia in the future, as well as she has been previously counseled for strict adherence to sleep apnea therapy with CPAP and perhaps repeat sleep evaluation would be appropriate to titrate her settings, as well as avoidance of caffeine ingestion including chocolate and minimization of mental stress.  She will be discharged on her usual robust AV nodal antiarrhythmic therapy with sotalol 80 mg p.o. b.i.d., metoprolol 50 mg p.o. b.i.d., Diltiazem CD 240 mg p.o. daily and digoxin 0.125 mg p.o. daily and to be clear she does have a permanent pacemaker implanted.  She will follow-up with her regular cardiologist, Dr. X, for whom I am covering this weekend.,This was all discussed in detail with the patient, as well as her granddaughter with the patient's verbal consent at the bedside.","surgery, atrial fibrillation, aortic valve, paroxysmal, normal sinus rhythm, sinus rhythm, cpap, cardioversion, fibrillation, atrial,"
 Cardiac catheterization and coronary intervention report., Surgery, Cardiac Catheterization - 9 ,"EXAM: , Cardiac catheterization and coronary intervention report.,PROCEDURES:,1.  Left heart catheterization, coronary angiography, left ventriculography.,2.  PTCA/Endeavor stent, proximal LAD.,INDICATIONS: , Acute anterior ST-elevation MI.,ACCESS: , Right femoral artery 6-French.,MEDICATIONS:,1.  IV Valium.,2.  IV Benadryl.,3.  Subcutaneous lidocaine.,4.  IV heparin.,5.  IV ReoPro.,6.  Intracoronary nitroglycerin.,ESTIMATED BLOOD LOSS: , 10 mL.,CONTRAST:  ,185 mL.,COMPLICATIONS: , None.,PROCEDURE: , The patient was brought to the cardiac catheterization laboratory with acute ST-elevation MI and EKG.  She was prepped and draped in the usual sterile fashion.  The right femoral region was infiltrated with subcutaneous lidocaine, adequate anesthesia was obtained.  The right femoral artery was entered with _______ modified Seldinger technique and a J wire was passed.  The needle was exchanged for 6 French sheath.  The wire was removed.  The sheath was washed with sterile saline.  Following this, the left coronary was attempted to be cannulated with an XP catheter, however, the catheter folded on itself and could not reach the left main, this was removed.  A second 6-French JL4 guiding catheter was then used to cannulate the left main and initial guiding shots demonstrated occlusion of the proximal LAD.  The patient had an ACT check, received additional IV heparin and IV ReoPro.  The lesion was crossed with 0.014 BMW wire and redilated with a 2.5 x 20-mm balloon at nominal pressures.  The balloon was deflated and angiography demonstrated establishment of flow.  Following this, the lesion was stented with a 2.5 x 18-mm Endeavor stent at 10 atmospheres.  The balloon was deflated, reinflated at 12 atmospheres, deflated and removed.  Final angiography demonstrated excellent clinical result.  Additional angiography was performed with a wire out.  Following this, the wire and the catheter was removed.  Following this, the right coronary was selectively cannulated with diagnostic catheter and angiographic views were obtained in multiple views.  This catheter was removed.  The pigtail catheter was placed in the left ventricle and left ventriculography was performed with pullback pressures across the aortic valve.  At the end of procedure, wires and catheter were removed.  Right femoral angiography was performed and a right femoral Angio-Seal kit was deployed at the right femoral arteriotomy site.  There was no hematoma.  Peripheral pulses _______ procedure.  The patient tolerated the procedure well.  Symptoms of chest pain resolved at the end of the procedure with no complications.,RESULTS:,1.  Coronary angiography.,A.  Left main free of obstruction.,B.  LAD, subtotal proximal stenosis.,C.  Circumflex large vessel with three large obtuse marginal branches.  No high-grade obstruction, evidence of minimal plaquing.,D.  Right coronary 70% mid vessel stenosis and 50% mid to distal stenosis before giving rise to a right dominant posterior lateral and posterior descending artery.,2.  Left ventriculogram.  Left ventricular ejection fraction estimated at 45% to 50%.  There was an akinetic apical wall.,3.  Hemodynamics.  Aortic pressure 145/109, left ventricular pressure 147/13, left ventricular end-diastolic pressure 34 mmHg.,IMPRESSION:,1.  Acute ST-elevation myocardial infarction, culprit lesion, left anterior descending occlusion.,2.  Two-vessel coronary disease.,3.  Mild-to-moderate impaired LV systolic function.,4.  Successful stent left anterior descending, 100% occlusion, 0% residual stenosis.,PLAN:  ,Overnight observation in ICU.  Start aspirin, Plavix, beta-blocker and ACE inhibitor.  Check serial cardiac enzymes.  Further recommendations to follow.  Check fasting lipid panel, in addition add a statin.  Further recommendations to follow.",
" Right heart and left heart catheterization by way of right femoral artery, right femoral vein, and right internal jugular vein.", Surgery, Cardiac Catheterization - 6 ,"PRECATHETERIZATION DIAGNOSIS (ES):, Hypoplastic left heart, status post Norwood procedure and Glenn shunt.,POSTCATHETERIZATION DIAGNOSIS (ES):,1. Hypoplastic left heart.,A. Status post Norwood.,B. Status post Glenn.,2. Left pulmonary artery hypoplasia.,3. Diminished right ventricular systolic function.,4. Trivial neo-aortic stenosis.,5. Trivial coarctation.,6. Flow to right upper lobe more than left upper lobe from collaterals arising from branches of the aortic arch.,PROCEDURE (S):, Right heart and left heart catheterization by way of right femoral artery, right femoral vein, and right internal jugular vein.,I. PROCEDURES:, XXXXXX was brought to the catheterization lab and was anesthetized by anesthesia. He was intubated. His supplemental oxygen was weaned to 24%, on which all of his hemodynamics were obtained. The patient was prepped and draped in the routine sterile fashion, including both groins and the right neck. Xylocaine was administered in the right femoral area. A 6-French sheath was introduced into the right femoral vein percutaneously without complication. A 4-French sheath was introduced into the right femoral artery percutaneously without complication. A 4-French pigtail catheter was introduced and passed to the abdominal aorta.,Dr. Hayes, using the SiteRite device, introduced a 5-French sheath into the right internal jugular vein without complication.,A 5-French wedge catheter was introduced through the sheath in the right internal jugular vein and was passed to the left pulmonary artery and further to the left pulmonary capillary wedge position. This catheter would not pass to the right pulmonary artery. The wedge catheter was removed. A 5-French IMA catheter was then introduced and passed to the right pulmonary artery. After right pulmonary artery pressure was measured, this catheter was removed.,The 5 wedge catheter was advanced through the right femoral sheath and was passed to the following chambers or vessels: Inferior vena cava, right atrium, left atrium, and right ventricle.,The previously introduced 4 pigtail catheter was advanced to the ascending aorta. Simultaneous right ventricular and ascending aortic pressures were measured. A pullback from ascending aorta to descending aorta was then performed. Simultaneous measurements of right ventricular and descending aortic pressures were measured.,The wedge catheter was removed. A 5-French Berman catheter was advanced down the Glenn shunt to the right pulmonary artery, where a pullback from right pulmonary artery to Glenn shunt was performed. An injection was then performed using Omnipaque 16 mL at 8 mL per second with the Berman catheter positioned in the Glenn shunt. The 5-French Berman was removed.,A 6-French Berman was introduced through the right femoral vein sheath and was advanced to the right ventricle. A right ventriculogram was performed using Omnipaque 18 mL at 12 mL per second. The Berman catheter was pulled back to the inferior vena cava, where an inferior vena cavagram was performed using Omnipaque 10 mL at 8 mL per second.,The 4-French pigtail catheter was advanced to the ascending aorta and an ascending aortogram was performed using Omnipaque 16 mL at 12 mL per second.,Following the ascending angiograms, two kidneys and a bladder were noted. The catheters and sheaths were removed, and hemostasis was obtained by direct pressure. The estimated blood loss was less than 30 mL, and none was replaced. Heparin was administered following placement of all of the sheaths. Pulse oximetry saturation, pulse in the right foot, and EKG were monitored continuously.,II. PRESSURES:,A. Left pulmonary artery, mean of 11; left capillary wedge, mean of 9; main pulmonary artery, mean of 12; right pulmonary artery, mean of 10; descending aorta, 75/45, mean of 57; right atrium, A6 to 9, V6 to 8, mean 7; left atrium, mean 8; inferior vena cava, mean 7.,B. Ascending aorta, 65/35, with a simultaneous right ventricular pressure of 70/10; descending aorta, 60/35, with a right ventricular pressure of 72/10.,C. Pullbacks, left pulmonary artery to main pulmonary artery, mean of 11 to mean of 12; main pulmonary artery to Glenn, mean of 12 to mean of 13; right pulmonary artery to Glenn, mean of 12 to mean of 13; ascending aorta 68/35 to descending aorta 62/35.,INTERPRETATION:, Right and left pulmonary artery pressures are appropriate for this situation. There is a gradient of, at most, 2 mmHg on pullback from both the right and left pulmonary arteries to the Glenn shunt. The left atrial mean pressure is normal. Right ventricular end-diastolic pressure is, at most, slightly elevated. There is a trivial gradient between the right ventricle and ascending aorta consistent with trivial neo-aortic valve stenosis. There is a roughly 10-mm gradient between the right ventricle and descending aorta, consistent with additional coarctation of the aorta. On pullback from ascending to descending aorta, there is a 6-mmHg gradient between the two. Systemic blood pressure is normal.,III. OXIMETRY:, Superior vena cava 65, right pulmonary artery 67, left pulmonary artery 65, left atrium 96, right atrium 87, inferior vena cava 69, aorta 86, right ventricle 83.,INTERPRETATION:, Systemic arteriovenous oxygenation difference is normal, consistent with a normal cardiac output. Left atrial saturation is fairly normal, consistent with normal oxygenation in the lungs. The saturation falls passing from the left atrium to the right atrium and further to the right ventricle, consistent with mixing of pulmonary venous return and inferior vena cava return, as would be expected in this patient.,IV. SPECIAL PROCEDURE (S):, None done.,V. CALCULATIONS:,Please see the calculation sheet. Calculations were based upon an assumed oxygen consumption. The _____ saturation used was 67%, with a pulmonary artery saturation of 65%, a left atrial saturation of 96%, and an aortic saturation of 86%. Using the above information, the pulmonary to systemic flow ratio was 0.6. Systemic blood flow was 5.1 liters per minute per meter squared. Pulmonary blood flow was 3.2 liters per minute per meter squared. Systemic resistance was 9.8 Wood's units times meter squared, which is mildly diminished. Pulmonary resistance was 2.5 Wood's units times meter squared, which is in the normal range.,VI. ANGIOGRAPHY:, The injection to the Glenn shunt demonstrates a wide-open Glenn connection. The right pulmonary artery is widely patent, without stenosis. The proximal portion of the left pulmonary artery is significantly narrowed, but does open up near its branch point. The right pulmonary artery measures 6.5, the left pulmonary artery measures 3.0 mm. The aorta at the diaphragm on a later injection was 5.5 mm. There is a small collateral off the innominate vein passing to the left upper lobe. Flow to both upper lobes is diminished versus lower lung fields. There is normal return of the pulmonary veins from the right, with simultaneous filling of the left atrium and right atrium. There is normal return of the left lower pulmonary vein and left upper pulmonary vein. There is some reflux of dye into the inferior vena cava from the right atrium.,The right ventriculogram demonstrates a heavily pedunculated right ventricle with somewhat depressed right ventricular systolic function. The calculated ejection fraction from the LAO projection is only mildly diminished at 59%. There is no significant tricuspid regurgitation. The neo-aortic valve appears to open well with no stenosis. The ascending aorta is dilated. There is mild narrowing of the aorta at the isthmal area. On some projections, there appears to be a partial duplication of the aortic arch, probably secondary to this patient's style of Norwood reconstruction. There is some filling of the right upper and left upper lobes from collateral blood flow, with the left being more opacified than the right.,The inferior vena cavagram demonstrates normal return of the inferior vena cava to the right atrium.,The ascending aortogram demonstrates trivial aortic insufficiency, which is probably catheter-induced. The coronary arteries are poorly seen. Again, a portion of the aorta appears to be partially duplicated. There is faint opacification of the left upper lung from collateral blood flow. The above-mentioned narrowing of the aortic arch is again noted.",
" White male with onset of chest pain, with history of on and off chest discomfort over the past several days.", Surgery, Cardiac Catheterization - 3 ,"INDICATIONS FOR PROCEDURE:, This is a 61-year-old, white male with onset of chest pain at 04: 30 this morning, with history of on and off chest discomfort over the past several days. CPK is already over 1000. There is ST elevation in leads II and aVF, as well as a Q wave. The chest pain is now gone, mild residual shortness of breath, no orthopnea. Cardiac monitor shows resolution of ST elevation lead III.,DESCRIPTION OF PROCEDURE:, Following sterile prep and drape of the right groin, installation of 1% Xylocaine anesthesia, the right common femoral artery was percutaneously entered and 6-French sheath inserted. ACT approximately 165 seconds on heparin. Borderline hypotension 250 mL fluid bolus given and nitroglycerin patch removed. Selective left and right coronary injections performed using Judkins coronary catheters with a 6-French pigtail catheter used to obtain left ventricular pressures and left ventriculography. Left pullback pressure. Sheath injection. Hemostasis obtained with a 6-French Angio-Seal device. He tolerated the procedure well and was transported to the Cardiac Step-Down Unit in stable condition.,HEMODYNAMIC DATA:, Left ventricular end diastolic pressure elevated post A-wave at 25 mm of Mercury with no aortic valve systolic gradient on pullback.,ANGIOGRAPHIC FINDINGS:,I. Left coronary artery: The left main coronary artery is unremarkable. The left anterior descending has 30 to 40% narrowing with tortuosity in its proximal portion, patent first septal perforator branch. The first diagonal branch is a 2 mm vessel with a 90% ostial stenosis. The second diagonal branch is unremarkable, as are the tiny distal diagonal branches. The intermediate branch is a small, normal vessel. The ostial non-dominant circumflex has some contrast thinning, but no stenosis, normal obtuse marginal branch, and small AV sulcus circumflex branch.,II. Right coronary artery: The right coronary artery is a large, dominant vessel which gives off large posterior descending and posterolateral left ventricular branches. There are luminal irregularities, less than 25%, within the proximal to mid vessel. Some contrast thinning is present in the distal RCA just before the bifurcation into posterior descending and posterolateral branches. A 25%, smooth narrowing at the origin of the posterior descending branch. Posterolateral branch is unremarkable and quite large, with secondary and tertiary branches.,III. Left ventriculogram: The left ventricle is normal in size. Ejection fraction estimated at 40 to 45%. No mitral regurgitation. Severe hypokinesis to akinesis is present in the posterobasal and posteromedial segments with normal anteroapical wall motion.,DISCUSSION:, Recent inferior myocardial infarction with only minor contrast thinning distal RCA remaining on coronary angiography with resolution of chest pain and ST segment elevation. Left coronary system has one hemodynamically significant stenosis (a 90% ostial stenosis at the first diagonal branch, which is a 2 mm vessel). Left ventricular function is reduced with ejection fraction 40 to 45% with inferior wall motion abnormality.,PLAN:, Medical treatment, including Plavix and nitrates, in addition to beta blocker, aspirin, and aggressive lipid reduction.","surgery, cpk, q wave, st elevation, french angio-seal, pigtail catheter, st segment, ejection fraction, wall motion, diagonal branch, posterior descending, coronary artery, catheterization, circumflex, rca, cardiac, st, elevation, ventricular, stenosis, artery, coronary, branch,"
" Left heart catheterization with coronary angiography, vein graft angiography and left ventricular pressure measurement and angiography.", Surgery, Cardiac Catheterization - 5 ,"PROCEDURE PERFORMED:,1. Left heart catheterization with coronary angiography, vein graft angiography and left ventricular pressure measurement and angiography.,2. Right femoral selective angiogram.,3. Closure device the seal the femoral arteriotomy using an Angio-Seal.,INDICATIONS FOR PROCEDURE: ,The patient with known coronary atherosclerotic heart disease and multiple risk factors of coronary disease, who had her last coronary arteriogram performed in 2004. She has had complaints of progressive chest discomfort, and has ongoing risks including current smoking, diabetes, hypertension, hyperlipidemia to name a few. The decision was made to proceed on with percutaneous evaluation and possible intervention given her known disease and the possibility of disease progression.,DESCRIPTION OF PROCEDURE:, After informed consent was obtained, The patient was taken to cardiac catheterization lab where her procedure was performed. She was prepped and prepared on the table; after which, her right groin was locally anesthetized with 1% lidocaine. Then, a 6-French sheath was inserted into the right femoral artery over a standard 0.035 guide wire. Coronary angiography and left ventricular measurement and angiography were performed using a 6-French JL4 diagnostic catheter to image the left coronary artery. A 6-French JR4 diagnostic catheter to image the right groin and her artery and the saphenous vein graft conduit. Subsequently, a 6-French angled pigtail catheter was used to measure left ventricular pressures and to perform a power injection, a left ventriculogram at 8 mL per second for a total of 30 mL. At the conclusion of the diagnostic evaluation, the patient had selective arteriography of her right femoral artery, which showed the right femoral artery to be free of significant atherosclerotic plaque. Did have a normal bifurcation into the superficial femoral and profunda femoris arteries and to have an arteriotomy that was in the common femoral artery away from the bifurcation. As such, an initial attempt to advance a Perclose device failed to allow the device descend to _____ tract and into the appropriate position within the artery. As such, the Perclose was never deployed and was removed intact over the wire from the system. We then replaced this with a 6-French Angio-Seal which was used to seal the femoral arteriotomy with achievement of hemostasis. The patient was subsequently dispositioned back to the MAC Unit where she will complete her bedrest prior to her disposition to home.,HEMODYNAMIC DATA:, Opening aortic pressure 125/60, left ventricular pressure 108/4 with an end-diastolic pressure of 16. There was no significant gradient across the aortic valve on pullback from the left ventricle. Left ventricular ejection fraction was 55%. Mitral regurgitation was less than or equal to 1+. There was normal wall motion in the RAO projection.,CORONARY ANGIOGRAM:, The left main coronary artery had mild atherosclerotic plaque. The proximal LAD was 100% occluded. The left circumflex had mild diffuse atherosclerotic plaque. The obtuse marginal branch which operates as an OM-2 had a mid approximately 80% stenosis at a kink in the artery. This appears to be the area of a prior anastomosis, the saphenous vein graft to the OM. This is a very small-caliber vessel and is 1.5-mm in diameter at best. The right coronary artery is dominant. The native right coronary artery had mild proximal and mid atherosclerotic plaque. The distal right coronary artery has an approximate 40% stenosis. The posterior left ventricular branch has a proximal 50 to 60% stenosis. The proximal PDA has a 40 to 50% stenosis. The saphenous vein graft to the right PDA is widely patent. There was competitive flow noted between the native right coronary artery and the saphenous vein graft to the PDA. The runoff from the PDA is nice with the native proximal PDA and PLV disease as noted above. There is also some retrograde filling of the right coronary artery from the runoff of this graft. The saphenous vein graft to the left anterior descending is widely patent. The LAD beyond the distal anastomosis is a relatively small-caliber vessel. There is some retrograde filling that allows some filling into a more proximal diagonal branch. The saphenous vein graft to the obtuse marginal was known to be occluded from the prior study in 2004. Overall, this study does not look markedly different than the procedure performed in 2004.,CONCLUSION:, 100% proximal LAD mild left circumflex disease with an OM that is a small-caliber vessel with an 80% lesion at a kink that is no amenable to percutaneous intervention. The native right coronary artery has mild to moderate distal disease with moderate PLV and PDA disease. The saphenous vein graft to the OM is known to be 100% occluded. The saphenous vein graft to the PDA and the saphenous vein graft to the LAD are open. Normal left ventricular systolic function.,PLAN:, The plan will be for continued medical therapy and risk factor modification. Aggressive antihyperlipidemic and antihypertensive control. The patient's goal LDL will be at or below 70 with triglyceride level at or below 150, and it is very imperative that the patient stop smoking.,After her bedrest is complete, she will be dispositioned to home, after which, she will be following up with me in the office within 1 month. We will also plan to perform a carotid duplex Doppler ultrasound to evaluate her carotid bruits.","surgery, catheterization, vein graft, angiography, angiogram, angio-seal, closure device, coronary atherosclerotic heart disease, saphenous vein graft, ventricular pressure, coronary artery, saphenous vein, atherosclerotic, coronary, artery, bifurcation, pda, ventricular, saphenous"
" Left heart catheterization, left ventriculogram, selective coronary arteriography, aortic arch angiogram, right iliofemoral angiogram, #6 French Angio-Seal placement.", Surgery, Cardiac Catheterization - 7 ,"INDICATIONS FOR PROCEDURE:, The patient has presented with crushing-type substernal chest pain, even in the face of a normal nuclear medicine study. She is here for catheterization.,APPROACH:, Right common femoral artery.,ANESTHESIA:, IV sedation per cardiac catheterization protocol. Local sedation with 1% Xylocaine.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS:, Less than 10 mL.,ESTIMATED CONTRAST:, Less than 150 mL.,PROCEDURES PERFORMED:, Left heart catheterization, left ventriculogram, selective coronary arteriography, aortic arch angiogram, right iliofemoral angiogram, #6 French Angio-Seal placement.,OPERATIVE TECHNIQUE:, The patient was brought to the cardiac catheterization lab in the usual fasting state. She was placed supine on the cardiac catheterization table and the right groin was prepped and draped in the usual sterile fashion. One percent Xylocaine was infiltrated into the right femoral vessels. Next, a #6 French sheath was then placed in the right common femoral artery by the modified Seldinger technique.,SELECTIVE CORONARY ARTERIOGRAPHY:, Next, right and left Judkins diagnostic catheters were advanced through their respective ostia and injected in multiple views.,LEFT VENTRICULOGRAM:, Next, a pigtail catheter was advanced across the aortic valve and left ventricular pressure recorded. Next, an LV-gram was then performed with a hand injection of 50 mL of contrast. Next, pull-back pressure was measured across the aortic valve.,AORTA ARCH ANGIOGRAM:, Next, aortic arch angiogram was then performed with injection of 50 mL of contrast at a rate of 20 mL/second to maximum pressure of 750 PSI performed in the 40-degree LAO view.,Next, right iliofemoral angiogram was performed in the 20-degree RAO view. Next Angio-Seal was applied successfully.,The patient left the cath lab without problems or issues.,DIAGNOSES:, Left ventricular end-diastolic pressure was 18 mmHg. There was no gradient across the aortic valve. The central aortic pressure was 160 mmHg.,LEFT VENTRICULOGRAM:, The left ventriculogram demonstrated normal LV systolic function with estimated ejection fraction greater than 50%.,AORTIC ARCH ANGIOGRAM: ,The aortic arch angiogram demonstrated normal aortic arch. No aortic regurgitation was seen.,SELECTIVE CORONARY ARTERIOGRAPHY:, The right coronary artery is large and dominant.,The left main is patent.,The left anterior descending is patent.,The left circumflex is patent.,IMPRESSION:, This study demonstrates normal coronary arteries in the presence of normal left ventricular systolic function. In addition, the aortic root is normal.",
 Cardiac catheterization.   Coronary artery disease plus intimal calcification in the mid abdominal aorta without significant stenosis., Surgery, Cardiac Catheterization - 12 ,"PREOPERATIVE DIAGNOSIS: , Coronary artery disease.,POSTOPERATIVE DIAGNOSIS: , Coronary artery disease plus intimal calcification in the mid abdominal aorta without significant stenosis.,DESCRIPTION OF PROCEDURE:,LEFT HEART CATHETERIZATION WITH ANGIOGRAPHY AND MID ABDOMINAL AORTOGRAPHY:,Under local anesthesia with 2% lidocaine with premedication, a right groin preparation was done.  Using the percutaneous Seldinger technique via the right femoral artery, a left heart catheterization was performed.  Coronary arteriography was performed with 6-French performed coronary catheters.  We used a 6-French JR4 and JL4 catheters to take multiple cineangiograms of the right and left coronary arteries.  After using the JR4 6-French catheter, nitroglycerin was administered because of the possibility of ostial spasm, and following that, we used a 5-French JR4 catheter for additional cineangiograms of the right coronary artery.  A pigtail catheter was placed in the mid abdominal aorta and abdominal aortic injection was performed to rule out abdominal aortic aneurysm, as there was dense calcification in the mid abdominal aorta.,ANALYSIS OF PRESSURE DATA: , Left ventricular end-diastolic pressure was 5 mmHg.  On continuous tracing from the left ventricle to the ascending aorta, there is no gradient across the aortic valve.  The aortic pressures were normal.  Contours of intracardiac pressure were normal.,ANALYSIS OF ANGIOGRAMS:,  Selective cineangiograms were obtained with injection of contrast to the left ventricle, coronary arteries, and mid abdominal aorta.  A pigtail catheter was introduced into the left ventricle and ventriculogram performed in right anterior oblique position.  The mitral valve is competent and demonstrates normal mobility.  The left ventricular cavity is normal in size with excellent contractility.  Aneurysmal dilatation and/or dyskinesia absent.  The aortic valve is tricuspid and normal mobility.  The ascending aorta appeared normal.,Pigtail catheter was introduced in the mid abdominal aorta and placed just above the renal arteries.  An abdominal aortic injection was performed.  Under fluoroscopy, we see heavy dense calcification of the mid abdominal aorta between the renal artery and the bifurcation.  There was some difficulty initially with maneuvering the wire pass that area and it was felt that might be a tight stenosis.  The abdominal aortogram reveals wide patency of that area with mild intimal irregularity.  There is a normal left renal artery, normal right renal artery.  The celiac seems to be normal, but what I believe is the splenic artery seen initially at its origin is normal.  The common left iliac and common right iliac arteries are essentially normal in this area.,CORONARY ANATOMY:,  One notes ostial coronary calcification of the right coronary artery.  Cineangiogram obtained with 6-French JR4 and 5-French JR4 catheters.  Prior to the introduction of the 5-French JR4 nitroglycerin was administered sublingually.  The 6-French JR4 catheters appeared to a show an ostial lesion of over 50%.  There was backwash of dye into the aorta, although there is a fine funneling of the ostium towards the proximal right coronary artery.  In the proximal portion of the right coronary artery just into the Shepherd turn, there is a 50% smooth tapering of the right coronary artery in the proximal third.  Then the artery seems to have a little bit more normal size and it divides into a large posterior descending artery posterolateral branch vessel.  The distal portion of the vessel is free of disease.  The conus branch is seen arising right at the beginning part of the right coronary artery.  We then removed the 6-French catheter and following nitroglycerin and sublingually we placed a 5-French catheter and again finding a stenosis, may be less than 50%.  At the ostium of the right coronary artery, calcification again is identified.  Backwash of dye noted at the proximal lesion, looked about the same 50% along the proximal turn of the Shepherd turn area.,The left coronary artery is normal, although there is a rim of ostial calcification, but there is no tapering or stenosis.  It forms the left anterior descending artery, the ramus branch, and the circumflex artery.,The left anterior descending artery is a very large vessel, very tortuous in its proximal segment, very tortuous in its mid and distal segment.  There appears to be some mild stenosis of 10% in the proximal segment.  It gives off a large diagonal branch in the proximal portion of the left anterior descending artery and it is free of disease.  The remaining portion of the left anterior descending artery is free of disease.  Upon injection of the left coronary artery, we see what I believe is the dye enters probably directly into the left ventricle, but via fistula excluding the coronary sinus, and we get a ventriculogram performed.  I could not identify an isolated area, but it seems to be from the interventricular septal collaterals that this is taking place.,The ramus branch is normal and free of disease.,The left circumflex artery is a tortuous vessel over the lateral wall and terminating in the inferoposterior wall that is free of disease.,The patient has a predominantly right coronary system.  There is no _______ circulation connecting the right and left coronary systems.,The patient tolerated the procedure well.  The catheter was removed.  Hemostasis was achieved.  The patient was transferred to the recovery room in a stable condition.,IMPRESSION:,1.  Excellent left ventricular contractility with normal left ventricular cavity size.,2.  Calcification of the mid abdominal aorta with wide patency of all vessels.  The left and right renal arteries are normal.  The external iliac arteries are normal.,3.  Essentially normal left coronary artery with some type of interventricular septal to left ventricular fistula.,4.  Ostial stenosis of the right coronary artery that appears to be about 50% or greater.  The proximal right coronary artery has 50% stenosis as well.,5.  Coronary calcification is seen under fluoroscopy at the ostia of the left and right coronary arteries.,RECOMMENDATIONS:  ,The patient has heavy calcification of the coronary arteries and continued risk factor management is needed.  The ostial lesion of the right coronary artery may be severe.  It is at least 50%, but it could be worse.  Therefore, she will be evaluated for the possibility of an IVUS and/or _______ analysis of the proximal right coronary artery.  We will reevaluate her stress nuclear study as well.  Continue aggressive medical therapy.","surgery, intimal calcification, stenosis, coronary artery disease, mid abdominal aorta, coronary artery, cardiac catheterization, coronary arteries, descending artery, calcification, mid, proximal, aorta, catheterization, abdominal, cardiac, intimal, coronary, artery, "
" Left Heart Catheterization.  Chest pain, coronary artery disease, prior bypass surgery.  Left coronary artery disease native.  Patent vein graft with obtuse marginal vessel and also LIMA to LAD.  Native right coronary artery is patent, mild disease.", Surgery, Cardiac Catheterization - 10 ,"EXAM: , Left Heart Catheterization,REASON FOR EXAM:,  Chest pain, coronary artery disease, prior bypass surgery.,INTERPRETATION: , The procedure and complications were explained to the patient in detail and formal consent was obtained.  The patient was brought to the cath lab.  The right groin was draped in the usual sterile manner.  Using modified Seldinger technique, a 6-French arterial sheath was introduced in the right common femoral artery.  A JL4 catheter was used to cannulate the left coronary arteries.  A JR4 catheter was used to cannulate the right coronary artery and also bypass grafts.  The same catheter was used to cannulate the vein graft and also LIMA.  I tried to attempt to cannulate other graft with Williams posterior catheter and also bypass catheter was unsuccessful.  A 6-French pigtail catheter was used to perform left ventriculography and pullback was done.  No gradient was noted.  Arterial sheath was removed.  Hemostasis was obtained with manual compression.  The patient tolerated the procedure very well without any complications.,FINDINGS:,1.  Native coronary arteries.  The left main is patent.  The left anterior descending artery is not clearly visualized.  The circumflex artery appears to be patent.  The proximal segment gives rise to small caliber obtuse marginal vessel.,2.  Right coronary artery is patent with mild distal and mid segment.  No evidence of focal stenosis or dominant system.,3.  Bypass graft LIMA to the left anterior descending artery patent throughout the body as well the anastomotic site.  There appears to be possible _______ graft to the diagonal 1 vessel.  The distal LAD wraps around the apex.  No stenosis following the anastomotic site noted.,4.  Vein graft to what appears to be obtuse marginal vessel was patent with a small caliber obtuse marginal 1 vessel.,5.  No other bypass grafts are noted by left ventriculography and also aortic root shot.,6.  Left ventriculography with an ejection fraction of 60%.,IMPRESSION:,1.  Left coronary artery disease native.,2.  Patent vein graft with obtuse marginal vessel and also LIMA to LAD.  _______ graft to the diagonal 1 vessel.,3.  Native right coronary artery is patent, mild disease.,RECOMMENDATIONS: , Medical treatment.","surgery, chest pain, coronary artery disease, bypass surgery, heart catheterization, lima, lad, obtuse marginal vessel, vein graft, obtuse marginal, marginal vessel, coronary artery, catheterization, coronary, artery, obtuse, marginal, bypass, vessel, graft"
" Left heart catheterization, LV cineangiography, selective coronary angiography, and right heart catheterization with cardiac output by thermodilution technique with dual transducer.", Surgery, Cardiac Catheterization ,"EXAMINATION: , Cardiac catheterization.,PROCEDURE PERFORMED: , Left heart catheterization, LV cineangiography, selective coronary angiography, and right heart catheterization with cardiac output by thermodilution technique with dual transducer.,INDICATION: , Syncope with severe aortic stenosis.,COMPLICATIONS:,  None.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained from the patient, the patient was brought to the cardiac catheterization laboratory in a post observed state.  The right groin was prepped and draped in the usual sterile fashion.  After adequate conscious sedation and local anesthesia was obtained, a 6-French sheath was placed in the right common femoral artery and a 8-French sheath was placed in the right common femoral vein.  Following this, a 7.5-French Swan-Ganz catheter was advanced into the right atrium where the right atrial pressure was 10/7 mmHg.  The catheter was then manipulated into the right ventricle where the right ventricular pressure was 37/10/4 mmHg.  The catheter was then manipulated into the wedge position where the wedge pressure was noted to be 22 mmHg.  The pulmonary arterial pressures were noted to be 31/14/21 mmHg.  Following this, the catheter was removed, the sheath was flushed and a 6-French JL4 diagnostic catheter was the advanced over the guidewire and the left main coronary artery was cannulated and selective angiogram was obtained in orthogonal views.  Following this, the catheter was exchanged over the guidewire for 6-French JR4 diagnostic catheter.  We were unable to cannulate the right coronary artery.  Therefore, we exchanged for a Williams posterior catheter and we were able to cannulate the right coronary artery and angiographs were performed in orthogonal views.  Following this, this catheter was exchanged over a guidewire for a 6-French Langston pigtail catheter and the left ventricle was entered and left ventriculography was performed.  Following this, the catheters were removed.  Sheath angiograms revealed the sheath to be in the right common femoral artery and the right common femoral arteriotomy was sealed using a 6-French Angio-Seal device.  The patient tolerated the procedure well.  There were no complications.,DESCRIPTION OF FINDINGS: , The left main coronary artery is a large vessel, which bifurcates into the left anterior descending artery and left circumflex artery and has moderate diffuse luminal irregularities with no critical lesions.  The left circumflex artery is a short vessel, which gives off one major obtuse marginal artery and has moderate diffuse luminal irregularities with no critical lesions.  The left anterior descending artery has moderate diffuse luminal irregularities and gives off two major diagonal branches.  There is a 70% ostial lesion in the first diagonal branch and the second diagonal branch has mild-to-moderate luminal irregularities.  The right coronary artery is a very large dominant vessel with a 60% to 70% lesion in its descending mid-portion.  The remainder of the vessel has moderate diffuse luminal irregularities with no critical lesions.  The left ventricle appears to be normal sized.  The aortic valve is heavily calcified.  The estimated ejection fraction is approximately 60%.  There was 4+ mitral regurgitation noted.  The mean gradient across the aortic valve was noted to be 33 mmHg yielding an aortic valve area of 0.89 cm2.,CONCLUSION:,1.  Moderate-to-severe coronary artery disease with a high-grade lesion seen at the ostium of the first diagonal artery as well as a 60% to 70% lesion seen at the mid portion of the right coronary artery.,2.  Moderate-to-severe aortic stenosis with an aortic valve area of 0.89 cm2.,3.  4+ mitral regurgitation.,PLAN: , The patient will most likely need a transesophageal echocardiogram to better evaluate the valvular architecture and the patient will be referred to Dr Kenneth Fang for possible aortic valve replacement as well as mitral valve repair/replacement and possible surgical revascularization.","surgery, heart catheterization, cineangiography, selective coronary angiography, thermodilution technique, transducer, diffuse luminal irregularities, cardiac catheterization, luminal irregularities, aortic valve, coronary artery, artery, catheterization, regurgitation, angiography, thermodilution, coronary,"
 The patient with atypical type right arm discomfort and neck discomfort., Surgery, Cardiac Catheterization - 2 ,"INDICATIONS FOR PROCEDURE:, The patient has presented with atypical type right arm discomfort and neck discomfort. She had noninvasive vascular imaging demonstrating suspected right subclavian stenosis. Of note, there was bidirectional flow in the right vertebral artery, as well as 250 cm per second velocities in the right subclavian. Duplex ultrasound showed at least a 50% stenosis.,APPROACH:, Right common femoral artery.,ANESTHESIA:, IV sedation with cardiac catheterization protocol. Local infiltration with 1% Xylocaine.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS:, Less than 10 ml.,ESTIMATED CONTRAST:, Less than 250 ml.,PROCEDURE PERFORMED:, Right brachiocephalic angiography, right subclavian angiography, selective catheterization of the right subclavian, selective aortic arch angiogram, right iliofemoral angiogram, 6 French Angio-Seal placement.,DESCRIPTION OF PROCEDURE:, The patient was brought to the cardiac catheterization lab in the usual fasting state. She was laid supine on the cardiac catheterization table, and the right groin was prepped and draped in the usual sterile fashion. 1% Xylocaine was infiltrated into the right femoral vessels. Next, a #6 French sheath was introduced into the right femoral artery via the modified Seldinger technique.,AORTIC ARCH ANGIOGRAM:, Next, a pigtail catheter was advanced to the aortic arch. Aortic arch angiogram was then performed with injection of 45 ml of contrast, rate of 20 ml per second, maximum pressure 750 PSI in the 4 degree LAO view.,SELECTIVE SUBCLAVIAN ANGIOGRAPHY:, Next, the right subclavian was selectively cannulated. It was injected in the standard AP, as well as the RAO view. Next pull back pressures were measured across the right subclavian stenosis. No significant gradient was measured.,ANGIOGRAPHIC DETAILS:, The right brachiocephalic artery was patent. The proximal portion of the right carotid was patent. The proximal portion of the right subclavian prior to the origin of the vertebral and the internal mammary showed 50% stenosis.,IMPRESSION:,1. Moderate grade stenosis in the right subclavian artery.,2. Patent proximal edge of the right carotid.","surgery, discomfort, subclavian stenosis, artery, french angio-seal, lao view, rao view, aortic arch angiogram, arch angiogram, cardiac catheterization, aortic arch, brachiocephalic, cardiac, angiography, aortic, angiogram, stenosis, catheterization, atypical, subclavian, "
 Percutaneous intervention with drug-eluting stent placement to the ostium of the PDA., Surgery, Cardiac Catheterization - 4 ,"PROCEDURES PERFORMED:,1. Left heart catheterization with coronary angiography and left ventricular pressure measurement.,2. Left ventricular angiography was not performed.,3. Right posterior descending artery percutaneous transluminal coronary angioplasty followed by stenting.,4. Right femoral artery angiography.,5. Perclose to seal the right femoral arteriotomy.,INDICATIONS FOR PROCEDURE:, Patient presenting with a history of coronary artery disease in the past with coronary angiography in the early 1990s. The patient presented with what appeared to be a COPD exacerbation and had mildly positive cardiac enzyme markers suggestive of a non-ST elevation myocardial infarction. He was subsequently dispositioned to the cardiac catheterization lab for further evaluation.,DESCRIPTION OF PROCEDURE:, After informed consent was obtained, the patient was taken to the cardiac catheterization lab, where his procedure was performed. The patient was appropriately prepped and prepared on the table, after which his right groin was locally anesthetized with 1% lidocaine. Then, a 6-French sheath was inserted into the right femoral artery. Over a standard 0.035 guidewire, coronary angiography and left ventricular pressure measurements were performed using a 6-French JL4 diagnostic catheter to image the left coronary artery, a 6-French JR4 diagnostic catheter to image the right coronary artery, a 6-French angled pigtail catheter to measure left ventricular pressure. At the conclusion of the diagnostic study, the case was progressed to percutaneous coronary intervention, which will be described below. Subsequently, right femoral artery angiography was performed which showed right femoral artery which was free of significant atherosclerotic plaque, and an arteriotomy that was suitable for a closure device. Then, a Perclose was used to seal the right femoral arteriotomy.,HEMODYNAMIC DATA:, The opening aortic pressure was 91/63. The left ventricular pressure was 94/13 with an end-diastolic pressure of 24. Left ventricular ejection fraction was not assessed, as ventriculogram was not performed. The patient did have some elevated creatinine earlier in this hospital course which warranted limitation of contrast where possible.,CORONARY ANGIOGRAM:, The left main coronary artery was angiographically okay. The LAD had mild diffuse disease. There appeared to be distal tapering of the LAD. The left circumflex had mild diffuse disease. In the very distal aspect of the circumflex after OM-3 and OM-4 type branch, there was a long, severely diseased segment that appeared to be chronic and subtotal in one area. The runoff from this area appeared to be a very small PLOM type branch and continuation of a circ which did not appear to supply much territory, and there was not much to salvage by approaching this lesion. The right coronary artery had mild diffuse disease. The PLV branch was 100% occluded at its ostium at the crux. The PDA at the ostium had an 80% stenosis. The PDA was a fairly sizeable vessel with a long course. The right coronary is dominant.,CONCLUSION:, Mild diffuse coronary artery disease with severe distal left circumflex lesion with not much runoff beyond this lesion. This circumflex appears to be chronically diseased and has areas that appear to be subtotal. There is a 100% PLV branch which is also chronic and reported in his angiogram in the 1990s. There is an ostial 80% right PDA lesion. The plan is to proceed with percutaneous intervention to the right PDA.,The case was then progressed to percutaneous intervention of the right PDA. A 6-French JR4 guide catheter with side holes was selected and used to engage the right coronary artery ostium. The lesion was crossed with a long BMW 0.014 guidewire. Then, we ballooned the lesion with a 2.5 x 9 mm Maverick balloon. Subsequently, we stented the lesion with a 2.5 x 16 mm Taxus drug-eluting stent with a nice angiographic result. The patient tolerated the procedure very well, without complications.,ANGIOPLASTY CONCLUSION:, Successful percutaneous intervention with drug-eluting stent placement to the ostium of the PDA.,RECOMMENDATIONS:, Aspirin indefinitely, and Plavix 75 mg p.o. daily for no less than six months. The patient will be dispositioned back to telemetry for further monitoring.,TOTAL MEDICATIONS DURING PROCEDURE:, Versed 1 mg and fentanyl 25 mcg for conscious sedation. Heparin 8400 units IV was given for anticoagulation. Ancef 1 g IV was given for closure device prophylaxis.,CONTRAST ADMINISTERED:, 200 mL.,FLUOROSCOPY TIME:, 12.4 minutes.","surgery, coronary angiography, ventricular pressure, coronary angioplasty, french, pda, drug-eluting stent, coronary artery disease, cardiac catheterization lab, plv branch, cardiac catheterization, femoral artery, coronary artery, artery, coronary, angioplasty, angiogram, angiographically, arteriotomy, angiography, cardiac, circumflex, ostium, ventricular, femoral, percutaneous, catheterization, "
" Left Cardiac Catheterization, Left Ventriculography, Coronary Angiography and Stent Placement.", Surgery, Cardiac Cath & Coronary Angiography ,"PROCEDURE:,  Left Cardiac Catheterization, Left Ventriculography, Coronary Angiography and Stent Placement.,INDICATIONS: , Atherosclerotic coronary artery disease.,PATIENT HISTORY: , This is a 55-year-old male.  He presented with 3 hours of unstable angina.,PAST CARDIAC HISTORY: , History of previous arteriosclerotic cardiovascular disease.  Previous ST elevation MI.,REVIEW OF SYSTEMS.,  The creatinine value is 1.3 mg/dL mg/dL.,PROCEDURE MEDICATIONS:,1.  Visipaque 361 mL total dose.,2.  Clopidogrel bisulphate (Plavix) 225 mg PO,3.  Promethazine (Phenergan) 12.5 mg total dose.,4.  Abciximab (Reopro) 10 mg IV bolus,5.  Abciximab (Reopro) 0.125 mcg/kg/minute, 4.5 mL/250 mL D5W x 17 mL,6.  Nitroglycerin 300 mcg IC total dose.,DESCRIPTION OF PROCEDURE:,APPROACH: , Left heart catheterization via right femoral artery approach.,ACCESS METHOD: , Percutaneous needle puncture.,DEVICES USED:,1.  Balloon catheter utilized:  Manufacturer:  Boston Sci Quantum Maverick RX 2.75mm x 20mm.,2.  Cordis Vista Brite Tip 6Fr JR 4.0,3.  ACS/Guidant Sport .014"" (190cm) Wire,4.  Stent utilized:  Boston Sci Taxus RX Stent 3.0mm x 32mm.,FINDINGS/INTERVENTIONS:,LEFT VENTRICULOGRAPHY:,  The overall left ventricular systolic function is mildly reduced.  Left ventricular ejection fraction is 40% by left ventriculogram.  Mild hypokinesis of the anterior wall of the left ventricle.  There was no transaortic gradient.  Mitral valve regurgitation is not seen.,LEFT MAIN CORONARY ARTERY:  ,  There were no obstructing lesions in the left main coronary artery.  Blood flow appeared normal.,LEFT ANTERIOR DESCENDING ARTERY: , There was a 95%, discrete stenosis in the mid left anterior descending artery.  A drug eluting, Boston Sci Taxus RX Stent 3.0mm x 32mm stent was placed in the mid left anterior descending artery and post-dilated to 3.5 mm.  Post-procedure stenosis was 0%.  There was no dissection and no perforation.,LEFT CIRCUMFLEX ARTERY: , There was a 50%, diffuse stenosis in the left circumflex artery.,RIGHT CORONARY ARTERY:,  The right coronary artery is dominant to the posterior circulation.  There were no obstructing lesions in the right coronary artery.  Blood flow appeared normal.,COMPLICATIONS:,There were no complications during the procedure., ,IMPRESSION:,1.  Severe two-vessel coronary artery disease.,2.  Severe left anterior descending coronary artery disease.  There was a 95% mid left anterior descending artery stenosis.  The lesion was successfully stented.,3.  Moderate left circumflex artery disease.  There was a 50% left circumflex artery stenosis.  Intervention not warranted.,4.  The overall left ventricular systolic function is mildly reduced with ejection fraction of 40%.  Mild hypokinesis of the anterior wall of the left ventricle.,RECOMMENDATION:,1.  Clopidogrel (Plavix) 75 mg PO daily for 1 year.",
 Patient with significant angina with moderate anteroapical ischemia on nuclear perfusion stress imaging only.  He has been referred for cardiac catheterization., Surgery, Cardiac Catheterization - 11 ,"The patient and his wife had the opportunity to ask questions, all of which were answered for them and the patient stated in a clear, competent and coherent fashion that he wished to go forward with cardiac catheterization which I felt was appropriate.,PROCEDURE NOTE:  ,The patient was brought to the Cardiac Catheterization Lab in a fasting state.  All appropriate labs had been reviewed.  Bilateral groins were prepped and draped in the usual fashion for sterile conditions.  The appropriate time-out procedure was performed with appropriate identification of the patient, procedure, physician, position and documentation all done under my direct supervision and there were no safety issues raised by the staff.  He received a total of 2 mg of Versed and 50 mcg of Fentanyl utilizing titrated concentration with good effect.  Bilateral groins had been prepped and draped in the usual fashion.  Right femoral inguinal fossa was anesthetized with 1% topical lidocaine and a 6-French vascular sheath was put into place percutaneously via guide-wire exchanger with a finder needle.  All catheters were passed using a J-tipped guide-wire.  Left heart catheterization and left ventriculography performed using a 6-French pigtail catheter.  Left system coronary angiography performed using a 6-French JL4 catheter.  Right system coronary angiography performed using a 6-French CDRC catheter.  Following the procedure, all catheters were removed.  Manual pressure was held with the Neptune pad and the patient was discharged back to his room.  I inspected the femoral arteriotomy site after the procedure was complete and it was benign without evidence of hematoma nor bruit with intact distal pulses.  There were no apparent complications.  A total of 77 cc of Isovue dye and 1.4 minutes of fluoroscopy time were utilized during the case.,FINDINGS:,HEMODYNAMICS: , LV pressure is 120, EDP is 20, aortic pressure 120/62, mean of 82.,LV function is normal, EF 60%, no wall motion abnormalities.,CORONARY ANATOMY:,1.  Left main demonstrates 30-40% distal left main lesion which is tapering, not felt significantly obstructive.,2.  The LAD demonstrates proximal moderate 50% lesion and a severe mid-LAD lesion immediately after the take-off of this large diagonal of 99% which is quite severe with TIMI-3 flow throughout the LAD and the left main.,3.  The left circumflex demonstrates mid-90% severe lesion with TIMI-3 flow.,4.  The right coronary artery was the dominant artery giving rise to right posterior descending artery demonstrates mild luminal irregularity.  There is a moderate distal PDA lesion of 60% seen.,IMPRESSION:,1.  Mild to moderate left main stenosis.,2.  Very severe mid-LAD stenosis with severe mid-left circumflex stenosis and moderate prox-LAD CAD.,We are going to continue the patient's aspirin, beta blocker as heart rate tolerates as he tends to run on the bradycardic side and add statin.  We will check a fasting lipid profile and ALT and titrate statin therapy to keep LDL of 70 mg/deciliter or less but in the past the patient's LDL had been higher or high.","surgery, wall motion abnormalities, cardiac catheterization, mid lad, timi flow, femoral arteriotomy, catheterization, ischemia, angina, distal, stenosis, stress, artery, coronary, lad, cardiac,"
 Left cardiac catheterization with selective right and left coronary angiography.   Post infarct angina., Surgery, Cardiac Cath & Selective Coronary Angiography ,"PREOPERATIVE DIAGNOSIS: , Post infarct angina.,TYPE OF PROCEDURE: , Left cardiac catheterization with selective right and left coronary angiography.,PROCEDURE: , After informed consent was obtained, the patient was brought to the Cardiac Catheterization Laboratory, and the groin was prepped in the usual fashion.  Using 1% lidocaine, the right groin was infiltrated, and using the Seldinger technique, the right femoral artery was cannulated.  Through this, a moveable guidewire was then advance to the level of the diaphragm, and through it, a 6 French pigtail catheter was advanced under hemodynamic monitoring to the ascending aorta and inserted into the left ventricle.  Pressure measurements were obtained and cineangiograms in the RAO and LAO positions were then obtained.  Catheter was then withdrawn and a #6 French non-bleed-back sidearm sheath was then introduced, and through this, a 6 French Judkins left coronary catheter was then advanced under hemodynamic monitoring to the left coronary ostium, engaged.  Cineangiograms were obtained of the left coronary system.  This catheter was then exchanged for a Judkins right 4 coronary catheter of similar dimension and under hemodynamic monitoring again was advanced to the right coronary ostium, engaged.  Cineangiograms were obtained, and the catheter and sheath were then withdrawn.  The patient tolerated the procedure well and left the Cardiac Catheterization Laboratory in stable condition.  No evidence of hematoma formation or active bleeding.  ,COMPLICATIONS: , None.  ,TOTAL CONTRAST: , 110 cc of Hexabrix.  ,TOTAL FLUOROSCOPY TIME:  ,1.8 minutes.  ,MEDICATIONS: , Reglan 10 mg p.o., 5 mg p.o.  Valium, Benadryl 50 mg p.o. and heparin 3,000 units IV push.","surgery, selective, angiography, post infarct angina, engaged cineangiograms, coronary angiography, hemodynamic monitoring, cardiac catheterization, catheterization, cineangiograms, cardiac, coronary,"
" Left calcaneal lengthening osteotomy with allograft, partial plantar fasciotomy, posterior subtalar and tibiotalar capsulotomy, and short leg cast placed.", Surgery, Calcaneal Lengthening Osteotomy ,"PREOPERATIVE DIAGNOSES:,  Left calcaneal valgus split.,POSTOPERATIVE DIAGNOSES:,  Left calcaneal valgus split.,PROCEDURES:  ,1.  Left calcaneal lengthening osteotomy with allograft.,2.  Partial plantar fasciotomy.,3.  Posterior subtalar and tibiotalar capsulotomy.,4.  Short leg cast placed.,ANESTHESIA: , Surgery performed under general anesthesia.,TOURNIQUET TIME: , 69 minutes.,The patient in local anesthetic of 20 mL of 0.25% Marcaine plain.,COMPLICATIONS: , No intraoperative complications.,DRAINS:  ,None.,SPECIMENS: , None.,HISTORY AND PHYSICAL: , The patient is a 13-year-old female who had previous bilateral feet correction at 1 year of age.  Since that time, the patient has developed significant calcaneal valgus deformity with significant pain.  Radiographs confirmed collapse of the spinal arch, as well as valgus position of the foot.  Given the patient's symptoms, surgery is recommended for calcaneal osteotomy and Achilles lengthening.  Risks and benefits of surgery were discussed with the mother.  Risks of surgery include risk of anesthesia; infection; bleeding; changes in sensation in most of extremity; hardware failure; need for later hardware removal; possible nonunion; possible failure to correct all the deformity; and need for other surgical procedures.  The patient will need to be strict nonweightbearing for at least 6 weeks and wear a brace for up to 6 months.  All questions were answered and parents agreed to the above surgical plan.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and placed supine on the operating table.  General anesthesia was then administered.  The patient received Ancef preoperatively.  A bump was placed underneath the left buttock.  A nonsterile tourniquet was placed on the upper aspect of the left thigh.  The extremity was then prepped and draped in a standard surgical fashion.  The patient had a previous incision along the calcaneocuboid lateral part of the foot.  This was marked and extended proximally through the Achilles tendon.  Extremity was wrapped in Esmarch.  Tourniquet inflation was noted to be 250 mmHg.  Decision was then made to protect the sural nerve.  There was one sensory nervous branch that did cross the field though it was subsequently sharply ligated because it was in the way.  Dissection was carried down to Achilles tendon, which was subsequently de-lengthened with the distal half performed down the lateral thigh.  Proximal end was tacked with an 0 Ethibond suture and subsequently repaired end-on-end at length with the heel in neutral.  Dissection was then carried on the lateral border of the foot with identification of the peroneal longus and valgus tendons, which were removed from the sheath and retracted dorsally.  At this time, we also noted that calcaneocuboid joint appeared to be fused.  The area between the anterior and middle facets were plicated on fluoroscopy for planned osteotomy.  This was performed with a saw.  After a partial plantar fasciotomy was performed, this was released off an abductor digiti minimi.  The osteotomy was completed with an osteotome and distracted with the lamina spreader.  A tricortical allograft was then shaped and subsequently impacted into this area.  Final positioning was checked with multiple views of fluoroscopy.  It was subsequently fixed using a 0.94 K-wire and drilled from the heel anteriorly.  A pin was subsequently bent and cut short at the level of the skin.  The wound was then irrigated with normal saline.  The Achilles was repaired with this tie.  Please note during the case, it was noted the patient had continued significant stiffness despite the Achilles lengthening.  A posterior capsulotomy of the tibiotalar and subtalar joints were performed with increased 10 degrees of dorsiflexion.  Wound was then closed using #2-0 Vicryl and #4-0 Monocryl.  The surgical field was irrigated with 0.25% Marcaine and subsequently injected with more Marcaine at the end of the case.  The wound was clean and dry and dressed with Steri-Strips and Xeroform.  Skin was dressed with Xeroform and 4 x 4's.  Everything was wrapped with 4 x 4's in sterile Webril.  The tourniquet was released after 69 minutes.  A short-leg cast was then placed with good return of capillary refill to his toes.  The patient tolerated the procedure well and was subsequently taken to the recovery room in stable condition.,POSTOPERATIVE PLAN: , The patient will be hospitalized overnight for elevation, ice packs, neurovascular checks, and pain control.  The patient to be strict nonweightbearing.  We will arrange for her to get a wheelchair.  The patient will then follow up in about 10 to 14 days for a cast check, as well as pain control.  The patient will need an AFO script at that time.  Intraoperative findings are relayed to the parents.","surgery, calcaneal lengthening, osteotomy, allograft, plantar fasciotomy, capsulotomy, calcaneal valgus split, partial plantar fasciotomy, short leg cast, achilles lengthening, calcaneal valgus, tourniquet, plantar, valgus, achilles, calcaneal, "
" Capsulotomy left breast and flat advancement V to Y, left breast, for correction of lower pole defect (breast assymetry) status post previous breast surgery.", Surgery," Capsulotomy & Flat Advancement, Left Breast ","PREOPERATIVE DIAGNOSIS: , Breast assymetry, status post previous breast surgery.,POSTOPERATIVE DIAGNOSIS:  ,Breast assymetry, status post previous breast surgery.,OPERATION: , Capsulotomy left breast, flat advancement V to Y left breast for correction lower pole defect.,ANESTHESIA:,  LMA.,FINDINGS AND PROCEDURE:  ,The patient is a 35-year-old female who presents status post multiple breast surgeries with resultant flatness of the lower pole of the left breast.  The nipple inframammary fold distance is approximately 1.5 cm shorter than the fuller right breast.  The patient has bilateral Mentor-Smooth round moderate projection jell-filled mammary prosthesis, 225 cc.,The patient was marked in the upright position for mobilization of lateral skin flaps and increase in the length of the nipple inframammary fold distance.  She was then brought to the operating room and after satisfactory LMA anesthesia had been induced, the patient was prepped and draped in the usual manger.  The patient received a gram of Kefzol prior to beginning the procedure.  The previous inverted T-scar was excised down to the underlying capsule of the breast implant.  The breast was carefully dissected off of the underlying capsule.  Care being taken to preserve the vascular supply to the skin and breast flap.  When the anterior portion of the breast was dissected free of the underlying capsule, the posterior aspect of the capsule was then dissected off of the underlying pectoralis muscle.  A posterior incision was made on the backside of the capsule at the proximate middle portion of the capsule and then reflected inferiorly thereby creating a superior based capsular flap.  The lateral aspects of the capsule were then opened and the inferior edge of the capsule was then sutured to the underside of the inframammary flap with 2-0 Monocryl statures.  Care was taken to avoid as much exposure of the implant, as well as damage to the implant.  When the flap had been created and advanced, hemostasis was obtained and the area copiously irrigated with a solution of Bacitracin 50,000 units, Kefzol 1 g, gentamicin 80 mg, and 500 cc of saline.  The lateral skin both medially and laterally were then completely freed and the vertical incision of the inverted T was then extended the 2 cm and sutured with a trifurcation suture of 2-0 Biosyn.  This lengthened the vertical portion of the mastopexy scar to allow for descent of the implant and roundness of the inferior pole of the left breast.  The remainder of the inverted T was closed with interrupted sutures of 3 and 2-0 Biosyn and the skin was closed with continuous suture of 5-0 nylon.  Bacitracin and a standard breast dressing were applied.,The anesthesia was terminated and the patient was recovered in the operating room.  Sponge, instrument, needle count reported as corrected.  Estimated blood loss negligible.","surgery, capsulotomy, biosyn, breast, breast assymetry, kefzol, mentor-smooth, breast surgeries, flat advancement, inframammary fold, lower pole defect, mammary, mammary prosthesis, nipple, breast surgery, assymetry, inframammary, capsule"
" Coronary artery bypass grafting (CABG) x2, left internal mammary artery to the left anterior descending and reverse saphenous vein graft to the circumflex, St. Jude proximal anastomosis used for vein graft.  Off-pump Medtronic technique for left internal mammary artery, and a BIVAD technique for the circumflex.", Surgery, CABG - 2 ,"PREOPERATIVE DIAGNOSIS: , Angina and coronary artery disease.,POSTOPERATIVE DIAGNOSIS: , Angina and coronary artery disease.,NAME OF OPERATION: , Coronary artery bypass grafting (CABG) x2, left internal mammary artery to the left anterior descending and reverse saphenous vein graft to the circumflex, St. Jude proximal anastomosis used for vein graft.  Off-pump Medtronic technique for left internal mammary artery, and a BIVAD technique for the circumflex.,ANESTHESIA: , General.,PROCEDURE DETAILS: , The patient was brought to the operating room and placed in the supine position upon the table.  After adequate general anesthesia, the patient was prepped with Betadine soap and solution in the usual sterile manner.  Elbows were protected to avoid ulnar neuropathy, chest wall expansion avoided to avoid ulnar neuropathy, phrenic nerve protectors used to protect the phrenic nerve and removed at the end of the case.,A midline sternal skin incision was made and carried down through the sternum which was divided with the saw.  Pericardial and thymus fat pad was divided.  The left internal mammary artery was harvested and spatulated for anastomosis.  Heparin was given.,Vein resected from the thigh, side branches secured using 4-0 silk and Hemoclips.  The thigh was closed multilayer Vicryl and Dexon technique.  A Pulsavac wash was done, drain was placed.,The left internal mammary artery is sewn to the left anterior descending using 7-0 running Prolene technique with the Medtronic off-pump retractors.  After this was done, the patient was fully heparinized, cannulated with a 6.5 atrial cannula and a 2-stage venous catheter and begun on cardiopulmonary bypass and maintained normothermia.  Medtronic retractors used to expose the circumflex.  Prior to going on pump, we stapled the vein graft in place to the aorta.,Then, on pump, we did the distal anastomosis with a 7-0 running Prolene technique.  The right side graft was brought to the posterior descending artery using running 7-0 Prolene technique.  Deairing procedure was carried out.  The bulldogs were removed.  The patient maintained good normal sinus rhythm with good mean perfusion.  The patient was weaned from cardiopulmonary bypass.  The arterial and venous lines were removed and doubly secured.  Protamine was delivered.  Meticulous hemostasis was present.  Platelets were given for coagulopathy.  Chest tube was placed and meticulous hemostasis was present.  The anatomy and the flow in the grafts was excellent.  Closure was begun.,The sternum was closed with wire, followed by linea alba and pectus fascia closure with running 0 Vicryl sutures in double-layer technique.  The skin was closed with subcuticular 4-0 Dexon suture technique.  The patient tolerated the procedure well and was transferred to the intensive care unit in stable condition.,We minimized the pump time to 16 minutes for just the distal anastomosis of the circumflex in order to lessen the insult to the kidneys as the patient already has kidney failure with a creatinine of 3.0.","surgery, coronary artery disease, angina, coronary artery bypass grafting, internal mammary artery, coronary artery, vein graft, artery, bivad, cabg, medtronic, anastomosis, mammary, vein, circumflex,"
" Orthostatic cardiac allograft transplantation utilizing total cardiopulmonary bypass, open sternotomy covered with Ioban, insertion of Mahurkar catheter for hemofiltration via the left common femoral vein.", Surgery, Cardiac Allograft Transplant ,"PREOPERATIVE DIAGNOSES:,1.  Ischemic cardiomyopathy.,2.  Status post redo coronary artery bypass.,3.  Status post insertion of intraaortic balloon.,POSTOPERATIVE DIAGNOSES:,1.  Ischemic cardiomyopathy.,2.  Status post redo coronary artery bypass.,3.  Status post insertion of intraaortic balloon.,4.  Postoperative coagulopathy.,OPERATIVE PROCEDURE:,1.  Orthostatic cardiac allograft transplantation utilizing total cardiopulmonary bypass.,2.  Open sternotomy covered with Ioban.,3.  Insertion of Mahurkar catheter for hemofiltration via the left common femoral vein.,ANESTHESIA: , General endotracheal.,OPERATIVE PROCEDURE: , With the patient in the supine position, he was prepped from shin to knees and draped in a sterile field.  A right common femoral artery vein were then exposed through a longitudinal incision in the right groin and prepared for cardiopulmonary bypass.  A sternotomy incision was then opened and the lesions from the previous operative procedures were lysed and they were very dense and firm, freeing up the right atrium and the ascending aorta and anterior right ventricle.  The patient was heparinized and then a pursestring suture was placed in the right atrium superior and inferior just above the superior and inferior vena cava.  A percutaneous catheter for arterial return was placed using Seldinger technique through exposed right femoral artery and then two 3-mm catheters were inserted with two pursestring sutures in the right atrium just superior to inferior vena cava.  After satisfactory heparinization has been obtained, the patient was placed on cardiopulmonary bypass and another pursestring suture was placed in the right superior pulmonary vein and a catheter was placed for suction in the left atrium.  After the heart was brought to the operating room and triggered, the patient had the ascending aorta clamped and tapes were placed around superior and inferior vena cava and were secured in place.  A cardiectomy was then performed by starting in the right atrium.  The wires from the pacemaker and defibrillator were transected coming from the superior vena cava and the Swan-Ganz catheter was brought out into the operative field.  Cardiectomy was then performed, first resecting the anterior portion of the right atrium and then transecting the aorta, the pulmonary artery, the septum between the right and left atriums, and then the heart was removed.  The right and left atrium, aorta, and pulmonary artery were prepared for the transplant.  First, we did a side-to-side anastomosis, continued to the left atrium and this was performed using 3-0 Prolene suture and a right atrial anastomosis side-to-side was performed using 3-0 Prolene suture.  The pulmonary artery was then anastomosed using 5-0 Prolene and the aorta was anastomosed with 4-0 Prolene.  The arterial anastomosis in the pulmonary artery and aorta were not completed until the heart was filled with blood.  Air was evacuated and the sutures were tied down.  The clamp on the ascending aorta was removed and the patient was gradually overtime weaned from cardiopulmonary bypass.  The patient had a postoperative coagulopathy which prolonged the period of time in the operating room after completion and weaning off of the cardiopulmonary bypass.  Blood factors and factor VII were given to try and correct the coagulopathy.  Because of excessive transfusions that were required, a Mahurkar catheter was inserted through the left common femoral vein, first placing a needle into the vein and then guidewire removed, and the needle dilators were then placed and then the Mahurkar catheter was then placed with 2-0 nylon suture.  Hemofiltration was started in the operating room at this time.  After he had satisfactory hemostasis, we decided to do the chest open and cover it with Ioban, which we did, and one chest tube was inserted into the mediastinum through a separate stab wound.  The patient also had an intraaortic balloon for counterpulsation which had been inserted into the left subclavian vein preoperatively.  This was left in place and the pulse generation, the pacemaker was in a right infraclavicular position, which was left in place because of the coagulopathy.  The patient received 11 units of packed red blood cells, 7 platelets, 23 fresh-frozen plasma, 20 cryoprecipitates, and factor VII.  Urine output for the procedure was 520 mL.  The preservation time of the heart is in the anesthesia sheet.  The estimated blood loss was at least 6 L.  The patient was taken to the intensive care unit in guarded condition.","surgery, cardiomyopathy, ioban, ischemic, ischemic cardiomyopathy, mahurkar catheter, orthostatic, seldinger, swan-ganz, allograft, aorta, balloon, cardiac, cardiopulmonary bypass, catheter, coagulopathy, coronary artery bypass, femoral vein, hemofiltration, intraaortic, intraaortic balloon, sternotomy, transplantation, ventricle, inferior vena cava, cardiac allograft, common femoral, vena cava, pulmonary artery, atrium, insertion, cardiopulmonary, artery"
" Cardiac Catheterization - An obese female with a family history of coronary disease and history of chest radiation for Hodgkin disease, presents with an acute myocardial infarction with elevated enzymes.", Surgery, Cardiac Catheterization - 1 ,"INDICATIONS FOR PROCEDURE:, A 51-year-old, obese, white female with positive family history of coronary disease and history of chest radiation for Hodgkin disease 20 years ago with no other identifiable risk factors who presents with an acute myocardial infarction with elevated enzymes. The chest pain occurred early Tuesday morning. She was treated with Plavix, Lovenox, etc., and transferred for coronary angiography and possible PCI. The plan was discussed with the patient and all questions answered.,PROCEDURE NOTE:, Following sterile prep and drape, the right groin and instillation of 1% Xylocaine anesthesia, the right femoral artery was percutaneously entered with a single wall puncture. A 6-French sheath inserted. Selective left and right coronary injections performed using Judkins coronary catheters with a 6-French pigtail catheter used to obtain left ventricle pressures, and a left ventriculography. The left pullback pressure. The catheters withdrawn. Sheath injection. Hemostasis obtained with a 6-French Angio-Seal device. She tolerated the procedure well.,Left ventricular end-diastolic pressure equals 25 mmHg post A wave. No aortic valve or systolic gradient on pullback.,ANGIOGRAPHIC FINDINGS:,I. Left coronary artery: The left main coronary artery is,normal. The left anterior descending extends to the apex and has only minor luminal irregularities within the midportion of the vessel. Normal diagonal branches. Normal septal perforator branches. The left circumflex is a nondominant vessel with only minor irregularities with normal obtuse marginal branches.,II. Right coronary artery: The proximal right coronary artery has a focal calcification. There is minor plaque with luminal irregularity in the proximal and midportion of the vessel with no narrowing greater than 10 to 20% at most. The right coronary artery is a dominant system which gives off normal posterior,descending and posterior lateral branches. TIMI 3 flow is present.,III. Left ventriculogram: The left ventricle is slightly enlarged with normal contraction of the base, but, with wall motion abnormality involving the anteroapical and inferoapical left ventricle with hypokinesis within the apical portion. Ejection fraction estimated 40%, 1+ mitral regurgitation (echocardiogram ordered).,DISCUSSION:, Recent inferoapical mild myocardial infarction by left ventriculography and cardiac enzymes with elevated left ventricular end-diastolic pressure post A wave, but, only minor residual coronary artery plaque with calcification proximal right coronary artery.,PLAN:, Medical treatment is contemplated, including ACE inhibitor, a beta blocker, aspirin, Plavix, nitrates. An echocardiogram is ordered to exclude apical left ventricular thrombus and to further assess ejection fraction.","surgery, cardiac catheterization, hodgkin disease, beta blocker, coronary angiography, coronary artery, coronary disease, elevated enzymes, inferoapical, myocardial infarction, ventriculogram, ventriculography, acute myocardial infarction, proximal right coronary, diastolic pressure, ejection fraction, coronary, echocardiogram, cardiac, catheterization, myocardial, enzymes, infarction, artery"
" Redo coronary bypass grafting x3, right and left internal mammary, left anterior descending, reverse autogenous saphenous vein graft to the obtuse marginal and posterior descending branch of the right coronary artery.  Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.  Placement of a right femoral intraaortic balloon pump.", Surgery, CABG - Redo ,"OPERATIVE PROCEDURE:,1.  Redo coronary bypass grafting x3, right and left internal mammary, left anterior descending, reverse autogenous saphenous vein graft to the obtuse marginal and posterior descending branch of the right coronary artery.  Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.,2.  Placement of a right femoral intraaortic balloon pump.,DESCRIPTION: , The patient was brought to the operating room and placed in the supine position.  After adequate endotracheal anesthesia was induced, appropriate monitoring lines were placed.  Chest, abdomen an legs were prepped and draped in sterile fashion.  The femoral artery on the right was punctured and a guidewire was placed.  The track was dilated and intraaortic balloon pump was placed in the appropriate position, sewn in place and ballooning started.,The left greater saphenous vein was harvested from the groin to the knee and prepared by ligating all branches with 4-0 silk and flushed with vein solution.  The leg was closed with running 3-0 Dexon subcu and running 4-0 Dexon on the skin.,The old mediastinal incision was opened.  The wires were cut and removed.  The sternum was divided in the midline.  Retrosternal attachments were taken down.  The left internal mammary was dissected free from its takeoff at the left subclavian bifurcation at the diaphragm and surrounded with papaverine-soaked gauze.  The heart was dissected free of its adhesions.  The patient was fully heparinized and cannulated with a single aorta and single venous cannula.  Retrograde cardioplegia cannula was attempted to be placed, but could not be fitted into the coronary sinus safely, therefore, it was banded and oversewn with 5-0 Prolene.  An antegrade cardioplegia needle sump was placed and secured to the ascending aorta.  Cardiopulmonary bypass ensued.  The ascending aorta was cross clamped.  Cold-blood potassium cardioplegia was given antegrade, a total of 10 cc/kg.  It was followed by sumping the ascending aorta.  The obtuse marginal was identified and opened and an end-to-side anastomosis was performed with a running 7-0 Prolene suture.  The vein was cut to length.  Antegrade cardioplegia was given, a total of 200 cc.  The posterior descending branch of the right coronary artery was identified, opened and end-to-side anastomosis then performed with a running 7-0 Prolene suture.  The vein was cut to length.  Antegrade cardioplegia was given.  The mammary was clipped distally, divided and spatulated for anastomosis.  The anterior descending was identified, opened and end-to-side anastomosis then performed with running 8-0 Prolene suture and warm blood potassium cardioplegia was given.  The cross clamp was removed.  A partial-occlusion clamp was placed.  Aortotomies were made.  The vein was cut to fit these and sutured in place with running 5-0 Prolene suture.  The partial-occlusion clamp was removed.  All anastomoses were inspected and noted to be patent and dry.  Atrial and ventricular pacing wires were placed.  The patient was fully warmed and ventilation was commenced.  The patient was weaned from cardiopulmonary bypass, ventricular balloon pumping and inotropic support and weaned from cardiopulmonary bypass.  The patient was decannulated in routine fashion.  Protamine was given.  Good hemostasis was noted.  A single mediastinal chest tube and bilateral pleural Blake drains were placed.  The sternum was closed with figure-of-eight stainless steel wire.  The linea alba was closed with figure-of-eight of #1 Vicryl, the sternal fascia closed with running #1 Vicryl, the subcu closed with running 2-0 Dexon, skin with running 4-0 Dexon subcuticular stitch.  The patient tolerated the procedure well.","surgery, coronary bypass grafting, internal mammary, cardiopulmonary, intraaortic, femoral artery, cabg, running prolene suture, intraaortic balloon, balloon pump, ascending aorta, prolene suture, cardiopulmonary bypass, potassium, aorta, anastomosis, prolene, coronary, cardioplegia, bypass,"
" Coronary artery bypass grafting (CABG) x4.  Progressive exertional angina, three-vessel coronary artery disease, left main disease, preserved left ventricular function.", Surgery, CABG x4 ,"PREOPERATIVE DIAGNOSES: , Progressive exertional angina, three-vessel coronary artery disease, left main disease, preserved left ventricular function.,POSTOPERATIVE DIAGNOSES:,  Progressive exertional angina, three-vessel coronary artery disease, left main disease, preserved left ventricular function.,OPERATIVE PROCEDURE: , Coronary artery bypass grafting (CABG) x4.,GRAFTS PERFORMED: , LIMA to LAD, left radial artery from the aorta to the PDA, left saphenous vein graft from the aorta sequential to the diagonal to the obtuse marginal.,INDICATIONS FOR PROCEDURE: , The patient is a 74-year-old gentleman, who presented with six-month history of progressively worsening exertional angina.  He had a positive stress test and cardiac cath showed severe triple-vessel coronary artery disease including left main disease with preserved LV function.  He was advised surgical revascularization of his coronaries.,FINDINGS DURING THE PROCEDURE:  ,The aorta was free of any significant plaque in the ascending portion at the sites of cannulation and cross clamp.  Left internal mammary artery and saphenous vein grafts were good quality conduits.  Radial artery graft was a smaller sized conduit, otherwise good quality.  All distal targets showed heavy plaque involvement with calcification present.  The smallest target was the PDA, which was about 1.5 mm in size.  All the other targets were about 2 mm in size or greater.  The patient came off cardiopulmonary bypass without any problems.  He was transferred on Neo-Synephrine, nitroglycerin, Precedex drips.  Cross clamp time was 102 minutes, bypass time was 120 minutes.,DETAILS OF THE PROCEDURE:  ,The patient was brought into the operating room and laid supine on the table.  After he had been interfaced with the appropriate monitors, general endotracheal anesthesia was induced and invasive monitoring lines including right IJ triple-lumen catheter and Cordis catheter, right radial A-line, Foley catheter, TEE probes were placed and interfaced appropriately.  The patient was then prepped and draped from chin to bilateral ankles including the left forearm in the usual sterile fashion.  Preoperative checkup of the left forearm has revealed good collateral filling from the ulnar with the radial occluded thus indicating good common arch and thus left radial artery was suitable for harvest.,After prepping and draping the patient from the chin to bilateral ankles including left forearm in the usual sterile fashion, proper time-out was conducted and site identification was performed, and subsequently incision was made overlying the sternum and median sternotomy was performed.  Left internal mammary artery was taken down.  Simultaneously, left forearm radial artery was harvested using endoscopic harvesting techniques.  Simultaneously, endoscopic left leg saphenous vein was harvested using endoscopic minimally invasive techniques.  Subsequent to harvest, the incisions were closed in layers during the course of the procedure.,Heparin was given.  Pericardium was opened and suspended.  During the takedown of the left internal mammary artery, it was noted that the left pleural space was globally softened and left lung was adherent to the chest wall and mediastinum globally.  Only a limited dissection was performed to free up the lung from the mediastinal structures to accommodate the left internal mammary artery.,Pericardium was opened and suspended.  Pursestring sutures were placed.  Aortic and venous as well as antegrade and retrograde cardioplegia cannulation was performed and the patient was placed on cardiopulmonary bypass.  With satisfactory flow, the aorta was cross clamped and the heart was arrested using a combination of antegrade and retrograde cold blood cardioplegia.  An initial dose of about 1500 mL was given and this was followed by intermittent doses given both antegrade and retrograde throughout the procedure to maintain a good arrest and to protect the heart.,PDA was exposed first.  The right coronary artery was calcified along its course all the way to its terminal bifurcation.  Even in the PDA, calcification was noted in a spotty fashion.  Arteriotomy on the PDA was performed in a soft area and 1.5 probe was noted to be accommodated in both directions.  End radial to side PDA anastomosis was constructed using running 7-0 Prolene.  Next, the posterolateral obtuse marginal was exposed.  Arteriotomy was performed.  An end saphenous vein to side obtuse marginal anastomosis was constructed using running 7-0 Prolene.  This graft was then apposed to the diagonal and corresponding arteriotomy and venotomies were performed and a diamond shaped side-to-side anastomosis was constructed using running 7-0 Prolene.  Next, a slit was made in the left side of the pericardium and LIMA was accommodated in the slit on its way to the LAD.  LAD was exposed.  Arteriotomy was performed.  An end LIMA to side LAD anastomosis was constructed using running 7-0 Prolene.  LIMA was tacked down to the epicardium securely utilizing its fascial pedicle.,Two stab incisions were made in the ascending aorta and enlarged using 4-mm punch.  Two proximal anastomosis were constructed between the proximal end of the saphenous vein graft and the side of the aorta, and the proximal end of the radial artery graft and the side of the aorta separately using running 6-0 Prolene.  The patient was given terminal dose of warm retrograde followed by antegrade cardioplegia during which de-airing maneuvers were performed.  Following this, the aortic cross clamp was removed and the heart was noted to resume spontaneous coordinated contractile activity.  Temporary V-pacing wires were placed.  Blake drains were placed in the left chest, the right chest, as well as in the mediastinum.  Left chest Blake drain was placed just in the medial section where dissection had been performed.  After an adequate period of rewarming during which time, temporary V-pacing wires were also placed, the patient was successfully weaned off cardiopulmonary bypass without any problems.  With satisfactory hemodynamics, good LV function on TEE and baseline EKG, heparin was reversed using protamine.  Decannulation was performed after volume resuscitation.  Hemostasis was assured.  Mediastinal and pericardial fat and pericardium were loosely reapproximated in the midline and chest was closed in layers using interrupted stainless steel wires to reappose the two sternal halves, heavy Vicryl for musculofascial closure, and Monocryl for subcuticular skin closure.  Dressings were applied.  The patient was transferred to the ICU in stable condition.  He tolerated the procedure well.  All counts were correct at the termination of the procedure.  Cross clamp time was 102 minutes.  Bypass time was 120 minutes.  The patient was transferred on Neo-Synephrine, nitroglycerin, and Precedex drips.","surgery, radial artery, lima, pda, obtuse marginal, exertional angina, coronary artery disease, triple-vessel, graft, conduit, ij triple-lumen catheter, cordis catheter, a-line, foley catheter, tee probes, coronary artery bypass grafting, cross clamp, mammary artery, saphenous vein, coronary artery, artery, cabg, coronary, grafting, aorta, angina, bypass"
" Coronary bypass graft x2 utilizing left internal mammary artery, the left anterior descending, reverse autogenous reverse autogenous saphenous vein graft to the obtuse marginal.  Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.", Surgery, CABG - 1 ,"PREOPERATIVE DIAGNOSIS: , Coronary occlusive disease.,POSTOPERATIVE DIAGNOSIS: , Coronary occlusive disease.,OPERATION PROCEDURE: , Coronary bypass graft x2 utilizing left internal mammary artery, the left anterior descending, reverse autogenous reverse autogenous saphenous vein graft to the obtuse marginal.  Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.,INDICATION FOR THE PROCEDURE:  ,The patient was a 71-year-old female transferred from an outside facility with the left main, proximal left anterior descending, and proximal circumflex severe coronary occlusive disease, ejection fraction about 40%.,FINDINGS: , The LAD was 2-mm vessel and good, mammary was good, and obtuse marginal was 2-mm vessel and good, and the main was good.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room and placed in the supine position.  Adequate general endotracheal anesthesia was induced.  Appropriate monitoring devices were placed.  The chest, abdomen and legs were prepped and draped in the sterile fashion.  The right greater saphenous vein was harvested and prepared by 2 interrupted skin incisions and by ligating all branches with 4-0 Surgilon and flushed with heparinized blood.  Hemostasis was achieved in the legs and closed with running 2-0 Dexon in the subcutaneous tissue and running 3-0 Dexon subcuticular in the skin.,Median sternotomy incision was made and the left mammary artery was dissected free from its takeoff of the subclavian to its bifurcation at the diaphragm and surrounded with papaverine-soaked gauze.  The pericardium was opened.  The pericardial cradle was created.  The patient was fully heparinized and cannulated with a single aortic and single venous cannula and bypass was instituted.  A retrograde cardioplegic cannula was placed with a pursestring suture of 4-0 Prolene suture in the right atrial wall into the coronary sinus and tied to a Rumel tourniquet.  An antegrade cardioplegic needle sump combination was placed in the ascending aorta and tied in place with 4-0 Prolene.  Cardiopulmonary bypass was instituted and the ascending aorta was crossclamped.  Antegrade cardioplegia was given at a total of 5 mL per kg through the aortic route.  This was followed by something in the aortic route and retrograde cardioplegia through the coronary sinus at a total of 5 mL per kg.  The obtuse marginal coronary was identified and opened.,End-to-side anastomosis was performed with a running 7-0 Prolene suture and the vein was cut to length.  Cold antegrade and retrograde potassium cardioplegia were given.  The mammary artery was clipped distally, divided and spatulated for anastomosis.  The anterior descending was identified and opened.  End-to-side anastomosis was performed with running 8-0 Prolene suture and the warm blood potassium cardioplegia was given antegrade and retrograde and the aortic cross-clamp was removed.  The partial occlusion clamp was placed.  Aortotomies were made.  The veins were cut to fit these and sutured in place with running 5-0 Prolene suture.  A partial occlusion clamp was removed.  All anastomoses were inspected and noted to be patent and dry.  Ventilation was commenced.  The patient was fully warm and the patient was then wean from cardiopulmonary bypass.  The patient was decannulated in routine fashion.  Protamine was given.  Good hemostasis was noted.  A single mediastinal chest tube and bilateral pleural Blake drains were placed.  The sternum was closed with figure-of-eight stainless steel wire plus two 5-mm Mersiline tapes.,The linea alba was closed with figure-of-eight of #1 Vicryl, the sternal fascia closed with running #1 Vicryl, the subcu closed with running 2-0 Dexon, skin with running 4-0 Dexon subcuticular stitch.  The patient tolerated the procedure well.","surgery, coronary occlusive disease, coronary bypass graft, cabg, myocardial, mammary artery, obtuse marginal, cardiopulmonary bypass, potassium cardioplegia, prolene suture, bypass, artery, anastomosis, autogenous, obtuse, marginal, cardiopulmonary, potassium, retrograde, cardioplegia, antegrade, coronary"
" Coronary artery bypass grafting times three utilizing the left internal mammary artery, left anterior descending and reversed autogenous saphenous vein graft to the posterior descending branch of the right coronary artery and obtuse marginal coronary artery, total cardiopulmonary bypass, cold blood potassium cardioplegia, antegrade and retrograde, for myocardial protection.", Surgery, CABG ,"TITLE OF PROCEDURE:  ,Coronary artery bypass grafting times three utilizing the left internal mammary artery, left anterior descending and reversed autogenous saphenous vein graft to the posterior descending branch of the right coronary artery and obtuse marginal coronary artery, total cardiopulmonary bypass, cold blood potassium cardioplegia, antegrade and retrograde, for myocardial protection.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room and placed in the supine position.  Adequate general endotracheal anesthesia was induced.  Appropriate monitoring devices were placed.  The chest, abdomen and legs were prepped and draped in the sterile fashion.  The right greater saphenous vein was harvested and prepared by ligating all branches with 4-0 Surgilon and flushed with heparinized blood.  Hemostasis was achieved in the legs and closed with running 2-0 Dexon in the subcutaneous tissue and running 3-0 Dexon subcuticular in the skin.  Median sternotomy incision was made and the left mammary artery was dissected free from its takeoff of the subclavian to its bifurcation at the diaphragm and surrounded with papaverine-soaked gauze.  The pericardium was opened.  The pericardial cradle was created.  The patient was fully heparinized and cannulated with a single aortic and single venous cannula and bypass was instituted.  A retrograde cardioplegic cannula was placed with a pursestring suture of 4-0 Prolene suture in the right atrial wall into the coronary sinus and tied to a Rumel tourniquet.  An antegrade cardioplegic needle sump combination was placed in the ascending aorta and tied in place with 4-0 Prolene.  The ascending aorta was crossclamped.  Cold blood potassium cardioplegia was given to the ascending aorta followed by sumping through the ascending aorta followed by cold retrograde potassium cardioplegia.  The obtuse marginal coronary artery was identified and opened and end-to-side anastomosis was performed to the reversed autogenous saphenous vein with running 7-0 Prolene suture and the vein was cut to length.  Cold antegrade and retrograde cardioplegia were given and the posterior descending branch of the right coronary artery was identified and opened.  End-to-side anastomosis was performed with a running 7-0 Prolene suture and the vein was cut to length.  Cold antegrade and retrograde potassium cardioplegia were given.  The mammary artery was clipped distally, divided and spatulated for anastomosis.  The anterior descending was identified and opened.  End-to-side anastomosis was performed through the left internal mammary artery with running 8-0 Prolene suture.  The mammary pedicle was sutured to the heart with interrupted 5-0 Prolene suture.  A warm antegrade and retrograde cardioplegia were given.  The aortic crossclamp was removed.  The partial occlusion clamp was placed.  Aortotomies were made.  The veins were cut to fit these and sutured in place with running 5-0 Prolene suture.  A partial occlusion clamp was removed.  All anastomoses were inspected and noted to be patent and dry.  Ventricular and atrial pacing wires were placed.  The patient was fully warmed and weaned from cardiopulmonary bypass.  The patient was decannulated in the routine fashion and Protamine was given.  Good hemostasis was noted.  A single mediastinal and left pleural chest tube were placed.  The sternum was closed with interrupted wire, linea alba with running 0 Prolene, the sternal fascia was closed with running 0 Prolene, the subcutaneous tissue with running 2-0 Dexon and the skin with running 3-0 Dexon subcuticular stitch.  The patient tolerated the procedure well.","surgery, cabg, cardioplegia, potassium, cardiopulmonary, coronary artery, marginal, obtuse, myocardial, autogenous, coronary artery bypass grafting, running prolene suture, saphenous vein, ascending aorta, prolene suture, artery, coronary, bypassNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Bunionectomy, right foot with Biopro hemi implant, right first metatarsophalangeal joint.  Arthrodesis, right second, third, and fourth toes with external rod fixation.  Hammertoe repair, right fifth toe.  Extensor tenotomy and capsulotomy, right fourth metatarsophalangeal joint.  Modified Tailor's bunionectomy, right fifth metatarsal.
", Surgery, Bunionectomy & Arthrodesis ,"PREOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus, right foot.,2.  Hammer toe, right foot, second, third, fourth and fifth toes.,3.  Tailor's bunionette, right foot.,4.  Degenerative joint disease, right first metatarsophalangeal joint.,5.  Rheumatoid arthritis.,6.  Contracted fourth right metatarsophalangeal joint.,POSTOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus, right foot.,2.  Hammer toe, right foot, second, third, fourth and fifth toes.,3.  Tailor's bunionette, right foot.,4.  Degenerative joint disease, right first metatarsophalangeal joint.,5.  Rheumatoid arthritis.,6.  Contracted fourth right metatarsophalangeal joint.,PROCEDURES PERFORMED:,1.  Bunionectomy, right foot with Biopro hemi implant, right first metatarsophalangeal joint.,2.  Arthrodesis, right second, third, and fourth toes with external rod fixation.,3.  Hammertoe repair, right fifth toe.,4.  Extensor tenotomy and capsulotomy, right fourth metatarsophalangeal joint.,5.  Modified Tailor's bunionectomy, right fifth metatarsal.,ANESTHESIA:,  TIVA/local.,HISTORY:,  This 51-year-old female presented to ABCD preoperative holding area after keeping herself NPO since mid night for surgery on her painful right foot bunion, hammer toes, and Tailor's bunion.  The patient has a long history of crippling severe rheumatoid arthritis.  She has pain with shoe gear and pain with every step.  She has tried multiple conservative measures under Dr. X's supervision consisting of wide shoe's and accommodative padding all which have provided inadequate relief.  At this time, she desires attempted surgical reconstruction/correction.  The consent is available on the chart for review and the risks versus benefits of this procedure have been discussed with patient in detail by Dr. X.,PROCEDURE IN DETAIL: , After IV was established by the Department of Anesthesia, the patient was taken to the operating room via cart and placed on the operating table in a supine position and a safety strap was placed across her waist for her protection.  Next, copious amounts of Webril were applied about the right ankle and a pneumatic ankle tourniquet was applied over the Webril.  Next, after adequate IV sedation was administered by the Department of Anesthesia, a total of 20 cc of 1:1 mixture of 0.5% Marcaine plain and 1% lidocaine were instilled into the right foot using a standard ankle block technique.  Next, the foot was prepped and draped in the usual aseptic fashion.  An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 230 mmHg.  The foot was lowered in the operative field.  The sterile stockinette was reflected and attention was directed to the right first metatarsophalangeal joint.  The joint was found to be severely contracted with lateral deviation of the hallux with a slightly overlapping contracted second toe.  In addition, the range of motion was less than 5 degrees of the first ray.  There was medial pinch callus and callus on the plantar right second metatarsal.  Using a #10 blade, a linear incision over the first metatarsophalangeal joint was then created approximately 4 cm in length.  Next, a #15 blade was used to deepen the incision to the subcutaneous tissue all which was found to be very thin taking care to protect the medial neurovascular bundle and the lateral extensor hallucis longus tendon.  Any small vein traversing the operative site were clamped with hemostat and ligated with electrocautery.  Next, the medial and lateral wound margins were undermined with sharp dissection.  The joint capsule was then visualized.  Two apparent soft tissue masses probably consistent with rheumatoid nodules were found at the distal medial aspect of the first metatarsal capsule.  A dorsal linear incision to the capsular tissue down to bone was performed with a #15 blade.  The capsule and periosteal tissues were elevated sharply off the metatarsal head and the base of proximal  phalanx.,A large amount of hypertrophic synovium was encountered over the metatarsophalangeal joint.  In addition, multiple hypertrophic exostosis were found dorsally, medially, and laterally over the metatarsal.  Upon entering the joint, the base of the proximal phalanx was grossly deformed and the medial and lateral aspect were widely flared and encompassing the metatarsal head.  A sagittal saw was used to carefully remove the base of the proximal phalanx just distal to the metaphyseal flare.  Next, the bone was passed out as specimen.  The head of the metatarsal had evidence of erosion and eburnation.  The tibial sesamoid was practically absent, but was found to be a conglomeration of hypertrophic synovium and poorly differentiated appearing exostosis and bony tissue.  This was hindering the range of motion of the joint and was removed.  The fibular sesamoid was in the interspace.  A lateral release was performed in addition.  Next, the McGlamry elevators were inserted into the first metatarsal head and all of the plantar adhesions were freed.  The metatarsal head was remodeled with a sagittal saw and all of the medial eminence the dorsal and lateral hypertropic bone was removed and the metatarsal head was shaped into more acceptable contoured structure.  Next, the Biopro sizer was used and it was found that a median large implant would be the best fit for this patient's joint.  A small drill hole was made in the central aspect at the base of the proximal phalanx.  The trial sizer median large was placed in the joint and an excellent fit and increased range of motion was observed.,Next, the joint was flushed with copious amounts of saline.  A median large porous Biopro implant was inserted using the standard technique and was tapped with the mallet into position.  It had an excellent fit and the range of motion again was markedly increased from the preoperative level.  Next, the wound was again flushed with copious amounts of saline.  The flexor tendon was inspected and was found to be intact plantarly.  A #3-0 Vicryl was used to close the capsule in a running fashion.  A medial capsulorrhaphy performed and the toe assumed to more rectus position and the joint was more congruous.  Next, the subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted technique.  Next, the skin was closed with #5-0 Monocryl in a running subcuticular fashion.,Attention was directed to the right second toe, which was found to be markedly contracted and rigid in nature.  There was a clavus in the dorsal aspect of the head of the proximal phalanx noted.  A linear incision was made over the proximal phalanx approximately 2 cm in length.  The incision was deepened with #15 blade down to the subcutaneous tissue.  Next, the medial and lateral aspects of the wound were undermined with sharp dissection taking care to protect the neurovascular structures.,Next, after identifying the extensor expansion and long extensor tendon, a #15 blade was used to transect the tendon at the level of the joint.  The tendon was peeled off sharply, proximally, and distally.  The medial and lateral collateral ligaments were released and the head of the proximal phalanx was delivered into the wound.  The bone was found to be extremely soft in the toe joints and the head of the proximal phalanx was oddly shaped and the cartilage was eroded.  The base of the middle phalanx, however, had a normal-appearing cartilage.  A sagittal saw was used to transect the head of the proximal phalanx just proximal to metaphyseal flare.  Next, the base of the middle phalanx was also resected.  A 0.045 inch Kirschner wire was retrograded out at the end of the toe and then back through the residual proximal phalanx shaft.  The toe assumed a straight and markedly increased straight position.  An extensor hood resection was performed to assist in keeping the proximal phalanx plantar flexed.  The joint was flushed with copious amounts of saline.  A #3-0 Vicryl was used to reapproximate the tendon after arthrodesis.  A #4-0 nylon was used to close the skin with a combination of simple interrupted and horizontal mattress suture technique.  The wire was cut, capped, and bent in the usual fashion.,Attention was directed to the right third toe where an exact same procedure as performed in the second digit was repeated.  The same suture material was used and the same 0.045 Kirschner wire was used for external wire fixation.,Attention was directed to the right fourth toe with exact same procedure was repeated.  The same suture material was used.  However, a 0.062 Kirschner wire was used to fixate the arthrodesis site as the bone was very soft and a 0.045 Kirschner wire was attempted but was found to be slipping in the soft bone and was inadequately holding the arthrodesis site tight.  Next, attention was directed to the fifth digit, which was found to be contracted as well.  A linear incision was made over the proximal phalanx with a #10 blade approximately 2 cm in length.  A #15 blade was used to deepen the incision to the subcutaneous tissue down to the level of the long extensor tendon, which was identified and transected.  The medial and lateral collateral ligaments were transected and the head of the proximal phalanx was delivered into the wound.  A sagittal saw was used to resect the head of the proximal phalanx just proximal to metaphyseal flare.  The toe assumed to more rectus position.  The reciprocating rasp was used to smooth the all bony surfaces.  The joint was again flushed with saline.  Next, the long extensor tendon was reapproximated with #3-0 Vicryl in a simple interrupted technique.  The skin was closed with #4-0 nylon in a simple interrupted technique.,Next, attention was directed to the fifth metatarsal head, which was found to have a lateral exostosis and bursa under the skin.  A #10 blade was used to make a 2.5 cm dorsal incision over the fifth metatarsal head.  The incision was deepened with a #15 blade to the subcutaneous tissue.  Any small vein traversing subcutaneous layer were ligated with electrocautery.  Care was taken to avoid abductor digiti minimi tendon and extensor digitorum longus tendon respectively.  Next, the dorsal linear capsular incision was made down to the bone with a #15 blade.  The capsular and periosteal tissues were elevated off the bone with a #15 blade and the metatarsal head was delivered into the wound.  Hypertrophic bone was noted to be found dorsally and laterally as well as plantarly.  A sagittal saw was used to resect all hypertrophic bone.  A reciprocating rasp was used to smooth all bony surfaces.  Next, the wound was flushed with copious amounts of saline.  The capsular and periosteal tissues wee closed with #3-0 Vicryl in a simple interrupted technique.  Next, the subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted technique.  A bursa which was found consisting of a white glistening hypertrophic synovium was removed and sent as specimen as was also found in two of the second and third digit in the above procedures.  The skin was closed with #5-0 Monocryl in a running subcuticular fashion.  The ______ was reinforced with horizontal mattress sutures with #5-0 Monocryl.  Attention was directed to the fourth metatarsophalangeal joint where the joint was found to be contracted and the proximal phalanx was still found to be elevated.  Therefore, a #15 blade was used to make a stab incision over the joint lateral to the extensor digitorum longus tendon.  The tendon was transected.  Next, a blade was inserted in the dorsal, medial, and lateral aspects of the metatarsophalangeal joint and tenotomy was performed.  Next, the proximal phalanx residual bone was plantar flexed and found to assume a more rectus position.  One #4-0 nylon suture was placed in the skin.,Mastisol tape was applied to the first metatarsal and fifth metatarsal postoperative wounds.  Betadine-soaked Owen silk was applied to all wounds.  Betadine-soaked 4 x 4 splints were applied to all toes.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all digits.  All the wires have previously been bent and cut and all were capped.  A standard postoperative consisting of 4x4s, Kling, Kerlix, and Coban were applied.  The patient tolerated the above anesthesia and procedure without complications.  She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact.  She was given prescription for Tylenol #3, #40 one to two p.o. q.4-6h. p.r.n. pain and Naprosyn 375 mg p.o. b.i.d. p.c.  She is to continue her rheumatoid arthritis drugs preoperatively prescribed by the rheumatologist.,She is to follow up with Dr. X in the office.  She was given emergency contact numbers and standard postoperative instructions.  She was given Darco OrthoWedge shoe and a pair of crutches.  She was discharged in stable condition.",
" Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left and arthroplasty left second toe.  Bunion left foot and hammertoe, left second toe.", Surgery, Bunionectomy & Metatarsal Osteotomy ,"PREOPERATIVE DIAGNOSES:,1.  Bunion left foot.,2.  Hammertoe, left second toe.,POSTOPERATIVE DIAGNOSES:,1.  Bunion left foot.,2.  Hammertoe, left second toe.,PROCEDURE PERFORMED:,1.  Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left.,2.  Arthroplasty left second toe.,HISTORY:  ,This 39-year-old female presents to ABCD General Hospital with the above chief complaint.  The patient states that she has had bunion for many months.  It has been progressively getting more painful at this time.  The patient attempted conservative treatment including wider shoe gear without long-term relief of symptoms and desires surgical treatment.,PROCEDURE: , An IV was instituted by the Department of Anesthesia in the preop holding area.  The patient was transported to the operating room and placed on the operating table in the supine position with a safety belt across her lap.  Copious amount of Webril were placed around the left ankle followed by a blood pressure cuff.  After adequate sedation was achieved by the Department of Anesthesia, a total of 15 cc of 0.5% Marcaine plain was injected in a Mayo and digital block to the left foot.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was elevated from the operating table and exsanguinated with an Esmarch bandage.  The pneumatic ankle tourniquet was inflated to 250 mmHg and the foot was lowered to the operating table.  The stockinette was reflected.  The foot was cleansed with wet and dry sponge.  Attention was then directed to the first metatarsophalangeal joint of the left foot.  An incision was created over this area approximately 6 cm in length.  The incision was deepened with a #15 blade.  All vessels encountered were ligated for hemostasis.  The skin and subcutaneous tissue was then dissected from the capsule.  Care was taken to preserve the neurovascular bundle.  Dorsal linear capsular incision was then created.  The capsule was then reflected from the head of the first metatarsal.  Attention was then directed to the first interspace where a lateral release was performed.  A combination of sharp and blunt dissection was performed until the abductor tendons were identified and transected.  A lateral capsulotomy was performed.  Attention was then directed back to the medial eminence where sagittal saw was used to resect the prominent medial eminence.  The incision was then extended proximally with further dissection down to the level of the bone.  Two 0.45 K-wires were then inserted as access guides for the SCARF osteotomy.  A standard SCARF osteotomy was then performed.  The head of the first metatarsal was then translocated laterally in order to reduce the first interspace in the metatarsal angle.  After adequate reduction of the bunion deformity was noted, the bone was temporarily fixated with a 0.45 K-wire.  A 3.0 x 12 mm screw was then inserted in the standard AO fashion with compression noted.  A second 3.0 x 14 mm screw was also inserted with tight compression noted.  The remaining prominent medial eminence medially was then resected with a sagittal saw.  Reciprocating rasps were then used to smooth any sharp bony edges.  The temporary fixation wires were then removed.  The screws were again checked for tightness, which was noted.  Attention was directed to the medial capsule where a medial capsulorrhaphy was performed.  A straight stat was used to assist in removing a portion of the capsule.  The capsule was then reapproximated with #2-0 Vicryl medially.  Dorsal capsule was then reapproximated with #3-0 Vicryl in a running fashion.  The subcutaneous closure was performed with #4-0 Vicryl followed by running subcuticular stitch with #5-0 Vicryl.  The skin was then closed with #4-0 nylon in a horizontal mattress type fashion.,Attention was then directed to the left second toe.  A dorsal linear incision was then created over the proximal phalangeal joint of the left second toe.  The incision was deepened with a #15 blade and the skin and subcutaneous tissue was dissected off the capsule to be aligned laterally.  An incision was made on either side of the extensor digitorum longus tendon.  A curved mosquito stat was then used to reflex the tendon laterally.  The joint was identified and the medial collateral ligamentous attachments were resected off the head of the proximal phalanx.  A sagittal saw was then used to resect the head of the proximal head.  The bone was then rolled and the lateral collateral attachments were transected and the bone was removed in toto.  The extensor digitorum longus tendon was inspected and noted to be intact.  Any sharp edges were then smoothed with reciprocating rasp.  The area was then flushed with copious amounts of sterile saline.  The skin was then reapproximated with #4-0 nylon.  Dressings consisted of Owen silk, 4x4s, Kling, Kerlix, and Coban.  Pneumatic ankle tourniquet was released and an immediate hyperemic flush was noted to all five digits of the left foot.  The patient tolerated the above procedure and anesthesia well without complications.  The patient was transported to PACU with vital signs stable and vascular status intact to the left foot.  The patient is to follow up with Dr. X in his clinic as directed.","surgery, hammertoe, osteotomy, internal screw fixation, scarf type, extensor digitorum, metatarsal osteotomy, foot, toe, metatarsal, bunionectomy,"
" Bunion, left foot.  Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation and Akin osteotomy with internal wire fixation of left foot.", Surgery, Bunionectomy & Akin Osteotomy ,"PREOPERATIVE DIAGNOSIS: , Bunion, left foot.,POSTOPERATIVE DIAGNOSIS: ,Bunion, left foot.,PROCEDURE PERFORMED:,1.  Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation.,2.  Akin osteotomy with internal wire fixation of left foot.,HISTORY: , This 19-year-old Caucasian female presents to ABCD General Hospital with the above chief complaint.  The patient states she has had worsening bunion deformity for as long as she could not remember.  She does have a history of Charcot-Marie tooth disease and desires surgical treatment at this time.,PROCEDURE: , An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported to the operating room and placed on operating table in the supine position with a safety belt across her lap.  Copious amounts of Webril were placed on the left ankle followed by a blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 15 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain were injected in a Mayo block type fashion surrounding the lower left first metatarsal.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was elevated from the operating table and exsanguinated with an Esmarch bandage.  The pneumatic ankle tourniquet was inflated to 250 mmHg and the foot was lowered to the operating field.  The stockinette was reflected, the foot was cleansed with a wet and dry sponge.  Approximately 5 cm incision was made dorsomedially over the first metatarsal.,The incision was then deepened with #15 blade.  All vessels encountered were ligated for hemostasis.  Care was taken to preserve the extensor digitorum longus tendon.  The capsule over the first metatarsal phalangeal then was identified where a dorsal capsular incision was then created down to the level of bone.  Capsule and periosteum was reflected off the first metatarsal head.  At this time, the cartilage was inspected and noted to be white, shiny, and healthy cartilage.  There was noted to be a prominent medial eminence.  Attention was then directed to first interspace where a combination of blunt and sharp dissection was done to perform a standard lateral release.  The abductor tendon attachments were identified and transected.  The lateral capsulotomy was performed.  The extensor digitorum brevis tendon was identified and transected.  Attention was then directed to the prominent medial eminence, which was resected with a sagittal saw.  Intraoperative assessment of pes was performed and pes was noted to be normal.,At this time, a regional incision was carried more approximately about 1.5 cm.  The capsular incision was then extended and the proximal capsule and periosteum were reflected off the first metatarsal.  The first metatarsal cuneiform joint was identified.  A 0.45 K-wire was then inserted into the base of the first metatarsal approximately 1 cm from the first cuneiform joint perpendicular to the weightbearing surface.  This K-wire was used as an access guide for a Juvaro type oblique base wedge osteotomy.  The sagittal saw was then used to creat a closing base wedge osteotomy with the apex being proximal medial.  The osteotomy site was then feathered and tilted with tight estimation of the bony edges.  The cortical hinge was maintained.  A 0.27 x 24 mm screw was then inserted in a standard AO fashion.  At this time, there was noted to be tight compression of the osteotomy site.  A second 2.7 x 16 mm screw was then inserted more distally in the standard AO fashion with compression noted.  The ________ angle was noted to be significantly released.  Reciprocating rasp was then used to smoothen any remaining sharp edges.  The 0.45 k-wire was removed.  The foot was loaded and was noted to fill the remaining abduction of the hallux.  At this time, it was incised to perform an Akin osteotomy.,Original incision was then extended distally approximately 1 cm.  The incision was then deepened down to the level of capsule over the base of the proximal phalanx.  Again care was taken to preserve the extensor digitorum longus tendon.  The capsule was reflected off of the base of the proximal phalanx.  An Akin osteotomy was performed with the apex being lateral and the base being medial.  After where the bone was resected, it was feathered until tight compression was noted without tension at the osteotomy site.  Care was taken to preserve the lateral hinge.  At 1.5 wire passed and a drill was then used to create drill hole proximal and distally to the osteotomy site in order for passage of 28 gauge monofilament wire.  The #28 gauge monofilament wire was passed through the drill hole and tightened down until compression and tight ________ osteotomy site was noted.  The remaining edge of the wire was then buried in the medial most distal drill hole.  The area was then inspected and the foot was noted with significant reduction of the bunion deformity.  The area was then flushed with copious amounts of sterile saline.  Capsule was closed with #3-0 Vicryl followed by subcutaneous closure with #4-0 Vicryl in order to decrease tension of the incision site.  A running #5-0 subcuticular stitch was then performed.  Steri-Strips were applied.  Total of 1 cc dexamethasone phosphate was then injected into the surgical site.  Dressings consisted of Owen silk, 4x4s, Kling, Kerlix.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot.  Posterior splint was then placed on the patient in the operating room.,The patient tolerated the above procedure and anesthesia well without complications.  The patient was transferred back to the PACU with vital signs stable and vascular status intact to the left foot.  The patient was given postoperative instructions to be strictly nonweightbearing on the left foot.  The patient was given postop pain prescriptions for Vicodin and instructed to take one q.4-6h. p.r.n. for pain as well as Naprosyn 500 mg p.o. q. b.i.d.  The patient is to follow-up with Dr. X in his office in four to five days as directed.","surgery, bunionectomy, akin osteotomy, internal wire fixation, internal screw fixation, osteotomy, metatarsal, metatarsal osteotomy, extensor digitorum, drill hole, osteotomy site, foot"
" Austin/akin bunionectomy, right foot.  Bunion, right foot.  The patient states she has had a bunion deformity for as long as she can remember that has progressively become worse and more painful.", Surgery, Bunionectomy - Austin - Akin ,"PREOPERATIVE DIAGNOSIS:,  Bunion, right foot.,POSTOPERATIVE DIAGNOSIS:,  Bunion, right foot.,PROCEDURE PERFORMED:,  Austin/akin bunionectomy, right foot.,HISTORY: , This 77-year-old African-American female presents to ABCD General Hospital with the above chief complaint.  The patient states she has had a bunion deformity for as long as she can remember that has progressively become worse and more painful.  The patient has attempted conservative treatment without long-term relief of symptoms and desires surgical treatment.,PROCEDURE DETAILS:,  An IV was instituted by Department of Anesthesia in the preop holding area.  The patient was transported to the operating room and placed on the operating table in the supine position with a safety strap across her lap.  Copious amounts of Webril were placed around the right ankle followed by blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 15 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain was injected in a Mayo block type fashion.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was elevated to the operating table and exsanguinated with an Esmarch bandage.  The pneumatic ankle tourniquet was inflated to 250 mmHg.  The foot was lowered to the operating field and the stockinet was reflected.  The foot was cleansed with wet and dry sponge.,Attention was directed to the bunion deformity on the right foot.  An approximately 6 cm dorsal medial incision was created over the first metatarsophalangeal joint.  The incision was then deepened with a #15 blade.  All vessels encountered were ligated with hemostasis.  The skin and subcutaneous tissue were then undermined off of the capsule medially.  A dorsal linear capsular incision was then created over the first metatarsophalangeal joint.  The periosteum and capsule were then reflected off of the first metatarsal.  There was noted to be a prominent medial eminence.  The articular cartilage was healthy for patient's age and race.  Attention was then directed to the first interspace where a lateral release was performed..  A combination of sharp and blunt dissection was carried out until the adductor tendon insertions were identified.  The adductor tendons were transected as well as a lateral capsulotomy was performed.  The extensor digitorum brevis tendon was identified and transected.  Care was taken to preserve the extensor hallucis longus to make sure that tendon that was transected was the extensor hallucis brevis at the _______ digitorum.  Extensor hallucis brevis tendon was transected and care was taken to preserve the extensor halucis longus tendon.  Attention was then directed to medial eminence, which was resected with a sagittal saw.  Sagittal was then used to create a long dorsal arm outside the Austin type osteotomy and the first metatarsal.  The head of the first metatarsal was then translocated laterally until correction of the intermetatarsal angle was noted.  The head was intact.  A 0.45 K-wire was inserted through subcutaneously from proximal medial to distal lateral.  A second K-wire was then inserted from distal lateral to proximal plantar medial.  Adequate fixation was noted at the osteotomy site.  The K-wires were bent, cut, and pin caps were placed.  Attention was then directed to the proximal phalanx of the hallux.  The capsular periostem was reflected off of the base of the proximal phalanx.  A sagittal was then used to create an akin osteotomy closing wedge.  The apex was lateral and the base of the wedge was medial.  The wedge was removed in the total and the osteotomy site was then feathered until closure was achieved without compression.  Two 0.45 K-wires were then inserted, one from distal medial to proximal lateral and the second from distal lateral to proximal medial across the osteotomy site.  Adequate fixation was noted at the osteotomy site and the osteotomy was closed.  The toe was noted to be in a markedly more rectus position.  Sagittal saw was then used to resect the remaining prominent medial eminence.  The area was then smoothed with a reciprocating rasp.  There was noted to be a small osteophytic formation laterally over first metatarsal head that was removed with a rongeur and smoothed with a reciprocating rasp.  The area was then inspected for any remaining short bony edges, none were noted.,Copious amounts of sterile saline was then used to flush the surgical site.  The capsule was closed with #3-0 Vicryl.  Subcutaneous closure was performed with #4-0 Vicryl followed by running subcuticular #5-0 Vicryl.  Steri-Strips were applied and 1 cc of dexamethasone phosphate was injected into the surgical site.,Dressings consisted of #0-1 silk, copious Betadine, 4 x 4s, Kling, Kerlix, and Coban.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the right foot.  A _______ cast was then applied postoperatively.  The patient tolerated the above procedure and anesthesia well without complications.  The patient was transported from the operating room to the PACU with vital signs stable and vascular status intact to the right foot.  The patient was given postoperative pain prescription for Tylenol #3 and instructed to take one q4-6h. p.o. p.r.n. for pain.  The patient is to follow up with Dr. X in his office as directed.","surgery, austin/akin bunionectomy, hallucis brevis, bunion deformity, extensor hallucis, osteotomy site, foot, austin, bunionectomy "
 A 60-year-old female presents today for care of painful calluses and benign lesions., Surgery, Bunions and Calluses  ,"S -, A 60-year-old female presents today for care of painful calluses and benign lesions.,O -, On examination, the patient has bilateral bunions at the first metatarsophalangeal joint.  She states that they do not hurt.  No pain appears to be produced by active or passive range of motion or palpation and direct pressure of the first metatarsophalangeal joint bilaterally.  The patient has a bilateral pinch callus on the medial aspect of both great toes and there are calluses along the medial aspect of the right foot.  She has a small intractable plantar keratoma, plantar to her left second metatarsal head, which measures 0.5 cm in diameter.  This is a central plug.  She also has a very, very painful lesion plantar to her right fourth metatarsal head which measures 3.1 x 1.8 cm in diameter.  This is a hyperkeratotic lesion that extends deep into the tissue with interrupted skin lines.,A - ,1.  Bilateral bunions.,","surgery, painful calluses, hibiclens, scrubbed, ointment and absorbent, heloma durum, plantar aspect, minimal hemostasis, neosporin ointment, absorbent dressing, benign lesions, metatarsophalangeal, bunions, calluses, plantar, "
 Wide local excision of left buccal mucosal lesion with full thickness skin graft closure in the left supraclavicular region and adjacent tissue transfer closure of the left supraclavicular grafting site, Surgery, Buccal Mucosal Lesion Excision ,"PREOPERATIVE DIAGNOSIS: , Left buccal mucosal verrucous squamous cell carcinoma.,POSTOPERATIVE DIAGNOSIS: , Left buccal mucosal verrucous squamous cell carcinoma.,PROCEDURE PERFORMED:,1.  Wide local excision of left buccal mucosal lesion with full thickness skin graft closure in the left supraclavicular region.,2.  Adjacent tissue transfer closure of the left supraclavicular grafting site.,ESTIMATED BLOOD LOSS: , Less than 30 cc.,COMPLICATIONS:, None.,INDICATIONS FOR PROCEDURE: , The patient is a 16-year-old Caucasian female with a history of left verrucous squamous cell carcinoma of the buccal mucosa, present for a number of months that was diagnosed in the office after two biopsies.  After risks, complications, consequences, and questions were addressed with the patient, medical clearance was obtained with the patient and a written consent was obtained.,PROCEDURE: , The patient was brought to operative suite by Anesthesia.  The patient was placed on the operative table in supine position.  After this, the patient was then placed under general endotracheal intubation anesthesia.  The operating bed was then turned 90 degrees away from anesthesia.  A shoulder roll was then placed followed by the patient's oral lesion being localized with 1% lidocaine with epinephrine 1:1000 approximately 5 cc total.  After this the patient was then prepped and draped in the usual sterile fashion including the left shoulder region.,After this sweetheart retractor along with a Minnesota retractor were utilized to lift the upper and lower lips along with tongue to gain access to this oral cavity lesion.  A #15 Bard Parker was then utilized to make an incision circumferentially around this lesion or mass with approximately a 1 cm margin.  The lesion was then grasped with a DeBakey forceps and grasped through in order to dissect this from the buccal mucosal sites with a #15 blade along with a curved sharp Joseph scissors.  After this the 12, 6, and 3 o'clock positions were marked with marking suture and the specimen was finally passed off the field.  It was sent to the frozen section's Pathology.  Hemostasis was maintained with bipolar cauterization.  Pathology called back into the room and verified that the regions from 12 to 3 and from 6 to 12 were still involved.  A second margin was obtained from the 6 o'clock position all the way to the 3 o'clock position with sutures again placed in the 12, 6, and 3 o'clock regions.  This was cut utilizing the #15 Bard-Parker and grasped with the DeBakey forceps.  It was passed off the field and sent to Pathology.  Pathology then called back into the room and verified that margins were clear.  After this the bipolar cauterization was then utilized to control a further bleeding.  After this the superior and inferior aspects of the defect were reapproximated with approximately one #4-0 Vicryl suture.  After this the left shoulder that was prepped previously was unveiled.  Surgical gloves were all changed and a 3 x 4 cm elliptical skin graft was taken from the left supraclavicular region.  First a #15 Bard-Parker was utilized to make an incision in the skin in elliptical fashion.  After this the skin was then grasped and a full thickness graft was taken with undermining performed by the #15 Bard-Parker.  After this the underlying subcutaneous tissue was then hemostatically controlled with bipolar cauterization.  After this the tissue was then reapproximated in multiple interrupted #4-0 undyed Vicryl followed by reapproximation of the skin with a #5-0 Prolene.  After this the skin graft was then defatted with a curved Joseph scissors.  It was then placed in the oral defect.  Circumferentially it was sutured down to the edge of the buccal mucosa with multiple interrupted #4-0 undyed Vicryl sutures.  It was then ________ with a #15 Bard-Parker and sutured in from the midportion of the multiple areas with multiple interrupted #4-0 undyed Vicryl.  After this the patient was then thoroughly cleaned and Mastisol Steri-Strips were then placed on the left shoulder defect along with the sterile dressing.  The patient was then turned back to the Anesthesia, extubated in the operating room and transferred to recovery room in stable condition.  The patient tolerated the procedure well and will be admitted to hospital for observation.","surgery, buccal mucosal verrucous squamous cell carcinoma, skin graft closure, supraclavicular, buccal mucosal lesion, squamous cell carcinoma, supraclavicular region, bard parker,"
" Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot.  Akin bunionectomy, right toe with internal wire fixation.", Surgery, Bunionectomy & Osteotomy ,"PREOPERATIVE DIAGNOSES:,1.  Hallux valgus, right foot.,2.  Hallux interphalangeus, right foot.,POSTOPERATIVE DIAGNOSES:,1.  Hallux valgus, right foot.,2.  Hallux interphalangeus, right foot.,PROCEDURES PERFORMED:,1.  Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot.,2.  Akin bunionectomy, right toe with internal wire fixation.,ANESTHESIA: , TIVA/local.,HISTORY:  ,This 51-year-old female presents to ABCD preoperative holding area after keeping herself NPO since mid night for a surgery on her painful bunion through her right foot.  The patient has a history of gradual onset of a painful bunion over the past several years.  She has tried conservative methods such as wide shoes, accommodative padding on an outpatient basis with Dr. X all of which have provided inadequate relief.  At this time, she desires attempted surgical correction.  The risks versus benefits of the procedure have been discussed with the patient in detail by Dr. X and the consent is available on the chart for review.,PROCEDURE IN DETAIL: , After IV was established by the Department of Anesthesia, the patient was taken to the operating room via cart and placed on the operative table in supine position and a safety strap was placed across her waist for her protection.  Copious amounts of Webril were applied about the right ankle and a pneumatic ankle tourniquet was placed over the Webril.,After adequate IV sedation was administered by the Department of Anesthesia, a total of 15 cc of 1:1 mixture of 0.5% Marcaine plain and 1% Lidocaine plain was injected into the foot in a standard Mayo block fashion.  The foot was elevated off the table.  Esmarch bandages were used to exsanguinate the right foot.  The pneumatic ankle tourniquet was elevated to 250 mmHg.  The foot was lowered in the operative field and the sterile stockinet was reflected.  A sterile Betadine was wiped away with a wet and dry sponge and one toothpick was used to test anesthesia, which was found to be adequate.  Attention was directed to the first metatarsophalangeal joint, which was found to be contracted, laterally deviated, and had decreased range of motion.  A #10 blade was used to make a 4 cm dorsolinear incision.  A #15 blade was used to deepen the incision through the subcutaneous layer.  All superficial subcutaneous vessels were ligated with electrocautery.  Next, a linear capsular incision was made down the bone with a #15 blade.  The capsule was elevated medially and laterally off the metatarsal head and the metatarsal head was delivered into the wound.  A hypertrophic medial eminence was resected with a sagittal saw taking care not to strike the head.  The medial plantar aspect of the metatarsal head had some erosive changes and eburnation.  Next, a 0.45 inch Kirschner wire was placed with some access guide slightly plantar flexing the metatarsal taking care not to shorten it.  A sagittal saw was used to make a long-arm Austin osteotomy in the usual fashion.  Standard lateral release was also performed as well as a lateral capsulotomy freeing the fibular sesamoid complex.,The capital head was shifted laterally and impacted on the residual metatarsal head.  Nice correction was achieved and excellent bone to bone contact was achieved.  The bone stock was slightly decreased, but adequate.  Next, a 0.45 inch Kirschner wire was used to temporarily fixate the metatarsal capital fragment.  A 2.7 x 18 mm Synthes cortical screw was thrown using standard AO technique.  Excellent rigid fixation was achieved.  A second 2.0 x 80 mm Synthes fully threaded cortical screw was also thrown using standard AO technique at the proximal aspect of the metatarsal head.  Again, an excellent rigid fixation was obtained and the screws were tight.  The temporary fixation was removed.  A medial overhanging bone was resected with a sagittal saw.  The foot was loaded and the hallux was found to have an interphalangeus deformity present.,A sagittal saw was used to make a proximal cut in approximately 1 cm dorsal to the base of the proximal phalanx, leaving a lateral intact cortical hinge.  A distal cut parallel with the nail base was performed and a standard proximal Akin osteotomy was done.,After the wedge bone was removed, the saw blade was reinserted and used to tether the osteotomy with counter-pressure used to close down the osteotomy.  A #15 drill blade was used to drill two converging holes on the medial aspect of the bone.  A #28 gauge monofilament wire was inserted loop to loop and pulled through the bone.  The monofilament wire was twisted down and tapped into the distal drill hole.  The foot was loaded again and the toe had an excellent cosmetic straight appearance and the range of motion of the first metatarsophalangeal joint was then improved.  Next, reciprocating rasps were used to smooth all bony surfaces.  Copious amounts of sterile saline was used to flush the joint.  Next, a #3-0 Vicryl was used to reapproximate the capsular periosteal tissue layer.  Next, #4-0 Vicryl was used to close the subcutaneous layer.  #5-0 Vicryl was used to the close the subcuticular layer in a running fashion.  Next, 1 cc of dexamethasone phosphate was then instilled in the joint.  The Steri-Strips were applied followed by standard postoperative dressing consisting of Owen silk, 4 x 4s, Kling, Kerlix, and Coban.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to the digits.  The patient tolerated the above anesthesia and procedure without complications.  She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot.  She is to be partial weightbearing with crutches.  She is to follow with Dr. X.  She was given emergency contact numbers and instructions to call if problems arise.  She was given prescription for Vicodin ES #25 one p.o. q.4-6h. p.r.n. pain and Naprosyn one p.o. b.i.d.  500 mg.  She was discharged in stable condition.","surgery, hallux interphalangeus, osteotomy, bunionectomy, akin, wire fixation, screw fixation, painful bunion, metatarsophalangeal joint, pneumatic ankle, metatarsal head, foot, toe, sagittal, metatarsal"
 Repeat low transverse cervical cesarean section with delivery of a viable female neonate.  Bilateral tubal ligation and partial salpingectomy.  Lysis of adhesions., Surgery, BTL & Salpingectomy ,"PREOPERATIVE DIAGNOSES:,1.  Pregnancy at 38 weeks and three days.,2.  Previous cesarean section x2.,3.  Refusing trial of labor.,4.  Multiparity, seeking family planning.,POSTOPERATIVE DIAGNOSES:,1.  Pregnancy at 38 weeks and three days.,2.  Previous cesarean section x2.,3.  Refusing trial of labor.,4.  Multiparity, seeking family planning.,5.  Pelvic adhesions.,PROCEDURE PERFORMED:,1.  Repeat low transverse cervical cesarean section with delivery of a viable female neonate.,2.  Bilateral tubal ligation and partial salpingectomy.,3.  Lysis of adhesions.,ANESTHESIA: , Spinal with Astramorph.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , 800 cc.,FLUIDS: , 1800 cc of crystalloids.,URINE OUTPUT:,  600 cc of clear urine at the end of the procedure.,INDICATIONS:  ,This is a 36-year-old African-American female gravida 4, para-2-0-1-2, who presents for elective repeat cesarean section.  The patient has previous cesarean section x2 and refuses trial of labor.  The patient also requests a tubal ligation for permanent sterilization and family planning.,FINDINGS:,  A female infant in cephalic presentation in a ROP position.  Apgars of 9 and 9 at one and five minutes respectively.  Weight is 6 lb 2 oz and loose nuchal cord x1.  Normal uterus, tubes, and ovaries.,PROCEDURE:  ,After consent was obtained, the patient was taken to the operating room, where spinal anesthetic was found to be adequate.  The patient was placed in the dorsal supine position with a leftward tilt and prepped and draped in the normal sterile fashion.  The patient's previous Pfannenstiel scar incision was removed and the incision was carried through the underlying layer of fascia using the second knife.  The fascia was incised in the midline and the fascial incision was extended laterally using the second knife.  The rectus muscles were separated in the midline.  The peritoneum was identified, grasped with hemostats, and entered sharply with Metzenbaum scissors.  This incision was extended superiorly and inferiorly with good visualization of the bladder.  The bladder blade was then inserted and vesicouterine peritoneum was identified, grasped with an Allis clamp and entered sharply with Metzenbaum scissors.  This incision was extended laterally and the bladder flap created digitally.  The bladder blade was then reinserted and a small transverse incision was made along the lower uterine segment.  This incision was extended laterally manually.  The amniotic fluid was ruptured at this point with clear fluid obtained.  The infant's head was delivered atraumatically.  The nose and mouth were both suctioned on delivery.  The cord was doubly clamped and cut.  The infant was handed off to the awaiting pediatrician.  Cord gases and cord bloods were obtained and sent.  The placenta was then removed manually and the uterus exteriorized and cleared of all clots and debris.  The uterine incision was reapproximated with #0 chromic in a running lock fashion.  A second layer of the same suture was used with excellent hemostasis.  Attention was now turned to the right fallopian tube, which was grasped with the Babcock and avascular space below the tube was entered using a hemostat.  The tube was doubly clamped using hemostat and the portion between the clamps was removed using Metzenbaum scissors.  The ends of the tube were cauterized using the Bovie and they were then tied off with #2-0 Vicryl.  Attention was then turned to the left fallopian tube, which was grasped with the Babcock and avascular space beneath the tube was entered using a hemostat.  The tube was then doubly clamped with hemostat and the portion of tube between them was removed using the Metzenbaum scissors.  The ends of the tubes were cauterized and the tube was suture-ligated with #2-0 Vicryl.  There were some adhesions of the omentum to the bilateral adnexa.  These were carefully taken down using Metzenbaum scissors with excellent hemostasis noted.  The uterus was then returned to the abdomen and the bladder was cleared of all clots.  The uterine incision was reexamined and found to be hemostatic.  The fascia was then reapproximated with #0 Vicryl in a running fashion.  Several interrupted sutures of #3-0 chromic were placed in the subcutaneous tissue.  The skin was then closed with #4-0 undyed Vicryl in a subcuticular fashion.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2.  The patient was taken to the recovery room in satisfactory condition.  She will be followed immediately postoperatively within the hospital.",
" Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot.  Proximal interphalangeal joint arthroplasty, bilateral fifth toes.  Distal interphalangeal joint arthroplasty, bilateral third and fourth toes.   Flexor tenotomy, bilateral third toes.", Surgery, Bunionectomy & Flexor Tenotomy ,"PREOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus, right foot.,2.  Hammertoe, bilateral third, fourth, and fifth toes.,POSTOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus, right foot.,2.  Hammertoe, bilateral third, fourth, and fifth toes.,PROCEDURE PERFORMED:,1.  Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot.,2.  Proximal interphalangeal joint arthroplasty, bilateral fifth toes.,3.  Distal interphalangeal joint arthroplasty, bilateral third and fourth toes.,4.  Flexor tenotomy, bilateral third toes.,HISTORY:,  This is a 36-year-old female who presented to ABCD preoperative holding area after keeping herself n.p.o. since mid night for surgery on her painful bunion to her right foot and her painful hammertoes to both feet.  The patient has a history of sharp pain, which is aggravated by wearing shoes and ambulation.  She has tried multiple conservative methods and treatment such as wide shoes and accommodative padding, all of which provided inadequate relief.  At this time, she desires attempted surgical correction.  The risks versus benefits of the procedure have been discussed in detail by Dr. Kaczander with the patient and the consent is available on the chart.,PROCEDURE IN DETAIL:,  After IV was established by the Department of Anesthesia, the patient was taken to the operating room and placed on the operating table in supine position with a safety strap placed across her waist for her protection.,Copious amounts of Webril were applied about both ankles and a pneumatic ankle tourniquet was applied over the Webril.  After adequate IV sedation was administered, a total of 18 cc of a 0.5% Marcaine plain was used to anesthetize the right foot, performing a Mayo block and a bilateral third, fourth, and fifth digital block.  Next, the foot was prepped and draped in the usual aseptic fashion bilaterally.  The foot was elevated off the table and an Esmarch bandage was used to exsanguinate the right foot.  The pneumatic ankle tourniquet was elevated on the right foot to 200 mmHg.  The foot was lowered into operative field and the sterile stockinet was reflected proximally.  Attention was directed to the right first metatarsophalangeal joint, it was found to be contracted and there was lateral deviation of the hallux.  There was decreased range of motion of the first metatarsophalangeal joint.  A dorsolinear incision was made with a #10 blade, approximately 4 cm in length.  The incision was deepened to the subcutaneous layer with a #15 blade.  Any small veins traversing the subcutaneous layer were ligated with electrocautery.  Next, the medial and lateral wound margins were undermined sharply.  Care was taken to avoid the medial neurovascular bundle and the lateral extensor hallucis longus tendon.  Next, the first metatarsal joint capsule was identified.  A #15 blade was used to make a linear capsular incision down to the bone.  The capsular periosteal tissues were elevated off the bone with a #15 blade and the metatarsal head was delivered into the wound.  The PASA was found to be within normal limits.  There was a hypertrophic medial eminence noted.  A sagittal saw was used to remove the hypertrophic medial eminence.  A 0.045 inch Kirschner wire was placed into the central medial aspect of the metatarsal head as an access guide.  A standard lateral release was performed.  The fibular sesamoid was found to be in the interspace, but was relocated onto the metatarsal head properly.  Next, a sagittal saw was used to perform a long arm Austin osteotomy.  The K-wire was removed.  The capital fragment was shifted laterally and impacted into the head.  A 0.045 inch Kirschner wire was used to temporarily fixate the osteotomy.  A 2.7 x 16 mm Synthes, fully threaded cortical screw was throne using standard AO technique.  A second screw was throne, which was a 2.0 x 12 mm Synthes cortical screw.  Excellent fixation was achieved and the screws tightly perched the bone.  Next, the medial overhanging wedge was removed with a sagittal saw.  A reciprocating rasp was used to smooth all bony prominences.  The 0.045 inch Kirschner wire was removed.  The screws were checked again for tightness and found to be very tight.  The joint was flushed with copious amounts of sterile saline.  A #3-0 Vicryl was used to close the capsular periosteal tissues with simple interrupted suture technique.  A #4-0 Vicryl was used to close the subcutaneous layer in a simple interrupted technique.  A #5-0 Monocryl was used to close the skin in a running subcuticular fashion.,Attention was directed to the right third digit, which was found to be markedly contracted at the distal interphalangeal joint.  A #15 blade was used to make two convergent semi-elliptical incisions over the distal interphalangeal joint.  The incision was deepened with a #15 blade.  The wedge of skin was removed in full thickness.  The long extensor tendon was identified and the distal and proximal borders of the wound were undermined.  The #15 blade was used to transect the long extensor tendon, which was reflected proximally.  The distal interphalangeal joint was identified and the #15 blade was placed in the joint and the medial and lateral collateral ligaments were released.  Crown and collar scissors were used to release the planar attachment to the head of the middle phalanx.  Next, a double action bone cutter was used to resect the head of the middle phalanx.  The toe was dorsiflexed and was found to have an excellent rectus position.  A hand rasp was used to smooth all bony surfaces.  The joint was flushed with copious amounts of sterile saline.  The flexor tendon was found to be contracted, therefore, a flexor tenotomy was performed through the dorsal incision.  Next, #3-0 Vicryl was used to close the long extensor tendon with two simple interrupted sutures.  A #4-0 nylon was used to close the skin and excellent cosmetic result was achieved.,Attention was directed to the fourth toe, which was found to be contracted at the distal interphalangeal joint and abducted and varus rotated.  An oblique skin incision with two converging semi-elliptical incisions was created using #15 blade.  The rest of the procedure was repeated exactly the same as the above paragraph to the third toe on the right foot.  All the same suture materials were used.  However, there was no flexor tenotomy performed on this toe, only on the third toe bilaterally.,Attention was directed to the fifth right digit, which was found to be contracted at the proximal interphalangeal joint.  A linear incision approximately 2 cm in length was made with a #15 blade over the proximal interphalangeal joint.  Next, a #15 blade was used to deepen the incision to the subcutaneous layer.  The medial and lateral margins were undermined sharply to the level of the long extensor tendon.  The proximal interphalangeal joint was identified and the tendon was transected with the #15 blade.  The tendon was reflected proximally, off the head of the proximal phalanx.  The medial and lateral collateral ligaments were released and the head of the proximal phalanx was delivered into the wound.  A double action bone nibbler was used to remove the head of the proximal phalanx.  A hand rasp was used to smooth residual bone.  The joint was flushed with copious amounts of saline.  A #3-0 Vicryl was used to close the long extensor tendon with two simple interrupted sutures.  A #4-0 nylon was used to close the skin with a combination of simple interrupted and horizontal mattress sutures.,A standard postoperative dressing consisting of saline-soaked #0-1 silk, 4 x 4s, Kerlix, Kling, and Coban were applied.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to the digits.,Attention was directed to the left foot.  The foot was elevated off the table and exsanguinated with an Esmarch bandage and the pneumatic ankle tourniquet was elevated to 200 mmHg.  Attention was directed to the left fifth toe, which was found to be contracted at the proximal interphalangeal joint.  The exact same procedure, performed to the right fifth digit, was performed on this toe, with the same materials being used for suture and closure.,Attention was then directed to the left fourth digit, which was found to contracted and slightly abducted and varus rotated.  The exact same procedure as performed to the right fourth toe was performed, consisting of two semi-elliptical skin incisions in an oblique angle.  The same suture material were used to close the incision.,Attention was directed to the left third digit, which was found to be contracted at the distal interphalangeal joint.  The same procedure performed on the right third digit was also performed.  The same suture materials were used to close the wound and the flexor tenotomy was also performed at this digit.  A standard postoperative dressing was also applied to the left foot consisting of the same materials as described for the right foot.  The pneumatic tourniquet was released and immediate hyperemic flush was noted to the digits.  The patient tolerated the above anesthesia and procedure without complications.  She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the foot.  She was given postoperative shoes and will be partial weighbearing with crutches.  She was admitted short-stay to Dr. Kaczander for pain control.  She was placed on Demerol 50 and Vistaril 25 mg IM q3-4h. p.r.n. for pain.  She will have Vicodin 5/500 one to two p.o. q.4-6h. p.r.n. for moderate pain.  She was placed on Subq. heparin and given incentive spirometry 10 times an hour.  She will be discharged tomorrow.  She is to ice and elevate both feet today and rest as much as possible.,Physical Therapy will teach her crutch training today.  X-rays were taken in the postoperative area and revealed excellent position of the screws and correction of bunion deformity as well as the hammertoe deformities.","surgery, hallux abductovalgus, hammertoe, bunionectomy, flexor, tenotomy, interphalangeal, arthroplasty, screw fixation, osteotomy, interphalangeal joint arthroplasty, distal interphalangeal joint, interphalangeal joint, flexor tenotomy, proximal interphalangeal, joint arthroplasty, distal interphalangeal, distal, blade, proximal, foot, joint, toes, tendon, "
 Lumbar osteomyelitis and need for durable central intravenous access.  Placement of left subclavian 4-French Broviac catheter., Surgery, Broviac Catheter Placement ,"PREOPERATIVE DIAGNOSES:,1.  Lumbar osteomyelitis.,2.  Need for durable central intravenous access.,POSTOPERATIVE DIAGNOSES:,1.  Lumbar osteomyelitis.,2.  Need for durable central intravenous access.,ANESTHESIA:,  General.,PROCEDURE:,  Placement of left subclavian 4-French Broviac catheter.,INDICATIONS:  ,The patient is a toddler admitted with a limp and back pain, who was eventually found on bone scan and septic workup to have probable osteomyelitis of the lumbar spine at disk areas.  The patient needs prolonged IV antibiotic therapy, but attempt at a PICC line failed.  She has exhausted most of her easy peripheral IV access routes and referral was made to the Pediatric Surgery Service for Broviac placement.  I met with the patient's mom.  With the help of a Spanish interpreter, I explained the technique for Broviac placement.  We discussed the surgical risks and alternatives, most of which have been exhausted.  All their questions have been answered, and the patient is fit for operation today.,DESCRIPTION OF OPERATION:  ,The patient came to the operating room and had an uneventful induction of general anesthesia.  We conducted a surgical time-out to reiterate all of the patient's important identifying information and to confirm that we were here to place the Broviac catheter.  Preparation and draping of her skin was performed with chlorhexidine based prep solution and then an infraclavicular approach to left subclavian vein was performed.  A flexible guidewire was inserted into the central location and then a 4-French Broviac catheter was tunneled through the subcutaneous tissues and exiting on the right anterolateral chest wall well below and lateral to the breast and pectoralis major margins.  The catheter was brought to the subclavian insertion site and trimmed so that the tip would lie at the junction of the superior vena cava and right atrium based on fluoroscopic guidelines.  The peel-away sheath was passed over the guidewire and then the 4-French catheter was deployed through the peel-away sheath.  There was easy blood return and fluoroscopic imaging showed initially the catheter had transited across the mediastinum up the opposite subclavian vein, then it was withdrawn and easily replaced in the superior vena cava.  The catheter insertion site was closed with one buried 5-0 Monocryl stitch and the same 5-0 Monocryl was used to tether the catheter at the exit site until fibrous ingrowth of the attached cuff has occurred.  Heparinized saline solution was used to flush the line.  A sterile occlusive dressing was applied, and the line was prepared for immediate use.  The patient was transported to the recovery room in good condition.  There were no intraoperative complications, and her blood loss was between 5 and 10 mL during the line placement portion of the procedure.","surgery, lumbar osteomyelitis, central intravenous access, subclavian, osteomyelitis, broviac catheter, catheter, toddler, intravenous,"
" Hairline biplanar temporal browlift, quadrilateral blepharoplasty, canthopexy, cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy.", Surgery," Browlift, Blepharoplasty, & Rhytidectomy ","PREOPERATIVE DIAGNOSES:,1.  Eyebrow ptosis.,2.  Dermatochalasia of upper and lower eyelids with tear trough deformity of the lower eyelid.,3.  Cervical facial aging with submental lipodystrophy.,OPERATION:,1.  Hairline biplanar temporal browlift.,2.  Quadrilateral blepharoplasty with lateral canthopexy with arcus marginalis release and fat transposition over inferior orbital rim to lower eyelid.,3.  Cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy.,ASSISTANT:  ,None.,ANESTHESIA: , General endotracheal anesthesia.,PROCEDURE: , The patient was placed in a supine position and prepped with general endotracheal anesthesia.  Local infiltration anesthesia with 1% Xylocaine and 1:100,000 epinephrine was infiltrated in upper and lower eyelids.,Markings were made and fusiform ellipse of skin was resected from the upper eyelid.  The lower limb of the fusiform ellipse was at the superior palpebral fold.  A 9 mm of upper eyelid skin was resected at the widest portion of the lips, which extended from medial canthal area to the lateral orbital rim.  This was performed bilaterally and symmetrically and the skin was removed.  Incision was made through the pretarsal orbicularis with small amount of fat being removed from the medial and middle fat pocket.  An incision was made over the superior orbital rim.  Subperiosteal dissection was performed over the forehead.  The dissection proceeded medially.  The corrugator and procerus muscles were carefully dissected from the supratrochlear nerves on both right and left side and cauterized.,Hemostasis was achieved with electrocautery in this fashion.  A 4-cm incision was made, and the forehead at the hairline, subcutaneous dissection was performed and extended over the frontalis muscle for approximately 4 cm.  A subperiosteal dissection was performed after the fibers of the frontalis muscle were separated and subperiosteal dissection from the forehead lead the subperiosteal dissection from the upper eyelid.  The incision was made in the lower lid just beneath the lashline.  Subcutaneous dissection was performed over the pretarsal and preseptal muscle.  Dissection was then proceeded down to the inferior orbital rim.  The arcus marginalis was released and the lower eyelid fat was teased over the inferior orbital rim and sutured to the suborbicularis oculi fat and periosteum, which was separated from the inferior orbital rim.  The orbital fat was sutured to the suborbicularis oculi fat with multiple preplaced sutures of 5-0 Vicryl on a P2 needle.  The upper eyelid incision was closed with a running subcuticular 6-0 Prolene suture bilaterally.  The forehead was then elevated, and the nonhairbearing forehead skin was resected 1.5 cm wide raising the tail of the eyebrow.  The head of the eyebrow was felt to be elevated by the antagonistic frontalis muscle now that the accessory muscles specifically the corrugator and procerus and depressor supercilii were released and divided.,A lateral canthopexy was performed with 5-0 Prolene suture on a C1 double-arm tapered needle being passed from the lateral commissure of the eyelid to the small stab incision being passed to the medial superior orbital rim and sutured to tighten the lower lid.  The distal lateral resection of excessive lower eyelid skin was reduced at risk of eyelid malposition.  The lower lid incision was closed after the redundancy of skin measuring approximately 3 mm was resected on both sides.  Closure was performed with interrupted 6-0 silk suture for the lower lid.  The eyebrow hairline brow lift was closed with interrupted 4-0 PDS suture, deep subcutaneous tissue, and dermis, and the skin closed with a running 5-0 Prolene suture.,Attention then was directed to the cervical facial rhytidectomy and purse-string SMAS elevation with submental lipectomy.  Incisions were made in preauricular area, postauricular area, mastoid and occipital area.  Subcutaneous dissection was performed to the nasolabial fold and cheek and extending across the neck in the midline.  Submental lipectomy was performed through the incision in the submental crease.  Fat was directly removed from the fascia.,Hemostasis was achieved with electrocautery.  A SMAS elevation was performed with a purse-string suture of 2-0 PDS suture from temporalis fascia in front of the ear extending beneath the mandible and then brought back up to be sutured to the temporalis fascia.  This was performed bilaterally and symmetrically.  Hemostasis was achieved with electrocautery.  The cheek flap was brought back posteriorly and the cervical flap posteriorly and superiorly with redundant skin on the right massaged and closed.  The skin of the cheek and neck were resected which was redundant after the ***** posteriorly and superiorly in the neck and transversely in the cheek.,Closure was performed with interrupted 3-0 and 4-0 PDS suture of deep subcutaneous tissue and dermis of the skin was closed with a running 5-0 Prolene suture.  Drains were placed prior to final closure.  A 7-mm flat Jackson-Pratt was then secured with 3-0 silk suture.  Dressing consisting of fluffs and Kerlix and a 4-inch Ace were applied to support mildly compressive dressing.  Scleral eye protectors were removed.  Maxitrol eye ointment was placed followed by Swiss therapy eye pads.  The patient tolerated the procedure well, and she returned to recovery room in satisfactory condition with Foley catheter and Pneumatic compression stockings, TED hose, two Jackson-Pratt drains, and an IV.","surgery, eyebrow ptosis, dermatochalasia, hairline, jackson-pratt, swiss therapy, arcus marginalis, blepharoplasty, browlift, canthopexy, fat transposition, inferior orbital rim, lipectomy, lipodystrophy, lower eyelid, purse-string, rhytidectomy, string smas elevation, suborbicularis oculi, frontalis muscle, pds suture, smas elevation, submental lipectomy, upper eyelid, subperiosteal dissection, lower lid, prolene suture, lower eyelids, orbital rim, lower, eyelids, sutured, subcutaneous, eyebrow, orbital,"
  Plastic piece foreign body in the right main stem bronchus.  Rigid bronchoscopy with foreign body removal., Surgery, Bronchoscopy & Foreign Body Removal ,"PREOPERATIVE DIAGNOSIS: , Foreign body in airway.,POSTOPERATIVE DIAGNOSIS:,  Plastic piece foreign body in the right main stem bronchus.,PROCEDURE: , Rigid bronchoscopy with foreign body removal.,INDICATIONS FOR PROCEDURE: , This patient is 7-month-old baby boy who presented to emergency room today with increasing stridor and shortness of breath according to mom.  The patient had a chest x-ray and based on that there is concern by the Radiology it could be a foreign body in the right main stem.  The patient has been taken to the operating room for rigid bronchoscopy and foreign body removal.,DESCRIPTION OF PROCEDURE:  ,The patient was taken to the operating room, placed supine, put under general mask anesthesia.  Using a 3.5 rigid bronchoscope we visualized between the cords into the trachea.  There were some secretions but that looked okay.  Got down at the level of the carina to see a foreign body flapping in the right main stem.  I then used graspers to grasp to try to pull into the scope itself.  I could not do that, I thus had to pull the scope out along with the foreign body that was held on to with a grasper.  It appeared to be consisting of some type of plastic piece that had broke off some different object.  I took the scope and put it back down into the airway again.  Again, there was secretion in the trachea that we suctioned out.  We looked down into the right bronchus intermedius.  There was no other pathology noted, just some irritation in the right main stem area.  I looked down the left main stem as well and that looked okay as well.  I then withdrew the scope.  Trachea looked fine as well as the cords.  I put the patient back on mask oxygen to wake the patient up.  The patient tolerated the procedure well.","surgery, main stem bronchus, bronchoscopy, airway, foreign body removal, rigid bronchoscopy, "
" Bronchoscopy with brush biopsies.  Persistent pneumonia, right upper lobe of the lung, possible mass.", Surgery, Bronchoscopy - 8 ,"PREOPERATIVE DIAGNOSIS: , Persistent pneumonia, right upper lobe of the lung, possible mass.,POSTOPERATIVE DIAGNOSIS: , Persistent pneumonia, right upper lobe of the lung, possible mass.,PROCEDURE:,  Bronchoscopy with brush biopsies.,DESCRIPTION OF PROCEDURE: , After obtaining an informed consent, the patient was taken to the operating room where he underwent a general endotracheal anesthesia.  A time-out process had been followed and then the flexible bronchoscope was inserted through the endotracheal tube after 2 cc of 4% lidocaine had been infused into the endotracheal tube.  First the trachea and the carina had normal appearance.  The scope was passed into the left side and the bronchial system was found to be normal.  There were scars and mucoid secretions.  Then the scope was passed into the right side where brown secretions were obtained and collected in a trap to be sent for culture and sensitivity of aerobic and anaerobic fungi and TB.  First, the basal lobes were explored and found to be normal.  Then, the right upper lobe was selectively cannulated and no abnormalities were found except some secretions were aspirated.  Then, the bronchi going to the three segments were visualized and no abnormalities or mass were found.  Brush biopsy was obtained from one of the segments and sent to Pathology.,The procedure had to be interrupted several times because of the patient's desaturation, but after a few minutes of Ambu bagging, he recovered satisfactorily.,At the end, the patient tolerated the procedure well and was sent to the recovery room in satisfactory condition.,","surgery, persistent pneumonia, bronchoscopy, brush biopsies, endotracheal tube, biopsies, bronchial, abnormalities, pneumonia, secretions, endotracheal, "
 Bronchoscopy with aspiration and left upper lobectomy.  Carcinoma of the left upper lobe., Surgery, Bronchoscopy & Lobectomy ,"PREOPERATIVE DIAGNOSIS:  ,Carcinoma of the left upper lobe.,PROCEDURES PERFORMED:,1.  Bronchoscopy with aspiration.,2.  Left upper lobectomy.,PROCEDURE DETAILS:  ,With patient in supine position under general anesthesia with endotracheal tube in place, the flexible bronchoscope was then placed down through the endotracheal tube to examine the carina.  The carina was in the midline and sharp.  Moving directly to the right side, the right upper and middle lower lobes were examined and found to be free of obstructions.  Aspiration was carried out for backlog ________ examination.  We then moved to left side, left upper lobe.  There was a tumor mass located in the lingula of the left lobe and left lower lobe found free of obstruction.  No anatomic lesions were demonstrated.  The patient was prepared for left thoracotomy rotated to his right side with a double lumen endotracheal tube in place with an NG tube and a Foley catheter.  After proper position, utilizing Betadine solution, they were draped.  A posterolateral left thoracotomy incision was performed.  Hemostasis was secured with electrocoagulation.  The chest wall muscle was then divided over the sixth rib.  The periosteum of the sixth rib was then removed superiorly and the pleural cavity was entered carefully.  At this time, the mass was felt in the left upper lobe, which measures greater than 3 cm by palpation.  We examined the superior mediastinum.  No lymph nodes were demonstrated as well as in the anterior mediastinum.  Direction was then moved to the fascia where by utilizing sharp and blunt dissection, lingual artery was separated into the left upper lobe.  Casual dissection was carried out with superior segmental arteries and left lower lobe was examined.,Dissection was carried out around the pulmonary artery thus exposing the posterior artery to the left upper lobe.  Direction was carried out to the superior pulmonary vein and utilizing sharp and blunt dissection the entire superior pulmonary vein was separated from the surrounding tissue.  From the top side, the bronchus was then separated away from the pulmonary artery anteriorly, thus exposing the apical posterior artery, which was short.  Tumor mass was close to the artery at this time.  We then directed ourselves once again to the lingual artery which was doubly ligated and cut free.  The posterior artery of the superior branch was doubly ligated and cut free also.  At this time, the bronchus of the left upper lobe was encountered in the fissure on palpation to separate the upper lobe bronchus from lower lobe bronchus and the area was accomplished.  We then moved anteriorly to doubly ligate the pulmonary vein using #00 silk sutures for ligation and a transection #00 silk suture was used to fixate the vein.  Using sharp and blunt dissection, the bronchus through the left upper lobe was freed proximal.  Using the TA 50, the bronchus was then cut free allowing the lung to fall superiorly at which time direction was carried out to the pulmonary artery where the tumor was in close proximity at this time.  A Potts clamp arterial was then placed over the artery and shaving off the tumor and the apical posterior artery was then accomplished.  The anterior artery was seen in the clamp also and was separated and ligated and separated.  At this time, the entire tumor in the left upper lobe was then removed.  ,Direction was carried to the suture where #000 silk was used as a running suture over the pulmonary artery and was here doubly run and tied in place.  The clamp was then removed.  No bleeding was seen at this time.  Lymph nodes were then removed from the sump of the separation between the upper lobe and the lower lobe and sent for separate pathology.  We then carried out incision in the inferior pulmonary ligament up to the pulmonary vein allowing the lung to reexpand to its normal position.  At this time, two chest tubes #28 and #32 were placed anteriorly and posteriorly to fixate the skin using raw silk suture.  The chest cavity was then closed.  After reexamination, no bleeding was seen with three pericostal sutures of #1 chromic double strength.  A #2-0 Polydek was then used to close the chest wall muscle the anterior as well as latissimus dorsi #000 chromic subcutaneous tissue skin clips to the skin.  The chest tubes were attached to the Pleur-Evac drainage and placed on suction at this time.  The patient was extubated in the room without difficulty and sent to Recovery in satisfactory.","surgery, ng tube, chest tubes, endotracheal tube, pulmonary vein, artery, aspiration, lobectomy, bronchoscopy, tumor, vein, bronchus, pulmonary,"
" Bronchoscopy with bronchoalveolar lavage.  Refractory pneumonitis.  A 69-year-old man status post trauma, slightly prolonged respiratory failure status post tracheostomy, requires another bronchoscopy for further evaluation of refractory pneumonitis.", Surgery, Bronchoscopy & Bronchoalveolar Lavage ,"PREOPERATIVE DIAGNOSIS:,  Refractory pneumonitis.,POSTOPERATIVE DIAGNOSIS: , Refractory pneumonitis.,PROCEDURE PERFORMED: , Bronchoscopy with bronchoalveolar lavage.,ANESTHESIA: , 5 mg of Versed.,INDICATIONS: , A 69-year-old man status post trauma, slightly prolonged respiratory failure status post tracheostomy, requires another bronchoscopy for further evaluation of refractory pneumonitis.,PROCEDURE: , The patient was sedated with 5 mg of Versed that was placed on the endotracheal tube.  Bronchoscope was advanced.  Both right and left mainstem bronchioles and secondary and tertiary bronchioles were cannulated sequentially, lavaged out.  Relatively few tenacious secretions were noted.  These were lavaged out.  Specimen collected for culture.  No obvious other abnormalities were noted.  The patient tolerated the procedure well without complication.","surgery, respiratory failure, bronchoalveolar lavage, refractory pneumonitis, tracheostomy, bronchoalveolar, bronchoscopy, pneumonitis"
 Diagnostic fiberoptic bronchoscopy., Surgery, Bronchoscopy - 7 ,"PROCEDURE:,  Diagnostic fiberoptic bronchoscopy.,ANESTHESIA:  ,  Plain lidocaine 2% was given intrabronchially for local anesthesia.,PREOPERATIVE MEDICATIONS:,  ,1.  Lortab (10 mg) plus Phenergan (25 mg), p.o.  1 hour before the procedure.,2.  Versed a total of 5 mg given IV push during the procedure.,INDICATIONS: ,","surgery, fiberoptic, intrabronchially, larynx, distal trachea, diagnostic fiberoptic bronchoscopy, bronchoscopy, bronchoscope,"
" Bronchoscopy brushings, washings and biopsies.  Patient with a bilateral infiltrates, immunocompromised host, and pneumonia.", Surgery, Bronchoscopy Brushings ,"OPERATIVE PROCEDURE:,  Bronchoscopy brushings, washings and biopsies.,HISTORY: , This is a 41-year-old woman admitted to Medical Center with a bilateral pulmonary infiltrate, immunocompromise.,INDICATIONS FOR THE PROCEDURE:,  Bilateral infiltrates, immunocompromised host, and pneumonia.,Prior to procedure, the patient was intubated with 8-French ET tube orally by Anesthesia due to her profound hypoxemia and respiratory distress.,DESCRIPTION OF PROCEDURE: , Under MAC and fluoroscopy, fiberoptic bronchoscope was passed through the ET tube.,ET tube was visualized approximately 2 cm above the carina.  Fiberoptic bronchoscope subsequently was passed through the right lower lobe area and transbronchial biopsies under fluoroscopy were done from the right lower lobe x3 as well as the brushings were obtained and the washings.  The patient tolerated the procedure well.  Postprocedure, the patient is to be placed on a ventilator as well as postprocedure chest x-ray pending.  Specimens are sent for immunocompromise panel including PCP stains.,POSTPROCEDURE DIAGNOSIS:,  Pneumonia, infiltrates.","surgery, mac, fluoroscopy, fiberoptic bronchoscope, bronchoscopy brushings, fiberoptic, bronchoscope, bronchoscopy, biopsies, pneumonia, immunocompromised"
" Fiberoptic bronchoscopy with endobronchial biopsies.  A CT scan done of the chest there which demonstrated bilateral hilar adenopathy with extension to the subcarinal space as well as a large 6-cm right hilar mass, consistent with a primary lung carcinoma.", Surgery, Bronchoscopy - Fiberoptic ,"HISTORY OF PRESENT ILLNESS:,  A 67-year-old gentleman who presented to the emergency room with chest pain, cough, hemoptysis, shortness of breath, and recent 30-pound weight loss.  He had a CT scan done of the chest there which demonstrated bilateral hilar adenopathy with extension to the subcarinal space as well as a large 6-cm right hilar mass, consistent with a primary lung carcinoma.  There was also a question of liver metastases at that time.,OPERATION PERFORMED:,  Fiberoptic bronchoscopy with endobronchial biopsies.,The bronchoscope was passed into the airway and it was noted that there was a large, friable tumor blocking the bronchus intermedius on the right.  The tumor extended into the carina, involving the lingula and the left upper lobe, appearing malignant.  Approximately 15 biopsies were taken of the tumor.,Attention was then directed at the left upper lobe and lingula.  Epinephrine had already been instilled and multiple biopsies were taken of the lingula and the left upper lobe and placed in a separate container for histologic review.  Approximately eight biopsies were taken of the left upper lobe.","surgery, endobronchial, intermedius, fiberoptic bronchoscopy, lung carcinoma, bronchoscopy, fiberoptic, chest, tumor, lobeNOTE"
" Diagnostic bronchoscopy and limited left thoracotomy with partial pulmonary decortication and insertion of chest tubes x2.  Bilateral bronchopneumonia and empyema of the chest, left.", Surgery, Bronchoscopy & Thoracotomy ,"PREOPERATIVE DIAGNOSES,1.  Bilateral bronchopneumonia.,2.  Empyema of the chest, left.,POSTOPERATIVE DIAGNOSES,1.  Bilateral bronchopneumonia.,2.  Empyema of the chest, left.,PROCEDURES,1.  Diagnostic bronchoscopy.,2.  Limited left thoracotomy with partial pulmonary decortication and insertion of chest tubes x2.,DESCRIPTION OF PROCEDURE:,  After obtaining an informed consent, the patient was taken to the operating room where a time-out process was followed.  Initially, the patient was intubated with a #6 French tube because of the presence of previous laryngectomy.  Because of this, I proceeded to use a pediatric bronchoscope, which provided limited visualization, but I was able to see the trachea and the carina and both left and right bronchial systems without significant pathology, although there was some mucus secretion that was aspirated.,Then, with the patient properly anesthetized and looking very stable, we decided to insert a larger endotracheal tube that allowed for the insertion of the regular adult bronchoscope.  Therefore, we were able to obtain a better visualization and see the trachea and the carina that were normal and also the left and right bronchial systems.  Some brownish secretions were obtained, particularly from the right side and were sent for culture and sensitivity, both aerobic and anaerobic fungi and acid fast.,Then, the patient was turned with left side up and prepped for a left thoracotomy.  He was properly draped.  I had recently re-inspected the CT of the chest and decided to make a limited thoracotomy of about 6 cm or so in the midaxillary line about the sixth intercostal space.  Immediately, it was evident that there was a large amount of pus in the left chest.  We proceeded to insert the suction catheters and we rapidly obtained about 1400 mL of frank pus.  Then, we proceeded to open the intercostal space a bit more with a Richardson retractor and it was immediately obvious that there was an abundant amount of solid exudate throughout the lung.  We spent several minutes trying to clean up this area.  Initially, I had planned only to drain the empyema because the patient was in a very poor condition, but at this particular moment, he was more stable and well oxygenated, and the situation was such that we were able to perform a partial pulmonary decortication where we broke up a number of loculations that were present and we were able to separate the lung from the diaphragm and also the pulmonary fissure.  On the upper part of the chest, we had limited access, but overall we obtained a large amount of solid exudate and we were able to break out loculations.  We followed by irrigation with 2000 cc of warm normal saline and then insertion of two #32 chest tubes, which are the largest one available in this institution; one we put over the diaphragm and the other one going up and down towards the apex.,The limited thoracotomy was closed with heavy intercostal sutures of Vicryl, then interrupted sutures of #0 Vicryl to the muscle layers, and I loosely approximately the skin with a few sutures of nylon because I am suspicious that the incision may become infected because he has been exposed to intrapleural pus.,The chest tubes were secured with sutures and then connected to Pleur-evac.  Then, the patient was transported.,Estimated blood loss was minimal and the patient tolerated the procedure well.  He was extubated in the operating room and he was transferred to the ICU to be admitted.  A chest x-ray was ordered stat.","surgery, chest tubes, insertion, partial pulmonary decortication, thoracotomy, bronchoscopy, empyema, bronchopneumonia, diagnostic bronchoscopy, pulmonary decortication, bilateral bronchopneumonia, decortication, intercostal, pulmonary, tubes,"
 Bronchoscopy for hypoxia and increasing pulmonary secretions, Surgery, Bronchoscopy - 6 ,"PREOPERATIVE DIAGNOSIS: , Hypoxia and increasing pulmonary secretions.,POSTOPERATIVE DIAGNOSIS: , Hypoxia and increasing pulmonary secretions.,OPERATION: , Bronchoscopy.,ANESTHESIA: , Moderate bedside sedation.,COMPLICATIONS:,  None.,FINDINGS:,  Abundant amount of clear thick secretions throughout the main airways.,INDICATIONS:,  The patient is a 43-year-old gentleman who has been in the ICU for several days following resection of small bowel for sequelae of SMV occlusion.  This morning, the patient developed worsening hypoxia with abundant sputum production requiring frequent suctioning from his ET tube.  The patient also had new-appearing atelectasis versus infiltrates in the right lower lobe of his lung on chest x-ray.  Given these findings, it was felt that bronchoscopy could further define source of secretions and send more appropriate specimen for culture if need be.,OPERATION:,  The patient was given additional fentanyl, Versed as well as paralytics for the procedure.  Small bronchoscope was inserted through the ET tube and to the trachea to the level of carina.  There was noted to be thick clear secretions adherent to the trachea walls as well as into the right mainstem bronchus.  Extensive secretions extended down into the secondary airways.  This was lavaged with saline and suctioned dry.  There is no overt specific occlusion of airways, nor was there any purulent-appearing sputum.  The bronchoscope was then advanced into the left mainstem bronchus, and there was noted to be a small amount of similar-appearing secretions which was likewise suctioned and cleaned.  The bronchoscope was removed, and the patient was increased to PEEP of 10 on the ventilator.  Please note that prior to starting bronchoscopy, he was pre oxygenated with 100% O2.  The patient tolerated the procedure well and lavage specimen was sent for gram stain as well as routine culture.","surgery, pulmonary secretions, bronchoscopy, hypoxia, peep, smv occlusion, atelectasis, bedside sedation, bronchoscope, chest x-ray, mainstem, right lower lobe, mainstem bronchus,"
 Bronchoscopy for persistent cough productive of sputum requiring repeated courses of oral antibiotics over the last six weeks in a patient who is a recipient of a bone marrow transplant with end-stage chemotherapy and radiation-induced pulmonary fibrosis., Surgery, Bronchoscopy - 2 ,"INDICATIONS FOR PROCEDURE:,  Persistent cough productive of sputum requiring repeated courses of oral antibiotics over the last six weeks in a patient who is a recipient of a bone marrow transplant with end-stage chemotherapy and radiation-induced pulmonary fibrosis.,PREMEDICATION:,1.  Demerol 50 mg.,2.  Phenergan 25 mg.,3.  Atropine 0.6 mg IM.,4.  Nebulized 4% lidocaine followed by nasal insufflation of lidocaine through the right naris and topical 4% lidocaine gel through the right naris, 4 mg of Versed was given at the start of the procedure and another 1 mg shortly after traversing the cords.,PROCEDURE DETAILS:,  With the patient breathing oxygen by nasal cannula, being monitored by noninvasive blood pressure cuff and continuous pulse oximetry, the Olympus bronchoscope was introduced through the right naris to the level of the cords.  The cords move normally with phonation and ventilation.  Two times 2 mL of 1% lidocaine were instilled on the cords and the cords were traversed.  Further 2 mL of 1% lidocaine was instilled in the trachea just distal to the cords, at mid trachea above the carina, and on the right, and on the left mainstem bronchus.  Scope was then introduced on to the left where immediately some hyperemia of the mucosa was noted.  Upper lobe and lingula were unremarkable.  There appeared to be some narrowing or tenting of the left lower lobe bronchus such that after inspection of the superior segment, one almost had to pop the bronchoscope around to go down the left mainstem.  This had been a change from the prior bronchoscopy of unclear significance.  Distal to this, there was no hyperemia or inspissated mucus or mucoid secretions or signs of infection.  The scope was wedged in the left lower lobe posterior basal segment and a BAL was done with good returns, which were faintly hemorrhagic.  The scope was then removed, re-introduced up to the right upper lobe, middle lobe, superior segment, right lower, anterior lateral, and posterior basal subsegments were all evaluated and unremarkable.  The scope was withdrawn.  The patient's saturation remained 93%-95% throughout the procedure.  Blood pressure was 103/62.  Heart rate at the end of the procedure was about 100.  The patient tolerated the procedure well.  Samples were sent as follows.  Washings for AFB, Gram-stain Nocardia, Aspergillus, and routine culture.  Lavage for AFB, Gram-stain Nocardia, Aspergillus, cell count with differential, cytology, viral mycoplasma, and Chlamydia culture, GMS staining, RSV by antigen, and Legionella and Chlamydia culture.","surgery, cough, bronchoscopy, olympus, bronchoscope, nasal insufflation, oral antibiotics, pulse oximetry, sputum, ventilation, antibiotics, nocardia, aspergillus, chlamydia, atropine, lidocaine, cords, topical,"
" Rigid bronchoscopy with dilation, excision of granulation tissue tumor, application of mitomycin-C, endobronchial ultrasound.", Surgery, Bronchoscopy - 4 ,"PREOPERATIVE DIAGNOSIS:  ,Tracheal stenosis and metal stent complications.,POSTOPERATIVE DIAGNOSIS:  ,Tracheal stenosis and metal stent complications.,ANESTHESIA:  ,General endotracheal.,ENDOSCOPIC FINDINGS:,1.  Normal true vocal cords.,2.  Subglottic stenosis down to 5 mm with mature cicatrix.,3.  Tracheal granulation tissue growing through the stents at the midway point of the stents.,5.  Three metallic stents in place in the proximal trachea.,6.  Distance from the true vocal cords to the proximal stent, 2 cm.,7.  Distance from the proximal stent to the distal stent, 3.5 cm.,8.  Distance from the distal stent to the carina, 8 cm.,9.  Distal airway is clear.,PROCEDURES:,1.  Rigid bronchoscopy with dilation.,2.  Excision of granulation tissue tumor.,3.  Application of mitomycin-C.,4.  Endobronchial ultrasound.,TECHNIQUE IN DETAIL:  ,After informed consent was obtained from the patient and her husband, she was brought to the operating theater after sequence induction was done.  She had a Dedo laryngoscope placed.  Her airways were inspected thoroughly with findings as described above.  She was intermittently ventilated with an endotracheal tube placed through the Dedo scope.  Her granulation tissue was biopsied and then removed with a microdebrider.  Her proximal trachea was dilated with a combination of balloon, Bougie, and rigid scopes.  She tolerated the procedure well, was extubated, and brought to the PACU.","surgery, tracheal stenosis, dedo scope, bronchoscopy, cicatrix, dilation, endotracheal, granulation, metal stent, mitomycin-c, proximal trachea, vocal cords, endobronchial ultrasound, granulation tissue, proximal, tracheal, stent,"
 Excision of left breast mass.  The mass was identified adjacent to the left nipple.  It was freely mobile and it did not seem to hold the skin. , Surgery, Breast Mass Excision - 2 ,"PREOPERATIVE DIAGNOSIS: , Breast mass, left.,POSTOPERATIVE DIAGNOSIS:,  Breast mass, left.,PROCEDURE:,  Excision of left breast mass.,OPERATION: , After obtaining an informed consent, the patient was taken to the operating room where he underwent general endotracheal anesthesia.  The time-out process was followed.  Preoperative antibiotic was given.  The patient was prepped and draped in the usual fashion.  The mass was identified adjacent to the left nipple.  It was freely mobile and it did not seem to hold the skin.  An elliptical skin incision was made over the mass and carried down in a pyramidal fashion towards the pectoral fascia.  The whole of specimen including the skin, the mass, and surrounding subcutaneous tissue and fascia were excised en bloc.  Hemostasis was achieved with the cautery.  The specimen was sent to Pathology and the tissues were closed in layers including a subcuticular suture of Monocryl.  A small pressure dressing was applied.,Estimated blood loss was minimal and the patient who tolerated the procedure very well was sent to recovery room in satisfactory condition.","surgery, breast mass excision, freely mobile, breast mass, endotracheal, fascia, specimen,"
" Bronchoscopy, right upper lobe biopsies and right upper lobe bronchial washing as well as precarinal transbronchial needle aspiration.", Surgery, Bronchoscopy - 1 ,"PROCEDURE:,  Bronchoscopy, right upper lobe biopsies and right upper lobe bronchial washing as well as precarinal transbronchial needle aspiration.,DETAILS OF THE PROCEDURE: , The risks, alternatives, and benefits of the procedure were explained to the patient as well as conscious sedation and she agrees to proceed.  The patient received topical lidocaine by nebulization.  The flexible fiberoptic bronchoscope was introduced orally.  The patient had normal teeth, normal tongue, normal jaw, and her vocal cords moved symmetrically and were without lesions.  I proceeded to the right upper lobe where a mucous plug was noted in the subsegmental bronchus of the posterior segment of the right upper lobe.  I proceeded under fluoroscopic guidance to guide the biopsy wire in this area and took four biopsies.  Followup fluoroscopy was negative for pneumothorax.  I wedged the bronchoscope in the subsegmental bronchus and achieved good hemostasis after three minutes.,I then proceeded to inspect the rest of the tracheobronchial tree, which was without lesions.  I performed a bronchial washing after the biopsies in the right upper lobe.  I then performed two transbronchial needle aspirations with a Wang needle biopsy in the precarinal area.  All of these samples were sent for histology and cytology respectively.  Estimated blood loss was approximately 5 cc.  Good hemostasis was achieved.  The patient received a total of 12.5 mg of Demerol and 3 mg of Versed and tolerated the procedure well.  Her ASA score was 2.","surgery, bronchoscopy, wang needle, biopsy, bronchial washing, bronchoscope, bronchus, fiberoptic, hemostasis, lidocaine, nebulization, right upper lobe, transbronchial, transbronchial needle aspiration, needle aspiration, transbronchial needle, upper lobe, bronchial, precarinal, biopsies, needle, lobeNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" Rigid bronchoscopy, removal of foreign body, excision of granulation tissue tumor, bronchial dilation , Argon plasma coagulation, placement of a tracheal and bilateral bronchial stents.", Surgery, Bronchoscopy - 5 ,"PREOPERATIVE DIAGNOSIS:,  Airway stenosis with self-expanding metallic stent complication.,POSTOPERATIVE DIAGNOSIS:,  Airway stenosis with self-expanding metallic stent complication.,PROCEDURES:,1.  Rigid bronchoscopy with removal of foreign body, prolonged procedure taking two hours to remove the stent piecemeal in a very difficult and trying situation.,2.  Excision of granulation tissue tumor.,3.  Bronchial dilation with a balloon bronchoplasty, right main bronchus.,4.  Argon plasma coagulation to control bleeding in the trachea.,5.  Placement of a tracheal and bilateral bronchial stents with a silicon wire stent.,ENDOSCOPIC FINDINGS:,1.  Normal true vocal cords.,2.  Proximal trachea with high-grade occlusion blocking approximately 90% of the trachea due to granulation tissue tumor and break down of metallic stent.,3.  Multiple stent fractures in the mid portion of the trachea with granulation tissue.,4.  High-grade obstruction of the right main bronchus by stent and granulation tissue.,5.  Left main bronchus was covered by the distal portion of the stent and was only being ventilated through the struts of the stent.,6.  All in all a high-grade terrible airway obstruction with involvement of the carina, left and right main stem bronchus, mid, distal, and proximal trachea.,TECHNIQUE IN DETAIL: , After informed consent was obtained from the patient, he was brought into the operating field.  A rapid sequence induction was done.  He was intubated with a rigid scope.  Jet ventilation technique was carried out using a rigid and flexible scope.  A thorough airway inspection was carried out with findings as described above.,Dr. D was present in the operating room and we conferred on operative strategy and agreed that the best of strategy would be to first dilate the right main bronchus, cauterize it to control bleeding and then piecemeal removed the stent from distal to proximal.  This is the technique that was carried out in a painstaking fashion removing bits of the stent piecemeal with finally getting all of the visible stent out of the airway.  It should be noted that Dr. Donovan and I felt that two of the metallic stents were probably in place but we cannot be sure because of the terrible anatomy and the fact that the stent pieces were coming out twisted metal in fragments.  Nevertheless, all the visible stent was removed, and the airway was much better after with the dilation of balloon and the rigid scope.  We took measurements and decided to place stents in the trachea, left and right main bronchus using a Dumon Y-stent.  It was measured 18 mm in tracheal diameter and 14 mm in bronchial diameter.  The right main stem stent was 2.25 cm in length, the left main stem stent was 3 cm in length and the tracheal portion was 9 cm in length.  After it was placed, excellent placement was achieved with the proximal end of the stent 3 cm below the true vocal cords.  The patient tolerated the procedure well and was brought to the recovery room extubated.","surgery, airway, argon plasma coagulation, bronchial dilation, balloon bronchoplasty, bronchoscopy, bronchus, foreign body, granulation, metallic stent, stenosis, vocal cords, granulation tissue tumor, plasma coagulation, granulation tissue, tracheal, argon, stents, bronchial, metallic,"
 Evaluation of airway for possible bacterial infection performed using bronchoalveolar lavage., Surgery, Bronchoalveolar lavage. ,"POSTOPERATIVE DIAGNOSIS:  Fever.,PROCEDURES:  Bronchoalveolar lavage.,INDICATIONS FOR PROCEDURE:  The patient is a 28-year-old male, status post abdominal trauma, splenic laceration, and splenectomy performed at the outside hospital, who was admitted to the Trauma Intensive Care Unit on the evening of August 4, 2008.  Greater than 24 hours postoperative, the patient began to run a fever in excess of 102.  Therefore, evaluation of his airway for possible bacterial infection was performed using bronchoalveolar lavage.,DESCRIPTION OF PROCEDURE:  The patient was preoxygenated with 100% FIO2 for approximately 5 to 10 minutes prior to the procedure.  The correct patient and procedure was identified by time out by all members of the team.  The patient was prepped and draped in a sterile fashion and sterile technique was used to connect the BAL lavage catheter to Lukens trap suction.  A catheter was introduced into the endotracheal tube through a T connector and five successive 20 mL aliquots of normal saline were flushed through the catheter, each time suctioning out the sample into the Lukens trap.  A total volume of 30 to 40 mL was collected in the trap and sent to the lab for quantitative bacteriology.  The patient tolerated the procedure well and had no episodes of desaturation, apnea, or cardiac arrhythmia.  A postoperative chest x-ray was obtained.","surgery, abdominal trauma, bal lavage, lukens trap suction, splenectomy, splenic laceration, bronchoalveolar lavage, fever, catheter, bronchoalveolar, lavage, airwayNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Right breast excisional biopsy with needle-localization.  The patient is a 41-year-old female with abnormal mammogram with a strong family history of breast cancer requesting needle-localized breast biopsy for nonpalpable breast mass., Surgery, Breast Excisional Biopsy ,"PREOPERATIVE DIAGNOSIS:,  Right breast mass with abnormal mammogram.,POSTOPERATIVE DIAGNOSIS:,  Right breast mass with abnormal mammogram.,PROCEDURE PERFORMED:,  Right breast excisional biopsy with needle-localization.,ANESTHESIA: , Local with sedation.,COMPLICATIONS: , None.,SPECIMEN: , Right breast mass and confirmation by Radiology that the specimen was received with the mass was in the specimen.,DISPOSITION: , The patient tolerated the procedure well and was transferred to recovery in stable condition.,BRIEF HISTORY:  ,The patient is a 41-year-old female who presented to Dr. X's office with abnormal mammogram with a strong family history of breast cancer requesting needle-localized breast biopsy for nonpalpable breast mass.,PROCEDURE: , After informed consent, the risks and benefits of the procedure were explained to the patient.  The patient was brought into the operating suite.  After IV sedation was given, the patient was prepped and draped in normal sterile fashion.  A radial incision was made in the right lateral breast with a #10 blade scalpel.  The needle was brought into the field.  An Allis was used to grasp the breast mass and breast tissue using the #10 scalpel.  The mass was completely excised and sent out for specimen after confirmation by Radiology that the mass was in the specimen.,Hemostasis was then obtained with electrobovie cautery.  The skin was then closed with #4-0 Monocryl in a running subcuticular fashion.  Steri-Strips and sterile dressings were applied.  The patient tolerated the procedure well and was transferred to Recovery in stable condition.","surgery, breast mass, mammogram, breast excisional biopsy, needle-localization, excisional biopsy, abnormal mammogram, breast, radiology, scalpel, excisional, biopsy, needle, specimen, mass"
 Fiberoptic bronchoscopy for diagnosis of right lung atelectasis and extensive mucus plugging in right main stem bronchus., Surgery, Bronchoscopy - 3 ,"PROCEDURE: , Fiberoptic bronchoscopy.,PREOPERATIVE DIAGNOSIS:,  Right lung atelectasis.,POSTOPERATIVE DIAGNOSIS:,  Extensive mucus plugging in right main stem bronchus.,PROCEDURE IN DETAIL:,  Fiberoptic bronchoscopy was carried out at the bedside in the medical ICU after Versed 0.5 mg intravenously given in 2 aliquots.  The patient was breathing supplemental nasal and mask oxygen throughout the procedure.  Saturations and vital signs remained stable throughout.  A flexible fiberoptic bronchoscope was passed through the right naris.  The vocal cords were visualized.  Secretions in the larynx were as aspirated.  As before, he had a mucocele at the right anterior commissure that did not obstruct the glottic opening.  The ports were anesthetized and the trachea entered.  There was no cough reflex helping explain the propensity to aspiration and mucus plugging.  Tracheal secretions were aspirated.  The main carinae were sharp.  However, there were thick, sticky, grey secretions filling the right mainstem bronchus up to the level of the carina.  This was gradually lavaged clear.  Saline and Mucomyst solution were used to help dislodge remaining plugs.  The airways appeared slightly friable, but were patent after the airways were suctioned.  O2 saturations remained in the mid-to-high 90s.  The patient tolerated the procedure well.  Specimens were submitted for microbiologic examination.  Despite his frail status, he tolerated bronchoscopy quite well.","surgery, bronchoscopy, fiberoptic, mucomyst, atelectasis, bronchoscope, bronchus, carinae, larynx, main stem, mucus, nasal, plugging, trachea, fiberoptic bronchoscopy, mucus plugging, secretions"
" Left breast mass and hypertrophic scar of the left breast.  Excision of left breast mass and revision of scar.  The patient is status post left breast biopsy, which showed a fibrocystic disease with now a palpable mass just superior to the previous biopsy site.", Surgery, Breast Mass Excision - 1 ,"PREOPERATIVE DIAGNOSES:,1.  Left breast mass.,2.  Hypertrophic scar of the left breast.,POSTOPERATIVE DIAGNOSES:,1.  Left breast mass.,2.  Hypertrophic scar of the left breast.,PROCEDURE PERFORMED:  ,Excision of left breast mass and revision of scar.,ANESTHESIA:  ,Local with sedation.,SPECIMEN: , Scar with left breast mass.,DISPOSITION:  ,The patient tolerated the procedure well and transferred to the recover room in stable condition.,BRIEF HISTORY:  ,The patient is an 18-year-old female who presented to Dr. X's office.  The patient is status post left breast biopsy, which showed a fibrocystic disease with now a palpable mass just superior to the previous biopsy site.  The patient also has a hypertrophic scar.  Thus, the patient elected to undergo revision of the scar at the same time as an excision of the palpable mass.,INTRAOPERATIVE FINDINGS: , A hypertrophic scar was found and removed.  The cicatrix was removed in its entirety and once opening the wound, the area of tissue where the palpable mass was, was excised as well and sent to the lab.,PROCEDURE: , After informed consent, risks, and benefits of the procedure were explained to the patient and the patient's family, the patient was brought to the operating suite, prepped and draped in the normal sterile fashion.  Elliptical incision was made over the previous cicatrix.  The total length of the incision was 5.5 cm.  Removing the cicatrix in its entirety with a #15 blade Bard-Parker scalpel after anesthetizing with local solution with 0.25% Marcaine.  Next, the area of tissue just inferior to the palpable mass, where the palpable was removed with electro Bovie cautery.  Hemostasis was maintained.  Attention was next made to approximating the deep dermal layers.  An interrupted #4-0 Vicryl suture was used and then a running subcuticular Monocryl suture was used to approximate the skin edges.  Steri-Strips as well as bacitracin and sterile dressings were applied.  The patient tolerated the procedure well and was transferred to recovery in stable condition.","surgery, hypertrophic scar, palpable mass, fibrocystic, scar, fibrocystic disease, breast mass, breast, cicatrix, excision, biopsy, hypertrophic, palpable,"
 Bronchoscopy.  Atelectasis and mucous plugging., Surgery, Bronchoscopy ,"PREOPERATIVE DIAGNOSIS: , Atelectasis.,POSTOPERATIVE DIAGNOSIS: , Mucous plugging.,PROCEDURE PERFORMED: , Bronchoscopy.,ANESTHESIA: , Lidocaine topical 2%, Versed 3 mg IV.  Conscious sedation.,PROCEDURE: , At bedside, a bronchoscope was passed down the tracheostomy tube under monitoring.  The main carina was visualized.  The trachea was free of any secretions.  The right upper lobe, middle and lower lobes appeared to have some mucoid secretions but minimal and with some erythema.  Left mainstem appeared patent.  Left lower lobe had slight plugging in the left base, but much better that previous bronchoscopy findings.  The area was lavaged with some saline and cleared.  The patient tolerated the procedure well.","surgery, "
 Excisional breast biopsy with needle localization.  The skin overlying the needle tip was incised in a curvilinear fashion. , Surgery, Breast Biopsy ,"PROCEDURE PERFORMED: , Excisional breast biopsy with needle localization.,ANESTHESIA:,  General.,PROCEDURE: , After informed consent was obtained, the patient was brought to the radiology suite where needle localization was performed with mammographic guidance.  I reviewed the localizing films with the radiologist, and the patient was then brought to the operative suite and placed supine on the operating table.  General endotracheal anesthesia was induced without incident.  The patient was prepped and draped in the usual sterile manner.,The skin overlying the needle tip was incised in a curvilinear fashion.  Dissection down to the needle tip was performed using a combination of Metzenbaum scissors and Bovie electrocautery.  Every attempt was made to get approximately 1 cm of normal tissue around the lesion.  The wire was released and the lesion having been excised was removed from the wound and sent to Radiology for confirmation of excision.  The wound was copiously irrigated with sterile water, and hemostasis was obtained using Bovie electrocautery.  Once Radiology called and confirmed complete excision of the mass, the skin incision was approximated with 4-0 Vicryl in a subcuticular fashion.  The skin was prepped with benzoin and Steri-Strips were applied.  A dressing was then applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.","surgery, curvilinear fashion, bovie electrocautery, breast biopsy, needle localization, needle tip, curvilinear, breast, biopsy, needle"
 Needle localization and left breast biopsy for left breast mass., Surgery, Breast Biopsy - 2 ,"PREOPERATIVE DIAGNOSIS,Left breast mass.,POSTOPERATIVE DIAGNOSIS,Left breast mass.,PROCEDURE PERFORMED,Needle localization and left breast biopsy.,ANESTHESIA,General.,FLUIDS,1000 cc.,ESTIMATED BLOOD LOSS,Minimal.,DRAINS,None.,COMPLICATIONS,None.,SPECIMEN,Breast biopsy specimen with localizing needle.,FINDINGS,Breast tissue surrounding needle localization while no palpable mass.,HISTORY,The patient is a very pleasant 51-year-old African-American female who presented to the office with a mass in the left breast.  She was seen and evaluated.  On routine mammography, revealed a density in the left breast approximately at 4 o'clock position several centimeters lateral to the nipple complex.  She was readmitted for excisional biopsy.,Due to the nonpalpable nature of this lesion, the patient underwent first needle localization of the breast at the  Hospital and was taken to the operating room.,PROCEDURE IN DETAIL,After informed consent was obtained from the patient, the patient taken to the operating room and placed in the supine position on the operating table.  After appropriate general endotracheal anesthesia has been administered to the patient, the left breast was prepped and draped in a standard surgical fashion using Betadine solution.,The localization wire was cut at skin.  The patient had previously had a reduction mammoplasty in the lateral aspect of the transverse where an incision was re-incised to distance of about 4 cm.  The wire was entering the skin about 2 cm above the incision.  Superior skin flap was raised using electrocautery, and the needle localization wire was brought into the incision.  At this point, a core breast tissue of approximately 2 cm surrounding the needle was excised superiorly, inferiorly, medially, and laterally until the tissue specimen was well below the hook of the needle localization wire.,The breast specimen was then removed from breast, and silk sutures were used to mark the superior and lateral margins.  This specimen was then sent for mammography.  Pathologist called in the room to verify that the entire needle localization wire and hook were intact in the specimen.  At this point, the breast cavity was palpated and no other abnormalities were noted.  ,The wound was irrigated.  Bleeding points were easily controlled using electrocautery.  The wound was closed in two layers using 3-0 Vicryl and 4-0 Monocryl suture in a subcuticular fashion.  Benzoin, Steri-Strips, 2 x 2's, Tegaderm were placed.  The patient was aroused from anesthesia and transported to the recovery room in stable condition.  There were no complications.  All instrument, needle, and sponge counts were correct x2 at the end of the case.","surgery, breast mass, needle localization, steri-strips, tegaderm, biopsy, breast biopsy, breast cavity, excisional biopsy, localization wire, room in stable condition, skin flap, specimen, needle localization wire, needle, breast, mammography, localization, "
 Left excisional breast biopsy due to atypical ductal hyperplasia of left breast., Surgery, Breast Biopsy - 1 ,"PREOPERATIVE DIAGNOSIS:,  Atypical ductal hyperplasia of left breast.,POSTOPERATIVE DIAGNOSIS: , Atypical ductal hyperplasia of left breast.,PROCEDURE: , Left excisional breast biopsy.,ANESTHESIA: , General.,INDICATIONS: , This is a 66-year-old female who has a history of a right lumpectomy for ductal carcinoma in situ in May 2001.  On recent mammogram, she was found to have calcifications in her left breast and a stereotactic biopsy revealed a typical ductal hyperplasia.  Excisional biopsy was, therefore, recommended.  Her family history was significant in her sister with breast cancer at the age of 34 and daughter at the age 38.,FINDINGS: , The area in question was excised.  See details below.  There was no gross evidence of malignancy.  Final evaluation will per the permanent sections.,PROCEDURE:,  Earlier today, the patient underwent a wire localization by Dr. A.  She was then taken to the operating room and placed in the supine position.  The left breast was prepped and draped in the usual sterile fashion.,A curvilinear incision was made in the upper outer quadrant to include a wire.  The skin was incised.  Hemostasis was achieved with cautery device where the breast tissue was excised around the wire.  The specimens were marked for the long stitch laterally and short stitch superiorly, and fair length superficially.  It was noted that the wire was fairly close to the superior deep aspect of the specimen.  I, therefore, excised a new superior deep margin.  This was performed with electrocautery device, the suture marks and new marks on the specimens.  The main specimen itself was sent for ***** and gross inspection.  The superior deep margin was soaked in Marcaine and the new margin was sent for permanent sections.,First, I went over to pathology and reviewed the specimen and radiograph with the radiologist Dr. A.  This revealed a clip in the tissue excised closer again to the superior deep edge of the tissue.  The specimens were then cut in serial fashion by Dr. Rust, the pathologist.  There was no gross evidence of malignancy.  As noted above, I previously excised the new superior deep margin and this was sent for permanent section.  ,The wound was thoroughly irrigated and hemostasis was carefully achieved.  The subdermal layer was closed with 4-0 PDS in simple interrupted fashion.  The skin was closed with 4-0 Monocryl in a running subcuticular fashion.  Steri-Strips and dressings were applied.  All sponge, needle, and instrument counts were correct.  The patient tolerated the procedure well and was taken to PACU in stable condition.,ESTIMATED BLOOD LOSS: , 5 mL.,COMPLICATIONS: , None.,DRAINS: , None.,SPECIMENS:,  Left breast tissue and new superior deep margin.","surgery, breast, atypical ductal hyperplasia, breast biopsy, carcinoma in situ, excisional, hyperplasia, instrument counts, mammogram, needle, pathology, specimen, sponge, superior deep margin, ductal hyperplasia, deep margin, hemostasis, biopsy, "
 Excision of right breast mass.  Right breast mass with atypical proliferative cells on fine-needle aspiration., Surgery, Breast Mass Excision ,"PREOPERATIVE DIAGNOSIS: , Right breast mass with atypical proliferative cells on fine-needle aspiration.,POSTOPERATIVE DIAGNOSIS:,  Benign breast mass.,ANESTHESIA: , General,NAME OF OPERATION:,  Excision of right breast mass.,PROCEDURE:,  With the patient in the supine position, the right breast was prepped and draped in a sterile fashion.  A curvilinear incision was made directly over the mass in the upper-outer quadrant of the right breast.  Dissection was carried out around a firm mass, which was dissected with surrounding margins of breast tissue.  Hemostasis was obtained using electrocautery.  Frozen section exam showed a fibroadenoma with some proliferative hyperplasia within the fibroadenoma, but appeared benign.  The breast tissues were approximated using 4-0 Vicryl.  The skin was closed using 5-0 Vicryl running subcuticular stitches.  A sterile bandage was applied.  The patient tolerated the procedure well.,","surgery, atypical proliferative cells, fine needle aspiration, proliferative cells, breast mass, breast, needle, aspiration, fibroadenoma, excision, proliferative, mass, "
" Brachytherapy, iodine-125 seed implantation, and cystoscopy.", Surgery, Brachytherapy ,"PREOPERATIVE DIAGNOSIS:,  Prostate cancer.,POSTOPERATIVE DIAGNOSIS:,  Prostate cancer.,OPERATIONS: , Brachytherapy, iodine-125 seed implantation, and cystoscopy.,ANESTHESIA:,  LMA.,ESTIMATED BLOOD LOSS: , Minimal.,Total number of seeds placed, 63.  Needles, 24.,BRIEF HISTORY OF THE PATIENT: , This is a 57-year-old male who was seen by us for elevated PSA.  The patient had a prostate biopsy with T2b disease, Gleason 6.  Options such as watchful waiting, robotic prostatectomy, seed implantation with and without radiation were discussed.  Risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, incontinence, rectal dysfunction, voiding issues, burning pain, unexpected complications such as fistula, rectal injury, urgency, frequency, bladder issues, need for chronic Foley for six months, etc., were discussed.  The patient understood all the risks, benefits, and options, and wanted to proceed with the procedure.  The patient was told that there could be other unexpected complications.  The patient has history of urethral stricture.  The patient was told about the risk of worsening of the stricture with radiation.  Consent was obtained.,DETAILS OF THE OPERATION: , The patient was brought to the OR.  Anesthesia was applied.  The patient was placed in the dorsal lithotomy position.  The patient had SCDs on.  The patient was given preop antibiotics.  The patient had done bowel prep the day before.  Transrectal ultrasound was performed.  The prostate was measured at about 32 gm.  The images were transmitted to the computer system for radiation oncologist to determine the dosing etc.  Based on the computer analysis, the grid was placed.  Careful attention was drawn to keep the grid away from the patient.  There was a centimeter distance between the skin and the grid.  Under ultrasound guidance, the needles were placed, first in the periphery of the prostate, a total of 63 seeds were placed throughout the prostate.  A total of 24 needles was used.  Careful attention was drawn to stay away from the urethra.  Under longitudinal ultrasound guidance, all the seeds were placed.  There were no seeds visualized in the bladder under ultrasound.  There was only one needle where the seeds kind of dragged as the needle was coming out on the left side and were dropped out of position.  Other than that, all the seeds were very well distributed throughout the prostate under fluoroscopy.  Please note that the Foley catheter was in place throughout the procedure.  Prior to the seed placement, the Foley was attempted to be placed, but we had to do it using a Glidewire to get the Foley in and we used a Councill-tip catheter.  The patient has had history of bulbar urethral stricture.  Pictures were taken of the strictures in the pre-seed placement cysto time frame.  We needed to do the cystoscopy and Glidewire to be able to get the Foley catheter in.  At the end of the procedure, again cystoscopy was done, the entire bladder was visualized.  The stricture was wide open.  The prostate was slightly enlarged.  The bladder appeared normal.  There was no sheath inside the urethra or in the bladder.  The cysto was done using 30-degree and 70-degree lens.  At the end of the procedure, a Glidewire was placed, and 18 Councill-tip catheter was placed.  The plan was for Foley to be left in place overnight since the patient has history of urethral strictures.  The patient is to follow up tomorrow to have the Foley removed.  The patient could also be shown to have it removed at home.,The patient was brought to Recovery in stable condition at the end of the procedure.  The patient tolerated the procedure well.","surgery, iodine-125 seed implantation, seed implantation, prostate cancer, cystoscopy, brachytherapy, councill tip catheter, brachytherapy iodine, ultrasound, catheter, urethral, prostate,"
" Bilateral myringotomy and tube placement, tonsillectomy and adenoidectomy.", Surgery, BMT & T&A ,"PREOPERATIVE DIAGNOSES: , Chronic otitis media and tonsillar adenoid hypertrophy.,POSTOPERATIVE DIAGNOSES:,  Chronic otitis media and tonsillar adenoid hypertrophy.,PROCEDURES:,  Bilateral myringotomy and tube placement, tonsillectomy and adenoidectomy.,INDICATIONS FOR PROCEDURE: , The patient is a 3-1/2-year-old child with history of recurrent otitis media as well as snoring and chronic mouth breathing.  Risks and benefits of surgery including risk of bleeding, general anesthesia, tympanic membrane perforation as well as persistent recurrent otitis media were discussed with the patient and parents and informed consent was signed by the parents.,FINDINGS:  ,The patient was brought to the operating room, placed in supine position, given general endotracheal anesthesia.  The left ear was then draped in a clean fashion.  Under microscopic visualization, the ear canal was cleaned of the wax.  Myringotomy incision was made in the anterior inferior quadrant.  There was no fluid in the middle ear space.  A Micron Bobbin tube was easily placed.  Floxin drops were placed in the ear.  The same was performed on the right side with similar findings.  The patient was then turned to be placed in Rose position.  The patient draped in clean fashion.  A small McIvor mouth gag was used to hold open the oral cavity.  The soft palate was palpated.  There was no submucous cleft felt.  Using a 1:1 mixture of 1% Xylocaine with 1:100,000 epinephrine and 0.25% Marcaine, both tonsillar pillars and the fossae injected with approximately 7 mL total.  Using a curved Allis the right tonsil was grasped and pulled medially.  Tonsil was dissected off the tonsillar fossa using a Coblator.  The left tonsil was removed in the similar fashion.  Hemostasis then achieved in tonsillar fossa using the Coblator on coagulation setting.  The soft palate was then retracted using red rubber catheter.  Under mirror visualization, the patient was found to have enlarged adenoids.  The adenoids were removed using the Coblator.  Hemostasis was also achieved using the Coblator on coagulation setting.  The rubber catheter was then removed.  Reexamining the oropharynx, small bleeding points were cauterized with the Coblator.  Stomach contents were then aspirated with saline sump.  The patient was woken up from anesthesia, extubated and brought to recovery room in stable condition.  There were no intraoperative complications.  Needle and sponge correct.  Estimated blood loss minimal.","surgery, bilateral myringotomy, tube placement, tonsillectomy, adenoidectomy, micron bobbin, myringotomy and tube, tonsillectomy and adenoidectomy, chronic otitis media, tonsillar adenoid, tonsillar fossa, rubber catheter, otitis media, adenoids, myringotomy, otitis, media, tonsillar, coblator, "
" Tailor's bunion, right foot.  Removal of bone, right fifth metatarsal head.", Surgery, Bone Removal - Metatarsal Head ,"PREOPERATIVE DIAGNOSIS: , Tailor's bunion, right foot.,POSTOPERATIVE DIAGNOSIS:  ,Tailor's bunion, right foot.,PROCEDURE PERFORMED: , Removal of bone, right fifth metatarsal head.,ANESTHESIA:  ,TIVA/local.,HISTORY: , This 60-year-old male presents to ABCD Preoperative Holding Area after keeping himself n.p.o., since mid night for surgery on his painful right Tailor's bunion.  The patient has a history of chronic ulceration to the right foot which has been treated on an outpatient basis with conservative methods Dr. X.  At this time, he desires surgical correction as the ulcer has been refractory to conservative treatment.  Incidentally, the ulcer is noninfective and practically healed at this date.  The consent is available on the chart for review and Dr. X has discussed the risks versus benefits of this procedure to the patient in detail.,PROCEDURE IN DETAIL: , After IV was established by the Department of Anesthesia, the patient was taken to the operating room, placed on the operating table in supine position and a safety strap was placed across his waist for his protection.  A pneumatic ankle tourniquet was applied about the right foot over copious amount of Webril for the patient's protection.  After adequate IV sedation was administered by the Department of Anesthesia, a total of 10 cc of 1:1 mixture of 1% lidocaine and 0.5% Marcaine plain were administered into the right fifth metatarsal using a Mayo type block technique.  Next, the foot was prepped and draped in the usual aseptic fashion.  An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg.  The foot was lowered in the operating field and a sterile stockinet was reflected.  The Betadine was cleansed with saline-soaked gauze and dried.  Anesthesia was tested with a one tooth pickup and found to be adequate.  A #10 blade was used to make 3.5 cm linear incision over the fifth metatarsophalangeal joint.  A #15 blade was used to deepen the incision to the subcutaneous layer.  Care was taken to retract the extensor digitorum longus tendon medially and the abductor digiti minimi tendon laterally.  Using a combination of sharp and blunt dissection, the medial and lateral edges of the wound were undermined down to the level of the capsule and deep fascia.  A linear capsular incision was made with a #15 blade down to the bone.  The capsular periosteal tissues were elevated off the bone with a #15 blade.  Metatarsal head was delivered into the wound.  There was hypertrophic exostosis noted laterally as well as a large bursa in the subcuteneous tissue layer.  The ulcer on the skin was approximately 2 x 2 mm, it was partial skin thickness and did not probe.  A sagittal saw was used to resect the hypertrophic lateral eminence.  The hypertrophic bone was split in half and one half was sent to Pathology and the other half was sent to Microbiology for culture and sensitivity.  Next, a reciprocating rasp was used to smoothen all bony surfaces.  The bone stock had an excellent healthy appearance and did not appear to be infected.  Copious amount of sterile gentamicin impregnated saline were used to flush the wound.  The capsuloperiosteal tissues were reapproximated with #3-0 Vicryl in simple interrupted technique.  The subcutaneous layer was closed with #4-0 Vicryl in simple interrupted technique.  Next, the skin was closed with #4-0 nylon in a horizontal mattress suture technique.  A standard postoperative dressing was applied consisting of Betadine-soaked Owen silk, 4x4s, Kerlix, and Kling.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted at the digits.  The patient tolerated the above anesthesia and procedure without complications.  He was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot.  He was given a postop shoe and will be full weightbearing.  He has prescription already at home for hydrocodone and does not need to refill.  He is to follow up with Dr. X and was given emergency contact numbers.  He was discharged in stable condition.","surgery, pneumatic ankle, metatarsal head, tailor's bunion, head, pneumatic, ulceration, metatarsal, bone"
"  Surgical removal of completely bony impacted teeth #1, #16, #17, and #32.  Completely bony impacted teeth #1, #16, #17, and #32.", Surgery, Bony Impacted Teeth Removal ,"PREOPERATIVE DIAGNOSIS:,  Completely bony impacted teeth #1, #16, #17, and #32.,POSTOPERATIVE DIAGNOSIS: , Completely bony impacted teeth #1, #16, #17, and #32.,PROCEDURE: , Surgical removal of completely bony impacted teeth #1, #16, #17, and #32.,ANESTHESIA: , General nasotracheal.,COMPLICATIONS: , None.,CONDITION:  ,Stable to PACU.,DESCRIPTION OF PROCEDURE: , Patient was brought to the operating room, placed on the table in a supine position, and after demonstration of an adequate plane of general anesthesia via the nasotracheal route, patient was prepped and draped in the usual fashion for an intraoral procedure.  A gauze throat pack was placed and local anesthetic was administered in all four quadrants, a total of 7.2 mL of lidocaine 2% with 1:100,000 epinephrine, and 3.6 mL of bupivacaine 0.5% with 1:200,000 epinephrine.  Beginning on the upper right tooth #1, incision was made with a #15 blade.  Envelope flap was raised with the periosteal elevator, and bone was removed on the buccal aspect with straight elevator.  Potts elevator was then used to luxate the tooth from the socket.  Remnants of the follicle were then removed with hemostat.  The area was irrigated and then closed with 3-0 gut suture.  On the lower right tooth #32, incision was made with a #15 blade.  Envelope flap was raised with the periosteal elevator, and bone was removed on the buccal and distal aspect with a high-speed drill with a round bur.  Tooth was then sectioned with the bur and removed in several pieces.  Remnants of the follicle were removed with a curved hemostat.  The area was irrigated with normal saline solution and closed with 3-0 gut sutures.  Moving to #16 on the upper left, incision was made with a #15 blade.  Envelope flap was raised with the periosteal elevator, and bone was removed on the buccal aspect with straight elevator.  Potts elevator was then used to luxate the tooth from the socket.  Remnants of the follicle were removed with a curved hemostat.  The area was irrigated with normal saline solution and closed with 3-0 gut sutures.  Moving to the lower left #17, incision was made with a #15 blade.  Envelope flap was  raised with the periosteal elevator, and bone was removed on the buccal and distal aspect with high-speed drill with a round bur.  Then the bur was used to section the tooth vertically.  Tooth was removed in several pieces followed by the removal of the remnants of the follicle.  The area was irrigated with normal saline solution and closed with 3-0 gut sutures.  Upon completion of the procedure, the throat pack was removed and the pharynx was suctioned.  An NG tube was then inserted and small amount of gastric contents were suctioned.  Patient was then awakened, extubated, and taken to the PACU in stable condition.","surgery, intraoral, bony impacted teeth, throat pack, buccal aspect, saline solution, gut sutures, envelope flap, periosteal elevator,"
 Bilateral myringotomy tubes and adenoidectomy., Surgery, BMT & Adenoidectomy ,"PREOPERATIVE DIAGNOSIS: , Chronic otitis media.,POSTOPERATIVE DIAGNOSIS: , Chronic otitis media.,PROCEDURE PERFORMED: , Bilateral myringotomy tubes and adenoidectomy.,INDICATIONS FOR PROCEDURE:,  The patient is an 8-year-old child with history of recurrent otitis media.  The patient has had previous tube placement.  Tubes have since plugged and are no more functioning.  The patient has had recent recurrent otitis media.  Risks and benefits in terms of bleeding, anesthesia, and tympanic membrane perforation were discussed with the mother.  Mother wished to proceed with the surgery.,PROCEDURE IN DETAIL: , The patient was brought to the room, placed supine.  The patient was given general endotracheal anesthesia.  Starting on the left ear, under microscopic visualization, the ear was cleaned of wax.  A Bobbin tube was found stuck to the tympanic membrane.  This was removed.  After removing the tube the patient was found to have microperforation through which serous fluid was draining.  A fresh myringotomy was made in the anterior inferior quadrant.  More serous fluid was aspirated from middle ear space.  The new Bobbin tube was easily placed.  Floxin drops were placed in the ear.  In the right ear again under microscopic visualization, the ear was cleaned, the tube was removed off tympanic membrane.  There was no perforation seen; however, there was some granulation tissue on the surface of tympanic membrane.  A fresh myringotomy incision was made in the anterior inferior quadrant.  More serous fluid was drained out of middle ear space.  The tube was easily placed and Floxin drops were placed in the ear.  This completes tube portion of the surgery.  The patient was then turned and placed in the Rose position.  Shoulder roll was placed for neck extension.  Using a small McIvor mouth gag mouth was held open.  Using a rubber catheter the soft palate was retracted.  Under mirror visualization, the nasopharynx was examined.  The patient was found to have minimal adenoidal tissue.  This was removed using a suction Bovie.  The patient was then awakened from anesthesia, extubated and brought to recovery room in stable condition.  There were no intraoperative complications.  Needle and sponge count correct.  Estimated blood loss none.","surgery, chronic otitis media, bilateral myringotomy tubes, adenoidectomy, myringotomy tubes and adenoidectomy, middle ear space, bilateral myringotomy, bobbin tube, fresh myringotomy, serous fluid, otitis media, tympanic membrane, tubes, myringotomy, otitis, media, membrane, "
 Frontal craniotomy for placement of deep brain stimulator electrode.  Microelectrode recording of deep brain structures. Intraoperative programming and assessment of device., Surgery, Brain Stimulator Electrode ,"PREOPERATIVE DIAGNOSIS: , Tremor, dystonic form.,POSTOPERATIVE DIAGNOSIS: , Tremor, dystonic form.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,ANESTHESIA:,  MAC (monitored anesthesia care) with local anesthesia.,TITLE OF PROCEDURES:,1.  Left frontal craniotomy for placement of deep brain stimulator electrode.,2.  Right frontal craniotomy for placement of deep brain stimulator electrode.,3.  Microelectrode recording of deep brain structures.,4.  Stereotactic volumetric CT scan of head for target coordinate determination.,5.  Intraoperative programming and assessment of device.,INDICATIONS:  ,The patient is a 61-year-old woman with a history of dystonic tremor.  The movements have been refractory to aggressive medical measures, felt to be candidate for deep brain stimulation.  The procedure is discussed below.,I have discussed with the patient in great deal the risks, benefits, and alternatives.  She fully accepted and consented to the procedure.,PROCEDURE IN DETAIL:,  The patient was brought to the holding area and to the operating room in stable condition.  She was placed on the operating table in seated position.  Her head was shaved.  Scalp was prepped with Betadine and a Leksell frame was mounted after anesthetizing the pin sites with a 50:50 mixture of 0.5% Marcaine and 2% lidocaine in all planes.  IV antibiotics were administered as was the sedation.  She was then transported to the CT scan and stereotactic volumetric CT scan of the head was undertaken.  The images were then transported to the surgery planned work station where a 3-D reconstruction was performed and the target coordinates were then chosen.  Target coordinates chosen were 20 mm to the left of the AC-PC midpoint, 3 mm anterior to the AC-PC midpoint, and 4 mm below the AC-PC midpoint.  Each coordinate was then transported to the operating room as Leksell coordinates.,The patient was then placed on the operating table in a seated position once again.  Foley catheter was placed, and she was secured to the table using the Mayfield unit.  At this point then the patient's right frontal and left parietal bossings were cleaned, shaved, and sterilized using Betadine soap and paint in scrubbing fashion for 10 minutes.  Sterile drapes placed around the perimeter of the field.  This same scalp region was then anesthetized with same local anesthetic mixture.,A bifrontal incision was made as well as curvilinear incision was made over the parietal bossings.  Bur holes were created on either side of the midline just behind the coronal suture.  Hemostasis was controlled using bipolar and Bovie, and self-retaining retractors had been placed in the field.  Using the drill, then two small grooves were cut in the frontal bone with a 5-mm cutting burs and Stryker drill.  The bur holes were then curetted free, the dura cauterized, and then opened in a cruciate manner on both sides with a #11 blade.  The cortical surface was then nicked with a #11 blade on both sides as well.  The Leksell arc with right-sided coordinate was dialed in, was then secured to the frame.  Microelectrode drive was secured to the arc.  Microelectrode recording was then performed.  The signatures of the cells were recognized.  Microelectrode unit was removed.  Deep brain stimulating electrode holding unit was mounted.  The DBS electrode was then loaded into target and intraoperative programming and testing was performed.  Using the screener box and standard parameters, the patient experienced some relief of symptoms on her left side.  This electrode was secured in position using bur-hole ring and cap system.,Attention was then turned to the left side, where left-sided coordinates were dialed into the system.  The microelectrode unit was then remounted.  Microelectrode recording was then undertaken.  After multiple passes, the microelectrode unit was removed.  Deep brain stimulator electrode holding unit was mounted at the desired trajectory.  The DBS electrode was loaded into target, and intraoperative programming and testing was performed once again using the screener box.  Using standard parameters, the patient experienced similar results on her right side.  This electrode was secured using bur-hole ring and cap system.  The arc was then removed.  A subgaleal tunnel was created between the two incisions whereby distal aspect of the electrodes led through this tunnel.,We then closed the electrode, replaced subgaleally.  Copious amounts of Betadine irrigation were used.  Hemostasis was controlled using the bipolar only.  Closure was instituted using 3-0 Vicryl in a simple interrupted fashion for the fascial layer followed by skin closure with staples.  Sterile dressings were applied.  The Leksell arc was then removed.,She was rotated into the supine position and transported to the recovery room in stable and satisfactory condition.  All needle, sponge, cottonoid, and blade counts were correct x2 as verified by the nurses.","surgery, dystonic, ac-pc, ct scan, dbs electrode, intraoperative programming, microelectrode, stereotactic, tremor, brain stimulator, craniotomy, device, dystonic tremor, electrode, frontal, screener box, target coordinate, volumetric, deep brain stimulator electrode, brain stimulator electrode, volumetric ct, stimulator, brain, "
 Lower lid blepharoplasty., Surgery, Blepharoplasty - Lower Lid ,"An orbital block was done.  An infraorbital block was also performed with a 25 gauge needle.  A skin muscle flap was elevated by sharp dissection down to the orbital rim area.  The herniated periorbital fat was removed by opening the orbital septum with sharp dissection using a 15 blade, teasing the periorbital fat out, cross clamping the fat and removing the fat with a scissor over the clamp.  The clamp was cauterized with needle cautery and then the clamp was scarped with a 15 blade.,The remaining fat was left to fall back into the orbit.  This was done in three compartments, the middle, medial and lateral compartments.  Fat was removed from all three compartments.  Then with the mouth open and the eyes in upward gaze, the lower skin muscle flap was redraped on the eyelids and tailored to fit exactly into place and then sutured into place with multiple 6-0 silk sutures.,Bleeding was minimal.  The patient tolerated the procedure well.","surgery, lower lid, wydase, blepharoplasty, infraorbital block, muscle flap, orbital rim area, orbital septum, periorbital fat, subciliary incision, upward gaze, orbital, clampingNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" Dentigerous cyst, left mandible associated with full bone impacted wisdom tooth #17.  Removal of benign cyst and extraction of full bone impacted tooth #17.", Surgery, Bone Impacted Tooth Removal ,"PREOPERATIVE DIAGNOSIS: , Dentigerous cyst, left mandible associated with full bone impacted wisdom tooth #17.,POSTOPERATIVE DIAGNOSIS: , Dentigerous cyst, left mandible associated with full bone impacted wisdom tooth #17.,PROCEDURE:,  Removal of benign cyst and extraction of full bone impacted tooth #17.,ANESTHESIA:  ,General anesthesia with nasal endotracheal intubation.,SPECIMEN: , Cyst and section tooth #17.,ESTIMATED BLOOD LOSS:,  10 mL.,FLUIDS:,  1200 of Lactated Ringer's.,COMPLICATIONS: , None.,CONDITION: , The patient was extubated and transported to the PACU in good condition.  Breathing spontaneously.,INDICATION FOR PROCEDURE:  ,The patient is a 38-year-old Caucasian male who was referred to clinic to evaluate a cyst in his left mandible.  Preoperatively, a biopsy of the cyst was obtained and it was noted to be a benign dentigerous cyst.,After evaluation of the location of the cyst and the impacted wisdom tooth approximately the inferior border of the mandible, it was determined that the patient would benefit from removal of the cyst and removal of tooth #17 under general anesthesia in the operating room.  Risks, benefits, and alternatives of treatment were thoroughly discussed with the patient and consent was obtained.,DESCRIPTION OF PROCEDURE:,  The patient was taken to the operating room #1 at Hospital and laid in the supine fashion on the operating room table.  As stated, general anesthesia was induced with IV anesthetics and maintained with nasal endotracheal intubation and inhalation anesthetics.  The patient was prepped and draped in usual oro-maxillofacial surgery fashion.,Approximately, #6 mL of 2% lidocaine with 1:100,000 epinephrine was injected in the usual nerve block fashion.  After waiting appropriate time for local anesthesia to take effect, a moistened Ray-Tec sponge was placed in the posterior pharynx.  Peridex mouth rinse was used to prep the oral cavity.  This was removed with suction.,Using a #15 blade a sagittal split osteotomy incision was made along the left ramus.  A full-thickness mucoperiosteal flap was elevated and the crest of the bone was identified where the crown had super-erupted since the biopsy 6 weeks earlier.  Using a Hall drill, a buccal osteotomy was developed, the tooth was sectioned in half, fractured with an elevator and delivered in two pieces.  Using a double-ended curette, the remainder of the cystic lining was removed from the left mandible and sent to pathology with the tooth for review.,The area was irrigated with copious amounts of sterile water and closed with 3-0 chromic gut suture.  The throat pack was removed.  The procedure was then determined to be over, and the patient was extubated, breathing spontaneously, and transported to the PACU in good condition.","surgery, dentigerous, wisdom tooth, extraction, bone impacted tooth, nasal endotracheal, dentigerous cyst, cyst, intubation, osteotomy, mandible, "
 Blepharoplasty with direct brow repair., Surgery, Blepharoplasty - Direct Brow Repair ,"PREOPERATIVE DX:, Dermatochalasis, mechanical ptosis, brow ptosis.,POSTOPERATIVE DX:, Same,PROCEDURE:,: Upper lid blepharoplasty and direct brow lift,ANESTHESIA:, Local with sedation,INDICATIONS FOR SURGERY: , In the preoperative evaluation the patient was found to have visually significant and symptomatic dermatochalasis and brow ptosis causing mechanical ptosis and visual field obstruction.  Visual field testing showed *% superior hemifield loss on the right, and *% superior hemifield loss on the left.  These field losses resolved with upper eyelid taping which simulates the expected surgical correction.  Photodocumentation also showed the upper eyelids resting on the upper eyelashes, as well as a decrease in the effective superior marginal reflex distance.  The risks, benefits, limitations, alternatives, and expected improvement in symptoms and visual field loss were discussed in preoperative evaluation.,DESCRIPTION OF PROCEDURE:, On the day of surgery, the surgical site and procedure were verified by the physician with the patient.  An informed consent was signed and witnessed.  EMLA cream was applied to the eyelids and eyebrow region for 10 minutes to provide skin anesthesia.  Two drops of topical proparacaine eye drops were placed on the ocular surface.  The skin was cleaned with alcohol prep pads.  The patient received 3 to 4 mL of 2% Lidocaine with epinephrine and 0.5% Marcaine mixture to each upper lid.  5 to 6 mL of local were also given to the brow region along the entire length.  Pressure was applied over each site for 5 minutes.  The patient was then prepped and draped in the normal sterile fashion for oculoplastic surgery.,The desired amount of redundant brow tissue to be excised was carefully marked with a surgical marking pen on each side.  The contour of the outline was created to provide a greater temporal lift.  Care was taken to preserve a natural contour to the brow shape consistent with the patient’s desired features.  Using a #15 blade, the initial incision was placed just inside the superior most row of brow hairs, in parallel with the follicle growth orientation.  The incision extended in a nasal to temporal fashion with the nasal portion incision being carried down to muscle and becoming progressively shallower toward the tail of the incision line.  The dimensions of the redundant tissue measured * horizontally and * vertically.  The redundant tissue was removed sharply with Westcott scissors.  Hemostasis was maintained with hand held cautery and/or electrocautery.  The closure was carried out in multiple layers.  The deepest muscular/subcutaneous tissue was closed with 4-0 transparent nylon in a horizontal mattress fashion.  The intermediate layer was closed with 5-0 Vicryl similarly.  The skin was closed with 6-0 nylon in a running lock fashion.  Iced saline gauze pads were placed over the incision sites.  This completed the brow repair portion of the case.,Using a surgical marking pen, a vertical line was drawn from the superior punctum to the eyebrow.  An angled line was drawn from the ala of the nares to the lateral canthus edge and extending to the tail of the brow.  These lines served as the relative boundary for the horizontal length of the blepharoplasty incision.  The desired amount of redundant tissue to be excised was carefully pinched together with 0.5 forceps.  This tissue was outlined with a surgical marking pen.  Care was taken to avoid excessive skin removal near the brow region.  A surgical ruler was used to ensure symmetry.  The skin and superficial orbicularis were incised with a #15 blade on the first upper lid.  This layer was removed with Westcott scissors.,Hemostasis was achieved with high-temp hand held pen cautery.  The remaining orbicularis and septum were grasped superiorly and inferiorly on each side of the incision and tented upward.  The high temp cautery pen was then used to incise these layers in a horizontal fashion until preapeuronotic fat was identified.  * amount of central preaponeurotic fat was removed with cautery.  * amount of nasal fat pad was removed in the same fashion.  Care was taken to not disturb the levator aponeurosis.  A symmetric amount of fat was removed from each side.  Iced gauze saline was placed over the site and the entire procedure repeated on the fellow eyelid.  Skin hooks were placed on either side of the incision and the skin was closed in a continuous running fashion with 6-0 nylon.  Erythromycin ophthalmic ointment was placed over the incision site and on the ocular surface.  Saline gauze and cold packs were placed over the upper lids.  The patient was taken from the surgical suite in good condition.,DISCHARGE:,  In the recovery area the results of surgery were discussed with the patient and their family.  Specific instructions to resume all p.o. oral medications including anticoagulants/antiplatelets were given.  Written instructions and restrictions after eyelid surgery were reviewed with the patient and family member.  Instructions on antibiotic ointment use were reviewed.  The incision sites were checked prior to release.  The patient was released to home with a driver after vital signs were deemed stable.","surgery, dermatochalasis, erythromycin ophthalmic, saline gauze, blepharoplasty, brow ptosis, cold packs, direct brow lift, follicle growth, hemifield loss, marginal reflex, mechanical ptosis, ocular surface, superficial orbicularis, visual field, surgical marking pen, direct brow, redundant tissue, incision sites, incision, brow, ptosis, surgical"
 Quad blepharoplasty for blepharochalasia and lower lid large primary and secondary bagging., Surgery, Blepharoplasty - Quad ,"PREOPERATIVE DIAGNOSES:,1.  Blepharochalasia.,2.  Lower lid large primary and secondary bagging.,POSTOPERATIVE DIAGNOSES:,1.  Blepharochalasia.,2.  Lower lid large primary and secondary bagging.,PROCEDURE: , Quad blepharoplasty.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Minimal.,CONDITION: , The patient did well.,PROCEDURE:  ,The patient had marks and measurements prior to surgery.  Additional marks and measurements were made at the time of surgery; these were again checked.  At this point, the area was injected with 0.5% lidocaine with 1:200,000 epinephrine.  Appropriate time waited for the anesthetic and epinephrine effect.,Beginning on the left upper lid, the skin excision was completed.  The muscle was opened, herniated, adipose tissue pad in the middle and medial aspect was brought forward, cross-clamped, excised, cauterized, and allowed to retract.  The eyes were kept irrigated and protected throughout the procedure.  Attention was turned to the opposite side.  Procedure was carried out in the similar manner.,At the completion, the wounds were then closed with a running 6-0 Prolene, skin adhesives, and Steri-Strips.  Attention was turned to the right lower lid.  A lash line incision was made.  A skin flap was elevated and the muscle was opened.  Large herniated adipose tissue pads were present in each of the three compartments.  They were individually elevated, cross-clamped, excised, cauterized, and allowed to retract.,At the completion, a gentle tension was placed on the facial skin and several millimeters of the skin excised.  Attention was turned to he opposite side.  The procedure was carried out as just described.  The contralateral side was reexamined and irrigated.  Hemostasis was good and it was closed with a running 6-0 Prolene.  The opposite side was closed in a similar manner.,Skin adhesives and Steri-Strips were applied.  The eyes were again irrigated and cool Swiss Eye compresses applied.  At the completion of the case, the patient was extubated in the operating room, breathing on her own, doing well, and transferred in good condition from operating room to recovering room.","surgery, blepharochalasia, lower lid, swiss eye compresses, adipose tissue pad, bagging, blepharoplasty, lash line incision, quad blepharoplasty,"
 Excisional biopsy of skin nevus and two-layer plastic closure.  Trichloroacetic acid treatment to left lateral nasal skin 2.5 cm to treat actinic keratosis., Surgery, Biopsy - Skin Nevus ,"PREOPERATIVE DIAGNOSES:  ,1.  Left back skin nevus 2 cm.,2.  Right mid back skin nevus 1 cm.,3.  Right shoulder skin nevus 2.5 cm.,4.  Actinic keratosis left lateral nasal skin 2.5 cm.,POSTOPERATIVE DIAGNOSES:  ,1.  Left back skin nevus 2 cm.,2.  Right mid back skin nevus 1 cm.,3.  Right shoulder skin nevus 2.5 cm.,4.  Actinic keratosis, left lateral nasal skin, 2.5 cm.,PATHOLOGY:  ,Pending.,TITLE OF PROCEDURES:  ,1.  Excisional biopsy of left back skin nevus 2 cm, two layer plastic closure.,2.  Excisional biopsy of mid back skin nevus 1 cm, one-layer plastic closure.,3.  Excisional biopsy of right shoulder skin nevus 2.5 cm, one-layer plastic closure.,4.  Trichloroacetic acid treatment to left lateral nasal skin 2.5 cm to treat actinic keratosis.,ANESTHESIA: , Xylocaine 1% with 1:100,000 dilution of epinephrine totaling 8 mL.,BLOOD LOSS: , Minimal.,COMPLICATIONS:,  None.,PROCEDURE:,  Consent was obtained.  The areas were prepped and draped and localized in the usual manner.  First attention was drawn to the left back.  An elliptical incision was made with a 15-blade scalpel.  The skin ellipse was then grasped with a Bishop forceps and curved Iris scissors were used to dissect the skin ellipse.  After dissection, the skin was undermined.  Radiofrequency cautery was used for hemostasis, and using a 5-0 undyed Vicryl skin was closed in the subcuticular plane and then skin was closed at the level of the skin with 4-0 nylon interrupted suture.,Next, attention was drawn to the mid back.  The skin was incised with a vertical elliptical incision with a 15-blade scalpel and then the mass was grasped with a Bishop forceps and excised with curved Iris scissors.  Afterwards, the skin was approximated using 4-0 nylon interrupted sutures.  Next, attention was drawn to the shoulder lesion.  It was previously marked and a 15-blade scalpel was used to make an elliptical incision into the skin.,Next, the skin was grasped with a small Bishop forceps and curved Iris scissors were used to dissect the skin ellipse and removed the skin.  The skin was undermined with the curved Iris scissors and then radio frequency treatment was used for hemostasis.,Next, subcuticular plain was closed with 5-0 undyed Vicryl interrupted suture.  Skin was closed with 4-0 nylon suture, interrupted.  Lastly, trichloroacetic acid chemical peel treatment to the left lateral nasal skin was performed.  Please refer to separate operative report for details.  The patient tolerated this procedure very well and we will follow up next week for postoperative re-evaluation or sooner if there are any problems.","surgery, mid back skin nevus, actinic keratosis, trichloroacetic acid treatment, bishop forceps, skin nevus, plastic closure, curved iris, iris scissors, nasal skin, nevus, biopsy, nasal, forceps, "
" Right axillary adenopathy, thrombocytopenia, and hepatosplenomegaly.  Right axillary lymph node biopsy.", Surgery, Biopsy - Axillary Lymph Node ,"PREOPERATIVE DIAGNOSES:,1.  Right axillary adenopathy.,2.  Thrombocytopenia.,3.  Hepatosplenomegaly.,POSTOPERATIVE DIAGNOSES:,1.  Right axillary adenopathy.,2.  Thrombocytopenia.,3.  Hepatosplenomegaly.,PROCEDURE PERFORMED:  ,Right axillary lymph node biopsy.,ANESTHESIA: , Local with sedation.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well and was transferred to the recovery room in stable condition.,BRIEF HISTORY:  ,The patient is a 37-year-old male who presented to ABCD General Hospital secondary to hiccups and was ultimately found to have a right axillary mass to be severely thrombocytopenic with a platelet count of 2000 as well as having hepatosplenomegaly.  The working diagnosis is lymphoma, however, the Hematology and Oncology Departments were requesting a lymph node biopsy in order to confirm the diagnosis as well as prognosis.  Thus, the patient was scheduled for a lymph node biopsy with platelets running secondary to thrombocytopenia at the time of surgery.,INTRAOPERATIVE FINDINGS: , The patient was found to have a large right axillary lymphadenopathy, one of the lymph node was sent down as a fresh specimen.,PROCEDURE:  ,After informed written consent, risks and benefits of this procedure were explained to the patient.  The patient was brought to the operating suite, prepped and draped in a normal sterile fashion.  Multiple lymph nodes were palpated in the right axilla, however, the most inferior node was to be removed.  First, the skin was anesthetized with 1% lidocaine solution.  Next, using a #15 blade scalpel, an incision was made approximately 4 cm in length transversally in the inferior axilla.  Next, using electro Bovie cautery, maintaining hemostasis, dissection was carried down to the lymph node.  The lymph node was then completely excised using electro Bovie cautery as well as hemostats to maintain hemostasis and then lymph node was sent to specimen fresh to the lab.  Several hemostats were used, suture ligated with #3-0 Vicryl suture and hemostasis was maintained.  Next the deep dermal layers were approximated with #3-0 Vicryl suture.  After the wound has been copiously irrigated, the skin was closed with running subcuticular #4-0 undyed Vicryl suture and the pathology is pending.  The patient did tolerated the procedure well.  Steri-Strips and sterile dressings were applied and the patient was transferred to the Recovery in stable condition.","surgery, hepatosplenomegaly, thrombocytopenia, axillary adenopathy, axillary lymph node biopsy, axillary lymph node, lymph node biopsy, lymph node, lymph, node, axillary, adenopathy, hemostasis, suture, biopsy,"
" Repair of entropion, left upper lid, with excision of anterior lamella and cryotherapy.  Repairs of blepharon, entropion, right lower lid with mucous membrane graft.", Surgery, Blepharon & Entropion Repair ,"PREOPERATIVE DIAGNOSES:,1.  Entropion, left upper lid.,2.  Entropion and some blepharon, right lower lid.,TITLE OF OPERATION:,1.  Repair of entropion, left upper lid, with excision of anterior lamella and cryotherapy.,2.  Repairs of blepharon, entropion, right lower lid with mucous membrane graft.,PROCEDURE IN DETAIL:  ,The patient was brought to the operating room and prepped and draped in the usual fashion.  The left upper lid and right lower lid were all infiltrated with 2% Xylocaine with Epinephrine.,The lid was then everted with special clips and the mucotome was then used to cut a large mucous membrane graft from the lower lid measuring 0.5 mm in thickness.  The graft was placed in saline and a 4 x 4 was placed over the lower lid.,Attention was then drawn to the left upper lid and the operating microscope was found to place.  An incision was made in the gray line nasally in the area of trichiasis and entropion, and the dissection was carried anterior to the tarsal plate and an elliptical piece of the anterior lamella was excised.  Bleeding was controlled with the wet-field cautery and the cryoprobe was then used with a temperature of -8 degree centigrade in the freeze-thaw-refreeze technique to treat the bed of the excised area.,Attention was then drawn to the right lower lid with the operating microscope and a large elliptical area of the internal aspect of the lid margin was excised with a super blade.  Some of the blepharon were dissected from the globe and bleeding was controlled with the wet-field cautery.  An elliptical piece of mucous membrane was then fashioned and placed into the defect in the lower lid and sutured with a running 6-0 chromic catgut suture anteriorly and posteriorly.,The graft was in good position and everything was satisfactory at the end of procedure.  Some antibiotic steroidal ointment was instilled in the right eye and a light pressure dressing was applied.  No patch was applied to the left eye.  The patient tolerated the procedure well and was sent to recovery room in good condition.","surgery, entropion, blepharon, catgut suture, cryoprobe, cryotherapy, freeze-thaw-refreeze, lamella, lid, lower lid, tarsal plate, trichiasis, upper lid, mucous membrane graft, anterior lamella, mucous membrane, membrane"
" Implantation of biventricular automatic implantable cardioverter defibrillator, fluoroscopic guidance for lead implantation for biventricular automatic implantable cardioverter defibrillator, coronary sinus venogram for left ventricular lead placement, and defibrillation threshold testing x2.", Surgery, Biventricular Cardioverter Defibrillator Implantation ,"REFERRAL INDICATION AND PREPROCEDURE DIAGNOSES,1.  Dilated cardiomyopathy.,2.  Ejection fraction less than 10%.,3.  Ventricular tachycardia.,4.  Bradycardia with likely high degree of pacing.,PROCEDURES PLANNED AND PERFORMED,1.  Implantation of biventricular automatic implantable cardioverter defibrillator.,2.  Fluoroscopic guidance for lead implantation for biventricular automatic implantable cardioverter defibrillator.,3.  Coronary sinus venogram for left ventricular lead placement.,4.  Defibrillation threshold testing x2.,FLUOROSCOPY TIME:  ,18.5 minutes.,MEDICATIONS AT THE TIME OF STUDY,1.  Vancomycin 1 g (the patient was allergic to penicillin).,2.  Versed 10 mg.,3.  Fentanyl 100 mcg.,4.  Benadryl 50 mg.,CLINICAL HISTORY: , The patient is a pleasant 57-year-old gentleman with a dilated cardiomyopathy, an ejection fraction of 10%, been referred for AICD implantation because of his low ejection fraction and a non-sustained ventricular tachycardia.  He has underlying sinus bradycardia.  Therefore, will likely be pacing much of the time and would benefit from a biventricular pacing device.,RISKS AND BENEFITS:,  Risks, benefits, and alternatives to implantation of biventricular AICD and defibrillation threshold testing were discussed with the patient.  Risks including but not limited to bleeding, infection, vascular injury, cardiac perforation, stroke, myocardial infarction, the need for urgent cardiovascular surgery, and death were discussed with the patient.  The patient agreed both verbally and via written consent.,DESCRIPTION OF PROCEDURE: , The patient was transported to the cardiac catheterization laboratory in the fasting state.  The region of the left deltopectoral groove was prepped and draped in the usual sterile manner.  Lidocaine 1% (20 mL) was administered to the area.  After achieving appropriate anesthesia, a percutaneous access of the left axillary vein was performed under fluoroscopy with two separate sticks.  Guidewires were advanced down into the left axillary vein.  Following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath.  Hemostasis was achieved with electrocautery.  Lidocaine 1% (10 mL) was administered to the medial aspect of the incision and a pocket was fashioned in the medial direction.  Using the more lateral of the guidewires, a 7-French side-arm sheath was advanced into the left axillary vein.  The dilator was removed and another wire was advanced down into the sheath.  The sheath was then backed up over the top of the two wires.  One wire was pinned to the drape and using the alternate wire, a 9-French side-arm sheath was advanced down into the left axillary vein.  The dilator and wire were removed.  A defibrillation lead was then advanced down into the atrium.  The peel-away sheath was removed.  The lead was then passed across the tricuspid valve and positioned in the apical septal location.  The active fix screw was deployed.  Adequate pacing and sensing functions were established.  A 10-volt pacing was used temporarily and there was no diaphragmatic stimulation.  The suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue.  Using the wire that had been pinned to the drape, a 7-French side-arm sheath was advanced over this wire into the axillary vein.  The wire and dilator were removed.  An active pacing lead was then advanced down to the right atrium and the peel-away sheath was removed.  The lead was parked until a later time.  Using the separate access point, a 9-French side-arm sheath was advanced into the left axillary vein.  The dilator and wire were removed.  A curved outer sheath catheter as well as an inner catheter were advanced down into the area of the coronary sinus.  The coronary sinus was cannulated.  Inner catheter was removed and a balloon-tipped catheter was advanced into the coronary sinus.  A coronary sinus venogram was then performed.  It was noted that the most suitable location for lead placement was the middle cardiac vein.  This was cannulated and a passive lead was advanced over a Whisper EDS wire into a distal position.  Adequate pacing and sensing functions were established.  A 10-volt pacing was used temporarily.  There was no diaphragmatic stimulation.  The outer sheath was peeled away.  The 9 French sheath was then peeled away.  Suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue.  At this point, the atrial lead was then positioned in the right atrial appendage using a preformed J-curved stylet.  The lead body was turned several times and the lead was affixed to the tissue.  Adequate pacing and sensing function were established.  A suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue.  The pocket was then washed with antibiotic-impregnated saline.  Pulse generator was obtained and connected securely to the leads.  The leads were carefully wrapped behind the pulse generator and the entire system was placed in the pocket.  The pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using a running mattress stitch.  Sponge and needle counts were correct at the end of the procedure and no acute complications were noted.,The patient was sedated further and shock on T was performed on two separate occasions.  The device was allowed to detect the charge and defibrillate, establishing the entire workings of the ICD system.,DEVICE DATA,1.  Pulse generator, manufacturer Boston Scientific, model # N119, serial #12345.,2.  Right atrial lead, manufacturer Guidant, model #4470, serial #12345.,3.  Right ventricular lead, manufacturer Guidant, model #0185, serial #12345.,4.  Left ventricular lead, manufacturer Guidant, model #4549, serial #12345.,MEASURED INTRAOPERATIVE DATA,1.  Right atrial lead impedance 705 ohms.  P-waves measured at 1.7 millivolts.  Pacing threshold 0.5 volt at 0.4 milliseconds.,2.  Right ventricular lead impedance 685 ohms.  R-waves measured 10.5 millivolts.  Pacing threshold 0.6 volt at 0.4 milliseconds.,3.  Left ventricular lead impedance 1098 ohms.  R-waves measured 5.2 millivolts.  Pacing threshold 1.4 volts at 0.4 milliseconds.,DEFIBRILLATION THRESHOLD TESTING,1.  Shock on T.  Charge time 2.9 seconds.  Energy delivered 17 joules, successful with lead impedance of 39 ohms.,2.  Shock on T.  Charge time 2.8 seconds.  Energy delivered 17 joules, successful with a type 2 break lead impedance of 38 ohms.,DEVICE SETTINGS,1.  A pacing DDD 60 to 120.,2.  VT-1 zone 165 beats per minute.  VT-2 zone 185 beats per minute.  VF zone 205 beats per minute.,CONCLUSIONS,1.  Successful implantation of a biventricular automatic implantable cardiovascular defibrillator,2.  Defibrillation threshold of less than or equal to 17.5 joules.,2.  No acute complications.,PLAN,1.  The patient will be taken back to his room for continued observation and dismissed to the discretion of the primary service.,2.  Chest x-ray to rule out pneumothorax and verified lead position.,3.  Device interrogation in the morning.,4.  Completion of the course of antibiotics.",
" Cystoscopy, bladder biopsies, and fulguration.  Bladder lesions with history of previous transitional cell bladder carcinoma, pathology pending.", Surgery, Bladder Biopsies & Fulguration ,"PREOPERATIVE DIAGNOSIS:,  Bladder lesions with history of previous transitional cell bladder carcinoma.,POSTOPERATIVE DIAGNOSIS: , Bladder lesions with history of previous transitional cell bladder carcinoma, pathology pending.,OPERATION PERFORMED:  ,Cystoscopy, bladder biopsies, and fulguration.,ANESTHESIA: , General.,INDICATION FOR OPERATION: , This is a 73-year-old gentleman who was recently noted to have some erythematous, somewhat raised bladder lesions in the bladder mucosa at cystoscopy.  He was treated for a large transitional cell carcinoma of the bladder with TURBT in 2002 and subsequently underwent chemotherapy because of pulmonary nodules.  He has had some low grade noninvasive small tumor recurrences on one or two occasions over the past 18 months.  Recent cystoscopy raises suspicion of another recurrence.,OPERATIVE FINDINGS: , The entire bladder was actually somewhat erythematous with mucosa looking somewhat hyperplastic particularly in the right dome and lateral wall of the bladder.  Scarring was noted along the base of the bladder from the patient's previous cysto TURBT.  Ureteral orifice on the right side was not able to be identified.  The left side was unremarkable.,DESCRIPTION OF OPERATION: , The patient was taken to the operating room.  He was placed on the operating table.  General anesthesia was administered after which the patient was placed in the dorsal lithotomy position.  The genitalia and lower abdomen were prepared with Betadine and draped subsequently.  The urethra and bladder were inspected under video urology equipment (25 French panendoscope) with the findings as noted above.  Cup biopsies were taken in two areas from the right lateral wall of the bladder, the posterior wall of bladder, and the bladder neck area.  Each of these biopsy sites were fulgurated with Bugbee electrodes.  Inspection of the sites after completing the procedure revealed no bleeding and bladder irrigant was clear.  The patient's bladder was then emptied.  Cystoscope removed and the patient was awakened and transferred to the postanesthetic recovery area.  There were no apparent complications, and the patient appeared to tolerate the procedure well.  Estimated blood loss was less than 15 mL.","surgery, cystoscope, carcinoma, transitional cell bladder carcinoma, bladder lesions, bladder, fulguration, biopsies, cystoscopy,"
 Excisional biopsy of right cervical lymph node., Surgery, Biopsy - Cervical Lymph Node ,"PREOPERATIVE DIAGNOSIS: , Cervical lymphadenopathy.,POSTOPERATIVE DIAGNOSIS:,  Cervical lymphadenopathy.,PROCEDURE: , Excisional biopsy of right cervical lymph node.,ANESTHESIA: , General endotracheal anesthesia.,SPECIMEN: , Right cervical lymph node.,EBL: , 10 cc.,COMPLICATIONS: , None.,FINDINGS:,  Enlarged level 2 lymph node was identified and removed and sent for pathologic examination.,FLUIDS: , Please see anesthesia report.,URINE OUTPUT: , None recorded during the case.,INDICATIONS FOR PROCEDURE: , This is a 43-year-old female with a several-year history of persistent cervical lymphadenopathy.  She reports that it is painful to palpation on the right and has had multiple CT scans as well as an FNA which were all nondiagnostic.  After risks and benefits of surgery were discussed with the patient, an informed consent was obtained.  She was scheduled for an excisional biopsy of the right cervical lymph node.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed in the supine position.  She was anesthetized with general endotracheal anesthesia.  The neck was then prepped and draped in the sterile fashion.  Again, noted on palpation there was an enlarged level 2 cervical lymph node.,A 3-cm horizontal incision was made over this lymph node.  Dissection was carried down until the sternocleidomastoid muscle was identified.  The enlarged lymph node that measured approximately 2 cm in diameter was identified and was removed and sent to Pathology for touch prep evaluation.  The area was then explored for any other enlarged lymph nodes.  None were identified, and hemostasis was achieved with electrocautery.  A quarter-inch Penrose drain was placed in the wound.,The wound was then irrigated and closed with 3-0 interrupted Vicryl sutures for a deep closure followed by a running 4-0 Prolene subcuticular suture.  Mastisol and Steri-Strip were placed over the incision, and sterile bandage was applied.  The patient tolerated this procedure well and was extubated without complications and transported to the recovery room in stable condition.  She will return to the office tomorrow in followup to have the Penrose drain removed.","surgery, lymphadenopathy, excisional biopsy, fna, mastisol, penrose drain, cervical, cervical lymph node, endotracheal anesthesia, lymph node, sternocleidomastoid, cervical lymph, lymph, anesthesia, "
 Blepharoplasty procedure, Surgery, Blepharoplasty ,"BLEPHAROPLASTY,The patient was prepped and draped.  The upper lid skin was marked out in a lazy S fashion, and the redundant skin marked out with a Green forceps.  Then the upper lids were injected with 2% Xylocaine and 1:100,000 epinephrine and 1 mL of Wydase per 20 mL of solution.,The upper lid skin was then excised within the markings.  Gentle pressure was placed on the upper eyelids, and the fat in each of the compartments was teased out using a scissor and cotton applicator; and then the fat was cross clamped, cut, and the clamp cauterized.  This was done in the all compartments of the middle and medial compartments of the upper eyelid, and then the skin sutured with interrupted 6-0 nylon sutures.  The first suture was placed in the lower eyelid skin picking up the periorbital muscle and then the upper portion of the tarsus and then the upper lid skin.  This created a significant crisp, supratarsal fold.  The upper lid skin was closed in this fashion, and then attention was turned to the lower lid.,An incision was made under the lash line and slightly onto the lateral canthus.  The #15 blade was used to delineate the plane in the lateral portion of the incision, and then using a scissor the skin was cut at the marking.  Then the skin muscle flap was elevated with sharp dissection.  The fat was located and using a scissor the three eyelid compartments were opened.  Fat was teased out, cross clamped, the fat removed, and then the clamp cauterized.  Once this was done the skin was tailored to the lower lid incision site with mouth open and eyes in upward gaze, and then the excess skin removed.  The suture line was sutured with interrupted 6-0 silk sutures.  Once this was done the procedure was finished.,The patient left the OR in satisfactory condition.  The patient was given 50 mg of Demerol IM with 25 mg of Phenergan.","surgery, blepharoplasty, green forceps, wydase, applicator, canthus, lash line, lazy s, lazy s fashion, muscle flap, periorbital muscle, prepped and draped, supratarsal fold, upper lid, upward gaze, upper lid skin, eyelidsNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" Closure of bladder laceration, during cesarean section.", Surgery, Bladder Laceration Closure ,"PREOPERATIVE DIAGNOSES: , Bladder laceration.,POSTOPERATIVE DIAGNOSES:,  Bladder laceration.,NAME OF OPERATION: , Closure of bladder laceration.,FINDINGS:,  The patient was undergoing a cesarean section for twins.  During the course of the procedure, a bladder laceration was notices and urology was consulted.  Findings were a laceration on the dome of the bladder.,PROCEDURE: , Initially there as a mucosal layer of suture already placed.  This was done with 3-0 chromic catgut.  The bladder was distended and, while the bladder was distended with physiologic saline, a second layer of 3-0 chromic catgut created a watertight closure.  The second layer included the mucosa an dinner layer of the detrusor muscle.  A third layer of 2-0 Dexon was used.  Each of these were placed in a continuous running-locked suture technique.  There was complete watertight closure of the bladder.  Hemostasis was assured and a Jackson-Pratt drain was brought out through a separate stab wound.  The remaining portion of the operation, both the cesarean section and the wound closure, will be dictated by Dr. Redmond.","surgery, mucosal layer, closure of bladder laceration, watertight closure, cesarean section, bladder laceration, bladder, cesarean, closure, laceration, "
" Cystoscopy, cystocele repair, BioArc midurethral sling.", Surgery, BioArc Midurethral Sling ,"PREOPERATIVE DIAGNOSIS:,  Stress urinary incontinence, intrinsic sphincter deficiency.,POSTOPERATIVE DIAGNOSES: , Stress urinary incontinence, intrinsic sphincter deficiency.,OPERATIONS: , Cystoscopy, cystocele repair, BioArc midurethral sling.,ANESTHESIA:,  Spinal.,EBL: , Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY:  ,The patient is a 69-year-old female with a history of hysterectomy, complained of urgency, frequency, and stress urinary incontinence.  The patient had urodynamics done and a cystoscopy, which revealed intrinsic sphincter deficiency.  Options such as watchful waiting, Kegel exercises, broad-based sling to help with ISD versus Coaptite bulking agents were discussed.  Risks and benefits of all the procedures were discussed.  The patient understood and wanted to proceed with BioArc.  Risk of failure of the procedure, recurrence of incontinence due to urgency, mesh erosion, exposure, etc., were discussed.  Risk of MI, DVT, PE, and bleeding etc., were discussed.  The patient understood the risk of infection and wanted to proceed with the procedure.  The patient was told that due to the intrinsic sphincter deficiency, we will try to make the sling little bit tighter to allow better urethral closure, which may put her a high risk of retention versus if we make it too loose, then she may leak afterwards.,The patient understood and wanted to proceed with the procedure.,DETAILS OF THE OPERATION: , The patient was brought to the OR and anesthesia was applied.  The patient was placed in dorsal lithotomy position.  The patient was prepped and draped in usual sterile fashion.  A Foley catheter was placed.  Bladder was emptied.  Two Allis clamps were placed on the anterior vaginal mucosa.  Lidocaine 1% with epinephrine was applied, and hydrodissection was done.  Incision was made.  A bladder was lifted off of the vaginal mucosa.  The bladder cystocele was reduced.  Two stab incisions were placed on the lateral thigh over the medial aspect of the obturator canal.  Using BioArc needle, the needles were passed through under direct palpation through the vaginal incision from the lateral thigh to the vaginal incision.  The mesh arms were attached and arms were pulled back the outer plastic sheath and the excess mesh was removed.  The mesh was right at the bladder neck to the mid-urethra, completely covering over the entire urethra.,The sling was kept little tight, even though the right angle was easily placed between the urethra and the BioArc material.  The urethra was coapted very nicely.  At the end of the procedure, cystoscopy was done and there was no injury to the bladder.  There was good efflux of urine with indigo carmine coming through from both the ureteral openings.  The urethra was normal, seemed to have closed up very nicely with the repair.  The vaginal mucosa was closed using 0 Vicryl in interrupted fashion.  The lateral thigh incisions were closed using Dermabond.  Please note that the irrigation with antibiotic solution was done prior to the BioArc mesh placement.  The mesh was placed in antibiotic solution prior to the placement in the body.  The patient tolerated the procedure well.  After closure, Premarin cream was applied.  The patient was told to use Premarin cream postop.  The patient was brought to Recovery in stable condition.,The patient was told not to do any heavy lifting, pushing, pulling, and no tub bath, etc., for at least 2 months.  The patient understood.  The patient was to follow up as an outpatient.","surgery, cystoscopy, cystocele repair, bioarc midurethral sling, sphincter, urinary incontinence, stress urinary incontinence, intrinsic sphincter deficiency, intrinsic sphincter, sphincter deficiency, incontinence, mesh, urethral, bioarc"
 Bilateral vasovasostomy surgery sample., Surgery, Bilateral Vasovasostomy ,"Initially a small incision was made in the right superior hemiscrotum and the incision was carried down to the vas deferens.  This incision was carried down to the area of the previous vasectomy.  A towel clip was placed around this.  Next the scarred area was dissected free back to normal vas proximally and distally.  Approximately 4 cm of vas was freed up.  Next the vas was amputated above and below the scar tissue.  Fine hemostats were used to grasp the adventitial tissue on each side of the vas, both the proximal and distal ends.  Both ends were then dilated very carefully with lacrimal duct probes up to a #2 successfully.  After accomplishing this, fluid could be milked from the proximal vas which was encouraging.,Next the reanastomosis was performed.  Three 7-0 Prolene were used and full thickness bites were taken through the muscle layer of the vas deferens and into the lumen.  This was all done with 3.5 loupe magnification.  Next the vas ends were pulled together by tying the sutures.  A good reapproximation was noted.  Next in between each of these sutures two to three of the 7-0 Prolenes were used to reapproximate the muscularis layer further in an attempt to make this fluid-tight.,There was no tension on the anastomosis and the vas was delivered back into the right hemiscrotum.  The subcuticular layers were closed with a running 3-0 chromic and the skin was closed with three interrupted 3-0 chromic sutures.,Next an identical procedure was done on the left side.,The patient tolerated the procedure well and was awakened and returned to the recovery room in stable condition.  Antibiotic ointment, fluffs, and a scrotal support were placed.","surgery, vasovasostomy, adventitial tissue, anastomosis, fluffs, hemiscrotum, loupe magnification, lumen, muscle layer, scrotal support, subcuticular, vas deferens, vas ends, bilateral vasovasostomy, chromic, suturesNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" Excisional biopsy of actinic keratosis and skin nevus, two-layer and one-layer plastic closures, ", Surgery, Biopsy - Actinic Keratosis ,"PREOPERATIVE DIAGNOSES:  ,1.  Left chest actinic keratosis, 2 cm.,2.  Left medial chest actinic keratosis, 1 cm.,3.  Left shoulder actinic keratosis, 1 cm.,POSTOPERATIVE DIAGNOSES:  ,1.  Left chest actinic keratosis, 2 cm.,2.  Left medial chest actinic keratosis, 1 cm.,3.  Left shoulder actinic keratosis, 1 cm.,TITLE OF PROCEDURES:  ,1.  Excisional biopsy of left chest 2 cm actinic keratosis.,2.  Two-layer plastic closure.,3.  Excisional biopsy of left chest medial actinic keratosis 1 cm with one-layer plastic closure.,4.  Excisional biopsy of left should skin nevus, 1 cm, one-layer plastic closure.,ANESTHESIA: , Xylocaine 1% with 1:100,000 dilution of epinephrine totaling 6 mL.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,PROCEDURE: , All areas were prepped, draped, and localized in the usual manner.  Afterwards, elliptical incisions were placed with a #15-blade scalpel and curved iris scissors and small bishop forceps were used for the dissection of the skin lesions.  After all were removed, they were closed with one-layer technique for the shoulder and medial lesion, and the larger left chest lesion was closed with two-layer closure using Monocryl 5-0 for subcuticular closure and 5-0 nylon for skin closure.  She tolerated this procedure very well, and postoperative care instructions were provided.  She will follow up next week for suture removal.  Of note, she had an episode of hemoptysis, which could not be explained prompting an emergency room visit, and I discussed if this continues we may wish to perform a fiberoptic laryngoscopy examination and possible further workup if a diagnosis cannot be made.","surgery, two-layer plastic closure, one-layer plastic closure, skin nevus, actinic keratosis, plastic closures, keratosis, actinic, biopsy, forceps, layer, closures, chest"
 Bilateral orbital frontozygomatic craniotomy with bilateral orbital advancement with Z-osteotomies and bilateral forehead reconstruction with autologous graft., Surgery, Bilateral Orbital Frontozygomatic Craniotomy ,"PREOPERATIVE DIAGNOSIS: , Metopic synostosis with trigonocephaly.,POSTOPERATIVE DIAGNOSIS: , Metopic synostosis with trigonocephaly.,PROCEDURES PERFORMED: , ,1.  Bilateral orbital frontozygomatic craniotomy with bilateral orbital advancement with Z-osteotomies.,2.  Bone grafts.,3.  Bilateral forehead reconstruction with autologous graft.,ANESTHESIA: , General endotracheal anesthesia.,COMPLICATIONS:,  None.,CONDITION OF THE PATIENT AT THE END OF THE PROCEDURE: , Stable, transferred to recovery room.,ESTIMATED BLOOD LOSS: , 300 mL.,CRYSTALLOIDS: , Packed red blood cells 440 mL, FFP 100 mL.,URINARY OUTPUT: , 160 mL.,INDICATIONS FOR PROCEDURE: , The patient is a 9-month-old baby with a history of trigonocephaly and metopic synostosis.  We have discussed locations, the nature of trigonocephaly's repair, metopic synostosis repair with bilateral fronto-orbital advancement, forehead reconstruction, and bone graft.  We have discussed risks and benefits.  Risks included, but not limited to risk of bleeding, infection, dehiscence, scarring, need for future revision surgeries, minimal possibility of death, the alternatives, devastating bleeding, anesthesia, death, dehiscence, infection.  The parents understand, decide to proceed with surgery.  Informed consent was obtained and we proceed with surgery.,DESCRIPTION OF PROCEDURE: , The patient was taken into the operating room, placed in the supine position.  General anesthetic was administered.  Prophylactic dose of antibiotic was given.  Lines were placed by Anesthesia and then the head of the bed was turned to 100 degrees.  The patient was once more positioned and padded in the usual manner.  The incision was marked with the help of a marking pen and local anesthetic was infiltrated after prepping the area one time, then the definitive prep and draping of the area was done.,The procedure began with an incision through the full-thickness of the skin into the subcutaneous tissue down to the subgaleal plane.  The subgaleal plane was developed and reflected anteriorly and slightly posteriorly.  Hemostasis achieved with electrocautery.  Raney clips were applied to both flaps to prevent significant bleeding.  Then, we proceed with craniotomy part and Dr. Y proceeded with this part of the procedure.  I assisted her and this will be described in a different operative report.  Then, the area corresponding to the C-shaped osteotomy was marked and then we proceed in conjunction with Dr. Y to develop these osteotomies with the help of the Midas by retracting the contents of the skull at the level of the anterior fossa as well as the orbital contents with the help of a ribbon retractor.  The osteotomies were done with the Midas and some irrigation.  There was an osteotomy done at the level of the frontozygomatic suture just posterior to the frontozygomatic suture and then these osteotomies continued down intraorbitally and lateral through the zygoma to the level of the intraorbital rim.  This was done on both sides.  Hemostasis achieved with bone wax and electrocautery.  Once the osteotomies were completed, __________ of the osteotomy sites allowed advancements.  On the left side, there was a minor fracture to the superior orbital rim that was plated.  The bone grafts were customized placing these at the level of the sphenoid bone in the posterior aspect of the orbital rim.  The temporalis muscle was advanced and attached to the orbital rim with holes that have been drilled with Midas and a 3-0 Vicryl interrupted stitches.  The forehead flaps were attached with the help of absorbable mesh.  The forehead portions were applied to the fronto-orbital advancement of fronto-orbital piece with the help of Synthes mesh and 3-mm screws.  Hemostasis was checked.  The flaps were retracted back into position.,The wound was closed with 3-0 Vicryl interrupted sutures, 4-0 Vicryl interrupted stitches, and 5-0 running fast absorbing gut.  Dressing was applied with Xeroform, bacitracin, and ABDs and a burn net.  The patient tolerated the procedure well without complications and was transferred to the recovery room in stable condition.  I was present and participated in all aspects of the procedure.  Sponge, needle, and instrument counts were completed at the end of the procedure.","surgery, metopic synostosis, craniotomy, z-osteotomies, orbital advancement, bone grafts, frontozygomatic, forehead reconstruction, autologous graft, bilateral orbital frontozygomatic craniotomy, orbital, osteotomies, forehead, "
 Desires permanent sterilization.  Laparoscopic bilateral tubal occlusion with Hulka clips., Surgery, Bilateral Tubal Occlusion - Laparoscopic ,"PREOPERATIVE DIAGNOSIS: , Desires permanent sterilization.,POSTOPERATIVE DIAGNOSIS: , Desires permanent sterilization.,PROCEDURE PERFORMED: , Laparoscopic bilateral tubal occlusion with Hulka clips.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 20 cc.,COMPLICATIONS:  ,None.,FINDINGS: , On bimanual exam, the uterus was found to be anteverted at approximately six weeks in size.  There were no adnexal masses appreciated.  The vulva and perineum appeared normal.  Laparoscopic findings revealed normal appearing uterus, fallopian tubes bilaterally as well as ovaries bilaterally.  There was a functional cyst on the left ovary.  There was filmy adhesion in the left pelvic sidewall.  There were two clear lesions consistent with endometriosis, one was on the right fallopian tube and the other one was in the cul-de-sac.  The uterosacrals and ovarian fossa as well as vesicouterine peritoneum were free of any endometriosis.  The liver was visualized and appeared normal.  The spleen was also visualized.,INDICATIONS: , This patient is a 34-year-old gravida 4, para-4-0-0-4 Caucasian female who desires permanent sterilization.  She recently had a spontaneous vaginal delivery in June and her family planning is complete.,PROCEDURE IN DETAIL: , After informed consent was obtained in layman's terms, the patient was taken back to the operating suite and placed under general anesthesia.  She was then prepped and draped and placed in the dorsal lithotomy position.  A bimanual exam was performed and the above findings were noted.  Prior to beginning the procedure, her bladder was drained with a red Robinson catheter.  A weighted speculum was placed in the patient's posterior vagina and the 12 o' clock position of the cervix was grasped with a single-toothed tenaculum.  The cervix was dilated so that the uterine elevator could be placed.  Gloves were exchanged and attention was then turned to the anterior abdominal wall where the skin at the umbilicus was everted and using the towel clips, a 1 cm infraumbilical skin incision was made.  The Veress needle was then inserted and using sterile saline ______ the pelvic cavity.  The abdomen was then insufflated with appropriate volume and flow of CO2.  The #11 bladed trocar was then placed and intraabdominal placement was confirmed with the laparoscope.  A second skin incision was made approximately 2 cm above the pubic symphysis and under direct visualization, a 7 mm bladed trocar was placed without difficulty.  Using the Hulka clip applicator, the left fallopian tube was identified, followed out to its fimbriated end and the Hulka clip was then placed snugly against the uterus across the entire diameter of the fallopian tube.  A second Hulka clip was then placed across the entire diameter just proximal to this.  There was good hemostasis at the fallopian tube.  The right fallopian tube was then identified and followed out to its fimbriated end and the Hulka clip was placed. snugly against the uterus across the entire portion of the fallopian tube in a 90 degree angle.  A second Hulka clip was placed just distal to this again across the entire diameter.  Good hemostasis was obtained.  At this point, the abdomen was desufflated and after it was desufflated, the suprapubic port site was visualized and found to be hemostatic.  The laparoscope and remaining trocars were then removed with good visualization of the peritoneum and fascia and the laparoscope was removed.  The umbilical incision was then closed with two interrupted #4-0 undyed Vicryl.  The suprapubic incision was then closed with Steri-Strips.  The uterine elevator was removed and the single-toothed tenaculum site was found to be hemostatic.  The patient tolerated that procedure well.  The sponge, lap, and needle counts were correct x2.  She will follow up postoperatively for followup care.","surgery, laparoscopic bilateral tubal occlusion, bilateral tubal occlusion, hulka clips, fallopian tubes, anesthesia, laparoscope, endometriosis, laparoscopic, sterilization, fallopian, tubes, clips,"
" Bilateral myringotomies, placement of ventilating tubes, nasal endoscopy, and adenoidectomy.", Surgery, Bilateral Myringotomies ,"PREOPERATIVE DIAGNOSES,1.  Recurrent acute otitis media, bilateral middle ear effusions.,2.  Chronic rhinitis.,3.  Recurrent adenoiditis with adenoid hypertrophy.,POSTOPERATIVE DIAGNOSES,1.  Recurrent acute otitis media, bilateral middle ear effusions.,2.  Chronic rhinitis.,3.  Recurrent adenoiditis with adenoid hypertrophy.,FINAL DIAGNOSES,1.  Recurrent acute otitis media, bilateral middle ear effusions.,2.  Chronic rhinitis.,3.  Recurrent adenoiditis with adenoid hypertrophy.,4.  Acute and chronic adenoiditis.,OPERATIONS PERFORMED,1.  Bilateral myringotomies.,2.  Placement of ventilating tubes.,3.  Nasal endoscopy.,4.  Adenoidectomy.,DESCRIPTION OF OPERATIONS: , The patient was brought to the operating room, endotracheal intubation carried out by Dr. X. Both sides of the patient's nose were then sprayed with Afrin.  Ears were inspected then with the operating microscope.  The anterior inferior quadrant myringotomy incisions were performed.  Then, a modest amount of serous and a trace of mucoid material encountered that was evacuated.  The middle ear mucosa looked remarkably clean.  Armstrong tubes were inserted.  Ciprodex drops were instilled.  Ciprodex will be planned for two postoperative days as well.  Nasal endoscopy was carried out, and evidence of acute purulent adenoiditis was evident in spite of the fact that clinically the patient has shown some modest improvement following cessation of all milk products.  The adenoids were shaved back, flushed with curette through a traditional transoral route with thick purulent material emanating from the crypts, and representative cultures were taken.  Additional adenoid tissue was shaved backwards with the RADenoid shaver.  Electrocautery was used to establish hemostasis, and repeat nasal endoscopy accomplished.  The patient still had residual evidence of inter choanal adenoid tissue, and video photos were taken.  That remaining material was resected, guided by the nasal endoscope using the RADenoid shaver to remove the material and flush with the posterior nasopharynx.  Electrocautery again used to establish hemostasis.  Bleeding was trivial.  Extensive irrigation accomplished.  No additional bleeding was evident.  The patient was awakened, extubated, taken to the recovery room in a stable condition.  Discharge anticipated later in the day on Augmentin 400 mg twice daily, Lortab or Tylenol p.r.n. for pain.  Office recheck would be anticipated if stable and doing well in approximately two weeks.  Parents were instructed to call, however, regarding the outcome of the culture on Monday next week to ensure adequate antibiotic coverage before cessation of the antibiotic.","surgery, bilateral middle ear effusions, recurrent acute otitis media, chronic rhinitis, recurrent adenoiditis with adenoid hypertrophy, adenoiditis, bilateral myringotomies, ventilating tubes, nasal endoscopy, adenoidectomy, adenoid hypertrophy, myringotomies, otitis, media, hypertrophy, endoscopy, intubation, nasal,"
" Bilateral myringotomies with Armstrong grommet tubes, Adenoidectomy, and Tonsillectomy.", Surgery, Bilateral Myringotomies - 1 ,"PREOPERATIVE DIAGNOSES:,  OM, chronic, serous, simple or unspecified.  Adenoid hyperplasia.  Hypertrophy of tonsils.,POSTOPERATIVE DIAGNOSIS: , Same as preoperative diagnosis.,OPERATION: , Bilateral myringotomies with Armstrong grommet tubes, Adenoidectomy, and Tonsillectomy.,ANESTHESIA:,  General.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , Minimal.,DRAINS: , None.,CONSENT:,  The procedure, benefits, and risks were discussed in detail preoperatively.  The parentsagreed to proceed after all questions were answered.,TECHNIQUE: , The patient was brought to the operating room and placed in the supine position.  After general mask anesthesia was adequately obtained, the right external auditory canal was cleaned out under the microscope.  Serous fluid was aspirated from the middle ear space.  An Armstrong grommet tube was placed down through the incision and rotated into place.  The opposite ear was then cleaned out under the microscope.  Serous fluid was aspirated from the middle ear space.  An Armstrong grommet tube was placed down through the incision and rotated into place.  Cortisporin suspension was placed in both ear canals.,Then the patient was intubated.  A Crowe-Davis mouth gag was placed into the mouth and extended and hung on the Mayo stand.  The red rubber catheter was placed down through the nose and brought out through the mouth to retract the palate.  The adenoid fossa was visualized with the mirror.  The adenoids were removed using the microdebrider.  Two adenoid packs were placed.  The packs were removed one by one.  Using mirror and suction bovie, adequate hemostasis was achieved.,The tonsils were quite large and cryptic.  The tenaculum was placed on the superior pole of the right tonsil.  Cheesy material came out from the crypts.  The tonsils were retracted medially.  The bovie electrocautery was used to make an incision in the right anterior tonsillar pillar, and the plane was developed between the tonsil and the musculature.  The tonsil was completely dissected out of this plane, preserving both the anterior and posterior tonsillar pillars.  All bleeders were cauterized as they were encountered.  The tenaculum was then placed on the superior pole of the left tonsil.  Cheesy material came out from the crypts.  The tonsils were retracted medially.  The bovie electrocautery was used to make an incision in the left anterior tonsillar pillar, and the plane was developed between the tonsil and the musculature.  The tonsil was completely dissected out of this plane, preserving both the anterior and posterior tonsillar pillars.  All bleeders were cauterized as they were encountered.  Both tonsil beds were then re-cauterized, paying particular attention to the inferior and superior poles.,The stomach was evacuated with the nasogastric tube.  The patient was then awakened in the operating room, extubated and taken to the recovery room in satisfactory condition.","surgery, adenoid hyperplasia, om, adenoidectomy, tonsillectomy, auditory canal, serous fluid, crowe-davis mouth gag, tonsils, adenoidectomy and tonsillectomy, armstrong grommet tubes, bovie electrocautery, tonsillar pillar, bilateral myringotomies, armstrong, tubes, grommet, tonsillar, bilateral, myringotomies, tenaculum"
 3-1/2-year-old presents with bilateral scrotal swellings consistent with bilateral inguinal hernias., Surgery, Bilateral Inguinal Herniorrhaphy ,"PREOPERATIVE DIAGNOSIS: , Bilateral inguinal hernias.,POSTOPERATIVE DIAGNOSIS:,  Bilateral inguinal hernias.,OPERATION PERFORMED:  ,Bilateral inguinal herniorrhaphy.,ANESTHESIA: , General.,INDICATIONS: , This 3-1/2-year-old presents with bilateral scrotal swellings, which both reduce and are consistent with bilateral inguinal hernias.  He comes to the operating room today for the repair.,OPERATIVE PROCEDURE:  ,After the induction of general anesthetic, the abdomen and perineum were prepped and draped in usual manner.  Transverse right lower quadrant skin fold incision was made and carried down through skin and subcutaneous tissue with sharp dissection.  The external oblique fascia identified upon course of its fibers.  The hernia sac was identified and brought into the operative field.  Hernia sac was grasped with hemostat and the cord structures were carefully stripped away from it until the entire circumference of the sac could be identified.  The sac clamped and divided.  The distal sac was then dissected down to where the large hydrocele with the testicle would be brought up and the sac opened, the fluid drained, and a portion of the sac removed.  The testicle was returned to the scrotum.  The proximal sac was then dissected free of the cord up to the peritoneal reflection at the internal ring where it was ligated with a #3-0 Vicryl stick tie and a #3-0 Vicryl free tie.  The excess removed.  The cord returned to the inguinal canal and external oblique fascia closed with interrupted sutures of #3-0 Vicryl and subcutaneous tissue with the same, skin closed with #5-0 subcuticular Monocryl.  Sterile dressing applied.  Attention was then turned to the left side where an identical procedure was carried out for his left hernia, although the only difference being with the sac was somewhat smaller and did not have the large hydrocele around the testicle.  Otherwise the procedure was carried down in identical manner.  Sterile dressings were then applied to both sides.  The child awakened and taken to the recovery room in satisfactory condition.","surgery, perineum, hernia sac, bilateral inguinal herniorrhaphy, external oblique fascia, bilateral inguinal hernias, inguinal herniorrhaphy, scrotal swellings, subcutaneous tissue, oblique fascia, inguinal, scrotal, herniorrhaphy, testicle, hernias"
 Bilateral upper lid blepharoplasty to correct bilateral upper eyelid dermatochalasis., Surgery, Bilateral Upper Lid Blepharoplasty ,"PREOPERATIVE DIAGNOSIS:,  Bilateral upper eyelid dermatochalasis.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE: , Bilateral upper lid blepharoplasty, (CPT 15822).,ANESTHESIA: , Lidocaine with 1:100,000 epinephrine.,DESCRIPTION OF PROCEDURE: , This 65-year-old female demonstrates conditions described above of excess and redundant eyelid skin with puffiness and has requested surgical correction.  The procedure, alternatives, risks and limitations in this individual case have been very carefully discussed with the patient.  All questions have been thoroughly answered, and the patient understands the surgery indicated.  She has requested this corrective repair be undertaken, and a consent was signed.,The patient was brought into the operating room and placed in the supine position on the operating table.  An intravenous line was started, and sedation and sedation anesthesia was administered IV after preoperative p.o. sedation.  The patient was monitored for cardiac rate, blood pressure, and oxygen saturation continuously.  The excess and redundant skin of the upper lids producing redundancy and impairment of lateral vision was carefully measured, and the incisions were marked for fusiform excision with a marking pen.  The surgical calipers were used to measure the supratarsal incisions so that the incision was symmetrical from the ciliary margin bilaterally.,The upper eyelid areas were bilaterally injected with 1% Lidocaine with 1:100,000 Epinephrine for anesthesia and vasoconstriction.  The plane of injection was superficial and external to the orbital septum of the upper and lower eyelids bilaterally.,The face was prepped and draped in the usual sterile manner.,After waiting a period of approximately ten minutes for adequate vasoconstriction, the previously outlined excessive skin of the right upper eyelid was excised with blunt dissection.  Hemostasis was obtained with a bipolar cautery.  A thin strip of orbicularis oculi muscle was excised in order to expose the orbital septum on the right.  The defect in the orbital septum was identified, and herniated orbital fat was exposed.  The abnormally protruding positions in the medial pocket were carefully excised and the stalk meticulously cauterized with the bipolar cautery unit.  A similar procedure was performed exposing herniated portion of the nasal pocket.  Great care was taken to obtain perfect hemostasis with this maneuver.  A similar procedure of removing skin and taking care of the herniated fat was performed on the left upper eyelid in the same fashion.  Careful hemostasis had been obtained on the upper lid areas.  The lateral aspects of the upper eyelid incisions were closed with a couple of interrupted 7-0 blue Prolene sutures.,At the end of the operation the patient's vision and extraocular muscle movements were checked and found to be intact.  There was no diplopia, no ptosis, no ectropion.  Wounds were reexamined for hemostasis, and no hematomas were noted.  Cooled saline compresses were placed over the upper and lower eyelid regions bilaterally.,The procedures were completed without complication and tolerated well.  The patient left the operating room in satisfactory condition.  A follow-up appointment was scheduled, routine post-op medications prescribed, and post-op instructions given to the responsible party.,The patient was released to return home in satisfactory condition.","surgery, bilateral upper eyelid dermatochalasis, blepharoplasty, upper lid, bilateral upper lid, eyelid, bilateral upper lid blepharoplasty, upper lid blepharoplasty, eyelid dermatochalasis, lid blepharoplasty, orbital septum, upper eyelid, anesthesia, dermatochalasis, hemostasis"
 Bilateral Myringotomy with placement of PE tubes, Surgery, Bilateral Myringotomies - 2 ,"PREOPERATIVE DIAGNOSES: , Bilateral chronic otitis media,POSTOPERATIVE DIAGNOSES:,  Bilateral chronic otitis media,ANESTHESIA:,  General mask,NAME OF OPERATION:,  Bilateral Myringotomy with placement of PE tubes,PROCEDURE:,  The patient was taken to the operating room and placed in the supine position.  After adequate general inhalation anesthesia was obtained, the operating microscope with brought in for full use throughout the case.  First, the left and then the right tympanic membrane, was approached.  An anterior-inferior radial incision was made in the left tympanic membrane.  Suction revealed a substantial amount of mucopurulent drainage.  A Sheehy pressure equalization tube was placed in the myringotomy site.  Floxin drops were added.  The same procedure was repeated on the right side with similar findings noted of mucopurulent drainage.  The patient tolerated the procedure well and returned to the recovery room awake and in stable condition.","surgery, placement of pe tubes, bilateral chronic otitis media, chronic otitis media, bilateral myringotomy, pe tubes, chronic otitis, otitis media, tympanic membrane, mucopurulent drainage, tympanic, membrane, mucopurulent, myringotomy, tubes, "
 Bilateral carotid cerebral angiogram and right femoral-popliteal angiogram., Surgery, Bilateral Carotid Cerebral Angiogram ,"PREOPERATIVE DIAGNOSES:,1.  Carotid artery occlusive disease.,2.  Peripheral vascular disease.,POSTOPERATIVE DIAGNOSES:,1.  Carotid artery occlusive disease.,2.  Peripheral vascular disease.,OPERATIONS PERFORMED:,1.  Bilateral carotid cerebral angiogram.,2.  Right femoral-popliteal angiogram.,FINDINGS: , The right carotid cerebral system was selectively catheterized and visualized.  The right internal carotid artery was found to be very tortuous with kinking in its cervical portions, but no focal stenosis was noted.  Likewise, the intracranial portion of the right internal carotid artery showed no significant disease nor did the right middle cerebral artery.,The left carotid cerebral system was selectively catheterized and visualized.  The cervical portion of the left internal carotid artery showed a 30 to 40% stenosis with small ulcer crater present.  The intracranial portion of the left internal carotid artery showed no significant disease nor did the left middle cerebral artery.,Visualization of the right lower extremity showed no significant disease.,PROCEDURE: , With the patient in supine position under local anesthesia plus intravenous sedation, the groin areas were prepped and draped in a sterile fashion.,The common femoral artery was punctured in a routine retrograde fashion and a 5-French introducer sheath was advanced under fluoroscopic guidance.  A catheter was then placed in the aortic arch and the right and left common carotid arteries were then selectively catheterized and visualized as described above.,Following completion of the above, the catheter and introducer sheath were removed.  Heparin had been initially given, which was reversed with protamine.  Firm pressure was held over the puncture site for 20 minutes, followed by application of a sterile Coverlet dressing and sandbag compression.,The patient tolerated the procedure well throughout.","surgery, femoral-popliteal angiogram, carotid cerebral angiogram, internal carotid artery, carotid artery, angiogram, carotid, cerebral, artery,"
" Ruptured distal biceps tendon, right elbow.  Repair of distal biceps tendon, right elbow.", Surgery, Biceps Tendon Repair ,"PREOPERATIVE DIAGNOSIS: , Ruptured distal biceps tendon, right elbow.,POSTOPERATIVE DIAGNOSIS:,  Ruptured distal biceps tendon, right elbow.,PROCEDURE PERFORMED: , Repair of distal biceps tendon, right elbow.,PROCEDURE:  ,The patient was taken to OR, Room #2 and administered a general anesthetic.  The right upper extremity was then prepped and draped in the usual manner.  A sterile tourniquet was placed on the proximal aspect of the right upper extremity.  The extremity was then elevated and exsanguinated with an Esmarch bandage and tourniquet was inflated to 250 mmHg.  Tourniquet time was 74 minutes.  A curvilinear incision was made in the antecubital fossa of the right elbow down through the skin.  Hemostasis was achieved utilizing electrocautery.  Subcutaneous fat was separated and the skin flaps elevated.  The _________ was identified.  It was incised.  The finger was placed approximately up the anterior aspect of the arm and the distal aspect of the biceps tendon was found.  There was some serosanguineous fluid from the previous rupture.  This area was suctioned clean.  The biceps tendon ends were then placed over a sterile tongue blade and were then sharply cut approximately 5 mm to 7 mm from the tip to create a fresh surface.  At this point, the #2 fiber wire was then passed through the tendon.  Two fiber wires were utilized in a Krackow-type suture.  Once this was completed, dissection was taken digitally down into the antecubital fossa in the path where the biceps tendon had been previously.  The radial tuberosity was palpated.  Just ulnar to this, a curved hemostat was passed through the soft tissues and was used to tent the skin on the radial aspect of the elbow.  A skin incision was made over this area.  Approximately two inches down to the skin and subcutaneous tissues, the fascia was split and the extensor muscle was also split.,A stat was then attached through the tip of that stat and passed back up through the antecubital fossa.  The tails of the fiber wire suture were grasped and pulled down through the second incision.  At this point, they were placed to the side.  Attention was directed at exposure of the radial tuberosity with a forearm fully pronated.  The tuberosity came into view.  The margins were cleared with periosteal elevator and sharp dissection.  Utilizing the power bur, a trough approximately 1.5 cm wide x 7 mm to 8 mm high was placed in the radial tuberosity.  Three small drill holes were then placed along the margin for passage of the suture.  The area was then copiously irrigated with gentamicin solution.  A #4-0 pullout wire was utilized to pass the sutures through the drill holes, one on each outer hole and two in the center hole.  The elbow was flexed and the tendon was then pulled into the trough with the forearm supinated.  The suture was tied over the bone islands.  Both wounds were then copiously irrigated with gentamicin solution and suctioned dry.  Muscle fascia was closed with running #2-0 Vicryl suture on the lateral incision followed by closure of the skin with interrupted #2-0 Vicryl and small staples.  The anterior incision was approximated with interrupted #2-0 Vicryl for Subq. and then skin was approximated with small staples.  Both wounds were infiltrated with a total of 30 cc of 0.25% Marcaine solution for postop analgesia.  A bulky fluff dressing was applied to the elbow, followed by application of a long-arm plaster splint maintaining the forearm in the supinated position.  Tourniquet was inflated prior to application of the splint.  Circulatory status returned to the extremity immediately.  The patient was awakened.  He was rather boisterous during his awakening, but care was taken to protect the right upper extremity.  He was then transferred to the recovery room in apparent satisfactory condition.","surgery, ruptured distal biceps tendon, gentamicin solution, antecubital fossa, distal biceps, biceps tendon, tendon, tuberosity, biceps, elbow,"
 Belly button piercing for insertion of belly button ring., Surgery, Belly Button Piercing ,"PROCEDURE:,  Belly button piercing for insertion of belly button ring.,DESCRIPTION OF PROCEDURE:,  The patient was prepped after informed consent was given of risk of infection and foreign body reaction.  The area was marked by the patient and then prepped.  The area was injected with 2% Xylocaine 1:100,000 epinephrine.,Then a #14-gauge needle was inserted above the belly button and inserted up to the skin just above the actual umbilical area and the ring was inserted into the #14-gauge needle and pulled through.  A small ball was placed over the end of the ring.  This terminated the procedure.,The patient tolerated the procedure well.  Postop instructions were given regarding maintenance.  Patient left the office in satisfactory condition.","surgery, belly button piercing, 2% xylocaine, belly button, postop instructions, the patient tolerated the procedure well, foreign body, gauge needle, needle, piercing, ring, satisfactory condition, umbilical, button piercing, belly, buttonNOTE"
" Hematemesis in a patient with longstanding diabetes.   Submucosal hemorrhage consistent with trauma from vomiting and grade 2 esophagitis.  Mallory-Weiss tear, successful BICAP cautery. ", Surgery, BICAP Cautery ,"PREOPERATIVE DIAGNOSIS: ,  Hematemesis in a patient with longstanding diabetes. ,POSTOPERATIVE DIAGNOSIS:  ,Mallory-Weiss tear, submucosal hemorrhage consistent with trauma from vomiting and grade 2 esophagitis.,PROCEDURE:  , The procedure, indications explained and he understood and agreed.  He was sedated with Versed 3, Demerol 25 and topical Hurricane spray to the oropharynx.  A bite block was placed.  The Pentax video gastroscope was advanced through the oropharynx into the esophagus under direct vision.  Esophagus revealed distal ulcerations.  Additionally, the patient had a Mallory-Weiss tear.  This was subjected to bicap cautery with good ablation.  The stomach was entered, which revealed areas of submucosal hemorrhage consistent with trauma from vomiting.  There were no ulcerations or erosions in the stomach.  The duodenum was entered, which was unremarkable.  The instrument was then removed.  The patient tolerated the procedure well with no complications.,IMPRESSION: , Mallory-Weiss tear, successful BICAP cautery. ,We will keep the patient on proton pump inhibitors.  The patient will remain on antiemetics and be started on a clear liquid diet.","surgery, mallory-weiss tear, submucosal hemorrhage, esophagitis, vomiting, bicap cautery, mallory weiss, diabetes, esophagus, submucosal, hemorrhage, trauma, hematemesis,"
" Excision of basal cell carcinoma.  Closure complex, open wound.  Bilateral capsulectomies.  Bilateral explantation and removal of ruptured silicone gel implants", Surgery, BCCa Excision - Cheek ,"PREOPERATIVE DIAGNOSES,1.  Basal cell carcinoma, right cheek.,2.  Basal cell carcinoma, left cheek.,3.  Bilateral ruptured silicone gel implants.,4.  Bilateral Baker grade IV capsular contracture.,5.  Breast ptosis.,POSTOPERATIVE DIAGNOSES,1.  Basal cell carcinoma, right cheek.,2.  Basal cell carcinoma, left cheek.,3.  Bilateral ruptured silicone gel implants.,4.  Bilateral Baker grade IV capsular contracture.,5.  Breast ptosis.,PROCEDURE,1.  Excision of basal cell carcinoma, right cheek, 2.7 cm x 1.5 cm.,2.  Excision of basal cell carcinoma, left cheek, 2.3 x 1.5 cm.,3.  Closure complex, open wound utilizing local tissue advancement flap, right cheek.,4. Closure complex, open wound, left cheek utilizing local tissue advancement flap.,5.  Bilateral explantation and removal of ruptured silicone gel implants.,6.  Bilateral capsulectomies.,7.  Replacement with bilateral silicone gel implants, 325 cc.,INDICATIONS FOR PROCEDURES,The patient is a 61-year-old woman who presents with a history of biopsy-proven basal cell carcinoma, right and left cheek.  She had no prior history of skin cancer.  She is status post bilateral cosmetic breast augmentation many years ago and the records are not available for this procedure.  She has noted progressive hardening and distortion of the implant.  She desires to have the implants removed, capsulectomy and replacement of implants.  She would like to go slightly smaller than her current size as she has ptosis going with a smaller implant combined with capsulectomy will result in worsening of her ptosis.  She may require a lift.  She is not consenting to lift due to the surgical scars.,PAST MEDICAL HISTORY,Significant for deep venous thrombosis and acid reflux.,PAST SURGICAL HISTORY,Significant for appendectomy, colonoscopy and BAM.,MEDICATIONS,1.  Coumadin.  She stopped her Coumadin five days prior to the procedures.,2.  Lipitor,3.  Effexor.,4.  Klonopin.,ALLERGIES,None.,REVIEW OF SYSTEMS,Negative for dyspnea on exertion, palpitations, chest pain, and phlebitis.,PHYSICAL EXAMINATION,VITAL SIGNS:  Height 5'8"", weight 155 pounds.,FACE:  Examination of the face demonstrates basal cell carcinoma, right and left cheek.  No lesions are noted in the regional lymph node base and no mass is appreciated.,BREAST:  Examination of the breast demonstrates bilateral grade IV capsular contracture.  She has asymmetry in distortion of the breast.  No masses are appreciated in the breast or the axilla.  The implants appear to be subglandular.,CHEST:  Clear to auscultation and percussion.,CARDIOVASCULAR:  Regular rate and rhythm.,EXTREMITIES:  Show full range of motion.  No clubbing, cyanosis or edema.,SKIN:  Significant environmental actinic skin damage.,I recommended excision of basal cell cancers with frozen section control of the margin, closure will require local tissue flaps.  I recommended exchange of the implants with reaugmentation.  No final size is guaranteed or implied.  We will decrease the size of the implants based on the intraoperative findings as the size is not known.  Several options are available.  Sizer implants will be placed to best estimate postoperative size.  Ptosis will be worse following capsulectomy and going with a smaller implant.  She may require a lift in the future.  We have obtained preoperative clearance from the patient's cardiologist, Dr. K.  The patient has been taken off Coumadin for five days and will be placed back on Coumadin the day after the surgery.  The risk of deep venous thrombosis is discussed.  Other risk including bleeding, infection, allergic reaction, pain, scarring, hypertrophic scarring and poor cosmetic resolve, worsening of ptosis, exposure, extrusion, the rupture of the implants, numbness of the nipple-areolar complex, hematoma, need for additional surgery, recurrent capsular contracture and recurrence of the skin cancer was all discussed, which she understands and informed consent is obtained.,PROCEDURE IN DETAIL,After appropriate informed consent was obtained, the patient was placed in the preoperative holding area with **** input.  She was then taken to the major operating room with ABCD Surgery Center, placed in a supine position.  Intravenous antibiotics were given.  TED hose and SCDs were placed.  After the induction of adequate general endotracheal anesthesia, she was prepped and draped in the usual sterile fashion.  Sites for excision and skin cancers were carefully marked with 5 mm margin.  These were injected with 1% lidocaine with epinephrine.,After allowing adequate time for basal constriction hemostasis, excision was performed, full thickness of the skin.  They were tagged at the 12 o'clock position and sent for frozen section.  Hemostasis was achieved using electrocautery.  Once margins were determined to be free of involvement, local tissue flaps were designed for advancement.  Undermining was performed.  Hemostasis was achieved using electrocautery.  Closure was performed under moderate tension with interrupted 5-0 Vicryl.  Skin was closed under loop magnification paying meticulous attention and cosmetic details with 6-0 Prolene.  Attention was then turned to the breast, clothes were changed, gloves were changed, incision was planned and the previous inframammary incision beginning on the right incision was made.  Dissection was carried down to the capsule.  It was extremely calcified.  Dissection of the anterior surface of the capsule was performed.  The implant was subglandular, the capsule was entered, implant was noted to be grossly intact; however, there was free silicone.  Implant was removed and noted to be ruptured.  No marking as to the size of the implant was found.,Capsulectomy was performed leaving a small portion in the axilla in the inframammary fold.  Pocket was modified to medialize the implant by placing 2-0 Prolene laterally in mattress sutures to restrict the pocket.  In identical fashion, capsulectomy was performed on the left.  Implant was noted to be grossly ruptured.  No marking was found for the size of the implant.  The entire content was weighed and found to be 350 grams.  Right side was weighed and noted to be 338 grams, although some silicone was lost in the transfer and most likely was identical 350 grams.  The implants appeared to be double lumen with the saline portion deflated.  Completion of the capsulectomy was performed on the left.",
" Bifrontal cranioplasty, cranial defect greater than 10 cm in diameter in the frontal region.", Surgery, Bifrontal Cranioplasty ,"PREOPERATIVE DIAGNOSIS:,  Cranial defect greater than 10 cm in diameter in the frontal region.,POSTOPERATIVE DIAGNOSIS: , Cranial defect greater than 10 cm in diameter in the frontal region.,PROCEDURE: , Bifrontal cranioplasty.,ANESTHESIA:,  General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , Nil.,INDICATIONS FOR PROCEDURE: , The patient is a 66-year-old gentleman, who has a history of prior chondrosarcoma that he had multiple resections for.  The most recent one which I performed quite a number of years ago that was complicated by a bone flap infection and he has had removal of his bone flap.  He has been without the bone flap for a number of years now but has finally decided that he wanted to proceed with a cranioplasty.  After discussing the risks, benefits, and alternatives of surgery, the decision was made to proceed with operative intervention in the form of a cranioplasty.  He had previously undergone a CT scan.  Premanufactured cranioplasty made for him that was sterile and ready to implant.,DESCRIPTION OF PROCEDURE: , After induction of adequate general endotracheal anesthesia, an appropriate time out was performed.  We identified the patient, the location of surgery, the appropriate surgical procedure, and the appropriate implant.  He was given intravenous antibiotics with ceftriaxone, vancomycin, and Flagyl appropriately for antibiotic prophylaxis and sequential compression devices were used for deep venous thromboembolism prophylaxis.  The scalp was prepped and draped in the usual sterile fashion.  A previous incision was reopened and the scalp flap was reflected forward.  We dissected off the dura and we were able to get a nice plane of dissection elevating the temporalis muscle along with the scalp flap.  We freed up the bony edges circumferentially, but except for the inferior frontal region where the vascularized pericranial graft took its vascular supply from we did not come across the base.  We did explore laterally and saw a little bit of the mesh on the lateral orbit.  Once we had the bony edges explored, we took the performed plate and secured it in a place with titanium plates and screws.  We had achieved good hemostasis.  The wound was closed in multiple layers in usual fashion over a Blake drain.  At the end of the procedure, all sponge and needle counts were correct.  A sterile dressing was applied to the incision.  The patient was transported to the recovery room in good condition after having tolerated the procedure well.  I was personally present and scrubbed and performed/supervised all key portions.","surgery, cranial defect, frontal region, bifrontal cranioplasty, cranioplasty, chondrosarcoma, scalp flap, bony edges, bone flap, bifrontal, cranial, endotracheal, frontal,"
" Excision of large basal cell carcinoma, right lower lid, and repaired with used dorsal conjunctival flap in the upper lid and a large preauricular skin graft.", Surgery, BCCa Excision - Lower Lid ,"PREOPERATIVE DIAGNOSIS: , Extremely large basal cell carcinoma, right lower lid.,POSTOPERATIVE DIAGNOSIS:,  Extremely large basal cell carcinoma, right lower lid.,TITLE OF OPERATION: , Excision of large basal cell carcinoma, right lower lid, and repaired with used dorsal conjunctival flap in the upper lid and a large preauricular skin graft.,PROCEDURE: , The patient was brought into the operating room and prepped and draped in usual fashion.  Xylocaine 2% with epinephrine was injected beneath the conjunctiva and skin of the lower lid and also beneath the conjunctiva and skin of the upper lid.  A frontal nerve block was also given on the right upper lid.  The anesthetic agent was also injected in the right preauricular region which would provide a donor graft for the right lower lid defect.  The area was marked with a marking pen with margins of 3 to 4 mm, and a #15 Bard-Parker blade was used to make an incision at the nasal and temporal margins of the lesion.,The incision was carried inferiorly, and using a Steven scissors the normal skin, muscle, and conjunctiva was excised inferiorly.  The specimen was then marked and sent to pathology for frozen section.  Bleeding was controlled with a wet-field cautery, and the right upper lid was everted, and an incision was made 3 mm above the lid margin with the Bard-Parker blade in the entire length of the upper lid.  The incision reached the orbicularis, and Steven scissors were used to separate the tarsus from the underlying orbicularis.  Vertical cuts were made nasally and temporally, and a large dorsal conjunctival flap was fashioned with the conjunctiva attached superiorly.  It was placed into the defect in the lower lid and sutured with multiple interrupted 6-0 Vicryl sutures nasally, temporally, and inferiorly.,The defect in the skin was measured and an appropriate large preauricular graft was excised from the right preauricular region.  The defect was closed with interrupted 5-0 Prolene sutures, and the preauricular graft was sutured in place with multiple interrupted 6-0 silk sutures.  The upper border of the graft was attached to the upper lid after incision was made in the gray line with a Superblade, and the superior portion of the skin graft was sutured to the upper lid through the anterior lamella created by the razor blade incision.,Cryotherapy was then used to treat the nasal and temporal margins of the area of excision because of positive margins, and following this an antibiotic steroid ointment was instilled and a light pressure dressing was applied.  The patient tolerated the procedure well and was sent to recovery room in good condition.","surgery, basal cell carcinoma, cryotherapy, steven scissors, conjunctiva, conjunctival flap, frontal nerve block, frozen section, lower lid, orbicularis, skin graft, nasal and temporal margins, dorsal conjunctival flap, upper lid, basal, carcinoma, preauricular, incision, conjunctival, "
" Excision of nasal tip basal carcinoma, previous positive biopsy.", Surgery, BCCa Excision - Nasal Tip ,"PREOPERATIVE DIAGNOSIS: , Basal cell carcinoma, nasal tip, previous positive biopsy.,POSTOPERATIVE DIAGNOSIS: , Basal cell carcinoma, nasal tip, previous positive biopsy.,OPERATION PERFORMED: , Excision of nasal tip basal carcinoma.  Total area of excision, approximately 1 cm to 12 mm frozen section x2, final margins clear.,INDICATION: , A 66-year-old female for excision of nasal basal cell carcinoma.  This area is to be excised accordingly and closed.  We had multiple discussions regarding types of closure.,SUMMARY: , The patient was brought to the OR in satisfactory condition and placed supine on the OR table.  Underwent general anesthesia along with Marcaine in the nasal tip areas for planned excision.  The area was injected, after sterile prep and drape, with Marcaine 0.25% with 1:200,000 adrenaline.,The specimen was sent to pathology.  Margins were still positive at the inferior 6 o'clock ***** margin and this was resubmitted accordingly.  Final margins were clear.,Closure consisted of undermining circumferentially.  Advancement closure with dog ear removal distally and proximally was accomplished without difficulty.  Closure with interrupted 5-0 Monocryl running 7-0 nylon followed by Xeroform gauze, light pressure dressing, and Steri-Strips.,The patient is discharged on minocycline and Darvocet-N 100.,NOTE:,  The 2.6 mm loupe magnification was utilized throughout the procedure.  No complications noted with excellent and all clear margins at the termination.  An advancement closure technique was utilized.","surgery, basal cell carcinoma, closure, steri-strips, xeroform gauze, excision, light pressure dressing, loupe magnification, nasal tip, basal carcinoma, basal cell, cell carcinoma, biopsy, basal, carcinoma, nasal"
" Excision basal cell carcinoma, right medial canthus with frozen section, and reconstruction of defect with glabellar rotation flap.", Surgery, BCCa Excision - Canthus ,"PREOPERATIVE DIAGNOSIS: , Basal cell carcinoma (0.8 cm diameter), right medial canthus.,POSTOPERATIVE DIAGNOSIS: , Basal cell carcinoma (0.8 cm diameter), right medial canthus.,OPERATION: , Excision basal cell carcinoma (0.8 cm diameter), right medial canthus with frozen section, and reconstruction of defect (1.2 cm diameter) with glabellar rotation flap.,ANESTHESIA:,  Monitored anesthesia care.,JUSTIFICATION: , The patient is an 80-year-old white female with a biopsy-proven basal cell carcinoma of the right medial canthus.  She was scheduled for elective excision with frozen section under local anesthesia as an outpatient.,PROCEDURE: , With an intravenous infusing and under suitable premedication, the patient was placed supine on the operative table.  The face was prepped with pHisoHex draped.  The right medial canthal region and the glabellar region were anesthetized with 1% Xylocaine with 1:100,000 epinephrine.,Under loupe magnification, the lesion was excised with 2 mm margins, oriented with sutures and submitted for frozen section pathology.  The report was ""basal cell carcinoma with all margins free of tumor.""  Hemostasis was controlled with the Bovie.  Excised lesion diameter was 1.2 cm.  The defect was closed by elevating a left laterally based rotation flap utilizing the glabellar skin.  The flap was elevated with a scalpel and Bovie, rotated into the defect without tension, ***** to the defect with scissors and inset in layer with interrupted 5-0 Vicryl for the dermis and running 5-0 Prolene for the skin.  Donor site was closed in V-Y fashion with similar suture technique.,The wounds were dressed with bacitracin ointment.  The patient was returned to the recovery room in satisfactory condition.  She tolerated the procedure satisfactorily, and then no complications.  Blood loss was essentially nil.","surgery, basal cell carcinoma, excision, bacitracin, canthal region, canthus, frozen section, glabellar, glabellar region, loupe magnification, phisohex, rotation flap, loupe, excision basal cell carcinoma, medial canthus, basal cell, cell carcinoma, basal, cell, carcinoma,"
 Right basilic vein transposition.  End-stage renal disease with need for a long-term hemodialysis access.  Excellent flow through fistula following the procedure., Surgery, Basilic Vein Transposition ,"PREOPERATIVE DIAGNOSIS:,  End-stage renal disease with need for a long-term hemodialysis access.,POSTOPERATIVE DIAGNOSIS: , End-stage renal disease with need for a long-term hemodialysis access.,PROCEDURE: , Right basilic vein transposition.,ANESTHESIA:  ,General endotracheal.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,FINDINGS:,  Excellent flow through fistula following the procedure.,STATEMENT OF MEDICAL NECESSITY:  ,The patient is a 68-year-old black female who recently underwent a brachiobasilic AV fistula, but without transposition.  She has good flow, excellent physical exam, and now is ready for superficialization of the basilic vein.  After discussing the risks and benefits of the procedure with the patient preoperatively, the patient voiced understanding and signed informed consent.,PROCEDURE IN DETAIL:  ,The patient was taken to the operating room, placed supine on the operating table.  After adequate general endotracheal anesthesia was obtained, the right arm was circumferentially prepped and draped in a standard sterile fashion.  A longitudinal incision was made from just above the antecubital crease along the medial aspect of the arm overlying the palpable thrill using a 15 blade knife.  The sharp dissection was then used to identify dissection created of the basilic vein from its surrounding tissues.  This was continued and the incision was elongated up the arm as the vein was exposed in a serial fashion.  Branch points were then taken down using multitude of techniques based upon the luminal diameter of the branch before transection.  The basilic vein was ultimately freed in its entirety from just above the antecubital crease to the axilla at the level of the axillary vein.  There was noted to be excellent flow through the vein.  A pocket was then created just lateral to the incision in the subcutaneous tissue.  The vein was then placed into this pocket securing with multiple interrupted 3-0 Vicryl sutures.  The bed of dissection of the basilic vein was then treated with fibrin sealant.  The subcutaneous tissue was then reapproximated with 3-0 Vicryl sutures in interrupted fashion.  The skin was closed using 4-0 Monocryl suture for a subcuticular stitch.  Dermabond was applied to the incision.  Again, there was noted to be good palpable thrill throughout the superficialized vein.  The patient was then awakened, and taken to the recovery room in stable condition.","surgery, end-stage renal disease, hemodialysis, av fistula, brachiobasilic, basilic vein transposition, hemodialysis access, vein, basilic,"
 Creation of autologous right brachiobasilic arteriovenous fistula - first stage., Surgery, AV Fistula - 4 ,"PREOPERATIVE DIAGNOSES,1.  End-stage renal disease.,2.  Left subclavian vein occlusion.,3.  Status post chronic tracheostomy.,4.  Status post coronary artery bypass grafting.,5.  Right subclavian vein stenosis.,POSTOPERATIVE DIAGNOSES,1.  End-stage renal disease.,2.  Left subclavian vein occlusion.,3.  Status post chronic tracheostomy.,4.  Status post coronary artery bypass grafting.,5.  Right subclavian vein stenosis.,OPERATIVE PROCEDURE,Creation of autologous right brachiobasilic arteriovenous fistula - first stage.,INDICATIONS FOR THE PROCEDURE,This patient has a known left subclavian vein occlusion.  The right subclavian vein has an estimated 50% stenosis.  The patient has a catheter traversed in the right innominate vein.  The right basilic vein was judged to be suitable for usage on vein mapping.,OPERATIVE FINDINGS,The basilic vein was of an adequate size, but somewhat sclerotic.  A first stage autologous right brachiobasilic arteriovenous fistula was created.  A grade 2 was felt at completion.,OPERATIVE PROCEDURE IN DETAIL,After informed consent was obtained, the patient was taken to the operating room.  The patient was placed in the supine position.  The patient received regional nerve block.  The patient also received intravenous sedation.  The right arm was prepped and draped in the usual sterile fashion.  We used ultrasound to locate the basilic vein at the cubital fossa.,A small transverse incision was made slightly above the basilic vein.  The basilic vein was identified and immobilized.  The basilic vein was of a good size, but somewhat sclerotic.  The underlying fascia was incised and the brachial artery was identified and immobilized.  The brachial artery was normal.  We then divided the basilic vein distally.  The distal end was ligated using silk suture.  The brachial artery was clamped proximally and distally.  A small longitudinal arteriotomy was made in the brachial artery.  We did not give heparin.  The end of the basilic vein was then sewn end-to-side to the brachial artery using a running 7-0 Prolene suture.  ,Just prior to completion of the anastomosis, it was flushed and anastomosis was completed.  Flow was then established.  A grade 2 was felt in the outflow basilic fistula.  Hemostasis was secured.  The wound was then closed in layers using interrupted PDS sutures for the fascia and a running 4-0 Monocryl subcuticular suture for the skin.  A sterile dry dressing was applied.,The patient tolerated the procedure well.  There were no operative complications.  The sponge, instrument, and needle counts were correct at the end of the case.  I was present and participated in all aspects of the procedure.  The patient was transferred to the recovery room in satisfactory condition.","surgery, end-stage renal disease, left subclavian vein occlusion, arteriovenous fistula, artery bypass grafting, autologous, basilic vein, brachial artery, brachiobasilic, clamped, fistula, sclerotic, subclavian vein, subclavian vein stenosis, tracheostomy, brachiobasilic arteriovenous fistula, subclavian vein occlusion, vein occlusion, subclavian, basilic, artery, "
" Left axillary dissection with incision and drainage of left axillary mass.  Right axillary mass excision and incision and drainage.   Bilateral axillary masses, rule out recurrent Hodgkin's disease.", Surgery, Axillary Dissection & Mass Excision ,"PREOPERATIVE DIAGNOSIS:,  Bilateral axillary masses, rule out recurrent Hodgkin's disease.,POSTOPERATIVE DIAGNOSIS:  ,Bilateral axillary masses, rule out recurrent Hodgkin's disease.,PROCEDURE PERFORMED:,1.  Left axillary dissection with incision and drainage of left axillary mass.,2.  Right axillary mass excision and incision and drainage.,ANESTHESIA: , LMA.,SPECIMENS:,  Left axillary mass with nodes and right axillary mass.,ESTIMATED BLOOD LOSS:  ,Less than 30 cc.,INDICATION: , This 56-year-old male presents to surgical office with history of bilateral axillary masses.  Upon evaluation, it was noted that the patient has draining bilateral masses with the left mass being approximately 8 cm in diameter upon palpation and the right being approximately 4 cm in diameter.  The patient had been continued on antibiotics preoperatively.  The patient with history of Hodgkin's lymphoma approximately 18 years ago and underwent therapy at that time and he was declared free of disease since that time.  Consent for possible recurrence of Hodgkin's lymphoma warranted exploration and excision of these masses.  The patient was explained the risks and benefits of the procedure and informed consent was obtained.,GROSS FINDINGS: , Upon dissection of the left axillary mass, the mass was removed in toto and noted to have a cavity within it consistent with an abscess.,No loose structures were identified and sent for frozen section, which upon intraoperative consultation with Pathology Department revealed no obvious evidence of lymphoma, however, the confirmed pathology report is pending at this time.  The right axillary mass was excised without difficulty without requiring full axillary dissection.,PROCEDURE: , The patient was placed in supine position after appropriate anesthesia was obtained and a sterile prep and drape complete.  A #10 blade scalpel was used to make an elliptical incision about the mass itself extending this incision further to aid in the mobilization of the mass.  Sharp dissection was utilized with Metzenbaum scissors about the mass to maintain the injury to the skin structure and upon showing out the mass, Bovie electrocautery was utilized adjacent to the wall structure to maintain hemostasis.  Identification of the axillary anatomy was made and care was made to avoid injury to nerve, vessel or musculature.  Once this mass was removed in toto, lymph node structures were as well delivered with this mass and sent to frozen section as well the specimen was sent to gram stain and culture.  Upon revaluation of the incisional site, it was noted to be hemostatic.  Warm lap sponge was then left in place at this site.  Next, attention was turned to the right axilla where a #10 blade scalpel was used to make a 4 cm incision about the mass including the cutaneous structures involved with the erythematous reaction.  This was as well removed in toto and sent to Pathology for gram stain and culture as well as pathologic evaluation.  This site was then made hemostatic as well with the aid of Bovie electrocautery and approximation of the deep dermal tissues after irrigation with warm saline was then done with #3-0 Vicryl suture followed by #4-0 Vicryl running subcuticular stitch.  Steri-Strips were applied.  Attention was returned back left axilla, which upon re-exploration was noted to be hemostatic and a #7 mm JP was then introduced making a skin stab inferior to the incision and bringing the end of the drain through this incision.  This was placed within the incision site, ________ drainage of the axillary potential space.  Approximation of the deep dermal tissues were then done with #3-0 Vicryl in an interrupted technique followed by #4-0 Vicryl with running subcuticular technique.  Steri-Strips and sterile dressings were applied.  JP bulb was then placed to suction and sterile dressings were applied to both axilla.  The patient tolerated the procedure well and sent to postanesthesia care unit in a stable condition.  He will be discharged to home upon ability of the patient to have pain tolerance with Vicodin 1-2 as needed every six hours for pain and continue on Keflex antibiotics until gram stain culture proves otherwise.","surgery, incision and drainage, axillary mass excision, axillary dissection, hodgkin's disease, axillary mass, mass, incision, axillary,"
 Left forearm arteriovenous fistula between cephalic vein and radial artery., Surgery, AV Fistula - 5 ,"PREOPERATIVE DIAGNOSES,1.  End-stage renal disease, hypertension, diabetes, need for chronic arteriovenous access.,2.  Ischemic cardiomyopathy, ejection fraction 20%.,POSTOPERATIVE DIAGNOSES,1.  End-stage renal disease, hypertension, diabetes, need for chronic arteriovenous access.,2.  Ischemic cardiomyopathy, ejection fraction 20%.,OPERATION,Left forearm arteriovenous fistula between cephalic vein and radial artery.,INDICATION FOR SURGERY,This is a patient referred by Dr. Michael Campbell.  He is a 44-year-old African-American, who has end-stage renal disease and also ischemic cardiomyopathy.  This morning, he received coronary angiogram by Dr. A, which was reportedly normal, after which, he was brought to the operating room for an AV fistula.  All the advantages, disadvantages, risks, and benefits of the procedure were explained to him for which he had consented.,ANESTHESIA,Monitored anesthesia care.,DESCRIPTION OF PROCEDURE,The patient was identified, brought to the operating room, placed supine, and IV sedation given.  This was done under monitored anesthesia care.  He was prepped and draped in the usual sterile fashion.  He received local infiltration of 0.25% Marcaine with epinephrine in the region of the proposed incision.,Incision was about 2.5 cm long between the cephalic vein and the distal part of the forearm and the radial artery.  Incision was deepened down through the subcutaneous fascia.  The vein was identified, dissected for a good length, and then the artery was identified and dissected.  Heparin 5000 units was given.  The artery clamped proximally and distally, opened up in the middle.  It was found to have Monckeberg's arteriosclerosis of a moderate intensity.  The vein was of good caliber and size.,The vein was clipped distally, fashioned to size and shape, and arteriotomy created in the distal radial artery and end-to-side anastomosis was performed using 7-0 Prolene and bled prior to tying it down.  Thrill was immediately felt and heard.,The incision was closed in two layers and sterile dressing applied.","surgery, end-stage renal disease, av fistula, marcaine with epinephrine, monckeberg's, monitored anesthesia care, angiogram, arteriosclerosis, arteriovenous fistula, cephalic vein, ischemic cardiomyopathy, radial artery, subcutaneous fascia, arteriovenous, forearm, ischemic"
" Creation of AV fistula, left wrist in the anatomic snuffbox.", Surgery, AV Fistula - 3 ,"TITLE OF PROCEDURE,Creation of AV fistula, left wrist in the anatomic snuffbox.,PREOPERATIVE DIAGNOSIS,End-stage renal disease, need for chronic access.,POSTOPERATIVE DIAGNOSIS,End-stage renal disease, need for chronic access.,INDICATION OF THE PROCEDURE,This 74-year-old lady was referred by Dr. P for placement of an AV fistula.  She has been on dialysis since December 2006 by a PermCath placed in her right internal jugular vein.  She undergoes dialysis on Monday, Wednesday, and Friday at DaVita in Alameda and is under the care of Dr. P.  She underwent coronary bypass surgery in 2000 and her cardiologist is Dr. T.  She lives with her husband and she also has a son at home and she is a very active lady.  She is right handed.  The plan was to place an AV fistula at the left wrist.  The risks and benefits were fully explained to her.  She elected to proceed as planned.,PROCEDURE IN DETAIL,In the operating room, under monitored anesthesia care with intravenous sedation, she was prepped and draped surgically.  Lidocaine 1% was used for local anesthesia in the anatomic snuffbox at the left wrist.  The cephalic vein was exposed.  The superficial branch of the radial artery was carefully protected and the radial artery was exposed.  There was moderate calcification of the radial artery.,The patient was heparinized and end-to-side anastomosis was performed between the cephalic vein and radial artery using a 7-0 Prolene suture.  There was an excellent Doppler signal in the cephalic vein all the way up the arm upon completion.,The wound was closed using absorbable suture and she was transferred to Recovery.  There were no complications.","surgery, av fistula, end-stage renal disease, permcath, chronic access, jugular vein, monitored anesthesia, monitored anesthesia care, prepped and draped, snuffbox, superficial branch, creation of av fistula, cephalic vein, radial artery, radial, artery, fistula"
 Creation of right brachiocephalic arteriovenous fistula., Surgery, AV Fistula - 2 ,"PREOPERATIVE DIAGNOSES,1.  End-stage renal disease.,2.  Diabetes.,POSTOPERATIVE DIAGNOSES,1.  End-stage renal disease.,2.  Diabetes.,OPERATIVE PROCEDURE,Creation of right brachiocephalic arteriovenous fistula.,INDICATIONS FOR THE PROCEDURE,This patient has end-stage renal disease.  Although, the patient is right-handed, preoperative vein mapping demonstrated much better vein in the right arm.  Hence, a right brachiocephalic fistula is being planned.,OPERATIVE FINDINGS,The right cephalic vein at the elbow is chosen to be suitable.  It is slightly sporadic, but of an adequate size.  An end-to-side right brachiocephalic arteriovenous fistula was created.  At completion, there was a great thrill.,OPERATIVE PROCEDURE IN DETAIL,After informed consent was obtained, the patient was taken to the operating room.  The patient was placed in the supine position.  The patient received a regional nerve block.  The patient also received intravenous sedation.  The right arm was prepped and draped in the usual sterile fashion.,We made a small transverse incision in the right cubital fossa.  The cephalic vein was identified and mobilized.  The fascia was incised, and the brachial artery was also identified and mobilized.  The brachial artery was free off significant disease.  A good pulse was noted.  The cephalic vein was mobilized proximally and distally.  The brachial artery was mobilized proximally and distally.  We did not give heparin.  The brachial artery was then clamped proximally and distally.  The cephalic vein was also clamped proximally and distally.  Longitudinal arteriotomy was made in brachial artery, and a longitudinal venotomy was made in the cephalic vein.  We then sewn the vein to the artery in a side-to-side fashion using a running 7-0 Prolene suture.,Just prior to completion of the anastomosis, it was flushed, and the anastomosis was then completed.  A great thrill was noted.  We then ligated the cephalic vein beyond the arteriovenous anastomosis and divided it.  This surrounded the anastomosis as an end-to-side functionally.  A great thrill remained in the fistula.  Hemostasis was secured.  We then closed the wound using interrupted PDS sutures for the fascia and a running 4-0 Monocryl subcuticular suture for the skin.  Sterile dry dressing was applied.,The patient tolerated the procedure well.  There were no operative complications.  The sponge, instrument, and needle counts were correct at the end of the case.  I was present and participated in all aspects of the procedure.  The patient was then transferred to the recovery room in satisfactory condition.  A great thrill was felt in the fistula completion.  There was also a palpable radial pulse distally.","surgery, end-stage renal disease, prolene suture, brachial artery, brachiocephalic, brachiocephalic arteriovenous fistula, cephalic vein, fistula, general anesthetic, prepped and draped, proximally and distally, renal disease, av, cephalic, artery, vein"
" Tailor's bunionectomy with metatarsal osteotomy of the left fifth metatarsal.  Excision of nerve lesion with implantation of the muscle belly of the left second interspace.  Excision of nerve lesion in the left third interspace.
", Surgery, Bbunionectomy & Metatarsal Osteotomy ,"PREOPERATIVE DIAGNOSIS:  ,Tailor's bunion and neuroma of the second and third interspace of the left foot.,POSTOPERATIVE DIAGNOSIS:, Tailor's bunion and neuroma of the second and third interspace, left foot.,PROCEDURE PERFORMED:,1.  Tailor's bunionectomy with metatarsal osteotomy of the left fifth metatarsal.,2.  Excision of nerve lesion with implantation of the muscle belly of the left second interspace.,3.  Excision of nerve lesion in the left third interspace.,ANESTHESIA:  ,Monitored IV sedation with local.,HISTORY:  ,This is a 37-year-old female who presents to ABCD's preoperative holding area, n.p.o. since mid night, last night for surgery of her painful left second and third interspaces and her left fifth metatarsal.  The patient has attempted conservative correction and injections with minimal improvement.  The patient desires surgical correction at this time.  The patient states that her pain has been increasingly worsening with activity and with time and it is currently difficult for her to ambulate and wear shoes.  At this time, the patient desires surgical intervention and correction.  The risks versus benefits of the procedure have been explained to the patient in detail by Dr. X and consent was obtained.,PROCEDURE IN DETAIL: , After an IV was instituted by the Department of Anesthesia in the preoperative holding area, the patient was taken to the Operating Suite via cart and placed on the operating table in the supine position.  A safety strap was placed across her waist for protection.,Next, a pneumatic ankle tourniquet was applied around her left ankle over copious amounts of Webril for the patient's protection.  After adequate IV sedation was administered by the Department of Anesthesia, a total of 20 cc of a mixture of 4.5 cc of 1% lidocaine plain, 4.5 cc of 0.5% Marcaine plain, and 1 cc of Solu-Medrol per 10 cc dose was administered to the patient for local anesthesia.  The foot was then prepped and draped in the usual sterile orthopedic manner.  The foot was then elevated and a tourniquet was then placed at 230 mmHg after applying Esmarch bandage.  The foot was then lowered down the operative field and sterile stockinet was draped.  The stockinet was then reflected.  Attention was then directed to the second intermetatarsal interspace.  After testing the anesthesia, a 4 cm incision was placed using a #10 blade over the dorsal surface of the foot in the second intermetatarsal space beginning from proximal third of the metatarsals distally to and beyond the metatarsal head.  Then, using #15 blade the incision was deepened through the skin into the subcutaneous tissue.  Care was taken to identify and avoid or to cauterize any local encountered vascular structures.  Incision was deepened using the combination of blunt and dull dissection using Mayo scissors, hemostat, and a #15 blade.  The incision was deepened distally down to the level of the deep transverse metatarsal ligament which was reflected and exposure of the intermetatarsal space was appreciated.  The individual branches of the plantar digital nerve were identified extending into the second and third digits plantarly.  These endings were dissected distally and cut at their most distal portions.  Following this, the nerve was dissected proximally into the common nerve and dissected proximally into the proximal portion of the intermetatarsal space.  Using careful meticulous dissection, there was noted to a be a enlarged bulbous mass of fibers and nerve tissue embedded with the adipose tissue.  This was also cut and removed.  The proximal portion of the nerve stump was identified and care was taken to suture this into the lumbrical muscle to leave no free nerve ending exposed.  Following this, the interspace was irrigated with copious amounts of sterile saline and interspace explored for any other portions of nerve which may been missed on the previous dissection.  It was noted that no other portions of the nerve were detectable and the proximal free nerve ending was embedded and found to be ________ the lumbrical muscle belly.  Following this, the interspace was packed using iodoform gauze packing and was closed in layers with the packing extruding from the wound.  Attention was then directed to the third interspace where in a manner as mentioned before.  A dorsal linear incision which measured 5 cm was made over the third interspace extending from the proximal portion of the metatarsal distally to the metatarsal head.  Like before, using a combination of blunt and dull dissection, with sharp dissection the incision was deepened down with care taken to cauterize all retracting vascular structures which were encountered.,The incision was deepened down to the level of the subcutaneous tissue and then down deeper to the interspace of the third and fourth metatarsal.  The dissection was deepened distally down to the level of the transverse intermetatarsal ligament, where upon this was reflected and the nerve fibers to the third and fourth digit plantarly were identified.  These were once again dissected distally out and transected at their most distal portions.  Care was then taken to dissect the nerve proximally into the proximal metatarsal region.  No other branches of the nerve were identified and the nerve in its entirety along with fibrous tissue encountered in the area was removed.  The proximal portion of the nerve which remained was not large enough to suture into lumbrical muscle as was done in the previous interspace.  Half of the nerve was transected proximally as was feasible and no exposed ending was noted.  Incision was then flushed and irrigated using sterile saline.  Following this, the incision wound was packed with iodoform gauze packed and closed in layers using as before #4-0 Vicryl and #4-0 nylon suture.,Following this, attention was directed to the fifth metatarsal head where a lateral 4 cm incision was placed along the lateral distal shaft and head of the fifth metatarsal using a fresh #10 blade.  The incision was then deepened using #15 blade down to the level of the subcutaneous tissue.  Care was taken to reflect any neurovascular structures which were encountered.  Following this the incision was deepened down to the level of the periosteum and periosteum was reflected, using the sharp dissection, to expose the head of the metatarsal along with the neck region.  After adequate exposure of the fifth metatarsal head was achieved, an oblique incision directed from distal lateral to proximal medial in a sagittal plane was performed and the head of the fifth metatarsal was shifted medially.  Following this, an OrthoSorb pin was retrograded through the fifth metatarsal head into the neck of the fifth metatarsal and was cut off first with the lateral surfaces of bone.  OrthoSorb pin was noted to be intact and the fifth metatarsal head was in good alignment and position.  Following this, the sagittal saw and the #138 blade were used to provide rasping and smoothing of the sharp acute edges of bone laterally.  Following this, the periosteum was closed using #4-0 Vicryl and the skin was closed in layers using #4-0 Vicryl and closed with running subcuticular #4-0 Monocryl suture.  Upon completion of this, the foot was noted to be in good position with good visual alignment of the fifth metatarsal head and digit.  The incisions in foot were then ________ draped in the normal manner using Owen silk, 4 x 4s, Kling, and Kerlix and covered with Coban bandage.  The tourniquet was then deflated with the total tourniquet time of 103 minutes at 230 mmHg and immediate hyperemia was noted to end digits one through five of the left foot.,The patient was then transferred to the cart and was escorted to the Postanesthesia Care Unit with vital signs stable and vascular status intact.  The patient tolerated the procedure well without any complications.  The patient was then given prescriptions for Vicoprofen #30 and Augmentin #14 to be taken twice daily.  The patient was instructed to followup with Dr. X after the weekend on Tuesday in his office.  The patient also given postoperative instructions and was placed in a postoperative shoe and instructed to limit weightbearing to the heel only, ice and elevate her foot 20 minutes every hour as tolerated.  The patient also instructed to take her medications and prescriptions as directed.  She was given the emergency contact numbers.  Postoperative x-rays were taken and the patient was discharged home in stable condition upon conclusion of this.","surgery, tailor's bunion, neuroma, nerve lesion, interspace, metatarsal, osteotomy, metatarsal osteotomy, metatarsal head, foot, distally, head, incision, nerve, intermetatarsal, portions,"
 Venogram of the left arm and creation of left brachiocephalic arteriovenous fistula., Surgery, AV Fistula - 1 ,"PREOPERATIVE DIAGNOSIS,End-stage renal disease.,POSTOPERATIVE DIAGNOSIS,End-stage renal disease.,PROCEDURE,Venogram of the left arm and creation of left brachiocephalic arteriovenous fistula.,ANESTHESIA,General.,DESCRIPTION OF PROCEDURE,The patient was taken to the operating room where after induction of general anesthetic, the patient's arm was prepped and draped in a sterile fashion.  The IV catheter was inserted into the vein on the lower surface of the left forearm.  Venogram was performed, which demonstrated adequate appearance of the cephalic vein above the elbow.,Through a transverse incision, the cephalic vein and brachial artery were both exposed at the antecubital fossa.  The cephalic vein was divided, and the proximal end was anastomosed to the artery in an end-to-side fashion with a running 6-0 Prolene suture.,The clamps were removed establishing flow through the fistula.  Hemostasis was obtained.  The wound was closed in layers with PDS sutures.  Sterile dressing was applied.  The patient was taken to recovery room in stable condition.","surgery, end-stage renal disease, prolene suture, venogram, antecubital fossa, arteriovenous, arteriovenous fistula, brachiocephalic arteriovenous fistula, cephalic vein, fistula, prepped and draped, brachiocephalic, cephalic, vein"
" Austin-Moore bipolar hemiarthroplasty, left hip utilizing a medium fenestrated femoral stem with a medium 0.8 mm femoral head, a 50 mm bipolar cup.  Displace subcapital fracture, left hip.", Surgery, Austin-Moore Bipolar Hemiarthroplasty ,"PREOPERATIVE DIAGNOSIS:,  Displace subcapital fracture, left hip.,POSTOPERATIVE DIAGNOSIS: , Displace subcapital fracture, left hip.,PROCEDURE PERFORMED: , Austin-Moore bipolar hemiarthroplasty, left hip utilizing a medium fenestrated femoral stem with a medium 0.8 mm femoral head, a 50 mm bipolar cup.,PROCEDURE: , The patient was taken to OR #2, administered a subarachnoid block anesthetic and was then positioned in the right lateral decubitus position on the beanbag on the operative table.  The right lower extremity was protectively padded.  The left leg was propped with multiple blankets.  The hip was then prepped and draped in the usual manner.  A posterior incision was made on the posterolateral aspect of the left hip down to the skin and subcutaneous tissues.  Hemostasis was achieved utilizing electrocautery.  Gluteus fascia was incised in line with a skin incision and the muscle was split posteriorly.  The external rotators were identified after removal of the trochanteric bursa.  Hemostat was utilized to separate the external rotators from the underlying capsule, they were then transected off from their attachment at the posterior intertrochanteric line.  They were then reflected distally.  The capsule was then opened in a T-fashion utilizing the cutting cautery.  Fraction hematoma exuded from the hip joint.  The cork screw was then impacted into the femoral head and it was removed from the acetabulum.  Bone fragments were removed from the neck and acetabulum.  The acetabulum was then inspected and noted to be free from debris.  The proximal femur was then delivered into the wound with the hip internally rotated.,A mortise chisel was then utilized to take the cancellous bone from the proximal femur.  The T-handle broach was then passed down the canal.  The canal was then sequentially broached up to a medium broach.  The calcar was then plained with the hand plainer.  The trial components were positioned into place.  The medium component fit fairly well with the medium 28 mm femoral head.  Once the trial reduction was performed, the hip was taken through range of motion.  There was physiologic crystalling with longitudinal traction.  There was no tendency towards dislocation with flexion of the hip past 90 degrees.  The trial implants were then removed.  The acetabulum was then copiously irrigated with gentamicin solution and suctioned dry.  The medium fenestrated femoral stem was prepared by placing a large segment of bone from the femoral head into the fenestration making it a little larger than the width of the implant to provide a press fit.  The implant was then impacted into place.  The 28 mm femoral head was impacted on the mortise stapler of the femoral stem followed by placement of the 50 mm bipolar cup.  The acetabulum was once again inspected, was free of debris.  The hip was reduced.  It was taken through full range of motion.  There was no tendency for dislocation.  The wound was copiously irrigated with gentamicin solution.  The capsule was then repaired with interrupted #1 Ethibond suture.  External rotators were then reapproximated to the posterior intertrochanteric line utilizing #1 Ethibond in a modified Kessler type stitch.  The wound was once again copiously irrigated with gentamicin solution and suctioned dry.  Gluteus fascia was approximated with interrupted #1 Ethibond.  Subcutaneous layers were approximated with interrupted #2-0 Vicryl and skin approximated with staples.  A bulky dressing was applied to the wound.  The patient was then transferred to the hospital bed, an abductor pillow was positioned into place.  Circulatory status was intact to the extremity at completion of the case.","surgery, austin moore, bipolar hemiarthroplasty, femoral head, femoral, hip, hemiarthroplasty, ethibond, acetabulum,"
" Austin bunionectomy with internal screw fixation, first metatarsal, left foot.", Surgery, Austin Bunionectomy ,"TITLE OF OPERATION: , Austin bunionectomy with internal screw fixation, first metatarsal, left foot.,PREOPERATIVE DIAGNOSIS:,  Bunion deformity, left foot.,POSTOPERATIVE DIAGNOSIS: , Bunion deformity, left foot.,ANESTHESIA: , Monitored anesthesia care with 15 mL of 1:1 mixture of 0.5% Marcaine and 1% lidocaine plain.,HEMOSTASIS: , 45 minutes, left ankle tourniquet set at 250 mmHg.,ESTIMATED BLOOD LOSS:,  Less than 10 mL.,MATERIALS USED: , 2-0 Vicryl, 3-0 Vicryl, 4-0 Vicryl, as well as a 16-mm and an 18-mm partially threaded cannulated screw from the OsteoMed Screw Fixation System.,DESCRIPTION OF THE PROCEDURE:,  The patient was brought to the operating room and placed on the operating table in a supine position.  After adequate sedation was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's left foot to anesthetize the future surgical sites.  The left ankle was covered with cast padding and an 18-inch ankle tourniquet was placed around the left ankle and set at 250 mmHg.  The left foot was then prepped, scrubbed, and draped in normal sterile technique.  The left ankle tourniquet was inflated.  Attention was then directed on the dorsomedial aspect of the first left metatarsophalangeal joint where a 6-cm linear incision was placed directly over the first left metatarsophalangeal joint parallel and medial to the course of the extensor hallucis longus tendon to the left great toe.  The incision was deepened through subcutaneous tissues.  All the bleeders were identified, cut, clamped, and cauterized.  The incision was deepened to the level of the capsule and the periosteum of the first left metatarsophalangeal joint.  All the tendinous neurovascular structures were identified and retracted from the site to be preserved.  Using sharp and dull dissection, the periosteal and capsular attachments were mobilized from the head of the first left metatarsal.  The conjoint tendon was identified on the lateral plantar aspect of the base of the proximal phalanx of the left great toe and transversally resected from its insertion.  A lateral capsulotomy was also performed at the level of the first left metatarsophalangeal joint.  The dorsomedial prominence of the first left metatarsal head was adequately exposed using sharp dissection and resected with the use of a sagittal saw.  The same saw was used to perform an Austin-type bunionectomy on the capital aspect of the first left metatarsal head with its apex distal and its base proximal on the shaft of the first left metatarsal.  The dorsal arm of the osteotomy was longer than the plantar arm in order to accommodate for the future internal fixation.  The capital fragment of the first left metatarsal was then transposed laterally and impacted on the shaft of the first left metatarsal.  Provisional fixation was achieved with two smooth wires that were inserted vertically to the dorsal osteotomy in a dorsal distal to plantar proximal direction.  The same wires were also used as guide wires for the insertion of a 16-mm and an 18-mm partially threaded screws from the 3.0 OsteoMed System upon insertion of the screws, which was accomplished using AO technique.  The wires were removed.  Fixation on the table was found to be excellent.  Reduction of the bunion deformity was also found to be excellent and position of the first left metatarsophalangeal joint was anatomical.  The remaining bony prominence from the shaft of the first left metatarsal was then resected with a sagittal saw.  The area was copiously flushed with saline.  The periosteal and capsular tissues were approximated with 2-0 and 3-0 Vicryl suture material, 4-0 Vicryl was used to approximate the subcutaneous tissues.  The incision site was reinforced with Steri-Strips.  At this time, the patient's left ankle tourniquet was deflated.  The time was 45 minutes.  Immediate hyperemia was noted to the entire right lower extremity upon deflation of the cuff.  The patient's incision was covered with Xeroform, copious amounts of fluff and Kling, stockinette, and an Ace bandage.  The patient's left foot was then placed in a surgical shoe.  The patient was then transferred to the recovered room under the care of the anesthesia team with her vital signs stable and her vascular status at appropriate levels.  The patient was given pain medication and instructions on how to control her postoperative course.  The patient was discharged from Hospital according to nursing protocol and was advised to follow up with Dr. X in one week's time for her first postoperative appointment.","surgery, internal screw fixation, first metatarsal, bunion deformity, osteomed, screw fixation system, subcutaneous tissues, metatarsal head, austin bunionectomy, screw fixation, ankle tourniquet, metatarsophalangeal joint, austin, tourniquet, metatarsophalangeal, bunionectomy, foot, metatarsal,"
" The patient is a 5-1/2-year-old with Down syndrome, complex heart disease consisting of atrioventricular septal defect and tetralogy of Fallot with pulmonary atresia, discontinuous pulmonary arteries and bilateral superior vena cava with a left cava draining to the coronary sinus and a right aortic arch. ", Surgery, Atrioventricular Septal Defect ,"HISTORY:  ,The patient is a 5-1/2-year-old with Down syndrome, complex heart disease consisting of atrioventricular septal defect and tetralogy of Fallot with pulmonary atresia, discontinuous pulmonary arteries and bilateral superior vena cava with a left cava draining to the coronary sinus and a right aortic arch.  As an infant, he was initially palliated with the right and modified Blalock-Taussig shunt in October of 2002 and underwent atrioventricular septal defect and repair of pulmonary artery unifocalization and homograft placement between the right ventricle and unifocalized pulmonary arteries.  He developed a significant branch of pulmonary artery stenosis for which on 07/20/2004, he underwent a bilateral balloon pulmonary arterioplasty and stent implantation at the San Diego at Children's Hospital.  This was followed on 09/13/2007 with replacement of pulmonary valve utilizing a 16-mm Contegra valve.  A recent echocardiogram demonstrated a significant branch of pulmonary artery stenosis with the predicted gradient of 41 to 55 mmHg and a well-functioning Contegra valve.  The lung perfusion scan from 11/14/2007 demonstrated 47% flow to the left lung and 53% flow to the right lung.  The patient underwent a repeat catheterization in consideration for further balloon angioplasty of the branch pulmonary arteries.,PROCEDURE: , After sedation, the patient was placed under general endotracheal anesthesia breathing 50% oxygen throughout the case.  The patient was prepped and draped.  Cardiac catheterization was performed as outlined in the attached continuation sheets.  Vascular entry was by percutaneous technique, and the patient was heparinized.  Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures,Using a 7-French sheath, 6-French wedge catheter was inserted into the right femoral vein and advanced through the right heart structures out to the branch pulmonary arteries.  This catheter was exchanged over wire.  A 5-French marker pigtail catheter was directed into the main pulmonary artery.  A second site of venous access was achieved in and the left femoral vein with the placement of 5-French sheath.,Using a 4-French sheath, a 4-French pigtail catheter was inserted in the right femoral artery and advanced retrograde to the descending aorta, ascending aorta and left ventricle.  Angiogram with injection in the main pulmonary artery demonstrated stable stent configuration of the proximal branch pulmonary arteries with intimal ingrowth in the region of the proximal stents.  The distal right pulmonary measured approximately 10 mm in diameter with a mid stent section measuring 9.4 mm and the proximal stent near the origin of the right pulmonary artery of 5.80 mm.  The distal left pulmonary measured approximately 10 mm in diameter with a mid stent measuring 10.3 mm and the proximal stent near the origin of the left pulmonary artery is 6.8 mm diameter.  The left femoral venous sheath was exchanged over wire for a 7-French sheath.  Guidewires were then advanced through the respective venous sheath into the branch pulmonary arteries and simultaneous balloon pulmonary arterioplasty was performed using the two Z-Med 12 x 4 cm balloon catheter was advanced into the branch of pulmonary arteries and inflated maximally to 9 hemispheres of pressure on 5 occasions near complete disappearance of proximal waist.  The balloon catheter was then exchanged for a 5-French Mistique catheter for pressure pull-back and measurement in the angiogram.  The catheter's wires were then removed and final hemodynamic assessment was made with the wedge catheter.,Flows were calculated by the Fick technique using a measured assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with angiograph injection in the main pulmonary artery.,After angiography, two normal-appearing renal collecting systems were visualized.  The catheters and sheaths were removed and topical pressure applied for hemostasis.  The patient was returned to the recovery room in satisfactory condition.  There were no complications.,DISCUSSION:  ,Oxygen consumption was assumed to be in normal.  Mixed venous saturation that was not normal with no evidence of intracardiac shunt.  Left side of the heart was mildly desaturated following a part to parenchymal lung disease with the partial pressure of oxygen of only 82 mmHg.  Aphasic right atrial pressures were normal with an A-wave similar to the normal right ventricular end-diastolic pressure.  Left ventricular systolic pressure was moderately elevated at 70% of systemic level and there was no obstruction into the proximal main pulmonary artery.  There was a 20 mmHg of peak systolic gradient across the branch pulmonary artery stents to the distal artery.  Right and left pulmonary artery capillary wedge pressures were normal with an A-wave similar to the mildly elevated left ventricular end-diastolic pressure of 13 mmHg.  Left ventricular systolic pressure was systemic.  No outflow constriction to the ascending aorta.  Phasic ascending and descending pressures were similar and normal.  The calculated systemic and pulmonary flows were equal and normal.  Vascular resistances were normal.  Angiogram with injection in the main pulmonary artery showed catheter induced pulmonary insufficiency, well functioning Contegra valve with no appreciable calcification.  The proximal narrowing of the distal main pulmonary artery was appreciated.  Neointimal ingrowth within the proximal stents were appreciated.  There is good distal growth of the pulmonary arteries.  Arborization appeared normal.  Levophase contrast returned to the heart appeared normal with a well-functioning left ventricle and the right aortic arch.  Following the branch pulmonary artery angioplasty that was increased in the mixed venous saturation, as well as an increase in the systemic arterial saturation.  Right ventricular systolic pressure felt slightly to 40 mmHg with an increase in systemic arterial pressure with a systolic pressure ratio of 54%.  The main pulmonary pressures remained similar.  There was 10 mmHg systolic gradient into the branch of pulmonary arteries.  There is an increase in distal branch of pulmonary arteries with the mean pressure increased from 16 mmHg to 21 mmHg.  Final angiogram with injection in the main pulmonary artery showed a competent Contegra valve.  A brisk flow through the proximal branch stents with the improved caliber of the branch pulmonary artery lumens.  There was no evidence of intimal disruption.,DIAGNOSES: ,1.  Atrioventricular septal defect.,2.  Tetralogy of Fallot with the pulmonary atresia.,3.  Bilateral superior vena cava.  The left cava draining to the coronary sinus.,4.  The right aortic arch.,5.  Discontinuous pulmonary arteries.,6.  Down syndrome.,PRIOR SURGERIES AND INTERVENTIONS:  ,1.  Right modified Blalock-Taussig shunt.,2.  Repair of tetralogy of Fallot with external conduit.,3.  The atrioventricular septal defect repair.,4.  Unifocalization of branch pulmonary arteries.,5.  Bilateral balloon pulmonary angioplasty and stent implantation.,6.  Pulmonary valve replacement with 16-mm Contegra valve.,CURRENT DIAGNOSES:  ,1.  Mild-to-moderate proximal branch pulmonary stenosis.,2.  Well-functioning Contegra valve and current intervention.  A balloon dilation of the right pulmonary artery.,3.  Balloon dilation of left pulmonary artery.,MANAGEMENT: , The case will be discussed at Combined Cardiology and Cardiothoracic Surgery Case Conference and conservative outpatient management will be pursued.  Further cardiologic care be directed by Dr. X.",
" Austin-Akin bunionectomy with internal screw fixation of the first right metatarsophalangeal joint.  Weil osteotomy with internal screw fixation, first right metatarsal.  Arthroplasty, second right PIP joint.", Surgery, Austin-Akin Bunionectomy ,"TITLE OF OPERATION:,1.  Austin-Akin bunionectomy with internal screw fixation of the first right metatarsophalangeal joint.,2.  Weil osteotomy with internal screw fixation, first right metatarsal.,3.  Arthroplasty, second right PIP joint.,PREOPERATIVE DIAGNOSES:,1.  Bunion deformity, right foot.,2.  Dislocated second right metatarsophalangeal joint.,3.  Hammertoe deformity, second right digit.,POSTOPERATIVE DIAGNOSES:,1.  Bunion deformity, right foot.,2.  Dislocated second right metatarsophalangeal joint.,3.  Hammertoe deformity, second right digit.,ANESTHESIA:,  Monitored anesthesia care with 20 mL of 1:1 mixture of 0.5% Marcaine and 1% lidocaine plain.,HEMOSTASIS:,  60 minutes, a right ankle tourniquet set at 250 mmHg.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,PREOPERATIVE INJECTABLES:  ,1 g Ancef IV 30 minutes preoperatively.,MATERIALS USED: , 3-0 Vicryl, 4-0 Vicryl, 5-0 Prolene, as well as two 16-mm partially treaded cannulated screws of the OsteoMed system, one 18-mm partially treaded cannulated screw of the OsteoMed system of the 3.0 size.  One 10-mm 2.0 partially threaded cannulated screw of the OsteoMed system.,DESCRIPTION OF THE PROCEDURE:  ,The patient was brought to the operating room and placed on the operating table in the supine position.  After adequate sedation was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's right foot to anesthetize the future surgical sites.  The right ankle was covered with cast padding and an 18-inch ankle tourniquet was placed around the right ankle and set up at 250 mmHg.  The right foot was then prepped, scrubbed, and draped in a normal sterile technique.  The right ankle tourniquet was then inflated.  Attention was then directed on the dorsomedial aspect of the first right metatarsophalangeal joint where a 6-cm linear incision was placed parallel and medial to the course of the extensor hallucis longus tendon to the right great toe.  The incision was deepened through subcutaneous tissues.  All the bleeders were identified, cut, clamped, and cauterized.  The incision was deepened to the level of the capsule and the periosteum of the first right metatarsophalangeal joint.  All the tendinous and neurovascular structures were identified and retracted from the site to be preserved.  Using sharp and dull dissection, the periosteal and capsular tissues were mobilized from the head and neck of the first right metatarsal and the base of the proximal phalanx of the right great toe.  The conjoint tendon was identified on the lateral plantar aspect of the base of the proximal phalanx and resected transversely.,A lateral capsulotomy was also performed at the level of the first right metatarsophalangeal joint.  Using sharp and dull dissection, the dorsomedial prominence of the first right metatarsal head was adequately exposed and resected with the use of a sagittal saw.  The same saw was used to perform the Austin osteotomy on the capital aspect of the first right metatarsal with its apex distal and its base proximal.  The dorsal arm of the osteotomy was longer than the plantar arm and noted to accommodate for the future internal fixation.  The capital fragment of the first right metatarsal was then transposed laterally and impacted on the shaft of the first right metatarsal.  Two wires of the OsteoMed system were also used as provisional fixation wires and also as guidewires for the insertion of the future screws.  The wires were inserted dorsal distal to plantar proximal through the dorsal arm of the osteotomy.  The two screws from the 3.0 OsteoMed system were inserted over the wires using AO technique.  One screw measured 16 mm, second screw measured 18 mm in length.  Both 3.0 screws were then evaluated for the fixation of the osteotomy after the wires were removed.  Fixation of the osteotomy was found to be excellent.  The dorsomedial prominence of the first right metatarsal shaft was then resected with the sagittal saw.  To improve the correction of the hallux abductus angle, an Akin osteotomy was also performed on the base of the proximal phalanx of the right great toe with its base medially and its apex laterally.  Upon removal of the base wedge from the base of the proximal phalanx, the osteotomy was reduced with the OsteoMed smooth wire, which was also used as a guidewire for the insertion of a 16-mm partially threaded cannulated screw from the OsteoMed 3.0 system.  Upon insertion of the screw, using AO technique, the wire was removed.  The screw was inserted proximal medial to distal lateral through the osteotomy of the base of the proximal phalanx of the right great toe.  Fixation of the osteotomy was found to be excellent.  Reduction of the bunion deformity was also found to be excellent and position of the first right metatarsophalangeal joint was found to be anatomical.  Range of motion of that joint was uninhibited.  The area was flushed copiously with saline.  Then, 3-0 suture material was used to approximate the periosteum and capsular tissues, 4-0 was used to approximate the subcutaneous tissues, and Steri-Strips were used to reinforce the incision.  Attention was directed over the neck of the second right metatarsal head where a 3-cm linear incision was placed directly over the surgical neck of the second right metatarsal.  The incision was deepened through subcutaneous tissues.  All the bleeders were identified, cut, clamped and cauterized.  The incision was deepened through the level of the periosteum over the surgical neck of the second right metatarsal.  All the tendinous and neurovascular structures were identified and retracted from the site to be preserved.  Using sharp and dull dissection, the surgical neck of the second right metatarsal was adequately exposed and then Weil-type osteotomy was performed from dorsal distal to plantar proximal through the surgical neck of the second right metatarsal.  The capital fragment was then transposed proximally and impacted on the shaft of the second right metatarsal.,The 2.0 Osteo-Med system was also used to fixate this osteotomy wire from that system was inserted dorsal proximal to plantar distal through the second right metatarsal osteotomy and the wire was used as a guidewire for the insertion of the 10-mm partially threaded 2.0 cannulated screw.  Upon insertion of the screw, using AO technique, the wire was then removed.  Fixation of the osteotomy with 2.0 screw was found to be excellent.  The second right metatarsophalangeal joint was then relocated and the dislocation of that joint was completely reduced.  Range of motion of the second right metatarsophalangeal joint was found to be excellent.  Then, 3-0 Vicryl suture material was used to approximate the periosteal tissues.  Then, 4-0 Vicryl was used to approximate the skin incision.  Attention was then directed at the level of the PIP joint of the second right toe where two semi-elliptical incisions were placed directly over the bony prominence at the level of the second right PIP joint.  The island of skin between the two semi-elliptical incisions was resected in toto.  The dissection was carried down to the level of extensor digitorum longus of the second right toe, which was resected transversely at the level of the PIP joint.  A capsulotomy and a medial and lateral collateral ligament release of the PIP joint of the second right toe was also performed and head of the proximal phalanx of the second right digit was adequately exposed.  Using the double-action bone cutter, the head of the proximal phalanx of the second right toe was then resected.  The area was copiously flushed with saline.  The capsular and periosteal tissues were approximated with 2-0 Vicryl and 3-0 Vicryl suture material was also used to approximate the extensor digitorum longus to the second right toe.  A 5-0 Prolene was used to approximate the skin edges of the two semi-elliptical incisions.  Correction of the hammertoe deformity and relocation of the second right metatarsophalangeal joint were evaluated with the foot loaded and were found to be excellent and anatomical.  At this time, the patient's three incisions were covered with Xeroform, copious amounts of fluff and Kling, stockinette, and Ace bandage.  The patient's right ankle tourniquet was deflated, time was 60 minutes.  Immediate hyperemia was noted on the entire right lower extremity upon deflation of the cuffs.,The patient's right foot was placed in a surgical shoe and the patient was transferred to the recovery room under the care of anesthesia team with the vital signs stable and the vascular status at appropriate levels.  The patient was given instructions and education on how to continue caring for her right foot surgery.  The patient was eventually discharged from Hospital according to nursing protocol and was advised to follow up with Dr. X's office in one week's time for her first postoperative appointment.","surgery, austin-akin bunionectomy, weil osteotomy, internal screw fixation, first right metatarsal, metatarsophalangeal joint, hammertoe deformity, extensor digitorum longus, austin akin bunionectomy, threaded cannulated screw, semi elliptical incisions, ankle tourniquet, surgical neck, cannulated screws, pip joint, proximal phalanx, fixation, metatarsophalangeal, proximal, screw, metatarsal, osteotomy, austin, joint, tourniquet, osteomed, phalanx, incision, "
" Erythema of the right knee and leg, possible septic knee. Aspiration through the anterolateral portal of knee joint.", Surgery, Aspiration - Knee Joint ,"PREOPERATIVE DIAGNOSES: , Erythema of the right knee and leg, possible septic knee.,POSTOPERATIVE DIAGNOSES:,  Erythema of the right knee superficial and leg, right septic knee ruled out.,INDICATIONS: , Mr. ABC is a 52-year-old male who has had approximately eight days of erythema over his knee.  He has been to multiple institutions as an outpatient for this complaint.  He has had what appears to be prepatellar bursa aspirated with little to no success.  He has been treated with Kefzol and 1 g of Rocephin one point.  He also reports, in the emergency department today, an attempt was made to aspirate his actual knee joint which was unsuccessful.  Orthopedic Surgery was consulted at this time.  Considering the patient's physical exam, there is a portal that would prove to be outside of the erythema that would be useful for aspiration of the knee.  After discussion of risks and benefits, the patient elected to proceed with aspiration through the anterolateral portal of his knee joint.,PROCEDURE:  ,The patient's right anterolateral knee area was prepped with Betadine times two and a 20-gauge spinal needle was used to approach the knee joint approximately 3 cm anterior and 2 cm lateral to the superolateral pole of the patella.  The 20-gauge spinal needle was inserted and entered the knee joint.  Approximately, 4 cc of clear yellow fluid was aspirated.  The patient tolerated the procedure well.,DISPOSITION: , Based upon the appearance of this synovial fluid, we have a very low clinical suspicion of a septic joint.  We will send this fluid to the lab for cell count, crystal exam, as well as culture and Gram stain.  We will follow these results.  After discussion with the emergency department staff, it appears that they tend to try to treat his erythema which appears to be cellulitis with IV antibiotics.","surgery, knee and leg, anterolateral portal, emergency department, spinal needle, septic knee, knee joint, knee, emergency, department, gauge, spinal, needle, aspiration, anterolateral, portal, aspirated, fluid, septic, erythema, joint, aspiraion, "
" Ash split venous port insertion. The right anterior chest and supraclavicular fossa area, neck, and left side of chest were prepped with Betadine and draped in a sterile fashion.", Surgery, Ash Split Venous Port ,"ASH SPLIT VENOUS PORT,PROCEDURE DETAILS:  ,The patient was taken to the operating room and placed in supine position and monitored anesthesia care provided by the anesthetist.  The right anterior chest and supraclavicular fossa area, neck, and left side of chest were prepped with Betadine and draped in a sterile fashion.  Xylocaine 1% was infiltrated in the supraclavicular area and anterior chest along the planned course of the catheter.  The patient was placed into Trendelenburg position.,The right internal jugular vein was accessed by a supraclavicular 19-gauge, thin-walled needle as demonstrated by easy withdrawal of venous blood on the first pass of the needle.  Under fluoroscopic control, a J-wire was advanced into the right atrium.  The needle was removed and the skin puncture site enlarged to about 8 mm with the scalpel.  A second incision was made 5 cm inferior to the right midclavicular line, through which an Ash split catheter was advanced, using the tunneling rod, in a gently curving pass to exit the skin of the neck incision.  The tunneling needle was removed and the catheter split up to the marker as indicated in the recommended use of the catheter.,Sequential dilators were advanced over the J-wire under fluoroscopic control to dilate the subcutaneous tunnel followed by advancement of a dilator and sheath into the right superior vena cava under fluoroscopic control.  The dilator and wire were removed, leaving the sheath in position, through which a double-lumen catheter was advanced into the central venous system.  The sheath was peeled away, leaving the catheter into position.  Each port of the catheter was flushed with dilute heparinized saline.,The patient was returned to the flat position.  The catheter was secured to the skin of the anterior chest using 2-0 Ethilon suture placed through the suture ""wings."",The neck incision was closed with 3-0 Vicryl subcuticular closure and pressure dressing applied.  Fluoroscopic examination of the chest revealed no evidence of pneumothorax upon completion of the procedure and the catheter was in excellent position.,The patient was returned to the recovery room for postoperative care.","surgery, ash split venous port, venous port, anterior chest, incision, dilators, sheath, port, supraclavicular, needle, fluoroscopic, venous, insertion, catheter"
" Hemarthrosis, left knee, status post total knee replacement, rule out infection.  Arthrotomy, irrigation and debridement, and polyethylene exchange, left knee.  No complications were encountered throughout the procedure.", Surgery, Arthrotomy & I&D ,"PREOPERATIVE DIAGNOSIS: , Hemarthrosis, left knee, status post total knee replacement, rule out infection.,POSTOPERATIVE DIAGNOSIS: , Hemarthrosis, left knee, status post total knee replacement, rule out infection.,OPERATIONS:,1.  Arthrotomy, left total knee.,2.  Irrigation and debridement, left knee.,3.  Polyethylene exchange, left knee.,COMPLICATION: , None.,TOURNIQUET TIME:  ,58 minutes.,ESTIMATED BLOOD LOSS: , Minimal.,ANESTHESIA:  ,General.,INDICATIONS:  ,This patient underwent an uncomplicated left total knee replacement.  Postoperatively, unfortunately did not follow up with PT/INR blood test and he was taking Coumadin.  His INR was seemed to elevated and developed hemarthrosis.  Initially, it did look very benign, although over the last 24 hours it did become irritable and inflamed, and he therefore was indicated with the above-noted procedure.,This procedure as well as alternatives was discussed in length with the patient and he understood them well.  Risks and benefits were also discussed.  Risks such as bleeding, infection, damage to blood vessels, damage to nerve roots, need for further surgeries, chronic pain with range of motion, risk of continued discomfort, risk of need for further reconstructive procedures, risk of need for total knee revision, risk of blood clots, pulmonary embolism, myocardial infarction, and risk of death were discussed.  He understood them well.  All questions were answered and he signed consent for the procedure as described.,DESCRIPTION OF PROCEDURE: , The patient was placed on operating table and general anesthesia was achieved.  The left lower extremity was then prepped and draped in the usual sterile manner.  The leg was elevated and the tourniquet was inflated to 325 mmHg.  A longitudinal incision was then made and carried down through subcutaneous tissues.  This was made through the prior incision site.  There were some fatty necrotic tissues through the incision region and all necrotic tissue was debrided sharply on both sides of the incision site.  Medial and lateral flaps were then made.  The prior suture was identified, the suture removed and then a medial parapatellar arthrotomy was then performed.  Effusion within the knee was noted.  All hematoma was evacuated.  I then did flex the knee and removed the polyethylene.  Once the polyethylene was removed I did irrigate the knee with total of 9 liters of antibiotic solution.  Further debridement was performed of all inflamed tissue and thickened synovial tissue.  A 6 x 16-mm Stryker polyethylene was then snapped back in position.  The knee has excellent stability in all planes and I did perform a light manipulation to improve the flexion of the knee.  Further irrigation was performed on the all soft tissue in the knee with additional 3 liters of normal saline.  The knee was placed in a flexed position and the extensor mechanism was reapproximated using #2 Ethibond suture in a figure-of-eight manner.  The subcutaneous tissue was reapproximated in layers using #1 and 2-0 Vicryl sutures, and the skin was reapproximated using staples.  Prior to closure a Hemovac drain was inserted through a superolateral approach into the knee joint.,No complications were encountered throughout the procedure, and the patient tolerated the procedure well.  The patient was taken to recovery room in stable condition.","surgery,"
" Arthroscopy of the left knee, left arthroscopic medial meniscoplasty of medial femoral condyle, and chondroplasty of the left knee as well.  Chondromalacia of medial femoral condyle.   Medial meniscal tear, left knee.", Surgery," Arthroscopy, Meniscoplasty, & Chondroplasty ","PREOPERATIVE DIAGNOSIS:,  Medial meniscal tear, left knee.,POSTOPERATIVE DIAGNOSIS: , Chondromalacia of medial femoral condyle.,PROCEDURE PERFORMED:,1.  Arthroscopy of the left knee.,2.  Left arthroscopic medial meniscoplasty of medial femoral condyle.,3.  Chondroplasty of the left knee as well.,ESTIMATED BLOOD LOSS: , 80 cc.,TOTAL TOURNIQUET TIME: , 19 minutes.,DISPOSITION: , The patient was taken to PACU in stable condition.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 41-year-old male with left knee pain for approximately two years secondary to hockey injury where he did have a prior MCL sprain.  He has had a positive symptomology of locking and pain since then.  He had no frank instability to it, however.,GROSS OPERATIVE FINDINGS: , We did find a tear to the medial meniscus as well as a large area of chondromalacia to the medial femoral condyle.,OPERATIVE PROCEDURE:  ,The patient was taken to the operating room.  The left lower extremity was prepped and draped in the usual sterile fashion.  Tourniquet was applied to the left thigh with adequate Webril padding, not inflated at this time.  After the left lower extremity had been prepped and draped in the usual sterile fashion, we applied an Esmarch tourniquet, exsanguinating the blood and inflated the tourniquet to 325 mmHg for a total of 19 minutes.  We established the lateral port of the knee with #11 blade scalpel.  We put in the arthroscopic trocar, instilled with water and inserted the camera.,On inspection of the patellofemoral joint, it was found to be quite smooth.  Pictures were taken there.  There was no evidence of chondromalacia, cracking, or fissuring of the articular cartilage.  The patella was well centered over the trochlear notch.  We then directed the arthroscope to the medial compartment of the knee.  It was felt that there was a tear to the medial meniscus.  We also saw large area of chondromalacia with grade-IV changes to bone over the medial femoral condyle.  This area was debrided with forceps and the arthroscopic shaver.  The cartilage was also smoothened over the medial femoral condyle.  This was curetted after the medial meniscus had been trimmed.  We looked into the notch.  We saw the ACL appeared stable, saw attachments to tibial as well as the femoral insertion with some evidence of laxity, wear and tear.  Attention then was taken to the lateral compartment with some evidence of tear to the lateral meniscus and the arterial surface of both the tibia as well as the femur were pristine in the lateral compartment.  All instruments were removed.  All loose cartilaginous pieces were suctioned from the knee and water was suctioned at the end.  We removed all instruments.  Marcaine was injected into the portal sites.  We placed a sterile dressing and stockinet on the left lower extremity.  He was transferred to the gurney and taken to PACU in stable condition.","surgery, medial meniscoplasty, arthroscopic, chondroplasty, arthroscopy, medial femoral condyle, medial meniscus, knee, meniscal, cartilage, meniscoplasty, meniscus, chondromalacia, condyle, femoral"
" Arthrotomy, removal humeral head implant, right shoulder.  Repair of torn subscapularis tendon (rotator cuff tendon) acute tear.  Debridement glenohumeral joint.  Biopsy and culturing the right shoulder.", Surgery, Arthrotomy & Subscapularis Tendon Repair ,"TITLE OF OPERATION:  ,1.  Arthrotomy, removal humeral head implant, right shoulder.,2.  Repair of torn subscapularis tendon (rotator cuff tendon) acute tear.,3.  Debridement glenohumeral joint.,4.  Biopsy and culturing the right shoulder.,INDICATION FOR SURGERY: , The patient had done well after a previous total shoulder arthroplasty performed by Dr. X.  However, the patient was lifted with subsequent significant pain and apparent tearing of his subscapularis.  Risks and benefits of the procedure had been discussed with the patient at length including, but not exclusive of infection, nerve or artery damage, stiffness, loss of range of motion, incomplete relief of pain, incomplete return of function, continued instability, retearing of the tendon, need for revision of his arthroplasty, permanent nerve or artery damage, etc.  The patient understood and wished to proceed.,PREOP DIAGNOSIS:  ,1.  Torn subscapularis tendon, right shoulder.,2.  Right total shoulder arthroplasty (Biomet system).,POSTOP DIAGNOSIS:  ,1.  Torn subscapularis tendon, right shoulder.,2.  Right total shoulder arthroplasty (Biomet system).,3.  Diffuse synovitis, right shoulder.,PROCEDURE: , The patient was anesthetized in the supine position.  A Foley catheter was placed in his bladder.  He was then placed in a beach chair position.  He was brought to the side of the table and the torso secured with towels and tape.  His head was then placed in the neutral position with no lateral bending or extension.  It was secured with paper tape over his forehead.  Care was taken to stay off his auricular cartilages and his orbits.  Right upper extremity was then prepped and draped in the usual sterile fashion.  The patient was given antibiotics well before the beginning of the procedure to decrease any risk of infection.  Once he had been prepped and draped with the standard prep, he was prepped a second time with a chlorhexidine-type skin prep.  This was allowed to dry and the skin was then covered with Ioban bandages also to decrease his risk of infection.,Also, preoperatively, the patient had his pacemaker defibrillator function turned off as a result during this case.  Bipolar type cautery had to be used as opposed to monopolar cautery.,The patient's deltopectoral incision was then opened and extended proximally and distally.  The patient had significant amount of scar already in this interval.  Once we got down to the deltoid and pectoralis muscle, there was no apparent cephalic vein present, as a result the rotator cuff interval had to be developed through an area of scar.  This created a significant amount of bleeding.  As a result a very slow and meticulous dissection was performed to isolate his coracoid and then his proximal humerus.  Care was taken to stay above the pectoralis minor and the conjoint tendon.  The deltoid had already started to scar down the proximal humerus as a result a very significant amount of dissection had to be performed to release the deltoid from proximal humerus.  Similarly, the deltoid insertion had to be released approximately 50% of its width to allow us enough mobility of the proximal humerus to be able to visualize the joint or the component.  It was clear that the patient had an avulsion of the subscapularis tendon as the tissue on the anterior aspect of the shoulder was very thin.  The muscle component of the subscapularis could be located approximately 1 cm off the glenoid rim and approximately 3 cm off the lesser tuberosity.  The soft tissue in this area was significantly scarred down to the conjoint tendon, which had to be very meticulously released.  The brachial plexus was identified as was the axillary nerve.  Once this was completed, an arthrotomy was then made leaving some tissue attached to the lesser tuberosity in case it was needed for closure later.  This revealed sanguineous fluid inside the joint.  We did not feel it was infected based upon the fluid that came from the joint.  The sutures for the subscapularis repair were still located in the proximal humerus with no tearing through the bone, which was fortunate because in that we could use the bone later for securing the sutures.  The remaining sutures were seen to be retracted medially to an area of the subscapularis as mentioned previously.  Some more capsule had to be released off the inferior neck in order for us to gain exposure during the scarring.  This was done also very meticulously.  The upper one half of the latissimus dorsi tendon was also released.  Once this was completed, the humerus could be subluxed enough laterally that we could remove the head.  This was done with no difficulty.  Fortunately, the humeral component stayed intact.  There were some exudates beneath the humeral head, which were somewhat mucinous.  However, these do not really appear to be infected, however, we sent them to pathology for a frozen section.  This frozen section later returned as possible purulent material.  I discussed this personally with the pathologist at that point.  We told him that the procedure is only 3 weeks old, but he was concerned that there might be more white blood cells in the tissue than he would expect.  As a result, all the mucinous exudates were carefully removed.  We also performed a fairly extensive synovectomy of the joint primarily to gain vision of the components, but also we irrigated the joint throughout the case with antibiotic impregnated irrigation.  At that point, we also had sent portions of this mucinous material to pathology for a stat Gram stain.  This came back as no organisms seen.  We also sent portions for culture and sensitivity both aerobic and anaerobic.,Once this was completed, attention was then directed to the glenoid.  The patient had significant amount of scar already.  The subscapularis itself was significantly scarred down to the anterior rim.  As a result, the adhesions along the anterior edge were released using a knife.  Also adhesions in the subcoracoid space area were released very carefully and meticulously to prevent any injury to the brachial plexus.  Two long retractors were placed medially to protect the brachial plexus during all portions of suturing of the subscapularis.  The subscapularis was then tagged with multiple number 2 Tycron sutures.  Adhesions were released circumferentially and it was found that with the arm in internal rotation about neutral degrees, the subscapularis could reach the calcar region without tension.  As a result, seven number 2 Tycron sutures were placed from the bicipital groove all the way down to the inferior calcar region of the humerus.  These all had excellent security in bone.  Once the joint had been debrided and irrigated, the real humeral head was then placed back on the proximal humerus.  Care was taken to remove fluid off the Morse taper.  The head was then impacted.  It should be noted that we tried multiple head sizes to see if a smaller or larger head size might be more appropriate for this patient.  Unfortunately, any of the larger head sizes would overstep the joint and any smaller sizes would not give good coverage to the proximal humerus.  As a result, it was felt to place the offset head back on the humerus, we did insert a new component as opposed to using the old component.  The old component was given to the family postoperatively.,With the arm in internal rotation, the Tycron sutures were then placed through the subscapularis tendon in the usual horizontal mattress fashion.  Also, it should be noted that the rotator cuff interval had to be released as part of the exposure.  We started the repair by closing the rotator cuff interval.  Anterior and posterior translation was then performed and was found to be very stable.  The remaining sutures were then secured through the subscapularis tendon taking care to make sure that very substantial bites were obtained.  This was then reinforced with the more flimsy tissue laterally being sewn into the tissue around the bicipital tuberosity essentially provided us with a two-layer repair of the subscapularis tendon.  After the tendon had been repaired, there was no tension on repair until 0 degrees external rotation was reached with the arm to the side.  Similarly with the arm abducted 90 degrees, tension was on repair at 0 degrees of external rotation.  It should be noted that the wound was thoroughly irrigated throughout with antibiotic impregnated irrigation.  The rotator cuff interval was closed with multiple number 2 Tycron sutures.  It was reinforced with 0 Vicryl sutures.  Two Hemovac drains were then placed inferiorly at the deltoid.  The deltopectoral interval was then closed with 0 Vicryl sutures.  A third drain was placed in the subcutaneous tissues to prevent any infections or any fluid collections.  This was sewn into place with the drain pulled out superiorly.  Once all the sutures have been secured and the drain visualized throughout this part of the closure, the drain was pulled distally until it was completely covered.  There were no signs that it had been tagged or hung up by any sutures.,The superficial subcutaneous tissues were closed with interrupted with 2-0 Vicryl sutures.  Skin was closed with staples.  A sterile bandage was applied along with a cold therapy device and a shoulder immobilizer.  The patient was sent to the intensive care unit in stable and satisfactory condition.,Due to the significant amount of scar and bleeding in this patient, a 22 modifier is being requested for this case.  This was a very difficult revision case and was significantly increased in technical challenges and challenges in the dissection and exposure of this implant compared to a standard shoulder replacement.  Similarly, the repair of the subscapularis tendon presented significantly more challenges than that of a standard rotator cuff repair because of the implant.  This was being dictated for insurance purposes only and reflects no inherent difficulties with this case.  The complexity and the time involved in this case was approximately 30% greater than that of a standard shoulder replacement or of a rotator cuff repair.  This is being dictated to indicate this was a revision case with significant amount of scar and bleeding due to the patient's situation with his pacemaker.  This patient also had multiple medical concerns, which increased the complexity of this case including the necessity to place him in intensive care unit postoperatively for observation.","surgery, arthrotomy, repair of torn subscapularis tendon, glenohumeral joint, biomet system, arthroplasty, diffuse synovitis, proximal humerus, torn subscapularis tendon, subscapularis tendon, rotator cuff, humerus, sutures, tendon, head, shoulder, subscapularis, torn,"
" Diagnostic arthroscopy exam under anesthesia, left shoulder.  Debridement of chondral injury, left shoulder.  Debridement, superior glenoid, left shoulder.  Arthrotomy.  Bankart lesion repair.  Capsular shift, left shoulder (Mitek suture anchors; absorbable anchors with nonabsorbable sutures).", Surgery," Arthroscopy, Arthrotomy, Bankart lesion repair ","TITLE OF OPERATION:,1.  Diagnostic arthroscopy exam under anesthesia, left shoulder.,2.  Debridement of chondral injury, left shoulder.,3.  Debridement, superior glenoid, left shoulder.,4.  Arthrotomy.,5.  Bankart lesion repair.,6.  Capsular shift, left shoulder (Mitek suture anchors; absorbable anchors with nonabsorbable sutures).,INDICATION FOR SURGERY: , The patient was seen multiple times preoperatively and found to have chronic instability of her shoulder.  Risks and benefits of the procedure had been discussed in length including but not exclusive of infection, nerve or artery damage, stiffness, loss of range of motion, incomplete relief of pain, continued instability, recurrent instability, medical complications, surgical complications, and anesthesia complications.  The patient understood and wishes to proceed.,PREOP DIAGNOSIS: , Anterior instability, left shoulder.,POSTOP DIAGNOSES:,1.  Anterior instability, left shoulder.,2.  Grade 4 chondromalacia, 10% humeral head, chondral defect 1 cm squared, left shoulder.,3.  Type 1 superior labrum anterior and posterior lesion, left shoulder.,4.  Anteroinferior glenoid erosions 10% bony surface, left shoulder.,5.  Bankart lesion, left shoulder.,PROCEDURE: , The patient was placed in a supine position and both shoulders examined systematically.  She had full range of motion with no joint adhesions.  She had equal range of motion bilaterally.  She had Hawkins 2 anteriorly and posteriorly in both shoulders with a grade 1 sulcus sign in both shoulders.  This was the same when the arm was in neutral or in external rotation.  The patient was then turned to right lateral decubitus position, axillary roll was placed, and beanbag was inflated.  Peroneal nerve was well protected.  All bony prominences were well protected.,The left upper extremity was then prepped and draped in the usual sterile fashion.  The patient was given antibiotics well before the start of the procedure to decrease the risk of infection.  The arm was placed in a arm holder with 10 pounds of traction.  A posterior portal was created in the usual manner by isolating gently with the spinal needle, it was insufflated with 30 cubic centimeters of saline.  A small incision was made after infiltrating the skin with Marcaine and epinephrine.  The scope was introduced into the shoulder with no difficulty.  It was then examined systematically.  The patient did have diffuse synovitis throughout her shoulder.  Her posterior humeral head showed an enlarged bold spot with some other areas of chondromalacia on the posterior head.  She also had an area 1 cm in diameter, which was on more central portion of the head and more inferiorly which appeared to be more of an impaction-type injury.  This had some portions of fibrillated and loose cartilage, hanging from the edges.  These were later debrided, but the dissection was proximally 10 to 15% of the humeral surface.,The biceps tendon appeared to be normal.  The supraspinatus, infraspinatus tendons were normal.  The inferior pouch was normal with no capsular tearing and no HAGL lesions.  The posteroinferior labrum was normal as well as the posterosuperior labrum.  There was some fraying in the posterosuperior labrum, which was later debrided.  It was found essentially to be a type 1 lesion anteriorly and superiorly.  The anterosuperior labrum appeared to be detached, which appeared to be more consistent with a sublabral hole.  The middle glenohumeral ligament was present as an entire sheath, but attach to the labrum.  The labrum did appeared to be detached from the anterior glenoid from the 11 o'clock position all the way down to the 6 o'clock position.  The biceps anchor itself was later probed and found to be stable and normal.  The subscapularis tendon was normal.  The anterior band of the glenohumeral ligament was present, but it was clearly avulsed off the glenoid.  There was some suggestion of anteroinferior bony erosions, which was later substantiated when the shoulder was opened.  The patient was missing about 10 to 15% of her anteroinferior glenoid rim.  The patient had a positive drive-through sign.,The arm was then moved to lateral and placed through range of motion.  There was contact of the rotator cuff to the superior glenoid in flexion at 115 degrees, maximum flexion was 150 degrees.  The arm abducted and externally rotated.  There was contact to the rotator cuff with posterosuperior labrum.  This occurred with the arm position of 90 degrees with abduction at 55 degrees of external rotation.  It should be noted that the maximum abduction is 150 degrees and with the arm abducted 90 degrees, maximum external rotation was 95 degrees.  The patient did have a positive relocation maneuver.  The posterior labrum did appear to tilt-off, but did not appear to peel off.,The arm was then placed back in the arm holder.  Anterior portal was created with Wissinger rod.  A blue cannula was inserted into the shoulder without difficulty.  Shaver was introduced in the labrum.  Also the area of chondromalacia as mentioned above was debrided.  The labrum was found to be stable with only a type 1 SLAP lesion, and there was no evidence as there was really a type 2 SLAP lesion.  The instruments were then removed along with excess fluid.  The posterior portals were closed with single 4-0 nylon suture.  The anterior portal was left open.  The patient was then placed in a supine position, and the extremity was reprepped and draped in anticipation of performing open capsular shift.,The patient's anterior incision made just lateral to the coracoid in the skin line.  Mediolateral skin flaps were developed, and cephalic vein was identified and protected throughout the case.  The interval was developed down the clavipectoral fascia.  The conjoined tendon was retracted medially and the deltoid laterally.  The patient's subscapularis was intact, and the subscapularis split was then made between the upper one half and lower one half in line with muscle fibers.  The capsule could easily be detached from the muscle, and the interval developed very easily.  A retractor was placed inferiorly to protect the axillary nerve.  Then Gelpi retractor was used to hold the subscapularis split open.,Next, an arthrotomy was made down at the 9 o'clock position.  The labrum was identified and found to be attached all the way down to 6 o'clock position.  The inferior flap was then created in a usual manner and tied with a 0 Vicryl suture.  The patient's glenoid rim did have some erosion as mentioned above with some bone loss and flattening.  This was debrided with the soft tissue.  Three Mitek suture anchors were then placed into the glenoid rim right at the margin of articular cartilage to the scapular neck.  These were absorbable anchors with nonabsorbable sutures.  They had excellent fixation once they had been placed.,Next, the capsular shift and Bankart repair were performed in the usual manner with the number 2 Ti-Cron sutures as an outside in and then inside out technique.  This brought the capsule right up to the edge of the glenoid rim.  With the arm in internal rotation and posterior pressure on the head, the capsule was then secured to the rim with no difficulty under direct visualization.  The capsule did come right up into the joint as expected with this type of repair.  The superior flap was then closed, the inferior flap over the superior anchor.  The interval between two flaps was closed with multiple number 2 Ti-Cron sutures.  Once this has been completed, there was no tension on the repair with the arm to side until 10 degrees of external rotation was reached.  The arm abducted 90 degrees.  There was tension on the repair until 20 degrees of external rotation reached.,The wound was thoroughly irrigated throughout with antibiotic-impregnated irrigation.  The subscapularis split was closed with interrupted 0 Vicryl sutures.  The deep subcutaneous tissues were closed with interrupted 0 Vicryl sutures.  The superficial subcutaneous tissues were closed with number 2-0 Vicryl sutures.  The skin was closed with 4-0 subcuticular Prolene, reinforced with Steri-Strips.  A sterile bandage was applied along with a cold therapy device and a shoulder immobilizer.  The patient was sent to the recovery room in stable and satisfactory condition.","surgery, diagnostic arthroscopy, chondral injury, debridement, superior glenoid, arthrotomy, bankart lesion, capsular shift, mitek suture, absorbable anchors, anterior instability, chondromalacia, superior labrum, glenoid erosion, glenoid rim, external rotation, glenoid, labrum, shoulder, arthroscopy, "
" Excision of capsular mass and arthrotomy with ostectomy of lateral femoral condyle, right knee.  Soft tissue mass and osteophyte lateral femoral condyle, right knee.", Surgery, Arthrotomy & Ostectomy & Capsular Mass Excision ,"PREOPERATIVE DIAGNOSIS:, Soft tissue mass, right knee.,POSTOPERATIVE DIAGNOSES:,1.  Soft tissue mass, right knee.,2.  Osteophyte lateral femoral condyle, right knee.,PROCEDURES PERFORMED:, Excision of capsular mass and arthrotomy with ostectomy of lateral femoral condyle, right knee.,SPECIFICATION: , The entire operative procedure was done in Inpatient Operating Suite, room #1 at ABCD General Hospital.  This was done under a local and IV sedation via the Anesthesia Department.,HISTORY AND GROSS FINDINGS:,  This is a 37-year-old African-American male with a mass present at the posterolateral aspect of his right knee.  On aspiration, it was originally attempted to no avail.  There was a long-standing history of this including two different MRIs, one about a year ago and one very recently both of which did not delineate the mass present.  During aspiration previously, the patient had experienced neuritic type symptoms down his calf, which have mostly resolved by the time that this had occurred.  The patient continued to complain of pain and dysfunction to his calf.  This was discussed with him at length.  He wished this to be explored and the mass excised even though knowing the possibility that they would not change his pain pattern with the potential of reoccurrence as well as the potential of scar stiffness, swelling, and peroneal nerve palsy.  With this, he decided to proceed.,Upon observation preoperatively, the patient was noted to have a hard mass present to the posterolateral aspect of the right knee.  It was noted to be tender.  It was marked preoperatively prior to an anesthetic.  Upon dissection, the patient was noted to have significant thickening of the posterior capsule.  The posterolateral aspect of the knee above the posterolateral complex at the gastroc attachment to the lateral femoral condyle.  There was also noted to be prominence of the lateral femoral condyle ridge.  The bifurcation at the tibial and peroneal nerves were identified and no neuroma was present.,OPERATIVE PROCEDURE:  ,The patient was laid supine upon the operating table.  After receiving IV sedation, he was placed prone.  Thigh tourniquet was placed.  He was prepped and draped in the usual sterile manner.  A transverse incision was carried down across the crease with a mass had been palpated through skin and subcutaneous tissue after exsanguination of the limb and tourniquet utilized.  The nerve was identified and carefully retracted throughout the case.  Both nerves were identified and carefully retracted throughout the case.  There was noted to be no neuroma present.  This was taken down until the gastroc was split.  There was gross thickening of the joint capsule and after arthrotomy, a section of the capsule was excised.  The lateral femoral condyle was then osteophied.  We then smoothed off with a rongeur.  After this, we could not palpate any mass whatsoever placing pressure upon the area of the nerve.  Tourniquet was deflated.  It was checked again.  There was no excessive swelling.  Swanson drain was placed to the depth of the wound and interrupted #2-0 Vicryl was utilized for subcutaneous fat closure and #4-0 nylon was utilized for skin closure.  Adaptic, 4x4s, ABDs, and Webril were placed for compression dressing.  Digits were warm _______ pulses distally at the end of the case.  The tourniquet as stated has been deflated prior to closure and hemostasis was controlled.  Expected surgical prognosis on this patient is guarded.","surgery, soft tissue mass, osteophyte, lateral femoral condyle, excision, capsular mass, arthrotomy, ostectomy, knee, soft tissue, femoral condyle, mass, subcutaneous, capsular, tourniquet, femoral, condyle,"
" Partial rotator cuff tear, left shoulder.  Arthroscopy of the left shoulder with arthroscopic rotator cuff debridement, soft tissue decompression of the subacromial space of the left shoulder.", Surgery, Arthroscopy - Shoulder ,"PREOPERATIVE DIAGNOSIS: , Partial rotator cuff tear, left shoulder.,POSTOPERATIVE DIAGNOSIS: , Partial rotator cuff tear, left shoulder.,PROCEDURE PERFORMED:, Arthroscopy of the left shoulder with arthroscopic rotator cuff debridement, soft tissue decompression of the subacromial space of the left shoulder.,ANESTHESIA:  ,Scalene block with general anesthesia.,ESTIMATED BLOOD LOSS: , 30 cc.,COMPLICATIONS: , None.,DISPOSITION:  ,The patient went to the PACU stable.,GROSS OPERATIVE FINDINGS: , There was no overt pathology of the biceps tendon.  There was some softening and loss of the articular cartilage over the glenoid.  The labrum was ________ attached permanently to the glenoid.  The biceps tendon was nonsubluxable.  Upon ranging of the shoulder in internal and external rotation showed no evidence of rotator cuff tear on the articular side.  Subacromial space did show excessive soft tissue causing some overstuffing of the subacromial space.  There was reconstitution of the bursa noted as well.,HISTORY OF PRESENT ILLNESS:,  This is a 51-year-old female had left shoulder pain of chronic nature who has had undergone prior rotator cuff debridement in May with partial pain relief and has had continued pain in the left shoulder.  MRI shows partial rotator cuff tear.,PROCEDURE: , The patient was taken to the operating room and placed in a beachchair position.  After all bony prominences were adequately padded, the head was placed in the headholder with no excessive extension in the neck on flexion.  The left extremity was prepped and draped in usual fashion.  The #18 gauge needles were inserted into the left shoulder to locate the AC joint, the lateral aspect of the acromion as well as the pass of the first trocar to enter the shoulder joint from the posterior aspect.  We took an #11 blade scalpel and made a small 1-cm skin incision posteriorly approximately 4-cm inferior and medial to the lateral port of the acromion.  A blunt trocar was used to bluntly cannulate the joint and we put the camera into the shoulder at that point of the joint and instilled sterile saline to distend the capsule and begin our arthroscopic assessment of the shoulder.  A second port was established superior to the biceps tendon anteriorly under direct arthroscopic visualization using #11 blade on the skin and inserted bluntly the trocar and the cannula.  The operative findings found intra-articularly were as described previously gross operative findings.  We did not see any evidence of acute pathology.  We then removed all the arthroscopic instruments as well as the trocars and tunneled subcutaneously into the subacromial space and reestablished the portal and camera and inflow with saline.  The subacromial space was examined and found to have excessive soft tissue and bursa that was in the subacromial space that we debrided using arthroscopic shaver after establishing a lateral portal.  All this was done and hemostasis was achieved.  The rotator cuff was examined from the bursal side and showed no evidence of tears.  There was some fraying out laterally near its attachment over the greater tuberosity, which was debrided with the arthroscopic shaver.  We removed all of our instruments and suctioned the subacromial space dry.  A #4-0 nylon was used on the three arthroscopic portal and on the skin we placed sterile dressing and the arm was placed in an arm sling.  She was placed back on the gurney, extubated and taken to the PACU in stable condition.","surgery, subacromial space, arthroscopic, biceps tendon, labrum, glenoid, cartilage, partial rotator cuff tear, rotator cuff tear, shoulder arthroscopy, rotator cuff, arthroscopy, shoulder, tissue, subacromial, rotator, cuff,"
" Diagnostic arthroscopy with partial chondroplasty of patella, lateral retinacular release, and open tibial tubercle transfer with fixation of two 4.5 mm cannulated screws.  Grade-IV chondromalacia patella and patellofemoral malalignment syndrome.", Surgery, Arthroscopy & Chondroplasty ,"PREOPERATIVE DIAGNOSES:,1.  Chondromalacia patella.,2.  Patellofemoral malalignment syndrome.,POSTOPERATIVE DIAGNOSES:,1.  Grade-IV chondromalacia patella.,2.  Patellofemoral malalignment syndrome.,PROCEDURE PERFORMED:,1.  Diagnostic arthroscopy with partial chondroplasty of patella.,2.  Lateral retinacular release.,3.  Open tibial tubercle transfer with fixation of two 4.5 mm cannulated screws.,ANESTHESIA:,  General.,COMPLICATIONS: , None.,TOURNIQUET TIME: , Approximately 70 minutes at 325 mmHg.,INTRAOPERATIVE FINDINGS: , Grade-IV chondromalacia noted to the central and lateral facet of the patella.  There was a grade II to III chondral changes to the patellar groove.  The patella was noted to be displaced laterally riding on the edge of the lateral femoral condyle.  The medial lateral meniscus showed small amounts of degeneration, but no frank tears were seen.  The articular surfaces and the remainder of the knee appeared intact.  Cruciate ligaments also appeared intact to direct stress testing.,HISTORY:  ,This is a 36-year-old Caucasian female with a long-standing history of right knee pain.  She has been diagnosed in the past with chondromalacia patella.  She has failed conservative therapy.  It was discussed with her the possibility of a arthroscopy lateral release and a tubercle transfer (anterior medialization of the tibial tubercle) to release stress from her femoral patellofemoral joint.  She elected to proceed with the surgical intervention.  All risks and benefits of the surgery were discussed with her.  She was in agreement with the treatment plan.,PROCEDURE: , On 09/04/03, she was taken to Operating Room at ABCD General Hospital.  She was placed supine on the operating table with the general anesthesia administered by the Anesthesia Department.  Her leg was placed in a Johnson knee holder and sterilely prepped and draped in the usual fashion.  A stab incision was made in inferolateral and parapatellar regions.  Through this the cannula was placed and the knee was inflated with saline solution.  Intraoperative pictures were obtained.  The above findings were noted.  Second portal site was initiated in the inferomedial parapatellar region.  Through this, a arthroscopic shaver was placed and the chondroplasty in the patella was performed and removed the loose articular debris.  Next, the camera was placed through the inferomedial portal.  An arthroscopic Bovie was placed through the inferolateral portal.  A release of lateral retinaculum was then performed using the Bovie.  Hemostasis was controlled with electrocautery.  Next, the knee was suctioned dry.  An Esmarch was used to exsanguinate the lower extremity.  Tourniquet was inflated to 325 mmHg.  An oblique incision was made along the medial parapatellar region of the knee.  The subcuticular tissues were carefully dissected and the hemostasis was again controlled with electrocautery.  The retinaculum was then incised in line with the incision.  The patellar tendon was identified.  The lateral and medial border of the tibial tubercle were cleared of all soft tissue debris.  Next, an osteotome was then used to cut the tibial tubercle to 45 degree angle leaving the base of the bone incision intact.  The tubercle was then pushed anteriorly and medially decreasing her Q-angle and anteriorizing the tibial tubercle.  It was then held in place with a Steinmann pin.  Following this, a two 4.5 mm cannulated screws, partially threaded, were drilled in place using standard technique to help fixate the tibial tubercle.  There was excellent fixation noted.  The Q-angle was noted to be decreased to approximately 15 degrees.  She was transferred approximately 1 cm in length.  The wound was copiously irrigated and suctioned dry.  The medial retinaculum was then plicated causing further medialization of the patella.  The retinaculum was reapproximated using #0 Vicryl.  Subcuticular tissue were reapproximated with #2-0 Vicryl.  Skin was closed with #4-0 Vicryl running PDS suture.  Sterile dressing was applied to the lower extremities.  She was placed in a Donjoy knee immobilizer locked in extension.  It was noted that the lower extremity was warm and pink with good capillary refill following deflation of the tourniquet.  She was transferred to recovery room in apparent stable and satisfactory condition.,Prognosis of this patient is poor secondary to the advanced degenerative changes to the patellofemoral joint.  She will remain in the immobilizer approximately six weeks allowing the tubercle to reapproximate itself to the proximal tibia.","surgery, diagnostic arthroscopy, patellofemoral malalignment syndrome, cannulated, partial chondroplasty, retinacular, chondromalacia patella, tibial tubercle, patella, tubercle, arthroscopy, tourniquet, chondroplasty, chondromalacia, patellofemoral, "
"  Rotator cuff tear, right shoulder.  Superior labrum anterior and posterior lesion (peel-back), right shoulder.  Arthroscopy with arthroscopic SLAP lesion.  Repair of soft tissue subacromial decompression rotator cuff repair, right shoulder.", Surgery, Arthroscopic SLAP lesion ,"PREOPERATIVE DIAGNOSIS: , Rotator cuff tear, right shoulder.,POSTOPERATIVE DIAGNOSIS: , Superior labrum anterior and posterior lesion (peel-back), right shoulder.,PROCEDURE PERFORMED:,1.  Arthroscopy with arthroscopic SLAP lesion.,2.  Repair of soft tissue subacromial decompression rotator cuff repair, right shoulder.,SPECIFICATIONS: , The entire operative procedure was done in Inpatient Operating Suite, room #1 at ABCD General Hospital.  This was done under a interscalene block anesthetic and subsequent general anesthetic in the modified beachchair position.,HISTORY AND GROSS FINDINGS:  ,This is a 54-year-old white female suffering an increasing right shoulder pain for a few months prior to surgical intervention.  She had an injury to her right shoulder when she fell off a bike.  She was diagnosed preoperatively with a rotated cuff tear.,Intra-articularly besides we noted a large SLAP lesion, superior and posterior to the attachment of the glenoid labrum from approximately 12:30 back to 10:30.  This acted as a peel-back type of mechanism and was displaced into the joint beyond the superior rim of the glenoid.  This was an obvious avulsion into subchondral bone with bone exposed.  The anterior aspect had degenerative changes, but did not have evidence of avulsion.  The subscapular was noted to be intact.  On the joint side of the supraspinatus, there was noted to be a laminated type of tearing to the rotated cuff to the anterior and mid-aspect of the supraspinatus attachment.,This was confirmed subacromially.  The patient had a type-I plus acromion in outlet view and thus it was elected to not perform a subacromial decompression, but soft tissue release of the CA ligament in a releasing resection type fashion.,OPERATIVE PROCEDURE: , The patient was placed supine upon the operative table after she was given interscalene and then general anesthesia by the Anesthesia Department.  She was safely placed in a modified beachchair position.  She was prepped and draped in the usual sterile manner.  The portals were created from outside the ends, posterior to the scope and anteriorly for an intraoperative portal and then laterally.  She had at least two other portals appropriate for both repair mechanisms described above.,Attention was then turned to the SLAP lesion.  The edges were debrided both on the bony side as well as soft tissue side.  We used the anterior portal to lift up the mechanism and created a superolateral portal through the rotator cuff and into the edge of the labrum.  Further debridement was carried out here.  A drill hole was made just on the articular surface superiorly for a knotless anchor.  A pull-through suture of #2 fiber wire was utilized with the ________.  This was pulled through.  It was tied to the leader suture of the knotless anchor.  This was pulled through and one limb of the anchor loop was grabbed and the anchor impacted with a mallet.  There was excellent fixation of the superior labrum.  It was noted to be solid and intact.  The anchor was placed safely in the bone.  There was no room for further knotless or other anchors.  After probing was carried out, hard copy Polaroid was obtained.,Attention was then turned to the articular side for the rotator cuff.  It was debrided.  Subchondral debridement was carried out to the tuberosity also.  Care was taken to go to the subchondral region but not beyond.  The bone was satisfactory.,Scope was then placed in the subacromial region.  Gross bursectomy was carried out with in the lateral portal.  This was done throughout as well as in the gutters anterolaterally and posteriorly.  Debridement was carried out further to the rotator cuff.  Two types of fixation were carried out, one with a superolateral portal a drill hole was made and anchor of the _knotless suture placed after PDS leader suture placed with a Caspari punch.  There was an excellent reduction of the tear posteriorly and then anteriorly.  Tendon to tendon repair was accomplished by placing a fiber wire across the tendon and tying sutured down through the anterolateral portal.  This was done with a sliding stitch and then two half stitches.  There was excellent reduction of the tear.,Attention was then turned to the CA ligament.  It was released along with periosteum and the undersurface of the anterior acromion.  The CA ligament was not only released but resected.  There was noted to be no evidence of significant spurring with only a mostly type-I acromion.  Thus, it was not elected to perform subacromial decompression for bone with soft tissue only.  A pain buster catheter was placed separately.  It was cut to length.  An interrupted #4-0 nylon was utilized for portal closure.  A 0.5% Marcaine was instilled subacromially.  Adaptic, 4x4s, ABDs, and Elastoplast tape placed for dressing.  The patient's arm was placed in a arm sling.  She was transferred to PACU in apparent satisfactory condition.  Expected surgical prognosis on this patient is fair.","surgery, rotator cuff tear, shoulder, labrum, lesion, decompression, subacromial, arthroscopic slap lesion, slap lesion, rotator cuff, anterior, arthroscopy, arthroscopic, slap, cuff"
" Arthroscopic rotator cuff repair, arthroscopic subacromial decompression, and arthroscopic extensive debridement, superior labrum anterior and posterior tear.", Surgery, Arthroscopic Rotator Cuff Repair - 2 ,"PROCEDURES,1.  Arthroscopic rotator cuff repair.,2.  Arthroscopic subacromial decompression.,3.  Arthroscopic extensive debridement, superior labrum anterior and posterior tear.,PROCEDURE IN DETAIL: , After written consent was obtained from the patient, the patient was brought back into the operating room and identified.  The patient was placed on the operating room table in supine position and given general anesthetic.  Once the patient was under general anesthetic, a careful examination of the shoulder was performed.  It revealed no patholigamentous laxity.  The patient was then carefully positioned into a beach-chair position.  We maintained the natural alignment of the head, neck, and thorax at all times.  The shoulder and upper extremity was then prepped and draped in the usual sterile fashion.,Once we fully prepped and draped, we then began the surgery.  We injected the glenohumeral joint with sterile saline with a spinal needle.  This consisted of 60 cc of fluid.  We then made a posterior incision for our portal, 2 cm inferior and 2 cm medial to the posterolateral angle of the acromion.  Through this incision, a blunt trocar and cannula were placed in the glenohumeral joint.  Through the cannula, a camera was placed; and the shoulder was insufflated with sterile saline through a preoperative feed.  We then carefully examined the glenohumeral joint.,We found the articular surface to be in good condition.  There was a superior labral tear (SLAP).  This was extensively debrided using a shaver through an anterior portal.  We also found a full thickness rotator cuff tear.  We then drained the glenohumeral joint.  We redirected our camera into the subacromial space.  An anterolateral portal was made, both superior and inferior.,We then proceeded to perform a subacromial decompression using high-speed shaver.  The bursa was extensively debrided.  We then abraded the bone over the footprint of where the rotator cuff is usually attached.  The corkscrew anchors were used to perform a rotator cuff repair.  Pictures were taken.,Through a separate incision, an indwelling pain catheter was then placed.  It was carefully positioned.  Pictures were taken.  We then drained the joint.  All instruments were removed.  The patient did receive IV antibiotic preoperatively.  All portals were closed using 4-0 nylon sutures.,Xeroform, 4 x 4s, and OpSite were applied over the pain pump.  ABD, tape, and a sling were also applied.  A Cryo/Cuff was also placed over the shoulder.  The patient was taken out of the beach-chair position maintaining the neutral alignment of the head, neck, and thorax.  The patient was extubated and brought to the recovery room in stable condition.  I then went out and spoke with the family, going over the case, postoperative instructions, and followup care.","surgery, debridement, superior labrum, patholigamentous, laxity, arthroscopic rotator cuff repair, subacromial decompression, glenohumeral joint, rotator cuff, arthroscopic, decompression, repair, glenohumeral, subacromial, rotator, cuff, "
" Arthroscopy of the arthroscopic glenoid labrum, rotator cuff debridement shaving glenoid and humeral head, and biceps tenotomy, right shoulder.  Massive rotator cuff tear, right shoulder, near complete biceps tendon tear of right shoulder, chondromalacia of glenohumeral joint or right shoulder, and glenoid labrum tear of right shoulder.", Surgery, Arthroscopy - Glenoid Labrum ,"PREOPERATIVE DIAGNOSIS:,  Rotator cuff tear, right shoulder.,POSTOPERATIVE DIAGNOSES:,1.  Massive rotator cuff tear, right shoulder.,2.  Near complete biceps tendon tear, right shoulder.,3.  Chondromalacia of glenohumeral joint, right shoulder.,4.  Glenoid labrum tear, right shoulder.,PROCEDURE PERFORMED:  ,1.  Arthroscopy of the arthroscopic glenoid labrum.,2.  Rotator cuff debridement shaving glenoid and humeral head.,3.  Biceps tenotomy, right shoulder.,SPECIFICATION: , The entire operative procedure was done in Inpatient Operating Suite, room #1 at ABCD General Hospital.  This was done under interscalene block anesthetic in the modified beachchair position.,HISTORY AND GROSS FINDINGS: , This is a 61-year-old white male who is dominantly right-handed.  He had increasing right shoulder pain and dysfunction for a number of years prior to surgical intervention.  This was gradually done over a period of time.  No specific accident or injury could be seen or pointed.  He was refractory to conservative outpatient therapy.  After discussing alternatives of the care as well as the advantages, disadvantages, risks, complications, and expectations, he elected to undergo the above-stated procedure on this date.,Preoperatively, the patient did not have limitation of motion.  He had gross weakness to his supraspinatus, mildly to the infraspinatus and subscapularis upon strength testing prior to his anesthetic.,Intraarticularly, the patient had an 80% biceps tendon tear that was dislocated.  His rotator interval was resolved as well as his subscapularis with tearing.  The supraspinatus was completely torn, retracted back beyond the level of the labrum and approximately one-third or so of the infraspinatus was involved with the remaining portion being greatly thinned as far as we could observe.  Glenoid labrum had degenerative tear in the inferior surface.  Gross chondromalacia was present to approximately 50% of the humeral head and approximately the upper 40% of the glenoid surface.,OPERATIVE PROCEDURE: , The patient was laid supine upon the operative table.  After receiving interscalene block anesthetic by the Anesthesia Department, he was safely placed in a modified beachchair position.  He was prepped and draped in the usual sterile manner.  The portals were created outside the end posteriorly and then anteriorly.  A full and complete diagnostic arthroscopy was carried out with the above-noted findings.  The shaver was placed anteriorly.  Debridement was carried out to the glenoid labrum tear and the last 20% of the biceps tendon tear was completed.  Debridement was carried out to the end or attachment of the bicep itself.,Debridement was carried out to what could be seen of the remaining rotator cuff there, but then the scope was redirected in a subacromial direction and gross bursectomy carried out.  Debridement was then carried out to the rotator cuff remaining tendon near the tuberosity.  No osteophytes were present.  Because of the massive nature of the tear, the CA ligament was maintained and there were no substantial changes to the subacromial region to necessitate burring.  There was concern because of instability that could be present at the end of this.,Another portal was created laterally to do all of this.  We did what we could to mobilize all sections of the rotator cuff, superiorly, posteriorly, and anteriorly.  We took this back to the level of coracoid base.  We released the coracohumeral ligament basically all but there was no excursion basically all to the portion of the rotator cuff torn.  Because of this, further debridement was carried out.  Debridement had been previously carried out to the humeral head as well as glenoid surface to debride the chondromalacia and take this down to the smooth edge.  Care was taken to not to debride deeper than that.  This was done prior to the above.,All instrumentation was removed.  A Pain-Buster catheter was placed into a separate anterolateral portal cut to length.  Interrupted #4-0 nylon was utilized for portal closures.  Adaptic, 4x4s, ABDs, Elastoplast tape were placed for a compression dressing.,The patient's arm was placed in an arm sling.  He was transferred to his cart and to the PACU in apparent satisfactory condition.  Expected surgical prognosis on this patient is quite guarded because of the above-noted pathology.","surgery, modified beachchair position, rotator cuff tear, glenoid labrum tear, glenohumeral joint, interscalene block, glenoid labrum, rotator cuff, rotator, debridement, glenoid, shoulder, tear, arthroscopy, arthroscopic, tenotomy, glenohumeral, supraspinatus, infraspinatus, subscapularis, chondromalacia, biceps, labrum, cuff, "
" Arthroscopy with arthroscopic subacromial decompression of the left shoulder.   Impingement syndrome, left shoulder.  Rule out superior labrum anterior and posterior lesion, left shoulder.", Surgery, Arthroscopic Subacromial Decompression - Shoulder ,"PREOPERATIVE DIAGNOSES:,1.  Impingement syndrome, left shoulder.,2.  Rule out superior labrum anterior and posterior lesion, left shoulder.,POSTOPERATIVE DIAGNOSES:,  Impingement syndrome, left shoulder.,PROCEDURE PERFORMED:,  Arthroscopy with arthroscopic subacromial decompression of the left shoulder.,ANESTHESIA: , The procedure was done under an interscalene block and subsequent general anesthetic in the modified beachchair position.,SPECIFICATIONS: , The entire operative procedure was done in Inpatient Operating Suite, room #1 at ABCD General Hospital.,HISTORY AND GROSS FINDINGS: , This is a 30-year-old white female suffering increasing left shoulder pain for a number of months prior to surgical intervention.  She was completely refractory to conservative outpatient therapy.  She had subacromial injection, which relieved the majority of her pain.  She also had medial bordered scapular pain unrelated directly to the present problem.  She had plus minus SLAP lesion testing preoperatively.,Operative findings in the joint included labrum was intact, long head of the biceps intact, laxity of 1+ all around, but clinically intact and without laxity.  Subacromially, type-II plus acromion and no evidence of significant rotator cuff tear with scuffing only.,She also had evidence of calcium deposition in the CA ligament and undersurface of the AC joint.,OPERATIVE PROCEDURE: , The patient was laid supine upon the operative table.  After receiving interscalene block general anesthetic by Anesthesia Department, she was placed in modified beachchair position.  She was prepped and draped in the usual sterile manner.  Portals were created outside the end, anterior and posterior, posterior and anterior, and subsequently laterally.  A full and complete diagnostic arthroscopy was carried out in the intraarticular aspect of the joint with the above noted findings.,Attention was then turned to the subacromial region.  The scope was placed.  A lateral portal was created.  Gross bursectomy was carried out.  This was done with a 4.2 meniscal shaver as well as a hot Bovie.  Calcium deposition mentioned was removed.  With the rotator cuff intact, the periosteum was burned off the undersurface of the acromion and the CA ligament released anteriorly.  A subacromial decompression sequentially from laterally to medially was then carried out.  There was an excellent decompression.  Debridement was carried out to the bursa.  The portals were ultimately closed with #4-0 after Pain Buster catheter had been placed.  Subacromial region was flooded with 0.5% Marcaine at approximately 15 cc or so.  Adaptic, 4x4s, ABDs, and Elastoplast tape placed for dressing.  The patient was awoken and transferred to PACU in apparent satisfactory condition.  Expected surgical prognosis on this patient is fair.","surgery, impingement syndrome, shoulder, arthroscopic subacromial decompression, beachchair position, subacromial region, arthroscopic, interscalene, arthroscopy, impingement, labrum, acromion, portals, decompression, subacromial,"
" Right shoulder arthroscopy, subacromial decompression, distal clavicle excision, bursectomy, and coracoacromial ligament resection, carpal tunnel release, left knee arthroscopy, and partial medial and lateral meniscectomy.", Surgery, Arthroscopy Shoulder/Knee ,"PREOPERATIVE DIAGNOSES:,1.  Medial meniscal tear, posterior horn of left knee.,2.  Carpal tunnel syndrome chronic right hand with intractable pain, numbness, and tingling.,3.  Impingement syndrome, right shoulder with acromioclavicular arthritis, bursitis, and chronic tendonitis.,POSTOPERATIVE DIAGNOSES:,1.  Carpal tunnel syndrome, right hand, severe.,2.  Bursitis, tendonitis, impingement, and AC arthritis, right shoulder.,3.  Medial and lateral meniscal tears, posterior horn old, left knee.,PROCEDURE:,1.  Right shoulder arthroscopy, subacromial decompression, distal clavicle excision, bursectomy, and coracoacromial ligament resection.,2.  Right carpal tunnel release.,3.  Left knee arthroscopy and partial medial and lateral meniscectomy.,ANESTHESIA: , General with regional.,COMPLICATIONS:  ,None.,DISPOSITION: , To recovery room in awake, alert, and in stable condition.,OPERATIVE INDICATIONS: , A very active 50-year-old gentleman who had the above problems and workup revealed the above problems.  He failed nonoperative management.  We discussed the risks, benefits, and possible complications of operative and continued nonoperative management, and he gave his fully informed consent to the following procedure.,OPERATIVE REPORT IN DETAIL: , The patient was brought to the operating room and placed in the supine position on the operating room table.  After adequate induction of general anesthesia, he was placed in the left lateral decubitus position.  All bony prominences were padded.  The right shoulder was prepped and draped in the usual sterile manner using standard Betadine prep, entered through three standard arthroscopic portals anterolateral and posterior incising the skin with a knife using sharp and blunt trocar.,Serial examination of the intraarticular portion of the shoulder showed all the structures to be normal including the biceps tendon ligaments, articular surfaces, and labrum.  Subacromial space was entered.  Visualization was poor due to the hemorrhagic bursitis, and this was resected back.  It was essentially a type-3 acromion, which was converted to a type 1 by aiming the burr anterior from the posterior portal excising the larger anterior spur.  Rotator cuff was little bit fray, but otherwise intact.  Thus, the deep deltoid bursa and the markedly thickened coracoacromial ligament were removed.  The burr was then introduced to the anterior portal and the distal clavicle excision carried out.  The width of burr about 6 mm being careful to preserve the ligaments in the capsule, but removing the spurs and the denuded arthritic joint.,The patient tolerated the procedure very well.  The shoulder was then copiously irrigated, drained free of any residual debris.  The wound was closed with 3-0 Prolene.  Sterile compressive dressing applied.,The patient was then placed on his back in the supine position and the right upper extremity and the left lower extremity were prepped and draped in usual sterile manner using a standard Betadine prep.,The attention was first turned to the right hand where it was elevated, exsanguinated using an Esmarch bandage, and the tourniquet was inflated to 250 mmHg for about 25 minutes.  Volar approach to the carpal ligament was performed incising the skin with a knife and using cautery for hemostasis.  Tenotomy and forceps dissection carried out through the superficial palmar fascia, carried down to the volar carpal ligament, which was then transected sharply with a knife and carried proximal and distal under direct vision using the scissors being careful to avoid the neurovascular structures.,Cautery was used for hemostasis.  The never had an hourglass appearance where it was a kind of constricted as a result of the compression from the ligament, and so a small amount of Celestone was dripped onto the nerve to help quite it down.  The patient tolerated this portion of the procedure very well.  The hand was then irrigated, closed with Monocryl and Prolene, and sterile compressive dressing was applied and the tourniquet deflated.,Attention was then turned to the left knee where it was entered through inferomedial and inferolateral portals incising the skin with a knife and using sharp and blunt trocars.  After entering the knee through inferomedial and inferolateral standard arthroscopic portals, examination of the knee showed a displaced bucket-handle tear in the medial meniscus and a radial tear at the lateral meniscus.  These were resected back to the stable surface using a basket forceps and full-radius shaver.  There was no evidence of any other significant arthritis in the knee.  There was a lot of synovitis, and so after the knee was irrigated out and free of any residual debris, the knee was injected with Celestone and Marcaine with epinephrine.,The patient tolerated the procedure very well, and the wounds were closed with 3-0 Prolene and sterile compressive dressing was applied, and then the patient was taken to the recovery room, extubated, awake, alert, and in stable condition.", 
 Primary right shoulder arthroscopic rotator cuff repair with subacromial decompression., Surgery, Arthroscopic Rotator Cuff Repair ,"PROCEDURE: , Primary right shoulder arthroscopic rotator cuff repair with subacromial decompression.,PATIENT PROFILE:,  This is a 42-year-old female.  Refer to note in patient chart for documentation of history and physical.  Due to the nature of the patient's increasing pain, surgery is recommended.  The alternatives, risks and benefits of surgery were discussed with the patient.  The patient verbalized understanding of the risks as well as the alternatives to surgery.  The patient wished to proceed with operative intervention.  A signed and witnessed informed consent was placed on the chart.  Prior to initiation of the procedure, patient identification and proposed procedure were verified by the surgeon in the pre-op area, and the operative site was marked by the patient and verified by the surgeon.,PRE-OP DIAGNOSIS: , Acute complete tear of the supraspinatus, Shoulder impingement syndrome.,POST-OP DIAGNOSIS:,  Acute complete tear of the supraspinatus, Shoulder impingement syndrome.,ANESTHESIA: , General - Endotracheal.,FINDINGS:,ACROMION:,1.  There was a medium-sized (5 - 10 mm) anterior acromial spur.,2.  The subacromial bursa was inflamed.,3.  The subacromial bursa was thickened.,4.  There was thickening of the coracoacromial ligament.,LIGAMENTS / CAPSULE: , Joint capsule within normal limits.,LABRUM: , The labrum is within normal limits.,ROTATOR CUFF: , Full thickness tear of the supraspinatus tendon, 5 mm anterior to posterior, by 10 mm medial to lateral.  Muscles and Tendons:  The biceps tendon is within normal limits.,JOINT:,  Normal appearance of the glenoid and humeral surfaces.,DESCRIPTION OF PROCEDURE:,PATIENT POSITIONING: , Following induction of anesthesia, the patient was placed in the beach-chair position on the standard operating table.  All body parts were well padded and protected to make sure there were no pressure points.  Subsequently, the surgical area was prepped and draped in the appropriate sterile fashion with Betadine.,INCISION TYPE:,1.  Scope Ports:  Anterior Portal.,2.  Scope Ports:  Posterior Portal.,3.  Scope Ports:  Accessory Anterior Portal.,INSTRUMENTS AND METHODS:,1.  The arthroscope and instruments were introduced into the shoulder joint through the arthroscopic portals.,2.  The subacromial space and bursa, biceps tendon, coracoacromial and glenohumeral ligaments, biceps tendon, rotator cuff, supraspinatus, subscapularis, infraspinatus, teres minor, capsulo-labral complex, capsule, glenoid labrum, humeral head, and glenoid, including the inner and outer surfaces of the rotator cuff, were visualized and probed.,3.  The subacromial bursa, subacromial soft tissues and frayed rotator cuff tissue were resected and debrided using a motorized resector and 4.5 Synovial Resector.,4.  The anterior portion of the acromion and acromial spur were resected with the 5.5 acromionizer burr.  Approximately 5 mm of bone was removed.  The coracoacromial ligament was released with the bony resection.  The shoulder joint was thoroughly irrigated.,5.  The edges of the cuff tissue were prepared, prior to the fixation, using the motorized resector.,6.  The supraspinatus tendon was reattached and sutured using the arthroscopic knot pusher and Mitek knotless anchor system and curved pointed suture passer and large bore cannula (to pass the sutures).  The repair was accomplished in a side-to-side and a tendon-to-bone fashion using three double loaded Mitek G IV suture anchors with 1 PDS suture.,7.  The repair was stable to palpation with the probe and watertight.,8.  The arthroscope and instruments were removed from the shoulder.,PATHOLOGY SPECIMEN: , No pathology specimens.,WOUND CLOSURE:,  The joint was thoroughly irrigated with 7 L of sterile saline.  The portal sites were infiltrated with 1% Xylocaine.  The skin was closed with 4-0 Vicryl using interrupted subcuticular technique.,DRAINS / DRESSING:,  Applied sterile dressing including gauze, iodoform gauze and Elastoplast.,SPONGE / INSTRUMENT / NEEDLE COUNTS:,  Final counts were correct.",
 Recurrent anterior dislocating left shoulder.  Arthroscopic debridement of the left shoulder with attempted arthroscopic Bankart repair followed by open Bankart arthroplasty of the left shoulder., Surgery, Arthroscopic Debridement - Shoulder ,"PREOPERATIVE DIAGNOSIS: , Recurrent anterior dislocating left shoulder.,POSTOPERATIVE DIAGNOSIS:,  Recurrent anterior dislocating left shoulder.,PROCEDURE PERFORMED:,  Arthroscopic debridement of the left shoulder with attempted arthroscopic Bankart repair followed by open Bankart arthroplasty of the left shoulder.,PROCEDURE:  ,The patient was taken to OR #2, administered general anesthetic after ineffective interscalene block had been administered in the preop area.  The patient was positioned in the modified beachchair position utilizing the Mayfield headrest.  The left shoulder was propped posteriorly with a rolled towel.  His head was secured to the Mayfield headrest.  The left shoulder and upper extremity were then prepped and draped in the usual manner.  A posterior lateral port was made for _____ the arthroscopic cannula.  The scope was introduced into the glenohumeral joint.  There was noted to be a complete tear of the anterior glenoid labrum off from superiorly at about 11:30 extending down inferiorly to about 6 o'clock.  The labrum was adherent to the underlying capsule.  The margin of the glenoid was frayed in this area.  The biceps tendon was noted to be intact.  The articular surface of the glenoid was fairly well preserved.  The articular surface on the humeral head was intact; however, there was a large Hill-Sachs lesion on the posterolateral aspect of the humeral head.  The rotator cuff was visualized and noted to be intact.  The axillary pouch was visualized and it was free of injury.  There were some cartilaginous fragments within the axillary pouch.  Attention was first directed after making an anterior portal to fixation of the anterior glenoid labrum.  Utilizing the Chirotech system through the anterior cannula, the labrum was secured with the pin and drill component and was then tacked back to the superior glenoid rim at about the 11 o'clock position.  A second tack was then placed at about the 8 o'clock position.  The labrum was then probed and was noted to be stable.  With some general ranging of the shoulder, the tissue was pulled out from the tacks.  An attempt was made at placement of two other tacks; however, the tissue was not of good quality to be held in position.  Therefore, all tacks were either buried down to a flat surface or were removed from the anterior glenoid area.  At this point, it was deemed that an open Bankart arthroplasty was necessary.  The arthroscopic instruments were removed.  An anterior incision was made extending from just lateral of the coracoid down toward the axillary fold.  The skin incision was taken down through the skin.  Subcutaneous tissues were then separated with the coag Bovie to provide hemostasis.  The deltopectoral fascia was identified.  It was split at the deltopectoral interval and the deltoid was reflected laterally.  The subdeltoid bursa was then removed with rongeurs.  The conjoint tendon was identified.  The deltoid and conjoint tendons were then retracted with a self-retaining retractor.  The subscapularis tendon was identified.  It was separated about a centimeter from its insertion, leaving the tissue to do sew later.  The subscapularis was reflected off superiorly and inferiorly and the muscle retracted medially.  This allowed for visualization of the capsule.  The capsule was split near the humeral head insertion leaving a tag for repair.  It was then split longitudinally towards the glenoid at approximately 9 o'clock position.  This provided visualization of the glenohumeral joint.  The friable labral and capsular tissue was identified.  The glenoid neck was already prepared for suturing, therefore, three Mitek suture anchors were then positioned to place at approximately 7 o'clock, 9 o'clock, and 10 o'clock.  The sutures were passed through the labral capsular tissue and tied securely.  At this point, the anterior glenoid rim had been recreated.  The joint was then copiously irrigated with gentamicin solution and suctioned dry.  The capsule was then repaired with interrupted #1 Vicryl suture and repaired back to its insertion site with #1 Vicryl suture.  This later was then copiously irrigated with gentamicin solution and suctioned dry.  Subscapularis was reapproximated on to the lesser tuberosity of the humerus utilizing interrupted #1 Vicryl suture.  This later was then copiously irrigated as well and suctioned dry.  The deltoid fascia was approximated with running #2-0 Vicryl suture.  Subcutaneous tissues were approximated with interrupted #2-0 Vicryl and the skin was approximated with a running #4-0 subcuticular Vicryl followed by placement of Steri-Strips.  0.25% Marcaine was placed in the subcutaneous area for postoperative analgesia.  The patient was then placed in a shoulder immobilizer after a bulky dressing had been applied.  The patient was then transferred to the recovery room in apparent satisfactory condition.","surgery, dislocating, bankart, arthroplasty, bankart repair, arthroscopic debridement, anterior, arthroscopic, debridement, deltoid, glenoid, humeral, interrupted, shoulder, subscapularis"
 Arthroplasty of the right second digit.  Hammertoe deformity of the right second digit., Surgery, Arthroplasty - Hammertoe ,"PREOPERATIVE DIAGNOSIS:,  Hammertoe deformity of the right second digit.,POSTOPERATIVE DIAGNOSIS: , Hammertoe deformity of the right second digit.,PROCEDURE PERFORMED: , Arthroplasty of the right second digit.,The patient is a 77-year-old Hispanic male who presents to ABCD Hospital for surgical correction of a painful second digit hammertoe.  The patient has failed attempts at conservative treatment and is unable to wear shoes without pain to his second toe.  The patient presents n.p.o. since mid night last night and consented to sign in the chart.  H&P is complete.,PROCEDURE IN DETAIL:,  After an IV was instituted by the Department of Anesthesia in the preoperative holding area, the patient was escorted to the operating room and placed on the table in the supine position.  Using Webril, the distal leg and ankle was padded and a ankle pneumatic tourniquet was placed around the right ankle, but left deflated at this time.  Restraining, a lap belt was then placed around the patient's abdomen while laying on the table.  After adequate anesthesia was administered by the Department of Anesthesia, a local digital block using 5 cc of 0.5% Marcaine plain was used to provide local anesthesia.  The foot was then prepped and draped in the normal sterile orthopedic manner.  The foot was then elevated and Esmarch bandage was applied, after which time the tourniquet was inflated to 250 mmHg.  The foot was then brought down to the level of the table and stockinet was cut and reflected after the Esmarch bandage was removed.  A wet and dry sponge was then used to cleanse the operative site and using a skin skribe a dorsal incisional line was outlined extending from the proximal phalanx over the proximal interphalangeal joint on to the middle phalanx.,Then using a fresh #15 blade, a dorsolinear incision was made, partial thickness through the skin after testing anesthesia with one to two pickup.  Then using a fresh #15 blade, incision was deepened and using medial to lateral pressure, the incision was opened into the subcutaneous tissue.  Care was taken to reflect the subcutaneous tissue from the underlying deep fascia to mobilize the skin.  This was performed with the combination of blunt and dull dissection.  Care was taken to avoid proper digital arteries and neurovascular bundles as were identified.  Attention was then directed to the proximal interphalangeal joint and after identifying the joint line, a transverse linear incision was made over the dorsal surface of the joint.  The medial and lateral sides of the joint capsule were then also incised on the superior half in order to provide increased exposure.  Following this, the proximal portion of the transected extensor digitorum longus tendon was identified using an Adson-Brown pickup.  It was elevated with fresh #15 blade.  The tendon and capsule was reflected along with the periosteum from the underlying bone dorsally.  Following this, the distal portion of the tendon was identified in a like manner.  The tendon and the capsule as well as the periosteal tissue was reflected from the dorsal surface of the bone.  The proximal interphalangeal joint was then distracted and using careful technique, #15 blade was used to deepen the incision and while maintaining close proximity to the bone and condyles, the lateral and medial collateral ligaments were freed up from the side of the proximal phalanx head.,Following this, the head of the proximal phalanx was known to have adequate exposure and was freed from soft tissues.  Then using a sagittal saw with a #139 blade, the head of he proximal phalanx was resected.  Care was taken to avoid the deep flexor tendon.  The head of the proximal phalanx was taken with the Adson-Brown and using a #15 blade, the plantar periosteal tissue was freed up and the head was removed and sent to pathology.  The wound was then flushed using a sterile saline with gentamicin and the digit was noted to be in good alignment.  The digit was also noted to be in rectus alignment.  Proximal portion of the tendon was shortened to allow for removal of the redundant tendon after correction of the deformity.  Then using a #3-0 Vicryl suture, three simple interrupted sutures were placed for closure of the tendon and capsular tissue.  Then following this, #4-0 nylon was used in a combination of horizontal mattress and simple interrupted sutures to close the skin.  The toe was noted to be in good alignment and then 1 cc of dexamethasone phosphate was injected into the incision site.  Following this, the incision was dressed using a sterile Owen silk soaked in saline and gentamicin.  The toe was bandaged using 4 x 4s, Kling, and Coban.  The tourniquet was deflated and immediate hyperemia was noted to the digits I through V of the right foot.,The patient was then transferred to the cart and was escorted to the Postanesthesia Care Unit where the patient was given postoperative surgical shoe.  Total tourniquet time for the case was 30 minutes.  While in the recovery, the patient was given postoperative instructions to include, ice and elevation to his right foot.  The patient was given pain medications of Tylenol #3, quantity 30 to be taken one to two tablets every six to eight hours as necessary for moderate to severe pain.  The patient was also given prescription for cane to aid in ambulation.  The patient will followup with Dr. X on Tuesday in his office for postoperative care.  The patient was instructed to keep the dressings clean, dry, and intact and to not remove them before his initial office visit.  The patient tolerated the procedure well and the anesthesia with no complications.","surgery, hammertoe deformity, arthroplasty, digit, proximal interphalangeal joint, periosteal tissue, interrupted sutures, interphalangeal joint, proximal phalanx, proximal, painful, tourniquet, hammertoe, phalanx, head, incisional, tendon"
" Hammertoe deformity, left fifth digit and ulceration of the left fifth digit plantolaterally.  Arthroplasty of the left fifth digit proximal interphalangeal joint laterally and excision of plantar ulceration of the left fifth digit 3 cm x 1 cm in size.", Surgery, Arthroplasty ,"PREOPERATIVE DIAGNOSES:,1.  Hammertoe deformity, left fifth digit.,2.  Ulceration of the left fifth digit plantolaterally.,POSTOPERATIVE DIAGNOSIS:,1.  Hammertoe deformity, left fifth toe.,2.  Ulceration of the left fifth digit plantolaterally.,PROCEDURE PERFORMED:,1.  Arthroplasty of the left fifth digit proximal interphalangeal joint laterally.,2.  Excision of plantar ulceration of the left fifth digit 3 cm x 1 cm in size.,OPERATIVE PROCEDURE IN DETAIL: , The patient is a 38-year-old female with longstanding complaint of painful hammertoe deformity of her left fifth toe.  The patient had developed ulceration plantarly after being scheduled for removal of a plantar mass in the same area.  The patient elects for surgical removal of this ulceration and correction of her hammertoe deformity at this time.,After an IV was instituted by the Department of Anesthesia, the patient was escorted to the OR where the patient was placed on the Operating Room table in the supine position.  After adequate amount of IV sedation was administered by Anesthesia Department, the patient was given a digital block to the left fifth toe using 0.5% Marcaine plain with 1% lidocaine plain in 1:1 mixture totaling 6 cc.  Following this, the patient was draped and prepped in a normal sterile orthopedic manner.  An ankle tourniquet was placed on the left ankle and the left foot was elevated and Esmarch bandage applied to exsanguinate the foot.  The ankle tourniquet was then inflated to 230 mmHg and then was brought back down to the level of the table.  The stockinette was then cut and reflected and held in place using towel clamp.,The skin was then cleansed using the wet and dry Ray-Tec sponge and then the plantar lesion was outlined.  The lesion measured 1 cm in diameter at the level of the skin and a 3 cm elliptical incision line was drawn on the surface of the skin in the plantolateral aspect of the left fifth digit.  Then using a fresh #15 blade, skin incision was made.  Following this, the incision was then deepened using a fresh #15 blade down to the level of the subcutaneous tissue.  Using a combination of sharp and blunt dissection, the skin was reflected distally and proximally to the lesion.  The lesion appeared well encapsulated with fibrous tissue and through careful dissection using combination of sharp and drill instrumentation the ulceration was removed in its entirety.  The next further exploration was performed to ensure that no residual elements of the fibrous capsular tissue remained within.  The lesion extended from the level of the skin down to the periosteal tissue of the middle and distal phalanx, however, did not show any evidence of extending beyond the level of a periosteum.  Remaining tissues were inspected and appeared healthy.  The lesion was placed in the specimen container and sent to pathology for microanalysis as well as growth.  Attention was then directed to the proximal interphalangeal joint of the left fifth digit and using further dissection with a #15 blade, the periosteum was reflected off the lateral aspect of the proximal ________ median phalanx.  The capsule was also reflected to expose the prominent lateral osseous portion of this joint.  Using a sagittal saw and #139 blade, the lateral osseous prominence was resected.  This was removed in entirety.  Then using power-oscillating rasp, the sharp edges were smoothed and recontoured to the desirable anatomic condition.  Then the incision and wound was flushed using copious amounts of sterile saline with gentamycin.  Following this, the bone was inspected and appeared to be healthy with no evidence of involvement from the removed aforementioned lesion.,Following this, using #4-0 nylon in a combination of horizontal mattress and simple interrupted sutures, the lesion wound was closed and skin was approximated well without tension to the surface skin.  Following this, the incision site was dressed using Owen silk, 4x4s, Kling, and Coban in a normal fashion.  The tourniquet was then deflated and hyperemia was noted to return to digits one through five of the left foot.  The patient was then escorted from the operative table into the Postanesthesia Care Unit.  The patient tolerated the procedure and anesthesia well and was brought to the Postanesthesia Care Unit with vital signs stable and vascular status intact.  In the recovery, the patient was given a surgical shoe as well as given instructions for postoperative care to include rest ice and elevation as well as the patient was given prescription for Naprosyn 250 mg to be taken three times daily as well as Vicodin ES to be taken q.6h. as needed.,The patient will follow-up on Friday with Dr. X in office for further evaluation.  The patient was also given instructions as to signs of infection and to monitor her operative site.  The patient was instructed to keep daily dressings intact, clean, dry, and to not remove them.","surgery, hammertoe deformity, plantolaterall, ulceration, arthroplasty, plantar ulceration, interphalangeal, painful hammertoe, proximal interphalangeal joint, interphalangeal joint, digit, toe, blade, deformity, incision, hammertoe, lesion"
" Torn lateral meniscus and chondromalacia of the patella, right knee.  Arthroscopic lateral meniscoplasty and patellar shaving of the right knee.", Surgery, Arthroscopic Meniscoplasty ,"PREOPERATIVE DIAGNOSES:,1.  Torn lateral meniscus, right knee.,2.  Chondromalacia of the patella, right knee.,POSTOPERATIVE DIAGNOSES:,1.  Torn lateral meniscus, right knee.,2.  Chondromalacia of the patella, right knee.,PROCEDURE PERFORMED:,1.  Arthroscopic lateral meniscoplasty.,2.  Patellar shaving of the right knee.,ANESTHESIA:  ,General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,TOTAL TOURNIQUET TIME:,  Zero.,GROSS FINDINGS: , A complex tear involving the lateral and posterior horns of the lateral meniscus and grade-II chondromalacia of the patella.,HISTORY OF PRESENT ILLNESS: , The patient is a 45-year-old Caucasian male presented to the office complaining of right knee pain.  He complained of pain on the medial aspect of his right knee after an injury at work, which he twisted his right knee.,PROCEDURE:  ,After all potential complications, risks, as well as anticipated benefits of the above-named procedures were discussed at length with the patient, informed consent was obtained.  The operative extremity was then confirmed with the operative surgeon, the patient, the Department of Anesthesia and the nursing staff.,The patient was then transferred to preoperative area to Operative Suite #2, placed on the operating table in supine position.  Department of Anesthesia administered general anesthetic to the patient.  All bony prominences were well padded at this time.  The right lower extremity was then properly positioned in a Johnson knee holder.  At this time, 1% lidocaine with epinephrine 20 cc was administered to the right knee intra-articularly under sterile conditions.  The right lower extremity was then sterilely prepped and draped in usual sterile fashion.  Next, after all bony soft tissue landmarks were identified, an inferolateral working portal was established by making a 1-cm transverse incision at the level of the joint line lateral to the patellar tendon.  The cannula and trocar were then inserted through this, putting the patellofemoral joint.  An arthroscopic camera was then inserted and the knee was sequentially examined including the patellofemoral joint, the medial and lateral gutters, medial lateral joints, and the femoral notch.  Upon viewing of the patellofemoral joint, there was noted to be grade-II chondromalacia changes of the patella.  There were no loose bodies noted in the either gutter.  Upon viewing of the medial compartment, there was no chondromalacia or meniscal tear was noted.  While in this area, attention was directed to establish the inferomedial instrument portal.  This was first done using a spinal needle for localization followed by 1-cm transverse incision at the joint line.  A probe was then inserted through this portal and the meniscus was further probed.  Again, there was noted to be no meniscal tear.  The knee was taken through range of motion and there was no chondromalacia.  Upon viewing of the femoral notch, there was noted to be intact ACL with negative drawer sign.  PCL was also noted to be intact.  Upon viewing of the lateral compartment, there was noted to be a large bucket-handle tear involving the lateral and posterior horns.  It was reduced from the place, however, involved the white and red white area was elected to excise the bucket-handle.  An arthroscopic scissor was then inserted and the two remaining attachments the posterior and lateral attachments were then clipped and a Schlesinger grasper was then used to remove the resected meniscus.  It was noted that the meniscus was followed out to the whole and the entire piece was taken out of the knee.  Pictures were taken both pre-meniscal resection and post-meniscal resection.  The arthroscopic shaver was then inserted into the medial portal and the remaining meniscus was contoured.  The lateral gutter was then examined and was noted to be no loose bodies and ______ was intact.  Next, attention was directed to the inner surface of the patella.  This was debrided using the 2.5 arthroscopic shaver.  It was noted to be quite smooth and postprocedure the patient was taken ________ well.  The knee was then copiously irrigated and suctioned dry and all instrumentation was removed.  20 cc of 0.25% Marcaine was then administered to each portal as well as intra-articularly.,Sterile dressing was then applied consisting of Adaptic, 4x4s, ABDs, and sterile Webril and a stockinette to the right lower extremity.  At this time, Department of Anesthesia reversed the anesthetic.  The patient was transferred back to the hospital gurney to the Postanesthesia Care Unit.  The patient tolerated the procedure and there were no complications.","surgery, patella, chondromalacia, lateral meniscus, complex tear, torn lateral meniscus, femoral notch, meniscal tear, bucket handle, meniscal resection, arthroscopic shaver, patellofemoral joint, arthroscopic, knee, torn, meniscoplasty, meniscal, joint, meniscus, "
 Laparoscopic appendectomy.  Acute appendicitis., Surgery, Appendectomy Laparoscopic ,"PREOPERATIVE DIAGNOSIS: , Acute appendicitis.,POSTOPERATIVE DIAGNOSIS: , Acute appendicitis.,PROCEDURE: , Laparoscopic appendectomy.,ANESTHESIA: , General endotracheal.,INDICATIONS: , Patient is a pleasant 31-year-old gentleman who presented to the hospital with acute onset of right lower quadrant pain.  History as well as signs and symptoms are consistent with acute appendicitis as was his CAT scan.  I evaluated the patient in the emergency room and recommended that he undergo the above-named procedure.  The procedure, purpose, risks, expected benefits, potential complications, alternative forms of therapy were discussed with him and he was agreeable with surgery.,FINDINGS: , Patient was found to have acute appendicitis with an inflamed appendix, which was edematous, but essentially no suppuration.,TECHNIQUE:  ,The patient was identified and then taken into the operating room, where after induction of general endotracheal anesthesia, the abdomen was prepped with Betadine solution and draped in sterile fashion.  An infraumbilical incision was made and carried down by blunt dissection to the level of the fascia, which was grasped with an Allis clamp and two stay sutures of 2-0 Vicryl were placed on either side of the midline.  The fascia was tented and incised and the peritoneum entered by blunt finger dissection.  A Hasson cannula was placed and a pneumoperitoneum to 15 mmHg pressure was obtained.  Patient was placed in the Trendelenburg position, rotated to his left, whereupon under direct vision, the 12-mm midline as well as 5-mm midclavicular and anterior axillary ports were placed.  The appendix was easily visualized, grasped with a Babcock's.  A window was created in the mesoappendix between the appendix and the cecum and the Endo GIA was introduced and the appendix was amputated from the base of the cecum.  The mesoappendix was divided using the Endo GIA with vascular staples.  The appendix was placed within an Endo bag and delivered from the abdominal cavity.  The intra-abdominal cavity was irrigated.  Hemostasis was assured within the mesentery and at the base of the cecum.  All ports were removed under direct vision and then wounds were irrigated with saline antibiotic solution.  The infraumbilical defect was closed with a figure-of-eight 0 Vicryl suture.  The remaining wounds were irrigated and then everything was closed subcuticular with 4-0 Vicryl suture and Steri-Strips.  Patient tolerated the procedure well, dressings were applied, and he was taken to recovery room in stable condition.","surgery, endo gia, babcock's, laparoscopic appendectomy, direct vision, abdominal cavity, acute appendicitis, appendectomy, hemostasis, laparoscopic, infraumbilical, appendix, appendicitis, endotracheal,"
" Femoroacetabular impingement.  Left hip arthroscopic debridement, femoral neck osteoplasty, and labral repair.", Surgery, Arthroscopic Debridement & Labral Repair - Hip ,"PREOPERATIVE DIAGNOSIS: , Femoroacetabular impingement.,POSTOPERATIVE DIAGNOSIS: , Femoroacetabular impingement.,OPERATIONS PERFORMED,1.  Left hip arthroscopic debridement.,2.  Left hip arthroscopic femoral neck osteoplasty.,3.  Left hip arthroscopic labral repair.,ANESTHESIA: , General.,OPERATION IN DETAIL: , The patient was taken to the operating room, where he underwent general anesthetic.  His bilateral lower extremities were placed under traction on the Hana table.  His right leg was placed first.  The traction post was left line, and the left leg was placed in traction.  Sterile Hibiclens and alcohol prep and drape were then undertaken.  A fluoroscopic localization was undertaken.  Gentle traction was applied.  Narrow arthrographic effect was obtained.  Following this, the ProTrac portal was made under the fluoro visualization, and then, a direct anterolateral portal made and a femoral neck portal made under direct visualization.  The diagnostic arthroscopy showed the articular surface to be intact with a moderate anterior lip articular cartilage delamination injury that propagated into the acetabulum.  For this reason, the acetabular articular cartilage was taken down and stabilized.  This necessitated takedown of the anterior lip of the acetabulum and subsequent acetabular osteoplasty debridement with associated labral repair.  The labrum was repaired using absorbable Smith & Nephew anchors with a sliding SMC knot.  After stabilization of the labrum and the acetabulum, the ligamentum teres was assessed and noted to be stable.  The remnant articular surface of the femoral artery and acetabulum was stable.  The posterior leg was stable.  The traction was left half off, and the anterolateral aspect of the head and neck junction was identified.  A stable femoral neck decompression was accomplished starting laterally and proceeding anteriorly.  This terminated with the hip coming out of traction and indeterminable flexion.  A combination of burs and shavers was utilized to perform a stable femoral neck osteoplasty decompression.  The decompression was completed with thorough irrigation of the hip.  The cannula was removed, and the portals were closed using interrupted nylon.  The patient was placed into a sterile bandage and anesthetized intraarticularly with 10 mL of ropivacaine subcutaneously with 20 mL of ropivacaine and at this point was taken to the recovery room.  He tolerated the procedure very well with no signs of complications.","surgery, labral repair, femoral neck osteoplasty, arthroscopic debridement, femoroacetabular impingement, arthroscopic, femoroacetabular, impingement, debridement, osteoplasty, acetabulum"
 Laparoscopic appendectomy.  Acute suppurative appendicitis.  A CAT scan of the abdomen and pelvis was obtained revealing findings consistent with acute appendicitis.  There was no evidence of colitis on the CAT scan. , Surgery, Appendectomy Laparoscopic - 1 ,"PREOPERATIVE DIAGNOSIS: , Acute appendicitis.,POSTOPERATIVE DIAGNOSIS:,  Acute suppurative appendicitis.,PROCEDURE PERFORMED: , Laparoscopic appendectomy.,ANESTHESIA: , General endotracheal and Marcaine 0.25% local.,INDICATIONS:,  This 29-year-old female presents to ABCD General Hospital Emergency Department on 08/30/2003 with history of acute abdominal pain.  On evaluation, it was noted that the patient has clinical findings consistent with acute appendicitis.  However, the patient with additional history of loose stools for several days prior to event.  Therefore, a CAT scan of the abdomen and pelvis was obtained revealing findings consistent with acute appendicitis.  There was no evidence of colitis on the CAT scan.  With this in mind and the patient's continued pain at present, the patient was explained the risks and benefits of appendectomy.  She agreed to procedure and informed consent was obtained.,GROSS FINDINGS: , The appendix was removed without difficulty with laparoscopic approach.  The appendix itself noted to have a significant inflammation about it.  There was no evidence of perforation of the appendix.,PROCEDURE DETAILS:,  The patient was placed in supine position.  After appropriate anesthesia was obtained and sterile prep and drape completed, a #10 blade scalpel was used to make a curvilinear infraumbilical incision.  Through this incision, a Veress needle was utilized to create a CO2 pneumoperitoneum of 15 mmHg.  The Veress needle was then removed.  A 10 mm trocar was then introduced through this incision into the abdomen.  A video laparoscope was then inserted and the above noted gross findings were appreciated upon evaluation.  Initially, bilateral ovarian cysts were appreciated, however, there was no evidence of acute disease on evaluation.  Photodocumentation was obtained.,A 5 mm port was then placed in the right upper quadrant.  This was done under direct visualization and a blunt grasper was utilized to mobilize the appendix.  Next, a 12 mm port was placed in the left lower quadrant lateral to the rectus musculature under direct visualization.  Through this port, the dissector was utilized to create a small window in the mesoappendix.  Next, an EndoGIA with GI staples was utilized to fire across the base of the appendix, which was done noting it to be at the base of the appendix.  Next, staples were changed to vascular staples and the mesoappendix was then cut and vessels were then ligated with vascular staples.  Two 6 X-loupe wires with EndoGIA were utilized in this prior portion of the procedure.  Next, an EndoCatch was placed through the 12 mm port and the appendix was placed within it.  The appendix was then removed from the 12 mm port site and taken off the surgical site.  The 12 mm port was then placed back into the abdomen and CO2 pneumoperitoneum was recreated.  The base of the appendix was reevaluated and noted to be hemostatic.  Aspiration of warm saline irrigant then done and noted to be clear.  There was a small adhesion appreciated in the region of the surgical site.  This was taken down with blunt dissection without difficulty.  There was no evidence of other areas of disease.  Upon re-exploration with a video laparoscope in the abdomen and after this noting the appendix base to be hemostatic and intact.  The instruments were removed from the patient and the port sites were then taken off under direct visualization.  The CO2 pneumoperitoneum was released into the air and the fascia was approximated in the 10 mm and 12 mm port sites with #0 Vicryl ligature x2.  Marcaine 0.25% was then utilized in all three incision sites and #4-0 Vicryl suture was used to approximate the skin and all three incision sites.  Steri-Strips and sterile dressings were applied.  The patient tolerated the procedure well and taken to Postoperative Care Unit in stable condition and monitored under General Medical Floor on IV antibiotics, pain medications, and return to diet.","surgery, abdomen, pelvis, laparoscopic appendectomy, suppurative appendicitis, veress needle, acute appendicitis, appendix, appendectomy, pneumoperitoneum, laparoscopic, appendicitis"
 Bilateral Crawford subtalar arthrodesis with open Achilles Z-lengthening and bilateral long-leg cast., Surgery, Arthrodesis ,"PREOPERATIVE DIAGNOSIS: , Congenital myotonic muscular dystrophy with bilateral planovalgus feet.,POSTOPERATIVE DIAGNOSIS: , Congenital myotonic muscular dystrophy with bilateral planovalgus feet.,PROCEDURE: , Bilateral Crawford subtalar arthrodesis with open Achilles Z-lengthening and bilateral long-leg cast.,ANESTHESIA: , Surgery performed under general anesthesia.  The patient received 6 mL of 0.25% Marcaine local anesthetic on each side.,TOURNIQUET TIME:  ,Tourniquet time was 53 minutes on the left and 45 minutes on the right.,COMPLICATIONS: , There were no intraoperative complications.,DRAINS:,  None.,SPECIMENS: , None.,HARDWARE USED: , Staple 7/8 inch x1 on each side.,HISTORY AND PHYSICAL:  ,The patient is a 5-year-4-month-old male who presents for evaluation of feet.  He has been having significant feet pain with significant planovalgus deformity.  The patient was noted to have flexible vertical talus.  It was decided that the patient would benefit by subtalar arthrodesis, possible autograft, and Achilles lengthening.  This was explained to the mother in detail.  This is going to be a stabilizing measure and the patient will probably need additional surgery at a later day when his foot is more mature.  Risks of surgery include risks of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, need for other surgical procedures, need to be nonweightbearing for some time.  All questions were answered and the mother agreed to the above plan.,PROCEDURE NOTE: , The patient was taken to the operating room, placed supine on the operating room, general anesthesia was administered.  The patient received Ancef preoperatively.  Bilateral nonsterile tourniquets were placed on each thigh.  A bump was placed underneath the left buttock.  Both the extremities were then prepped and draped in standard surgical fashion.  Attention was first turned towards the left side.  Intended incision was marked on the skin.  The ankle was taken through a range of motion with noted improvement in the reduction of the talocalcaneal alignment with the foot in plantar flexion on the lateral view.  The foot was wrapped in Esmarch prior to inflation of tourniquet to 200 mmHg.  Incision was then made over the left lateral aspect of the hind foot to expose the talocalcaneal joint.  The sinus tarsi was then identified using a U-shaped flap to tack muscles, and periosteum was retracted distally.  Once the foot was reduced a Steinman pin was used to hold it in position.  This position was first checked on the fluoroscopy.  The 7/8th inch staple was then placed across the sinus tarsi to maintain the reduction.  This was also checked with fluoroscopy.  The incision was then extended posteriorly to allow for visualization of the Achilles, which was Z-lengthened with the release of the lateral distal half.  This was sutured using 2-0 Ethibond and that was also oversewn.  The wound was irrigated with normal saline.  The periosteal flap was sutured over the staple using 2-0 Vicryl.  Skin was closed using 2-0 Vicryl interrupted and then with 4-0 Monocryl.  The area was injected with 6 mL of 0.25% Marcaine local anesthetic.  The wound was cleaned and dried, dressed with Steri-Strips, Xeroform, and 4 x 4s and Webril.  Tourniquet was released after 53 minutes.  The exact same procedure was repeated on the right side with no changes or complications.  Tourniquet time on the right side was 45 minutes.  The patient tolerated the procedure well.  Bilateral long-leg casts were then placed with the foot in neutral with some moulding of his medial plantar arch.  The patient was subsequently was taken to Recovery in stable condition.,POSTOPERATIVE PLAN: , The patient will be hospitalized overnight for pain as per parents' request.  The patient is to be strict nonweightbearing for at least 6 weeks.  He is to follow up in the next 10 days for a check.  We will plan of changing to short-leg casts in about 4 weeks postop.","surgery, myotonic muscular dystrophy, muscular dystrophy, planovalgus feet, achilles z-lengthening, subtalar arthrodesis, bilateral crawford subtalar arthrodesis, bilateral long leg cast, sinus tarsi, leg casts, tourniquet time, arthrodesis, intraoperative, fluoroscopy, tourniquet, subtalar, achilles, anesthesia, planovalgus, foot, bilateral, "
" Acute appendicitis, gangrenous.  Appendectomy.", Surgery, Appendectomy - 1 ,"PREOPERATIVE DIAGNOSIS:,  Acute appendicitis.,POSTOPERATIVE DIAGNOSIS: , Acute appendicitis, gangrenous.,PROCEDURE: , Appendectomy.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room under urgent conditions.  After having obtained an informed consent, he was placed in the operating room and under anesthesia.  Followed by a time-out process, his abdominal wall was prepped and draped in the usual fashion.  Antibiotics had been given prior to incision.  A McBurney incision was performed and it carried out through the peritoneal cavity.  Immediately there was  purulent material seen in the area.  Samples were taken for culture and sensitivity of aerobic and anaerobic sets.  The appendix was markedly swollen particularly in its distal three-fourth, where the distal appendix showed an abscess formation and devitalization of the wall.  There was quite a bit of local peritonitis.  The mesoappendix was clamped, divided and ligated, and then the appendix was ligated and divided, and the stump buried with a pursestring suture of Vicryl and then a Z stitch.  The area was abundantly irrigated with normal saline and also the pelvis.  The distal foot of small bowel had been explored and because it delivered itself __________ the incision and showed no pathology.,Then the peritoneal and internal fascia were approximated with a suture of 0 Vicryl and then the incision was closed in layers and after each layer the wound was irrigated with normal saline.  The skin was closed with a combination of a subcuticular suture of fine Monocryl followed by the application of Dermabond.  The patient tolerated the procedure well.  Estimated blood loss was minimal, and the patient was sent to the recovery room for recovery in satisfactory condition.,","surgery, mcburney incision, abdominal, small bowel, acute appendicitis, appendectomy, gangrenous, appendix, "
 Acute appendicitis and 29-week pregnancy.  Appendectomy., Surgery, Appendectomy - 2 ,"PREOPERATIVE DIAGNOSES,1.  Acute appendicitis.,2.  29-week pregnancy.,POSTOPERATIVE DIAGNOSES,1.  Acute appendicitis.,2.  29-week pregnancy.,OPERATION: , Appendectomy.,DESCRIPTION OF THE PROCEDURE:  ,After obtaining the informed consent including all risks and benefits of the procedure, the patient was urgently taken to the operating room where a spinal anesthetic was given and the patient's abdomen was prepped and draped in a usual fashion.  Preoperative antibiotics were given.  A time-out process was followed.  Local anesthetics were infiltrated in the area of the proposed incision.  A modified McBurney incision was performed.  A very abnormal appendix was immediately found.  There was a milky fluid around the area and this was cultured both for aerobic and anaerobic cultures.  The distal end of the appendix had transformed itself into an abscess.  The proximal portion was normal.  The appendix was very friable and a no-touch technique was used.  It was carefully dissected off the cecum, and then it was ligated and excised after the mesoappendix had been taken care of.  Then the stump was buried with a pursestring of 2-0 Vicryl.  The operative area was abundantly irrigated with warm saline and then closed in layers.  The layer was further irrigated.  A subcuticular suture of Monocryl was performed in the skin followed by the application of Dermabond.,Further local anesthetic was infiltrated at the end of the procedure in the operative area and the patient tolerated the procedure well, and with an estimated blood loss that was not consequential, was transferred from recovery to ICU in a satisfactory condition.","surgery, mcburney incision, appendectomy, appendicitis, appendix, "
" Aortoiliac occlusive disease.  Aortobifemoral bypass.  The aorta was of normal size and consistency consistent with arteriosclerosis.  A 16x8 mm Gore-Tex graft was placed without difficulty.  The femoral vessels were small somewhat thin and there was posterior packing, but satisfactory bypass was performed.", Surgery, Aortobifemoral Bypass ,"PREOPERATIVE DIAGNOSIS:,  Aortoiliac occlusive disease.,POSTOPERATIVE DIAGNOSIS:, Aortoiliac occlusive disease.,PROCEDURE PERFORMED:, Aortobifemoral bypass.,OPERATIVE FINDINGS: , The patient was taken to the operating room.  The abdominal contents were within normal limits.  The aorta was of normal size and consistency consistent with arteriosclerosis.  A 16x8 mm Gore-Tex graft was placed without difficulty.  The femoral vessels were small somewhat thin and there was posterior packing, but satisfactory bypass was performed.,PROCEDURE: , The patient was taken to the operating room, placed in a supine position, and prepped and draped in the usual sterile manner with Betadine solution.  A longitudinal incision was made after a Betadine-coated drape was placed over the incisional area.  Longitudinal incision was made over each groin initially and carried down to the subcutaneous fat and fascia.  Hemostasis was obtained with electrocautery.  The common deep and superficial femoral arteries were exposed and then these incisions were covered with antibiotic soaked sponges.  Attention was then turned to the abdomen, where a longitudinal incision was made from the pubis xiphoid, carried down subcutaneous fat and fascia.  Hemostasis was obtained with electrocautery.  The abdomen was entered above the umbilicus and then this was extended with care inferiorly as the patient has undergone previous abdominal surgery.  Mild adhesions were lysed.  The omentum was freed.  The small and large intestine were run with no evidence of abnormalities.  The liver and gallbladder were within normal limits.  No abnormalities were noted.  At this point, the Bookwalter retractor was placed.  NG tube was placed in the stomach and placed on suction.  The intestines were gently packed intraabdominally and laterally.  The rest of the peritoneum was then opened.  The aorta was cleared, both proximally and distally.  The left iliac was completely occluded.  The right iliac was to be cleansed.  At this point, 5000 units of aqueous heparin was administered to allow take effect.  The aorta was then clamped below the renal arteries and opened in a longitudinal fashion.  A single lumbar was ligated with #3-0 Prolene.  The inferior mesenteric artery was occluded intraluminally and required no suture closure.  Care was taken to preserve collaterals.  The aorta was measured, and a 16 mm Gore-Tex graft was brought on the field and anastomosed to the proximal aorta using #3-0 Prolene in a running fashion.  Last stitch was tied.  Hemostasis was excellent.  The clamp was gradually removed and additional Prolene was placed in the right posterolateral aspect to obtain better hemostasis.  At this point, strong pulses were present within the graft.  The limbs were vented and irrigated.  Using bimanual technique, the retroperitoneal tunnels were developed immediately on top of the iliac arteries into the groin.  The grafts were then brought through these, care being taken to avoid twisting of the graft.  At this point, the right iliac was then ligated using #0 Vicryl and the clamp was removed.  Hemostasis was excellent.  The right common femoral artery was then clamped proximally and distally, opened with #11 blade extended with Potts scissors.  The graft was _____ and anastomosed to the artery using #5-0 Prolene in a continuous fashion with a stitch _______ running fashion.  Prior to tying the last stitch, the graft and artery were vented and the last stitch was tied.  Flow was initially restored proximally then distally with good results.  Attention was then turned to the left groin and the artery grafts were likewise exposed, cleared proximally and distally.  The artery was opened, extended with a Potts scissors and anastomosis was performed with #5-0 Prolene again with satisfactory hemostasis.  The last stitch was tied.  Strong pulses were present within the artery and graft itself.  At this point, 25 mg of protamine was administered.  The wounds were irrigated with antibiotic solution.  The groins were repacked.  Attention was then returned to the abdomen.  The retroperitoneal area and the anastomotic sites were checked for bleeding and none was present.  The shell of the aorta was closed over the proximal anastomosis and the retroperitoneum was then repaired over the remaining portions of the graft.  The intraabdominal contents were then allowed to resume their normal position.  There was no evidence of ischemia to the large or small bowel.  At this point, the omentum and stomach were repositioned.  The abdominal wall was closed in a running single layer fashion using #1 PDS.  The skin was closed with skin staples.  The groins were again irrigated, closed with #3-0 Vicryl and #4-0 undyed Vicryl and Steri-Strips.  The patient was then taken into the recovery room in satisfactory condition after tolerating the procedure well.  Sponges and instrument counts were correct.  Estimated blood loss 900 cc.","surgery, aorta, bypass, arteriosclerosis, abdominal contents, aortoiliac occlusive disease, gore tex graft, aortobifemoral bypass, longitudinal incision, aortobifemoral, hemostasis, artery, graft, "
" Aortogram with bilateral, segmental lower extremity run off.  Left leg claudication.  The patient presents with lower extremity claudication. ", Surgery, Aortogram - Leg claudication. ,"PREPROCEDURE DIAGNOSIS:,  Left leg claudication.,POSTPROCEDURE DIAGNOSIS: ,  Left leg claudication.,OPERATION PERFORMED: , Aortogram with bilateral, segmental lower extremity run off.,ANESTHESIA: , Conscious sedation.,INDICATION FOR PROCEDURE:  ,The patient presents with lower extremity claudication.  She is a 68-year-old woman, who is very fearful of the aforementioned procedures.  Risks and benefits of the procedure were explained to her to include bleeding, infection, arterial trauma requiring surgery, access issues and recurrence.  She appears to understand and agrees to proceed.,DESCRIPTION OF PROCEDURE: , The patient was taken to the Angio Suite, placed in a supine position.  After adequate conscious sedation, both groins were prepped with Chloraseptic prep.  Cloth towels and paper drapes were placed.  Local anesthesia was administered in the common femoral artery and using ultrasound guidance, the common femoral artery was accessed.  Guidewire was threaded followed by a ,4-French sheath.  Through the 4-French sheath a 4-French Omni flush catheter was placed.  The glidewire was removed and contrast administered to identify the level of the renal artery.  Using power injector an aortogram proceeded.,The catheter was then pulled down to the aortic bifurcation.  A timed run-off view of both legs was performed and due to a very abnormal and delayed run-off in the left, I opted to perform an angiogram of the left lower extremity with an isolated approach.  The catheter was pulled down to the aortic bifurcation and using a glidewire, I obtained access to the contralateral left external iliac artery.  The Omni flush catheter was advanced to the left distal external iliac artery.  The glidewire rather exchanged for an Amplatz stiff wire.  This was left in place and the 4-French sheath removed and replaced with a 6-French destination 45-cm sheath.  This was advanced into the proximal superficial femoral artery and an angiogram performed.  I identified a functionally occluded distal superficial femoral artery and after obtaining views of the run off made plans for angioplasty.,The patient was given 5000 units of heparin and this was allowed to circulate.  A glidewire was carefully advanced using Roadmapping techniques through the functionally occluded blood vessels.  A 4-mm x 4-cm angioplasty balloon was used to dilate the area in question.,Final views after dilatation revealed a dissection.  A search for a 5-mm stent was performed, but none of this was available.  For this reason, I used a 6-mm x 80-mm marked stent and placed this at the distal superficial femoral artery.  Post dilatation was performed with a 4-mm angioplasty balloon.  Further views of the left lower extremity showed irregular change in the popliteal artery.  No significant stenosis could be identified in the left popliteal artery and noninvasive scan.  For this reason, I chose not to treat any further areas in the left leg.,I then performed closure of the right femoral artery with a 6-French Angio-Seal device.  Attention was turned to the left femoral artery and local anesthesia administered.  Access was obtained with the ultrasound and the femoral artery identified.  Guidewire was threaded followed by a 4-French sheath.  This was immediately exchanged for the 6-French destination sheath after the glidewire was used to access the distal external iliac artery.  The glidewire was exchanged for the Amplatz stiff wire to place the destination sheath.  The destination was placed in the proximal superficial femoral artery and angiogram obtained.  Initial views had been obtained from the right femoral sheath before removal.,Views of the right superficial femoral artery demonstrated significant stenosis with accelerated velocities in the popliteal and superficial femoral artery.  For this reason, I performed the angioplasty of the superficial femoral artery using the 4-mm balloon.  A minimal dissection plane measuring less than 1 cm was identified at the proximal area of dilatation.  No further significant abnormality was identified.  To avoid placing a stent in the small vessel I left it alone and approached the popliteal artery.  A 3-mm balloon was chosen to dilate a 50 to 79% popliteal artery stenosis.  Reasonable use were obtained and possibly a 4-mm balloon could have been used.  However, due to her propensity for dissection I opted not to.  I then exchanged the glidewire for an O1 for Thruway guidewire using an exchange length.  This was placed into the left posterior tibial artery.  A 2-mm balloon was used to dilate the orifice of the posterior tibial artery.  I then moved the wire to the perineal artery and dilated the proximal aspect of this vessel.  Final images showed improved run-off to the right calf.  The destination sheath was pulled back into the left external iliac artery and an Angio-Seal deployed.,FINDINGS: , Aortogram demonstrates a dual right renal artery with the inferior renal artery supplying the lower one third of the right renal parenchyma.  No evidence of renal artery stenosis is noted bilaterally.  There is a single left renal artery.  The infrarenal aorta, both common iliac and the external iliac arteries are normal.  On the right, a superficial femoral artery is widely patent and normal proximally.  At the distal third of the thigh there is diffuse disease with moderate stenosis noted.  Moderate stenosis is also noted in the popliteal artery and single vessel run-off through the posterior tibial artery is noted.  The perineal artery is functionally occluded at the midcalf.  The dorsal pedal artery filled by collateral at the high ankle level.,On the left, the proximal superficial femoral artery is patent.  Again, at the distal third of the thigh, there is a functional occlusion of the superficial femoral artery with poor collateralization to the high popliteal artery.  This was successfully treated with angioplasty and a stent placement.  The popliteal artery is diffusely diseased without focal stenosis.  The tibioperoneal trunk is patent and the anterior tibial artery occluded at its orifice.,IMPRESSION,1.  Normal bilateral renal arteries with a small accessory right renal artery.,2.  Normal infrarenal aorta as well as normal bilateral common and external iliac arteries.,3.  The proximal right renal artery is normal with moderately severe stenosis in the superficial femoral popliteal and tibial arteries.  Successful angioplasty with reasonable results in the distal superficial femoral, popliteal and proximal posterior tibial artery as described.,4.  Normal proximal left superficial femoral artery with functional occlusion of the distal left superficial femoral artery successfully treated with angioplasty and stent placement.  Run-off to the left lower extremity is via a patent perineal and posterior tibial artery.","surgery, claudication, extremity run off, angio suite, superficial femoral artery, popliteal, superficial, femoral, aortogram, artery, balloon, glidewire, angioplasty, stenosis, renal, "
" Rotated cuff tear, right shoulder.  Glenoid labrum tear.  Arthroscopy with arthroscopic glenoid labrum debridement, subacromial decompression, and rotator cuff repair, right shoulder.", Surgery, Arthroscopic Rotator Cuff Repair - 1 ,"PREOPERATIVE DIAGNOSIS: , Rotated cuff tear, right shoulder.,POSTOPERATIVE DIAGNOSES:,1.  Rotated cuff tear, right shoulder.,2.  Glenoid labrum tear.,PROCEDURE PERFORMED:,1.  Arthroscopy with arthroscopic glenoid labrum debridement.,2.  Subacromial decompression.,3.  Rotator cuff repair, right shoulder.,SPECIFICATIONS:,  Intraoperative procedure was done at Inpatient Operative Suite, room #1 at ABCD Hospital.  This was done under interscalene and subsequent general anesthetic in the modified beach chair position.,HISTORY AND GROSS FINDINGS: , The patient is a 48-year-old with male who has been suffering increasing right shoulder pain for a number of months prior to surgical intervention.  He was completely refractory to conservative outpatient therapy.  After discussing the alternative care as well as the advantages, disadvantages, risks, complications, and expectations, he elected to undergo the above stated procedure on this date.,Intraarticularly, the joint was observed.  There was noted to be a degenerative glenoid labrum tear.  The biceps complex was otherwise intact.  There were minimal degenerative changes at the glenohumeral joint.  Rotator cuff tear was appreciated on the inner surface.  Subacromially, the same was true.  This was an elliptical to V-type tear.  The patient has a grossly positive type III acromion.,OPERATIVE PROCEDURE: , The patient was laid supine on the operating table after receiving interscalene and then general anesthetic by the Anesthesia Department.  He was safely placed in modified beach chair position.  He was prepped and draped in the usual sterile manner.  Portals were created outside to end, posterior to anterior, and ultimately laterally in the typical fashion.  Upon complete diagnostic arthroscopy was carried out in the intraarticular aspect of the joint, a 4.2 meniscus shaver was placed anteriorly with the scope posteriorly.  Debridement was carried out to the glenoid labrum.  The biceps was probed and noted to be intact.  Undersurface of the rotator cuff was debrided with the shaver along with debridement of the subchondral region of the greater tuberosity attachment.,After this, instrumentation was removed.  The scope was placed subacromially and a lateral portal created.  Gross bursectomy was carried out in a stepwise fashion to the top part of the cuff as well as in the gutters.  An anterolateral portal was created.  Sutures were placed via express silk as well as other sutures with a #2 fiber wire.  With passing of the suture, they were tied with a slip-tight knot and then two half stitches.  There was excellent reduction of the tear.  Superolateral portal was then created.  A #1 Mitek suture anchor was then placed in the posterior cuff to bring this over to bleeding bone.  _______ suture was placed.  The implant was put into place.  The loop was grabbed and it was impacted in the previously drilled holes.  There was excellent reduction of the tear.,Trial range of motion was carried out and seemed to be satisfactory.,Prior to this, a subacromial decompression was accomplished after release of CA ligament with the vapor Bovie.  A 4.8 motorized barrel burr was utilized to sequentially take this down from the type III acromion to a flat type I acromion.,After all was done, copious irrigation was carried out throughout the joint.  Gross bursectomy lightly was carried out to remove all bony elements.  A pain buster catheter was placed through a separate portal and cut to length.  0.5% Marcaine was instilled after portals were closed with #4-0 nylon.  Adaptic, 4 x 4s, ABDs, and Elastoplast tape placed for dressing.  The patient was ultimately transferred to his cart and PACU in apparent satisfactory condition.  Expected surgical prognosis of this patient is fair.","surgery, subacromial decompression, rotator cuff repair, arthroscopic glenoid labrum debridement, arthroscopy, glenoid labrum tear, glenoid labrum, cuff, tear, arthroscopic, subacromial, decompression, debridement, rotator, glenoid, labrum, shoulder,"
 Aortic valve replacement using a mechanical valve and two-vessel coronary artery bypass grafting procedure using saphenous vein graft to the first obtuse marginal artery and left radial artery graft to the left anterior descending artery., Surgery, Aortic Valve Replacement ,"DIAGNOSIS: , Aortic valve stenosis with coronary artery disease associated with congestive heart failure.  The patient has diabetes and is morbidly obese.,PROCEDURES: , Aortic valve replacement using a mechanical valve and two-vessel coronary artery bypass grafting procedure using saphenous vein graft to the first obtuse marginal artery and left radial artery graft to the left anterior descending artery.,ANESTHESIA: , General endotracheal,INCISION: , Median sternotomy,INDICATIONS: , The patient presented with severe congestive heart failure associated with the patient's severe diabetes.  The patient was found to have moderately stenotic aortic valve.  In addition, The patient had significant coronary artery disease consisting of a chronically occluded right coronary artery but a very important large obtuse marginal artery coming off as the main circumflex system.  The patient also has a left anterior descending artery which has moderate disease and this supplies quite a bit of collateral to the patient's right system.  It was decided to perform a valve replacement as well as coronary artery bypass grafting procedure.,FINDINGS: , The left ventricle is certainly hypertrophied· The aortic valve leaflet is calcified and a severe restrictive leaflet motion.  It is a tricuspid type of valve.  The coronary artery consists of a large left anterior descending artery which is associated with 60% stenosis but a large obtuse marginal artery which has a tight proximal stenosis.,The radial artery was used for the left anterior descending artery.  Flow was excellent.  Looking at the targets in the posterior descending artery territory, there did not appear to be any large branches.  On the angiogram these vessels appeared to be quite small.  Because this is a chronically occluded vessel and the patient has limited conduit due to the patient's massive obesity, attempt to bypass to this area was not undertaken.  The patient was brought to the operating room,PROCEDURE: , The patient was brought to the operating room and placed in supine position.  A median sternotomy incision was carried out and conduits were taken from the left arm as well as the right thigh.  The patient weighs nearly three hundred pounds.  There was concern as to taking down the left internal mammary artery.  Because the radial artery appeared to be a good conduit The patient would have arterial graft to the left anterior descending artery territory.  The patient was cannulated after the aorta and atrium were exposed and full heparinization.,The patient went on cardiopulmonary bypass and the aortic cross-clamp was applied Cardioplegia was delivered through the coronary sinuses in a retrograde manner.  The patient was cooled to 32 degrees.  Iced slush was applied to the heart.  The aortic valve was then exposed through the aortic root by transverse incision.  The valve leaflets were removed and the #23 St. Jude mechanical valve was secured into position by circumferential pledgeted sutures.  At this point, aortotomy was closed.,The first obtuse marginal artery was a very large target and the vein graft to this target indeed produced an excellent amount of flow.  Proximal anastomosis was then carried out to the foot of the aorta.  The left anterior descending artery does not have severe disease but is also a very good target and the radial artery was anastomosed to this target in an end-to-side manner.  The two proximal anastomoses were then carried out to the root of the aorta.,The patient came off cardiopulmonary bypass after aortic cross-clamp was released.  The patient was adequately warmed.  Protamine was given without adverse effect.  Sternal closure was then done using wires.  The subcutaneous layers were closed using Vicryl suture.  The skin was approximated using staples.","surgery, coronary artery bypass grafting, saphenous vein graft, radial artery graft, coronary artery disease, congestive heart failure, descending artery territory, aortic cross clamp, aortic valve replacement, coronary artery bypass, obtuse marginal artery, anterior descending artery, mechanical valve, artery bypass, bypass grafting, marginal artery, radial artery, aortic valve, coronary artery, anterior descending, descending artery, valve, artery, aortic, grafting,"
 Laparoscopic appendectomy and peritoneal toilet and photos.  Pelvic inflammatory disease and periappendicitis., Surgery, Appendectomy - Laparoscopic  ,"PREOPERATIVE DIAGNOSIS:,  Acute appendicitis.,POSTOPERATIVE DIAGNOSES:,1.  Pelvic inflammatory disease.,2.  Periappendicitis.,PROCEDURE PERFORMED:,1.  Laparoscopic appendectomy.,2.  Peritoneal toilet and photos.,ANESTHESIA:  ,General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  Less than 10 cc.,INDICATIONS FOR PROCEDURE: , The patient is a 31-year-old African-American female who presented with right lower quadrant abdominal pain presented with acute appendicitis.  She also had mild leukocytosis with bright blood cell count of 12,000.  The necessity for diagnostic laparoscopy was explained and possible appendectomy.  The patient is agreeable to proceed and signed preoperatively informed consent.,PROCEDURE: , The patient was taken to the operative suite and placed in the supine position under general anesthesia by Anesthesia Department.,The preoperative Foley, antibiotics, and NG tube are placed for decompression and the anterior abdominal wall was prepped and draped in the usual sterile fashion and infraumbilical incision is performed with a #10 blade scalpel with anterior and superior traction on the abdominal wall.  A Veress needle was introduced and 15 mm pneumoperitoneum is created with CO2 insufflation.  At this point, the Veress needle was removed and a 10 mm trocar is introduced intraperitoneally.  A second 5 mm port was introduced in the right upper quadrant under direct visualization and blunted graspers were introduced to bring the appendix into view.  With the aid of a laparoscope, the pelvis was visualized.  The ovaries are brought in views and photos are taken.  There is evidence of a purulence in the cul-de-sac and ________ with a right ovarian hemorrhagic cyst.  Attention was then turned on the right lower quadrant.  The retrocecal appendix is freed with peritoneal adhesions removed with Endoshears.  Attention was turned to the suprapubic area.  The 12 mm port was introduced under direct visualization and the mesoappendix was identified.  A 45 mm endovascular stapling device was fired across the mesoappendix and the base of the appendix sequentially with no evidence of bleeding or leakage from the staple line.  Next, ________ tube was used to obtain Gram stain and cultures of the pelvic fluid and a pelvic toilet was performed with copious irrigation of sterile saline.  Next, attention was turned to the right upper quadrant.  There is evidence of adhesions from the liver surface to the anterior abdominal wall consistent with Fitz-Hugh-Curtis syndrome also a prior pelvic inflammatory disease.  All free fluid is aspirated and patient's all port sites are removed under direct visualization and the appendix is submitted to pathology for final pathology.  Once the ports are removed the pneumoperitoneum is allowed to escape for patient's postoperative comfort and two larger port sites at the suprapubic and infraumbilical sites are closed with #0 Vicryl suture on a UR-6 needle.  Local anesthetic is infiltrated at L3 port sites for postoperative analgesia and #4-0 Vicryl subcuticular closure is performed with undyed Vicryl.  Steri-Strips are applied along with sterile dressings.  The patient was awakened from anesthesia without difficulty and transferred to recovery room with postoperative broad-spectrum IV antibiotics in the General Medical Floor.  Routine postoperative care will be continued on this patient.","surgery, acute appendicitis, periappendicitis, peritoneal toilet, pelvic inflammatory disease, abdominal wall, direct visualization, toilet, appendectomy, mesoappendix, laparoscopic, port, inflammatory"
" Appendicitis, nonperforated.  Appendectomy.  A transverse right lower quadrant incision was made directly over the point of maximal tenderness. ", Surgery, Appendectomy ,"PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS:,  Appendicitis, nonperforated.,PROCEDURE PERFORMED:,  Appendectomy.,ANESTHESIA: , General endotracheal.,PROCEDURE: , After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table.  General endotracheal anesthesia was induced without incident.  The patient was prepped and draped in the usual sterile manner.,A transverse right lower quadrant incision was made directly over the point of maximal tenderness.  Sharp dissection utilizing Bovie electrocautery was used to expose the external oblique fascia.  The fascia of the external oblique was incised in the direction of the fibers, and the muscle was spread with a clamp.  The internal oblique fascia was similarly incised and its muscular fibers were similarly spread.  The transversus abdominis muscle, transversalis fascia and peritoneum were incised sharply gaining entrance into the abdominal cavity without incident.  Upon entering the peritoneal cavity, the peritoneal fluid was noted to be clean.,The cecum was then grasped along the taenia with a moist gauze sponge and was gently mobilized into the wound.  After the appendix was fully visualized, the mesentery was divided between Kelly clamps and ligated with 2-0 Vicryl ties.  The base of the appendix was crushed with a clamp and then the clamp was reapplied proximally on the appendix.  The base was ligated with 2-0 Vicryl tie over the crushed area, and the appendix amputated along the clamp.  The stump of the appendix was cauterized and the cecum was returned to the abdomen.,The peritoneum was irrigated with warm sterile saline.  The mesoappendix and cecum were examined for hemostasis which was present.  The wound was closed in layers using 2-0 Vicryl for the peritoneum and 0 Vicryl for the internal oblique and external oblique layers.  The skin incision was approximated with 4-0 Monocryl in a subcuticular fashion.  The skin was prepped with benzoin, and Steri-Strips were applied.  A dressing was placed on the wound.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition.","surgery, peritoneal cavity, peritoneal fluid, abdominal cavity, abdominis muscle, transversalis fascia, peritoneum, internal oblique fascia, vicryl ties, appendectomy, appendicitis, appendix,"
" Irrigation and debridement of skin, subcutaneous tissue, fascia and bone associated with an open fracture and placement of antibiotic-impregnated beads.  Open calcaneus fracture on the right.", Surgery, Antibiotic-Impregnated Beads Placement ,"PREOPERATIVE DIAGNOSIS:,  Open calcaneus fracture on the right.,POSTOPERATIVE DIAGNOSIS:,  Open calcaneus fracture on the right.,PROCEDURES:,  ,1.  Irrigation and debridement of skin, subcutaneous tissue, fascia and bone associated with an open fracture.,2.  Placement of antibiotic-impregnated beads.,ANESTHESIA:,  General.,BLOOD LOSS:,  Minimal.,COMPLICATIONS:,  None.,FINDINGS:,  Healing skin with no gross purulence identified, some fibrinous material around the beads.,SUMMARY:,  After informed consent was obtained and verified, the patient was brought to the operating room and placed supine on the operating table.  After uneventful general anesthesia was obtained, her right leg was sterilely prepped and draped in a normal fashion.  The tourniquet was inflated and the previous wound was opened.  Dr. X came in to look at the wound and the beads were removed, all 25 beads were extracted, and pulsatile lavage, and curette, etc., were used to debride the wound.  The wound margins were healthy with the exception of very central triangular incision area.  The edges were debrided and then 19 antibiotic-impregnated beads with gentamicin and tobramycin were inserted and the wound was further closed today.,The skin edges were approximated under minimal tension.  The soft dressing was placed.  An Ace was placed.  She was awakened from the anesthesia and taken to recovery room in a stable condition.  Final needle, instrument, and sponge counts were correct.","surgery, open calcaneus fracture, irrigation and debridement, antibiotic impregnated beads, irrigation, subcutaneous, placement, debridement, calcaneus, fracture, wound, beads, antibiotic"
 Dementia and aortoiliac occlusive disease bilaterally.  Aortobifemoral bypass surgery utilizing a bifurcated Hemashield graft., Surgery, Aortobifemoral Bypass - 1 ,"PREOPERATIVE DIAGNOSIS,1.  Aortoiliac occlusive disease bilaterally.,2.  Dementia.,POSTOPERATIVE DIAGNOSIS,1.  Aortoiliac occlusive disease bilaterally.,2.  Dementia.,OPERATION: , Aortobifemoral bypass surgery utilizing a bifurcated Hemashield graft.,ANESTHESIA:,  General endotracheal,ESTIMATED BLOOD LOSS: , 300 cc,INTRAVENOUS FLUIDS: , 1200 cc of crystalloid,URINE OUTPUT: , 250 cc,OPERATION IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered.  Note that previously the patient was found to have some baseline dementia, although slight.  The patient was seen and evaluated by the neurology team, who cleared the patient for surgery.  The patient was taken to the operating room and general endotracheal anesthesia was administered.  The abdomen was prepped and draped in the standard surgical fashion.  We first began our dissection by using a #10-blade scalpel to incise the skin over the femoral artery in the groin bilaterally.  Dissection was carried down to the level of the femoral vessels using Bovie electrocautery.  The common femoral, superficial femoral, and profunda femoris arteries were encircled and dissected out peripherally.  Vessel loops were placed around the aforementioned arteries.  After doing so, we turned our attention to beginning our abdominal dissection.  We used a #10-blade scalpel to make a midline laparotomy incision.  Dissection was carried down to the level of the fascia using Bovie electrocautery.  The abdomen was opened and an Omni retractor was positioned.  The aorta was dissected out in the abdomen.  The left femoral vein was identified.  There was a nicely clampable portion of aorta visible.  We, as mentioned, placed our Omni retractor and then turned our attention to performing our anastomosis.  Full-dose heparin was given.  Next, vascular clamps were applied to the iliac vessels as well as to the proximal aorta just below the renal vessels.  A #11-blade scalpel was used to make an arteriotomy in the aorta, which was lengthened both proximally and distally using Potts scissors.  We then beveled our proximal graft and constructed an end graft-to-side artery anastomosis using 3-0 Prolene in a running fashion.  Upon completion of our anastomosis, we flushed our graft and noted there was no evidence of a leak from the newly constructed anastomosis.  We then created our tunnels over the iliac vessels.  We pulled the distal limbs over our ABF graft into the groin.  We then proceeded to perform our right anastomosis first.  We applied vascular clamps on the proximal common femoral, profunda, and superficial femoral arteries.  We incised the common femoral artery and lengthened our arteriotomy in the vessel both proximally and distally.  We then footed the graft down onto the common femoral artery to the level of the SFA and constructed our anastomosis using 6-0 Prolene in a running fashion.  Upon completion of our anastomosis, we flushed the common femoral, SFA, and profunda femoris arteries.  We then removed our clamp.  We opened the limb more proximally in the abdomen on the right side.  We then turned our attention to the left side and similarly placed our vascular clamps.  We used a #11-blade scalpel to make an arteriotomy in the vessel.  We then lengthened our arteriotomy both proximally and distally again onto the SFA.  We constructed a footed end graft-to-side artery anastomosis using 6-0 Prolene in a running fashion.  Upon completion of our anastomosis, we opened our clamps.  There was no noticeable leak from the newly constructed anastomosis.  We checked our proximal graft to aortic anastomosis, which was noted to be in good condition.  We then gave full-dose protamine.  We closed the peritoneum over the graft with 4-0 Vicryl in a running fashion.  The abdomen was closed with #1 nylon in a running fashion.  The skin was closed with subcuticular 4-0 Monocryl in a running subcuticular fashion.  The instrument and sponge count was correct at end of case.  Patient tolerated the procedure well and was transferred to the intensive care unit in good condition.","surgery, bifurcated, hemashield graft, aortoiliac occlusive disease, aortobifemoral bypass, vascular clamps, common femoral, graft, femoral, anastomosis, aortobifemoral, aortoiliac, proximal, arteriotomy, bypass, artery, endotracheal, vessels,"
 Anterior cervical discectomy for neural decompression and anterior interbody fusion C5-C6 utilizing Bengal cage.  , Surgery, Anterior Cervical Discectomy & Interbody Fusion - 3 ,"PREOPERATIVE DIAGNOSES:,  ,1.  Spondylosis with cervical stenosis C5-C6 greater than C4-C5, C6-C7, (721.0, 723.0).,2.  Neck pain with left radiculopathy, progressive (723.1/723.4).,3.  Headaches, progressive (784.0).,POSTOPERATIVE DIAGNOSES:,  ,1.  Spondylosis with cervical stenosis C5-C6 greater than C4-C5, C6-C7, (721.0, 723.0).,2.  Neck pain with left radiculopathy, progressive (723.1/723.4).,3.  Headaches, progressive (784.0).,PROCEDURES:,  ,1.  Anterior cervical discectomy at C5-C6 for neural decompression (63075).,2.  Anterior interbody fusion C5-C6 (22554) utilizing Bengal cage (22851).,3.  Anterior cervical instrumentation at C5-C6 for stabilization by Uniplate construction at C5-C6 (22845); with intraoperative x-ray x2.,SERVICE:  ,  Neurosurgery,ANESTHESIA:,","surgery, spondylosis, neck pain, headaches, decompression, uniplate, anterior cervical discectomy, neural decompression, cervical stenosis, prevertebral space, antibiotic solution, cervical discectomy, interbody fusion, bengal cage, interbody, anterior, cervical, discectomy,"
 Anterior cervical discectomy with spinal cord and spinal canal decompression and Anterior interbody fusion at C5-C6 utilizing Bengal cage., Surgery, Anterior Cervical Discectomy & Interbody Fusion - 2 ,"PREOPERATIVE DIAGNOSES:  ,1.  Large herniated nucleus pulposus, C5-C6 with myelopathy (722.21).,2.  Cervical spondylosis.,3.  Cervical stenosis, C5-C6 secondary to above (723.0).,POSTOPERATIVE DIAGNOSES:  ,1.  Large herniated nucleus pulposus, C5-C6 with myelopathy (722.21).,2.  Cervical spondylosis.,3.  Cervical stenosis, C5-C6 secondary to above (723.0), with surgical findings confirmed.,PROCEDURES: , ,1.  Anterior cervical discectomy at C5-C6 with spinal cord and spinal canal decompression (63075).,2.  Anterior interbody fusion at C5-C6, (22554) utilizing Bengal cage (22851).,3.  Anterior instrumentation for stabilization by Uniplate construction, C5-C6, (22845); with intraoperative x-ray times two.,ANESTHESIA: , General.,SERVICE: , Neurosurgery.,OPERATION:  ,The patient was brought into the operating room, placed in a supine position where general anesthesia was administered.  Then the anterior aspect of the neck was prepped and draped in a routine sterile fashion.  A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma, which was dissected only in a subplatysmal manner bluntly, and with only blunt dissection at the prevertebral space where a localizing intraoperative x-ray was obtained, once self-retaining retractors were placed along the mesial edge of a cauterized longus colli muscle, to protect surrounding tissues throughout the remainder of the case.  A prominent anterior osteophyte at C5-C6 was then localized, compared to preoperative studies in the usual fashion intraoperatively, and the osteophyte was excised with a rongeur and bony fragments saved.  This allowed for an annulotomy, which was carried out with a #11 blade and discectomy, removed with straight disc forceps portions of the disc, which were sent to Pathology for a permanent section.  Residual osteophytes and disc fragments were removed with 1 and 2-mm micro Kerrison rongeurs as necessary as drilling extended into normal cortical and cancellous elements widely laterally as well.  A hypertrophied ligament and prominent posterior spurs were excised as well until the dura bulged into the interspace, a sign of a decompressed status.  At no time during the case was evidence of CSF leakage, and hemostasis was readily achieved with pledgets of Gelfoam subsequently removed with copious amounts of antibiotic irrigation.  Once the decompression was inspected with a double ball dissector and all found to be completely decompressed, and the dura bulged at the interspace, and pulsated, then a Bengal cage was filled with the patient's own bone elements and fusion putty and countersunk into position, and was quite tightly applied.  Further stability was added nonetheless with an appropriate size Uniplate, which was placed of appropriate size with appropriate size screws and these were locked into place in the usual manner.  The wound was inspected, and irrigated again with antibiotic solution and after further inspection was finally closed in a routine closure in a multiple layer event by first approximation of the platysma with interrupted 3-0 Vicryl, and the skin with a subcuticular stitch of 4-0 Vicryl, and this was Steri-Stripped for reinforcement, and a sterile dressing was applied, incorporating a Penrose drain, which was carried from the prevertebral space externally to the skin wound and safety pin for security in the usual manner.  Once the sterile dressing was applied, the patient was taken from the operating room to the recovery area having left in stable condition.,At the conclusion of the case, all instruments, needle, and sponge counts were accurate and correct, and there were no intraoperative complications of any type.","surgery, herniated nucleus pulposus, myelopathy, cervical spondylosis, cervical stenosis, anterior instrumentation, uniplate, decompression, anterior cervical discectomy, spinal cord, spinal canal, sterile dressing, interbody fusion, bengal cage, interbody, cervical, anterior, discectomy,"
" Anterior lumbar fusion, L4-L5, L5-S1, PEEK vertebral spacer, structural autograft from L5 vertebral body, BMP and anterior plate.  Severe low back pain.", Surgery, Anterior Lumbar Fusion ,"PREOPERATIVE DIAGNOSIS: , Severe low back pain.,POSTOPERATIVE DIAGNOSIS: , Severe low back pain.,OPERATIONS PERFORMED: , Anterior lumbar fusion, L4-L5, L5-S1, PEEK vertebral spacer, structural autograft from L5 vertebral body, BMP and anterior plate.,ANESTHESIA:,  General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 50 mL.,DRAINS:,  None.,COMPLICATIONS: , None.,PATHOLOGICAL FINDINGS:,  Dr. X made the approach and once we were at the L5-S1 disk space, we removed the disk and we placed a 13-mm PEEK vertebral spacer filled with a core of bone taken from the L5 vertebral body.  This was filled with a 15 x 20-mm Chronos VerteFill tricalcium phosphate plug.  At L4-L5, we used a 13-mm PEEK vertebral spacer with structural autograft and BMP, and then we placed a two-level 87-mm Integra sacral plate with 28 x 6-mm screws, two each at L4 and L5 and 36 x 6-mm screws at S1.,OPERATION IN DETAIL:,  The patient was placed under general endotracheal anesthesia.  The abdomen was prepped and draped in the usual fashion.  Dr. X made the approach, and once the L5-S1 disk space was identified, we incised this with a knife and then removed a large core of bone taking rotating cutters.  I was able to remove additional disk space and score the vertebral bodies.  The rest of the disk removal was done with the curette, scraping the endplates.  I tried various sized spacers, and at this point, we exposed the L5 body and took a dowel from the body and filled the hole with a 15 x 20-mm Chronos VerteFill tricalcium phosphate plug.  Half of this was used to fill the spacer at L5-S1, BMP was placed in the spacer as well and then it was tapped into place.  We then moved the vessels over the opposite way approaching the L4-L5 disk space laterally, and the disk was removed in a similar fashion and we also used a 13-mm PEEK vertebral spacer, but this is the variety that we could put in from one side.  This was filled with bone and BMP as well.  Once this was done, we were able to place an 87-mm Integra sacral plate down over the three vertebral bodies and place these screws.  Following this, bleeding points were controlled and Dr. X proceeded with the closure of the abdomen.,SUMMARY: , This is a 51-year-old man who reports 15-year history of low back pain and intermittent bilateral leg pain and achiness.  He has tried multiple conservative treatments including physical therapy, epidural steroid injections, etc.  MRI scan shows a very degenerated disk at L5-S1, less so at L3-L4 and L4-L5.  A discogram was positive with the lower 3 levels, but he has pain, which starts below the iliac crest and I feel that the L3-L4 disk is probably that symptomatic.  An anterior lumbar interbody fusion was suggested.  Procedure, risks, and complications were explained.","surgery, peek vertebral spacer, autograft, anterior lumbar fusion, lumbar fusion, vertebral body, vertebral spacer, vertebral, spacer, anterior, lumbar, fusion,"
 Arthroscopy of the left knee was performed with the anterior cruciate ligament reconstruction.  Removal of loose bodies.  Medial femoral chondroplasty and meniscoplasty., Surgery, Anterior Cruciate Ligament Reconstruction ,"PREOPERATIVE DIAGNOSIS: , Anterior cruciate ligament rupture.,POSTOPERATIVE DIAGNOSES:,1.  Anterior cruciate ligament rupture.,2.  Medial meniscal tear.,3.  Medial femoral chondromalacia.,4.  Intraarticular loose bodies.,PROCEDURE PERFORMED:,1.  Arthroscopy of the left knee was performed with the anterior cruciate ligament reconstruction.,2.  Removal of loose bodies.,3.  Medial femoral chondroplasty.,4.  Medial meniscoplasty.,OPERATIVE PROCEDURE:  ,The patient was taken to the operative suite, placed in supine position, and administered a general anesthetic by the Department of Anesthesia.  Following this, the knee was sterilely prepped and draped as discussed for this procedure.  The inferolateral and inferomedial portals were then established; however, prior to this, a graft was harvested from the semitendinosus and gracilis region.  After the notch was identified, then ACL was confirmed and ruptured.  There was noted to be a torn, slipped up area of the medial meniscus, which was impinging and impinged on the articular surface.  The snare was smoothed out.  Entire area was thoroughly irrigated.  Following this, there was noted in fact to be significant degenerative changes from this impingement of the meniscus again to the periarticular cartilage.  The areas of the worn away portion of the medial femoral condyle was then debrided and ________ chondroplasty was then performed of this area in order to stimulate bleeding and healing.  There were multiple loose bodies noted in the knee and these were then __________ and then removed.  The tibial and femoral drill holes were then established and the graft was then put in place, both which locations after a notchplasty was performed.  The knee was taken through a full range of motion without any impingement.  An Endobutton was used for proximal fixation.  Distal fixation was obtained with an independent screw and a staple.  The patient was then taken to Postanesthesia Care Unit at the conclusion of the procedure.,","surgery, femoral chondroplasty, intraarticular loose bodies, anterior cruciate ligament reconstruction, anterior, arthroscopy, meniscoplasty, fixation, reconstruction, chondroplasty, ligament, femoral, intraarticular, medial"
" C5-C6 anterior cervical discectomy, allograft fusion, and anterior plating.", Surgery, Anterior Cervical Discectomy & Fusion - 8 ,"PROCEDURES PERFORMED: , C5-C6 anterior cervical discectomy, allograft fusion, and anterior plating.,ESTIMATED BLOOD LOSS: , 10 mL.,CLINICAL NOTE: , This is a 57-year-old gentleman with refractory neck pain with single-level degeneration of the cervical spine and there was also some arm pain.  We decided go ahead with anterior cervical discectomy at C5-C6 and fusion.  The risks of lack of pain relief, paralysis, hoarse voice, nerve injuries, and infection were explained and the patient agreed to proceed.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room where a general endotracheal anesthesia was induced without complication.  The patient was placed in the slightly extended position with the neck and the head was restrained in a doughnut and the occiput was restrained by the doughnut.  He had tape placed over the shoulders during intraoperative x-rays and his elbows were well padded.  The tape was placed and his arms were well padded.  He was prepped and draped in a sterile fashion.  A linear incision was fashioned at the cricothyroid level from near the midline to over the sternocleidomastoid muscle.  We separated the platysma from the subcutaneous tissue and then opened the platysma along the medial border of the sternocleidomastoid muscle.  We then dissected sharply medial to carotid artery, which we palpated to the prevertebral region.  We placed Caspar retractors for medial and lateral exposure over the C5-C6 disc space, which we confirmed with the lateral cervical spine x-ray including 18-gauge needle in the disc space.  We then marked the disc space.  We then drilled off ventral osteophyte as well as osteophyte creating concavity within the disc space.  We then under magnification removed all the disc material, we could possibly see down to bleeding bone and both the endplates.  We took down posterior longitudinal ligament as well.  We incised the 6-mm cornerstone bone.  We placed a 6-mm parallel medium bone nicely into the disc space.  We then sized a 23-mm plate.  We inserted the screws nicely above and below.  We tightened down the lock-nuts.  We irrigated the wound.  We assured hemostasis using bone wax prior to placing the plate.  We then assured hemostasis once again.  We reapproximated the platysma using 3-0 Vicryl in a simple interrupted fashion.  The subcutaneous level was closed using 3-0 Vicryl in a simple buried fashion.  The skin was closed with 3-0 Monocryl in a running subcuticular stitch.  Steri-Strips were applied.  Dry sterile dressing with Telfa was applied over this.  We obtained an intraoperative x-ray to confirm the proper level and good position of both plates and screw construct on the lateral x-ray and the patient was transferred to the recovery room, moving all four extremities with stable vital signs.  I was present as a primary surgeon throughout the entire case.","surgery, allograft fusion, anterior cervical discectomy, neck pain, cervical spine, discectomy, fusion, sternocleidomastoid muscle, assured hemostasis, anterior cervical, cervical discectomy, disc space, cervical, anterior, allograft"
 Anterior cervical discectomy and osteophytectomy.  Application of prosthetic interbody fusion device.  Anterior cervical interbody arthrodesis.  Anterior cervical instrumentation, Surgery, Anterior Cervical Discectomy & Osteophytectomy ,"PREOPERATIVE DIAGNOSES,1.  Cervical radiculopathy, C5-C6 and C6-C7.,2.  Symptomatic cervical spondylosis, C5-C6 and C6-C7.,3.  Symptomatic cervical stenosis, C5-C6 and C6-C7.,4.  Symptomatic cervical disc herniations, C5-C6 and C6-C7.,POSTOPERATIVE DIAGNOSES,1.  Cervical radiculopathy, C5-C6 and C6-C7.,2.  Symptomatic cervical spondylosis, C5-C6 and C6-C7.,3.  Symptomatic cervical stenosis, C5-C6 and C6-C7.,4.  Symptomatic cervical disc herniations, C5-C6 and C6-C7.,OPERATIVE PROCEDURE,1.  CPT code 63075:  Anterior cervical discectomy and osteophytectomy, C5-C6.,2.  CPT code 63076:  Anterior cervical discectomy and osteophytectomy, C6-C7, additional level.,3.  CPT code 22851:  Application of prosthetic interbody fusion device, C5-C6.,4.  CPT code 22851-59:  Application of prosthetic interbody fusion device, C6-C7, additional level.,5.  CPT code 22554-51:  Anterior cervical interbody arthrodesis, C5-C6.,6.  CPT code 22585:  Anterior cervical interbody arthrodesis, C6-C7, additional level.,7.  CPT code 22845:  Anterior cervical instrumentation, C5-C7.,ANESTHESIA:,  General endotracheal.,ESTIMATED BLOOD LOSS:  ,Negligible.,DRAINS: , Small suction drain in the cervical wound.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL:,  The patient was given intravenous antibiotic prophylaxis and thigh-high TED hoses were placed on the lower extremities while in the preanesthesia holding area.  The patient was transported to the operative suite and on to the operative table in the supine position.  General endotracheal anesthesia was induced.  The head was placed on a well-padded head holder.  The eyes and face were protected from pressure.  A well-padded roll was placed beneath the neck and shoulders to help preserve the cervical lordosis.  The arms were tucked and draped to the sides.  All bony prominences were well padded.  An x-ray was taken to confirm the correct level of the skin incision.  The anterior neck was then prepped and draped in the usual sterile fashion.,A straight transverse skin incision over the left side of the anterior neck was made and carried down sharply through the skin and subcutaneous tissues to the level of the platysma muscle, which was divided transversely using the electrocautery.  The superficial and deep layers of the deep cervical fascia were divided.  The midline structures were reflected to the right side.  Care was taken during the dissection to avoid injury to the recurrent laryngeal nerve and the usual anatomical location of that nerve was protected.  The carotid sheath was palpated and protected laterally.  An x-ray was taken to confirm the level of C5-C6 and C6-C7.,The longus colli muscle was dissected free bilaterally from C5 to C7 using blunt dissection.  Hemostasis was obtained using the electrocautery.  The blades of the cervical retractor were placed deep to the longus colli muscles bilaterally.  At C5-C6, the anterior longitudinal ligament was divided transversely.  Straight pituitary rongeurs and a curette were used to remove the contents of the disc space.  All cartilages were scraped off the inferior endplate of C5 and from the superior endplate of C6.  The disc resection was carried posteriorly to the posterior longitudinal ligament and laterally to the uncovertebral joints.  The posterior longitudinal ligament was resected using a 1 mm Kerrison rongeur.  Beginning in the midline and extending into both neural foramen, posterior osteophytes were removed using a 1 m and a 2 mm Kerrison rongeurs.  The patient was noted to have significant bony spondylosis causing canal and foraminal stenosis as well as a degenerative and protruding disc in agreement with preoperative diagnostic imaging studies.  Following completion of the discectomy and osteophytectomy, a blunt nerve hook was passed into the canal superiorly and inferiorly as well as in the both neural foramen to make sure that there were no extruded disc fragments and to make sure the bony decompression was complete.  A portion of the uncovertebral joint was resected bilaterally for additional nerve root decompression.  Both nerve roots were visualized and noted to be free of encroachment.  The same procedure was then carried out at C6-C7 with similar findings.  The only difference in the findings was that at C6-C7 on the left side, the patient was found to have an extruded disc fragment in the canal and extending into the left side neural foramen causing significant cord and nerve root encroachment.,In preparation for the arthrodesis, the endplates of C5, C6, and C7 were burred in a parallel fashion down to the level of bleeding bone using a high-speed cutting bur with irrigant solution for cooling.  The disc spaces were then measured to the nearest millimeter.  Attention was then turned toward preparation of the structural allograft, which consisted of two pieces of pre-machined corticocancellous bone.  The grafts were further shaped to fit the disc spaces exactly in a press-fit manner with approximately 1.5 mm of distraction at each disc space.  The grafts were shaped to be slightly lordotic to help preserve the cervical lordosis.  The grafts were impacted into the disc spaces.  There was complete bony apposition between the ends of the bone grafts and the vertebral bodies of C5, C6, and C7.  A blunt nerve hook was passed posterior to each bone graft to make sure that the bone grafts were in good position.  Anterior osteophytes were removed using a high-speed cutting bur with irrigant solution for cooling.  An appropriate length Synthes cervical plate was selected and bent slightly to conform to the patient's cervical lordosis.  The plate was held in the midline with provided instrumentation while a temporary fixation screw was applied at C6.  Screw holes were then drilled using the provided drill and drill guide taking care to avoid injury to neurovascular structures.  The plate was then rigidly fixed to the anterior spine using 14-mm cancellous screws followed by locking setscrews added to the head of each screw to prevent postoperative loosening of the plate and/or screws.,An x-ray was taken, which confirmed satisfactory postioning of the plate, screws, and bone grafts.,Blood loss was minimal.  The wound was irrigated with irrigant solution containing antibiotics.  The wound was inspected and judged to be dry.  The wound was closed over a suction drain placed in the deepest portion of the wound by reapproximating the platysma muscle with #4-0 Vicryl running suture, the subdermal and subcuticular layers with #4-0 Monocryl interrupted sutures, and the skin with Steri-Strips.  The sponge and needle count were correct.  A sterile dressing was applied to the wound.  The neck was placed in a cervical orthosis.  The patient tolerated the procedure and was transferred to the recovery room in stable condition.",
" Anterior cervical discectomy with decompression, C5-C6, arthrodesis with anterior interbody fusion, C5-C6, spinal instrumentation, C5-C6 using Pioneer 18-mm plate and four 14 x 4.0 mm screws (all titanium), implant using PEEK 7 mm, and Allograft using Vitoss.", Surgery, Anterior Cervical Discectomy & Interbody Fusion ,"PREOPERATIVE DIAGNOSES,1.  Neck pain with bilateral upper extremity radiculopathy, left more than the right.,2.  Cervical spondylosis with herniated nucleus pulposus, C5-C6.,POSTOPERATIVE DIAGNOSES,1.  Neck pain with bilateral upper extremity radiculopathy, left more than the right.,2.  Cervical spondylosis with herniated nucleus pulposus, C5-C6.,OPERATIVE PROCEDURES,1.  Anterior cervical discectomy with decompression, C5-C6.,2.  Arthrodesis with anterior interbody fusion, C5-C6.,3.  Spinal instrumentation, C5-C6 using Pioneer 18-mm plate and four 14 x 4.0 mm screws (all titanium).,4.  Implant using PEEK 7 mm.,5.  Allograft using Vitoss.,DRAINS: , Round French 10 JP drain.,FLUIDS:  ,1200 cc of crystalloids.,URINE OUTPUT: , No Foley catheter.,SPECIMENS: , None.,COMPLICATIONS: , None.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,INDICATIONS FOR THE OPERATION:,  This is a case of a very pleasant 38-year-old Caucasian female who has been complaining over the last eight years of neck pain and shoulder pain radiating down across the top of her left shoulder and also across her shoulder blades to the right side, but predominantly down the left upper extremity into the wrist.  The patient has been diagnosed with fibromyalgia and subsequently, has been treated with pain medications, anti-inflammatories and muscle relaxants.  The patient's symptoms continued to persist and subsequently, an MRI of the C-spine was done, which showed disc desiccation, spondylosis and herniated disk at C5-C6, an EMG and CV revealed a presence of mild-to-moderate carpal tunnel syndrome.  The patient is now being recommended to undergo decompression and spinal instrumentation and fusion at C5-C6.  The patient understood the risks and benefits of the surgery.  Risks include but not exclusive of bleeding and infection.  Bleeding can be in the form of soft tissue bleeding, which may compromise airway for which she can be brought emergently back to the operating room for emergent evacuation of the hematoma as this may cause weakness of all four extremities, numbness of all four extremities, as well as impairment of bowel and bladder function.  This could also result in dural tear with its attendant symptoms of headache, nausea, vomiting, photophobia, and posterior neck pain as well as the development of pseudomeningocele.  Should the symptoms be severe or the pseudomeningocele be large, she can be brought back to the operating room for repair of the CSF leak and evacuation of the pseudomeningocele.  There is also the risk of pseudoarthrosis and nonfusion, for which she may require redo surgery at this level.  There is also the possibility of nonimprovement of her symptoms in about 10% of cases.  The patient understands this risk on top of the potential injury to the esophagus and trachea as well as the carotid artery.  There is also the risk of stroke, should an undiagnosed plaque be propelled into the right cerebral circulation.  The patient also understands that there could be hoarseness of the voice secondary to injury to the recurrent laryngeal nerve.  She understood these risks on top of the risks of anesthesia and gave her consent for the procedure.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room, awake, alert and not in any form of distress.  After smooth induction and intubation, the patient was positioned supine on the operating table with the neck placed on hyperextension and the head supported on a foam doughnut.  A marker was placed.  This verified the level to be at the C5-C6 level and incision was then marked in a transverse fashion starting from the midline extending about 5 mm beyond the anterior border of the sternocleidomastoid muscle.  The area was then prepped with DuraPrep after the head was turned 45 degrees to the left.,After sterile drapes were laid out, an incision was made using a scalpel blade #10.  Wound edge bleeders were carefully controlled with bipolar coagulation and the platysma was cut using a hot knife in a transverse fashion.  Dissection was then carried underneath the platysma superiorly inferiorly.  The anterior border of the sternocleidomastoid was identified and dissection was carried out lateral to the esophagus to trachea as well as medial to the carotid sheath in the sternocleidomastoid muscle.  The prevertebral fascia was noted to be taken her case with a lot of fat deposition.  Bipolar coagulation of bleeders was done; however, branch of the superior thyroid artery was ligated with Hemoclips x4.  After this was completed, a localizing x-ray verified the marker to be at the C6-C7 level.  We proceeded to strip the longus colli muscles off the vertebral body of the C5 and C6.  Self-retaining retractor was then laid down.  An anterior osteophyte was carefully drilled using a Midas 5-mm bur and the disk together with the inferior endplate of C5 and the superior endplate of C6 was also drilled down with the Midas 5-mm bur.  This was later followed with a 3-mm bur and the disk together with posterior longitudinal ligament was removed using Kerrison's ranging from 1 to 4 mm.  The herniation was noted on the right.  However, there was significant neuroforaminal stenosis on the left.  Decompression on both sides was done and after this was completed, a Valsalva maneuver showed no evidence of any CSF leakage.  The area was then irrigated with saline with bacitracin solution.  A 7 mm implant with its inferior packed with Vitoss was then laid down and secured in place with four 14 x 4.0 mm screws and plate 18 mm, all of which were titanium.  X-ray after this placement showed excellent position of all these implants and screws and _____ and the patient's area was also irrigated with saline with bacitracin solution.  A round French 10 JP drain was then laid down and exteriorized through a separate stab incision on the patient's right inferiorly.  The catheter was then anchored to the skin with a nylon 3-0 stitch and connected to a sterile draining system.  The wound was then closed in layers with Vicryl 3-0 inverted interrupted sutures for the platysma, Vicryl subcuticular 4-0 Stitch for the dermis, and the wound was reinforced with Dermabond.  Dressing was placed only at the exit site of the catheter.  C-collar was placed.  The patient was extubated and transferred to recovery.",
" C4-C5, C5-C6 anterior cervical discectomy and fusion.  The patient is a 62-year-old female who presents with neck pain as well as upper extremity symptoms.  Her MRI showed stenosis at portion of C4 to C6.", Surgery, Anterior Cervical Discectomy & Fusion - 7 ,"PREOPERATIVE DIAGNOSIS:,  C4-C5, C5-C6 stenosis.,PREOPERATIVE DIAGNOSIS: , C4-C5, C5-C6 stenosis.,PROCEDURE: , C4-C5, C5-C6 anterior cervical discectomy and fusion.,COMPLICATIONS: , None.,ANESTHESIA: , General.,INDICATIONS OF PROCEDURE: , The patient is a 62-year-old female who presents with neck pain as well as upper extremity symptoms.  Her MRI showed stenosis at portion of C4 to C6.  I discussed the procedure as well as risks and complications.  She wishes to proceed with surgery.  Risks will include but are not limited to infection, hemorrhage, spinal fluid leak, worsened neurologic deficit, recurrent stenosis, requiring further surgery, difficulty with fusion requiring further surgery, long-term hoarseness of voice, difficulty swallowing, medical anesthesia risk.,PROCEDURE:  ,The patient was taken to the operating room on 10/02/2007.  She was intubated for anesthesia.  TEDS and boots as well as Foley catheter were placed.  She was placed in a supine position with her neck in neutral position.  Appropriate pads were also used.  The area was prepped and draped in usual sterile fashion.  Preoperative localization was taken.  _____ not changed.  Incision was made on the right side in transverse fashion over C5 vertebral body level.  This was made with a #10 blade knife and further taken down with pickups and scissors.  The plane between the esophagus and carotid artery was carefully dissected both bluntly and sharply down to the anterior aspect of the cervical spine.  Intraoperative x-ray was taken.  Longus colli muscles were retracted laterally.  Caspar retractors were used.  Intraoperative x-ray was taken.  I first turned by attention at C5-C6 interspace.  This was opened with #15 blade knife.  Disc material was taken out using pituitary as well as Kerrison rongeur.  Anterior aspects were taken down.  End plates were arthrodesed using curettes.  This was done under distraction.  Posterior longitudinal ligament was opened with a nerve hook and Kerrison rongeur.  Bilateral foraminotomies were done.  At this point, I felt that there was a good decompression.  The foramen appeared to be opened.  Medtronic cage was then encountered and sent few millimeters.  This was packed with demineralized bone matrix.  The distraction was then taken down.  The cage appeared to be strong.  This procedure was then repeated at C4-C5.  A 42-mm AcuFix plate was then placed between C4 and C6.  This was carefully screwed and locked.  The instrumentation appeared to be strong.  Intraoperative x-ray was taken.  Irrigation was used.  Hemostasis was achieved.  The platysmas was closed with 3-0 Vicryl stitches.  The subcutaneous was closed with 4-0 Vicryl stitches.  The skin was closed with Steri-strips.  The area was clean and dry and dressed with Telfa and Tegaderm.  Soft cervical collar was placed for the patient.  She was extubated per anesthesia and brought to the recovery in stable condition.","surgery, anterior cervical discectomy, fusion, infection, hemorrhage, spinal fluid leak, anesthesia, foley catheter, teds, anterior cervical, cervical discectomy, anterior, cervical, discectomy, stenosis,"
" Anterior cervical discectomy for neural decompression and anterior interbody fusion at C4-C5, C5-C6, and C6-C7 utilizing Bengal cages times three.", Surgery, Anterior Cervical Discectomy & Interbody Fusion - 1 ,"PREOPERATIVE DIAGNOSES:  ,1.  Herniated nucleus pulposus, C5-C6, greater than C6-C7 and C4-C5 with left radiculopathy.,2.  Cervical stenosis with cord compression, C5-C6 (723.0).,POSTOPERATIVE DIAGNOSES:  ,1.  Herniated nucleus pulposus, C5-C6, greater than C6-C7 and C4-C5 with left radiculopathy.,2.  Cervical stenosis with cord compression, C5-C6 (723.0), with surgical findings confirmed.,PROCEDURES:  ,1.  Anterior cervical discectomy at C4-C5, C5-C6, and C6-C7 for neural decompression (63075, 63076, 63076).,2.  Anterior interbody fusion at C4-C5, C5-C6, and C6-C7 (22554, 22585, 22585) utilizing Bengal cages times three (22851).,3.  Anterior instrumentation for stabilization by Slim-LOC plate C4, C5, C6, and C7 (22846); with intraoperative x-ray times two.,ANESTHESIA:,  General.,SERVICE: , Neurosurgery.,OPERATION: , The patient was brought into the operating room, placed in a supine position where general anesthesia was administered.  Then the anterior aspect of the neck was prepped and draped in a routine sterile fashion.  A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma, which was dissected in a subplatysmal manner, and then the prevertebral space was encountered and prominent anterior osteophytes were well visualized once longus colli muscle was cauterized along its mesial border, and self-retaining retractors were placed to reveal the anterior osteophytic spaces.  Large osteophytes were excised with a rongeur at C4-5, C5-C6, and C6-C7 revealing a collapsed disc space and a #11 blade was utilized to create an annulotomy at all three interspaces with discectomies being performed with straight disc forceps removing grossly degenerated and very degenerated discs at C4-C5, then at C5-C6, then at C6-C7 sending specimen for permanent section to Pathology in a routine and separate manner.  Residual disc fragments were drilled away as drilling extended into normal cortical and cancellous elements in order to perform a wide decompression all the way posteriorly to the spinal canal itself finally revealing a ligament, which was removed in a similar piecemeal fashion with 1 and 2-mm micro Kerrison rongeurs also utilizing these instruments to remove prominent osteophytes, widely laterally bilaterally at each interspace with one at C4-C5, more right-sided.  The most prominent osteophyte and compression was at C5-C6 followed by C6-C7 and C4-C5 with a complete decompression of the spinal canal allowing the dura to finally bulge into the interspace at all three levels, once the ligaments were proximally removed as well and similarly a sign of a decompressed status.  The nerve roots themselves were inspected with a double ball dissector and found to be equally decompressed.  The wound was irrigated with antibiotic solution and hemostasis was well achieved with pledgets of Gelfoam subsequently irrigated away.  Appropriate size Bengal cages were filled with the patient's own bone elements and countersunk into position, filled along with fusion putty, and once these were quite tightly applied and checked, further stability was added by the placement of a Slim-LOC plate of appropriate size with appropriate size screws, and a post placement x-ray showed well-aligned elements.,The wound was irrigated with antibiotic solution again and inspected, and hemostasis was completely achieved and finally the wound was closed in a routine closure by approximation of the platysma with interrupted 3-0 Vicryl, and the skin with a subcuticular stitch of 4-0 Vicryl, and this was sterilely dressed, and incorporated a Penrose drain, which was carried from the prevertebral space externally to the skin wound and safety pin for security in a routine fashion.  At the conclusion of the case, all instruments, needle, and sponge counts were accurate and correct, and there were no intraoperative complications of any type.","surgery, herniated nucleus pulposus, radiculopathy, cervical stenosis, anterior instrumentation, stabilization, slim-loc, neural decompression, anterior cervical discectomy, cord compression, interbody fusion, bengal cages, interbody, compression, anterior, fusion, decompression, discectomy, cervical"
"  Herniated nucleus pulposus C5-C6.  Anterior cervical discectomy fusion C5-C6 followed by instrumentation C5-C6 with titanium dynamic plating system, Aesculap.  Operating microscope was used for both illumination and magnification.", Surgery, Anterior Cervical Discectomy & Fusion - 9 ,"PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus C5-C6.,POSTOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus C5-C6.,PROCEDURE:,  Anterior cervical discectomy fusion C5-C6 followed by instrumentation C5-C6 with titanium dynamic plating system, Aesculap.  Operating microscope was used for both illumination and magnification.,FIRST ASSISTANT: , Nurse practitioner.,PROCEDURE IN DETAIL: , The patient was placed in supine position.  The neck was prepped and draped in the usual fashion for anterior discectomy and fusion.  An incision was made midline to the anterior body of the sternocleidomastoid at C5-C6 level.  The skin, subcutaneous tissue, and platysma muscle was divided exposing the carotid sheath, which was retracted laterally.  Trachea and esophagus were retracted medially.  After placing the self-retaining retractors with the longus colli muscles having been dissected away from the vertebral bodies at C5 and C6 and confirming our position with intraoperative x-rays, we then proceeded with the discectomy.,We then cleaned out the disc at C5-C6 after incising the annulus fibrosis.  We cleaned out the disc with a combination of angled and straight pituitary rongeurs and curettes, and the next step was to clean out the disc space totally.  With this having been done, we then turned our attention with the operating microscope to the osteophytes.  We drilled off the vertebral osteophytes at C5-C6, as well as the uncovertebral osteophytes.  This was removed along with the posterior longitudinal ligament.  After we had done this, the dural sac was opposed very nicely and both C6 nerve roots were thoroughly decompressed.  The next step after the decompression of the thecal sac and both C6 nerve roots was the fusion.  We observed that there was a ____________ in the posterior longitudinal ligament.  There was a free fragment disc, which had broken through the posterior longitudinal ligament just to the right of midline.,The next step was to obtain the bone from the back bone, using cortical cancellous graft 10 mm in size after we had estimated the size.  That was secured into place with distraction being applied on the vertebral bodies using vertebral body distractor.,After we had tapped in the bone plug, we then removed the distraction and the bone plug was fitting nicely.,We then use the Aesculap cervical titanium instrumentation with the 16-mm screws.  After securing the C5-C6 disc with four screws and titanium plate, x-rays showed good alignment of the spine, good placement of the bone graft, and after x-rays showed excellent position of the bone graft and instrumentation, we then placed in a Jackson-Pratt drain in the prevertebral space brought out through a separate incision.  The wound was closed with 2-0 Vicryl for subcutaneous tissues and skin was closed with Steri-Strips.  Blood loss during the operation was less than 10 mL.  No complications of the surgery.  Needle count, sponge count, and cottonoid count were correct.,","surgery, aesculap, titanium dynamic plating system, anterior cervical discectomy, herniated nucleus pulposus, cervical discectomy, operating microscope, longitudinal ligament, discectomy, anterior, instrumentation, cervical, titanium"
 Anterior cervical discectomy with decompression of spinal cord.  Anterior cervical fusion.  Anterior cervical instrumentation.  Insertion of intervertebral device.  Use of operating microscope., Surgery, Anterior Cervical Discectomy & Fusion - 6 ,"PREOPERATIVE DIAGNOSIS:  ,Symptomatic disk herniation, C7-T1.,FINAL DIAGNOSIS:  ,Symptomatic disk herniation, C7-T1.,PROCEDURES PERFORMED,1.  Anterior cervical discectomy with decompression of spinal cord C7-T1.,2.  Anterior cervical fusion, C7-T1.,3.  Anterior cervical instrumentation, anterior C7-T1.,4.  Insertion of intervertebral device, C7-T1.,5.  Use of operating microscope.,ANESTHESIOLOGY: , General endotracheal.,ESTIMATED BLOOD LOSS:  ,A 30 mL.,PROCEDURE IN DETAIL:  ,The patient was taken to the operating room where he was orally intubated by The Anesthesiology Service.  He was placed in the supine position on an OR table.  His arms were carefully taped down.  He was sterilely prepped and draped in the usual fashion.,A 4-cm incision was made obliquely over the left side of his neck.  Subcutaneous tissue was dissected down to the level of the platysma.  The platysma was incised using electrocautery.  Blunt dissection was done to create a plane between the strap muscles and the sternoclavicular mastoid muscle.  This allowed us to get right down on to the anterior cervical spine.  Blunt dissection was done to sweep off the longus colli.  We isolated the C7-T1 interspace.  An x-ray was taken to verify; we were indeed at the C7-T1 interspace.,Shadow-Line retractor was placed as well as Caspar pins.  This provided very, very good access to the C7-T1 disk.,At this point, the operating microscope was brought into the decompression.,A thorough and aggressive C7-T1 discectomy was done using a succession of curettes, pituitary rongeur, 4-mm cutting bur and a #2 Kerrison rongeur.  At the end of the discectomy, the cartilaginous endplates were carefully removed using 4-mm cutting burr.  The posterior longitudinal ligament was carefully resected using #2 Kerrison rongeur.  Left-sided C8 foraminotomy was accomplished using nerve hook and a 2-mm Kerrison rongeur.  At the end of the decompression, there was no further compression on the left C8 nerve root.,A Synthes cortical cancellous ____________ bone was placed in the interspace.  Sofamor Danek Atlantis plate was then placed over the interspace and four screws were placed, two in the body of C7 and two in the body of T1.  An x-ray was taken.  It showed good placement of the plate and screws.,A deep drain was placed.  The platysma layer was closed in running fashion using #1 Vicryl.  Subcutaneous tissue was closed in an interrupted fashion using 2-0 Vicryl.  Skin was closed in a running fashion using 4-0 Monocryl.  Steri-Strips and dressings were applied.  All counts were correct.  There were no complications.","surgery, disk herniation, cervical discectomy, decompression, spinal cord, anterior cervical fusion, anterior cervical discectomy, kerrison rongeur, anterior cervical, instrumentation, cervical, anterior, platysma, kerrison, fashion, interspace, rongeur, discectomy, herniation,"
 Anterior cervical discectomy fusion C3-C4 and C4-C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure.  Cervical spondylotic myelopathy with cord compression and cervical spondylosis., Surgery, Anterior Cervical Discectomy & Fusion ,"PREOPERATIVE DIAGNOSES:,  Cervical spondylotic myelopathy with cord compression and cervical spondylosis.,POSTOPERATIVE DIAGNOSES:,  Cervical spondylotic myelopathy with cord compression and cervical spondylosis.  In addition to this, he had a large herniated disk at C3-C4 in the midline.,PROCEDURE: , Anterior cervical discectomy fusion C3-C4 and C4-C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure.,PROCEDURE IN DETAIL: , The patient placed in the supine position, the neck was prepped and draped in the usual fashion.  Incision was made in the midline the anterior border of the sternocleidomastoid at the level of C4.  Skin, subcutaneous tissue, and vertebral muscles divided longitudinally in the direction of the fibers and the trachea and esophagus was retracted medially.  The carotid sheath was retracted laterally after dissecting the longus colli muscle away from the vertebral osteophytes we could see very large osteophytes at C4-C5.  It appeared that the C5-C6 disk area had fused spontaneously.  We then confirmed that position by taking intraoperative x-rays and then proceeded to do discectomy and fusion at C3-C4, C4-C5.,After placing distraction screws and self-retaining retractors with the teeth beneath the bellies of the longus colli muscles, we then meticulously removed the disk at C3-C4, C4-C5 using the combination of angled strip, pituitary rongeurs, and curettes after we had incised the anulus fibrosus with #15 blade.,Next step was to totally decompress the spinal cord using the operating microscope and high-speed cutting followed by the diamond drill with constant irrigation.  We then drilled off the uncovertebral osteophytes and midline osteophytes as well as thinning out the posterior longitudinal ligaments.  This was then removed with 2-mm Kerrison rongeur.  After we removed the posterior longitudinal ligament, we could see the dura pulsating nicely.  We did foraminotomies at C3-C4 as well as C4-C5 as well.  After having totally decompressed both the cord as well as the nerve roots of C3-C4, C4-C5, we proceeded to the next step, which was a fusion.,We sized two 8-mm cortical cancellous grafts and after distracting the bone at C3-C4, C4-C5, we gently tapped the grafts into place.  The distraction was removed and the grafts were now within.  We went to the next step for the procedure, which was the instrumentation and stabilization of the fused area.,We then placed a titanium ABC plate from C3-C5, secured it with 16-mm titanium screws.  X-rays showed good position of the screws end plate.,The next step was to place Jackson-Pratt drain to the vertebral fascia.  Meticulous hemostasis was obtained.  The wound was closed in layers using 2-0 Vicryl for the subcutaneous tissue.  Steri-Strips were used for skin closure.  Blood loss less than about 200 mL.  No complications of the surgery.  Needle counts, sponge count, and cottonoid count was correct.","surgery, titanium plates fixation, bone black bone procedure, anterior cervical discectomy, titanium plates, cervical discectomy, spondylotic myelopathy, cord compression, cervical spondylosis, foraminotomies, cervical, anterior "
" Anterior cervical discectomy at C5-C6 and C6-C7 for neural decompression and anterior interbody fusion at C5-C6 and C6-C7 utilizing Bengal cages x2.  Anterior instrumentation by Uniplate construction C5, C6, and C7 with intraoperative x-ray x2.", Surgery, Anterior Cervical Discectomy & Fusion - 5 ,"PREOPERATIVE DIAGNOSES:  ,1.  Cervical spondylosis C5-C6 greater than C6-C7 (721.0).,2.  Neck pain, progressive (723.1) with right greater than left radiculopathy (723.4).,POSTOPERATIVE DIAGNOSES:  ,1.  Cervical spondylosis C5-C6 greater than C6-C7 (721.0).,2.  Neck pain, progressive (723.1) with right greater than left radiculopathy (723.4), surgical findings confirmed.,PROCEDURES:  ,1.  Anterior cervical discectomy at C5-C6 and C6-C7 for neural decompression (63075, 63076).,2.  Anterior interbody fusion at C5-C6 and C6-C7 (22554, 22585) utilizing Bengal cages x2 (22851).,3.  Anterior instrumentation by Uniplate construction C5, C6, and C7 (22845); with intraoperative x-ray x2.,ANESTHESIA:  ,General.,OPERATIONS: , The patient was brought to the operating room and placed in the supine position where general anesthesia was administered.  Then the anterior aspect of the neck was prepped and draped in the routine sterile fashion.  A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma, which was dissected in a subplatysmal manner and then with only blunt dissection, the prevertebral space was encountered and localizing intraoperative x-ray was obtained once cauterized the longus colli muscle bilaterally allowed for the placement along its mesial portion of self-retaining retractors for exposure of tissues.  Prominent anterior osteophytes once identified and compared to preoperative studies were removed at C5-C6 and then at C6-C7 with rongeur, allowing for an annulotomy with an #11 blade through collapsed disc space at C5-6, and even more collapsed at C6-C7.  Gross instability appeared and though minimally at both interspaces and residual disc were removed then with the straight disc forceps providing a discectomy at both levels, sending to Pathology in a routine fashion as disc specimen.  This was sent separately and allowed for residual disc removal of power drill where drilling extended in normal cortical and cancellous elements of the C5 and C6 interspaces and at C6-C7 removing large osteophytes and process, residual osteophytes from which were removed finally with 1 and 2 mm micro Kerrison rongeurs allowing for excision of other hypertrophied ligament posteriorly as well.  This allowed for the bulging into the interspace of the dura, sign of decompressed status, and this was done widely bilaterally to decompress the nerve roots themselves and this was assured by inspection with a double ball dissector as needed.  At no time during the case was there evidence of CSF leakage and hemostasis was well achieved with pledgets of Gelfoam and subsequently removed with copious amounts of antibiotic irrigation as well as Surgifoam.  Once hemostasis well achieved, Bengal cage was filled with the patient's own bone elements of appropriate size, and this was countersunk into position and quite tightly applied it at first C5-C6, then secondly at C6-C7.  These were checked and found to be well applied and further stability was then added by placement nonetheless of a Uniplate of appropriate size.  The appropriate size screws and post-placement x-ray showed well-aligned elements and removal of osteophytes, etc.  The wound was again irrigated with antibiotic solution, inspected, and finally closed in a multiple layered closure by approximation of platysma with interrupted #3-0 Vicryl and the skin with subcuticular stitch of #4-0 Vicryl incorporating a Penrose drain from vertebral space externally through the skin wound and safety pin, and later incorporated itself into sterile bandage.,Once the bandage was placed, the patient was taken, extubated from the operating room to the Recovery area, having in stable, but guarded condition.  At the conclusion of the case, all instrument, needle, and sponge counts were accurate and correct.  There were no intraoperative complications of any type.","surgery, cervical spondylosis, anterior cervical discectomy, anterior instrumentation, annulotomy, kerrison rongeurs, surgifoam, vertebral space, uniplate construction, bengal cages, neural decompression, anterior cervical, cervical discectomy, interbody, anterior, cervical, discectomy"
 Anterior cervical discectomy with decompression and arthrodesis with anterior interbody fusion.  Spinal instrumentation using Pioneer 18-mm plate and four 14 x 4.3 mm screws (all titanium)., Surgery, Anterior Cervical Discectomy & Fusion - 4 ,"PREOPERATIVE DIAGNOSIS: , Cervical myelopathy, C3-4, secondary to stenosis from herniated nucleus pulposus, C3-4.,POSTOPERATIVE DIAGNOSES: , Cervical myelopathy, C3-4, secondary to stenosis from herniated nucleus pulposus, C3-4.,OPERATIVE PROCEDURES,1.  Anterior cervical discectomy with decompression, C3-4.,2.  Arthrodesis with anterior interbody fusion, C3-4.,3.  Spinal instrumentation using Pioneer 18-mm plate and four 14 x 4.3 mm screws (all titanium).,4.  Implant using PEEK 7 mm.,5.  Allograft using Vitoss.,DRAINS: , Round French 10 JP drain.,FLUIDS: , 1800 mL of crystalloids.,URINE OUTPUT:  ,1000 mL.,SPECIMENS: , None.,COMPLICATIONS:  ,None.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS:  ,Less than 100 mL.,CONDITION:  ,To postanesthesia care unit extubated with stable vital signs.,INDICATIONS FOR THE OPERATION:  ,This is a case of a very pleasant 32-year-old Caucasian male who had been experiencing posterior neck discomfort and was shooting basketball last week, during which time he felt a pop.  Since then, the patient started complaining of acute right arm and right leg weakness, which had been progressively worsening.  About two days ago, he started noticing weakness on the left arm.  The patient also noted shuffling gait.  The patient presented to a family physician and was referred to Dr. X for further evaluation.  Dr. X could not attempt to this, so he called me at the office and the patient was sent to the emergency room, where an MRI of the brain was essentially unremarkable as well as MRI of the thoracic spine.  MRI of the cervical spine, however, revealed an acute disk herniation at C3-C4 with evidence of stenosis and cord changes.  Based on these findings, I recommended decompression.  The patient was started on Decadron at 10 mg IV q.6h.  Operation, expected outcome, risks, and benefits were discussed with him.  Risks to include but not exclusive of bleeding and infection.  Bleeding can be superficial, but can compromise airway, for which he has been told that he may be brought emergently back to the operating room for evacuation of said hematoma.  The hematoma could also be an epidural hematoma, which may compress the spinal cord and result in weakness of all four extremities, numbness of all four extremities, and impairment of bowel and bladder function.  Should this happen, he needs to be brought emergently back to the operating room for evacuation of said hematoma.  There is also the risk by removing the hematoma that he can deteriorate as far as neurological condition, but this hopefully with the steroid prep will be prevented or if present will only be transient.  There is also the possibility of infection, which can be superficial and treated with IV and p.o. antibiotics.  However, should the infection be extensive or be deep, he may require return to the operating room for debridement and irrigation.  This may pose a medical problem since in the presence of infection, the graft as well as spinal instrumentation may have to be removed.  There is also the possibility of dural tear with its attendant complaints of headache, nausea, vomiting, photophobia, as well as the development of pseudomeningocele.  This too can compromise airway and may require return to the operating room for repair of the dural tear.  There is also potential risk of injury to the esophagus, the trachea, as well as the carotid.  The patient can also have a stroke on the right cerebral circulation should the plaque be propelled into the right circulation.  The patient understood all these risks together with the risk associated with anesthesia and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room, awake, alert and not in any form of distress.  After smooth induction and intubation, a Foley catheter was inserted.  No monitoring leads were placed.  The patient was then positioned supine on the operating table with the head supported on a foam doughnut and the neck placed on hyperextension with a shoulder roll under both shoulders.  Localizing x-ray verified the marker to be right at the C3-4 interspace.  Proceeded to mark an incision along the anterior border of the sternocleidomastoid with the central point at the area of the marker measuring about 3 cm in length.  The area was then prepped with DuraPrep.,After sterile drapes were laid out, an incision was made using a scalpel blade #10.  Wound edge bleeders were controlled with bipolar coagulation and a hot knife was utilized to cut the platysma in a similar fashion.  The anterior border of the sternocleidomastoid was identified and dissection was carried superior to and lateral to the esophagus and trachea, but medial to the carotid sheath.  The prevertebral fascia was identified.  Localizing x-ray verified another marker to be at the C3-4 interspace.  Proceeded to strip the longus colli muscles off the vertebral body of C3 and C4 and a self-retaining retractor was then laid out.  There was some degree of anterior osteophyte and this was carefully drilled down with a Midas 5-mm bur.  The disk was then cut through the annulus and removal of the disk was done with the use of the Midas 5-mm bur and later a 3-mm bur.  The inferior endplate of C3 and the superior endplate of C4 were likewise drilled out together with posterior inferior osteophyte at the C3 and the posterior superior osteophyte at C4.  There was note of a central disk herniation centrally, but more marked displacement of the cord on the left side.  By careful dissection of this disk, posterior longitudinal ligament was removed and pressure on the cord was removed.  Hemostasis of the epidural bleeders was done with a combination of bipolar coagulation, but we needed to put a small piece of Gelfoam on the patient's left because of profuse venous bleeder.  With this completed, the Valsalva maneuver showed no evidence of any CSF leakage.  A 7-mm implant with its interior packed with Vitoss was then tapped into place.  An 18-mm plate was then screwed down with four 14 x 4.0 mm screws.  The area was irrigated with saline, with bacitracin solution.  Postoperative x-ray showed excellent placement of the graft and spinal instrumentation.  A round French 10 JP drain was laid over the construct and exteriorized though a separate stab incision on the patient's right inferiorly.  The wound was then closed in layers with Vicryl 3-0 inverted interrupted sutures for the platysma, Vicryl 4-0 subcuticular stitch for the dermis and Dermabond.  The catheter was anchored to the skin with a nylon 3-0 stitch.  Dressing was placed only on the exit site of the drain.  C-collar was placed, and the patient was transferred to the recovery awake and moving all four extremities.",
" Radical anterior discectomy with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal.  Anterior cervical fusion.  Utilization of allograft for purposes of spinal fusion.  Application of anterior cervical locking plate.", Surgery, Anterior Cervical Discectomy & Fusion - 3 ,"PREOPERATIVE DIAGNOSES,1.  Cervical spinal stenosis, C3-c4 and C4-C5.,2.  Cervical spondylotic myelopathy.,POSTOPERATIVE DIAGNOSES,1.  Cervical spinal stenosis, C3-C4 and C4-C5.,2.  Cervical spondylotic myelopathy.,OPERATIVE PROCEDURES,1.  Radical anterior discectomy, C3-C4 with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal (CPT 63075).,2.  Radical anterior discectomy C4-C5 with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal (CPT 63076).,3.  Anterior cervical fusion, C3-C4 (CPT 22554),4.  Anterior cervical fusion, C4-C5 (CPT 22585).,5.  Utilization of allograft for purposes of spinal fusion (CPT 20931).,6.  Application of anterior cervical locking plate C3-C5 (CPT 22845).,ANESTHESIA:,  General endotracheal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:  ,250 cc.,OPERATIVE INDICATIONS:  ,The patient is a 50-year-old gentleman who presented to the hospital after a fall, presenting with neck and arm pain as well as weakness.  His MRI confirmed significant neurologic compression in the cervical spine, combined with a clinical exam consistent with radiculopathy, myelopathy, and weakness.  We discussed the diagnosis and the treatment options.  Due to the severity of his neurologic symptoms as well as the amount of neurologic compression seen radiographically, I recommended that he proceed with surgical intervention as opposed to standard nonsurgical treatment such as physical therapy, medications, and steroid injections.  I explained the surgery itself which will be to remove pressure from the spinal cord via anterior cervical discectomy and fusion at C3-C4 and C4-C5.  We reviewed the surgery itself as well as risks including infection and blood vessels or nerves, leakage of spinal fluid, weakness or paralysis, failure of the pain to improve, possible worsening of the pain, failure of the neurologic symptoms to improve, possible worsening of the neurologic symptoms, and possible need for further surgery including re-revision and/or removal.  Furthermore I explained that the fusion may not become solid or that the hardware could break.  We discussed various techniques available for obtaining fusion and I recommended allograft and plate fixation.  I explained the rationale for this as well as the options of using his own bone.  Furthermore, I explained that removing motion at the fusion sites will transfer stress to other disc levels possibly accelerating there degeneration and causing additional symptoms and/or necessitating additional surgery in the future.,OPERATIVE TECHNIQUE: , After obtaining the appropriate signed and informed consent, the patient was taken to the operating room, where he underwent general endotracheal anesthesia without complications.  He was then positioned supine on the operating table, and all bony prominences were padded.  Pulse oximetry was maintained on both feet throughout the case.  The arms were carefully padded and tucked at his sides.  A roll was placed between the shoulder blades.  The areas of the both ears were sterilely prepped and cranial tongs were applied in routine fashion.  Ten pounds of traction was applied.  A needle was taped to the anterior neck and an x-ray was done to determine the appropriate level for the skin incision.  The entire neck was then sterilely prepped and draped in the usual fashion.,A transverse skin incision was made and carried down to the platysma muscle.  This was then split in line with its fibers.  Blunt dissection was carried down medial to the carotid sheath and lateral to the trachea and esophagus until the anterior cervical spine was visualized.  A needle was placed into a disc and an x-ray was done to determine its location.  The longus colli muscles were then elevated bilaterally with the electrocautery unit.  Self-retaining retractors were placed deep to the longus colli muscle in an effort to avoid injury to the sympathetic chains.,Radical anterior discectomies were performed at C3-C4 and C4-C5.  This included complete removal of the anterior annulus, nucleus, and posterior annulus.  The posterior longitudinal ligament was removed as were the posterior osteophytes.  Foraminotomies were then accomplished bilaterally.  Once all of this was accomplished, the blunt-tip probe was used to check for any residual compression.  The central canal was wide open at each level as were the foramen.,A high-speed bur was used to remove the cartilaginous endplates above and below each interspace.  Bleeding cancellous bone was exposed.  The disc spaces were measured and appropriate size allografts were placed sterilely onto the field.  After further shaping of the grafts with the high-speed bur, they were carefully impacted in to position.  There was good juxtaposition against the bleeding decorticated surfaces and good distraction of each interspace.  All weight was then removed from the crania tongs.,The appropriate size anterior cervical locking plate was chosen and bent into gentle lordosis.  Two screws were then placed into each of the vertebral bodies at C3, C4, and C5.  There was excellent purchase.  A final x-ray was done confirming good position of the hardware and grafts.  The locking screws were then applied, also with excellent purchase.,Following a final copious irrigation, there was good hemostasis and no dural leaks.  The carotid pulse was strong.  A drain was placed deep to the level of the platysma muscle and left at the level of the hardware.  The wounds were then closed in layers using 4-0 Vicryl suture for the platysma muscle, 4-0 Vicryl suture for the subcutaneous tissue, and 4-0 Vicryl suture in a subcuticular skin closure.  Steri-Strips were placed followed by application of a sterile dressing.  The drain was hooked to bulb suction.  A Philadelphia collar was applied.,The cranial tongs were carefully removed.  The soft tissue overlying the puncture site was massaged to free it up from the underlying bone.  There was good hemostasis.,The patient was then carefully returned to the supine position on his hospital bed where he was reversed and extubated and taken to the recovery room having tolerated the procedure well.",
" Herniated nucleus pulposus, C5-C6, with spinal stenosis.  Anterior cervical discectomy with fusion C5-C6.", Surgery, Anterior Cervical Discectomy & Fusion - 2 ,"PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus, C5-C6, with spinal stenosis.,POSTOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus, C5-C6, with spinal stenosis.,PROCEDURE: , Anterior cervical discectomy with fusion C5-C6.,PROCEDURE IN DETAIL: , The patient was placed in supine position.  The neck was prepped and draped in the usual fashion.  An incision was made from midline to the anterior border of the sternocleidomastoid in the right side.  Skin and subcutaneous tissue were divided sharply.  Trachea and esophagus were retracted medially.  Carotid sheath was retracted laterally.  Longus colli muscles were dissected away from the vertebral bodies of C5-C6.  We confirmed our position by taking intraoperative x-rays.  We then used the operating microscope and cleaned out the disk completely.  We then sized the interspace and then tapped in a #7 mm cortical cancellous graft.  We then used the DePuy Dynamic plate with 14-mm screws.  Jackson-Pratt drain was placed in the prevertebral space and brought out through a separate incision.  The wound was closed in layers using 2-0 Vicryl for muscle and fascia.  The blood loss was less than 10-20 mL.  No complication.  Needle count, sponge count, and cottonoid count was correct.","surgery, carotid sheath, jackson-pratt drain, anterior cervical discectomy, herniated nucleus pulposus, cervical discectomy, herniated nucleus, nucleus pulposus, spinal stenosis, discectomy, fusion, herniated, nucleus, pulposus, spinal, stenosis, anterior"
" Anterior cervical discectomy with decompression C6-C7, arthrodesis with anterior interbody fusion C6-C7, spinal instrumentation using Pioneer 20 mm plate and four 12 x 4.0 mm screws, PEEK implant 7 mm, and Allograft using Vitoss.", Surgery, Anterior Cervical Discectomy & Decompression ,"PREOPERATIVE DIAGNOSES,1.  Left neck pain with left upper extremity radiculopathy.,2.  Left C6-C7 neuroforaminal stenosis secondary to osteophyte.,POSTOPERATIVE DIAGNOSES,1.  Left neck pain with left upper extremity radiculopathy.,2.  Left C6-C7 neuroforaminal stenosis secondary to osteophyte.,OPERATIVE PROCEDURE,1.  Anterior cervical discectomy with decompression C6-C7.,2.  Arthrodesis with anterior interbody fusion C6-C7.,3.  Spinal instrumentation using Pioneer 20 mm plate and four 12 x 4.0 mm screws.,4.  PEEK implant 7 mm.,5.  Allograft using Vitoss.,ANESTHESIA: , General endotracheal anesthesia.,FINDINGS: , Showed osteophyte with a disc complex on the left C6-C7 neural foramen.,FLUIDS:  ,1800 mL of crystalloids.,URINE OUTPUT: , No Foley catheter.,DRAINS:  ,Round French 10 JP drain.,SPECIMENS,:  None.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  250 mL.,The need for an assistant is important in this case, since her absence would mean prolonged operative time and may increase operative morbidity and mortality.,CONDITION: , Extubated with stable vital signs.,INDICATIONS FOR THE OPERATION:,  This is the case of a very pleasant 46-year-old Caucasian female with subarachnoid hemorrhage secondary to ruptured left posteroinferior cerebellar artery aneurysm, which was clipped.  The patient last underwent a right frontal ventricular peritoneal shunt on 10/12/07.  This resulted in relief of left chest pain, but the patient continued to complaint of persistent pain to the left shoulder and left elbow.  She was seen in clinic on 12/11/07 during which time MRI of the left shoulder showed no evidence of rotator cuff tear.  She did have a previous MRI of the cervical spine that did show an osteophyte on the left C6-C7 level.  Based on this, negative MRI of the shoulder, the patient was recommended to have anterior cervical discectomy with anterior interbody fusion at C6-C7 level.  Operation, expected outcome, risks, and benefits were discussed with her.  Risks include, but not exclusive of bleeding and infection, bleeding could be soft tissue bleeding, which may compromise airway and may result in return to the operating room emergently for evacuation of said hematoma.  There is also the possibility of bleeding into the epidural space, which can compress the spinal cord and result in weakness and numbness of all four extremities as well as impairment of bowel and bladder function.  Should this occur, the patient understands that she needs to be brought emergently back to the operating room for evacuation of said hematoma.  There is also the risk of infection, which can be superficial and can be managed with p.o. antibiotics.  However, the patient may develop deeper-seated infection, which may require return to the operating room.  Should the infection be in the area of the spinal instrumentation, this will cause a dilemma since there might be a need to remove the spinal instrumentation and/or allograft.  There is also the possibility of potential injury to the esophageus, the trachea, and the carotid artery.  There is also the risks of stroke on the right cerebral circulation should an undiagnosed plaque be propelled from the right carotid.  There is also the possibility hoarseness of the voice secondary to injury to the recurrent laryngeal nerve.  There is also the risk of pseudoarthrosis and hardware failure.  She understood all of these risks and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE: , The patient brought to the operating room, awake, alert, not in any form of distress.  After smooth induction and intubation, a Foley catheter was inserted.  Monitoring leads were placed by Premier Neurodiagnostics and this revealed normal findings, which remained normal during the entire case.  The EMGs were silent and there was no evidence of any stimulation.  After completion of the placement of the monitoring leads, the patient was positioned supine on the operating table with the neck placed on hyperextension.  The head was supported on a foam doughnut.  The right cervical area was then exposed by turning the head about 45 to 60 degrees to the left side.  A linear incision was made about two to three fingerbreadths from the suprasternal notch along the anterior border of the sternocleidomastoid muscle to a distance of about 3 cm.  The area was then prepped with DuraPrep.,After sterile drapes were laid out, the incision was made using a scalpel blade #10.  Wound edge bleeders were controlled with bipolar coagulation and a hot knife was utilized to carry the dissection down to the platysma in the similar fashion as the skin incision.  The anterior border of the sternocleidomastoid muscle was identified as well as the sternohyoid/omohyoid muscles.  Dissection was then carried lateral and superior to the omohyoid muscle and lateral to the esophagus and the trachea, and medial to the sternocleidomastoid muscle and the carotid sheath.  The prevertebral fascia was identified and cut sharply.  A localizing x-ray verified the marker to be at the C6-C7 interspace.  Proceeded to the strip the longus colli muscles off the vertebral body of C6 and C7.  Self-retaining retractor was then laid out.  The annulus was then cut in a quadrangular fashion and piecemeal removal of the dura was done using a straight pituitary rongeurs, 3 and 5 mm burr.  The interior endplate of C6 and superior endplate of C7 was likewise was drilled down together with posteroinferior edge of C6 and the posterior superior edge of C7.  There was note of a new osteophyte on the left C6-C7 foramen.  This was carefully drilled down.  After decompression and removal of pressure, there was noted to be release of the epidural space with no significant venous bleeders.  They were controlled with slight bipolar coagulation, temporary tamponade with Gelfoam.  After this was completed, Valsalva maneuver showed no evidence of any CSF leakage.  A 7-mm implant was then tapped into placed after its interior was packed with Vitoss.  The plate was then applied and secured in place with four 12 x 4.7 mm screws.  Irrigation of the area was done.  A round French 10 JP drain was laid out over the graft and exteriorized through a separate stab incision on the patient's right inferiorly.  The wound was then closed in layers with Vicryl 3-0 inverted interrupted sutures as well as Vicryl 4-0 subcuticular stitch for the dermis.  The wound was reinforced with Dermabond.  The catheter was anchored to the skin with nylon 3-0 stitch and dressing was applied only at the exit site.  C-collar was placed and the patient was transferred to Recovery after extubation.",
" Anterior cervical discectomy with decompression, anterior cervical fusion, anterior cervical instrumentation, and Allograft C5-C6.", Surgery, Anterior Cervical Discectomy & Decompression - 1 ,"PREOPERATIVE DIAGNOSES,1.  Herniated disc, C5-C6.,2.  Cervical spondylosis, C5-C6.,POSTOPERATIVE DIAGNOSES,1.  Herniated disc, C5-C6.,2.  Cervical spondylosis, C5-C6.,PROCEDURES,1.  Anterior cervical discectomy with decompression, C5-C6.,2.  Anterior cervical fusion, C5-C6.,3.  Anterior cervical instrumentation, C5-C6.,4.  Allograft C5-C6.,ANESTHESIA:  ,General endotracheal.,COMPLICATIONS:,  None.,PATIENT STATUS: , Taken to recovery room in stable condition.,INDICATIONS: , The patient is a 36-year-old female who has had severe, recalcitrant right upper extremity pain, numbness, tingling, shoulder pain, axial neck pain, and headaches for many months.  Nonoperative measures failed to relieve her symptoms and surgical intervention was requested.  We discussed reasonable risks, benefits, and alternatives of various treatment options.  Continuation of nonoperative care versus the risks associated with surgery were discussed.  She understood the risks including bleeding, nerve vessel damage, infection, hoarseness, dysphagia, adjacent segment degeneration, continued worsening pain, failed fusion, and potential need for further surgery.  Despite these risks, she felt that current symptoms will be best managed operatively.,SUMMARY OF SURGERY IN DETAIL: , Following informed consent and preoperative administration of antibiotics, the patient was brought to the operating suite.  General anesthetic was administered.  The patient was placed in the supine position.  All prominences and neurovascular structures were well accommodated.  The patient was noted to have pulse in this position.  Preoperative x-rays revealed appropriate levels for skin incision.  Ten pound inline traction was placed via Gardner-Wells tongs and shoulder roll was placed.  The patient was then prepped and draped in sterile fashion.  Standard oblique incision was made over the C6 vertebral body in the proximal nuchal skin crease.  Subcutaneous tissue was dissected down to the level of the omohyoid which was transected.  Blunt dissection was carried out with the trachea and the esophagus in the midline and the carotid sheath in its vital structures laterally.  This was taken down to the prevertebral fascia which was bluntly split.  Intraoperative x-ray was taken to ensure proper levels.  Longus colli was identified and reflected proximally 3 to 4 mm off the midline bilaterally so that the anterior cervical Trimline retractor could be placed underneath the longus colli, thus placing no new traction on the surrounding vital structures.  Inferior spondylosis was removed with high-speed bur.  A scalpel and curette was used to remove the disc.  Decompression was carried posterior to the posterior longitudinal ligament down to the uncovertebral joints bilaterally.  Disc herniation was removed from the right posterolateral aspect of the interspace.  High-speed bur was used to prepare the endplate down to good bleeding bone and preparation for fusion.  Curette and ball tip dissector was then passed out the foramen and along the ventral aspect of the dura.  No further evidence of compression was identified.  Hemostasis was achieved with thrombin-soaked Gelfoam.  Interspace was then distracted with Caspar pin distractions set gently.  Interspace was then gently retracted with the Caspar pin distraction set.  An 8-mm allograft was deemed in appropriate fit.  This was press fit with demineralized bone matrix and tamped firmly into position achieving excellent interference fit.  The graft was stable to pull-out forces.  Distraction and traction was then removed and anterior cervical instrumentation was completed using a DePuy Trimline anterior cervical plate with 14-mm self-drilling screws.  Plate and screws were then locked to the plate.  Final x-rays revealed proper positioning of the plate, excellent distraction in the disc space, and apposition of the endplates and allograft.  Wounds were copiously irrigated with normal saline.  Omohyoid was approximated with 3-0 Vicryl.  Running 3-0 Vicryl was used to close the platysma.  Subcuticular Monocryl and Steri-Strips were used to close the skin.  A deep drain was placed prior to wound closure.  The patient was then allowed to awake from general anesthetic and was taken to the recovery room in stable condition.  There were no intraoperative complications.  All needle and sponge counts were correct.  Intraoperative neurologic monitoring was used throughout the entirety of the case and was normal.","surgery, cervical spondylosis, cervical fusion, decompression, instrumentation, anterior cervical discectomy, anterior cervical, herniated disc, cervical discectomy, anterior, cervical, fusion, allograft, discectomy"
" Anterior cervical discectomy and fusion, C2-C3, C3-C4.  Removal of old instrumentation, C4-C5.  Fusion C3-C4 and C2-C3 with instrumentation using ABC plates.", Surgery, Anterior Cervical Discectomy & Fusion - 1 ,"PREOPERATIVE DIAGNOSES,1.  Herniated nucleus pulposus C2-C3.,2.  Spinal stenosis C3-C4.,POSTOPERATIVE DIAGNOSES,1.  Herniated nucleus pulposus C2-C3.,2.  Spinal stenosis C3-C4.,PROCEDURES,1.  Anterior cervical discectomy, C3-C4, C2-C3.,2.  Anterior cervical fusion, C2-C3, C3-C4.,3.  Removal of old instrumentation, C4-C5.,4.  Fusion C3-C4 and C2-C3 with instrumentation using ABC plates.,PROCEDURE IN DETAIL: , The patient was placed in the supine position.  The neck was prepped and draped in the usual fashion for anterior cervical discectomy.  A high incision was made to allow access to C2-C3.  Skin and subcutaneous tissue and the platysma were divided sharply exposing the carotid sheath which was retracted laterally and the trachea and esophagus were retracted medially.  This exposed the vertebral bodies of C2-C3 and C4-C5 which was bridged by a plate.  We placed in self-retaining retractors.  With the tooth beneath the blades, the longus colli muscles were dissected away from the vertebral bodies of C2, C3, C4, and C5.  After having done this, we used the all-purpose instrumentation to remove the instrumentation at C4-C5, we could see that fusion at C4-C5 was solid.,We next proceeded with the discectomy at C2-C3 and C3-C4 with disc removal.  In a similar fashion using a curette to clean up the disc space and the space was fairly widened, as well as drilling up the vertebral joints using high-speed cutting followed by diamond drill bit.  It was obvious that the C3-C4 neural foramina were almost totally obliterated due to the osteophytosis and foraminal stenosis.  With the operating microscope; however, we had good visualization of these nerve roots, and we were able to ___________ both at C2-C3 and C3-C4.  We then placed the ABC 55-mm plate from C2 down to C4.  These were secured with 16-mm titanium screws after excellent purchase.  We took an x-ray which showed excellent position of the plate, the screws, and the graft themselves.  The next step was to irrigate the wound copiously with saline and bacitracin solution and s Jackson-Pratt drain was placed in the prevertebral space and brought out through a separate incision.  The wound was closed with 2-0 Vicryl for subcutaneous tissues and Steri-Strips used to close the skin.  Blood loss was about 50 mL.  No complication of the surgery.  Needle count, sponge count, cottonoid count was correct.,The operating microscope was used for the entirety for both visualization and magnification and illumination which was quite superb.  At the time of surgery, he had total collapse of the C2, C3, and C4 disc with osteophyte formation.  At both levels, he has high-grade spinal stenosis at these levels, especially foramen stenosis causing the compression, neck pain, headaches, and arm and shoulder pain.  He does have degenerative changes at C5-C6, C6-C7, C7-T1; however, they do not appear to be symptomatic, although x-rays show the disks to be partially collapsed at all levels with osteophyte formation beginning to form.","surgery, abc plates, osteophyte, cervical, discectomy, cervical fusion, herniated nucleus pulposus, anterior cervical discectomy, nucleus pulposus, vertebral bodies, osteophyte formation, spinal stenosis, cervical discectomy, anterior, instrumentation, vertebral, stenosis, fusion"
" Anterior cervical discectomy C4-C5 arthrodesis with 8 mm lordotic ACF spacer, corticocancellous, and stabilization with Synthes Vector plate and screws.  Cervical spondylosis and herniated nucleus pulposus of C4-C5.", Surgery, Anterior Cervical Discectomy & Arthrodesis - 2 ,"PREOPERATIVE DIAGNOSIS:  ,Cervical spondylosis and herniated nucleus pulposus of C4-C5.,POSTOPERATIVE DIAGNOSIS:,  Cervical spondylosis and herniated nucleus pulposus of C4-C5.,TITLE OF OPERATION:,  Anterior cervical discectomy C4-C5 arthrodesis with 8 mm lordotic ACF spacer, corticocancellous, and stabilization with Synthes Vector plate and screws.,ESTIMATED BLOOD LOSS:,  Less than 100 mL.,OPERATIVE PROCEDURE IN DETAIL: , After identification, the patient was taken to the operating room and placed in supine position.  Following the induction of satisfactory general endotracheal anesthesia, the patient was prepared for surgery.  A shoulder roll was placed between the scapula and the head was rested on a doughnut in a slightly extended position.  A preoperative x-ray was obtained to identify the operative level and neck position.  An incision was marked at the C4-C5 level on the right side.  The incision was opened with #10 blade knife.  Dissection was carried down through subcutaneous tissues using Bovie electrocautery.  The platysma muscle was divided with the cautery and mobilized rostrally and caudally.  The anterior border of sternocleidomastoid muscle was then dissected rostrally and caudally with sharp and blunt dissection.  The avascular plane was then entered and dissection was carried bluntly down to the anterior cervical fascia.  This was opened with scissors and dissected rostrally and caudally with the peanut dissectors.  The operative level was confirmed with an intraoperative x-ray.  The longus colli muscles were mobilized bilaterally using bipolar electrocautery and periosteal elevator.  The anterior longitudinal ligament was then taken down with the insulated Bovie electrocautery tip exposing the vertebral bodies of C4 and C5.  Self-retaining retractor was placed in submuscular position, and distraction pins were placed in the vertebral bodies of C4 and C5, and distraction was instituted.  We then incise the annulus of C4-C5 and a discectomy was now carried out using pituitary rongeurs and straight and angled curettes.  Operating microscope was draped and brought into play.  Dissection was carried down through the disc space to the posterior aspect of the disc space removing the disc with the angled curette as we went.  We now use the diamond bit to thin the posterior bone spurs and osteophytes at the uncovertebral joints bilaterally.  Bone was then removed with 2 mm Kerrison punch and then we were able to traverse the posterior longitudinal ligament and this ligament was now removed in a piecemeal fashion with a 2 mm Kerrison punch.  There was a transligamentous disc herniation, which was removed during this process.  We then carried out bilateral foraminotomies with removal of the uncovertebral osteophytes until the foramina were widely patent.  Cord was seen to be pulsating freely behind the dura.  There appeared to be no complications and the decompression appeared adequate.  We now used a cutting bit to prepare the inner space for arthrodesis fashioning a posterior ledge on the posterior aspect of the C5 vertebral body.  An 8 mm lordotic trial was used and appeared perfect.  We then used a corticocancellous 8 mm lordotic graft.  This was tapped into position.  Distraction was released, appeared to be in excellent position.  We then positioned an 18 mm Vector plate over the inner space.  Intraoperative x-ray was obtained with the stay screw in place; plates appeared to be in excellent position.  We then use a 14 mm self-tapping variable angle screws in each of the four locations drilling 14 mm pilot holes at each location prior to screw insertion.  All of the screws locked to the plate and this was confirmed on visual inspection.  Intraoperative x-ray was again obtained.  Construct appeared satisfactory.  Attention was then directed to closure.  The wound was copiously irrigated.  All of the self-retaining retractors were removed.  Bleeding points were controlled with bone wax and bipolar electrocautery.  The platysma layer was now closed with interrupted 3-0 Vicryl sutures.  The skin was closed with running 3-0 Vicryl subcuticular stitch.  Steri-Strips were applied.  A sterile bandage was applied.  All sponge, needle, and cottonoid counts were reported as correct.  The patient tolerated the procedure well.  He was subsequently extubated in the operating room and transferred to PACU in satisfactory condition.","surgery, synthes vector plate, lordotic, acf spacer, corticocancellous, arthrodesis, anterior cervical discectomy, herniated nucleus pulposus, anterior, cervical, spacer, screws, discectomy, "
 Anterior cervical discectomy at C5-6 and placement of artificial disk replacement.  Right C5-C6 herniated nucleus pulposus., Surgery, Anterior Cervical Discectomy - 2 ,"ADMITTING DIAGNOSIS: , Right C5-C6 herniated nucleus pulposus.,PRIMARY OPERATIVE PROCEDURE: , Anterior cervical discectomy at C5-6 and placement of artificial disk replacement.,SUMMARY:,  This is a pleasant, 43-year-old woman, who has been having neck pain and right arm pain for a period of time which has not responded to conservative treatment including ESIs.  She underwent another MRI and significant degenerative disease at C5-6 with a central and right-sided herniation was noted.  Risks and benefits of the surgery were discussed with her and she wished to proceed with surgery.  She was interested in participating in the artificial disk replacement study and was entered into that study.  She was randomly picked for the artificial disk and underwent the above named procedure on 08/27/2007.  She has done well postoperatively with a sensation of right arm pain and numbness in her fingers.  She will have x-rays AP and lateral this morning which will be reviewed and she will be discharged home today if she is doing well.  She will follow up with Dr. X in 2 weeks in the clinic as per the study protocol with cervical AP and lateral x-rays with ring prior to the appointment.  She will contact our office prior to her appointment if she has problems.  Prescriptions were written for Flexeril 10 mg 1 p.o. t.i.d. p.r.n.  #50 with 1 refill and Lortab 7.5/500 mg 1 to 2 q.6 h. p.r.n.  #60 with 1 refill.","surgery, herniated nucleus pulposus, anterior cervical discectomy, artificial disk replacement, cervical, discectomy, nucleusNOTE"
" Anterior cervical discectomy, arthrodesis, partial corpectomy, Machine bone allograft, placement of anterior cervical plate with a Zephyr.
7.  Microscopic dissection.", Surgery, Anterior Cervical Discectomy & Arthrodesis ,"PREOPERATIVE DIAGNOSIS:,  Cervical myelopathy secondary to very large disc herniations at C4-C5 and C5-C6.,POSTOPERATIVE DIAGNOSIS: , Cervical myelopathy secondary to very large disc herniations at C4-C5 and C5-C6.,PROCEDURE PERFORMED:,1.  Anterior cervical discectomy, C4-C5 and C5-C6.,2.  Arthrodesis, C4-C5 and C5-C6.,3.  Partial corpectomy, C5.,4.  Machine bone allograft, C4-C5 and C5-C6.,5.  Placement of anterior cervical plate with a Zephyr C4 to C6.,6.  Fluoroscopic guidance.,7.  Microscopic dissection.,ANESTHESIA:,  General.,ESTIMATED BLOOD LOSS: , 60 mL.,COMPLICATIONS: , None.,INDICATIONS:,  This is a patient who presents with progressive weakness in the left upper extremity as well as imbalance.  He has also noted to have cord signal at the C4-C5 level secondary to a very large disc herniation that came behind the body at C5 as well and as well as a large disc herniation at C5-C6.  Risks and benefits of the surgery including bleeding, infection, neurologic deficit, nonunion, progressive spondylosis, and lack of improvement were all discussed.  He understood and wished to proceed.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room and placed in the supine position.  Preoperative antibiotics were given.  The patient was placed in the supine position with all pressure points noted and well padded.  The patient was prepped and draped in standard fashion.  An incision was made approximately above the level of the cricoid.  Blunt dissection was used to expose the anterior portion of the spine with carotid moved laterally and trachea and esophagus moved medially.  We then placed needle into the disc spaces and was found to be at C5-C6.  Distracting pins were placed in the body of C4 and in to the body of C6.  The disc was then completely removed at C4-C5.  There was very significant compression of the cord.  This was carefully removed to avoid any type of pressure on the cord.  This was very severe and multiple free fragments were noted.  This was taken down to the level of ligamentum.  Both foramen were then also opened.  Other free fragments were also found behind the body of C5, part of the body of C5 was taken down to assure that all of these were removed.  The exact same procedure was done at C5-C6; however, if there were again free fragments noted, there was less not as severe compression at the C4-C5 area.  Again part of the body at C5 was removed to make sure that there was no additional constriction.  Both nerve roots were then widely decompressed.  Machine bone allograft was placed into the C4-C5 as well as C5-C6 and then a Zephyr plate was placed in the body of C4 and to the body of C6 with a metal pin placed into the body at C5.  Excellent purchase was obtained.  Fluoroscopy showed good placement and meticulous hemostasis was obtained.  Fascia was closed with 3-0 Vicryl, subcuticular 3-0 Dermabond for skin.  The patient tolerated the procedure well and went to recovery in good condition.","surgery, fluoroscopic guidance, microscopic dissectio, cervical plate, zephyr, corpectomy, arthrodesis, anterior cervical discectomy, machine bone allograft, cervical discectomy, bone allograft, disc herniations, anterior, cervical, discectomy,"
" Herniated nucleus pulposus.  Anterior cervical decompression, anterior spine instrumentation, anterior cervical spine fusion, and application of machined allograft.", Surgery, Anterior Cervical Decompression ,"PREOPERATIVE DIAGNOSES,1.  Herniated nucleus pulposus, C5-C6.,2.  Herniated nucleus pulposus, C6-C7.,POSTOPERATIVE DIAGNOSES,1.  Herniated nucleus pulposus, C5-C6.,2.  Herniated nucleus pulposus, C6-C7.,PROCEDURE PERFORMED,1.  Anterior cervical decompression, C5-C6.,2.  Anterior cervical decompression, C6-C7.,3.  Anterior spine instrumentation.,4.  Anterior cervical spine fusion, C5-C6.,5.  Anterior cervical spine fusion, C6-C7.,6.  Application of machined allograft at C5-C6.,7.  Application of machined allograft at C6-C7.,8.  Allograft, structural at C5-C6.,9.  Allograft, structural at C6-C7.,ANESTHESIA: , General.,PREOPERATIVE NOTE:  ,This patient is a 47-year-old male with chief complaint of severe neck pain and left upper extremity numbness and weakness.  Preoperative MRI scan showed evidence of herniated nucleus pulposus at C5-C6 and C6-C7 on the left.  The patient has failed epidural steroid injections.  Risks and benefits of the above procedure were discussed with the patient including bleeding, infection, muscle loss, nerve damage, paralysis, and death.,OPERATIVE REPORT: , The patient was taken to the OR and placed in the supine position.  After general endotracheal anesthesia was obtained, the patient's neck was sterilely prepped and draped in the usual fashion.  A horizontal incision was made on the left side of the neck at the level of the C6 vertebral body.  It was taken down through the subcutaneous tissues exposing the platysmus muscle.  The platysmus muscle was incised along the skin incision and the deep cervical fascia was bluntly dissected down to the anterior cervical spine.  An #18 gauge needle was placed in the C5-C6 interspace and the intraoperative x-ray confirmed that this was the appropriate level.  Next, the longus colli muscles were resected laterally on both the right and left side, and then a complete anterior cervical discectomy was performed.  The disk was very degenerated and brown in color.  There was an acute disk herniation through posterior longitudinal ligament.  The posterior longitudinal ligament was removed and a bilateral foraminotomy was performed.  Approximately, 5 mm of the nerve root on both the right and left side was visualized.  A ball-ended probe could be passed up the foramen.  Bleeding was controlled with bipolar electrocautery and Surgiflo.  The end plates of C5 and C6 were prepared using a high-speed burr and a 6-mm lordotic machined allograft was malleted into place.  There was good bony apposition both proximally and distally.  Next, attention was placed at the C6-C7 level.  Again, the longus colli muscles were resected laterally and a complete anterior cervical discectomy at C6-C7 was performed.  The disk was degenerated and there was acute disk herniation in the posterior longitudinal ligament on the left.  The posterior longitudinal ligament was removed.  A bilateral foraminotomy was performed.  Approximately, 5 mm of the C7 nerve root was visualized on both sides.  A micro nerve hook was able to be passed up the foramen easily.  Bleeding was controlled with bipolar electrocautery and Surgiflo.  The end plates at C6-C7 were then prepared using a high-speed burr and then a 7-mm machined lordotic allograft was malleted into place.  There was good bony apposition, both proximally and distally.  Next, a 44-mm Blackstone low-profile anterior cervical plate was applied to the anterior cervical spine with six 14 mm screws.  Intraoperative x-ray confirmed appropriate positioning of the plate and the graft.  The wound was then copiously irrigated with normal saline and bacitracin.  There was no active bleeding upon closure of the wound.  A small drain was placed deep.  The platysmal muscle was closed with 3-0 Vicryl.  The skin was closed with #4-0 Monocryl.  Mastisol and Steri-Strips were applied.  The patient was monitored throughout the procedure with free-running EMGs and SSEPs and there were no untoward events.  The patient was awoken and taken to the recovery room in satisfactory condition.","surgery, herniated nucleus pulposus, anterior cervical decompression, spine fusion, cervical spine, allograft, anterior cervical spine, anterior, cervical,"
" Arthrodesis - anterior interbody technique, anterior cervical discectomy, anterior instrumentation with a 23-mm Mystique plate and the 13-mm screws, implantation of machine bone implant.  Disc herniation with right arm radiculopathy.", Surgery, Anterior Cervical Discectomy & Arthrodesis - 1 ,"PREOPERATIVE DIAGNOSES: , C5-C6 disc herniation with right arm radiculopathy.,POSTOPERATIVE DIAGNOSES: , C5-C6 disc herniation with right arm radiculopathy.,PROCEDURE:,1.  C5-C6 arthrodesis, anterior interbody technique.,2.  C5-C6 anterior cervical discectomy.,3.  C5-C6 anterior instrumentation with a 23-mm Mystique plate and the 13-mm screws.,4.  Implantation of machine bone implant.,5.  Microsurgical technique.,ANESTHESIA:  ,General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,BACKGROUND INFORMATION AND SURGICAL INDICATIONS:  ,The patient is a 45-year-old right-handed gentleman who presented with neck and right arm radicular pain.  The pain has become more and more severe.  It runs to the thumb and index finger of the right hand and it is accompanied by numbness.  If he tilts his neck backwards, the pain shoots down the arm.  If he is working with the computer, it is very difficult to use his mouse.  He tried conservative measures and failed to respond, so he sought out surgery.  Surgery was discussed with him in detail.  A C5-C6 anterior cervical discectomy and fusion was recommended.  He understood and wished to proceed with surgery.  Thus, he was brought in same day for surgery on 07/03/2007.,DESCRIPTION OF PROCEDURE: , He was given Ancef 1 g intravenously for infection prophylaxis and then transported to the OR.  There general endotracheal anesthesia was induced.  He was positioned on the OR table with an IV bag between the scapulae.  The neck was slightly extended and taped into position.  A metal arch was placed across the neck and intraoperative x-ray was obtain to verify a good position for skin incision and the neck was prepped with Betadine and draped in the usual sterile fashion.,A linear incision was created in the neck beginning just to the right of the midline extending out across the anterior border of the sternocleidomastoid muscle.  The incision was extended through skin, subcutaneous fat, and platysma.  Hemostasis was assured with Bovie cautery.  The anterior aspect of the sternocleidomastoid muscle was identified and dissection was carried medial to this down to the carotid sheath.  The trachea and the esophagus were swept out of the way and dissection proceeded medial to the carotid sheath down between the two bellies of the longus colli muscle on to the anterior aspect of the spine.  A Bovie cautery was used to mobilize the longus colli muscle around initially what turned out to be C6-C7 disk based on x-rays and then around the C5-C6 disk space.  An intraoperative x-ray confirmed C5-C6 disk space had been localized and then the self-retained distraction system was inserted to maintain exposure.  A 15-blade knife was used to incise the C5-C6 disk and remove disk material. and distraction pins were inserted into C5-C6 and distraction placed across the disk space.  The operating microscope was then brought into the field and used throughout the case except for the closure.  Various pituitaries, #15 blade knife, and curette were used to evacuate the disk as best as possible.  Then, the Midas Rex drill was taken under the microscope and used to drill where the cartilaginous endplate driven back all the way into the posterior aspect of the vertebral body.  A nerve hook was swept underneath the posterior longitudinal ligament and a fragment of disk was produced and was pulled up through the ligament.  A Kerrison rongeur was used to open up the ligament in this opening and then to march out in the both neural foramina.  A small amount of disk material was found at the right neural foramen.  After a good decompression of both neural foramina was obtained and the thecal sac was exposed throughout the width of the exposure, the wound was thoroughly irrigated.  A spacing mechanism was intact into the disk space and it was determined that a #7 spacer was appropriate.  So, a #7 machine bone implant was taken and tapped into disk space and slightly counter sunk.  The wound was thoroughly irrigated and inspected for hemostasis.  A Mystique plate 23 mm in length was then inserted and anchored to the anterior aspect of C5-C6 to hold the bone into position and the wound was once again irrigated.  The patient was valsalved.  There was no further bleeding seen and intraoperative x-ray confirmed a good position near the bone, plate, and screws and the wound was enclosed in layers.  The 3-0 Vicryl was used to approximate platysma and 3-0 Vicryl was used in inverted interrupted fashion to perform a subcuticular closure of the skin.  The wound was cleaned.,Mastisol was placed on the skin, and Steri-strips were used to approximate skin margins.  Sterile dressing was placed on the patient's neck.  He was extubated in the OR and transported to the recovery room in stable condition.  There were no complications.","surgery, herniation, radiculopathy, interbody, mystique, bone implant, anterior cervical discectomy, neural foramina, mystique plate, disc herniation, arm radiculopathy, cervical discectomy, disk space, disk, cervical, anterior, wound, discectomy,"
" Anterior cervical discectomy, removal of herniated disc and osteophytes, bilateral C4 nerve root decompression, harvesting of bone for autologous vertebral bodies for creation of arthrodesis, grafting of fibular allograft bone for creation of arthrodesis, creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies, and placement of anterior spinal instrumentation using the operating microscope and microdissection technique.", Surgery, Anterior Cervical Discectomy - 1 ,"PREOPERATIVE DIAGNOSIS: , Cervical spondylosis at C3-C4 with cervical radiculopathy and spinal cord compression.,POSTOPERATIVE DIAGNOSIS:,  Cervical spondylosis at C3-C4 with cervical radiculopathy and spinal cord compression.,OPERATION PERFORMED,1.  Anterior cervical discectomy of C3-C4.,2.  Removal of herniated disc and osteophytes.,3.  Bilateral C4 nerve root decompression.,4.  Harvesting of bone for autologous vertebral bodies for creation of arthrodesis.,5.  Grafting of fibular allograft bone for creation of arthrodesis.,6.  Creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies.,7.  Placement of anterior spinal instrumentation using the operating microscope and microdissection technique.,INDICATIONS FOR PROCEDURE: , This 62-year-old man has progressive and intractable right C4 radiculopathy with neck and shoulder pain.  Conservative therapy has failed to improve the problem.  Imaging studies showed severe spondylosis of C3-C4 with neuroforaminal narrowing and spinal cord compression.,A detailed discussion ensued with the patient as to the nature of the procedure including all risks and alternatives.  He clearly understood it and had no further questions and requested that I proceed.,PROCEDURE IN DETAIL: , The patient was placed on the operating room table and was intubated using a fiberoptic technique.  The methylprednisolone spinal cord protocol was instituted with bolus and continuous infusion doses.  The neck was carefully prepped and draped in the usual sterile manner.,A transverse incision was made on a skin crease on the left side of the neck.  Dissection was carried down through the platysmal musculature and the anterior spine was exposed.  The medial borders of the longus colli muscles were dissected free from their attachments to the spine.  A needle was placed and it was believed to be at the C3-C4 interspace and an x-ray properly localized this space.  Castoff self-retaining pins were placed into the body of the C3 and C4.  Self-retaining retractors were placed in the wound keeping the blades of the retractors underneath the longus colli muscles.,The annulus was incised and a discectomy was performed.  Quite a bit of overhanging osteophytes were identified and removed.  As I worked back to the posterior lips of the vertebral body, the operating microscope was utilized.,There was severe overgrowth of spondylitic spurs.  A high-speed diamond bur was used to slowly drill these spurs away.  I reached the posterior longitudinal ligament and opened it and exposed the underlying dura.,Slowly and carefully I worked out towards the C3-C4 foramen.  The dura was extremely thin and I could see through it in several areas.  I removed the bony compression in the foramen and identified soft tissue and veins overlying the root.  All of these were not stripped away for fear of tearing this very tissue-paper-thin dura.  However, radical decompression was achieved removing all the bony compression in the foramen, out to the pedicle, and into the foramen.  An 8-mm of the root was exposed although I left the veins over the root intact.,The microscope was angled to the left side where a similar procedure was performed.,Once the decompression was achieved, a high-speed cortisone bur was used to decorticate the body from the greater posterior shelf to prevent backward graft migration.  Bone thus from the drilling was preserved for use for the arthrodesis.,Attention was turned to creation of the arthrodesis.  As I had drilled quite a bit into the bodies, I selected a large 12-mm graft and distracted the space maximally.  Under distraction the graft was placed and fit well.  An x-ray showed good graft placement.,Attention was turned to spinal instrumentation.  A Synthes Short Stature plate was used with four 3-mm screws.  Holes were drilled with all four screws were placed with pretty good purchase.  Next, the locking screws were then applied.  An x-ray was obtained which showed good placement of graft, plate, and screws.  The upper screws were near the upper endplate of C3.  The C3 vertebral body that remained was narrow after drilling off the spurs.  Rather than replace these screws and risk that the next holes would be too near the present holes I decided to leave these screws intact because their position is still satisfactory as they are below the disc endplate.,Attention was turned to closure.  A Hemovac drain was placed in the anterior vertebral body space and brought out through a separate stab wound incision in the skin.  The wound was then carefully closed in layers.  Sterile dressings were applied along with a rigid Philadelphia collar.  The operation was then terminated.,The patient tolerated the procedure well and left for the recovery room in excellent condition.  The sponge and needle counts were reported as correct and there were no intraoperative complications.,Specimens were sent to Pathology consisted of bone and soft tissue as well as C3-C4 disc material.","surgery, herniated, osteophytes, nerve root decompression, harvesting, autologous, vertebral, arthrodesis, anterior technique, anterior cervical discectomy, spinal cord compression, fibular allograft bone, creation of arthrodesis, cervical discectomy, spinal instrumentation, cord compression, vertebral body, vertebral bodies, spinal cord, bone, instrumentation, cervical, anterior, grafting, spinal, discectomy, allograft, "
" C5-C6 anterior cervical discectomy, bone bank allograft, and anterior cervical plate.   Left cervical radiculopathy.", Surgery, Anterior Cervical Discectomy - 4 ,"PREOPERATIVE DIAGNOSIS: , Left cervical radiculopathy.,POSTOPERATIVE DIAGNOSIS:  ,Left cervical radiculopathy.,PROCEDURES PERFORMED:,1.  C5-C6 anterior cervical discectomy.,2.  Bone bank allograft.,3.  Anterior cervical plate.,TUBES AND DRAINS LEFT IN PLACE: , None.,COMPLICATIONS: , None.,SPECIMEN SENT TO PATHOLOGY: , None.,ANESTHESIA: , General endotracheal.,INDICATIONS: , This is a middle-aged man who presented to me with left arm pain.  He had multiple levels of disease, but clinically, it was C6 radiculopathy.  We tested him in the office and he had weakness referable to that nerve.  The procedure was done at that level.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room at which time an intravenous line was placed.  General endotracheal anesthesia was obtained.  He was positioned supine in the operative area and the right neck was prepared.,An incision was made and carried down to the ventral spine on the right in the usual manner.  An x-ray confirmed our location.,We were impressed by the degenerative change and the osteophyte overgrowth.,As we had excepted, the back of the disk space was largely closed off by osteophytes.  We patiently drilled through them to the posterior ligament.  We went through that until we saw the dura.,We carefully went to the patient's symptomatic, left side.  The C6 foramen was narrowed by uncovertebral joint overgrowth.  The foramen was open widely.,An allograft was placed.  An anterior Steffee plate was placed.  Closure was commenced.,The wound was closed in layers with Steri-Strips on the skin.  A dressing was applied.,It should be noted that the above operation was done also with microscopic magnification and illumination.","surgery, cervical radiculopathy, anterior cervical discectomy, bank allograft, cervical discectomy, anterior, cervical, foramen, discectomy, allograft, radiculopathy, "
 Anterior cervical discectomy (two levels) and C5-C6 and C6-C7 allograft fusions.  A C5-C7 anterior cervical plate fixation (Sofamor Danek titanium window plate) intraoperative fluoroscopy used and intraoperative microscopy used.  Intraoperative SSEP and EMG monitoring used., Surgery, Anterior Cervical Discectomy - 3 ,"PREOPERATIVE DIAGNOSES: , Cervical disk protrusions at C5-C6 and C6-C7, cervical radiculopathy, and cervical pain.,POSTOPERATIVE DIAGNOSES:,  Cervical disk protrusions at C5-C6 and C6-C7, cervical radiculopathy, and cervical pain.,PROCEDURES:,  C5-C6 and C6-C7 anterior cervical discectomy (two levels) C5-C6 and C6-C7 allograft fusions.  A C5-C7 anterior cervical plate fixation (Sofamor Danek titanium window plate) intraoperative fluoroscopy used and intraoperative microscopy used.  Intraoperative SSEP and EMG monitoring used.,ANESTHESIA: , General endotracheal.,COMPLICATIONS:,  None.,INDICATION FOR THE PROCEDURE: , This lady presented with history of cervical pain associated with cervical radiculopathy with cervical and left arm pain, numbness, weakness, with MRI showing significant disk protrusions with the associate complexes at C5-C6 and C6-C7 with associated cervical radiculopathy.  After failure of conservative treatment, this patient elected to undergo surgery.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the OR and after adequate general endotracheal anesthesia, she was placed supine on the OR table with the head of the bed about 10 degrees.  A shoulder roll was placed and the head supported on a donut support.  The cervical region was prepped and draped in the standard fashion.  A transverse cervical incision was made from the midline, which was lateral to the medial edge of the sternocleidomastoid two fingerbreadths above the right clavicle.  In a transverse fashion, the incision was taken down through the skin and subcutaneous tissue and through the platysmata and a subplatysmal dissection done.  Then, the dissection continued medial to the sternocleidomastoid muscle and then medial to the carotid artery to the prevertebral fascia, which was gently dissected and released superiorly and inferiorly.  Spinal needles were placed into the displaced C5-C6 and C6-C7 to confirm these disk levels using lateral fluoroscopy.  Following this, monopolar coagulation was used to dissect the medial edge of the longus colli muscles off the adjacent vertebrae between C5-C7 and then the Trimline retractors were placed to retract the longus colli muscles laterally and blunt retractors were placed superiorly and inferiorly.  A #15 scalpel was used to do a discectomy at C5-C6 from endplate-to-endplate and uncovertebral joint.  On the uncovertebral joint, a pituitary rongeur was used to empty out any disk material ____________ to further remove the disk material down to the posterior aspect.  This was done under the microscope.  A high-speed drill under the microscope was used to drill down the endplates to the posterior aspect of the annulus.  A blunt trocar was passed underneath the posterior longitudinal ligament and it was gently released using the #15 scalpel and then Kerrison punches 1-mm and then 2-mm were used to decompress further disk calcified material at the C5-C6 level.  This was done bilaterally to allow good decompression of the thecal sac and adjacent neuroforamen.  Then, at the C6-C7 level, in a similar fashion, #15 blade was used to do a discectomy from uncovertebral joint to uncovertebral joint and from endplate-to-endplate using a #15 scalpel to enter the disk space and then the curette was then used to remove the disk calcified material in the endplate, and then high-speed drill under the microscope was used to drill down the disk space down to the posterior aspect of the annulus where a blunt trocar was passed underneath the posterior longitudinal ligament which was gently released.  Then using the Kerrison punches, we used 1-mm and 2-mm, to remove disk calcified material, which was extending more posteriorly to the left and the right.  This was gently removed and decompressed to allow good decompression of the thecal sac and adjacent nerve roots.  With this done, the wound was irrigated.  Hemostasis was ensured with bipolar coagulation.  Vertebral body distraction pins were then placed to the vertebral body of C5 and C7 for vertebral distraction and then a 6-mm allograft performed grafts were taken and packed in either aspect with demineralized bone matrix and this was tapped in flush with the vertebral bodies above and below C5-C6 and C6-C7 discectomy sites.  Then, the vertebral body distraction pins were gently removed to allow for graft seating and compression and then the anterior cervical plate (Danek windows titanium plates) was then taken and sized and placed.  A temporary pin was initially used to align the plate and then keeping the position and then two screw holes were drilled in the vertebral body of C5, two in the vertebral body of C6, and two in the vertebral body of C7.  The holes were then drilled and after this self-tapping screws were placed into the vertebral body of C5, C6, and C7 across the plate to allow the plate to fit and stay flush with the vertebral body between C5, C6, and C7.  With this done, operative fluoroscopy was used to check good alignment of the graft, screw, and plate, and then the wound was irrigated.  Hemostasis was ensured with bipolar coagulation and then the locking screws were tightened down.  A #10 round Jackson-Pratt drain was placed into the prevertebral space and brought out from a separate stab wound skin incision site.  Then, the platysma was approximated using 2-0 Vicryl inverted interrupted stitches and the skin closed with 4-0 Vicryl running subcuticular stitch.  Steri-Strips and sterile dressings were applied.  The patient remained hemodynamically stable throughout the procedure.  Throughout the procedure, the microscope had been used for the disk decompression and high-speed drilling.  In addition, intraoperative SSEP, EMG monitoring, and motor-evoked potentials remained stable throughout the procedure.  The patient remained stable throughout the procedure.","surgery, cervical disk protrusions, cervical radiculopathy, cervical pain, cervical plate fixation, sofamor danek titanium window plate, anterior cervical discectomy, vertebral body, vertebral, disk, intraoperative, anterior, decompression, fluoroscopy, radiculopathy, discectomy, cervical,"
 Anterior cervical discectomy and removal of herniated disk and osteophytes and decompression of spinal cord and bilateral nerve root decompression.  Harvesting of autologous bone from the vertebral bodies.  Grafting of allograft bone for creation of arthrodesis., Surgery, Anterior Cervical Discectomy ,"PREOPERATIVE DIAGNOSES,1.  Cervical spondylosis with myelopathy.,2.  Herniated cervical disk, C4-C5.,POSTOPERATIVE DIAGNOSES,1.  Cervical spondylosis with myelopathy.,2.  Herniated cervical disk, C4-C5.,OPERATIONS PERFORMED,1.  Anterior cervical discectomy and removal of herniated disk and osteophytes and decompression of spinal cord at C5-C6.,2.  Bilateral C6 nerve root decompression.,3.  Anterior cervical discectomy at C4-C5 with removal of herniated disk and osteophytes and decompression of spinal cord.,4.  Bilateral C5 nerve root decompression.,5.  Anterior cervical discectomy at C3-C4 with removal of herniated disk and osteophytes, and decompression of spinal cord.,6.  Bilateral C4 nerve root decompression.,7.  Harvesting of autologous bone from the vertebral bodies.,8.  Grafting of allograft bone for creation of arthrodesis.,9.  Creation of arthrodesis with allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C5-C6.,10.  Creation of additional arthrodesis using allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C4-C5.,11.  Creation of additional arthrodesis using allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C3-C4.,12.  Placement of anterior spinal instrumentation from C3 to C6 using a Synthes Small Stature Plate, using the operating microscope and microdissection technique.,INDICATIONS FOR PROCEDURE: , This 62-year-old man has severe cervical spondylosis with myelopathy and cord compression at C5-C6.  There was a herniated disk with cord compression and radiculopathy at C4-C5.  C3-C4 was the source of neck pain as documented by facet injections.,A detailed discussion ensued with the patient as to the pros and cons of the surgery by two levels versus three levels.  Because of the severe component of the neck pain that has been relieved with facet injections, we elected to proceed ahead with anterior cervical discectomy and fusion at C3-C4, C4-C5, and C5-C6.,I explained the nature of this procedure in great detail including all risks and alternatives.  He clearly understands and has no further questions and requests that I proceed.,PROCEDURE:  ,The patient was placed on the operating room table and was intubated taking great care to keep the neck in a neutral position.  The methylprednisolone spinal cord protocol was instituted with bolus and continuous infusion dosages.,The left side of the neck was carefully prepped and draped in the usual sterile manner.,A transverse incision was made in the neck crease.  Dissection was carried down through the platysma musculature and the anterior spine was exposed.  The medial borders of the longus colli muscle were dissected free from their attachments to the spine.  Caspar self-retaining pins were placed into the bodies of C3, C4, C5, and C6 and x-ray localization was obtained.  A needle was placed in what was revealed to be the disk space at C4-C5 and an x-ray confirmed proper localization.,Self-retaining retractors were then placed in the wound, taking great care to keep the blades of the retractors underneath the longus colli muscles.,First I removed the large amount of anterior overhanging osteophytes at C5-C6 and distracted the space.  The high-speed cutting bur was used to drill back the osteophytes towards the posterior lips of the vertebral bodies.,An incision was then made at C4-C5 and the annulus was incised and a discectomy was performed back to the posterior lips of the vertebral bodies.,The retractors were then adjusted and again discectomy was performed at C3-C4 back to the posterior lips of the vertebral bodies.  The operating microscope was then utilized.,Working under magnification, I started at C3-C4 and began to work my way down to the posterior longitudinal ligament.  The ligament was incised and the underlying dura was exposed.  I worked out laterally towards the takeoff of the C4 nerve root and widely decompressed the nerve root edge of the foramen.  There were a large number of veins overlying the nerve root which were oozing and rather than remove these and produce tremendous amount of bleeding, I left them intact.  However, I could to palpate the nerve root along the pedicle into the foramen and widely decompressed it on the right.  The microscope was angled to the left side where similar decompression was achieved.,The retractors were readjusted and attention was turned to C4-C5.  I worked down through bony osteophytes and identified the posterior longitudinal ligament.  The ligament was incised; and as I worked to the right of the midline, I encountered herniated disk material which was removed in a number of large pieces.  The C5 root was exposed and then widely decompressed until I was flush with the pedicle and into the foramen.  The root had a somewhat high takeoff but I worked to expose the axilla and widely decompressed it.  Again the microscope was angled to the left side where similar decompression was achieved.  Central decompression was achieved here where there was a moderate amount of spinal cord compression.  This was removed by undercutting with 1 and 2-mm Cloward punches.,Attention was then turned to the C5-C6 space.  Here there were large osteophytes projecting posteriorly against the cord.  I slowly and carefully used the high-speed cutting diamond bur to drill these and then used 1 to 2-mm Cloward punches to widely decompress the spinal cord.  This necessitated undercutting the bodies of both C5 and C6 extensively, but I was then able to achieve a good decompression of the cord.  I exposed the C6 root and widely decompressed it until I was flush with the pedicle and into the foramen on the right.  The microscope was angled to the left side where a similar decompression was achieved.,Attention was then turned to creation of the arthrodesis.  A high-speed Cornerstone bur was used to decorticate the bodies of C5-C6, C4-C5 and C3-C4 to create a posterior shelf to prevent backwards graft migration.  Bone dust during the drilling was harvested for later use.,Attention was turned to creation of the arthrodesis.  Using the various Synthes sizers, I selected a 7-mm lordotic graft at C5-C6 and an 8-mm lordotic graft at C4-C5 and a 9-mm lordotic graft at C3-C4.  Each graft was filled with autologous bone from the vertebral bodies and bone morphogenetic protein soaked sponge.  I decided to use BMP in this case because there were three levels of fusion and because this patient has a very heavy history of smoking and having just recently discontinued for two weeks.  The BMP sponge and the ____________ bone were then packed in the center of the allograft.,Under distraction, the graft was placed at C3-C4, C4-C5, and C5-C6 as described.  An x-ray was obtained which showed good graft placement with preservation of the cervical lordosis.,Attention was turned to the placement of anterior spinal instrumentation.  Various sizes of Synthes plates were selected until I decided that a 54-mm plate was appropriate.  The plate had to be somewhat contoured and bent inferiorly and the vertebral bodies had to be drilled so that the plates would sit flush.  The holes were drilled and the screws were placed.  Eight screws were placed with two screws at C3, two screws at C4, two screws at C5, and two screws at C6.  All eight screws had good purchase.  The locking screws were tightly applied.  An x-ray was obtained which showed good placement of the graft, plate, and screws.,Attention was turned to closure.  The wound was copiously irrigated with Bacitracin solution and meticulous hemostasis was obtained.  A medium Hemovac drain was placed in the anterior vertebral body space and brought out through a separate stab incision in the skin.  The wound was then carefully closed in layers.  Sterile dressings were applied, and the operation was terminated.,The patient tolerated the procedure well and left for the recovery room in excellent condition.  The sponge and needle counts were reported as correct.  There were no intraoperative complications.,Specimens were sent to Pathology consisting of disk material and bone and soft tissue.",
" Selective coronary angiography of the right coronary artery, left main LAD, left circumflex artery, left ventricular catheterization, left ventricular angiography, angioplasty of totally occluded mid RCA, arthrectomy using 6-French catheter, stenting of the mid RCA, stenting of the proximal RCA, femoral angiography and Perclose hemostasis.", Surgery, Angiography & Catheterization - 1 ,"INDICATION:,  Acute coronary syndrome.,CONSENT FORM: , The procedure of cardiac catheterization/PCI risks included but not restricted to death, myocardial infarction, cerebrovascular accident, emergent open heart surgery, bleeding, hematoma, limb loss, renal failure requiring dialysis, blood loss, infection had been explained to him.  He understands.  All questions answered and is willing to sign consent.,PROCEDURE PERFORMED:,  Selective coronary angiography of the right coronary artery, left main LAD, left circumflex artery, left ventricular catheterization, left ventricular angiography, angioplasty of totally occluded mid RCA, arthrectomy using 6-French catheter, stenting of the mid RCA, stenting of the proximal RCA, femoral angiography and Perclose hemostasis.,NARRATIVE: , The patient was brought to the cardiac catheterization laboratory in a fasting state.  Both groins were draped and sterilized in the usual fashion.  Local anesthesia was achieved with 2% lidocaine to the right groin area and a #6-French femoral sheath was inserted via modified Seldinger technique in the right common femoral artery.  Selective coronary angiography was performed with #6 French JL4 catheter for the left coronary system and a #6 French JR4 catheter of the right coronary artery.  Left ventricular catheterization and angiography was performed at the end of the procedure with a #6-French angle pigtail catheter.,FINDINGS,1.  Hemodynamics systemic blood pressure 140/70 mmHg.  LVEDP at the end of the procedure was 13 mmHg.,2.  The left main coronary artery is a large with mild diffuse disease in the distal third resulting in less than 20% angiographic stenosis at the take off of the left circumflex artery.  The left circumflex artery is a large caliber vessel with diffuse disease in the ostium of the proximal segment resulting in less than 30% angiographic stenosis.  The left circumflex artery gives rise to a high small obtuse marginal branch that has high moderate-to-severe ostium.  The rest of the left circumflex artery has mild diffuse disease and it gives rise to a second large obtuse marginal branch that bifurcates into an upper and lower trunk.,The LAD is calcified and diffusely disease in the proximal and mid portion.  There is mild nonobstructive disease in the proximal LAD resulting in less than 20% angiographic stenosis.,3.  The right coronary artery is dominant.  It is septal to be occluded in the mid portion.,The findings were discussed with the patient and she opted for PCI.  Angiomax bolus was started.  The ACT was checked.  It was higher in 300.  I have given the patient 600 mg of oral Plavix.,The right coronary artery was engaged using a #6-French JR4 guide catheter.  I was unable to cross through this lesion using a BMW wire and a 3.0x8 mm balloon support.  I was unable to cross with this lesion using a whisper wire.  I was unable to cross with this lesion using Cross-IT 100 wire.  I have also used second #6-French Amplatz right I guide catheter.  At one time, I have lost flow in the distal vessel.  The patient experienced severe chest pain, ST-segment elevation, bradycardia, and hypotension, which responded to intravenous fluids and atropine along with intravenous dopamine.,Dr. X was notified.,Eventually, an Asahi grand slam wire using the same 3.0 x 8 mm Voyager balloon support, I was able to cross into the distal vessel.  I have performed careful balloon angioplasty of the mid RCA.  I have given nitroglycerin under the nursing several times during the procedure.,I then performed arthrectomy using #5-French export catheter.,I performed more balloon predilation using a 3.0 x16 mm Voyager balloon.  I then deployed 4.0 x15 mm, excised, and across the mid RCA at 18 atmospheres with good angiographic result.  Proximal to the proximal edge of the stent, there was still some persistent haziness most likely just diseased artery/diffuse plaquing.  I decided to cover this segment using a second 4.0 x 15 mm, excised, and two stents were overlapped, the overlap was postdilated using the same stent delivery balloon at high pressure with excellent angiographic result.,Left ventricular catheterization was performed with #6-French angle pigtail catheter.  The left ventricle is rather smaller in size.  The mid inferior wall is minimally hypokinetic, ejection fraction is 70%.  There is no evidence of aortic wall stenosis or mitral regurgitation.,Femoral angiography revealed that the entry point was above the bifurcation of the right common femoral artery and I have performed this as Perclose hemostasis.,CONCLUSIONS,1.  Normal left ventricular size and function.  Ejection fraction is 65% to 70%.  No MR.,2.  Successful angioplasty and stenting of the subtotally closed mid RCA.  This was hard, organized thrombus, very difficult to penetrate.  I have deployed two overlapping 4.0 x15 mm excised and with excellent angiographic result.  The RCA is dominant.,3.  No moderate disease in the distal left main.  Moderate disease in the ostium of the left circumflex artery.  Mild disease in the proximal LAD.,PLAN: , Recommend smoking cessation.  Continue aspirin lifelong and continue Plavix for at least 12 months.","surgery, acute coronary syndrome, circumflex artery, ventricular catheterization, ventricular angiography, angioplasty, coronary artery, coronary angiography, arthrectomy, femoral angiography, perclose hemostasis, selective coronary angiography, angiographic stenosis, rca, coronary, catheterization, artery, angiography, hemostasis, wire, lad, femoral, angiographic, stenting, proximal, "
" Adenotonsillectomy, primary, patient under age 12.", Surgery, Adenotonsillectomy ,"PREOPERATIVE DIAGNOSIS: , Chronic hypertrophic adenotonsillitis.,POSTOPERATIVE DIAGNOSIS: , Chronic hypertrophic adenotonsillitis.,OPERATIVE PROCEDURE:,  Adenotonsillectomy, primary, patient under age 12.,ANESTHESIA: , General endotracheal anesthesia.,PROCEDURE IN DETAIL: , This patient was brought from the holding area and did receive preoperative antibiotics of Cleocin as well as IV Decadron.  She was placed supine on the operating room table.  General endotracheal anesthesia was induced without difficulty.  In the holding area, her allergies were reviewed.  It is unclear whether she is actually allergic to penicillin.  Codeine caused her to be excitable, but she did not actually have an allergic reaction to codeine.  She might be allergic to BACTRIM and SULFA.  After positioning a small shoulder roll and draping sterilely, McIvor mouthgag, #3 blade was inserted and suspended from the Mayo stand.  There was no bifid uvula or submucous cleft.  She had 3+ cryptic tonsils with significant debris in the tonsillar crypts.  Injection at each peritonsillar area with 0.25% with Marcaine with 1:200,000 Epinephrine, approximately 1.5 mL total volume.  The left superior tonsillar pole was then grasped with curved Allis forceps.  _______ incision and dissection in the tonsillar capsule and hemostasis and removal of the tonsil was obtained with Coblation Evac Xtra Wand on 7/3.  Mouthgag was released, reopened, no bleeding was seen.  The right tonsil was then removed in the same fashion.  The mouthgag released, reopened, and no bleeding was seen.  Small red rubber catheter in the nasal passage was used to retract the soft palate.  She had mild-to-moderate adenoidal tissue residual.  It was removed with Coblation Evac Xtra gently curved Wand on 9/5.  Red rubber catheter was then removed.  Mouthgag was again released, reopened, no bleeding was seen.  Orogastric suction carried out with only scant clear stomach contents.  Mouthgag was then removed.  Teeth and lips were inspected and were in their preoperative condition.  The patient then awakened, extubated, and taken to recovery room in good condition.,TOTAL BLOOD LOSS FROM TONSILLECTOMY: , Less than 2 mL.,TOTAL BLOOD LOSS FROM ADENOIDECTOMY: , Less than 2 mL.,COMPLICATIONS: , No intraoperative events or complications occurred.,PLAN:,  Family will be counseled postoperatively.  Postoperatively, the patient will be on Zithromax oral suspension 500 mg daily for 5 to 7 days, Lortab Elixir for pain.  _______ and promethazine if needed for nausea and vomiting.","surgery, hypertrophic adenotonsillitis, adenotonsillitis, endotracheal anesthesia, coblation evac xtra wand, lortab elixir, red rubber catheter, total blood loss, adenotonsillectomy, forceps, mouthgag,"
 Adenoidectomy.  Adenoid hypertrophy.  The McIvor mouth gag was placed in the oral cavity and the tongue depressor applied. , Surgery, Adenoidectomy - 1 ,"PREOPERATIVE DIAGNOSIS: , Adenoid hypertrophy.,POSTOPERATIVE DIAGNOSIS: , Adenoid hypertrophy.,PROCEDURE PERFORMED:  ,Adenoidectomy.,ANESTHESIA: , General endotracheal.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and prepped and draped in the usual fashion after induction of general endotracheal anesthesia.  The McIvor mouth gag was placed in the oral cavity and the tongue depressor applied.  Two #12-French red rubber Robinson catheters were placed, 1 in each nasal passage, and brought out through the oral cavity and clamped over a dental gauze roll placed on the upper lip to provide soft palate retraction.  The nasopharynx was inspected with the laryngeal mirror.  Serial passages of the curettes were utilized to remove the nasopharyngeal tissue, following which the nasopharynx was packed with 2 cherry gauze sponges coated in a solution of 0.25% Neo-Synephrine and tannic acid powder.,Attention was then redirected to the oropharynx.  The McIvor was reopened, packs removed, and the bleeding was controlled with the suction Bovie unit.  The catheters were removed, and the nasal passages and oropharynx were suctioned free of debris.  The McIvor was then removed, and the procedure was terminated.,The patient tolerated the procedure well and left the operating room in good condition.","surgery, palate, nasal passage, mcivor mouth gag, oral cavity, nasal, nasopharynx, oropharynx, hypertrophy, oral, cavity, mcivor, tongue, adenoidectomy"
 The Ahmed shunt was primed and placed in the superior temporal quadrant and it was sutured in place with two 8-0 nylon sutures.  The knots were trimmed. , Surgery, Ahmed Shunt Placement ,"PROCEDURE IN DETAIL:  ,While in the holding area, the patient received a peripheral IV from the nursing staff.  In addition, pilocarpine 1% was placed into the operative eye, two times, separated by 10 minutes.  The patient was wheeled to the operating suite where the anesthesia team established peripheral monitoring lines.  Through the IV, the patient received IV sedation in the form of propofol and once somnolent from this, a retrobulbar block was administrated consisting of 2% Xylocaine plain.  Approximately 3 mL were administered.  The patient then underwent a Betadine prep with respect to the face, lens, lashes, and eye.  During the draping process, care was taken to isolate the lashes.  A Vicryl traction suture was placed through the superior cornea and the eye was reflected downward to expose the superior temporal conjunctiva.  Approximately 8 to 10 mm posterior to limbus, the conjunctiva was incised and dissected forward to the limbus.  Blunt dissection was carried out in the superotemporal quadrant.  Next, a 2 x 3-mm scleral flap was outlined that was one-half scleral depth in thickness.  This flap was cut forward to clear cornea using a crescent blade.  The Ahmed shunt was then primed and placed in the superior temporal quadrant and it was sutured in place with two 8-0 nylon sutures.  The knots were trimmed.  The tube was then cut to an appropriate length to enter the anterior chamber.  The anterior chamber was then entered after a paracentesis wound had been made temporally.  A trabeculectomy was done and then the tube was threaded through the trabeculectomy site.  The tube was sutured in place with a multi-wrapped 8-0 nylon suture.  The scleral flap was then sutured in place with two 10-0 nylon sutures.  The knots were trimmed, rotated and buried.  A scleral patch was then placed of an appropriate size over the two.  It was sutured in place with interrupted 8-0 nylon sutures.  The knots were trimmed.  The overlying conjunctiva was then closed with a running 8-0 Vicryl suture with a BV needle.  The anterior chamber was filled with Viscoat to keep it deep as the eye was somewhat soft.  A good flow was established with irrigation into the anterior chamber.  Homatropine, Econopred, and Vigamox drops were placed into the eye.  A patch and shield were placed over the eye after removing the draping and the speculum.  The patient tolerated the procedure well.  He was taken to the recovery in good condition.  He will be seen in followup in the office tomorrow.","surgery, cornea, ahmed shunt, nylon sutures, trabeculectomy, conjunctiva, chamberNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair.  Patient with a 5.5-cm diameter nonfunctioning mass in his right adrenal., Surgery, Adrenalectomy & Umbilical Hernia Repair ,"PREOPERATIVE DIAGNOSES,1.  Adrenal mass, right sided.,2.  Umbilical hernia.,POSTOPERATIVE DIAGNOSES,1.  Adrenal mass, right sided.,2.  Umbilical hernia.,OPERATION PERFORMED: , Laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair.,ANESTHESIA:  ,General.,CLINICAL NOTE: , This is a 52-year-old inmate with a 5.5 cm diameter nonfunctioning mass in his right adrenal.  Procedure was explained including risks of infection, bleeding, possibility of transfusion, possibility of further treatments being required.  Alternative of fully laparoscopic are open surgery or watching the lesion.,DESCRIPTION OF OPERATION:  ,In the right flank-up position, table was flexed.  He had a Foley catheter in place.  Incision was made from just above the umbilicus, about 5.5 cm in diameter.  The umbilical hernia was taken down.  An 11 mm trocar was placed in the midline, superior to the GelPort and a 5 mm trocar placed in the midaxillary line below the costal margin.  A liver retractor was placed to this.,The colon was reflected medially by incising the white line of Toldt.  The liver attachments to the adrenal kidney were divided and the liver was reflected superiorly.  The vena cava was identified.  The main renal vein was identified.  Coming superior to the main renal vein, staying right on the vena cava, all small vessels were clipped and then divided.  Coming along the superior pole of the kidney, the tumor was dissected free from top of the kidney with clips and Bovie.  The harmonic scalpel was utilized superiorly and laterally.  Posterior attachments were divided between clips and once the whole adrenal was mobilized, the adrenal vein and one large adrenal artery were noted, doubly clipped, and divided.  Specimen was placed in a collection bag, removed intact.,Hemostasis was excellent.,The umbilical hernia had been completely taken down.  The edges were freshened up.  Vicryl #1 was utilized to close the incision and 2-0 Vicryl was used to close the fascia of the trocar.,Skin closed with clips.,He tolerated the procedure well.  All sponge and instrument counts were correct.  Estimated blood loss less than 100 mL.,The patient was awakened, extubated, and returned to recovery room in satisfactory condition.","surgery, adrenalectomy, laparoscopic hand-assisted, umbilical hernia repair, vena cava, renal vein, hernia repair, laparoscopic, umbilical, hernia,"
" Left heart catheterization, bilateral selective coronary angiography, left ventriculography, and right heart catheterization.  Positive nuclear stress test involving reversible ischemia of the lateral wall and the anterior wall consistent with left anterior descending artery lesion.", Surgery, Angiography & Catheterization ,"PROCEDURES PERFORMED:,1.  Left heart catheterization.,2.  Bilateral selective coronary angiography.,3.  Left ventriculography.,4.  Right heart catheterization.,INDICATION: , Positive nuclear stress test involving reversible ischemia of the lateral wall and the anterior wall consistent with left anterior descending artery lesion.,PROCEDURE: , After risks, benefits, and alternatives of the above-mentioned procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing.  The patient was taken to cardiac catheterization suite where the right femoral region was prepped and draped in the usual sterile fashion.  1% lidocaine solution was used to infiltrate the skin overlying the right femoral artery and vein.  Once adequate anesthesia has been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right femoral artery.  A steel guidewire was inserted through the needle into the vascular lumen without resistance.  A small nick was then made in the skin.  The pressure was held.  The needle was removed over the guidewire.  Next, a #6 French arterial sheath was then advanced over the guidewire into the vascular lumen without resistance.  The guidewire and dilator were then removed.  The sheath was flushed.  Next, an angulated pigtail catheter was advanced to the level of the ascending aorta under the direct fluoroscopy visualization with the use of a guidewire.  The catheter was then guided into the left ventricle.  The guidewire and dilator were then removed.  The catheter was then flushed.  LVEDP was measured and found to be favorable for a left ventriculogram.  The left ventriculogram was performed in the RAO position with a single power injection of nonionic contrast material.  LVEDP was then remeasured.  Pullback was performed, which failed to reveal an LVAO gradient.  The catheter was then removed.  Next, a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  The ostium of the left main coronary was unable to be engaged with this catheter.  Thus it was removed over a guidewire.  Next, a Judkins left #5 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  Left main coronary artery was then engaged.  Using hand injections of nonionic contrast material, the left coronary system was evaluated in several different views.  The catheter was then removed from the ostium of the left main coronary artery and was removed over a guidewire.  Next, a Judkins right #4 catheter was then advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  Using hand injections of nonionic contrast material, the right coronary system was evaluated in several different views.  The catheter was then removed from the ostium of the right coronary artery and then removed.  The sheath was then flushed.  Because the patient did have high left ventricular end-diastolic pressures, it was determined that the patient wound need a right heart catheterization.  Thus an #18 gauge Argon needle was used to cannulate the right femoral vein.  A steel guidewire was inserted through the needle into the vascular lumen.  The needle was removed over the guidewire.  Next, an #8 French venous sheath was advanced over the guidewire into lumen without resistance.  The guidewire and dilator were then removed.  The sheath was then flushed.  Next, a Swan-Ganz catheter was advanced to the level of 20 cm.  The balloon was inflated.  Under fluoroscopic visualization, the catheter was guided into the right atrium, right ventricle, and into the pulmonary artery wedge position.  Hemodynamics were measured along the way.  PA saturation, right atrial saturation, femoral artery saturation were all obtained.  Once adequate study has been performed, the catheter was then removed.  Both sheaths were flushed and found fine.  The patient was returned to the cardiac catheterization holding area in stable satisfactory condition.,FINDINGS:,LEFT VENTRICULOGRAM:  ,There is no evidence of any wall motion abnormalities with estimated ejection fraction of 60%.  Left ventricular end-diastolic pressure was 38 mmHg preinjection and 40 mmHg postinjection.  There is no LVAO.  There is no mitral regurgitation.  There is a trileaflet aortic valve noted.,LEFT MAIN CORONARY ARTERY:  ,The left main is a moderate caliber vessel, which bifurcates into the left anterior descending and circumflex arteries.  There is no evidence of any hemodynamically significant stenosis.,LEFT ANTERIOR DESCENDING: , The LAD is a moderate caliber vessel, which traverses through the intraventricular groove and reaches the apex of the heart.  There is a proximal 60% to 70% stenotic lesion.  There was also a mid 70% to 80% stenotic lesion at the takeoff of the first and second diagonal branches.,CIRCUMFLEX ARTERY:  ,The circumflex is a moderate caliber vessel, which traverses through the atrioventricular groove.  There is a mid 60% to 70% stenotic lesion followed by a second mid 90% stenotic lesion.  The first obtuse marginal branch is small and the second obtuse marginal branch is large without any evidence of critical disease.  The third obtuse marginal branch is also small.,RIGHT CORONARY ARTERY:  ,The RCA is a moderate caliber vessel with minor luminal irregularities throughout.  There is no evidence of any critical disease.  The right coronary artery is the dominant right coronary vessel.,RIGHT HEART FINDINGS:  ,Pulmonary artery pressure equals 61/23 with a mean of 44.  Pulmonary artery wedge pressure equals 32.  Right ventricle pressure equals 65/24.  The right atrial pressure equals to 22.  Cardiac output by Fick is 4.9.  Cardiac index by Fick is 2.3.  Hand calculated cardiac output equals 7.8.  Hand calculated cardiac index equals 3.7.  On 2 liters nasal cannula, pulmonary artery saturation equals 77.8%.  Femoral artery saturation equals 99.1%.  Pulse oximetry is 99%.  Right atrial saturation is 76.3%.  Systemic blood pressure is 166/58.  Body surface area equals 2.12.  Hemoglobin equals 12.6.,IMPRESSION:,1.  Two-vessel coronary artery disease with a complex left anterior descending arterial lesion as well as circumflex disease.,2.  Normal left ventricular function with an estimated ejection fraction of 60%.,3.  Biventricular overload.,4.  Moderate pulmonary hypertension.,5.  There is no evidence of shunt.,PLAN:,1.  The patient will be admitted for IV diuresis in light of the biventricular overload.,2.  The findings of the heart catheterization were discussed in detail with the patient and the patient's family.  There is some concern with the patient's two-vessel coronary artery disease in light of the patient's diabetic history.  We will obtain a surgical evaluation for the possibility of a coronary artery bypass grafting.,3.  The patient will remain on aggressive medical regimen including ACE inhibitor, aspirin, Plavix, and nitrate.,4.  The patient will need to undergo aggressive risk factor modification including weight loss and diet control.,5.  The patient will have an Internal Medicine evaluation regarding the patient's diabetic history.",
" Lower extremity angiogram, superficial femoral artery laser atherectomy and percutaneous transluminal balloon angioplasty, external iliac artery angioplasty and stent placement, and completion angiogram.", Surgery, Angiogram & Angioplasty ,"PREOPERATIVE DIAGNOSES:,1.  Left superficial femoral artery subtotal stenosis.,2.  Arterial insufficiency, left lower extremity.,POSTOPERATIVE DIAGNOSES:,1.  Left superficial femoral artery subtotal stenosis.,2.  Arterial insufficiency, left lower extremity.,OPERATIONS PERFORMED:,1.  Left lower extremity angiogram.,2.  Left superficial femoral artery laser atherectomy.,3.  Left superficial femoral artery percutaneous transluminal balloon angioplasty.  ,4.  Left external iliac artery angioplasty.,5.  Left external iliac artery stent placement.,6.  Completion angiogram.,FINDINGS:  ,This patient was brought to the OR with a non-severe stenosis of the proximal left superficial femoral artery in the upper one-third of his thigh.  He is also known to have severe calcific disease involving the entire left external iliac system as well as the common femoral and deep femoral arteries.,Our initial plan today was to perform an atherectomy with angioplasty and stenting of the left superficial femoral artery as necessary.  However, whenever we started the procedure, it became clear that there was a severe stenosis of the left superficial femoral artery at its takeoff from the left common femoral artery.  The area was severely calcified including the external iliac artery extending up underneath the left inguinal ligament.  Indeed, this ultimately was dissected due to manipulation of sheath catheters and sheath through the area.  Ultimately, this wound up being a much more complex case than initially anticipated.,Because of the above, we ultimately performed a laser atherectomy of the left superficial femoral artery, which then had to be angioplastied to obtain a satisfactory result.  The completion angiogram showed that there was a dissection of the left external iliac artery, which precluded flow down into the left lower extremity.  We then had to come up and perform angioplasty and stenting of the left external iliac artery as well as aggressively dilating the takeoff of the less superficial femoral artery from the common femoral artery.,The left superficial femoral artery was dilated with a 6-mm balloon.,The left external iliac artery and common femoral arteries were dilated with an 8-mm balloon.,A 2.5-mm ClearPath laser probe was used to initially arthrectomize and debulk the superficial femoral artery starting at its takeoff from the common femoral artery and extending down to the tight stenotic area in the upper one-third of the thigh.  After the laser atherectomy was performed, the area still did not look good and so an angioplasty was then done, which looked good; however, as noted above, after we had dealt with the superficial femoral artery, we then had proximal inflow problems, which had to be dealt by angioplasty and stenting.,The patient had good dorsalis pedis pulses bilaterally upon completion.,The right common femoral artery was used for access in an up-and-over technique.,PROCEDURE: , With the patient in the supine position under general anesthesia, the abdomen and lower extremities were prepped and draped in the sterile fashion.,The right common femoral artery was punctured percutaneously, and a #5-French sheath was initially placed.  We used a pigtail catheter to go up and over the aortic bifurcation and placed a stiff Amplatz guidewire down into the left common femoral artery.  We then heparinized the patient and placed a #7-French Raby sheath over the Amplatz wire.  A selective left lower extremity angiogram was then done with the above-noted findings.,We then used a ClearPath 2.5-mm laser probe to laser the proximal superficial femoral artery.  Because of the findings as noted above, this became more involved than initially hoped for.  Once the laser atherectomy had been completed, the vessel still did not look good, so we used a 6-mm balloon to thoroughly dilate the area.  Once that had been done, it looked good and we performed what we felt would be a completion angiogram only to find out that we had a more proximal problem precluding flow down into the left femoral artery.,Once that was discovered, we then had to proceed with angioplasty and stenting of the left external iliac artery right down to the acetabular level.,Once we had dealt with our run-on problems, we then did another completion angiogram, which showed a good flow through the entire area and down into the left lower extremity.,Following completion of the above, all wires, sheaths, and catheters were removed from the right common femoral artery.  Firm pressure was held over the puncture site for 20 minutes followed by application of a sterile Coverlet dressing and a firm pressure dressing.,The patient tolerated the procedure well throughout.  He had good palpable dorsalis pedis pulses bilaterally on completion.  He was taken to the recovery room in satisfactory condition.  Protamine was given to partially reverse the heparin.",
" Grade 1 endometrial adenocarcinoma and low-grade mesothelioma of the ovary - Omentectomy, pelvic lymph node dissection, and laparoscopy.", Surgery, Adenocarcinoma & Mesothelioma ,"PREOPERATIVE DIAGNOSES,1.  Incomplete surgical staging of recent diagnosis of grade 1 endometrial adenocarcinoma and also low-grade mesothelioma of the ovary.,2.  Status post laparoscopic-assisted vaginal hysterectomy with bilateral salpingo-oophorectomy.,POSTOPERATIVE DIAGNOSES,1.  Incomplete surgical staging of recent diagnosis of grade 1 endometrial adenocarcinoma and also low-grade mesothelioma of the ovary.,2.  Status post laparoscopic-assisted vaginal hysterectomy with bilateral salpingo-oophorectomy.,OPERATIONS PERFORMED,1.  Robotic-assisted omentectomy.,2.  Robotic-assisted pelvic lymph node dissection.,3.  Attempted laparoscopy.,4.  Exploratory laparotomy with bilateral pelvic bilateral periaortic lymph node dissection with multiple biopsies.,ANESTHESIA:,  General/epidural anesthesia.,ESTIMATED BLOOD LOSS:,  200 mL.,COMPLICATIONS:,  None.,FINAL SPONGE AND NEEDLE COUNTS: , Correct, confirmed by x-ray JP drain x1.,INDICATIONS FOR SURGERY: , Mrs. A is a pleasant 66-year-old female who was diagnosed with an unsuspected grade 1 endometrial adenocarcinoma and low-grade mesothelioma of the ovary.  The patient is status post laparoscopic-assisted vaginal hysterectomy BSO.  The patient was referred to me by Dr. X.  Because of the incomplete staging, the patient was advised to undergo a robotic-assisted surgical staging.  Risks, benefits, and rationale of these procedures were reviewed.  The patient has understanding of these risks and wishes to proceed with the surgery as planned.,INTRAOPERATIVE FINDINGS,1.  No evidence of ascites.,2.  At the time of the exploratory laparotomy, the diaphragm was well palpated.  They were clear.  The low attachments were removed.  The lesser omentum was unremarkable.  The pancreas, spleen, and liver were unremarkable.  The gallbladder was unremarkable.  The stomach appeared grossly normal.  The small bowel was inspected from the ligament which starts to the ileocecal valve.  There is no evidence of disease.  Paracolic gutter and peritoneum was free.  The omentum was grossly normal.,3.  In the pelvis, uterus, tubes, and ovaries were absent.  There was no evidence seeding along the bladder, pelvic, cul-de-sac, and peritoneum.,4.  Retroperitoneally, pelvic lymph nodes were mostly normal; however, at the right aortic, there are nodes.  These nodes were extremely fibrotic and they were densely adherent to the anterior wall of the vena cava which precluded me from performing a robotic periaortic lymph node dissection.  There was some area that was suspicious right at the low right periaortic lymph node.  They were sent for frozen section and they came back as benign.  It is unclear to me why did the lymph nodes were quite fibrotic and firm, but we will wait for the pathology report.,PROCEDURE IN DETAIL: , The patient was given IV antibiotics prior to our incision site, sequential compression device was placed as part of the DVT prophylaxis.  I have requested an epidural catheter be placed for purpose of the periaortic lymph node dissection.  With this in mind, we proceeded as such.,We initially began with the robotic portion of the procedure.,A 1-cm supraumbilical incision made.  A Veress needle was inserted without difficulty.  Pneumoperitoneum was achieved to the abdominal pressure of 15 mmHg.  A 12mm trocar was inserted without difficulty.  After completion of this, a 12mm trocar was placed in the left lower quadrant 2 fingerbreadths medial to the anterior superior iliac spine under direct laparoscopic visualization.  After completion of this, a laparoscope was then placed in the left lower quadrant port to assist in the placement of the remainder of the da Vinci ports.  Two 8-mm ports were placed in the right upper quadrant 8 cm apart while one 8-mm port was placed in the left upper quadrant 8 cm apart.  After completion of this, the patient was placed in steep Trendelenburg position.  The robotic system was then docked and after docking the robotic system, the instrumentation was inserted under direct laparoscopic visualization to ensure that there was no injury to the abdominal contents.  Once this was completed, the robotic camera was then docked.  We then proceeded with our daVinci portion of the procedure.,I then proceeded now with the omentectomy.  The omentum was taken off the transverse colon with the harmonic scalpel.  The entire omentum was removed and placed in the pelvis.  After completion of this, I then proceeded now with the pelvic lymph node dissection.,An incision was made parallel along the peritoneum overlying the psoas muscle.  All the lymph node bearing tissues along the external iliac artery and vein were subsequently skeletonized off the vessels and resected.  The lymph node bearing tissues interposed between the external iliac vein and psoas muscle were mobilized into the obturator fossa and subsequently removed off the accessory obturator vein, artery and nerve.  In the process of removing the lymphoid tissues, the genitofemoral nerve along with the accessory obturator vein, obturator artery and nerve were all preserved.  The lymphoid tissues interposed between the external iliac vein and psoas muscle along with the common iliac vessels were also subsequently removed.  The lymph node bearing tissues bifurcating at the hypogastric and the external iliac vein were likewise removed in addition to the hypogastric lymph nodes.  All the lymph node tissues were placed in an Endobag and removed and submitted as pelvic nodes on the right side and subsequently the left side.  Boundaries of the pelvic nodal dissection distally were the external circumflex iliac vein, laterally the psoas muscle along with the obturator internus fascia, medially the superior vesical artery along with the ureter, and inferiorly below the obturator nerve.,At this point in time, we have attempted the periaortic lymph node dissection.  I did open up the peritoneum overlying the bifurcation of the aorta.  This peritoneum was incised up to the level of the duodenal recess.  It was at this point in time that the periaortic lymph node dissection was extremely difficult.  I was unable to get a tissue plane as the lymph nodes were apparently very fibrotic.  I was concerned that I would tear off the anterior wall of the cava in the process of trying to perform the right periaortic lymph node.  For this reason, I aborted the robotic procedure or in after nearly attempting for about an hour and a half for the periaortic lymph nodes.  Once this was unsuccessful, the robotic system was then dedocked.  I then placed additional ports.  A 5-mm port was placed in the suprapubic region, two fingerbreadths above.  A right lower quadrant 12-mm port was placed.  After completion of this, I had attempted to see whether we could do the remainder of the periaortic lymph node dissection via laparoscopically.  Despite an attempt for a nearly 35 minutes, I was not able to get adequate exposure.  The small bowel kept on falling in the operative field which precluded us to perform the procedure safely.  For this reason, I converted to an open procedure.,A midline incision was made from suprapubic bone and extended above the umbilicus.  The abdominal cavity was entered without injuring the bell.  After entering the abdomen, omentum was removed.  Ray-Tec sponges were removed.  We covered for the Ray-Tec sponges.  After completion of this, Thompson retractor was placed.  The patient was placed in C-Trendelenburg position.  The bowel was packed cephalad.  Retroperitoneum space was entered right and left ureters were identified.  I then meticulously resected the lymphoid-bearing tissues anterior and lateral to the cava.  This dissection was quite difficult as the lymph nodes were extremely fibrotic and adherent to the caval wall.  I was able to freed up these lymph nodes without injuring of the cava.  Likewise, the left periaortic lymph node dissection was carried out from the level of the bifurcation to 1 cm above the IMA.  All the periaortic lymph node dissection was then carried out.  After completion of this, I then took washings.  Random biopsies were obtained of the cul-de-sac and right and left pelvic side wall along with the right and left paracolic gutter.  After completion of this, the patient appears to have tolerated the procedure well.  There was no obvious gross disease.  The bowel was inspected meticulously to ensure that there was no evidence of injury.  Once this was completed, the bowel was placed back to its normal position.  Several film solutions were placed.  We counted for sponges, needles, and instruments.  Once this was counted for, the fascia was then closed with #2 Vicryl suture in a mass closure fashion.  The subcutaneous route was copiously irrigated with water.  The JP drain was brought to the right lower quadrant incision.  All the incision ports were then closed with 3-0 Monocryl suture.  Likewise, the midline incision was closed with 3-0 Monocryl sutures.,At the conclusion of the procedure, there was no obvious gross disease left.,",
 Adenoidectomy procedure, Surgery, Adenoidectomy ,"ADENOIDECTOMY,PROCEDURE:,  The patient was brought into the operating room suite, anesthesia administered via endotracheal tube.  Following this the patient was draped in standard fashion.  The Crowe-Davis mouth gag was inserted in the oral cavity.  The palate and tonsils were inspected, the palate was suspended with a red rubber catheter passed through the right nostril.  Following this, the mirror was used to visualize the adenoid pad and an adenoid curet was seated against the vomer.  The adenoid pad was removed without difficulty.  The nasopharynx was packed.  Following this, the nasopharynx was unpacked, several discrete bleeding sites were gently coagulated with electrocautery and the nasopharynx and oral cavity were irrigated.  The Crowe-Davis was released.,The patient tolerated the procedure without difficulty and was in stable condition on transfer to recovery.","surgery, adenoidectomy, crowe-davis, adenoid pad, electrocautery, endotracheal tube, gently coagulated, mouth gag, nasopharynx, oral cavity, red rubber catheter, vomer, palate, tonsilsNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Adenotonsillectomy.  Adenotonsillitis with hypertrophy.  The patient is a very nice patient with adenotonsillitis with hypertrophy and obstructive symptoms.  Adenotonsillectomy is indicated., Surgery, Adenotonsillectomy - 2 ,"POSTOPERATIVE DIAGNOSIS:  Adenotonsillitis with hypertrophy.,OPERATION PERFORMED:  Adenotonsillectomy.,ANESTHESIA:  General endotracheal.,INDICATIONS:  The patient is a very nice patient with adenotonsillitis with hypertrophy and obstructive symptoms.  Adenotonsillectomy is indicated.,DESCRIPTION OF PROCEDURE:  The patient was placed on the operating room table in the supine position.  After adequate general endotracheal anesthesia was administered, table was turned and shoulder roll was placed on the shoulders and face was draped in clean fashion.  A McIvor mouth gag was applied.  The tongue was retracted anteriorly and the McIvor was gently suspended from a Mayo stand.  A red rubber Robinson catheter was inserted through the left naris and the soft palate was retracted superiorly.  The adenoids were removed with suction electrocautery under mere visualization.  The left tonsil was grasped with a curved Allis forceps, retracted medially and the anterior tonsillar pillar was incised with Bovie electrocautery.  The tonsil was removed from the superior and inferior pole using Bovie electrocautery in its entirety in the subcapsular fashion.  The right tonsil was grasped in the similar fashion and retracted medially and the anterior tonsillar pillar was incised with Bovie electrocautery.  The tonsil was removed from the superior pole and inferior pole using Bovie electrocautery in its entirety in the subcapsular fashion.  The inferior, middle and superior pole vessels were further cauterized with suction electrocautery.  Copious saline irrigation of the oral cavity was then performed.  There was no further identifiable bleeding at the termination of the procedure.  The estimated blood loss was less than 10 mL.  The patient was extubated in the operating room, brought to the recovery room in satisfactory condition.  There were no intraoperative complications.","surgery, hypertrophy, adenotonsillitis, tonsillar pillar, bovie electrocautery, adenotonsillectomyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Adenotonsillectomy.  Recurrent tonsillitis.  The adenoid bed was examined and was moderately hypertrophied.  Adenoid curettes were used to remove this tissue and packs placed. , Surgery, Adenotonsillectomy - 1 ,"PREOPERATIVE DIAGNOSIS: , Recurrent tonsillitis.,POSTOPERATIVE DIAGNOSIS: , Recurrent tonsillitis.,PROCEDURE:  ,Adenotonsillectomy.,COMPLICATIONS:,  None.,PROCEDURE DETAILS:, The patient was brought to the operating room and, under general endotracheal anesthesia in supine position, the table turned and a McIvor mouthgag placed.  The adenoid bed was examined and was moderately hypertrophied.  Adenoid curettes were used to remove this tissue and packs placed.  Next, the right tonsil was grasped with a curved Allis and, using the gold laser, the anterior tonsillar pillar incised and, with this laser, dissection carried from the superior pole to the inferior pole and removed off the tonsillar muscular bed.  A similar procedure was performed on the contralateral tonsil.  Following meticulous hemostasis, saline was used to irrigate and no further bleeding noted.  The patient was then allowed to awaken and was brought to the recovery room in stable condition.","surgery, curved allis, tonsillitis, hypertrophied, curettes, tonsillar, adenoid, adenotonsillectomy, "
 Bilateral open Achilles lengthening with placement of short leg walking cast., Surgery, Achilles Lengthening ,"PREOPERATIVE DIAGNOSIS: , Idiopathic toe walker.,POSTOPERATIVE DIAGNOSIS: , Idiopathic toe walker.,PROCEDURE: , Bilateral open Achilles lengthening with placement of short leg walking cast.,ANESTHESIA: , Surgery performed under general anesthesia.  A total of 10 mL of 0.5% Marcaine local anesthetic was used.,COMPLICATIONS:  ,No intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,TOURNIQUET TIME:  ,On the left side was 30 minutes, on the right was 21 minutes.,HISTORY AND PHYSICAL:,  The patient is a 10-year-old boy who has been a toe walker since he started ambulating at about a year.  The patient had some mild hamstring tightness with his popliteal angle of approximately 20 degrees bilaterally.  He does not walk with a crouched gait but does toe walk.  Given his tightness, surgery versus observation was recommended to the family.  Family however wanted to correct his toe walking.  Surgery was then discussed.  Risks of surgery include risks of anesthesia, infection, bleeding, changes in sensation and motion of the extremities, failure to resolve toe walking, possible stiffness, cast, and cast problems.  All questions were answered and parents agreed to above surgical plan.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating table  General anesthesia was then administered.  The patient received Ancef preoperatively.  The patient was then subsequently placed prone with all bony prominences padded.  Two bilateral nonsterile tourniquets were placed on each thigh.  Both extremities were then prepped and draped in a standard surgical fashion.  We turned our attention first towards the left side.  A planned incision of 1 cm medial to the Achilles tendon was marked on the skin.  The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg.  Incision was then made and carried down through subcutaneous fat down to the tendon sheath.  Achilles tendon was identified and Z-lengthening was done with the medial distal half cut.  Once Z-lengthening was completed proximally, the length of the Achilles tendon was then checked.  This was trimmed to obtain an end-on-end repair with 0 Ethibond suture.  This was also oversewn.  Wound was then irrigated.  Achilles tendon sheath was reapproximated using 2-0 Vicryl as well as the subcutaneous fat.  The skin was closed using 4-0 Monocryl.  Once the wound was cleaned and dried and dressed with Steri-Strips and Xeroform, the area was injected with 0.5% Marcaine.  It was then dressed with 4 x 4 and Webril.  Tourniquet was released at 30 minutes.  The same procedure was repeated on the right side with tourniquet time of 21 minutes.  While the patient was still prone, two short-leg walking casts were then placed.  The patient tolerated the procedure well and was subsequently flipped supine on to hospital gurney and taken to PACU in stable condition.,POSTOPERATIVE PLAN:  ,The patient will be discharged on the day of surgery.  He may weightbear as tolerated in his cast, which he will have for about 4 to 6 weeks.  He is to follow up in approximately 10 days for recheck as well as prescription for intended AFOs, which he will need up to 6 months.  The patient may or may not need physical therapy while his Achilles lengthenings are healing.  The patient is not to participate in any PE for at least 6 months.  The patient is given Tylenol No. 3 for pain.","surgery, toe walker, achilles lengthening, idiopathic toe walker, short leg walking, subcutaneous fat, tendon sheath, leg walking, achilles tendon, toe, tourniquet, tendon, intraoperative,"
 Adenoidectomy and tonsillectomy and lingual frenulectomy.   Chronic adenotonsillitis and ankyloglossia., Surgery, Adenoidectomy & Tonsillectomy & Lingual Frenulectomy ,"PREOPERATIVE DIAGNOSES:,1.  Chronic adenotonsillitis.,2.  Ankyloglossia,POSTOPERATIVE DIAGNOSES:,1.  Chronic adenotonsillitis.,2.  Ankyloglossia,PROCEDURE PERFORMED:,1.  Adenoidectomy and tonsillectomy.,2.  Lingual frenulectomy.,ANESTHESIA: , General endotracheal.,FINDINGS/SPECIMEN:,  Tonsil and adenoid tissue.,COMPLICATIONS: , None.,CONDITION:  ,The patient is stable and tolerated the procedure well, and sent to PACU.,HISTORY OF PRESENT ILLNESS: , This is a 3-year-old child with a history of adenotonsillitis.,PROCEDURE: , The patient was prepped and draped in the usual sterile fashion.  A curved hemostat was used to grasp the lingual frenulum.  The stat was removed and Metzenbaum scissors were used to free the lingual frenulum.  Cautery was used to allow hemostasis.  The patient was then turned.  McIvor mouth gag was inserted.  Tonsils and adenoids were exposed.  The patient's right tonsil was first grasped with a curved hemostat.  Needle tip cautery was used to free the superior pole of tonsil.  The tonsil was then grasped in medial superior aspect with a straight hemostat.  The tonsil fascia planes were identified with Bovie dissection along the plane.  The tonsil was freed from anterior pillar and posterior pillar.  Amputation occurred along the same plane as the patient's tongue.  Suction cautery was then used to allow for hemostasis.  The patient's adenoids were then viewed with an adenoid mirror.  An adenoid curet was used to remove the patient's adenoid tissue.  Specimen sent.  Suction cautery was used to allow for hemostasis.  Superior pole of left tonsil was then grasped with a curved hemostat.  Superior pole was freed using needle tip Bovie dissection.  Beginning with 15 desiccate, after superior pole was free, Bovie was switched to 15 fulgurate, and the tonsil was stripped from anterior and posterior pillars.  The tonsil was then amputated at the same plane as tongue base.  Hemostasis was achieved with using suction cautery.  Mouth gag was removed.  Dual position and occlusion were tested.  The patient was extubated and tolerated the procedure well and sent back to PACU.","surgery, adenotonsillitis, ankyloglossia, adenoidectomy, tonsillectomy, frenulectomy, tonsil, adenoid tissue, metzenbaum scissors, lingual frenulectomy, chronic adenotonsillitis, curved hemostat, suction cautery, hemostat, hemostasis, lingual, cautery"
" Achilles tendon rupture, left lower extremity.  Primary repair left Achilles tendon.  The patient was stepping off a hilo at work when he felt a sudden pop in the posterior aspect of his left leg.  The patient was placed in posterior splint and followed up at ABC orthopedics for further care.", Surgery, Achilles Tendon Repair ,"PREOPERATIVE DIAGNOSIS: , Achilles tendon rupture, left lower extremity.,POSTOPERATIVE DIAGNOSIS: , Achilles tendon rupture, left lower extremity.,PROCEDURE PERFORMED:,  Primary repair left Achilles tendon.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,TOTAL TOURNIQUET TIME:  ,40 minutes at 325 mmHg.,POSITION:,  Prone.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 26-year-old African-American male who states that he was stepping off a hilo at work when he felt a sudden pop in the posterior aspect of his left leg.  The patient was placed in posterior splint and followed up at ABC orthopedics for further care.,PROCEDURE:,  After all potential complications, risks, as well as anticipated benefits of the above-named procedure were discussed at length with the patient, informed consent was obtained.  The operative extremity was then confirmed with the patient, the operative surgeon, Department Of Anesthesia, and nursing staff.  While in this hospital, the Department Of Anesthesia administered general anesthetic to the patient.  The patient was then transferred to the operative table and placed in the prone position.  All bony prominences were well padded at this time.,A nonsterile tourniquet was placed on the left upper thigh of the patient, but not inflated at this time.  Left lower extremity was sterilely prepped and draped in the usual sterile fashion.  Once this was done, the left lower extremity was elevated and exsanguinated using an Esmarch and the tourniquet was inflated to 325 mmHg and kept up for a total of 40 minutes.  After all bony and soft tissue land marks were identified, a 6 cm longitudinal incision was made paramedial to the Achilles tendon from its insertion proximal.  Careful dissection was then taken down to the level of the peritenon.  Once this was reached, full thickness flaps were performed medially and laterally.  Next, retractor was placed.  All neurovascular structures were protected.  A longitudinal incision was then made in the peritenon and opened up exposing the tendon.  There was noted to be complete rupture of the tendon approximately 4 cm proximal to the insertion point.  The plantar tendon was noted to be intact.  The tendon was debrided at this time of hematoma as well as frayed tendon.  Wound was copiously irrigated and dried.  Most of the ankle appeared that there was sufficient tendon links in order to do a primary repair.  Next #0 PDS on a taper needle was selected and a Krackow stitch was then performed.  Two sutures were then used and tied individually ________ from the tendon.  The tendon came together very well and with a tight connection.  Next, a #2-0 Vicryl suture was then used to close the peritenon over the Achilles tendon.  The wound was once again copiously irrigated and dried.  A #2-0 Vicryl sutures were then used to close the skin and subcutaneous fashion followed by #4-0 suture in the subcuticular closure on the skin.  Steri-Strips were then placed over the wound and the sterile dressing was applied consisting of 4x4s, Kerlix roll, sterile Kerlix and a short length fiberglass cast in a plantar position.  At this time, the Department of anesthesia reversed the anesthetic.  The patient was transferred back to hospital gurney to the Postanesthesia Care Unit.  The patient tolerated the procedure well.  There were no complications.","surgery, repair, achilles tendon rupture, longitudinal incision, tendon rupture, achilles tendon, tendon, achilles, rupture, extremity"
 Removal of the hardware and revision of right AC separation.  Loose hardware with superior translation of the clavicle implants.  Arthrex bioabsorbable tenodesis screws., Surgery, AC Separation Revision & Hardware Removal ,"PREOPERATIVE DIAGNOSIS:,  Right AC separation.,POSTOPERATIVE DIAGNOSIS:,  Right AC separation.,PROCEDURES:,  Removal of the hardware and revision of right AC separation.,ANESTHESIA:,  General.,BLOOD LOSS:,  100 cc.,COMPLICATIONS:,  None.,FINDINGS: , Loose hardware with superior translation of the clavicle implants.,IMPLANTS: , Arthrex bioabsorbable tenodesis screws.,SUMMARY: , After informed consent was obtained and verified, the patient was brought to the operating room and placed supine on the operating table.  After uneventful general anesthesia was obtained, he was positioned in the beach chair and his right shoulder was sterilely prepped and draped in a normal fashion.  The incision was reopened and the hardware was removed without difficulty.  The AC joint was inspected and reduced.  An allograft was used to recreate the coracoacromial ligaments and then secured to decorticate with a bioabsorbable tenodesis screw and then to the clavicle.  And two separate areas that were split, one taken medially and one taken laterally, and then sewed together for further stability.  This provided good stability with no further superior translation of the clavicle as viewed under fluoroscopy.  The wound was copiously irrigated and the wound was closed in layers and a soft dressing was applied.  He was awakened from anesthesia and taken to recovery room in a stable condition.,Final needle and instrument counts were correct.","surgery, loose hardware, superior translation, clavicle implants, ac separation, removal of the hardware, arthrex bioabsorbable tenodesis screws, bioabsorbable tenodesis, tenodesis screws, translation, implants, bioabsorbable, tenodesis, clavicle, separation, hardware"
" Excision of abscess, removal of foreign body.  Repair of incisional hernia.  Recurrent re-infected sebaceous cyst of abdomen.  Abscess secondary to retained foreign body and incisional hernia.", Surgery, Abscess Excision ,"PREOPERATIVE DIAGNOSIS: , Recurrent re-infected sebaceous cyst of abdomen.,POSTOPERATIVE DIAGNOSES:,1.  Abscess secondary to retained foreign body.,2.  Incisional hernia.,PROCEDURES,1.  Excision of abscess, removal of foreign body.,2.  Repair of incisional hernia.,ANESTHESIA: , LMA.,INDICATIONS: , Patient is a pleasant 37-year-old gentleman who has had multiple procedures including a laparotomy related to trauma.  The patient has had a recurrently infected cyst of his mass at the superior aspect of his incision, which he says gets larger and then it drains internally, causing him to be quite ill.  He presented to my office and I recommended that he undergo exploration of this area and removal.  The procedure, purpose, risks, expected benefits, potential complications, and alternative forms of therapy were discussed with him and he was agreeable to surgery.,FINDINGS:,  The patient was found upon excision of the cyst that it contained a large Prolene suture, which is multiply knotted as it always is; beneath this was a very small incisional hernia, the hernia cavity, which contained omentum; the hernia was easily repaired.,DESCRIPTION OF PROCEDURE: , The patient was identified, then taken into the operating room, where after induction of an LMA anesthetic, his abdomen was prepped with Betadine solution and draped in sterile fashion.  The puncta of the wound lesion was infiltrated with methylene blue and peroxide.  The lesion was excised and the existing scar was excised using an ellipse and using a tenotomy scissors, the cyst was excised down to its base.  In doing so, we identified a large Prolene suture within the wound and followed this cyst down to its base at which time we found that it contained omentum and was in fact overlying a small incisional hernia.  The cyst was removed in its entirety, divided from the omentum using a Metzenbaum and tying with 2-0 silk ties.  The hernia repair was undertaken with interrupted 0 Vicryl suture with simple sutures.  The wound was then irrigated and closed with 3-0 Vicryl subcutaneous and 4-0 Vicryl subcuticular and Steri-Strips.  Patient tolerated the procedure well.  Dressings were applied and he was taken to recovery room in stable condition.","surgery, sebaceous cyst, prolene suture, incisional hernia, incisional, abscess, hernia, abdomen, omentum, excision, cyst,"
 Congenital chylous ascites and chylothorax and rule out infradiaphragmatic lymphatic leak.   Diffuse intestinal and mesenteric lymphangiectasia.  , Surgery, Abdominal Exploration ,"PREOPERATIVE DIAGNOSES:  ,1.  Congenital chylous ascites and chylothorax.,2.  Rule out infradiaphragmatic lymphatic leak.,POSTOPERATIVE DIAGNOSES: , Diffuse intestinal and mesenteric lymphangiectasia.,ANESTHESIA: , General.,INDICATION:  ,The patient is an unfortunate 6-month-old baby boy, who has been hospitalized most of his life with recurrent chylothoraces and chylous ascites.  The patient has been treated somewhat successfully with TPN and voluntary restriction of enteral nutrition, but he had repeated chylothoraces.  Last week, Dr. X took the patient to the operating room in hopes that with thoracotomy, a thoracic duct leak could be found, which would be successfully closed surgically.  However at the time of his thoracotomy exploration what was discovered was a large amount of transdiaphragmatic transition of chylous ascites coming from the abdomen.  Dr. X opened the diaphragm and could literally see a fountain of chylous fluid exiting through the diaphragmatic hole.  This was closed, and we decided that perhaps an abdominal exploration as a last stage effort would allow us to find an area of lymphatic leak that could potentially help the patient from this dismal prognostic disease.  We met with his parents and talked to them about this, and he is here today for that attempt.,OPERATIVE FINDINGS:  ,The patient's abdomen was relatively soft, minimally distended.  Exploration through supraumbilical transverse incision immediately revealed a large amount of chylous ascites upon entering into the peritoneal cavity.  What we found which explains the chronic chylous ascites and chylothorax was a diffuse lymphangiectatic picture involving the small bowel mesentery approximately two thirds to three quarters of the distal small bowel including all of the ileum, the cecum, and the portion of the ascending colon.  It appeared that any attempt to resect this area would have been met with failure because of the extensive lymphatic dilatation all the way down towards the root of the supramesenteric artery.  There was about one quarter to one third of the jejunum that did not appear to be grossly involved, but I did not think that resection of three quarters of the patient's small bowel would be viable surgical option.  Instead, we opted to close his abdomen and refer for potential small intestine transplantation procedure in the future if he is a candidate for that.,The lymphatic abnormality was extensive.  They were linear dilated lymphatic channels on the serosal surface of the bowel in the mesentery.  They were small aneurysm-like pockets of chyle all along the course of the mesenteric structures and in the mesentery medially adjacent to the bowel as well.  No other major retroperitoneal structure or correctable structure was identified.  Both indirect inguinal hernias were wide open and could be palpated from an internal aspect as well.,DESCRIPTION OF OPERATION:  ,The patient was brought from the Pediatric Intensive Care Unit to the operating room within an endotracheal tube im place and with enteral feeds established at full flow to provide maximum fat content and maximum lymphatic flow.  We conducted a surgical time-out and reiterated all of the patient's important identifying information and confirmed the operative plan as described above.  Preparation and draping of his abdomen was done with chlorhexidine based prep solution and then we opened his peritoneal cavity through a transverse supraumbilical incision dividing both rectus muscles and all layers of the abdominal wall fascia.  As the peritoneal cavity was entered, we divided the umbilical vein ligamentum teres remnant between Vicryl ties, and we were able to readily identify a large amount of chylous ascites that had been previously described.  The bowel was eviscerated, and then with careful inspection, we were able to identify this extensive area of intestinal and mesenteric lymphangiectasia that was a source of the patient's chylous ascites.  The small bowel from the ligament of Treitz to the proximal to mid jejunum was largely unaffected, but did not appear that resection of 75% of the small intestine and colon would be a satisfactory tradeoff for The patient, but would likely render him with significant short bowel and nutritional and metabolic problems.  Furthermore, it might burn bridges necessary for consideration of intestinal transplantation in the future if that becomes an option.  We suctioned free all of the chylous accumulations, replaced the intestines to their peritoneal cavity, and then closed the patient's abdominal incision with 4-0 PDS on the posterior sheath and 3-0 PDS on the anterior rectus sheath.  Subcuticular 5-0 Monocryl and Steri-Strips were used for skin closure.,The patient tolerated the procedure well.  He lost minimal blood, but did lose approximately 100 mL of chylous fluid from the abdomen that was suctioned free as part of the chylous ascitic leak.  The patient was returned to the Pediatric Intensive Care Unit with his endotracheal tube in place and to consider the next stage of management, which might be an attempted additional type of feeding or referral to an Intestinal Transplantation Center to see if that is an option for the patient because he has no universally satisfactory medical or surgical treatment for this at this time.","surgery, intestinal, mesenteric, lymphangiectasia, ascites, chylothorax, lymphatic leak, infradiaphragmatic, abdominal exploration, congenital chylous, mesenteric lymphangiectasia, peritoneal cavity, chylous, abdominal, congenital, abdomen, lymphatic"
" Incision and drainage (I&D) of abdominal abscess, excisional debridement of nonviable and viable skin, subcutaneous tissue and muscle, then removal of foreign body.", Surgery, Abdominal Abscess I&D ,"PREOPERATIVE DIAGNOSIS: , Abdominal wall abscess.,POSTOPERATIVE DIAGNOSIS: , Abdominal wall abscess.,PROCEDURE: , Incision and drainage (I&D) of abdominal abscess, excisional debridement of nonviable and viable skin, subcutaneous tissue and muscle, then removal of foreign body.,ANESTHESIA: , LMA.,INDICATIONS: , Patient is a pleasant 60-year-old gentleman, who initially had a sigmoid colectomy for diverticular abscess, subsequently had a dehiscence with evisceration.  Came in approximately 36 hours ago with pain across his lower abdomen.  CT scan demonstrated presence of an abscess beneath the incision.  I recommended to the patient he undergo the above-named procedure.  Procedure, purpose, risks, expected benefits, potential complications, alternatives forms of therapy were discussed with him, and he was agreeable to surgery.,FINDINGS:,  The patient was found to have an abscess that went down to the level of the fascia.  The anterior layer of the fascia was fibrinous and some portions necrotic.  This was excisionally debrided using the Bovie cautery, and there were multiple pieces of suture within the wound and these were removed as well.,TECHNIQUE:  ,Patient was identified, then taken into the operating room, where after induction of appropriate anesthesia, his abdomen was prepped with Betadine solution and draped in a sterile fashion.  The wound opening where it was draining was explored using a curette.  The extent of the wound marked with a marking pen and using the Bovie cautery, the abscess was opened and drained.  I then noted that there was a significant amount of undermining.  These margins were marked with a marking pen, excised with Bovie cautery; the curette was used to remove the necrotic fascia.  The wound was irrigated; cultures sent prior to irrigation and after achievement of excellent hemostasis, the wound was packed with antibiotic-soaked gauze.  A dressing was applied.  The finished wound size was 9.0 x 5.3 x 5.2 cm in size.  Patient tolerated the procedure well.  Dressing was applied, and he was taken to recovery room in stable condition.","surgery, excisional debridement, subcutaneous tissue, abdominal wall abscess, foreign body, abdominal abscess, bovie cautery, abdominal, i&d, wound, incision, abscess,"
 Speech therapy discharge summary.  The patient was admitted for skilled speech therapy secondary to cognitive-linguistic deficits. , Speech - Language, Speech Therapy - Discharge Summary ,"LONG-TERM GOALS:,  Both functional and cognitive-linguistic ability to improve safety and independence at home and in the community.  This goal has been met based on the patient and husband reports the patient is able to complete all activities, which she desires to do at home.  During the last reevaluation, the patient had a significant progress and all cognitive domains evaluated, which are attention, memory, executive functions, language, and visuospatial skill.  She continues to have an overall mild cognitive-linguistic deficit, but this is significantly improved from her initial evaluation, which showed severe impairment., ,The patient does no longer need a skilled speech therapy because she has accomplished all of her goals and her progress has plateaued.  The patient and her husband both agreed with the patient's discharge.","speech - language, narrative, memory, executive function, attention, speech therapy, visuospatial, accuracy, linguistic, cognitive, speechNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Global aphasia.  The patient is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.   ", Speech - Language, Speech Therapy Evaluation ,"MEDICAL DIAGNOSIS:,  Strokes.,SPEECH AND LANGUAGE THERAPY DIAGNOSIS:  ,Global aphasia.,SUBJECTIVE:  ,The patient is a 44-year-old female who is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.  The patient's sister-in-law was present throughout this assessment and provided all the patient's previous medical history.  Based on the sister-in-law's report, the patient had a stroke on 09/19/08.  The patient spent 6 weeks at XY Medical Center, where she was subsequently transferred to XYZ for therapy for approximately 3 weeks.  ABCD brought the patient to home the Monday before Thanksgiving, because they were not satisfied with the care the patient was receiving at a skilled nursing facility in Tucson.  The patient's previous medical history includes a long history of illegal drug use to include cocaine, crystal methamphetamine, and marijuana.  In March of 2008, the patient had some type of potassium issue and she was hospitalized at that time.  Prior to the stroke, the patient was not working and ABCD reported that she believes the patient completed the ninth grade, but she did not graduate from high school.  During the case history, I did pose several questions to the patient, but her response was often ""no.""  She was very emotional during this evaluation and crying occurred multiple times.,OBJECTIVE:  ,To evaluate the patient's overall communication ability, a Western Aphasia Battery was completed.  Also tests were not done due to time constraint and the patient's severe difficulty and emotional state.  Speech automatic tests were also completed to determine if the patient had any functional speech.,ASSESSMENT:,  Based on the results of the Weston aphasia battery, the patient's deficits most closely resemble global aphasia.  On the spontaneous speech subtest, the patient responded ""no"" to all questions asked except for how are you today where she gave a thumbs-up.  She provided no responses to picture description task and it is unclear if the patient was unable to follow the direction or if she was unable to see the picture clearly.  The patient's sister-in-law did state that the patient wore glasses, but she currently does not have them and she did not know the extent the patient's visual deficit.,On the auditory verbal comprehension portion of the Western Aphasia Battery, the patient answered ""no"" to all ""yes/no"" questions.  The auditory word recognition subtest, the patient had 5 out of 60 responses correct.  With the sequential command, she had 10 out of 80 corrects.  She was able to shut her eyes, point to the window, and point to the pen after directions.  With repetition subtest, she repeated bed correctly, but no other stimuli.  At this time, the patient became very emotional and repeatedly stated ""I can't"".  During the naming subtest of the Western Aphasia Battery, the patient's responses contained numerous paraphasias and her speech was often unintelligible due to jargon.  The word fluency test was not administered and the patient scored 2 out of 10 on the sentence completion task and 0 out of 10 on the responsive speech.  In regards to speech automatics, the patient is able to count from 1 to 9 accurately; however, stated 7 instead of 10 at the end of the task.  She is not able to state the days of the week or months in the year or her name at this time.  She cannot identify the day on calendar and was unable to verbally state the date or month.,DIAGNOSTIC IMPRESSION:  ,The patient's communication deficits most closely resemble global aphasia where she has difficulty with both receptive as well as expressive communication.  She does perseverate and is very emotional due to probable frustration.  Outpatient skilled speech therapy is recommended to improve the patient's functional communication skills.,PATIENT GOAL: , Her sister-in-law stated that they would like to improve upon the patient's speech to allow her to communicate more easily at home.,PLAN OF CARE: , Outpatient skilled speech therapy two times a week for the next 12 weeks.  Therapy to include aphasia treatment and home activities.,SHORT-TERM GOALS (8 WEEKS):,1.  The patient will answer simple ""yes/no"" questions with greater than 90% accuracy with minimal cueing.,2.  The patient will be able to complete speech automatic tasks with greater than 80% accuracy without models or cueing.,3.  The patient will be able to complete simple sentence completion and/or phrase completion with greater than 80% accuracy with minimal cueing.,4.  The patient will be able to follow simple one-step commands with greater than 80% accuracy with minimal cueing.,5.  The patient will be able to name 10 basic everyday objects with greater than 80% accuracy with minimal cueing.,SHORT-TERM GOALS (12 WEEKS):,  Functional communication abilities to allow the patient to express her basic wants and needs.","speech - language, speech automatic tasks, minimal cueing, sentence completion, western aphasia battery, skilled speech therapy, global aphasia, speech therapy, speech, aphasia, "
" The patient was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke.  The patient attended nine outpatient skilled speech therapy sessions.", Speech - Language, Speech Therapy - Discharge Summary - 2 ,"The patient made some progress during therapy.  She accomplished two and a half out of her five short-term therapy goals.  We did complete an oral mechanism examination and clinical swallow evaluation, which showed her swallowing to be within functional limits.  The patient improved on her turn taking skills during conversation, and she was able to listen to a narrative and recall the main idea plus five details after a three-minute delay independently.  The patient continues to have difficulty with visual scanning in cancellation task, secondary to her significant left neglect.  She also did not accomplish her sustained attention goal, which required her to complete tasks greater than 80% accuracy for at least 15 minutes independently.  Thus she also continued to have difficulty with reading, comprehension, secondary to the significance of her left neglect.  The patient was initially authorized for 12 outpatient speech therapy sessions, but once again she only attended 9.  Her last session occurred on 01/09/09.  She has not made any additional followup sessions with me for over three weeks, so she is discharged from my services at this time.","speech - language, outpatient speech therapy, swallow evaluation, swallowing, skilled speech therapy, hemisphere disorder, speech therapy, speechNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 The patient was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety., Speech - Language, Speech Therapy - Discharge Summary - 1 ,"HISTORY: , The patient is a 67-year-old female, was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.  At the onset of therapy, on 03/26/08, the patient was NPO with a G-tube and the initial speech and language evaluation revealed global aphasia with an aphasia quotient of 3.6/100 based on the Western Aphasia Battery.  Since the initial evaluation, the patient has attended 60 outpatient speech therapy sessions, which have focussed on her receptive communication, expressive language, multimodality communication skills, and swallowing function and safety.,SHORT-TERM GOALS:,1.  The patient met 3 out of 4 original short-term therapy goals, which were to complete a modified barium swallow study, which she did do and which revealed no aspiration.  At this time, the patient is eating and drinking and taking all medications by mouth; however, her G-tube is still present.  The patient was instructed to talk to the primary care physician about removal of her feeding tube.,2.  The patient will increase accuracy of yes-no responses to greater than 80% accuracy.  She did accomplish this goal.  The patient is also able to identify named objects with greater than 80% accuracy.,ADDITIONAL GOALS: , Following the completion of these goals, additional goals were established.  Based on reevaluation, the patient met 2 out of these 3 initial goals and she is currently able to read and understand simple sentences with greater than 90% accuracy independently and she is able to write 10 words related to basic wants and needs with greater than 80% accuracy independently.  The patient continues to have difficulty stating verbally, yes or no, to questions as well as accurately using head gestures and to respond to yes-no questions.  The patient continues to have marked difficulty with her expressive language abilities.  She is able to write simple words to help express her basic wants and needs.  She has made great strides; however, with her receptive communication, she is able to read words as well as short phrases and able to point to named objects and answer simple-to-moderate complex yes-no questions.  A reevaluation completed on 12/01/08, revealed an aphasia quotient of 26.4.  Once again, she made significant improvement and comprehension, but continues to have unintelligible speech.  An alternative communication device was discussed with the patient and her husband, but at this time, the patient does not want to utilize a communication device.  If, in the future, the patient continues to struggle with her expressive communication, an alternative augmented communication device would be a benefit to her.  Please reconsult at that time if and when the patient is ready to use a speech generating device.  The patient is discharged from my services at this time due to a plateau in her progress.  Numerous home activities were recommended to allow her to continue to make progress at home.","speech - language, communication skills, g-tube, aphasia, language evaluation, western aphasia battery, skilled speech therapy, swallowing function, speech therapy, therapy, swallowing, aspiration, speech, communication,"
" Abdominosacrocolpopexy, enterocele repair, cystoscopy, and lysis of adhesions.", Surgery, Abdominosacrocolpopexy ,"PREOPERATIVE DIAGNOSES:,1.  Vault prolapse.,2.  Enterocele.,PREOPERATIVE DIAGNOSES:,1.  Vault prolapse.,2.  Enterocele.,OPERATIONS:,1.  Abdominosacrocolpopexy.,2.  Enterocele repair.,3.  Cystoscopy.,4.  Lysis of adhesions.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:,  Less than 100 mL.,SPECIMEN: , None.,BRIEF HISTORY:,  The patient is a 53-year-old female with history of hysterectomy presented with vaginal vault prolapse.  The patient had good support in the anterior vagina and in the posterior vagina but had significant apical prolapse.  Options such as watchful waiting, pessary, abdominal surgery, robotic sacrocolpopexy versus open sacrocolpopexy were discussed.,The patient already had multiple abdominal scars.  Risk of open surgery was little bit higher for the patient.  After discussing the options the patient wanted to proceed a Pfannenstiel incision and repair of the sacrocolpopexy.  Risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, mesh erogenic exposure, complications with mesh were discussed.  The patient understood the risks of recurrence, etc, and wanted to proceed with the procedure.  The patient was told to perform no heavy lifting for 3 months, etc.  The patient was bowel prepped, preoperative antibiotics were given.,DETAILS OF THE OPERATION: , The patient was brought to the OR, anesthesia was applied.  The patient was placed in dorsal lithotomy position.  The patient was prepped and draped in usual sterile fashion.  A Pfannenstiel low abdominal incision was done at the old incision site.  The incision was carried through the subcutaneous tissue through the fascia and the fascia was lifted off the rectus abdominus muscle.  The muscle was split in the middle and peritoneum was entered using sharp mets.  There was no injury to the bowel upon entry.  There were significant adhesions which were unleashed.  All the adhesions in the sigmoid colon from the right lower quadrant and left lower quadrant were released, similarly colon was mobilized.  There was minimal space, everything was packed, Bookwalter placed then over the sacral bone.  The middle of the sacral bone was identified.  The right ureter was clearly identified and was lateral to where the posterior peritoneum was opened.  The ligament over the sacral or sacral __________ was easily identified, 0 Ethibond stitches were placed x3.  A 1 cm x 5 cm mesh was cut out.  This was a Prolene soft mesh which was tied at the sacral ligament.  The bladder was clearly off the vault area which was exposed, in the raw surface 0 Ethibond stitches were placed x3.  The mesh was attached.  The apex was clearly up enterocele sac was closed using 4-0 Vicryl without much difficulty.  The ureter was not involved at all in this process.  The peritoneum was closed over the mesh.  Please note that the peritoneum was opened and it was brought around and over the mesh so that the mesh would not be exposed to the bowel.  Prior to closure antibiotic irrigation was done using Ancef solution.  The mesh has been exposed in antibiotic solution prior to the usage.,After a through irrigation with L and half of antibiotic solution.  All the solution was removed.  Good hemostasis was obtained.  All the packing was removed.  Count was correct.  Rectus abdominus muscle was brought together using 4-0 Vicryl.  The fascia was closed using loop #1 PDS in running fascia from both sides and was tied in the middle.  Subcutaneous tissue was closed using 4-0 Vicryl and the skin was closed using 4-0 Monocryl in subcuticular fashion.  Cystoscopy was done at the end of the procedure.  Please note that the Foley was in place throughout the entire procedure which was placed thoroughly at the beginning of the procedure.  Cystoscopy was done and indigo carmine has been given.  There was good efflux of indigo carmine in both of the ureteral opening.  There was no injury to the rectum or the bladder.  The bladder appeared completely normal.  The rectal exam was done at the end of the procedure after the cystoscopy.  After the cysto was done, the scope was withdrawn, Foley was placed back.  The patient was brought to recovery in the stable condition.","surgery, enterocele repair, cystoscopy, lysis of adhesions, enterocele, ethibond stitches, indigo carmine, vault prolapse, sacrocolpopexy, peritoneum, abdominosacrocolpopexy, "
" Status post brain tumor with removal.  The patient did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.  ", Speech - Language, Speech Therapy Evaluation - 1 ,"DIAGNOSIS: , Status post brain tumor with removal.,SUBJECTIVE:  ,The patient is a 64-year-old female with previous medical history of breast cancer that has metastasized to her lung, liver, spleen, and brain, status post radiation therapy.  The patient stated that on 10/24/08 she had a brain tumor removed with subsequent left-sided weakness.  The patient was readmitted to ABC Hospital on 12/05/08 and was found to have massive swelling in the brain and a second surgery was performed to reduce the swelling.  The patient remained at the acute rehab at ABC until she was discharged home on 01/05/09.  The patient did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.  The patient also complains of difficulty with word retrieval and slurring of speech.  The patient denies any difficulty with swallowing at this time.,OBJECTIVE:  ,Portions of the cognitive linguistic quick test was administered.  An oral mechanism exam was performed.  A motor speech protocol was completed.,The cognitive linguistic subtests of recalling personal facts, symbol cancellation, confrontational naming, clock drawing, story retelling, generative naming, design and memory, and completion of mazes was administered.,The patient was 100% accurate with recalling personal facts, completion of the symbol cancellation tasks, and with confrontational naming.  She had no difficulty with the clock drawing task; however, she has considerable hand tremors, which makes writing difficult.  In the storytelling task, she scored within normal limits.  She was also within normal limits for generative naming.  She did have difficulty with the design, memory, and mazes subtests.  She was unable to complete the second maze during the allotted time.  The design generation subtest was also completed.  She was able to draw four unique designs, and toward the end of the tasks was no longer able to recall the stated direction.,ORAL MECHANISM EXAMINATION:,  The patient has mild left facial droop with decreased nasolabial fold.  Tongue is at midline, and lingual range of motion and strength are within functional limit.  The patient does complain of biting her tongue on occasion, but denied biting the inside of her cheeks.  Her AMRs are judged to be within functional limit.  Her rate of speech is decreased with a monotonous vocal quality.  The decreased rate may be a compensation for decreased word retrieval ability.  The patient's speech is judged to be 100% intelligible without background noise.,DIAGNOSTIC IMPRESSION:  ,The patient has mild cognitive linguistic deficits in the areas of higher level cognitive function seen in mental flexibility, memory, and executive function.,PLAN OF CARE:,  Outpatient skilled speech therapy two times a week for four weeks to include cognitive linguistic treatment.,SHORT-TERM GOALS (THREE WEEKS):,1.  The patient will complete deductive reasoning and mental flexibility tasks with greater than 90% accuracy, independently.,2.  The patient will complete perspective memory test with 100% accuracy using compensatory strategy.,3.  The patient will complete visual perceptual activities, which focus on scanning, flexibility, and problem solving with greater than 90% accuracy with minimal cueing.,4.  The patient will listen to and/or read a lengthy narrative and be able to recall at least 6 details after a 15-minute delay, independently.,PATIENT'S GOAL:  ,To improve functional independence and cognitive abilities.,LONG-TERM GOAL (FOUR WEEKS):  ,Functional cognitive linguistic abilities to improve safety and independence at home and to decrease burden of care on caregiver.,","speech - language, linguistic skills, memory, mental flexibility, deductive reasoning, skilled speech therapy, speech therapy, cognitive linguistic, therapy, linguistic, speech, cognitive, "
 Cognitive linguistic impairment secondary to stroke.  The patient was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.  , Speech - Language, Cognitive Linguistic Impairment - Discharge ,"DIAGNOSIS: , Cognitive linguistic impairment secondary to stroke.,NUMBER OF SESSIONS COMPLETED:,  5,HOSPITAL COURSE:  ,The patient is a 73-year-old female who was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.  Based on the initial evaluation completed 12/29/08, the patient had mild difficulty with generative naming and auditory comprehension and recall.  The patient's skilled speech therapy was recommended for three times a week for 8 weeks to improve her overall cognitive linguistic abilities.  At this time, the patient has accomplished all 5 of her short-term therapy goals.  She is able to complete functional mass tasks with 100% accuracy independently.  She is able to listen to a narrative and recall the main idea plus at least five details after a 10 minute delay independently.,She is able to read a newspaper article and recall the main idea plus five details after a 15 minute delay independently.  She is able to state 15 items in a broad category within a minute and a half independently.  The patient is also able to complete deductive reasoning tasks to promote her mental flexibility with 100% accuracy independently.  The patient also met her long-term therapy goal of functional cognitive linguistic abilities to return to teaching and improve her independence and safety at home.  The patient is no longer in need of skilled speech therapy and is discharged from my services.  She did quite well in therapy and also agreed with this discharge.","speech - language, stroke, linguistic deficits, speech therapy, skilled speech therapy, linguistic impairment, cognitive linguistic, cognitive, linguistic,"
" The patient is a 67-year-old white female with a history of uterine papillary serous carcinoma who is status post 6 cycles of carboplatin and Taxol, is here today for followup. ", SOAP / Chart / Progress Notes, Uterine Papillary Serous Carcinoma ,"HISTORY OF PRESENT ILLNESS:,  The patient is a 67-year-old white female with a history of uterine papillary serous carcinoma who is status post 6 cycles of carboplatin and Taxol, is here today for followup.  Her last cycle of chemotherapy was finished on 01/18/08, and she complains about some numbness in her right upper extremity.  This has not gotten worse recently and there is no numbness in her toes.  She denies any tingling or burning.,REVIEW OF SYSTEMS: , Negative for any fever, chills, nausea, vomiting, headache, chest pain, shortness of breath, abdominal pain, constipation, diarrhea, melena, hematochezia or dysuria.  The patient is concerned about her blood pressure being up a little bit and also a mole that she had noticed for the past few months in her head.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 35.6, blood pressure 143/83, pulse 65, respirations 18, and weight 66.5 kg.  GENERAL:  She is a middle-aged white female, not in any distress.  HEENT:  No lymphadenopathy or mucositis.  CARDIOVASCULAR:  Regular rate and rhythm.  LUNGS:  Clear to auscultation bilaterally.  EXTREMITIES:  No cyanosis, clubbing or edema.  NEUROLOGICAL:  No focal deficits noted.  PELVIC:  Normal-appearing external genitalia.  Vaginal vault with no masses or bleeding.,LABORATORY DATA: , None today.,RADIOLOGIC DATA: , CT of the chest, abdomen, and pelvis from 01/28/08 revealed status post total abdominal hysterectomy/bilateral salpingo-oophorectomy with an unremarkable vaginal cuff.  No local or distant metastasis.  Right probably chronic gonadal vein thrombosis.,ASSESSMENT: , This is a 67-year-old white female with history of uterine papillary serous carcinoma, status post total abdominal hysterectomy and bilateral salpingo-oophorectomy and 6 cycles of carboplatin and Taxol chemotherapy.  She is doing well with no evidence of disease clinically or radiologically.,PLAN:,1.  Plan to follow her every 3 months and CT scans every 6 months for the first 2 years.,2.  The patient was advised to contact the primary physician for repeat blood pressure check and get started on antihypertensives if it is persistently elevated.,3.  The patient was told that the mole that she is mentioning in her head is no longer palpable and just to observe it for now.,4.  The patient was advised about doing Kegel exercises for urinary incontinence, and we will address this issue again during next clinic visit if it is persistent.,","soap / chart / progress notes, chemotherapy, uterine papillary serous carcinoma, oophorectomy, carboplatin, taxol, abdominal, uterine, papillary, carcinoma,"
 The patient was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities.  The patient is currently NPO with G-tube to meet all of his hydration and nutritional needs.  A trial of Passy-Muir valve was completed to allow the patient to achieve hands-free voicing., Speech - Language, Barium Swallow Study & Speech Evaluation ,"CURRENT MEDICATIONS:,  Lortab.,PREVIOUS MEDICAL HISTORY: , Cardiac stent in 2000.,PATIENT'S GOAL: , To eat again by mouth.,STUDY:  ,A trial of Passy-Muir valve was completed to allow the patient to achieve hands-free voicing and also to improve his secretion management.  A clinical swallow evaluation was not completed due to the severity of the patient's mucus and lack of saliva control.,The patient's laryngeal area was palpated during a dry swallow and he does have significantly reduced laryngeal elevation and radiation fibrosis.  The further evaluate of his swallowing function is safety; a modified barium swallow study needs to be concluded to objectively evaluate his swallow safety, and to rule out aspiration.  A trial of neuromuscular electrical stimulation therapy was completed to determine if this therapy protocol will be beneficial and improving the patient's swallowing function and safety.,For his neuromuscular electrical stimulation therapy, the type was BMR with a single mode cycle time is 4 seconds and 12 seconds off with frequency was 60 __________ with a ramp of 2 seconds, phase duration was 220 with an output of 99 milliamps.  Electrodes were placed on the suprahyoid/submandibular triangle with an upright body position, trial length was 10 minutes.  On a pain scale, the patient reported no pain with the electrical stimulation therapy.,FINDINGS:  ,The patient was able to tolerate a 5-minute placement of the Passy-Muir valve.  He reported no discomfort on the inhalation; however, he felt some resistance on exhalation.  Instructions were given on care placement and cleaning of the Passy-Muir valve.  The patient was instructed to buildup tolerance over the next several days of his Passy-Muir valve and to remove the valve at anytime or he is going to be sleeping or napping throughout the day.  The patient's voicing did improve with the Passy-Muir valve due to decreased leakage from his trach secondary to finger occlusion.  Mucus production also seemed to decrease when the Passy-Muir was placed.,On the dry swallow during this evaluation, the patient's laryngeal area is reduced and tissues around his larynx and showed radiation fibrosis.  The patient's neck range of motion appears to be adequate and within normal limits.,A trial of neuromuscular electrical stimulation therapy:,The patient tolerating the neuromuscular electrical stimulation, we did achieve poor passive response, but these muscles were contracting and the larynx was moving upon stimulation.  The patient was able to actively swallow with stimulation approximately 30% of presentation.,DIAGNOSTIC IMPRESSION: , The patient with a history of head and neck cancer status post radiation and chemotherapy with radiation fibrosis, which is impeding his swallowing abilities.  The patient would benefit from outpatient skilled speech therapy for neuromuscular electrical stimulation for muscle reeducation to improve his swallowing function and safety and he would benefit from a placement of a Passy-Muir valve to have hands-free communication.,PLAN OF CARE: , Outpatient skilled speech therapy two times a week to include neuromuscular electrical stimulation therapy, Passy-Muir placement and a completion of the modified barium swallow study.,SHORT-TERM GOALS (6 WEEKS):,1.  Completion of modified barium swallow study.,2.  The patient will coordinate volitional swallow with greater than 75% of the neuromuscular electrical stimulations.,3.  The patient will increase laryngeal elevation by 50% for airway protection.,4.  The patient will tolerate placement of Passy-Muir valve for greater than 2 hours during awaking hours.,5.  The patient will tolerate therapeutic feedings with the speech and language pathologist without signs and symptoms of aspiration.,6.  The patient will decrease mild facial restrictions to the anterior neck by 50% to increase laryngeal movement.,LONG-TERM GOALS (8 WEEKS):,1.  The patient will improve secretion management to tolerable levels.,2.  The patient will increase amount and oral consistency of p.o. intake tolerated without signs and symptoms of aspirations.,3.  The patient will be able to communicate without using finger occlusion with the assistance of a Passy-Muir valve.",
" This is a pleasant 50-year-old female who has undergone an APR secondary to refractory ulcerative colitis.  Overall, her quality of life has significantly improved since she had her APR.  She is functioning well with her ileostomy. ", SOAP / Chart / Progress Notes, Wound Check - Status Post APR ,"HISTORY OF PRESENT ILLNESS:,  Ms. Connor is a 50-year-old female who returns to clinic for a wound check.  The patient underwent an APR secondary to refractory ulcerative colitis.  Subsequently, she developed a wound infection, which has since healed.  On our most recent visit to our clinic, she has her perineal stitches removed and presents today for followup of her perineal wound.  She describes no drainage or erythema from her bottom.  She is having good ostomy output.  She does not describe any fevers, chills, nausea, or vomiting.  The patient does describe some intermittent pain beneath the upper portion of the incision as well as in the right lower quadrant below her ostomy.  She has been taking Percocet for this pain and it does work.  She has since run out has been trying extra strength Tylenol, which will occasionally help this intermittent pain.  She is requesting additional pain medications for this occasional abdominal pain, which she still experiences.,PHYSICAL EXAMINATION: , Temperature 95.8, pulse 68, blood pressure 132/73, and weight 159 pounds.  This is a pleasant female in no acute distress.  The patient's abdomen is soft, nontender, nondistended with a well-healed midline scar.  There is an ileostomy in the right hemiabdomen, which is pink, patent, productive, and protuberant.  There are no signs of masses or hernias over the patient's abdomen.,ASSESSMENT AND PLAN: , This is a pleasant 50-year-old female who has undergone an APR secondary to refractory ulcerative colitis.  Overall, her quality of life has significantly improved since she had her APR.  She is functioning well with her ileostomy.  She did have concerns or questions about her diet and we discussed the BRAT diet, which consisted of foods that would slow down the digestive tract such as bananas, rice, toast, cheese, and peanut butter.  I discussed the need to monitor her ileostomy output and preferential amount of daily output is 2 liters or less.  I have counseled her on refraining from soft drinks and fruit drinks.  I have also discussed with her that this diet is moreover a trial and error and that she may try certain foods that did not agree with her ileostomy, however others may and that this is something she will just have to perform trials with over the next several months until she finds what foods that she can and cannot eat with her ileostomy.  She also had questions about her occasional abdominal pain.  I told her that this was probably continue to improve as months went by and I gave her a refill of her Percocet for the continued occasional pain.  I told her that this would the last time I would refill the Percocet and if she has continued pain after she finishes this bottle then she would need to start ibuprofen or Tylenol if she had continued pain.  The patient then brought up some right hand and arm numbness, which has been there postsurgically and was thought to be from positioning during surgery.  This is all primarily gone away except for a little bit of numbness at the tip of the third digit as well as some occasional forearm muscle cramping.  I told her that I felt that this would continue to improve as it has done over the past two months since her surgery.  I told her to continue doing hand exercises as she has been doing and this seems to be working for her.  Overall, I think she has healed from her surgery and is doing very well.  Again, her quality of life is significantly improved.  She is happy with her performance.  We will see her back in six months just for a general routine checkup and see how she is doing at that time.","soap / chart / progress notes, perineal wound, wound infection, wound, wound check, ulcerative colitis, apr, ileostomyNOTE"
 Followup on weight loss on phentermine., SOAP / Chart / Progress Notes, Weight Loss on Phentermine ,"SUBJECTIVE:,  She is here for a followup on her weight loss on phentermine.  She has gained another pound since she was here last.  We talked at length about the continued plateau she has had with her weight.  She gained a pound the month before and really has not been able to get her weight any farther down than she had when her lowest level was 136.  She is frustrated with this as well.  We agree that if she continues to plateau she really should not stay on phentermine.  We would not want her to take it to maintain her weight but only to help her get her weight down, and she may have really lost any benefit from it, and she agrees.,REVIEW OF SYSTEMS:,  Otherwise negative.  She has no specific complaints.  No shortness of breath, chest pain or palpitations.,PHYSICAL EXAM:,Vital signs:  Her blood pressure is fine.  Her diastolic is a little bit high, but otherwise okay.,General:  She appears in good spirits.  No apparent distress.,HEENT:  Negative.,Neck:  Supple without bruits.,Chest:  Clear.,Cardiac exam:  Regular without extra sounds.,ASSESSMENT:,  Weight loss on phentermine, really has plateaued.,PLAN:,  If she does not lose weight in the next month we will probably consider having her go off the phentermine.  If she does lose a couple of pounds, then we will keep her on it until she gets closer to her goal of 135 and then try to keep her there for one or two months and then stop.  She agrees with this plan.","soap / chart / progress notes, followup, phentermine, plateau, weight, weight loss, weight loss on phentermine, loss"
" Chronic laryngitis, hoarseness.  The patient was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.  ", Speech - Language, Laryngitis - Discharge ,"DIAGNOSIS: , Chronic laryngitis, hoarseness.,HISTORY:  ,The patient is a 68-year-old male, was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.  The patient attended initial evaluation plus 3 outpatient speech therapy sessions, which focused on training the patient to complete resonant voice activities and to improve his vocal hygiene.  The patient attended therapy one time a week and was given numerous home activities to do in between therapy sessions.  The patient made great progress and he came in to discuss with an appointment on 12/23/08 stating that his voice had finally returned to ""normal"".,SHORT-TERM GOALS:,1.  To be independent with relaxation and stretching exercises and Lessac-Madsen Resonant Voice Therapy Protocol.,2.  He also met short-term goal therapy 3 and he is independent with resonant voice therapy tasks.,3.  We did not complete his __________ ratio during his last session; so, I am unsure if he had met his short-term goal number 2.,4.  To be referred for a videostroboscopy, but at this time, the patient is not in need of this evaluation.  However, in the future if hoarseness returns, it is strongly recommended that he be referred for a videostroboscopy prior to returning to additional outpatient therapy.,LONG-TERM GOALS:,1.  The patient did reach his long-term goal of improved vocal quality to return to prior level of function and to utilize his voice in all settings without vocal hoarseness or difficulty.,2.  The patient appears very pleased with his return of his normal voice and feels that he no longer needs outpatient skilled speech therapy.,The patient is discharged from my services at this time with a home program to continue to promote normal voicing.","speech - language, vocal hygiene, voice activities, hoarseness, skilled speech therapy, chronic laryngitis, voice therapy, resonant voice, videostroboscopy, laryngitis "
 , Speech - Language, Barium Swallow Study & Speech Evaluation - 1 ,"SUBJECTIVE: , The patient is a 60-year-old female, who complained of coughing during meals.  Her outpatient evaluation revealed a mild-to-moderate cognitive linguistic deficit, which was completed approximately 2 months ago.  The patient had a history of hypertension and TIA/stroke.  The patient denied history of heartburn and/or gastroesophageal reflux disorder.  A modified barium swallow study was ordered to objectively evaluate the patient's swallowing function and safety and to rule out aspiration.,OBJECTIVE: , Modified barium swallow study was performed in the Radiology Suite in cooperation with Dr. ABC.  The patient was seated upright in a video imaging chair throughout this assessment.  To evaluate the patient's swallowing function and safety, she was administered graduated amounts of liquid and food mixed with barium in the form of thin liquid (teaspoon x2, cup sip x2); nectar-thick liquid (teaspoon x2, cup sip x2); puree consistency (teaspoon x2); and solid food consistency (1/4 cracker x1).,ASSESSMENT,ORAL STAGE:,  Premature spillage to the level of the valleculae and pyriform sinuses with thin liquid.  Decreased tongue base retraction, which contributed to vallecular pooling after the swallow.,PHARYNGEAL STAGE: , No aspiration was observed during this evaluation.  Penetration was noted with cup sips of thin liquid only.  Trace residual on the valleculae and on tongue base with nectar-thick puree and solid consistencies.  The patient's hyolaryngeal elevation and anterior movement are within functional limits.  Epiglottic inversion is within functional limits.,CERVICAL ESOPHAGEAL STAGE:  ,The patient's upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus.  Radiologist noted reduced peristaltic action of the constricted muscles in the esophagus, which may be contributing to the patient's complaint of globus sensation.,DIAGNOSTIC IMPRESSION:,  No aspiration was noted during this evaluation.  Penetration with cup sips of thin liquid.  The patient did cough during this evaluation, but that was noted related to aspiration or penetration.,PROGNOSTIC IMPRESSION: ,Based on this evaluation, the prognosis for swallowing and safety is good.,PLAN: , Based on this evaluation and following recommendations are being made:,1.  The patient to take small bite and small sips to help decrease the risk of aspiration and penetration.,2.  The patient should remain upright at a 90-degree angle for at least 45 minutes after meals to decrease the risk of aspiration and penetration as well as to reduce her globus sensation.,3.  The patient should be referred to a gastroenterologist for further evaluation of her esophageal function.,The patient does not need any skilled speech therapy for her swallowing abilities at this time, and she is discharged from my services.","speech - language, gastroesophageal reflux disorder, cognitive linguistic deficit, tia, stroke, swallowing function, swallow study, barium swallow study, globus sensation, esophageal, penetration"
 Comes in complaining that he was stung by a Yellow Jacket Wasp yesterday and now has a lot of swelling in his right hand and right arm., SOAP / Chart / Progress Notes, Wasp Sting - SOAP ,"SUBJECTIVE:,  He is a 29-year-old white male who is a patient of Dr. XYZ and he comes in today complaining that he was stung by a Yellow Jacket Wasp yesterday and now has a lot of swelling in his right hand and right arm.  He says that he has been stung by wasps before and had similar reactions.  He just said that he wanted to catch it early before he has too bad of a severe reaction like he has had in the past.  He has had a lot of swelling, but no anaphylaxis-type reactions in the past; no shortness of breath or difficultly with his throat feeling like it is going to close up or anything like that in the past; no racing heart beat or anxiety feeling, just a lot of localized swelling where the sting occurs.,OBJECTIVE:,Vitals:  His temperature is 98.4.  Respiratory rate is 18.  Weight is 250 pounds.,Extremities:  Examination of his right hand and forearm reveals that he has an apparent sting just around his wrist region on his right hand on the medial side as well as significant swelling in his hand and his right forearm; extending up to the elbow.  He says that it is really not painful or anything like that.  It is really not all that red and no signs of infection at this time.,ASSESSMENT:,  Wasp sting to the right wrist area.,PLAN:,1.  Solu-Medrol 125 mg IM X 1.,2.  Over-the-counter Benadryl, ice and elevation of that extremity.,3.  Follow up with Dr. XYZ if any further evaluation is needed.","soap / chart / progress notes, yellow jacket wasp, wasp sting, swelling, solu-medrol, lot of swelling, stung, sting, wasp, "
 Evaluation of possible tethered cord.  She underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age. , SOAP / Chart / Progress Notes, Tethered Cord Evaluation ,"REASON FOR VISIT: , The patient referred by Dr. X for evaluation of her possible tethered cord.,HISTORY OF PRESENT ILLNESS:,  Briefly, she is a 14-year-old right handed female who is in 9th grade, who underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age.  The last surgery was in 03/95.  She did well; however, in the past several months has had some leg pain in both legs out laterally, worsening at night and requiring Advil, Motrin as well as Tylenol PM.,Denies any new bowel or bladder dysfunction or increased sensory loss.  She had some patchy sensory loss from L4 to S1.,MEDICATIONS: , Singulair for occasional asthma.,FINDINGS: , She is awake, alert, and oriented x 3.  Pupils equal and reactive.  EOMs are full.  Motor is 5 out of 5.  She was able to toe and heel walk without any difficulties as well as tendon reflexes were 2 plus.  There is no evidence of clonus.  There is diminished sensation from L4 to S1, having proprioception.,ASSESSMENT AND PLAN: , Possible tethered cord.  I had a thorough discussion with the patient and her parents.  I have recommended a repeat MRI scan.  The prescription was given today.  MRI of the lumbar spine was just completed.  I would like to see her back in clinic.  We did discuss the possible symptoms of this tethering.","soap / chart / progress notes, tethering, lipomyomeningocele repair, sensory loss, tethered cord, mri, cord, lipomyomeningocele, "
 Sore throat - Upper respiratory infection., SOAP / Chart / Progress Notes, URI - SOAP ,"SUBJECTIVE:,  Mom brings patient in today because of sore throat starting last night.  Eyes have been very puffy.  He has taken some Benadryl when all of this congestion started but with a sudden onset just yesterday.  He has had low-grade fever and just felt very run down, appearing very tired.  He is still eating and drinking well, and his voice has been hoarse but no coughing.  No shortness of breath, vomiting, diarrhea or abdominal pain.,PAST MEDICAL HISTORY:,  Unremarkable.  There is no history of allergies.  He does have some history of some episodes of high blood pressure, and his weight is up about 14 pounds from the last year.,FAMILY HISTORY: , Noncontributory.  No one else at home is sick.,OBJECTIVE:,General:  A 13-year-old male appearing tired but in no acute distress.,Neck:  Supple without adenopathy.,HEENT:  Ear canals clear.  TMs, bilaterally, gray in color.  Good light reflex.  Oropharynx pink and moist.  No erythema or exudate.  Some drainage is seen in the posterior pharynx.  Nares:  Swollen, red.  No drainage seen.  No sinus tenderness.  Eyes are clear.,Chest:  Respirations are regular and nonlabored.,Lungs:  Clear to auscultation throughout.,Heart:  Regular rhythm without murmur.,Skin:  Warm, dry and pink, moist mucous membranes.  No rash.,LABORATORY:,  Strep test is negative.  Strep culture is negative.,RADIOLOGY:,  Water's View of the sinuses is negative for any sinusitis or acute infection.,ASSESSMENT:,  Upper respiratory infection.,PLAN:,  At this point just treat symptomatically.  I gave him some samples of Levall for the congestion and as an expectorant.  Push fluids and rest.  May use ibuprofen or Tylenol for discomfort.","soap / chart / progress notes, soap, uri, upper respiratory infection, water's view, congestion, light reflex, sore throat, respiratory, strep, infection,"
" Postoperative day #1, total abdominal hysterectomy.  Normal postoperative course.", SOAP / Chart / Progress Notes, Total Abdominal Hysterectomy - Followup ,"POSTOPERATIVE DAY #1, TOTAL ABDOMINAL HYSTERECTOMY,SUBJECTIVE: , The patient is alert and oriented x3 and sitting up in bed.  The patient has been ambulating without difficulty.  The patient is still NPO.  The patient denies any new symptomatology from  6/10/2009.  The patient has complaints of incisional tenderness.  The patient was given a full explanation about her clinical condition and all her questions were answered.,OBJECTIVE:,VITAL SIGNS:  Afebrile now.  Other vital signs are stable.,GU:  Urinating through Foley catheter.,ABDOMEN:  Soft, negative rebound.,EXTREMITIES:  Without Homans, nontender.,BACK:  Without CVA tenderness.,GENITALIA:  Vagina, slight spotting.  Wound dry and intact.,ASSESSMENT:,  Normal postoperative course.,PLAN:,1.  Follow clinically.,2.  Continue present therapy.,3.  Ambulate with nursing assistance only.,","soap / chart / progress notes, postoperative course, total abdominal hysterectomy, postoperative"
" The patient comes for three-week postpartum checkup, complaining of allergies.", SOAP / Chart / Progress Notes, Three-Week Postpartum Checkup ,"CHIEF COMPLAINT:,  The patient comes for three-week postpartum checkup, complaining of allergies.,HISTORY OF PRESENT ILLNESS:,  She is doing well postpartum.  She has had no headache.  She is breastfeeding and feels like her milk is adequate.  She has not had much bleeding.  She is using about a mini pad twice a day, not any cramping or clotting and the discharge is turned from red to brown to now slightly yellowish.  She has not yet had sexual intercourse.  She does complain that she has had a little pain with the bowel movement, and every now and then she notices a little bright red bleeding.  She has not been particularly constipated but her husband says she is not eating her vegetables like she should.  Her seasonal allergies have back developed and she is complaining of extremely itchy watery eyes, runny nose, sneezing, and kind of a pressure sensation in her ears.,MEDICATIONS:,  Prenatal vitamins.,ALLERGIES:,  She thinks to Benadryl.,FAMILY HISTORY: , Mother is 50 and healthy.  Dad is 40 and healthy.  Half-sister, age 34, is healthy.  She has a sister who is age 10 who has some yeast infections.,PHYSICAL EXAMINATION:,VITALS:  Weight:  124 pounds.  Blood pressure 96/54.  Pulse:  72.  Respirations:  16.  LMP:  10/18/03.  Age:  39.,HEENT:  Head is normocephalic.  Eyes:  EOMs intact.  PERRLA.  Conjunctiva clear.  Fundi:  Discs flat, cups normal.  No AV nicking, hemorrhage or exudate.  Ears:  TMs intact.  Mouth:  No lesion.  Throat:  No inflammation.  She has allergic rhinitis with clear nasal drainage, clear watery discharge from the eyes.,Abdomen:  Soft.  No masses.,Pelvic:  Uterus is involuting.,Rectal:  She has one external hemorrhoid which has inflamed.  Stool is guaiac negative and using anoscope, no other lesions are identified.,ASSESSMENT/PLAN:,  Satisfactory three-week postpartum course, seasonal allergies.  We will try Patanol eyedrops and Allegra 60 mg twice a day.  She was cautioned about the possibility that this may alter her milk supply.  She is to drink extra fluids and call if she has problems with that.  We will try ProctoFoam HC.  For the hemorrhoids, also increase the fiber in her diet.  That prescription was written, as well as one for Allegra and Patanol.  She additionally will be begin on Micronor because she would like to protect herself from pregnancy until her husband get scheduled in and has a vasectomy, which is their ultimate plan for birth control, and she anticipates that happening fairly soon.  She will call and return if she continues to have problems with allergies.  Meantime, rechecking in three weeks for her final six-week postpartum checkup.","soap / chart / progress notes, checkup, allergies, postpartum, complaining of allergies, seasonal allergies, postpartum checkup,"
"  Essential thrombocytosis.  He underwent a bone marrow biopsy, which showed essential thrombocytosis.  His CBC has been very stable.  ", SOAP / Chart / Progress Notes, Thrombocytosis Followup ,"CHIEF COMPLAINT:,  Essential thrombocytosis.,HISTORY OF PRESENT ILLNESS: , This is an extremely pleasant 64-year-old gentleman who I am following for essential thrombocytosis.  He was first diagnosed when he first saw a hematologist on 07/09/07.  At that time, his platelet count was 1,240,000.  He was initially started on Hydrea 1000 mg q.d.  On 07/11/07, he underwent a bone marrow biopsy, which showed essential thrombocytosis.  He was positive for the JAK-2 mutation.  On 11/06/07, his platelets were noted to be 766,000.  His current Hydrea dose is now 1500 mg on Mondays and Fridays and 1000 mg on all other days.  He moved to ABCD in December 2009 in an attempt to improve his wife's rheumatoid arthritis.,Overall, he is doing well.  He has a good energy level, and his ECOG performance status is 0.  He denies any fevers, chills, or night sweats.  No lymphadenopathy.  No nausea or vomiting.  No change in bowel or bladder habits.,CURRENT MEDICATIONS: , Hydrea 1500 mg on Mondays and Fridays and 1000 mg the other days of the week,  Flomax q.d., vitamin D q.d, saw palmetto q.d., aspirin 81 mg q.d., and vitamin C q.d.,ALLERGIES: , No known drug allergies.,REVIEW OF SYSTEMS:,  As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1.  He is status post an appendectomy.,2.  Status post a tonsillectomy and adenoidectomy.,3.  Status post bilateral cataract surgery.,4.  BPH.,SOCIAL HISTORY:  ,He has a history of tobacco use, which he quit at the age of 37.  He has one alcoholic drink per day.  He is married.  He is a retired lab manager.,FAMILY HISTORY:  ,There is no history of solid tumor or hematologic malignancies in his family.,PHYSICAL EXAM:,VIT:",
 Patient with immune thrombocytopenia, SOAP / Chart / Progress Notes, Thrombocytopenia - SOAP Note ,"SUBJECTIVE: , I am following the patient today for immune thrombocytopenia.  Her platelets fell to 10 on 01/09/07 and shortly after learning of that result, I increased her prednisone to 60 mg a day.  Repeat on 01/16/07 revealed platelets up at 43.  No bleeding problems have been noted.  I have spoken with her hematologist who recommends at this point we decrease her prednisone to 40 mg for 3 days and then go down to 20 mg a day.  The patient had been on 20 mg every other day at least for a while, and her platelets hovered at least above 20 or so.,PHYSICAL EXAMINATION: , Vitals:  As in chart.  The patient is alert, pleasant, and cooperative.  She is in no apparent distress.  The petechial areas on her legs have resolved.,ASSESSMENT AND PLAN: , Patient with improvement of her platelet count on burst of prednisone.  We will decrease her prednisone to 40 mg for 3 days, then go down to 20 mg a day.  Basically thereafter, over time, I may try to sneak it back a little bit further.  She is on medicines for osteoporosis including bisphosphonate and calcium with vitamin D.  We will arrange to have a CBC drawn weekly.,","soap / chart / progress notes, platelets, platelet count, thrombocytopenia, prednisone,"
" Persistent frequency and urgency, in a patient with a history of neurogenic bladder and history of stroke. ", SOAP / Chart / Progress Notes, Urinary Frequency & Urgency - Followup ,"HISTORY OF PRESENT ILLNESS:  ,This is a 55-year-old female with a history of stroke, who presents today for followup of frequency and urgency with urge incontinence.  This has been progressively worsening, and previously on VESIcare with no improvement.  She continues to take Enablex 50 mg and has not noted any improvement of her symptoms.  The nursing home did not do a voiding diary.  She is accompanied by her power of attorney.  No dysuria, gross hematuria, fever or chills.  No bowel issues and does use several Depends a day.,Recent urodynamics in April 2008, here in the office, revealed significant detrusor instability with involuntary urinary incontinence and low bladder volumes, and cystoscopy was unremarkable.,IMPRESSION:  ,Persistent frequency and urgency, in a patient with a history of neurogenic bladder and history of stroke.  This has not improved on VESIcare as well as Enablex.  Options are discussed.,We discussed other options of pelvic floor rehabilitation, InterStim by Dr. X, as well as more invasive procedure.  The patient and the power of attorney would like him to proceed with meeting Dr. X to discuss InterStim, which was briefly reviewed here today and brochure for this is provided today.  Prior to discussion, the nursing home will do an extensive voiding diary for one week, while she is on Enablex, and if this reveals no improvement, the patient will be started on Ventura twice daily and prescription is provided.  They will see Dr. X with a prior voiding diary, which is again discussed.  All questions answered.,PLAN:,  As above, the patient will be scheduled to meet with Dr. X to discuss option of InterStim, and will be accompanied by her power of attorney.  In the meantime, Sanctura prescription is provided, and voiding diaries are provided.  All questions answered.","soap / chart / progress notes, neurogenic bladder, urge incontinence, urgency, frequency, vesicare, enablex, persistent frequency and urgency, frequency and urgency, persistent frequency, voiding diary, voiding"
" The patient noted for improving retention of urine, postop vaginal reconstruction, very concerned of possible vaginal prolapse.", SOAP / Chart / Progress Notes, Urinary Retention - Followup ,"HISTORY OF PRESENT ILLNESS: , The patient presents today for followup.  No dysuria, gross hematuria, fever, chills.  She continues to have urinary incontinence, especially while changing from sitting to standing position, as well as urge incontinence.  She is voiding daytime every 1 hour in the morning especially after taking Lasix, which tapers off in the afternoon, nocturia time 0.  No incontinence.  No straining to urinate.  Good stream, emptying well.  No bowel issues, however, she also indicates that while using her vaginal cream, she has difficulty doing this as she feels protrusion in the vagina, and very concerned if she has a prolapse.,IMPRESSION:  ,1.  The patient noted for improving retention of urine, postop vaginal reconstruction, very concerned of possible vaginal prolapse, especially while using the cream.,2.  Rule out ascites, with no GI issues other than lower extremity edema.,PLAN: , Following a detailed discussion with the patient, she elected to proceed with continued Flomax and will wean off the Urecholine to two times daily.  She will follow up next week, request Dr. X to do a pelvic exam, and in the meantime, she will obtain a CT of the abdomen and pelvis to further evaluate the cause of the abdominal distention.  All questions answered.","soap / chart / progress notes, urinary retention, dysuria, gross hematuria, postop vaginal reconstruction, vaginal reconstruction, vaginal prolapse, urinary, retention, prolapse, vaginal, incontinence,"
" He got addicted to drugs.  He decided it would be a good idea to get away from the ""bad crowd"" and come up and live with his mom.", SOAP / Chart / Progress Notes, SOAP - Substance Abuse ,"SUBJECTIVE: , This patient presents to the office today with his mom for checkup.  He used to live in the city.  He used to go to college down in the city.  He got addicted to drugs.  He decided it would be a good idea to get away from the ""bad crowd"" and come up and live with his mom.  He has a history of doing heroin.  He was injecting into his vein.  He was seeing a physician in the city.  They were prescribing methadone for some time.  He says that did help.  He was on 10 mg of methadone.  He was on it for three to four months.  He tried to wean down on the methadone a couple of different times, but failed.  He has been intermittently using heroin.  He says one of the big problems is that he lives in a household full of drug users and he could not get away from it.  All that changed now that he is living with his mom.  The last time he did heroin was about seven to eight days ago.  He has not had any methadone in about a week either.  He is coming in today specifically requesting methadone.  He also admits to being depressed.  He is sad a lot and down.  He does not have much energy.  He does not have the enthusiasm.  He denies any suicidal or homicidal ideations at the present time.  I questioned him on the symptoms of bipolar disorder and he does not seem to have those symptoms.  His past medical history is significant for no medical problems.  Surgical history, he voluntarily donated his left kidney.  Family and social history were reviewed per the nursing notes.  His allergies are no known drug allergies.  Medications, he takes no medications regularly.,OBJECTIVE: , His weight is 164 pounds, blood pressure 108/60, pulse 88, respirations 16, and temperature was not taken.  General:  He is nontoxic and in no acute distress.  Psychiatric:  Alert and oriented times 3.  Skin:  I examined his upper extremities.  He showed me his injection sites.  I can see marks, but they seem to be healing up nicely.  I do not see any evidence of cellulitis.  There is no evidence of necrotizing fasciitis.,ASSESSMENT: , Substance abuse.,PLAN: , I had a long talk with the patient and his mom.  I am not prescribing him any narcotics or controlled substances.  I am not in the practice of trading one addiction for another.  It has been one week without any sort of drugs at all.  I do not think he needs weaning.  I think right now it is mostly psychological, although there still could be some residual physical addiction.  However, once again I do not believe it to be necessary to prescribe him any sort of controlled substance at the present time.  I do believe that his depression needs to be treated.  I gave him fluoxetine 20 mg one tablet daily.  I discussed the side effects in detail.  I did also warn him that all antidepressant medications carry an increased risk of suicide.  If he should start to feel any of these symptoms, he should call #911 or go to the emergency room immediately.  If he has any problems or side effects, he was also directed to call me here at the office.  After-hours, he can go to the emergency room or call #911.  I am going to see him back in three weeks for the depression.  I gave him the name and phone number of Behavioral Health and I told him to call so that he can get into rehabilitation program or at least a support group.  We are unable to make a referral for him to do that.  He has to call on his own.  He has no insurance.  However, I think fluoxetine is very affordable.  He can get it for $4 per month at Wal-Mart.  His mom is going to keep an eye on him as well.  He is going to be staying there.  It sounds like he is looking for a job.","soap / chart / progress notes, addicted to drugs, substance abuse, abuse, heroin, methadone"
" The patient is admitted for shortness of breath, continues to do fairly well.  The patient has chronic atrial fibrillation, on anticoagulation, INR of 1.72.  The patient did undergo echocardiogram, which shows aortic stenosis, severe.  The patient does have an outside cardiologist. ", SOAP / Chart / Progress Notes, SOAP - Shortness of Breath ,"SUBJECTIVE: , The patient is admitted for shortness of breath, continues to do fairly well.  The patient has chronic atrial fibrillation, on anticoagulation, INR of 1.72.  The patient did undergo echocardiogram, which shows aortic stenosis, severe.  The patient does have an outside cardiologist.  I understand she was scheduled to undergo workup in this regard.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse of 78 and blood pressure 130/60.,LUNGS:  Clear.,HEART:  A soft systolic murmur in the aortic area.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema.,IMPRESSION:,1.  Status shortness of breath responding well to medical management.,2.  Atrial fibrillation, chronic, on anticoagulation.,3.  Aortic stenosis.,RECOMMENDATIONS:,1.  Continue medications as above.,2.  The patient would like to follow with her cardiologist regarding aortic stenosis.  She may need a surgical intervention in this regard, which I explained to her.  The patient will be discharged home on medical management and she has an appointment to see her cardiologist in the next few days.,In the interim, if she changes her mind or if she has any concerns, I have requested to call me back.","soap / chart / progress notes, shortness of breath, medical management, atrial fibrillation, aortic stenosis, atrial, fibrillation, breath, stenosis, cardiologist, aortic, anticoagulation, inr,"
" She is a 79-year-old female who came in with acute cholecystitis and underwent attempted laparoscopic cholecystectomy 8 days ago.  The patient has required conversion to an open procedure due to difficult anatomy.  Her postoperative course has been lengthened due to a prolonged ileus, which resolved with tetracycline and Reglan.  The patient is starting to improve, gain more strength.  She is tolerating her regular diet.", SOAP / Chart / Progress Notes, SOAP - Cholecystitis ,"SUBJECTIVE: , She is a 79-year-old female who came in with acute cholecystitis and underwent attempted laparoscopic cholecystectomy 8 days ago.  The patient has required conversion to an open procedure due to difficult anatomy.  Her postoperative course has been lengthened due to a prolonged ileus, which resolved with tetracycline and Reglan.  The patient is starting to improve, gain more strength.  She is tolerating her regular diet.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Today, her temperature is 98.4, heart rate 84, respirations 20, and BP is 140/72.,LUNGS:  Clear to auscultation.  No wheezes, rales, or rhonchi.,HEART:  Regular rhythm and rate.,ABDOMEN:  Soft, less tender.,LABORATORY DATA:,  Her white count continues to come down.  Today, it is 11.6, H&H of 8.8 and 26.4, platelets 359,000.  We have ordered type and cross for 2 units of packed red blood cells.  If it drops below 25, she will receive a transfusion.  Her electrolytes today show a glucose of 107, sodium 137, potassium 4.0, chloride 103.2, bicarbonate 29.7.  Her AST is 43, ALT is 223, her alkaline phosphatase is 214, and her bilirubin is less than 0.10.,ASSESSMENT AND PLAN:,  She had a bowel movement today and is continuing to improve.,I anticipate another 3 days in the hospital for strengthening and continued TPN and resolution of elevated white count.","soap / chart / progress notes, laparoscopic cholecystectomy, anatomy, acute cholecystitis, prolonged ileus, white count, cholecystitis"
" Pulmonary disorder with lung mass, pleural effusion, and chronic uncontrolled atrial fibrillation secondary to pulmonary disorder. The patient is admitted for lung mass and also pleural effusion.  The patient had a chest tube placement, which has been taken out.  The patient has chronic atrial fibrillation, on anticoagulation. ", SOAP / Chart / Progress Notes, SOAP - Lung Mass ,"SUBJECTIVE:,  The patient is admitted for lung mass and also pleural effusion.  The patient had a chest tube placement, which has been taken out.  The patient has chronic atrial fibrillation, on anticoagulation.  The patient is doing fairly well.  This afternoon, she called me because heart rate was in the range of 120 to 140.  The patient is lying down.  She does have shortness of breath, but denies any other significant symptoms.,PAST MEDICAL HISTORY:,  History of mastectomy, chest tube placement, and atrial fibrillation; chronic.,MEDICATIONS:,1.  Cardizem, which is changed to 60 mg p.o. t.i.d.,2.  Digoxin 0.25 mg daily.,3.  Coumadin, adjusted dose.,4.  Clindamycin.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse 122 and blood pressure 102/68.,LUNGS:  Air entry decreased.,HEART:  PMI is displaced.  S1 and S2 are irregular.,ABDOMEN:  Soft and nontender.,IMPRESSION:,1.  Pulmonary disorder with lung mass.,2.  Pleural effusion.,3.  Chronic uncontrolled atrial fibrillation secondary to pulmonary disorder.,RECOMMENDATIONS:,1.  From cardiac standpoint, follow with pulmonary treatment.,2.  The patient has an INR of 2.09.  She is on anticoagulation.  Atrial fibrillation is chronic with the rate increased.,Adjust the medications accordingly as above.","soap / chart / progress notes, lung mass, pleural effusion, chest tube placement, chest tube, pulmonary disorder, atrial fibrillation, chest, anticoagulation, effusion, lung, pulmonary, atrial, fibrillation,"
" Numbness and tingling in the right upper extremity, intermittent and related to the positioning of the wrist.  Carpal tunnel syndrome suspected.", SOAP / Chart / Progress Notes, SOAP - Numbness & Tingling ,"SUBJECTIVE: , This patient presents to the office today because of some problems with her right hand.  It has been going tingling and getting numb periodically over several weeks.  She just recently moved her keyboard down at work.  She is hoping that will help.  She is worried about carpal tunnel.  She does a lot of repetitive type activities.  It is worse at night.  If she sleeps on it a certain way, she will wake up and it will be tingling then she can usually shake out the tingling, but nonetheless it is very bothersome for her.  It involves mostly the middle finger, although, she says it also involves the first and second digits on the right hand.  She has some pain in her thumb as well.  She thinks that could be arthritis.,OBJECTIVE: , Weight 213.2 pounds, blood pressure 142/84, pulse 92, respirations 16.  General:  The patient is nontoxic and in no acute distress.  Musculoskeletal:  The right hand was examined.  It appears to be within normal limits and the appearance is similar to the left hand.  She has good and equal grip strength noted bilaterally.  She has negative Tinel's bilaterally.  She has a positive Phalen's test.  The fingers on the right hand are neurovascularly intact with a normal capillary refill.,ASSESSMENT:  ,Numbness and tingling in the right upper extremity, intermittent and related to the positioning of the wrist.  I suspect carpal tunnel syndrome.,PLAN:  ,The patient is going to use Anaprox double strength one pill every 12 hours with food as well as a cock-up wrist splint.  We are going to try this for two weeks and if the condition is still present, then we are going to proceed with EMG test at that time.  She is going to let me know.  While she is here, I am going to also get her the blood test she needs for her diabetes.  I am noting that her blood pressure is elevated, but improved from the last visit.  I also noticed that she has lost a lot of weight.  She is working on diet and exercise and she is doing a great job.  Right now for the blood pressure we are going to continue to observe as she carries forward additional measures in her diet and exercise to lose more weight and I expect the blood pressure will continue to improve.","soap / chart / progress notes, tinel's, phalen's, positioning of the wrist, numbness and tingling, carpal tunnel syndrome, carpal tunnel, numbness, tingling"
 MRI demonstrated right contrast-enhancing temporal mass., SOAP / Chart / Progress Notes, SOAP - Temporal Mass ,"SUBJECTIVE: , The patient is a 55-year-old African-American male that was last seen in clinic on 07/29/2008 with diagnosis of new onset seizures and an MRI scan, which demonstrated right contrast-enhancing temporal mass.  Given the characteristics of this mass and his new onset seizures, it is significantly concerning for a high-grade glioma.  ,OBJECTIVE: , The patient is alert and oriented times three, GCS of 15.  Cranial nerves II to XII are grossly intact.  Motor exam demonstrates 5/5 strength in all four extremities.  Sensation is intact to light touch, pain, temperature, and proprioception.  Cerebellar exam is intact.  Gait is normal and tandem on heels and toes.  Speech is appropriate.  Judgment is intact.  Pupils are equal and reactive to light.,ASSESSMENT AND PLAN: , The patient is a 55-year-old African-American male with a new diagnosis of rim-enhancing right temporal mass.  Given the characteristics of the MRI scan, it is highly likely that he demonstrates high-grade glioma and concerning for glioblastoma multiforme.  We have discussed in length the possible benefits of biopsy, surgical resection, medical management, as well as chemotherapy, radiation treatments, and doing nothing.  Given the high probability that the mass represents a high-grade glioma, the patient, after weighing the risks and the benefits of surgery, has agreed to undergo a surgical biopsy and resection of the mass as well as concomitant chemotherapy and radiation as the diagnosis demonstrates a high-grade glioma.  The patient has signed consent for his right temporal craniotomy for biopsy and likely resection of right temporal brain tumor.  He agrees that he will be n.p.o. after mid night on Wednesday night.  He is sent for preoperative assessment with the Anesthesiology tomorrow morning.  He has undergone vocational rehab assessment.","soap / chart / progress notes, new onset seizures, temporal mass, cerebellar exam, glioma, temporal, massNOTE"
 Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia.  This patient presents with history of sleep disruption and daytime sleepiness with fatigue.  Her symptoms are multifactorial., SOAP / Chart / Progress Notes, Sleep Study Followup ,"REASON FOR VISIT:,  This 48-year-old woman returns in followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia.,HISTORY OF PRESENT ILLNESS: , The patient presented initially to the Pulmonary Clinic with dyspnea on minimal exertion.  At that time, she was evaluated and found to have evidence for sleep disruption and daytime fatigue.  She also complained of nocturnal choking episodes that have since abated over the past several months.  In the meantime, she had been scheduled for an overnight sleep study performed to evaluate her for sleep apnea, returns today to review her study results.,The patient's sleep patterns consist of going to bed between 9.00 and 10.00 p.m. and awakening in the morning between 5.00 and 6.00 a.m.  She reports difficulty in initiating sleep and then recurrent awakenings every 1 to 2 hours throughout the night.  She reports tossing and turning throughout the night and awakening with the sheets in disarray.  She reports that her sleep was much better quality in the sleep laboratory as compared to home.  When she awakens, she might have a dull headache and feels tired in the morning.  Her daughter reports that she has heard the patient talking during sleep and snoring.  There are no apneic episodes.  The patient reports that she used to cough a lot in the middle of the night, but has no longer been doing so in recent weeks.,During the daytime, the patient reports spending a lot of sedentary time reading and watching TV.  She routinely dozes off during these sedentary activities.  She also might nap between 2.00 and 3.00 p.m., and nods off in the evening hours.,The patient smokes perhaps one to two packs of cigarettes per day, particularly after dinner.,She reports that her weight has fluctuated and peaked at 260 pounds approximately 1 year ago.  Since that time, her weight is down by approximately 30 pounds.,The patient is managed in Outpatient Psychiatry and at her Maintenance Clinic.  She takes methadone, trazodone, and Seroquel.,PAST MEDICAL HISTORY:,1.  Depression.,2.  Hepatitis C.,3.  Hypertension.,4.  Inhaled and intravenous drug abuse history.,The patient has a history of smoking two packs per day of cigarettes for approximately 25 pounds.  She also has a history of recurrent atypical chest pain for which she has been evaluated.,FAMILY HISTORY: , As previously documented.,SOCIAL HISTORY:  ,The patient has a history of inhalation on intravenous drug abuse.  She is currently on methadone maintenance.  She is being followed in Psychiatry for depression and substance abuse issues.  She lives with a room-mate.,REVIEW OF SYSTEMS:,  Not contributory.,MEDICATIONS: , Current medications include the following:,1.  Methadone 110 mg by mouth every day.,2.  Paxil 60 mg by mouth every day.,3.  Trazodone 30 mg by mouth nightly.,4.  Seroquel 20 mg by mouth nightly.,5.  Avalide (irbesartan) and hydrochlorothiazide.,6.  Albuterol and Flovent inhalers two puffs by mouth twice a day.,7.  Atrovent as needed.,FINDINGS: , Vital Signs:  Blood pressure 126/84, pulse 67, respiratory rate 18, weight 232 pounds, height 5 feet 8 inches, temperature 97.4 degrees, SaO2 is 99 percent on room air at rest.  HEENT:  Sclerae anicteric.  Conjunctivae pink.  Extraocular movements are intact.  Pupils are equal, round, and reactive to light.  The nasal passages show deviation in the nasal septum to the right.  There is a slight bloody exudate at the right naris.  Some nasal mucosal edema was noted with serous exudate bilaterally.  The jaw is not foreshortened.  The tongue is not large.  Mallampati airway score was 3.  The oropharynx was not shallow.  There is no pharyngeal mucosa hypertrophy.  No tonsillar tissue noted.  The tongue is not large.  Neck is supple.  Thyroid without nodules or masses.  Carotid upstrokes normal.  No bruits.  No jugular venous distention.  Chest is clear to auscultation and percussion.  No wheezing, rales, rhonchi or adventitious sounds.  No prolongation of the expiratory phase.  Cardiac:  PMI not palpable.  Regular rate and rhythm.  S1 and S2 normal.  No murmurs or gallops.  Abdomen:  Nontender.  Bowel sounds normal.  No liver or spleen palpable.  Extremities:  No clubbing or cyanosis.  There is 1+ pretibial edema.  Pulses are 2+ in upper and lower extremities.  Neurologic:  Grossly nonfocal.,LABORATORIES:,  Pulmonary function studies reportedly show a mild restrictive ventilatory defect without obstruction.  Diffusing capacity is well preserved.,An overnight sleep study was performed on this patient at the end of 02/07.  At that time, she reported that her sleep was better in the laboratories compared to home.  She slept for a total sleep time of 398 minutes out of 432 minutes in bed (sleep proficiency 92 percent).  She fell asleep in the middle of latency of less than 1 minute.  She woke up after sleep onset of 34 minutes.  She had stage I sleep that was some elevated at 28 percent of total sleep time, and stage I sleep is predominantly evident in the lateral portion of the night.  The remainders were stage II at 69 percent, stage III and IV at 3 percent of total sleep time.,The patient had no REM sleep.,The patient had no periodic limb movements during sleep.,The patient had no significant sleep-disordered breathing during non-REM sleep with less than one episode per hour.  Oxyhemoglobin saturation remained in the low to mid 90s throughout the night.,Intermittent inspiratory flow limitation compatible with snoring was observed during non-REM sleep.,ASSESSMENT AND PLAN: , This patient presents with history of sleep disruption and daytime sleepiness with fatigue.  Her symptoms are multifactorial.,Regarding the etiology of difficulty in initiating and maintaining sleep, the patient has a component of psychophysiologic insomnia, based on reports of better sleep in the laboratory as compared to home.  In addition, nontrivial smoking in the home setting may be contributing significantly to sleep disruption.,Regarding her daytime sleepiness, the patient is taking a number of long-acting central nervous system acting medications to sedate her and can produce a lasting sedation throughout the daytime.  These include trazodone, Seroquel, and methadone.  Of these medications, the methadone is clearly indicative, given the history of substance abuse.  It would be desirable to reduce or discontinue trazodone and then perhaps consider doing the same with Seroquel.  I brought this possibility up with the patient, and I asked her to discuss this further with her psychiatrist.,Finally, to help mitigate sleep disruption at night, I have provided her with tips for sleep hygiene.  These include bedtime rituals, stimulus control therapy, and sleep restriction as well as avoidance of nicotine in the evening hours.",
 The patient was admitted approximately 3 days ago with increasing shortness of breath secondary to pneumonia.  Pulmonary Medicine Associates have been contacted to consult in light of the ICU admission. , SOAP / Chart / Progress Notes, Shortness Of Breath - Progress Note ,"She was evaluated this a.m. and was without any significant clinical change.  Her white count has been improving and down to 12,000.  A chest x-ray obtained today showed some bilateral infiltrates, but no acute cardiopulmonary change.  There was a suggestion of a bilateral lower lobe pneumonitis or pneumonia.,She has been on Zosyn for the infection.,Throughout her hospitalization, we have been trying to adjust her pain medications.  She states that the methadone did not work for her.  She was ""immune"" to oxycodone.  She had been on tramadol before and was placed back on that.  There was some question that this may have been causing some dizziness.  She also was on clonazepam and alprazolam for the underlying bipolar disorder.,Apparently, her husband was in this afternoon.  He had a box of her pain medications.  It is unclear whether she took a bunch of these or precisely what happened.  I was contacted that she was less responsive.  She periodically has some difficulty to arouse due to pain medications, which she has been requesting repeatedly, though at times does not appear to have objective signs of ongoing pain.  The nurse found her and was unable to arouse her at this point.  There was a concern that she had taken some medications from home.  She was given Narcan and appeared to come around some.  Breathing remained somewhat labored and she had some diffuse scattered rhonchi, which certainly changed from this a.m.  Additional Narcan was given as well as some medications to reverse a possible benzodiazepine toxicity.  With O2 via mask, oxygenation was stable at 90% to 95% after initial hypoxia was noted.  A chest x-ray was obtained at this time.  An ECG was obtained, which shows a sinus tachycardia, noted to have ischemic abnormalities.,In light of the acute decompensation, she was then transferred to the ICU.  We will continue the IV Zosyn.  Respiratory protocol with respiratory management.  Continue alprazolam p.r.n., but avoid if she appears sedated.  We will attempt to avoid additional pain medications, but we will continue with the Dilaudid for time being.  I suspect she will need something to control her bipolar disorder.,Pulmonary Medicine Associates have been contacted to consult in light of the ICU admission.  At this juncture, she does not appear to need an intubation.  Pending chest x-ray, she may require additional IV furosemide.","soap / chart / progress notes, shortness of breath, pulmonary medicine, bipolar disorder, icuNOTE"
 Followup of moderate-to-severe sleep apnea.  The patient returns today to review his response to CPAP.  Recommended a fiberoptic ENT exam to exclude adenoidal tissue that may be contributing to obstruction. , SOAP / Chart / Progress Notes, Sleep Apnea ,"REASON FOR VISIT: , Mr. ABC is a 30-year-old man who returns in followup of his still moderate-to-severe sleep apnea.  He returns today to review his response to CPAP.,HISTORY OF PRESENT ILLNESS: , The patient initially presented with loud obnoxious snoring that disrupted the sleep of his bed partner.  He was found to have moderate-to-severe sleep apnea (predominantly hypopnea), was treated with nasal CPAP at 10 cm H2O nasal pressure.  He has been on CPAP now for several months, and returns for followup to review his response to treatment.,The patient reports that the CPAP has limited his snoring at night.  Occasionally, his bed partner wakes him in the middle of the night, when the mask comes off, and reminds him to replace the mask.  The patient estimates that he uses the CPAP approximately 5 to 7 nights per week, and on occasion takes it off and does not replace the mask when he awakens spontaneously in the middle of the night.,The patient's sleep pattern consists of going to bed between 11:00 and 11:30 at night and awakening between 6 to 7 a.m. on weekdays.  On weekends, he might sleep until 8 to 9 a.m.  On Saturday night, he might go to bed approximately mid night.,As noted, the patient is not snoring on CPAP.  He denies much tossing and turning and does not awaken with the sheets in disarray.  He awakens feeling relatively refreshed.,In the past few months, the patient has lost between 15 and 18 pounds in combination of dietary and exercise measures.,He continues to work at Smith Barney in downtown Baltimore.  He generally works from 8 to 8:30 a.m. until approximately 5 to 5:30 p.m.  He is involved in training purpose to how to sell managed funds and accounts.,The patient reports no change in daytime stamina.  He has no difficulty staying awake during the daytime or evening hours.,The past medical history is notable for allergic rhinitis.,MEDICATIONS: , He is maintained on Flonase and denies much in the way of nasal symptoms.,ALLERGIES: , Molds.,FINDINGS:  ,Vital signs:  Blood pressure 126/75, pulse 67, respiratory rate 16, weight 172 pounds, height 5 feet 9 inches, temperature 98.4 degrees and SaO2 is 99% on room air at rest.,The patient has adenoidal facies as noted previously.,Laboratories:  The patient forgot to bring his smart card in for downloading today.,ASSESSMENT: , Moderate-to-severe sleep apnea.  I have recommended the patient continue CPAP indefinitely.  He will be sending me his smart card for downloading to determine his CPAP usage pattern.  In addition, he will continue efforts to maintain his weight at current levels or below.  Should he succeed in reducing further, we might consider re-running a sleep study to determine whether he still requires a CPAP.,PLANS: , In the meantime, if it is also that the possible nasal obstruction is contributing to snoring and obstructive hypopnea.  I have recommended that a fiberoptic ENT exam be performed to exclude adenoidal tissue that may be contributing to obstruction.  He will be returning for routine followup in 6 months.","soap / chart / progress notes, daytime stamina, fiberoptic ent exam, moderate to severe, smart card, sleep apnea, cpap, apnea, sleep, "
" Refractory hypertension, much improved, history of cardiac arrhythmia and history of pacemaker secondary to AV block, history of GI bleed, and history of depression.", SOAP / Chart / Progress Notes, Refractory Hypertension - Followup ,"PROBLEM LIST:,1.  Refractory hypertension, much improved.,2.  History of cardiac arrhythmia and history of pacemaker secondary to AV block.,3.  History of GI bleed in 1995.,4.  History of depression.,HISTORY OF PRESENT ILLNESS:,  This is a return visit to the renal clinic for this patient.  She is an 85-year-old woman with history as noted above.  Her last visit was approximately four months ago.  Since that time, the patient has been considerably more compliant with her antihypertensive medications and actually had a better blood pressure reading today than she had had for many visits previously.  She is not reporting any untoward side effect.  She is not having weakness, dizziness, lightheadedness, nausea, vomiting, constipation, diarrhea, abdominal pain, chest pain, shortness of breath or difficulty breathing.  She has no orthopnea.  Her exercise capacity is about the same.  The only problem she has is musculoskeletal and that pain in the right buttock, she thinks originating from her spine.  No history of extremity pain.,CURRENT MEDICATIONS:,1.  Triamterene/hydrochlorothiazide 37.5/25 mg.,2.  Norvasc 10 mg daily.,3.  Atenolol 50 mg a day.,4.  Atacand 32 mg a day.,5.  Cardura 4 mg a day.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 36.2, pulse 47, respirations 16, and blood pressure 157/56.  THORAX:  Revealed lungs that are clear, PA and lateral without adventitious sounds.  CARDIOVASCULAR:  Demonstrated regular rate and rhythm.  S1 and S2 without murmur.  No S3.  I could not hear murmur today.  ABDOMEN:  Above plane, but nontender.  EXTREMITIES:  Revealed no edema.,ASSESSMENT:,  This is a return visit for this patient who has refractory hypertension.  This seems to be doing very well given her current blood pressure reading, at least much improved from what she had been previously.  We had discussed with her in the past beginning to see an internist at the senior center.  She apparently had an appointment scheduled and it was missed.  We are going to reschedule that today given her overall state of well-being and the fact that she has no evidence of GFR that is greater than 60%.,PLAN: , The plan will be for her to follow up at the senior center for her routine health care, and should the need arise for further management of blood pressure, a referral back to us.  In the meantime, we will discharge her from our practice.  Should there be confusion or difficulty getting in the senior center, we can always see her back in followup","soap / chart / progress notes, cardiac arrhythmia, av block, refractory hypertension, blood pressure, pacemaker, atenolol, arrhythmia"
" A 33-year-old black male with main complaint of sexual dysfunction, would like to try Cialis.", SOAP / Chart / Progress Notes, Sexual Dysfunction - Chart Note ,"SUBJECTIVE:,  The patient is a 33-year-old black male who comes in to the office today main complaint of sexual dysfunction.  Patient reports that he would like to try Cialis to see if it will improve his erectile performance.  Patient states that he did a quiz on-line at the Cialis web site and did not score in the normal range, so he thought he should come in.  Patient states that perhaps his desire has been slightly decreased, but that has not been the primary problem.  In discussing with me directly, patient primarily expresses that he would like to have his erections last longer.  However, looking at the quiz as he filled it out, he reported that much less than half the time was he able to get erections during sexual activity and only about half of the time he was able to maintain his erection after penetration.  However, he only reports that it is slightly difficult to maintain the erection until completion of intercourse.  Patient has no significant past medical history.  He has never had any previous testicular infections.  He denies any history of injuries to the groin and he has never been told that he has a hernia.,CURRENT MEDICATIONS:,  None.,ALLERGIES: , No drug allergies.,SOCIAL: , Only occasionally drinks alcohol and he is a nonsmoker.  He currently is working as a nurse aid, second shift, at a nursing home.  He states that he did not enroll in Wichita State this semester.  Stating he just was tired and wanted to take some time off.  He states he is in a relationship with one partner and denies any specific stress in the relationship.,OBJECTIVE:,General:  He appears in no distress.,Vital Signs:  Blood pressure:  With large cuff is 120/90.,Lungs:  Clear to auscultation.,Cardiovascular:  Normal S1-S2 without murmur.,Abdomen:  Soft, nontender.  Femoral pulses are 2+.,GU:  Testicles descended bilaterally.  No evidence of masses.  No evidence of inguinal hernias.,ASSESSMENT:,  Sexual dysfunction.,PLAN:,  We will check a free and total testosterone level as he does note some diminished desire.  He was given a sample of Cialis 10 mg with instructions on usage and a prescription for that if that is successful.  He will follow up here p.r.n.  Lastly, I did give him a blood pressure recording card, as his blood pressure is borderline today.  He will have that checked weekly at his workplace and follow up if they remain elevated.","soap / chart / progress notes, cialis, able to maintain, erectile, sexual activity, sexual dysfunction, blood pressure, maintain, dysfunction, erections, sexual"
 Epicondylitis. history of lupus.  Injected with 40-mg of Kenalog mixed with 1 cc of lidocaine., SOAP / Chart / Progress Notes, Rheumatology Progress Note ,"SUBJECTIVE:,  The patient is here for a follow-up.  The patient has a history of lupus, currently on Plaquenil 200-mg b.i.d.  Eye report was noted and appreciated.  The patient states that she is having some aches and pains of the hands and elbows that started recently a few weeks ago.  She denied having any trauma.  She states that the pain is bothering her.  She denies having any fevers, chills, or any joint effusion or swelling at this point.  She noted also that there is some increase in her hair loss in the recent times.,OBJECTIVE:,  The patient is alert and oriented.  General physical exam is unremarkable.  Musculoskeletal exam reveals positive tenderness in both lateral epicondyles of both elbows, no effusion.  Hand examination is unremarkable today.  The rest of the musculoskeletal exam is unremarkable.,ASSESSMENT:,  Epicondylitis, both elbows, possibly secondary to lupus flare-up.,PLAN:,  We will inject both elbows with 40-mg of Kenalog mixed with 1 cc of lidocaine.  The posterior approach was chosen under sterile conditions.  The patient tolerated both procedures well.  I will obtain CBC and urinalysis today.  If the patient's pain does not improve, I will consider adding methotrexate to her therapy.,Sample Doctor M.D.","soap / chart / progress notes, rheumatology, 1 cc of lidocaine, epicondylitis, kenalog, kenalog mixed with 1 cc of lidocaine, progress note, aches and pains, history of lupus, lidocaine, lupus, methotrexate, kenalog mixed, injected,"
 Patient returns to Pulmonary Medicine Clinic for followup evaluation of COPD and emphysema., SOAP / Chart / Progress Notes, Pulmonary Medicine Clinic Followup ,"SUBJECTIVE:,  The patient returns to the Pulmonary Medicine Clinic for followup evaluation of COPD and emphysema.  She was last seen in the clinic in March 2004.  Since that time, she has been hospitalized for psychiatric problems and now is in a nursing facility.  She is very frustrated with her living situation and would like to return to her own apartment, however, some believes she is to ill to care for herself.,At the present time, respiratory status is relatively stable.  She is still short of breath with activity, but all-in-all her pulmonary disease has not changed significantly since her last visit.  She does have occasional cough and a small amount of sputum production.  No fever or chills.  No chest pains.,CURRENT MEDICATIONS:,  The patient’s current medications are as outlined.,ALLERGIES TO MEDICATIONS:,  Erythromycin.,REVIEW OF SYSTEMS:,  Significant for problems with agitated depression.  Her respiratory status is unchanged as noted above.,EXAMINATION:,General:  The patient is in no acute distress.,Vital signs:  Blood pressure is 152/80, pulse 80 and respiratory rate 16.,HEENT:  Nasal mucosa was mild-to-moderately erythematous and edematous.  Oropharynx was clear.,Neck:  Supple without palpable lymphadenopathy.,Chest:  Chest demonstrates decreased breath sounds throughout all lung fields, coarse but relatively clear.,Cardiovascular:  Distant heart tones.  Regular rate and rhythm.,Abdomen:  Soft and nontender.,Extremities:  Without edema.,Oxygen saturation was checked today on room air, at rest it was 90%.,ASSESSMENT:,1.  Chronic obstructive pulmonary disease/emphysema, severe but stable.,2.  Mild hypoxemia, however, oxygen saturation at rest is stable without supplemental oxygen.,3.  History of depression and schizophrenia.,PLAN:,  At this point, I have recommended that she continue current respiratory medicine.  I did suggest that she would not use her oxygen when she is simply sitting, watching television or reading.  I have recommended that she use it with activity and at night.  I spoke with her about her living situation.  Encouraged her to speak with her family, as well as primary care physician about making efforts for her to return to her apartment.  Follow up evaluation is planned in Pulmonary Medicine Clinic in approximately three months or sooner if need be.","soap / chart / progress notes, respiratory, copd, chronic obstructive pulmonary disease, pulmonary medicine clinic, depression, emphysema, followup, hypoxemia, oxygen, schizophrenia, oxygen saturation, pulmonary medicine, medicine clinic, chest, medicine, pulmonary, "
" Followup left-sided rotator cuff tear and cervical spinal stenosis.  Physical examination and radiographic findings are compatible with left shoulder pain and left upper extremity pain, which is due to a combination of left-sided rotator cuff tear and moderate cervical spinal stenosis.", SOAP / Chart / Progress Notes, Rotator Cuff Tear ,"REASON FOR VISIT: , Followup left-sided rotator cuff tear and cervical spinal stenosis.,HISTORY OF PRESENT ILLNESS: , Ms. ABC returns today for followup regarding her left shoulder pain and left upper extremity C6 radiculopathy.  I had last seen her on 06/21/07.,At that time, she had been referred to me Dr. X and Dr. Y for evaluation of her left-sided C6 radiculopathy.  She also had a significant rotator cuff tear and is currently being evaluated for left-sided rotator cuff repair surgery, I believe on, approximately 07/20/07.  At our last visit, I only had a report of her prior cervical spine MRI.  I did not have any recent images.  I referred her for cervical spine MRI and she returns today.,She states that her symptoms are unchanged.  She continues to have significant left-sided shoulder pain for which she is being evaluated and is scheduled for surgery with Dr. Y.,She also has a second component of pain, which radiates down the left arm in a C6 distribution to the level of the wrist.  She has some associated minimal weakness described in detail in our prior office note.  No significant right upper extremity symptoms.  No bowel, bladder dysfunction.  No difficulty with ambulation.,FINDINGS: , On examination, she has 4 plus over 5 strength in the left biceps and triceps muscle groups, 4 out of 5 left deltoid, 5 out of 5 otherwise in both muscle groups and all muscle groups of upper extremities.  Light touch sensation is minimally decreased in the left C6 distribution; otherwise, intact.  Biceps and brachioradialis reflexes are 1 plus.  Hoffmann sign normal bilaterally.  Motor strength is 5 out of 5 in all muscle groups in lower extremities.  Hawkins and Neer impingement signs are positive at the left shoulder.,An EMG study performed on 06/08/07 demonstrates no evidence of radiculopathy or plexopathy or nerve entrapment to the left upper extremity.,Cervical spine MRI dated 06/28/07 is reviewed.  It is relatively limited study due to artifact.  He does demonstrate evidence of minimal-to-moderate stenosis at the C5-C6 level but without evidence of cord impingement or cord signal change.  There appears to be left paracentral disc herniation at the C5-C6 level, although axial T2-weighted images are quite limited.,ASSESSMENT AND PLAN: , Ms. ABC's history, physical examination and radiographic findings are compatible with left shoulder pain and left upper extremity pain, which is due to a combination of left-sided rotator cuff tear and moderate cervical spinal stenosis.,I agree with the plan to go ahead and continue with rotator cuff surgery.  With regard to the radiculopathy, I believe this can be treated non-operatively to begin with.  I am referring her for consideration of cervical epidural steroid injections.  The improvement in her pain may help her recover better from the shoulder surgery.,I will see her back in followup in 3 months, at which time she will be recovering from a shoulder surgery and we will see if she needs any further intervention with regard to the cervical spine.,I will also be in touch with Dr. Y to let him know this information prior to the surgery in several weeks.","soap / chart / progress notes, upper extremity, radiculopathy, rotator cuff repair, cervical spinal stenosis, rotator cuff tear, physical examination, cuff, impingement, stenosis, extremity, surgery, tear, shoulder, rotator, cervical,"
" A 6-year-old male with attention deficit hyperactivity disorder, doing fairly well with the Adderall.", SOAP / Chart / Progress Notes, Recheck of ADHD Meds ,"SUBJECTIVE:,  This is a 6-year-old male who comes in rechecking his ADHD medicines.  We placed him on Adderall, first time he has been on a stimulant medication last month.  Mother said the next day, he had a wonderful improvement, and he has been doing very well with the medicine.  She has two concerns.  It seems like first thing in the morning after he takes the medicine and it seems like it takes a while for the medicine to kick in.  It wears off about 2 and they have problems in the evening with him.  He was initially having difficulty with his appetite but that seems to be coming back but it is more the problems early in the morning after he takes this medicine than in the afternoon when the thing wears off.  His teachers have seen a dramatic improvement and she did miss a dose this past weekend and said he was just horrible.  The patient even commented that he thought he needed his medication.,PAST HISTORY:,  Reviewed from appointment on 08/16/2004.,CURRENT MEDICATIONS:,  He is on Adderall XR 10 mg once daily.,ALLERGIES: , To medicines are none.,FAMILY AND SOCIAL HISTORY:,  Reviewed from appointment on 08/16/2004.,REVIEW OF SYSTEMS:,  He has been having problems as mentioned in the morning and later in the afternoon but he has been eating well, sleeping okay.  Review of systems is otherwise negative.,OBJECTIVE:,  Weight is 46.5 pounds, which is down just a little bit from his appointment last month.  He was 49 pounds, but otherwise, fairly well controlled, not all that active in the exam room.  Physical exam itself was deferred today because he has otherwise been very healthy.,ASSESSMENT:,  At this point is attention deficit hyperactivity disorder, doing fairly well with the Adderall.,PLAN:,  Discussed with mother two options.  Switch him to the Ritalin LA, which I think has better release of the medicine early in the morning or to increase his Adderall dose.  As far as the afternoon, if she really wanted him to be on the medication, we will do a small dose of the Adderall, which she would prefer.  So I have decided at this point to increase him to the Adderall XR 15 mg in the morning and then Adderall 5 mg in the afternoon.  Mother is to watch his diet.  We would like to recheck his weight if he is doing very well, in two months.  But if there are any problems, especially in the morning then we would do the Ritalin LA.  Mother understands and will call if there are problems.  Approximately 25 minutes spent with patient, all in discussion.","soap / chart / progress notes, adhd, attention deficit hyperactivity disorder, adderall xr, recheck, medicines, adderall,"
 Pulmonary Medicine Clinic for followup evaluation of interstitial disease secondary to lupus pneumonitis., SOAP / Chart / Progress Notes, Pulmonary - Followup Note ,"SUBJECTIVE:,  The patient returns to the Pulmonary Medicine Clinic for followup evaluation of interstitial disease secondary to lupus pneumonitis.  She was last seen in the Pulmonary Medicine Clinic in January 2004.  Since that time, her respiratory status has been quite good.  She has had no major respiratory difficulties; however, starting yesterday she began with increasing back and joint pain and as a result a deep breath has caused some back discomfort.  She denies any problems with cough or sputum production.  No fevers or chills.  Recently, she has had a bit more problems with fatigue.  For the most part, she has had no pulmonary limitations to her activity.,CURRENT MEDICATIONS:,  Synthroid 0.112 mg daily; Prilosec 20 mg daily; prednisone, she was 2.5 mg daily, but discontinued this on 06/16/2004; Plaquenil 200 mg b.i.d.; Imuran 100 mg daily; Advair one puff b.i.d.; Premarin 0.3 mg daily; Lipitor 10 mg Monday through Friday; Actonel 35 mg weekly; and aspirin 81 mg daily.  She is also on calcium, vitamin D, vitamin E, vitamin C and a multivitamin.,ALLERGIES:,  Penicillin and also intolerance to shellfish.,REVIEW OF SYSTEMS:,  Noncontributory except as outlined above.,EXAMINATION:,General:  The patient was in no acute distress.,Vital signs:  Blood pressure 122/60, pulse 72 and respiratory rate 16.,HEENT:  Nasal mucosa was mild-to-moderately erythematous and edematous.  Oropharynx was clear.,Neck:  Supple without palpable lymphadenopathy.,Chest:  Chest demonstrates decreased breath sounds, but clear.,Cardiovascular:  Regular rate and rhythm.,Abdomen:  Soft and nontender.,Extremities:  Without edema.  No skin lesions.,O2 saturation was checked at rest.  On room air it was 96% and on ambulation it varied between 94% and 96%.  Chest x-ray obtained today showed mild increased interstitial markings consistent with a history of lupus pneumonitis.  She has not had the previous chest x-ray with which to compare; however, I did compare the markings was less prominent when compared with previous CT scan.,ASSESSMENT:,1.  Lupus with mild pneumonitis.,2.  Respiratory status is stable.,3.  Increasing back and joint pain, possibly related to patient’s lupus, however, in fact may be related to recent discontinuation of prednisone.,PLAN:,  At this time, I have recommended to continue her current medications.  We would like to see her back in approximately four to five months, at which time I would like to recheck her pulmonary function test as well as check CAT scan.  At that point, it may be reasonable to consider weaning her Imuran if her pulmonary status is stable and the lupus appears to be under control.","soap / chart / progress notes, pulmonary medicine clinic, cat scan, lupus, respiratory status, chest x-ray, interstitial disease, lupus pneumonitis, pneumonitis, pulmonary function test, pulmonary status, respiratory difficulties, chest x ray, interstitial, respiratory, chest, pulmonary, "
 A 16-year-old male with Q-fever endocarditis., SOAP / Chart / Progress Notes, Q-Fever Endocarditis ,"HISTORY OF PRESENT ILLNESS: , This is a follow-up visit on this 16-year-old male who is currently receiving doxycycline 150 mg by mouth twice daily as well as hydroxychloroquine 200 mg by mouth three times a day for Q-fever endocarditis.  He is also taking digoxin, aspirin, warfarin, and furosemide.  Mother reports that he does have problems with 2-3 loose stools per day since September, but tolerates this relatively well.  This has not increased in frequency recently.,Mark recently underwent surgery at Children's Hospital and had on 10/15/2007, replacement of pulmonary homograft valve, resection of a pulmonary artery pseudoaneurysm, and insertion of Gore-Tex membrane pericardial substitute.  He tolerated this procedure well.  He has been doing well at home since that time.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature is 98.5, pulse 84, respirations 19, blood pressure 101/57, weight 77.7 kg, and height 159.9 cm.,GENERAL APPEARANCE:  Well-developed, well-nourished, slightly obese, slightly dysmorphic male in no obvious distress.,HEENT:  Remarkable for the badly degenerated left lower molar.  Funduscopic exam is unremarkable.,NECK:  Supple without adenopathy.,CHEST:  Clear including the sternal wound.,CARDIOVASCULAR:  A 3/6 systolic murmur heard best over the upper left sternal border.,ABDOMEN:  Soft.  He does have an enlarged spleen, however, given his obesity, I cannot accurately measure its size.,GU:  Deferred.,EXTREMITIES:  Examination of extremities reveals no embolic phenomenon.,SKIN:  Free of lesions.,NEUROLOGIC:  Grossly within normal limits.,LABORATORY DATA: , Doxycycline level obtained on 10/05/2007 as an outpatient was less than 0.5.  Hydroxychloroquine level obtained at that time was undetectable.  Of note is that doxycycline level obtained while in the hospital on 10/21/2007 was 6.5 mcg/mL.  Q-fever serology obtained on 10/05/2007 was positive for phase I antibodies in 1/2/6 and phase II antibodies at 1/128, which is an improvement over previous elevated titers.  Studies on the pulmonary valve tissue removed at surgery are pending.,IMPRESSION: , Q-fever endocarditis.,PLAN:  ,1.  Continue doxycycline and hydroxychloroquine.  I carefully questioned mother about compliance and concomitant use of dairy products while taking these medications.  She assures me that he is compliant with his medications.  We will however repeat his hydroxychloroquine and doxycycline levels.,2.  Repeat Q-fever serology.,3.  Comprehensive metabolic panel and CBC.,4.  Return to clinic in 4 weeks.,5.  Clotting times are being followed by Dr. X.","soap / chart / progress notes, q-fever, q-fever endocarditis, endocarditis, doxycycline, fever, "
" Moderately differentiated adenocarcinoma, 1+ enlarged prostate with normal seminal vesicles.", SOAP / Chart / Progress Notes, Prostate Adenocarcinoma - 3 ,"PHYSICAL EXAMINATION: , The patient is a 63-year-old executive who was seen by his physician for a company physical.  He stated that he was in excellent health and led an active life.  His physical examination was normal for a man of his age.  Chest x-ray and chemical screening blood work were within normal limits.  His PSA was elevated.,IMAGING:,Chest x-ray:  Normal.,CT scan of abdomen and pelvis:  No abnormalities.,LABORATORY:,  PSA 14.6.,PROCEDURES: , Ultrasound guided sextant biopsy of prostate:  Digital rectal exam performed at the time of the biopsy showed a 1+ enlarged prostate with normal seminal vesicles.,PATHOLOGY:  ,Prostate biopsy:  Left apex:  adenocarcinoma, moderately differentiated, Gleason's score 3 + 4 = 7/10.  Maximum linear extent in apex of tumor was 6 mm.  Left mid region prostate:  moderately differentiated adenocarcinoma, Gleason's 3 + 2 = 5/10.  Left base, right apex, and right mid-region and right base:  negative for carcinoma.,TREATMENT:,  The patient opted for low dose rate interstitial prostatic implants of I-125.  It was performed as an outpatient on 8/10.","soap / chart / progress notes, sextant biopsy, vesicles, seminal, apex, interstitial prostatic implants, moderately differentiated adenocarcinoma, normal seminal vesicles, enlarged prostate, gleason's, moderately, differentiated, prostate, adenocarcinoma "
 Moderate to poorly differentiated adenocarcinoma in the right lobe and poorly differentiated tubular adenocarcinoma in the left lobe of prostate., SOAP / Chart / Progress Notes, Prostate Adenocarcinoma - 2 ,"PHYSICAL EXAMINATION:,  This 71-year-old man went to his primary care physician for a routine physical.  His only complaints were nocturia times two and a gradual ""slowing down"" feeling.  The physical examination on 1/29 was within normal limits except for the digital rectal exam which revealed an asymmetric prostate gland with nodularity, R>L.  PSA was elevated.  The differential diagnosis for the visit was abnormal prostate, suggestive of CA.,IMAGING:  ,CT pelvis:  Irregular indentation of bladder.  Seminal vesicles enlarged.  Streaky densities in periprostatic fat consistent with transcapular spread to periprostatic plexus.  Impression:  prostatic malignancy with extracapsular extension and probable regional node metastasis.,Bone scan:  Negative for distant metastasis.,LABORATORY:,  PSA 32.1,PROCEDURES:,  Transrectal needle biopsy of prostate.  Pelvic lymphadenectomy and radical prostatectomy.,PATHOLOGY:  ,Prostate biopsy:  Moderate to poorly differentiated adenocarcinoma in the right lobe and poorly differentiated tubular adenocarcinoma in the left lobe of prostate.,Lymphadenectomy and prostatectomy:  Frozen section of removed pelvic lymph nodes demonstrated metastatic adenocarcinoma in one lymph node in the right obturator fossa.  Therefore, the radical prostatectomy was canceled.  ,Final pathology diagnosis:  Pelvic lymphadenectomy; left obturator fossa, single negative lymph node.  Right obturator fossa; metastatic adenocarcinoma in 1/5 lymph nodes.  Largest involved node 1.5 cm.,TREATMENT: , Patient began external beam radiation therapy to the pelvis.","soap / chart / progress notes, nocturia, asymmetric prostate gland, periprostatic, metastasis, poorly differentiated adenocarcinoma, differentiated adenocarcinoma, radical prostatectomy, metastatic adenocarcinoma, lymph nodes, prostatectomy, prostate, lymphadenectomy, adenocarcinoma"
 A 65-year-old man with chronic prostatitis returns for recheck., SOAP / Chart / Progress Notes, Prostatitis - Recheck ,"SUBJECTIVE:,  The patient is a 65-year-old man with chronic prostatitis who returns for recheck.  He follow with Dr. XYZ about every three to four months.  His last appointment was in May 2004.  Has had decreased libido since he has been on Proscar.  He had tried Viagra with some improvement.  He has not had any urinary tract infection since he has been on Proscar.  Has nocturia x 3 to 4.,PAST MEDICAL HISTORY/SURGERIES/HOSPITALIZATIONS:  ,Soon after birth for treatment of an inperforated anus and curvature of the penis.  At the age of 70 had another penile operation.  At the age of 27 and 28 he had repeat operations to correct this.  He did have complications of deep vein thrombosis and pulmonary embolism with one of those operations.  He has had procedures in the past for hypospadias, underwent an operation in 1988 to remove some tissue block in the anus.  In January of 1991 underwent cystoscopy.  He was hospitalized in 1970 for treatment of urinary tract infection.  In 2001, left rotator cuff repair with acromioplasty and distal clavicle resection.  In 2001, colonoscopy that was normal.  In 2001, prostate biopsy that showed chronic prostatitis.  In 2003, left inguinal hernia repair with MESH.,MEDICATIONS:,  Bactrim DS one pill a day, Proscar 5 mg a day, Flomax 0.4 mg daily.  He also uses Metamucil four times daily and stool softeners for bedtime.,ALLERGIES:,  Cipro.,FAMILY HISTORY:,  Father died from CA at the age of 79.  Mother died from postoperative infection at the age of 81.  Brother died from pancreatitis at the age of 40 and had a prior history of mental illness.  Father also had a prior history of lung cancer.  Mother had a history of breast cancer.  Father also had glaucoma.  He does not have any living siblings.  Friend died a year and half ago.,PERSONAL HISTORY:,  Negative for use of alcohol or tobacco.  He is a professor at College and teaches history and bible.,REVIEW OF SYSTEMS:,Eyes, nose and throat:  Wears eye glasses.  Has had some gradual decreased hearing ability.,Pulmonary:  Denies difficulty with cough or sputum production or hemoptysis.,Cardiac:  Denies palpitations, chest pain, orthopnea, nocturnal dyspnea, or edema.,Gastrointestinal:  Has had difficulty with constipation.  He denies any positive stools.  Denies peptic ulcer disease.  Denies reflux or melena.,Genitourinary:  As mentioned previously.,Neurologic:  Without symptoms.,Bones and Joints:  He has had occasional back pain.,Hematologic:  Occasionally has had some soreness in the right axillary region, but has not had known lymphadenopathy.,Endocrine:  He has not had a history of hypercholesterolemia or diabetes.,Dermatologic:  Without symptoms.,Immunization:  He had pneumococcal vaccination about three years ago.  Had an adult DT immunization five years ago.,PHYSICAL EXAMINATION:,Vital Signs:  Weight:  202.8 pounds.  Blood pressure:  126/72.  Pulse:  60.  Temperature:  96.8 degrees.,General Appearance:  He is a middle-aged man who is not in any acute distress.,HEENT:  Eyes:  Pupils are equally regular, round and reactive to light.  Extraocular movements are intact without nystagmus.  Visual fields were full to direct confrontation.  Funduscopic exam reveals middle size disc with sharp margins.  Ears:  Tympanic membranes are clear.  Mouth:  No oral mucosal lesions are seen.,Neck:  Without adenopathy or thyromegaly.,Chest:  Lungs are resonant to percussion.  Auscultation reveals normal breath sounds.,Heart:  Normal S1 and S2 without gallops or rubs.,Abdomen:  Without tenderness or masses to palpation.,Genitorectal exam:  Not repeated since these have been performed recently by Dr. Tandoc.,Extremities:  Without edema.,Neurologic:  Reflexes are +2 and symmetric throughout.  Babinski is negative and sensation is intact.  Cranial nerves are intact without localizing signs.  Cerebellar tension is normal.,IMPRESSION/PLAN:,1.  Chronic prostatitis.  He has been stable in this regard.,2.  Constipation.  He is encouraged to continue with his present measures.  Additionally, a TSH level will be obtained.,3.  Erectile dysfunction.  Testosterone level and comprehensive metabolic profile will be obtained.,4.  Anemia.  CBC will be rechecked.  Additional stools for occult blood will be rechecked.",
" Prostate gland showing moderately differentiated infiltrating adenocarcinoma - Excised prostate including capsule, pelvic lymph nodes, seminal vesicles, and small portion of bladder neck.", SOAP / Chart / Progress Notes, Prostate Adenocarcinoma - 4 ,"PHYSICAL EXAMINATION:,  Patient is a 46-year-old white male seen for annual physical exam and had an incidental PSA elevation of 4.0.  All other systems were normal.,PROCEDURES:  ,Sextant biopsy of the prostate.,Radical prostatectomy:  Excised prostate including capsule, pelvic lymph nodes, seminal vesicles, and small portion of bladder neck.,PATHOLOGY:,Prostate biopsy:  Right lobe, negative.  Left lobe, small focus of adenocarcinoma, Gleason's 3 + 3 in approximately 5% of the tissue.,Radical prostatectomy:  Negative lymph nodes.  Prostate gland showing moderately differentiated infiltrating adenocarcinoma, Gleason 3 + 2 extending to the apex involving both lobes of the prostate, mainly right.  Tumor overall involved less than 5% of the tissue.  Surgical margin was reported and involved at the apex.  The capsule and seminal vesicles were free.,DISCHARGE NOTE:,  Patient has made good post-op recovery other than mild urgency incontinence.  His post-op PSA is 0.1 mg/ml.","soap / chart / progress notes, capsule, bladder neck, surgical margin, moderately differentiated infiltrating adenocarcinoma, pelvic lymph nodes, prostate gland, infiltrating adenocarcinoma, radical prostatectomy, seminal vesicles, gleason's, seminal, vesicles, adenocarcinoma, prostate, "
" Complete urinary obstruction, underwent a transurethral resection of the prostate - adenocarcinoma of the prostate.", SOAP / Chart / Progress Notes, Prostate Adenocarcinoma - 1 ,"HISTORY:,  This 75-year-old man was transferred from the nursing home where he lived to the hospital late at night on 4/11 through the Emergency Department in complete urinary obstruction.  After catheterization, the patient underwent cystoscopy on 4/13.  On 4/14 the patient underwent a transurethral resection of the prostate and was discharged back to the nursing home later that day with voiding improved.  Final diagnosis was adenocarcinoma of the prostate.  Because of his mental status and general debility, the patient's family declined additional treatment.,LABORATORY:,  None,PROCEDURES:,Cystoscopy:  Blockage of the urethra by a markedly enlarged prostate.,Transurethral resection of prostate:  45 grams of tissue were sent to the Pathology Department for analysis.,PATHOLOGY: , Well differentiated adenocarcinoma, microacinar type, in 1 of 25 chips of prostatic tissue.","soap / chart / progress notes, urinary obstruction, voiding, resection of the prostate, adenocarcinoma of the prostate, complete urinary obstruction, prostate adenocarcinoma, transurethral resection, cystoscopy, transurethral, resection, prostate, adenocarcinoma,"
 The patient returns for followup evaluation 21 months after undergoing prostate fossa irradiation for recurrent Gleason 8 adenocarcinoma.    Concerning slow ongoing rise in PSA., SOAP / Chart / Progress Notes, Prostate Fossa Irradiation - Followup ,"HISTORY OF PRESENT ILLNESS: , The patient returns for followup evaluation 21 months after undergoing prostate fossa irradiation for recurrent Gleason 8 adenocarcinoma.  His urinary function had been stable until 2 days ago.  Over the past couple of days he has been waking every 1 to 1-1/2 hours and has had associated abdominal cramping, as well as a bit of sore throat (his wife has had a cold for about 2 weeks).  His libido remains intact (but he has not been sexually functional), but his erections have been dysfunctional.  The bowel function is stable with occasional irritative hemorrhoidal symptoms.  He has had no hematochezia.  The PSA has been slowly rising in recent months.  This month it reached 1.2.,PAIN ASSESSMENT: , Abdominal cramping in the past 2 days.  No more than 1 to 2 of 10 in intensity.,PERFORMANCE STATUS: , Karnofsky score 100.  He continues to work full-time.,NUTRITIONAL STATUS: , Appetite has been depressed over the past couple of days, and he has lost about 5 pounds.  (Per him, mostly this week.),PSYCHIATRIC: , Some stress regarding upcoming IRS audits of clients.,REVIEW OF SYSTEMS: , Otherwise noncontributory.,MEDICATIONS,1.  NyQuil.,2.  Timolol eye drops.,3.  Aspirin.,4.  Advil.,5.  Zinc.,PHYSICAL EXAMINATION,GENERAL:  Pleasant, well-developed, gentleman in no acute distress.  Weight is 197 pounds.,HEENT:  Sclerae and conjunctivae are clear.  Extraocular movement are intact.  Hearing is grossly intact.  The oral cavity is without thrush.  There is minor pharyngitis.,LYMPH NODES:  No palpable lymphadenopathy.,SKELETAL:  No focal skeletal tenderness.,LUNGS:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  Regular rate and rhythm.,ABDOMEN:  Soft, nontender without palpable mass or organomegaly.,DIGITAL RECTAL EXAMINATION:  There are external hemorrhoids.  The prostate fossa is flat without suspicious nodularity.  There is no blood on the examining glove.,EXTREMITIES:  Without clubbing, cyanosis, or edema.,NEUROLOGIC:  Without focal deficit.,IMPRESSION:,  Concerning slow ongoing rise in PSA.,PLAN: , Discussed significance of this in detail with the patient.  He understands the probability that there may be residual cancer although the location is unknown.  For now there is no good evidence that early management affects the ultimate prognosis.  Accordingly, he is comfortable with careful monitoring, and I have asked him to return here in 3 months with an updated PSA.  I also suggested that he reestablish contact with Dr. X at his convenience.",
 Acute supraglottitis with airway obstruction and parapharyngeal cellulitis and peritonsillar cellulitis., SOAP / Chart / Progress Notes, Progress Note - Supraglottitis ,"HISTORY: , A 59-year-old male presents in followup after being evaluated and treated as an in-patient by Dr. X for acute supraglottitis with airway obstruction and parapharyngeal cellulitis and peritonsillar cellulitis, admitted on 05/23/2008, discharged on 05/24/2008.  Please refer to chart for history and physical and review of systems and medical record.,PROCEDURES PERFORMED:  ,Fiberoptic laryngoscopy identifying about 30% positive Muller maneuver.  No supraglottic edema; +2/4 tonsils with small tonsil cyst, mid tonsil, left.,IMPRESSION:  ,1.  Resolving acute supraglottic edema secondary to pharyngitis and tonsillar cellulitis.,2.  Possible obstructive sleep apnea; however, the patient describes no known history of this phenomenon.,3.  Hypercholesterolemia.,4.  History of anxiety.,5.  History of coronary artery disease.,6.  Hypertension.,RECOMMENDATIONS: , Recommend continuing on Augmentin and tapered prednisone as prescribed by Dr. X.  Cultures are still pending and follow up with Dr. X in the next few weeks for re-evaluation.  I did discuss with the patient whether or not a sleep study would be beneficial and the patient denies any history of obstructive sleep apnea and wishes not to pursue this, but we will leave this open for him to talk with Dr. X on his followup, and he will pay more attention on his sleep pattern.","soap / chart / progress notes, acute supraglottic edema, obstructive sleep apnea, acute supraglottitis, airway obstruction, parapharyngeal cellulitis, peritonsillar cellulitis, supraglottic edema, supraglottitis, tonsils, cellulitis "
" Patient seen initially with epigastric and right upper quadrant abdominal pain, nausea, dizziness, and bloating.", SOAP / Chart / Progress Notes, Progress Note - Liver Cirrhosis ,"HISTORY OF PRESENT ILLNESS: , The patient is a 55-year-old Hispanic male who was seen initially in the office February 15, 2006, with epigastric and right upper quadrant abdominal pain, nausea, dizziness, and bloating.  The patient at that time stated that he had established diagnosis of liver cirrhosis.  Since the last visit the patient was asked to sign a lease of information form and we sent request for information from the doctor the patient saw before, Dr. X in Las Cruces and his primary care physician in Silver City, and unfortunately we did not get any information from anybody.  Also the patient had admission in Gila Medical Center with epigastric pain, diarrhea, and confusion.  He spent 3 days in the hospital.  He was followed by Dr. X and unfortunately we also do not have the information of what was wrong with the patient.  From the patient's report he was diagnosed with some kind of viral infection.  At the time of admission he had a lot of epigastric pain, nausea, vomiting, fever, and chills.,PHYSICAL EXAMINATION,VITAL SIGNS:  Weight 107, height 6 feet 1 inch, blood pressure 128/67, heart rate 74, saturation 98%; pain is 3/10 with localization of the pain in the epigastric area.,HEENT:  PERRLA.  EOM intact.  Oropharynx is clear of lesions.,NECK:  Supple.  No lymphadenopathy.  No thyromegaly.,LUNGS:  Clear to auscultation and percussion bilateral.,CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs, rubs, or gallops.,ABDOMEN:  Not tender, not distended.  Splenomegaly about 4 cm under the costal margin.  No hepatomegaly.  Bowel sounds present.,MUSCULOSKELETAL:  No cyanosis, no clubbing, no pitting edema.,NEUROLOGIC:  Nonfocal.  No asterixis.  No costovertebral tenderness.,PSYCHE:  The patient is oriented x4, alert and cooperative.,LABORATORY DATA: , We were able to collect lab results from Medical Center; we got only CMP from the hospital which showed glucose level 79, BUN 9, creatinine 0.6, sodium 136, potassium 3.5, chloride 104, CO2 23.7, calcium 7.3, total protein 5.9, albumin 2.5, total bilirubin 5.63.  His AST 56, ALT 37, alkaline phosphatase 165, and his ammonia level was 53.  We do not have any other results back.  No hepatitis panels.  No alpha-fetoprotein level.  The patient told me today that he also got an ultrasound of the abdomen and the result was not impressive, but we do not have this result despite calling medical records in the hospital to release this information.,ASSESSMENT AND PLAN:,  The patient is a 55-year-old with established diagnosis of liver cirrhosis, unknown cause.,1.  Epigastric pain.  The patient had chronic pain syndrome, he had multiple back surgeries, and he has taken opiate for a prolonged period of time.  In the office twice the patient did not have any abdominal pain on physical exam.  His pain does not sound like obstruction of common bile duct and he had these episodes of abdominal pain almost continuously.  He probably requires increased level of pain control with increased dose of opiates, which should be addressed with his primary care physician.,2.  End-stage liver disease.  Of course, we need to find out the cause of the liver cirrhosis.  We do not have hepatitis panel yet and we do not have information about the liver biopsy which was performed before.  We do not have any information of any type of investigation in the past.  Again, patient was seen by gastroenterologist already in Las Cruces, Dr. X.  The patient was advised to contact Dr. X by himself to convince him to send available information because we already send release information form signed by the patient without any result.  It will be not reasonable to repeat unnecessary tests in that point in time.,We are waiting for the hepatitis panel and alpha-fetoprotein level.  We will also need to get information about ultrasound which was done in Gila Medical Center, but obviously no tumor was found on this exam of the liver.  We have to figure out hepatitis status for another reason if he needs vaccination against hepatitis A and B.  Until now we do not know exactly what the cause of the patient's end-stage liver disease is and my differential diagnosis probably is hepatitis C.  The patient denied any excessive alcohol intake, but I could not preclude alcohol-related liver cirrhosis also.  We will need to look for nuclear antibody if it is not done before.  PSC is extremely unlikely but possible.  Wilson disease also possible diagnosis but again, we first have to figure out if these tests were done for the patient or not.  Alpha1-antitrypsin deficiency will be extremely unlikely because the patient has no lung problem.  On his end-stage liver disease we already know that he had low platelet count splenomegaly.  We know that his bilirubin is elevated and albumin is very low.  I suspect that at the time of admission to the hospital the patient presented with encephalopathy.  We do not know if INR was checked to look for coagulopathy.  The patient had an EGD in 2005 as well as colonoscopy in Silver City.  We have to have this result to evaluate if the patient had any varices and if he needs any intervention for that.,At this point in time, I recommended the patient to continue to take lactulose 50 mL 3 times daily.  The patient tolerated it well; no diarrhea at this point in time.  I also recommended for him to contact his primary care physician for increased dose of opiates for him.  As a primary prophylaxis of GI bleeding in patient with end-stage liver disease we will try to use Inderal.  The patient got a prescription for 10 mg pills.  He will take 10 mg twice daily and we will gradually increase his dose until his heart rate will drop to 25% from 75% to probably 60-58.  The patient was educated how to use Inderal and he was explained why we decided to use this medication.  The patient will hold this medication if he is orthostatic or bradycardic.,Again, the patient and his wife were advised to contact all offices they have seen before to get information about what tests were already done and if on the next visit in 2 weeks we still do not have any information we will need to repeat all these tests I mentioned above.,We also discussed nutrition issues.  The patient was provided information that his protein intake is supposed to be about 25 g per day.  He was advised not to over-eat protein and advised not to starve.  He also was advised to stay away from alcohol.  His next visit is in 2 weeks with all results available.","soap / chart / progress notes, abdominal pain, nausea, dizziness, liver disease, epigastric pain, liver cirrhosis, liver, abdominal, cirrhosis, epigastric, hepatitis,"
 Patient developed iron deficiency anemia and had blood in his stool. , SOAP / Chart / Progress Notes, Progress Note - Iron Deficiency Anemia ,"HISTORY OF PRESENT ILLNESS:,  The patient is a 55-year-old gentleman, a patient of Mrs. A, who was referred to me because the patient developed iron deficiency anemia and he had blood in his stool.  The patient also has chronic diarrhea.  His anemia was diagnosed months ago when he presented with unusual pruritus and he got a CBC.  At that time he was discovered to have hemoglobin of 9 and MCV 65.  The patient also had multiple episodes of dark blood and bright blood in the stool for the last 5 months on and off.  Last colonoscopy was performed by Dr. X in Las Cruces 3 years ago.  At that time the patient had polyps removed from the colon, all of them were hyperplastic in nature.  The patient also was diagnosed with lymphocytic colitis.  He was not treated for diarrhea for more than 3 years.,PAST MEDICAL HISTORY: , Includes chronic diarrhea as I mentioned before and chronic obstructive pulmonary disease secondary to heavy smoking.,MEDICATIONS: , Iron supplement.,ALLERGIES:  ,The patient has no known drug allergies.,FAMILY HISTORY:,  Includes coronary artery disease, hypertension.  Nobody in the family was diagnosed with any type of colon cancer or any type of other cancer.,SOCIAL HISTORY:,  The patient smoked 1-1/2 packs for more than 40 years.  He consumes 6 beers per day.  He denies any drug use.,REVIEW OF SYSTEMS: , The patient has no night sweats.  Good appetite.  Stable weight.  No chills, no fevers.  No visual problems.  No hearing problems.  The patient denies any difficulty swallowing, any nausea or vomiting, any burning sensation in the esophagus.  The patient has had chronic diarrhea for more than 3 years.  His stool is daily, 1-2 times per day and very loose.  He also admitted to have dark and bright blood in the stool on and off for more than 5 months.  Respiratory review of systems was significant for COPD.  The patient is not on oxygen and his COPD is mild.  He denies any neurological problems, psychiatric problems, endocrine problems, hematological problems, lymphatic problems, immunological problems, allergy problems.  The patient had recent episode of significant skin itching all over the body.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Weight 221 pounds.  Height 6 feet 1 inch.  Blood pressure 124/62, heart rate 87, temperature 98.4, saturation 98%.  Pain is 0/10.,GENERAL:  Well-developed, well-nourished, normal asthenic.  Good attention to grooming.,HEENT:  PERRLA.  EOM intact.  Oropharynx is clear of lesions.  Good dentition.,NECK:  Supple.  No lymphadenopathy.  No thyromegaly.,LUNGS:  Clear to auscultation and percussion bilaterally.  No wheezing, no rhonchi, no crackles.,CARDIOVASCULAR:  Regular rate and rhythm.  The patient had 2/6 systolic ejection murmur on aortic valve projected to carotid artery.  No rubs, no gallops.  No JVD.  Peripheral pulses 2+ in both radialis and both dorsalis pedis bilaterally.,ABDOMEN:  No masses, no tenderness.  No distention.  No hepatosplenomegaly.  Bowel sounds present.,RECTAL:  Good sphincter tone.  No palpable nodules.  No masses.  No blood.  Dark stool, the patient is taking iron.  Test was sent for occult blood test.,BACK:  No costovertebral tenderness bilaterally.,LYMPHATICS:  The patient had no neck, axial, groin or supraclavicular lymphadenopathy on exam.,MUSCULOSKELETAL:  The patient had good, stable gait.  No clubbing, no cyanosis, no pitting edema.  Full range of motion.  No joint deformities.,SKIN:  Clear of rashes and lesions.  No ulcers.,NEUROLOGICAL:  Cranial nerves II-XII within normal limits.  Deep tendon reflexes 2+ in both knees and both biceps.  Babinski negative bilaterally.  Good control of bowel and urinary bladder.  No local weakness.,PSYCHIATRIC:  The patient had good judgment and insight.  Oriented x4.  Good recent and remote memory.  Appropriate mood and affect.,ASSESSMENT & PLAN:  ,The patient is a 55-year-old gentleman with iron deficiency anemia, blood in the stool.  The patient needs evaluation for source of bleeding with a colonoscopy.  The patient was explained rationale, risks, benefits, and alternatives of the procedure.  He accepted the recommendation.  Colonoscopy scheduled.  The patient will need antibiotic prophylaxis prior to procedure because of valvular abnormality and we are not completely aware of what type of abnormality.  The patient had multiple tests from a previous examination.  One of the pathology reports from Dr. X from 2003 showed lymphocytic microscopic colitis, hyperplastic polyps.  Reviewed also multiple lab tests including CBC, CMP.  The patient had Coombs' test negative.  His reticulocyte count is 2.41.  His iron TIBC 514, serum iron 29, ferritin 7.  He had no liver function test abnormality.  PSA was in the normal range.  The patient had x-ray which showed pulmonary hyperinflation and emphysema.  The patient will be followed up with result of colonoscopy.",
 Polycythemia rubra vera.  The patient is an 83-year-old female with a history of polycythemia vera.  She comes in to clinic today for followup.  She has not required phlebotomies for several months., SOAP / Chart / Progress Notes, Polycythemia Rubra Vera ,"CHIEF COMPLAINT: , Polycythemia rubra vera.,HISTORY OF PRESENT ILLNESS: , The patient is an 83-year-old female with a history of polycythemia vera.  She comes in to clinic today for followup.  She has not required phlebotomies for several months.  The patient comes to clinic unaccompanied.,CURRENT MEDICATIONS: , Levothyroxine 200 mcg q.d., Nexium 40 mg q.d., Celebrex 200 mg q.d., vitamin D3 2000 IU q.d., aspirin 81 mg q.d., selenium 200 mg q.d., Aricept 10 mg q.d., Skelaxin 800 mg q.d., ropinirole 1 mg q.d., vitamin E 1000 IU q.d., vitamin C 500 mg q.d., flaxseed oil 100 mg daily, fish oil 100 units q.d., Vicodin q.h.s., and stool softener q.d.,ALLERGIES:  ,Penicillin.,REVIEW OF SYSTEMS:  ,The patient's chief complaint is her weight.  She brings in a packet of information on HCZ Diovan and also metabolic assessment that was done at the key.  She has questions as to whether or not there would be any contra indications to her going on the diet.  Otherwise, she feels great.  She had family reunion in Iowa once in four days out there.  She continues to volunteer Hospital and is walking and enjoying her summer.  She denies any fevers, chills, or night sweats.  She has some mild constipation problem but has had under control.  The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:","soap / chart / progress notes, polycythemia rubra vera, phlebotomy, hematocrit, polycythemia, "
 This patient is one-day postop open parathyroid exploration with subtotal parathyroidectomy and intraoperative PTH monitoring for parathyroid hyperplasia.  She has had an uneventful postoperative night. , SOAP / Chart / Progress Notes, Postop Parathyroid Exploration & Parathyroidectomy ,"SUMMARY:  ,This patient is one-day postop open parathyroid exploration with subtotal parathyroidectomy and intraoperative PTH monitoring for parathyroid hyperplasia.  She has had an uneventful postoperative night.  She put out 1175 mL of urine since surgery.  Her incision looks good.  IV site and extremities are unremarkable.,LABORATORY DATA:  ,Her calcium level was 7.5 this morning.  She has been on three Tums orally b.i.d. and I am increasing three Tums orally q.i.d. before meals and at bedtime.,PLAN:,  I will heparin lock her IV, advance her diet, and ambulate her.  I have asked her to increase her prednisone when she goes home.  She will double her regular dose for the next five days.  I will advance her diet.  I will continue to monitor her calcium levels throughout the day.  If they stabilize, I am hopeful that she will be ready for discharge either later today or tomorrow.  She will be given Lortab Elixir 2 to 4 teaspoons orally every four hours p.r.n. pain, dispensed #240 mL with one refill.  Her final calcium dosage will be determined prior to discharge.  I will plan to see her back in the office on the 12/30/08, and she has been instructed to call or return sooner for any problems.","soap / chart / progress notes, parathyroid hyperplasia, parathyroid exploration, pth, hyperplasia, parathyroidectomy, parathyroidNOTE"
 Followup for polycythemia vera with secondary myelofibrosis.  JAK-2 positive myeloproliferative disorder.   He is not a candidate for chlorambucil or radioactive phosphorus because of his young age and the concern for secondary malignancy., SOAP / Chart / Progress Notes, Polycythemia Vera Followup ,"DIAGNOSIS:,  Polycythemia vera with secondary myelofibrosis.,REASON FOR VISIT:, Followup of the above condition.,CHIEF COMPLAINT: , Left shin pain.,HISTORY OF PRESENT ILLNESS: , A 55-year-old white male who carries a diagnosis of polycythemia vera with secondary myelofibrosis.  Diagnosis was made some time in 2005/2006.  Initially, he underwent phlebotomy.  He subsequently transferred his care here.  In the past, he has been on hydroxyurea and interferon but did not tolerate both of them.  He is JAK-2 positive.  He does not have any siblings for a match-related transplant.  He was seen for consideration of a MUD transplant, but was deemed not to be a candidate because of the social support as well as his reasonably good health.,At our institution, the patient received a trial of lenalidomide and prednisone for a short period.  He did well with the combination.  Subsequently, he developed intolerance to lenalidomide.  He complained of severe fatigue and diarrhea.  This was subsequently stopped.,The patient reports some injury to his left leg last week.  His left leg apparently was swollen.  He took steroids for about 3 days and stopped.  Left leg swelling has disappeared.  The patient denies any other complaints at this point in time.  He admits to smoking marijuana.  He says this gives him a great appetite and he has actually gained some weight.  Performance status in the ECOG scale is 1.,PHYSICAL EXAMINATION:,VITAL SIGNS:  He is afebrile.  Blood pressure 144/85, pulse 86, weight 61.8 kg, and respiratory rate 18 per minute.  GENERAL:  He is in no acute distress.  HEENT:  There is no pallor, icterus or cervical adenopathy that is noted.  Oral cavity is normal to exam.  CHEST:  Clear to auscultation.  CARDIOVASCULAR:  S1 and S2 normal with regular rate and rhythm.  ABDOMEN:  Soft and nontender with no hepatomegaly.  Spleen is palpable 4 fingerbreadths below the left costal margin.  There is no guarding, tenderness, rebound or rigidity noted.  Bowel sounds are present.  EXTREMITIES:  Reveal no edema.  Palpation of the left tibia revealed some mild tenderness.  However, I do not palpate any bony abnormalities.  There is no history of deep venous thrombosis.,LABORATORY DATA: , CBC from today is significant for a white count of 41,900 with an absolute neutrophil count of 34,400, hemoglobin 14.8 with an MCV of 56.7, and platelet count 235,000.,ASSESSMENT AND PLAN:,1.  JAK-2 positive myeloproliferative disorder.  The patient has failed pretty much all available options.  He is not a candidate for chlorambucil or radioactive phosphorus because of his young age and the concern for secondary malignancy.  I have e-mailed Dr. X to see whether he will be a candidate for the LBH trial.  Hopefully, we can get a JAK-2 inhibitor trial quickly on board.,2.  I am concerned about the risk of thrombosis with his elevated white count.  He is on aspirin prophylaxis.  The patient has been told to call me with any complaints.,3.  Left shin pain.  I have ordered x-rays of the left tibia and knee today.  The patient will return to the clinic in 3 weeks.  He is to call me in the interim for any problems.","soap / chart / progress notes, jak-2 positive myeloproliferative disorder, secondary myelofibrosis, mud transplant, ecog scale, myeloproliferative disorder, radioactive phosphorus, jak positive, polycythemia vera, thrombosis, myelofibrosis,"
 Plantar fascitis/heel spur syndrome.  The patient was given injections of 3 cc 2:1 mixture of 1% lidocaine plain with dexamethasone phospate., SOAP / Chart / Progress Notes, Podiatry - Progress Note ,"SUBJECTIVE:,  Mr. Sample Patient returns to the Sample Clinic with the chief complaint of painful right heel.  The patient states that the heel has been painful for approximately two weeks, it is starts with the first step in the morning and gets worse with activity during the day.  The patient states that he is currently doing no treatment for it.  He states that most of his pain is along medial tubercle of the right calcaneus and extends to the medial arch.  The patient states that he has no change in the past medical history since his last visit and denies any fever, chills, vomiting, headache, chest, or shortness of breath.,OBJECTIVE:,  Upon removal of shoes and socks bilaterally, neurovascular status remains unchanged since the last visit.  There is tenderness to palpation to the medial tubercle of the right foot.  The pain is elicited along the medial arch as well.  There are no open areas or signs of infection noted.,ASSESSMENT:,  Plantar fascitis/heel spur syndrome, right foot.,PLAN:,  The patient was given injections of 3 cc 2:1 mixture of 1% lidocaine plain with dexamethasone phospate.  He was given a low dye strapping and a heel lift was placed in his right shoe.  The patient will be seen back in approximately one month for further evaluation if necessary.  He was told to call if anything should occur before that.  The patient was told to continue with the good work on his diabetic control.","soap / chart / progress notes, progress note, plantar fascitis, podiatry, soap, dexamethasone phospate, heel lift, heel spur syndrome, lidocaine, low dye strapping, mixture of 1% lidocaine, dexamethasone, phospate, injections, heel"
" Posttransplant lymphoproliferative disorder, chronic renal insufficiency, squamous cell carcinoma of the skin, anemia secondary to chronic renal insufficiency and chemotherapy, and hypertension.  The patient is here for followup visit and chemotherapy.", SOAP / Chart / Progress Notes, Posttransplant Lymphoproliferative Disorder ,"CHIEF COMPLAINT: , The patient is here for followup visit and chemotherapy.,DIAGNOSES:,1.  Posttransplant lymphoproliferative disorder.,2.  Chronic renal insufficiency.,3.  Squamous cell carcinoma of the skin.,4.  Anemia secondary to chronic renal insufficiency and chemotherapy.,5.  Hypertension.,HISTORY OF PRESENT ILLNESS: , A 51-year-old white male diagnosed with PTLD in latter half of 2007.  He presented with symptoms of increasing adenopathy, abdominal pain, weight loss, and anorexia.  He did not seek medical attention immediately.  He was finally hospitalized by the renal transplant service and underwent a lymph node biopsy in the groin, which showed diagnosis of large cell lymphoma.  He was discussed at the hematopathology conference.  Chemotherapy with rituximab plus cyclophosphamide, daunorubicin, vincristine, and prednisone was started.  First cycle of chemotherapy was complicated by sepsis despite growth factor support.  He also appeared to have become disoriented either secondary to sepsis or steroid therapy.,The patient has received 5 cycles of chemotherapy to date.  He did not keep his appointment for a PET scan after 3 cycles because he was not feeling well.  His therapy has been interrupted for infection related to squamous cell cancer, skin surgery as well as complaints of chest infection.,The patient is here for the sixth and final cycle of chemotherapy.  He states he feels well.  He denies any nausea, vomiting, cough, shortness of breath, chest pain or fatigue.  He denies any tingling or numbness in his fingers.  Review of systems is otherwise entirely negative.,Performance status on the ECOG scale is 1.,PHYSICAL EXAMINATION:,VITAL SIGNS:  He is afebrile.  Blood pressure 161/80, pulse 65, weight 71.5 kg, which is essentially unchanged from his prior visit.  There is mild pallor noted.  There is no icterus, adenopathy or petechiae noted.  CHEST:  Clear to auscultation.  CARDIOVASCULAR:  S1 and S2 normal with regular rate and rhythm.  Systolic flow murmur is best heard in the pulmonary area.  ABDOMEN:  Soft and nontender with no organomegaly.  Renal transplant is noted in the right lower quadrant with a scar present.  EXTREMITIES:  Reveal no edema.,LABORATORY DATA: , CBC from today shows white count of 9.6 with a normal differential, ANC of 7400, hemoglobin 8.9, hematocrit 26.5 with an MCV of 109, and platelet count of 220,000.,ASSESSMENT AND PLAN:,1.  Diffuse large B-cell lymphoma following transplantation.  The patient is to receive his sixth and final cycle of chemotherapy today.  PET scan has been ordered to be done within 2 weeks.  He will see me back for the visit in 3 weeks with CBC, CMP, and LDH.,2.  Chronic renal insufficiency.,3.  Anemia secondary to chronic renal failure and chemotherapy.  He is to continue on his regimen of growth factor support.,4.  Hypertension.  This is elevated today because he held his meds because he is getting rituximab other than that this is well controlled.  His CMP is pending from today.,5.  Squamous cell carcinoma of the skin.  The scalp is well healed.  He still has an open wound on the right posterior aspect of his trunk.  This has no active drainage, but it is yet to heal.  This probably will heal by secondary intention once chemotherapy is finished.  Prescription for prednisone as part of his chemotherapy has been given to him.","soap / chart / progress notes, anemia, chemotherapy, posttransplant lymphoproliferative disorder, squamous cell carcinoma, chronic renal insufficiency, renal insufficiency, adenopathy, lymphoproliferative, "
" A 44-year-old, 250-pound male presents with extreme pain in his left heel.", SOAP / Chart / Progress Notes, Plantar Fasciitis ,"S -, A 44-year-old, 250-pound male presents with extreme pain in his left heel.  This is his chief complaint.  He says that he has had this pain for about two weeks.  He works on concrete floors.  He says that in the mornings when he gets up or after sitting, he has extreme pain and great difficulty in walking.  He also has a macular blotching of skin on his arms, face, legs, feet and the rest of his body that he says is a pigment disorder that he has had since he was 17 years old.  He also has redness and infection of the right toes.,O -, The patient apparently has a pigmentation disorder, which may or may not change with time, on his arms, legs and other parts of his body, including his face.  He has an erythematous moccasin-pattern tinea pedis of the plantar aspects of both feet.  He has redness of the right toes 2, 3 and 4.  Extreme exquisite pain can be produced by direct pressure on the plantar aspect of his left heel.,A -, 1.  Plantar fasciitis.,","soap / chart / progress notes, plantar fasciitis, tinea pedis, tinea purpura, heel, fasciitis, plantar, "
" Outpatient rehabilitation physical therapy progress note.  A 52-year-old male referred to physical therapy secondary to chronic back pain, weakness, and debilitation secondary to chronic pain. ", SOAP / Chart / Progress Notes, Physical Therapy - Outpatient Rehab ,"SUMMARY:  ,The patient has attended physical therapy from 11/16/06 to 11/21/06.  The patient has 3 call and cancels and 3 no shows.  The patient has been sick for several weeks due to a cold as well as food poisoning, so has missed many appointments.,SUBJECTIVE:  ,The patient states pain still significant, primarily 1st seen in the morning.  The patient was evaluated 1st thing in the morning and did not take his pain medications, so objective findings may reflect that.  The patient states overall functionally he is improving where he is able to get out in the house and visit and do activities outside the house more.  The patient does feel like he is putting on more muscle girth as well.  The patient states he is doing well with his current home exercise program and feels like pool therapy is also helping as well.,OBJECTIVE: , Physical therapy has consisted of:,1.  Pool therapy incorporating endurance and general lower and upper extremity strengthening.,2.  Clinical setting incorporating core stabilization and general total body strengthening and muscle wasting.,3.  The patient has just begun this, so it is on a very beginners level at this time.,ASSESSMENT, DONE ON 12/21/06,STRENGTH,Activities",
 Six-month follow-up visit for paroxysmal atrial fibrillation (PAF).  She reports that she is getting occasional chest pains with activity.  Sometimes she feels that at night when she is lying in bed and it concerns her., SOAP / Chart / Progress Notes, PAF - 6-Month Followup ,"REASON FOR VISIT:,  Six-month follow-up visit for paroxysmal atrial fibrillation (PAF).,She reports that she is getting occasional chest pains with activity.  Sometimes she feels that at night when she is lying in bed and it concerns her.,She is frustrated by her inability to lose weight even though she is hyperthyroid.,MEDICATIONS: , Tapazole 10 mg b.i.d., atenolol/chlorthalidone 50/25 mg b.i.d., Micro-K 10 mEq q.d., Lanoxin 0.125 mg q.d., spironolactone 25 mg q.d., Crestor 10 mg q.h.s., famotidine 20 mg, Bayer Aspirin 81 mg q.d., Vicodin p.r.n., and Nexium 40 mg-given samples of this today.,REVIEW OF SYSTEMS:,  No palpitations.  No lightheadedness or presyncope.  She is having mild pedal edema, but she drinks a lot of fluid.,PEX: , BP:  112/74.  PR:  70.  WT:  223 pounds (up three pounds).  Cardiac:  Regular rate and rhythm with a 1/6 murmur at the upper sternal border.  Chest:  Nontender.  Lungs:  Clear.  Abdomen:  Moderately overweight.  Extremities:  Trace edema.,EKG: , Sinus bradycardia at 58 beats per minute, mild inferolateral ST abnormalities.,IMPRESSION:,1.  Chest pain-Mild.  Her EKG is mildly abnormal.  Her last stress echo was in 2001.  I am going to have her return for one just to make sure it is nothing serious.  I suspect; however, that is more likely due to her weight and acid reflux.  I gave her samples of Nexium.,2.  Mild pedal edema-Has to cut down on fluid intake, weight loss will help as well, continue with the chlorthalidone.,3.  PAF-Due to hypertension, hyperthyroidism and hypokalemia.  Staying in sinus rhythm.,4.  Hyperthyroidism-Last TSH was mildly suppressed, she had been out of her Tapazole for a while, now back on it.,5.  Dyslipidemia-Samples of Crestor given.,6.  LVH.,7.  Menometrorrhagia.,PLAN:,1.  Return for stress echo.,2.  Reduce the fluid intake to help with pedal edema.,3.  Nexium trial.","soap / chart / progress notes, atrial fibrillation, ekg, paroxysmal atrial fibrillation, chest pains, pedal edema, hyperthyroidism, paf, atrial, "
 Pain management sample progress note., SOAP / Chart / Progress Notes, Pain Management Progress Note ,"DIAGNOSES:,1.  Cervical dystonia.,2.  Post cervical laminectomy pain syndrome.,Ms. XYZ states that the pain has now shifted to the left side.  She has noticed a marked improvement on the right side, which was subject to a botulinum toxin injection about two weeks ago.  She did not have any side effects on the Botox injection and she feels that her activities of daily living are increased, but she is still on the oxycodone and methadone.  The patient's husband confirms the fact that she is doing a lot better, that she is more active, but there are still issues yet regarding anxiety, depression, and frustration regarding the pain in her neck.,PHYSICAL EXAMINATION:,  The patient is appropriate.  She is well dressed and oriented x3.  She still smells of some cigarette smoke.  Examination of the neck shows excellent reduction in muscle spasm on the right paraspinals, trapezius and splenius capitis muscles.  There are no trigger points felt and her range of motion of the neck is still somewhat guarded, but much improved.  On the left side, however, there is significant muscle spasm with tight bands involving the multifidus muscle with trigger point activity and a lot of tenderness and guarding.  This extends down into the trapezius muscle, but the splenius capitis seems to be not involved.,TREATMENT PLAN:,  After a long discussion with the patient and the husband, we have decided to go ahead and do botulinum toxin injection into the left multifidus/trapezius muscles.  A total of 400 units of Botox is anticipated.  The procedure is being scheduled.  The patient's medications are refilled.  She will continue to see Dr. Berry and continue her therapy with Mary Hotchkinson in Victoria.","soap / chart / progress notes, progress note, management, muscle"
 Overactive bladder with microscopic hematuria., SOAP / Chart / Progress Notes, Overactive Bladder ,"REASON FOR VISIT: , Overactive bladder with microscopic hematuria.,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old noted to have microscopic hematuria with overactive bladder.  Her cystoscopy performed was unremarkable.  She continues to have some episodes of frequency and urgency mostly with episodes during the day and rare at night.  No gross hematuria, dysuria, pyuria, no other outlet obstructive and/or irritative voiding symptoms.  The patient had been previously on Ditropan and did not do nearly as well.  At this point, what we will try is a different medication.  Renal ultrasound is otherwise unremarkable, notes no evidence of any other disease.,IMPRESSION: , Overactive bladder with microscopic hematuria most likely some mild atrophic vaginitis is noted.  She has no other significant findings other than her overactive bladder, which had continued.  At this juncture what I would like to do is try a different anticholinergic medication.  She has never had any side effects from her medication.,PLAN: , The patient will discontinue Ditropan.  We will start Sanctura XR and we will follow up as scheduled.  Otherwise we will continue to follow her urinalysis over the next year or so.","soap / chart / progress notes, overactive bladder with microscopic hematuria, irritative voiding symptoms, anticholinergic, microscopic hematuria, overactive bladder, ditropan, microscopic, hematuria, bladder, overactive"
" The patient is now on his third postoperative day for an open reduction and internal fixation for two facial fractures, as well as open reduction nasal fracture.  He is on his eighth hospital day.", SOAP / Chart / Progress Notes, ORIF Facial Fractures - Followup ,"Mr. ABC was transferred to room 123 this afternoon.  We discussed this with the nurses, and it was of course cleared by Dr. X.  The patient is now on his third postoperative day for an open reduction and internal fixation for two facial fractures, as well as open reduction nasal fracture.  He is on his eighth hospital day.,The patient had nasal packing in place, which was removed this evening.  This will make it much easier for him to swallow.  This will facilitate p.o. fluids and IMF diet.,Examination of the face revealed some decreased swelling today.  He had good occlusion with intact intermaxillary fixation.,His tracheotomy tube is in place.  It is a size 8 Shiley nonfenestrated.  He is being suctioned comfortably.,The patient is in need of something for sleep in the evening, so we have recommended Halcion 5 mg at bedtime and repeat of 5 mg in 1 hour if needed.,Tomorrow, we will go ahead and change his trach to a noncuffed or a fenestrated tube, so he may communicate and again this will facilitate his swallowing.  Hopefully, we can decannulate the tracheotomy tube in the next few days.,Overall, I believe this patient is doing well, and we will look forward to being able to transfer him to the prison infirmary.","soap / chart / progress notes, fenestrated tube, nasal fracture, facial fractures, orif, tracheotomy, tube, fractures,"
 A 47-year-old white female presents with concern about possible spider bite to the left side of her neck., SOAP / Chart / Progress Notes, Possible Spider Bite ,"SUBJECTIVE:,  This 47-year-old white female presents with concern about possible spider bite to the left side of her neck.  She is not aware of any specific injury.  She noticed a little tenderness and redness on her left posterior shoulder about two days ago.  It seems to be getting a little bit larger in size, and she saw some red streaks extending up her neck.  She has had no fever.  The area is very minimally tender, but not particularly so.,CURRENT MEDICATIONS:,  Generic Maxzide, Climara patch, multivitamin, Tums, Claritin, and vitamin C.,ALLERGIES:,  No known medicine allergies.,OBJECTIVE:,Vital Signs:  Weight is 150 pounds.  Blood pressure 122/82.,Extremities:  Examination of the left posterior shoulder near the neckline is an area of faint erythema which is 6 cm in diameter.  In the center is a tiny mark which could certainly be an insect or spider bite.  There is no eschar there, but just a tiny marking.  There are a couple of erythematous streaks extending towards the neck.,ASSESSMENT:,  Possible insect bite with lymphangitis.,PLAN:,1.  Duricef 1 g daily for seven days.,2.  Cold packs to the area.,3.  Discussed symptoms that were suggestive of the worsening, in which case she would need to call me.,4.  Incidentally, she has noticed a little bit of dryness and redness on her eyelids, particularly the upper ones’ and the lower lateral areas.  I suspect she has a mild contact dermatitis and suggested hydrocortisone 1% cream to be applied sparingly at bedtime only.","soap / chart / progress notes, spider bite, injury, tenderness, redness, insect bite, lymphangitis, streaks, spider, neck, bite,"
" Maculopapular rash in kind of a linear pattern over arms, legs, and chest area which are consistent with a poison ivy or a poison oak.", SOAP / Chart / Progress Notes, Poison Ivy - SOAP ,"SUBJECTIVE:,  He is a 24-year-old male who said that he had gotten into some poison ivy this weekend while he was fishing.  He has had several cases of this in the past and he says that is usually takes quite awhile for him to get over it; he said that the last time he was here he got a steroid injection by Dr. Blackman; it looked like it was Depo-Medrol 80 mg.  He said that it worked fairly well, although it seemed to still take awhile to get rid of it.  He has been using over-the-counter Benadryl as well as cortisone cream on the areas of the rash and having a little bit of improvement, but this last weekend he must have gotten into some more poison ivy because he has got another outbreak along his chest, legs, arms and back.,OBJECTIVE:,Vitals:  Temperature is 99.2.  His weight is 207 pounds.,Skin:  Examination reveals a raised, maculopapular rash in kind of a linear pattern over his arms, legs and chest area which are consistent with a poison ivy or a poison oak.,ASSESSMENT AND ,PLAN:,  Poison ivy.  Plan would be Solu-Medrol 125 mg IM X 1.  Continue over-the-counter Benadryl or Rx allergy medicine that he was given the last time he was here, which is a one-a-day allergy medicine; he can not exactly remember what it is, which would also be fine rather than the over-the-counter Benadryl if he would like to use that instead.","soap / chart / progress notes, poison ivy, steroid injection, depo-medrol, maculopapular rash, poison oak, maculopapular, chest, ivy, poison"
 Followup visit status post removal of external fixator and status post open reduction internal fixation of right tibial plateau fracture., SOAP / Chart / Progress Notes, ORIF - Followup ,"REASON FOR VISIT:,  Followup visit status post removal of external fixator and status post open reduction internal fixation of right tibial plateau fracture.,HISTORY OF PRESENT ILLNESS: , The patient is now approximately week status post removal of Ex-Fix from the right knee with an MUA following open reduction internal fixation of right tibial plateau fracture.  The patient states that this pain is well controlled.  He has had no fevers, chills or night sweats.  He has had some mild drainage from his pin sites.  He just started doing range of motion type exercises for his right knee.  He has had no numbness or tingling.,FINDINGS: , On exam, his pin sites had no erythema.  There is some mild drainage but they have been dressing with bacitracin, it looks like there may be part of the fluid noted.  The patient had 3/5 strength in the EHL, FHL.  He has intact sensation to light touch in a DP, SP, and tibial nerve distribution.,X-rays taken include three views of the right knee.  It demonstrate status post open reduction internal fixation of the right tibial plateau with excellent hardware placement and alignment.,ASSESSMENT: , Status post open reduction and internal fixation of right tibial plateau fracture with removal ex fix.,PLANS: , I gave the patient a prescription for aggressive range of motion of the right knee.  I would like to really work on this as he has not had much up to this time.  He should remain nonweightbearing.  I would like to have him return in 2 weeks' time to assess his knee range of motion.  He should not need x-rays at that time.","soap / chart / progress notes, external fixator, open reduction internal fixation, tibial plateau fracture., ex fix, tibial plateau fracture, internal fixation, tibial plateau, orif, "
 Ophthalmology followup visit note., SOAP / Chart / Progress Notes, Ophthalmology Progress Note - 2 ,A fluorescein angiogram was ordered at today's visit to rule out macular edema.  We have asked her to return in one to two weeks' time to discuss the results of her angiogram and possible intervention and will be sure to keep you apprised of her ongoing progress.  A copy of the angiogram is enclosed for your records.,"soap / chart / progress notes, visual acuities, 78-diopter lens, extraocular muscle movement, afferent, angiogram, applanation, detachment, dilated fundus examination, fluorescein, hemorrhages, intraocular, intraocular lenses, left eye, posterior chamber, pupillary, retinopathy, right eye, slit-lamp, ophthalmology, lensesNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" Orthopedic progress note for follow up of osteoarthritis, knees.", SOAP / Chart / Progress Notes, Osteoarthritis - Progress Note ,"CHIEF COMPLAINT: , Right knee. ,HISTORY OF THE PRESENT ILLNESS: , The patient presents today for follow up of osteoarthritis Grade IV of the bilateral knees and flexion contracture, doing great.  Physical therapy is helping. The subjective pain is on the bilateral knees right worse than left.,Pain:  Localized to the bilateral knees right worse than left.,Quality:  There is no swelling, no redness, or warmth.  The pain is described as aching occasionally.  There is no burning. ,Duration:  Months.,Associated symptoms:  Includes stiffness and weakness.  There is no sleep loss and no instability.  ,Hip Pain:  None. ,Back pain: None. ,Radicular type pain:  None. ,Modifying factors: Includes weight bearing pain and pain with ambulation.  There is no sitting, and no night pain.  There is no pain with weather change.,VISCOSUPPLEMENTATION IN PAST:,  No Synvisc.,VAS PAIN SCORE: , 10 bilaterally.,WOMAC SCORE: , 8,A-1 WOMAC SCORE: , 0,See the enclosed WOMAC osteoarthritis index, which accompanies the patient's chart, for complete details of the patient's limitations to activities of daily living.  ,REVIEW OF SYSTEMS:,  No change.,Constitutional:  Good appetite and energy.  No fever.  No general complaints.,HEENT:  No headaches, no difficulty swallowing, no change in vision, no change in hearing.,CV - RESP:  No shortness of breath at rest or with exertion.  No paroxysmal nocturnal dyspnea, orthopnea, and without significant cough, hemoptysis, or sputum.  No chest pain on exertion.,GI:",
 Ophthalmology followup visit note., SOAP / Chart / Progress Notes, Ophthalmology Progress Note - 1 ,"She is stable at this time and does not require any intervention at today's visit.  I have asked her to return in six months' for a followup dilated examination, but would be happy to see her sooner should you or she notice any changes in her vision.","soap / chart / progress notes, visual acuities, extraocular muscle, intraocular pressure, pupils, afferent, applanation, binocular, dilated fundus, left eye, lens, movements, ophthalmoscope, pigmentary, retina, retinal, right eye, ophthalmology, acuitiesNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" MGUS.  His bone marrow biopsy showed a normal cellular bone marrow; however, there were 10% plasma cells and we proceeded with the workup for a plasma cell dyscrasia.  All his tests came back as consistent with an MGUS.", SOAP / Chart / Progress Notes, MGUS Followup ,"CHIEF COMPLAINT: , MGUS.,HISTORY OF PRESENT ILLNESS:,  This is an extremely pleasant 86-year-old gentleman, who I follow for his MGUS.  I initially saw him for thrombocytopenia when his ANC was 1300.  A bone marrow biopsy was obtained.  Interestingly enough, at the time of his bone marrow biopsy, his hemoglobin was 13.0 and his white blood cell count was 6.5 with a platelet count of 484,000.  His bone marrow biopsy showed a normal cellular bone marrow; however, there were 10% plasma cells and we proceeded with the workup for a plasma cell dyscrasia.  All his tests came back as consistent with an MGUS.,Overall, he is doing well.  Since I last saw him, he tells me that he has had onset of atrial fibrillation.  He has now started going to the gym two times per week, and has lost over 10 pounds.  He has a good energy level and his ECOG performance status is 0.  He denies any fever, chills, or night sweats.  No lymphadenopathy.  No nausea or vomiting.  No change in bowel or bladder habits.,CURRENT MEDICATIONS: , Multivitamin q.d., aspirin one tablet q.d., Lupron q. three months, Flomax  0.4 mg q.d., and Warfarin 2.5 mg q.d.,ALLERGIES:  ,No known drug allergies.,REVIEW OF SYSTEMS: , As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1.  He is status post left inguinal hernia repair.,2.  Prostate cancer diagnosed in December 2004, which was a Gleason 3+4.  He is now receiving Lupron.,SOCIAL HISTORY: , He has a very remote history of tobacco use.  He has one to two alcoholic drinks per day.  He is married.,FAMILY HISTORY: , His brother had prostate cancer.,PHYSICAL EXAM:,VIT:",
" Septic from nephrolithiasis - Nephrolithiasis status post lithotripsy and stent placed in the left ureter, urinary incontinence, recent sepsis.", SOAP / Chart / Progress Notes, Nephrolithiasis - Progress Note ,"SUBJECTIVE:,  The patient returns today for a followup.  She was recently in the hospital and was found to be septic from nephrolithiasis.  This was all treated.  She did require a stent in the left ureter.  Dr. XYZ took care of this.  She had a stone, which was treated with lithotripsy.  She is now back here for followup.  I had written out all of her medications with their dose and schedule on a progress sheet.  I had given her instructions regarding follow up here and follow with Dr. F.  Unfortunately, that piece of paper was lost.  Somehow between the hospital and home she lost it and has not been able to find it.  She has no followup appointment with Dr. F.  The day after she was dismissed, her nephew called me stating that the prescriptions were lost, instructions were lost, etc.  Later she apparently found the prescriptions and they were filled.  She tells me she is taking the antibiotic, which I believe was Levaquin and she has one more to take.  She had no clue as to seeing Dr. XYZ again.  She says she is still not feeling very well and feels somewhat sick like.  She has no clue as to still having a ureteral stent.  I explained this to she and her husband again today.,ALLERGIES: , Sulfa.,CURRENT MEDICATIONS:,  As I have given are Levaquin, Prinivil 20 mg a day, Bumex 0.5 mg a day, Levsinex 0.375 mg a day, cimetidine 400 mg a day, potassium chloride 8 mEq a day, and atenolol 25 mg a day.,REVIEW OF SYSTEMS:,  She says she is voiding okay.  She denies fever, chills, or sweats.,OBJECTIVE:,General:  She was able to get up on the table by herself although she is quite unstable.,Vital Signs:  Blood pressure was okay at about 120/70 by me.,Neck:  Supple.,Lungs:  Clear.,Heart:  Regular rate and rhythm.,Abdomen:  Soft.,Extremities:  There is no edema.,IMPRESSION:,1.  Hypertension controlled.,2.  Nephrolithiasis status post lithotripsy and stent placed in the left ureter by Dr. F.,3.  Urinary incontinence.,4.  Recent sepsis.,PLAN:,1.  I discussed at length with she and her husband again the need to get into at least an assisted living apartment.,2.  I gave her instructions, in writing, to stop by Dr. F’s office on the way out today to get an appointment for followup regarding her stent.,3.  See me back here in two months.,4.  I made no changes in her medications.","soap / chart / progress notes, nephrolithiasis, septic, lithotripsy, nephrolithiasis status post lithotripsy, septic from nephrolithiasis, urinary incontinence, incontinence, atenolol, stent, medications, "
 A woman with end-stage peritoneal mesothelioma with multiple bowel perforations., SOAP / Chart / Progress Notes, Mesothelioma - Chart Note ,"The patient's home regimen includes Duragesic patch at 125 mcg every 3 days.  She is currently on a Dilaudid PCA of 1 mg every 10 minutes lockout, Dilaudid boluses 2 mg q.3 h. p.r.n., Ativan 2 mg q.4 h., Tylenol per rectum.  The patient was offered multiple procedures to help with her abdominal pain including a thoracic epidural placement for sympathetic block for pain control and a celiac plexuses/neurolytic block.  The patient's family and she will continue to think about these pain procedures and let us know if they are interested in either.  For the moment, we will not make any further recommendations on her current medical management.  We did ask Dr. X, a psychiatrist, who works for the Pain Service to come in and see Ms. A as anxiety is a large component of her suffering at this time.,","soap / chart / progress notes, pleurodesis, abdominal pain, multiple bowel perforations, peritoneal mesothelioma, mesothelioma, peritonealNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Multiple Progress Notes for different dates in a patient with respiratory failure, on ventilator.", SOAP / Chart / Progress Notes, Multiple Progress Notes ,"PROGRESS NOTES,4/16/01:,Patient in respiratory failure, on ventilator,Request airline placement,Airline tracing good,4/17/01:,S: Sedated, intubated in NAD,O: Lungs: Increased bibasilar crackles,A/P: Respiratory arrest, pneumonia, COPD exacerbation,Replete K+, continue IVABX, start TPN, decrease TV, review ABGs,4/18/01:,S: Sedated and intubated, one episode NSVT,O: ABGs: 7.38/67/86/97,4/19/01:,S: Sedated and intubated, scant blood material from NGT,A/P: 1) Respiratory arrest,2) Exacerbation COPD - gastro cath NG aspiration,4/20/01:,S: Intubated/sedated, w/ NAD,O: Pulmonary - Increase L. basilar inspiration,A/P: Pneumonia,Respiratory arrest,COPD exacerbation,New onset low grade fever,D/C NGT - suspect sensitivity,4/20/01:,O: Preliminary blood culture gram + cocci,Dr. A called w/ result, no orders left,Pt. afebrile, WBC increase to 20.2,ABGs improved from 4/20/01, pt. noted to have less secretions,Last night had 8 beat run V-Tach,4/21/01:,O: Chest x-rays reviewed - improvement in lower lobe infiltrate,Gram + cocci in blood,Sputum H. influen. gram neg.,4/22/01:,atient up in chair,Decrease ventilator support,Preliminary blood cultures - Staph coag neg 1 of 2,04/23/01:,S: Awake, alert in NAD,O: Temp 99.8,Blood cultures: Staph coag. Neg. 1 of 2,A/P: Pneumonia, respiratory arrest, COPD,Continue wearing tirals,4/24/01:,S: Awake and alert, +N, refused trach,If fails extubation, will allow for reintubation",
" Patient with multiple medical problems (Alzheimer’s dementia, gradual weight loss, fatigue, etc.)", SOAP / Chart / Progress Notes, Multiple Medical Problems ,"SUBJECTIVE:,  The patient was seen today by me at Nursing Home for her multiple medical problems.  The nurses report that she has been confused at times, having incontinent stool in the sink one time but generally she does not do that poorly.  She does have trouble walking which she attributes to weak legs.  She fell a couple of months ago.  Her eating has been fair.  She has been losing weight a little bit.  She denies diarrhea.  She does complain of feeling listless and unambitious and would like to try some Ensure.,CURRENT MEDICATIONS:,  Her meds are fairly extensive and include B12 1000 mg IM monthly, Digitek 250 p.o. every other day alternating with 125 mcg p.o. every other day, aspirin 81 mg daily, Theragran-M daily, Toprol XL 25 mg daily, vitamin B6 100 mg daily, Prevacid 30 mg daily, Oyster Shell calcium with D 500 mg t.i.d., Aricept 5 mg daily, Tylenol 650 mg q.4h. p.r.n., furosemide 20 mg daily p.r.n., and sublingual Nitro p.r.n., and alprazolam 0.25 mg p.r.n.,ALLERGIES:,  Sulfa and trimethoprim.,OBJECTIVE:,General:  She is a well-developed, well-nourished, elderly female in no acute distress.,Vital Signs:  Her age is 90.  Temperature is 98.5 degrees.  Blood pressure:  100/54.  Pulse:  60.  Respirations:  18.  Weight was 132.6 about a week ago, which is down one pound from couple of months ago.,HEENT:  Head was normocephalic.,Neck:  Supple.,Lungs:  Clear.,Heart:  Regular rate and rhythm.,Abdomen:  Soft, nontender without hepatosplenomegaly or mass.,Extremities:  No calf tenderness or significant ankle edema x 2 in the lower extremities is noted.,Mental Status Exam:  She was uncertain what season we are in.  She thought we were almost in winter.  She did know that today of the week was Friday.  She seemed to recognize me.,ASSESSMENT:,1.  Alzheimer’s dementia.,2.  Gradual weight loss.,3.  Fatigue.,4.  B12 deficiency.,5.  Osteoporosis.,6.  Hypertension.,PLAN:,  I ordered yearly digoxin levels.  Increased her Aricept to 10 mg daily.  She apparently does have intermittent atrial fibrillation as a reason for being on the digoxin.  We will plan to recheck her in a couple of months.  Ordered health supplement to be offered after each meal due to her weight loss.","soap / chart / progress notes, progress note, alzheimer’s dementia, b12 deficiency, fatigue, hypertension, osteoporosis, digoxin, incontinent stool, multiple medical problems, weak, weight loss, multiple, dementia, alzheimer’s, incontinent, "
" Obesity hypoventilation syndrome.  A 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study.", SOAP / Chart / Progress Notes, Obesity Hypoventilation Syndrome ,"HISTORY OF PRESENT ILLNESS: , This is a 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study, on CPAP and oxygen to evaluate her for difficulty in initiating and maintaining sleep.  She returns today to review results of an inpatient study performed approximately two weeks ago.,In the meantime, the patient reports she continues on substantial doses of opiate medication to control leg pain from mononeuritis multiplex.,She also takes Lasix for lower extremity edema.,The patient reports that she generally initiates sleep on CPAP, but rips her mask off, tosses and turns throughout the night and has ""terrible quality sleep."",MEDICATIONS: , Current medications are as previously noted.  Changes include reduction in prednisone from 9 to 6 mg by mouth every morning.  She continues to take Ativan 1 mg every six hours as needed.  She takes imipramine 425 mg at bedtime.,Her MS Contin dose is 150 mg every 8 to 12 hours and an immediate release morphine preparation, 45 to 75 mg by mouth every 8 hours as needed.,FINDINGS: , Vital signs:  Blood pressure 153/81, pulse 90, respiratory rate 20, weight 311.8 pounds (up 10 pounds from earlier this month), height 5 feet 6 inches, temperature 98.4 degrees, SaO2 is 88% on room air at rest.  Chest is clear.  Extremities show lower extremity pretibial edema with erythema.,LABORATORIES: , An arterial blood gas on room air showed a pH of 7.38, PCO2 of 52, and PO2 of 57.,CPAP compliance monitoring over the past two to three weeks showed average use of 3 hours 26 minutes on nights used.  She used it for greater than 4 hours per night on 67% of night surveyed.  Her estimated apnea/hypopnea index was 3 per hour.  Her average leak flow was 67 liters per minute.,The patient's overnight sleep study was performed as an inpatient sleep study during a routine hospitalization for intravenous gamma globulin therapy.  She slept for a total sleep time of 257 minutes out of 272 minutes in bed (sleep efficiency approximately 90%).  Sleep stage distribution was relatively normal with 2% stage I, 72% stage II, 24% stage III, IV, and 2% stage REM sleep.,There were no periodic limb movements during sleep.,There was evidence of a severe predominantly central sleep apnea during non-REM sleep at 173 episodes per hour and during REM sleep at 77 episodes per hour.  Oxyhemoglobin saturations during non-REM sleep fluctuated from the baseline of 92% to an average low of 82%.  During REM sleep, the baseline oxyhemoglobin saturation was 87% , decreased to 81% with sleep-disordered breathing episodes.,Of note, the sleep study was performed on CPAP at 10.5 cm of H2O with oxygen at 8 liters per minute.,ASSESSMENT:,1.  Obesity hypoventilation syndrome.  The patient has evidence of a well-compensated respiratory acidosis, which is probably primarily related to severe obesity.  In addition, there may be contribution from large doses of opiates and standing doses of gabapentin.,2.  Severe central sleep apnea, on CPAP at 10 cmH2O and supplemental oxygen at 8 liters per minute.  The breathing pattern is that of cluster or Biot's breathing throughout sleep.  The primary etiology is probably opiate use, with contribution with further exacerbation by severe obesity which acts to lower the baseline oxyhemoglobin saturation, and worsen desaturations during apneic episodes.,3.  Mononeuritis multiplex with pain requiring significant substantial doses of analgesia.,4.  Hypoxemia primarily due to obesity, hypoventilation, and presumably basilar atelectasis and a combination of V/Q mismatch and shunt on that basis.,PLANS: , My overall impression is that we should treat this patient's sleep disruption with measures to decrease central sleep apnea during sleep.  These will include, (1).  Decrease in evening doses of MS Contin, (2).  Modest weight loss of approximately 10 to 20 pounds, and (3).  Instituting Automated Servo Ventilation via nasal mask.  With regard to latter, the patient will be returning for a trial of ASV to examine its effect on sleep-disordered breathing patterns.,In addition, the patient will benefit from modest diuresis, with improvement of oxygenation, as well as nocturnal desaturation and oxygen requirements.  I have encouraged the patient to increase her dose of Lasix from 100 to 120 mg by mouth every morning as previously prescribed.  I have also asked her to add Lasix in additional late afternoon to evening dose of Lasix at 40 mg by mouth at that time.  She was instructed to take between one and two K-Tab with her evening dose of Lasix (10 to 20 mEq).,In addition, we will obtain a complete set of pulmonary function studies to evaluate this patient for underlying causes of parenchymal lung disease that may interfere with oxygenation.  Further workup for hypoxemia may include high-resolution CT scanning if evidence for significant pulmonary restriction and/or reductions in diffusion capacity is evident on pulmonary function testing.","soap / chart / progress notes, polyarteritis nodosa, obesity hypoventilation syndrome, pulmonary function, obesity hypoventilation, mononeuritis multiplex, sleep apnea, sleep study, rem sleep, ativan, sleep, hypoventilation, obesity, "
 A 61-year-old white male with a diagnosis of mantle cell lymphoma status post autologous transplant with BEAM regimen followed by relapse.  Allogeneic peripheral stem cell transplant from match-related brother and the patient is 53 months out from transplant., SOAP / Chart / Progress Notes, Mantle Cell Lymphoma ,"PRINCIPAL DIAGNOSES:,1.  A 61-year-old white male with a diagnosis of mantle cell lymphoma, diagnosed in 2001, status post autologous transplant with BEAM regimen in 04/02 followed by relapse.,2.  Allogeneic peripheral stem cell transplant from match-related brother and the patient is 53 months out from transplant.,3.  Graft versus host disease involving GI tracts, skin, and liver presently off immunosuppression.,4.  Diabetes.,5.  Bipolar disorder.,6.  Chronic muscle aches.,7.  Chronic lower extremity edema.,8.  ECOG performance status 1.,INTERIM HISTORY: , The patient comes to the clinic today for followup.  I am seeing him once every 4 to 8 weeks.  He is off of all immunosuppression.  He does have mild chronic GVHD but not enough to warrant any therapy and the disease has been under control and he is 4-1/2-years posttransplant.,He has multiple complaints.  He has had hematochezia.  I referred him to gastroenterology.  They did an upper and lower endoscopy.  No evidence of ulcers or any abnormality was found.  Some polyps were removed.  They were benign.  He may have mild iron deficiency, but he is fatigued and has several complaints related to his level of activity.,CURRENT MEDICATIONS:,1.  Paxil 40 mg once daily.,2.  Cozaar.,3.  Xanax 1 mg four times a day.,4.  Prozac 20 mg a day.,5.  Lasix 40 mg a day.,6.  Potassium 10 mEq a day.,7.  Mirapex two tablets every night.,8.  Allegra 60 mg twice a day.,9.  Avandamet 4/1000 mg daily.,10.  Nexium 20 mg a day.,11.  NovoLog 25/50.,REVIEW OF SYSTEMS:,  Fatigue, occasional rectal bleeding, and obesity.  Other systems were reviewed and were found to be unremarkable.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Today revealed that temperature 35.8, blood pressure 120/49, pulse 85, and respirations 18.  HEENT:  Oral cavity, no mucositis.  NECK:  No nodes.  AXILLA:  No nodes.  LUNGS:  Clear.  CARDIAC:  Regular rate and rhythm without murmurs.  ABDOMEN:  No palpable masses.  Morbid obesity.  EXTREMITIES:  Mild lower extremity edema.  SKIN:  Mild dryness.  CNS:  Grossly intact.,LABORATORY DATA:,  White count 4.4, hemoglobin 10.1, platelet count 132,000, sodium 135, potassium 3.9, chloride 105, bicarbonate 24, BUN 15, and creatinine 0.9.  Normal alkaline phosphatase 203, AST 58, and ALT 31.,ASSESSMENT AND PLAN:,1.  The patient with mantle cell lymphoma who is 4-1/2 years post allotransplant.  He is without evidence of disease at the present time.  Since he is 4-1/2 years posttransplant, I do not plan to scan him or obtain chimerisms unless there is reason to.,2.  He is slightly anemic, may be iron deficient.  He has had recurrent rectal bleeding.  I told him to take multivitamin with iron and see how that helps the anemia.,3.  Regarding the hematochezia, he had an endoscopy.  I reviewed the results from the previous endoscopy.  It appears that he has polyps, but there is no evidence of graft versus host disease.,4.  Regarding the fatigue, I just reassured him that he should increase his activity level, but I am not sure how realistic that is going to be.,5.  He is followed for his diabetes by his internist.,6.  If he should have any fever or anything suggestive of infection, I advised him to call me.  I will see him back in about 2 months from now.",
" Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath. ", SOAP / Chart / Progress Notes, Melena - ICU Followup ,"HISTORY:,  Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath.  Please see dictated ICU transfer note yesterday detailing the need for emergent transfer transfusion and EGD in this patient.  Over the last 24 hours, the patient has received 2 units of packed red blood cells and his hematocrit and hemoglobin have returned to their baseline of approximately 11 appropriate for hemoglobin value.  He also underwent EGD earlier today with Dr. X.  I have discussed the case with him at length earlier this afternoon and the patient had symptoms of ulcerative esophagitis with no active bleeding.  Dr. X recommended to increase the doses of his proton pump inhibitor and to avoid NSAIDs in the future.  The patient today complains that he is still having issues with shortness of breath and wheezing and productive cough, now producing yellow-brown sputum with increasing frequency, but he has had no further episodes of melena since transfer to the ICU.  He is also complaining of some laryngitis and some pharyngitis, but is denying any abdominal complaints, nausea, or diarrhea.,PHYSICAL EXAMINATION,VITAL SIGNS:  Blood pressure is 100/54, heart rate 80 and temperature 98.8.  Is and Os negative fluid balance of 1.4 liters in the last 24 hours.,GENERAL:  This is a somnolent 68-year-old male, who arouses to voice, wakes up, seems to have good appetite, has continuing cough.  Pallor is improved.,EYES:  Conjunctivae are now pink.,ENT:  Oropharynx is clear.,CARDIOVASCULAR:  Reveals distant heart tones with regular rate and rhythm.,LUNGS:  Have coarse breath sounds with wheezes, rhonchi, and soft crackles in the bases.,ABDOMEN:  Soft and nontender with no organomegaly appreciated.,EXTREMITIES:  Showed no clubbing, cyanosis or edema.  Capillary refill time is now normal in the fingertips.,NEUROLOGICAL:  Cranial nerves II through XII are grossly intact with no focal neurological deficits.,LABORATORY DATA:,  Laboratories drawn at 1449 today, WBC 10, hemoglobin and hematocrit 11.5 and 33.1, and platelets 288,000.  This is up from 8.6 and 24.7.  Platelets are stable.  Sodium is 134, potassium 4.0, chloride 101, bicarb 26, BUN 19, creatinine 1.0, glucose 73, calcium 8.4, INR 0.96, iron 13%, saturations 4%, TIBC 312, TSH 0.74, CEA elevated at 8.6, ferritin 27.5 and occult blood positive.  EGD, final results pending per Dr. X's note and conversation with me earlier, ulcerative esophagitis without signs of active bleeding at this time.,IMPRESSION/PLAN,1.  Melena secondary to ulcerative esophagitis.  We will continue to monitor the patient overnight to ensure there is no further bleeding.  If there are no further episodes of melena and hemoglobin is stable or unchanged in the morning, the patient will be transferred back to medical floor for continuing treatment of his chronic obstructive pulmonary disease exacerbation.,2.  Chronic obstructive pulmonary disease exacerbation.  The patient is doing well, taking PO.  We will continue him on his oral Omnicef and azithromycin and continuing breathing treatments.  We will add guaifenesin and N-acetyl-cysteine in a hope to mobilize some of his secretions.  This does appear to be improving.  His white count is normalized and I am hopeful we can discharge him on oral antibiotics within the next 24 to 48 hours if there are no further complications.,3.  Elevated CEA.  The patient will need colonoscopy on an outpatient basis.  He has refused this today.  We would like to encourage him to do so.  Of note, the patient when he came in was on bloodless protocol, but with urging did accept the transfusion.  Similarly, I am hoping that with proper counseling, the patient will consent to further examination with colonoscopy given his guaiac-positive status, elevated CEA and risk factors.,4.  Anemia, normochromic normocytic with low total iron binding capacity.  This appears to be anemia of chronic disease.  However, this is likely some iron deficiency superimposed on top of this given his recent bleeding, with consider iron, vitamin C, folate and B12 supplementation and discharge given his history of alcoholic malnutrition and recent gastrointestinal bleeding.  Total critical care time spent today discussing the case with Dr. X, examining the patient, reviewing laboratory trends, adjusting medications and counseling the patient in excess is 35 minutes.","soap / chart / progress notes, anemia, gi bleeding, hemoglobin, ulcerative, esophagitis, obstructive pulmonary disease, icu followup, infection, obstructive, pulmonary, egd, melena, bleeding"
 Follicular non-Hodgkin's lymphoma.  Biopsy of a left posterior auricular lymph node and pathology showed follicular non-Hodgkin's lymphoma.  Received six cycles of CHOP chemotherapy. , SOAP / Chart / Progress Notes, Non-Hodgkin lymphoma Followup ,"CHIEF COMPLAINT:,  Follicular non-Hodgkin's lymphoma.,HISTORY OF PRESENT ILLNESS: , This is an extremely pleasant 69 year-old gentleman, who I follow for his follicular lymphoma.  His history is that in February of 1988 he had a biopsy of a left posterior auricular lymph node and pathology showed follicular non-Hodgkin's lymphoma.  From 03/29/88 to 08/02/88, he received six cycles of CHOP chemotherapy.  In 1990, his CT scan showed retroperitoneal lymphadenopathy.  Therefore from 04/02/90 to 08/20/90, he received seven cycles of CVP.  In 1999, he was treated with m-BACOD.  He also received radiation to his pelvis.  On 03/21/01, he had a right cervical lymph node biopsy, which again showed follicular lymphoma.  His most recent PET scan dated 12/31/08 showed resolution of previously described hypermetabolic lymph nodes in the right lower neck.,Overall, he is doing well.  He has a good energy level, his ECOG performance status is 0.  He denies any fever, chills or night sweats.  No lymphadenopathy.  No nausea or vomiting.  No change in bowel or bladder habits.,CURRENT MEDICATIONS: , Avelox 400 mg q.d. p.r.n., cefuroxime 200 mg q.d. to be altered monthly with doxycycline 100 mg q.d., Coumadin 5 mg on Monday and 2.5 mg on all other days, dicyclomine 10 mg q.d., Coreg 6.25 mg b.i.d., Vasotec 2.5 mg b.i.d., Zantac 150 mg q.d., Claritin D q.d., Centrum q.d., calcium q.d., omega-3 b.i.d., Metamucil q.d., and Lasix 40 mg t.i.d.,ALLERGIES: , No known drug allergies.,REVIEW OF SYSTEMS:  ,As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1.  He has chronic lymphedema of the bilateral lower extremities secondary to his pelvic radiation.,2.  He had bilateral ureteral obstruction and is status post a stent placement.  The obstruction was secondary to his pelvic radiation.,3.  History of congestive heart failure.,4.  History of schwannoma resection.  It was resected from T12 to L1 in 1991.,5.  He has chronic obstruction of his inferior vena cava.,6.  Recurrent lower extremity cellulitis.,SOCIAL HISTORY:  ,He has no tobacco use.  No alcohol use.  He is married.  He is a retired Methodist minister.,FAMILY HISTORY: , His mother just died two days ago.  There is no history of solid tumors or hematologic malignancies in his family.,PHYSICAL EXAM:,VIT:",
 Neurologic examination sample.  , SOAP / Chart / Progress Notes, Neurologic Examination ,"NEUROLOGICAL EXAMINATION: , At present the patient is awake, alert and fully oriented.  There is no evidence of cognitive or language dysfunction.  Cranial nerves:  Visual fields are full.  Funduscopic examination is normal.  Extraocular movements full.  Pupils equal, round,  react to light.  There is no evidence of nystagmus noted.  Fifth nerve function is normal.  There is no facial asymmetry noted.  Lower cranial nerves are normal.  ,Manual motor testing reveals good tone and bulk throughout.  There is no evidence of pronator drift or decreased fine finger movements.  Muscle strength is 5/5 throughout.  Deep tendon reflexes are 2+ throughout with downgoing toes.  Sensory examination is intact to all modalities including stereognosis, graphesthesia.,TESTING OF STATION AND GAIT:, The patient is able to walk toe-heel and tandem walk.  Finger-to-nose and heel-to-shin moves are normal.  Romberg sign negative.  I appreciate no carotid bruits or cardiac murmurs.,Noncontrast CT scan of the head shows no evidence of acute infarction, hemorrhage or extra-axial collection.","soap / chart / progress notes, station, motor testing, nerve function, neurologic examination, cranial nerves, cranial, extraocular, movementsNOTE"
 Extensive stage small cell lung cancer.  Chemotherapy with carboplatin and etoposide.  Left scapular pain status post CT scan of the thorax., SOAP / Chart / Progress Notes, Lung Cancer Followup ,"CHIEF COMPLAINT:,1.  Extensive stage small cell lung cancer.,2.  Chemotherapy with carboplatin and etoposide.,3.  Left scapular pain status post CT scan of the thorax.,HISTORY OF PRESENT ILLNESS: , The patient is a 67-year-old female with extensive stage small cell lung cancer.  She is currently receiving treatment with carboplatin and etoposide.  She completed her fifth cycle on 08/12/10.  She has had ongoing back pain and was sent for a CT scan of the thorax.  She comes into clinic today accompanied by her daughters to review the results.,CURRENT MEDICATIONS: , Levothyroxine 88 mcg daily, Soriatane 25 mg daily, Timoptic 0.5% solution b.i.d., Vicodin 5/500 mg one to two tablets q.6 hours p.r.n.,ALLERGIES: , No known drug allergies.,REVIEW OF SYSTEMS:  ,The patient continues to have back pain some time she also take two pain pill.  She received platelet transfusion the other day and reported mild fever.  She denies any chills, night sweats, chest pain, or shortness of breath.  The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:","soap / chart / progress notes, small cell lung cancer, carboplatin, etoposide, pet/ct, pleural base, base mass, extensive stage, ct scan, lung cancer, lung, cancer, "
 Patient is here to discuss possible open lung biopsy., SOAP / Chart / Progress Notes, Lung Biopsy Discussion ,"CHART NOTE:,  She is here to discuss possible open lung biopsy that she has actually scheduled for tomorrow.  Dr. XYZ had seen her because of her complaints of shortness of breath.  Then she had the pulmonary function test and CT scan and he felt that she probably had usual interstitial pneumonitis, but wanted her to have an open lung biopsy so he had her see Dr. XYZ Estep.  He had concurred with Dr. XYZ that an open lung biopsy was appropriate and she was actually scheduled for this but both Dr. XYZ and I were unavailable before the procedure was originally scheduled so he had it delayed so that she could talk with us prior to having the biopsy.  She was ready to go ahead with this and felt that it was important she find out why she is short of breath.  She is very concerned about the findings on her CAT scan and pulmonary function test.  She seemed alarmed to report that Dr. XYZ had found that her lung capacity was reduced to 60% of what should be normal.  However, I told her that two years ago Dr. XYZ did pulmonary function studies which showed the same change in function.  And that really her pulmonary function test, at least compared from two years ago, had not really changed over this period of time.  After discussing the serious nature of an open lung biopsy, the fact that her pulmonary function studies have not changed in two years, the fact that she likely has a number of other things that are contributing to her being out of breath, which is deconditioning and obesity, she seemed comfortable with the thought of simply monitoring this a little bit longer before undergoing something as risky as an open lung biopsy.  In fact when I called Dr. XYZ to talk to him about cancelling the procedure, he stated he would be very uncomfortable with doing an open lung biopsy on someone with pulmonary function studies which had not changed.  I also explained to patient that I did not think Dr. XYZ was aware that she had had pulmonary function studies two years previously and certainly did not know that there results of those.  And also I spoke with Dr. XYZ who agreed that although the two different tests may have some minor differences accounting for some of the similarity in results that may or may not be completely accurate, that generally a person with progressive interstitial lung disease without a fairly substantial change on pulmonary function tests even if they were done at different facilities.,I had a 30-minute discussion with patient about all of this and showed her the different test results and had a lengthy talk with her about the open lung biopsy and she ultimately felt very uncomfortable with going ahead and decided to cancel it.  I also told her we could continue to monitor her breathing problems and continue to monitor her CAT scan, x-ray, and pulmonary function tests.  And if there was some sign that this was a progressive problem, she could still go ahead with the lung biopsy.  But she needed to understand that the treatment and likely diagnosis found from an open lung biopsy were not highly likely to be of any great help to her.  She understands that the diagnoses made from open lung biopsy are not all that specific and that the treatment for the few specific things that can be detected are not often well tolerated or extremely helpful.,We are going to see her back in a month to see how her breathing is doing.  We will cancel her open lung biopsy for tomorrow and decide whether she should follow up with a pulmonologist at that time.  I told her I would try to talk to her sister sometime in the next day or two.","soap / chart / progress notes, discuss, interstitial pneumonitis, lung biopsy, lung capacity, pulmonary function test, shortness of breath, pulmonary function studies, pulmonary function, function, biopsy, lung, interstitial, pulmonaryNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" A female who has pain in her legs at nighttime that comes and goes, radiates from her buttocks to her legs, sometimes in her ankle.", SOAP / Chart / Progress Notes, Leg Pain & Bone Pain ,"CHIEF COMPLAINT:,  Leg pain.,HISTORY OF PRESENT ILLNESS:,  This is a 56-year-old female who has pain in her legs at nighttime and when she gets up it comes and goes, radiates from her buttocks to her legs, sometimes it is her ankle.  She has noticed it since she has been on Lipitor.  She has had some night sweats occasionally.  She has had a little bit of fever and nausea.  She has noticed her blood sugars have been low.  She has lost over 30 pounds after exercising doing water aerobics at Genesis in Wichita.  She has noticed her fasting blood sugars have been ranging from 100 to 120.  Blood sugars one and a half hours after meals have been 185.  She is coming in for a diabetic checkup in one month and wants lab prior to that time.  She has been eating more meat recently and has not been on a diet for cholesterol.,CURRENT MEDICATIONS:,  Include Lipitor 80 mg q.d. discontinued today, Vioxx 25 mg q.d., Maxzide 37/25 q.d., Protonix 40 mg q.d., hydroxyzine pamoate 50 mg at h.s., aspirin 81 mg q.d., Glucovance 1.25/250 b.i.d. decreased to one a day today, Monopril 20 mg q.d., estradiol one mg q.d., and glucosamine 1000 mg q.d.,ALLERGIES:,  Cipro, sulfa, Bactrim, and Demerol.,OBJECTIVE:,Vital Signs:  Weight is 248 pounds which is a 12-pound drop from January.  Blood pressure 120/70.  Pulse 68.,General:  This is a well-developed adult female, awake, alert, and in no acute distress.,HEENT:  Oropharynx and HEENT are within normal limits.,Lungs:  Clear.,Heart:  Regular rhythm and rate.,Abdomen:  Soft, nontender, and nondistended without organomegaly.,GU:  Palpation of femurs do not cause pain, rotation of hips do not cause pain, and compression of the hips do not cause pain.,Neurologic:  Deep tendon reflexes are normal.,Extremities:  Pulses in lower extremities are normal.  Straight leg lifts are normal.,ASSESSMENT/PLAN:,1.  Leg pain/bone pain, I am going to check her CMP.  I think this possibly is a side effect from Lipitor.  We will stop Lipitor, have her follow up in one month which she has already got planned for diabetes appointment and check symptoms at that time.  Certainly if her pain improves might consider something like Crestor, which is more water soluble, which may cause less adverse effects.  We will check her comprehensive metabolic panel to make sure the alkaline phosphatase is okay, may need an x-ray of back, hip, and legs at that time if symptoms are not gone.,2.  Hypercholesterolemia, this is somewhat bothersome as she is a diabetic.  Did discuss with her that we need to stick to the diet especially after going off of Lipitor.  We will see how she does with her bone pain/leg pain off of Lipitor.  If she has improvement may consider Crestor in one month.  I am going to check her lipid panel and a CMP.  Apparently, she is going to get this at a different site, Mapleridge in Wichita.,3.  Type II diabetes.  We will decrease her Glucovance because she is having frequent low blood sugars.  Her previous hemoglobin A1c was 5.6 so we will see if this improves her symptoms.  I am also going to check a hemoglobin A1c at Mapleridge in Wichita and have a followup here in one month for that diabetes appointment.","soap / chart / progress notes, cmp, hypercholesterolemia, leg pain, type ii diabetes, ankle, blood sugars, bone pain, buttocks, pain, radiates from her buttocks, leg pain/bone, leg, sugars, weight,"
 History of right leg pain.  Leg pain is no longer present., SOAP / Chart / Progress Notes, Leg Pain - Progress Note ,"HISTORY OF PRESENT ILLNESS: , The patient is a 44-year-old man who was seen for complaints of low back and right thigh pain.  He attributes this to an incident in which he was injured in 1994.  I do not have any paperwork authenticating his claim that there is an open claim.  Most recently he was working at Taco Bell, when he had a recurrence of back pain, and he was seen in our clinic on 04/12/05.  He rated pain of approximately 8/10 in severity., ,He took a Medrol Dosepak and states that his pain level has decreased to approximately 4-5/10.  He still localizes it to a band between L4 and the sacrum.  He initially had some right leg pain but states that this is minimal and intermittent at the present time.  His back history is significant for two laminectomies and a discectomy performed from 1990 to 1994.  The area of concern was L4-L5., ,The patient's MRI dated 10/18/04 showed multi-level degenerative changes, with facet involvement at L2-L3, L3-L4 and L5-S1.  There was no neural impingement.  He also had an MR myelogram, which showed severe stenosis at L3-L4, however it was qualified in that it may have been artifact, rather than a genuine finding., ,REVIEW OF SYSTEMS:,  Focal lower paralumbar pain, affecting both right and left sides, as well as intermittent right leg pain which appears to have improved significantly with the Medrol Dosepak.  He denies any recent illness.  He has no constitutional complaints such as fevers, chills or sweats.  HEENT: The patient denies any cephalgia, ocular, nasopharyngeal symptoms.  He has no dysphagia.  Cardiovascular: He denies any palpitations, chest pain, syncope or near-syncope.  Pulmonary: He denies any dyspnea or respiratory difficulties.  GI: The patient has no abdominal pain, nausea or vomiting.  GU: The patient denies any urinary frequency or dysuria. There is no gross hematuria.  Dermatologic: The patient notes no new onset of rash or other dermatological abnormalities.  Musculoskeletal: Denies any recent falls or near-falls.  He denies any abnormalities of endocrine, immunologic, hematologic, organ systems.  , ,MEDICATIONS: , Atenolol, Zestril, Vicodin., ,ALLERGIES:,  None., ,SOCIOECONOMIC STATUS:,  Lifting limitations of 5 pounds and limited stooping, bending and twisting., ,PHYSICAL EXAMINATION: , Vital signs:  Blood pressure 158/86, respiration 14, pulse 60, temperature 100.2.  He is sitting upright, alert and oriented and in no acute distress.  Skin is warm and dry.  Gross neurologic examination is normal.  ENT examination reveals normal oropharynx, nasopharynx, and tympanic membranes.  Neck: Full range of motion with no adenopathy or thyromegaly.  Cardiovascular: Regular rate and rhythm.  Lungs: Clear.  , ,On examination of the lumbar spine, he is minimally tender to palpation.  There is no overt muscular spasm.  His range of motion is estimated at 40 degrees of flexion and 15 degrees of extension.  Straight leg raises do not elicit any leg complaints on today's visit.  Lower extremity reflexes are symmetric., ,DIAGNOSIS: , Low back pain with a history of right leg pain.  The leg pain is no longer present.  His pain level has improved., ,PLAN:  ,1.  The patient will take another Medrol Dosepak.,2.  He can continue with physical therapy.,3.  He also continues with the same lifting restrictions.,4.  Follow up is within one week.",
 Patient status post lap band placement., SOAP / Chart / Progress Notes, Lap Band Adjustment ,"REASON FOR VISIT:,  Lap band adjustment.,HISTORY OF PRESENT ILLNESS:,  Ms. A is status post lap band placement back in 01/09 and she is here on a band adjustment.  Apparently, she had some problems previously with her adjustments and apparently she has been under a lot of stress.  She was in a car accident a couple of weeks ago and she has problems, she does not feel full.  She states that she is not really hungry but she does not feel full and she states that she is finding when she is hungry at night, having difficulty waiting until the morning and that she did mention that she had a candy bar and that seemed to make her feel better.,PHYSICAL EXAMINATION: , On exam, her temperature is 98, pulse 76, weight 197.7 pounds, blood pressure 102/72, BMI is 38.5, she has lost 3.8 pounds since her last visit.  She was alert and oriented in no apparent distress.  ,PROCEDURE:  ,I was able to access her port.  She does have an AP standard low profile.  I aspirated 6 mL, I did add 1 mL, so she has got approximately 7 mL in her band, she did tolerate water postprocedure.,ASSESSMENT:,  The patient is status post lap band adjustments, doing well, has a total of 7 mL within her band, tolerated water postprocedure.  She will come back in two weeks for another adjustment as needed.,","soap / chart / progress notes, lap band adjustment, lap band placement, lap band, "
 Patient with a history of ischemic cardiac disease and hypercholesterolemia., SOAP / Chart / Progress Notes, Ischemic Cardiac Disease - Progress Note ,"HISTORY OF PRESENT ILLNESS:,  The patient is a 68-year-old man who returns for recheck.  He has a history of ischemic cardiac disease, he did see Dr. XYZ in February 2004 and had a thallium treadmill test.  He did walk for 8 minutes.  The scan showed some mild inferior wall scar and ejection fraction was well preserved.  He has not had difficulty with chest pain, palpitations, orthopnea, nocturnal dyspnea, or edema.,PAST MEDICAL HISTORY/SURGERIES/HOSPITALIZATIONS: , He had tonsillectomy at the age of 8.  He was hospitalized in 1996 with myocardial infarction and subsequently underwent cardiac catheterization and coronary artery bypass grafting procedure.  He did have LIMA to the LAD and had three saphenous vein grafts performed otherwise.,MEDICATIONS:,  Kerlone 10 mg 1/2 pill daily, gemfibrozil 600 mg twice daily, Crestor 80 mg 1/2 pill daily, aspirin 325 mg daily, vitamin E 400 units daily, and Citrucel one daily.,ALLERGIES: , None known.,FAMILY HISTORY:  ,Father died at the age of 84.  He had a prior history of cancer of the lung and ischemic cardiac disease.  Mother died in her 80s from congestive heart failure.  He has two brothers and six sisters living who remain in good health.,PERSONAL HISTORY:  ,Quit smoking in 1996.  He occasionally drinks alcoholic beverages.,REVIEW OF SYSTEMS:,Endocrine:  He has hypercholesterolemia treated with diet and medication.  He reports that he did lose 10 pounds this year.,Neurologic:  Denies any TIA symptoms.,Genitourinary:  He has occasional nocturia.  Denies any difficulty emptying his bladder.,Gastrointestinal:  He has a history of asymptomatic cholelithiasis.,PHYSICAL EXAMINATION:,Vital Signs:  Weight:  225 pounds.  Blood pressure:  130/82.  Pulse:  83.  Temperature:  96.4 degrees.,General Appearance:  He is a middle-aged man who is not in any acute distress.,HEENT:  Mouth:  The posterior pharynx is clear.,Neck:  Without adenopathy or thyromegaly.,Chest:  Lungs are resonant to percussion.  Auscultation reveals normal breath sounds.,Heart:  Normal S1, S2, without gallops or rubs.,Abdomen:  Without tenderness or masses.,Extremities:  Without edema.,IMPRESSION/PLAN:,1.  Ischemic cardiac disease.  This remains stable.  He will continue on the same medication.  He reports he has had some laboratory studies today.,2.  Hypercholesterolemia.  He will continue on the same medication.,3.  Facial tic.  We also discussed having difficulty with the facial tic at the left orbital region.  This occurs mainly when he is under stress.  He has apparently had numerous studies in the past and has seen several doctors in Wichita about this.  At one time was being considered for some type of operation.  His description, however, suggests that they were considering an operation for tic douloureux.  He does not have any pain with this tic and this is mainly a muscle spasm that causes his eye to close.  Repeat neurology evaluation was advised.  He will be scheduled to see Dr. XYZ in Newton on 09/15/2004.,4.  Immunization.  Addition of pneumococcal vaccination was discussed with him but had been decided by him at the end of the appointment.  We will have this discussed with him further when his laboratory results are back.",
 The patient is a 65-year-old female who underwent left upper lobectomy for stage IA non-small cell lung cancer.  She returns for a routine surveillance visit.  The patient has no evidence of disease now status post left upper lobectomy for stage IA non-small cell lung cancer 13 months ago., SOAP / Chart / Progress Notes, Lobectomy - Followup ,"HISTORY OF PRESENT ILLNESS: , The patient is a 65-year-old female who underwent left upper lobectomy for stage IA non-small cell lung cancer.  She returns for a routine surveillance visit.,She has undergone since her last visit an abdominopelvic CT, which shows an enlarging simple cyst of the left kidney.  She underwent barium swallow, which demonstrates a small sliding hiatal hernia with minimal reflux.  She has a minimal delayed emptying secondary tertiary contractions.  PA and lateral chest x-ray from the 11/23/09 was also reviewed, which demonstrates no lesions or infiltrates.  Review of systems, the patient continues to have periodic odynophagia and mid thoracic dysphagia.  This most likely is secondary to tertiary contractions with some delayed emptying.  She has also had increased size of the left calf without tenderness, which has not resolved over the past several months.  She has had a previous DVT in 1975 and 1985.  She denies weight loss, anorexia, fevers, chills, headaches, new aches or pains, cough, hemoptysis, shortness of breath at rest, or dyspnea on exertion.,MEDICATIONS: , Aspirin 81 mg p.o. q.d., Spiriva 10 mcg q.d., and albuterol p.r.n.,PHYSICAL EXAMINATION: , BP:  117/78.  RR:  18.  P:  93.,WT:  186 lbs.  RAS:  100%.,HEENT:  Mucous membranes are moist.  No cervical or supraclavicular lymphadenopathy.,LUNGS:  Clear to auscultation bilaterally.,CARDIAC:  Regular rate and rhythm without murmurs.,EXTREMITIES:  No cyanosis, clubbing or edema.,NEURO:  Alert and oriented x3.  Cranial nerves II through XII intact.,ASSESSMENT: , The patient has no evidence of disease now status post left upper lobectomy for stage IA non-small cell lung cancer 13 months ago.,PLAN:  ,She is to return to clinic in six months with a chest CT.  She was given a prescription for an ultrasound of the left lower extremity to rule out DVT.  She will be called with the results.  She was given a prescription for nifedipine 10 mg p.o. t.i.d. p.r.n. esophageal spasm.","soap / chart / progress notes, non-small cell lung cancer, lobectomy, lung cancer, non-small cell, lung, cancer"
" Followup status post L4-L5 laminectomy and bilateral foraminotomies, and L4-L5 posterior spinal fusion with instrumentation.", SOAP / Chart / Progress Notes, Laminectomy & Foraminotomy Followup ,"REASON FOR VISIT:,  Followup status post L4-L5 laminectomy and bilateral foraminotomies, and L4-L5 posterior spinal fusion with instrumentation.,HISTORY OF PRESENT ILLNESS:,  Ms. ABC returns today for followup status post L4-L5 laminectomy and bilateral foraminotomies, and posterior spinal fusion on 06/08/07.,Preoperatively, her symptoms, those of left lower extremity are radicular pain.,She had not improved immediately postoperatively.  She had a medial breech of a right L4 pedicle screw.  We took her back to the operating room same night and reinserted the screw.  Postoperatively, her pain had improved.,I had last seen her on 06/28/07 at which time she was doing well.  She had symptoms of what she thought was ""restless leg syndrome"" at that time.  She has been put on ReQuip for this.,She returned.  I had spoken to her 2 days ago and she had stated that her right lower extremity pain was markedly improved.  I had previously evaluated this for a pain possibly relating to deep venous thrombosis and ultrasound was negative.  She states that she had recurrent left lower extremity pain, which was similar to the pain she had preoperatively but in a different distribution, further down the leg.  Thus, I referred her for a lumbar spine radiograph and lumbar spine MRI and she presents today for evaluation.,She states that overall, she is improved compared to preoperatively.  She is ambulating better than she was preoperatively.  The pain is not as severe as it was preoperatively.  The right leg pain is improved.  The left lower extremity pain is in a left L4 and L5 distribution radiating to the great toe and first web space on the left side.,She denies any significant low back pain.  No right lower extremity symptoms.,No infectious symptoms whatsoever.  No fever, chills, chest pain, shortness of breath.  No drainage from the wound.  No difficulties with the incision.,FINDINGS:  ,On examination, Ms. ABC is a pleasant, well-developed, well-nourished female in no apparent distress.  Alert and oriented x 3.  Normocephalic, atraumatic.  Respirations are normal and nonlabored.  Afebrile to touch.,Left tibialis anterior strength is 3 out of 5, extensor hallucis strength is 2 out of 5.  Gastroc-soleus strength is 3 to 4 out of 5.  This has all been changed compared to preoperatively.  Motor strength is otherwise 4 plus out of 5.  Light touch sensation decreased along the medial aspect of the left foot.  Straight leg raise test normal bilaterally.,The incision is well healed.  There is no fluctuance or fullness with the incision whatsoever.  No drainage.,Radiographs obtained today demonstrate pedicle screw placement at L4 and L5 bilaterally without evidence of malposition or change in orientation of the screws.,Lumbar spine MRI performed on 07/03/07 is also reviewed.,It demonstrates evidence of adequate decompression at L4 and L5.  There is a moderate size subcutaneous fluid collection seen, which does not appear compressive and may be compatible with normal postoperative fluid collection, especially given the fact that she had a revision surgery performed.,ASSESSMENT AND PLAN:  ,Ms. ABC is doing relatively well status post L4 and L5 laminectomy and bilateral foraminotomies, and posterior spinal fusion with instrumentation on 07/08/07.  The case is significant for merely misdirected right L4 pedicle screw, which was reoriented with subsequent resolution of symptoms.,I am uncertain with regard to the etiology of the symptoms.  However, it does appear that the radiographs demonstrate appropriate positioning of the instrumentation, no hardware shift, and the MRI demonstrates only a postoperative suprafascial fluid collection.  I do not see any indication for another surgery at this time.,I would also like to hold off on an interventional pain management given the presence of the fluid collection to decrease the risk of infection.,My recommendation at this time is that the patient is to continue with mobilization.  I have reassured her that her spine appears stable at this time.  She is happy with this.,I would like her to continue ambulating as much as possible.  She can go ahead and continue with ReQuip for the restless leg syndrome as her primary care physician has suggested.  I have also her referred to Mrs. Khan at Physical Medicine and Rehabilitation for continued aggressive management.,I will see her back in followup in 3 to 4 weeks to make sure that she continues to improve.  She knows that if she has any difficulties, she may follow up with me sooner.","soap / chart / progress notes, spinal fusion, restless leg syndrome, posterior spinal fusion, pedicle screw, lumbar spine, bilateral foraminotomies, fluid collection, foraminotomy, instrumentation, laminectomy, screw, spine, "
 This patient has reoccurring ingrown infected toenails., SOAP / Chart / Progress Notes, Infected Toenails ,"S - ,This patient has reoccurring ingrown infected toenails.  He presents today for continued care.,O - ,On examination, the left great toenail is ingrown on the medial and lateral toenail border.  The right great toenail is ingrown on the lateral nail border only.  There is mild redness and granulation tissue growing on the borders of the toes.  One on the medial and one on the lateral aspect of the left great toe and one on the lateral aspect of the right great toe.  These lesions measure 0.5 cm in diameter each.  I really do not understand why this young man continues to develop ingrown nails and infections.,A - ,1.  Onychocryptosis.,","soap / chart / progress notes, infected toenails, onychocryptosis, benign lesions, toenail border, left great toe, neosporin ointment, hemostasis was achieved, ointment and absorbent, toenails, ingrown, lesions, benign, infected,"
" Patient with hypertension, syncope, and spinal stenosis - for recheck.", SOAP / Chart / Progress Notes, Hypertension - Progress Note ,"SUBJECTIVE:,  The patient is a 78-year-old female who returns for recheck.  She has hypertension.  She denies difficulty with chest pain, palpations, orthopnea, nocturnal dyspnea, or edema.,PAST MEDICAL HISTORY / SURGERY / HOSPITALIZATIONS:,  Reviewed and unchanged from the dictation on 12/03/2003.,MEDICATIONS:  ,Atenolol 50 mg daily, Premarin 0.625 mg daily, calcium with vitamin D two to three pills daily, multivitamin daily, aspirin as needed, and TriViFlor 25 mg two pills daily.  She also has Elocon cream 0.1% and Synalar cream 0.01% that she uses as needed for rash.,ALLERGIES:  ,Benadryl, phenobarbitone, morphine, Lasix, and latex.,FAMILY HISTORY / PERSONAL HISTORY: , Reviewed.  Mother died from congestive heart failure.  Father died from myocardial infarction at the age of 56.  Family history is positive for ischemic cardiac disease.  Brother died from lymphoma.  She has one brother living who has had angioplasties x 2.  She has one brother with asthma.,PERSONAL HISTORY:,  Negative for use of alcohol or tobacco.,REVIEW OF SYSTEMS:,Bones and Joints:  She has had continued difficulty with lower back pain particularly with standing which usually radiates down her right leg.  She had been followed by Dr. Mills, but decided to see Dr. XYZ who referred to her Dr Isaac.  She underwent several tests.  She did have magnetic resonance angiography of the lower extremities and the aorta which were normal.  She had nerve conduction study that showed several peripheral polyneuropathy.  She reports that she has myelogram last week but has not got results of this.  She reports that the rest of her tests have been normal, but it seems that vertebrae shift when she stands and then pinches the nerve.  She is now seeing Dr. XYZ who comes to Hutchison from KU Medical Center, and she thinks that she probably will have surgery in the near future.,Genitourinary:  She has occasional nocturia.,PHYSICAL EXAMINATION:,Vital Signs:  Weight:  227.2 pounds.  Blood pressure:  144/72.  Pulse:  80.  Temperature:  97.5 degrees.,General Appearance:  She is an elderly female patient who is not in acute distress.,Mouth:  Posterior pharynx is clear.,Neck:  Without adenopathy or thyromegaly.,Chest:  Lungs are resonant to percussion.  Auscultation reveals normal breath sounds.,Heart:  Normal S1 and S2 without gallops or rubs.,Abdomen:  Without masses or tenderness to palpation.,Extremities:  Without edema.,IMPRESSION/PLAN:,1.  Hypertension.  She is advised to continue with the same medication.,2.  Syncope.  She previously had an episode of syncope around Thanksgiving.  She has not had a recurrence of this and her prior cardiac studies did not show arrhythmias.,3.  Spinal stenosis.  She still is being evaluated for this and possibly will have surgery in the near future.","soap / chart / progress notes, progress note, hypertension, spinal stenosis, syncope, spinal, stenosis, infarction, orthopnea, "
" Human immunodeficiency virus, stable on Trizivir.  Hepatitis C with stable transaminases.  History of depression, stable off meds.   Hypertension, moderately controlled on meds.", SOAP / Chart / Progress Notes, HIV Followup - 1 ,"PROBLEM LIST:,1.  HIV stable.,2.  Hepatitis C chronic.,3.  History of depression, stable off meds.,4.  Hypertension, moderately controlled.,CHIEF COMPLAINT: , The patient comes for a routine followup appointment.,HISTORY OF PRESENTING ILLNESS: , This is a 34-year-old African American female who comes today for routine followup.  She has no acute complaints.  She reports that she has a muscle sprain on her upper back from lifting.  The patient is a housekeeper by profession.  It does not impede her work in anyway.  She just reports that it gives her some trouble sleeping at night, pain on 1 to 10 scale was about 2 and at worse it is 3 to 4 but relieved with over-the-counter medication.  No other associated complaints.  No neurological deficits or other specific problems.  The patient denies any symptoms associated with opportunistic infection.,PAST MEDICAL HISTORY:,1.  Significant for HIV.,2.  Hepatitis.,3.  Depression.,4.  Hypertension.,CURRENT MEDICATIONS:,1.  She is on Trizivir 1 tablet p.o. b.i.d.,2.  Ibuprofen over-the-counter p.r.n.,MEDICATION COMPLIANCE: , The patient is 100% compliant with her meds.  She reports she does not miss any doses.,ALLERGIES: , She has no known drug allergies.,DRUG INTOLERANCE:  ,There is no known drug intolerance in the past.,NUTRITIONAL STATUS: , The patient eats regular diet and eats 3 meals a day.,REVIEW OF SYSTEMS: , Noncontributory except as mentioned in the HPI.,LABORATORY DATA: , Most recent labs from 11/07.,RADIOLOGICAL DATA:,  She has had no recent radiological procedures.,IMMUNIZATIONS: , Up-to-date.,SEXUAL HISTORY: , She has had no recent STDs and she is not currently sexually active.  PPD status was negative in the past.  PPD will be placed again today.,Treatment adherence counseling was performed by both nursing staff and myself.  Again, the patient is a 100% compliant with her meds.  Last dental exam was in 11/07, where she had 2 teeth extracted.  Last Pap smear was 1 year ago was negative.  The patient has not had mammogram yet, as she is not of the age where she would start screening mammogram.  She has no family history of breast cancer.,MENTAL HEALTH AND SUBSTANCE ABUSE: , The patient has a history of depression.  No history of substance abuse.,ADVANCED DIRECTIVE: , Unknown.,PHYSICAL EXAMINATION:,GENERAL:  This is a thinly built female, not in acute distress.  VITAL SIGNS:  Temperature 36.5, blood pressure 132/89, pulse of 82, and weight of 104 pounds.  HEAD AND NECK:  Reveals bilaterally reactive pupils.  Supple neck.  No thrush.  No adenopathy.  HEART:  Heart sounds S1 and S2 regular.  No murmur.  LUNGS:  Clear bilaterally to auscultation.  ABDOMEN:  Soft and nontender with good bowel sounds.  NEUROLOGIC:  She is alert and oriented x3 with no focal neurological deficit.  EXTREMITIES:  Peripheral pulses are felt bilaterally.  She has no pitting pedal edema, clubbing or cyanosis.  GU:  Examination of external genitalia is unremarkable.  There are no lesions.,LABORATORY DATA: , From 11/07 shows hemoglobin and hematocrit of 16 and 46.  Creatinine of 0.6.  LFTs within normal limits.  Viral load of less than 48 and CD4 count of 918.,ASSESSMENT:,1.  Human immunodeficiency virus, stable on Trizivir.,2.  Hepatitis C with stable transaminases.,3.  History of depression, stable off meds.",
" Upper respiratory tract infection, persistent.  Tinea pedis.  Wart on the finger.  Hyperlipidemia.  Tobacco abuse.", SOAP / Chart / Progress Notes, Gen Med SOAP - 9 ,"SUBJECTIVE:  ,This patient presents to the office today for a checkup.  He has several things to go over and discuss.  First he is sick.  He has been sick for a month intermittently, but over the last couple of weeks it is worse.  He is having a lot of yellow phlegm when he coughs.  It feels likes it is in his chest.  He has been taking Allegra-D intermittently, but he is almost out and he needs a refill.  The second problem, his foot continues to breakout.  It seems like it was getting a lot better and now it is bad again.  He was diagnosed with tinea pedis previously, but he is about out of the Nizoral cream.  I see that he is starting to breakout again now that the weather is warmer and I think that is probably not a coincidence.  He works in the flint and it is really hot where he works and it has been quite humid lately.  The third problem is that he has a wart or a spot that he thinks is a wart on the right middle finger.  He is interested in getting that frozen today.  Apparently, he tells me I froze a previous wart on him in the past and it went away.  Next, he is interested in getting some blood test done.  He specifically mentions the blood test for his prostate, which I informed him is called the PSA.  He is 50 years old now.  He will also be getting his cholesterol checked again because he has a history of high cholesterol.  He made a big difference in his cholesterol by quitting smoking, but unfortunately after taking his social history today he tells me that he is back to smoking.  He says it is difficult to quit.  He tells me he did quit chewing tobacco.  I told him to keep trying to quit smoking.  ,REVIEW OF SYSTEMS:,  General:  With this illness he has had no problems with fever.  HEENT:  Some runny nose, more runny nose than congestion.  Respiratory:  Denies shortness of breath.  Skin:  He has a peeling skin on the bottom of his feet, mostly the right foot that he is talking about today.  At times it is itchy.,OBJECTIVE: , His weight is 238.4 pounds, blood pressure 128/74, temperature 97.8, pulse 80, and respirations 16.  General exam:  The patient is nontoxic and in no acute distress.  Ears:  Tympanic membranes pearly gray bilaterally.  Mouth:  No erythema, ulcers, vesicles, or exudate noted.  Neck is supple.  No lymphadenopathy.  Lungs:  Clear to auscultation.  No rales, rhonchi, or wheezing.  Cardiac:  Regular rate and rhythm without murmur.  Extremities:  No edema, cyanosis, or clubbing.  Skin exam:  I checked out the bottom of his right foot.  He has peeling skin visible consistent with tinea pedis.  On the anterior aspect of the right third finger there is a small little raised up area that I believe represents a wart.  The size of this wart is approximately 3 mm in diameter.,ASSESSMENT:  ,1.  Upper respiratory tract infection, persistent.,2.  Tinea pedis.,3.  Wart on the finger.,4.  Hyperlipidemia.,5.  Tobacco abuse.,PLAN: , The patient is getting a refill on Allegra-D.  I am giving him a refill on the Nizoral 2% cream that he should use to the foot area twice a day.  I gave him instructions on how to keep the foot clean and dry because I think the reason we are dealing with this persistent problem is the fact that his feet are hot and sweaty a lot because of his work.  His wart has been present for some time now and he would like to get it frozen.  I offered him the liquid nitrogen treatment and he did agree to it.  I used liquid nitrogen after a verbal consent was obtained from the patient to freeze the wart.  He tolerated the procedure very well.  I froze it once and I allowed for a 3 mm freeze zone.  I gave him verbal wound care instructions after the procedure.  Lastly, when he is fasting I am going to send him to the lab with a slip, which I gave him today for a basic metabolic profile, CBC, fasting lipid profile, and a screening PSA test.  Lastly, for the upper respiratory tract infection, I am giving him amoxicillin 500 mg three times a day for 10 days.","soap / chart / progress notes, hyperlipidemia, allegra-d, upper respiratory tract infection, tinea pedis wart, tobacco abuse, blood test, runny nose, peeling skin, tinea pedis, abuse, infection, wart,"
" One-month followup for unintentional weight loss, depression, paranoia, dementia, and osteoarthritis of knees.  Doing well.", SOAP / Chart / Progress Notes, Gen Med SOAP - 7 ,"CHIEF COMPLAINT:,  One-month followup.,HISTORY OF PRESENT ILLNESS:,  The patient is an 88-year-old Caucasian female.  She comes here today with a friend.  The patient has no complaints.  She states she has been feeling well.  Her knees are not hurting her at all anymore and she is not needing Bextra any longer.  I think the last steroid injection that she had with Dr. XYZ really did help.  The patient denies any shortness of breath or cough.  Has no nausea, vomiting, abdominal pain.  No diarrhea or constipation.  She states her appetite is good.  She clears her plate at noon.  She has had no fevers, chills, or sweats.  The friend with her states she is doing very well.  Seems to eat excellently at noontime, despite this, the patient continues to lose weight.  When I asked her what she eats for breakfast and for supper, she states she really does not eat anything.  Her only meal that she eats at the nursing home is the noon meal and then I just do not think she is eating much the rest of the time.  She states she is really not hungry the rest of the time except at lunchtime.  She denies any fevers, chills, or sweats.  We did do some lab work at the last office visit and CBC was essentially normal.  Comprehensive metabolic was essentially normal as was of the BUN of 32 and creatinine of 1.3.  This is fairly stable for her.  Liver enzymes were normal.  TSH was normal.  Free albumin was normal at 23.  She is on different antidepressants and that may be causing some difficulties with unintentional weight loss.,MEDICATIONS:  ,Currently are Aricept 10 mg a day, Prevacid 30 mg a day, Lexapro 10 mg a day, Norvasc 2.5 mg a day, Milk of Magnesia 30 cc daily, and Amanda 10 mg b.i.d.,ALLERGIES:,  No known drug allergies.,PAST MEDICAL HISTORY:,  Reviewed from 05/10/2004 and unchanged other than the addition of paranoia, which is much improved on her current medications.,SOCIAL HISTORY:,  The patient is widow.  She is a nonsmoker, nondrinker.  She lives at Kansas Christian Home independently, but actually does get a lot of help with medications, having a driver to bring her here, and going to the noon meal.,REVIEW OF SYSTEMS:,  As above in HPI.,PHYSICAL EXAM:,General:  This is a well-developed, pleasant Caucasian female, who appears thinner especially in her face.  States are clothes are fitting more loosely.,Vital Signs:  Weight:  123, down 5 pounds from last month and down 11 pounds from May 2004.  Blood pressure:  128/62.  Pulse:  60.  Respirations:  20.  Temperature:  96.8.,Neck:  Supple.  Carotids are silent.,Chest:  Clear to auscultation.,Cardiovascular:  Regular rate and rhythm.,Abdomen:  Soft and nontender, nondistended with positive bowel sounds.  No organomegaly or masses are appreciated.,Extremities:  Free of edema.,ASSESSMENT:,1.  Unintentional weight loss.  I think this is more a problem of just not getting in any calories though does not appear to be a medical problem go on, although her dementia may make it difficult for her to remember to eat, and with her antidepressant medication she is on, she just may not have much of an appetite to eat unless food is prepared for her.,2.  Depression, doing well.,3.  Paranoia, doing well.,4.  Dementia, stable.,5.  Osteoarthritis of the knees, pain is much improved.,PLAN:,1.  Continue on current medications.,2.  I did call and talk with doctor at hospital.  We discussed different options.  We have decided to have the patient eat the evening meal at the nursing home also and have her take a supplement drink such as Ensure at breakfast time.  Connie will weigh the patient once a week and I will go ahead and see the patient in one month.  We can see how she is doing at that time.  If she continues to lose weight despite eating better, then I think we will need to do further evaluation.",
 Patient today with multiple issues.  , SOAP / Chart / Progress Notes, Gen Med SOAP - 8 ,"SUBJECTIVE: , I am following the patient today for multiple issues.  He once again developed gross hematuria, which was unprovoked.  His Coumadin has been held.  The patient has known BPH and is on Flomax.  He is being treated with Coumadin because of atrial fibrillation and stroke.  This is the second time he has had significant gross hematuria this month.  He also fell about a week ago and is complaining of buttock pain and leg pain.  We did get x-rays of hips, knees, and ankles.  Clearly, he has significant degenerative disease in all these areas.  No fractures noted however.  He felt that the pain is pretty severe and particularly worse in the morning.  His sinuses are bothering him.  He wonders about getting some nasal saline spray.  We talked about Coumadin, stroke risk, etc. in the setting of atrial fibrillation.,PHYSICAL EXAMINATION: , Vitals:  As in chart.  The patient is alert, pleasant, and cooperative.  He is not in any apparent distress.  He is comfortable in a seated position.  I did not examine him further today.,ASSESSMENT AND PLAN:,1.  Hematuria.  Coumadin needs to be stopped, so we will evaluate what is going on, which is probably just some BPH.  We will also obtain a repeat UA as he did describe to me some dysuria.  However, I do not think this would account for the gross hematuria.  He will be started on an aspirin 81 mg p.o. daily.,2.  For the pain we will try him on Lortab.  He will get a Lortab everyday in the morning 5/500 prior to getting out of bed, and then he will have the option of having a few more throughout the day if he requires it.,3.  We will see about getting him set up with massage therapy and/or physical therapy as well for his back pain.,4.  For his sinuses, we will arrange for him to have saline nasal spray at the bedside for p.r.n. use.","soap / chart / progress notes, multiple issues, atrial fibrillation, gross hematuria, multiple, bph, fibrillation, hematuria,"
" Human immunodeficiency virus disease with stable control on Atripla.  Resolving left gluteal abscess, completing Flagyl.  Diabetes mellitus, currently on oral therapy.  Hypertension, depression, and chronic musculoskeletal pain of unclear etiology.", SOAP / Chart / Progress Notes, HIV Followup ,"HISTORY OF PRESENT ILLNESS: , The patient is a 41-year-old white male with a history of HIV disease.  His last CD4 count was 425, viral load was less than 50 in 08/07.  He was recently hospitalized for left gluteal abscess, for which he underwent I&D and he has newly diagnosed diabetes mellitus.  He also has a history of hypertension and hypertriglyceridemia.  He had been having increased urination and thirst.  He was seen in the hospital by the endocrinology staff and treated with insulin while hospitalized and getting treatment for his perirectal abscess.  The endocrine team apparently felt that insulin might be best for this patient, but because of financial issues, elected to place him on Glucophage and glyburide.  The patient reports that he has been taking the medication.  He is in general feeling better.  He says that his gluteal abscess is improving and he will be following up with Surgery today.,CURRENT MEDICATIONS:,1.  Gabapentin 600 mg at night.,2.  Metformin 1000 mg twice a day.,3.  Glipizide 5 mg a day.,4.  Flagyl 500 mg four times a day.,5.  Flexeril 10 mg twice a day.,6.  Paroxetine 20 mg a day.,7.  Atripla one at night.,8.  Clonazepam 1 mg twice a day.,9.  Blood pressure medicine, name unknown.,REVIEW OF SYSTEMS:,  He otherwise has a negative review of systems.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 36.6, blood pressure 145/90, pulse 123, respirations 20, and weight is 89.9 kg (198 pounds.)  HEENT:  Unremarkable except for some submandibular lymph nodes.  His fundi are benign.  NECK:  Supple.  LUNGS:  Clear to auscultation and percussion.  CARDIAC:  Reveals regular rate and rhythm without murmur, rub or gallop.  ABDOMEN:  Soft and nontender without organomegaly or mass.  EXTREMITIES:  Show no cyanosis, clubbing or edema.  GU:  Examination of the perineum revealed an open left gluteal wound that appears clear with no secretions.,IMPRESSION:,1.  Human immunodeficiency virus disease with stable control on Atripla.,2.  Resolving left gluteal abscess, completing Flagyl.,3.  Diabetes mellitus, currently on oral therapy.,4.  Hypertension.,5.  Depression.,6.  Chronic musculoskeletal pain of unclear etiology.,PLAN: , The patient will continue his current medications.  He will have laboratory studies done in 3 to 4 weeks, and we will see him a few weeks thereafter.  He has been encouraged to keep his appointment with his psychologist.","soap / chart / progress notes, human immunodeficiency virus disease, diabetes mellitus, atripla, hiv, depression, musculoskeletal, diabetes, hypertension, "
" Patient with several medical problems - mouth being sore, cough, right shoulder pain, and neck pain", SOAP / Chart / Progress Notes, Gen Med SOAP - 6 ,"SUBJECTIVE:,  The patient is in with several medical problems.  He complains his mouth being sore since last week and also some ""trouble with my eyes.""  He states that they feel ""funny"" but he is seeing okay.  He denies any more diarrhea or abdominal pain.  Bowels are working okay.  He denies nausea or diarrhea.  Eating is okay.  He is emptying his bladder okay.  He denies dysuria.  His back is hurting worse.  He complains of right shoulder pain and neck pain over the last week but denies any injury.  He reports that his cough is about the same.,CURRENT MEDICATIONS:,  Metronidazole 250 mg q.i.d., Lortab 5/500 b.i.d., Allegra 180 mg daily, Levothroid 100 mcg daily, Lasix 20 mg daily, Flomax 0.4 mg at h.s., aspirin 81 mg daily, Celexa 40 mg daily, verapamil SR 180 mg one and a half tablet daily, Zetia 10 mg daily, Feosol b.i.d.,ALLERGIES: , Lamisil, Equagesic, Bactrim, Dilatrate, cyclobenzaprine.,OBJECTIVE:,General:  He is a well-developed, well-nourished, elderly male in no acute distress.,Vital Signs:  His age is 66.  Temperature:  97.7.  Blood pressure:  134/80.  Pulse:  88.  Weight:  201 pounds.,HEENT:  Head was normocephalic.  Examination of the throat reveals it to be clear.  He does have a few slight red patches on his upper inner lip consistent with yeast dermatitis.,Neck:  Supple without adenopathy or thyromegaly.,Lungs:  Clear.,Heart:  Regular rate and rhythm.,Extremities:  He has full range of motion of his shoulders but some tenderness to the trapezius over the right shoulder.  Back has limited range of motion.  He is nontender to his back.  Deep tendon reflexes are 2+ bilaterally in lower extremities.  Straight leg raising is positive for back pain on the right side at 90 degrees.,Abdomen:  Soft, nontender without hepatosplenomegaly or mass.  He has normal bowel sounds.,ASSESSMENT:,1.  Clostridium difficile enteritis, improved.,2.  Right shoulder pain.,3.  Chronic low back pain.,4.  Yeast thrush.,5.  Coronary artery disease.,6.  Urinary retention, which is doing better.,PLAN:,  I put him on Diflucan 200 mg daily for seven days.  We will have him stop his metronidazole little earlier at his request.  He can drop it down to t.i.d. until Friday of this week and then finish Friday’s dose and then stop the metronidazole and that will be more than a 10-day course.  I ordered physical therapy to evaluate and treat his right shoulder and neck as indicated x 6 visits and he may see Dr. XYZ p.r.n. for his eye discomfort and his left eye pterygium which is noted on exam (minimal redness is noted to the conjunctiva on the left side but no mattering was seen.)  Recheck with me in two to three weeks.","soap / chart / progress notes, clostridium difficile enteritis, coronary artery disease, urinary retention, yeast thrush, cough, neck pain, several medical problems, shoulder pain, range of motion, soap, metronidazole, shoulder, neck, "
" Followup of left hand discomfort and systemic lupus erythematosus.  Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.", SOAP / Chart / Progress Notes, Hand Discomfort - Followup ,"REASON FOR RETURN VISIT: , Followup of left hand discomfort and systemic lupus erythematosus.,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old female with a history of systemic lupus erythematosus, who was last seen in rheumatology clinic approximately 4 months ago for bilateral hand discomfort, left greater than right.  The patient was seen on 10/30/07.  She had the same complaint.  She was given a trial of Elavil at bedtime because the thought was to see that represented ulnar or radial neuropathy.  She was also given a prescription for Zostrix cream but was unable to get it filled because of insurance coverage.  The patient reports some worsening of the symptoms especially involving at the dorsum of the left hand, and she points to the area that actually involves the dorsal aspect of the second, third, and fourth digits.  The patient recently has developed what sounds like an upper respiratory problem with a nonproductive cough for 3 days, although she reports that she has had subjective fevers for the past 3 or 4 days, but has not actually taken the temperature.  She has not had any night sweats or chills.  She has had no recent problems with chest pain, chest discomfort, shortness of breath or problems with GU or GI complaints.  She is returning today for routine followup evaluation.,CURRENT MEDICATIONS:,1.  Plaquenil 200 mg twice a day.,2.  Fosamax 170 mg once a week.,3.  Calcium and vitamin D complex twice daily.,4.  Folic acid 1 mg per day.,5.  Trilisate 1000 mg a day.,6.  K-Dur 20 mEq twice a day.,7.  Hydrochlorothiazide 15 mg once a day.,8.  Lopressor 50 mg one-half tablet twice a day.,9.  Trazodone 100 mg at bedtime.,10.  Prempro 0.625 mg per day.,11.  Aspirin 325 mg once a day.,12.  Lipitor 10 mg per day.,13.  Pepcid 20 mg twice a day.,14.  Reglan 10 mg before meals and at bedtime.,15.  Celexa 20 mg per day.,REVIEW OF SYSTEMS: , Noncontributory except for what was noted in the HPI and the remainder or complete review of systems is unremarkable.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure 155/84, pulse 87, weight 223 pounds, and temperature 99.2.  GENERAL:  She is a well-developed, well-nourished female appearing her staged age.  She is alert, oriented, and cooperative.  HEENT:  Normocephalic and atraumatic.  There is no facial rash.  No oral lesions.  LUNGS:  Clear to auscultation.  CARDIOVASCULAR:  Regular rate and rhythm without murmurs, rubs or gallops.  EXTREMITIES:  No cyanosis or clubbing.  Sensory examination of the upper extremity decreased to light touch on the distal tips of the left second and third digits compared to the fifth digit.  Positive Tinel sign.  Full range of motion of the wrist with no evidence of motor atrophy or muscle loss.,LABORATORY DATA:  ,WBC 5100, hemoglobin 11.1, hematocrit 32.8, and platelets 200,000.  Westergren sedimentation rate of 47.  Urinalysis is negative for protein and blood.  Lupus serology is pending.,ASSESSMENT:,1.  Systemic lupus erythematosus that is chronically stable at this point.,2.  Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.,3.  Upper respiratory infection with cough, cold, and congestion.,RECOMMENDATIONS:,1.  The patient will have a trial of a resting wrist splint at night for the next 4 to 6 weeks.  If there is no improvement, the patient will return for corticosteroid injection of her carpal tunnel.,2.  Azithromycin 5-day dose pack.,3.  Robitussin Cough and Cold Flu to be taken twice a day.,4.  Atarax 25 mg at bedtime for sleep.,5.  The patient will return to the rheumatology clinic for a routine followup evaluation in 4 months.",
 The patient has recently had an admission for pneumonia with positive blood count.  She returned after vomiting and a probable seizure., SOAP / Chart / Progress Notes, Gen Med SOAP - 11 ,"SUBJECTIVE:,  The patient has recently had an admission for pneumonia with positive blood count.  She was treated with IV antibiotics and p.o. antibiotics; she improved on that.  She was at home and doing quite well for approximately 10 to 12 days when she came to the ER with a temperature of 102.  She was found to have strep.  She was treated with penicillin and sent home.  She returned about 8 o'clock after vomiting and a probable seizure.  Temperature was 104.5; she was lethargic after that.  She had an LP, which was unremarkable.  She had blood cultures, which have not grown anything.  The CSF has not grown anything at this point.,PHYSICAL EXAMINATION:,  She is alert, recovering from anesthesia.  Head, eyes, ears, nose and throat are unremarkable.  Chest is clear to auscultation and percussion.  Abdomen is soft.  Extremities are unremarkable.,LAB STUDIES: , White count in the emergency room was 9.8 with a slight shift.  CSF glucose was 68, protein was 16, and there were no cells.  The Gram-stain was unremarkable.,ASSESSMENT: , I feel that this patient has a febrile seizure.,PLAN: , My plan is to readmit the patient to control her temperature and assess her white count.  I am going to observe her overnight.","soap / chart / progress notes, antibiotics, febrile seizure, temperature, blood count, white count, pneumonia, seizure, "
 The patient has NG tube in place for decompression., SOAP / Chart / Progress Notes, Gen Med SOAP - 10 ,"SUBJECTIVE: , The patient has NG tube in place for decompression.  She says she is feeling a bit better.,PHYSICAL EXAMINATION:,VITAL SIGNS:  She is afebrile.  Pulse is 58 and blood pressure is 110/56.,SKIN:  There is good skin turgor.,GENERAL:  She is not in acute distress.,CHEST:  Clear to auscultation.  There is good air movement bilaterally.,CARDIOVASCULAR:  First and second sounds are heard.  No murmurs appreciated.,ABDOMEN:  Less distended.  Bowel sounds are absent.,EXTREMITIES:  She has 3+ pedal swelling.,NEUROLOGICAL:  The patient is alert and oriented x3.  Examination is nonfocal.,LABORATORY DATA:,  White count is down from 20,000 to 12.5, hemoglobin is 12, hematocrit 37, and platelets 199,000.  Glucose is 157, BUN 14, creatinine 0.6, sodium is 131, potassium is 4.0, and CO2 is 31.,ASSESSMENT AND PLAN:,1.  Small bowel obstruction/paralytic ileus, rule out obstipation.  Continue with less aggressive decompression.  Follow surgeon's recommendation.,2.  Pulmonary fibrosis, status post biopsy.  Manage as per pulmonologist.,3.  Leukocytosis, improving.  Continue current antibiotics.,4.  Bilateral pedal swelling.  Ultrasound of the lower extremity negative for DVT.,5.  Hyponatremia, improving.,6.  DVT prophylaxis.,7.  GI prophylaxis.","soap / chart / progress notes, small bowel obstruction, paralytic ileus, decompression, ng tube, pedal swelling, prophylaxis"
" Patient with NIDDM, hypertension, CAD status post CABG, hyperlipidemia, etc.", SOAP / Chart / Progress Notes, Gen Med SOAP - 2 ,"SUBJECTIVE:,  Overall, she has been doing well.  Her blood sugars have usually been less than or equal to 135 by home glucose monitoring.  Her fasting blood sugar today is 120 by our Accu-Chek.  She is exercising three times per week.  Review of systems is otherwise unremarkable. ,OBJECTIVE:,  Her blood pressure is 110/60.  Other vitals are stable.  HEENT:  Unremarkable.  Neck:  Unremarkable.  Lungs:  Clear.  Heart:  Regular.  Abdomen:  Unchanged.  Extremities:  Unchanged.  Neurologic:  Unchanged. ,ASSESSMENT:,  ,1.  NIDDM with improved control. ,2.  Hypertension. ,3.  Coronary artery disease status post coronary artery bypass graft. ,4.  Degenerative arthritis. ,5.  Hyperlipidemia. ,6.  Hyperuricemia. ,7.  Renal azotemia. ,8.  Anemia. ,9.  Fibroglandular breasts. ,PLAN:,  We will get follow-up labs today.  We will continue with current medications and treatment.  We will arrange for a follow-up mammogram as recommended by the radiologist in six months, which will be approximately Month DD, YYYY.  The patient is advised to proceed with previous recommendations.  She is to follow-up with Ophthalmology and Podiatry for diabetic evaluation and to return for follow-up as directed.","soap / chart / progress notes, general medicine, accu-chek, heent: unremarkable, hyperlipidemia, hypertension, lungs: clear, niddm, neck: unremarkable, progress note, soap, coronary artery bypass graft, follow-up labs, glucose monitoring, coronary artery"
" Short-term followup - Hypertension, depression, osteoporosis, and osteoarthritis.", SOAP / Chart / Progress Notes, Gen Med Progress Note - 8 ,"SUBJECTIVE:,  The patient is an 89-year-old lady.  She actually turns 90 later this month, seen today for a short-term followup.  Actually, the main reasons we are seeing her back so soon which are elevated blood pressure and her right arm symptoms are basically resolved.  Blood pressure is better even though she is not currently on the higher dose Mavik likely recommended.  She apparently did not feel well with the higher dose, so she just went back to her previous dose of 1 mg daily.  She thinks, she also has an element of office hypertension.  Also, since she is on Mavik plus verapamil, she could switch over to the combined drug Tarka.  However, when we gave her samples of that she thought they were too big for her to swallow.  Basically, she is just back on her previous blood pressure regimen.  However, her blood pressure seems to be better today.  Her daughter says that they do check it periodically and it is similar to today’s reading.  Her right arm symptoms are basically resolved and she attributed that to her muscle problem back in the right shoulder blade.  We did do a C-spine and right shoulder x-ray and those just mainly showed some degenerative changes and possibly some rotator cuff injury with the humeral head quite high up in the glenoid in the right shoulder, but this does not seem to cause her any problems.  She has some vague “stomach problems”, although apparently it is improved when she stopped Aleve and she does not have any more aches or pains off Aleve.  She takes Tylenol p.r.n., which seems to be enough for her.  She does not think she has any acid reflux symptoms or heartburn.  She does take Tums t.i.d. and also Mylanta at night.  She has had dentures for many, many years and just recently I guess in the last few months, although she was somewhat vague on this, she has had some sores in her mouth.  They do heal up, but then she will get another one.  She also thinks since she has been on the Lexapro, she has somewhat of a tremor of her basically whole body at least upper body including the torso and arms and had all of the daughters who I not noticed to speak of and it is certainly difficult to tell her today that she has much tremor.  They do think the Lexapro has helped to some extent.,ALLERGIES: , None.,MEDICATION: , Verapamil 240 mg a day, Mavik 1 mg a day, Lipitor 10 mg one and half daily, vitamins daily, Ocuvite daily, Tums t.i.d., Tylenol 2-3 daily p.r.n., and Mylanta at night.,REVIEW OF SYSTEMS:,  Mostly otherwise as above.,OBJECTIVE:,General:  She is a pleasant elderly lady.  She is in no acute distress, accompanied by daughter.,Vital signs:  Blood pressure:  128/82.  Pulse:  68.  Weight:  143 pounds.,HEENT:  No acute changes.  Atraumatic, normocephalic.  On mouth exam, she does have dentures.  She removed her upper denture.  I really do not see any sores at all.  Her mouth exam was unremarkable.,Neck:  No adenopathy, tenderness, JVD, bruits, or mass.,Lungs:  Clear.,Heart:  Regular rate and rhythm.,Extremities:  No significant edema.  Reasonable pulses.  No clubbing or cyanosis, may be just a minimal tremor in head and hands, but it is very subtle and hardly noticeable.  No other focal or neurological deficits grossly.,IMPRESSION:,1.  Hypertension, better reading today.,2.  Right arm symptoms, resolved.,3.  Depression probably somewhat improved with Lexapro and she will just continue that.  She only got up to the full dose 10 mg pill about a week ago and apparently some days does not need to take it.,4.  Perhaps a very subtle tremor.  I will just watch that.,5.  Osteoporosis.,6.  Osteoarthritis.,PLAN:,  I think I will just watch everything for now.  I would continue the Lexapro, we gave her more samples plus a prescription for the 20 mg that she can cut in half.  I offered to see her for again short-term followup.  However, they both preferred just to wait until the annual check up already set up for next April and they know they can call sooner.  She might get a flu shot here in the next few weeks.  Daughter mentioned here today that she thinks her mom is doing pretty well, especially given that she is turning 90 here later this month and I would tend to agree with that.","soap / chart / progress notes, osteoporosis, osteoarthritis, hypertension, depression, short term followup, blood pressure, progress, blood, pressure, dose, "
" General Medicine SOAP note.  Patient with shoulder bursitis, pharyngitis, attention deficit disorder, ", SOAP / Chart / Progress Notes, Gen Med SOAP - 5 ,"S:,  The patient is here today with his mom for several complaints.  Number one, he has been having issues with his right shoulder.  Approximately 10 days ago he fell, slipping on ice, did not hit his head but fell straight on his shoulder.  He has been having issues ever since.  He is having difficulties raising his arm over his head.  He does have some intermittent numbness in his fingers at night.  He is not taking any anti-inflammatories or pain relievers.  He is also complaining of a sore throat.  He did have some exposure to Strep and he has a long history of strep throat.  Denies any fevers, rashes, nausea, vomiting, diarrhea, and constipation.  He is also being seen for ADHD by Dr. B.  Adderall and Zoloft.  He takes these once a day.  He does notice when he does not take his medication.  He is doing well in school.  He is socializing well.  He is maintaining his weight and tolerating the medications.  However, he is having issues with anger control.  He realizes when he has anger outbursts that it is a problem.  His mom is concerned.  He actually was willing to go to counseling and was wondering if there was anything available for him at this time.,PAST MEDICAL/SURGICAL/SOCIAL HISTORY:,  Reviewed and unchanged.,O:,  VSS.  In general, patient is A&Ox3.  NAD.  Heart:  RRR.  Lungs:  CTA.  HEENT:  Unremarkable.  He does have 2+ tonsils, no erythema or exudate noted except for some postnasal drip.  Musculoskeletal:  Limited in range of motion, active on the right.  He stops at about 95 degrees.  No muscle weakness.  Neurovascularly intact.  Negative biceps tenderness.  Psych:  No suicidal, homicidal ideations.  Answering questions appropriately.  No hallucinations.","soap / chart / progress notes, general medicine, adhd, attention deficit disorde, pharyngitis, anger control, anti-inflammatories, bursitis, diarrhea, fevers, nausea, numbness, rashes, shoulder, strep throat, vomiting, attention deficit, deficit disorder, anti inflammatories, soap, anger, intermittent"
 General Medicine SOAP note., SOAP / Chart / Progress Notes, Gen Med SOAP - 3 ,"S:,  XYZ is in today not feeling well for the last three days.  She is a bit sick with bodyaches.  She is coughing.  She has a sore throat, especially when she coughs.  Her cough is productive of green colored sputum.  She has had some chills.  No vomiting.  No diarrhea.  She is sleeping okay.  She does not feel like she needs anything for the cough.  She did call in yesterday, and got a refill of her Keflex.  She took two Keflex this morning and she is feeling a little bit better now.  She is tearful, just tired of feeling ran down.,O:,  Vital signs as per chart.  Respirations 15.  Exam:  Nontoxic.  No acute distress.  Alert and oriented.  HEENT:  TMs are clear bilaterally without erythema or bulging.  Clear external canals.  Clear tympanic.  Conjunctivae are clear.  Clear nasal mucosa.  Clear oropharynx with moist mucous membranes.  NECK is soft and supple without lymphadenopathy.  LUNGS are coarse with no severe rhonchi or wheezes.  HEART is regular rate and rhythm without murmur.  ABDOMEN is soft and nontender.,Chest x-ray reveals no obvious consolidation or infiltrates.  We will send the x-ray for over-read.,Influenza test is negative.  Rapid strep screen is negative.,A:,  Bronchitis/URI.,P: , ,1.  Motrin as needed for fever and discomfort.,2.  Push fluids.,3.  Continue on the Keflex.,4.  Follow up with Dr. ABC if symptoms persist or worsen, otherwise as needed.","soap / chart / progress notes, bodyaches, alert and oriented, no acute distress, soap, diarrhea, general medicine, lymphadenopathy, regular rate and rhythm, rhonchi, soft and nontender, supple, vomiting, wheezes, coughing, keflex, oriented,"
" Palpitations, possibly related to anxiety. Fatigue. Loose stools with some green color and also some nausea.", SOAP / Chart / Progress Notes, Gen Med SOAP ,"SUBJECTIVE: , This patient presents to the office today because he has not been feeling well.  He was in for a complete physical on 05/02/2008.  According to the chart, the patient gives a history of feeling bad for about two weeks.  At first he thought it was stress and anxiety and then he became worried it was something else.  He says he is having a lot of palpitations.  He gets a fluttering feeling in his chest.  He has been very tired over two weeks as well.  His job has been really getting to him.  He has been feeling nervous and anxious.  It seems like when he is feeling stressed he has more palpitations, sometimes they cause chest pain.  These symptoms are not triggered by exertion.  He had similar symptoms about 9 or 10 years ago.  At that time he went through a full workup.  Everything ended up being negative and they gave him something that he took for his nerves and he says that helped.  Unfortunately, he does not remember what it was.  Also over the last three days he has had some intestinal problems.  He has had some intermittent nausea and his stools have been loose.  He has been having some really funny green color to his bowel movements.  There has been no blood in the stool.  He is not having any abdominal pain, just some nausea.  He does not have much of an appetite.  He is a nonsmoker.,OBJECTIVE: , His weight today is 168.4 pounds, blood pressure 142/76, temperature 97.7, pulse 68, and respirations 16.  General exam:  The patient is nontoxic and in no acute distress.  There is no labored breathing.  Psychiatric:  He is alert and oriented times 3.  Ears:  Tympanic membranes pearly gray bilaterally.  Mouth:  No erythema, ulcers, vesicles, or exudate noted.  Eyes:  Pupils equal, round, and reactive to light bilaterally.  Neck is supple.  No lymphadenopathy.  Lungs:  Clear to auscultation.  No rales, rhonchi, or wheezing.  Cardiac:  Regular rate and rhythm without murmur.  Extremities:  No edema, cyanosis, or clubbing.,ASSESSMENT:  ,1.  Palpitations, possibly related to anxiety.,2.  Fatigue.,3.  Loose stools with some green color and also some nausea.  There has been no vomiting, possibly a touch of gastroenteritis going on here.,PLAN: , The patient admits he has been putting this off now for about two weeks.  He says his work is definitely contributing to some of his symptoms and he feels stressed.  He is leaving for a vacation very soon.  Unfortunately, he is actually leaving Wednesday for XYZ, which puts us into a bit of a bind in terms of doing testing on him.  My overall opinion is he has some anxiety related issues and he may also have a touch of gastroenteritis.  A 12-lead EKG was performed on him in the office today.  This EKG was compared with the previous EKG contained in the chart from 2006 and I see that these EKGs look very similar with no significant changes noted, which is definitely a good news.  I am going to send him to the lab from our office to get the following tests done:  Comprehensive metabolic profile, CBC, urinalysis with reflex to culture and we will also get a chest X-ray.  Tomorrow morning I will manage to schedule him for an exercise stress test at Bad Axe Hospital.  We were able to squeeze him in.  His appointment is at 8:15 in the morning.  He is going to have the stress test done in the morning and he will come back to the office in the afternoon for recheck.  I am not going to be here so he is going to see Dr. X.  Dr. X should hopefully be able to call over and speak with the physician who attended the stress test and get a preliminary result before he leaves for XYZ.  Certainly, if something comes up we may need to postpone his trip.  We petitioned his medical records from his former physician and with luck we will be able to find out what medication he was on about nine or ten years ago.  In the meantime I have given him Ativan 0.5 mg one tablet two to three times a day as needed for anxiety.  I talked about Ativan, how it works.  I talked about the side effects.  I told him to use it only as needed and we can see how he is doing tomorrow when he comes back for his recheck.  I took him off of work today and tomorrow so he could rest.","soap / chart / progress notes, palpitations, nausea, loose stools, fatigue, related to anxiety, stress test, anxiety, "
 Sample progress note - Gen Med., SOAP / Chart / Progress Notes, Gen Med SOAP - 1 ,"SUBJECTIVE:,","soap / chart / progress notes, progress note, clear to auscultation, s1, s2, s3, s4, blood pressure, clubbing, cyanosis, general medicine, peripheral edema, rubs, tenderness, abdomen, pressure, soap, blood"
 General Medicine SOAP note., SOAP / Chart / Progress Notes, Gen Med SOAP - 4 ,"S:,  ABC is in today for a followup of her atrial fibrillation.  They have misplaced the Cardizem.  She is not on this and her heart rate is up just a little bit today.  She does complain of feeling dizziness, some vertigo, some lightheadedness, and has attributed this to the Coumadin therapy.  She is very adamant that she wants to stop the Coumadin.  She is tired of blood draws.  We have had a difficult time getting her regulated.  No chest pains.  No shortness of breath.  She is moving around a little bit better.  Her arm does not hurt her.  Her back pain is improving as well.,O:,  Vital signs as per chart.  Respirations 15.  Exam:  Nontoxic.  No acute distress.  Alert and oriented.  HEENT:  TMs are clear bilaterally without erythema or bulging.  Clear external canals.  Clear tympanic.  Conjunctivae are clear.  Clear nasal mucosa.  Clear oropharynx with moist mucous membranes.  NECK is soft and supple.  LUNGS are clear to auscultation.  HEART is irregularly irregular, mildly tachycardic.  ABDOMEN is soft and nontender.  EXTREMITIES:  No cyanosis, no clubbing, no edema.,EKG shows atrial fibrillation with a heart rate of 104.,A:,1.","soap / chart / progress notes, soap, alert and oriented, no acute distress, no cyanosis, atrial fibrillation, blood draw, dizziness, general medicine, irregularly irregular, lightheadedness, no clubbing, no edema, shortness of breath, soft and nontender, vertigo, heart, fibrillation, coumadin, atrial, "
" Multiple problems including left leg swelling, history of leukocytosis, joint pain left shoulder, low back pain, obesity, frequency with urination, and tobacco abuse.", SOAP / Chart / Progress Notes, Gen Med Progress Note - 9 ,"SUBJECTIVE:,  The patient is a 44-year-old white female who is here today with multiple problems.  The biggest concern she has today is her that left leg has been swollen.  It is swollen for three years to some extent, but worse for the past two to three months.  It gets better in the morning when she is up, but then through the day it begins to swell again.  Lately it is staying bigger and she somewhat uncomfortable with it being so large.  The right leg also swells, but not nearly like the left leg.  The other problem she had was she has had pain in her shoulder and back.  These occurred about a year ago, but the pain in her left shoulder is of most concern to her.  She feels like the low back pain is just a result of a poor mattress.  She does not remember hurting her shoulder, but she said gradually she has lost some mobility.  It is hard time to get her hands behind her back or behind her head.  She has lost strength in the left shoulder.  As far as the blood count goes, she had an elevated white count.  In April of 2005, Dr. XYZ had asked Dr. XYZ to see her because of the persistent leukocytosis; however, Dr. XYZ felt that this was not a problem for the patient and asked her to just return here for follow up.  She also complains of a lot of frequency with urination and nocturia times two to three.  She has gained weight; she thinks about 12 pounds since March.  She now weighs 284.  Fortunately, her blood pressure is staying stable.  She takes atenolol 12.5 mg per day and takes Lasix on a p.r.n. basis, but does not like to take it because it causes her to urinate so much.  She denies chest pain, but she does feel like she is becoming gradually more short of breath.  She works for the city of Wichita as bus dispatcher, so she does sit a lot, and just really does not move around much.  Towards the end of the day her leg was really swollen.  I reviewed her lab work.  Other than the blood count her lab work has been pretty normal, but she does need to have a cholesterol check.,OBJECTIVE:,General:  The patient is a very pleasant 44-year-old white female quite obese.,Vital Signs:  Blood pressure:  122/70.  Temperature:  98.6.,HEENT:  Head:  Normocephalic.  Ears:  TMs intact.  Eyes:  Pupils round, and equal.  Nose:  Mucosa normal.  Throat:  Mucosa normal.,Lungs:  Clear.,Heart:  Regular rate and rhythm.,Abdomen:  Soft and obese.,Extremities:  A lot of fluid in both legs, but especially the left leg is really swollen.  At least 2+ pedal edema.  The right leg just has a trace of edema.  She has pain in her low back with range of motion.  She has a lot of pain in her left shoulder with range of motion.  It is hard for her to get her hand behind her back.  She cannot get it up behind her head.  She has pain in the anterior left shoulder in that area.,ASSESSMENT:,1.  Multiple problems including left leg swelling.,2.  History of leukocytosis.,3.  Joint pain involving the left shoulder, probably impingement syndrome.,4.  Low back pain, chronic with obesity.,5.  Obesity.,6.  Frequency with urination.,7.  Tobacco abuse.,PLAN:,1.  I will schedule for a venous Doppler of the left leg and will have her come back in the morning for a CBC and a metabolic panel.  We will start her on Detrol 0.4 mg one daily and also started on Mobic 15 mg per day.,2.  Elevate her leg as much as possible and wear support hose if possible.  Keep her foot up during the day.  We will see her back in two weeks.  We will have the results of the Doppler, the lab work and see how she is doing with the Detrol and the joint pain.  If her shoulder pain is not any better, we probably should refer her on over to orthopedist.  We did do x-rays of her shoulder today that did not show anything remarkable.  See her in two weeks or p.r.n.","soap / chart / progress notes, leg swelling, leukocytosis, joint pain, left shoulder, low back pain, obesity, frequency with urination, tobacco abuse, multiple problems, blood count, blood pressure, leg, shoulder, tobacco, swelling, weight"
 Sample progress note - Gen Med., SOAP / Chart / Progress Notes, Gen Med Progress Note - 2 ,"CHIEF COMPLAINT:,  Followup on hypertension and hypercholesterolemia.,SUBJECTIVE:,  This is a 78-year-old male who recently had his right knee replaced and also back surgery about a year and a half ago.  He has done well with that.  He does most of the things that he wants to do.  He travels at every chance he has, and he just got back from a cruise.  He denies any type of chest pain, heaviness, tightness, pressure, shortness of breath with stairs only, cough or palpitations.  He sees Dr. Ferguson.  He is known to have Crohn's and he takes care of that for him.  He sees Dr. Roszhart for his prostate check.  He is a nonsmoker and denies swelling in his ankles.,MEDICATIONS:, Refer to chart.,ALLERGIES:, Refer to chart.,PHYSICAL EXAMINATION:, ,Vitals:  Wt; 172 lbs, up 2 lbs,  B/P; 150/60, T; 96.4, P; 72 and regular.  ,General:  A 78-year-old male who does not appear to be in any acute distress.  Glasses.  Good dentition.,CV: Distant S1, S2 without murmur or gallop. No carotid bruits. P: 2+ all around.,Lungs: Diminished with increased AP diameter. ,Abdomen:  Soft, bowel sounds active x 4 quadrants. No tenderness, no distention, no masses or organomegaly noted.,Extremities:  Well-healed surgical scar on the right knee.  No edema.  Hand grasps are strong and equal.,Back:  Surgical scar on the lower back.,Neuro: Intact.  A&O. Moves all four with no focal motor or sensory deficits.,IMPRESSION:,1.  Hypertension.,2.  Hypercholesterolemia.,3.  Osteoarthritis.,4.  Fatigue.,PLAN:,  We will check a BMP, lipid, liver profile, CPK, and CBC.  Refill his medications x 3 months.  I gave him a copy of Partners in Prevention.  Increase his Altace to 5 mg day for better blood pressure control.  Diet, exercise, and weight loss, and we will see him back in three months and p.r.n.","soap / chart / progress notes, progress note, fatigue, osteoarthritis, back surgery, chest pain, cough, general medicine, heaviness, hypercholesterolemia, hypertension, palpitations, pressure, shortness of breath, tightness, surgical scar, progress, "
" A 3-year-old male brought in by his mother with concerns about his eating - a very particular eater, not eating very much in general.", SOAP / Chart / Progress Notes, Gen Med Progress Note - 6 ,"SUBJECTIVE:,  This 3-year-old male is brought by his mother with concerns about his eating.  He has become a very particular eater, and not eating very much in general.  However, her primary concern was he was vomiting sometimes after particular foods.  They had noted that when he would eat raw carrots, within 5 to 10 minutes he would complain that his stomach hurt and then vomit.  After this occurred several times, they stopped giving him carrots.  Last week, he ate some celery and the same thing happened.  They had not given him any of that since.  He eats other foods without any apparent pain or vomiting.  Bowel movements are normal.  He does have a history of reactive airway disease, intermittently.  He is not diagnosed with intrinsic asthma at this time and takes no medication regularly.,CURRENT MEDICATIONS:,  He is on no medications.,ALLERGIES: , He has no known medicine allergies.,OBJECTIVE:,Vital Signs:  Weight:  31.5 pounds, which is an increase of 2.5 pounds since May.  Temperature is 97.1.  He certainly appears in no distress.  He is quite interested in looking at his books.,Neck:  Supple without adenopathy.,Lungs:  Clear.,Cardiac:  Regular rate and rhythm without murmurs.,Abdomen:  Soft without organomegaly, masses, or tenderness.,ASSESSMENT:,  Report of vomiting and abdominal pain after eating raw carrots and celery.  Etiology of this is unknown.,PLAN:,  I talked with mother about this.  Certainly, it does not suggest any kind of an allergic reaction, nor obstruction.  At this time, they will simply avoid those foods.  In the future, they may certainly try those again and see how he tolerates those.  I did encourage a wide variety of fruits and vegetables in his diet as a general principle.  If worsening symptoms, she is welcome to contact me again for reevaluation.","soap / chart / progress notes, eating, foods, vomiting, reactive airway disease, raw carrots, carrots,"
 Patient with a three-day history of emesis and a four-day history of diarrhea, SOAP / Chart / Progress Notes, Gen Med Progress Note - 7 ,"SUBJECTIVE:,  The patient is a 7-year-old male who comes in today with a three-day history of emesis and a four-day history of diarrhea.  Apparently, his brother had similar symptoms.  They had eaten some chicken and then ate some more of it the next day, and I could not quite understand what the problem was because there is a little bit of language barrier, although dad was trying very hard to explain to me what had happened.  But any way, after he and his brother got done eating with chicken, they both felt bad and have continued to feel bad.  The patient has had diarrhea five to six times a day for the last four days and then he had emesis pretty frequently three days ago and then has just had a couple of it each day in the last two days.  He has not had any emesis today.  He has urinated this morning.  His parents are both concerned because he had a fever of 103 last night.  Also, he ate half of a hamburger yesterday and he tried drinking some milk and that is when he had an emesis.  He has been drinking Pedialyte, Gatorade, white grape juice, and 7Up, otherwise he has not been eating anything.,MEDICATIONS:  ,None.,ALLERGIES:  ,He has no known drug allergies.,REVIEW OF SYSTEMS:,  Negative as far as sore throat, earache, or cough.,PHYSICAL EXAMINATION:,General:  He is awake and alert, no acute distress.,Vital Signs:  Blood pressure:  106/75.  Temperature:  99.  Pulse:  112.  Weight is 54 pounds.,HEENT:  His TMs are normal bilaterally.  Posterior pharynx is unremarkable.,Neck:  Without adenopathy or thyromegaly.,Lungs:  Clear to auscultation.,Heart:  Regular rate and rhythm without murmur.,Abdomen:  Benign.,Skin:  Turgor is intact.  His capillary refill is less than 3 seconds.,LABORATORY: , White blood cell count is 5.3 with 69 segs, 15 lymphs, and 13 monos.  His platelet count on his CBC is 215.,ASSESSMENT:,  Viral gastroenteritis.,PLAN:,  The parents did point out to me a rash that he had on his buttock.  There were some small almost pinpoint erythematous patches of papules that have a scab on them.  I did not see any evidence of petechiae.  Therefore, I just reassured them that this is a viral gastroenteritis.  I recommended that they stop giving him juice and just go with the Gatorade and water.  He is to stay away from milk products until his diarrhea and stomach upset have calmed down.  We talked about BRAT diet and slowly advancing his diet as he tolerates.  They have used some Kaopectate, which did not really help with the diarrhea.  Otherwise follow up as needed.","soap / chart / progress notes, diarrhea, emesis, history of, gastroenteritis, viral, brat diet, progress note, "
 A 62-year-old white female with multiple chronic problems including hypertension and a lipometabolism disorder., SOAP / Chart / Progress Notes, Gen Med Progress Note - 5 ,"SUBJECTIVE:,  The patient is a 62-year-old white female with multiple chronic problems including hypertension and a lipometabolism disorder.  She follows with Dr. XYZ on her hypertension, as well as myself.  She continues to gain weight.  Diabetes is therefore a major concern.  In fact, her dad had diabetes and she has a brother who has diabetes.  The patient also has several additional concerns she brings up today.  One is that her left knee continues to bother her and it hurts.  She cannot really isolate where the pain is, it just seems to hurt through her knee.  She has had this for some time now and in fact as we reviewed her records, her left knee has been x-rayed in 1999.  There was some minimal narrowing of the weightbearing joint with some minor hypertrophic spurring medially.  She would like to have this x-rayed again today.  She is certainly not interested in any surgery.  She has noted that it particularly hurts to kneel.  In addition, she complains of her stools being a baby-yellow.  She has rectal bleeding off and on.  It is bright red.  She had a colonoscopy done in 1999.  She does have a family history of colon cancer questionable in her mother, who is deceased.  She complains of some diffuse abdominal pain off and on.  She has given up fast foods and her pop and this has not seemed to help.  She does admit however, that she is not eating right.  Sometimes her stools are hard.  Sometimes they are runny.  The blood does not really seem to be related to necessarily a hard stool.  It is always bright red and will sometimes drip into the toilet.  Over the last couple of days, she had also been sneezing and has had an itchy throat.  She tried some Claritin and this did not help.  She has had some body aches.  She is finally feeling better today with this.  She also is questioning whether she has some sleep apnea.  She will awaken suddenly in the middle of the night.  She was told that she does snore.  She does not smoke.  As stated, she has gained significant weight.,GYNECOLOGICAL HISTORY: , She does not bleed.  She has both ovaries, as well as her uterus and cervix.  She is on no hormonal therapy.,PREVENTATIVE HISTORY:,  She is not exercising.  She does not do self breast examinations.  She has recently had her mammogram and it was unremarkable.  She does take her low-dose aspirin daily as well as her multivitamin.  She does wear her seatbelt.  As previously noted, she does not smoke or drink alcohol.,PAST MEDICAL, FAMILY AND SOCIAL HISTORY:,  Per health summary sheet, unchanged.,REVIEW OF SYSTEMS:,  Unremarkable with the exception of that above. ,ALLERGIES: , No known drug allergies.,CURRENT MEDICATIONS:,  Benicar 20 mg daily; multivitamin; glucosamine; vitamin B complex; vitamin E and a low-dose aspirin.,OBJECTIVE:,General:  Well-nourished, well-developed, a very pleasant 61-year-old in no acute distress.,Vitals:  Her weight today is 246 pounds.  In March of 2002 she weighed 231 pounds.  In March 2001 she weighed 203 pounds.  Her blood pressure is 160/78.  Pulse is 84.  Respiratory rate of 20.  She is afebrile.,HEENT:  Head is of normocephalic, atraumatic.  PERLA.  Conjunctivae clear.  TMs are unremarkable and canals are patent.  Nasal mucosa is slightly reddened.  Nares are patent.  Throat shows some clear posterior pharyngeal drainage.  Throat is slightly reddened.  Non-exudative.  No oral lesions or dental caries noted.,Neck:  Supple, No adenopathy.  Thyroid without any nodules or enlargements, no JVD or carotid bruits.,Heart:  Regular rate and rhythm without murmurs, clicks or rubs.  PMI is nondisplaced.,Lungs:  Clear to A&P.  No CVA tenderness.,Breast exam:  Negative for any axillary nodes, skin changes, discrete nodules or nipple discharge.  Breasts were examined both lying and sitting.,Abdomen:  Soft, nondistended, normoactive bowel sounds, no hepatosplenomegaly or masses.  Non tender.,Pelvic exam:  BUS unremarkable.  Speculum exam shows normal physiologic discharge.  There are some atrophic vaginal changes.  Cervix visualized, no gross abnormalities.  Pap smear obtained.  Bimanual is negative for any adnexal masses or tenderness.  Rectal exam is negative for any adnexal masses or tenderness.  No rectal masses.  She does have some external hemorrhoids, none of which are inflamed at this time.  No palpable rectal masses.,Neuromusculoskeletal exam:  Cranial nerves II-XII are grossly intact.  No cerebellar signs are noted.  No evidence of a gait disturbance.  DTRs are 1+/4+ and equal throughout.  Good uptoeing.  Skin:  Inspection of her skin, subcuticular tissues negative for any concerning skin lesions, rashes or subcuticular masses.,ASSESSMENT:,1.  Weight-gain.,2.  Hypertension.,3.  Lipometabolism disorder.,4.  Rectal bleeding.,5.  Left knee pain.,6.  Question of sleep apnea.,7.  Upper respiratory infection, improving.,8.  Gynecological examination is unremarkable for her age.,PLAN:,  We discussed at length, the issue of sleep apnea and its negative sequela.  I have recommended that she be referred for a sleep study.  She is certainly at risk for sleep apnea.  She refuses this.  I do not think that her upper respiratory tract infection needs any further treatment at this time since she is feeling better.  I did x-ray her knee and with the exception of some degenerative changes, it was unremarkable.  I reviewed this with her.  I do think that since she is having rectal bleeding, while this is not real unusual for her, with her family history of colon cancer, I am going to have her discuss this further with Dr. XYZ and leave further studies up to them.  I will dictate Dr. XYZ a note.  I am not going to order any further studies at this time in terms of her yellow stools and right upper quadrant discomfort.  She has had a gallbladder sonogram done in the past, this has been unremarkable and these symptoms really have not changed for her.  This however, has been some time ago.  I suspect she has an element of irritable bowel syndrome.  I have strongly encouraged weight reduction, both through diet and exercise.  I would like to see her back in the office in six months.  I did retake her blood pressure today and it was 130/70.  She is fasting this morning, so we will get a fasting blood sugar, chem-12, lipid profile, and CPK.  I will her mail the results.  I have strongly encouraged medication management if her lipids are elevated.  I think she is amenable to this.  Her DEXA scan is up to date having been done on 04/09/03.  I do not recommend one this year.",
 The patient is in complaining of headaches and dizzy spells., SOAP / Chart / Progress Notes, Gen Med Progress Note - 4 ,"SUBJECTIVE:,  The patient is in complaining of headaches and dizzy spells, as well as a new little rash on the medial right calf.  She describes her dizziness as both vertigo and lightheadedness.  She does not have a headache at present but has some intermittent headaches, neck pains, and generalized myalgias.  She has noticed a few more bruises on her legs.  No fever or chills with slight cough.  She has had more chest pains but not at present.  She does have a little bit of nausea but no vomiting or diarrhea.  She complains of some left shoulder tenderness and discomfort.  She reports her blood sugar today after lunch was 155.,CURRENT MEDICATIONS:,  She is currently on her nystatin ointment to her lips q.i.d. p.r.n.  She is still using a triamcinolone 0.1% cream t.i.d. to her left wrist rash and her Bactroban ointment t.i.d. p.r.n. to her bug bites on her legs.  Her other meds remain as per the dictation of 07/30/2004 with the exception of her Klonopin dose being 4 mg in a.m. and 6 mg at h.s. instead of what the psychiatrist had recommended which should be 6 mg and 8 mg.,ALLERGIES: , Sulfa, erythromycin, Macrodantin, and tramadol.,OBJECTIVE:,General:  She is a well-developed, well-nourished, obese female in no acute distress.,Vital Signs:  Her age is 55.  Temperature:  98.2.  Blood pressure:  110/70.  Pulse:  72.  Weight:  174 pounds.,HEENT:  Head was normocephalic.  Throat:  Clear.  TMs clear.,Neck:  Supple without adenopathy.,Lungs:  Clear.,Heart:  Regular rate and rhythm without murmur.,Abdomen:  Soft, nontender without hepatosplenomegaly or mass.,Extremities:  Trace of ankle edema but no calf tenderness x 2 in lower extremities is noted.  Her shoulders have full range of motion.  She has minimal tenderness to the left shoulder anteriorly.,Skin:  There is bit of an erythematous rash to the left wrist which seems to be clearing with triamcinolone and her rash around her lips seems to be clearing nicely with her nystatin.,ASSESSMENT:,1.  Headaches.,2.  Dizziness.,3.  Atypical chest pains.,4.  Chronic renal failure.,5.  Type II diabetes.,6.  Myalgias.,7.  Severe anxiety (affect is still quite anxious.),PLAN:,  I strongly encouraged her to increase her Klonopin to what the psychiatrist recommended, which should be 6 mg in the a.m. and 8 mg in the p.m.  I sent her to lab for CPK due to her myalgias and pro-time for monitoring her Coumadin.  Recheck in one week.  I think her dizziness is multifactorial and due to enlarged part of her anxiety.  I do note that she does have a few new bruises on her extremities, which is likely due to her Coumadin.","soap / chart / progress notes, headaches and dizzy spells, chest pains, shoulder, progress, headaches, "
 Sepsis due to urinary tract infection., SOAP / Chart / Progress Notes, Gen Med Progress Note - 13 ,"SUBJECTIVE: , The patient states she is feeling a bit better.,OBJECTIVE:,VITAL SIGNS:  Temperature is 95.4.  Highest temperature recorded over the past 24 hours is 102.1.,CHEST:  Examination of the chest is clear to auscultation.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmurs appreciated.,ABDOMEN:  Benign.  Right renal angle is tender.  Bowel sounds are positive.,EXTREMITIES:  There is no swelling.,NEUROLOGIC:  The patient is alert and oriented x3.  Examination is nonfocal.,LABORATORY DATA: , White count is down from 35,000 to 15.5.  Hemoglobin is 9.5, hematocrit is 30, and platelets are 269,000.  BUN is down to 22, creatinine is within normal limits.,ASSESSMENT AND PLAN:,1.  Sepsis due to urinary tract infection.  Urine culture shows Escherichia coli, resistant to Levaquin.  We changed to doripenem.,2.  Urinary tract infection, we will treat with doripenem, change Foley catheter,3.  Hypotension.  Resolved, continue intravenous fluids.,4.  Ischemic cardiomyopathy.  No evidence of decompensation, we with monitor.,5.  Diabetes type 2.  Uncontrolled.  Continue insulin sliding scale.,6.  Recent pulmonary embolism, INR is above therapeutic range, Coumadin is on hold, we will monitor.,7.  History of coronary artery disease.  Troponin indeterminate.  Cardiologist intends no further workup.  Continue medical treatment.  Most likely troponin is secondary to impaired clearance.","soap / chart / progress notes, sepsis, escherichia coli, urinary tract infection, doripenem, troponin, urinary, infection"
" Rhabdomyolysis, acute on chronic renal failure, anemia, leukocytosis, elevated liver enzyme, hypertension, elevated cardiac enzyme, obesity.", SOAP / Chart / Progress Notes, Gen Med Progress Note - 12 ,"SUBJECTIVE: , The patient was seen and examined.  He feels much better today, improved weakness and decreased muscular pain.  No other complaints.,PHYSICAL EXAMINATION:,GENERAL:  Not in acute distress, awake, alert and oriented x3.,VITAL SIGNS:  Blood pressure 147/68, heart rate 82, respiratory rate 20, temperature 97.7, O2 saturation 99% on 3 L.,HEENT:  NC/T, PERRLA, EOMI.,NECK:  Supple.,HEART: Regular rate and rhythm.,RESPIRATORY:  Clear bilateral.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema.  Pulses present bilateral.,LABORATORY DATA: , Total CK coming down 70,142 from 25,573, total CK is 200, troponin is 2.3 from 1.9 yesterday.,BNP, blood sugar 93, BUN of 55.7, creatinine 2.7, sodium 137, potassium 3.9, chloride 108, and CO2 of 22.,Liver function test, AST 704, ALT 298, alkaline phosphatase 67, total bilirubin 0.3.  CBC, WBC count 9.1, hemoglobin 9.9, hematocrit 29.2, and platelet count 204.  Blood cultures are still pending.,Ultrasound of abdomen, negative abdomen, both kidneys were echogenic, cortices suggesting chronic medical renal disease.  Doppler of lower extremities negative for DVT., ,ASSESSMENT AND PLAN:,1.  Rhabdomyolysis, most likely secondary to statins, gemfibrozil, discontinue it on admission.  Continue IV fluids.  We will monitor.,2.  Acute on chronic renal failure.  We will follow up with Nephrology recommendation.,3.  Anemia, drop in hemoglobin most likely hemodilutional.  Repeat CBC in a.m.,4.  Leukocytosis, improving.,5.  Elevated liver enzyme, most likely secondary to rhabdomyolysis.  The patient denies any abdominal pain and ultrasound is unremarkable.,6.  Hypertension.  Blood pressure controlled.,7.  Elevated cardiac enzyme, follow up with Cardiology recommendation.,8.  Obesity.,9.  Deep venous thrombosis prophylaxis.  Continue Lovenox 40 mg subcu daily.","soap / chart / progress notes, rhabdomyolysis, acute on chronic renal failure, anemia, leukocytosis, elevated liver enzyme, hypertension, elevated cardiac enzyme, obesity, cardiac enzyme, blood pressure, "
 Sample progress note - Gen Med., SOAP / Chart / Progress Notes, Gen Med Progress Note - 3 ,"CHIEF COMPLAINT:, Followup on diabetes mellitus, hypercholesterolemia, and sinusitis. ,SUBJECTIVE:,  A 70-year-old female who was diagnosed with diabetes mellitus last fall.  She has been checking her Accu-Cheks generally once a day, and they range from 82 to a high of 132.  She feels well.  She walks 1-2 miles most days.  If the weather is bad, they go to a local mall.  Otherwise they walk outside.  She does complain of some sinus congestion and drainage for the last several days.  She is up-to-date on her mammogram that she had at the Baylis Building.  She sees Dr. Cheng for her gynecological care.  She is a nonsmoker.  Denies abdominal pain, nausea, vomiting, diarrhea, constipation, blood in her urine, blood in her stools.  She has nocturia x 1.  Denies swelling in her ankles.  She checks her feet regularly., ,PAST MEDICAL HISTORY:,  Refer to chart.,MEDICATIONS:, Refer to chart.,ALLERGIES:, Refer to chart.,PHYSICAL EXAMINATION: ,Vitals: Wt:  185 B/P: 142/70.  When she checks it at the mall and other places, it is usually about 120/56. T: 96.5 P:  84 and regular.,General: A 70-year-old female who does not appear to be in acute distress.  ,HEENT: She has frontal and maxillary sinus tenderness on the right to palpation.  The right TM is slightly dull.",
" Patient comes in for two-month followup - Hypertension, family history of CVA, Compression fracture of L1, and osteoarthritis of knee.", SOAP / Chart / Progress Notes, Gen Med Progress Note - 10 ,"CHIEF COMPLAINT:,  The patient is here for two-month followup.,HISTORY OF PRESENT ILLNESS:,  The patient is a 55-year-old Caucasian female.  She has hypertension.  She has had no difficulties with chest pain.  She has some shortness of breath only at walking up the stairs.  She has occasional lightheadedness only if she bends over then stands up quickly.  She has had no nausea, vomiting, or diarrhea.  She does have severe osteoarthritis of the left knee and is likely going to undergo total knee replacement with Dr. XYZ in January of this coming year.  The patient is wanting to lose weight before her surgery.  She is concerned about possible coronary disease or stroke risk.  She has not had any symptoms of cardiac disease other than some shortness of breath with exertion, which she states has been fairly stable.  She has had fairly normal lipid panel, last being checked on 11/26/2003.  Cholesterol was 194, triglycerides 118, HDL 41, and LDL 129.  The patient is a nonsmoker.  Her fasting glucose in November 2003 was within normal limits at 94.  Her fasting insulin level was normal.  Repeat nonfasting glucose was 109 on 06/22/2004.  She does not have history of diabetes.  She does not exercise regularly and is not able to because of knee pain.  She also has had difficulties with low back pain.  X-ray of the low back did show a mild compression fracture of L1.  She has had no falls that would contribute to a compression fracture.  She has had a normal DEXA scan on 11/07/2003 that does not really correlate with having a compression fracture of the lumbar spine; however, it is possible that arthritis could contribute to falsely high bone density reading on DEXA scan.  She is wanting to consider treatment for prevention of further compression fractures and possible osteoporosis.,CURRENT MEDICATIONS:,  Hydrochlorothiazide 12.5 mg a day, Prozac 20 mg a day, Vioxx 25 mg a day, vitamin C 250 mg daily, vitamin E three to four tablets daily, calcium with D 1500 mg daily, multivitamin daily, aspirin 81 mg daily, Monopril 40 mg daily, Celexa p.r.n.,ALLERGIES:  ,Bactrim, which causes nausea and vomiting, and adhesive tape.,PAST MEDICAL HISTORY:,1.  Hypertension.,2.  Depression.,3.  Myofascitis of the feet.,4.  Severe osteoarthritis of the knee.,5.  Removal of the melanoma from the right thigh in 1984.,6.  Breast biopsy in January of 1997, which was benign.,7.  History of Holter monitor showing ectopic beat.  Echocardiogram was normal.  These were in 1998.,8.  Compression fracture of L1, unknown cause.  She had had no injury.  Interestingly, DEXA scan was normal 11/07/2003, which is somewhat conflicting.,SOCIAL HISTORY:,  The patient is married.  She is a nonsmoker and nondrinker.,REVIEW OF SYSTEMS:,  As per the HPI.,PHYSICAL EXAMINATION:,General:  This is a well-developed, well-nourished, pleasant Caucasian female, who is overweight.,Vital signs:  Weight:  Refused.  Blood pressure:  148/82, on recheck by myself with a large cuff, it was 125/60.  Pulse:  64.  Respirations:  20.  Temperature:  96.3.,Neck:  Supple.  Carotids are silent.,Chest:  Clear to auscultation.,Cardiovascular:  Revealed a regular rate and rhythm without murmur, S3, or S4.,Extremities:  Revealed no edema.,Neurologic:  Grossly intact.,RADIOLOGY:  EKG revealed normal sinus rhythm, rate 61, borderline first degree AV block, and poor R-wave progression in the anterior leads.,ASSESSMENT:,1.  Hypertension, well controlled.,2.  Family history of cerebrovascular accident.,3.  Compression fracture of L1, mild.,4.  Osteoarthritis of the knee.,5.  Mildly abnormal chest x-ray.,PLAN:,1.  We will get a C-reactive protein cardiac.,2.  We discussed weight loss options.  I would recommend Weight Watchers or possibly having her see a dietician.  She will think about these options.  She is not able to exercise regularly right now because of knee pain.,3.  We would recommend a screening colonoscopy.  She states that we discussed this in the past and she canceled her appointment to have that done.  She will go ahead and make an appointment to see Dr. XYZ for screening colonoscopy.,4.  We will start Fosamax 70 mg once weekly.  She is to take this in the morning on an empty stomach with full glass of water.  She is not to eat, lie down, or take other medications for at least 30 minutes after taking Fosamax.,5.  I would like to see her back in one to two months.  At that time, we can do preoperative evaluation and we will probably send her to a cardiologist because of mildly abnormal EKG for preoperative cardiac testing.  One would also consider preoperative beta-blocker for cardiac protection.",
 Sample progress note - Gen Med., SOAP / Chart / Progress Notes, Gen Med Progress Note - 1 ,"CHIEF COMPLAINT:,  Followup on diabetes mellitus, status post cerebrovascular accident.,SUBJECTIVE:,  This is a 70-year-old male who has no particular complaints other than he has just discomfort on his right side.  We have done EMG studies.  He has noticed it since his stroke about five years ago.  He has been to see a neurologist.  We have tried different medications and it just does not seem to help.  He checks his blood sugars at home two to three times a day.  He kind of adjusts his own insulin himself.  Re-evaluation of symptoms is essentially negative.  He has a past history of heavy tobacco and alcohol usage.,MEDICATIONS:, Refer to chart.,ALLERGIES:, Refer to chart.,PHYSICAL EXAMINATION: ,Vitals: Wt; 118 lbs, B/P; 108/72, T; 96.5, P; 80 and regular.  ,General:  A 70-year-old male who does not appear to be in acute distress but does look older than his stated age.  He has some missing dentition.,Skin:  Dry and flaky. ,CV:  Heart tones are okay, adequate carotid pulsations.  He has 2+ pedal pulse on the left and 1+ on the right.,Lungs: Diminished but clear.,Abdomen:  Scaphoid.,Rectal:  His prostate check was normal per Dr. Gill.,Neuro:  Sensation with monofilament testing is better on the left than it is on the right.,IMPRESSION:,1.  Diabetes mellitus.,2.  Neuropathy.,3.  Status post cerebrovascular accident.,PLAN:,  Refill his medications x 3 months.  We will check an A1c and BMP.  I have talked to him several times about a colonoscopy, which he has refused, and so we have been doing stools for occult blood.  We will check a PSA.  Continue with yearly eye exams, foot exams, Accu-Cheks, and we will see him in three months and p.r.n.","soap / chart / progress notes, diabetes mellitus, neuropathy, genernal medicine, post cerebrovascular accident, progerss note, post cerebrovascular, cerebrovascular accident, accident, cerebrovascular, neurologist, insulin, "
 Patient having foot pain., SOAP / Chart / Progress Notes, Foot Pain - SOAP ,"SUBJECTIVE:,  This 32-year-old female comes in again still having not got a primary care physician.  She said she was at Dr. XYZ office today for her appointment, and they cancelled her appointment because she has not gotten her Project Access insurance into affect.  She says that Project Access is trying to find her a doctor.  She is not currently on Project Access, and so she is here to get something for the pain in her foot.  I did notice that she went in to see Dr. XYZ for a primary care physician on 05/14/2004.  She said she does not have a primary care physician.  She was in here just last week and saw Dr. XYZ for back pain and was put on pain medicines and muscle relaxers.  She has been in here multiple times for different kinds of pain.  This pain she is having is in her foot.  She had surgery on it, and she has plates and screws.  She said she was suppose to see Dr. XYZ about getting some of the hardware out of it.  The appointment was cancelled, and that is why she came here.  It started hurting a lot yesterday, but she had this previous appointment with Dr. XYZ so she thought she would take care of it there, but they would not see her.  She did not injure her foot in any way recently.  It is chronically painful.  Every time she does very much exercise it hurts more.  We have x-rayed it in the past.  She has some hardware there.  It does not appear to be grossly abnormal or causing any loosening or problems on x-ray.,PHYSICAL EXAM: , Examination of her foot shows some well-healed surgical scars.  On the top of her foot she has two, and then on the lateral aspect below her ankle she has a long scar.  They are all old, and the surgery was done over a year ago.  She is walking with a very slight limp.  There is no redness.  No heat.  No swelling of the foot or the ankle.  It is mildly tender around the medial side of the foot just inferior to the medial malleolus.  It is not warm or red.,ASSESSMENT:,  Foot pain.,PLAN:,  She has been in here before.  She seems very pleasant.  Thought maybe she certainly might be having some significant pain, so I gave her some Lortab 7.5 to take with a refill.  After she left, I got to thinking about it and looked into her record.  She has been in here multiple times for pain medicine.  She has a primary care physician, and now she is telling us she does not have a primary care physician even though she had seen Dr. XYZ not too long ago.  We called Dr. XYZ office.  Dr. XYZ nurse said that the patient did not have an appointment today.  She has an appointment on June 15, 2004, for a postop check.  They did not tell her they would not see her today because of insurance, so the patient was lying to me.  We will keep that in mind the next time she returns, because she will likely be back.  She did say that Project Access will be approving her insurance next week, so she will be able to see Dr. XYZ soon.","soap / chart / progress notes, soap, foot pain, primary care physician, project access, insurance, foot, project, access, care, appointment"
 The patient states that he feels sick and weak., SOAP / Chart / Progress Notes, Gen Med Progress Note ,"SUBJECTIVE:,  The patient states that he feels sick and weak.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Highest temperature recorded over the past 24 hours was 101.1, and current temperature is 99.2.,GENERAL:  The patient looks tired.,HEENT:  Oral mucosa is dry.,CHEST:  Clear to auscultation.  He states that he has a mild cough, not productive.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmur was appreciated.,ABDOMEN:  Soft and nontender.  Bowel sounds are positive. Murphy's sign is negative.,EXTREMITIES:  There is no swelling.,NEURO:  The patient is alert and oriented x 3.  Examination is nonfocal.,LABORATORY DATA: , White count is normal at 6.8, hemoglobin is 15.8, and platelets 257,000.  Glucose is in the low 100s.  Comprehensive metabolic panel is unremarkable.  UA is negative for infection.,ASSESSMENT AND PLAN:,1.  Fever of undetermined origin, probably viral since white count is normal.  Would continue current antibiotics empirically.,2.  Dehydration.  Hydrate the patient.,3.  Prostatic hypertrophy.  Urologist, Dr. X.,4.  DVT prophylaxis with subcutaneous heparin.","soap / chart / progress notes, fever, dehydration, prophylaxis, white count is normal, white count, sick, weak, temperature,"
 Followup of laparoscopic fundoplication and gastrostomy.  Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access., SOAP / Chart / Progress Notes, Fundoplication & Gastrostomy Followup ,"REASON FOR VISIT: , Followup of laparoscopic fundoplication and gastrostomy.,HISTORY OF PRESENT ILLNESS: , The patient is a delightful baby girl, who is now nearly 8 months of age and had a tracheostomy for subglottic stenosis.  Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access and to protect her airway at a time when it is either going to heal enough to improve and allow decannulation or eventually prove that she will need laryngotracheoplasty.  Dr. X is following The patient for this and currently plans are to perform a repeat endoscopic exam every couple of months to assist the status of her airway caliber.,The patient had a laparoscopic fundoplication and gastrostomy on 10/05/2007.  She has done well since that time.  She has had some episodes of retching intermittently and these seemed to be unpredictable.  She also had some diarrhea and poor feeding tolerance about a week ago but that has also resolved.  The patient currently takes about 1 ounce to 1.5 ounce of her feedings by mouth and the rest is given by G-tube.  She seems otherwise happy and is not having an excessive amount of stools.  Her parents have not noted any significant problems with the gastrostomy site.,The patient's exam today is excellent.  Her belly is soft and nontender.  All of her laparoscopic trocar sites are healing with a normal amount of induration, but there is no evidence of hernia or infection.  We removed The patient's gastrostomy button today and showed her parents how to reinsert one without difficulty.  The site of the gastrostomy is excellent.  There is not even a hint of granulation tissue or erythema, and I am very happy with the overall appearance.,IMPRESSION: , The patient is doing exceptionally well status post laparoscope fundoplication and gastrostomy.  Hopefully, the exquisite control of acid reflux by fundoplication will help her airway heal, and if she does well, allow decannulation in the future.  If she does require laryngotracheoplasty, the protection from acid reflux will be important to healing of that procedure as well.,PLAN:  ,The patient will follow up as needed for problems related to gastrostomy.  We will see her when she comes in the hospital for endoscopic exams and possibly laryngotracheoplasty in the future.","soap / chart / progress notes, decannulation, enteral feeding, feeding access, laparoscopic fundoplication, gastrostomy, airway, laryngotracheoplasty, laparoscopic, fundoplication, "
" Follow up consultation, second opinion, foreskin.", SOAP / Chart / Progress Notes, Foreskin - Followup ,"REASON FOR VISIT: , Follow up consultation, second opinion, foreskin.,HISTORY OF PRESENT ILLNESS: , A 2-week-old who at this point has otherwise been doing well.  He has a relatively unremarkable foreskin.  At this point in time, he otherwise seems to be doing reasonably well.  The question is about the foreskin.  He otherwise has no other significant issues.  Severity low, ongoing since birth two weeks.  Thank you for allowing me to see this patient in consultation.,PHYSICAL EXAMINATION:,  Male exam.  Normal and under the penis, report normal uncircumcised 2-week-old.  He has a slightly insertion on the penile shaft from the median raphe of the scrotum.,IMPRESSION: , Slightly high insertion of the median raphe.  I see no reason he cannot be circumcised as long as they are careful and do a very complete Gomco circumcision.  This kid should otherwise do reasonably well.,PLAN:  ,Follow up as needed.  But my other recommendation is that this kid as I went over with the mother may actually do somewhat better if he simply has a formal circumcision at one year of age, but may do well with a person who is very accomplished doing a Gomco circumcision.","soap / chart / progress notes, formal circumcision, median raphe, penis, gomco circumcision, gomco, circumcision, foreskin, "
" 5-month recheck on type II diabetes mellitus, as well as hypertension.", SOAP / Chart / Progress Notes, Gen Med Progress Note - 11 ,"SUBJECTIVE:,  The patient is a 66-year-old female who presents to the clinic today for a five-month recheck on her type II diabetes mellitus, as well as hypertension.  While here she had a couple of other issues as well.  She stated that she has been having some right shoulder pain.  She denies any injury but certain range of motion does cause it to hurt.  No weakness, numbness or tingling.  As far as her diabetes she states that she only checks her blood sugars in the morning and those have all been ranging less than 100.  She has not been checking any two hours after meals.  Her blood pressures when she does check them have been running normal as well but she does not have any record of these present with her.  No other issues or concerns.  Upon review of her chart it did show that she had a benign breast biopsy done back on 06/11/04 and was told to have a repeat mammogram in six months but she has never had that done so she is needing to have this done as well.,ALLERGIES: , None.,MEDICATIONS:,  She is on Hyzaar 50/12.5 one-half p.o. daily, coated aspirin daily, lovastatin 40 mg one-half tab p.o. daily, multivitamin daily, metformin 500 mg one tab p.o. b.i.d.; however, she has been skipping her second dose during the day.,SOCIAL HISTORY:,  She is a nonsmoker.,REVIEW OF SYSTEMS:,  As noted above.,OBJECTIVE:,Vital Signs:  Temperature:  98.2.  Pulse:  64.  Respirations:  16.  Blood pressure:  110/56.  Weight:  169.,General:  Alert and oriented x 3.  No acute distress noted.,Neck:  No lymphadenopathy, thyromegaly, JVD or bruits.,Lungs:  Clear to auscultation.,Heart:  Regular rate and rhythm without murmur or gallops present.,Breasts:  Exam performed with a female nurse present.  The breasts do have some scars present underneath them bilaterally from prior breast reduction surgery.  There is no axillary adenopathy or tenderness.  Breasts appear to be symmetric.  There was no nipple discharge or retraction.  No breast tissue retraction noted in either the sitting or the supine position.  Upon palpation there were no palpable lumps or bumps and no palpable discharge.,Musculoskeletal:  She did have full range of motion of her shoulders.  She did have tenderness upon palpation over the right bicipital tendon.  There is no swelling, crepitus or discoloration noted.,MEDICAL DECISION MAKING:  Most recent hemoglobin A1c was 5.6% back in October 2004.  Most recent lipid checks were obtained back in July 2004.  We have not had this checked since that time.,ASSESSMENT:,1.  Type II diabetes mellitus.,2.  Hypertension.,3.  Right shoulder pain.,4.  Hyperlipidemia.,PLAN:,1.  She is going to go to lab to obtain a hemoglobin A1c, BMP, lipids, CPK, liver enzymes and quantitative microalbumin.,2.  We are going to set her up for a diagnostic bilateral mammogram due to a history of abnormal mammogram in the past which subsequently showed a benign breast cyst.,3.  I told her for her shoulder to take ibuprofen 600 mg three times daily with her meals for a minimum of the next one week.,4.  She is going to follow up in the clinic in three months for a complete comprehensive examination.  If any questions, concerns or problems arise between now and then she should let us know.", 
" Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.", SOAP / Chart / Progress Notes, Evaluation of Allergies ,"HISTORY:,  A 55-year-old female presents self-referred for the possibility of evaluation and treatment of allergies, diminished taste, xerostomia, gastroesophageal reflux disease, possible food allergies, chronic GI irritability, asthma, and environmental inhalant allergies.  Please refer to chart for history and physical and review of systems and detailed medical history.,IMPRESSION:  ,1.  Chronic glossitis/xerostomia/probable environmental inhalant allergies/probable food allergies/history of asthma.,2.  History of fibromyalgia.,3.  History of peptic ulcer disease, history of gastritis, history of gastroesophageal disease.,4.  History of chronic fatigue.,5.  History of hypothyroidism.,6.  History of depression.,7.  History of dysphagia.,RECOMMENDATIONS: , RAST allergy testing was ordered for food allergy evaluation.  The patient had previous allergy testing done less than one year ago iby Dr. X, which was requested.  The patient will follow up after RAST allergy testing for further treatment recommendations.  At this point, no changes in her medication were prescribed until her followup visit.","soap / chart / progress notes, chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, environmental inhalant allergies, rast allergy testing, rast, inhalant, food, allergy"
 Fifth disease with sinusitis, SOAP / Chart / Progress Notes, Fifth Disease - SOAP ,"SUBJECTIVE:,  Grandfather brings the patient in today because of headaches, mostly in her face.  She is feeling pressure there with a lot of sniffles.  Last night, she complained of sore throat and a loose cough.  Over the last three days, she has had a rash on her face, back and arms.  A lot of fifth disease at school.  She says it itches and they have been doing some Benadryl for this.  She has not had any wheezing lately and is not taking any ongoing medications for her asthma.,PAST MEDICAL HISTORY:,  Asthma and allergies.,FAMILY HISTORY:  ,Sister is dizzy but no other acute illnesses.,OBJECTIVE:,General:  The patient is an 11-year-old female.  Alert and cooperative.  No acute distress.,Neck:  Supple without adenopathy.,HEENT:  Ear canals clear.  TMs, bilaterally, gray in color and good light reflex.  Oropharynx is pink and moist.  No erythema or exudates.  She has postnasal discharge.  Nares are swollen and red.  Purulent discharge in the posterior turbinates.  Both maxillary sinuses are tender.  She has some mild tenderness in the left frontal sinus.  Eyes are puffy and she has dark circles.,Chest:  Respirations are regular and nonlabored.,Lungs:  Clear to auscultation throughout.,Heart:  Regular rhythm without murmur.,Skin:  Warm, dry and pink.  Moist mucous membranes.  Red, lacey rash from the wrists to the elbows, both sides.  It is very faint on the lower back and she has reddened cheeks, as well.,ASSESSMENT:,  Fifth disease with sinusitis.,PLAN:,  Omnicef 300 mg daily for 10 days.  May use some Zyrtec for the itching.  Samples are given.","soap / chart / progress notes, fifth disease, soap, asthma, headaches, sinusitis, sore throat, oropharynx,"
 Preop evaluation regarding gastric bypass surgery., SOAP / Chart / Progress Notes, Gastric Bypass - Preop Eval ,"REASON FOR VISIT:,  Preop evaluation regarding gastric bypass surgery.,The patient has gone through the evaluation process and has been cleared from psychological, nutritional, and cardiac standpoint, also had great success on the preop Medifast diet.,PHYSICAL EXAMINATION: , The patient is alert and oriented x3.  Temperature of 97.9, pulse of 76, blood pressure of 114/74, weight of 247.4 pounds.  Abdomen:  Soft, nontender, and nondistended.,ASSESSMENT AND PLAN:,  The patient is currently in stable condition with morbid obesity, scheduled for gastric bypass surgery in less than two weeks.  Risks and benefits of the procedure were reiterated with the patient and significant other and mother, which included but not limited to death, pulmonary embolism, anastomotic leak, reoperation, prolonged hospitalization, stricture, small bowel obstruction, bleeding, and infection.  Questions regarding hospital course and recovery were addressed.  We will continue on the Medifast diet until the time of surgery and cleared for surgery.","soap / chart / progress notes, medifast, medifast diet, preop evaluation, gastric bypass surgery, bypass surgery, gastric bypass,"
 Patient with complaint of a very painful left foot because of the lesions on the bottom of the foot. , SOAP / Chart / Progress Notes, Foot Lesions ,"S -, An 84-year-old diabetic female, 5'7-1/2"" tall, 148 pounds, history of hypertension and diabetes.  She presents today with complaint of a very painful left foot because of the lesions on the bottom of the foot.  She also has a left great toenail that is giving her problems as well.,O - ,Plantar to the left first metatarsal head is a very panful hyperkeratotic lesion that measures 1.1 cm in diameter.  There is a second lesion plantar to the fifth plantarflex metatarsal head which also measures 1.1 cm in diameter.  These lesions have become so painful that the patient is now having difficulty walking wearing shoes or even doing gardening.  The first and fifth metatarsal heads are plantarflexed.  Vibratory sensation appears to be absent.  Dorsal pedal pulses are nonpalpable.  Varicose veins are visible to the skin on the patient's feet that are very thin, almost transparent.  The medial aspect of the left great toenail has dried blood under the nail.  The nail itself is very opaque, loose from the nailbed almost rotten, opaque, discolored, hypertrophic.  All of the patient's toenails are elongated and discolored and opaque as well.  There is dried blood under the medial aspect of the left great toenail.,A - ,1.  Painful feet.,","soap / chart / progress notes, painful left foot, lesions, plantar, metatarsal head, hyperkeratotic lesion, toenail, nail matrix, metatarsal, metatarsal heads, foot, painful"
 Evaluation and recommendations regarding facial rhytids., SOAP / Chart / Progress Notes, Facial Rhytids ,"HISTORY: , This 57-year-old female who presented today for evaluation and recommendations regarding facial rhytids.  In summary, the patient is a healthy 57-year-old female, nonsmoker with no history of skin disease, who has predominant fullness in the submandibular region and mid face region and prominent nasolabial folds.,RECOMMENDATIONS: , I do believe a facelift procedure would be of maximum effect for the patient's areas of concern and a ""quick lift"" type procedure certainly would address these issues.  I went over risks and benefits with the patient along with the preoperative and postoperative care, and risks include but are not limited to bleeding, infection, discharge, scar formation, need for further surgery, facial nerve injury, numbness, asymmetry of face, problems with hypertrophic scarring, problems with dissatisfaction with anticipated results, and she states she will contact us later in the summer to possibly make arrangements for a quick lift through Memorial Medical Center.","soap / chart / progress notes, quick lift, hypertrophic scarring, facial rhytids, mid face region, nasolabial folds, liftNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Followup 4 months status post percutaneous screw fixation of a right Schatzker IV tibial plateau fracture and second through fifth metatarsal head fractures treated nonoperatively., SOAP / Chart / Progress Notes, Followup Screw Fixation ,"REASON FOR VISIT:  ,Followup 4 months status post percutaneous screw fixation of a right Schatzker IV tibial plateau fracture and second through fifth metatarsal head fractures treated nonoperatively.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 59-year-old gentleman who is now approximately 4 months status post percutaneous screw fixation of Schatzker IV tibial plateau fracture and nonoperative management of second through fifth metatarsal head fractures.  He is currently at home and has left nursing home facility.  He states that his pain is well controlled.  He has been working with physical therapy two to three times a week.  He has had no drainage or fever.  He has noticed some increasing paresthesias in his bilateral feet but has a history of spinal stenosis with lower extremity neuropathy.,FINDINGS: , On physical exam, his incision is near well healed.  He has no effusion noted.  His range of motion is 10 to 105 degrees.  He has no pain or crepitance.  On examination of his right foot, he is nontender to palpation of the metatarsal heads.  He has 4 out of 5 strength in EHL, FHL, tibialis, and gastroc-soleus complex.  He does have decreased sensation to light touch in the L4-L5 distribution of his feet bilaterally.,X-rays taken including AP and lateral of the right knee demonstrate a healed medial tibial plateau fracture status post percutaneous screw fixation.  Examination of three views of the right foot demonstrates the second through fifth metatarsal head fractures.  These appear to be extraarticular.  They are all in a bayonet arrangement, but there appears to be bridging callus between the fragments on the oblique film.,ASSESSMENT:  ,Four months status post percutaneous screw fixation of the right medial tibial plateau and second through fifth metatarsal head fractures.,PLANS: , I would like the patient to continue working with physical therapy.  He may be weightbearing as tolerated on his right side.  I would like him to try to continue to work to gain full extension of the right knee and increase his knee flexion.  I also would like him to work on ambulation and strengthening.,I discussed with the patient his concerning symptoms of paresthesias.  He said he has had the left thigh for a number of years and has been followed by a neurologist for this.  He states that he has had some right-sided paresthesias now for a number of weeks.  He claims he has no other symptoms of any worsening stenosis.  I told him that I would see his neurologist for evaluation or possibly a spinal surgeon if his symptoms progress.,The patient should follow up in 2 months at which time he should have AP and lateral of the right knee and three views of the right foot.","soap / chart / progress notes, metatarsal head fractures, tibial plateau fracture, schatzker, percutaneous screw fixation, tibial plateau, metatarsal head, screw fixation, head, screw, fixation, metatarsal "
" Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.", SOAP / Chart / Progress Notes, Dietary Consult - Weight Reduction ,"SUBJECTIVE:,  This is a 56-year-old female who comes in for a dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.  The patient states that her husband has been diagnosed with high blood cholesterol as well.  She wants some support with some dietary recommendations to assist both of them in healthier eating.  The two of them live alone now, and she is used to cooking for large portions.  She is having a hard time adjusting to preparing food for the two of them.  She would like to do less food preparation, in fact.  She is starting a new job this week.,OBJECTIVE:,  Her reported height is 5 feet 4 inches.  Today’s weight was 170 pounds.  BMI is approximately 29.  A diet history was obtained.  I instructed the patient on a 1200 calorie meal plan emphasizing low-saturated fat sources with moderate amounts of sodium as well.  Information on fast food eating was supplied, and additional information on low-fat eating was also supplied.,ASSESSMENT:,  The patient’s basal energy expenditure is estimated at 1361 calories a day.  Her total calorie requirement for weight maintenance is estimated at 1759 calories a day.  Her diet history reflects that she is making some very healthy food choices on a regular basis.  She does emphasize a lot of fruits and vegetables, trying to get a fruit or a vegetable or both at most meals.  She also is emphasizing lower fat selections.  Her physical activity level is moderate at this time.  She is currently walking for 20 minutes four or five days out of the week but at a very moderate pace with a friend.  We reviewed the efforts at weight reduction identifying 3500 calories in a pound of body fat and the need to gradually and slowly chip away at this number on a long-term basis for weight reduction.  We discussed the need to reduce calories from what her current patterns are and to hopefully increase physical activity slightly as well.  We discussed menu selection, as well as food preparation techniques.  The patient appears to have been influenced by the current low-carb, high-protein craze and had really limited her food selections based on that.  I was able to give her some more room for variety including some moderate portions of potatoes, pasta and even on occasion breading her meat as long as she prepares it in a low-fat fashion which was discussed.,PLAN:,  Recommend the patient increase the intensity and the duration of her physical activity with a goal of 30 minutes five days a week working at a brisk walk.  Recommend the patient reduce calories by 500 daily to support a weight loss of one pound a week.  This translates into a 1200-calorie meal plan.  I encouraged the patient to keep food records in order to better track calories consumed.  I recommended low fat selections and especially those that are lower in saturated fats.  Emphasis would be placed on moderating portions of meat and having more moderate snacks between meals as well.  This was a one-hour consultation.  I provided my name and number should additional needs arise.","soap / chart / progress notes, hyperlipidemia, hypertension, gastroesophageal reflux disease, weight reduction, dietary recommendations, healthier eating, meal plan, dietary consultation, low fat, physical activity, weight, gastroesophageal, dietary, calories, food"
 Recurrent urinary tract infection in a patient recently noted for another Escherichia coli urinary tract infection., SOAP / Chart / Progress Notes, E. Coli UTI - Followup ,"HISTORY OF PRESENT ILLNESS:,  The patient presents today for followup, recently noted for E. coli urinary tract infection.  She was treated with Macrobid for 7 days, and only took one nighttime prophylaxis.  She discontinued this medication to due to skin rash as well as hives.  Since then, this had resolved.  Does not have any dysuria, gross hematuria, fever, chills.  Daytime frequency every two to three hours, nocturia times one, no incontinence, improving stress urinary incontinence after Prometheus pelvic rehabilitation.,Renal ultrasound, August 5, 2008, reviewed, no evidence of hydronephrosis, bladder mass or stone.  Discussed.,Previous urine cultures have shown E. coli, November 2007, May 7, 2008 and July 7, 2008.,CATHETERIZED URINE: , Discussed, agreeable done using standard procedure.  A total of 30 mL obtained.,IMPRESSION: , Recurrent urinary tract infection in a patient recently noted for another Escherichia coli urinary tract infection, completed the therapeutic dose, but stopped the prophylactic Macrodantin due to hives.  This has resolved.,PLAN: , We will send the urine for culture and sensitivity, if no infection, patient will call results on Monday, and she will be placed on Keflex nighttime prophylaxis, otherwise followup as previously scheduled for a diagnostic cystoscopy with Dr. X.  All questions answered.","soap / chart / progress notes, urinary tract infection, escherichia coli, prophylactic macrodantin, e. coli, infection, "
" Stage IIIC endometrial cancer.  Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane.  The patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009. ", SOAP / Chart / Progress Notes, Endometrial Cancer Followup ,"CHIEF COMPLAINT:,1.  Stage IIIC endometrial cancer.,2.  Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane.,HISTORY OF PRESENT ILLNESS: , The patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009.  In March 2010, she had an abnormal endometrial ultrasound with thickening of the endometrium and an enlarged uterus.  CT scan of the abdomen on 03/22/2010 showed an enlarged uterus, thickening of the endometrium, and a mass structure in the right and left adnexa that was suspicious for ovarian metastasis.  On 04/01/2010, she had a robotic modified radical hysterectomy with bilateral salpingo-oophorotomy and appendectomy with pelvic and periaortic lymphadenectomy.  The pathology was positive for grade III endometrial adenocarcinoma, 9.5 cm in size with 2 cm of invasion.  Four of 30 lymph nodes were positive for disease.  The left ovary was positive for metastatic disease.  Postsurgical PET/CT scan showed left lower pelvic side wall seroma and hypermetabolic abdominal and right pelvic retroperitoneal lymph nodes suspicious for metastatic disease.  The patient has completed five of planned six cycles of chemotherapy and comes in to clinic today for followup.  Of note, we had sent off genetic testing which was denied back in June.  I have been trying to get this testing completed.,CURRENT MEDICATIONS: , Synthroid q.d., ferrous sulfate 325 mg b.i.d., multivitamin q.d., Ativan 0.5 mg q.4 hours p.r.n. nausea and insomnia, gabapentin one tablet at bedtime.,ALLERGIES:","soap / chart / progress notes, adjuvant, adjuvant chemotherapy, cisplatin, adriamycin, abraxane, endometrial cancer, lymphadenectomy, chemotherapy, endometrial, disease, "
" Some improvement of erectile dysfunction, on low dose of Cialis, with no side effects.  ", SOAP / Chart / Progress Notes, Erectile Dysfunction - Followup ,"HISTORY OF PRESENT ILLNESS: , The patient presents today for followup, history of erectile dysfunction, last visit started on Cialis 10 mg.  He indicates that he has noticed some mild improvement of his symptoms, with no side effect.  On this dose, he is having firm erection, able to penetrate, lasting for about 10 or so minutes.  No chest pain, no nitroglycerin usage, no fever, no chills.  No dysuria, gross hematuria, fever, chills.  Daytime frequency every three hours, nocturia times 0, good stream.  He does have a history of elevated PSA and biopsy June of this year was noted for high grade PIN, mid left biopsy, with two specimens being too small to evaluate.  PSA 11.6.  Dr. X's notes are reviewed.,IMPRESSION:  ,1.  Some improvement of erectile dysfunction, on low dose of Cialis, with no side effects.  The patient has multiple risk factors, but denies using any nitroglycerin or any cardiac issues at this time.  We reviewed options of increasing the medication, versus trying other medications, options of penile prosthesis, Caverject injection use as well as working pump is reviewed.,2.  Elevated PSA in a patient with a recent biopsy showing high-grade PIN, as well as two specimens not being large enough to evaluate.  The patient tells me he has met with his primary care physician and after discussion, he is in consideration of repeating a prostate ultrasound and biopsy.  However, he would like to meet with Dr. X to discuss these prior to biopsy.,PLAN: , Following detailed discussion, the patient wishes to proceed with Cialis 20 mg, samples are provided as well as Levitra 10 mg, may increase this to 20 mg and understand administration of each and contraindication as well as potential side effects are reviewed.  The patient not to use them at the same time.  Will call if any other concern.  In the meantime, he is scheduled to meet with Dr. X, with a prior PSA in consideration of a possible repeating prostate ultrasound and biopsy.  He declined scheduling this at this time.  All questions answered.","soap / chart / progress notes, improvement of erectile dysfunction, erectile dysfunction, erectile, dysfunction, cialis, psa, biopsy,"
" A 46-year-old white male with Down’s syndrome presents for followup of hypothyroidism, as well as onychomycosis.", SOAP / Chart / Progress Notes, Down's syndrome ,"SUBJECTIVE:,  This 46-year-old white male with Down’s syndrome presents with his mother for followup of hypothyroidism, as well as onychomycosis.  He has finished six weeks of Lamisil without any problems.  He is due to have an ALT check today.  At his appointment in April, I also found that he was hypothyroid with elevated TSH.  He was started on Levothroid 0.1 mg and has been taking that daily.  We will recheck a TSH today as well.  His mother notes that although he does not like to take the medications, he is taking it with encouragement.  His only other medications are some eyedrops for his cornea.,OBJECTIVE:,  Weight was 149 pounds, which is up 2 pounds.  Blood pressure was 120/80.  Pulse is 80 and regular.,Neck:  Supple without adenopathy.  No thyromegaly or nodules were palpable.,Cardiac:  Regular rate and rhythm without murmurs.,Skin:  Examination of the toenails showed really no change yet.  They are still quite thickened and yellowed.,ASSESSMENT:,1.  Down’s syndrome.,2.  Onychomycosis.,3.  Hypothyroidism.,PLAN:,1.  Recheck ALT and TSH today and call results.,2.  Lamisil 250 mg #30 one p.o. daily with one refill.  They will complete the next eight weeks of therapy as long as the ALT is normal.  I again reviewed the symptoms of liver dysfunction.,3.  Continue Levothroid 0.1 mg daily unless dosage need to be adjusted based on the TSH.","soap / chart / progress notes, down’s syndrome, hypothyroidism, onychomycosis, hypothyroid, tsh, down’s"
" Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome", SOAP / Chart / Progress Notes, Dietary Consult - Hyperlipidemia ,"SUBJECTIVE:,  This is a followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome.  The patient reports that she has worked hard for a number of weeks following the meal plan prescribed, but felt like she was gaining weight and not losing weight on it.  She is not sure that she was following it accurately.  She is trying to walk 1-1/2 to 2 miles every other day, but is increasing her time in the garden and doing other yard work as well.  Once she started experiencing some weight gain, she went back to her old South Beach Diet and felt like she was able to take some of that weight off.  However she realizes that the South Beach Diet is not a healthy diet for her and so is coming back for better instruction on safe weight loss and low-fat eating.,OBJECTIVE:,  Weight is 275 pounds.  Food records were reviewed.,ASSESSMENT:,  The patient experienced a weight gain of 2 pounds since our last consultation which was two months ago.  I did carefully review her food records and evaluated calories consumed.  While she was carefully tracking the volume of protein and carbohydrates, she was getting some excess calories from the fatty proteins selected.  Thus we rearranged her meal plan a little bit and talked about how to track her fat calories as well.  She was more open to reducing the amount of protein from the previous meal plan and increasing slightly the amount of carbohydrates.  While this still is not as much carbohydrate as I would normally recommend, I am certainly willing to work with her on how she feels her body best handles weight reduction.  We also discussed a snack that could be eliminated in the morning because she really is not hungry at that time.,PLAN:,  A new 1500 calorie meal plan was developed based on 35% of the calories coming from protein, 40% of the calories from carbohydrate, and 25% of the calories from fat.  This translates in to 10 servings at 15 grams a piece of carbohydrates throughout the day dividing them in to groups of two servings per meal and per snack.  This also translates in to 2 ounces of protein at breakfast, 6 ounces at lunch, 2 ounces in the afternoon snack, 6 ounces at supper, and 2 ounces in the evening snack.  We have eliminated the morning snack.  The patient will now track the grams of fat in her meats as well as added fats.  Her goal for total fats over the course of the day is no more than 42 grams of fat per day.  This was a half hour consultation.  We will plan to see the patient back in one month for support.","soap / chart / progress notes, hyperlipidemia, hypertension, metabolic syndrome, meal, food records, south beach diet, dietary consultation, meal plan, carbohydrates, snack, dietary, calories, weight"
 The patient is brought in by an assistant with some of his food diary sheets., SOAP / Chart / Progress Notes, Dietary Consult - 3 ,"SUBJECTIVE:,  The patient is brought in by an assistant with some of his food diary sheets.  They wonder if the patient needs to lose anymore weight.,OBJECTIVE:,  The patient's weight today is 186-1/2 pounds, which is down 1-1/2 pounds in the past month.  He has lost a total of 34-1/2 pounds.  I praised this.  I went over his food diary and praised all of his positive food choices reported, especially his use of sugar-free Kool-Aid, sugar-free pudding, and diet pop.  I encouraged him to continue all of that, as well as his regular physical activity.,ASSESSMENT:,  The patient is losing weight at an acceptable rate.  He needs to continue keeping a food diary and his regular physical activity.,PLAN:,  The patient plans to see Dr. XYZ at the end of May 2005.  I recommended that they ask Dr. XYZ what weight he would like for the patient to be at.  Follow up will be with me June 13, 2005.","soap / chart / progress notes, weight, kool-aid, food diary sheets, diary sheets, physical activity, food diary, dietary, sheets, diary, food"
 Dietary consultation for gestational diabetes., SOAP / Chart / Progress Notes, Dietary Consult - Gestational Diabetes ,"SUBJECTIVE:,  This is a 38-year-old female who comes for dietary consultation for gestational diabetes.  Patient reports that she is scared to eat because of its impact on her blood sugars.  She is actually trying not to eat while she is working third shift at Wal-Mart.  Historically however, she likes to eat out with a high frequency.  She enjoys eating rice as part of her meals.  She is complaining of feeling fatigued and tired all the time because she works from 10 p.m. to 7 a.m. at Wal-Mart and has young children at home.  She sleeps two to four hours at a time throughout the day.  She has been testing for ketones first thing in the morning when she gets home from work.,OBJECTIVE:,  Today's weight:  155.5 pounds.  Weight from 10/07/04 was 156.7 pounds.  A diet history was obtained.  Blood sugar records for the last three days reveal the following:  fasting blood sugars 83, 84, 87, 77; two-hour postprandial breakfast 116, 107, 97; pre-lunch 85, 108, 77; two-hour postprandial lunch 86, 131, 100; pre-supper 78, 91, 100; two-hour postprandial supper 125, 121, 161; bedtime 104, 90 and 88.  I instructed the patient on dietary guidelines for gestational diabetes.  The Lily Guide for Meal Planning was provided and reviewed.  Additional information on gestational diabetes was applied.  A sample 2000-calorie meal plan was provided with a carbohydrate budget established.,ASSESSMENT:,  Patient's basal energy expenditure adjusted for obesity is estimated at 1336 calories a day.  Her total calorie requirements, including a physical activity factor as well as additional calories for pregnancy, totals to 2036 calories per day.  Her diet history reveals that she has somewhat irregular eating patterns.  In the last 24 hours when she was working at Wal-Mart, she ate at 5 a.m. but did not eat anything prior to that since starting work at 10 p.m.  We discussed the need for small frequent eating.  We identified carbohydrate as the food source that contributes to the blood glucose response.  We identified carbohydrate sources in the food supply, recognizing that they are all good for her.  The only carbohydrates she was asked to entirely avoid would be the concentrated forms of refined sugars.  In regard to use of her traditional foods of rice, I pulled out a one-third cup measuring cup to identify a 15-gram equivalent of rice.  We discussed the need for moderating the portion of carbohydrates consumed at one given time.  Emphasis was placed at eating with a high frequency with a goal of eating every two to four hours over the course of the day when she is awake.  Her weight loss was discouraged.  Patient was encouraged to eat more generously but with attention to the amount of carbohydrates consumed at a time.,PLAN:,  The meal plan provided has a carbohydrate content that represents 40 percent of a 2000-calorie meal plan.  The meal plan was devised to distribute her carbohydrates more evenly throughout the day.  The meal plan was meant to reflect an example for her eating, while the patient was encouraged to eat according to appetite and not to go without eating for long periods of time.  The meal plan is as follows:  breakfast 2 carbohydrate servings, snack 1 carbohydrate serving, lunch 2-3 carbohydrate servings, snack 1 carbohydrate serving, dinner 2-3 carbohydrate servings, bedtime snack 1-2 carbohydrate servings.  Recommend patient include a solid protein with each of her meals as well as with her snack that occurs before going to sleep.  Encouraged adequate rest.  Also recommend adequate calories to sustain weight gain of one-half to one pound per week.  If the meal plan reflected does not support slow gradual weight gain, then we will need to add more foods accordingly.  This was a one-hour consultation.  I provided my name and number should additional needs arise.","soap / chart / progress notes, blood sugars, fatigued, total calorie, carbohydrate content, consultation for gestational diabetes, dietary consultation, weight gain, gestational diabetes, carbohydrate servings, meal planning, meals, weight, carbohydrate, dietary, servings, planning"
" Counting calorie points, exercising pretty regularly, seems to be doing well", SOAP / Chart / Progress Notes, Dietary Consult - 4 ,"SUBJECTIVE:,  The patient is keeping a food journal that she brought in.  She is counting calorie points, which ranged 26 to 30 per day.  She is exercising pretty regularly.  She attends Overeaters Anonymous and her sponsor is helping her and told her to get some ideas on how to plan snacks to prevent hypoglycemia.  The patient requests information on diabetic exchanges.  She said she is feeling better since she has lost weight.,OBJECTIVE:,Vital Signs:  The patient's weight today is 209 pounds, which is down 22 pounds since I last saw her on 06/07/2004.  I praised her weight loss and her regular exercising.  I looked at her food journal.  I praised her record keeping.  I gave her a list of the diabetic exchanges and explained them.  I also gave her a food dairy sheet so that she could record exchanges.  I encouraged her to continue.,ASSESSMENT:,  The patient seems happy with her progress and she seems to be doing well.  She needs to continue.,PLAN:,  Followup is on a p.r.n. basis.  She is always welcome to call or return.","soap / chart / progress notes, overeaters anonymous, diabetic exchanges, exercising pretty regularly, food journal, diabetic, exercising, exchanges, regularly"
 Dietary consultation for diabetes during pregnancy., SOAP / Chart / Progress Notes, Dietary Consult - Diabetes - 1 ,"SUBJECTIVE:,  This is a 28-year-old female who comes for dietary consultation for diabetes during pregnancy.  Patient reports that she had gestational diabetes with her first pregnancy.  She did use insulin at that time as well.  She does not fully understand what ketones are.  She walks her daughter to school and back home each day which takes 20 minutes each way.  She is not a big milk drinker, but she does try to drink some.,OBJECTIVE:,  Weight is 238.3 pounds.  Weight from last week’s visit was 238.9 pounds.  Prepregnancy weight is reported at 235 pounds.  Height is 62-3/4 inches.  Prepregnancy BMI is approximately 42-1/2.  Insulin schedule is NovoLog 70/30, 20 units in the morning and 13 units at supper time.  Blood sugar records for the last week reveal the following:  Fasting blood sugars ranging from 92 to 104 with an average of 97, two-hour postprandial breakfast readings ranging from 172 to 196 with an average of 181, two-hour postprandial lunch readings ranging from 149 to 189 with an average of 168 and two-hour postprandial dinner readings ranging from 109 to 121 with an average of 116.  Overall average is 140.  A diet history was obtained.  Expected date of confinement is May 1, 2005.  Instructed the patient on dietary guidelines for gestational diabetes.  A 2300 meal plan was provided and reviewed.  The Lily Guide for Meal Planning was provided and reviewed.,ASSESSMENT:,  Patient’s basal energy expenditure adjusted for obesity is estimated at 1566 calories a day.  Her total calorie requirements, including physical activity factors as well as additional calories for pregnancy, totals 2367 calories a day.  Her diet history reveals that she is eating three meals a day and three snacks.  The snacks were just added last week following presence of ketones in her urine.  We identified carbohydrate sources in the food supply, recognizing that they are the foods that raise blood sugar the most.  We identified 15 gram equivalents of carbohydrate and established a carbohydrate budget.  We also discussed the goal of balancing food intake with blood sugar control and adequate caloric intake to sustain appropriate weight gain for the pregnancy of 1/2 a pound a week through the duration of the pregnancy.  We discussed the physiology of ketone production from inadequate calories or inadequate insulin and elevated blood sugars.  While a sample meal plan was provided reflecting the patient’s carbohydrate budget I emphasized the need for her to eat according to her appetite, but to work at consistency in the volume of carbohydrates consumed at a given meal or a given snack from day to day.  Patient was assured that we can titrate the insulin to match whatever eating pattern is suitable for her as long as she can do it on a consistent basis.  At the same time she was encouraged to continue to eliminate the more concentrated forms of refined carbohydrates.,PLAN:,  Recommend the patient work with the following meal plan with a carbohydrate budget representing approximately 45% of the calories from carbohydrate.  Breakfast:  Three carbohydrate servings.  Morning snack:  One carbohydrate serving.  Lunch:  Four carbohydrate servings.  Afternoon snack:  One carbohydrate serving.  Supper:  Four carbohydrate servings.  Bedtime snack:  One carbohydrate serving.  Encouraged patient to include some solid protein with each of her meals as well as with the bedtime snack.  Encouraged three servings of dairy products per day to meet nutritional needs for calcium during pregnancy.  Recommend patient include a fruit or a vegetable with most of her meals.  Also recommend including solid protein with each meal as well as with the bedtime snack.  Charlie Athene reviewed blood sugars at this consultation as well, and made the following insulin adjustment:  Morning 70/30, will increase from 20 units up to 24 units and evening 70/30, we will increase from 13 units up to 16 units.  Patient was encouraged to call in blood sugars at the end of the week if they are outside of the range of over 90 fasting and over 120 two-hour postprandial.  Provided my name and number should there be additional dietary questions.","soap / chart / progress notes, diabetes during pregnancy, diabetes, insulin, gestational diabetes, adjusted for obesity, calorie requirements, dietary consultation, carbohydrate, postprandial, meal, calories, dietary, pregnancy, servings, snacks"
" The patient has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.", SOAP / Chart / Progress Notes, Dietary Consult - 2 ,"SUBJECTIVE:,  The patient's assistant brings in her food diary sheets.  The patient says she stays active by walking at the mall.,OBJECTIVE:,  Weight today is 201 pounds, which is down 3 pounds in the past month.  She has lost a total of 24 pounds.  I praised this and encouraged her to continue.  I went over her food diary.  I praised her three-meal pattern and all of her positive food choices, especially the use of sugar-free Kool-Aid, sugar-free Jell-O, sugar-free lemonade, diet pop, as well as the variety of foods she is using in her three-meal pattern.  I encouraged her to continue all of this.,ASSESSMENT:,  The patient has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.  She needs to continue all this.,PLAN:,  Followup is set for 06/13/05 to check the patient's weight, her food diary, and answer any questions.","soap / chart / progress notes, food diary sheets, active, balanced diet, three-meal pattern, weight loss, sugar free, food diary, dietary, weight, meal, diary, sheets, food"
 Patient today with ongoing issues with diabetic control., SOAP / Chart / Progress Notes, Diabetes Mellitus - SOAP Note - 2 ,"SUBJECTIVE:,  I am asked to see the patient today with ongoing issues around her diabetic control.  We have been fairly aggressively, downwardly adjusting her insulins, both the Lantus insulin, which we had been giving at night as well as her sliding scale Humalog insulin prior to meals.  Despite frequent decreases in her insulin regimen, she continues to have somewhat low blood glucoses, most notably in the morning when the glucoses have been in the 70s despite decreasing her Lantus insulin from around 84 units down to 60 units, which is a considerable change.  What I cannot explain is why her glucoses have not really climbed at all despite the decrease in insulin.  The staff reports to me that her appetite is good and that she is eating as well as ever.  I talked to Anna today.  She feels a little fatigued.  Otherwise, she is doing well.,PHYSICAL EXAMINATION:  ,Vitals as in the chart.  The patient is a pleasant and cooperative.  She is in no apparent distress.,ASSESSMENT AND PLAN: , Diabetes, still with some problematic low blood glucoses, most notably in the morning.  To address this situation, I am going to hold her Lantus insulin tonight and decrease and then change the administration time to in the morning.  She will get 55 units in the morning.  I am also decreasing once again her Humalog sliding scale insulin prior to meals.  I will review the blood glucoses again next week.,","soap / chart / progress notes, diabetic control, insulin prior to meals, low blood glucoses, sliding scale, lantus insulin, diabetes, mellitus, lantus, glucoses,"
 Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983., SOAP / Chart / Progress Notes, Dietary Consult - Diabetes - 2 ,"SUBJECTIVE:,  The patient is a 79-year-old African-American female with a self reported height of 5 foot 3 inches and weight of 197 pounds.  She was diagnosed with type 2 diabetes in 1983.  She is not allergic to any medicines.,DIABETES MEDICATIONS:,  Her diabetes medications include Humulin insulin 70/30, 44 units at breakfast and 22 units at supper.  Also metformin 500 mg at supper.,OTHER MEDICATIONS: , Other medications include verapamil, Benicar, Toprol, clonidine, and hydrochlorothiazide.,ASSESSMENT:,  The patient and her daughter completed both days of diabetes education in a group setting.  Blood glucose records and food diaries are reviewed by the diabetes educator and the dietician.  Fasting blood sugars are 127, 80, and 80.  Two-hour postprandial breakfast reading was 105, two-hour postprandial lunch reading was 88, and two-hour postprandial dinner reading was 73 and 63.  Her diet was excellent.,Seven hours of counseling about diabetes mellitus was provided on this date.,Blood glucose values obtained at 10 a.m. were 84 and at 2.30 p.m. were 109.  Assessment of her knowledge is completed at the end of the counseling session.  She demonstrated increased knowledge in all areas and had no further questions.  She also completed an evaluation of the class.,The patient's feet were examined during the education session.  She had flat feet bilaterally.  Skin color was pink, temperature warm.  Pedal pulses 2+.  Her right second and third toes lay on each other.  Also, the same on her left foot.  However, there was no skin breakdown.  She had large bunions, medial aspect of the ball of both feet.  She had positive sensitivity to most areas of her feet, however, she had negative sensitivity to the medial and lateral aspect of the balls of her left foot.,During the education session, she set behavioral goals for self care.  First goal is to eat three meals a day and eat three snacks daily to improve her blood glucose levels.  Second goal is to eat a well balanced meal at 1200 calories in order to lose one-half pound of weight per week and improve her blood glucose control.  Third goal is to exercise by walking for 15 to 30 minutes a day, three to five days a week to increase her blood glucose control.  Her success in achieving these goals will be followed in three months by a letter from the diabetes education class.,RECOMMENDATIONS:,  Since she is doing so well with her diet changes, her blood sugars have been within normal limits and sometimes on the low side, especially considering the fact that she has low blood sugar unawareness.  She is to followup with Dr. XYZ for possible reduction in her insulin doses.","soap / chart / progress notes, dietary consult, diabetes education, glucose control, blood sugars, blood glucose, dietary, diabetes,"
 Elevated PSA with nocturia and occasional daytime frequency., SOAP / Chart / Progress Notes, Elevated PSA - Chart Note ,"REASON FOR VISIT:  ,Elevated PSA with nocturia and occasional daytime frequency.,HISTORY: , A 68-year-old male with a history of frequency and some outlet obstructive issues along with irritative issues.  The patient has had history of an elevated PSA and PSA in 2004 was 5.5.  In 2003, he had undergone a biopsy by Dr. X, which was negative for adenocarcinoma of the prostate.  The patient has had PSAs as high as noted above.  His PSAs have been as low as 1.6, but those were on Proscar.  He otherwise appears to be doing reasonably well, off the Proscar, otherwise does have some irritative symptoms.  This has been ongoing for greater than five years.  No other associated symptoms or modifying factors.  Severity is moderate.  PSA relatively stable over time.,IMPRESSION: , Stable PSA over time, although he does have some irritative symptoms.  After our discussion, it does appear that if he is not drinking close to going to bed, he notes that his nocturia has significantly decreased.  At this juncture what I would like to do is to start with behavior modification.  There were no other associated symptoms or modifying factors.,PLAN: , The patient will discontinue all caffeinated and carbonated beverages and any fluids three hours prior to going to bed.  He already knows that this does decrease his nocturia.  He will do this without medications to see how well he does and hopefully he may need no other additional medications other than may be changing his alpha-blocker to something of more efficacious.","soap / chart / progress notes, daytime frequency, psa, irritative symptoms, elevated psa, frequency, nocturia"
" Followup diabetes mellitus, type 1.", SOAP / Chart / Progress Notes, Diabetes Mellitus - SOAP Note - 1 ,"CHIEF COMPLAINT:  ,Followup diabetes mellitus, type 1., ,SUBJECTIVE:,  Patient is a 34-year-old male with significant diabetic neuropathy.  He has been off on insurance for over a year.  Has been using NPH and Regular insulin to maintain his blood sugars.  States that he is deathly afraid of having a low blood sugar due to motor vehicle accident he was in several years ago.  Reports that his blood sugar dropped too low which caused the accident.  Since this point in time, he has been unwilling to let his blood sugars fall within a normal range, for fear of hypoglycemia. Also reports that he regulates his blood sugars with how he feels, rarely checking his blood sugar with a glucometer., ,Reports that he has been worked up extensively at hospital and was seeing an Endocrinologist at one time.  Reports that he had some indications of kidney damage when first diagnosed.  His urine microalbumin today is 100.  His last hemoglobin A1C drawn at the end of December is 11.9.  Reports that at one point, he was on Lantus which worked well and he did not worry about his blood sugars dropping too low. While using Lantus, he was able to get his hemoglobin A1C down to 7.  His last CMP shows an elevated alkaline phosphatase level of 168. He denies alcohol or drug use and is a non smoker.  Reports he quit drinking 3 years ago. I have discussed with patient that it would be appropriate to do an SGGT and hepatic panel today.  Patient also has a history of gastroparesis and impotence.  Patient requests Nexium and Viagra, neither of which are covered under the Health Plan.  , ,Patient reports that he was in a scooter accident one week ago, fell off his scooter, hit his head.  Was not wearing a helmet.  Reports that he did not go to the emergency room and had a headache for several days after this incident.  Reports that an ambulance arrived at the scene and he was told he had a scalp laceration and to go into the emergency room.  Patient did not comply.  Reports that the headache has resolved.  Denies any dizziness, nausea, vomiting, or other neurological abnormalities., ,PHYSICAL EXAMINATION: , WD, WN.  Slender, 34-year-old white male.  VITAL SIGNS:  Blood sugar 145, blood pressure 120/88, heart rate 104, respirations 16.  Microalbumin 100. SKIN:  There appears to be 2 skin lacerations on the left parietal region of the scalp, each approximately 1 inch long.  No signs of infection.  Wound is closed with new granulation tissue.  Appears to be healing well.  HEENT:  Normocephalic.  PERRLA.  EOMI.  TMs pearly gray with landmarks present.  Nares patent.  Throat with no redness or swelling.  Nontender sinuses.  NECK:  Supple.  Full ROM.  No LAD. CARDIAC:","soap / chart / progress notes, diabetes mellitus, nph, regular insulin, sggt, diabetic neuropathy, dizziness, followup, glucometer, hypoglycemia, microalbumin, nausea, neurological, vomiting, mellitus type, blood sugars, blood, diabetes, mellitus, sugars"
 Hand dermatitis., SOAP / Chart / Progress Notes, Dermatitis - SOAP ,"SUBJECTIVE:,  This is a 29-year-old Vietnamese female, established patient of dermatology, last seen in our office on 07/13/04.  She comes in today as a referral from ABC, D.O. for a reevaluation of her hand eczema.  I have treated her with Aristocort cream, Cetaphil cream, increased moisturizing cream and lotion, and wash her hands in Cetaphil cleansing lotion.  She comes in today for reevaluation because she is flaring.  Her hands are very dry, they are cracked, she has been washing with soap.  She states that the Cetaphil cleansing lotion apparently is causing some burning and pain because of the fissures in her skin.  She has been wearing some gloves also apparently.  The patient is single.  She is unemployed.,FAMILY, SOCIAL, AND ALLERGY HISTORY: , The patient has asthma, sinus, hives, and history of psoriasis.  No known drug allergies.,MEDICATIONS: , The patient is a nonsmoker.  No bad sunburns or blood pressure problems in the past.,CURRENT MEDICATIONS:,  Claritin and Zyrtec p.r.n.,PHYSICAL EXAMINATION:,  The patient has very dry, cracked hands bilaterally.,IMPRESSION:,  Hand dermatitis.,TREATMENT:,1.  Discussed further treatment with the patient and her interpreter.,2.  Apply Aristocort ointment 0.1% and equal part of Polysporin ointment t.i.d. and p.r.n. itch.,3.  Discontinue hot soapy water and wash her hands with Cetaphil cleansing lotion.,4.  Keflex 500 mg b.i.d. times two weeks with one refill.  Return in one month if not better; otherwise, on a p.r.n. basis and send Dr. XYZ a letter on this office visit.","soap / chart / progress notes, cetaphil cleansing lotion, hand dermatitis, aristocort, wash, ointment, hand, lotion, dermatitis"
 An 83-year-old diabetic female presents today stating that she would like diabetic foot care., SOAP / Chart / Progress Notes, Diabetic Foot Care ,"S - ,An 83-year-old diabetic female presents today stating that she would like diabetic foot care.,O - ,On examination, the lateral aspect of her left great toenail is deeply ingrown.  Her toenails are thick and opaque.  Vibratory sensation appears to be intact.  Dorsal pedal pulses are 1/4.  There is no hair growth seen on her toes, feet or lower legs.  Her feet are warm to the touch.  All of her toenails are hypertrophic, opaque, elongated and discolored.,A - ,1.  Onychocryptosis.,","soap / chart / progress notes, onychocryptosis, onychomycosis, great toenail, diabetic foot care, diabetic foot, foot, toenail, ingrown, toenails, diabetic, "
" The patient is a 40-year-old female with a past medical history of repair of deviated septum with complication of a septal perforation.  At this time, the patient states that her septal perforation bothers her as she feels that she has very dry air through her nose as well as occasional epistaxis.", SOAP / Chart / Progress Notes, Deviated Septum Repair - Followup ,"CHIEF COMPLAINT: , Septal irritation.,HISTORY OF PRESENT ILLNESS: , The patient is a 39-year-old African-American female status post repair of septal deviation but unfortunately, ultimately ended with a large septal perforation.  The patient has been using saline nasal wash 2-3 times daily, however, she states that she still has discomfort in her nose with a ""stretching"" like pressure.  She says her nose is frequently dry and she occasionally has nosebleeds due to the dry nature of her nose.  She has no other complaints at this time.,PHYSICAL EXAM:,GENERAL:  This is a pleasant African-American female resting in the examination room chair in no apparent distress.,ENT:  External auditory canals are clear.  Tympanic membrane shows no perforation, is intact.,NOSE:  The patient has a slightly deviated right septum.  Septum has a large perforation in the anterior 2/3rd of the septum.  This appears to be well healed.  There is no sign of crusting in the nose.,ORAL CAVITY:  No lesions or sores.  Tonsils show no exudate or erythema.,NECK:  No cervical lymphadenopathy.,VITAL SIGNS:  Temperature 98 degrees Fahrenheit, pulse 77, respirations 18, blood pressure 130/73.,ASSESSMENT AND PLAN:  ,The patient is a 40-year-old female with a past medical history of repair of deviated septum with complication of a septal perforation.  At this time, the patient states that her septal perforation bothers her as she feels that she has very dry air through her nose as well as occasional epistaxis.  At this time, I counseled the patient on the risks and benefits of surgery.  She will consider surgery but at this time, would like to continue using the saline nasal wash as well as occasional Bactroban to the nose if there is occasional irritation or crusting, which she will apply with the edge of a Q-tip.  We will see her back in 3 weeks and if the patient does not feel relieved from the Bactroban as well as saline nasal spray wash, we will consider setting the patient for surgery at that time.","soap / chart / progress notes, saline nasal wash, deviated septum, saline nasal, septal perforation, nose, septum, septal, perforation "
 Elevated cholesterol and is on medication to lower it., SOAP / Chart / Progress Notes, Dietary Consult - 1 ,"SUBJECTIVE:,  His brother, although he is a vegetarian, has elevated cholesterol and he is on medication to lower it.  The patient started improving his diet when he received the letter explaining his lipids are elevated.  He is consuming less cappuccino, quiche, crescents, candy from vending machines, etc.  He has started packing his lunch three to four times per week instead of eating out so much.  He is exercising six to seven days per week by swimming, biking, running, lifting weights one and a half to two and a half hours each time.  He is in training for a triathlon.  He says he is already losing weight due to his efforts.,OBJECTIVE:,  Height:  6 foot 2 inches.  Weight:  204 pounds on 03/07/05.  Ideal body weight:  190 pounds, plus or minus ten percent.  He is 107 percent standard of midpoint ideal body weight.  BMI:  26.189.  A 48-year-old male.  Lab on 03/15/05:  Cholesterol:  251.  LDL:  166.  VLDL:  17.  HDL:  68.  Triglycerides:  87.  I explained to the patient the dietary guidelines to help improve his lipids.  I recommend a 26 to 51 to 77 fat grams per day for a 10 to 20 to 30 percent fat level of 2,300 calories since he is interested in losing weight.  I went over the printed information sheet on lowering your cholesterol and that was given to him along with a booklet on the same topic to read.  I encouraged him to continue as he is doing.,ASSESSMENT:,  Basal energy expenditure 1960 x 1.44 activity factor is approximately 2,800 calories.  His 24-hour recall shows he is making many positive changes already to lower his fat and cholesterol intake.  He needs to continue as he is doing.  He verbalized understanding and seemed receptive.,PLAN:,  The patient plans to recheck his lipids through Dr. XYZ  I gave him my phone number and he is to call me if he has any further questions regarding his diet.","soap / chart / progress notes, vegetarian, lipids, cholesterol intake, elevated cholesterol, losing weight, body weight, dietary, cholesterol"
 Return visit to the endocrine clinic for followup management of type 1 diabetes mellitus.  Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin., SOAP / Chart / Progress Notes, Diabetes Mellitus Followup ,"PROBLEM LIST:,1.  Type 1 diabetes mellitus, insulin pump.,2.  Hypertension.,3.  Hyperlipidemia.,HISTORY OF PRESENT ILLNESS: , The patient is a 39-year-old woman returns for followup management of type 1 diabetes mellitus.  Her last visit was approximately 4 months ago.  Since that time, the patient states her health had been good and her glycemic control had been good, however, within the past 2 weeks she had a pump malfunction, had to get a new pump and was not certain of her pump settings and has been having some difficulty with glycemic control over the past 2 weeks.  She is not reporting any severe hypoglycemic events, but is having some difficulty with hyperglycemia both fasting and postprandial.  She is not reporting polyuria, polydipsia or polyphagia.  She is not exercising at this point and has a diet that is rather typical of woman with twins and a young single child as well.  She is working on a full-time basis and so eats on the run a lot, probably eats more than she should and not making the best choices, little time for physical activity.  She is keeping up with all her other appointments and has recently had a good eye examination.  She had lab work done at her previous visit and this revealed persistent hyperlipidemic state with a LDL of 144.,CURRENT MEDICATIONS:,1.  Zoloft 50 mg p.o. once daily.,2.  Lisinopril 40 mg once daily.,3.  Symlin 60 micrograms, not taking at this point.,4.  Folic acid 2 by mouth every day.,5.  NovoLog insulin via insulin pump about 90 units of insulin per day.,REVIEW OF SYSTEMS:,  She denies fever, chills, sweats, nausea, vomiting, diarrhea, constipation, abdominal pain, chest pain, shortness of breath, difficulty breathing, dyspnea on exertion or change in exercise tolerance.  She is not having painful urination or blood in the urine.  She is not reporting polyuria, polydipsia or polyphagia.,PHYSICAL EXAMINATION:,GENERAL:  Today showed a very pleasant, well-nourished woman, in no acute distress.  VITAL SIGNS:  Temperature not taken, pulse 98, respirations 20, blood pressure 148/89, and weight 91.19 kg.  THORAX:  Revealed lungs clear, PA and lateral without adventitious sounds.  CARDIOVASCULAR:  Demonstrated regular rate and rhythm.  S1 and S2 without murmur.  No S3, no S4 auscultated.  ABDOMEN:  Nontender.  EXTREMITIES:  Showed no clubbing, cyanosis or edema.  SKIN:  Intact and do not appear atrophic.  Deep tendon reflexes were 2+/4 without a delayed relaxation phase.,LABORATORY DATA:,  Dated 10/05/08 showed a total cholesterol of 223, triglyceride 140, HDL 54, and LDL 144.  The hemoglobin A1c was 6.4 and the spot urine for microalbumin was 9.2 micrograms of protein, 1 mg of creatinine.  Sodium 136, potassium 4.5, chloride 102, CO2 30 mEq, BUN 11 mg/dL, creatinine 0.6 mg, estimated GFR greater than 60, blood sugar 118, calcium 9.4, and her LFTs were unremarkable.  TSH is 1.07 and free T4 is 0.81.,ASSESSMENT AND PLAN:,1.  This is a return visit to the endocrine clinic for the patient, a 39-year-old woman with history as noted above.  Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin.  Basal rate is as follows, 12 a.m. 1.5, 02:30 a.m. 1.75, and 6 a.m. 1.5.  Her correction factor is 19.  Her carb/insulin ratio is 6.  Her active insulin time is 5 and her targets are at 12 a.m. 110 and 6 a.m. to midnight is 100.  We made adjustments to her pump and the plan will be to see her back in approximately 2 months.,2.  Hyperlipidemia.  The patient is not taking statin, therefore, we will prescribe Lipitor 20 mg one p.o. once daily.  Have her watch for side effects from the medication and plan to do a fasting lipid panel and CMP approximately 8 weeks from now.,3.  We will get a hemoglobin A1c and spot urine for albumin in 8 weeks as well.","soap / chart / progress notes, endocrine clinic, insulin pump, diabetes mellitus, insulin, glycemic, fasting, polyuria, polydipsia, polyphagia, diabetes,"
" Acute on chronic COPD exacerbation and community acquired pneumonia both resolving.  However, she may need home O2 for a short period of time.", SOAP / Chart / Progress Notes, COPD & Pneumonia - SOAP ,"SUBJECTIVE: , Review of the medical record shows that the patient is a 97-year-old female patient who has been admitted and has been treated for community acquired pneumonia along with COPD exacerbation.  The patient does have a longstanding history of COPD.  However, she does not use oxygen at her independent assisted living home.  Yesterday, she had made improvement since being here at the hospital.  She needed oxygen.  She was tested for home O2 and qualified for it yesterday also.  Her lungs were very tight.  She did have wheezes bilaterally and rhonchi on the right side mostly.  She appeared to be a bit weak and although she was requesting to be discharged home, she did not appear to be fit for it.,Overnight, the patient needed to use the rest room.  She stated that she needed to urinate.  She awoke, decided not to call for assistance.  She stated that she did have her nurse call light button next to her and she was unable to gain access to her walker.  She attempted to walk to the rest room on her own.  She sustained a fall.  She stated that she just felt weak.  She bumped her knee and her elbow.  She had femur x-rays, knee x-rays also.  There was possibility of subchondral fracture and some swelling of her suprapatellar bursa on the right side.  This morning, she denied any headache, back pain or neck pain.  She complained mostly of right anterior knee pain for which she had some bruising and swelling.,OBJECTIVE:,VITAL SIGNS:  The patient's max temperature over the past 24 hours was 36.5; her blood pressure is 148/77, her pulse is 87 to 106.  She is 95% on 2 L via nasal cannula.,HEART:  Regular rate and rhythm without murmur, gallop or rub.,LUNGS:  Reveal no expiratory wheezing throughout.  She does have some rhonchi on the right mid base.  She did have a productive cough this morning and she is coughing green purulent sputum finally.,ABDOMEN:  Soft and nontender.  Her bowel sounds x4 are normoactive.,NEUROLOGIC:  She is alert and oriented x3.  Her pupils are equal and reactive.  She has got a good head and facial muscle strength.  Her tongue is midline.  She has got clear speech.  Her extraocular motions are intact.  Her spine is nontender on palpation from neck to lumbar spine.  She has good range of motion with regard to her shoulders, elbows, wrists and fingers.  Her grip strengths are equal bilaterally.  Both elbows are strong from extension to flexion.  Her hip flexors and extenders are also strong and equal bilaterally.  Extension and flexion of the knee bilaterally and ankles also are strong.  Palpation of her right knee reveals no crepitus.  She does have suprapatellar inflammation with some ecchymosis and swelling.  She has got good joint range of motion however.,SKIN:  She did have a skin tear involving her right forearm lateral, which is approximately 2 to 2.5 inches in length and is at this time currently Steri-Stripped and wrapped with Coban and is not actively bleeding.,ASSESSMENT:,1.  Acute on chronic COPD exacerbation.,2.  Community acquired pneumonia both resolving.  However, she may need home O2 for a short period of time.,3.  Generalized weakness and deconditioning secondary to the above.  Also sustained a fall secondary to instability and not using her walker or calling for assistance.  The patient stated that she knew better and she should have called for assistance and she had been told repeatedly from her family members and staff to call for assistance if she needed to get out of bed.,PLAN:,1.  I will have PT and OT evaluate the patient and give recommendation to safety and appliance use at home i.e. walker.  Myself and one of her daughter's spoke today about the fact that she generally lives independently at the Brooke and she may need assisted living along with physical therapy and oxygen for a period of time rather than going back to independent living.,2.  We will obtain an orthopedic consult secondary to her fall to evaluate her x-rays and function.","soap / chart / progress notes, community acquired pneumonia, copd exacerbation, home o2, acute on chronic, pneumonia, exacerbation, copd"
 The patient is a 61-year-old female who was treated with CyberKnife therapy to a right upper lobe stage IA non-small cell lung cancer.  CyberKnife treatment was completed one month ago.  She is now being seen for her first post-CyberKnife treatment visit., SOAP / Chart / Progress Notes, CyberKnife Treatment - Followup ,"HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old female who was treated with CyberKnife therapy to a right upper lobe stage IA non-small cell lung cancer.  CyberKnife treatment was completed one month ago.  She is now being seen for her first post-CyberKnife treatment visit.,Since undergoing CyberKnife treatment, she has had low-level nausea without vomiting.  She continues to have pain with deep inspiration and resolving dysphagia.  She has no heartburn, cough, hemoptysis, rash, or palpable rib pain.,MEDICATIONS: , Dilantin 100 mg four times a day, phenobarbital 30 mg three times per day, levothyroxine 0.025 mg p.o. q. day, Tylenol with Codeine b.i.d., prednisone 5 mg p.r.n., citalopram 10 mg p.o. q. day, Spiriva q. day, Combivent inhaler p.r.n., omeprazole 20 mg p.o. q. day, Lidoderm patch every 12 hours, Naprosyn 375 mg p.o. b.i.d., oxaprozin 600 mg p.o. b.i.d., Megace 40 mg p.o. b.i.d., and Asacol p.r.n.,PHYSICAL EXAMINATION: , BP:  122/86.  Temp:  96.8.  HR:  79.  RR:  26.  RAS:  100%.,HEENT:  Normocephalic.  Pupils are equal and reactive to light and accommodation.  EOMs intact.,NECK:  Supple without masses or lymphadenopathy.,LUNGS:  Clear to auscultation bilaterally,CARDIAC:  Regular rate and rhythm without rubs, murmurs, or gallops.,EXTREMITIES:  No cyanosis, clubbing or edema.,ASSESSMENT: , The patient has done well with CyberKnife treatment of a stage IA non-small cell lung cancer, right upper lobe, one month ago.,PLAN: , She is to return to clinic in three months with a PET CT.","soap / chart / progress notes, non-small cell lung cancer, cyberknife therapy, lung cancer, cell, lung, cancer, cyberknife,"
" Postoperative visit for craniopharyngioma with residual disease.  According to him, he is doing well, back at school without any difficulties.  He has some occasional headaches and tinnitus, but his vision is much improved.", SOAP / Chart / Progress Notes, Craniopharyngioma - Postop ,"REASON FOR VISIT:,  Postoperative visit for craniopharyngioma.,HISTORY OF PRESENT ILLNESS:,  Briefly, a 16-year-old right-handed boy who is in eleventh grade, who presents with some blurred vision and visual acuity difficulties, was found to have a suprasellar tumor.  He was brought to the operating room on 01/04/07, underwent a transsphenoidal resection of tumor.  Histology returned as craniopharyngioma.  There is some residual disease; however, the visual apparatus was decompressed.  According to him, he is doing well, back at school without any difficulties.  He has some occasional headaches and tinnitus, but his vision is much improved.,MEDICATIONS: , Synthroid 100 mcg per day.,FINDINGS: , On exam, he is awake, alert and oriented x 3.  Pupils are equal and reactive.  EOMs are full.  His visual acuity is 20/25 in the right (improved from 20/200) and the left is 20/200 improved from 20/400.  He has a bitemporal hemianopsia, which is significantly improved and wider.  His motor is 5 out of 5.  There are no focal motor or sensory deficits.  The abdominal incision is well healed.  There is no evidence of erythema or collection.  The lumbar drain was also well healed.,The postoperative MRI demonstrates small residual disease.,Histology returned as craniopharyngioma.,ASSESSMENT: , Postoperative visit for craniopharyngioma with residual disease.,PLANS: , I have recommended that he call.  I discussed the options with our radiation oncologist, Dr. X. They will schedule the appointment to see him.  In addition, he probably will need an MRI prior to any treatment, to follow the residual disease.","soap / chart / progress notes, visual acuity, blurred vision, tinnitus, headaches, residual disease, tumor, histology, craniopharyngioma,"
" Still having diarrhea, decreased appetite.", SOAP / Chart / Progress Notes, Clostridium Difficile Colitis Followup ,"SUBJECTIVE:  ,The patient seen and examined feels better today.  Still having diarrhea, decreased appetite.  Good urine output 600 mL since 7 o'clock in the morning.  Afebrile.,PHYSICAL EXAMINATION,GENERAL:  Nonacute distress, awake, alert, and oriented x3.,VITAL SIGNS:  Blood pressure 102/64, heart rate of 89, respiratory rate of 12, temperature 96.8, and O2 saturation 94% on room air.,HEENT:  PERRLA, EOMI.,NECK:  Supple.,CARDIOVASCULAR:  Regular rate and rhythm.,RESPIRATORY:  Clear to auscultation bilaterally.,ABDOMEN:  Bowel sounds are positive, soft, and nontender. EXTREMITIES:  No edema.  Pulses present bilaterally.,LABORATORY DATA:  ,CBC, WBC count today down 10.9 from 17.3 yesterday 26.9 on admission, hemoglobin 10.2, hematocrit 31.3, and platelet count 370,000.  BMP, BUN of 28.3 from 32.2, creatinine 1.8 from 1.89 from 2.7.  Calcium of 8.2.  Sodium 139, potassium 3.9, chloride 108, and CO2 of 22.  Liver function test is unremarkable.,Stool positive for Clostridium difficile.  Blood culture was 131.  O2 saturation result is pending.,ASSESSMENT AND PLAN:,1.  Most likely secondary to Clostridium difficile colitis and urinary tract infection improving.  The patient hemodynamically stable, leukocytosis improved and today he is afebrile.,2.  Acute renal failure secondary to dehydration, BUN and creatinine improving.,3.  Clostridium difficile colitis, Continue Flagyl, evaluation Dr. X in a.m.,4.  Urinary tract infection, continue Levaquin for last during culture.,5.  Leucocytosis, improving.,6.  Minimal elevated cardiac enzyme on admission.  Followup with Cardiology recommendations.,7.  Possible pneumonia, continue vancomycin and Levaquin.,8.  The patient may be transferred to telemetry.","soap / chart / progress notes, decreased appetite, acute renal failure, urinary tract infection, leucocytosis, clostridium difficile colitis,"
" D&C and hysteroscopy.  Abnormal uterine bleeding, enlarged fibroid uterus, hypermenorrhea, intermenstrual spotting, and thickened endometrium per ultrasound of a 2 cm lining.
6.  Grade 1+ rectocele.", SOAP / Chart / Progress Notes, D&C & Hysteroscopy Followup ,"PREOPERATIVE DIAGNOSES:,1.  Abnormal uterine bleeding.,2.  Enlarged fibroid uterus.,3.  Hypermenorrhea.,4.  Intermenstrual spotting.,5.  Thickened endometrium per ultrasound of a 2 cm lining.,POSTOPERATIVE DIAGNOSES:,1.  Abnormal uterine bleeding.,2.  Enlarged fibroid uterus.,3.  Hypermenorrhea.,4.  Intermenstrual spotting.,5.  Thickened endometrium per ultrasound of a 2 cm lining.,6.  Grade 1+ rectocele.,PROCEDURE PERFORMED:  ,D&C and hysteroscopy.,COMPLICATIONS: , None.,HISTORY: , The patient is a 48-year-old para 2, vaginal delivery.  She has heavy periods lasting 7 to 14 days with spotting in between her periods.  The patient's uterus is 12.2 x 6.2 x 5.3 cm.  Her endometrial thickness is 2 cm.  Her adnexa is within normal limits.  The patient and I had a long discussion.  Consent was reviewed in layman's terms.  The patient understood the foreseeable risks and complications, the alternative treatments and procedure itself and recovery.  Questions were answered.  The patient was taken back to the operative suite.  The patient underwent pelvic examination and then carefully placed in dorsal lithotomy position.  The patient had excellent femoral pulses and there was no excessive extension or hyperflexion of the lower extremities.  The patient's history is that she is at risk for development of condyloma.  The patient's husband was found to have a laryngeal papillomatosis.  She has had a laparotomy, which is an infraumbilical incision appendectomy, a laparoscopy, and bilateral tubal ligation.  Her uterus appears to be mobile by 12-week size.  There is a good descend.  There appears to be no adnexal abnormalities.  Uterus is 12-week sized and has fibroids, it is boggy and probably has a component of adenomyosis.  The patient's cervix was dilated without difficulty utilizing Circon ACMI hysteroscope with a 12-degree lens.  The patient underwent hysteroscopy.  The outflow valve was opened at all times.  The inflow valve was opened just to achieve appropriate distension.  The patient did have no evidence of trauma of the cervix.  No Trendelenburg as we were in room #9.  The patient also had the bag held two fingerbreadths above the level of the heart.  The patient was seen.  There is a 2 x 3 cm focal thickening of the posterior wall of the uterus' endometrial lining, a more of a polypoid nature.  The patient also has one in the fundal area.  The thickened tissue was removed via sharp curettage.  Therefore, we reinserted the hysteroscope.  It appeared that there was an appropriate curettage and that all areas of suspicion were indeed removed.  The patient's procedure was ended with specimen being obtained and sent to Department of Pathology.  We will follow her up in the office.","soap / chart / progress notes, pelvic examinatio, abnormal uterine bleeding, enlarged fibroid uterus, hypermenorrhea, intermenstrual spotting, thickened endometrium, intermenstrual, d&c, uterine, bleeding, fibroid, endometrium, hysteroscopy, uterus"
 Followup circumcision.  The patient had a pretty significant phimosis and his operative course was smooth.  Satisfactory course after circumcision for severe phimosis with no perioperative complications., SOAP / Chart / Progress Notes, Circumcision Followup ,"REASON FOR VISIT: , Followup circumcision.,HISTORY OF PRESENT ILLNESS: , The patient had his circumcision performed on 09/16/2007 here at Children's Hospital.  The patient had a pretty significant phimosis and his operative course was smooth.  He did have a little bit of bleeding when he woke in recovery room, which required placement of some additional sutures, but after that, his recovery has been complete.  His mom did note that she had to him a couple of days of oral analgesics, but he seems to be back to normal and pain free now.  He is having no difficulty urinating, and his bowel function remains normal.,PHYSICAL EXAMINATION:  ,Today, The patient looks healthy and happy.  We examined his circumcision site.  His Monocryl sutures are still in place.  The healing is excellent, and there is only a mild amount of residual postoperative swelling.  There was one area where he had some recurrent adhesions at the coronal sulcus, and I gently lysed this today and applied antibiotic ointment showing this to mom had to especially lubricate this area until the healing is completed.,IMPRESSION: , Satisfactory course after circumcision for severe phimosis with no perioperative complications.,PLAN:  ,The patient came in followup for his routine care with Dr. X, but should not need any further routine surgical followup unless he develops any type of difficulty with this surgical wound.  If that does occur, we will be happy to see him back at any time.,","soap / chart / progress notes, circumcision, adhesions, followup circumcision, sutures, phimosis, "
" Chronic kidney disease, stage IV, secondary to polycystic kidney disease.  Hypertension, which is finally better controlled.  Metabolic bone disease and anemia.", SOAP / Chart / Progress Notes, Chronic Kidney Disease Followup ,"HISTORY OF PRESENT ILLNESS: , This is a followup for this 69-year-old African American gentleman with stage IV chronic kidney disease secondary to polycystic kidney disease.  His creatinine has ranged between 4 and 4.5 over the past 6 months, since I have been following him.  I have been trying to get him educated about end-stage kidney disease and we have been unsuccessful in getting him into classes.  On his last visit, I really stressed the importance of him taking his medications adequately and not missing some of the doses, and he returns today with much better blood pressure control.  He has also brought a machine at home, and states his blood pressure readings have been better.  He has not gone to the transplant orientation class yet and has not been to dialysis education yet, and both of these I have discussed with him in the past.  He also needs followup for his elevated PSA in the past, which has not been done for over 2 years and will likely need cardiac clearance if we ever are able to evaluate him for transplant.,REVIEW OF SYSTEMS: , Really negative.  He continues to feel well.  He denies any problems with shortness of breath, chest pain, swelling in his legs, nausea or vomiting, and his appetite remains good.,CURRENT MEDICATIONS:,1.  Vytorin 10/40 mg one a day.,2.  Rocaltrol 0.25 micrograms a day.,3.  Carvedilol 12.5 mg twice a day.,4.  Cozaar 50 mg twice a day.,5.  Lasix 40 mg a day.,PHYSICAL EXAMINATION:,VITAL SIGNS:  On exam, his blood pressure is 140/57, pulse 58, current weight is 67.1 kg, and again his blood pressure is markedly improved over his previous readings.  GENERAL:  He is a thin African American gentleman in no distress.  LUNGS:  Clear.  CARDIOVASCULAR:  Regular rate and rhythm.  Normal S1 and S2.  I did not appreciate a murmur.  ABDOMEN:  Soft.  He has a very soft systolic murmur at the left lower sternal border.  No rubs or gallops.  EXTREMITIES:  No significant edema.,LABORATORY DATA: , Today indicates that his creatinine is 4.5 and stable, ionized calcium 8.5, intact PTH 458, and hemoglobin stable at 10.9.  He is not on EPO yet.  His UA has been negative.,IMPRESSION:,1.  Chronic kidney disease, stage IV, secondary to polycystic kidney disease.  His estimated GFR is 16 mL per minute.  He has no uremic symptoms.,2.  Hypertension, which is finally better controlled.,3.  Metabolic bone disease.,4.  Anemia.,RECOMMENDATION:,  He needs a number of things done in terms of followup and education.  I gave him more information again about dialysis education and transplant, and instructed him he needs to go to these classes.  I also gave him websites that he can get on to find out more information.  I have not made any changes in his medications.  He is getting blood work done prior to his next visit with me.  I will check a PSA on him but he needs to get back into see urology, as his last PSA that I see was 37 and this was from 02/05.  He will see me back in about 4 to 6 weeks.","soap / chart / progress notes, metabolic bone disease, anemia, polycystic kidney disease, chronic kidney disease, blood pressure, transplant, metabolic, kidney"
" Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc.", SOAP / Chart / Progress Notes, Chiropractic Progress Note ,"CHIEF COMPLAINT:  ,Hip pain.,HISTORY OF PRESENTING ILLNESS:  ,The patient is a very pleasant 41-year-old white female that is known to me previously from our work at the Pain Management Clinic, as well as from my residency training program, San Francisco. We have worked collaboratively for many years at the Pain Management Clinic and with her departure there, she has asked to establish with me for clinic pain management at my office.  She reports moderate to severe pain related to a complicated past medical history.  In essence, she was seen at a very young age at the clinic for bilateral knee and hip pain and diagnosed with bursitis at age 23.  She was given nonsteroidals at that time, which did help with this discomfort.  With time, however, this became inadequate and she was seen later in San Francisco in her mid 30s by Dr. V, an orthopedist who diagnosed retroverted hips at Hospital.  She was referred for rehabilitation and strengthening.  Most of this was focused on her SI joints.  At that time, although she had complained of foot discomfort, she was not treated for it.  This was in 1993 after which she and her new husband moved to the Boston area, where she lived from 1995-1996.  She was seen at the Pain Center by Dr. R with similar complaints of hip and knee pain.  She was seen by rheumatologists there and diagnosed with osteoarthritis as well as osteophytosis of the back.  Medications at that time were salicylate and Ultram.,When she returned to Portland in 1996, she was then working for Dr. B.  She was referred to a podiatrist by her local doctor who found several fractured sesamoid bones in her both feet, but this was later found not to be the case.  Subsequently, nuclear bone scans revealed osteoarthritis.  Orthotics were provided.  She was given Paxil and Tramadol and subsequently developed an unfortunate side effect of grand mal seizure.  During this workup of her seizure, imaging studies revealed a pericardial fluid-filled cyst adhered to her ventricle.  She has been advised not to undergo any corrective or reparative surgery as well as to limit her activities since.  She currently does not have an established cardiologist having just changed insurance plans.  She is establishing care with Dr. S, of Rheumatology for her ongoing care.  Up until today, her pain medications were being written by Dr. Y prior to establishing with Dr. L.,Pain management in town had been first provided by the office of Dr. F. Under his care, followup MRIs were done which showed ongoing degenerative disc disease, joint disease, and facet arthropathy in addition to previously described sacroiliitis.  A number of medications were attempted there, including fentanyl patches with Flonase from 25 mcg titrated upwards to 50 mcg, but this caused oversedation.  She then transferred her care to Ab Cd, FNP under the direction of Dr. K.  Her care there was satisfactory, but because of her work schedule, the patient found this burdensome as well as the guidelines set forth in terms of monthly meetings and routine urine screens.  Because of a previous commitment, she was unable to make one unscheduled request to their office in order to produce a random urine screen and was therefore discharged.,PAST MEDICAL HISTORY:  ,1.  Attention deficit disorder.,2.  TMJ arthropathy.,3.  Migraines.,4.  Osteoarthritis as described above.,PAST SURGICAL HISTORY:,1.  Cystectomies.,2.  Sinuses.,3.  Left ganglia of the head and subdermally in various locations.,4.  TMJ and bruxism.,FAMILY HISTORY:  ,The patient's father also suffered from bilateral hip osteoarthritis.,MEDICATIONS:,1.  Methadone 2.5 mg p.o. t.i.d.,2.  Norco 10/325 mg p.o. q.i.d.,3.  Tenormin 50 mg q.a.m.,4.  Skelaxin 800 mg b.i.d. to t.i.d. p.r.n.,5.  Wellbutrin SR 100 mg q.d.,6.  Naprosyn 500 mg one to two pills q.d. p.r.n.,ALLERGIES: , IV morphine causes hives.  Sulfa caused blisters and rash.,PHYSICAL EXAMINATION: , A well-developed, well-nourished white female in no acute distress, sitting comfortably and answering questions appropriately, making good eye contact, and no evidence of pain behavior.,VITAL SIGNS:  Blood pressure 110/72 with a pulse of 68.,HEENT:  Normocephalic.  Atraumatic.  Pupils are equal and reactive to light and accommodation.  Extraocular motions are intact.  No scleral icterus.  No nystagmus.  Tongue is midline.  Mucous membranes are moist without exudate.,NECK:  Free range of motion without thyromegaly.,CHEST:  Clear to auscultation without wheeze or rhonchi.,HEART:  Regular rate and rhythm without murmur, gallop, or rub.,ABDOMEN:  Soft, nontender.,MUSCULOSKELETAL:  There is musculoskeletal soreness and tenderness found at the ankles, feet, as well as the low back, particularly above the SI joints bilaterally.  Passive hip motion also elicits bilateral hip pain referred to the ipsilateral side.  Toe-heel walking is performed without difficulty.  Straight leg raises are negative.  Romberg's are negative.,NEUROLOGIC:  Grossly intact.  Intact reflexes in all extremities tested.  Romberg is negative and downgoing.,ASSESSMENT:,1. Osteoarthritis.,2. Chronic sacroiliitis.,3. Lumbar spondylosis.,4. Migraine.,5. TMJ arthropathy secondary to bruxism.,6. Mood disorder secondary to chronic pain.,7. Attention deficit disorder, currently untreated and self diagnosed.,RECOMMENDATIONS:,1. Agree with Rheumatology referral and review.  I would particularly be interested in the patient pursuing a bone density scan as well as thyroid and parathyroid studies.,2. Given the patient's previous sulfa allergies, we would recommend decreasing her Naprosyn usage.",
" Followup evaluation and management of chronic medical conditions.  Congestive heart failure, stable on current regimen.  Diabetes type II, A1c improved with increased doses of NPH insulin.  Hyperlipidemia, chronic renal insufficiency, and arthritis.", SOAP / Chart / Progress Notes, Chronic Medical Conditions - Followup ,"REASON FOR VISIT: , Followup evaluation and management of chronic medical conditions.,HISTORY OF PRESENT ILLNESS:,  The patient has been doing quite well since he was last seen.  He comes in today with his daughter.  He has had no symptoms of CAD or CHF.  He had followup with Dr. X and she thought he was doing quite well as well.  He has had no symptoms of hyperglycemia or hypoglycemia.  He has had no falls.  His right knee does pain him at times and he is using occasional doses of Tylenol for that.  He wonders whether he could use a knee brace to help him with that issue as well.  His spirits are good.  He has had no incontinence.  His memory is clear, as is his thinking.,MEDICATIONS:,1.  Bumex - 2 mg daily.,2.  Aspirin - 81 mg daily.,3.  Lisinopril - 40 mg daily.,4.  NPH insulin - 65 units in the morning and 25 units in the evening.,5.  Zocor - 80 mg daily.,6.  Toprol-XL - 200 mg daily.,7.  Protonix - 40 mg daily.,8.  Chondroitin/glucosamine - no longer using.,MAJOR FINDINGS:,  Weight 240, blood pressure by nurse 160/80, by me 140/78, pulse 91 and regular, and O2 saturation 94%.  He is afebrile.  JVP is normal without HJR.  CTAP.  RRR.  S1 and S2.  Aortic murmur unchanged.  Abdomen:  Soft, NT without HSM, normal BS.  Extremities:  No edema on today's examination.  Awake, alert, attentive, able to get up on to the examination table under his own power.  Able to get up out of a chair with normal get up and go.  Bilateral OA changes of the knee.,Creatinine 1.7, which was down from 2.3.  A1c 7.6 down from 8.5.  Total cholesterol 192, HDL 37, and triglycerides 487.,ASSESSMENTS:,1.  Congestive heart failure, stable on current regimen.  Continue.,2.  Diabetes type II, A1c improved with increased doses of NPH insulin.  Doing self-blood glucose monitoring with values in the morning between 100 and 130.  Continue current regimen.  Recheck A1c on return.,3.  Hyperlipidemia, at last visit, he had 3+ protein in his urine.  TSH was normal.  We will get a 24-hour urine to rule out nephrosis as the cause of his hypertriglyceridemia.  In the interim, both Dr. X and I have been considering together as to whether the patient should have an agent added to treat his hypertriglyceridemia.  Specifically we were considering TriCor (fenofibrate).  Given his problems with high CPK values in the past for now, we have decided not to engage in that strategy.  We will leave open for the future.  Check fasting lipid panel today.,4.  Chronic renal insufficiency, improved with reduction in dose of Bumex over time.,5.  Arthritis, stable.  I told the patient he could use Extra Strength Tylenol up to 4 grams a day, but I suggest that he start with a regular dose of 1 to 2 to 3 grams per day.  He states he will inch that up slowly.  With regard to a brace, he stated he used one in the past and that did not help very much.  I worry a little bit about the tourniquet type effect of a brace that could increase his edema or put him at risk for venous thromboembolic disease.  For now he will continue with his cane and walker.,6.  Health maintenance, flu vaccination today.,PLANS: , Followup in 3 months, by phone sooner as needed.","soap / chart / progress notes, congestive heart failure, diabetes, hyperlipidemia, chronic renal insufficiency, arthritis, chronic medical conditions, heart, "
" Type 1 diabetes mellitus, insulin pump requiring.  Chronic kidney disease, stage III.  Sweet syndrome, hypertension, and dyslipidemia.", SOAP / Chart / Progress Notes, Chronic Kidney Disease Followup - 1 ,"PROBLEMS LIST:,1.  Type 1 diabetes mellitus, insulin pump requiring.,2.  Chronic kidney disease, stage III.,3.  Sweet syndrome.,4.  Hypertension.,5.  Dyslipidemia.,6.  Osteoporosis.,7.  Anemia.,8.  A 25-hydroxy-vitamin D deficiency.,9.  Peripheral neuropathy manifested by insensate feet.,10.  Hypothyroidism.,11.  Diabetic retinopathy.,HISTORY OF PRESENT ILLNESS:,  This is a return visit to the renal clinic for the patient where she is followed up for diabetes and kidney disease management.  Her last visit to this clinic was approximately three months ago.  Since that time, the patient states that she has had some variability in her glucose control too largely to recent upper and lower respiratory illnesses.  She did not seek attention for these, and the symptoms have begun to subside on their own and in the meantime, she continues to have some difficulties with blood sugar management.  Her 14-day average is 191.  She had a high blood sugar this morning, which she attributed to a problem with her infusion set; however, in the clinic after an appropriate correction bolus, she subsequently became quite low.  She was treated appropriately with glucose and crackers, and her blood sugar came back up to over 100.  She was able to manage this completely on her own.  In the meantime, she is not having any other medical problems that have interfered with glucose control.  Her diet has been a little bit different in that she had been away visiting with her family for some period of time as well.,CURRENT MEDICATIONS:,1.  A number of topical creams for her rash.,2.  Hydroxyzine 25 mg 4 times a day.,3.  Claritin 5 mg a day.,4.  Fluoxetine 20 mg a day.,5.  Ergocalciferol 800 international units a day.,6.  Protonix 40 mg a day.,7.  Iron sulfate 1.2 cc every day.,8.  Actonel 35 mg once a week.,9.  Zantac 150 mg daily.,10.  Calcium carbonate 500 mg 3 times a day.,11.  NovoLog insulin via insulin pump about 30 units of insulin daily.,12.  Zocor 40 mg a day.,13.  Valsartan 80 mg daily.,14.  Amlodipine 5 mg a day.,15.  Plavix 75 mg a day.,16.  Aspirin 81 mg a day.,17.  Lasix 20 mg a day.,18.  Levothyroxine 75 micrograms a day.,REVIEW OF SYSTEMS: , Really not much change.  Her upper respiratory symptoms have resolved.  She is not describing fevers, chills, sweats, nausea, vomiting, constipation, diarrhea or abdominal pain.  She is not having any decreased appetite.  She is not having painful urination, any blood in the urine, frequency or hesitancy.  She is not having polyuria, polydipsia or polyphagia.  Her visual acuity has declined, but she does not appear to have any acute change.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 36.1, pulse 56, respirations 16, blood pressure 117/48, and weight is 109.7 pounds.  HEENT:  Examination found her to be atraumatic and normocephalic.  She has pupils that are equal, round, and reactive to light.  Extraocular muscles intact.  Sclerae and conjunctivae are clear.  The paranasal sinuses are nontender.  The nose is patent.  The external auditory canal and tympanic membranes are clear A.U.  Oral cavity and oropharynx examination is free of lesions.  The mucosus membranes are moist.  NECK:  Supple.  There is no lymphadenopathy.  There is no thyromegaly.  THORAX:  Reveals lungs that are clear, PA and lateral, without adventitious sounds.  CARDIOVASCULAR:  Demonstrated regular rate and rhythm.  EXTREMITIES:  Reveal no edema and is otherwise deferred.,ASSESSMENT AND PLAN: , This is a return visit to the renal clinic for the patient with history as noted above.  She has had variability in her glucose control, and the plan today is to continue her current regimen, which includes the following:  Basal rate, 12 a.m. 0.6 units per hour, 4 a.m. 0.7 units per hour, and 9 a.m. 0.6 units per hour.  Her target pre-meal is 120 and bedtime is 150.  Her insulin/carbohydrate ratio is 10 and her correction factor is 60.  We are not going to make any changes to her insulin pump settings at this time.  I have encouraged her to watch the number of processed high-calorie foods that she is consuming late at night.  She has agreed to try that and cut back on this a little bit.  I want to get fasting labs to include her standard labs for us today but include a fasting C-peptide and a hemoglobin A1C, so that we can make arrangements for her to get an upgraded insulin pump.  She states to me that she has been having some battery problems in the recent past, although she says the last time that she went four weeks without having to change batteries and that is about the appropriate amount of time.  Nonetheless, she is out of warranty and we will try to get her a new pump.,Plan to see the patient back here in approximately two months, and we will try to get the new pump through Medicare.",
" Postoperative followup note - Cervicalgia, cervical radiculopathy, and difficulty swallowing status post cervical fusion C3 through C7 with lifting of the plate.", SOAP / Chart / Progress Notes, Cervicalgia ,"FAMILY HISTORY: , Her father died at the age of 80 from prostate cancer.  Her mother died at the age of 67.  She did abuse alcohol.  She had a brother died at the age of 70 from bone and throat cancer.  She has two sons, ages 37 and 38 years old who are healthy.  She has two daughters, ages 60 and 58 years old, both with cancer.  She describes cancer hypertension, nervous condition, kidney disease, lung disease, and depression in her family.,SOCIAL HISTORY: , She is married and has support at home.  Denies tobacco, alcohol, and illicit drug use.,ALLERGIES: , Aspirin.,MEDICATIONS:  ,The patient does not list any current medications.,PAST MEDICAL HISTORY: , Hypertension, depression, and osteoporosis.,PAST SURGICAL HISTORY: , She has had over her over her lifetime four back surgeries and in 2005 she had anterior cervical discectomy and fusion of C3 through C7 by Dr. L.  She is G10, P7, no cesarean sections.,REVIEW OF SYSTEMS: , HEENT:  Headaches, vision changes, dizziness, and sore throat.  GI:  Difficulty swallowing.  Musculoskeletal:  She is right-handed with joint pain, stiffness, decreased range of motion, and arthritis.  Respiratory:  Shortness of breath and cough.  Cardiac:  Chest pain and swelling in her feet and ankle.  Psychiatric:  Anxiety and depression.  Urinary:  Negative and noncontributory.  Hem-Onc:  Negative and noncontributory.  Vascular:  Negative and noncontributory.  Genital:  Negative and noncontributory.,PHYSICAL EXAMINATION:,  On physical exam, she is 5 feet tall and currently weighs 110 pounds; weight one year ago was 145 pounds.  BP 138/78, pulse is 64.  General:  A well-developed, well-nourished female, in no acute distress.  HEENT exam, head is atraumatic and normocephalic.  Eyes, sclerae are anicteric.  Teeth, she does have some poor dentition.  She does say that she needs some of her teeth pulled on her lower mouth.  Cranial nerves II, III, IV, and VI, vision is intact and visual fields are full to confrontation.  EOMs are full bilaterally.  Pupils are equal, round, and reactive to light.  Cranial nerves V and VII, normal facial sensation and symmetrical facial movements.  Cranial nerve VIII, hearing is intact, although decreased bilaterally right worse than left.  Cranial nerves IX, X, and XII, tongue protrudes midline and palate elevates symmetrically.  Cranial nerve XI, strong and symmetrical shoulder shrugs against resistance.  Cardiac, regular rate and rhythm.  Chest and lungs are clear bilaterally.  Skin is warm and dry.  Normal turgor and texture.  No rashes or lesions are noted.  General musculoskeletal exam reveals no gross deformity, fasciculations, and atrophy.  Peripheral vascular, no cyanosis, clubbing, or edema.  She does have some tremoring of her bilateral upper arms as she said.  Strength testing reveals difficulty when testing due to the fact that the patient does have a lot of pain, but she seems to be pretty equal in the bilateral upper extremities with no obvious weakness noted.  She is about 4+/5 in the deltoids, biceps, triceps, wrist flexors, wrist extensors, dorsal interossei, and grip strength.,It is much more painful for her on the left.  Deep tendon reflexes are 2+ bilaterally only at biceps, triceps, and brachioradialis, knees, and ankles.  No ankle clonus is elicited.  Hoffmann's is negative bilaterally.  Sensation is intact.  She ambulates with slow short steps.  No spastic gait is noted.  She has appropriate station and gait with no assisted devices, although she states that she is supposed to be using a cane.  She does not bring one in with her today.,FINDINGS: , Patient brings in cervical spine x-rays and she has had an MRI taken but does not bring that in with her today.  She will obtain that and x rays, which showed at cervical plate C3, C4, C5, C6, and C7 anteriorly with some lifting with the most lifted area at the C3 level.  No fractures are noted.,ASSESSMENT: , Cervicalgia, cervical radiculopathy, and difficulty swallowing status post cervical fusion C3 through C7 with lifting of the plate.,PLAN:,  We went ahead and obtained an EKG in the office today, which demonstrated normal sinus rhythm.  She went ahead and obtained her x-rays and will pick her MRI and return to the office for surgical consultation with Dr. L first available.  She would like the plate removed, so that she can eat and drink better, so that she can proceed with her shoulder surgery.  All questions and concerns were addressed with her.  Warning signs and symptoms were gone over with her.  If she should have any further questions, concerns, or complications, she will contact our office immediately; otherwise, we will see her as scheduled.  I am quite worried about the pain that she is having in her arms, so I would like to see the MRI as well.  Case was reviewed and discussed with Dr. L.","soap / chart / progress notes, c3 through c7, pain scale, mris, x-rays, cervical discectomy and fusion, cervical radiculopathy, cervical fusion, cervical discectomy, cervical plate, difficulty swallowing, cranial nerves, radiculopathy, discectomy, cervicalgia, postoperative, fusion, swallowing, "
 A lady was admitted to the hospital with chest pain and respiratory insufficiency.  She has chronic lung disease with bronchospastic angina., SOAP / Chart / Progress Notes, Chest Pain & Respiratory Insufficiency ,"We discovered new T-wave abnormalities on her EKG.  There was of course a four-vessel bypass surgery in 2001.  We did a coronary angiogram.  This demonstrated patent vein grafts and patent internal mammary vessel and so there was no obvious new disease.,She may continue in the future to have angina and she will have nitroglycerin available for that if needed.,Her blood pressure has been elevated and so instead of metoprolol, we have started her on Coreg 6.25 mg b.i.d.  This should be increased up to 25 mg b.i.d. as preferred antihypertensive in this lady's case.  She also is on an ACE inhibitor.,So her discharge meds are as follows:,1.  Coreg 6.25 mg b.i.d.,2.  Simvastatin 40 mg nightly.,3.  Lisinopril 5 mg b.i.d.,4.  Protonix 40 mg a.m.,5.  Aspirin 160 mg a day.,6.  Lasix 20 mg b.i.d.,7.  Spiriva puff daily.,8.  Albuterol p.r.n. q.i.d.,9.  Advair 500/50 puff b.i.d.,10.  Xopenex q.i.d. and p.r.n.,I will see her in a month to six weeks.  She is to follow up with Dr. X before that.","soap / chart / progress notes, chest pain, respiratory insufficiency, chronic lung disease, bronchospastic angina, insufficiency, chest, angina, respiratory, bronchospastic"
" Followup cervical spinal stenosis.  Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident when she thought she had exacerbated her conditions while lifting several objects.", SOAP / Chart / Progress Notes, Cervical Spinal Stenosis ,"REASON FOR VISIT:  ,Followup cervical spinal stenosis.,HISTORY OF PRESENT ILLNESS:  ,Ms. ABC returns today for followup regarding her cervical spinal stenosis.  I have last seen her on 06/19/07.  Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident on 06/04/07, when she thought she had exacerbated her conditions while lifting several objects.,I referred her to obtain a cervical spine MRI.,She returns today stating that she continues to have right upper extremity pain, paresthesias, weakness, which she believes radiates from her neck.  She had some physical therapy, which has been helping with the neck pain.  The right hand weakness continues.  She states she has a difficult time opening jars, and doors, and often drops items from her right greater than left upper extremity.  She states she have several occasions when she is sleeping at night, she has had sharp shooting radicular pain and weakness down her left upper extremity and she feels that these symptoms somewhat scare her.,She has been undergoing nonoperative management by Dr. X and feels this has been helping her neck pain, but not the upper extremity symptoms.,She denies any bowel and bladder dysfunction.  No lower back pain, no lower extremity pain, and no instability with ambulation.,REVIEW OF SYSTEMS:,  Negative for fevers, chills, chest pain, and shortness of breath.,FINDINGS:  ,On examination, Ms. ABC is a very pleasant well-developed, well-nourished female in no apparent distress.  Alert and oriented x3.  Normocephalic and atraumatic.  Afebrile to touch.,She ambulates with a normal gait.,Motor strength is 4 plus out of 5 in the bilateral deltoids, biceps, triceps muscle groups, 4 out of 5 in the bilateral hand intrinsic muscle groups, grip strength 4 out of 5, 4 plus out of 5 bilateral wrist extension and wrist flexion.,Light touch sensation decreased in the right greater than left C6 distribution.  Biceps and brachioradialis reflexes are 3 plus.  Hoffman sign normal bilaterally.,Lower extremity strength is 5 out of 5 in all muscle groups.  Patellar reflex is 3 plus.  No clonus.,Cervical spine radiographs dated 06/21/07 are reviewed.,They demonstrate evidence of spondylosis including degenerative disk disease and anterior and posterior osteophyte formation at C4-5, C5-6, C6-7, and C3-4 demonstrates only minimal if any degenerative disk disease.  There is no significant instability seen on flexion-extension views.,Updated cervical spine MRI dated 06/21/07 is reviewed.,It demonstrates evidence of moderate stenosis at C4-5, C5-6.  These stenosis is in the bilateral neural foramina and there is also significant disk herniation noted at the C6-7 level.  Minimal degenerative disk disease is seen at the C6-7.  This stenosis is greater than C5-6 and the next level is more significantly involved at C4-5.,Effacement of the ventral and dorsal CSF space is seen at C4-5, C5-6.,ASSESSMENT AND PLAN: , Ms. ABC's history, physical examination, and radiographic findings are compatible with C4-5, C5-6 cervical spinal stenosis with associated right greater than left upper extremity radiculopathy including weakness.,I spent a significant amount of time today with the patient discussing the diagnosis, prognosis, natural history, nonoperative, and operative treatment options.,I laid out the options as continued nonoperative management with physical therapy, the same with the addition of cervical epidural steroid injections and surgical interventions.,The patient states she would like to avoid injections and is somewhat afraid of having these done.  I explained to her that they may help to improve her symptoms, although they may not help with the weakness.,She feels that she is failing maximum nonoperative management and would like to consider surgical intervention.,I described the procedure consisting of C4-5, C5-6 anterior cervical decompression and fusion to the patient in detail on a spine model.,I explained the rationale for doing so including the decompression of the spinal cord and improvement of her upper extremity weakness and pain.  She understands.,I discussed the risks, benefits, and alternative of the procedure including material risks of bleeding, infection, neurovascular injury, dural tear, singular or multiple muscle weakness, paralysis, hoarseness of voice, difficulty swallowing, pseudoarthrosis, adjacent segment disease, and the risk of this given the patient's relatively young age.  Of note, the patient does have a hoarse voice right now, given the fact that she feels she has allergies.,I also discussed the option of disk arthroplasty.  She understands.,She would like to proceed with the surgery, relatively soon.  She has her birthday coming up on 07/20/07 and would like to hold off, until after then.  Our tentative date for the surgery is 08/01/07.  She will go ahead and continue the preoperative testing process.",
" Patient  follows up for cataract extraction with lens implant 2 weeks ago.   Recovering well from her cataract operation in the right eye with residual corneal swelling, which should resolve in the next 2 to 3 weeks.", SOAP / Chart / Progress Notes, Cataract Extraction Followup ,"Her past medical history includes insulin requiring diabetes mellitus for the past 28 years.  She also has a history of gastritis and currently is being evaluated for inflammatory bowel disease.  She is scheduled to see a gastroenterologist in the near future.  She is taking Econopred 8 times a day to the right eye and Nevanac, OD, three times a day.  She is allergic to penicillin.,The visual acuity today was 20/50, pinholing, no improvement in the right eye.  In the left eye, the visual acuity was 20/80, pinholing, no improvement.  The intraocular pressure was 14, OD and 9, OS.  Anterior segment exam shows normal lids, OU.  The conjunctiva is quiet in the right eye.  In the left eye, she has an area of sectoral scleral hyperemia superonasally in the left eye.  The cornea on the right eye shows a paracentral area of mild corneal edema.  In the left eye, cornea is clear.  Anterior chamber in the right eye shows trace cell.  In the left eye, the anterior chamber is deep and quiet.  She has a posterior chamber intraocular lens, well centered and in sulcus of the left eye.  The lens in the left eye shows 3+ nuclear sclerosis.  Vitreous is clear in both eyes.  The optic nerves appear healthy in color and normal in size with cup-to-disc ratio of approximately 0.48.  The maculae are flat in both eyes.  The retinal periphery is flat in both eyes.,Ms. ABC is recovering well from her cataract operation in the right eye with residual corneal swelling, which should resolve in the next 2 to 3 weeks.  She will continue her current drops.  In the left eye, she has an area of what appears to be sectoral scleritis.  I did a comprehensive review of systems today and she reports no changes in her pulmonary, dermatologic, neurologic, gastroenterologic or musculoskeletal systems.  She is, however, being evaluated for inflammatory bowel disease.  The mild scleritis in the left eye may be a manifestation of this.  We will notify her gastroenterologist of this possibility of scleritis and will start Ms. ABC on a course of indomethacin 25 mg by mouth two times a day.  I will see her again in one week.  She will check with her primary physician prior to starting the Indocin.","soap / chart / progress notes, visual acuity, photophobia, lens implant, cataract extraction, eye, cataract, cornealNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a patient with code last night with CPR and advanced cardiac life support., SOAP / Chart / Progress Notes, Care Conference With Family ,"REASON FOR FOLLOWUP:,  Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a patient with code last night with CPR and advanced cardiac life support.,HISTORY OF PRESENT ILLNESS: , This is a 65-year-old patient originally admitted by me several weeks ago with profound hyponatremia and mental status changes.  Her history is also significant for likely recurrent aspiration pneumonia and intubation earlier on this admission as well.  Previously while treating this patient I had met with the family and discussed how aggressive the patient would wish her level of care to be given that there was evidence of possible ovarian malignancy with elevated CA-125 and a complex mass located in the ovary.  As the patient was showing signs of improvement with some speech and ability to follow commands, decision was made to continue to pursue an aggressive level of care, treat her dysphagia, hypertension, debilitation and this was being done.  However, last night the patient had apparently catastrophic event around 2:40 in the morning.  Rapid response was called and the patient was intubated, started on pressure support, and given CPR.  This morning I was called to the bedside by nursing stating the family had wished at this point not to continue this aggressive level of care.  The patient was seen and examined, she was intubated and sedated.  Limbs were cool.  Cardiovascular exam revealed tachycardia.  Lungs had coarse breath sounds.  Abdomen was soft.  Extremities were cool to the touch.  Pupils were 6 to 2 mm, doll's eyes were not intact.  They were not responsive to light.  Based on discussion with all family members involved including both sons, daughter and daughter-in-law, a decision was made to proceed with terminal wean and comfort care measures.  All pressure support was discontinued.  The patient was started on intravenous morphine and respiratory was requested to remove the ET tube.  Monitors were turned off and the patient was made as comfortable as possible.  Family is at the bedside at this time.  The patient appears comfortable and the family is in agreement that this would be her wishes per my understanding of the family and the patient dynamics over the past month, this is a very reasonable and appropriate approach given the patient's failure to turn around after over a month of aggressive treatment with likely terminal illness from ovarian cancer and associated comorbidities.,Total time spent at the bedside today in critical care services, medical decision making and explaining options to the family and proceeding with terminal weaning was excess of 37 minutes.","soap / chart / progress notes, full code status, terminal wean, comfort care, cpr, advanced cardiac life support, care conference, family, bedsideNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 A 60-year-old female presents today for care of painful calluses and benign lesions., SOAP / Chart / Progress Notes, Bunions and Calluses  ,"S -, A 60-year-old female presents today for care of painful calluses and benign lesions.,O -, On examination, the patient has bilateral bunions at the first metatarsophalangeal joint.  She states that they do not hurt.  No pain appears to be produced by active or passive range of motion or palpation and direct pressure of the first metatarsophalangeal joint bilaterally.  The patient has a bilateral pinch callus on the medial aspect of both great toes and there are calluses along the medial aspect of the right foot.  She has a small intractable plantar keratoma, plantar to her left second metatarsal head, which measures 0.5 cm in diameter.  This is a central plug.  She also has a very, very painful lesion plantar to her right fourth metatarsal head which measures 3.1 x 1.8 cm in diameter.  This is a hyperkeratotic lesion that extends deep into the tissue with interrupted skin lines.,A - ,1.  Bilateral bunions.,","soap / chart / progress notes, painful calluses, hibiclens, scrubbed, ointment and absorbent, heloma durum, plantar aspect, minimal hemostasis, neosporin ointment, absorbent dressing, benign lesions, metatarsophalangeal, bunions, calluses, plantar, "
 Problem of essential hypertension.  Symptoms that suggested intracranial pathology., SOAP / Chart / Progress Notes, Cardiology Progress Note ,"SUBJECTIVE:,  The patient is a 78-year-old female with the problem of essential hypertension.  She has symptoms that suggested intracranial pathology, but so far work-up has been negative.,She is taking hydrochlorothiazide 25-mg once a day and K-Dur 10-mEq once a day with adequate control of her blood pressure.  She denies any chest pain, shortness of breath, PND, ankle swelling, or dizziness.,OBJECTIVE:,  Heart rate is 80 and blood pressure is 130/70.  Head and neck are unremarkable.  Heart sounds are normal.  Abdomen is benign.  Extremities are without edema.,ASSESSMENT AND PLAN:,  The patient reports that she had an echocardiogram done in the office of Dr. Sample Doctor4 and was told that she had a massive heart attack in the past.  I have not had the opportunity to review any investigative data like chest x-ray, echocardiogram, EKG, etc.  So, I advised her to have a chest x-ray and an EKG done before her next appointment, and we will try to get hold of the echocardiogram on her from the office of Dr. Sample Doctor4.  In the meantime, she is doing quite well, and she was advised to continue her current medication and return to the office in three months for followup.","soap / chart / progress notes, cardiology, ekg, k-dur, progerss note, soap, ankle swelling, blood pressure, chest x-ray, echocardiogram, essential hypertension, heart attack, hydrochlorothiazide, hypertension, pathology, chest, heart, intracranial,"
" He is a 67-year-old man who suffers from chronic anxiety and coronary artery disease and DJD.  He has been having some chest pains, but overall he does not sound too concerning.  He does note some more shortness of breath than usual.  He has had no palpitations or lightheadedness.  No problems with edema.", SOAP / Chart / Progress Notes, CAD - 6-Month Followup ,"REASON FOR VISIT:,  Six-month follow-up visit for CAD.,He is a 67-year-old man who suffers from chronic anxiety and coronary artery disease and DJD.,He has been having a lot of pain in his back and pain in his left knee.  He is also having trouble getting his nerves under control.  He is having stomach pains and occasional nausea.  His teeth are bad and need to be pulled.,He has been having some chest pains, but overall he does not sound too concerning.  He does note some more shortness of breath than usual.  He has had no palpitations or lightheadedness.  No problems with edema.,MEDICATIONS:,  Lipitor 40 mg q.d., metoprolol 25 mg b.i.d., Plavix 75 mg q.d-discontinued, enalapril 10 mg b.i.d., aspirin 325 mg-reduced to 81 mg, Lorcet 10/650-given a 60 pill prescription, and Xanax 0.5 mg b.i.d-given a 60 pill prescription.,REVIEW OF SYSTEMS: , Otherwise unremarkable.,PEX:,  BP:  140/78.  HR:  65.  WT:  260 pounds (which is up one pound).  There is no JVD.  No carotid bruit.  Cardiac:  Regular rate and rhythm and distant heart sounds with a 1/6 murmur at the upper sternal border.  Lungs:  Clear.  Abdomen:  Mildly tender throughout the epigastrium.,Extremities:  No edema.,EKG:,  Sinus rhythm, left axis deviation, otherwise unremarkable.,Echocardiogram (for dyspnea and CAD):  Normal systolic and diastolic function.  Moderate LVH.  Possible gallstones seen.,IMPRESSION:,1.  CAD-Status post anterior wall MI 07/07 and was found to a have multivessel CAD.  He has a stent in his LAD and his obtuse marginal.  Fairly stable.,2.  Dyspnea-Seems to be due to his weight and the disability from his knee.  His echocardiogram shows no systolic or diastolic function.,3.  Knee pain-We well refer to Scotland Orthopedics and we will refill his prescription for Lorcet 60 pills with no refills.,4.  Dyslipidemia-Excellent numbers today with cholesterol of 115, HDL 45, triglycerides 187, and LDL 33, samples of Lipitor given.,5.  Panic attacks and anxiety-Xanax 0.5 mg b.i.d., 60 pills with no refills given.,6.  Abdominal pain-Asked to restart his omeprazole and I am also going to reduce his aspirin to 81 mg q.d.,7.  Prevention-I do not think he needs to be on the Plavix any more as he has been relatively stable for two years.,PLAN:,1.  Discontinue Plavix.,2.  Aspirin reduced to 81 mg a day.,3.  Lorcet and Xanax prescriptions given.,4.  Refer over to Scotland Orthopedics.,5.  Peridex mouthwash given for his poor dentition and told he was cardiovascularly stable and have his teeth extracted.", 
  Congestive heart failure due to rapid atrial fibrillation and systolic dysfunction., SOAP / Chart / Progress Notes, Cardiology Progress Note - 1 ,"SUBJECTIVE: , The patient is not in acute distress.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure of 121/63, pulse is 75, and O2 saturation is 94% on room air.,HEAD AND NECK:  Face is symmetrical.  Cranial nerves are intact.,CHEST:  There is prolonged expiration.,CARDIOVASCULAR:  First and second heart sounds are heard.  No murmur was appreciated.,ABDOMEN:  Soft and nontender.  Bowel sounds are positive.,EXTREMITIES:  He has 2+ pedal swelling.,NEUROLOGIC:  The patient is asleep, but easily arousable.,LABORATORY DATA:,  PTT is 49.  INR is pending.  BUN is improved to 20.6, creatinine is 0.7, sodium is 123, and potassium is 3.8.  AST is down to 45 and ALT to 99.,DIAGNOSTIC STUDIES: , Nuclear stress test showed moderate size, mostly fixed defect involving the inferior wall with a small area of peri-infarct ischemia.  Ejection fraction is 25%.,ASSESSMENT AND PLAN:,1.  Congestive heart failure due to rapid atrial fibrillation and systolic dysfunction.  Continue current treatment as per Cardiology.  We will consider adding ACE inhibitors as renal function improves.,2.  Acute pulmonary edema, resolved.,3.  Rapid atrial fibrillation, rate controlled.  The patient is on beta-blockers and digoxin.  Continue Coumadin.  Monitor INR.,4.  Coronary artery disease with ischemic cardiomyopathy.  Continue beta-blockers.,5.  Urinary tract infection.  Continue Rocephin.,6.  Bilateral perfusion secondary to congestive heart failure.  We will monitor.,7.  Chronic obstructive pulmonary disease, stable.,8.  Abnormal liver function due to congestive heart failure with liver congestion, improving.,9.  Rule out hypercholesterolemia.  We will check lipid profile.,10.  Tobacco smoking disorder.  The patient has been counseled.,11.  Hyponatremia, stable.  This is due to fluid overload.  Continue diuresis as per Nephrology.,12.  Deep venous thrombosis prophylaxis.  The patient is on heparin drip.","soap / chart / progress notes, atrial fibrillation, systolic dysfunction, ace inhibitors, coronary artery disease, rapid atrial fibrillation, congestive heart failure, beta blockers, heart failure, congestive, heart, asleep, "
 Dietary consultation for carbohydrate counting for type I diabetes., SOAP / Chart / Progress Notes, Carbohydrate Counting ,"SUBJECTIVE:,  This is a 62-year-old female who comes for dietary consultation for carbohydrate counting for type I diabetes.  The patient reports that she was hospitalized over the weekend for DKA.  She indicates that her blood sugar on Friday night was 187 at bedtime and that when she woke up in the morning her blood sugar was 477.  She gave herself, in smaller increments, a total of 70 extra units of her Humalog.  Ten of those units were injectable; the others were in the forms of pump.  Her blood sugar was over 600 when she went to the hospital later that day.  She is here at this consultation complaining of not feeling well still because she has a cold.  She realizes that this is likely because her immune system was so minimized in the hospital.,OBJECTIVE:,  Current insulin doses on her insulin pump are boluses set at 5 units at breakfast, 6 units at lunch and 11 units at supper.  Her basal rates have not been changed since her last visit with Charla Yassine and totaled 30.5 units per 24 hours.  A diet history was obtained.  I instructed the patient on carbohydrate counting at 1 unit of insulin for every 10 g carbohydrate ratio was recommended.  A correction dose of approximately 1 unit of insulin to bring the blood sugars down 30 mg/dl was also recommended.  The Lilly guide for meal planning was provided and reviewed.  Additional carbohydrate counting book was provided.,ASSESSMENT:,  The patient was taught an insulin-to-carbohydrate ratio of 1 unit to 10 g of carbohydrates as recommended at the previous visit two years ago, which she does not recall.  It is based on the 500 rule which suggests this ratio.  We did identify carbohydrate sources in the food supply, recognizing 15-g equivalents.  We also identified the need to dose her insulin at the time that she is eating her carbohydrate sources.  She does seem to have a pattern of fixing blood sugars later in the day after they are elevated.  We discussed the other option of trying to eat a consistent amount of carbohydrates at meals from day to day and taking a consistent amount of insulin at those meals.  With this in mind, she was recommended to follow with three servings or 45 g of carbohydrate at breakfast, three servings or 45 g of carbohydrate at lunch and four servings or 60 g of carbohydrate at dinner.  Joanne Araiza joined our consultation briefly to discuss whether her pump was working appropriately.  The patient was given an 800 number for the pump to contact should there be any question about its failure to deliver insulin appropriately.,PLAN:,  Recommend the patient use 1 unit of insulin for every 10-g carbohydrate load consumed.  Recommend the patient either use this as a carbohydrate counting tool or work harder at keeping carbohydrate content consistent at meals from day to day.  This was a one-hour consultation.  Provided my name and number should additional needs arise.","soap / chart / progress notes, insulin pump, carbohydrate load, immune system, dietary consultation, carbohydrate ratio, blood sugars, carbohydrate counting, carbohydrate, dietary, blood, counting, insulin"
 The patient seeks evaluation for a second opinion concerning cataract extraction.  , SOAP / Chart / Progress Notes, Cataract - Second Opinion ,"SUBJECTIVE:  ,The patient seeks evaluation for a second opinion concerning cataract extraction.  She tells me cataract extraction has been recommended in each eye; however, she is nervous to have surgery.  Past ocular surgery history is significant for neurovascular age-related macular degeneration.  She states she has had laser four times to the macula on the right and two times to the left, she sees Dr. X for this.,OBJECTIVE: , On examination, visual acuity with correction measures 20/400 OU.  Manifest refraction does not improve this.  There is no afferent pupillary defect.  Visual fields are grossly full to hand motions.  Intraocular pressure measures 17 mm in each eye.  Slit-lamp examination is significant for clear corneas OU.  There is early nuclear sclerosis in both eyes.  There is a sheet like 1-2+ posterior subcapsular cataract on the left.  Dilated examination shows choroidal neovascularization with subretinal heme and blood in both eyes.,ASSESSMENT/PLAN:  ,Advanced neurovascular age-related macular degeneration OU, this is ultimately visually limiting.  Cataracts are present in both eyes.  I doubt cataract removal will help increase visual acuity; however, I did discuss with the patient, especially in the left, cataract surgery will help Dr. X better visualize the macula for future laser treatment so that her current vision can be maintained.  This information was conveyed with the use of a translator.,","soap / chart / progress notes, advanced neurovascular age-related macular degeneration, neurovascular age, macular degeneration, visual acuity, cataract extraction, neurovascular, degeneration, visual, eyes, macular, cataract,"
" Breast radiation therapy followup note. Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.", SOAP / Chart / Progress Notes, Breast Radiation Therapy Followup ,"DIAGNOSIS: , Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.,She has been found more recently to have stage IV disease with metastatic deposits and recurrence involving the chest wall and lower left neck lymph nodes.,CURRENT MEDICATIONS,1.  Glucosamine complex.,2.  Toprol XL.,3.  Alprazolam,4.  Hydrochlorothiazide.,5.  Dyazide.,6.  Centrum.,Dr. X has given her some carboplatin and Taxol more recently and feels that she would benefit from electron beam radiotherapy to the left chest wall as well as the neck.  She previously received a total of 46.8 Gy in 26 fractions of external beam radiotherapy to the left supraclavicular area.  As such, I feel that we could safely re-treat the lower neck.  Her weight has increased to 189.5 from 185.2.  She does complain of some coughing and fatigue.,PHYSICAL EXAMINATION,NECK:  On physical examination palpable lymphadenopathy is present in the left lower neck and supraclavicular area.  No other cervical lymphadenopathy or supraclavicular lymphadenopathy is present.,RESPIRATORY:  Good air entry bilaterally. Examination of the chest wall reveals a small lesion where the chest wall recurrence was resected.  No lumps, bumps or evidence of disease involving the right breast is present.,ABDOMEN:  Normal bowel sounds, no hepatomegaly.  No tenderness on deep palpation. She has just started her last cycle of chemotherapy today, and she wishes to visit her daughter in Brooklyn, New York. After this she will return in approximately 3 to 4 weeks and begin her radiotherapy treatment at that time.,I look forward to keeping you informed of her progress.  Thank you for having allowed me to participate in her care.","soap / chart / progress notes, carboplatin, taxol, radiation therapy, breast adenocarcinoma, beam radiotherapy, chest wall, radiotherapy, supraclavicular, lymphadenopathy, adenocarcinoma, breast,"
" Atrial fibrillation with rapid ventricular response, Wolff-Parkinson White Syndrome, recent aortic valve replacement with bioprosthetic Medtronic valve, and hyperlipidemia.", SOAP / Chart / Progress Notes, Atrial Fibrillation - SOAP ,"SUBJECTIVE: , The patient states that she feels better.  She is on IV amiodarone, the dosage pattern is appropriate for ventricular tachycardia.  Researching the available records, I find only an EMS verbal statement that tachycardia of wide complex was seen.  There is no strip for me to review all available EKG tracings show a narrow complex atrial fibrillation pattern that is now converted to sinus rhythm.,The patient states that for a week, she has been home postoperative from aortic valve replacement on 12/01/08 at ABC Medical Center.  The aortic stenosis was secondary to a congenital bicuspid valve, by her description.  She states that her shortness of breath with exertion has been stable, but has yet to improve from its preoperative condition.  She has not had any decline in her postoperative period of her tolerance to exertion.,The patient had noted intermittent bursts of fast heart rate at home that had been increasing over the last several days.  Last night, she had a prolonged episode for which she contacted EMS.  Her medications at home had been uninterrupted and without change from those listed, being Toprol-XL 100 mg q.a.m., Dyazide 25/37.5 mg, Nexium 40 mg, all taken once a day.  She has been maintaining her Crestor and Zetia at 20 and 10 mg respectively.  She states that she has been taking her aspirin at 325 mg q.a.m.  She remains on Zyrtec 10 mg q.a.m.  Her only allergy is listed to latex.,OBJECTIVE:,VITAL SIGNS:  Temperature 36.1, heart rate 60, respirations 14, room air saturation 98%, and blood pressure 108/60.  The patient shows a normal sinus rhythm on the telemetry monitor with an occasional PAC.,GENERAL:  She is alert and in no apparent distress.,HEENT:  Eyes:  EOMI.  PERRLA.  Sclerae nonicteric.  No lesions of lids, lashes, brows, or conjunctivae noted.  Funduscopic examination unremarkable.  Ears:  Normal set, shape, TMs, canals and hearing.  Nose and Sinuses:  Negative.  Mouth, Tongue, Teeth, and Throat:  Negative except for dental work.,NECK:  Supple and pain free without bruit, JVD, adenopathy or thyroid abnormality.,CHEST:  Lungs are clear bilaterally to auscultation.  The incision is well healed and without evidence of significant cellulitis.,HEART:  Shows a regular rate and rhythm without murmur, gallop, heave, click, thrill or rub.  There is an occasional extra beat noted, which corresponds to a premature atrial contraction on the monitor.,ABDOMEN:  Soft and benign without hepatosplenomegaly, rebound, rigidity or guarding.,EXTREMITIES:  Show no evidence of DVT, acute arthritis, cellulitis or pedal edema.,NEUROLOGIC:  Nonfocal without lateralizing findings for cranial or peripheral nervous systems, strength, sensation, and cerebellar function.  Gait and station were not tested.,MENTAL STATUS:  Shows the patient to be alert, coherent with full capacity for decision making.,BACK:  Negative to inspection or percussion.,LABORATORY DATA: , Shows from 12/15/08 2100, hemoglobin 11.6, white count 12.9, and platelets 126,000.  INR 1.0.  Electrolytes are normal with exception potassium 3.3.  GFR is decreased at 50 with creatinine of 1.1.  Glucose was 119.  Magnesium was 2.3.  Phosphorus 3.8.  Calcium was slightly low at 7.8.  The patient has had ionized calcium checked at Munson that was normal at 4.5 prior to her discharge.  Troponin is negative x2 from 2100 and repeat at 07:32.  This morning, her BNP was 163 at admission.  Her admission chest x-ray was unremarkable and did not show evidence of cardiomegaly to suggest pericardial effusion.  Her current EKG tracing from 05:42 shows a sinus bradycardia with Wolff-Parkinson White Pattern, a rate of 58 beats per minute, and a corrected QT interval of 557 milliseconds.  Her PR interval was 0.12.,We received a call from Munson Medical Center that a bed had been arranged for the patient.  I contacted Dr. Varner and we reviewed the patient's managed to this point.  All combined impression is that the patient was likely to not have had actual ventricular tachycardia.  This is based on her EP study from October showing her to be non-inducible.  In addition, she had a cardiac catheterization that showed no evidence of coronary artery disease.  What is most likely that the patient has postoperative atrial fibrillation.  Her WPW may have degenerated into a ventricular tachycardia, but this is unlikely.  At this point, we will convert the patient from IV amiodarone to oral amiodarone and obtain an echocardiogram to verify that she does not have evidence of pericardial effusion in the postoperative period.  I will recheck her potassium, magnesium, calcium, and phosphorus at this point and make adjustments if indicated.  Dr. Varner will be making arrangements for an outpatient Holter monitor and further followup post-discharge.,IMPRESSION:,1.  Atrial fibrillation with rapid ventricular response.,2.  Wolff-Parkinson White Syndrome.,3.  Recent aortic valve replacement with bioprosthetic Medtronic valve.,4.  Hyperlipidemia.","soap / chart / progress notes, ventricular tachycardia, wolff-parkinson white syndrome., ventricular response, medtronic valve, wolff parkinson white syndrome, aortic valve replacement, atrial fibrillation, atrial, aortic, tachycardia, fibrillation, ventricular, valve, medtronic, "
" A nurse with a history of breast cancer enrolled is clinical trial C40502.  Her previous treatments included Zometa, Faslodex, and Aromasin.  She was found to have disease progression first noted by rising tumor markers.", SOAP / Chart / Progress Notes, Breast Cancer Followup ,"CHIEF COMPLAINT:,1.  Metastatic breast cancer.,2.  Enrolled is clinical trial C40502.,3.  Sinus pain.,HISTORY OF PRESENT ILLNESS: , She is a very pleasant 59-year-old nurse with a history of breast cancer.  She was initially diagnosed in June 1994.  Her previous treatments included Zometa, Faslodex, and Aromasin.  She was found to have disease progression first noted by rising tumor markers.  PET/CT scan revealed metastatic disease and she was enrolled in clinical trial of CTSU/C40502.  She was randomized to the ixabepilone plus Avastin.  She experienced dose-limiting toxicity with the fourth cycle.  The Ixempra was skipped on day 1 and day 8.  She then had a dose reduction and has been tolerating treatment well with the exception of progressive neuropathy.  Early in the month she had concerned about possible perforated septum.  She was seen by ENT urgently.  She was found to have nasal septum intact.  She comes into clinic today for day eight Ixempra.,CURRENT MEDICATIONS:  ,Zometa monthly, calcium with Vitamin D q.d., multivitamin q.d., Ambien 5 mg q.h.s., Pepcid AC 20 mg q.d., Effexor 112 mg q.d., Lyrica 100 mg at bedtime, Tylenol p.r.n., Ultram p.r.n., Mucinex one to two tablets b.i.d., Neosporin applied to the nasal mucosa b.i.d. nasal rinse daily.,ALLERGIES:  ,Compazine.,REVIEW OF SYSTEMS: , The patient is comfort in knowing that she does not have a septal perforation.  She has progressive neuropathy and decreased sensation in her fingertips.  She makes many errors when keyboarding.  I would rate her neuropathy as grade 2.  She continues to have headaches respond to Ultram which she takes as needed.  She occasionally reports pain in her right upper quadrant as well as right sternum.  He denies any fevers, chills, or night sweats.  Her diarrhea has finally resolved and her bowels are back to normal.  The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:","soap / chart / progress notes, zometa, faslodex, aromasin, dose-limiting toxicity, metastatic breast cancer, perforated septum, nasal septum, clinical trial, breast cancer, disease, metastatic, breast, cancer, "
" School reports continuing difficulties with repetitive questioning, obsession with cleanness on a daily basis, concerned about his inability to relate this well in the classroom.   Asperger disorder.  Obsessive compulsive disorder.", SOAP / Chart / Progress Notes, Asperger Disorder ,"SUBJECTIVE:  ,School reports continuing difficulties with repetitive questioning, obsession with cleanness on a daily basis, concerned about his inability to relate this well in the classroom.  He appears confused and depressed at times.  Mother also indicates that preservative questioning had come down, but he started collecting old little toys that he did in the past.  He will attend social skills program in the summer.  ABCD indicated to me that they have identified two psychologists to refer him to for functional behavioral analysis.  There is lessening of tremoring in both hands since discontinuation of Zoloft.  He is now currently taking Abilify at 7.5 mg.,OBJECTIVE: , He came in less perseverative questioning, asked appropriate question about whether I talked to ABCD or not, greeted me with Japanese word to say hello, seemed less.,I also note that his tremors were less from the last time.,ASSESSMENT: , 299.8 Asperger disorder, 300.03 obsessive compulsive disorder.,PLAN:,  Decrease Abilify from 7.5 mg to 5 mg tablet one a day, no refills needed.  I am introducing slow Luvox 25 mg tablet one-half a.m. for OCD symptoms, if no side effects in one week we will to tablet one up to therapeutic level.,I also will call ABCD regarding the referral to psychologists for functional behavioral analysis.  Parents will call me in two weeks.  I will see him for medication review in four weeks.  Mother signed informed consent.  I reviewed side effects to observe including behavioral activation.,Abilify has been helpful in decreasing high emotional arousal.  Combination of medication and behavioral intervention is recommended.","soap / chart / progress notes, repetitive questioning, obsession with cleanness, inability to relate, obsessive compulsive disorder, functional behavioral analysis, asperger disorder, inability, asperger, "
" Stage IIA right breast cancer.  The pathology showed an infiltrating ductal carcinoma Nottingham grade II.  The tumor was ER positive, PR positive and HER-2/neu negative.", SOAP / Chart / Progress Notes, Breast Cancer Followup - 1 ,"CHIEF COMPLAINT:,  Stage IIA right breast cancer.,HISTORY OF PRESENT ILLNESS:  ,This is an extremely pleasant 58-year-old woman, who I am following for her stage IIA right breast cancer.  She noticed a lump in the breast in November of 2007.  A mammogram was obtained dated 01/28/08, which showed a mass in the right breast.  On 02/10/08, she underwent an ultrasound-guided biopsy.  The pathology showed an infiltrating ductal carcinoma Nottingham grade II.  The tumor was ER positive, PR positive and HER-2/neu negative.  On 02/22/08, she underwent a lumpectomy and sentinel lymph node biopsy.  The pathology showed a 3.3 cm infiltrating ductal carcinoma grade I, one sentinel lymph node was negative.  Therefore it was a T2, N0, M0 stage IIA breast cancer.  Of note, at that time she was taking hormone replacement therapy and that was stopped.  She underwent radiation treatment ending in May 2008.  She then started on Arimidex, but unfortunately she did not tolerate the Arimidex and I changed her to Femara.  She also did not tolerate the Femara and I changed it to tamoxifen.  She did not tolerate the tamoxifen and therefore when I saw her on 11/23/09, she decided that she would take no further antiestrogen therapy.  She met with me again on 02/22/10, and decided she wants to rechallenge herself with tamoxifen.  When I saw her on 04/28/10, she was really doing quite well with tamoxifen.  She tells me 2 weeks after that visit, she developed toxicity from the tamoxifen and therefore stopped it herself.  She is not going take to any further tamoxifen.,Overall, she is feeling well.  She has a good energy level and her ECOG performance status is 0.  She denies any fevers, chills, or night sweats.  No lymphadenopathy.  No nausea or vomiting.  No change in bowel or bladder habits.,CURRENT MEDICATIONS:,  Avapro 300 mg q.d., Pepcid q.d., Zyrtec p.r.n., and calcium q.d.,ALLERGIES:,  Sulfa, Betadine, and IV contrast.,REVIEW OF SYSTEMS: , As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1.  Asthma.,2.  Hypertension.,3.  GERD.,4.  Eczema.,5.  Status post three cesarean sections.,6.  Status post a hysterectomy in 1981 for fibroids.  They also removed one ovary.,7.  Status post a cholecystectomy in 1993.,8.  She has a history of a positive TB test.,9.  She is status post repair of ventral hernia in November 2008.,SOCIAL HISTORY: , She has no tobacco use.  Only occasional alcohol use.  She has no illicit drug use.  She has two grown children.  She is married.  She works as a social worker dealing with adult abuse and neglect issues.  Her husband is a high school chemistry teacher.,FAMILY HISTORY:  ,Her father had prostate cancer.  Her maternal uncle had Hodgkin's disease, melanoma, and prostate cancer.,PHYSICAL EXAM:,VIT:",
 A 75-year-old female comes in with concerns of having a stroke., SOAP / Chart / Progress Notes, Bell's Palsy ,"SUBJECTIVE:,  The patient is a 75-year-old female who comes in today with concerns of having a stroke.  She states she feels like she has something in her throat.  She started with some dizziness this morning and some left hand and left jaw numbness.  She said that she apparently had something about three weeks ago where she was dizzy and ended up falling down and she saw Dr. XYZ for that who gave her some Antivert.  She said that today though she woke up in the middle of the night and her left hand was numb and she was having numbness on the left side of her face, as well as the left side of her neck.  She said she had an earache a day or so ago.  She has not had any cold symptoms.,ALLERGIES:,  Demerol and codeine.,MEDICATIONS: , Lotensin, Lopid, metoprolol, and Darvocet.,REVIEW OF SYSTEMS:,  The patient says that she feels little bit nauseated at times.  She denies chest pain or shortness of breath and again feels like she has something in her throat.  She has been able to swallow liquids okay.  She said that she did brush her teeth this morning and did not have any fluid dripping out of her mouth.  She does say that she occasionally has numbness in her left hand prior to today.,PHYSICAL EXAMINATION:,General:  She is awake and alert, no acute distress.,Vital Signs:  Blood pressure:  175/86.  Temperature:  She is afebrile.  Pulse:  78.  Respiratory rate:  20.  O2 sat:  93% on room air.,HEENT:  Her TMs are normal bilaterally.  Posterior pharynx is unremarkable.  It should be noted that her uvula did not deviate and neither did her tongue.  When she smiles though she has some drooping of the left side of her face, as well as some mild nasolabial fold flattening.,Neck:  Without adenopathy or thyromegaly.  Carotids pulses are brisk without bruits.,Lungs:  Clear to auscultation.,Heart:  Regular rate and rhythm without murmur.,Extremities:  Her muscle strength is symmetrical and intact bilaterally.  DTRs are 2+/4+ bilaterally and muscle strength is intact in the upper extremities.  She has a positive Tinel’s sign on her left wrist.,Neurological:  I also took monofilament and she could sense it easily when testing her sensation on her face.,ASSESSMENT:,  Bell’s Palsy.,PLAN:,  We did get an EKG showed some ST segment changes anterolaterally.  The only EKG I have here is from 1998 and she actually had bypass in 1999, but there certainly does not appear to be anything acute on his EKG.  I assured her that it does not look like she has a stroke.  If she wants to prevent a stroke, obviously quitting her smoking would help.  It should be noted she also takes Synthroid and Zocor.  We are going to give her Valtrex 1 g t.i.d. for seven days and then if she starts noticing any other drooping or worsening of her symptoms on the left side of her face, she needs to come back, but I will not start her on steroids at this time, which she agreed with.","soap / chart / progress notes, stroke, bell’s palsy, st segment changes, ekg, dizziness, numbness, dizzy, muscle strength, palsy, bell’s"
 A critically ill 67-year-old with multiple medical problems probably still showing signs of volume depletion with hypotension and atrial flutter with difficult to control rate., SOAP / Chart / Progress Notes, Atrial Flutter - Progress Note ,"HISTORY OF PRESENT ILLNESS: , Hospitalist followup is required for continuing issues with atrial flutter with rapid ventricular response, which was resistant to treatment with diltiazem and amiodarone, being followed by Dr. X of cardiology through most of the day.  This afternoon, when I am seeing the patient, nursing informs me that rate has finally been controlled with esmolol, but systolic blood pressures have dropped to the 70s with a MAP of 52.  Dr. X was again consulted from the bedside.  We agreed to try fluid boluses and then to consider Neo-Synephrine pressure support if this is not successful.  In addition, over the last 24 hours, extensive discussions have been held with the family and questions answered by nursing staff concerning the patient's possible move to Tahoe Pacific or a long-term acute care.  Other issues requiring following up today are elevated transaminases, continuing fever, pneumonia, resolving adult respiratory distress syndrome, ventilatory-dependent respiratory failure, hypokalemia, non-ST-elevation MI, hypernatremia, chronic obstructive pulmonary disease, BPH, atrial flutter, inferior vena cava filter, and diabetes.,PHYSICAL EXAMINATION,VITAL SIGNS:  T-max 103.2, blood pressure at this point is running in the 70s/mid 40s with a MAP of 52, heart rate is 100.,GENERAL:  The patient is much more alert appearing than my last examination of approximately 3 weeks ago.  He denies any pain, appears to have intact mentation, and is in no apparent distress.,EYES:  Pupils round, reactive to light, anicteric with external ocular motions intact.,CARDIOVASCULAR:  Reveals an irregularly irregular rhythm.,LUNGS:  Have diminished breath sounds but are clear anteriorly.,ABDOMEN:  Somewhat distended but with no guarding, rebound, or obvious tenderness to palpation.,EXTREMITIES:  Show trace edema with no clubbing or cyanosis.,NEUROLOGICAL:  The patient is moving all extremities without focal neurological deficits.,LABORATORY DATA: , Sodium 149; this is down from 151 yesterday.  Potassium 3.9, chloride 114, bicarb 25, BUN 35, creatinine 1.5 up from 1.2 yesterday, hemoglobin 12.4, hematocrit 36.3, WBC 16.5, platelets 231,000.  INR 1.4.  Transaminases are continuing to trend upwards of SGOT 546, SGPT 256.  Also noted is a scant amount of very concentrated appearing urine in the bag.,IMPRESSION: , Overall impressions continues to be critically ill 67-year-old with multiple medical problems probably still showing signs of volume depletion with hypotension and atrial flutter with difficult to control rate.,PLAN,1.  Hypotension.  I would aggressively try and fluid replete the patient giving him another liter of fluids.  If this does not work as discussed with Dr. X, we will start some Neo-Synephrine, but also continue with aggressive fluid repletion as I do think that indications are that with diminished and concentrated urine that he may still be down and fluids will still be required even if pressure support is started.,2.  Increased transaminases.  Presumably this is from increased congestion.  This is certainly concerning.  We will continue to follow this.  Ultrasound of the liver was apparently negative.,3.  Fever and elevated white count.  The patient does have a history of pneumonia and empyema.  We will continue current antibiotics per infectious disease and continue to follow the patient's white count.  He is not exceptionally toxic appearing at this time.  Indeed, he does look improved from my last examination.,4.  Ventilatory-dependent respiratory failure.  The patient has received a tracheostomy since my last examination.  Vent management per PMA.,5.  Hypokalemia.  This has resolved.  Continue supplementation.,6.  Hypernatremia.  This is improving somewhat.  I am hoping that with increased fluids this will continue to do so.,7.  Diabetes mellitus.  Fingerstick blood glucoses are reviewed and are at target.  We will continue current management.  This is a critically ill patient with multiorgan dysfunction and signs of worsening renal, hepatic, and cardiovascular function with extremely guarded prognosis.  Total critical care time spent today 37 minutes.","soap / chart / progress notes, rapid ventricular response, volume depletion, atrial flutter, atrial, hypotension, flutter, "
" Aplastic anemia.  After several bone marrow biopsies, she was diagnosed with aplastic anemia.  She started cyclosporine and prednisone.", SOAP / Chart / Progress Notes, Aplastic Anemia Followup ,"CHIEF COMPLAINT: , Aplastic anemia.,HISTORY OF PRESENT ILLNESS: , This is a very pleasant 72-year-old woman, who I have been following for her pancytopenia.  After several bone marrow biopsies, she was diagnosed with aplastic anemia.  She started cyclosporine and prednisone on 03/30/10.  She was admitted to the hospital from 07/11/10 to 07/14/10 with acute kidney injury.  Her cyclosporine level was 555.  It was thought that her acute kidney injury was due to cyclosporine toxicity and therefore that was held.,Overall, she tells me that now she feels quite well since leaving the hospital.  She was transfused 2 units of packed red blood cells while in the hospital.  Repeat CBC from 07/26/10 showed white blood cell count of 3.4 with a hemoglobin of 10.7 and platelet count of 49,000.,CURRENT MEDICATIONS:,  Folic acid, Aciphex, MiraLax, trazodone, prednisone for 5 days every 4 weeks, Bactrim double strength 1 tablet b.i.d. on Mondays, Wednesdays and Fridays.,ALLERGIES:  ,No known drug allergies.,REVIEW OF SYSTEMS: , As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1.  Hypertension.,2.  GERD.,3.  Osteoarthritis.,4.  Status post tonsillectomy.,5.  Status post hysterectomy.,6.  Status post bilateral cataract surgery.,7.  Esophageal stricture status post dilatation approximately four times.,SOCIAL HISTORY:  ,She has no tobacco use.  She has rare alcohol use.  She has three children and is a widow.  Her husband died after they were married only eight years.  She is retired.,FAMILY HISTORY: , Her sister had breast cancer.,PHYSICAL EXAM:,VIT:",
" Return visit to the endocrine clinic for acquired hypothyroidism, papillary carcinoma of the thyroid gland status post total thyroidectomy in 1992, and diabetes mellitus.", SOAP / Chart / Progress Notes, Acquired Hypothyroidism Followup ,"PROBLEM LIST:,1.  Acquired hypothyroidism.,2.  Papillary carcinoma of the thyroid gland, status post total thyroidectomy in 1992.,3.  Diabetes mellitus.,4.  Insomnia with sleep apnea.,HISTORY OF PRESENT ILLNESS: , This is a return visit to the endocrine clinic for the patient with history as noted above.  She is 45 years old.  Her last visit was about 6 months ago.  Since that time, the patient states her health has remained unchanged.  Currently, primary complaint is one of fatigue that she feels throughout the day.  She states, however, she is doing well with CPAP and wakes up feeling refreshed but tends to tire out later in the day.  In terms of her thyroid issues, the patient states that she is not having signs or symptoms of thyroid excess or hypothyroidism.  She is not reporting temperature intolerance, palpitations, muscle weakness, tremors, nausea, vomiting, constipation, hyperdefecation or diarrhea.  Her weight has been stable.  She is not reporting proximal muscle weakness.,CURRENT MEDICATIONS:,1.  Levothyroxine 125 micrograms p.o. once daily.,2.  CPAP.,3.  Glucotrol.,4.  Avandamet.,5.  Synthroid.,6.  Byetta injected twice daily.,REVIEW OF SYSTEMS: , As stated in the HPI.  She is not reporting polyuria, polydipsia or polyphagia.  She is not reporting fevers, chills, sweats, visual acuity changes, nausea, vomiting, constipation or diarrhea.  She is not having any lightheadedness, weakness, chest pain, shortness of breath, difficulty breathing, orthopnea or dyspnea on exertion.,PHYSICAL EXAMINATION:,GENERAL:  She is an overweight, very pleasant woman, in no acute distress.  VITAL SIGNS:  Temperature 96.9, pulse 85, respirations not counted, blood pressure 135/65, and weight 85.7 kg.  NECK:  Reveals well healed surgical scar in the anteroinferior aspect of the neck.  There is no palpable thyroid tissue noted on this examination today.  There is no lymphadenopathy.  THORAX:  Reveals lungs that are clear, PA and lateral, without adventitious sounds.  CARDIOVASCULAR:  Demonstrated regular rate and rhythm.  S1 and S2 without murmur.  No S3, no S4 is auscultated.  EXTREMITIES:  Deep tendon reflexes 2+/4 without a delayed relaxation phase.  No fine resting tremor of the outstretched upper extremity.  SKIN, HAIR, AND NAILS:  All are unremarkable.,LABORATORY DATABASE: , Lab data on 08/29/07 showed the following:  Thyroglobulin quantitative less than 0.5 and thyroglobulin antibody less than 20, free T4 1.35, and TSH suppressed at 0.121.,ASSESSMENT AND PLAN:,This is a 45-year-old woman with history as noted above.,1.  Acquired hypothyroidism, status post total thyroidectomy for papillary carcinoma in 1992.,2.  Plan to continue following thyroglobulin levels.,3.  Plan to obtain a free T4, TSH, and thyroglobulin levels today.,4.  Have the patient call the clinic next week for followup and continued management of her hypothyroid state.,5.  Plan today is to repeat her thyroid function studies.  This case was discussed with Dr. X and the recommendation.  We are giving the patient today is for us to taper her medication to get her TSH somewhere between 0.41 or less.  Therefore, labs have been drawn.  We plan to see the patient back in approximately 6 months or sooner.  A repeat body scan will not been done, the one in 03/06 was negative.","soap / chart / progress notes, thyroid function studies, thyroid gland, diabetes mellitus, papillary carcinoma, total thyroidectomy, acquired hypothyroidism, carcinoma, thyroidectomy, thyroglobulin, hypothyroidism, "
 Acne with folliculitis., SOAP / Chart / Progress Notes, Acne - SOAP ,"SUBJECTIVE:,  The patient is a 49-year-old white female, established patient to Dermatology, last seen in the office on 08/10/2004.  She comes in today for reevaluation of her acne plus she has had what she calls a rash for the past two months now on her chest, stomach, neck, and back.  On examination, this is a flaring of her acne with small folliculitis lesions.  The patient has been taking amoxicillin 500 mg b.i.d. and using Tazorac cream 0.1, and her face is doing well, but she has been out of her medicine now for three days also.  She has also been getting photofacials at Healing Waters and was wondering about what we could offer as far as cosmetic procedures and skin care products, etc.  The patient is married.  She is a secretary.,FAMILY, SOCIAL, AND ALLERGY HISTORY:,  She has hay fever, eczema, sinus, and hives.  She has no melanoma or skin cancers or psoriasis.  Her mother had oral cancer.  The patient is a nonsmoker.  No blood tests.  Had some sunburn in the past.  She is on benzoyl peroxide and Daypro.,CURRENT MEDICATIONS:,  Lexapro, Effexor, Ditropan, aspirin, vitamins.,PHYSICAL EXAMINATION:,  The patient is well developed, appears stated age.  Overall health is good.  She has a couple of acne lesions, one on her face and neck but there are a lot of small folliculitis-like lesions on her abdomen, chest, and back.,IMPRESSION:,  Acne with folliculitis.,TREATMENT:,1.  Discussed condition and treatment with the patient.,2.  Continue the amoxicillin 500 mg two at bedtime.,3.  Add Septra DS every morning with extra water.,4.  Continue the Tazorac cream 0.1; it is okay to use on back and chest also.,5.  Referred to ABC clinic for an aesthetic consult.  Return in two months for followup evaluation of her acne.","soap / chart / progress notes, acne with folliculitis, tazorac cream, acne, dermatology, tazorac, cream, folliculitis,"
" EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity.", Sleep Medicine, Video EEG - 2 ,"IMPRESSION:  ,EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity.","sleep medicine, ekg artifact, video monitoring, wakefulness, drowsiness, eegNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 A 23-year-old white female presents with complaint of allergies., SOAP / Chart / Progress Notes, Allergic Rhinitis ,"SUBJECTIVE:,  This 23-year-old white female presents with complaint of allergies.  She used to have allergies when she lived in Seattle but she thinks they are worse here.  In the past, she has tried Claritin, and Zyrtec.  Both worked for short time but then seemed to lose effectiveness.  She has used Allegra also.  She used that last summer and she began using it again two weeks ago.  It does not appear to be working very well.  She has used over-the-counter sprays but no prescription nasal sprays.  She does have asthma but doest not require daily medication for this and does not think it is flaring up.,MEDICATIONS: , Her only medication currently is Ortho Tri-Cyclen and the Allegra.,ALLERGIES: , She has no known medicine allergies.,OBJECTIVE:,Vitals:  Weight was 130 pounds and blood pressure 124/78.,HEENT:  Her throat was mildly erythematous without exudate.  Nasal mucosa was erythematous and swollen.  Only clear drainage was seen.  TMs were clear.,Neck:  Supple without adenopathy.,Lungs:  Clear.,ASSESSMENT:,  Allergic rhinitis.,PLAN:,1.  She will try Zyrtec instead of Allegra again.  Another option will be to use loratadine.  She does not think she has prescription coverage so that might be cheaper.,2.  Samples of Nasonex two sprays in each nostril given for three weeks.  A prescription was written as well.","soap / chart / progress notes, allergic rhinitis, allergies, asthma, nasal sprays, rhinitis, nasal, erythematous, allegra, sprays, allergic,"
" Chronic lymphocytic leukemia (CLL), autoimmune hemolytic anemia, and oral ulcer.  The patient was diagnosed with chronic lymphocytic leukemia and was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis.", SOAP / Chart / Progress Notes, Anemia & Leukemia Followup ,"CHIEF COMPLAINT:,1.  Chronic lymphocytic leukemia (CLL).,2.  Autoimmune hemolytic anemia.,3.  Oral ulcer.,HISTORY OF PRESENT ILLNESS: , The patient is a 72-year-old gentleman who was diagnosed with chronic lymphocytic leukemia in May 2008.  He was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis.  He has been on chronic steroids to control his hemolysis and is currently on prednisone 5 mg every other day.  He comes in to clinic today for follow-up and complete blood count.  At his last office visit we discontinued this prophylactic antivirals and antibacterial.,CURRENT MEDICATIONS:,  Prilosec 20 mg b.i.d., levothyroxine 50 mcg q.d., Lopressor 75 mg q.d., vitamin C 500 mg q.d., multivitamin q.d., simvastatin 20 mg q.d., and prednisone 5 mg q.o.d.,ALLERGIES:  ,Vicodin.,REVIEW OF SYSTEMS:  ,The patient reports ulcer on his tongue and his lip.  He has been off of Valtrex for five days.  He is having some difficulty with his night vision with his left eye.  He has a known cataract.  He denies any fevers, chills, or night sweats.  He continues to have headaches.  The rest of his review of systems is negative.,PHYSICAL EXAM:,VITALS:","soap / chart / progress notes, oral ulcer, leukemia, anemia, hemolysis, blood count, chronic lymphocytic leukemia, autoimmune hemolytic anemia, hemolytic, cll, lymphocytic, autoimmune, "
" EEG during wakefulness and light sleep is abnormal with independent, positive sharp wave activity seen in both frontotemporal head regions, more predominant in the right frontotemporal region.", Sleep Medicine, Video EEG - 3 ,"PROCEDURE: , EEG during wakefulness demonstrates background activity consisting of moderate-amplitude beta activity seen bilaterally.  The EEG background is symmetric.  Independent, small, positive, sharp wave activity is seen in the frontotemporal regions bilaterally with sharp-slow wave discharges seen more predominantly in the right frontotemporal head region.  No clinical signs of involuntary movements are noted during synchronous video monitoring.  Recording time is 22 minutes and 22 seconds.  There is attenuation of the background, faster activity during drowsiness and some light sleep is recorded.  No sustained epileptogenic activity is evident, but the independent bilateral sharp wave activity is seen intermittently.  Photic stimulation induced a bilaterally symmetric photic driving response.,IMPRESSION:,  EEG during wakefulness and light sleep is abnormal with independent, positive sharp wave activity seen in both frontotemporal head regions, more predominant in the right frontotemporal region.  The EEG findings are consistent with potentially epileptogenic process.  Clinical correlation is warranted.","sleep medicine, epileptogenic, wakefulness, eeg, frontotemporal, activityNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 The patient has a history of epilepsy and has also had non-epileptic events in the past.  Video EEG monitoring is performed to assess whether it is epileptic seizures or non-epileptic events., Sleep Medicine, Video EEG - 1 ,"DATE OF EXAMINATION: , Start:  12/29/2008 at 1859 hours.  End:  12/30/2008 at 0728 hours.,TOTAL RECORDING TIME:,  12 hours, 29 minutes.,PATIENT HISTORY:,  This is a 46-year-old female with a history of events concerning for seizures.  The patient has a history of epilepsy and has also had non-epileptic events in the past.  Video EEG monitoring is performed to assess whether it is epileptic seizures or non-epileptic events.,VIDEO EEG DIAGNOSES,1.  Awake:  Normal.,2.  Sleep:  Activation of a single left temporal spike seen maximally at T3.,3.  Clinical events:  None.,DESCRIPTION:  ,Approximately 12 hours of continuous 21-channel digital video EEG monitoring was performed.  During the waking state, there is a 9-Hz dominant posterior rhythm.  The background of the record consists primarily of alpha frequency activity.  At times, during the waking portion of the record, there appears to be excessive faster frequency activity.  No activation procedures were performed.,Approximately four hours of intermittent sleep was obtained.  A single left temporal, T3, spike is seen in sleep.  Vertex waves and sleep spindles were present and symmetric.,The patient had no clinical events during the recording.,CLINICAL INTERPRETATION:  ,This is abnormal video EEG monitoring for a patient of this age due to the presence of a single left temporal spike seen during sleep.  The patient had no clinical events during the recording period.  Clinical correlation is required.","sleep medicine, non-epileptic events, temporal spike, eeg monitoring, video eeg, epilepsy, frequency, eeg, epileptic,"
 This is a 43-year-old female with a history of events concerning for seizures.  Video EEG monitoring is performed to capture events and/or identify etiology., Sleep Medicine, Video EEG ,"TIME SEEN: , 0734 hours and 1034 hours.,TOTAL RECORDING TIME: , 27 hours 4 minutes.,PATIENT HISTORY: , This is a 43-year-old female with a history of events concerning for seizures.  Video EEG monitoring is performed to capture events and/or identify etiology.,VIDEO EEG DIAGNOSES,1.  AWAKE:  Normal.,2.  SLEEP:  No activation.,3.  CLINICAL EVENTS:  None.,DESCRIPTION: , Approximately 27 hours of continuous 21-channel digital video EEG monitoring was performed.  The waking background is unchanged from that previously reported.  Hyperventilation produced no changes in the resting record.  Photic stimulation failed to elicit a well-developed photic driving response.,Approximately five-and-half hours of spontaneous intermittent sleep was obtained.  Sleep spindles were present and symmetric.,The patient had no clinical events during the recording.,CLINICAL INTERPRETATION:  ,This is normal video EEG monitoring for a patient of this age.  No interictal epileptiform activity was identified.  The patient had no clinical events during the recording.  Clinical correlation is required.","sleep medicine, electroencephalography, eeg monitoring, video eeg, seizures, eeg,"
 Chronic snoring in children, Sleep Medicine, Snoring ,"CHRONIC SNORING,Chronic snoring in children can be associated with obstructive sleep apnea or upper airway resistant syndrome.  Both conditions may lead to sleep fragmentation and/or intermittent oxygen desaturation, both of which have significant health implications including poor sleep quality and stress on the cardiovascular system.  Symptoms like daytime somnolence, fatigue, hyperactivity, behavior difficulty (i.e., ADHD) and decreased school performance have been reported with these conditions.  In addition, the most severe cases may be associated with right ventricular hypertrophy, pulmonary and/or systemic hypertension and even cor pulmonale.,In this patient, the risks for a sleep-disordered breathing include obesity and the tonsillar hypertrophy.  It is therefore indicated and medically necessary to perform a polysomnogram for further evaluation.  A two week sleep diary will be given to the parents to fill out daily before the polysomnogram is performed.","sleep medicine, snoring, chronic snoring, behavior difficulty, fatigue, hyperactivity, obstructive sleep apnea, oxygen, oxygen desaturation, polysomnogram, poor sleep quality, right ventricular hypertrophy, school performance, sleep fragmentation, somnolence, systemic hypertension, upper airway, upper airway resistant syndrome, snoring chronic, hypertrophy, sleepNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia.  This patient presents with history of sleep disruption and daytime sleepiness with fatigue.  Her symptoms are multifactorial., Sleep Medicine, Sleep Study Followup ,"REASON FOR VISIT:,  This 48-year-old woman returns in followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia.,HISTORY OF PRESENT ILLNESS: , The patient presented initially to the Pulmonary Clinic with dyspnea on minimal exertion.  At that time, she was evaluated and found to have evidence for sleep disruption and daytime fatigue.  She also complained of nocturnal choking episodes that have since abated over the past several months.  In the meantime, she had been scheduled for an overnight sleep study performed to evaluate her for sleep apnea, returns today to review her study results.,The patient's sleep patterns consist of going to bed between 9.00 and 10.00 p.m. and awakening in the morning between 5.00 and 6.00 a.m.  She reports difficulty in initiating sleep and then recurrent awakenings every 1 to 2 hours throughout the night.  She reports tossing and turning throughout the night and awakening with the sheets in disarray.  She reports that her sleep was much better quality in the sleep laboratory as compared to home.  When she awakens, she might have a dull headache and feels tired in the morning.  Her daughter reports that she has heard the patient talking during sleep and snoring.  There are no apneic episodes.  The patient reports that she used to cough a lot in the middle of the night, but has no longer been doing so in recent weeks.,During the daytime, the patient reports spending a lot of sedentary time reading and watching TV.  She routinely dozes off during these sedentary activities.  She also might nap between 2.00 and 3.00 p.m., and nods off in the evening hours.,The patient smokes perhaps one to two packs of cigarettes per day, particularly after dinner.,She reports that her weight has fluctuated and peaked at 260 pounds approximately 1 year ago.  Since that time, her weight is down by approximately 30 pounds.,The patient is managed in Outpatient Psychiatry and at her Maintenance Clinic.  She takes methadone, trazodone, and Seroquel.,PAST MEDICAL HISTORY:,1.  Depression.,2.  Hepatitis C.,3.  Hypertension.,4.  Inhaled and intravenous drug abuse history.,The patient has a history of smoking two packs per day of cigarettes for approximately 25 pounds.  She also has a history of recurrent atypical chest pain for which she has been evaluated.,FAMILY HISTORY: , As previously documented.,SOCIAL HISTORY:  ,The patient has a history of inhalation on intravenous drug abuse.  She is currently on methadone maintenance.  She is being followed in Psychiatry for depression and substance abuse issues.  She lives with a room-mate.,REVIEW OF SYSTEMS:,  Not contributory.,MEDICATIONS: , Current medications include the following:,1.  Methadone 110 mg by mouth every day.,2.  Paxil 60 mg by mouth every day.,3.  Trazodone 30 mg by mouth nightly.,4.  Seroquel 20 mg by mouth nightly.,5.  Avalide (irbesartan) and hydrochlorothiazide.,6.  Albuterol and Flovent inhalers two puffs by mouth twice a day.,7.  Atrovent as needed.,FINDINGS: , Vital Signs:  Blood pressure 126/84, pulse 67, respiratory rate 18, weight 232 pounds, height 5 feet 8 inches, temperature 97.4 degrees, SaO2 is 99 percent on room air at rest.  HEENT:  Sclerae anicteric.  Conjunctivae pink.  Extraocular movements are intact.  Pupils are equal, round, and reactive to light.  The nasal passages show deviation in the nasal septum to the right.  There is a slight bloody exudate at the right naris.  Some nasal mucosal edema was noted with serous exudate bilaterally.  The jaw is not foreshortened.  The tongue is not large.  Mallampati airway score was 3.  The oropharynx was not shallow.  There is no pharyngeal mucosa hypertrophy.  No tonsillar tissue noted.  The tongue is not large.  Neck is supple.  Thyroid without nodules or masses.  Carotid upstrokes normal.  No bruits.  No jugular venous distention.  Chest is clear to auscultation and percussion.  No wheezing, rales, rhonchi or adventitious sounds.  No prolongation of the expiratory phase.  Cardiac:  PMI not palpable.  Regular rate and rhythm.  S1 and S2 normal.  No murmurs or gallops.  Abdomen:  Nontender.  Bowel sounds normal.  No liver or spleen palpable.  Extremities:  No clubbing or cyanosis.  There is 1+ pretibial edema.  Pulses are 2+ in upper and lower extremities.  Neurologic:  Grossly nonfocal.,LABORATORIES:,  Pulmonary function studies reportedly show a mild restrictive ventilatory defect without obstruction.  Diffusing capacity is well preserved.,An overnight sleep study was performed on this patient at the end of 02/07.  At that time, she reported that her sleep was better in the laboratories compared to home.  She slept for a total sleep time of 398 minutes out of 432 minutes in bed (sleep proficiency 92 percent).  She fell asleep in the middle of latency of less than 1 minute.  She woke up after sleep onset of 34 minutes.  She had stage I sleep that was some elevated at 28 percent of total sleep time, and stage I sleep is predominantly evident in the lateral portion of the night.  The remainders were stage II at 69 percent, stage III and IV at 3 percent of total sleep time.,The patient had no REM sleep.,The patient had no periodic limb movements during sleep.,The patient had no significant sleep-disordered breathing during non-REM sleep with less than one episode per hour.  Oxyhemoglobin saturation remained in the low to mid 90s throughout the night.,Intermittent inspiratory flow limitation compatible with snoring was observed during non-REM sleep.,ASSESSMENT AND PLAN: , This patient presents with history of sleep disruption and daytime sleepiness with fatigue.  Her symptoms are multifactorial.,Regarding the etiology of difficulty in initiating and maintaining sleep, the patient has a component of psychophysiologic insomnia, based on reports of better sleep in the laboratory as compared to home.  In addition, nontrivial smoking in the home setting may be contributing significantly to sleep disruption.,Regarding her daytime sleepiness, the patient is taking a number of long-acting central nervous system acting medications to sedate her and can produce a lasting sedation throughout the daytime.  These include trazodone, Seroquel, and methadone.  Of these medications, the methadone is clearly indicative, given the history of substance abuse.  It would be desirable to reduce or discontinue trazodone and then perhaps consider doing the same with Seroquel.  I brought this possibility up with the patient, and I asked her to discuss this further with her psychiatrist.,Finally, to help mitigate sleep disruption at night, I have provided her with tips for sleep hygiene.  These include bedtime rituals, stimulus control therapy, and sleep restriction as well as avoidance of nicotine in the evening hours.",
 The patient underwent an overnight polysomnogram., Sleep Medicine, Overnight Polysomnogram ,"The patient underwent an overnight polysomnogram on 09/22/06 and the details of the polysomnographic study are reported separately.  The highlights of the study include the following:,A.  Obstructive apneas and hypopneas were identified with an overall apnea-hypopnea index of 15.2 events per hour in the supine position.  All events occurred in the supine position and were more prominent during stage REM sleep.  Minimum oxygen saturation was 88%.,B.  Periodic limb movements in sleep were identified with an overall index of 32 events per hour of sleep.,C.  The patient's sleep efficiency was reduced to 89.2%.  There was significant sleep fragmentation due to the obstructive apneas and hypopneas as well as due to the periodic limb movements in sleep disorder.  The patient did not achieve any stage III/IV sleep and stage REM sleep was diminished at 12.7%.  There was a corresponding increase in stage I sleep and stage II sleep at 10.8% and 65.7% respectively.,DIAGNOSTIC IMPRESSION:,1.  Obstructive sleep apnea syndrome, supine position dependent, moderate (780.53-0).,2.  Periodic limb movement in sleep disorder, moderate (780.53-4).,CASE DISCUSSION: , Thank you once again for allowing us to participate in the care of the patient here at the Sleep Clinic.,The patient exhibits obstructive sleep apnea, a condition associated with increased risk of myocardial infarction, stroke and sudden death.  Furthermore, patients with this condition are susceptible to excessive daytime sleepiness while driving and there is a higher incidence of automobile accident.  The patient should be warned with regards to these possibilities.,Patients with this condition can be successfully treated with nasal CPAP (continuous positive airway pressure), so that the patient should return to the sleep laboratory for repeat overnight polysomnogram with CPAP titration.  The sleep laboratory if necessary can introduce the patient to the proper use of the CPAP equipment and to determine a necessary pressure to prevent apneas.,It is reported that the patient undergo careful ENT/maxillofacial evaluation by a physician familiar with sleep disorders.  Anatomical abnormalities in the upper airway often cause or predispose to this condition.  Surgical intervention may be helpful or necessary if such conditions exist.  Alternatively, ________ may be of benefit in some patients depending upon the anatomical abnormalities.,Obstructive sleep apnea is worsened by obesity.  The patient should be encouraged to lose weight.  Patients usually lose weight more effectively when involved in a behavioral weight loss program.  It is sometimes difficult for patients to lose weight until the OSA is adequately treated because excessive daytime sleepiness results in decreased physical activity in the daytime.,Patient may have worsening obstructive sleep apnea by nasal airway obstruction and nasal congestion.  If present, these conditions should be treated.  In addition, any home allergens such as pets, down bedding or other factors should be removed from the sleep environment.,The patient should be informed that obstructive sleep apnea may be worsened by the use of alcohol or sedative medications particularly taken in the evening.  Therefore, the evening use of sedative medications and alcohol are to be avoided.,The patient also exhibits periodic limb movements in sleep disorder.  This may require treatment.  However, it will be appropriate to obtain the repeat overnight polysomnogram with CPAP titration to see if the PLMS continues to be troublesome.  If so, treatment recommendations will be made.","sleep medicine, periodic limb movement, cpap, limb movements in sleep, obstructive sleep apnea, overnight polysomnogram, sleep, overnight, polysomnogram, obstructive, apneas,"
 Obstructive sleep apnea syndrome.  Loud snoring.  Schedule an overnight sleep study., Sleep Medicine, Pulmonary Consultation - 1 ,"CHIEF COMPLAINT:,  Rule out obstructive sleep apnea syndrome.,Sample Patient is a pleasant, 61-year-old, obese, African-American male with a past medical history significant for hypertension, who presents to the Outpatient Clinic with complaints of loud snoring and witnessed apnea episodes by his wife for at least the past five years.  He denies any gasping, choking, or coughing episodes while asleep at night.  His bedtime is between 10 to 11 p.m., has no difficulty falling asleep, and is usually out of bed around 7 a.m. feeling refreshed.  He has two to three episodes of nocturia per night.  He denies any morning symptoms.  He has mild excess daytime sleepiness manifested by dozing off during boring activities.,PAST MEDICAL HISTORY:,  Hypertension, gastritis, and low back pain.,PAST SURGICAL HISTORY:,  TURP.,MEDICATIONS:,  Hytrin, Motrin, Lotensin, and Zantac.,ALLERGIES:,  None.,FAMILY HISTORY:,  Hypertension.,SOCIAL HISTORY:,  Significant for about a 20-pack-year tobacco use, quit in 1991.  No ethanol use or illicit drug use.  He is married.  He has one dog at home.  He used to be employed at Budd Automotors as a die setter for about 37 to 40 years.,REVIEW OF SYSTEMS:,  His weight has been steady over the years.  Neck collar size is 17½"".  He denies any chest pain, cough, or shortness of breath.  Last chest x-ray within the past year, per his report, was normal.,PHYSICAL EXAM:,  A pleasant, obese, African-American male in no apparent respiratory distress.  T:  98.  P:  90.  RR:  20.  BP:  156/90.  O2 saturation:  97% on room air.  Ht:  5' 5"".  Wt:  198 lb.  HEENT:  A short thick neck, low-hanging palate, enlarged scalloped tongue, narrow foreshortened pharynx, clear nares, and no JVD.  CARDIAC:  Regular rate and rhythm without any adventitious sounds.  CHEST:  Clear lungs bilaterally. ABDOMEN:  An obese abdomen with active bowel sounds.  EXTREMITIES:  No cyanosis, clubbing, or edema.  NEUROLOGIC:  Non-focal.,IMPRESSION:,1.  Probable obstructive sleep apnea syndrome.,2.  Hypertension.,3.  Obesity.,4.  History of tobacco use.,PLAN:,1.  We will schedule an overnight sleep study to evaluate obstructive sleep apnea syndrome.,2.  Encouraged weight loss.,3.  Check TSH.,4.  Asked not to drive and engage in any activity that could endanger himself or others while sleepy.,5.  Asked to return to the clinic one week after sleep the study is done.",
 Followup of moderate-to-severe sleep apnea.  The patient returns today to review his response to CPAP.  Recommended a fiberoptic ENT exam to exclude adenoidal tissue that may be contributing to obstruction. , Sleep Medicine, Sleep Apnea ,"REASON FOR VISIT: , Mr. ABC is a 30-year-old man who returns in followup of his still moderate-to-severe sleep apnea.  He returns today to review his response to CPAP.,HISTORY OF PRESENT ILLNESS: , The patient initially presented with loud obnoxious snoring that disrupted the sleep of his bed partner.  He was found to have moderate-to-severe sleep apnea (predominantly hypopnea), was treated with nasal CPAP at 10 cm H2O nasal pressure.  He has been on CPAP now for several months, and returns for followup to review his response to treatment.,The patient reports that the CPAP has limited his snoring at night.  Occasionally, his bed partner wakes him in the middle of the night, when the mask comes off, and reminds him to replace the mask.  The patient estimates that he uses the CPAP approximately 5 to 7 nights per week, and on occasion takes it off and does not replace the mask when he awakens spontaneously in the middle of the night.,The patient's sleep pattern consists of going to bed between 11:00 and 11:30 at night and awakening between 6 to 7 a.m. on weekdays.  On weekends, he might sleep until 8 to 9 a.m.  On Saturday night, he might go to bed approximately mid night.,As noted, the patient is not snoring on CPAP.  He denies much tossing and turning and does not awaken with the sheets in disarray.  He awakens feeling relatively refreshed.,In the past few months, the patient has lost between 15 and 18 pounds in combination of dietary and exercise measures.,He continues to work at Smith Barney in downtown Baltimore.  He generally works from 8 to 8:30 a.m. until approximately 5 to 5:30 p.m.  He is involved in training purpose to how to sell managed funds and accounts.,The patient reports no change in daytime stamina.  He has no difficulty staying awake during the daytime or evening hours.,The past medical history is notable for allergic rhinitis.,MEDICATIONS: , He is maintained on Flonase and denies much in the way of nasal symptoms.,ALLERGIES: , Molds.,FINDINGS:  ,Vital signs:  Blood pressure 126/75, pulse 67, respiratory rate 16, weight 172 pounds, height 5 feet 9 inches, temperature 98.4 degrees and SaO2 is 99% on room air at rest.,The patient has adenoidal facies as noted previously.,Laboratories:  The patient forgot to bring his smart card in for downloading today.,ASSESSMENT: , Moderate-to-severe sleep apnea.  I have recommended the patient continue CPAP indefinitely.  He will be sending me his smart card for downloading to determine his CPAP usage pattern.  In addition, he will continue efforts to maintain his weight at current levels or below.  Should he succeed in reducing further, we might consider re-running a sleep study to determine whether he still requires a CPAP.,PLANS: , In the meantime, if it is also that the possible nasal obstruction is contributing to snoring and obstructive hypopnea.  I have recommended that a fiberoptic ENT exam be performed to exclude adenoidal tissue that may be contributing to obstruction.  He will be returning for routine followup in 6 months.","sleep medicine, daytime stamina, fiberoptic ent exam, moderate to severe, smart card, sleep apnea, cpap, apnea, sleep, "
 Sleep study - patient with symptoms of obstructive sleep apnea with snoring., Sleep Medicine, Sleep Study Interpretation ,"PROCEDURE:, Sleep study.,CLINICAL INFORMATION:, This patient is a 56-year-old gentleman who had symptoms of obstructive sleep apnea with snoring, hypertension. The test was done 01/24/06. The patient weighed 191 pounds, five feet, seven inches tall.,SLEEP QUESTIONNAIRE:, According to the patient's own estimate, the patient took about 15 minutes to fall asleep, slept for six and a half hours, did have some dreams. Did not wake up and the sleep was less refreshing. He was sleepy in the morning.,STUDY PROTOCOL:, An all night polysomnogram was recorded with a Compumedics E Series digital polysomnograph. After the scalp was prepared, Ag/AgCl electrodes were applied to the scalp according to the International 10-20 System. EEG was monitored from C4-A1, C3-A2, O2-A1 and O2-A1. EOG and EMG were continuously monitored by electrodes placed at the outer canthi and chin respectively. Nasal and oral airflow were monitored using a triple port Thermistor. Respiratory effort was measured by piezoelectric technology employing an abdominal and thoracic belt. Blood oxygen saturation was continuously monitored by pulse oximetry. Heart rate and rhythm were monitored by surface electrocardiography. Anterior tibialis EMG was studied by using surface mounted electrodes placed 5 cm apart on both legs. Body position and snoring level were also monitored.,TECHNICAL QUALITY OF STUDY:, Good.,ELECTROPHYSIOLOGIC MEASUREMENTS:, Total recording time 406 minutes, total sleep time 365 minutes, sleep latency 25.5 minutes, REM latency 49 minutes, _____ 90%, sleep latency measured 86%. _____ period was obtained. The patient spent 10% of the time awake in bed.,Stage I: 3.8,Stage II: 50.5,Stage III: 14%,Stage REM: 21.7%,The patient had relatively good sleep architecture, except for excessive waking.,RESPIRATORY MEASUREMENTS:, Total apnea/hypopnea 75, age index 12.3 per hour. REM age index 15 per hour. Total arousal 101, arousal index 15.6 per hour. Oxygen desaturation was down to 88%. Longest event 35 second hypopnea with an FiO2 of 94%. Total limb movements 92, PRM index 15.1 per hour. PRM arousal index 8.9 per hour.,ELECTROCARDIOGRAPHIC OBSERVATIONS:, Heart rate while asleep 60 to 64 per minute, while awake 70 to 78 per minute.,CONCLUSIONS:, Obstructive sleep apnea syndrome with moderately loud snoring and significant apnea/hypopnea index.,RECOMMENDATIONS:,AXIS B: Overnight polysomnography.,AXIS C: Hypertension.,The patient should return for nasal CPAP titration. Sleep apnea if not treated, may lead to chronic hypertension, which may have cardiovascular consequences. Excessive daytime sleepiness, dysfunction and memory loss may also occur.","sleep medicine, sleep study, obstructive sleep apnea, snoring, hypertension, polysomnogram, compumedics, polysomnograph, ag/agcl electrodes, triple port thermistor, rem, latency, polysomnography, cpap titration, sleep latency, apnea, sleep, obstructive, index, "
" Obesity hypoventilation syndrome.  A 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study.", Sleep Medicine, Obesity Hypoventilation Syndrome ,"HISTORY OF PRESENT ILLNESS: , This is a 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study, on CPAP and oxygen to evaluate her for difficulty in initiating and maintaining sleep.  She returns today to review results of an inpatient study performed approximately two weeks ago.,In the meantime, the patient reports she continues on substantial doses of opiate medication to control leg pain from mononeuritis multiplex.,She also takes Lasix for lower extremity edema.,The patient reports that she generally initiates sleep on CPAP, but rips her mask off, tosses and turns throughout the night and has ""terrible quality sleep."",MEDICATIONS: , Current medications are as previously noted.  Changes include reduction in prednisone from 9 to 6 mg by mouth every morning.  She continues to take Ativan 1 mg every six hours as needed.  She takes imipramine 425 mg at bedtime.,Her MS Contin dose is 150 mg every 8 to 12 hours and an immediate release morphine preparation, 45 to 75 mg by mouth every 8 hours as needed.,FINDINGS: , Vital signs:  Blood pressure 153/81, pulse 90, respiratory rate 20, weight 311.8 pounds (up 10 pounds from earlier this month), height 5 feet 6 inches, temperature 98.4 degrees, SaO2 is 88% on room air at rest.  Chest is clear.  Extremities show lower extremity pretibial edema with erythema.,LABORATORIES: , An arterial blood gas on room air showed a pH of 7.38, PCO2 of 52, and PO2 of 57.,CPAP compliance monitoring over the past two to three weeks showed average use of 3 hours 26 minutes on nights used.  She used it for greater than 4 hours per night on 67% of night surveyed.  Her estimated apnea/hypopnea index was 3 per hour.  Her average leak flow was 67 liters per minute.,The patient's overnight sleep study was performed as an inpatient sleep study during a routine hospitalization for intravenous gamma globulin therapy.  She slept for a total sleep time of 257 minutes out of 272 minutes in bed (sleep efficiency approximately 90%).  Sleep stage distribution was relatively normal with 2% stage I, 72% stage II, 24% stage III, IV, and 2% stage REM sleep.,There were no periodic limb movements during sleep.,There was evidence of a severe predominantly central sleep apnea during non-REM sleep at 173 episodes per hour and during REM sleep at 77 episodes per hour.  Oxyhemoglobin saturations during non-REM sleep fluctuated from the baseline of 92% to an average low of 82%.  During REM sleep, the baseline oxyhemoglobin saturation was 87% , decreased to 81% with sleep-disordered breathing episodes.,Of note, the sleep study was performed on CPAP at 10.5 cm of H2O with oxygen at 8 liters per minute.,ASSESSMENT:,1.  Obesity hypoventilation syndrome.  The patient has evidence of a well-compensated respiratory acidosis, which is probably primarily related to severe obesity.  In addition, there may be contribution from large doses of opiates and standing doses of gabapentin.,2.  Severe central sleep apnea, on CPAP at 10 cmH2O and supplemental oxygen at 8 liters per minute.  The breathing pattern is that of cluster or Biot's breathing throughout sleep.  The primary etiology is probably opiate use, with contribution with further exacerbation by severe obesity which acts to lower the baseline oxyhemoglobin saturation, and worsen desaturations during apneic episodes.,3.  Mononeuritis multiplex with pain requiring significant substantial doses of analgesia.,4.  Hypoxemia primarily due to obesity, hypoventilation, and presumably basilar atelectasis and a combination of V/Q mismatch and shunt on that basis.,PLANS: , My overall impression is that we should treat this patient's sleep disruption with measures to decrease central sleep apnea during sleep.  These will include, (1).  Decrease in evening doses of MS Contin, (2).  Modest weight loss of approximately 10 to 20 pounds, and (3).  Instituting Automated Servo Ventilation via nasal mask.  With regard to latter, the patient will be returning for a trial of ASV to examine its effect on sleep-disordered breathing patterns.,In addition, the patient will benefit from modest diuresis, with improvement of oxygenation, as well as nocturnal desaturation and oxygen requirements.  I have encouraged the patient to increase her dose of Lasix from 100 to 120 mg by mouth every morning as previously prescribed.  I have also asked her to add Lasix in additional late afternoon to evening dose of Lasix at 40 mg by mouth at that time.  She was instructed to take between one and two K-Tab with her evening dose of Lasix (10 to 20 mEq).,In addition, we will obtain a complete set of pulmonary function studies to evaluate this patient for underlying causes of parenchymal lung disease that may interfere with oxygenation.  Further workup for hypoxemia may include high-resolution CT scanning if evidence for significant pulmonary restriction and/or reductions in diffusion capacity is evident on pulmonary function testing.","sleep medicine, polyarteritis nodosa, obesity hypoventilation syndrome, pulmonary function, obesity hypoventilation, mononeuritis multiplex, sleep apnea, sleep study, rem sleep, ativan, sleep, hypoventilation, obesity, "
" Electroencephalogram, electromyogram of the chin and lower extremities, electrooculogram, electrocardiogram, air flow from the nose and mouth, respiratory effort at the chest and abdomen, and finger oximetry.", Sleep Medicine, Sleep Difficulties ,"CLINICAL HISTORY: , This is a 16-year-old man evaluated for sleep difficulties.  He states he is ""feeling bad in the mornings"" that he has daytime somnolence and ""whenever I wake up I experience dizziness, weakness, stomachache, loss of appetite, drowsiness, overall sore body and a general feeling of unwell.""  He does state that he has only rarely he got anything suggestive of restless leg syndrome, is unaware of any apnea or like symptoms.  He has a mouth breather.  He states he wakens up during the night, usually goes to bed at 10 to 11, gets up at 7 to 7:30.  In the weekends, he stays up late and sleeps until 1 in the afternoon.  He lists sporadic use of melatonin and Benadryl, and Tylenol PM for sleep.  His other medicines are Accutane, Nasonex and oxymetazoline.  There is no smoking, no alcohol intake.  He does have three caffeinated beverages a week.  He is 75 inches, 185 pounds, BMI 23.1.  He rated himself 4/7 on the Stanford Sleepiness Scale at the onset of the study and 6 on the Epworth Sleeping Scale, said that his night sleep in the lab was characterized by a longer than usual sleep onset latency with more arousals than usual.  He woke up feeling equally rested and the only comment he made on the post sleep questionnaire was ""some of the wires"" is the source of problems.,TECHNIQUE: , The study was performed with the following parameters measured throughout the entirety of the recording:,Electroencephalogram, electromyogram of the chin and lower extremities, electrooculogram, electrocardiogram, air flow from the nose and mouth, respiratory effort at the chest and abdomen, and finger oximetry.,The record was scored for sleep and the various other parameters in 30-second epochs.,RESULTS: , This study was performed in 61 minutes in duration during which he slept 432 minutes after 19 minutes sleep onset latency; thereafter, he had 10 awakenings for 6 minutes of wakefulness giving him a normal sleep efficiency of 95%.  Sleep staging was actually fairly deep and normal for age with 5% stage I, 51% stage II, 22% slow wave sleep and 22% REM.  He had 5 REM periods during the night.  The first beginning 66 minutes after sleep onset.  He did have 63 arousals, giving him a borderline elevated arousal index of 8.8, 16 were driven by limb movements, 41 of unclear origin, 6 from hypopneas.,EEG PARAMETERS: , No abnormalities.,EKG PARAMETERS: , Normal sinus rhythm, mean rate 76, no ectopics noted.,EMG PARAMETERS: , 88 PLMs were noted.  There was fairly small excursion with a movement index of 12, only 16 led to arousals with a movement arousal index of 2.2, not considered as a significant feature for sleep fragmentation.,RESPIRATORY PARAMETERS:,  Breathing rate in the high teens, reaching as high as 20 in REM.  There was really no snoring noted.  He slept in all positions and during the night had 9 respiratory events, one was a postarousal central event, the other eight were obstructive hypopneas mean duration 26 seconds, little worse in the supine position where his AHI was 4.7, but overall his AHI was 1.3.  This is only a marginal abnormality and is well below the threshold for CPAP intervention.,IMPRESSION:,  Largely normal polysomnogram demonstrating very modest obstructive sleep apnea in the supine position and a very modest periodic limb movement disturbance.","sleep medicine, sleep, sleep difficulties, mouth breather, epworth sleeping scale, stanford sleepiness scale, sleep onset latency, arousals, electroencephalogram, electromyogram, electrooculogram, electrocardiogram, polysomnogram, sleep apnea, periodic limb movement, hypopneas, accutane,"
" The patient was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.  The test was performed due to suspicion of sleep apnea and poor sleep quality with frequent awakenings.", Sleep Medicine, Polysomnography ,"PROCEDURE:,  The test was performed in an observed hospital laboratory.  The patient was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.  The test was performed due to suspicion of sleep apnea and poor sleep quality with frequent awakenings.,The patient's height 6 feet, 1 inch and his weight 260 pounds.,DETAILS: , Total sleep period 377 minutes, total sleep time 241 minutes, sleep onset 33 minutes, and sleep efficiency 64%.  Stage I 9%, stage II 59%, stage III 23%, and REM stage 9%.  There were 306 apneas and hypopnea with apnea/hypopnea index 76.  Out of them 109 apneas and 197 hypopneas.  There were 40 arousals with index 9.9.  Mean oxygen saturation 91% with lowest oxygen saturation 70%.  A 19% of sleep time was spent with oxygen saturation less than 90% and 1% with less than 80%.  Oxygen saturation during awake 95%.  The patient slept in supine left side and right side, no preferred body position identified for apneas.  Average pulse 85 BPMs with lowest 61 and highest 116 BPMs.  No significant snoring throughout the study.  No significant leg jerk movement.,SUMMARY: , Severe obstructive sleep apnea with apnea/hypopnea index 76 and respiratory disturbance index 9.9.  Suggest weight loss, thyroid function evaluation, and CPAP titration study.","sleep medicine, thoracoabdominal impedance, oral/nasal thermistors, obstructive sleep apnea, titration study, eeg, eog, emgs, cpap, sleep,"
" Abnormal electroencephalogram revealing generalized poorly organized slowing, with more prominent slowing noted at the right compared to the left hemisphere head regions and rare sharp wave activity noted bilaterally, somewhat more prevalent on the right. ", Sleep Medicine, Electroencephalogram - 3 ,"IMPRESSION:,  Abnormal electroencephalogram revealing generalized poorly organized slowing, with more prominent slowing noted at the right compared to the left hemisphere head regions and rare sharp wave activity noted bilaterally, somewhat more prevalent on the right.  Clinical correlation is suggested.","sleep medicine, sleep, vertex activity, muscle artifact, sharp wave activity, electroencephalogramNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Electroencephalogram (EEG).  This is an 18-channel recording obtained using the standard scalp and referential electrodes observing the 10/20 international system., Sleep Medicine, Electroencephalogram - 2 ,"REPORT:  ,This is an 18-channel recording obtained using the standard scalp and referential electrodes observing the 10/20 international system.  The patient was reported to be cooperative and was awake throughout the recording.,CLINICAL NOTE:  ,This is a 51-year-old male, who is being evaluated for dizziness.  Spontaneous activity is fairly well organized, characterized by low-to-medium voltage waves of about 8 to 9 Hz seen mainly from the posterior head region.  Intermixed with it is a moderate amount of low voltage fast activity seen from the anterior head region.,Eye opening caused a bilateral symmetrical block on the first run.  In addition to the above description, movement of muscle and other artifacts are seen.,On subsequent run, no additional findings were seen.,During subsequent run, again no additional findings were seen.,Hyperventilation was omitted.,Photic stimulation was performed, but no clear-cut photic driving was seen.,EKG was monitored during this recording and it showed normal sinus rhythm when monitored.,IMPRESSION:  ,This record is essentially within normal limits.  Clinical correlation is recommended.","sleep medicine, referential electrodes, scalp, hyperventilation, photic stimulation, electroencephalogram"
 Electroencephalographic findings and interpretation, Sleep Medicine, Electroencephalography ,"HISTORY:, This is a digital EEG performed on a 75-year-old male with seizures.,BACKGROUND ACTIVITY:, The background activity consists of a 8 Hz to 9 Hz rhythm arising in the posterior head region. This rhythm is also accompanied by some beta activity which occurs infrequently. There are also muscle contractions occurring at 4 Hz to 5 Hz which suggests possible Parkinson's. Part of the EEG is obscured by the muscle contraction artifact. There are also left temporal sharps occurring infrequently during the tracing. At one point of time, there was some slowing occurring in the right frontal head region.,ACTIVATION PROCEDURES:, Photic stimulation was performed and did not show any significant abnormality.,SLEEP PATTERNS:, No sleep architecture was observed during this tracing.,IMPRESSION:, This awake/alert/drowsy EEG is abnormal due to the presence of slowing in the right frontal head region, due to the presence of sharps arising in the left temporal head region, and due to the tremors. The slowing can be consistent with underlying structural abnormalities, so a stroke, subdural hematoma, etc., should be ruled out. The tremor probably represents a Parkinson's tremor and the sharps arising in the left temporal head region can potentially give way to seizures or may also represent underlying structural abnormalities, so clinical correlation is recommended.","sleep medicine, electroencephalography, eeg, hz rhythm, parkinson's tremor, photic stimulation, frontal head region, temporal head region, muscle contractions, seizures, parkinson's, temporal, "
 Electroencephalogram (EEG).  Photic stimulation reveals no important changes.  Essentially normal., Sleep Medicine, Electroencephalogram - 1 ,"REPORT:,  The electroencephalogram shows background activity at about 9-10 cycle/second bilaterally.  Little activity in the beta range is noted.  Waves of 4-7 cycle/second of low amplitude were occasionally noted.  Abundant movements and technical artifacts are noted throughout this tracing.  Hyperventilation was not performed.  Photic stimulation reveals no important changes.,CLINICAL INTERPRETATION:,  The electroencephalogram is essentially normal.","sleep medicine, beta range, hyperventilation, photic stimulation, electroencephalogramNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 A 21-channel digital electroencephalogram was performed on a patient in the awake state., Sleep Medicine, Electroencephalogram - 4 ,"PROCEDURE:,  A 21-channel digital electroencephalogram was performed on a patient in the awake state.  Per the technician's notes, the patient is taking Depakene.,The recording consists of symmetric 9 Hz alpha activity.  Throughout the recording, repetitive episodes of bursts of 3 per second spike and wave activity are noted.  The episodes last from approximately1 to 7 seconds.  The episodes are exacerbated by hyperventilation.,IMPRESSION:,  Abnormal electroencephalogram with repetitive bursts of 3 per second spike and wave activity exacerbated by hyperventilation.  This activity could represent true petit mal epilepsy.  Clinical correlation is suggested.","sleep medicine, alpha activity, wave activity, hyperventilation, electroencephalogramNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" The patient was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.", Sleep Medicine, CPAP Titration Study ,"PROCEDURE: , The test was performed in an observed hospital laboratory due to the evidence of obstructive sleep apnea.  The patient was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.,CPAP TITRATION STUDY:,  Total sleep time 425 minutes, sleep onset 7.8 minutes, and sleep efficiency 95%.  Stage I 6%, stage II 53%, stage III 20%, and REM stage 15%, and awake 5%.  Number of awakenings 6.  Total arousals 36 with index 5.4, mild leg jerk movement with index 10.1.  There was one apnea and 17 hypopneas with apnea/hypopnea index 2.7.  The pressures required to prevent apnea/hypopnea varied between 5 and 11 cm H2O.  The optimal pressure was 11 cm H2O, which prevented all of the apneas/hypopneas.  The patient spent all his sleeping time in supine position.  Average oxygen saturation 94% with lowest oxygen saturation 89%.  Only less than 0.2 minutes was spent with oxygen saturation less than 90%.,SUMMARY: , Weight loss, PFTs if not done and CPAP with nasal mask at 11 cm H2O.","sleep medicine, obstructive sleep apnea, cpap titration study, cpap titration, oral/nasal thermistors, thermistors ekg, oxygen saturation, eeg, eog, emg, thoracoabdominal, thermistors, ekg, oximetry, apnea, cpap, oral/nasalNOTE"
 A sample note on Rheumatoid Arthritis, Rheumatology, Rheumatoid Arthritis ,"RHEUMATOID ARTHRITIS, (or RA) is a chronic, systemic condition with primary involvement of the joints.  Joint inflammation is present due to an abnormal immune response in which the body attacks its own tissue.  Specifically, the tissues lining the joint are involved as well as cartilage and muscle and sometimes the eyes and blood vessels.  The cause of rheumatoid arthritis is obscure but it is associated with a family history, genetic and autoimmune problems, people ages 20-60, female gender 3:1 or a Native American background.,SIGNS AND SYMPTOMS:,*  Joint pain, swelling, redness, warmth.  Commonly involved joints are the small joints of the hands and feet and the ankles, wrists, knees, shoulders and elbows.,*  Multiple swollen joints (more than 3) with simultaneous involvement of same joints on opposite side of the body.,*  Morning stiffness that lasts longer than 30 minutes.,*  Difficulty making a fist; poor grip strength.,*  Night pain.,*  Feeling ""sick"" - low fever, loss of appetite, tiredness, generalized aching and stiffness, weakness.,*  Rheumatoid nodules under the skin, usually along the surface of tendons or over bony prominences.,*  Disease may lead to deformed joints, decreased vision, anemia, muscle weakness, peripheral nerve problems, pericarditis, enlarged spleen, increased frequency of infections.,*  Blood tests will reveal a positive rheumatoid factor (RF) to be present the majority of the time.,TREATMENT:,*  To diagnose RA, blood studies are done to detect a substance known as rheumatoid factor and x-rays may show typical findings.,*  Night splints for involved joints.  Avoid putting a pillow under the knees as this will contribute to joint contracture.,*  Heat helps relieve the pain; hot water soaks, whirlpool baths, heat lamps, heating pads, etc. applied to affected joints 15-20 minutes 3 times per day is helpful.,*  Sleep on a firm mattress and sleep at least 10-12 hours per night.  Get rest during the day; take naps.,*  Get bed rest during an active flare-up until symptoms subside.,*  Avoid humid weather if possible.,*  NSAIDs (non-steroidal anti-inflammatory drugs).,*  DMARDs (disease-modifying anti-rheumatic drugs) - gold compounds, D-penicillamine, sulfasalazine, methotrexate, antimalarials.,*  Immunosuppressive drugs.,*  Acetaminophen (Tylenol) for pain relief only when necessary.,*  Oral corticosteroids short term; corticosteroid injection into joint can temporarily relieve pain and inflammation.,*  Exercise as recommended by your physician.  Exercise helps keep the joints limber and increases strength.  Swimming and water activities are a good way to workout.  Put all your joints through their full ranges of motion every day to prevent contractures. *  Physical therapy may be recommended.,*  Surgical intervention.,*  Lose excess weight as being overweight will only stress the joints further.,*  Eat a normal, well-balanced diet.","rheumatology, ra, rheumatoid arthritis, joint inflammation, swollen joints, arthritis, joints, inflammation, corticosteroids, rheumatoid, "
 Normal awake and drowsy (stage I sleep) EEG for patient's age., Sleep Medicine, Electroencephalogram ,"DESCRIPTION OF RECORD:  ,This tracing was obtained utilizing 27 paste-on gold-plated surface disc electrodes placed according to the International 10-20 system.  Electrode impedances were measured and reported at less than 5 kilo-ohms each.,FINDINGS: , In general, the background rhythms are bilaterally symmetrical.  During the resting awake state they are composed of moderate amounts of low amplitude fast activity intermixed with moderate amounts of well-modulated 9-10 Hz alpha activity best seen posteriorly.  The alpha activity attenuates with eye opening.,During some portions of the tracing the patient enters a drowsy state in which the background rhythms are composed predominantly of moderate amounts of low amplitude fast activity intermixed with moderate amounts of low to medium amplitude polymorphic theta activity.,There is no evidence of focal slowing or paroxysmal activity.,IMPRESSION: , Normal awake and drowsy (stage I sleep) EEG for patient's age.","sleep medicine, gold-plated surface disc electrodes, paroxysmal activity, eeg, drowsy stage, sleep eeg, stage, sleep, electrodes, awake, moderate, activity"
 Epicondylitis. history of lupus.  Injected with 40-mg of Kenalog mixed with 1 cc of lidocaine., Rheumatology, Rheumatology Progress Note ,"SUBJECTIVE:,  The patient is here for a follow-up.  The patient has a history of lupus, currently on Plaquenil 200-mg b.i.d.  Eye report was noted and appreciated.  The patient states that she is having some aches and pains of the hands and elbows that started recently a few weeks ago.  She denied having any trauma.  She states that the pain is bothering her.  She denies having any fevers, chills, or any joint effusion or swelling at this point.  She noted also that there is some increase in her hair loss in the recent times.,OBJECTIVE:,  The patient is alert and oriented.  General physical exam is unremarkable.  Musculoskeletal exam reveals positive tenderness in both lateral epicondyles of both elbows, no effusion.  Hand examination is unremarkable today.  The rest of the musculoskeletal exam is unremarkable.,ASSESSMENT:,  Epicondylitis, both elbows, possibly secondary to lupus flare-up.,PLAN:,  We will inject both elbows with 40-mg of Kenalog mixed with 1 cc of lidocaine.  The posterior approach was chosen under sterile conditions.  The patient tolerated both procedures well.  I will obtain CBC and urinalysis today.  If the patient's pain does not improve, I will consider adding methotrexate to her therapy.,Sample Doctor M.D.","rheumatology, 1 cc of lidocaine, epicondylitis, kenalog, kenalog mixed with 1 cc of lidocaine, progress note, aches and pains, history of lupus, lidocaine, lupus, methotrexate, kenalog mixed, injected,"
 Patient presents for treatment of suspected rheumatoid arthritis., Rheumatology, Rheumatoid Arthritis - H&P ,"CHIEF COMPLAINT:,  This 26 year old male presents today for treatment of suspected rheumatoid arthritis.  Associated signs and symptoms include aching, joint pain, and symmetrical joint swelling bilateral.  Patient denies any previous history, related trauma or previous treatments for this condition.  Condition has existed for 2 weeks.  He indicates the problem location is the right hand and left hand.  Patient indicates no modifying factors.  Severity of condition is slowly worsening.  Onset was unknown.,ALLERGIES:,  Patient admits allergies to aspirin resulting in GI upset, disorientation.,MEDICATION HISTORY: , Patient is currently taking amoxicillin-clavulanate 125 mg-31.25 mg tablet, chewable medication was prescribed by A. General Practitioner MD, Adrenocot 0.5 mg tablet medication was prescribed by A. General Practitioner MD.,PAST MEDICAL HISTORY:,  Past medical history is unremarkable.,PAST SURGICAL HISTORY: , Patient admits past surgical history of (+) appendectomy in 1989.,FAMILY HISTORY: , Patient admits a family history of rheumatoid arthritis associated with maternal grandmother.,SOCIAL HISTORY:  ,Patient denies alcohol use.  Patient denies illegal drug use.  Patient denies STD history.  Patient denies tobacco use.,REVIEW OF SYSTEMS: , Neurological: (+) paralysis Musculoskeletal: (+) joint pain (+) joint swelling (+) stiffness Cardiovascular: (+) ankle swelling Neurological: (-) numbness,Musculoskeletal: (-) back pain (chronic) (-) decreased ROM (-) episodic weakness,Cardiovascular: (-) chest pressure Respiratory: (-) breathing difficulties, respiratory symptoms (-) sleep apnea,PHYSICAL EXAM: , BP Standing:  120/84 HR:  79 Temp:  98.6 Height:  5 ft.  8 in.  Weight:  168 lbs.  Patient is a 26 year old male who appears pleasant, in no apparent distress, his given age, well developed, well nourished and with good attention to hygiene and body habitus.  Skin:  No skin rash, subcutaneous nodules, lesions or ulcers observed.  Palpation of skin shows no abnormalities.,HEENT:  Inspection of head and face shows no abnormalities.  Hair growth and distribution is normal.  Examination of scalp shows no abnormalities.  Conjunctiva and lids reveal no signs or symptoms of infection.  Pupil exam reveals round and reactive pupils without afferent pupillary defect.  Ocular motility exam reveals gross orthotropia with full ductions and versions bilateral.  Bilateral retinas reveal normal color, contour, and cupping.  Inspection of ears reveals no abnormalities.  Otoscopic examination reveals no abnormalities.  Examination of oropharynx reveals no abnormalities and tissues pink and moist.  ENT:  Inspection of ears reveals no abnormalities.  Examination of larynx reveals no abnormalities.  Inspection of nose reveals no abnormalities.,Neck:  Neck exam reveals neck supple and trachea that is midline, without adenopathy or crepitance palpable.  Thyroid examination reveals no abnormalities and smooth and symmetric gland with no enlargement, tenderness or masses noted.  Lymphatic:  Neck lymph nodes are normal.,Respiratory:  Assessment of respiratory effort reveals even respirations without use of accessory muscles and no intercostal retractions noted.  Chest inspection reveals chest configuration non-hyperinflated and symmetric expansion.  Auscultation of lungs reveals clear lung fields and no rubs noted.,Cardiovascular:  Heart auscultation reveals normal S1 and S2 and no murmurs, gallop, rubs or clicks.  Examination of peripheral vascular system reveals full to palpation, varicosities absent, extremities warm to touch and no edema.,Abdomen:  Abdominal contour is slightly rounded.  Abdomen soft, nontender, bowel sounds present x 4 without palpable masses.  Palpation of liver reveals no abnormalities.  Palpation of spleen reveals no abnormalities.,Musculoskeletal:  Gait and station examination reveals normal arm swing, with normal heel-toe and tandem walking.  Inspection and palpation of bones, joints and muscles is unremarkable.  Muscle strength is 5/5 for all groups tested.  Muscle tone is normal.,Neurologic/Psychiatric:  Psychiatric:  Oriented to person, place and time.  Mood and affect normal and appropriate to situation.  Testing of cranial nerves reveals no deficits.  Coordination is good.  Touch, pin, vibratory and proprioception sensations are normal.  Deep tendon reflexes normal.,TEST & X-RAY RESULTS:,  Rheumatoid factor:  52 U/ml.  Sed rate:  31 mm/hr.  C4 complement:  19 mg/dl.,IMPRESSION: , Rheumatoid arthritis.,PLAN:,  ESR ordered; automated.  Ordered RBC.  Ordered quantitative rheumatoid factor.  Return to clinic in 2 week (s).,PRESCRIPTIONS:,  Vioxx Dosage:  12.5 mg tablet Sig:  BID Dispense:  30 Refills:  2 Allow Generic:  No",
" A 7-year-old white male started to complain of pain in his fingers, elbows, and neck.  This patient may have had reactive arthritis.  ", Rheumatology, Pediatric Rheumatology Consult ,"HISTORY:  ,We had the pleasure of seeing the patient today in our Pediatric Rheumatology Clinic.  He was sent here with a chief complaint of joint pain in several joints for few months.  This is a 7-year-old white male who has no history of systemic disease, who until 2 months ago, was doing well and 2 months ago, he started to complain of pain in his fingers, elbows, and neck.  At this moment, this is better and is almost gone, but for several months, he was having pain to the point that he would cry at some point.  He is not a complainer according to his mom and he is a very active kid.  There is no history of previous illness to this or had gastrointestinal problems.  He has problems with allergies, especially seasonal allergies and he takes Claritin for it.  Other than that, he has not had any other problem.  Denies any swelling except for that doctor mentioned swelling on his elbow.  There is no history of rash, no stomach pain, no diarrhea, no fevers, no weight loss, no ulcers in his mouth except for canker sores.  No lymphadenopathy, no eye problems, and no urinary problems.,MEDICATIONS: , His medications consist only of Motrin only as needed and Claritin currently for seasonal allergies and rhinitis.,ALLERGIES: , He has no allergies to any drugs.,BIRTH HISTORY:  ,Pregnancy and delivery with no complications.  He has no history of hospitalizations or surgeries.,FAMILY HISTORY: , Positive for arthritis in his grandmother.  No history of pediatric arthritis.  There is history of psoriasis in his dad.,SOCIAL HISTORY: , He lives with mom, dad, brother, sister, and everybody is healthy.  They live in Easton.  They have 4 dogs, 3 cats, 3 mules and no deer.  At school, he is in second grade and he is doing PE without any limitation.,PHYSICAL EXAMINATION: ,VITAL SIGNS:  Temperature is 98.7, pulse is 96, respiratory rate is 24, height is 118.1 cm, weight is 22.1 kg, and blood pressure is 61/44.,GENERAL:  He is alert, active, in no distress, very cooperative.,HEENT:  He has no facial rash.  No lymphadenopathy.  Oral mucosa is clear.  No tonsillitis.  His ear canals are clear and pupils are reactive to light and accommodation.,CHEST:  Clear to auscultation.,HEART:  Regular rhythm and no murmur.,ABDOMEN:  Soft, nontender with no visceromegaly.,MUSCULOSKELETAL:  Shows no limitation in any of his joints or active swelling today.  He has no tenderness either in any of his joints.  Muscle strength is 5/5 in proximal muscles.,LABORATORY DATA:,  Includes an arthritis panel.  It has normal uric acid, sedimentation rate of 2, rheumatoid factor of 6, and antinuclear antibody that is negative and C-reactive protein that is 7.1.  His mother stated that this was done while he was having symptoms.,ASSESSMENT AND PLAN: , This patient may have had reactive arthritis.  He is seen frequently and the patient has family history of psoriatic arthritis or psoriasis.  I do not see any problems at this moment on his laboratories or on his physical examination.  This may have been related to recent episode of viral infection or infection of some sort.  Mother was oriented about the finding and my recommendation is to observe him and if there is any recurrence of the symptoms or persistence of swelling or limitation in any of his joints, I will be glad to see him back.,If you have any question on further assessment and plan, please do no hesitate to contact us.","rheumatology, pediatric, reactive arthritis, psoriatic arthritis, psoriasis, joints, swelling, arthritis, "
" A 71-year-old female who I am seeing for the first time.  She has a history of rheumatoid arthritis for the last 6 years.  She is not on DMARD, but as she recently had a surgery followed by a probable infection.", Rheumatology, Rheumatoid Arthritis - Consult ,"HISTORY OF PRESENT ILLNESS: , A 71-year-old female who I am seeing for the first time.  She has a history of rheumatoid arthritis for the last 6 years.  She was followed by another rheumatologist.  She says she has been off and on, on prednisone and Arava.  The rheumatologist, as per the patient, would not want her to be on a long-term medicine, so he would give her prednisone and then switch to Arava and then switch her back to prednisone.  She says she had been on prednisone for the last 6 to 9 months.  She is on 5 mg a day.  She recently had a left BKA and there was a question of infection, so it had to be debrided.  I was consulted to see if her prednisone is to be continued.  The patient denies any joint pains at the present time.  She says when this started she had significant joint pains and was unable to walk.  She had pain in the hands and feet.  Currently, she has no pain in any of her joints.,REVIEW OF SYSTEMS: , Denies photosensitivity, oral or nasal ulcer, seizure, psychosis, and skin rashes.,PAST MEDICAL HISTORY: , Significant for hypertension, peripheral vascular disease, and left BKA.,FAMILY HISTORY:  ,Noncontributory.,SOCIAL HISTORY: , Denies tobacco, alcohol or illicit drugs.,PHYSICAL EXAMINATION:,VITAL SIGNS:  BP 130/70, heart rate 80, and respiratory rate 14.,HEENT:  EOMI.  PERRLA.,NECK:  Supple.  No JVD.  No lymphadenopathy.,CHEST:  Clear to auscultation.,HEART:  S1 and S2.  No S3, no murmurs.,ABDOMEN:  Soft and nontender.  No organomegaly.,EXTREMITIES:  No edema.,NEUROLOGIC:  Deferred.,ARTICULAR:  She has swelling of bilateral wrists, but no significant tenderness.,LABORATORY DATA:,  Labs in chart was reviewed.,ASSESSMENT AND PLAN:,  A 71-year-old female with a history of rheumatoid arthritis, on longstanding prednisone.  She is not on DMARD, but as she recently had a surgery followed by a probable infection, I will hold off on that.  As she has no pain, I have decreased the prednisone to 2.5 mg a day starting tomorrow if she is to go back to her nursing home tomorrow.  If in a couple of weeks her symptoms stay the same, then I would discontinue the prednisone.  I would defer that to Dr. X.  If she flares up at that point, prednisone may have to be restarted with a DMARD, so that eventually she could stay off the prednisone.  I discussed this at length with the patient and she is in full agreement with the plan.  I explained to her that if she is to be discharged, if she wishes, she could follow up with me in clinic or if she goes back to Victoria, then see her rheumatologist over there.","rheumatology, prednisone, joint pains, rheumatoid arthritis, arthritis, dmard, rheumatologist, rheumatoid, pains, "
" Followup of left hand discomfort and systemic lupus erythematosus.  Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.", Rheumatology, Hand Discomfort - Followup ,"REASON FOR RETURN VISIT: , Followup of left hand discomfort and systemic lupus erythematosus.,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old female with a history of systemic lupus erythematosus, who was last seen in rheumatology clinic approximately 4 months ago for bilateral hand discomfort, left greater than right.  The patient was seen on 10/30/07.  She had the same complaint.  She was given a trial of Elavil at bedtime because the thought was to see that represented ulnar or radial neuropathy.  She was also given a prescription for Zostrix cream but was unable to get it filled because of insurance coverage.  The patient reports some worsening of the symptoms especially involving at the dorsum of the left hand, and she points to the area that actually involves the dorsal aspect of the second, third, and fourth digits.  The patient recently has developed what sounds like an upper respiratory problem with a nonproductive cough for 3 days, although she reports that she has had subjective fevers for the past 3 or 4 days, but has not actually taken the temperature.  She has not had any night sweats or chills.  She has had no recent problems with chest pain, chest discomfort, shortness of breath or problems with GU or GI complaints.  She is returning today for routine followup evaluation.,CURRENT MEDICATIONS:,1.  Plaquenil 200 mg twice a day.,2.  Fosamax 170 mg once a week.,3.  Calcium and vitamin D complex twice daily.,4.  Folic acid 1 mg per day.,5.  Trilisate 1000 mg a day.,6.  K-Dur 20 mEq twice a day.,7.  Hydrochlorothiazide 15 mg once a day.,8.  Lopressor 50 mg one-half tablet twice a day.,9.  Trazodone 100 mg at bedtime.,10.  Prempro 0.625 mg per day.,11.  Aspirin 325 mg once a day.,12.  Lipitor 10 mg per day.,13.  Pepcid 20 mg twice a day.,14.  Reglan 10 mg before meals and at bedtime.,15.  Celexa 20 mg per day.,REVIEW OF SYSTEMS: , Noncontributory except for what was noted in the HPI and the remainder or complete review of systems is unremarkable.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure 155/84, pulse 87, weight 223 pounds, and temperature 99.2.  GENERAL:  She is a well-developed, well-nourished female appearing her staged age.  She is alert, oriented, and cooperative.  HEENT:  Normocephalic and atraumatic.  There is no facial rash.  No oral lesions.  LUNGS:  Clear to auscultation.  CARDIOVASCULAR:  Regular rate and rhythm without murmurs, rubs or gallops.  EXTREMITIES:  No cyanosis or clubbing.  Sensory examination of the upper extremity decreased to light touch on the distal tips of the left second and third digits compared to the fifth digit.  Positive Tinel sign.  Full range of motion of the wrist with no evidence of motor atrophy or muscle loss.,LABORATORY DATA:  ,WBC 5100, hemoglobin 11.1, hematocrit 32.8, and platelets 200,000.  Westergren sedimentation rate of 47.  Urinalysis is negative for protein and blood.  Lupus serology is pending.,ASSESSMENT:,1.  Systemic lupus erythematosus that is chronically stable at this point.,2.  Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.,3.  Upper respiratory infection with cough, cold, and congestion.,RECOMMENDATIONS:,1.  The patient will have a trial of a resting wrist splint at night for the next 4 to 6 weeks.  If there is no improvement, the patient will return for corticosteroid injection of her carpal tunnel.,2.  Azithromycin 5-day dose pack.,3.  Robitussin Cough and Cold Flu to be taken twice a day.,4.  Atarax 25 mg at bedtime for sleep.,5.  The patient will return to the rheumatology clinic for a routine followup evaluation in 4 months.",
 A 12-year-old with discoid lupus on the control with optimal regimen., Rheumatology, Discoid Lupus ,"HISTORY:  ,A is 12-year-old female who comes today for follow-up appointment and a CCS visit.  She has the diagnosis of discoid lupus and we have been following her for her conditions, her treatments, and also to watch her for any development of her systemic lupus.  A has been doing well with just Plaquenil alone and mother said that during the summer, the rash gets brighter, but now that it is getting darker and she is at school, the rash is starting to become lighter again.  She has been using her cream, which is hydrocortisone at night and applying it with no problems.  She denies any hair losses, denies any decrease in appetite, actually, she has been gaining some weight.  She denies any ulcerations in her mouth, eye problems, or any lumps in her body.  She denies any fevers or any problems with the urine.,PHYSICAL EXAMINATION: ,VITAL SIGNS:  Today temperature is 100.1, weight is 73.5 kg, blood pressure is 121/61, height is 158, and pulse is 84.,GENERAL:  She is alert, active, and oriented in no distress.,HEENT:  She had a head full of hair with no bald spots.  She has a macular rash on her cheeks bilaterally with hyperpigmented circles.  No scales, no excoriations, and no palpable erythema.  Oral mucosa is clear with no ulcerations.,NECK:  Soft with no masses.  She does have acanthosis nigricans on the base of the neck.,CHEST:  Clear to auscultation.,HEART:  Regular rhythm with no murmur.,ABDOMEN:  Soft and nontender with no visceromegaly.,MUSCULOSKELETAL:  Shows no limitation, swelling, or tenderness in any of her joints.,SKIN:  Shows a discoid rash with macules approximately 1 cm in diameter in different shapes and size, but most of them are about 1 cm in diameter, which are hyperpigmented.  No erythema, no purpura, no petechiae, and no raised borders.  They look more like cigarette points.  She has this in her upper extremities especially in the forearms and also on her lower extremities, on the legs, but just very few lesions and very light.  She has some periungual erythema, as well as some palmar erythema, but this is minimal.,LABORATORY DATA:,  Laboratories today done, we have a CBC with a white blood cell count of 7.9, hemoglobin is 14.3, platelet count is 321,000, sed rate is only 11, and CMP shows no abnormalities.  Pending is antinuclear antibody complement level.,ASSESSMENT: , She is 12-year-old with discoid lupus on the control with optimal regimen.  We are going to switch her to Protopic at night, especially in the face.  Continue on Plaquenil, get some laboratories and wait for the results.  Diet evaluation today because of the gaining weight and acanthosis nigricans, and will see her back in about 3 months for follow-up.  Future plans will be depending on whether or not she evolves into a full-blown lupus.  I discussed the plan with her mother and they had no further questions.","rheumatology, lupus, systemic lupus, acanthosis nigricans, discoid lupus, extremities, rash, erythema, discoid,"
 Consultation - an 87-year-old white female with weakness and a history of polymyositis., Rheumatology, Consult - Weankness & Polymyositis ,"REASON FOR CONSULTATION:, Regarding weakness and a history of polymyositis.,HISTORY OF PRESENT ILLNESS:, The patient is an 87-year-old white female who gives a history of polymyositis diagnosed in 1993. The patient did have biopsy of the quadriceps muscle performed at that time which, per her account, did show an abnormality. She was previously followed by Dr. C, neurology, over several years but was last followed up in the last three to four years. She is also seeing Dr. R at rheumatology in the past. Initially, she was treated with steroids but apparently was intolerant of that. She was given other therapy but she is unclear of the details of that. She has had persistent weakness of the bilateral lower extremities and has ambulated with the assistance of a walker for many years. She has also had a history of spine disease though the process there is not known to me at this time.,She presented on February 1, 2006 with productive cough, fevers and chills, left flank rash and pain there as well as profound weakness. Since admission, she has been diagnosed with a left lower lobe pneumonic process as well as shingles and is on therapy for both. She reports that strength in the proximal upper extremities has remained good. However, she has no grip strength. Apparently, this has been progressive over the last several years as well. She also presently has virtually no strength in the lower extremities and that is worse within the last few days. Prior to admission, she has had cough with mild shortness of breath. Phlegm has been dark in color. She has had reflux and occasional dysphagia. She has also had constipation but no other GI issues. She has no history of seizure or stroke like symptoms. She occasionally has headaches. No vision changes. Other than the left flank skin changes, she has had no other skin issues. She does have a history of DVT but this was 30 to 40 years ago. No history of dry eyes or dry mouth. She denies chest pain at present.,PAST MEDICAL AND SURGICAL HISTORY:, Hysterectomy, cholecystectomy, congestive heart failure, hypertension, history of DVT, previous colonoscopy that was normal, renal artery stenosis.,MEDICATIONS:, Medications prior to admission: Os-Cal, Zyrtec, potassium, Plavix, Bumex, Diovan.,CURRENT MEDICATIONS:, Acyclovir, azithromycin, ceftriaxone, Diovan, albuterol, Robitussin, hydralazine, Atrovent.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY:, She is a widow. She has 8 children that are healthy with the exception of one who has coronary artery disease and has had bypass. She also has a son with lumbar spine disease. No tobacco, alcohol or IV drug abuse.,FAMILY HISTORY:, No history of neurologic or rheumatologic issues.,REVIEW OF SYSTEMS:, As above.,PHYSICAL EXAMINATION:,VITAL SIGNS: She is afebrile. Current temperature 98. Respirations 16, heart rate 80 to 90. Blood pressure 114/55.,GENERAL APPEARANCE: She is alert and oriented and in no acute distress. She is pleasant. She is reclining in the bed.,HEENT: Pupils are reactive. Sclera are clear. Oropharynx is clear.,NECK: No thyromegaly. No lymphadenopathy.,CARDIOVASCULAR: Heart is regular rate and rhythm.,RESPIRATORY: Lungs have a few rales only.,ABDOMEN: Positive bowel sounds. Soft, nontender, nondistended. No hepatosplenomegaly.,EXTREMITIES: No edema.,SKIN: Left flank dermatome with vesicular rash that is red and raised consistent with zoster.,JOINTS: No synovitis anywhere. Strength is 5/5 in the proximal upper extremities. Proximal lower extremities are 0 out of 5. She has no grip strength at present.,NEUROLOGICAL: Cranial nerves II through XII grossly intact. Reflexes 2/4 at the biceps, brachial radialis, triceps. Nil out of four at the patella and Achilles bilaterally. Sensation seems normal. Chest x-ray shows COPD, left basilar infiltrate, cardiomegaly, atherosclerotic changes.,LABORATORY DATA:, White blood cell count 6.1, hemoglobin 11.9, platelets 314,000. Sed rate 29 and 30. Electrolytes: Sodium 134, potassium 4.9, creatinine 1.2, normal liver enzymes. TSH is slightly elevated at 5.38. CPK 36, BNP 645. Troponin less than 0.04.,IMPRESSION:,1. The patient has a history of polymyositis, apparently biopsy proven with a long standing history of bilateral lower extremity weakness. She has experienced dramatic worsening in the last 24 hours of the lower extremity weakness. This in the setting of an acute illness, presumably a pneumonic process.,2. She also gives a history of spine disease though the details of that process are not available either.,The question raised at this time is of recurrence in inflammatory myopathy which would need to include not only polymyositis but also inclusion body myositis versus progressive spine disease versus weakness secondary to acute illness versus neuropathic process versus other.,3. Zoster of the left flank.,4. Left lower lobe pneumonic process.,5. Elevation of the thyroid stimulating hormone.,RECOMMENDATIONS:,1. I have asked Dr. C to see the patient and he has done so tonight. He is planning for EMG nerve conduction study in the morning.,2. I would consider further spine evaluation pending review of the EMG nerve conduction study.,3. Agree with supportive care being administered thus far and will follow along with you.",
 A lady with symptoms consistent with possible oligoarticular arthritis of her knees., Rheumatology, Oligoarticular Arthritis - 2 ,"HISTORY: , A is a young lady, who came here with a diagnosis of seizure disorder and history of Henoch-Schonlein purpura with persistent proteinuria.  A was worked up for collagen vascular diseases and is here to find out the results.  Also was recommended to take 7.5 mg of Mobic every day for her joint pains.  She states that she continues with some joint pain and feeling tired all the time.  Mother states that also her seizure has continued without any control so far.  She is having some studies in the next few days.  She is mostly stiff on her legs, neck, and also on her hands.  The rest of the review of systems is in the chart.,PHYSICAL EXAMINATION: , ,VITAL SIGNS:  Temperature today is 99.2 degrees Fahrenheit, weight is 45.9 kg, blood pressure is 123/59, height is 149.5 cm, and pulse is 94.,HEENT:  She has no facial rashes, no lymphadenopathy, no alopecia, no oral ulcerations.  Pupils are reactive to accommodation.  Funduscopic examination is within normal limits.,NECK:  No neck masses.,CHEST:  Clear to auscultation.,HEART:  Regular rhythm with no murmur.,ABDOMEN:  Soft, nontender with no visceromegaly.,SKIN:  No rashes today.,MUSCULOSKELETAL:  Examination shows good range of motion with no swelling or tenderness in any of her joints of the upper extremities, but she does have minus/plus swelling of her knees with flexion contracture bilaterally on both.,LABORATORY DATA: , Laboratories were not done recently, but we have some lab results from the previous evaluation that basically is negative for any collagen vascular disease, but shows some evidence of decreased calcium and vitamin D levels.,ASSESSMENT: , This is a patient, who today presents with symptoms consistent with possible oligoarticular arthritis of her knees with also arthralgias and deficiency in vitamin D.  She also has chronic proteinuria and seizure disorder.  My recommendation is to start her on vitamin D and calcium supplements, and also increase the Mobic to 50 mg, which is one of the few things she can tolerate with all the medication she is taking.  We are going to refer her to physical therapy and see her back in 2 months for followup.  The plan was discussed with A and her parents and they have no further questions.","rheumatology, arthralgias, deficiency, vitamin d, collagen vascular diseases, seizure disorder, vascular diseases, joint pains, oligoarticular arthritis, arthritis, oligoarticular,"
 Ultrasound examination of the scrotum due to scrotal pain.  Duplex and color flow imaging as well as real time gray-scale imaging of the scrotum and testicles was performed. , Radiology, Ultrasound Scrotum ,"EXAM: , Ultrasound examination of the scrotum.,REASON FOR EXAM: , Scrotal pain.,FINDINGS:  ,Duplex and color flow imaging as well as real time gray-scale imaging of the scrotum and testicles was performed.  The left testicle measures 5.1 x 2.8 x 3.0 cm.  There is no evidence of intratesticular masses.  There is normal Doppler blood flow.  The left epididymis has an unremarkable appearance.  There is a trace hydrocele.,The right testicle measures 5.3 x 2.4 x 3.2 cm.  The epididymis has normal appearance.  There is a trace hydrocele.  No intratesticular masses or torsion is identified.  There is no significant scrotal wall thickening.,IMPRESSION:  ,Trace bilateral hydroceles, which are nonspecific, otherwise unremarkable examination.","radiology, scrotal pain, epididymis, torsion, ultrasound examination, intratesticular masses, ultrasound, scrotal, testicles, scrotum,"
 X-RAY of the soft tissues of the neck., Radiology, X-RAY - Neck Soft Tissues ,"EXAM: , Two views of the soft tissues of the neck.,HISTORY:,  Patient has swelling of the left side of his neck.,TECHNIQUE:,  Frontal and lateral views of the soft tissues of the neck were evaluated. There were no soft tissues of the neck radiographs for comparison. However, there was an ultrasound of the neck performed on the same day.,FINDINGS: , Frontal and lateral views of the soft tissues of the neck were evaluated and reveal there is an asymmetry seen to the left-sided soft tissues of the patient's neck which appear somewhat enlarged when compared to patient's right side. However the trachea appears to be normal caliber and contour.  Lateral views show a patent airway. The adenoids and tonsils appear normal caliber without evidence of hypertrophy. Airway appears patent. Osseous structures appear grossly normal.,IMPRESSION:,1. Patent airway. No evidence of any soft tissue swelling involving the patient's adenoids/tonsils, epiglottis or aryepiglottic folds. No evidence of any prevertebral soft tissue swelling.,2. Slight asymmetry seen to the soft tissues of the left side of the patient's neck which appears somewhat larger when compared to the right side.","radiology, swelling, soft tissues, ultrasound, tonsils, adenoids, osseous structures, epiglottis, aryepiglottic folds, frontal and lateral, normal caliber, frontal, asymmetry, "
 A 17-year-old male with oligoarticular arthritis of his right knee., Rheumatology, Oligoarticular Arthritis - 1 ,"HISTORY:,  A is here for a follow up appointment at our Pediatric Rheumatology Clinic as well as the CCS Clinic.  A is a 17-year-old male with oligoarticular arthritis of his right knee.  He had a joint injection back in 03/2007 and since then he has been doing relatively well.  He is taking Indocin only as needed even though he said he has pain regularly, and he said that his knee has not changed since the beginning, but he said he only takes the medicine when he has pain, which is not every day, but almost every day.  He denies any swelling more than what it was before, and he denies any other joints are affected at this moment.  Denies any fevers or any rashes.,PHYSICAL EXAMINATION:,  On physical examination, his temperature is 98.6, weight is 104.6 kg; which is 4.4 kg less than before, 108/70 is his blood pressure, weight is 91.0 kg, and his pulse is 80.  He is alert, active, and oriented in no distress.  He has no facial rashes, no lymphadenopathy, no alopecia.  Funduscopic examination is within normal limit.  He has no cataracts and symmetric pupils to light and accommodation.  His chest is clear to auscultation.  The heart has a regular rhythm with no murmur.  The abdomen is soft and nontender with no :  visceromegaly.  Musculoskeletal examination showed good range of motion of all his upper extremities with no swelling or tenderness.  Lower extremities:  He still has some weakness of the knees, hip areas, and the calf muscles.  He does have minus/plus swelling of the right knee with a very hypermobile patella.  There is no limitation in his range of motion, and the swelling is very minimal with some mild tenderness.,In terms of his laboratories, they were not done today.,ASSESSMENT: , This is a 17-year-old male with oligoarticular arthritis.  He is HLA-B27 negative.,PLAN:,  In terms of the plan, I discussed with him what things he should be taking and the fact that since he has persistent symptoms, he should be on medication every day.  I am going to switch him to Indocin 75 mg SR just to give more sustained effect to his joints, and if he does not respond to this or continue with the symptoms, we may need to get an MRI.  We will see him back in three months.  He was evaluated by our physical therapist, who gave him some recommendations in terms of exercise for his lower extremities.  Future plans for A may include physical therapy and more stronger medications as well as imaging studies with an MRI.  Today he received his flu shot.  Discussed this with A and his aunt and they had no further questions.","rheumatology, rheumatology clinic, lower extremities, oligoarticular arthritis, arthritis, oligoarticular, knee, swelling,"
 This is a 24-year-old pregnant patient to evaluate fetal weight and placental grade., Radiology, Ultrasound OB - 5 ,"GENERAL EVALUATION:,Fetal Cardiac Activity: Normal with a heart rate of 135BPM,Fetal Presentation: Cephalic.,Placenta: Anterior,Placentral grade: II,Previa: ? None.,Amniotic Fluid: 1.5 + 2.5 + 0.0 + 0.0 = 4cm compatible with oligohydramnios.,BIOMETRY:,BPD: 9.0cm consistent with 36weeks, 4days gestation,HC: 34.6cm which equals 40weeks and 1day gestational age.,FL: 6.9cm which equals 35weeks and 3days gestational age.,AC: 34.6cm which equals 38weeks and 4days gestational age.,CI (BPD/OFD):  (70-86) 73,FL/BPD: (71-87) 77,FL/HC: (20.8-22.6) 19.9,FL/AC (20-24) 20,HC/AC: (0.92-1.05) 1.00,GESTATIONAL AGE BY CURRENT ULTRASOUND: 37weeks 4days.,FETAL WEIGHT BY CURRENT ULTRASOUND: 3289grams (7pounds 4ounces).,ESTIMATED FETAL WEIGHT PERCENTILE: 24%.,EDD BY CURRENT ULTRASOUND: 06/04/07.,GESTATIONAL AGE BY DATES: 40weeks 0days.,L M P: Unknown.,EDD BY DATES: 05/18/07.,DATE OF PREVIOUS ULTRASOUND: 03/05/07.,EDD BY PREVIOUS ULTRASOUND: 05/24/07.,FETAL ANATOMY:,Fetal Ventricles: Normal,Fetal Cerebellum: Normal,Fetal Cranium: Normal,Fetal Face: Normal Nose and Mouth,Fetal Heart (4 Chamber View): Normal,Fetal Diaphragm: Normal,Fetal Stomach: Normal,Fetal Cord: Normal three-vessel cord,Fetal Abdominal Wall: Normal,Fetal Spine: Normal,Fetal Kidneys: Normal,Fetal Bladder: Normal,Fetal Limbs: Normal,IMPRESSION:,Active intrauterine pregnancy with a sonographic gestational age of 37weeks and 4days.,AFI=4cm compatible with mild oligohydramnios.,Fetal weight equals 3289grams (7pounds 4ounces). EFW percentile is 24%.,Placental grade is II.,No evidence of gross anatomical abnormality, with a biophysical profile total equal to 8 out of 8.,",
 Whole body radionuclide bone scan due to prostate cancer., Radiology, Whole Body Radionuclide Bone Scan ,"INDICATION:,  Prostate Cancer.,TECHNIQUE:,  3.5 hours following the intravenous administration of 26.5 mCi of Technetium 99m MDP, the skeleton was imaged in the anterior and posterior projections.,FINDINGS:,  There is a focus of abnormal increased tracer activity overlying the right parietal region of the skull.  The uptake in the remainder of the skeleton is within normal limits.  The kidneys image normally.  There is increased activity in the urinary bladder suggesting possible urinary retention.,CONCLUSION:,1.  Focus of abnormal increased tracer activity overlying the right parietal region of the skull.  CT scanning of magnetic resonance imaging of the skull and brain could be done for further assessment if it is clinically indicated.,2.  There is probably some degree of urinary retention.,","radiology, prostate cancer, technetium, whole body, urinary retention, bone scan, radionuclide, "
 A 27-year-old female with a size and date discrepancy., Radiology, Ultrasound OB - 7 ,"GENERAL EVALUATION:,Fetal Cardiac Activity: Normal at 150BPM.  Fetal Lie: Longitudinal.  Fetal Presentation: Cephalic.  Placenta: Anterior Grade I.  Uterus: Normal.  Cervix: Closed.  Adnexa: Not seen.  Amniotic Fluid: Normal.,BIOMETRY:,BPD: 8.4 cm consistent with 33 weeks, 6 days gestation,HC: 29.8 cm consistent with 33 weeks, 0 days gestation,AC: 29.7 cm consistent with 33 weeks, 5 days gestation,FL:",
" Pregnant female with nausea, vomiting, and diarrhea.  OB ultrasound less than 14 weeks, transvaginal.", Radiology, Ultrasound OB - 8 ,"REASON FOR EXAM: , Pregnant female with nausea, vomiting, and diarrhea.,FINDINGS: , The uterus measures 8.6 x 4.4 x 5.4 cm and contains a gestational sac with double decidual sac sign.  A yolk sac is visualized.  What appears to represent a crown-rump length measures 3.3 mm for an estimated sonographic age of 6 weeks 0 days and estimated date of delivery of 09/28/09.,Please note however that no fetal heart tones are seen.  However, fetal heart tones would be expected at this age.,The right ovary measures 3.1 x 1.6 x 2.3 cm.  The left ovary measures 3.3 x 1.9 x 3.5 cm.  No free fluid is detected.,IMPRESSION: , Single intrauterine pregnancy at 6 weeks 0 days with an estimated date of delivery of 09/28/09.  A live intrauterine pregnancy, however, could not be confirmed, as a sonographic fetal heart rate would be expected at this time.  A close interval followup in correlation with beta-hCG is necessary as findings may represent an inevitable abortion.","radiology, intrauterine pregnancy, estimated date of delivery, nausea, vomiting, fetal heart tones, ovary measures, fetal heart, ultrasound, ob, ovary, pregnancy, sac, fetal, intrauterine"
 Ultrasound - a 22-year-old pregnant female., Radiology, Ultrasound OB - 6 ,"GENERAL EVALUATION:,Fetal Cardiac Activity: Normal at 140 BPM,Fetal Position: Variable,Placenta: Posterior without evidence of placenta previa.,Uterus: Normal,Cervix:","radiology, pregnant female, fetal anatomy, pregnant, placenta, gestational, ultrasound, fetal, "
 Twin pregnancy with threatened preterm labor., Radiology, Ultrasound OB - 4 ,"GENERAL EVALUATION: ,(Twin A),Fetal Cardiac Activity: Normal at 166 BPM,Fetal Lie: Twin A lies to the maternal left.,Fetal Presentation: Cephalic,Placenta: Posterior fused placenta Grade I-II,Uterus: Normal,Cervix: Closed,Adnexa: Not seen,Amniotic Fluid: There is a single 3.9cm anterior pocket.,BIOMETRY:,BPD: 8.7cm consistent with 35 weeks, 1 day,HC: 30.3cm consistent with 33 weeks, 5 days.,AC: 28.2cm consistent with 32 weeks, 1 day,FL:",
 A 37 year-old female with twin pregnancy with threatened premature labor., Radiology, Ultrasound OB - 3 ,"GENERAL EVALUATION: ,Twin B,Fetal Cardiac Activity: Normal at 166 BPM,Fetal Lie: Longitudinal, to the maternal right.,Fetal Presentation: Cephalic.,Placenta: Fused, posterior placenta, Grade I to II.,Uterus: Normal,Cervix: Closed.,Adnexa: Not seen,Amniotic Fluid: AFI 5.5cm in a single AP pocket.,BIOMETRY:,BPD: 7.9cm consistent with 31weeks, 5 days gestation,HC: 31.1cm consistent with 33 weeks, 3 days gestation,AC: 30.0cm consistent with 34 weeks, 0 days gestation,FL:",
 A 34-year old female with no fetal heart motion noted on office scan., Radiology, Ultrasound OB - 2 ,"FINDINGS:,By dates the patient is 8 weeks, 2 days.,There is a gestational sac within the endometrial cavity measuring 2.1cm consistent with 6 weeks 4 days. There is a fetal pole measuring 7mm consistent with 6 weeks 4 days. There was no fetal heart motion on Doppler or on color Doppler.,There is no fluid within the endometrial cavity.,There is a 2.8 x 1.2cm right adnexal cyst.,IMPRESSION:,Gestational sac with a fetal pole but no fetal heart motion consistent with fetal demise at 6 weeks 4 days. By dates the patient is 8 weeks, 2 days.,A preliminary report was called by the ultrasound technologist to the referring physician.","radiology, fetal heart motion, gestational sac, endometrial cavity, fetal pole, fetal heart, heart motion, gestational, fetal"
 Ultrasound of pelvis - menorrhagia., Radiology, Ultrasound - Pelvis  ,"EXAM: , Ultrasound of pelvis.,HISTORY:, Menorrhagia.,FINDINGS: , Uterus is enlarged measuring 11.0 x 7.5 x 11.0 cm.  It appears to be completely replaced by multiple ill-defined fibroids.  The endometrial echo complex was not visualized due to the contents of replacement of the uterus with fibroids.  The right ovary measures 3.9 x 1.9 x 2.3 cm.  The left ovary is not seen.  No complex cystic adnexal masses are identified.,IMPRESSION:  ,Essential replacement of the uterus by fibroids.  It is difficult to measure given their heterogenous and diffuse nature.  MRI of the pelvis could be performed for further evaluation to evaluate for possible uterine fibroid embolization.","radiology, pelvis, mri, menorrhagia, ultrasound, adnexa, echo complex, endometrial, fibroids, ovary, uterine fibroid, uterus, ultrasound of pelvis"
 Transvaginal ultrasound to evaluate pelvic pain., Radiology, Ultrasound - Transvaginal ,"EXAM: , Transvaginal ultrasound.,HISTORY: , Pelvic pain.,FINDINGS: , The right ovary measures 1.6 x 3.4 x 2.0 cm.  There are several simple-appearing probable follicular cysts. There is no abnormal flow to suggest torsion on the right.  Left ovary is enlarged, demonstrating a 6.0 x 3.5 x 3.7 cm complex cystic mass of uncertain etiology.  This could represent a large hemorrhagic cyst versus abscess.  There is no evidence for left ovarian torsion.  There is a small amount of fluid in the cul-de-sac likely physiologic.,The uterus measures 7.7 x 5.0 cm.  The endometrial echo is normal at 6 mm.,IMPRESSION:,1.  No evidence for torsion.,2.  Large, complex cystic left ovarian mass as described.  This could represent a large hemorrhagic cyst; however, an abscess/neoplasm cannot be excluded.  Recommend either short interval followup versus laparoscopic evaluation given the large size and complex nature.","radiology, ultrasound, pelvic pain, transvaginal, cul-de-sac, cystic mass, echo, endometrial, flow, follicular cysts, hemorrhagic cyst, laparoscopic, neoplasm, ovarian, ovary, uterus, transvaginal ultrasound, complex cystic, torsion, "
 OB Ultrasound - A 29-year-old female requests for size and date of pregnancy., Radiology, Ultrasound OB - 1 ,"EXAM: , OB Ultrasound.,HISTORY:,  A 29-year-old female requests for size and date of pregnancy.,FINDINGS: , A single live intrauterine gestation in the cephalic presentation, fetal heart rate is measured 147 beats per minute.  Placenta is located posteriorly, grade 0 without previa.  Cervical length is 4.2 cm.  There is normal amniotic fluid index of 12.2 cm.  There is a 4-chamber heart.  There is spontaneous body/limb motion.  The stomach, bladder, kidneys, cerebral ventricles, heel, spine, extremities, and umbilical cord are unremarkable.,BIOMETRIC DATA:,BPD = 7.77 cm = 31 weeks, 1 day,HC = 28.26 cm = 31 weeks, 1 day,AC = 26.63 cm = 30 weeks, 5 days,FL = 6.06 cm = 31 weeks, 4 days,Composite sonographic age 30 weeks 6 days plus minus 17 days.,ESTIMATED DATE OF DELIVERY: , Month DD, YYYY.,Estimated fetal weight is 3 pounds 11 ounces plus or minus 10 ounces.,IMPRESSION: , Single live intrauterine gestation without complications as described.","radiology, ultrasound, ac, bpd, cervical length, estimated date of delivery, fl, hc, placenta, single live, amniotic fluid, bladder, cephalic, cephalic presentation, cerebral ventricles, extremities, fetal heart rate, fetal weight, gestation, heel, intrauterine, kidneys, pregnancy, previa, spine, stomach, umbilical cord, live intrauterine, intrauterine gestation"
 Bilateral lower extremity ultrasound for deep venous thrombus., Radiology, Ultrasound - Lower Extremity ,"EXAM: , Bilateral lower extremity ultrasound for deep venous thrombus.,REASON FOR EXAM: , Lower extremity edema bilaterally.,TECHNIQUE: , Colored, grayscale, and Doppler imaging is all employed.,FINDINGS: , This examination is limited.  There is prominent edema bilaterally and there is large body habitus.  These two limit assessment especially of the right lower extremity.,As visualized, there is no gross evidence of DVT.  The right leg grayscale images are limited.  No obvious clot identified on the color flow or Doppler images.  The left leg is better visualized than the right, but again is limited.  No definite clot is seen.,IMPRESSION: , Limited study secondary to body habitus and edema.  No obvious DVT as visualized.","radiology, edema, grayscale images, deep venous thrombus, lower extremity, grayscale, doppler, ultrasound, extremity, "
 AP abdomen and ultrasound of kidney., Radiology, Ultrasound - Kidney ,"EXAM: , AP abdomen and ultrasound of kidney.,HISTORY:,  Ureteral stricture.,AP ABDOMEN ,FINDINGS:,  Comparison is made to study from Month DD, YYYY.  There is a left lower quadrant ostomy.  There are no dilated bowel loops suggesting obstruction.  There is a double-J right ureteral stent, which appears in place.  There are several pelvic calcifications, which are likely vascular.  No definite pathologic calcifications are seen overlying the regions of the kidneys or obstructing course of the ureters.  Overall findings are stable versus most recent exam.,IMPRESSION: , Properly positioned double-J right ureteral stent.  No evidence for calcified renal or ureteral stones.,ULTRASOUND KIDNEYS,FINDINGS:,  The right kidney is normal in cortical echogenicity of solid mass, stone, hydronephrosis measuring 9.0 x 2.9 x 4.3 cm.  There is a right renal/ureteral stent identified.  There is no perinephric fluid collection.,The left kidney demonstrates moderate-to-severe hydronephrosis.  No stone or solid masses seen.  The cortex is normal.,The bladder is decompressed.,IMPRESSION:,1.  Left-sided hydronephrosis.,2.  No visible renal or ureteral calculi.,3.  Right ureteral stent.","radiology, ureteral stricture, ap abdomen, bowel loops, calcified, calculi, double-j, echogenicity, hydronephrosis, kidney, left lower quadrant, obstruction, ostomy, perinephric, renal, solid mass, stent, ultrasound, ureteral stent, ureteral stones, ureters, ureteral,"
" Ultrasound left lower extremity, duplex venous, due to swelling and to rule out DVT.  Duplex and color Doppler interrogation of the left lower extremity deep venous system was performed.", Radiology, Ultrasound - Lower Extremity - 1 ,"EXAM:  ,Ultrasound left lower extremity, duplex venous,REASON FOR EXAM: , Swelling and rule out DVT.,FINDINGS: , Duplex and color Doppler interrogation of the left lower extremity deep venous system was performed. Compressibility, augmentation, and color flow as well as Doppler flow was demonstrated within the common femoral vein, superficial femoral vein, and popliteal vein. The posterior tibial vein also demonstrated flow along its proximal visualized extent.,IMPRESSION: , No evidence of left lower extremity deep venous thrombosis.","radiology, color doppler, superficial femoral vein, popliteal vein, common femoral vein, deep venous, lower extremity, ultrasound, doppler, duplex, vein, venous"
 Bilateral carotid ultrasound to evaluate pain., Radiology, Ultrasound - Carotid - 2 ,"EXAM: , Ultrasound carotid, bilateral.,REASON FOR EXAMINATION: , Pain.,COMPARISON:,  None.,FINDINGS: , Bilateral common carotid arteries/branches demonstrate minimal, predominantly noncalcified plaquing with mild calcific plaquing in the left internal carotid artery.  There are no different colors or spectral Doppler waveform abnormalities.,PARAMETRIC DATA:,  Right CCA PSV 0.72 m/s.  Right ICA PSV is 0.595 m/s.  Right ICA EDV 0.188 m/s.  Right vertebral 0.517 m/s. Right IC/CC is 0.826. Left CCA PSV 0.571 m/s, left ICA PSV 0.598 m/s.  Left ICA EDV 0.192 m/s.  Left vertebral 0.551 m/s.  Left IC/CC is 1.047.,IMPRESSION:,1.  No evidence for clinically significant stenosis.,2.  Minimal, predominantly soft plaquing.,","radiology, carotid, cca psv, doppler, ic/cc, ica edv, ica psv, ultrasound, arteries, calcific plaquing, common carotid, internal carotid artery, spectral, stenosis, waveform, ultrasound carotid bilateral, ultrasound carotid, plaquing,"
 Ultrasound OB - followup for fetal growth., Radiology, Ultrasound OB ,"REASON FOR EXAM: , Followup for fetal growth. , ,INTERPRETATION: , Real-time exam demonstrates a single intrauterine fetus in cephalic presentation with a regular cardiac rate of 147 beats per minute documented. ,FETAL BIOMETRY:  ,BPD = 8.3 cm = 33 weeks, 4 days,HC = 30.2 cm = 33 weeks, 4 days,AC = 27.9 cm = 32 weeks, 0 days,FL =  6.4 cm = 33 weeks, 1 day,The head to abdomen circumference ratio is normal at 1.08, and the femur length to abdomen circumference ratio is normal at 23.0%.  Estimated fetal weight is 2,001 grams.  ,The amniotic fluid volume appears normal, and the calculated index is normal for the age at 13.7 cm.  ,A detailed fetal anatomic exam was not performed at this setting, this being a limited exam for growth.  The placenta is posterofundal and grade 2., ,IMPRESSION: , Single viable intrauterine pregnancy in cephalic presentation with a composite gestational age of 32 weeks, 5 days, plus or minus 17 days, giving and estimated date of confinement of 8/04/05.  There has been normal progression of fetal growth compared to the two prior exams of 2/11/05 and 4/04/05.  The examination of 4/04/05 questioned an echogenic focus within the left ventricle.  The current examination does not demonstrate any significant persistent echogenic focus involving the left ventricle.","radiology, amniotic fluid volume, placenta, posterofundal, intrauterine pregnancy, followup for fetal growth, ultrasound ob, cephalic presentation, abdomen circumference, circumference ratio, echogenic focus, fetal growth, fetal,"
 Ultrasound of the right mandibular region., Radiology, Ultrasound - Neck Soft Tissue ,"EXAM:  ,Ultrasound neck/soft tissue, head.,HISTORY: , Right-sided facial swelling and draining wound.,TECHNIQUE AND FINDINGS:,  Ultrasound of the right mandibular region was performed.,No focal collection is identified.  This whole region appears to be phlegmonous.  It is hard to adequately delineate the exact margins of this region.,IMPRESSION:  ,Abnormal appearing right mandibular region has more phlegmonous changes.  No focal fluid collection.,Had a discussion with Dr. xx.  Consider CT for further evaluation.","radiology, soft tissue, mandibular region, tissue, draining, phlegmonous, mandibular, ultrasound, "
 Transesophageal Echocardiogram.  A woman admitted to the hospital with a large right MCA CVA causing a left-sided neurological deficit incidentally found to have atrial fibrillation on telemetry. , Radiology, Transesophageal Echocardiogram - 6 ,"HISTORY OF PRESENT ILLNESS: , I was kindly asked to see this patient for transesophageal echocardiogram performance by Dr. A and Neurology.  Please see also my cardiovascular consultation dictated separately.  But essentially, this is a pleasant 72-year-old woman admitted to the hospital with a large right MCA CVA causing a left-sided neurological deficit incidentally found to have atrial fibrillation on telemetry.  She has been recommended for a transesophageal echocardiogram for cardioembolic source of her CNS insult.,I discussed the procedure in detail with the patient as well as with her daughter, who was present at the patient's bedside with the patient's verbal consent.  I then performed a risk/benefit/alternative analysis with benefits being more definitive exclusion of intracardiac thrombus as well as assessment for intracardiac shunts; alternatives being transthoracic echo imaging, which she had already had, with an inherent false negativity for this indication as well as empiric medical management, which the patient was not interested in; risks including, but not limited to, and the patient was aware this was not an all-inclusive list, of oversedation from conscious sedation, risk of aspiration pneumonia from regurgitation of stomach contents, risk of oropharyngeal, esophageal, oral, tracheal, pulmonary and/or gastric perforation, hemorrhage, or tear.  The patient expressed understanding of this risk/benefit/alternative analysis, had the opportunity to ask questions, which I invited from her and her daughter, all of which were answered to their self-stated satisfaction.  The patient then stated in a clear competent and coherent fashion that she wished to go forward with the transesophageal echocardiogram.,PROCEDURE: , The appropriate time-out procedure was performed as per Medical Center protocol under my direct supervision with appropriate identification of the patient, position, physician, procedure documentation; there were no safety issues identified by staff nor myself.  She received 20 cc of viscous lidocaine for topical oral anesthetic effect.  She received a total of 4 mg of Versed and 100 micrograms of fentanyl utilizing titrated conscious sedation with continuous hemodynamic and oximetric monitoring with reasonable effect.  The multi-plane probe was passed using digital guidance for several passes, after an oral bite block had been put into place for protection of oral dentition.  This was placed into the posterior oropharynx and advanced into the esophagus, then advanced into the stomach and then rotated and withdrawn and removed with adequate imaging obtained throughout.  She was recovered as per the Medical Center conscious sedation protocol, and there were no apparent complications of the procedure.,FINDINGS: , Normal left ventricular size and systolic function.  LVEF of 60%.  Mild left atrial enlargement.  Normal right atrial size.  Normal right ventricular size and systolic function.  No left ventricular wall motion abnormalities identified.  The four pulmonary veins are identified.  The left atrial appendage is interrogated, including with Doppler and color flow, and while there is good to-and-fro motion seen, echo smoke is seen, and in fact, an intracardiac thrombus is identified and circumscribed at 1.83 cm in circumference at the base of the left atrial appendage.  No intracardiac vegetations nor endocarditis seen on any of the intracardiac valves.  The mitral valve is seen.  There is mild mitral regurgitation with two jets.  No mitral stenosis.  Four pulmonary veins were identified without reversible pulmonary venous flow.  There are three cusps of the aortic valve seen.  No aortic stenosis.  There is trace aortic insufficiency.  There is trace pulmonic insufficiency.  The pulmonary artery is seen and is within normal limits.  There is trace to mild tricuspid regurgitation.  Unable to estimate PA systolic pressure accurately; however, on the recent transthoracic echocardiogram (which I would direct the reader to) on January 5, 2010, RVSP was calculated at 40 mmHg on that study.  E wave velocity on average is 0.95 m/sec with a deceleration time of 232 milliseconds.  The proximal aorta is within normal limits, annulus 1.19 cm, sinuses of Valsalva 2.54 cm, ascending aorta 2.61 cm.  The intra-atrial septum is identified as are the SVC and IVC, and these are within normal limits.  The intra-atrial septum is interrogated with color flow as well as agitated D5W and there is no evidence of intracardiac shunting, including no atrial septal defect nor patent foramen ovale.  No pericardial effusion.  There is mild nonmobile descending aortic atherosclerosis seen.,IMPRESSION:,1.  Normal left ventricular size and systolic function.  Left ventricular ejection fraction visually estimated at 60% without regional wall motion abnormalities.,2.  Mild left atrial enlargement.,3.  Intracardiac thrombus identified at the base of the left atrial appendage.,4.  Mild mitral regurgitation with two jets.,5.  Mild nonmobile descending aortic atherosclerosis.,Compared to the transthoracic echocardiogram done previously, other than identification of the intracardiac thrombus, other findings appear quite similar.,These results have been discussed with Dr. A of inpatient Internal Medicine service as well as the patient, who was recovering from conscious sedation, and her daughter with the patient's verbal consent.","radiology, echo, thrombus, intracardiac, cardiovascular, pulmonary veins, intracardiac thrombus, transesophageal echocardiogram, echocardiogram, atrial, mca, cva, transesophageal, pulmonary, ventricular, aortic"
" Coronary artery bypass surgery and aortic stenosis.  Transthoracic echocardiogram was performed of technically limited quality.  Concentric hypertrophy of the left ventricle with left ventricular function.  Moderate mitral regurgitation.  Severe aortic stenosis, severe.", Radiology, Transthoracic Echocardiography ,"REASON FOR EXAM: , Coronary artery bypass surgery and aortic stenosis.,FINDINGS: , Transthoracic echocardiogram was performed of technically limited quality.  The left ventricle was normal in size and dimensions with normal LV function.  Ejection fraction was 50% to 55%.  Concentric hypertrophy noted with interventricular septum measuring 1.6 cm, posterior wall measuring 1.2 cm.  Left atrium is enlarged, measuring 4.42 cm.  Right-sided chambers are normal in size and dimensions.  Aortic root has normal diameter.,Mitral and tricuspid valve reveals annular calcification.  Fibrocalcific valve leaflets noted with adequate excursion.  Similar findings noted on the aortic valve as well with significantly adequate excursion of valve leaflets.  Atrial and ventricular septum are intact.  Pericardium is intact without any effusion.  No obvious intracardiac mass or thrombi noted.,Doppler study reveals mild-to-moderate mitral regurgitation.  Severe aortic stenosis with peak velocity of 2.76 with calculated ejection fraction 50% to 55% with severe aortic stenosis.  There is also mitral stenosis.,IMPRESSION:,1.  Concentric hypertrophy of the left ventricle with left ventricular function.,2.  Moderate mitral regurgitation.,3.  Severe aortic stenosis, severe.,RECOMMENDATIONS: , Transesophageal echocardiogram is clinically warranted to assess the aortic valve area.","radiology, coronary artery bypass surgery, aortic stenosis, annular calcification, tricuspid, mitral, regurgitation, severe aortic stenosis, concentric hypertrophy, mitral regurgitation, transthoracic, echocardiogram, hypertrophy, ventricular, valve, stenosis, aortic"
 Ultrasound Abdomen - elevated liver function tests., Radiology, Ultrasound - Abdomen - 1 ,"EXAM: , Ultrasound Abdomen., ,REASON FOR EXAM: , Elevated liver function tests., ,INTERPRETATION: , The liver demonstrates heterogeneously increased echotexture with significant fatty infiltration.  The gallbladder is surgically absent. There is no fluid collection in the cholecystectomy bed.  There is dilatation of the common bile duct up to 1 cm.  There is also dilatation of the pancreatic duct that measures up to 3 mm.  There is caliectasis in the right kidney.  The bladder is significantly distended measuring 937 cc in volume.  The caliectasis in the right kidney may be secondary to back pressure from the distended bladder.  The aorta is normal in caliber., ,IMPRESSION:,1.  Dilated common duct as well as pancreatic duct as described.  Given the dilatation of these two ducts, ERCP versus MRCP is recommended to exclude obstructing mass.  The findings could reflect changes of cholecystectomy.  ,2.  Significantly distended bladder with probably resultant caliectasis in the right kidney.  Clinical correlation recommended.","radiology, aorta, dilated common duct, mrcp, ercp, elevated liver function tests, pancreatic duct, distended bladder, ultrasound abdomen, cholecystectomy, ultrasound, abdomen, liver, dilatation, caliectasis, kidney, bladder, duct"
 Transesophageal echocardiogram.   The transesophageal probe was introduced into the posterior pharynx and esophagus without difficulty., Radiology, Transesophageal Echocardiogram - 4 ,"PROCEDURE NOTE:,  The patient was brought to the transesophageal echo laboratory after informed consent was obtained.  The patient was seen by Anesthesia for MAC anesthesia.  The patient's posterior pharynx was anesthetized with local Cetacaine spray.  The transesophageal probe was introduced into the posterior pharynx and esophagus without difficulty.,FINDINGS: ,1.  Left ventricle is normal in size and function; ejection fraction approximately 60%.,2.  Right ventricle is normal in size and function.,3.  Left atrium and right atrium are normal in size.,4.  Mitral valve, aortic valve, tricuspid valve, and pulmonic valve with no evidence of vegetation.  Aortic valve is only minimally thickened.,5.  Mild mitral regurgitation and mild tricuspid regurgitation.,6.  No left ventricular thrombus.,7.  No pericardial effusion.,8.  There is evidence of patent foramen ovale by contrast study.,The patient tolerated the procedure well and is sent to recovery in stable condition.  He should be n.p.o. x4 hours, then liquid, then increase as tolerated.  Once his infection is cleared, he should follow up with us with regard to followup of patent foramen ovale.","radiology, ventricle, atrium, mitral valve, aortic valve, tricuspid valve, pulmonic valve, regurgitation, transesophageal probe, transesophageal echocardiogram, posterior pharynx, transesophageal, valve"
 Right and Left carotid ultrasound  , Radiology, Ultrasound - Carotid - 1 ,"RIGHT:,1.  Mild heterogeneous plaque seen in common carotid artery.,2.  Moderate heterogeneous plaque seen in the bulb and internal carotid artery.,3.  Severe heterogeneous plaque seen in external carotid artery with degree of stenosis around 70%.  ,4.  Peak systolic velocity is normal in common carotid, bulb, and internal carotid artery.,5.  Peak systolic velocity is 280 cm/sec in external carotid artery with moderate spectral broadening.,LEFT: , ,1.  Mild heterogeneous plaque seen in common carotid artery and external carotid artery.,2.  Moderate heterogeneous plaque seen in the bulb and internal carotid artery with degree of stenosis less than 50%.,3.  Peak systolic velocity is normal in common carotid artery and in the bulb.,4.  Peak systolic velocity is 128 cm/sec in internal carotid artery and 156 cm/sec in external carotid artery.,VERTEBRALS:,  Antegrade flow seen bilaterally.","radiology, carotid ultrasound, antegrade flow, peak systolic velocity, bulb, carotid artery, homogeneous plaque, plaque, spectral broadening, bulb and internal carotid, velocity is normal, common carotid artery, internal carotid artery, external carotid artery, internal carotid, external carotid, peak systolic, systolic velocity, artery, carotid, ultrasound, velocity, heterogeneous,"
" Ultrasound abdomen, complete", Radiology, Ultrasound - Abdomen ,"EXAM: , Ultrasound abdomen, complete.,HISTORY: , 38-year-old male admitted from the emergency room 04/18/2009, decreased mental status and right upper lobe pneumonia.  The patient has diffuse abdominal pain.  There is a history of AIDS.,TECHNIQUE:,  An ultrasound examination of the abdomen was performed.,FINDINGS:,  The liver has normal echogenicity.  The liver is normal sized.  The gallbladder has a normal appearance without gallstones or sludge.  There is no gallbladder wall thickening or pericholecystic fluid.  The common bile duct has a normal caliber at 4.6 mm.  The pancreas is mostly obscured by gas.  A small portion of the head of pancreas is visualized which has a normal appearance.  The aorta has a normal caliber.  The aorta is smooth walled.  No abnormalities are seen of the inferior vena cava.  The right kidney measures 10.8 cm in length and the left kidney 10.5 cm.  No masses, cysts, calculi, or hydronephrosis is seen.  There is normal renal cortical echogenicity.  The spleen is somewhat prominent with a maximum diameter of 11.2 cm.  There is no ascites.  The urinary bladder is distended with urine and shows normal wall thickness without masses.  The prostate is normal sized with normal echogenicity.,IMPRESSION:  ,1.  Spleen size at the upper limits of normal.,2.  Except for small portions of pancreatic head, the pancreas could not be visualized because of bowel gas.  The visualized portion of the head had a normal appearance.,3.  The gallbladder has a normal appearance without gallstones.  There are no renal calculi.","radiology, echogenicity, gallbladder, ultrasound abdomen complete, ultrasound abdomen, abdomen, liver, gallstones, kidney, calculi, renal, spleen, pancreas, ultrasound"
" Transesophageal echocardiogram. MRSA bacteremia, rule out endocarditis.  The patient has aortic stenosis.", Radiology, Transesophageal Echocardiogram - 5 ,"CLINICAL INDICATIONS: , MRSA bacteremia, rule out endocarditis.  The patient has aortic stenosis.,DESCRIPTION OF PROCEDURE: , The transesophageal echocardiogram was performed after getting verbal and a written consent signed.  Then a multiplane TEE probe was introduced into the upper esophagus, mid esophagus, lower esophagus, and stomach and multiple views were obtained.  There were no complications.  The patient's throat was numbed with Cetacaine spray and IV sedation was achieved with Versed and fentanyl.,FINDINGS:,1.  Aortic valve is thick and calcified, a severely restricted end opening and there is 0.6 x 8 mm vegetation attached to the right coronary cusp.  The peak velocity across the aortic valve was 4.6 m/sec and mean gradient was 53 mmHg and peak gradient 84 mmHg with calculated aortic valve area of 0.6 sq cm by planimetry.,2.  Mitral valve is calcified and thick.  No vegetation seen.  There is mild-to-moderate MR present.  There is mild AI present also.,3.  Tricuspid valve and pulmonary valve are structurally normal.,4.  There is a mild TR present.,5.  There is no clot seen in the left atrial appendage.  The velocity in the left atrial appendage was 0.6 m/sec.,6.  Intraatrial septum was intact.  There is no clot or mass seen.,7.  Normal LV and RV systolic function.,8.  There is thick raised calcified plaque seen in the thoracic aorta and arch.,SUMMARY:,1.  There is a 0.6 x 0.8 cm vegetation present in the aortic valve with severe aortic stenosis.  Calculated aortic valve area was 0.6 sq. cm.,2.  Normal LV systolic function.,","radiology, endocarditis, aortic stenosis, tee probe, mrsa bacteremia, transesophageal echocardiogram, aortic, echocardiogram, esophagus, vegetation, transesophageal"
 Transesophageal echocardiogram for aortic stenosis.  Normal left ventricular size and function.  Benign Doppler flow pattern.   Doppler study essentially benign.  Aorta essentially benign.  Atrial septum intact.  Study was negative., Radiology, Transesophageal Echocardiogram - 1 ,"INDICATION: , Aortic stenosis.,PROCEDURE: , Transesophageal echocardiogram.,INTERPRETATION:  ,Procedure and complications explained to the patient in detail.  Informed consent was obtained.  The patient was anesthetized in the throat with lidocaine spray.  Subsequently, 3 mg of IV Versed was given for sedation.  The patient was positioned and transesophageal probe was introduced without any difficulty.  Images were taken.  The patient tolerated the procedure very well without any complications.  Findings as mentioned below.,FINDINGS:,1.  Left ventricle is in normal size and dimension.  Normal function.  Ejection fraction of 60%.,2.  Left atrium and right-sided chambers are of normal size and dimension.,3.  Mitral, tricuspid, and pulmonic valves are structurally normal.,4.  Aortic valve reveals annular calcification with fibrocalcific valve leaflets with decreased excursion.,5.  Left atrial appendage is clean without any clot or smoke effect.,6.  Atrial septum intact.  Study was negative.,7.  Doppler study essentially benign.,8.  Aorta essentially benign.,9.  Aortic valve planimetry valve area average about 1.3 cm2 consistent with moderate aortic stenosis.,SUMMARY:,1.  Normal left ventricular size and function.,2.  Benign Doppler flow pattern.,3.  Aortic valve area of 1.3 cm2 planimetry.,","radiology, aortic valve, ejection fraction, planimetry, ventricular, transesophageal, echocardiogram, atrial septum, septum intact, transesophageal echocardiogram, aortic stenosis, doppler, aortic, valves"
 Left testicular swelling for one day.  Testicular Ultrasound.  Hypervascularity of the left epididymis compatible with left epididymitis.  Bilateral hydroceles., Radiology, Testicular Ultrasound ,"TESTICULAR ULTRASOUND,REASON FOR EXAM:  ,Left testicular swelling for one day.,FINDINGS:  ,The left testicle is normal in size and attenuation, it measures 3.2 x 1.7 x 2.3 cm.  The right epididymis measures up to 9 mm.  There is a hydrocele on the right side.  Normal flow is seen within the testicle and epididymis on the right.,The left testicle is normal in size and attenuation, it measures 3.9 x 2.1 x 2.6 cm.  The left testicle shows normal blood flow.  The left epididymis measures up to 9 mm and shows a markedly increased vascular flow.  There is mild scrotal wall thickening.  A hydrocele is seen on the left side.,IMPRESSION:,1.  Hypervascularity of the left epididymis compatible with left epididymitis.,2.  Bilateral hydroceles.","radiology, hypervascularity, bilateral hydroceles, epididymis, epididymitis, testicular ultrasound, ultrasound, flow, hydroceles, testicle, testicular,"
 Nerve root decompression at L45 on the left side.  Tun-L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left.  Interpretation of radiograph., Radiology, Tun-L Catheter Placement ,"PREOPERATIVE DIAGNOSIS:,  Low Back Syndrome - Low back pain with left greater than right lower extremity radiculopathy.,POSTOPERATIVE DIAGNOSIS:,  Same.,PROCEDURE:,1.  Nerve root decompression at L45 on the left side.,2.  Tun-L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left.,3.  Interpretation of radiograph.,ANESTHESIA: , IV sedation with Versed and Fentanyl.,ESTIMATED BLOOD LOSS:,  None.,COMPLICATIONS:,  None.,INDICATION FOR PROCEDURE: , Severe and excruciating pain in the lumbar spine and lower extremity.  MRI shows disc pathology as well as facet arthrosis.,SUMMARY OF PROCEDURE: , The patient was admitted to the operating room, consent was obtained and signed.  The patient was taken to the Operating room and was placed in the prone position.  Monitors were placed, including EKG, pulse oximeter and blood pressure monitoring.  After adequate IV sedation with Versed and Fentanyl the procedure was begun.,The lumbar sacral region was prepped and draped in sterile fashion with Betadine and four sterile towels.  After the towels were places then sterile drapes were placed on top of that.,After which time the Epimed catheter was then placed, this was done by first repositioning the C-Arm to visualize the lumbar spine and the vertebral bodies were then counted beginning at L5, verifying the sacral hiatus.  The skin over the sacral hiatus was then injected with 1% Lidocaine and an #18-gauge needle was used for skin puncture.  The #18-gauge needle was inserted off of midline.  A #16-gauge RK needle was then placed into the skin puncture and using the paramedian approach and loss-of-resistance technique the needle was placed.  Negative aspiration was carefully performed.  Omnipaque 240 dye was then injected through the #16-gauge RK needle.  The classical run off was noted.  A filling defect was noted @ L45 nerve root on the left side.  After which time 10 cc of 0.25% Marcaine/Triamcinolone (9/1 mixture) was then infused through the 16 R-K Needle.  Some additional lyses of adhesions were visualized as the local anesthetic displaced the Omnipaque 240 dye using this barbotage technique.,An Epimed Tun-L catheter was then inserted through the #16-gauage R-K needle and threaded up to the L45 interspace under continuous fluoroscopic guidance.  As the catheter was threaded up under continuous fluoroscopic visualization lyses of adhesions were visualized.  The tip of the catheter was noted to be @ L45 level on the left side.  After this the #16-gauge RK needle was then removed under fluoroscopic guidance verifying that the tip of the catheter did not migrate from the L45 nerve root region on the left side.  After this was successfully done, the catheter was then secured in place; this was done with Neosporin ointment, a Split 2x2, Op site and Hypofix tape.  The catheter was then checked with negative aspiration and the Omnipaque 240 dye was then injected.  The classical run off was noted in the lumbar region.  Some lyses of adhesions were also visualized at this time with barbotage technique.  Good dye spread was noted to extend one level above and one level below the L45 nerve root and bilateral spread was noted.  Nerve root decompression was visualized as dye spread into the nerve root whereas prior this was a filling defect.  After which time negative aspiration was again performed through the Epimed® Tun-L catheter and then 10 cc of solution was then infused through the catheter, this was done over a 10-minute period with initial 3 cc test dose.  Approximately 3 minutes elapsed and then the remaining 7 cc were infused (Solution consisting of 8 cc of 0.25% Marcaine, 2 cc of Triamcinolone and 1 cc of Wydase.)  The catheter was then capped with a bacterial filter.  The patient was noted to have tolerated the procedure well without any complications.,Interpretation of radiograph revealed nerve root adhesions present with lysis of these adhesions as the procedure was performed.  A filling defect was seen at the L45 nerve root and this filling defect being significant of fibrosis and adhesions in this region was noted to be lysed with the insertion of the catheter as well as the barbotage procedure.  This verified positive nerve root decompression.  The tip of the Epimed Tun L catheter was noted to be at L45 level on the left side.  Positive myelogram without dural puncture was noted during this procedure; no sub-dural spread of Omnipaque 240 dye was noted.  This patient did not report any problems and reported pain reduction.","radiology, low back syndrome, low back pain, nerve root decompression, steroid solution, c-arm, epimed, tun l catheter, nerve root, negative aspiration, omnipaque dye, filling defect, nerve, root, catheter, adhesions, injection, needle,"
 Transesophageal echocardiogram and direct current cardioversion., Radiology, Transesophageal Echocardiogram ,"EXAM: , Transesophageal echocardiogram and direct current cardioversion.,REASON FOR EXAM:  ,1.  Atrial fibrillation with rapid ventricular rate.,2.  Shortness of breath.,PROCEDURE: , After informed consent was obtained, the patient was then sedated using a total of 4 mg of Versed and 50 mcg of fentanyl.  Following this, transesophageal probe was placed in the esophagus.  Transesophageal views of the heart were then obtained.,FINDINGS:,1.  Left ventricle is of normal size.  Overall LV systolic function is preserved.  Estimated ejection fraction is 60% to 65%.  No wall motion abnormalities are noted.,2.  Left atrium is dilated.,3.  Left atrial appendage is free of clots.,4.  Right atrium is of normal size.,5.  Right ventricle is of normal size.,6.  Mitral valve shows evidence of mild MAC.,7.  Aortic valve is sclerotic without significant restriction of leaflet motion.,8.  Tricuspid valve appears normal.,9.  Pulmonic valve appears normal.,10.  Pacer wires are noted in the right atrium and in the right ventricle.,11.  Doppler interrogation of moderate mitral regurgitation is present.,12.  Mild-to-moderate AI is seen.,13.  No significant TR is noted.,14.  No significant TI is noted.,15.  No pericardial disease seen.,IMPRESSION:,1.  Preserved left ventricular systolic function.,2.  Dilated left atrium.,3.  Moderate mitral regurgitation.,4.  Aortic valve sclerosis with mild-to-moderate aortic insufficiency.,5.  Left atrial appendage is free of clots.,Following these, direct current cardioversion was performed.  Three biphasic shock waves of 150 and two of 200 joules were then applied to the patient's chest in anteroposterior direction without success in conversion to sinus rhythm.  The patient remained in atrial fibrillation.,PLAN: , Plan will be to continue medical therapy.  We will consider using beta-blocker, calcium channel blockers for better ventricular rate control.",
 Transesophageal echocardiographic examination report.   Aortic valve replacement.  Assessment of stenotic valve.  Evaluation for thrombus on the valve., Radiology, Transesophageal Echocardiogram - 3 ,"REASON FOR EXAM: , Aortic valve replacement.  Assessment of stenotic valve.  Evaluation for thrombus on the valve.,PREOPERATIVE DIAGNOSIS:  ,Atrial valve replacement.,POSTOPERATIVE DIAGNOSES:,  Moderate stenosis of aortic valve replacement.  Mild mitral regurgitation.  Normal left ventricular function.,PROCEDURES IN DETAIL: , The procedure was explained to the patient with risks and benefits.  The patient agreed and signed the consent form.  The patient received a total of 3 mg of Versed and 50 mcg of fentanyl for conscious sedation and pain control.  The oropharynx anesthetized with benzocaine spray and lidocaine solution.,Esophageal intubation was done with no difficulty with the second attempt.  In a semi-Fowler position, the probe was passed to transthoracic views at about 40 to 42 cm.  Multiple pictures obtained.  Assessment of the peak velocity was done later.,The probe was pulled to the mid esophageal level.  Different pictures including short-axis views of the aortic valve was done.  Extubation done with no problems and no blood on the probe.  The patient tolerated the procedure well with no immediate postprocedure complications.,INTERPRETATION: , The left atrium was mildly dilated.  No masses or thrombi were seen.  The left atrial appendage was free of thrombus.  Pulse wave interrogation showed peak velocities of 60 cm per second.,The left ventricle was normal in size and contractility with mild LVH.  EF is normal and preserved.,The right atrium and right ventricle were both normal in size.,Mitral valve showed no vegetations or prolapse.  There was mild-to-moderate regurgitation on color flow interrogation.  Aortic valve was well-seated mechanical valve, bileaflet with acoustic shadowing beyond the valve noticed.  No perivalvular leak was noticed.  There was increased velocity across the valve with peak velocity of 3.2 m/sec with calculated aortic valve area by continuity equation at 1.2 cm2 indicative of moderate aortic valve stenosis based on criteria for native heart valves.,No AIC.,Pulmonic valve was somewhat difficult to see because of acoustic shadowing from the aortic valve.  Overall showed no abnormalities.  The tricuspid valve was structurally normal.,Interatrial septum appeared to be intact, confirmed by color flow interrogation as well as agitated saline contrast study.,The aorta and aortic arch were unremarkable.  No dissection.,IMPRESSION:,1.  Mildly dilated left atrium.,2.  Mild-to-moderate regurgitation.,3.  Well-seated mechanical aortic valve with peak velocity of 3.2 m/sec and calculated valve area of 1.2 cm2 consistent with moderate aortic stenosis.  Reevaluation in two to three years with transthoracic echocardiogram will be recommended.","radiology, aortic valve replacement, stenotic valve, thrombus, stenosis, ventricular, esophageal, peak velocity, valve replacement, aortic valve, aortic, transesophageal, valve, oropharynx, atrium, interrogation, atrial, moderate, "
 Transesophageal echocardiogram due to vegetation and bacteremia. Normal left ventricular size and function.  Echodensity involving the aortic valve suggestive of endocarditis and vegetation. Doppler study as above most pronounced being moderate-to-severe aortic insufficiency., Radiology, Transesophageal Echocardiogram - 2 ,"REASON FOR EXAM: , Vegetation and bacteremia.,PROCEDURE: , Transesophageal echocardiogram.,INTERPRETATION: , The procedure and its complications were explained to the patient in detail and formal consent was obtained.  The patient was brought to special procedure unit.  His throat was anesthetized with lidocaine spray.  Subsequently, 2 mg of IV Versed was given for sedation.  The patient was positioned.  Probe was introduced without any difficulty.  The patient tolerated the procedure very well.  Probe was taken out.  No complications were noted.  Findings are as mentioned below.,FINDINGS:,1.  Left ventricle has normal size and dimensions with normal function.  Ejection fraction of 60%.,2.  Left atrium and right-sided chambers were of normal size and dimensions.,3.  Left atrial appendage is clean without any clot or smoke effect.,4.  Atrial septum is intact.  Bubble study was negative.,5.  Mitral valve is structurally normal.,6.  Aortic valve reveals echodensity suggestive of vegetation.,7.  Tricuspid valve was structurally normal.,8.  Doppler reveals moderate mitral regurgitation and moderate-to-severe aortic regurgitation.,9.  Aorta is benign.,IMPRESSION:,1.  Normal left ventricular size and function.,2.  Echodensity involving the aortic valve suggestive of endocarditis and vegetation.,3.  Doppler study as above most pronounced being moderate-to-severe aortic insufficiency.","radiology, ventricle, atrium, atrial, septum, mitral valv, aortic valve, tricuspid valve, doppler, ventricular size, transesophageal echocardiogram, severe aortic, bacteremia, transesophageal, echocardiogram, echodensity, vegetation, valve, aortic,"
 Pain.  Three views of the right ankle.  Three views of the right ankle are obtained., Radiology, Three Views - Ankle ,"EXAM: , Three views of the right ankle.,INDICATIONS:  ,Pain.,FINDINGS: , Three views of the right ankle are obtained.  There is no evidence of fractures or dislocations.  No significant degenerative changes or destructive osseous lesions of the ankle are noted.  There is a small plantar calcaneal spur.  There is no significant surrounding soft tissue swelling.,IMPRESSION:  ,Negative right ankle.","radiology, three views, calcaneal, plantar, spur, osseous, ankle"
" Tailor bunionectomy, right foot, Weil-type with screw fixation.  Hallux abductovalgus deformity and tailor bunion deformity, right foot.", Radiology, Tailor Bunionectomy with Screw Fixation ,"PREOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus deformity, right foot.,2.  Tailor bunion deformity, right foot.,POSTOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus deformity, right foot.,2.  Tailor bunion deformity, right foot.,PROCEDURES PERFORMED:  ,Tailor bunionectomy, right foot, Weil-type with screw fixation.,ANESTHESIA: , Local with MAC, local consisting of 20 mL of 0.5% Marcaine plain.,HEMOSTASIS:,  Pneumatic ankle tourniquet at 200 mmHg.,INJECTABLES:,  A 10 mL of 0.5% Marcaine plain and 1 mL of dexamethasone phosphate.,MATERIAL: , A 2.4 x 14 mm, 2.4 x 16 mm, and 2.0 x 10 mm OsteoMed noncannulated screw.  A 2-0 Vicryl, 3-0 Vicryl, 4-0 Vicryl, and 5-0 nylon.,COMPLICATIONS: , None.,SPECIMENS: , None.,ESTIMATED BLOOD LOSS:,  Minimal.,PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed on the operating table in the usual supine position.  At this time, a pneumatic ankle tourniquet was placed on the patient's right ankle for the purpose of maintaining hemostasis.  Number of the anesthesias was obtained and then induced mild sedation and local anesthetic as described above was infiltrated about the surgical site.  The right foot was then scrubbed, prepped, and draped in the usual aseptic manner.  An Esmarch bandage was then used to exsanguinate the patient's right foot, and the pneumatic ankle tourniquet inflated to 200 mmHg.  Attention was then directed to dorsal aspect of the first metatarsophalangeal joint where a linear longitudinal incision measuring approximately a 3.5 cm in length was made.  The incision was carried deep utilizing both sharp and blunt dissections.  All major neurovascular structures were avoided.  At this time, through the original skin incision, attention was directed to the first intermetatarsal space where utilizing both sharp and blunt dissection the deep transverse intermetatarsal ligament was identified.  This was then incised fully exposing the tendon and the abductor hallucis muscle.  This was then resected from his osseous attachments and a small tenotomy was performed.  At this time, a small lateral capsulotomy was also performed.  Lateral contractures were once again reevaluated and noted to be grossly reduced.,Attention was then directed to the dorsal aspect of the first metatarsal phalangeal joint where linear longitudinal and periosteal and capsular incisions were made following the first metatarsal joint and following the original shape of the skin incision.  The periosteal capsular layers were then reflected both medially and laterally from the head of the first metatarsal and a utilizing an oscillating bone saw, the head of the first metatarsal and medial eminence was resected and passed from the operative field.  A 0.045 inch K-wire was then driven across the first metatarsal head in order to act as an access dye.  The patient was then placed in the frog-leg position, and two osteotomy cuts were made, one from the access guide to the plantar proximal position and one from the access guide to the dorsal proximal position.  The dorsal arm was made longer than the plantar arm to accommodate for fixation.  At this time, the capital fragment was resected and shifted laterally into a more corrected position.  At this time, three portions of the 0.045-inch K-wire were placed across the osteotomy site in order to access temporary forms of fixation.  Two of the three of these K-wires were removed in sequence and following the standard AO technique two 3.4 x 15 mm and one 2.4 x 14 mm OsteoMed noncannulated screws were placed across the osteotomy site.  Compression was noted to be excellent.  All guide wires and 0.045-inch K-wires were then removed.  Utilizing an oscillating bone saw, the overhanging wedge of the bone on the medial side of the first metatarsal was resected and passed from the operating field.  The wound was then once again flushed with copious amounts of sterile normal saline.  At this time, utilizing both 2-0 and 3-0 Vicryl, the periosteal and capsular layers were then reapproximated.  At this time, the skin was then closed in layers utilizing 4-0 Vicryl and 4-0 nylon.  At this time, attention was directed to the dorsal aspect of the right fifth metatarsal where a linear longitudinal incision was made over the metatarsophalangeal joint just lateral to the extensor digitorum longus tension.  Incision was carried deep utilizing both sharp and blunt dissections and all major neurovascular structures were avoided.,A periosteal and capsular incision was then made on the lateral aspect of the extensor digitorum longus tendon and periosteum and capsular layers were then reflected medially and laterally from the head of the fifth metatarsal.  Utilizing an oscillating bone saw, the lateral eminence was resected and passed from the operative field.  Utilizing the sagittal saw, a Weil-type osteotomy was made at the fifth metatarsal head.  The head was then shifted medially into a more corrected position.  A 0.045-inch K-wire was then used as a temporary fixation, and a 2.0 x 10 mm OsteoMed noncannulated screw was placed across the osteotomy site.  This was noted to be in correct position and compression was noted to be excellent.  Utilizing a small bone rongeur, the overhanging wedge of the bone on the dorsal aspect of the fifth metatarsal was resected and passed from the operative field.  The wound was once again flushed with copious amounts of sterile normal saline.  The periosteal and capsular layers were reapproximated utilizing 3-0 Vicryl, and the skin was then closed utilizing 4-0 Vicryl and 4-0 nylon.  At this time, 10 mL of 0.5% Marcaine plain and 1 mL of dexamethasone phosphate were infiltrated about the surgical site.  The right foot was then dressed with Xeroform gauze, fluffs, Kling, and Ace wrap, all applied in mild compressive fashion.  The pneumatic ankle tourniquet was then deflated and a prompt hyperemic response was noted to all digits of the right foot.  The patient was then transported from the operating room to the recovery room with vital sings stable and neurovascular status grossly intact to the right foot.  After a brief period of postoperative monitoring, the patient was discharged to home with proper written and verbal discharge instructions, which included to keep dressing clean, dry, and intact and to follow up with Dr. A.  The patient is to be nonweightbearing to the right foot.  The patient was given a prescription for pain medications on nonsteroidal anti-inflammatory drugs and was educated on these.  The patient tolerated the procedure and anesthesia well.  Dr. A was present throughout the entire case.","radiology, tailor bunionectomy, weil-type, screw fixation, hallux, abductovalgus, bunion, tailor, deformity, metatarsal, phalangeal, capsulotomy, abductor, hallucis, "
 Right foot trauma.  Three views of the right foot.  Three views of the right foot were obtained.  , Radiology, Three Views - Foot ,"EXAM:  ,Three views of the right foot.,REASON FOR EXAM: , Right foot trauma.,FINDINGS: , Three views of the right foot were obtained.  There are no comparison studies.  There is no evidence of fractures or dislocations.  No significant degenerative changes or obstructive osseous lesions were identified.  There are no radiopaque foreign bodies.,IMPRESSION: , Negative right foot.","radiology, three views, radiopaque, fractures, foot trauma"
" Chest pain,  Chest wall tenderness occurred with exercise.", Radiology, Stress Test Graded Exercise Treadmill ,"INDICATIONS:,  Chest pain.,PROCEDURE DONE:,  Graded exercise treadmill stress test.,STRESS ECG RESULTS:,  The patient was stressed by continuous graded treadmill testing for nine minutes of the standard Bruce protocol.  The heart rate increased from 68 beats per minute to 178 beats per minute, which is 100% of the maximum predicted target heart rate.  The blood pressure increased from 120/70 to 130/80.  The baseline resting electrocardiogram reveals a regular sinus rhythm.  The tracing is within normal limits.  Symptoms of chest pain occurred with exercise.  The pain persisted during the recovery process and was aggravated by deep inspiration.  Marked chest wall tenderness noted.  There were no ischemic ST segment changes seen during exercise or during the recovery process.,CONCLUSIONS,:,1.  Stress test is negative for ischemia.,2.  Chest wall tenderness occurred with exercise.,3.  Blood pressure response to exercise is normal.","radiology, stress test, blood pressure, bruce protocol, chest pain, graded exercise, graded exercise treadmill, electrocardiogram, ischemia, sinus rhythm, treadmill, chest wall tenderness, chest wall, stress, chest, "
 Thallium stress test for chest pain., Radiology, Stress Test Thallium ,"INDICATIONS:  ,Chest pain.,STRESS TECHNIQUE:,","radiology, chest pain, ecg stress, thallium stress test, aerobic capacity, ejection fraction, gated tomographic spect system, myocardial perfusion, thallous chloride, ventricle, wall motion, stress test, stress"
 Stress test with Bruce protocol due to chest pain., Radiology, Stress Test Bruce Protocol ,"PROTOCOL:,  Bruce.,PERTINENT MEDICATION: , None.,REASON FOR TEST:,  Chest pain.,PROCEDURE AND INTERPRETATION: ,1.  Baseline heart rate:  67.,2.  Baseline blood pressure:  150/86.,3.  Total time:  6 minute 51 seconds.,4.  METs:  10.1.,5.  Peak heart rate:  140.,6.  Percent of maximum-predicted heart rate:  90.,7.  Peak blood pressure:  200/92.,8.  Reason test terminated:  Shortness of breath and fatigue.,9.  Estimated aerobic capacity:  Average.,10. Heart rate response:  Normal.,11. Blood pressure response:  Hypertensive.,12. ST segment response:  Normal.,13. Chest pain:  None.,14. Symptoms:  None.,15. Arrhythmia:  None.,CONCLUSION:,1.  Average aerobic capacity.,2.  Normal heart rate and blood pressure response to exercise.,3.  No symptomatic electrocardiographic evidence of ischemia.,CONDITION: , Stable with normal vital signs.,DISPOSITION:  ,The patient was discharged home and was asymptomatic.,",
" Chest pain, hypertension.  Stress test negative for dobutamine-induced myocardial ischemia.  Normal left ventricular size, regional wall motion, and ejection fraction.", Radiology, Stress Test Dobutamine Myoview ,"INDICATIONS:  ,Chest pain, hypertension, type II diabetes mellitus.,PROCEDURE DONE:,  Dobutamine Myoview stress test.,STRESS ECG RESULTS:,  The patient was stressed by dobutamine infusion at a rate of 10 mcg/kg/minute for three minutes, 20 mcg/kg/minute for three minutes, and 30 mcg/kg/minute for three additional minutes.  Atropine 0.25 mg was given intravenously eight minutes into the dobutamine infusion.  The resting electrocardiogram reveals a regular sinus rhythm with heart rate of 86 beats per minute, QS pattern in leads V1 and V2, and diffuse nonspecific T wave abnormality.  The heart rate increased from 86 beats per minute to 155 beats per minute, which is about 90% of the maximum predicted target heart rate.  The blood pressure increased from 130/80 to 160/70.  A maximum of 1 mm J-junctional depression was seen with fast up sloping ST segments during dobutamine infusion.  No ischemic ST segment changes were seen during dobutamine infusion or during the recovery process.,MYOCARDIAL PERFUSION IMAGING:,  Resting myocardial perfusion SPECT imaging was carried out with 10.9 mCi of Tc-99m Myoview.  Dobutamine infusion myocardial perfusion imaging and gated scan were carried out with 29.2 mCi of Tc-99m Myoview.  The lung heart ratio is 0.36.  Myocardial perfusion images were normal both at rest and with stress.  Gated myocardial scan revealed normal regional wall motion and ejection fraction of 67%.,CONCLUSIONS:,1.  Stress test is negative for dobutamine-induced myocardial ischemia.,2.  Normal left ventricular size, regional wall motion, and ejection fraction.","radiology, chest pain, dobutamine myoview, dobutamine myoview stress test, spect imaging, stress test, dobutamine infusion, ejection fraction, hypertension, myocardial ischemia, myocardial perfusion, ventricular size, wall motion, dobutamine, stress, myocardial, myoview, ischemia, ventricular, perfusion, "
 Dobutrex stress test for abnormal EKG, Radiology, Stress Test Dobutrex ,"INDICATIONS:,","radiology, dobutrex stress test, abnormal ekg, dobutrex, inferior abnormality, ischemic heart disease, ventricle, µg/kg/minute, stress test, stress,"
 Dobutamine stress test for atrial fibrillation., Radiology, Stress Test Dobutamine ,"INDICATIONS:,  Atrial fibrillation, coronary disease.,STRESS TECHNIQUE:, The patient was infused with dobutamine to a maximum heart rate of 142.  ECG exhibits atrial fibrillation.,IMAGE TECHNIQUE:,  The patient was injected with 5.2 millicuries of thallous chloride and subsequently imaged on the gated tomographic SPECT system.,IMAGE ANALYSIS:,  It should be noted that the images are limited slightly by the patient's obesity with a weight of 263 pounds.  There is normal LV myocardial perfusion.  The LV systolic ejection fraction is normal at 65%.  There is normal global and regional wall motion.,CONCLUSIONS:,1.  Basic rhythm of atrial fibrillation with no change during dobutamine stress, maximum heart rate of 142.,2.  Normal LV myocardial perfusion.,3.  Normal LV systolic ejection fraction of 65%.,4.  Normal global and regional wall motion.","radiology, dobutamine stress test, atrial fibrillation, lv myocardial perfusion, lv systolic ejection fraction, coronary disease, dobutamine, ejection fraction, gated tomographic spect system, thallous chloride, wall motion, stress, fibrillation, atrial "
 Frontal and lateral views of the hip and pelvis., Radiology, Slipped Capital Femoral Epiphysis (SCFE) ,"EXAM: , Two views of the pelvis.,HISTORY:,  This is a patient post-surgery, 2-1/2 months.  The patient has a history of slipped capital femoral epiphysis (SCFE) bilaterally.,TECHNIQUE: , Frontal and lateral views of the hip and pelvis were evaluated and correlated with the prior film dated MM/DD/YYYY.  Lateral view of the right hip was evaluated.,FINDINGS:,  Frontal view of the pelvis and a lateral view of the right hip were evaluated and correlated with the patient's most recent priors dated MM/DD/YYYY.  Current films reveal stable appearing post-surgical changes.  Again demonstrated is a single intramedullary screw across the left femoral neck and head.  There are 2 intramedullary screws through the greater trochanter of the right femur.  There is a lucency along the previous screw track extending into the right femoral head and neck.  There has been interval removal of cutaneous staples and/or surgical clips.  These were previously seen along the lateral aspect of the right hip joint.,Deformity related to the previously described slipped capital femoral epiphysis is again seen.,IMPRESSION:,1.  Stable-appearing right hip joint status-post pinning.,2.  Interval removal of skin staples as described above.","radiology, scfe, frontal and lateral views, slipped capital femoral epiphysis, lateral views, slipped, capital, epiphysis, frontal, pelvis, femoral, hip"
 Stress test - Adenosine Myoview.  Ischemic cardiomyopathy.  Inferoseptal and apical transmural scar., Radiology, Stress Test Adenosine Myoview ,"INDICATIONS:,  Ischemic cardiomyopathy, status post inferior wall myocardial infarction, status post left anterior descending PTCA and stenting.,PROCEDURE DONE:,  Adenosine Myoview stress test.,STRESS ECG RESULTS:,  The patient was stressed by intravenous adenosine, 140 mcg/kg/minute infused over four minutes.  The baseline resting electrocardiogram revealed an electronic pacemaker depolarizing the ventricles regularly at a rate of 70 beats per minute.  Underlying atrial fibrillation noted, very wide QRS complexes.  The heart rate remained unchanged at 70 beats per minute as the blood pressure decreased from 140/80 to 110/70 with adenosine infusion.","radiology, stress test, adenosine, adenosine myoview stress test, ischemic cardiomyopathy, spect, cardiomyopathy, electrocardiogram, myocardial infarction, stress test adenosine myoview, adenosine myoview stress, myoview stress test, ptca and stenting, myoview stress, transmural scar, adenosine infusion, septal motion, adenosine myoview, myocardial perfusion, hypokinesis, inferoseptal, ischemic, myocardial, myoview, perfusion, scan"
" HCT: SAH, Contusion, Skull fracture", Radiology," SAH, Contusion, Skull Fracture ","CC: ,Headache.,HX:, This 51 y/o RHM was moving furniture several days prior to presentation when he struck his head (vertex) against a door panel. He then stepped back and struck his back on a trailer hitch. There was no associated LOC but he felt ""dazed."" He complained a HA since the accident. The following day he began experiencing episodic vertigo lasting several minutes with associated nausea and vomiting. He has been lying in bed most of the time since the accident. He also complained of transient left lower extremity weakness. The night before admission he went to his bedroom and his girlfriend heard a loud noise. She found him on the floor unable to speak or move his left side well. He was taken to a local ER. In the ER experienced a spell in which he stared to the right for approximately one minute. During this time he was unable to speak and did not seem to comprehend verbal questions. This resolved. ER staff noted decreased left sided movement and a left Babinski sign.,He was given valium 5 mg, and DPH 1.0g. A HCT was performed and he was transferred to UIHC.,PMH:, DM, Coronary Artery Disease, Left femoral neuropathy of unknown etiology. Multiple head trauma in past (?falls/fights).,MEDS:, unknown oral med for DM.,SHX:, 10+pack-year h/o Tobacco use; quit 2 years ago. 6-pack beer/week. No h/o illicit drug use.,FHX:, unknown.,EXAM: ,70BPM, BP144/83, 16RPM, 36.0C,MS: Alert and oriented to person, place, time. Fluent speech.,CN: left lower facial weakness with right gaze preference. Pupils 3/3 decreasing to 2/2 on exposure to light. Optic disks flat.,MOTOR: decreased spontaneous movement of left-sided extremities. 5/4 strength in both upper and lower extremities. Normal muscle tone and bulk.,SENSORY: withdrew equally to noxious stimulation in all four extremities. GAIT/STATION/COORDINATION: not tested.,The general physical exam was unremarkable.,During the exam the patient experienced a spell during which his head turned and eyes deviated to the leftward, and his right hand twitched. The entire spell lasted one minute.,During the episode he was verbally unresponsive. He appeared groggy and lethargic after the event.,HCT without contrast: 11/18/92: right frontal skull fracture with associated minimal epidural hematoma and small subdural hematoma, as well as some adjacent subarachnoid blood and brain contusion.,LABS:, CBC, GS, PT/PTT were all WNL.,COURSE:, The patient was diagnosed with a right frontal SAH/contusion and post traumatic seizures. DPH was continued and he was given a Librium taper for possible alcoholic withdrawal. A neurosurgical consult was obtained. He did not receive surgical intervention and was discharged 12/1/92. Neuropsychological testing on 11/25/92 revealed: poor orientation to time or place and poor attention. Anterograde verbal and visual memory was severely impaired. Speech became mildly dysarthric when fatigued. Defective word finding. Difficulty copying 2 of 3 three dimensional figures. Recent head injury as well as a history of ETOH abuse and multiple prior head injuries probably contribute to his deficits.","radiology, sah, contusion, skull fracture, headache, post traumatic seizures, lower extremity weakness, loud noise, hct, weakness, skull, hematoma, fracture, "
" Chest, Single view post OP for ASD (Atrial Septal Defect).", Radiology, Single Frontal View of Chest ,"EXAM: , Single frontal view of the chest.,HISTORY: , Atelectasis.  Patient is status-post surgical correction for ASD.,TECHNIQUE: , A single frontal view of the chest was evaluated and correlated with the prior film dated mm/dd/yy.,FINDINGS:,  Current film reveals there is a right-sided central venous catheter, the distal tip appears to be in the superior vena cava.  Endotracheal tube with the distal tip appears to be in appropriate position, approximately 2 cm superior to the carina.  Sternotomy wires are noted.  They appear in appropriate placement.  There are no focal areas of consolidation to suggest pneumonia.  Once again seen is minimal amount of bilateral basilar atelectasis.  The cardiomediastinal silhouette appears to be within normal limits at this time.  No evidence of any pneumothoraces or pleural effusions.,IMPRESSION:,1.  There has been interval placement of a right-sided central venous catheter, endotracheal tube, and sternotomy wires secondary to patient's most recent surgical intervention.,2.  Minimal bilateral basilar atelectasis with no significant interval changes from the patient's most recent prior.,3.  Interval decrease in the patient's heart size which may be secondary to the surgery versus positional and technique.","radiology, atrial septal defect, central venous catheter, bilateral basilar atelectasis, single frontal view, distal tip, endotracheal tube, sternotomy wires, basilar atelectasis, atrial, venous, catheter, endotracheal, tube, sternotomy, atelectasis, chest, asd"
 Single frontal view of the chest. Respiratory distress.  The patient has a history of malrotation., Radiology, Single Frontal View - Chest - Pediatric ,"EXAM:,  Single frontal view of the chest.,HISTORY:,  Respiratory distress.  The patient has a history of malrotation.  The patient is back for a re-anastomosis of the bowel with no acute distress.,TECHNIQUE:,  Single frontal view of the chest was evaluated and correlated with the prior film dated MM/DD/YY.,FINDINGS:,  A single frontal view of the chest was evaluated.  It reveals interval placement of an ET tube and an NG tube.  ET tube is midway between the patient's thoracic inlet and carina.  NG tube courses with the distal tip in the left upper quadrant beneath the left hemidiaphragm.  There is no evidence of any focal areas of consolidation, pneumothoraces, or pleural effusions.  The mediastinum seen was slightly prominent; however, this may be secondary to thymus and/or technique.  There is a slight increase seen with regards to the central pulmonary vessels.  Again, this may represent a minimal amount of pulmonary vascular congestion.  There is paucity of bowel gas seen in the upper abdomen.  The osseous thorax appears to be grossly intact and symmetrical.  Slightly low lung volumes, however, this may be secondary to the film being taken on the expiratory phase of respiration.,IMPRESSION:,1.  No evidence of any focal areas of consolidation, pneumothoraces, or pleural effusions.,2.  Slight prominence to the mediastinum which may be secondary to thymus and/or technique.,3.  Slight prominence of some of the central pulmonary vasculature which may represent a minimal amount of vascular congestion.","radiology, malrotation, consolidation, pneumothoraces, single frontal view, respiratory distress, vascular congestion, frontal view, effusions, mediastinum, vascular, congestion, respiratory, anastomosis, pulmonary, single, frontal, chest"
 Complex Regional Pain Syndrome Type I.  Stellate ganglion RFTC (radiofrequency thermocoagulation)  left side and interpretation of Radiograph., Radiology, Radiofrequency Thermocoagulation - 2 ,"PREOPERATIVE DIAGNOSIS:,  Complex Regional Pain Syndrome Type I.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE:,1.  Stellate ganglion RFTC (radiofrequency thermocoagulation)  left side.,2.  Interpretation of Radiograph.,ANESTHESIA:  ,IV Sedation with Versed and Fentanyl.,ESTIMATED BLOOD LOSS:,  None.,COMPLICATIONS:,  None.,INDICATIONS: , Patient with reflex sympathetic dystrophy, left side.  Positive for allodynia, pain, mottled appearance, skin changes upper extremities as well as swelling.,SUMMARY OF PROCEDURE: , Patient is admitted to the Operating Room.  Monitors placed, including EKG, Pulse oximeter, and BP cuff.  Patient had a pillow placed under the shoulder blades.  The head and neck was allowed to fall back into hyperextension.  The neck region was prepped and draped in sterile fashion with Betadine and alcohol.  Four sterile towels were placed.  The cricothyroid membrane was palpated, then going one finger's breadth lateral from the cricothyroid membrane and one finger's breadth inferior, the carotid pulse was palpated and the sheath was retracted laterally.  A 22 gauge SMK 5-mm bare tipped needle was then introduced in between the cricothyroid membrane and the carotid sheath and directed inferiomedially.  The needle is advanced prudently through the tissues, avoiding the carotid artery laterally.  The tip of the needle is perceived to intersect with the vertebral body of Cervical #7 and this was visualized by fluoroscopy.  Aspiration was cautiously performed after the needle was retracted approximately 1 mm and held steady with left hand.  No venous or arterial blood return is noted.  No cerebral spinal fluid is noted.  Positive sensory stimulation was elicited using the Radionics unit at 50 Hz from 0-0.1 volts and negative motor stimulation was elicited from 1-10 volts at 2 Hz.  After negative aspiration through the 22 gauge SMK 5mm bare tipped needle is absolutely confirmed, 5 cc of solution (solution consisting of 5 cc of 0.5% Marcaine, 1 cc of triamcinolone) was then injected into the stellate ganglion region.  This was done with intermittent aspiration vigilantly verifying negative aspiration.  The stylet was then promptly replaced and neurolysis (nerve decompression) was then carried out for 60 seconds at 80 degrees centigrade.  This exact same procedure using the exact same protocol was repeated one more time to complete the two lesions of the stellate ganglion.  The patient was immediately placed in the sitting position to reduce any side effect from the stellate ganglion block associated with cephalad spread of the solution.  Pressure was placed over the puncture site for approximately five minutes to eliminate any hemorrhage from blood vessels that may have been punctured and a Band-Aid was placed over the puncture site.  Patient was monitored for an additional ten to fifteen minutes and was noted to have tolerated the procedure well without any adverse sequelae.  Significant temperature elevation was noted on the affected side verifying neurolysis of the ganglion.  ,Interpretation of radiograph reveals placement of the 22-gauge SMK 5-mm bare tipped needle in the region of the stellate ganglion on the affected side.  Four lesions were carried out.","radiology, sheath, vertebral body, regional pain syndrome, radiofrequency thermocoagulation, stellate ganglion, rftc, radiofrequency, radiograph, cricothyroid, thermocoagulation, ganglion,"
" Ultrasound kidneys/renal for renal failure, neurogenic bladder, status-post cystectomy", Radiology, Renal Ultrasound ,"EXAM:,  Renal ultrasound.,HISTORY: , Renal failure, neurogenic bladder, status-post cystectomy.,TECHNIQUE: , Multiple ultrasonographic images of the kidneys were obtained in the transverse and longitudinal planes.,COMPARISON:,  Most recently obtained mm/dd/yy.,FINDINGS:,  The right kidney measures 12 x 5.2 x 4.6 cm and the left kidney measures 12.2 x 6.2 x 4.4 cm.  The imaged portions of the kidneys fail to demonstrate evidence of mass, hydronephrosis or calculus.  There is no evidence of cortical thinning.,Incidentally there is a rounded low-attenuation mass within the inferior aspect of the right lobe of the liver measuring 2.1 x 1.5 x 1.9 cm which has suggestion of some peripheral blood flow.,IMPRESSION:,1.  No evidence of hydronephrosis.,2.  Mass within the right lobe of the liver.  The patient apparently has a severe iodine allergy.  Further evaluation with MRI is recommended.,3.  The results of this examination were given to XXX in Dr. XXX office on mm/dd/yy at XXX,","radiology, lobe of the liver, status post cystectomy, renal ultrasound, renal failure, neurogenic bladder, bladder status, neurogenic, bladder, cystectomy, hydronephrosis, lobe, liver, ultrasound, mass, renal, kidneys/renal,"
" Elevated cardiac enzymes, fullness in chest, abnormal EKG, and risk factors.  No evidence of exercise induced ischemia at a high myocardial workload.  This essentially excludes obstructive CAD as a cause of her elevated troponin.", Radiology, Radionuclide Stress Test ,"INDICATION FOR STUDY: , Elevated cardiac enzymes, fullness in chest, abnormal EKG, and risk factors.,MEDICATIONS:,  Femara, verapamil, Dyazide, Hyzaar, glyburide, and metformin.,BASELINE EKG: , Sinus rhythm at 84 beats per minute, poor anteroseptal R-wave progression, mild lateral ST abnormalities.,EXERCISE RESULTS:,1.  The patient exercised for 3 minutes stopping due to fatigue.  No chest pain.,2.  Heart rate increased from 84 to 138 or 93% of maximum predicted heart rate.  Blood pressure rose from 150/88 to 210/100.  There was a slight increase in her repolorization abnormalities in a non-specific pattern.,NUCLEAR PROTOCOL:  ,Same day rest/stress protocol was utilized with 11 mCi for the rest dose and 33 mCi for the stress test.,NUCLEAR RESULTS:,1.  Nuclear perfusion imaging, review of the raw projection data reveals adequate image acquisition.  The resting images showed decreased uptake in the anterior wall.  However the apex is spared of this defect.  There is no significant change between rest and stress images.  The sum score is 0.,2.  The Gated SPECT shows moderate LVH with slightly low EF of 48%.,IMPRESSION:,1.  No evidence of exercise induced ischemia at a high myocardial workload.  This essentially excludes obstructive CAD as a cause of her elevated troponin.,2.  Mild hypertensive cardiomyopathy with an EF of 48%.,3.  Poor exercise capacity due to cardiovascular deconditioning.,4.  Suboptimally controlled blood pressure on today's exam.","radiology, sinus rhythm, cardiac enzymes, abnormal ekg, stress test, elevated troponin, heart rate, blood pressure, radionuclide, chest, ekg, stress, ischemia"
 Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain., Radiology, Radiofrequency Thermocoagulation - 1 ,"PROCEDURE: , Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain.,ANESTHESIA: , Local sedation.,VITAL SIGNS: , See nurse's notes.,COMPLICATIONS: , None.,DETAILS OF PROCEDURE:  ,INT was placed.  The patient was in the operating room in the prone position with the back prepped and draped in a sterile fashion.  The patient was given sedation and monitored.  Lidocaine 1.5% for skin wheal was made 10 cm from the midline to the bilateral L2 distal vertebral body.  A 20-gauge, 15 cm SMK needle was then directed using AP and fluoroscopic guidance so that the tip of the needle was noted to be along the distal one-third and anterior border on the lateral view and on the AP view the tip of the needle was inside the lateral third of the border of the vertebral body.  At this time a negative motor stimulation was obtained.  Injection of 10 cc of 0.5% Marcaine plus 10 mg of Depo-Medrol was performed. Coagulation was then carried out for 90oC for 90 seconds.  At the conclusion of this, the needle under fluoroscopic guidance was withdrawn approximately 5 mm where again a negative motor stimulation was obtained and the sequence of injection and coagulation was repeated.  This was repeated one more time with a 5 mm withdrawal and coagulation.,At that time, attention was directed to the L3 body where the needle was placed to the upper one-third/distal two-thirds junction and the sequence of injection, coagulation, and negative motor stimulation with needle withdrawal one time of a 5 mm distance was repeated.  There were no compilations from this.  The patient was discharged to operating room recovery in stable condition.","radiology, lumbar sympathetic chain, vertebral body, radiofrequency thermocoagulation, motor stimulation, thermocoagulation, radiofrequency, coagulation, needle, "
 Bilateral renal ultrasound., Radiology, Renal Ultrasound - 1 ,"EXAM: , Bilateral renal ultrasound.,CLINICAL INDICATION: , UTI.,TECHNIQUE: , Transverse and longitudinal sonograms of the kidneys were obtained.,FINDINGS:  ,The right kidney is of normal size and echotexture and measures 5.7 x 2.2 x 3.8 cm.  The left kidney is of normal size and echotexture and measures 6.2 x 2.8 x 3.0 cm.  There is no evidence for ,HYDRONEPHROSIS, or ,PERINEPHRIC ,fluid collections.  The bladder is of normal size and contour.  The bladder contains approximately 13 mL of urine after recent voiding.  This is a small postvoid residual.,IMPRESSION: , Normal renal ultrasound.  Small postvoid residual.","radiology, bilateral renal ultrasound, postvoid residual, renal ultrasound, residual, kidneys, renal, ultrasound,"
 Right sacral alar notch and sacroiliac joint/posterior rami radiofrequency thermocoagulation., Radiology, Radiofrequency Thermocoagulation ,"PROCEDURE: , Right sacral alar notch and sacroiliac joint/posterior rami radiofrequency thermocoagulation.,ANESTHESIA:  ,Local sedation.,VITAL SIGNS: , See nurse's notes.,COMPLICATIONS: , None.,DETAILS OF PROCEDURE: , INT was placed.  The patient was in the operating room in the prone position.  The back prepped with Betadine.  The patient was given sedation and monitored.  Under fluoroscopy, the right sacral alar notch was identified.  After placement of a 20-gauge, 10 cm SMK needle into the notch, a positive sensory, negative motor stimulation was obtained.  Following negative aspiration, 5 cc of 0.5% of Marcaine and 20 mg of Depo-Medrol were injected.  Coagulation was then carried out at 90oC for 90 seconds.  The SMK needle was then moved to the mid-inferior third of the right sacroiliac joint.  Again the steps dictated above were repeated.,The above was repeated for the posterior primary ramus branch right at S2 and S3 by stimulating along the superior lateral wall of the foramen; then followed by steroid injected and coagulation as above.,There were no complications.  The patient was returned to outpatient recovery in stable condition.","radiology, posterior rami, sacroiliac joint, sacral alar notch, radiofrequency thermocoagulation, thermocoagulation, radiofrequency, sacroiliac, sacral, alar, notch"
" Cervical, lumbosacral, thoracic spine flexion and extension to evaluate back and neck pain.", Radiology, Radiologic Exam - Spine  ,"EXAM: , Cervical, lumbosacral, thoracic spine flexion and extension.,HISTORY: , Back and neck pain.,CERVICAL SPINE,FINDINGS:  ,AP, lateral with flexion and extension, and both oblique projections of the cervical spine demonstrate alignment and soft tissue structures to be unremarkable.","radiology, radiologic exam, ap, back, cervical, oblique views, alignment, disc space, extension, fixation, flexion, foramina, intervertebral, lateral views, lumbosacral, neck, neck pain, oblique, odontoid view, pain, physiologic, projections, spine, subluxation, thoracic, flexion and extension, thoracic spine, vertebral"
 Prostate Brachytherapy - Prostate I-125 Implantation, Radiology, Prostate Brachytherapy ,"PROSTATE BRACHYTHERAPY - PROSTATE I-125 IMPLANTATION,This patient will be treated to the prostate with ultrasound-guided I-125 seed implantation.  The original consultation and treatment planning will be separately performed.  At the time of the implantation, special coordination will be required.  Stepping ultrasound will be performed and utilized in the pre-planning process.  Some discrepancies are frequently identified, based on the positioning, edema, and/or change in the tumor since the pre-planning process.  Re-assessment is required at the time of surgery, evaluating the pre-plan and comparing to the stepping ultrasound.  Modifications will be made in real time to add or subtract needles and seeds as required.  This may be integrated with the loading of the seeds performed by the brachytherapist, as well as coordinated with the urologist, dosimetrist or physicist.,The brachytherapy must be customized to fit the individual's tumor and prostate.  Attention is given both preoperatively and intraoperatively to avoid overdosage of rectum and bladder.","radiology, i-125 implantation, tumor, prostate, prostate brachytherapy, implantationNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Right foot series after a foot injury., Radiology, Right Foot Series ,"EXAM: , Right foot series.,REASON FOR EXAM:  ,Injury.,FINDINGS: , Three images of the right foot were obtained.  On the AP image only, there is a subtle lucency seen in the proximal right fourth metatarsal and a mild increased sclerosis in the proximal fifth metatarsal.  Also on a single image, there is a lucency seen in the lateral aspect of the calcaneus that is seen on the oblique image only.  Fractures in these bones cannot be completely excluded.  There is soft tissue swelling seen overlying the calcaneus within this region.,IMPRESSION: , Cannot exclude nondisplaced fractures in the lateral aspect of the calcaneus or at the base of the fourth and fifth metatarsals.  Recommend correlation with site of pain in addition to conservative management and followup imaging.  A phone call will be placed to the emergency room regarding these findings.","radiology, sclerosis, calcaneus, metatarsal, foot series"
 Ultrasound-Guided Paracentesis for Ascites, Radiology, Paracentesis - Ultrasound-Guided ,"EXAM:,  Ultrasound-guided paracentesis,HISTORY: , Ascites.,TECHNIQUE AND FINDINGS:  ,Informed consent was obtained from the patient after the risks and benefits of the procedure were thoroughly explained.  Ultrasound demonstrates free fluid in the abdomen.  The area of interest was localized with ultrasonography.  The region was sterilely prepped and draped in the usual manner.  Local anesthetic was administered.  A 5-French Yueh catheter needle combination was taken.  Upon crossing into the peritoneal space and aspiration of fluid, the catheter was advanced out over the needle.  A total of approximately 5500 mL of serous fluid was obtained.  The catheter was then removed.  The patient tolerated the procedure well with no immediate postprocedure complications.,IMPRESSION: , Ultrasound-guided paracentesis as above.","radiology, yueh catheter, aspiration of fluid, ultrasound guided paracentesis, ultrasound guided, needle, catheter, paracentesis, ultrasound, ascites"
 Left breast cancer.  Nuclear medicine lymphatic scan.  A 16-hour left anterior oblique imaging was performed with and without shielding of the original injection site., Radiology, Nuclear Medicine Lymphatic Scan ,"EXAM:,  Nuclear medicine lymphatic scan.,REASON FOR EXAM: , Left breast cancer.,TECHNIQUE: , 1.0 mCi of Technetium-99m sulfur colloid was injected within the dermis surrounding the left breast biopsy site at four locations.  A 16-hour left anterior oblique imaging was performed with and without shielding of the original injection site.,FINDINGS:  ,There are two small foci of increased activity in the left axilla.  This is consistent with the sentinel lymph node.  No other areas of activity are visualized outside of the injection site and two axillary lymph nodes.,IMPRESSION:  ,Technically successful lymph node injection with two areas of increased activity in the left axilla consistent with sentinel lymph node.","radiology, technetium-99m, mci, biopsy, breast cancer, nuclear medicine, lymphatic scan, lymph node, nuclear, breast, "
 Nuclear cardiac stress report.  Recurrent angina pectoris in a patient with documented ischemic heart disease and underlying ischemic cardiomyopathy., Radiology, Nuclear Cardiac Stress Report ,"NUCLEAR CARDIOLOGY/CARDIAC STRESS REPORT,INDICATION FOR STUDY: , Recurrent angina pectoris in a patient with documented ischemic heart disease and underlying ischemic cardiomyopathy.,PROCEDURE: , The patient was studied in the resting state following intravenous delivery of adenosine triphosphate at 140 mcg/kg/min delivered over a total of 4 minutes.  At completion of the second minute of infusion, the patient received technetium Cardiolite per protocol.  During this interval, the blood pressure 150/86 dropped to near 136/80 and returned to near 166/84 at completion.  No diagnostic electrocardiographic abnormalities were elaborated during this study.,REGIONAL MYOCARDIAL PERFUSION WITH ADENOSINE PROVOCATION: , Scintigraphic study reveals at this time multiple fixed defects in perfusion suggesting indeed multivessel coronary artery disease, yet no active ischemia at this time.  A fixed defect is seen in the high anterolateral segment.  A further fixed perfusion defect is seen in the inferoapical wall extending from close to the septum.  There is no evidence for active ischemia in either distribution.  Lateral wall moving towards the apex of the left ventricle is further involved from midway through the ventricle moving upward and into the high anterolateral vicinity.  When viewed from the vertical projection, the high septal wall is preserved with significant loss of the mid anteroapical wall moving to the apex and in a wraparound fashion in the inferoapical wall.  A limited segment of apical myocardium is still viable.,No gated wall motion study was obtained.,CONCLUSIONS:  ,Cardiolite perfusion findings support multivessel coronary artery disease and likely previous multivessel infarct as has been elaborated above.  There is no indication for active ischemia at this time.","radiology, angina pectoris, ischemic cardiomyopathy, myocardial perfusion, adenosine provocation, cardiolite perfusion, nuclear cardiac stress report, coronary artery disease, active ischemia, ischemic, angina, "
 Whole body PET scanning., Radiology, PET Report - Whole Body Scan ,"INDICATION: , Lung carcinoma.,Whole body PET scanning was performed with 11 mCi of 18 FDG. Axial, coronal and sagittal imaging was performed over the neck, chest abdomen and pelvis.,FINDINGS:,There is normal physiologic activity identified in the myocardium, liver, spleen, ureters, kidneys and bladder.,There is abnormal FDG-avid activity identified in the posterior left paraspinal region best seen on axial images 245-257 with an SUV of 3.8, no definite bone lesion is identified on the CT scan or the bone scan dated 08/14/2007 (It may be purely lytic).,Additionally there is a significant area of activity corresponding to a mass in the region of the left hilum that is visible on the CT scan with an SUV of 18.1, the adjacent atelectasis as likely post obstructive in nature.,Additionally, although there is no definite lesion identified on CT , there is a tiny satellite nodule in the left upper lobe that is hypermetabolic with an SUV of 5.0. The spiculated density seen in the right upper lobe on the CT scan does not demonstrate FDG activity on this PET scan.,There is a hypermetabolic lymph node identified in the aorta pulmonary window with an SUV of 3.7 in the mediastinum.,IMPRESSION:,No prior PET scans for comparison, there is a large lesion identified in the area of the left hilum with an SUV of 18.1 likely causing the obstructive atelectasis seen on the CT scan.,There is a tiny satellite area of hypermetabolic FDG in the left upper lobe adjacent to the pleura with an SUV of 5.0.,There is a area of hypermetabolic activity in the left paraspinal soft tissues at the level of the lung apices which may represent a focal bone lesion. However no lesion is identified on bone scan or CT scan.,There is a hypermetabolic lymph node identified. The aorta pulmonary window with a corresponding finding on CT scan with an SUV of 3.7.","radiology, whole body scan, pet scanning, lung carcinoma, axial, coronal, sagittal, imaging, pet scans, hypermetabolic lymph node, hypermetabolic lymph, lymph node, pulmonary window, ct scan, scan, fdg, pet, suv, ct,"
" Nuclear medicine tumor localization, whole body - status post subtotal thyroidectomy for thyroid carcinoma.", Radiology, Nuclear Medicine Tumor Localization ,"EXAM:,  Nuclear medicine tumor localization, whole body.,HISTORY: , Status post subtotal thyroidectomy for thyroid carcinoma, histology not provided.,FINDINGS: , Following the oral administration of 4.3 mCi Iodine-131, whole body planar images were obtained in the anterior and posterior projections at 24, 48, and 72 hours.,There is increased uptake in the left upper quadrant, which persists throughout the examination.  There is a focus of increased activity in the right lower quadrant, which becomes readily apparent at 72 hours.  Physiologic uptake in the liver, spleen, and transverse colon is noted.  Physiologic urinary bladder uptake is also appreciated.  There is low-grade uptake in the oropharyngeal region.,IMPRESSION:  ,Iodine-avid foci in the right lower quadrant and left upper quadrant medially suspicious for distant metastasis.  Anatomical evaluation, i.e., CT is advised to determine if there are corresponding mesenteric lesions.  Ultimately (provided that the original pathology of the thyroid tumor with iodine-avid) PET scanning may be necessary.  No evidence of iodine added locoregional metastasis.","radiology, nuclear medicine, iodine-131, pet scanning, anterior, left upper quadrant, liver, localization, oropharyngeal, planar images, posterior, spleen, thyroid carcinoma, thyroidectomy, transverse colon, tumor, urinary bladder, nuclear medicine tumor localization, thyroidectomy for thyroid, tumor localization, nuclear, medicine, iodine,"
" Bilateral L5, S1, S2, and S3 radiofrequency ablation for sacroiliac joint pain.  Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.", Radiology, Radiofrequency Ablation ,"PROCEDURE: , Bilateral L5, S1, S2, and S3 radiofrequency ablation.,INDICATION: , Sacroiliac joint pain.,INFORMED CONSENT: , The risks, benefits and alternatives of the procedure were discussed with the patient.  The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible of vascular entry of medications.  I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing.  The patient understood the informed consent and desired to have the procedure performed.,PROCEDURE: , Oxygen saturation and vital signs were monitored continuously throughout the procedure.  The patient remained awake throughout the procedure in order to interact and give feedback.  The x-ray technician was supervised and instructed to operate the fluoroscopy machine.,The patient was placed in a prone position on the treatment table with a pillow under the chest and head rotated.  The skin over and surrounding the treatment area was cleaned with Betadine.  The area was covered with sterile drapes, leaving a small window opening for needle placement.  Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.,With fluoroscopy, a 20 gauge 10-mm bent Teflon coated needle was gently guided into the groove between the SAP and the sacrum for the dorsal ramus of L5 and the lateral border of the posterior sacral foramen, for the lateral branches of S1, S2, and S3.  Also, fluoroscopic views were used to ensure proper needle placement.,The following technique was used to confirm correct placement.  Motor stimulation was applied at 2 Hz with 1 millisecond duration.  No extremity movement was noted at less than 2 volts.  Following this, the needle trocar was removed and a syringe containing 1% lidocaine was attached.  At each level, after syringe aspiration with no blood return, 0.5 mL of 1% lidocaine was injected to anesthetize the lateral branch and the surrounding tissue.  After completion, a lesion was created at that level with a temperature of 80 degrees for 90 seconds.,All injected medications were preservative free.  Sterile technique was used throughout the procedure.,ADDITIONAL DETAILS:  ,None.,COMPLICATIONS: , None.,DISCUSSION: , Post-procedure vital signs and oximetry were stable.  The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day.  The patient was told to resume all medications.  The patient was told to be in relative rest for 1 day but then could resume all normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes, or changes in bowel or bladder function.,Follow up appointment was made at PM&R Spine Clinic in approximately one to two weeks.","radiology, sacroiliac joint pain, sacroiliac, teflon coated needle, fluoroscopy, needle placement, radiofrequency ablation, ablation, tissue, lidocaine, needle,"
 Resting Myoview perfusion scan and gated myocardial scan.  Findings consistent with an inferior non-transmural scar, Radiology, Myoview Perfusion Scan ,"INDICATIONS:,  Previously markedly abnormal dobutamine Myoview stress test and gated scan.,PROCEDURE DONE:,  Resting Myoview perfusion scan and gated myocardial scan.,MYOCARDIAL PERFUSION IMAGING:,  Resting myocardial perfusion SPECT imaging and gated scan were carried out with 32.6 mCi of Tc-99m Myoview.  Rest study was done and compared to previous dobutamine Myoview stress test done on Month DD, YYYY.  The lung heart ratio is 0.34.  There appears to be a moderate size inferoapical perfusion defect of moderate degree.  The gated myocardial scan revealed mild apical and distal inferoseptal hypokinesis with ejection fraction of 55%.,CONCLUSIONS:,  Study done at rest only revealed findings consistent with an inferior non-transmural scar of moderate size and moderate degree.  The left ventricular systolic function is markedly improved with much better regional wall motion of all left ventricular segments when compared to previous study done on Month DD, YYYY.  We cannot assess the presence of any reversible perfusion defects because no stress imaging was performed.","radiology, myoview perfusion scan, rest study, spect imaging, dobutamine myoview stress test, ejection fraction, gated myocardial scan, hypokinesis, ventricular systolic function, resting myoview perfusion scan, myoview stress test, resting myoview, myocardial perfusion, myoview perfusion, perfusion scan, myocardial scan, myocardial, myoview, perfusion"
 MRI T-spine: Metastatic Adenocarcinoma of the T3-T4 vertebrae and invading the spinal canal., Radiology, MRI T-Spine - Spinal Mets ,"CC: ,BLE weakness and numbness.,HX:, This 59 y/o RHM was seen and released from an ER 1 week prior to this presentation for a 3 week history of progressive sensory and motor deficits in both lower extremities. He reported numbness beginning about his trunk and slowly progressing to involve his lower extremities over a 4 week period. On presentation, he felt numb from the nipple line down. In addition, he began experiencing progressive weakness in his lower extremities for the past week. He started using a cane 5 days before being seen and had been having difficulty walking and traversing stairs. He claimed he could not stand. He denied loss of bowel or bladder control. However, he had not had a bowel movement in 3 days and he had not urinated 24 hours. His lower extremities had been feeling cold for a day. He denied any associated back or neck pain. He has chronic shortness of breath, but felt it had become worse. He had also been experiencing lightheadedness upon standing more readily than usual for 2 days prior to presentation.,PMH:, 1)CAD with chronic CP, 2)NQWMI 1994, S/P Coronary Angioplasty, 3)COPD (previous FEV 11.48, and FVC 2.13), 4)Anxiety D/O, 5)DJD, 6)Developed confusion with metoprolol use, 7)HTN.,MEDS:, Benadryl, ECASA, Diltiazem, Isordil, Enalapril, Indomethacin, Terbutaline MDI, Ipratropium MDI, Folic Acid, Thiamine.,SHX:, 120pk-yr smoking, ETOH abuse in past, Retired Dock Hand,FHX: ,unremarkable except for ETOH abuse,EXAM:,  T98.2 96bpm 140/74mmHg R18,Thin cachetic male in moderate distress.,MS: A&O to person, place and time. Speech was fluent and without dysarthria. Comprehension, naming and reading were intact.,CN: unremarkable.,Motor: Full strength in both upper extremities.,HF HE HAdd HAbd KF KE AF AE,RLE 3 3 4 4 3 4 1 1,LLE 4 4 4+ 4+ 4+ 4 4 4,There was mild spastic muscle tone in the lower extremities. There was normal muscle bulk throughout.,SENSORY: Decreased PP in the LLE from the foot to nipple line, and in the RLE from the knee to nipple line. Decreased Temperature sensation from the feet to the umbilicus, bilaterally. No loss of Vibration or Proprioception. Decreased light touch from the feet to nipple line, bilaterally.,Gait: unable to walk. Stands with support only.,Station: no pronator drift or truncal ataxia.,Reflexes: 2+/2+ in BUE, 3+/3+ patellae, 0/1 ankles. Babinski signs were present, bilaterally. The abdominal reflexes were absent.,CV: RRR with a 2/6 systolic ejection murmur at the left sternal border. Lungs: CTA with mildly labored breathing. Abdomen: NT, ND, NBS, but bladder distended. Extremities were cool to touch. Peripheral pulses were intact and capillary refill was brisk. Rectal: decreased rectal tone and absent anal reflex. Right prostate nodule at the inferior pole.,COURSE: ,Admission Labs: FEV1=1.17, FVC 2.19, ABG 7.39/42/79 on room air. WBC 10/5, Hgb 13, Hct 39, Electrolytes were normal. PT & PTT were normal. Straight catheterization revealed a residual volume of 400cc of urine.,He underwent emergent T-spine MRI. This revealed a T3-4 vertebral body lesion which had invaded the spinal canal was compressing the spinal cord. He was treated with Decadron and underwent emergent spinal cord decompression on 5/7/95. He recovered some lower extremity strength following surgery. Pathological analysis of the tumor was consistent with adenocarcinoma. His primary tumor was not located despite chest-abdominal-pelvic CT scans, and a GI and GU workup which included cystoscopy and endoscopy. He received 3000cGy of XRT and died 5 months after presentation.",
" Myocardial perfusion imaging - patient with history of MI, stents placement, and chest pain.", Radiology, Myocardial Perfusion Imaging - 1 ,"MEDICATIONS: , Plavix, atenolol, Lipitor, and folic acid.,CLINICAL HISTORY:  ,This is a 41-year-old male patient who comes in with chest pain, had had a previous MI in 07/2003 and stents placement in 2003, who comes in for a stress myocardial perfusion scan.,With the patient at rest, 10.3 mCi of Cardiolite technetium-99 m sestamibi was injected and myocardial perfusion imaging was obtained.,PROCEDURE AND INTERPRETATION:  ,The patient exercised for a total of 12 minutes on the standard Bruce protocol.  The peak workload was 12.8 METS.  The resting heart rate was 57 beats per minute and the peak heart rate was 123 beats per minute, which was 69% of the age-predicted maximum heart rate response.  The blood pressure response was normal with a resting blood pressure of 130/100 and a peak blood pressure of 158/90.  The test was stopped due to fatigue and leg pain.  EKG at rest showed normal sinus rhythm.  The peak stress EKG did not reveal any ischemic ST-T wave abnormalities.  There was ventricular bigeminy seen during exercise, but no sustained tachycardia was seen.  At peak, there was no chest pain noted.  The test was stopped due to fatigue and left pain.  At peak stress, the patient was injected with 30.3 mCi of Cardiolite technetium-99 m sestamibi and myocardial perfusion imaging was obtained, and was compared to resting myocardial perfusion imaging.,MYOCARDIAL PERFUSION IMAGING:,1.  The overall quality of the scan was good.,2.  There was no diagnostic abnormality on the rest and stress myocardial perfusion imaging.,3.  The left ventricular cavity appeared normal in size.,4.  Gated SPECT images revealed mild septal hypokinesis and mild apical hypokinesis.  Overall left ventricular systolic function was low normal with calculated ejection fraction of 46% at rest.,CONCLUSIONS:,1.  Good exercise tolerance.,2.  Less than adequate cardiac stress.  The patient was on beta-blocker therapy.,3.  No EKG evidence of stress induced ischemia.,4.  No chest pain with stress.,5.  Mild ventricular bigeminy with exercise.,6.  No diagnostic abnormality on the rest and stress myocardial perfusion imaging.,7.  Gated SPECT images revealed septal and apical hypokinesis with overall low normal left ventricular systolic function with calculated ejection fraction of 46% at rest.","radiology, myocardial perfusion imaging, bruce protocol, cardiolite, ekg, mets, mi, spect, st-t, bigeminy, blood pressure, chest pain, exercise tolerance, myocardial perfusion, normal sinus rhythm, peak workload, sestamibi, stents, stress, tachycardia, ventricular, ventricular cavity, stress myocardial perfusion, perfusion imaging, myocardial, perfusion, mci, hypokinesis, imaging,"
" Myocardial perfusion study at rest and stress, gated SPECT wall motion study at stress and calculation of ejection fraction.", Radiology, Myocardial Perfusion Imaging - 3 ,"DIAGNOSIS:  ,Shortness of breath.  Fatigue and weakness.  Hypertension.  Hyperlipidemia.,INDICATION: , To evaluate for coronary artery disease.,","radiology, myocardial perfusion imaging, spect wall motion study at stress, rest and stress, perfusion study at rest, calculation of ejection fraction, normal left ventricular wall, spect wall motion study, ventricular wall motion, myocardial perfusion study, perfusion imaging, blood pressure, nonspecific st, ventricular wall, gated spect, spect wall, motion study, stress test, heart rate, ejection fraction, myocardial perfusion, technetium, tetrofosmin, ischemia, ekg, imaging, spect, heart, ventricular, mci, resting, perfusion, stress, myocardial, "
" Patient with wrist pain and swelling, status post injury.", Radiology, MRI Wrist - 1 ,"FINDINGS:,There are posttraumatic cysts along the volar midline and volar lateral aspects of the lunate which are likely posttraumatic. There is no acute marrow edema (series #12 images #5-7). Marrow signal is otherwise normal in the distal radius and ulna, throughout the carpals and throughout the proximal metacarpals.,There is a partial tear of the volar component of the scapholunate ligament in the region of the posttraumatic lunate cyst with retraction and thickening towards the scaphoid (series #6 image #5, series #8 images #22-36). There is tearing of the membranous portion of the ligament. The dorsal component is intact.,The lunatotriquetral ligament is thickened and lax, but intact (series #8 image #32).,There is no tearing of the radial or ulnar attachment of the triangular fibrocartilage (series #6 image #7). There is a mildly positive ulnar variance. Normal ulnar collateral ligament.,The patient was positioned in dorsiflexion. Carpal alignment is normal and there are no tears of the dorsal or ventral intercarpal ligaments (series #14 image #9).,There is a longitudinal split tear of the ECU tendon which is enlarged both at the level of and distal to the ulnar styloid with severe synovitis (series #4 images #8-16, series #3 images #9-16).,There is thickening of the extensor tendon sheaths within the fourth dorsal compartment with intrinsically normal tendons (series #4 image #12).,There is extensor carpi radialis longus and brevis synovitis in the second dorsal compartment (series #4 image #13).,Normal flexor tendons within the carpal tunnel. There is mild thickening of the tendon sheaths and the median nerve demonstrates increased signal without compression or enlargement (series #3 image #7, series #4 image #7).,There are no pathological cysts or soft tissue masses.,IMPRESSION:,Partial tear of the volar and membranous components of the scapholunate ligament with an associated posttraumatic cyst in the lunate. There is thickening and laxity of the lunatotriquetral ligament.,Longitudinal split tear of the ECU tendon with tendinosis and severe synovitis.,Synovitis of the second dorsal compartment and tendon sheath thickening in the fourth dorsal compartment.,Tendon sheath thickening within the carpal tunnel with increased signal within the median nerve.","radiology, fourth dorsal compartment, tendon sheath thickening, tendon sheaths, dorsal compartment, volar, carpals, tear, ulnar, synovitis, sheaths, ligament, thickening, dorsal, tendon, injury,"
" Skull, complete, five images.", Radiology, Multiple Images of Skull (Pediatric) ,"EXAM:,  Skull, complete, five images,HISTORY:,  Plagiocephaly.,TECHNIQUE: , Multiple images of the skull were evaluated.  There are no priors for comparison.,FINDINGS: , Multiple images of the skull were evaluated and they reveal radiographic visualization of the cranial sutures without evidence of closure.  There is no evidence of any craniosynostosis.  There is no radiographic evidence of plagiocephaly.,IMPRESSION: , No evidence of craniosynostosis or radiographic characteristics for plagiocephaly.","radiology, craniosynostosis, plagiocephaly, complete five images, multiple images, radiographic, images, skull, "
 MRI L-Spine - Bilateral lower extremity numbness, Radiology, Normal L-Spine MRI ,"CC: ,Bilateral lower extremity numbness.,HX: ,21 y/o RHM complained of gradual onset numbness and incoordination of both lower extremities beginning approximately 11/5/96. The symptoms became maximal over a 12-24 hour period and have not changed since. The symptoms consist of tingling in the distal lower extremities approximately half way up the calf bilaterally. He noted decreased coordination of both lower extremities which he thought might be due to uncertainty as to where his feet were being placed in space. He denied bowel/bladder problems, or weakness or numbness elsewhere. Hot showers may improve his symptoms. He has suffered no recent flu-like illness. Past medical and family histories are unremarkable. He was on no medications.,EXAM:, Unremarkable except for mild distal vibratory sensation loss in the toes (R>L).,LAB:, CBC, Gen Screen, TSH, FT4, SPE, ANA were all WNL.,MRI L-SPINE:, Normal.,COURSE:, Normal exam and diminished symptoms at following visit 4/23/93.","radiology, bilateral lower extremity numbness, mri l spine, bilateral lower extremity, lower extremity numbness, bilateral, spine, mri, extremities, numbness"
 Myocardial perfusion imaging - patient had previous abnormal stress test.  Stress test with imaging for further classification of CAD and ischemia., Radiology, Myocardial Perfusion Imaging - 2 ,"CLINICAL HISTORY: , This is a 64-year-old male patient, who had a previous stress test, which was abnormal and hence has been referred for a stress test with imaging for further classification of coronary artery disease and ischemia.,PERTINENT MEDICATIONS:,  Include Tylenol, Robitussin, Colace, Fosamax, multivitamins, hydrochlorothiazide, Protonix and flaxseed oil.,With the patient at rest 10.5 mCi of Cardiolite technetium-99 m sestamibi was injected and myocardial perfusion imaging was obtained.,PROCEDURE AND INTERPRETATION: , The patient exercised for a total of 4 minutes and 41 seconds on the standard Bruce protocol.  The peak workload was 7 METs.  The resting heart rate was 61 beats per minute and the peak heart rate was 173 beats per minute, which was 85% of the age-predicted maximum heart rate response.  The blood pressure response was normal with the resting blood pressure 126/86, and the peak blood pressure of 134/90.  EKG at rest showed normal sinus rhythm with a right-bundle branch block.  The peak stress EKG was abnormal with 2 mm of ST segment depression in V3 to V6, which remained abnormal till about 6 to 8 minutes into recovery.  There were occasional PVCs, but no sustained arrhythmia.  The patient had an episode of supraventricular tachycardia at peak stress.  The ischemic threshold was at a heart rate of 118 beats per minute and at 4.6 METs.  At peak stress, the patient was injected with 30.3 mCi of Cardiolite technetium-99 m sestamibi and myocardial perfusion imaging was obtained, and was compared to resting images.,MYOCARDIAL PERFUSION IMAGING:,1.  The overall quality of the scan was fair in view of increased abdominal uptake, increased bowel uptake seen.,2.  There was a large area of moderate to reduced tracer concentration seen in the inferior wall and the inferior apex.  This appeared to be partially reversible in the resting images.,3.  The left ventricle appeared normal in size.,4.  Gated SPECT images revealed normal wall motion and normal left ventricular systolic function with normal wall thickening.  The calculated ejection fraction was 70% at rest.,CONCLUSIONS:,1.  Average exercise tolerance.,2.  Adequate cardiac stress.,3.  Abnormal EKG response to stress, consistent with ischemia.  No symptoms of chest pain at rest.,4.  Myocardial perfusion imaging was abnormal with a large-sized, moderate intensity partially reversible inferior wall and inferior apical defect, consistent with inferior wall ischemia and inferior apical ischemia.,5.  The patient had run of SVT at peak stress.,6.  Gated SPECT images revealed normal wall motion and normal left ventricular systolic function.","radiology, stress test, arrhythmia, baseline heart rate, bruce, chest pain, mets, protocol, peak heart rate, spect, st segment response, svt, aerobic capacity, blood pressure, exercise, heart rate, ischemia, ventricular systolic function, myocardial perfusion imaging, cardiolite technetium, inferior apical, myocardial perfusion, perfusion imaging, stress, myocardial, imaging, perfusion"
" The thoracic spine was examined in the AP, lateral and swimmer's projections.", Radiology, MRI T-Spine - 1 ,"EXAM:  ,Thoracic Spine.,REASON FOR EXAM: , Injury.,INTERPRETATION: , The thoracic spine was examined in the AP, lateral and swimmer's projections.  There is mild chronic-appearing anterior wedging of what is believed to represent T11 and 12 vertebral bodies.  A mild amount of anterior osteophytic lipping is seen involving the thoracic spine.  There is a suggestion of generalized osteoporosis.  The intervertebral disc spaces appear generally well preserved.,The pedicles appear intact.,IMPRESSION:,1. Mild chronic-appearing anterior wedging of what is believed to represent the T11 and 12 vertebral bodies.,2. Mild degenerative changes of the thoracic spine.,3. Osteoporosis.","radiology, thoracic spine, swimmer's projections, osteoporosis, osteophytic lipping, anterior wedging, vertebral bodies, thoracic, spine, "
 MRI T-spine and CXR - Aortic Dissection., Radiology, MRI T-Spine ,"CC:, BLE weakness.,HX:, This 82y/o RHM was referred to the Neurology service by the Neurosurgery service for evaluation of acute onset paraplegia. He was in his usual state of health until 5:30PM on 4/6/95, when he developed sudden ""pressure-like"" epigastric discomfort associated with bilateral lower extremity weakness, SOB, lightheadedness and diaphoresis. He knelt down to the floor and ""went to sleep."" The Emergency Medical Service was alert and arrived within minutes, at which time he was easily aroused though unable to move or feel his lower extremities. No associated upper extremity or bulbar dysfunction was noted. He was taken to a local hospital where an INR was found to be 9.1. He was given vitamin K 15mg, and transferred to UIHC to rule out spinal epidural hemorrhage. An MRI scan of the T-spine was obtained and the preliminary reading was ""normal."" The Neurology service was then asked to evaluate the patient.,MEDS:, Coumadin 2mg qd, Digoxin 0.25mg qd, Prazosin 2mg qd.,PMH:, 1)HTN. 2)A-Fib on coumadin. 3)Peripheral vascular disease:s/p left Femoral-popliteal bypass (8/94) and graft thrombosis-thrombolisis (9/94). 4)Adenocarcinoma of the prostate: s/p TURP (1992).,FHX: ,unremarkable.,SHX:, Farmer, Married, no Tobacco/ETOH/illicit drug use.,EXAM:, BP165/60 HR86 RR18 34.2C SAO2 98% on room air.,MS: A&O to person, place, time. In no acute distress. Lucid.,CN: unremarkable.,MOTOR: 5/5 strength in BUE. Flaccid paraplegia in BLE,Sensory: T6 sensory level to LT/PP, bilaterally. Decreased vibratory sense in BLE in a stocking distribution, distally.,Coord: Intact FNF and RAM in BUE. Unable to do HKS.,Station: no pronator drift.,Gait: not done.,Reflexes: 2/2 BUE, Absent in BLE, plantar responses were flexor, bilaterally.,Rectal: decreased rectal tone.,GEN EXAM: No carotid bruitts. Lungs: bibasilar crackles. CV: Irregular rate and rhythm with soft diastolic murmur at the left sternal border. Abdomen: flat, soft, non-tender without bruitt or pulsatile mass. Distal pulses were strong in all extremities.,COURSE:, Hgb 12.6, Hct 40%, WBC 11.7, Plt 154k, INR 7.6, PTT 50, CK 41, the GS was normal. EKG showed A-Fib at 75BPM with competing junctional pacemaker, essentially unchanged from 9/12/94.,It was suspected that the patient sustained an anterior-cervico-thoracic spinal cord infarction with resultant paraplegia and T6 sensory level. A CXR was done in the ER prior to admission. This revealed cardiomegaly and a widened mediastinum. He returned from the x-ray suite and suddenly became unresponsive and went into cardiopulmonary arrest. Resuscitative measures failed. Pericardiocentesis was unremarkable. Autopsy revealed a massive aortic dissection extending from the aortic root to the origin of the iliac arteries with extensive pericardial hematoma. The dissection was seen in retrospect on the MRI T-spine.","radiology, mri, a&o, aortic dissection, cxr, irregular rate and rhythm, mri scan, neurology service, t-spine, carotid bruitts, epidural hemorrhage, mediastinum, paraplegia, person, place, stocking distribution, time, weakness, mri t spine, sensory level, neurology, spine, "
 A 51-year-old female with left shoulder pain and restricted external rotation and abduction x 6 months., Radiology, MRI Shoulder - 2 ,"EXAM:,MRI LEFT SHOULDER,CLINICAL:,This is a 51-year-old female with left shoulder pain and restricted external rotation and abduction x 6 months. Received for second opinion. Study performed on 10/04/05.,FINDINGS:,The patient was scanned in a 1.5 Tesla magnet.,There is a flat undersurface of the acromion (Type I) morphology, with anterior downsloping orientation.,There is inflammation of the anterior rotator interval capsule with peritendinous edema involving the intracapsular long biceps tendon best appreciated on the (axial gradient echo T2 series #3 images #6-9). There is edema with thickening of the superior glenohumeral ligament (axial T2 series #3 image #7). There is flattening of the long biceps tendon as it enters the bicipital groove (axial T2 series #3 image #9-10), but no subluxation. The findings suggest early changes of a “hidden” lesion.,Normal biceps labral complex and superior labrum, and there is no demonstrated superior labral tear.,There is minimal tendinitis with intratendinous edema of the insertion of the subscapularis tendon (axial T2 series #3 image #10). There is minimal fluid within the glenohumeral joint capsule within normal physiologic volume limits.,Normal anterior and posterior glenoid labra.,Normal supraspinatus, infraspinatus, and teres minor tendons.,Normal muscles of the rotator cuff and there is no muscular atrophy.,There is minimal fluid loculated within the labral ligamentous capsular complex along the posterior-superior labrum (sagittal T2 series #7 image #5; coronal T2 series #5 image #7), but there is no demonstrated posterior-superior labral tear or paralabral cyst or ganglion.,Normal acromioclavicular articulation.,IMPRESSION:,Inflammation of the anterior rotator interval capsule with interstitial edema of the superior glenohumeral ligament.,Flattening of the long biceps tendon as it enters the bicipital groove, but no subluxation. Findings suggest early changes of a hidden lesion.,Mild tendinitis of the distal insertion of the subscapularis tendon, but no tendon tear.,Normal supraspinatus, infraspinatus, and teres minor tendons and muscular complexes.,Type I morphology with an anterior downsloping orientation of the acromion, but no inferior acromial osteophyte.","radiology, insertion of the subscapularis, supraspinatus infraspinatus and teres, infraspinatus and teres minor, axial t series, supraspinatus infraspinatus, teres minor, minor tendons, posterior superior, biceps tendon, rotator, capsule, glenohumeral, tendon, series, superior"
 MRI T-L spine - L2 conus medullaris lesion and syndrome secondary to Schistosomiasis., Radiology, MRI T-L Spine - Schistosomiasis ,"CC: ,Paraplegia.,HX:, This 32 y/o RHF had been performing missionary work in Jos, Nigeria for several years and delivered her 4th child by vaginal delivery on 4/10/97. The delivery was induced with Pitocin, but was otherwise uncomplicated. For the first 4 days post-partum she noted clear liquid diarrhea without blood and minor abdominal discomfort. This spontaneous resolved without medical treatment. The second week post-partum she had 4-5 days of sinusitis, purulent nasal discharge and facial pain. She was otherwise well until 5/4/97 when stationed in a more rural area of Nigeria, she noted a dull ache in both knees (lateral to the patellae) and proximal tibia, bilaterally. The pain was not relieved by massage and seemed more bothersome when seated or supine. She had no sensory loss at the time.,On 5/6/97, she awakened to pain radiating down her knees to her anterior tibia. Over the next few hours the pain radiated circumferentially around both calves, and involved the soles of her feet and posterior BLE to her buttocks. Rising from bed became a laborious task and she required assistance to walk to the bathroom. Ibuprofen provided minimal analgesia. By evening the sole of one foot was numb.,She awoke the next morning, 5/9/97, with ""pins & needles"" sensation in BLE up to her buttocks. She was given Darvocet for analgesia and took an airplane back to the larger city she was based in. During the one hour flight her BLE weakness progressed to a non-weight bearing state (i.e. she could not stand). Local evaluation revealed 3/3 proximal and 4/4 distal BLE weakness. She had a sensory level to her waist on PP and LT testing. She also had mild lumbar back pain. Local laboratory evaluation: WBC 12.7, ESR 10. She was presumed to have Guillain-Barre syndrome and was placed on Solu-Cortef 1000mg qd and Sandimmune IV IgG 12.0 g.,On 5/10/97, she was airlifted to Geneva, Switzerland. Upon arrival there she had total anesthesia from the feet up to the inguinal region, bilaterally. There was flaccid areflexic paralysis of BLE and she was unable to void or defecate. Straight catheterization of the bladder revealed a residual volume of 1000cc. On 5/12/ CSF analysis revealed: Protein 1.5g/l, Glucose 2.2mmol/l, WBC 92 (O PMNS, 100% Lymphocytes), RBC 70, Clear CSF, bacterial-fungal-AFB-cultures were negative. Broad spectrum antibiotics and Solu-Medrol 1g IV qd were started. MRI T-L-spine, 5/12/97 revealed an intradural T12-L1 lesion that enhanced minimally with gadolinium and was associated with spinal cord edema in the affected area. MRI Brain, 5/12/97, was unremarkable and showed no evidence of demyelinating disease. HIV, HTLV-1, HSV, Lyme, EBV, Malaria and CMV serological titers were negative. On 5/15/97 the Schistosomiasis Mekongi IFAT serological titer returned positive at 1:320 (normal<1:80). 5/12/97 CSF Schistosomiasis Mekongi IFAT and ELISA were negative. She was then given a one day course of Praziquantel 3.6g total in 3 doses; and started on Prednisone 60 mg po qd; the broad spectrum antibiotics and Solu-Medrol were discontinued.,On 5/22/97, a rectal biopsy was performed to evaluate parasite eradication. The result came back positive for ova and granulomata after she had left for UIHC. The organism was not speciated. 5/22/97 CSF schistosomiasis ELISA and IFAT titers were positive at 1.09 and 1:160, respectively. These titers were not known when she initially arrived at UIHC.,Following administration of Praziquantel, she regained some sensation in BLE but the paraplegia, and urinary retention remained.,MEDS:, On 5/24/97 UIHC arrival: Prednisone 60mg qd, Zantac 50 IV qd, Propulsid 20mg tid, Enoxaparin 20mg qd.,PMH:, 1)G4P4.,FHX:, unremarkable.,SHX: ,Missionary. Married. 4 children ( ages 7,5,3,6 weeks).,EXAM:, BP110/70, HR72, RR16, 35.6C,MS: A&O to person, place and time. Speech fluent and without dysarthria. Lucid thought process.,CN: unremarkable.,Motor: 5/5 BUE strength. Lower extremities: 1/1 quads and hamstrings, 0/0 distally.,Sensory: Decreased PP/LT/VIB from feet to inguinal regions, bilaterally. T12 sensory level to temperature (ice glove).,Coord: normal FNF.,Station/Gait: not done.,Reflexes: 2/2 BUE. 0/0 BLE. No plantar responses, bilaterally.,Rectal: decreased to no rectal tone. Guaiac negative.,Other: No Lhermitte's sign. No paraspinal hypertonicity noted. No vertebral tenderness.,Gen exam: Unremarkable.,COURSE:, MRI T-L-spine, 5/24/97, revealed a 6 x 8 x 25 soft tissue mass at the L1 level posterior to the tip of the conus medullaris and extending into the canal below that level. This appeared to be intradural. There was mild enhancement. There was more enhancement along the distal cord surface and cauda equina. The distal cord had sign of diffuse edema. She underwent exploratory and decompressive laminectomy on 5/27/97, and was retreated with a one day course of Praziquantel 40mg/kg/day. Praziquantel is reportedly only 80% effective at parasite eradication.,She continued to reside on the Neurology/Neurosurgical service on 5/31/97 and remained paraplegic.",
 MRI Spine - T12-L5 epidural lipoma and thoracic spinal cord infarction vs. transverse myelitis., Radiology, MRI Spine - Epidural Lipoma ,"CC:, Progressive lower extremity weakness.,HX: ,This 54 y/o RHF presented on 7/3/93 with a 2 month history of lower extremity weakness. She was admitted to a local hospital on 5/3/93 for a 3 day h/o of progressive BLE weakness associated with incontinence and BLE numbness. There was little symptom of upper extremity weakness at that time, according to the patient. Her evaluation was notable for a bilateral L1 sensory level and 4/4 strength in BLE. A T-L-S Spine MRI revealed a T4-6 lipomatosis with anterior displacement of the cord without cord compression. CSF analysis yielded: opening pressure of 14cm H20, protein 88, glucose 78, 3 lymphocytes and 160 RBC, no oligoclonal bands or elevated IgG index, and negative cytology. Bone marrow biopsy was negative. B12, Folate, and Ferritin levels were normal. CRP 5.2 (elevated). ANA was positive at 1:5,120 in speckled pattern. Her hospital course was complicated by deep venous thrombosis, which recurred after heparin was stopped to do the bone marrow biopsy. She was subsequently placed on Coumadin. EMG/NCV testing revealed "" lumbosacral polyradiculopathy with axonal degeneration and nerve conduction block."" She was diagnosed with atypical Guillain-Barre vs. polyradiculopathy and received a single course of Decadron; and no plasmapheresis or IV IgG. She was discharged home o 6/8/93.,She subsequently did not improve and after awaking from a nap on her couch the day of presentation, 7/3/93, she found she was paralyzed from the waist down. There was associated mild upper lumbar back pain without radiation. She had had no bowel movement or urination since that time. She had no recent trauma, fever, chills, changes in vision, dysphagia or upper extremity deficit.,MEDS:, Coumadin 7.5mg qd, Zoloft 50mg qd, Lithium 300mg bid.,PMH:, 1) Bi-polar Affective Disorder, dx 1979 2) C-section.,FHX:, Unremarkable.,SHX:, Denied Tobacco/ETOH/illicit drug use.,EXAM: ,BP118/64, HR103, RR18, Afebrile.,MS: ,A&O to person, place, time. Speech fluent without dysarthria. Lucid thought processes.,CN: ,Unremarkable.,MOTOR:, 5/5 strength in BUE. Plegic in BLE. Flaccid muscle tone.,SENSORY:, L1 sensory level (bilaterally) to PP and TEMP, without sacral sparing. Proprioception was lost in both feet.,CORD: ,Normal in BUE.,Reflexes were 2+/2+ in BUE. They were not elicited in BLE. Plantar responses were equivocal, bilaterally.,RECTAL: ,Poor rectal tone. stool guaiac negative. She had no perirectal sensation.,COURSE:, CRP 8.8 and ESR 76. FVC 2.17L. WBC 1.5 (150 bands, 555 neutrophils, 440 lymphocytes and 330 monocytes), Hct 33%, Hgb 11.0, Plt 220K, MCV 88, GS normal except for slightly low total protein (8.0). LFT were normal. Creatinine 1.0. PT and PTT were normal. ABCG 7.46/25/79/96% O2Sat. UA notable for 1+ proteinuria. EKG normal.,MRI L-spine, 7/3/93, revealed an area of abnormally increased T2 signal extending from T12 through L5. This area causes anterior displacement of the spinal cord and nerve roots. The cauda equina are pushed up against the posterior L1 vertebral body. There bilaterally pulmonary effusions. There is also abnormally increased T2 signal in the center of the spinal cord extending from the mid thoracic level through the conus. In addition, the Fila Terminale appear thickened. There is increased signal in the T3 vertebral body suggestion a hemangioma. The findings were felt consistent with a large epidural lipoma displacing the spinal cord anteriorly. there also appeared spinal cord swelling and increased signal within the spinal cord which suggests an intramedullary process.,CSF analysis revealed: protein 1,342, glucose 43, RBC 4,900, WBC 9. C3 and C$ complement levels were 94 and 18 respectively (normal) Anticardiolipin antibodies were negative. Serum Beta-2 microglobulin was elevated at 2.4 and 3.7 in the CSF and Serum, respectively. It was felt the patient had either a transverse myelitis associated with SLE vs. partial cord infarction related to lupus vasculopathy or hypercoagulable state. She was place on IV Decadron. Rheumatology felt that a diagnosis of SLE was likely. Pulmonary effusion analysis was consistent with an exudate. She was treated with plasma exchange and place on Cytoxan.,On 7/22/93 she developed fever with associated proptosis and sudden loss of vision, OD. MRI Brain, 7/22/93, revealed a 5mm thick area of intermediate signal adjacent to the posterior aspect of the right globe, possibly representing hematoma. Ophthalmology felt she had a central retinal vein occlusion; and it was surgically decompressed.,She was placed on prednisone on 8/11/93 and Cytoxan was started on 8/16/93. She developed a headache with meningismus on 8/20/93. CSF analysis revealed: protein 1,002, glucose2, WBC 8,925 (majority were neutrophils). Sinus CT scan negative. She was placed on IV Antibiotics for presumed bacterial meningitis. Cultures were subsequently negative. She spontaneously recovered. 8/25/93, cisternal tap CSF analysis revealed: protein 126, glucose 35, WBC 144 (neutrophils), RBC 95, Cultures negative, cytology negative. MRI Brain scan revealed diffuse leptomeningeal enhancement in both brain and spinal canal.,DSDNA negative. She developed leukopenia in 9/93, and she was switched from Cytoxan to Imuran. Her LFT's rose and the Imuran was stopped and she was placed back on prednisone.,She went on to have numerous deep venous thrombosis while on Coumadin. This required numerous hospital admissions for heparinization. Anticardiolipin antibodies and Protein C and S testing was negative.",
 A 69-year-old male with pain in the shoulder. Evaluate for rotator cuff tear., Radiology, MRI Shoulder - 4 ,"EXAM:,MRI LEFT SHOULDER,CLINICAL:,This is a 69-year-old male with pain in the shoulder. Evaluate for rotator cuff tear.,FINDINGS:,Examination was performed on 9/1/05.,There is marked supraspinatus tendinosis and extensive tearing of the substance of the tendon and articular surface, extending into the myotendinous junction as well. There is still a small rim of tendon along the bursal surface, although there may be a small tear at the level of the rotator interval. There is no retracted tendon or muscular atrophy (series #6 images #6-17).,Normal infraspinatus tendon.,There is subscapularis tendinosis with fraying and partial tearing of the superior most fibers extending to the level of the rotator interval (series #9 images #8-13; series #3 images #8-14). There is no complete tear, gap or fiber retraction and there is no muscular atrophy.,There is tendinosis and superficial tearing of the long biceps tendon within the bicipital groove, and there is high grade (near complete) partial tearing of the intracapsular portion of the tendon. The biceps anchor is intact. There are degenerative changes in the greater tuberosity of the humerus but there is no fracture or subluxation.,There is degeneration of the superior labrum and there is a small nondisplaced tear in the posterior superior labrum at the one to two o’clock position (series #6 images #12-14; series #3 images #8-10; series #9 images #5-8). There is a small sublabral foramen at the eleven o’clock position (series #9 image #6). There is no osseous Bankart lesion.,Normal superior, middle and inferior glenohumeral ligaments.,There is hypertrophic osteoarthropathy of the acromioclavicular joint with narrowing of the subacromial space and flattening of the superior surface of the supraspinatus musculotendinous junction, which in the appropriate clinical setting is an MRI manifestation of an impinging lesion (series #8 images #3-12).,Normal coracoacromial, coracohumeral and coracoclavicular ligaments. There is minimal fluid within the glenohumeral joint. There is no atrophy of the deltoid muscle.,IMPRESSION:,  There is extensive supraspinatus tendinosis and partial tearing as described. There is no retracted tendon or muscular atrophy, but there may be a small tear along the anterior edge of the tendon at the level of the rotator interval, and this associated partial tearing of the superior most fibers of the subscapularis tendon.  There is also a high-grade partial tear of the long biceps tendon as it courses under the transverse humeral ligament. There is no evidence of a complete tear or retracted tendon. Small nondisplaced posterior superior labral tear. Outlet narrowing from the acromioclavicular joint, which in the appropriate clinical setting is an MRI manifestation of an impinging lesion.","radiology, level of the rotator, impinging lesion, rotator interval, retracted tendon, muscular atrophy, partial tearing, tendon, mri, shoulder, rotator, superior, tear,"
 MRI left shoulder., Radiology, MRI Shoulder - 5 ,"EXAM:,MRI LEFT SHOULDER,CLINICAL:,This is a 26 year old with a history of instability. Examination was preformed on 12/20/2005.,FINDINGS:,There is supraspinatus tendinosis without a full-thickness tear, gap or fiber retraction and there is no muscular atrophy (series #105 images #4-6).,Normal infraspinatus and subscapularis tendons.,Normal long biceps tendon within the bicipital groove. There is medial subluxation of the tendon under the transverse humeral ligament, and there is tendinosis of the intracapsular portion of the tendon with partial tearing, but there is no complete tear or discontinuity. Biceps anchor is intact (series #105 images #4-7; series #102 images #10-22).,There is a very large Hill-Sachs fracture, involving almost the entire posterior half of the humeral head (series #102 images #13-19). This is associated with a large inferior bony Bankart lesion that measures approximately 15 x 18mm in AP and craniocaudal dimension with impaction and fragmentation (series #104 images #10-14; series #102 images #18-28). There is medial and inferior displacement of the fragment. There are multiple interarticular bodies, some of which may be osteochondromatous and some may be osseous measuring up to 8mm in diameter. (These are too numerous to count.) There is marked stretching, attenuation and areas of thickening of the inferior and middle glenohumeral ligaments, compatible with a chronic tear with scarring but there is no discontinuity or demonstrated HAGL lesion (series #105 images #5-10).,Normal superior glenohumeral ligament.,There is no SLAP tear.,Normal acromioclavicular joint without narrowing of the subacromial space.,Normal coracoacromial, coracohumeral and coracoclavicular ligaments.,There is fluid in the glenohumeral joint and biceps tendon sheath.,IMPRESSION:,There is a very large Hill-Sachs fracture involving most of the posterior half of the humeral head with an associated large and inferior and medial displaced osseous Bankart lesion.,There are multiple intraarticular bodies, and there is a partial tear of the inferior and middle glenohumeral ligaments.,There is medial subluxation of the long biceps tendon under the transverse humeral ligament with partial tearing of the intracapsular portion.,","radiology, inferior and middle glenohumeral, biceps tendon, partial tearing, glenohumeral ligaments, mri, shoulder, ligament, ligaments, biceps, humeral, glenohumeral, tear, tendons"
 A 32-year-old male with shoulder pain., Radiology, MRI Shoulder - 3 ,"EXAM:,MRI RIGHT SHOULDER,CLINICAL:, A 32-year-old male with shoulder pain.,FINDINGS:,This is a second opinion interpretation of the examination performed on 02/16/06.,Normal supraspinatus tendon without surface fraying, gap or fiber retraction and there is no muscular atrophy.,Normal infraspinatus and subscapularis tendons.,Normal long biceps tendon within the bicipital groove. There is no subluxation of the tendon under the transverse humeral ligament and the intracapsular portion of the tendon is normal.,Normal humeral head without fracture or subluxation.,There is myxoid degeneration within the superior labrum (oblique coronal images #47-48), but there is no discrete tear. The remaining portions of the labrum are normal without osseous Bankart lesion.,Normal superior, middle and inferior glenohumeral ligaments.,There is a persistent os acromiale, and there is minimal reactive marrow edema on both sides of the synchondrosis, suggesting that there may be instability (axial images #3 and 4). There is no diastasis of the acromioclavicular joint itself. There is mild narrowing of the subacromial space secondary to the os acromiale, in the appropriate clinical setting, this may be acting as an impinging lesion (sagittal images #56-59).,Normal coracoacromial, coracohumeral and coracoclavicular ligaments.,There are no effusions or masses.,IMPRESSION:,Changes in the superior labrum compatible with degeneration without a discrete surfacing tear.,There is a persistent os acromiale, and there is reactive marrow edema on both sides of the synchondrosis suggesting instability. There is also mild narrowing of the subacromial space secondary to the os acromiale. This may be acting as an impinging lesion in the appropriate clinical setting.,There is no evidence of a rotator cuff tear.","radiology, impinging lesion, os acromiale, shoulder, tendon, acromiale, osseous"
" MRI of the Cervical, Thoracic, and Lumbar Spine", Radiology, MRI Spine ,"INTERPRETATION: , MRI of the cervical spine without contrast showed normal vertebral body height and alignment with normal cervical cord signal.  At C4-C5, there were minimal uncovertebral osteophytes with mild associated right foraminal compromise.  At C5-C6, there were minimal diffuse disc bulge and uncovertebral osteophytes with indentation of the anterior thecal sac, but no cord deformity or foraminal compromise.  At C6-C7, there was a central disc herniation resulting in mild deformity of the anterior aspect of the cord with patent neuroforamina.  MRI of the thoracic spine showed normal vertebral body height and alignment.  There was evidence of disc generation, especially anteriorly at the T5-T6 level.  There was no significant central canal or foraminal compromise.  Thoracic cord normal in signal morphology.  MRI of the lumbar spine showed normal vertebral body height and alignment.  There is disc desiccation at L4-L5 and L5-S1 with no significant central canal or foraminal stenosis at L1-L2, L2-L3, and L3-L4.  There was a right paracentral disc protrusion at L4-L5 narrowing of the right lateral recess.  The transversing nerve root on the right was impinged at that level.  The right foramen was mildly compromised.  There was also a central disc protrusion seen at the L5-S1 level resulting in indentation of the anterior thecal sac and minimal bilateral foraminal compromise.,IMPRESSION: , Overall impression was mild degenerative changes present in the cervical, thoracic, and lumbar spine without high-grade central canal or foraminal narrowing.  There was narrowing of the right lateral recess at L4-L5 level and associated impingement of the transversing nerve root at that level by a disc protrusion.  This was also seen on a prior study.,","radiology, cervical spine, mri, cervical, thoracic, lumbar, transversing nerve root, vertebral body height, vertebral body, disc protrusion, foraminal compromise, central, foraminal, disc, spineNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 MRI of the brain without contrast to evaluate daily headaches for 6 months in a 57-year-old., Radiology, MRI of Brain w/o Contrast. ,"EXAM: , MRI of the brain without contrast.,HISTORY: , Daily headaches for 6 months in a 57-year-old.,TECHNIQUE:  ,Noncontrast axial and sagittal images were acquired through the brain in varying degrees of fat and water weighting.,FINDINGS: , The brain is normal in signal intensity and morphology for age.  There are no extraaxial fluid collections.  There is no hydrocephalus/midline shift.  Posterior fossa, 7th and 8th nerve complexes and intraorbital contents are within normal limits.  The normal vascular flow volumes are maintained.  The paranasal sinuses are clear.,Diffusion images demonstrate no area of abnormally restricted diffusion that suggests acute infarct.,IMPRESSION: , Normal MRI brain.  Specifically, no findings to explain the patient's headaches are identified.","radiology, mri, diffusion, posterior fossa, axial, brain, contrast, extraaxial, flow, fluid collections, headaches, hydrocephalus, intraorbital, morphology, paranasal, sagittal, sinuses, vascular, weighting, without contrast, mri of the brain, noncontrast, "
 MRI of lumbar spine without contrast to evaluate chronic back pain., Radiology, MRI of Lumbar Spine w/o Contrast ,"EXAM: , MRI of lumbar spine without contrast.,HISTORY:,  A 24-year-old female with chronic back pain.,TECHNIQUE: , Noncontrast axial and sagittal images were acquired through the lumbar spine in varying degrees of fat and water weighting.,FINDINGS: , The visualized cord is normal in signal intensity and morphology with conus terminating in proper position.  Visualized osseous structures are normal in marrow signal intensity and morphology without evidence for fracture/contusion, compression deformity, or marrow replacement process.  There are no paraspinal masses.,Disc heights, signal, and vertebral body heights are maintained throughout the lumbar spine.,L5-S1:  Central canal, neural foramina are patent.,L4-L5:  Central canal, neural foramina are patent.,L3-L4:  Central canal, neural foramen is patent.,L2-L3:  Central canal, neural foramina are patent.,L1-L2:  Central canal, neural foramina are patent.,The visualized abdominal aorta is normal in caliber.  Incidental note has been made of multiple left-sided ovarian, probable physiologic follicular cysts.,IMPRESSION: , No acute disease in the lumbar spine.","radiology, mri, central canal, noncontrast, abdominal aorta, axial, back pain, contrast, follicular cysts, images, lumbar spine, morphology, neural foramina, sagittal, signal intensity, without contrast, mri of lumbar spine, mri of lumbar, lumbar, foramina, neural, patent, spine"
" MRI L-spine - History of progressive lower extremity weakness, right frontal glioblastoma with lumbar subarachnoid seeding.", Radiology, MRI L-Spine - Subarachnoid Seeding ,"CC:, Progressive lower extremity weakness.,HX: ,This 52y/o RHF had a h/o right frontal glioblastoma multiforme (GBM) diagnosed by brain biopsy/partial resection, on 1/15/1991. She had been healthy until 1/6/91, when she experienced a generalized tonic-clonic type seizure during the night. She subsequently underwent an MRI brain scan and was found to have a right frontal enhancing lesion in the mesial aspect of the right frontal lobe at approximately the level of the coronal suture. There was minimal associated edema and no mass effect. Following extirpation of the tumor mass, she underwent radioactive Iodine implantation and 6020cGy radiation therapy in 35 fractions. In 11/91 she received BCNU and Procarbazine chemotherapy protocols. This was followed by four courses of 5FU/Carboplatin (3/92, 6/92, 9/92 ,10/92) chemotherapy.,On 10/12/92 she presented for her 4th course of 5FU/Carboplatin and complained of non-radiating dull low back pain, and proximal lower extremity weakness, but was still able to ambulate. She denied any bowel/bladder difficulty.,PMH: ,s/p oral surgery for wisdom tooth extraction.,FHX/SHX: ,1-2 ppd cigarettes. rare ETOH use. Father died of renal CA.,MEDS: ,Decadron 12mg/day.,EXAM: ,Vitals unremarkable.,MS: Unremarkable.,Motor: 5/5 BUE, LE: 4+/5- prox, 5/5 distal to hips. Normal tone and muscle bulk.,Sensory: No deficits appreciated.,Coord: Unremarkable.,Station: No mention in record of being tested.,Gait: Mild difficulty climbing stairs.,Reflexes: 1+/1+ throughout and symmetric. Plantar responses were down-going bilaterally.,INITIAL IMPRESSION:, Steroid myopathy. Though there was enough of a suspicion of ""drop"" metastasis that an MRI of the L-spine was obtained.,COURSE:, The MRI L-spine revealed fine linear enhancement along the dorsal aspect of the conus medullaris, suggestive of subarachnoid seeding of tumor. No focal mass or cord compression was visualized. CSF examination revealed: 19RBC, 22WBC, 17 Lymphocytes, and 5 histiocytes, Glucose 56, Protein 150. Cytology (negative). The patient was discharged home on 10/17/92, but experienced worsening back pain and lower extremity weakness and became predominantly wheelchair bound within 4 months. She was last seen on 3/3/93 and showed signs of worsening weakness (left hemiplegia: R > L) as her tumor grew and spread. She then entered a hospice.","radiology, glioblastoma multiforme, gbm, steroid myopathy, hemiplegia, progressive lower extremity weakness, mri l spine, lower extremity weakness, frontal glioblastoma, subarachnoid seeding, lower extremity, glioblastoma, subarachnoid, spine, mri, lower, weakness, "
 MRI Orbit/Face/Neck with MR Angiography of the Head - An infant with facial mass, Radiology, MRI Orbit/Face/Neck ,"EXAM: , MRI orbit/face/neck with and without contrast; MR angiography of the head,CLINICAL HISTORY: , 1-day-old female with facial mass.,TECHNIQUE:,1.  Multisequence, multiplanar images of the orbits/face/neck were obtained with and without contrast.  0.5 ml Magnevist was used as the intravenous contrast agent.,2.  MR angiography of the head was obtained using a time-of-flight technique.,3.  The patient was under general anesthesia during the exam.,FINDINGS:,  MRI orbits/face/neck:  There is a pedunculated mass measuring 5.7 x 4.4 x 6.7 cm arising from the patient's lip on the right side.  The mass demonstrates a heterogeneous signal.  There is also heterogeneous enhancement which may relate to a high vascular tumor given the small amount of contrast for the exam.  The origin of the mass from the upper lip demonstrates intact soft tissue planes.,Limited evaluation of the head demonstrates normal appearing midline structures.  Incidental note is made of a small arachnoid cyst within the anterior left middle cranial fossa.  The mastoid air cells on the right are opacified; while the left demonstrates appropriate aeration.,MR angiography of the head:  Angiography is limited such that the vessel feeding the mass cannot be identified with certainty.  The right external carotid artery is noted to be asymmetrically larger than the left, the phenomenon likely related to provision of feeding vessels to the mass.  There is no carotid stenosis.,IMPRESSION:,1.  The mass arising from the right upper lip measures 5.7 x 4.4 x 6.7 cm with a heterogeneous appearance and enhancement pattern.  Hemangioma should be considered in the differential diagnosis as well as other mesenchymal neoplasms.,2.  MR angiography is suboptimal such that feeding vessels to the mass cannot be identified with certainty.","radiology, orbit, face, neck, multisequence, multiplanar, time-of-flight, angiography of the head, facial mass, upper lip, feeding vessels, angiography, head, mri, mass"
 Left shoulder pain. Evaluate for rotator cuff tear., Radiology, MRI Shoulder - 1 ,"EXAM:,MRI-UP EXT JOINT LEFT SHOULDER,CLINICAL:,Left shoulder pain. Evaluate for rotator cuff tear.,FINDINGS:,  Multiple T1 and gradient echo axial images were obtained, as well as T1 and fat suppressed T2-weighted coronal images.,The rotator cuff appears intact and unremarkable. There is no significant effusion seen. Osseous structures are unremarkable. There is no significant downward spurring at the acromioclavicular joint. The glenoid labrum is intact and unremarkable.,IMPRESSION:,  Unremarkable MRI of the left shoulder.,","radiology, rotator cuff tear, cuff tear, rotator cuff, joint, mri, rotator, cuff, shoulder, tear, "
 MRI: Right parietal metastatic adenocarcinoma (LUNG) metastasis., Radiology, MRI of Lung - Adenocarcinoma ,"CC:, Found unresponsive.,HX: ,  39 y/o RHF complained of a severe HA at 2AM 11/4/92. It was unclear whether she had been having HA prior to this. She took an unknown analgesic, then vomited, then lay down in bed with her husband. When her husband awoke at 8AM he found her unresponsive with ""stiff straight arms"" and a ""strange breathing pattern."" A Brain CT scan revealed a large intracranial mass. She was intubated and hyperventilated to ABG (7.43/36/398). Other local lab values included: WBC 9.8, RBC 3.74, Hgb 13.8, Hct 40.7, Cr 0.5, BUN 8.5, Glucose 187, Na 140, K 4.0, Cl 107. She was given Mannitol 1gm/kg IV load, DPH 20mg/kg IV load, and transferred by helicopter to UIHC.,PMH:, 1)Myasthenia Gravis for 15 years, s/p Thymectomy,MEDS:, Imuran, Prednisone, Mestinon, Mannitol, DPH, IV NS,FHX/SHX:, Married. Tobacco 10 pack-year; quit nearly 10 years ago. ETOH/Substance Abuse unknown.,EXAM:, 35.8F, 99BPM, BP117/72, Mechanically ventilated at a rate of 22RPM on !00%FiO2. Unresponsive to verbal stimulation. CN: Pupils 7mm/5mm and unresponsive to light (fixed). No spontaneous eye movement or blink to threat. No papilledema or intraocular hemorrhage noted. Trace corneal reflexes bilaterally. No gag reflex. No oculocephalic reflex. MOTOR/SENSORY: No spontaneous movement. On noxious stimulation (Deep nail bed pressure) she either extended both upper extremities (RUE>LUE), or withdrew the stimulated extremity (right > left). Gait/Station/Coordination no tested. Reflexes: 1+ on right and 2+ on left with bilateral Babinski signs.,HCT 11/4/92: Large heterogeneous mass in the right temporal-parietal region causing significant parenchymal distortion and leftward subfalcine effect . There is low parenchymal density within the white matter. A hyperdense ring lies peripherally and may represent hemorrhage or calcification. The mass demonstrates inhomogeneous enhancement with contrast.,COURSE:, Head of bed elevated to 30 degrees, Mannitol and DPH were continued. MRI of Brain demonstrated a large right parietal mass with necrotic appearing center and leftward shift of midline structures. She underwent surgical resection of the tumor. Pathological analysis was consistent with adenocarcinoma. GYN exam, CT Abdomen and Pelvis, Bone scan were unremarkable. CXR revealed an right upper lobe lung nodule. She did not undergo thoracic biopsy due to poor condition. She received 3000 cGy cranial XRT in ten fractions and following this was discharged to a rehabilitation center.,In March, 1993 the patient exhibited right ptosis, poor adduction and abduction OD, 4/4 strength in the upper extremities and 5-/5- strength in the lower extremities. She was ambulatory with an ataxic gait.,She was admitted on 7/12/93 for lower cervical and upper thoracic pain, paraparesis and T8 sensory level. MRI brainstem/spine on that day revealed decreased T1 signal in the C2, C3, C6 vertebral bodies, increased T2 signal in the anterior medulla, and tectum, and spinal cord (C7-T3). Following injection of Gadolinium there was diffuse leptomeningeal enhancement from C7-T7 These findings were felt consistent with metastatic disease including possible leptomeningeal spread. Neurosurgery and Radiation Oncology agreed that the patients symptoms could be due to either radiation injury and/or metastasis. The patient was treated with Decadron and analgesics and discharged to a hospice center (her choice). She died a few months later.","radiology, mri, lung, metastatic adenocarcinoma, parietal, breathing pattern, cranial xrt, t1 signal, sensory level, iv load, adenocarcinoma, metastatic, leptomeningeal"
 MRI L-S-Spine for Cauda Equina Syndrome secondary to L3-4 disc herniation - Low Back Pain (LBP) with associated BLE weakness., Radiology, MRI L-S Spine - Cauda Equina Syndrome ,"CC: ,Low Back Pain (LBP) with associated BLE weakness.,HX:, This 75y/o RHM presented with a 10 day h/o progressively worsening LBP. The LBP started on 12/3/95; began radiating down the RLE, on 12/6/95; then down the LLE, on 12/9/95. By 12/10/95, he found it difficult to walk. On 12/11/95, he drove himself to his local physician, but no diagnosis was rendered. He was given some NSAID and drove home. By the time he got home he had great difficulty walking due to LBP and weakness in BLE, but managed to feed his pets and himself. On 12/12/95 he went to see a local orthopedist, but on the way to his car he crumpled to the ground due to BLE weakness and LBP pain. He also had had BLE numbness since 12/11/95. He was evaluated locally and an L-S-Spine CT scan and L-S Spine X-rays were ""negative."" He was then referred to UIHC.,MEDS: ,SLNTC, Coumadin 4mg qd, Propranolol, Procardia XL, Altace, Zaroxolyn.,PMH: ,1) MI 11/9/78, 2) Cholecystectomy, 3) TURP for BPH 1980's, 4) HTN, 5) Amaurosis Fugax, OD, 8/95 (Mayo Clinic evaluation--TEE (-), but Carotid Doppler (+) but ""non-surgical"" so placed on Coumadin).,FHX:, Father died age 59 of valvular heart disease. Mother died of DM. Brother had CABG 8/95.,SHX:, retired school teacher. 0.5-1.0 pack cigarettes per day for 60 years.,EXAM:, BP130.56, HR68, RR16, Afebrile.,MS: A&O to person, place, time. Speech fluent without dysarthria. Lucid. Appeared uncomfortable.,CN: Unremarkable.,MOTOR: 5/5 strength in BUE. Lower extremity strength: Hip flexors & extensors 4-/4-, Hip abductors 3+/3+, Hip adductors 5/5, Knee flexors & extensors 4/4-, Ankle flexion 4-/4-, Tibialis Anterior 2/2-, Peronei 3-/3-. Mild atrophy in 4 extremities. Questionable fasciculations in BLE. Spasms illicited on striking quadriceps with reflex hammer (? percussion myotonia). No rigidity and essential normal muscle tone on passive motion.,SENSORY: Decreased vibratory sense in stocking distribution from toes to knees in BLE (worse on right). No sensory level. PP/LT/TEMP testing unremarkable.,COORD: Normal FNF-RAM. Slowed HKS due to weakness.,Station: No pronator drift. Romberg testing not done.,Gait: Unable to stand.,Reflexes: 2/2 BUE. 1/trace patellae, 0/0 Achilles. Plantar responses were flexor, bilaterally. Abdominal reflex was present in all four quadrants. Anal reflex was illicited from all four quadrants. No jaw jerk or palmomental reflexes illicited.,Rectal: normal rectal tone, guaiac negative stool.,GEN EXAM: Bilateral Carotid Bruits, No lymphadenopathy, right inguinal hernia, rhonchi and inspiratory wheeze in both lung fields.,COURSE: ,WBC 11.6, Hgb 13.4, Hct 38%, Plt 295. ESR 40 (normal 0-14), CRP 1.4 (normal <0.4), INR 1.5, PTT 35 (normal), Creatinine 2.1, CK 346. EKG normal. The differential diagnosis included Amyotrophy, Polymyositis, Epidural hematoma, Disc Herniation and Guillain-Barre syndrome. An MRI of the lumbar spine was obtained, 12/13/95. This revealed an L3-4 disc herniation extending inferiorly and behind the L4 vertebral body. This disc was located more on the right than on the left , compromised the right neural foramen, and narrowed the spinal canal. The patient underwent a L3-4 laminectomy and diskectomy and subsequently improved. He was never seen in follow-up at UIHC.","radiology, ble weakness, carotid doppler, disc herniation, guillain-barre syndrome, amyotrophy, polymyositis, epidural hematoma, mri l s spine, cauda equina syndrome, flexors & extensors, cauda equina, herniation, cauda, equina, extensors, reflexes, mri, hip, flexors, weakness, "
 MRI left knee without contrast., Radiology, MRI Knee - 4 ,"EXAM:,MRI OF THE LEFT KNEE WITHOUT CONTRAST,CLINICAL:,Left knee pain. Twisting injury.,FINDINGS:,The images reveal a sizable joint effusion. The joint effusion appears to be complex with mixed signal intensity material within. The patella is slightly laterally tilted towards the left. The mid portion of the patella cartilage shows some increased signal and focal injury to the patellar cartilage is suspected. Mildly increased bone signal overlying the inferolateral portion of the patella is identified. No significant degenerative changes about the patella can be seen. The quadriceps tendon as well as the infrapatellar ligament both look intact. There is some prepatellar soft tissue edema.,The bone signal shows a couple of small areas of cystic change in the proximal aspect of the tibia. NO significant areas of bone edema are appreciated.,There is soft tissue edema along the lateral aspect of the knee. There is a partial tear of the lateral collateral ligament complex. The medial collateral ligament complex looks intact. A small amount of edema is identified immediately adjacent to the medial collateral ligament complex.,The posterior cruciate ligament looks intact. The anterior cruciate ligament is thickened with significant increased signal. I suspect at least a high grade partial tear.,The posterior horn of the medial meniscus shows some myxoid degenerative changes. The posterior horn and anterior horn of the lateral meniscus likewise shows myxoid degenerative type changes. I don’t see a definite tear extending to the articular surface.,IMPRESSION:,Sizeable joint effusion which is complex and may contain blood products.,Myxoid degenerative type changes medial and lateral meniscus with no definite evidence of a tear.,Soft tissue swelling and partial tear of the lateral collateral ligament complex.,At least high grade partial tear of the anterior cruciate ligament with significant thickening and increased signal of this structure.,The posterior cruciate ligament is intact.,Injury to the patellar cartilage as above.","radiology, lateral collateral ligament, medial collateral ligament, posterior cruciate ligament, anterior cruciate ligament, collateral ligament complex, myxoid degenerative, partial tear, collateral ligament, ligament complex, cruciate ligament, mri, effusion, cartilage, collateral, cruciate, knee, tear, ligament"
 MRI left knee., Radiology, MRI Knee - 3 ,"EXAM:,MRI LEFT KNEE,CLINICAL:,This is a 41 -year-old-male with knee pain, mobility loss and swelling. The patient had a twisting injury one week ago on 8/5/05. The examination was performed on 8/10/05,FINDINGS:,There is intrasubstance degeneration within the medial meniscus without a discrete surfacing tear.,There is intrasubstance degeneration within the lateral meniscus, and there is a probable small tear in the anterior horn along the undersurface at the meniscal root.,There is an interstitial sprain/partial tear of the anterior cruciate ligament. There is no complete tear or discontinuity, and the ligament has a celery stick appearance.,Normal posterior cruciate ligament.,Normal medial collateral ligament.,There is a sprain of the femoral attachment of the fibular collateral ligament, without complete tear or discontinuity. The fibular attachment is intact.,Normal biceps femoris tendon, popliteus tendon and iliotibial band.,Normal quadriceps and patellar tendons.,There are no fractures.,There is arthrosis, with high-grade changes in the patellofemoral compartment, particularly along the midline patellar ridge and lateral facet. There are milder changes within the medial femorotibial compartments. There are subcortical cystic changes subjacent to the tibial spine, which appear chronic.,There is a joint effusion. There is synovial thickening.,IMPRESSION:,Probable small tear in the anterior horn of the lateral meniscus at the meniscal root.,Interstitial sprain/partial tear of the anterior cruciate ligament.,Arthrosis, joint effusion and synovial hypertrophy.,There are several areas of focal prominent medullary fat within the medial and lateral femoral condyles.","radiology, mri left knee, interstitial sprain/partial tear, anterior cruciate ligament, lateral meniscus, cruciate ligament, synovial, mri, meniscus, sprain/partial, cruciate, knee, ligament"
 MRI right knee without gadolinium, Radiology, MRI Knee - 5 ,"EXAM:,MRI RIGHT KNEE WITHOUT GADOLINIUM,CLINICAL:,This is a 21-year-old male with right knee pain after a twisting injury on 7/31/05. Patient has had prior lateral meniscectomy in 2001.,FINDINGS:,Examination was performed on 8/3/05,Normal medial meniscus without intrasubstance degeneration, surface fraying or discrete meniscal tear.,There is subtle irregularity along the superior and inferior articular surfaces of the lateral meniscus, likely reflecting previous partial meniscectomy and contouring, although subtle surface tearing cannot be excluded, particularly along the undersurface of the lateral meniscus (series #3, image #17). There is no displaced tear or displaced meniscal fragment.,There is a mild interstitial sprain of the anterior cruciate ligament without focal tear or discontinuity.,Normal posterior cruciate ligament.,Normal medial collateral ligament.,There is a strain of the popliteus muscle and tendon without complete tear.,There is a sprain of the posterolateral and posterocentral joint capsule (series #5 images #10-18). There is marrow edema within the posterolateral corner of the tibia, and there is linear signal adjacent to the cortex suggesting that there may be a Segond fracture for which correlation with radiographs is recommended (series #6, images #4-7).,Biceps femoris tendon and iliotibial band are intact and there is no discrete fibular collateral ligament tear. Normal quadriceps and patellar tendons.,There is contusion within the posterior non-weight bearing surface of the medial femoral condyle, as well as in the posteromedial corner of the tibia. There is linear vertically oriented signal within the distal tibial diaphyseal-metaphyseal junction (series #7, image #8; series #2, images #4-5). There is no discrete fracture line, and this is of uncertain significance, but this should be correlated with radiographs.,The patellofemoral joint is congruent without patellar tilt or subluxation. Normal medial and lateral patellar retinacula. There is a joint effusion.,IMPRESSION:,Changes within the lateral meniscus most likely reflect previous partial meniscectomy and re-contouring although a subtle undersurface tear in the anterior horn may be present.,Mild anterior cruciate ligament interstitial sprain.,There is a strain of the popliteus muscle and tendon and there is a sprain of the posterolateral and posterocentral joint capsule with a possible Second fracture which should be correlated with radiographs.,","radiology, mri right knee, posterolateral and posterocentral, posterocentral joint capsule, lateral meniscus, cruciate ligament, mri, meniscectomy, cruciate, tendon, posterolateral, patellar, ligament, tear"
" Pain and swelling in the right foot, peroneal tendon tear.", Radiology, MRI Foot - 1 ,"EXAM:,MRI/LOW EX NOT JNT RT W/O CONTRAST,CLINICAL:,Pain and swelling in the right foot, peroneal tendon tear.,FINDINGS:,  Contours of marrow signal patterns of the regional bones are within normal range treating there is increased T2 signal within the soft tissues at the lateral margin of the cuboid bone. A small effusion is noted within the peroneal tendon sheath. There is a 3mm slight separation of the distal tip of the peroneus longus tendon from the lateral margin of the cuboid bone, consistent with an avulsion. There is no sign of cuboid fracture. The fifth metatarsal base appears intact. The calcaneus is also normal in appearance.,IMPRESSION:  ,Findings consistent with an avulsion of the peroneus longus tendon from the insertion on the lateral aspect of cuboid bone.,","radiology, peroneus longus tendon, peroneal tendon, lateral margin, peroneus longus, longus tendon, cuboid bone, foot, peroneal, peroneus, longus, avulsion, tendon, bones, cuboid,"
 MRI Head W&WO Contrast., Radiology, MRI Head ,"EXAM:,  MRI Head W&WO Contrast.,REASON FOR EXAM:,  Dyspnea.,COMPARISON:,  None. ,TECHNIQUE:,  MRI of the head performed without and with 12 ml of IV gadolinium (Magnevist).  ,INTERPRETATION: , There are no abnormal/unexpected foci of contrast enhancement.  There are no diffusion weighted signal abnormalities.  There are minimal, predominantly periventricular, deep white matter patchy foci of FLAIR/T2 signal hyperintensity, the rest of the brain parenchyma appearing unremarkable in signal.  The ventricles and sulci are prominent, but proportionate.  Per T2 weighted sequence, there is no hyperdense vascularity.  There are no calvarial signal abnormalities.  There is no significant mastoid air cell fluid.  No significant sinus mucosal disease per MRI.,IMPRESSION:,1.  No abnormal/unexpected foci of contrast enhancement; specifically, no evidence for metastases or masses.  ,2.  No evidence for acute infarction. ,3.  Mild, scattered, patchy, chronic small vessel ischemic disease changes. ,4.  Diffuse cortical volume loss, consistent with patient's age. ,5.  Preliminary report was issued at the time of dictation.  ,","radiology, dyspnea, mri of the head, foci of contrast, patchy foci, white matter, w&wo contrast, mri head, mri"
" A 49-year-old female with ankle pain times one month, without a specific injury. ", Radiology, MRI Foot - 3 ,"EXAM:,MRI LEFT FOOT,CLINICAL:, A 49-year-old female with ankle pain times one month, without a specific injury. Patient complains of moderate to severe pain, worse with standing or walking on hard surfaces, with tenderness to palpation at the plantar aspect of the foot and midfoot region and tenderness over the course of the posterior tibialis tendon.,FINDINGS:,Received for second opinion interpretations is an MRI examination performed on 05/27/2005.,There is edema of the subcutis adipose space extending along the medial and lateral aspects of the ankle.,There is edema of the subcutis adipose space posterior to the Achilles tendon. Findings suggest altered biomechanics with crural fascial strains.,There is tendinosis of the posterior tibialis tendon as it rounds the tip of the medial malleolus with mild tendon thickening. There is possible partial surface tearing of the anterior aspect of the tendon immediately distal to the tip of the medial malleolus (axial inversion recovery image #16) which is a possible hypertrophic tear less than 50% in cross sectional diameter. The study has been performed with the foot in neutral position. Confirmation of this possible partial tendon tear would require additional imaging with the foot in a plantar flexed position with transaxial images of the posterior tibialis tendon as it rounds the tip of the medial malleolus oriented perpendicular to the course of the posterior tibialis tendon.,There is minimal synovitis of the flexor digitorum longus and flexor hallucis longus tendon sheaths consistent with flexor splinting but intrinsically normal tendons.,Normal peroneal tendons.,There is tendinosis of the tibialis anterior tendon with thickening but no demonstrated tendon tear. Normal extensor hallucis longus and extensor digitorum tendons.,Normal Achilles tendon. There is a low-lying soleus muscle that extends to within 2cm of the teno-osseous insertion of the Achilles tendon.,Normal distal tibiofibular syndesmotic ligamentous complex.,Normal lateral, subtalar and deltoid ligamentous complexes.,There are no erosions of the inferior neck of the talus and there are no secondary findings of a midfoot pronating force.,Normal plantar fascia. There is no plantar calcaneal spur.,There is venous engorgement of the plantar veins of the foot extending along the medial and lateral plantar cutaneous nerves which may be acting as intermittent entrapping lesions upon the medial and lateral plantar cutaneous nerves.,Normal tibiotalar, subtalar, talonavicular and calcaneocuboid articulations.,The metatarsophalangeal joint of the hallux was partially excluded from the field-of-view of this examination.,IMPRESSION:,Tendinosis of the posterior tibialis tendon with tendon thickening and possible surface fraying / tearing of the tendon immediately distal to the tip of the medial malleolus, however, confirmation of this finding would require additional imaging.,Minimal synovitis of the flexor digitorum longus and flexor hallucis longus tendon sheaths, consistent with flexor splinting.,Edema of the subcutis adipose space along the medial and lateral aspects of the ankle suggesting altered biomechanics and crural fascial strain.,Mild tendinosis of the tibialis anterior tendon with mild tendon thickening.,Normal plantar fascia and no plantar fasciitis.,Venous engorgement of the plantar veins of the foot which may be acting as entrapping lesions upon the medial and lateral plantar cutaneous nerves.","radiology, lateral plantar cutaneous, plantar cutaneous nerves, posterior tibialis tendon, medial and lateral, subcutis adipose, adipose space, achilles tendon, tendon thickening, hallucis longus, lateral plantar, plantar cutaneous, cutaneous nerves, medial malleolus, posterior tibialis, tibialis tendon, plantar, tendon, posterior, flexor, tibialis, medial, "
 A 53-year-old female with left knee pain being evaluated for ACL tear., Radiology, MRI Knee - 2 ,"EXAM:,MRI LEFT KNEE WITHOUT CONTRAST,CLINICAL:,This is a 53-year-old female with left knee pain being evaluated for ACL tear.,FINDINGS:,This examination was performed on 10-14-05.,Normal medial meniscus without intrasubstance degeneration, surface fraying or discrete meniscal tear.,There is a discoid lateral meniscus and although there may be minimal superficial fraying along the inner edge of the body, there is no discrete tear (series #6 images #7-12).,There is a near-complete or complete tear of the femoral attachment of the anterior cruciate ligament. The ligament has a balled-up appearance consistent with at least partial retraction of most of the fibers of the ligament. There may be a few fibers still intact (series #4 images #12-14; series #5 images #12-14). The tibial fibers are normal.,Normal posterior cruciate ligament.,There is a sprain of the medial collateral ligament, with mild separation of the deep and superficial fibers at the femoral attachment (series #7 images #6-12). There is no complete tear or discontinuity and there is no meniscocapsular separation.,There is a sprain of the lateral ligament complex without focal tear or discontinuity of any of the intraarticular components.,Normal iliotibial band.,Normal quadriceps and patellar tendons.,There is contusion within the posterolateral corner of the tibia. There is also contusion within the patella at the midline patellar ridge where there is an area of focal chondral flattening (series #8 images #10-13). The medial and lateral patellar facets are otherwise normal as is the femoral trochlea in the there is no patellar subluxation.,There is a mild strain of the vastus medialis oblique muscle extending into the medial patellofemoral ligament and medial patellar retinaculum but there is no complete tear or discontinuity.,Normal lateral patellar retinaculum. There is a joint effusion and plica.,IMPRESSION:, Discoid lateral meniscus without a tear although there may be minimal superficial fraying along the inner edge of the body.  Near-complete if not complete tear of the femoral attachment of the anterior cruciate ligament.  Medial capsule sprain with associated strain of the vastus medialis oblique muscle.  There is focal contusion within the patella at the midline patella ridge. Joint effusion and plica.","radiology, vastus medialis oblique muscle, medialis oblique, oblique muscle, patellar retinaculum, joint effusion, femoral attachment, cruciate ligament, complete tear, meniscus, superficial, cruciate, sprain, femoral, medial, ligament, tear, patellar"
 MRI head without contrast., Radiology, MRI Head - 1 ,"EXAM:,  MRI head without contrast.,REASON FOR EXAM: , Severe headaches.,INTERPRETATION:,  Imaging was performed in the axial and sagittal planes using numerous pulse sequences at 1 tesla.  Correlation is made with the head CT of 4/18/05.,On the diffusion sequence, there is no significant bright signal to indicate acute infarction.  There is a large degree of increased signal involving the periventricular white matter extending around to the subcortical regions in symmetrical fashion consistent with chronic microvascular ischemic disease.  There is mild chronic ischemic change involving the pons bilaterally, slightly greater on the right, and when correlating with the recent scan, there is an old tiny lacunar infarct of the right brachium pontis measuring roughly 4 mm in size.  There are prominent perivascular spaces of the lenticulostriate distribution compatible with the overall degree of moderate to moderately advanced atrophy.  There is an old moderate-sized infarct of the mid and lateral aspects of the right cerebellar hemisphere as seen on the recent CT scan.  This involves mostly the superior portion of the hemisphere in the superior cerebellar artery distribution.  No abnormal mass effect is identified.  There are no findings to suggest active hydrocephalus.  No abnormal extra-axial collection is identified.  There is normal flow void demonstrated in the major vascular systems.,The sagittal sequence demonstrates no Chiari malformation.  The region of the pituitary/optic chiasm grossly appears normal.  The mastoids and paranasal sinuses are clear.,IMPRESSION:,1.  No definite acute findings identified involving the brain.,2.  There is prominent chronic cerebral ischemic change as described with mild chronic pontine ischemic changes.  There is an old moderate-sized infarct of the superior portion of the right cerebellar hemisphere.,3.  Moderate to moderately advanced atrophy.","radiology, severe headaches, chiari malformation, cerebral ischemic change, mri head without contrast, cerebellar hemisphere, superior portion, mri head, cerebellar, infarction, ischemic"
 MRI left knee without contrast., Radiology, MRI Knee - 1 ,"EXAM:,MRI LEFT KNEE WITHOUT CONTRAST,CLINICAL:,Left knee pain.,FINDINGS:,Comparison is made with 10/13/05 radiographs.,There is a prominent suprapatellar effusion. Patient has increased signal within the medial collateral ligament as well as fluid around it, compatible with type 2 sprain. There is fluid around the lateral collateral ligament without increased signal within the ligament itself, compatible with type 1 sprain.,Medial and lateral menisci contain some minimal increased signal centrally that does not extend through an articular surface and findings are felt to represent minimal myxoid degeneration. No tear is seen. Anterior cruciate and posterior cruciate ligaments are intact. There is a bone bruise of medial patellar facet measuring approximately 8 x 5 mm. There is suggestion of some mild posterior aspect of the lateral tibial plateau. MR signal on the bone marrow is otherwise normal.,IMPRESSION:,Type 2 sprain in the medial collateral ligament and type sprain in the lateral collateral ligament.,Joint effusion and bone bruise with suggestion of some minimal overlying chondromalacia and medial patellar facet.","radiology, collateral ligament, mri, knee, collateral, sprain, medial, ligament, "
 Pain and swelling in the right foot., Radiology, MRI Foot - 2 ,"EXAM:,MRI RIGHT FOOT,CLINICAL:,Pain and swelling in the right foot.,FINDINGS: ,Obtained for second opinion interpretation is an MRI examination performed on 11-04-05.,There is a transverse fracture of the anterior superior calcaneal process of the calcaneus. The fracture is corticated however and there is an active marrow stress phenomenon. There is a small ganglion measuring approximately 8 x 5 x 5mm in size extending along the bifurcate ligament.,There is no substantial joint effusion of the calcaneocuboid articulation. There is minimal interstitial edema involving the short plantar calcaneal cuboid ligament.,Normal plantar calcaneonavicular spring ligament.,Normal talonavicular articulation.,There is minimal synovial fluid within the peroneal tendon sheaths.,Axial imaging of the ankle has not been performed orthogonal to the peroneal tendon distal to the retromalleolar groove. The peroneus brevis tendon remains intact extending to the base of the fifth metatarsus. The peroneus longus tendon can be identified in its short axis extending to its distal plantar insertion upon the base of the first metatarsus with minimal synovitis.,There is minimal synovial fluid within the flexor digitorum longus and flexor hallucis longus tendon sheath with pooling of the fluid in the region of the knot of Henry.,There is edema extending along the deep surface of the extensor digitorum brevis muscle.,Normal anterior, subtalar and deltoid ligamentous complex.,Normal naviculocuneiform, intercuneiform and tarsometatarsal articulations.,The Lisfranc’s ligament is intact.,The Achilles tendon insertion has been excluded from the field-of-view.,Normal plantar fascia and intrinsic plantar muscles of the foot.,There is mild venous distention of the veins of the foot within the tarsal tunnel.,There is minimal edema of the sinus tarsus. The lateral talocalcaneal and interosseous talocalcaneal ligaments are normal.,Normal deltoid ligamentous complex.,Normal talar dome and no occult osteochondral talar dome defect.,IMPRESSION:,Transverse fracture of the anterior calcaneocuboid articulation with cortication and cancellous marrow edema.,Small ganglion intwined within the bifurcate ligament.,Interstitial edema of the short plantar calcaneocuboid ligament.,Minimal synovitis of the peroneal tendon sheaths but no demonstrated peroneal tendon tear.,Minimal synovitis of the flexor tendon sheaths with pooling of fluid within the knot of Henry.,Minimal interstitial edema extending along the deep surface of the extensor digitorum brevis muscle.",
" MRI of elbow - A middle-aged female with moderate pain, severe swelling and a growth on the arm.", Radiology, MRI Elbow - 2 ,"FINDINGS:,There is diffuse subcutis space edema extending along the posteromedial aspect of the elbow adjacent to the medial epicondyle, extending to the olecranon process and along the superficial aspect of the epicondylo-olecranon ligament. There is no demonstrated solid, cystic or lipomatous mass lesion. There is enlargement with hyperintense signal of the ulnar nerve within the cubital tunnel. There is inflammation with mild laxity of the epicondylo-olecranon ligament. The combined findings are most consistent with a ulnar nerve neuritis possibly secondary to a subluxing ulnar nerve however the ulnar nerve at this time is within the cubital tunnel. There is no accessory muscle within the cubital tunnel. The common flexor tendon origin is normal.,Normal ulnar collateral ligamentous complex.,There is mild epimysial sheath edema of the pronator teres muscle consistent with a mild epimysial sheath sprain but no muscular tear.,There is minimal intratendinous inflammation of the common extensor tendon origin consistent with a mild tendinitis. There is no demonstrated common extensor tendon tear. Normal radial collateral ligamentous complex.,Normal radiocapitellum and ulnotrochlear articulations.,Normal triceps and biceps tendon insertions.,There is peritendinous inflammation of the brachialis tendon insertion but an intrinsically normal tendon.,IMPRESSION:,Edema of the subcutis adipose space overlying the posteromedial aspect of the elbow with interstitial inflammation of the epicondylo-olecranon ligament.,Enlarged edematous ulnar nerve most compatible with ulnar nerve neuritis.,The above combined findings suggest a subluxing ulnar nerve.,Mild epimysial sheath strain of the pronator teres muscle but no muscular tear.,Mild lateral epicondylitis with focal tendinitis of the origin of the common extensor tendon.,Peritendinous edema of the brachialis tendon insertion.,No solid, cystic or lipomatous mass lesion.,","radiology, growth on the arm, subluxing ulnar nerve, collateral ligamentous complex, common extensor tendon, posteromedial aspect, epimysial sheath, extensor tendon, tendon insertions, ulnar nerve, elbow, edema, olecranon, inflammation, nerve, ulnar, tendon"
 MRI report Cervical Spine (Chiropractic Specific), Radiology, MRI Cervical Spine - Chiropractic Specific ,"FINDINGS:,Normal foramen magnum.,Normal brainstem-cervical cord junction. There is no tonsillar ectopia. Normal clivus and craniovertebral junction. Normal anterior atlantoaxial articulation.,C2-3: There is disc desiccation but no loss of disc space height, disc displacement, endplate spondylosis or uncovertebral joint arthrosis. Normal central canal and intervertebral neural foramina.,C3-4: There is disc desiccation with a posterior central disc herniation of the protrusion type. The small posterior central disc protrusion measures 3 x 6mm (AP x transverse) in size and is producing ventral thecal sac flattening. CSF remains present surrounding the cord. The residual AP diameter of the central canal measures 9mm. There is minimal right-sided uncovertebral joint arthrosis but no substantial foraminal compromise.,C4-5: There is disc desiccation, slight loss of disc space height with a right posterior lateral pre-foraminal disc osteophyte complex with right-sided uncovertebral and apophyseal joint arthrosis. The disc osteophyte complex measures approximately 5mm in its AP dimension. There is minimal posterior annular bulging measuring approximately 2mm. The AP diameter of the central canal has been narrowed to 9mm. CSF remains present surrounding the cord. There is probable radicular impingement upon the exiting right C5 nerve root.,C5-6: There is disc desiccation, moderate loss of disc space height with a posterior central disc herniation of the protrusion type. The disc protrusion measures approximately 3 x 8mm (AP x transverse) in size. There is ventral thecal sac flattening with effacement of the circumferential CSF cleft. The residual AP diameter of the central canal has been narrowed to 7mm. Findings indicate a loss of the functional reserve of the central canal but there is no cord edema. There is bilateral uncovertebral and apophyseal joint arthrosis with moderate foraminal compromise.,C6-7: There is disc desiccation, mild loss of disc space height with 2mm of posterior annular bulging. There is bilateral uncovertebral and apophyseal joint arthrosis (left greater than right) with probable radicular impingement upon the bilateral exiting C7 nerve roots.,C7-T1, T1-2: There is disc desiccation with no disc displacement. Normal central canal and intervertebral neural foramina.,T3-4: There is disc desiccation with minimal 2mm posterior annular bulging but normal central canal and CSF surrounding the cord.,IMPRESSION:,Multilevel degenerative disc disease with uncovertebral joint arthrosis with foraminal compromise as described above.,C3-4 posterior central disc herniation of the protrusion type but no cord impingement.,C4-5 right posterior lateral disc osteophyte complex with right-sided uncovertebral and apophyseal joint arthrosis with probable radicular impingement upon the right C5 nerve root.,C5-6 degenerative disc disease with a posterior central disc herniation of the protrusion type producing borderline central canal stenosis with effacement of the circumferential CSF cleft indicating a limited functional reserve of the central canal.,C6-7 degenerative disc disease with annular bulging and osseous foraminal compromise with probable impingement upon the bilateral exiting C7 nerve roots.,T3-4 degenerative disc disease with posterior annular bulging.","radiology, exiting c nerve roots, loss of disc space, posterior central disc herniation, herniation of the protrusion, uncovertebral and apophyseal joint, intervertebral neural foramina, ventral thecal sac, thecal sac flattening, disc osteophyte complex, disc space height, central disc herniation, apophyseal joint arthrosis, posterior annular bulging, degenerative disc disease, posterior central disc, csf cleft, osteophyte complex, radicular impingement, disc disease, central disc, annular bulging, disc desiccation, joint arthrosis, central canal, cervical, degenerative, csf, foraminal, bulging, impingement, protrusion, uncovertebral, arthrosis, canal"
 MRI C-spine: C4-5 Transverse Myelitis., Radiology, MRI C-spine ,"CC:, Left hemibody numbness.,HX:, This 44y/o RHF awoke on 7/29/93 with left hemibody numbness without tingling, weakness, ataxia, visual or mental status change. She had no progression of her symptoms until 7/7/93 when she notices her right hand was stiff and clumsy. She coincidentally began listing to the right when walking. She denied any recent colds/flu-like illness or history of multiple sclerosis. She denied symptoms of Lhermitte's or Uhthoff's phenomena.,MEDS:, none.,PMH:, 1)Bronchitis twice in past year (last 2 months ago).,FHX:, Father with HTN and h/o strokes at ages 45 and 80; now 82 years old. Mother has DM and is age 80.,SHX:, Denies Tobacco/ETOH/illicit drug use.,EXAM:, BP112/76 HR52 RR16 36.8C,MS: unremarkable.,CN: unremarkable.,Motor: 5/5 strength throughout except for slowing of right hand fine motor movement. There was mildly increased muscle tone in the RUE and RLE.,Sensory: decreased PP below T2 level on left and some dysesthesias below L1 on the left.,Coord: positive rebound in RUE.,Station/Gait: unremarkable.,Reflexes: 3+/3 throughout all four extremities. Plantar responses were flexor, bilaterally.,Rectal exam not done.,Gen exam reportedly ""normal."",COURSE:, GS, CBC, PT, PTT, ESR, Serum SSA/SSB/dsDNA, B12 were all normal. MRI C-spine, 7/145/93, showed an area of decreased T1 and increased T2 signal at the C4-6 levels within the right lateral spinal cord. The lesion appeared intramedullary and eccentric, and peripherally enhanced with gadolinium. Lumbar puncture, 7/16/93, revealed the following CSF analysis results: RBC 0, WBC 1 (lymphocyte), Protein 28mg/dl, Glucose 62mg/dl, CSF Albumin 16 (normal 14-20), Serum Albumin 4520 (normal 3150-4500), CSF IgG 4.1mg/dl (normal 0-6.2), CSF IgG, % total CSF protein 15% (normal 1-14%), CSF IgG index 1.1 (normal 0-0.7), Oligoclonal bands were present. She was discharged home.,The patient claimed her symptoms resolved within one month. She did not return for a scheduled follow-up MRI C-spine.","radiology, mri c-spine, c-spine, lhermitte's, myelitis, transverse myelitis, uhthoff's, ataxia, clumsy, hemibody numbness, mental status, numbness, tingling, weakness, mri c spine, hemibody, mri, spine, csf, "
 MRI C-spine to evaluate right shoulder pain - C5-6 disk herniation., Radiology, MRI C-Spine - C5-6 Disk Herniation ,"CC:, Right shoulder pain.,HX: ,This 46 y/o RHF presented with a 4 month history of right neck and shoulder stiffness and pain. The symptoms progressively worsened over the 4 month course. 2 weeks prior to presentation she began to develop numbness in the first and second fingers of her right hand and RUE pain. The later was described as a throbbing pain. She also experienced numbness in both lower extremities and pain in the coccygeal region. The pains worsened at night and impaired sleep. She denied any visual change, bowel or bladder difficulties and symptoms involving the LUE. She occasionally experienced an electric shock like sensation shooting down her spine when flexing her neck (Lhermitte's phenomena). She denied any history of neck/back/head trauma.,She had been taking Naprosyn with little relief.,PMH: ,1) Catamenial Headaches. 2) Allergy to Macrodantin.,SHX/FHX:, Smokes 2ppd cigarettes.,EXAM: ,Vital signs were unremarkable.,CN: unremarkable.,Motor: full strength throughout. Normal tone and muscle bulk.,Sensory: No deficits on LT/PP/VIB/TEMP/PROP testing.,Coord/Gait/Station: Unremarkable.,Reflexes: 2/2 in BUE except 2+ at left biceps. 1+/1+BLE except an absent right ankle reflex.,Plantar responses were flexor bilaterally. Rectal exam: normal tone.,IMPRESSION:, C-spine lesion.,COURSE: ,MRI C-spine revealed a central C5-6 disk herniation with compression of the spinal cord at that level. EMG/NCV showed normal NCV, but 1+ sharps and fibrillations in the right biceps (C5-6), brachioradialis (C5-6), triceps (C7-8) and teres major; and 2+ sharps and fibrillations in the right pronator terres. There was increased insertional activity in all muscles tested on the right side. The findings were consistent with a C6-7 radiculopathy.,The patient subsequently underwent C5-6 laminectomy and her symptoms resolved.","radiology, shoulder pain, stiffness, numbness, lhermitte's phenomena, c-spine lesion, disk herniation, mri c spine, reflexes, biceps, mri, disk, shoulder, spine, herniation,"
 MRI Elbow - A middle-aged female complaining of elbow pain., Radiology, MRI Elbow - 1 ,"FINDINGS:,There is severe tendinitis of the common extensor tendon origin with diffuse intratendinous inflammation (coronal T2 image #1452, sagittal T2 image #1672). There is irregularity of the deep surface of the tendon consistent with mild fraying (#1422 and 1484) however there is no distinct tear.,There is a joint effusion of the radiocapitellar articulation with mild fluid distention.,The radial collateral (proper) ligament remains intact. There is periligamentous inflammation of the lateral ulnar collateral ligament (coronal T2 image #1484) of the radial collateral ligamentous complex. There is no articular erosion or osteochondral defect with no intra-articular loose body.,There is minimal inflammation of the subcutis adipose space extending along the origin of the common flexor tendon (axial T2 image #1324). The common flexor tendon otherwise is normal.,There is minimal periligamentous inflammation of the anterior band of the ulnar collateral ligament (coronal T2 image #1516, axial T2 image #1452) with an intrinsically normal ligament.,The ulnotrochlear articulation is normal.,The brachialis and biceps tendons are normal with a normal triceps tendon. The anterior, posterior, medial and lateral muscular compartments are normal.,The radial, median and ulnar nerves are normal with no apparent ulnar neuritis.,IMPRESSION:,Lateral epicondylitis with severe tendinitis of the common extensor tendon origin and minimal deep surface fraying, without a discrete tendon tear.,Periligamentous inflammation of the radial collateral ligamentous complex as described above with intrinsically normal ligaments.,Small joint effusion of the radiocapitellar articulation with no osteochondral defect or intra-articular loose body.,Mild peritendinous inflammation of the subcutis adipose space adjacent to the common flexor tendon origin with an intrinsically normal tendon.,Minimal periligamentous inflammation of the anterior band of the ulnar collateral ligament with an intrinsically normal ligament.","radiology, radial collateral ligamentous complex, intra articular loose body, axial t image, ulnar collateral ligament, common flexor tendon, mri elbow, ligamentous complex, radial collateral, ulnar collateral, collateral ligament, flexor tendon, periligamentous inflammation, mri, tendon"
 Left third digit numbness and wrist pain., Radiology, MRI C3 - Cord Compression. ,"CC:, Left third digit numbness and wrist pain.,HX: ,This 44 y/o LHM presented with a one month history of numbness and pain of the left middle finger and wrist. The numbness began in the left middle finger and gradually progressed over the course of a day to involve his wrist as well. Within a few days he developed pain in his wrist. He had been working as a cook and cut fish for prolonged periods of time. This activity exacerbated his symptoms. He denied any bowel/bladder difficulties, neck pain, or weakness. He had no history of neck injury.,SHX/FHX:, 1-2 ppd Cigarettes. Married. Off work for two weeks due to complaints.,EXAM: ,Vital signs unremarkable.,MS:, A & O to person, place, time. Fluent speech without dysarthria.,CN II-XII: ,Unremarkable,MOTOR:, 5/5 throughout, including intrinsic muscles of hands. No atrophy or abnormal muscle tone.,SENSORY:, Decreased PP in third digit of left hand only (palmar and dorsal sides).,STATION/GAIT/COORD:, Unremarkable.,REFLEXES: ,1+ throughout, plantar responses were downgoing bilaterally.,GEN EXAM: ,Unremarkable.,Tinel's manuever elicited pain and numbness on the left. Phalens sign present on the left.,CLINICAL IMPRESSION: ,Left Carpal Tunnel Syndrome,EMG/NCV: ,Unremarkable.,MRI C-spine, 12/1/92: Congenitally small spinal canal is present. Superimposed on this is mild spondylosis and disc bulge at C6-7, C5-6, C4-5, and C3-4. There is moderate central spinal stenosis at C3-4. Intervertebral foramina at these levels appear widely patent.,COURSE:, The MRI findings did not correlate with the clinical findings and history. The patient was placed on Elavil and was subsequently lost to follow-up.",
 MRI cervical spine., Radiology, MRI Cervical Spine - 1 ,"EXAM:,MRI CERVICAL SPINE,CLINICAL:, A57-year-old male. Received for outside consultation is an MRI examination performed on 11/28/2005.,FINDINGS:,Normal brainstem-cervical cord junction. Normal cisterna magna with no tonsillar ectopia. Normal clivus with a normal craniovertebral junction. Normal anterior atlantoaxial articulation.,C2-3: Normal intervertebral disc with no spondylosis or uncovertebral joint arthrosis. Normal central canal and intervertebral neural foramina with no cord or radicular impingement.,C3-4: There is disc desiccation with minimal annular bulging. The residual AP diameter of the central canal measures approximately 10mm. CSF remains present surrounding the cord.,C4-5: There is disc desiccation with endplate spondylosis and mild uncovertebral joint arthrosis. The residual AP diameter of the central canal measures approximately 8mm with effacement of the circumferential CSF cleft producing a borderline central canal stenosis but no cord distortion or cord edema. There is minimal uncovertebral joint arthrosis.,C5-6: There is disc desiccation with minimal posterior annular bulging and a right posterolateral preforaminal disc protrusion measuring approximately 2 x 8mm (AP x transverse). The disc protrusion produces minimal rightward ventral thecal sac flattening but no cord impingement.,C6-7: There is disc desiccation with mild loss of disc space height and posterior endplate spondylosis and annular bulging producing central canal stenosis. The residual AP diameter of the central canal measures 8 mm with effacement of the circumferential CSF cleft. There is a left posterolateral disc-osteophyte complex encroaching upon the left intervertebral neural foramen with probable radicular impingement upon the exiting left C7 nerve root.,C7-T1, T1-2: Minimal disc desiccation with no disc displacement or endplate spondylosis.,IMPRESSION:,Multilevel degenerative disc disease as described above.,C4-5 borderline central canal stenosis with mild bilateral foraminal compromise.,C5-6 disc desiccation with a borderline central canal stenosis and a right posterolateral preforaminal disc protrusion producing thecal sac distortion.,C6-7 degenerative disc disease and endplate spondylosis with a left posterolateral disc-osteophyte complex producing probable neural impingement upon the exiting left C7 nerve root with a borderline central canal stenosis.,Normal cervical cord.","radiology, borderline central canal stenosis, mri cervical spine, borderline central canal, central canal stenosis, degenerative disc, annular bulging, ap diameter, endplate spondylosis, borderline central, canal stenosis, disc desiccation, central canal, cervical, disc, spondylosis, stenosis, cord, canal,"
 MRI Brain: Subacute right thalamic infarct., Radiology, MRI Brain: Thalamic Infarct ,"CC:, Left hemiplegia.,HX: , A 58 y/o RHF awoke at 1:00AM on 10/23/92 with left hemiplegia and dysarthria which cleared within 15 minutes. She was seen at a local ER and neurological exam and CT Brain were reportedly unremarkable. She was admitted locally. She then had two more similar spells at 3AM and 11AM with resolution of the symptoms within an hour. She was placed on IV Heparin following the 3rd episode and was transferred to UIHC. She had not been taking ASA.,PMH:, 1)HTN. 2) Psoriasis.,SHX:, denied ETOH/Tobacco/illicit drug use.,FHX:, Unknown.,MEDS:, Heparin only.,EXAM:, BP160/90 HR145 (supine). BP105/35 HR128 (light headed, standing) RR12 T37.7C,MS: Dysarthria only. Lucid thought process.,CN: left lower facial weakness only.,Motor: mild left hemiparesis with normal muscle bulk. Mildly increased left sided muscle tone.,Sensory: unremarkable.,Coordination: impaired secondary to weakness on left. Otherwise unremarkable.,Station: left pronator drift. Romberg testing not done.,Gait: not tested.,Reflexes: symmetric; 2+ throughout.,Gen Exam: CV: Tachycardic without murmur.,COURSE:, The patients signs and symptoms worsening during and after standing to check orthostatic blood pressures. She was immediately placed in a reverse Trendelenburg position and given IV fluids. Repeat neurologic exam at 5PM on the day of presentation revealed a return to the initial presentation of signs and symptoms. PT/PTT/GS/CBC/ABG were unremarkable. EKG revealed sinus tachycardia with rate dependent junctional changes. CXR unremarkable. MRI Brain was obtained and showed an evolving right thalamic/lentiform nucleus infarction best illustrated by increased signal on the Proton density weighted images. Over the ensuing days of admission she had significant fluctuations of her BP (200mmHG to 140mmHG systolic). Her symptoms worsened with falls in BP. Her BP was initially controlled with esmolol or labetalol. Renal Ultrasound, abdominal/pelvic CT, renal function scan, serum and urine osmolality, urine catecholamines/metanephrine studies were unremarkable. Carotid doppler study revealed 0-15%BICA stenosis and antegrade vertebral artery flow, bilaterally. Transthoracic echocardiogram was unremarkable. Cerebral angiogram was performed to r/o vasculitis. This revealed narrowing of the M1 segment of the right MCA. This was thought secondary to atherosclerosis and not vasculitis. She was discharged on ASA, Procardia XL, and Labetalol.","radiology, mri brain, ct brain, heparin, dysarthria, hemiplegia, infarct, neurological exam, thalamic, thalamic infarct, mri, brain, "
 MRI Cervical Spine without contrast., Radiology, MRI Cervical Spine - 2 ,"EXAM:,MRI SPINAL CORD CERVICAL WITHOUT CONTRAST,CLINICAL:,Right arm pain, numbness and tingling.,FINDINGS:,Vertebral alignment and bone marrow signal characteristics are unremarkable. The C2-3 and C3-4 disk levels appear unremarkable.,At C4-5, broad based disk/osteophyte contacts the ventral surface of the spinal cord and may mildly indent the cord contour. A discrete cord signal abnormality is not identified. There may also be some narrowing of the neuroforamina at this level.,At C5-6, central disk-osteophyte contacts and mildly impresses on the ventral cord contour. Distinct neuroforaminal narrowing is not evident.,At C6-7, mild diffuse disk-osteophyte impresses on the ventral thecal sac and contacts the ventral cord surface. Distinct cord compression is not evident. There may be mild narrowing of the neuroforamina at his level.,A specific abnormality is not identified at the C7-T1 level.,IMPRESSION:,Disk/osteophyte at C4-5 through C6-7 with contact and may mildly indent the ventral cord contour at these levels. Some possible neuroforaminal narrowing is also noted at levels as stated above.","radiology, mri cervical spine, ventral cord contour, cervical spine, spinal cord, cord contour, ventral cord, mri, narrowing, ventral, cord"
 MRI Brain & T-spine - Demyelinating disease., Radiology, MRI Brain & T-spine - Demyelinating disease. ,"CC: ,Sensory loss.,HX: ,25y/o RHF began experiencing pruritus in the RUE, above the elbow and in the right scapular region, on 10/23/92. In addition she had paresthesias in the proximal BLE and toes of the right foot. Her symptoms resolved the following day. On 10/25/92, she awoke in the morning and her legs felt ""asleep"" with decreased sensation. The sensory loss gradually progressed rostrally to the mid chest. She felt unsteady on her feet and had difficulty ambulating. In addition she also began to experience pain in the right scapular region. She denied any heat or cold intolerance, fatigue, weight loss.,MEDS:, None.,PMH:, Unremarkable.,FHX: ,GF with CAD, otherwise unremarkable.,SHX:, Married, unemployed. 2 children. Patient was born and raised in Iowa. Denied any h/o Tobacco/ETOH/illicit drug use.,EXAM:,  BP121/66 HR77 RR14 36.5C,MS: A&O to person, place and time. Speech normal with logical lucid thought process.,CN: mild optic disk pallor OS. No RAPD. EOM full and smooth. No INO. The rest of the CN exam was unremarkable.,MOTOR: Full strength throughout all extremities except for 5/4+ hip extensors. Normal muscle tone and bulk.,Sensory: Decreased PP/LT below T4-5 on the left side down to the feet. Decreased PP/LT/VIB in BLE (left worse than right). Allodynic in RUE.,Coord: Intact FNF, HKS and RAM, bilaterally.,Station: No pronator drift. Romberg's test not documented.,Gait: Unsteady wide-based. Able to TT and HW. Poor TW.,Reflexes: 3/3 BUE. Hoffman's signs were present bilaterally. 4/4 patellae. 3+/3+ Achilles with 3-4 beat nonsustained clonus. Plantar responses were extensor on the right and flexor on the left.,Gen. Exam: Unremarkable.,COURSE:, CBC, GS, PT, PTT, ESR, FT4, TSH, ANA, Vit B12, Folate, VDRL and Urinalysis were normal. MRI T-spine, 10/27/92, was unremarkable. MRI Brain, 10/28/92, revealed multiple areas of abnormally increased signal on T2 weighted images in the white matter regions of the right corpus callosum, periventricular region, brachium pontis and right pons. The appearance of the lesions was felt to be strongly suggestive of multiple sclerosis. 10/28/92, Lumbar puncture revealed the following CSF results: RBC 1, WBC 9 (8 lymphocytes, 1 histiocyte), Glucose 55mg/dl, Protein 46mg/dl (normal 15-45), CSF IgG 7.5mg/dl (normal 0.0-6.2), CSF IgG index 1.3 (normal 0.0-0.7), agarose gel electrophoresis revealed oligoclonal bands in the gamma region which were not seen on the serum sample. Beta-2 microglobulin was unremarkable. An abnormal left tibial somatosensory evoked potential was noted consistent with central conduction slowing. Visual and Brainstem Auditory evoked potentials were normal. HTLV-1 titers were negative. CSF cultures and cytology were negative. She was not treated with medications as her symptoms were primarily sensory and non-debilitating, and she was discharged home.,She returned on 11/7/92 as her symptoms of RUE dysesthesia, lower extremity paresthesia and weakness, all worsened. On 11/6/92, she developed slow slurred speech and had marked difficulty expressing her thoughts. She also began having difficulty emptying her bladder. Her 11/7/92 exam was notable for normal vital signs, lying motionless with eyes open and nodding and rhythmically blinking every few minutes. She was oriented to place and time of day, but not to season, day of the week and she did not know who she was. She had a leftward gaze preference and right lower facial weakness. Her RLE was spastic with sustained ankle clonus. There was dysesthetic sensory perception in the RUE. Jaw jerk and glabellar sign were present.,MRI brain, 11/7/92, revealed multiple enhancing lesions in the peritrigonal region and white matter of the centrum semiovale. The right peritrigonal region is more prominent than on prior study. The left centrum semiovale lesion has less enhancement than previously. Multiple other white matter lesions are demonstrated on the right side, in the posterior limb of the internal capsule, the anterior periventricular white matter, optic radiations and cerebellum. The peritrigonal lesions on both sides have increased in size since the 10/92 MRI. The findings were felt more consistent with demyelinating disease and less likely glioma. Post-viral encephalitis, Rapidly progressive demyelinating disease and tumor were in the differential diagnosis. Lumbar Puncture, 11/8/92, revealed: RBC 2, WBC 12 (12 lymphocytes), Glucose 57, Protein 51 (elevated), cytology and cultures were negative. HIV 1 titer was negative. Urine drug screen, negative. A stereotactic brain biopsy of the right parieto-occipital region was consistent with demyelinating disease. She was treated with Decadron 6mg IV qhours and Cytoxan 0.75gm/m2 (1.25gm). On 12/3/92, she has a focal motor seizure with rhythmic jerking of the LUE, loss of consciousness and rightward eye deviation. EEG revealed diffuse slowing with frequent right-sided sharp discharges. She was placed on Dilantin. She became depressed.","radiology, sensory loss, lumbar puncture, peritrigonal region, centrum semiovale, mri brain, white matter, demyelinating disease, csf, demyelinating, mri, brain, "
 MRI Brain & MRI C-T spine: Multiple hemangioblastoma in Von Hippel Lindau Disease., Radiology, MRI Brain and C-T Spine ,"CC:, Weakness.,HX:, This 30 y/o RHM was in good health until 7/93, when he began experiencing RUE weakness and neck pain. He was initially treated by a chiropractor and, after an unspecified length of time, developed atrophy and contractures of his right hand. He then went to a local neurosurgeon and a cervical spine CT scan, 9/25/92, revealed an intramedullary lesion at C2-3 and an extramedullary lesion at C6-7. He underwent a C6-T1 laminectomy with exploration and decompression of the spinal cord. His clinical condition improved over a 3 month post-operative period, and then progressively worsened. He developed left sided paresthesia and upper extremity weakness (right worse than left). He then developed ataxia, nausea, vomiting, and hyperreflexia. On 8/31/93, MRI C-spine showed diffuse enlargement of the cervical and thoracic spine and multiple enhancing nodules in the posterior fossa. On 9/1/93, he underwent suboccipital craniotomy with tumor excision, decompression, and biopsy which was consistent with hemangioblastoma. His symptoms stabilized and he underwent 5040 cGy in 28 fractions to his brain and 3600 cGy in 20 fractions to his cervical and thoracic spinal cord from 9/93 through 1/19/94.,He was evaluated in the NeuroOncology clinic on 10/26/95 for consideration of chemotherapy. He complained of progressive proximal weakness of all four extremities and dysphagia. He had difficulty putting on his shirt and raising his arms, and he had been having increasing difficulty with manual dexterity (e.g. unable to feed himself with utensils). He had difficulty going down stairs, but could climb stairs. He had no bowel or bladder incontinence or retention.,MEDS:, none.,PMH:, see above.,FHX:, Father with Von Hippel-Lindau Disease.,SHX:, retired truck driver. smokes 1-3 packs of cigarettes per day, but denied alcohol use. He is divorced and has two sons who are healthy. He lives with his mother.,ROS:, noncontributory.,EXAM:, Vital signs were unremarkable.,MS: A&O to person, place and time. Speech fluent and without dysarthria. Thought process lucid and appropriate.,CN: unremarkable exept for 4+/4+ strength of the trapezeii. No retinal hemangioblastoma were seen.,MOTOR: 4-/4- strength in proximal and distal upper extremities. There is diffuse atrophy and claw-hands, bilaterally. He is unable to manipulate hads to any great extent. 4+/4+ strength throughout BLE. There is also diffuse atrophy throughout the lower extremities though not as pronounced as in the upper extremities.,SENSORY: There was a right T3 and left T8 cord levels to PP on the posterior thorax. Decreased LT in throughout the 4 extremities.,COORD: difficult to assess due to weakness.,Station: BUE pronator drift.,Gait: stands without assistance, but can only manage to walk a few steps. Spastic gait.,Reflexes: Hyperreflexic on left (3+) and Hyporeflexic on right (1). Babinski signs were present bilaterally.,Gen exam: unremarkable.,COURSE: ,9/8/95, GS normal. By 11/14/95, he required NGT feeding due to dysphagia and aspiration risk confirmed on cookie swallow studies.MRI Brain, 2/19/96, revealed several lesions (hemangioblastoma) in the cerebellum and brain stem. There were postoperative changes and a cyst in the medulla.,On 10/25/96, he presented with a 1.5 week h/o numbness in BLE from the mid- thighs to his toes, and worsening BLE weakness. He developed decubitus ulcers on his buttocks. He also had had intermittent urinary retention for month, chronic SOB and dysphagia. He had been sitting all day long as he could not move well and had no daytime assistance. His exam findings were consistent with his complaints. He had had no episodes of diaphoresis, headache, or elevated blood pressures. An MRI of the C-T spine, 10/26/96, revealed a prominent cervicothoracic syrinx extending down to T10. There was evidence of prior cervical laminectomy of C6-T1 with expansion of the cord in the thecalsac at that region. Multiple intradural extra spinal nodular lesions (hyperintense on T2, isointense on T1, enhanced gadolinium) were seen in the cervical spine and cisterna magna. The largest of which measures 1.1 x 1.0 x 2.0cm. There are also several large ring enhancing lesions in cerebellum. The lesions were felt to be consistent with hemangioblastoma. No surgical or medical intervention was initiated. Visiting nursing was provided. He has since been followed by his local physician", 
 Bilateral breast MRI with & without IV contrast., Radiology, MRI Breast - 1 ,"FINDINGS:,There are post biopsy changes seen in the retroareolar region, middle third aspect of the left breast at the post biopsy site.,There is abnormal enhancement seen in this location compatible with patient’s history of malignancy.,There is increased enhancement seen in the inferior aspect of the left breast at the 6:00 o’clock, N+5.5 cm position measuring 1.2 cm. Further work-up with ultrasound is indicated.,There are other multiple benign appearing enhancing masses seen in both the right and left breasts.,None of the remaining masses appear worrisome for malignancy based upon MRI criteria.,IMPRESSION:,  BIRADS CATEGORY M/5,There is a malignant appearing area of enhancement in the left breast which does correspond to the patient’s history of recent diagnosis of malignancy.,She has been scheduled to see a surgeon, as well as Medical Oncologist.,Dedicated ultrasonography of the inferior aspect of the left breast should be performed at the 6:00 o’clock, N+5.5 cm position for further evaluation of the mass. At that same time, ultrasonography of the remaining masses should also be performed.,Please note, however that the remaining masses have primarily benign features based upon MRI criteria. However, further evaluation with ultrasound should be performed.","radiology, breast cancer, bilateral breast mri, bilateral breast, iv contrast, contrast, ultrasound, ultrasonography, malignancy, mri, benign, masses, breast"
 MRI Brain and Brainstem - Falling (Multiple System Atrophy), Radiology, MRI Brain and Brainstem ,"CC:, Falling.,HX:, This 67y/o RHF was diagnosed with Parkinson's Disease in 9/1/95, by a local physician. For one year prior to the diagnosis, the patient experienced staggering gait, falls and episodes of lightheadedness. She also noticed that she was slowly ""losing"" her voice, and that her handwriting was becoming smaller and smaller. Two months prior to diagnosis, she began experienced bradykinesia, but denied any tremor. She noted no improvement on Sinemet, which was started in 9/95. At the time of presentation, 2/13/96, she continued to have problems with coordination and staggering gait. She felt weak in the morning and worse as the day progressed. She denied any fever, chills, nausea, vomiting, HA, change in vision, seizures or stroke like events, or problems with upper extremity coordination.,MEDS:, Sinemet CR 25/100 1tab TID, Lopressor 25mg qhs, Vitamin E 1tab TID, Premarin 1.25mg qd, Synthroid 0.75mg qd, Oxybutynin 2.5mg has, isocyamine 0.125mg qd.,PMH:, 1) Hysterectomy 1965. 2) Appendectomy 1950's. 3) Left CTR 1975 and Right CTR 1978. 4) Right oophorectomy 1949 for ""tumor."" 5) Bladder repair 1980 for unknown reason. 6) Hypothyroidism dx 4/94. 7) HTN since 1973.,FHX: ,Father died of MI, age 80. Mother died of MI, age73. Brother died of Brain tumor, age 9.,SHX: ,Retired employee of Champion Automotive Co.,Denies use of TOB/ETOH/Illicit drugs.,EXAM: ,BP (supine)182/113 HR (supine)94. BP (standing)161/91 HR (standing)79. RR16 36.4C.,MS: A&O to person, place and time. Speech fluent and without dysarthria. No comment regarding hypophonia.,CN: Pupils 5/5 decreasing to 2/2 on exposure to light. Disks flat. Remainder of CN exam unremarkable.,Motor: 5/5 strength throughout. NO tremor noted at rest or elicited upon movement or distraction,Sensory: Unremarkable PP/VIB testing.,Coord: Did not show sign of dysmetria, dyssynergia, or dysdiadochokinesia. There was mild decrement on finger tapping and clasping/unclasping hands (right worse than left).,Gait: Slow gait with difficulty turning on point. Difficulty initiating gait. There was reduced BUE swing on walking (right worse than left).,Station: 3-4step retropulsion.,Reflexes: 2/2 and symmetric throughout BUE and patellae. 1/1 Achilles. Plantar responses were flexor.,Gen Exam: Inremarkable. HEENT: unremarkable.,COURSE:, The patient continued Sinemet CR 25/100 1tab TID and was told to monitor orthostatic BP at home. The evaluating Neurologist became concerned that she may have Parkinsonism plus dysautonomia.,She was seen again on 5/28/96 and reported no improvement in her condition. In addition she complained of worsening lightheadedness upon standing and had an episode, 1 week prior to 5/28/96, in which she was at her kitchen table and became unable to move. There were no involuntary movements or alteration in sensorium/mental status. During the episode she recalled wanting to turn, but could not. Two weeks prior to 5/28/96 she had an episode of orthostatic syncope in which she struck her head during a fall. She discontinued Sinemet 5 days prior to 5/28/96 and felt better. She felt she was moving slower and that her micrographia had worsened. She had had recent difficulty rolling over in bed and has occasional falls when turning. She denied hypophonia, dysphagia or diplopia.,On EXAM: BP (supine)153/110 with HR 88. BP (standing)110/80 with HR 96. (+) Myerson's sign and mild hypomimia, but no hypophonia. There was normal blinking and EOM. Motor strength was full throughout. No resting tremor, but mild postural tremor present. No rigidity noted. Mild decrement on finger tapping noted. Reflexes were symmetric. No Babinski signs and no clonus. Gait was short stepped with mild anteroflexed posture. She was unable to turn on point. 3-4 step Retropulsion noted. The Parkinsonism had been unresponsive to Sinemet and she had autonomic dysfunction suggestive of Shy-Drager syndrome. It was recommended that she liberalize dietary salt use and lie with head of the bed elevate at 20-30 degrees at night. Indomethacin was suggested to improve BP in future.","radiology, myerson's sign, falling, dysautonomia, mri brain and brainstem, brain and brainstem, mri brain, sinemet cr, mri, brainstem, ctr, tumor, retropulsion, parkinsonism, brain, lightheadedness, hypophonia, standing, sinemet, "
 MRI brain & Cerebral Angiogram: CNS Vasculitis with evidence of ischemic infarction in the right and left frontal lobes., Radiology, MRI Brain & Cerebral Angiogram ,"CC:, Difficulty with word finding.,HX: ,This 27y/o RHF experienced sudden onset word finding difficulty and slurred speech on the evening of 2/19/96. She denied any associated dysphagia, diplopia, numbness or weakness of her extremities. She went to sleep with her symptoms on 2/19/96, and awoke with them on 2/20/96. She also awoke with a headache (HA) and mild neck stiffness. She took a shower and her HA and neck stiffness resolved. Throughout the day she continued to have difficulty with word finding and had worsening of her slurred speech. That evening, she began to experience numbness and weakness in the lower right face. She felt like there was a ""rubber-band"" wrapped around her tongue.,For 3 weeks prior to presentation, she experienced transient episodes of a ""boomerang"" shaped field cut in the left eye. The episodes were not associated with any other symptoms. One week prior to presentation, she went to a local ER for menorrhagia. She had just resumed taking oral birth control pills one week prior to the ER visit after having stopped their use for several months. Local evaluation included an unremarkable carotid duplex scan. However, a HCT with and without contrast reportedly revealed a left frontal gyriform enhancing lesion. An MRI brain scan on 2/20/96 revealed nonspecific white matter changes in the right periventricular region. EEG reportedly showed diffuse slowing. CRP was reportedly ""too high"" to calibrate.,MEDS:, Ortho-Novum 7-7-7 (started 2/3/96), and ASA (started 2/20/96).,PMH:, 1)ventral hernia repair 10 years ago, 2)mild ""concussion"" suffered during a MVA; without loss of consciousness, 5/93, 3) Anxiety disorder, 4) One childbirth.,FHX: ,She did not know her father and was not in contact with her mother.,SHX:, Lives with boyfriend. Smokes one pack of cigarettes every three days and has done so for 10 years. Consumes 6 bottles of beers, one day a week. Unemployed and formerly worked at an herbicide plant.,EXAM: ,BP150/79, HR77, RR22, 37.4C.,MS: A&O to person, place and time. Speech was dysarthric with mild decreased fluency marked by occasional phonemic paraphasic errors. Comprehension, naming and reading were intact. She was able to repeat, though her repetition was occasionally marked by phonemic paraphasic errors. She had no difficulty with calculation.,CN: VFFTC, Pupils 5/5 decreasing to 3/3. EOM intact. No papilledema or hemorrhages seen on fundoscopy. No RAPD or INO. There was right lower facial weakness. Facial sensation was intact, bilaterally. The rest of the CN exam was unremarkable.,MOTOR: 5/5 strength throughout with normal muscle bulk and tone.,Sensory: No deficits.,Coord/Station/Gait: unremarkable.,Reflexes 2/2 throughout. Plantar responses were flexor, bilaterally.,Gen Exam: unremarkable.,COURSE:, CRP 1.2 (elevated), ESR 10, RF 20, ANA 1:40, ANCA <1:40, TSH 2.0, FT4 1.73, Anticardiolipin antibody IgM 10.8GPL units (normal <10.9), Anticardiolipin antibody IgG 14.8GPL (normal<22.9), SSA and SSB were normal. Urine beta-hCG pregnancy and drug screen were negative. EKG, CXR and UA were negative.,MRI brain, 2/21/96 revealed increased signal on T2 imaging in the periventricular white matter region of the right hemisphere. In addition, there were subtle T2 signal changes in the right frontal, right parietal, and left parietal regions as seen previously on her local MRI can. In addition, special FLAIR imaging showed increased signal in the right frontal region consistent with ischemia.,She underwent Cerebral Angiography on 2/22/96. This revealed decreased flow and vessel narrowing the candelabra branches of the RMCA supplying the right frontal lobe. These changes corresponded to the areas of ischemic changes seen on MRI. There was also segmental narrowing of the caliber of the vessels in the circle of Willis. There was a small aneurysm at the origin of the LPCA. There was narrowing in the supraclinoid portion of the RICA and the proximal M1 and A1 segments. The study was highly suggestive of vasculitis.,2/23/96, Neuro-ophthalmology evaluation revealed no evidence of retinal vasculitic change. Neuropsychologic testing the same day revealed slight impairment of complex attention only. She was started on Prednisone 60mg qd and Tagamet 400mg qhs.,On 2/26/96, she underwent a right frontal brain biopsy. Pathologic evaluation revealed evidence of focal necrosis (stroke/infarct), but no evidence of vasculitis. Immediately following the brain biopsy, while still in the recovery room, she experienced sudden onset right hemiparesis and transcortical motor type aphasia. Initial HCT was unremarkable. An EEG was consistent with a focal lesion in the left hemisphere. However, a 2/28/96 MRI brain scan revealed new increased signal on T2 weighted images in a gyriform pattern from the left precentral gyrus to the superior frontal gyrus. This was felt consistent with vasculitis.,She began q2month cycles of Cytoxan (1,575mg IV on 2/29/96. She became pregnant after her 4th cycle of Cytoxan, despite warnings to the contrary. After extensive discussions with OB/GYN it was recommended she abort the pregnancy. She underwent neuropsychologic testing which revealed no significant cognitive deficits. She later agreed to the abortion. She has undergone 9 cycles of Cytoxan ( one cycle every 2 months) as of 4/97. She had complained of one episode of paresthesias of the LUE in 1/97. MRI then showed no new signs ischemia.", 
 MRI Brain: Thrombus in torcula of venous sinuses., Radiology, MRI Brain - Thrombus ,"CC: ,Motor vehicle-bicycle collision.,HX:, A 5 y/o boy admitted 10/17/92. He was struck while riding his bicycle by a motor vehicle traveling at a high rate of speed. First responders found him unconscious with left pupil 6 mm and unreactive and the right pupil 3 mm and reactive. He had bilateral decorticate posturing and was bleeding profusely from his nose and mouth. He was intubated and ventilated in the field, and then transferred to UIHC.,PMH/FHX/SHX:, unremarkable.,MEDS:, none,EXAM:, BP 127/91 HR69 RR30,MS: unconscious and intubated,Glasgow coma scale=4,CN: Pupils 6/6 fixed. Corneal reflex: trace OD, absent OS. Gag present on manipulation of endotracheal tube.,MOTOR/SENSORY: bilateral decorticate posturing to noxious stimulation (chest).,Reflexes: bilaterally.,Laceration of mid forehead exposing calvarium.,COURSE:, Emergent Brain CT scan revealed: Displaced fracture of left calvarium. Left frontoparietal intraparenchymal hemorrhage. Right ventricular collection of blood. Right cerebral intraparenchymal hemorrhage. Significant mass effect with deviation of the midline structures to right. The left ventricle was compressed with obliteration of the suprasellar cistern. Air within the soft tissues in the left infra temporal region. C-spine XR, Abdominal/Chest CT were unremarkable.,Patient was taken to the OR emergently and underwent bifrontal craniotomy, evacuation of a small epidural and subdural hematomas, and duraplasty. He was given mannitol enroute to the OR and hyperventilated during and after the procedure. Postoperatively he continued to manifest decerebrate posturing . On 11/16/92 he underwent VP shunting with little subsequent change in his neurological status. On 11/23/92 he underwent tracheostomy. On 12/11/92 he underwent bifrontal acrylic prosthesis implantation for repair of the bifrontal craniectomy. By the time of discharge, 1/14/93, he tracked relatively well OD, but had a CN3 palsy OS. He had relatively severe extensor rigidity in all extremities (R>L). His tracheotomy was closed prior to discharge. A 11/16/92 Brain MRI demonstrated infarction in the upper brain stem (particularly in the Pons), left cerebellum, right basil ganglia and thalamus.,He was initially treated for seizure prophylaxis with DPH, but developed neutropenia, so it was discontinued. He developed seizures within several months of discharge and was placed on VPA (Depakene). This decreased seizure frequency but his liver enzymes became elevated and he changed over to Tegretol. 10/8/93 Brain MRI (one year after MVA) revealed interval appearance of hydrocephalus, abnormal increased T2 signal (in the medulla, right pons, both basal ganglia, right frontal and left occipital regions), a small mid-brain, and a right subdural fluid collection. These findings were consistent with diffuse axonal injury of the white matter and gray matter contusion, and signs of a previous right subdural hematoma.,He was last seen 10/30/96 in the pediatric neurology clinic--age 9 years. He was averaging 2-3 seizures per day---characterized by extension of BUE with tremor and audible cry or laughter---on Tegretol and Diazepam. In addition he experiences 24-48hour periods of ""startle response (myoclonic movement of the shoulders)"" with or without stimulation every 6 weeks. He had limited communication skills (sparse speech). On exam he had disconjugate gaze, dilated/fixed left pupil, spastic quadriplegia.","radiology, mri brain, brain mri, thrombus, intraparenchymal hemorrhage, motor vehicle, prophylaxis, sinuses, torcula venous sinuses, venous, brain thrombus, bilateral decorticate, decorticate posturing, subdural hematomas, subdural, mri, brain, torcula"
" MRI Brain: Left Basal Ganglia, Posterior temporal lobe, and Left cerebellar (lacunar) infarctions with Wernickes Aphasia.", Radiology, MRI Brain - Wernicke aphasia ,"CC: ,Difficulty with speech.,HX:, This 72 y/o RHM awoke early on 8/14/95 to prepare to play golf. He felt fine. However, at 6:00AM, on 8/14/95, he began speaking abnormally. His wife described his speech as ""word salad"" and ""complete gibberish."" She immediately took him to a local hospital . Enroute, he was initially able to understand what was spoken to him. By the time he arrived at the hospital at 6:45AM, he was unable to follow commands. His speech was reportedly unintelligible the majority of the time, and some of the health care workers thought he was speaking a foreign language. There were no other symptoms or signs. He had no prior history of cerebrovascular disease. Blood pressure 130/70 and Pulse 82 upon admission to the local hospital on 8/14/95.,Evaluation at the local hospital included: 1)HCT scan revealed an old left putaminal hypodensity, but no acute changes or evidence of hemorrhage, 2) Carotid Duplex scan showed ICA stenosis of 40%, bilaterally. He was placed on heparin and transferred to UIHC on 8/16/95.,In addition, he had noted memory and word finding difficulty for 2 months prior to presentation. He had undergone a gastrectomy 16 years prior for peptic ulcer disease. His local physician found him vitamin B12 deficient and he was placed on vitamin B12 and folate supplementation 2 months prior to presentation. He and his wife felt that this resulted in improvement of his language and cognitive skills.,MEDS:, Heparin IV, Vitamin B12 injection q. week, Lopressor, Folate, MVI.,PMH:, 1)Hypothyroidism (reportedly resolved), 2) Gastrectomy, 3)Vitamin B12 deficiency.,FHX: ,Mother died of MI, age 70. Father died of prostate cancer, age 80. Bother died of CAD and prostate cancer, age 74.,SHX:, Married. 3 children who are alive and well. Semi-retired Attorney. Denied h/o tobacco/ETOH/illicit drug use.,EXAM:, BP 110/70, HR 50, RR 14, Afebrile.,MS: A&O to person and place, but not time. Oral comprehension was poor beyond the simplest of conversational phrases. Speech was fluent, but consisted largely of ""word salad."" When asked how he was, he replied: ""abadeedleedlebadle."" Repetition was defective, especially with long phrases. On rare occasions, he uttered short comments appropriately. Speech was marred by semantic and phonemic paraphasias. He named colors and described most actions well, although he described a ""faucet dripping"" as a ""faucet drop."" He called ""red"" ""reed."" Reading comprehension was better than aural comprehension. He demonstrated excellent written calculations. Spoken calculations were accurate except when the calculations became more complex. For example, he said that ten percent of 100 was equal to ""1,200."",CN: Pupils 2/3 decreasing to 1/1 on exposure to light. VFFTC. There were no field cuts or evidence of visual neglect. EOM were intact. Face moved symmetrically. The rest of the CN exam was unremarkable.,MOTOR: Full strength throughout with normal muscle tone and bulk. There was no evidence of drift.,SENSORY: unremarkable.,COORD: unremarkable.,Station: unremarkable. Gait: mild difficulty with TW.,Reflexes: 2/2 in BUE. 2/2+ patellae, 1/1 Achilles. Plantar responses were flexor on the left and equivocal on the right.,Gen Exam: unremarkable.,COURSE:, Lab data on admission: Glucose 97, BUN 20, Na 134, K 4.0, Cr 1.3, Chloride 98, CO2 24, PT 11, PTT 42, WBC 12.0 (normal differential), Hgb 11.4, Hct 36%, Plt=203k. UA normal. TSH 6.0, FT4 0.88, Vit B12 876, Folate 19.1. He was admitted and continued on heparin. MRI scan, 8/16/95, revealed increased signal on T2-weighted images in Wernicke's area in the left temporal region. Transthoracic echocardiogram on 8/17/95 was unremarkable. Transesophageal echocardiogram on 8/18/95 revealed a sclerotic aortic valve and myxomatous degeneration of the anterior leaflet of the mitral valve. LAE 4.8cm, and spontaneous echo contrast in the left atrium were noted. There was no evidence of intracardiac shunt or clot. Carotid duplex scan on 8/16/95 revealed 0-15% BICA stenosis with anterograde vertebral artery flow, bilaterally. Neuropsychologic testing revealed a Wernicke's aphasia.,The impression was that the patient had had a cardioembolic stroke involving a lower-division branch of the left MCA. He was subsequently placed on warfarin. Thoughout his hospital stay he showed continued improvement of language skills and was enrolled in speech therapy following discharge, 8/21/95.,He has had no further stroke like episodes up until his last follow-up visit in 1997.","radiology, mri brain, difficulty with speech, left basal ganglia, posterior temporal lobe, wernicke's area, wernickes aphasia, cerebellar, infarctions, lacunar, word finding difficulty, carotid duplex scan, aphasia, wernicke's, mri, brain, "
 MRI Brain - Right frontal white matter infarct in patient with Anticardiolipin antibody syndrome and SLE., Radiology, MRI Brain - SLE & Stroke ,"CC:, Episodic monocular blindness, OS.,HX:, This 29 y/o RHF was in her usual healthy state until 2 months prior to her 3/11/96 presentation when she developed episodic arthralgias of her knees and ankles, bilaterally. On 3/3/96, she experienced sudden onset monocular blindness, OS, lasting 5-10 minutes in duration. Her vision ""greyed out"" from the periphery to center of her visual field, OS; and during some episodes progressed to complete blindness (not even light perception). This resolved within a few minutes. She had multiple episodes of vision loss, OS, every day until 3/7/96 when she was placed on heparin for suspected LICA dissection. She saw a local ophthalmologist on 3/4/96 and was told she had a normal funduscopic exam. She experienced 0-1 spell of blindness (OS) per day from 3/7/96 to 3/11/96. In addition, she complained of difficulty with memory since 3/7/96. She denied dysarthria, aphasia or confusion, but had occasional posterior neck and bioccipital-bitemporal headaches.,She had no history of deep venous or arterial thrombosis.,3/4/96, ESR=123. HCT with and without contrast on 3/7/96 and 3/11/96, and Carotid Duplex scan were ""unremarkable."" Rheumatoid factor=normal. 3-vessel cerebral angiogram (done locally) was reportedly ""unremarkable."",She was thought to have temporal arteritis and underwent Temporal Artery biopsy (which was unremarkable), She received Prednisone 80 mg qd for 2 days prior to presentation.,On admission she complained of a left temporal headache at the biopsy site, but no loss of vision or weakness,She had been experiencing mild fevers and chills for several weeks prior to presentation. Furthermore, she had developed cyanosis of the distal #3 toes on feet, and numbness and rash on the lateral aspect of her left foot. She developed a malar rash on her face 1-2 weeks prior to presentation.,MEDS:, Depo-Provera, Prednisone 80mg qd, and Heparin IV.,PMH:, 1)Headaches for 3-4 years, 2)Heart murmur, 3) cryosurgery of cervix, 4)tonsillectomy and adenoidectomy, 5) elective abortion. She had no history of spontaneous miscarriage and had used oral birth control pill for 10 years prior to presentation.,FHX:, Migraine headaches on maternal side, including her mother. No family history of thrombosis.,SHX:, works as a metal grinder and was engaged to be married. She denied any tobacco or illicit drug use. She consumed 1 alcoholic drink per month.,EXAM: ,BP147/74, HR103, RR14, 37.5C.,MS: A&O to person, place and time. Speech was fluent without dysarthria. Repetition, naming and comprehension were intact. 2/3 recall at 2 minutes.,CN: unremarkable.,Motor: unremarkable.,Coord: unremarkable.,Sensory: decreased LT, PP, TEMP, along the lateral aspect of the left foot.,Gait: narrow-based and able to TT, HW and TW without difficulty.,Station: unremarkable.,Reflexes: 2/2 throughout. Plantar responses were flexor, bilaterally.,Skin: Cyanosis of the distal #3 toes on both feet. There was a reticular rash about the lateral aspect of her left foot. There were splinter-type hemorrhages under the fingernails of both hands.,COURSE: ,  ESR=108 (elevated), Hgb 11.3, Hct 33%, WBC 10.0, Plt 148k, MCV 92 (low) Cr 1.3, BUN 26, CXR and EKG were unremarkable. PTT 42 (elevated). PT normal. The rest of the GS and CBC were normal. Dilute Russell Viper venom time was elevated at 27 and a 1:1 prothrombin time mix corrected to only 36.,She was admitted to the Neurology service. Blood cultures were drawn and were negative. Transthoracic and transesophageal echocardiography on 3/12/96 was unremarkable.,Her symptoms and elevated PTT suggested an ischemic syndrome involving anticardiolipin antibody and/or lupus anticoagulant. Her signs of rash and cyanosis suggested SLE. ANA was positive at 1:640 (speckled), RF (negative), dsDNA, 443 (elevated). Serum cryoglobulins were positive at 1% (fractionation data lost). Serum RPR was positive, but FTA-ABS was negative (thereby confirming a false-positive RPR). Anticardiolipin antibodies IgM and IgG were positive at 56.1 and 56.3 respectively. Myeloperoxidase antibody was negative, ANCA was negative and hepatitis screen unremarkable.,The Dermatology Service felt the patient's reticular foot rash was livedo reticularis. Rheumatology felt the patient met criteria for SLE. Hematology felt the patient met criteria for Anticardiolipin Antibody and/or Lupus anticoagulant Syndrome. Neurology felt the episodic blindness was secondary to thromboembolic events.,Serum Iron studies revealed: FeSat 6, Serum Fe 15, TIBC 237, Reticulocyte count 108.5. The patient was placed on FeSO4 225mg tid.,She was continued on heparin IV, but despite this she continued to have occasional episodes of left monocular blindness or ""gray outs"" up to 5 times per day. She was seen by the Neuro-ophthalmology Service. The did not think she had evidence of vasculitis in her eye. They recommended treatment with ASA 325mg bid. She was placed on this 3/15/96 and tapered off heparin. She continued to have 0-4 episodes of monocular blindness (OS) for 5-10 seconds per episodes. She was discharged home.,She returned 3/29/96 for episodic diplopia lasting 5-10 minutes per episode. The episodes began on 3/27/96. During the episodes her left eye deviated laterally while the right eye remained in primary gaze. She had no prior history of diplopia or strabismus. Hgb 10.1, Hct 30%, WBC 5.2, MCV 89 (low), Plt 234k. ESR 113mm/hr. PT 12, PTT 45 (high). HCT normal. MRI brain, 3/30/96, revealed a area of increased signal on T2 weighted images in the right frontal lobe white matter. This was felt to represent a thromboembolic event. She was place on heparin IV and treated with Solu-Medrol 125mg IV q12 hours. ASA was discontinued. Hematology, Rheumatology and Neurology agreed to place her on Warfarin. She was placed on Prednisone 60mg qd following the Solu-Medrol. She continued to have transient diplopia and mild vertigo despite INR's of 2.0-2.2. ASA 81mg qd was added to her regimen. In addition, Rheumatology recommended Plaquenil 200mg bid. The neurologic symptoms decreased gradually over the ensuing 3 days. Warfarin was increased to achieve INR 2.5-3.5.,She reported no residual symptoms or new neurologic events on her 5/3/96 Neurology Clinic follow-up visit. She continues to be event free on Warfarin according to her Hematology Clinic notes up to 12/96.",
 Right pontine pyramidal tract infarct., Radiology, MRI Brain - Pontine Stroke ,"CC:, Left sided weakness.,HX:, 74 y/o RHF awoke from a nap at 11:00 AM on 11/22/92 and felt weak on her left side. She required support on that side to ambulate. In addition, she felt spoke as though she ""was drunk."" Nevertheless, she was able to comprehend what was being spoken around her. Her difficulty with speech completely resolved by 12:00 noon. She was brought to UIHC ETC at 8:30AM on 11/23/92 for evaluation.,MEDS:, none. ,ALLERGIES:,  ASA/ PCN both cause rash.,PMH:, 1)?HTN. 2)COPD. 3)h/o hepatitis (unknown type). 4)Macular degeneration.,SHX:, Widowed; lives alone. Denied ETOH/Tobacco/illicit drug use.,FHX:, unremarkable.,EXAM: , BP191/89 HR68 RR16 37.2C,MS: A & O to person, place and time. Speech fluent; without dysarthria. Intact naming, comprehension, and repetition.,CN: Central scotoma, OS (old). Mild upper lid ptosis, OD (old per picture). Lower left facial weakness.,Motor: Mild Left hemiparesis (4+ to 5- strength throughout affected side). No mention of muscle tone in chart.,Sensory: unremarkable.,Coord: impaired FNF and HKS movement secondary to weakness.,Station: Left pronator drift. No Romberg sign seen.,Gait: Left hemiparetic gait with decreased LUE swing.,Reflexes: 3/3+ biceps and triceps. 3/3+ patellae. 2/3+ ankles with 3-4beats of non-sustained ankle clonus on left. Plantars: Left babinski sign; and flexor on right.,General Exam: 2/6 SEM at left sternal border.,COURSE:, GS, CBC, PT, PTT, CK, ESR were within normal limits. ABC 7.4/46/63 on room air. EKG showed a sinus rhythm with right bundle branch block. MRI brain, 11/23/95, revealed a right pontine pyramidal tract infarction. She was treated with Ticlopidine 250mg bid. On 11/26/92, her left hemiparesis worsened. A HCT, 11/27/92, was unremarkable. The patient was treated with IV Heparin. This was discontinued the following day when her strength returned to that noted on 11/23/95. On 11/27/92, she developed angina and was ruled out for MI by serial EKG and cardiac enzyme studies. Carotid duplex showed 0-15% bilateral ICA stenosis and antegrade vertebral artery flow bilaterally. Transthoracic echocardiogram revealed aortic insufficiency only. Transesophageal echocardiogram revealed trivial mitral and tricuspid regurgitation, aortic valvular fibrosis. There was calcification and possible thrombus seen in the descending aorta. Cardiology did not feel the later was an indication for anticoagulation. She was discharged home on Isordil 20 tid, Metoprolol 25mg q12hours, and Ticlid 250mg bid.","radiology, mri brain, pontine stroke, difficulty with speech, hemiparesis, pontine pyramidal tract infarct, weakness, mri, brain, pyramidal, echocardiogram, pontine, infarct, "
 A middle-aged female with memory loss., Radiology, MRI Brain - Memory Loss ,"FINDINGS:,There is moderate to severe generalized neuronal loss of the cerebral hemispheres with moderate to severe ventricular enlargement and prominent CSF within the subarachnoid spaces. There is confluent white matter hyperintensity in a bi-hemispherical centrum semiovale distribution extending to the lateral ventricles consistent with severe vasculopathic small vessel disease and extensive white matter ischemic changes. There is normal enhancement of the dural sinuses and cortical veins and there are no enhancing intra-axial or extraaxial mass lesions. There is a cavum velum interpositum (normal variant).,There is a linear area of T1 hypointensity becoming hyperintense on T2 images in a left para-atrial trigonal region representing either a remote lacunar infarction or prominent perivascular space.,Normal basal ganglia and thalami. Normal internal and external capsules. Normal midbrain.,There is amorphus hyperintensity of the basis pontis consistent with vasculopathic small vessel disease. There are areas of T2 hyperintensity involving the bilateral brachium pontis (left greater than right) with no enhancement following gadolinium augmentation most compatible with areas of chronic white matter ischemic changes. The area of white matter signal alteration in the left brachium pontis is of some concern in that is has a round morphology. Interval reassessment of this lesion is recommended.,There is a remote lacunar infarction of the right cerebellar hemisphere. Normal left cerebellar hemisphere and vermis.,There is increased CSF within the sella turcica and mild flattening of the pituitary gland but no sellar enlargement. There is elongation of the basilar artery elevating the mammary bodies but no dolichoectasia of the basilar artery.,Normal flow within the carotid arteries and circle of Willis.,Normal calvarium, central skull base and temporal bones.  There is no demonstrated calvarium metastases.,IMPRESSION:,Severe generalized cerebral atrophy.,Extensive chronic white matter ischemic changes in a bi-hemispheric centrum semiovale distribution with involvement of the basis pontis and probable bilateral brachium pontis. The area of white matter hyperintensity in the left brachium pontis is of some concern is that it has a round morphology but no enhancement following gadolinium augmentation. Interval reassessment of this lesion is recommended.,Remote lacunar infarction in the right cerebellar hemisphere.,Linear signal alteration of the left periatrial trigonal region representing either a prominent vascular space or,lacunar infarction.,No demonstrated calvarial metastases.","radiology, white matter ischemic, remote lacunar infarction, memory loss, matter ischemic, remote lacunar, cerebellar hemisphere, lacunar infarction, brachium pontis, white matter, basilar, calvarium, ischemic, enhancement, cerebellar, hemispheres, hyperintensity, infarction, brachium,"
 A middle-aged male with increasing memory loss and history of Lyme disease., Radiology, MRI Brain - Lyme Disease ,"FINDINGS:,There is a large intrasellar mass lesion producing diffuse expansion of the sella turcica. This mass lesions measures approximately 16 x 18 x 18mm (craniocaudal x AP x mediolateral) in size.","radiology, increasing memory loss, intrasellar mass lesion, memory loss, sella turcica, cavernous sinus, sphenoid sinus, ct imaging, white matter, retention cyst, maxillary antrum, lyme disease, mass lesion, disease, cavernous, cortical, mass, lesion,"
 MRI brain (Atrophy Left fronto-temporal lobe) and HCT (Left frontal SDH), Radiology, MRI Brain - Progressive Aphasia ,"CC: ,Fall with subsequent nausea and vomiting.,HX: ,This 52 y/o RHM initailly presented in 10/94 with a two year hisotry of gradual progressive difficulty with speech. He ""knew what he wanted to say, but could not say it."",His speech was slurred and he found it difficult to control his tongue. Examination at that time was notable for phonemic paraphasic errors, fair repetition of short phrases with decreased fluency, and slurred nasal speech. He could read, but could not write. He exhibited facial-limb apraxia, decreased gag reflex and positive grasp reflex. He was thougth to have possible Pick's disease vs. Cortical Basal Ganglia Degeneration.,On 11/18/94, he fell and was seen in Neurology clinic on 11/23/94. EEG showed borderline background slowing and no other abnormalities. An MRI on 11/8/94, revealed mild atrophy of the left temporal lobe. Neuropsychological evaluations were obtained on 10/25/94 and 11/8/94. These were consistent with progressive aphasia and apraxia with relative sparing of nonverbal reasoning.,He reported consuming 8 beers on the evening of 1/1/95. On 1/2/95, at 9:30AM, he fell forward while stading in his kitchen and struck his forehead on the counter top, and then struck his occiput on the floor. He subsequently developed nausea and vomiting, tinnitus, vertigo, headache and mild shortness of breath. He was taken to the ETC at UIHC. Skull films were negative and he was treated with IV Compazine and IV fluid hydration and sent home. His nausea and vomiting persisted and he became generally weak. He returned to the ETC at UIHC on 1/5/95. HCT scan revealed a right frontal SDH containing signs of both chronic and acute bleeding.,MEDS:, None.,PMH:, 1)fell in 1990 from 15 feet up and landed on his feet sustaining crush injury to both feet and ankles. He reportedly had brief loss of consciousness with no reported head injury.,2)Progressive aphasia. In 10/93, he was able to draw blue prints and write checks for his family business, 3) Left frontoparietal headache for 1.5 years prior to 10/94. Headaches continue to occur once a week, 4)right ankle fusion 4/94, right ankle fusion pending at present.,FHX:, No neurologic disease in family.,SHX:, Divorced and lives with girlfriend. One child by current girlfriend. He has 3 children with former wife. Smoked more than 15 years ago. Drinks 1-2 beers/day. Former Iron worker.,EXAM: ,BP128/83, HR68, RR18, 36.5C. Supine: BP142/71, HR64; Sitting: BP127/73, HR91 and lightheaded.,MS: Appeared moderately distressed and persistently held his forehead. A&O to person, place and time. Dysarthric and dysphagic. Non-fluent speech and able to say single syllable words such as ""up"" or ""down"". He comprehended speech, but could not repeat or write.,CN: Pupils 4/3.5 decreasing to 2/2 on exposure to light. EOM were full and smooth. Optic disks were flat and without sign of hemorrhage. Moderate facial apraxia, but had intact facial sensation.,Motor: 5/5 strength with normal muscle bulk and tone.,Sensory: no abnormalities noted.,Coord: Decreased RAM in the RUE. He had difficulty mmicking movements and postures with his RUE,Gait: ND.,Station: No truncal ataxia, but he had a slight RUE upward drift.,Reflexes 2/2 BUE, 2+/2+ patellae, 2/2 archilles, and plantar responses were flexor, bilaterally.,Rectal exam was unremarkable. The rest of the General Physical exam was unremarkable.,HEENT: atraumatic normocephalic skull. No carotid bruitts.,COURSE:, PT, PTT, CBC, GS, UA and Skull XR were negative. HCT brain, revealed a left frontal SDH with acute and cronic componenets.,He was markedly orthostatic during the first few days of his hospital stay. He was given a 3 day trial of Florinef, which showed mild to moderate improvement of his symptoms of lightheadedness. This improved still further with a trial of Sigvaris pressure stockings. A second HCT was obtained on 12/10/94 and revealed decreased intensity and sized of the left frontal SDH. He was discharged home.,His ideomotor apraxia worsened by 1/96. He developed seizures and was treated with CBZ. He progressively worsened and his overall condition was marked by aphasia, dysphagia, apraxia, and rigidity. He was last seen in 10/96 and the working diagnosis was CBGD vs. Pick's Disease.",
 MRI Brain: Probable CNS Lymphoma v/s toxoplasmosis in a patient with AIDS/HIV., Radiology, MRI Brain - Toxoplasmosis ,"CC:, Lethargy.,HX:, This 28y/o RHM was admitted to a local hospital on 7/14/95 for marked lethargy. He had been complaining of intermittent headaches and was noted to have subtle changes in personality for two weeks prior to 7/14/95. On the morning of 7/14/95, his partner found him markedly lethargic and complaingin of abdominal pain and vomiting. He denied fevers, chills, sweats, cough, CP, SOB or diarrhea. Upon evaluation locally, he had a temperature of 99.5F and appeared lethargic. He also had anisocoria with left pupil 0.5mm bigger than the right. There was also question of left facial weakness. An MRI was obtained and revealed a large left hemispheric mass lesion with surrounding edema and mass effect. He was given 10mg of IV Decardron,100gm of IV Mannitol, intubated and hyperventilated and transferred to UIHC.,He was admitted to the Department of Medicine on 7/14/95, and transferred to the Department of Neurology on 7/17/95, after being extubated.,MEDS ON ADMISSION:, Bactrim DS qd, Diflucan 100mg qd, Acyclovir 400mg bid, Xanax, Stavudine 40mg bid, Rifabutin 300mg qd.,PMH:, 1) surgical correction of pyoloric stenosis, age 1, 2)appendectomy, 3) HIV/AIDS dx 1991. He was initially treated with AZT, then DDI. He developed chronic diarrhea and was switched to D4T in 1/95. However, he developed severe neuropathy and this was stopped 4/95. The diarrhea recured. He has Acyclovir resistant genital herpes and generalized psoriasis. He most recent CD4 count (within 1 month of admission) was 20.,FHX:, HTN and multiple malignancies of unknown type.,SHX:, Homosexual, in monogamous relationship with an HIV infected partner for the past 3 years.,EXAM: ,7/14/95 (by Internal Medicine): BP134/80, HR118, RR16 on vent, 38.2C, Intubated.,MS: Somnolent, but opened eyes to loud voices and would follow most commands.,CN: Pupils 2.5/3.0 and ""equally reactive to light."" Mild horizontal nystagmus on rightward gaze. EOM were otherwise intact.,MOTOR: Moved 4 extremities well.,Sensory/Coord/Gait/Station/Reflexes: not done.,Gen EXAM: Penil ulcerations.,EXAM:, 7/17/96 (by Neurology): BP144/73, HR59, RR20, 36.0, extubated.,MS: Alert and mildly lethargic. Oriented to name only. Thought he was a local hospital and that it was 1/17/1994. Did not understand he had a brain lesion.,CN: Pupils 6/5.5 decreasing to 4/4 on exposure to light. EOM were full and smooth. No RAPD or light-near dissociation. papilledema (OU). Right lower facial weakness and intact facial sensation to PP testing. Gag-shrug and corneal responses were intact, bilaterally. Tongue midline.,MOTOR: Grade 5- strength on the right side.,Sensory: no loss of sensation on PP/VIB/PROP testing.,Coord: reduced speed and accuracy on right FNF and right HKS movements.,Station: RUE pronator drift.,Gait: not done.,Reflexes: 2+/2 throughout. Babinski sign present on right and absent on left.,Gen Exam: unremarkable except for the genital lesion noted by Internal medicine.,COURSE:, The outside MRI was reviewed and was notable for the left frontal/parietal mass lesion with surround edema. The mass inhomogenously enhanced with gadolinium contrast.,The findings were consistent most with lymphoma, though toxoplasmosis could not be excluded. He refused brain biopsy and was started on empiric treatment for toxoplasmosis. This consisted of Pyrimethamine 75mg qd and Sulfadiazine 2 g bid. He later became DNR and was transferred at his and his partner's request Back to a local hospital.,He never returned for follow-up.",
 MRI Brain to evaluate sudden onset blindness - Basilar/bilateral thalamic strokes., Radiology, MRI Brain - Bilateral Thalamic Strokes ,"CC:, Sudden onset blindness.,HX:, This 58 y/o RHF was in her usual healthy state, until 4:00PM, 1/8/93, when she suddenly became blind. Tongue numbness and slurred speech occurred simultaneously with the loss of vision. The vision transiently improved to ""severe blurring"" enroute to a local ER, but worsened again once there. While being evaluated she became unresponsive, even to deep noxious stimuli. She was transferred to UIHC for further evaluation. Upon arrival at UIHC her signs and symptoms were present but markedly improved.,PMH:, 1) Hysterectomy many years previous. 2) Herniorrhaphy in past. 3) DJD, relieved with NSAIDs.,FHX/SHX:, Married x 27yrs. Husband denied Tobacco/ETOH/illicit drug use for her.,Unremarkable FHx.,MEDS:, none.,EXAM:, Vitals: 36.9C.  HR 93.  BP 151/93.  RR 22.  98% O2Sat.,MS: somnolent, but arousable to verbal stimulation. minimal speech. followed simple commands on occasion.,CN: Blinked to threat from all directions. EOM appeared full, Pupils 2/2 decreasing to 1/1. +/+Corneas. Winced to PP in all areas of Face. +/+Gag. Tongue midline. Oculocephalic reflex intact.,Motor: UE 4/5 proximally. Full strength in all other areas. Normal tone and muscle bulk.,Sensory: Withdrew to PP in all extremities.,Gait: ND.,Reflexes: 2+/2+ throughout UE, 3/3 patella, 2/2 ankles, Plantar responses were flexor bilaterally.,Gen exam: unremarkable.,COURSE: ,MRI Brain revealed bilateral thalamic strokes. Transthoracic echocardiogram (TTE) showed an intraatrial septal aneurysm with right to left shunt. Transesophageal echocardiogram (TEE) revealed the same. No intracardiac thrombus was found. Lower extremity dopplers were unremarkable. Carotid duplex revealed 0-15% bilateral ICA stenosis. Neuroophthalmologic evaluation revealed evidence of a supranuclear vertical gaze palsy OU (diminished up and down gaze). Neuropsychologic assessment 1/12-15/93 revealed severe impairment of anterograde verbal and visual memory, including acquisition and delayed recall and recognition. Speech was effortful and hypophonic with very defective verbal associative fluency. Reading comprehension was somewhat preserved, though she complained that despite the ability to see type clearly, she could not make sense of words. There was impairment of 2-D constructional praxis. A follow-up Neuropsychology evaluation in 7/93 revealed little improvement. Laboratory studies, TSH, FT4, CRP, ESR, GS, PT/PTT were unremarkable. Total serum cholesterol 195, Triglycerides 57, HDL 43, LDL 141. She was placed on ASA and discharged1/19/93.,She was last seen on 5/2/95 and was speaking fluently and lucidly. She continued to have mild decreased vertical eye movements. Coordination and strength testing were fairly unremarkable. She continues to take ASA 325 mg qd.","radiology, blindness, mri, transthoracic echocardiogram, transesophageal echocardiogram, tsh, ft4, crp, esr, gs, pt/ptt, bilateral thalamic strokes, sudden onset blindness, mri brain, thalamic strokes, brain, thalamic, strokes, "
 MRI Brain - Progressive Multifocal Leukoencephalopathy (PML) occurring in an immunosuppressed patient with polymyositis., Radiology, MRI Brain - Leukoencephalopathy ,"CC: ,Progressive left visual field loss.,HX:, This 46y/o RHF with polymyositis since 1988, presented with complaint of visual field loss since 12/94. The visual field loss was of gradual onset and within a month of onset became a left homonymous hemianopsia. She began experiencing stiffness, numbness, tingling and incoordination of her left hand, 6 weeks prior to this admission,. These symptoms were initially attributed to carpal tunnel syndrome. MRI scan of the brain (done locally) on 6/23/95 revealed increased periventricular white matter signal on T2 images, particularly in the left temporo-occipital and right parietal lobes. There was ring enhancement of a lesion in the left occipital lobe on T1 gadolinium contrast enhanced images. There was gyral enhancement near the right Sylvian fissure. Cerebral angiogram on 7/19/95 (done locally) was unremarkable. Lumbar puncture on 7/19/95 was unremarkable. She complained of frequent holocranial throbbing headaches for the past 6 months; the HA's are associated with photophobia, phonophobia and nausea, but no vomiting. She has also been experiencing chills and night sweats for the past 2-3 weeks. She denies weight loss, but acknowledged decreased appetite and increased generalized fatigue for the past 3-4 months.,She was diagnosed with polymyositis in 1988 with slowly progressive bilateral lower extremity weakness. She has been on immunosuppressive drugs since 1988, including Prednisone, Prednisone and methotrexate, Cyclosporin, Imuran, Cytoxan, and Plaquenil. At present she in ambulatory with use of walker. Her last CK=3,125 and ESR=16, on 6/28/95.,MEDS:, Prednisone 20mg qd, Cytoxan 75mg qd, Zantac 150mg bid, Vasotec 10mg bid, Premarin 0.625 qd, Provera 2.5mg qd, CaCO3 500mg bid, Vit D 50,000units qweek, Vit E qd, MVI 1 tab qd.,PMH:, 1)polymyositis diagnosed in 1988 by muscle biopsy. 2)hypertension. 3)lichen planus. 4)Lower extremity deep venous thrombosis one year ago--placed on Coumadin and this resulted in postmenopausal bleeding.,FHX:, Mother is alive and has a h/o HTN and stroke. Father died in motor vehicle accident at age 40 years.,SHX:, Married, 3 children who are healthy. She denied any Tobacco/ETOH/Illicit drug use.,EXAM:, BP160/74 HR95 RR12 35.8C Wt. 86.4kg Ht. 5'6"",MS: A&O to person, place and time. Speech was normal. Mood euthymic with appropriate affect.,CN: Pupils 4/4 decreasing to 2/2 on exposure to light. No RAPD noted. Optic Disk were flat. EOM testing unremarkable. Confrontational visual field testing revealed a left homonymous hemianopsia. The rest of the CN exam was unremarkable.,MOTOR: Upper extremities: 5/5 proximally, 5/4 @ elbow/wrist/hand. Lower extremities: 4/4 proximally and 5/5 @ and below knees.,SENSORY: unremarkable.,COORD: Dyssynergia of LUE FNF movement. Slowed finger tapping on left. HNS movements were normal, bilaterally.,Station: LUE drift and fix on arm roll. No Romberg sign elicited.,Gait: Waddling gait, but could TT and stand on both heels. She had difficulty with tandem walking, but did not fall to any particular side.,Reflexes: 2/2 brachioradialis and biceps. 2/2+ triceps, 1+/1+ patellae, 1/1 Achilles. Plantar responses were flexor on the right and withdrawal response on the left.,GEN EXAM: No rashes. II/VI systolic ejection murmur at the left sternal border.,COURSE:, Electrolytes, PT/PTT, Urinalysis and CXR were normal. ESR=38 (normal<20), CRP1.4 (normal<0.4). CK 2,917, LDH 356, AST 67. MRI Brain, 8/8/95, revealed slight improvement of the abnormal white matter changes seen on previous outside MRI. In addition new sphenoid sinus disease suggestive of sinusitis was seen. She underwent stereotactic biopsy of the right parietal region on 8/10/95 which on H&E and LFB stained sections revealed multiple discrete areas of demyelination, containing dense infiltrates of foamy macrophages in association with scattered large oligodendroglia with deeply basophilic, ground-glass nuclei, enlarged astrocytes, and sparse perivascular lymphocytic infiltrates. In situ hybridization performed on block A2 (at the university of Pittsburgh) is positive for JC virus. The ultrastructural studies demonstrated no viral particles.,She was tapered off all immunosuppressive medications and her polymyositis remained clinically stable. She had a seizure in 12/95 and was placed on Dilantin. Her neurologic deficits worsened slightly, but reached a plateau by 10/96, as indicated by a 4/14/97 Neurology clinic visit note.,1/22/96, MRI Brain demonstrated widespread hyperintense signal on T2 and Proton Density weighted images throughout the deep white matter in both hemispheres, worse on the right side. There was interval progression of previously noted abnormalities and extension into the right frontal and left parieto-occipital regions. There was progression of abnormal signal in the Basal Ganglia, worse on the right, and new involvement of the brainstem.","radiology, mri brain, pml, progressive multifocal leukoencephalopathy, polymyositis, visual field loss, leukoencephalopathy, lower extremity, field loss, white matter, visual field, signal, brain, mri, "
 MRI Brain - Pilocytic Astrocytoma in thalamus and caudate., Radiology, MRI Brain - Pilocytic Astrocytoma ,"CC:, Headache.,HX: ,The patient is an 8y/o RHM with a 2 year history of early morning headaches (3:00-6:00AM) intermittently relieved by vomiting only. He had been evaluated 2 years ago and an EEG was ""normal"" then, but no brain imaging was performed. His headaches progressively worsened, especially in the past two months prior to this presentation. For 2 weeks prior to his 1/25/93 evaluation at UIHC, he would awake screaming. His parent spoke with a local physician who thought this might be due to irritability secondary to pinworms and,Vermox was prescribed and arrangements were made for a neurologic evaluation. On the evening of 1/24/93 the patient awoke screaming and began to vomit. This was followed by a 10 min period of tonic-clonic type movements and postictal lethargy. He was taken to a local ER and a brain CT revealed an intracranial mass. He was given Decadron and Phenytoin and transferred to UIHC for further evaluation.,MEDS:, noted above.,PMH: ,1)Born at 37.5 weeks gestation by uncomplicated vaginal delivery to a G1P0 mother. Pregnancy complicated by vaginal bleeding at 7 months. Met developmental milestones without difficulty. 2) Frequent otitis media, now resolved. 3) Immunizations were ""up to date."",FHX:, non-contributory.,SHX:, lives with biologic father and mother. No siblings. In 3rd grade (mainstream) and maintaining good marks in schools.,EXAM:, BP121/57mmHg HR103 RR16 36.9C,MS: Sleepy, but cooperative.,CN: EOM full and smooth. Advanced papilledema, OU. VFFTC. Pupils 4/4 decreasing to 2/2. Right lower facial weakness. Tongue midline upon protrusion. Corneal reflexes intact bilaterally.,Motor: 5/5 strength. Slightly increased muscle on right side.,Sensory. No deficit to PP/VIB noted.,Coord: normal FNF, HKS and RAM, bilaterally.,Station: Mild truncal ataxia. Tends to fall backward.,Reflexes: BUE 2+/2+, Patellar 3/3, Ankles 3+/3+ with 6 beats of nonsustained clonus bilaterally.,Gen exam: unremarkable.,COURSE:, The patient was continued on Dilantin 200mg qd and Decadron 5mg IV q6hrs. Brain MRI, 1/26/93, revealed a large mass lesion in the region of the left caudate nucleus and thalamus which was hyperintense on T2 weighted images. There were areas of cystic formation at its periphery. The mass appeared to enhance on post gadolinium images. there was associated white matter edema and compression of the left lateral ventricle, and midline shift to the right. There was no sign of uncal herniation. He underwent bilateral VP shunting on 1/26/93; and then, subtotal resection (left frontal craniotomy with excision of the left caudate and thalamus with creation of an opening in the septum pellucidum) on 1/28/93. He then received 5040cGy of radiation therapy in 28 fractions completed on 3/25/93. A 3/20/95 neuropsychological evaluation revealed low average intellect on the WISC-III. There were also signs of memory, attention, reading and spelling deficits; and mild right-sided motor incoordination and mood variability. He remained in mainstream classes at school, but his physical and cognitive performance began to deteriorate in 4/95. Neurosurgical evaluation in 4/95 noted increased right hemiplegia and right homonymous hemianopia. MRI revealed tumor progression and he was subsequently placed on Carboplatin/VP-16 (CG 9933 protocol chemotherapy, regimen A). He was last seen on 4/96 and was having difficulty in the 6th grade; he was also undergoing physical therapy for his right hemiplegia.","radiology, mri brain, pilocytic astrocytoma, caudate, thalamus, headache, astrocytoma, hemiplegia, pilocytic, mri, "
" MRI Brain, Carbon Monoxide poisoning.", Radiology, MRI Brain - CO poisoning ,"CC:, Found down.,HX:, 54y/o RHF went to bed at 10 PM at her boyfriend's home on 1/16/96. She was found lethargic by her son the next morning. Three other individuals in the house were lethargic and complained of HA that same morning. Her last memory was talking to her granddaughter at 5:00PM on 1/16/96. She next remembered riding in the ambulance from a Hospital. Initial Carboxyhemoglobin level was 24% (normal < 1.5%) and ABG 7.41/30/370 with O2Sat 75% on 100%FiO2.,MEDS:, unknown anxiolytic, estrogen.,PMH:, PUD, ?stroke and memory difficulty in the past 1-2 years.,FHX:, unknown.,SHX:, divorced. unknown history of tobacco/ETOH/illicit drug use.,EXAM: ,BP126/91, HR86, RR 30, 37.1C.,MS:, Oriented to name only. Speech without dysarthria. 2/3 recall at 5minutes.,CN:, unremarkable.,MOTOR: ,full strength throughout with normal muscle tone and bulk.,SENSORY: ,unremarkable.,COORD/STATION:, unremarkable.,GAIT:, not tested on admission.,GEN EXAM:, notable for erythema of the face and chest.,COURSE:, She underwent a total of four dives under Hyperbaric Oxygen ( 2 dives on 1/17 and 2 dives on 1/18). Neuropsychologic assessment on 1/18/96 revealed marked cognitive impairments with defects in anterograde memory, praxis, associative fluency, attention, and speed of information processing. She was discharged home on 1/19/96 and returned on 2/11/96 after neurologic deterioration. She progressively developed more illogical behavior, anhedonia, anorexia and changes in sleep pattern. She became completely dependent and could not undergo repeat neuropsychologic assessment in 2/96. She was later transferred to another care facility against medical advice. The etiology for these changes became complicated by a newly discovered history of possible ETOH abuse and usual ""anxiety"" disorder.,MRI brain, 2/14/96, revealed increased T2 signal within the periventricular white matter, bilaterally. EEG showed diffuse slowing without epileptiform activity.",
 MRI Brain - Olfactory groove meningioma., Radiology, MRI Brain -  Meningioma (Olfactory) ,"CC:, Progressive visual loss.,HX:, 76 y/o male suddenly became anosmic following shoulder surgery 13 years prior to this presentation. He continues to be anosmic, but has also recently noted decreased vision OD. He denies any headaches, weakness, numbness, weight loss, or nasal discharge.,MEDS:, none.,PMH:, 1) Diabetes Mellitus dx 1 year ago. 2) Benign Prostatic Hypertrophy, s/p TURP. 3) Right shoulder surgery (?DJD).,FHX:, noncontributory.,SHX:, Denies history of Tobacco/ETOH/illicit drug use.,EXAM:, BP132/66 HR78 RR16 36.0C,MS: A&O to person, place, and time. No other specifics given in Neurosurgery/Otolaryngology/Neuro-ophthalmology notes.,CN: Visual acuity has declined from 20/40 to 20/400, OD; 20/30, OS. No RAPD. EOM was full and smooth and without nystagmus. Goldmann visual fields revealed a central scotoma and enlarged blind spot OD and OS (OD worse) with a normal periphery. Intraocular pressures were 15/14 (OD/OS). There was moderate pallor of the disc, OD. Facial sensation was decreased on the right side (V1 distribution).,Motor/Sensory/Coord/Station/Gait: were all unremarkable.,Reflexes: 2/2 and symmetric throughout. Plantars were flexor, bilaterally.,Gen Exam: unremarkable.,COURSE:, MRI Brain, 10/7/92, revealed: a large 6x5x6cm slightly heterogeneous, mostly isointense lesion on both T1 and T2 weighted images arising from the planum sphenoidale and olfactory groove. The mass extends approximately 3.6cm superior to the planum into both frontal regions with edema in both frontal lobes. The mass extends 2.5cm inferiorly involving the ethmoid sinuses with resultant obstruction of the sphenoid and frontal sinuses.,It also extends into the superomedial aspect of the right maxillary sinus. There is probable partial encasement of both internal carotid arteries just above the siphon. The optic nerves are difficult to visualize but there is also probable encasement of these structures as well. The mass enhances significantly with gadolinium contrast. These finds are consistent with Meningioma.,The patient underwent excision of this tumor by simultaneous bifrontal craniotomy and lateral rhinotomy following an intrasinus biopsy which confirmed the meningioma. Postoperatively, he lost visual acuity, OS, but this gradually returned to baseline. His 9/6/96 neuro-ophthalmology evaluation revealed visual acuity of 20/25-3 (OD) and 20/80-2 (OS). His visual fields continued to abnormal, but improved and stable when compared to 10/92. His anosmia never resolved.","radiology, mri brain, olfactory, groove, headaches, meningioma, nasal discharge, numbness, visual loss, weakness, weight loss, visual acuity, mri, brain, isointense, sinuses, visual, "
 MRI right ankle., Radiology, MRI Ankle - 2 ,"EXAM:,MRI OF THE RIGHT ANKLE,CLINICAL:,Pain.,FINDINGS:,The bone marrow demonstrates normal signal intensity. There is no evidence of bone contusion or fracture. There is no evidence of joint effusion. Tendinous structures surrounding the ankle joint are intact. No abnormal mass or fluid collection is seen surrounding the ankle joint.,IMPRESSION,: NORMAL MRI OF THE RIGHT ANKLE.","radiology, ankle joint, bone, mri, ankle"
 Cerebral Angiogram - moyamoya disease., Radiology, Moyamoya Disease ,"CC:, Confusion and slurred speech.,HX , (primarily obtained from boyfriend): This 31 y/o RHF experienced a ""flu-like illness 6-8 weeks prior to presentation. 3-4 weeks prior to presentation, she was found ""passed out"" in bed, and when awoken appeared confused, and lethargic. She apparently recovered within 24 hours. For two weeks prior to presentation she demonstrated emotional lability, uncharacteristic of her ( outbursts of anger and inappropriate laughter). She left a stove on.,She began slurring her speech 2 days prior to admission. On the day of presentation she developed right facial weakness and began stumbling to the right. She denied any associated headache, nausea, vomiting, fever, chills, neck stiffness or visual change. There was no history of illicit drug/ETOH use or head trauma.,PMH:, Migraine Headache.,FHX: , Unremarkable.,SHX: ,Divorced. Lives with boyfriend. 3 children alive and well. Denied tobacco/illicit drug use. Rarely consumes ETOH.,ROS:, Irregular menses.,EXAM: ,BP118/66.  HR83. RR 20. T36.8C.,MS: Alert and oriented to name only. Perseverative thought processes. Utilized only one or two word answers/phrases. Non-fluent. Rarely followed commands. Impaired writing of name.,CN: Flattened right nasolabial fold only.,Motor: Mild weakness in RUE manifested by pronator drift. Other extremities were full strength.,Sensory: withdrew to noxious stimulation in all 4 extremities.,Coordination: difficult to assess.,Station: Right pronator drift.,Gait: unremarkable.,Reflexes: 2/2BUE, 3/3BLE, Plantars were flexor bilaterally.,General Exam: unremarkable.,INITIAL STUDIES:, CBC, GS, UA, PT, PTT, ESR, CRP, EKG were all unremarkable. Outside HCT showed hypodensities in the right putamen, left caudate, and at several subcortical locations (not specified).,COURSE: ,MRI Brian Scan, 2/11/92 revealed an old lacunar infarct in the right basal ganglia, edema within the head of the left caudate nucleus suggesting an acute ischemic event, and arterial enhancement of the left MCA distribution suggesting slow flow. The latter suggested a vasculopathy such as Moya Moya, or fibromuscular dysplasia. HIV, ANA, Anti-cardiolipin Antibody titer, Cardiac enzymes, TFTs, B12, and cholesterol studies were unremarkable.,She underwent a cerebral angiogram on 2/12/92. This revealed an occlusion of the left MCA just distal to its origin. The distal distribution of the left MCA filled on later films through collaterals from the left ACA. There was also an occlusion of the right MCA just distal to the temporal branch. Distal branches of the right MCA filled through collaterals from the right ACA. No other vascular abnormalities were noted. These findings were felt to be atypical but nevertheless suspicious of a large caliber vasculitis such as Moya Moya disease. She was subsequently given this diagnosis. Neuropsychologic testing revealed widespread cognitive dysfunction with particular impairment of language function. She had long latencies responding and understood only simple questions. Affect was blunted and there was distinct lack of concern regarding her condition. She was subsequently discharged home on no medications.,In 9/92 she was admitted for sudden onset right hemiparesis and mental status change. Exam revealed the hemiparesis and in addition she was found to have significant neck lymphadenopathy. OB/GYN exam including cervical biopsy, and abdominal/pelvic CT scanning revealed stage IV squamous cell cancer of the cervix. She died 9/24/92 of cervical cancer.",
" MRI Brain: Ventriculomegaly of the lateral, 3rd and 4th ventricles secondary to obstruction of the foramen of Magendie secondary to Cryptococcus (unencapsulated) in a non-immune suppressed, HIV negative, individual.", Radiology, MRI Brain - Cryptococcus ,"CC: ,Headache.,HX: ,This 37y/o LHM was seen one month prior to this presentation for HA, nausea and vomiting. Gastrointestinal evaluation at that time showed no evidence of bowel obstruction and he was released home. These symptoms had been recurrent since onset.,At presentation he complained of mild blurred vision (OU), difficulty concentrating and HA which worsened upon sitting up. The headaches were especially noticeable in the early morning. He described them as non-throbbing headaches. They begin in the bifrontal region and radiate posteriorly. They occurred up to 6 times/day. The HA improved with lying down or dropping the head down between the knees towards the floor. The headaches were associated with blurred vision, nausea,vomiting, photophobia, and phonophobia. He denied any scotomata or positive visual phenomena. He denies any weakness, numbness, tingling, dysarthria or diplopia. His weight has fluctuated from 163# to 148# over the past 3 months and at present he weighs 154#. His appetite has been especially poor in the past month.,MEDS:,Sulfasalazine qid. Tylenol 650mg q4hours.,PMH:, 1)Ulcerative Colitis dx 1989. 2)HTN 3) occasional HAs since the early 1980s which are different in character and much less severe than his current HAs. They were not associated with nausea, vomiting, photophobia, phonophobia or difficulty thinking.,FHX:, MGF with h/o stroke. Mother and Father were healthy. No h/o of migraine in family.,SHX:, Single. Works as a newpaper printing press worker. Denies tobacco, ETOH or illicit drug use, but admits he was a heavy drinker until the last 1970s when he quit.,EXAM: ,BP159/92 HR 48 (sitting): BP126/70 HR48 (supine). RR14 36.2C,MS: A&O to person, place and time. Speech clear. Appears uncomfortable but acts appropriately and cooperatively. No difficulty with short and long term memory.,CN: Grad 2-3 papilledema OS; Grade 1 papilledema (@2 o'clock) OD. Pupils 4/4 decreasing to 2/2 on exposure to light. Bilateral horizontal sustained nystagmus on right and leftward gaze. Bilateral vertical sustained nystagmus on up and downward gaze. Face symmetric with full movement and PP sensation. Tongue midline with full ROM. Gag and SCM were intact bilaterally.,Motor: Full strength throughout with normal muscle bulk and tone.,Sensory: Unremarkable.,Coord: Mild dysynergia on FNF movements in BUE. HNS and RAM were unremarkable.,Station: Unsteady with and without eyes open on Romberg test. No drift in any particular direction.,Gait: Wide based, ataxic and to some degree magnetic and apraxic.,Gen Exam: Unremarkable.,COURSE:, Urinalysis revealed 1-2RBC, 2-3WBC and bacteria were noted. Repeat Urinalysis was negative the next day. PT, PTT, CXR and GS were normal. CBC revealed 10.4WBC with 7.1Granulocytes. HCT, 10/18/95, revealed hydrocephalus. MRI, 10/18/95, revealed ventriculomegaly of the lateral, 3rd and 4th ventricles. There was enhancement of the meninges about the prepontine cisterna and internal auditory canals, and enhancement of a scar or inflammed lining of the foramen of Magendie. These changes were felt suggestive of bacterial or granulomatous meningitis. The patient underwent ventriculostomy on 10/19/94. CSF taken on 10/19/94 via V-P shunt insertion revealed: 22 WBC (21 lymphocytes, 1 monocyte), 380 RBC, Glucose 58, Protein 29, GS negative, Cultures (bacterial, fungal, AFB) negative, Cryptococcal Antigen and India Ink were negative. Numerous CSF samples were taken from the lumbar region and shunt reservoir and these were consistantly unremarkable except for an occasional CSF protein of up to 99mg/dl. Serum and CSF toxoplasma titers and ACE levels were negative on multiple occasions. VDRL and HIV testing was unremarkable. 10/27/94 and 10/31/94 CSF cultures taken from the cervical region eventually grew non-encapsulated crytococcus neoformans. The patient was treated with amphotericin and showed some improvement. However, scarring had probably occurred by then and the V-P shunt was left in place.","radiology, ventriculomegaly, foramen of magendie, mri brain, blurred vision, headache, brain, ventricles, cryptococcus, foramen, csf, "
 Patient with right ankle pain., Radiology, MRI Ankle - 1 ,"EXAM:,MRI RIGHT ANKLE,CLINICAL:,This is a 51 year old female who first came into the office 3/4/05 with right ankle pain. She stepped on ice the evening prior and twisted her ankle. PF's showed no frank fracture, dislocation, or subluxations.,FINDINGS:,Received for interpretation is an MRI examination performed on 4/28/2005.,There is a ""high ankle sprain"" of the distal tibiofibular syndesmotic ligamentous complex involving the anterior tibiofibular ligament with marked ligamentous inflammatory thickening and diffuse interstitial edema. There is osteoarthritic spur formation at the anterior aspect of the fibula with a small 2mm osseous structure within the markedly thickened anterior talofibular ligament suggesting a small ligamentous osseous avulsion. The distal tibiofibular syndesmotic ligamentous complex remains intact without a complete rupture. There is no widening of the ankle mortis. The posterior talofibular ligament remains intact.,There is marked ligamentous thickening of the anterior talofibular ligament of the lateral collateral ligamentous complex suggesting the sequela of a remote lateral ankle sprain. There is thickening of the posterior talofibular and calcaneofibular ligaments.,There is a flat retromalleolar sulcus.,There is a full-thickness longitudinal split tear of the peroneus brevis tendon within the retromalleolar groove. The tear extends to the level of the inferior peroneal retinaculum. There is anterior displacement of the peroneus longus tendon into the split peroneus tendon tear.,There is severe synovitis of the peroneus longus tendon sheath with prominent fluid distention. The synovitis extends to the level of the inferior peroneal retinaculum.,There is a focal area of chondral thinning of the hyaline cartilage of the medial talar dome with a focal area of subchondral plate cancellous marrow resorption consistent with and area of prior talar dome contusion but there is no focal osteochondral impaction or osteochondral defect.,There is minimal fluid within the tibiotalar articulation.,There is minimal fluid within the posterior subtalar articulation with mild anterior capsular prolapse. Normal talonavicular and calcaneocuboid articulations. The anterior superior calcaneal process is normal.,There is mild tenosynovitis of the posterior tibialis tendon sheath but an intrinsically normal tendon. There is an os navicularis (Type II synchondrosis) with an intact synchondrosis and no active marrow stress phenomenon.,Normal flexor digitorum longus tendon.,There is prominent fluid distention of the flexor hallucis longus tendon sheath with capsular distention proximal to the posterior talar processes with prominent fluid distention of the synovial sheath.,There is a loculated fluid collection within Kager’s fat measuring approximately 1 x 1 x 2.5cm in size, extending to the posterior subtalar facet joint consistent with a ganglion of either posterior subtalar facet origin or arising from the flexor hallucis longus tendon sheath.,There is mild tenosynovitis of the Achilles tendon with mild fusiform enlargement of the non-insertional Watershed zone of the Achilles tendon but there is no demonstrated tendon tear or tenosynovitis. There is a low-lying soleus muscle that extends to within 4cm of the teno-osseous insertion of the Achilles tendon. There is no Haglund’s deformity.,There is a plantar calcaneal spur measuring approximately 6mm in size, without a reactive marrow stress phenomenon. Normal plantar fascia.,IMPRESSION:,Partial high ankle sprain with diffuse interstitial edema of the anterior tibiofibular ligament with a ligamentous chip avulsion but without a disruption of the anterior tibiofibular ligament.,Marked ligamentous thickening of the lateral collateral ligamentous complex consistent with the sequela of a remote lateral ankle sprain.,Full-thickness longitudinal split tear of the peroneus brevis tendon with severe synovitis of the peroneal tendon sheath.,Post-traumatic deformity of the medial talar dome consistent with a prior osteochondral impaction injury but no osteochondral defect. Residual subchondral plate cancellous marrow edema.,Severe synovitis of the flexor hallucis longus tendon sheath with prominent fluid distention of the synovial sheath proximal to the posterior talar processes.,Septated cystic structure within Kager’s fat triangle extending along the superior aspect of the calcaneus consistent with a ganglion of either articular or synovial sheath origin.,Plantar calcaneal spur but no reactive marrow stress phenomenon.,Mild tendinosis of the Achilles tendon but no tendinitis or tendon tear.,Os navicularis (Type II synchondrosis) without an active marrow stress phenomenon.",
 Lexiscan myoview stress study.  Chest discomfort.  Normal stress/rest cardiac perfusion with no indication of ischemia.  Normal LV function and low likelihood of significant epicardial coronary narrowing., Radiology, Mayoview - 2 ,"LEXISCAN MYOVIEW STRESS STUDY,REASON FOR THE EXAM: , Chest discomfort.,INTERPRETATION: , The patient exercised according to the Lexiscan study, received a total of 0.4 mg of Lexiscan IV injection.  At peak hyperemic effect, 24.9 mCi of Myoview were injected for the stress imaging and earlier 8.2 mCi were injected for the resting and the usual SPECT and gated SPECT protocol was followed and the data was analyzed using Cedars-Sinai software.  The patient did not walk because of prior history of inability to exercise long enough on treadmill.,The resting heart rate was 57 with the resting blood pressure 143/94.  Maximum heart rate achieved was 90 with a maximum blood pressure unchanged.,EKG at rest showed sinus rhythm with no significant ST-T wave changes of reversible ischemia or injury.  Subtle nonspecific in III and aVF were seen.  Maximum stress test EKG showed inverted T wave from V4 to V6.  Normal response to Lexiscan.,CONCLUSION:  ,Maximal Lexiscan perfusion with subtle abnormalities non-conclusive.  Please refer to the Myoview interpretation.,MYOVIEW INTERPRETATION: , The left ventricle appeared to be normal in size on both stress and rest with no change between the stress and rest with left ventricular end-diastolic volume of 115 and end-systolic of 51.  EF estimated and calculated at 56%.,Cardiac perfusion reviewed, showed no reversible defect indicative of myocardium risk and no fixed defect indicative of myocardial scarring.,IMPRESSION:,1.  Normal stress/rest cardiac perfusion with no indication of ischemia.,2.  Normal LV function and low likelihood of significant epicardial coronary narrowing.,","radiology, chest discomfort, lexiscan myoview stress study, mci, spect, gated spect, myoview, lexiscan, stress test, ekg, lexiscan myoview, lv function, coronary narrowing, heart rate, blood pressure, myoview interpretation, cardiac perfusion, cardiac, ischemia, perfusion, stress,"
 Left lower extremity venous Doppler ultrasound, Radiology, Lower Extremity Venous Doppler ,"LEFT LOWER EXTREMITY VENOUS DOPPLER ULTRASOUND,REASON FOR EXAM: , Status post delivery five weeks ago presenting with left calf pain.,INTERPRETATIONS: , There was normal flow, compression and augmentation within the right common femoral, superficial femoral and popliteal veins.  Lymph nodes within the left inguinal region measure up to 1 cm in short-axis.,IMPRESSION: , Lymph nodes within the left inguinal region measure up to 1 cm in short-axis, otherwise no evidence for left lower extremity venous thrombosis.","radiology, popliteal veins, superficial femoral, common femoral, inguinal region, lymph nodes, venous doppler, lower extremity, lymph, inguinal, axis, doppler, extremity, venous,"
 Lexiscan Nuclear Myocardial Perfusion Scan.  Chest pain.  Patient unable to walk on a treadmill.  Nondiagnostic Lexiscan.  Normal nuclear myocardial perfusion scan., Radiology, Lexiscan Nuclear Scan ,"EXAM:,  Lexiscan Nuclear Myocardial Perfusion Scan.,INDICATION:,  Chest pain.,TYPE OF TEST:  ,Lexiscan, unable to walk on a treadmill.,INTERPRETATION: , Resting heart rate of 96, blood pressure of 141/76.  EKG, normal sinus rhythm, nonspecific ST-T changes, left bundle branch block.  Post Lexiscan 0.4 mg injected intravenously by standard protocol.  Peak heart rate was 105, blood pressure of 135/72.  EKG remains the same.  No symptoms are noted.,SUMMARY:,1.  Nondiagnostic Lexiscan.,2.  Nuclear interpretation as below.,NUCLEAR MYOCARDIAL PERFUSION SCAN WITH STANDARD PROTOCOL:,  Resting and stress images were obtained with 10.4, 32.5 mCi of tetrofosmin injected intravenously by standard protocol.  Myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake.  There is no evidence of reversible or fixed defect.  Gated SPECT revealed mild global hypokinesis, more pronounced in the septal wall possibly secondary to prior surgery.  Ejection fraction calculated at 41%.  End-diastolic volume of 115, end-systolic volume of 68.,IMPRESSION:,1.  Normal nuclear myocardial perfusion scan.,2.  Ejection fraction 41% by gated SPECT.","radiology, lexiscan nuclear myocardial perfusion scan, treadmill, bundle branch block, mci, tetrofosmin, nuclear myocardial perfusion scan, blood pressure, gated spect, ejection fraction, myocardial perfusion, ejection, fraction, myocardial, lexiscan, nuclear,"
" Myoview nuclear stress study.  Angina, coronary artery disease.  Large fixed defect, inferior and apical wall, related to old myocardial infarction.", Radiology, Mayoview - 1 ,"MYOVIEW NUCLEAR STRESS STUDY,REASON FOR THE TEST:,  Angina, coronary artery disease.,FINDINGS: , The patient exercised according to the Lexiscan nuclear stress study, received a total of 0.4 mg of Lexiscan.  At peak hyperemic effect, 25.8 mCi of Myoview injected for the stress imaging and earlier 8.1 mCi of Myoview injected for the resting and the usual SPECT and gated SPECT protocol was followed in the rest-stress sequence.,The data analyzed using Cedars-Sinai software.,The resting heart rate was 49 with the resting blood pressure of 149/86.  Maximum heart rate achieved was 69 with a maximum blood pressure achieved of 172/76.,EKG at rest showed to be abnormal with sinus rhythm, left atrial enlargement, and inverted T-wave in 1, 2, and aVL as well as from V4 to V6 with LVH.  Maximal stress test EKG showed no change from baseline.,IMPRESSION:  ,Maximal Lexiscan stress test with abnormal EKG at baseline maximal stress test, please refer to the Myoview interpretation.,MYOVIEW INTERPRETATIONS,FINDINGS: , The left ventricle appears to be dilated on both stress and rest with no significant change between stress and rest with left ventricular end-diastolic volume of 227, end-systolic volume of 154 with moderately to severely reduced LV function with akinesis of the inferior and inferoseptal wall.  EF was calculated at 32%, estimated 35% to 40%.,Cardiac perfusion reviewed, showed a large area of moderate-to-severe intensity in the inferior wall and small-to-medium area of severe intensity at the apex and inferoapical wall.  Both defects showed no change on the resting indicative of a fixed defect in the inferior and inferoapical wall consistent with old inferior inferoapical MI.  No reversible defects indicative of myocardium at risk.  The lateral walls as well as the septum and most of the anterior wall showed no reversibility and near-normal perfusion.,IMPRESSION:,1.  Large fixed defect, inferior and apical wall, related to old myocardial infarction.,2.  No reversible ischemia identified.,3.  Moderately reduced left ventricular function with ejection fraction of about 35% consistent with ischemic cardiomyopathy.","radiology, myoview, myoview interpretations, spect, gated spect protocol, myoview nuclear stress study, nuclear stress study, stress study, stress test, stress, lexiscan, ekg, inferoapical, angina, wall, resting,"
" Magnified Airway Study - An 11-month-old female with episodes of difficulty in breathing, cough.", Radiology, Magnified Airway Study ,"EXAM:,  Magnified airway.,CLINICAL HISTORY: , An 11-month-old female with episodes of difficulty in breathing, cough.,TECHNIQUE: , Multiple fluoroscopic spot images of the pharyngeal airway, trachea, and mainstem bronchi were performed in various phases of respiration.,FINDINGS:,  The airway is patent throughout its course.  Specifically, the trachea and both mainstem bronchi do not demonstrate evidence of dynamic collapse greater than 50%.,No filling defects are identified.,The vocal cords demonstrate normal opening and closing.,IMPRESSION: , Normal magnified airway examination.","radiology, magnified airway study, difficulty in breathing, airway study, breathing cough, mainstem bronchi, magnified airway, cough, trachea, mainstem, bronchi, airway"
" Lumbar discogram L2-3, L3-4, L4-5, and L5-S1.  Low back pain.", Radiology, Lumbar Discogram ,"PREOPERATIVE DIAGNOSIS: , Low back pain.,POSTOPERATIVE DIAGNOSIS: , Low back pain.,PROCEDURE PERFORMED:,1.  Lumbar discogram L2-3.,2.  Lumbar discogram L3-4.,3.  Lumbar discogram L4-5.,4.  Lumbar discogram L5-S1.,ANESTHESIA:  ,IV sedation.,PROCEDURE IN DETAIL:  ,The patient was brought to the Radiology Suite and placed prone onto a radiolucent table.  The C-arm was brought into the operative field and AP, left right oblique and lateral fluoroscopic images of the L1-2 through L5-S1 levels were obtained.  We then proceeded to prepare the low back with a Betadine solution and draped sterile.  Using an oblique approach to the spine, the L5-S1 level was addressed using an oblique projection angled C-arm in order to allow for perpendicular penetration of the disc space.  A metallic marker was then placed laterally and a needle entrance point was determined.  A skin wheal was raised with 1% Xylocaine and an #18-gauge needle was advanced up to the level of the disc space using AP, oblique and lateral fluoroscopic projections.  A second needle, #22-gauge 6-inch needle was then introduced into the disc space and with AP and lateral fluoroscopic projections, was placed into the center of the nucleus.  We then proceeded to perform a similar placement of needles at the L4-5, L3-4 and L2-3 levels.,A solution of Isovue 300 with 1 gm of Ancef was then drawn into a 10 cc syringe and without informing the patient of our injecting, we then proceeded to inject the disc spaces sequentially.","radiology, back pain, c-arm, fluoroscopic projections, disc space, lumbar discogram, fluoroscopic, needle,"
 Resting Myoview and adenosine Myoview SPECT, Radiology, Mayoview ,"PROCEDURE DONE:  ,Resting Myoview and adenosine Myoview SPECT.,INDICATIONS:,  Chest pain.,PROCEDURE:,  13.3 mCi of Tc-99m tetrofosmin was injected and resting Myoview SPECT was obtained.  Pharmacologic stress testing was done using adenosine infusion.  Patient received 38 mg of adenosine infused at 140 mcg/kg/minute over a period of four minutes.  Two minutes during adenosine infusion, 31.6 mCi of Tc-99m tetrofosmin was injected.  Resting heart rate was 90 beats per minute.  Resting blood pressure was 130/70.  Peak heart rate obtained during adenosine infusion was 102 beats per minute.  Blood pressure obtained during adenosine infusion was 112/70.  During adenosine infusion, patient experienced dizziness and shortness of breath.  No significant ST segment, T wave changes, or arrhythmias were seen.,Resting Myoview and adenosine Myoview SPECT showed uniform uptake of isotope throughout myocardium without any perfusion defect.  Gated dynamic imaging showed normal wall motion and normal systolic thickening throughout left ventricular myocardium.  Left ventricular ejection fraction obtained during adenosine Myoview SPECT was 77%.  Lung heart ratio was 0.40.  TID ratio was 0.88.,IMPRESSION:,  Normal adenosine Myoview myocardial perfusion SPECT.  Normal left ventricular regional and global function with left ventricular ejection fraction of 77%.","radiology, myoview, gated dynamic imaging, myoview spect, resting myoview, spect, tc-99m, adenosine myoview, adenosine infusion, ejection fraction, myocardium, systolic thickening, tetrofosmin, adenosine myoview spect, adenosine,"
 Lower Extremity Arterial Doppler, Radiology, Lower Extremity Arterial Doppler ,"RIGHT LOWER EXTREMITY:,  The arterial system was visualized showing triphasic waveform from the common femoral to popliteal and biphasic waveform at the posterior tibial artery with ankle brachial index of 0/8.,LEFT LOWER EXTREMITY:,  The arterial system was visualized with triphasic waveform from the common femoral to the popliteal artery, with biphasic waveform at the posterior tibial artery.  Ankle brachial index of 0.9.,IMPRESSION: , Mild bilateral lower extremity arterial obstructive disease.,","radiology, lower extremity arterial doppler, posterior tibial artery, ankle brachial index, arterial doppler, triphasic waveform, common femoral, biphasic waveform, tibial artery, ankle brachial, brachial index, lower extremity, doppler, triphasic, femoral, popliteal, brachial, waveform, extremity, arterial,"
 Diagnostic laparoscopy and drainage of cyst., Radiology, Laparoscopy - Drainage of Cyst ,"PREOPERATIVE DIAGNOSIS:,  Ovarian cyst, persistent.,POSTOPERATIVE DIAGNOSIS: , Ovarian cyst.,ANESTHESIA:,  General,NAME OF OPERATION:,  Diagnostic laparoscopy and drainage of cyst.,PROCEDURE:,  The patient was taken to the operating room, prepped and draped in the usual manner, and adequate anesthesia was induced.  An infraumbilical incision was made, and Veress needle placed without difficulty.  Gas was entered into the abdomen at two liters.  The laparoscope was entered, and the abdomen was visualized.  The second puncture site was made, and the second trocar placed without difficulty.  The cyst was noted on the left, a 3-cm, ovarian cyst.  This was needled, and a hole cut in it with the scissors.  Hemostasis was intact.  Instruments were removed.  The patient was awakened and taken to the recovery room in good condition.","radiology, ovarian cyst, infraumbilical incision, drainage of cyst, diagnostic laparoscopy, laparoscopy, drainage, ovarian, "
 Comprehensive electrophysiology studies with attempted arrhythmia induction and IV Procainamide infusion for Brugada syndrome., Radiology, IV Procainamide Infusion ,"PREOPERATIVE DIAGNOSIS: , Syncopal episodes with injury.  See electrophysiology consultation.,POSTOPERATIVE DIAGNOSES:,1.  Normal electrophysiologic studies.,2.  No inducible arrhythmia.,3.  Procainamide infusion negative for Brugada syndrome.,PROCEDURES:,1.  Comprehensive electrophysiology studies with attempted arrhythmia induction.,2.  IV Procainamide infusion for Brugada syndrome.,DESCRIPTION OF PROCEDURE:, The patient gave informed consent for comprehensive electrophysiologic studies.  She received small amounts of intravenous fentanyl and Versed for conscious sedation.  Then 1% lidocaine local anesthesia was used.  Three catheters were placed via the right femoral vein; 5-French catheters to the right ventricular apex and right atrial appendage; and a 6-French catheter to the His bundle.  Later in the procedure, the RV apical catheter was moved to RV outflow tract.,ELECTROPHYSIOLOGICAL FINDINGS:,  Conduction intervals in sinus rhythm were normal.  Sinus cycle length 768 ms, PA interval 24 ms, AH interval 150 ms, HV interval 46 ms.  Sinus node recovery times were also normal at 1114 ms.  Corrected sinus node recovery time was normal at 330 ms.  One-to-one AV conduction was present to cycle length 480 ms, AH interval 240 ms, HV interval 54 ms.  AV nodal effective refractory period was normal, 440 ms at drive cycle length 600 ms.  RA-ERP was 250 ms.  With ventricular pacing, there was VA disassociation present.,Since there was no evidence for dual AV nodal pathways, and poor retrograde conduction, isoproterenol infusion was not performed to look for SVT.,Programmed ventricular stimulation was performed at both right ventricular apex and right ventricular outflow tracts.  Drive cycle length 600, 500, and 400 ms was used with triple extrastimuli down to troubling intervals of 180 ms, or refractoriness.  There was no inducible VT.  Longest run was 5 beats of polymorphic VT, which is a nonspecific finding.  From the apex 400-600 with 2 extrastimuli were delivered, again with no inducible VT.,Procainamide was then infused, 20 mg/kg over 10 minutes.  There were no ST segment changes.  HV interval after IV Procainamide remained normal at 50 ms.,ASSESSMENT: , Normal electrophysiologic studies.  No evidence for sinus node dysfunction or atrioventricular block.  No inducible supraventricular tachycardia or ventricular tachycardia, and no evidence for Brugada syndrome.,PLAN: , The patient will follow up with Dr. X.  She recently had an ambulatory EEG.  I will plan to see her again on a p.r.n. basis should she develop a recurrent syncopal episodes.  Reveal event monitor was considered, but not placed since she has only had one single episode.","radiology, arrhythmia, attempted arrhythmia induction, conduction, sinus rhythm, electrophysiologic studies, sinus node, iv procainamide, brugada syndrome, electrophysiology, sinus, ventricular,"
 Nuclear Medicine Therapy Intraarterial Particulate Administration, Radiology, Intraarterial Particulate Administration ,"EXAM: , Therapy intraarterial particulate administration.,HISTORY: , Hepatocellular carcinoma.,TECHNIQUE: , The patient was brought to the interventional radiology suite where catheterization of the right hepatic artery was performed.  The patient had previously given oral and written consent to the radioembolization procedure.  After confirmation of proper positioning of the hepatic artery catheter, 3.78 GBq of yttrium-90 TheraSphere microspheres were infused through the catheter under strict radiation safety procedures.,FINDINGS: , There were no apparent complications.  Using data on tumor burden, right lobe liver volume, vascularity of the tumor obtained from angiography and quantitative CT, and measurement of residual activity tumor, the expected radiation dose to the tumor burden in the right lobe of the liver was calculated at 201 Gy.  The expected dose to the remaining right liver parenchyma is 30 Gy.,Following the procedure there was no evidence of radioactive contamination of the room, equipment or personnel.,IMPRESSION: , Radioembolization therapy of hepatocellular carcinoma in the right lobe of the liver using 3.78 GBq of yttrium-90 microspheres TheraSphere.","radiology, lobe of the liver, intraarterial particulate administration, hepatocellular carcinoma, hepatic artery, tumor burden, particulate administration, hepatocellular, carcinoma, hepatic, artery, radioembolization, therasphere, microspheres, radiation, gy, therapy, particulate, administration, catheterization, tumor, liver, intraarterial, "
 Laparoscopic cholecystectomy with cholangiogram.  Acute gangrenous cholecystitis with cholelithiasis.  The patient had essentially a dead gallbladder with stones and positive wide bile/pus coming from the gallbladder., Radiology, Laparoscopic Cholecystectomy & Cholangiogram ,"PREOPERATIVE DIAGNOSIS:,  Acute cholecystitis.,POSTOPERATIVE DIAGNOSIS:,  Acute gangrenous cholecystitis with cholelithiasis.,OPERATION PERFORMED: , Laparoscopic cholecystectomy with cholangiogram.,FINDINGS:  ,The patient had essentially a dead gallbladder with stones and positive wide bile/pus coming from the gallbladder.,COMPLICATIONS:  ,None.,EBL: , Scant.,SPECIMEN REMOVED: , Gallbladder with stones.,DESCRIPTION OF PROCEDURE:  ,The patient was prepped and draped in the usual sterile fashion under general anesthesia.  A curvilinear incision was made below the umbilicus.  Through this incision, the camera port was able to be placed into the peritoneal cavity under direct visualization.  Once this complete, insufflation was begun.  Once insufflation was adequate, additional ports were placed in the epigastrium as well as right upper quadrant.  Once all four ports were placed, the right upper quadrant was then explored.  The patient had significant adhesions of omentum and colon to the liver, the gallbladder constituting definitely an acute cholecystitis.  This was taken down using Bovie cautery to free up visualization of the gallbladder.  The gallbladder was very thick and edematous and had frank necrosis of most of the anterior gallbladder wall.  Adhesions were further taken down between the omentum, the colon, and the gallbladder slowly starting superiorly and working inferiorly towards the cystic duct area.  Once the adhesions were fully removed, the cholangiogram was done which did not show any evidence of any common bile duct dilatation or obstruction.  At this point, due to the patient's gallbladder being very necrotic, it was deemed that the patient should have a drain placed.  The cystic duct and cystic artery were serially clipped and transected.  The gallbladder was removed from the gallbladder fossa removing the entire gallbladder.  Adequate hemostasis with Bovie cautery was achieved.  The gallbladder was then placed into a bag and removed from the peritoneal cavity through the camera port.  A JP drain was then run through the anterior port and out of one of the trochar sites and secured to the skin using 3-0 nylon suture.  Next, the right upper quadrant was copiously irrigated out using the suction irrigator.  Once this was complete, the additional ports were able to be removed.  The fascial opening at the umbilicus was reinforced by closing it using a 0 Vicryl suture in a figure-of-8 fashion.  All skin incisions were injected using Marcaine 1/4 percent plain.  The skin was reapproximated further using 4-0 Monocryl sutures in a subcuticular technique.  The patient tolerated the procedure well and was able to be transferred to the recovery room in stable condition.","radiology, acute cholecystitis, cholangiogram, cholelithiasis, cholecystitis, gallbladder, gangrenous cholecystitis, bovie cautery, cystic duct, laparoscopic cholecystectomy, laparoscopic, cholecystectomy, cystic, duct,"
 Sellar HCT - Pituitary mass, Radiology, HCT - Pituitary Mass ,"CC:, HA and vision loss.,HX: ,71 y/o RHM developed a cataclysmic headache on 11/5/92 associated with a violent sneeze. The headache lasted 3-4 days. On 11/7/92, he had acute pain and loss of vision in the left eye. Over the following day his left pupil enlarged and his left upper eyelid began to droop. He was seen locally and a brain CT showed no sign of bleeding, but a tortuous left middle cerebral artery was visualized. The patient was transferred to UIHC 11/12/92.,FHX:, HTN, stroke, coronary artery disease, melanoma.,SHX:, Quit smoking 15 years ago.,MEDS:, Lanoxin, Capoten, Lasix, KCL, ASA, Voltaren, Alupent MDI,PMH: ,CHF, Atrial Fibrillation, Obesity, Anemia, Duodenal Ulcer, Spinal AVM resection 1986 with residual T9 sensory level, hyperreflexia and bilateral babinski signs, COPD.,EXAM: ,35.5C, BP 140/91, P86, RR20. Alert and oriented to person, place, and time. CN: No light perception OS, Pupils: 3/7 decreasing to 2/7 on exposure to light (i.e., fixed/dilated pupil OS). Upon neutral gaze the left eye deviated laterally and inferiorly. There was complete ptosis OS. On downward gaze their was intorsion OS. The left eye could not move superiorly, medially or effectively downward, but could move laterally. EOM were full OD. The rest of the CN exam was unremarkable. Motor, Coordination, Station and Gait testing were unremarkable. Sensory exam revealed decreased pinprick and light touch below T9 (old). Muscle stretch reflexes were increased (3+/3+) in both lower extremities and there were bilateral babinski signs (old). The upper extremity reflexes were symmetrical (2/2). Cardiovascular exam revealed an irregularly irregular rhythm and lung sounds were coarse bilaterally. The rest of the general exam was unremarkable.,LAB:, CBC, PT/PTT, General Screen were unremarkable except for a BUN 21mg/DL. CSF: protein 88mg/DL, glucose 58mg/DL, RBC 2800/mm3, WBC 1/mm3. ANA, RF, TSH, FT4 were WNL.,IMPRESSION:, CN3 palsy and loss of vision. Differential diagnosis: temporal arteritis, aneurysm, intracranial mass.,COURSE:, The outside Brain CT revealed a tortuous left MCA. A four-vessel cerebral angiogram revealed a dolichoectatic basilar artery and tortuous LICA. There was no evidence of aneursym. Transesophageal Echocardiogram revealed atrial enlargement only. Neuroopthalmologic evaluation revealed: Loss of color vision and visual acuity OS, RAPD OS, bilateral optic disk pallor (OS > OD), CN3 palsy and bilateral temporal field loss, OS >> OD . ESR, CRP, MRI were recommended to rule out temporal arteritis and intracranial mass. ESR 29mm/Hr, CRP 4.3mg/DL (high) , The patient was placed on prednisone. Temporal artery biopsy showed no evidence of vasculitis. MRI scan could not be obtained due to patient weight. Sellar CT was done instead: coronal sections revealed sellar enlargement and upward bowing of the diaphragm sella suggesting a pituitary mass. In retrospect sellar enlargement could be seen on the angiogram X-rays. Differential consideration was given to cystic pituitary adenoma, noncalcified craniopharyngioma, or Rathke's cleft cyst with solid component. The patient refused surgery. He was seen in Neuroopthalmology Clinic 2/18/93 and was found to have mild recovery of vision OS and improved visual fields. Aberrant reinnervation of the 3rd nerve was noted as there was constriction of the pupil (OS) on adduction, downgaze and upgaze. The upper eyelid, OS, elevated on adduction and down gaze, OS. EOM movements were otherwise full and there was no evidence of ptosis. In retrospect he was felt to have suffered pituitary apoplexy in 11/92.","radiology, sellar, hct, htn, pituitary, aneurysm, brain ct, cataclysmic, coronary artery disease, headache, intracranial mass, loss of vision, mass, melanoma, palsy, sneeze, stroke, temporal arteritis, vision loss, bilateral babinski signs, sellar enlargement, pituitary mass, temporal, vision,"
 Intensity-modulated radiation therapy simulation note.  The patient will receive intensity-modulated radiation therapy in order to deliver high-dose treatment to sensitive structures. , Radiology, Intensity-Modulated Radiation Therapy Simulation ,"INTENSITY-MODULATED RADIATION THERAPY SIMULATION,The patient will receive intensity-modulated radiation therapy in order to deliver high-dose treatment to sensitive structures.  The target volume is adjacent to significant radiosensitive structures.,Initially, the preliminary isocenter is set on a fluoroscopically-based simulation unit.  The patient is appropriately immobilized using a customized immobilization device.  Preliminary simulation films are obtained and approved by me.  The patient is marked and transferred to the CT scanner.  Sequential images are obtained and transferred electronically to the treatment planning software.  Extensive analysis then occurs.  The target volume, including margins for uncertainty, patient movement and occult tumor extension are selected.  In addition organs at risk are outlined.  Appropriate doses are selected, both for the target, as well as constraints for organs at risk.  Inverse treatment planning is performed by the physics staff under my supervision.  These are reviewed by the physician and ultimately performed only following approval by the physician and completion of successful quality assurance.","radiology, target volume, intensity modulated radiation therapy, simulationNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Right upper quadrant pain.  Nuclear medicine hepatobiliary scan.  Radiopharmaceutical 6.9 mCi of Technetium-99m Choletec., Radiology, Hepatobiliary Scan ,"NUCLEAR MEDICINE HEPATOBILIARY SCAN,REASON FOR EXAM: , Right upper quadrant pain.,COMPARISONS:  ,CT of the abdomen dated 02/13/09 and ultrasound of the abdomen dated 02/13/09.,Radiopharmaceutical 6.9 mCi of Technetium-99m Choletec.,FINDINGS:,  Imaging obtained up to 30 minutes after the injection of radiopharmaceutical shows a normal hepatobiliary transfer time.  There is normal accumulation within the gallbladder.,After the injection of 2.1 mcg of intravenous cholecystic _______, the gallbladder ejection fraction at 30 minutes was calculated to be 32% (normal is greater than 35%).  The patient experienced 2/10 pain at 5 minutes after the injection of the radiopharmaceutical and the patient also complained of nausea.,IMPRESSION:,1.  Negative for acute cholecystitis or cystic duct obstruction.,2.  Gallbladder ejection fraction just under the lower limits of normal at 32% that can be seen with very mild chronic cholecystitis.","radiology, radiopharmaceutical, gallbladder ejection fraction, nuclear medicine hepatobiliary, hepatobiliary scan, quadrant, nuclear, technetium, choletec, ejection, fraction, cholecystitis, scan, abdomen, injection, gallbladder, hepatobiliary, medicine"
 Intensity-modulated radiation therapy is a complex set of procedures which requires appropriate positioning and immobilization typically with customized immobilization devices., Radiology, Intensity-Modulated Radiation Therapy ,"INTENSITY-MODULATED RADIATION THERAPY,Intensity-modulated radiation therapy is a complex set of procedures which requires appropriate positioning and immobilization typically with customized immobilization devices.  The treatment planning process requires at least 4 hours of physician time.  The technology is appropriate in this patient's case due to the fact that the target volume is adjacent to significant radiosensitive structures.  Sequential CT scans are obtained and transferred to the treatment planning software.  Extensive analysis occurs.  The target volumes, including margins for uncertainty, patient movement and occult tumor extension are selected.  In addition, organs at risk are outlined.  Doses are selected both for targets, as well as for organs at risk.  Associated dose constraints are placed.  Inverse treatment planning is then performed in conjunction with the physics staff.  These are reviewed by the physician and ultimately performed only following approval by the physician.  Multiple beam arrangements may be tested for appropriateness and optimal dose delivery in order to maximize the chance of controlling disease, while minimizing exposure to organs at risk.  This is performed in hopes of minimizing associated complications.  The physician delineates the treatment type, number of fractions and total volume.  During the time of treatment, there is extensive physician intervention, monitoring the patient set up and tolerance.  In addition, specific QA is performed by the physics staff under the physician's direction.,In view of the above, the special procedure code 77470 is deemed appropriate.","radiology, multiple beam arrangements, intensity modulated radiation therapyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Bilateral Screening Mammogram Full-Field Digital Mammography (FFDM) (Benign Findings), Radiology, Full-Field Digital Mammogram (FFDM) - 1 ,"EXAM: , Digital screening mammogram.,HISTORY:,  51-year-old female presents for screening mammography.  Patient denies personal history of breast cancer.  Breast cancer was reported in her maternal aunt.,TECHNIQUE:,  Craniocaudal and mediolateral oblique projections of bilateral breasts were obtained on mm/dd/yy.  Comparison is made with the previous performed on mm/dd/yy. iCAD Second Look proprietary software was utilized.,FINDINGS:  ,The breasts demonstrate a mixture of adipose and fibroglandular elements.  Composition appears similar.  Multiple tiny punctate benign-appearing calcifications are visualized bilaterally.  No dominant mass, areas of architecture distortion, or malignant-type calcifications are seen.  Skin overlying both breasts is unremarkable.,IMPRESSION: , Stable and benign mammographic findings.  Continued yearly mammographic screening is recommended.,BIRADS Classification 2 - Benign,MAMMOGRAPHY INFORMATION:,1.  A certain percentage of cancers, probably 10% to 15%, will not be identified by mammography.,2.  Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present.,3.  These images were obtained with FDA-approved digital mammography equipment, and iCAD SecondLook Software Version 7.2 was utilized.","radiology, mediolateral, craniocaudal, fibroglandular, bilateral screening mammogram, breast cancer, screening mammogram, mammographic, mammogram, breasts, screening, mammography"
 Hyperfractionation.  This patient is to undergo a course of hyperfractionated radiotherapy in the treatment of known malignancy.  , Radiology, Hyperfractionation ,"HYPERFRACTIONATION,This patient is to undergo a course of hyperfractionated radiotherapy in the treatment of known malignancy.  The radiotherapy will be given in a hyperfractionated fraction (decreased dose per fraction but 2 fractions delivered daily separated by a period of at least 6 hours).  The rationale for this treatment is based on radiobiologic principles that make this type of therapy more effective in rapidly growing, previously irradiated or poorly oxygenated tumors.  The dose per fraction and the total dose are calculated by me, and this is individualized for each patient according to radiobiologic principles.,During the hyperfractionated radiotherapy, the chance of severe acute side effects is increased, so the patient will be followed more intensively for the development of any side effects and treatment instituted accordingly.","radiology, irradiated, oxygenated, tumors, malignancy, radiobiologic, hyperfractionation, hyperfractionated, radiotherapyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Sample Radiology report of knee (growth arrest lines)., Radiology, Five views of the right knee. ,"EXAM: , Five views of the right knee.,HISTORY: , Pain.  The patient is status-post surgery, he could not straighten his leg, pain in the back of the knee.,TECHNIQUE:,  Five views of the right knee were evaluated.  There are no priors for comparison.,FINDINGS: , Five views of the right knee were evaluated and they reveal there is no evidence of any displaced fractures, dislocations, or subluxations.  There are multiple areas of growth arrest lines seen in the distal aspect of the femur and proximal aspect of the tibia.  There is also appearance of a high-riding patella suggestive of patella alta.,IMPRESSION:,1.  No evidence of any displaced fractures, dislocations, or subluxations.,2.  Growth arrest lines seen in the distal femur and proximal tibia.,3.  Questionable appearance of a slightly high-riding patella, possibly suggesting patella alta.","radiology, fractures dislocations or subluxations, femur and proximal, growth arrest lines, patella alta, fractures, dislocations, subluxations, distal, femur, patella"
 HDR Brachytherapy, Radiology, HDR Brachytherapy ,"HDR BRACHYTHERAPY,The intracavitary brachytherapy applicator was placed appropriately and secured after the patient was identified.  Simulation films were obtained, documenting its positioning.  The 3-dimensional treatment planning process was accomplished utilizing the CT derived data.  A treatment plan was selected utilizing sequential dwell positions within a single catheter.  The patient was taken to the treatment area.  The patient was appropriately positioned and the position of the intracavitary device was checked.  Catheter length measurements were taken.  Appropriate measurements of the probe dimensions and assembly were also performed.  The applicator was attached to the HDR after-loader device.  The device ran through its checking sequences appropriately and the brachytherapy was then delivered without difficulty or complication.  The brachytherapy source was appropriately removed back to the brachytherapy safe within the device.  Radiation screening was performed with the Geiger-Muller counter both prior to and after the brachytherapy procedure was completed and the results were deemed appropriate.,Following completion of the procedure, the intracavitary device was removed without difficulty.  The patient was in no apparent distress and was discharged home.","radiology, geiger-muller, treatment planning, hdr brachytherapy, intracavitary, applicator, brachytherapyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" Mammogram, bilateral full-field digital mammography FFDM (patient with positive history of breast cancer).", Radiology, Full-Field Digital Mammogram (FFDM) - 2 ,"EXAM: , Screening full-field digital mammogram.,HISTORY:,  Screening examination of a 58-year-old female who currently denies complaints.  Patient has had diagnosis of right breast cancer in 1984 with subsequent radiation therapy.  The patient's sister was also diagnosed with breast cancer at the age of 59.,TECHNIQUE: , Standard digital mammographic imaging was performed.  The examination was performed with iCAD Second Look Version 7.2.,COMPARISON: , Most recently obtained __________.,FINDINGS: , The right breast is again smaller than the left.  There is a scar marker with underlying skin thickening and retraction along the upper margin of the right breast.  The breasts are again composed of a mixture of adipose tissue and a moderate amount of heterogeneously-dense fibroglandular tissue.  There is again some coarsening of the right breast parenchyma with architectural distortion which is unchanged and most consistent with postsurgical and postradiation changes.  A few benign-appearing microcalcifications are present.,No dominant malignant-appearing mass lesion, developing area of architectural distortion or suspicious-appearing cluster of microcalcifications are identified.  The skin is stable.  No enlarged axillary lymph node is seen.,IMPRESSION:,1.  No significant interval changes are seen.  No mammographic evidence of malignancy is identified.,2.  Annual screening mammography is recommended or sooner if clinical symptoms warrant.,BIRADS Classification 2 - Benign,MAMMOGRAPHY INFORMATION:,1.  A certain percentage of cancers, probably 10% to 15%, will not be identified by mammography.,2.  Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present.,3.  These images were obtained with FDA-approved digital mammography equipment, and iCAD Second Look Software Version 7.2 was utilized.","radiology, digital mammography, full-field digital mammogram, ffdm, second look version, field digital mammogram, digital mammogram, breast cancer, mammographic, icad, microcalcifications, mammogram, screening, digital, mammography, breast"
" Bilateral facet Arthrogram and injections at L34, L45, L5S1.  Interpretation of radiograph.  Low Back Syndrome - Low Back Pain.", Radiology, Facet Arthrogram & Injection ,"PREOPERATIVE DIAGNOSIS: , Low Back Syndrome - Low Back Pain.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE:,1.  Bilateral facet Arthrogram at L34, L45, L5S1.,2.  Bilateral facet injections at L34, L45, L5S1.,3.  Interpretation of radiograph.,ANESTHESIA:  ,IV sedation with Versed and Fentanyl.,ESTIMATED BLOOD LOSS: , None.,COMPLICATIONS:  ,None.,INDICATION: , Pain in the lumbar spine secondary to facet arthrosis that was demonstrated by physical examination and verified with x-ray studies and imaging scans.,SUMMARY OF PROCEDURE: , The patient was admitted to the OR, consent was obtained and signed.  The patient was taken to the Operating room and was placed in the prone position.  Monitors were placed, including EKG, pulse oximeter and blood pressure monitoring.  Prior to sedation vitals signs were obtained and were continuously monitored throughout the procedure for amount of pain or changes in pain, EKG, respiration and heart rate and at intervals of three minutes for blood pressure.  After adequate IV sedation with Versed and Fentanyl the procedure was begun.,The lumbar sacral regions were prepped and draped in sterile fashion with Betadine prep and four sterile towels.,The facets in the lumbar regions were visualized with Fluoroscopy using an anterior posterior view.  A skin wheal was placed with 1% Lidocaine at the L34 facet region on the left.  Under fluoroscopic guidance a 22 gauge spinal needle was then placed into the L34 facet on the left side.  This was performed using the oblique view under fluoroscopy to the enable the view of the ""Scotty Dog,"" After obtaining the ""Scotty Dog"" view the joints were easily seen.  Negative aspiration was carefully performed to verity that there was no venous, arterial or cerebral spinal fluid flow.  After negative aspiration was verified, 1/8th of a cc of Omnipaque 240 dye was then injected.  Negative aspiration was again performed and 1/2 cc of solution (Solution consisting of 9 cc of 0.5% Marcaine with 1 cc of Triamcinolone) was then injected into the joint.  The needle was then withdrawn out of the joint and 1.5 cc of this same solution was injected around the joint.  The 22-gauge needle was then removed.  Pressure was place over the puncture site for approximately one minute.  This exact same procedure was then repeated along the left-sided facets at L45, and L5S1.  This exact same procedure was then repeated on the right side.  At each level, vigilance was carried out during the aspiration of the needle to verify negative flow of blood or cerebral spinal fluid.,The patient was noted to have tolerated the procedure well without any complications.,Interpretation of the radiograph revealed placement of the 22-gauge spinal needles into the left-sided and right-sided facet joints at, L34, L45, and L5S1.  Visualizing the ""Scotty Dog"" technique under fluoroscopy facilitated this.  Dye spread into each joint space is visualized.  No venous or arterial run-off is noted.  No epidural run-off is noted.  The joints were noted to have chronic inflammatory changes noted characteristic of facet arthrosis.","radiology, low back syndrome, low back pain, facet injection, fluoroscopy, iv sedation, spinal fluid, facet arthrogram, aspiration, arthrogram, injection, facet,"
 HCT for memory loss and for calcification of basal ganglia (globus pallidi)., Radiology, HCT - Calcification of Basal Ganglia ,"CC:, Memory loss.,HX:, This 77 y/o RHF presented with a one year history of progressive memory loss. Two weeks prior to her evaluation at UIHC she agreed to have her sister pick her up for church at 8:15AM, Sunday morning. That Sunday she went to pick up her sister at her sister's home and when her sister was not there (because the sister had gone to pick up the patient) the patient left. She later called the sister and asked her if she (sister) had overslept. During her UIHC evaluation she denied she knew anything about the incident. No other complaints were brought forth by the patients family.,PMH:, Unremarkable.,MEDS:, None,FHX: ,Father died of an MI, Mother had DM type II.,SHX: , Denies ETOH/illicit drug/Tobacco use.,ROS:, Unremarkable.,EXAM:, Afebrile, 80BPM, BP 158/98, 16RPM. Alert and oriented to person, place, time. Euthymic. 29/30 on Folstein's MMSE with deficit on drawing. Recalled 2/6 objects at five minutes and could not recite a list of 6 objects in 6 trials. Digit span was five forward and three backward. CN: mild right lower facial droop only. MOTOR: Full strength throughout. SENSORY: No deficits to PP/Vib/Prop/LT/Temp. COORD: Poor RAM in LUE only. GAIT: NB and ambulated without difficulty. STATION: No drift or Romberg sign. REFLEXES: 3+ bilaterally with flexor plantar responses. There were no frontal release signs.,LABS:, CMB, General Screen, FT4, TSH, VDRL were all WNL.,NEUROPSYCHOLOGICAL EVALUATION, 12/7/92: ,Verbal associative fluency was defective. Verbal memory, including acquisition, and delayed recall and recognition, was severely impaired. Visual memory, including immediate and delayed recall was also severely impaired. Visuoperceptual discrimination was mildly impaired, as was 2-D constructional praxis.,HCT, 12/7/92: , Diffuse cerebral atrophy with associative mild enlargement of the ventricles consistent with patient's age. Calcification is seen in both globus pallidi and this was felt to be a normal variant.","radiology, memory loss, romberg sign, hct, cerebral atrophy, calcification of basal ganglia, basal ganglia, globus pallidi, basal, ganglia, globus, pallidi, calcification,"
 Exercise myocardial perfusion study.  The exercise myocardial perfusion study shows possibility of mild ischemia in the inferolateral wall and normal LV systolic function with LV ejection fraction of 59%, Radiology, Exercise Myocardial Perfusion Study ,"CLINICAL INDICATION:,  Chest pain.,INTERPRETATION: , The patient received 14.9 mCi of Cardiolite for the rest portion of the study and 11.5 mCi of Cardiolite for the stress portion of the study.,The patient's baseline EKG was normal sinus rhythm.  The patient was stressed according to Bruce protocol by Dr. X.  Exercise test was supervised and interpreted by Dr. X.  Please see the separate report for stress portion of the study.,The myocardial perfusion SPECT study shows there is mild anteroseptal fixed defect seen, which is most likely secondary to soft tissue attenuation artifact.  There is, however, mild partially reversible perfusion defect seen, which is more pronounced in the stress images and short-axis view suggestive of minimal ischemia in the inferolateral wall.,The gated SPECT study shows normal wall motion and wall thickening with calculated left ventricular ejection fraction of 59%.,CONCLUSION:,1.  The exercise myocardial perfusion study shows possibility of mild ischemia in the inferolateral wall.,2.  Normal LV systolic function with LV ejection fraction of 59%.","radiology, chest pain, cardiolite, ekg, spect, lv systolic function, lv ejection fraction, myocardial perfusion study, spect study, ejection fraction, myocardial, perfusion, ischemia, "
 Endovascular Brachytherapy (EBT), Radiology, Endovascular Brachytherapy ,"ENDOVASCULAR BRACHYTHERAPY (EBT),The patient is to undergo a course of angioplasty for in-stent restenosis.  The radiotherapy will be planned using simulation films when the Novoste system catheter markers are placed on either side of the coronary artery injury site.  After this, a calculation will take place to determine the length of time at which the strontium sources will be left in place to deliver an adequate dose given the reference vessel diameter.  The rationale for this treatment is based on radiobiological principles that make this type of therapy more effective than blade atherectomy or laser atherectomy.  The does per fraction is individualized for each patient according to radiobiological principles and reference vessel diameter.  Given that this is a very high dose rate source and the chances of severe acute toxicity such as cardiac ischemia and machine malfunction are present, it is imperative that the patient be followed closely by myself and monitored for ST segment elevation and correct machine function.","radiology, endovascular brachytherapy, ebt, angioplasty, stent, vessel, atherectomy, endovascular, brachytherapyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Nerve conduction screen demonstrates borderline median sensory and borderline distal median motor responses in both hands.   The needle EMG examination is remarkable for rather diffuse active denervation changes in most muscles of the right upper and right lower extremity tested., Radiology, EMG/Nerve Conduction Study - 9 ,"NERVE CONDUCTION TESTING AND EMG EVALUATION,1.  Right median sensory response 3.0, amplitude 2.5, distance 100.,2.  Right ulnar sensory response 2.1, amplitude 1, distance 90.,3.  Left median sensory response 3.0, amplitude 1.2, distance 100.,4.  Left median motor response distal 4.2, proximal 9, amplitude 2.2, distance 290, velocity 60.4 m/sec.,5.  Right median motor response distal 4.3, proximal 9.7, amplitude 2, and velocity 53.7 m/sec.,6.  Right ulnar motor response distal 2.5, proximal 7.5, amplitude 2, distance 300, velocity 60 m/sec.,NEEDLE EMG TESTING,1.  ,RIGHT BICEPS:,  Fibrillations 0, fasciculations occasional, positive waves 0.  Motor units, increased needle insertional activity and mild decreased number of motor units firing.,2.  ,RIGHT TRICEPS:,  Fibrillations 1+, fasciculations occasional to 1+, positive waves 1+.  Motor units, increased needle insertional activity and decreased number of motor units firing.,3.  ,EXTENSOR DIGITORUM:,  Fibrillations 0, fasciculations rare, positive waves 0, motor units probably normal.,4.  ,FIRST DORSAL INTEROSSEOUS: , Fibrillations 2+, fasciculations 1+, positive waves 2+.  Motor units, decreased number of motor units firing.,5.  ,RIGHT ABDUCTOR POLLICIS BREVIS:,  Fibrillations 1+, fasciculations 1+, positive waves 0.  Motor units, decreased number of motor units firing.,6. , FLEXOR CARPI ULNARIS:,  Fibrillations 1+, occasionally entrained, fasciculations rare, positive waves 1+.  Motor units, decreased number of motor units firing.,7.  ,LEFT FIRST DORSAL INTEROSSEOUS:,  Fibrillations 1+, fasciculations 1+, positive waves occasional.  Motor units, decreased number of motor units firing.,8.  ,LEFT EXTENSOR DIGITORUM:,  Fibrillations 1+, fasciculations 1+.  Motor units, decreased number of motor units firing.,9.  ,RIGHT VASTUS MEDIALIS:,  Fibrillations 1+ to 2+, fasciculations 1+, positive waves 1+.  Motor units, decreased number of motor units firing.,10.  ,ANTERIOR TIBIALIS: , Fibrillations 2+, occasionally entrained, fasciculations 1+, positive waves 1+.  Motor units, increased proportion of polyphasic units and decreased number of motor units firing.  There is again increased needle insertional activity.,11.  ,RIGHT GASTROCNEMIUS:,  Fibrillations 1+, fasciculations 1+, positive waves 1+.  Motor units, marked decreased number of motor units firing.,12.  ,LEFT GASTROCNEMIUS:,  Fibrillations 1+, fasciculations 1+, positive waves 2+.  Motor units, marked decreased number of motor units firing.,13.  ,LEFT VASTUS MEDIALIS: , Fibrillations occasional, fasciculations occasional, positive waves 1+.  Motor units, decreased number of motor units firing.,IMPRESSION: ",
 The patient is status post C3-C4 anterior cervical discectomy and fusion., Radiology, EMG/Nerve Conduction Study - 5 ,"She has an extensive past medical history of rheumatoid arthritis, fibromyalgia, hypertension, hypercholesterolemia, and irritable bowel syndrome.  She has also had bilateral carpal tunnel release.,On examination, normal range of movement of C-spine.  She has full strength in upper and lower extremities.  Normal straight leg raising.  Reflexes are 2 and symmetric throughout.  No Babinski.  She has numbness to light touch in her right big toe.,NERVE CONDUCTION STUDIES:  The right median palmar sensory distal latencies are minimally prolonged with minimally attenuated evoked response amplitude.  Bilateral tibial motor nerves could not be obtained (technical).  The remaining nerves tested revealed normal distal latencies, evoked response amplitudes, conduction velocities, F-waves, and H. reflexes.,NEEDLE EMG:  Needle EMG was performed on the right arm and leg and lumbosacral and cervical paraspinal muscles and the left FDI.  It revealed 2+ spontaneous activity in the right APB and FDI and 1+ spontaneous activity in lower cervical paraspinals, lower and middle lumbosacral paraspinals, right extensor digitorum communis muscle, and right pronator teres.  There was evidence of chronic denervation in the right first dorsal interosseous, pronator teres, abductor pollicis brevis, and left first dorsal interosseous.,IMPRESSION:  This electrical study is abnormal.  It reveals the following:,1.  An active right C8/T1 radiculopathy.  Electrical abnormalities are moderate.,2.  An active right C6/C7 radiculopathy.  Electrical abnormalities are mild.,3.  Evidence of chronic left C8/T1 denervation.  No active denervation.,4.  Mild right lumbosacral radiculopathies.  This could not be further localized because of normal EMG testing in the lower extremity muscles.,5.  There is evidence of mild sensory carpal tunnel on the right (she has had previous carpal tunnel release).,Results were discussed with the patient.  It appears that she has failed conservative therapy and I have recommended to her that she return to Dr. X for his assessment for possible surgery to her C-spine.  She will continue with conservative therapy for the mild lumbosacral radiculopathies.","radiology, emg, nerve conduction study, needle emg, paraspinal muscles, radiculopathy, electrical abnormalities, carpal tunnel release, evoked response, lumbosacral radiculopathies, conservative therapy, carpal tunnel, conduction, emg/nerve, "
" The patient is a 39-year-old gravida 3, para 2, who is now at 20 weeks and 2 days gestation.  This pregnancy is a twin gestation.  The patient presents for her fetal anatomical survey.  ", Radiology, Fetal Anatomical Survey ,"PAST MEDICAL HISTORY:  ,The patient denies any significant past medical history.,PAST SURGICAL HISTORY: , The patient denies any significant surgical history.,MEDICATIONS: , The patient takes no medications.,ALLERGIES: , No known drug allergies.,SOCIAL HISTORY: , She denies use of cigarettes, alcohol or drugs.,FAMILY HISTORY: , No family history of birth defects, mental retardation or any psychiatric history.,DETAILS: , I performed a transabdominal ultrasound today using a 4 MHz transducer.  There is a twin gestation in the vertex transverse lie with an anterior placenta and a normal amount of amniotic fluid surrounding both of the twins.  The fetal biometry of twin A is as follows.  The biparietal diameter is 4.9 cm consistent with 20 weeks and 5 days, head circumference 17.6 cm consistent with 20 weeks and 1 day, the abdominal circumference is 15.0 cm consistent with 20 weeks and 2 days, and femur length is 3.1 cm consistent with 19 weeks and 5 days, and the humeral length is 3.0 cm consistent with 20 weeks and 0 day.  The average gestational age by ultrasound is 20 weeks and 1 day and the estimated fetal weight is 353 g.  The following structures are seen as normal on the fetal anatomical survey, the shape of the fetal head, the choroid plexuses, the cerebellum, nuchal fold thickness, the fetal spine and fetal face, the four-chamber view of the fetal heart, the outflow tracts of the fetal heart, the stomach, the kidneys, and cord insertion site, the bladder, the extremities, the genitalia, the cord, which appeared to have three vessels and the placenta.,Limited in views of baby A with a nasolabial region.,The following is the fetal biometry for twin B. The biparietal diameter is 4.7 cm consistent with 20 weeks and 2 days, head circumference 17.5 cm consistent with 20 weeks and 0 day, the abdominal circumference is 15.5 cm consistent with 20 weeks and 5 days, the femur length is 3.3 cm consistent with 20 weeks and 3 days, and the humeral length is 3.1 cm consistent with 20 weeks and 2 days, the average gestational age by ultrasound is 22 weeks and 2 days, and the estimated fetal weight is 384 g.  The following structures were seen as normal on the fetal anatomical survey.  The shape of the fetal head, the choroid plexuses, the cerebellum, nuchal fold thickness, the fetal spine and fetal face, the four-chamber view of the fetal heart, the outflow tracts of the fetal heart, the stomach, the kidneys, and cord insertion site, the bladder, the extremities, the genitalia, the cord, which appeared to have three vessels, and the placenta.  Limited on today's ultrasound the views of nasolabial region.,In summary, this is a twin gestation, which may well be monochorionic at 20 weeks and 1 day.  There is like gender and a single placenta.  One cannot determine with certainty whether or not this is a monochorionic or dichorionic gestation from the ultrasound today.,I sat with the patient and her husband and discussed alternative findings and the complications.  We focused our discussion today on the association of twin pregnancy with preterm delivery.  We discussed the fact that the average single intrauterine pregnancy delivers at 40 weeks' gestation while the average twin delivery occurs at 35 weeks' gestation.  We discussed the fact that 15% of twins deliver prior to 32 weeks' gestation.  These are the twins which we have the most concern regarding the long-term prospects of prematurity.  We discussed several etiologies of preterm delivery including preterm labor, incompetent cervix, premature rupture of the fetal membranes as well as early delivery from preeclampsia and growth restriction.  We discussed the use of serial transvaginal ultrasound to assess for early cervical change and the use of serial transabdominal ultrasound to assess for normal interval growth.  We discussed the need for frequent office visits to screen for preeclampsia.  We also discussed treatment options such as cervical cerclage, bedrest, tocolytic medications, and antenatal steroids.  I would recommend that the patient return in two weeks for further cervical assessment and assessment of fetal growth and well-being.,In closing, I do want to thank you very much for involving me in the care of your delightful patient.  I did review all of the above findings and recommendations with the patient today at the time of her visit.  Please do not hesitate to contact me if I could be of any further help to you.,Total visit time 40 minutes.","radiology, vaginal delivery, transducer, transabdominal ultrasound, placenta, amniotic fluid, fetal anatomical survey, preterm delivery, twin gestation, gestation, infant, fetal, anatomical, delivery, ultrasound,"
" A woman with a history of progression of dysphagia for the past year, dysarthria, weakness of her right arm, cramps in her legs, and now with progressive weakness in her upper extremities.  Abnormal electrodiagnostic study. ", Radiology, EMG/Nerve Conduction Study - 8 ,"REFERRING DIAGNOSIS: , Motor neuron disease.,PERTINENT HISTORY AND EXAMINATION:,  Briefly, the patient is an 83-year-old woman with a history of progression of dysphagia for the past year, dysarthria, weakness of her right arm, cramps in her legs, and now with progressive weakness in her upper extremities.,SUMMARY:  ,The right median sensory response showed a borderline normal amplitude for age with mild slowing of conduction velocity.  The right ulnar sensory amplitude was reduced with slowing of the conduction velocity.  The right radial sensory amplitude was reduced with slowing of the conduction velocity.  The right sural and left sural sensory responses were absent.  The right median motor response showed a prolonged distal latency across the wrist, with proximal slowing.  The distal amplitude was very reduced, and there was a reduction with proximal stimulation.  The right ulnar motor amplitude was borderline normal, with slowing of the conduction velocity across the elbow.  The right common peroneal motor response showed a decreased amplitude when recorded from the EDB, with mild slowing of the proximal conduction velocity across the knee.  The right tibial motor response showed a reduced amplitude with prolongation of the distal latency.  The left common peroneal response recorded from the EDB showed a decreased amplitude with mild distal slowing.  The left tibial motor response showed a decreased amplitude with a borderline normal distal latency.  The minimum F-wave latencies were normal with the exception of a mild prolongation of the ulnar F-wave latency, and the tibial F-wave latency as indicated above.  With repetitive nerve stimulation, there was no significant decrement noted in either the right nasalis or the right trapezius muscles.  Concentric needle EMG studies were performed in the right lower extremity, right upper extremity, thoracic paraspinals, and in the tongue.  There was evidence of increased insertional activity in the right tibialis anterior muscle, with evidence of fasciculations noted in several lower and upper extremity muscles and in the tongue.  In addition, there was evidence of increased amplitude, long duration and polyphasic motor units with a decreased recruitment noted in most muscles tested as indicated in the table above.,INTERPRETATION: , Abnormal electrodiagnostic study.  There is electrodiagnostic evidence of a disorder of the anterior motor neurons affecting at least four segments.  There is also evidence of a more generalized neuropathy that seems to be present in both the upper and lower extremities.  There is also evidence of a right median mononeuropathy at the wrist and a right ulnar neuropathy at the elbow.  Even despite the patient's age, the decrease in sensory responses is concerning, and makes it difficult to be certain about the diagnosis of motor neuron disease.  However, the overall changes on the needle EMG would be consistent with a diagnosis of motor neuron disease.  The patient will return for further evaluation.","radiology, electrodiagnostic study, electrodiagnostic, edb, latency, nerve conduction study, emg, motor neuron disease, distal latency, motor response, motor, amplitude, conduction"
 Common Excretory Urogram - IVP template, Radiology, Excretory Urogram - IVP  ,"There is normal and symmetrical filling of the caliceal system.  Subsequent films demonstrate that the kidneys are of normal size and contour bilaterally.  The caliceal system and ureters are in their usual position and show no signs of obstruction or intraluminal defects. The postvoid films demonstrate normal emptying of the collecting system, including the urinary bladder.,IMPRESSION:,  Negative intravenous urogram.,","radiology, intravenous urogram, caliceal system, urinary bladder, excretory urogram, collecting systems, ivp, urogram, intravenousNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time. ", Radiology, EMG/Nerve Conduction Study - 3 ,"HISTORY: , The patient is a 56-year-old right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident in September of 2005.  At that time, she did not notice any specific injury.  Five days later, she started getting abnormal right low back pain.  At this time, it radiates into the buttocks down the posterior aspect of her thigh and into the right lateral aspect of her calf.  Symptoms are worse when sitting for any length of time, such as driving a motor vehicle.  Mild symptoms when walking for long periods of time.  Relieved by standing and lying down.  She denies any left leg symptoms or right leg weakness.  No change in bowel or bladder function.  Symptoms have slowly progressed.  She has had Medrol Dosepak and analgesics, which have not been very effective.  She underwent a spinal epidural injection, which was effective for the first few hours, but she had recurrence of the pain by the next day.  This was done four and a half weeks ago.,On examination, lower extremities strength is full and symmetric.  Straight leg raising is normal.,OBJECTIVE:,  Sensory examination is normal to all modalities.  Full range of movement of lumbosacral spine.  Mild tenderness over lumbosacral paraspinal muscles and sacroiliac joint.  Deep tendon reflexes are 2+ and symmetric at the knees, 2 at the left ankle and 1+ at the right ankle.,NERVE CONDUCTION STUDIES:,  Motor and sensory distal latencies, evoked response, amplitudes, conduction velocities, and F-waves are normal in the lower extremities.  Right tibial H-reflex is slightly prolonged when compared to the left tibial H-reflex.,NEEDLE EMG:,  Needle EMG was performed in both lower extremities and lumbosacral paraspinal muscles using the disposable concentric needle.  It revealed increased insertional activity in the right mid and lower lumbosacral paraspinal muscles as well as right peroneus longus muscle.  There were signs of chronic denervation in right tibialis anterior, peroneus longus, gastrocnemius medialis, and left gastrocnemius medialis muscles.,IMPRESSION: , This electrical study is abnormal.  It reveals the following:,1.  A mild right L5 versus S1 radiculopathy.,2.  Left S1 nerve root irritation.  There is no evidence of active radiculopathy.,3.  There is no evidence of plexopathy, myopathy or peripheral neuropathy.,MRI of the lumbosacral spine was personally reviewed and reveals bilateral L5-S1 neuroforaminal stenosis, slightly worse on the right.  Results were discussed with the patient and her daughter.  I would recommend further course of spinal epidural injections with Dr. XYZ.  If she has no response, then surgery will need to be considered.  She agrees with this approach and will followup with you in the near future.","radiology, emg, nerve conduction study, radiculopathy, peripheral neuropathy, nerve root irritation, motor vehicle accident, lumbosacral paraspinal muscles, spinal epidural, lumbosacral spine, peroneus longus, gastrocnemius medialis, lower extremities, emg/nerve, conduction, needle"
" Patient had movor vehicle accirdent and may have had a brief loss of consciousness.  Shortly thereafter she had some blurred vision,  Since that time she has had right low neck pain and left low back pain.  ", Radiology, EMG/Nerve Conduction Study - 7 ,"HISTORY: , The patient is a 34-year-old right-handed female who states her symptoms first started after a motor vehicle accident in September 2005.  She may have had a brief loss of consciousness at the time of the accident since shortly thereafter she had some blurred vision, which lasted about a week and then resolved.  Since that time she has had right low neck pain and left low back pain.  She has been extensively worked up and treated for this.  MRI of the C & T spine and LS spine has been normal.  She has improved significantly, but still complains of pain.  In June of this year she had different symptoms, which she feels are unrelated.  She had some chest pain and feeling of tightness in the left arm and leg and face.  By the next morning she had numbness around her lips on the left side and encompassing the whole left arm and leg.  Symptoms lasted for about two days and then resolved.  However, since that time she has had intermittent numbness in the left hand and leg.  The face numbness has completely resolved.  Symptoms are mild.  She denies any previous similar episodes.  She denies associated dizziness, vision changes incoordination, weakness, change in gait, or change in bowel or bladder function.  There is no associated headache.,Brief examination reveals normal motor examination with no pronator drift and no incoordination.  Normal gait.  Cranial nerves are intact.  Sensory examination reveals normal facial sensation.  She has normal and symmetrical light touch, temperature, and pinprick in the upper extremities.  In the lower extremities she has a feeling of dysesthesia in the lateral aspect of the left calf into the lateral aspect of the left foot.  In this area she has normal light touch and pinprick.  She describes it as a strange unusual sensation.,NERVE CONDUCTION STUDIES: , Motor and sensory distal latencies, evoked response amplitudes, conduction velocities, and F-waves are normal in the left arm and leg.,NEEDLE EMG: , Needle EMG was performed in the left leg, lumbosacral paraspinal, right tibialis anterior, and right upper thoracic paraspinal muscles using a disposable concentric needle.  It revealed normal insertional activity, no spontaneous activity, and normal motor unit action potential form in all muscles tested.,IMPRESSION: , This electrical study is normal.  There is no evidence for peripheral neuropathy, entrapment neuropathy, plexopathy, or lumbosacral radiculopathy.  EMG was also performed in the right upper thoracic paraspinal where she has experienced a lot of pain since the motor vehicle accident.  This was normal.,Based on her history of sudden onset of left face, arm, and leg weakness as well as a normal EMG and MRI of her spine I am concerned that she had a central event in June of this year.  Symptoms are now very mild, but I have ordered an MRI of the brain with and without contrast and MRA of the head and neck with contrast to further elucidate her symptoms.  Once she has the test done she will phone me and further management will be based on the results.","radiology, nerve conduction studies, motor, sensory, distal latencies, evoked response, conduction velocities, needle emg, loss of consciousness, motor vehicle accident, thoracic paraspinal, needle, paraspinal, conduction, "
" EMG/Nerve Conduction Study showing sensory motor length-dependent neuropathy consistent with diabetes, severe left ulnar neuropathy, and moderate-to-severe left median neuropathy, ", Radiology, EMG/Nerve Conduction Study - 4 ,"NERVE CONDUCTION STUDIES:,  Bilateral ulnar sensory responses are absent.  Bilateral median sensory distal latencies are prolonged with a severely attenuated evoked response amplitude.  The left radial sensory response is normal and robust.  Left sural response is absent.  Left median motor distal latency is prolonged with attenuated evoked response amplitude.  Conduction velocity across the forearm is mildly slowed.  Right median motor distal latency is prolonged with a normal evoked response amplitude and conduction velocity.  The left ulnar motor distal latency is prolonged with a severely attenuated evoked response amplitude both below and above the elbow.  Conduction velocities across the forearm and across the elbow are prolonged.  Conduction velocity proximal to the elbow is normal.  The right median motor distal latency is normal with normal evoked response amplitudes at the wrist with a normal evoked response amplitude at the wrist.  There is mild diminution of response around the elbow.  Conduction velocity slows across the elbow.  The left common peroneal motor distal latency evoked response amplitude is normal with slowed conduction velocity across the calf and across the fibula head.  F-waves are prolonged.,NEEDLE EMG: , Needle EMG was performed on the left arm and lumbosacral and cervical paraspinal muscles as well as middle thoracic muscles using a disposable concentric needle.  It revealed spontaneous activity in lower cervical paraspinals, left abductor pollicis brevis, and first dorsal interosseous muscles.  There were signs of chronic reinnervation in triceps, extensor digitorum communis, flexor pollicis longus as well first dorsal interosseous and abductor pollicis brevis muscles.,IMPRESSION: , This electrical study is abnormal.  It reveals the following:,1.  A sensory motor length-dependent neuropathy consistent with diabetes.,2.  A severe left ulnar neuropathy.  This is probably at the elbow, although definitive localization cannot be made.,3.  Moderate-to-severe left median neuropathy.  This is also probably at the carpal tunnel, although definitive localization cannot be made.,4.  Right ulnar neuropathy at the elbow, mild.,5.  Right median neuropathy at the wrist consistent with carpal tunnel syndrome, moderate.,6.  A left C8 radiculopathy (double crush syndrome).,7.  There is no evidence for thoracic radiculitis.,The patient has made very good response with respect to his abdominal pain since starting Neurontin.  He still has mild allodynia and is waiting for authorization to get insurance coverage for his Lidoderm patch.  He is still scheduled for MRI of C-spine and T-spine.  I will see him in followup after the above scans.","radiology, emg, nerve conduction study, nerve conduction studies, needle emg, electrical study, neuropathy, ulnar neuropathy, median neuropathy, severely attenuated evoked response, normal evoked response amplitude, attenuated evoked response amplitude, median motor distal latency, motor distal latency, abductor pollicis, pollicis brevis, dorsal interosseous, carpal tunnel, conduction, emg/nerve, needle,"
 Patient with a past medical history of a left L5-S1 lumbar microdiskectomy with complete resolution of left leg symptoms., Radiology, EMG/Nerve Conduction Study - 6 ,"HISTORY:,  The patient is a 46-year-old right-handed gentleman with a past medical history of a left L5-S1 lumbar microdiskectomy in 1998 with complete resolution of left leg symptoms, who now presents with a four-month history of gradual onset of right-sided low back pain with pain radiating down into his buttock and posterior aspect of his right leg into the ankle.  Symptoms are worsened by any activity and relieved by rest.  He also feels that when the pain is very severe, he has some subtle right leg weakness.  No left leg symptoms.  No bowel or bladder changes.,On brief examination, full strength in both lower extremities.  No sensory abnormalities.  Deep tendon reflexes are 2+ and symmetric at the patellas and absent at both ankles.  Positive straight leg raising on the right.,MRI of the lumbosacral spine was personally reviewed and reveals a right paracentral disc at L5-S1 encroaching upon the right exiting S1 nerve root.,NERVE CONDUCTION STUDIES:,  Motor and sensory distal latencies, evoked response amplitudes, and conduction velocities are normal in the lower extremities.  The right common peroneal F-wave is minimally prolonged.  The right tibial H reflex is absent.,NEEDLE EMG:,  Needle EMG was performed on the right leg, left gastrocnemius medialis muscle, and right lumbosacral paraspinal muscles using a disposable concentric needle.  It revealed spontaneous activity in the right gastrocnemius medialis, gluteus maximus, and lower lumbosacral paraspinal muscles.  There was evidence of chronic denervation in right gastrocnemius medialis and gluteus maximus muscles.,IMPRESSION: , This electrical study is abnormal.  It reveals an acute right S1 radiculopathy.  There is no evidence for peripheral neuropathy or left or right L5 radiculopathy.,Results were discussed with the patient and he is scheduled to follow up with Dr. X in the near future.","radiology, microdiskectomy, needle emg, nerve conduction studies, lumbosacral paraspinal muscles, lumbar microdiskectomy, lower extremities, lumbosacral paraspinal, paraspinal muscles, gluteus maximus, leg symptoms, gastrocnemius medialis, emg/nerve, conduction, lumbosacral, needle, gastrocnemius, medialis, muscles, "
" A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back pain radiating into the right leg.", Radiology, EMG/Nerve Conduction Study - 2 ,"HISTORY: , The patient is a 78-year-old right-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back pain radiating into the right leg.  She was undergoing a spinal epidural injection about a month ago and had worsening of right low back pain, which radiates down into her buttocks and down to posterior aspect of her thigh into her knee.  This has required large amounts of opioid analgesics to control.  She has been basically bedridden because of this.  She was brought into hospital for further investigations.,PHYSICAL EXAMINATION: , On examination, she has positive straight leg rising on the right with severe shooting, radicular type pain with right leg movement.  Difficult to assess individual muscles, but strength is largely intact.  Sensory examination is symmetric.  Deep tendon reflexes reveal hyporeflexia in both patellae, which probably represents a cervical myelopathy from prior cord compression.  She has slightly decreased right versus left ankle reflexes.  The Babinski's are positive.  On nerve conduction studies, motor and sensory distal latencies, evoked response amplitudes, conduction velocities, and F-waves are normal in lower extremities.,NEEDLE EMG: , Needle EMG was performed on the right leg and lumbosacral paraspinal muscles using a disposable concentric needle.  It reveals the spontaneous activity in right peroneus longus and gastrocnemius medialis muscles as well as the right lower lumbosacral paraspinal muscles.  There is evidence of denervation in right gastrocnemius medialis muscle.,IMPRESSION: , This electrical study is abnormal.  It reveals the following:,1.  Inactive right S1 (L5) radiculopathy.,2.  There is no evidence of left lower extremity radiculopathy, peripheral neuropathy or entrapment neuropathy.,Results were discussed with the patient and she is scheduled for imaging studies in the next day.","radiology, needle emg, radiculopathy, electrical study, emg, nerve conduction study, cervical spinal stenosis, lumbosacral paraspinal muscles, gastrocnemius medialis muscles, spinal stenosis, post decompression, lumbosacral paraspinal, paraspinal muscles, gastrocnemius medialis, medialis muscles, decompression, emg/nerve, conduction, cervical, spinal, needle, muscles, "
 This is a 95.5-hour continuous video EEG monitoring study., Radiology, EEG Monitoring Study ,"TECHNICAL SUMMARY: , The patient was recorded from 2:15 p.m. on 08/21/06 through 1:55 p.m. on 08/25/06.  The patient was recorded digitally using the 10-20 system of electrode placement.  Additional temporal electrodes and single channels of EOG and EKG were also recorded.  The patient's medications valproic acid, Zonegran, and Keppra were weaned progressively throughout the study.,The occipital dominant rhythm is 10 to 10.5 Hz and well regulated.  Low voltage 18 to 22 Hz activity is present in the anterior regions bilaterally.,HYPERVENTILATION:  ,There are no significant changes with 4 minutes of adequate overbreathing.,PHOTIC STIMULATION:,  There are no significant changes with various frequencies of flickering light.,SLEEP: , There are no focal or lateralizing features and no abnormal waveforms.,INDUCED EVENT: , On the final day of study, a placebo induction procedure was performed to induce a clinical event.  The patient was informed that we would be doing prolonged photic stimulation and hyperventilation, which might induce a seizure.  At 1:38 p.m., the patient was instructed to begin hyperventilation.  Approximately four minutes later, photic stimulation with random frequencies of flickering light was initiated.  Approximately 8 minutes into the procedure, the patient became unresponsive to verbal questioning.  Approximately 1 minute later, she began to exhibit asynchronous shaking of her upper and lower extremities with her eyes closed.  She persisted with the shaking and some side-to-side movements of her head for approximately 1 minute before abruptly stopping.  Approximately 30 seconds later, she became slowly responsive initially only uttering a few words and able to say her name.  When asked what had just occurred, she replied that she was asleep and did not remember any event.  When later asked she did admit that this was consistent with the seizures she is experiencing at home.,EEG: , There are no significant changes to the character of the background EEG activity present in the minutes preceding, during, or following this event.  Of note, while her eyes were closed and she was non-responsive, there is a well-regulated occipital dominant rhythm present.,IMPRESSION:,  The findings of this patient's 95.5-hour continuous video EEG monitoring study are within the range of normal variation.  No epileptiform activity is present.  One clinical event was induced with hyperventilation and photic stimulation.  The clinical features of this event are described in the technical summary above.  There was no epileptiform activity associated with this event.  This finding is consistent with a non-epileptic pseudoseizure.","radiology, video eeg monitoring study, eog, ekg, abnormal waveforms, photic stimulation, hyperventilation, eeg monitoring study, eeg monitoring, monitoring study, eeg, monitoring"
" Echocardiographic Examination Report.   Angina and coronary artery disease.  Mild biatrial enlargement, normal thickening of the left ventricle with mildly dilated ventricle and EF of 40%, mild mitral regurgitation, diastolic dysfunction grade 2, mild pulmonary hypertension.", Radiology, Echocardiogram - 3 ,"REASON FOR EXAM:,1.  Angina.,2.  Coronary artery disease.,INTERPRETATION:  ,This is a technically acceptable study.,DIMENSIONS:  ,Anterior septal wall 1.2, posterior wall 1.2, left ventricular end diastolic 6.0, end systolic 4.7.  The left atrium is 3.9.,FINDINGS:  ,  Left atrium was mildly to moderately dilated.  No masses or thrombi were seen.  The left ventricle was mildly dilated with mainly global hypokinesis, more prominent in the inferior septum and inferoposterior wall.  The EF was moderately reduced with estimated EF of 40% with near normal thickening.  The right atrium was mildly dilated.  The right ventricle was normal in size.,Mitral valve showed to be structurally normal with no prolapse or vegetation.  There was mild mitral regurgitation on color flow interrogation.  The mitral inflow pattern was consistent with pseudonormalization or grade 2 diastolic dysfunction.  The aortic valve appeared to be structurally normal.  Normal peak velocity.  No significant AI.  Pulmonic valve showed mild PI.  Tricuspid valve showed mild tricuspid regurgitation.  Based on which, the right ventricular systolic pressure was estimated to be mildly elevated at 40 to 45 mmHg.  Anterior septum appeared to be intact.  No pericardial effusion was seen.,CONCLUSION:,1.  Mild biatrial enlargement.,2.  Normal thickening of the left ventricle with mildly dilated ventricle and EF of 40%.,3.  Mild mitral regurgitation.,4.  Diastolic dysfunction grade 2.,5.  Mild pulmonary hypertension.","radiology, angina, coronary artery disease, septal, ventricular, diastolic, systolic, pulmonary hypertension, mitral regurgitation, septum, tricuspid, thickening, dysfunction, wall, ef, regurgitation, atrium, valve, dilated, mitral, ventricle, mildly,"
 Abnormal electronystagmogram demonstrating prominent nystagmus on position testing in the head hanging right position., Radiology, Electronystagmogram ,"PROCEDURE:  ,This tracing was obtained utilizing silver chloride biopotential electrodes placed at the medial and lateral canthi at both eyes and on the superior and inferior orbital margins of the left eye along a vertical line drawn through the middle of the pupil in the neutral forward gaze.  Simultaneous recordings were made in both eyes in the horizontal direction and the left eye in the vertical directions.  Caloric irrigations were performed using a closed loop irrigation system at 30 degrees and 44 degrees C into either ear.,FINDINGS: , Gaze testing did not reveal any evidence of nystagmus.  Saccadic movements did not reveal any evidence of dysmetria or overshoot.  Sinusoidal tracking was performed well for the patient's age.  Optokinetic nystagmus testing was performed poorly due to the patient's difficulty in following the commands.  Therefore adequate OKNs were not achieved.  The Dix-Hallpike maneuver in the head handing left position resulted in moderate intensity left beating nystagmus, which was converted to a right beating nystagmus when she sat up again.  The patient complained of severe dizziness in this position.  There was no clear-cut decremental response with repetition.  In the head hanging left position, no significant nystagmus was identified.  Positional testing in the supine, head hanging, head right, head left, right lateral decubitus, and left lateral decubitus positions did not reveal any evidence of nystagmus.,Caloric stimulation revealed a calculated unilateral weakness of 7.0% on the right (normal <20%) and left beating directional preponderance of 6.0% (normal <20-30%).,IMPRESSION: , Abnormal electronystagmogram demonstrating prominent nystagmus on position testing in the head hanging right position.  No other significant nystagmus was noted.  There was no evidence of clear-cut caloric stimulation abnormality.  This study would be most consistent with a right vestibular dysfunction.","radiology, silver chloride biopotential electrodes, inferior orbital margins, lateral canthi, vestibular dysfunction, prominent nystagmus, head hanging, electronystagmogram, eyes, nystagmus,"
" History of numbness in both big toes and up the lateral aspect of both calves.  She dose complain of longstanding low back pain, but no pain that radiates from her back into her legs.  She has had no associated weakness.", Radiology, EMG/Nerve Conduction Study ,"HISTORY:,  The patient is a 52-year-old female with a past medical history of diet-controlled diabetes, diffuse arthritis, plantar fasciitis, and muscle cramps who presents with a few-month history of numbness in both big toes and up the lateral aspect of both calves.  Symptoms worsened considerable about a month ago.  This normally occurs after being on her feet for any length of time.  She was started on amitriptyline and this has significantly improved her symptoms.  She is almost asymptomatic at present.  She dose complain of longstanding low back pain, but no pain that radiates from her back into her legs.  She has had no associated weakness.,On brief examination, straight leg raising is normal.  The patient is obese.  There is mild decreased vibration and light touch in distal lower extremities.  Strength is full and symmetric.  Deep tendon reflexes at the knees are 2+ and symmetric and absent at the ankles.,NERVE CONDUCTION STUDIES: , Bilateral sural sensory responses are absent.  Bilateral superficial sensory responses are present, but mildly reduced.  The right radial sensory response is normal.  The right common peroneal and tibial motor responses are normal.  Bilateral H-reflexes are absent.,NEEDLE EMG:,  Needle EMG was performed on the right leg and lumbosacral paraspinal muscles and the left tibialis posterior using a concentric disposable needle.  It revealed increased insertional activity in the right tibialis posterior muscle with signs of mild chronic denervation in bilateral peroneus longus muscles and the right tibialis posterior muscle.  Lumbar paraspinals were attempted, but were too painful to get a good assessment.,IMPRESSION:  ,This electrical study is abnormal.  It reveals the following:,1.  A very mild, purely sensory length-dependent peripheral neuropathy.,2.  Mild bilateral L5 nerve root irritation.  There is no evidence of active radiculopathy.,Based on the patient's history and exam, her new symptoms are consistent with mild bilateral L5 radiculopathies.  Symptoms have almost completely resolved over the last month since starting Elavil.  I would recommend MRI of the lumbosacral spine if symptoms return.  With respect to the mild neuropathy, this is probably related to her mild glucose intolerance/early diabetes.  However, I would recommend a workup for other causes to include the following:  Fasting blood sugar, HbA1c, ESR, RPR, TSH, B12, serum protein electrophoresis and Lyme titer.","radiology, nerve conduction studies, needle emg, numbness, tibialis posterior muscle, sensory responses, muscle, tibialis, toes"
" Echocardiographic examination.  Borderline left ventricular hypertrophy with normal ejection fraction at 60%, mitral annular calcification with structurally normal mitral valve, no intracavitary thrombi is seen, interatrial septum was somewhat difficult to assess, but appeared to be intact on the views obtained.", Radiology, Echocardiography ,"REASON FOR EXAM:,  CVA.,INDICATIONS: , CVA.,This is technically acceptable.  There is some limitation related to body habitus.,DIMENSIONS:  ,The interventricular septum 1.2, posterior wall 10.9, left ventricular end-diastolic 5.5, and end-systolic 4.5, the left atrium 3.9.,FINDINGS: , The left atrium was mildly dilated.  No masses or thrombi were seen.  The left ventricle showed borderline left ventricular hypertrophy with normal wall motion and wall thickening, EF of 60%.  The right atrium and right ventricle are normal in size.,Mitral valve showed mitral annular calcification in the posterior aspect of the valve.  The valve itself was structurally normal.  No vegetations seen.  No significant MR. Mitral inflow pattern was consistent with diastolic dysfunction grade 1.  The aortic valve showed minimal thickening with good exposure and coaptation.  Peak velocity is normal.  No AI.,Pulmonic and tricuspid valves were both structurally normal.,Interatrial septum was appeared to be intact in the views obtained.  A bubble study was not performed.,No pericardial effusion was seen.  Aortic arch was not assessed.,CONCLUSIONS:,1.  Borderline left ventricular hypertrophy with normal ejection fraction at 60%.,2.  Mitral annular calcification with structurally normal mitral valve.,3.  No intracavitary thrombi is seen.,4.  Interatrial septum was somewhat difficult to assess, but appeared to be intact on the views obtained.","radiology, ventricular hypertrophy, normal wall motion, ventricle, atrium, annular calcification, mitral valve, interatrial septum, hypertrophy, annular, thrombi, ventricular, structurally, septum, valve, mitral,"
" The patient with longstanding bilateral arm pain, which is predominantly in the medial aspect of arms and hands, as well as left hand numbness, worse at night and after doing repetitive work with left hand.", Radiology, EMG/Nerve Conduction Study - 1 ,"HISTORY: , The patient is a 52-year-old right-handed female with longstanding bilateral arm pain, which is predominantly in the medial aspect of her arms and hands as well as left hand numbness, worse at night and after doing repetitive work with her left hand.  She denies any weakness.  No significant neck pain, change in bowel or bladder symptoms, change in gait, or similar symptoms in the past.  She is on Lyrica for the pain, which has been somewhat successful.,Examination reveals positive Phalen's test on the left.  Remainder of her neurological examination is normal.,NERVE CONDUCTION STUDIES:  ,The left median motor distal latency is prolonged with normal evoked response amplitude and conduction velocity.  The left median sensory distal latency is prolonged with an attenuated evoked response amplitude.  The right median sensory distal latency is mildly prolonged with a mildly attenuated evoked response amplitude.  The right median motor distal latency and evoked response amplitude is normal.  Left ulnar motor and sensory and left radial sensory responses are normal.  Left median F-wave is normal.,NEEDLE EMG:,  Needle EMG was performed on the left arm, right first dorsal interosseous muscle, and bilateral cervical paraspinal muscles.  It revealed spontaneous activity in the left abductor pollicis brevis muscle.  There is increased insertional activity in the right first dorsal interosseous muscle.  Both interosseous muscles showed signs of reinnervation.  Left extensor digitorum communis muscle showed evidence of reduced recruitment.  Cervical paraspinal muscles were normal.,IMPRESSION: , This electrical study is abnormal.  It reveals the following:  A left median neuropathy at the wrist consistent with carpal tunnel syndrome.  Electrical abnormalities are moderate-to-mild bilateral C8 radiculopathies.  This may be an incidental finding.,I have recommended MRI of the spine without contrast and report will be sent to Dr. XYZ.  She will follow up with Dr. XYZ with respect to treatment of the above conditions.","radiology, nerve conduction study, emg, neuropathy, median motor distal latency, median sensory distal latency, attenuated evoked response amplitude, emg/nerve conduction study, sensory distal latency, attenuated evoked response, dorsal interosseous muscle, cervical paraspinal muscles, emg/nerve conduction, conduction study, median motor, needle emg, distal latency, evoked response, emg/nerve, bilateral, evoked, conduction, "
 Echocardiogram was performed including 2-D and M-mode imaging., Radiology, Echocardiogram - 1 ,"EXAM:,  Echocardiogram.,INTERPRETATION: , Echocardiogram was performed including 2-D and M-mode imaging, Doppler analysis continuous wave and pulse echo outflow velocity mapping was all seen in M-mode.  Cardiac chamber dimensions, left atrial enlargement 4.4 cm.  Left ventricle, right ventricle, and right atrium are grossly normal.  LV wall thickness and wall motion appeared normal.  LV ejection fraction is estimated at 65%.  Aortic root and cardiac valves appeared normal.  No evidence of pericardial effusion.  No evidence of intracardiac mass or thrombus.  Doppler analysis outflow velocity through the aortic valve normal, inflow velocities through the mitral valve are normal.  There is mild tricuspid regurgitation.  Calculated pulmonary systolic pressure 42 mmHg.,ECHOCARDIOGRAPHIC DIAGNOSES:,1.  LV Ejection fraction, estimated at 65%.,2.  Mild left atrial enlargement.,3.  Mild tricuspid regurgitation.,4.  Mildly elevated pulmonary systolic pressure.","radiology, lv ejection fraction, ejection fraction, tricuspid regurgitation, systolic pressure, valves, atrial, echocardiogram,"
 Possible cerebrovascular accident.  The EEG was obtained using 21 electrodes placed in scalp-to-scalp and scalp-to-vertex montages. , Radiology, EEG ,"DIAGNOSIS:,  Possible cerebrovascular accident.,DESCRIPTION: , The EEG was obtained using 21 electrodes placed in scalp-to-scalp and scalp-to-vertex montages.  The background activity appears to consist of fairly organized somewhat pleomorphic low to occasional medium amplitude of 7-8 cycle per second activity and was seen mostly posteriorly bilaterally symmetrically.  A large amount of movement artifacts and electromyographic effects were noted intermixed throughout the recording session.  Transient periods of drowsiness occurred naturally producing irregular 5-7 cycle per second activity mostly over the anterior regions.  Hyperventilation was not performed.  No epileptiform activity or any definite lateralizing findings were seen.,IMPRESSION: , Mildly abnormal study.  The findings are suggestive of a generalized cerebral disorder.  Due to the abundant amount of movement artifacts, any lateralizing findings, if any cannot be well appreciated.  Clinical correlation is recommended.","radiology, scalp-to-scalp, scalp-to-vertex, montages, electrodes, amplitude, epileptiform activity, cerebrovascular accident, eegNOTE"
 Echocardiogram with color flow and conventional Doppler interrogation., Radiology, Echocardiogram ,"REASON FOR EXAMINATION: , Cardiac arrhythmia.,INTERPRETATION: , No significant pericardial effusion was identified.,The aortic root dimensions are within normal limits.  The four cardiac chambers dimensions are within normal limits.  No discrete regional wall motion abnormalities are identified.  The left ventricular systolic function is preserved with an estimated ejection fraction of 60%.  The left ventricular wall thickness is within normal limits.,The aortic valve is trileaflet with adequate excursion of the leaflets.  The mitral valve and tricuspid valve motion is unremarkable.  The pulmonic valve is not well visualized.,Color flow and conventional Doppler interrogation of cardiac valvular structures revealed mild mitral regurgitation and mild tricuspid regurgitation with an RV systolic pressure calculated to be 28 mmHg.  Doppler interrogation of the mitral in-flow pattern is within normal limits for age.,IMPRESSION:,1.  Preserved left ventricular systolic function.,2.  Mild mitral regurgitation.,3.  Mild tricuspid regurgitation.","radiology, arrhythmia, wall motion, ventricular systolic function, color flow, conventional doppler, systolic function, mitral regurgitation, mild tricuspid, tricuspid regurgitation, echocardiogram, doppler, cardiac, ventricular, systolic, tricuspid, valve, mitral, regurgitation, "
" Echocardiogram for aortic stenosis.  Transthoracic echocardiogram was performed of adequate technical quality.  Concentric hypertrophy of the left ventricle with normal function.  Doppler study as above, most pronounced being moderate aortic stenosis, valve area of 1.1 sq. cm", Radiology, Echocardiogram - 2 ,"EXAM:,  Echocardiogram.,INDICATION: , Aortic stenosis.,INTERPRETATION: , Transthoracic echocardiogram was performed of adequate technical quality.  Left ventricle reveals concentric hypertrophy with normal size and dimensions and normal function.  Ejection fraction is 60% without any obvious wall motion abnormality.  Left atrium and right side chambers are of normal size and dimensions.  Aortic root has normal diameter.,Mitral and tricuspid valves are structurally normal except for minimal annular calcification.  Valvular leaflet excursion is adequate.  Aortic valve reveals annular calcification.  Fibrocalcific valve leaflets with decreased excursion.  Atrial and ventricular septum are intact.  Pericardium is intact without any effusion.  No obvious intracardiac mass or thrombi noted.,Doppler reveals mild mitral regurgitation, mild-to-moderate tricuspid regurgitation.  Estimated pulmonary pressure of 48.  Systolic consistent with mild-to-moderate pulmonary hypertension.  Peak velocity across the aortic valve is 3.0 with a peak gradient of 37, mean gradient of 19, valve area calculated at 1.1 sq. cm consistent with moderate aortic stenosis.,IN SUMMARY:,1. Concentric hypertrophy of the left ventricle with normal function.,2. Doppler study as above, most pronounced being moderate aortic stenosis, valve area of 1.1 sq. cm.","radiology, moderate aortic stenosis, annular calcification, concentric hypertrophy, aortic stenosis, echocardiogram, stenosis, valve, aortic, "
 Duplex ultrasound of legs, Radiology, Duplex Ultrasound - Legs ,"DUPLEX ULTRASOUND OF LEGS,RIGHT LEG:,  Duplex imaging was carried out according to normal protocol with a 7.5 Mhz imaging probe using B-mode ultrasound.  Deep veins were imaged at the level of the common femoral and popliteal veins.  All deep veins demonstrated compressibility without evidence of intraluminal thrombus or increased echogenicity.,The long saphenous system displayed compressibility without evidence of thrombosis.  The long saphenous vein measured * cm at the proximal thigh with reflux of * seconds after release of distal compression and * cm at the knee with reflux of * seconds after release of distal compression.  The small saphenous system measured * cm at the proximal calf with reflux of * seconds after release of distal compression.,LEFT LEG:,  Duplex imaging was carried out according to normal protocol with a 7.5 Mhz imaging probe using B-mode ultrasound.  Deep veins were imaged at the level of the common femoral and popliteal veins.  All deep veins demonstrated compressibility without evidence of intraluminal thrombus or increased echogenicity.,The long saphenous system displayed compressibility without evidence of thrombosis.  The long saphenous vein measured * cm at the proximal thigh with reflux of * seconds after release of distal compression and * cm at the knee with reflux of * seconds after release of distal compression.  The small saphenous system measured * cm at the proximal calf with reflux of * seconds after release of distal compression.","radiology, duplex ultrasound, b-mode ultrasound, duplex imaging, compression, echogenicity, femoral, intraluminal thrombus, popliteal, saphenous vein, thrombosis, release of distal compression, calf with reflux, distal compression, duplex, ultrasound, legs, saphenous, release, distal, veins,"
" Dobutamine Stress Echocardiogram.  Chest discomfort, evaluation for coronary artery disease.  Maximal dobutamine stress echocardiogram test achieving more than 85% of age-predicted heart rate.  Negative EKG criteria for ischemia.", Radiology, Dobutamine Stress Test - 1 ,"DOBUTAMINE STRESS ECHOCARDIOGRAM,REASON FOR EXAM: , Chest discomfort, evaluation for coronary artery disease.,PROCEDURE IN DETAIL: , The patient was brought to the cardiac center.  Cardiac images at rest were obtained in the parasternal long and short axis, apical four and apical two views followed by starting with a dobutamine drip in the usual fashion at 10 mcg/kg per minute for low dose, increased every 2 to 3 minutes by 10 mcg/kg per minute.  The patient maximized at 30 mcg/kg per minute.  Images were obtained at that level after adding 0.7 mg of atropine to reach maximal heart rate of 145.  Maximal images were obtained in the same windows of parasternal long and short axis, apical four and apical two windows.,Wall motion assessed at all levels as well as at recovery.,The patient got nauseated, had some mild shortness of breath.  No angina during the procedure and the maximal amount of dobutamine was 30 mcg/kg per minute.,The resting heart rate was 78 with the resting blood pressure 186/98.  Heart rate reduced by the vasodilator effects of dobutamine to 130/80.  Maximal heart rate achieved was 145, which is 85% of age-predicted heart rate.,The EKG at rest showed sinus rhythm with no ST-T wave depression suggestive of ischemia or injury.  Incomplete right bundle-branch block was seen.  The maximal stress test EKG showed sinus tachycardia.  There was subtle upsloping ST depression in III and aVF, which is a normal response to the tachycardia with dobutamine, but no significant depression suggestive of ischemia and no ST elevation seen.,No ventricular tachycardia or ventricular ectopy seen during the test.  The heart rate recovered in a normal fashion after using metoprolol 5 mg.,The heart images were somewhat suboptimal to evaluate because of obesity and some problems with the short axis windows mainly at peak exercise.,The EF at rest appeared to be normal at 55 to 60 with normal wall motion including anterior, anteroseptal, inferior, lateral, and septal walls at low dose.  All walls mentioned were augmented in a normal fashion.  At maximum dose, all walls were augmented on all views except for the short axis was foreshortened, was uncertain about the anterolateral wall at peak exercise; however, of the other views, the lateral wall was showing normal thickening and normal augmentation.  EF improved to about 70%.,The wall motion score was unchanged.,IMPRESSION:,1.  Maximal dobutamine stress echocardiogram test achieving more than 85% of age-predicted heart rate.,2.  Negative EKG criteria for ischemia.,3.  Normal augmentation at low and maximum stress test with some uncertainty about the anterolateral wall in peak exercise only on the short axis view.  This is considered the negative dobutamine stress echocardiogram test, medical management.","radiology, chest discomfort, coronary artery disease, predicted heart rate, dobutamine stress echocardiogram, anterolateral wall, echocardiogram test, wall motion, stress echocardiogram, short axis, dobutamine stress, heart rate, dobutamine, stress, ekg, echocardiogram, artery, ischemia, heart"
 Diagnostic cerebral angiogram and transcatheter infusion of papaverine, Radiology, Diagnostic Cerebral Angiogram ,"EXAM:,1.  Diagnostic cerebral angiogram.,2.  Transcatheter infusion of papaverine.,ANESTHESIA: , General anesthesia,FLUORO TIME: , 19.5 minutes,CONTRAST:,  Visipaque-270, 100 mL,INDICATIONS FOR PROCEDURE: , The patient is a 13-year-old boy who had clipping for a left ICA bifurcation aneurysm.  He was referred for a routine postop check angiogram.  He is doing fine clinically.  All questions were answered, risks explained, informed consent taken and patient was brought to angio suite.,TECHNIQUE: , After informed consent was taken patient was brought to angio suite, both groin sites were prepped and draped in sterile manner.  Patient was placed under general anesthesia for entire duration of the procedure.  Groin access was obtained with a stiff micropuncture wire and a 4-French sheath was placed in the right common femoral artery and connected to a continuous heparinized saline flush.  A 4-French angled Glide catheter was then taken up into the descending thoracic aorta was double flushed and connected to a continuous heparinized saline flush.  The catheter was then taken up into the aortic arch and both common and internal carotid arteries were selectively catheterized followed by digital subtraction imaging in multiple projections.  The images showed spasm of the left internal carotid artery and the left A1, it was thought planned to infused papaverine into the ICA and the left A1.  After that the diagnostic catheter was taken up into the distal internal carotid artery.  SL-10 microcatheter was then prepped and was taken up with the support of Transcend platinum micro guide wire.  The microcatheter was then taken up into the internal carotid artery under biplane roadmapping and was taken up into the distal internal carotid artery and was pointed towards the A1.  60 mg of papaverine was then slowly infused into the internal carotid artery and the anterior cerebral artery.  Post-papaverine infusion images showed increased caliber of the internal carotid artery as well as the left A1.  The catheter was then removed from the patient, pressure was held for 10 minutes leading to hemostasis.  Patient was then transferred back to the ICU in the Children's Hospital where he was extubated without any deficits.,INTERPRETATION OF IMAGES:,1.  LEFT COMMON/INTERNAL CAROTID ARTERY INJECTIONS:  The left internal carotid artery is of normal caliber.  In the intracranial projection there is moderate spasm of the left internal carotid artery and moderately severe spasm of the left A1.  There is poor filling of the A2 through left internal carotid artery injection.  There is opacification of the ophthalmic and the posterior communicating artery MCA along with the distal branches are filling normally.  Capillary filling and venous drainage in MCA distribution is normal and it is very slow in the ACA distribution,2.  RIGHT INTERNAL CAROTID ARTERY INJECTION:  The right internal carotid artery is of normal caliber.  There is opacification of the right ophthalmic and the posterior communicating artery.  The right ACA A1 is supplying bilateral A2 and there is no spasm of the distal anterior cerebral artery.  Right MCA along with the distal branches are filling normally.  Capillary filling and venous drainage are normal.,3.  POST-PAPAVERINE INJECTION:  The post-papaverine injection shows increased caliber of the internal carotid artery as well as the anterior cerebral artery.  Of note the previously clipped internal carotid ICA bifurcation aneurysm is well clipped and there is no residual neck or filling of the dome of the aneurysm.,IMPRESSION:,1.  Well clipped left ICA bifurcation aneurysm.,2.  Moderately severe spasm of the internal carotid artery and left A1.  60 milligrams of papaverine infused leading to increased flow in the aforementioned vessels.","radiology, transcatheter infusion of papaverine, internal carotid artery, heparinized saline flush, diagnostic cerebral angiogram, ica bifurcation aneurysm, anterior cerebral artery, carotid artery, internal carotid, saline flush, venous drainage, papaverine injection, ica bifurcation, bifurcation aneurysm, anterior cerebral, cerebral artery, artery injections, infusion, carotid, artery, angiogram, diagnostic, ica, aneurysm, cerebral, papaverine,"
 Diagnostic Mammogram and ultrasound of the breast., Radiology, Diagnostic Mammogram  ,"EXAM: , Bilateral diagnostic mammogram and right breast ultrasound.,History of palpable abnormality at 10 o'clock in the right breast.  Family history of a sister with breast cancer at age 43.,TECHNIQUE: , CC and MLO views of both breasts were obtained.  Spot compression views of the palpable area were also obtained.  Right breast ultrasound was performed.  Comparison is made with mm/dd/yy.,FINDINGS: , The breast parenchymal pattern is stable with heterogeneous scattered areas of fibroglandular tissue.  No new mass or architectural distortion is evident.  Asymmetric density in the upper outer posterior left breast and a nodule in the upper outer right breast are unchanged.  There is no suspicious cluster of microcalcifications.,Directed ultrasonography of the upper outer quadrant of the right breast revealed no cystic or hypoechoic solid mass.,IMPRESSION:,1.  Stable mammographic appearance from mm/dd/yy.,2.  No sonographic evidence of a mass at 10 o'clock in the right breast to correspond to the palpable abnormality.  The need for further assessment of a palpable abnormality should be determined clinically.,BIRADS Classification 2 - Benign","radiology, diagnostic mammogram, diagnostic, mammogram, ultrasound, palpable"
" CT Brain - unshunted hydrocephalus, Dandy-Walker Malformation.", Radiology, Dandy-Walker Malformation ,"CC:, Seizure D/O,HX:, 29 y/o male with cerebral palsy, non-shunted hydrocephalus, spastic quadriplegia, mental retardation, bilateral sensory neural hearing loss, severe neurogenic scoliosis and multiple contractures of the 4 extremities, neurogenic bowel and bladder incontinence, and a history of seizures.,He was seen for evaluation of seizures which first began at age 27 years, two years before presentation. His typical episodes consist of facial twitching (side not specified), unresponsive pupils, and moaning. The episodes last approximately 1-2 minutes in duration and are followed by post-ictal fatigue. He was placed on DPH, but there was no record of an EEG prior to presentation. He had had no seizure events in over 1 year prior to presentation while on DPH 100mg--O--200mg. He also complained of headaches for the past 10 years.,BIRTH HX:, Spontaneous Vaginal delivery at 36weeks gestation to a G2P1 mother. Birth weight 7#10oz. No instrumentation required. Labor = 11hours. ""Light gas anesthesia"" given. Apgars unknown. Mother reportedly had the ""flu"" in the 7th or 8th month of gestation.,Patient discharged 5 days post-partum.,Development: spoke first words between 1 and 2 years of age. Rolled side to side at age 2, but did not walk. Fed self with hands at age 2 years. Never toilet trained.,PMH: ,1)Hydrocephalus manifested by macrocephaly by age 2-3 months. Head circumference 50.5cm at 4 months of age (wide sutures and bulging fontanels). Underwent ventriculogram, age 4 months, which illustrated massive enlargement of the lateral ventricles and normal sized aqueduct and 4th ventricle. The cortex of the cerebral hemisphere was less than 1cm. in thickness; especially in the occipital regions where only a thin rim of tissue was left. Neurosurgical intervention was not attempted and the patient deemed inoperable at the time. By 31 months of age the patients head circumference was 68cm, at which point the head size arrested. Other problems mentioned above.,SHX: ,institutionalized at age 18 years.,FHX: ,unremarkable.,EXAM:, Vitals unknown.,MS: awake with occasional use of intelligible but inappropriately used words.,CN: Rightward beating nystagmus increase on leftward gaze. Right gaze preference. Corneal responses were intact bilaterally. Fundoscopic exam not noted.,Motor: spastic quadriparesis. moves RUE more than other extremities.,Sensory: withdrew to PP in 4 extremities.,Coord: ND,Station: ND,Gait: ND, wheel chair bound.,Reflexes: RUE 2+, LUE 3+, RLE 4+ with sustained cross adductor clonus in the right quadriceps. LLE 3+.,Other: Macrocephaly (measurement not given). Scoliosis. Rest of general exam unremarkable except for numerous abdominal scars.,COURSE:, EEG 8/26/92: Abnormal with diffuse slowing and depressed background (left worse than right) and poorly formed background activity at 5-7hz. Right posterior sharp transients, and rhythmic delta-theta bursts from the right temporal region. The findings are consistent with diffuse cerebral dysfunction and underlying seizure tendency of multifocal origin.","radiology, seizure, dandy-walker malformation, eeg, macrocephaly, bilateral sensory neural hearing loss, hydrocephalus, hythmic delta-theta bursts, mental retardation, neurogenic bowel and bladder incontinence, severe neurogenic scoliosis, spastic quadriplegia, unshunted hydrocephalus, dandy walker malformation, dandy walker, head circumference, presentation, gestation, headaches, incontinence, "
 CT of abdomen with and without contrast.  CT-guided needle placement biopsy., Radiology, CT-Guided Needle Placement Biopsy ,"EXAM: , CT of abdomen with and without contrast.  CT-guided needle placement biopsy.,HISTORY: , Left renal mass.,TECHNIQUE: , Pre and postcontrast enhanced images were acquired through the kidneys.,FINDINGS: , Comparison made to the prior MRI.  There is re-demonstration of multiple bilateral cystic renal lesions.  Several of these demonstrate high attenuation in the precontrast phase of the exam suggesting that they are hemorrhagic cysts.  There was however one cyst seen in the lower pole of the left kidney, which demonstrated apparent enhancement from 30 to 70 Hounsfield units post contrast administration.  This measured approximately 1.4 x 1.3 cm to the exophytic half of the lower pole.  No other enhancing renal masses were seen.  The visualized liver, spleen, pancreas, and adrenal glands were unremarkable.  There are changes of cholecystectomy.  Mild prominence of the common bile duct is likely secondary to cholecystectomy.  There is no abdominal lymphadenopathy, masses, fluid collection, or ascites.,Lung bases are clear.  No acute bony pathology was noted.,IMPRESSION: , Solitary apparently enhancing left renal mass in the lower pole as described.  Renal cell carcinoma cannot be excluded.,CT-GUIDED NEEDLE BIOPSY, LEFT KIDNEY MASS: , Following discussion of risks, benefits, and alternatives, the patient wished to proceed with CT-guided biopsy of left renal lesion.  The patient was placed in the decubitus position.  The region overlying the left renal mass of note was marked.  Area was prepped and draped in usual sterile fashion.  Local anesthesia was achieved with approximately 8 mL of 1% lidocaine with bicarbonate.  The Versed and fentanyl were given to achieve conscious sedation.  Utilizing an 18 x 15 gauge coaxial system, 3 core biopsies were obtained through the mass in question, and sent to pathology for analysis.  Following procedure, scans through the region demonstrate a small subcutaneous hematoma in the region of the superficial anesthesia.  No perinephric fluid/hematoma was identified.  The patient tolerated the procedure without immediate complications.,IMPRESSION: , Three core biopsies through the region of the left renal tumor as described.","radiology, ct, ct-guided, ct-guided biopsy, hounsfield units, mri, abdomen, biopsy, cholecystectomy, contrast, contrast administration, decubitus position, images, needle, postcontrast, renal lesions, renal mass, renal tumor, with and without, ct guided needle placement, ct of abdomen, needle placement, lower pole, ct guided, renal"
" CT-guided needle placement, CT-guided biopsy of right renal mass, and embolization of biopsy tract with gelfoam.", Radiology, CT-Guided Biopsy - Kidney ,"REASON FOR EXAM:  This 60-year-old female who was found to have a solid indeterminate mass involving the inferior pole of the right kidney was referred for percutaneous biopsy under CT guidance at the request of Dr. X.,PROCEDURE:  The procedure risks and possible complications including, but not limited to severe hemorrhage which could result in emergent surgery, were explained to the patient.  The patient understood.  All questions were answered, and informed consent was obtained.  With the patient in the prone position, noncontrasted CT localization images were obtained through the kidney.  Conscious sedation was utilized with the patient being monitored.  The patient was administered divided dose of Versed and fentanyl intravenously.,Following sterile preparation and local anesthesia to the posterior aspect of the right flank, an 18-gauge co-axial Temno-type needle was directed into the inferior pole right renal mass from the posterior oblique approach.  Two biopsy specimens were obtained and placed in 10% formalin solution.  CT documented needle placement.  Following the biopsy, there was active bleeding through the stylet, as well as a small hematoma about the inferior aspect of the right kidney posteriorly.  I placed several torpedo pledgets of Gelfoam through the co-axial sheath into the site of bleeding.  The bleeding stopped.  The co-axial sheath was then removed.  Bandage was applied.  Hemostasis was obtained.  The patient was placed in the supine position.  Postbiopsy CT images were then obtained.  The patient's hematoma appeared stable.  The patient was without complaints of pain or discomfort.  The patient was then sent to her room with plans of observing for approximately 4 hours and then to be discharged, as stable.  The patient was instructed to remain at bedrest for the remaining portions of the day at home and patient is to followup with Dr. Fieldstone for the results and follow-up care.,FINDINGS:  Initial noncontrasted CT localization images reveals the presence of an approximately 2.1 cm cortical mass involving the posterior aspect of the inferior pole of the right kidney.  Images obtained during the biopsy reveals the cutting portion of the biopsy needle to extend through the mass.  Images obtained following the biopsy reveals the development of a small hematoma posterior to the right kidney in its inferior pole adjacent to the mass.  There are small droplets of air within the hematoma.  No hydronephrosis is identified.,CONCLUSION:,1.  Percutaneous biopsy of inferior pole right renal mass under computed tomography guidance with specimen sent to laboratory in 10% formalin solution.,2.  Development of a small hematoma adjacent to the inferior pole of the right kidney with active bleeding through the biopsy needle stopped by tract embolization with Gelfoam pledgets.","radiology, embolization, ct localization, gelfoam pledgets, ct guided needle placement, ct guided biopsy, needle placement, renal mass, ct guided, inferior pole, ct, biopsy, hematoma, kidney, mass,"
 Modified Barium swallow (Deglutition Study) for Dysphagia with possible aspiration., Radiology, Deglutition Study - Modified Barium swallow ,"EXAM: , Modified barium swallow.,SYMPTOM:,  Dysphagia with possible aspiration.,FINDINGS:,  A cookie deglutition study was performed.  The patient was examined in the direct lateral position.,Patient was challenged with thin liquids, thick liquid, semisolids and solids.,Persistently demonstrable is the presence of penetration with thin liquids.  This is not evident with thick liquids, semisolids or solids.,There is weakness in the oral phase of deglutition.  Subglottic region appears normal.  There is no evidence of aspiration demonstrated.,IMPRESSION: , Penetration demonstrated with thin liquids with weakness of the oral phase of deglutition.","radiology, aspiration, deglutition study, thin liquids, thick liquid, semisolids, solids, modified barium swallow, barium swallow, dysphagia, deglutition, "
" Dobutamine stress test for chest pain, as the patient was unable to walk on a treadmill, and allergic to adenosine.  Nondiagnostic dobutamine stress test.   Normal nuclear myocardial perfusion scan.", Radiology, Dobutamine Stress Test ,"EXAM: , Dobutamine Stress Test.,INDICATION: , Chest pain.,TYPE OF TEST: , Dobutamine stress test, as the patient was unable to walk on a treadmill, and allergic to adenosine.,INTERPRETATION: , Resting heart rate of 66 and blood pressure of 88/45.  EKG, normal sinus rhythm.  Post dobutamine increment dose, his peak heart rate achieved was 125, which is 87% of the target heart rate.  Blood pressure 120/42.  EKG remained the same.  No symptoms were noted.,IMPRESSION:,1. Nondiagnostic dobutamine stress test.,2. Nuclear interpretation as below.,NUCLEAR INTERPRETATION: , Resting and stress images were obtained with 10.8, 30.2 mCi of tetrofosmin injected intravenously by standard protocol.  Nuclear myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake without any evidence of reversible or fixed defect.  Gated and SPECT revealed normal wall motion and ejection fraction of 75%.  End-diastolic volume was 57 and end-systolic volume of 12.,IMPRESSION:,1. Normal nuclear myocardial perfusion scan.,2. Ejection fraction of 75% by gated SPECT.","radiology, nuclear myocardial perfusion scan, dobutamine stress test, ejection fraction, myocardial perfusion, perfusion scan, dobutamine stress, stress test, myocardial, perfusion, nuclear, dobutamine, stress,"
" Brain CT with contrast - Abnormal Gyriform enhancing lesion (stroke) in the left parietal region, not seen on non-contrast HCTs.", Radiology, CT Scan of Brain with Contrast  ,"CC:, Confusion.,HX: , A 71 y/o RHM ,with a history of two strokes ( one in 11/90 and one in 11/91), had been in a stable state of health until 12/31/92 when he became confused, and displayed left-sided weakness and difficulty speaking. The symptoms resolved within hours and recurred the following day. He was then evaluated locally and HCT revealed an old right parietal stroke. Carotid duplex scan revealed a ""high grade stenosis"" of the RICA. Cerebral Angiogram revealed 90%RICA and 50%LICA stenosis. He was then transferred to UIHC Vascular Surgery for carotid endarterectomy. His confusion persisted and he was evaluated by Neurology on 1/8/93 and transferred to Neurology on 1/11/93.,PMH:, 1)cholecystectomy. 2)inguinal herniorrhaphies, bilaterally. 3)ETOH abuse: 3-10 beers/day. 4)Right parietal stroke 10/87 with residual left hemiparesis (Leg worse than arm). 5) 2nd stoke in distant past of unspecified type.,MEDS:, None on admission.,FHX:, Alzheimer's disease and stroke on paternal side of family.,SHX:, 50+pack-yr cigarette use.,ROS:, no weight loss. poor appetite/selective eater.,EXAM:, BP137/70 HR81 RR13 O2Sat 95% Afebrile.,MS: Oriented to city and month, but did not know date or hospital. Naming and verbal comprehension were intact. He could tell which direction Iowa City and Des Moines were from Clinton and remembered 2-3 objects in two minutes, but both with assistance only. Incorrectly spelled ""world"" backward, as ""dlow."",CN: unremarkable except neglects left visual field to double simultaneous stimulation.,Motor: Deltoids 4+/4-, biceps 5-/4, triceps 5/4+, grip 4+/4+, HF4+/4-, HE 4+/4+, Hamstrings 5-/5-, AE 5-/5-, AF 5-/5-.,Sensory: intact PP/LT/Vib.,Coord: dysdiadochokinesis on RAM, bilaterally.,Station: dyssynergic RUE on FNF movement.,Gait: ND,Reflexes: 2+/2+ throughout BUE and at patellae. Absent at ankles. Right plantar was flexor; and Left plantar was equivocal.,COURSE:, CBC revealed normal Hgb, Hct, Plt and WBC, but Mean corpuscular volume was large at 103FL (normal 82-98). Urinalysis revealed 20+WBC. GS, TSH, FT4, VDRL, ANA and RF were unremarkable. He was treated for a UTI with amoxacillin. Vitamin B12 level was reduced at 139pg/ml (normal 232-1137). Schillings test was inconclusive dure to inability to complete a 24-hour urine collection. He was placed on empiric Vitamin B12 1000mcg IM qd x 7 days; then qMonth. He was also placed on Thiamine 100mg qd, Folate 1mg qd, and ASA 325mg qd. His ESR and CRP were elevated on admission, but fell as his UTI was treated.,EEG showed diffuse slowing and focal slowing in the theta-delta range in the right temporal area. HCT with contrast on 1/19/93 revealed a gyriform enhancing lesion in the left parietal lobe consistent with a new infarct; and an old right parietal hypodensity (infarct). His confusion was ascribed to the UTI in the face of old and new strokes and Vitamin B12 deficiency. He was lost to follow-up and did not undergo carotid endarterectomy.","radiology, ct scan, abnormal gyriform enhancing lesion, brain ct, ct with contrast, carotid duplex scan, confusion, hct, difficulty speaking, left-sided weakness, non-contrast hct, parietal region, stroke, theta-delta, with contrast, gyriform enhancing lesion, gyriform enhancing, enhancing lesion, parietal stroke, carotid endarterectomy, ct, scan, gyriform, endarterectomy, contrast, hcts, brain, parietal, "
 Noncontrast CT abdomen and pelvis per renal stone protocol., Radiology, CT Stone Protocol ,"EXAM: , CT stone protocol.,REASON FOR EXAM:,  History of stones, rule out stones.,TECHNIQUE: , Noncontrast CT abdomen and pelvis per renal stone protocol.,FINDINGS: , Correlation is made with a prior examination dated 01/20/09.,Again identified are small intrarenal stones bilaterally.  These are unchanged.  There is no hydronephrosis or significant ureteral dilatation.  There is no stone along the expected course of the ureters or within the bladder.  There is a calcification in the low left pelvis not in line with ureter, this finding is stable and is compatible with a phlebolith.  There is no asymmetric renal enlargement or perinephric stranding.,The appendix is normal.  There is no evidence of a pericolonic inflammatory process or small bowel obstruction.,Scans through the pelvis disclose no free fluid or adenopathy.,Lung bases aside from very mild dependent atelectasis appear clear.,Given the lack of contrast, liver, spleen, adrenal glands, and the pancreas are grossly unremarkable.  The gallbladder is present.  There is no abdominal free fluid or pathologic adenopathy.,IMPRESSION:,1. Bilateral intrarenal stones, no obstruction.,2. Normal appendix.","radiology, noncontrast ct, abdomen and pelvis, renal stone protocol, renal stone, intrarenal stones, stone protocol, ureteral, adenopathy, renal, ct, protocol, pelvis, intrarenal, stone, abdomen, noncontrast,"
 CT Scan of  brain without contrast., Radiology, CT Scan of  Brain w/o Contrast ,"REASON FOR EXAMINATION:  Face asleep.,COMPARISON EXAMINATION:  None.,TECHNIQUE:  Multiple axial images were obtained of the brain.  5 mm sections were acquired.  2.5-mm sections were acquired without injection of intravenous contrast.  Reformatted sagittal and coronal images were obtained.,DISCUSSION:  No acute intracranial abnormalities appreciated.  No evidence for hydrocephalus, midline shift, space occupying lesions or abnormal fluid collections.  No cortical based abnormalities appreciated.  The sinuses are clear.  No acute bony abnormalities identified.,Preliminary report given to emergency room at conclusion of exam by Dr. Xyz.,IMPRESSION:  No acute intracranial abnormalities appreciated.,","radiology, ct scan, multiple axial images, asleep, brain, coronal, coronal images, hydrocephalus, intracranial, intravenous contrast, sagittal, without contrast, ct, scan, contrast, abnormalities,"
 CT scan of the abdomen and pelvis with contrast to evaluate abdominal pan., Radiology, CT Scan of Abdomen & Pelvis with Contrast ,"EXAM: , CT scan of the abdomen and pelvis with contrast.,REASON FOR EXAM: , Abdominal pain.,COMPARISON EXAM: , None.,TECHNIQUE: , Multiple axial images of the abdomen and pelvis were obtained.  5-mm slices were acquired after injection of 125 cc of Omnipaque IV.  In addition, oral ReadiCAT was given.  Reformatted sagittal and coronal images were obtained.,DISCUSSION:,  There are numerous subcentimeter nodules seen within the lung bases.  The largest measures up to 6 mm.  No hiatal hernia is identified.  Consider chest CT for further evaluation of the pulmonary nodules.  The liver, gallbladder, pancreas, spleen, adrenal glands, and kidneys are within normal limits.  No dilated loops of bowel.  There are punctate foci of air seen within the nondependent portions of the peritoneal cavity as well as the anterior subcutaneous fat.  In addition, there is soft tissue stranding seen of the lower pelvis.  In addition, the uterus is not identified.  Correlate with history of recent surgery.  There is no free fluid or lymphadenopathy seen within the abdomen or pelvis.  The bladder is within normal limits for technique.,No acute bony abnormalities appreciated.  No suspicious osteoblastic or osteolytic lesions.,IMPRESSION:,1.  Postoperative changes seen within the pelvis without appreciable evidence for free fluid.,2.  Numerous subcentimeter nodules seen within the lung bases.  Consider chest CT for further characterization.","radiology, ct scan, abdominal pain, multiple axial images, abdomen and pelvis, adrenal glands, chest ct, coronal, gallbladder, kidneys, liver, lymphadenopathy, nodules, osteoblastic, osteolytic, pancreas, sagittal, spleen, with contrast, free fluid, ct, abdomen, pelvis,"
 CT of chest with contrast.  Abnormal chest x-ray demonstrating a region of consolidation versus mass in the right upper lobe., Radiology, CT of Chest with Contrast ,"EXAM: , CT chest with contrast.,HISTORY: , Abnormal chest x-ray, which demonstrated a region of consolidation versus mass in the right upper lobe.,TECHNIQUE:  ,Post contrast-enhanced spiral images were obtained through the chest.,FINDINGS:  ,There are several, discrete, patchy air-space opacities in the right upper lobe, which have the appearance most compatible with infiltrates.  The remainder of the lung parenchyma is clear.  There is no pneumothorax or effusion.  The heart size and pulmonary vessels appear unremarkable.  There was no axillary, hilar or mediastinal lymphadenopathy.,Images of the upper abdomen are unremarkable.,Osseous windows are without acute pathology.,IMPRESSION: , Several discrete patchy air-space opacities in the right upper lobe, compatible with pneumonia.","radiology, ct chest, air-space, axillary, chest x-ray, consolidation, contrast, contrast-enhanced, effusion, hilar, infiltrates, lung, lymphadenopathy, mass, mediastinal, parenchyma, patchy air-space, pneumonia, pneumothorax, right upper lobe, spiral images, with contrast, air space opacities, upper lobe, opacities, ct, lobe, chest"
 CT of the facial bones without contrast due to hit in nose., Radiology, CT of Facial Wones w/o Contrast ,"EXAM:,  CT of the facial bones without contrast.,REASON FOR EXAM:,  Hit in nose.,COMPARISON EXAM: , Plain films of the same date.,TECHNIQUE: , Multidetector helicoaxial images were acquired in the axial plane and were reconstructed in bone and soft tissue algorithms for viewing in multiplanar format.,FINDINGS: , There is a fracture of the frontal process of the maxilla on both sides with displacement with angulation to the right and very minimal displacement of the distal fragments.  In addition, there is slight comminution of the right nasal bone without displacement.  The bony portion of the nasal septum is intact, although it is bowed to the left.  Soft tissue swelling is seen overlying the left side of the nose.  There is no nasoseptal hematoma.  Moderate mucosal thickening is seen in both maxillary sinuses.  The right maxillary sinus is hypoplastic.  Moderate mucosal thickening is seen in the left ethmoid sinus and marked mucosal thickening in the left sphenoid sinus.  The right sphenoid sinus is hypoplastic.  No abnormality of the orbits is seen.  The imaged portions of the brain are unremarkable.,IMPRESSION:,1.  Bilateral fractures of the frontal process of the maxilla and with displacement to the right.,2.  The findings were reported to Dr. Xyz of the emergency room on 04/30/07 at 1715 hours.","radiology, plain films, ct, multidetector, axial plane, bone, contrast, frontal, helicoaxial, maxilla, mucosal thickening, multiplanar, nasal bone, nasoseptal hematoma, sinus, soft tissue, sphenoid, without contrast, sinus is hypoplastic, facial, mucosal, thickening "
 CT of Lumbar Spine without Contrast.  Patient with history of back pain after a fall., Radiology, CT of Lumbar Spine w/o Contrast ,"EXAM: , Lumbar spine CT without contrast.,HISTORY: , Back pain after a fall.,TECHNIQUE:,  Noncontrast axial images were acquired through the lumbar spine. Coronal and sagittal reconstruction views were also obtained.,FINDINGS: , There is no evidence for acute fracture or subluxation.  There is no spondylolysis or spondylolisthesis.  The central canal and neuroforamen are grossly patent at all levels.  There are no abnormal paraspinal masses. There is no wedge/compression deformity.  There is intervertebral disk space narrowing to a mild degree at L2-3 and L4-5.,Soft tissue windows demonstrate atherosclerotic calcification of the abdominal aorta, which is not dilated.  There was incompletely visualized probable simple left renal cyst, exophytic at the lower pole.,IMPRESSION:,1.  No evidence for acute fracture or subluxation.,2.  Mild degenerative changes.,3.  Probable left simple renal cyst.,","radiology, lumbar spine, back pain, ct, coronal, atherosclerotic, axial images, central canal, compression, deformity, degenerative, disk space, fracture, intervertebral, neuroforamen, sagittal, spondylolisthesis, spondylolysis, subluxation, wedge, without contrast, contrast, spine, lumbar, noncontrast,"
 CT maxillofacial for trauma.  CT examination of the maxillofacial bones was performed without contrast.  Coronal reconstructions were obtained for better anatomical localization., Radiology, CT Maxillofacial ,"EXAM:  ,CT maxillofacial for trauma.,FINDINGS: , CT examination of the maxillofacial bones was performed without contrast.  Coronal reconstructions were obtained for better anatomical localization.,There is normal appearance to the orbital rims.  The ethmoid, sphenoid, and frontal sinuses are clear.  There is polypoid mucosal thickening involving the floor of the maxillary sinuses bilaterally.  There is soft tissue or fluid opacification of the ostiomeatal complexes bilaterally.  The nasal bones appear intact.  The zygomatic arches are intact.  The temporomandibular joints are intact and demonstrate no dislocations or significant degenerative changes.  The mandible and maxilla are intact.  There is soft tissue swelling seen involving the right cheek.,IMPRESSION:,1.  Mucosal thickening versus mucous retention cyst involving the maxillary sinuses bilaterally.  There is also soft tissue or fluid opacification of the ostiomeatal complexes bilaterally.,2.  Mild soft tissue swelling about the right cheek.","radiology, ethmoid, sphenoid, frontal sinuses, mandible, maxilla, ct examination, maxillofacial bones, mucosal thickening, maxillary sinuses, ct, maxillofacial"
 CT REPORT - Soft Tissue Neck, Radiology, CT Neck - 2 ,"FINDINGS:,There is a well demarcated mass lesion of the deep lobe of the left parotid gland measuring approximately 2.4 X 3.9 X 3.0cm (AP X transverse X craniocaudal) in size. The lesion is well demarcated. There is a solid peripheral rim with a mean attenuation coefficient of 56.3. There is a central cystic appearing area with a mean attenuation coefficient of 28.1 HU, suggesting an area of central necrosis. There is the suggestion of mild peripheral rim enhancement. This large lesion within the deep lobe of the parotid gland abuts and effaces the facial nerve. Primary consideration is of a benign mixed tumor (pleomorphic adenoma), however, other solid mass lesions cannot be excluded, for which histologic evaluation would be necessary for definitive diagnosis. The right parotid gland is normal.,There is mild enlargement of the left jugulodigastric node, measuring 1.1cm in size, with normal morphology (image #33/68). There is mild enlargement of the right jugulodigastric node, measuring 1.2cm in size, with normal morphology (image #38/68).,There are demonstrated bilateral deep lateral cervical nodes at the midlevel, measuring 0.6cm on the right side and 0.9cm on the left side (image #29/68). There is a second midlevel deep lateral cervical node demonstrated on the left side (image #20/68), measuring 0.7cm in size. There are small bilateral low level nodes involving the deep lateral cervical nodal chain (image #15/68) measuring 0.5cm in size.,There is no demonstrated nodal enlargement of the spinal accessory or pretracheal nodal chains.,The right parotid gland is normal and there is no right parotid gland mass lesion.,Normal bilateral submandibular glands.,Normal parapharyngeal, retropharyngeal and perivertebral spaces.,Normal carotid spaces.,IMPRESSION:,Large, well demarcated mass lesion of the deep lobe of the left parotid gland, with probable involvement of the left facial nerve. See above for size, morphology and pattern enhancement. Primary consideration is of a benign mixed tumor (pleomorphic adenoma), however, other solid mass lesions cannot be excluded, for which histologic evaluation is necessary for specificity.,Multiple visualized nodes of the bilateral deep lateral cervical nodal chain, within normal size and morphology, most compatible with mild hyperplasia.","radiology, cervical nodal, mass lesion, deep lobe, deep lateral, lateral cervical, parotid gland, cervical, lesion, gland, parotid, deep"
 CT REPORT - Soft Tissue Neck, Radiology, CT Neck - 1 ,"FINDINGS:,There is a lobulated mass lesion of the epiglottis measuring approximately 22 x 16 x 30 mm (mediolateral x AP x craniocaudal) in size. There is slightly greater involvement on the right side however there is bilateral involvement of the aryepiglottic folds. There is marked enlargement of the bilateral aryepiglottic folds (left greater than right). There is thickening of the glossoepiglottic fold. There is an infiltrative mass like lesion extending into the pre-epiglottic space.,There is no demonstrated effacement of the piriform sinuses. The mass obliterates the right vallecula. The paraglottic spaces are normal. The true and false cords appear normal. Normal thyroid, cricoid and arytenoid cartilages.,There is lobulated thickening of the right side of the tongue base, for which invasion of the tongue cannot be excluded. A MRI examination would be of benefit for further evaluation of this finding.,There is a 14 x 5 x 12 mm node involving the left submental region (Level I).,There is borderline enlargement of the bilateral jugulodigastric nodes (Level II). The left jugulodigastric node,measures 14 x 11 x 8 mm while the right jugulodigastric node measures 15 x 12 x 8 mm.,There is an enlarged second left high deep cervical node measuring 19 x 14 x 15 mm also consistent with a left Level II node, with a probable necrotic center.,There is an enlarged second right high deep cervical node measuring 12 x 10 x 10 mm but no demonstrated central necrosis.,There is an enlarged left mid level deep cervical node measuring 9 x 16 x 6 mm, located inferior to the hyoid bone but cephalad to the cricoid consistent with a Level III node.,There are two enlarged matted nodes involving the right mid level deep cervical chain consistent with a right Level III nodal disease, producing a conglomerate nodal mass measuring approximately 26 x 12 x 10 mm.,There is a left low level deep cervical node lying along the inferior edge of the cricoid cartilage measuring approximately 18 x 11 x 14 mm consistent with left Level IV nodal disease.,There is no demonstrated pretracheal, prelaryngeal or superior mediastinal nodes. There is no demonstrated retropharyngeal adenopathy.,There is thickening of the adenoidal pad without a mass lesion of the nasopharynx. The torus tubarius and fossa of Rosenmuller appear normal.,IMPRESSION:,Epiglottic mass lesion with probable invasion of the glossoepiglottic fold and pre-epiglottic space with invasion of the bilateral aryepiglottic folds.,Lobulated tongue base for which tongue invasion cannot be excluded. An MRI may be of benefit for further assessment of this finding.,Borderline enlargement of a submental node suggesting Level I adenopathy.,Bilateral deep cervical nodal disease involving bilateral Level II, Level III and left Level IV.","radiology, deep cervical node, epiglottic mass, epiglottic space, aryepiglottic folds, jugulodigastric nodes, level deep, cervical node, deep cervical, node, jugulodigastric, aryepiglottic, deep, cervical"
 This is a middle-aged female with two month history of low back pain and leg pain., Radiology, CT Lumbar Spine - 2 ,"FINDINGS:,Axial scans were performed from L1 to S2 and reformatted images were obtained in the sagittal and coronal planes.,Preliminary scout film demonstrates anterior end plate spondylosis at T11-12 and T12-L1.,L1-2: There is normal disc height, anterior end plate spondylosis, very minimal vacuum change with no posterior annular disc bulging or protrusion. Normal central canal, intervertebral neural foramina and facet joints (image #4).,L2-3: There is mild decreased disc height, anterior end plate spondylosis, circumferential disc protrusion measuring 4.6mm (AP) and right extraforaminal osteophyte disc complex. There is mild non-compressive right neural foraminal narrowing, minimal facet arthrosis, normal central canal and left neural foramen (image #13).,L3-4: There is normal disc height, anterior end plate spondylosis, and circumferential non-compressive annular disc bulging. The disc bulging flattens the ventral thecal sac and there is minimal non-compressive right neural foraminal narrowing, minimal to mild facet arthrosis with vacuum change on the right, normal central canal and left neural foramen (image #25).,L4-5:","radiology, anterior end plate spondylosis, compressive right neural foraminal, compressive annular disc bulging, anterior end plate, annular disc bulging, normal central canal, plate spondylosis, central canal, vacuum change, disc bulging, neural foraminal, facet arthrosis, anterior, spondylosis, neural, lumbar, disc, bulging, foraminal, arthrosis, facet"
 Common CT Neck template., Radiology, CT Neck ,"TECHNIQUE: , Sequential axial CT images were obtained from the base of the brain to the thoracic inlet following the uneventful administration of 100 CC Optiray 320 intravenous contrast.,FINDINGS:,  Scans through the base of the brain are unremarkable.  The oropharynx and nasopharynx are within normal limits.  The airway is patent.  The epiglottis and epiglottic folds are normal.  The thyroid, submandibular, and parotid glands enhance homogenously.  The vascular and osseous structures in the neck are intact.  There is no lymphadenopathy.  The visualized lung apices are clear.,IMPRESSION:  ,No acute abnormalities.","radiology, sequential axial ct images, optiray, parotid glands, epiglottic folds, epiglottis, base of the brain, ct neckNOTE"
" Motor vehicle collision.  CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.  ", Radiology," CT Head, Facial Bones, Cervical Spine - 1 ","CT HEAD WITHOUT CONTRAST, CT FACIAL BONES WITHOUT CONTRAST, AND CT CERVICAL SPINE WITHOUT CONTRAST,REASON FOR EXAM: , Motor vehicle collision.,CT HEAD,TECHNIQUE: , Noncontrast axial CT images of the head were obtained without contrast.,FINDINGS: , There is no acute intracranial hemorrhage, mass effect, midline shift, or extra-axial fluid collection.  The ventricles and cortical sulci are normal in shape and configuration.  The gray/white matter junctions are well preserved.  No calvarial fracture is seen.,IMPRESSION:  ,Negative for acute intracranial disease.,CT FACIAL BONES WITHOUT CONTRAST,TECHNIQUE:  ,Noncontrast axial CT images of the facial bones were obtained with coronal reconstructions.,FINDINGS:,  There is no facial bone fracture.  The maxilla and mandible are intact.  The visualized paranasal sinuses are clear.  The temporomandibular joints are intact.  The nasal bone is intact.  The orbits are intact.  The extra-ocular muscles and orbital nerves are normal.  The orbital globes are normal.,IMPRESSION: , No evidence for a facial bone fracture.,CT CERVICAL SPINE WITHOUT CONTRAST,TECHNIQUE: , Noncontrast axial CT images of the cervical spine were obtained with sagittal and coronal reconstructions.,FINDINGS: , There is a normal lordosis of the cervical spine, no fracture or subluxation is seen.  The vertebral body heights are normal.  The intervertebral disk spaces are well preserved.  The atlanto-dens interval is normal.  No abnormal anterior cervical soft tissue swelling is seen.  There is no spinal compression deformity.,IMPRESSION: , Negative for a facial bone fracture.","radiology, intracranial disease, motor vehicle collision, orbital nerves, extra-ocular muscles, cervical spine, ct cervical spine, ct facial bones, ct head, axial ct images, facial bone fracture, facial bones, ct, noncontrast, intracranial, axial, spine, fracture, cervical, contrast, facial, bones, "
" CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.", Radiology," CT Head, Facial Bones, Cervical Spine ","EXAM: , CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.,REASON FOR EXAM:,  A 68-year-old status post fall with multifocal pain.,COMPARISONS: , None.,TECHNIQUE: , Sequential axial CT images were obtained from the vertex to the thoracic inlet without contrast.  Additional high-resolution sagittal and/or coronal reconstructed images were obtained through the facial bones and cervical spine for better visualization of the osseous structures.,INTERPRETATIONS:,HEAD:,There is mild generalized atrophy.  Scattered patchy foci of decreased attenuation is seen in the subcortical and periventricular white matter consistent with chronic small vessel ischemic changes.  There are subtle areas of increased attenuation seen within the frontal lobes bilaterally.  Given the patient's clinical presentation, these likely represent small hemorrhagic contusions.  Other differential considerations include cortical calcifications, which are less likely.  The brain parenchyma is otherwise normal in attenuation without evidence of mass, midline shift, hydrocephalus, extra-axial fluid, or acute infarction.  The visualized paranasal sinuses and mastoid air cells are clear.  The bony calvarium and skull base are unremarkable.,FACIAL BONES:,The osseous structures about the face are grossly intact without acute fracture or dislocation.  The orbits and extra-ocular muscles are within normal limits.  There is diffuse mucosal thickening in the ethmoid and right maxillary sinuses.  The remaining visualized paranasal sinuses and mastoid air cells are clear.  Diffuse soft tissue swelling is noted about the right orbit and right facial bones without underlying fracture.,CERVICAL SPINE:,There is mild generalized osteopenia.  There are diffuse multilevel degenerative changes identified extending from C4-C7 with disk space narrowing, sclerosis, and marginal osteophyte formation.  The remaining cervical vertebral body heights are maintained without acute fracture, dislocation, or spondylolisthesis.  The central canal is grossly patent.  The pedicles and posterior elements appear intact with multifocal facet degenerative changes.  There is no prevertebral or paravertebral soft tissue masses identified.  The atlanto-dens interval and dens are maintained.,IMPRESSION:,1.Subtle areas of increased attenuation identified within the frontal lobes bilaterally suggesting small hemorrhagic contusions.  There is no associated shift or mass effect at this time.  Less likely, this finding could be secondary to cortical calcifications.  The patient may benefit from a repeat CT scan of the head or MRI for additional evaluation if clinically indicated.,2.Atrophy and chronic small vessel ischemic changes in the brain.,3.Ethmoid and right maxillary sinus congestion and diffuse soft tissue swelling over the right side of the face without underlying fracture.,4.Osteopenia and multilevel degenerative changes in the cervical spine as described above.,5.Findings were discussed with Dr. X from the emergency department at the time of interpretation.","radiology, sagittal, coronal, soft tissue swelling, paranasal sinuses, mastoid air, acute fracture, maxillary sinuses, tissue swelling, underlying fracture, multilevel degenerative, ct head, soft tissue, facial bones, cervical spine, ct, facial, bones, spine, cervical"
" The patient is a 79-year-old man with adult hydrocephalus who was found to have large bilateral effusions on a CT scan.  The patient's subdural effusions are still noticeable, but they are improving.", Radiology, CT Head - 2 ,"REASON FOR CT SCAN: , The patient is a 79-year-old man with adult hydrocephalus who was found to have large bilateral effusions on a CT scan performed on January 16, 2008.  I changed the shunt setting from 1.5 to 2.0 on February 12, 2008 and his family obtained this repeat CT scan to determine whether his subdural effusions were improving.,CT scan from 03/11/2008 demonstrates frontal horn span at the level of foramen of Munro of 2.6 cm.  The 3rd ventricular contour which is flat with a 3rd ventricular span of 10 mm.  There is a single shunt, which enters on the right occipital side and ends in the left lateral ventricle.  He has symmetric bilateral subdurals that are less than 1 cm in breadth each, which is a reduction from the report from January 16, 2008, which states that he had a subdural hygroma, maximum size 1.3 cm on the right and 1.1 cm on the left.,ASSESSMENT: , The patient's subdural effusions are still noticeable, but they are improving at the setting of 2.0.,PLAN: , I would like to see the patient with a new head CT in about three months, at which time we can decide whether 2.0 is the appropriate setting for him to remain at or whether we can consider changing the shunt setting.","radiology, ct scan, subdural, adult hydrocephalus, bilateral effusions, shunt setting, subdural effusions, hydrocephalus, ventricular, scan, ct,"
 Left arm and hand numbness.  CT head without contrast.  Noncontrast axial CT images of the head were obtained with 5 mm slice thickness., Radiology, CT Head - 3 ,"REASON FOR EXAM:  ,Left arm and hand numbness.,TECHNIQUE: , Noncontrast axial CT images of the head were obtained with 5 mm slice thickness.,FINDINGS:  ,There is an approximately 5-mm shift of the midline towards the right side.  Significant low attenuation is seen throughout the white matter of the right frontal, parietal, and temporal lobes.  There is loss of the cortical sulci on the right side.  These findings are compatible with edema.  Within the right parietal lobe, a 1.8 cm, rounded, hyperintense mass is seen.,No hydrocephalus is evident.,The calvarium is intact.  The visualized paranasal sinuses are clear.,IMPRESSION:  ,A 5 mm midline shift to the left side secondary to severe edema of the white matter of the right frontal, parietal, and temporal lobes.  A 1.8 cm high attenuation mass in the right parietal lobe is concerning for hemorrhage given its high density.  A postcontrast MRI is required for further characterization of this mass.  Gradient echo imaging should be obtained.","radiology, numbness, head, ct images, frontal, parietal, temporal, axial ct images, parietal and temporal, ct head, slice thickness, white matter, frontal parietal, temporal lobes, parietal lobe, edema, intact, noncontrast, mass, ct, lobes, arm, "
" Noncontrast CT scan of the lumbar spine.  Left lower extremity muscle spasm.  Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested.", Radiology, CT Lumbar Spine ,"EXAM:,  Noncontrast CT scan of the lumbar spine,REASON FOR EXAM: , Left lower extremity muscle spasm.,COMPARISONS: , None.,FINDINGS: , Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested.,No abnormal paraspinal masses are identified.,There are sclerotic changes with anterior effusion of the sacroiliac joints bilaterally.,There is marked intervertebral disk space narrowing at the L5-S1 level with intervertebral disk vacuum phenomenon and advanced endplate degenerative changes.  Posterior disk osteophyte complex is present, most marked in the left paracentral to lateral region extending into the lateral recess on the left.  This most likely will affect the S1 nerve root on the left.  There are posterior hypertrophic changes extending into the neural foramina bilaterally inferiorly.  There is mild neural foraminal stenosis present.  Small amount of extruded disk vacuum phenomenon is present on the left in the region of the exiting nerve root.  There is facet sclerosis bilaterally.  Mild lateral recess stenosis just on the right, there is prominent anterior spondylosis.,At the L4-5 level, mild bilateral facet arthrosis is present.  There is broad based posterior annular disk bulging or protrusion, which mildly effaces the anterior aspect of the thecal sac and extends into the inferior aspect of the neural foramina bilaterally.  No moderate or high-grade central canal or neural foraminal stenosis is identified.,At the L3-4 level anterior spondylosis is present.  There are endplate degenerative changes with mild posterior annular disk bulging, but no evidence of moderate or high-grade central canal or neural foraminal stenosis.,At the L2-3 level, there is mild bilateral ligamentum flavum hypertrophy.  Mild posterior annular disk bulging is present without evidence of moderate or high-grade central canal or neural foraminal stenosis.,At the T12-L1 and L1-2 levels, there is no evidence of herniated disk protrusion, central canal, or neural foraminal stenosis.,There is arteriosclerotic vascular calcification of the abdominal aorta and iliac arteries without evidence of aneurysm or dilatation.  No bony destructive changes or acute fractures are identified.,CONCLUSIONS:,1. Advanced degenerative disk disease at the L5-S1 level.,2. Probable chronic asymmetric herniated disk protrusion with peripheral calcification at the L5-S1 level, laterally in the left paracentral region extending into the lateral recess causing lateral recess stenosis.,3. Mild bilateral neural foraminal stenosis at the L5-S1 level.,4. Posterior disk bulging at the L2-3, L3-4, and L4-5 levels without evidence of moderate or high-grade central canal stenosis.,5. Facet arthrosis to the lower lumbar spine.,6. Arteriosclerotic vascular disease.","radiology, noncontrast ct scan, lower extremity muscle spasm, neural foraminal stenosis, lumbar spine, spine, disk, lumbar, ct, intervertebral, canal, foraminal, noncontrast, stenosis, "
 This is a middle-aged female with low back pain radiating down the left leg and foot for one and a half years., Radiology, CT Lumbar Spine - 1 ,"FINDINGS:,High resolution computerized tomography was performed from T12-L1 to the S1 level with reformatted images in the sagittal and coronal planes and 3D reconstructions performed. COMPARISON: Previous MRI examination 10/13/2004.,There is minimal curvature of the lumbar spine convex to the left.,T12-L1, L1-2, L2-3: There is normal disc height with no posterior annular disc bulging or protrusion. Normal central canal, intervertebral neural foramina and facet joints.,L3-4: There is normal disc height and non-compressive circumferential annular disc bulging eccentrically greater to the left. Normal central canal and facet joints (image #255).,L4-5: There is normal disc height, circumferential annular disc bulging, left L5 hemilaminectomy and posterior central/right paramedian broad-based disc protrusion measuring 4mm (AP) contouring the rightward aspect of the thecal sac. Orthopedic hardware is noted posteriorly at the L5 level. Normal central canal, facet joints and intervertebral neural foramina (image #58).,L5-S1: There is minimal decreased disc height, postsurgical change with intervertebral disc spacer, posterior lateral orthopedic hardware with bilateral pedicle screws in good postsurgical position. The orthopedic hardware creates mild streak artifact which mildly degrades images. There is a laminectomy defect, spondylolisthesis with 3.5mm of anterolisthesis of L5, posterior annular disc bulging greatest in the left foraminal region lying adjacent to the exiting left L5 nerve root. There is fusion of the facet joints, normal central canal and right neural foramen (image #69-70, 135).,There is no bony destructive change noted.,There is no perivertebral soft tissue abnormality.,There is minimal to mild arteriosclerotic vascular calcifications noted in the abdominal aorta and right proximal common iliac artery.,IMPRESSION:,Minimal curvature of the lumbar spine convex to the left.,L3-4 posterior non-compressive annular disc bulging eccentrically greater to the left.,L4-5 circumferential annular disc bulging, non-compressive central/right paramedian disc protrusion, left L5 laminectomy.,L5-S1 postsurgical change with posterolateral orthopedic fusion hardware in good postsurgical position, intervertebral disc spacer, spondylolisthesis, laminectomy defect, posterior annular disc bulging greatest in the left foraminal region adjacent to the exiting left L5 nerve root with questionable neural impingement.,Minimal to mild arteriosclerotic vascular calcifications.","radiology, posterior annular disc, circumferential annular disc, normal central canal, annular disc bulging, lumbar spine, posterior annular, facet joints, annular disc, disc bulging, tomography, disc, lumbar, orthopedic, postsurgical, spine, annular, bulging,"
 Common CT Head template., Radiology, CT Head ,"TECHNIQUE: , Sequential axial CT images were obtained from the vertex to the skull base without contrast.,FINDINGS: , There is mild generalized atrophy.  Scattered patchy foci of decreased attenuation are seen within the sub cortical and periventricular white matter compatible with chronic small vessel ischemic changes.  The brain parenchyma is otherwise normal in attenuation with no evidence of mass, hemorrhage, midline shift, hydrocephalus, extra-axial fluid, or acute infarction.  The visualized paranasal sinuses and mastoid air cells are clear.  The bony calvarium and skull base are within normal limits.  ,IMPRESSION: , No acute abnormalities.","radiology, decreased attenuation, skull base, sequential axial ct images, bony calvarium, extra-axial fluid, ct head, attenuationNOTE"
 Common CT Facial template., Radiology, CT Facial ,"TECHNIQUE: , Sequential axial CT images were obtained through the facial bones without contrast.  Additional high resolution coronal reconstructed images were also obtained for better visualization of the osseous structures.,FINDINGS:,  The osseous structures within the face are intact with no evidence of fracture or dislocation.  The visualized paranasal sinuses and mastoid air cells are clear.  The orbits and extra-ocular muscles are within normal limits.  The soft tissues are unremarkable.  ,IMPRESSION: , No acute abnormalities.","radiology, sequential axial ct image, ct facial, osseous structuresNOTE"
 Noncontrast CT abdomen and pelvis per renal stone protocol., Radiology, CT KUB ,"EXAM:  ,CT KUB.,REASON FOR EXAM: , Flank pain.,TECHNIQUE:,  Noncontrast CT abdomen and pelvis per renal stone protocol.,Correlation is made with the prior examination dated 01/16/09.,FINDINGS: , There is no intrarenal stone or obstruction bilaterally.  There is no hydronephrosis, ureteral dilatation.  There are calcifications about the pelvis including one in the left upper pelvis, but these are stable from the prior study and there is no upstream ureteral dilatation, the findings therefore are favored to represent phleboliths.  The bladder is nearly completely decompressed.  There is no asymmetric renal enlargement or perinephric stranding as secondary evidence of obstruction.,The appendix is normal.  There is no evidence for a pericolonic inflammatory process or small bowel obstruction.,Dedicated scan to the pelvis disclosed the aforementioned presumed phleboliths.  There is no pelvic free fluid or adenopathy.,Lung bases appear clear.  Given the lack of contrast, liver, spleen, adrenal glands, and the pancreas appear grossly unremarkable.  The gallbladder has been resected.  There is no abdominal free fluid or pathologic adenopathy.,IMPRESSION:,1. No renal stone or evidence of obstruction.  Stable appearing pelvic calcifications likely indicate phleboliths.,2. Normal appendix.","radiology, pericolonic inflammatory process, phleboliths, renal stone protocol, ct kub, ct abdomen, ureteral dilatation, free fluid, renal stone, noncontrast, kub, adenopathy, abdomen, ct, renal, stone, obstruction, pelvis"
  CT cervical spine for trauma.  CT examination of the cervical spine was performed without contrast.  Coronal and sagittal reformats were obtained for better anatomical localization., Radiology, CT C-Spine - 2 ,"EXAM:,  CT cervical spine (C-spine) for trauma.,FINDINGS:,  CT examination of the cervical spine was performed without contrast.  Coronal and sagittal reformats were obtained for better anatomical localization.  Cervical vertebral body height, alignment and interspacing are maintained.  There is no evidence of fractures or destructive osseous lesions.  There are no significant degenerative endplate or facet changes.  No significant osseous central canal or foraminal narrowing is present.,IMPRESSION: , Negative cervical spine.","radiology, c-spine, anatomical, degenerative endplate, ct examination, cervical spine, coronal, ct, spine, cervicalNOTE"
 Noncontrast CT head due to seizure disorder., Radiology, CT Head - 1 ,"EXAM:,  CT head.,REASON FOR EXAM:,  Seizure disorder.,TECHNIQUE:,  Noncontrast CT head.,FINDINGS: , There is no evidence of an acute intracranial hemorrhage or infarction.  There is no midline shift, intracranial mass, or mass effect.  There is no extra-axial fluid collection or hydrocephalus.  Visualized portions of the paranasal sinuses and mastoid air cells appear clear aside from mild right frontal sinus mucosal thickening.,IMPRESSION:,  No acute process in the brain.","radiology, mass effect, extra-axial fluid, hydrocephalus, midline shift, intracranial mass, paranasal sinuses, mastoid air cells, frontal sinus, mucosal thickening, seizure disorder, ct head, seizure, sinuses, ct, head, noncontrast, "
 Axial images through the cervical spine with coronal and sagittal reconstructions., Radiology, CT C-Spine - 1  ,"EXAM: , CT cervical spine.,REASON FOR EXAM: , MVA, feeling sleepy, headache, shoulder and rib pain.,TECHNIQUE:,  Axial images through the cervical spine with coronal and sagittal reconstructions.,FINDINGS:,  There is reversal of the normal cervical curvature at the vertebral body heights.  The intervertebral disk spaces are otherwise maintained.  There is no prevertebral soft tissue swelling.  The facets are aligned.  The tip of the clivus and occiput appear intact.  On the coronal reconstructed sequence, there is satisfactory alignment of C1 on C2, no evidence of a base of dens fracture.,The included portions of the first and second ribs are intact.  There is no evidence of a posterior element fracture.  Included portions of the mastoid air cells appear clear.  There is no CT evidence of a moderate or high-grade stenosis.,IMPRESSION: , No acute process, cervical spine.","radiology, c-spine, axial images, sagittal reconstructions, cervical spine, sagittal, fracture, coronal, spine, axial, cervical, ct, "
" CT head without contrast.  Assaulted, positive loss of consciousness, rule out bleed.  CT examination of the head was performed without intravenous contrast administration.", Radiology, CT Head - 4 ,"EXAM: , CT head without contrast.,INDICATIONS: , Assaulted, positive loss of consciousness, rule out bleed.,TECHNIQUE: , CT examination of the head was performed without intravenous contrast administration.  There are no comparison studies.,FINDINGS:  ,There are no abnormal extraaxial fluid collections.  There is no midline shift or mass effect.  Ventricular system demonstrates no dilatation.  There is no evidence of acute intracranial hemorrhage.  The calvarium is intact.  There is a laceration in the left parietal region of the scalp without underlying calvarial fractures.  The mastoid air cells are clear.,IMPRESSION:  ,No acute intracranial process.","radiology, extraaxial fluid, intracranial hemorrhage, parietal region, scalp, loss of consciousness, ct examination, ct head, intracranial, intravenous, contrast, "
 Motor vehicle collision.  CT head without contrast and CT cervical spine without contrast.  Noncontrast axial CT images of the head were obtained., Radiology, CT Head and C Spine ,"CT HEAD WITHOUT CONTRAST AND CT CERVICAL SPINE WITHOUT CONTRAST,REASON FOR EXAM: , Motor vehicle collision.,CT HEAD WITHOUT CONTRAST,TECHNIQUE:,  Noncontrast axial CT images of the head were obtained.,FINDINGS: , There is no acute intracranial hemorrhage, mass effect, midline shift, or extra-axial fluid collection.  The ventricles and cortical sulci are normal in shape and configuration.  The gray/white matter junctions are well preserved.  There is no calvarial fracture.  The visualized paranasal sinuses and mastoid air cells are clear.,IMPRESSION: , Negative for acute intracranial disease.,CT CERVICAL SPINE,TECHNIQUE:  ,Noncontrast axial CT images of the cervical spine were obtained.  Sagittal and coronal images were obtained.,FINDINGS:,  Straightening of the normal cervical lordosis is compatible with patient position versus muscle spasms.  No fracture or subluxation is seen.  Anterior and posterior osteophyte formation is seen at C5-C6.  No abnormal anterior cervical soft tissue swelling is seen.  No spinal compression is noted.  The atlanto-dens interval is normal.  There is a large retention cyst versus polyp within the right maxillary sinus.,IMPRESSION:,1.  Straightening of the normal cervical lordosis compatible with patient positioning versus muscle spasms.,2.  Degenerative disk and joint disease at C5-C6.,3.  Retention cyst versus polyp of the right maxillary sinus.","radiology, muscle spasms, cervical lordosis, intracranial hemorrhage, motor vehicle collision, axial ct images, ct head, ct, anterior, cyst, polyp, maxillary, contrast, intracranial, sinuses, spine, axial, head, cervical, noncontrast"
 Common CT Chest template, Radiology, CT Chest ,"TECHNIQUE: , Sequential axial CT images were obtained from the base of the brain to the upper abdomen following the uneventful administration of 100cc Optiray 350 intravenous contrast.,FINDINGS: , The heart size is normal and there is no pericardial effusion.  The aorta and great vessels are normal in caliber.  The central pulmonary arteries are patent with no evidence of embolus.  There is no significant mediastinal, hilar, or axillary lymphadenopathy.  The trachea and mainstem bronchi are patent.  The esophagus is normal in course and caliber.  The lungs are clear with no infiltrates, effusions, or masses.  There is no pneumothorax.  Scans through the upper abdomen are unremarkable.  The osseous structures in the chest are intact.  ,IMPRESSION: , No acute abnormalities.","radiology, sequential axial ct images, optiray, pericardial effusion, mediastinal, hilar, axillary, lymphadenopathy, ct chest, upper abdomenNOTE"
 Common CT C-Spine template, Radiology, CT C-Spine ,"TECHNIQUE: , Sequential axial CT images were obtained through the cervical spine without contrast.  Additional high resolution coronal and sagittal reconstructed images were also obtained for better visualization of the osseous structures.  ,FINDINGS: , The cervical spine demonstrates normal alignment and mineralization with no evidence of fracture, dislocation, or spondylolisthesis.  The vertebral body heights and disc spaces are maintained.  The central canal is patent.  The pedicles and posterior elements are intact.  The paravertebral soft tissues are within normal limits.  The atlanto-dens interval and the dens are intact.  The visualized lung apices are clear.,IMPRESSION: , No acute abnormalities.","radiology, sequential axial ct images, atlanto-dens interval, dens, ct c spine, cervical spineNOTE"
 Stroke in distribution of recurrent artery of Huebner (left), Radiology, CT Brain - Stroke  ,"CC:, Falls.,HX: ,This 51y/o RHF fell four times on 1/3/93, because her ""legs suddenly gave out."" She subsequently noticed weakness involving the right leg, and often required the assistance of her arms to move it. During some of these episodes she appeared mildly pale and felt generally weak; her husband would give her 3 teaspoons of sugar and she would appear to improve, thought not completely. During one episode she held her RUE in an ""odd fisted posture."" She denied any other focal weakness, sensory change, dysarthria, diplopia, dysphagia or alteration of consciousness. She did not seek medical attention despite her weakness. Then, last night, 1/4/93, she fell again ,and because her weakness did not subsequently improve she came to UIHC for evaluation on 1/5/93.,MEDS: ,Micronase 5mg qd, HCTZ, quit ASA 6 months ago (tired of taking it).,PMH:, 1)DM type 2, dx 6 months ago. 2)HTN. 3)DJD. 4)s/p Vitrectomy and retinal traction OU for retinal detachment 7/92. 5) s/p Cholecystemomy,1968. 6) Cataract implant, OU,1992. 7) s/p C-section.,FHX: ,Grand Aunt (stroke), MG (CAD), Mother (CAD, died MI age 63), Father (with unknown CA), Sisters (HTN), No DM in relatives.,SHX: ,Married, lives with husband, 4 children alive and well. Denied tobacco/ETOH/illicit drug use.,ROS:, intermittent diarrhea for 20 years.,EXAM: ,BP164/82 HR64 RR18 36.0C,MS: A & O to person, place, time. Speech fluent and without dysarthria. Intact naming, comprehension, reading.,CN: Pupils 4.5 (irregular)/4.0 (irregular) and virtually fixed. Optic disks flat. EOM intact. VFFTC. Right lower facial weakness. The rest of the CN exam was unremarkable.,Motor: 5/5 BUE with some question of breakaway. LE: HF and HE 4+/5, KF5/5, AF and AE 5/5. Normal muscle bulk and tone.,Sensory: intact PP/VIB/PROP/LT/T/graphesthesia.,Coord: slowed FNF and HKS (worse on right).,Station: no pronator drift or Romberg sign.,Gait: Unsteady wide-based gait. Unable to heel walk on right.,Reflexes: 2/2+ throughout (Slightly more brisk on right). Plantar responses were downgoing bilaterally.,HEENT: N0 Carotid or cranial bruits.,Gen Exam: unremarkable.,COURSE:, CBC, GS (including glucose), PT/PTT, EKG, CXR on admission, 1/5/93, were unremarkable. HCT, 1/5/93, revealed a hypodensity in the left caudate consistent with ischemic change. Carotid Duplex: 0-15%RICA, 16-49%LICA; antegrade vertebral artery flow, bilaterally. Transthoracic echocardiogram showed borderline LV hypertrophy and normal LV function. No valvular abnormalities or thrombus were seen.,The patient's history and exam findings of right facial and RLE weakness with sparing of the RUE would invoke a RACA territory stroke with recurrent artery of Heubner involvement causing the facial weakness.", 
 A 68-year-old white male with recently diagnosed adenocarcinoma by sputum cytology.  An abnormal chest radiograph shows right middle lobe infiltrate and collapse.  Patient needs staging CT of chest with contrast. , Radiology, CT Chest - 2 ,"CLINICAL HISTORY: , A 68-year-old white male with recently diagnosed adenocarcinoma by sputum cytology.  An abnormal chest radiograph shows right middle lobe infiltrate and collapse.  Patient needs staging CT of chest with contrast.  Right sided supraclavicular and lower anterior cervical adenopathy noted on physical exam.,TECHNIQUE: , Multiple transaxial images utilized in 10 mm sections were obtained through the chest.  Intravenous contrast was administered.,FINDINGS: , There is a large 3 x 4 cm lymph node seen in the right supraclavicular region.  There is a large right paratracheal lymph node best appreciated on image #16 which measures 3 x 2 cm.  A subcarinal lymph node is enlarged also.  It measures 6 x 2 cm.  Multiple pulmonary nodules are seen along the posterior border of the visceral as well as parietal pleura.  There is a pleural mass seen within the anterior sulcus of the right hemithorax as well as the right crus of the diaphragm.  There is also a soft tissue density best appreciated on image #36 adjacent to the inferior aspect of the right lobe of the liver which most likely also represents metastatic deposit.  The liver parenchyma is normal without evidence of any dominant masses.  The right kidney demonstrates a solitary cyst in the mid pole of the right kidney.,IMPRESSION:,1.  Greater than twenty pulmonary nodules demonstrated on the right side to include pulmonary nodules within the parietal as well as various visceral pleura with adjacent consolidation most likely representing pulmonary neoplasm.,2.  Extensive mediastinal adenopathy as described above.,3.  No lesion seen within the left lung at this time.,4.  Supraclavicular adenopathy.","radiology, supraclavicular, cervical adenopathy, pulmonary nodules, lymph node, adenopathy, pulmonary, chest, "
 CT of Brain - Subacute SDH., Radiology, CT Brain: Subdural hematoma ,"CC:, Progressive unsteadiness following head trauma.,HX:,  A7 7 y/o male fell, as he was getting out of bed, and struck his head, 4 weeks prior to admission. He then began to experience progressive unsteadiness and gait instability for several days after the fall. He was then evaluated at a local ER and prescribed meclizine. This did not improve his symptoms, and over the past one week prior to admission began to develop left facial/LUE/LLE weakness. He was seen by a local MD on the 12/8/92 and underwent and MRI Brain scan. This showed a right subdural mass. He was then transferred to UIHC for further evaluation.,PMH:, 1)cardiac arrhythmia. 2)HTN. 3) excision of lip lesion 1 yr ago.,SHX/FHX:, Unremarkable. No h/o ETOH abuse.,MEDS:, Meclizine, Procardia XL.,EXAM:, Afebrile, BP132/74 HR72 RR16,MS: A & O x 3. Speech fluent. Comprehension, naming, repetition were intact.,CN: Left lower facial weakness only.,MOTOR: Left hemiparesis, 4+/5 throughout.,Sensory: intact PP/TEMP/LT/PROP/VIB,Coordination: ND,Station: left pronator drift.,Gait: left hemiparesis evident by decreased LUE swing and LLE drag.,Reflexes: 2/3 in UE; 2/2 LE; Right plantar downgoing; Left plantar equivocal.,Gen Exam: unremarkable.,COURSE:, Outside MRI revealed a loculated subdural hematoma extending throughout the frontotemporoparieto-occipital regions on the right. There was effacement of the right lateral ventricle. and a 0.5 cm leftward midline shift.,He underwent a HCT on admission, 12/8/92, which showed a right subdural hematoma. He then underwent emergent evacuation of this hematoma. He was discharged home 6 days after surgery.","radiology, ct brain, mri, sdh, subdural hematoma, gait instability, head trauma, hematoma, subacute, subdural, weakness, hemiparesis, "
 CT chest with contrast., Radiology, CT Chest - 1 ,"EXAM: , CT chest with contrast.,REASON FOR EXAM: , Pneumonia, chest pain, short of breath, and coughing up blood.,TECHNIQUE: , Postcontrast CT chest 100 mL of Isovue-300 contrast.,FINDINGS: , This study demonstrates a small region of coalescent infiltrates/consolidation in the anterior right upper lobe.  There are linear fibrotic or atelectatic changes associated with this.  Recommend followup to ensure resolution.  There is left apical scarring.  There is no pleural effusion or pneumothorax.  There is lingular and right middle lobe mild atelectasis or fibrosis.,Examination of the mediastinal windows disclosed normal inferior thyroid.  Cardiac and aortic contours are unremarkable aside from mild atherosclerosis.  The heart is not enlarged.  There is no pathologic adenopathy identified in the chest including the bilateral axillary and hilar regions.,Very limited assessment of the upper abdomen demonstrates no definite abnormalities.,There are mild degenerative changes in the thoracic spine.,IMPRESSION:,1.Anterior small right upper lobe infiltrate/consolidation.  Recommend followup to ensure resolution given its consolidated appearance.,2.Bilateral atelectasis versus fibrosis.","radiology, pneumonia, chest pain, short of breath, coughing up blood, upper lobe infiltrate, ct chest, ct, chest, isovue,"
 CT Brain: Subarachnoid hemorrhage., Radiology, CT Brain - SAH ,"CC:, Headache,HX: ,This 16 y/o RHF was in good health, until 11:00PM, the evening of 11/27/87, when she suddenly awoke from sleep with severe headache. Her parents described her as holding her head between her hands. She had no prior history of severe headaches. 30 minutes later she felt nauseated and vomited. The vomiting continued every 30 minutes and she developed neck stiffness. At 2:00AM on 11/28/97, she got up to go to the bathroom and collapsed in her mother's arms. Her mother noted she appeared weak on the left side. Shortly after this she experienced fecal and urinary incontinence. She was taken to a local ER and transferred to UIHC.,PMH/FHX/SHX:, completely unremarkable FHx. Has boyfriend and is sexually active.,Denied drug/ETOH/Tobacco use.,MEDS:, Oral Contraceptive pill QD.,EXAM:, BP152/82 HR74 RR16 T36.9C,MS: Somnolent and difficult to keep awake. Prefer to lie on right side because of neck pain/stiffness. Answers appropriately though when questioned.,CN: No papilledema noted. Pupils 4/4 decreasing to 2/2. EOM Intact. Face: ?left facial weakness. The rest of the CN exam was unremarkable.,Motor: Upper extremities: 5/3 with left pronator drift. Lower extremities: 5/4 with LLE weakness evident throughout.,Coordination: left sided weakness evident.,Station: left pronator drift.,Gait: left hemiparesis.,Reflexes: 2/2 throughout. No clonus. Plantars were flexor bilaterally.,Gen Exam: unremarkable.,COURSE: ,The patient underwent emergent CT Brain. This revealed a perimesencephalic subarachnoid hemorrhage and contrast enhancing structures in the medial aspect of the parietotemporal region. She then underwent a 4-vessel cerebral angiogram. This study was unremarkable except for delayed transit of the contrast material through the vascular system of the brain and poor opacification of the straight sinus. This suggested straight sinus thromboses. MRI Brain was then done; this was unremarkable and did not show sign of central venous thrombosis. CBC/Blood Cx/ESR/PT/PTT/GS/CSF Cx/ANA were negative.,Lumbar puncture on 12/1/87 revealed an opening pressure of 55cmH20, RBC18550, WBC25, 18neutrophils, 7lymphocytes, Protein25mg/dl, Glucose47mg/dl, Cx negative.,The patient was assumed to have had a SAH secondary to central venous thrombosis due to oral contraceptive use. She recovered well, but returned to Neurology at age 32 for episodic blurred vision and lightheadedness. EEG was compatible with seizure tendency (right greater than left theta bursts from the mid-temporal regions), and she was recommended an anticonvulsant which she refused.","radiology, ct, brain, sah, cerebral angiogram, blurred vision, lightheadedness, central venous thrombosis, subarachnoid hemorrhage, pronator drift, venous thrombosis, ct brain, subarachnoid, hemorrhage, pronator, venous, thrombosis, weakness, "
 CT Brain: Midbrain hemangioma, Radiology, CT Brain - Hemangioma ,"CC:, Horizontal diplopia.,HX: , This 67 y/oRHM first began experiencing horizontal binocular diplopia 25 years prior to presentation in the Neurology Clinic. The diplopia began acutely and continued intermittently for one year. During this time he was twice evaluated for myasthenia gravis (details of evaluation not known) and was told he probably did not have this disease. He received no treatment and the diplopia spontaneously resolved. He did well until one year prior to presentation when he experienced sudden onset horizontal binocular diplopia. The diplopia continues to occur daily and intermittently; and lasts for only a few minutes in duration. It resolves when he covers one eye. It is worse when looking at distant objects and objects off to either side of midline. There are no other symptoms associated with the diplopia.,PMH:, 1)4Vessel CABG and pacemaker placement, 4/84. 2)Hypercholesterolemia. 3)Bipolar Affective D/O.,FHX: ,HTN, Colon CA, and a daughter with unknown type of ""dystonia."",SHX:, Denied Tobacco/ETOH/illicit drug use.,ROS:, no recent weight loss/fever/chills/night sweats/CP/SOB. He occasionally experiences bilateral lower extremity cramping (?claudication) after walking for prolonged periods.,MEDS: ,Lithium 300mg bid, Accupril 20mg bid, Cellufresh Ophthalmologic Tears, ASA 325mg qd.,EXAM:, BP216/108 HR72 RR14 Wt81.6kg T36.6C,MS: unremarkable.,CN: horizontal binocular diplopia on lateral gaze in both directions. No other CN deficits noted.,Motor: 5/5 full strength throughout with normal muscle bulk and tone.,Sensory: unremarkable.,Coord: mild ""ataxia"" of RAM (left > right),Station: no pronator drift or Romberg sign,Gait: unremarkable. Reflexes: 2/2 symmetric throughout. Plantars (bilateral dorsiflexion),STUDIES/COURSE:, Gen Screen: unremarkable. Brain CT revealed 1.0 x 1.5 cm area of calcific density within the medial two-thirds of the left cerebral peduncle. This shows no mass effect, but demonstrates mild contrast enhancement. There are patchy areas of low density in the periventricular white matter consistent with age related changes from microvascular disease. The midbrain findings are most suggestive of a hemangioma, though another consideration would be a low grade astrocytoma (this would likely show less enhancement). Metastatic lesions could show calcification but one would expect to see some degree of edema. The long standing clinical history suggest the former (i.e. hemangioma).,No surgical or neuroradiologic intervention was done and the patient was simply followed. He was lost to follow-up in 1993.","radiology, hemangioma, brain ct, ct brain, binocular diplopia, calcific density, diplopia, horizontal binocular diplopia, myasthenia gravis, horizontal binocular, midbrain, binocular, ct, horizontal, "
 HCT: Subdural hemorrhage., Radiology, CT Brain: Subdural Hemorrhage. ,"CC: ,Difficulty with speech.,HX:, This 84 y/o RHF presented with sudden onset word finding and word phonation difficulties. She had an episode of transient aphasia in 2/92 during which she had difficulty with writing, written and verbal comprehension, and exhibited numerous semantic and phonemic paraphasic errors of speech. These problems resolved within 24 hours of onset and she had no subsequent speech problems prior to this presentation. Workup at that time revealed a right to left shunt on trans-thoracic echocardiogram. Carotid doppler studies showed 0-15% BICA stenosis and a LICA aneurysm (mentioned above). Brain CT was unremarkable. She was placed on ASA after the 2/92 event.,In 5/92 she was involved in a motor vehicle accident and suffered a fractured left humerus and left occipital scalp laceration. HCT at that time showed a small area of slightly increased attenuation at the posterior right claustrum only. This was not felt to be a contusion; nevertheless, she was placed on Dilantin seizure prophylaxis. Her left arm was casted and she returned home.,5 hours prior to presentation today, the patient began having difficulty finding words and putting them into speech. She was able to comprehend speech. This continued for an hour; then partially resolved for one hour; then returned; then waxed and waned. There was no reported weakness, numbness, incontinence, seizure-like activity, incoordination, HA, nausea, vomiting, or lightheadedness,MEDS:, ASA , DPH, Tenormin, Premarin, HCTZ,PMH:, 1)transient fluent aphasia 2/92 (which resolved), 2)bilateral carotid endarterectomies 1986, 3)HTN, 4)distal left internal carotid artery aneurysm.,EXAM:,  BP 168/70, Pulse 82, RR 16, 35.8F,MS:A & O x 3, Difficulty following commands, Speech fluent, and without dysarthria. There were occasional phonemic paraphasic errors.,CN: Unremarkable.,Motor: 5/5 throughout except for 4+ right wrist extension and right knee flexion.,Sensory: unremarkable.,Coordination: mild left finger-nose-finger dysynergia and dysmetria.,Gait: mildly unsteady tandem walk.,Station: no Romberg sign.,Reflexes: slightly more brisk at the left patella than on the right. Plantar responses were flexor bilaterally.,The remainder of the neurologic exam and the general physical exam were unremarkable.,LABS:, CBC WNL, Gen Screen WNL, , PT/PTT WNL, DPH 26.2mcg/ml, CXR WNL, EKG: LBBB, HCT revealed a left subdural hematoma.,COURSE:, Patient was taken to surgery and the subdural hematoma was evacuated. Her mental status, language skills, improved dramatically. The DPH dosage was adjusted appropriately.","radiology, ct brain, ct, difficulty with speech, hct, subdural hemorrhage, hemorrhage, phonation difficulties, subdural, transient fluent aphasia, phonemic paraphasic errors, hematoma, carotid, speech, "
" CT Brain to evaluate episodic mental status change, RUE numbness, chorea, and calcification of Basal Ganglia (globus pallidi).", Radiology, CT Brain - Calcification of Basal Ganglia ,"CC:, Episodic mental status change and RUE numbness, and chorea (found on exam).,HX:, This 78y/o RHM was referred for an episode of unusual behavior and RUE numbness. In 9/91, he experienced near loss of consciousness, generalized weakness, headache and vomiting. Evaluation at that time revealed an serum glucose of >500mg/dL and he was placed on insulin therapy with subsequent resolution of his signs and symptoms. Since then, he became progressively more forgetful, and at the time of evaluation, 1/17/93, had lost his ability to perform his job repairing lawn mowers. His wife had taken over the family finances.,He had also been ""stumbling,"" when ambulating, for 2 months prior to presentation. He was noted to be occasionally confused upon awakening for last several months. On 1/15/93, he was lying on a couch when he suddenly began throwing pillows and blankets for no apparent reason. There had been no change in sleep, appetite, or complaint of depression.,In addition, for two months prior to presentation, he had been experiencing 10-15minute episodes of RUE numbness. There was no face or lower extremity involvement.,During the last year he had developed unusual movements of his extremities.,MEDS:, NPH Humulin 12U qAM and 6U qPM. Advil prn.,PMH:, 1) Traumatic amputation of the 4th and 5th digits of his left hand.  2) Hospitalized for an unknown ""nervous"" condition in the 1940's.,SHX/FHX:, Retired small engine mechanic who worked in a poorly ventilated shop. Married with 13 children. No history of ETOH, Tobacco or illicit drug use. Father had tremors following a stroke. Brother died of brain aneurysm. No history of depression, suicide, or Huntington's disease in family.,ROS:, no history of CAD, Renal or liver disease, SOB, Chest pain, fevers, chills, night sweats or weight loss. No report of sign of bleeding.,EXAM:, BP138/63 HR65 RR15 36.1C,MS: Alert and oriented to self, season; but not date, year, or place. Latent verbal responses and direction following. Intact naming, but able to repeat only simple but not complex phrases. Slowed speech, with mild difficulty with word finding. 2/3 recall at one minute and 0/3 at 3 minutes. Knew the last 3 presidents. 14/27 on MMSE: unable to spell ""world"" backwards. Unable to read/write for complaint of inability to see without glasses.,CN: II-XII appeared grossly intact. EOM were full and smooth and without unusual saccadic pursuits. OKN intact. Choreiform movements of the tongue were noted.,Motor: 5/5 strength throughout with Guggenheim type resistance. there were choreiform type movements of all extremities bilaterally. No motor impersistence noted.,Sensory: unreliable.,Cord: ""normal"" FNF, HKS, and RAM, bilaterally.,Station: No Romberg sign.,Gait: unsteady and wide-based.,Reflexes: BUE 2/2, Patellar 2/2, Ankles Trace/Trace, Plantars were flexor bilaterally.,Gen Exam: 2/6 Systolic ejection murmur in aortic area.,COURSE:, No family history of Huntington's disease could be elicited from relatives. Brain CT, 1/18/93: bilateral calcification of the globus pallidi and a high attenuation focus in the right occipital lobe thought to represent artifact. Carotid duplex, 1/18/93: RICA 0-15%, LICA 16-49% stenosis and normal vertebral artery flow bilaterally. Transthoracic Echocardiogram (TTE),1/18/93: revealed severe aortic fibrosis or valvular calcification with ""severe"" aortic stenosis in the face of ""normal"" LV function. Cardiology felt the patient the patient had asymptomatic aortic stenosis. EEG, 1/20/93, showed low voltage Delta over the left posterior quadrant and intermittent background slowing over the same region consistent with focal dysfunction in this quadrant. MRI Brain, 1/22/93: multiple focal and more confluent areas of increased T2 signal in the periventricular white matter, more prominent on the left; in addition, there were irregular shaped areas of increased T2 signal and decreased T1 signal in both cerebellar hemispheres; and age related atrophy; incidentally, there is a cavum septum pellucidum et vergae and mucosal thickening of the maxillary sinuses. Impression: diffuse bilateral age related ischemic change, age related atrophy and maxillary sinus disease. There were no masses or areas of abnormal enhancement. TSH, FT4, Vit B12, VDRL, Urine drug and heavy metal screens were unremarkable. CSF,1/19/93: glucose 102 (serum glucose 162mg/dL), Protein 45mg/dL, RBC O, WBC O, Cultures negative. SPEP negative. However serum and CSF beta2 microglobulin levels were elevated at 2.5 and 3.1mg/L, respectively. Hematology felt these may have been false positives. CBC, 1/17/93: Hgb 10.4g/dL (low), HCT 31% (low), RBC 3/34mil/mm3 (low), WBC 5.8K/mm3, Plt 201K/mm3. Retic 30/1K/mm3 (normal). Serum Iron 35mcg/dL (low), TIBC 201mcg/dL (low), FeSat 17% (low), CRP 0.1mg/dL (normal), ESR 83mm/hr (high). Bone Marrow Bx: normal with adequate iron stores. Hematology felt the finding were compatible with anemia of chronic disease. Neuropsychologic evaluation on 1/17/93 revealed significant impairments in multiple realms of cognitive function (visuospatial reasoning, verbal and visual memory, visual confrontational naming, impaired arrhythmatic, dysfluent speech marked by use of phrases no longer than 5 words, frequent word finding difficulty and semantic paraphasic errors) most severe for expressive language, attention and memory. The pattern of findings reveals an atypical aphasia suggestive of left temporo-parietal dysfunction. The patient was discharged1/22/93 on ASA 325mg qd. He was given a diagnosis of senile chorea and dementia (unspecified type). 6/18/93 repeat Neuropsychological evaluation revealed moderate decline in all areas tested reflecting severe dementia.","radiology, episodic mental status change, huntington's disease, brain ct, transthoracic echocardiogram, carotid duplex, mental status change, ct brain, basal ganglia, mental status, globus pallidi, aortic stenosis, maxillary sinuses, rue numbness, basal, ganglia, globus, pallidi, therapy, chorea, ct, rue, brain, "
" CT Brain: Suprasellar aneurysm, pre and post bleed.", Radiology, CT Brain - Aneurysm ,"CC:, Decreasing visual acuity.,HX: ,This 62 y/o RHF presented locally with a 2 month history of progressive loss of visual acuity, OD. She had a 2 year history of progressive loss of visual acuity, OS, and is now blind in that eye. She denied any other symptomatology. Denied HA.,PMH:, 1) depression. 2) Blind OS,MEDS:, None.,SHX/FHX: ,unremarkable for cancer, CAD, aneurysm, MS, stroke. No h/o Tobacco or ETOH use.,EXAM:, T36.0, BP121/85, HR 94, RR16,MS: Alert and oriented to person, place and time. Speech fluent and unremarkable.,CN: Pale optic disks, OU. Visual acuity: 20/70 (OD) and able to detect only shadow of hand movement (OS). Pupils were pharmacologically dilated earlier. The rest of the CN exam was unremarkable.,MOTOR: 5/5 throughout with normal bulk and tone.,Sensory: no deficits to LT/PP/VIB/PROP.,Coord: FNF-RAM-HKS intact bilaterally.,Station: No pronator drift. Gait: ND,Reflexes: 3/3 BUE, 2/2 BLE. Plantar responses were flexor bilaterally.,Gen Exam: unremarkable. No carotid/cranial bruits.,COURSE:, CT Brain showed large, enhancing 4 x 4 x 3 cm suprasellar-sellar mass without surrounding edema. Differential dx: included craniopharyngioma, pituitary adenoma, and aneurysm. MRI Brain findings were consistent with an aneurysm. The patient underwent 3 vessel cerebral angiogram on 12/29/92. This clearly revealed a supraclinoid giant aneurysm of the left internal carotid artery. Ten minutes following contrast injection the patient became aphasic and developed a right hemiparesis. Emergent HCT showed no evidence of hemorrhage or sign of infarct. Emergent carotid duplex showed no significant stenosis or clot. The patient was left with an expressive aphasia and right hemiparesis. SPECT scans were obtained on 1/7/93 and 2/24/93. They revealed hypoperfusion in the distribution of the left MCA and decreased left basal-ganglia perfusion which may represent in part a mass effect from the LICA aneurysm. She was discharged home and returned and underwent placement of a Selverstone Clamp on 3/9/93. The clamp was gradually and finally closed by 3/14/93. She did well, and returned home. On 3/20/93 she developed sudden confusion associated with worsening of her right hemiparesis and right expressive aphasia. A HCT then showed SAH around her aneurysm, which had thrombosed. She was place on Nimodipine. Her clinical status improved; then on 3/25/93 she rapidly deteriorated over a 2 hour period to the point of lethargy, complete expressive aphasia, and right hemiplegia. An emergent HCT demonstrated a left ACA and left MCA infarction. She required intubation and worsened as cerebral edema developed. She was pronounced brain dead. Her organs were donated for transplant.","radiology, ct brain, hct, mri brain, suprasellar, suprasellar aneurysm, aneurysm, cerebral angiogram, craniopharyngioma, internal carotid artery, loss of visual acuity, pituitary adenoma, suprasellar-sellar mass, visual acuity, expressive aphasia, cerebral, ct, hemiparesis, aphasia, brain,"
 Abdominal pain.  CT examination of the abdomen and pelvis with intravenous contrast., Radiology, CT Abdomen & Pelvis - OB-GYN ,"EXAM:,  CT examination of the abdomen and pelvis with intravenous contrast.,INDICATIONS:,  Abdominal pain.,TECHNIQUE:  ,CT examination of the abdomen and pelvis was performed after 100 mL of intravenous Isovue-300 contrast administration.  Oral contrast was not administered.  There was no comparison of studies.,FINDINGS,CT PELVIS:,Within the pelvis, the uterus demonstrates a thickened-appearing endometrium.  There is also a 4.4 x 2.5 x 3.4 cm hypodense mass in the cervix and lower uterine segment of uncertain etiology.  There is also a 2.5 cm intramural hypodense mass involving the dorsal uterine fundus likely representing a fibroid.  Several smaller fibroids were also suspected.,The ovaries are unremarkable in appearance.  There is no free pelvic fluid or adenopathy.,CT ABDOMEN:,The appendix has normal appearance in the right lower quadrant.  There are few scattered diverticula in the sigmoid colon without evidence of diverticulitis.  The small and large bowels are otherwise unremarkable.  The stomach is grossly unremarkable.  There is no abdominal or retroperitoneal adenopathy.  There are no adrenal masses.  The kidneys, liver, gallbladder, and pancreas are in unremarkable appearance.  The spleen contains several small calcified granulomas, but no evidence of masses.  It is normal in size.  The lung bases are clear bilaterally.  The osseous structures are unremarkable other than mild facet degenerative changes at L4-L5 and L5-S1.,IMPRESSION:,1.  Hypoattenuating mass in the lower uterine segment and cervix of uncertain etiology measuring approximately 4.4 x 2.5 x 3.4 cm.,2.  Multiple uterine fibroids.,3.  Prominent endometrium.,4.  Followup pelvic ultrasound is recommended.","radiology, ovaries, pelvic fluid, adenopathy, uterine segment, cervix, hypodense mass, ct examination, fibroids, pelvic, ct, pelvis, isovue, abdomen"
" Lower quadrant pain with nausea, vomiting, and diarrhea.  CT abdomen without contrast and CT pelvis without contrast.  Noncontrast axial CT images of the abdomen and pelvis are obtained.", Radiology, CT Abdomen & Pelvis - 7 ,"REASON FOR EXAM: , Lower quadrant pain with nausea, vomiting, and diarrhea.,TECHNIQUE: , Noncontrast axial CT images of the abdomen and pelvis are obtained.,FINDINGS: , Please note evaluation of the abdominal organs is secondary to the lack of intravenous contrast material.,Gallstones are seen within the gallbladder lumen.  No abnormal pericholecystic fluid is seen.,The liver is normal in size and attenuation.,The spleen is normal in size and attenuation.,A 2.2 x 1.8 cm low attenuation cystic lesion appears to be originating off of the tail of the pancreas.  No pancreatic ductal dilatation is seen.  There is no abnormal adjacent stranding.  No suspected pancreatitis is seen.,The kidneys show no stone formation or hydronephrosis.,The large and small bowels are normal in course and caliber.  There is no evidence for obstruction.  The appendix appears within normal limits.,In the pelvis, the urinary bladder is unremarkable.  There is a 4.2 cm cystic lesion of the right adnexal region.  No free fluid, free air, or lymphadenopathy is detected.,There is left basilar atelectasis.,IMPRESSION:,1.  A 2.2 cm low attenuation lesion is seen at the pancreatic tail.  This is felt to be originating from the pancreas, a cystic pancreatic neoplasm must be considered and close interval followup versus biopsy is advised.  Additionally, when the patient's creatinine improves, a contrast-enhanced study utilizing pancreatic protocol is needed.  Alternatively, an MRI may be obtained.,2.  Cholelithiasis.,3.  Left basilar atelectasis.,4.  A 4.2 cm cystic lesion of the right adnexa, correlation with pelvic ultrasound is advised.","radiology, ct abdomen, ct pelvis, neoplasm, lesion, attenuation, hydronephrosis, stone formation, ct images, cystic lesion, abdomen, cystic, pancreatic, ct, pelvis, intravenous, noncontrast"
" Generalized abdominal pain, nausea, diarrhea, and recent colonic resection.  CT abdomen with and without contrast and CT pelvis with contrast.  Axial CT images of the abdomen were obtained without contrast.  Axial CT images of the abdomen and pelvis were then obtained utilizing 100 mL of Isovue-300.", Radiology, CT Abdomen & Pelvis - 8 ,"CT ABDOMEN WITH AND WITHOUT CONTRAST AND CT PELVIS WITH CONTRAST,REASON FOR EXAM: , Generalized abdominal pain, nausea, diarrhea, and recent colonic resection in 11/08.,TECHNIQUE:,  Axial CT images of the abdomen were obtained without contrast.  Axial CT images of the abdomen and pelvis were then obtained utilizing 100 mL of Isovue-300.,FINDINGS: , The liver is normal in size and attenuation.,The gallbladder is normal.,The spleen is normal in size and attenuation.,The adrenal glands and pancreas are unremarkable.,The kidneys are normal in size and attenuation.,No hydronephrosis is detected.  Free fluid is seen within the right upper quadrant within the lower pelvis.  A markedly thickened loop of distal small bowel is seen.  This segment measures at least 10-cm long.  No definite pneumatosis is appreciated.  No free air is apparent at this time.  Inflammatory changes around this loop of bowel.  Mild distention of adjacent small bowel loops measuring up to 3.5 cm is evident.  No complete obstruction is suspected, as there is contrast material within the colon.  Postsurgical changes compatible with the partial colectomy are noted.  Postsurgical changes of the anterior abdominal wall are seen.  Mild thickening of the urinary bladder wall is seen.,IMPRESSION:,1.  Marked thickening of a segment of distal small bowel is seen with free fluid within the abdomen and pelvis.  An inflammatory process such as infection or ischemia must be considered.  Close interval followup is necessary.,2.  Thickening of the urinary bladder wall is nonspecific and may be due to under distention.  However, evaluation for cystitis is advised.","radiology, abdominal pain, nausea, diarrhea, colonic resection, axial ct images, ct abdomen, isovue, inflammatory, urinary, bladder, abdominal, colonic, wall, thickening, axial, bowel, contrast, attenuation, pelvis, ct, abdomen"
" Chest pain, shortness of breath and cough, evaluate for pulmonary arterial embolism.   CT angiography chest with contrast.  Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.", Radiology, CT Angiography ,"CT ANGIOGRAPHY CHEST WITH CONTRAST,REASON FOR EXAM: , Chest pain, shortness of breath and cough, evaluate for pulmonary arterial embolism.,TECHNIQUE:  ,Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.,FINDINGS:  ,There is no evidence for pulmonary arterial embolism.,The lungs are clear of any abnormal airspace consolidation, pleural effusion, or pneumothorax.  No abnormal mediastinal or hilar lymphadenopathy is seen.,Limited images of the upper abdomen are unremarkable.  No destructive osseous lesion is detected.,IMPRESSION: , Negative for pulmonary arterial embolism.","radiology, airspace consolidation, pleural effusion, pneumothorax, lymphadenopathy, hilar, ct angiography, pulmonary arterial, arterial embolism, angiography, ct, chest, arterial, pulmonary, embolism, isovue, "
"  CT abdomen without contrast and pelvis without contrast, reconstruction.", Radiology, CT Abdomen & Pelvis - 5 ,"EXAM: , CT abdomen without contrast and pelvis without contrast, reconstruction.,REASON FOR EXAM: , Right lower quadrant pain, rule out appendicitis.,TECHNIQUE:  ,Noncontrast CT abdomen and pelvis.  An intravenous line could not be obtained for the use of intravenous contrast material.,FINDINGS: , The appendix is normal.  There is a moderate amount of stool throughout the colon.  There is no evidence of a small bowel obstruction or evidence of pericolonic inflammatory process.  Examination of the extreme lung bases appear clear, no pleural effusions.  The visualized portions of the liver, spleen, adrenal glands, and pancreas appear normal given the lack of contrast.  There is a small hiatal hernia.  There is no intrarenal stone or evidence of obstruction bilaterally.  There is a questionable vague region of low density in the left anterior mid pole region, this may indicate a tiny cyst, but it is not well seen given the lack of contrast.  This can be correlated with a followup ultrasound if necessary.  The gallbladder has been resected.  There is no abdominal free fluid or pathologic adenopathy.  There is abdominal atherosclerosis without evidence of an aneurysm.,Dedicated scans of the pelvis disclosed phleboliths, but no free fluid or adenopathy.  There are surgical clips present.  There is a tiny airdrop within the bladder.  If this patient has not had a recent catheterization, correlate for signs and symptoms of urinary tract infection.,IMPRESSION:,1.Normal appendix.,2.Moderate stool throughout the colon.,3.No intrarenal stones.,4.Tiny airdrop within the bladder.  If this patient has not had a recent catheterization, correlate for signs and symptoms of urinary tract infection.  The report was faxed upon dictation.","radiology, reconstruction, appendicitis, urinary tract infection, ct abdomen, abdomen, ct, pelvis, contrast, noncontrast,"
 Shortness of breath for two weeks and a history of pneumonia.  CT angiography chest with contrast.  Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300., Radiology, CT Angiography - 1 ,"CT ANGIOGRAPHY CHEST WITH CONTRAST,REASON FOR EXAM:  ,Shortness of breath for two weeks and a history of pneumonia.  The patient also has a history of left lobectomy.,TECHNIQUE: , Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.,FINDINGS: , There is no evidence of any acute pulmonary arterial embolism.,The main pulmonary artery is enlarged showing a diameter of 4.7 cm.,Cardiomegaly is seen with mitral valvular calcifications.,Postsurgical changes of a left upper lobectomy are seen.  Left lower lobe atelectasis is noted.  A 7 mm and a 5 mm pulmonary nodule are seen within the left lower lobe (image #12).  A small left pleural effusion is noted.,Right lower lobe atelectasis is present.  There is a right pleural effusion, greater than as seen on the left side.  A right lower lobe pulmonary nodule measures 1.5 cm.  There is a calcified granuloma within the right lower lobe.,IMPRESSION:,1.  Negative for pulmonary arterial embolism.,2.  Enlargement of the main pulmonary artery as can be seen with pulmonary arterial hypertension.,3.  Cardiomegaly with mitral valvular calcifications.,4.  Postsurgical changes of a left upper lobectomy.,5.  Bilateral pleural effusions, right greater than left with bilateral lower lobe atelectasis.,6.  Bilateral lower lobe nodules, pulmonary nodules, and interval followup in three months to confirm stability versus further characterization with prior studies is advised.","radiology, shortness of breath, pneumonia, pulmonary embolism, isovue-300, axial ct images, ct angiography, lower lobe, pulmonary, lobectomy, isovue, angiography, arterial, atelectasis, pleural, ct, embolism,"
 Right-sided abdominal pain with nausea and fever.  CT abdomen with contrast and CT pelvis with contrast.  Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300., Radiology, CT Abdomen & Pelvis - 6 ,"REASON FOR EXAM: , Right-sided abdominal pain with nausea and fever.,TECHNIQUE: , Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.,CT ABDOMEN:  ,The liver, spleen, pancreas, gallbladder, adrenal glands, and kidney are unremarkable.,CT PELVIS: , Within the right lower quadrant, the appendix measures 16 mm and there are adjacent inflammatory changes with fluid in the right lower quadrant.  Findings are compatible with acute appendicitis.,The large and small bowels are normal in course and caliber without obstruction.  The urinary bladder is normal.  The uterus appears unremarkable.  Mild free fluid is seen in the lower pelvis.,No destructive osseous lesions are seen.  The visualized lung bases are clear.,IMPRESSION: , Acute appendicitis.","radiology, adrenal glands, appendicitis, gallbladder, kidney, liver, pancreas, spleen, acute appendicitis, ct pelvis, ct abdomen, abdominal, contrast, fluid, abdomen, inflammatory, pelvis, ct"
 CT brain (post craniectomy) - RMCA stroke and SBE., Radiology, CT Brain ,"CC:, Left-sided weakness.,HX:, This 28y/o RHM was admitted to a local hospital on 6/30/95 for a 7 day history of fevers, chills, diaphoresis, anorexia, urinary frequency, myalgias and generalized weakness. He denied foreign travel, IV drug abuse, homosexuality, recent dental work, or open wound. Blood and urine cultures were positive for Staphylococcus Aureus, oxacillin sensitive. He was place on appropriate antibiotic therapy according to sensitivity.. A 7/3/95 transthoracic echocardiogram revealed normal left ventricular function and a damaged mitral valve with regurgitation. Later that day he developed left-sided weakness and severe dysarthria and aphasia. HCT, on 7/3/95 revealed mild attenuated signal in the right hemisphere. On 7/4/95 he developed first degree AV block, and was transferred to UIHC.,MEDS: ,Nafcillin 2gm IV q4hrs, Rifampin 600mg q12hrs, Gentamicin 130mg q12hrs.,PMH:, 1) Heart murmur dx age 5 years.,FHX:, Unremarkable.,SHX:, Employed cook. Denied ETOH/Tobacco/illicit drug use.,EXAM:, BP 123/54, HR 117, RR 16, 37.0C,MS: Somnolent and arousable only by shaking and repetitive verbal commands. He could follow simple commands only. He nodded appropriately to questioning most of the time. Dysarthric speech with sparse verbal output.,CN: Pupils 3/3 decreasing to 2/2 on exposure to light. Conjugate gaze preference toward the right. Right hemianopia by visual threat testing. Optic discs flat and no retinal hemorrhages or Roth spots were seen. Left lower facial weakness. Tongue deviated to the left. Weak gag response, bilaterally. Weak left corneal response.,MOTOR: Dense left flaccid hemiplegia.,SENSORY: Less responsive to PP on left.,COORD: Unable to test.,Station and Gait: Not tested.,Reflexes: 2/3 throughout (more brisk on the left side). Left ankle clonus and a Left Babinski sign were present.,GEN EXAM: Holosystolic murmur heard throughout the precordium. Janeway lesions were present in the feet and hands. No Osler's nodes were seen.,COURSE:, 7/6/95, HCT showed a large RMCA stroke with mass shift. His neurologic exam worsened and he was intubated, hyperventilated, and given IV Mannitol. He then underwent emergent left craniectomy and duraplasty. He tolerated the procedure well and his brain was allowed to swell. He then underwent mitral valve replacement on 7/11/95 with a St. Judes valve. His post-operative recovery was complicated by pneumonia, pericardial effusion and dysphagia. He required temporary PEG placement for feeding. The 7/27/95, 8/6/95 and 10/18/96 HCT scans show the chronologic neuroradiologic documentation of a large RMCA stroke. His 10/18/96 Neurosurgery Clinic visit noted that he can ambulate without assistance with the use of a leg brace to prevent left foot drop. His proximal LLE strength was rated at a 4. His LUE was plegic. He had a seizure 6 days prior to his 10/18/96 evaluation. This began as a Jacksonian march of shaking in the LUE; then involved the LLE. There was no LOC or tongue-biting. He did have urinary incontinence. He was placed on DPH. His speech was dysarthric but fluent. He appeared bright, alert and oriented in all spheres.","radiology, ct brain, rmca, anorexia, chills, craniectomy, diaphoresis, fevers, myalgias, stroke, urinary frequency, echocardiogram, holosystolic murmur, pneumonia, pericardial effusion, tongue-biting, sided weakness, mitral valve, rmca stroke, ct, hct, weakness, "
 Generalized abdominal pain with swelling at the site of the ileostomy.  CT abdomen with contrast and CT pelvis with contrast.  Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300., Radiology, CT Abdomen & Pelvis - 9 ,"CT ABDOMEN WITH CONTRAST AND CT PELVIS WITH CONTRAST,REASON FOR EXAM: , Generalized abdominal pain with swelling at the site of the ileostomy.,TECHNIQUE:,  Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.,CT ABDOMEN:  ,The liver, spleen, pancreas, adrenal glands, and kidneys are unremarkable.  Punctate calcifications in the gallbladder lumen likely represent a gallstone.,CT PELVIS:  ,Postsurgical changes of a left lower quadrant ileostomy are again seen.  There is no evidence for an obstruction.  A partial colectomy and diverting ileostomy is seen within the right lower quadrant.  The previously seen 3.4 cm subcutaneous fluid collection has resolved.  Within the left lower quadrant, a 3.4 cm x 2.5 cm loculated fluid collection has not significantly changed.  This is adjacent to the anastomosis site and a pelvic abscess cannot be excluded.  No obstruction is seen.  The appendix is not clearly visualized.  The urinary bladder is unremarkable.,IMPRESSION:,1.  Resolution of the previously seen subcutaneous fluid collection.,2.  Left pelvic 3.4 cm fluid collection has not significantly changed in size or appearance.  These findings may be due to a pelvic abscess.,3.  Right lower quadrant ileostomy has not significantly changed.,4.  Cholelithiasis.","radiology, axial ct images, isovue-300, ct pelvis, ct abdomen, fluid collection, abdomen, obstruction, subcutaneous, abscess, pelvic, fluid, collection, pelvis, ileostomy, ct, isovue,"
" Evaluate for retroperitoneal hematoma, the patient has been following, is currently on Coumadin.  CT abdomen without contrast and CT pelvis without contrast.", Radiology, CT Abdomen & Pelvis - 10 ,"CT ABDOMEN WITHOUT CONTRAST AND CT PELVIS WITHOUT CONTRAST,REASON FOR EXAM: , Evaluate for retroperitoneal hematoma, the patient has been following, is currently on Coumadin.,CT ABDOMEN: , There is no evidence for a retroperitoneal hematoma.,The liver, spleen, adrenal glands, and pancreas are unremarkable.  Within the superior pole of the left kidney, there is a 3.9 cm cystic lesion.  A 3.3 cm cystic lesion is also seen within the inferior pole of the left kidney.  No calcifications are noted.  The kidneys are small bilaterally.,CT PELVIS: , Evaluation of the bladder is limited due to the presence of a Foley catheter, the bladder is nondistended.  The large and small bowels are normal in course and caliber.  There is no obstruction.,Bibasilar pleural effusions are noted.,IMPRESSION:,1. No evidence for retroperitoneal bleed.,2. There are two left-sided cystic lesions within the kidney, correlation with a postcontrast study versus further characterization with an ultrasound is advised as the cystic lesions appear slightly larger as compared to the prior exam.,3. The kidneys are small in size bilaterally.,4. Bibasilar pleural effusions.","radiology, cystic lesion, superior pole, kidney, ct pelvis, ct abdomen, retroperitoneal hematoma, lesion, kidneys, bladder, bibasilar, pleural, effusions, lesions, pelvis, hematoma, retroperitoneal, cystic, ct, abdomen,"
" CT abdomen and pelvis without contrast, stone protocol, reconstruction.", Radiology, CT Abdomen & Pelvis - 4 ,"EXAM: , CT abdomen and pelvis without contrast, stone protocol, reconstruction.,REASON FOR EXAM: , Flank pain.,TECHNIQUE: , Noncontrast CT abdomen and pelvis with coronal reconstructions.,FINDINGS: , There is no intrarenal stone bilaterally.  However, there is very mild left renal pelvis and proximal ureteral dilatation with a small amount of left perinephric stranding asymmetric to the right.  The right renal pelvis is not dilated.  There is no stone along the course of the ureter.  I cannot exclude the possibility of recent stone passage, although the findings are ultimately technically indeterminate and clinical correlation is advised.  There is no obvious solid-appearing mass given the lack of contrast.,Scans of the pelvis disclose no evidence of stone within the decompressed bladder.  No pelvic free fluid or adenopathy.,There are few scattered diverticula.  There is a moderate amount of stool throughout the colon.  There are scattered diverticula, but no CT evidence of acute diverticulitis.  The appendix is normal.,There are mild bibasilar atelectatic changes.,Given the lack of contrast, visualized portions of the liver, spleen, adrenal glands, and the pancreas are grossly unremarkable.  The gallbladder is present.  There is no abdominal free fluid or pathologic adenopathy.,There are degenerative changes of the lumbar spine.,IMPRESSION:,1.Very mild left renal pelvic dilatation and proximal ureteral dilatation with mild left perinephric stranding.  There is no stone identified along the course of the left ureter or in the bladder.  Could this patient be status post recent stone passage?  Clinical correlation is advised.,2.Diverticulosis.,3.Moderate amount of stool throughout the colon.,4.Normal appendix.","radiology, coronal reconstructions, stone protocol, renal pelvic dilatation, proximal ureteral dilatation, ct abdomen and pelvis, stone protocol reconstruction, abdomen and pelvis, perinephric stranding, free fluid, scattered diverticula, renal, dilatation, contrast, ureteral, ct, abdomen, pelvis, stone, noncontrast,"
 CT scan of the abdomen and pelvis without and with intravenous contrast., Radiology, CT Abdomen & Pelvis - 2 ,"EXAM: , CT scan of the abdomen and pelvis without and with intravenous contrast.,CLINICAL INDICATION: , Left lower quadrant abdominal pain.,COMPARISON: , None.,FINDINGS: , CT scan of the abdomen and pelvis was performed without and with intravenous contrast.  Total of 100 mL of Isovue was administered intravenously.  Oral contrast was also administered.,The lung bases are clear.  The liver is enlarged and decreased in attenuation.  There are no focal liver masses.,There is no intra or extrahepatic ductal dilatation.,The gallbladder is slightly distended.,The adrenal glands, pancreas, spleen, and left kidney are normal.,A 12-mm simple cyst is present in the inferior pole of the right kidney.  There is no hydronephrosis or hydroureter.,The appendix is normal.,There are multiple diverticula in the rectosigmoid.  There is evidence of focal wall thickening in the sigmoid colon (image #69) with adjacent fat stranding in association with a diverticulum.  These findings are consistent with diverticulitis.  No pneumoperitoneum is identified.  There is no ascites or focal fluid collection.,The aorta is normal in contour and caliber.,There is no adenopathy.,Degenerative changes are present in the lumbar spine.,IMPRESSION: , Findings consistent with diverticulitis.  Please see report above.","radiology, extrahepatic ductal dilatation, gallbladder, glands, pancreas, spleen, kidney, adrenal, abdomen and pelvis, ct scan, intravenous, abdomen,"
 Abnormal liver enzymes and diarrhea.  CT pelvis with contrast and ct abdomen with and without contrast., Radiology, CT Abdomen & Pelvis - 11 ,"EXAM: , CT pelvis with contrast and ct abdomen with and without contrast.,INDICATIONS:  ,Abnormal liver enzymes and diarrhea.,TECHNIQUE: , CT examination of the abdomen and pelvis was performed after 100 mL of intravenous contrast administration and oral contrast administration.  Pre-contrast images through the abdomen were also obtained.,COMPARISON:  ,There were no comparison studies.,FINDINGS:  ,The lung bases are clear.,The liver demonstrates mild intrahepatic biliary ductal dilatation.  These findings may be secondary to the patient's post cholecystectomy state.  The pancreas, spleen, adrenal glands, and kidneys are unremarkable.,There is a 13 mm peripheral-enhancing fluid collection in the anterior pararenal space of uncertain etiology.  There are numerous nonspecific retroperitoneal and mesenteric lymph nodes.  These may be reactive; however, an early neoplastic process would be difficult to totally exclude.,There is a right inguinal hernia containing a loop of small bowel.  This may produce a partial obstruction as there is mild fluid distention of several small bowel loops, particularly in the right lower quadrant.  The large bowel demonstrates significant diverticulosis coli of the sigmoid and distal descending colon without evidence of diverticulitis.,There is diffuse osteopenia along with significant degenerative changes in the lower lumbar spine.,The urinary bladder is unremarkable.  The uterus is not visualized.,IMPRESSION:,1.  Right inguinal hernia containing small bowel.  Partial obstruction is suspected.,2.  Nonspecific retroperitoneal and mesenteric lymph nodes.,3.  Thirteen millimeter of circumscribed fluid collection in the anterior pararenal space of uncertain etiology.,4.  Diverticulosis without evidence of diverticulitis.,5.  Status post cholecystectomy with mild intrahepatic biliary ductal dilatation.,6.  Osteopenia and degenerative changes of the spine and pelvis.","radiology, pre-contrast images, contrast, biliary ductal dilatation, pancreas, spleen, adrenal glands, kidneys, mesenteric lymph nodes, fluid collection, inguinal hernia, ct abdomen, hernia, diverticulosis, diverticulitis, osteopenia, degenerative, spine, bowel, pelvis, ct, abdomen,"
 CT of the abdomen and pelvis without contrast., Radiology, CT Abdomen & Pelvis - 3 ,"EXAM: , CT of the abdomen and pelvis without contrast.,HISTORY: , Lower abdominal pain.,FINDINGS:,  Limited views of the lung bases demonstrate linear density most likely representing dependent atelectasis.  There is a 1.6 cm nodular density at the left posterior sulcus.,Noncontrast technique limits evaluation of the solid abdominal organs.  Cardiomegaly and atherosclerotic calcifications are seen.,Hepatomegaly is observed.  There is calcification within the right lobe of the liver likely related to granulomatous changes.  Subtle irregularity of the liver contour is noted, suggestive of cirrhosis.  There is splenomegaly seen.  There are two low-attenuation lesions seen in the posterior aspect of the spleen, which are incompletely characterized that may represent splenic cyst.  The pancreas appears atrophic.  There is a left renal nodule seen, which measures 1.9 cm with a Hounsfield unit density of approximately 29, which is indeterminate.,There is mild bilateral perinephric stranding.  There is an 8-mm fat density lesion in the anterior inner polar region of the left kidney, compatible in appearance with angiomyolipoma.  There is a 1-cm low-attenuation lesion in the upper pole of the right kidney, likely representing a cyst, but incompletely characterized on this examination.  Bilateral ureters appear normal in caliber along their visualized course.  The bladder is partially distended with urine, but otherwise unremarkable.,Postsurgical changes of hysterectomy are noted.  There are pelvic phlebolith seen.  There is a calcified soft tissue density lesion in the right pelvis, which may represent an ovary with calcification, as it appears continuous with the right gonadal vein.,Scattered colonic diverticula are observed.  The appendix is within normal limits.  The small bowel is unremarkable.  There is an anterior abdominal wall hernia noted containing herniated mesenteric fat.  The hernia neck measures approximately 2.7 cm.  There is stranding of the fat within the hernia sac.,There are extensive degenerative changes of the right hip noted with changes suggestive of avascular necrosis.  Degenerative changes of the spine are observed.,IMPRESSION:,1.  Anterior abdominal wall hernia with mesenteric fat-containing stranding, suggestive of incarcerated fat.,2.  Nodule in the left lower lobe, recommend follow up in 3 months.,3.  Indeterminate left adrenal nodule, could be further assessed with dedicated adrenal protocol CT or MRI.,4.  Hepatomegaly with changes suggestive of cirrhosis.  There is also splenomegaly observed.,5.  Low-attenuation lesions in the spleen may represent cyst, that are incompletely characterized on this examination.,6.  Fat density lesion in the left kidney, likely represents angiomyolipoma.,7.  Fat density soft tissue lesion in the region of the right adnexa, this contains calcifications and may represent an ovary or possibly dermoid cyst.","radiology, abdominal pain, cardiomegaly, atherosclerotic calcifications, hepatomegaly, perinephric stranding, low attenuation lesions, abdominal, calcifications, lesions, abdomen,"
 CT Abdomen and Pelvis with contrast , Radiology, CT Abdomen & Pelvis - 1 ,"EXAM: , CT Abdomen and Pelvis with contrast ,REASON FOR EXAM:, Nausea, vomiting, diarrhea for one day.  Fever.  Right upper quadrant pain for one day.  ,COMPARISON: , None. ,TECHNIQUE:,  CT of the abdomen and pelvis performed without and with approximately 54 ml Isovue 300 contrast enhancement.  ,CT ABDOMEN: , Lung bases are clear.  The liver, gallbladder, spleen, pancreas, and bilateral adrenal/kidneys are unremarkable.  The aorta is normal in caliber.  There is no retroperitoneal lymphadenopathy.  ,CT PELVIS: , The appendix is visualized along its length and is diffusely unremarkable with no surrounding inflammatory change.  Per CT, the colon and small bowel are unremarkable.  The bladder is distended.  No free fluid/air.  Visualized osseous structures demonstrate no definite evidence for acute fracture, malalignment, or dislocation.,IMPRESSION:,1.  Unremarkable exam; specifically no evidence for acute appendicitis. ,2.  No acute nephro-/ureterolithiasis. ,3.  No secondary evidence for acute cholecystitis.,Results were communicated to the ER at the time of dictation.","radiology, liver, gallbladder, spleen, pancreas, adrenal, kidneys, lymphadenopathy, abdomen and pelvis, contrast, ct"
 A 62-year-old male with a history of ischemic cardiomyopathy and implanted defibrillator., Radiology, Coronary CT Angiography (CCTA) - 5 ,"COMPARISON STUDIES:, None.,MEDICATION: ,  Lopressor 5 mg IV.,HEART RATE AFTER MEDICATION:, 64bpm,EXAM:,TECHNIQUE: Tomographic images were obtained of the heart and chest with a 64 detector row scanner using slice thicknesses of less than 1 mm. 80cc’s of Isovue 370 was injected in the right arm.,TECHNICAL QUALITY:,Examination is limited secondary to extensive artifact from defibrillator wires.,There is good demonstration of the coronary arteries and there is good bolus timing.,FINDINGS:,LEFT MAIN CORONARY ARTERY:,The left main coronary artery is a moderate-sized vessel with a normal ostium. There is no calcific or non-calcific plaque. The vessel bifurcates into a left anterior descending artery and a left circumflex artery.,LEFT ANTERIOR DESCENDING ARTERY:,The left anterior descending artery is a moderate-sized vessel, with a small first diagonal branch and a large second diagonal branch. The vessel continues as a small vessel, tapering at the apex of the left ventricle. There is calcific plaque within the mid vessel, with dense calcific plaque at the bifurcation of the second diagonal branch. This limits evaluation of the vessel lumen, and although a flow-limiting lesion cannot be excluded, there is no evidence of a high-grade stenosis. There is ostial calcification within the second diagonal branch as well. The LAD distal to the second diagonal branch is small relative to the more proximal vessel, and this is worrisome for a proximal flow-limiting lesion.,In addition, there is marked tapering of the D2 branch distal to the proximal and ostial calcific plaque. This is worrisome for either occlusion or a high-grade stenosis. There is only minimal contrast that is identified in the distal vessel.,LEFT CIRCUMFLEX ARTERY:,The left circumflex artery is a moderate-sized vessel with a patent ostium. There is calcific plaque within the proximal vessel. There is dense calcific plaque at the bifurcation of the OM1, and the AV groove branch. The AV groove branch tapers as a small vessel at the base of the heart. The dense calcific plaque within the bifurcation of the OM1 and the AV groove branch limits evaluation of the vessel lumen. There is no demonstrated high-grade stenosis, but a flow-limiting lesion cannot be excluded here.,RIGHT CORONARY ARTERY:,The right coronary artery is a moderate-sized vessel with a patent ostium. There is proximal mixed calcific and non-calcific plaque, but there is no flow-limiting lesion. The vessel continues as a moderate-sized vessel to the crux of the heart, supplying a small posterior descending artery and moderate to large posterolateral ventricular branches.,There is scattered calcific plaque within the mid vessel and there is also calcific plaque within the distal vessel at the origin of the posterior descending artery. There is no flow-limited lesion demonstrated.,The right coronary artery is dominant.,NONCORONARY CARDIAC STRUCTURE:,CARDIAC CHAMBERS:, There is diffuse myocardial thinning within the left ventricle, particularly within the apex where there is subendocardial calcification, consistent with chronic infarction. There is ventricular enlargement. There is no demonstrated aneurysm or pseudoaneurysm.,CARDIAC VALVES: ,There is calcification within the left aortic valve cusp. The aortic valve is tri-leaflet. Normal mitral valve.,PERICARDIUM:, Normal.,GREAT VESSELS: ,There are atherosclerotic changes within the aorta.,VISUALIZED LUNG PARENCHYMA, MEDIASTINUM AND CHEST WALL: ,Normal.,IMPRESSION:,Limited examination secondary to extensive artifact from the pacemaker wires.,There is extensive calcific plaque within the left anterior descending artery as well as within the proximal second diagonal branch. There is marked tapering of the LAD distal to the bifurcation of the D1 and this is worrisome for a flow-limiting lesion, but there is no evidence of occlusion.,There is marked tapering of the D1 branch distal to the calcific plaque and occlusion cannot be excluded.,There is dense calcific plaque within the left circumflex artery, and although a flow-limiting lesion cannot be excluded here, there is no evidence of an occlusion or high-grade stenosis.,There is mixed soft and calcific plaque within the proximal RCA, but there is no flow limiting lesion demonstrated.,There is diffuse thinning of the left ventricular wall, most focal at the apex where there is also dense calcification, consistent with chronic infarction. There is no demonstrated aneurysm or pseudoaneurysm.",
 CT Abdomen & Pelvis W&WO Contrast, Radiology, CT Abdomen & Pelvis ,"EXAM:,  CT Abdomen & Pelvis W&WO Contrast, ,REASON FOR EXAM: , Status post aortobiiliac graft repair. , ,TECHNIQUE: , 5 mm spiral thick spiral CT scanning was performed through the entire abdomen and pelvis utilizing intravenous dynamic bolus contrast enhancement.  No oral or rectal contrast was utilized.  Comparison is made with the prior CT abdomen and pelvis dated 10/20/05.  There has been no significant change in size of the abdominal aortic aneurysm centered roughly at the renal artery origin level which has dimensions of 3.7 cm transversely x 3.4 AP.  Just below this level is the top of the endoluminal graft repair with numerous surrounding surgical clips.  The size of the native aneurysm component at this level is stable at 5.5 cm in diameter with mural thrombus surrounding the enhancing endolumen.  There is no abnormal entrance of contrast agent into the mural thrombus to indicate an endoluminal leak.  Further distally, there is extension of the graft into both proximal common iliac arteries without evidence for endoluminal leak at this level either.  No exoluminal leakage is identified at any level.  There is no retroperitoneal hematoma present.  The findings are unchanged from the prior exam.  ,The liver, spleen, pancreas, adrenals and right kidney are unremarkable with moderate diffuse atrophy of the pancreas present.  There is advanced atrophy of the left kidney.  No hydronephrosis is present.  No acute findings are identified elsewhere in the abdomen. ,The lung bases are clear. ,Concerning the remainder of the pelvis, no acute pathology is identified.  There is prominent streak artifact from the left total hip replacement.  There is diffuse moderate sigmoid diverticulosis without evidence for diverticulitis.  The bladder grossly appears normal.  A hysterectomy has been performed.  ,IMPRESSION:,1.  No complications identified regarding endoluminal aortoiliac graft repair as described.  The findings are stable compared to the study of 10/20/04.  ,2.  Stable mild aneurysm of aortic aneurysm, centered roughly at renal artery level.  ,3.  No other acute findings noted. ,4.  Advanced left renal atrophy.","radiology, aortobiiliac graft repair, renal atrophy, ct abdomen & pelvis, w&wo contrast, aortic aneurysm, renal artery, mural thrombus, endoluminal leak, ct abdomen, ct, contrast, pelvis, abdomen,"
 CCTA with Cardiac Function/Calcium Scoring, Radiology, Coronary CT Angiography (CCTA) - 2 ,"CARDIAC CT INCLUDING CORONARY CT ANGIOGRAPHY,PROCEDURE: , Breath hold cardiac CT was performed using a 64-channel CT scanner with a 0.5-second rotation time.  Contrast injection was timed using a 10 mL bolus of Ultravist 370 IV.  Then the patient received 75 mL of Ultravist 370 at a rate of 5 mL/sec.,Retrospective ECG gating was performed.  The patient received 0.4 milligrams of sublingual nitroglycerin prior to the to the scan.  The average heart rate was 62 beats/min.,The patient had no adverse reaction to the contrast.  Multiphase retrospective reconstructions were performed.  Small field of view cardiac and coronary images were analyzed on a 3D work station.  Multiplanar reformatted images and 3D volume rendering was performed by the attending physician for the purpose of defining coronary anatomy and determining the extent of coronary artery disease.,CORONARY CTA:,1.  The technical quality of the scan is adequate.,2.  The coronary ostia are in their normal position.  The coronary anatomy is right dominant.,3.  LEFT MAIN:  The left main coronary artery is patent without angiographic stenosis.,4.  LEFT ANTERIOR DESCENDING ARTERY:  The proximal aspect of the left anterior descending artery demonstrates a mixed plaque consisting of both calcified and noncalcified lesion which is less than 30% in stenosis severity.  Diagonal 1 and diagonal 2 branches of the left anterior descending artery demonstrate mild irregularities.,5.  The ramus intermedius is a small vessel with minor irregularities.,6.  LEFT CIRCUMFLEX:  The left circumflex and obtuse marginal 1 and obtuse marginal 2 branches of the vessel are patent without significant stenosis.,7.  RIGHT CORONARY ARTERY:  The right coronary artery is a large and dominant vessel.  It demonstrates within its mid-segment calcified atherosclerosis, less than 50% stenosis severity.  Left ventricular ejection fraction is calculated to be 69%.  There are no wall motion abnormalities.,8.  Coronary calcium score was calculated to be 79, indicating at least mild atherosclerosis within the coronary vessels.,ANCILLARY FINDINGS: , None.,FINAL IMPRESSION:,1.  Mild coronary artery disease with a preserved left ventricular ejection fraction of 69%.,2.  Recommendation is aggressive medical management consisting of aggressive lifestyle modifications and statin therapy.,Thank you for referring this patient to us.","radiology, coronary ct angiography, ventricular ejection fraction, anterior descending artery, coronary artery disease, coronary ct, ct angiography, cardiac ct, obtuse marginal, ventricular ejection, ejection fraction, coronary artery, artery, angiography, coronary, ccta, atherosclerosis, ventricular, beats/min, anterior, vessel, stenosis, ct, cardiac, disease,"
 Coronary Artery CTA with Calcium Scoring and Cardiac Function, Radiology, Coronary CT Angiography (CCTA) - 3 ,"EXAM: , Coronary artery CTA with calcium scoring and cardiac function.,HISTORY: , Chest pain.,TECHNIQUE AND FINDINGS: , Coronary artery CTA was performed on a Siemens dual-source CT scanner.  Post-processing on a Vitrea workstation.  150 mL Ultravist 370 was utilized as the intravenous contrast agent.  Patient did receive nitroglycerin sublingually prior to the contrast.,HISTORY: , Significant for high cholesterol, overweight, chest pain, family history,Patient's total calcium score (Agatston) is 10. his places the patient just below the 75th percentile for age.,The LAD has a moderate area of stenosis in its midportion due to a focal calcified plaque.  The distal LAD was unreadable while the proximal was normal.  The mid and distal right coronary artery are not well delineated due to beam-hardening artifact.  The circumflex is diminutive in size along its proximal portion.  Distal is not readable.,Cardiac wall motion within normal limits.  No gross pulmonary artery abnormality however they are not well delineated.  A full report was placed on the patient's chart.  Report was saved to PACS.","radiology, coronary artery cta, calcium scoring, cardiac function, coronary artery, ct, scoring, lad, midportion, cta, calcium, cardiac, coronary, artery, angiography, "
 Conformal simulation with coplanar beams.  This patient is undergoing a conformal simulation as the method to precisely define the area of disease which needs to be treated. , Radiology, Conformal Simulation ,"CONFORMAL SIMULATION WITH COPLANAR BEAMS,This patient is undergoing a conformal simulation as the method to precisely define the area of disease which needs to be treated.  It allows us to highly focus the beam of radiation and shape the beam to the target volume, delivering a homogenous dosage through it while sparing the surrounding, more radiosensitive, normal tissues.  This will allow us to give the optimum chance of tumor control while minimizing the acute and long-term side effects.,A conformal simulation is a simulation which involves extended physician, therapist, and dosimetrist time and effort.  The patient is initially taken into a conventional simulator room, where appropriate markers are placed, and the patient is positioned and immobilized.  One then approximates the field sizes and arrangements (gantry angles, collimator angles, and number of fields).  Radiographs are taken, and these fields are marked on the patient's skin.  The patient is then transferred to the diagnostic facility and placed on a flat CT scan table.  Scans are then performed through the targeted area.  The CT scans are evaluated by the radiation oncologist, and the tumor volume, target volume, and critical structures are outlined on each slice of the CT scan.  The dosimetrist then evaluates each individual slice in the treatment planning computer with the appropriately marked structures.  This volume is then reconstructed in 3-dimensional space.  Utilizing the beam's-eye view features, the appropriate blocks are designed.  Multiplane computerized dosimetry is performed throughout the volume.  Field arrangements and blocking are modified as necessary to provide homogenous coverage of the target volume while minimizing the dose to normal structures.  Once all appropriate beam parameters and isodate distributions have been confirmed on the computer scan, each individual slice is then reviewed by the physician.  The beam's-eye view, block design, and appropriate volumes are also printed and reviewed by the physician.  Once these are approved, Cerrobend blocks will be custom fabricated.,If significant changes are made in the field arrangements from the original simulation, the patient is brought back to the simulator where the computer-designed fields are re-simulated.","radiology, coplanar beams, ct scan, target volume, conformal simulation, beamsNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 A 51-year-old male with chest pain and history of coronary artery disease., Radiology, Coronary CT Angiography (CCTA) - 4 ,"COMPARISON:, None.,MEDICATIONS:, Lopressor 5mg IV at 0920 hours.,HEART RATE: ,Recorded heart rate 55 to 57bpm.,EXAM:,Initial unenhanced axial CT imaging of the heart was obtained with ECG gating for the purpose of coronary artery calcium scoring (Agatston Method) and calcium volume determination.,18 gauge IV Intracath was inserted into the right antecubital vein.,A 20cc saline bolus was injected intravenously to confirm vein patency and adequacy of venous access.,Multi-detector CT imaging was performed with a 64 slice MDCT scanner with images obtained from the mid ascending aorta to the diaphragm at 0.5mm slice thickness during breath-holding.,95 cc of Isovue was administered followed by a 90cc saline “bolus chaser”. Image reconstruction was performed using retrospective cardiac gating. Calcium scoring analysis (Agatston Method and volume determination) was performed.,FINDINGS:,CALCIUM SCORE:  The patient's total Agatston calcium score is: 115. The Agatston score for the individual vessels are: LM: 49. RCA: 1. LAD: 2. CX: 2. Other: 62. The Agatston calcium score places the patient in the 90th percentile, which means 10 percent of the male population in this age group would have a higher calcium score.,QUALITY ASSESSMENT:,  Examination is of good quality with good bolus timing and good demonstration of coronary arteries.,LEFT MAIN CORONARY ARTERY:,  The left main coronary artery has a posteriorly positioned take-off from the valve cusp, with a patent ostium, and it has an extramural (non-malignant) course. The vessel is of moderate size. There is an apparent second ostium, in a more normal anatomic location, but quite small. This has an extramural (non-malignant) course. There is mixed calcific/atheromatous plaque within the distal vessel, as well as positive remodeling. There is no high grade stenosis but a flow-limiting lesion can not be excluded. The vessel trifurcates into a left anterior descending artery, a ramus intermedius and a left circumflex artery.,LEFT ANTERIOR DESCENDING CORONARY ARTERY:,  The left anterior descending artery is a moderate-size vessel, with ostial calcific plaque and soft plaque without a high-grade stenosis, but there may be a flow-limiting lesion here. There is a moderate size bifurcating first diagonal branch with ostial calcification, but no flow-limiting lesion. LAD continues as a moderate-size vessel to the posterior apex of the left ventricle.,Ramus intermedius branch is a moderate to large-size vessel with extensive calcific plaque, but no ostial stenosis. The dense calcific plaque limits evaluation of the vessel lumen, and a flow-limiting lesion within the proximal vessel cannot be excluded. The vessel continues as a small vessel on the left lateral ventricular wall.,LEFT CIRCUMFLEX CORONARY ARTERY:, The left circumflex artery is a moderate-size vessel with a normal ostium giving rise to a small OM1 branch and a large OM2 branch supplying much of the posterolateral wall of the left ventricular. The AV-groove branch tapers at the base of the heart. There is minimal calcific plaque within the mid vessel, but there is no flow-limiting stenosis.,RIGHT CORONARY ARTERY:, The right coronary artery is a large vessel with a normal ostium giving rise to a moderate-size acute marginal branch and continuing as a large vessel to the crux of the heart supplying a left posterior descending artery and small posterolateral ventricular branches. There is minimal calcific plaque within the mid vessel, but there is no flow-limiting lesion.,Coronary circulation is right dominant.,FUNCTIONAL ANALYSIS:, End diastolic volume: 106ml End systolic volume: 44ml Ejection fraction: 58 percent,ANATOMIC ANALYSIS:,Normal heart size with no demonstrated ventricular wall abnormalities. There are no demonstrated myocardial,bridges. Normal left atrial appendage with no evidence of thrombosis.,Cardiac valves are normal.,The aortic diameter measures 33mm just distal to the sino-tubular junction. The visualized thoracic aorta appears normal in size.,Normal pericardium without pericardial thickening or effusion.,There is no demonstrated mediastinal or hilar adenopathy. The visualized lung parenchyma is unremarkable.,There are two left and two right pulmonary veins.,IMPRESSION:,Ventricular function: Normal.,Single vessel coronary artery analysis:,LM: There is a posterior origin from the valve cusp. There is mixed calcific/atheromatous plaque and positive remodeling plaque within the LM, and although there is no high grade stenosis, a flow-limiting lesion can not be excluded. In addition, there is an apparent second ostium of indeterminate significance, but both ostia have extramural (non-malignant) courses.,LAD: Dense calcific plaque within the proximal vessel with ostial calcification and possible flow-limiting proximal lesion. There is a ramus branch with dense calcific plaque limiting evaluation of the vessel lumen, but a flow-limiting lesion cannot be excluded here.,CX: Minimal calcific plaque with no flow-limiting lesion.,RCA: Minimal calcific plaque with no flow-limiting lesion.,Coronary artery dominance: Right.",
 CCTA with cardiac function and calcium scoring., Radiology, Coronary CT Angiography (CCTA) - 1 ,"HISTORY: , Coronary artery disease.,TECHNIQUE AND FINDINGS:  ,Calcium scoring and coronary artery CTA with cardiac function was performed on Siemens dual-source CT scanner with postprocessing on Vitrea workstation.  Patient received oral Metoprolol 100 milligrams.  100 ml Ultravist 370 was utilized as the contrast agent.  0.4 milligrams of nitroglycerin was given.,Patient's calcium score 164, volume 205; this places the patient between the 75th and 90th percentile for age.  There is at least moderate atherosclerotic plaque with mild coronary artery disease and significant narrowings possible.,Cardiac wall motion was within normal limits.  Left ventricular ejection fraction calculated to be 82%.  End-diastolic volume 98 mL, end-systolic volume calculated to be 18 mL.,There is normal coronary artery origins.  There is codominance between the right coronary artery and the circumflex artery.  There is mild to moderate stenosis of the proximal LAD with mixed plaque.  Mild stenosis mid LAD with mixed plaque.  No stenosis.  Distal LAD with the distal vessel becoming diminutive in size.  Right coronary artery shows mild stenosis proximally and in the midportion due to calcified focal plaque.  Once again the distal vessel becomes diminutive in size.  Circumflex shows mild stenosis due to focal calcified plaque proximally.  No stenosis is seen involving the mid or distal circumflex.  The distal circumflex also becomes diminutive in size.  The left main shows small amount of focal calcified plaque without stenosis.  Myocardium, pericardium and wall motion was unremarkable as seen.,IMPRESSION:,1.  Atherosclerotic coronary artery disease with values as above.  There are areas of stenosis most pronounced in the LAD with mild to moderate change and mild stenosis involving the circumflex and right coronary artery.,2.  Consider cardiology consult and further evaluation if clinically indicated.,3.  Full report was sent to the PACS.  Report will be mailed to Dr. ABC.","radiology, coronary ct angiography, vitrea workstation, cardiac wall motion, proximal lad, distal lad, focal calcified plaque, coronary artery disease, cardiac function, calcium scoring, wall motion, distal vessel, calcified plaque, distal circumflex, artery disease, mild stenosis, coronary artery, ccta, scoring, atherosclerotic, vessel, calcium, calcified, lad, circumflex, distal, plaque, coronary, artery, stenosis, "
 Chest PA & Lateral to evaluate shortness of breath and pneumothorax versus left-sided effusion., Radiology, Chest PA & Lateral ,"EXAM: , Chest PA & Lateral.,REASON FOR EXAM: , Shortness of breath, evaluate for pneumothorax versus left-sided effusion.,INTERPRETATION:  ,There has been interval development of a moderate left-sided pneumothorax with near complete collapse of the left upper lobe.  The lower lobe appears aerated.  There is stable, diffuse, bilateral interstitial thickening with no definite acute air space consolidation.  The heart and pulmonary vascularity are within normal limits.  Left-sided port is seen with Groshong tip at the SVC/RA junction.  No evidence for acute fracture, malalignment, or dislocation.,IMPRESSION:,1.  Interval development of moderate left-sided pneumothorax with corresponding left lung atelectasis.,2.  Rest of visualized exam nonacute/stable.,3.  Left central line appropriately situated and stable.,4.  Preliminary report was issued at time of dictation.  Dr. X was called for results.","radiology, effusion, interstitial thickening, chest pa & lateral, shortness of breath, chest, pneumothorax, "
 Cerebral Angiogram and MRA for bilateral ophthalmic artery aneurysms., Radiology, Cerebral Angiogram & MRA ,"CC:, Transient visual field loss.,HX: ,This 58 y/o RHF had a 2 yr h/o increasing gait difficulty which she attributed to generalized weakness and occasional visual obscurations. She was evaluated by a local physician several days prior to this presentation (1/7/91), for clumsiness of her right hand and falling. HCT and MRI brain revealed bilateral posterior clinoid masses.,MEDS:, Colace, Quinidine, Synthroid, Lasix, Lanoxin, KCL, Elavil, Tenormin.,PMH: ,1) Obesity.  2) VBG, 1990.  3) A-Fib. 4) HTN.  5) Hypothyroidism.  6) Hypercholesterolemia. 7) Briquet's syndrome: h/o of hysterical paralysis. 8) CLL, dx 1989; in 1992 presented with left neck lymphadenopathy and received 5 cycles of chlorambucil/prednisone chemotherapy; 10/95 parotid gland biopsy was consistent with CLL and she received 5 more cycles of chlorambucil/prednisone; 1/10/96, she received 3000cGy to right parotid mass. 9) SNHL,FHX:, Father died, MI age 61.,SHX:, Denied Tobacco/ETOH/illicit drug use.,EXAM:, Vitals were unremarkable.,The neurologic exam was unremarkable except for obesity and mild decreased PP about the right upper and lower face, diffusely about the left upper and lower face, per neurosurgery notes. The neuro-ophthalmologic exam was unremarkable, per Neuro-ophthalmology.,COURSE:, She underwent Cerebral Angiography on 1/8/91. This revealed a 15x17x20mm LICA paraclinoid/ophthalmic artery aneurysm and a 5x7mm RICA paraclinoid/ophthalmic artery aneurysm. On 1/16/91 she underwent a left frontotemporal craniotomy and exploration of the left aneurysm. The aneurysm neck went into the cavernous sinus and was unclippable so it was wrapped. She has complained of headaches since.","radiology, visual field loss, transient, visual field, cerebral angiography, ophthalmic, paraclinoid, aneurysm, paraclinoid/ophthalmic, cavernous, frontotemporal, craniotomy, exam was unremarkable, artery aneurysms, mra, visual, parotid, cerebral, artery, neurologic, aneurysms, angiogram"
 Chest CT - Thymoma and history of ocular myasthenia gravis., Radiology, Chest CT - Myasthenia Gravis ,"CC:, Intermittent binocular horizontal, vertical, and torsional diplopia.,HX: ,70y/o RHM referred by Neuro-ophthalmology for evaluation of neuromuscular disease. In 7/91, he began experiencing intermittent binocular horizontal, vertical and torsional diplopia which was worse and frequent at the end of the day, and was eliminated when closing one either eye. An MRI Brain scan at that time was unremarkable. He was seen at UIHC Strabismus Clinic in 5/93 for these symptoms. On exam, he was found to have intermittent right hypertropia in primary gaze, and consistent diplopia in downward and rightward gaze. This was felt to possibly represent Grave's disease. Thyroid function studies were unremarkable, but orbital echography suggested Graves orbitopathy. The patient was then seen in the Neuro-ophthalmology clinic on 12/23/92. His exam remained unchanged. He underwent Tensilon testing which was unremarkable. On 1/13/93, he was seen again in Neuro-ophthalmology. His exam remained relatively unchanged and repeat Tensilon testing was unremarkable. He then underwent a partial superior rectus resection, OD, with only mild improvement of his diplopia. During his 8/27/96 Neuro-ophthalmology clinic visit he was noted to have hypertropia OD with left pseudogaze palsy and a right ptosis. The ptosis improved upon administration of Tensilon and he was placed on Mestinon 30mg tid. His diplopia subsequently improved, but did not resolve. The dosage was increased to 60mg tid and his diplopia worsened and the dose decreased back to 30mg tid. At present he denied any fatigue on repetitive movement. He denied dysphagia, SOB, dysarthria, facial weakness, fevers, chills, night sweats, weight loss or muscle atrophy.,MEDS: , Viokase, Probenecid, Mestinon 30mg tid.,PMH:, 1) Gastric ulcer 30 years ago, 2) Cholecystectomy, 3) Pancreatic insufficiency, 4) Gout, 5) Diplopia.,FHX:, Mother died age 89 of ""old age."" Father died age 89 of stroke. Brother, age 74 with CAD, Sister died age 30 of cancer.,SHX:, Retired insurance salesman and denies history of tobacco or illicit drug us. He has no h/o ETOH abuse and does not drink at present.,EXAM: ,BP 155/104.  HR 92. RR 12.  Temp 34.6C. WT 76.2kg.,MS: Unremarkable. Normal speech with no dysarthria.,CN: Right hypertropia (worse on rightward gaze and less on leftward gaze). Minimal to no ptosis, OD. No ptosis, OS. VFFTC. No complaint of diplopia. The rest of the CN exam was unremarkable.,MOTOR: 5/5 strength throughout with normal muscle bulk and tone.,SENSORY: No deficits appreciated on PP/VIB/LT/PROP/TEMP testing.,Coordination/Station/Gait: Unremarkable.,Reflexes: 2/2 throughout. Plantar responses were flexor on the right and withdrawal on the left.,HEENT and GEN EXAM: Unremarkable.,COURSE:, EMG/NCV, 9/26/96: Repetitive stimulation studies of the median, facial, and spinal accessory nerves showed no evidence of decrement at baseline, and at intervals up to 3 minutes following exercise. The patient had been off Mestinon for 8 hours prior to testing. Chest CT with contrast, 9/26/96, revealed a 4x2.5x4cm centrally calcified soft tissue anterior mediastinal mass adjacent to the aortic arch. This was highly suggestive of a thymoma. There were diffuse emphysematous disease with scarring in the lung bases. A few nodules suggestive of granulomas and few calcified perihilar lymph nodes. He underwent thoracotomy and resection of the mass. Pathologic analysis was consistent with a thymoma, lymphocyte predominant type, with capsular and pleural invasion, and extension to the phrenic nerve resection margin. Acetylcholine Receptor-binding antibody titer 12.8nmol/L (normal<0.7), Acetylcholine receptor blocking antibody <10% (normal), Acetylcholine receptor modulating antibody 42% (normal<19), Striated muscle antibody 1:320 (normal<1:10). Striated muscle antibody titers tend to be elevated in myasthenia gravis associated with thymoma. He was subsequently treated with XRT and continued to complain of fatigue at his 4/18/97 Oncology visit.","radiology, diplopia, neuromuscular disease, muscle antibody titers, chest ct, intermittent binocular, rightward gaze, striated muscle, myasthenia gravis, intermittent, torsional, binocular, myasthenia, chest, thymoma, ophthalmology, antibody, "
 Cerebral Angiogram - Lobulated aneurysm of the supraclinoid portion of the left internal carotid artery close to the origin of the left posterior communicating artery., Radiology, Cerebral Angiogram - Left ICA/PCA Aneurysm ,"CC:, Fluctuating level of consciousness.,HX:, 59y/o male experienced a ""pop"" in his head on 10/10/92 while showering in Cheyenne, Wyoming. He was visiting his son at the time. He was found unconscious on the shower floor 1.5 hours later. His son then drove him Back to Iowa. Since then he has had recurrent headaches and fluctuating level of consciousness, according to his wife. He presented at local hospital this AM, 10/13/92. A HCT there demonstrated a subarachnoid hemorrhage. He was then transferred to UIHC.,MEDS:, none.,PMH:, 1) Right hip and clavicle fractures many years ago. 2) All of his teeth have been removed., ,FHX:, Not noted.,SHX:, Cigar smoker. Truck driver.,EXAM: , BP 193/73.  HR 71.  RR 21.  Temp 37.2C.,MS: A&O to person, place and time. No note regarding speech or thought process.,CN: Subhyaloid hemorrhages, OU. Pupils 4/4 decreasing to 2/2 on exposure to light. Face symmetric. Tongue midline. Gag response difficult to elicit. Corneal responses not noted.,MOTOR: 5/5 strength throughout.,Sensory: Intact PP/VIB.,Reflexes: 2+/2+ throughout. Plantars were flexor, bilaterally.,Gen Exam: unremarkable.,COURSE:, The patient underwent Cerebral Angiography on 10/13/92. This revealed a lobulated aneurysm off the supraclinoid portion of the left internal carotid artery close to the origin of the posterior communication artery. The patient subsequently underwent clipping of this aneurysm. He recovery was complicated severe vasospasm and bacterial meningitis. HCT on 10/19/92 revealed multiple low density areas in the left hemisphere in the LACA-LPCA watershed, left fronto-parietal area and left thalamic region. He was left with residual right hemiparesis, urinary incontinence, some (unspecified) degree of mental dysfunction. He was last seen 2/26/93 in Neurosurgery clinic and had stable deficits.","radiology, consciousness, level of consciousness, hct, subhyaloid hemorrhages, cerebral angiography, carotid artery, communication artery, laca-lpca, fluctuating level of consciousness, internal carotid artery, lobulated aneurysm, lobulated, supraclinoid, cerebral, aneurysm, artery, angiogram, "
" Postcontrast CT chest pulmonary embolism protocol, 100 mL of Isovue-300 contrast is utilized.", Radiology, Chest Pulmonary Angio ,"EXAM: , CTA chest pulmonary angio.,REASON FOR EXAM: , Evaluate for pulmonary embolism.,TECHNIQUE: , Postcontrast CT chest pulmonary embolism protocol, 100 mL of Isovue-300 contrast is utilized.,FINDINGS: , There are no filling defects in the main or main right or left pulmonary arteries.  No central embolism.  The proximal subsegmental pulmonary arteries are free of embolus, but the distal subsegmental and segmental arteries especially on the right are limited by extensive pulmonary parenchymal, findings would be discussed in more detail below.  There is no evidence of a central embolism.,As seen on the prior examination, there is a very large heterogeneous right chest wall mass, which measures at least 10 x 12 cm based on axial image #35.  Just superior to the mass is a second heterogeneous focus of neoplasm measuring about 5 x 3.3 cm.  Given the short interval time course from the prior exam, dated 01/23/09, this finding has not significantly changed.  However, there is considerable change in the appearance of the lung fields.  There are now bilateral pleural effusions, small on the right and moderate on the left with associated atelectasis.  There are also extensive right lung consolidations, all new or increased significantly from the prior examination.  Again identified is a somewhat spiculated region of increased density at the right lung apex, which may indicate fibrosis or scarring, but the possibility of primary or metastatic disease cannot be excluded.  There is no pneumothorax in the interval.,On the mediastinal windows, there is presumed subcarinal adenopathy, with one lymph node measuring roughly 12 mm suggestive of metastatic disease here.  There is aortic root and arch and descending thoracic aortic calcification.  There are scattered regions of soft plaque intermixed with this.  The heart is not enlarged.  The left axilla is intact in regards to adenopathy.  The inferior thyroid appears unremarkable.,Limited assessment of the upper abdomen discloses a region of lower density within the right hepatic lobe, this finding is indeterminate, and if there is need for additional imaging in regards to hepatic metastatic disease, follow up ultrasound.  Spleen, adrenal glands, and upper kidneys appear unremarkable.  Visualized portions of the pancreas are unremarkable.,There is extensive rib destruction in the region of the chest wall mass.  There are changes suggesting prior trauma to the right clavicle.,IMPRESSION:,1.  Again demonstrated is a large right chest wall mass.,2.  No central embolus, distal subsegmental and segmental pulmonary artery branches are in part obscured by the pulmonary parenchymal findings, are not well assessed.,3.  New bilateral pleural effusions and extensive increasing consolidations and infiltrates in the right lung.,4.  See above regarding other findings.","radiology, chest pulmonary embolism, chest pulmonary embolism protocol, bilateral pleural effusions, chest wall mass, metastatic disease, pulmonary, isovue, subsegmental, metastatic, disease, mass, lung, embolism, chest, angio"
 Cerebral Angiogram - Lateral medullary syndrome secondary to left vertebral artery dissection., Radiology, Cerebral Angiogram - Lateral Medullary Syndrome ,"CC: ,Falling to left.,HX:, 26y/oRHF fell and struck her head on the ice 3.5 weeks prior to presentation. There was no associated loss of consciousness. She noted a dull headache and severe sharp pain behind her left ear 8 days ago. The pain lasted 1-2 minutes in duration. The next morning she experienced difficulty walking and consistently fell to the left. In addition the left side of her face had become numb and she began choking on food. Family noted her pupils had become unequal in size. She was seen locally and felt to be depressed and admitted to a psychiatric facility. She was subsequently transferred to UIHC following evaluation by a local ophthalmologist.,MEDS:, Prozac and Ativan (both recently started at the psychiatric facility).,PMH: ,1) Right esotropia and hyperopia since age 1year. 2) Recurrent UTI.,FHX:, Unremarkable.,SHX:, Divorced. Lives with children. No spontaneous abortions. Denied ETOH/Tobacco/Illicit Drug use.,EXAM:, BP 138/110.  HR 85.  RR 16.  Temp 37.2C.,MS: A&O to person, place, time. Speech fluent and without dysarthria. Intact naming, comprehension, repetition.,CN: Pupils 4/2 decreasing to 3/1 on exposure to light. Optic Disks flat. VFFTC. Esotropia OD, otherwise EOM full. Horizontal nystagmus on leftward gaze. Decreased corneal reflex, OS. Decreased PP/TEMP sensation on left side of face. Light touch testing normal. Decreased gag response on left. Uvula deviates to right. The rest of the CN exam was unremarkable.,Motor: 5/5 strength throughout with normal muscle bulk and tone.,Sensory: Decreased PP and TEMP on right side of body. PROP/VIB intact.,Coord: Difficulty with FNF/HKS/RAM on left. Normal on right side.,Station: No pronator drift. Romberg test not noted.,Gait: unsteady with tendency to fall to left.,Reflexes: 3/3 throughout BUE and Patellae. 2+/2+ Achilles. Plantar responses were flexor, bilaterally.,Gen Exam: Obese. In no acute distress. Otherwise unremarkable.,HEENT: No carotid/vertebral/cranial bruits.,COURSE:, PT/PTT, GS, CBC, TSH, FT4 and Cholesterol screen were all within normal limits. HCT on admission was negative. MRI Brain (done locally 2/2/93) was reviewed and a left lateral medullary stroke was appreciated. The patient underwent a cerebral angiogram on 2/3/93 which revealed significant narrowing of the left vertebral artery beginning at C2 and extending to and involving the basilar artery. There is severe, irregular narrowing of the horizontal portion above the posterior arch of C1. The findings were felt consistent with a left vertebral artery dissection. Neuro-opthalmology confirmed a left Horner's pupil by clinical exam and history. Cookie swallow study was unremarkable. The Patient was placed on Heparin then converted to Coumadin. The PT on discharge was 17.,She remained on Coumadin for 3 months and then was switched to ASA for 1 year. An Otolaryngologic evaluation on 10/96 noted true left vocal cord paralysis with full glottic closure. A prosthesis was made and no surgical invention was done.","radiology, horner's pupil, mri brain, otolaryngologic, cerebral angiogram, cerebral angiogram lateral, medullary syndrome, vertebral artery, angiogram, syndrome, falling, narrowing, medullary, vertebral, cerebral, "
 Concomitant chemoradiotherapy for curative intent patients., Radiology, Concomitant Chemoradiotherapy ,"CONCOMITANT CHEMORADIOTHERAPY FOR CURATIVE INTENT PATIENTS,This patient is receiving combined radiotherapy and chemotherapy in an effort to maximize the chance of control of this cancer.  The chemotherapy is given in addition to the radiotherapy, not only to act as a cytotoxic agent on its own, but also to potentiate and enhance the effect of radiotherapy on tumor cells.  It has been shown in the literature that this will maximize the chance of control.,During the course of the treatment, the patient's therapy must be closely monitored by the attending physician to be sure that the proper chemotherapy drugs are given at the proper time during the radiotherapy course.  It is also important to closely monitor the patient to know when treatment with either chemotherapy or radiotherapy needs to be held.  This combined treatment usually produces greater side effects than either treatment alone, and these need to be constantly monitored and treatment initiated on a timely basis to minimize these effects.  In accordance, this requires more frequency consultation and coordination with the medical oncologist.  Therefore, this becomes a very time intensive treatment and justifies CPT Code 77470.","radiology, tumor cells, concomitant chemoradiotherapy, chemotherapy, radiotherapyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" Patient with chest pains, CAD, and cardiomyopathy.", Radiology, Cardiac Radionuclide Stress Test ,"INDICATION FOR STUDY: , Chest pains, CAD, and cardiomyopathy.,MEDICATIONS:,  Humulin, lisinopril, furosemide, spironolactone, omeprazole, carvedilol, pravastatin, aspirin, hydrocodone, and diazepam.,BASELINE EKG: , Sinus rhythm at 71 beats per minute, left anterior fascicular block, LVBB.,PERSANTINE RESULTS: , Heart rate increased from 70 to 72.  Blood pressure decreased from 160/84 to 130/78.  The patient felt slightly dizziness, but there was no chest pain or EKG changes.,NUCLEAR PROTOCOL: , Same day rest/stress protocol was utilized with 12 mCi for the rest dose and 33 mCi for the stress test.  53 mg of Persantine were used, reversed with 125 mg of aminophylline.,NUCLEAR RESULTS:,1.  Nuclear perfusion imaging, review of the raw projection data reveals adequate image acquisition.  The resting images are normal.  The post Persantine images show mildly decreased uptake in the septum.  The sum score is 0.,2.  The Gated SPECT shows enlarged heart with a preserved EF of 52%.,IMPRESSION:,1.  Mild septal ischemia.  Likely due to the left bundle-branch block.,2.  Mild cardiomyopathy, EF of 52%.,3.  Mild hypertension at 160/84.,4.  Left bundle-branch block.,","radiology, cardiac radionuclide, spect, sinus rhythm, cardiac radionuclide stress test, bundle branch block, stress test, bundle branch, chest pains, stress, test, cardiomyopathy, nuclear"
 Carotid and cerebral arteriogram - abnormal carotid duplex studies demonstrating occlusion of the left internal carotid artery., Radiology, Carotid & Cerebral Arteriograms ,"EXAM: , Carotid and cerebral arteriograms.,INDICATION: , Abnormal carotid duplex studies demonstrating occlusion of the left internal carotid artery.,IMPRESSION:,1.  Complete occlusion of the left common carotid artery approximately 3 cm distal to its origin.,2.  Mild stenosis of the right internal carotid artery measured at 20%.,3.  Patent bilateral vertebral arteries.,4.  No significant disease was identified of the anterior cerebral vessels.,DISCUSSION:  ,Carotid and cerebral arteriograms were performed on Month DD, YYYY, previous studies are not available for comparison.,The right groin was sterilely cleansed and draped.  Lidocaine 1% buffered with sodium bicarbonate was used as local anesthetic.  A 19-French needle was then advanced into the common femoral artery and a wire was advanced.  Over the wire, a sheath was placed.  A wire was then advanced into the abdominal aorta and over the wire and the flushed catheter was then advanced to the arch of the aorta over a wire.  Flushed arteriogram was performed.  Arteriogram demonstrated no significant disease of the great vessels at their origins.  There is demonstration of complete occlusion of the left common carotid artery approximately 3 cm distal to its origin.  The vertebral arteries were widely patent.  Following this, the flushed catheter was exchanged for ***** catheter and selective catheterization of the common carotid artery on the right was performed.  Carotid and cerebral arteriograms were performed.  The carotid arteriograms on the right demonstrated the carotid bulb to be unremarkable.  The external carotid artery on the right is quite tortuous in its appearance.  The internal carotid artery demonstrates a mild plaque creating stenosis, which is measured approximately 20%.  Cerebral arteriogram on the right demonstrated the A1 and M1 segments bilaterally to be normal.  No significant stenosis identified.  There is complete cross-filling into the left brain via the right.  No significant stenosis was appreciated.,Following this, the catheter was parked at the origin of the left common carotid artery and ejection demonstrated complete occlusion.,The patient tolerated the procedure well.  No complications occurred during or immediately after the procedure.  Stasis was achieved of the puncture site using a VasoSeal.  The patient will be observed for at least 2-1/2 hours prior to being discharged to home.","radiology, carotid, arteriogram, bulb, carotid duplex, catheter, cerebral, distal, femoral artery, internal carotid artery, needle, occlusion, sheath, stenosis, vertebral arteries, vessels, cerebral arteriograms, carotid artery, artery, arteriograms, wire,"
 Cardiolite treadmill exercise stress test.  The patient was exercised on the treadmill to maximum tolerance achieving after 5 minutes a peak heart rate of 137 beats per minute with a workload of 2.3 METS., Radiology, Cardiolite Treadmill Stress Test ,"CARDIOLITE TREADMILL EXERCISE STRESS TEST,CLINICAL DATA:,  This is a 72-year-old female with history of diabetes mellitus, hypertension, and right bundle branch block.,PROCEDURE:,  The patient was exercised on the treadmill to maximum tolerance achieving after 5 minutes a peak heart rate of 137 beats per minute with a workload of 2.3 METS.  There was a normal blood pressure response.  The patient did not complain of any symptoms during the test and other than the right bundle branch block that was present at rest, no other significant electrographic abnormalities were observed.,Myocardial perfusion imaging was performed at rest following the injection of 10 mCi Tc-99 Cardiolite.  At peak pharmacological effect, the patient was injected with 30 mCi Tc-99 Cardiolite.,Gating poststress tomographic imaging was performed 30 minutes after the stress.,FINDINGS:,1.  The overall quality of the study is fair.,2.  The left ventricular cavity appears to be normal on the rest and stress studies.,3.  SPECT images demonstrate fairly homogeneous tracer distribution throughout the myocardium with no overt evidences of fixed and/or reperfusion defect.,4.  The left ventricular ejection fraction was normal and estimated to be 78%.,IMPRESSION: , Myocardial perfusion imaging is normal.  Result of this test suggests low probability for significant coronary artery disease.","radiology, peak heart rate, bundle branch block, perfusion imaging, stress test, mci, ventricular, cardiolite, treadmill,"
 Cerebral Angiogram for avascular mass - cavernous angioma (with hematoma on MRI and Bx)., Radiology, Cerebral Angiogram ,"CC: ,Headache (HA),HX:, 10 y/o RHM awoke with a bilateral parieto-occipital HA associated with single episode of nausea and vomiting, 2 weeks prior to presentation. The nausea and vomiting resolved and did not recur. However, he continued to experience similar HA 3-4 times per week during the early morning upon awakening. He never felt the HA awakened him from sleep. The HA were partially relieved by Tylenol or Advil, and he distracted himself from the pain by remaining active. One week prior to presentation, he started to experience short episodes of blurred vision and diplopia. He also became fatigued, less active, and frequently yawned.,He had no prior history of HA and he and his family denied any sign or symptom of focal weakness or numbness, dysphagia, dysarthria, or loss of consciousness.,The patient underwent an MRI brain scan prior to transfer to UIHC. This revealed a mass in the left frontal region adjacent to the left temporal horn. The mass was an inhomogeneous blend of signals on T1 and T2 images giving a suggestion of acute bleeding, hemosiderin deposition and multiple vessels within the mass.,MEDS:, None.,PMH:, 1) He was a 7# 15oz. product of a full term, uncomplicated pregnancy and spontaneous vaginal delivery. His post-partum course was unremarkable. 2)Developmental milestones were reached at the appropriate times; though he was diagnosed with dyslexia 4 years ago. 3) No significant illnesses or hospitalizations.,FHX:, MGF (meningioma). PGF (lymphoma). Mother (migraine HA). Father and 22yr old brother are alive and well.,SHX: ,lives with parents and attends mainstream 5th grade classes.,EXAM:, BP124/93 HR96 RR20 37.9C (tympanic),MS:  A & O to person, place, time. Cooperative and interactive. Speech fluent and without dysarthria.,CN: EOM intact. VFFTC, Pupils 3/3 decreasing to 2/2 on exposure to light. Fundoscopy: optic disks flat, no evidence of hemorrhage. The rest of the CN exam was unremarkable.,MOTOR: full strength throughout all 4 extremities. Normal muscle tone and bulk.,Sensory: unremarkable.,Coord: unremarkable.,Station: no pronator drift or Romberg sign,Gait: unremarkable.,Reflexes: 2+ in RUE and RLE. 3 in LUE and LLE. Plantar responses were flexor, bilaterally.,HEENT: no meningismus. no cranial bruits. no skull defects palpated.,GEN EXAM: unremarkable.,COURSE:, GS, PT/PTT, CBC were unremarkable. The MRI finding above lead to a differential diagnosis of Venous Angioma, Arteriovenous Malformation, Ependymoma, Neurocytoma, Glioma: all with associated hemorrhage.,He underwent cerebral angiography on 1/25/93. Upon injection of the RCCA an avascular mass was identified in the right temporal lobe displacing the anterior choroidal artery, and temporal branches of the middle cerebral arteries. The internal cerebral vein is displaced to the left suggesting mass effect. There is a hypoplastic A1 segment and fetal origin of the LPCA. The mass was felt by neuroradiology to represent a hematoma.,He underwent a right frontal craniotomy, 1/28/93. Pathological evaluation of the resected tissue was consistent with a vascular malformation with inclusive reactive glial tissue and evidence of recurrent and remote hemorrhage. There were dilated vascular channels having walls of variable thickness, but without evidence of elastic lamina by elastic staining. This was consistent with venous angioma/malformation.",
 Bilateral carotid ultrasound., Radiology, Carotid Ultrasound ,"EXAM:,  Bilateral carotid ultrasound.,REASON FOR EXAM: , Headache.,TECHNIQUE:  ,Color grayscale and Doppler analysis is employed.,FINDINGS:,  On the grayscale images, the right common carotid artery demonstrates patency with mild intimal thickening only.  At the level of the carotid bifurcation, there is heterogeneous hard plaque present, but without grayscale evidence of greater than 50% stenosis.  Right common carotid waveform is normal with a peak systolic velocity of 0.474 m/second and an end-diastolic velocity of 0.131 m/second.  The right ECA is patent as well with the velocity measurement 0.910 m/second.,The right internal carotid artery at the bifurcation demonstrates plaque formation, but no evidence of greater than 50% stenosis.  Proximal peak systolic velocity in the internal carotid artery is 0.463 m/second with proximal end-diastolic velocity of 0.170.  The mid internal carotid peak systolic velocity is 0.564 m/second, and mid ICA end-diastolic velocity is 0.199 m/second.  Right ICA distal PSV 0.580 m/second, right ICA distal EDV 0.204 m/second.  Vertebral flow is antegrade on the right at 0.469 m/second.,On the left, the common carotid artery demonstrates intimal thickening, but is otherwise patent.  At the level of the bifurcation, however, there is more pronounced plaque formation with approximately 50% stenosis by the grayscale analysis.  See the velocity measurements below:,Left carotid ECA measurement 0.938 m/second.  Left common carotid PSV 0.686 m/second, and left common carotid end-diastolic velocity 0.137 m/second.,Left internal carotid artery again demonstrates prominent focus of hard plaque with up to at least 50% stenosis.  This should be further assessed with CTA for more precise measurement.  The left proximal ICA/PSV 0.955 m/second, left proximal ICA/EDV 0.287 m/second.  There is spectral broadening in the proximal aspect of the carotid waveform.  The left carotid ICA mid PSV 0.895, left carotid ICA mid EDV 0.278 with also spectral broadening present.,The left distal ICA/PSV 0.561, left distal ICA/EDV 0.206, again the spectral broadening present.  Vertebral flow is antegrade at 0.468 m/second.,IMPRESSION: , The study demonstrates bilateral hard plaque at the bifurcation, left greater than right.  There is at least 50% stenosis of the left internal carotid artery at its bifurcation and a followup CTA is recommended for further assessment.","radiology, doppler analysis, headache, edv, ica, eca, psv, distal ica/edv, hard plaque, bilateral carotid ultrasound, peak systolic velocity, internal carotid artery, plaque formation, carotid ultrasound, carotid artery, carotid, stenosis, proximal, artery, velocity"
 Carotid Ultrasonic & Color Flow Imaging, Radiology, Carotid Doppler Report ,"Grade II:  Atherosclerotic plaques are seen which appear to be causing 40-60% obstruction.,Grade III:  Atherosclerotic plaques are seen which appear to be causing greater than 60% obstruction.,Grade IV:  The vessel is not pulsating and the artery appears to be totally obstructed with no blood flow in it.,RIGHT CAROTID SYSTEM: , The common carotid artery and bulb area shows mild intimal thickening with no increase in velocity and no evidence for any obstructive disease.  The internal carotid artery shows intimal thickening with some mixed plaques, but no increase in velocity and no evidence for any significant obstructive disease.  The external carotid artery shows no disease.  The vertebral was present and was antegrade.,LEFT CAROTID SYSTEM: , The common carotid artery and bulb area shows mild intimal thickening, but no increase in velocity and no evidence for any significant obstructive disease. the internal carotid artery shows some intimal thickening with mixed plaques, but no increase in velocity and no evidence for any significant obstructive disease.  The external carotid artery shows no disease.  The vertebral was present and was antegrade.,IMPRESSION:,  Bilateral atherosclerotic changes with no evidence for any significant obstructive disease.","radiology, atherosclerotic, atherosclerotic plaques, obstructive disease, carotid artery, carotid artery and bulb, common carotid artery, mild intimal thickening, external carotid artery, common carotid, internal carotid, external carotid, intimal thickening, carotid, intimal, plaques, artery,"
" Bilateral Mammogram, (abnormal) additional views requested", Radiology, Bilateral Mammogram ,"EXAM:,  Mammographic screening FFDM,HISTORY: , 40-year-old female who is on oral contraceptive pills.  She has no present symptomatic complaints.  No prior history of breast surgery nor family history of breast CA.,TECHNIQUE: , Standard CC and MLO views of the breasts.,COMPARISON: , This is the patient's baseline study.,FINDINGS: , The breasts are composed of moderately to significantly dense fibroglandular tissue.  The overlying skin is unremarkable.,There are a tiny cluster of calcifications in the right breast, near the central position associated with 11:30 on a clock.,There are benign-appearing calcifications in both breasts as well as unremarkable axillary lymph nodes.,There are no spiculated masses or architectural distortion.,IMPRESSION:,  Tiny cluster of calcifications at the 11:30 position of the right breast.  Recommend additional views; spot magnification in the MLO and CC views of the right breast.,BIRADS Classification 0 - Incomplete,MAMMOGRAPHY INFORMATION:,1.  A certain percentage of cancers, probably 10% to 15%, will not be identified by mammography.,2.  Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present.,3.  These images were obtained with FDA-approved digital mammography equipment, and iCAD Second Look Software Version 7.2 was utilized.","radiology, ffdm, mammographic screening, tiny cluster of calcifications, bilateral mammogram, additional views, bilateral, mammogram, cluster, breasts, calcifications, mammography,"
 Carotid artery angiograms., Radiology, Bilateral Carotid Angiography ,"PROCEDURE PERFORMED:,1.  Selective ascending aortic arch angiogram.,2.  Selective left common carotid artery angiogram.,3.  Selective right common carotid artery angiogram.,4.  Selective left subclavian artery angiogram.,5.  Right iliac angio with runoff.,6.  Bilateral cerebral angiograms were performed as well via right and left common carotid artery injections.,INDICATIONS FOR PROCEDURE: , TIA, aortic stenosis, postoperative procedure.  Moderate carotid artery stenosis.,ESTIMATED BLOOD LOSS:,  400 ml.,SPECIMENS REMOVED:,  Not applicable.,TECHNIQUE OF PROCEDURE: , After obtaining informed consent, the patient was brought to the cardiac catheterization suite in postabsorptive and nonsedated state.  The right groin was prepped and draped in the usual sterile fashion.  Lidocaine 2% was used for infiltration anesthesia.  Using modified Seldinger technique, a 6-French sheath was placed into the right common femoral artery and vein without complication.  Using injection through the side port of the sheath, a right iliac angiogram with runoff was performed.  Following this, straight pigtail catheter was used to advance the aortic arch and aortic arch angiogram under digital subtraction was performed.  Following this, selective engagement in left common carotid artery, right common carotid artery, and left subclavian artery angiograms were performed with a V-Tech catheter over an 0.035-inch wire.,ANGIOGRAPHIC FINDINGS:,1.  Type 2 aortic arch.,2.  Left subclavian artery was patent.,3 Left vertebral artery was patent.,4.  Left internal carotid artery had a 40% to 50% lesion with ulceration, not treated and there was no cerebral cross over.,5.  Right common carotid artery had a 60% to 70% lesion which was heavily calcified and was not treated with the summed left-to-right cross over flow.,6.  Closure was with a 6-French Angio-Seal of the artery, and the venous sheath was sutured in.,PLAN:,  Continue aspirin, Plavix, and Coumadin to an INR of 2 with a carotid duplex followup.","radiology, aortic arch angiogram, carotid artery angiogram, artery was patent, common carotid artery, arch angiogram, subclavian artery, aortic arch, carotid artery, carotid, angiography, artery, angiograms, subclavian, catheterization, aortic, angiogram, "
 Ultrasound BPP - Advanced maternal age and hypertension., Radiology, Biophysical Profile - 1 ,"HISTORY: , Advanced maternal age and hypertension.,FINDINGS:,  There is a single live intrauterine pregnancy with a vertex lie, posterior placenta, and adequate amniotic fluid.  The amniotic fluid index is 23.2 cm.  Estimated gestational age based on prior ultrasound is 36 weeks 4 four days with an estimated date of delivery of 03/28/08.  Based on fetal measurements obtained today, estimated fetal weight is 3249 plus or minus 396 g, 7 pounds 3 ounces plus or minus 14 ounces, which places the fetus in the 66th percentile for the estimated gestational age.  Fetal heart motion at a rate of 156 beats per minute is documented.  The cord Doppler ratio is normal at 2.2.  The biophysical profile score, assessing fetal breathing movement, gross body movement, fetal tone, and qualitative amniotic fluid volume is 8/8.,IMPRESSION:,1.  Single live intrauterine pregnancy in vertex presentation with an estimated gestational age of 36 weeks 4 days and established due date of 03/28/08.,2.  Biophysical profile (BPP) score 8/8.","radiology, ultrasound, bpp, maternal age, intrauterine pregnancy, biophysical profile, amniotic fluid, gestational age, amniotic, gestational, fetal,"
" Diagnostic mammogram, full-field digital, ultrasound of the breast and mammotome core biopsy of the left breast.", Radiology, Breast Ultrasound & Biopsy ,"EXAM:  ,Bilateral diagnostic mammogram, left breast ultrasound and biopsy.,HISTORY: , 30-year-old female presents for digital bilateral mammography secondary to a soft tissue lump palpated by the patient in the upper right shoulder.  The patient has a family history of breast cancer within her mother at age 58.  Patient denies personal history of breast cancer.,TECHNIQUE AND FINDINGS:  ,Craniocaudal and mediolateral oblique projections of bilateral breasts were obtained on mm/dd/yy.  An additional lateromedial projection of the right breast was obtained.  The breasts demonstrate heterogeneously-dense fibroglandular tissue.  Within the upper outer aspect of the left breast, there is evidence of a circumscribed density measuring approximately 1 cm x 0.7 cm in diameter.  No additional dominant mass, areas of architectural distortion, or malignant-type calcifications are seen.  Multiple additional benign-appearing calcifications are visualized bilaterally.  Skin overlying both breasts is unremarkable.,Bilateral breast ultrasound was subsequently performed, which demonstrated an ovoid mass measuring approximately 0.5 x 0.5 x 0.4 cm in diameter located within the anteromedial aspect of the left shoulder.  This mass demonstrates isoechoic echotexture to the adjacent muscle, with no evidence of internal color flow.  This may represent benign fibrous tissue or a lipoma.,Additional ultrasonographic imaging of the left breast demonstrates a complex circumscribed solid and cystic lesion with hypervascular properties at the 2 o'clock position, measuring 0.7 x 0.7 x 0.8 cm in diameter.  At this time, the lesion was determined to be amenable by ultrasound-guided core biopsy.,The risks and complications of the procedure were discussed with the patient for biopsy of the solid and cystic lesion of the 2 o'clock position of the left breast.  Informed consent was obtained.  The lesion was re-localized under ultrasound guidance.  The left breast was prepped and draped in the usual sterile fashion.  2% lidocaine was administered locally for anesthesia.  Additional lidocaine with epinephrine was administered around the distal aspect of the lesion.  A small skin nick was made.  Color Doppler surrounding the lesion demonstrates multiple vessels surrounding the lesion at all sides.  The lateral to medial approach was performed with an 11-gauge Mammotome device.  The device was advanced under ultrasound guidance, with the superior aspect of the lesion placed within the aperture.  Two core biopsies were obtained.  The third core biopsy demonstrated evidence of an expanding hypoechoic area surrounding the lesion, consistent with a rapidly-expanding hematoma.  Arterial blood was visualized exiting the access site.  A biopsy clip was attempted to be placed, however could not be performed secondary to the active hemorrhage.  Therefore, the Mammotome was removed, and direct pressure over the access site and biopsy location was applied for approximately 20 minutes until hemostasis was achieved.  Postprocedural imaging of the 2 o'clock position of the left breast demonstrates evidence of a hematoma measuring approximately 1.9 x 4.4 x 1.3 cm in diameter.  The left breast was re-cleansed with a ChloraPrep, and a pressure bandage and ice packing were applied to the left breast.  The patient was observed in the ultrasound department for the following 30 minutes without complaints.  The patient was subsequently discharged with information and instructions on utilizing the ice bandage.  The obtained specimens were sent to pathology for further analysis.,IMPRESSION:,1.  A mixed solid and cystic lesion at the 2 o'clock position of the left breast was accessed under ultrasound guidance utilizing a Mammotome core biopsy instrument, and multiple core biopsies were obtained.  Transient arterial hemorrhage was noted at the biopsy site, resulting in a localized 4 cm hematoma.  Pressure was applied until hemostasis was achieved.  The patient was monitored for approximately 30 minutes after the procedure, and was ultimately discharged in good condition.  The core biopsies were submitted to pathology for further analysis.,2.  Small isoechoic ovoid mass within the anteromedial aspect of the left shoulder does not demonstrate color flow, and likely represents fibrotic changes or a lipoma.,3.  Suspicious mammographic findings.  The circumscribed density measuring approximately 8 mm at the 2 o'clock position of the left breast was subsequently biopsied.  Further pathologic analysis is pending.,BIRADS Classification 4 - Suspicious findings.,MAMMOGRAPHY INFORMATION:,1.  A certain percentage of cancers, probably 10% to 15%, will not be identified by mammography.,2.  Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present.,3.  These images were obtained with FDA-approved digital mammography equipment, and iCAD SecondLook Software Version 7.2 was utilized.","radiology, mammotome core biopsy, diagnostic mammogram, breast cancer, bilateral breasts, circumscribed density, ovoid mass, breast ultrasound, core biopsy, lesion, biopsy, breast, hematoma, mammotome, mammography, ultrasound,"
" BPP of Gravida 1, para 0 at 33 weeks 5 days by early dating.  The patient is developing gestational diabetes.", Radiology, Biophysical Profile ,"CLINICAL HISTORY:,  Gravida 1, para 0 at 33 weeks 5 days by early dating.  The patient is developing gestational diabetes.,Transabdominal ultrasound examination demonstrated a single fetus and uterus in vertex presentation.  The placenta was posterior in position.  There was normal fetal breathing movement, gross body movement, and fetal tone, and the qualitative amniotic fluid volume was normal with an amniotic fluid index of 18.2 cm.,The following measurements were obtained:  Biparietal diameter 8.54 cm, head circumference 30.96 cm, abdominal circumference 29.17 cm, and femoral length 6.58 cm.  These values predict a fetal weight of 4 pounds 15 ounces plus or minus 12 ounces or at the 42nd percentile based on gestation.,CONCLUSION:,  Normal biophysical profile (BPP) with a score of 8 out of possible 8.  The fetus is size appropriate for gestation.","radiology, biophysical profile, gestational diabetes, amniotic fluid, bpp, gravida, para, diabetes, fetus, fetalNOTE"
 Brain CT and MRI - suprasellar mass (pituitary adenoma), Radiology, Brain MRI - Pituitary Adenoma ,"CC:, Orthostatic lightheadedness.,HX:, This 76 y/o male complained of several months of generalized weakness and malaise, and a two week history of progressively worsening orthostatic dizziness. The dizziness worsened when moving into upright positions. In addition, he complained of intermittent throbbing holocranial headaches, which did not worsen with positional change, for the past several weeks. He had lost 40 pounds over the past year and denied any recent fever, SOB, cough, vomiting, diarrhea, hemoptysis, melena, hematochezia, bright red blood per rectum, polyuria, night sweats, visual changes, or syncopal episodes.,He had a 100+ pack-year history of tobacco use and continued to smoke 1 to 2 packs per day. He has a history of sinusitis.,EXAM:, BP 98/80 mmHg and pulse 64 BPM (supine); BP 70/palpable mmHG and pulse 84BPM (standing). RR 12, Afebrile. Appeared fatigued.,CN: unremarkable.,Motor and Sensory exam: unremarkable.,Coord: Slowed but otherwise unremarkable movements.,Reflexes: 2/2 and symmetric throughout all 4 extremities. Plantar responses were flexor, bilaterally.,The rest of the neurologic and general physical exam was unremarkable.,LAB:, Na 121 meq/L, K 4.2 meq/L, Cl 90 meq/L, CO2 20meq/L, BUN 12mg/DL, CR 1.0mg/DL, Glucose 99mg/DL, ESR 30mm/hr, CBC WNL with nl WBC differential, Urinalysis: SG 1.016 and otherwise WNL, TSH 2.8 IU/ML, FT4 0.9ng/DL, Urine Osmolality 246 MOSM/Kg (low), Urine Na 35 meq/L,,COURSE:, The patient was initially hydrated with IV normal saline and his orthostatic hypotension resolved, but returned within 24-48hrs. Further laboratory studies revealed: Aldosterone (serum)<2ng/DL (low), 30 minute Cortrosyn Stimulation test: pre 6.9ug/DL (borderline low), post 18.5ug/DL (normal stimulation rise), Prolactin 15.5ng/ML (no baseline given), FSH and LH were within normal limits for males. Testosterone 33ng/DL (wnl). Sinus XR series (done for history of headache) showed an abnormal sellar region with enlarged sella tursica and destruction of the posterior clinoids. There was also an abnormal calcification seen in the middle of the sellar region. A left maxillary sinus opacity with air-fluid level was seen. Goldman visual field testing was unremarkable. Brain CT and MRI revealed suprasellar mass most consistent with pituitary adenoma. He was treated with Fludrocortisone 0.05 mg BID and within 24hrs, despite discontinuation of IV fluids, remained hemodynamically stable and free of symptoms of orthostatic hypotension. His presumed pituitary adenoma continues to be managed with Fludrocortisone as of this writing (1/1997), though he has developed dementia felt secondary to cerebrovascular disease (stroke/TIA).","radiology, brain ct, goldman, mri, orthostatic, adenoma, generalized weakness, hypotension, lightheadedness, malaise, pituitary, sinus opacity, suprasellar mass, brain ct and mri, orthostatic hypotension, pituitary adenoma, brain, sinusitis, sellar,"
 Barium enema - history of encopresis and constipation., Radiology, Barium Enema ,"EXAM: , Barium enema.,CLINICAL HISTORY: , A 4-year-old male with a history of encopresis and constipation.,TECHNIQUE:  ,A single frontal scout radiograph of the abdomen was performed.  A rectal tube was inserted in usual sterile fashion, and retrograde instillation of barium contrast was followed via spot fluoroscopic images.  A post-evacuation overhead radiograph of the abdomen was performed.,FINDINGS:,  The scout radiograph demonstrates a nonobstructive gastrointestinal pattern.  There are no suspicious calcifications seen or evidence of gross free intraperitoneal air.  The visualized lung bases and osseous structures are within normal limits.,The rectum and colon is of normal caliber throughout its course.  There is no evidence of obstruction, as contrast is seen to flow without difficulty into the right colon and cecum.  A small amount of contrast is seen to opacify small bowel loops on the post-evacuation image.  There is also opacification of a normal-appearing appendix documented.,IMPRESSION: , Normal barium enema.","radiology, encopresis and constipation, scout radiograph, post evacuation, barium enema, encopresis, constipation, evacuation, colon, radiograph, contrast, enema, barium, "
 Arterial imaging of bilateral lower extremities.  , Radiology, Arterial Imaging ,"INDICATIONS:,  Peripheral vascular disease with claudication.,RIGHT:,  ,1.  Normal arterial imaging of right lower extremity.,2.  Peak systolic velocity is normal.,3.  Arterial waveform is triphasic.,4.  Ankle brachial index is 0.96.,LEFT:,1.  Normal arterial imaging of left lower extremity.,2.  Peak systolic velocity is normal.,3.  Arterial waveform is triphasic throughout except in posterior tibial artery where it is biphasic.,4.  Ankle brachial index is 1.06.,IMPRESSION,:,Normal arterial imaging of both lower extremities.","radiology, peripheral vascular disease, ankle brachial index, arterial waveform, peak systolic velocity, arterial imaging, biphasic, claudication, lower extremities, lower extremity, posterior tibial artery, triphasic, systolic velocity is normal, arterial waveform is triphasic, waveform is triphasic, normal arterial imaging, systolic velocity, brachial index, velocity, brachial, imaging, arterial,"
 MRI brain & PET scan - Dementia of Alzheimer type with primary parietooccipital involvement., Radiology, Alzheimer Disease ,"CC:, Memory difficulty.,HX: ,This 64 y/o RHM had had difficulty remembering names, phone numbers and events for 12 months prior to presentation, on 2/28/95. This had been called to his attention by the clerical staff at his parish--he was a Catholic priest. He had had no professional or social faux pas or mishaps due to his memory. He could not tell whether his problem was becoming worse, so he brought himself to the Neurology clinic on his own referral.,MEDS:, None.,PMH: ,1)appendectomy, 2)tonsillectomy, 3)childhood pneumonia, 4)allergy to sulfa drugs.,FHX:, Both parents experienced memory problems in their ninth decades, but not earlier. 5 siblings have had no memory trouble. There are no neurological illnesses in his family.,SHX:, Catholic priest. Denied Tobacco/ETOH/illicit drug use.,EXAM:,  BP131/74, HR78, RR12, 36.9C, Wt. 77kg, Ht. 178cm.,MS: A&O to person, place and time. 29/30 on MMSE; 2/3 recall at 5 minutes. 2/10 word recall at 10 minutes. Unable to remember the name of the President (Clinton). 23words/60 sec on Category fluency testing (normal). Mild visual constructive deficit.,The rest of the neurologic exam was unremarkable and there were no extrapyramidal signs or primitive reflexes noted.,COURSE:, TSH 5.1, T4 7.9, RPR non-reactive. Neuropsychological evaluation, 3/6/95, revealed: 1)well preserved intellectual functioning and orientation, 2) significant deficits in verbal and visual memory, proper naming, category fluency and working memory, 3)performances which were below expectations on tests of speed of reading, visual scanning, visual construction and clock drawing, 4)limited insight into the scope and magnitude of cognitive dysfunction. The findings indicated multiple areas of cerebral dysfunction. With the exception of the patient's report of minimal occupational dysfunction ( which may reflect poor insight), the clinical picture is consistent with a progressive dementia syndrome such as Alzheimer's disease. MRI brain, 3/6/95, showed mild generalized atrophy, more severe in the occipital-parietal regions.,In 4/96, his performance on repeat neuropsychological evaluation was relatively stable. His verbal learning and delayed recognition were within normal limits, whereas delayed recall was ""moderately severely"" impaired. Immediate and delayed visual memory were slightly below expectations. Temporal orientation and expressive language skills were below expectation, especially in word retrieval. These findings were suggestive of particular, but not exclusive, involvement of the temporal lobes.,On 9/30/96, he was evaluated for a 5 minute spell of visual loss, OU. The episode occurred on Friday, 9/27/96, in the morning while sitting at his desk doing paperwork. He suddenly felt that his gaze was pulled toward a pile of letters; then a ""curtain"" came down over both visual fields, like ""everything was in the shade."" During the episode he felt fully alert and aware of his surroundings. He concurrently heard a ""grating sound"" in his head. After the episode, he made several phone calls, during which he reportedly sounded confused, and perseverated about opening a bank account. He then drove to visit his sister in Muscatine, Iowa, without accident. He was reportedly ""normal"" when he reached her house. He was able to perform Mass over the weekend without any difficulty. Neurologic examination, 9/30/96, was notable for: 1)category fluency score of 18items/60 sec. 2)VFFTC and EOM were intact. There was no RAPD, INO, loss of visual acuity. Glucose 178 (elevated), ESR ,Lipid profile, GS, CBC with differential, Carotid duplex scan, EKG, and EEG were all normal. MRI brain, 9/30/96, was unchanged from previous, 3/6/95.,On 1/3/97, he had a 30 second spell of lightheadedness without vertigo, but with balance difficulty, after picking up a box of books. The episode was felt due to orthostatic changes.,1/8/97 neuropsychological evaluation was stable and his MMSE score was 25/30 (with deficits in visual construction, orientation, and 2/3 recall at 1 minute). Category fluency score 23 items/60 sec. Neurologic exam was notable for graphesthesia in the left hand.,In 2/97, he had episodes of anxiety, marked fluctuations in job performance and resigned his pastoral position. His neurologic exam was unchanged. An FDG-PET scan on 2/14/97 revealed decreased uptake in the right posterior temporal-parietal and lateral occipital regions.","radiology, dementia, a&o to person, alzheimer's disease, alzheimer's type, mmse, mmse score, mri brain, memory difficulty, neuropsychological, balance difficulty, category fluency, faux pas, minimal occupational dysfunction, parieto-occipital, progressive dementia syndrome, visual acuity, visual loss, visual memory, pet scan, neuropsychological evaluation, alzheimer's, neurological, memory, "
" Left heart cath, selective coronary angiogram, right common femoral angiogram, and StarClose closure of right common femoral artery.", Radiology, Angiogram & StarClose Closure ,"EXAM: , Left heart cath, selective coronary angiogram, right common femoral angiogram, and StarClose closure of right common femoral artery.,REASON FOR EXAM: , Abnormal stress test and episode of shortness of breath.,PROCEDURE: , Right common femoral artery, 6-French sheath, JL4, JR4, and pigtail catheters were used.,FINDINGS:,1.  Left main is a large-caliber vessel.  It is angiographically free of disease,,2.  LAD is a large-caliber vessel.  It gives rise to two diagonals and septal perforator.  It erupts around the apex.  LAD shows an area of 60% to 70% stenosis probably in its mid portion.  The lesion is a type A finishing before the takeoff of diagonal 1.  The rest of the vessel is angiographically free of disease.,3.  Diagonal 1 and diagonal 2 are angiographically free of disease.,4.  Left circumflex is a small-to-moderate caliber vessel, gives rise to 1 OM.  It is angiographically free of disease.,5.  OM-1 is angiographically free of disease.,6.  RCA is a large, dominant vessel, gives rise to conus, RV marginal, PDA and one PL.  RCA has a tortuous course and it has a 30% to 40% stenosis in its proximal portion.,7.  LVEDP is measured 40 mmHg.,8.  No gradient between LV and aorta is noted.,Due to contrast concern due to renal function, no LV gram was performed.,Following this, right common femoral angiogram was performed followed by StarClose closure of the right common femoral artery.,IMPRESSION:,1.  60% to 70% mid left anterior descending stenosis.,2.  Mild 30% to 40% stenosis of the proximal right coronary artery.,3.  Status post StarClose closure of the right common femoral artery.,PLAN:  ,Plan will be to perform elective PCI of the mid LAD.","radiology, heart cath, selective coronary angiogram, common femoral angiogram, abnormal stress test, common femoral artery, starclose closure, femoral artery, angiogram, angiographically, artery, femoral, "
 CT Brain - arachnoid cyst Arachnoid cyst diagnosed by CT brain., Radiology, Arachnoid Cyst ,"CC:, Seizures.,HX: ,The patient was initially evaluated at UIHC at 7 years of age. He had been well until 7 months prior to evaluation when he started having spells which were described as ""dizzy spells"" lasting from several seconds to one minute in duration. They occurred quite infrequently and he was able to resume activity immediately following the episodes. The spell became more frequent and prolonged, and by the time of initial evaluation were occurring 2-3 times per day and lasting 2-3 minutes in duration. In addition, in the 3 months prior to evaluation, the right upper extremity would become tonic and flexed during the episodes, and he began to experience post ictal fatigue.,BIRTH HX:, 32 weeks gestation to a G4 mother and weighed 4#11oz. He was placed in an incubator for 3 weeks. He was jaundiced, but there was no report that he required treatment.,PMH: ,Single febrile convulsion lasting ""3 hours"" at age 2 years.,MEDS: ,none.,EXAM:, Appears healthy and in no acute distress. Unremarkable general and neurologic exam.,Impression: Psychomotor seizures.,Studies: Skull X-Rays were unremarkable.,EEG showed ""minimal spike activity during hyperventilation, as well as random sharp delta activity over the left temporal area, in drowsiness and sleep. This record also showed moderate amplitude asymmetry ( left greater than right) over the frontal central and temporal areas, which is a peculiar finding."",COURSE:, The patient was initially treated with Phenobarbital; then Dilantin was added (early 1970's); then Depakene was added ( early 1980's) due to poor seizure control. An EEG on 8/22/66 showed ""Left mid-temporal spike focus with surrounding slow abnormality, especially posterior to the anterior temporal areas (sparing the parasagittal region). In addition, the right lateral anterior hemisphere voltage is relatively depressed. ...this suggests two separate areas of cerebral pathology."" He underwent his first HCT scan in Sioux City in 1981, and this revealed an right temporal arachnoid cyst. The patient had behavioral problems throughout elementary/junior high/high school. He underwent several neurosurgical evaluations at UIHC and Mayo Clinic and was told that surgery was unwarranted. He was placed on numerous antiepileptic medication combinations including Tegretol, Dilantin, Phenobarbital, Depakote, Acetazolamide, and Mysoline. Despite this he averaged 2-3 spells a month. He was last seen, 6/19/95, and was taking Dilantin and Tegretol. His typical spells were described as sudden in onset and without aura. He frequently becomes tonic or undergoes tonic-clonic movement and falls with associated loss of consciousness. He usually has rapid recovery and can return to work in 20 minutes. He works at a Turkey packing plant. Serial HCT scans showed growth in the arachnoid cyst until 1991, when growth arrest appeared to have occurred.","radiology, arachnoid cyst, hct scan, seizures, serial hct scans, dizzy spells, drowsiness, hyperventilation, loss of consciousness, moderate amplitude asymmetry, temporal area, tonic-clonic movement, phenobarbital, dilantin, cyst, temporal, arachnoid"
 Adenosine with nuclear scan as the patient unable to walk on a treadmill.  Nondiagnostic adenosine stress test.  Normal nuclear myocardial perfusion scan., Radiology, Adenosine Nuclear Scan ,"INDICATION: , Chest pain.,TYPE OF TEST: , Adenosine with nuclear scan as the patient unable to walk on a treadmill.,INTERPRETATION:, Resting heart rate of 67, blood pressure of 129/86.  EKG, normal sinus rhythm.  Post-Lexiscan 0.4 mg, heart rate was 83, blood pressure 142/74.  EKG remained the same.  No symptoms were noted.,SUMMARY:,1.  Nondiagnostic adenosine stress test.,2.  Nuclear interpretation as below.,NUCLEAR INTERPRETATION:,  Resting and stress images were obtained with 10.4, 33.1 mCi of tetrofosmin injected intravenously by standard protocol.  Nuclear myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake without any evidence of reversible or fixed defect.  Gated SPECT revealed normal wall motion, ejection fraction of 58%.  End-diastolic volume of 74, end-systolic volume of 31.,IMPRESSION:,1.  Normal nuclear myocardial perfusion scan.,2.  Ejection fraction 58% by gated SPECT.","radiology, adenosine nuclear myocardial perfusion scan, chest pain, adenosine stress test, nuclear myocardial perfusion scan, gated spect, spect, mci, myocardial perfusion scan, myocardial, perfusion, adenosine, nuclear,"
 MRI - Intracerebral hemorrhage (very acute clinical changes occurred immediately prior to scan)., Radiology, Acute Intracerebral Hemorrhage ,"CC: ,Left hand numbness on presentation; then developed lethargy later that day.,HX: ,On the day of presentation, this 72 y/o RHM suddenly developed generalized weakness and lightheadedness, and could not rise from a chair. Four hours later he experienced sudden left hand numbness lasting two hours. There were no other associated symptoms except for the generalized weakness and lightheadedness. He denied vertigo.,He had been experiencing falling spells without associated LOC up to several times a month for the past year.,MEDS:, procardia SR, Lasix, Ecotrin, KCL, Digoxin, Colace, Coumadin.,PMH: ,1)8/92 evaluation for presyncope (Echocardiogram showed: AV fibrosis/calcification, AV stenosis/insufficiency, MV stenosis with annular calcification and regurgitation, moderate TR, Decreased LV systolic function, severe LAE. MRI brain: focal areas of increased T2 signal in the left cerebellum and in the brainstem probably representing microvascular ischemic disease. IVG (MUGA scan)revealed: global hypokinesis of the LV and biventricular dysfunction, RV ejection Fx 45% and LV ejection Fx 39%. He was subsequently placed on coumadin severe valvular heart disease), 2)HTN, 3)Rheumatic fever and heart disease, 4)COPD, 5)ETOH abuse, 6)colonic polyps, 7)CAD, 8)CHF, 9)Appendectomy, 10)Junctional tachycardia.,FHX:, stroke, bone cancer, dementia.,SHX: ,2ppd smoker since his teens; quit 2 years ago. 6-pack beer plus 2 drinks per day for many years: now claims he has been dry for 2 years. Denies illicit drug use.,EXAM: ,36.8C, 90BPM, BP138/56.,MS: Alert and oriented to person, place, but not date. Hypophonic and dysarthric speech. 2/3 recall. Followed commands.,CN: Left homonymous hemianopia and left CN7 nerve palsy (old).,MOTOR: full strength throughout.,SENSORY: unremarkable.,COORDINATION: dysmetric FNF and HKS movements (left worse than right).,STATION: RUE pronator drift and Romberg sign present.,GAIT: shuffling and bradykinetic.,REFLEXES: 1+/1+ to 2+/2+ and symmetric throughout. Plantar responses were flexor bilaterally.,HEENT: Neck supple and no carotid bruits.,CV: RRR with 3/6 SEM and diastolic murmurs throughout the precordium.,Lungs: bibasilar crackles.,LABS:, PT 19 (elevated) and PTT 46 (elevated).,COURSE:, Coumadin was discontinued on admission as he was felt to have suffered a right hemispheric stroke. The initial HCT revealed a subtle low density area in the right occipital lobe and no evidence of hemorrhage. He was scheduled to undergo an MRI Brain scan the same day, and shortly before the procedure became lethargic. By the time the scan was complete he was stuporous. MRI Scan then revealed a hypointense area of T1 signal in the right temporal lobe with a small foci of hyperintensity within it. The hyperintense area seen on T1 weighted images appeared hypointense on T2 weighted images. There was edema surrounding the lesion The findings were consistent with a hematoma. A CT scan performed 4 hours later confirmed a large hematoma with surrounding edema involving the right temporal/parietal/occipital lobes. The patient subsequently died.",
 MRI - Arteriovenous malformation with hemorrhage., Radiology, AVM with Hemorrhage ,"CC:, Headache.,HX:, 63 y/o RHF first seen by Neurology on 9/14/71 for complaint of episodic vertigo. During that evaluation she described a several year history of ""migraine"" headaches. She experienced her first episode of vertigo in 1969. The vertigo (clockwise) typically began suddenly after lying down, and was not associated with nausea/vomiting/headache. The vertigo had not been consistently associated with positional change and could last hours to days.,On 3/15/71, after 5 day bout of vertigo, right ear ache, and difficulty ambulating (secondary to the vertigo) she sought medical attention and underwent an audiogram which reportedly showed a 20% decline in low tone acuity AD. She complained of associated tinnitus which she described as a ""whistle."" In addition, her symptoms appeared to worsen with changes in head position (i.e. looking up or down). The symptoms gradually resolved and she did well until 8/71 when she experienced a 19-day episode of vertigo, tinnitus and intermittent headaches. She was seen 9/14/71, in Neurology, and admitted for evaluation.,Her neurologic exam at that time was unremarkable except for prominent bilateral systolic carotid bruits. Cerebral angiogram revealed an inoperable 7 x 6cm AVM in the right parietal region. The AVM was primarily fed by the right MCA. Otolaryngologic evaluation concluded that she probably also suffered from Meniere's disease.,On 10/14/74 she underwent a 21 day admission for SAH secondary to right parietal AVM.,On 11/23/91 she was admitted for left sided weakness (LUE > LLE), headache, and transient visual change. Neurological exam confirmed left sided weakness, and dysesthesia of the LUE only. Brain CT confirmed a 3 x 4 cm left parietal hemorrhage. She underwent unsuccessful embolization. Neuroradiology had planned to do 3 separate embolizations, but during the first, via the left MCA, they were unable to cannulate many of the AVM vessels and abandoned the procedure. She recovered with residual left hemisensory loss.,In 12/92 she presented with an interventricular hemorrhage and was managed conservatively and refused any future neuroradiologic intervention.,In 1/93 she reconsidered neurointerventional procedure and was scheduled for evaluation at the Barrows Neurological Institute in Phoenix, AZ.","radiology, arteriovenous malformation, avm, brain ct, cerebral angiogram, headache, neurology, audiogram, carotid bruits, difficulty ambulating, hemorrhage, interventricular hemorrhage, migraine, tinnitus, vertigo, visual change, weakness, episode of vertigo, evaluation, "
 MRI - Right temporal lobe astrocytoma., Radiology, Astrocytoma ,"CC: ,Episodic confusion.,HX: ,This 65 y/o RHM reportedly suffered a stroke on 1/17/92. He presented locally at that time with complaint of episodic confusion and memory loss lasting several minutes per episode. The ""stroke"" was reportedly verified on MRI scan dated 1/17/92. He was subsequently placed on ASA and DPH. He admitted that there had been short periods (1-2 days duration) since then, during which he had forgotten to take his DPH. However, even when he had been taking his DPH regularly, he continued to experience the spells mentioned above. He denied any associated tonic/clonic movement, incontinence, tongue-biting, HA, visual change, SOB, palpitation, weakness or numbness. The episodes of confusion and memory loss last 1-2 minutes in duration, and have been occurring 2-3 times per week.,PMH:, Bilateral Hearing Loss of unknown etiology, S/P bilateral ear surgery many years ago.,MEDS:, DPH and ASA,SHX/FHX:, 2-4 Beers/day. 1-2 packs of cigarettes per day.,EXAM:, BP 111/68, P 68BPM, 36.8C. Alert and Oriented to person, place and time, 30/30 on mini-mental status test, Speech fluent and without dysarthria. CN: Left superior quandranopia only. Motor: 5/5 strength throughout. Sensory: unremarkable except for mild decreased vibration sense in feet. Coordination: unremarkable. Gait and station testing were unremarkable. He was able to tandem walk without difficulty. Reflexes: 2+ and symmetric throughout. Flexor plantar responses bilaterally.,LAB:, Gen Screen, CBC, PT, PTT all WNL. DPH 4.6mcg/ml.,Review of outside MRI Brain done 1/17/92 revealed decreased T1 and increased T2 signal in the Right temporal lobe involving the uncus and adjacent hippocampus. The area did not enhance with gadolinium contrast.,CXR:, 8/31/92: 5 x 6 mm spiculated opacity in apex right lung.,EEG:, 8/24/92: normal awake and asleep,MRI Brain with/without contrast: 8/31/92: Decreased T1 and increased T2 signal in the right temporal lobe. The lesion increased in size and enhances more greatly when compared to the 1/17/92 MRI exam. There is also edema surrounding the affected area and associated mass effect.,NEUROPSYCHOLOGICAL TESTING:, Low-average digit symbol substitution, mildly impaired verbal learning, and severely defective delayed recall. There was relative preservation of other cognitive functions. The findings were consistent with left mesiotemporal dysfunction.,COURSE: ,Patient underwent right temporal lobectomy on 9/16/92 following initial treatment with Decadron. Pathologic analysis was consistent with a Grade 2 astrocytoma. GFAP staining positive. Following surgery he underwent 5040 cGy radiation therapy in 28 fractions to the tumor bed.","radiology, confusion, gfap, gfap staining, mri scan, astrocytoma, hippocampus, memory loss, palpitation, signal, stroke, temporal lobe, tongue-biting, tonic/clonic movement, weakness, increased t signal, mri brain, mri, temporal, "
 2-D Echocardiogram, Radiology, 2-D Echocardiogram - 2 ,"1.  The left ventricular cavity size and wall thickness appear normal.  The wall motion and left ventricular systolic function appears hyperdynamic with estimated ejection fraction of 70% to 75%.  There is near-cavity obliteration seen.  There also appears to be increased left ventricular outflow tract gradient at the mid cavity level consistent with hyperdynamic left ventricular systolic function.  There is abnormal left ventricular relaxation pattern seen as well as elevated left atrial pressures seen by Doppler examination.,2.  The left atrium appears mildly dilated.,3.  The right atrium and right ventricle appear normal.,4.  The aortic root appears normal.,5.  The aortic valve appears calcified with mild aortic valve stenosis, calculated aortic valve area is 1.3 cm square with a maximum instantaneous gradient of 34 and a mean gradient of 19 mm.,6.  There is mitral annular calcification extending to leaflets and supportive structures with thickening of mitral valve leaflets with mild mitral regurgitation.,7.  The tricuspid valve appears normal with trace tricuspid regurgitation with moderate pulmonary artery hypertension.  Estimated pulmonary artery systolic pressure is 49 mmHg.  Estimated right atrial pressure of 10 mmHg.,8.  The pulmonary valve appears normal with trace pulmonary insufficiency.,9.  There is no pericardial effusion or intracardiac mass seen.,10.  There is a color Doppler suggestive of a patent foramen ovale with lipomatous hypertrophy of the interatrial septum.,11.  The study was somewhat technically limited and hence subtle abnormalities could be missed from the study.,","radiology, 2-d, doppler, echocardiogram, annular, aortic root, aortic valve, atrial, atrium, calcification, cavity, ejection fraction, mitral, obliteration, outflow, regurgitation, relaxation pattern, stenosis, systolic function, tricuspid, valve, ventricular, ventricular cavity, wall motion, pulmonary artery"
 3-Dimensional Simulation.  This patient is undergoing 3-dimensionally planned radiation therapy in order to adequately target structures at risk while diminishing the degree of exposure to uninvolved adjacent normal structures., Radiology, 3-Dimensional Simulation ,"3-DIMENSIONAL SIMULATION,This patient is undergoing 3-dimensionally planned radiation therapy in order to adequately target structures at risk while diminishing the degree of exposure to uninvolved adjacent normal structures.  This optimizes the chance of controlling tumor while diminishing the acute and long-term side effects.  With conformal 3-dimensional simulation, there is extended physician, therapist, and dosimetrist effort and time expended.  The patient is initially taken into a conventional simulator room where appropriate markers are placed and the patient is positioned and immobilized.  Preliminary filed sizes and arrangements, including gantry angles, collimator angles, and number of fields are conceived.  Radiographs are taken and these films are approved by the physician.  Appropriate marks are placed on the patient's skin or on the  immobilization device.,The patient is transferred to the diagnostic facility and placed on a flat CT scan table.  Scans are performed through the targeted area.  The scans are evaluated by the radiation oncologist and the tumor volume, target volume, and critical structures are outlined on the CT images.  The dosimetrist then evaluates the slices in the treatment-planning computer with appropriately marked structures.  This volume is reconstructed in a virtual 3-dimensional space utilizing the beam's-eye view features.  Appropriate blocks are designed.  Multiplane computerized dosimetry is performed throughout the volume.  Field arrangements and blocking are modified as necessary to provide coverage of the target volume while minimizing dose to normal structures.,Once appropriate beam parameters and isodose distributions have been confirmed on the computer scan, the individual slices are then reviewed by the physician.  The beam's-eye view, block design, and appropriate volumes are also printed and reviewed by the physician.  Once these are approved, physical blocks or multi-leaf collimator equivalents will be devised.  If significant changes are made in the field arrangements from the original simulation, the patient is brought back to the simulator where computer designed fields are re-simulated.,In view of the extensive effort and time expenditure required, this procedure justifies the special procedure code, 77470.","radiology, 3-dimensional simulation, planned radiation therapy, ct scan, ct images, beam's eye view, field arrangements, normal structures, therapy, dimensional, simulationNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 2-D Echocardiogram, Radiology, 2-D Echocardiogram - 3 ,"2-D ECHOCARDIOGRAM,Multiple views of the heart and great vessels reveal normal intracardiac and great vessel relationships.  Cardiac function is normal.  There is no significant chamber enlargement or hypertrophy.  There is no pericardial effusion or vegetations seen.  Doppler interrogation, including color flow imaging, reveals systemic venous return to the right atrium with normal tricuspid inflow.  Pulmonary outflow is normal at the valve.  Pulmonary venous return is to the left atrium.  The interatrial septum is intact.  Mitral inflow and ascending aorta flow are normal.  The aortic valve is trileaflet.  The coronary arteries appear to be normal in their origins.  The aortic arch is left-sided and patent with normal descending aorta pulsatility.","radiology, 2-d echocardiogram, cardiac function, doppler, echocardiogram, multiple views, aortic valve, coronary arteries, descending aorta, great vessels, heart, hypertrophy, interatrial septum, intracardiac, pericardial effusion, tricuspid, vegetation, venous, pulmonaryNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Echocardiogram and Doppler, Radiology, 2-D Echocardiogram - 4 ,"DESCRIPTION:,1.  Normal cardiac chambers size.,2.  Normal left ventricular size.,3.  Normal LV systolic function.  Ejection fraction estimated around 60%.,4.  Aortic valve seen with good motion.,5.  Mitral valve seen with good motion.,6.  Tricuspid valve seen with good motion.,7.  No pericardial effusion or intracardiac masses.,DOPPLER:,1.  Trace mitral regurgitation.,2.  Trace tricuspid regurgitation.,IMPRESSION:,1.  Normal LV systolic function.,2.  Ejection fraction estimated around 60%.,","radiology, ejection fraction, lv systolic function, cardiac chambers, regurgitation, tricuspid, normal lv systolic function, normal lv systolic, ejection fraction estimated, normal lv, lv systolic, systolic function, function ejection, echocardiogram, doppler, lv, systolic, ejection, mitral, valve"
" A 6-year-old male with attention deficit hyperactivity disorder, doing fairly well with the Adderall.", Psychiatry / Psychology, Recheck of ADHD Meds ,"SUBJECTIVE:,  This is a 6-year-old male who comes in rechecking his ADHD medicines.  We placed him on Adderall, first time he has been on a stimulant medication last month.  Mother said the next day, he had a wonderful improvement, and he has been doing very well with the medicine.  She has two concerns.  It seems like first thing in the morning after he takes the medicine and it seems like it takes a while for the medicine to kick in.  It wears off about 2 and they have problems in the evening with him.  He was initially having difficulty with his appetite but that seems to be coming back but it is more the problems early in the morning after he takes this medicine than in the afternoon when the thing wears off.  His teachers have seen a dramatic improvement and she did miss a dose this past weekend and said he was just horrible.  The patient even commented that he thought he needed his medication.,PAST HISTORY:,  Reviewed from appointment on 08/16/2004.,CURRENT MEDICATIONS:,  He is on Adderall XR 10 mg once daily.,ALLERGIES: , To medicines are none.,FAMILY AND SOCIAL HISTORY:,  Reviewed from appointment on 08/16/2004.,REVIEW OF SYSTEMS:,  He has been having problems as mentioned in the morning and later in the afternoon but he has been eating well, sleeping okay.  Review of systems is otherwise negative.,OBJECTIVE:,  Weight is 46.5 pounds, which is down just a little bit from his appointment last month.  He was 49 pounds, but otherwise, fairly well controlled, not all that active in the exam room.  Physical exam itself was deferred today because he has otherwise been very healthy.,ASSESSMENT:,  At this point is attention deficit hyperactivity disorder, doing fairly well with the Adderall.,PLAN:,  Discussed with mother two options.  Switch him to the Ritalin LA, which I think has better release of the medicine early in the morning or to increase his Adderall dose.  As far as the afternoon, if she really wanted him to be on the medication, we will do a small dose of the Adderall, which she would prefer.  So I have decided at this point to increase him to the Adderall XR 15 mg in the morning and then Adderall 5 mg in the afternoon.  Mother is to watch his diet.  We would like to recheck his weight if he is doing very well, in two months.  But if there are any problems, especially in the morning then we would do the Ritalin LA.  Mother understands and will call if there are problems.  Approximately 25 minutes spent with patient, all in discussion.","psychiatry / psychology, adhd, attention deficit hyperactivity disorder, adderall xr, recheck, medicines, adderall,"
 2-D M-Mode. Doppler.  , Radiology, 2-D Echocardiogram - 1 ,"2-D M-MODE: , ,1.  Left atrial enlargement with left atrial diameter of 4.7 cm.,2.  Normal size right and left ventricle.,3.  Normal LV systolic function with left ventricular ejection fraction of 51%.,4.  Normal LV diastolic function.,5.  No pericardial effusion.,6.  Normal morphology of aortic valve, mitral valve, tricuspid valve, and pulmonary valve.,7.  PA systolic pressure is 36 mmHg.,DOPPLER: , ,1.  Mild mitral and tricuspid regurgitation.,2.  Trace aortic and pulmonary regurgitation.","radiology, 2-d m-mode, doppler, aortic valve, atrial enlargement, diastolic function, ejection fraction, mitral, mitral valve, pericardial effusion, pulmonary valve, regurgitation, systolic function, tricuspid, tricuspid valve, normal lv "
 Comprehensive Clinical Psychological Evaluation as part of a Disability Determination action., Psychiatry / Psychology, Psychological Evaluation ,"COMPREHENSIVE CLINICAL PSYCHOLOGICAL EVALUATION,CURRENT MEDICATIONS:,  Nexium 4 mg 4 times per day, Propanolol 10 mg 4 times a day, Spironolactone 100 mg 3 times per day, Lactulose 60 cc's 3 times a day.,GENERAL OBSERVATIONS:  ,Mr. Abc, a 54-year-old black married male who was referred for a Comprehensive Clinical Psychological Evaluation as part of a Disability Determination action.  Mr. Abc arrived five minutes late for his scheduled appointment.  He was accompanied to the office by his sister-in-law who drove him to the appt.  Mr. Abc currently does not receive Disability benefits.  This is the first time he has filed for Disability.  The Authorization form listed Mr. Abc's current complaints as ""cirrhosis of the liver and mental issues.""  Mr. Abc was well groomed and wore casual attire.  He looked older than his stated age.  The whites of his eyes were very jaundiced.  His posture was slightly stooped and his gait was slow.  He was winded after walking up the stairs.  Psychomotor activity was retarded.  Mr. Abc was cooperative throughout the interview.  Although he appeared to be answering most questions to the best of his ability, he appeared to be minimizing his emotional distress.  ,PRESENT ILLNESS: , Most information was provided by Mr. Abc who appeared to be a fairly reliable source.  His information was supplemented by review of his medical records.  Mr. Abc has applied for Federal Disability benefits believing that he qualifies based on his cirrhosis of the liver and his cognitive dysfunction.  Mr. Abc was diagnosed with cirrhosis in 1991.  His condition has worsened to the point that he is experiencing liver failure and is awaiting a liver transplant.  He stated that his main symptom is extreme fatigue.  He has no energy and is unable to engage in many activities.  Over the past year he was admitted to the hospital four times for confusion and bizarre behavior.  He stated that his sister-in-law and his wife told him that he had become violent and he fought with the Sherriff who was trying to take him to the hospital.  He has no memory of this.  Mr. Abc stated that he was hospitalized one time.  Actually he had begun having problems with confusion in July of 2004 and he has been treated four times since that time.  According to his medical records, he was found wandering outside of his home.  He was apparently delusional believing that a tree branch was a doorknob.  Mr. Abc also suffers from edema and swelling in his legs and his feet.  Mr. Abc attempted to return to work and found that he was unable to do his job due to the necessity of walking one-quarter mile from the front to the back of the plant.  He was unable to walk very far without becoming fatigued.  He had instances where he had passed out after becoming faint.  He had trouble at work sitting for very long because his feet swelled.  He was unable to lift the required 10 pounds of medication boxes.  When he found himself unable to do his regular job, he tried another job at the same plant but was unable to do that job.  He also became confused easily at work.  His doctor advised him to quit and then he did so in March of this year.  In addition to his cognitive symptoms, Mr. Abc has had some disturbance in mood as well.  He related that he feels very sad since he lost his job.  A lot of his self-esteem came from working.  He worries about financial problems.  His sleep has been disturbed.  He sleeps four to five hours a night with trouble falling asleep and frequent awakening in the middle of the night.  His appetite is fair.  ,PERSONAL, FAMILY AND SOCIAL HISTORY:,  Mr. Abc completed the 11th grade. He went on to get his GED in 1971.  He stated that he has never failed a grade and he has no history of a learning disability.  He received no special education services.  His grades were Bs and Cs. He stated that he was suspended from school one time for fighting but got along well in general. Mr. Abc is currently unemployed.  His last job was at Baxter Health Care where he worked for four years.  It was his longest place of employment.  He quit in March of 2005 because of fatigue and inability to perform the necessary job duties.  He denies that he was ever fired from a job and he reported good work relationships.  Mr. Abc has been married for two years. He has no prior marriages.  He has one daughter age 13.  He currently lives with his wife. Has been at his current address for four years.  ,HISTORY OF OTHER PERTINENT MEDICAL EVENTS: , Mr. Abc has cirrhosis of the liver, hepatitis C, hepatic encephalopathy, and gastroesophageal reflux disease, and hypertension. Surgeries include a cardiac catheterization in 2001, a liver biopsy in 2003.  Over the past year he has been hospitalized four times due to confusion and bizarre behaviors stemming from his liver failure.  ,DAILY ACTIVITIES AND FUNCTIONING:  ,Mr. Abc stated that he tries to do things but he has been severely restricted due to his extreme fatigue.  He enjoys reading and does it regularly.  He tries to help his wife with the household chores as he can.  He has washed dishes, cooked, mopped, dusted, vacuumed and has done laundry occasionally over the past month but not as much as he used to.  He stated that he used to mow the yard and do yard work but he can no longer do it because of his extreme fatigue.  He has given up driving all together and he no longer goes out alone.  He spends most days at home.  He enjoys going to church and he prays daily.  ,MENTAL HEALTH HISTORY: , Mr. Abc has never been diagnosed or treated for a mental health disorder.  He denied any history of mental health problems in his family.  He stated that he was evaluated one time earlier this year by a psychiatrist to determine his suitability for a liver transplant.  He was approved and he is now on the waiting list to receive a liver.  ,SUBSTANCE USE HISTORY:  ,Mr. Abc has a history of substance use beginning in his teenage years.  He has used alcohol, marijuana and cocaine.  He stated that he only used the marijuana and cocaine a few times when he was young but he continued using alcohol until recently.  His alcohol use became problematic and he was arrested for DWI three times.  He attended AA and the DART program.  Mr. Abc stated that he has been clean for eight years and five months.",
 Psychosocial Evaluation of patient before kidney transplant., Psychiatry / Psychology, Psychosocial Eval for Kidney Transplant ,"HISTORY OF PRESENT ILLNESS:,  In 2002, the patient had a blood test during her routine screening, which revealed anemia and an elevated creatinine.  Two weeks later she saw a nephrologist at ABCDE were she worked at that time.  An ultrasound revealed that she had Parenchymal disease in which tissue around the kidney is diseased.  No particular treatment was advised.  She was laid off 6 months later.  In 2004, she began working at The ABCD Hospital and began seeing Dr. A.  She was put on Procrit, but could not keep the stringent appointment scheduled for the injection because of her work.  She began seeing Dr. B and was put on Procrit and Renagel.  She was advised to go on dialysis, but she felt she did not have enough information to such a drastic step.  She saw an endocrinologist for some thyroid problem and her blood work showed that her creatinine was now at 7.  She was referred to Dr. Xyz who found after a parathyroid scan that she may have an adenoma.  Her creatinine is now 7.4.,TREATMENT AND IMPACT OF DISEASE:,  She is on several medications.  She is not on a renal diet yet.  Her energy is good and she is still working full time.,TRANSPLANT FIRST MENTIONED AS TREATMENT OPTION: , She has wanted to transplant ever since dialysis was first mentioned.,EMOTIONAL REACTION TO DIAGNOSIS AND TREATMENT COURSE:,  She is frustrated by the lack of information about what exactly has caused her renal failure and has had a real feeling of helplessness in her efforts to pursue this understanding.,OTHER SIGNIFICANT MEDICAL HISTORY/SURGERIES:,  She had a Bartholin cyst removed in 2002.,PSYCHIATRIC HISTORY:,  None.,COPING STRATEGIES:,  She used to exercise vigorously, but has stopped at this time.  She enjoys watching movies with her children.,COMPLIANCE:,  She feels she watches her diet and medication regimen very closely.  She said she communicates daily with Dr. Xyz,PAST AND PRESENT SMOKING:,  She began smoking 2 cigarettes a day when she was 22, but stopped after a year.,PAST AND PRESENT ALCOHOL USE:,  None.,PAST AND PRESENT DRUG USE:,  None.,LEGAL ISSUES:,  None.,TATTOOS:,  None.,MARITAL STATUS:  LENGTH OF THE TIME MARRIED:,  She has been married for 25 years.,AGE AND HEALTH OF SPOUSE:,  Xyz is 62 and in good health.,CHILDREN:,  Four, all are in good health.,FATHER:,  Father died in 2001, at the age of 62 of cardiac cancer.,MOTHER:,  Dolorous Massey is 63 and in good health.,SIBLINGS:,  Ben Doherty died in 1984 at the age of 26 in an automobile accident; Steven Doherty is 46 and is in good health.,PREVIOUS MARRIAGES AND DURATION OF EACH:,  None.,PERSONS LIVING IN HOUSEHOLD:,  Six.,RELATIONSHIP WITH FAMILY MEMBERS/IDENTIFIED PRIMARY SUPPORT SYSTEM:,  She is close to her brother.,HIGHEST LEVEL OF EDUCATION:,  She has 2 years of college at ABCD College.  She is a licensed LVN.,MILITARY SERVICE:,  None.",
 Psychological Testing for ADHD, Psychiatry / Psychology, Psychological Testing ,"REFERRAL QUESTIONS:,  Mr. Abcd was referred for psychological assessment by his primary medical provider, to help clarify his diagnosis, especially with respect to Attention Deficit Hyperactivity Disorder, a depression, or a Bipolar Spectrum Disorder.  The information will be used for treatment planning.,BACKGROUND INFORMATION:,  Mr. Abcd is a 33-year-old married man who lives with his wife and three children.  He has been married since 1995 and lost a son to SIDS over seven years ago.  He served in the army for two years, and did attend some college at UAA.  He still wants to get a degree in engineering.  Mr. Abcd indicated that he did use THC at the time of his initial intake with me in January 2006, but there are no other substance abuse issues as an adult so far as I am aware.  He has had multiple stressors, including a bankruptcy in 2000, as well as his wife's significant health problems.  He also reported having herniated discs incurred in an injury over a year ago.  He has received counseling in the past, and did try both Lexapro and Wellbutrin, which he stopped taking in October 2005.  He indicated these medications tended to decrease libido and flatten all of his emotions.  He indicated that he thought he might have Attention Deficit Hyperactivity Disorder, but that this had not been formally evaluated or treated.  There is no reported bipolar illness in his immediate family, but there is some depression.  A recent stressor involved OCS involvement, apparently because his infant child tested positive for THC.  So far as I am aware, this case is closed at this time.  ,BEHAVIORAL OBSERVATIONS:,  Mr. Abcd arrived on time for his testing session dressed casually and with good hygiene and grooming.  Mood is reported to be generally okay, though with some stress.  Affect was bright and appropriate to the situation.  Speech was a little pressured, but was of normal content and was at all times coherent and goal directed.  He was a very pleasant and cooperative testing subject, who appeared to give a good effort on the tasks requested of him.  The results appear to provide a useful sample of his current attitudes, opinions, and functional levels in the areas assessed.,ASSESSMENT RESULTS:,  Mr. Abcd's responses to a brief self-report instrument given to him by Dr. Starks was suggestive of symptoms that could be consistent with Attention Deficit Hyperactivity Disorder.  I therefore had him complete the Conners CPT-II, which showed good performance and no indications of attention problems.  The Confidence Index associated with ADHD was over 58 percent that no clinical attention problems are present.  While a diagnosis of Attention Deficit Hyperactivity Disorder should not unequivocally be ruled out based on the results of this test, there is nothing in the CPT-II measures indicating attention problems, and that diagnosis appears to be unlikely.  The MMPI-2 profile is a technically valid and interpretable one.  The Modified Welsh Code is as follows:  49+86-231/570:  F'+-/:LK#.  The high F scale may reflect some moodiness, restlessness, dissatisfaction, and changeableness in his typical behavior.  The Basic Clinical Profile is similar to persons who tend to get into trouble for violating social norms and rules.  Such persons are more likely to experience conflicts with authority.  They also are prone to impulsivity, self-indulgence, problems with delay of gratification, exercise problematic judgment, and often have low frustration tolerance.  Those with similar scores tend to be moody, irritable, extraverted, and often do not trust others very much.  Mr. Abcd may tend to keep others at a distance, yet feel rather insecure and dependent.  A bipolar diagnosis is a possibility, and an antisocial personality disorder cannot be entirely ruled out either, though I am less confident that that is correct.  The MMPI-2 Content Scale scores indicate some mild depression and family stressors, and the Supplementary Scales has a single clinical elevation on Addiction Admission, which is entirely consistent with his interview data.  Posttraumatic stress scales are not elevated at a clear clinical level on the MMPI-2.,SUMMARY AND RECOMMENDATIONS:,","psychiatry / psychology, psychological testing, adhd, attention deficit hyperactivity disorder, bipolar spectrum disorder, cpt-ii, mmpi-2, posttraumatic stress disorder, welsh code, depression, psychological assessment, personality disorder, family stressors, posttraumatic stress, disorder, attention, psychological, "
 Psychosocial donor evaluation.  Following questions are mostly involved in a psychosocial donor evaluation., Psychiatry / Psychology, Psychosocial Eval - Donor - 1 ,"PSYCHOSOCIAL DONOR EVALUATION,Following questions are mostly involved in a psychosocial donor evaluation:,A.  DECISION TO DONATE,What is your understanding of the recipient's illness and why a transplant is needed?,When and how did the subject of donation arise?,What was the recipient's reaction to your offer?,What are your family's feelings about your being a donor?,How did you arrive at the decision to be a donor?,How would your family and friends react if you decided not to be a donor?,How would you feel if you cannot be the donor for any reason?,What is your relationship to the recipient?,How will your relationship with the recipient change if you donate your kidney?,Will your being a donor affect any other relationships in your life?,B. TRANSPLANT ISSUES,Do you have an understanding of the process of transplant?,Do you understand the risk of rejection of your kidney by the recipient at some point after transplant?,Have you thought about how you might feel if the kidney/liver is rejected?,Do you have any doubts or concerns about donating?,Do you understand that there will be pain and soreness after the transplant?,What are your expectations about your recuperation?,Do you need to speak further to any of the transplant team members?,C.  MEDICAL HISTORY,What previous illnesses or surgeries have you had? ,Are you currently on any medications?,Have you ever spoken with a counselor, a therapist or a psychiatrist?,Do you smoke?,In a typical week, how many drinks do you consume?  What drink do you prefer?,What kinds of recreational drugs have you tried?  Have you used any recently?,D. FAMILY AND SUPPORT SYSTEM,With whom do you live?  ,If you are in a relationship:,- length of the relationship:  ,- name of spouse/partner:  ,- age and health of spouse/partner:  ,- children:  ,E. POST-SURGICAL PLANS,With whom will you stay after discharge?  ,What is your current occupation:  ,Do you have the support of your employer?",
 Psychosocial evaluation of kidney donor.  Questions - Answers, Psychiatry / Psychology, Psychosocial Eval - Donor ,"DONOR'S PERCEPTION OF RECIPIENT'S ILLNESS:,What is your understanding of the recipient's illness and why they need a kidney - ""This kidney is for my mother who is on dialysis and my mother has been suffering long enough, and I want to relieve the suffering so that she is able to have a kidney transplant."",When and how did subject of donation arise - ""My mom and I talked about it together as a family."",RECIPIENT'S REACTION TO OFFER:,What was the recipient's reaction to your offer:  ""I would rather not go there.  Well, since we were talking, ""I will tell you that my mother really does not understand.  She is very worried.  She is very afraid that something might happen to me, and she would feel terrible if I had any problems as a result of being a donor.  I don't think my mom really understands, and I know that she really needs a kidney.  I think she is coming around to accepting."",FAMILY'S REACTION TO OFFER:,What are your family feelings about your being a donor - ""Well, my children are fine and my husband is very supportive."",CANDIDATE'S MOTIVATION TO DONATE:,How did you arrive at the decision to be a donor - ""My brothers and sisters and I got together and we all decided since my schedule was the most flexible and I was used to traveling, I seem like to the best candidate."",How would your family and friends react if you decided not to be a donor - ""I don't think that is going to happen."",CANDIDATE'S MOTIVATION TO DONATE:,How would you feel if you cannot be the donor for any reason - ""I would feel very upset because I know that this is the best for my mother, and I want to do this very badly for my mother.  I am hoping my headache is away and my blood pressure comes down so that I will start to feel better during this workup."",CANDIDATE'S DESCRIPTION OF RELATIONSHIP WITH RECIPIENT:,What is your relationship to the recipient - ""That is my mother."",How your relationship with the recipient change if you donate your kidney - ""I am not sure that it will change at all.  I know that I will feel better about doing this for my mother, because my mother is always sacrificing and helping others."",With your being a donor affect any other relationships in your life - No, I don't think it will have that much of an impact.  I am away from my children and my husband a lot because of I travel with my job.  So I don't think being donor will really have that dramatic affect.,Do you have an understanding of the process of transplant - ""Yes, I have a very good understanding of the transplant process.  I work as a contract nursing all over the country.  I am able to see patients doing different things in different places and so I feel like I have a very realistic perceptive on the process."",CANDIDATE'S UNDERSTANDING OF TRANSPLANTATION AND RISK OF REJECTION:,Do you understand the risk of rejection of your kidney by the recipient - ""Yes, I do understand all the risks.  I have had a long conversation with the coordinator and we have talked about these things."",Have you thought about how you might feel if the kidney is rejected - ""I guess, I am just sure that I won't be rejected and I am just sure that everything will be fine.  It is a part of the way I am managing my stress about this."",Do you have any doubts or concerns about donating - ""No, I don't have any doubts or any concerns right now.  I just wish this headache would go away.,Do you understand that there will be pain after the transplant - ""Of course, I do."",What are your expectations about your recuperation - ""I am planning on staying with my mom for three months in the Houston area after the transplant.  We live outside of Tampa, Florida; so this will be an adventure for both of us."",Do you need to speak further to any of the transplant team members - ""No, I have had a long talk with ABC.  I feel pretty comfortable about my conversation with her as well as my conversation with the Nephrologist.,MEDICAL HISTORY:,What previous illnesses or surgeries have you had - ""I had a one cesarian section, and I also suffered from asthma as a child.  I am in otherwise good health."",Are you currently on any medication - ""Yes, I am on Folic acid."",PSYCHIATRIC HISTORY:,Have you ever spoken with a counselor, therapist, or psychiatrist - ""No, I have not.  I have a good supportive system and a lot of people that I can talk to when I need to."",ALCOHOL, NICOTINE, DRUG USE:,Do you smoke - ""No."",Any typical drinks you prefer - ""I am a nondrinker."",What kinds of recreational drugs have you tried?  Have you used any recently - ""None."",FAMILY AND SUPPORT SYSTEMS:,MARITAL STATUS:  LENGTH OF TIME MARRIED:  ""I live with my family, my husband, and my two children with good relationship.  We have been married for 29 years."",NAME OF SPOUSE/PARTNER:  ""His name is Xyz."",AGE AND HEALTH OF SPOUSE/PARTNER:  He is in his 40s and he is healthy and lives outside of Tampo with our 6-year-old daughter.  Our elder child has just finished college."",CHILDREN:  I have two children; ages 28 and also 6.,POST-SURGICAL HOUSING PLAN:,With whom will you stay after discharge - ""I will stay with a friend.  He lives in the Houston area.  I am staying with that friend right now, while I am here for my workup."",CURRENT OCCUPATION:,What is your current occupation - ""I currently work on a contract basis as a nurse.  I go on assignments all over the country, and I work until the contract is over.  This allowed me to be flexible and the best candidate for donation to mom."",Do you have the support of your employer - ""Absolutely."",PAID OFF TIME:,Paid leave - ""None."",Disability coverage:  ""None."",SUPPORTIVE ENVIRONMENT:,  ""Yes.""",
" Normal left ventricle, moderate biatrial enlargement, and mild tricuspid regurgitation, but only mild increase in right heart pressures.", Radiology, 2-D Doppler ,"2-D STUDY,1. Mild aortic stenosis, widely calcified, minimally restricted.,2. Mild left ventricular hypertrophy but normal systolic function.,3. Moderate biatrial enlargement.,4. Normal right ventricle.,5. Normal appearance of the tricuspid and mitral valves.,6. Normal left ventricle and left ventricular systolic function.,DOPPLER,1. There is 1 to 2+ aortic regurgitation easily seen, but no aortic stenosis.,2. Mild tricuspid regurgitation with only mild increase in right heart pressures, 30-35 mmHg maximum.,SUMMARY,1. Normal left ventricle.,2. Moderate biatrial enlargement.,3. Mild tricuspid regurgitation, but only mild increase in right heart pressures.","radiology, 2-d study, doppler, tricuspid regurgitation, heart pressures, stenosis, ventricular, heart, ventricle, tricuspid, regurgitation,"
 She was admitted following an overdose of citalopram and warfarin.  The patient has had increasing depression and has been under stress as a result of dissolution of her second marriage., Psychiatry / Psychology, Psychiatric Consult - 2 ,"HISTORY OF PRESENT ILLNESS:,  This is a 41-year-old registered nurse (R.N.).  She was admitted following an overdose of citalopram and warfarin.  The patient has had increasing depression and has been under stress as a result of dissolution of her second marriage.  She notes starting in January, her husband of five years seemed to be quite withdrawn.  It turned out, he was having an affair with one of her best friends and he subsequently moved in with this woman.  The patient is distressed, as over the five years of their marriage, she has gotten herself into considerable debt supporting him and trying to find a career that would work for him.  They had moved to ABCD where he had recently been employed as a restaurant manager.  She also moved her mother and son out there and is feeling understandably upset that he was being dishonest and deceitful with her.  She has history of seasonal affective disorder, winter depressions, characterized by increased sleep, increased irritability, impatience, and fatigue.  Some suggestion on her part that her father may have had some mild bipolar disorder and including the patient has a cyclical and recurrent mood disorder.  In January, she went on citalopram.  She reports since that time, she has lost 40 pounds of weight, has trouble sleeping at night, thinks perhaps her mood got worse on the citalopram, which is possible, though it is also possible that the progressive nature of getting divorce than financial problems has contributed to her worsening mood.,PAST AND DEVELOPMENTAL HISTORY: , She was born in XYZ.  She describes the family as being somewhat dysfunctional.  Father was a truckdriver.  She is an only child.  She reports that she had a history of anorexia and bulimia as a teenager.  In her 20s, she served six years in Naval Reserve.  She was previously married for four years.  She described that as an abusive relationship.  She had a history of being in counseling with ABC, but does not think this therapist, who is now by her estimate 80 years old, is still in practice.,PHYSICAL EXAMINATION:  ,GENERAL:  This is an alert and cooperative woman.,VITAL SIGNS:  Temperature 98.1, pulse 60, respirations 18, blood pressure 95/54, oxygen saturation 95%, and weight is 132.,PSYCHIATRIC:  She makes good eye contact.  Speech is normal in rate, volume, grammar, and vocabulary.  There is no thought disorder.  She denies being suicidal.  Her affect is appropriate for material being discussed.  She has a sense of future, wants to get back to work, has plans to return to counseling.  She appeared to have normal orientation, concentration, memory, and judgment.,Medical history is notable for factor V Leiden deficiency, history of pulmonary embolus, restless legs syndrome.  She has been off her Mirapex.  I did encourage her to go back on the Mirapex, which would likely lead to some improvement in mood by facilitating better sleep.,The patient at this time can contract for safety.  She has made plans for outpatient counseling this Saturday and we will get a referral to a psychiatrist for which she is agreeable to following up with.,LABORATORY DATA: , INR, which is still 8.8.  In 1998, she had a normal MRI.  Electrolytes, BUN, creatinine, and CBC were all normal.,DIAGNOSES:  ,1.  Seasonal depressive disorder.,2.  Restless legs syndrome.,3.  Overdose of citalopram and warfarin.,RECOMMENDATIONS: , The patient reports she has been feeling better since discontinuing antidepressants.  I, therefore, recommend she stay off antidepressants at present.  If needed, she can take Prozac, which has been effective for her in the past and she plans to see a psychiatrist for consultation.  She does give a fairly good history of seasonal depression and given that her mood has improved in the past with Prozac, this will be an appropriate agent to try as needed in the future, but given the situational nature of the depression, she primarily appears to need counseling.,Please feel free to contact me at digital pager if there is additional information I can provide.","psychiatry / psychology, citalopram, depressive disorder, overdose, warfarin, restless legs syndrome, disorder, mood"
 Discharge summary of a patient with depression and high risk behavior., Psychiatry / Psychology, Psychiatric Discharge Summary - 2 ,"DISCHARGE SUMMARY,SUMMARY OF TREATMENT PLANNING:,  This discharge is at the family's request.,IDENTIFIED PROBLEMS/OUTCOMES:,1.",
 Psychiatric evaluation for major depression without psychotic features., Psychiatry / Psychology, Psychiatric Evaluation - 2 ,"IDENTIFICATION OF PATIENT: , The patient is a 34-year-old Caucasian female.,CHIEF COMPLAINT:,  Depression.,HISTORY OF PRESENT ILLNESS:,  The patient's depression began in her teenage years.  Sleep has been poor, for multiple reasons.  She has obstructive sleep apnea, and has difficulties with a child who has insomnia related to medications that he takes.  The patient tends to feel irritable, and has crying spells.  She sometimes has problems with motivation.  She has problems with memory, and energy level is poor. Appetite has been poor, but without weight change.  Because of her frequent awakening, her CPAP machine monitor has indicated she is not using it enough, and Medicaid is threatening to refuse to pay for the machine.  She does not have suicidal thoughts.  ,The patient also has what she describes as going into a ""panic mode.""  During these times, she feels as if her whole body is going to explode.  She has a hard time taking a deep breath, her heart rate goes up, blood pressure is measured as higher shortly afterward, and she gets a sense of impending doom.  These spells may last a couple of hours, but once lasted for about two day.  She does not get chest pain.  These attacks tend to be precipitated by bills that cannot be paid, or being on a ""time crunch."" ,PSYCHIATRIC HISTORY:,  The patient's nurse practitioner had started her on Cymbalta, up to 60 mg per day. This was helpful, but then another physician switched her to Wellbutrin in the hope that this would help her quit smoking.  Although she was able to cut down on tobacco usage, the depression has been more poorly controlled.  She has used Wellbutrin up to 200 mg b.i.d. and Cymbalta up to 60 mg per day, at different times.  At age 13, the patient cut her wrists because of issues with a boyfriend, and as she was being sutured she realized that this was a very stupid thing to do.  She has never been hospitalized for psychiatric purposes.  She did see a psychologist at age 16 briefly because of prior issues in her life, but she did not fully reveal information, and it was deemed that she did not need services.  She has not previously spoken with a psychiatrist, but has been seeing a therapist, Stephanie Kitchen, at this facility.,SUBSTANCE ABUSE HISTORY:,Caffeine:  The patient has two or three drinks per day of tea or Diet Pepsi.,Tobacco:  She smokes about one pack of cigarettes per week since being on Wellbutrin, and prior to that time had been smoking one-half pack per day.  She is still committed to quitting.,Alcohol: Denied.,Illicit drugs:  Denied.  In her earlier years, someone once put some unknown drug in her milk, and she ""came to"" when she was dancing on the table in front of the school nurse.,MEDICAL HISTORY/REVIEW OF SYSTEMS:,Constitutional:  See History of Present Illness. No recent fever or sweats.",
 Admission Psychiatric Evaluation, Psychiatry / Psychology, Psychiatric Evaluation - 4 ,"ADMISSION PSYCHIATRIC EVALUATION,IDENTIFYING INFORMATION/REFERRAL DATA:  ,This is a 16-year-old Caucasian adolescent female who is going into ninth grade and lives with her mother, the mother's boyfriend, and a 12, 11, and 10-year-old sister.  She also has a stepsister that is 8 years old.  The patient was brought in by her mother after being picked up by Anchorage Police Department (APD).  She was brought to our institution for an assessment.  ,REASON FOR ADMISSION/CHIEF COMPLAINT:  ,The patient ran away in the middle of the night on Sunday, 07/19/04, and she has been on the run since then.  Her friends report to the parents that she is suicidal and that she had a knife.  A friend took a knife away from her to keep her from cutting herself.  ,HISTORY OF PRESENT ILLNESS:  ,This is a 16-year-old Caucasian adolescent girl who was brought in by APD and her parents.  This is her first admission.  APD picked her up from a runaway and brought her at her mother's request after some friends told the mother that she was suicidal.  The mother found journals in her room talking about suicide, and that she has been raped.  There were no details and the client denies that she was raped.  She is sexually active with one boyfriend, also 16 years old, that she met while going to school in Ketchican in the last school year.  She has been with the mother only the last two months and the same Ketchican boyfriend, Michael, followed her to Anchorage.  She reports symptoms of depression, no energy, initial and middle insomnia, eating more.  She is very irritable and has verbal altercations wither sister who is 14.  She admits to being sad and also having poor concentration.  She had marked drop in school functioning in the last year, and will need to repeat the ninth grade.  The mother is very concerned with the patent's safety and feels she is not able to control her.  She lived with her stepfather when she was 8 to 9 years old, but she was too problematic and not successful living there in Ketchican.  She went to live with her dad up to age 16.  Now she is living with her mother and her mother's boyfriend for the last two months.  In December, her grandmother passed away and she was with her grandmother and her mother during all this process, which is when she started feeling depressed.,LEGAL HISTORY:  ,No legal history.,TREATMENT/PSYCHIATRIC HISTORY:  ,The patient was evaluated once at XYZ when she was 14 due to depression, also when she was 3 years old when a new sibling came into the family.  ,FAMILY PSYCHIATRIC HISTORY:  ,The patient has three siblings with ADHD (Attention Deficit Hyperactivity Disorder) and two of her siblings are in an RTC (Residential Treatment Center) Program, one with the diagnosis of Bipolar Disorder, and the other with ADHD and bipolar condition.,PERTINENT MEDICAL HISTORY:  ,She was born with some eczema.  At age 4 she was involved in an accident where she cut one of her legs and needed sutures.  There is no history of seizure or head injury.  She reports loss of consciousness.  This will be investigated; there are no details about it.  She admits to being sexually active, protecting herself using condoms.  Her last menstruation period was 07/20/04.  ,ALLERGIES:  ,No allergies.,DEVELOPMENT AGE FACTORS: , The mother reports she was born with some jaundice and eczema.  Early milestones walk and talk.  The patient appears to function at the expected age level.  ,PERTINENT PSYCHOSOCIAL DATA:  ,Complete pertinent psychosocial will be obtained by our clinician.  The patient admits witnessing seeing some domestic violence when she was small, around five years old.  There is an allegation of a rape that the mother found in her journal, but this is going to be investigated.  ,SCHOOL HISTORY:",
 Patient with a long history of depression and attention deficits., Psychiatry / Psychology, Psychiatric Evaluation - 1 ,"IDENTIFYING DATA:,  The patient is a 36-year-old Caucasian male.,CHIEF COMPLAINT:,  The patient relates that he originally came to this facility because of failure to accomplish task, difficulty saying what he wanted to say, and being easily distracted.,HISTORY OF PRESENT ILLNESS:,  The patient has been receiving services at this facility previously, under the care of ABC, M.D., and later XYZ, M.D.  Historically, he has found it very easy to be distracted in the ""cubicle"" office setting where he sometimes works.  He first remembers having difficulty with concentration in college, but his mother has pointed out to him that at some point in his early education, one teacher commented that he may have problems with attention-deficit hyperactivity disorder.  Symptoms have included difficulty sustaining attention (especially in reading), not seeming to listen one spoke into directly, failure to finish task, difficulty with organization, avoiding task requiring sustained mental effort, losing things, being distracted by extraneous stimuli, being forgetful.  In the past, probably in high school, the patient recalled being more figidity than now.  He tensed to feel anxious.  Sleep has been highly variable.  He will go for perhaps months at a time with middle insomnia and early morning awakening (3:00 a.m.), and then may sleep well for a month.  Appetite has been good.  He has recently gained about 15 pounds, but notes that he lost about 30 pounds during the time he was taking Adderall.  He tends to feel depressed.  His energy level is ""better now,"" but this was very problematic in the past.  He has problems with motivation.  In the past, he had passing thoughts of suicide, but this is no longer a problem.,PSYCHIATRIC HISTORY:,  The patient has never been hospitalized for psychiatric purposes.  His only treatment has been at this facility.  He tried Adderall for a time, and it helped, but he became hypertensive.  Lunesta is effective for his insomnia issues.  Effexor has helped to some degree.  He has been prescribed Provigil, as much as 200 mg q.a.m., but has been cutting it down to 100 mg q.a.m. with some success.  He sometimes takes the other half of the tablet in the afternoon.",
 The patient was discharged by court as a voluntary drop by prosecution. , Psychiatry / Psychology, Psychiatric Discharge Summary ,"DISCHARGE DISPOSITION:,  The patient was discharged by court as a voluntary drop by prosecution.  This was AMA against hospital advice.,DISCHARGE DIAGNOSES:,AXIS I:  Schizoaffective disorder, bipolar type.,AXIS II:  Deferred.,AXIS III:  Hepatitis C.,AXIS IV:  Severe.,AXIS V:  19.,CONDITION OF PATIENT ON DISCHARGE: , The patient remained disorganized.  The patient was suffering from prolactinemia secondary to medications.,DISCHARGE FOLLOWUP:  ,To be arranged per the patient as the patient was discharged by court.,DISCHARGE MEDICATIONS: , A 2-week supply of the following was phoned into the patient's pharmacy:  Seroquel 25 mg p.o. nightly.  Zyprexa 5 mg p.o. b.i.d.,MENTAL STATUS AT THE TIME OF DISCHARGE:,  Attitude was cooperative.  Appearance showed fair hygiene and grooming.  Psychomotor behavior showed restlessness.  No EPS or TD was noted.  Affect was restricted.  Mood remained anxious and speech was pressured.  Thoughts remained tangential, and the patient endorsed paranoid delusions.  The patient denied auditory hallucinations.  The patient denied suicidal or homicidal ideation, was oriented to person and place.  Overall, insight into her illness remained impaired.,HISTORY AND HOSPITAL COURSE: , The patient is a 22-year-old female with a history of bipolar affective disorder, was initially admitted for evaluation of increasing mood lability, disorganization, and inappropriate behaviors.  The patient reportedly was asking her father to have sex with her and tried to pull down her mother's pants.  The patient took her clothing off, was noted to be very disorganized sexually, and religiously preoccupied, and endorsed auditory hallucinations of voices telling her to calm herself and others.  The patient has a history of depression versus bipolar disorder, last hospitalized in Pierce County in 2008, but without recent treatment.  The patient on admission interview was noted to be labile and disorganized.  The patient was initiated on Risperdal M-Tab 2 mg p.o. b.i.d. for psychosis and mood lability, and also medically evaluated by Rebecca Richardson, MD.  The patient remained labile and suspicious during her hospital stay.  The patient continued to be sexually preoccupied and had poor insight into her need for treatment.  The patient denied further auditory hallucinations.  The patient was treated with Seroquel for persistent mood lability and psychosis.  The patient was noted to develop prolactinemia with Risperdal and this was changed to Zyprexa prior to discharge.  The patient remained disorganized, but was given a voluntary drop by prosecution against medical advice when she went to court on 01/11/2010.  The patient was discharged to return home to her parents and was referred to Community Mental Health Agencies.  The patient was thus discharged in symptomatic condition.","psychiatry / psychology, schizoaffective disorder, bipolar type, mood lability, disorganization, bipolar affective disorder, voluntary drop, auditory hallucinations, psychiatric, axis,"
" Psychiatric evaluation for ADHD, combined type.", Psychiatry / Psychology, Psychiatric Evaluation - 3 ,"IDENTIFICATION OF PATIENT: , ABCD is an 8-year-old Hispanic male currently in the second grade.,CHIEF COMPLAINT/HISTORY OF PRESENT ILLNESS: , ABCD presents to this visit with his mother, Xyz, and her significant other, Pqr.  Circumstances leading to this admission:  In the past, ABCD has been diagnosed and treated for ADHD, combined type, and has been on Concerta 54 mg one p.o. q.8h.  Since he has been on the 54 mg, mother has concerns because he has not been sleeping well at night, consistently he is staying up until 12:00 or 1:00, and he is not eating the noonday meal and not that much for supper.  ABCD is also complaining of headaches when he takes the medication.  Mother reports that on the weekends he is off the medication.  She does notice that his sisters become more irritated with him and say he is either hitting them or bothering them and he will say, ""It's an accident.""  She sees him as impulsive on the weekends, but is not sure if this just isn't ""all boy."",Mother reports ABCD has been on medication since kindergarten.  Currently, the teachers say he is able to pay attention and he is well behaved in school.  Prior to being on medication, there were issues with the teachers saying he was distractible and had difficulty paying attention.,He had a psychological evaluation done on 07/16/06 by Dr. X, in which he was diagnosed with ADHD, combined type; ODD; rule out depressive disorder, NOS; rule out adjustment disorder with depressed mood; and rule out adjustment disorder with mixed features of conduct.  He also has seen XYZ, LCSW, in the past for outpatient therapy.,ABCD's mother, A, as well as her significant other, R, and his teachers are not convinced that he needs his medication and would like to either trial him off or trial him on a lower dose.,REVIEW OF SYSTEMS:,Sleep:  As stated before, he is having much difficulty on a consistent basis falling asleep.  It is 12:00 to 1:00 a.m. before he falls to sleep.  When he was on the 36 mg of Concerta, he was able to fall asleep without difficulty.  On the weekends, he is also having difficulty falling asleep, even though he is not taking the medication.,Appetite:  He will eat breakfast and supper, but not much lunch, if any at all.  He has not lost weight that mother is aware of, nor is he getting more sick than normal.,Mood control:  Mother reports he has not been aggressive since he has been on the medication, nor is he getting in trouble at school for aggression or misbehavior.  The only exception to this is he gets in occasional fights with his sisters.  ABCD denies visual or auditory hallucinations or racing thoughts.  He reports his thoughts are sometimes bad because he says sometimes he thinks of the ""S"" word.,Energy:  Mother reports a lot of energy.,Pain:  ABCD denies any pain in his body.,Suicidal or homicidal thoughts:  He denies suicidal thoughts or plan to hurt himself or anyone else.,PAST TREATMENT AND/OR MEDICATIONS:,ABCD was originally tried on Ritalin in kindergarten, and he has been on Concerta since 07/14/06.  He has received outpatient therapy from XYZ, LCSW.  He is currently not in outpatient therapy.,FAMILY PSYCHIATRIC HISTORY:,Mother reports that on her side of the family she is currently being assessed for mood disorder/bipolar.  She reports she has significant moodiness episodes and believes in the past she has had a manic episode.  She is currently not on medication.  She does not know of anyone else in her family, with the exception of she said her father's behavior was ""weird.""  Biological father's side of the family, mother reports father was very impulsive.  He had anger issues.  He had drug and alcohol issues.  He was in jail for three years for risky behavior.  There was also domestic violence when mother was married to father.,FAMILY AND SOCIAL HISTORY:,Biological mother and father were married for five years.  They divorced when ABCD was 2-1/2 years of age.  Currently, father has been deported back to Mexico.  He last saw ABCD in March 2006 for one day when they went down to AAAA.  He does call on special holidays and his birthday.  Contact is brief, but so far has been consistent.  Mother is currently seeing R, a significant other, and has been seeing him for the last seven months.  ABCD had a good relationship with R.  ABCD has an older sister, M, age 9, who they describe as very gifted and creative without attention issues or oppositional issues, and a younger sister, S, age 7, who mother describes as ""all wisdom."",PREGNANCY:,  Mother reports her pregnancy was within normal limits as well as the labor and birth; although, she was exposed to domestic violence while ABCD was in utero.  She did not use drugs or alcohol while she was pregnant.,DEVELOPMENTAL MILESTONES:,  Developmental milestones were all met on time, although ABCD has had speech therapy since he was young.,PHYSICAL ABUSE:,  Mother and ABCD deny any history of physical or sexual abuse or emotional abuse, with the exception of exposure to domestic violence when he was very young, age 2 and before.,DISCIPLINE PROBLEMS:,  Mother reports ABCD was a very cuddly infant and could sleep well.  As a toddler, he was all over the place, climbing and always busy.  Elementary school:  In kindergarten, the teacher said it was very emphatic that he needed medication because he could not focus or sit still or listen.  ABCD has no history of fire setting or abuse to animals.  He does not lie more than other kids his age and he does not have any issues with stealing.,PAST DRUG AND ALCOHOL HISTORY:,  Noncontributory.,MEDICAL STATUS AND HISTORY:,  ABCD has no known drug allergies.  He has no history of heart murmur, heart defect of other heart problems.  No history of asthma, seizures or head injuries.  He no medical diagnosis and he has ever spent an overnight in a medical hospital.,SCHOOL:,  When I asked ABCD whether he likes school, he stated, ""No.""  His grades are okay, per mother.  He does have an IEP for the ADHD, but she does not believe he has a learning disability.  Behavior problems:  He currently is not having any behavior problems in the school.  He reports he does not get along with his teachers because they tell him what to do.  Strengths:  He reports he loves to read and he can focus and concentrate on his reading and he dislikes centers.,RELATIONSHIPS:,  He reports he has best friends.  He named two, D and B, and he does have a friend that is a girl named Kim.  When asked if church or God were important to him, he stated, ""God is.""  He is in a Roman Catholic family and that is an important aspect of his life.,WORK HISTORY:,  In the home, he has chores of taking out the trash.,LEGAL:,  He has not been involved in the legal system.,SUPPORT SYSTEMS:,  When asked if he feels safe in his home, he stated, ""Yes.""  When asked who he talks to if he is hurt or upset, he stated, ""Mom.""  (At first, he said video games, but then he said mom).,TALENTS AND GIFTS:,  He is good at basketball, video games, and reading books.,MENTAL STATUS EXAM:,  This was a very long appointment, approximately two hours in length, due to mother and significant other had many questions.  ABCD kept himself occupied throughout and was very well behaved throughout the session.  He had some significant memory responses in that he remembered the last holiday was Martin Luther King Day, which is somewhat unusual for a child his age, but he could only recall one of three items after five minutes.  Distractibility and attention:  He, at times, was very mildly distracted, but otherwise did not appear hyperactive.  His judgment was adequate.  When asked what he would do if there was a fire in his house, he said, ""Get out!""  Insight was poor to adequate.  Fund of information was good.  When asked who the president was, he said, ""George Washington."" Intelligence is probably average to above average.  Speech was normal.  He had some difficulty with abstract thinking.  He could not see any similarities between an orange and an apple, but was able to see similarities of wheels between an airplane and a bicycle.  On serial 7's he could do 100 minus 7, but then unable to subtract any of the others, but he completed serial 3's very rapidly.  When given three commands in a row, he used his left hand instead of his right hand, but followed the last two commands correctly.  Appearance was casual.  Hygiene was good.  Attitude was cooperative.  Speech was normal.  Psychomotor was between normal and slightly hyperactive.  Orientation was x2.  Attention/concentration was intact.  Memory was intact at times and then had some memory recall problems with three words.  Mood was euthymic.  Affect was bright.  He has no suicidal or homicidal/violence risks.  Perceptions were normal.  Thought process logical.  Thought content normal.  Disassociation none.  Sleep:  He is having some insomnia.  Appetite/eating are decreased.,STRENGTHS AND SUPPORTS:,  He has a strong support system in his mother, grandmother, and mother's significant other, Richard.  He has good health.  He has shown gain from past treatment.  He has a sense of humor and a positive relationship with his mother and her significant other, as well as good school behavior.",
 Discharge summary of a patient with mood swings and oppositional and defiant behavior., Psychiatry / Psychology, Psychiatric Discharge Summary - 1 ,"DISCHARGE SUMMARY,SUMMARY OF TREATMENT PLANNING:,Two major problems were identified at the admission of this adolescent:,1.",
" Bipolar disorder, apparently stable on medications.  Mild organic brain syndrome, presumably secondary to her chronic inhalant, paint, abuse.", Psychiatry / Psychology, Psychiatric Consult - 1 ,"HISTORY OF PRESENT ILLNESS:,  This is a 53-year-old widowed woman, she lives at ABC Hotel.  She presented with a complaint of chest pain, evaluations revealed severe aortic stenosis.  She has been refusing cardiac catheter and she may well need aortic valve replacement.  She states that she does not want heart surgery or valve replacement.  She has a history of bipolar disorder and has been diagnosed at times with schizophrenia.  She is on Depakote 500 mg three times a day and Geodon 80 mg twice a day.  The patient receives mental health care through the XYZ Health System and there is a psychiatrist who makes rounds at the ABC Hotel.  She denies hallucinations, psychosis, paranoia, and suicidal ideation at this time.  States that she does not want surgery because the chest pain that was a presenting complaint has gone away that she did not feel her problem is severe enough to require surgery, and medical records does show in this obese individual that cardiac surgery would present substantial risks and for this individual with the chronic mental illness and behavioral problems of a chronic nature, surgery does present some additional risks.  The patient notes that she has a long history of substance abuse, primarily inhalation of paint vapors that she had more than 100 incarcerations in the XYZ County Jail related to offenses related to her lifestyle at that time such as shoplifting, violation of orders to abstain from substance abuse and the longest confinement of these was 100 days.,The patient is able to write a fairly reasonable explanation for why she does not want to pursue medical care.,PAST AND DEVELOPMENTAL HISTORY: , She was born in XYZ.  She is a high-school graduate from ABCD High School.  She did have an abusive childhood.  She is married four times.  She notes she developed depression when a number of her children died.,PHYSICAL EXAMINATION:  ,GENERAL: , This is an obese woman in bed.  She is somewhat restless and moving during the interview.,VITAL SIGNS,:  Temperature of 97.3, pulse 70, respirations 18, blood pressure 113/68, and oxygen saturation 94% on 3 L of oxygen.,PSYCHIATRY:  ,Speech is normal, rate, volume, grammar, and vocabulary consistent with her educational level.  There is no overt thought disorder.  She does not appear psychotic.  She is not suicidal on formal testing.  She gives the date as Sunday, 05/19/2007 when it is the 20th and 207 when it is 2007.  She is oriented to place.  She can memorize four times, repeats two at five minutes, gets the other two with category hints, this places short-term memory in normal limits.  She had difficulty with serial three subtractions, counting on her fingers and had difficulty naming the months in reverse order stating, ""December, November, September, October, June, July, August, September,"" but recognizes this was not right and then said, ""March, April, May.""  She is able to name objects appropriately.,LABORATORY DATA: , Chest x-ray showing no acute changes.  Carotid duplex shows no stenosis.  Electrolytes and liver function tests are normal.  TSH normal.  Hematocrit 31%.  Triglycerides 152.,DIAGNOSES:  ,1.  Bipolar disorder, apparently stable on medications.,2.  Mild organic brain syndrome, presumably secondary to her chronic inhalant, paint, abuse.,3.  Aortic stenosis.,4.  Sleep apnea.,5.  Obesity.,6.  Anemia.,7.  Gastroesophageal reflux disease.,RECOMMENDATIONS:,  It is my impression at present that the patient retains ability to make decisions on her own behalf.  Given this lady's underlying mental problems, I would recommend that her treating physicians discuss her circumstances with physicians who round on her at the ABC Hotel.  While she may well need surgery and cardiac catheter, she may be more willing to accept this in the context of some continued encouragement from care providers who usually provide care for her.  She clearly at this time wants to leave this hospital; she normally gets her care through XYZ Health.  Again, in summary, I would consider her to retain the ability to make decisions on her own behalf.,Please feel free to contact me at digital pager if additional information is needed.","psychiatry / psychology, organic brain syndrom, substance abuse, bipolar disorder, mental, abuse, "
 Psychiatric Assessment of a patient with bipolar and anxiety disorder having posttraumatic stress syndrome., Psychiatry / Psychology, Psychiatric Assessment ,"IDENTIFICATION OF PATIENT: , This is a 31-year-old female who was referred by herself.  She was formerly seen at Counseling Center.  She is a reliable historian.,CHIEF COMPLAINT:,  ""I'm bipolar and I have severe anxiety disorder.  I have posttraumatic stress syndrome."" ,HISTORY OF PRESENT ILLNESS: , At age 19, Ms. Abc had a recurrence of memories.  Her father had molested her, and the memories returned.  In 1992, at the age of 18, she entered her first abusive marriage.  She was beaten and her husband shared her sexually with his friends.  This lasted until age 24.  The second marriage was age 26, her second husband was a drug abuser and ""he slapped me around.""  She had two children during that marriage.  In 2001, she was married in Indiana to a military man.  This was her third marriage and she stated, ""This marriage is good.""  She had EMDR in Indiana when she was being treated for Posttraumatic Stress Disorder.  ,Historically, her first husband threw her down the stairs at age 21, and she had a miscarriage.  Her sexual abuse began at age 5, and at that time she lost interest in other activities that normal school children have.  Currently, she is unable to have sex with the lights on.  She states, ""Sometimes I hurt all over.""  Her husband was deployed three days ago, on April 21, to a foreign theater of operations.  She has panic attacks every day.,Review of symptoms shows her to have physiological distress at the memory of her trauma, she has psychological distress, and this comes about when she smells Old Spice aftershave.  She does not avoid thoughts of her trauma, but she avoids the perpetrators and placements.  She is not unable to recall details of her trauma.  She does feel detached and isolated.  She has restrictive range of affect and she had a foreshortened future.  She also had a loss of interest in things, starting at age 5.  She has anger, which is uncontrollable at times, she has poor sleep, she has nightmares, flashbacks, she is hypervigilant, she has exaggerated startle reflex, and with respect to concentration, she says, ""I don't do as good as I can.""  Further review of symptoms shows her to have periods of constant cleaning and increased sex drive.  She also has had euphoria, poor judgment, distractibility, and inability to concentrate.  She has been irritable.  She has had a decreased need for sleep, which lasts for six or seven days.  She had racing thoughts, rapid speech, but has not had grandiosity.  These symptoms of mania occurred in the last week of November 2005 and lasted for seven days from, which she was not hospitalized.  Furthermore, she endorses the following symptoms:  She states, ""When I'm depressed, I have neck pain, jaw pain, abdominal pain.  I have migraines and urinary tract pain.""  She also complains of chest pain, pain during sex, and excess pain during her menstrual period.  She has an increased gag reflex, which has caused her to have emesis.  She states it is easy to choke.  She has had physical symptoms, ""for as long as I can remember,"" and she states, ""I've felt like crap most of my life,""  ""it affects my marriage.""  She has also admitted to having nausea and vomiting, with excess gas.  She has constipation and she cannot eat certain foods, mainly broccoli and cauliflower, and she does not have diarrhea.  She states that sex is only important to her in mania.  Otherwise, she has no desire.  She has had irregular periods for two or three weeks at a time.  She has had no episodes of excess bleeding.  She has had no paralysis, no balance issues, no diplopia, no seizures, no blindness, no deafness, no amnesia, no loss of consciousness, but she does have a lump in her throat on occasion.  Currently, she is sleeping from 10 p.m. to 3 a.m., and that is under the influence of Lunesta.  Her energy is ""not good.  Her appetite is ""I'm craving crap,"" stating that she wants to eat carbohydrates.  Concentration is poor today.  She feels worthless, hopeless, and guilty.  Her self-esteem is ""I don't have any.""  She has no anhedonia, and she has no libido.  She also has had feelings of chronic emptiness.  She feels abandoned.  She has had unstable relationships.  She self-mutilated, but she stopped at age 22.  She has trouble controlling her anger.  She did not have stress-related paranoia or dissociative phenomena, but she did have those during the sexual transgressions when she was a child.  She has no identity disturbance.  ,CURRENT MEDICATIONS: , Seroquel 700 mg p.o. q.d.; Wellbutrin XL 300 mg p.o. q.d.; Desyrel 100 mg p.o. q.h.s.; Ativan p.r.n. dosage unknown.  In the past, she has been on Prozac, Paxil, lithium, Depakote, Depakene, and Zoloft. ,PSYCHIATRIC HISTORY: , She saw Dr. B.  She saw Chris.  She is diagnosed with Posttraumatic Stress Disorder, depression, and Bipolar Disorder.  She had counseling in Indiana in 2001.  She had inpatient treatment in Indiana in 2001 also, at age 19.  She had three suicide attempts.  At age 14, she took too many aspirin; the second one was at age 19, she took pain medication and sleep medication; and when she discussed her third suicide attempt, she began to cry and would not speak of it any more.  She has had no psychological testing.  ,MEDICAL HISTORY: , Significant for migraines, hyperactive and gag reflex.  She states she has had cardiovascular workups due to panic disorder, but nothing was found.  She also has astigmatism.  She states she has stomach pain and may have irritable bowel syndrome, and she had had recurrent kidney infections with a stent in the right kidney during one of her pregnancy.  She has no history of head injury or MRI test of the brain.  No history of EEG, seizures, thyroid problems, or asthma.  There are no drug allergies.  She has never had an EKG.  She does have musculoskeletal problems and has arthritis-like joint pains on occasion.  She has had ear infections and sinus infections intermittently.  Hearing test was normal.  She is currently not pregnant.  She saw her gynecologist four months ago at Elmendorf Air Force Base.  ,Surgical history is significant for having a tubal ligation at age 27, an appendectomy at age 19.  She had surgery on her right ovary due to pain, a cyst was found; the date on that is unknown.  ,She has no hypertension, no diabetes, no glaucoma.,FAMILY HISTORY: , Significant for her paternal grandmother not being mentally competent.  Her mother was depressed and was treated.  Her mother is currently age 55.  She has a paternal grandmother who may have had Schizophrenia.  There is also a family history of the paternal grandfather using substance.  He was ""an extreme alcoholic.""  She had maternal aunts who used alcohol, and a maternal uncle use alcohol to excess.  The maternal uncle committed suicide; he drowned himself.  ,There is no family history of bipolar disorder, anxiety, nor attention deficit, mental netardation, Tourette's syndrome, or learning disabilities. ,Medical history in the family is significant for her son, age 4, who is having seizures ruled out.  Her mother and two maternal aunts have thyroid disease.  She has a brother, age 32, with diabetes, a maternal uncle with heart disease, and several paternal great aunts had breast cancer.  There is no family history of hypertension.,ABUSE HISTORY: , Significant for being physically abused by her father, her first husband, and her second husband.  She was sexually abused by her father from age 5 to age 18.  She states, ""my first husband gave me away for four years to his friends to be used sexually.""  She was emotionally abused by her mother, father, and both of her first two husbands.  She was neglected by her mother and her father.  She never witnessed domestic violence.  She has not witnessed traumatic events.  ,SUBSTANCE ABUSE: , Significant for having used nerve pills, but she stated she has not used them excessively, and never had to get her prescription refilled early.  She has never used alcohol, tobacco, marijuana, or any other drugs.,PARENT/SIBLING RELATIONSHIP INFORMATION: , She had had a poor relationship with her parents.  She has no contact with them.  She has no contact with her brother.  She was married three times, as stated in the history.  She has two children with Asperger's and autism.  ,HOBBIES/SPIRITUAL: , She likes to read and write.  She likes to cross-stitch, quilt, and do music, and has found a good church in Anchorage.  ,EDUCATIONAL:,  She states she was teased in school because ""I was so depressed.""  She got good grades otherwise.  She finished high school.,WORK HISTORY:,  She has worked in the past managing a Dollar General store.  She has been a waitress and an executive secretary.  ,LEGAL HISTORY:,  She has never been arrested.,MENTAL STATUS:,  Significant for a well groomed, well kempt young white female who appears her stated age.  She has a pierced nose and has a nose ring.  She is cooperative, alert, and attentive.  She makes good eye contact.  Her speech is normal, prosody is normal, and rate and rhythm are normal.  Motor is normal.  She has no gait abnormalities.  No psychomotor retardation or agitation.  Her mood is ""I'm sad and depressed.""  Her affect is restricted.  She is tearful at times when discussing the sexual traumas, and she became anxious and panicky at certain points during the interviews.  Perception is normal.  She denies auditory and visual hallucinations.  She denies depersonalization and derealization, except that those occurred when the sexual transgressions occurred.  Otherwise, she has not had dissociative phenomena.  Thought processes are normal.  She has no loosening of association, no flight of ideas, no tangentiality, and no circumstantiality.  She is goal directed and oriented.  Insight and judgment are good.  She is alert and oriented to person, place, and time, stating it was 04/18/06, Tuesday, it was Anchorage in the spring.  She is able to register three words and recall them at five minutes.  She is able to do simple calculations, stating 2x3 is 6, and 1 dollar 15 cents has 23 nickels.  She is given a proverb to interpret.  She was asked what judging a book by its cover meant.  She said, ""You can't always tell what a person is by looking at them on the outside.""  She is appropriate in her abstraction, and is able to identify the last four presidents.,CLINICAL IMPRESSION:  ,Abc is a 31-year-old female with a family history of mood disorder, suicide, alcoholism, and possible psychosis.  She has had an extensive history of sexual abuse and emotional abuse.  She has not used drugs and alcohol, and she has been treated in the past.  She was treated with EMDR and stated that she did not benefit from that.  She has an extensive medical history and brought her medical records, and they were thoroughly reviewed.  She currently has symptoms of dysthymia and she had had a recent bout of bipolar hypomania, which was in November of 2005.  She also has symptoms of somatization, but these are not chronic in the fact that they only exist during her dysphoric periods and do not exist when she has mania.  Medical records review a history of dysmenorrhea with surgery to the right cystic ovary.  The EMDR did not benefit her in the past.  She also has not had good psychotherapeutic consultation.  ,DIAGNOSES:,AXIS  I.  309.81  Posttraumatic Stress Disorder.",
 Psychiatric consultation for substance abuse., Psychiatry / Psychology, Psych Consult - Substance abuse ,"REASON FOR CONSULT: , Substance abuse.,HISTORY OF PRESENT ILLNESS: , The patient is a 42-year-old white male with a history of seizures who was brought to the ER in ABCD by his sister following cocaine and nitrous oxide use.  The patient says he had been sober from any illicit substance for 15 months prior to most recent binge, which occurred approximately 2 days ago.  The patient is unable to provide accurate history as to amount use in this most recent binge or time period it was used over.  The patient had not used cocaine for 15 years prior to most recent usage but had used alcohol and nitrous oxide up until 15 months ago.  The patient says he was depressed and agitated.  He says he used cocaine by snorting and nitrous oxide but denies other drug usage.  He says he experienced visual hallucinations while intoxicated, but has not had hallucinations since being in the hospital.  The patient states he has had cocaine-induced seizures several times in the past but is not able to provide an accurate history as to the time period of the seizure.  The patient denies suicidal ideation, homicidal ideation, auditory hallucinations, visual hallucinations, or tactile hallucinations.  The patient is A&O x3.,PAST PSYCHIATRIC HISTORY:,  Substance abuse as per HPI.  The patient went to a well sober for 15 months.,PAST MEDICAL HISTORY:,  Seizures.,PAST SURGICAL HISTORY:,  Shoulder injury.,SOCIAL HISTORY:,  The patient lives alone in an apartment uses prior to sobriety 15 months ago.  He was a binge drinker, although unable to provide detail about frequency of binges.  The patient does not work since brother became ill 3 months ago when he quit his job to care for him.,FAMILY HISTORY:,  None reported.,MEDICATIONS OUTPATIENT:,  Seroquel 100 mg p.o. daily for insomnia.,MEDICATIONS INPATIENT:,1.  Gabapentin 300 mg q.8h.,2.  Seroquel 100 mg p.o. q.h.s.,3.  Seroquel 25 mg p.o. q.8h. p.r.n.,4.  Phenergan 12.5 mg IV q.4h. p.r.n.,5.  Acetaminophen 650 mg q.4h. p.r.n.,6.  Esomeprazole 40 mg p.o. daily. ,MENTAL STATUS EXAMINATION: , The patient is a 42-year-old male who appears stated age, dressed in a hospital gown.  The patient shows psychomotor agitation and is somewhat irritable.  The patient makes fair eye contact and is cooperative.  He had answers my questions with ""I do not know.""  Mood ""depressed"" and ""agitated.""  Affect is irritable.  Thought process logical and goal directed with thought content.  He denies suicidal ideation, homicidal ideation, auditory hallucinations, visual hallucinations, or tactile hallucinations.  Insight and judgment are both fair.  The patient seems to understand why he is in the hospital and patient says he will return to Alcoholics Anonymous and will try to stay sober in all substances following discharge.  The patient is A&O x3.,ASSESSMENT:,AXIS I:  Substance withdrawal, substance abuse, and substance dependence.,AXIS II:  Deferred.,AXIS III:  History of seizures.,AXIS IV:  Lives alone and unemployed.,AXIS V:  55.,IMPRESSION:,  The patient is a 42-year-old white male who recently had a cocaine binge following 15 months of sobriety.  The patient is experiencing mild symptoms of cocaine withdrawal.,RECOMMENDATIONS:,1.  Gabapentin 300 mg q.8h. for agitation and history of seizures.,2.  Reassess this afternoon for reduction in agitation and withdrawal seizures.,Thank you for the consult.  Please call with further questions.",
" Psychiatric consultation has been requested as the patient has been noncompliant with treatment, leave the unit, does not return when requested, and it was unclear as to whether this is secondary to confusion or willful behavior.", Psychiatry / Psychology, Psychiatric Consult ,"HISTORY OF PRESENT ILLNESS:  ,This is a 23-year-old married man who had an onset of aplastic anemia in December, underwent a bone marrow transplant in the end of March, has developed very severe graft-versus-host reaction.  Psychiatric consultation has been requested as the patient has been noncompliant with treatment, leave the unit, does not return when requested, and it was unclear as to whether this is secondary to confusion or willful behavior.,The patient gives a significant history of behavioral problems from late adolescence until the onset of illness, states he had lot of trouble with law, he was convicted of assault, he was also arrested with small amount of cannabis, states he served one year incarcerated in ABCD that was about two years ago.  Gives an ongoing history of substance abuse until one year ago when he went into a drug rehabilitation program, he was discharged from that on 05/28/2006 and states he has been clean and sober since then.  Prior to going to rehabilitation, he was using intravenous heroin couple of times a week since age 17, which would have been over a period of about five years, reports heavy use of cannabis, smoking pot up to five times a day if he could.  He would drink up to half of a fifth of rum on a daily basis when available.,The patient is currently on Lexapro 10 mg in the morning and diazepam 10 mg at bedtime.  He complained of some depressive and some anxiety symptoms, but these do not appear to be out of proportion to his medical issues and, for this individual, the frustrations of his treatments.  He would have a limited support system here in Colorado.  He married in January and states that the marriage is not going particularly well, being young, sick, and hospitalized, has not helped his relationship with his new wife who apparently is expecting a child in July.  I would recommend some couples counseling as a part of their treatment here.,The patient was fairly drowsy during the interview and full past and developmental history was not obtained.  The patient's comment is that he grew up all over, that his parents had separated, that he lived with his mother, that he dropped out of school in eleventh grade, at that time was living in XYZ area because he did not like school.,PHYSICAL EXAMINATION:  ,GENERAL: , This is a cooperative man, speech is soft and difficult to understand.  There is no thought disorder and no hallucination.  He denies being suicidal, but does express at times feelings about giving up on his treatments and primarily complaints about feeling that he is treated like a child and confined in the hospital.,VITAL SIGNS: , Temperature 97.2, pulse 117, respirations 16, blood pressure 127/74, oxygen saturation 97%, and weight is 154 pounds.,PSYCHIATRY:,  There is no thought disorder, no paranoia, no delusions, and no psychotic symptoms.  Activities of daily living (ADLs) appear intact.  On formal testing, he is oriented to place.  He can give a reasonable recitation of his medical history.  He is oriented to the year, knows it is the 15th, but gave the month as June instead of May.  He can memorize four items, repeats three out of four at five minutes, gives the fourth through the category, which places short-term memory in normal limits.  He can do serial three subtractions accurately, can name objects appropriately.,LABORATORY DATA:,  Sodium of 135, BUN of 24, and glucose 119.  GGT of 355, ALT of 97, LDH of 703, and alk phos of 144.  FK506 is 28.8, which is elevated tacrolimus level.  Hematocrit 29% and white count is 7000.,DIAGNOSES:  ,AXIS I:,  Depressive disorder secondary to the underlying medical condition of graft-versus-host reaction.,AXIS II: , Personality disorder, not otherwise specified (NOS).,AXIS III: , History of polysubstance abuse, in remission.,RECOMMENDATIONS:  ,1.  This patient appears to retain the ability to make decisions on his own behalf.  I think he is mentally competent.  Unfortunately, his impulsive low frustration personality dynamics do not fit well with the demands and requirements for treatment of this chronic illness.  If the patient refuses treatment, he understands that the consequences of this would likely be hastened mortality and he does state that he does not want to die.,2.  The patient does complain of depressed mood, also of anxiety.  We did discuss medications.  He appeared somewhat sedated at the time of my interview.  I would recommend that we try Seroquel 25 mg twice daily on an as-needed basis to see if this diminishes anxiety.  I will have Dr. X followup with him.,Please feel free to contact me at digital pager if additional information is needed.,My overall recommendation would be that the patient be on some random urine drug screening, that he use cell phone if he goes off the unit, to be called back up when treatments are scheduled, and hopefully he will be agreeable to complying with this.","psychiatry / psychology, noncompliant, confusion, graft versus host reaction, psychiatric consultation, willful behavior, cannabis, "
" A 30-year-old white male with a history of schizophrenia, chronic paranoid, was admitted for increasing mood lability, paranoia, and agitation.", Psychiatry / Psychology, Psych Consult - Paranoia ,"IDENTIFYING DATA: , The patient is a 30-year-old white male with a history of schizophrenia, chronic paranoid, was admitted for increasing mood lability, paranoia, and agitation.,CHIEF COMPLAINT: , ""I am not sure."" The patient has poor insight into hospitalization and need for treatment.,HISTORY OF PRESENT ILLNESS: , The patient has a history of schizophrenia and chronic paranoid, for which she has received treatment in Houston, Texas.  According to mental health professionals, the patient had been noncompliant with medications for approximately two weeks.  The patient had taken an airplane from Houston to Seattle, but became agitated, paranoid, expressing paranoid delusions that the stewardess and pilots were trying to reject him and was deplaned in Seattle.  The patient was taken to the local shelter where he remained labile, breaking a window, and was taken to jail.  The patient has now been discharged from jail but involuntarily detained for persistent paranoia and disorganization (no jail hold).,PAST PSYCHIATRIC HISTORY: , History of schizophrenia, chronic paranoid.  The patient as noted has been treated in Houston but has not had recent treatment or medications.,PAST MEDICAL HISTORY:  ,No acute medical problems noted.,CURRENT MEDICATIONS: , None.  The patient was most recently treated with Invega and Abilify according to his records.,FAMILY SOCIAL HISTORY: , The patient resides with his father in Houston.  The patient has no known history of substances abuse.  The patient as noted was in jail prior to admission after breaking a window at the local shelter but has no current jail hold.,FAMILY PSYCHIATRIC HISTORY:,  Need to increase database.,MENTAL STATUS EXAMINATION:,Attitude:  Calm and cooperative.,Appearance:  Shows poor hygiene and grooming.,Psychomotor:  Behavior is within normal limits without agitation or retardation.  No EPS or TDS noted.,Affect:  Is suspicious.,Mood:  Anxious but cooperative.,Speech:  Shows normal rate and rhythm.,Thoughts:  Disorganized,Thought Content:  Remarkable for paranoia ""they want to hurt me."",Psychosis:  The patient endorses paranoid delusions as above.  The patient denies auditory hallucinations.,Suicidal/Homicidal Ideation:  The patient denies on admission.,Cognitive Assessment:  Grossly intact.  The patient is alert and oriented x 3.,Judgment:  Poor, shown by noncompliance with treatment.,Assets:  Include stable physical status.,Limitations:  Include recurrent psychosis.,FORMULATION:  ,The patient with a history of schizophrenia was admitted for increasing mood lability and psychosis due to noncompliance with treatment.,INITIAL IMPRESSION:,AXIS I:  Schizophrenia, chronic paranoid.,AXIS II:  None.,AXIS III:  None.,AXIS IV:  Severe.,AXIS V:  10.,ESTIMATED LENGTH OF STAY: , 12 days.,PLAN:  ,The patient will be restarted on Invega and Abilify for psychosis.  The patient will also be continued on Cogentin for EPS.  Increased database will be obtained.",
 Psychiatric History and Physical - Patient with schizoaffective disorder., Psychiatry / Psychology, Psych H&P - 2 ,"HISTORY OF PRESENT ILLNESS:,  The patient is a 69-year-old single Caucasian female with a past medical history of schizoaffective disorder, diabetes, osteoarthritis, hypothyroidism, GERD, and dyslipidemia who presents to the emergency room with the complaint of ""manic"" symptoms due to recent medication adjustments.  The patient had been admitted to St. Luke's Hospital on Month DD, YYYY for altered mental status and at that time, the medical team discontinued Zyprexa and lithium.  In the emergency room, the patient reported elevated mood, pressured speech, irritability, decreased appetite, and impulsivity.  She also added that over the past three days, she felt more confused and reported having blackouts as well as hallucinations about white lines and dots on her arms and face from the medication changes.  She was admitted voluntarily to the inpatient unit and medications were not restarted for her.  On the unit this morning, the patient is loud and nonredirectable, she is singing loudly and speaking in a very pressured manner.  She reports that she would like to speak with Dr. A, the neurologist who saw her at St. Luke's, because she ""trust him.""  The patient is somewhat reluctant to answer questions stating that she has answered enough of people's questions; however, she is talkative and reports that she feels as though she needs a sedative.  The patient reports that she is originally from Brooklyn, New York, and she moved down to Houston about a year ago to be with her daughter.  She also expressed frustration over the fact that her daughter wanted her removed from the apartment she was in initially and had her placed in a nursing home due to inability to care for herself.  The patient also complains that her daughter is ""trying to tell me what medications to take.""  The patient sees Dr. B in the Woodlands for outpatient care.,PAST PSYCHIATRIC HISTORY:,  Per chart.  The patient has been mentally ill for over 30 years with past diagnoses of bipolar disorder, schizoaffective disorder, and schizophrenia.  She has been stable on lithium and Zyprexa according to her daughter and was recently taken off those medications, changed to Seroquel, and the daughter reports that she has decompensated since then.  It is not known whether the patient has had prior psychiatric inpatient admissions; however, she denies that she has.,MEDICATIONS: ,1.  Seroquel 100 mg, 1 p.o. b.i.d.,2.  Risperdal 1 mg tab, 1 p.o. t.i.d.,3.  Actos 30 mg, 1 p.o. daily.,4.  Lipitor 10 mg, 1 p.o. at bedtime.,5.  Gabapentin 100 mg, 1 p.o. b.i.d.,6.  Glimepiride 2 mg, 1 p.o. b.i.d.,7.  Levothyroxine 25 mcg, 1 p.o. q.a.m.,8.  Protonix 40 mg, 1 p.o. daily.,ALLERGIES: , No known drug allergies.,FAMILY HISTORY:,  Per chart; her mother died of stroke, father with alcohol abuse and diabetes, one sister with diabetes, and one uncle died of leukemia.,SOCIAL HISTORY:,  The patient is from Brooklyn, New York and moved to Houston approximately one year ago.  She lived independently in an apartment until about one month ago when her daughter moved her into a nursing home.  She has been married once, but her spouse left her when her three children were young.  Her children are ages 47, 49, and 51.  She had one year of college, and she currently is retired after working in New York public schools for 20 or more years.  She reports that her spouse was physically abusive to her.  She reports occasional alcohol use and quit smoking 11 years ago.,MENTAL STATUS EXAM:  ,GENERAL:  The patient is an obese, white female who appears older than stated age, seated in a chair wearing large dark glasses.,BEHAVIOR:  The patient is singing loudly and joking with interviewers.  She is pleasant, but non-cooperative with interview.,SPEECH:  Increased volume, rate, and tone.  Normal in flexion and articulation.  MOTOR:  Agitated.,MOOD:  Okay.,AFFECT:  Elevated and congruent.,THOUGHT PROCESSES:  Tangential and logical at times.,THOUGHT CONTENTS:  Denies suicidal or homicidal ideation.  Denies auditory or visual hallucination.  Positive grandiose delusions and positive paranoid delusions.,INSIGHT:  Poor to fair.,JUDGMENT:  Impaired.  The patient is alert and oriented to person, place, date, year, but not day of the week.,LABORATORY DATA:,  Sodium 144, potassium 4.2, chloride 106, bicarbonate 27, glucose 183, BUN 23, creatinine 1.1, and calcium 10.6.  Acetaminophen level 3.3 and salicylate level less than 0.14.  WBC 7.41, hemoglobin 13.8, hematocrit 43.1, and platelets 229,000.  Urinalysis within normal limits.,PHYSICAL EXAMINATION:,GENERAL:  Alert and oriented, in no acute distress.,VITAL SIGNS:  Blood pressure 152/92, heart rate 81, and temperature 97.2.,HEENT:  Normocephalic and atraumatic.  PERRLA.  EOMI.  MMM.  OP clear.,NECK:  Supple.  No LAD, no JVD, and no bruits.,CHEST:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  Regular rate and rhythm.  S1 and S2 heard.  No murmurs, rubs, or gallops.,ABDOMEN:  Obese, soft, nontender, and nondistended.  Positive bowel sounds x4.,EXTREMITIES:  No cyanosis, clubbing, or edema.,ASSESSMENT:,  This is a 69-year-old Caucasian female with a past medical history of schizoaffective disorder, diabetes, hypothyroidism, osteoarthritis, dyslipidemia, and GERD who presents to the emergency room with complaints of inability to sleep, irritability, elevated mood, and impulsivity over the past 3 days, which she attributes to a recent change in medication after an admission to St. Luke's Hospital during which time the patient was taken off her usual medications of lithium and Zyprexa.  The patient is manic and disinhibited and is unable to give a sufficient interview at this time.,AXIS I:  Schizoaffective disorder.,AXIS II:  Deferred.,AXIS III:  Diabetes, hypothyroidism, osteoarthritis, gastroesophageal reflux disease, and dyslipidemia.,AXIS IV:  Family strife and recent relocation.,AXIS V:  GAF equals 25.,PLAN:  ",
 Psychiatric History and Physical - Patient with major depression, Psychiatry / Psychology, Psych H&P - 1 ,"HISTORY OF PRESENT ILLNESS: , This 40-year-old white single man was hospitalized at XYZ Hospital in the mental health ward, issues were filled up by his sister and his mother.  The issues involved include the fact that for the last 10 years he has been on disability for psychiatric reasons and has been not working, and in the last several weeks to month he began to call his family talking about the fact that he had been sexually abused by brother.  He has been in outpatient therapy with Jeffrey Silverberg for the past 10 years and Mr. Silverberg became concerned about his behavior, called the family and told them to have him put in the hospital, and at one point called the police because the patient was throwing cellphones and having tantrums in his office.,The history includes the fact that the patient is the 3rd of 4 children.  A brother who is approximately 8 years older, sexually abused brother who is 4 years older.  The brother who is 8 years older lives in California and will contact the family, has had minimal contact for many years.,That brother in California is gay.  The brother who is 4 years older, sexually abused, the patient from age 8 to 12 on a regular basis.  He said, he told his mother several years ago, but she did nothing about it.,The patient finished high school and with some struggle completed college at the University of Houston.  He has a sister who is approximately a year and half younger than he is, who was sexually abused by the brothers will, but only on one occasion.  She has been concerned about patient's behavior and was instrumental in having him committed.,Reportedly, the patient ran away from home at the age of 12 or 13 because of the abuse, but was not able to tell his family what happened.,He had no or minimal psychiatric treatment growing up and after completing college worked in retail part time.,He states he injured his back about 10 yeas ago.  He told he had disk problems but never had surgery.  He subsequently was put on psychiatric disability for depression, states he has been unable to get out of bed at times and isolates and keeps to himself.,He has been on a variety of different medications including Celexa 40 mg and ADD medication different times, and reportedly has used amphetamines in the past, although he denies it at this time.  He minimizes any alcohol use which appears not to be a problem, but what does appear to be a problem is he isolates, stays at home, has been in situations where he brings in people he does not know well and he runs the risk of getting himself physically harmed.,He has never been psychiatrically hospitalized before.,MENTAL STATUS EXAMINATION:,  Revealed a somewhat disheveled 40-year-old man who was clearly quite depressed and somewhat shocked at his family's commitment.  He says he has not seen them on a regular basis because every time he sees them he feels hurt and acknowledged that he called up the brother who abused him and told the brother's wife what had happened.  The brother has a child and wife became very upset with him.,Normocephalic.  Pleasant, cooperative, disheveled man with about 37 to 40, thoughts were somewhat guarded.  His affect was anxious and depressed and he denied being suicidal, although the family said that he has talked about it at times.,Recent past memory were intact.,DIAGNOSES:,Axis I:  Major depression rule out substance abuse.,Axis II:  Deferred at this time.,Axis III:  Noncontributory.,Axis IV:  Family financial and social pressures.,Axis V:  Global Assessment of Functioning 40.,RECOMMENDATION:,  The patient will be hospitalized to assess.,Along the issues, the fact that he is been living in disability in the fact that his family has had to support him for all this time despite the fact that he has had a college degree.  He says he has had several part time jobs, but never been able to sustain employment, although he would like to.","psychiatry / psychology, history of present illness:, global assessment of functioning, mental status examination, major depression, psychiatric, abuse, behavior, depression, mental health, mental health ward, psychiatric disability, sexually abused, substance abuse, health, "
 A 45-year-old white male with a history of schizophrenia and AIDS.  He was admitted for disorganized and assaultive behaviors while off all medications for the last six months., Psychiatry / Psychology, Psych Consult - Schizophrenia ,"IDENTIFYING DATA:,  The patient is a 45-year-old white male.  He is unemployed, presumably on disability and lives with his partner.,CHIEF COMPLAINT: , ""I'm in jail because I was wrongly arrested."" The patient is admitted on a 72-hour Involuntary Treatment Act for grave disability.,HISTORY OF PRESENT ILLNESS: , The patient has minimal insight into the circumstances that resulted in this admission.  He reports being diagnosed with AIDS and schizophrenia for some time, but states he believes that he has maintained his stable baseline for many months of treatment for either condition.  Prior to admission, the patient was brought to Emergency Room after he attempted to shoplift from a local department store, during which he apparently slapped his partner.  The patient was disorganized with police and emergency room staff, and he was ultimately detained on a 72-hour Involuntary Treatment Act for grave disability.,On the interview, the patient is still disorganized and confused.  He believes that he has been arrested and is in jail.  Reports a history of mental health treatment, but denies benefiting from this in the past and does not think that it is currently necessary.,I was able to contact his partner by telephone.  His partner reports the patient is paranoid and has bizarre behavior at baseline over the time that he has known him for the last 16 years, with occasional episodes of symptomatic worsening, from which he spontaneously recovers.  His partner estimates the patient spends about 20% of the year in episodes of worse symptoms.  His partner states that in the last one to two months, the patient has become worse than he has ever seen him with increased paranoia above the baseline and he states the patient has been barricading himself in his house and unplugging all electrical appliances for unclear reasons.  He also reports the patient has been sleeping less and estimates his average duration to be three to four hours a night.  He also reports the patient has been spending money impulsively in the last month and has actually incurred overdraft charges on his checking account on three different occasions recently.  He also reports that the patient has been making threats of harm to him and that His partner no longer feels that he is safe having him at home.  He reports that the patient has been eating regularly with no recent weight loss.  He states that the patient is observed responding to internal stimuli, occasionally at baseline, but this has gotten worse in the last few months.  His partner was unaware of any obvious medical changes in the last one to two months coinciding with onset of recent symptomatic worsening.  He reports of the patient's longstanding poor compliance with treatment of his mental health or age-related conditions and attributes this to the patient's dislike of taking medicine.  He also reports that the patient has expressed the belief in the past that he does not suffer from either condition.,PAST PSYCHIATRIC HISTORY: , The patient's partner reports that the patient was diagnosed with schizophrenia in his 20s and he has been hospitalized on two occasions in the 1980s and that there was a third admission to a psychiatric facility, but the date of this admission is currently unknown.  The patient was last enrolled in an outpatient mental health treatment in mid 2009.  He dropped out of care about six months ago when he moved with his partner.  His partner reports the patient was most recently prescribed Seroquel, which, though the patient denied benefiting from, his partner felt was ""useful, but not dosed high enough."" Past medication trials that the patient reports include Haldol and lithium, neither of which he found to be particularly helpful.,MEDICAL HISTORY: , The patient reports being diagnosed with HIV and AIDS in 1994 and believes this was secondary to unprotected sexual contact in the years prior to his diagnosis.  He is currently followed at Clinic, where he has both an assigned physician and a case manager, but treatment compliance has been poor with no use of antiretroviral meds in the last year.  The patient is fairly vague on his history of AIDS related conditions, but does identify the following:  Thrush, skin lesions, and lung infections; additional details of these problems are not currently known.,CURRENT MEDICATIONS: , None.,ALLERGIES:,  No known drug allergies.,SOCIAL AND DEVELOPMENTAL HISTORY: , The patient lives with his partner.  He is unemployed.  Details of his educational and occupational history are not currently known.  His source of finances is also unknown, though social security disability is presumed.,SUBSTANCE AND ALCOHOL HISTORY: , The patient smoked one to two packs per day for most of the last year, but has increased this to two to three packs per day in the last month.  His partner reports that the patient consumed alcohol occasionally, but denies any excessive or binge use recently.  The patient reports smoking marijuana a few times in his life, but not recently.  Denies other illicit substance use.,LEGAL HISTORY:  ,Unknown.,GENETIC PSYCHIATRIC HISTORY:,  Also unknown.,MENTAL STATUS EXAM:,Attitude:  The patient demonstrates only variable cooperation with interview, requires frequent redirection to respond to questions.  His appearance is cachectic.  The patient is poorly groomed.,Psychomotor:  There is no psychomotor agitation or retardation.  No other observed extrapyramidal symptoms or tardive dyskinesia.,Affect:  His affect is fairly detached.,Mood:  Describes his mood is ""okay."",Speech:  His speech is normal rate and volume.  Tone, his volume was decreased initially, but this improved during the course of the interview.,Thought Process:  His thought processes are markedly tangential.,Thought content:  The patient is fairly scattered.  He will provide history with frequent redirection, but he does not appear to stay on one topic for any length of time.  He denies currently auditory or visual hallucinations, though his partner says that this is a feature present at baseline.  Paranoid delusions are elicited.,Homicidal/Suicidal Ideation:  He denies suicidal or homicidal ideation.  Denies previous suicide attempts.,Cognitive Assessment:  Cognitively, he is alert and oriented to person and year only.  His memory is intact to names of his Madison Clinic providers.,Insight/Judgment:  His insight is absent as evidenced by his repeated questioning of the validity of his AIDS and mental health diagnoses.  His judgment is poor as evidenced by his longstanding pattern of minimal engagement in treatment of his mental health and physical health conditions.,Assets:  His assets include his housing and his history of supportive relationship with his partner over many years.,Limitations:  His limitations include his AIDS and his history of poor compliance with treatment.,FORMULATION:  ,The patient is a 45-year-old white male with a history of schizophrenia and AIDS.  He was admitted for disorganized and assaultive behaviors while off all medications for the last six months.  It is unclear to me how much his presentation is a direct expression of an AIDS-related condition, though I suspect the impact of his HIV status is likely to be substantial.,DIAGNOSES:,AXIS I:  Schizophrenia by history.  Rule out AIDS-induced psychosis.  Rule out AIDS-related cognitive disorder.,AXIS II:  Deferred.,AXIS III:  AIDS (stable by his report).  Anemia.,AXIS IV:  Relationship strain and the possibility that he may be unable to return to his home upon discharge; minimal engagement in mental health and HIV-related providers.,AXIS V:  Global Assessment Functioning is currently 15.,PLAN: , I will attempt to increase the database, will specifically request records from the last mental health providers.  The Internal Medicine Service will evaluate and treat any acute medical issues that could be helpful to collaborate with his providers at Clinic regarding issues related to his AIDS diagnosis.  With the patient's permission, I will start quetiapine at a dose of 100 mg at bedtime, given the patient's partner report of partial, but response to this agent in the past.  I anticipate titrating further for effect during the course of his admission.",
" Patient with a history of PTSD, depression, and substance abuse.", Psychiatry / Psychology, Psych Consult - Psychosis  ,"IDENTIFYING DATA:,  Psychosis.,HISTORY OF PRESENT ILLNESS: , The patient is a 28-year-old Samoan female who was her grandmother's caretaker.  Her grandmother unfortunately had passed away recently and then the patient had developed erratic behavior.  She had lived with her parents and son, but parents removed son from the home, secondary to the patient's erratic behavior.  Recently, she was picked up by Kent Police Department ""leaping on Highway 99."",PAST MEDICAL HISTORY: , PTSD, depression, and substance abuse.,PAST SURGICAL HISTORY:  ,Unknown.,ALLERGIES:,  Unknown.,MEDICATIONS: , Unknown.,REVIEW OF SYSTEMS: , Unable to obtain secondary to the patient being in seclusion.,OBJECTIVE:,  Vital signs that were previously taken revealed a blood pressure of 152/86, pulse of 106, respirations of 18, and temperature is 97.6 degrees Fahrenheit.  General appearance, HEENT, and history and physical examination was unable to be obtained today, as patient was put into seclusion.,LABORATORY DATA: , Laboratory reviewed reveals a BMP, slightly elevated glucose at 100.2.  Previous urine tox was positive for THC.  Urinalysis was negative, but did note positive UA wbc's.  CBC, slightly elevated leukocytosis at 12.0, normal range is 4 to 11.,ASSESSMENT AND PLAN:,AXIS I:  Psychosis.  Inpatient Psychiatric Team to follow.,AXIS II:  Deferred.,AXIS III:  We were unable to perform physical examination on the patient today secondary to her being in seclusion.  Laboratory was reviewed revealing leukocytosis, possibly secondary to a UTI.  We will wait until the patient is out of seclusion to perform examination.  Should she have some complaints of dysuria or any suprapubic pain, then we will begin on appropriate antimicrobial therapy.  We will followup with the patient should any new medical issues arise.","psychiatry / psychology, ptsd, depression, psychosis, psychiatric, substance abuse, erratic behavior, behavior, axis,"
 The patient was found by outpatient case manager to be unresponsive and incontinent of urine and feces at his father's home., Psychiatry / Psychology, Psych Consult - Psychosis - 1 ,"IDENTIFYING DATA: , This is a 26-year-old Caucasian male of unknown employment, who has been living with his father.,CHIEF COMPLAINT AND/OR REACTION TO HOSPITALIZATION: , The patient is unresponsive.,HISTORY OF PRESENT ILLNESS: , The patient was found by outpatient case manager to be unresponsive and incontinent of urine and feces at his father's home.  It is unknown how long the patient has been decompensated after a stay at Hospital.,PAST PSYCHIATRIC HISTORY: , Inpatient ITA stay at Hospital one year ago, outpatient at Valley Cities, but currently not engaged in treatment.,MEDICAL HISTORY: , Due to the patient being unresponsive and very little information available in the chart, the only medical history that we can identify is to observe that the patient is quite thin for height.  He is likely dehydrated, as it appears that he has not had food or fluids for quite some time.,CURRENT MEDICATIONS:,  Prior to admission, we do not have that information.  He has been started on Ativan 2 mg p.o. or IM if he refuses the p.o. and this would be t.i.d. to treat the catatonia.,SOCIAL AND DEVELOPMENTAL HISTORY:  ,The patient has been living in his father's home and this is all the information that we have available from the chart.,SUBSTANCE AND ALCOHOL HISTORY:  ,It is unknown with the exception of nicotine use.,LEGAL HISTORY: , Unknown.,GENETIC PSYCHIATRIC HISTORY: , Unknown.,MENTAL STATUS EXAM:,Attitude:  The patient is unresponsive.,Appearance:  He is lying in bed in the fetal position with a blanket over his head.,Psychomotor:  Catatonic.,EPS/TD:  Unable to assess though his limbs are quite contracted.,Affect:  Unresponsive.,Mood:  Unresponsive.,Speech:  Unresponsive.,Thought Process And Thought Content:  Unresponsive.,Psychosis:  Unable to elicit information to make this assessment.,Suicidal/Homicidal:  Also unable to elicit this information.,Cognitive Assessment:  Unable to elicit.,Judgment And Insight:  Unable to elicit.,Assets:  The patient is young.,Limitations:  Severe decompensation.,FORMULATION:  ,This is a 26-year-old Caucasian male with a diagnosis of psychosis, NOS, admitted with catatonia.,DIAGNOSES:,AXIS I:  Psychosis, NOS.,AXIS II:  Deferred.,AXIS III:  Dehydration.,AXIS IV:  Severe.,AXIS V:  10.,ESTIMATED LENGTH OF STAY: , 10 to 14 days.,RECOMMENDATIONS AND PLAN:,1.  Stabilize medically from the dehydration per internal medicine.,2.  Medications, milieu therapy to assist with re-compensation.",
 Psychiatric consultation for management of pain medications., Psychiatry / Psychology, Psych Consult - Pain Meds ,"REASON FOR CONSULTATION: , Management of pain medications.,HISTORY OF PRESENT ILLNESS: , This is a 60-year-old white male with history of coronary artery disease, status post CABG in 1985 with subsequent sternal dehiscence with rewiring in December 2005 and stent placement in LAD region in 2005, who developed sudden chest pain and was taken to San Jacinto via ambulance where he was diagnosed with acute MI and then went into atrial fibrillation.  An intraaortic balloon pump was placed for cardiogenic shock, and then he was transferred to the ABCD Hospital on October 22, 2006, for continued critical care.  He was in a state of cardiogenic shock and multiorgan system failure including respiratory failure and acute renal insufficiency when he was transferred.  He is currently on dialysis due to end-stage renal disease and has a tracheostomy.  He is receiving fentanyl since he has been here for back pain, leg pain, abdominal pain, and pain in the feet.  He states that he is currently in pain and the fentanyl only helps for about an hour or so before the pain resumes.  He currently rates his pain as 7 out of 10.  He denies a depressed mood or anxiety and states that he knows he is getting better.  He describes his sleep as erratic and states that he will sleep for 1 hour after giving fentanyl IV and then will wake up until he gets another fentanyl.  He has PEG for tube feeding.  He has weakness on left side of his body as well as both legs since his MI.  He has been switched from fentanyl IV q.2h. to the fentanyl patch today.  He also has been started on Seroquel 12.5 mg p.o. at bedtime and will receive his first dose on the evening of Monday, February 12, 2007.  He denies any other psychiatric symptoms including auditory or visual hallucinations or delusions.  His wife was present in the room and both him and his wife seemed to be offended by the suggestion of any psychiatric history or any psychiatric problems.,PAST MEDICAL HISTORY:,1.  DVT in December 2005.,2.  Three MI's (1996, 2005, and 2006).,3.  Diabetes for 5 years.,4.  Coronary artery disease for 10 years.,PAST SURGERIES:,1.  Appendectomy as a child.,2.  CABG x3, November 2005.,3.  Sternal rewiring, December 2005.,MEDICATIONS:,1.  Restoril 7.5 mg p.o. at bedtime p.r.n.,2.  Acetaminophen 650 mg p.o. q.6h. p.r.n. fever.,3.  Aspirin 81 mg p.o. daily.,4.  Bisacodyl suppository 10 mg per rectum daily.,5.  Erythropoietin injection 100 mcg subcutaneously every week at 5 p.m.,6.  Esomeprazole 40 mg IV q.12h.,7.  Fentanyl patch 25 mcg per hour.,8.  Transderm patch every 72 hours.,9.  Heparin IV.,10.  Lactulose 30 mL p.o. daily p.r.n. constipation.,11.  Metastron injection 4 mg IV q.6h. p.r.n. nausea.,12.  Seroquel 12 mg p.o. at bedtime.,13.  Saliva substitute 30 mL spray p.o. q.3h. p.r.n. dry mouth.,14.  Simethicone drops 80 mg per G-tube p.r.n. gas pain.,15.  Bactrim suspension p.o. daily.,16.  Insulin medium dose sliding scale.,17.  Albumin 25% IV p.r.n. hemodialysis.,18.  Ipratropium solution for nebulizer.,ALLERGIES:,  No known drug allergies.,PAST PSYCHIATRIC HISTORY:,  The patient denies any past psychiatric problems.  No medications.  He denies any outpatient visits or inpatient hospitalizations for psychiatric reasons.,SOCIAL HISTORY:,  He lives with his wife in New Jersey.  He has 2 children.  One son in Texas City and 1 daughter in Florida.  He is a master mechanic for a trucking company since 1968.  He retired in the May 2006.  The highest level of education that he received was 1 year in college.,Ethanol, tobacco, or drugs; he smoked 2 packs per day for 40 years, but quit in 1996.  He occasionally has a beer, but denies any continuous use of alcohol.  He denies any illicit drug use.,FAMILY HISTORY:,  Both parents died with myocardial infarctions.  He has 2 sisters and a brother with diabetes mellitus and coronary artery disease.  He denies any history of psychiatric problems in family.,MENTAL STATUS EXAMINATION:,  The patient was sitting in his bed in hospital gown with tracheostomy and receiving tube feeding.  The patient's appearance was appropriate with fair-to-good grooming and hygiene.  He had little-to-no psychomotor activity secondary to weakness post MI.  He had good eye contact.  His speech was of decreased rate volume and flexion secondary to tracheostomy.  The patient was cooperative.  He described his mood is not good in congruent stable and appropriate affect with decreased range.  His thought process is logical and goal directed.  His thought content was negative for delusions, phobias, obsessions, suicidal ideation, or homicidal ideation.  He denied any perceptional disturbances including any auditory or visual hallucinations.  He was alert and oriented x3.,Mini mental status exams not completed.,ASSESSMENT:,AXIS I:  Pain with physical symptoms and possibly psychological symptoms.,AXIS II:  Deferred.,AXIS III:  See above.",
 Psychiatric Consultation of patient with altered mental status., Psychiatry / Psychology, Psych Consult - Altered Mental Status ,"REASON FOR CONSULT:,  Altered mental status.,HPI:,  The patient is 77-year-old Caucasian man with benign prostatic hypertrophy, status post cardiac transplant 10 years ago who was admitted to the Physical Medicine and Rehab Service for inpatient rehab after suffering a right cerebellar infarct last month.  Last night, he became confused and he eloped from the unit.  When he was found, he became combative.  This a.m., he continued to be aggressive and required administration of four-point soft restraints in addition to Haldol 1 mg intramuscularly.  There was also documentation of him having paranoid thoughts that his wife was going out spending his money instead of being with him in the hospital.  Given this presentation, Psychiatry was consulted to evaluate and offer management recommendations.,The patient states that he does remember leaving the unit looking for his wife, but does not recall becoming combative, needing restrains and emergency medications.  He reports feeling fine currently, denying any complaints.  The patient's wife notes that her husband might be confused and disoriented due to being in the hospital environment.  She admits that he has some difficulty with memory for sometime and becomes irritable when she is not around.  However, he has never become as combative as he has this particular episode.,He negates any symptoms of depression or anxiety.  He also denies any hallucinations or delusions.  He endorses problems with insomnia.  At home, he takes temazepam.  His wife and son note that the temazepam makes him groggy and disoriented at times when he is at home.,PAST PSYCHIATRIC HISTORY:,  He denies any prior psychiatric treatment or intervention.  However, he was placed on Zoloft 10 years ago after his heart transplant, in addition to temazepam for insomnia.  During this hospital course, he was started on Seroquel 20 mg p.o. q.h.s. in addition to Aricept 5 mg daily.  He denies any history of suicidal or homicidal ideations or attempts.,PAST MEDICAL HISTORY:,1.  Heart transplant in 1997.,2.  History of abdominal aortic aneurysm repair.,3.  Diverticulitis.,4.  Cholecystectomy.,5.  Benign prostatic hypertrophy.,ALLERGIES:,  MORPHINE AND DEMEROL.,MEDICATIONS:,1.  Seroquel 50 mg p.o. q.h.s., 25 mg p.o. q.a.m.,2.  Imodium 2 mg p.o. p.r.n., loose stool.,3.  Calcium carbonate with vitamin D 500 mg b.i.d.,4.  Prednisone 5 mg p.o. daily.,5.  Bactrim DS Monday, Wednesday, and Friday.,6.  Flomax 0.4 mg p.o. daily.,7.  Robitussin 5 mL every 6 hours as needed for cough.,8.  Rapamune 2 mg p.o. daily.,9.  Zoloft 50 mg p.o. daily.,10.  B vitamin complex daily.,11.  Colace 100 mg b.i.d.,12.  Lipitor 20 mg p.o. q.h.s.,13.  Plavix 75 mg p.o. daily.,14.  Aricept 5 mg p.o. daily.,15.  Pepcid 20 mg p.o. daily.,16.  Norvasc 5 mg p.o. daily.,17.  Aspirin 325 mg p.o. daily.,SOCIAL HISTORY:,  The patient is a retired paster and missionary to Mexico.  He is still actively involved in his church.  He denies any history of alcohol or substance abuse.,MENTAL STATUS EXAMINATION:,  He is an average-sized white male, casually dressed, with wife and son at bedside.  He is pleasant and cooperative with good eye contact.  He presents with paucity of speech content; however, with regular rate and rhythm.  He is tremulous which is worse with posturing also some increased motor tone noted.  There is no evidence of psychomotor agitation or retardation.  His mood is euthymic and supple and reactive, appropriate to content with reactive affect appropriate to content.  His thoughts are circumstantial but logical.  He defers most of his responses to his wife.  There is no evidence of suicidal or homicidal ideations.  No presence of paranoid or bizarre delusions.  He denies any perceptual abnormalities and does not appear to be responding to internal stimuli.  His attention is fair and his concentration impaired.  He is oriented x3 and his insight is fair.  On mini-mental status examination, he has scored 22 out of 30.  He lost 1 for time, lost 1 for immediate recall, lost 2 for delayed recall, lost 4 for reverse spelling and could not do serial 7s.  On category fluency, he was able to name 17 animals in one minute.  He was unable to draw clock showing 2 minutes after 10.  His judgment seems limited.,LABORATORY DATA:,  Calcium 8.5, magnesium 1.8, phosphorous 3, pre-albumin 27, PTT 24.8, PT 14.1, INR 1, white blood cell count 8.01, hemoglobin 11.5, hematocrit 35.2, and platelet count 255,000.  Urinalysis on January 21, 2007, showed trace protein, trace glucose, trace blood, and small leukocyte esterase.,DIAGNOSTIC DATA:,  MRI of brain with and without contrast done on January 21, 2007, showed hemorrhagic lesion in right cerebellar hemisphere with diffuse volume loss and chronic ischemic changes.,ASSESSMENT:,AXIS I:,1.  Delirium resulting due to general medical condition versus benzodiazepine ,intoxication/withdrawal.,2.  Cognitive disorder, not otherwise specified, would rule out vascular dementia.,3.  Depressive disorder, not otherwise specified.",
 Psychiatric consultation of patient with lethargy., Psychiatry / Psychology, Psych Consult - Lethargy ,"REASON FOR CONSULTATION: , Lethargy.,HISTORY OF PRESENT ILLNESS:,  The patient is a 62-year-old white female with a past medical history of left frontal glioblastoma with subsequent craniotomy infection for PE, DVT, hyperlipidemia, and hypertension who is according to the patient's daughter expressing signs of depression.  Symptoms began on February 5, 2007, upon receiving the unexpected news, the patient would need three to four more days of chemotherapy and radiation therapy for her glioblastoma, described as a sudden onset of symptoms including hypersomnia (18 to 20 hours per day), drastic decrease in energy level, anhedonia, feelings of hopelessness and helplessness, psychomotor retardation, and past history of suicidal ideations.  The patient's appetite is unknown since she had been fed by NG tube after being diagnosed with neuromuscular oropharyngeal dysphagia.  Prior to receiving the news for needing more cancer therapy, the patient was described as being ""fine,"" participating in physical therapy and talking regularly as she was looking forward to leaving the hospital.  Now, the patient has become angry, socially withdrawn, not wanting to see anyone including her own grandchildren, and not participating in physical therapy.  Has been on a daily dose of Lexapro since January 08, 2007, was increased from 10 mg to 20 mg on January 24, 2007, which is her current dose.  Has been on Provigil 100 mg b.i.d. since February 06, 2007, but has not noticed an impact.  Had been on Zyprexa 2.5 mg p.o. q.p.m. from December 20, 2006, to February 01, 2007, but has been discontinued.  Currently, the patient has not displayed any manic symptoms, auditory or visual hallucinations, or symptoms of anxiety.  Also, denies any homicidal ideations.,PAST PSYCHIATRIC HISTORY:,  Was prescribed Prozac for depression, felt during husband's successful battle with prostate cancer.  Never been diagnosed with psychiatric illness.  Displayed some psychotic symptoms, status post craniotomy while in ICU, treated with Zyprexa and Xanax during hospitalization in 2006.,PAST MEDICAL HISTORY:,  Craniotomy November 2006 with subsequent CSF infection of enterobacter, status post glioblastoma multiforme, PE, DVT, hypertension, SIADH, and IVC filter.  No history of thyroid problems, seizures, strokes, or traumatic head injuries.,HOME MEDICATIONS:,  Norvasc 5 mg daily, TriCor 145 mg daily, aspirin one tablet daily, Tylenol, and glucosamine chondroitin sulfate.,CURRENT MEDICATIONS:,  Norvasc 10 mg p.o. daily, Decadron injection 6 mg IV q.12h., Colace 100 mg liquid b.i.d., Cardura 2 mg p.o. daily, Lexapro 20 mg p.o. daily, Lopressor 50 mg p.o. q.12h., Flagyl 500 mg via PEG tube q.8h., modafinil 100 mg p.o. b.i.d., Lovenox 60 mg subcu q.12h., insulin sliding scale, Tylenol suppositories 650 mg rectal q.4h. p.r.n., and Ambien 5 mg p.o. q.h.s. p.r.n.,ALLERGIES:,  PHENYTOIN (STEVENS-JOHNSON SYNDROME), CODEINE, NOVOCAIN, UNKNOWN ALLERGY.,FAMILY MEDICAL HISTORY:,  Father had lung cancer, was smoker for 40 years.  Father's aunt have heart disease.,SOCIAL AND DEVELOPMENTAL HISTORY:,  Currently lives with husband of 40 years in League City, has a Masters in Education, is a retired reading specialist which she did it for 33 years.  Has one younger brother, one daughter.  Denies use of tobacco, alcohol and illicit drugs.  The child as per daughter was picked on and has a strained relationship with her mother, but they still are communicating.,MENTAL STATUS EXAMINATION:,  The patient is a 62-year-old white female, lying in hospital bed, with gown on, eyes closed, short shaven hair, and golf ball-sized indentation in the anterior fontanelle from craniotomy.  Psychomotor retardation, poor eye contact, speech low volume, slow rate, poor flexion, essentially unresponsive, and somnolent during interview.  Poor concentration, mood unknown (the patient did not respond to questions), affect flat, thought process logical and goal directed, thought content unable to assess from the patient but the patient's daughter denied delusions and homicidal ideations.  Positive for passive suicidal ideations and perceptions.  No auditory or visual hallucinations.  Sensorium stuporous, did not answer orientation questions.  Memory information, intelligence, judgment, and insight unknown.,Mini-Mental status examination unable to be performed.,ASSESSMENT:,  A 62-year-old white female status post craniotomy for glioblastoma multiforme with subsequent CNS infection and currently has been displaying symptoms of depression for the past seven days and hence was told she needed more chemotherapy and radiation therapy.,Axis I:  Depression, NOS.  Rule out depression secondary to general medical condition.,Axis II:  Deferred.,Axis III:  Craniotomy with subsequent CSF infection, PE, DVT, and hypertension.,Axis IV:  Hospitalization.,Axis V:  11.,PLAN:,  Continue Lexapro 20 mg p.o. daily.  Discontinue Provigil, begin Ritalin 5 mg p.o. q.a.m. and q. noon.,Thank you for the consultation.",
 Psychiatric Consultation of patient with major depression disorder., Psychiatry / Psychology, Psych Consult - Depression - 2 ,"REASON FOR CONSULT:,  Depression.,HPI:,  The patient is an 87-year-old white female admitted for low back pain status post hip fracture sustained a few days before Thanksgiving in 2006.  The patient was diagnosed and treated for a T9 compression fraction with vertebroplasty.  Soon after discharge, the patient was readmitted with severe mid low back pain and found to have a T8 compression fracture.  This was also treated with vertebroplasty.  The patient is now complaining of back pain that fluctuates at time, acknowledging her pain medication works but not all the time.  Her pain is in her upper back around her shoulder blades.  The patient says lying down with the heated pad lessens the pain and that any physical activity increases it.  MRI on January 29, 2007, was positive for possible meningioma to the left of anterior box.,The patient reports of many depressive symptoms, has lost all interest in things she used to do (playing cards, reading).  Has no energy to do things she likes, but does participate in physical therapy, cries often and what she believes for no reason.  Does not see any future for herself.  Reports not being able to concentrate on anything saying she gets distracted by thoughts of how she does not want to live anymore.  Admits to decreased appetite, feeling depressed, and always wanting to be alone.  Claims that before her initial hospitalization for her hip fracture, she was highly active, enjoyed living independently at Terrace.  Denies suicidal ideations and homicidal ideations, but that she did not mind dying, and denies any manic symptoms including decreased need to sleep, inflated self-worth, and impulsivity.  Denies auditory and visual hallucinations.  No paranoid, delusions, or other abnormalities of thought content.  Denies panic attacks, flashbacks, and other feelings of anxiety.  Does admit to feeling restless at times.  Is concerned with her physical appearance while in the hospital, i.e., her hair looking ""awful."",PAST MEDICAL HISTORY:,  Hypertension, cataracts, hysterectomy, MI, osteoporosis, right total knee replacement in April 2004, hip fracture, and newly diagnosed diabetes.  No history of thyroid problems, seizures, strokes, or head injuries.,CURRENT MEDICATIONS:,  Norvasc 10 mg p.o. daily, aspirin 81 mg p.o. daily, Lipitor 20 mg p.o. daily, Klonopin 0.5 mg p.o. b.i.d., digoxin 0.125 mg p.o. daily, Lexapro 10 mg p.o. daily, TriCor 145 mg p.o. each bedtime, Lasix 20 mg p.o. daily, Ismo 20 mg p.o. daily, lidocaine patch, Zestril, Prinivil 40 mg p.o. daily, Lopressor 75 mg p.o. b.i.d., Starlix 120 mg p.o. t.i.d., Pamelor 25 mg p.o. each bedtime, polyethylene glycol 17 g p.o. every other day, potassium chloride 20 mEq p.o. t.i.d., Norco one tablet p.o. q.4h. p.r.n., Zofran 4 mg IV q.6h.,HOME MEDICATIONS:,  Unknown.,ALLERGIES:,  CODEINE (HALLUCINATIONS).,FAMILY MEDICAL HISTORY:,  Unremarkable.,PAST PSYCHIATRIC HISTORY:,  Unremarkable.  Never taken any psychiatric medications or have ever had a family member with psychiatric illness.,SOCIAL/DEVELOPMENTAL HISTORY:,  Unremarkable childhood.  Married for 40 plus years, widowed in 1981.  Worked as administrative assistant in UTMB Hospitals VP's office.  Two children.  Before admission, lived in the Terrace Independent Living Center.  Was happy and very active while living there.  Had friends in the Terrace and would not mind going back there after discharge.  Occasional glass of wine at dinner.  Denies ever using illicit drugs and tobacco.,MENTAL STATUS EXAM:,  The patient is an 87-year-old white female with appropriate appearance, wearing street clothes while lying in bed with her eyes tightly closed.  Slight decrease in motor activity.  Normal eye contact.  Speech, low volume and rate.  Good articulation and inflexion.  Normal concentration.  Mood, labile, tearful at times, depressed, then euthymic.  Affect, mood congruent, full range.  Thought process, logical and goal directed.  Thought content, no delusions, suicidal or homicidal ideations.  Perception, no auditory or visual hallucinations.  Sensorium, alert, and oriented x3.  Memory, fair.  Information and intelligence, average.  Judgment and insight, fair.,MINI MENTAL STATUS EXAM,:  A 28/30.  Could not remember two out of the three recalled words.,ASSESSMENT:,  The patient is an 87-year-old white female with recent history of hip fracture and two thoracic compression fractures.  The patient reports being high functioning prior to admission and says her depression symptoms have occurred while being in the hospital.,Axis I:  Major depression disorder.,Axis II:  Deferred.,Axis III:  Osteoporosis, hypertension, hip fracture, possible diabetes, meningioma, MI, and right total knee replacement.,Axis IV:  Lives independently at Terrace, difficulty walking, hospitalization.,Axis V:  45.,PLAN:,  Continue Lexapro 10 mg daily and Pamelor 25 mg each bedtime monitor for adverse effects of TCA and worsening of depressive symptoms.  Discussed about possible inpatient psychiatric care.,Thank you for the consultation.",
 Psychiatric Consultation of patient with dementia., Psychiatry / Psychology, Psych Consult - Dementia ,"REASON FOR CONSULT,:  Dementia.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 33-year-old black female, referred to the hospital by a neurologist in Tyler, Texas for disorientation and illusions.  Symptoms started in June of 2006, when the patient complained of vision problems and disorientation.  The patient was seen wearing clothes inside out along with other unusual behaviors.  In August or September of 2006, the patient reported having a sudden onset of headaches, loss of vision, and talking sporadically without making any sense.  The patient sought treatment from an ophthalmologist.  We did not find any abnormality in the Behavior Center in Tyler, Texas.  The Behavior Center referred the patient to Dr. Abc, a neurologist in Tyler, who then referred the patient to this hospital.,According to the mother, the patient has had no past major medical or psychiatric illnesses.  The patient was functioning normally before June 2006, working as accounting tech after having completed 2 years of college.  She reports of worsening in symptoms, mainly unable to communicate about auditory or visual hallucinations or any symptoms of anxiety.  Currently, the patient lives with mother and requires her assistance to perform ADLs and the patient has become ataxic since November 2006.  Sleeping patterns and the amount is unknown.  Appetite is okay.,PAST PSYCHIATRIC HISTORY:,  The patient was diagnosed with severe depression in November 2006 at the Behavior Center in Tyler, Texas, where she was given Effexor.  She stopped taking it soon after, since they worsened her eye vision and balance.,PAST MEDICAL HISTORY: , In 2001 diagnosed with Meniere disease, was treated such that she could function normally in everyday activities including work.  No current medications.  Denies history of seizures, strokes, diabetes, hypertension, heart disease, or head injury.,FAMILY MEDICAL HISTORY:  ,Father's grandmother was diagnosed with Alzheimer disease in her 70s with symptoms similar to the patient described by the patient's mother.  Both, the mother's father and father's mother had ""nervous breakdowns"" but at unknown dates.,SOCIAL HISTORY: , The patient lives with a mother, who takes care of the patient's ADLs.  The patient completed school, up to two years in college and worked as accounting tech for eight years.  Denies use of alcohol, tobacco, or illicit drugs.,MENTAL STATUS EXAMINATION: , The patient is 33-year-old black female wearing clean clothes, a small towel on her head and over a wheel chair with her head rested on a pillow and towel.  Decreased motor activity, but did blink her eyes often, but arrhythmically.  Poor eye contact.  Speech illogic.  Concentration was not able to be assessed.  Mood is unknown.  Flat and constricted affect.  Thought content, thought process and perception could not be assessed.  Sensorial memory, information, intelligence, judgment, and insight could not be evaluated due to lack of communication by the patient.,MINI-MENTAL STATUS EXAM: , Unable to be performed.,AXIS I:  Rapidly progressing early onset of dementia, rule out dementia secondary to general medical condition, rule out dementia secondary to substance abuse.,AXIS II:  Deferred.,AXIS III:  Deferred.,AXIS IV:  Deferred.,AXIS V:  1.,ASSESSMENT: , The patient is a 32-year-old black female with rapid and early onset of dementia with no significant past medical history.  There is no indication as to what precipitated these symptoms, as the mother is not aware of any factors and the patient is unable to communicate.  The patient presented with headaches, vision forms, and disorientation in June 2006.  She currently presents with ataxia, vision loss, and illusions.,PLAN: , Wait for result of neurological tests.  Thank you very much for the consultation.","psychiatry / psychology, reason for consult:, concentration, dementia, mood, psychiatric consultation, sensorial memory, affect, disorientation, illusions, information, insight, intelligence, judgment, loss of vision, motor activity, neurologist, thought process, unusual behaviors, mental status examination, consultation, headaches, "
 Psychiatric Consultation of patient with recurring depression., Psychiatry / Psychology, Psych Consult - Depression - 1 ,"CC: , ""Five years ago, I stopped drinking and since that time, I have had severe depression.  I was doing okay when I stopped my medications in April for a few weeks, but then I got depressed again.  I started lithium three weeks ago."",HPI:  ,The patient is a 45-year-old married white female without children currently working as a billing analyst for Northwest Natural.  The patient has had one psychiatric hospitalization for seven days in April of 1999.  The patient now presents with recurrent depressive symptoms for approximately four months.  The patient states that she has decreased energy, suicidal ideation, suicide plan, feelings of guilt, feelings of extreme anger, psychomotor agitation, and increased appetite.  The patient states her sleep is normal and her ability to concentrate is normal.  The patient states that last night she had an argument with her husband in which he threaten to divorce her.  The patient went into the rest room, tried to find a razor blade, could not find one but instead found a scissor and cut her arm moderately with some moderate depth.  She felt better after doing so and put a bandage over the wound and did not report to her husband or anybody else what she had done.  The patient reports that she has had increased tension with her husband as of recent.  She notes that approximately a week ago she struck her husband several times.  She states that he has never hit her but instead pushed her back after she was hitting him.  She reports no history of abuse in the past.  The patient identifies recent stressors as having ongoing conflict at work with her administrator with them ""cracking down on me."" The patient also notes that her longstanding therapy will be temporarily interrupted by the therapist having a child.  She states that her recent depression seems to coincide with her growing knowledge that her therapist was pregnant.  The patient states that she has a tremendous amount of anger towards her therapist for discontinuing or postponing treatment.  She states that she feels ""abandoned."" The patient notes that it does raise issues with her past, where she had a child at the age of 17 who she gave away for adoption and a second child that she was pregnant by the age of 42 that she aborted at the request of her husband.  The patient states she saw her therapist most recently last Friday.  She sees the therapy weekly and indicates the therapy helps, although she is unable to specify how.  When asked for specifics of what she has learned from the therapy, the patient was unable to reply.  It appears that she is very concrete and has difficulty with symbolization and abstractions and self-observation.  The patient reports that at her last visit her therapist was concerned that she may be suicidal and was considering hospitalization.  The patient, at that point, stated that she would be safe through Monday despite having made a gesture last night.  At present, the patient's mood is reactive and for much of the session she appears angry and irritated with me but at the end of the session, after I have given her my assessment, she appears calmed and not depressed.  When asked if she is suicidal at present, she states no.  The patient does not want to go into the hospital.  The patient also indicates at the end of the session she felt hopeful.  The patient reports her current sleep is about eight hours per night.  She states that longest she has been able to stay awake in the past has been 24 hours.  She states that during periods where she feels up she sleeps perhaps six hours per night.  The patient reports no spending sprees and no reports no sexual indiscretions.  The patient states that her sexuality does increase when she is feeling better but not enormously so.  The patient denies any history of delusions or hallucinations.  The patient denies any psychosis.  The patient states that she does have mood swings and that the upstate lasts for a couple of weeks at longest.  She states that more predominately she has depression.  The patient states that she does not engage in numerous projects when she is in an upstate although does imagine doing so.  The patient notes that suicidality and depression seems to often arise around disputes with her husband and/or feelings of abandonment.  The patient indicates some satisfaction when she is called on her behavior ""I need to answer for my actions."" The patient gives a substantial history of alcohol abuse lasting up to about five years ago when she was hospitalized.  Most typically, the patient will drink at least a bottle of wine per day.  The patient has attended AA but at present going once a week, although she states that she is not engaged as she has been in the past; and when asked if she may be in early relapse, she indicates that yes that is a very real possibility.  The patient states she is not working through any of the steps at present.,PPH: , The patient denies any sexual abuse as a child.  She states that she was disciplined primarily by her father with spankings.  She states that on occasion her mother would use a belt to spank her or with her hand or with a spoon.  The patient has been seeing Dr. A for the past five years.  Prior to that she was admitted to a hospital for her suicide attempt.  The patient also has one short treatment experienced with the Day Treatment Program here in Portland.  The patient states that it was not useful as it focused on group work with pts that she did not feel any similarity with.  The patient, also as a child, had a history of cutting behaviors.  The patient was admitted to the hospital after lacerating her arm.,MEDICAL HISTORY:  ,The patient has hypothyroidism and last had her TSH drawn a week ago but does not know the results.  Janet Green is her primary physician.  The patient also has had herniated disc in the neck and a sinus inflammation, both of which were treated surgically.,CURRENT MEDICATIONS: , The patient currently is taking Synthroid 75 mcg per day and lithium 1200 mg p.o. q.d. The patient started the lithium approximately three weeks ago and has not had a recent lithium level or kidney function test.,ALLERGIES: , No known drug allergies.,SUBSTANCE HISTORY: , The patient has been sober for five years.  She drank one bottle of wine per day as per HPI.  History of drinking for approximately 25 years.  The patient does not currently have a sponsor.  The patient experimented with amphetamines, cocaine, marijuana approximately 16 years ago.,SOCIAL HISTORY: , The patient's mother is age 66, father is age 70, and she has a brother age 44.  Her brother has been incarcerated numerous times for assaults and has difficulty with anger and rage.  He made a suicide attempt at age 17.  The patient's father is a machinist who she describes as somewhat narcissistic and with alcohol abuse problem.  He also has arthritis.  The patient's mother is arthritic.  She states that her mother stopped working at middle age after being laid off and appears somewhat reclusive.,EDUCATIONAL HISTORY: , The patient was educated through high school and has two years of Night College.  The patient states that she grew up and was raised in Portland but notes her childhood was primarily lonely.  She states she was unliked and unpopular child because she was ""shy"" and ""not smart enough."" The patient denies having secrets.  The patient reports that this is her second marriage, which has lasted two years.  Her first marriage lasted I believe it was five years.  The patient also had a relationship in recovery for four years, which ended after they went ""different directions."",MSE:,  The patient is middle-aged white female, dressed in a red sweater with a white shirt, full patterned skirt, and open sandals.  The patient is suspicious and somewhat confrontative early in the session.  She asked me regarding my cancellation policy, why I require seven days and not 24 hours.  The patient also is irritated with paper required of her.  Psychomotor is increased slightly.  The patient makes strong eye contact.  Speech is normal rate, rhythm, and volume.  Mood is ""irritated."" Affect is irritated, angry, demanding, attempting to wrest control from me, depressed, frustrated.  Thought is directed.  Content is nondelusional.  There are no auditory and no visual hallucinations.  The patient has no homicidal ideation.  The patient does endorse suicidal ideations.  Regarding plan, the patient notes that cutting herself hurts too much therefore she would like to take some benzodiazepines or barbiturates but has access to none.  The patient states that she will not try to hurt herself currently and that she poses no risk at present.  The patient notes that she does not want to go to the hospital at present.  The patient is alert and oriented x 3.  Recall is three for three at five minutes.  Proverbs are concrete.  She has fair impulse control, poor judgment, and poor insight.,FORMULATION:  ,The patient is a 45-year-old married white female with no children now presenting with recurrent depressive symptoms and active suicidal ideation and planning.  The patient reports longstanding depressive symptoms that were subthreshold punctuated by periods of more severe depression.  The patient also reports some up periods, which do not meet most criteria for a bipolar disorder or manic states.  The patient notes that current depression started with approximately the same time that she became aware that her therapist was pregnant.  She notes that the current depression is atypical in that it is primarily anger based and she does not have the typical hypersomnia that she gets.  The patient reports being unable to express anger to her therapist and being unable to discuss her feeling regarding the pregnancy.  The patient also states that she feels abandoned with the upcoming discontinuation of treatment while the therapist is giving birth and thereafter.  Symptoms are consistent with a longstanding dysthymia and reoccurring depression.  In addition, diagnosis is highly complicated by presence of a strong personality disorder component, most likely borderline personality disorder.  This latter diagnosis seems to be the most active at this time with the patient acutely reacting to perceived therapist's absence and departure.  This is exacerbated by instability in the patient's marital life.,DIAGNOSIS:,Axis I:  Dysthymia.  Major depression, moderate severity, recurrent, with partial remission.,Axis II:  Borderline personality disorder.,Axis III:  Hypothyroidism and cervical disc herniation and sinus surgery.,Axis IV:  Medical access.  Marital discord.,Axis V:  A GAF of 30.,PLAN:  ,The patient is unlikely to have bipolar disorder.  We will recommend the patient's thyroid be rechecked to ensure she is currently euthymic.  We would recommend continued weekly or twice weekly insight oriented psychotherapy with aggressive exploration of the patient's reaction to her therapist's departure.  We would also recommend dialectical behavioral therapy while the therapist is on leave.  We would recommend continued treatment with SSRIs for dysthymia and depression.  We would suggest prescribing long acting antidepressant such as Prozac, given the patient's ambivalence regarding medications.  Prozac should be pushed to minimum of 40 mg, which the patient has already tolerated in the past, but most likely up to 60 or 80 mg.  We might also supplement the Prozac with a (anti-sleep medication).,Time spent with the patient was 1.5 hours.",
" A 41-year-old African-American male with a history of bipolar affective disorder, was admitted for noncompliance to the outpatient treatment and increased mood lability.", Psychiatry / Psychology, Psych Consult - Bipolar Affective Disorder ,"IDENTIFYING DATA: , The patient is a 41-year-old African-American male with a history of bipolar affective disorder, was admitted for noncompliance to the outpatient treatment and increased mood lability.,CHIEF COMPLIANT: , ""I'm here because I'm different."" The patient exhibits poor insight into illness and need for treatment.,HISTORY OF PRESENT ILLNESS: , The patient has a history of bipolar affective disorder and poor outpatient compliance.  According to mental health professionals, he had not been compliant with medications or outpatient followup, and over the past several weeks, the patient had become increasingly labile.  The patient had expressed grandiose delusions that he is Martin Luther King, and was found recently at a local church agitated throwing a pew and a lectern and required Tasering by police.  On admission interview, the patient remains euphoric with poor insight.,PAST PSYCHIATRIC HISTORY: , History of bipolar affective disorder.  The patient has been treated with Depakote and Seroquel, but has had no recent treatment or followup.  Dates of previous hospitalizations are not known.,PAST MEDICAL HISTORY: , None known.,CURRENT MEDICATIONS: , None.,FAMILY SOCIAL HISTORY: , Unemployed.  The patient resides independently.  The patient denies recent substance abuse, although tox screen was positive for benzodiazepines.,LEGAL HISTORY: , Need to increase database.,FAMILY PSYCHIATRIC HISTORY: , Need to increase database.,MENTAL STATUS EXAMINATION:  ,Attitude:  Suspicious, but cooperative.,Appearance:  Shows appropriate hygiene and grooming.,Psychomotor Behavior:  Within normal limits.  No agitation or retardation.  No EPS or TDS noted.,Affect:  Labile.,Mood:  Euphoric.,Speech:  Pressured.,Thoughts:  Disorganized.,Thought Content:  Remarkable for grandiose delusions as noted.  The patient denies auditory hallucinations.,Psychosis:  Grandiose delusions as noted above.,Suicidal/Homicidal Ideation:  The patient denies on admission.,Cognitive Assessment:  Grossly intact.  The patient is oriented x 3.,Judgment:  Poor shown by noncompliance to the outpatient treatment.,Assets:  Include stable physical status.,Limitations:  Include recurrent psychosis.,FORMULATION: , The patient with a history of bipolar affective disorder, was admitted for increasing mood lability and noncompliance to the outpatient treatment.,INITIAL IMPRESSION:,AXIS I:  BAD, manic with psychosis.,AXIS II:  None.,AXIS III:  None known.,AXIS IV:  Severe.,AXIS V:  10.,ESTIMATED LENGTH OF STAY: , 12 days.,PLAN: , The patient will be restarted on Depakote for mood lability and Seroquel for psychosis and his response will be monitored closely.  The patient will be evaluated for more structural outpatient followup following stabilization.",
 Psychiatric consultation for alcohol withdrawal and dependance., Psychiatry / Psychology, Psych Consult - Alcohol Withdrawal ,"REASON FOR CONSULT:,  Evaluation of alcohol withdrawal and dependance as well as evaluation of anxiety.,HISTORY OF PRESENT ILLNESS: , This is a 50-year-old male who was transferred from Sugar Land ER to ABCD Hospital for admission to the MICU for acute alcohol withdrawal.  The patient had been on a drinking binge for the past 12 days prior to admission and had not been eating.  He reported that he called 911 secondary to noticing bilious vomiting and dry heave.  The patient has been drinking for the past 25 years and has noted it to be a problem for at least the past 3 years.  He has been away from work secondary to alcohol cravings and drinking.  He has also experienced marital and family conflict as a result of his drinking habit.  On average, the patient drinks 5 to 8 glasses or cups of vodka or rum per day, and on the weekend, he tends to drink more heavily.  He reports a history of withdrawal symptoms, but denied history of withdrawal seizures.  His longest period of sobriety was one year, and this was due to the assistance of attending AA meetings.  The patient reports problems with severe insomnia, more so late insomnia and low self esteem as a result of feeling guilty about what he has done to his family due to his drinking habit.  He reports anxiety that is mostly related to concern about his wife's illness and fear of his wife leaving him secondary to his drinking habits.  He denies depressive symptoms.  He denies any psychotic symptoms or perceptual disturbances.  There are no active symptoms of withdrawal at this time.,PAST PSYCHIATRIC HISTORY: , There are no previous psychiatric hospitalizations or evaluations.  The patient denies any history of suicidal attempts.  There is no history of inpatient rehabilitation programs.  He has attended AA for periodic moments throughout the past few years.  He has been treated with Antabuse before.,PAST MEDICAL HISTORY:,  The patient has esophagitis, hypertension, and fatty liver (recently diagnosed).,MEDICATIONS: , His outpatient medications include Lotrel 30 mg p.o. q.a.m. and Restoril 30 mg p.o. q.h.s.,Inpatient medications are Vitamin supplements, potassium chloride, Lovenox 40 mg subcutaneously daily, Lactulose 30 mL q.8h., Nexium 40 mg IV daily, Ativan 1 mg IV p.r.n. q.6-8h.,ALLERGIES:,  No known drug allergies.,FAMILY HISTORY: , Distant relatives with alcohol dependance.  No other psychiatric illnesses in the family.,SOCIAL HISTORY:,  The patient has been divorced twice.  He has two daughters one from each marriage, ages 15 and 22.  He works as a geologist at Petrogas.  He has limited contact with his children.  He reports that his children's mothers have turned them against him.  He and his wife have experienced marital discord secondary to his alcohol use.  His wife is concerned that he may loose his job because he has skipped work before without reporting to his boss.  There are no other illicit drugs except alcohol that the patient reports.,PHYSICAL EXAMINATION:,  VITAL SIGNS:  Temperature 98, pulse 89, and respiratory rate 20, and blood pressure is 129/83.,MENTAL STATUS EXAMINATION:,  This is a well-groomed male.  He appears his stated age.  He is lying comfortably in bed.  There are no signs of emotional distress.  He is pleasant and engaging.  There are no psychomotor abnormalities.  No signs of tremulousness.  His speech is with normal rate, volume, and inflection.  Mood is reportedly okay.  Affect euthymic.  Thought content, no suicidal or homicidal ideations.  No delusions.  Thought perception, there are no auditory or visual hallucinations.  Thought process, Logical and goal directed.  Insight and judgment are fair.  The patient knows he needs to stop drinking and knows the hazardous effects that drinking will have on his body.,LABORATORY DATA:,  CBC:  WBC 5.77, H&H 14 and 39.4 respectively, and platelets 102,000.  BMP:  Sodium 140, potassium 3, chloride 104, bicarbonate 26, BUN 13, creatinine 0.9, glucose 117, calcium 9.5, magnesium 2.1, phosphorus 2.9, PT 13.4, and INR 1.0.  LFTs:  ALT 64, AST 69, direct bilirubin 0.5, total bilirubin 1.3, protein 5.8, and albumin 4.2.  PFTs within normal limits.,IMAGING:,  CAT scan of the abdomen and pelvis reveals esophagitis and fatty liver.  No splenomegaly.,ASSESSMENT:,  This is a 50-year-old male with longstanding history of alcohol dependence admitted secondary to alcohol withdrawal found to have derangement in liver function tests and a fatty liver.  The patient currently has no signs of withdrawal.  The patient's anxiety is likely secondary to situation surrounding his wife and their marital discord and the effect of chronic alcohol use.  The patient had severe insomnia that is likely secondary to alcohol use.  Currently, there are no signs of primary anxiety disorder in this patient.,DIAGNOSES:,  Axis I:  Alcohol dependence.,Axis II:  Deferred.,Axis III:  Fatty liver, esophagitis, and hypertension.,Axis IV:  Marital discord, estranged from children.,Axis V:  Global assessment of functioning equals 55.,RECOMMENDATIONS:,1.  Continue to taper off p.r.n. Ativan and discontinue all Ativan prior to discharge, benzodiazepine use, also on the same receptor as alcohol and prolonged use can cause relapse in the patient.  Discontinue outpatient Restoril.  The patient has been informed of the hazards of using benzodiazepines along with alcohol.,2.  Continue Alcoholics Anonymous meetings to maintain abstinence.,3.  Recommend starting Campral 666 mg p.o. t.i.d. to reduce alcohol craving.,4.  Supplement with multivitamin, thiamine, and folate upon discharge and before.  Marital counseling strongly advised as well as individual therapy for patient once sobriety is reached.  Referral has been given to the patient and his wife for the sets of counseling #713-263-0829.,5.  Alcohol education and counseling provided during consultation.,6.  Trazodone 50 mg p.o. q.h.s. for insomnia.,7.  Follow up with PCP in 1 to 2 weeks.",
" The patient is admitted on a 72-hour involuntary treatment for dangerousness to others after repeated assaultive behaviors at Hospital Emergency Room, the morning prior to admission.", Psychiatry / Psychology, Psych Consult - Assaultive Behavior ,"IDENTIFYING DATA:  ,The patient is a 40-year-old white male.  He is married, on medical leave from his job as a tree cutter, and lives with his wife and five children.,CHIEF COMPLAINT AND REACTION TO HOSPITALIZATION:  ,The patient is admitted on a 72-hour involuntary treatment for dangerousness to others after repeated assaultive behaviors at Hospital Emergency Room, the morning prior to admission.,HISTORY OF PRESENT ILLNESS:  ,The patient was very sleepy this morning, only minimally cooperative with interview.  Additional information taken from the emergency room records that accompanied him from Hospital yesterday as well as from his wife, who I contacted by telephone.  The patient was apparently at his stable baseline when discharged from the Hospital on 01/21/10, status post back surgery following a work-related injury.  The patient returned to Emergency Room on the evening prior to admission complaining of severe back pain.  His ER course is notable for yelling, spitting, and striking multiple staff members.  The patient was originally to be admitted for pain control, but when he threatened to leave, he was referred to MHPs, who subsequently detained him for 72 hours for dangerousness to others.  On interview, the patient reports only hazy memories of these incidences and states this behavior was secondary to his pain and his medications.  He was contrite about the violence.  When his wife was contacted by telephone, she agreed with this assessment and reports that he has a history of domestic violence usually in the setting of alcohol and illicit substance intoxication, but denies any events in the last 3 years.,His wife reports that after discharge from the hospital, on 01/21/10, he was prescribed Percocet, Soma, hydroxyzine, and Valium.  He essentially exhausted his approximately 10 days' supply of these agents on the morning of 01/23/10, and as above believes that this was responsible for his presentation yesterday.  She reports that she has been in contact with him since his arrival in our facility and reports that he is ""back to normal."" She denies feeling that he currently represents a threat to her or her five children.  She was unaware of his mental health history, but denies that he has received care for any condition since they were married three years ago.,PAST PSYCHIATRIC HISTORY: , The patient has a history of Involuntary Treatment Act of 72 hours in our facility in 2004 or 2005 for assaultive behaviors; however, these records are not currently available for review.  The patient denies any outpatient mental health treatment before or since this hospitalization.  He describes his mental health diagnosis of bipolar affective disorder; however, he denies a history of dramatic mood swings in the absence of illicit substances or alcohol intoxication.,PAST MEDICAL HISTORY:,  Notable for status post back surgery, discharged from Hospital on 01/21/10.,MEDICATIONS:,  From discharge from Hospital on 01/21/10, include Percocet, Valium, Soma, and Vistaril, doses and frequency are not currently known.  His wife reports that he was discharged with approximately 10 days' supply of these agents.,SOCIAL AND DEVELOPMENTAL HISTORY:  ,The patient is employed as a tree cutter, currently on medical leave for the last 2 months following a back injury.  He lives with his wife and children.  He has a history of domestic violence, but not recently.  Other details of occupational, educational history not currently known.,SUBSTANCE AND ALCOHOL HISTORY:,  Records indicate a previous history of methamphetamine and alcohol abuse/dependence.  The wife states that he has not consumed either since 12/07.  Of note, urine tox screen at Hospital was positive for marijuana.,LEGAL HISTORY:  ,The patient has been charged with domestic violence in the past, but his wife denies any repeat instances since in the last 3 years.  It is not known whether the patient is currently on probation.,GENETIC PSYCHIATRIC HISTORY: , Unknown.,MENTAL STATUS EXAMINATION:,Attitude:  The patient is only minimally cooperative with interview secondary to being sleepy, and after repeated attempts to ask questions, he rolled over and went to bed.,Appearance: He is unkempt and there are multiple visible tattoos on his biceps.,Psychomotor:  There is no obvious psychomotor agitation or retardation.  There are no obvious extrapyramidal symptoms of tardive dyskinesia.,Affect:  His affect is notably restricted probably due to the fact that he is sleepy.,Mood:  Describes his mood as ""okay."",Speech:  Speech is normal rate, volume, and tone.,Thought Processes:  His thought processes appear to be linear.,Thought Content:  His thought content is notable for his expressions of contrition about violence at Hospital last night.  He denies suicidal or homicidal ideation.,Cognitive Assessment:  Cognitively, he is alert and oriented to person, place, and date but not situation.  Attributes this to not really remembering the events at Hospital that resulted in this hospitalization.,Judgment and Insight:  His insight and judgment are both appear to be improving.,Assets:  Include his supportive wife and the fact he has been able to remain alcohol and methamphetamine sobriety for the last 3 years.,Limitations:  Include his back injury and possible need for improvement of health treatment engagement.,FORMULATION:  ,This is a 40-year-old white male, who was admitted for an acute agitation in the setting of misuse of prescribed opiates, Soma, hydroxyzine, and Valium.  He appears much improved from his condition at Hospital last night and I suspect that his behavior is most likely attributed to delirium and this since resolved.  He reports historical diagnosis of bipolar affective disorder, however, the details of this diagnosis are not currently available for review.,DIAGNOSES:,AXIS I:  Delirium, resolved (recent mental status changes likely secondary to misuse of prescribed opiates, Soma, Valium, and hydroxyzine.)  Rule out bipolar affective disorder.,AXIS II:  Deferred.,AXIS III:  Chronic pain status post back surgery.,AXIS IV:  Appears to be moderate.  He is currently on medical leave from his job.,AXIS V:  Global Assessment of Functioning is currently 50 (his GAF was 20 approximately 24 hours ago).,ESTIMATED LENGTH OF STAY:,  Three days.,PLAN:,  I will hold psychiatric medications for now given the patient's fairly rapid improvement as he cleared from the condition, I suspect is likely due to misuse of prescribed medications.  The patient will be placed on CIWA protocol given that one of the medications he overused was Valium.  Of note, he does not currently appear to be withdrawing and I anticipate that his CIWA will be discontinued prior to discharge.  I would like to increase the database regarding the details of his historical diagnosis of bipolar affective disorder before pursuing referrals for outpatient mental health care.  The internal medicine service will evaluate for treatment for any underlying medical problems specifically to provide recommendations regarding pain management.",
 The patient is a 58-year-old African-American right-handed female with 16 years of education who was referred for a neuropsychological evaluation by Dr. X.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning., Psychiatry / Psychology, Neuropsychological Evaluation - 4 ,"REASON FOR REFERRAL:,  The patient is a 58-year-old African-American right-handed female with 16 years of education who was referred for a neuropsychological evaluation by Dr. X. She is presenting for a second opinion following a recent neuropsychological evaluation that was ordered by her former place of employment that suggested that she was in the ""early stages of a likely dementia"" and was thereafter terminated from her position as a psychiatric nurse.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.  Note that this evaluation was undertaken as a clinical exam and intended for the purposes of aiding with treatment planning.  The patient was fully informed about the nature of this evaluation and intended use of the results.,RELEVANT BACKGROUND INFORMATION:  ,Historical information was obtained from a review of available medical records and clinical interview with the patient.  A summary of pertinent information is presented below.  Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM:,  The patient reported that she had worked as a nurse supervisor for Hospital Center for four years.  She was dismissed from this position in September 2009, although she said that she is still under active status technically, but is not able to work.  She continues to receive some compensation through FMLA hours.  She said that she was told that she had three options, to resign, to apply for disability retirement, and she had 90 days to complete the process of disability retirement after which her employers would file for charges in order for her to be dismissed from State Services.  She said that these 90 days are up around the end of November.  She said the reason for her dismissal was performance complaints.  She said that they began ""as soon as she arrived and that these were initially related to problems with her taking too much sick time off secondary to diabetes and fibromyalgia management and at one point she needed to obtain a doctor's note for any days off.  She said that her paperwork was often late and that she received discipline for not disciplining her staff frequently enough for tardiness or missed workdays.  She described it as a very chaotic and hectic work environment in which she was often putting in extra time.  She said that since September 2008 she only took two sick days and was never late to work, but that she continued to receive a lot of negative feedback.,In July of this year, she reportedly received a letter from personnel indicating that she was being referred to a state medical doctor because she was unable to perform her job duties and due to excessive sick time.  Following a brief evaluation with this doctor whose records we do not have, she was sent to a neuropsychologist, Dr. Y, Ph.D.  He completed a Comprehensive Independent Medical Evaluation on 08/14/2009.  She said that on 08/27/2009, she returned to see the original doctor who told her that based on that evaluation she was not able to work anymore.  Please note that we do not have copies of any of her work-related correspondence.  The patient never received a copy of the neuropsychological evaluation because she was told that it was ""too derogatory.""  A copy of that evaluation was provided directly to this examiner for the purpose of this evaluation.  To summarize, the results indicated ""diagnostically, The patient presents cognitive deficits involving visual working memory, executive functioning, and motor functioning along with low average intellectual functioning that is significantly below her memory functioning and below expectation based on her occupational and academic history.  This suggests that her intellectual functioning has declined.""  It concluded that ""results overall suggest early stages of a likely dementia or possibly the effects of diabetes, although her deficits are greater than expected for diabetes-related executive functioning problems and peripheral neuropathy…  The patient' deficits within the current test battery suggest that she would not be able to safely and effectively perform the duties of a nurse supervisor without help handling documentary demands and some supervision of her visual processing.  The prognosis for improvement is not good, although she might try stimulant medication if compatible with her other.  Following her dismissal, The patient presented to her primary physician, Henry Fein, M.D., who referred her to Dr. X for a second opinion regarding her cognitive deficits.  His neurological examination on 09/23/2009 was unremarkable.  The patient scored 20/30 on the Mini-Mental Status Exam missing one out of three words on recall, but was able to do so with prompting.  A repeat neurocognitive testing was suggested in order to assess for subtle deficits in memory and concentration that were not appreciated on this gross cognitive measure.,IMAGING STUDIES: , MRI of the brain on 09/14/2009 was unremarkable with no evidence of acute intracranial abnormality or abnormal enhancing lesions.  Note that the MRI was done with and without gadolinium contrast.,CURRENT FUNCTIONING:  ,The patient reported that she had experienced some difficulty completing paperwork on time due primarily to the chaoticness of the work environment and the excessive amount of responsibility that was placed upon her.  When asked about changes in cognitive functioning, she denied noticing any decline in problem solving, language, or nonverbal skills.  She also denied any problems with attention and concentration or forgetfulness or memory problems.  She continues to independently perform all activities of daily living.  She is in charge of the household finances, has had no problems paying bills on time, has had no difficulties with driving or accidents, denied any missed appointments and said that no one has provided feedback to her that they have noticed any changes in her cognitive functioning.  She reported that if her children had noticed anything they definitely would have brought it to her attention.  She said that she does not currently have a lawyer and does not intend to return to her previous physician.  She said she has not yet proceeded with the application for disability retirement because she was told that her doctors would have to fill out that paperwork, but they have not claimed that she is disabled and so she is waiting for the doctors at her former workplace to initiate the application.  Other current symptoms include excessive fatigue.  She reported that she was diagnosed with chronic fatigue syndrome in 1991, but generally symptoms are under better control now, but she still has difficulty secondary to fibromyalgia.  She also reported having fallen approximately five times within the past year.  She said that this typically occurs when she is climbing up steps and is usually related to her right foot ""like dragging.""  Dr. X's physical examination revealed no appreciable focal peripheral deficits on motor or sensory testing and notes that perhaps these falls are associated with some stiffness and pain of her right hip and knee, which are chronic symptoms from her fibromyalgia and osteoarthritis.  She said that she occasionally bumps into objects, but denied noticing it happening one on any particular part of her body.  Muscle pain secondary to fibromyalgia reportedly occurs in her neck and shoulders down both arms and in her left hip.,OTHER MEDICAL HISTORY: , The patient reported that her birth and development were normal.  She denied any significant medical conditions during childhood.  As mentioned, she now has a history of fibromyalgia.  She also experiences some restriction in the range of motion with her right arm.  MRI of the C-spine 04/02/2009 showed a hemangioma versus degenerative changes at C7 vertebral body and bulging annulus with small central disc protrusion at C6-C7.  MRI of the right shoulder on 06/04/2009 showed small partial tear of the distal infraspinatus tendon and prominent tendinopathy of the distal supraspinatus tendon.  As mentioned, she was diagnosed with chronic fatigue syndrome in 1991.  She thought that this may actually represent early symptoms of fibromyalgia and said that symptoms are currently under control.  She also has diabetes, high blood pressure, osteoarthritis, tension headaches, GERD, carpal tunnel disease, cholecystectomy in 1976, and ectopic pregnancy in 1974.  Her previous neuropsychological evaluation referred to an outpatient left neck cystectomy in 2007.  She has some difficulty falling asleep, but currently typically obtains approximately seven to eight hours of sleep per night.  She did report some sleep disruption secondary to unusual dreams and thought that she talked to herself and could sometimes hear herself talking in her sleep.,CURRENT MEDICATIONS:,  NovoLog, insulin pump, metformin, metoprolol, amlodipine, Topamax, Lortab, tramadol, amitriptyline, calcium plus vitamin D, fluoxetine, pantoprazole, Naprosyn, fluticasone propionate, and vitamin C.,SUBSTANCE USE: , The patient reported that she rarely drinks alcohol and she denied smoking or using illicit drugs.  She drinks two to four cups of coffee per day.,SOCIAL HISTORY:  ,The patient was born and raised in North Carolina.  She was the sixth of nine siblings.  Her father was a chef.  He completed third grade and died at 60 due to complications of diabetes.  Her mother is 93 years old.  Her last job was as a janitor.  She completed fourth grade.  She reported that she has no cognitive problems at this time.  Family medical history is significant for diabetes, heart disease, hypertension, thyroid problems, sarcoidosis, and possible multiple sclerosis and depression.  The patient completed a Bachelor of Science in Nursing through State University in 1979.  She denied any history of problems in school such as learning disabilities, attentional problems, difficulty learning to read, failed grades, special help in school or behavioral problems.  She was married for two years.  Her ex-husband died in 1980 from acute pancreatitis secondary to alcohol abuse.  She has two children ages 43 and 30.  Her son whose age is 30 lives nearby and is in consistent contact with her and she is also in frequent contact and has a close relationship with her daughter who lives in New York.  In school, the patient reported obtaining primarily A's and B's.  She said that her strongest subject was math while her worst was spelling, although she reported that her grades were still quite good in spelling.  The patient worked for Hospital Center for four years.  Prior to that, she worked for an outpatient mental health center for 2-1/2 years.  She was reportedly either terminated or laid off and was unsure of the reason for that.  Prior to that, she worked for Walter P. Carter Center reportedly for 21 years.  She has also worked as an OB nurse in the past.  She reported that other than the two instances reported above, she had never been terminated or fired from a job.  In her spare time, the patient enjoys reading, participating in women's groups doing puzzles, playing computer games.,PSYCHIATRIC HISTORY: , The patient reported that she sought psychotherapy on and off between 1991 and 1997 secondary to her chronic fatigue.  She was also taking Prozac during that time.  She then began taking Prozac again when she started working at secondary to stress with the work situation.  She reported a chronic history of mild sadness or depression, which was relatively stable.  When asked about her current psychological experience, she said that she was somewhat sad, but not dwelling on things.  She denied any history of suicidal ideation or homicidal ideation.,TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II), Token Test, Sentence Repetition, Visual Naming, Controlled Oral Word Association, Spelling Test, Aural Comprehension, Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Test",
 Psychiatric Consultation of patient with anxiety., Psychiatry / Psychology, Psych Consult - Anxiety ,"REASON FOR CONSULT:, Anxiety.,CHIEF COMPLAINT:,  ""I felt anxious yesterday."",HPI:,  A 69-year-old white female with a history of metastatic breast cancer, depression, anxiety, recent UTI, and obstructive uropathy, admitted to the ABCD Hospital on February 6, 2007, for lightheadedness, weakness, and shortness of breath.  The patient was consulted by Psychiatry for anxiety.  I know this patient from a previous consult.  During this recent admission, the patient has experienced anxiety and had a panic attack yesterday with ""syncopal episodes.""  She was given Ativan 0.25 mg on a p.r.n. basis with relief after one to two hours.  The patient was seen by Abc, MD, and Def, Ph.D.  The laboratories were reviewed and were positive for UTI, and anemia is also present.  The TSH level was within normal limits.  She previously responded well to trazodone for depression, poor appetite, and decreased sleep and anxiety.  A low dose of Klonopin was also helpful for sedation.,PAST MEDICAL HISTORY:,  Metastatic breast cancer to bone.  The patient also has a history of hypertension, hypothyroidism, recurrent UTI secondary to obstruction of left ureteropelvic junction, cholelithiasis, chronic renal insufficiency, Port-A-Cath placement, and hydronephrosis.,PAST PSYCHIATRIC HISTORY:,  The patient has a history of depression and anxiety.  She was taking Remeron 15 mg q.h.s., Ambien 5 mg q.h.s. on a p.r.n. basis, Ativan 0.25 mg every 6 hours on a p.r.n. basis, and Klonopin 0.25 mg at night while she was at home.,FAMILY HISTORY:,  There is a family history of colorectal cancer, lung cancer, prostate cancer, cardiac disease, and Alzheimer disease in the family.,SOCIAL HISTORY:,  The patient is married and lives at home with her husband.  She has a history of smoking one pack per day for 18 years.  The patient quit in 1967.  According to the chart, the patient also drinks wine everyday for the last 50 years, usually one to two drinks per day.,MEDICATIONS:,1.  Klonopin 0.25 mg p.o. every evening.,2.  Fluconazole 200 mg p.o. daily.,3.  Synthroid 125 mcg p.o. everyday.,4.  Remeron 15 mg p.o. at bedtime.,5.  Ceftriaxone IV 1 g in 1/2 NS every 24 hours.,P.R.N. MEDICATIONS:,1.  Tylenol 650 mg p.o. every 4 hours.,2.  Klonopin 0.5 mg p.o. every 8 hours.,3.  Promethazine 12.5 mg every 4 hours.,4.  Ambien 5 mg p.o. at bedtime.,ALLERGIES:,No known drug allergies,LABORATORY DATA:,These laboratories were done on February 6,2007, sodium 137, potassium 3.9, chloride 106, bicarbonate 21, BUN 35, creatinine 1.5, glucose 90.  White blood cell 5.31, hemoglobin 11.2, hematocrit 34.7, platelet count 152000.  TSH level 0.88.  The urinalysis was positive for UTI.,MENTAL STATUS EXAMINATION:,GENERAL APPEARANCE:  The patient is dressed in a hospital gown.  She is lying in bed during the interview.  She is well groomed with good hygiene.,MOTOR ACTIVITY:  No psychomotor retardation or agitation noted.  Good eye contact.,ATTITUDE:  Pleasant and cooperative.,ATTENTION AND CONCENTRATION:  Normal.  The patient does not appear to be distracted during the interview.,MOOD:  Okay.,AFFECT:  Mood congruent normal affect.,THOUGHT PROCESS:  Logical and goal directed.,THOUGHT CONTENT:  No delusions noted.,PERCEPTION:  Did not assess.,MEMORY:  Not tested.,SENSORIUM:  Alert.,JUDGMENT:  Good.,INSIGHT:  Good.,IMPRESSION:,1.  AXIS I:  Possibly major depression or generalized anxiety disorder.,2.  AXIS II:  Deferred.,3.  AXIS III:  Breast cancer with metastasis, hydronephrosis secondary to chronic uteropelvic junction obstruction status post stent placement, hypothyroidism.,4.  AXIS IV:  Interpersonal stressors.",
 The patient was referred due to a recent admission for pseudoseizures., Psychiatry / Psychology, Pseudoseizures ,"REASON FOR REFERRAL: , The patient was referred to me by Dr. X of the Hospitalist Service at Children's Hospital due to a recent admission for pseudoseizures.  This was a 90-minute initial intake completed on 10/19/2007 with the patient's mother.  I have reviewed with her the boundaries of confidentiality and the treatment consent form, and she stated that she had understood these concepts.,PRESENTING PROBLEM: , It is reported that the patient was recently hospitalized and has been hospitalized in 2 occasions for pseudoseizure activity.  These were confirmed by video EEG and consist of trembling, shaking, and things of that nature.  She does have a history of focal seizures and perhaps simple seizures, which were diagnosed when she was 5 years old, but the seizure activity that was documented during the hospital stay is of a significant different quality.  I had met with them in the hospital and introduced myself and gathered some basic background information, but this is a supplement to that information, which is contained within this chart.  It was reported to me that she has been under considerable stress.  First of all, it should be noted that the patient is developmentally delayed.  Although she is 17 years old, she operates at about a fourth grade level.  Mother reported that The patient becomes stressed because she thinks that everyone is against her, that she cannot do anything unless someone is there, that she needs a lot of direction, that she gets confused easily, that she thinks that people become angry at her, that she misinterprets what people are saying and thinks that they are upset.  It is reported, the patient feels that her mother yells at her, and that is mad at her often.  It was reported that in addition she recently has had change in her visitation with her father, that she within the last 6 months, has started seeing her father every other weekend after he had been discharged from prison.  She reported that what is stress for her is that sometimes he does not always show up for visits or is late and that upsets her a lot and that she is upset when she has to leave him, also additional stressor is at school.  She reports that she has no friends that she feels unwanted and picked on.  She gets confused easily at school, worries about things, and believes that the teachers become angry with her.  In regards to her mood, mother reported that she is usually happy, unless things do not go her way, and then, she becomes upset and says that nobody cares about her.  She sits in the couch, she become angry, does not speak.  Mother sends her to her room, and she calms down, takes a couple of deep breaths, and that passes.  It is reported that the patient has ""always been this way"" and that is not a change in her behavior.  Mother did think that she did seem a little more depressed, that she seems more lonely.  Over the last few months, she has seemed a little bit more down because she does not have any friends and that she is bored.  Mother reported that she frequently complains of being bored, but has always been this way.  No sleep disturbance was noted.  No changes in weight.  No suicidal ideation.  No deficits in energy were noted.  Mother did report that she does tend to worry, but her worries tend to be because she gets confused, does not understand what she needs to do, and is quite rigid, but mother did not feel that the worry was actually affecting her functioning on a daily basis.,DEVELOPMENTAL HISTORY:,  The patient was the 5 pound 12 ounce product of an unplanned pregnancy and normal spontaneous vaginal delivery.  She was delivered at 36 weeks' gestation.  Mother reported that she received prenatal care.  Difficulties during the pregnancy were denied.  The use of drugs, alcohol, tobacco during the pregnancy were denied.  No eating or sleeping difficulties during the perinatal period were reported.  Temperament was described as easy.  The patient is described as a cuddly baby.  In terms of serious injuries, they were denied.  Serious illnesses:  She has been diagnosed since age 5 with seizures.  Mother was not able to tell me the exact kind of seizures, but it would appear from I could gather that they are focal seizures and possibly simple-to-complex partial seizures.  The patient does not have a history of allergy or toileting problems.  She is currently taking Trileptal 450 mg b.i.d., and she is currently taking Depakote, although she is going to be weaned off the Depakote by her neurologist.  She is taking Prevacid and ibuprofen.  The neurologist that she sees is Dr. Y here at Children's Hospital.,FAMILY BACKGROUND:,  In terms of family background, the patient lives with her mother age 38 and her mother's partner, who is age 40, and with her 16-year-old sister who does not have any developmental delays.  Mother had been married to the patient's father, but they were together as a couple beginning 1990, married in 1997, separated in 2002, and divorced in 2003; he lives in the ABC area and visits them every other Saturday, but there are no overnight visits.  The paternal grandparents are both living here in California, but are separated.  They are 3 paternal uncles and 2 paternal aunts.  In terms of the maternal family, maternal grandmother and grandfather are deceased.  Maternal grandfather deceased in 1991 due to cancer.  Maternal grandmother deceased in 2001 due to cancer.  There are 5 maternal aunts and 2 maternal uncles, all who live in California.  She reported that the patient is particularly close to her maternal aunt, whose name is Carmen.  Mother's partner had been married previously; he has 2 children from that relationship, a 23-year-old, and a 20-year-old female, who really are not part of the patient's daily life.  In terms of other family background, it was reported that the mother's partner gets frustrated with The patient, does not completely understand the degree of her delay and how that may affect her ability to do things as well as her interpretation of things.  The sister was described as having some resentment towards her older sister, that she feels like she was just to watch out for her, care for her, and that sister has always wanted to follow her around and do the things that she does.  The biological father allegedly was in jail for a year due to drug possession.  Mother reported that he had a problem with methamphetamine.  In addition, she reported there is an accusation that he had molested their niece; however, she stated that there was a trial, and he was found to be not guilty of that.  She stated there was no evidence that he had ever molested the patient or her sister.  There had been quite a bit of chaos in the family when the mother and father were together.  There was a lot of arguing.  There were a lot of moves, there was domestic violence both from father to mother and mother to father consisting mostly of pushing and shoving by mother's report.  The patient did observe this.  After the separation, it was reported that there were continued difficulties that the father took the patient and her sister from school without mother's knowledge and had filed to get custody of them and actually ended up having custody of them for a month, and told the patient and her sister that the mother had abandoned them.  Mother reported that they went to court, and there was a court order giving the mother custody back after the father went to jail.  Mother stated that was approximately 5 years ago.  In terms of current, mother reports that she currently works 2 jobs from 8 to 5 on Monday and Friday and from 6 to 10 on Monday, Wednesday's, and Friday's, but she does have the weekends off.  The patient was reported also to have a job through her school on several weeknights.,Mother reported that she graduated from high school, had a year of college.  She was an average student, had learning difficulties in reading.  No psychological or drug or alcohol history was reported by mother.  In terms of the biological father, mother stated that he graduated from high school, had a couple of years of college, was a good student, no learning problems or psychological problems for him were reported.  Mother reported that he had a history of methamphetamine use.,Other psychiatric history in the family was denied.,SOCIAL HISTORY: , She reported that the patient feels like she does not have any friends, that she is lonely and bored, really does not do much for fun.  Her fun consists primarily of doing crafts with mother, sewing, painting, drawing, beadwork, and things like that.  It was reported that she really feels that she is bored and does not have much to do.,ACADEMIC BACKGROUND:  ,The patient is in the 11th grade at High School.  She has 2 regular education classes, mother could not tell me what they were, but the rest of her classes are special education.  Mother could not tell me what her IQ was, although she noticed she works at about a 4th or 5th grade level.  Mother reported that the terminology most often used with the patient was developmental delay.  Her counselor's name is Mr. XYZ, but she reported that overall she is a good student, but she does have sometimes some difficulties at school, becoming upset or angry regarding the little things that she does not seem to understand.  It is reported that the patient feels that she has no friends at school that she is lonely, and that is she does not really care for school.  She reported that the patient is involved in a work program through the school where she works at Pet Extreme on Mondays and Wednesdays from 3 to 8 p.m. where she stocks shelves.  It is reported that she does not like to go to school because she feels like nobody likes her.  She is not involved in any kind of clubs or groups at school.  Mother reported that she is also not receiving CVRC services.,PREVIOUS COUNSELING: , Mother reported that she has been in counseling before, but mother could not give me any information about that, who did the counseling, or what it was about.  She does receive evidently some peer counseling at school because she gets upset and needs help in calming down.,DIAGNOSTIC SUMMARY AND IMPRESSION:,  It appears that the patient best qualifies for a diagnosis of conversion disorder, and information from Neurology suggests that the ""seizure episodes"" are not true seizures, but appear to be pseudoseizures.  The patient is experiencing quite bit of stress with a lot of changes in her life, also difficulty in functioning likely due to her developmental delay makes it difficult for her to understand.,PLAN:,  My plan is to meet with the patient in approximately 1 to 2 weeks to complete a clinical interview with her, and then to begin teaching coping skills as well as explore ways for reducing her stress.,DSM IV DIAGNOSES:  ,AXIS I:  Conversion disorder (300.11).,AXIS II:  Diagnoses deferred.,AXIS III:  Seizure disorder.,AXIS IV:  Problems with primary support group, peer problems, and educational problems.,AXIS V:  Global assessment of functioning equals 60.","psychiatry / psychology, conversion disorder, global assessment of functioning, primary support group, peer problems, developmental delays, seizures, developmentally, axis, pseudoseizures, "
" The patient comes in for a neurology consultation regarding her difficult headaches, tunnel vision, and dizziness. ", Psychiatry / Psychology, Neuropsychological Evaluation - 5 ,"PROBLEMS AND ISSUES:,1.  Headaches, nausea, and dizziness, consistent with a diagnosis of vestibular migraine, recommend amitriptyline for prophylactic treatment and Motrin for abortive treatment.,2.  Some degree of peripheral neuropathy, consistent with diabetic neuropathy, encouraged her to watch her diet and exercise daily.,HISTORY OF PRESENT ILLNESS: , The patient comes in for a neurology consultation regarding her difficult headaches, tunnel vision, and dizziness.  I obtained and documented a full history and physical examination.  I reviewed the new patient questionnaire, which she completed prior to her arrival today.  I also reviewed the results of tests, which she had brought with her.,Briefly, she is a 60-year-old woman initially from Ukraine, who had headaches since age 25.  She recalls that in 1996 when her husband died her headaches became more frequent.  They were pulsating.  She was given papaverine, which was successful in reducing the severity of her symptoms.  After six months of taking papaverine, she no longer had any headaches.  In 2004, her headaches returned.  She also noted that she had ""zig-zag lines"" in her vision.  Sometimes she would not see things in her peripheral visions.  She had photophobia and dizziness, which was mostly lightheadedness.  On one occasion she almost had a syncope.  Again she has started taking Russian medications, which did help her.  The dizziness and headaches have become more frequent and now occur on average once to twice per week.  They last two hours since she takes papaverine, which stops the symptoms within 30 minutes.,PAST MEDICAL HISTORY: ,Her past medical history is significant for injury to her left shoulder, gastroesophageal reflux disorder, diabetes, anxiety, and osteoporosis.,MEDICATIONS:,  Her medications include hydrochlorothiazide, lisinopril, glipizide, metformin, vitamin D, Centrum multivitamin tablets, Actos, lorazepam as needed, Vytorin, and Celexa.,ALLERGIES: , She has no known drug allergies.,FAMILY HISTORY:  ,There is family history of migraine and diabetes in her siblings.,SOCIAL HISTORY: , She drinks alcohol occasionally.,REVIEW OF SYSTEMS: , Her review of systems was significant for headaches, pain in her left shoulder, sleeping problems and gastroesophageal reflex symptoms.  Remainder of her full 14-point review of system was unremarkable.,PHYSICAL EXAMINATION:,  On examination, the patient was pleasant.  She was able to speak English fairly well.  Her blood pressure was 130/84.  Heart rate was 80.  Respiratory rate was 16.  Her weight was 188 pounds.  Her pain score was 0/10.  Her general exam was completely unremarkable.  Her neurological examination showed subtle weakness in her left arm due to discomfort and pain.  She had reduced vibration sensation in her left ankle and to some degree in her right foot.  There was no ataxia.  She was able to walk normally.  Reflexes were 2+ throughout.,She had had a CT scan with constant, which per Dr. X's was unremarkable.  She reports that she had a brain MRI two years ago which was also unremarkable.,IMPRESSION AND PLAN:,  The patient is a delightful 60-year-old chemist from Ukraine who has had episodes of headaches with nausea, photophobia, and dizziness since her 20s.  She has had some immigration problems in recent months and has experienced increased frequency of her migraine symptoms.  Her diagnosis is consistent with vestibular migraine.  I do not see evidence of multiple sclerosis, Ménière's disease, or benign paroxysmal positional vertigo.,I talked to her in detail about the importance of following a migraine diet.  I gave her instructions including a list of foods times, which worsen migraine.  I reviewed this information for more than half the clinic visit.  I would like to start her on amitriptyline at a dose of 10 mg at time.  She will take Motrin at a dose of 800 mg as needed for her severe headaches.,She will make a diary of her migraine symptoms so that we can find any triggering food items, which worsen her symptoms.  I encouraged her to walk daily in order to improve her fitness, which helps to reduce migraine symptoms.","psychiatry / psychology, nausea, dizziness, migraine, peripheral neuropathy, diabetic neuropathy, neuropathy, positional vertigo, photophobia and dizziness, neurology consultation, tunnel vision, vestibular migraine, migraine symptoms, headaches, photophobia, ataxia, "
" Patient was referred for a neuropsychological evaluation after a recent hospitalization for possible transient ischemic aphasia.  Two years ago, a similar prolonged confusional spell was reported as well.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.", Psychiatry / Psychology, Neuropsychological Evaluation - 3 ,"REASON FOR REFERRAL:,  The patient is a 76-year-old Caucasian gentleman who works full-time as a tax attorney.  He was referred for a neuropsychological evaluation by Dr. X after a recent hospitalization for possible transient ischemic aphasia.  Two years ago, a similar prolonged confusional spell was reported as well.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.,RELEVANT BACKGROUND INFORMATION: , Historical information was obtained from a review of available medical records and clinical interview with the patient.  A summary of pertinent information is presented below.  Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM: , The patient was brought to the Hospital Emergency Department on 09/30/09 after experiencing an episode of confusion for which he has no recall the previous day.  He has no recollection of the event.  The following information is obtained from his medical record.  On 09/29/09, he reportedly went to a five-hour meeting and stated several times ""I do not feel well"" and looked ""glazed.""  He does not remember anything from midmorning until the middle of the night and when his wife came home, she found him in bed at 6 p.m., which is reportedly unusual.  She thought he was warm and had chills.  He later returned to his baseline.  He was seen by Dr. X in the hospital on 09/30/09 and reported to him at that time that he felt that he had returned entirely to baseline.  His neurological exam at that time was unremarkable aside from missing one of three items on recall for the Mini-Mental Status Examination.  Due to mild memory complaints from himself and his wife, he was referred for more extensive neuropsychological testing.  Note that reportedly when his wife found him in bed, he was shaking and feeling nauseated, somewhat clammy and kept saying that he could not remember anything and he was repeating himself, asking the same questions in an agitated way, so she brought him to the emergency room.  The patient had an episode two years ago of transient loss of memory during which he was staring blankly while sitting at his desk at work and the episode lasted approximately two hours.  He was hospitalized at Hospital at that time as well and evaluation included negative EEG, MRI showing mild atrophy, and a neurological consultation, which did not result in a specific diagnosis, but during this episode he was also reportedly nauseous.  He was also reportedly amnestic for this episode.,In 2004, he had a sense of a funny feeling in his neck and electrodes in his head and had an MRI at that time which showed some small vessel changes.,During this interview, the patient reported that other than a coworker noticing a few careless errors in his completion of some documents and his wife reporting some mild memory changes that he had not noticed any significant decline.  He thought that his memory abilities were similar to those of his peers of his same age.  When I asked about this episode, he said he had no recall of it at all and that he ""felt fine the whole time.""  He appeared to be somewhat questioning of the validity of reports that he was amnestic and confused at that time.  So, The patient reported some age related ""memory lapses"" such as going into a room and forgetting why, sometimes putting something down and forgetting where he had put it.  However, he reported that these were entirely within normal expectations and he denied any type of impairment in his ability to continue to work full-time as a tax attorney other than his wife and one coworker, he had not received any feedback from his children or friends of any problems.  He denied any missed appointments, any difficulty scheduling and maintaining appointments.  He does not have to recheck information for errors.  He is able to complete tasks in the same amount of time as he always has.  He reported that he has not made additional errors in tasks that he completed.  He said he does write everything down, but has always done things that way.  He reported that he works in a position that requires a high level of attentiveness and knowledge and that will become obvious very quickly if he was having difficulties or making mistakes.  He did report some age related changes in attention as well, although very mild and he thought these were normal and not more than he would expect for his age.  He remains completely independent in his ADLs.  He denied any difficulty with driving or maintaining any activities that he had always participated in.  He is also able to handle their finances.  He did report significant stress recently particularly in relation to his work environment.,PAST MEDICAL HISTORY:,  Includes coronary artery disease, status post CABG in 1991, radical prostate cancer, status post radical prostatectomy, nephrectomy for the same cancer, hypertension, lumbar surgery done twice previously, lumbar stenosis many years ago in the 1960s and 1970s, now followed by Dr. Y with another lumbar surgery scheduled to be done shortly after this evaluation, and hyperlipidemia.  Note that due to back pain, he had been taking Percocet daily prior to his hospitalization.,CURRENT MEDICATIONS: , Celebrex 200 mg, levothyroxine 0.025 mg, Vytorin 10/40 mg, lisinopril 10 mg, Coreg 10 mg, glucosamine with chondroitin, prostate 2.2, aspirin 81 mg, and laxative stimulant or stool softener.  Note that medical records say that he was supposed to be taking Lipitor 40 mg, but it is not clear if he was doing so and also there was no specific reason found for why he was taking the levothyroxine.,OTHER MEDICAL HISTORY: , Surgical history is significant for hernia repair in 2007 as well.  The patient reported drinking an occasional glass of wine approximately two days of the week.  He quit smoking cigarettes 25 to 30 years ago and he was diagnosed with cancer.  He denied any illicit drug use.  Please add that his prostatectomy was done in 1993 and nephrectomy in 1983 for carcinoma.  He also had right carpal tunnel surgery in 2005 and has cholelithiasis.  Upon discharge from the hospital, the patient's sleep deprived EEG was recommended.,MRI completed on 09/30/09 showed ""mild cerebral and cerebellar atrophy with no significant interval change from a prior study dated June 15, 2007.  No evidence of acute intracranial processes identified.  CT scan was also unremarkable showing only mild cerebral and cerebellar atrophy.  EEG was negative.  Deferential diagnosis was transient global amnesia versus possible seizure disorder.  Note that he also reportedly has some hearing changes, but has not followed up with an evaluation for hearing aid.,FAMILY MEDICAL HISTORY:, Reportedly significant for TIAs in his mother, although the patient did not report this during our evaluation and so that she had no memory problems or dementia when she passed away of old age at the age of 85.  In addition, his father had a history of heart disease and passed away at the age of 75.  He has one sister with diabetes and thought his mom might have had diabetes as well.,SOCIAL HISTORY:,  The patient obtained a law degree from the University of Baltimore.  He did not complete his undergraduate degree from the University of Maryland because he was able to transfer his credits in order to attend law school at that time.  He reported that he did not obtain very good grades until he reached law school, at which point he graduated in the top 10 of his class and had no problem passing the Bar.  He thought that effort and motivation were important to his success in his school and he had not felt very motivated previously.  He reported that he repeated math classes ""every year of school"" and attended summer school every year due to that.  He has worked as a tax attorney for the past 48 years and reported having a thriving practice with clients all across the country.  He served also in the U.S.  Coast Guard between 1951 and 1953.  He has been married for the past 36 years to his wife, Linda, who is a homemaker.  They have four children and he reported having good relationship with them.  He described being very active.  He goes for dancing four to five times a week, swims daily, plays golf regularly and spends significant amounts of time socializing with friends.,PSYCHIATRIC HISTORY: , The patient denied any history of psychological or psychiatric treatment.  He reported that some stressors occasionally contribute to mildly low mood at this time, but that these are transient.,TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II), Token Test, Sentence Repetition, Visual Naming, Controlled Oral Word Association, Spelling Test, Aural Comprehension, Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Test",
" A neuropsychological evaluation to assess neuropsychological factors, clarify areas of strength and weakness, and to assist in therapeutic program planning in light of episodes of syncope.", Psychiatry / Psychology, Neuropsychological Evaluation - 2 ,"REASON FOR REFERRAL:  ,The patient was referred for a neuropsychological evaluation by Dr. X.  A comprehensive evaluation was requested to assess neuropsychological factors, clarify areas of strength and weakness, and to assist in therapeutic program planning in light of episodes of syncope.,BRIEF SUMMARY & IMPRESSIONS:,RELEVANT HISTORY:,Historical information was obtained from a review of available medical records and an interview with ,the patient.,The patient presented to Dr. X on August 05, 2008 as she had been recently hospitalized for prolonged episodes of syncope.  She was referred to Dr. X for diagnostic differentiation for possible seizures or other causes of syncope.  The patient reports an extensive neurological history.  Her mother used alcohol during her pregnancy with the patient.  In spite of exposure to alcohol in utero, the patient reported that she achieved ""honors in school"" and ""looked smart.""  She reported that she began to experience migraines at 11 years of age.  At 15 years of age, she reported that she was thought to have hydrocephalus.  She reported that she will frequently ""bang her head against the wall"" to relieve the pain.  The patient gave birth to her daughter at 17 years of age.  At 18 years of age, she received a spinal tap as a procedure to determine the cause of her severe headaches.  She reported, in 1995 to 1996 she experienced a severe head injury, as she was struck by a car as a pedestrian and ""thrown two and a half city blocks.""  The patient reported that she could recall before being hit, but could not recall the activities of that same day or the following day.  She reported that she had difficulty walking following this head injury, but received rehabilitation for approximately one month.  Her migraines became more severe following the head injury.  In 1998, she reportedly was experiencing episodes of syncope where she would experience a headache with photophobia, phonophobia, and flashing lights.  Following the syncope episode, she would experience some confusion.  These episodes reportedly were related to her donating plasma.,The patient also reported that her ex-husband stated that she frequently jerked and would shake in her sleep.  She reported that upon awakening, she would feel off balanced and somewhat confused.  These episodes diminished from 2002 to June 2008.  When making dinner, she suddenly dropped and hit the back of her head on refrigerator.  She reported that she was unconscious for five to six minutes.  A second episode occurred on July 20th when she lost consciousness for may be a full day.  She was admitted to Sinai Hospital and assessed by a neurologist.  Her EEG and head CT were considered to be completely normal.  She did not report any typical episodes during the time of her 36-hour EEG.  She reported that her last episode of syncope occurred prior to her being hospitalized.  She stated that she had an aura of her ears ringing, vision being darker and ""tunnel vision"" (vision goes smaller to a pinpoint), and she was ""spazzing out"" on the floor.  During these episodes, she reports that she cannot talk and has difficulty understanding.,The patient also reports that she has experienced some insomnia since she was 6 years old.  She reported that she was a heavy drinker until about 1998 or 1999 and that she would drink a gallon daily of Jack Daniel.  She stopped the use of alcohol and that time she experienced a suicide attempt.  In 2002, she was diagnosed with bipolar disorder and was started on medication.  At the time of the neuropsychological evaluation, she had stopped taking her medicine as she felt that she was now in remission and could manage her symptoms herself.  The patient's medical history is also significant for postpartum depression.,The patient reported that she has been experiencing difficulty with cognitive abilities of attention/concentration, spelling, tangential and slow thinking, poor sequencing memory for events, and variable verbal memory.  She reported that she sometimes has difficulty understanding what people say, specifically she has difficulty understanding jokes.  She finds that she often has difficulty with expressing her thoughts, as she is very tangential.  She experiences episodes of not recalling what she was speaking of or remembering what activities she was trying to perform.  She reported that she had a photographic memory for directions.  She said that she experienced a great deal of emotional lability, but in general her personality has become more subdued.  At the present time, her daughter has now moved on to college.  The patient is living with her biological mother.  Although she is going through divorce, she reported that it was not really stressful.  She reported that she spends her day driving other people around and trying to be helpful to them.,At the time of the neuropsychological evaluation, the patient's medication included Ativan, Imitrex, Levoxyl, vitamin B12, albuterol metered dose inhaler as needed, and Zofran as needed.  (It should be noted that The patient by the time of the feedback on September 19, 2008 had resumed taking her Trileptal for bipolar disorder.).  The patient's familial medical history is significant for alcohol abuse, diabetes, hypertension, and high cholesterol.,TESTS ADMINISTERED:,Clinical Interview,Cognistat,Mattis Dementia Rating Scale,Wechsler Adult Intelligence Scale - III (WAIS-III),Wechsler Abbreviated Scale of Intelligence (WASI),Selected Subtests from the Delis Kaplan Executive Function System (DKEFS),  Trail Making Test,  Verbal Fluency (Letter Fluency & Category Fluency),  Design Fluency,  Color-Word Interference Test,  Tower,Wisconsin Card Sorting Test (WCST),Stroop Test,Color Trails,Trails A & B,Test of Variables of Attention,Multilingual Aphasia Examination II,  Token Test,  Sentence Repetition,  Visual Naming,  Controlled Oral Word Association,  Spelling Test,  Aural Comprehension,  Reading Comprehension,Boston Naming Test-2 (BNT-2),Animal Naming Test,The Beery-Buktenica Developmental Test of Visual-Motor Integration (VMI),The Beery-Buktenica Developmental Test of Motor Coordination,The Beery-Buktenica Developmental Test of Visual Perception,Judgment Line Orientation,Grooved Pegboard,Purdue Pegboard,Finger Tapping Test,Rey Complex Figure,Wechsler Memory Scale -III (WMS-III),California Verbal Learning Test",
 Mental status changes after a fall.  She sustained a concussion with postconcussive symptoms and syndrome that has resolved. , Psychiatry / Psychology, Mental Status Changes - Consult ,"CHIEF COMPLAINT: , Mental status changes after a fall.,HISTORY: , Ms. ABC is a 76-year-old female with Alzheimer's, apparently is normally very talkative, active, independent, but with advanced Alzheimer's.  Apparently, she tripped backwards hitting her head on a wheelchair and, had although no loss consciousness, had altered mental status changes.  She was very confused, incomprehensible speech, and was not responding appropriately.  She was transported here stable, with no significant changes.  She ultimately upon arrival here was unchanged in that she was not responding appropriately.  She would have garbled speech, somewhat inappropriate at times, and unable to follow commands.  No other history was able to be obtained.  All pertinent history is documented within the records.  Physical examination also documented in the records, essentially as above.,PHYSICAL EXAMINATION: , HEENT:  Without any obvious signs of trauma.  Pupils are equal and reactive.  Extraocular movements are difficult to assess with her eyes closed, but she will open to voice.  TMs, canals are normal without any signs of hemotympanum.  Nasal mucosa and oropharynx are normal.,NECK:  Nontender, full range of motion, was not examined initially, a collar was placed.,HEART:  Regular.,LUNGS:  Clear.,CHEST/BACK/ABDOMEN:  Without trauma.,SKIN:  With multiple excoriations from scratching and itching.,NEUROLOGIC:  Otherwise she has good sensation, withdrawals to pain.  When lifting the arm, she will hold them up and draw, let them down slowly.  With movement of the legs, she did straighten them back out slowly.  DTRs were intact and equal bilaterally.  Otherwise, the remainder of the examination was unable to be done because of patient's non-cooperation and mental status change.,LABORATORY DATA: , CT scan of the head was negative as was cervical spine.  She has a history of being on Coumadin.  Her INR is 1.92, CBC was with a white count of 3.8, 50% neutrophils, 8% bands.  CMP did note a potassium, which was elevated at 5.9, troponin was normal, mag is 2.5, valproic acid level 24.3.,ASSESSMENT AND PLAN: , Ms. ABC is a 76-year-old female with multiple medical problems who has sustained a head injury with mental status changes that on repeat examination now at approximately 1930 hours, has completely resolved.  It is likely she sustained a concussion with postconcussive symptoms and syndrome that has resolved.  At this time, she has some other abnormalities in her lab work and I recommend she be admitted for observation and further investigation.  I have discussed this with her son, he agrees.  Otherwise, she has improved significantly.  The patient was discussed with XYZ, who will admit the patient for further evaluation and treatment.","psychiatry / psychology, alzheimer's, no loss consciousness, mental status,"
" Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.", Psychiatry / Psychology, Major Depressive Disorder - IME Consult ,"IDENTIFYING DATA:  ,Mr. T is a 45-year-old white male.,CHIEF COMPLAINT: , Mr. T presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.  His confidence and self-esteem are significantly low.  He stated he has excessive somnolence, his energy level is extremely low, motivation is low, and he has a lack for personal interests.  He has had suicidal ideation, but this is currently in remission.  Furthermore, he continues to have hopeless thoughts and crying spells.  Mr. T stated these symptoms appeared approximately two months ago.,HISTORY OF PRESENT ILLNESS: , On March 25, 2003, Mr. T was fired from his job secondary, to an event at which he stated he was first being harassed by another employee."" This other, employee had confronted Mr. T with a very aggressive, verbal style, where this employee had placed his face directly in front of Mr. T was spitting on him, and called him ""bitch."" Mr. T then retaliated, and went to hit the other employee.  Due to this event, Mr. T was fired.  It should be noted that Mr. T stated he had been harassed by this individual for over a year and had reported the harassment to his boss and was told to ""deal with it."",There are no other apparent stressors in Mr. T's life at this time or in recent months.  Mr. T stated that work was his entire life and he based his entire identity on his work ethic.  It should be noted that Mr. T was a process engineer for Plum Industries for the past 14 years.,PAST PSYCHIATRIC HISTORY:,  There is no evidence of any psychiatric hospitalizations or psychiatric interventions other than a recent visit to Mr. T's family physician, Dr. B at which point Mr. T was placed on Lexapro with an unknown dose at this time.  Mr. T is currently seeing Dr. J for psychotherapy where he has been in treatment since April, 2003.,PAST PSYCHIATRIC REVIEW OF SYSTEMS:,  Mr. T denied any history throughout his childhood, adolescence, and early adulthood for depressive, anxiety, or psychotic disorders.  He denied any suicide attempts, or profound suicidal or homicidal ideation.  Mr. T furthermore stated that his family psychiatric history is unremarkable.,SUBSTANCE ABUSE HISTORY:,  Mr. T stated he used alcohol following his divorce in 1993, but has not used it for the last two years.  No other substance abuse was noted.,LEGAL HISTORY: , Currently, charges are pending over the above described incident.,MEDICAL HISTORY: , Mr. T denied any hospitalizations, surgeries, or current medications use for any heart disease, lung disease, liver disease, kidney disease, gastrointestinal disease, neurological disease, closed head injury, endocrine disease, infectious, blood or muscles disease other than stating he has a hiatal hernia and hypercholesterolemia.,PERSONAL AND SOCIAL HISTORY: , Mr. T was born in Dwyne, Missouri, with no complications associated with his birth.  Originally, he was raised by both parents, but they separated at an early age.  When he was about seven years old, he was raised by his mother and stepfather.  He did not sustain a relationship with his biological father from that time on.  He stated his parents moved a lot, and because this many times he was picked on in his new environments, Mr. T stated he was, at times, a rebellious teenager, but he denied any significant inability to socialize, and denied any learning disabilities or the need for special education.,Mr. T stated his stepfather was somewhat verbally abusive, and that he committed suicide when Mr. T was 18 years old.  He graduated from high school and began work at Dana Corporation for two to three years, after which he worked as an energy, auditor for a gas company.  He then became a homemaker while his wife worked for Chrysler for approximately two years.  Mr. T was married for eleven years, and divorced in 1993.  He has a son who is currently 20 years old.  After being a home maker, Mr. T worked for his mother in a restaurant, and moved on from there to work for Borg-Warner corporation for one to two years before beginning at Plum Industries, where he worked for 14 years and worked his way up to lead engineer.,Mental Status Exam:  Mr. T presented with a hyper vigilant appearance, his eye contact was appropriate to the interview, and his motor behavior was tense.  At times he showed some involuntary movements that would be more akin to a resting tremor.  There was no psychomotor retardation, but there was some mild psychomotor excitement.  His speech was clear, concise, but pressured.  His attitude was overly negative and his mood was significant for moderate depression, anxiety, anhedonia and loneliness, and mild evidence of anger.  There was no evidence of euphoria or diurnal mood variation.  His affective expression was restricted range, but there was no evidence of lability.  At times, his affective tone and facial expressions were inappropriate to the interview.  There was no evidence of auditory, visual, olfactory, gustatory, tactile or visceral hallucinations.  There was no evidence of illusions, depersonalizations, or derealizations.  Mr. T presented with a sequential and goal directed stream of thought.  There was no evidence of incoherence, irrelevance, evasiveness, circumstantiality, loose associations, or concrete thinking.  There was no evidence of delusions; however, there was some ambivalence, guilt, and self-derogatory thoughts.  There was evidence of concreteness for similarities and proverbs.  His intelligence was average.  His concentration was mildly impaired, and there was no evidence of distractibility.  He was oriented to time, place, person and situation.  There was no evidence of clouded consciousness or dissociation.  His memory was intact for immediate, recent, and remote events.,He presented with poor appetite, easily fatigued, and decreased libidinal drive, as well as excessive somnolence.  There was a moderate preoccupation with his physical health pertaining to his headaches.  His judgment was poor for finances, family relations, social relations, employment, and, at this time, he had no future plans.  Mr. T's insight is somewhat moderate as he is aware of his contribution to the problem.  His motivation for getting well is good as he accepts offered treatment, complies with recommended treatment, and seeks effective treatments.  He has a well-developed empathy for others and capacity for affection.,There was no evidence of entitlement, egocentricity, controllingness, intimidation, or manipulation.  His credibility seemed good.  There was no evidence for potential self-injury, suicide, or violence.  The reliability and completeness of information was very good, and there were no barriers to communication.  The information gathered was based on the patient's self-report and objective testing and observation.  His attitude toward the examiner was neutral and his attitude toward the examination process was neutral.  There was no evidence for indices of malingering as there was no marked discrepancy between claimed impairment and objective findings, and there was no lack of cooperation with the evaluation or poor compliance with treatment, and no evidence of antisocial personality disorder.,IMPRESSIONS: , Major Depressive Disorder, single episode,RECOMMENDATIONS AND PLAN: , I recommend Mr. T continue with psychopharmacologic care as well as psychotherapy.  At this time, the excessive amount of psychiatric symptoms would impede Mr. T from seeking employment.  Furthermore, it appears that the primary precipitating event had occurred on March 25, 2003, when Mr. T was fired from his job after being harassed for over a year.  As Mr. T placed his entire identity and sense of survival on his work, this was a deafening blow to his psychological functioning.  Furthermore, it only appears logical that this would precipitate a major depressive episode.","psychiatry / psychology, muscle tremor, headaches, excessive nervousness, poor concentration, independent medical evaluation, psychopharmacologic, poor ability to focus, major depressive disorder, tremor, depressive, psychiatric, "
 Patient demonstrated mild cognitive deficits on a neuropsychological screening evaluation during a followup appointment for stroke., Psychiatry / Psychology, Neuropsychological Evaluation ,"REASON FOR REFERRAL: , Ms. A is a 60-year-old African-American female with 12 years of education who was referred for neuropsychological evaluation by Dr. X after she demonstrated mild cognitive deficits on a neuropsychological screening evaluation during a followup appointment with him for stroke in July.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.,RELEVANT BACKGROUND INFORMATION:,  Historical information was obtained from a review of available medical records and clinical interview with Ms. A.  A summary of pertinent information is presented below.  Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM:,  Ms. A presented to the ABC Hospital emergency department on 07/26/2009 reporting that after she had woken up that morning she noticed numbness and weakness in her left hand, slurred speech, and left facial droop.  Neurological evaluation with Dr. X confirmed left hemiparesis.  Brain CT showed no evidence of intracranial hemorrhage or mass effect and that she received TPA and had moderate improvement in left-sided weakness.  These symptoms were thought to be due to a right middle cerebral artery stroke.  She was transferred to the ICU for monitoring.  Ultrasound of the carotids showed 20% to 30% stenosis of the right ICA and 0% to 19% stenosis of the left ICA.  On 07/29/2009, she was admitted for acute inpatient rehabilitation for the treatment of residual functional deficits of her acute ischemic right MCA/CVA.  At discharge on 08/06/2009, she was mainly on supervision for all ADLs and walking with a rolling walker, but tolerating increased ambulation with a cane.  She was discharged home with recommendations for outpatient physical therapy.  She returned to the Sinai ER on 08/2009/2009 due to reported left arm pain, numbness, and weakness, which lasted 10 to 15 minutes and she reported that it felt ""just like the stroke.""  Brain CT on 08/2009/2009 was read as showing ""mild chronic microvascular ischemic change of deep white matter,"" but no acute or significant interval change compared to her previous scan.  Neurological examination with Dr. Y was within normal limits, but she was admitted for a more extensive workup.  Due to left arm pain an ultrasound was completed on her left upper extremity, but it did not show deep vein thrombosis.,Followup CT on 08/10/2009 showed no significant interval change.  MRI could not be completed due to the patient's weight.  She was discharged on 08/11/2009 in stable condition after it was determined that this event was not neurological in origin; however, note that Ms. A referred to this as a second stroke.,Ms. A presented for a followup outpatient neurological evaluation with Dr. X on 09/22/2009, at which time a brief neuropsychological screening was also conducted.  She demonstrated significant impairments in confrontation naming, abstract verbal reasoning, and visual and verbal memory and thus a more comprehensive evaluation was suggested due to her intent to return to her full-time work duty.  During the current interview, Ms. A reported that she noticed mild memory problems including some difficultly remembering conversations, events, and at times forgetting to take her medications.  She also reported mild difficulty finding words in conversation, solving novel problems and tasks (e.g. difficulty learning to use her camcorder), but overall denied significant cognitive deficits in attention, concentration, language or other areas of cognitive functioning.  When asked about her return to work, she said that she was still on light duty due to limited physical activity because of residual left leg weakness.  She reported that no one had indicated to her that she appeared less capable of performing her job duties, but said that she was also receiving fewer files to process and enter data into the computer at the Social Security Agency that she works at.  Note also that she had some difficulty explaining exactly what her job involved.  She also reported having problems falling asleep at work and that she is working full-time although on light duty.,OTHER MEDICAL HISTORY:  ,As mentioned, Ms. A continues to have some residual left leg weakness and continues to use a rolling walker for ambulation, but she reported that her motor functioning had improved significantly.  She was diagnosed with sleep apnea approximately two years ago and was recently counseled by Dr. X on the need to use her CPAP because she indicated she never used it at night.  She reported that since her appointment with Dr. X, she has been using it ""every other night.""  When asked about daytime fatigue, Ms. A initially denied that she was having any difficulties, but repeatedly indicated that she was falling asleep at work and thought that it was due to looking at a computer screen.  She reported at times ""snoring"" and forgetting where she is at and said that a supervisor offered to give her coffee at one point.  She receives approximately two to five hours of sleep per night.  Other current untreated risk factors include obesity and hypercholesterolemia.  Her medical history is also significant for hypertension, asthma, abdominal adenocarcinoma status post hysterectomy with bilateral salpingo-oophorectomy, colonic benign polyps status post resection, benign lesions of the breast status post lumpectomy, and deep vein thrombosis in the left lower extremity status post six months of anticoagulation (which she had discontinued just prior to her stroke).,CURRENT MEDICATIONS: , Aspirin 81 mg daily, Colace 100 mg b.i.d., Lipitor 80 mg daily, and albuterol MDI p.r.n.,SUBSTANCE USE:,  Ms. A denied drinking alcohol or using illicit drugs.  She used to smoke a pack of cigarettes per day, but quit five to six years ago.,FAMILY MEDICAL HISTORY: , Ms. A had difficulty providing information on familial medical history.  She reported that her mother died three to four years ago from lung cancer.  Her father has gout and blood clots.  Siblings have reportedly been treated for asthma and GI tumors.  She was unsure of familial history of other conditions such as hypertension, high cholesterol, stroke, etc.,SOCIAL HISTORY: , Ms. A completed high school degree.  She reported that she primarily obtained B's and C's in school.  She received some tutoring for algebra in middle school, but denied ever having been held back a grade failing any classes or having any problems with attention or hyperactivity.,She currently works for the Social Security Administration in data processing.  As mentioned, she has returned to full-time work, but continues to perform only light duties due to her physical condition.  She is now living on her own.  She has never driven.  She reported that she continues to perform ADLs independently such as cooking and cleaning.  She lost her husband in 2005 and has three adult daughters.  She previously reported some concerns that her children wanted her to move into assisted living, but she did not discuss that during this current evaluation.  She also reported number of other family members who had recently passed away.  She has returned to activities she enjoys such as quire, knitting, and cooking and plans to go on a cruise to the Bahamas at the end of October.,PSYCHIATRIC HISTORY: , Ms. A did not report a history of psychological or psychiatric treatment.  She reported that her current mood was good, but did describe some anxiety and nervousness about various issues such as her return to work, her upcoming trip, and other events.  She reported that this only ""comes and goes."",TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II),  Token Test,  Sentence Repetition,  Visual Naming,  Controlled Oral Word Association,  Spelling Test,  Aural Comprehension,  Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Test",
" This is a 69-year-old white woman with Huntington disease, who presents with the third suicide attempt in the past two months. ", Psychiatry / Psychology, Huntington's Disease - Consult ,"CHIEF COMPLAINT: , ""A lot has been thrown at me."",The patient is interviewed with husband in room.,HISTORY OF PRESENT ILLNESS: , This is a 69-year-old Caucasian woman with a history of Huntington disease, who presented to Hospital four days ago after an overdose of about 30 Haldol tablets 5 mg each and Tylenol tablet 325 mg each, 40 tablets.  She has been on the medical floor for monitoring and is medically stable and was transferred to the psychiatric floor today.  The patient states she had been thinking about suicide for a couple of weeks.  Felt that her Huntington disease had worsened and she wanted to spare her family and husband from trouble.  Reports she has been not socializing with her family because of her worsening depression.  Husband notes that on Monday after speaking to Dr. X, they had been advised to alternate the patient's Pamelor (nortriptyline) to every other day because the patient was reporting dry mouth.  They did as they have instructed and husband feels this may have had some factor on her worsening depression.  The patient decided to ingest the pills when her husband went to work on Friday.  She thought Friday would be a good day because there would be less medical people working so her chances of receiving medical care would be lessened.  Her husband left around 7 in the morning and returned around 11 and found her sleeping.  About 30 minutes after his arrival, he found the empty bottles and woke up the patient to bring her to the hospital.,She says she wishes she would have died, but is happy she is alive and is currently not suicidal because she notes her sons may be have to be tested for the Huntington gene.  She does not clearly explain how this has made her suicidality subside.,This is the third suicide attempt in the last two months for this patient.  About two months ago, the patient took an overdose of Tylenol and some other medication, which the husband and the patient are not able to recall.  She was taken to Southwest Memorial Hermann Hospital.  A few weeks ago, the patient tried to shoot herself and the gun was fired and there is a blow-hole in the floor.  Husband locked the gun after that and she was taken to Bellaire Hospital.  The patient has had three psychiatric admissions in the past two months, two to Southwest Memorial and one to Bellaire Hospital for 10 days.  She sees Dr. X once or twice weekly.  He started seeing her after her first suicide attempt.,The patient's husband and the patient state that until March 2009, the patient was independent, was driving herself around and was socially active.  Since then she has had worsening of her Huntington symptoms including short-term memory loss.  At present, the patient could not operate the microwave or operate her cell phone and her husband says that she is progressively more withdrawn, complains about anxiety, and complains about shortness of breath.  The patient notes that she has had depressive symptoms of quitting social life, the patient being withdrawn for the past few months and excessive worry about her Huntington disease.,The patient's mother passed away 25 years ago from Huntington's.  Her grandmother passed away 50 years ago and two brothers also passed away of Huntington's.  The patient has told her husband that she does not want to go that way.  The patient denies auditory or visual hallucinations, denies paranoid ideation.  The husband and the patient deny any history of manic or hypomanic symptoms in the past.,PAST PSYCHIATRIC HISTORY: , As per the HPI, this is her third suicide attempt in the last two months and started seeing Dr. X.  She has a remote history of being on Lexapro for depression.,MEDICATIONS: , Her medications on admission, alprazolam 0.5 mg p.o. b.i.d., Artane 2 mg p.o. b.i.d., Haldol 2.5 mg p.o. t.i.d., Norvasc 10 mg p.o. daily, nortriptyline 50 mg p.o. daily.  Husband has stated that the patient's chorea becomes better when she takes Haldol.  Alprazolam helps her with anxiety symptoms.,PAST MEDICAL HISTORY: , Huntington disease, symptoms of dementia and hypertension.  She has an upcoming appointment with the Neurologist.  Currently, does have a primary care physician and _______ having an outpatient psychiatrist, Dr. X, and her current Neurologist, Dr. Y.,ALLERGIES: , CODEINE AND KEFLEX.,FAMILY MEDICAL HISTORY:  ,Strong family history for Huntington disease as per the HPI.  Mother and grandmother died of Huntington disease.  Two young brothers also had Huntington disease.,FAMILY PSYCHIATRIC HISTORY: , The patient denies history of depression, bipolar, schizophrenia, or suicide attempts.,SOCIAL HISTORY:  ,The patient lives with her husband of 48 years.  She used to be employed as a registered nurse.  Her husband states that she does have a pattern of self-prescribing for minor illness, but does not think that she has ever taken muscle relaxants or sedative medications without prescriptions.  She rarely drinks socially.  She denies any illicit substance usage.  Her husband reportedly gives her medication daily.  Has been proactive in terms of seeking mental health care and medical care.  The patient and husband report that from March 2009, she has been relatively independent, more socially active.,MENTAL STATUS EXAM:  ,This is an elderly woman appearing stated age.  Alert and oriented x4 with poor eye contact.  Appears depressed, has psychomotor retardation, and some mild involuntary movements around her lips.  She is cooperative.  Her speech is of low volume and slow rate and rhythm.  Her mood is sad.  Her affect is constricted.  Her thought process is logical and goal-directed.  Her thought content is negative for current suicidal ideation.  No homicidal ideation.  No auditory or visual hallucinations.  No command auditory hallucinations.  No paranoia.  Insight and judgment are fair and intact.,LABORATORY DATA:,  A CT of the brain without contrast, without any definite evidence of acute intracranial abnormality.  U-tox positive for amphetamines and tricyclic antidepressants.  Acetaminophen level 206.7, alcohol level 0.  The patient had a leukocytosis with white blood cell of 15.51, initially TSH 1.67, T4 10.4.,ASSESSMENT: , This is a 69-year-old white woman with Huntington disease, who presents with the third suicide attempt in the past two months.  She took 30 tablets of Haldol and 40 tablets of Tylenol.  At present, the patient is without suicidal ideation.  She reports that her worsening depression has coincided with her worsening Huntington disease.  She is more hopeful today, feels that she may be able to get help with her depression.,The patient was admitted four days ago to the medical floor and has subsequently been stabilized.  Her liver function tests are within normal limits.,AXIS I:  Major depressive disorder due to Huntington disease, severe.  Cognitive disorder, NOS.,AXIS II:  Deferred.,AXIS III:  Hypertension, Huntington disease, status post overdose.,AXIS IV:  Chronic medical illness.,AXIS V:  30.,PLAN,1.  Safety.  The patient would be admitted on a voluntary basis to Main-7 North.  She will be placed on every 15-minute checks with suicidal precautions.,2.  Primary psychiatric issues/medical issues.  The patient will be restarted as per written by the consult service for Prilosec 200 mg p.o. daily, nortriptyline 50 mg p.o. nightly, Haldol 2 mg p.o. q.8h., Artane 2 mg p.o. daily, Xanax 0.5 mg p.o. q.12h., fexofenadine 180 mg p.o. daily, Flonase 50 mcg two sprays b.i.d., amlodipine 10 mg p.o. daily, lorazepam 0.5 mg p.o. q.6h. p.r.n. anxiety and agitation.,3.  Substance abuse.  No acute concern for alcohol or benzo withdrawal.,4.  Psychosocial.  Team will update and involve family as necessary.,DISPOSITION: , The patient will be admitted for evaluation, observation, treatment.  She will participate in the milieu therapy with daily rounds, occupational therapy, and group therapy.  We will place occupational therapy consult and social work consults.",
 Bender-Gestalt Neurological Battery and Beck testing., Psychiatry / Psychology, Neurobehavioral Assessment ,"BENDER-GESTALT TEST: , Not organic.,BECK TESTING:,Depression: 37,Anxiety: 41,Hopelessness: 10,Suicide Ideation:  18,SUMMARY:,  The patient was cooperative and appeared to follow the test instructions. There is no evidence of organicity on the Bender. He endorsed symptoms of depression and anxiety. He has moderately negative expectancies regarding his future and is expressing suicidal ideation. Great care should be taken to confirm the accuracy of the results as the patients seems over-medicated and/or drunk.","psychiatry / psychology, bender-gestalt neurological battery, beck anxiety inventory, beck depression inventory, beck hopelessness scale, beck scale, suicide ideation, bender-gestalt test, beck testing, bender gestalt, beck,"
 Sample for Neuropsychological Evaluation, Psychiatry / Psychology, Neuropsychological Evaluation - 1 ,"REASON FOR EVALUATION: , The patient is a 37-year-old white single male admitted to the hospital through the emergency room.  I had seen him the day before in my office and recommended him to go into the hospital.  He had just come from a trip to Taho in Nevada and he became homicidal while there.  He started having thoughts about killing his mother.  He became quite frightened by that thought and called me during the weekend we were able to see him on that Tuesday after talking to him.,HISTORY OF PRESENT ILLNESS: , This is a patient that has been suffering from a chronic psychotic condition now for a number of years.  He began to have symptoms when he was approximately 18 or 19 with auditory and visual hallucinations and paranoid delusions.  He was using drugs and smoking marijuana at that time has experimenting with LXV and another drugs too.  The patient has not used any drugs since age 25.  However, he has continued having intense and frequent psychotic bouts.  I have seen him now for approximately one year.  He has been quite refractory to treatment.  We tried different types of combination of medications, which have included Clozaril, Risperdal, lithium, and Depakote with partial response and usually temporary.  The patient has had starting with probably has had some temporary relief of the symptoms and they usually do not last more than a few days.  The dosages that we have used have been very high.  He has been on Clozaril 1200 mg combined with Risperdal up to 9 mg and lithium at a therapeutic level.  However, he has not responded.,He has delusions of antichrist.  He strongly believes that the dogs have a home in the neighborhood are communicating with him and criticizing him and he believes that all the people can communicate to him with telepathy including the animals.  He has paranoid delusions.  He also gets homicidal like prior to this admission.,PAST PSYCHIATRIC HISTORY:,  As mentioned before, this patient has been psychotic off and on for about 20 years now.  He has had years in which he did better on Clozaril and also his other medications.,With typical anti-psychotics, he has done well at times, but he eventually gets another psychotic bout.,PAST MEDICAL HISTORY: , He has a history of obesity and also of diabetes mellitus.  However, most recently, he has not been treated for diabetes since his last regular weight since he stopped taking Zyprexa.  The patient has chronic bronchitis.  He smokes cigarettes constantly up to 60 a day.,DRUG HISTORY:,  He stopped using drugs when he was 25.  He has got a lapse, but he was more than 10 years and he has been clean ever since then.  As mentioned before, he smokes cigarettes quite heavily and which has been a problem for his health since he also has chronic bronchitis.,PSYCHOSOCIAL STATUS: , The patient lives with his mother and has been staying with her for a few years now.  We have talked to her.  She is very supportive.  His only sister is also very supportive of him.  He has lived in the ABCD houses in the past.  He has done poorly in some of them.,MENTAL STATUS EXAMINATION:,  The patient appeared alert, oriented to time, place, and person.  His affect is flat.  He talked about auditory hallucinations, which are equivocal in nature.  He is not homicidal in the hospital as he was when he was at home.  His voice and speech are normal.  He believes in telepathy.  His memory appears intact and his intelligence is calculated as average.,INITIAL DIAGNOSES:,AXIS I:  Schizophrenia.,AXIS II:  Deferred.,AXIS III:  History of diabetes mellitus, obesity, and chronic bronchitis.,AXIS IV:  Moderate.,AXIS V:  GAF of 35 on admission.,INITIAL TREATMENT AND PLAN:,  Since, the patient has been on high dosages of medications, we will give him a holiday and a structured environment.  We will put him on benzodiazepines and make a decision anti-psychotic later.  We will make sure that he is safe and that he addresses his medical needs well.","psychiatry / psychology, neuropsychological, gaf, schizophrenia, anti-psychotic, chronic psychotic condition, delusions, hallucination, homicidal, marijuana, psychological, psychotic, smokes cigarettes, smoking, neuropsychological evaluation, clozaril, bronchitis, axis, "
 Falls at home.  Anxiety and depression.  The patient had been increasingly anxious and freely admitted that she was depressed at home., Psychiatry / Psychology, Falls - Discharge Summary ,"CHIEF COMPLAINT:,  Falls at home.,HISTORY OF PRESENT ILLNESS:,  The patient is an 82-year-old female who fell at home and presented to the emergency room with increased anxiety.  Family members who are present state that the patient had been increasingly anxious and freely admitted that she was depressed at home.  They noted that she frequently came to the emergency room for ""attention.""  The patient denied any chest pain or pressure and no change to exercise tolerance.  The patient denied any loss of consciousness or incontinence.  She denies any seizure activity.  She states that she ""tripped"" at home.  Family states she frequently takes Darvocet for her anxiety and that makes her feel better, but they are afraid she is self medicating.  They stated that she has numerous medications at home, but they were not sure if she was taking them.  The patient been getting along for a number of years and has been doing well, but recently has been noting some decline primarily with regards to her depression.  The patient denied SI or HI.,PHYSICAL EXAMINATION:,GENERAL:  The patient is pleasant 82-year-old female in no acute distress.,VITAL SIGNS:  Stable.,HEENT:  Negative.,NECK:  Supple.  Carotid upstrokes are 2+.,LUNGS:  Clear.,HEART:  Normal S1 and S2.  No gallops.  Rate is regular.,ABDOMEN:  Soft.  Positive bowel sounds.  Nontender.,EXTREMITIES:  No edema.  There is some ecchymosis noted to the left great toe.  The area is tender; however, metatarsal is nontender.,NEUROLOGICAL:  Grossly nonfocal.,HOSPITAL COURSE: , A psychiatric evaluation was obtained due to the patient's increased depression and anxiety.  Continue Paxil and Xanax use was recommended.  The patient remained medically stable during her hospital stay and arrangements were made for discharge to a rehabilitation program given her recent falls.,DISCHARGE DIAGNOSES:,1.  Falls ,2.  Anxiety and depression.,3.  Hypertension.,4.  Hypercholesterolemia.,5.  Coronary artery disease.,6.  Osteoarthritis.,7.  Chronic obstructive pulmonary disease.,8.  Hypothyroidism.,CONDITION UPON DISCHARGE: , Stable.,DISCHARGE MEDICATIONS: , Tylenol 650 mg q.6h. p.r.n., Xanax 0.5 q.4h. p.r.n., Lasix 80 mg daily, Isordil 10 mg t.i.d., KCl 20 mEq b.i.d., lactulose 10 g daily, Cozaar 50 mg daily, Synthroid 75 mcg daily, Singulair 10 mg daily, Lumigan one drop both eyes at bed time, NitroQuick p.r.n., Pravachol 20 mg daily, Feldene 20 mg daily, Paxil 20 mg daily, Minipress 2 mg daily, Provera p.r.n., Advair 250/50 one puff b.i.d., Senokot one tablet b.i.d., Timoptic one drop OU daily, and verapamil 80 mg b.i.d.,ALLERGIES: , None.,ACTIVITY: , Per PT.,FOLLOW-UP: , The patient discharged to a skilled nursing facility for further rehabilitation.",
 The patient was referred after he was hospitalized for what eventually was diagnosed as a conversion disorder. , Psychiatry / Psychology, Conversion Disorder ,"REASON FOR REFERRAL:  ,The patient was referred to me by Dr. X of Children's Hospital after he was hospitalized for what eventually was diagnosed as a conversion disorder.  I had met the patient and his mother in the hospital and had begun getting information regarding his symptoms and background at that time.  After his discharge, the patient was scheduled to see me for followup services.  This was a 90-minute intake that was completed on 10/10/2007 with the patient's mother.  I reviewed with her the treatment consent form as well as the boundaries of confidentiality, and she stated that she understood these concepts.,PRESENTING PROBLEMS:,  Please see the inpatient hospital progress note contained in his chart for additional background information.  The patient's mother reported that he continues with his conversion episodes.  She noted that they are occurring approximately 6 times a day.  They consist primarily of tremors, arching his back, and, by her report, doing some gang signs during the episode.  She reported that the conversion reactions had decreased after his hospitalization, and he had none for 3 days, but then, they began picking up again.  From information gathered from mother, it would suggest that she frequently does ""status checks,"" where she asks him how he is doing, and that after she began checking on him more that he began having more conversion reactions.  In terms of what she does when he has a conversion reaction, she reported that primarily that she tries to keep him safe.  She puts a sheath under him because the carpeting is dirty.  She removes any furniture, she wraps his legs together so they do not knock together, she sits with him and she gives him attention and says ""calm down, breathe"" and after it is over, she continues to tell him to be calm and to breathe.  She denied that she gives them any more attention.  I strongly encouraged her to stop doing status checks, as this likely is reinforcing the behavior.  I also noted that while he certainly needs to be kept safe, that she does not want to give a lot of attention to this behavior, and that over time we will teach him ways of coping with this independently.  In regards to his mood, she reported that his mood is quite good.  She denied any sadness or irritability.  She denied anhedonia.  She reports that he is a little bit hard to get up in the morning.  He is going to bed at about 11, getting up at 8 or 9.  No changes in weight or eating were noted.  No changes in concentration, suicidal ideation, and any suicidal history was denied.  She denied symptoms of anxiety, although she did note that she thought he worried a little about going to school and some financial stress.  Other symptoms of psychopathology were denied.,DEVELOPMENTAL HISTORY: , The patient was reportedly a 7 pounds 12 ounces product of an unplanned and uncomplicated pregnancy and planned cesarean delivery.  Mother reported that she did receive prenatal care.  The use of alcohol, drugs, or tobacco during the pregnancy were denied.  She denied that he had any feeding or sleeping problems in the perinatal period.  She described him as a fussy and active baby, but he was described as a cuddly baby.  She noted that the pediatricians never expressed any concerns regarding his developmental milestones.  SHE REPORTED THAT HE IS ALLERGIC TO PENICILLIN.  Serious injures or toileting problems were denied as were a history of seizures.,FAMILY BACKGROUND: , The patient currently lives with his mother who is age 57 and with her partner who is age 40.  They have been together since 1994, and he is the only father figure that the patient has even known.  The father was previously in a relationship that resulted in an 11-year-old daughter who visits the patient's home every other weekend.  The patient's father's whereabouts are unknown.  There is no information on his family.  Mother stated that he discontinued his involvement in her life when she was about 3 months pregnant with the patient, and the patient has never met him.  As noted, there is no information on the paternal side of the family.  In terms of the mother's side of family, the maternal grandfather died in his 60s due to what mother described as ""hardening of the arteries,"" and the maternal grandmother died in 2003 due to stroke.  There were 4 maternal aunts, one of them died at age 9 months from pneumonia, one of them died at 19 years old from what was described as a brain tumor, and there are 3 maternal uncles.  In terms of family relationships, it was reported that overall the patient tends to get along fairly well with his parents, who reported that the patient and her partner tend to compete for mother's attention, and she noted this is difficult at times.  She reported that the patient and her partner do not really do anything together.  Mother reported that there is no domestic violence in the home, but there is some marital conflict, and this is may be difficult for The patient, as it is carried on in Spanish, and he does not speak Spanish.  There also is some stress in the home due to the stepdaughter, as there are some concerns that her mother may be involved in drugs.  The mother reported that she attended high school, did not attend any college.  She denied learning problems.  She denied psychological problems or any drug/alcohol history.  In terms of the biological father, she reported he did not graduate from high school.  She did not know of learning problems, psychological problems.  She denied that he had a drug/alcohol history.  There is a family history of alcoholism in one of the maternal uncles as well as in the maternal grandfather.  It should be noted that the patient and his family live in a small 4-bedroom apartment, where privacy is very difficult.,SOCIAL BACKGROUND:,  She reported that the patient is able to make and keep friends, but he enjoys lifting weights, skateboarding, and that he recently had an opportunity to do rock climbing, he really enjoyed that.  I encouraged her to have him involved in physical activity, as this is good for discharge the stress, to encourage the weightlifting, as well as the skateboarding.  Mother is going to check further information regarding the rock climbing that the patient had been involved in, which was at it sounds like by her description as some sort of boys' and girls' type of club.  Abuse of drugs or alcohol were denied.  The patient was not described as being sexually active.,ACADEMIC BACKGROUND: , The patient is currently in the 10th grade.  At present, he is on independent studies, which began after his hospitalization.  The mother reported that the teacher, who had come to school saw one of his episodes, and stated that, they would not want him to be attending school.  I spoke with her very clearly and directly regarding the fact that it was probably not best for the patient to be on independent studies, that he needed to be returned to his normal school environment.  He has never had an episode at school, and he needs to be back with his peers, back in a regular environment, where he is under normal expectations.  I spoke with her regarding my concerns, regarding the fact that he is unsupervised during the day, and we do not want this turning into one big long vacation, where he is not getting his work done, and he gets himself in trouble.  Normally, he would be attending at High School.  The mother stated that she would contact them as well as check into possibly a 504-Plan.  She reported that he really does not to go back to High School.  He says, the ""kids are bad;"" however, she denied that he has any history of fighting.  She noted that he is stressed by the school, there have been some peer problems, possibly some bullying.  I noted these need to be addressed with the school, as she had not done so.  She stated that she would speak with a counselor.  She noted, however, that he has a history of not liking school and avoiding going to school.  She noted that he is somewhat behind in his work due to the hospitalization.  His grades traditionally are C's.  She denied any Special Education Services.,PREVIOUS COUNSELING: , Denied.,DIAGNOSTIC SUMMARY AND IMPRESSION: , Similar to my impression at the hospital, it would appear that the patient clearly qualifies for a diagnosis of conversion disorder.  It appears that there are multiple stressors in the family, and that the mother is reinforcing his conversion reaction.  I am also very concerned regarding the fact that he is not attending school and want him back in the normal school environment as quickly as possible.  My plan is to meet the patient at the next session to update the information regarding his functioning and to begin to teach him skills for reducing his stress and relaxing.,DSM-IV DIAGNOSES:  ,AXIS I:  Conversion disorder (300.11).,AXIS II:  No diagnosis (V71.09).,AXIS III:  No diagnosis.,AXIS IV:  Problems with primary support group, educational problems, and peer problems.,AXIS V:  Global Assessment of Functioning equals 60.","psychiatry / psychology, developmental history, academic background, global assessment of functioning, normal school environment, conversion reactions, conversion disorder, conversion, background, environment, peers, disorder, axis,"
 Comprehensive Mental Status Evaluation for the purpose of assisting in the determination of eligibility for Disability, Psychiatry / Psychology, Mental Status Evaluation ,"COMPREHENSIVE MENTAL STATUS EVALUATION,REASON FOR REFERRAL/GENERAL OBSERVATIONS:,  The patient was referred for a Comprehensive Mental Status Evaluation for the purpose of assisting in the determination of eligibility for Disability.  He is a 43-year-old married, white male who came unaccompanied to the evaluation.  He drove himself suggesting that he drives regularly.  He reportedly has been on Disability since around 2002.  He was a good historian, freely offering information.  He was dressed and groomed casually, yet neat and appropriate in appearance.  He was cooperative with all questions presented and the information collected is felt to be a reliable indication of current functioning.  No censorship of data was indicated.  ,PRESENT PROBLEMS:,  The claimant described his recent problems as, ""serious depression.  Very hard to concentrate.  Very short tempered.  Usually distracted."" ,The claimant reportedly has had significant problems with depression since around 1997.,The claimant last worked about six weeks ago.  He was drafting at a company in Stanfield, North Carolina, for almost six months and was laid off because ""I had a breakdown and ended up in the hospital.  They said that I wasn't reliable enough and laid me off.""  Prior to that he worked for two and a half months doing drafting at another company and was laid off because he was no longer needed.  ,The claimant has had significant emotional problems since around 1997.  He was first hospitalized in that year and has been hospitalized five more times since then.  The last hospitalization was last month in Atlanta, Georgia.  He has tried to overdose in the past as well as cut his wrist.  He even had to undergo electroconvulsive therapy in 2001, because of depression.  He also, supposedly, has a history of sexual assault towards a minor and his on probation for that incident.  Details regarding this episode of child sexual assault were not forthcoming.,The claimant now takes Effexor 75 mg b.i.d.  He is not involved in outpatient therapy.  ,PERSONAL, FAMILY AND SOCIAL HISTORY:,  The claimant indicated that he graduated from high school in regular classes.  He did have to repeat the kindergarten because he was too young.  He worked for about 10 years at a company in Massachusetts.  He was not advancing on that job and therefore quit.  He has had three subsequent jobs and a number of emotional problems since.  He indicated usually getting along with others but stated, ""I had trouble taking direction from someone younger than me.  I resent getting nagged at.  I'd get angry or just seethe.""  He has been let go from his last two jobs because of emotional issues.  ,The claimant was married the first time for five years.  He has no children.  He now lives at home with his wife., ,The claimant denied any legal problems.  He suggested that his mother had bipolar disorder.  He has never served in the military.,The claimant denied the use or abuse of tobacco, alcohol or illicit drugs.  He stopped drinking in 1997.  Prior to that he drank about a six pack of beer per day for about 15 years.,The claimant takes the no other prescribed medications., ,DAILY ACTIVITIES AND FUNCTIONING:,  The claimant described his typical day as follows, ""I usually get up about 7:00 to 7:30.  Have breakfast.  Take a shower about 8:30.  Do errands.  Me and my wife are out of the house by 9:00.  Check e-mail at the library.  I like the computer.  We have lunch 11:30 or 12:00.  Do errands or watch talk shows or I'll read.  I love to read.  Around 5:00 to 5:30, have supper.  Watch the news, game shows.  In bed by 10:00.""  He will help with vacuuming, doing the dishes or yard work.  His wife does most of the house cleaning.  He does no cooking.  He and his wife get out every day usually for three or four hours.  He has a neighbor next door that he will see twice a week.  He used to go to the gym but has not been in a few weeks.  No other family contact was described and he does not go to church.  When asked what he enjoys he stated, ""read, use my computer or go ride my bike."", ,MENTAL STATUS EVALUATION:,  On interview, the claimant looked his stated age of 43 years.  He was tall in stature and thin in weight.  He was neat and clean in appearance.  Posture was somewhat tense but psychomotor activity was not remarkable.  Eye contact was fleeting with fair social skills evident.  Facial expression was tense and affect was restricted with little animation noted.  General mood appeared dysphoric.  Speech was clear, coherent, logical, goal-directed and relevant.  He was cooperative in attitude toward the examiner.  He described his recent mood as, ""cloudy, gray because we've got a lot of personal problems right now.  I'm frustrated because I don't know where things are going.""  He described some problems with falling asleep and staying asleep at night as well as decreased energy level.  He denied appetite disturbance.  He has lost interest in some activities suggesting mild anhedonia.  He has trouble with attention and concentration stating, ""I have trouble recalling how to do things on the computer. I've always been technically minded, but now it's harder.""  He has thoughts of suicide about once or twice a week and has often fled situations in the past.  He stated, ""I try to keep myself from running away.""  He denied any plan or intent for suicide.  He suggested significant anxiety problems as well.  He stated, ""I'm dealing with pedophilia.  I try to time it so that I don't go to a store with lots of people around.  If there is people I get real edgy, heart pounds, shortness of breath.  A lot of chest discomfort.""  He has these panic symptoms quite regularly and they have occurred ever since 1997.  That was the time that he engaged in some type of sexual assault with a minor and spent about a week in jail.  No phobic processes were suggested.  No psychotic symptoms were revealed.  He denied hallucinations and no delusional material was elicited.  Thought content was appropriate to mood and circumstances.,The claimant was oriented in all spheres.  He evidenced adequate memory for both recent and remote events.  He was able to recall 3 of 3 words after a 1 minute and 10 minute delay.  Fair sustained attention and concentration skills were shown.  He was able to spell a word backward and performed a serial 7 subtraction task affectively.  Basic calculation skills were intact and no language-based dysfunction was noted.  Social judgment was also intact as he gave a good response to finding a wallet in the street, ""find who the owner was, bring it to the police station or contact the person,"" and to seeing smoke in a theater, ""Get a hold of staff so they could evacuate.""  Adequate conceptual abilities was shown with similarity comparisons.  Somewhat limited abstraction was shown with proverb interpretation, glass houses, ""don't do anything you're not supposed to do.""  Premorbid intellect is estimated to be at least in the average range.  Insight regarding his situation was fair.,DIAGNOSTIC IMPRESSION:,Axis I:  Major Depression, recurrent, moderate.  Panic disorder without agoraphobia.,SUMMARY AND CONCLUSIONS:,  Based on this evaluation, I believe the claimant's current condition would continue to result in difficulty with work-related activities.  He continues to show significant problems with depression and anxiety.  He is quite withdrawn and socially isolated and has panic attacks whenever he is confronted with public situations.  He relies on his wife to take care of most all household task.  He engages in very few simple, routine and repetitive activities. Cognitive capacity was relatively intact suggesting no significant problems in maintaining focus and pace with task.,RECOMMENDATIONS/CAPABILITY:,  The claimant was strongly encouraged to get some additional help for his emotional problems.  He would benefit from having someone to speak with on a regular basis and some referrals were offered. ,It is the opinion of this examiner that the claimant is capable of handling his own funds if so assigned.",
" The patient has a manic disorder, is presently psychotic with flight of ideas, tangential speech, rapid pressured speech and behavior, impulsive behavior.   Bipolar affective disorder, manic state.  Rule out depression.", Psychiatry / Psychology, Bipolar Affective Disorder - Consult ,"IDENTIFYING DATA:  ,The patient is a 35-year-old Caucasian female who speaks English.,CHIEF COMPLAINT:  ,The patient has a manic disorder, is presently psychotic with flight of ideas, believes, ""I can fly,"" tangential speech, rapid pressured speech and behavior, impulsive behavior.  Last night, she tried to turn on the garbage disposal and put her hand in it, in the apartment shared by her husband.  She then turned on the oven and put her head in the oven and then tried to climb over the second storied  balcony.  All of these behaviors were interrupted by her husband who called 911.  He reports that she has not slept in 3 to 5 days and has not taken her meds in at least that time period.,HISTORY OF PRESENT ILLNESS:  ,The patient was treated most recently at ABCD Hospital and decompensated during that admission resulting in her 90-day LR being revoked.  After leaving ABCD approximately 01/25/2010, she stopped taking her Abilify and lithium.  Her husband states that he restrained her from jumping, ""so she would not kill herself,"" and this was taken as a statement in his affidavit.  The patient was taken to X Hospital, medically cleared, given Ativan 2 mg p.o. and transferred on an involuntary status to XYZ Hospital.  She arrives here and is today pacing on the unit and in and out of the large TV room area.  She is friendly towards the patients although sometimes raises her voice and comes too close to other patients in a rapid manner.  She is highly tangential, delusional, and disorganized.  She refused to sign all admit papers and a considerable part of her immediate history is unknown.,PAST PSYCHIATRIC HISTORY:  ,The patient was last admitted to XYZ Hospital on January 14, 2009, and discharged on January 23, 2009.  Please see the excellent discharge summary of Dr. X regarding this admission for information, which the patient is unable to give at the present.  She is currently treated by Dr. Y.  She has been involuntarily detained at least 7 times and revoked at least 6 times.  She was on XYZ Inpatient in 2001 and in 01/2009.  She states that she ""feels invincible"" when she becomes manic and this is also the description given by her husband.,MEDICAL HISTORY:  ,The patient has a history of a herniated disc in 1999.,MEDICATIONS: , Current meds, which are her outpatient meds, which she is not taking at the moment are lithium 300 mg p.o.  AM and 600 mg p.o. q.p.m., Abilify 15 mg p.o. per day, Lyrica 100 mg p.o. per day, it is not clear if she is taking Geodon as the record is conflicting in this regard.  She is being given Vicodin, is not sure who the prescriber for that medication is and it is presumably due to her history of herniated disc.  Of note, she also has a history of abusing Vicodin.,ALLERGIES:  ,Said to be PENICILLIN, LAMICTAL, and ZYPREXA.,SOCIAL AND DEVELOPMENTAL HISTORY: , The patient lives with her husband.  There are no children.  She reportedly has a college education and has 2 brothers.,SUBSTANCE AND ALCOHOL HISTORY: , Per ABCD information, the patient has a history of abusing opiates, benzodiazepines, and Vicodin.  The X Hospital tox screen of last night was positive for opiates.  Her lithium level per last night at X Hospital was 0.42 mEq/L.  She smokes nicotine, the amount is not known although she has asked and received Nicorette gum.,LEGAL HISTORY: , She had a 90-day LR, which was revoked at ABCD Hospital, 12/ 25/2009, when she quickly deteriorated.,MENTAL STATUS EXAM:,ATTITUDE: ,The patient's attitude is agitated when asked questions, loud and evasive.,APPEARANCE:,  Disheveled and moderately well nourished.,PSYCHOMOTOR: , Restless with erratic sudden movements.,EPS:,  None.,AFFECT: , Hyperactive, hostile, and labile.,MOOD: , Her mood is agitated, suspicious, and angry.,SPEECH:  ,Circumstantial and sometimes intelligible when asked simple direct questions and at other points becomes completely tangential describing issues which are not real.,THOUGHT CONTENT: , Delusional, disorganized, psychotic, and paranoid.  Suicidal ideation, the patient refuses to answer the questions, but the record shows a past history of suicide attempt.,COGNITIVE ASSESSMENT:  ,The patient was said on her nursing admit to be oriented to place and person, but could not answer that question for me, and appeared to think that she may still be at ABCD Hospital.  Her recent, intermediate, and remote memory are impaired although there is a lack of cooperation in this testing.,JUDGMENT AND INSIGHT:,  Nil.  When asked, are there situations when you lose control, she refuses to answer.  When asked, are meds helpful, she refuses to answer.  She refuses to give her family information nor release of information to contact them.,ASSETS:,  The patient has an outpatient psychiatrist and she does better or is more stable when taking her medications.,LIMITATIONS:,  The patient goes off her medications routinely, behaves unsafely and in a potentially suicidal manner.,FORMULATION,:  The patient has bipolar affective disorder in a manic state at present.  She also may be depressed and is struggling with marital issues.,DIAGNOSES:",
" The patient is a 21-year-old Caucasian male, who attempted suicide by trying to jump from a moving car, which was being driven by his mother. ", Psychiatry / Psychology, Attempted Suicide - Consult ,"IDENTIFYING DATA: , The patient is a 21-year-old Caucasian male, who attempted suicide by trying to jump from a moving car, which was being driven by his mother.  Additionally, he totaled his own car earlier in the day, both of which occurrences occurred approximately 72 hours before arriving at ABCD Hospital.  He says he had a ""panic attack leading to the car wreck"" and denies that any of his behavior was suicidal in nature responding, ""I was just trying to scare my mother."",CHIEF COMPLAINT: , The patient does say, ""I screwed up my whole life and wrecked my car."" The patient claims he is med compliant, although his mother, and stepfather saying he is off his meds.  He had a two-day stay at XYZ Hospital for medical clearance after his car accident, and no injuries were found other than a sore back, which was negative by x-ray and CT scan.,PRESENT ILLNESS:  ,The patient is on a 72-your involuntary hold for danger to self and grave disability.  He has a history of bipolar disorder with mania and depression with anxiety and panic attacks.  Today, he went to involuntary court hearing and was released by the court.  He is now being discharged from second floor ABCD Psychiatric Hospital.,PAST PSYCHIATRIC HISTORY:,  Listed extensively in his admission note and will not be repeated.,MEDICAL HISTORY: , Includes migraine headaches and a history of concussion.  He describes ""allergy"" to Haldol medication.,OUTPATIENT CARE: , The patient sees a private psychiatrist, Dr. X.  Followup with Dr. X is arranged in four days' time and the patient is discharged with four days of medication.  This information is known to Dr. X.,DISCHARGE MEDICATIONS:,The patient is discharged with:,1.  Klonopin 1 mg t.i.d. p.r.n.,2.  Extended-release lithium 450 mg b.i.d.,3.  Depakote 1000 mg b.i.d.,4.  Seroquel 1000 mg per day.,SOCIAL HISTORY:  ,The patient lives with his girlfriend on an on-and-off basis and is unclear if they will be immediately moving back in together.,SUBSTANCE ABUSE: , The patient was actively tox screen positive for benzodiazepines, cocaine, and marijuana.  The patient had an inpatient stay in 2008 at ABC Lodge for drug abuse treatment.,MENTAL STATUS EXAM:,  Notable for lack of primary psychotic symptoms, some agitation, and psychomotor hyperactivity, uncooperative behavior regarding his need for ongoing acute psychiatric treatment and stabilization.  There is an underlying hostile oppositional message in his communications.,FORMULATION: , The patient is a 21-year-old male with a history of bipolar disorder, anxiety, polysubstance abuse, and in addition ADHD.  His recent behavior is may be at least in part associated with active polysubstance abuse and also appears to be a result of noncompliance with meds.,DIAGNOSES:,AXIS I:,1.  Bipolar disorder.,2.  Major depression with anxiety and panic attacks.,3.  Polysubstance abuse, benzodiazepines, and others street meds.,4.  ADHD.,AXIS II: , Deferred at present, but consider personality disorder traits.,AXIS III:,  History of migraine headaches and past history of concussion.,AXIS IV: , Stressors are moderate.,AXIS V: , GAF is 40.,PLAN: , The patient is released from the hospital secondary to court evaluation, which did not extend his involuntary stay.  He has an appointment in four days with his outpatient psychiatrist, Dr. X.  He has four days' worth of medications and agrees to no self-harm or harm of others.  Additionally, he agrees to let staff know or authorities know if he becomes acutely unsafe.  His mother and stepfather have been informed of the patient's discharge and the followup plan.",
" Painful enlarged navicula, right foot.  Osteochondroma of right fifth metatarsal. Partial tarsectomy navicula and partial metatarsectomy, right foot.", Podiatry, Tarsectomy ,"PREOPERATIVE DIAGNOSES:,1.  Painful enlarged navicula, right foot.,2.  Osteochondroma of right fifth metatarsal.,POSTOPERATIVE DIAGNOSES:,1.  Painful enlarged navicula, right foot.,2.  Osteochondroma of right fifth metatarsal.,PROCEDURE PERFORMED:,1.  Partial tarsectomy navicula, right foot.,2.  Partial metatarsectomy, right foot.,HISTORY:  ,This 41-year-old Caucasian female who presents to ABCD General Hospital with the above chief complaint.  The patient states that she has extreme pain over the navicular bone with shoe gear as well as history of multiple osteochondromas of unknown origin.  She states that she has been diagnosed with hereditary osteochondromas.  She has had previous dissection of osteochondromas in the past and currently has not been diagnosed in her feet as well as spine and back.  The patient desires surgical treatment at this time.,PROCEDURE:  ,An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported to the operating room and placed on operating table in the supine position with a safety belt across her lap.  Copious amounts of Webril were placed on the left ankle followed by a blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 5 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain were injected in the diamond block type fashion around the navicular bone as well as the fifth metatarsal.  Foot was then prepped and draped in the usual sterile orthopedic fashion.,Foot was elevated from the operating table and exsanguinated with an Esmarch bandage.  The pneumatic ankle tourniquet was then inflated to 250 mmHg.  The foot was lowered as well as the operating table.  The sterile stockinet was reflected and the foot was cleansed with wet and dry sponge.  Attention was then directed to the navicular region on the right foot.  The area was palpated until the bony prominence was noted.  A curvilinear incision was made over the area of bony prominence.  At that time, a total of 10 cc with addition of 1% additional lidocaine plain was injected into the surgical site.  The incision was then deepened with #15 blade.  All vessels encountered were ligated for hemostasis.  The dissection was carried down to the level of the capsule and periosteum.  A linear incision was made over the navicular bone obliquely from proximal dorsal to distal plantar over the navicular bone.  The periosteum and the capsule were then reflected from the navicular bone at this time.  A bony prominence was noted both medially and plantarly to the navicular bone.  An osteotome and mallet were then used to resect the enlarged portion of the navicular bone.  After resection with an osteotome there was noted to be a large plantar shelf.  The surrounding soft tissues were then freed from this plantar area.  Care was taken to protect the attachments of the posterior tibial tendon as much as possible.  Only minimal resection of its attachment to the fiber was performed in order to expose the bone.  Sagittal saw was then used to resect the remaining plantar medial prominent bone.  The area was then smoothed with reciprocating rasp until no sharp edges were noted.  The area was flushed with copious amount of sterile saline at which time there was noted to be a palpable ________ where the previous bony prominence had been noted.  The area was then again flushed with copious amounts of sterile saline and the capsule and periosteum were then reapproximated with #3-0 Vicryl.  The subcutaneous tissues were then reapproximated with #4-0 Vicryl to reduce tension from the incision and running #5-0 Vicryl subcuticular stitch was performed.,Attention was then directed to the fifth metatarsal.  There was noted to be a palpable bony prominence dorsally with fifth metatarsal head as well as radiographic evidence laterally of an osteochondroma at the neck of the fifth metatarsal.  Approximately 7 cm incision was made dorsolaterally over the fifth metatarsal.  The incision was then deepened with #15 blade.  Care was taken to preserve the extensor tendon.  The incision was then created over the capsule and periosteum of the fifth metatarsal head.  Capsule and periosteum were reflected both dorsally, laterally, and plantarly.  At that time, there was noted to be a visible osteochondroma on the plantar lateral aspect of the fifth metatarsal neck as well as on the dorsal aspect of the head of the fifth metatarsal.  A sagittal saw was used to resect both of these osteal prominences.,All remaining sharp edges were then smoothed with reciprocating rasp.  The area was inspected for the remaining bony prominences and none was noted.  The area was flushed with copious amounts of sterile saline.  The capsule and periosteum were then reapproximated with #3-0 Vicryl.  Subcutaneous closure was then performed with #4-0 Vicryl in order to reduce tension around the incision line.  Running #5-0 subcutaneous stitch was then performed.  Steri-Strips were applied to both surgical sites.  Dressings consisted of Adaptic, soaked in Betadine, 4x4s, Kling, Kerlix, and Coban.  The pneumatic ankle tourniquet was released and the hyperemic flush was noted to all five digits of the right foot.,The patient tolerated the above procedure and anesthesia well without complications.  The patient was transferred to the PACU with vital signs stable and vascular status intact.  The patient was given postoperative pain prescription and instructed to be partially weightbearing with crutches as tolerated.  The patient is to follow-up with Dr. X in his office as directed or sooner if any problems or questions arise.","podiatry, navicula, metatarsal, osteochondroma, tarsectomy, metatarsectomy, painful enlarged navicula, navicular bone, foot, bony, capsule, periosteum, navicular, incision, bone"
 Itchy red rash on feet - Tinea Pedis, Podiatry, Tinea Pedis - H&P ,"CHIEF COMPLAINT (1/1):  ,This 24 year-old female presents today complaining of itchy, red rash on feet.  Associated signs and symptoms:  Associated signs and symptoms include tingling, right.  Context:  Patient denies any previous history, related trauma or previous treatments for this condition.  Duration:  Condition has existed for 4 weeks.  Location:  She indicates the problem location is right great toe, right 2nd toe, right 3rd toe and right 4th toe.  Modifying factors:  Patient indicates ice improves condition.  Quality:  Quality of the itch is described by the patient as constant.  Severity:  Severity of condition is unbearable.  Timing (onset/frequency):  Onset was after leaving on sweaty socks.,ALLERGIES: , Patient admits allergies to adhesive tape resulting in severe rash.,MEDICATION HISTORY:,  None.,PAST MEDICAL HISTORY: , Childhood Illnesses: (+) chickenpox, (+) frequent ear infections.,PAST SURGICAL HISTORY:  ,Patient admits past surgical history of ear tubes.,SOCIAL HISTORY: , Patient admits alcohol use Drinking is described as social, Patient denies tobacco use, Patient denies illegal drug use, Patient denies STD history.,FAMILY HISTORY:,  Patient admits a family history of cataract associated with maternal grandmother,,headaches/migraines associated with maternal aunt.,REVIEW OF SYSTEMS:,  Unremarkable with exception of chief complaint.,PHYSICAL EXAM: , BP Sitting:  110/64 Resp:  18 HR:  66 Temp:  98.6,Patient is a 24 year old female who appears well developed, well nourished and with good attention to hygiene and body habitus.  Cardiovascular:  Skin temperature of the lower extremities is warm to cool, proximal to distal.,DP pulses palpable bilateral.,PT pulses palpable bilateral.,CFT immediate.,No edema observed.,Varicosities are not observed.  Skin:  Right great toe, right 2nd toe, right 3rd toe and right 4th toenail shows erythema and scaling.,Neurological:  Touch, pin, vibratory and proprioception sensations are normal.  Deep tendon reflexes normal.,Musculoskeletal:  Muscle strength is 5/5 for all groups tested.  Muscle tone is normal.  Inspection and palpation of bones, joints and muscles is unremarkable.,TEST RESULTS:,  No tests to report at this time,IMPRESSION: , Tinea pedis.,PLAN:  ,Obtained fungal culture of skin from right toes.  KOH prep performed revealed no visible microbes.,PRESCRIPTIONS:,  Lotrimin AF  Dosage:  1% cream  Sig:  apply qid  Dispense:  4oz tube Refills:  0  Allow Generic:  Yes",
 Right foot trauma.  Three views of the right foot.  Three views of the right foot were obtained.  , Podiatry, Three Views - Foot ,"EXAM:  ,Three views of the right foot.,REASON FOR EXAM: , Right foot trauma.,FINDINGS: , Three views of the right foot were obtained.  There are no comparison studies.  There is no evidence of fractures or dislocations.  No significant degenerative changes or obstructive osseous lesions were identified.  There are no radiopaque foreign bodies.,IMPRESSION: , Negative right foot.","podiatry, three views, radiopaque, fractures, foot trauma"
" School reports continuing difficulties with repetitive questioning, obsession with cleanness on a daily basis, concerned about his inability to relate this well in the classroom.   Asperger disorder.  Obsessive compulsive disorder.", Psychiatry / Psychology, Asperger Disorder ,"SUBJECTIVE:  ,School reports continuing difficulties with repetitive questioning, obsession with cleanness on a daily basis, concerned about his inability to relate this well in the classroom.  He appears confused and depressed at times.  Mother also indicates that preservative questioning had come down, but he started collecting old little toys that he did in the past.  He will attend social skills program in the summer.  ABCD indicated to me that they have identified two psychologists to refer him to for functional behavioral analysis.  There is lessening of tremoring in both hands since discontinuation of Zoloft.  He is now currently taking Abilify at 7.5 mg.,OBJECTIVE: , He came in less perseverative questioning, asked appropriate question about whether I talked to ABCD or not, greeted me with Japanese word to say hello, seemed less.,I also note that his tremors were less from the last time.,ASSESSMENT: , 299.8 Asperger disorder, 300.03 obsessive compulsive disorder.,PLAN:,  Decrease Abilify from 7.5 mg to 5 mg tablet one a day, no refills needed.  I am introducing slow Luvox 25 mg tablet one-half a.m. for OCD symptoms, if no side effects in one week we will to tablet one up to therapeutic level.,I also will call ABCD regarding the referral to psychologists for functional behavioral analysis.  Parents will call me in two weeks.  I will see him for medication review in four weeks.  Mother signed informed consent.  I reviewed side effects to observe including behavioral activation.,Abilify has been helpful in decreasing high emotional arousal.  Combination of medication and behavioral intervention is recommended.","psychiatry / psychology, repetitive questioning, obsession with cleanness, inability to relate, obsessive compulsive disorder, functional behavioral analysis, asperger disorder, inability, asperger, "
" Excision of mass, left second toe and distal Symes amputation, left hallux with excisional biopsy.  Mass, left second toe.  Tumor.  Left hallux bone invasion of the distal phalanx.", Podiatry, Symes Amputation - Hallux ,"PREOPERATIVE DIAGNOSES:,1.  Mass, left second toe.,2.  Tumor.,3.  Left hallux bone invasion of the distal phalanx.,POSTOPERATIVE DIAGNOSES:,1.  Mass, left second toe.,2.  Tumor.,3.  Left hallux with bone invasion of the distal phalanx.,PROCEDURE PERFORMED:,1.  Excision of mass, left second toe.,2.  Distal Syme's amputation, left hallux with excisional biopsy.,HISTORY: , This 47-year-old Caucasian male presents to ABCD General Hospital with a history of tissue mass on his left foot.  The patient states that the mass has been present for approximately two weeks and has been rapidly growing in size.  The patient also has history of shave biopsy in the past.  The patient does state that he desires surgical excision at this time.,PROCEDURE IN DETAIL:,  An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported from the operating room and placed on the operating room table in the supine position with the safety belt across his lap.  Copious amount of Webril was placed around the left ankle followed by a blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 6 cc mixed with 1% lidocaine plain with 0.5% Marcaine plain was injected in a digital block fashion at the base of the left hallux as well as the left second toe.,The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was elevated from the operating table and exsanguinated with an Esmarch bandage.  Care was taken with the exsanguination to perform exsanguination below the level of the digits so as not to rupture the masses.  The foot was lowered to the operating table.  The stockinet was reflected and the foot was cleansed with wet and dry sponge.  A distal Syme's incision was planned over the distal aspect of the left hallux.  The incision was performed with a #10 blade and deepened with #15 down to the level of bone.  The dorsal skin flap was removed and dissected in toto off of the distal phalanx.  There was noted to be in growth of the soft tissue mass into the dorsal cortex with erosion in the dorsal cortex and exposure of cortical bone at the distal phalanx.  The tissue was sent to Pathology where Dr. Green stated that a frozen sample would be of less use for examining for cancer.  Dr. Green did state that he felt that there was an adequate incomplete excision of the soft tissue for specimen.  At this time, a sagittal saw was then used to resect all ends of bone of the distal phalanx.  The area was inspected for any remaining suspicious tissues.  Any suspicious tissue was removed.  The area was then flushed with copious amounts of sterile saline.  The skin was then reapproximated with #4-0 nylon with a combination of simple and vertical mattress sutures.,Attention was then directed to the left second toe.  There was noted to be a dorsolateral mass over the dorsal distal aspect of the left second toe.  A linear incision was made just medial to the tissue mass.  The mass was then dissected from the overlying skin and off of the underlying capsule.  This tissue mass was hard, round, and pearly-gray in appearance.  It does not invade into any other surrounding tissues.  The area was then flushed with copious amounts of sterile saline and the skin was closed with #4-0 nylon.  Dressings consisted of Owen silk soaked in Betadine, 4x4s, Kling, Kerlix, and an Ace wrap.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot.  The patient tolerated the above procedure and anesthesia well without complications.  The patient was transported to PACU with vital signs stable and vascular status intact.  The patient was given postoperative pain prescription for Vicodin and instructed to follow up with Dr. Bonnani in his office as directed.  The patient will be contacted immediately pending the results of pathology.  Cultures obtained in the case were aerobic and anaerobic gram stain, Silver stain, and a CBC.","podiatry, distal phalanx, mass, tumor., hallux bone, phalanx, symes amputation, excisional biopsy, distal, amputation, invasion, toe, symes, incision, flushed, excision, tissue, hallux"
 The patient was referred due to concerns regarding behavioral acting out as well as encopresis., Psychiatry / Psychology, Adjustment Disorder & Encopresis ,"REASON FOR REFERRAL:,  The patient was referred to me by Dr. X of the Clinic due to concerns regarding behavioral acting out as well as encopresis.  This is a 90-minute initial intake completed on 10/03/2007.  I met with the patient's mother individually for the entire session.  I reviewed with her the treatment, consent form, as well as the boundaries of confidentiality, and she stated that she understood these concepts.,PRESENTING PROBLEMS: , Mother reported that her primary concern in regard to the patient had to do with his oppositionality.  She was more ambivalent regarding addressing the encopresis.  In regards to his oppositionality, she reported that the onset of his oppositionality was approximately at 4 years of age, that before that he had been a very compliant and happy child, and that he has slowly worsened over time.  She noted that the oppositionality occurred approximately after his brother, who has multiple medical problems, was born.  At that time, mother had spent 2 months back East with the brother due to his feeding issues and will have to go again next year.  She reported that in terms of the behaviors that he loses his temper frequently, he argues with her that he defies her authority that she has to ask him many times to do things, that she has to repeat instructions, that he ignores her, that he whines, and this is when he is told to do something that he does not want to do.  She reported that he deliberately annoys other people, that he can be angry and resentful.  She reported that he does not display these behaviors with the father nor does he display them at home, but they are specific to her.  She reported that her response to him typically is that she repeats what she wants him to do many, many times, that eventually she gets upset.  She yells at him, talks with him, and tries to make him go and do what she wants him to do.  Mother also noted that she probably ignores some his misbehaviors.  She stated that the father tends to be more firm and more direct with him, and that, the father sometimes thinks that the mother is too easy on him.  In regards to symptoms of depression, she denied symptoms of depression, noting that he tends to only become unhappy when he has to do something that he does not want to do, such as go to school or follow through on a command.  She denied any suicidal ideation.  She denied all symptoms of anxiety.  PTSD was denied.  ADHD symptoms were denied, as were all other symptoms of psychopathology.,In regards to the encopresis, she reported that he has always soiled, he does so 2 to 3 times a day.  She reported that he is concerned about this issue.  He currently wears underwear and had a pull-up.  She reported that he was seen at the Gastroenterology Department here several years ago, and has more recently been seen at the Diseases Center, seen by Dr. Y, reported that the last visit was several months ago, that he is on MiraLax.  He does sit on the toilet may be 2 times a day, although that is not consistent.  Mother believes that he is probably constipated or impacted again.  He refuses to eat any fiber.  In regards to what happens when he soils, mother basically takes full responsibility.  She cleans and changes his underwear, thinks of things that she has tried, she mostly gets frustrated, makes negative comments, even though she knows that he really cannot help it.  She has never provided him with any sort of rewards, because she feels that this is something he just needs to learn to do.  In regards to other issues, she noted that he becomes frustrated quite easily, especially around homework, that when mother has to correct him, or when he has had difficulty doing something that he becomes upset, that he will cry, and he will get angry.  Mother's response to him is that either she gets agitated and raises her voice, tells him to stop etc.  Mother reported it is not only with homework, but also with other tasks, such as if he is trying to build with his LEGOs and things do not go well.,DEVELOPMENTAL BACKGROUND: , The patient was reported to be the 8 pound 12 ounce product of a planned and noncomplicated pregnancy and emergency cesarean delivery.  The patient presented in a breech position.  Mother denied the use of drugs, alcohol, or tobacco during the pregnancy.  No sleeping or eating issues were present in the perinatal period.  Temperament was described as easy.  He was described as a cuddly baby.  No concerns expressed regarding his developmental milestones.  No serious injuries reported.  No hospitalizations or surgeries.  No allergies.  The patient has been encopretic for all of his life.  He currently is taking MiraLax.,FAMILY BACKGROUND: , The patient lives with his mother who is age 37, and is primarily a homemaker, but does work approximately 48 hours a month as a beautician; with his father, age 35, who is a police officer; and also, with his younger brother who is age 3, and has significant medical problems as will be noted in a moment.  Mother and father have been together since 1997, married in 1999.  The maternal grandmother and grandfather are living and are together, and live in the Central California Coast Area.  There is one maternal aunt, age 33, and then, two adopted maternal aunt and uncle, age 18 and age 13.  In regards to the father's side of the family, the paternal grandparents are divorced.  Grandfather was in Arkansas, grandmother lives in Dos Palos.  The patient does not see his grandfather.  Mother stated that her relationship with her child was as described, that he very much stresses her out, that she wishes that he was not so defiant, that she finds him to be a very stressful child to deal with.  In regards to the relationship with the father, it was reported that the father tends to leave most of the parenting over to the mother, unless she specifically asks him to do something, and then, he will follow through and do it.  He will step in and back mother up in terms of parenting, tell the child not to speak to his mother that way etc.  Mother reported that he does spend some time with the children, but not as much as mother would like him to, but occasionally, he will go outside and do things with them.  The mother reported that sometimes she has a problem in interfering with his parenting, that she steps in and defends The patient.  It was reported that mother stated that she tries the parenting technique, primarily of yelling and tried time-out, although her description suggests that she is not doing time-out correctly, as he simply gets up from his time-out, and she does not follow through.  Mother reported that she and the patient are very much alike in temperament, and this has made things more difficult.  Mother tends to be stubborn and gets angry easily also.  Mother reported becoming fatigued in her parenting, that she lets him get away with things sometimes because she does not want to punish him all day long, sometimes ignores problems that she probably should not ignore.  There was reported to be jealousy between The patient and his brother, B.  B evidently has some heart problems and feeding issues, and because of that, tends to get more attention in terms of his medical needs, and that the patient is very jealous of that attention and feels that B is favored and that he get things that The patient does not get, and that there is some tension between the brothers.  They do play well together; however, The patient does tend to be somewhat intrusive, gets in his space, and then, B will hit him.  Mother reported that she graduated from high school, went to Community College, and was an average student.  No learning problems.  Mother has a history of depression.  She has currently been taking 100 mg of Zoloft administered by her primary medical doctor.  She is not receiving counseling.  She has been on the medications for the last 5 years.  Her dosage has not been changed in a year.  She feels that she is getting more irritable and more angry.  I  encouraged her to see a primary medical doctor.  Mother has no drug or alcohol history.  Father graduated from high school, went to the Police Academy, average student.  No learning problems, no psychological problems, no drug or alcohol problems are reported.  In terms of extended family, maternal grandmother as well as maternal great grandfather have a history of depression.  Other psychiatric symptoms were denied in the family.,Mother reported that the marriage is generally okay, that there is some arguing.  She reported that it was in the normal range.,ACADEMIC BACKGROUND: , The patient attends the Roosevelt Elementary School, where he is in a regular first grade classroom with Mrs. The patient.  This is in the Kingsburg Unified School District.  No behavior problems, academic problems were reported.  He does not receive special education services.,SOCIAL HISTORY: , The patient was described as being able to make and keep friends, but at this point in time, there has been no teasing regarding smell from the encopresis.  He does have kids over to play at the house.,PREVIOUS COUNSELING:,  Denied.,DIAGNOSTIC SUMMARY AND IMPRESSION: , My impression is that the patient has a long history of constipation and impaction, which has been treated medically, but it would appear that the mother has not followed through consistently with the behavioral component of toilet sitting, increased fiber, regular medication, so that the problem has likely continued.  She also has not used any sort of rewards as a way to encourage him, in the encopresis.  The patient clearly qualifies for a diagnosis of disruptive behavior disorder, not otherwise specified, and possibly oppositional defiant disorder.  It would appear that mother needs help in her parenting, and that she tends to mostly use yelling and anger as a way, and tends to repeat herself a lot, and does not have a strategy for how to follow through and to deal with defiant behavior.  Also, mother and father, may not be on the same page in terms of parenting.,PLAN:,  In terms of my plan, I will meet with the child in the next couple of weeks.  I also asked the mother to bring the father in, so he could be involved in the treatment also, and I gave the mother a behavioral checklist to be completed by herself and the father as well as the teacher.,DSM IV DIAGNOSES:  ,AXIS I:  Adjustment disorder with disturbance of conduct (309.3).  Encopresis, without constipation, overflow incontinence (307.7),AXIS II:  No diagnoses (V71.09).,AXIS III:  No diagnoses.,AXIS IV:  Problems with primary support group.,AXIS V:  Global assessment of functioning equals 65.","psychiatry / psychology, developmental background, axis, dsm iv, adjustment disorder, behavioral, adjustment, depression, oppositionality, encopresis, "
 Pain.  Three views of the right ankle.  Three views of the right ankle are obtained., Podiatry, Three Views - Ankle ,"EXAM: , Three views of the right ankle.,INDICATIONS:  ,Pain.,FINDINGS: , Three views of the right ankle are obtained.  There is no evidence of fractures or dislocations.  No significant degenerative changes or destructive osseous lesions of the ankle are noted.  There is a small plantar calcaneal spur.  There is no significant surrounding soft tissue swelling.,IMPRESSION:  ,Negative right ankle.","podiatry, three views, calcaneal, plantar, spur, osseous, ankle"
 Right foot series after a foot injury., Podiatry, Right Foot Series ,"EXAM: , Right foot series.,REASON FOR EXAM:  ,Injury.,FINDINGS: , Three images of the right foot were obtained.  On the AP image only, there is a subtle lucency seen in the proximal right fourth metatarsal and a mild increased sclerosis in the proximal fifth metatarsal.  Also on a single image, there is a lucency seen in the lateral aspect of the calcaneus that is seen on the oblique image only.  Fractures in these bones cannot be completely excluded.  There is soft tissue swelling seen overlying the calcaneus within this region.,IMPRESSION: , Cannot exclude nondisplaced fractures in the lateral aspect of the calcaneus or at the base of the fourth and fifth metatarsals.  Recommend correlation with site of pain in addition to conservative management and followup imaging.  A phone call will be placed to the emergency room regarding these findings.","podiatry, sclerosis, calcaneus, metatarsal, foot series"
 Plantar fascitis/heel spur syndrome.  The patient was given injections of 3 cc 2:1 mixture of 1% lidocaine plain with dexamethasone phospate., Podiatry, Podiatry - Progress Note ,"SUBJECTIVE:,  Mr. Sample Patient returns to the Sample Clinic with the chief complaint of painful right heel.  The patient states that the heel has been painful for approximately two weeks, it is starts with the first step in the morning and gets worse with activity during the day.  The patient states that he is currently doing no treatment for it.  He states that most of his pain is along medial tubercle of the right calcaneus and extends to the medial arch.  The patient states that he has no change in the past medical history since his last visit and denies any fever, chills, vomiting, headache, chest, or shortness of breath.,OBJECTIVE:,  Upon removal of shoes and socks bilaterally, neurovascular status remains unchanged since the last visit.  There is tenderness to palpation to the medial tubercle of the right foot.  The pain is elicited along the medial arch as well.  There are no open areas or signs of infection noted.,ASSESSMENT:,  Plantar fascitis/heel spur syndrome, right foot.,PLAN:,  The patient was given injections of 3 cc 2:1 mixture of 1% lidocaine plain with dexamethasone phospate.  He was given a low dye strapping and a heel lift was placed in his right shoe.  The patient will be seen back in approximately one month for further evaluation if necessary.  He was told to call if anything should occur before that.  The patient was told to continue with the good work on his diabetic control.","podiatry, progress note, plantar fascitis, soap, dexamethasone phospate, heel lift, heel spur syndrome, lidocaine, low dye strapping, mixture of 1% lidocaine, dexamethasone, phospate, injections, heel"
 Acute episode of agitation.  She was complaining that she felt she might have been poisoned at her care facility., Psychiatry / Psychology, Agitation - ER Visit ,"HISTORY OF PRESENT ILLNESS:  This is a 91-year-old female who was brought in by family.  Apparently, she was complaining that she felt she might have been poisoned at her care facility.  The daughter who accompanied the patient states that she does not think anything is actually wrong, but she became extremely agitated and she thinks that is the biggest problem with the patient right now.  The patient apparently had a little bit of dry heaves, but no actual vomiting.  She had just finished eating dinner.  No one else in the facility has been ill.,PAST MEDICAL HISTORY: Remarkable for previous abdominal surgeries.  She has a pacemaker.  She has a history of recent collarbone fracture.,REVIEW OF SYSTEMS:  Very difficult to get from the patient herself.  She seems to deny any significant pain or discomfort, but really seems not particularly intent on letting me know what is bothering her.  She initially stated that everything was wrong, but could not specify any specific complaints.  Denies chest pain, back pain, or abdominal pain.  Denies any extremity symptoms or complaints.,SOCIAL HISTORY:  The patient is a nonsmoker.  She is accompanied here with daughter who brought her over here.  They were visiting the patient when this episode occurred.,MEDICATIONS:  Please see list.,ALLERGIES:  NONE.,PHYSICAL EXAMINATION:  VITAL SIGNS:  The patient is afebrile, actually has a very normal vital signs including normal pulse oximetry at 99% on room air.  GENERAL:  The patient is an elderly frail looking little lady lying on the gurney.  She is awake, alert, and not really wanted to answer most of the questions I asked her.  She does have a tremor with her mouth, which the daughter states has been there for ""many years"".  HEENT:  Eye exam is unremarkable.  Oral mucosa is still moist and well hydrated.  Posterior pharynx is clear.  NECK:  Supple.  LUNGS:  Actually clear with good breath sounds.  There are no wheezes, no rales, or rhonchi.  Good air movement.  CARDIAC:  Without murmur.  ABDOMEN:  Soft.  I do not elicit any tenderness.  There is no abdominal distention.  Bowel sounds are present in all quadrants.  SKIN:  Skin is without rash or petechiae.  There is no cyanosis.  EXTREMITIES:  No evidence of any trauma to the extremities.,EMERGENCY DEPARTMENT COURSE:  I had a long discussion with the family and they would like the patient receive something for agitation, so she was given 0.5 mg of Ativan intramuscularly.  After about half an hour, I came back to talk to the patient and the family, the patient states that she feels better.  Family states she seems more calm.  They do not want to pursue any further workup at this time.,IMPRESSION:  ACUTE EPISODE OF AGITATION.,PLAN:  At this time, I had reviewed the patient's records and it is not particularly enlightening as to what could have triggered off this episode.  The patient herself has good vital signs.  She does not seem to have any specific acute process going on and seemed to feel comfortable after the Ativan was given, a small quantity was given to the patient.  Family and daughter specifically did not want to pursue any workup at this point, which at this point I think is reasonable and we will have her follow up with ABC.  She is discharged in stable condition.","psychiatry / psychology, acute episode of agitation, agitation, "
" A 44-year-old, 250-pound male presents with extreme pain in his left heel.", Podiatry, Plantar Fasciitis ,"S -, A 44-year-old, 250-pound male presents with extreme pain in his left heel.  This is his chief complaint.  He says that he has had this pain for about two weeks.  He works on concrete floors.  He says that in the mornings when he gets up or after sitting, he has extreme pain and great difficulty in walking.  He also has a macular blotching of skin on his arms, face, legs, feet and the rest of his body that he says is a pigment disorder that he has had since he was 17 years old.  He also has redness and infection of the right toes.,O -, The patient apparently has a pigmentation disorder, which may or may not change with time, on his arms, legs and other parts of his body, including his face.  He has an erythematous moccasin-pattern tinea pedis of the plantar aspects of both feet.  He has redness of the right toes 2, 3 and 4.  Extreme exquisite pain can be produced by direct pressure on the plantar aspect of his left heel.,A -, 1.  Plantar fasciitis.,","podiatry, plantar fasciitis, tinea pedis, tinea purpura, heel, fasciitis, plantar, "
" Plantar fascitis, left foot.  Partial plantar fasciotomy.", Podiatry, Plantar Fasciotomy ,"PREOPERATIVE DIAGNOSIS:,  Plantar fascitis, left foot.,POSTOPERATIVE DIAGNOSIS: , Plantar fascitis, left foot.,PROCEDURE PERFORMED: , Partial plantar fasciotomy, left foot.,ANESTHESIA:,  10 cc of 0.5% Marcaine plain with TIVA.,HISTORY:  ,This 35-year-old Caucasian female presents to ABCD General Hospital with above chief complaint.  The patient states she has extreme pain with plantar fascitis in her left foot and has attempted conservative treatment including orthotics without long-term relief of symptoms and desires surgical treatment.  The patient has been NPO since mid night.  Consent is signed and in the chart.  No known drug allergies.,Details Of Procedure:  An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported to the operating room and placed on the operating table in supine position with a safety belt across the stomach.  Copious amounts of Webril were placed on the left ankle followed by blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 10 cc of 0.5% Marcaine plain was injected into the surgical site both medially and laterally across the plantar fascia.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  An Esmarch bandage was applied for exsanguination and the pneumatic ankle tourniquet was inflated to 250 mmHg.  The foot was then reflected on the operating, stockinet reflected, and the foot cleansed with a wet and dry sponge.  Attention was then directed to the plantar medial aspect of the left heel.  An approximately 0.75 cm incision was then created in the plantar fat pad over the area of maximal tenderness.,The incision was then deepened with a combination of sharp and blunt dissection until the plantar fascia was palpated.  A #15 blade was then used to transect the medial and central bands of the plantar fascia.  Care was taken to preserve the lateral fibroids.  The foot was dorsiflexed against resistance as the fibers were released and there was noted to be increased laxity after release of the fibers on the plantar aspect of the foot indicating that plantar fascia has in fact been transacted.  The air was then flushed with copious amounts of sterile saline.  The skin incision was then closed with #3-0 nylon in simple interrupted fashion.  Dressings consisted of #0-1 silk, 4 x 4s, Kling, Kerlix, and Coban.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted throughout all digits of the left foot.  The patient tolerated the above procedure and anesthesia well without complications.  The patient was transported to the PACU with vital signs stable and vascular status intact to the left foot.  Intraoperatively, an additional 80 cc of 1% lidocaine was injected for additional anesthesia in the case.  The patient is to be nonweightbearing on the left lower extremity with crutches.  The patient is given postoperative pain prescriptions for Vicodin ES, one q3-4h. p.o. p.r.n. for pain as well as Celebrex 200 mg one p.o. b.i.d.  The patient is to follow-up with Dr. X as directed.","podiatry, foot, plantar fasciotomy, plantar fascitis, plantar fascia, plantar, fasciotomy, ankle, medially, fascitis, fascia"
" Toenails are discolored, thickened, and painful - Onychomycosis", Podiatry, Onychomycosis - H&P ,"CHIEF COMPLAINT (1/1):, This 59 year old female presents today complaining that her toenails are discolored, thickened, and painful. Duration: Condition has existed for 6 months. Severity: Severity of condition is worsening.,ALLERGIES: ,Patient admits allergies to dairy products, penicillin.,MEDICATION HISTORY:, None.,PAST MEDICAL HISTORY:, Past medical history is unremarkable.,PAST SURGICAL HISTORY:, Patient admits past surgical history of eye surgery in 1999.,SOCIAL HISTORY:, Patient denies alcohol use, Patient denies illegal drug use, Patient denies STD history, Patient denies tobacco use.,FAMILY HISTORY:, Unremarkable.,REVIEW OF SYSTEMS:, Psychiatric: (+) poor sleep pattern, Respiratory: (+) breathing difficulties, respiratory symptoms.,PHYSICAL EXAM:, Patient is a 59 year old female who appears well developed, well nourished and with good attention to hygiene and body habitus. Toenails 1-5 bilateral appear crumbly, discolored - yellow, friable and thickened.,Cardiovascular: DP pulses palpable bilateral. PT pulses palpable bilateral. CFT immediate. No edema observed.  Varicosities are not observed.,Skin: Skin temperature of the lower extremities is warm to cool, proximal to distal. No skin rash, subcutaneous nodules, lesions or ulcers observed.,Neurological: Touch, pin, vibratory and proprioception sensations are normal. Deep tendon reflexes normal.,Musculoskeletal: Muscle strength is 5/5 for all groups tested. Muscle tone is normal. Inspection and palpation of bones, joints and muscles is unremarkable.,TEST RESULTS:, No tests to report at this time.,IMPRESSION:, Onychomycosis.,PLAN:, Debrided 10 nails.,PRESCRIPTIONS:, Penlac Dosage: 8% Topical Solution Sig:",
" Excision of neuroma, third interspace, left foot.  Morton's neuroma, third interspace, left foot.", Podiatry, Neuroma Excision ,"PREOPERATIVE DIAGNOSIS: , Morton's neuroma, third interspace, left foot.,POSTOPERATIVE DIAGNOSIS:,  Morton's neuroma, third interspace, left foot.,OPERATION PERFORMED: , Excision of neuroma, third interspace, left foot.,ANESTHESIA: , General (local was confirmed by surgeon).,HEMOSTASIS: , Ankle pneumatic tourniquet 225 mmHg.,TOURNIQUET TIME: , 18 minutes.  Electrocautery was necessary.,INJECTABLES: , 50:50 mixture of 0.5% Marcaine and 1% Xylocaine, both plain.  Also, 0.5 mL dexamethasone phosphate (4 mg/mL).,INDICATIONS: , Please see dictated H&P for specifics.,PROCEDURE:  ,After proper identification was made, the patient was brought to the operating room and placed on the table in supine position.  The patient was then placed under general anesthesia.  A local block was then injected into the third ray of the left foot.  The left foot was then prepped with chlorhexidine gluconate and then draped in the usual sterile technique.  The left foot was then exsanguinated with an Esmarch bandage and elevated and an ankle pneumatic tourniquet was then inflated.  Attention was then directed to the third interspace where a longitudinal incision was placed just proximal to the webspace.  The incision was deepened via sharp and blunt dissection with care taken to protect all vital structures.  Identification of the neuroma was made following plantar flexion of the digits.  It was grasped with a hemostat and it was dissected in toto and removed.  It was then sent to pathology.  The area was then flushed with copious amounts of sterile saline.  Closure was with 4-0 Vicryl in the subcutaneous tissue and then running subcuticular 4-0 nylon suture in the skin.  Steri-Strips were then placed over that area.  A sterile compressive dressing consisting of saline-soaked gauze, ABD, Kling, Coban was placed over the foot.  The tourniquet was then released.  Good flow was noted to return to all digits.  The patient did tolerate the procedure well.  He left the operating room with all vital signs stable and neurovascular status intact.  The patient went to the recovery.  The patient previously had been given both oral and written preoperative as well as postoperative instructions and a prescription for pain.  The patient will follow up with me in approximately 4 days for dressing change.","podiatry, interspace, ankle pneumatic, pneumatic tourniquet, morton's neuroma, tourniquet, neuroma, foot, anesthesia,"
" Amputation distal phalanx and partial proximal phalanx, right hallux.   Osteomyelitis, right hallux.", Podiatry, Phalanx Amputation ,"PREOPERATIVE DIAGNOSIS:,  Osteomyelitis, right hallux.,POSTOPERATIVE DIAGNOSIS: , Osteomyelitis, right hallux.,PROCEDURE PERFORMED:,  Amputation distal phalanx and partial proximal phalanx, right hallux.,ANESTHESIA:,  TIVA/local.,HISTORY:,  This 44-year-old male patient was admitted to ABCD General Hospital on 09/02/2003 with a diagnosis of osteomyelitis of the right hallux and cellulitis of the right lower extremity.  The patient has a history of diabetes and has had a chronic ulceration to the right hallux and has been on outpatient antibiotics, which he failed.  The patient after a multiple conservative treatments such as wound care antibiotics, the patient was given the option of amputation as a treatment for the chronic resistant osteomyelitis.  The patient desires to attempt a surgical correction.  The risks versus benefits of the procedure were discussed with the patient in detail by Dr. X.  The consent was available on the chart for review.,PROCEDURE IN DETAIL: , After patient was taken to the operating room via cart and placed on the operating table in the supine position, a safety strap was placed across his waist.  Adequate IV sedation was administered by the Department of Anesthesia and a total of 3.5 cc of 1:1 mixture 1% lidocaine and 0.5% Marcaine plain were injected into the right hallux as a digital block.  The foot was prepped and draped in the usual aseptic fashion lowering the operative field.,Attention was directed to the hallux where there was a full-thickness ulceration to the distal tip of the hallux measuring 0.5 cm x 0.5 cm.  There was a ________ tract, which probed through the distal phalanx and along the sides of the proximal phalanx laterally.  The toe was 2.5 times to the normal size.  There were superficial ulcerations in the medial arch of both feet secondary to history of a burn, which were not infected.  The patient had dorsalis pedis and posterior tibial pulses that were found to be +2/4 bilaterally preoperatively.  X-ray revealed complete distraction of the distal phalanx and questionable distraction of the lateral aspect of the proximal phalanx.  A #10 blade was used to make an incision down the bone in a transverse fashion just proximal to the head of the proximal phalanx.  The incision was carried mediolaterally and plantarly encompassing the toe leaving a large amount of plantar skin intact.  Next, the distal phalanx was disarticulated at the interphalangeal joint and removed.  The distal toe was amputated and sent to laboratory for bone culture and sensitivity as well as tissue pathology.  Next, the head of the proximal phalanx was inspected and found to be soft on the distal lateral portion as suspected.  Therefore, a sagittal saw was used to resect approximately 0.75 cm of the distal aspect of head of the proximal phalanx.  This bone was also sent off for culture and was labeled proximal margin.  Next, the flexor hallucis longus tendon was identified and retracted as far as possible distally and transected.  The flexor tendon distally was gray discolored and was not viable.  A hemostat was used to inspect the flexor sheath to ensure no infection tracking up the sheath proximally.  None was found.  No purulent drainage or abscess was found.  The proximal margin of the surgical site tissue was viable and healthy.  There was no malodor.  Anaerobic and aerobic cultures were taken and passed this as a specimen to microbiology.  Next, copious amounts of gentamicin and impregnated saline were instilled into the wound.,A #3-0 Vicryl was used to reapproximate the deep subcutaneous layer to release skin tension.  The plantar flap was viable and was debulked with Metzenbaum scissors.  The flap was folded dorsally and reapproximated carefully with #3-0 nylon with a combination of simple interrupted and vertical mattress sutures.  Iris scissors were used to modify and remodel the plantar flap.  An excellent cosmetic result was achieved.  No tourniquet was used in this case.  The patient tolerated the above anesthesia and surgery without apparent complications.  A standard postoperative dressing was applied consisting of saline-soaked Owen silk, 4x4s, Kerlix, and Coban.  The patient was transported via cart to Postanesthesia Care Unit with vital signs able and vascular status intact to right foot.  He will be readmitted to Dr. Katzman where we will continue to monitor his blood pressure and regulate his medications.  Plan is to continue the antibiotics until further IV recommendations.,He will be nonweightbearing to the right foot and use crutches.  He will elevate his right foot and rest the foot, keep it clean and dry.  He is to follow up with Dr. X on Monday or Tuesday of next week.","podiatry, osteomyelitis, phalanx, phalanx amputation, proximal margin, plantar flap, distal phalanx, proximal phalanx, proximal, hallux, amputation, foot, plantarly, distal"
" Onychomycosis present, #1, #2, #3, #4, and #5 right and left.", Podiatry, Onychomycosis - 1 ,"S: , The patient presents to podiatry clinic today at the request of her primary physician, Dr. XYZ for initial examination, evaluation, and treatment of her nails.  The patient has last seen primary in December 2006.,PRIMARY MEDICAL HISTORY: , Edema, venous insufficiency, schizophrenia, and anemia.,ALLERGIES: , THE PATIENT HAS NO KNOWN ALLERGIES.,MEDICATIONS: , Refer to chart.,O: , The patient presents in wheelchair, verbal and alert.  Vascular:  She has absent pedal pulses bilaterally.  Trophic changes include absent hair growth and mycotic nails.  Skin texture is dry.  Skin color is rubor.  Classic findings include temperature change and  edema +1.  Nails:  Hypertrophic with crumbly subungual debris, #1, #2, #3, #4, and #5 right and #1, #2, #3, #4, and #5 left.,A:,1.  Onychomycosis present, #1, #2, #3, #4, and #5 right and left.,2.  Peripheral vascular disease as per classic findings.,3.  Pain on palpation.,P: , Nails #1, #2, #3, #4, and #5 right and #1, #2, #3, #4, and #5 left were debrided for length and thickness.  The patient will be seen again at the request of the nursing staff for treatment of painful mycotic nails.","podiatry, debrided, thickness, mycotic nails, onychomycosis, nails,"
" A 49-year-old female with ankle pain times one month, without a specific injury. ", Podiatry, MRI Foot - 3 ,"EXAM:,MRI LEFT FOOT,CLINICAL:, A 49-year-old female with ankle pain times one month, without a specific injury. Patient complains of moderate to severe pain, worse with standing or walking on hard surfaces, with tenderness to palpation at the plantar aspect of the foot and midfoot region and tenderness over the course of the posterior tibialis tendon.,FINDINGS:,Received for second opinion interpretations is an MRI examination performed on 05/27/2005.,There is edema of the subcutis adipose space extending along the medial and lateral aspects of the ankle.,There is edema of the subcutis adipose space posterior to the Achilles tendon. Findings suggest altered biomechanics with crural fascial strains.,There is tendinosis of the posterior tibialis tendon as it rounds the tip of the medial malleolus with mild tendon thickening. There is possible partial surface tearing of the anterior aspect of the tendon immediately distal to the tip of the medial malleolus (axial inversion recovery image #16) which is a possible hypertrophic tear less than 50% in cross sectional diameter. The study has been performed with the foot in neutral position. Confirmation of this possible partial tendon tear would require additional imaging with the foot in a plantar flexed position with transaxial images of the posterior tibialis tendon as it rounds the tip of the medial malleolus oriented perpendicular to the course of the posterior tibialis tendon.,There is minimal synovitis of the flexor digitorum longus and flexor hallucis longus tendon sheaths consistent with flexor splinting but intrinsically normal tendons.,Normal peroneal tendons.,There is tendinosis of the tibialis anterior tendon with thickening but no demonstrated tendon tear. Normal extensor hallucis longus and extensor digitorum tendons.,Normal Achilles tendon. There is a low-lying soleus muscle that extends to within 2cm of the teno-osseous insertion of the Achilles tendon.,Normal distal tibiofibular syndesmotic ligamentous complex.,Normal lateral, subtalar and deltoid ligamentous complexes.,There are no erosions of the inferior neck of the talus and there are no secondary findings of a midfoot pronating force.,Normal plantar fascia. There is no plantar calcaneal spur.,There is venous engorgement of the plantar veins of the foot extending along the medial and lateral plantar cutaneous nerves which may be acting as intermittent entrapping lesions upon the medial and lateral plantar cutaneous nerves.,Normal tibiotalar, subtalar, talonavicular and calcaneocuboid articulations.,The metatarsophalangeal joint of the hallux was partially excluded from the field-of-view of this examination.,IMPRESSION:,Tendinosis of the posterior tibialis tendon with tendon thickening and possible surface fraying / tearing of the tendon immediately distal to the tip of the medial malleolus, however, confirmation of this finding would require additional imaging.,Minimal synovitis of the flexor digitorum longus and flexor hallucis longus tendon sheaths, consistent with flexor splinting.,Edema of the subcutis adipose space along the medial and lateral aspects of the ankle suggesting altered biomechanics and crural fascial strain.,Mild tendinosis of the tibialis anterior tendon with mild tendon thickening.,Normal plantar fascia and no plantar fasciitis.,Venous engorgement of the plantar veins of the foot which may be acting as entrapping lesions upon the medial and lateral plantar cutaneous nerves.","podiatry, lateral plantar cutaneous, plantar cutaneous nerves, posterior tibialis tendon, medial and lateral, subcutis adipose, adipose space, achilles tendon, tendon thickening, hallucis longus, lateral plantar, plantar cutaneous, cutaneous nerves, medial malleolus, posterior tibialis, tibialis tendon, plantar, tendon, posterior, flexor, tibialis, medial, "
 Pain and swelling in the right foot., Podiatry, MRI Foot - 2 ,"EXAM:,MRI RIGHT FOOT,CLINICAL:,Pain and swelling in the right foot.,FINDINGS: ,Obtained for second opinion interpretation is an MRI examination performed on 11-04-05.,There is a transverse fracture of the anterior superior calcaneal process of the calcaneus. The fracture is corticated however and there is an active marrow stress phenomenon. There is a small ganglion measuring approximately 8 x 5 x 5mm in size extending along the bifurcate ligament.,There is no substantial joint effusion of the calcaneocuboid articulation. There is minimal interstitial edema involving the short plantar calcaneal cuboid ligament.,Normal plantar calcaneonavicular spring ligament.,Normal talonavicular articulation.,There is minimal synovial fluid within the peroneal tendon sheaths.,Axial imaging of the ankle has not been performed orthogonal to the peroneal tendon distal to the retromalleolar groove. The peroneus brevis tendon remains intact extending to the base of the fifth metatarsus. The peroneus longus tendon can be identified in its short axis extending to its distal plantar insertion upon the base of the first metatarsus with minimal synovitis.,There is minimal synovial fluid within the flexor digitorum longus and flexor hallucis longus tendon sheath with pooling of the fluid in the region of the knot of Henry.,There is edema extending along the deep surface of the extensor digitorum brevis muscle.,Normal anterior, subtalar and deltoid ligamentous complex.,Normal naviculocuneiform, intercuneiform and tarsometatarsal articulations.,The Lisfranc’s ligament is intact.,The Achilles tendon insertion has been excluded from the field-of-view.,Normal plantar fascia and intrinsic plantar muscles of the foot.,There is mild venous distention of the veins of the foot within the tarsal tunnel.,There is minimal edema of the sinus tarsus. The lateral talocalcaneal and interosseous talocalcaneal ligaments are normal.,Normal deltoid ligamentous complex.,Normal talar dome and no occult osteochondral talar dome defect.,IMPRESSION:,Transverse fracture of the anterior calcaneocuboid articulation with cortication and cancellous marrow edema.,Small ganglion intwined within the bifurcate ligament.,Interstitial edema of the short plantar calcaneocuboid ligament.,Minimal synovitis of the peroneal tendon sheaths but no demonstrated peroneal tendon tear.,Minimal synovitis of the flexor tendon sheaths with pooling of fluid within the knot of Henry.,Minimal interstitial edema extending along the deep surface of the extensor digitorum brevis muscle.",
 Patient with right ankle pain., Podiatry, MRI Ankle - 1 ,"EXAM:,MRI RIGHT ANKLE,CLINICAL:,This is a 51 year old female who first came into the office 3/4/05 with right ankle pain. She stepped on ice the evening prior and twisted her ankle. PF's showed no frank fracture, dislocation, or subluxations.,FINDINGS:,Received for interpretation is an MRI examination performed on 4/28/2005.,There is a ""high ankle sprain"" of the distal tibiofibular syndesmotic ligamentous complex involving the anterior tibiofibular ligament with marked ligamentous inflammatory thickening and diffuse interstitial edema. There is osteoarthritic spur formation at the anterior aspect of the fibula with a small 2mm osseous structure within the markedly thickened anterior talofibular ligament suggesting a small ligamentous osseous avulsion. The distal tibiofibular syndesmotic ligamentous complex remains intact without a complete rupture. There is no widening of the ankle mortis. The posterior talofibular ligament remains intact.,There is marked ligamentous thickening of the anterior talofibular ligament of the lateral collateral ligamentous complex suggesting the sequela of a remote lateral ankle sprain. There is thickening of the posterior talofibular and calcaneofibular ligaments.,There is a flat retromalleolar sulcus.,There is a full-thickness longitudinal split tear of the peroneus brevis tendon within the retromalleolar groove. The tear extends to the level of the inferior peroneal retinaculum. There is anterior displacement of the peroneus longus tendon into the split peroneus tendon tear.,There is severe synovitis of the peroneus longus tendon sheath with prominent fluid distention. The synovitis extends to the level of the inferior peroneal retinaculum.,There is a focal area of chondral thinning of the hyaline cartilage of the medial talar dome with a focal area of subchondral plate cancellous marrow resorption consistent with and area of prior talar dome contusion but there is no focal osteochondral impaction or osteochondral defect.,There is minimal fluid within the tibiotalar articulation.,There is minimal fluid within the posterior subtalar articulation with mild anterior capsular prolapse. Normal talonavicular and calcaneocuboid articulations. The anterior superior calcaneal process is normal.,There is mild tenosynovitis of the posterior tibialis tendon sheath but an intrinsically normal tendon. There is an os navicularis (Type II synchondrosis) with an intact synchondrosis and no active marrow stress phenomenon.,Normal flexor digitorum longus tendon.,There is prominent fluid distention of the flexor hallucis longus tendon sheath with capsular distention proximal to the posterior talar processes with prominent fluid distention of the synovial sheath.,There is a loculated fluid collection within Kager’s fat measuring approximately 1 x 1 x 2.5cm in size, extending to the posterior subtalar facet joint consistent with a ganglion of either posterior subtalar facet origin or arising from the flexor hallucis longus tendon sheath.,There is mild tenosynovitis of the Achilles tendon with mild fusiform enlargement of the non-insertional Watershed zone of the Achilles tendon but there is no demonstrated tendon tear or tenosynovitis. There is a low-lying soleus muscle that extends to within 4cm of the teno-osseous insertion of the Achilles tendon. There is no Haglund’s deformity.,There is a plantar calcaneal spur measuring approximately 6mm in size, without a reactive marrow stress phenomenon. Normal plantar fascia.,IMPRESSION:,Partial high ankle sprain with diffuse interstitial edema of the anterior tibiofibular ligament with a ligamentous chip avulsion but without a disruption of the anterior tibiofibular ligament.,Marked ligamentous thickening of the lateral collateral ligamentous complex consistent with the sequela of a remote lateral ankle sprain.,Full-thickness longitudinal split tear of the peroneus brevis tendon with severe synovitis of the peroneal tendon sheath.,Post-traumatic deformity of the medial talar dome consistent with a prior osteochondral impaction injury but no osteochondral defect. Residual subchondral plate cancellous marrow edema.,Severe synovitis of the flexor hallucis longus tendon sheath with prominent fluid distention of the synovial sheath proximal to the posterior talar processes.,Septated cystic structure within Kager’s fat triangle extending along the superior aspect of the calcaneus consistent with a ganglion of either articular or synovial sheath origin.,Plantar calcaneal spur but no reactive marrow stress phenomenon.,Mild tendinosis of the Achilles tendon but no tendinitis or tendon tear.,Os navicularis (Type II synchondrosis) without an active marrow stress phenomenon.",
" Onychomycosis present, #1 right and #1 left.", Podiatry, Onychomycosis - 2 ,"S:,  The patient presents to Podiatry Clinic today for initial examination, evaluation, and treatment of her nails.,PRIMARY MEDICAL HISTORY:,  Adenocarcinoma, delirium, recent dehydration, anemia, history of hypertension, and hyperlipidemia.,MEDICATIONS: , Refer to chart.,ALLERGIES: , PENICILLIN AND ASPIRIN.,O: , The patient  presents in wheelchair, verbal and alert.  Vascular:  She has absent pedal pulses bilaterally.  Trophic changes include absent hair growth and mycotic nails.  Skin texture is dry and shiny.  Skin color is rubor.  Classic findings are temperature change and edema +1.  Nails:  Hypertrophic with crumbly subungual debris, # 1 right and #1 left.,A:,1.  Onychomycosis present, #1 right and #1 left.,2.  Peripheral vascular disease as per classic findings.,3.  Pain on palpation.,P: , Nails #1 right and #1 left were debrided for length and thickness.  All the nails were reduced.  The patient will be seen at the request of the nursing staff for treatment of painful mycotic nails.","podiatry, length and thickness, mycotic nails, classic findings, onychomycosis, nails,"
" Pain and swelling in the right foot, peroneal tendon tear.", Podiatry, MRI Foot - 1 ,"EXAM:,MRI/LOW EX NOT JNT RT W/O CONTRAST,CLINICAL:,Pain and swelling in the right foot, peroneal tendon tear.,FINDINGS:,  Contours of marrow signal patterns of the regional bones are within normal range treating there is increased T2 signal within the soft tissues at the lateral margin of the cuboid bone. A small effusion is noted within the peroneal tendon sheath. There is a 3mm slight separation of the distal tip of the peroneus longus tendon from the lateral margin of the cuboid bone, consistent with an avulsion. There is no sign of cuboid fracture. The fifth metatarsal base appears intact. The calcaneus is also normal in appearance.,IMPRESSION:  ,Findings consistent with an avulsion of the peroneus longus tendon from the insertion on the lateral aspect of cuboid bone.,","podiatry, peroneus longus tendon, peroneal tendon, lateral margin, peroneus longus, longus tendon, cuboid bone, foot, peroneal, peroneus, longus, avulsion, tendon, bones, cuboid,"
" Painful ingrown toenail, left big toe.  Removal of an ingrown part of the left big toenail with excision of the nail matrix.", Podiatry, Ingrown Toenail Removal ,"PREOPERATIVE DIAGNOSIS: , Painful ingrown toenail, left big toe.,POSTOPERATIVE DIAGNOSIS: , Painful ingrown toenail, left big toe.,OPERATION: , Removal of an ingrown part of the left big toenail with excision of the nail matrix.,DESCRIPTION OF PROCEDURE:  ,After obtaining informed consent, the patient was taken to the minor OR room and intravenous sedation with morphine and Versed was performed and the toe was blocked with 1% Xylocaine after having been prepped and draped in the usual fashion.  The ingrown part of the toenail was freed from its bed and removed, then a flap of skin had been made in the area of the matrix supplying the particular part of the toenail.  The matrix was excised down to the bone and then the skin flap was placed over it.  Hemostasis had been achieved with a cautery.  A tubular dressing was performed to provide a bulky dressing.,The patient tolerated the procedure well.  Estimated blood loss was negligible.  The patient was sent back to Same Day Surgery for recovery.","podiatry, toenail, nail matrix, ingrown toenail, painful, ingrown,"
" Excision of soft tissue mass, right foot.  The patient is a 51-year-old female with complaints of soft tissue mass over the dorsum of the right foot.", Podiatry, Mass Excision - Foot ,"PREOPERATIVE DIAGNOSIS: , Soft tissue mass, right foot.,POSTOPERATIVE DIAGNOSIS: , Soft tissue mass, right foot.,PROCEDURE PERFORMED: , Excision of soft tissue mass, right foot.,HISTORY:  ,The patient is a 51-year-old female with complaints of soft tissue mass over the dorsum of the right foot.  The patient has had previous injections to the site which have caused the mass to decrease in size, however, the mass continues to be present and is irritated and painful with shoes.  The patient has requested surgical intervention at this time.,PROCEDURE:  ,After an IV was instituted by the Department of Anesthesia, the patient was escorted from the preoperative holding area to the operating room.  The patient was then placed on the operating room table in the supine position and a towel was placed around the patient's abdomen and secured her to the table.  Using copious amounts of Webril, a pneumatic ankle tourniquet was applied to her right ankle.  Using a Skin Skribe, the area of the soft tissue mass was outlined over the dorsum of her foot.  After adequate amount of anesthesia was provided by the Department of Anesthesia, a local ankle block was given using 10 cc of 4.5 mL of 1% lidocaine plain, 4.5 mL of 0.5% Marcaine plain and 1.0 mL of Solu-Medrol and the foot was scrubbed and prepped in a normal sterile orthopedic manner.  Following this, the ankle was elevated and Esmarch bandage applied to exsanguinate the foot and the ankle tourniquet was inflated to 250 mmHg.  The foot was then brought back down to the table using bandage scissors.  The stockinette was reflected and the right foot was exposed.  Using a fresh #10 blade, a curvilinear incision was performed over the dorsum of the right foot.  Then using a #15 blade, the incision was deepened with care taken to identify and avoid or cauterize any bleeders which were noted.  Following this, the incision was deepened using a combination of sharp and blunt dissection and the muscle belly of the extensor digitorum brevis muscle was identified.  Further dissection was then performed in the medial direction in the area of the soft tissue mass.  The intermediate dorsal cutaneous nerve was identified and gently retracted laterally.  Large amounts of adipose tissue were noted medial to the belly of the extensor digitorum brevis muscle.  Using careful dissection, adipose tissue in this area was removed and saved for pathology.  Following removal of adipose tissue in this area and identification of no more adipose tissue, attention was directed lateral to the belly of the extensor digitorum brevis muscle, which was also noted to have large amounts of adipose tissue in this area as well.  Using careful dissection, from the lateral border of the foot as much adipose tissue as possible was removed from this area as well and saved for pathology.  There was noted to be no other fluid-filled masses or lesions identifiable in this area then between the slits of the extensor digitorum brevis muscle, careful dissection was performed to examine the underside of the belly of the muscle as well as structures beneath and no abnormal structures were identified here as well.  Following this, feeling adequately that no other mass remained in the area, the incision was flushed using copious amounts of sterile saline.  The wound was then reinspected and all remaining tissues appeared healthy including the subcutaneous tissue.  The tendon and muscle belly of the extensor digitorum brevis muscle, the nerves of the intermediate dorsal cutaneous nerve and also the medial dorsal cutaneous nerve which were identified medially, all appeared intact.  No deficits were noted.  No abnormal appearing tissue was present within the surgical site.  Following this, the skin edges were reapproximated using #4-0 Vicryl deep closure of the subcutaneous layer was performed.  Then, using #4-0 nylon and simple interrupted suture, the skin was reapproximated and closed with care taken to ensure eversion of the skin edges and good approximation of the borders.  The patient was also given 7 cc of 1% lidocaine plain throughout the procedure to augment local anesthesia.  Following this, the wound was dressed using Xeroform gauze and 4x4s and was dressed using two ABD pads, dorsal and plantar for compression and using Kling, Kerlix and Coban.  The patient then had the ankle tourniquet deflated with a total tourniquet time of 55 minutes at 250 mmHg and immediate hyperemia was noted to digits one through five of the right foot.  The patient tolerated the procedure and anesthesia well and was noted to have vascular status intact.  The patient was then escorted to the Postanesthesia Care Unit where she was placed in a surgical shoe.  The patient was then given postoperative instructions to include ice and elevation to her right foot.  The patient was cleared for ambulation as tolerated, but was instructed that with increased ambulation will come increased swelling and pain.  The patient will follow up with Dr. X in his office on Tuesday, 08/26/03 for further follow up.  The patient was given prescription for Vicoprofen #25 taken one tablet q.4h. p.r.n., moderate to severe pain and also prescription for Keflex #20 500 mg tablets to be taken b.i.d. x10 days.  The patient was given a number for the Emergency Room and instructed to return if any sign or symptom of infection should present and the patient was educated as to the nature of these.  The patient had no further questions and recovered without any complications in the Postanesthesia Care Unit.","podiatry, excision, digitorum brevis muscle, soft tissue mass, adipose tissue, soft tissue, mass, injections, foot, tissue, xeroform, dorsum, belly, extensor, digitorum, brevis, ankle, adipose, muscle, "
 This patient has reoccurring ingrown infected toenails., Podiatry, Infected Toenails ,"S - ,This patient has reoccurring ingrown infected toenails.  He presents today for continued care.,O - ,On examination, the left great toenail is ingrown on the medial and lateral toenail border.  The right great toenail is ingrown on the lateral nail border only.  There is mild redness and granulation tissue growing on the borders of the toes.  One on the medial and one on the lateral aspect of the left great toe and one on the lateral aspect of the right great toe.  These lesions measure 0.5 cm in diameter each.  I really do not understand why this young man continues to develop ingrown nails and infections.,A - ,1.  Onychocryptosis.,","podiatry, infected toenails, onychocryptosis, benign lesions, toenail border, left great toe, neosporin ointment, hemostasis was achieved, ointment and absorbent, toenails, ingrown, lesions, benign, infected,"
 Procedure note on Keller Bunionectomy, Podiatry, Keller Bunionectomy ,"PROCEDURE: , Keller Bunionectomy.,For informed consent, the more common risks, benefits, and alternatives to the procedure were thoroughly discussed with the patient.  An appropriate consent form was signed, indicating that the patient understands the procedure and its possible complications.,This 59 year-old female was brought to the operating room and placed on the surgical table in a supine position.  Following anesthesia, the surgical site was prepped and draped in the normal sterile fashion.,Attention was then directed to the right foot where, utilizing a # 15 blade, a 6 cm. linear incision was made over the 1st metatarsal head, taking care to identify and retract all vital structures.  The incision was medial to and parallel to the extensor hallucis longus tendon.  The incision was deepened through subcutaneous underscored, retracted medially and laterally - thus exposing the capsular structures below, which were incised in a linear longitudinal manner, approximately the length of the skin incision.  The capsular structures were sharply underscored off the underlying osseous attachments, retracted medially and laterally.,Utilizing an osteotome and mallet, the exostosis was removed, and the head was remodeled with the Liston bone forceps and the bell rasp.  The surgical site was then flushed with saline.  The base of the proximal phalanx of the great toe was osteotomized approximately 1 cm. distal to the base and excised to toto from the surgical site.,Superficial closure was accomplished using Vicryl 5-0 in a running subcuticular fashion.  Site was dressed with a light compressive dressing.  The tourniquet was released.  Excellent capillary refill to all the digits was observed without excessive bleeding noted.,ANESTHESIA: , local.,HEMOSTASIS: , Accomplished with pinpoint electrocoagulation.,ESTIMATED BLOOD LOSS: , 10 cc.,MATERIALS:,  None.,INJECTABLES:,  Agent used for local anesthesia was Lidocaine 2% without epi.,PATHOLOGY:,  Sent no specimen.,DRESSINGS: , Site was dressed with a light compressive dressing.,CONDITION: , Patient tolerated procedure and anesthesia well.  Vital signs stable.  Vascular status intact to all digits.  Patient recovered in the operating room.,SCHEDULING: , Return to clinic in 2 week (s).","podiatry, keller bunionectomy, metatarsal head, incision, capsular, osteotome, compressive dressing, keller, bunionectomy, "
 MRI right ankle., Podiatry, MRI Ankle - 2 ,"EXAM:,MRI OF THE RIGHT ANKLE,CLINICAL:,Pain.,FINDINGS:,The bone marrow demonstrates normal signal intensity. There is no evidence of bone contusion or fracture. There is no evidence of joint effusion. Tendinous structures surrounding the ankle joint are intact. No abnormal mass or fluid collection is seen surrounding the ankle joint.,IMPRESSION,: NORMAL MRI OF THE RIGHT ANKLE.","podiatry, ankle joint, bone, mri, ankle"
  Right hallux abductovalgus deformity.  Right McBride bunionectomy.  Right basilar wedge osteotomy with OrthoPro screw fixation., Podiatry, McBride Bunionectomy & Wedge Osteotomy ,"PREOPERATIVE DIAGNOSIS:,  Right hallux abductovalgus deformity.,POSTOPERATIVE DIAGNOSIS:,  Right hallux abductovalgus deformity.,PROCEDURES PERFORMED:,1.  Right McBride bunionectomy.,2.  Right basilar wedge osteotomy with OrthoPro screw fixation.,ANESTHESIA: , Local with IV sedation.,HEMOSTASIS: , With pneumatic ankle cuff.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room and placed in a supine position.  The right foot was prepared and draped in usual sterile manner.  Anesthesia was achieved utilizing a 50:50 mixture of 2% lidocaine plain with 0.5 Marcaine plain infiltrated just proximal to the first metatarsocuneiform joint.  Hemostasis was achieved utilizing a pneumatic ankle Tourniquet placed above the right ankle and inflated to a pressure of 225 mmHg.  At this time, attention was directed to the dorsal aspect of the right first metatarsophalangeal joint where dorsal linear incision approximately 3 cm in length was made.  The incision was deepened within the same plain taking care of the Bovie and retracted all superficial nerves and vessels as necessary.  The incision was then carried down to the underlying capsular structure once again taking care of the Bovie and retracted all superficial nerves and vessels as necessary.  The capsular incision following the same outline as the skin incision was made and carried down to the underlying bony structure.  The capsule was then freed from the underling bony structure utilizing sharp and blunt dissection.  Using a microsagittal saw, the medial and dorsal very prominent bony eminence were removed and the area was inspected for any remaining bony prominences following resection of bone and those noted were removed using a hand rasp.  At this time, attention was directed to the first inner space using sharp and blunt dissection.  Dissection was carried down to the underling level of the adductor hallucis tendon, which was isolated and freed from its phalangeal, sesamoidal, and metatarsal attachments.  The tendon was noted to lap the length and integrity for transfer and at this time was tenotomized taking out resection of approximately 0.5 cm to help prevent any re-fibrous attachment.  At this time, the lateral release was stressed and was found to be complete.  The extensor hallucis brevis tendon was then isolated using blunt dissection and was tenotomized as well taking out approximately 0.5-cm resection.  The entire area was copiously flushed 3 times using a sterile saline solution and was inspected for any bony prominences remaining and it was noted that the base of the proximal phalanx on the medial side due to the removal of the extensive buildup of the metatarsal head was going to be very prominent in nature and at this time was removed using a microsagittal saw.  The area was again copiously flushed and inspected for any abnormalities and/or prominences and none were noted.  At this time, attention was directed to the base of the first metatarsal where a second incision was made approximately 4 cm in length.  The incision was deepened within the same plain taking care of Bovie and retracted all superficial nerves and vessels as necessary.  The incision was then carried down to the level of the metatarsal and using sharp and blunt dissection periosteal capsule structures were freed from the base of the metatarsal and taking care to retract the long extensive tendon and any neurovascular structures to avoid any disruption.  At this time, there was a measurement made of 1 cm just distal to the metatarsocuneiform joint on the medial side and 2 cm distal to the metatarsocuneiform joint from the lateral aspect of the joint.  At this time, 0.5 cm was measured distal to that lateral measurement and using microsagittal saw, a wedge osteotomy was taken from the base with the apex of the osteotomy being medial, taking care to keep the medial cortex intact as a hinge.  The osteotomy site was feathered down until the osteotomy site could be closed with little tension on it and at this time using an OrthoPro screw 3.0 x 22 mm.  The screw was placed following proper technique.  The osteotomy site was found to be fixated with absolutely no movement and good stability upon manual testing.  A very tiny gap on the lateral aspect of the osteotomy site was found and this was filled in packing it with the cancellous bone that was left over from the wedge osteotomy.  The packing of the cancellous bone was held in place with bone wax.  The entire area was copiously flushed 3 times using a sterile saline solution and was inspected and tested again for any movement of the osteotomy site or any gapping and then removed.  At this time, a deep closure was achieved utilizing #2-0 Vicryl suture, subcuticular closure was achieved using #4-0 Vicryl suture, and skin repair was achieved at both surgical sites with #5-0 nylon suture in a running interlocking fashion.  The hallux was found to have excellent movement upon completion of the osteotomy and the second procedure of the McBride bunionectomy and the metatarsal was found to stay in excellent alignment with good stability at the proximal osteotomy site.  At this time, the surgical site was postoperatively injected with 0.5 Marcaine plain as well as dexamethasone 4 mg primarily.  The surgical sites were then dressed with sterile Xeroform, sterile 4x4s, cascading, and Kling with a final protective layer of fiberglass in a nonweightbearing cast fashion.  The tourniquet was dropped and color and temperature of all digits returned to normal.  The patient tolerated the anesthesia and the procedure well and left the operating room in stable condition.,The patient has been given written and verbal postoperative instructions and has been instructed to call if she has any questions, problems, or concerns at any time with the numbers provided.  The patient has also been warned a number of times the importance of elevation and no weightbearing on the surgical foot.,","podiatry, hallux, abductovalgus, bunionectomy, mcbride, basilar, wedge, osteotomy, orthopro, screw, fixation, wedge osteotomy"
" Resection of infected bone, left hallux, proximal phalanx, and distal phalanx.  Osteomyelitis, left hallux.", Podiatry, Hallux Infected Bone Resection ,"PREOPERATIVE DIAGNOSIS: , Osteomyelitis, left hallux.,POSTOPERATIVE DIAGNOSIS: , Osteomyelitis, left hallux.,PROCEDURES PERFORMED: , Resection of infected bone, left hallux, proximal phalanx, and distal phalanx.,ANESTHESIA: , TIVA/Local.,HISTORY:,  This 77-year-old male presents to ABCD preoperative holding area after keeping himself NPO since mid night for surgery on his infected left hallux.  The patient has a history of chronic osteomyelitis and non-healing ulceration to the left hallux of almost 10 years' duration.  He has failed outpatient antibiotic therapy and conservative methods.  At this time, he desires to attempt surgical correction.  The patient is not interested in a hallux amputation at this time; however, he is consenting to removal of infected bone.  He was counseled preoperatively about the strong probability of the hallux being a ""floppy tail"" after the surgery and accepts the fact.  The risks versus benefits of the procedure were discussed with the patient in detail by Dr. X and the consent is available on the chart for review.,PROCEDURE IN DETAIL:  ,The patient's wound was debrided with a #15 blade and down to good healthy tissue preoperatively.  The wound was on the planar medial, distal and dorsal medial.  The wound's bases were fibrous.  They did not break the bone at this point.  They were each approximately 0.5 cm in diameter.  After IV was established by the Department of Anesthesia, the patient was taken to the operating room and placed on the operating table in supine position with safety straps placed across his waist for his protection.,Due to the patient's history of diabetes and marked calcifications on x-ray, a pneumatic ankle tourniquet was not applied.  Next, a total of 3 cc of a 1:1 mixture of 0.5% Marcaine plain and 1% lidocaine plain was used to infiltrate the left hallux and perform a digital block.  Next, the foot was prepped and draped in the usual aseptic fashion.  It was lowered in the operative field and attention was directed to the left hallux after the sterile stockinet was reflected.  Next, a #10 blade was used to make a linear incision approximately 3.5 cm in length along the dorsal aspect of the hallux from the base to just proximal to the eponychium.  Next, the incision was deepened through the subcutaneous tissue.  A heavy amount of bleeding was encountered.  Therefore, a Penrose drain was applied at the tourniquet, which failed.  Next, an Esmarch bandage was used to exsanguinate the distal toes and forefoot and was left in the forefoot to achieve hemostasis.  Any small veins crossing throughout the subcutaneous layer were ligated via electrocautery.  Next, the medial and lateral margins of the incision were under marked with a sharp dissection down to the level of the long extension tendon.  The long extensor tendon was thickened and overall exhibited signs of hypertrophy.  The transverse incision through the long extensor tendon was made with a #15 blade.  Immediately upon entering the joint, yellow discolored fluid was drained from the interphalangeal joint.  Next, the extensor tendon was peeled dorsally and distally off the bone.  Immediately the head of the proximal phalanx was found to be lytic, disease, friable, crumbly, and there were free fragments of the medial aspect of the bone, the head of the proximal phalanx.  This bone was removed with a sharp dissection.  Next, after adequate exposure was obtained and the collateral ligaments were released off the head of proximal phalanx, a sagittal saw was used to resect the approximately one-half of the proximal phalanx.  This was passed off as the infected bone specimen for microbiology and pathology.  Next, the base of the distal phalanx was exposed with sharp dissection and a rongeur was used to remove soft crumbly diseased medial and plantar aspect at the base of distal phalanx.  Next, there was diseased soft tissue envelope around the bone, which was also resected to good healthy tissue margins.  The pulse lavage was used to flush the wound with 1000 cc of gentamicin-impregnated saline.  Next, cleaned instruments were used to take a proximal section of proximal phalanx to label a clean margin.  This bone was found to be hard and healthy appearing.  The wound after irrigation was free of all debris and infected tissue.  Therefore anaerobic and aerobic cultures were taken and sent to microbiology.  Next, OsteoSet beads, tobramycin-impregnated, were placed.  Six beads were placed in the wound.  Next, the extensor tendon was re-approximated with #3-0 Vicryl.  The subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted technique.  Next, the skin was closed with #4-0 nylon in a horizontal mattress technique.,The Esmarch bandage was released and immediate hyperemic flush was noted at the digits.  A standard postoperative dressing was applied consisting of 4 x 4s, Betadine-soaked #0-1 silk, Kerlix, Kling, and a loosely applied Ace wrap.  The patient tolerated the above anesthesia and procedure without complications.  He was transported via a cart to the Postanesthesia Care Unit.  His vitals signs were stable and vascular status was intact.  He was given a medium postop shoe that was well-formed and fitting.  He is to elevate his foot, but not apply ice.  He is to follow up with Dr. X.  He was given emergency contact numbers.  He is to continue the Vicodin p.r.n. pain that he was taking previously for his shoulder pain and has enough of the medicine at home.  The patient was discharged in stable condition.","podiatry, osteomyelitis, proximal phalanx, distal phalanx, infected bone, proximal, bone, phalanx, healing, hallux, infected, tissue, distal,"
" Incision and drainage and removal of foreign body, right foot.  The patient has had previous I&D but continues to have to purulent drainage.  The patient's parents agreed to performing a surgical procedure to further clean the wound.", Podiatry, I&D & Foreign Body Removal ,"PREOPERATIVE DIAGNOSIS:,  Foreign body, right foot.,POSTOPERATIVE DIAGNOSIS: , Foreign body, right foot.,PROCEDURE PERFORMED:,1.  Incision and drainage, right foot.,2.  Removal of foreign body, right foot.,HISTORY: , This 7-year-old Caucasian male is an inpatient at ABCD General Hospital with a history of falling off his bike and having a root ________ angle inside of his foot.  The patient has had previous I&D but continues to have to purulent drainage.  The patient's parents agreed to performing a surgical procedure to further clean the wound.,PROCEDURE:,  An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported to the operating room and placed on the operating table in a supine position with a safety strap across his lap.  General anesthesia was administered by the Department of Anesthesia.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  The stockinette was reflected and the foot was cleansed with wet and dry sponge.  There was noted to be some remaining periwound erythema.  There was noted to be some mild crepitation about 2 cm proximal from the entry wound.  The entry wound was noted to be over the third metatarsal head dorsally.  Upon inspection of the wound, there was noted to be hard foreign filling substance deep within the wound.  The entry site from the foreign body was extended proximally approximately about 0.5 cm.  At this time, a large wooden foreign body was visualized and removed with a straight stat.,The area was carefully inspected for any remaining piece of foreign body.  Several small pieces were noted and they were removed.  The area was palpated and there was no more remaining foreign body noted.  At this time, the wound was inspected thoroughly.  There was noted to be an area along the third metatarsal head more distally that did probe to the bone.  There was no purulent drainage expressed.  Area was flushed with copious amounts of sterile saline.  Pulse lavage was performed with 3 liters of plain sterile saline.  Wound cultures were obtained, aerobic and aerobic.  The wound was then again inspected for any remaining foreign body or purulent drainage.  None was noticed.  The wound was packed with sterile new gauze packing lately and dressings consisted of 4x4s, ABDs, Kling, and Kerlix.,The patient tolerated the above procedure and anesthesia well without complications.  The patient was transported to the PACU with vital signs stable and vascular status intact.  The patient is to be readministered to the pediatrics where daily dressing changes will be performed by podiatry.  The patient had a postoperative pain prescription written for Tylenol, Elixir with codeine as needed.","podiatry, incision and drainage, removal of foreign body, purulent drainage, foreign body, metatarsal head, orthopedic, metatarsal, i&d, incision, drainage, foot "
" Gangrene osteomyelitis, right second toe.  The patient is a 58-year-old female with poorly controlled diabetes with severe lower extremity lymphedema.  The patient has history of previous right foot infection requiring first ray resection.", Podiatry, Gangrene Surgery ,"PREOPERATIVE DIAGNOSIS: , Gangrene osteomyelitis, right second toe.,POSTOPERATIVE DIAGNOSIS: , Gangrene osteomyelitis, right second toe.,OPERATIVE REPORT:  ,The patient is a 58-year-old female with poorly controlled diabetes with severe lower extremity lymphedema.  The patient has history of previous right foot infection requiring first ray resection.  The patient has ulcerations of right second toe dorsally at the proximal interphalangeal joint, which has failed to respond to conservative treatment.  The patient now has exposed bone and osteomyelitis in the second toe.  The patient has been on IV antibiotics as an outpatient and has failed to respond to these and presents today for surgical intervention.,After an IV was started by the Department of Anesthesia, the patient was taken back to the operating room and placed on the operative table in the supine position.  A restraint belt was placed around the patient's waist using copious amounts of Webril and an ankle pneumatic tourniquet was placed around the patient's right ankle and the patient was made comfortable by the Department of Anesthesia.  After adequate amounts of sedation had been given to the patient, we administered a block of 10 cc of 0.5% Marcaine plain in proximal digital block around the second digit.  The foot and ankle were then prepped in the normal sterile orthopedic manner.  The foot was elevated and an Esmarch bandage applied to exsanguinate the foot.  The tourniquet was then inflated to 250 mmHg and the foot was brought back onto the table.  Using Band-Aid scissors, the stockinet was cut and reflected and using a wet and dry sponge, the foot was wiped, cleaned, and the second toe identified.,Using a skin scrape, a racket type incision was planned around the second toe to allow also remodelling of previous operative site.  Using a fresh #10 blade, skin incision was made circumferentially in the racket-shaped manner around the second digit.  Then, using a fresh #15 blade, the incision was deepened and was taken down to the level of the second metatarsophalangeal joint.  Care was taken to identify bleeders and cautery was used as necessary for hemostasis.  After cleaning up all the soft tissue attachments, the second digit was disarticulated down to the level of the metatarsophalangeal joint.  The head of the second metatarsal was inspected and was noted to have good glistening white cartilage with no areas of erosion evident by visual examination.  Attention was then directed to closure of the wound.  All remaining tissue was noted to be healthy and granular in appearance with no necrotic tissue evident.  Areas of subcutaneous tissue were then removed through a sharp dissection in order to allow better approximation of the skin edges.  Due to long-standing lower extremity lymphedema and postoperative changes on previous surgery, I thought that we were unable to close the incision in entirety.  Therefore, after copious amounts of irrigation using sterile saline, it was determined to use modified dental rolls using #4-0 gauze to remove tension from the skin.  Deep vertical mattress sutures were used in order to reapproximate more closely, the skin edges and bring the plantar flap of skin up to the dorsal skin.  This was obtained using #2-0 nylon suture.  Following this, the remaining exposed tissue from the wound was covered using moist to dry saline soaked 4 x 4 gauze.  The wound was then dressed using 4 x 4 gauze fluffed with abdominal pads, then using Kling and Kerlix and an ACE bandage to provide compression.  The tourniquet was deflated at 42 minutes' time and hemostasis was noted to be achieved.  The ACE bandage was extended up to just below the knee and no bleeding striking to the bandages was appreciated.  The patient tolerated the procedure well and was escorted to the Postanesthesia Care Unit with vital signs stable and vascular status intact, as was evidenced by capillary bleeding, which was present during the procedure.  Sedation was given postoperative introductions, which include to remain nonweightbearing to her right foot.  The patient was instructed to keep the foot elevated and to apply ice behind her knee as necessary, no more than 20 minutes each hour.  The patient was instructed to continue her regular medications.  The patient was to continue IV antibiotic course and was given prescription for Vicoprofen to be taken q.4h. p.r.n. for moderate to severe pain #30.  The patient will followup with Podiatry on Monday morning at 8:30 in the Podiatry Clinic for dressing change and evaluation of her foot at that time.,The patient was instructed as to signs and symptoms of infection, was instructed to return to the Emergency Department immediately if these should present.  The second digit was sent to Pathology for gross and micro.","podiatry, dorsally, toe, ulcerations, foot infection, ray resection, metatarsophalangeal joint, ace bandage, gangrene osteomyelitis, foot, infection, gangrene, digital,"
" Cellulitis with associated abscess and foreign body, right foot. Irrigation debridement and removal of foreign body of right foot.  Purulent material from the abscess located in the plantar aspect of the foot between the third and fourth metatarsal heads.", Podiatry, Foreign Body Removal - Foot - 1 ,"PREOPERATIVE DIAGNOSES:,1.  Cellulitis with associated abscess, right foot.,2.  Foreign body, right foot.,POSTOPERATIVE DIAGNOSES:,1.  Cellulitis with associated abscess, right foot.,2.  Foreign body, right foot.,PROCEDURE PERFORMED:,1.  Irrigation debridement.,2.  Removal of foreign body of right foot.,ANESTHESIA:,  Spinal with sedation.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , Minimal.,GROSS FINDINGS: , Include purulent material from the abscess located in the plantar aspect of the foot between the third and fourth metatarsal heads.,HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old Caucasian male with a history of uncontrolled diabetes mellitus.  The patient states that he was working in his garage over the past few days when he noticed some redness and edema in his right foot.  He notes some itching as well as increasing pain and redness in the right foot and presented to ABCD General Hospital Emergency Room.  He was evaluated by the Emergency Room staff as well as the medical team and the Department of Orthopedics.  It was noted upon x-ray a foreign body in his foot and he had significant amount of cellulitis as well ________ right lower extremity.  After a long discussion held with the patient, it was elected to proceed with irrigation debridement and removal of the foreign body.,PROCEDURE: , After all potential complications, risks, as well as anticipated benefits of the above-named procedures were discussed at length with the patient, informed consent was obtained.  The operative extremity was then confirmed with the patient, operative surgeon, the Department of Anesthesia and nursing staff.  The patient was then transferred to preoperative area to Operative Suite #5 and placed on the operating table in supine position.  All bony prominences were well padded at this time.  The Department of Anesthesia was administered spinal anesthetic to the patient.  Once this anesthesia was obtained, the patient's right lower extremity was sterilely prepped and draped in the usual sterile fashion.  Upon viewing of the plantar aspect of the foot, there was noted to be a swollen ecchymotic area with a small hole in it, which purulent fluid was coming from.  At this time, after all bony and soft tissue landmarks were identified as well as the localization of the pus, a 2 cm longitudinal incision was made directly over this area, which was located between the second and third metatarsal heads.  Upon incising this, there was a foul smelling purulent fluid, which flowed from this region.  Aerobic and anaerobic cultures were taken as well as gram stain.  The area was explored and it ________ to the dorsum of the foot.  There was no obvious joint involvement.  After all loculations were broken, 3 liters antibiotic-impregnated fluid were pulse-evac through the wound.  The wound was again inspected with no more gross purulent or necrotic appearing tissue.  The wound was then packed with an iodoform gauge and a sterile dressing was applied consisting of 4x4s, floss, and Kerlix covered by an Ace bandage.  At this time, the Department of Anesthesia reversed the sedation.  The patient was transferred back to the hospital gurney to Postanesthesia Care Unit.  The patient tolerated the procedure well and there were no complications.,DISPOSITION:  ,The patient will be followed on a daily basis for possible repeat irrigation debridement.","podiatry, removal of foreign body, purulent material, metatarsal, cellulitis, abscess, kerlix, foreign body, foot, irrigation, debridement, purulent, "
 Patient with complaint of a very painful left foot because of the lesions on the bottom of the foot. , Podiatry, Foot Lesions ,"S -, An 84-year-old diabetic female, 5'7-1/2"" tall, 148 pounds, history of hypertension and diabetes.  She presents today with complaint of a very painful left foot because of the lesions on the bottom of the foot.  She also has a left great toenail that is giving her problems as well.,O - ,Plantar to the left first metatarsal head is a very panful hyperkeratotic lesion that measures 1.1 cm in diameter.  There is a second lesion plantar to the fifth plantarflex metatarsal head which also measures 1.1 cm in diameter.  These lesions have become so painful that the patient is now having difficulty walking wearing shoes or even doing gardening.  The first and fifth metatarsal heads are plantarflexed.  Vibratory sensation appears to be absent.  Dorsal pedal pulses are nonpalpable.  Varicose veins are visible to the skin on the patient's feet that are very thin, almost transparent.  The medial aspect of the left great toenail has dried blood under the nail.  The nail itself is very opaque, loose from the nailbed almost rotten, opaque, discolored, hypertrophic.  All of the patient's toenails are elongated and discolored and opaque as well.  There is dried blood under the medial aspect of the left great toenail.,A - ,1.  Painful feet.,","podiatry, painful left foot, lesions, plantar, metatarsal head, hyperkeratotic lesion, toenail, nail matrix, metatarsal, metatarsal heads, foot, painful"
" Abscess of the left foot, etiology unclear at this time.  Possibility of foreign body.", Podiatry, Foot Infection Management ,"REASON FOR CONSULTATION:  ,Management for infection of the left foot.,HISTORY: , The patient is a 26-year-old short Caucasian male who appears in excellent health, presented a week ago as he felt some pain in the ball of his left foot.  He noticed a small dark spot.  He did not remember having had any injuries to that area specifically no puncture wounds.  He had not been doing any outdoor works or activities.  No history of working outdoors, has not been to the beach or to the lake, has not been out of town.  His swelling progressed so he went to see Dr. X 4 days ago.  The area was debrided in the office and he was placed on Keflex.  It was felt that may be he had a foreign body, but nothing was found in the office and x-ray was negative for opaque foreign bodies.  His foot got worse with more swelling and at this time purulent, too red and was admitted to the hospital today, is scheduled for surgical exploration this evening.  Ancef and Cipro were prescribed today.  He denies any fever, chills, red streaks, lymphadenitis.  He had a tetanus shot in 2002 most recently.  He had childhood asthma.  He uses alcohol socially.  He works full time.  He is an electrician.,ALLERGIES:,  ACCUTANE.,PHYSICAL EXAMINATION,GENERAL:  Well-developed, well-nourished adult Caucasian male in no acute distress.,VITAL SIGNS:  His weight is 190 pounds, height 69 inches, temperature 98, respirations 20, pulse 78, and blood pressure 143/63, O2 sat 98% on room air.,HEENT:  Mouth unremarkable.,NECK:  Supple.,LUNGS:  Clear.,HEART:  Regular rate rhythm.  No murmur or gallop.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  Left foot on the plantar side by the head of the first metatarsal has an open wound of about 10 mm in diameter with thick reddish purulent discharge and surrounding edema.  There is bloodied blister around it.  The area is tender to touch, warm with a slight edema of the rest of the foot with very faint erythema.  There is some mild intertrigo between the fourth and fifth left toes.  Palpable pedal pulses.  Leg unremarkable.  No femoral or inguinal lymphadenopathy.,LABORATORY: , Labs show white cell count of 6300, hemoglobin 13.6, platelet count of _____ with 80 monos, 17 eos _____, creatinine 1.3, BUN of 16, glucose 110.  Calcium, ferritin, albumin, bilirubin, ALT, AST, alkaline phosphatase are normal.  PT and PTT normal and the sed rate was 35 mm per hour.,IMPRESSION:  ,Abscess of the left foot, etiology unclear at this time.  Possibility of foreign body.,RECOMMENDATIONS/PLAN: , He is going to be discharged in about half-an-hour.  Cultures, Gram stain, fungal cultures, and smear to be obtained.  I have changed his antibiotic to vancomycin plus Maxipime.  He is currently on tetanus immunizations so no need for booster at this time.,","podiatry, accutane, possibility of foreign body, foot etiology, foreign body, infection, foot, abscess,"
" Excision of foreign body, right foot and surrounding tissue.  This 41-year-old male presents to preoperative holding area after keeping himself n.p.o., since mid night for removal of painful retained foreign body in his right foot.  The patient works in the Electronics/Robotics field and relates that he stepped on a wire at work, which somehow got into his shoe.  The wire entered his foot.", Podiatry, Foreign Body Removal - Foot ,"PREOPERATIVE DIAGNOSIS: , Foreign body, right foot.,POSTOPERATIVE DIAGNOSIS: , Foreign body in the right foot.,PROCEDURE PERFORMED:,  Excision of foreign body, right foot and surrounding tissue.,ANESTHESIA: , TIVA and local.,HISTORY:,  This 41-year-old male presents to preoperative holding area after keeping himself n.p.o., since mid night for removal of painful retained foreign body in his right foot.  The patient works in the Electronics/Robotics field and relates that he stepped on a wire at work, which somehow got into his shoe.  The wire entered his foot.  His family physician attempted to remove the wire, but it only became deeper in the foot.  The wound eventually healed, but a scar tissue was formed.  The patient has had constant pain with ambulation intermittently since the incident occurred.  He desires attempted surgical removal of the wire.  The risks and benefits of the procedure have been explained to the patient in detail by Dr. X.  The consent is available on the chart for review.,PROCEDURE IN DETAIL: , After IV was established by the Department of Anesthesia, the patient was taken to the operating room via cart and placed on the operating table in a supine position with a safety strap placed across his waist for his protection.,A pneumatic ankle tourniquet was applied about the right ankle over copious amounts of Webril for the patient's protection.  After adequate IV sedation was administered by the Department of Anesthesia, a total of 12 cc of 0.5% Marcaine plain was used to administer an ankle block.  Next, the foot was prepped and draped in the usual aseptic fashion.  An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg.  The foot was lowered into the operative field and the sterile stockinet was reflected.  Attention was directed to the plantar aspect of the foot where approximately a 5 mm long cicatrix was palpated and visualized.  This was the origin and entry point of the previous puncture wound from the wire.  This cicatrix was found lateral to the plantar aspect of the first metatarsal between the first and second metatarsals in a nonweightbearing area.  Next, the Xi-scan was draped and brought into the operating room.  A #25 gauge needles under fluoroscopy were inserted into the plantar aspect of the foot and three planes to triangulate the wire.  Next, a #10 blade was used to make approximately a 3 cm curvilinear ""S""-shaped incision.  Next, the #15 blade was used to carry the incision through the subcutaneous tissue.  The medial and lateral margins of the incision were undermined.  Due to the small nature of the foreign body and the large amount of fat on the plantar aspect of the foot, the wires seemed to serve no benefit other then helping with the incision planning.  Therefore, they were removed.  Once the wound was opened, a hemostat was used to locate the wire very quickly and the wire was clamped.  A second hemostat was used to clamp the wire.  A #15 blade was used to carefully transect the fatty tissue around the tip of the hemostats, which were visualized in the base of the wound.  The wire quickly came into visualization.  It measured approximately 4 mm in length and was approximately 1 mm in diameter.  The wire was green colored and metallic in nature.  It was removed with the hemostat and passed off as a specimen to be sent to Pathology for identification.  The wire was found at the level of deep fascia at the capsular level just plantar to the deep transverse intermetatarsal ligament.  Next, copious amounts of sterile gentamicin impregnated saline was instilled in the wound for irrigation and the wound base was thoroughly cleaned and inspected.  Next, a #3-0 Vicryl was used to throw two simple interrupted deep sutures to remove the dead space.  Next, #4-0 Ethibond was used to close the skin in a combination of simple interrupted and horizontal mattress suture technique.  The standard postoperative dressing consisting of saline-soaked Owen silk, 4x4s, Kling, Kerlix, and Coban were applied.  The pneumatic ankle tourniquet was released.  There was immediate hyperemic flush to the digits noted.  The patient's anesthesia was reversed.  He tolerated the above anesthesia and procedure without complications.  The patient was transported via cart to the Postanesthesia Care Unit.,Vital signs were stable and vascular status was intact to the right foot.  He was given OrthoWedge shoe.  Ice was applied behind the knee and his right lower extremity was elevated on to pillows.  He was given standard postoperative instructions consisting of rest, ice and elevation to the right lower extremity.  He is to be non-weightbearing for three weeks, at which time, the wound will be evaluated and sutures will be removed.  He is to follow up with Dr. X on 08/22/2003 and was given emergency contact number to call if problems arise.  He was given a prescription for Tylenol #4, #30 one p.o. q.4-6h. p.r.n., pain as well as Celebrex 200 mg #30 take two p.o. q.d. p.c., with 200 mg 12 hours later as a rescue dose.  He was given crutches.  He was discharged in stable condition.","podiatry, foreign body removal, excision of foreign body, ankle tourniquet, plantar aspect, foreign body, foot, ankle, plantar, wound,"
 The patient presents for evaluation at the request of his primary physician for treatment for dystrophic nails. , Podiatry, Dystrophic Nails ,"S: , The patient presents for evaluation at the request of his primary physician for treatment for nails.  He has last seen the primary physician in December 2006.,PRIMARY MEDICAL HISTORY:,  Femoral embolectomy, GI bleed, hypertension, PVD, hypothyroid, GERD, osteoarthritis, diabetes, CAD, renal artery stenosis, COPD, and atrial fibrillation.,MEDICATIONS:,  Refer to chart.,O: , The patient presents in wheelchair, verbal and alert.  Vascular:  He has absent pedal pulses bilaterally.  Trophic changes include absent hair growth and dystrophic nails.  Skin texture is dry and shiny.  Skin color is rubor.  Classic findings include temperature change and edema +2.  Nails:  Thickened and hypertrophic, #1, #2, #3, #4, and #5 right and #1, #2, #3, #4, and #5 left.,A:,1.  Dystrophic nails.,2.  Peripheral vascular disease as per classic findings.,3.  Pain on palpation.,4.  Diabetes.,P:  ,Nails #1, #2, #3, #4, and #5 right and #1, #2, #3, #4, and #5 left were debrided.  The patient will be seen at the request of the nursing staff for therapeutic treatment of dystrophic nails.","podiatry, debrided, nails, dystrophic nails, dystrophic"
 Patient dropped a weight on the dorsal aspects of his feet., Podiatry, Foot Pain ,"CHIEF COMPLAINT: , Foot pain.,HISTORY OF PRESENT ILLNESS: , This is a 17-year-old high school athlete who swims for the swimming team.  He was playing water polo with some of his teammates when he dropped a weight on the dorsal aspects of his feet.  He was barefoot at that time.  He had been in the pool practicing an hour prior to this injury.  Because of the contusions and abrasions to his feet, his athletic trainer brought in him to the urgent care.  He is able to bear weight; however, complains of pain in his toes.  The patient did have some avulsion of the skin across the second and third toes of the left foot with contusions across the second, third, and fourth toes and dorsum of the foot.  According to the patient, he was at his baseline state of health prior to this acute event.,PAST MEDICAL HISTORY: , Significant for attention deficit hyperactivity disorder.,PAST SURGICAL HISTORY:  ,Positive for wisdom tooth extraction.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:  ,He does not use alcohol, tobacco or illicit drugs.  He plays water polo for the school team.,IMMUNIZATION HISTORY: , All immunizations are up-to-date for age.,REVIEW OF SYSTEMS: , The pertinent review of systems is as noted above; the remaining review of systems was reviewed and is noted to be negative.,PRESENT MEDICATIONS: , Provigil, Accutane and Rozerem.,ALLERGIES:  ,None.,PHYSICAL EXAMINATION:,GENERAL:  This is a pleasant white male in no acute distress.,VITAL SIGNS:  He is afebrile.  Vitals are stable and within normal limits.,HEENT:  Negative for acute evidence of trauma, injury or infection.,LUNGS:  Clear.,HEART:  Regular rate and rhythm with S1 and S2.,ABDOMEN:  Soft.,EXTREMITIES:  There are some abrasions across the dorsum of the right foot including the second, third and fourth toes.  There is some mild tenderness to palpation.  However, there are no clinical fractures.  Distal pulses are intact.  The left foot notes superficial avulsion lacerations to the third and fourth digit.  There are no subungual hematomas.  Range of motion is decreased secondary to pain.  No obvious fractures identified.,BACK EXAM:  Nontender.,NEUROLOGIC EXAM:  He is alert, awake and appropriate without deficit.,RADIOLOGY: , AP, lateral, and oblique views of the feet were conducted per Radiology, which were negative for acute fractures and significant soft tissue swelling or bony injuries.,On reevaluation, the patient was resting comfortably.  He was informed of the x-ray findings.  The patient was discharged in the care of his mother with a preliminary diagnosis of bilateral foot contusions with superficial avulsion lacerations, not requiring surgical repair.,DISCHARGE MEDICATIONS: , Darvocet.,The patient's condition at discharge was stable.  All medications, discharge instructions and follow-up appointments were reviewed with the patient/family prior to discharge.  The patient/family understood the instructions and was discharged without further incident.",
 An 83-year-old diabetic female presents today stating that she would like diabetic foot care., Podiatry, Diabetic Foot Care ,"S - ,An 83-year-old diabetic female presents today stating that she would like diabetic foot care.,O - ,On examination, the lateral aspect of her left great toenail is deeply ingrown.  Her toenails are thick and opaque.  Vibratory sensation appears to be intact.  Dorsal pedal pulses are 1/4.  There is no hair growth seen on her toes, feet or lower legs.  Her feet are warm to the touch.  All of her toenails are hypertrophic, opaque, elongated and discolored.,A - ,1.  Onychocryptosis.,","podiatry, onychocryptosis, onychomycosis, great toenail, diabetic foot care, diabetic foot, foot, toenail, ingrown, toenails, diabetic, "
 A 60-year-old female presents today for care of painful calluses and benign lesions., Podiatry, Bunions and Calluses  ,"S -, A 60-year-old female presents today for care of painful calluses and benign lesions.,O -, On examination, the patient has bilateral bunions at the first metatarsophalangeal joint.  She states that they do not hurt.  No pain appears to be produced by active or passive range of motion or palpation and direct pressure of the first metatarsophalangeal joint bilaterally.  The patient has a bilateral pinch callus on the medial aspect of both great toes and there are calluses along the medial aspect of the right foot.  She has a small intractable plantar keratoma, plantar to her left second metatarsal head, which measures 0.5 cm in diameter.  This is a central plug.  She also has a very, very painful lesion plantar to her right fourth metatarsal head which measures 3.1 x 1.8 cm in diameter.  This is a hyperkeratotic lesion that extends deep into the tissue with interrupted skin lines.,A - ,1.  Bilateral bunions.,","podiatry, painful calluses, hibiclens, scrubbed, ointment and absorbent, heloma durum, plantar aspect, minimal hemostasis, neosporin ointment, absorbent dressing, benign lesions, metatarsophalangeal, bunions, calluses, plantar, "
 Debridement of left lateral foot ulcer with excision of infected and infarcted interosseous space muscle tendons and fat.  Sharp excision of left distal foot plantar fascia., Podiatry, Debridement - Foot Ulcer ,"PREOPERATIVE DIAGNOSES,1.  Left lateral fifth ray amputation site cellulitis with infected left fourth metatarsophalangeal joint.,2.  Osteomyelitis of left distal fifth metatarsal bone at left proximal fourth toe phalanx.,3.  Plantar fascitis of left distal lateral foot.,POSTOPERATIVE DIAGNOSES,1.  Left lateral fifth ray amputation site cellulitis with infected left fourth metatarsophalangeal joint.,2.  Osteomyelitis of left distal fifth metatarsal bone at left proximal fourth toe phalanx.,3.  Plantar fascitis of left distal lateral foot.,OPERATION PERFORMED,1.  Debridement of left lateral foot ulcer with excision of infected and infarcted interosseous space muscle tendons and fat.,2.  Sharp excision of left distal foot plantar fascia.,ANESTHESIA:,  None required.,INDICATIONS:,  The patient is a 51-year-old diabetic female with severe peripheral vascular disease, who has had angioplasties and single perineal artery runoff to the left leg who developed gangrene of her left fifth toe requiring left fifth ray amputation.  She has developed cellulitis of the lateral foot with osteomyelitis and now requires debridement of the local fascitis and necrotic tissue to evaluate for current infectious status and prepare for future amputation.,PROCEDURE IN DETAIL:,  The procedure was performed in the patient's room.  The dressing was removed exposing about a 4 cm x 2.5 cm left distal lateral foot fifth ray amputation open wound.  Distally, there is infarcted left fourth metatarsophalangeal joint capsule, as well as plantar fat below the joint.,She has neuropathy allowing debridement of the tissues.,Using sharp scissors and forceps all the necrotic fat and joint capsule area was easily debrided.  There was complete infarction of the lateral joint capsule and the head of the phalanx, as well as distal metatarsal head were chronically infected.,The wound was packed with 4x4 gauze pads and dry gauze pads were placed between the toes followed by Kerlix roll pad.,The patient suffered no complications from the procedure.","podiatry, plantar fascia, foot ulcer, interosseous, metatarsal, cellulitis, amputation, osteomyelitis, plantar fascitis, joint capsule, ray amputation, debridement, plantar, foot"
" Bunion, left foot.  Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation and Akin osteotomy with internal wire fixation of left foot.", Podiatry, Bunionectomy & Akin Osteotomy ,"PREOPERATIVE DIAGNOSIS: , Bunion, left foot.,POSTOPERATIVE DIAGNOSIS: ,Bunion, left foot.,PROCEDURE PERFORMED:,1.  Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation.,2.  Akin osteotomy with internal wire fixation of left foot.,HISTORY: , This 19-year-old Caucasian female presents to ABCD General Hospital with the above chief complaint.  The patient states she has had worsening bunion deformity for as long as she could not remember.  She does have a history of Charcot-Marie tooth disease and desires surgical treatment at this time.,PROCEDURE: , An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported to the operating room and placed on operating table in the supine position with a safety belt across her lap.  Copious amounts of Webril were placed on the left ankle followed by a blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 15 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain were injected in a Mayo block type fashion surrounding the lower left first metatarsal.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was elevated from the operating table and exsanguinated with an Esmarch bandage.  The pneumatic ankle tourniquet was inflated to 250 mmHg and the foot was lowered to the operating field.  The stockinette was reflected, the foot was cleansed with a wet and dry sponge.  Approximately 5 cm incision was made dorsomedially over the first metatarsal.,The incision was then deepened with #15 blade.  All vessels encountered were ligated for hemostasis.  Care was taken to preserve the extensor digitorum longus tendon.  The capsule over the first metatarsal phalangeal then was identified where a dorsal capsular incision was then created down to the level of bone.  Capsule and periosteum was reflected off the first metatarsal head.  At this time, the cartilage was inspected and noted to be white, shiny, and healthy cartilage.  There was noted to be a prominent medial eminence.  Attention was then directed to first interspace where a combination of blunt and sharp dissection was done to perform a standard lateral release.  The abductor tendon attachments were identified and transected.  The lateral capsulotomy was performed.  The extensor digitorum brevis tendon was identified and transected.  Attention was then directed to the prominent medial eminence, which was resected with a sagittal saw.  Intraoperative assessment of pes was performed and pes was noted to be normal.,At this time, a regional incision was carried more approximately about 1.5 cm.  The capsular incision was then extended and the proximal capsule and periosteum were reflected off the first metatarsal.  The first metatarsal cuneiform joint was identified.  A 0.45 K-wire was then inserted into the base of the first metatarsal approximately 1 cm from the first cuneiform joint perpendicular to the weightbearing surface.  This K-wire was used as an access guide for a Juvaro type oblique base wedge osteotomy.  The sagittal saw was then used to creat a closing base wedge osteotomy with the apex being proximal medial.  The osteotomy site was then feathered and tilted with tight estimation of the bony edges.  The cortical hinge was maintained.  A 0.27 x 24 mm screw was then inserted in a standard AO fashion.  At this time, there was noted to be tight compression of the osteotomy site.  A second 2.7 x 16 mm screw was then inserted more distally in the standard AO fashion with compression noted.  The ________ angle was noted to be significantly released.  Reciprocating rasp was then used to smoothen any remaining sharp edges.  The 0.45 k-wire was removed.  The foot was loaded and was noted to fill the remaining abduction of the hallux.  At this time, it was incised to perform an Akin osteotomy.,Original incision was then extended distally approximately 1 cm.  The incision was then deepened down to the level of capsule over the base of the proximal phalanx.  Again care was taken to preserve the extensor digitorum longus tendon.  The capsule was reflected off of the base of the proximal phalanx.  An Akin osteotomy was performed with the apex being lateral and the base being medial.  After where the bone was resected, it was feathered until tight compression was noted without tension at the osteotomy site.  Care was taken to preserve the lateral hinge.  At 1.5 wire passed and a drill was then used to create drill hole proximal and distally to the osteotomy site in order for passage of 28 gauge monofilament wire.  The #28 gauge monofilament wire was passed through the drill hole and tightened down until compression and tight ________ osteotomy site was noted.  The remaining edge of the wire was then buried in the medial most distal drill hole.  The area was then inspected and the foot was noted with significant reduction of the bunion deformity.  The area was then flushed with copious amounts of sterile saline.  Capsule was closed with #3-0 Vicryl followed by subcutaneous closure with #4-0 Vicryl in order to decrease tension of the incision site.  A running #5-0 subcuticular stitch was then performed.  Steri-Strips were applied.  Total of 1 cc dexamethasone phosphate was then injected into the surgical site.  Dressings consisted of Owen silk, 4x4s, Kling, Kerlix.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot.  Posterior splint was then placed on the patient in the operating room.,The patient tolerated the above procedure and anesthesia well without complications.  The patient was transferred back to the PACU with vital signs stable and vascular status intact to the left foot.  The patient was given postoperative instructions to be strictly nonweightbearing on the left foot.  The patient was given postop pain prescriptions for Vicodin and instructed to take one q.4-6h. p.r.n. for pain as well as Naprosyn 500 mg p.o. q. b.i.d.  The patient is to follow-up with Dr. X in his office in four to five days as directed.","podiatry, bunionectomy, akin osteotomy, internal wire fixation, internal screw fixation, osteotomy, metatarsal, metatarsal osteotomy, extensor digitorum, drill hole, osteotomy site, foot"
 Arthroplasty of the right second digit.  Hammertoe deformity of the right second digit., Podiatry, Arthroplasty - Hammertoe ,"PREOPERATIVE DIAGNOSIS:,  Hammertoe deformity of the right second digit.,POSTOPERATIVE DIAGNOSIS: , Hammertoe deformity of the right second digit.,PROCEDURE PERFORMED: , Arthroplasty of the right second digit.,The patient is a 77-year-old Hispanic male who presents to ABCD Hospital for surgical correction of a painful second digit hammertoe.  The patient has failed attempts at conservative treatment and is unable to wear shoes without pain to his second toe.  The patient presents n.p.o. since mid night last night and consented to sign in the chart.  H&P is complete.,PROCEDURE IN DETAIL:,  After an IV was instituted by the Department of Anesthesia in the preoperative holding area, the patient was escorted to the operating room and placed on the table in the supine position.  Using Webril, the distal leg and ankle was padded and a ankle pneumatic tourniquet was placed around the right ankle, but left deflated at this time.  Restraining, a lap belt was then placed around the patient's abdomen while laying on the table.  After adequate anesthesia was administered by the Department of Anesthesia, a local digital block using 5 cc of 0.5% Marcaine plain was used to provide local anesthesia.  The foot was then prepped and draped in the normal sterile orthopedic manner.  The foot was then elevated and Esmarch bandage was applied, after which time the tourniquet was inflated to 250 mmHg.  The foot was then brought down to the level of the table and stockinet was cut and reflected after the Esmarch bandage was removed.  A wet and dry sponge was then used to cleanse the operative site and using a skin skribe a dorsal incisional line was outlined extending from the proximal phalanx over the proximal interphalangeal joint on to the middle phalanx.,Then using a fresh #15 blade, a dorsolinear incision was made, partial thickness through the skin after testing anesthesia with one to two pickup.  Then using a fresh #15 blade, incision was deepened and using medial to lateral pressure, the incision was opened into the subcutaneous tissue.  Care was taken to reflect the subcutaneous tissue from the underlying deep fascia to mobilize the skin.  This was performed with the combination of blunt and dull dissection.  Care was taken to avoid proper digital arteries and neurovascular bundles as were identified.  Attention was then directed to the proximal interphalangeal joint and after identifying the joint line, a transverse linear incision was made over the dorsal surface of the joint.  The medial and lateral sides of the joint capsule were then also incised on the superior half in order to provide increased exposure.  Following this, the proximal portion of the transected extensor digitorum longus tendon was identified using an Adson-Brown pickup.  It was elevated with fresh #15 blade.  The tendon and capsule was reflected along with the periosteum from the underlying bone dorsally.  Following this, the distal portion of the tendon was identified in a like manner.  The tendon and the capsule as well as the periosteal tissue was reflected from the dorsal surface of the bone.  The proximal interphalangeal joint was then distracted and using careful technique, #15 blade was used to deepen the incision and while maintaining close proximity to the bone and condyles, the lateral and medial collateral ligaments were freed up from the side of the proximal phalanx head.,Following this, the head of the proximal phalanx was known to have adequate exposure and was freed from soft tissues.  Then using a sagittal saw with a #139 blade, the head of he proximal phalanx was resected.  Care was taken to avoid the deep flexor tendon.  The head of the proximal phalanx was taken with the Adson-Brown and using a #15 blade, the plantar periosteal tissue was freed up and the head was removed and sent to pathology.  The wound was then flushed using a sterile saline with gentamicin and the digit was noted to be in good alignment.  The digit was also noted to be in rectus alignment.  Proximal portion of the tendon was shortened to allow for removal of the redundant tendon after correction of the deformity.  Then using a #3-0 Vicryl suture, three simple interrupted sutures were placed for closure of the tendon and capsular tissue.  Then following this, #4-0 nylon was used in a combination of horizontal mattress and simple interrupted sutures to close the skin.  The toe was noted to be in good alignment and then 1 cc of dexamethasone phosphate was injected into the incision site.  Following this, the incision was dressed using a sterile Owen silk soaked in saline and gentamicin.  The toe was bandaged using 4 x 4s, Kling, and Coban.  The tourniquet was deflated and immediate hyperemia was noted to the digits I through V of the right foot.,The patient was then transferred to the cart and was escorted to the Postanesthesia Care Unit where the patient was given postoperative surgical shoe.  Total tourniquet time for the case was 30 minutes.  While in the recovery, the patient was given postoperative instructions to include, ice and elevation to his right foot.  The patient was given pain medications of Tylenol #3, quantity 30 to be taken one to two tablets every six to eight hours as necessary for moderate to severe pain.  The patient was also given prescription for cane to aid in ambulation.  The patient will followup with Dr. X on Tuesday in his office for postoperative care.  The patient was instructed to keep the dressings clean, dry, and intact and to not remove them before his initial office visit.  The patient tolerated the procedure well and the anesthesia with no complications.","podiatry, hammertoe deformity, arthroplasty, digit, proximal interphalangeal joint, periosteal tissue, interrupted sutures, interphalangeal joint, proximal phalanx, proximal, painful, tourniquet, hammertoe, phalanx, head, incisional, tendon"
" Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot.  Akin bunionectomy, right toe with internal wire fixation.", Podiatry, Bunionectomy & Osteotomy ,"PREOPERATIVE DIAGNOSES:,1.  Hallux valgus, right foot.,2.  Hallux interphalangeus, right foot.,POSTOPERATIVE DIAGNOSES:,1.  Hallux valgus, right foot.,2.  Hallux interphalangeus, right foot.,PROCEDURES PERFORMED:,1.  Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot.,2.  Akin bunionectomy, right toe with internal wire fixation.,ANESTHESIA: , TIVA/local.,HISTORY:  ,This 51-year-old female presents to ABCD preoperative holding area after keeping herself NPO since mid night for a surgery on her painful bunion through her right foot.  The patient has a history of gradual onset of a painful bunion over the past several years.  She has tried conservative methods such as wide shoes, accommodative padding on an outpatient basis with Dr. X all of which have provided inadequate relief.  At this time, she desires attempted surgical correction.  The risks versus benefits of the procedure have been discussed with the patient in detail by Dr. X and the consent is available on the chart for review.,PROCEDURE IN DETAIL: , After IV was established by the Department of Anesthesia, the patient was taken to the operating room via cart and placed on the operative table in supine position and a safety strap was placed across her waist for her protection.  Copious amounts of Webril were applied about the right ankle and a pneumatic ankle tourniquet was placed over the Webril.,After adequate IV sedation was administered by the Department of Anesthesia, a total of 15 cc of 1:1 mixture of 0.5% Marcaine plain and 1% Lidocaine plain was injected into the foot in a standard Mayo block fashion.  The foot was elevated off the table.  Esmarch bandages were used to exsanguinate the right foot.  The pneumatic ankle tourniquet was elevated to 250 mmHg.  The foot was lowered in the operative field and the sterile stockinet was reflected.  A sterile Betadine was wiped away with a wet and dry sponge and one toothpick was used to test anesthesia, which was found to be adequate.  Attention was directed to the first metatarsophalangeal joint, which was found to be contracted, laterally deviated, and had decreased range of motion.  A #10 blade was used to make a 4 cm dorsolinear incision.  A #15 blade was used to deepen the incision through the subcutaneous layer.  All superficial subcutaneous vessels were ligated with electrocautery.  Next, a linear capsular incision was made down the bone with a #15 blade.  The capsule was elevated medially and laterally off the metatarsal head and the metatarsal head was delivered into the wound.  A hypertrophic medial eminence was resected with a sagittal saw taking care not to strike the head.  The medial plantar aspect of the metatarsal head had some erosive changes and eburnation.  Next, a 0.45 inch Kirschner wire was placed with some access guide slightly plantar flexing the metatarsal taking care not to shorten it.  A sagittal saw was used to make a long-arm Austin osteotomy in the usual fashion.  Standard lateral release was also performed as well as a lateral capsulotomy freeing the fibular sesamoid complex.,The capital head was shifted laterally and impacted on the residual metatarsal head.  Nice correction was achieved and excellent bone to bone contact was achieved.  The bone stock was slightly decreased, but adequate.  Next, a 0.45 inch Kirschner wire was used to temporarily fixate the metatarsal capital fragment.  A 2.7 x 18 mm Synthes cortical screw was thrown using standard AO technique.  Excellent rigid fixation was achieved.  A second 2.0 x 80 mm Synthes fully threaded cortical screw was also thrown using standard AO technique at the proximal aspect of the metatarsal head.  Again, an excellent rigid fixation was obtained and the screws were tight.  The temporary fixation was removed.  A medial overhanging bone was resected with a sagittal saw.  The foot was loaded and the hallux was found to have an interphalangeus deformity present.,A sagittal saw was used to make a proximal cut in approximately 1 cm dorsal to the base of the proximal phalanx, leaving a lateral intact cortical hinge.  A distal cut parallel with the nail base was performed and a standard proximal Akin osteotomy was done.,After the wedge bone was removed, the saw blade was reinserted and used to tether the osteotomy with counter-pressure used to close down the osteotomy.  A #15 drill blade was used to drill two converging holes on the medial aspect of the bone.  A #28 gauge monofilament wire was inserted loop to loop and pulled through the bone.  The monofilament wire was twisted down and tapped into the distal drill hole.  The foot was loaded again and the toe had an excellent cosmetic straight appearance and the range of motion of the first metatarsophalangeal joint was then improved.  Next, reciprocating rasps were used to smooth all bony surfaces.  Copious amounts of sterile saline was used to flush the joint.  Next, a #3-0 Vicryl was used to reapproximate the capsular periosteal tissue layer.  Next, #4-0 Vicryl was used to close the subcutaneous layer.  #5-0 Vicryl was used to the close the subcuticular layer in a running fashion.  Next, 1 cc of dexamethasone phosphate was then instilled in the joint.  The Steri-Strips were applied followed by standard postoperative dressing consisting of Owen silk, 4 x 4s, Kling, Kerlix, and Coban.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to the digits.  The patient tolerated the above anesthesia and procedure without complications.  She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot.  She is to be partial weightbearing with crutches.  She is to follow with Dr. X.  She was given emergency contact numbers and instructions to call if problems arise.  She was given prescription for Vicodin ES #25 one p.o. q.4-6h. p.r.n. pain and Naprosyn one p.o. b.i.d.  500 mg.  She was discharged in stable condition.","podiatry, hallux interphalangeus, osteotomy, bunionectomy, akin, wire fixation, screw fixation, painful bunion, metatarsophalangeal joint, pneumatic ankle, metatarsal head, foot, toe, sagittal, metatarsal"
" Austin/akin bunionectomy, right foot.  Bunion, right foot.  The patient states she has had a bunion deformity for as long as she can remember that has progressively become worse and more painful.", Podiatry, Bunionectomy - Austin - Akin ,"PREOPERATIVE DIAGNOSIS:,  Bunion, right foot.,POSTOPERATIVE DIAGNOSIS:,  Bunion, right foot.,PROCEDURE PERFORMED:,  Austin/akin bunionectomy, right foot.,HISTORY: , This 77-year-old African-American female presents to ABCD General Hospital with the above chief complaint.  The patient states she has had a bunion deformity for as long as she can remember that has progressively become worse and more painful.  The patient has attempted conservative treatment without long-term relief of symptoms and desires surgical treatment.,PROCEDURE DETAILS:,  An IV was instituted by Department of Anesthesia in the preop holding area.  The patient was transported to the operating room and placed on the operating table in the supine position with a safety strap across her lap.  Copious amounts of Webril were placed around the right ankle followed by blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 15 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain was injected in a Mayo block type fashion.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was elevated to the operating table and exsanguinated with an Esmarch bandage.  The pneumatic ankle tourniquet was inflated to 250 mmHg.  The foot was lowered to the operating field and the stockinet was reflected.  The foot was cleansed with wet and dry sponge.,Attention was directed to the bunion deformity on the right foot.  An approximately 6 cm dorsal medial incision was created over the first metatarsophalangeal joint.  The incision was then deepened with a #15 blade.  All vessels encountered were ligated with hemostasis.  The skin and subcutaneous tissue were then undermined off of the capsule medially.  A dorsal linear capsular incision was then created over the first metatarsophalangeal joint.  The periosteum and capsule were then reflected off of the first metatarsal.  There was noted to be a prominent medial eminence.  The articular cartilage was healthy for patient's age and race.  Attention was then directed to the first interspace where a lateral release was performed..  A combination of sharp and blunt dissection was carried out until the adductor tendon insertions were identified.  The adductor tendons were transected as well as a lateral capsulotomy was performed.  The extensor digitorum brevis tendon was identified and transected.  Care was taken to preserve the extensor hallucis longus to make sure that tendon that was transected was the extensor hallucis brevis at the _______ digitorum.  Extensor hallucis brevis tendon was transected and care was taken to preserve the extensor halucis longus tendon.  Attention was then directed to medial eminence, which was resected with a sagittal saw.  Sagittal was then used to create a long dorsal arm outside the Austin type osteotomy and the first metatarsal.  The head of the first metatarsal was then translocated laterally until correction of the intermetatarsal angle was noted.  The head was intact.  A 0.45 K-wire was inserted through subcutaneously from proximal medial to distal lateral.  A second K-wire was then inserted from distal lateral to proximal plantar medial.  Adequate fixation was noted at the osteotomy site.  The K-wires were bent, cut, and pin caps were placed.  Attention was then directed to the proximal phalanx of the hallux.  The capsular periostem was reflected off of the base of the proximal phalanx.  A sagittal was then used to create an akin osteotomy closing wedge.  The apex was lateral and the base of the wedge was medial.  The wedge was removed in the total and the osteotomy site was then feathered until closure was achieved without compression.  Two 0.45 K-wires were then inserted, one from distal medial to proximal lateral and the second from distal lateral to proximal medial across the osteotomy site.  Adequate fixation was noted at the osteotomy site and the osteotomy was closed.  The toe was noted to be in a markedly more rectus position.  Sagittal saw was then used to resect the remaining prominent medial eminence.  The area was then smoothed with a reciprocating rasp.  There was noted to be a small osteophytic formation laterally over first metatarsal head that was removed with a rongeur and smoothed with a reciprocating rasp.  The area was then inspected for any remaining short bony edges, none were noted.,Copious amounts of sterile saline was then used to flush the surgical site.  The capsule was closed with #3-0 Vicryl.  Subcutaneous closure was performed with #4-0 Vicryl followed by running subcuticular #5-0 Vicryl.  Steri-Strips were applied and 1 cc of dexamethasone phosphate was injected into the surgical site.,Dressings consisted of #0-1 silk, copious Betadine, 4 x 4s, Kling, Kerlix, and Coban.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the right foot.  A _______ cast was then applied postoperatively.  The patient tolerated the above procedure and anesthesia well without complications.  The patient was transported from the operating room to the PACU with vital signs stable and vascular status intact to the right foot.  The patient was given postoperative pain prescription for Tylenol #3 and instructed to take one q4-6h. p.o. p.r.n. for pain.  The patient is to follow up with Dr. X in his office as directed.","podiatry, austin/akin bunionectomy, hallucis brevis, bunion deformity, extensor hallucis, osteotomy site, foot, austin, bunionectomy "
" A simple note on Athlete's foot, tinea pedis, a very common fungal skin infection of the foot.", Podiatry, Athlete's Foot ,"ATHLETE'S FOOT, TINEA PEDIS,, is a very common fungal skin infection of the foot.  It often first appears between the toes.  It can be a one-time occurrence or it can be chronic.  The fungus, known as Trichophyton, thrives under warm, damp conditions so people whose feet sweat a great deal are more susceptible.  It is easily transmitted in showers and pool walkways.  Those people with immunosuppressive conditions, such as diabetes mellitus, are also more susceptible to athlete's foot.,SIGNS AND SYMPTOMS:,*  Itchy feet.,*  White or red and soft scaling on feet, usually in between toes.,*  Small blisters may be present.,*  Bad foot odor.,*  Very rare involvement of hands and simultaneously (called an Id reaction).,TREATMENT:,*  Diagnosis is via symptoms or sometimes by examining skin scrapings under a microscope..  A bacterial infection may also be suspected in which case a skin culture will confirm this.,*  Try a non-prescription antifungal powder or cream available in drugstores; your doctor can prescribe a stronger topical antifungal medication if necessary.,*  Oral antibiotics may be prescribed for a possible bacterial infection.,*  Keep feet as dry as possible! Change socks twice a day if necessary and wear those made of natural fibers, such as cotton.  Go barefoot when you have a chance or wear sandals.  Dry thoroughly in between toes after swimming or bathing.,*  A special powder to absorb moisture on feet is also available in drugstores.  Ask the pharmacist about this.,*  Spray your shower at home with a 10% bleach solution after bathing.  This may help decrease the chance that other family members will be infected.,*  Wear sandals or thongs in public showers and around pools.,*  Keep in mind that it may take up to a month or more to get rid of your athlete's foot.  Be diligent in using the antifungal medication.  Unfortunately, recurrence of athlete's foot is common.  Luckily, the condition does not cause serious problems for the majority of people who have it.,*  Call the office if your athlete's foot spreads or worsens despite treatment.,PLANTAR FASCIAL STRETCHES,1.  Raise toes toward you while bending your ankle as high as you can.,2.  Hold this position for 15 seconds.,3.  Alternate doing this with the opposite foot 10 times.,4.  Perform this exercise 2- 3 times a day.,WOUND CARE INSTRUCTIONS,1.  Clean the area daily with soap and water.,2.  Every day apply a thin coat of polysporin ointment.,3.  Change the dressing daily and keep the area covered with an adhesive bandage until completely healed.,4.  Notify the office if you have any increasing wound pain or any evidence of infection.","podiatry, tinea pedis, infection, foot, athlete's foot, trichophyton, itchy, athlete's foot tinea pedis, fungal skin infection, fungal, athlete's, "
" Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot.  Proximal interphalangeal joint arthroplasty, bilateral fifth toes.  Distal interphalangeal joint arthroplasty, bilateral third and fourth toes.   Flexor tenotomy, bilateral third toes.", Podiatry, Bunionectomy & Flexor Tenotomy ,"PREOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus, right foot.,2.  Hammertoe, bilateral third, fourth, and fifth toes.,POSTOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus, right foot.,2.  Hammertoe, bilateral third, fourth, and fifth toes.,PROCEDURE PERFORMED:,1.  Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot.,2.  Proximal interphalangeal joint arthroplasty, bilateral fifth toes.,3.  Distal interphalangeal joint arthroplasty, bilateral third and fourth toes.,4.  Flexor tenotomy, bilateral third toes.,HISTORY:,  This is a 36-year-old female who presented to ABCD preoperative holding area after keeping herself n.p.o. since mid night for surgery on her painful bunion to her right foot and her painful hammertoes to both feet.  The patient has a history of sharp pain, which is aggravated by wearing shoes and ambulation.  She has tried multiple conservative methods and treatment such as wide shoes and accommodative padding, all of which provided inadequate relief.  At this time, she desires attempted surgical correction.  The risks versus benefits of the procedure have been discussed in detail by Dr. Kaczander with the patient and the consent is available on the chart.,PROCEDURE IN DETAIL:,  After IV was established by the Department of Anesthesia, the patient was taken to the operating room and placed on the operating table in supine position with a safety strap placed across her waist for her protection.,Copious amounts of Webril were applied about both ankles and a pneumatic ankle tourniquet was applied over the Webril.  After adequate IV sedation was administered, a total of 18 cc of a 0.5% Marcaine plain was used to anesthetize the right foot, performing a Mayo block and a bilateral third, fourth, and fifth digital block.  Next, the foot was prepped and draped in the usual aseptic fashion bilaterally.  The foot was elevated off the table and an Esmarch bandage was used to exsanguinate the right foot.  The pneumatic ankle tourniquet was elevated on the right foot to 200 mmHg.  The foot was lowered into operative field and the sterile stockinet was reflected proximally.  Attention was directed to the right first metatarsophalangeal joint, it was found to be contracted and there was lateral deviation of the hallux.  There was decreased range of motion of the first metatarsophalangeal joint.  A dorsolinear incision was made with a #10 blade, approximately 4 cm in length.  The incision was deepened to the subcutaneous layer with a #15 blade.  Any small veins traversing the subcutaneous layer were ligated with electrocautery.  Next, the medial and lateral wound margins were undermined sharply.  Care was taken to avoid the medial neurovascular bundle and the lateral extensor hallucis longus tendon.  Next, the first metatarsal joint capsule was identified.  A #15 blade was used to make a linear capsular incision down to the bone.  The capsular periosteal tissues were elevated off the bone with a #15 blade and the metatarsal head was delivered into the wound.  The PASA was found to be within normal limits.  There was a hypertrophic medial eminence noted.  A sagittal saw was used to remove the hypertrophic medial eminence.  A 0.045 inch Kirschner wire was placed into the central medial aspect of the metatarsal head as an access guide.  A standard lateral release was performed.  The fibular sesamoid was found to be in the interspace, but was relocated onto the metatarsal head properly.  Next, a sagittal saw was used to perform a long arm Austin osteotomy.  The K-wire was removed.  The capital fragment was shifted laterally and impacted into the head.  A 0.045 inch Kirschner wire was used to temporarily fixate the osteotomy.  A 2.7 x 16 mm Synthes, fully threaded cortical screw was throne using standard AO technique.  A second screw was throne, which was a 2.0 x 12 mm Synthes cortical screw.  Excellent fixation was achieved and the screws tightly perched the bone.  Next, the medial overhanging wedge was removed with a sagittal saw.  A reciprocating rasp was used to smooth all bony prominences.  The 0.045 inch Kirschner wire was removed.  The screws were checked again for tightness and found to be very tight.  The joint was flushed with copious amounts of sterile saline.  A #3-0 Vicryl was used to close the capsular periosteal tissues with simple interrupted suture technique.  A #4-0 Vicryl was used to close the subcutaneous layer in a simple interrupted technique.  A #5-0 Monocryl was used to close the skin in a running subcuticular fashion.,Attention was directed to the right third digit, which was found to be markedly contracted at the distal interphalangeal joint.  A #15 blade was used to make two convergent semi-elliptical incisions over the distal interphalangeal joint.  The incision was deepened with a #15 blade.  The wedge of skin was removed in full thickness.  The long extensor tendon was identified and the distal and proximal borders of the wound were undermined.  The #15 blade was used to transect the long extensor tendon, which was reflected proximally.  The distal interphalangeal joint was identified and the #15 blade was placed in the joint and the medial and lateral collateral ligaments were released.  Crown and collar scissors were used to release the planar attachment to the head of the middle phalanx.  Next, a double action bone cutter was used to resect the head of the middle phalanx.  The toe was dorsiflexed and was found to have an excellent rectus position.  A hand rasp was used to smooth all bony surfaces.  The joint was flushed with copious amounts of sterile saline.  The flexor tendon was found to be contracted, therefore, a flexor tenotomy was performed through the dorsal incision.  Next, #3-0 Vicryl was used to close the long extensor tendon with two simple interrupted sutures.  A #4-0 nylon was used to close the skin and excellent cosmetic result was achieved.,Attention was directed to the fourth toe, which was found to be contracted at the distal interphalangeal joint and abducted and varus rotated.  An oblique skin incision with two converging semi-elliptical incisions was created using #15 blade.  The rest of the procedure was repeated exactly the same as the above paragraph to the third toe on the right foot.  All the same suture materials were used.  However, there was no flexor tenotomy performed on this toe, only on the third toe bilaterally.,Attention was directed to the fifth right digit, which was found to be contracted at the proximal interphalangeal joint.  A linear incision approximately 2 cm in length was made with a #15 blade over the proximal interphalangeal joint.  Next, a #15 blade was used to deepen the incision to the subcutaneous layer.  The medial and lateral margins were undermined sharply to the level of the long extensor tendon.  The proximal interphalangeal joint was identified and the tendon was transected with the #15 blade.  The tendon was reflected proximally, off the head of the proximal phalanx.  The medial and lateral collateral ligaments were released and the head of the proximal phalanx was delivered into the wound.  A double action bone nibbler was used to remove the head of the proximal phalanx.  A hand rasp was used to smooth residual bone.  The joint was flushed with copious amounts of saline.  A #3-0 Vicryl was used to close the long extensor tendon with two simple interrupted sutures.  A #4-0 nylon was used to close the skin with a combination of simple interrupted and horizontal mattress sutures.,A standard postoperative dressing consisting of saline-soaked #0-1 silk, 4 x 4s, Kerlix, Kling, and Coban were applied.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to the digits.,Attention was directed to the left foot.  The foot was elevated off the table and exsanguinated with an Esmarch bandage and the pneumatic ankle tourniquet was elevated to 200 mmHg.  Attention was directed to the left fifth toe, which was found to be contracted at the proximal interphalangeal joint.  The exact same procedure, performed to the right fifth digit, was performed on this toe, with the same materials being used for suture and closure.,Attention was then directed to the left fourth digit, which was found to contracted and slightly abducted and varus rotated.  The exact same procedure as performed to the right fourth toe was performed, consisting of two semi-elliptical skin incisions in an oblique angle.  The same suture material were used to close the incision.,Attention was directed to the left third digit, which was found to be contracted at the distal interphalangeal joint.  The same procedure performed on the right third digit was also performed.  The same suture materials were used to close the wound and the flexor tenotomy was also performed at this digit.  A standard postoperative dressing was also applied to the left foot consisting of the same materials as described for the right foot.  The pneumatic tourniquet was released and immediate hyperemic flush was noted to the digits.  The patient tolerated the above anesthesia and procedure without complications.  She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the foot.  She was given postoperative shoes and will be partial weighbearing with crutches.  She was admitted short-stay to Dr. Kaczander for pain control.  She was placed on Demerol 50 and Vistaril 25 mg IM q3-4h. p.r.n. for pain.  She will have Vicodin 5/500 one to two p.o. q.4-6h. p.r.n. for moderate pain.  She was placed on Subq. heparin and given incentive spirometry 10 times an hour.  She will be discharged tomorrow.  She is to ice and elevate both feet today and rest as much as possible.,Physical Therapy will teach her crutch training today.  X-rays were taken in the postoperative area and revealed excellent position of the screws and correction of bunion deformity as well as the hammertoe deformities.","podiatry, hallux abductovalgus, hammertoe, bunionectomy, flexor, tenotomy, interphalangeal, arthroplasty, screw fixation, osteotomy, interphalangeal joint arthroplasty, distal interphalangeal joint, interphalangeal joint, flexor tenotomy, proximal interphalangeal, joint arthroplasty, distal interphalangeal, distal, blade, proximal, foot, joint, toes, tendon, "
" Tailor's bunion, right foot.  Removal of bone, right fifth metatarsal head.", Podiatry, Bone Removal - Metatarsal Head ,"PREOPERATIVE DIAGNOSIS: , Tailor's bunion, right foot.,POSTOPERATIVE DIAGNOSIS:  ,Tailor's bunion, right foot.,PROCEDURE PERFORMED: , Removal of bone, right fifth metatarsal head.,ANESTHESIA:  ,TIVA/local.,HISTORY: , This 60-year-old male presents to ABCD Preoperative Holding Area after keeping himself n.p.o., since mid night for surgery on his painful right Tailor's bunion.  The patient has a history of chronic ulceration to the right foot which has been treated on an outpatient basis with conservative methods Dr. X.  At this time, he desires surgical correction as the ulcer has been refractory to conservative treatment.  Incidentally, the ulcer is noninfective and practically healed at this date.  The consent is available on the chart for review and Dr. X has discussed the risks versus benefits of this procedure to the patient in detail.,PROCEDURE IN DETAIL: , After IV was established by the Department of Anesthesia, the patient was taken to the operating room, placed on the operating table in supine position and a safety strap was placed across his waist for his protection.  A pneumatic ankle tourniquet was applied about the right foot over copious amount of Webril for the patient's protection.  After adequate IV sedation was administered by the Department of Anesthesia, a total of 10 cc of 1:1 mixture of 1% lidocaine and 0.5% Marcaine plain were administered into the right fifth metatarsal using a Mayo type block technique.  Next, the foot was prepped and draped in the usual aseptic fashion.  An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg.  The foot was lowered in the operating field and a sterile stockinet was reflected.  The Betadine was cleansed with saline-soaked gauze and dried.  Anesthesia was tested with a one tooth pickup and found to be adequate.  A #10 blade was used to make 3.5 cm linear incision over the fifth metatarsophalangeal joint.  A #15 blade was used to deepen the incision to the subcutaneous layer.  Care was taken to retract the extensor digitorum longus tendon medially and the abductor digiti minimi tendon laterally.  Using a combination of sharp and blunt dissection, the medial and lateral edges of the wound were undermined down to the level of the capsule and deep fascia.  A linear capsular incision was made with a #15 blade down to the bone.  The capsular periosteal tissues were elevated off the bone with a #15 blade.  Metatarsal head was delivered into the wound.  There was hypertrophic exostosis noted laterally as well as a large bursa in the subcuteneous tissue layer.  The ulcer on the skin was approximately 2 x 2 mm, it was partial skin thickness and did not probe.  A sagittal saw was used to resect the hypertrophic lateral eminence.  The hypertrophic bone was split in half and one half was sent to Pathology and the other half was sent to Microbiology for culture and sensitivity.  Next, a reciprocating rasp was used to smoothen all bony surfaces.  The bone stock had an excellent healthy appearance and did not appear to be infected.  Copious amount of sterile gentamicin impregnated saline were used to flush the wound.  The capsuloperiosteal tissues were reapproximated with #3-0 Vicryl in simple interrupted technique.  The subcutaneous layer was closed with #4-0 Vicryl in simple interrupted technique.  Next, the skin was closed with #4-0 nylon in a horizontal mattress suture technique.  A standard postoperative dressing was applied consisting of Betadine-soaked Owen silk, 4x4s, Kerlix, and Kling.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted at the digits.  The patient tolerated the above anesthesia and procedure without complications.  He was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot.  He was given a postop shoe and will be full weightbearing.  He has prescription already at home for hydrocodone and does not need to refill.  He is to follow up with Dr. X and was given emergency contact numbers.  He was discharged in stable condition.","podiatry, pneumatic ankle, metatarsal head, tailor's bunion, head, pneumatic, ulceration, metatarsal, bone"
" Acute foot or ankle sprain, possible small fracture.", Podiatry, Ankle pain ,"CHIEF COMPLAINT:,  Ankle pain.,HISTORY OF PRESENT ILLNESS:  ,The patient is a pleasant 17-year-old gentleman who was playing basketball today in gym.  Two hours prior to presentation, he started to fall and someone stepped on his ankle and kind of twisted his right ankle and he cannot bear weight on it now.  It hurts to move or bear weight.  No other injuries noted.  He does not think he has had injuries to his ankle in the past.,PAST MEDICAL HISTORY: , None.,PAST SURGICAL HISTORY: , None.,SOCIAL HISTORY: , He does not drink or smoke.,ALLERGIES: , Unknown.,MEDICATIONS: , Adderall and Accutane.,REVIEW OF SYSTEMS: , As above.  Ten systems reviewed and are negative.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 97.6, pulse 70, respirations 16, blood pressure 120/63, and pulse oximetry 100% on room air.,GENERAL:","podiatry, accutane, foot or ankle sprain, ankle sprain, ankle, sprain, splint, fracture, "
" Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left and arthroplasty left second toe.  Bunion left foot and hammertoe, left second toe.", Podiatry, Bunionectomy & Metatarsal Osteotomy ,"PREOPERATIVE DIAGNOSES:,1.  Bunion left foot.,2.  Hammertoe, left second toe.,POSTOPERATIVE DIAGNOSES:,1.  Bunion left foot.,2.  Hammertoe, left second toe.,PROCEDURE PERFORMED:,1.  Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left.,2.  Arthroplasty left second toe.,HISTORY:  ,This 39-year-old female presents to ABCD General Hospital with the above chief complaint.  The patient states that she has had bunion for many months.  It has been progressively getting more painful at this time.  The patient attempted conservative treatment including wider shoe gear without long-term relief of symptoms and desires surgical treatment.,PROCEDURE: , An IV was instituted by the Department of Anesthesia in the preop holding area.  The patient was transported to the operating room and placed on the operating table in the supine position with a safety belt across her lap.  Copious amount of Webril were placed around the left ankle followed by a blood pressure cuff.  After adequate sedation was achieved by the Department of Anesthesia, a total of 15 cc of 0.5% Marcaine plain was injected in a Mayo and digital block to the left foot.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was elevated from the operating table and exsanguinated with an Esmarch bandage.  The pneumatic ankle tourniquet was inflated to 250 mmHg and the foot was lowered to the operating table.  The stockinette was reflected.  The foot was cleansed with wet and dry sponge.  Attention was then directed to the first metatarsophalangeal joint of the left foot.  An incision was created over this area approximately 6 cm in length.  The incision was deepened with a #15 blade.  All vessels encountered were ligated for hemostasis.  The skin and subcutaneous tissue was then dissected from the capsule.  Care was taken to preserve the neurovascular bundle.  Dorsal linear capsular incision was then created.  The capsule was then reflected from the head of the first metatarsal.  Attention was then directed to the first interspace where a lateral release was performed.  A combination of sharp and blunt dissection was performed until the abductor tendons were identified and transected.  A lateral capsulotomy was performed.  Attention was then directed back to the medial eminence where sagittal saw was used to resect the prominent medial eminence.  The incision was then extended proximally with further dissection down to the level of the bone.  Two 0.45 K-wires were then inserted as access guides for the SCARF osteotomy.  A standard SCARF osteotomy was then performed.  The head of the first metatarsal was then translocated laterally in order to reduce the first interspace in the metatarsal angle.  After adequate reduction of the bunion deformity was noted, the bone was temporarily fixated with a 0.45 K-wire.  A 3.0 x 12 mm screw was then inserted in the standard AO fashion with compression noted.  A second 3.0 x 14 mm screw was also inserted with tight compression noted.  The remaining prominent medial eminence medially was then resected with a sagittal saw.  Reciprocating rasps were then used to smooth any sharp bony edges.  The temporary fixation wires were then removed.  The screws were again checked for tightness, which was noted.  Attention was directed to the medial capsule where a medial capsulorrhaphy was performed.  A straight stat was used to assist in removing a portion of the capsule.  The capsule was then reapproximated with #2-0 Vicryl medially.  Dorsal capsule was then reapproximated with #3-0 Vicryl in a running fashion.  The subcutaneous closure was performed with #4-0 Vicryl followed by running subcuticular stitch with #5-0 Vicryl.  The skin was then closed with #4-0 nylon in a horizontal mattress type fashion.,Attention was then directed to the left second toe.  A dorsal linear incision was then created over the proximal phalangeal joint of the left second toe.  The incision was deepened with a #15 blade and the skin and subcutaneous tissue was dissected off the capsule to be aligned laterally.  An incision was made on either side of the extensor digitorum longus tendon.  A curved mosquito stat was then used to reflex the tendon laterally.  The joint was identified and the medial collateral ligamentous attachments were resected off the head of the proximal phalanx.  A sagittal saw was then used to resect the head of the proximal head.  The bone was then rolled and the lateral collateral attachments were transected and the bone was removed in toto.  The extensor digitorum longus tendon was inspected and noted to be intact.  Any sharp edges were then smoothed with reciprocating rasp.  The area was then flushed with copious amounts of sterile saline.  The skin was then reapproximated with #4-0 nylon.  Dressings consisted of Owen silk, 4x4s, Kling, Kerlix, and Coban.  Pneumatic ankle tourniquet was released and an immediate hyperemic flush was noted to all five digits of the left foot.  The patient tolerated the above procedure and anesthesia well without complications.  The patient was transported to PACU with vital signs stable and vascular status intact to the left foot.  The patient is to follow up with Dr. X in his clinic as directed.","podiatry, hammertoe, osteotomy, internal screw fixation, scarf type, extensor digitorum, metatarsal osteotomy, foot, toe, metatarsal, bunionectomy,"
" Incision and drainage, first metatarsal head, left foot with culture and sensitivity.", Podiatry, Abscess with Cellulitis - Discharge Summary ,"ADMITTING DIAGNOSIS:,  Abscess with cellulitis, left foot.,DISCHARGE DIAGNOSIS:,  Status post I&D, left foot.,PROCEDURES:,  Incision and drainage, first metatarsal head, left foot with culture and sensitivity.,HISTORY OF PRESENT ILLNESS:,  The patient presented to Dr. X's office on 06/14/07 complaining of a painful left foot.  The patient had been treated conservatively in office for approximately 5 days, but symptoms progressed with the need of incision and drainage being decided.,MEDICATIONS:,  Ancef IV.,ALLERGIES:,  ACCUTANE.,SOCIAL HISTORY:,  Denies smoking or drinking.,PHYSICAL EXAMINATION: , Palpable pedal pulses noted bilaterally.  Capillary refill time less than 3 seconds, digits 1 through 5 bilateral.  Skin supple and intact with positive hair growth.  Epicritic sensation intact bilateral.  Muscle strength +5/5, dorsiflexors, plantar flexors, invertors, evertors.  Left foot with erythema, edema, positive tenderness noted, left forefoot area.,LABORATORY: , White blood cell count never was abnormal.  The remaining within normal limits.  X-ray is negative for osteomyelitis.  On 06/14/07, the patient was taken to the OR for incision and drainage of left foot abscess.  The patient tolerated the procedure well and was admitted and placed on vancomycin 1 g q.12h after surgery and later changed Ancef 2 g IV every 8 hours.  Postop wound care consists of Aquacel Ag and dry dressing to the surgical site everyday and the patient remains nonweightbearing on the left foot.  The patient progressively improved with IV antibiotics and local wound care and was discharged from the hospital on 06/19/07 in excellent condition.,DISCHARGE MEDICATIONS: , Lorcet 10/650 mg, dispense 24 tablets, one tablet to be taken by mouth q.6h as needed for pain.  The patient was continued on Ancef 2 g IV via PICC line and home health administration of IV antibiotics.,DISCHARGE INSTRUCTIONS: , Included keeping the foot elevated with long periods of rest.  The patient is to wear surgical shoe at all times for ambulation and to avoid excessive ambulation.  The patient to keep dressing dry and intact, left foot.  The patient to contact Dr. X for all followup care, if any problems arise.  The patient was given written and oral instruction about wound care before discharge.  Prior to discharge, the patient was noted to be afebrile.  All vitals were stable.  The patient's questions were answered and the patient was discharged in apparent satisfactory condition.  Followup care was given via Dr. X' office.","podiatry, accutane, metatarsal head left foot, abscess with cellulitis, culture and sensitivity, incision and drainage, metatarsal head, foot, cellulitis, ancef, abscess, incision, drainage,"
" Hammertoe deformity, left fifth digit and ulceration of the left fifth digit plantolaterally.  Arthroplasty of the left fifth digit proximal interphalangeal joint laterally and excision of plantar ulceration of the left fifth digit 3 cm x 1 cm in size.", Podiatry, Arthroplasty ,"PREOPERATIVE DIAGNOSES:,1.  Hammertoe deformity, left fifth digit.,2.  Ulceration of the left fifth digit plantolaterally.,POSTOPERATIVE DIAGNOSIS:,1.  Hammertoe deformity, left fifth toe.,2.  Ulceration of the left fifth digit plantolaterally.,PROCEDURE PERFORMED:,1.  Arthroplasty of the left fifth digit proximal interphalangeal joint laterally.,2.  Excision of plantar ulceration of the left fifth digit 3 cm x 1 cm in size.,OPERATIVE PROCEDURE IN DETAIL: , The patient is a 38-year-old female with longstanding complaint of painful hammertoe deformity of her left fifth toe.  The patient had developed ulceration plantarly after being scheduled for removal of a plantar mass in the same area.  The patient elects for surgical removal of this ulceration and correction of her hammertoe deformity at this time.,After an IV was instituted by the Department of Anesthesia, the patient was escorted to the OR where the patient was placed on the Operating Room table in the supine position.  After adequate amount of IV sedation was administered by Anesthesia Department, the patient was given a digital block to the left fifth toe using 0.5% Marcaine plain with 1% lidocaine plain in 1:1 mixture totaling 6 cc.  Following this, the patient was draped and prepped in a normal sterile orthopedic manner.  An ankle tourniquet was placed on the left ankle and the left foot was elevated and Esmarch bandage applied to exsanguinate the foot.  The ankle tourniquet was then inflated to 230 mmHg and then was brought back down to the level of the table.  The stockinette was then cut and reflected and held in place using towel clamp.,The skin was then cleansed using the wet and dry Ray-Tec sponge and then the plantar lesion was outlined.  The lesion measured 1 cm in diameter at the level of the skin and a 3 cm elliptical incision line was drawn on the surface of the skin in the plantolateral aspect of the left fifth digit.  Then using a fresh #15 blade, skin incision was made.  Following this, the incision was then deepened using a fresh #15 blade down to the level of the subcutaneous tissue.  Using a combination of sharp and blunt dissection, the skin was reflected distally and proximally to the lesion.  The lesion appeared well encapsulated with fibrous tissue and through careful dissection using combination of sharp and drill instrumentation the ulceration was removed in its entirety.  The next further exploration was performed to ensure that no residual elements of the fibrous capsular tissue remained within.  The lesion extended from the level of the skin down to the periosteal tissue of the middle and distal phalanx, however, did not show any evidence of extending beyond the level of a periosteum.  Remaining tissues were inspected and appeared healthy.  The lesion was placed in the specimen container and sent to pathology for microanalysis as well as growth.  Attention was then directed to the proximal interphalangeal joint of the left fifth digit and using further dissection with a #15 blade, the periosteum was reflected off the lateral aspect of the proximal ________ median phalanx.  The capsule was also reflected to expose the prominent lateral osseous portion of this joint.  Using a sagittal saw and #139 blade, the lateral osseous prominence was resected.  This was removed in entirety.  Then using power-oscillating rasp, the sharp edges were smoothed and recontoured to the desirable anatomic condition.  Then the incision and wound was flushed using copious amounts of sterile saline with gentamycin.  Following this, the bone was inspected and appeared to be healthy with no evidence of involvement from the removed aforementioned lesion.,Following this, using #4-0 nylon in a combination of horizontal mattress and simple interrupted sutures, the lesion wound was closed and skin was approximated well without tension to the surface skin.  Following this, the incision site was dressed using Owen silk, 4x4s, Kling, and Coban in a normal fashion.  The tourniquet was then deflated and hyperemia was noted to return to digits one through five of the left foot.  The patient was then escorted from the operative table into the Postanesthesia Care Unit.  The patient tolerated the procedure and anesthesia well and was brought to the Postanesthesia Care Unit with vital signs stable and vascular status intact.  In the recovery, the patient was given a surgical shoe as well as given instructions for postoperative care to include rest ice and elevation as well as the patient was given prescription for Naprosyn 250 mg to be taken three times daily as well as Vicodin ES to be taken q.6h. as needed.,The patient will follow-up on Friday with Dr. X in office for further evaluation.  The patient was also given instructions as to signs of infection and to monitor her operative site.  The patient was instructed to keep daily dressings intact, clean, dry, and to not remove them.","podiatry, hammertoe deformity, plantolaterall, ulceration, arthroplasty, plantar ulceration, interphalangeal, painful hammertoe, proximal interphalangeal joint, interphalangeal joint, digit, toe, blade, deformity, incision, hammertoe, lesion"
 Therapeutic recreation initial evaluation.  Patient is a 54-year-old male admitted with diagnosis of CVA with right hemiparesis., Physical Medicine - Rehab, Therapeutic Recreation Initial Evaluation ,"HISTORY:,  Patient is a 54-year-old male admitted with diagnosis of CVA with right hemiparesis.,Patient is currently living in ABC with his son as this was closer his to his job.  At discharge, he will live with his spouse in a new job.  The home is single level with no steps.,Prior to admission, his wife reports that he was independent with all activities.  He was working full time for an oil company.,Past medical history includes hypertension and diabetes, mental status, and dysphagia.,Ability to follow instruction/rules:  Not able to identify cognitive status as of yet.,COMMUNICATION SKILLS: , No initiation of conversation.  He answered 1 yes/no question.,PHYSICAL STATUS:,  Fall/safety.  Aspiration precautions.,Endurance:  Ball activities 4 to 5 minutes.  Restorator 25 minutes.  Standing and rolling type of 3 minutes.,LEISURE LIFESTYLE:,Level of participation/activities involved in:  Reading and housework.,INFORMATION OBTAINED:,  Interview, observation, and chart review.,TREATMENT PLAN:  ,Treatment plan and goals were discussed with patient along with identification of results of FUNCTIONAL ASSESSMENT OF CHARACTERISTICS FOR THERAPEUTIC RECREATION identifying need for intervention in the following problem areas:  Patient scored 10/11 in physical domain due to decreased endurance.  He scored 11/11 in the cognitive and social domain.,Patient will attend 1 session per day focusing on:  Endurance activities.,Patient will attend 1-2 group sessions per week focusing on leisure awareness and postdischarge resources.,GOALS:,PATIENT GOALS: , Not able to identify, but cooperative with all activities.  He answered yes that he enjoyed the restorator.,SHORT TERM GOALS/ONE WEEK GOALS:,1.  Patient to increase tolerance for ball activities to 7 minutes.,2.  Patient provided to use the restorator as he enjoys and it is good for endurance.,LONG TERM GOALS:,  Patient to increase standing tolerance, standing leisure activities to 7 to 10 minutes.,Patient has concurred with the above treatment planning goals.","physical medicine - rehab, endurance, ball activities, therapeutic recreation, hemiparesis, tolerance, recreation, restorator, leisure, therapeutic, "
 Status post brain tumor removal.   The patient is a 64-year-old female referred to physical therapy following complications related to brain tumor removal.  She had a brain tumor removed and had left-sided weakness.  , Physical Medicine - Rehab, Physical Therapy - Brain Tumor Removal ,"DIAGNOSIS:,  Status post brain tumor removal.,HISTORY:,  The patient is a 64-year-old female referred to physical therapy following complications related to brain tumor removal.  The patient reports that on 10/24/08 she had a brain tumor removed and had left-sided weakness.  The patient was being seen in physical therapy from 11/05/08 to 11/14/08 then she began having complications.  The patient reports that she was admitted to Hospital on 12/05/08.  At that time, they found massive swelling on the brain and a second surgery was performed.  The patient then remained in acute rehab until she was discharged to home on 01/05/09.  The patient's husband, Al, is also present and he reports that during rehabilitation the patient did have a DVT in the left calf that has since been resolved.,PAST MEDICAL HISTORY: , Unremarkable.,MEDICATIONS:  ,Coumadin, Keppra, Decadron, and Glucophage.,SUBJECTIVE: , The patient reports that the pain is not an issue at this time.  The patient states that her primary concern is her left-sided weakness as related to her balance and her walking and her left arm weakness.,PATIENT GOAL:  ,To increase strength in her left leg for better balance and walking.,OBJECTIVE:,RANGE OF MOTION:  Bilateral lower extremities are within normal limits.,STRENGTH:  Bilateral lower extremities are grossly 5/5 with one repetition, except left hip reflexion 4+/5.,BALANCE:  The patient's balance was assessed with a Berg balance test.  The patient has got 46/56 points, which places her at moderate risk for falls.,GAIT:  The patient ambulates with contact guard assist.  The patient ambulates with a reciprocal gait pattern with good bilateral foot clearance.  However, the patient has been reports that with increased fatigue, left footdrop tends to occur.  A 6-minute walk test will be performed at the next visit due to time constraints.,ASSESSMENT: , The patient is a 64-year-old female referred to Physical Therapy status post brain surgery.  Examination indicates deficits in strength, balance, and ambulation.  The patient will benefit from skilled physical therapy to address these impairments.,TREATMENT PLAN: , The patient will be seen three times per week for 4 weeks and then reduce it to two times per week for 4 additional weeks.  Interventions include:,1.  Therapeutic exercise.,2.  Balance training.,3.  Gait training.,4.  Functional mobility training.,SHORT TERM GOAL TO BE COMPLETED IN 4 WEEKS:,1.  The patient is to tolerate 30 repetitions of all lower extremity exercises.,2.  The patient is to improve balance with a score of 50/56 points.,3.  The patient is to ambulate 1000 feet in a 6-minute walk test with standby assist.,LONG TERM GOAL TO BE ACHIEVED IN 8 WEEKS:,1.  The patient is to ambulate independently within her home and standby to general supervision within the community.,2.  Berg balance test to be 52/56.,3.  The patient is to ambulate a 6-minute walk test for 1500 feet independently including safe negotiation of corners and busy areas.,4.  The patient is to demonstrate safely stepping over and around objects without loss of balance.,Prognosis for the above-stated goals is good.  The above treatment plan has been discussed with the patient and her husband.  They are in agreement.",
" Ankle sprain, left ankle.  The patient tripped over her dog toy and fell with her left foot inverted.  The patient states that she received a series of x-rays and MRIs that were unremarkable.  After approximately 1 month, the patient continued to have significant debilitating pain in her left ankle.  She then received a walking boot and has been in the boot for the past month.", Physical Medicine - Rehab, Physical Therapy - Ankle Sprain ,"DIAGNOSIS: , Ankle sprain, left ankle.,HISTORY: , The patient is a 31-year-old female who was referred to Physical Therapy secondary to a fall on 10/03/08.  The patient states that she tripped over her dog toy and fell with her left foot inverted.  The patient states that she received a series of x-rays and MRIs that were unremarkable.  After approximately 1 month, the patient continued to have significant debilitating pain in her left ankle.  She then received a walking boot and has been in the boot for the past month.,PAST MEDICAL HISTORY: , Significant for hypertension, asthma, and cervical cancer.  The cervical cancer was diagnosed as 15 years old.  The patient states that her cancer is ""dormant."",MEDICATIONS:,1.  Hydrochlorothiazide.,2.  Lisinopril.,3.  Percocet.,The patient states that the Percocet helps to take the edge of her pain, but does not completely eliminate it.,SUBJECTIVE: , The patient rates the pain at 2/10 on the pain analog scale.  The patient states that with elevation and rest, her pain subsides.,FUNCTIONAL ACTIVITIES/HOBBIES: , Currently limited including basic household chores and activities, this does increases her pain.  The patient states she also recently joined Weight Watchers and was involved in a walking routine and is currently unable to participate in this activity.,WORK STATUS: , The patient is currently on medical leave as a paraprofessional.  The patient states that she works as a teacher's aide in the school system and is required to complete extensive walking and standing activities.  The patient states that she is primarily on her feet while at work and rarely has a sitting break for extensive period of time.  The patient's goal is to be able to stand and walk without pain.,SOCIAL HISTORY:  ,The patient lives in a private home with children and her father.  The patient states that she does have stairs to negotiate without the use of a railing.  She states that she is able to manage the stairs, however, is very slow with her movement.  The patient smokes 1-1/2 packs of cigarettes a day and does not have a history of regular exercise routine.,OBJECTIVE: , Upon observation, the patient is a very obese female who is ambulating with significant antalgic gait pattern and altered normal gait due to the pain as well as the walking boot.  Upon inspection of the left ankle, it appears to have swelling, unsure if this swelling is secondary to injury or water retention as the patient states she has significant water retention.  When compared to right ankle edema, it is approximately equal.  There is no evidence of discoloration or temperature.  The patient states that she had no bruising at the time of injury.,Active range of motion of left ankle is as follows:  Dorsiflexion is 6 degrees past neutral and plantar flexion is 54 degrees, eversion 20 degrees, and inversion is 30 degrees.  Left ankle dorsiflexion lacks 10 degrees from neutral and plantar flexion is 36 degrees, this motion is very painful.  The patient was tearful during this activity.  Eversion is 3 degrees and inversion is 25 degrees.  The patient states this movement was difficult, but not painful.  Strength testing of the right lower extremity is grossly 4+-5/5 and left ankle is 2/5 as the patient is unable to obtain full range of motion.,PALPATION: , The patient is very tender to palpation primarily along the lateral malleolus of the left ankle.,JOINT PLAY: , Unable to be assessed secondary to the patient's extreme tenderness and guarding of the ankle joint.,SPECIAL TESTS:,  A 6-minute walk test.  The patient was able to ambulate approximately 600 feet while wearing her walking boot prior to her pain significantly increasing in the ankle and requiring the test to be stopped.,ASSESSMENT:  ,The patient would benefit from skilled physical therapy intervention as a trial of treatment in order to address the following problem list:,1.  Increased pain.,2.  Decreased range of motion.,3.  Decreased strength.,4.  Decreased ability to complete work task and functional activities in the home.,5.  Decreased gait pattern.,SHORT-TERM GOALS TO BE COMPLETED IN 3 WEEKS:,1.  The patient will demonstrate independence with home exercise program.,2.  The patient will ambulate without her boot for 48 hours in order to decrease reliance upon the boot for ankle stabilization.,3.  The patient will achieve left ankle dorsiflexion to neutral and plantar flexion to 45 degrees without significant increase in pain.,4.  The patient will demonstrate 3/5 strength of the left ankle.,5.  The patient will tolerate the completion of the 6-minute walk test without the use of a boot with minimal increase in pain.,LONG-TERM GOALS TO BE COMPLETED IN 6 WEEKS:,1.  The patient will report 0/10 pain in the 48-hour period without the use of medication and without wearing her boot.,2.  The patient will return to go through the work without the use of the walking boot with report of minimal increase in pain and discomfort.,PROGNOSIS:,  Fair for above-stated goals with full compliance to home exercise program and therapy treatment as well as the patient motivation.,PLAN: , The patient to be seen three times a week for 6 weeks for the following:",
" The patient is a 58-year-old female, referred to therapy due to left knee osteoarthritis.  The patient states that approximately 2 years ago, she fell to the ground and thereafter had blood clots in the knee area.  The patient was transferred from the hospital to a nursing home and lived there for 1 year.  The patient states that her primary concern is her left knee pain and they desire to walk short distances again in her home.", Physical Medicine - Rehab, Physical Therapy - Osteoarthritis ,"DIAGNOSIS: , Left knee osteoarthritis.,HISTORY: , The patient is a 58-year-old female, referred to therapy due to left knee osteoarthritis.  The patient states that approximately 2 years ago, she fell to the ground and thereafter had blood clots in the knee area.  The patient was transferred from the hospital to a nursing home and lived there for 1 year.  Prior to this incident, the patient was ambulating independently with a pickup walker throughout her home.  Since that time, the patient has only been performing transverse and has been unable to ambulate.  The patient states that her primary concern is her left knee pain and they desire to walk short distances again in her home.,PAST MEDICAL HISTORY: , High blood pressure, obesity, right patellar fracture with pin in 1990, and history of blood clots.,MEDICATIONS:  ,Naproxen, Plavix, and stool softener.,MEDICAL DIAGNOSTICS: , The patient states that she had an x-ray of the knee in 2007 and was diagnosed with osteoarthritis.,SUBJECTIVE:,  The patient reports that when seated and at rest, her knee pain is 0/10.  The patient states that with active motion of the left knee, the pain in the anterior portion increases to 5/10.,PATIENT'S GOAL: , To transfer better and walk 5 feet from her bed to the couch.,INSPECTION: , The right knee has a large 8-inch long and very wide tight scar with adhesions to the underlying connective tissue due to her patellar fracture and surgery following an MVA in 1990, bilateral knees are very large due to obesity.  There are no scars, bruising or increased temperature noted in the left knee.,RANGE OF MOTION: , Active and passive range of motion of the right knee is 0 to 90 degrees and the left knee, 0 to 85 degrees.  Pain is elicited during active range of motion of the left knee.,PALPATION: , Palpation to the left knee elicits pain around the patellar tendon and to each side of this area.,FUNCTIONAL MOBILITY:  ,The patient reports that she transfers with standby to contact-guard assist in the home from her bed to her wheelchair and return.  The patient is able to stand modified independent from wheelchair level and tolerates at least 15 seconds of standing prior to needing to sit down due to the left knee pain.,ASSESSMENT:  ,The patient is a 58-year-old female with left knee osteoarthritis.  Examination indicates deficits in pain, muscle endurance, and functional mobility.  The patient would benefit from skilled physical therapy to address these impairments.,TREATMENT PLAN:  ,The patient will be seen two times per week for an initial 4 weeks with re-assessment at that time for an additional 4 weeks if needed.,INTERVENTIONS INCLUDE:,1.  Modalities including electrical stimulation, ultrasound, heat, and ice.,2.  Therapeutic exercise.,3.  Functional mobility training.,4.  Gait training.,LONG-TERM GOALS TO BE ACHIEVED IN 4 WEEKS:,1.  The patient is to have increased endurance in bilateral lower extremities as demonstrated by being able to perform 20 repetitions of all lower extremity exercises in seated and supine positions with minimum 2-pound weight.,2.  The patient is to perform standby assist transfer using a pickup walker.,3.  The patient is to demonstrate 4 steps of ambulation using forward and backward using a pickup walker or front-wheeled walker.,4.  The patient is to report maximum 3/10 pain with weightbearing of 2 minutes in the left knee.,LONG-TERM GOALS TO BE ACHIEVED IN 8 WEEKS:,1.  The patient is to be independent with the home exercise program.,2.  The patient is to tolerate 20 reps of standing exercises with pain maximum of 3/10.,3.  The patient is to ambulate 20 feet with the most appropriate assistive device.,PROGNOSIS TO THE ABOVE-STATED GOALS:,  Fair to good.,The above treatment plan has been discussed with the patient.  She is in agreement.",
" The patient is a 26-year-old female, referred to Physical Therapy for low back pain.  The patient has a history of traumatic injury to low back.", Physical Medicine - Rehab, Physical Therapy - Low Back Pain  ,"HISTORY OF PRESENT ILLNESS: , The patient is a 26-year-old female, referred to Physical Therapy for low back pain.  The patient has a history of traumatic injury to low back.  The patient stated initial injury occurred eight years ago, when she fell at a ABC Store.  The patient stated she received physical therapy, one to two visits and received modality treatment only, specifically electrical stimulation and heat pack per patient recollection.  The patient stated that she has had continuous low-back pain at varying degrees for the past eight years since that fall.  The patient gave birth in August 2008 and since the childbirth, has experienced low back pain.  The patient also states that she fell four to five days ago, while mopping her floor.  The patient stated that she landed on her tailbone and symptoms have increased since that fall.  The patient stated that her initial physician examination with Dr. X was on 01/10/09, and has a followup appointment on 02/10/09.,PAST MEDICAL HISTORY: , The patient denies high blood pressure, diabetes, heart disease, lung disease, thyroid, kidney, or bladder dysfunctions.  The patient stated that she quit smoking prior to her past childbirth and is currently not pregnant.  The patient has had a C-section and also an appendectomy.  The patient was involved in a motor vehicle accident four to five years ago and at that time, the patient did not require any physical therapy nor did she report any complaints of increased back pain following that accident.,MEDICATIONS: , Patient currently states she is taking:,1.  Vicodin 500 mg two times a day.,2.  Risperdal.,3.  Zoloft.,4.  Stool softeners.,5.  Prenatal pills.,DIAGNOSTIC IMAGERY:  ,The patient states she has not had an MRI performed on her lumbar spine.  The patient also states that Dr. X took x-rays two weeks ago, and no fractures were found at that time.  Per physician note, dated 12/10/08, Dr. X dictated that the x-ray showed an anterior grade 1 spondylolisthesis of L5 over S1, and requested Physical Therapy to evaluate and treat.,SUBJECTIVE:  ,The patient states that pain is constant in nature with a baseline of 6-7/10 with pain increasing to 10/10 during the night or in cold weather.  The patient states that pain is dramatically less, when the weather is warmer.  The patient also states that pain worsens as the day progresses, in that she also hard time getting out of bed in the morning.  The patient states that she does not sleep at night well and sleeps less than one hour at a time.,Aggravating factors include, sitting for periods greater than 20 minutes or lying supine on her back.  Easing factors include side lying position in she attempts to sleep.,OBJECTIVE: , AGE:  26 years old.  HEIGHT:  5 feet 2 inches.  WEIGHT:  The patient is an obese 26-year-old female.,ACTIVE RANGE OF MOTION: , Lumbar spine, flexion, lateral flexion and rotation all within functional limits without complaints of pain or soreness while performing them during evaluation.,PALPATION:  ,The patient complained of bilateral SI joint point tenderness.  The patient also complained of left greater trochanter hip point tenderness.  The patient also complained of bilateral paraspinal tenderness on cervical spine to lumbar spine.,STRENGTH:  ,RIGHT LOWER EXTREMITY:,Knee extension 5/5, hip flexion 5/5, knee flexion 4/5, internal and external hip rotation was 4/5.  With manual muscle testing of knee flexion, hip, internal and external rotation, the patient reports an increase in right SI joint pain to 8/10.,LEFT LOWER EXTREMITY:,Hip flexion 5/5, knee extension 5/5, knee flexion 4/5, hip internal and external rotation 4/5, with slight increase in pain level with manual muscle testing and resistance.  It must be noted that PT did not apply as much resistance during manual muscle testing, secondary to the 8/10 pain elicited during the right lower extremity.,NEUROLOGICAL:  ,The patient subjectively complains of numbness with tingling in her bilateral extremities when she sits longer than 25 minutes.  However, they subside when she stands.  The patient did complain of this numbness and tingling during the evaluation and the patient was seated for a period of 20 minutes.  Upon standing, the patient stated that the numbness and tingling subsides almost immediately.  The patient stated that Dr. X told her that he believes that during her past childbirth when the epidural was being administered that there was a possibility that a sensory nerve may have been also affected during the epidural less causing the numbness and tingling in her bilateral lower extremities.  The patient does not demonstrate any sensation deficits with gentle pressure to the lumbar spine and during manual muscle testing.,GAIT:  ,The patient ambulated out of the examination room, while carrying her baby in a car seat.,ASSESSMENT:  ,The patient is a 26-year-old overweight female, referred to Physical Therapy for low back pain.  The patient presents with lower extremity weakness, which may be contributing to her lumbosacral pain, in that she has poor lumbar stabilization with dynamic ADLs, transfers, and gait activity when fatigued.  At this time, the patient may benefit from skilled physical therapy to address her decreased strength and core stability in order to improve her ADL, transfer, and mobility skills.,PROGNOSIS: , The patient's prognosis for physical therapy is good for dictated goals.,SHORT-TERM GOALS TO BE ACHIEVED IN TWO WEEKS:,1.  The patient will be able to sit for greater than 25 minutes without complaints of paraesthesia or pain in her bilateral lower extremities or bilateral SI joints.,2.  The patient will increase bilateral hip internal and external rotation to 4/5 with SI joint pain less than or equal to 5/10.,3.  The patient will report 25% improvement in her functional and ADL activities.,4.  Pain will be less than 4/10 while performing __________ while at PT session.,LONG-TERM GOALS TO BE ACCOMPLISHED IN ONE MONTH:,1.  The patient will be independent with home exercise program.,2.  Bilateral hamstring, bilateral hip internal and external rotation strength to be 4+/5 with SI joint pain less than or equal to 2/10, while performing manual muscle test.,3.  The patient will report 60% improvement or greater in functional transfers in general ADL activity.,4.  The patient will be able to sit greater than or equal to 45 minutes without complaint of lumbosacral pain.,5.  The patient will be able to sleep greater than 2 hours without pain.,TREATMENT PLAN:,1.  Therapeutic exercises to increase lower extremity strength and assist with lumbar sacral stability.",
" Patient was referred to Physical Therapy, secondary to low back pain and degenerative disk disease.  The patient states she has had a cauterization of some sort to the nerves in her low back to help alleviate with painful symptoms.  The patient would benefit from skilled physical therapy intervention.", Physical Medicine - Rehab, Physical Therapy - Back Pain ,"DIAGNOSIS: , Low back pain and degenerative lumbar disk.,HISTORY:,  The patient is a 59-year-old female, who was referred to Physical Therapy, secondary to low back pain and degenerative disk disease.  The patient states she has had a cauterization of some sort to the nerves in her low back to help alleviate with painful symptoms.  The patient states that this occurred in October 2008 as well as November 2008.  The patient has a history of low back pain, secondary to a fall that originally occurred in 2006.  The patient states that she slipped on a newly waxed floor and fell on her tailbone and low back region.  The patient then had her second fall in March 2006.  The patient states that she was qualifying on the range with a handgun and lost her footing and states that she fell more due to weakness in her lower extremities rather than loss of balance.,PAST MEDICAL HISTORY:,  Past medical history is significant for allergies and thyroid problems.,PAST SURGICAL HISTORY: , The patient has a past surgical history of appendectomy and hysterectomy.,MEDICATIONS:,1.  TriCor.,2.  Vytorin.,3.  Estradiol.,4.  Levothyroxine.,5.  The patient is also taking ibuprofen 800 mg occasionally as needed for pain management.  The patient states she rarely takes this and does not like to take pain medication if at all possible.  The patient states that she has had uncomplicated pregnancies in the past.,SOCIAL HISTORY:,  The patient states she lives in a single-level home with her husband, who is in good health and is able to assist with any tasks or activities the patient is having difficulty with.  The patient rates her general health as excellent and denies any smoking and reports very occasional alcohol consumption.  The patient does state that she has completed exercises on a daily basis of one to one and a half hours a day.  However, has not been able to complete these exercise routine since approximately June 2008, secondary to back pain.  The patient is working full-time as a project manager, and is required to do extensive walking at various periods during a workday.,MEDICAL IMAGING:,  The patient states that she has had an MRI recently performed; however, the results are not available at the time of the evaluation.  The patient states she is able to bring the report in upon next visit.,SUBJECTIVE:  ,The patient rates her pain at 7/10 on a Pain Analog Scale, 0 to 10, 10 being worse.  The patient describes her pain as a deep aching, primarily on the right lower back and gluteal region.  Aggravating factors include stairs and prolonged driving, as well as general limitations with home tasks and projects.  The patient states she is a very active individual and is noticing extreme limitations with ability to complete home tasks and projects she used to be able to complete.,NEUROLOGICAL SYMPTOMS:,  The patient reports having occasional shooting pains into the lower extremities.  However, these are occurring less frequently and is now occurring more frequently in the right versus the left lower extremity when they do occur.,FUNCTIONAL ACTIVITIES AND HOBBIES: , Include exercising and general activities.,PATIENT'S GOAL: , The patient would like to improve her overall body movements and return to daily exercise routine as able and well maintaining safety.,OBJECTIVE: , Upon observation, the patient ambulates independently without the use of assistive device.  However, does present with mild limp and favoring the left lower extremity after extensive standing and walking activity.  The patient does have mild difficulty transferring from the seated position to standing.  However, once is upright, the patient denies any increased pain or symptoms.,ACTIVE RANGE OF MOTION OF LUMBAR SPINE:  ,Forward flexion is 26 cm, fingertip to floor, lateral side bend, fingertip to floor is 52.5 cm bilaterally.,STRENGTH: , Strength is grossly 4/5.  The patient denies any significant tenderness to palpation.  However, does have mild increase in tenderness on the right versus left.  A six-minute walk test revealed painful symptoms and achiness occurring after approximately 400 feet of walking.  The patient was able to continue; however, stopped after 700 feet.  There were two minutes remaining in the six-minute walk test.  The patient does have tight hamstrings as well as a negative slump test.,ASSESSMENT: , The patient would benefit from skilled physical therapy intervention in order to address the following problem list.,PROBLEM LIST:,1.  Increased pain.,2.  Decreased ability to complete tasks and hobbies.,3",
" Synovitis - anterior cruciate ligament tear of the left knee.  The patient is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain.   The patient fell in a grocery store.  He reports slipping on a grape that was on the floor. ", Physical Medicine - Rehab, Physical Therapy - Synovitis ,"DIAGNOSIS:,  Synovitis/anterior cruciate ligament tear of the left knee.,HISTORY: , The patient is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain.  The patient states that on 10/02/08, the patient fell in a grocery store.  He reports slipping on a grape that was on the floor.  The patient states he went to the emergency room and then followed up with his primary care physician.  The patient was then ultimately referred to Physical Therapy.  After receiving a knee brace, history and information was received through a translator as the patient is Spanish speaking only.,PAST MEDICAL HISTORY: , Past medical history is unremarkable.,MEDICAL IMAGING: , Medical imaging is significant for x-rays and MRIs.  The report was available at the time of the evaluation.  The patient reports abnormal posterior horn of medial meniscus consistent with knee degenerative change and possibly tears.,MEDICATIONS:,1.  Tramadol.,2.  Diclofenac.,3.  Advil.,4.  Tylenol.,SUBJECTIVE: , The patient rates his pain at 6/10 on the Pain Analog Scale, primarily with ambulation.  The patient does deny pain at night.  The patient does present with his knee brace on the exterior of his __________ leg and appears to be on backboard.,FUNCTIONAL ACTIVITIES AND HOBBIES:  ,Functional activities and hobbies that are currently limited include any work as the patient is currently unemployed and is looking for a job; however, his primary skills are of a laborer and a street broker for new homes.,OBJECTIVE:  ,Upon observation, the patient is ambulating with a significant antalgic gait pattern.  However, he is not using any assistive device.  The knee brace was corrected and the patient and his wife demonstrated understanding and knowledge of how to place the knee brace on correctly.,ACTIVE RANGE OF MOTION: , Active range of motion of the left knee is 0 to 105 degrees with pain during range of motion.  Right knee active range of motion is 0 to 126 degrees.,STRENGTH:  ,Strength is 3/5 for left knee, 4+/5 for right knee.  The patient denies any pain upon light and deep palpation at the knee joints.  There is no evidence of temperature change, increased swelling or any discoloration at the left knee joint.  The patient does not appear to have instability at this time with formal tests at the left knee joint.,SPECIAL TESTS:  ,The patient performed a six-minute walk test.  He was able to complete 600 feet; however, had to stop this test at approximately five minutes, secondary to significant increase in pain.,ASSESSMENT:,  The patient would benefit from skilled physical therapy intervention in order to address the following problem list:,1.  Increased pain.,2.  Decreased range of motion.,3.  Decreased strength.,4.  Decreased ability to perform functional activities and work tasks.,5.  Decreased ambulation tolerance.,SHORT-TERM GOALS TO BE COMPLETED IN THREE WEEKS:,1.  Patient will demonstrate independence with the home exercise program.,2.  Patient will report maximum pain of 2/10 on a Pain Analog Scale within a 24-hour period.,3.  The patient will demonstrate left knee active range of motion, 0 to 120 degrees, without significant increase in pain during motion.,4.  The patient will demonstrate 4/5 strength for the left knee.,5.  The patient will complete 800 feet in a six-minute walk test without significant increase in pain.,LONG-TERM GOALS TO BE COMPLETED IN SIX WEEKS:,1.  The patient will demonstrate bilateral knee active range of motion, 0 to 130 degrees.,2.  The patient will demonstrate 5/5 lower extremity strength bilaterally without significant increase in pain.,3.  Patient will complete 1000 feet in a six-minute walk test without increase in pain and tolerate full completion of the six minutes.,4.  The patient will improve confidence with ability to perform work activity, when the situation improves and resolves.,PROGNOSIS:  ,Prognosis is good for above-stated goals, with compliance to a home exercise program and treatment.,SESSION PLAN: , The patient to be seen two to three times a week for six weeks for the following:,1.  Therapeutic exercise with home exercise program.",
" Outpatient rehabilitation physical therapy progress note.  A 52-year-old male referred to physical therapy secondary to chronic back pain, weakness, and debilitation secondary to chronic pain. ", Physical Medicine - Rehab, Physical Therapy - Outpatient Rehab ,"SUMMARY:  ,The patient has attended physical therapy from 11/16/06 to 11/21/06.  The patient has 3 call and cancels and 3 no shows.  The patient has been sick for several weeks due to a cold as well as food poisoning, so has missed many appointments.,SUBJECTIVE:  ,The patient states pain still significant, primarily 1st seen in the morning.  The patient was evaluated 1st thing in the morning and did not take his pain medications, so objective findings may reflect that.  The patient states overall functionally he is improving where he is able to get out in the house and visit and do activities outside the house more.  The patient does feel like he is putting on more muscle girth as well.  The patient states he is doing well with his current home exercise program and feels like pool therapy is also helping as well.,OBJECTIVE: , Physical therapy has consisted of:,1.  Pool therapy incorporating endurance and general lower and upper extremity strengthening.,2.  Clinical setting incorporating core stabilization and general total body strengthening and muscle wasting.,3.  The patient has just begun this, so it is on a very beginners level at this time.,ASSESSMENT, DONE ON 12/21/06,STRENGTH,Activities",
 Status post left hip fracture and hemiarthroplasty.   Rehab transfer as soon as medically cleared., Physical Medicine - Rehab, Hip Fracture - Rehab Consult ,"ADMISSION DIAGNOSIS: , Left hip fracture.,CHIEF COMPLAINT: , Diminished function, secondary to the above.,HISTORY: , This pleasant 70-year-old gentleman had a ground-level fall at home on 05/05/03 and was brought into ABCD Medical Center, evaluated by Dr. X and brought in for orthopedic stay.  He had left hip fracture identified on x-rays at that time.  Pain and inability to ambulate brought him in.  He was evaluated and then underwent medical consultation as well, where they found a history of resolving pneumonia, hypertension, chronic obstructive pulmonary disease, congestive heart failure, hypothyroidism, depression, anxiety, seizure and chronic renal failure, as well as anemia.  His medical issues are under good control.  The patient underwent left femoral neck fixation with hemiarthroplasty on that left side on 05/06/03.  The patient has had some medical issues including respiratory insufficiency, perioperative anemia, pneumonia, and hypertension.  Cardiology has followed closely, and the patient has responded well to medical treatment, as well as physical therapy and occupational therapy.  He is gradually tolerating more activities with less difficulties, made good progress and tolerated more consistent and more prolonged interventions.,PAST MEDICAL HISTORY: , Positive for congestive heart failure, chronic renal insufficiency, azotemia, hyperglycemia, coronary artery disease, history of paroxysmal atrial fibrillation.  Remote history of subdural hematoma precluding the use of Coumadin.  History of depression, panic attacks on Doxepin.  Perioperative anemia.  Swallowing difficulties.,ALLERGIES:,  Zyloprim, penicillin, Vioxx, NSAIDs.,CURRENT MEDICATIONS,1.  Heparin.,2.  Albuterol inhaler.,3.  Combivent.,4.  Aldactone.,5.  Doxepin.,6.  Xanax.,7.  Aspirin.,8.  Amiodarone.,9.  Tegretol.,10.  Synthroid.,11.  Colace.,SOCIAL HISTORY: , Lives in a 1-story home with 1 step down; wife is there.  Speech and language pathology following with current swallowing dysfunction.  He is minimum assist for activities of daily living, bed mobility.,REVIEW OF SYSTEMS:,  Currently negative for headache, nausea and vomiting, fevers, chills or shortness of breath or chest pain.,PHYSICAL EXAMINATION,HEENT:  Oropharynx clear.,CV:  Regular rate and rhythm without murmurs, rubs or gallops.,LUNGS:  Clear to auscultation bilaterally.,ABDOMEN:  Nontender, nondistended.  Bowel sounds positive.,EXTREMITIES:  Without clubbing, cyanosis, or edema.,NEUROLOGIC:  There are no focal motor or sensory losses to the lower extremities.  Bulk and tone normal in the lower extremities.  Wound site has healed well with staples out.,IMPRESSION ,1.  Status post left hip fracture and hemiarthroplasty.,2.  History of panic attack, anxiety, depression.,3.  Myocardial infarction with stent placement.,4.  Hypertension.,5.  Hypothyroidism.,6.  Subdural hematoma.,7.  Seizures.,8.  History of chronic obstructive pulmonary disease.  Recent respiratory insufficiency.,9.  Renal insufficiency.,10.  Recent pneumonia.,11.  O2 requiring.,12.  Perioperative anemia.,PLAN: , Rehab transfer as soon as medically cleared.",
 Encephalopathy related to normal-pressure hydrocephalus., Physical Medicine - Rehab, Encephalopathy  - Rehab Consult  ,"ADMITTING DIAGNOSIS: , Encephalopathy related to normal-pressure hydrocephalus.,CHIEF COMPLAINT:,  Diminished function secondary to above.,HISTORY:  ,This pleasant gentleman was recently admitted to ABCD Medical Center and followed by the neurosurgical staff, including Dr. X, where normal-pressure hydrocephalus was diagnosed.  He had a shunt placed and was stabilized medically.  He has gotten a return of function to the legs and was started on some early therapy.  Significant functional limitations have been identified and ongoing by the rehab admission team.  Significant functional limitations have been ongoing.  He will need to be near-independent at home for periods of time, and he is brought in now for rehabilitation to further address functional issues, maximize skills and safety and allow a safe disposition home.,PAST MEDICAL HISTORY: , Positive for prostate cancer, intermittent urinary incontinence and left hip replacement.,ALLERGIES: , No known drug allergies.,CURRENT MEDICATIONS,1.  Tylenol as needed.  ,2.  Peri-Colace b.i.d.,SOCIAL HISTORY:,  He is a nonsmoker and nondrinker.  Prior boxer.  He lives in a home where he would need to be independent during the day.  Family  relatives intermittently available.  Goal is to return home to an independent fashion to that home setting.,FUNCTIONAL HISTORY: , Prior to admission was independent with activities of daily living and ambulatory skills.  Presently, he has resumed therapies and noted to have supervision levels for most activities of daily living.  Memory at minimal assist.  Walking at supervision., REVIEW OF SYSTEMS:  ,Negative for headaches, nausea, vomiting, fevers, chills, shortness of breath or chest pain currently.  He has had some dyscoordination recently and headaches on a daily basis, most days, although the Tylenol does seem to control that pain.,PHYSICAL EXAMINATION,VITAL SIGNS:  The patient is afebrile with vital signs stable.,HEENT:  Oropharynx clear, extraocular muscles are intact.,CARDIOVASCULAR:  Regular rate and rhythm, without murmurs, rubs or gallops.,LUNGS:  Clear to auscultation bilaterally.,ABDOMEN:  Nontender, nondistended,  positive bowel sounds.,EXTREMITIES:  Without clubbing, cyanosis, or edema.  The calves are soft and nontender bilaterally.,NEUROLOGIC:  No focal, motor or sensory losses through the lower extremities.  He moves upper and lower extremities well.  Bulk and tone normal in the upper and lower extremities.  Cognitively showing intact with appropriate receptive and expressive skills.,IMPRESSION ,",
 Nerve conduction screen demonstrates borderline median sensory and borderline distal median motor responses in both hands.   The needle EMG examination is remarkable for rather diffuse active denervation changes in most muscles of the right upper and right lower extremity tested., Physical Medicine - Rehab, EMG/Nerve Conduction Study - 9 ,"NERVE CONDUCTION TESTING AND EMG EVALUATION,1.  Right median sensory response 3.0, amplitude 2.5, distance 100.,2.  Right ulnar sensory response 2.1, amplitude 1, distance 90.,3.  Left median sensory response 3.0, amplitude 1.2, distance 100.,4.  Left median motor response distal 4.2, proximal 9, amplitude 2.2, distance 290, velocity 60.4 m/sec.,5.  Right median motor response distal 4.3, proximal 9.7, amplitude 2, and velocity 53.7 m/sec.,6.  Right ulnar motor response distal 2.5, proximal 7.5, amplitude 2, distance 300, velocity 60 m/sec.,NEEDLE EMG TESTING,1.  ,RIGHT BICEPS:,  Fibrillations 0, fasciculations occasional, positive waves 0.  Motor units, increased needle insertional activity and mild decreased number of motor units firing.,2.  ,RIGHT TRICEPS:,  Fibrillations 1+, fasciculations occasional to 1+, positive waves 1+.  Motor units, increased needle insertional activity and decreased number of motor units firing.,3.  ,EXTENSOR DIGITORUM:,  Fibrillations 0, fasciculations rare, positive waves 0, motor units probably normal.,4.  ,FIRST DORSAL INTEROSSEOUS: , Fibrillations 2+, fasciculations 1+, positive waves 2+.  Motor units, decreased number of motor units firing.,5.  ,RIGHT ABDUCTOR POLLICIS BREVIS:,  Fibrillations 1+, fasciculations 1+, positive waves 0.  Motor units, decreased number of motor units firing.,6. , FLEXOR CARPI ULNARIS:,  Fibrillations 1+, occasionally entrained, fasciculations rare, positive waves 1+.  Motor units, decreased number of motor units firing.,7.  ,LEFT FIRST DORSAL INTEROSSEOUS:,  Fibrillations 1+, fasciculations 1+, positive waves occasional.  Motor units, decreased number of motor units firing.,8.  ,LEFT EXTENSOR DIGITORUM:,  Fibrillations 1+, fasciculations 1+.  Motor units, decreased number of motor units firing.,9.  ,RIGHT VASTUS MEDIALIS:,  Fibrillations 1+ to 2+, fasciculations 1+, positive waves 1+.  Motor units, decreased number of motor units firing.,10.  ,ANTERIOR TIBIALIS: , Fibrillations 2+, occasionally entrained, fasciculations 1+, positive waves 1+.  Motor units, increased proportion of polyphasic units and decreased number of motor units firing.  There is again increased needle insertional activity.,11.  ,RIGHT GASTROCNEMIUS:,  Fibrillations 1+, fasciculations 1+, positive waves 1+.  Motor units, marked decreased number of motor units firing.,12.  ,LEFT GASTROCNEMIUS:,  Fibrillations 1+, fasciculations 1+, positive waves 2+.  Motor units, marked decreased number of motor units firing.,13.  ,LEFT VASTUS MEDIALIS: , Fibrillations occasional, fasciculations occasional, positive waves 1+.  Motor units, decreased number of motor units firing.,IMPRESSION: ",
" Occupational therapy discharge summary.  Traumatic brain injury, cervical musculoskeletal strain.", Physical Medicine - Rehab, Occupational Therapy Discharge Summary ,"DIAGNOSES: , Traumatic brain injury, cervical musculoskeletal strain.,DISCHARGE SUMMARY: , The patient was seen for evaluation on 12/11/06 followed by 2 treatment sessions.  Treatment consisted of neuromuscular reeducation including therapeutic exercise to improve range of motion, strength, and coordination; functional mobility training; self-care training; cognitive retraining; caregiver instruction; and home exercise program.  Goals were not achieved, as the patient was admitted to inpatient rehabilitation center.,RECOMMENDATIONS: , Discharged from OT this date, as the patient has been admitted to Inpatient Rehabilitation Center.,Thank you for this referral.","physical medicine - rehab, musculoskeletal strain, occupational therapy, traumatic, brain, cervical, musculoskeletal, rehabilitation,"
 Patient with a past medical history of a left L5-S1 lumbar microdiskectomy with complete resolution of left leg symptoms., Physical Medicine - Rehab, EMG/Nerve Conduction Study - 6 ,"HISTORY:,  The patient is a 46-year-old right-handed gentleman with a past medical history of a left L5-S1 lumbar microdiskectomy in 1998 with complete resolution of left leg symptoms, who now presents with a four-month history of gradual onset of right-sided low back pain with pain radiating down into his buttock and posterior aspect of his right leg into the ankle.  Symptoms are worsened by any activity and relieved by rest.  He also feels that when the pain is very severe, he has some subtle right leg weakness.  No left leg symptoms.  No bowel or bladder changes.,On brief examination, full strength in both lower extremities.  No sensory abnormalities.  Deep tendon reflexes are 2+ and symmetric at the patellas and absent at both ankles.  Positive straight leg raising on the right.,MRI of the lumbosacral spine was personally reviewed and reveals a right paracentral disc at L5-S1 encroaching upon the right exiting S1 nerve root.,NERVE CONDUCTION STUDIES:,  Motor and sensory distal latencies, evoked response amplitudes, and conduction velocities are normal in the lower extremities.  The right common peroneal F-wave is minimally prolonged.  The right tibial H reflex is absent.,NEEDLE EMG:,  Needle EMG was performed on the right leg, left gastrocnemius medialis muscle, and right lumbosacral paraspinal muscles using a disposable concentric needle.  It revealed spontaneous activity in the right gastrocnemius medialis, gluteus maximus, and lower lumbosacral paraspinal muscles.  There was evidence of chronic denervation in right gastrocnemius medialis and gluteus maximus muscles.,IMPRESSION: , This electrical study is abnormal.  It reveals an acute right S1 radiculopathy.  There is no evidence for peripheral neuropathy or left or right L5 radiculopathy.,Results were discussed with the patient and he is scheduled to follow up with Dr. X in the near future.","physical medicine - rehab, microdiskectomy, needle emg, nerve conduction studies, lumbosacral paraspinal muscles, lumbar microdiskectomy, lower extremities, lumbosacral paraspinal, paraspinal muscles, gluteus maximus, leg symptoms, gastrocnemius medialis, emg/nerve, conduction, lumbosacral, needle, gastrocnemius, medialis, muscles, "
" A woman with a history of progression of dysphagia for the past year, dysarthria, weakness of her right arm, cramps in her legs, and now with progressive weakness in her upper extremities.  Abnormal electrodiagnostic study. ", Physical Medicine - Rehab, EMG/Nerve Conduction Study - 8 ,"REFERRING DIAGNOSIS: , Motor neuron disease.,PERTINENT HISTORY AND EXAMINATION:,  Briefly, the patient is an 83-year-old woman with a history of progression of dysphagia for the past year, dysarthria, weakness of her right arm, cramps in her legs, and now with progressive weakness in her upper extremities.,SUMMARY:  ,The right median sensory response showed a borderline normal amplitude for age with mild slowing of conduction velocity.  The right ulnar sensory amplitude was reduced with slowing of the conduction velocity.  The right radial sensory amplitude was reduced with slowing of the conduction velocity.  The right sural and left sural sensory responses were absent.  The right median motor response showed a prolonged distal latency across the wrist, with proximal slowing.  The distal amplitude was very reduced, and there was a reduction with proximal stimulation.  The right ulnar motor amplitude was borderline normal, with slowing of the conduction velocity across the elbow.  The right common peroneal motor response showed a decreased amplitude when recorded from the EDB, with mild slowing of the proximal conduction velocity across the knee.  The right tibial motor response showed a reduced amplitude with prolongation of the distal latency.  The left common peroneal response recorded from the EDB showed a decreased amplitude with mild distal slowing.  The left tibial motor response showed a decreased amplitude with a borderline normal distal latency.  The minimum F-wave latencies were normal with the exception of a mild prolongation of the ulnar F-wave latency, and the tibial F-wave latency as indicated above.  With repetitive nerve stimulation, there was no significant decrement noted in either the right nasalis or the right trapezius muscles.  Concentric needle EMG studies were performed in the right lower extremity, right upper extremity, thoracic paraspinals, and in the tongue.  There was evidence of increased insertional activity in the right tibialis anterior muscle, with evidence of fasciculations noted in several lower and upper extremity muscles and in the tongue.  In addition, there was evidence of increased amplitude, long duration and polyphasic motor units with a decreased recruitment noted in most muscles tested as indicated in the table above.,INTERPRETATION: , Abnormal electrodiagnostic study.  There is electrodiagnostic evidence of a disorder of the anterior motor neurons affecting at least four segments.  There is also evidence of a more generalized neuropathy that seems to be present in both the upper and lower extremities.  There is also evidence of a right median mononeuropathy at the wrist and a right ulnar neuropathy at the elbow.  Even despite the patient's age, the decrease in sensory responses is concerning, and makes it difficult to be certain about the diagnosis of motor neuron disease.  However, the overall changes on the needle EMG would be consistent with a diagnosis of motor neuron disease.  The patient will return for further evaluation.","physical medicine - rehab, electrodiagnostic study, electrodiagnostic, edb, latency, nerve conduction study, emg, motor neuron disease, distal latency, motor response, motor, amplitude, conduction"
" A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time. ", Physical Medicine - Rehab, EMG/Nerve Conduction Study - 3 ,"HISTORY: , The patient is a 56-year-old right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident in September of 2005.  At that time, she did not notice any specific injury.  Five days later, she started getting abnormal right low back pain.  At this time, it radiates into the buttocks down the posterior aspect of her thigh and into the right lateral aspect of her calf.  Symptoms are worse when sitting for any length of time, such as driving a motor vehicle.  Mild symptoms when walking for long periods of time.  Relieved by standing and lying down.  She denies any left leg symptoms or right leg weakness.  No change in bowel or bladder function.  Symptoms have slowly progressed.  She has had Medrol Dosepak and analgesics, which have not been very effective.  She underwent a spinal epidural injection, which was effective for the first few hours, but she had recurrence of the pain by the next day.  This was done four and a half weeks ago.,On examination, lower extremities strength is full and symmetric.  Straight leg raising is normal.,OBJECTIVE:,  Sensory examination is normal to all modalities.  Full range of movement of lumbosacral spine.  Mild tenderness over lumbosacral paraspinal muscles and sacroiliac joint.  Deep tendon reflexes are 2+ and symmetric at the knees, 2 at the left ankle and 1+ at the right ankle.,NERVE CONDUCTION STUDIES:,  Motor and sensory distal latencies, evoked response, amplitudes, conduction velocities, and F-waves are normal in the lower extremities.  Right tibial H-reflex is slightly prolonged when compared to the left tibial H-reflex.,NEEDLE EMG:,  Needle EMG was performed in both lower extremities and lumbosacral paraspinal muscles using the disposable concentric needle.  It revealed increased insertional activity in the right mid and lower lumbosacral paraspinal muscles as well as right peroneus longus muscle.  There were signs of chronic denervation in right tibialis anterior, peroneus longus, gastrocnemius medialis, and left gastrocnemius medialis muscles.,IMPRESSION: , This electrical study is abnormal.  It reveals the following:,1.  A mild right L5 versus S1 radiculopathy.,2.  Left S1 nerve root irritation.  There is no evidence of active radiculopathy.,3.  There is no evidence of plexopathy, myopathy or peripheral neuropathy.,MRI of the lumbosacral spine was personally reviewed and reveals bilateral L5-S1 neuroforaminal stenosis, slightly worse on the right.  Results were discussed with the patient and her daughter.  I would recommend further course of spinal epidural injections with Dr. XYZ.  If she has no response, then surgery will need to be considered.  She agrees with this approach and will followup with you in the near future.","physical medicine - rehab, emg, nerve conduction study, radiculopathy, peripheral neuropathy, nerve root irritation, motor vehicle accident, lumbosacral paraspinal muscles, spinal epidural, lumbosacral spine, peroneus longus, gastrocnemius medialis, lower extremities, emg/nerve, conduction, needle"
" EMG/Nerve Conduction Study showing sensory motor length-dependent neuropathy consistent with diabetes, severe left ulnar neuropathy, and moderate-to-severe left median neuropathy, ", Physical Medicine - Rehab, EMG/Nerve Conduction Study - 4 ,"NERVE CONDUCTION STUDIES:,  Bilateral ulnar sensory responses are absent.  Bilateral median sensory distal latencies are prolonged with a severely attenuated evoked response amplitude.  The left radial sensory response is normal and robust.  Left sural response is absent.  Left median motor distal latency is prolonged with attenuated evoked response amplitude.  Conduction velocity across the forearm is mildly slowed.  Right median motor distal latency is prolonged with a normal evoked response amplitude and conduction velocity.  The left ulnar motor distal latency is prolonged with a severely attenuated evoked response amplitude both below and above the elbow.  Conduction velocities across the forearm and across the elbow are prolonged.  Conduction velocity proximal to the elbow is normal.  The right median motor distal latency is normal with normal evoked response amplitudes at the wrist with a normal evoked response amplitude at the wrist.  There is mild diminution of response around the elbow.  Conduction velocity slows across the elbow.  The left common peroneal motor distal latency evoked response amplitude is normal with slowed conduction velocity across the calf and across the fibula head.  F-waves are prolonged.,NEEDLE EMG: , Needle EMG was performed on the left arm and lumbosacral and cervical paraspinal muscles as well as middle thoracic muscles using a disposable concentric needle.  It revealed spontaneous activity in lower cervical paraspinals, left abductor pollicis brevis, and first dorsal interosseous muscles.  There were signs of chronic reinnervation in triceps, extensor digitorum communis, flexor pollicis longus as well first dorsal interosseous and abductor pollicis brevis muscles.,IMPRESSION: , This electrical study is abnormal.  It reveals the following:,1.  A sensory motor length-dependent neuropathy consistent with diabetes.,2.  A severe left ulnar neuropathy.  This is probably at the elbow, although definitive localization cannot be made.,3.  Moderate-to-severe left median neuropathy.  This is also probably at the carpal tunnel, although definitive localization cannot be made.,4.  Right ulnar neuropathy at the elbow, mild.,5.  Right median neuropathy at the wrist consistent with carpal tunnel syndrome, moderate.,6.  A left C8 radiculopathy (double crush syndrome).,7.  There is no evidence for thoracic radiculitis.,The patient has made very good response with respect to his abdominal pain since starting Neurontin.  He still has mild allodynia and is waiting for authorization to get insurance coverage for his Lidoderm patch.  He is still scheduled for MRI of C-spine and T-spine.  I will see him in followup after the above scans.","physical medicine - rehab, emg, nerve conduction study, nerve conduction studies, needle emg, electrical study, neuropathy, ulnar neuropathy, median neuropathy, severely attenuated evoked response, normal evoked response amplitude, attenuated evoked response amplitude, median motor distal latency, motor distal latency, abductor pollicis, pollicis brevis, dorsal interosseous, carpal tunnel, conduction, emg/nerve, needle,"
 The patient is status post C3-C4 anterior cervical discectomy and fusion., Physical Medicine - Rehab, EMG/Nerve Conduction Study - 5 ,"She has an extensive past medical history of rheumatoid arthritis, fibromyalgia, hypertension, hypercholesterolemia, and irritable bowel syndrome.  She has also had bilateral carpal tunnel release.,On examination, normal range of movement of C-spine.  She has full strength in upper and lower extremities.  Normal straight leg raising.  Reflexes are 2 and symmetric throughout.  No Babinski.  She has numbness to light touch in her right big toe.,NERVE CONDUCTION STUDIES:  The right median palmar sensory distal latencies are minimally prolonged with minimally attenuated evoked response amplitude.  Bilateral tibial motor nerves could not be obtained (technical).  The remaining nerves tested revealed normal distal latencies, evoked response amplitudes, conduction velocities, F-waves, and H. reflexes.,NEEDLE EMG:  Needle EMG was performed on the right arm and leg and lumbosacral and cervical paraspinal muscles and the left FDI.  It revealed 2+ spontaneous activity in the right APB and FDI and 1+ spontaneous activity in lower cervical paraspinals, lower and middle lumbosacral paraspinals, right extensor digitorum communis muscle, and right pronator teres.  There was evidence of chronic denervation in the right first dorsal interosseous, pronator teres, abductor pollicis brevis, and left first dorsal interosseous.,IMPRESSION:  This electrical study is abnormal.  It reveals the following:,1.  An active right C8/T1 radiculopathy.  Electrical abnormalities are moderate.,2.  An active right C6/C7 radiculopathy.  Electrical abnormalities are mild.,3.  Evidence of chronic left C8/T1 denervation.  No active denervation.,4.  Mild right lumbosacral radiculopathies.  This could not be further localized because of normal EMG testing in the lower extremity muscles.,5.  There is evidence of mild sensory carpal tunnel on the right (she has had previous carpal tunnel release).,Results were discussed with the patient.  It appears that she has failed conservative therapy and I have recommended to her that she return to Dr. X for his assessment for possible surgery to her C-spine.  She will continue with conservative therapy for the mild lumbosacral radiculopathies.","physical medicine - rehab, emg, nerve conduction study, needle emg, paraspinal muscles, radiculopathy, electrical abnormalities, carpal tunnel release, evoked response, lumbosacral radiculopathies, conservative therapy, carpal tunnel, conduction, emg/nerve, "
" A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back pain radiating into the right leg.", Physical Medicine - Rehab, EMG/Nerve Conduction Study - 2 ,"HISTORY: , The patient is a 78-year-old right-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back pain radiating into the right leg.  She was undergoing a spinal epidural injection about a month ago and had worsening of right low back pain, which radiates down into her buttocks and down to posterior aspect of her thigh into her knee.  This has required large amounts of opioid analgesics to control.  She has been basically bedridden because of this.  She was brought into hospital for further investigations.,PHYSICAL EXAMINATION: , On examination, she has positive straight leg rising on the right with severe shooting, radicular type pain with right leg movement.  Difficult to assess individual muscles, but strength is largely intact.  Sensory examination is symmetric.  Deep tendon reflexes reveal hyporeflexia in both patellae, which probably represents a cervical myelopathy from prior cord compression.  She has slightly decreased right versus left ankle reflexes.  The Babinski's are positive.  On nerve conduction studies, motor and sensory distal latencies, evoked response amplitudes, conduction velocities, and F-waves are normal in lower extremities.,NEEDLE EMG: , Needle EMG was performed on the right leg and lumbosacral paraspinal muscles using a disposable concentric needle.  It reveals the spontaneous activity in right peroneus longus and gastrocnemius medialis muscles as well as the right lower lumbosacral paraspinal muscles.  There is evidence of denervation in right gastrocnemius medialis muscle.,IMPRESSION: , This electrical study is abnormal.  It reveals the following:,1.  Inactive right S1 (L5) radiculopathy.,2.  There is no evidence of left lower extremity radiculopathy, peripheral neuropathy or entrapment neuropathy.,Results were discussed with the patient and she is scheduled for imaging studies in the next day.","physical medicine - rehab, needle emg, radiculopathy, electrical study, emg, nerve conduction study, cervical spinal stenosis, lumbosacral paraspinal muscles, gastrocnemius medialis muscles, spinal stenosis, post decompression, lumbosacral paraspinal, paraspinal muscles, gastrocnemius medialis, medialis muscles, decompression, emg/nerve, conduction, cervical, spinal, needle, muscles, "
 1-month-old for a healthy checkup - Well child check, Pediatrics - Neonatal, Well-Child Check - 7 ,"SUBJECTIVE:,  This is a 1-month-old who comes in for a healthy checkup.  Mom says things are gone very well.  He is kind of acting like he has got a little bit of sore throat but no fevers.  He is still eating well.  He is up to 4 ounces every feeding.  He has not been spitting up.  Voiding and stooling well.,PAST MEDICAL HISTORY:,  Reviewed, very healthy.,CURRENT MEDICATIONS:,  None.,ALLERGIES TO MEDICINES:,  None.,DIETARY: , His formula fed on Enfamil Lipil.  Voiding and stooling well.  Growth chart reviewed with Mom.,DEVELOPMENTAL:,  He is starting to track with his eyes.  He is smiling a little bit, moving hands and feet symmetrically.,PHYSICAL EXAMINATION:,  In general well-developed, well-nourished male in no acute distress.,DERMATOLOGIC:  Without rash or lesion.,HEENT:  Head normocephalic and atraumatic.  Anterior fontanel soft and flat.  Eyes:  Pupils equal, round and reactive to light.  Extraocular movements intact.  Red reflexes present bilaterally.  Does appear to have conjugate gaze.  Ears:  Tympanic membranes are pink to gray, translucent, neutral position, normal light reflex and mobility.  Nares are patent, pink mucosa, moist.  Oropharynx clear with pink mucosa, normal moisture.,NECK:  Supple without masses.,CHEST:  Clear to auscultation and percussion with easy respirations and no accessory muscle use.,CARDIOVASCULAR:  Regular rate and rhythm without murmurs, rubs, heaves or gallops.,ABDOMEN:  Soft, nontender, nondistended without hepatosplenomegaly.,GU EXAM:  Normal Tanner I male.  Testes descended bilaterally.  No hernias noted.,EXTREMITIES:  Pink and warm.  Moving all extremities well.  No subluxation of the hips and leg creases appear symmetric.,NEUROLOGIC:  Alert, otherwise nonfocal.  2+ deep tendon reflexes at the knees.  Fixes and follows appropriately to both voice and face.,ASSESSMENT:,  Well child check.,PLAN:,1.  Diet, growth and safety discussed.,2.  Immunizations discussed and updated with hepatitis B.,3.  Return to clinic at two months of age.  Call if problems.", 
" Patient had movor vehicle accirdent and may have had a brief loss of consciousness.  Shortly thereafter she had some blurred vision,  Since that time she has had right low neck pain and left low back pain.  ", Physical Medicine - Rehab, EMG/Nerve Conduction Study - 7 ,"HISTORY: , The patient is a 34-year-old right-handed female who states her symptoms first started after a motor vehicle accident in September 2005.  She may have had a brief loss of consciousness at the time of the accident since shortly thereafter she had some blurred vision, which lasted about a week and then resolved.  Since that time she has had right low neck pain and left low back pain.  She has been extensively worked up and treated for this.  MRI of the C & T spine and LS spine has been normal.  She has improved significantly, but still complains of pain.  In June of this year she had different symptoms, which she feels are unrelated.  She had some chest pain and feeling of tightness in the left arm and leg and face.  By the next morning she had numbness around her lips on the left side and encompassing the whole left arm and leg.  Symptoms lasted for about two days and then resolved.  However, since that time she has had intermittent numbness in the left hand and leg.  The face numbness has completely resolved.  Symptoms are mild.  She denies any previous similar episodes.  She denies associated dizziness, vision changes incoordination, weakness, change in gait, or change in bowel or bladder function.  There is no associated headache.,Brief examination reveals normal motor examination with no pronator drift and no incoordination.  Normal gait.  Cranial nerves are intact.  Sensory examination reveals normal facial sensation.  She has normal and symmetrical light touch, temperature, and pinprick in the upper extremities.  In the lower extremities she has a feeling of dysesthesia in the lateral aspect of the left calf into the lateral aspect of the left foot.  In this area she has normal light touch and pinprick.  She describes it as a strange unusual sensation.,NERVE CONDUCTION STUDIES: , Motor and sensory distal latencies, evoked response amplitudes, conduction velocities, and F-waves are normal in the left arm and leg.,NEEDLE EMG: , Needle EMG was performed in the left leg, lumbosacral paraspinal, right tibialis anterior, and right upper thoracic paraspinal muscles using a disposable concentric needle.  It revealed normal insertional activity, no spontaneous activity, and normal motor unit action potential form in all muscles tested.,IMPRESSION: , This electrical study is normal.  There is no evidence for peripheral neuropathy, entrapment neuropathy, plexopathy, or lumbosacral radiculopathy.  EMG was also performed in the right upper thoracic paraspinal where she has experienced a lot of pain since the motor vehicle accident.  This was normal.,Based on her history of sudden onset of left face, arm, and leg weakness as well as a normal EMG and MRI of her spine I am concerned that she had a central event in June of this year.  Symptoms are now very mild, but I have ordered an MRI of the brain with and without contrast and MRA of the head and neck with contrast to further elucidate her symptoms.  Once she has the test done she will phone me and further management will be based on the results.","physical medicine - rehab, nerve conduction studies, motor, sensory, distal latencies, evoked response, conduction velocities, needle emg, loss of consciousness, motor vehicle accident, thoracic paraspinal, needle, paraspinal, conduction, "
" The patient with longstanding bilateral arm pain, which is predominantly in the medial aspect of arms and hands, as well as left hand numbness, worse at night and after doing repetitive work with left hand.", Physical Medicine - Rehab, EMG/Nerve Conduction Study - 1 ,"HISTORY: , The patient is a 52-year-old right-handed female with longstanding bilateral arm pain, which is predominantly in the medial aspect of her arms and hands as well as left hand numbness, worse at night and after doing repetitive work with her left hand.  She denies any weakness.  No significant neck pain, change in bowel or bladder symptoms, change in gait, or similar symptoms in the past.  She is on Lyrica for the pain, which has been somewhat successful.,Examination reveals positive Phalen's test on the left.  Remainder of her neurological examination is normal.,NERVE CONDUCTION STUDIES:  ,The left median motor distal latency is prolonged with normal evoked response amplitude and conduction velocity.  The left median sensory distal latency is prolonged with an attenuated evoked response amplitude.  The right median sensory distal latency is mildly prolonged with a mildly attenuated evoked response amplitude.  The right median motor distal latency and evoked response amplitude is normal.  Left ulnar motor and sensory and left radial sensory responses are normal.  Left median F-wave is normal.,NEEDLE EMG:,  Needle EMG was performed on the left arm, right first dorsal interosseous muscle, and bilateral cervical paraspinal muscles.  It revealed spontaneous activity in the left abductor pollicis brevis muscle.  There is increased insertional activity in the right first dorsal interosseous muscle.  Both interosseous muscles showed signs of reinnervation.  Left extensor digitorum communis muscle showed evidence of reduced recruitment.  Cervical paraspinal muscles were normal.,IMPRESSION: , This electrical study is abnormal.  It reveals the following:  A left median neuropathy at the wrist consistent with carpal tunnel syndrome.  Electrical abnormalities are moderate-to-mild bilateral C8 radiculopathies.  This may be an incidental finding.,I have recommended MRI of the spine without contrast and report will be sent to Dr. XYZ.  She will follow up with Dr. XYZ with respect to treatment of the above conditions.","physical medicine - rehab, nerve conduction study, emg, neuropathy, median motor distal latency, median sensory distal latency, attenuated evoked response amplitude, emg/nerve conduction study, sensory distal latency, attenuated evoked response, dorsal interosseous muscle, cervical paraspinal muscles, emg/nerve conduction, conduction study, median motor, needle emg, distal latency, evoked response, emg/nerve, bilateral, evoked, conduction, "
" History of numbness in both big toes and up the lateral aspect of both calves.  She dose complain of longstanding low back pain, but no pain that radiates from her back into her legs.  She has had no associated weakness.", Physical Medicine - Rehab, EMG/Nerve Conduction Study ,"HISTORY:,  The patient is a 52-year-old female with a past medical history of diet-controlled diabetes, diffuse arthritis, plantar fasciitis, and muscle cramps who presents with a few-month history of numbness in both big toes and up the lateral aspect of both calves.  Symptoms worsened considerable about a month ago.  This normally occurs after being on her feet for any length of time.  She was started on amitriptyline and this has significantly improved her symptoms.  She is almost asymptomatic at present.  She dose complain of longstanding low back pain, but no pain that radiates from her back into her legs.  She has had no associated weakness.,On brief examination, straight leg raising is normal.  The patient is obese.  There is mild decreased vibration and light touch in distal lower extremities.  Strength is full and symmetric.  Deep tendon reflexes at the knees are 2+ and symmetric and absent at the ankles.,NERVE CONDUCTION STUDIES: , Bilateral sural sensory responses are absent.  Bilateral superficial sensory responses are present, but mildly reduced.  The right radial sensory response is normal.  The right common peroneal and tibial motor responses are normal.  Bilateral H-reflexes are absent.,NEEDLE EMG:,  Needle EMG was performed on the right leg and lumbosacral paraspinal muscles and the left tibialis posterior using a concentric disposable needle.  It revealed increased insertional activity in the right tibialis posterior muscle with signs of mild chronic denervation in bilateral peroneus longus muscles and the right tibialis posterior muscle.  Lumbar paraspinals were attempted, but were too painful to get a good assessment.,IMPRESSION:  ,This electrical study is abnormal.  It reveals the following:,1.  A very mild, purely sensory length-dependent peripheral neuropathy.,2.  Mild bilateral L5 nerve root irritation.  There is no evidence of active radiculopathy.,Based on the patient's history and exam, her new symptoms are consistent with mild bilateral L5 radiculopathies.  Symptoms have almost completely resolved over the last month since starting Elavil.  I would recommend MRI of the lumbosacral spine if symptoms return.  With respect to the mild neuropathy, this is probably related to her mild glucose intolerance/early diabetes.  However, I would recommend a workup for other causes to include the following:  Fasting blood sugar, HbA1c, ESR, RPR, TSH, B12, serum protein electrophoresis and Lyme titer.","physical medicine - rehab, nerve conduction studies, needle emg, numbness, tibialis posterior muscle, sensory responses, muscle, tibialis, toes"
 A 3-month well-child check. , Pediatrics - Neonatal, Well-Child Check - 6 ,"SUBJECTIVE:,  Patient presents with Mom and Dad for her 5-year 3-month well-child check.  Family has not concerns stating patient has been doing well overall since last visit.  Taking in a well-balanced diet consisting of milk and dairy products, fruits, vegetables, proteins and grains with minimal junk food and snack food.  No behavioral concerns.  Gets along well with peers as well as adults.  Is excited to start kindergarten this upcoming school year.  Does attend daycare.  Normal voiding and stooling pattern.  No concerns with hearing or vision.  Sees the dentist regularly.  Growth and development:  Denver II normal passing all developmental milestones per age in areas of fine motor, gross motor, personal and social interaction and speech and language development.  See Denver II form in the chart.,ALLERGIES:,  None.,MEDICATIONS: , None.,FAMILY SOCIAL HISTORY:,  Unchanged since last checkup.  Lives at home with mother, father and sibling.  No smoking in the home.,REVIEW OF SYSTEMS:,  As per HPI; otherwise negative.,OBJECTIVE:,Vital Signs:  Weight 43 pounds.  Height 42-1/4 inches.  Temperature 97.7.  Blood pressure 90/64.,General:  Well-developed, well-nourished, cooperative, alert and interactive 5-year -3month-old white female in no acute distress.,HEENT:  Atraumatic, normocephalic.  Pupils equal, round and reactive.  Sclerae clear.  Red reflex present bilaterally.  Extraocular muscles intact.  TMs clear bilaterally.  Oropharynx:  Mucous membranes moist and pink.  Good dentition.,Neck:  Supple, no lymphadenopathy.,Chest:  Clear to auscultation bilaterally.  No wheeze or crackles.  Good air exchange.,Cardiovascular:  Regular rate and rhythm.  No murmur.  Good pulses bilaterally.,Abdomen:  Soft, nontender.  Nondistended.  Positive bowel sounds.  No masses or organomegaly.,GU:  Tanner I female genitalia.  Femoral pulses equal bilaterally.  No rash.,Extremities:  Full range of motion.  No cyanosis, clubbing or edema.,Back:  Straight.  No scoliosis.,Integument:  Warm, dry and pink without lesions.,Neurological:  Alert.  Good muscle tone and strength.  Cranial nerves II-XII grossly intact.  DTRs 2+/4+ bilaterally.,ASSESSMENT/PLAN:,1. Well 5-year 3-month-old white female.,2. Anticipatory guidance for growth and diet development and safety issues as well as immunizations.  Will receive MMR, DTaP and IPV today.  Discussed risks and benefits as well as possible side effects and symptomatic treatment.  Gave 5-year well-child check handout to mom.  Completed school pre-participation physical.  Copy in the chart.  Completed vision and hearing screening.  Reviewed results with family.,3. Follow up in one year for next well-child check or as needed for acute care.","pediatrics - neonatal, denver ii, child check, mom, diet, growth, denver, family, development, child, check, "
 1-year well child check., Pediatrics - Neonatal, Well-Child Check - 4 ,"SUBJECTIVE:,  The patient presents with Mom and Dad for her 1-year well child check.  The family has no concerns stating the patient has been doing well overall since the last visit taking in a well-balanced diet consisting of formula transitioning to whole milk, fruits, vegetables, proteins and grains.  Normal voiding and stooling pattern.  No concerns with hearing or vision.  Growth and development:  Denver II normal passing all developmental milestones per age in areas of fine motor, gross motor, personal and social interaction as well as speech and language development.  See Denver II form in the chart.,PAST MEDICAL HISTORY:,  Allergies:  None.  Medications:  Tylenol this morning in preparation for vaccines and a multivitamin daily.,FAMILY SOCIAL HISTORY:,  Unchanged since last checkup.,REVIEW OF SYSTEMS:,  As per HPI; otherwise negative.,OBJECTIVE:,  Weight 24 pounds 1 ounce.  Height 30 inches.  Head circumference 46.5 cm.  Temperature afebrile.,General:  A well-developed, well-nourished, cooperative, alert and interactive 1-year-old white female smiling, happy and drooling.,HEENT:  Atraumatic, normocephalic.  Anterior fontanel is closed.  Pupils equally round and reactive.  Sclerae are clear.  Red reflex present bilaterally.  Extraocular muscles intact.  TMs are clear bilaterally.  Oropharynx:  Mucous membranes are moist and pink.  Good dentition.  Drooling and chewing with teething behavior today.  Neck is supple.  No lymphadenopathy.,Chest:  Clear to auscultation bilaterally.  No wheeze.  No crackles.  Good air exchange.,Cardiovascular:  Regular rate and rhythm.  No murmur.  Good pulses bilaterally.,Abdomen:  Soft, nontender.  Nondistended.  Positive bowel sounds.  No mass.  No organomegaly.,Genitourinary:  Tanner I female genitalia.  Femoral pulses equal bilaterally.  No rash.,Extremities:  Full range of motion.  No cyanosis, clubbing or edema.  Negative Ortolani and Barlow maneuver.,Back:  Straight.  No scoliosis.,Integument:  Warm, dry and pink without lesions.,Neurological:  Alert.  Good muscle tone and strength.  Cranial nerves II through XII are grossly intact.,ASSESSMENT AND PLAN:,1.  Well 1-year-old white female.,2.  Anticipatory guidance.  Reviewed growth, diet development and safety issues as well as immunizations.  Will receive Pediarix and HIB today.  Discussed risks and benefits as well as possible side effects and symptomatic treatment.  Will also obtain a screening CBC and lead level today via fingerstick and call the family with results as they become available.  Gave 1-year well child checkup handout to Mom and Dad.,3.  Follow up for the 15-month well child check or as needed for acute care.","pediatrics - neonatal, well child check, denver ii, child check, checkup, check, child, "
 A well-child check with concern of some spitting up quite a bit., Pediatrics - Neonatal, Well-Child Check - 5 ,"SUBJECTIVE:,  The patient presents with Mom for a first visit to our office for a well-child check with concern of some spitting up quite a bit.  Mom wants to make sure that this is normal.  The patient is nursing well every two to three hours.  She does have some spitting up on occasion.  It has happened two or three times with some curdled appearance x 1.  No projectile in nature, nonbilious.  Normal voiding and stooling pattern.  Growth and Development:  Denver II normal, passing all developmental milestones per age.  See Denver II form in the chart.,PAST MEDICAL HISTORY:,  Mom reports uncomplicated pregnancy with prenatal care provided by Dr. XYZ in Wichita, Kansas.  Delivery after induction secondary to postdate at St. Joseph Hospital.  Infant delivered by SVD with birth weight of 6 pounds 13 ounce.  Length of 19 inches.  Did well after delivery and dismissed to home with Mom.  Received hepatitis B #1 prior to dismissal.  No other hospitalizations.  No surgeries.  No known medical allergies.  No medications.  Mom has tried Mylicon drops on occasion.,FAMILY HISTORY: , Significant for cardiovascular disease, hypertension, diabetes mellitus and thyroid problems in maternal and paternal grandparents.  Healthy Mother, Father.  There is also history of breast, colon and ovarian cancer on the maternal side of the family, her grandmother who is present at visit today.  There is history of asthma in the patient's father.,SOCIAL HISTORY:,  The patient lives at home with 23-year-old mother, who is a homemaker and 24-year-old father, John, who is a supervisor at Excel.  The family lives in Bentley, Kansas.  No smoking in the home.  Family does have one pet cat.,REVIEW OF SYSTEMS:,  As per HPI, otherwise, negative.,OBJECTIVE:,  Weight:  7 pounds 12 ounces.  Height:  21 inches.  Head circumference:  35 cm.  Temperature:  97.2 degrees.,General:  Well-developed, well-nourished, cooperative, alert, interactive 2-week-old white female in no acute distress.,HEENT:  Atraumatic, normocephalic.  Anterior fontanel is soft and flat.  Pupils are equal, round and reactive.  Sclerae clear.  Red reflexes present bilaterally.  TMs are clear bilaterally.  Oropharynx:  Mucous membranes are moist and pink.,Neck:  Supple, no lymphadenopathy.,Chest:  Clear to auscultation bilaterally.  No wheeze or crackles.  Good air exchange.,Cardiovascular:  Regular rate and rhythm.  No murmur.  Good pulses bilaterally.,Abdomen:  Soft, nontender, nondistended.  Positive bowel sounds.  No mass nor organomegaly.,Genitourinary:  Tanner I female genitalia.  Femoral pulses are equal bilaterally.  No rash.,Extremities:  Full range of motion.  No cyanosis, clubbing or edema.  Negative Ortolani or Barlow maneuver.,Back:  Straight.  No scoliosis.,Integument:  Warm, dry and pink without lesions.,Neurologic:  Alert.  Good muscle tone and strength.,ASSESSMENT/PLAN:,1.  Well 2-week-old white female.,2.  Anticipatory guidelines for growth, diet, development, safety issues as well as immunizations and visitation schedule.  Gave 2-week well-child check handout and American Academy of Pediatrics book Birth to 5 years to Mom and family.,3.  Call the office or on-call physician if the patient has fever, feeding problems or breathing problems.  Otherwise plan to recheck at 1-month of age.","pediatrics - neonatal, well-child check, denver ii, child check, growth, development, denver, cardiovascular, maternal, mother, spitting, father, child, check, asthma, family, mom, "
 A 9-month well-child check., Pediatrics - Neonatal, Well-Child Check - 2 ,"SUBJECTIVE:,  This 9-month-old Hispanic male comes in today for a 9-month well-child check.  They are visiting from Texas until the end of April 2004.  Mom says he has been doing well since last seen.  He is up-to-date on his immunizations per her report.  She notes that he has developed some bumps on his chest that have been there for about a week.  Two weeks ago he was diagnosed with left otitis media and was treated with antibiotics.  Mom says he has been doing fine since then.  She has no concerns about him.,PAST MEDICAL HISTORY:,  Significant for term vaginal delivery without complications.,MEDICATIONS: , None.,ALLERGIES:,  None.,SOCIAL HISTORY:,  Lives with parents.  There is no smoking in the household.,REVIEW OF SYSTEMS:,  Developmentally is appropriate.  No fevers.  No other rashes.  No cough or congestion.  No vomiting or diarrhea.  Eating normally.,OBJECTIVE:,  His weight is 16 pounds 9 ounces.  Height is 26-1/4 inches.  Head circumference is 44.75 cm.  Pulse is 124.  Respirations are 26.  Temperature is 98.1 degrees.  Generally, this is a well-developed, well-nourished, 9-month-old male, who is active, alert, and playful in no acute distress.,HEENT:  Normocephalic, atraumatic.  Anterior fontanel is soft and flat.  Tympanic membranes are clear bilaterally.  Conjunctivae are clear.  Pupils equal, round and reactive to light.  Nares without turbinate edema.  Oropharynx is nonerythematous.,NECK:  Supple, without lymphadenopathy, thyromegaly, carotid bruit, or JVD.,CHEST:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  Regular rate and rhythm, without murmur.,ABDOMEN:  Soft, nontender, nondistended, normoactive bowel sounds.  No masses or organomegaly to palpation.,GU:  Normal male external genitalia.  Uncircumcised penis.  Bilaterally descended testes.  Femoral pulses 2/4.,EXTREMITIES:  Moves all four extremities equally.  Minimal tibial torsion.,SKIN:  Without abnormalities other than five small molluscum contagiosum with umbilical herniation noted on chest.,ASSESSMENT/PLAN:,1.  Well-child check.  Is doing well.  Will recommend a followup well-child check at 1 year of age and immunizations at that time.  Discussed safety issues, including poisons, choking hazards, pet safety, appropriate nutrition with Mom.  She is given a parenting guide handout.,2.  Molluscum contagiosum.  Described the viral etiology of these.  Told her they are self limited, and we will continue to monitor at this time.,3.  Left otitis media, resolved.  Continue to monitor.  We will plan on following up in three months if they are still in the area, or p.r.n.","pediatrics - neonatal, well-child check, otitis media, molluscum contagiosum, immunizations, developed, atraumatic, child, "
 Bilateral tympanostomy with myringotomy tube placement.    The patient is a 1-year-old male with a history of chronic otitis media with effusion and conductive hearing loss refractory to outpatient medical therapy. , Pediatrics - Neonatal, Tympanostomy & Myringotomy Tube Placement ,"PREOPERATIVE DIAGNOSES:,1.  Chronic otitis media with effusion.,2.  Conductive hearing loss.,POSTOPERATIVE DIAGNOSES:,1.  Chronic otitis media with effusion.,2.  Conductive hearing loss.,PROCEDURE PERFORMED: , Bilateral tympanostomy with myringotomy tube placement _______ split tube 1.0 mm.,ANESTHESIA:  ,Total IV general mask airway.,ESTIMATED BLOOD LOSS:  ,None.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE:,  The patient is a 1-year-old male with a history of chronic otitis media with effusion and conductive hearing loss refractory to outpatient medical therapy.  After risks, complications, consequences, and questions were addressed with the family, a written consent was obtained for the procedure.,PROCEDURE:,  The patient was brought to the operative suite by Anesthesia.  The patient was placed on the operating table in supine position.  After this, the patient was then placed under general mask airway and the patient's head was then turned to the left.,The Zeiss operative microscope and medium-sized ear speculum were placed and the cerumen from the external auditory canals were removed with a cerumen loop to #5 suction.  After this, the tympanic membrane is then brought into direct visualization with no signs of any gross retracted pockets or cholesteatoma.  A myringotomy incision was then made within the posterior inferior quadrant and the middle ear was then suctioned with a #5 suction demonstrating dry contents.  A _____ split tube 1.0 mm was then placed in the myringotomy incision utilizing a alligator forcep.  Cortisporin Otic drops were placed followed by cotton balls.  Attention was then drawn to the left ear with the head turned to the right and the medium sized ear speculum placed.  The external auditory canal was removed off of its cerumen with a #5 suction which led to the direct visualization of the tympanic membrane.  The tympanic membrane appeared with no signs of retraction pockets, cholesteatoma or air fluid levels.  A myringotomy incision was then made within the posterior inferior quadrant with a myringotomy blade after which a _________ split tube 1.0 mm was then placed with an alligator forcep.  After this, the patient had Cortisporin Otic drops followed by cotton balls placed.  The patient was then turned back to Anesthesia and transferred to recovery room in stable condition and tolerated the procedure very well.  The patient will be followed up approximately in one week and was sent home with a prescription for Ciloxan ear drops to be used as directed and with instructions not to get any water in the ears.","pediatrics - neonatal, chronic otitis media with effusion, conductive hearing loss, bilateral tympanostomy, myringotomy tube placement, cortisporin otic drops, otitis media, tympanostomy, tympanic, membrane, otitis, media, effusion, conductive, hearing, ear, tube, myringotomy"
 Viral upper respiratory infection (URI) with sinus and eustachian congestion.  Patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain. , Pediatrics - Neonatal, URI & Eustachian Congestion ,"HISTORY OF PRESENT ILLNESS: , Patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain.  She has had a dry cough and a fever as high as 100, but this has not been since the first day.  She denies any vomiting or diarrhea.  She did try some Tylenol Cough and Cold followed by Tylenol Cough and Cold Severe, but she does not think that this has helped.,FAMILY HISTORY: , The patient's younger sister has recently had respiratory infection complicated by pneumonia and otitis media.,REVIEW OF SYSTEMS:,  The patient does note some pressure in her sinuses.  She denies any skin rash.,SOCIAL HISTORY:,  Patient lives with her mother, who is here with her.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS:  Temp is 38.1, pulse is elevated at 101, other vital signs are all within normal limits.  Room air oximetry is 100%.,GENERAL:  Patient is a healthy-appearing, white female, adolescent who is sitting on the stretcher, and appears only mildly ill.,HEENT:  Head is normocephalic, atraumatic.  Pharynx shows no erythema, tonsillar edema, or exudate.  Both TMs are easily visualized and are clear with good light reflex and no erythema.  Sinuses do show some mild tenderness to percussion.,NECK:  No meningismus or enlarged anterior/posterior cervical lymph nodes.,HEART:  Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS:  Clear without rales, rhonchi, or wheezes.,SKIN:  No rash.,ASSESSMENT:,  Viral upper respiratory infection (URI) with sinus and eustachian congestion.,PLAN:,  I did educate the patient about her problem and urged her to switch to Advil Cold & Sinus for the next three to five days for better control of her sinus and eustachian discomfort.  I did urge her to use Afrin nasal spray for the next three to five days to further decongest her sinuses.  If she is unimproved in five days, follow up with her PCP for re-exam.","pediatrics - neonatal, upper respiratory infection, eustachian congestion, erythema, uri, nasal, cough, eustachian, respiratory, sinus, congestion, infection, tonsillar"
 Thyroid mass diagnosed as papillary carcinoma.  The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary.  The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis., Pediatrics - Neonatal, Thyroid Mass Consult ,"REASON FOR CONSULTATION: , Thyroid mass diagnosed as papillary carcinoma.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 16-year-old young lady, who was referred from the Pediatric Endocrinology Department by Dr. X for evaluation and surgical recommendations regarding treatment of a mass in her thyroid, which has now been proven to be papillary carcinoma on fine needle aspiration biopsy.  The patient's parents relayed that they first noted a relatively small but noticeable mass in the middle portion of her thyroid gland about 2004.  An ultrasound examination had reportedly been done in the past and the mass is being observed.  When it began to enlarge recently, she was referred to the Pediatric Endocrinology Department and had an evaluation there.  The patient was referred for fine needle aspiration and the reports recently returned a diagnosis of papillary thyroid carcinoma.  The patient has not had any hoarseness, difficulty swallowing, or any symptoms of endocrine dysfunction.  She has no weight changes consistent with either hyper or hypothyroidism.  There is no family history of thyroid cancer in her family.  She has no notable discomfort with this lesion.  There have been no skin changes.  Historically, she does not have a history of any prior head and neck radiation or treatment of any unusual endocrinopathy.,PAST MEDICAL HISTORY:,  Essentially unremarkable.  The patient has never been hospitalized in the past for any major illnesses.  She has had no prior surgical procedures.,IMMUNIZATIONS: , Current and up to date.,ALLERGIES: , She has no known drug allergies.,CURRENT MEDICATIONS:  ,Currently taking no routine medications.  She describes her pain level currently as zero.,FAMILY HISTORY: , There is no significant family history, although the patient's father does note that his mother had a thyroid surgery at some point in life, but it was not known whether this was for cancer, but he suspects it might have been for goiter.  This was done in Tijuana.  His mom is from central portion of Mexico.  There is no family history of multiple endocrine neoplasia syndromes.,SOCIAL HISTORY:  ,The patient is a junior at Hoover High School.  She lives with her mom in Fresno.,REVIEW OF SYSTEMS: , A careful 12-system review was completely normal except for the problems related to the thyroid mass.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a 55.7 kg, nondysmorphic, quiet, and perhaps slightly apprehensive young lady, who was in no acute distress.  She was alert and oriented x3 and had an appropriate affect.,HEENT:  The head and neck examination is most significant.  There is mild amount of facial acne.  The patient's head, eyes, ears, nose, and throat appeared to be grossly normal.,NECK:  There is a slightly visible midline bulge in the region of the thyroid isthmus.  A firm nodule is present there, and there is also some nodularity in the right lobe of the thyroid.  This mass is relatively hard, slightly fixed, but not tethered to surrounding tissues, skin, or muscles that I can determine.  There are some shotty adenopathy in the area.  No supraclavicular nodes were noted.,CHEST:  Excursions are symmetric with good air entry.,LUNGS:  Clear.,CARDIOVASCULAR:  Normal.  There is no tachycardia or murmur noted.,ABDOMEN:  Benign.,EXTREMITIES:  Extremities are anatomically correct with full range of motion.,GENITOURINARY:  External genitourinary exam was deferred at this time and can be performed later during anesthesia.  This is same as too for her rectal examination.,SKIN:  There is no acute rash, purpura, or petechiae.,NEUROLOGIC:  Normal and no focal deficits.  Her voice is strong and clear.  There is no evidence of dysphonia or vocal cord malfunction.,DIAGNOSTIC STUDIES: , I reviewed laboratory data from the Diagnostics Lab, which included a mild abnormality in the AST at 11, which is slightly lower than the normal range.  T4 and TSH levels were recorded as normal.  Free thyroxine was normal, and the serum pregnancy test was negative.  There was no level of thyroglobulin recorded on this.  A urinalysis and comprehensive metabolic panel was unremarkable.  A chest x-ray was obtained, which I personally reviewed.  There is a diffuse pattern of tiny nodules in both lungs typical of miliary metastatic disease that is often seen in patients with metastatic thyroid carcinoma.,IMPRESSION/PLAN: , The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary.  The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis and is unfortunate in that it generally means a more advanced stage of disease.  I spent approximately 30 minutes with the patient and her family today discussing the surgical aspects of the treatment of this disease.  During this time, we talked about performing a total thyroidectomy to eradicate as much of the native thyroid tissue and remove the primary source of the cancer in anticipation of radioactive iodine therapy.  We talked about sentinel node dissection, and we spent significant amount of time talking about the possibility of hypoparathyroidism if all four of the parathyroid glands were damaged during this operation.  We also discussed the recurrent laryngeal and external laryngeal branches of the nerve supplying the vocal cord function and how they cane be damaged during the thyroidectomy as well.  I answered as many of the family's questions as they could mount during this stressful time with this recent information supplied to them.  I also did talk to them about the chest x-ray pattern, which was complete __________ as the film was just on the day prior to my clinic visit.  This will have some impact on the postoperative adjunctive therapy.  The radiologist commented about the risk of pulmonary fibrosis and the use of radioactive iodine in this situation, but it seems likely that is going to be necessary to attempt to treat this disease in the patient's case.  I did discuss with them the possibility of having to take large doses of calcium and vitamin D in the event of hypoparathyroidism if that does happen, and we also talked about possibly sparing parathyroid tissue and reimplanting it in a muscle belly either in the neck or forearm if that becomes a necessity.  All of the family's questions have been answered.  This is a very anxious and anxiety provoking time in the family.  I have made every effort to get the patient under schedule within the next 48 hours to have this operation done.  We are tentatively planning on proceeding this upcoming Friday afternoon with total thyroidectomy.",
 A two week well-child check., Pediatrics - Neonatal, Well-Child Check - 3 ,"SUBJECTIVE:,  Patient presents with Mom for first visit to the office for two week well-child check.  Mom has no concerns stating that patient has been doing well overall since dismissal from the hospital.  Nursing every two to three hours with normal voiding and stooling pattern.  She does have a little bit of some gas and Mom has been using Mylicon drops which are helpful.  She is burping well, hiccuping, sneezing and burping appropriately.  Growth and development:  Denver II normal passing all developmental milestones per age in areas of fine motor, gross motor, personal and social interaction and speech and language development.  See Denver II form in the chart.,PAST MEDICAL HISTORY:,  Mom reports uncomplicated pregnancy and delivery with prenatal care provided by Dr. Hoing.  Delivery at Newton Medical Center at 39 weeks, 5 days gestation.  Birth weight was 3160 g.  Length 49.5 cm.  Head circumference 33 cm.  Infant was delivered to 22-year-old A-positive mom who is G1 P0, now P1.  Infant did well after delivery and was dismissed to home with Mom the following day.  No other hospitalizations.  No surgeries.,ALLERGIES: , None.,MEDICATIONS:,  Gas drops p.r.n.,FAMILY HISTORY: , Significant for cardiovascular problems and hypertension as well as diabetes mellitus on the maternal side of the family.  History of cancer and asthma on the paternal side of the family.  Mom unsure of what type of cancer.,SOCIAL HISTORY:,  Patient lives at home with 22-year-old mother Aubrey Mizel and her parents Bud and Sue Mizel in Newton, Kansas.  Father of the baby, Shivanka Silva age 30, is a full-time student at WSU in Wichita, Kansas and does help with care of the newborn.  There is no smoking in the home.  Family does have one pet dog in home.,REVIEW OF SYSTEMS:,  As per HPI; otherwise negative.,OBJECTIVE:,Vital Signs:  Weight 7 pounds, 1-1/5 ounces.  Height 21 inches.  Head circumference 35.8 cm.  Temperature 97.7.,General:  Well-developed, well-nourished, cooperative, alert and interactive 2-week-old female in no acute distress.,HEENT:  Atraumatic, normocephalic.  Anterior fontanel soft and flat.  Pupils equal, round and reactive.  Sclerae clear.  Red reflex present bilaterally.  TMs clear bilaterally.  Oropharynx:  Mucous membranes moist and pink.,Neck:  Supple, no lymphadenopathy.,Chest:  Clear to auscultation bilaterally.  No wheeze or crackles.  Good air exchange.,Cardiovascular:  Regular rate and rhythm.  No murmur.  Good pulses bilaterally.,Abdomen:  Soft, nontender.  Nondistended.  Positive bowel sounds.  No masses or organomegaly.  Healing umbilicus.,GU:  Tanner I female genitalia.  Femoral pulses equal bilaterally.  No rash.,Extremities:  Full range of motion.  No cyanosis, clubbing or edema.  Negative Ortolani and Barlow maneuver.,Back:  Straight.  No scoliosis.  Some increased pigment over the sacrum.,Integument:  Warm, dry and pink without lesions.,Neurological:  Alert.  Good muscle tone and strength.,ASSESSMENT/PLAN:,1. Well 2-week-old mixed race Caucasian and Middle Eastern descent female.,2. Anticipatory guidance for growth and diet development and safety issues as well as immunizations and visitation schedule.  Gave two week well-child check handout to Mom.  Plan follow up for the one month well-child check or as needed for acute care.  Mom will call for feeding problems, breathing problems or fever.  Otherwise, plan to see at one month.",
 Well child - Left lacrimal duct stenosis, Pediatrics - Neonatal, Well-Child Check - 1 ,"CHIEF COMPLAINT:,  Well-child check.,HISTORY OF PRESENT ILLNESS:,  This is a 12-month-old female here with her mother for a well-child check.  Mother states she has been doing well.  She is concerned about drainage from her left eye.  Mother states she was diagnosed with a blocked tear duct on that side shortly after birth, and normally she has crusted secretions every morning.  She states it is worse when the child gets a cold.  She has been using massaging when she can remember to do so.  The patient is drinking whole milk without problems.  She is using solid foods three times a day.  She sleeps well without problems.  Her bowel movements are regular without problems.  She does not attend daycare.,DEVELOPMENTAL ASSESSMENT:,  Social:  She can feed herself with fingers.  She is comforted by parent’s touch.  She is able to separate and explore.  Fine motor:  She scribbles.  She has a pincer grasp.  She can drink from a cup.  Language:  She says dada.  She says one to two other words and she indicates her wants.  Gross motor:  She can stand alone.  She cruises.  She walks alone.  She stoops and recovers.,PHYSICAL EXAMINATION:,General:  She is alert, in no distress.,Vital signs:  Weight:  25th percentile.  Height:  25th percentile.  Head circumference:  50th percentile.,HEENT:  Normocephalic, atraumatic.  Pupils are equal, round, and reactive to light.  Left eye with watery secretions and crusted lashes.  Conjunctiva is clear.  TMs are clear bilaterally.  Nares are patent.  Mild nasal congestion present.  Oropharynx is clear.,Neck:  Supple.,Lungs:  Clear to auscultation.,Heart:  Regular.  No murmur.,Abdomen:  Soft.  Positive bowel sounds.  No masses.  No hepatosplenomegaly.,GU:  Female external genitalia.,Extremities:  Symmetrical.  Femoral pulses are 2+ bilaterally.  Full range of motion of all extremities.,Neurologic:  Grossly intact.,Skin:  Normal turgor.,Testing:  Hearing and vision assessments grossly normal.,ASSESSMENT:,1.  Well child.,2.  Left lacrimal duct stenosis.,PLAN:,  MMR #1 and Varivax #1 today.  VIS statements given to Mother after discussion.  Evaluation and treatment as needed with Dr. XYZ with respect to the blocked tear duct.  Anticipatory guidance for age.  She is to return to the office in three months.","pediatrics - neonatal, well-child check, drainage, eye, lacrimal duct stenosis, lacrimal duct, mmr, varivax, vis statements, tear duct, lacrimal, percentile, mother, child, "
 The patient is a 4-month-old who presented with supraventricular tachycardia and persistent cyanosis., Pediatrics - Neonatal, Supraventricular Tachycardia - Consult ,"HISTORY: , The patient is a 4-month-old who presented today with supraventricular tachycardia and persistent cyanosis.  The patient is a product of a term pregnancy that was uncomplicated and no perinatal issues are raised.  Parents; however, did note the patient to be quite dusky since the time of her birth; however, were reassured by the pediatrician that this was normal.  The patient demonstrates good interval weight gain and only today presented to an outside hospital with significant duskiness, some irritability, and rapid heart rate.  Parents do state that she does appear to breathe rapidly, tires somewhat with the feeding with increased respiratory effort and diaphoresis.  The patient is exclusively breast fed and feeding approximately 2 hours.  Upon arrival at Children's Hospital, the patient was found to be in a narrow complex tachycardia with the rate in excess of 258 beats per minute with a successful cardioversion to sinus rhythm with adenosine.  The electrocardiogram following the cardioversion had demonstrated normal sinus rhythm with a right atrial enlargement, northwest axis, and poor R-wave progression, possible right ventricular hypertrophy.,FAMILY HISTORY:,  Family history is remarkable for an older sibling found to have a small ventricular septal defect that is spontaneously closed.,REVIEW OF SYSTEMS: , A complete review of systems including neurologic, respiratory, gastrointestinal, genitourinary are otherwise negative.,PHYSICAL EXAMINATION:,GENERAL:  Physical examination that showed a sedated, acyanotic infant who is in no acute distress.,VITAL SIGNS:  Heart rate of 170, respiratory rate of 65, saturation, it is nasal cannula oxygen of 74% with a prostaglandin infusion at 0.5 mcg/kg/minute.,HEENT:  Normocephalic with no bruit detected.  She had symmetric shallow breath sounds clear to auscultation.  She had full symmetrical pulses.,HEART:  There is normoactive precordium without a thrill.  There is normal S1, single loud S2, and a 2/6 continuous shunt type of murmur could be appreciated at the left upper sternal border.,ABDOMEN:  Soft.  Liver edge is palpated at 3 cm below the costal margin and no masses or bruits detected.,X-RAYS:,  Review of the chest x-ray demonstrated a normal situs, normal heart size, and adequate pulmonary vascular markings.  There is a prominent thymus.  An echocardiogram demonstrated significant cyanotic congenital heart disease consisting of normal situs, a left superior vena cava draining into the left atrium, a criss-cross heart with atrioventricular discordance of the right atrium draining through the mitral valve into the left-sided morphologic left ventricle.  The left atrium drained through the tricuspid valve into a right-sided morphologic right ventricle.  There is a large inlet ventricular septal defect as pulmonary atresia.  The aorta was malopposed arising from the right ventricle in the anterior position with the left aortic arch.  There was a small vertical ductus as a sole source of pulmonary artery blood flow.  The central pulmonary arteries appeared confluent although small measuring 3 mm in the diameter.  Biventricular function is well maintained.,FINAL IMPRESSION: , The patient has significant cyanotic congenital heart disease physiologically with a single ventricle physiology and ductal-dependent pulmonary blood flow and the incidental supraventricular tachycardia now in the sinus rhythm with adequate ventricular function.  The saturations are now also adequate on prostaglandin E1.,RECOMMENDATION: , My recommendation is that the patient be continued on prostaglandin E1.  The patient's case was presented to the cardiothoracic surgical consultant, Dr. X.  The patient will require further echocardiographic study in the morning to further delineate the pulmonary artery anatomy and confirm the central confluence.  A consideration will be made for diagnostic cardiac catheterization to fully delineate the pulmonary artery anatomy prior to surgical intervention.  The patient will require some form of systemic to pulmonary shunt, modified pelvic shunt or central shunt as a durable source of pulmonary blood flow.  Further surgical repair was continued on the size and location of the ventricular septal defect over the course of the time for consideration of possible Rastelli procedure.  The current recommendation is for proceeding with a central shunt and followed then by bilateral bidirectional Glenn shunt with then consideration for a septation when the patient is 1 to 2 years of age.  These findings and recommendations were reviewed with the parents via a Spanish interpreter.","pediatrics - neonatal, congenital heart disease, cyanotic, ductal-dependent, pulmonary blood flow, ventricular septal defect, blood flow, supraventricular tachycardia, tachycardia, ventricular, supraventricular, shunt, heart, pulmonary,"
" Healthy checkups and sports physical - 12 years old - Healthy Tanner III male, developing normally.", Pediatrics - Neonatal, Sports Physical - 3 ,"SUBJECTIVE:,  This is a 12-year-old male who comes in for healthy checkups and sports physical.  No major concerns today.  He is little bit congested at times.  He has been told he is allergic to grasses.  They have done over-the-counter Claritin and that seems to help but he is always sniffling mother reports.  He has also got some dryness on his face as far as the skin and was wondering what cream he could put on.,PAST MEDICAL HISTORY:,  Otherwise, reviewed.  Very healthy.,CURRENT MEDICATIONS:,  Claritin p.r.n.,ALLERGIES TO MEDICINES:,  None.,FAMILY SOCIAL HISTORY:,  Everyone else is healthy at home currently.,DIETARY:,  He is on whole milk and does a variety of foods.  Growth chart is reviewed with mother.  Voids and stools well.,DEVELOPMENTAL:,  He is in seventh grade and going out for cross-country and track.  He is supposed to be wearing glasses, is not today.  We did not test his vision because he recently saw the eye doctor though we did discuss the need for him to wear glasses with mother.  His hearing was normal today and no concerns with speech.,PHYSICAL EXAMINATION:,General:  A well-developed, well-nourished male in no acute distress.,Dermatologic:  Without rash or lesion.,HEENT:  Head normocephalic and atraumatic.  Eyes:  Pupils equal, round and reactive to light.  Extraocular movements intact.  Red reflexes are present bilaterally.  Optic discs are sharp with normal vasculature.  Ears:  Tympanic membranes are gray, translucent with normal light reflex.  Nares are very congested.  Turbinates swollen and boggy.,Neck:  Supple without masses.,Chest:  Clear to auscultation and percussion, easy respirations.  No accessory muscle use.,Cardiovascular:  Regular rate and rhythm without murmurs, rubs, heaves or gallops.,Back:  Symmetric with no scoliosis or kyphosis noted.  Normal flexibility.  Femoral pulses 2+ and symmetric.,Abdomen:  Soft, nontender, nondistended without hepatosplenomegaly.,GU Exam:  Normal Tanner III male.  Testes descended bilaterally.  No abnormal rash, discharge, or scars.,Extremities:  Pink and warm.  Moves all extremities well with normal function and strength in the arms and legs.  Normal balance, station, and gait.  Normal speech.,Neurologic:  Nonfocal with normal speech, station, gait, and balance.,ASSESSMENT:,  Healthy Tanner III male, developing normally.,PLAN:,1.  Diet, growth, safety, drugs, violence, and social competence all discussed.,2.  Immunizations reviewed.,3.  We will place him on Clarinex 5 mg once daily, some Rhinocort-AQ nasal spray one spray each nostril once daily and otherwise discussed the importance of him wearing glasses.,4.  Return to clinic p.r.n. and at two to three years for a physical, otherwise return p.r.n.",
 Single frontal view of the chest. Respiratory distress.  The patient has a history of malrotation., Pediatrics - Neonatal, Single Frontal View - Chest - Pediatric ,"EXAM:,  Single frontal view of the chest.,HISTORY:,  Respiratory distress.  The patient has a history of malrotation.  The patient is back for a re-anastomosis of the bowel with no acute distress.,TECHNIQUE:,  Single frontal view of the chest was evaluated and correlated with the prior film dated MM/DD/YY.,FINDINGS:,  A single frontal view of the chest was evaluated.  It reveals interval placement of an ET tube and an NG tube.  ET tube is midway between the patient's thoracic inlet and carina.  NG tube courses with the distal tip in the left upper quadrant beneath the left hemidiaphragm.  There is no evidence of any focal areas of consolidation, pneumothoraces, or pleural effusions.  The mediastinum seen was slightly prominent; however, this may be secondary to thymus and/or technique.  There is a slight increase seen with regards to the central pulmonary vessels.  Again, this may represent a minimal amount of pulmonary vascular congestion.  There is paucity of bowel gas seen in the upper abdomen.  The osseous thorax appears to be grossly intact and symmetrical.  Slightly low lung volumes, however, this may be secondary to the film being taken on the expiratory phase of respiration.,IMPRESSION:,1.  No evidence of any focal areas of consolidation, pneumothoraces, or pleural effusions.,2.  Slight prominence to the mediastinum which may be secondary to thymus and/or technique.,3.  Slight prominence of some of the central pulmonary vasculature which may represent a minimal amount of vascular congestion.","pediatrics - neonatal, malrotation, consolidation, pneumothoraces, single frontal view, respiratory distress, vascular congestion, frontal view, effusions, mediastinum, vascular, congestion, respiratory, anastomosis, pulmonary, single, frontal, chest"
 Sports physical with normal growth and development., Pediatrics - Neonatal, Sports Physical - 1 ,"HISTORY: , This child is seen for a sports physical.,NUTRITIONAL HISTORY:,  She takes meats, vegetables, and fruits.  Eats well.  Has may be 1 to 2 cups a day of milk.  Her calcium intake could be better.  She does not drink that much pop but she likes koolaid.  Her stools are normal.  Brushes her teeth.  Sees a dentist.,DEVELOPMENTAL HISTORY: , She did well in school last year.  Hearing and vision, no problems.  She wears corrective lenses.  She will be in 8th grade and involved in volleyball, basketball, and she will be moving to Texas.  She did go to Burton this last year.  She also plays clarinet, and will be involved also in cheerleading.  She likes to swim in the summer time.  Her menarche was January 2004.  It occurs every 7 weeks.  No particular problems at this time.,OTHER ACTIVITIES:  ,TV time about 2 to 3 hours a day.  She does not use drugs, alcohol, or smoke, and denies sexual activity.,MEDICATIONS:,  Advair 250/50 b.i.d., Flonase b.i.d., Allegra q.d.  120 mg, Xopenex and albuterol p.r.n.,ALLERGIES:,  No known drug allergies.,OBJECTIVE:,Vital Signs:  Blood pressure:  98/60.  Temperature:  96.6 tympanic.  Weight:  107 pounds, which places her at approximately the 60th percentile for weight and the height is about 80th percentile at 64-1/2 inches.  Her body mass index is 18.1, which is 40th percentile.  Pulse:  68.,HEENT:  Normocephalic.  Fundi benign.  Pupils are equal and reactive to light and accommodation.  Conjunctivae were non-injected.  Her pupils were equal, and reactive to light and accommodation.  No strabismus.  She wears glasses.  Her vision was 20/20 in both eyes.  TMs are bilaterally clear.  Nonerythematous.  Hearing in the ears, she was able to pass 40 decibel to 30 decibel.  With the right ear, she has some problems, but the left ear she passed.  Throat was clear.  Nonerythematous.  Good dentition.,Neck:  Supple.  Thyroid normal sized.  No increased lymphadenopathy in the submandibular nodes and no axillary nodes.,Respiratory:  Clear.  No wheezes and no crackles.  No tachypnea and no retractions.,Cardiovascular:  Regular rate and rhythm.  S1 and S2 normal.  No murmur.,Abdomen:  Soft.  No organomegaly and no masses.  No hepatosplenomegaly.,GU:  Normal female genitalia.  Tanner stage III in breast and pubic hair development and she was given a breast exam.  Negative for any masses.,Skin:  Without rash.,Extremities:  Deep tendon reflexes 2+/4+ bilaterally and equal.,Neurological:  Romberg negative.,Back:  No scoliosis.,She had good circumduction at the shoulder joints and duck walk is normal.,ASSESSMENT:,  Sports physical with normal growth and development.,PLAN:,  If problems continue, she will need to have her hearing rechecked.  Hopefully in the school, there will be a screening mat.  She received her first hepatitis A vaccine and she needs to have a booster in 6 to 12 months.  We reviewed her immunizations for tetanus and her last acellular DPT was 11/25/1996.  When she goes to Texas, Mom has an appointment already to see an allergist but she needs to find a primary care physician and we will ask for record release.  We talked about her menarche.  Recommended the exam of the breast regularly.  Talked about other anticipatory guidance including sunscreen, use of seat belts, and drugs, alcohol, and smoking, and sexual activity and avoidance at her age and to continue on her present medications.  She also has had problems with her ankles in the past.  She had no limitation here, but we gave her some ankle strengthening exercise handouts while she was in the office.", 
 Consult and Spinal fluid evaluation in a 15-day-old, Pediatrics - Neonatal, Spinal fluid evaluation ,"HISTORY:  ,This 15-day-old female presents to Children's Hospital and transferred from Hospital Emergency Department for further evaluation.  Information is obtained in discussion with the mother and the grandmother in review of previous medical records.  This patient had the onset on the day of presentation of a jelly-like red-brown stool started on Tuesday morning.  Then, the patient was noted to vomit after feeds.  The patient was evaluated at Hospital with further evaluation with laboratory data showing a white blood cell count elevated at 22.2; hemoglobin 14.1; sodium 138; potassium 7.2, possibly hemolyzed; chloride 107; CO2 23; BUN 17; creatinine 1.2; and glucose of 50, which was repeated and found to be stable in that range.  The patient underwent a barium enema, which was read by the radiologist as negative.  The patient was transferred to Children's Hospital for further evaluation after being given doses of ampicillin, cefotaxime, and Rocephin.,PAST MEDICAL HISTORY: , Further, the patient was born in Hospital.  Birth weight was 6 pounds 4 ounces.  There was maternal hypertension.  Mother denies group B strep or herpes.  Otherwise, no past medical history.,IMMUNIZATIONS: , None today.,MEDICATIONS: , Thrush medicine identified as nystatin.,ALLERGIES: , Denied.,PAST SURGICAL HISTORY: , Denied.,SOCIAL HISTORY:  ,Here with mother and grandmother, lives at home.  There is no smoking at home.,FAMILY HISTORY: , None noted exposures.,REVIEW OF SYSTEMS:  ,The patient is fed Enfamil, bottle-fed.  Has had decreased feeding, has had vomiting, has had diarrhea, otherwise negative on the 10 plus systems reviewed.,PHYSICAL EXAMINATION:,VITAL SIGNS/GENERAL:  On physical examination, the initial temperature 97.5, pulse 140, respirations 48 on this 2 kg 15-day-old female who is small, well-developed female, age appropriate.,HEENT: Head is atraumatic and normocephalic with a soft and flat anterior fontanelle.  Pupils are equal, round, and reactive to light.  Grossly conjugate.  Bilateral red reflex appreciated bilaterally.  Clear TMs, nose, and oropharynx.  There is a kind of abundant thrush and white patches on the tongue.,NECK:  Supple, full, painless, and nontender range of motion.,CHEST:  Clear to auscultation, equal, and stable.,HEART:  Regular without rubs or murmurs, and femoral pulses are appreciated bilaterally.,ABDOMEN:  Soft and nontender.  No hepatosplenomegaly or masses.,GENITALIA:  Female genitalia is present on a visual examination.,SKIN:  No significant bruising, lesions, or rash.,EXTREMITIES:  Moves all extremities, and nontender.  No deformity.,NEUROLOGICALLY:  Eyes open, moves all extremities, grossly age appropriate.,MEDICAL DECISION MAKING: , The differential entertained on this patient includes upper respiratory infection, gastroenteritis, urinary tract infection, dehydration, acidosis, and viral syndrome.  The patient is evaluated in the emergency department laboratory data, which shows a white blood cell count of 13.1, hemoglobin 14.0, platelets 267,000, 7 stabs, 68 segs, 15 lymphs, and 9 monos.  Serum electrolytes not normal.  Sodium 138, potassium 5.0, chloride 107, CO2 acidotic at 18, glucose normal at 88, and BUN markedly elevated at 22 as is the creatinine of 1.4.  AST and ALT were elevated as well at 412 and 180 respectively.  A cath urinalysis showing no signs of infection.  Spinal fluid evaluation, please see procedure note below.  White count 0, red count 2060.  Gram stain negative.,PROCEDURE NOTE: , After discussion of the risks, benefits, and indications, and obtaining informed consent with the family and their agreement to proceed, this patient was placed in the left lateral position and using aseptic Betadine preparation, sterile draping, and sterile technique pursued throughout, this patient's L4- L5 interspace was anesthetized with the 1% lidocaine solution following the above sterile preparation, entered with a 22-gauge styletted spinal needle of approximately 0.5 mL clear CSF, they were very slow to obtain.  The fluid was obtained, the needle was removed, and sterile bandage was placed.  The fluid was sent to laboratory for further evaluation (aunt and grandmother) were present throughout the period of time during this procedure and the procedure was tolerated well.  An i-STAT initially obtained showed somewhat of an acidosis with a base excess of -12.  A repeat i-STAT after a bolus of normal saline and a second bolus of normal saline, her maintenance rate of D5 half showed a base excess of -11, which is slowly improving, but not very fast.  Based on the above having this patient consulted to the Hospitalist Service at 2326 hours of request, this patient was consulted to PICU with the plan that the patient need to have continued IV fluids.  Showing signs of dehydration, a third bolus of normal saline was provided, twice maintenance D5 half was continued.  The patient was admitted to the Hospitalist Service for continued IV fluids.  The patient maintains to have clear lungs, has been feeding well here in the department, took virtually a whole small bottle of the appropriate formula.  She has not had any vomiting, is burping.  The patient is admitted for continued close observation and rehydration due to the working diagnoses of gastroenteritis, metabolic acidosis, and dehydration.  Critical care time on this patient is less than 30 minutes, exclusive, otherwise time has been spent evaluating this patient according to this patient's care and admission to the Hospitalist Service.",
" Repair of total anomalous pulmonary venous connection, ligation of patent ductus arteriosus, repair secundum type atrial septal defect (autologous pericardial patch), subtotal thymectomy, and insertion of peritoneal dialysis catheter.", Pediatrics - Neonatal, Septal Defect Repair ,"TITLE OF OPERATION:,1.  Repair of total anomalous pulmonary venous connection.,2.  Ligation of patent ductus arteriosus.,3.  Repair secundum type atrial septal defect (autologous pericardial patch).,4.  Subtotal thymectomy.,5.  Insertion of peritoneal dialysis catheter.,INDICATION FOR SURGERY: , This neonatal was diagnosed postnatally with total anomalous pulmonary venous connection.  Following initial stabilization, she was transferred to the Hospital for complete correction.,PREOP DIAGNOSIS:  ,1.  Total anomalous pulmonary venous connection.,2.  Atrial septal defect.,3.  Patent ductus arteriosus.,4.  Operative weight less than 4 kilograms (3.2 kilograms).,COMPLICATIONS: , None.,CROSS-CLAMP TIME: , 63 minutes.,CARDIOPULMONARY BYPASS TIME MONITOR:,  35 minutes, profound hypothermic circulatory arrest time (4 plus 19) equals 23 minutes.  Low flow perfusion 32 minutes.,FINDINGS:,  Horizontal pulmonary venous confluence with right upper and middle with two veins entering the confluence on the right and multiple entry sites for left-sided veins.  Large patulous anastomosis between posterior aspect of the left atrium and anterior aspect of the pulmonary venous confluence.  Nonobstructed ascending vein ligated.  Patent ductus arteriosus diminutive left atrium with posterior atrial septal defect with deficient inferior margin.  At completion of the procedure, right ventricular pressure approximating one-half of systemic, normal sinus rhythm, good biventricular function by visual inspection.,PROCEDURE: , After the informed consent, the patient was brought to the operating room and placed on the operating room table in supine position.  Upon induction of general endotracheal anesthesia and placement of indwelling arterial and venous monitoring lines.  The patient was prepped and draped in the usual sterile fashion from chin to groins.  A median sternotomy incision was performed.  Dissection was carried through the deeper planes until the sternum was scored and divided with an oscillating saw.  A subtotal thymectomy was performed.  Systemic heparinization was achieved and the pericardium was entered and fashioned until cradle.  A small portion of the anterior pericardium was procured and fixed in glutaraldehyde for patch closure of segment of the atrial septal defect during the procedure.  Pursestrings were deployed on the ascending aorta on the right.  Atrial appendage.  The aorta was then cannulated with an 8-French aorta cannula and the right atrium with an 18-French Polystan right-angle cannula.  With an ACT greater than 400, greater pulmonary bypass was commenced with excellent cardiac decompression and the patent ductus arteriosus was ligated with a 2-0 silk tie.  Systemic cooling was started and the head was packed  and iced and systemic steroids were administered.  During cooling, traction suture was placed in the apex of the left ventricle.  After 25 minutes of cooling, the aorta was cross-clamped and the heart arrested by administration of 30 cubic centimeter/kilogram of cold-blood cardioplegia delivered directly within the aortic root following the aorta cross-clamping.  Following successful cardioplegic arrest, a period of low flow perfusion was started and a 10-French catheter was inserted into the right atrial appendage substituting the 18-French Polystan venous cannula.  The heart was then rotated to the right side and the venous confluence was exposed.  It was incised and enlarged and a corresponding incision in the dorsal and posterior aspect of the left atrium was performed.  The two openings were then anastomosed in an end-to-side fashion with several interlocking sutures to avoid pursestring effect with a running 7-0 PDS suture.  Following completion of the anastomosis, the heart was returned into the chest and the patient's blood volume was drained into the reservoir.  A right atriotomy was then performed during the period of circulatory arrest.  The atrial septal defect was very difficult to expose, but it was sealed with an autologous pericardial patch was secured in place with a running 6-0 Prolene suture.  The usual deairing maneuvers were carried out and lining was administered and the right atriotomy was closed in two layers with a running 6-0 Prolene sutures.  The venous cannula was reinserted.  Cardiopulmonary bypass restarted and the aorta cross-clamp was released.  The patient returned to normal sinus rhythm spontaneously and started regaining satisfactory hemodynamics which, following a prolonged period of rewarming, allow for us to wean her from cardiopulmonary bypass successfully and moderate inotropic support and sinus rhythm.  Modified ultrafiltration was carried out and two sets of atrial and ventricular pacing wires were placed as well as the peritoneal dialysis catheter and two 15-French Blake drains.  Venous decannulation was followed by aortic decannulation and administration of protamine sulfate.  All cannulation sites were oversewn with 6-0 Prolene sutures and the anastomotic sites noticed to be hemostatic.  With good hemodynamics and hemostasis, the sternum was then smeared with vancomycin, placing closure with stainless steel wires.  The subcutaneous tissues were closed in layers with the reabsorbable monofilament sutures.  Sponge and needle counts were correct times 2 at the end of the procedure.  The patient was transferred in very stable condition to the pediatric intensive care unit .,I was the surgical attending present in the operating room and in charge of the surgical procedure throughout the entire length of the case.  Given the magnitude of the operation, the unavailability of an appropriate level, cardiac surgical resident, Mrs. X (attending pediatric cardiac surgery at the Hospital) participated during the cross-clamp time of the procedure in quality of first assistant.","pediatrics - neonatal, total anomalous pulmonary venous connection, patent ductus arteriosus, ligation, secundum type atrial septal defect, atrial septal defect, subtotal thymectomy, peritoneal dialysis catheter, cross clamp, cardiopulmonary bypass, pulmonary venous, atrial septal, septal defect, anomalous, venous, atrial, arteriosus, patent, ductus, septal, aorta, pulmonary, "
 Pediatric Gastroenterology - Rectal Bleeding Consult., Pediatrics - Neonatal, Rectal Bleeding - 1-year-old ,"HISTORY OF PRESENT ILLNESS:,  This is a 1-year-old male patient who was admitted on 12/23/2007 with a history of rectal bleeding.  He was doing well until about 2 days prior to admission and when he passes hard stools, there was bright red blood in the stool.  He had one more episode that day of stool; the stool was hard with blood in it.  Then, he had one episode of rectal bleeding yesterday and again one stool today, which was soft and consistent with dark red blood in it.  No history of fever, no diarrhea, no history of easy bruising.  Excessive bleeding from minor cut.  He has been slightly fussy.,PAST MEDICAL HISTORY:  ,Nothing significant.,PREGNANCY DELIVERY AND NURSERY COURSE: , He was born full term without complications.,PAST SURGICAL HISTORY: , None.,SIGNIFICANT ILLNESS AND REVIEW OF SYSTEMS: , Negative for heart disease, lung disease, history of cancer, blood pressure problems, or bleeding problems.,DIET:,  Regular table food, 24 ounces of regular milk.  He is n.p.o. now.,TRAVEL HISTORY: , Negative.,IMMUNIZATION: , Up-to-date.,ALLERGIES: , None.,MEDICATIONS: , None, but he is on IV Zantac now.,SOCIAL HISTORY: , He lives with parents and siblings.,FAMILY HISTORY:,  Nothing significant.,LABORATORY EVALUATION: , On 12/24/2007, WBC 8.4, hemoglobin 7.6, hematocrit 23.2 and platelets 314,000.  Sodium 135, potassium 4.7, chloride 110, CO2 20, BUN 6 and creatinine 0.3.  Albumin 3.3.  AST 56 and ALT 26.  CRP less than 0.3.  Stool rate is still negative.,DIAGNOSTIC DATA: , CT scan of the abdomen was read as normal.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Temperature 99.5 degrees Fahrenheit, pulse 142 per minute and respirations 28 per minute.  Weight 9.6 kilogram.,GENERAL:  He is alert and active child in no apparent distress.,HEENT:  Atraumatic and normocephalic.  Pupils are equal, round and reactive to light.  Extraocular movements, conjunctivae and sclerae fair.  Nasal mucosa pink and moist.  Pharynx is clear.,NECK:  Supple without thyromegaly or masses.,LUNGS:  Good air entry bilaterally.  No rales or wheezing.,ABDOMEN:  Soft and nondistended.  Bowel sounds positive.  No mass palpable.,GENITALIA:  Normal male.,RECTAL:  Deferred, but there was no perianal lesion.,MUSCULOSKELETAL:  Full range of movement.  No edema.  No cyanosis.,CNS:  Alert, active and playful.,IMPRESSION: , A 1-year-old male patient with history of rectal bleeding.  Possibilities include Meckel's diverticulum, polyp, infection and vascular malformation.,PLAN:,  To proceed with Meckel scan today.  If Meckel scan is negative, we will consider upper endoscopy and colonoscopy.  We will start colon clean out if Meckel scan is negative.  We will send his stool for C. diff toxin, culture, blood for RAST test for cow milk, soy, wheat and egg.  Monitor hemoglobin.",
 Frontal and lateral views of the hip and pelvis., Pediatrics - Neonatal, Slipped Capital Femoral Epiphysis (SCFE) ,"EXAM: , Two views of the pelvis.,HISTORY:,  This is a patient post-surgery, 2-1/2 months.  The patient has a history of slipped capital femoral epiphysis (SCFE) bilaterally.,TECHNIQUE: , Frontal and lateral views of the hip and pelvis were evaluated and correlated with the prior film dated MM/DD/YYYY.  Lateral view of the right hip was evaluated.,FINDINGS:,  Frontal view of the pelvis and a lateral view of the right hip were evaluated and correlated with the patient's most recent priors dated MM/DD/YYYY.  Current films reveal stable appearing post-surgical changes.  Again demonstrated is a single intramedullary screw across the left femoral neck and head.  There are 2 intramedullary screws through the greater trochanter of the right femur.  There is a lucency along the previous screw track extending into the right femoral head and neck.  There has been interval removal of cutaneous staples and/or surgical clips.  These were previously seen along the lateral aspect of the right hip joint.,Deformity related to the previously described slipped capital femoral epiphysis is again seen.,IMPRESSION:,1.  Stable-appearing right hip joint status-post pinning.,2.  Interval removal of skin staples as described above.","pediatrics - neonatal, scfe, frontal and lateral views, slipped capital femoral epiphysis, lateral views, slipped, capital, epiphysis, frontal, pelvis, femoral, hip"
  This patient was seen in clinic for a school physical., Pediatrics - Neonatal, School Physical - 1 ,"SUBJECTIVE:,  This patient was seen in clinic for a school physical.,NUTRITIONAL HISTORY:,  She eats well, takes meats, vegetables, and fruits, but her calcium intake is limited.  She does not drink a whole lot of pop.  Her stools are normal.  Brushes her teeth, sees a dentist.,Developmental History:  Hearing and vision is okay.  She did well in school last year.  She will be going to move to Texas, will be going to Bowie High School.  She will be involved in cheerleading, track, volleyball, and basketball.  She will be also playing the clarinet and will be a freshman in that school.  Her menarche was 06/30/2004.,PAST MEDICAL HISTORY:,  She is still on medications for asthma.  She has a problem with her eye lately, this has been bothering her, and she also has had a rash in the left leg.  She had been pulling weeds on 06/25/2004 and then developed a rash on 06/27/2004.,Review of her immunizations, her last tetanus shot was 06/17/2003.,MEDICATIONS:  ,Advair 100/50 b.i.d., Allegra 60 mg b.i.d., Flonase q.d., Xopenex, Intal, and albuterol p.r.n.,ALLERGIES: , No known drug allergies.,OBJECTIVE:,Vital Signs:  Weight:  112 pounds about 40th percentile.  Height:  63-1/4 inches, also the 40th percentile.  Her body mass index was 19.7, 40th percentile.  Temperature:  97.7 tympanic.  Pulse:  80.  Blood pressure:  96/64.,HEENT:  Normocephalic.  Fundi benign.  Pupils equal and reactive to light and accommodation.  No strabismus.  Her vision was 20/20 in both eyes and each with contacts.  Hearing:  She passed that test.  Her TMs are bilaterally clear and nonerythematous.  Throat was clear.  Good mucous membrane moisture and good dentition.,Neck:  Supple.  Thyroid normal sized.  No increased lymphadenopathy in the submandibular nodes and no axillary nodes.,Abdomen:  No hepatosplenomegaly.,Respiratory:  Clear.  No wheezes.  No crackles.  No tachypnea.  No retractions.,Cardiovascular:  Regular rate and rhythm.  S1 and S2 normal.  No murmur.,Abdomen:  Soft.  No organomegaly and no masses.,GU:  Normal female genitalia.  Tanner stage 3, breast development and pubic hair development.  Examination of the breasts was negative for any masses or abnormalities or discharge from her areola.,Extremities:  She has good range of motion of upper and lower extremities.  Deep tendon reflexes were 2+/4+ bilaterally and equal.  Romberg negative.,Back:  No scoliosis.  She had good circumduction at shoulder joint and her duck walk was normal.,SKIN:  She did have some rash on the anterior left thigh region and also some on the right lower leg that had Kebner phenomenon and maculopapular vesicular eruption.  No honey crusting was noted on the skin.  She also had some mild rash on the anterior abdominal area near the panty line similar to that rash.  It was raised and blanch with pressure, it was slightly erythematous.,ASSESSMENT AND PLAN:,1.  Sports physical.,2.  The patient received her first hepatitis A vaccine.  She will get a booster in 6 to 12 months.  Prescription for Atarax 10 mg tablets one to two tablets p.o. q.4-6h. p.r.n. and a prescription for Elocon ointment to be applied topically, except for the face, once a day with a refill.  She will be following up with an allergist as soon as she gets to Texas and needs to find a primary care physician.  We talked about anticipatory guidance including breast exam, which we have reviewed with her today, seatbelt use, and sunscreen.  We talked about avoidance of drugs and alcohol and sexual activity.  Continue on her present medications and if her rash is not improved and goes to the neck or the face, she will need to be on PO steroid medication, but presently that was held and moved to treatment with Atarax and Elocon.  Also talked about cleaning her clothes and bedding in case she has any poison ivy oil that is harboring on any clothing.","pediatrics - neonatal, school physical, calcium intake, hearing and vision, hepatitis a vaccine, booster, anticipatory guidance, developmental, percentile, physical, school, rash, "
 Well-child check and school physical., Pediatrics - Neonatal, School Physical - 2 ,"CHIEF COMPLAINT:,  Well-child check and school physical.,HISTORY OF PRESENT ILLNESS:,  This is a 9-year-old African-American male here with his mother for a well-child check.  Mother has no concerns at the time of the visit.  She states he had a pretty good school year.  He still has some fine motor issues, especially writing, but he is receiving help with that and math.  He continues to eat well.  He could do better with milk intake, but Mother states he does eat cheese and yogurt.  He brushes his teeth daily.  He has regular dental visits every six months.  Bowel movements are without problems.  He is having some behavior issues, and sometimes he tries to emulate his brother in some of his negative behaviors.,DEVELOPMENTAL ASSESSMENT:,  Social:  He has a sense of humor.  He knows his rules.  He does home chores.  Fine motor:  He is as mentioned before.  He can draw a person with six parts.  Language:  He can tell time.  He knows the days of the week.  He reads for pleasure.  Gross motor:  He plays active games.  He can ride a bicycle.,REVIEW OF SYSTEMS:,  He has had no fever and no vision problems.  He had an eye exam recently with Dr. Crum.  He has had some headaches which precipitated his vision exam.  No earache or sore throat.  No cough, shortness of breath or wheezing.  No stomachache, vomiting or diarrhea.  No dysuria, urgency or frequency.  No excessive bleeding or bruising.,MEDICATIONS:,  No daily medications.,ALLERGIES:,  Cefzil.,IMMUNIZATIONS:,  His immunizations are up to date.,PHYSICAL EXAMINATION:,General:  He is alert and in no distress, afebrile.,HEENT:  Normocephalic, atraumatic.  Pupils equal, round and react to light.  TMs are clear bilaterally.  Nares:  Patent.  Oropharynx is clear.,Neck:  Supple.,Lungs:  Clear to auscultation.,Heart:  Regular.  No murmur.,Abdomen:  Soft.  Positive bowel sounds.  No masses.  No hepatosplenomegaly.,GU:  Tanner III.,Extremities:  Symmetrical.  Femoral pulses 2+ bilaterally.  Full range of motion of all extremities.,Back:  No scoliosis.,Neurological:  Grossly intact.,Skin:  Normal turgor.  No rashes.,Hearing:  Grossly normal.,ASSESSMENT:,  Well child.,PLAN:,  Anticipatory guidance for age.  He is to return to the office in one year.",
" Well-child check sports physical - Well child asthma with good control, allergic rhinitis.", Pediatrics - Neonatal, Sports Physical - 2 ,"CHIEF COMPLAINT:,  Well-child check sports physical.,HISTORY OF PRESENT ILLNESS:,  This is a 14-1/2-year-old white male known to have asthma and allergic rhinitis.  He is here with his mother for a well-child check.  Mother states he has been doing well with regard to his asthma and allergies.  He is currently on immunotherapy and also takes Advair 500/50 mg, Flonase, Claritin and albuterol inhaler as needed.  His last exacerbation was 04/04.  He has been very competitive in his sports this spring and summer and has had no issues since that time.  He eats well from all food groups.  He has very good calcium intake.  He will be attending Maize High School in the ninth grade.  He has same-sex and opposite-sex friends.  He has had a girlfriend in the past.  He denies any sexual activity.  No use of alcohol, cigarettes or other drugs.  His bowel movements are without problems.  His immunizations are up to date.  His last tetanus booster was in 07/03.,CURRENT MEDICATIONS:,  As above.,ALLERGIES: , He has no known medication allergies.,REVIEW OF SYSTEMS:,Constitutional:  He has had no fever.,HEENT:  No vision problems.  No eye redness, itching or drainage.  No earache.  No sore throat or congestion.,Cardiovascular:  No chest pain.,Respiratory:  No cough, shortness of breath or wheezing.,GI:  No stomachache, vomiting or diarrhea.,GU:  No dysuria, urgency or frequency.,Hematological:  No excessive bruising or bleeding.  He did have a minor concussion in 06/04 while playing baseball.,PHYSICAL EXAMINATION:,General:  He is alert and in no distress.,Vital signs:  He is afebrile.  His weight is at the 75th percentile.  His height is about the 80th percentile.,HEENT:  Normocephalic.  Atraumatic.  Pupils are equal, round and reactive to light.  TMs are clear bilaterally.  Nares patent.  Nasal mucosa is mildly edematous and pink.  No secretions.  Oropharynx is clear.,Neck:  Supple.,Lungs:  Good air exchange bilaterally.,Heart:  Regular.  No murmur.,Abdomen:  Soft.  Positive bowel sounds.  No masses.  No hepatosplenomegaly.,GU:  Male.  Testes descended bilaterally.  Tanner IV.  No hernia appreciated.,Extremities:  Symmetrical.  Femoral pulses 2+ bilaterally.  Full range of motion of all extremities.,Back:  No scoliosis.,Neurological:  Grossly intact.,Skin:  Normal turgor.  Minor sunburn on upper back.,Neurological:  Grossly intact.,ASSESSMENT:,1.  Well child.,2.  Asthma with good control.,3.  Allergic rhinitis, stable.,PLAN:,  Hearing and vision assessment today are both within normal limits.  Will check an H&H today.  Continue all medications as directed.  Prescription written for albuterol inhaler, #2, one for home and one for school to be used for rescue.  Anticipatory guidance for age.  He is to return to the office in one year or sooner if needed.",
" A 7-year-old white male started to complain of pain in his fingers, elbows, and neck.  This patient may have had reactive arthritis.  ", Pediatrics - Neonatal, Pediatric Rheumatology Consult ,"HISTORY:  ,We had the pleasure of seeing the patient today in our Pediatric Rheumatology Clinic.  He was sent here with a chief complaint of joint pain in several joints for few months.  This is a 7-year-old white male who has no history of systemic disease, who until 2 months ago, was doing well and 2 months ago, he started to complain of pain in his fingers, elbows, and neck.  At this moment, this is better and is almost gone, but for several months, he was having pain to the point that he would cry at some point.  He is not a complainer according to his mom and he is a very active kid.  There is no history of previous illness to this or had gastrointestinal problems.  He has problems with allergies, especially seasonal allergies and he takes Claritin for it.  Other than that, he has not had any other problem.  Denies any swelling except for that doctor mentioned swelling on his elbow.  There is no history of rash, no stomach pain, no diarrhea, no fevers, no weight loss, no ulcers in his mouth except for canker sores.  No lymphadenopathy, no eye problems, and no urinary problems.,MEDICATIONS: , His medications consist only of Motrin only as needed and Claritin currently for seasonal allergies and rhinitis.,ALLERGIES: , He has no allergies to any drugs.,BIRTH HISTORY:  ,Pregnancy and delivery with no complications.  He has no history of hospitalizations or surgeries.,FAMILY HISTORY: , Positive for arthritis in his grandmother.  No history of pediatric arthritis.  There is history of psoriasis in his dad.,SOCIAL HISTORY: , He lives with mom, dad, brother, sister, and everybody is healthy.  They live in Easton.  They have 4 dogs, 3 cats, 3 mules and no deer.  At school, he is in second grade and he is doing PE without any limitation.,PHYSICAL EXAMINATION: ,VITAL SIGNS:  Temperature is 98.7, pulse is 96, respiratory rate is 24, height is 118.1 cm, weight is 22.1 kg, and blood pressure is 61/44.,GENERAL:  He is alert, active, in no distress, very cooperative.,HEENT:  He has no facial rash.  No lymphadenopathy.  Oral mucosa is clear.  No tonsillitis.  His ear canals are clear and pupils are reactive to light and accommodation.,CHEST:  Clear to auscultation.,HEART:  Regular rhythm and no murmur.,ABDOMEN:  Soft, nontender with no visceromegaly.,MUSCULOSKELETAL:  Shows no limitation in any of his joints or active swelling today.  He has no tenderness either in any of his joints.  Muscle strength is 5/5 in proximal muscles.,LABORATORY DATA:,  Includes an arthritis panel.  It has normal uric acid, sedimentation rate of 2, rheumatoid factor of 6, and antinuclear antibody that is negative and C-reactive protein that is 7.1.  His mother stated that this was done while he was having symptoms.,ASSESSMENT AND PLAN: , This patient may have had reactive arthritis.  He is seen frequently and the patient has family history of psoriatic arthritis or psoriasis.  I do not see any problems at this moment on his laboratories or on his physical examination.  This may have been related to recent episode of viral infection or infection of some sort.  Mother was oriented about the finding and my recommendation is to observe him and if there is any recurrence of the symptoms or persistence of swelling or limitation in any of his joints, I will be glad to see him back.,If you have any question on further assessment and plan, please do no hesitate to contact us.","pediatrics - neonatal, rheumatology, pediatric, reactive arthritis, psoriatic arthritis, psoriasis, joints, swelling, arthritis, "
" Prematurity, 34 weeks' gestation, now 5 days old, group B streptococcus exposure, but no sepsis, physiologic jaundice, and feeding problem.", Pediatrics - Neonatal, Prematurity - Discharge Summary ,"ADMITTING DIAGNOSES,1. Prematurity.,2. Appropriate for gestational age.,3. Maternal group B streptococcus positive culture.,DISCHARGE DIAGNOSES,1. Prematurity, 34 weeks' gestation, now 5 days old.,2. Group B streptococcus exposure, but no sepsis.,3. Physiologic jaundice.,4. Feeding problem.,HISTORY OF ILLNESS:  ,This is a 4-pound female infant born to a 26-year-old gravida 1, now para 1-0-0-1 lady with an EDC of November 19, 2003.  Group B streptococcus culture was positive on September 29, 2003, and betamethasone was given 1 dose prior to delivery.  Mother also received 1 dose of penicillin approximately 1-1/2 hours prior to delivery.  The infant delivered vaginally, had a double nuchal cord and required CPAP and free flow oxygen.  Her Apgars were 8 at 1 minute and 9 at 5 minutes.  At the end of delivery, it was noted there was a partial placental abruptio.,HOSPITAL COURSE:  ,The infant has had a basically uncomplicated hospital course.  She did not require oxygen.  She did have antibiotics, ampicillin and gentamicin for approximately 48 hours to cover for possible group B streptococcus.  The culture was negative and the antibiotics were stopped at 48 hours.,The infant was noted to have physiologic jaundice and her highest bilirubin was 7.1.  She was treated for approximately 24 hours with phototherapy and the bilirubin on October 15, 2003 was 3.4.,FEEDING: , The infant has had some difficulty with feeding, but at the time of discharge, she is taking approximately 30 mL every feeding and is taking Formula or breast milk, that is, ___ 24 calories per ounce.,PHYSICAL EXAMINATION:, ,VITAL SIGNS:  At discharge, reveals a well-developed infant whose temperature is 98.3, pulse 156, respirations 35, her weight is 1779 g (1% below her birthweight).,HEENT:  Head is normocephalic.  Eyes are without conjunctival injection.  Red reflex is elicited bilaterally.  TMs not well visualized.  Nose and throat are patent without palatal defect.,NECK:  Supple without clavicular fracture.,LUNGS:  Clear to auscultation.,HEART:  Regular rate without murmur, click or gallop present.,EXTREMITIES:  Pulses are 2/4 for brachial and femoral.  Extremities without evidence of hip defects.,ABDOMEN:  Soft, bowel sounds present.  No masses or organomegaly.,GENITALIA:  Normal female, but the clitoris is not covered by the labia majora.,NEUROLOGICAL:  The infant has good Moro, grasp, and suck reflexes.,INSTRUCTIONS FOR CONTINUING CARE,The infant will be discharged home.  She will have home health visits one time per week for 3 weeks, and she will be seen in followup at San Juan Pediatrics the week of October 20, 2003.  She is to continue feeding with either breast milk or Formula, that is, ___ to 24 calories per ounce.,CONDITION: , Her condition at discharge is good.",
" A 23-month-old girl has a history of reactive airway disease, is being treated on an outpatient basis for pneumonia, presents with cough and fever.", Pediatrics - Neonatal, Reactive Airway Disease ,"CHIEF COMPLAINT AND IDENTIFICATION:,  A is a 23-month-old girl, who has a history of reactive airway disease who is being treated on an outpatient basis for pneumonia who presents with cough and fever.,HISTORY OF PRESENT ILLNESS: , The patient is to known to have reactive airway disease and uses Pulmicort daily and albuterol up to 4 times a day via nebulization.,She has no hospitalizations.,The patient has had a 1 week or so history of cough.  She was seen by the primary care provider and given amoxicillin for yellow nasal discharge according to mom.  She has been taking 1 teaspoon every 6 hours.  She originally was having some low-grade fever with a maximum of 100.4 degrees Fahrenheit; however, on the day prior to admission, she had a 104.4 degrees Fahrenheit temperature, and was having posttussive emesis.  She is using her nebulizer, but the child was in respiratory distress, and this was not alleviated by the nebulizer, so she was brought to Children's Hospital Central California.,At Children's Hospital, the patient was originally treated as an asthmatic and was receiving nebulized treatments; however, a chest x-ray did show right-sided pneumonia, and the patient was hypoxemic after resolution of her respiratory distress, so the Hospitalist Service was contacted regarding admission.  The patient was seen and admitted through the emergency room.,REVIEW OF SYSTEMS: , Negative except that indicated in the history of present illness.  All systems were checked.,PAST MEDICAL HISTORY: , As stated in the history of present illness, no hospitalizations, no surgeries.,IMMUNIZATIONS: , The patient is up-to-date on her shots.  She has a schedule for her 2-year-old shot soon.,ALLERGIES: , No known drug allergies.,DEVELOPMENT HISTORY: , Developmentally, she is within normal limits.,FAMILY HISTORY:,  Her maternal uncles have asthma.  There are multiple family members on the maternal side that have diabetes mellitus, otherwise the family history is negative for other chronic medical conditions.,SOCIAL HISTORY: , Her sister has a runny nose, but no other sick contacts.  The family lives in Delano.  She lives with her mom and sister.  The dad is involved, but the parents are separated.  There is no smoking exposure.,PHYSICAL EXAMINATION:,  ,GENERAL:  The child was in no acute distress.,VITAL SIGNS:  Temperature 99.8 degrees Fahrenheit, heart rate 144, respiratory rate 28.  Oxygen saturations 98% on continuous.  Off of oxygen shows 85% laying down on room air.  The T-max in the ER was 101.3 degrees Fahrenheit.,SKIN:  Clear.,HEENT:  Pupils were equal, round, react to light.  No conjunctival injection or discharge.  Tympanic membranes were clear.  No nasal discharge.  Oropharynx moist and clear.,NECK:  Supple without lymphadenopathy, thyromegaly, or masses.,CHEST:  Clear to auscultation bilaterally; no tachypnea, wheezing, or retractions.,CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs noted.  Well perfused peripherally.,ABDOMEN:  Bowel sounds are present.  The abdomen is soft.  There is no hepatosplenomegaly, no masses, nontender to palpation.,GENITOURINARY:  No inguinal lymphadenopathy.  Tanner stage I female.,EXTREMITIES:  Symmetric in length.  No joint effusions.  She moves all extremities well.,BACK:  Straight.  No spinous defects.,NEUROLOGIC:  The patient has a normal neurologic exam.  She is sitting up solo in bed, gets on her knees, stands up, is playful, smiles, is interactive.  She has no focal neurologic deficits.,LABORATORY DATA: , Chest x-ray by my reading shows a right lower lobe infiltrate.  Metabolic panel:  Sodium 139, potassium 3.5, chloride 106, total CO2 22, BUN and creatinine are 5 and 0.3 respectively, glucose 84, CRP 4.3.  White blood cell count 13.7, hemoglobin and hematocrit 9.6 and 29.9 respectively, and platelets 294,000.  Differential of the white count 34% lymphocytes, 55% neutrophils.,ASSESSMENT AND PLAN: , This is a 22-month-old girl, who has an infiltrate on the x-ray, hypoxemia, and presented in respiratory distress.  I believe, she has bacterial pneumonia, which is partially treated by her amoxicillin, which is a failure of her outpatient treatment.  She will be placed on the pneumonia pathway and started on cefuroxime to broaden her coverage.  She is being admitted for hypoxemia.  I hope that this will resolve overnight, and she will be discharged in the morning.  I will start her home medications of Pulmicort twice daily and albuterol on a p.r.n. basis; however, at this point, she has no wheezing, so no systemic steroids will be instituted.,Further interventions will depend on the clinical course.",
" A 3-year-old female for evaluation of chronic ear infections bilateral - OM (otitis media), suppurative without spontaneous rupture.  Adenoid hyperplasia bilateral.", Pediatrics - Neonatal, Otitis Media - H&P ,"CHIEF COMPLAINT:,  This 3-year-old female presents today for evaluation of chronic ear infections bilateral.,ASSOCIATED SIGNS AND SYMPTOMS FOR OTITIS MEDIA: , Associated signs and symptoms include:  cough, fever, irritability and speech and language delay.  Duration (ENT):  Duration of symptom:  12 rounds of antibiotics for otitis media.  Quality of ear problems:  Quality of the pain is throbbing.,ALLERGIES: , No known medical allergies.,MEDICATIONS:,  None currently.,PMH:,  Past medical history is unremarkable.,PSH: , No previous surgeries.,SOCIAL HISTORY:,  Parent admits child is in a large daycare.,FAMILY HISTORY:,  Parent admits a family history of Alzheimer's disease associated with paternal grandmother.,ROS:,  Unremarkable with exception of chief complaint.,PHYSICAL EXAM:,  Temp:  99.6 Weight:  38 lbs.,Patient is a 3-year-old female who appears pleasant, in no apparent distress, her given age, well developed, well nourished and with good attention to hygiene and body habitus.,The child is accompanied by her mother who communicates well in English.,Head & Face:  Inspection of head and face shows no abnormalities.  Examination of salivary glands shows no abnormalities.  Facial strength is normal.,Eyes:  Pupil exam reveals PERRLA.,ENT:  Otoscopic examination reveals otitis media bilateral.,Hearing exam using tuning fork shows hearing to be diminished bilateral.,Inspection of left ear reveals drainage of a small amount.,Inspection of nasal mucosa, septum and turbinates reveals no abnormalities.,Frontal and maxillary sinuses all transilluminate well bilaterally.,Inspection of lips, teeth, gums, and palate reveals no gingival hypertrophy, no pyorrhea, healthy gums, healthy teeth and no abnormalities.,Inspection of the tongue reveals normal color, good motility and midline position.,Examination of oropharynx reveals no abnormalities.,Examination of nasopharynx reveals adenoid hypertrophy.,Neck:  Neck exam reveals no abnormalities.,Lymphatic:  No neck or supraclavicular lymphadenopathy noted.,Respiratory:  Chest inspection reveals chest configuration non-hyperinflated and symmetric expansion.  Auscultation of lungs reveal clear lung fields and no rubs noted.,Cardiovascular:  Heart auscultation reveals no murmurs, gallop, rubs or clicks.,Neurological/Psychiatric:  Testing of cranial nerves reveals no deficits.  Mood and affect normal and appropriate to situation.,TEST RESULTS:,  Audiometry test shows conductive hearing loss at 30 decibels and flat tympanogram.,IMPRESSION: , OM, suppurative without spontaneous rupture.  Adenoid hyperplasia bilateral.,PLAN:,  Patient scheduled for myringotomy and tubes, with adenoidectomy, using general anesthesia, as outpatient and scheduled for 08/07/2003.  Surgery will be performed at Children's Hospital.  Pre-operative consent form read and signed by parent.  Common risks and side effects of the procedure and anesthesia were mentioned.  Parent questions elicited and answered satisfactorily regarding planned procedure.  ,EDUCATIONAL MATERIAL PROVIDED: , Hospital preregistration, middle ear infection and myringtomy and tubes surgery.,PRESCRIPTIONS:,  Augmentin  Dosage:  400 mg-57 mg/5 ml powder for reconstitution  Sig:  One PO Q8h  Dispense:  1 Refills:  0  Allow Generic:  No",
" 9-month-old male product of a twin gestation complicated by some very mild prematurity having problems with wheezing, cough and shortness of breath over the last several months.", Pediatrics - Neonatal, Pediatric - Letter ,"Sample Address,RE:  Sample Patient,Dear Doctor:,We had the pleasure of seeing Abc and his mother in the clinic today.  As you certainly know, he is now a 9-month-old male product of a twin gestation complicated by some very mild prematurity.  He has been having problems with wheezing, cough and shortness of breath over the last several months.  You and your partners have treated him aggressively with inhaled steroids and bronchodilator.  Despite this, however; he has had persistent problems with a cough and has been more recently started on both a short burst of prednisolone as well as a more prolonged alternating day course.  ,Although there is no smoke exposure there is a significant family history with both Abc's father and uncle having problems with asthma as well as his older sister.  The parents now maintain separate households and there has been a question about the consistency of his medication administration at his father's house.  ,On exam today, Abc had some scattered rhonchi which cleared with coughing but was otherwise healthy.  ,We spent the majority of our 45-minute just reviewing basic principles of asthma management and I believe that Abc's mother is fairly well versed in this.  I think the most important thing to realize is that Abc probably does have fairly severe childhood asthma and fortunately has avoided hospitalization.  ,I think it would be prudent to continue his alternate day steroids until he is completely symptom free on the days off steroids but it would be reasonable to continue to wean him down to as low as 1.5 milligrams (0.5 milliliters on alternate days).  I have encouraged his mother to contact our office so that we can answer questions if necessary by phone.,Thanks so much for allowing us to be involved in his care.  ,Sincerely,","pediatrics - neonatal, gestation, bronchodilator, childhood, childhood asthma, cough, father, healthy, letter, mother, pediatric, prematurity, shortness of breath, sister, wheezing, wheezing cough, asthma, "
" He continues to have abdominal pain, and he had a diuretic renal scan, which indicates no evidence of obstruction and good differential function bilaterally. ", Pediatrics - Neonatal, Pediatric Urology Letter ,"XYZ, M.D. ,Suite 123, ABC Avenue ,City, STATE 12345 ,RE:  XXXX, XXXX ,MR#:  0000000,Dear Dr. XYZ: ,XXXX was seen in followup in the Pediatric Urology Clinic.  I appreciate you speaking with me while he was in clinic.  He continues to have abdominal pain, and he had a diuretic renal scan, which indicates no evidence of obstruction and good differential function bilaterally. ,When I examined him, he seems to indicate that his pain is essentially in the lower abdomen in the suprapubic region; however, on actual physical examination, he seems to complain of pain through his entire right side.  His parents have brought up the question of whether this could be gastrointestinal in origin and that is certainly an appropriate consideration.  They also feel that since he has been on Detrol, his pain levels have been somewhat worse, and so, I have given them the option of stopping the Detrol initially.  I think he should stay on MiraLax for management of his bowels.  I would also suggest that he be referred to Pediatric Gastroenterology for evaluation.  If they do not find any abnormalities from a gastrointestinal perspective, then the next step would be to endoscope his bladder and then make sure that he does not have any evidence of bladder anatomic abnormalities that is leading to this pain. ,Thank you for following XXXX along with us in Pediatric Urology Clinic.  If you have any questions, please feel free to contact me. ,Sincerely yours,","pediatrics - neonatal, differential function, diuretic renal scan, abdominal pain, renal scan, pediatric urology, "
 Increasing oxygen requirement.  Baby boy has significant pulmonary hypertension.  , Pediatrics - Neonatal, Pulmonary Hypertension - Pediatric Consult ,"INDICATION FOR CONSULTATION: , Increasing oxygen requirement.,HISTORY: , Baby boy, XYZ, is a 29-3/7-week gestation infant.  His mother had premature rupture of membranes on 12/20/08.  She then presented to the Labor and Delivery with symptoms of flu.  The baby was then induced and delivered.  The mother had a history of premature babies in the past.  This baby was doing well, and then, we had a significant increasing oxygen requirement from room air up to 85%.  He is now on 60% FiO2.,PHYSICAL FINDINGS,GENERAL:  He appears to be pink, well perfused, and slightly jaundiced.,VITAL SIGNS:  Pulse 156, 56 respiratory rate, 92% sat, and 59/28 mmHg blood pressure.,SKIN:  He was pink.,He was on the high-frequency ventilator with good wiggle.,His echocardiogram showed normal structural anatomy.  He has evidence for significant pulmonary hypertension.  A large ductus arteriosus was seen with bidirectional shunt.  A foramen ovale shunt was also noted with bidirectional shunt.  The shunting for both the ductus and the foramen ovale was equal left to right and right to left.,IMPRESSION: , My impression is that baby boy, XYZ, has significant pulmonary hypertension.  The best therapy for this is to continue oxygen.  If clinically worsens, he may require nitric oxide.  Certainly, Indocin should not be used at this time.  He needs to have lower pulmonary artery pressures for that to be considered.,Thank you very much for allowing me to be involved in baby XYZ's care.","pediatrics - neonatal, high-frequency ventilator, structural anatomy, foramen ovale, oxygen requirement, hypertension, pulmonary "
 Ligation (clip interruption) of patent ductus arteriosus.  This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch. , Pediatrics - Neonatal, Patent Ductus Arteriosus Ligation ,"TITLE OF OPERATION: , Ligation (clip interruption) of patent ductus arteriosus.,INDICATION FOR SURGERY: , This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch.  She has now been put forward for operative intervention.,PREOP DIAGNOSIS:  ,1.  Patent ductus arteriosus.,2.  Severe prematurity.,3.  Operative weight less than 4 kg (600 grams).,COMPLICATIONS: , None.,FINDINGS: , Large patent ductus arteriosus with evidence of pulmonary over circulation.  After completion of the procedure, left recurrent laryngeal nerve visualized and preserved.  Substantial rise in diastolic blood pressure.,DETAILS OF THE PROCEDURE: , After obtaining information consent, the patient was positioned in the neonatal intensive care unit, cribbed in the right lateral decubitus, and general endotracheal anesthesia was induced.  The left chest was then prepped and draped in the usual sterile fashion and a posterolateral thoracotomy incision was performed.  Dissection was carried through the deeper planes until the second intercostal space was entered freely with no damage to the underlying lung parenchyma.  The lung was quite edematous and was retracted anteriorly exposing the area of the isthmus.  The pleura overlying the ductus arteriosus was inside and the duct dissected in a nearly circumferential fashion.  It was then test occluded and then interrupted with a medium titanium clip.  There was preserved pulsatile flow in the descending aorta.  The left recurrent laryngeal nerve was identified and preserved.  With excellent hemostasis, the intercostal space was closed with 4-0 Vicryl sutures and the muscular planes were reapproximated with 5-0 Caprosyn running suture in two layers.  The skin was closed with a running 6-0 Caprosyn suture.  A sterile dressing was placed.  Sponge and needle counts were correct times 2 at the end of the procedure.  The patient was returned to the supine position in which palpable bilateral femoral pulses were noted.,I was the surgical attending present in the neonatal intensive care unit and in-charge of the surgical procedure throughout the entire length of the case.","pediatrics - neonatal, clip interruption, ligation, patent ductus arteriosus, premature baby, intercostal space, arteriosus, interruption, pulmonary, circulation"
 Template for History and Physical for a newborn., Pediatrics - Neonatal, Normal Newborn H&P Template ,"HISTORY OF PRESENT ILLNESS: , This is a ** week gestational age ** delivered by ** at ** on **.  Gestational age was determined by last menstrual period and consistent with ** trimester ultrasound.  ** rupture of membranes occurred ** prior to delivery and amniotic fluid was clear.  The baby was vertex presentation.  The baby was dried, stimulated, and bulb suctioned.  Apgar scores of ** at one minute and ** at five minutes.,PAST MEDICAL HISTORY,MATERNAL HISTORY:,  The mother is a **-year-old, G**, P** female with blood type **.  She is rubella immune, hepatitis surface antigen negative, RPR nonreactive, HIV negative.  Mother was group B strep **.  Mother's past medical history is **.,PRENATAL CARE: , Mother began prenatal care in the ** trimester and had at least ** documented prenatal visits.  She did not smoke, drink alcohol, or use illicit drugs during pregnancy.,SURGICAL HISTORY: , **,MEDICATIONS:,  Medications taken during this pregnancy were **.,ALLERGIES: , **,FAMILY HISTORY: , **,SOCIAL HISTORY: , **,PHYSICAL EXAMINATION,VITAL SIGNS:  Temperature **, heart rate **, respiratory rate **.  Dextrose stick **.  Ballard score by the RN is ** weeks.  Birth weight is ** grams, which is the ** percentile for gestational age.  Length is ** centimeters which is ** percentile for gestational age.  Head circumference is ** centimeters which is ** percentile for gestational age.,GENERAL:  **Alert, active, nondysmorphic-appearing infant in no acute distress.,HEENT:  Anterior fontanelle open and flat.  Positive bilateral red reflexes.,Ears have normal shape and position with no pits or tags.  Nares patent.  Palate intact.  Mucous membranes moist.,NECK:  Full range of motion.,CARDIOVASCULAR:  Normal precordium, regular rate and rhythm.  No murmurs.  Normal femoral pulses.,RESPIRATORY;  Clear to auscultation bilaterally.  No retractions.,ABDOMEN:  Soft, nondistended.  Normal bowel sounds.  No hepatosplenomegaly.  Umbilical stump is clean, dry, and intact.,GENITOURINARY:  Normal tanner I **.  Anus patent.,MUSCULOSKELETAL:  Negative Barlow and Ortolani.  Clavicles intact.  Spine straight.  No sacral dimple or hair tuft.  Leg lengths grossly symmetric.  Five fingers on each hand and five toes on each foot.,SKIN:  Warm and pink with brisk capillary refill.  No jaundice.,NEUROLOGICAL:  Normal tone.  Normal root, suck, grasp, and Moro reflexes.  Moves all extremities equally.,DIAGNOSTIC STUDIES,LABORATORY DATA:,  **,ASSESSMENT: , Full term, appropriate for gestational age **.,PLAN:,1.  Routine newborn care.,2.  Anticipatory guidance.,3.  Hepatitis B immunization prior to discharge.,",
" Fever, otitis media, and possible sepsis.", Pediatrics - Neonatal, Otitis Media - Discharge Summary ,"ADMITTING DIAGNOSES:,1.  Fever.,2.  Otitis media.,3.  Possible sepsis.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 10-month-old male who was seen in the office 1 day prior to admission.  He has had a 2-day history of fever that has gone up to as high as 103.6 degrees F. He has also had intermittent cough, nasal congestion, and rhinorrhea and no history of rashes.  He has been taking Tylenol and Advil to help decrease the fevers, but the fever has continued to rise.  He was noted to have some increased workup of breathing and parents returned to the office on the day of admission.,PAST MEDICAL HISTORY: , Significant for being born at 33 weeks' gestation with a birth weight of 5 pounds and 1 ounce.,PHYSICAL EXAMINATION: , On exam, he was moderately ill appearing and lethargic.  HEENT:  Atraumatic, normocephalic.  Pupils are equal, round, and reactive to light.  Tympanic membranes were red and yellow, and opaque bilaterally.  Nares were patent.  Oropharynx was slightly moist and pink.  Neck was soft and supple without masses.  Heart is regular rate and rhythm without murmurs.  Lungs showed increased workup of breathing, moderate tachypnea.  No rales, rhonchi or wheezes were noted.  Abdomen:  Soft, nontender, nondistended.  Active bowel sounds.  Neurologic exam showed good muscle strength, normal tone.  Cranial nerves II through XII are grossly intact.,LABORATORY FINDINGS: , He had electrolytes, BUN and creatinine, and glucose all of which were within normal limits.  White blood cell count was 8.6 with 61% neutrophils, 21% lymphocytes, 17% monocytes, suggestive of a viral infection.  Urinalysis was completely unremarkable.  Chest x-ray showed a suboptimal inspiration, but no evidence of an acute process in the chest.,HOSPITAL COURSE: , The patient was admitted to the hospital and allowed a clear liquid diet.  Activity is as tolerates.  CBC with differential, blood culture, electrolytes, BUN, and creatinine, glucose, UA, and urine culture all were ordered.  Chest x-ray was ordered as well with 2 views to evaluate for a possible pneumonia.  Pulse oximetry checks were ordered every shift and as needed with O2 ordered per nasal cannula if O2 saturations were less that 94%.  Gave D5 and quarter of normal saline at 45 mL per hour, which was just slightly above maintenance rate to help with hydration.  He was given ceftriaxone 500 mg IV once daily to treat otitis media and possible sepsis, and I will add Tylenol and ibuprofen as needed for fevers.  Overnight, he did have his oxygen saturations drop and went into oxygen overnight.  His lungs remained clear, but because of the need for O2, we instituted albuterol aerosols every 6 hours to help maintain good lung function.  The nurses were instructed to attempt to wean O2 if possible and advance the diet.  He was doing clear liquids well and so I saline locked to help to accommodate improve the mobility with the patient.  He did well the following evening with no further oxygen requirement.  He continued to spike fevers but last fever was around 13:45 on the previous day.  At the time of exam, he had 100% oxygen saturations on room air with temperature of 99.3 degrees F. with clear lungs.  He was given additional dose of Rocephin when it was felt that it would be appropriate for him to be discharged that morning.,CONDITION OF THE PATIENT AT DISCHARGE: , He was at 100% oxygen saturations on room air with no further dips at night.  He has become afebrile and was having no further increased work of breathing.,DISCHARGE DIAGNOSES:,1.  Bilateral otitis media.,2.  Fever.,PLAN:  ,Recommended discharge.  No restrictions in diet or activity.  He was continued Omnicef 125 mg/5 mL one teaspoon p.o. once daily and instructed to follow up with Dr. X, his primary doctor, on the following Tuesday.  Parents were instructed also to call if new symptoms occurred or he had return if difficulties with breathing or increased lethargy.","pediatrics - neonatal, sepsis, cough, nasal congestion, rhinorrhea, oxygen saturations, otitis media, otitis, breathing, lungs, oropharynx, fever"
 Normal newborn infant physical exam.  A well-developed infant in no acute respiratory distress., Pediatrics - Neonatal, Normal Newborn Infant Physical Exam ,"GENERAL: , A well-developed infant in no acute respiratory distress.,VITAL SIGNS:  ,Initial temperature was XX, pulse XX, respirations XX.  Weight XX grams, length XX cm, head circumference XX cm.,HEENT:  ,Head is normocephalic with anterior fontanelle open, soft, and non-bulging.  Eyes:  Red reflex elicited bilaterally.  TMs occluded with vernix and not well visualized.  Nose and throat are patent without palatal defect.,NECK: , Supple without clavicular fracture.,LUNGS:,  Clear to auscultation.,HEART:,  Regular rate without murmur, click, or gallop present.  Pulses are 2/4 for brachial and femoral.,ABDOMEN:,  Soft with bowel sounds present.  No masses or organomegaly.,GENITALIA: , Normal.,EXTREMITIES: , Without evidence of hip defects.,NEUROLOGIC:  ,The infant has good Moro, grasp, and suck reflexes.,SKIN: , Warm and dry without evidence of rash.","pediatrics - neonatal, fontanelle, normocephalic, newborn infant, physical exam, acute respiratory, newborn, respiratory, distress, head, infant,"
" A 2-1/2-year-old female with history of febrile seizures, now with concern for spells of unclear etiology, but somewhat concerning for partial complex seizures and to a slightly lesser extent nonconvulsive generalized seizures.", Pediatrics - Neonatal, New Onset Seizure ,"REASON FOR CONSULTATION: , New-onset seizure.,HISTORY OF PRESENT ILLNESS: , The patient is a 2-1/2-year-old female with a history of known febrile seizures, who was placed on Keppra oral solution at 150 mg b.i.d. to help prevent febrile seizures.  Although this has been a very successful treatment in terms of her febrile seizure control, she is now having occasional brief periods of pauses and staring, where she becomes unresponsive, but does not lose her postural tone.  The typical spell according to dad last anywhere from 10 to 15 seconds, mom says 3 to 4 minutes, which likely means probably somewhere in the 30- to 40-second period of time.  Mom did note that an episode had happened outside of a store recently, was associated with some perioral cyanosis, but there has never been a convulsive activity noted.  There have been no recent changes in her Keppra dosing and she is currently only at 20 mg/kg per day, which is overall a low dose for her.,PAST MEDICAL HISTORY: , Born at 36 weeks' gestation by C-section delivery at 8 pounds 3 ounces.  She does have a history of febrile seizures and what parents reported an abdominal migraine, but on further questioning, it appears to be more of a food intolerance issue.,PAST SURGICAL HISTORY: , She has undergone no surgical procedures.,FAMILY MEDICAL HISTORY: , There is a strong history of epilepsy on the maternal side of family including mom with some nonconvulsive seizure during childhood and additional seizures in maternal great grandmother and a maternal great aunt.  There is no other significant neurological history on the paternal side of the family.,SOCIAL HISTORY: , Currently lives with her mom, dad, and two siblings.  She is at home full time and does not attend day care.,REVIEW OF SYSTEMS:  ,Clear review of 10 systems are taken and revealed no additional findings other than those mentioned in the history of present illness.,PHYSICAL EXAMINATION:,Vital Signs:  Weight was 15.6 kg.  She was afebrile.  Remainder of her vital signs were stable and within normal ranges for her age as per the medical record.,General:  She was awake, alert, and oriented.  She was in no acute distress, only slightly flustered when trying to place the EEG leads.,HEENT:  Showed normocephalic and atraumatic head.  Her conjunctivae were nonicteric and sclerae were clear.  Her eye movements were conjugate in nature.  Her tongue and mucous membranes were moist.,Neck:  Trachea appeared to be in the midline.,Chest:  Clear to auscultation bilaterally without crackles, wheezes or rhonchi.,Cardiovascular:  Showed a normal sinus rhythm without murmur.,Abdomen:  Showed soft, nontender, and nondistended, with good bowel sounds.  There was no hepatomegaly or splenomegaly, or other masses noted on examination.,Extremities:  Showed IV placement in the right upper extremity with appropriate restraints from the IV.  There was no evidence of clubbing, cyanosis or edema throughout.  She had no functional deformities in any of her peripheral limbs.,Neurological:  From neurological standpoint, her cranial nerves were grossly intact throughout.  Her strength was good in the bilateral upper and lower extremities without any distal to proximal variation.  Her overall resting tone was normal.  Sensory examination was grossly intact to light touch throughout the upper and lower extremities.  Reflexes were 1+ in bilateral patella.  Toes were downgoing bilaterally.  Coordination showed accurate striking ability and good rapid alternating movements.  Gait examination was deferred at this time due to EEG lead placement.,ASSESSMENT:,  A 2-1/2-year-old female with history of febrile seizures, now with concern for spells of unclear etiology, but somewhat concerning for partial complex seizures and to a slightly lesser extent nonconvulsive generalized seizures.,RECOMMENDATIONS,1.  For now, we will go ahead and try to capture EEG as long as she tolerates it; however, if she would require sedation, I would defer the EEG until further adjustments to seizure medications are made and we will see her response to these medications.,2.  As per the above, I will increase her Keppra to 300 mg p.o. b.i.d. bringing her to a total daily dose of just under 40 mg/kg per day.  If further spells are noted, we may increase upwards again to around 4.5 to 5 mL each day.,3.  I do not feel like any specific imaging needs to be done at this time until we see her response to the medication and review her EEG findings.  EEG, hopefully, will be able to be reviewed first thing tomorrow morning; however, I would not delay discharge the patient to wait on the EEG results.  The patient has been discharged and we will contact the family as an outpatient.,4.  The patient will need followup arrangement with me in 5 to 6 weeks' time, so we may recheck and see how she is doing and arrange for further followup then.",
"  The patient is an 1812 g baby boy born by vaginal delivery to a 32-year-old gravida 3, para 2 at 34 weeks of gestation.  Mother had two previous C-sections.", Pediatrics - Neonatal, Neonatal Discharge Summary ,"HOSPITAL COURSE:,  The patient is an 1812 g baby boy born by vaginal delivery to a 32-year-old gravida 3, para 2 at 34 weeks of gestation.  Mother had two previous C-sections.  Baby was born at 5:57 on 07/30/2006.  Mother received ampicillin 2 g 4 hours prior to delivery.  Mother came with preterm contractions, with progressive active labor in spite of the terbutaline and magnesium sulfate.  Baby was born with Apgar scores of 8 and 9 at delivery.  Fluid was cleared.  Nuchal cord x1.  Prenatal was at ABC Valley.  Prenatal labs were O positive, antibody negative, rubella immune, RPR nonreactive.  Baby was suctioned on perineum with good support.  The baby was admitted to the NICU for prematurity and to rule out sepsis.  Baby's cry was good.  Color, tone, and __________ mild retractions.  CBC, CRP, blood cultures were done.  IV fluids of D10 at a rate of 6 mL an hour.  Ampicillin and gentamicin were started via protocol.  At the time of admission, the patient was stable on room air and has feeding issues.  Baby was fed EBM 22 and NeoSure per os.  Ampicillin and gentamicin were started per protocol but were discontinue when blood cultures came out negative after 48 hours.  The patient continues on feeding issues, will not suck properly, was kept in the NICU, and put on OG tube for a couple of days after which p.o. feeds were advanced.  Also, the baby was able to suck properly and was tolerating feeds.  The baby was fed EBM 22 and NeoSure was added a day before discharge.  At the time of discharge, baby was stable on room air, baby was tolerated p.o. foods and was sucking properly, was taking ad lib feeds and gaining weight.,ADMISSION DIAGNOSES:,  Respiratory distress, rule out sepsis and prematurity.,DISCHARGE DIAGNOSES:,  Stable, ex-34-week preemie.,Pediatrician after discharge will be Dr. X.,DISCHARGE INSTRUCTIONS: , To follow up with Dr. X in 2 to 3 days, an appointment was made for 08/14/2006.  CPR teaching was completed on 08/11/2006 to parents.  Formula feeding schedule with breast and NeoSure 2 to 3 ounces per feed.  Ad lib feeding on demand.","pediatrics - neonatal, gestation, preemie, prematurity, sepsis, neosure, feeds, born, delivery, perineum, discharge,"
 Normal child physical exam template., Pediatrics - Neonatal, Normal Child Exam Template ,"CHILD PHYSICAL EXAMINATION,VITAL SIGNS:  Birth weight is ** grams, length **, occipitofrontal circumference **.  Character of cry was lusty.,GENERAL APPEARANCE:  Well.,BREATHING:  Unlabored.,SKIN:  Clear.  No cyanosis, pallor, or icterus.  Subcutaneous tissue is ample.,HEAD:  Normal.  Fontanelles are soft and flat.  Sutures are opposed.,EYES:  Normal with red reflex x2.,EARS:  Patent.  Normal pinnae, canals, TMs.,NOSE:  Patent nares.,MOUTH:  No cleft.,THROAT:  Clear.,NECK:  No masses.,CHEST:  Normal clavicles.,LUNGS:  Clear bilaterally.,HEART:  Regular rate and rhythm without murmur.,ABDOMEN:  Soft, flat.  No hepatosplenomegaly.  The cord is three vessel.,GENITALIA:  Normal ** genitalia **with testes descended bilaterally.,ANUS:  Patent.,SPINE:  Straight and without deformity.,EXTREMITIES:  Equal movements.,MUSCLE TONE:  Good.,REFLEXES:  Moro, grasp, and suck are normal.,HIPS:  No click or clunk.","pediatrics - neonatal, child physical examination, physical, genitalia, child, "
" Skull, complete, five images.", Pediatrics - Neonatal, Multiple Images of Skull (Pediatric) ,"EXAM:,  Skull, complete, five images,HISTORY:,  Plagiocephaly.,TECHNIQUE: , Multiple images of the skull were evaluated.  There are no priors for comparison.,FINDINGS: , Multiple images of the skull were evaluated and they reveal radiographic visualization of the cranial sutures without evidence of closure.  There is no evidence of any craniosynostosis.  There is no radiographic evidence of plagiocephaly.,IMPRESSION: , No evidence of craniosynostosis or radiographic characteristics for plagiocephaly.","pediatrics - neonatal, craniosynostosis, plagiocephaly, complete five images, multiple images, radiographic, images, skull, "
" Respiratory distress syndrome, intrauterine growth restriction, thrombocytopenia, hypoglycemia, retinal immaturity.  The baby is an ex-32 weeks small for gestational age infant with birth weight 1102.", Pediatrics - Neonatal, Neonatal Discharge Summary - 1 ,"ADMITTING DIAGNOSES:,  Respiratory distress syndrome, intrauterine growth restriction, thrombocytopenia, hypoglycemia, retinal immaturity.,HISTORY OF PRESENTING ILLNESS: , The baby is an ex-32 weeks small for gestational age infant with birth weight 1102.  Baby was born at ABCD Hospital at 1333 on 07/14/2006.  Mother is a 20-year-old gravida 1, para 0 female who received prenatal care.  Prenatal course was complicated by low amniotic fluid index and hypertension.  She was evaluated for evolving preeclampsia and had a C-section secondary to the nonreassuring fetal status.  Baby delivered operatively, Apgar scores were 8 and 9 initially taken to level 2 satellite nursery and arrangements were to transfer to Children's Hospital.  Infant was transferred to Children's Hospital for higher level of care, stayed at Children's Hospital for approximately 2 weeks, and was transferred back to ABCD where he stayed until he was discharged on 08/16/2006.,HOSPITAL COURSE: , At the time of transfer to ABCD, these were the following issues.,FEEDING AND NUTRITION: , Baby was on TPN and p.o. feeds had been started and were advanced 1 ml q.6h.  Baby was tolerating p.o. feeds of expressed breast milk and baby began to experience some abdominal distention.  The p.o. feeds were held and IV D10 water was given.  Baby was started on Mylicon drops and glycerin suppositories.  Abdominal ultrasound showed gaseous distention without signs of obstruction.  OG tube was passed.  Baby improved after couple of days when p.o. feedings were restarted.  Baby was also given Reglan.  At the time of discharge, baby was tolerating p.o. feeds well of BM fortified with 22-cal NeoSure.  Feeding amounts at the time of discharge was between 35 to 50 mL per feed and weight was 1797 grams.,RESPIRATIONS: , At the time of admission, baby was not having any apnea spells, no bradycardia or desaturations, was saturating well on room air and continued to do well on room air until the time of discharge.,HYPOGLYCEMIA: , Baby began to experience hypoglycemic episodes on 07/24/2006.  Blood glucose level was as low as 46.  D10 was given initially as bolus.  Baby continued to experience hypoglycemic episodes.  Diazoxide was started 5 mg/kg per os every 8 hours and fingersticks were done to monitor blood glucose level.  The baby improved with diazoxide, hypoglycemic issues resolved and then began again.  Diazoxide was discontinued, but the hypoglycemic issues restarted.  The Diazoxide was restarted again.  Blood glucose level stabilized and then diazoxide was weaned off until daily dose of 6 mg/kg and then the diazoxide was discontinued.  At the time of discharge, blood glucose levels were not being stable for 24 hours.,CARDIOVASCULAR: , Infant was hemodynamically stable on admission from Madera.  Infant has a closed PDA.  Infant had two cardiac echograms done.  The lab showing normal antegrade flow across the right coronary artery as well as the left main and left anterior descending coronary artery, then the circumflex coronary artery.,CNS:,  Infant had a head ultrasound done to rule out intracranial abnormalities and intracranial hemorrhage.  The ultrasound was negative for intracranial hemorrhage.,INFECTIOUS DISEASE:,  The patient had been on antibiotics during the stay at Madera.  At the time of admission to the ABCD, the patient was not on any antibiotics and his clinically condition has remained stable.,HEMATOLOGY: , The patient is status post phototherapy at Madera and was started on iron.,OPHTHALMOLOGY: ,  Exam on 07/17/2006 showed immature retina.  The patient is to get followup exam after discharge.,DISCHARGE DIAGNOSIS: , Stable ex-32-weeks preemie.,DISCHARGE INSTRUCTIONS: , The patient has been educated on CPR measures.  Followup appointment has been made at Kid's Care.  Calcium challenge has been done.  The patient's parents are comfortable with feeding.  The patient has been discharged on NeoSure and expressed breast milk.,","pediatrics - neonatal, delivered, preeclampsia, immaturity, intrauterine, prenatal, coronary artery, blood glucose, discharge, baby, coronary, intracranial, hypoglycemia, hypoglycemic, infant, "
" Suspected mastoiditis ruled out, right acute otitis media, and severe ear pain resolving.  The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis.  ", Pediatrics - Neonatal, Mastoiditis - Discharge Summary ,"DISCHARGE DIAGNOSES:  ,1.  Suspected mastoiditis ruled out.,2.  Right acute otitis media.,3.  Severe ear pain resolving.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis.  The child has had very severe ear pain and blood draining from the right ear.  The child had a temperature maximum of 101.4 in the ER.  The patient was admitted and started on IV Unasyn, which he tolerated well and required Morphine and Vicodin for pain control.  In the first 12 hours after admission, the patient's pain decreased and also swelling of his cervical area decreased.  The patient was evaluated by Dr. X from the ENT while in house.  After reviewing the CT scan, it was felt that the CT scan was not consistent with mastoiditis.  The child was continued on IV fluid and narcotics for pain as well as Unasyn until the time of discharge.  At the time of discharge his pain is markedly decreased about 2/10 and swelling in the area has improved.  The patient is also able to take p.o. well.,DISCHARGE PHYSICAL EXAMINATION:,GENERAL:  The patient is alert, in no respiratory distress.,VITAL SIGNS:  His temperature is 97.6, heart rate 83, blood pressure 105/57, respiratory rate 16 on room air.,HEENT:  Right ear shows no redness.  The area behind his ear is nontender.  There is a large posterior chains node that is nontender and the swelling in this area has decreased markedly.,NECK:  Supple.,CHEST:  Clear breath sounds.,CARDIAC:  Normal S1, S2 without murmur.,ABDOMEN:  Soft.  There is no hepatosplenomegaly or tenderness.,SKIN:  Warm and well perfused.,DISCHARGE WEIGHT: , 38.7 kg.,DISCHARGE CONDITION: , Good.,DISCHARGE DIET:,  Regular as tolerated.,DISCHARGE MEDICATIONS:  ,1.  Ciprodex Otic Solution in the right ear twice daily.,2.  Augmentin 500 mg three times daily x10 days.,FOLLOW UP:  ,1.  Dr. Y in one week (ENT).,2.  The primary care physician in 2 to 3 days.,TIME SPENT: , Approximate discharge time is 28 minutes.", 
 Mediastinal exploration and delayed primary chest closure.  The patient is a 12-day-old infant who has undergone a modified stage I Norwood procedure with a Sano modification. , Pediatrics - Neonatal, Mediastinal Exploration ,"TITLE OF OPERATION:,  Mediastinal exploration and delayed primary chest closure.,INDICATION FOR SURGERY:,  The patient is a 12-day-old infant who has undergone a modified stage I Norwood procedure with a Sano modification.  The patient experienced an unexplained cardiac arrest at the completion of the procedure, which required institution of extracorporeal membrane oxygenation for more than two hours following discontinuation of cardiopulmonary bypass.  The patient has been successfully resuscitated with extracorporeal membrane oxygenation and was decannulated 48 hours ago.  She did not meet the criteria for delayed primary chest closure.,PREOP DIAGNOSIS: , Open chest status post modified stage I Norwood procedure.,POSTOP DIAGNOSIS: , Open chest status post modified stage I Norwood procedure.,ANESTHESIA:,  General endotracheal.,COMPLICATIONS:,  None.,FINDINGS: , No evidence of intramediastinal purulence or hematoma.  At completion of the procedure no major changes in hemodynamic performance.,DETAILS OF THE PROCEDURE: , After obtaining informed consent, the patient was brought to the room, placed on the operating room table in supine position.  Following the administration of general endotracheal anesthesia, the chest was prepped and draped in the usual sterile fashion and all the chest drains were removed.  The chest was then prepped and draped in the usual sterile fashion and previously placed segmental AlloDerm was removed.  The mediastinum was then thoroughly irrigated with diluted antibiotic irrigation and both pleural cavities suctioned.  Through a separate incision and another 15-French Blake drain was inserted and small titanium clips were utilized to mark the rightward aspect of the RV-PA connection as well as inferior most aspect of the ventriculotomy.  The pleural spaces were opened widely and the sternum was then spilled with vancomycin paste and closed the sternum with steel wires.  The subcutaneous tissue and skin were closed in layers.  There was no evidence of significant increase in central venous pressure or desaturation.  The patient tolerated the procedure well.  Sponge and needle counts were correct times 2 at the end of the procedure.  The patient was transferred to the Pediatric Intensive Care Unit shortly thereafter in critical but stable condition.,I was the surgical attending present in the operating room in charge of the surgical  procedure throughout the entire length of the case.","pediatrics - neonatal, mediastinal exploration, delayed primary chest closure, extracorporeal membrane oxygenation, stage i norwood procedure, sano modification, chest closure, infant, mediastinal, exploration, closure, endotracheal, chest"
" This is a 14-month-old baby boy Caucasian who came in with presumptive diagnosis of Kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated neutrophils and thrombocytosis, elevated CRP and ESR. ", Pediatrics - Neonatal, Kawasaki Disease - Discharge Summary ,"ADMITTING DIAGNOSIS: , Kawasaki disease.,DISCHARGE DIAGNOSIS:,  Kawasaki disease, resolving.,HOSPITAL COURSE:,  This is a 14-month-old baby boy Caucasian who came in with presumptive diagnosis of Kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated neutrophils and thrombocytosis, elevated CRP and ESR.  When he was sent to the hospital, he had a fever of 102.  Subsequently, the patient was evaluated and based on the criteria, he was started on high dose of aspirin and IVIG.  Echocardiogram was also done, which was negative.  IVIG was done x1, and between 12 hours of IVIG, he spiked fever again; it was repeated twice, and then after second IVIG, he did not spike any more fever.  Today, his fever and his rash have completely resolved.  He does not have any conjunctivitis and no redness of mucous membranes.  He is more calm and quite and taking good p.o.; so with a very close followup and a cardiac followup, he will be sent home.,DISCHARGE ACTIVITIES:,  Ad-lib.,DISCHARGE DIET: , PO ad-lib.,DISCHARGE MEDICATIONS: , Aspirin high dose 340 mg q.6h. for 1 day and then aspirin low dose 40 mg q.d. for 14 days and then Prevacid also to prevent his GI from aspirin 15 mg p.o. once a day.  He will be followed by his primary doctor in 2 to 3 days.  Cardiology for echo followup in 4 to 6 weeks and instructed not to give any vaccine in less than 11 months because of IVIG, all the live virus vaccine, and if he gets any rashes, any fevers, should go to primary care doctor as soon as possible.","pediatrics - neonatal, mucous membranes, conjunctivitis, ad lib, kawasaki disease, vaccine, fever, aspirin"
" The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma of the right adrenal gland with favorable Shimada histology and history of stage 2 left adrenal neuroblastoma, status post gross total resection.", Pediatrics - Neonatal, Neuroblastoma - Consult ,"REASON FOR VISIT:,  The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma here for ongoing management of his disease and the visit is supervised by Dr. X.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-month-old with neuroblastoma, which initially presented on the left when he was 6 weeks old and was completely resected.  It was felt to be stage 2.  It was not N-Myc amplified and had favorable Shimada histology.  In followup, he was found to have a second primary in his right adrenal gland, which was biopsied and also consistent with neuroblastoma with favorable Shimada histology.  He is now being treated with chemotherapy per protocol P9641 and not on study.  He last received chemotherapy on 05/21/07, with carboplatin, cyclophosphamide, and doxorubicin.  He received G-CSF daily after his chemotherapy due to neutropenia that delayed his second cycle.  In the interval since he was last seen, his mother reports that he had a couple of days of nasal congestion, but it is now improving.  He is not acted ill or had any fevers.  He has had somewhat diminished appetite, but it seems to be improving now.  He is peeing and pooping normally and has not had any diarrhea.  He did not have any appreciated nausea or vomiting.  He has been restarted on fluconazole due to having redeveloped thrush recently.,REVIEW OF SYSTEMS: , The following systems reviewed and negative per pathology except as noted above.  Eyes, ears, throat, cardiovascular, GI, genitourinary, musculoskeletal skin, and neurologic., PAST MEDICAL HISTORY:,  Reviewed as above and otherwise unchanged.,FAMILY HISTORY:,  Reviewed and unchanged.,SOCIAL HISTORY: , The patient's parents continued to undergo a separation and divorce.  The patient spends time with his father and his family during the first part of the week and with his mother during the second part of the week.,MEDICATIONS:  ,1.  Bactrim 32 mg by mouth twice a day on Friday, Saturday, and Sunday.,2.  G-CSF 50 mcg subcutaneously given daily in his thighs alternating with each dose.,3.  Fluconazole 37.5 mg daily.,4.  Zofran 1.5 mg every 6 hours as needed for nausea.,ALLERGIES: , No known drug allergies.,FINDINGS: , A detailed physical exam revealed a very active and intractable, well-nourished 11-month-old male with weight 10.5 kilos and height 76.8 cm.  Vital Signs:  Temperature is 35.3 degrees Celsius, pulse is 121 beats per minute, respiratory rate 32 breaths per minute, blood pressure 135/74 mmHg.  Eyes:  Conjunctivae are clear, nonicteric.  Pupils are equally round and reactive to light.  Extraocular muscle movements appear intact with no strabismus.  Ears:  TMs are clear bilaterally.  Oral Mucosa:  No thrush is appreciated.  No mucosal ulcerations or erythema.  Chest:  Port-a-Cath is nonerythematous and nontender to VP access port.  Respiratory:  Good aeration, clear to auscultation bilaterally.  Cardiovascular:  Regular rate, normal S1 and S2, no murmurs appreciated.  Abdomen is soft, nontender, and no organomegaly, unable to appreciate a right-sided abdominal mass or any other masses.  Skin:  No rashes.  Neurologic:  The patient walks without assistance, frequently falls on his bottom.,LABORATORY STUDIES: , CBC and comprehensive metabolic panel were obtained and they are significant for AST 51, white blood cell count 11,440, hemoglobin 10.9, and platelets 202,000 with ANC 2974.  Medical tests none.  Radiologic studies are none.,ASSESSMENT: , This patient's disease is life threatening, currently causing moderately severe side effects.,PROBLEMS DIAGNOSES:  ,1.  Neuroblastoma of the right adrenal gland with favorable Shimada histology.,2.  History of stage 2 left adrenal neuroblastoma, status post gross total resection.,3.  Immunosuppression.,4.  Mucosal candidiasis.,5.  Resolving neutropenia.,PROCEDURES AND IMMUNIZATIONS:,  None.,PLANS:  ,1.  Neuroblastoma.  The patient will return to the Pediatric Oncology Clinic on 06/13/07 to 06/15/07 for his third cycle of chemotherapy.  I will plan for restaging with CT of the abdomen prior to the cycle.,2.  Immunosuppression.  The patient will continue on his Bactrim twice a day on Thursday, Friday, and Saturday.  Additionally, we will tentatively plan to have him continue fluconazole since this is his second episode of thrush.,3.  Mucosal candidiasis.  We will continue fluconazole for thrush.  I am pleased that the clinical evidence of disease appears to have resolved.  For resolving neutropenia, I advised Gregory's mother about it is okay to discontinue the G-CSF at this time.  We will plan for him to resume G-CSF after his next chemotherapy and prescription has been sent to the patient's pharmacy.,PEDIATRIC ONCOLOGY ATTENDING: , I have reviewed the history of the patient.  This is an 11-month-old with neuroblastoma who received chemotherapy with carboplatin, cyclophosphamide, and doxorubicin on 05/21/07 for cycle 2 of POG-9641 due to his prior history of neutropenia, he has been on G-CSF.  His ANC is nicely recovered.  He will have a restaging CT prior to his next cycle of chemotherapy and then return for cycle 3 chemotherapy on 06/13/07 to 06/15/07.  He continues on fluconazole for recent history of thrush.  Plans are otherwise documented above.",
" This is a 3-week-old, NSVD, Caucasian baby boy transferred from ABCD Memorial Hospital for rule out sepsis and possible congenital heart disease. ", Pediatrics - Neonatal, Neonatal Consult ,"INFORMANT:,  Dad on phone.  Transferred from ABCD Memorial Hospital, rule out sepsis.,HISTORY:  ,This is a 3-week-old, NSVD, Caucasian baby boy transferred from ABCD Memorial Hospital for rule out sepsis and possible congenital heart disease.  The patient had a fever of 100.1 on 09/13/2006 taken rectally, and mom being a nurse, took the baby to the hospital and he was admitted for rule out sepsis.  All the sepsis workup was done, CBC, UA, LP, and CMP, and since a murmur was noted 2/5, he also had an echo done.  The patient was put on ampicillin and cefotaxime.  Echo results came back and they showed patent foramen ovale/ASD with primary pulmonary stenosis and then considering severe congenital heart disease, he was transferred here on vancomycin, ampicillin, and cefotaxime.  The patient was n.p.o. when he came in.  He was on 3/4 L of oxygen.  According to the note, it conveyed that he had some subcostal retractions.  On arriving here, baby looks very healthy.  He has no subcostal retractions.  He is not requiring any oxygen and he is positive for urine and stool.  The stool is although green in color, and in the morning today, he spiked a fever of 100.1, but right now he is afebrile.  ED called that case is a direct admit.,REVIEW OF SYSTEMS:  ,The patient supposedly had fever, some weight loss, poor appetite.  The day he had fever, no rash, no ear pain, no congestion, no rhinorrhea, no throat pain, no neck pain, no visual changes, no conjunctivitis, no cough, no dyspnea, no vomiting, no diarrhea, and no dysuria.  According to mom, baby felt floppy on the day of fever and he also used to have stools every day 4 to 6 which is yellowish-to-green in color, but today the stool we noticed was green in color.  He usually has urine 4 to 5 a day, but the day he had fever, his urine also was low.  Mom gave baby some Pedialyte.,PAST MEDICAL HISTORY:,  None.,HOSPITALIZATIONS:,  Recent transfer from ABCD for the rule out sepsis and heart disease.,BIRTH HISTORY:  ,Born on 08/23/2006 at Memorial Hospital, NSVD, no complications.  Hospital stay 24 hours.  Breast-fed, no formula, no jaundice, 7 pounds 8 ounces.,FAMILY HISTORY:,  None.,SURGICAL HISTORY: , None.,SOCIAL HISTORY:  ,Lives with mom and dad.  Dad is a service manager at GMC; 4-year-old son, who is healthy; and 2 cats, 2 dogs, 3 chickens, 1 frog.  They usually visit to a ranch, but not recently.  No sick contact and no travel.,MEDICATIONS: , Has been on vancomycin, cefotaxime, and ampicillin.,ALLERGIES:,  No allergies.,DIET:,  Breast feeds q.2h.,IMMUNIZATIONS: , No immunizations.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 99, pulse 158, respiratory rate 68, blood pressure 87/48, oxygen 100% on room air.,MEASUREMENTS:  Weight 3.725 kg.,GENERAL:  Alert and comfortable and sleeping.,SKIN:  No rash.,HEENT:  Intact extraocular movements.  PERRLA.  No nasal discharge.  No nasal cannula, but no oxygen is flowing active, and anterior fontanelle is flat.,NECK:  Soft, nontender, supple.,CHEST:  CTAP.,GI:  Bowel sounds present.  Nontender, nondistended.,GU:  Bilaterally descended testes.,BACK:  Straight.,NEUROLOGIC:  Nonfocal.,EXTREMITIES:  No edema.  Bilateral pedal pulses present and upper arm pulses are also present.,LABORATORY DATA:,  As drawn on 09/13/2006 at ABCD showed WBC 4.2, hemoglobin 11.8, hematocrit 34.7, platelets 480,000.  Sodium 140, potassium 4.9, chloride 105, bicarbonate 28, BUN 7, creatinine 0.4, glucose 80, CRP 0.5.  Neutrophils 90, bands 7, lymphocytes 27, monocytes 12, and eosinophils 4.  Chest x-ray done on 09/13/2006 read as mild left upper lobe infiltrate, but as seen here, and discussed with Dr. X, we did not see any infiltrate and CBG was normal.  UA and LP results are pending.  Also pending are cultures for blood, LP, and urine.,ASSESSMENT AND PLAN: , This is a 3-week-old Caucasian baby boy admitted for rule out sepsis and congenital heart disease.,INFECTIOUS DISEASE/PULMONARY: , Afebrile with so far 20-hour blood cultures, LP and urine cultures are negative.  We will get all the results from ABCD and until then we will continue to rule out sepsis protocol and put the patient on ampicillin and cefotaxime.  The patient could be having fever due to mild gastroenteritis or urinary tract infection, so to rule out all these things we have to wait for all the results.,CVS: , He had a grade 2/5 murmur status post echo, which showed a patent foramen ovale, as well as primary pulmonary stenosis.  These are the normal findings in a newborn as discussed with Dr. Y, so we will just observe the patient.  He does not need any further workup.,GASTROINTESTINAL: ",
" A 1-month-26-day-old with failure-to-thrive. was only at her birth weight, and was noted to have murmur.", Pediatrics - Neonatal, Infant Not Gaining Weight ,"CHIEF COMPLAINT:,  Not gaining weight.,HISTORY OF PRESENT ILLNESS:,  The patient is a 1-month-26-day-old African-American female in her normal state of health until today when she was taken to her primary care physician's office to establish care and to follow up on her feeds.  The patient appeared to have failure-to-thrive. was only at her birth weight but when eating one may be possibly gaining 2 ounces every 3-4 hours, and was noted to have a murmur.  At this point, the Hospitalist Service was contacted for admission.  The patient was directly admitted to Children's Hospital Explore Ward.,In the explore ward, she was noted to be in mild respiratory distress and has some signs and symptoms of heart failure and had a prominent murmur, so an echo was done at bedside, which did show a moderately-sized patent ductus arteriosus and very small VSD and some mild signs and symptoms of congestive heart failure.  The patient was also seen by Dr. X of Cardiology Service and a plan was then obtained.,PAST MEDICAL/BIRTH HISTORY: , The patient was born at term repeat C-section to a 27-year-old G3, P2 African-American female.  Pregnancy was not complicated by hypertension, diabetes, drugs, alcohol abuse or smoking.  Birthweight was 7 pounds 4 ounces at Community Hospital.  The mother did have a repeat C-section.  There is no rupture of membranes or group B strep status.  The prenatal care began in the second month of pregnancy and was otherwise uncomplicated.  Mother denies any sexual transmitted diseases or other significant illness.  The patient was discharged home on day of life #3 without any complications.,ALLERGIES:,  No known drug allergies.,DIET: , The patient only takes Enfamil 20 calories, 1-3 ounces per history every 3-4 hours.,ELIMINATION: , The patient urinates 3-4 times a day and has a bowel movement 3-4 times a day.,FAMILY HISTORY/SOCIAL HISTORY: , The patient lives with the mother.  She has 2 older male siblings.  All were reported good health.  Family history is negative for any congenital heart disease, syndromes, hypertension, sickle cell anemia or sickle cell trait and no significant positive PPD contacts and history of second-hand smoke exposures.,REVIEW OF SYSTEMS:  ,GENERAL:  The patient has been reported to have normal activity and normal cry with no significant weight loss per mom's report, but conversely no significant weight gain.  Mother does not report that she sweats whenever she eats or has any episodes of cyanosis.  ,HEENT:  Denies any significant nasal congestion or cough.  ,RESPIRATORY:  Denies any difficulty breathing or wheezing.  ,CARDIOVASCULAR:  As per above.  GI:  No history of any persistent vomiting or diarrhea.  ,GU:  Denies any decreased urinary output.  ,MUSCULOSKELETAL:  Negative.  ,NEUROLOGICAL:  Negative.  ,SKIN:  Negative.,All other systems reviewed are negative.,PHYSICAL EXAMINATION:,GENERAL:  The patient is examined in her room, our next floor.  She is crying very vigorously, especially when I examined but she is consolable.,VITAL SIGNS:  Temperature currently is 96.3, heart rate 137, respirations 36, blood pressure 105/61 while crying.,HEENT:  Normocephalic.  The patient has a possible right temporoparietal bossing noted and slightly irregular shaped trapezoidal-shaped head.  The anterior fontanelle is soft and flat.  Pupils are equal, reactive to light and accommodation, but there is some mild hypertelorism.  There is also some mild posterior rotation of the ears.  Oropharynx, mucous membranes are pink and moist.  There is a slightly high arched palate.,NECK:  Significant for possible mild reddening of the neck.,LUNGS:  Significant for perihilar crackles.  Mild tachypnea is noted.  O2 saturations are currently 97% on room air.  There is mild intercostal retraction.,CARDIOVASCULAR:  Heart has regular rate and rhythm.  Peripheral pulses are only 1+.  Capillary refills less than 3-4 seconds.,EXTREMITIES:  Slightly cool to touch.  There is 2-3/6 systolic murmur along the left sternal border.  Does radiate to the axilla and to the back.,ABDOMEN:  Soft, slightly distended, but nontender.  The liver edge is palpable 4 cm below right costal margin.  The spleen tip is also palpable.,GU:  Normal female external genitalia is noted.,MUSCULOSKELETAL:  The patient has poor fat deposits in her extremities.  Strength is only 2/4.  She had normal number of fingers and toes.,SKIN:  Significant for slight mottling.  There are very poor subcutaneous fat deposits in her skin.,LABORATORY DATA: , The i-STAT only shows sodium 135, potassium on a heel stick was 6.3, hemoglobin and hematocrit are 14 and 41, and white count was 1.4.  CBG on i-STAT showed the pH of 7.34 with CO2 of 55, O2 sat of 51, CO2 of 29 with the base excess of 4.  Chest x-ray shows bilateral infiltrates and significant cardiomegaly consistent with congenital heart disease and mild congestive heart failure.,ASSESSMENT: , This is an almost 2-month-old presents with:,1.  Failure-to-thrive.,2.  Significant murmur and patent ductus arteriosus.,3.  Congestive heart failure.,PLAN:  ,At present, we are going to admit and monitor closely tonight.  We will get a chest x-ray and start Lasix at 1 mg/kg twice daily.  We will also get a CBC and check a blood culture and further workup as necessary.",
" Left communicating hydrocele.  Left inguinal hernia and hydrocele repair.  The patient is a 5-year-old young man with fluid collection in the tunica vaginalis and peritesticular space on the left side consistent with a communicating hydrocele. 
", Pediatrics - Neonatal, Inguinal Hernia & Hydrocele Repair ,"PREOPERATIVE DIAGNOSIS:  ,Left communicating hydrocele.,POSTOPERATIVE DIAGNOSIS: , Left communicating hydrocele.,ANESTHESIA: , General.,PROCEDURE:  ,Left inguinal hernia and hydrocele repair.,INDICATIONS: , The patient is a 5-year-old young man with fluid collection in the tunica vaginalis and peritesticular space on the left side consistent with a communicating hydrocele.  The fluid size tends to fluctuate with time but has been relatively persistent for the past year.  I met with the patient's mom and also spoke with his father by phone in the past couple of months and explained the diagnosis of patent processus vaginalis for communicating hydrocele and talked to them about the surgical treatment and options.  All their questions have been answered and the patient is fit for operation today.,OPERATIVE FINDINGS:  ,The patient had a very thin patent processus vaginalis leading to a rather sizeable hydrocele sac in the left hemiscrotum.  We probably drained around 10 to 15 mL of fluid from the hydrocele sac.  The processus vaginalis was clearly seen back to the peritoneal reflection where a high ligation was successfully performed.  There were no other abnormalities noted in the inguinal scrotal region.,DESCRIPTION OF OPERATION: , The patient came to the operating room and had an uneventful induction of inhalation anesthetic.  A peripheral IV was placed, and we conducted a surgical time-out to reiterate all of The patient's important identifying information and to confirm that we were indeed going to perform a left inguinal hernia and hydrocele repair.  After preparation and draping was done with chlorhexidine based prep solution, a local infiltration block as well as an ilioinguinal and iliohypogastric nerve block was performed with 0.25% Marcaine with dilute epinephrine.  A curvilinear incision was made low in the left inguinal area along one of prominent skin folds.  Soft tissue dissection was carried down through Scarpa's layer to the external oblique fascia, which was then opened to expose the underlying spermatic cord structures.  The processus vaginalis was dissected free from the spermatic cord structures, and the distal hydrocele sac was widely opened and drained of its fluid contents.  The processus vaginalis was cleared back to peritoneal reflection at the deep inguinal ring and a high ligation was performed there using both the transfixing and a mass ligature of 3-0 Vicryl.  After the excess hydrocele and processus vaginalis tissue was excised, the spermatic cord structures were replaced and the external oblique and Scarpa's layers were closed with interrupted 3-0 Vicryl sutures.  Subcuticular 5-0 Monocryl and Steri-Strips were used for the final skin closure.  The patient tolerated the operation well.  He was awakened and taken to the recovery room in good condition.  Blood loss was minimal.  No specimen was submitted.,","pediatrics - neonatal, hydrocele, hydrocele repair, hernia, inguinal, fluid collection, tunica vaginalis, peritesticular space, hydrocele sac, spermatic cord, cord structures, inguinal hernia, communicating hydrocele, fluid, vaginalis"
" A 10-day-old Caucasian female with bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then.", Pediatrics - Neonatal, Infantile Spasms ,"CHIEF COMPLAINT:,  Arm and leg jerking.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 10-day-old Caucasian female here for approximately 1 minute bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then.  Mom denies any apnea, perioral cyanosis, or color changes.  These movements are without any back arching.  They mainly occur during sleep, so mom is unaware of any eye rolling.  Mom is able to wake the patient up during this periods and stop the patient's extremity movements.,Otherwise, this patient has been active, breast-feeding well, although she falls asleep at the breast.  She is currently taking in 15 to 20 minutes of breast milk every 2 to 3 hours.  She is having increased diapers up to 8 wet and 6 to 7 dirty-yellow stools per day.,REVIEW OF SYSTEMS:,  Negative fever, negative fussiness, tracks with her eyes, some sneezing and hiccups.  This patient has developed some upper airway congestion in the past day.  She has not had any vomiting or diarrhea.  Per mom, she does not spit up, and mom is also unable to notice any relationship between these movements and feeds.  This patient has not had any rashes.  Mom was notified by the nurses at birth that her temperature may be low of approximately 97.5 degrees Fahrenheit.  Otherwise, the above history of present illness and other review of systems negative.,BIRTH/PAST MEDICAL HISTORY: , The patient was an 8 pound 11 ounce baby, ex-41-weeker born via vaginal delivery without vacuum assist or forceps.  There were no complications during pregnancy such as diabetes or hypertension.  Prenatal care started at approximately 3 weeks, and mom maintained all visits.  She also denies any smoking, alcohol, or drug use during the pregnancy.  Mom was GBS status positive, but denies any other infections such as urinary tract infections.  She did not have any fever during labor and received inadequate intrapartum antibiotics prophylaxis.  After delivery, this patient did not receive antibiotics secondary to ""borderline labs.""  She was jaundiced after birth and received photo treatments.  Her discharge bilirubin level was approximately 11.  Mom and child stayed in the hospital for approximately 3-1/2 days.,Mom denies any history of sexually transmitted disease in her or dad.  She specifically denies any blistering, herpetic genital lesions.  She does have a history though of human papillomavirus warts (vaginal), removed 20 years ago.,PAST SURGICAL HISTORY:,  Negative.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , None.,SOCIAL HISTORY: , At home live mom, dad, and 18-, 16-, 14-, 12-year-old brothers, and a 3-year-old sister.  All the residents at home are sick currently with cold, cough, runny nose, except for mom.  At home also live 2 dogs and 2 outside cats.  Mom denies any recent travel history, especially during the recent holidays and no smoke exposures.,FAMILY HISTORY:,  Dad is with a stepdaughter with seizures starting at 14 years old, on medications currently.  The patient's 16-year-old brother has incessant nonsustained ventricular tachycardia.  The maternal grandmother is notable for hypertension and diabetes.  There are no other children in the family who see a specialist or no child death less than 1 year of age.,PHYSICAL EXAMINATION:",
 4-day-old with hyperbilirubinemia and heart murmur., Pediatrics - Neonatal, Hyperbilirubinemia - 4-day-old ,"HISTORY: , The patient is a 4-day-old being transferred here because of hyperbilirubinemia and some hypoxia.  Mother states that she took the child to the clinic this morning since the child looked yellow and was noted to have a bilirubin of 23 mg%.  The patient was then sent to Hospital where she had some labs drawn and was noted to be hypoxic, but her oxygen came up with minimal supplemental oxygen.  She was also noted to have periodic breathing.  The patient is breast and bottle-fed and has been feeding well.  There has been no diarrhea or vomiting.  Voiding well.  Bowels have been regular.,According to the report from referring facility, because the patient had periodic breathing and was hypoxic, it was thought the patient was septic and she was given a dose of IM ampicillin.,The patient was born at 37 weeks' gestation to gravida 3, para 3 female by repeat C-section.  Birth weight was 8 pounds 6 ounces and the mother's antenatal other than was normal except for placenta previa.  The patient's mother apparently went into labor and then underwent a cesarean section.,FAMILY HISTORY: , Positive for asthma and diabetes and there is no exposure to second-hand smoke.,PHYSICAL EXAMINATION: , ,VITAL SIGNS:  The patient has a temperature of 36.8 rectally, pulse of 148 per minute, respirations 50 per minute, oxygen saturation is 96 on room air, but did go down to 90 and the patient was given 1 liter by nasal cannula.,GENERAL:  The patient is icteric, well hydrated.  Does have periodic breathing.  Color is pink and also icterus is noted, scleral and skin.,HEENT:  Normal.,NECK:  Supple.,CHEST:  Clear.,HEART:  Regular with a soft 3/6 murmur.  Femorals are well palpable.  Cap refill is immediate,ABDOMEN:  Soft, small, umbilical hernia is noted, which is reducible.,EXTERNAL GENITALIA:  Those of a female child.,SKIN:  Color icteric.  Nonspecific rash on the body, which is sparse.  The patient does have a cephalhematoma hematoma about 6 cm over the left occipitoparietal area.,EXTREMITIES:  The patient moves all extremities well.  Has a normal tone and a good suck.,EMERGENCY DEPARTMENT COURSE: , It was indicated to the parents that I would be repeating labs and also catheterize urine specimen.  Parents were made aware of the fact that child did have a murmur.  I spoke to Dr. X, who suggested doing an EKG, which was normal and since the patient will be admitted for hyperbilirubinemia, an echo could be done in the morning.  The case was discussed with Dr. Y and he will be admitting this child for hyperbilirubinemia.,CBC done showed a white count of 15,700, hemoglobin 18 gm%, hematocrit 50.6%, platelets 245,000, 10 bands, 44 segs, 34 lymphs, and 8 monos.  Chemistries done showed sodium of 142 mEq/L, potassium 4.5 mEq/L, chloride 104 mEq/L, CO2 28 mmol/L, glucose 75 mg%, BUN 8 mg%, creatinine 0.7 mg%, and calcium 8.0 mg%.  Total bilirubin was 25.4 mg, all of which was unconjugated.  CRP was 0.3 mg%.  Blood culture was drawn.  Catheterized urine specimen was normal.  Parents were kept abreast of what was going on all the time and the need for admission.  Phototherapy was instituted in the ER almost after the baby got to the emergency room.,IMPRESSION:,  Hyperbilirubinemia and heart murmur.,DIFFERENTIAL DIAGNOSES: , Considered breast milk, jaundice, ABO incompatibility, galactosemia, and ventricular septal defect.","pediatrics - neonatal, hypoxia, periodic breathing, heart murmur, urine specimen, yellow, bilirubin, heart, murmur, hyperbilirubinemia, "
" Gastrostomy, a 6-week-old with feeding disorder and Down syndrome.", Pediatrics - Neonatal, Gastrostomy ,"PREOPERATIVE DIAGNOSES:,1.  Feeding disorder.,2.  Down syndrome.,3.  Congenital heart disease.,POSTOPERATIVE DIAGNOSES:,1.  Feeding disorder.,2.  Down syndrome.,3.  Congenital heart disease.,OPERATION PERFORMED: , Gastrostomy.,ANESTHESIA: , General.,INDICATIONS:  ,This 6-week-old female infant had been transferred to Children's Hospital because of Down syndrome and congenital heart disease.  She has not been able to feed well and in fact has to now be NG tube fed.  Her swallowing mechanism does not appear to be very functional, and therefore, it was felt that in order to aid in her home care that she would be better served with a gastrostomy.,OPERATIVE PROCEDURE:  ,After the induction of general anesthetic, the abdomen was prepped and draped in usual manner.  Transverse left upper quadrant incision was made and carried down through skin and subcutaneous tissue with sharp dissection.  The muscle was divided and the peritoneal cavity entered.  The greater curvature of the stomach was grasped with a Babcock clamp and brought into the operative field.  The site for gastrostomy was selected and a pursestring suture of #4-0 Nurolon placed in the gastric wall.  A 14-French 0.8 cm Mic-Key tubeless gastrostomy button was then placed into the stomach and the pursestring secured about the tube.  Following this, the stomach was returned to the abdominal cavity and the posterior fascia was closed using a #4-0 Nurolon affixing the stomach to the posterior fascia.  The anterior fascia was then closed with #3-0 Vicryl, subcutaneous tissue with the same, and the skin closed with #5-0 subcuticular Monocryl.  The balloon was inflated to the full 5 mL.  A sterile dressing was then applied and the child awakened and taken to the recovery room in satisfactory condition.,","pediatrics - neonatal, feeding disorder, down syndrome, congenital heart disease, mic-key tubeless, nurolon, subcutaneous tissue, fascia, syndrome, stomach, gastrostomy"
 Followup of laparoscopic fundoplication and gastrostomy.  Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access., Pediatrics - Neonatal, Fundoplication & Gastrostomy Followup ,"REASON FOR VISIT: , Followup of laparoscopic fundoplication and gastrostomy.,HISTORY OF PRESENT ILLNESS: , The patient is a delightful baby girl, who is now nearly 8 months of age and had a tracheostomy for subglottic stenosis.  Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access and to protect her airway at a time when it is either going to heal enough to improve and allow decannulation or eventually prove that she will need laryngotracheoplasty.  Dr. X is following The patient for this and currently plans are to perform a repeat endoscopic exam every couple of months to assist the status of her airway caliber.,The patient had a laparoscopic fundoplication and gastrostomy on 10/05/2007.  She has done well since that time.  She has had some episodes of retching intermittently and these seemed to be unpredictable.  She also had some diarrhea and poor feeding tolerance about a week ago but that has also resolved.  The patient currently takes about 1 ounce to 1.5 ounce of her feedings by mouth and the rest is given by G-tube.  She seems otherwise happy and is not having an excessive amount of stools.  Her parents have not noted any significant problems with the gastrostomy site.,The patient's exam today is excellent.  Her belly is soft and nontender.  All of her laparoscopic trocar sites are healing with a normal amount of induration, but there is no evidence of hernia or infection.  We removed The patient's gastrostomy button today and showed her parents how to reinsert one without difficulty.  The site of the gastrostomy is excellent.  There is not even a hint of granulation tissue or erythema, and I am very happy with the overall appearance.,IMPRESSION: , The patient is doing exceptionally well status post laparoscope fundoplication and gastrostomy.  Hopefully, the exquisite control of acid reflux by fundoplication will help her airway heal, and if she does well, allow decannulation in the future.  If she does require laryngotracheoplasty, the protection from acid reflux will be important to healing of that procedure as well.,PLAN:  ,The patient will follow up as needed for problems related to gastrostomy.  We will see her when she comes in the hospital for endoscopic exams and possibly laryngotracheoplasty in the future.","pediatrics - neonatal, decannulation, enteral feeding, feeding access, laparoscopic fundoplication, gastrostomy, airway, laryngotracheoplasty, laparoscopic, fundoplication, "
" Head injury, anxiety, and hypertensive emergency.", Pediatrics - Neonatal, Head Injury ,"CHIEF COMPLAINT:,  Head injury.,HISTORY: , This 16-year-old female presents to Children's Hospital via paramedic ambulance with a complaint at approximately 6 p.m. while she was at band practice using her flag device.  She struck herself in the head with the flag.  There was no loss of consciousness.  She did feel dizzy.  She complained of a headache.  She was able to walk.  She continued to participate in her flag practice.  She got dizzier.  She sat down for a while and walked and during the second period of walking, she had some episodes of diplopia, felt that she might faint and was assisted to the ground and was transported via paramedic ambulance to Children's Hospital for further evaluation.,PAST MEDICAL HISTORY: , Hypertension.,ALLERGIES:,  DENIED TO ME; HOWEVER, IT IS NOTED BEFORE SEVERAL ACCORDING TO MEDITECH.,CURRENT MEDICATIONS: , Enalapril.,PAST SURGICAL HISTORY: , She had some kind of an abdominal obstruction as an infant.,SOCIAL HISTORY: , She is here with mother and father who lives at home.  There is no smoking at home.  There is second-hand smoke exposure.,FAMILY HISTORY:  ,No noted family history of infectious disease exposure.,IMMUNIZATIONS:,  She is up-to-date on her shots, otherwise negative.,REVIEW OF SYSTEMS:  ,On the 10-plus systems reviewed with the section of those noted on the template.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Her temperature 100 degrees, pulse 86, respirations 20, and her initial blood pressure 166/116, and a weight of 55.8 kg.,GENERAL:  She is supine awake, alert, cooperative, and active child.,HEENT:  Head atraumatic, normocephalic.  Pupils equal, round, reactive to light.  Extraocular motions intact and conjugate.  Clear TMs, nose and oropharynx.  Moist oral mucosa without noted lesions.,NECK:  Supple, full painless nontender range motion.,CHEST:  Clear to auscultation, equal, stable to palpation.,HEART:  Regular without rubs or murmurs.,ABDOMEN:  No abdominal bruits are heard.,EXTREMITIES:  Equal femoral pulses are appreciated.  Equal radial and dorsalis pedis pulses are appreciated.  He moves all extremities without difficulty.  Nontender.  No deformity.  No swelling.,SKIN:  There was no significant bruising, lesions or rash about her abdomen.  No significant bruising, lesions or rash.,NEUROLOGIC:  Symmetric face and extremity motion.  Ambulates without difficulty.  She is awake, alert, and appropriate.,MEDICAL DECISION MAKING:,  The differential entertained includes head injury, anxiety, and hypertensive emergency.  She is evaluated in the emergency department with serial blood pressure examinations, which are noted to return to a more baseline state for her 130s/90s.  Her laboratory data shows a mildly elevated creatinine of 1.3.  Urine is within normal.  Urinalysis showing no signs of infection.  Head CT read by staff has no significant intracranial pathology.  No mass shift, bleed or fracture per Dr. X.  A 12-lead EKG reviewed preliminarily by myself noting normal sinus rhythm, normal axis rates of 90.  No significant ST-T wave changes.  No significant change from previous 09/2007 EKG.  Her headache has resolved.  She is feeling better.  I spoke with Dr. X at 0206 hours consulting Nephrology regarding this patient's presentation with the plan for home.  Follow up with her regular doctor.  Blood pressures have normalized for her.  She should return to emergency department on concern.  They are to call the family to Nephrology Clinic next week for optimization of her blood pressure control with a working diagnosis of head injury, hypertension, and syncope.",
 Pediatric Gastroenterology - History of gagging., Pediatrics - Neonatal, Gagging - 3-year-old ,"HISTORY OF PRESENT ILLNESS: , This is a 3-year-old female patient, who was admitted today with a history of gagging.  She was doing well until about 2 days ago, when she developed gagging.  No vomiting.  No fever.  She has history of constipation.  She normally passes stool every two days after giving an enema.  No rectal bleeding.  She was brought to the Hospital with some loose stool.  She was found to be dehydrated.  She was given IV fluid bolus, but then she started bleeding from G-tube site.  There was some fresh blood coming out of the G-tube site.  She was transferred to PICU.  She is hypertensive.  Intensivist Dr. X requested me to come and look at her, and do upper endoscopy to find the site of bleeding.,PAST MEDICAL HISTORY: , PEHO syndrome, infantile spasm, right above knee amputation, developmental delay, G-tube fundoplication.,PAST SURGICAL HISTORY: , G-tube fundoplication on 05/25/2007.  Right above knee amputation.,ALLERGIES:,  None.,DIET: , She is NPO now, but at home she is on PediaSure 4 ounces 3 times a day through G-tube, 12 ounces of water per day.,MEDICATIONS: , Albuterol, Pulmicort, MiraLax 17 g once a week, carnitine, phenobarbital, Depakene and Reglan.,FAMILY HISTORY:,  Positive for cancer.,PAST LABORATORY EVALUATION: , On 12/27/2007; WBC 9.3, hemoglobin 7.6, hematocrit 22.1, platelet 132,000.  KUB showed large stool with dilated small and large bowel loops.  Sodium 140, potassium 4.4, chloride 89, CO2 21, BUN 61, creatinine 2, AST 92 increased, ALT 62 increased, albumin 5.3, total bilirubin 0.1.  Earlier this morning, she had hemoglobin of 14.5, hematocrit 41.3, platelets 491,000.  PT 58 increased, INR 6.6 increased, PTT 75.9 increased.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Temperature 99 degrees Fahrenheit, pulse 142 per minute, respirations 34 per minute, weight 8.6 kg.,GENERAL:  She is intubated.,HEENT:  Atraumatic.  She is intubated.,LUNGS:  Good air entry bilaterally.  No rales or wheezing.,ABDOMEN:  Distended.  Decreased bowel sounds.,GENITALIA:  Grossly normal female.,CNS:  She is sedated.,IMPRESSION: , A 3-year-old female patient with history of passage of blood through G-tube site with coagulopathy.  She has a history of G-tube fundoplication, developmental delay, PEHO syndrome, which is progressive encephalopathy optic atrophy.,PLAN:  ,Plan is to give vitamin K, FFP, blood transfusion.  Consider upper endoscopy.  Procedure and informed consent discussed with the family.","pediatrics - neonatal, g-tube, peho syndrome, tube site, gagging, constipation, endoscopy, peho, hemoglobin, hematocrit, intubated, bleeding, blood, fundoplication, tube, "
" Questionable foreign body, right nose.  Belly and back pain.   Mild constipation.", Pediatrics - Neonatal, Foreign Body - Right Nose ,"CHIEF COMPLAINT:,  Questionable foreign body, right nose.  Belly and back pain.  ,SUBJECTIVE: , Mr. ABC is a 2-year-old boy, who is brought in by parents, stating that the child keeps complaining of belly and back pain.  This does not seem to be slowing him down.  They have not noticed any change in his urine or bowels.  They have not noted him to have any fevers or chills or any other illness.  They state he is otherwise acting normally.  He is eating and drinking well.  He has not had any other acute complaints, although they have noted a foul odor coming from his nose.  Apparently, he was seen here a few weeks ago for a foreign body in the right nose, which was apparently a piece of cotton; this was removed and placed on antibiotics.  His nose got better and then started to become malodorous again.  Mother restarted him on the remainder of the antibiotics and they are also stating that they think there is something still in there.  Otherwise, he has not had any runny nose, earache, no sore throat.  He has not had any cough, congestion.  He has been acting normally.  Eating and drinking okay.  No other significant complaints.  He has not had any pain with bowel movement or urination, nor have they noted him to be more frequently urinating, then again he is still on a diaper.,PAST MEDICAL HISTORY: , Otherwise negative.,ALLERGIES: , No allergies.,MEDICATIONS: , No medications other than recent amoxicillin.,SOCIAL HISTORY: , Parents do smoke around the house.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Stable.  He is afebrile.,GENERAL:  This is a well-nourished, well-developed 2-year-old little boy, who is appearing very healthy, normal for his stated age, pleasant, cooperative, in no acute distress, looks very healthy, afebrile and nontoxic in appearance.,HEENT:  TMs, canals are normal.  Left naris normal.  Right naris, there is some foul odor as well as questionable purulent drainage.  Examination of the nose, there was a foreign body noted, which was the appearance of a cotton ball in the right nose, that was obviously infected and malodorous.  This was removed and reexamination of the nose was done and there was absolutely no foreign body left behind or residual.  There was some erythema.  No other purulent drainage noted.  There was some bloody drainage.  This was suctioned and all mucous membranes were visualized and are negative.,NECK:  Without lymphadenopathy.  No other findings.,HEART:  Regular rate and rhythm.,LUNGS:  Clear to auscultation.,ABDOMEN:  His abdomen is entirely benign, soft, nontender, nondistended.  Bowel sounds active.  No organomegaly or mass noted.,BACK:  Without any findings.  Diaper area normal.,GU:  No rash or infections.  Skin is intact.,ED COURSE: , He also had a P-Bag placed, but did not have any urine.  Therefore, a straight catheter was done, which was done with ease without complication and there was no leukocytes noted within the urine.  There was a little bit of blood from catheterization but otherwise normal urine.  X-ray noted some stool within the vault.  Child is acting normally.  He is jumping up and down on the bed without any significant findings.,ASSESSMENT:,1.  Infected foreign body, right naris.,2.  Mild constipation.,PLAN:,  As far as the abdominal pain is concerned, they are to observe for any changes.  Return if worse, follow up with the primary care physician.  The right nose, I will place the child on amoxicillin 125 per 5 mL, 1 teaspoon t.i.d.  Return as needed and observe for more foreign bodies.  I suspect, the child had placed this cotton ball in his nose again after the first episode.", 
" Irritable baby, 6-week-old, with fever for approximately 24 hours.", Pediatrics - Neonatal, H&P - Infant with fever ,"CHIEF COMPLAINT:, Irritable baby with fever for approximately 24 hours.,HISTORY OF PRESENT ILLNESS:, This 6-week-old infant was doing well until about 48 hours prior to admission, developed irritability, fussiness, a little bit of vomiting, and then fever up to 103-degrees. The child was brought into the emergency room and a complete septic workup was done, and the child is being treated in a rule out sepsis protocol.,PAST MEDICAL HISTORY:, This child was born by term pregnancy, spontaneous vaginal delivery, to a mother who was a teenager. He is bottle fed and he has had his hepatitis B vaccine. He lives in a home where there are smokers. This is his first illness.,PAST SURGICAL HISTORY:, He has had no previous surgeries.,MEDICATION (S):, He takes no medications on a regular basis.,REVIEW OF SYSTEMS:, Positive for those things mentioned already in the past medical history and history of present illness.,FAMILY HISTORY:, The family history is noncontributory.,SOCIAL HISTORY:, This child lives with his mother and father, both are teenagers, unmarried, who are not well educated. Grandmother is a heavy smoker.,PHYSICAL EXAMINATION:,VITAL SIGNS: The vital signs are stable, the patient is febrile at 101-degrees.,HEAD, EYES, EARS, NOSE, AND THROAT/GENERAL: The anterior fontanelle is not bulging. The rest of the examination is within normal limits. The neck is supple, no nuchal rigidity noted, though this child is irritable and fussy, and whines and cries where ever you make touch him. He has an irritable disposition no matter what you do to him, and whines even while at rest.,HEART: The heart rate is rapid, but there was no murmur noted.,LUNGS: The lungs are clear.,ABDOMEN: The abdomen is without mass, distention, or visceromegaly.,GENITOURINARY/RECTAL: Examination within normal limits.,EXTREMITIES: The extremities are normal. No Kernig's or Brudzinski sign.,NEUROLOGIC: Cranial nerves II through XII are intact, no focal deficits. As I mentioned before, the child is extremely irritable, fussy, and has a great deal of general inconsolability.,SKIN: The child, in addition, has a skin pattern of cutis marmorata, which I think is a bit more exaggerated since the child is febrile and has some peripheral vasodilatation.,CLINICAL IMPRESSION (S):, Likely viral syndrome, viral meningitis, flu syndrome.,PLAN:, Continue the septic workup protocol, supportive care with IV fluids, and Tylenol as needed for fever, and continue the antibiotics until spinal fluid cultures and blood cultures are negative for 48 hours. In addition, I believe that the rapid heart rate is a sinus tachycardia, and is related to the child's illness, irritability, and his fever. In addition, there were no intracranial bruits noted.",
" Gastroenteritis versus bowel obstruction, gastroesophageal reflux, Goldenhar syndrome, and anemia, probably iron deficiency.", Pediatrics - Neonatal, Goldenhar Syndrome - Discharge Summary  ,"ADMITTING DIAGNOSES,1.  Vomiting, probably secondary to gastroenteritis.,2.  Goldenhar syndrome.,3.  Severe gastroesophageal reflux.,4.  Past history of aspiration and aspiration pneumonia.,DISCHARGE DIAGNOSES,1.  Gastroenteritis versus bowel obstruction.,2.  Gastroesophageal reflux.,3.  Goldenhar syndrome.,4.  Anemia, probably iron deficiency.,HISTORY OF PRESENT ILLNESS:,  This is a 10-week-old female infant who has Goldenhar syndrome and has a gastrostomy tube in place and a J-tube in place.  She was noted to have vomiting approximately 18 to 24 hours prior to admission and was seen in the emergency department and then admitted.,Because of her Goldenhar syndrome and previous problems with aspiration, she is not fed my mouth, but does have a G-tube.  However, she has not been tolerating feedings through this prior to admission.,PHYSICAL EXAMINATION:,GENERAL:  At transfer to UNM on October 13, 2003 reveals a dysmorphic infant who is small and slightly cachectic.  Her left side of the face is deformed with microglia present, micrognathia present, and a moderate amount of torticollis.,VITAL SIGNS:  Presently, her temperature is 98, pulse 152, respirations 36, weight is 3.98 kg, pulse oximetry on room air is 95%.,HEENT:  Head is with anterior fontanelle open.  Eyes:  Red reflex elicited bilaterally.  Left ear is without an external ear canal and the right is not well visualized at this time.  Nose is presently without any discharge, and throat is nonerythematous.  NECK:  Neck with torticollis exhibited.,LUNGS:  Presently are clear to auscultation.,HEART:  Regular rate without murmur, click or gallop present.  ABDOMEN:  Moderately distended, but soft.  Bowel sounds are decreased, and there is a G-tube and a J-tube in place.  The skin surrounding the G-tube is moderately erythematous, but without any discharges present.  J-tube is with a dressing in place and well evaluated.,EXTREMITIES:  Grossly normal.  Hip defects are not checked at this time.,GENITALIA:  Normal female.,NEUROLOGIC:  The infant does have a suck reflex, feeding grasp-reflex, and a feeding Moro reflex.,SKIN:  Warm and dry and there is a macular area to the left ___ that is approximately 1 cm in length.,LABORATORY DATA: , WBC count on October 12, 2003 is 12,600 with 16 segs, 6 bands, 54 lymphocytes, 13% of which are noted to be reactive.  Hemoglobin is 10.4, hematocrit 30.8, and she has abnormal red blood cell morphology.  RDW is 13.1 and MCV is 91.  Sodium level is 138, potassium 5.4, chloride 103, CO2 23, BUN 7, creatinine 0.4, glucose 84, calcium 9.9, and at this dictation, the report on the abdominal flat plate is pending.,HOSPITAL COURSE:  ,The child was placed at bowel rest initially and then re-tried on full strength formula, but she did not tolerate.  She was again placed on bowel rest and her medications, Pepcid and Reglan, were given in an attempt to increase bowel motility.  Feedings were re-attempted with Pedialyte through the J-tube and these did not result in production of any stool and the child then began having vomiting again.  The vomitus was noted to be bilious in nature and with particulate matter present.,After consultation with Dr. X, it was determined the child probably needed further evaluation, and she had both of her drains placed to gravity and was kept n.p.o.  Her fluids have been D5 and 0.25 normal saline with 20 mEq/L of potassium chloride, which has run at her maintenance of 16 mL/h.,CONSULTATIONS: , With Dr. X and Dr. Y and the child is now ready for transport for continued diagnosis and treatment.  Her condition at discharge is stable.",
 13 years old complaining about severe ear pain - Chronic otitis media., Pediatrics - Neonatal, Ear pain - Pediatric Consult ,"PRESENTATION: , Patient, 13 years old, comes to your office with his mother complaining about severe ear pain.  He awoke during the night with severe ear pain, and mom states that this is the third time this year he has had earaches.,HISTORY OF PRESENT ILLNESS:  ,Patient reports that he felt good after taking antibiotics with each earache episode and has recently started on the wrestling team.  Mom reports that patient has been afebrile with each of the earache episodes, and he has not had upper respiratory symptoms.  Patient denies any head trauma associated with wrestling practice.,BIRTH AND DEVELOPMENTAL HISTORY:,  Patient's mother reports a normal pregnancy with no complications, having received prenatal care from 12 weeks.  Vaginal delivery was uneventful with a normal perinatal course.  Patient sat alone at 6 months, crawled at 9 months, and walked at 13 months.  His verbal and motor developmental milestones were as expected.,FAMILY/SOCIAL HISTORY: , Patient lives with both parents and two siblings (brother - age 11 years, sister - age 15 years).  He reports enjoying school, remains active in scouts, and is very excited about being on the wresting team.  Mom reports that he has several friends, but she is concerned about the time required for the wrestling team.  Patient is in 8th grade this year and an A/B student.  Both siblings are healthy.  His Dad has hypertension and has frequent heartburn symptoms that he treats with over-the-counter (OTC) medications.  Mom is healthy and has asthma.,PAST MEDICAL HISTORY:  ,Patient has been seen in the clinic yearly for well child exams.  He has had no major illnesses or hospitalizations.  He had one emergency room visit 2 years ago for a knee laceration.  Patient has been healthy except for the past year when he had two episodes of otitis media not associated with respiratory infections.  He received antibiotic therapy (amoxicillin) for the otitis media and both episodes resolved without problems.  Patient's Mom states that he takes no prescribed medications or OTC medications, but he admits that he has been taking his dad's OTC Pepcid AE sometimes when he gets heartburn.  Upon further examination, he reports taking Pepcid when he eats pizza or Mexican food.  He does complain of sore throats sometimes and often feels burning in his throat when he goes to sleep at night after a late evening snack.,NUTRITIONAL HISTORY: , Patient eats cereal bars or pop tarts with milk for breakfast most days.  He takes his lunch (usually a sandwich and chips or yogurt and fruit) for lunch.  Mom or his sister cooks supper in the evening.  The family goes out to eat once or twice a week and he only gets ""fast food"" once or twice a week according to his Mom.  He says he eats ""a lot"" especially after a wrestling meet.,PHYSICAL EXAM:,Height/weight:  Patient weighs 109 pounds (60th percentile) and is 69 inches tall (93rd percentile).  He is following the growth pattern he established in infancy.,Vital signs:  BP 110/60, T 99.2, HR 70, R 16.,General:  Alert, cooperative but a bit shy.,Neuro:  DTRs symmetric, 2+, negative Romberg, able to perform simple calculations without difficulty, short-term memory intact.  He responds appropriately to verbal and visual cues, and movements are smooth and coordinated.,HEENT:  Normocephalic, PEERLA, red reflex present, optic disk and ocular vessels normal.  TMs deep red, dull, landmarks obscured, full bilaterally.  Post auricular and submandibular nodes on left are palpable and slightly tender.,Lungs:  CTA, breath sounds equal bilaterally, excursion and chest configuration normal.,Cardiac:  S1, S2 split, no murmurs, pulses equal bilaterally.,Abdomen:  Soft, rounded, reports no epigastric tenderness but states that heartburn begins in epigastric area and rises to throat.  Bowel sounds active in all quadrants.  No hepatosplenomegaly or tenderness.  No CVA tenderness.,Musculoskeletal:  Full range of motion, all extremities.  Spine straight, able to perform jumping jacks and duck walk without difficulty.,Genital:  Normal male, Tanner stage 4.  Rectal exam - small amount of soft stool, no fissures or masses.,LABS:  ,Stool negative for blood and H. pylori antigen.  Normal CBC and urinalysis.  A barium swallow and upper GI was scheduled for the following week.  It showed marked GE reflux.,ASSESSMENT: , The differential diagnoses for patient included (a) chronic otitis media/treatment failure, (b) peptic ulcer disease/gastritis, (c) gastro esophageal reflux disease (GERD) or carbonated beverage syndrome, (d) trauma.,CHRONIC OTITIS MEDIA. , Chronic otitis media due to a penicillin resistant organism would be the obvious diagnosis in this case.  It is rare for an adolescent to have otitis media with no precipitating factor (such as being on a swim team or otherwise exposed to unusual organisms or in an unusual environment).  It is certainly unusual for him to have three episodes in 1 year.,PEPTIC ULCER DISEASE.,  There were no symptoms of peptic ulcer disease, a negative H. pylori screen and lack of pain made this diagnosis less likely.  Trauma.  Trauma was a possibility, particularly since adolescent males frequently minimize symptoms especially if they might limit participation in a sport but patient maintained that he had not had an event where he struck his head or neck and that he always wore his helmet with ear padding.,GERD.,  The history of ""heartburn"" relieved by his father's medication was striking.  The positive study supported the diagnosis of GERD, which was severe and chronic enough to cause irritation of the mucosal surfaces exposed to the gastric juices and edema, inflammation in the inner ears.,PLAN:,  Patient and his Mom agreed to a trial of omeprazole 20 mg at bedtime for 2 weeks.  Patient was to keep a diary of any episodes of heartburn, including what foods seemed to aggravate it.  The clinician asked him to avoid using any antacid products in the meantime to gage the effectiveness of the medication.  He was also given a prescription for 10 days of Augmentin99 and a follow-up appointment for 2 weeks.  At his follow-up appointment he reported one episode after he ate a whole large pizza after wrestling practice but said it went away pretty quickly after he took his medication.  A 6-month follow up appointment was scheduled.",
 Circumcision.  Normal male phallus.   The infant is without evidence of hypospadias or chordee prior to the procedure., Pediatrics - Neonatal, Circumcision - Infant ,"PROCEDURE: , Circumcision.,PRE-PROCEDURE DIAGNOSIS: , Normal male phallus.,POST-PROCEDURE DIAGNOSIS: , Normal male phallus.,ANESTHESIA:  ,1% lidocaine without epinephrine.,INDICATIONS: , The risks and benefits of the procedure were discussed with the parents.  The risks are infection, hemorrhage, and meatal stenosis.  The benefits are ease of care and cleanliness and fewer urinary tract infections.  The parents understand this and have signed a permit.,FINDINGS: , The infant is without evidence of hypospadias or chordee prior to the procedure.,TECHNIQUE:  ,The infant was given a dorsal penile block with 1% lidocaine without epinephrine using a tuberculin syringe and 0.5 cc of lidocaine was delivered subcutaneously at 10:30 and at 1:30 o'clock at the dorsal base of the penis.,The infant was prepped then with Betadine and draped with a sterile towel in the usual manner.  Clamps were placed at 10 o'clock and 2 o'clock and the adhesions between the glans and mucosa were instrumentally lysed.  Dorsal hemostasis was established and a dorsal slit was made.  The foreskin was fully retracted and remaining adhesions between the glans and mucosa were manually lysed.  The infant was fitted with a XX-cm Plastibell.  The foreskin was retracted around the Plastibell and circumferential hemostasis was established.  The excess foreskin was removed with scissors and the infant tolerated the procedure well with a minimum amount of blood loss.  Instructions for continuing care are to watch for any evidence of hemorrhage or urination and the parents are instructed in the care of the circumcised penis.","pediatrics - neonatal, dorsal slit, hypospadias, chordee, epinephrine, hemorrhage, penis, adhesions, circumcision, phallus, lidocaine, foreskin, infant"
" The patient is 14 months old, comes in with a chief complaint of difficulty breathing.  ", Pediatrics - Neonatal, Difficulty Breathing - ER Visit  ,"HISTORY:,  The patient is 14 months old, comes in with a chief complaint of difficulty breathing.  Difficulty breathing began last night.  He was taken to Emergency Department where he got some Xopenex, given a prescription for amoxicillin and discharged home.  They were home for about an hour when he began to get worse and they drove here to Children's Hospital.  He has a history of reactive airway disease.  He has been seen here twice in the last month on 10/04/2007 and 10/20/2007, both times with some wheezing.  He was diagnosed with pneumonia back on 06/12/2007 here in the Emergency Department but was not admitted at that time.  He has been on albuterol off and on over that period.  He has had fever overnight.  No vomiting, no diarrhea.  Increased work of breathing with retractions and audible wheezes noted and thus brought to the Emergency Department.  Normal urine output.  No rashes have been seen.,PAST MEDICAL HISTORY: , As noted above.  No hospitalizations, surgeries, allergies.,MEDICATIONS: , Xopenex.,IMMUNIZATIONS:,  Up-to-date.,BIRTH HISTORY:,  The child was full term, no complications, home with mom.  No surgeries.,FAMILY HISTORY: , Negative.,SOCIAL HISTORY: , No smokers or pets in the home.  No ill contacts, no travel, no change in living condition.,REVIEW OF SYSTEMS: , Ten are asked, all are negative, except as noted above.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temp 37.1, pulse 158, respiratory rate 48, 84% on room air indicating hypoxia.,GENERAL:  The child is awake, alert, in moderate respiratory distress.,HEENT:  Pupils equal, round, reactive to light.  Extraocular movements are intact.  The TMs are clear.  The nares show some dry secretions.  Audible congestion and wheezing is noted.  Mucous membranes are dry.  Throat is clear.  No oral lesions noted.,NECK:  Supple without lymphadenopathy or masses.  Trachea is midline.,LUNGS:  Show inspiratory and expiratory wheezes in all fields.  Audible wheezes are noted.  There are intercostal and subcostal retractions and suprasternal muscle use is noted.,HEART:  Shows tachycardia.  Regular rhythm.  Normal S1, S2.  No murmur.,ABDOMEN:  Soft, nontender.  Positive bowel sounds.  No guarding.  No rebound.  No hepatosplenomegaly.,EXTREMITIES:  Capillary refill is brisk.  Good distal pulses.,NEUROLOGIC:  Cranial nerves II through XII intact.  Moves all 4 extremities equally and normally.,HOSPITAL COURSE: , The child has an IV placed.  I felt the child was dehydrated on examination.  We gave 20 mL/kg bolus of normal saline over one hour.  The child was given Solu-Medrol 2 mg/kg IV.  He was initially started on unit dose albuterol and Atrovent but high-dose albuterol for continuous nebulization was ordered.,A portable chest x-ray was done showing significant peribronchial thickening bilaterally.  Normal heart size.  No evidence of pneumothorax.  No evidence of focal pneumonia.  After 3 unit dose of albuterol/Atrovent breathing treatments, there was much better air exchange bilaterally but still with inspiratory/expiratory wheezes and high-dose continuous albuterol was started at that time.  The child was monitored closely while on high-dose albuterol and slowly showed improvement resulting in only expiratory wheezes after one hour.  The child's pulse ox on breathing treatments with 100% oxygen was 100%.  Respiratory rate remained about 40 to 44 breaths per minute indicating tachypnea.  The child's color improved with oxygen therapy, and the capillary refill was always less than 2 seconds.,The child has failed outpatient therapy at this time.  After 90 minutes of continuous albuterol treatment, the child still has expiratory wheezes throughout.  After I removed the oxygen, the pulse ox was down at 91% indicating hypoxia.  The child has a normal level of alertness; however, has not had any vomiting here.  I spoke with Dr. X, on call for hospitalist service.  She has come down and evaluated the patient.  We both feel that since this child had two ER visits this last month, one previous ER visit within the last 5 hours, we should admit the child for continued albuterol treatments, IV steroids, and asthma teaching for the family.  The child is admitted in a stable condition.,DIFFERENTIAL DIAGNOSES:  ,Ruled out pneumothorax, pneumonia, bronchiolitis, croup.,TIME SPENT:  ,Critical care time outside billable procedures was 45 minutes with this patient.,IMPRESSION:  ,Status asthmaticus, hypoxia.,PLAN:  ,Admitted to Pediatrics.",
 A 3-year-old abrupt onset of cough and increased work of breathing., Pediatrics - Neonatal, Discharge Summary - Respiratory Distress ,"ADMITTING DIAGNOSES:,1.  Respiratory distress.,2.  Reactive airways disease.,DISCHARGE DIAGNOSES:,1.  Respiratory distress.,2.  Reactive airways disease.,3.  Pneumonia.,HISTORY OF PRESENT ILLNESS: , The patient is a 3-year-old boy previously healthy who has never had a history of asthma or reactive airways disease who presented with a 36-hour presentation of URI symptoms, then had an abrupt onset of cough and increased work of breathing.  Child was brought to Children's Hospital and received nebulized treatments in the ER and the Hospitalist Service was contacted regarding admission.  The patient was seen and admitted through the emergency room.,He was placed on the hospitalist system and was started on continuous nebulized albuterol secondary to his respiratory distress.  He also received inhaled as well as systemic corticosteroids.  An x-ray was without infiltrate on initial review by the hospitalist, but there was a right upper lobe infiltrate versus atelectasis per the official radiology reading.  The patient was not started on any antibiotics and his fever resolved.  However, the CRP was relatively elevated at 6.7.  The CBC was normal with a white count of 9.6; however, the bands were 84%.  Given these results, which she is to treat the pneumonia as bacterial and discharge the child with amoxicillin and Zithromax.,He was taken off of continuous and he was not on room air all night.  In the morning, he still had some bilateral wheezing, but no tachypnea.,DISCHARGE PHYSICAL EXAMINATION: , ,GENERAL:  No acute distress, running around the room.,HEENT:  Oropharynx moist and clear.,NECK:  Supple without lymphadenopathy, thyromegaly or masses.,CHEST:  Bilateral basilar wheezing.  No distress.,CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs noted.  Well perfused peripherally.,ABDOMEN:  Bowel sounds present.  The abdomen is soft.  There is no hepatosplenomegaly, no masses.  Nontender to palpation.,GENITOURINARY:  Deferred.,EXTREMITIES:  Warm and well perfused.,DISCHARGE INSTRUCTIONS:,  As follows:,1.  Activity, regular.,2.  Diet is regular.,3.  Follow up with Dr. X in 2 days.,DISCHARGE MEDICATIONS:,1.  Xopenex MDI 2 puffs every 4 hours for 2 days and then as needed for cough or wheeze.,2.  QVAR 40, 2 puffs twice daily until otherwise instructed by the primary care provider.,3.  Amoxicillin 550 mg p.o. twice daily for 10 days.,4.  Zithromax 150 mg p.o. on day 1, then 75 mg p.o. daily for 4 more days.,Total time for this discharge 37 minutes.",
 A 2-month-old female with 1-week history of congestion and fever x2 days., Pediatrics - Neonatal, Congestion & Fever - 2-month-old ,"CHIEF COMPLAINT:,  A 2-month-old female with 1-week history of congestion and fever x2 days.,HISTORY OF PRESENT ILLNESS:,  The patient is a previously healthy 2-month-old female, who has had a cough and congestion for the past week.  The mother has also reported irregular breathing, which she describes as being rapid breathing associated with retractions.  The mother states that the cough is at times paroxysmal and associated with posttussive emesis.  The patient has had short respiratory pauses following the coughing events.  The patient's temperature has ranged between 102 and 104.  She has had a decreased oral intake and decreased wet diapers.  The brother is also sick with URI symptoms, and the patient has had no diarrhea.  The mother reports that she has begun to regurgitate after her feedings.  She did not do this previously.,MEDICATIONS: , None.,SMOKING EXPOSURE: , None.,IMMUNIZATIONS: , None.,DIET:  ,Similac 4 ounces every 2 to 3 hours.,ALLERGIES:,  No known drug allergies.,PAST MEDICAL HISTORY:  ,The patient delivered at term.  Birth weight was 6 pounds 1 ounce.  Postnatal complications:  Neonatal Jaundice.  The patient remained in the hospital for 3 days.  The in utero ultrasounds were reported to be normal.,PRIOR HOSPITALIZATIONS: , None.,FAMILY/SOCIAL HISTORY: , Family history is positive for asthma and diabetes.  There is also positive family history of renal disease on the father's side of the family.,DEVELOPMENT: , Normal.  The patient tests normal on the newborn hearing screen.,REVIEW OF SYSTEMS:  GENERAL: , The patient has had fever, there have been no chills.  SKIN:  No rashes.  HEENT:  Mild congestion x1 week.  Cough, at times paroxysmal, no cyanosis.  The patient turns red in the face during coughing episodes, posttussive emesis.  CARDIOVASCULAR:  No cyanosis.  GI:  Posttussive emesis, decreased oral intake.  GU:  Decreased urinary output.  ORTHO:  No current issues.  NEUROLOGIC:  No change in mental status.  ENDOCRINE:  There is no history of weight loss.  DEVELOPMENT:  No loss of developmental milestones.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Weight is 4.8 kg, temperature 100.4, heart rate is 140, respiratory rate 30, and saturations 100%.,GENERAL:  This is a well-appearing infant in no acute distress.,HEENT:  Shows anterior fontanelle to be open and flat.  Pupils are equal and reactive to light with red reflex.  Nares are patent.  Oral mucosa is moist.  Posterior pharynx is clear.  Hard palate is intact.  Normal gingiva.,HEART:  Regular rate and rhythm without murmur.,LUNGS:  A few faint rales.  No retractions.  No stridor.  No wheezing on examination.  Mild tachypnea.,EXTREMITIES:  Warm, good perfusion.  No hip clicks.,NEUROLOGIC:  The patient is alert.  Normal tone throughout.  Deep tendon reflexes are 2+/4.  No clonus.,SKIN:  Normal.,LABORATORY DATA:,  CBC shows a white count of 12.4, hemoglobin 10.1, platelet count 611,000; 38 segs 3 bands, 42 lymphocytes, and 10 monocytes.  Electrolytes were within normal limits.  C-reactive protein 0.3.  Chest x-ray shows no acute disease with the exception of a small density located in the retrocardiac area on the posterior view.  UA shows 10 to 25 bacteria.,ASSESSMENT/PLAN:  ,This is a 2-month-old, who presents with fever, paroxysmal cough and episodes of respiratory distress.  The patient is currently stable in the emergency room.  We will admit the patient to the pediatric floor.  We will send out pertussis PCR.  We will also follow results of urine culture and that the urine dip shows 10 to 25 bacteria.  The patient will be followed up for signs of sepsis, apnea, urinary tract infection, and pneumonia.  We will wait for a radiology reading on the chest x-ray to determine if the density seen on the lateral film is a normal variant or represents pathology.",
" Congestion, tactile temperature.", Pediatrics - Neonatal, Congestion - 21-day-old ,"CHIEF COMPLAINT:,  Congestion, tactile temperature.,HISTORY OF PRESENT ILLNESS: , The patient is a 21-day-old Caucasian male here for 2 days of congestion - mom has been suctioning yellow discharge from the patient's nares, plus she has noticed some mild problems with his breathing while feeding (but negative for any perioral cyanosis or retractions).  One day ago, mom also noticed a tactile temperature and gave the patient Tylenol.,Baby also has had some decreased p.o. intake.  His normal breast-feeding is down from 20 minutes q.2h. to 5 to 10 minutes secondary to his respiratory congestion.  He sleeps well, but has been more tired and has been fussy over the past 2 days.  The parents noticed no improvement with albuterol treatments given in the ER.  His urine output has also decreased; normally he has 8 to 10 wet and 5 dirty diapers per 24 hours, now he has down to 4 wet diapers per 24 hours.  Mom denies any diarrhea.  His bowel movements are yellow colored and soft in nature.,The parents also noticed no rashes, just his normal neonatal acne.  The parents also deny any vomiting, apnea.,EMERGENCY ROOM COURSE: , In the ER, the patient received a lumbar puncture with CSF fluid sent off for culture and cell count.  This tap was reported as clear, then turning bloody in nature.  The patient also received labs including a urinalysis and urine culture, BMP, CBC, CRP, blood culture.  This patient also received as previously noted, 1 albuterol treatment, which did not help his respiratory status.  Finally, the patient received 1 dose of ampicillin and cefotaxime respectively each.,REVIEW OF SYSTEMS: , See above history of present illness.  Mom's nipples are currently cracked and bleeding.  Mom has also noticed some mild umbilical discharge as well as some mild discharge from the penile area.  He is status post a circumcision.  Otherwise, review of systems is negative.,BIRTH/PAST MEDICAL HISTORY: , The patient was an 8 pounds 13 ounces' term baby born 1 week early via a planned repeat C-section.  Mom denies any infections during pregnancy, except for thumb and toenail infections, treated with rubbing alcohol (mom denies any history of boils in the family).  GBS status was negative.  Mom smoked up to the last 5 months of the pregnancy.  Mom and dad both deny any sexually transmitted diseases or genital herpetic lesions.  Mom and baby were both discharged out of the hospital last 48 hours.  This patient has received no hospitalizations so far.,PAST SURGICAL HISTORY:,  Circumcision.,ALLERGIES: , No known drug allergies.,MEDICATIONS:,  Tylenol.,IMMUNIZATIONS:,  None of the family members this year have received a flu vaccine.,SOCIAL HISTORY:,  At home lives mom, dad, a 2-1/2-year-old brother, and a 5-1/2-year-old maternal stepbrother.  Both brothers at home are sick with cold symptoms including diarrhea and vomiting.  The brother (2-1/2-year-old) was seen in the ER tonight with this patient and discharged home with an albuterol prescription.  A nephew of the mom with an ear infection.  Mom also states that she herself was sick with the flu soon after delivery.  There has been recent travel exposure to dad's family over the Christmas holidays.  At this time, there is also exposure to indoor cats and dogs.  This patient also has positive smoking exposure coming from mom.,FAMILY HISTORY: , Paternal grandmother has diabetes and hypertension, paternal grandfather has emphysema and was a smoker.  There are no children needing the use of a pediatric subspecialist or any childhood deaths less than 1 year of age.,PHYSICAL EXAMINATION:  ,VITALS:  Temperature max is 99, heart rate was 133 to 177, blood pressure is 114/43 (while moving), respiratory rate was 28 to 56 with O2 saturations 97 to 100% on room air.  Weight was 4.1 kg.,GENERAL:  Not in acute distress, sneezing, positive congestion with breaths taken.,HEENT:  Normocephalic, atraumatic head.  Anterior fontanelle was soft, open, and flat.  Bilateral red reflexes were positive.  Oropharynx is clear with palate intact, negative rhinorrhea.,CARDIOVASCULAR:  Heart was regular rate and rhythm with a 2/6 systolic ejection murmur heard best at the upper left sternal border, vibratory in nature.  Capillary refill was less than 3 seconds.,LUNGS:  Positive upper airway congestion, transmitted sounds; negative retractions, nasal flaring, or wheezes.,ABDOMEN:  Bowel sounds are positive, nontender, soft, negative hepatosplenomegaly.  Umbilical site was with scant dried yellow discharge.,GU:  Tanner stage 1 male, circumcised.  There was mild hyperemia to the penis with some mild yellow dried discharge.,HIPS:  Negative Barlow or Ortolani maneuvers.,SKIN:  Positive facial erythema toxicum.,LABORATORY DATA: , CBC drawn showed a white blood cell count of 14.5 with a differential of 25 segmental cells, 5% bands, 54% lymphocytes.  The hemoglobin was 14.4, hematocrit was 40.  The platelet count was elevated at 698,000.  A CRP was less than 0.3.,A hemolyzed BMP sample showed a sodium of 139, potassium of 5.6, chloride 105, bicarb of 21, and BUN of 4, creatinine 0.4, and a glucose of 66.,A cath urinalysis was negative.,A CSF sample showed 0 white blood cells, 3200 red blood cells (again this was a bloody tap per ER personnel), CSF glucose was 41, CSF protein was 89.  A Gram stain showed rare white blood cells, many red blood cells, no organisms.,ASSESSMENT: , A 21-day-old with:,1.  Rule out sepsis.,2.  Possible upper respiratory infection.,Given the patient's multiple sick contacts, he is possibly with a viral upper respiratory infection causing his upper airway congestion plus probable fever.  The bacterial considerations although to consider in this child include group B streptococcus, E. coli, and Listeria.  We should also consider herpes simplex virus, although these 3200 red blood cells from his CSF could be due to his bloody tap in the ER.  Also, there is not a predominant lymphocytosis of his CSF sample (there is 0 white blood cell count in the cell count).,Also to consider in this child is RSV.  The patient though has more congested, nasal breathing more than respiratory distress, for example retractions, desaturations, or accessory muscle use.  Also, there is negative apnea in this patient.,PLAN:  ,1.  We will place this patient on the rule out sepsis pathway including IV antibiotics, ampicillin and gentamicin for at least 48 hours.,2.  We will follow up with his blood, urine, and CSF cultures.",
 Newborn circumcision.  The penile foreskin was removed using Gomco. , Pediatrics - Neonatal, Circumcision - Newborn  ,"PROCEDURE: , Newborn circumcision.,INDICATIONS: , Parental preference.,ANESTHESIA:,  Dorsal penile nerve block.,DESCRIPTION OF PROCEDURE:,  The baby was prepared and draped in a sterile manner.  Lidocaine 1% 4 mL without epinephrine was instilled into the base of the penis at 2 o'clock and 10 o'clock.  The penile foreskin was removed using a XXX Gomco.  Hemostasis was achieved with minimal blood loss.  There was no sign of infection.  The baby tolerated the procedure well.  Vaseline was applied to the penis, and the baby was diapered by nursing staff.","pediatrics - neonatal, nerve block, newborn circumcision, foreskin, gomco, penis, circumcision, newborn, penile"
 Circumcision.  The child appeared to tolerate the procedure well.  Care instructions were given to the parents., Pediatrics - Neonatal, Circumcision - Child  ,"PROCEDURE: , Circumcision.,Signed informed consent was obtained and the procedure explained.,The child was placed in a Circumstraint board and restrained in the usual fashion.  The area of the penis and scrotum were prepared with povidone iodine solution.  The area was draped with sterile drapes, and the remainder of the procedure was done with sterile procedure.  A dorsal penile block was done using 2 injections of 0.3 cc each, 1% plain lidocaine.  A dorsal slit was made, and the prepuce was dissected away from the glans penis.  A ** Gomco clamp was properly placed for 5 minutes.  During this time, the foreskin was sharply excised using a #10 blade.  With removal of the clamp, there was a good cosmetic outcome and no bleeding.  The child appeared to tolerate the procedure well.  Care instructions were given to the parents.","pediatrics - neonatal, circumstraint, dorsal slit, gomco clamp, circumcision, childNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" A 5-month-old infant with cold, cough, and runny nose for 2 days.  Mom states she had no fever.  Her appetite was good but she was spitting up a lot.", Pediatrics - Neonatal, Congestion & Cough - 5-month-Old ,"CHIEF COMPLAINT: , Congestion and cough.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 5-month-old infant who presented initially on Monday with a cold, cough, and runny nose for 2 days.  Mom states she had no fever.  Her appetite was good but she was spitting up a lot.  She had no difficulty breathing and her cough was described as dry and hacky.  At that time, physical exam showed a right TM, which was red.  Left TM was okay.  She was fairly congested but looked happy and playful.  She was started on Amoxil and Aldex and we told to recheck in 2 weeks to recheck her ear.  Mom returned to clinic again today because she got much worse overnight.  She was having difficulty breathing.  She was much more congested and her appetite had decreased significantly today.  She also spiked a temperature yesterday of 102.6 and always having trouble sleeping secondary to congestion.,ALLERGIES: , She has no known drug allergies.,MEDICATIONS:  ,None except the Amoxil and Aldex started on Monday.,PAST MEDICAL HISTORY:  ,Negative.,SOCIAL HISTORY: , She lives with mom, sister, and her grandparent.,BIRTH HISTORY: , She was born, normal spontaneous vaginal delivery at Woman's weighing 7 pounds 3 ounces.  No complications.  Prevented, she passed her hearing screen at birth.,IMMUNIZATIONS: , Also up-to-date.,PAST SURGICAL HISTORY: , Negative.,FAMILY HISTORY:  ,Noncontributory.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Her respiratory rate was approximately 60 to 65.,GENERAL:  She was very congested and she looked miserable.  She had no retractions at this time.,HEENT:  Her right TM was still red and irritated with no light reflex.  Her nasal discharge was thick and whitish yellow.  Her throat was clear.  Her extraocular muscles were intact.,NECK:  Supple.  Full range of motion.,CARDIOVASCULAR EXAM:  She was tachycardic without murmur.,LUNGS:  Revealed diffuse expiratory wheezing.,ABDOMEN:  Soft, nontender, and nondistended.,EXTREMITIES:  Showed no clubbing, cyanosis or edema.,LABORATORY DATA:  ,Her chem panel was normal.  RSV screen is positive.  Chest x-ray and CBC are currently pending.,IMPRESSION AND PLAN:  ,RSV bronchiolitis with otitis media.  Admit for oral Orapred, IV Rocephin, nebulizer treatments and oxygen as needed.",
" A 14-month-old with history of chronic recurrent episodes of otitis media, totalling 6 bouts, requiring antibiotics since birth. ", Pediatrics - Neonatal, Chronic Otitis Media ,"CHIEF COMPLAINT:,  Chronic otitis media.,HISTORY OF PRESENT ILLNESS:,  This is a 14-month-old with history of chronic recurrent episodes of otitis media, totalling 6 bouts, requiring antibiotics since birth.  There is also associated chronic nasal congestion.  There had been no bouts of spontaneous tympanic membrane perforation, but there had been elevations of temperature up to 102 during the acute infection.  He is being admitted at this time for myringotomy and tube insertion under general facemask anesthesia.,ALLERGIES:,  None.,MEDICATIONS:,  None.,FAMILY HISTORY:,  Noncontributory.,MEDICAL HISTORY: , Mild reflux.,PREVIOUS SURGERIES:,  None.,SOCIAL HISTORY: , The patient is not in daycare.  There are no pets in the home.  There is no secondhand tobacco exposure.,PHYSICAL EXAMINATION: , Examination of ears reveals retracted poorly mobile tympanic membranes on the right side with a middle ear effusion present.  Left ear is still little bit black.  Nose, moderate inferior turbinate hypertrophy.  No polyps or purulence.  Oral cavity, oropharynx 2+ tonsils.  No exudates.  Neck, no nodes, masses or thyromegaly.  Lungs are clear to A&P.  Cardiac exam, regular rate and rhythm.  No murmurs.  Abdomen is soft and nontender.  Positive bowel sounds.,IMPRESSION: , Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, and wax accumulation.,PLAN:,  The patient will be admitted to the operating room for myringotomy and tube insertion under general facemask anesthesia.","pediatrics - neonatal, chronic nasal congestion, tympanic membrane perforation, chronic otitis media, tube insertion, facemask anesthesia, otitis media, otitis, media,"
 Lumbar osteomyelitis and need for durable central intravenous access.  Placement of left subclavian 4-French Broviac catheter., Pediatrics - Neonatal, Broviac Catheter Placement ,"PREOPERATIVE DIAGNOSES:,1.  Lumbar osteomyelitis.,2.  Need for durable central intravenous access.,POSTOPERATIVE DIAGNOSES:,1.  Lumbar osteomyelitis.,2.  Need for durable central intravenous access.,ANESTHESIA:,  General.,PROCEDURE:,  Placement of left subclavian 4-French Broviac catheter.,INDICATIONS:  ,The patient is a toddler admitted with a limp and back pain, who was eventually found on bone scan and septic workup to have probable osteomyelitis of the lumbar spine at disk areas.  The patient needs prolonged IV antibiotic therapy, but attempt at a PICC line failed.  She has exhausted most of her easy peripheral IV access routes and referral was made to the Pediatric Surgery Service for Broviac placement.  I met with the patient's mom.  With the help of a Spanish interpreter, I explained the technique for Broviac placement.  We discussed the surgical risks and alternatives, most of which have been exhausted.  All their questions have been answered, and the patient is fit for operation today.,DESCRIPTION OF OPERATION:  ,The patient came to the operating room and had an uneventful induction of general anesthesia.  We conducted a surgical time-out to reiterate all of the patient's important identifying information and to confirm that we were here to place the Broviac catheter.  Preparation and draping of her skin was performed with chlorhexidine based prep solution and then an infraclavicular approach to left subclavian vein was performed.  A flexible guidewire was inserted into the central location and then a 4-French Broviac catheter was tunneled through the subcutaneous tissues and exiting on the right anterolateral chest wall well below and lateral to the breast and pectoralis major margins.  The catheter was brought to the subclavian insertion site and trimmed so that the tip would lie at the junction of the superior vena cava and right atrium based on fluoroscopic guidelines.  The peel-away sheath was passed over the guidewire and then the 4-French catheter was deployed through the peel-away sheath.  There was easy blood return and fluoroscopic imaging showed initially the catheter had transited across the mediastinum up the opposite subclavian vein, then it was withdrawn and easily replaced in the superior vena cava.  The catheter insertion site was closed with one buried 5-0 Monocryl stitch and the same 5-0 Monocryl was used to tether the catheter at the exit site until fibrous ingrowth of the attached cuff has occurred.  Heparinized saline solution was used to flush the line.  A sterile occlusive dressing was applied, and the line was prepared for immediate use.  The patient was transported to the recovery room in good condition.  There were no intraoperative complications, and her blood loss was between 5 and 10 mL during the line placement portion of the procedure.","pediatrics - neonatal, lumbar osteomyelitis, central intravenous access, subclavian, osteomyelitis, broviac catheter, catheter, toddler, intravenous,"
 Delayed primary chest closure.  Open chest status post modified stage 1 Norwood operation.  The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation., Pediatrics - Neonatal, Chest Closure ,"PROCEDURE:, Delayed primary chest closure.,INDICATIONS: , The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation.  Given the magnitude of the operation and the size of the patient (2.5 kg), we have elected to leave the chest open to facilitate postoperative management.  He is now taken back to the operative room for delayed primary chest closure.,PREOP DX: , Open chest status post modified stage 1 Norwood operation.,POSTOP DX:,  Open chest status post modified stage 1 Norwood operation.,ANESTHESIA: , General endotracheal.,COMPLICATIONS: , None.,FINDINGS:,  No evidence of intramediastinal purulence or hematoma.  He tolerated the procedure well.,DETAILS OF PROCEDURE: , The patient was brought to the operating room and placed on the operating table in the supine position.  Following general endotracheal anesthesia, the chest was prepped and draped in the usual sterile fashion.  The previously placed AlloDerm membrane was removed.  Mediastinal cultures were obtained, and the mediastinum was then profusely irrigated and suctioned.  Both cavities were also irrigated and suctioned.  The drains were flushed and repositioned.  Approximately 30 cubic centimeters of blood were drawn slowly from the right atrial line.  The sternum was then smeared with a vancomycin paste.  The proximal aspect of the 5 mm RV-PA conduit was marked with a small titanium clip at its inferior most aspect and with an additional one on its rightward inferior side.  The sternum was then closed with stainless steel wires followed by closure of subcutaneous tissues with interrupted monofilament stitches.  The skin was closed with interrupted nylon sutures and a sterile dressing was placed.  The peritoneal dialysis catheter, atrial and ventricular pacing wires were removed.  The patient was transferred to the pediatric intensive unit shortly thereafter in very stable condition.,I was the surgical attending present in the operating room and in charge of the surgical procedure throughout the entire length of the case.","pediatrics - neonatal, open chest, stage 1 norwood operation, hypoplastic left heart syndrome, delayed primary chest closure, chest closure, norwood operation"
 Health maintenance exam for 1-year-old female., Pediatrics - Neonatal, 1-year-old Exam - H&P ,"CHIEF COMPLAINT:,  This 1-year-old female presents today for a health maintenance exam.  Patient was accompanied by mother.,The child eats 3 meals a day plus 2 snacks and is off the bottle.  She sleeps through the night.  She takes morning and afternoon naps.  Mother is concerned about child's red, matted eye and not walking completely alone yet.  Immunizations need to be updated at today's visit.,DEVELOPMENTAL MILESTONES:,  1 year developmental milestones reached:  bangs blocks together, drinks from cup, eating finger foods, feeds self, gives toys on request, imitates vocalizations, looks for dropped or hidden objects, points to desired objects, pulls to stand and cruises, releases cube into cup after demonstration, says ""mama"" and ""dada"" with meaning, says one or two other words, tries to build tower of 2 cubes and waves bye.,ALLERGIES:,  No known medical allergies.,MEDICATIONS:,  None.,PMH: , Past medical history is unremarkable.,PSH: , No previous surgeries.,FAMILY HISTORY:,  Patient admits a family history of cancer associated with maternal aunt, hypertension associated with paternal grandfather.,SOCIAL HISTORY:,  She lives at home with parents.  Patient admits being in daycare.,REVIEW OF SYSTEMS:,  No change since last visit,PHYSICAL EXAM:,  Temp:  97.6 Height:  0 ft.  31 in.  Weight:  28 lbs.  BMI:  20,Growth Chart Entry:  Weight:  28 lbs 0 ozs Height:  0 ft 31 in Head Circumference:  18.50 in Patient is a 1 year-old female who appears in no apparent distress, well developed and well nourished.,Inspection of head and face shows anterior fontanel normal, posterior fontanel normal and head is normocephalic and atraumatic.,Eyes:  Fundoscopic exam reveals red reflex is present bilaterally.,Alignment is normal.,Sclera is white bilaterally.,Left inferior palpebral conjunctiva reveals conjunctivitis.,Ocular motility exam reveals gross orthotropia with full ductions and versions bilateral.,ENT:  Pinna:  normal.,Otoscopic examination reveals no abnormalities of external auditory canals and tympanic membranes.,Inspection of nose reveals no abnormalities and nares that are normal.,Nasal mucosa moist, pink, and without mass or exudate with no abnormalities of the septum and turbinates noted.,Inspection of lips, gums, and palate reveals no abnormalities.,Examination of oropharynx reveals no abnormalities and tissues pink and moist.,Neck:  Neck exam reveals no masses.,Respiratory:  Assessment of respiratory effort reveals even and nonlabored respirations.  Auscultation of lungs reveal clear lung fields and no rubs noted.,Cardiovascular:  Heart auscultation reveals rate is regular, rhythm is regular and no murmurs, gallop, rubs or clicks.  Femoral pulses are 2 /4, bilateral.,Abdomen:  Abdomen soft, nontender, bowel sounds present x 4 without palpable masses.  Palpation of liver reveals no abnormalities.  Palpation of spleen reveals no abnormalities.,Genitourinary:  Examination of anus and perineum shows no abnormalities.,Musculoskeletal:  Inspection and palpation of bones, joints and muscles is unremarkable.,Muscle tone is normal.,Skin:  Skin is not pale, jaundice, or cyanotic.  Skin turgor, hydration, and texture is good.  Palpation of skin shows no abnormalities.,Neurologic/Psychiatric:  Moves all extremities.,TEST & X-RAY RESULTS:,  Hb:  12 g/dl.,IMPRESSION:,  Routine well child care.  Acute conjunctivitis.,PLAN:",
" 1+ year, black female for initial evaluation of a lifelong history of atopic eczema.", Pediatrics - Neonatal, Atopic Eczema ,"SUBJECTIVE:,  This 1+ year, black female, new patient in dermatology, sent in for consult from ABC Practice for initial evaluation of a lifelong history of atopic eczema.  The patient’s mom is from Tanzania.  The patient has been treated with Elidel cream b.i.d. for six months but apparently this has stopped working now and it seems to make her more dry and plus she has been using some Johnson's Baby Oil on her.  The patient is a well-developed baby.  Appears stated age.  Overall health is good.,FAMILY, SOCIAL, AND ALLERGY HISTORY: , The patient has eczema and a positive atopic family history.  No psoriasis.  No known drug allergies.,CURRENT MEDICATIONS:,  None.,PHYSICAL EXAMINATION:, The patient has eczematous changes today on her face, trunk, and extremities.,IMPRESSION:,  Atopic eczema.,TREATMENT:,1.  Discussed condition and treatment with Mom.,2.  Continue bathing twice a week.,3.  Discontinue hot soapy water.,4.  Discontinue Elidel for now.,5.  Add Aristocort cream 0.25%, Polysporin ointment, Aquaphor b.i.d. and p.r.n. itch.  We will see her in one month if not better otherwise on a p.r.n. basis.  Send a letter to ABC Practice program.","pediatrics - neonatal, dermatology, elidel cream, johnson's baby oil, polysporin ointment, atopic eczema, eczema, eczematous, hot soapy water, atopic, elidel,"
 Nerve root decompression at L45 on the left side.  Tun-L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left.  Interpretation of radiograph., Pain Management, Tun-L Catheter Placement ,"PREOPERATIVE DIAGNOSIS:,  Low Back Syndrome - Low back pain with left greater than right lower extremity radiculopathy.,POSTOPERATIVE DIAGNOSIS:,  Same.,PROCEDURE:,1.  Nerve root decompression at L45 on the left side.,2.  Tun-L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left.,3.  Interpretation of radiograph.,ANESTHESIA: , IV sedation with Versed and Fentanyl.,ESTIMATED BLOOD LOSS:,  None.,COMPLICATIONS:,  None.,INDICATION FOR PROCEDURE: , Severe and excruciating pain in the lumbar spine and lower extremity.  MRI shows disc pathology as well as facet arthrosis.,SUMMARY OF PROCEDURE: , The patient was admitted to the operating room, consent was obtained and signed.  The patient was taken to the Operating room and was placed in the prone position.  Monitors were placed, including EKG, pulse oximeter and blood pressure monitoring.  After adequate IV sedation with Versed and Fentanyl the procedure was begun.,The lumbar sacral region was prepped and draped in sterile fashion with Betadine and four sterile towels.  After the towels were places then sterile drapes were placed on top of that.,After which time the Epimed catheter was then placed, this was done by first repositioning the C-Arm to visualize the lumbar spine and the vertebral bodies were then counted beginning at L5, verifying the sacral hiatus.  The skin over the sacral hiatus was then injected with 1% Lidocaine and an #18-gauge needle was used for skin puncture.  The #18-gauge needle was inserted off of midline.  A #16-gauge RK needle was then placed into the skin puncture and using the paramedian approach and loss-of-resistance technique the needle was placed.  Negative aspiration was carefully performed.  Omnipaque 240 dye was then injected through the #16-gauge RK needle.  The classical run off was noted.  A filling defect was noted @ L45 nerve root on the left side.  After which time 10 cc of 0.25% Marcaine/Triamcinolone (9/1 mixture) was then infused through the 16 R-K Needle.  Some additional lyses of adhesions were visualized as the local anesthetic displaced the Omnipaque 240 dye using this barbotage technique.,An Epimed Tun-L catheter was then inserted through the #16-gauage R-K needle and threaded up to the L45 interspace under continuous fluoroscopic guidance.  As the catheter was threaded up under continuous fluoroscopic visualization lyses of adhesions were visualized.  The tip of the catheter was noted to be @ L45 level on the left side.  After this the #16-gauge RK needle was then removed under fluoroscopic guidance verifying that the tip of the catheter did not migrate from the L45 nerve root region on the left side.  After this was successfully done, the catheter was then secured in place; this was done with Neosporin ointment, a Split 2x2, Op site and Hypofix tape.  The catheter was then checked with negative aspiration and the Omnipaque 240 dye was then injected.  The classical run off was noted in the lumbar region.  Some lyses of adhesions were also visualized at this time with barbotage technique.  Good dye spread was noted to extend one level above and one level below the L45 nerve root and bilateral spread was noted.  Nerve root decompression was visualized as dye spread into the nerve root whereas prior this was a filling defect.  After which time negative aspiration was again performed through the Epimed® Tun-L catheter and then 10 cc of solution was then infused through the catheter, this was done over a 10-minute period with initial 3 cc test dose.  Approximately 3 minutes elapsed and then the remaining 7 cc were infused (Solution consisting of 8 cc of 0.25% Marcaine, 2 cc of Triamcinolone and 1 cc of Wydase.)  The catheter was then capped with a bacterial filter.  The patient was noted to have tolerated the procedure well without any complications.,Interpretation of radiograph revealed nerve root adhesions present with lysis of these adhesions as the procedure was performed.  A filling defect was seen at the L45 nerve root and this filling defect being significant of fibrosis and adhesions in this region was noted to be lysed with the insertion of the catheter as well as the barbotage procedure.  This verified positive nerve root decompression.  The tip of the Epimed Tun L catheter was noted to be at L45 level on the left side.  Positive myelogram without dural puncture was noted during this procedure; no sub-dural spread of Omnipaque 240 dye was noted.  This patient did not report any problems and reported pain reduction.","pain management, low back syndrome, low back pain, nerve root decompression, steroid solution, c-arm, epimed, tun l catheter, nerve root, negative aspiration, omnipaque dye, filling defect, nerve, root, catheter, adhesions, injection, needle,"
 A 5-month-old boy brought by his parents because of 2 days of cough. , Pediatrics - Neonatal, A 5-month-old boy with cough ,"CHIEF COMPLAINT:,  A 5-month-old boy with cough.,HISTORY OF PRESENT ILLNESS:,  A 5-month-old boy brought by his parents because of 2 days of cough.  Mother took him when cough started 2 days go to Clinic where they told the mother he has viral infection and gave him Tylenol, but yesterday at night cough got worse and he also started having fever.  Mother did not measure it.,REVIEW OF SYSTEMS:,  No vomiting.  No diarrhea.  He had runny nose started with the cough two days ago.  No skin rash.  No cyanosis.  Pulling on his right ear.  Feeding, he is bottle-fed 2 ounces every 2 hours.  Mother states he urinates like 5 to 6 times a day, stools 1 time a day.  He is still feeding good to mom.,IMMUNIZATIONS: , He received first set of shot and due for the second set on 01/17/2008.,BIRTH HISTORY:,  He was premature at 33 weeks born at Hospital kept in NICU for 2 weeks for feeding problem as the mother said.  Mother had good prenatal care at 4 weeks for more than 12 visits.  No complications during pregnancy.  Rupture of membranes happened two days before the labor.  Mother received the antibiotics, but she is not sure, if she received steroids also or not.,FAMILY HISTORY: , No history of asthma or lung disease.,SOCIAL HISTORY: , Lives with parents and with two siblings, one 18-year-old and the other is 14-year-old in house, in Corrales.  They have animals, but outside the house and father smokes outside house.  No sick contacts as the mother said.,PAST MEDICAL HISTORY:,  No hospitalizations.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,MEDICATIONS: , No medications.,History of 2 previous ear infection, last one was in last November treated with ear drops, because there was pus coming from the right ear as the mother said.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Temperature 100.1, heart rate 184, respiratory rate 48.  Weight 7 kg.,GENERAL:  In no acute distress.,HEAD:  Normocephalic and atraumatic.  Open, soft, and flat anterior fontanelle.,NECK:  Supple.,NOSE:  Dry secretions.,EAR:  Right ear full of yellowish material most probably pus and necrotic tissue.  Tympanic membrane bilaterally visualized.,MOUTH:  No pharyngitis.  No ulcers.  Moist mucous membranes.,CHEST:  Bilateral audible breath sound.  No wheezes.  No palpitation.,HEART:  Regular rate and rhythm with no murmur.,ABDOMEN:  Soft, nontender, and nondistended.,GENITOURINARY:  Tanner I male with descended testes.,EXTREMITIES:  Capillary refill less than 2 seconds.,LABS:,  White blood cell 8.1, hemoglobin 10.5, hematocrit 30.9, and platelets 380,000.  CRP 6, segments 41, and bands 41.  RSV positive.  Chest x-ray evidenced bronchiolitis with hyperinflation and bronchial wall thickening in the central hilar region.  Subsegmental atelectasis in the right upper lobe and left lung base.,ASSESSMENT:,  A 5-month-old male with 2 days of cough and 1 day of fever.  Chest x-ray shows bronchiolitis with atelectasis, and RSV antigen is positive.,DIAGNOSES: , Respiratory syncytial virus bronchiolitis with right otitis externa.,PLAN: , Plan was to admit to bronchiolitis pathway, and ciprofloxacin for right otitis externa eardrops twice daily.,",
 Trigger Point Injection.  The area over the myofascial spasm was prepped with alcohol utilizing sterile technique. , Pain Management, Trigger Point Injection ,"OPERATION:,","pain management, myofascial spasm, trigger point injection, trigger, injection, spasm"
 Mother states he has been wheezing and coughing., Pediatrics - Neonatal, Asthma in a 5-year-old ,"CHIEF COMPLAINT: , This 5-year-old male presents to Children's Hospital Emergency Department by the mother with ""have asthma.""  Mother states he has been wheezing and coughing.  They saw their primary medical doctor.  He was evaluated at the clinic, given the breathing treatment and discharged home, was not having asthma, prescribed prednisone and an antibiotic.  They told to go to the ER if he got worse.  He has had some vomiting and some abdominal pain.  His peak flows on the morning are normal at 150, but in the morning, they were down to 100 and subsequently decreased to 75 over the course of the day.,PAST MEDICAL HISTORY:,  Asthma with his last admission in 07/2007.  Also inclusive of frequent pneumonia by report.,IMMUNIZATIONS: , Up-to-date.,ALLERGIES: , Denied.,MEDICATIONS:  ,Advair, Nasonex, Xopenex, Zicam, Zithromax, prednisone, and albuterol.,PAST SURGICAL HISTORY: , Denied.,SOCIAL HISTORY: , Lives at home, here in the ED with the mother and there is no smoking in the home.,FAMILY HISTORY: , No noted exposures.,REVIEW OF SYSTEMS:  ,Documented on the template.  Systems reviewed on the template.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 98.7, pulse 105, respiration is 28, blood pressure 112/65, and weight of 16.5 kg.  Oxygen saturation low at 91% on room air.,GENERAL:  This is a well-developed male who is cooperative, alert, active with oxygen by facemask.,HEENT:  Head is atraumatic and normocephalic.  Pupils are equal, round, and reactive to light.  Extraocular motions are intact and conjugate.  Clear TMs, nose, and oropharynx.,NECK:  Supple.  Full painless nontender range of motion.,CHEST:  Tight wheezing and retractions heard bilaterally.,HEART:  Regular without rubs or murmurs.,ABDOMEN:  Soft, nontender.  No masses.  No hepatosplenomegaly.,GENITALIA:  Male genitalia is present on a visual examination.,SKIN:  No significant bruising, lesions or rash.,EXTREMITIES:  Moves all extremities without difficulty, nontender.  No deformity.,NEUROLOGIC:  Symmetric face, cooperative, and age appropriate.,MEDICAL DECISION MAKING:,  The differential entertained on this patient includes reactive airways disease, viral syndrome, and foreign body pneumonia.  He is evaluated in the emergency department with continuous high-dose albuterol, Decadron by mouth, pulse oximetry, and close observation.  Chest x-ray reveals bronchial thickening, otherwise no definite infiltrate.  She is further treated in the emergency department with continued breathing treatments.  At 0048 hours, he has continued tight wheezes with saturations 99%, but ED sats are 92% with coughing spells.  Based on the above, the hospitalist was consulted and accepts this patient for admission to the hospital with the working diagnosis of respiratory distress and asthma.",
" Transforaminal Epidural, lumbar - Template.  Fluoroscopy was used to identify the boney landmarks of the facet joints and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1 % lidocaine.", Pain Management, Transforaminal Epidural Steroid Injection - 1 ,"PROCEDURE:  ,Transforaminal Epidural, lumbar.,INFORMED CONSENT: , The risks, benefits and alternatives of the procedure were discussed with the patient.  The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible of vascular entry of medications.  I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing.  The patient understood the informed consent and desired to have the procedure performed.,PROCEDURE: , Oxygen saturation and vital signs were monitored continuously throughout the procedure.  The patient remained awake throughout the procedure in order to interact and give feedback.  The X-ray technician was supervised and instructed to operate the fluoroscopy machine.,The patient was placed in the prone position on the treatment table with a pillow under the lower abdomen to reduce the natural lumbar lordosis.  The skin over and surrounding the treatment area was cleaned with betadine.  The area was covered with sterile drapes, leaving a small window opening for needle placement.  Fluoroscopy was used to identify the boney landmarks of the facet joints and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1 % lidocaine.,With fluoroscopy, a *** spinal needle was gently guided into the superior-anterior neuroforamin lateral to the mid-pedicular line at ***.  Multiple fluoroscopic views were used to ensure proper needle placement.  Approximately *** of non-ionic contrast agent was injected into the joint under real time fluoroscopic observation.  Correct needle placement was confirmed by production of an appropriate epidurogram and radiculogram without concurrent vascular dye pattern.  Finally the treatment solution, consisting of *** was injected.,All injected medications were preservative free.  Sterile techniques were used throughout the procedure.,COMPLICATIONS:  ,None.  No complications.,The patient tolerated the procedure well and was sent to the recovery room in good condition.,DISCUSSION: , Post-procedure vital signs and oximetry were stable.  The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day.  The patient was told to resume all medications.  The patient was told to be in relative rest for 1 day but then could resume all normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes, or changes in bowel or bladder function.,Follow up appointment was made in approximately 1 week.","pain management, epidural lumbar, facet joints, transforaminal epidural, injection, transforaminal, epidural, lumbar, fluoroscopy, needle,"
" Left carpal tunnel release with flexor tenosynovectomy; cortisone injection of trigger fingers, left third and fourth fingers; injection of Dupuytren's nodule, left palm.", Pain Management, Tenosynovectomy & Cortisone Injection ,"PREOPERATIVE DIAGNOSES,1.  EMG-proven left carpal tunnel syndrome.,2.  Tenosynovitis of the left third and fourth fingers at the A1 and A2 pulley level.,3.  Dupuytren's nodule in the palm.,POSTOPERATIVE DIAGNOSES,1.  EMG-proven left carpal tunnel syndrome.,2.  Tenosynovitis of the left third and fourth fingers at the A1 and A2 pulley level.,3.  Dupuytren's nodule in the palm.,PROCEDURE: , Left carpal tunnel release with flexor tenosynovectomy; cortisone injection of trigger fingers, left third and fourth fingers; injection of Dupuytren's nodule, left palm.,ANESTHESIA: , Local plus IV sedation (MAC).,ESTIMATED BLOOD LOSS:  ,Zero.,SPECIMENS:  ,None.,DRAINS: , None.,PROCEDURE DETAIL: , Patient brought to the operating room.  After induction of IV sedation the left hand was anesthetized suitable for carpal tunnel release; 10 cc of a mixture of 1% Xylocaine and 0.5% Marcaine was injected in the distal forearm and proximal palm suitable for carpal tunnel surgery.  Routine prep and drape was employed.  Arm was exsanguinated by means of elevation of Esmarch elastic tourniquet and tourniquet inflated to 250 mmHg pressure.  Hand was positioned palm up in the lead hand-holder.  A short curvilinear incision about the base of the thenar eminence was made.  Skin was sharply incised.  Sharp dissection was carried down to the transverse carpal ligament and this was carefully incised longitudinally along its ulnar margin.  Care was taken to divide the entire length of the transverse retinaculum including its distal insertion into deep palmar fascia in the midpalm.  Proximally the antebrachial fascia was released for a distance of 2-3 cm proximal to the wrist crease to insure complete decompression of the median nerve.  Retinacular flap was retracted radially to expose the contents of the carpal canal.  Median nerve was identified, seen to be locally compressed with moderate erythema and mild narrowing.  Locally adherent tenosynovium was present and this was carefully dissected free.  Additional tenosynovium was dissected from the flexor tendons, individually stripping and peeling each tendon in sequential order so as to debulk the contents of the carpal canal.  Epineurotomy and partial epineurectomy were carried out on the nerve in the area of mild constriction to relieve local external scarring of the epineurium.  When this was complete retinacular flap was laid loosely in place over the contents of the carpal canal and skin only was closed with interrupted 5-0 nylon horizontal mattress sutures.  A syringe with 3 cc of Kenalog-10 and 3 cc of 1% Xylocaine using a 25 gauge short needle was then selected; 1 cc of this mixture was injected into the third finger A1 and A2 pulley tendon sheaths using standard trigger finger injection technique; 1 cc was injected into the fourth finger A1/A2 pulley tendon sheath using standard tendon sheath injection technique; 1 cc was injected into the Dupuytren's nodule in the midpalm to relieve local discomfort.  Routine postoperative hand dressing with well-padded, well-molded volar plaster splint and lightly compressive Ace wrap was applied.  Tourniquet was deflated.  Good vascular color and capillary refill were seen to return to the tips of all digits.  Patient discharged to the ambulatory recovery area and from there discharged home.  Discharge medication is Darvocet-N 100, 30 tablets, one to two PO q.4h. p.r.n.  Patient asked to begin gentle active flexion, extension and passive nerve glide exercises beginning 24-48 hours after surgery.  She was asked to keep the dressings clean, dry and intact and follow up in my office.","pain management, carpal tunnel syndrome, pulley, dupuytren's, tenosynovitis, tenosynovectomy, carpal tunnel release, flexor tenosynovectomy, cortisone injection, dupuytren's nodule, injection, cortisone,"
 Thoracic epidural steroid injection without fluoroscopy.  An 18-gauge Tuohy needle was then placed into the epidural space using loss of resistance technique., Pain Management, Thoracic epidural steroid injection ,"PROCEDURE: , Thoracic epidural steroid injection without fluoroscopy.,ANESTHESIA: , Local sedation.,VITAL SIGNS: , See nurse's notes.,COMPLICATIONS: , None.,DETAILS OF PROCEDURE: , INT was placed.  The patient was in the sitting position and the back was prepped with Betadine.  Lidocaine 1.5% was used for skin wheal made between __________.  An 18-gauge Tuohy needle was then placed into the epidural space using loss of resistance technique with no cerebrospinal fluid or blood noted.  After negative aspiration, a mixture of 7 cc preservative free normal saline and 160 mg preservative free Depo-Medrol was injected.  Neosporin and band-aid were applied over the puncture site.  The patient was discharged to recovery room in stable condition.","pain management, loss of resistance, cerebrospinal fluid, thoracic epidural steroid injection, fluoroscopy, thoracic, steroid, epidural, injection, "
 Flexible Bronchoscopy (pediatric), Pediatrics - Neonatal, Bronchoscopy - Pediatric ,"FLEXIBLE BRONCHOSCOPY,The flexible bronchoscopy is performed under conscious sedation in the Pediatric Intensive Care Unit.  I explained to the parents that the possible risks include:  irritation of the nasal mucosa, which can be associated with some bleeding; risk of contamination of the lower airways by passage of the scope in the nasopharynx; respiratory depression from sedation; and a very small risk of pneumothorax.  A bronchoalveolar lavage may be obtained by injecting normal saline in one of the bronchi and suctioning the fluid back.  The sample will then be sent for testing.  The flexible bronchoscopy is mainly diagnostic, any therapeutic intervention, if deemed necessary, will be planned and will require a separate procedure.,The parents seem to understand, had the opportunity to ask questions and were satisfied with the information.  A booklet containing the description of the procedure and other information was provided.","pediatrics - neonatal, flexible bronchoscopy, pediatric intensive care unit, bleeding, bronchi, bronchoalveolar lavage, bronchoscopy, conscious sedation, nasal mucosa, nasopharynx, pneumothorax, respiratory, pediatric flexible bronchoscopyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Left L3-L4 transforaminal epidural steroid injection (L3 nerve root) and Left L4-L5 transforaminal epidural steroid injection (L4 nerve root) under fluoroscopic guidance., Pain Management, Transforaminal Epidural Steroid Injection ,"PROCEDURE: , Left L3-L4 transforaminal epidural steroid injection (L3 nerve root) and Left L4-L5 transforaminal epidural steroid injection (L4 nerve root) under fluoroscopic guidance.,PATIENT PROFILE: , This is a 44-year-old female.  The patient reports greatly increasing pain over the past several weeks.  In addition, the patient has associated radicular symptoms of aching, radiating to the L3 dermatome distribution and L4 dermatome distribution.  She is status post posterior fusion and lumbar decompression within the past several years.  Due to the nature of the patient's persistent pain, epidural steroid injection is recommended.  The alternatives, benefits, and risks were discussed with the patient.  The patient verbalized understanding of the risks as well as the alternatives and wished to proceed with the procedure.  A signed and witnessed informed consent was placed on the chart.,PRE-OP DIAGNOSIS:,  Left leg pain, Left leg weakness, Left L3-4 radicular pain, Left L4-5 radicular pain, Lumbar spondylosis.,POST-OP DIAGNOSIS:,  Left leg pain, Left leg weakness, Left L3-4 radicular pain, Left, L4-5 radicular pain, Lumbar spondylosis.,ANESTHESIA:,  Midazolam 2 mg IV Fentanyl 50 mcg IV.,FINDINGS:,PAIN MANAGEMENT:,  The patient reports greatly increasing pain over the past several weeks.  The patient now rates pain as 8/10.  The reported pain is at L3-4 and L4-5.,DESCRIPTION OF PROCEDURE:,  The patient was placed in the prone position on the radiolucent operating table.  The lumbar area was prepped and draped in the appropriate sterile fashion.  The left L3-L4 level was identified for a transforaminal epidural injection and the overlying skin and subcutaneous tissue were anesthetized.  A 22 gauge 3.5 inch B-bevel spinal needle was passed through the skin wheal and advanced in a ventral direction until the tip of the needle was properly placed in the left superior posterior intervertebral foramen as confirmed by AP and lateral fluoroscopic views.  No blood was aspirated.  There was no CSF flow.  Following negative aspiration, 1 mL Isovue-M200 was injected to produce the epidurogram.  There was appropriate needle placement and no intravascular or intrathecal flow.  1 mL of a 40 mg/mL solution of Kenalog and 1 mL of 1% Lidocaine was injected.,Attention was then turned to the next injection.  The lumbar area was prepped and draped in the appropriate sterile fashion.  The left L4-L5 level was identified for a transforaminal epidural injection and a skin wheal was made at the spinal needle entry site.  A 22 gauge 3.5 inch spinal needle was passed through the skin wheal and advanced in a ventral direction until the tip of the needle was properly placed in the left superior posterior intervertebral foramen as confirmed by AP and lateral fluoroscopic views.  No blood was aspirated.  There was no CSF flow.  Following negative aspiration 1 mL Isovue-M200 was injected to produce the epidurogram.  There was appropriate needle placement and no intravascular or intrathecal flow.  1 mL of a 40 mg/mL solution of Kenalog and 1 mL of 1% Lidocaine was injected.  The patient tolerated the procedure well.,DRAINS / DRESSING:,  Applied sterile dressing including BAND-AID.,PATIENT TO RECOVERY ROOM: , The patient tolerated the procedure well, and was brought to the recovery room in excellent condition.,COMPLICATIONS: , No immediate complications,DISCHARGE ORDERS:,DISPOSITION: , Discharge patient to home today.,ACTIVITY: , Patient may resume normal activity level in 1 day.,FOLLOW-UP: , Appointment to Surgeon's Office in 2 weeks,CPT4 CODE(S):,64483 LT, Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level.,64484 LT, Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, each additional level (List separately in addition to code for primary procedure).,76005, Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint), including neurolytic agent destruction.,ICD9 CODE(S):,724.4  Thoracic or lumbosacral neuritis or radiculitis.,721.3  Lumbosacral spondylosis without myelopathy.",
 Placement of SynchroMed infusion pump and tunneling of SynchroMed infusion pump catheter.  Anchoring of the intrathecal catheter and connecting of the right lower quadrant SynchroMed pump catheter to the intrathecal catheter., Pain Management, SynchroMed Pump Placement ,"PROCEDURES:,1.  Placement of SynchroMed infusion pump.,2.  Tunneling of SynchroMed infusion pump catheter,3.  Anchoring of the intrathecal catheter and connecting of the right lower quadrant SynchroMed pump catheter to the intrathecal catheter.,DESCRIPTION OF PROCEDURE: , Under general endotracheal anesthesia, the patient was placed in a lateral decubitus position.  The patient was prepped and draped in a sterile manner.  The intrathecal catheter was placed via a percutaneous approach by the pain management specialist at which point an incision was made adjacent to the needle containing the intrathecal catheter.  This incision was carried down through the skin and subcutaneous tissue to the paraspinous muscle fascia which was cleared around the entry point of the intrathecal catheter needle.  A pursestring suture of 3-0 Prolene was placed around the needle in the paraspinous muscle.  The needle was withdrawn.  The pursestring suture was tied to snug the tissues around the catheter and prevent cerebrospinal fluid leak.  The catheter demonstrated free flow of cerebrospinal fluid,throughout the RV procedure.  The catheter was anchored to the paraspinous muscle with an anchoring device using interrupted sutures of 3-0 Prolene.  Antibiotic irrigation and antibiotic soak sponge were placed into the wound, and the catheter was clamped to prevent persistent leakage of cerebrospinal fluid while the SynchroMed-pump pocket was created.  Then, I turned my attention to the anterior abdominal wall where an oblique incision was made and carried down through the skin and subcutaneous tissue to the external oblique fascia, which was freed from attachments to the overlying subcutaneous tissue utilizing blunt and sharp dissection with electrocautery.  A pocket was created that would encompass the SynchroMed fusion pump.  A tunneling device was then passed through the subcutaneous tissue from the back incision to the abdominal incision, and a SynchroMed pump catheter was placed to the tunneling device.  The tunneling device was then removed leaving the SynchroMed pump catheter extending from the anterior abdominal wall incision to the posterior back incision.  The intrathecal catheter was trimmed.  A clear plastic boot was placed over the intrathecal catheter, and the connecting device was advanced from the SynchroMed pump catheter into the intrathecal catheter connecting the 2 catheters together.  The clear plastic boot was then placed over the connection, and it was anchored in place with 0-silk ties.  Good CSF was then demonstrated flowing through the SynchroMed pump catheter.  The SynchroMed pump catheter was connected to the SynchroMed pump and anchored in place with a 0-silk tie.  Excess catheter was coiled and placed behind the pump.  The pump was placed into the subcutaneous pocket created for it on the anterior abdominal wall.  The pump was anchored to the anterior abdominal wall fascia with interrupted sutures of 2-0 Prolene; 4 of the sutures were placed.  The subcutaneous tissues were irrigated with normal saline.  The subcutaneous tissue of both wounds was closed with running suture of 3-0 Vicryl.  The skin of both wounds was closed with staples.  Antibiotic ointment and a sterile dressing were applied.  The patient was awake and taken to the recovery room.  The patient tolerated the procedure well and was stable at the completion of the procedure.  All sponge and lap, needle and instrument counts were correct at the completion of the procedure.","pain management, intrathecal, catheter, paraspinous, cerebrospinal, synchromed infusion pump, synchromed pump catheter, synchromed pump, paraspinous muscle, cerebrospinal fluid, tunneling device, infusion pump, subcutaneous tissue, infusion, synchromed, pump, incision,"
 Consultation for right shoulder pain., Pain Management, Shoulder Pain Consult ,"CHIEF COMPLAINT:,  Right shoulder pain.,HISTORY OF PRESENT PROBLEM:","pain management, shoulder pain, history of present problem:, cortisone shot, no numbness or tingling, rhomboids, scapula, shoulder impingement, focal findings, shoulder,"
 Right sacral alar notch and sacroiliac joint/posterior rami radiofrequency thermocoagulation., Pain Management, Radiofrequency Thermocoagulation ,"PROCEDURE: , Right sacral alar notch and sacroiliac joint/posterior rami radiofrequency thermocoagulation.,ANESTHESIA:  ,Local sedation.,VITAL SIGNS: , See nurse's notes.,COMPLICATIONS: , None.,DETAILS OF PROCEDURE: , INT was placed.  The patient was in the operating room in the prone position.  The back prepped with Betadine.  The patient was given sedation and monitored.  Under fluoroscopy, the right sacral alar notch was identified.  After placement of a 20-gauge, 10 cm SMK needle into the notch, a positive sensory, negative motor stimulation was obtained.  Following negative aspiration, 5 cc of 0.5% of Marcaine and 20 mg of Depo-Medrol were injected.  Coagulation was then carried out at 90oC for 90 seconds.  The SMK needle was then moved to the mid-inferior third of the right sacroiliac joint.  Again the steps dictated above were repeated.,The above was repeated for the posterior primary ramus branch right at S2 and S3 by stimulating along the superior lateral wall of the foramen; then followed by steroid injected and coagulation as above.,There were no complications.  The patient was returned to outpatient recovery in stable condition.","pain management, posterior rami, sacroiliac joint, sacral alar notch, radiofrequency thermocoagulation, thermocoagulation, radiofrequency, sacroiliac, sacral, alar, notch"
" Superior Gluteal Nerve Block, Left - Superior Gluteal Neuralgia/Neurapraxia-impingement Syndrome.", Pain Management, Superior Gluteal Nerve Block ,"PRE-OPERATIVE DIAGNOSIS:, Superior Gluteal Neuralgia/Neurapraxia-impingement Syndrome.,POST-OPERATIVE DIAGNOSIS:, Same,PROCEDURE:, Superior Gluteal Nerve Block, Left.,After verbal informed consent, whereby the patient is made aware of the risks of the procedure, the patient was placed in the standing position with the arms flaccid by the side. Alcohol was used to prep the skin 3 times, and a 27-gauge needle was advanced deep to the attachment of the Gluteus Medius Muscle near its attachment on the PSIS. The needle entered the plane between the Gluteus Medius and Gluteus Maximus Muscle, in close proximity to the Superior Gluteal Nerve. Aspiration was negative, and the mixture was easily injected. Aseptic technique was observed at all times, and there were no complications noted.,INJECTATE INCLUDED:,Methyl Prednisolone (DepoMedrol): 20 mg,Ketorolac (Toradol): 6 mg,Sarapin: 1 cc,Bupivacaine (Marcaine): Q.S.  2 cc.,The procedures, above were performed for diagnostic, as well as therapeutic purposes. This treatment plan is medically necessary to decrease pain and suffering, increase activities of daily living and improve sleep.,ZUNG SELF-RATING DEPRESSION SCALE© (SDS) RESULTS:, The patient scored as 'mildly depressed.,NOTE:, The pain was gone post procedure, consistent with the diagnosis, as well as with adequacy of medication placement.","pain management, neurapraxia, impingement syndrome, neuralgia, superior gluteal, superior gluteal nerve block, gluteus medius muscle, gluteus maximus muscle, gluteus medius, nerve block, gluteal nerve, block, gluteus, nerve, gluteal"
" Bilateral L5, S1, S2, and S3 radiofrequency ablation for sacroiliac joint pain.  Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.", Pain Management, Radiofrequency Ablation ,"PROCEDURE: , Bilateral L5, S1, S2, and S3 radiofrequency ablation.,INDICATION: , Sacroiliac joint pain.,INFORMED CONSENT: , The risks, benefits and alternatives of the procedure were discussed with the patient.  The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible of vascular entry of medications.  I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing.  The patient understood the informed consent and desired to have the procedure performed.,PROCEDURE: , Oxygen saturation and vital signs were monitored continuously throughout the procedure.  The patient remained awake throughout the procedure in order to interact and give feedback.  The x-ray technician was supervised and instructed to operate the fluoroscopy machine.,The patient was placed in a prone position on the treatment table with a pillow under the chest and head rotated.  The skin over and surrounding the treatment area was cleaned with Betadine.  The area was covered with sterile drapes, leaving a small window opening for needle placement.  Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.,With fluoroscopy, a 20 gauge 10-mm bent Teflon coated needle was gently guided into the groove between the SAP and the sacrum for the dorsal ramus of L5 and the lateral border of the posterior sacral foramen, for the lateral branches of S1, S2, and S3.  Also, fluoroscopic views were used to ensure proper needle placement.,The following technique was used to confirm correct placement.  Motor stimulation was applied at 2 Hz with 1 millisecond duration.  No extremity movement was noted at less than 2 volts.  Following this, the needle trocar was removed and a syringe containing 1% lidocaine was attached.  At each level, after syringe aspiration with no blood return, 0.5 mL of 1% lidocaine was injected to anesthetize the lateral branch and the surrounding tissue.  After completion, a lesion was created at that level with a temperature of 80 degrees for 90 seconds.,All injected medications were preservative free.  Sterile technique was used throughout the procedure.,ADDITIONAL DETAILS:  ,None.,COMPLICATIONS: , None.,DISCUSSION: , Post-procedure vital signs and oximetry were stable.  The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day.  The patient was told to resume all medications.  The patient was told to be in relative rest for 1 day but then could resume all normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes, or changes in bowel or bladder function.,Follow up appointment was made at PM&R Spine Clinic in approximately one to two weeks.","pain management, sacroiliac joint pain, sacroiliac, teflon coated needle, fluoroscopy, needle placement, radiofrequency ablation, ablation, tissue, lidocaine, needle,"
 Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain., Pain Management, Radiofrequency Thermocoagulation - 1 ,"PROCEDURE: , Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain.,ANESTHESIA: , Local sedation.,VITAL SIGNS: , See nurse's notes.,COMPLICATIONS: , None.,DETAILS OF PROCEDURE:  ,INT was placed.  The patient was in the operating room in the prone position with the back prepped and draped in a sterile fashion.  The patient was given sedation and monitored.  Lidocaine 1.5% for skin wheal was made 10 cm from the midline to the bilateral L2 distal vertebral body.  A 20-gauge, 15 cm SMK needle was then directed using AP and fluoroscopic guidance so that the tip of the needle was noted to be along the distal one-third and anterior border on the lateral view and on the AP view the tip of the needle was inside the lateral third of the border of the vertebral body.  At this time a negative motor stimulation was obtained.  Injection of 10 cc of 0.5% Marcaine plus 10 mg of Depo-Medrol was performed. Coagulation was then carried out for 90oC for 90 seconds.  At the conclusion of this, the needle under fluoroscopic guidance was withdrawn approximately 5 mm where again a negative motor stimulation was obtained and the sequence of injection and coagulation was repeated.  This was repeated one more time with a 5 mm withdrawal and coagulation.,At that time, attention was directed to the L3 body where the needle was placed to the upper one-third/distal two-thirds junction and the sequence of injection, coagulation, and negative motor stimulation with needle withdrawal one time of a 5 mm distance was repeated.  There were no compilations from this.  The patient was discharged to operating room recovery in stable condition.","pain management, lumbar sympathetic chain, vertebral body, radiofrequency thermocoagulation, motor stimulation, thermocoagulation, radiofrequency, coagulation, needle, "
" Complex regional pain syndrome, right upper extremity.  Stellate ganglion block.", Pain Management, Stellate Ganglion Block ,"PREOPERATIVE DIAGNOSIS:,  Complex Regional Pain Syndrome, right upper extremity.,POSTOPERATIVE DIAGNOSIS:,  Same.,OPERATION:,","pain management, chassaignac's tubercle, horner's sign, stellate ganglion block, sheath, vertebral, stellate, ganglion, cervical, block,"
 Pain management sample progress note., Pain Management, Pain Management Progress Note ,"DIAGNOSES:,1.  Cervical dystonia.,2.  Post cervical laminectomy pain syndrome.,Ms. XYZ states that the pain has now shifted to the left side.  She has noticed a marked improvement on the right side, which was subject to a botulinum toxin injection about two weeks ago.  She did not have any side effects on the Botox injection and she feels that her activities of daily living are increased, but she is still on the oxycodone and methadone.  The patient's husband confirms the fact that she is doing a lot better, that she is more active, but there are still issues yet regarding anxiety, depression, and frustration regarding the pain in her neck.,PHYSICAL EXAMINATION:,  The patient is appropriate.  She is well dressed and oriented x3.  She still smells of some cigarette smoke.  Examination of the neck shows excellent reduction in muscle spasm on the right paraspinals, trapezius and splenius capitis muscles.  There are no trigger points felt and her range of motion of the neck is still somewhat guarded, but much improved.  On the left side, however, there is significant muscle spasm with tight bands involving the multifidus muscle with trigger point activity and a lot of tenderness and guarding.  This extends down into the trapezius muscle, but the splenius capitis seems to be not involved.,TREATMENT PLAN:,  After a long discussion with the patient and the husband, we have decided to go ahead and do botulinum toxin injection into the left multifidus/trapezius muscles.  A total of 400 units of Botox is anticipated.  The procedure is being scheduled.  The patient's medications are refilled.  She will continue to see Dr. Berry and continue her therapy with Mary Hotchkinson in Victoria.","pain management, progress note, management, muscle"
 Injection of Morton's neuroma., Pain Management, Mortons Neuroma Injection  ,"POST PROCEDURE INSTRUCTIONS:, The patient has been asked to report to us any redness, swelling, inflammation, or fevers.  The patient has been asked to restrict the use of the * extremity for the next 24 hours.","pain management, injection, depo-medrol, morton's neuroma, gauge needle, inflammation, metatarsal ligament, metatarsal space, neuroma, redness, swelling, morton'sNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Cervical spondylosis.  Radiofrequency thermocoagulation (RFTC), medial branch posterior sensory rami.", Pain Management, Radiofrequency Thermocoagulation - 3 ,"PREOPERATIVE DIAGNOSIS:,  Cervical spondylosis.,POSTOPERATIVE DIAGNOSIS:,  Cervical spondylosis.,OPERATION PERFORMED:,  Radiofrequency thermocoagulation (RFTC), medial branch posterior sensory rami of cervical at ***.,SURGEON:,  Ralph Menard, M.D.,ANESTHESIA:,  Local and IV.,COMPLICATIONS:,  None.,DESCRIPTION OF PROCEDURE: , After proper consent was obtained, the patient was taken to the fluoroscopy suite and placed on a fluoroscopy table in a prone position with a chest roll in place.  The neck was placed in a flexed position.  The patient was monitored with blood pressure cuff, EKG, and pulse oximetry and given oxygen via nasal cannula.  The patient was lightly sedated.  The skin was prepped and draped in a sterile classical fashion.,Under fluoroscopy control, the waists of the articular pillars were identified and marked.  Local anesthesia infiltrated subcutaneously and deep extending down toward these previously marked points.  Once the anesthesia was established, an insulated 10-cm, 22-gauge needle with a 5-mm non-insulated stimulating tip was placed in contact with the waists of the articular pillars at the affected levels that were previously mentioned.  This was done under direct fluoroscopic control utilizing a gun barrel technique with PA views initially for orientation and then a lateral view to determine the depth of the needle.  For C3 to C6 medial branch RFTC's, the needles are placed along the ventral aspect of a line that connects the greatest antero-posterior diameter of the articular pillar but remains dorsal to the foramen as seen on lateral imaging.  For a C7 medial branch RFTC, the needle tip is positioned more superiorly such that it overlies the superior articular process.  For a C8 medial branch RFTC, the needle is placed at the junction of the superior articulating facet and the base of the transverse process of T1.,Sensory stimulation was carried out at 50 Hz from 0 to 2.0 volts.  Stimulation was stopped once the maximum voltage was delivered or the patient either described a buzzing sensation indicating that it was a nonpainful nerve, or it caused replication of their concordant pain.  The stimulation was then changed to 2 Hz for motor stimulation and advanced up to 2.0 volts or until motor stimulation was found at that level.  If motor stimulation occurred, the needle was repositioned to abolish it but still cause concordant pain, or the RFTC was aborted at this level.,If the sensory stimulation caused concordant pain without motor stimulation, the area was then anesthetized with 1 cc of Marcaine 0.5% with 5 mg of methyl prednisolone acetate.  Once the anesthesia was established, a radiofrequency lesioning was then done at 65 degrees for 60 seconds.  The same procedure was carried out at all the affected levels.  The patient tolerated the procedure well without any difficulties or complications.","pain management, rami, fluoroscopic control, radiofrequency thermocoagulation, cervical spondylosis, articular pillars, motor stimulation, medial branch, thermocoagulation, rftc, needle, cervical, stimulation"
 Right sacral alar notch and sacroiliac joint/posterior rami injections with/without fluoroscopy., Pain Management, Sacral Alar Notch Injection ,"PROCEDURE:,  Right sacral alar notch and sacroiliac joint/posterior rami injections with fluoroscopy.,ANESTHESIA:,  Local sedation.,VITAL SIGNS: , See nurse's notes.,COMPLICATIONS:  ,None.,DETAILS OF PROCEDURE: , INT was placed.  The patient was in the operating room with intravenous line in place and intravenous sedation was given.  The patient was in the prone position.  The back was prepped with Betadine.  Under fluoroscopy, the right sacral alar notch was identified and after placement of a 22-gauge, 3-1/2 inch spinal needle in to the notch, negative aspiration was performed and 5 cc of 0.5% Marcaine plus 20 mg of Depo-Medrol was injected.  The needle was then placed in to the right sacroiliac joint (distal third) and the same local anesthetic mixture was injected.  This was repeated for the right sacral alar notch and the right sacroiliac joint (distal third).  The needle was withdrawn.  The above was repeated for the posterior primary rami branch at S2 and S3 by stimulating along the superior lateral wall of the foramen; then followed by steroid injection and coagulation as above.,There were no complications.  Needles removed.  Band-aids were applied over the puncture sites.  The patient was discharged to operating room recovery in stable condition.","pain management, fluoroscopy, sacroiliac joint, sacral alar notch, posterior rami, sacroiliac, alar, sacral, notch, "
 Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection., Pain Management, Neuroplasty ,"PREOPERATIVE DIAGNOSES:,  ,1.  Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2.  Epidural fibrosis with nerve root entrapment.,POSTOPERATIVE DIAGNOSES:,  ,1.  Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2.  Epidural fibrosis with nerve root entrapment.,OPERATION PERFORMED:,  Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,ANESTHESIA:,  Local/IV sedation.,COMPLICATIONS:,  None.,SUMMARY:  ,The patient in the operating room, status post transforaminal epidurogram (see operative note for further details).  Using AP and lateral fluoroscopic views to confirm the needle location the superior most being in the left L4 neural foramen and the inferior most in the left L5 neural foramen, 375 units of Wydase was injected through each needle.  After two minutes, 3.5 cc of 0.5% Marcaine and 80 mg of Depo-Medrol was injected through each needle.  These needles were removed and the patient was discharged in stable condition.","pain management, nerve root decompression, discectomy, epidural fibrosis, nerve root entrapment, transforaminal neuroplasty, neural foramen, nerve root, foramen, neuroplasty, transforaminal, needle, epidural,"
 Complex Regional Pain Syndrome Type I.  Stellate ganglion RFTC (radiofrequency thermocoagulation)  left side and interpretation of Radiograph., Pain Management, Radiofrequency Thermocoagulation - 2 ,"PREOPERATIVE DIAGNOSIS:,  Complex Regional Pain Syndrome Type I.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE:,1.  Stellate ganglion RFTC (radiofrequency thermocoagulation)  left side.,2.  Interpretation of Radiograph.,ANESTHESIA:  ,IV Sedation with Versed and Fentanyl.,ESTIMATED BLOOD LOSS:,  None.,COMPLICATIONS:,  None.,INDICATIONS: , Patient with reflex sympathetic dystrophy, left side.  Positive for allodynia, pain, mottled appearance, skin changes upper extremities as well as swelling.,SUMMARY OF PROCEDURE: , Patient is admitted to the Operating Room.  Monitors placed, including EKG, Pulse oximeter, and BP cuff.  Patient had a pillow placed under the shoulder blades.  The head and neck was allowed to fall back into hyperextension.  The neck region was prepped and draped in sterile fashion with Betadine and alcohol.  Four sterile towels were placed.  The cricothyroid membrane was palpated, then going one finger's breadth lateral from the cricothyroid membrane and one finger's breadth inferior, the carotid pulse was palpated and the sheath was retracted laterally.  A 22 gauge SMK 5-mm bare tipped needle was then introduced in between the cricothyroid membrane and the carotid sheath and directed inferiomedially.  The needle is advanced prudently through the tissues, avoiding the carotid artery laterally.  The tip of the needle is perceived to intersect with the vertebral body of Cervical #7 and this was visualized by fluoroscopy.  Aspiration was cautiously performed after the needle was retracted approximately 1 mm and held steady with left hand.  No venous or arterial blood return is noted.  No cerebral spinal fluid is noted.  Positive sensory stimulation was elicited using the Radionics unit at 50 Hz from 0-0.1 volts and negative motor stimulation was elicited from 1-10 volts at 2 Hz.  After negative aspiration through the 22 gauge SMK 5mm bare tipped needle is absolutely confirmed, 5 cc of solution (solution consisting of 5 cc of 0.5% Marcaine, 1 cc of triamcinolone) was then injected into the stellate ganglion region.  This was done with intermittent aspiration vigilantly verifying negative aspiration.  The stylet was then promptly replaced and neurolysis (nerve decompression) was then carried out for 60 seconds at 80 degrees centigrade.  This exact same procedure using the exact same protocol was repeated one more time to complete the two lesions of the stellate ganglion.  The patient was immediately placed in the sitting position to reduce any side effect from the stellate ganglion block associated with cephalad spread of the solution.  Pressure was placed over the puncture site for approximately five minutes to eliminate any hemorrhage from blood vessels that may have been punctured and a Band-Aid was placed over the puncture site.  Patient was monitored for an additional ten to fifteen minutes and was noted to have tolerated the procedure well without any adverse sequelae.  Significant temperature elevation was noted on the affected side verifying neurolysis of the ganglion.  ,Interpretation of radiograph reveals placement of the 22-gauge SMK 5-mm bare tipped needle in the region of the stellate ganglion on the affected side.  Four lesions were carried out.","pain management, sheath, vertebral body, regional pain syndrome, radiofrequency thermocoagulation, stellate ganglion, rftc, radiofrequency, radiograph, cricothyroid, thermocoagulation, ganglion,"
 Plantar Fascia Injection, Pain Management, Plantar Fascia Injection ,"PROCEDURE:,:  Informed consent was obtained from the patient.  Special mention was made of the possibility of infection and necrosis of the heel pad.  The patient was placed in the supine position.  The tender area in the medial aspect of the heel was identified by palpation.  After proper preparation with antiseptic solution of the skin, a syringe containing 2 mL of 1% lidocaine was attached to 1.5"" 27 gauge needle.  The needle was carefully advanced through the carefully identified point at a right angle to the skin, directly towards the central and medial aspect of the calcaneus.  The needle was advanced very slowly until the needle impinged on the bone, and then was withdrawn slowly.  The contents of the syringe were then gently injected.  Subsequently, the needle was left in place and a syringe containing 2 mL of 0.25% Marcaine and 1 mL of Depo-Medrol was attached to the needle and injected after aspiration at this site.  Subsequently the needle was removed.  Pressure was applied at the site of insertion and once it was made sure there was no bleeding taking place, a small bandage was applied.,POST PROCEDURE INSTRUCTIONS:, The patient has been asked to report to us any redness, swelling, inflammation, or fevers.  The patient has been asked to restrict the use of the * extremity for the next 24 hours.","pain management, plantar fascia injection, plantar fascia, calcaneus, heel pad, necrosis, depo-medrol, bandage, medial aspect, heel, syringe, injection, needleNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Lumbar epidural steroid injection, L5-S1.  Low back pain.", Pain Management, Lumbar Epidural Steroid Injection - 2 ,"PREOPERATIVE DIAGNOSIS: , Low back pain.,POSTOPERATIVE DIAGNOSIS: , Low back pain.,PROCEDURE: , Lumbar epidural steroid injection, L5-S1.,ANESTHESIA: , Local.,SPECIAL EQUIPMENT: , Fluoroscopic unit.,DETAILS OF PROCEDURE: , The patient was taken to the Radiology Suite and was placed in the prone position where the entire back region was scrubbed, prepped, and draped in a sterile fashion with Betadine solution.  The lumbar area was then draped with sterile towels and sterile drapes.  The surgeon was gloved with sterile gloves and mask in order to create a sterile environment for the epidural injection.  The fluoroscopy x-ray unit was then brought into the sterile field for a PA x-ray visualization of the spine.  A Steinmann pin was then placed across the spine to localize the level of the planned injection.  Local infiltration using 0.5% preservative-free Xylocaine via a 25-gauge needle was then placed into the dermis and subcutaneous tissue.  A Tuohy needle was then oriented perpendicular to the skin and was then advanced through the dermis and subcutaneous tissues.  Continuous injection of 0.5% preservative-free Xylocaine was used during the advancement of the Tuohy needle into the deeper spinous tissues.  A solution of 80 mg of Depo-Medrol with 2 cc of 1% Xylocaine injectable and 5 cc of normal saline were then injected into the epidural space.","pain management, back pain, lumbar epidural steroid injection, tuohy needle, steroid injection, subcutaneous, epidural, steroid, lumbar, sterile, injection"
 Lumbar epidural steroid injection for lumbar radiculopathy., Pain Management, Lumbar Epidural Steroid Injection - 3 ,"PREOPERATIVE DIAGNOSIS:  ,Lumbar radiculopathy, 724.4.,POSTOPERATIVE DIAGNOSIS:,  Lumbar radiculopathy, 724.4.,PROCEDURE:,  Lumbar epidural steroid injection.,ANESTHESIOLOGIST:,  Monitored anesthesia care,INJECTATE USED:,  10 mL of 0.5% lidocaine and 80 mg of Depo-Medrol.,ESTIMATED BLOOD LOSS:,  None.,COMPLICATIONS:,  None.,DETAILS OF THE PROCEDURE:,  The patient arrived at the preoperative holding area where informed consent, stable vital signs, and intravenous access were obtained.  A thorough discussion of the potential risks, benefits, and complications was made prior to the procedure including potential for post-dural puncture headache and its associated treatment as well as potential for increased neurological dysfunction and/or nerve root injury, infection, bleeding and even death.  There were no known EKG, chest X-ray, or laboratory contraindications to the procedure.,The patient has presented with significant apprehension concerning the proposed procedure and is fearful of movement during the procedure producing further neurological injury.  Arrangements will be made to have an anesthesia care provider present to provide heavier sedation while in the prone position with optimal airway management for improved patient safety and comfort.,The L4-L5 interspace was identified fluoroscopically.  A left paramedian insertion was marked and after sedation was established by the anesthesia department the skin and subcutaneous tissue over the proposed insertion site was infiltrated with 3 millimeters of 0.5% Lidocaine initially through a #25-gauge 5/8-inch needle later a #22-gauge 1-1/2-inch needle.,A number #18-gauge Tuohy epidural needle was then inserted and advanced with fluoroscopic guidance until passing just superior to the lamina of L5.  Needle tip position was confirmed in the anterior posterior fluoroscopic view.  The epidural space was located with the loss of pulsation technique.  Aspiration of the syringe was negative for blood or cerebrospinal fluid.  One millimeter of 0.9% preservative was injected with good loss resistance noted.,DISCHARGE SUMMARY:,  Following the completion of this procedure, the patient underwent monitoring in the recovery room and was discharged, to be followed as an outpatient.",pain management
" Medial branch rhizotomy, lumbosacral.  Fluoroscopy was used to identify the boney landmarks of the spine and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.", Pain Management, Medial Branch Rhizotomy ,"PROCEDURE: , Medial branch rhizotomy, lumbosacral.,INFORMED CONSENT:,  The risks, benefits and alternatives of the procedure were discussed with the patient.  The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible of vascular entry of medications.  I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing.  The patient understood the informed consent and desired to have the procedure performed.,SEDATION: , The patient was given conscious sedation and monitored throughout the procedure.  Oxygenation was given.  The patient's oxygenation and vital signs were closely followed to ensure the safety of the administration of the drugs.,PROCEDURE:  ,The patient remained awake throughout the procedure in order to interact and give feedback.  The x-ray technician was supervised and instructed to operate the fluoroscopy machine.  The patient was placed in the prone position on the treatment table with a pillow under the abdomen to reduce the natural lumbar lordosis.  The skin over and surrounding the treatment area was cleaned with Betadine.  The area was covered with sterile drapes, leaving a small window opening for needle placement.  Fluoroscopy was used to identify the boney landmarks of the spine and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.  With fluoroscopy, a Teflon coated needle, ***, was gently guided into the region of the Medial Branch nerves from the Dorsal Ramus of ***.  Specifically, each needle tip was inserted to the bone at the groove between the transverse process and superior articular process on lumbar vertebra, or for sacral vertebrae at the lateral-superior border of the posterior sacral foramen.  Needle localization was confirmed with AP and lateral radiographs.,The following technique was used to confirm placement at the Medial Branch nerves.  Sensory stimulation was applied to each level at 50 Hz; paresthesias were noted at,*** volts.  Motor stimulation was applied at 2 Hz with 1 millisecond duration; corresponding paraspinal muscle twitching without extremity movement was noted at *** volts.,Following this, the needle Trocar was removed and a syringe containing 1% lidocaine was attached.  At each level, after syringe aspiration with no blood return, 1cc 1% lidocaine was injected to anesthetize the Medial Branch nerve and surrounding tissue.  After completion of each nerve block a lesion was created at that level with a temperature of 85 degrees Celsius for 90 seconds.  All injected medications were preservative free.  Sterile technique was used throughout the procedure.,COMPLICATIONS:,  None.  No complications.,The patient tolerated the procedure well and was sent to the recovery room in good condition.,DISCUSSION: , Post-procedure vital signs and oximetry were stable.  The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day.  The patient was told to resume all medications.  The patient was told to be in relative rest for 1 day but then could resume all normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes, or changes in bowel or bladder function.,Follow up appointment was made in approximately 1 week.","pain management, lumbosacral, medial branch rhizotomy, medial branch nerves, rhizotomy, fluoroscopy,"
" Lumbar discogram L2-3, L3-4, L4-5, and L5-S1.  Low back pain.", Pain Management, Lumbar Discogram ,"PREOPERATIVE DIAGNOSIS: , Low back pain.,POSTOPERATIVE DIAGNOSIS: , Low back pain.,PROCEDURE PERFORMED:,1.  Lumbar discogram L2-3.,2.  Lumbar discogram L3-4.,3.  Lumbar discogram L4-5.,4.  Lumbar discogram L5-S1.,ANESTHESIA:  ,IV sedation.,PROCEDURE IN DETAIL:  ,The patient was brought to the Radiology Suite and placed prone onto a radiolucent table.  The C-arm was brought into the operative field and AP, left right oblique and lateral fluoroscopic images of the L1-2 through L5-S1 levels were obtained.  We then proceeded to prepare the low back with a Betadine solution and draped sterile.  Using an oblique approach to the spine, the L5-S1 level was addressed using an oblique projection angled C-arm in order to allow for perpendicular penetration of the disc space.  A metallic marker was then placed laterally and a needle entrance point was determined.  A skin wheal was raised with 1% Xylocaine and an #18-gauge needle was advanced up to the level of the disc space using AP, oblique and lateral fluoroscopic projections.  A second needle, #22-gauge 6-inch needle was then introduced into the disc space and with AP and lateral fluoroscopic projections, was placed into the center of the nucleus.  We then proceeded to perform a similar placement of needles at the L4-5, L3-4 and L2-3 levels.,A solution of Isovue 300 with 1 gm of Ancef was then drawn into a 10 cc syringe and without informing the patient of our injecting, we then proceeded to inject the disc spaces sequentially.","pain management, back pain, c-arm, fluoroscopic projections, disc space, lumbar discogram, fluoroscopic, needle,"
" Lumbar epidural steroid injection without fluoroscopy.  A 18-gauge Tuohy needle was placed into the epidural space, using loss of resistance technique, with no cerebrospinal fluid or blood noted.", Pain Management, Lumbar Epidural Steroid Injection ,"PROCEDURE:,  Lumbar epidural steroid injection without fluoroscopy.,ANESTHESIA:,  Local sedation.,VITAL SIGNS:,  See nurse's records.,COMPLICATIONS:,  None.,DETAILS OF PROCEDURE:,  INT was placed.  The patient was in the sitting position and the back was prepped with Betadine.  Lidocaine 1.5% was used for skin wheal made between __________.  A 18-gauge Tuohy needle was placed into the epidural space, using loss of resistance technique, with no cerebrospinal fluid or blood noted.  After negative aspiration, a mixture of 10 cc of preservative free normal saline and 160 mg of preservative free Depo-Medrol was injected.  Neosporin and a band-aid were applied over the puncture site.  The patient was then placed in supine position.  The patient was discharged to the recovery room in stable condition.","pain management, neosporin, band-aid, epidural space, lumbar epidural steroid injection, loss of resistance, tuohy needle, fluoroscopy, cerebrospinal, lumbar, epidural, injection, "
 Bilateral lumbar sympathetic block.  The patient was in the prone position and the back prepped with Betadine.  The patient was given sedation and monitored. , Pain Management, Lumbar Sympathetic Block ,"PROCEDURE:,  Bilateral lumbar sympathetic block.,ANESTHESIA: , Local sedation.,VITAL SIGNS:,  See nurse's notes.,COMPLICATIONS:,  None.,DETAILS OF PROCEDURE: , INT was placed.  The patient was in the prone position and the back prepped with Betadine.  The patient was given sedation and monitored.  Xylocaine 1.5% for skin wheal 6 cm lateral and slightly inferior to the bilateral L2 transverse process was made.  A 20-gauge, 15 cm LSB needle was then directed using AP and lateral fluoroscopic guidance until the tip of the needle was just inside the lateral aspect of the vertebral body and on the lateral projection, it was noted to be along the anterior vertebral body, at the junction of the upper two thirds, lower one third of the body.  After negative aspiration 3 cc of Omnipaque dye was injected showing linear spread along the body.  After negative aspiration 18 cc of 0.25% Marcaine was injected.  Attention was then directed to the L3 level with the tip of the needle guided to the junction of the upper one third, lower two third of L3.  At this point, after confirmation of the linear spread of dye along the anterior portion of the body, negative aspiration was performed and 18 cc of 0.25% Marcaine was injected.  Neosporin and band-aids were applied over the sites.  The patient was taken to the outpatient recovery room in stable condition.","pain management, transverse process, fluoroscopic guidance, lateral projection, lumbar sympathetic block, vertebral body, sympathetic, betadine, needle, aspiration, lumbar, "
 Osteoarthritis of the right knee.  Right knee joint steroid injection., Pain Management, Knee Injection - 1 ,"PROCEDURE: , Right knee joint steroid injection.,PREOPERATIVE DIAGNOSIS:,  Osteoarthritis of the right knee.,POSTOPERATIVE DIAGNOSIS:,  Osteoarthritis of the right knee.,PROCEDURE:  ,The patient was apprised of the risks and the benefits of the procedure and consented.  The patient's right knee was sterilely prepped with Betadine.  A 4 mg of dexamethasone was drawn up into a 5 mL syringe with a 3 mL of 1% lidocaine.  The patient was injected with a 1.5-inch 25-gauze needle at the medial aspect of his right flexed knee.  There were no complications.  The patient tolerated the procedure well.  There was minimal bleeding.  The patient was instructed to ice his knee upon leaving clinic and refrain from overuse over the next 3 days.  The patient was instructed to go to the emergency room with any usual pain, swelling, or redness occurred in the injected area.  The patient was given a followup appointment to evaluate response to the injection to his increased range of motion and reduction of pain.","pain management, injection, knee joint, steroid injection, osteoarthritis, knee"
 Lumbar facet injections done under fluoroscopic control.  Lumbar spondylosis., Pain Management, Lumbar Facet Injections ,"PREOPERATIVE DIAGNOSIS:,  Lumbar spondylosis.,POSTOPERATIVE DIAGNOSIS:,  Lumbar spondylosis.,OPERATION PERFORMED:,  Lumbar facet injections done under fluoroscopic control.,ANESTHESIA:,  Local and IV.,COMPLICATIONS:,  None.,DESCRIPTION OF PROCEDURE:  ,After proper consent was obtained, the patient was taken to the fluoroscopy suite and placed in a prone position on a fluoroscopy table with abdominal rolls in place.  The skin was prepped and draped in a sterile classical fashion.  The patient was monitored with blood pressure cuff, electrocardiogram, and pulse oximeter.  The patient was given oxygen, intravenous sedation and analgesics as needed.  The facets were identified and marked under fluoroscopic control by rotating the C-arm obliquely, laterally and caudocranial as needed for optimal visualization of the facet joint's ""Scottie dog"" and the opening of the facet.,After each facet joint was identified and marked, local anesthesia was infiltrated subcutaneously and deep over each of the identified facets.  A 22-gauge spinal needle was then utilized to cannulate the facet joint under fluoroscopic control utilizing a gun barrel technique.  After negative aspiration, 0.25 - 0.5 cc of Omnipaque 240 contrast media was injected into the facet as an arthrogram to visualize the joint and the capsule.  After another negative aspiration, 1cc of a 10cc solution of Marcaine 0.5% and 100 milligrams of methyl prednisolone acetate was injected into each facet.  The patient tolerated the procedure well without apparent difficulty or complication unless otherwise noted.","pain management, fluoroscopic control, c-arm, lumbar facet injections, lumbar spondylosis, fluoroscopy, spondylosis, fluoroscopic, lumbar, injections, facet "
" Lumbar epidural steroid injection, intralaminar approach, seated position.  An 18-gauge Tuohy needle was then placed in the epidural space utilizing a midline intralaminar approach with loss of resistance technique and a saline-filled syringe.", Pain Management, Lumbar Epidural Steroid Injection - 1 ,"OPERATION:,  Lumbar epidural steroid injection, intralaminar approach, seated position.,ANESTHESIA:,","pain management, loss of resistance technique, methylprednisolone acetate, lumbar epidural steroid injection, epidural steroid injection, tuohy needle, steroid injection, epidural space, intralaminar approach, injection, intralaminar, saline, epidural"
 Evaluation for right L4 selective nerve root block., Pain Management, Lower Extremity Pain ,"REASON FOR REFERRAL:,  Evaluation for right L4 selective nerve root block.,CHIEF COMPLAINT:,",
" She is a 14-year-old Hispanic female with history of pauciarticular arthritis in particular arthritis of her left knee, although she has complaints of arthralgias in multiple joints.  Under general anesthesia, 20 mg of Aristospan were injected on the left knee.", Pain Management, Knee Injection - 2 ,"INDICATIONS FOR PROCEDURE: , The patient was here for joint injection.  She is a 14-year-old Hispanic female with history of pauciarticular arthritis in particular arthritis of her left knee, although she has complaints of arthralgias in multiple joints.  What bother her the most is the joint swelling of her left knee that has been for several months.  She has been taking Naprosyn on her last visit.  She was feeling better but still has significant symptoms especially when she was active.  After evaluation in the clinic, she decided to have a joint injection as it was discussed before.  I discussed the side effects and the complications with the parents and the patient and the possibility of doing it in the clinic, but she decided that she did not want to do it in the clinic and she wanted to be sedated for this.,DESCRIPTION OF PROCEDURE: , So under aseptic technique and under general anesthesia, 20 mg of Aristospan were injected on the left knee.  No fluid was obtained.  Her swelling was about 1+.  No complications.  No bleeding was observed, and the patient tolerated the procedure without any complications or side effects.  After that she went to the recovery room where is going to be discharged with her parents and see her back in the clinic for re-evaluation in a few weeks after the procedure.  If the patient has any problems overnight, she is going to call us.  If she had any fevers or strange swelling, she is to call us for advice.  We will see her in the clinic as scheduled.","pain management, arthralgias, aristospan, pauciarticular arthritis, joint injection, injection, swelling, arthritis, joints, kneeNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Intercostal block from fourth to tenth intercostal spaces, left.  Chest pain secondary to fractured ribs, unmanageable with narcotics.", Pain Management, Intercostal block - 1 ,"PREPROCEDURE DIAGNOSIS:,  Chest pain secondary to fractured ribs, unmanageable with narcotics.,POSTPROCEDURE DIAGNOSIS:,  Chest pain secondary to fractured ribs, unmanageable with narcotics.,PROCEDURE: , Intercostal block from fourth to tenth intercostal spaces, left.,INDICATIONS: , I was requested by Dr. X to do an intercostal block on this lady who fell and has fractured ribs, whose chest pain is paralyzing and not responding well to increasing doses of narcotics.,PROCEDURE DETAIL:,  After obtaining an informed consent with the patient on her bedside, she was placed in the right decubitus position with the left side up.  The posterior left chest wall was prepped and draped in the usual fashion and then a mixture of 1% Xylocaine 20 mL and Marcaine 0.25% 20 mL were mixed together and the intercostal spaces from the fourth to the tenth ribs were anesthetized.  A total of 30 mL worth of solution was used.  I also injected some local anesthetic subcutaneously into an area of contusion in the left lumbar area.,The patient tolerated the procedure well.  She had no respiratory distress.  Immediately, the patient felt some relief from the pain.  Chest x-ray was ordered for the following day.","pain management, xylocaine, marcaine, intercostal spaces, intercostal block, fractured ribs, intercostal, fractured, narcotics, chest, "
 Left L5 transforaminal epidural steroid injection with 40 mg of Kenalog under fluoroscopic guidance.  The patient is a 78-year-old female with back pain referring into the left side. , Pain Management, Kenalog Injection ,"PROCEDURE:,  Left L5 transforaminal epidural steroid injection with 40 mg of Kenalog under fluoroscopic guidance.,INDICATIONS:  ,The patient is a 78-year-old female with back pain referring into the left side.  She has had a couple of epidurals in the past, both of which led to only short-term improvement with intralaminar and caudal placements.  Therefore, transforaminal approach was selected for today's procedure.,Risks and benefits were discussed with the patient.  She agreed to accept the risks and signed informed consent to proceed.,PROCEDURE DETAILS:,  The patient was placed prone on the table.  The skin was thoroughly cleansed with betadine swabs x3 and wiped off with a sterile gauze.  The subcutaneous intramuscular and interligamentous region was anesthetized with buffered 1% lidocaine.,A 5-inch, 22-gauge spinal needle was directed under intermittent fluoroscopic guidance using an oblique approach at the opening of the L5 nerve root.  Once bony contact was made, a lateral was obtained and showed the needle tip to be against the posterior spinal body in the anterior epidural space.  Then an AP view was obtained which showed the needle tip to be below the 6 o'clock position of the pedicle.,EPIDUROGRAM: , Omnipaque 300, 1 mL, was placed through the foraminal opening of the L5 nerve root on the left.  This did show dye spread pattern which was narrowed consistent with foraminal stenosis.  The dye did traverse the foraminal opening and was seen spreading around the pedicle into the anterior epidural space.  It was also spreading peripherally along the L5 nerve root.,The patient tolerated the procedure well.  She did feel that the needle tip was placed at the epicenter of her pain, and this was improved with the placement of the anesthetic.,I will see the patient back in the office in the next few weeks to monitor response of the injection.","pain management, transforaminal approach, epidural steroid injection, nerve root, needle tip, kenalog, transforaminal, fluoroscopic, guidance, foraminal, injection"
 Knee injection, Pain Management, Knee Injection ,"The patient was told that the injection may cause more pain for two to three days afterwards and if this occurred they would best be served by icing the area 15-20 minutes every 6 hours.  The patient was advised to protect the knee by limiting repetitive bending, squatting , kneeling and excessive heavy use for a week.  Also, they were asked to follow up in two weeks p.r.n.","pain management, knee injection, hibistat, xylocaine, bending, epinephrine, knee joint, kneeling, needle, patella, squatting, superolateral approach, cleansed, kneeNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" Hip injection.  Fluoroscopy was used to identify the boney landmarks of the hip and the planned needle approach.  The femoral artery was located by palpation of the pulse.  The skin, subcutaneous tissue, and muscle within the planned needle approach were anesthetized with 1% Lidocaine.", Pain Management, Hip Injection ,"PROCEDURE: , Hip injection.,INFORMED CONSENT:  ,The risks, benefits and alternatives of the procedure were discussed with the patient.  The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible of vascular entry of medications.  I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing.  The patient understood the informed consent and desired to have the procedure performed.,PROCEDURE:  ,Oxygen saturation and vital signs were monitored continuously throughout the procedure.  The patient remained awake throughout the procedure in order to interact and give feedback.  The X-ray technician was supervised and instructed to operate the fluoroscopy machine.,The patient was placed in the prone position on the treatment table.  The skin over and surrounding the treatment area was cleaned with Betadine.  The area was covered with sterile drapes, leaving a small window opening for needle placement.  Fluoroscopy was used to identify the boney landmarks of the hip and the planned needle approach.  The femoral artery was located by palpation of the pulse.  The skin, subcutaneous tissue, and muscle within the planned needle approach were anesthetized with 1% Lidocaine.  All injected medications were preservative free.  With fluoroscopy, a *** spinal needle was gently guided into the ***.  Multiple fluoroscopic views were used to ensure proper needle placement.  Approximately *** nonionic contrast agent was injected under direct real-time fluoroscopic observation.  Correct needle placement was confirmed by production of an appropriate arthrogram without concurrent vascular dye pattern.  Finally, the treatment solution, consisting of ***.  All injected medications were preservative free.  Sterile technique was used throughout the procedure,COMPLICATIONS: , None.  No complications.  The patient tolerated the procedure well and was sent to the recovery room in good condition.,DISCUSSION: , Post-procedure vital signs and oximetry were stable.  The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day.  The patient was told to resume all medications.  The patient was told to be in relative rest for 1 day but then could resume all normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes, or changes in bowel or bladder function.,Follow up appointment was made in approximately 1 week.","pain management, boney landmarks, fluoroscopy, femoral artery, planned needle approach, hip injection, injection, hip, needle"
 Standard hypogastric plexus block procedure note., Pain Management, Hypogastric Plexus Block ,"NAME OF PROCEDURE:,  Hypogastric plexus block.,ANESTHESIA:,  Local.,PROCEDURE: , The patient was in the operating room in the prone position with the back prepped and draped in sterile fashion.  Local anesthesia was used to make a skin wheal 8-10 cm lateral to the L4 spinous process bilaterally from the midline.  Starting from the left side, a 20-gauge 6-inch needle was placed to the left L5-S1 facet level under AP fluoroscopic view.  On lateral view, the tip of the needle was at the inferior one-third of the LS vertebral body, anterior aspect.  Next 5 cc of Omnipaque dye was injection showing a linear spread along the anterior portion of L5 down the sacral promontory.  After negative aspiration 18 cc of 0.25% Marcaine plus 40 mg of Depo-Medrol was injection.  There were no complications.  The above sequence was repeated for the right side.  There were no complications.  The patient was discharged back to outpatient recovery in stable condition.","pain management, vertebral body, fluoroscopic view, omnipaque, hypogastric plexus blockNOTE"
 Caudal epidural steroid injection without fluoroscopy., Pain Management, Epidural Steroid Injection - 2 ,"PROCEDURE:  ,Caudal epidural steroid injection without fluoroscopy.,ANESTHESIA:,  Local sedation.,VITAL SIGNS: , See nurse's records.,PROCEDURE DETAILS: , INT was placed.  The patient was in the prone position.  The back was prepped with Betadine.  Lidocaine 1.5% was used to make a skin wheal over the sacral hiatus.  A 18-gauge Tuohy needle was then placed into the epidural space.  There were no complications from this (no blood or CSF).  After negative aspiration was performed, a mixture of 10 cc preservative free normal saline plus 160 mg preservative free Depo-Medrol was injected.  Neosporin and band-aid were applied over the puncture site.  The patient was then placed in supine position.  The patient was discharged to outpatient recovery in stable condition.","pain management, epidural space, epidural steroid injection, caudal epidural, caudal, fluoroscopy, steroid, epidural, injection"
" Intercostal block, left.   Severe post thoracotomy pain.", Pain Management, Intercostal Block ,"PREOPERATIVE DIAGNOSIS: , Severe post thoracotomy pain.,POSTOPERATIVE DIAGNOSIS: , Severe post thoracotomy pain.,PROCEDURE: , Intercostal block, left.,PROCEDURE DETAIL: , With the patient in the ICU bed who was having a large amount of intravenous narcotic to control his thoracotomy pain, after obtaining informed consent, his left posterior chest was prepped and draped in the usual fashion and Marcaine 0.025% was injected in the spaces four to eight sequentially.  A total of 40 mL of Marcaine was used.,The patient tolerated the procedure well and experienced immediate benefit out of the procedure.","pain management, thoracotomy pain, intercostal block, marcaine, thoracotomy, intercostal,"
" Bilateral facet Arthrogram and injections at L34, L45, L5S1.  Interpretation of radiograph.  Low Back Syndrome - Low Back Pain.", Pain Management, Facet Arthrogram & Injection ,"PREOPERATIVE DIAGNOSIS: , Low Back Syndrome - Low Back Pain.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE:,1.  Bilateral facet Arthrogram at L34, L45, L5S1.,2.  Bilateral facet injections at L34, L45, L5S1.,3.  Interpretation of radiograph.,ANESTHESIA:  ,IV sedation with Versed and Fentanyl.,ESTIMATED BLOOD LOSS: , None.,COMPLICATIONS:  ,None.,INDICATION: , Pain in the lumbar spine secondary to facet arthrosis that was demonstrated by physical examination and verified with x-ray studies and imaging scans.,SUMMARY OF PROCEDURE: , The patient was admitted to the OR, consent was obtained and signed.  The patient was taken to the Operating room and was placed in the prone position.  Monitors were placed, including EKG, pulse oximeter and blood pressure monitoring.  Prior to sedation vitals signs were obtained and were continuously monitored throughout the procedure for amount of pain or changes in pain, EKG, respiration and heart rate and at intervals of three minutes for blood pressure.  After adequate IV sedation with Versed and Fentanyl the procedure was begun.,The lumbar sacral regions were prepped and draped in sterile fashion with Betadine prep and four sterile towels.,The facets in the lumbar regions were visualized with Fluoroscopy using an anterior posterior view.  A skin wheal was placed with 1% Lidocaine at the L34 facet region on the left.  Under fluoroscopic guidance a 22 gauge spinal needle was then placed into the L34 facet on the left side.  This was performed using the oblique view under fluoroscopy to the enable the view of the ""Scotty Dog,"" After obtaining the ""Scotty Dog"" view the joints were easily seen.  Negative aspiration was carefully performed to verity that there was no venous, arterial or cerebral spinal fluid flow.  After negative aspiration was verified, 1/8th of a cc of Omnipaque 240 dye was then injected.  Negative aspiration was again performed and 1/2 cc of solution (Solution consisting of 9 cc of 0.5% Marcaine with 1 cc of Triamcinolone) was then injected into the joint.  The needle was then withdrawn out of the joint and 1.5 cc of this same solution was injected around the joint.  The 22-gauge needle was then removed.  Pressure was place over the puncture site for approximately one minute.  This exact same procedure was then repeated along the left-sided facets at L45, and L5S1.  This exact same procedure was then repeated on the right side.  At each level, vigilance was carried out during the aspiration of the needle to verify negative flow of blood or cerebral spinal fluid.,The patient was noted to have tolerated the procedure well without any complications.,Interpretation of the radiograph revealed placement of the 22-gauge spinal needles into the left-sided and right-sided facet joints at, L34, L45, and L5S1.  Visualizing the ""Scotty Dog"" technique under fluoroscopy facilitated this.  Dye spread into each joint space is visualized.  No venous or arterial run-off is noted.  No epidural run-off is noted.  The joints were noted to have chronic inflammatory changes noted characteristic of facet arthrosis.","pain management, low back syndrome, low back pain, facet injection, fluoroscopy, iv sedation, spinal fluid, facet arthrogram, aspiration, arthrogram, injection, facet,"
 Epidural steroid injection.  A total of 5 mL containing 4 mL of 0.25% bupivacaine and 80 mg of methylprednisolone acetate were infiltrated. , Pain Management, Epidural Steroid Injection - 3 ,"PROCEDURE NOTE:,  The patient was placed in a prone position.  The neck was sterilely prepped using a cervical prep set.  A lidocaine skin wheal was raised over the C5-6 interspace.  A 20-gauge Tuohy needle was used.  Loss of resistance was obtained using hanging drop technique.  This was followed by 2 mL of radiograph contrast material which showed spread of the dye into the epidural space.  A total of 5 mL containing 4 mL of 0.25% bupivacaine and 80 mg of methylprednisolone acetate were then infiltrated.  Following the infiltration, the patient noted warming of his arms and dramatic improvement of his symptoms.  He was observed for 30 minutes and discharged home in good condition.  There were no apparent complications to the procedure.","pain management, methylprednisolone acetate, steroid, bupivacaine, methylprednisolone, acetate, epidural, injectionNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 L3-L5 epidural steroid injection with epidural catheter under fluoroscopy., Pain Management, Epidural Steroid Injection - 1 ,"PREOPERATIVE DIAGNOSIS:,  Herniated lumbar disk with intractable back pain.,POSTOPERATIVE DIAGNOSIS: , Herniated lumbar disk with intractable back pain.,OPERATION PERFORMED: , L3-L5 epidural steroid injection with epidural catheter under fluoroscopy.,ANESTHESIA: , Local/IV sedation.,COMPLICATIONS: , None.,SUMMARY:  ,The patient in the operating room in the prone position with the back prepped and draped in the sterile fashion.  The patient was given sedation and monitored.  Local anesthetic was used to insufflate the skin over sacral hiatus.  A 16-gauge RK needle was placed at the sacral hiatus into the caudal canal with no CSF or blood.  A Racz tunnel catheter was then placed to the needle and guided up to the L3-L4 level.  After negative aspiration 4 cc of 0.5% Marcaine and 80 mg of Depo-Medrol were injected.  The catheter was then repositioned at the L4-L5 level where after negative aspiration same local anesthetic steroid mixture was injected.  Needle and catheter were removed intact.  The patient was discharged in stable condition.","pain management, epidural catheter, epidural steroid injection, lumbar disk, steroid injection, fluoroscopy, herniated, lumbar, needle, steroid, epidural, catheter, injection"
" Right L4, attempted L5, and S1 transforaminal epidurogram for neural mapping.", Pain Management, Epidurogram ,"PREOPERATIVE DIAGNOSES:  ,1.  Right lower extremity radiculopathy with history of post laminectomy pain.,2.  Epidural fibrosis with nerve root entrapment.,POSTOPERATIVE DIAGNOSES:  ,1.  Right lower extremity radiculopathy with history of post laminectomy pain.,2.  Epidural fibrosis with nerve root entrapment.,OPERATION PERFORMED: , Right L4, attempted L5, and S1 transforaminal epidurogram for neural mapping.,ANESTHESIA:,  Local/IV sedation.,COMPLICATIONS: , None.,SUMMARY: , The patient in the operating room in the prone position with the back prepped and draped in the sterile fashion.  The patient was given sedation and monitored.  Local anesthetic was used to insufflate the skin and paraspinal tissues and the L5 disk level on the right was noted to be completely collapsed with no way whatsoever to get a needle to the neural foramen of the L5 root.  The left side was quite open; however, that was not the side of her problem.  At this point using a oblique fluoroscopic projection and gun-barrel technique, a 22-gauge 3.5 inch spinal needle was placed at the superior articular process of L5 on the right, stepped off laterally and redirected medially into the intervertebral foramen to the L4 nerve root.  A second needle was taken and placed at the S1 nerve foramen using AP and lateral fluoroscopic views to confirm location.  After negative aspiration, 2 cc of Omnipaque 240 dye was injected through each needle.,There was a defect flowing in the medial epidural space at both sides.  There were no complications.","pain management, laminectomy, radiculopathy, nerve root entrapment, epidural fibrosis, nerve root, epidurogram, neural, epidural, foramen, nerve, needle"
 Transforaminal epidural steroid block with fluoroscopy., Pain Management, Epidural Steroid Block ,"DIAGNOSIS: , Left sciatica.,ANESTHESIA: , Intravenous sedation,NAME OF OPERATION:,1.  Left L5-S1 transforaminal epidural steroid block with fluoroscopy.,2.  Left L4-5 transforaminal epidural steroid block with fluoroscopy.,3.  Monitored intravenous Versed sedation.,PROCEDURE: , The patient was taken to the block room.  He was placed prone on the fluoroscopy table.  He was monitored appropriately.  He was administered Versed 2 mg IV.  His O2 saturation remained greater than 90%.  His back was prepped and draped.  The C-arm was brought in.  The endplates at L5-S1 were squared off.  The C-arm was rotated to the left.  The L5 pedicle, the superior articular process of the L5-S1 facet, and the ""neck of the scotty dog"" were all visualized.  After adequate local anesthesia, a 22-gauge, 3-1/2-inch spinal needle was inserted using down-the-barrel-of-the-needle technique.  The needle was advanced into the posterior aspect of the foramen and then advanced anteriorly toward the 6 o'clock position on the pedicle.  No paresthesias were noted.  One-half cc of contrast was injected and spread medially around the pedicle and into the epidural space, and the L5 nerve root was visualized.  Depo-Medrol 80 mg plus 1 cc of 4% preservative-free lidocaine was injected.  The needle was flushed and removed.,I then went up to the L4-5 level, and using a similar technique, injected the patient transforaminally at the L4-5 level.  Depo-Medrol 80 mg plus 1 cc of 4% preservative-free lidocaine was injected at the L4-5 level just as at the L5-S1 level.  The patient had pain down his left leg during the injection, primarily at the L5-S1 level similar to what he normally experiences.  He was awake and alert, and taken to the recovery room in good condition.  His left leg pain was relieved.","pain management, c-arm, epidural steroid block with fluoroscopy, sciatica, transforaminal, steroid block with fluoroscopy, epidural steroid block, depo medrol, transforaminal epidural, steroid block, fluoroscopy, epidural, intravenous, steroid, "
" Bilateral L5 dorsal ramus block and bilateral S1, S2, and S3 lateral branch block for sacroiliac joint pain.  Fluoroscopic pillar view was used to identify the bony landmarks of the sacrum and sacroiliac joint and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.", Pain Management, Dorsal Ramus & Branch Block ,"PROCEDURE: , Bilateral L5 dorsal ramus block and bilateral S1, S2, and S3 lateral branch block.,INDICATION: , Sacroiliac joint pain.,INFORMED CONSENT: , The risks, benefits and alternatives of the procedure were discussed with the patient.  The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible vascular entry of medications.  I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing.  The patient understood the informed consent and desired to have the procedure performed.,PROCEDURE:  ,Oxygen saturation and vital signs were monitored continuously throughout the procedure.  The patient remained awake throughout the procedure in order to interact and give feedback.  The X-ray technician was supervised and instructed to operate the fluoroscopy machine.,The patient was placed in the prone position on the treatment table, pillow under the chest, and head rotated contralateral to the side being treated.  The skin over and surrounding the treatment area was cleaned with Betadine.  The area was covered with sterile drapes, leaving a small window opening for needle placement.  Fluoroscopic pillar view was used to identify the bony landmarks of the sacrum and sacroiliac joint and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.,With fluoroscopy, a 25-gauge 3.5-inch spinal needle was gently guided into the groove between the SAP and sacrum through the dorsal ramus of the L5 and the lateral and superior border of the posterior sacral foramen with the lateral branches of S1, S2, and S3.  Multiple fluoroscopic views were used to ensure proper needle placement.  Approximately 0.25 mL of nonionic contrast agent was injected showing no concurrent vascular dye pattern.  Finally, the treatment solution, consisting of 0.5% of bupivacaine was injected to each area.  All injected medications were preservative free.  Sterile technique was used throughout the procedure.,ADDITIONAL DETAILS: , This was then repeated on the left side.,COMPLICATIONS: , None.,DISCUSSION:  ,Postprocedure vital signs and oximetry were stable.  The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day.  The patient was told to resume all medications.  The patient was told to resume normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes or changes in bowel or bladder function.,Follow up appointment was made at the PM&R Spine Clinic in approximately 1 week.","pain management, sacroiliac, lateral branch block, ramus block, branch block, sacroiliac joint, dorsal ramus, fluoroscopic, branch, dorsal, ramus, bilateral, needle, block,"
 Epidural Blood Patch.  An 18-gauge Tuohy needle was then placed in the epidural space on the first pass utilizing loss of resistance technique with a saline filled syringe. , Pain Management, Epidural Blood Patch ,"OPERATION:,","pain management, epidural space, loss of resistance technique, epidural blood patch, tuohy needle, tourniquet, epidural"
" Epidural steroid injection, epidurogram, fluroscopy - Low back pain, herniated disc, lumbosacral Facet, arthropathy.", Pain Management, Epidural Steroid Injection ,"PRE-OP DIAGNOSES:,  Low back pain - 724.2, Herniated disc - 722.10, Lumbosacral Facet, arthropathy - 724.4.,POST-OP DIAGNOSES: , Low back pain - 724.2, Herniated disc - 722.10, Lumbosacral Facet, arthropathy - 724.4.,INTERVAL HISTORY:,  Plans, risks and options were reviewed with the patient in detail.  The patient understands and agrees to proceed.,ANESTHESIA: , General Anesthesia,PROCEDURE PERFORMED:,  Epidural steroid injection, epidurogram, fluroscopy.,PROCEDURE:,  After informed consent, the patient was taken to the procedure room and placed in the prone position.  EKG, blood pressure and pulse oximetry were monitored and remained stable throughout the procedure.  The area was prepped and draped in the usual sterile fashion.  Local anesthetic was infiltrated at the appropriate level.  Fluoroscopic guidance was used to place a #20-gauge Tuohy epidural needle gently into the epidural space at L4-L5 using a paramedian approach.  No blood or CSF was obtained on aspiration.,RADIOLOGY: , Injection of 3 cc of OMNIPAQUE showed spread of the dye into the epidural space on AP and Lateral imaging.  The Needle was injected with Depo-Medrol 80 mg with Bupivacaine 1/16th , 8 cc total vol.  Patient tolerated procedure well and was transferred to recovery room.  Patient was discharged home with escort.  Discharge instructions were given.,POST-OP PLAN:,  I will see the patient back in my office in two weeks.  Continue p.r.n. medications as needed.","pain management, back pain, herniated disc, lumbosacral facet, epidural needle, lumbosacral facet arthropathy, epidural steroid injection, facet arthropathy, epidural space, injection, epidurogram, fluroscopy, herniated, lumbosacral, steroid, arthropathy, epidural,"
 Cervical Selective Nerve Root Block, Pain Management, Cervical Selective Nerve Root Block ,"CERVICAL SELECTIVE NERVE ROOT BLOCK,PREPROCEDURE PREPARATION:,  After being explained the risks and benefits of the procedure, the patient signed the standard informed consent form.  The patient was placed in the prone position and standard ASA monitors applied.  Intravenous access was established and IV sedation was used.  For further details of IV sedation and infusion, please refer to anesthesia notes.  The patient was able to respond appropriately throughout the procedure.  * Fluoroscopy was used to identify the appropriate anatomy.  The skin was prepped and draped in a sterile fashion and sterile technique was maintained throughout the procedure.,PROCEDURE DETAILS:,  The patient was laid supine.  Oblique placement was achieved by placing pillow below the shoulder and turning the head.  The C# neural foramina was identified by counting down from the C2-3 foramen.  The external carotid artery was marked off by palpation.  The neck was aseptically prepared.  1% lidocaine was used for local infiltration and subsequently a 25-gauge spinal needle was passed down to the C# neural foramen under fluoroscopic control.  The posterior inferior edge of the foramen bone was contacted.  The needle was then redirected and slowly walked off the bone into the foramen by a few millimeters.  Care was taken to remain in the posterior inferior edge of the foramen.  Positioning was checked by AP view, in which the needle tip extended no further medially than the midpoint of the adjacent pedicle.  1 mL of contrast was used to confirm position under fluoroscopy after aspiration.  Acceptable dye pattern was seen.  Subsequent 1 mL of 1% lidocaine was injected after aspiration and the patient was monitored.  No adverse affects with 1% lidocaine were noted and subsequently 1 mL of Celestone was injected.  Compression bandage was applied to the neck and no complications were noted.,POSTPROCEDURE EVALUATION:,  After a 30-minute recovery period, during which no complications were noted, the patient was discharged home.  Pulse oximetry was carried out on room air in recovery and all oxygen saturations were above 95% with no respiratory distress observed.","pain management, nerve root block, 1% lidocaine, asa monitors, cervical selective nerve root block, fluoroscopy, iv sedation, nerve root, oblique, selective nerve root, carotid artery, foramen, neural foramina, edge of the foramen, selective nerve root block, cervical,"
 Coccygeal injection, Pain Management, Coccygeal injection ,"COCCYGEAL INJECTION,PROCEDURE:,:  Informed consent was obtained from the patient.  A gloved little finger was inserted into the anal region and the sacral/coccygeal joint was palpated and the coccyx was moved and it was confirmed that this reproduced pain.  After aseptic cleaning, a 25-gauge needle was inserted through the skin into the sacral/coccygeal joint.  It was confirmed that the needle was not entering the rectal cavity by finger placed in the rectum.  After aspiration, 1 mL of cortisone and 2 mL of 0.25% Marcaine were injected at the site.  Postprocedure, the needle was withdrawn.  A small pressure dressing was placed and no hematoma was observed to form.,POST PROCEDURE INSTRUCTIONS:, The patient has been asked to report to us any redness, swelling, inflammation, or fevers.  The patient has been asked to restrict the use of the * extremity for the next 24 hours.","pain management, coccygeal injection, 0.25% marcaine, 1 ml of cortisone, coccygeal joint, coccyx, fevers, inflammation, redness, sacral, swelling, coccygeal, injectionNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Cervical spondylosis.  Cervical medial branch blocks under fluoroscopic control., Pain Management, Cervical Medial Branch Blocks ,"PREOPERATIVE DIAGNOSIS:,  Cervical spondylosis.,POSTOPERATIVE DIAGNOSIS:,  Cervical spondylosis.,OPERATION PERFORMED:,  Cervical Medial Branch Blocks under fluoroscopic control.,ANESTHESIA:,  Local and IV.,COMPLICATIONS:,  None.,DESCRIPTION OF PROCEDURE:,  After proper consent was obtained, the patient was taken to the fluoroscopy suite and place on a fluoroscopy table in a prone position with a chest roll in place.  The neck was placed in a flexed position.  The patient was monitored with blood pressure cuff, EKG, and pulse oximetry and given oxygen via nasal cannula.  The patient was lightly sedated.  The skin was prepped and draped in a sterile classical fashion.,Under fluoroscopy control, the waists of the articular pillars were identified and marked.  Local anesthesia infiltrated subcutaneously and deep extending down toward these previously marked points.  Once the anesthesia was established, a 10-cm, 22-gauge needle was placed in contact with the waists of the articular pillars at the affected levels that were previously mentioned.  This was done under direct fluoroscopic control with PA views initially for orientation utilizing a gun barrel technique and then a lateral view to determine the depth of the needle.  The needle tip was positioned such that the tip was at the posterior aspect of the articular pillar's waist and was then incrementally advanced until the tip was at the center of the pedicle, where the medial branch lies.  For C3 to C6, the medial branch is along the ventral aspect of a line that connects the greatest antero-posterior diameter of the articular pillar but remains dorsal to the foramen as seen on lateral imaging.  For a C7 medial branch block, the needle tip is positioned more superiorly such that it overlies the superior articular process.  For a C8 medial branch block, the needle is placed at the junction of the superior articulating facet and the base of the transverse process of T1.,Once the needles were in place, each level was then injected with 1cc of a 10 cc solution of Marcaine 0.5% mixed with 50mg on methyl prednisolone acetate.  The patient tolerated the procedure well without any difficulties or complications.","pain management, fluoroscopic control, fluoroscopy, cervical medial branch blocks, medial branch blocks, cervical spondylosis, articular pillars, cervical, anesthesia, spondylosis, fluoroscopic, blocks, needle, medial, branch,"
 Costochondral Cartilage Injection, Pain Management, Costochondral Cartilage Injection ,"COSTOCHONDRAL CARTILAGE INJECTION,PROCEDURE PREPARATION:,  After being explained the risks and benefits of the procedure, the patient signed the standard informed consent form.  The patient was placed in the supine position.,Intravenous access was established.  The patient was given mild narcotics for sedation.  For further details, please refer to anesthesia note.,DESCRIPTION OF PROCEDURE:,  The area of discomfort was palpated under fluoroscopy and the costochondral cartilages that were symptomatic were marked out.  After careful asepsis, local anesthesia was given subcutaneously and a 0.25-gauge hypodermic needle was inserted into the costochondral cartilage junction, taking care not to stray from the rib.  Fluoroscopy in AP and lateral positions confirmed good position of the needle in the * costochondral junction and subsequently after aspiration, 0.5 mL of Depo-Medrol 80 and 0.5 mL of 0.5% Marcaine was injected.  The same procedure was carried out at the * costochondral junction.,POSTPROCEDURE INSTRUCTIONS:,1.  After a period of 30 minutes of observation, during which there was no distress and good relief of symptoms was noted, the patient was discharged home.,2.  The patient has been given instructions on watching for possible pneumothorax and any respiratory distress.  The patient will call us if any inflammation, swelling, or other associated discomfort arises.  We will call the patient in 48 hours.","pain management, costochondral cartilage injection, 0.5% marcaine, ap and lateral, costochondral, depo-medrol, costochondral junction, fluoroscopy, hypodermic needle, pneumothorax, subcutaneously, supine position, cartilage injection, costochondral cartilage, needle, distress, cartilage, injection,"
 Caudal epidural steroid injection, Pain Management, Caudal Epidural Steroid Injection ,"CAUDAL EPIDURAL STEROID INJECTION,PROCEDURE:,:,1.  Caudal epidural steroid injection with contrast.,2.  Utilization of fluoroscopy for confirmation of needle placement.,PREPROCEDURE PREPARATION:,  After being explained the risks and benefits of the procedure, the patient signed the standard informed consent form.  The patient was placed in the prone position and standard ASA monitors applied.  Intravenous access was established and IV sedation was used.  For further details of IV sedation and infusion, please refer to anesthesia notes.  Fluoroscopy was used to identify the appropriate anatomy.  The skin was prepped and draped in a sterile fashion and sterile technique was maintained throughout the procedure.,PROCEDURE DETAILS:,","pain management, steroid injection, 1% lidocaine, ap and lateral, asa monitors, caudal epidural steroid injection, epidural, fluoroscopy, ligament, needle placement, sacral hiatus, sacrococcygeal, caudal epidural, epidural steroid, caudal, steroid, injection, "
 Cervical epidural steroid injection without fluoroscopy.  An 18-gauge Tuohy needle was placed into the epidural space using loss of resistance technique., Pain Management, Cervical Epidural Steroid Injection ,"PROCEDURE:,  Cervical epidural steroid injection without fluoroscopy.,ANESTHESIA: , Local sedation.,VITAL SIGNS: , See nurse's notes.,COMPLICATIONS: , None.,DETAILS OF PROCEDURE: , INT was placed.  The patient was in the sitting position.  The posterior neck and upper back were prepped with Betadine.  Lidocaine 1.5% was used for skin wheal made between C7-T1 ________.  An 18-gauge Tuohy needle was placed into the epidural space using loss of resistance technique and no cerebrospinal fluid or blood was noted.  After negative aspiration, a mixture of 5 cc preservative-free normal saline plus 160 mg Depo-Medrol was injected.  Neosporin and band-aid were applied over the site. The patient discharged to recovery room in stable condition.","pain management, epidural space, loss of resistance, cervical epidural steroid injection, fluoroscopy, lidocaine, steroid, epidural, cervical, injection, "
 Right L5-S1 intralaminar epidural steroid injection with 120 mg of Depo-Medrol under fluoroscopic guidance.  The patient is a 51-year-old female with back pain referring into the right leg., Pain Management, Depo-Medrol Injection ,"PROCEDURE: , Right L5-S1 intralaminar epidural steroid injection with 120 mg of Depo-Medrol under fluoroscopic guidance.,INDICATION: , The patient is a 51-year-old female with back pain referring into the right leg.,RISKS VERSUS BENEFITS: , The risks and benefits were discussed with the patient prior to the procedure.  She agrees to accept the risks and signs a written consent to proceed with the procedure.,DESCRIPTION OF PROCEDURE: , The patient was placed prone on the table.  The skin was thoroughly cleansed with Betadine swabs x3 and wiped off with a sterile gauze.  The subcutaneous intramuscular and interligamentous region was anesthetized with 4% lidocaine.,A 3-1/2-inch 20-gauge Tuohy catheter was directed under intermittent fluoroscopic guidance at the lamina.  Once the lamina was detected, the catheter was directed cephalad and medially and loss of resistance technique was used to determine the epidural space.,EPIDUROGRAM: , Omnipaque 300 1.5 mL was placed just to the right of the midline.  This was viewed on the AP and lateral projections.  It showed typical epidural spread pattern with good cephalad and caudad flow, and the flow was unrestricted.,Depo-Medrol 120 mg along with an additional bacteriostatic normal saline for a total of 60 mL injected solution was placed just to the right of the midline at L5-S1.,The patient tolerated the procedure well without procedural complications.  She will follow up with me in the office in the next few weeks to monitor her response to the injection.","pain management, epidural steroid injection, fluoroscopic guidance, depo medrol, injection "
 Standard celiac plexus block procedure note., Pain Management, Celiac Plexus Block ,"NAME OF PROCEDURE: , Celiac plexus block.,ANESTHESIA:,  Local/IV sedation.,COMPLICATIONS:,  None.,PROCEDURE: , INT was placed.  The patient was in the prone position back prepped and draped in sterile fashion.  Then 1.5% of Lidocaine for skin wheal was made approximately 10 cm lateral to the L1-L2 vertebral junction.  A 20 gauge, 15 cm needle was then placed in a cephalad medial 45o direction; the tip of the needle was just inside the L1 vertebral body.  On lateral view, this was noted to be approximately 1.5-2.5 cm anterior to the vertebral body.  At this time, 3 cc of Omnipaque dye was injected to the opposite side where the same sequence was performed.  Following this, a mixture of 18 cc of 0.5% Marcaine was injected on each side Neosporin and band-aids was applied over the puncture sites.  The patient was taken to the outpatient recovery where blood pressure was monitored and fluids given as needed.  The patient was discharged to operating room recovery in stable condition.","pain management, omnipaque, vertebral body, puncture sites, celiac plexus block, celiac, plexus, block, vertebral"
" Cervical epidural steroid injection, C5-6.  The C-arm was brought into the operative field and an AP view of the lumbar spine was obtained with particular attention to the C5-6 level. ", Pain Management, Cervical Epidural Steroid Injection - 2 ,"PROCEDURE PERFORMED:,  Cervical epidural steroid injection, C5-6.,ASSISTANT:,  None.,ANESTHESIA:,  Local.,DETAILS OF PROCEDURE: , The patient was brought to the operating theater and placed prone onto the radiolucent table.  Subsequent monitored anesthesia care was administered.  The C-arm was brought into the operative field and an AP view of the lumbar spine was obtained with particular attention to the C5-6 level.  The neck area was then prepped with Betadine solution and draped sterile.  A metallic marker was placed over the C5-6 lamina and a skin wheal was raised in the skin.  A #20-gauge Tuohy needle was then advanced into the spinal canal using 1% Xylocaine anesthetic and the depth of penetration to the C5 lamina was determined.  The needle was redirected into the interlaminar space and advanced to the previously determined level.  A 10 cc syringe was then placed onto the end of the needle and, using an air-negative technique, the needle was advanced into the epidural space.  When a free flow of air was produced, a solution of 80 mg Depo-Medrol, 2 cc of 1% Xylocaine injectable, and 5 cc of normal saline was then injected into the epidural space.  The Tuohy needle was removed.  Betadine was cleansed from the skin.  A bandage was placed over the needle entrance point.  The patient was turned supine onto a regular hospital bed and subsequently allowed to be awakened from anesthesia.  The patient was taken to the recovery room in stable condition.","pain management, c-arm, cervical epidural steroid injection, ap view, lumbar spine, tuohy needle, epidural steroid, steroid injection"
 Cervical facet joint injection with contrast, Pain Management, Cervical Facet Joint Injection ,"CERVICAL FACET JOINT INJECTION WITH CONTRAST.,PREPROCEDURE PREPARATION:,  After being explained the risks and benefits of the procedure, the patient signed the standard informed consent form. the patient was placed in the prone position and standard ASA monitors applied.  Intravenous access was established and IV sedation was used.  For further details of IV sedation and infusion, please refer to anesthesia notes.  Fluoroscopy was used to identify the appropriate anatomy and symptomatic facet joints.  The skin was prepped and draped in a sterile fashion and sterile technique was maintained throughout the procedure.,PROCEDURE DETAILS:,  The patient was laid supine.  Appropriate view of facet joints was achieved by placing pillow below the shoulder and turning the head.  The neck was aseptically prepared.  1% lidocaine was used for local infiltration and subsequently a 25-gauge spinal needle was passed down to the C4-5 facet joint under fluoroscopic control.  Positioning was checked and 0.2 mL of dye was injected.  Acceptable dye pattern was seen.  Subsequent 1 mL of a mixture of 0.5 mL of 1% lidocaine and 0.5 mL of Celestone was injected after aspiration and the patient was monitored.  Needle was removed and same procedure carried out on the other side.  Postprocedure, no complications were noted.","pain management, injection, 1% lidocaine, asa monitors, cervical, cervical facet joint injection, celestone, facet joint, facet joint injection, fluoroscopy, iv sedation, facet joints, spinal needle, cervical facet joint, joint injection, joint, facetNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Cervical epidural steroid injection C7-T1.  An 18-gauge Tuohy needle was then placed in the epidural space with loss of resistance technique and a saline-filled syringe utilizing a midline intralaminar approach., Pain Management, Cervical Epidural Steroid Injection - 1 ,"OPERATION PERFORMED: , Cervical epidural steroid injection C7-T1.,ANESTHESIA:,  Local and Versed 2 mg IV.,COMPLICATIONS:  ,None.,DESCRIPTION OF PROCEDURE:  ,The patient was placed in the seated position with the neck flexed the forehead was placed on a cervical rest.  The head and cervical spine were restrained.  The patient was monitored with a blood pressure cuff, EKG and pulse oximetry.  The skin was prepped and draped in sterile classical fashion.  Excess cleansing solution was removed from the skin.  Local anesthesia was injected at C7-T1.  An 18-gauge Tuohy needle was then placed in the epidural space with loss of resistance technique and a saline-filled syringe utilizing a midline intralaminar approach.,Once the epidural space was identified, a negative aspiration for heme or CSF was done.  This was followed by the injection of 6 cc of saline mixed with methyl prednisolone acetate 120 mg in aliquots of 2 cc.  Negative aspirations were done prior to each injection.  The needle was cleared with saline prior to its withdrawal.  The patient tolerated the procedure well without any apparent difficulties or complications.","pain management, tuohy needle, cleansing solution, epidural space, loss of resistance, cervical epidural steroid injection, resistance technique, steroid injection, injection, intralaminar, steroid, epidural,"
 Acromioclavicular joint injection, Pain Management, Acromioclavicular Joint Injection ,"ACROMIOCLAVICULAR JOINT INJECTION,PROCEDURE:,:  Informed consent was obtained from the patient.  All possible complications were mentioned including joint swelling, infection, and bruising.  The joint was prepared with Betadine and alcohol.  Then 1 mL of Depo-Medrol and 2 mL of 0.25% Marcaine were injected using the anterior approach.  This was injected easily using a 25 gauge needle with the patient sitting and the shoulder propped up on a pillow.  The joint was entered easily without any great difficulty.  Aspiration was performed prior to the injection to make sure there was no intravascular injection.  There were no complications and good relief of symptoms.,POST PROCEDURE INSTRUCTIONS:, The patient has been asked to report to us any redness, swelling, inflammation, or fevers.  The patient has been asked to restrict the use of the * extremity for the next 24 hours.","pain management, acromioclavicular joint injection, acromioclavicular, betadine, depo-medrol, alcohol, fevers, inflammation, intravascular injection, joint injection, redness, swelling, acromioclavicular joint, injection, jointNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Youngswick osteotomy with internal screw fixation of the first right metatarsophalangeal joint of the right foot., Orthopedic, Youngswick Osteotomy ,"TITLE OF OPERATION: , Youngswick osteotomy with internal screw fixation of the first right metatarsophalangeal joint of the right foot.,PREOPERATIVE DIAGNOSIS: , Hallux limitus deformity of the right foot.,POSTOPERATIVE DIAGNOSIS: , Hallux limitus deformity of the right foot.,ANESTHESIA:,  Monitored anesthesia care with 15 mL of 1:1 mixture of 0.5% Marcaine and 1% lidocaine plain.,ESTIMATED BLOOD LOSS:,  Less than 10 mL.,HEMOSTASIS:,  Right ankle tourniquet set at 250 mmHg for 35 minutes.,MATERIALS USED: , 3-0 Vicryl, 4-0 Vicryl, and two partially threaded cannulated screws from 3.0 OsteoMed System for internal fixation.,INJECTABLES:  ,Ancef 1 g IV 30 minutes preoperatively.,DESCRIPTION OF THE PROCEDURE: , The patient was brought to the operating room and placed on the operating table in the supine position.  After adequate sedation was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's right foot to anesthetize the future surgical site.  The right ankle was then covered with cast padding and an 18-inch ankle tourniquet was placed around the right ankle and set at 250 mmHg.  The right ankle tourniquet was then inflated.  The right foot was prepped, scrubbed, and draped in normal sterile technique.  Attention was then directed on the dorsal aspect of the first right metatarsophalangeal joint where a 6-cm linear incision was placed just parallel and medial to the course of the extensor hallucis longus to the right great toe.  The incision was deepened through the subcutaneous tissues.  All the bleeders were identified, cut, clamped, and cauterized.  The incision was deepened to the level of the capsule and the periosteum of the first right metatarsophalangeal joint.  All the tendinous and neurovascular structures were identified and retracted from the site to be preserved.  Using sharp and dull dissection, all the capsular and periosteal attachments were mobilized from the base of the proximal phalanx of the right great toe and head of the first right metatarsal.  Once the base of the proximal phalanx of the right great toe and the first right metatarsal head were adequately exposed, multiple osteophytes were encountered.  Gouty tophi were encountered both intraarticularly and periarticularly for the first right metatarsophalangeal joint, which were consistent with a medical history that is positive for gout for this patient.,Using sharp and dull dissection, all the ligamentous and soft tissue attachments were mobilized and the right first metatarsophalangeal joint was freed from all adhesions.  Using the sagittal saw, all the osteophytes were removed from the dorsal, medial, and lateral aspect of the first right metatarsal head as well as the dorsal, medial, and lateral aspect of the base of the proximal phalanx of the right great toe.  Although some improvement of the range of motion was encountered after the removal of the osteophytes, some tightness and restriction was still present.  The decision was thus made to perform a Youngswick-type osteotomy on the head of the first right metatarsal.  The osteotomy consistent of two dorsal cuts and a plantar cut in a V-pattern with the apex of the osteotomy distal and the base of the osteotomy proximal.  The two dorsal cuts were longer than the plantar cut in order to accommodate for the future internal fixation.  The wedge of bone that was formed between the two dorsal cuts was resected and passed off to Pathology for further examination.  The head of the first right metatarsal was then impacted on the shaft of the first right metatarsal and provisionally stabilized with two wires from the OsteoMed System.  The wires were inserted from a dorsal distal to plantar proximal direction through the dorsal osteotomy.  The wires were also used as guidewires for the insertion of two 16-mm proximally threaded cannulated screws from the OsteoMed System.  The 2 screws were inserted using AO technique.  Upon insertion of the screws, the two wires were removed.  Fixation of the osteotomy on the table was found to be excellent.  The area was copiously flushed with saline and range of motion was reevaluated and was found to be much improved from the preoperative levels without any significant restriction.  The cartilaginous surfaces on the base of the first right metatarsal and the base of the proximal phalanx were also fenestrated in order to induce some cartilaginous formation.  The capsule and periosteal tissues were then reapproximated with 3-0 Vicryl suture material, 4-0 Vicryl was used to approximate the subcutaneous tissues.  Steri-Strips were used to approximate and reinforce the skin edges.  At this time, the right ankle tourniquet was deflated.  Immediate hyperemia was noted in the entire right lower extremity upon deflation of the cuff.  The patient's surgical site was then covered with Xeroform, copious amounts of fluff and Kling, stockinette, and Ace bandage.  The patient's right foot was placed in a surgical shoe and the patient was then transferred to the recovery room under the care of the anesthesia team with her vital signs stable and neurovascular status at appropriate levels.  The patient was given instructions and education on how to continue caring for her right foot surgery at home.  The patient was also given pain medication instructions on how to control her postoperative pain.  The patient was eventually discharged from Hospital according to nursing protocol and was advised to follow up with Dr. X's office in one week's time for her first postoperative appointment.","orthopedic, hallux limitus deformity, metatarsophalangeal joint, plantar cut, youngswick osteotomy, dorsal cuts, ankle tourniquet, proximal phalanx, anesthesia, tourniquet, youngswick, phalanx, metatarsophalangeal, proximal, metatarsal, dorsal, osteotomy"
 Injection of bilateral carpal tunnels, Pain Management, Bilateral Carpal Tunnels Injection ,"POST PROCEDURE INSTRUCTIONS:, The patient has been asked to report to us any redness, swelling, inflammation, or fevers.  The patient has been asked to restrict the use of the * extremity for the next 24 hours.","pain management, injection. carpal tunnel, bilateral carpal tunnels, inflammation, longus tendon, palmaris longus, palmaris longus tendon, redness, rolled-up towel, swelling, volar aspect, wrist, wrist crease, bilateral carpal, carpal tunnels, paresthesias, carpal, tunnels, towelNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Bilateral sacroiliac joint injections, Pain Management, Bilateral sacroiliac joint injections ,"BILATERAL SACROILIAC JOINT INJECTIONS,PROCEDURE:,:  Informed consent was obtained from the patient.  The patient was placed in the prone position.  After preparation and local anesthetic administration, and image intensifier control a 25 gauge spinal needle was directed into the inferior aspect of the sacroiliac joint using a posterior approach.  A small amount of contrast material was administered to outline the recesses of the joints.  Verification of the initial needle position with contrast administration, 1 mL of solution was administered at this site after aspiration, consisting of 0.5 mL of 0.25% Marcaine and 0.5 mL of Celestone.  Postprocedure, the needles were withdrawn and dressing was applied.  Postprocedure no complications were noted.,POST PROCEDURE INSTRUCTIONS:, The patient has been asked to report to us any redness, swelling, inflammation, or fevers.  The patient has been asked to restrict the use of the * extremity for the next 24 hours.","pain management, bilateral sacroiliac joint injections, 0.25% marcaine, celestone, postprocedure, fevers, image intensifier, inflammation, posterior approach, redness, sacroiliac joint, spinal needle, swelling, bilateral sacroiliac joint, sacroiliac joint injections, sacroiliac, injectionsNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" Austin & Youngswick bunionectomy with Biopro implant.  Screw fixation, left foot.", Orthopedic, Youngswick Bunionectomy ,"PREOPERATIVE DIAGNOSES:,1.  Hallux rigidus, left foot.,2.  Elevated first metatarsal, left foot.,POSTOPERATIVE DIAGNOSES:,1.  Hallux rigidus, left foot.,2.  Elevated first metatarsal, left foot.,PROCEDURE PERFORMED:,1.  Austin/Youngswick bunionectomy with Biopro implant.,2.  Screw fixation, left foot.,HISTORY: , This 51-year-old male presents to ABCD General Hospital with the above chief complaint.  The patient states that he has had degenerative joint disease in his left first MPJ for many years that has been progressively getting worse and more painful over time.  The patient desires surgical treatment.,PROCEDURE IN DETAIL: , An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported from the operating room and placed on the operating room table in the supine position with the safety belt across his lap.  Copious amount of Webril was placed around the left ankle followed by a blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 7 cc of 0.5% Marcaine plain was injected in a Mayo-type block.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was elevated from the operating table and exsanguinated with an Esmarch bandage.  The pneumatic ankle tourniquet was then inflated to 250 mmHg.  The foot was lowered to the operating table, the stockinet was reflected, and the foot was cleansed with wet and dry sponge.,Attention was then directed to the left first metatarsophalangeal joint.  Approximately a 6 cm dorsomedial incision was created over the first metatarsophalangeal joint, just medial to the extensor hallucis longus tendon.  The incision was then deepened with a #15 blade.  All vessels encountered were ligated for hemostasis.  The skin and subcutaneous tissue was undermined medially, off of the joint capsule.  A dorsal linear capsular incision was then made.  Care was taken to identify and preserve the extensor hallucis longus tendon.  The capsule and periosteum were then reflected off of the head of the first metatarsal as well as the base of the proximal phalanx.  There was noted to be a significant degenerative joint disease.  There was little to no remaining healthy articular cartilage left on the head of the first metatarsal.  There was significant osteophytic formation medially, dorsally, and laterally in the first metatarsal head as well as at the base of the proximal phalanx.  A sagittal saw was then used to resect the base of the proximal phalanx.  Care was taken to ensure that the resection was parallel to the nail.  After the bone was removed in toto, the area was inspected and the flexor tendon was noted to be intact.  The sagittal saw was then used to resect the osteophytic formation medially, dorsally, and laterally on the first metatarsal.  The first metatarsal was then re-modelled and smoothed in a more rounded position with a reciprocating rasp.  The sizers were then inserted for the Biopro implant.  A large was noted to be of the best size.  There was noted to be some hypertrophic bone laterally in the base of the proximal phalanx.  Following inspection, the sagittal saw was used to clean both the medial and lateral sides of the base.  A small bar drill was then used to pre-drill for the Biopro sizer.  The bone was noted to be significantly hardened.  The sizer was placed and a large Biopro was deemed to be the correct size implant.  The sizer was removed and bar drill was then again used to ream the medullary canal.  The hand reamer with a Biopro set was then used to complete the process.  The Biopro implant was then inserted and tamped with a hammer and rubber mallet to ensure tight fit.  There was noted to be distally increased range of motion after insertion of the implant.,Attention was then directed to the first metatarsal.  A long dorsal arm Austin osteotomy was then created.  A second osteotomy was then created just plantar and parallel to the first osteotomy site.  The wedge was then removed in toto.  The area was feathered to ensure high compression of the osteotomy site.  The head was noted to be in a more plantar flexed position.  The capital fragment was then temporarily fixated with two 0.45 K-wires.  A 2.7 x 16 mm screw was then inserted in the standard AO fashion.  A second more proximal 2.7 x 60 mm screw was also inserted in a standard AO fashion.  With both screws, there was noted to be tight compression at the osteotomy sites.,The K-wires were removed and the areas were then smoothed with reciprocating rash.  A screw driver was then used to check and ensure screw tightness.  The area was then flushed with copious amounts of sterile saline.  Subchondral drilling was performed with a 1.5 drill bit.  The area was then flushed with copious amounts of sterile saline.  Closure consisted of capsular closure with #3-0 Vicryl followed by subcutaneous closure with #4-0 Vicryl, followed by running subcuticular stitch of #5-0 Vicryl.  Dressings consisted of Steri-Strips, Owen silk, 4x4s, Kling, Kerlix, and Coban.  A total of 10 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain was injected intraoperatively for further anesthesia.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot.  The patient tolerated the above procedure and anesthesia well.  The patient was transported to PACU with vital signs stable and vascular status intact to the right foot.  The patient was given postoperative pain prescription for Vicodin ES and instructed to take 1 q.  4-6h. p.o. p.r.n. pain.  The patient was instructed to ice and elevate his left lower extremity as much as possible to help decrease postoperative edema.  The patient is to follow up with Dr. X in his office as directed.","orthopedic, hallux rigidus, metatarsal, youngswick, bunionectomy, screw fixation, ankle tourniquet, metatarsophalangeal joint, biopro implant, proximal phalanx, foot, austin, anesthesia, osteotomy, screw,"
 Consultation for wrist pain., Orthopedic, Wrist Pain ,"CHIEF COMPLAINT:,  Left wrist pain.,HISTORY OF PRESENT PROBLEM:,","orthopedic, wrist pain, scapholunate, tenderness to palpation, three views, traumatic wrist injury, ulnar styloid nonunion, ulnar styloid, wrist, union, soreness, styloid, ulnar,"
" Excision of dorsal wrist ganglion.  Made a transverse incision directly over the ganglion.  Dissection was carried down through the extensor retinaculum, identifying the 3rd and the 4th compartments and retracting them.", Orthopedic, Wrist Ganglion Excision ,"PREOPERATIVE DIAGNOSIS: , Wrist ganglion.,POSTOPERATIVE DIAGNOSIS: , Wrist ganglion.,TITLE OF PROCEDURE: , Excision of dorsal wrist ganglion.,PROCEDURE: , After administering appropriate antibiotics and general anesthesia, the upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with an Esmarch and tourniquet inflated to 250 mmHg.  I made a transverse incision directly over the ganglion.  Dissection was carried down through the extensor retinaculum, identifying the 3rd and the 4th compartments and retracting them.  I then excised the ganglion and its stalk.  In addition, approximately a square centimeter of the dorsal capsule was removed at the origin of stalk, leaving enough of a defect to prevent formation of a one-way valve.  We then identified the scapholunate ligament, which was uninjured.  I irrigated and closed in layers and injected Marcaine with epinephrine.  I dressed and splinted the wound.  The patient was sent to the recovery room in good condition, having tolerated the procedure well.","orthopedic, origin of stalk, extensor retinaculum, wrist ganglion, incision, excision, dorsal, tourniquet, wrist, ganglion"
 Unilateral transpedicular T11 vertebroplasty., Orthopedic, Vertebroplasty ,"PREOPERATIVE DIAGNOSIS:,  T11 compression fracture with intractable pain.,POSTOPERATIVE DIAGNOSIS:,  T11 compression fracture with intractable pain.,OPERATION PERFORMED:,  Unilateral transpedicular T11 vertebroplasty.,ANESTHESIA:,  Local with IV sedation.,COMPLICATIONS:,  None.,SUMMARY: , The patient in the operating room in the prone position with the back prepped and draped in the sterile fashion.  The patient was given sedation and monitored.  Using AP and lateral fluoroscopic projections the T11 compression fracture was identified.  Starting from the left side local anesthetic was used for skin wheal just lateral superior to the 10 o'clock position of the lateral aspect of the T11 pedicle on the left.  The 13-gauge needle and trocar were then taken and placed to 10 o'clock position on the pedicle.  At this point using AP and lateral fluoroscopic views, the needle and trocar were advanced into the vertebral body using the fluoroscopic images and making sure that the needle was lateral to the medial wall of the pedicle of the pedicle at all times.  Once the vertebral body was entered then using lateral fluoroscopic views, the needle was advanced to the junction of the anterior one third and posterior two thirds of the body.  At this point polymethylmethacrylate was mixed for 60 seconds.  Once the consistency had hardened and the __________ was gone, incremental dose of the cement were injected into the vertebral body.  It was immediately seen that the cement was going cephalad into the vertebral body and was exiting through the crack in the vertebra.  A total 1.2 cc of cement was injected.  On lateral view, the cement crushed to the right side as well.  There was some dye infiltration into the disk space.  There was no dye taken whatsoever into the posterior aspect of the epidural space or intrathecal canal.,At this point, as the needle was slowly withdrawn under lateral fluoroscopic images, visualization was maintained to ensure that none of the cement was withdrawn posteriorly into the epidural space.  Once the needle was withdrawn safely pressure was held over the site for three minutes.  There were no complications.  The patient was taken back to the recovery area in stable condition and kept flat for one hour.  Should be followed up the next morning.","orthopedic, transpedicular, vertebroplasty, fluoroscopic views, fluoroscopic images, epidural space, compression fracture, vertebral body, compression, pedicle, fluoroscopic, vertebral, needle "
 Trigger point injections with Botox., Pain Management, Botox Injection - Trigger Point ,"PROCEDURE PERFORMED: , Trigger point injections with Botox.,PREPROCEDURE DIAGNOSES:,1. Cervical spondylosis without myelopathy.,2. Myofascial pain syndrome.,3. Cervical dystonia.,4. Status post C5-6 anterior cervical fusion.,5. Multilevel degenerative disc disease.,6. Cervicogenic migraines.,7. Hypertension.,8. Hypothyroidism.,POSTPROCEDURE DIAGNOSES:,1. Cervical spondylosis without myelopathy.,2. Myofascial pain syndrome.,3. Cervical dystonia.,4. Status post C5-6 anterior cervical fusion.,5. Multilevel degenerative disc disease.,6. Cervicogenic migraines.,7. Hypertension.,8. Hypothyroidism.,COMPLICATIONS: , None.,The risks, benefits, complications, and alternatives to the procedure were discussed in detail and informed written consent was obtained.,INDICATIONS:, The patient is here today after establishing care at my new office.  She is a long-term patient of mine at the Pain Management Clinic and has requested transference because of insurance reasons.  Today, she is here for not only establishment of care, but continued management of her many neck-related complaints.  Among these are spasms and ongoing pain for which she receives long-acting opioids.  She states that she is in fact doing quite well since her cervical fusion.  She is requesting that we decrease her medications from 480 mg to 240 mg to 360 mg of morphine per day in the form of Avinza.  She also is quite pleased with her other medication regimen which has been greatly simplified over the past year.,Other treatment modalities that have been helpful have included cervical epidural steroid injections.  The patient is requesting that we schedule this as well, as the relief provided by that lasted anywhere from four to six months.  I agree that because of intermittent radicular symptoms that this may be helpful particularly in light of her recent surgery.  She does complain of hand tingling and numbness, although she is not dropping objects or having difficulties with coordination.  I believe that in addition, the steroid injections may help expedite her desire to decrease her reliance on medications which have been oversedating as well as racked with other side effects.,DETAILS OF PROCEDURE: , Alcohol prep and sterile technique were used. A total of 6 cc of preservative-free 1% lidocaine was used and injected into eight different sites using a 25-gauge, 1-1/2-inch needle at the trapezius muscles bilaterally as well as the levator scapulae, the splenius capitis, and the semispinalis musculature.  The procedure was well tolerated.,TREATMENT PLAN:,1. The patient is tentatively scheduled for a cervical epidural steroid injection on March 14, 2005.,2. We will begin a weaning schedule for the patient's Avinza by decreasing in 60 mg intervals.  The patient will have a target of 120 mg p.o. b.i.d., and then be reassessed.  This is expected to occur after her cervical epidural steroid injection.",
 Greater trochanteric bursal injection., Pain Management, Bursal Injection ,,"pain management, greater trochanteric, depo-medrol, hibistat, bursal injection, excessive heavy use, lateral decubitus position, mid-trochanter, needle, no touch technique, spinal needle, trochanteric, xylocaine, bursal, injectionNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Trigger thumb release.  Right trigger thumb.  The A-1 pulley was divided along its radial border, completely freeing the stenosing tenosynovitis (trigger release). ", Orthopedic, Trigger Thumb Release - 1 ,"PREOPERATIVE DIAGNOSIS:  ,Right trigger thumb.,POSTOPERATIVE DIAGNOSIS:,  Right trigger thumb.,OPERATIONS PERFORMED:,  Trigger thumb release.,ANESTHESIA:,  Monitored anesthesia care with regional anesthesia applied by surgeon with local.,COMPLICATIONS:,","orthopedic, trigger thumb, trigger thumb release, tenosynovitis trigger, tenosynovitis, release, thumb, tourniquet, trigger,"
" Right ulnar nerve transposition, right carpal tunnel release, and right excision of olecranon bursa.  Right cubital tunnel syndrom, carpal tunnel syndrome, and olecranon bursitis.", Orthopedic, Ulnar Nerve Transposition & Olecranon Bursa Excision ,"PREOPERATIVE DIAGNOSIS:  ,1.  Right cubital tunnel syndrome.,2.  Right carpal tunnel syndrome.,3.  Right olecranon bursitis.,POSTOPERATIVE DIAGNOSIS:,  ,1.  Right cubital tunnel syndrome.,2.  Right carpal tunnel syndrome.,3.  Right olecranon bursitis.,PROCEDURES:,  ,1.  Right ulnar nerve transposition.,2.  Right carpal tunnel release.,3.  Right excision of olecranon bursa.,ANESTHESIA:,  General.,BLOOD LOSS:,  Minimal.,COMPLICATIONS:,  None.,FINDINGS: , Thickened transverse carpal ligament and partially subluxed ulnar nerve.,SUMMARY: , After informed consent was obtained and verified, the patient was brought to the operating room and placed supine on the operating table.  After uneventful general anesthesia was obtained, his right arm was sterilely prepped and draped in normal fashion.  After elevation and exsanguination with an Esmarch, the tourniquet was inflated.  The carpal tunnel was performed first with longitudinal incision in the palm carried down through the skin and subcutaneous tissues.  The palmar fascia was divided exposing the transverse carpal ligament, which was incised longitudinally.  A Freer was then inserted beneath the ligament, and dissection was carried out proximally and distally.,After adequate release has been formed, the wound was irrigated and closed with nylon.  The medial approach to the elbow was then performed and the skin was opened and subcutaneous tissues were dissected.  A medial antebrachial cutaneous nerve was identified and protected throughout the case.  The ulnar nerve was noted to be subluxing over the superior aspect of the medial epicondyle and flattened and inflamed.  The ulnar nerve was freed proximally and distally.  The medial intramuscular septum was excised and the flexor carpi ulnaris fascia was divided.  The intraarticular branch and the first branch to the SCU were transected; and then the nerve was transposed, it did not appear to have any significant tension or sharp turns.  The fascial sling was made from the medial epicondyle and sewn to the subcutaneous tissues and the nerve had good translation with flexion and extension of the elbow and not too tight.  The wound was irrigated.  The tourniquet was deflated and the wound had excellent hemostasis.  The subcutaneous tissues were closed with #2-0 Vicryl and the skin was closed with staples.  Prior to the tourniquet being deflated, the subcutaneous dissection was carried out over to the olecranon bursa, where the loose fragments were excised with a rongeurs as well as abrading the ulnar cortex and excision of hypertrophic bursa.  A posterior splint was applied.  Marcaine was injected into the incisions and the splint was reinforced with tape.  He was awakened from the anesthesia and taken to recovery room in a stable condition.  Final needle, instrument, and sponge counts were correct.","orthopedic, cubital tunnel syndrome, carpal tunnel syndrome, olecranon bursitis, ulnar nerve transposition, carpal tunnel release, excision of olecranon bursa, transposition, ligament, tourniquet, excision, bursa, syndrome, subcutaneous, ulnar, olecranon, carpal, nerve, tunnel, "
" Subcutaneous ulnar nerve transposition.  A curvilinear incision was made over the medial elbow, starting proximally at the medial intermuscular septum, curving posterior to the medial epicondyle, then curving anteriorly along the path of the ulnar nerve.  Dissection was carried down to the ulnar nerve. ", Orthopedic, Ulnar Nerve Transposition ,"PROCEDURE:,  Subcutaneous ulnar nerve transposition.,PROCEDURE IN DETAIL: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A curvilinear incision was made over the medial elbow, starting proximally at the medial intermuscular septum, curving posterior to the medial epicondyle, then curving anteriorly along the path of the ulnar nerve.  Dissection was carried down to the ulnar nerve.  Branches of the medial antebrachial and the medial brachial cutaneous nerves were identified and protected.,Osborne's fascia was released, an ulnar neurolysis performed, and the ulnar nerve was mobilized.  Six cm of the medial intermuscular septum was excised, and the deep periosteal origin of the flexor carpi ulnaris was released to avoid kinking of the nerve as it was moved anteriorly.,The subcutaneous plane just superficial to the flexor-pronator mass was developed.  Meticulous hemostasis was maintained with bipolar electrocautery.  The nerve was transposed anteriorly, superficial to the flexor-pronator mass.  Motor branches were dissected proximally and distally to avoid tethering or kinking the ulnar nerve.,A semicircular medially based flap of flexor-pronator fascia was raised and sutured to the subcutaneous tissue in such a way as to prevent the nerve from relocating.  The subcutaneous tissue and skin were closed with simple interrupted sutures.  Marcaine with epinephrine was injected into the wound.  The elbow was dressed and splinted.  The patient was awakened and sent to the recovery room in good condition, having tolerated the procedure well.","orthopedic, neurolysis, ulnar, periosteal, flexor-pronator mass, ulnar nerve transposition, medial intermuscular septum, nerve transposition, intermuscular septum, flexor pronator, ulnar nerve, nerve"
" Trigger finger release.  A longitudinal incision was made over the digit's A1 pulley.  Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles.  The sheath was opened under direct vision with a scalpel, and then a scissor was used to release it under direct vision from the proximal extent of the A1 pulley to just proximal to the proximal digital crease. ", Orthopedic, Trigger Finger Release ,"PROCEDURE: , Trigger finger release.,PROCEDURE IN DETAIL: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A longitudinal incision was made over the digit's A1 pulley.  Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles.  The sheath was opened under direct vision with a scalpel, and then a scissor was used to release it under direct vision from the proximal extent of the A1 pulley to just proximal to the proximal digital crease.  Meticulous hemostasis was maintained with bipolar electrocautery.,The tendons were identified and atraumatically pulled to ensure that no triggering remained.  The patient then actively moved the digit, and no triggering was noted.,After irrigating out the wound with copious amounts of sterile saline, the skin was closed with 5-0 nylon simple interrupted sutures.,The wound was dressed and the patient was sent to the recovery room in good condition, having tolerated the procedure well.","orthopedic, a1 pulley, neurovascular bundles, trigger finger release, proximal digital, digital crease, trigger finger, trigger, finger, sheath, incision"
" Decompression of the ulnar nerve, left elbow.  Left cubital tunnel syndrome and ulnar nerve entrapment.", Orthopedic, Ulnar Nerve Decompression ,"PREOPERATIVE DIAGNOSES: , Left cubital tunnel syndrome and ulnar nerve entrapment.,POSTOPERATIVE DIAGNOSES: , Left cubital tunnel syndrome and ulnar nerve entrapment.,PROCEDURE PERFORMED: , Decompression of the ulnar nerve, left elbow.,ANESTHESIA: , General.,FINDINGS OF THE OPERATION:,  The ulnar nerve appeared to be significantly constricted as it passed through the cubital tunnel.  There was presence of hourglass constriction of the ulnar nerve.,PROCEDURE: , The patient was brought to the operating room and once an adequate general anesthesia was achieved, his left upper extremity was prepped and draped in standard sterile fashion.  A sterile tourniquet was positioned and tourniquet was inflated at 250 mmHg.  Perioperative antibiotics were infused.  Time-out procedure was called.  The medial epicondyle and the olecranon tip were well palpated.  The incision was initiated at equidistant between the olecranon and the medial epicondyle extending 3-4 cm proximally and 6-8 cm distally.  The ulnar nerve was identified proximally.  It was mobilized with a blunt and a sharp dissection proximally to the arcade of Struthers, which was released sharply.  The roof of the cubital tunnel was then incised and the nerve was mobilized distally to its motor branches.  The ulnar nerve was well-isolated before it entered the cubital tunnel.  The arch of the FCU was well defined.  The fascia was elevated from the nerve and both the FCU fascia and the Osborne fascia were divided protecting the nerve under direct visualization.  Distally, the dissection was carried between the 2 heads of the FCU.  Decompression of the nerve was performed between the heads of the FCU.  The muscular branches were well protected.  Similarly, the cutaneous branches in the arm and forearm were well protected.  The venous plexus proximally and distally were well protected.  The nerve was well mobilized from the cubital tunnel preserving the small longitudinal vessels accompanying it.  Proximally, multiple vascular leashes were defined near the incision of the septum into the medial epicondyle, which were also protected.  Once the in situ decompression of the ulnar nerve was performed proximally and distally, the elbow was flexed and extended.  There was no evidence of any subluxation.  Satisfactory decompression was performed.  Tourniquet was released.  Hemostasis was achieved.  Subcutaneous layer was closed with 2-0 Vicryl and skin was approximated with staples.  A well-padded dressing was applied.  The patient was then extubated and transferred to the recovery room in stable condition.  There were no intraoperative complications noted.  The patient tolerated the procedure very well.","orthopedic, ulnar nerve entrapment, ulnar nerve, ulnar nerve decompression, cubital tunnel syndrome, ulnar, nerve, fascia, decompression, cubital, tunnel"
" Total knee replacement.  A midline incision was made, centered over the patella.  Dissection was sharply carried down through the subcutaneous tissues.  A median parapatellar arthrotomy was performed.", Orthopedic, Total Knee Replacement - 1 ,"PROCEDURES: , Total knee replacement.,PROCEDURE DESCRIPTION:,  The patient was bought to the operating room and placed in the supine position.  After induction of anesthesia, a tourniquet was placed on the upper thigh.  Sterile prepping and draping proceeded.  The tourniquet was inflated to 300 mmHg.  A midline incision was made, centered over the patella.  Dissection was sharply carried down through the subcutaneous tissues.  A median parapatellar arthrotomy was performed.  The lateral patellar retinacular ligaments were released and the patella was retracted laterally.  Proximal medial tibia was denuded, with mild release of medial soft tissues.  The ACL and PCL were released.  The medial and lateral menisci and suprapatellar fat pad were removed.  These releases allowed for anterior subluxation of tibia.  An extramedullary tibial cutting jig was pinned to the proximal tibia in the appropriate alignment and flush cut was made along tibial plateau, perpendicular to the axis of the tibia.  Its alignment was checked with the rod and found to be adequate.  The tibia was then allowed to relocate under the femur.,An intramedullary hole was drilled into the femur and a femoral rod attached to the anterior cutting block was inserted, and the block was pinned in appropriate position, judging correct rotation using a variety of techniques.  An anterior rough cut was made.  The distal cutting jig was placed atop this cut surface and pinned to the distal femur, and the rod was removed.  The distal cut was performed.,A spacer block was placed, and adequate balance in extension was adjusted and confirmed, as was knee alignment.  Femoral sizing was performed with the sizer, and the appropriate size femoral 4-in-1 chamfer-cutting block was pinned in place and the cuts were made.  The notch-cutting block was pinned to the cut surface, slightly laterally, and the notch cut was then made.  The trial femoral component was impacted onto the distal femur and found to have an excellent fit.  A trial tibial plate and polyethylene were inserted, and stability was judged and found to be adequate in all planes.  Appropriate rotation of the tibial component was identified and marked.  The trials were removed and the tibia was brought forward again.  The tibial plate size was checked and the plate was pinned to plateau.  A keel guide was placed and the keel was then made.  The femoral intramedullary hole was plugged with bone from the tibia.  The trial tibial component and poly placed; and, after placement of the femoral component, range of motion and stability were checked and found to be adequate in various ranges of flexion and extension.,The patella was held in a slightly everted position with knee in extension.  Patellar width was checked with calipers.  A free-hand cut of the patellar articular surface was performed and checked to ensure symmetry with the calipers.  Sizing was then performed and 3 lug holes were drilled with the jig in place, taking care to medialize and superiorize the component as much as possible, given bony anatomy.  Any excess lateral patellar bone was recessed.  The trial patellar component was placed and found to have adequate tracking.  The trials were removed; and as the cement was mixed, all cut surfaces were thoroughly washed and dried.  The cement was applied to the components and the cut surfaces with digital pressurization, and then the components were impacted.  The excess cement was removed from the gutters and anterior and posterior parts of the knee.  The knee was brought into full extension with the trial polyethylene and further axially pressurized as cement hardened.  Once the cement had hardened, the tourniquet was deflated.  The knee was dislocated again, and any excess cement was removed with an osteotome.  Thorough irrigation and hemostasis were performed.  The real polyethylene component was placed and pinned.  Further vigorous power irrigation was performed, and adequate hemostasis was obtained and confirmed.  The arthrotomy was closed using 0 Ethibond and Vicryl sutures.  The subcutaneous tissues were closed after further irrigation with 2-0 Vicryl and Monocryl sutures.  The skin was sealed with staples.  Xeroform and a sterile dressing were applied followed by a cold-pack and Ace wrap.  The patient was transferred to the recovery room in stable condition, having tolerated the procedure well.","orthopedic, proximal medial tibia, total knee replacement, parapatellar arthrotomy, subcutaneous tissues, tibial plateau, incision, cutting, patella, femur, femoral, component, knee,"
" Right total knee arthroplasty - Osteoarthritis, right knee.", Orthopedic, Total Knee Arthroplasty - Right ,"PREOPERATIVE DIAGNOSIS (ES):, Osteoarthritis, right knee.,POSTOPERATIVE DIAGNOSIS (ES):, Osteoarthritis, right knee.,PROCEDURE:, Right total knee arthroplasty.,DESCRIPTION OF THE OPERATION:, The patient was brought to the Operating Room and after the successful placement of an epidural, as well as general anesthesia, administration 1 gm of Ancef preoperatively, the patient's right thigh, knee and leg were scrubbed, prepped and draped in the usual sterile fashion. The leg was exsanguinated by gravity and pneumatic tourniquet was inflated to 300 mmHg.,A straight anterior incision was carried down through the skin and subcutaneous tissue. Unilateral flaps were developed and a median retinacular parapatellar incision was made. The extensor mechanism was partially divided and the patella was everted. Some of the femoral bone spurs were resected using an osteotome and a rongeur. Ascending drill hole was made in the distal femur and the distal femoral cut, anterior and posterior and chamfer cuts were accomplished for a 67.5 femoral component.,At this point the ACL was resected. Some of the fat pad and synovium were resected, as well as both medial and lateral menisci. A posterior cruciate retractor was utilized, the tibia brought forward and a centering drill hole made in the tibia. The intramedullary guide was used for cutting the tibia. It was set at 8 mm. An additional 2 mm was resected because of a moderate defect medially.,A trial reduction was done with a 71 tibial baseplate. This was pinned and drilled and then trial reduction done with a 10-mm insert.,This gave good stability and a full range of motion.,The patella was measured with the calibers and 9 mm of bone was resected with an oscillating saw. A 34-mm component was drilled for.,A further trial reduction was done and two liters of pulse lavage were used to clean the bony surfaces. A packet of cement was hand mixed, pressurized with a spatula into the proximal tibia. Multiple drill holes were made on the medial side of the tibia where the bone was somewhat sclerotic. The tibia baseplate was secured and the patella was inserted, held with a clamp. The extraneous cement was removed. At this point the tibial baseplate was locked into place and the femoral component also seated solidly.,The knee was extended, held in this position for another 5-6 minutes until the cement was cured. Further extraneous cement was removed. The pneumatic tourniquet was released, hemostasis was obtained with electrocoagulation.,Retinaculum, quadriceps and extensor were repaired with multiple figure-of-eight #1 Vicryl sutures, the subcutaneous tissue with 2-0 and the skin with skin staples. A sterile, bulky compression dressing was placed. The patient was stable on operative release.","orthopedic, osteoarthritis, arthroplasty, knee, patella, retinacular parapatellar, total knee arthroplasty, total knee, knee arthroplasty, baseplate, femoral, tibia,"
" Total left knee replacement.  Degenerative arthritis of the left knee.  Degenerative ware of three compartments of the trochlea, the medial, as well as the lateral femoral condyles as well was the plateau.  ", Orthopedic, Total Knee Replacement ,"PREOPERATIVE DIAGNOSIS: ,Degenerative arthritis of the left knee.,POSTOPERATIVE DIAGNOSIS:, Degenerative arthritis of the left knee.,PROCEDURE PERFORMED: , Total left knee replacement on 08/19/03.  The patient also underwent a bilateral right total knee replacement in the same sitting and that will be dictated by Dr. X.,TOURNIQUET TIME: , 76 minutes.,BLOOD LOSS: , 150 cc.,ANESTHESIA:  ,General.,IMPLANT USED FOR PROCEDURE:,  NexGen size F femur on the left with #8 size peg tibial tray, a #12 mm polyethylene insert and this a cruciate retaining component.  The patella on the left was not resurfaced.,GROSS INTRAOPERATIVE FINDINGS: , Degenerative ware of three compartments of the trochlea, the medial, as well as the lateral femoral condyles as well was the plateau.  The surface of the patella was with a minimal ware and minimal osteophytes and we decided not to resurface the patellar component.,HISTORY:  ,This is a 69-year-old male with complaints of bilateral knee pain for several years and increased intensity in the past several months where it has affected his activities of daily living.  He attempted conservative treatment, which includes anti-inflammatory medications as well as cortisone and Synvisc.  This has only provided him with temporary relief.  It is for that reason, he is elected to undergo the above-named procedure.,All risks as well as complications were discussed with the patient, which include, but are not limited to infection, deep vein thrombosis, pulmonary embolism, need for further surgery, and further pain.  He has agreed to undergo this procedure and a consent was obtained preoperatively.,PROCEDURE: , The patient was wheeled back to operating room #2 at ABCD General Hospital on 08/19/03 and was placed supine on the operating room table.  At this time, a nonsterile tourniquet was placed on the left upper thigh, but not inflated.  An Esmarch was then used to exsanguinate the extremity and the left extremity was then prepped and draped in the usual sterile fashion for this procedure.  The tourniquet was then inflated to 325 mmHg.  At this time, a standard midline incision was made towards the total knee.  We did discuss preoperatively for a possible unicompartmental knee replacement for this patient, but he did have radiographic evidence of chondrocalcinosis of the lateral meniscus.  We did start off with a small midline skin incision in case we were going to do a unicompartmental.  Once we exposed the medial parapatellar mini-arthrotomy and visualized the lateral femoral condyle, we decided that this patient would not be an optimal candidate for unicompartmental knee replacement.  It is for this reason that we extended the incision and underwent with the total knee replacement.  Once the full medial parapatellar arthrotomy was performed with the subperiosteal dissection of the proximal tibia in order to evert the patella.  Once the patella was everted, we then used a drill to cannulate the distal femoral canal in order to place the intramedullary guide.  A Charnley awl was then used to remove all the intramedullary contents and they were removed from the knee.  At this time, a femoral sizer was then placed with reference to the posterior condyles and we measured a size F. Once this was performed, three degrees of external rotation was then drilled into the condyle in alignment with the epicondyles of the femur.  At this time, the intramedullary guide was then inserted and placed in three degrees of external rotation.  Our anterior cutting guide was then placed and an anterior cut was performed with careful protection of the soft tissues.  Next, this was removed and the distal femoral cutting guide was then placed in five degrees of valgus.  This was pinned to the distal femur and with careful protection of the collateral ligaments, a distal femoral cut was performed.  At this time, the intramedullary guide was removed and a final cutting block was placed.  This was placed in the center on the distal femur with 1 mm to 2 mm laterally translated for better patellar tracking.  At this time, the block was pinned and screwed in place with spring pins with careful protection of the soft tissues.  An oscillating saw was then used to resect the posterior and anterior cutting blocks with anterior and posterior chamfer as well as the notch cut.  Peg holes were then drilled.,The block was then removed and an osteotome was then used to remove all the bony cut pieces.  At this time with a better exposure of the proximal tibia, we placed external tibial guide.  This was placed with longitudinal axis of the tibia and carefully positioned in order to obtain an optimal cut for the proximal tibia.  At this time with careful soft tissue retraction and protection, an oscillating saw was used to make a proximal tibial osteotomy.  Prior to the osteotomy, the cut was checked with a depth gauge in order to assure appropriate bony resection.  At this time, a _blunt Kocher and Bovie cautery were used to remove the proximal tibial cut, which had soft tissue attachments.  Once this was removed, we then implanted our trial components of size F to the femur and a size 8 mm tibial tray with 12 mm plastic articulating surface.  The knee was taken through range of motion and revealed excellent femorotibial articulation.  The patella did tend to sublux somewhat laterally with extremes of flexion and it was for this reason, we performed a minimal small incision lateral retinacular release.  Distal lateral patella was tracked more uniformly within the patellar groove of the prosthesis.  At this time, an intraoperative x-ray was performed, which revealed excellent alignment with no varus angulation especially of the whole femur and tibial alignment and tibial cut.  At this time, the prosthesis was removed.  A McGill retractor was then reinserted and replaced peg tibial tray in order to peg the proximal tibia.  Once the drill holes were performed, we then copiously irrigated the wound and then suctioned it dry to get ready and prepped for cementation of the drilled components.  At this time, polymethyl methacrylate cement was then mixed.  The cement was placed on the tibial surface as well as the underneath surface of the component.  The component was then placed and impacted with excess cement removed.  In a similar fashion, the femoral component was also placed.  A 12 mm plastic tray was then placed and the leg held in full extension and compression in order to obtain adequate bony cement content.  Once the cement was fully hardened, the knee was flexed and a small osteotome was used to remove any extruding cement from around the prosthesis of the bone.  Once this was performed, copious irrigation was used to irrigate the wound and the wound was then suctioned dry.  The knee was again taken through range of motion with a 12 mm plastic as well as #14.  The #14 appeared to be a bit too tight especially in extremes of flexion.  We decided to go with a #12 mm polyethylene tray.  At this time, this was placed to the tibial articulation and then left in place.  This was rechecked with careful attention to detail with checking no soft tissue interpositioned between the polyethylene tray and the metal tray of the tibia.  The knee was again taken through range of motion and revealed excellent tracking of the patella with good femur and tibial contact.  A drain was placed and cut to length.,At this time, the knee was irrigated and copiously suction dried.  #1-0 Ethibond suture was then used to approximate the medial parapatellar arthrotomy in figure-of-eight fashion.  A tight capsular closure was performed.  This was reinforced with a #1-0 running Vicryl suture.  At this time, the knee was again taken through range of motion to assure tight capsular closure.  At this time, copious irrigation was used to irrigate the superficial wound.  #2-0 Vicryl was used to approximate the wound with figure-of-eight inverted suture.  The skin was then approximated with staples.  The leg was then cleansed.  Sterile dressing consisting of Adaptic, 4x4, ABDs, and Kerlix roll were then applied.  At this time, the patient was extubated and transferred to recovery in stable condition.  Prognosis is good for this patient.","orthopedic, degenerative arthritis, nexgen, polyethylene, cruciate, total knee replacement, proximal tibia, knee replacement, femoral, cutting, tibial, knee, arthritis, femur, cementation, "
 Trigger thumb release.  A transverse incision was made over the MPJ crease of the thumb.  Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles.  , Orthopedic, Trigger Thumb Release ,"PROCEDURE:  ,Trigger thumb release.,PROCEDURE IN DETAIL: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual sterile fashion.  The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A transverse incision was made over the MPJ crease of the thumb.  Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles.  The flexor sheath was opened under direct vision with a scalpel, and then a scissor was used to release the A1 pulley under direct vision on the radial side, from its proximal extent to its distal extent at the junction of the proximal and middle thirds of the proximal phalanx.  Meticulous hemostasis was maintained with bipolar electrocautery.,The flexor pollicis longus tendon was identified and atraumatically pulled to ensure that no triggering remained.  The patient then actively moved the thumb and no triggering was noted.,After irrigating out the wound with copious amounts of sterile saline, the skin was closed with 5-0 nylon simple interrupted sutures.,The wound was dressed and the patient was sent to the recovery room in good condition, having tolerated the procedure well.","orthopedic, neurovascular, a1 pulley, trigger thumb release, mpj crease, trigger thumb, flexor sheath, triggering, sheath, proximal, incision"
"  Right knee total arthroplasty.  Degenerative osteoarthritis, right knee.", Orthopedic, Total Knee Arthroplasty ,"PREOPERATIVE DIAGNOSIS:,  Degenerative osteoarthritis, right knee.,POSTOPERATIVE DIAGNOSIS: , Degenerative osteoarthritis, right knee.,PROCEDURE PERFORMED: ,Right knee total arthroplasty.,ANESTHESIA: , The procedure was done under a subarachnoid block anesthetic in the supine position with a tourniquet utilized.,TOTAL TOURNIQUET TIME: , Approximately 90 minutes.,SPECIFICATIONS: , The entire procedure is done in the inpatient operating suite in the Room #1 at ABCD General Hospital.  The following sizes of NexGen system were utilized:  E on right femur, cemented; 5 tibial stem tray with a 10 mm polyethylene insert, and a 32 mm patellar button.,HISTORY AND GROSS FINDINGS: , This is a 58-year-old white female suffering increasing right knee pain for number of years prior to surgical intervention.  She was completely refractory to conservative outpatient therapy.  She had undergone two knee arthroscopies in the years preceding this.  They were performed by myself.  She ultimately failed this treatment and developed a collapsing-type valgus degenerative osteoarthritis with complete collapse and ware of the lateral compartment and degenerative changes noted to the femoral sulcus that were proved live.  Medial compartment had minor changes present.  There was no contracture of the lateral collateral ligament, but instead mild laxity on both sides.  There was no significant flexion contracture preoperatively.,OPERATIVE PROCEDURE:  ,The patient was laid supine upon the operating table after receiving a subarachnoid block anesthetic by the Anesthesia Department.  Thigh tourniquet was placed upon the patient's right leg.  She was prepped and draped in the usual sterile manner.  The limb was elevated and exsanguinated and tourniquet placed 325 mmHg for the above noted time.  A straight incision was carried down through the skin and subcutaneous tissue.  Hemostasis was controlled with electrocoagulation.  Medial parapatellar arthrotomy was created and the knee cap was everted.  The ligaments were balanced.  A portion of the fat pad was removed and the ACL was completely removed.  Drill hole was made in the distal femur.  The size to an E, right.  Care was taken to make up for the severe loss of articular cartilage on the posterior condyle in the lateral side.  This was checked with the epicondylar abscess and with three degrees of external rotation, drill holes were made.  Intramedullary guide was then placed, pegged, and anterior cut carried out.  There was excellent resection.  It was flat.  Distal cutting guide was then placed in five degrees of valgus.  Appropriate cuts were carried out.  The standard cut was utilized.,The finishing guide for E was held with pins as well as screws.  Cutting was carried out posterior to anterior, then posterior chamfer and anterior chamfer, femoral sulcus cut was carried out and drill holes for pegs were made.  The cutting guide was then removed.  The bone was removed.  Excess bone was taken out posteriorly.  The posterior capsule was loosened up.  There were two different fabellas in the posterolateral compartment and they were loosened.  Posterolateral corner was then anchored with osteotome and was taken around the posterolateral corner.  An extramedullary tibial cutting guide was then placed, pinned, and held.  A cut was carried out parallel to the foot.  Hard copy ________ was obtained, deemed to be satisfactory after evening up the edges.  Trial range of motion was satisfactory.  It was necessary to perform a lateral retinacular release to the patella.  The patella was isolated.  Approximately 10 mm to 11 mm were reamed off.  The size to 32 mm button and drill hole guide was placed, impacted, and drilled.  Trial range of motion was satisfactory.  The tibial guide was then pinned.  Drill hole was placed, broached, and utilized.  Copious irrigation was carried out.  Methylmethacrylate was mixed and was sequentially placed from the femur to the tibia to the patella.  The implants were sequentially placed in tibia to femur to patella.  Once excess methylmethacrylate was removed and cured, 10 mm Poly was placed.  There was excellent ligament balancing.  A separate portal was utilized for subcutaneous drain.  Tourniquet was deflated and hemostasis was controlled with electrocoagulation.  Interrupted #1 Ethibond suture was utilized for parapatellar closure, running #1 Vicryl suture was utilized for overstitch.,Trial range of motion was satisfactory.  Interrupted #2-0 Vicryl was utilized for subcutaneous fat closure and skin staples were placed to the skin.  Adaptic, 4x4s, ABDs, and Webril were placed for compression dressing.  Digits were pink and warm with brawny pulses distally at the end of the case.  The patient was then transferred to PACU in apparent satisfactory condition.  Expected surgical prognosis on this patient is fair.","orthopedic, arthroplasty, knee, degenerative osteoarthritis, subcutaneous, osteoarthritis, degenerative, tourniquet, drill,"
 Foraminal disc herniation of left L3-L4.  Enlarged dorsal root ganglia of the left L3 nerve root.  Transpedicular decompression of the left L3-L4 with discectomy., Orthopedic, Transpedicular Decompression ,"PREOPERATIVE DIAGNOSIS: , Foraminal disc herniation of left L3-L4.,POSTOPERATIVE DIAGNOSES:,1.  Foraminal disc herniation of left L3-L4.,2.  Enlarged dorsal root ganglia of the left L3 nerve root.,PROCEDURE PERFORMED:, Transpedicular decompression of the left L3-L4 with discectomy.,ANESTHESIA:,  General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,SPECIMEN: , None.,HISTORY: , This is a 55-year-old female with a four-month history of left thigh pain.  An MRI of the lumbar spine has demonstrated a mass in the left L3 foramen displacing the nerve root, which appears to be a foraminal disc herniation effacing the L3 nerve root.  Upon exploration of the nerve root, it appears that there was a small disc herniation in the foramen, but more impressive was the abnormal size of the dorsal root ganglia that was enlarged more medially than laterally.  There was no erosion into the bone surrounding the area rather in the pedicle above or below or into the vertebral body, so otherwise the surrounding anatomy is normal.  I was prepared to do a discectomy and had not consented the patient for a biopsy of the nerve root.  But because of the sequela of cutting into a nerve root with residual weakness and persistent pain that the patient would suffer, at this point I was not able to perform this biopsy without prior consent from the patient.  So, surgery ended decompressing the L3 foramen and providing a discectomy with idea that we will obtain contrasted MRIs in the near future and I will discuss the findings with the patient and make further recommendations.,OPERATIVE PROCEDURE: , The patient was taken to OR #5 at ABCD General Hospital in a gurney.  Department of Anesthesia administered general anesthetic.  Endotracheal intubation followed.  The patient received the Foley catheter.  She was then placed in a prone position on a Jackson table.  Bony prominences were well padded.  Localizing x-rays were obtained at this time and the back was prepped and draped in the usual sterile fashion.  A midline incision was made over the L3-L4 disc space taking through subcutaneous tissues sharply, dissection was then carried out to the left of the midline with lumbodorsal fascia incised and the musculature was elevated in a supraperiosteal fashion from the level of L3.  Retractors were placed into the wound to retract the musculature.  At this point, the pars interarticularis was identified and the facet joint of L2-L3 was identified.  A marker was placed over the pedicle of L3 and confirmed radiographically.  Next, a microscope was brought onto the field.  The remainder of the procedure was noted with microscopic visualization.  A high-speed drill was used to remove the small portions of the lateral aspects of the pars interarticularis.  At this point, soft tissue was removed with a Kerrison rongeur and the nerve root was clearly identified in the foramen.  As the disc space of L3-L4 is identified, there is a small prominence of the disc, but not as impressive as I would expect on the MRI.  A discectomy was performed at this time removing only small portions of the lateral aspect of the disc.  Next, the nerve root was clearly dissected out and visualized, the lateral aspect of the nerve root appears to be normal in structural appearance.  The medial aspect with the axilla of the nerve root appears to be enlarged.  The color of the tissue was consistent with a nerve root tissue.  There was no identifiable plane and this is a gentle enlargement of the nerve root.  There are no circumscribed lesions or masses that can easily be separated from the nerve root.  As I described in the initial paragraph, since I was not prepared to perform a biopsy on the nerve and the patient had not been consented, I do not think it is reasonable to take the patient to this procedure, because she will have persistent weakness and pain in the leg following this procedure.  So, at this point there is no further decompression.  A nerve fork was passed both ventral and dorsal to the nerve root and there was no compression for lateral.  The pedicle was palpated inferiorly and medially and there was no compression, as the nerve root can be easily moved medially.  The wound was then irrigated copiously and suctioned dry.  A concoction of Duramorph and ______ was then placed over the nerve root for pain control.  The retractors were removed at this point.  The fascia was reapproximated with #1 Vicryl sutures, subcutaneous tissues with #2 Vicryl sutures, and Steri-Strips covering the incision.  The patient transferred to the hospital gurney, extubated by Anesthesia, and subsequently transferred to Postanesthesia Care Unit in stable condition.","orthopedic, dorsal root ganglia, nerve root, discectomy, foraminal disc herniation, transpedicular decompression, lateral aspects, disc herniation, nerve, anesthesia, foraminal"
" Total hip arthroplasty on the left.  Left hip degenerative arthritis.  Severe degenerative changes within the femoral head as well as the acetabulum, anterior as well as posterior osteophytes. ", Orthopedic, Total Hip Arthroplasty ,"PREOPERATIVE DIAGNOSIS: , Left hip degenerative arthritis.,POSTOPERATIVE DIAGNOSIS: , Left hip degenerative arthritis.,PROCEDURE PERFORMED:  ,Total hip arthroplasty on the left.,ANESTHESIA:  ,General.,BLOOD LOSS: , 800 cc.,The patient was positioned with the left hip exposed on the beanbag.,IMPLANT SPECIFICATION: , A 54 mm Trilogy cup with cluster holes 3 x 50 mm diameter with a appropriate liner, a 28 mm cobalt-chrome head with a zero neck length head, and a 12 mm porous proximal collared femoral component.,GROSS INTRAOPERATIVE FINDINGS:  ,Severe degenerative changes within the femoral head as well as the acetabulum, anterior as well as posterior osteophytes.  The patient also had a rent in the attachment of the hip abductors and a partial rent in the vastus lateralis.  This was revealed once we removed the trochanteric bursa.,HISTORY:  ,This is a 56-year-old obese female with a history of bilateral degenerative hip arthritis.  She underwent a right total hip arthroplasty by Dr. X in the year of 2000, and over the past three years, the symptoms in her left hip had increased tremendously especially in the past few months.,Because of the increased amount of pain as well as severe effect on her activities of daily living and uncontrollable pain with narcotic medication, the patient has elected to undergo the above-named procedure.  All risks as well complications were discussed with the patient including but not limited to infection, scar, dislocation, need for further surgery, risk of anesthesia, deep vein thrombosis, and implant failure.  The patient understood all these risks and was willing to continue further on with the procedure.,PROCEDURE: , The patient was wheeled back to the Operating Room #2 at ABCD General Hospital on 08/27/03.  The general anesthetic was first performed by the Department of Anesthesia.  The patient was then positioned with the left hip exposed on the beanbag in the lateral position.  Kidney rests were also used because of the patient's size.  An axillary roll was also inserted for comfort in addition to a Foley catheter, which was inserted by the OR nurse.  All her bony prominences were well padded.  At this time, the left hip and left lower extremity was then prepped and draped in the usual sterile fashion for this procedure.  At this time, an anterolateral approach was then performed, first incising through the skin in approximately 5 to 6 inches of subcutaneous fat.  The tensor fascia lata was then identified.  A self-retainer was then inserted to expose the operative field.  Bovie cautery was used for hemostasis.  At this time, a fresh blade was then used to incise the tensor fascia lata over the posterior one-third of the greater trochanter.  At this time, a blunt dissection was taken proximally.  The tensor fascia lata was occluded with a hip retractor.  At this time, after hemostasis was obtained, Bovie cautery was used to incise the proximal end of the vastus lateralis and removing the partial portion of the hip abductor, the gluteus medius.  At this time, a periosteal elevator was used to expose anterior hip capsule.  A ________ was then inserted over the femoral head purchasing of the acetabulum underneath the reflected head of the quadriceps muscle.  Once this was performed, Homan retractors were then inserted superiorly and inferiorly underneath the femoral neck.  At this time, a capsulotomy was then performed using a Bovie cautery and the capsulotomy was ________ and then edged over the acetabulum.  At this point, a large bone hook was then inserted over the neck and with gentle traction and external rotation, the femoral head was dislocated out of the acetabulum.  At this time, we had an exposure of the femoral head, which did reveal degenerative changes of the femoral head and once the acetabulum was visualized, we did see degenerative changes within the acetabulum as well as osteophyte formation around the rim of the acetabulum.  At this time, a femoral stem guide was then used to measure proximal femoral neck cut.  We made a cut approximately a fingerbreadth above the lesser trochanter.  At this time, with protection of the soft tissues an oscillating saw was used to make femoral neck cut.,The femoral head was then removed.  At this time, we removed the leg out of the bag and Homan retractors were then used to expose the acetabulum.  A long-handle knife was used to cut through the remainder of the capsule and remove the glenoid labrum around the rim of the acetabulum.  With better exposure of the acetabulum, we started reaming the acetabulum.  We started with a size #44 and progressively reamed to a size #50.  At the size #50 mm reamer, we obtained excellent bony bleeding with good remainder of bone stalk both anteriorly and posteriorly as well as superiorly within the acetabulum.  We then reamed up to size #52 in order to get bony bleeding around the rim as well as anterior and posterior within the acetabulum.  A size 54 mm Trilogy cup was then implanted with excellent approaches approximately 45 degrees of abduction and 10 to 15 degrees of anteversion dialed in.  Once the cup was impacted in place, we did visualize that the cup was well seated on to the internal portion of the acetabulum.  At this time, two screws were the placed within the superior table for better approaches securing the acetabular cup.  At this time, a plastic liner was then inserted for protection.  The leg was then placed back in the bag.  A Bennett retractor was used to retract the tensor fascia lata and femoral elevator was used to elevate the femur for better exposure and at this time, we began working on the femur.  A rongeur was used to lateralize over the greater trochanter.  A Box osteotome was used to remove the cancellous portion of the femoral neck.  A Charnley awl was then used to cannulate through the proximal femoral canal.  A power reamer was then used to ream the lateral aspect of the greater trochanter in order to provide maximal lateralization and prevent varus implantation of our stem.  At this time, we began broaching.  We started with a size #10 and progressively worked up to a size #12 mm broach.  Once the 12 mm broach was inserted in place, it was seated approximately 1 mm below the calcar.  A calcar reamer was then placed and the calcar was reamed smoothly.  A standard neck as well as a 28 mm plastic head was then placed and a trial reduction was then performed.  Once this was performed, the hip was taken to range of motion with external rotation, longitudinal traction as well as flexion and revealed good stability with no impingement or dislocation.  At this time, we removed 12 mm broach and proceeded with implanting our polyethylene liner within the acetabulum.  This was impacted and placed and checked to assure that it was well seated with no loosening.  Once this was performed, we then exposed the proximal femur one more time.  We copiously irrigated within the canal and then suctioned it dry.  At this time, a 12 mm porous proximal collared stem, a femoral component was then impacted in place.  Once it was well seated on the calcar, we double checked to assure that there was no evidence of calcar fractures, which there were none.  The 28 mm zero neck length cobalt-chrome femoral head was then impacted in place and the Morse taper assured that this was well fixed by ________.,Next, the hip was then reduced within the acetabulum and again we checked range of motion as well as ligamentous stability with gentle traction, external rotation, as well as hip flexion.  We were satisfied with components as well as the alignment of the components.  Copious irrigation was then used to irrigate the wound.  #1 Ethibond was then used to approximate the anterior hip capsule.  #1 Ethibond in interrupted fashion was used to approximate the vastus lateralis as well as the gluteus medius attachment over the partial gluteus medius attachment which was resected off the greater trochanter.  Next, a #1 Ethibond was then used to approximate the tensor fascia lata with figure-of-eight closure.  A tight closure was performed.  Since the patient did have a lot of subcutaneous fat, multiple #2-0 Vicryl sutures were then used to approximate the bed space and then #2-0 Vicryl for the subcutaneous skin.  Staples were then used for skin closure.  The patient's hip was then cleansed.  Sterile dressings consisting of Adaptic, 4 x 4, ABDs, and foam tape were then placed.  A drain was placed prior to wound closure for postoperative drainage.  After the dressing was applied, the patient was extubated safely and transferred to recovery in stable condition.  Prognosis is good.","orthopedic, degenerative arthritis, total hip arthroplasty, tensor fascia lata, vastus lateralis, gluteus medius, femoral neck, femoral head, head, femoral, acetabulum, hip, attachment, arthroplasty,"
" Total hip replacement.  An incision was made, centered over the greater trochanter.  Dissection was sharply carried down through the subcutaneous tissues. ", Orthopedic, Total Hip Replacement - 1 ,"PROCEDURE:,  Total hip replacement.,PROCEDURE DESCRIPTION:,  The patient was bought to the operating room and placed in the supine position.  After induction of anesthesia, the patient was turned on the side and secured in the hip table.  An incision was made, centered over the greater trochanter.  Dissection was sharply carried down through the subcutaneous tissues.  The gluteus maximus was incised and split proximally.  The piriformis and external rotators were identified.  These were removed from their insertions on the greater trochanter as a sleeve with the hip capsule.  The hip was dislocated.  A femoral neck cut was made using the guidance of preoperative templating.  The femoral head was removed.  Extensive degenerative disease was found on the femoral head as well as in the acetabulum.,Baseline leg-length measurements were taken.  The femur was retracted anteriorly and a complete labrectomy was performed.  Reaming of the acetabulum was then performed until adequate bleeding subchondral bone was identified in the key areas.  The trial shell was placed and found to have an excellent fit.  The real shell was opened and impacted into position in the appropriate amount of anteversion and abduction.  Screws were placed by drilling into the pelvis, measuring, and placing the appropriate length screw.  Excellent purchase was obtained.  The trial liner was placed.,The femur was then flexed and internally rotated.  The extra trochanteric bone was removed, as was any leftover lateral soft tissue at the piriformis insertion.  An intramedullary hole was drilled into the femur to define the canal.  Reaming was performed until the appropriate size was reached.  The broaches were then used to prepare the femur with the appropriate amount of version.  Once the appropriate size broach was reached, it was used as a trial with head and neck placement.  Hip range-of-motion was checked in all planes, including flexion-internal rotation, the position of sleep, and extension-external rotation.  The hip was found to have excellent stability with the final chosen head-neck combination.  Leg length measurements were taken and found to be within acceptable range, given the necessity for stability.,The real stem was opened and impacted into position.  The real head was impacted atop the stem.  If cement was used, the canal was thoroughly washed and dried and plugged with a restrictor, and then the cement was injected and pressurized and the stem was implanted in the appropriate version.  Excess cement was removed from the edges of the component.  Range of motion and stability were once again checked and found to be excellent.  Adequate hemostasis was obtained.  Vigorous power irrigation was used to remove all debris from the joint prior to final reduction.,The arthrotomy and rotators were closed using #1 Ethibond through drill holes in the bone, recreating the posterior hip structural anatomy.  The gluteus maximus was repaired using 0 Ethibond and 0 Vicryl.  The subcutaneous tissues were closed after further irrigation with 2-0 Vicryl and Monocryl sutures.  The skin was closed with nylon.  Xeroform and a sterile dressing were applied followed by a cold pack and Ace wrap.  The patient was transferred to the recovery room in stable condition, having tolerated the procedure well.","orthopedic, range-of-motion, hip, total hip replacement, gluteus maximus, femoral head, subcutaneous tissues, incision, ethibond, trochanter, subcutaneous, acetabulum, femur"
" Right total knee arthroplasty using a Biomet cemented components, 62.5-mm right cruciate-retaining femoral component, 71-mm Maxim tibial component, and 12-mm polyethylene insert with 31-mm patella.  All components were cemented with Cobalt G.", Orthopedic, Total Knee Arthoplasty - Right - 1 ,"PREOPERATIVE DIAGNOSIS:,  Severe degenerative joint disease of the right knee.,POSTOPERATIVE DIAGNOSIS: , Severe degenerative joint disease of the right knee.,PROCEDURE:,  Right total knee arthroplasty using a Biomet cemented components, 62.5-mm right cruciate-retaining femoral component, 71-mm Maxim tibial component, and 12-mm polyethylene insert with 31-mm patella.  All components were cemented with Cobalt G.,ANESTHESIA:,  Spinal.,ESTIMATED BLOOD LOSS: , Minimal.,TOURNIQUET TIME: , Less than 60 minutes.,The patient was taken to the Postanesthesia Care Unit in stable condition.  The patient tolerated the procedure well.,INDICATIONS:  ,The patient is a 51-year-old female complaining of worsening right knee pain.  The patient had failed conservative measures and having difficulties with her activities of daily living as well as recurrent knee pain and swelling.  The patient requested surgical intervention and need for total knee replacement.,All risks, benefits, expectations, and complications of surgery were explained to her in great detail and she signed informed consent.  All risks including nerve and vessel damage, infection, and revision of surgery as well as component failure were explained to the patient and she did sign informed consent.  The patient was given antibiotics preoperatively.,PROCEDURE DETAIL:  ,The patient was taken to the operating suite and placed in supine position on the operating table.  She was placed in the seated position and a spinal anesthetic was placed, which the patient tolerated well.  The patient was then moved to supine position again and a well-padded tourniquet was placed on the right thigh.  Right lower extremity was prepped and draped in sterile fashion.  All extremities were padded prior to this.,The right lower extremity, after being prepped and draped in the sterile fashion, the tourniquet was elevated and maintained for less than 60 minutes in this case.  A midline incision was made over the right knee and medial parapatellar arthrotomy was performed.  Patella was everted.  The infrapatellar fat pad was incised and medial and lateral meniscectomy was performed and the anterior cruciate ligament was removed.  The posterior cruciate ligament was intact.,There was severe osteoarthritis of the lateral compartment on the lateral femoral condyle as well as mild-to-moderate osteoarthritis in the medial femoral compartment as well severe osteoarthritis along the patellofemoral compartment.  The medial periosteal tissue on the proximal tibia was elevated to the medial collateral ligament and medial collateral ligament was left intact throughout the entirety of the case.,At the extramedullary tibial guide, an extended cut was made adjusting for her alignment.  Once this was performed, excess bone was removed.  The reamer was placed along on the femoral canal, after which a 6-degree valgus distal cut was made along the distal femur.  Once this was performed, the distal femoral size in 3 degrees external rotation, 62.5-mm cutting block was placed in 3 degrees external rotation with anterior and posterior cuts as well as anterior and posterior Chamfer cuts remained in the standard fashion.  Excess bone was removed.,Next, the tibia was brought anterior and excised to 71 mm.  It was then punched in standard fashion adjusting for appropriate rotation along the alignment of the tibia.  Once this was performed, a 71-mm tibial trial was placed as well as a 62.5-mm femoral trial was placed with a 12-mm polyethylene insert.,Next, the patella was cut in the standard fashion measuring 31 mm and a patella bed was placed.  The knee was taken for range of motion; had excellent flexion and extension as well as adequate varus and valgus stability.  There was no loosening appreciated.  There is no laxity appreciated along the posterior cruciate ligament.,Once this was performed, the trial components were removed.  The knee was irrigated with fluid and antibiotics, after which the cement was put on the back table, this being Cobalt G, it was placed on the tibia.  The tibial components were tagged in position and placed on the femur.  The femoral components were tagged into position.  All excess cement was removed ___ placement of patella.  It was tagged in position.  A 12-mm polyethylene insert was placed; knee was held in extension and all excess cement was removed.  The cement hardened with the knee in full extension, after which any extra cement was removed.,The wounds were copiously irrigated with saline and antibiotics, and medial parapatellar arthrotomy was closed with #2 Vicryl.  Subcutaneous tissue was approximated with #2-0 Vicryl and the skin was closed with staples.  The patient was awakened from general anesthetic, transferred to the gurney, and taken into postanesthesia care unit in stable condition.  The patient tolerated the procedure well.","orthopedic, degenerative joint disease, knee, total knee arthroplasty, biomet, cemented, cobalt g, arthoplasty, osteoarthritis, polyethylene, cruciate, ligament, patella, femoral, tibial, "
 Right hip osteoarthritis.  Total hip replacement on the right side., Orthopedic, Total Hip Replacement  ,"PREOPERATIVE DIAGNOSIS: , Right hip osteoarthritis.,POSTOPERATIVE DIAGNOSIS: , Right hip osteoarthritis.,PROCEDURES PERFORMED: , Total hip replacement on the right side using the following components:,1.  Zimmer trilogy acetabular system 10-degree elevated rim located at the 12 o'clock position.,2.  Trabecular metal modular acetabular system 48 mm in diameter.,3.  Femoral head 32 mm diameter +0 mm neck length.,4.  Alloclassic SL offset stem uncemented for taper.,ANESTHESIA: , Spinal.,DESCRIPTION OF PROCEDURE IN DETAIL:,  The patient was brought into the operating room and was placed on the operative table in a lateral decubitus position with the right side up.  After review of allergies, antibiotics were administered and time out was performed.  The right lower extremity was prepped and draped in a sterile fashion.  A 15 cm to 25 cm in length, an incision was made over the greater trochanter.  This was angled posteriorly.  Access to the tensor fascia lata was performed.  This was incised with the use of scissors.  Gluteus maximus was separated.  The bursa around the hip was identified, and the bleeders were coagulated with the use of Bovie.  Hemostasis was achieved.  The piriformis fossa was identified, and the piriformis fossa tendon was elevated with the use of a Cobb.  It was detached from the piriformis fossa and tagged with 2-0 Vicryl.  Access to the capsule was performed.  The capsule was excised from the posterior and superior aspects.  It was released also in the front with the use of a Mayo scissors.  The hip was then dislocated.  With the use of an oscillating saw, the femoral neck cut was performed.  The acetabulum was then visualized and debrided from soft tissues and osteophytes.  Reaming was initiated and completed for a 48 mm diameter cap without complications.  The trial component was put in place and was found to be stable in an anatomic position.  The actual component was then impacted in the acetabulum.  A 10-degree lip polyethylene was also placed in the acetabular cap.  Our attention was then focused to the femur.  With the use of a cookie cutter, the femoral canal was accessed.  The broaching process was initiated for No.4 trial component.  Trialing of the hip with the hip flexed at 90 degrees and internally rotated to 30 degrees did not demonstrate any obvious instability or dislocation.  In addition, in full extension and external rotation, there was no dislocation.  The actual component was inserted in place and hemostasis was achieved again.  The wound was irrigated with normal saline.  The wound was then closed in layers.  Before performing that the medium-sized Hemovac drain was placed in the wound.  The tensor fascia lata was closed with 0 PDS and the wound was closed with 2-0 Monocryl.  Staples were used for the skin.  The patient recovered from anesthesia without complications.,EBL: , 50 mL.,IV FLUIDS: , 2 liters.,DRAINS: , One medium-sized Hemovac.,COMPLICATIONS: , None.,DISPOSITION: , The patient was transferred to the PACU in stable condition.  She will be weightbearing as tolerated to the right lower extremity with posterior hip precautions.  We will start the DVT prophylaxis after the removal of the epidural catheter.","orthopedic, total hip replacement, epidural catheter, tensor fascia lata, hemostasis was achieved, medium sized hemovac, tensor fascia, fascia lata, trial component, medium sized, sized hemovac, total hip, hip replacement, hip osteoarthritis, piriformis fossa, total, hip, acetabular, extremity, tensor, fascia, hemostasis, acetabulum, dislocation, hemovac, replacement, osteoarthritis, femoral, piriformis, fossa, components, anesthesia, "
 NexGen left total knee replacement.  Degenerative arthritis of left knee.  The patient is a 72-year-old female with a history of bilateral knee pain for years progressively worse and decreasing quality of life and ADLs., Orthopedic, Total Knee Replacement - NexGen ,"PREOPERATIVE DIAGNOSIS: , Degenerative arthritis of left knee.,POSTOPERATIVE DIAGNOSIS:,  Degenerative arthritis of left knee.,PROCEDURE PERFORMED: , NexGen left total knee replacement.,ANESTHESIA: , Spinal.,TOURNIQUET TIME:  Approximately 66 minutes.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , Approximately 50 cc.,COMPONENTS: , A NexGen stemmed tibial component size 5 was used, 10 mm cruciate retaining polyethylene surface, a NexGen cruciate retaining size E femoral component, and a size 38 9.5 mm thickness All-Poly Patella.,BRIEF HISTORY:,  The patient is a 72-year-old female with a history of bilateral knee pain for years progressively worse and decreasing quality of life and ADLs.  She wishes to proceed with arthroplasty at this time.,PROCEDURE:  ,The patient was taken to the Operative Suite at ABCD General Hospital on 09/11/03.  She was placed on the operating table.  Department of Anesthesia administered a spinal anesthetic.  Once adequately anesthetized, the left lower extremity was prepped and draped in the usual sterile fashion.  An Esmarch was applied and a tourniquet was inflated to 325 mmHg on the left thigh.  A longitudinal incision was made over the anterior portion of the knee and this was taken down through the subcutaneous tissue to the level of the patella retinaculum.  A medial peripatellar arthrotomy was then made and taken down to the level of the tibial tubercle.  Care was then ensured that the patellar tendon was not violated.  The proximal tibia was then skeletonized both medially and laterally to the level of the axis through the joint line.  Again care was ensured that the patellar tendon was not avulsed from the insertion on the tibia.  The intramedullary canal was then opened using a drill and the anterior sizing guide was then placed.  Rongeur was used to take out any osteophytes and the size of approximately size E. At this point, the epicondyle axis guide was then inserted and aligned in a proper orientation.  The anterior cutting guide was then placed.  Care was checked for the amount of resection that the femur would be notched and the oscillating saw was used to cut the anterior portion of the femur.  After this was performed, this was removed and the distal femoral cutting guide was then placed.  The left knee placed in 5 degrees of valgus, guide was then placed, and a standard distal cut was then taken.  After the cuts were ensured further to be leveled and they were, and we proceeded to place the finishing guide size E and distal femur.  This was placed slightly in lateral position and secured in position with spring tense and head lift tense.  Once adequately secured and placed in the appropriate orientation, the alignment was again verified with the epicondyle axis and appeared to be externally rotated appropriately.  The chamfer cuts and anterior and posterior cuts were then made as well as the notch cut using the reciprocating and oscillating saws.  After this was performed, the guide was removed and all bony fragments were then removed.  Attention was then directed to the tibia.  The external tibial alignment guide was then placed and pinned to the proximal tibia in a proper position.  Care was ensured if it is was a varus or valgus and the appropriate.  The femur gauge was then used to provide us appropriate amount of bony resection.  This was then pinned and secured into place.  Ligament retractors were used to protect the collateral ligaments and the tip proximal tibial cut was then made.  This bony portion was then removed and remaining meniscal fragments were removed as well as the ACL till adequate exposure was obtained.  Trial components were then inserted into position and taken the range of motion and found to have good and full excellent range of motion stability.  The trial components were then removed.  The tibia was then stemmed in standard fashion after the tibial plate was placed in some degree of external rotation with appropriate alignment.  After it was stemmed and broached, these were removed and the patella was then incised, a size 41 patella reamer blade was then used and was taken down, a size 38 patella button was then placed intact.  Again the trial components were placed back into position.  Patella button was placed and the tracking was evaluated.  They tracked centrally with no touch technique.  Again, all components were now removed and the knee was then copiously irrigated and suctioned dry.  Once adequately suctioned dry, the tibial portion was cemented and packed into place.  Also excess cement was removed.  The femoral component was then cemented into position.  All excess cement was removed.  A size 12 poly was then inserted in trial to provide compression at cement adhered.  The patella was then cemented and held into place.  All components were held under compression until cement had adequately adhered all excess cement was then removed.  The knee was then taken through range of motion and size 12 felt to be slightly too big, this was removed and the size 10 trial was replaced, and again had excellent varus and valgus stability with full range of motion and felt to be the articulate surface of choice.  The knee was again copiously irrigated and suctioned dry.  One last check in the posterior aspect of the knee for any loose bony fragments or osteophytes was performed, there were none found and a final articulating surface was impacted and locked into place.  After this, the knee was taken again for final range of motion and found to have excellent position, stability, and good alignment of the components.  The knee was once again copiously irrigated, and the tourniquet was deflated.  Bovie cautery was used to cauterize the knee bleeding that was seen until good hemostasis obtained.  A drain was then placed deep to the retinaculum and the retinaculum repair was performed using #2-0 Ethibond and oversewn with a #1 Vicryl.  This was flexed and the repair was found held securely.  At this point, the knee was again copiously irrigated and suctioned dry.  The subcutaneous tissue was closed with #2-0 Vicryl, and the skin was approximated with skin staples.  Sterile dressing with Adaptic, 4x4s, ABDs, and Kerlix rolls was then applied.  The patient was then transferred back to the gurney in a supine position.,DISPOSITION: , The patient tolerated well with no complications, to PACU in satisfactory condition.","orthopedic, degenerative arthritis, nexgen stemmed tibial component, all-poly patella, nexgen cruciate, total knee replacement, patellar tendon, proximal tibia, epicondyle axis, bony fragments, patella button, tibial, knee, arthritis, nexgen, patella"
" Transforaminal lumbar interbody fusion, placement of intervertebral prosthetic device.", Orthopedic, TLIF ,"PREOPERATIVE DIAGNOSIS (ES):, L4-L5 and L5-S1 degenerative disk disease/disk protrusions/spondylosis with radiculopathy.,POSTOPERATIVE DIAGNOSIS (ES):, L4-L5 and L5-S1 degenerative disk disease/disk protrusions/spondylosis with radiculopathy.,PROCEDURE:,1. Left L4-L5 and L5-S1 Transforaminal Lumbar Interbody Fusion (TLIF).,2. L4 to S1 fixation (Danek M8 system).,3. Right posterolateral L4 to S1 fusion.,4. Placement of intervertebral prosthetic device (Danek Capstone spacers L4-L5 and L5-S1).,5. Vertebral autograft plus bone morphogenetic protein (BMP).,COMPLICATIONS:, None.,ANESTHESIA:, General endotracheal.,SPECIMENS:, Portions of excised L4-L5 and L5-S1 disks.,ESTIMATED BLOOD LOSS:, 300 mL.,FLUIDS GIVEN:, IV crystalloid.,OPERATIVE INDICATIONS:, The patient is a 37-year-old male presenting with a history of chronic, persistent low back pain as well as left lower extremity of radicular character were recalcitrant to conservative management. Preoperative imaging studies revealed the above-noted abnormalities. After a detailed review of management considerations with the patient and his wife, he was elected to proceed as noted above.,Operative indications, methods, potential benefits, risks and alternatives were reviewed. The patient and his wife expressed understanding and consented to proceed as above.,OPERATIVE FINDINGS:, L4-L5 and L5-S1 disk protrusion with configuration as anticipated from preoperative imaging studies. Pedicle screw placement appeared satisfactory with satisfactory purchase and positioning noted at all sites as well as satisfactory findings upon probing of the pedicular tracts at each site. In addition, all pedicle screws were stimulated with findings of above threshold noted at all sites. Spacer snugness and positioning appeared satisfactory. Electrophysiological monitoring was carried out throughout the procedure and remained stable with no undue changes reported.,DESCRIPTION OF THE OPERATION:, After obtaining proper patient identification and appropriate preoperative informed consent, the patient was taken to the operating room on a hospital stretcher in the supine position. After the induction of satisfactory general endotracheal anesthesia and placement of appropriate monitoring equipment by Anesthesiology as well as placement of electrophysiological monitoring equipment by the Neurology team, the patient was carefully turned to the prone position and placed upon the padded Jackson table with appropriate additional padding placed as needed. The patient's posterior lumbosacral region was thoroughly cleansed and shaved. The patient was then scrubbed, prepped and draped in the usual manner. After local infiltration with 1% lidocaine with 1: 200,000 epinephrine solution, a posterior midline skin incision was made extending from approximately L3 to the inferior aspect of the sacrum. Dissection was continued in the midline to the level of the posterior fascia. Self-retaining retractors were placed and subsequently readjusted as needed. The fascia was opened in the midline, and the standard subperiosteal dissection was then carried out to expose the posterior and posterolateral elements from L3-L4 to the sacrum bilaterally with lateral exposure carried out to the lateral aspect of the transverse processes of L4 and L5 as well as the sacral alae bilaterally. _____ by completing the exposure, pedicle screw fixation was carried out in the following manner. Screws were placed in systematic caudal in a cranial fashion. The pedicle screw entry sites were chosen using standard dorsal landmarks and fluoroscopic guidance as needed. Cortical openings were created at these sites using a small burr. The pedicular tracts were then preliminarily prepared using a Lenke pedicle finder. They were then probed and subsequently tapped employing fluoroscopic guidance as needed. Each site was ""under tapped"" and reprobed with satisfactory findings noted as above. Screws in the following dimensions were placed. 6.5-mm diameter screws were placed at all sites. At S1, 40-mm length screws were placed bilaterally. At L5, 40-mm length screws were placed bilaterally, and at L4, 40-mm length screws were placed bilaterally with findings as noted above. The rod was then contoured to span from the L4 to the S1 screws on the right. The distraction was placed across the L4-L5 interspace, and the connections were temporarily secured. Using a matchstick burr, a trough was then carefully created slightly off the midline of the left lamina extending from its caudal aspect to its more cranial aspect at the foraminal level. This was longitudinally oriented. A transverse trough was similarly carefully created from the cranial point of the longitudinal trough out to the lateral aspect of the pars against the foraminal level that is slightly caudal to the L4 pedicle. This trough was completed to the level of the ligamentum flavum using small angled curettes and Kerrison rongeurs, and this portion of the lamina along with the inferior L4 articular process was then removed as a unit using rongeurs and curettes. The cranial aspect of the left L5 superior articular process was then removed using a small burr and angled curettes and Kerrison rongeurs. A superior laminotomy was performed from the left L5 lamina and flavectomy was then carried out across this region of decompression, working from caudally to cranially and medially to laterally, again using curettes and Kerrison rongeurs under direct visualization. In this manner, the left lateral aspect of the thecal sac passing left L5 spinal nerve and exiting left L4 spinal nerve along with posterolateral aspect of disk space was exposed. Local epidural veins were coagulated with bipolar and divided. Gelfoam was then placed in this area. This process was then repeated in similar fashion; thereby, exposing the posterolateral aspect of the left L5-S1 disk space. As noted, distraction had previously been placed at L4-L5, this was released. Distraction was placed across the L5-S1 interspace. After completing satisfactory exposure as noted, a annulotomy was made in the posterolateral left aspect of the L5-S1 disk space. Intermittent neural retraction was employed with due caution afforded to the neural elements throughout the procedure. The disk space was entered, and diskectomy was carried out in routine fashion using pituitary rongeurs followed by the incremental sized disk space shavers as well as straight and then angled TLIF curettes to prepare the front plate. Herniated portions of the disk were also removed in routine fashion. The diskectomy and endplate preparation were carried out working progressively from the left towards the right aspect of the disk across the midline in routine fashion. After completing this disk space preparation, Gelfoam was again placed. The decompression was assessed and appeared to be satisfactory. The distraction was released, and attention was redirected at L4-L5, where again, distraction was placed and diskectomy and endplate preparation was carried out at this interspace again in similar fashion. After completing the disk space preparation, attention was redirected to L5-S1. Distraction was released at L4-L5 and again, reapplied at L5-S1, incrementally increasing size. Trial spaces were used, and a 10-mm height by 26-mm length spacer was chosen. A medium BMP kit was appropriately reconstituted. A BMP sponge containing morcellated vertebral autograft was then placed into the anterior aspect of the disk space. The spacer was then carefully impacted into position. The distraction was released. The spacer was checked with satisfactory snugness and positioning noted. This process was then repeated in similar fashion at L4-L5, again with placement of a 10-mm height by 26-mm length Capstone spacer, again containing BMP and again with initial placement of a BMP sponge with vertebral autograft anteriorly within the interspace. This spacer was also checked again with satisfactory snugness and positioning noted. The prior placement of the spacers and BMP, the wound was thoroughly irrigated and dried with satisfactory hemostasis noted. Surgicel was placed over the exposed dura and disk space. The distraction was released on the right and compression plates across the L5-S1 and L4-L5 interspaces and the connections fully tightened in routine fashion. The posterolateral elements on the right from L4 to S1 were prepared for fusion in routine fashion, and BMP sponges with supplemental vertebral autograft was placed in the posterolateral fusion bed as well as the vertebral autograft in the dorsal aspect of the L4-L5 and L5-S1 facets on the right in a routine fashion. A left-sided rod was appropriated contoured and placed to span between the L4 to S1 screws. Again compression was placed across the L4-L5 and L5-S1 segments, and these connections were fully secured. Thorough hemostasis was ascertained after checking the construct closely and fluoroscopically. The wound was closed using multiple simple interrupted 0-Vicryl sutures to reapproximate the deep paraspinal musculature in the midline. The superficial paraspinal musculature in posterior fashion was closed in the midline using multiple simple interrupted 0-Vicryl sutures. The suprafascial subcutaneous layers were closed using multiple simple interrupted #0 and 2-0 Vicryl sutures. The skin was then closed using staples. Sterile dressings were then applied and secured in place. The patient tolerated the procedure well and was to the recovery room in satisfactory condition.","orthopedic, degenerative disk disease, disk protrusions, spondylosis, radiculopathy, tlif, transforaminal lumbar interbody fusio, danek m8, intervertebral prosthetic device, danek capstone, matchstick burr, capstone, bmp, vertebral autograft, screws were placed bilaterally, pedicle screw, kerrison rongeurs, disk space, disk, spacers, kerrison, interbody, rongeurs, pedicle, lumbar, screws, "
" Infected right hip bipolar arthroplasty, status post excision and placement of antibiotic spacer.  Removal of antibiotic spacer and revision total hip arthroplasty.", Orthopedic, Total Hip Arthroplasty - Revision ,"PREOPERATIVE DIAGNOSIS: , Infected right hip bipolar arthroplasty, status post excision and placement of antibiotic spacer.,POSTOPERATIVE DIAGNOSIS:,  Infected right hip bipolar arthroplasty, status post excision and placement of antibiotic spacer.,PROCEDURES:,1.  Removal of antibiotic spacer.,2.  Revision total hip arthroplasty.,IMPLANTS,1.  Hold the Zimmer trabecular metal 50 mm acetabular shell with two 6.5 x 30 mm screws.,2.  Zimmer femoral component, 13.5 x 220 mm with a size AA femoral body.,3.  A 32-mm femoral head with a +0 neck length.,ANESTHESIA:  ,Regional.,ESTIMATED BLOOD LOSS: , 500 cc.,COMPLICATIONS:,  None.,DRAINS: , Hemovac times one and incisional VAC times one.,INDICATIONS:,  The patient is a 66-year-old female with a history of previous right bipolar hemiarthroplasty for trauma.  This subsequently became infected.  She has undergone removal of this prosthesis and placement of antibiotic spacer.  She currently presents for stage II reconstruction with removal of antibiotic spacer and placement of a revision total hip.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room by anesthesia personnel.  She was placed supine on the operating table.  A Foley catheter was inserted.  A formal time out was obtained in identifying the correct patient, operative site.  Preoperative antibiotics were held for intraoperative cultures.  The patient was placed into the lateral decubitus position with the right side up.  The previous surgical incision was identified.  The right lower extremity was prepped and draped in standard fashion.  The old surgical incision was reopened along its proximal extent.  Immediately encountered was a large amount of fibrous scar tissue.  Dissection was carried sharply down through this scar tissue.  Soft tissue plains were extremely difficult to visualize due to all the scarring.  There was no native tissue to orient oneself with.  We carried our dissection down through the scar tissue to what seemed to be a fascial layer.  We incised through the fascial layer down to some scarred gluteus maximus muscle and down over what was initially felt to be the greater trochanter.  Dissection was carried down through soft tissue and the distal located antibiotic spacer was exposed.  This was used as a landmark to orient remainder of the dissection.  The antibiotic spacer was exposed and followed distally to expose the proximal femur.  Dissection was continued posteriorly and proximally to expose the acetabulum.  A cobra retractor was able to be inserted across the superior aspect of the acetabulum to enhance exposure.  Once improved visualization was obtained, the antibiotic spacer was removed from the femur.  This allowed further improved visualization of the acetabulum.  The acetabulum was filled with soft tissue debris and scar tissue.  This was removed with sharp excision with a knife as well as with a rongeur and a Bovie.  Once soft tissue was removed, the acetabulum was reamed.  Reaming was started with a 46-mm reamer and carried up sequentially to prepare for 50-mm shell.  The 50 mm shell was trialed and had good stability and fit.  Attention was then turned to continue preparation of the femur.  The canal was then debrided with femoral canal curettes.  Some fibrous tissue was removed from the canal.  The length of the femoral stem was then checked with this canal curette in place.  Following x-rays, we prepared to begin reaming the femur.  This femur was reamed over a guide rod using flexible reaming rods.  The canal was reamed up to 13.5 mm distally in preparation for 14 mm stem.  The stem was selected and initially size A body was placed in trial.  The body was too tight proximally to fit.  The proximal canal was then reamed for a size AA body.  A longer stem with an anterior bow was selected and a size AA trial was assembled.  This fit nicely in the canal and had good fit and fill.  Intraoperative radiographs were obtained to determine component position.  Intraoperative radiographs revealed satisfactory length of the component past the distal of fractures in the femur.  The remainder of the trial was then assembled and the hip was relocated and trialed.  Initially, it was found to be unstable posteriorly.  We changed from a 10 degree lip liner to 20 degree lip liner.  Again, the hip was trialed and found to be unstable posteriorly.  This was due to reversion of the femoral component.  As we attempted to seat the prosthesis, the stent continued to attempt to turn in retroversion.  The stem was extracted and retrialed.  Improved stability was obtained and we decided to proceed with the real components.  A 20 degree liner was inserted into the acetabular shell.  The real femoral components were assembled and inserted into the femoral canal.  Again, the hip was trialed.  The components were found to be in relative retroversion.  The real components were then backed down and the neck was placed in the more anteversion and reinserted.  Again, the stem attempted to follow in the relative retroversion.  Along with this time, however, it was improved from previous attempts.  The femoral head trial was placed back on the components and the hip relocated.  It was taken to a range of motion and found to have improved stability compared to previous trialing.  Decision was made to accept the component position.  The real femoral head was selected and implanted.  The hip was then taken again to a range of motion.  It was stable at 90 degrees of flexion with 20 degrees of adduction and 40 degrees of internal rotation.  The patient reached full extension and had no instability anteriorly.,The wound was then irrigated again with pulsatile lavage.  Six liters of pulsatile lavage was used during the procedure.,The wound was then closed in a layered fashion.  A Hemovac drain was placed deep to the fascial layer.  The subcutaneous tissues were closed with #1 PDS, 2-0 PDS, and staples in the skin.  An incisional VAC was then placed over the wound as well.  Sponge and needle counts were correct at the close of the case.,DISPOSITION:,  The patient will be weightbearing as tolerated with posterior hip precautions.","orthopedic, infected, bipolar arthroplasty, antibiotic spacer, revision, placement of antibiotic spacer, total hip arthroplasty, scar tissue, soft tissue, antibiotic, spacer, femoral, hip, arthroplasty, total, acetabulum, femur, "
" History of compartment syndrome, right lower extremity, status post 4 compartments fasciotomy, to do incision for compartment fasciotomy. Wound debridement x2, including skin, subcutaneous, and muscle.  Insertion of tissue expander to the medial and lateral wound.", Orthopedic, Tissue Expander Insertion ,"PREOPERATIVE DIAGNOSES: , History of compartment syndrome, right lower extremity, status post 4 compartments fasciotomy, to do incision for compartment fasciotomy.,POSTOPERATIVE DIAGNOSES: , History of compartment syndrome, right lower extremity, status post 4 compartments fasciotomy, to do incision for compartment fasciotomy.,OPERATIONS:,1.  Wound debridement x2, including skin, subcutaneous, and muscle.,2.  Insertion of tissue expander to the medial wound.,3.  Insertion of tissue expander to the lateral wound.,COMPLICATIONS: , None.,TOURNIQUET: , None.,ANESTHESIA:  ,General.,INDICATIONS: , This patient developed a compartment syndrome.  She underwent 4 compartment fasciotomy with dual incision on medial and lateral aspect of the right lower leg.  She was doing very well and was obviously improving.,The swelling was reduced.  A compartment pressure had obviously improved based on examination.  She was therefore indicated for placement of tissue expander for ventral wound closure.  The risks of procedure as well as alternatives of this procedure were discussed at length with the patient and he understood them well.  Risks and benefits were all discussed, risk of bleeding, infection, damage to blood vessels, damage to nerve roots, need for further surgery, chronic pain with range of motion, risk of continued discomfort, risk of need for further reconstructive procedures, risk of blood clots, pulmonary embolism, myocardial infarction, and risk of death were discussed.  She understood them well.  All questions were answered, and she signed the consent for the procedure as described.,DESCRIPTION OF THE PROCEDURE:,  The patient was placed on the operating table and general anesthesia was achieved.  The medial wound was noted to be approximately 10.5 cm in length x 4 cm.  The lateral wound was noted in approximately 14 cm in length x 5 x 5 cm in width.  Both wounds were then thoroughly debrided.  The debridement of both wounds included skin and subcutaneous tissue and nonviable muscle portion.  This involve very small portion of muscle as well as skin edge and the subcutaneous tissue did require debridement on both sides.  At this point adequate debridement was performed and healthy tissue did appear to be present.  Initially on the medial wound I did place the DermaClose RC continuous external tissue expander.  On the medial wound the 5 skin anchors were placed on each side of the wound and separated appropriately.  I then did place the line loop from the tension controller in a lace like manner through the skin anchors and the tension controller was attached to the middle anchor.  I then did place adequate tension on the sutures.  Continued tension will be noted after engaging the tension controller.  At this point I performed the similar procedure to the lateral wound.  The skin anchors were placed separately and appropriately on either side of the skin margin.  The line loop from the tension controller was placed in lace like manner through the skin anchors.  The tension controller was then attached to the mid anchor and appropriate tension was applied.,It must be noted I did undermine the skin edges both sides of flap from both incision site prior to placement of the skin anchor and adequate mobilization was obtained.  Adequate tension was placed in this region.  A non thick dressing was then applied to the open-wound region and sterile dressing was then applied.  No complications were encountered throughout the procedure and the patient tolerated the procedure well.  The patient was taken to recovery room in stable condition.","orthopedic, fasciotomy, subcutaneous, muscle, wound debridement, insertion of tissue expander, compartment syndrome, compartment fasciotomy, lateral wound, medial wound, tension controller, tissue expander, wound, tissue, compartment,"
 Pain.  Three views of the right ankle.  Three views of the right ankle are obtained., Orthopedic, Three Views - Ankle ,"EXAM: , Three views of the right ankle.,INDICATIONS:  ,Pain.,FINDINGS: , Three views of the right ankle are obtained.  There is no evidence of fractures or dislocations.  No significant degenerative changes or destructive osseous lesions of the ankle are noted.  There is a small plantar calcaneal spur.  There is no significant surrounding soft tissue swelling.,IMPRESSION:  ,Negative right ankle.","orthopedic, three views, calcaneal, plantar, spur, osseous, ankle"
 Right foot trauma.  Three views of the right foot.  Three views of the right foot were obtained.  , Orthopedic, Three Views - Foot ,"EXAM:  ,Three views of the right foot.,REASON FOR EXAM: , Right foot trauma.,FINDINGS: , Three views of the right foot were obtained.  There are no comparison studies.  There is no evidence of fractures or dislocations.  No significant degenerative changes or obstructive osseous lesions were identified.  There are no radiopaque foreign bodies.,IMPRESSION: , Negative right foot.","orthopedic, three views, radiopaque, fractures, foot trauma"
" Left carpal tunnel release with flexor tenosynovectomy; cortisone injection of trigger fingers, left third and fourth fingers; injection of Dupuytren's nodule, left palm.", Orthopedic, Tenosynovectomy & Cortisone Injection ,"PREOPERATIVE DIAGNOSES,1.  EMG-proven left carpal tunnel syndrome.,2.  Tenosynovitis of the left third and fourth fingers at the A1 and A2 pulley level.,3.  Dupuytren's nodule in the palm.,POSTOPERATIVE DIAGNOSES,1.  EMG-proven left carpal tunnel syndrome.,2.  Tenosynovitis of the left third and fourth fingers at the A1 and A2 pulley level.,3.  Dupuytren's nodule in the palm.,PROCEDURE: , Left carpal tunnel release with flexor tenosynovectomy; cortisone injection of trigger fingers, left third and fourth fingers; injection of Dupuytren's nodule, left palm.,ANESTHESIA: , Local plus IV sedation (MAC).,ESTIMATED BLOOD LOSS:  ,Zero.,SPECIMENS:  ,None.,DRAINS: , None.,PROCEDURE DETAIL: , Patient brought to the operating room.  After induction of IV sedation the left hand was anesthetized suitable for carpal tunnel release; 10 cc of a mixture of 1% Xylocaine and 0.5% Marcaine was injected in the distal forearm and proximal palm suitable for carpal tunnel surgery.  Routine prep and drape was employed.  Arm was exsanguinated by means of elevation of Esmarch elastic tourniquet and tourniquet inflated to 250 mmHg pressure.  Hand was positioned palm up in the lead hand-holder.  A short curvilinear incision about the base of the thenar eminence was made.  Skin was sharply incised.  Sharp dissection was carried down to the transverse carpal ligament and this was carefully incised longitudinally along its ulnar margin.  Care was taken to divide the entire length of the transverse retinaculum including its distal insertion into deep palmar fascia in the midpalm.  Proximally the antebrachial fascia was released for a distance of 2-3 cm proximal to the wrist crease to insure complete decompression of the median nerve.  Retinacular flap was retracted radially to expose the contents of the carpal canal.  Median nerve was identified, seen to be locally compressed with moderate erythema and mild narrowing.  Locally adherent tenosynovium was present and this was carefully dissected free.  Additional tenosynovium was dissected from the flexor tendons, individually stripping and peeling each tendon in sequential order so as to debulk the contents of the carpal canal.  Epineurotomy and partial epineurectomy were carried out on the nerve in the area of mild constriction to relieve local external scarring of the epineurium.  When this was complete retinacular flap was laid loosely in place over the contents of the carpal canal and skin only was closed with interrupted 5-0 nylon horizontal mattress sutures.  A syringe with 3 cc of Kenalog-10 and 3 cc of 1% Xylocaine using a 25 gauge short needle was then selected; 1 cc of this mixture was injected into the third finger A1 and A2 pulley tendon sheaths using standard trigger finger injection technique; 1 cc was injected into the fourth finger A1/A2 pulley tendon sheath using standard tendon sheath injection technique; 1 cc was injected into the Dupuytren's nodule in the midpalm to relieve local discomfort.  Routine postoperative hand dressing with well-padded, well-molded volar plaster splint and lightly compressive Ace wrap was applied.  Tourniquet was deflated.  Good vascular color and capillary refill were seen to return to the tips of all digits.  Patient discharged to the ambulatory recovery area and from there discharged home.  Discharge medication is Darvocet-N 100, 30 tablets, one to two PO q.4h. p.r.n.  Patient asked to begin gentle active flexion, extension and passive nerve glide exercises beginning 24-48 hours after surgery.  She was asked to keep the dressings clean, dry and intact and follow up in my office.","orthopedic, carpal tunnel syndrome, pulley, dupuytren's, tenosynovitis, tenosynovectomy, carpal tunnel release, flexor tenosynovectomy, cortisone injection, dupuytren's nodule, injection, cortisone,"
" Painful enlarged navicula, right foot.  Osteochondroma of right fifth metatarsal. Partial tarsectomy navicula and partial metatarsectomy, right foot.", Orthopedic, Tarsectomy ,"PREOPERATIVE DIAGNOSES:,1.  Painful enlarged navicula, right foot.,2.  Osteochondroma of right fifth metatarsal.,POSTOPERATIVE DIAGNOSES:,1.  Painful enlarged navicula, right foot.,2.  Osteochondroma of right fifth metatarsal.,PROCEDURE PERFORMED:,1.  Partial tarsectomy navicula, right foot.,2.  Partial metatarsectomy, right foot.,HISTORY:  ,This 41-year-old Caucasian female who presents to ABCD General Hospital with the above chief complaint.  The patient states that she has extreme pain over the navicular bone with shoe gear as well as history of multiple osteochondromas of unknown origin.  She states that she has been diagnosed with hereditary osteochondromas.  She has had previous dissection of osteochondromas in the past and currently has not been diagnosed in her feet as well as spine and back.  The patient desires surgical treatment at this time.,PROCEDURE:  ,An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported to the operating room and placed on operating table in the supine position with a safety belt across her lap.  Copious amounts of Webril were placed on the left ankle followed by a blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 5 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain were injected in the diamond block type fashion around the navicular bone as well as the fifth metatarsal.  Foot was then prepped and draped in the usual sterile orthopedic fashion.,Foot was elevated from the operating table and exsanguinated with an Esmarch bandage.  The pneumatic ankle tourniquet was then inflated to 250 mmHg.  The foot was lowered as well as the operating table.  The sterile stockinet was reflected and the foot was cleansed with wet and dry sponge.  Attention was then directed to the navicular region on the right foot.  The area was palpated until the bony prominence was noted.  A curvilinear incision was made over the area of bony prominence.  At that time, a total of 10 cc with addition of 1% additional lidocaine plain was injected into the surgical site.  The incision was then deepened with #15 blade.  All vessels encountered were ligated for hemostasis.  The dissection was carried down to the level of the capsule and periosteum.  A linear incision was made over the navicular bone obliquely from proximal dorsal to distal plantar over the navicular bone.  The periosteum and the capsule were then reflected from the navicular bone at this time.  A bony prominence was noted both medially and plantarly to the navicular bone.  An osteotome and mallet were then used to resect the enlarged portion of the navicular bone.  After resection with an osteotome there was noted to be a large plantar shelf.  The surrounding soft tissues were then freed from this plantar area.  Care was taken to protect the attachments of the posterior tibial tendon as much as possible.  Only minimal resection of its attachment to the fiber was performed in order to expose the bone.  Sagittal saw was then used to resect the remaining plantar medial prominent bone.  The area was then smoothed with reciprocating rasp until no sharp edges were noted.  The area was flushed with copious amount of sterile saline at which time there was noted to be a palpable ________ where the previous bony prominence had been noted.  The area was then again flushed with copious amounts of sterile saline and the capsule and periosteum were then reapproximated with #3-0 Vicryl.  The subcutaneous tissues were then reapproximated with #4-0 Vicryl to reduce tension from the incision and running #5-0 Vicryl subcuticular stitch was performed.,Attention was then directed to the fifth metatarsal.  There was noted to be a palpable bony prominence dorsally with fifth metatarsal head as well as radiographic evidence laterally of an osteochondroma at the neck of the fifth metatarsal.  Approximately 7 cm incision was made dorsolaterally over the fifth metatarsal.  The incision was then deepened with #15 blade.  Care was taken to preserve the extensor tendon.  The incision was then created over the capsule and periosteum of the fifth metatarsal head.  Capsule and periosteum were reflected both dorsally, laterally, and plantarly.  At that time, there was noted to be a visible osteochondroma on the plantar lateral aspect of the fifth metatarsal neck as well as on the dorsal aspect of the head of the fifth metatarsal.  A sagittal saw was used to resect both of these osteal prominences.,All remaining sharp edges were then smoothed with reciprocating rasp.  The area was inspected for the remaining bony prominences and none was noted.  The area was flushed with copious amounts of sterile saline.  The capsule and periosteum were then reapproximated with #3-0 Vicryl.  Subcutaneous closure was then performed with #4-0 Vicryl in order to reduce tension around the incision line.  Running #5-0 subcutaneous stitch was then performed.  Steri-Strips were applied to both surgical sites.  Dressings consisted of Adaptic, soaked in Betadine, 4x4s, Kling, Kerlix, and Coban.  The pneumatic ankle tourniquet was released and the hyperemic flush was noted to all five digits of the right foot.,The patient tolerated the above procedure and anesthesia well without complications.  The patient was transferred to the PACU with vital signs stable and vascular status intact.  The patient was given postoperative pain prescription and instructed to be partially weightbearing with crutches as tolerated.  The patient is to follow-up with Dr. X in his office as directed or sooner if any problems or questions arise.","orthopedic, navicula, metatarsal, osteochondroma, tarsectomy, metatarsectomy, painful enlarged navicula, navicular bone, foot, bony, capsule, periosteum, navicular, incision, bone"
" Tailor bunionectomy, right foot, Weil-type with screw fixation.  Hallux abductovalgus deformity and tailor bunion deformity, right foot.", Orthopedic, Tailor Bunionectomy with Screw Fixation ,"PREOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus deformity, right foot.,2.  Tailor bunion deformity, right foot.,POSTOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus deformity, right foot.,2.  Tailor bunion deformity, right foot.,PROCEDURES PERFORMED:  ,Tailor bunionectomy, right foot, Weil-type with screw fixation.,ANESTHESIA: , Local with MAC, local consisting of 20 mL of 0.5% Marcaine plain.,HEMOSTASIS:,  Pneumatic ankle tourniquet at 200 mmHg.,INJECTABLES:,  A 10 mL of 0.5% Marcaine plain and 1 mL of dexamethasone phosphate.,MATERIAL: , A 2.4 x 14 mm, 2.4 x 16 mm, and 2.0 x 10 mm OsteoMed noncannulated screw.  A 2-0 Vicryl, 3-0 Vicryl, 4-0 Vicryl, and 5-0 nylon.,COMPLICATIONS: , None.,SPECIMENS: , None.,ESTIMATED BLOOD LOSS:,  Minimal.,PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed on the operating table in the usual supine position.  At this time, a pneumatic ankle tourniquet was placed on the patient's right ankle for the purpose of maintaining hemostasis.  Number of the anesthesias was obtained and then induced mild sedation and local anesthetic as described above was infiltrated about the surgical site.  The right foot was then scrubbed, prepped, and draped in the usual aseptic manner.  An Esmarch bandage was then used to exsanguinate the patient's right foot, and the pneumatic ankle tourniquet inflated to 200 mmHg.  Attention was then directed to dorsal aspect of the first metatarsophalangeal joint where a linear longitudinal incision measuring approximately a 3.5 cm in length was made.  The incision was carried deep utilizing both sharp and blunt dissections.  All major neurovascular structures were avoided.  At this time, through the original skin incision, attention was directed to the first intermetatarsal space where utilizing both sharp and blunt dissection the deep transverse intermetatarsal ligament was identified.  This was then incised fully exposing the tendon and the abductor hallucis muscle.  This was then resected from his osseous attachments and a small tenotomy was performed.  At this time, a small lateral capsulotomy was also performed.  Lateral contractures were once again reevaluated and noted to be grossly reduced.,Attention was then directed to the dorsal aspect of the first metatarsal phalangeal joint where linear longitudinal and periosteal and capsular incisions were made following the first metatarsal joint and following the original shape of the skin incision.  The periosteal capsular layers were then reflected both medially and laterally from the head of the first metatarsal and a utilizing an oscillating bone saw, the head of the first metatarsal and medial eminence was resected and passed from the operative field.  A 0.045 inch K-wire was then driven across the first metatarsal head in order to act as an access dye.  The patient was then placed in the frog-leg position, and two osteotomy cuts were made, one from the access guide to the plantar proximal position and one from the access guide to the dorsal proximal position.  The dorsal arm was made longer than the plantar arm to accommodate for fixation.  At this time, the capital fragment was resected and shifted laterally into a more corrected position.  At this time, three portions of the 0.045-inch K-wire were placed across the osteotomy site in order to access temporary forms of fixation.  Two of the three of these K-wires were removed in sequence and following the standard AO technique two 3.4 x 15 mm and one 2.4 x 14 mm OsteoMed noncannulated screws were placed across the osteotomy site.  Compression was noted to be excellent.  All guide wires and 0.045-inch K-wires were then removed.  Utilizing an oscillating bone saw, the overhanging wedge of the bone on the medial side of the first metatarsal was resected and passed from the operating field.  The wound was then once again flushed with copious amounts of sterile normal saline.  At this time, utilizing both 2-0 and 3-0 Vicryl, the periosteal and capsular layers were then reapproximated.  At this time, the skin was then closed in layers utilizing 4-0 Vicryl and 4-0 nylon.  At this time, attention was directed to the dorsal aspect of the right fifth metatarsal where a linear longitudinal incision was made over the metatarsophalangeal joint just lateral to the extensor digitorum longus tension.  Incision was carried deep utilizing both sharp and blunt dissections and all major neurovascular structures were avoided.,A periosteal and capsular incision was then made on the lateral aspect of the extensor digitorum longus tendon and periosteum and capsular layers were then reflected medially and laterally from the head of the fifth metatarsal.  Utilizing an oscillating bone saw, the lateral eminence was resected and passed from the operative field.  Utilizing the sagittal saw, a Weil-type osteotomy was made at the fifth metatarsal head.  The head was then shifted medially into a more corrected position.  A 0.045-inch K-wire was then used as a temporary fixation, and a 2.0 x 10 mm OsteoMed noncannulated screw was placed across the osteotomy site.  This was noted to be in correct position and compression was noted to be excellent.  Utilizing a small bone rongeur, the overhanging wedge of the bone on the dorsal aspect of the fifth metatarsal was resected and passed from the operative field.  The wound was once again flushed with copious amounts of sterile normal saline.  The periosteal and capsular layers were reapproximated utilizing 3-0 Vicryl, and the skin was then closed utilizing 4-0 Vicryl and 4-0 nylon.  At this time, 10 mL of 0.5% Marcaine plain and 1 mL of dexamethasone phosphate were infiltrated about the surgical site.  The right foot was then dressed with Xeroform gauze, fluffs, Kling, and Ace wrap, all applied in mild compressive fashion.  The pneumatic ankle tourniquet was then deflated and a prompt hyperemic response was noted to all digits of the right foot.  The patient was then transported from the operating room to the recovery room with vital sings stable and neurovascular status grossly intact to the right foot.  After a brief period of postoperative monitoring, the patient was discharged to home with proper written and verbal discharge instructions, which included to keep dressing clean, dry, and intact and to follow up with Dr. A.  The patient is to be nonweightbearing to the right foot.  The patient was given a prescription for pain medications on nonsteroidal anti-inflammatory drugs and was educated on these.  The patient tolerated the procedure and anesthesia well.  Dr. A was present throughout the entire case.","orthopedic, tailor bunionectomy, weil-type, screw fixation, hallux, abductovalgus, bunion, tailor, deformity, metatarsal, phalangeal, capsulotomy, abductor, hallucis, "
" Excision of mass, left second toe and distal Symes amputation, left hallux with excisional biopsy.  Mass, left second toe.  Tumor.  Left hallux bone invasion of the distal phalanx.", Orthopedic, Symes Amputation - Hallux ,"PREOPERATIVE DIAGNOSES:,1.  Mass, left second toe.,2.  Tumor.,3.  Left hallux bone invasion of the distal phalanx.,POSTOPERATIVE DIAGNOSES:,1.  Mass, left second toe.,2.  Tumor.,3.  Left hallux with bone invasion of the distal phalanx.,PROCEDURE PERFORMED:,1.  Excision of mass, left second toe.,2.  Distal Syme's amputation, left hallux with excisional biopsy.,HISTORY: , This 47-year-old Caucasian male presents to ABCD General Hospital with a history of tissue mass on his left foot.  The patient states that the mass has been present for approximately two weeks and has been rapidly growing in size.  The patient also has history of shave biopsy in the past.  The patient does state that he desires surgical excision at this time.,PROCEDURE IN DETAIL:,  An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported from the operating room and placed on the operating room table in the supine position with the safety belt across his lap.  Copious amount of Webril was placed around the left ankle followed by a blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 6 cc mixed with 1% lidocaine plain with 0.5% Marcaine plain was injected in a digital block fashion at the base of the left hallux as well as the left second toe.,The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was elevated from the operating table and exsanguinated with an Esmarch bandage.  Care was taken with the exsanguination to perform exsanguination below the level of the digits so as not to rupture the masses.  The foot was lowered to the operating table.  The stockinet was reflected and the foot was cleansed with wet and dry sponge.  A distal Syme's incision was planned over the distal aspect of the left hallux.  The incision was performed with a #10 blade and deepened with #15 down to the level of bone.  The dorsal skin flap was removed and dissected in toto off of the distal phalanx.  There was noted to be in growth of the soft tissue mass into the dorsal cortex with erosion in the dorsal cortex and exposure of cortical bone at the distal phalanx.  The tissue was sent to Pathology where Dr. Green stated that a frozen sample would be of less use for examining for cancer.  Dr. Green did state that he felt that there was an adequate incomplete excision of the soft tissue for specimen.  At this time, a sagittal saw was then used to resect all ends of bone of the distal phalanx.  The area was inspected for any remaining suspicious tissues.  Any suspicious tissue was removed.  The area was then flushed with copious amounts of sterile saline.  The skin was then reapproximated with #4-0 nylon with a combination of simple and vertical mattress sutures.,Attention was then directed to the left second toe.  There was noted to be a dorsolateral mass over the dorsal distal aspect of the left second toe.  A linear incision was made just medial to the tissue mass.  The mass was then dissected from the overlying skin and off of the underlying capsule.  This tissue mass was hard, round, and pearly-gray in appearance.  It does not invade into any other surrounding tissues.  The area was then flushed with copious amounts of sterile saline and the skin was closed with #4-0 nylon.  Dressings consisted of Owen silk soaked in Betadine, 4x4s, Kling, Kerlix, and an Ace wrap.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot.  The patient tolerated the above procedure and anesthesia well without complications.  The patient was transported to PACU with vital signs stable and vascular status intact.  The patient was given postoperative pain prescription for Vicodin and instructed to follow up with Dr. Bonnani in his office as directed.  The patient will be contacted immediately pending the results of pathology.  Cultures obtained in the case were aerobic and anaerobic gram stain, Silver stain, and a CBC.","orthopedic, distal phalanx, mass, tumor., hallux bone, phalanx, symes amputation, excisional biopsy, distal, amputation, invasion, toe, symes, incision, flushed, excision, tissue, hallux"
 Arthroscopic irrigation and debridement of same with partial synovectomy.  Septic left total knee arthroplasty., Orthopedic, Synovectomy - Partial ,"PREOPERATIVE DIAGNOSIS: , Septic left total knee arthroplasty.,POSTOPERATIVE DIAGNOSIS: , Septic left total knee arthroplasty.,OPERATION PERFORMED: , Arthroscopic irrigation and debridement of same with partial synovectomy.,ANESTHESIA:,  LMA.,ESTIMATED BLOOD LOSS:,  Minimal.,COMPLICATIONS: , None.,DRAINS:,  None.,INDICATIONS:,  The patient is an 81-year-old female, who is approximately 10 years status post total knee replacement performed in another state, who presented a couple of days ago to the office with worsening pain without injury and whose symptoms have been present for approximately a month following a possible urinary tract infection.  The patient' knee was aspirated in the office and cultures were positive for Escherichia coli.  She presents for operative therapy.,DESCRIPTION OF OPERATION: , After obtaining informed consent and the administration of antibiotics since her cultures had already been obtained, the patient was taken to the operating room and following satisfactory induction and the patient was placed on the table in supine position.  The left upper extremity was prepped and draped without a tourniquet.  The knee was injected with 30 mL of normal saline and standard arthroscopy portals were created.  The arthroscopy was inserted and a complete diagnostic was performed.  Arthroscopic pictures were taken throughout the procedure.  The knee was copiously irrigated with 9 L of irrigant.  A partial synovectomy was performed in all compartments.  Minimal amount of polyethylene wear was noted.  The total knee components were identified arthroscopically for future revision surgery.  The knee was then drained and the arthroscopic instruments were removed.  The portals were closed with 4-0 nylon and local anesthetic was injected.  A sterile dressing was applied and the patient was placed in a knee immobilizer, awakened from anesthesia and transported to the recovery room in stable condition and tolerated the procedure well.","orthopedic, total knee arthroplasty, arthroscopic irrigation, debridement, partial synovectomy, knee, arthroscopic, irrigation, arthroscopy, synovectomy,"
" Excision of volar radial wrist mass (inflammatory synovitis) and radial styloidectomy, right wrist.  Right wrist pain with an x-ray showing a scapholunate arthritic collapse pattern arthritis with osteophytic spurring of the radial styloid and a volar radial wrist mass suspected of being a volar radial ganglion.", Orthopedic, Styloidectomy ,"PREOPERATIVE DIAGNOSIS: , Right wrist pain with an x-ray showing a scapholunate arthritic collapse pattern arthritis with osteophytic spurring of the radial styloid and a volar radial wrist mass suspected of being a volar radial ganglion.,POSTOPERATIVE DIAGNOSIS: , Right wrist pain with an x-ray showing a scapholunate arthritic collapse pattern arthritis with osteophytic spurring of the radial styloid and a volar radial wrist mass suspected of being a volar radial ganglion; finding of volar radial wrist mass of bulging inflammatory tenosynovitis from the volar radial wrist joint rather than a true ganglion cyst; synovitis was debrided and removed.,PROCEDURE: , Excision of volar radial wrist mass (inflammatory synovitis) and radial styloidectomy, right wrist.,ANESTHESIA:,  Axillary block plus IV sedation.,ESTIMATED BLOOD LOSS:,  Zero.,SPECIMENS,1.  Inflammatory synovitis from the volar radial wrist area.,2.  Inflammatory synovitis from the dorsal wrist area.,DRAINS:,  None.,PROCEDURE DETAIL: , Patient brought to the operating room.  After induction of IV sedation a right upper extremity axillary block anesthetic was performed by anesthesia staff.  Routine prep and drape was employed.  Patient received 1 gm of IV Ancef preoperatively.  Arm was exsanguinated by means of elevation of Esmarch elastic tourniquet.  Tourniquet inflated to 250 mmHg pressure.  Hand positioned palm up in a lead hand-holder.  A longitudinal zigzag incision over the volar radial wrist mass was made.  Skin was sharply incised.  Careful blunt dissection was used in the subcutaneous tissue.  Antebrachial fascia was bluntly dissected and incised to reveal the radial artery.  Radial artery was mobilized preserving its dorsal and palmar branches.  Small transverse concomitant vein branches were divided to facilitate mobilization of the radial artery.  Wrist mass was exposed by blunt dissection.  This appeared to be an inflammatory arthritic mass from the volar radial wrist capsule.  This was debrided down to the wrist capsule with visualization of the joint through a small capsular window.  After complete volar synovectomy the capsular window was closed with 4-0 Mersilene figure-of-eight suture.  Subcutaneous tissue was closed with 4-0 PDS and the skin was closed with a running subcuticular 4-0 Prolene.  Forearm was pronated and C-arm image intensifier was used to confirm localization of the radial styloid for marking of the skin incision.  An oblique incision overlying the radial styloid centered on the second extensor compartment was made.  Skin was sharply incised.  Blunt dissection was used in the subcutaneous tissue.  Care was taken to identify and protect the superficial radial nerve.  Blunt dissection was carried out in the extensor retinaculum.  This was incised longitudinally over the second extensor compartment.  EPL tendon was identified, mobilized and released to facilitate retraction and prevent injury.  The interval between the ECRL and the ECRB was developed down to bone.  Dorsal capsulotomy was made and local synovitis was identified.  This was debrided and sent as second pathologic specimen.  Articular surface of the scaphoid was identified and seen to be completely devoid of articular cartilage with hard, eburnated subchondral bone consistent with a SLAC pattern arthritis.  Radial styloid had extensive spurring and was exposed subperiosteally and osteotomized in a dorsal oblique fashion preserving the volar cortex as the attachment point of the deep volar carpal ligament layer.  Dorsally the styloidectomy was beveled smooth and contoured with a rongeur.  Final x-rays documenting the styloidectomy were obtained.  Local synovitis beneath the joint capsule was debrided.  Remnants of the scapholunate interosseous which was completely deteriorated were debrided.  The joint capsule was closed anatomically with 4-0 PDS and extensor retinaculum was closed with 4-0 PDS.  Subcutaneous tissues closed with 4-0 Vicryl.  Skin was closed with running subcuticular 4-0 Prolene.  Steri-Strips were applied to wound edge closure; 10 cc of 0.5% plain Marcaine was infiltrated into the areas of the surgical incisions and radial styloidectomy for postoperative analgesia.  A bulky gently compressive wrist and forearm bandage incorporating an EBI cooling pad were applied.  Tourniquet was deflated.  Good vascular color and capillary refill were seen to return to the tips of all digits.  Patient discharged to the ambulatory recovery area and from there discharged home.,DISCHARGE PRESCRIPTIONS:,1.  Keflex 500 mg tablets, #20, one PO q.6h. x 5 days.,2.  Vicodin, 40 tablets, one to two PO q.4h. p.r.n.,3.  Percocet, #20 tablets, one to two PO q.3-4h. p.r.n. severe pain.","orthopedic, osteophytic, spurring, ganglion, synovitis, volar radial wrist mass, excision, inflammatory synovitis, radial styloidectomy, inflammatory, styloidectomy, volar, wrist, radial, mass"
 Posterior spinal fusion and spinal instrumentation.  Posterior osteotomy; posterior elements to include laminotomy-foraminotomy and decompression of the nerve roots., Orthopedic, Spinal Fusion & Instrumentation ,"PREOPERATIVE DIAGNOSIS: , Severe scoliosis.,ANESTHESIA: , General.  Lines were placed by Anesthesia to include an A line.,PROCEDURES: ,1.  Posterior spinal fusion from T2-L2.,2.  Posterior spinal instrumentation from T2-L2.,3.  A posterior osteotomy through T7-T8 and T8-T9.  Posterior elements to include laminotomy-foraminotomy and decompression of the nerve roots.,IMPLANT: , Sofamor Danek (Medtronic) Legacy 5.5 Titanium system.,MONITORING: , SSEPs, and the EPs were available.,INDICATIONS: , The patient is a 12-year-old female, who has had a very dysmorphic scoliosis.  She had undergone a workup with an MRI, which showed no evidence of cord abnormalities.  Therefore, the risks, benefits, and alternatives were discussed with Surgery with the mother, to include infections, bleeding, nerve injuries, vascular injuries, spinal cord injury with catastrophic loss of motor function and bowel and bladder control.  I also discussed ___________ and need for revision surgery.  The mom understood all this and wished to proceed.,PROCEDURE: , The patient was taken to the operating room and underwent general anesthetic.  She then had lines placed, and was then placed in a prone position.  Monitoring was then set up, and it was then noted that we could not obtain motor-evoked potentials.  The SSEPs were clear and were compatible with the preoperative, but no preoperative motors had been done, and there was a concern that possibly this could be from the result of the positioning.  It was then determined at that time, that we would go ahead and proceed to wake her up, and make sure she could move her feet.  She was then lightened under anesthesia, and she could indeed dorsiflex and plantarflex her feet, so therefore, it was determined to go ahead and proceed with only monitoring with the SSEPs.,The patient after being prepped and draped sterilely, a midline incision was made, and dissection was carried down.  The dissection utilized a combination of hand instruments and electrocautery and dissected out along the laminae and up to the transverse processes.  This occurred from T2-L2.  Fluoroscopy was brought in to verify positions and levels.  Once this was done, and all bleeding was controlled, retractors were then placed.  Attention was then turned towards placing screws first on the left side.  Lumbar screws were placed at the junction of the transverse process and the facets under fluoroscopic guidance.  The area was opened with a high speed burr, and then the track was defined with a blunt probe, and a ball-tipped feeler was then utilized to verify all walls were intact.  They were then tapped, and then screws were then placed.  This technique was used at L1 and L2, both the right and left.  At T12, a direct straight-ahead technique was utilized, where the facet was removed, and then the position was chosen under the fluoroscopy, and then it was spurred, the track was defined and then probed and tapped, and it was felt to be in good position.  Two screws, in the right and left were placed at T12 as well, reduction screws on the left.  The same technique was used for T11, where right and left screws were placed as well as T10 on the left.  At T9, a screw was placed on the left, and this was a reduction screw.  On the left at T8, a screw could not be placed due to the dysmorphic nature of the pedicle.  It was not felt to be intact; therefore, a screw was left out of this.  On the right, a thoracic screw was placed as well as at 7 and 6.  This was the dysmorphic portion of this.  Screws were attempted to be placed up, they could not be placed, so attention was then turned towards placing pedicle hooks.  Pedicle hooks were done by first making a box out of the pedicle, removing the complete pedicle, feeling the undersurface of the pedicle with a probe, and then seating the hook.  Upgoing pedicle hooks were placed at T3, T4, and T5.  A downgoing laminar hook was placed at the T7 level.  Screws had been placed at T6 and T7 on the right.  An upgoing pedicle hook was also placed at T3 on the right, and then, downgoing laminar hooks were placed at T2.  This was done by first using a transverse process, lamina finders to go around the transverse process and then ___________ laminar hooks.  Once all hooks were in place, spinal osteotomies were performed at T7-T8 and T8-T9.  This was the level of the kyphosis, to bring her back out of her kyphoscoliosis.  First the ligamentum flavum was resected using a large Kerrisons.  Next, the laminotomy was performed, and then a Kerrison was used to remove the ligamentum flavum at the level of the facet.  Once this was accomplished, a laminotomy was performed by removing more of the lamina, and to create a small wedge that could be closed down later to correct the kyphosis.  This was then brought out with resection of bone out to the foramen, doing a foraminotomy to free up the foramen on both sides.  This was done also between the T8-T9.  Once this was completed, Gelfoam was then placed.  Next, we observed, and measured and contoured.  The rods were then seated on the left, and then a derotation maneuver was performed.  Hooks had come loose, so the rod was removed on the left.  The hooks were then replaced, and the rod was reseated.  Again, it was derotated to give excellent correction.  Hooks were then well seated underneath, and therefore, they were then locked.  A second rod was then chosen on the right, and was measured, contoured, and then seated.  Next, once this was done, the rods were locked in the midsubstance, and then the downgoing pedicle hook, which had been placed at T7 was then helped to compress T8 as was the pedicle screw, and then this compressed the osteotomy sites quite nicely.  Next, distraction was then utilized to further correct at the spine, and to correct on the left, the left concave curve, which gave excellent correction.  On the right, compression was used to bring it down, and then, in the lower lumbar areas, distraction and compression were used to level out L2.  Once this was done, all screws were tightened.  Fluoroscopy was then brought in to verify L1 was level, and the first ribs were also level, and it gave a nice balanced spine.  Everything was copiously irrigated, ___________.  Next, a wake-up test was performed, and the patient was then noted to flex and extend the knees as well as dorsiflex and plantar flex both the feet.  The patient was then again sedated and brought back under general anesthesia.  Next, a high-speed burr was used for decortication.  After final tightening had been accomplished, and then allograft bone and autograft bone were mixed together with 10 mL of iliac crest aspirate and were placed into the wound.  The open canal areas had been protected with Gelfoam.  Once this was accomplished, the deep fascia was closed with multiple figure-of-eight #1's, oversewn with a running #1, _________ were then placed in the subcutaneous spaces which were then closed with 3-0 Vicryl, and then the skin was closed with 3-0 Monocryl and Dermabond.  Sterile dressing was applied.  Drains had been placed in the subcutaneous layer x2.  The patient during the case had no changes in the SSEPs, had a normal wake-up test, and had received Ancef and clindamycin during the case.  She was taken from the operating room in good condition.","orthopedic, osteotomy, laminotomy-foraminotomy, sofamor danek, sseps, spinal fusion, transverse processes, pedicle hooks, pedicle, laminotomy, hooks, screws, instrumentation, decompression, scoliosis, sofamor, foraminotomy, spinal"
 Thoracic right-sided discectomy at T8-T9.   The patient is a 53-year-old female with a history of right thoracic rib pain related to a herniated nucleus pulposus at T8-T9.  , Orthopedic, Thoracic Discectomy ,"PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus T8-T9.,POSTOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus T8-T9.,OPERATION PERFORMED: , Thoracic right-sided discectomy at T8-T9.,BRIEF HISTORY AND INDICATION FOR OPERATION: , The patient is a 53-year-old female with a history of right thoracic rib pain related to a herniated nucleus pulposus at T8-T9.  She has failed conservative measures and sought operative intervention for relief of her symptoms.  For details of workup, please see the dictated operative report.,DESCRIPTION OF OPERATION:  ,Appropriate informed consent was obtained and the patient was taken to the operating room and placed under general anesthetic.  She was placed in a position of comfort on the operating table with all bony prominences and soft tissues well padded and protected.  Second check was made prior to prepping and draping.  Following this, we did needle localization with reviews of AP and lateral multiple times to make sure we had the T8-T9 level.  We then made an approach through a midline incision and came out over the pars.  We dissected down carefully to identify the pars.  We then went on the outside of the pars and identified the foramen and then we took another series of x-rays to confirm the T8-T9 level.  We did this under live fluoroscopy.  We confirmed T8-T9 and then went ahead and took a Midas Rex and removed the superior portion of the pedicle overlying the outside of the disc and then worked our way downward removing portion of the transverse process as well.  We found the edge of the disc and then worked our way and we were able to remove some of the disc material but then decided to go ahead and take down the pars.  The pars was then drilled out.  We identified the disc even further and found the disc herniation material that was under the spinal cord.  We then took a combination of small pituitaries and removed the disc material without difficulty.  Once we had disc material out, we went ahead and made a small cruciate incision in the disc space and entered the disc space in earnest removing more disc material making sure there is nothing free to herniate further.  Once we had done that, we inspected up by the nerve root, found some more disc material there and removed that as well.  We could trace the nerve root out freely and easily.  We made sure there was no evidence of further disc material.  We used an Epstein curette and placed a nerve hook under the nerve root.  The Epstein curette removed some more disc material.  Once we had done this, we were satisfied with the decompression.  We irrigated the wound copiously to make sure there is no further disc material and then ready for closure.  We did place some steroid over the nerve root and readied for closure.  Hemostasis was meticulous.  The wound was closed with #1 Vicryl suture for the fascial layer, 2 Vicryl suture for the skin, and Monocryl and Steri-Strips applied.  Dressing was applied.  The patient was awoken from anesthesia and taken to the recovery room in stable condition.,ESTIMATED BLOOD LOSS:,  150 mL.,COMPLICATIONS: , None.,DISPOSITION:,  To PACU in stable condition having tolerated the procedure well, to mobilize routinely when she is comfortable to go to her home.","orthopedic, thoracic right-sided discectomy, herniated nucleus pulposus, discectomy, thoracic, herniated,"
 Repeat irrigation and debridement of Right distal femoral subperiosteal abscess., Orthopedic, Subperiosteal Abscess Debridement ,"PREOPERATIVE DIAGNOSIS: , Right distal femoral, subperiosteal abscess.,POSTOPERATIVE DIAGNOSIS: , Right distal femoral, subperiosteal abscess.,OPERATION:,  Repeat irrigation and debridement of above.,ANESTHESIA: , General.,BLOOD LOSS:,  Minimal.,FLUID: , Per anesthesia.,DRAINS: , Hemovac times two.,COMPLICATIONS: , None apparent.,SPECIMENS:,  To microbiology.,INDICATIONS: , She is a 10-year-old girl who has history of burns and has developed a subperiosteal abscess at her right distal femur.  I am bringing her back to the operating room for another exploration of this area and washout.  This will be the third procedure for this.  At the last time, there was gross purulence that was encountered.  Since that time, the patient has defervesced.  Her white count is slowly coming down.  Her C-reactive protein is slowly coming down.,PROCEDURE IN DETAIL:,  After informed consent was obtained, operative site marked, and after preoperative antibiotics were given, the patient was brought back to the operating room and placed supine on the operating table, where Anesthesia induced general anesthesia.  The patient's right lower extremity was prepped and draped in normal sterile fashion.  Surgical timeout occurred verifying the patient's identification, surgical site, surgical procedure, and administration of antibiotics.  The patient's previous incision sites had the sutures removed.  We bluntly dissected down through to the IT band.  These deep stitches were then removed.  We exposed the area of the subperiosteal abscess.  The tissue looked much better than at the last surgery.  We irrigated this area with three liters of saline containing bacitracin.  Next, we made our small medial window to assist with washout of the joint itself.  We put another three liters of saline containing bacitracin through the knee joint.  Lastly, we did another three liters into the area of the distal femur with three liters of plain saline.  We then placed two Hemovac drains, one in the metaphysis and one superficially.  We closed the deep fascia with #1 PDS.  Subcutaneous layers with 2-0 Monocryl and closed the skin with 2-0 nylon.  We placed a sterile dressing.  We then turned the case over to Dr. Petty for dressing change and skin graft.,PLAN:  ,Our plan will be to pull the drains in 48 hours.  We will then continue to watch the patient's fever curve and follow her white count to see how she is responding to the operative and medical therapies.,","orthopedic, repeat irrigation and debridement, repeat irrigation, distal femur, distal femoral, femoral subperiosteal, subperiosteal abscess, hemovac, femur, debridement, irrigation, saline, anesthesia, distal, subperiosteal, abscess, "
 Subcutaneous transposition of the right ulnar nerve.  Right carpal tunnel syndrome and right cubital tunnel syndrome., Orthopedic, Subcutaneous Transposition of Ulnar Nerve ,"PREOPERATIVE DIAGNOSIS:  ,1.  Right carpal tunnel syndrome.,2.","orthopedic, subcutaneous transposition, ulnar nerve, carpal tunnel syndrome, cubital tunnel syndrome, tourniquet, subcutaneous, epicondyle, antebrachial, syndrome, cubital, ulnar, nerve, tunnel"
" Anterior spine fusion from T11-L3.  Posterior spine fusion from T3-L5.  Posterior spine segmental instrumentation from T3-L5, placement of morcellized autograft and allograft.", Orthopedic, Spine Fusion ,"PREOPERATIVE DIAGNOSIS: , Severe neurologic or neurogenic scoliosis.,POSTOPERATIVE DIAGNOSIS: , Severe neurologic or neurogenic scoliosis.,PROCEDURES:  ,1.  Anterior spine fusion from T11-L3.,2.  Posterior spine fusion from T3-L5.,3.  Posterior spine segmental instrumentation from T3-L5, placement of morcellized autograft and allograft.,ESTIMATED BLOOD LOSS: , 500 mL.,FINDINGS: , The patient was found to have a severe scoliosis.  This was found to be moderately corrected.  Hardware was found to be in good positions on AP and lateral projections using fluoroscopy.,INDICATIONS: , The patient has a history of severe neurogenic scoliosis.  He was indicated for anterior and posterior spinal fusion to allow for correction of the curvature as well as prevention of further progression.  Risks and benefits were discussed at length with the family over many visits.  They wished to proceed.,PROCEDURE:,  The patient was brought to the operating room and placed on the operating table in the supine position.  General anesthesia was induced without incident.  He was given a weight-adjusted dose of antibiotics.  Appropriate lines were then placed.  He had a neuromonitoring performed as well.,He was then initially placed in the lateral decubitus position with his left side down and right side up.  An oblique incision was then made over the flank overlying the 10th rib.  Underlying soft tissues were incised down at the skin incision.  The rib was then identified and subperiosteal dissection was performed.  The rib was then removed and used for autograft placement later.,The underlying pleura was then split longitudinally.  This allowed for entry into the pleural space.  The lung was then packed superiorly with wet lap.  The diaphragm was then identified and this was split to allow for access to the thoracolumbar spine.,Once the spine was achieved, subperiosteal dissection was performed over the visualized vertebral bodies.  This required cauterization of the segmental vessels.  Once the subperiosteal dissection was performed to the posterior and anterior extents possible, the diskectomies were performed.  These were performed from T11-L3.  This was over 5 levels.  Disks and endplates were then removed.  Once this was performed, morcellized rib autograft was placed into the spaces.  The table had been previously bent to allow for easier access of the spine.  This was then straightened to allow for compression and some correction of the curvature.,The diaphragm was then repaired as was the pleura overlying the thoracic cavity.  The ribs were held together with #1 Vicryl sutures.  Muscle layers were then repaired using a running #2-0 PDS sutures and the skin was closed using running inverted #2-0 PDS suture as well.  Skin was closed as needed with running #4-0 Monocryl.  This was dressed with Xeroform dry sterile dressings and tape.,The patient was then rotated into a prone position.  The spine was prepped and draped in a standard fashion.,Longitudinal incision was made from T2-L5.  The underlying soft tissues were incised down at the skin incision.  Electrocautery was then used to maintain hemostasis.  The spinous processes were then identified and the overlying apophyses were split.  This allowed for subperiosteal dissection over the spinous processes, lamina, facet joints, and transverse processes.  Once this was completed, the C-arm was brought in, which allowed for easy placement of screws in the lumbar spine.  These were placed at L4 and L5.  The interspaces between the spinous processes were then cleared of soft tissue and ligamentum flavum.  This was done using a rongeur as well as a Kerrison rongeur.  Spinous processes were then harvested for morcellized autograft.,Once all the interspaces were prepared, Songer wires were then passed.  These were placed from L3-T3.,Once the wires were placed, a unit rod was then positioned.  This was secured initially at the screws distally on both the left and right side.  The wires were then tightened in sequence from the superior extent to the inferior extent, first on the left-sided spine where I was operating and then on the right side spine.  This allowed for excellent correction of the scoliotic curvature.,Decortication was then performed and placement of a morcellized autograft and allograft was then performed after thoroughly irrigating the wound with 4 liters of normal saline mixed with bacitracin.  This was done using pulsed lavage.,The wound was then closed in layers.  The deep fascia was closed using running #1 PDS suture, subcutaneous tissue was closed using running inverted #2-0 PDS suture, the skin was closed using #4-0 Monocryl as needed.  The wound was then dressed with Steri-Strips, Xeroform dry sterile dressings, and tape.  The patient was awakened from anesthesia and taken to the intensive care unit in stable condition.  All instrument, sponge, and needle counts were correct at the end of the case.,The patient will be managed in the ICU and then on the floor as indicated.","orthopedic, anterior spine fusion, posterior spine fusion, spine segmental instrumentation, dry sterile dressings, autograft and allograft, pds sutures, spinous processes, spine fusion, spine, instrumentation, morcellized, allograft, fusion, autograft, "
 Superior labrum anterior and posterior lesion repair., Orthopedic, Superior Labrum Lesions Repair ,"PROCEDURE IN DETAIL:,  After written consent was obtained from the patient, the patient was brought back into the operating room and identified.  The patient was placed on the operating room table in supine position and given anesthetic.,Once adequate anesthesia had been achieved, a careful examination of the shoulder was performed.  It revealed no patholigamentous laxity.  We then placed the patient into a beach-chair position, maintaining a neutral alignment of the head, neck, and thorax.  The shoulder was then prepped and draped in the usual sterile fashion.  We then injected the glenohumeral joint with 60 cc of sterile saline solution.  A small stab incision was made 2 cm inferior and 2 cm medial to the posterolateral angle of the acromion.  Through this incision, a blunt trocar was placed.,We then placed the camera through this cannula and the shoulder was insufflated with sterile saline solution.  An anterior portal was made just below the subscapularis and then we began to inspect the shoulder joint.,We found that the articular surface was in good condition.  The biceps was found to be intact.  There was a SLAP tear noted just posterior to the biceps.  Pictures were taken.  No Bankart or Hill-Sachs lesions were noted.  The rotator cuff was examined and there were no undersurface tears.  Pictures were again taken.,We then made a lateral portal going through the muscle belly of the rotator cuff.  A drill hole was made and then knotless suture anchor was placed to repair this.  Pictures were taken.  We then washed out the joint with copious amounts of sterile saline solution.  It was drained.  Our 3 incisions were closed using 3-0 nylon suture.  A pain pump catheter was introduced into the shoulder joint.  Xeroform, 4 x 4s, ABDs, tape, and sling were placed.,The patient was successfully taken out of the beach-chair position, extubated and brought to the recovery room in stable condition.  I then went out and spoke with the patient's family, going over the case, postoperative instructions, and followup care.","orthopedic, laxity, patholigamentous, superior labrum, saline solution, anterior, superior, lesions, repair, sterile, joint, shoulder,"
" Spinal Manipulation under Anesthesia - Sacro-iliitis, lumbo-sacral segmental dysfunction, thoraco-lumbar segmental dysfunction, associated with myalgia/fibromyositis.", Orthopedic, Spinal Manipulation ,"PREOPERATIVE DIAGNOSIS: , Sacro-iliitis (720.2), lumbo-sacral segmental dysfunction (739.3), thoraco-lumbar segmental dysfunction (739.2), associated with myalgia/fibromyositis (729.1).,POSTOPERATIVE DIAGNOSIS: , Sacro-iliitis (720.2), lumbo-sacral segmental dysfunction (739.3), thoraco-lumbar segmental dysfunction (739.2), associated with myalgia/fibromyositis (729.1).,ANESTHESIA: , Conscious Sedation.,INFORMED CONSENT: , After adequate explanation of the medical surgical and procedural options, this patient has decided to proceed with the recommended spinal Manipulation under Anesthesia (MUA).  The patient has been informed that more than one procedure may be necessary to achieve the satisfactory results.,INDICATION:,  This patient has failed extended conservative care of condition/dysfunction by means of aggressive physical medical and pharmacological intervention.,COMMENTS: , This patient understands the essence of the diagnosis and the reasons for the MUA- The associated risks of the procedure, including anesthesia complications, fracture, vascular accidents, disc herniation and post-procedure discomfort, were thoroughly discussed with the patient.  Alternatives to the procedure, including the course of the condition without MUA, were discussed.  The patient understands the chances of success from undergoing MUA and that no guarantees are made or implied regarding outcome.  The patient has given both verbal and written informed consent for the listed procedure.,PROCEDURE IN DETAIL: , The patient was draped in the appropriate gowning and accompanied to the operative area.  Following their sacral block injection, they were asked to lie supine on the operative table and they were placed on the appropriate monitors for this procedure.  When the patient and I were ready, the anesthesiologist administered the appropriate medications to assist the patient into the twilight sedation using medication which allows the stretching, mobilization, and adjustments necessary for the completion of the outcome I desired.,THORACIC SPINE: , With the patient in the supine position on the operative table, the upper extremities were flexed at the elbow and crossed over the patient's chest to achieve maximum traction to the patient's thoracic spine.  The first assistant held the patient's arms in the proper position and assisted in rolling the patient for the adjusting procedure.  With the help of the first assist, the patient was rolled to their right side, selection was made for the contact point and the patient was rolled back over the doctor's hand.  The elastic barrier of resistance was found, and a low velocity thrust was achieved using a specific closed reduction anterior to posterior/superior manipulative procedure.  The procedure was completed at the level of TI-TI2.  Cavitation was achieved.,LUMBAR SPINE/SACRO-ILIAC JOINTS:,  With the patient supine on the procedure table, the primary physician addressed the patient's lower extremities which were elevated alternatively in a straight leg raising manner to approximately 90 degrees from the horizontal.  Linear force was used to increase the hip flexion gradually during this maneuver.  Simultaneously, the first assist physician applied a myofascial release technique to the calf and posterior thigh musculature.  Each lower extremity was independently bent at the knee and tractioned cephalad in a neutral sagittal plane, lateral oblique cephalad traction, and medial oblique cephalad traction maneuver.  The primary physician then approximated the opposite single knee from his position from neutral to medial slightly beyond the elastic barrier of resistance. (a piriformis myofascial release was accomplished at this time).  This was repeated with the opposite lower extremity.  Following this, a Patrick-Fabere maneuver was performed up to and slightly beyond the elastic barrier of resistance.,With the assisting physician stabling the pelvis and femoral head (as necessary), the primary physician extended the right lower extremity in the sagittal plane, and while applying controlled traction gradually stretched the para-articular holding elements of the right hip by means gradually describing an approximately 30-35 degree horizontal arc.  The lower extremity was then tractioned, and straight caudal and internal rotation was accomplished.  Using traction, the lower extremity was gradually stretched into a horizontal arch to approximately 30 degrees.  This procedure was then repeated using external rotation to stretch the para-articular holding elements of the hips bilaterally.  These procedures were then repeated on the opposite lower extremity.,By approximating the patient's knees to the abdomen in a knee-chest fashion (ankles crossed), the lumbo-pelvic musculature was stretched in the sagittal plane, by both the primary and first assist, contacting the base of the sacrum and raising the lower torso cephalad, resulting in passive flexion of the entire lumbar spine and its holding elements beyond the elastic barrier of resistance","orthopedic, fibromyositis, myalgia, segmental dysfunction, sacro-iliitis, spinal manipulation under anesthesia, lumbar segmental dysfunction, informed consent, iliac joints, spinal manipulation, sacro iliitis, lower extremity, spinal, mua, cephalad, dysfunction, segmental, lumbar, "
 Frontal and lateral views of the hip and pelvis., Orthopedic, Slipped Capital Femoral Epiphysis (SCFE) ,"EXAM: , Two views of the pelvis.,HISTORY:,  This is a patient post-surgery, 2-1/2 months.  The patient has a history of slipped capital femoral epiphysis (SCFE) bilaterally.,TECHNIQUE: , Frontal and lateral views of the hip and pelvis were evaluated and correlated with the prior film dated MM/DD/YYYY.  Lateral view of the right hip was evaluated.,FINDINGS:,  Frontal view of the pelvis and a lateral view of the right hip were evaluated and correlated with the patient's most recent priors dated MM/DD/YYYY.  Current films reveal stable appearing post-surgical changes.  Again demonstrated is a single intramedullary screw across the left femoral neck and head.  There are 2 intramedullary screws through the greater trochanter of the right femur.  There is a lucency along the previous screw track extending into the right femoral head and neck.  There has been interval removal of cutaneous staples and/or surgical clips.  These were previously seen along the lateral aspect of the right hip joint.,Deformity related to the previously described slipped capital femoral epiphysis is again seen.,IMPRESSION:,1.  Stable-appearing right hip joint status-post pinning.,2.  Interval removal of skin staples as described above.","orthopedic, scfe, frontal and lateral views, slipped capital femoral epiphysis, lateral views, slipped, capital, epiphysis, frontal, pelvis, femoral, hip"
 Arthroscopic subacromial decompression and repair of rotator cuff through mini-arthrotomy., Orthopedic, Rotator Cuff Repair ,"PREOPERATIVE DIAGNOSIS: , Rotator cuff tear, left.,POSTOPERATIVE DIAGNOSES:,1.  Sixty-percent rotator cuff tear, joint side.,2.  Impingement syndrome.,ANESTHESIA: , General,NAME OF OPERATION:,1.  Arthroscopic subacromial decompression.,2.  Repair of rotator cuff through mini-arthrotomy.,FINDINGS AT OPERATION: , The patient's glenohumeral joint was completely clear, other than obvious tear of the rotator cuff.  The midportion of this appeared to be complete, but for the most part, this was about a 60% rupture of the tendon.  This was confirmed later when the bursal side was opened up.  Note, the patient also had abrasion of the coracoacromial ligament under the anterolateral edge of the acromion.  He did not have any acromioclavicular joint pain or acromioclavicular joint disease noted.,PROCEDURE:,  He was given an anesthetic, examined, prepped, and draped in a sterile fashion in a beach-chair position.  The shoulder was instilled with fluid from posteriorly, followed by the arthroscope.  The shoulder was instilled with fluid from posteriorly, followed by the arthroscope.  Arthroscopy was then carried out in standard fashion using a 30-degree Dionic scope.  With the scope in the posterior portal, the above findings were noted, and an anterior portal was established.  A curved shaver was placed for debridement of the tear.  I established this was about a 60-70% tear with a probable complete area of tear which was very small.  There were no problems at the biceps or the rest of the joint.  The subacromial space showed findings, as noted above, and a thorough subacromial decompression was carried out with a Bovie, rotary shaver, and bur.  I did not debride the acromioclavicular joint.  The lateral portal was then extended to a mini-arthrotomy, and subacromial space was entered by blunt dissection through the deltoid.  The area of weakness of the tendon was found, and was transversely cut, and findings were confirmed.  The diseased tissue was removed, and the greater tuberosity was abraded with a rongeur.  Tendon-to-tendon repair was then carried out with buried sutures of 2-0 Ethibond, giving a very nice repair.  The shoulder was carried through a range of motion.  I could see no evidence of impingement.  Copious irrigation was carried out.  The deltoid deep fascia was anatomically closed, as was the superficial fascia.  The subcutaneous tissue and skin were closed in layers.  A sterile dressing was applied.  The patient appeared to tolerate the procedure well.","orthopedic, rotator cuff tear, mini-arthrotomy, repair of rotator cuff, arthroscopic subacromial decompression, arthroscopic subacromial, cuff tear, subacromial space, subacromial decompression, mini arthrotomy, acromioclavicular joint, rotator cuff, arthroscopic, decompression, acromioclavicular, impingement, rotator, cuff,"
 Left shoulder injury.   A 41-year-old male presenting for initial evaluation of his left shoulder., Orthopedic, Shoulder Contusion ,"CHIEF COMPLAINT:  ,","orthopedic, shoulder, injury, two views, shoulder contusion, "
 Consultation for right shoulder pain., Orthopedic, Shoulder Pain Consult ,"CHIEF COMPLAINT:,  Right shoulder pain.,HISTORY OF PRESENT PROBLEM:","orthopedic, shoulder pain, history of present problem:, cortisone shot, no numbness or tingling, rhomboids, scapula, shoulder impingement, focal findings, shoulder,"
" Followup left-sided rotator cuff tear and cervical spinal stenosis.  Physical examination and radiographic findings are compatible with left shoulder pain and left upper extremity pain, which is due to a combination of left-sided rotator cuff tear and moderate cervical spinal stenosis.", Orthopedic, Rotator Cuff Tear ,"REASON FOR VISIT: , Followup left-sided rotator cuff tear and cervical spinal stenosis.,HISTORY OF PRESENT ILLNESS: , Ms. ABC returns today for followup regarding her left shoulder pain and left upper extremity C6 radiculopathy.  I had last seen her on 06/21/07.,At that time, she had been referred to me Dr. X and Dr. Y for evaluation of her left-sided C6 radiculopathy.  She also had a significant rotator cuff tear and is currently being evaluated for left-sided rotator cuff repair surgery, I believe on, approximately 07/20/07.  At our last visit, I only had a report of her prior cervical spine MRI.  I did not have any recent images.  I referred her for cervical spine MRI and she returns today.,She states that her symptoms are unchanged.  She continues to have significant left-sided shoulder pain for which she is being evaluated and is scheduled for surgery with Dr. Y.,She also has a second component of pain, which radiates down the left arm in a C6 distribution to the level of the wrist.  She has some associated minimal weakness described in detail in our prior office note.  No significant right upper extremity symptoms.  No bowel, bladder dysfunction.  No difficulty with ambulation.,FINDINGS: , On examination, she has 4 plus over 5 strength in the left biceps and triceps muscle groups, 4 out of 5 left deltoid, 5 out of 5 otherwise in both muscle groups and all muscle groups of upper extremities.  Light touch sensation is minimally decreased in the left C6 distribution; otherwise, intact.  Biceps and brachioradialis reflexes are 1 plus.  Hoffmann sign normal bilaterally.  Motor strength is 5 out of 5 in all muscle groups in lower extremities.  Hawkins and Neer impingement signs are positive at the left shoulder.,An EMG study performed on 06/08/07 demonstrates no evidence of radiculopathy or plexopathy or nerve entrapment to the left upper extremity.,Cervical spine MRI dated 06/28/07 is reviewed.  It is relatively limited study due to artifact.  He does demonstrate evidence of minimal-to-moderate stenosis at the C5-C6 level but without evidence of cord impingement or cord signal change.  There appears to be left paracentral disc herniation at the C5-C6 level, although axial T2-weighted images are quite limited.,ASSESSMENT AND PLAN: , Ms. ABC's history, physical examination and radiographic findings are compatible with left shoulder pain and left upper extremity pain, which is due to a combination of left-sided rotator cuff tear and moderate cervical spinal stenosis.,I agree with the plan to go ahead and continue with rotator cuff surgery.  With regard to the radiculopathy, I believe this can be treated non-operatively to begin with.  I am referring her for consideration of cervical epidural steroid injections.  The improvement in her pain may help her recover better from the shoulder surgery.,I will see her back in followup in 3 months, at which time she will be recovering from a shoulder surgery and we will see if she needs any further intervention with regard to the cervical spine.,I will also be in touch with Dr. Y to let him know this information prior to the surgery in several weeks.","orthopedic, upper extremity, radiculopathy, rotator cuff repair, cervical spinal stenosis, rotator cuff tear, physical examination, cuff, impingement, stenosis, extremity, surgery, tear, shoulder, rotator, cervical,"
 Scarf bunionectomy procedure of the first metatarsal of the left foot.  Hallux abductovalgus deformity with bunion of the left foot., Orthopedic, Scarf Bunionectomy ,"PREOPERATIVE DIAGNOSIS: , Hallux abductovalgus deformity with bunion of the left foot.,POSTOPERATIVE DIAGNOSIS: , Hallux abductovalgus deformity with bunion of the left foot.,PROCEDURE PERFORMED: , Scarf bunionectomy procedure of the first metatarsal of the left foot.,ANESTHESIA:,  IV sedation with local.,HISTORY: , This patient is a 55-year-old female who presents to ABCD preoperative holding area after keeping herself n.p.o., since mid night for surgery for her painful left bunion.  The patient has had increasing pain over time and is having difficulty ambulating and wearing shoes.  The patient has failed to conservative treatment and desires surgical correction at this time.  Risks versus benefits of the procedure have been explained in detail by Dr. X, and consent is available on the chart for review.,PROCEDURE IN DETAIL:,  After an IV established by the Department of Anesthesia, the patient was given preoperatively 600 mg of clindamycin intravenously.  The patient was then taken to the Operating Suite via cart and was placed on the operating table in a supine position and a safety strap was placed across her waist for protection.  Next, a pneumatic ankle tourniquet was applied over her left ankle with copious amounts of Webril for the patient's protection.  After adequate IV sedation was applied, the patient was given a local injection consisting of 17 cc of 4.5 cc 1% lidocaine plain, 4.5 cc of 0.5% Marcaine plain, and 1.0 cc of Solu-Medrol mixture in the standard Mayo block to the left foot.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was then elevated, the Esmarch was applied and the tourniquet was inflated to 250 mmHg.  The foot was then lowered to the operating field.,A sterile stockinet was reflected and the attention was directed to the first metatarsophalangeal joint of the left foot.  After sufficient anesthesia, using a #10 blade a linear incision was made approximately 5 to 6 cm in length over the first metatarsophalangeal joint dorsally, just near to the extensor hallucis longus tendon.  Then using a fresh #15 blade, this incision was deepened through the skin into the subcutaneous layer after all small traversing veins were ligated and cauterized with electrocautery.  A neurovascular bundle was identified and reflected medially.  Laterally the extensor hallucis longus tendon was identified and protected with retraction as well.  Care was then taken to undermine the medial and lateral margins of the first metatarsophalangeal joint carefully.  The first metatarsophalangeal joint capsule was then identified and using a #15 blade, a linear incision made down to the bone through the joint capsule.  The periosteum was reflected and elevated off of its bone and the metatarsal head as well as the base of the proximal phalanx to a small degree.  Noted was a large hypertrophic bone spur on the dorsal medial aspect of the first metatarsal head as well as some small osteophytes along the medial portion of the proximal phalanx.  Care was then taken to reflect and dissect the periosteum off of the shaft of the first metatarsal proximally into the proximal portion of the metatarsal close to the first metatarsocuneiform joint.  The bone cortex was noted to be intact and in good condition.  Following this, using a sagittal saw with a #138 blade, the attention was directed to the medial hypertrophic bone of the first metatarsal head.  In the sagittal plane with the blade angulated from dorsolateral to proximal medial, the medial eminence of bone was resected.  Plantarly it was noted that the tibial sesamoid groove was intact and the sesamoid apparatus was intact as well.  Following this bone cut, 0.45 K-wire was inserted from medial to lateral through the medial portion of the first metatarsal head directed in the dorsal third of the metatarsal head.  Then using the Reese osteotomy guide, the guide was directed from the distal portion of the metatarsal head proximally to the proximal portion of the first metatarsal.  A second 0.45 K-wire was inserted proximally as well.  Following this, using the sagittal saw with the #138 blade a transverse linear osteotomy cut was made through the first metatarsal from medial to lateral.  After reaching the distal as well as the proximal portions of the bone and ensuring that cortex was cut on both the medial as well as lateral side, the Reese osteotomy guide was removed and the dorsal and plantar incision cuts were made.  This began with the dorsal distal cut, which extended from medial to lateral with the dorsal portion of the blade angled proximally about five degrees through the dorsal third of the distal first metatarsal.  Following this, attention was directed proximally and an incision osteotomy cut through the bone was made, directed medially to laterally with the inferior portion of the blade angled distally to transect the cortex of the bone.  Following this, the distal portion of the osteotomy cut was freely movable and was able to be translocated medially.  The head was then slit medially several millimeters until it was noted to be in good position and no chopping was present in the medullary canal of the bone.  Following this, the bone was stabilized using a 0.45 K-wire distally as well as proximally directed from dorsal to planar direction.  Next using the normal AO manner, the distal cortex was drilled from dorsal to plantar with a 2.0 mm drill bit and then over drilled proximally with the cortex using a 2.7 mm drill bit.  The proximal cortex was then _________ and then the drill hole was measured and it was determined to be 18 mm in length from dorsal to plantar cortex.  Then using 2.7 mm tap, the thread holes were placed and using an 18 x 2.7 mm screw ___________ was achieved and good apposition of the bone and tightness were achieved.  Intramedullary sludge was noted to exit from the osteotomy cut.  Following this, attention was directed proximally and the 0.45 K-wire was removed and the holes were predrilled using a 2.0 mm screw then over-drilled using 2.7 mm screw and counter sucked.  Following this, the holes were measured, found to 20 mm in length and the drill hole was tapped using a 2.7 mm tap.  Following this, a 20 mm full threaded screw was inserted and tightened.  Good intramedullary sludge was noted and compression was achieved.  Attention was then directed to the distal screw where it was once again tightened and found to be in good position with good bite.  Following this, range of motion was performed on the first metatarsophalangeal joint and some lateral deviation of the hallux was noted.  Based on this, a lateral release was performed.  The extensor hallucis longus tendon was identified and was transected medially and a linear incision was placed down using a #15 blade into the first interspace.  The incision was then deepened with sharp and blunt dissection and using a curved hemostat, the transverse as well as the oblique fibers of the abductor hallucis tendon were identified and transected.  Care was taken to perform lateral release around the fibular sesamoid through these suspensory ligaments as well as the transverse metatarsal ligament and the collateral ligament.  Upon completion of this, the hallux was noted to be in a rectus position with good alignment.  The area was then flushed and irrigated with copious amounts of sterile saline.  After this, attention was directed back to the medial capsule and a medial capsulorrhaphy was performed and the capsule was closed using #3-0 Vicryl suture.  Subcutaneous tissues were closed using #3-0 and #4-0 Vicryl sutures to close in layers.  The skin was then reapproximated and closed using #5-0 Monocryl suture.  Following this, the incisions were dressed and bandaged in the normal manner using Owen silk, 4x4s, Kling, and Kerlix as well as Coban dressing.  The tourniquet was then dropped with a total tourniquet time of 99 minutes at 250 mmHg.  The patient followed the procedure and the anesthesia well and vascular status was intact as noted by immediate hyperemia to digits one through five of the left foot.  The patient was then transferred back to the cart and escorted on the cart to the Postanesthesia Care Unit.  Following this, the patient was given prescription for Vicoprofen total #20 to be taken one every six hours as necessary for moderate to severe pain.  The patient was also given prescription for clindamycin to be taken 300 mg four times a day.  The patient was given surgical shoe and was placed in a posterior sling.  The patient was given crutches and instructed to use them for ambulation.  The patient was instructed to keep her foot iced and elevated and to remain nonweightbearing over the weekend.  The patient will follow up with Dr. X on Tuesday morning at 11'o clock in his Livonia office.  The patient was concerned about any possible allergic reaction to medication and was placed on codeine and antibiotics due to that.  The patient has Dr. X's pager and will contact him over this weekend if she has any problems or complaints or return to Emergency Department if any difficulty should arise.  X-rays were taken and the patient was discharged home upon completion of this.","orthopedic, hallux abductovalgus deformity, scarf bunionectomy, metatarsal, bunion, hallux abductovalgus, metatarsophalangeal joint, dorsally, foot, bone, abductovalgus "
" Right shoulder hemi-resurfacing using a size 5 Biomet Copeland humeral head component, noncemented.  Severe degenerative joint disease of the right shoulder.", Orthopedic, Shoulder Hemi-resurfacing ,"PREOPERATIVE DIAGNOSIS: , Severe degenerative joint disease of the right shoulder.,POSTOPERATIVE DIAGNOSIS:,  Severe degenerative joint disease of the right shoulder.,PROCEDURE: , Right shoulder hemi-resurfacing using a size 5 Biomet Copeland humeral head component, noncemented.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,COMPLICATIONS:,  None.  The patient was taken to Postanesthesia Care Unit in stable condition.  The patient tolerated the procedure well.,INDICATIONS: , The patient is a 55-year-old female who has had increased pain in to her right shoulder.  X-rays as well as an MRI showed a severe arthritic presentation of the humeral head with mild arthrosis of the glenoid.  She had an intact rotator cuff being at a young age and with potential of glenoid thus it was felt that a hemi-resurfacing was appropriate for her right shoulder focusing in the humeral head.  All risks, benefits, expectations and complications of surgery were explained to her in detail including nerve and vessel damage, infection, potential for hardware failure, the need for revision surgery with potential of some problems even with surgical intervention.  The patient still wanted to proceed forward with surgical intervention.  The patient did receive 1 g of Ancef preoperatively.,PROCEDURE: , The patient was taken to the operating suite, placed in supine position on the operating table.  The Department of anesthesia administered a general endotracheal anesthetic, which the patient tolerated well.  The patient was moved to a beach chair position.  All extremities were well padded.  Her head was well padded to the table.  Her right upper extremity was draped in sterile fashion.  A saber incision was made from the coracoid down to the axilla.  Skin was incised down to the subcutaneous tissue, the cephalic vein was retracted as well as all neurovascular structures were retracted in the case.  Dissecting through the deltopectoral groove, the subscapularis tendon was found as well as the bicipital tendon, 1 finger breadth medial to the bicipital tendon an incision was made.  Subscapularis tendon was released.  The humeral head was brought in to; there were large osteophytes that were removed with an osteotome.  The glenoid then was evaluated and noted to just have mild arthrosis, but there was no need for surgical intervention in this region.  A sizer was placed.  It was felt that size 5 was appropriate for this patient, after which the guide was used to place the stem and pin.  This was placed, after which a reamer was placed along the humeral head and reamed to a size 5.  All extra osteophytes were excised.  The supraspinatus and infraspinatus tendons were intact.  Next, the excess bone was removed and irrigated after which reaming of the central portion of the humeral head was performed of which a trial was placed and showed that there was adequate fit and appropriate fixation.  The arm had excellent range of motion.  There are no signs of gross dislocation.  Drill holes were made into the humeral head after which a size 5 Copeland hemi-resurfacing component was placed into the humeral head, kept down in appropriate position, had excellent fixation into the humeral head.  Excess bone that had been reamed was placed into the Copeland metal component, after which this was tapped into position.  After which the wound site was copiously irrigated with saline and antibiotics and the humeral head was reduced and taken through range of motion; had adequate range of motion, full internal and external rotation as well as forward flexion and abduction.  There was no gross sign of dislocation.  Wound site once again it was copiously irrigated with saline antibiotics.  The subscapularis tendon was approximated back into position with #2 Ethibond after which the bicipital tendon did have significant tear to it; therefore it was tenodesed in to the pectoralis major tendon.  After which, the wound site again was irrigated with saline antibiotics after which subcutaneous tissue was approximated with 2-0 Vicryl.  The skin was closed with staples.  A sterile dressing was placed.  The patient was awakened from general anesthetic and transferred to hospital gurney to the postanesthesia care unit in stable condition.","orthopedic, degenerative joint disease, hemi-resurfacing, biomet copeland, shoulder hemi resurfacing, humeral, head, degenerative, glenoid, subscapularis, antibiotics, resurfacing, tendon, shoulder,"
 Right shoulder hemiarthroplasty.   Right shoulder rotator cuff tear.  Glenohumeral rotator cuff arthroscopy.  Degenerative joint disease., Orthopedic, Right Shoulder Hemiarthroplasty ,"PREOPERATIVE DIAGNOSES:,1.  Right shoulder rotator cuff tear.,2.  Glenohumeral rotator cuff arthroscopy.,3.  Degenerative joint disease.,POSTOPERATIVE DIAGNOSES:,1.  Right shoulder rotator cuff tear.,2.  Glenohumeral rotator cuff arthroscopy.,3.  Degenerative joint disease.,PROCEDURE PERFORMED: ,Right shoulder hemiarthroplasty.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Approximately 125 cc.,COMPLICATIONS:,  None.,COMPONENTS: , A DePuy 10 mm global shoulder system stem was used cemented and a DePuy 44 x 21 mm articulating head was used.,BRIEF HISTORY:  ,The patient is an 82-year-old right-hand dominant female who presents for shoulder pain for many years now and affecting her daily living and function and pain is becoming unbearable failing conservative treatment.,PROCEDURE: , The patient was taken to the operative suite, placed on the operative field.  Department of Anesthesia administered general anesthetic.  Once adequately sedated, the patient was placed in the beach chair position.  Care was ensured that she was well positioned, adequately secured and padded.  At this point, the right upper extremity was then prepped and draped in the usual sterile fashion.  A deltopectoral approach was used and taken down to the skin with a #15 blade scalpel.,At this point, blunt dissection with Mayo scissors was used to come to the overlying subscapular tendon and bursal tissue.  Any perforating bleeders were cauterized with Bovie to obtain hemostasis.  Once the bursa was seen, it was removed with a Rongeur and subscapular tendon could be easily visualized.  At this point, the rotator cuff in the subacromial region was evaluated.  There was noted to be a large rotator cuff, which was irreparable.  There was eburnated bone on the greater tuberosity noted.  The articular surface could be visualized.  The biceps tendon was intact.  There was noted to be diffuse discolored synovium around this as well as some fraying of the tendon in the intraarticular surface.  The under surface of the acromion, it was felt there was mild ware on this as well.  At this point, the subscapular tendon was then taken off using Bovie cautery and Metzenbaum scissors that was tied with Metzenbaum suture.  It was separated from the capsule to have a two layered repair at closure.  The capsule was also reflected posterior.  At this point, the glenoid surface could be easily visualized.  It was evaluated and had good cartilage contact and appeared to be intact.  The humeral head was evaluated.  There was noted to be ware of the cartilage and eburnated bone particularly in the central portion of the humeral head.  At this point, decision was made to proceed with the arthroplasty, since the rotator cuff tear was irreparable and there was significant ware of the humoral head.  The arm was adequately positioned.  An oscillating saw was used to make the head articular cut.  This was done at the margin of the articular surface with the anatomic neck.  This was taken down to appropriate level until this articular surface was adequately removed.  At this point, the intramedullary canal and cancellous bone could be easily visualized.  The opening hand reamers were then used and this was advanced to a size #10.  Under direct visualization, this was performed easily.  At this point, the 10 x 10 proximal flange cutter was then inserted and impacted into place to cut grooves for the fins.  This was then removed.  A trial component was then impacted into place, which did fit well and trial heads were then sampled and it was felt that a size 44 x 21 mm head gave us the best fit and appeared adequately secured.  It did not appear overstuffed with evidence of excellent range of motion and no impingement.  At this point, the trial component was removed.  Wound was copiously irrigated and suctioned dry.  Cement was then placed with a cement gun into the canal and taken up to the level of the cut.  The prosthesis was then inserted into place and held under direct visualization.  All excess cement was removed and care was ensured that no cement was left in the posterior aspect of the joint itself.  This _______ cement was adequately hard at this point.  The final component of the head was impacted into place, secured on the Morris taper and checked, and this was reduced.,The final component was then taken through range of motion and found to have excellent stability and was satisfied with its position.  The wound was again copiously irrigated and suctioned dry.  At this point, the capsule was then reattached to its insertion site in the anterior portion.  Once adequately sutured with #1-Vicryl, attention was directed to the subscapular.  The subscapular was advanced superiorly and anchored not only to the biceps tendon region, but also to the top anterior portion of the greater tuberosity.  This was opened to allow some type of coverage points of the massive rotator cuff tear.  This was secured to the tissue and interosseous sutures with size #2 fiber wire.  After this was adequately secured, the wound was again copiously irrigated and suctioned dry.  The deltoid fascial split was then repaired using interrupted #2-0 Vicryl, subcutaneous tissue was then approximated using interrupted #24-0 Vicryl, skin was approximated using a running #4-0 Vicryl.  Steri-Strips and Adaptic, 4 x 4s, and ABDs were then applied.  The patient was then placed in a sling and transferred back to the gurney, reversed by Department of Anesthesia.,DISPOSITION: , The patient tolerated well and transferred to Postanesthesia Care Unit in satisfactory condition.","orthopedic, glenohumeral rotator cuff, arthroscopy, degenerative joint disease, shoulder hemiarthroplasty, rotator, cuff, subscapular, shoulder, "
" Shoulder pain, right shoulder diffusely - Rotator cuff syndrome, right.", Orthopedic, Rotator cuff syndrome - H&P ,"CHIEF COMPLAINT:  ,This 18 year old male presents today with shoulder pain right.  Location:  He indicates the problem location is the right shoulder diffusely.  Quality:  Quality of the pain is described by the patient as aching, throbbing and tolerable.  Patient relates pain on a scale from 0 to 10 as 5/10.  Severity:  The severity has worsened over the past 3 months.  Timing (onset/frequency):  Onset was gradual and after pitching a baseball game.  Modifying Factors:  Patient's condition is aggravated by throwing.  He participates with difficulty in basketball.  Past conservative treatments include NSAID and muscle relaxant medications.,ALLERGIES: , No known medical allergies.,MEDICATION HISTORY:,  None.,PAST MEDICAL HISTORY:  ,Childhood Illnesses: (+) strep throat (+) mumps (+) chickenpox,PAST SURGICAL HISTORY:,  No previous surgeries.,FAMILY HISTORY:,  Patient admits a family history of arthritis associated with mother.,SOCIAL HISTORY: , Patient denies smoking, alcohol abuse, illicit drug use and STDs.,REVIEW OF SYSTEMS:,Musculoskeletal: (+) joint or musculoskeletal symptoms (+) stiffness in AM.,Psychiatric: (-) psychiatric or emotional difficulties.,Eyes: (-) visual disturbance or change.,Neurological: (-) neurological symptoms or problems Endocrine: (-) endocrine-related symptoms.,Allergic / Immunologic: (-) allergic or immunologic symptoms.,Ears, Nose, Mouth, Throat: (-) symptoms involving ear, nose, mouth, or throat.,Gastrointestinal: (-) GI symptoms.,Genitourinary: (-) GU symptoms.,Constitutional Symptoms: (-) constitutional symptoms such as fever, headache, nausea, dizziness.,Cardiovascular: (-) cardiovascular problems or chest symptoms.,Respiratory: (-)breathing difficulties, respiratory symptoms.,Physical Exam:  BP Standing:  116/68 Resp:  16 HR:  68 Temp:  98.1 Height:  5 ft.  11 in.  Weight:  165 lbs.  Patient is a 18 year old male who appears pleasant, in no apparent distress, his given age, well developed, well nourished and with good attention to hygiene and body habitus.  Oriented to person, place and time.  Right shoulder shows evidence of swelling and tenderness.  Radial pulses are 2 /4, bilateral.  Brachial pulses are 2 /4, bilateral.,Appearance:  Normal.,Tenderness:  Anterior - moderate, Biceps - none, Posterior - moderate and Subacromial - moderate right.,Range of Motion:  Right shoulder ROM shows decreased flexion, decreased extension, decreased adduction, decreased abduction, decreased internal rotation, decreased external rotation.  L shoulder normal.,Strength:  External rotation - fair.  Internal rotation - poor right.,AC Joint:  Pain with ABD and cross-chest - mild right.,Rotator Cuff:  Impingement - moderate.  Painful arc - moderate right.,Instability:  None.,TEST & X-RAY RESULTS:,  X-rays of the shoulder were performed.  X-ray of right shoulder reveals cuff arthropathy present.,IMPRESSION: , Rotator cuff syndrome, right.,PLAN: , Diagnosis of a rotator cuff tendinitis and shoulder impingement were discussed.  I noted that this is a very common condition resulting in significant difficulties with use of the arm.  Several treatment options and their potential benefits were described.  Nonsteroidal anti-inflammatories can be helpful but typically are slow acting.  Cortisone shots can be very effective and are quite safe.  Often more than one injection may be required.  Physical therapy can also be helpful, particularly if there is any loss of shoulder mobility or strength.  If these treatments fail to resolve symptoms, an MRI or shoulder arthrogram may be required to rule out a rotator cuff tear.  Injected shoulder joint and with Celestone Soluspan 1.0 cc .  Ordered x-rays of shoulder right.,PRESCRIPTIONS:,  Vioxx Dosage:  25 mg tablet Sig:  TID Dispense:  60 Refills:  0 Allow Generic:  Yes,PATIENT INSTRUCTIONS:,  Patient was instructed to restrict activity.  Patient was given instructions on RICE therapy.",
" Release of A1 pulley, right thumb.   Stenosing tendinosis, right thumb (trigger finger).  There was noted to be thickening of the A1 pulley.  There was a fibrous nodule noted within the flexor tendon of the thumb, which caused triggering sensation to the thumb.", Orthopedic, Release of A1 Pulley - 1 ,"PREOPERATIVE DIAGNOSIS: , Stenosing tendinosis, right thumb (trigger finger).,POSTOPERATIVE DIAGNOSIS: , Stenosing tendinosis, right thumb (trigger finger).,PROCEDURE PERFORMED:,  Release of A1 pulley, right thumb.,ANESTHESIA:,  IV regional with sedation.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,TOURNIQUET TIME: , Approximately 20 minutes at 250 mmHg.,INTRAOPERATIVE FINDINGS: , There was noted to be thickening of the A1 pulley.  There was a fibrous nodule noted within the flexor tendon of the thumb, which caused triggering sensation to the thumb.,HISTORY:  ,This is a 51-year-old right hand dominant female with a longstanding history of pain as well as locking sensation to her right thumb.  She was actually able to spontaneously trigger the thumb.  She was diagnosed with stenosing tendinosis and wishes to proceed with release of A1 pulley.  All risks and benefits of the surgery was discussed with her at length.  She was in agreement with the above treatment plan.,PROCEDURE:  ,On 08/21/03, she was taken to operating room at ABCD General Hospital and placed supine on the operating table.  A regional anesthetic was applied by the Anesthesia Department.  Tourniquet was placed on her proximal arm.  The upper extremity was sterilely prepped and draped in the usual fashion.,An incision was made over the proximal crease of the thumb.  Subcuticular tissues were carefully dissected.  Hemostasis was controlled with electrocautery.  The nerves were identified and retracted throughout the entire procedure.  The fibers of the A1 pulley were identified.  They were sharply dissected to release the tendon.  The tendon was then pulled up into the wound and inspected.  There was no evidence of gross tear noted.  Fibrous nodule was noted within the tendon itself.  There was no evidence of continuous locking.  Once release of the pulley had been performed, the wound was copiously irrigated.  It was then reapproximated using #5-0 nylon simple interrupted and horizontal mattress sutures.  Sterile dressing was applied to the upper extremity.  Tourniquet was deflated.  It was noted that the thumb was warm and pink with good capillary refill.  The patient was transferred to Recovery in apparent stable and satisfactory condition.  Prognosis is fair.","orthopedic, release of a1 pulley, tendinosis, thumb, flexor tendon, trigger finger, fibrous nodule, stenosing tendinosis, tourniquet, stenosing, tendon, release, pulley"
 Epicondylitis. history of lupus.  Injected with 40-mg of Kenalog mixed with 1 cc of lidocaine., Orthopedic, Rheumatology Progress Note ,"SUBJECTIVE:,  The patient is here for a follow-up.  The patient has a history of lupus, currently on Plaquenil 200-mg b.i.d.  Eye report was noted and appreciated.  The patient states that she is having some aches and pains of the hands and elbows that started recently a few weeks ago.  She denied having any trauma.  She states that the pain is bothering her.  She denies having any fevers, chills, or any joint effusion or swelling at this point.  She noted also that there is some increase in her hair loss in the recent times.,OBJECTIVE:,  The patient is alert and oriented.  General physical exam is unremarkable.  Musculoskeletal exam reveals positive tenderness in both lateral epicondyles of both elbows, no effusion.  Hand examination is unremarkable today.  The rest of the musculoskeletal exam is unremarkable.,ASSESSMENT:,  Epicondylitis, both elbows, possibly secondary to lupus flare-up.,PLAN:,  We will inject both elbows with 40-mg of Kenalog mixed with 1 cc of lidocaine.  The posterior approach was chosen under sterile conditions.  The patient tolerated both procedures well.  I will obtain CBC and urinalysis today.  If the patient's pain does not improve, I will consider adding methotrexate to her therapy.,Sample Doctor M.D.","orthopedic, rheumatology, 1 cc of lidocaine, epicondylitis, kenalog, kenalog mixed with 1 cc of lidocaine, progress note, aches and pains, history of lupus, lidocaine, lupus, methotrexate, kenalog mixed, injected,"
 The patient was found to have limitations to extension at the IP joint to the right thumb and he had full extension after release of A1 pulley., Orthopedic, Release of A1 Pulley ,"PREOPERATIVE DIAGNOSIS: , Right trigger thumb.,POSTOPERATIVE DIAGNOSIS:,  Right trigger thumb.,SURGERY: , Release of A1 pulley, CPT code 26055.,ANESTHESIA:,  General LMA.,TOURNIQUET TIME:  ,9 minutes at 200 torr.,FINDINGS:,  The patient was found to have limitations to extension at the IP joint to the right thumb.  He was found to have full extension after release of A1 pulley.,INDICATIONS:,  The patient is 2-1/2-year-old.  He has a history of a trigger thumb.  This was evaluated in the office.  He was indicated for release of A1 pulley to allow for full excursion.  Risks and benefits including recurrence, infection, and problems with anesthesia were discussed at length with the family.  They wanted to proceed.,PROCEDURE:,  The patient was brought into the operating room and placed on the operating table in supine position.  General anesthesia was induced without incident.  He was given a weight-adjusted dose of antibiotics.  The right upper extremity was then prepped and draped in a standard fashion.  Limb was exsanguinated with an Esmarch bandage.  Tourniquet was raised to 200 torr.  Transverse incision was then made at the base of thumb.  The underlying soft tissues were carefully spread in line longitudinally.  The underlying tendon was then identified.  The accompanied A1 pulley was also identified.  This was incised longitudinally using #11 blade.  Inspection of the entire tendon then demonstrated good motion both in flexion and extension.  The leaflets of the pulley were easily identified.,The wound was then irrigated and closed.  The skin was closed using interrupted #4-0 Monocryl simple sutures.  The area was injected with 5 mL of 0.25% Marcaine.  The wound was dressed with Xeroform, dry sterile dressings, hand dressing, Kerlix, and Coban.  The patient was awakened from anesthesia and taken to the recovery room in good condition.  There were no complications.  All instrument, sponge, needle counts were correct at the end of case.,PLAN: , The patient will be discharged home.  He will return in 1-1/2 weeks for wound inspection.","orthopedic, a1 pulley, release of a1 pulley, trigger thumb, limitations to extension, ip joint"
" Application of PMT large halo crown and vest.  Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion.", Orthopedic, PMT Halo Crown & Vest ,"PREOPERATIVE DIAGNOSES: , Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion.,POSTOPERATIVE DIAGNOSES: , Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion, and potentially unstable cervical spine.,OPERATIVE PROCEDURE:  ,Application of PMT large halo crown and vest.,ESTIMATED BLOOD LOSS: , None.,ANESTHESIA:  ,Local, conscious sedation with Morphine and Versed.,COMPLICATIONS: , None.  Post-fixation x-rays, nonalignment, no new changes.  Post-fixation neurologic examination normal.,CLINICAL HISTORY:  ,The patient is a 41-year-old female who presented to me with severe cervical spondylosis and myelopathy.  She was referred to me by Dr. X.  The patient underwent a complicated anterior cervical discectomy, 2-level corpectomy, spinal cord decompression and fusion with fibular strut and machine allograft in the large cervical plate.  Surgery had gone well, and the patient has done well in the last 2 days.  She is neurologically improved and is moving all four extremities.  No airway issues.  It was felt that the patient was now a candidate for a halo vest placement given that chance of going to the OR were much smaller.  She was consented for the procedure, and I sought the help of ABC and felt that a PMT halo would be preferable to a Bremer halo vest.  The patient had this procedure done at the bedside, in the SICU room #1.  I used a combination of some morphine 1 mg and Versed 2 mg for this procedure.  I also used local anesthetic, with 1% Xylocaine and epinephrine a total of 15 to 20 cc.,PROCEDURE DETAILS:,  The patient's head was positioned on some towels, the retroauricular region was shaved, and the forehead and the posterolateral periauricular regions were prepped with Betadine.  A large PMT crown was brought in and fixed to the skull with pins under local anesthetic.  Excellent fixation achieved.  It was lateral to the supraorbital nerves and 1 fingerbreadth above the brows and the ear pinnae.,I then put the vest on, by sitting the patient up, stabilizing her neck.  The vest was brought in from the front as well and connected.  Head was tilted appropriately, slightly extended, and in the midline.  All connections were secured and pins were torqued and tightened.,During the procedure, the patient did fine with no significant pain.,Post-procedure, she is neurologically intact and she remained intact throughout.  X-rays of the cervical spine AP, lateral, and swimmer views showed excellent alignment of the hardware construct in the graft with no new changes.,The patient will be subjected to a CT scan to further define the alignment, and barring any problems, she will be ambulating with the halo on.,The patient will undergo pin site care as per protocol, and likely she will go in the next 2 to 3 days.  Her prognosis indeed is excellent, and she is already about 90% or so better from her surgery.  She is also on a short course of Decadron, which we will wean off in due course.,The matter was discussed with the patient and the patient's family.","orthopedic, cervical spondylosis, anterior cervical discectomy, corpectomy, decompression, fusion, pmt, crown, vest, pmt halo, cervical,"
 A sample note on RICE Therapy, Orthopedic, RICE Therapy ,"RICE, stands for the most important elements of treatment for many injuries---rest, ice, compression, and elevation.,REST:,Stop using the injured part as soon as you realize that an injury has taken place. Use crutches to avoid bearing weight on injuries of the foot, ankle, knee, or leg. Use splints for injuries of the hand, wrist, elbow, or arm. Continued exercise or activity could cause further injury, increased pain, or a delay in healing.,ICE:,Ice helps stop bleeding from injured blood vessels and capillaries. Sudden cold causes the small blood vessels to contract. This contraction decreases the amount of blood that can collect around the wound. The more blood that collects, the longer the healing time. Ice can be safely applied in many ways:,*  For injuries to small areas, such as a finger, toe, foot, or wrist, immerse the injured area for 15 to 35 minutes in a bucket of ice water. Use ice cubes to keep the water cold, adding more as the ice cubes dissolve.,*  For injuries to larger areas, use ice packs. Avoid placing the ice directly on the skin. Before applying the ice, place a towel, cloth, or one or two layers of an elasticized compression bandage on the skin to be iced. To make the ice pack, put ice chips or ice cubes in a plastic bag or wrap them in a thin towel. Place the ice pack over the cloth. The pack may sit directly on the injured part, or it may be wrapped in place.,*  Ice the injured area for about 30 minutes.,*  Remove the ice to allow the skin to warm for 15 minutes.,*  Reapply the ice.,*  Repeat the icing and warming cycles for 3 hours. Follow the instructions below for compression and elevation. If pain and swelling persist after 3 hours call our office. You may need to change the icing schedule after the first 3 hours. Regular ice treatment is often discontinued after 24 to 48 hours. At that point, heat is sometimes more comfortable.,COMPRESSION:,Compression decreases swelling by slowing bleeding and limiting the accumulation of blood and plasma near the injured site. Without compression, fluid from adjacent normal tissue seeps into the injured area. To apply compression safely to an injury:,*  Use an elasticized bandage (Ace bandage) for compression, if possible. If you do not have one available, any kind of cloth will suffice for a short time.,*  Wrap the injured part firmly, wrapping over the ice. Begin wrapping below the injury site and extend above the injury site.,*  Be careful not to compress the area so tightly that the blood supply is impaired. Signs of deprivation of the blood supply include pain, numbness, cramping, and blue or dusky nails. Remove the compression bandage immediately if any of theses symptoms appears. Leave the bandage off until all signs of impaired circulation disappear. Then rewrap the area--less tightly this time.,ELEVATION:,Elevating the injured part above the level of the heart is another way to decrease swelling and pain at the injury site. Elevate the iced, compressed area in whatever way is most convenient. Prop an injured leg on a solid object or pillows. Elevate an injured arm by lying down and placing pillows under the arm or on the chest with the arm folded across.","orthopedic, rest, ice, compression, and elevation, foot, ankle, knee, leg, splints, hand, wrist, elbow, arm, ace bandage, compression and elevation, rice therapy, compression bandage, ice packs, rice, elevation, swelling, bandage, therapy"
" Cervical, lumbosacral, thoracic spine flexion and extension to evaluate back and neck pain.", Orthopedic, Radiologic Exam - Spine  ,"EXAM: , Cervical, lumbosacral, thoracic spine flexion and extension.,HISTORY: , Back and neck pain.,CERVICAL SPINE,FINDINGS:  ,AP, lateral with flexion and extension, and both oblique projections of the cervical spine demonstrate alignment and soft tissue structures to be unremarkable.","orthopedic, radiologic exam, ap, back, cervical, oblique views, alignment, disc space, extension, fixation, flexion, foramina, intervertebral, lateral views, lumbosacral, neck, neck pain, oblique, odontoid view, pain, physiologic, projections, spine, subluxation, thoracic, flexion and extension, thoracic spine, vertebral"
 Closed reduction and pinning of the right ulna with placement of a long-arm cast., Orthopedic, Pinning - Ulna ,"PREOPERATIVE DIAGNOSIS:,  Right both bone forearm refracture.,POSTOPERATIVE DIAGNOSIS: , Right both bone forearm refracture.,PROCEDURE:,  Closed reduction and pinning of the right ulna with placement of a long-arm cast.,ANESTHESIA: , Surgery performed under general anesthesia.  Local anesthetic was 10 mL of 0.25% Marcaine plain.,COMPLICATIONS: , No intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,HARDWARE:  ,Hardware was 0.79 K-wire.,HISTORY AND PHYSICAL: , The patient is a 5-year-old male who sustained refracture of his right forearm on 12/05/2007.  The patient was seen in the emergency room.  The patient had a complete fracture of both bones with shortening bayonet apposition.  Treatment options were offered to the family including casting versus closed reduction and pinning.  The parents opted for the latter.  Risks and benefits of surgery were discussed.  Risks of surgery included risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, and need for later hardware removal, cast tightness.  All questions were answered, and the parents agreed to the above plan.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating room table.  General anesthesia was then administered.  The patient received Ancef preoperatively.  The right upper extremity was then prepped and draped in standard surgical fashion.  A small incision was made at the tip of the olecranon.  Initially, a 1.11 guidewire was placed, but this was noted to be too wide for this canal.  This was changed for a 0.79 K-wire.  This was driven up to the fracture site.  The fracture was manually reduced and then the K-wire passed through the distal segment.  This demonstrated adequate fixation and reduction of both bones.  The pin was then cut short.  The fracture site and pin site was infiltrated with 0.25% Marcaine.  The incision was closed using 4-0 Monocryl.  The wounds were cleaned and dried.  Dressed with Xeroform, 4 x 4.  The patient was then placed in a well-moulded long-arm cast.  He tolerated the procedure well.  He was subsequently taken to Recovery in stable condition.,POSTOPERATIVE PLAN: , The patient will be maintain current pin, and long-arm cast for 4 weeks at which time he will return for cast removal.  X-rays of the right forearm will be taken.  The patient may need additional mobilization time.  Once the fracture has healed, we will take the pin out, usually at the earliest 3 to 4 months.  Intraoperative findings were relayed to the parents.  All questions were answered.","orthopedic, closed reduction, pinning, forearm refracture, fracture site, arm cast,"
 Patient did undergo surgical intervention as related to the right knee and it was noted that the reconstruction had failed.   A screw had come loose., Orthopedic, Records Review - Orthopedic ,"Thereafter, he was evaluated and it was felt that further reconstruction as related to the anterior cruciate ligament was definitely not indicated.  On December 5, 2008, Mr. XXXX did undergo a total knee replacement arthroplasty performed by Dr. X.,Thereafter, he did an extensive course of physical therapy, work hardening, and a work conditioning type program.,At the present time, he does complain of significant pain and swelling as related to the right knee.  He is unable to crawl and/or kneel.  He does state he is able to walk a city block and in fact, he is able to do 20 minutes of a treadmill.  Stairs are a significant problem.  His pain is a 5 to 6 on a scale of 1 to 10.,He is better when he is resting, sitting, propped up, and utilizing his ice.  He is much worse when he is doing any type of physical activity.,He has denied having any previous history of similar problems.,CURRENT MEDICATIONS:  ,Over-the-counter pain medication.,ALLERGIES: , NKA.,SURGERIES: , Numerous surgeries as related to the right lower extremity.,SOCIAL HISTORY: , He does admit to one half pack of cigarette consumption per day.  He denies any alcohol consumption.,PHYSICAL EXAMINATION:  ,On examination today, he is 28-year-old male who is 6 feet 1, weighs 250 pounds.  He does not appear to be in distress at this time.  One could appreciate 1-2/4 intraarticular effusion.  The range of motion is 0 to a 110 degrees of flexion.  I could not appreciate any evidence of instability medial, lateral, anterior or posterior.  Crepitus is noted with regards to range of motion testing.  His strength is 4 to 5 as related to the quadriceps and hamstring.,There is atrophy as related to the right thigh.  The patient is able to stand from a seated position and sit from a standing position without difficulty.,RECORDS REVIEW:,1.  First report of injury.,2.  July 17, 2002, x-rays of the right knee were negative.,3.  Notes of the Medina General Hospital Occupational Health, Steven Rodgers, M.D.,4.  August 5, 2002, an MRI scan of the right knee which demonstrated peripheral tear of the posterior horn of the medial",
" Bilateral L5, S1, S2, and S3 radiofrequency ablation for sacroiliac joint pain.  Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.", Orthopedic, Radiofrequency Ablation ,"PROCEDURE: , Bilateral L5, S1, S2, and S3 radiofrequency ablation.,INDICATION: , Sacroiliac joint pain.,INFORMED CONSENT: , The risks, benefits and alternatives of the procedure were discussed with the patient.  The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible of vascular entry of medications.  I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing.  The patient understood the informed consent and desired to have the procedure performed.,PROCEDURE: , Oxygen saturation and vital signs were monitored continuously throughout the procedure.  The patient remained awake throughout the procedure in order to interact and give feedback.  The x-ray technician was supervised and instructed to operate the fluoroscopy machine.,The patient was placed in a prone position on the treatment table with a pillow under the chest and head rotated.  The skin over and surrounding the treatment area was cleaned with Betadine.  The area was covered with sterile drapes, leaving a small window opening for needle placement.  Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.,With fluoroscopy, a 20 gauge 10-mm bent Teflon coated needle was gently guided into the groove between the SAP and the sacrum for the dorsal ramus of L5 and the lateral border of the posterior sacral foramen, for the lateral branches of S1, S2, and S3.  Also, fluoroscopic views were used to ensure proper needle placement.,The following technique was used to confirm correct placement.  Motor stimulation was applied at 2 Hz with 1 millisecond duration.  No extremity movement was noted at less than 2 volts.  Following this, the needle trocar was removed and a syringe containing 1% lidocaine was attached.  At each level, after syringe aspiration with no blood return, 0.5 mL of 1% lidocaine was injected to anesthetize the lateral branch and the surrounding tissue.  After completion, a lesion was created at that level with a temperature of 80 degrees for 90 seconds.,All injected medications were preservative free.  Sterile technique was used throughout the procedure.,ADDITIONAL DETAILS:  ,None.,COMPLICATIONS: , None.,DISCUSSION: , Post-procedure vital signs and oximetry were stable.  The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day.  The patient was told to resume all medications.  The patient was told to be in relative rest for 1 day but then could resume all normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes, or changes in bowel or bladder function.,Follow up appointment was made at PM&R Spine Clinic in approximately one to two weeks.","orthopedic, sacroiliac joint pain, sacroiliac, teflon coated needle, fluoroscopy, needle placement, radiofrequency ablation, ablation, tissue, lidocaine, needle,"
" External fixation of left pilon fracture and closed reduction of left great toe, T1 fracture.  Due to the comminuted nature of her tibia fracture as well as soft tissue swelling, the patient is in need of a staged surgery with the 1st stage external fixation followed by open treatment and definitive plate and screw fixation.  ", Orthopedic, Pilon Fracture External Fixation ,"PREOP DIAGNOSES:,1.  Left pilon fracture.,2.  Left great toe proximal phalanx fracture.,POSTOP DIAGNOSES:,1.  Left pilon fracture.,2.  Left great toe proximal phalanx fracture.,OPERATION PERFORMED:,1.  External fixation of left pilon fracture.,2.  Closed reduction of left great toe, T1 fracture.,ANESTHESIA:  ,General.,BLOOD LOSS:  ,Less than 10 mL.,Needle, instrument, and sponge counts were done and correct.,DRAINS AND TUBES: , None.,SPECIMENS:,  None.,INDICATION FOR OPERATION:  ,The patient is a 58-year-old female who was involved in an auto versus a tree accident on 6/15/2009.  The patient suffered a fracture of a distal tibia and fibula as well as her great toe on the left side at that time.  The patient was evaluated by the emergency room and did undergo further evaluation due to loss of consciousness.  She underwent a provisional reduction and splinting in the emergency room followed by further evaluation for her heart and brain by the Medicine Service following this and she was appropriate for surgical intervention.  Due to the comminuted nature of her tibia fracture as well as soft tissue swelling, the patient is in need of a staged surgery with the 1st stage external fixation followed by open treatment and definitive plate and screw fixation.  The patient had swollen lower extremities, however, compartments were soft and she had no sign of compartment syndrome.  Risks and benefits of procedure were discussed in detail with the patient and her husband.  All questions were answered, and consent was obtained.  The risks including damage to blood vessels and nerves with painful neuroma or numbness, limb altered function, loss of range of motion, need for further surgery, infection, complex regional pain syndrome and deep vein thrombosis were all discussed as potential risks of the surgery.,FINDINGS:,1.  There was a comminuted distal tibia fracture with a fibular shaft fracture.  Following traction, there was adequate coronal and sagittal alignment of the fracture fragments and based on the length of the fibula, the fracture fragments were out to length.,2.  The base of her proximal phalanx fracture was assessed and reduced with essentially no articular step-off and approximately 1-mm displacement.  As the reduction was stable with buddy taping, no pinning was performed.,3.  Her compartments were full, but not firm nor did she have any sign of compartment syndrome and no compartment releases were performed.,OPERATIVE REPORT IN DETAIL:  ,The patient was identified in the preoperative holding area.  The left leg was identified and marked at the surgical site of the patient.  She was then taken to the operating room where she was transferred to the operating room in the supine position, placed under general anesthesia by the anesthesiology team.  She received Ancef for antibiotic prophylaxis.  A time-out was then undertaken verifying the correct patient, extremity, visibility of preoperative markings, availability of equipment, and administration of preoperative antibiotics.  When all was verified by the surgeon, anesthesia and circulating personnel left lower extremity was prepped and draped in the usual fashion.  At this point, intraoperative fluoroscopy was used to identify the fracture site as well as the appropriate starting point both in the calcaneus for a transcalcaneal cross stent and in the proximal tibia with care taken to leave enough room for later plate fixation without contaminating the future operative site.  A single centrally threaded calcaneal cross tunnel was then placed across the calcaneus parallel to the joint surface followed by placement of 2 Schantz pins in the tibia and a frame type external fixator was then applied in traction with attempts to get the fracture fragments out to length, but not overly distract the fracture and restore coronal and sagittal alignment as much as able.  When this was adequate, the fixator apparatus was locked in place, and x-ray images were taken verifying correct placement of the hardware and adequate alignment of the fracture.  Attention was then turned to the left great toe, where a reduction of the proximal phalanx fracture was performed and buddy taping as this provided good stability and was least invasive.  X-rays were taken showing good reduction of the base of the proximal phalanx of the great toe fracture.  At this point, the pins were cut short and capped to protect the sharp ends.  The stab wounds for the Schantz pin and cross pin were covered with gauze with Betadine followed by dry gauze, and the patient was then awakened from anesthesia and transferred to the progressive care unit in stable condition.  Please note there was no break in sterile technique throughout the case.,PLAN:  ,The patient will require definitive surgical treatment in approximately 2 weeks when the soft tissues are amenable to plate and screw fixation with decreased risk of wound complication.  She will maintain her buddy taping in regards to her great toe fracture.","orthopedic, phalanx fracture, schantz pins, toe fracture, tibia fracture, pilon fracture, external fixation, proximal phalanx, fracture, toe, pilon, phalanx, reduction, tibia, proximal, fixation, "
 Revision and in situ pinning of the right hip., Orthopedic, Pinning - Hip ,"PREOPERATIVE DIAGNOSIS: , Right acute on chronic slipped capital femoral epiphysis.,POSTOPERATIVE DIAGNOSIS: , Right acute on chronic slipped capital femoral epiphysis.,PROCEDURE: , Revision and in situ pinning of the right hip.,ANESTHESIA: , Surgery performed under general anesthesia.,COMPLICATIONS:  ,There were no intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,LOCAL:  ,10 mL of 0.50% Marcaine local anesthetic.,HISTORY AND PHYSICAL: , The patient is a 13-year-old girl who presented in November with an acute on chronic right slipped capital femoral epiphysis.  She underwent in situ pinning.  The patient on followup; however, noted to have intraarticular protrusion of her screw.  This was not noted intraoperatively on previous fluoroscopic views.  Given this finding, I explained to the father and especially the mother that this can cause further joint damage and that the screw would need to be exchanged for a shorter one.  Risks and benefits of surgery were discussed.  Risks of surgery include risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, failure to remove the screw, possible continued joint stiffness or damage.  All questions were answered and parents agreed to above plan.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating table.  General anesthesia was then administered.  The patient received Ancef preoperatively.  A small bump was placed underneath her right buttock.  The right upper thigh was then prepped and draped in standard surgical fashion.  The upper aspect of the incision was reincised.  The dissection was carried down to the crew, which was easily found.  A guidewire was placed inside the screw with subsequent removal of the previous screw.  The previous screw measured 65 mm.  A 60 mm screw was then placed under direct visualization with fluoroscopy.  The hip was taken through full range of motion to check on the length of the screw, which demonstrated no intraarticular protrusion.  The guidewire was removed.  The wound was then irrigated and closed using 2-0 Vicryl in the fascial layer as well as the subcutaneous fat.  The skin was closed with 4-0 Monocryl.  The wound was cleaned and dried, dressed with Steri-Strips, Xeroform, 4 x 4s, and tape.  The area was infiltrated with total 10 mL of 0.5% Marcaine local anesthetic.,POSTOPERATIVE PLAN: , The patient will be discharged on the day of surgery.  She should continue toe touch weightbearing on her leg.  The wound may be wet in approximately 5 days.  The patient should follow up in clinic in about 10 days.  The patient is given Vicodin for pain.  Intraoperative findings were relayed to the mother.","orthopedic, guidewire, capital femoral epiphysis, intraarticular protrusion, femoral epiphysis, pinning, screw,"
" Amputation distal phalanx and partial proximal phalanx, right hallux.   Osteomyelitis, right hallux.", Orthopedic, Phalanx Amputation ,"PREOPERATIVE DIAGNOSIS:,  Osteomyelitis, right hallux.,POSTOPERATIVE DIAGNOSIS: , Osteomyelitis, right hallux.,PROCEDURE PERFORMED:,  Amputation distal phalanx and partial proximal phalanx, right hallux.,ANESTHESIA:,  TIVA/local.,HISTORY:,  This 44-year-old male patient was admitted to ABCD General Hospital on 09/02/2003 with a diagnosis of osteomyelitis of the right hallux and cellulitis of the right lower extremity.  The patient has a history of diabetes and has had a chronic ulceration to the right hallux and has been on outpatient antibiotics, which he failed.  The patient after a multiple conservative treatments such as wound care antibiotics, the patient was given the option of amputation as a treatment for the chronic resistant osteomyelitis.  The patient desires to attempt a surgical correction.  The risks versus benefits of the procedure were discussed with the patient in detail by Dr. X.  The consent was available on the chart for review.,PROCEDURE IN DETAIL: , After patient was taken to the operating room via cart and placed on the operating table in the supine position, a safety strap was placed across his waist.  Adequate IV sedation was administered by the Department of Anesthesia and a total of 3.5 cc of 1:1 mixture 1% lidocaine and 0.5% Marcaine plain were injected into the right hallux as a digital block.  The foot was prepped and draped in the usual aseptic fashion lowering the operative field.,Attention was directed to the hallux where there was a full-thickness ulceration to the distal tip of the hallux measuring 0.5 cm x 0.5 cm.  There was a ________ tract, which probed through the distal phalanx and along the sides of the proximal phalanx laterally.  The toe was 2.5 times to the normal size.  There were superficial ulcerations in the medial arch of both feet secondary to history of a burn, which were not infected.  The patient had dorsalis pedis and posterior tibial pulses that were found to be +2/4 bilaterally preoperatively.  X-ray revealed complete distraction of the distal phalanx and questionable distraction of the lateral aspect of the proximal phalanx.  A #10 blade was used to make an incision down the bone in a transverse fashion just proximal to the head of the proximal phalanx.  The incision was carried mediolaterally and plantarly encompassing the toe leaving a large amount of plantar skin intact.  Next, the distal phalanx was disarticulated at the interphalangeal joint and removed.  The distal toe was amputated and sent to laboratory for bone culture and sensitivity as well as tissue pathology.  Next, the head of the proximal phalanx was inspected and found to be soft on the distal lateral portion as suspected.  Therefore, a sagittal saw was used to resect approximately 0.75 cm of the distal aspect of head of the proximal phalanx.  This bone was also sent off for culture and was labeled proximal margin.  Next, the flexor hallucis longus tendon was identified and retracted as far as possible distally and transected.  The flexor tendon distally was gray discolored and was not viable.  A hemostat was used to inspect the flexor sheath to ensure no infection tracking up the sheath proximally.  None was found.  No purulent drainage or abscess was found.  The proximal margin of the surgical site tissue was viable and healthy.  There was no malodor.  Anaerobic and aerobic cultures were taken and passed this as a specimen to microbiology.  Next, copious amounts of gentamicin and impregnated saline were instilled into the wound.,A #3-0 Vicryl was used to reapproximate the deep subcutaneous layer to release skin tension.  The plantar flap was viable and was debulked with Metzenbaum scissors.  The flap was folded dorsally and reapproximated carefully with #3-0 nylon with a combination of simple interrupted and vertical mattress sutures.  Iris scissors were used to modify and remodel the plantar flap.  An excellent cosmetic result was achieved.  No tourniquet was used in this case.  The patient tolerated the above anesthesia and surgery without apparent complications.  A standard postoperative dressing was applied consisting of saline-soaked Owen silk, 4x4s, Kerlix, and Coban.  The patient was transported via cart to Postanesthesia Care Unit with vital signs able and vascular status intact to right foot.  He will be readmitted to Dr. Katzman where we will continue to monitor his blood pressure and regulate his medications.  Plan is to continue the antibiotics until further IV recommendations.,He will be nonweightbearing to the right foot and use crutches.  He will elevate his right foot and rest the foot, keep it clean and dry.  He is to follow up with Dr. X on Monday or Tuesday of next week.","orthopedic, osteomyelitis, phalanx, phalanx amputation, proximal margin, plantar flap, distal phalanx, proximal phalanx, proximal, hallux, amputation, foot, plantarly, distal"
" Open repair of right pectoralis major tendon.   Right pectoralis major tendon rupture.  On MRI evaluation, a complete rupture of a portion of the pectoralis major tendon was noted.", Orthopedic, Pectoralis Tendon Repair ,"PREOPERATIVE DIAGNOSIS: , Right pectoralis major tendon rupture.,POSTOPERATIVE DIAGNOSIS: , Right pectoralis major tendon rupture.,OPERATION PERFORMED: , Open repair of right pectoralis major tendon.,ANESTHESIA:,  General with an interscalene block.,COMPLICATIONS:,  None.,Needle and sponge counts were done and correct.,INDICATION FOR OPERATION:  ,The patient is a 26-year-old right hand dominant male who works in sales, who was performing heavy bench press exercises when he felt a tearing burning pain severe in his right shoulder.  The patient presented with mild bruising over the proximal arm of the right side with x-ray showing no fracture.  Over concerns for pectoralis tendon tear, he was sent for MRI evaluation where a complete rupture of a portion of the pectoralis major tendon was noted.  Due to the patient's young age and active lifestyle surgical treatment was recommended in order to obtain best result.  The risks and benefits of the procedure were discussed in detail with the patient including, but not limited to scarring, infection, damage to blood vessels and nerves, re-rupture, need further surgery, loss of range of motion, inability to return to heavy activity such as weight lifting, complex usual pain syndrome, and deep vein thrombosis as well as anesthetic risks.  Understanding all risks and benefits, the patient desires to proceed with surgery as planned.,FINDINGS:,1.  Following deltopectoral approach to the right shoulder, the pectoralis major tendon was encountered.  The clavicular head was noted to be intact.  There was noted to be complete rupture of the sternal head of the pectoralis major tendon with an oblique-type tear having some remaining cuff on the humerus and some tendon attached to the retracted portion.,2.  Following freeing of adhesions using tracks and sutures, the pectoralis major tendon was able to reapproximated to its insertion site on the humerus just lateral to the biceps.,3.  A soft tissue repair was performed with #5 FiberWire suture and a single suture anchor of 5 x 5 bioabsorbable anchor was placed in order to decrease tension at the repair site.  Following repair of soft tissue and using the bone anchor, there was noted to be good apposition of the tendon with edges and a solid repair.,OPERATIVE REPORT IN DETAIL: , The patient was identified in the preop holding area.  His right shoulder was identified, marked his appropriate surgical site after verification with the patient.  He was then taken to the operating room where he was transferred to the operative table in supine position and placed under general anesthesia by anesthesiology team.  He then received prophylactic antibiotics.  A time-out was then undertaken verifying the correct patient, extremity, surgery performed, administration of antibiotics, and the availability of equipment.  At this point, the patient was placed to a modified beech chair position with care taken to ensure all appropriate pressure points were padded and there was no pressure over the eyes.  The right upper extremity was then prepped and draped in the usual sterile fashion.  Preoperative markings were still visible at this point.  A deltopectoral incision was made utilizing the inferior portion.  Dissection was carried down.  The deltoid was retracted laterally.  The clavicular head of the pectoralis major was noted to be intact with the absence of the sternal insertion.  There was a small cuff of tissue left on the proximal humerus associated with the clavicular head.  Gentle probing medially revealed the end of the sternal retracted portion, traction sutures of #5 Ethibond were used in this to allow for retraction and freeing from light adhesion.  This allowed reapproximation of the retracted tendon to the tendon stump.  At this point, a repair using #5 FiberWire was then performed of the pectoralis major tendon back to stump on the proximal humerus noting good apposition of the tendon edges and no gapping of the repair site.  At this point, a single metal suture anchor was attempted to be implanted just lateral to the insertion of the pectoralis in order to remove tension off the repair site; however, the inserted device attached to the metal anchor broke during insertion due to significant hardness of the bone.  For this reason, the starting hole was tapped and a 5x5 bioabsorbable anchor was placed, doubly loaded.  The sutures were then weaved through the lateral aspect of the torn tendon and a modified Krackow type performed and sutured thereby relieving tension off the soft tissue repair.  At this point, there was noted to be excellent apposition of the soft tissue ends and a solid repair to gentle manipulation.  Aggressive external rotation was not performed.  The wound was then copiously irrigated.  The cephalic vein was not injured during the case.  The skin was then closed using a 2-0 Vicryl followed by a 3-0 subcuticular Prolene suture with Steri-Strips.  Sterile dressing was then placed.  Anesthesia was then performed, interscalene block.  The patient was then awakened from anesthesia and transported to postanesthesia care in stable condition in a shoulder immobilizer with the arm adducted and internally rotated.,Plan for this patient, the patient will remain in the shoulder immobilizer until followup visit in approximately 10 days.  We will then start a gentle Codman type exercises and having limited motion until the 4-6 week point based on the patient's progression.","orthopedic, tendon rupture, interscalene block, pectoralis major tendon rupture, pectoralis major tendon, repair, pectoralis, interscalene, tendon, rupture, sutures,"
" Patient was referred to Physical Therapy, secondary to low back pain and degenerative disk disease.  The patient states she has had a cauterization of some sort to the nerves in her low back to help alleviate with painful symptoms.  The patient would benefit from skilled physical therapy intervention.", Orthopedic, Physical Therapy - Back Pain ,"DIAGNOSIS: , Low back pain and degenerative lumbar disk.,HISTORY:,  The patient is a 59-year-old female, who was referred to Physical Therapy, secondary to low back pain and degenerative disk disease.  The patient states she has had a cauterization of some sort to the nerves in her low back to help alleviate with painful symptoms.  The patient states that this occurred in October 2008 as well as November 2008.  The patient has a history of low back pain, secondary to a fall that originally occurred in 2006.  The patient states that she slipped on a newly waxed floor and fell on her tailbone and low back region.  The patient then had her second fall in March 2006.  The patient states that she was qualifying on the range with a handgun and lost her footing and states that she fell more due to weakness in her lower extremities rather than loss of balance.,PAST MEDICAL HISTORY:,  Past medical history is significant for allergies and thyroid problems.,PAST SURGICAL HISTORY: , The patient has a past surgical history of appendectomy and hysterectomy.,MEDICATIONS:,1.  TriCor.,2.  Vytorin.,3.  Estradiol.,4.  Levothyroxine.,5.  The patient is also taking ibuprofen 800 mg occasionally as needed for pain management.  The patient states she rarely takes this and does not like to take pain medication if at all possible.  The patient states that she has had uncomplicated pregnancies in the past.,SOCIAL HISTORY:,  The patient states she lives in a single-level home with her husband, who is in good health and is able to assist with any tasks or activities the patient is having difficulty with.  The patient rates her general health as excellent and denies any smoking and reports very occasional alcohol consumption.  The patient does state that she has completed exercises on a daily basis of one to one and a half hours a day.  However, has not been able to complete these exercise routine since approximately June 2008, secondary to back pain.  The patient is working full-time as a project manager, and is required to do extensive walking at various periods during a workday.,MEDICAL IMAGING:,  The patient states that she has had an MRI recently performed; however, the results are not available at the time of the evaluation.  The patient states she is able to bring the report in upon next visit.,SUBJECTIVE:  ,The patient rates her pain at 7/10 on a Pain Analog Scale, 0 to 10, 10 being worse.  The patient describes her pain as a deep aching, primarily on the right lower back and gluteal region.  Aggravating factors include stairs and prolonged driving, as well as general limitations with home tasks and projects.  The patient states she is a very active individual and is noticing extreme limitations with ability to complete home tasks and projects she used to be able to complete.,NEUROLOGICAL SYMPTOMS:,  The patient reports having occasional shooting pains into the lower extremities.  However, these are occurring less frequently and is now occurring more frequently in the right versus the left lower extremity when they do occur.,FUNCTIONAL ACTIVITIES AND HOBBIES: , Include exercising and general activities.,PATIENT'S GOAL: , The patient would like to improve her overall body movements and return to daily exercise routine as able and well maintaining safety.,OBJECTIVE: , Upon observation, the patient ambulates independently without the use of assistive device.  However, does present with mild limp and favoring the left lower extremity after extensive standing and walking activity.  The patient does have mild difficulty transferring from the seated position to standing.  However, once is upright, the patient denies any increased pain or symptoms.,ACTIVE RANGE OF MOTION OF LUMBAR SPINE:  ,Forward flexion is 26 cm, fingertip to floor, lateral side bend, fingertip to floor is 52.5 cm bilaterally.,STRENGTH: , Strength is grossly 4/5.  The patient denies any significant tenderness to palpation.  However, does have mild increase in tenderness on the right versus left.  A six-minute walk test revealed painful symptoms and achiness occurring after approximately 400 feet of walking.  The patient was able to continue; however, stopped after 700 feet.  There were two minutes remaining in the six-minute walk test.  The patient does have tight hamstrings as well as a negative slump test.,ASSESSMENT: , The patient would benefit from skilled physical therapy intervention in order to address the following problem list.,PROBLEM LIST:,1.  Increased pain.,2.  Decreased ability to complete tasks and hobbies.,3",
" Specimen labeled ""sesamoid bone left foot"".", Orthopedic, Pathology - Sesamoid Bone ,"GROSS DESCRIPTION: , Specimen labeled ""sesamoid bone left foot"" is received in formalin and consists of three irregular fragments of grey-brown, hard, bony tissue admixed with multiple fragments of brown-tan, rubbery, fibrocollagenous, soft tissue altogether measuring 3.1 x 1.5 x 0.9 cm.  The specimen is entirely submitted, after decalcification.,DIAGNOSIS:,  Acute Osteomyelitis, with foci of marrow fibrosis.,Focal acute and chronic inflammation of fascia and soft tissue.  Arteriosclerosis, severely occlusive.","orthopedic, marrow fibrosis, osteomyelitis, arteriosclerosis, inflammation of fascia, specimen, fragmentsNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" Synovitis - anterior cruciate ligament tear of the left knee.  The patient is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain.   The patient fell in a grocery store.  He reports slipping on a grape that was on the floor. ", Orthopedic, Physical Therapy - Synovitis ,"DIAGNOSIS:,  Synovitis/anterior cruciate ligament tear of the left knee.,HISTORY: , The patient is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain.  The patient states that on 10/02/08, the patient fell in a grocery store.  He reports slipping on a grape that was on the floor.  The patient states he went to the emergency room and then followed up with his primary care physician.  The patient was then ultimately referred to Physical Therapy.  After receiving a knee brace, history and information was received through a translator as the patient is Spanish speaking only.,PAST MEDICAL HISTORY: , Past medical history is unremarkable.,MEDICAL IMAGING: , Medical imaging is significant for x-rays and MRIs.  The report was available at the time of the evaluation.  The patient reports abnormal posterior horn of medial meniscus consistent with knee degenerative change and possibly tears.,MEDICATIONS:,1.  Tramadol.,2.  Diclofenac.,3.  Advil.,4.  Tylenol.,SUBJECTIVE: , The patient rates his pain at 6/10 on the Pain Analog Scale, primarily with ambulation.  The patient does deny pain at night.  The patient does present with his knee brace on the exterior of his __________ leg and appears to be on backboard.,FUNCTIONAL ACTIVITIES AND HOBBIES:  ,Functional activities and hobbies that are currently limited include any work as the patient is currently unemployed and is looking for a job; however, his primary skills are of a laborer and a street broker for new homes.,OBJECTIVE:  ,Upon observation, the patient is ambulating with a significant antalgic gait pattern.  However, he is not using any assistive device.  The knee brace was corrected and the patient and his wife demonstrated understanding and knowledge of how to place the knee brace on correctly.,ACTIVE RANGE OF MOTION: , Active range of motion of the left knee is 0 to 105 degrees with pain during range of motion.  Right knee active range of motion is 0 to 126 degrees.,STRENGTH:  ,Strength is 3/5 for left knee, 4+/5 for right knee.  The patient denies any pain upon light and deep palpation at the knee joints.  There is no evidence of temperature change, increased swelling or any discoloration at the left knee joint.  The patient does not appear to have instability at this time with formal tests at the left knee joint.,SPECIAL TESTS:  ,The patient performed a six-minute walk test.  He was able to complete 600 feet; however, had to stop this test at approximately five minutes, secondary to significant increase in pain.,ASSESSMENT:,  The patient would benefit from skilled physical therapy intervention in order to address the following problem list:,1.  Increased pain.,2.  Decreased range of motion.,3.  Decreased strength.,4.  Decreased ability to perform functional activities and work tasks.,5.  Decreased ambulation tolerance.,SHORT-TERM GOALS TO BE COMPLETED IN THREE WEEKS:,1.  Patient will demonstrate independence with the home exercise program.,2.  Patient will report maximum pain of 2/10 on a Pain Analog Scale within a 24-hour period.,3.  The patient will demonstrate left knee active range of motion, 0 to 120 degrees, without significant increase in pain during motion.,4.  The patient will demonstrate 4/5 strength for the left knee.,5.  The patient will complete 800 feet in a six-minute walk test without significant increase in pain.,LONG-TERM GOALS TO BE COMPLETED IN SIX WEEKS:,1.  The patient will demonstrate bilateral knee active range of motion, 0 to 130 degrees.,2.  The patient will demonstrate 5/5 lower extremity strength bilaterally without significant increase in pain.,3.  Patient will complete 1000 feet in a six-minute walk test without increase in pain and tolerate full completion of the six minutes.,4.  The patient will improve confidence with ability to perform work activity, when the situation improves and resolves.,PROGNOSIS:  ,Prognosis is good for above-stated goals, with compliance to a home exercise program and treatment.,SESSION PLAN: , The patient to be seen two to three times a week for six weeks for the following:,1.  Therapeutic exercise with home exercise program.",
" The patient is a 58-year-old female, referred to therapy due to left knee osteoarthritis.  The patient states that approximately 2 years ago, she fell to the ground and thereafter had blood clots in the knee area.  The patient was transferred from the hospital to a nursing home and lived there for 1 year.  The patient states that her primary concern is her left knee pain and they desire to walk short distances again in her home.", Orthopedic, Physical Therapy - Osteoarthritis ,"DIAGNOSIS: , Left knee osteoarthritis.,HISTORY: , The patient is a 58-year-old female, referred to therapy due to left knee osteoarthritis.  The patient states that approximately 2 years ago, she fell to the ground and thereafter had blood clots in the knee area.  The patient was transferred from the hospital to a nursing home and lived there for 1 year.  Prior to this incident, the patient was ambulating independently with a pickup walker throughout her home.  Since that time, the patient has only been performing transverse and has been unable to ambulate.  The patient states that her primary concern is her left knee pain and they desire to walk short distances again in her home.,PAST MEDICAL HISTORY: , High blood pressure, obesity, right patellar fracture with pin in 1990, and history of blood clots.,MEDICATIONS:  ,Naproxen, Plavix, and stool softener.,MEDICAL DIAGNOSTICS: , The patient states that she had an x-ray of the knee in 2007 and was diagnosed with osteoarthritis.,SUBJECTIVE:,  The patient reports that when seated and at rest, her knee pain is 0/10.  The patient states that with active motion of the left knee, the pain in the anterior portion increases to 5/10.,PATIENT'S GOAL: , To transfer better and walk 5 feet from her bed to the couch.,INSPECTION: , The right knee has a large 8-inch long and very wide tight scar with adhesions to the underlying connective tissue due to her patellar fracture and surgery following an MVA in 1990, bilateral knees are very large due to obesity.  There are no scars, bruising or increased temperature noted in the left knee.,RANGE OF MOTION: , Active and passive range of motion of the right knee is 0 to 90 degrees and the left knee, 0 to 85 degrees.  Pain is elicited during active range of motion of the left knee.,PALPATION: , Palpation to the left knee elicits pain around the patellar tendon and to each side of this area.,FUNCTIONAL MOBILITY:  ,The patient reports that she transfers with standby to contact-guard assist in the home from her bed to her wheelchair and return.  The patient is able to stand modified independent from wheelchair level and tolerates at least 15 seconds of standing prior to needing to sit down due to the left knee pain.,ASSESSMENT:  ,The patient is a 58-year-old female with left knee osteoarthritis.  Examination indicates deficits in pain, muscle endurance, and functional mobility.  The patient would benefit from skilled physical therapy to address these impairments.,TREATMENT PLAN:  ,The patient will be seen two times per week for an initial 4 weeks with re-assessment at that time for an additional 4 weeks if needed.,INTERVENTIONS INCLUDE:,1.  Modalities including electrical stimulation, ultrasound, heat, and ice.,2.  Therapeutic exercise.,3.  Functional mobility training.,4.  Gait training.,LONG-TERM GOALS TO BE ACHIEVED IN 4 WEEKS:,1.  The patient is to have increased endurance in bilateral lower extremities as demonstrated by being able to perform 20 repetitions of all lower extremity exercises in seated and supine positions with minimum 2-pound weight.,2.  The patient is to perform standby assist transfer using a pickup walker.,3.  The patient is to demonstrate 4 steps of ambulation using forward and backward using a pickup walker or front-wheeled walker.,4.  The patient is to report maximum 3/10 pain with weightbearing of 2 minutes in the left knee.,LONG-TERM GOALS TO BE ACHIEVED IN 8 WEEKS:,1.  The patient is to be independent with the home exercise program.,2.  The patient is to tolerate 20 reps of standing exercises with pain maximum of 3/10.,3.  The patient is to ambulate 20 feet with the most appropriate assistive device.,PROGNOSIS TO THE ABOVE-STATED GOALS:,  Fair to good.,The above treatment plan has been discussed with the patient.  She is in agreement.",
" A 7-year-old white male started to complain of pain in his fingers, elbows, and neck.  This patient may have had reactive arthritis.  ", Orthopedic, Pediatric Rheumatology Consult ,"HISTORY:  ,We had the pleasure of seeing the patient today in our Pediatric Rheumatology Clinic.  He was sent here with a chief complaint of joint pain in several joints for few months.  This is a 7-year-old white male who has no history of systemic disease, who until 2 months ago, was doing well and 2 months ago, he started to complain of pain in his fingers, elbows, and neck.  At this moment, this is better and is almost gone, but for several months, he was having pain to the point that he would cry at some point.  He is not a complainer according to his mom and he is a very active kid.  There is no history of previous illness to this or had gastrointestinal problems.  He has problems with allergies, especially seasonal allergies and he takes Claritin for it.  Other than that, he has not had any other problem.  Denies any swelling except for that doctor mentioned swelling on his elbow.  There is no history of rash, no stomach pain, no diarrhea, no fevers, no weight loss, no ulcers in his mouth except for canker sores.  No lymphadenopathy, no eye problems, and no urinary problems.,MEDICATIONS: , His medications consist only of Motrin only as needed and Claritin currently for seasonal allergies and rhinitis.,ALLERGIES: , He has no allergies to any drugs.,BIRTH HISTORY:  ,Pregnancy and delivery with no complications.  He has no history of hospitalizations or surgeries.,FAMILY HISTORY: , Positive for arthritis in his grandmother.  No history of pediatric arthritis.  There is history of psoriasis in his dad.,SOCIAL HISTORY: , He lives with mom, dad, brother, sister, and everybody is healthy.  They live in Easton.  They have 4 dogs, 3 cats, 3 mules and no deer.  At school, he is in second grade and he is doing PE without any limitation.,PHYSICAL EXAMINATION: ,VITAL SIGNS:  Temperature is 98.7, pulse is 96, respiratory rate is 24, height is 118.1 cm, weight is 22.1 kg, and blood pressure is 61/44.,GENERAL:  He is alert, active, in no distress, very cooperative.,HEENT:  He has no facial rash.  No lymphadenopathy.  Oral mucosa is clear.  No tonsillitis.  His ear canals are clear and pupils are reactive to light and accommodation.,CHEST:  Clear to auscultation.,HEART:  Regular rhythm and no murmur.,ABDOMEN:  Soft, nontender with no visceromegaly.,MUSCULOSKELETAL:  Shows no limitation in any of his joints or active swelling today.  He has no tenderness either in any of his joints.  Muscle strength is 5/5 in proximal muscles.,LABORATORY DATA:,  Includes an arthritis panel.  It has normal uric acid, sedimentation rate of 2, rheumatoid factor of 6, and antinuclear antibody that is negative and C-reactive protein that is 7.1.  His mother stated that this was done while he was having symptoms.,ASSESSMENT AND PLAN: , This patient may have had reactive arthritis.  He is seen frequently and the patient has family history of psoriatic arthritis or psoriasis.  I do not see any problems at this moment on his laboratories or on his physical examination.  This may have been related to recent episode of viral infection or infection of some sort.  Mother was oriented about the finding and my recommendation is to observe him and if there is any recurrence of the symptoms or persistence of swelling or limitation in any of his joints, I will be glad to see him back.,If you have any question on further assessment and plan, please do no hesitate to contact us.","orthopedic, rheumatology, pediatric, reactive arthritis, psoriatic arthritis, psoriasis, joints, swelling, arthritis, "
" The patient is a 26-year-old female, referred to Physical Therapy for low back pain.  The patient has a history of traumatic injury to low back.", Orthopedic, Physical Therapy - Low Back Pain  ,"HISTORY OF PRESENT ILLNESS: , The patient is a 26-year-old female, referred to Physical Therapy for low back pain.  The patient has a history of traumatic injury to low back.  The patient stated initial injury occurred eight years ago, when she fell at a ABC Store.  The patient stated she received physical therapy, one to two visits and received modality treatment only, specifically electrical stimulation and heat pack per patient recollection.  The patient stated that she has had continuous low-back pain at varying degrees for the past eight years since that fall.  The patient gave birth in August 2008 and since the childbirth, has experienced low back pain.  The patient also states that she fell four to five days ago, while mopping her floor.  The patient stated that she landed on her tailbone and symptoms have increased since that fall.  The patient stated that her initial physician examination with Dr. X was on 01/10/09, and has a followup appointment on 02/10/09.,PAST MEDICAL HISTORY: , The patient denies high blood pressure, diabetes, heart disease, lung disease, thyroid, kidney, or bladder dysfunctions.  The patient stated that she quit smoking prior to her past childbirth and is currently not pregnant.  The patient has had a C-section and also an appendectomy.  The patient was involved in a motor vehicle accident four to five years ago and at that time, the patient did not require any physical therapy nor did she report any complaints of increased back pain following that accident.,MEDICATIONS: , Patient currently states she is taking:,1.  Vicodin 500 mg two times a day.,2.  Risperdal.,3.  Zoloft.,4.  Stool softeners.,5.  Prenatal pills.,DIAGNOSTIC IMAGERY:  ,The patient states she has not had an MRI performed on her lumbar spine.  The patient also states that Dr. X took x-rays two weeks ago, and no fractures were found at that time.  Per physician note, dated 12/10/08, Dr. X dictated that the x-ray showed an anterior grade 1 spondylolisthesis of L5 over S1, and requested Physical Therapy to evaluate and treat.,SUBJECTIVE:  ,The patient states that pain is constant in nature with a baseline of 6-7/10 with pain increasing to 10/10 during the night or in cold weather.  The patient states that pain is dramatically less, when the weather is warmer.  The patient also states that pain worsens as the day progresses, in that she also hard time getting out of bed in the morning.  The patient states that she does not sleep at night well and sleeps less than one hour at a time.,Aggravating factors include, sitting for periods greater than 20 minutes or lying supine on her back.  Easing factors include side lying position in she attempts to sleep.,OBJECTIVE: , AGE:  26 years old.  HEIGHT:  5 feet 2 inches.  WEIGHT:  The patient is an obese 26-year-old female.,ACTIVE RANGE OF MOTION: , Lumbar spine, flexion, lateral flexion and rotation all within functional limits without complaints of pain or soreness while performing them during evaluation.,PALPATION:  ,The patient complained of bilateral SI joint point tenderness.  The patient also complained of left greater trochanter hip point tenderness.  The patient also complained of bilateral paraspinal tenderness on cervical spine to lumbar spine.,STRENGTH:  ,RIGHT LOWER EXTREMITY:,Knee extension 5/5, hip flexion 5/5, knee flexion 4/5, internal and external hip rotation was 4/5.  With manual muscle testing of knee flexion, hip, internal and external rotation, the patient reports an increase in right SI joint pain to 8/10.,LEFT LOWER EXTREMITY:,Hip flexion 5/5, knee extension 5/5, knee flexion 4/5, hip internal and external rotation 4/5, with slight increase in pain level with manual muscle testing and resistance.  It must be noted that PT did not apply as much resistance during manual muscle testing, secondary to the 8/10 pain elicited during the right lower extremity.,NEUROLOGICAL:  ,The patient subjectively complains of numbness with tingling in her bilateral extremities when she sits longer than 25 minutes.  However, they subside when she stands.  The patient did complain of this numbness and tingling during the evaluation and the patient was seated for a period of 20 minutes.  Upon standing, the patient stated that the numbness and tingling subsides almost immediately.  The patient stated that Dr. X told her that he believes that during her past childbirth when the epidural was being administered that there was a possibility that a sensory nerve may have been also affected during the epidural less causing the numbness and tingling in her bilateral lower extremities.  The patient does not demonstrate any sensation deficits with gentle pressure to the lumbar spine and during manual muscle testing.,GAIT:  ,The patient ambulated out of the examination room, while carrying her baby in a car seat.,ASSESSMENT:  ,The patient is a 26-year-old overweight female, referred to Physical Therapy for low back pain.  The patient presents with lower extremity weakness, which may be contributing to her lumbosacral pain, in that she has poor lumbar stabilization with dynamic ADLs, transfers, and gait activity when fatigued.  At this time, the patient may benefit from skilled physical therapy to address her decreased strength and core stability in order to improve her ADL, transfer, and mobility skills.,PROGNOSIS: , The patient's prognosis for physical therapy is good for dictated goals.,SHORT-TERM GOALS TO BE ACHIEVED IN TWO WEEKS:,1.  The patient will be able to sit for greater than 25 minutes without complaints of paraesthesia or pain in her bilateral lower extremities or bilateral SI joints.,2.  The patient will increase bilateral hip internal and external rotation to 4/5 with SI joint pain less than or equal to 5/10.,3.  The patient will report 25% improvement in her functional and ADL activities.,4.  Pain will be less than 4/10 while performing __________ while at PT session.,LONG-TERM GOALS TO BE ACCOMPLISHED IN ONE MONTH:,1.  The patient will be independent with home exercise program.,2.  Bilateral hamstring, bilateral hip internal and external rotation strength to be 4+/5 with SI joint pain less than or equal to 2/10, while performing manual muscle test.,3.  The patient will report 60% improvement or greater in functional transfers in general ADL activity.,4.  The patient will be able to sit greater than or equal to 45 minutes without complaint of lumbosacral pain.,5.  The patient will be able to sleep greater than 2 hours without pain.,TREATMENT PLAN:,1.  Therapeutic exercises to increase lower extremity strength and assist with lumbar sacral stability.",
" Patellar tendon and medial and lateral retinaculum repair, right knee.   Patellar tendon retinaculum ruptures, right knee.", Orthopedic, Patellar Tendon & Retinaculum Repair ,"PREOPERATIVE DIAGNOSIS:  , Patellar tendon retinaculum ruptures, right knee.,POSTOPERATIVE DIAGNOSIS: , Patellar tendon retinaculum ruptures, right knee.,PROCEDURE PERFORMED: , Patellar tendon and medial and lateral retinaculum repair, right knee.,SPECIFICATIONS:  ,Intraoperative procedure done at Inpatient Operative Suite, room #2 of ABCD Hospital.  This was done under subarachnoid block anesthetic in supine position.,HISTORY AND GROSS FINDINGS: , The patient is a 45-year-old African-American male who suffered acute rupture of his patellar tendon diagnosed both by exam as well as x-ray the evening before surgical intervention.  He did this while playing basketball.,He had a massive deficit at the inferior pole of his patella on exam.  Once opened, he had complete rupture of this patellar tendon as well as a complete rupture of his medial lateral retinaculum.  Minimal cartilaginous pieces were at the patellar tendon.  He had grade II changes to his femoral sulcus as well as grade I-II changes to the undersurface of the patella.,OPERATIVE PROCEDURE: , The patient was laid supine on the operative table receiving a subarachnoid block anesthetic by Anesthesia Department.  A thigh high tourniquet was placed.  He is prepped and draped in the usual sterile manner.  Limb was elevated, exsanguinated and tourniquet placed at 325 mmHg for approximately 30 to 40 minutes.  Straight incision is carried down through skin and subcutaneous tissue anteriorly.  Hemostasis was controlled via electrocoagulation.  Patellar tendon was isolated along with the patella itself.,A 6 mm Dacron tape x2 was placed with a modified Kessler tendon stitch with a single limb both medially and laterally and a central limb with subsequent shared tape.  The inferior pole was freshened up.  Drill bit was utilized to make holes x3 longitudinally across the patella and the limbs strutted up through the patella with a suture passer.  This was tied over the bony bridge superiorly.  There was excellent reduction of the tendon to the patella.  Interrupted running #1-Vicryl suture was utilized for over silk.  A running #2-0 Vicryl for synovial closure medial and laterally as well as #1-Vicryl medial and lateral retinaculum.  There was excellent repair.  Copious irrigation was carried out.  Tourniquet was dropped and hemostasis controlled via electrocoagulation.  Interrupted #2-0 Vicryl was utilized for subcutaneous fat closure and skin staples were placed through the skin.  Adaptic, 4 x 4s, ABDs, and sterile Webril were placed for compression dressing.  Digits were warm and no brawny pulses present at the end of the case.  The patient's leg was placed in a Don-Joy brace 0 to 20 degrees of flexion.  He will leave this until seen in the office.,Expected surgical prognosis on this patient is fair.","orthopedic, subarachnoid, patellar tendon retinaculum, tendon, patellar, tourniquet, knee, ruptures, retinaculum"
" Ankle sprain, left ankle.  The patient tripped over her dog toy and fell with her left foot inverted.  The patient states that she received a series of x-rays and MRIs that were unremarkable.  After approximately 1 month, the patient continued to have significant debilitating pain in her left ankle.  She then received a walking boot and has been in the boot for the past month.", Orthopedic, Physical Therapy - Ankle Sprain ,"DIAGNOSIS: , Ankle sprain, left ankle.,HISTORY: , The patient is a 31-year-old female who was referred to Physical Therapy secondary to a fall on 10/03/08.  The patient states that she tripped over her dog toy and fell with her left foot inverted.  The patient states that she received a series of x-rays and MRIs that were unremarkable.  After approximately 1 month, the patient continued to have significant debilitating pain in her left ankle.  She then received a walking boot and has been in the boot for the past month.,PAST MEDICAL HISTORY: , Significant for hypertension, asthma, and cervical cancer.  The cervical cancer was diagnosed as 15 years old.  The patient states that her cancer is ""dormant."",MEDICATIONS:,1.  Hydrochlorothiazide.,2.  Lisinopril.,3.  Percocet.,The patient states that the Percocet helps to take the edge of her pain, but does not completely eliminate it.,SUBJECTIVE: , The patient rates the pain at 2/10 on the pain analog scale.  The patient states that with elevation and rest, her pain subsides.,FUNCTIONAL ACTIVITIES/HOBBIES: , Currently limited including basic household chores and activities, this does increases her pain.  The patient states she also recently joined Weight Watchers and was involved in a walking routine and is currently unable to participate in this activity.,WORK STATUS: , The patient is currently on medical leave as a paraprofessional.  The patient states that she works as a teacher's aide in the school system and is required to complete extensive walking and standing activities.  The patient states that she is primarily on her feet while at work and rarely has a sitting break for extensive period of time.  The patient's goal is to be able to stand and walk without pain.,SOCIAL HISTORY:  ,The patient lives in a private home with children and her father.  The patient states that she does have stairs to negotiate without the use of a railing.  She states that she is able to manage the stairs, however, is very slow with her movement.  The patient smokes 1-1/2 packs of cigarettes a day and does not have a history of regular exercise routine.,OBJECTIVE: , Upon observation, the patient is a very obese female who is ambulating with significant antalgic gait pattern and altered normal gait due to the pain as well as the walking boot.  Upon inspection of the left ankle, it appears to have swelling, unsure if this swelling is secondary to injury or water retention as the patient states she has significant water retention.  When compared to right ankle edema, it is approximately equal.  There is no evidence of discoloration or temperature.  The patient states that she had no bruising at the time of injury.,Active range of motion of left ankle is as follows:  Dorsiflexion is 6 degrees past neutral and plantar flexion is 54 degrees, eversion 20 degrees, and inversion is 30 degrees.  Left ankle dorsiflexion lacks 10 degrees from neutral and plantar flexion is 36 degrees, this motion is very painful.  The patient was tearful during this activity.  Eversion is 3 degrees and inversion is 25 degrees.  The patient states this movement was difficult, but not painful.  Strength testing of the right lower extremity is grossly 4+-5/5 and left ankle is 2/5 as the patient is unable to obtain full range of motion.,PALPATION: , The patient is very tender to palpation primarily along the lateral malleolus of the left ankle.,JOINT PLAY: , Unable to be assessed secondary to the patient's extreme tenderness and guarding of the ankle joint.,SPECIAL TESTS:,  A 6-minute walk test.  The patient was able to ambulate approximately 600 feet while wearing her walking boot prior to her pain significantly increasing in the ankle and requiring the test to be stopped.,ASSESSMENT:  ,The patient would benefit from skilled physical therapy intervention as a trial of treatment in order to address the following problem list:,1.  Increased pain.,2.  Decreased range of motion.,3.  Decreased strength.,4.  Decreased ability to complete work task and functional activities in the home.,5.  Decreased gait pattern.,SHORT-TERM GOALS TO BE COMPLETED IN 3 WEEKS:,1.  The patient will demonstrate independence with home exercise program.,2.  The patient will ambulate without her boot for 48 hours in order to decrease reliance upon the boot for ankle stabilization.,3.  The patient will achieve left ankle dorsiflexion to neutral and plantar flexion to 45 degrees without significant increase in pain.,4.  The patient will demonstrate 3/5 strength of the left ankle.,5.  The patient will tolerate the completion of the 6-minute walk test without the use of a boot with minimal increase in pain.,LONG-TERM GOALS TO BE COMPLETED IN 6 WEEKS:,1.  The patient will report 0/10 pain in the 48-hour period without the use of medication and without wearing her boot.,2.  The patient will return to go through the work without the use of the walking boot with report of minimal increase in pain and discomfort.,PROGNOSIS:,  Fair for above-stated goals with full compliance to home exercise program and therapy treatment as well as the patient motivation.,PLAN: , The patient to be seen three times a week for 6 weeks for the following:",
 Pain management sample progress note., Orthopedic, Pain Management Progress Note ,"DIAGNOSES:,1.  Cervical dystonia.,2.  Post cervical laminectomy pain syndrome.,Ms. XYZ states that the pain has now shifted to the left side.  She has noticed a marked improvement on the right side, which was subject to a botulinum toxin injection about two weeks ago.  She did not have any side effects on the Botox injection and she feels that her activities of daily living are increased, but she is still on the oxycodone and methadone.  The patient's husband confirms the fact that she is doing a lot better, that she is more active, but there are still issues yet regarding anxiety, depression, and frustration regarding the pain in her neck.,PHYSICAL EXAMINATION:,  The patient is appropriate.  She is well dressed and oriented x3.  She still smells of some cigarette smoke.  Examination of the neck shows excellent reduction in muscle spasm on the right paraspinals, trapezius and splenius capitis muscles.  There are no trigger points felt and her range of motion of the neck is still somewhat guarded, but much improved.  On the left side, however, there is significant muscle spasm with tight bands involving the multifidus muscle with trigger point activity and a lot of tenderness and guarding.  This extends down into the trapezius muscle, but the splenius capitis seems to be not involved.,TREATMENT PLAN:,  After a long discussion with the patient and the husband, we have decided to go ahead and do botulinum toxin injection into the left multifidus/trapezius muscles.  A total of 400 units of Botox is anticipated.  The procedure is being scheduled.  The patient's medications are refilled.  She will continue to see Dr. Berry and continue her therapy with Mary Hotchkinson in Victoria.","orthopedic, progress note, management, muscle"
" Distal metaphyseal osteotomy and bunionectomy with internal screw fixation, right foot.  Reposition osteotomy with internal screw fixation to correct angulation deformity of proximal phalanx, right foot.", Orthopedic, Osteotomy & Bunionectomy ,"PREOPERATIVE DIAGNOSES:,1.  Metatarsus primus varus with bunion deformity, right foot.,2.  Hallux abductovalgus with angulation deformity, right foot.,POSTOPERATIVE DIAGNOSES:,1.  Metatarsus primus varus with bunion deformity, right foot.,2.  Hallux abductovalgus with angulation deformity, right foot.,PROCEDURES:,1.  Distal metaphyseal osteotomy and bunionectomy with internal screw fixation, right foot.,2.  Reposition osteotomy with internal screw fixation to correct angulation deformity of proximal phalanx, right foot.,ANESTHESIA:,Local infiltrate with IV sedation.,INDICATION FOR SURGERY: , The patient has had a longstanding history of foot problems.  The foot problem has been progressive in nature and has not been responsive to conservative treatment.  The preoperative discussion with the patient included the alternative treatment options.,The procedure was explained in detail and risk factors such as infection, swelling, scarred tissue; numbness, continued pain, recurrence, and postoperative management were explained in detail.  The patient has been advised, although no guaranty for success could be given, most patients have improved function and less pain.  All questions were thoroughly answered.  The patient requested surgical repair since the problem has reached a point that interferes with her normal daily activities.  The purpose of the surgery is to alleviate the pain and discomfort.,DETAILS OF PROCEDURE:  ,The patient was brought to the operating room and placed in a supine position.  No tourniquet was utilized.  IV sedation was administered and during that time local anesthetic consisting of approximately 10 mL total in a 1:1 mixture of 0.25% Marcaine and 1% lidocaine with epinephrine was locally infiltrated proximal to the operative site.  The lower extremity was prepped and draped in the usual sterile manner.  Balanced anesthesia was obtained.,PROCEDURE #1: , Distal metaphyseal osteotomy with internal screw fixation with bunionectomy, right foot.  A dorsal curvilinear incision medial to the extensor hallucis longus tendon was made, extending from the distal third of the shaft of the first metatarsal to a point midway on the shaft of the proximal phalanx.  Care was taken to identify and retract the vital structures and when necessary, vessels were ligated via electrocautery.  Sharp and blunt dissection was carried down through the subcutaneous tissue, superficial fascia, and then down to the capsular and periosteal layer, which was visualized.  A linear periosteal capsular incision was made in line with the skin incision.  The capsular tissue and periosteal layer were underscored, free from its underlying osseous attachments, and they refracted to expose the osseous surface.  Inspection revealed increased first intermetatarsal angle and hypertrophic changes to the first metatarsal head.  The head of the first metatarsal was dissected free from its attachment medially and dorsally, delivered dorsally and may be into the wound.,Inspection revealed the first metatarsophalangeal joint surface appeared to be in satisfactory condition.  The sesamoid was in satisfactory condition.  An oscillating saw was utilized to resect the hypertrophic portion of the first metatarsal head to remove the normal and functional configuration.  Care was taken to preserve the sagittal groove.  The rough edges were then smoothed with a rasp.,Attention was then focused on the medial mid portion of the first metatarsal head where a K-wire access guide was positioned to define the apex and direction of displacement for the capital fragment.  The access guide was noted to be in good position.  A horizontally placed, through-and-through osteotomy with the apex distal and the base proximal was completed.  The short plantar arm was from the access guide to proximal plantar and the long dorsal arm was from the access guide to proximal dorsal.  The capital fragment was distracted off the first metatarsal, moved laterally to decrease the intermetatarsal angle to create a more anatomical and functional position of the first metatarsal head.  The capital fragment was impacted upon the metatarsal.,Inspection revealed satisfactory reduction of the intermetatarsal angle and good alignment of the capital fragment.  It was then fixated with 1 screw.  A guide pin was directed from the dorsal aspect of the capital fragment to the plantar aspect of the shaft and first metatarsal in a distal dorsal to proximal plantar direction.  The length was measured, __________ mm cannulated cortical screw was placed over the guide pin and secured in position.  Compression and fixation were noted to be satisfactory.  Inspection revealed good fixation and alignment at the operative site.  Attention was then directed to the medial portion of the distal third of the shaft of the first metatarsal where an oscillating saw was used to resect the small portion of the bone that was created by shifting the capital fragment laterally.  All rough edges were rasped smooth.  Examination revealed there was still lateral deviation of the hallux.  A second procedure, the reposition osteotomy of the proximal phalanx with internal screw fixation to correct angulation deformity was indicated., ,PROCEDURE #2:,  Reposition osteotomy with internal screw fixation to correct angulation deformity, proximal phalanx, right hallux.  The original skin incision was extended from the point just distal to the interphalangeal joint.  All vital structures were identified and retracted.  Sharp and blunt dissection was carried down through the subcutaneous tissue, superficial fascia, and down to the periosteal layer, which was underscored, free from its underlying osseous attachments and reflected to expose the osseous surface.  The focus of the deformity was noted to be more distal on the hallux.  Utilizing an oscillating saw, a more distal, wedge-shaped transverse oblique osteotomy was made with the apex being proximal and lateral and the base medial distal was affected.  The proximal phalanx was then placed in appropriate alignment and stabilized with a guide pin, which was then measured, __________ 14 mm cannulated cortical screw was placed over the guide pin and secured into position.,Inspection revealed good fixation and alignment at the osteotomy site.  The alignment and contour of the first way was now satisfactorily improved.  The entire surgical wound was flushed with copious amounts of sterile normal saline irrigation.  The periosteal and capsular layer was closed with running sutures of #3-0 Vicryl.  The subcutaneous tissue was closed with #4-0 Vicryl and the skin edges coapted well with #4-0 nylon with running simples, reinforced with Steri-Strips.,Approximately 6 mL total in a 1:1 mixture of 0.25% Marcaine and 1% lidocaine plain was locally infiltrated proximal to the operative site for postoperative anesthesia.  A dressing consisting of Adaptic and 4 x 4 was applied to the wound making sure the hallux was carefully splinted, followed by confirming bandages and an ACE wrap to provide mild compression.  The patient tolerated the procedure and anesthesia well and left the operating room to recovery room in good postoperative condition with vital signs stable and arterial perfusion intact as evident by the normal capillary fill time.,A walker boot was dispensed and applied.  The patient should wear it when walking or standing., ,The next office visit will be in 4 days.  The patient was given prescriptions for Percocet 5 mg #40 one p.o. q.4-6h. p.r.n. pain, along with written and oral home instructions.  The patient was discharged home with vital signs stable in no acute distress.", 
 Pain management for post-laminectomy low back syndrome and radiculopathy.  , Orthopedic, Pain Management Consult - 1 ,"Mr. XYZ forgot his hearing aids at home today and is severely hearing impaired and most of the interview had to be conducted with me yelling at him at the top of my voice.  For all these reasons, this was not really under the best circumstances and I had to curtail the amount of time I spent trying to get a history because of the physical effort required in extracting information from this patient.  The patient was seen late because he had not filled in the patient questionnaire.  To summarize the history here, Mr. XYZ who is not very clear on events from the past, sustained a work-related injury some time in 1998.  At that time, he was driving an 18-wheeler truck.  The patient indicated that he slipped off the rear of his truck while loading vehicles to his trailer.  He experienced severe low back pain and eventually a short while later, underwent a fusion of L4-L5 and L5-S1.  The patient had an uneventful hospital course from the surgery, which was done somewhere in Florida by a surgeon, who he does not remember.  He was able to return to his usual occupation, but then again had a second work-related injury in May of 2005.  At that time, he was required to boat trucks to his rig and also to use a chain-pulley system to raise and lower the vehicles.  Mr. XYZ felt a popping sound in his back and had excruciating low back pain and had to be transported to the nearest hospital.  He was MRI'ed at that time, which apparently showed a re-herniation of an L5-S1 disc and then, he somehow ended up in Houston, where he underwent fusion by Dr. W from L3 through S2.  This was done on 12/15/2005.  Initially, he did fairly well and was able to walk and move around, but then gradually the pain reappeared and he started getting severe left-sided leg pain going down the lateral aspect of the left leg into his foot.  He is still complaining of the severe pain right now with tingling in the medial two toes of the foot and significant weakness in his left leg.  The patient was referred to Dr. A, pain management specialist and Dr. A has maintained him on opioid medications consisting of Norco 10/325 mg for breakthrough pain and oxycodone 30 mg t.i.d. with Lunesta 3 mg q.h.s. for sleep, Carisoprodol 350 mg t.i.d., and Lyrica 100 mg q.daily.  The patient states that he is experiencing no side effects from medications and takes medications as required.  He has apparently been drug screened and his drug screening has been found to be normal.  The patient underwent an extensive behavioral evaluation on 05/22/06 by TIR Rehab Center.  At that time, it was felt that Mr. XYZ showed a degree of moderate level of depression.  There were no indications in the evaluation that Mr. XYZ showed any addictive or noncompliant type behaviors.  It was felt at that time that Mr. XYZ would benefit from a brief period of individual psychotherapy and a course of psychotropic medications.  Of concern to the therapist at that time was the patient's untreated and unmonitored hypertension and diabetes.  Mr. XYZ indicated at that time, they had not purchased any prescription medications or any of these health-related issues because of financial limitations.  He still apparently is not under really good treatment for either of these conditions and on today's evaluation, he actually denies that he had diabetes.  The impression was that the patient had axis IV diagnosis of chronic functional limitations, financial loss, and low losses with no axis III diagnosis.  This was done by Rhonda Ackerman, Ph.D., a psychologist.  It was also suggested at that time that the patient should quit smoking.  Despite these evaluations, Mr. XYZ really did not get involved in psychotherapy and there was poor attendance of these visits, there was no clearance given for any surgical interventions and it was felt that the patient has benefited from the use of SSRIs.  Of concern in June of 2006 was that the patient had still not stopped smoking despite warnings.  His hypertension and diabetes were still not under good control and the patient was assessed at significant risk for additional health complications including stroke, reduced mental clarity, and future falls.  It was felt that any surgical interventions should be put on hold at that time.  In September of 2006, the patient was evaluated at Baylor College of Medicine in the Occupational Health Program.  The evaluation was done by a physician at that time, whose report is clearly documented in the record.  Evaluation was done by Dr. B.  At present, Mr. XYZ continues on with his oxycodone and Norco.  These were prescribed by Dr. A two and a half weeks ago and the patient states that he has enough medication left to last him for about another two and a half weeks.  The patient states that there has been no recent change in either the severity or the distribution of his pain.  He is unable to sleep because of pain and his activities of daily living are severely limited.  He spends most of his day lying on the floor, watching TV and occasionally will walk a while.  ***** from detailed questioning shows that his activities of daily living are practically zero.  The patient denies smoking at this time.  He denies alcohol use or aberrant drug use.  He obtains no pain medications from no other sources.  Review of MRI done on 02/10/06 shows laminectomies at L3 through S1 with bilateral posterior plates and pedicle screws with granulation tissue around the thecal sac and around the left L4-5 and S1 nerve roots, which appear to be retracted posteriorly.  There is a small right posterior herniation at L1-L2.,PAST MEDICAL HISTORY:,  Significant for hypertension, hypercholesterolemia and non-insulin-dependent diabetes mellitus.  The patient does not know what medications he is taking for diabetes and denies any diabetes.  CABG in July of 2006 with no preoperative angina, shortness of breath, or myocardial infarction.  History of depression, lumbar fusion surgery in 2000, left knee surgery 25 years ago.,SOCIAL HISTORY:,  The patient is on disability.  He does not smoke.  He does not drink alcohol.  He is single.  He lives with a girlfriend.  He has minimal activities of daily living.  The patient cannot recollect when last a urine drug screen was done.,REVIEW OF SYSTEMS:,  No fevers, no headaches, chest pain, nausea, shortness of breath, or change in appetite.  Depressive symptoms of crying and decreased self-worth have been noted in the past.  No neurological history of strokes, epileptic seizures.  Genitourinary negative.  Gastrointestinal negative.  Integumentary negative.  Behavioral, depression.,PHYSICAL EXAMINATION:,  The patient is short of hearing.  His cognitive skills appear to be significantly impaired.  The patient is oriented x3 to time and place.  Weight 185 pounds, temperature 97.5, blood pressure 137/92, pulse 61.  The patient is complaining of pain of a 9/10.,Musculoskeletal:  The patient's gait is markedly antalgic with predominant weightbearing on the left leg.  There is marked postural deviation to the left.  Because of pain, the patient is unable to heel-toe or tandem gait.  Examination of the neck and cervical spine are within normal limits.  Range of motion of the elbow, shoulders are within normal limits.  No muscle spasm or abnormal muscle movements noted in the neck and upper extremities.  Head is normocephalic.  Examination of the anterior neck is within normal limits.  There is significant muscle wasting of the quadriceps and hamstrings on the left, as well as of the calf muscles.  Skin is normal.  Hair distribution normal.  Skin temperature normal in both the upper and lower extremities.  The lumbar spine curvature is markedly flattened.  There is a well-healed central scar extending from T12 to L1.  The patient exhibits numerous positive Waddell's signs on exam of the low back with inappropriate flinching and wincing with even the lightest touch on the paraspinal muscles.  Examination of the paraspinal muscles show a mild to moderate degree of spasm with a significant degree of tenderness and guarding, worse on the left than the right.  Range of motion testing of the lumbar spine is labored in all directions.  It is interesting that the patient cannot flex more than 5  in the standing position, but is able to sit without any problem.  There is a marked degree of sciatic notch tenderness on the left.  No abnormal muscle spasms or muscle movements were noted.  Patrick's test is negative bilaterally.  There are no provocative facetal signs in either the left or right quadrants of the lumbar area.  Neurological exam:  Cranial nerves II through XII are within normal limits.  Neurological exam of the upper extremities is within normal limits with good motor strength and normal biceps, triceps and brachioradialis reflexes.  Neurological exam of the lower extremities shows a 2+ right patellar reflex and -1 on the left.  There is no ankle clonus.  Babinski is negative.  Sensory testing shows a minimal degree of sensory loss on the right L5 distribution.  Muscle testing shows decreased L4-L5 on the left with extensor hallucis longus +2/5.  Ankle extensors are -3 on the left and +5 on the right.  Dorsiflexors of the left ankle are +2 on the left and +5 on the right.  Straight leg raising test is positive on the left at about 35 .  There is no ankle clonus.  Hoffman's test and Tinel's test are normal in the upper extremities.,Respiratory:  Breath sounds normal.  Trachea is midline.,Cardiovascular:  Heart sounds normal.  No gallops or murmurs heard.  Carotid pulses present.  No carotid bruits.  Peripheral pulses are palpable.,Abdomen:  Hernia site is intact.  No hepatosplenomegaly.  No masses.  No areas of tenderness or guarding.,IMPRESSION:,1.  Post-laminectomy low back syndrome.,2.  Left L5-S1 radiculopathy.,3.  Severe cognitive impairment with minimal ***** for rehabilitation or return to work.,4.  Opioid dependence for pain control.,TREATMENT PLAN:,  The patient will continue on with his medications prescribed by Dr. Chang and I will see him in two weeks' time and probably suggest switching over from OxyContin to methadone.  I do not think this patient is a good candidate for spinal cord stimulation due to his grasp of exactly what is happening and his cognitive impairment.  I will get a behavioral evaluation from Mr. Tom Welbeck and refer the patient for ongoing physical therapy.  The prognosis here for any improvement or return to work is zero.","orthopedic, pain management, opioid dependence, patrick's test, behavioral evaluation, cognitive impairment, low back syndrome, motor strength, pain control, physical therapy, radiculopathy, spinal cord stimulation, activities of daily living, neurological exam, laminectomy, hearing, diabetes, muscle, syndrome,"
" Plantar flex third metatarsal and talus bunion, right foot.  Third metatarsal osteotomy, talus bunionectomy, and application of short-leg cast, right foot.  Patient has tried conservative methods such as wide shoes and serial debridement and accommodative padding, all of which provided inadequate relief.  At this time she desires to attempt a surgical correction. ", Orthopedic, Osteotomy & Bunionectomy - 1 ,"PREOPERATIVE DIAGNOSES:,1.  Plantar flex third metatarsal, right foot.,2.  Talus bunion, right foot.,POSTOPERATIVE DIAGNOSES:,1.  Plantar flex third metatarsal, right foot.,2.  Talus bunion, right foot.,PROCEDURE PERFORMED:,1.  Third metatarsal osteotomy, right foot.,2.  Talus bunionectomy, right foot.,3.  Application of short-leg cast, right foot.,ANESTHESIA: , TIVA/local.,HISTORY:  ,This 31-year-old female presents to ABCD Preoperative Holding Area after keeping herself n.p.o., since mid night for surgery on her painful right third plantar flex metatarsal.  In addition, she complains of a painful right talus bunion to the right foot.  She has tried conservative methods such as wide shoes and serial debridement and accommodative padding, all of which provided inadequate relief.  At this time she desires to attempt a surgical correction.  The risks versus benefits of the procedure have been explained to the patient by Dr. X and the consent is available on the chart for review.,PROCEDURE IN DETAIL:  ,After IV was established by the Department Of Anesthesia, the patient was taken to the operating room via cart.  She was placed on the operating table in supine position and a safety strap was placed across her waist for retraction.  Next, copious amounts of Webril were applied around the right ankle and a pneumatic ankle tourniquet was applied.,Next, after adequate IV sedation was administered by the Department Of Anesthesia, a total of 10 cc mixture of 4.5 cc of 1% lidocaine/4.5 cc of 0.5% Marcaine/1 cc of Kenalog was injected into the right foot in an infiltrative type block.  Next, the foot was prepped and draped in the usual aseptic fashion.  An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg.  Next, the foot was lowered in the operative field and attention was directed to the dorsal third metatarsal area.  There was a plantar hyperkeratotic lesion and a plantar flex palpable third metatarsal head.  A previous cicatrix was noted with slight hypertrophic scarring.  Using a #10 blade, a lazy S-type incision was created over the dorsal aspect of the third metatarsal, approximately 3.5 cm in length.  Two semi-elliptical converging incisions were made over the hypertrophic scar and it was removed and passed off as a specimen.  Next, the #15 blade was used to deepen the incision down to the subcutaneous tissue.  Any small traversing veins were ligated with electrocautery.  Next, a combination of blunt and sharp dissection were used to undermine the long extensor tendon, which was tacked down with a moderate amount of fibrosis and fibrotic scar tissue.  Next, the extensor tendon was retracted laterally and the deep fascia over the metatarsals was identified.  A linear incision down to bone was made with a #15 blade to the capsuloperiosteal tissues.  Next, the capsuloperiosteal tissues were elevated using a sharp dissection with a #15 blade, off of the third metatarsal.  McGlamry elevator was carefully inserted around the head of the metatarsal and freed and all the plantar adhesions were freed.  A moderate amount of plantar adhesions were encountered.  The third toe was plantar flex and the third metatarsal was delivered into the wound.  Next, a V-shaped osteotomy with an apex distally was created using a sagittal saw.  The metatarsal head was allowed to float.  The wound was flushed with copious amounts of sterile saline.  #3-0 Vicryl was used to close the capsuloperiosteal tissues, which kept the metatarsal head contained.  Next, #4-0 Vicryl was used to close the subcutaneous layer in a simple interrupted suture technique.  Next, #4-0 nylon was used to close the skin in a simple interrupted technique.,Attention was directed to the right fifth metatarsal.  There was a large palpable hypertrophic prominence, which is the area of maximal pain, which the patient complained of preoperatively.  A #10 blade was used to make a 3 cm incision through the skin.  Next, a #15 blade was used to deepen the incision through the subcutaneous tissue.  Next, the medial and lateral aspects were undermined.  The abductor tendon was identified and retracted.  A capsuloperiosteal incision was made with a #15 blade in a linear fashion down to the bone.  The capsuloperiosteal tissues were elevated off the bone with a Freer elevator and a #15 blade.,Next, the sagittal saw was used to resect the large hypertrophic dorsal exostosis.  A reciprocating rasp was used to smooth all bony prominences.  The wound was flushed with copious amount of sterile saline.  #3-0 Vicryl was used to close the capsuloperiosteal tissues.  #4-0 Vicryl was used to close subcutaneous layer with a simple interrupted suture.  Next, #4-0 nylon was used to close the skin in a simple interrupted technique.  Next, attention was directed to the plantar aspect of the third metatarsal where a bursal sac was felt to be palpated under the plantar flex third metatarsal head.  A #15 blade was used to make a small linear incision under the third metatarsal head.  The incision was deepened through the dermal layer and curved hemostats and Metzenbaum scissors were used to undermine the skin from the underlying bursa.  The wound was flushed and two simple interrupted sutures with #4-0 nylon were applied.,Standard postoperative dressing was applied consisting of Xeroform, 4x4s, Kerlix, Kling, and Coban.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to the digits.,A sterile stockinet was placed on the toes just below the knee.  Copious amounts of Webril were placed on all bony prominences.  3 inch and 4 inch fiberglass cast tape was used to create a below the knee well-padded, well-moulded cast.  One was able to insert two fingers to the distal and proximal aspects of the _cast.  The capillary refill time to the digits was less than three seconds after cast application.  The patient tolerated the above anesthesia and procedures without complications.  She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot.  She was given standard postoperative instructions to rest, ice and elevate her right foot.  She was counseled on smoking cessation.  She was given Vicoprofen #30 1 p.o. q.4-6h p.r.n., pain.  She was given Keflex #30 1 p.o. t.i.d.  She is to follow up with Dr. X on Monday.  She is to be full weightbearing with a cast boot.  She was given emergency contact numbers to call us if problem arises.","orthopedic, plantar flex, talus bunion, talus bunionectomy, metatarsal osteotomy, osteotomy, short-leg cast, hypertrophic scarring, subcutaneous tissue, sharp dissection, linear incision, foot talus, pneumatic ankle, capsuloperiosteal tissues, plantar, foot, metatarsal, capsuloperiosteal, bunionectomy"
" Orthopedic progress note for follow up of osteoarthritis, knees.", Orthopedic, Osteoarthritis - Progress Note ,"CHIEF COMPLAINT: , Right knee. ,HISTORY OF THE PRESENT ILLNESS: , The patient presents today for follow up of osteoarthritis Grade IV of the bilateral knees and flexion contracture, doing great.  Physical therapy is helping. The subjective pain is on the bilateral knees right worse than left.,Pain:  Localized to the bilateral knees right worse than left.,Quality:  There is no swelling, no redness, or warmth.  The pain is described as aching occasionally.  There is no burning. ,Duration:  Months.,Associated symptoms:  Includes stiffness and weakness.  There is no sleep loss and no instability.  ,Hip Pain:  None. ,Back pain: None. ,Radicular type pain:  None. ,Modifying factors: Includes weight bearing pain and pain with ambulation.  There is no sitting, and no night pain.  There is no pain with weather change.,VISCOSUPPLEMENTATION IN PAST:,  No Synvisc.,VAS PAIN SCORE: , 10 bilaterally.,WOMAC SCORE: , 8,A-1 WOMAC SCORE: , 0,See the enclosed WOMAC osteoarthritis index, which accompanies the patient's chart, for complete details of the patient's limitations to activities of daily living.  ,REVIEW OF SYSTEMS:,  No change.,Constitutional:  Good appetite and energy.  No fever.  No general complaints.,HEENT:  No headaches, no difficulty swallowing, no change in vision, no change in hearing.,CV - RESP:  No shortness of breath at rest or with exertion.  No paroxysmal nocturnal dyspnea, orthopnea, and without significant cough, hemoptysis, or sputum.  No chest pain on exertion.,GI:",
 OssaTron extracorporeal shockwave therapy to right lateral epicondyle.  Right lateral epicondylitis., Orthopedic, OssaTron Extracorporeal Shockwave Therapy ,"PREOPERATIVE DIAGNOSIS:,  Right lateral epicondylitis.,POSTOPERATIVE DIAGNOSIS:,  Right lateral epicondylitis.,OPERATION PERFORMED:,  OssaTron extracorporeal shockwave therapy to right lateral epicondyle.,ANESTHESIA:,  Bier block.,DESCRIPTION OF PROCEDURE: , With the patient under adequate Bier block anesthesia, the patient was positioned for extracorporeal shockwave therapy.  The OssaTron equipment was brought into the field and the nose piece for treatment was placed against the lateral epicondyle targeting the area previously determined with the patient's input of maximum pain.  Then using standard extracorporeal shockwave protocol, the OssaTron treatment was applied to the lateral epicondyle of the elbow.  After completion of the treatment, the tourniquet was deflated, and the patient was returned to the holding area in satisfactory condition having tolerated the procedure well.","orthopedic, epicondylitis, ossatron extracorporeal shockwave therapy, bier block, epicondyle, ossatron, extracorporeal, shockwave, "
" Acetabular fracture on the left posterior column/transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip.  Osteosynthesis of acetabular fracture on the left, complex variety and total hip replacement.", Orthopedic, Osteosynthesis ,"PREOPERATIVE DIAGNOSIS:,  Acetabular fracture on the left posterior column/transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip.,POSTOPERATIVE DIAGNOSIS:,  Acetabular fracture on the left posterior column/transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip.,PROCEDURES:,1.  Osteosynthesis of acetabular fracture on the left, complex variety.,2.  Total hip replacement.,ANESTHESIA: , General.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE: , The patient in the left side up lateral position under adequate general endotracheal anesthesia, the patient's left lower extremity and buttock area were prepped with iodine and alcohol in the usual fashion, draped with sterile towels and drapes so as to create a sterile field.  Kocher Langenbeck variety incision was utilized and carried down through the fascia lata with the split fibers of the gluteus maximus in line.  The femoral insertion of gluteus maximus was tenotomized close to its femoral insertion.  The piriformis and obturator internus tendons and adjacent gemelli were tenotomized close to their femoral insertion, tagged, and retractor was placed in the lesser notch as well as a malleable retractor in the greater notch enabling the exposure of the posterior column.  The major transverse fracture was freed of infolded soft tissue, clotted blood, and lavaged copiously with sterile saline solution and then reduced anatomically with the aid of bone hook in the notch and provisionally stabilized utilizing a tenaculum clamp and definitively stabilized utilizing a 7-hole 3.5 mm reconstruction plate with the montage including two interfragmentary screws.  It should be mentioned that prior to reduction and stabilization of the acetabular fracture its femoral head component was removed from the joint enabling direct visualization of the articular surface.  Once a stable fixation of the reduced fracture of the acetabulum was accomplished, it should be mentioned that in the process of doing this, the posterior wall fragment was hinged on its soft tissue attachments and a capsulotomy was made in the capsule in line with the rent at the level of the posterior wall.  Once this was accomplished, the procedure was turned over to Dr. X and his team, who proceeded with placement of cup and femoral components as well and cup was preceded by placement of a trabecular metal tray for the cup with screw fixation of same.  This will be dictated in separate note.  The patient tolerated the procedure well.  The sciatic nerve was well protected and directly visualized to the level of the notch.","orthopedic, hip replacement, osteosynthesis, intertrochanteric variety, femoral insertion, acetabular fracture, fracture, acetabular, intertrochanteric, femoral "
 Patient with back and hip pain., Orthopedic, Orthopedic Consult - 5 ,"Chief Complaint:, Back and hip pain.,History of Present Illness:, The patient is a 73 year old Caucasian male with a history of hypertension, end-stage renal disease secondary to reflux nephropathy / restriction of bladder neck requiring hemodialysis and eventual cadaveric renal transplant now on chronic immunosuppression, peripheral vascular disease with non-healing ulcer of right great toe, and peripheral neuropathy who initially presented to his primary care physician in May 2001 with complaints of low back pain and bilateral hip pain. The pain was described as a constant pain in the middle to lower back and hips. The pain was exacerbated by climbing stairs and in the morning after sleeping. He reported occasional radiation of pain from back into buttocks (greatest on the right side). He has history of chronic feet and leg numbness and paraesthesias related to his neuropathy, but he denied any recent changes in these symptoms in relation to the back pain. He denied any history of trauma. He was treated symptomatically with Acetaminophen with only some relief. He continued to complain intermittently of pain in his back and hips, and occasionally even in his elbows during the next 8 months. In January 2002, plain pelvic films showed no fracture or dislocation of the hips. Elbow films also showed no acute injury, but there were some erosions along the posterior aspect of the olecranon. An MRI was performed of his lumbar spine which showed degenerative disk disease, spondylosis, and annular bulging/herniation at L4-L5 with resultant encroachment on the neural foramen. He was evaluated by neurosurgery, who felt he should not have surgery at this time. His pain continued and progressively worsened, becoming unresponsive to medical therapy including narcotics,In May 2002, as part of a vascular work-up for the patient’s non-healing right toe, an MRA showed extensive vascular disease in the vessels of both legs below the knees and evidence of bilateral trochanteric bursitis. It also revealed an abnormal enhancing lesion in the left proximal femur, the left iliac bone, the right iliac bone, and possibly the right tibia.,Past Medical History:,End stade renal disease secondary to reflux nephropathy,a. numerous related urinary tract infections,b. hemodialysis (1983-1988),c. s/p cadaveric renal transplant (1988),d. baseline creatinine about 2.3.,Hypertension,Peripheral vascular disease,a. history of right foot infected toenail and non-healing ulcer since 2000; receiving hyperbaric oxygen therapy; recent surgery on infected toe in March, 2002,Peripheral Neuropathy,Chronic anemia (on Epogen injections),History of several partial small bowel obstructions - six times during the last 10 years,Past Surgical History:,1. Tonsillectomy and adenoidectomy (1943),2. Left ureter re-implantation (1960),3. Repair of splenic artery aneurysm (1968),4. Left arm AV fistula graft placement and numerous procedures for dialysis access (1983-1988),5. Cadaveric renal transplant (1988),6. Cataract surgery in bilateral eyes,Medications:,1. Imuran 100mg po QD,2. Prednisone 7.5mg po QD,3. Aspirin 81mg po QD,4. Trental 400mg po TID,5. Norvasc 5mg po BID,6. Prinivil 20mg po BID,7. Hydralazine 50mg po Q6H,8. Clonidine TTS III on Thursdays,9. Terasozin 5mg po BID,10. Elavil 30mg po QHS,11. Vicodin 1-2tabs po Q6H prn,12. Epoetin SR 10,000Units SQ QM and F,13. Sodium bicarbonate 648mg po QD,14. Calcium carbonate 2gm po QID,15. Docusate sodium 100mg po QD,16. Chocolate Ensure one can po QID,17. Multivitamin,18. Vitamin E,Social History:, The patient is married with five children and lives with his wife. He is a retired engineer and real estate broker. He denies tobacco use. He drinks alcohol occasionally with up to three drinks a week. No history of drug abuse.,Allergies:, No known drug allergies.,Family History:",
 Patient with chronic pain plus lumbar disk replacement with radiculitis and myofascial complaints. , Orthopedic, Orthopedic Consult - 4 ,"CHIEF COMPLAINT: , Chronic low back, left buttock and leg pain.,HISTORY OF PRESENT ILLNESS: , This is a pleasant 49-year-old gentleman post lumbar disc replacement from January 2005.  Unfortunately, the surgery and interventional procedures have not been helpful in alleviating his pain.  He has also tried acupuncture, TENS unit, physical therapy, chiropractic treatment and multiple neuropathic medications including Elavil, Topamax, Cymbalta, Neurontin, and Lexapro, which he discontinued either due to side effects or lack of effectiveness in decreasing his pain.  Most recently, he has had piriformis injections, which did give him a brief period of relief; however, he reports that the Botox procedure that was done on March 8, 2006 has not given him any relief from his buttock pain.  He states that approximately 75% of his pain is in his buttock and leg and 25% in his back.  He has tried to increase in his activity with walking and does note increased spasm with greater activity in the low back.  He rated his pain today as 6/10, describing it is shooting, sharp and aching.  It is increased with lifting, prolonged standing or walking and squatting, decreased with ice, reclining and pain medication.  It is constant but variable in degree.  It continues to affect activities and sleep at night as well as mood at times.  He is currently not satisfied completely with his level of pain relief.,MEDICATIONS: , Kadian 30 mg b.i.d., Zanaflex one-half to one tablet p.r.n. spasm, and Advil p.r.n.,ALLERGIES:,  No known drug allergies.,REVIEW OF SYSTEMS:,  Complete multisystem review was noted and signed in the chart.,SOCIAL HISTORY:,  Unchanged from prior visit.,PHYSICAL EXAMINATION: , Blood pressure 123/87, pulse 89, respirations 18, and weight 220 lbs.  He is a well-developed obese male in no acute distress.  He is alert and oriented x3, and displays normal mood and affect with no evidence of acute anxiety or depression.  He ambulates with normal gait and has normal station.  He is able to heel and toe walk.  He denies any sensory changes.,ASSESSMENT & PLAN: , This is a pleasant 49-year-old with chronic pain plus lumbar disk replacement with radiculitis and myofascial complaints.  We discussed treatment options at length and he is willing to undergo a trial of Lyrica.,He is sensitive to medications based on his past efforts and is given a prescription for 150 mg that he will start at bedtime.  We discussed the up taper schedule and he understands that he will have to be on this for some time before we can decide whether or not it is helpful to him.  We also briefly touched on the possibility of a spinal cord stimulator trial if this medication is not helpful to him.  He will call me if there are any issues with the new prescription and follow in four weeks for reevaluation.","orthopedic, radiculitis, myofascial, acupuncture, tens unit, physical therapy, chiropractic treatment, lumbar disk replacement, lumbar disk, disk replacement"
" Back pain and right leg pain.  Small cell lung cancer with metastasis at the lower lumbar spine, pelvis, and both femurs", Orthopedic, Orthopedic Consult - 3 ,"CHIEF COMPLAINT:,  Back pain and right leg pain.  The patient has a three-year history of small cell lung cancer with metastases.,HISTORY OF PRESENT ILLNESS:,  The patient is on my schedule today to explore treatment of the above complaints.  She has a two-year history of small cell lung cancer, which she says has spread to metastasis in both femurs, her lower lumbar spine, and her pelvis.  She states she has had numerous chemotherapy and radiation treatments and told me that she has lost count.  She says she has just finished a series of 10 radiation treatments for pain relief.  She states she continues to have significant pain symptoms.  Most of her pain seems to be in her low back on the right side, radiating down the back of her right leg to her knee.  She has also some numbness in the bottom of her left foot, and some sharp pain in the left foot at times.  She complains of some diffuse, mid back pain.  She describes the pain as sharp, dull, and aching in nature.  She rates her back pain as 10, her right leg pain as 10, with 0 being no pain and 10 being the worst possible pain.  She states that it seems to be worse while sitting in the car with prolonged sitting, standing, or walking.  She is on significant doses of narcotics.  She has had multiple CT scans looking for metastasis.,PAST MEDICAL HISTORY:,  Significant for cancer as above.  She also has a depression.,PAST SURGICAL HISTORY:,  Significant for a chest port placement.,CURRENT MEDICATIONS:,  Consist of Duragesic patch 250 mcg total, Celebrex 200 mg once daily, iron 240 mg twice daily, Paxil 20 mg daily, and Percocet.  She does not know of what strength up to eight daily.  She also is on warfarin 1 mg daily, which she states is just to keep her chest port patent.  She is on Neurontin 300 mg three times daily.,HABITS:,  She smokes one pack a day for last 30 years.  She drinks beer approximately twice daily.  She denies use of recreational drugs.,SOCIAL HISTORY:,  She is married.  She lives with her spouse.,FAMILY HISTORY: , Significant for two brothers and father who have cancer.,REVIEW OF SYSTEMS:,  Significant mainly for her pain complaints.  For other review of systems the patient seems stable.,PHYSICAL EXAMINATION:,General:  Reveals a pleasant somewhat emaciated Caucasian female.,Vital Signs:  Height is 5 feet 2 inches.  Weight is 130 pounds.  She is afebrile.,HEENT:  Benign.,Neck:  Shows functional range of movements with a negative Spurling's.,Chest:  Clear to auscultation.,Heart:  Regular rate and rhythm.,Abdomen:  Soft, regular bowel sounds.,Musculoskeletal:  Examination shows functional range of joint movements.  No focal muscle weakness.  She is deconditioned.,Neurologic:  She is alert and oriented with appropriate mood and affect.  The patient has normal tone and coordination.  Reflexes are 2+ in both knees and absent at both ankles.  Sensations are decreased distally in the left foot, otherwise intact to pinprick.,Spine:  Examination of her lumbar spine shows normal lumbar lordosis with fairly functional range of movement.  The patient had significant tenderness at her lower lumbar facet and sacroiliac joints, which seems to reproduce a lot of her low back and right leg complaints.,FUNCTIONAL EXAMINATION: , Gait has a normal stance and swing phase with no antalgic component to it.,INVESTIGATION: , She has had again multiple scans including a whole body bone scan, which showed abnormal uptake involving the femurs bilaterally.  She has had increased uptake in the sacroiliac joint regions bilaterally.  CT of the chest showed no evidence of recurrent metastatic disease.  CT of the abdomen showed no evidence of metastatic disease.  MRI of the lower hip joints showed heterogenous bone marrow signal in both proximal femurs.  CT of the pelvis showed a trabecular pattern with healed metastases.  CT of the orbits showed small amount of fluid in the mastoid air cells on the right, otherwise normal CT scan.  MR of the brain showed no acute intracranial abnormalities and no significant interval changes.,IMPRESSION:,1.  Small cell lung cancer with metastasis at the lower lumbar spine, pelvis, and both femurs.,2.  Symptomatic facet and sacroiliac joint syndrome on the right.,3.  Chronic pain syndrome.,RECOMMENDATIONS:,  Dr. XYZ and I discussed with the patient her pathology.  Dr. XYZ explained her although she does have lung cancer metastasis, she seems to be symptomatic with primarily pain at her lower lumbar facet and sacroiliac joints on the right.  Secondary to the patient's significant pain complaints today, Dr. XYZ will plan on injecting her right sacroiliac and facet joints under fluoroscopy today.  I explained the rationale for the procedure, possible complications, and she voiced understanding and wished to proceed.  She understands that she is on warfarin therapy and that we generally do not perform injections while they are on this.  We have asked for stat protime today.  She is on a very small dose, she states she has had previous biopsies while on this before, and did not have any complications.  She is on significant dose of narcotics already, however, she continues to have pain symptoms.  Dr. XYZ advised that if she continues to have pain, even after this injection, she could put on an extra 50 mcg patch and take a couple of extra Percocet if needed.  I will plan on evaluating her in the Clinic on Tuesday.  I have also asked that she stop her Paxil, and we plan on starting her on Cymbalta instead.  She voiced understanding and is in agreement with this plan.  I have also asked her to get an x-ray of the lumbar spine for further evaluation.  Physical exam, findings, history of present illness, and recommendations were performed with and in agreement with Dr. G's findings.  Peripheral neuropathy of her left foot is most likely secondary to her chemo and radiation treatments.",
" Degenerative disk disease of the right hip, low back pain with lumbar scoliosis post laminectomy syndrome, lumbar spinal stenosis, facet and sacroiliac joint syndrome, and post left hip arthroplasty.", Orthopedic, Orthopedic Consult - 2 ,"SUBJECTIVE:,  The patient comes back to see me today.  She is a pleasant 77-year-old Caucasian female who had seen Dr. XYZ with right leg pain.  She has a history of prior laminectomy for spinal stenosis.  She has seen Dr. XYZ with low back pain and lumbar scoliosis post laminectomy syndrome, lumbar spinal stenosis, and clinical right L2 radiculopathy, which is symptomatic.  Dr. XYZ had performed two right L2-L3 transforaminal epidural injections, last one in March 2005.  She was subsequently seen and Dr. XYZ found most of her remaining symptoms are probably coming from her right hip.  An x-ray of the hip showed marked degenerative changes with significant progression of disease compared to 08/04/2004 study.  Dr. XYZ had performed right intraarticular hip injection on 04/07/2005.  She was last seen on 04/15/2005.  At that time, she had the hip injection that helped her briefly with her pain.  She is not sure whether or not she wants to proceed with hip replacement.  We recommend she start using a cane and had continued her on some pain medicines.,The patient comes back to see me today.  She continues to complain of significant pain in her right hip, especially with weightbearing or with movement.  She said she had made an appointment to see an orthopedic surgeon in Newton as it is closer and more convenient for her.  She is taking Ultracet or other the generic it sounds like, up to four times daily.  She states she can take this much more frequently as she still has significant pain symptoms.  She is using a cane to help her ambulate.,PAST MEDICAL HISTORY:,  Essentially unchanged from her visit of 04/15/2005.,PHYSICAL EXAMINATION:,General:  Reveals a pleasant Caucasian female.,Vital Signs:  Height is 5 feet 4 inches.  Weight is 149 pounds.  She is afebrile.,HEENT:  Benign.,Neck:  Shows functional range of movements with a negative Spurling's.,Musculoskeletal:  Examination shows some mild degenerative joint disease of both knees with grade weakness of her right hip flexors and half-grade weakness of her right hip adductors and right quadriceps, as compared to the left.  Straight leg raises are negative bilaterally.  Posterior tibials are palpable bilaterally.,Skin and Lymphatics:  Examination of the skin does not reveal any additional scars, rashes, cafe au lait spots or ulcers.  No significant lymphadenopathy noted.,Spine:  Examination shows lumbar scoliosis with surgical scar with no major tenderness.  Spinal movements are limited but functional.,Neurological:  She is alert and oriented with appropriate mood and affect.  She has normal tone and coordination.  Reflexes are 2+ and symmetrical.  Sensations are intact to pinprick.,FUNCTIONAL EXAMINATION:,  Gait has a normal stance and swing phase with no antalgic component to it.,IMPRESSION:,1.  Degenerative disk disease of the right hip, symptomatic.,2.  Low back syndrome, lumbar spinal stenosis, clinically right L2 radiculopathy, stable.,3.  Low back pain with lumbar scoliosis post laminectomy syndrome, stable.,4.  Facet and sacroiliac joint syndrome on the right, stable.,5.  Post left hip arthroplasty.,6.  Chronic pain syndrome.,RECOMMENDATIONS:,  The patient is symptomatic primarily on her right hip and is planning on seeing an orthopedic surgeon for possible right hip replacement.  In the interim, her Ultracet is not quite taking care of her pain.  I have asked her to discontinue it and we will start her on Tylenol #3, up to four times a day.  I have written a prescription for this for 120 tablets and two refills.  The patient will call for the refills when she needs them.  I will plan further follow up in six months, sooner if needed.  She voiced understanding and is in agreement with this plan.  Physical exam findings, history of present illness and recommendations were performed with and in agreement with Dr. Goel's findings.","orthopedic, scoliosis, lumbar, laminectomy, spinal stenosis, radiculopathy, chronic pain syndrome, low back pain, facet and sacroiliac joint, degenerative disk disease, sacroiliac joint syndrome, lumbar spinal stenosis, disk disease, sacroiliac joint, hip arthroplasty, hip injection, hip replacement, lumbar scoliosis, injections, hip, "
 Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left., Orthopedic, Pain Management Consult - 2 ,"HPI - WORKERS COMP:, The current problem began on or about 2/10/2000. The symptoms were sudden in onset. According to the patient, the current problem is a result of a work injury involving lifting approximately 40 pounds. Pain location (lower body): left hip. The patient describes the pain as dull, aching and stabbing. The severity of the pain ranges from mild to severe. The pain is severe occasionally. It is present constantly. The pain is made worse by sitting, riding in a car, twisting and lifting. The pain is made better by rest. The patient's symptoms appear to be soft tissue (spine), myofascial (spine) and musculoskeletal (spine) in origin. Sleep alteration because of pain: positive and wakes up after getting to sleep nightly. Systemic signs/symptoms relevant or potentially relevant to the spine: none. Patient reports the following symptoms: depressed mood, loss of interest or pleasure in all or most activities, insomnia, inability to concentrate, fatigue and loss of energy.,WORK STATUS:,",
" Medical management, status post left total knee arthroplasty.", Orthopedic, Orthopedic Consult ,"REASON FOR CONSULT: , Medical management, status post left total knee arthroplasty.,PAST MEDICAL HISTORY:,1.  Polyarthritis.,2.  Acromegaly.,3.  Hypothyroidism.,4.  Borderline hypertension.,5.  Obesity.,PAST SURGICAL HISTORY: , Hernia repair, resection of tumor, right thumb arthrodesis, carpal tunnel decompression, bilateral hip replacement, right total knee replacement about 2 months ago, open reduction of left elbow fracture.,REVIEW OF SYSTEMS:,CONSTITUTIONAL SYMPTOMS:  No fever or recent general malaise.,ENT:  Not remarkable.,RESPIRATORY:  No cough or shortness of breath.,CARDIOVASCULAR:  The patient denies any heart problems.  No orthopnea.  No palpitations.  No syncopal episodes.,GASTROINTESTINAL:  No nausea.  No vomiting.  No history of GI bleed.,GENITOURINARY:  No dysuria, no hematuria.,ENDOCRINE:  The patient is status post pituitary tumor resection and is on supplemental hormone.,MEDICATIONS:  Depo-Testosterone 200 mg IM q.3 weekly, prednisone 1 tablet p.o. daily, octreotide IM on a monthly basis, morphine extended release 50 mg p.o. b.i.d., Synthroid 100 mcg p.o. daily, desmopressin 1 tablet p.o. every bedtime, aspirin/oxycodone on a p.r.n. basis, aspirin on p.r.n. basis.,ALLERGIES: , IBUPROFEN AND TYLENOL.,SOCIAL HISTORY: , The patient does not smoke nor drink alcohol.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION,GENERAL:  Obese, 57-year-old gentleman, not in acute distress.,VITAL SIGNS:  Blood pressure of 105/55, pulse is 90.  He is afebrile.  O2 saturation is 95% on room air.,HEAD AND NECK:  Face symmetrical.  Cranial nerves are intact.  No distended neck veins.  No palpable neck masses.,CHEST:  Clear to auscultation.  No wheezing.  No crepitations.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmur was appreciated.,ABDOMEN:  Benign.,EXTREMITIES:  The left knee is in closed dressing.  The lower extremities are still numb from spinal anesthesia.,ASSESSMENT AND PLAN:,1.  Polyarthritis, status post left total knee replacement.  The patient tolerated the procedure well.,2.  Acromegaly, status post pituitary resection.  Continue supplemental hormones.,3.  Borderline hypertension, blood pressure is under control with monitoring.,4.  Deep venous thrombosis prophylaxis as per surgeon.,5.  Anemia due to repeated blood loss with monitor hemoglobin and hematocrit.",
" Low back pain, lumbar degenerative disc disease, lumbar spondylosis, facet and sacroiliac joint syndrome, lumbar spinal stenosis primarily bilateral recess, intermittent lower extremity radiculopathy, DJD of both knees, bilateral pes anserinus bursitis, and chronic pain syndrome.", Orthopedic, Orthopedic Consult - 1 ,"SUBJECTIVE:,  The patient comes back to see me today.  She is a pleasant 73-year-old Caucasian female who had seen Dr. XYZ with low back pain, lumbar degenerative disc disease, lumbar spondylosis, facet and sacroiliac joint syndrome, lumbar spinal stenosis primarily bilateral recess, intermittent lower extremity radiculopathy, DJD of both knees, bilateral pes anserinus bursitis, and chronic pain syndrome.  Dr. XYZ had performed right and left facet and sacroiliac joint injections, subsequent right L3 to S1 medial branch blocks and radiofrequency ablation on the right from L3 to S1.  She was subsequently seen with some mid back pain and she had right T8-T9 and T9-T10 facet injections on 10/28/2004.  She was last seen on 04/08/2005 with recurrent pain in her low back on the right.  Dr. XYZ repeated her radiofrequency ablation on the right side from L3-S1 on 05/04/2005.,The patient comes back to see me today.  She states that the radiofrequency ablation has helped her significantly there, but she still has one spot in her low back that seems to be hurting her on the right, and seems to be pointing to her right sacroiliac joint.  She is also complaining of pain in both knees.  She says that 20 years ago she had a cortisone shot in her knees, which helped her significantly.  She has not had any x-rays for quite some time.  She is taking some Lortab 7.5 mg tablets, up to four daily, which help her with her pain symptoms.  She is also taking Celebrex through Dr. S’ office.,PAST MEDICAL HISTORY:,  Essentially unchanged from my visit of 04/08/2005.,PHYSICAL EXAMINATION:,General:  Reveals a pleasant Caucasian female.,Vital Signs:  Height is 5 feet 5 inches.  Weight is 183 pounds.  She is afebrile.,HEENT:  Benign.,Neck:  Shows functional range of movements with a negative Spurling's.,Musculoskeletal:  Examination shows degenerative joint disease of both knees, with medial and lateral joint line tenderness, with tenderness at both pes anserine bursa.  Straight leg raises are negative bilaterally.  Posterior tibials are palpable bilaterally.,Skin and Lymphatics:  Examination of the skin does not reveal any additional scars, rashes, cafe au lait spots or ulcers.  No significant lymphadenopathy noted.,Spine:  Examination shows decreased lumbar lordosis with tenderness that seems to be in her right sacroiliac joint.  She has no other major tenderness.  Spinal movements are limited but functional.,Neurological:  She is alert and oriented with appropriate mood and affect.  She has normal tone and coordination.  Reflexes are 2+ and symmetrical.  Sensation is intact to pinprick.,FUNCTIONAL EXAMINATION:,  Gait has a normal stance and swing phase with no antalgic component to it.,IMPRESSION:,1.  Low back syndrome with lumbar degenerative disc disease, lumbar spinal stenosis, and facet joint syndrome on the right L4-5 and L5-S1.,2.  Improved, spinal right L3-S1 radiofrequency ablation.,3.  Right sacroiliac joint sprain/strain, symptomatic.,4.  Left lumbar facet joint syndrome, stable.,6.  Right thoracic facet joint syndrome, stable.,7.  Lumbar spinal stenosis, primarily lateral recess with intermittent lower extremity radiculopathy, stable.,8.  Degenerative disc disease of both knees, symptomatic.,9.  Pes anserinus bursitis, bilaterally symptomatic.,10.  Chronic pain syndrome.,RECOMMENDATIONS:,  Dr. XYZ and I discussed with the patient her pathology.  She has some symptoms in her low back on the right side at the sacroiliac joint.  Dr. XYZ will plan having her come in and injecting her right sacroiliac joint under fluoroscopy.  She is also having pain in both knees.  We will plan on x-rays of both knees, AP and lateral, and plan on seeing her back on Monday or Friday for possible intraarticular and/or pes anserine bursa injections bilaterally.  I explained the rationale for each of these injections, possible complications and she wishes to proceed.  In the interim, she can continue on Lortab and Celebrex.  We will plan for the follow up following these interventions, sooner if needed.  She voiced understanding and agreement.  Physical exam findings, history of present illness, and recommendations were performed with and in agreement with Dr. Goel's findings.","orthopedic, low back pain, lumbar degenerative disc disease, lumbar spondylosis, facet, sacroiliac joint syndrome, lumbar spinal stenosis, intermittent lower extremity radiculopathy, djd of both knees, bilateral pes anserinus bursitis, chronic pain syndrome, degenerative disc disease, pes anserinus bursitis, pes anserine bursa, sacroiliac joint, joint syndrome, degenerative disc, lumbar spinal, bilateral recess, lumbar, joint, intermittent, djd, pes, spinal, spondylosis, sacroiliac, syndrome, "
 A 19-year-old right-handed male injured in a motor vehicle accident., Orthopedic, Ortho - Letter - 1 ,"XYZ, D.C.,Re:  ABC,Dear Dr. XYZ:,I had the pleasure of seeing your patient, ABC, today MM/DD/YYYY in consultation.  He is an unfortunate 19-year-old right-handed male who was injured in a motor vehicle accident on MM/DD/YYYY, where he was the driver of an automobile, which was struck on the front passenger's side.  The patient sustained impact injuries to his neck and lower back.  There was no apparent head injury or loss of consciousness and he denied any posttraumatic seizures.  He was taken to Hospital, x-rays were taken, apparently which were negative and he was released.,At the present time, he complains of neck and lower back pain radiating into his right arm and right leg with weakness, numbness, paraesthesia, and tingling in his right arm and right leg.  He has had no difficulty with bowel or bladder function.  He does experience intermittent headaches associated with his neck pain with no other associated symptoms.,PAST HEALTH:,  He was injured in a prior motor vehicle accident on MM/DD/YYYY.  At the time of his most recent injuries, he was completely symptom free and under no active therapy.  There is no history of hypertension, diabetes, heart disease, neurological disorders, ulcers or tuberculosis.,SOCIAL HISTORY: , He denies tobacco or alcohol consumption.,ALLERGIES: , No known drug allergies.,CURRENT MEDICATIONS:  ,None.,FAMILY HISTORY: , Otherwise noncontributory.,FUNCTIONAL INQUIRY: , Otherwise noncontributory.,REVIEW OF DIAGNOSTIC STUDIES:,  Includes an MRI scan of the cervical spine dated MM/DD/YYYY which showed evidence for disc bulging at the C6-C7 level.  MRI scan of the lumbar spine on MM/DD/YYYY, showed evidence of a disc herniation at the L1-L2 level as well as a disc protrusion at the L2-L3 level with disc herniations at the L3-L4 and L4-L5 level and disc protrusion at the L5-S1 level.,PHYSICAL EXAMINATION: , Reveals an alert and oriented male with normal language function.  Vital Signs:  Blood pressure was 105/68 in the left arm sitting.  Heart rate was 70 and regular.  Height was 5 feet 8 inches.  Weight was 182 pounds.  Cranial nerve evaluation was unremarkable.  Pupils were equal and reactive.  Funduscopic evaluation was clear.  There was no evidence for nystagmus.  There was decreased range of motion noted in both the cervical and lumbar regions to a significant degree, with tenderness and spasm in the paraspinal musculature.  Straight leg raising was limited to 45 degrees on the right and 90 degrees on the left.  Motor strength was 5/5 on the MRC scale.  Reflexes were 2+ symmetrical and active.  No pathological responses were noted.  Sensory examination showed a diffuse decreased sensation to pinprick in the right upper extremity.  Cerebellar function was normal.  There was normal station and gait.  Chest and cardiovascular evaluations were unremarkable.  Heart sounds were normal.  There were no extra sounds or murmurs.  Palpable trigger points were noted in the right trapezius and right cervical and lumbar paraspinal musculature.,CLINICAL IMPRESSION: , Reveals a 19-year-old male suffering from a posttraumatic cervical and lumbar radiculopathy, secondary to traumatic injuries sustained in a motor vehicle accident on MM/DD/YYYY.  In view of the persistent radicular complaints associated with the weakness, numbness, paraesthesia, and tingling as well as the objective sensory loss noted on today's evaluation as well as the non-specific nature of the radiculopathy, I have scheduled him for an EMG study on his right upper and right lower extremity in two week's time to rule out any nerve root irritation versus any peripheral nerve entrapment or plexopathy as the cause of his symptoms.  Palpable trigger points were noted on today's evaluation.  He is suffering from ongoing myofascitis.  His treatment plan will consist of a series of trigger point injections to be initiated at his next follow up visit in two weeks' time.  I have encouraged him to continue with his ongoing treatment program under your care and supervision.  I will be following him in two weeks' time.  Once again, thank you kindly for allowing me to participate in this patient's care and management.,Yours sincerely,,","orthopedic, numbness paraesthesia and tingling, paraesthesia and tingling, cervical and lumbar, motor vehicle accident, mri scan, disc protrusion, paraspinal musculature, letter, musculature, radiculopathy, nerve, trigger, vehicle, accident, cervical, lumbar, evaluation, disc, ortho, "
 Open reduction and internal fixation (ORIF) of the right wrist using an Acumed locking plate.  Closed displaced angulated fracture of the right distal radius., Orthopedic, ORIF Wrist - Acumed Locking Plate ,"PREOPERATIVE DIAGNOSIS:  ,Closed displaced angulated fracture of the right distal radius.,POSTOPERATIVE DIAGNOSIS: , Closed displaced angulated fracture of the right distal radius.,PROCEDURE: , Open reduction and internal fixation (ORIF) of the right wrist using an Acumed locking plate.,ANESTHESIA: , General laryngeal mask airway.,ESTIMATED BLOOD LOSS: , Minimal.,TOURNIQUET TIME: , 40 minutes.,COMPLICATIONS: , None.,The patient was taken to the postanesthesia care unit in stable condition.  The patient tolerated the procedure well.,INDICATIONS:  ,The patient is a 23-year-old gentleman who was involved in a crush injury to his right wrist.  He was placed into a well-molded splint after reduction was performed in the emergency department.  Further x-rays showed further distal fragment dorsal angulation that progressively worsened and it was felt that surgical intervention was warranted.  All risks, benefits, expectations, and complications of the surgery were explained to the patient in detail, and he signed the informed consent for ORIF of the right wrist.,PROCEDURE: , The patient was taken to the operating suite, placed in supine position on the operative table.  The Department of anesthesia administered a general endotracheal anesthetic, which the patient tolerated well.  The right upper extremity had a well-padded tourniquet placed on the right arm, which was insufflated and maintained for 40 minutes at 250 mmHg pressure.  The right upper extremity was prepped and draped in a sterile fashion.  A 5-cm incision was made over the flexor carpi radialis of the right wrist.  The skin was incised down to the subcutaneous tissue, the deep tissue was retracted, blunt dissection was performed down to the pronator quadratus.  Sharp dissection was performed through the pronator quadratus after which a tissue elevator was used to elevate this tissue.  Next, a reduction was performed placing the distal fragment into appropriate alignment.  This was checked under fluoroscopy, and was noted to be adequately reduced and in appropriate position.  An Acumed Accu-lock plate was placed along the volar aspect of the distal radius.  This was checked under AP and lateral views with C-arm, noted to be in appropriate alignment.  A 3.5-mm cortical screw was placed through the proximal aspect of the plate, positioned it into position.  Two distal locking screws were placed along the plate itself.  The screws were checked under AP and lateral views noting the fracture fragment was well aligned and appropriately reduced with the 2 screws being placed into appropriate position with the appropriate length as well as not being intraarticular.  Four more screws were placed along the distal aspect of the plate and 2 more proximal along the plate.  All locking screws placed into position and had excellent purchase into the bone or had excellent fixation into the plate and maintained the alignment of the fracture.  AP and lateral views were taken of these screw placements again.  None of these screws were into the joint and all had appropriate length into the dorsal cortex.  Two more 3.5 fully threaded cortical screws were placed along the proximal aspect of the plate and had excellent bicortical purchase.  AP and lateral views were taken of the wrist once again showing that this was appropriate reduction of the fracture as well as appropriate placement of the screws.  Bicortical purchase was appreciated and no screws were placed into the joint.  The wound itself was copiously irrigated with saline and Kantrex after which the subcutaneous tissue was approximated with 2-0 Vicryl, and the skin was closed with running 4-0 nylon stitch; 10 mL of 0.5% Marcaine plain was injected into the wound site after which sterile dressing was placed as well as the volar splint.  The patient was awakened from general anesthetic, transferred to the hospital gurney and taken to the postanesthesia care unit in stable condition.  The patient tolerated the procedure well.","orthopedic, open reduction, angulated fracture, distal radius, acumed locking plate, internal fixation, tourniquet, acumed, orif, reduction, fracture, wrist"
 The patient continues to suffer from ongoing neck and lower back pain with no recent radicular complaints., Orthopedic, Ortho Office Visit ,"Her evaluation today reveals restriction in the range of motion of the cervical and lumbar region with tenderness and spasms of the paraspinal musculature.  Motor strength was 5/5 on the MRC scale.  Reflexes were 2+ and symmetrical.  Palpable trigger points were noted bilaterally in the trapezius and lumbar paraspinal musculature bilaterally.,Palpable trigger points were noted on today's evaluation.  She is suffering from ongoing myofascitis.  Her treatment plan will consist of a series of trigger point injections, which were performed today.  She tolerated the procedure well.  I have asked her to ice the region intermittently for 15 minutes off and on x 3.  She will be followed in four weeks' time for repeat trigger point injections if indicated.,","orthopedic, back pain, trigger point injections, paraspinal musculature, lumbar, paraspinal, musculature, palpable, injections, evaluation, triggerNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" Open reduction and internal fixation (ORIF) of comminuted C2 fracture.  Posterior spinal instrumentation C1-C3, using Synthes system.  Posterior cervical fusion C1-C3.  Insertion of morselized allograft at C1to C3.", Orthopedic, ORIF & Cervical Fusion ,"PREOPERATIVE DIAGNOSIS: , Fracture dislocation, C2.,POSTOPERATIVE DIAGNOSIS:  ,Fracture dislocation, C2.,OPERATION PERFORMED,1.  Open reduction and internal fixation (ORIF) of comminuted C2 fracture.,2.  Posterior spinal instrumentation C1-C3, using Synthes system.,3.  Posterior cervical fusion C1-C3.,4.  Insertion of morselized allograft at C1to C3.,ANESTHESIA:,  GETA.,ESTIMATED BLOOD LOSS:,  100 mL.,COMPLICATIONS: , None.,DRAINS: , Hemovac x1.,Spinal cord monitoring is stable throughout the entire case.,DISPOSITION:,  Vital signs are stable, extubated and taken back to the ICU in a satisfactory and stable condition.,INDICATIONS FOR OPERATION:,  The patient is a middle-aged female, who has had a significantly displaced C2 comminuted fracture.  This is secondary to a motor vehicle accident and it was translated appropriately 1 cm.  Risks and benefits have been conferred with the patient as well as the family, they wish to proceed.  The patient was taken to the operating room for a C1-C3 posterior cervical fusion, instrumentation, open reduction and internal fixation.,OPERATION IN DETAIL: , After appropriate consent was obtained from the patient, the patient was wheeled back to the operating theater room #5.  The patient was placed in the usual supine position and intubated and under general anesthesia without any difficulties.  Spinal cord monitoring was induced.  No changes were seen from the beginning to the end of the case.,Mayfield tongues were placed appropriately.  This was placed in line with the pinna of the ear as well as a cm above the tip of the earlobes.  The patient was subsequently rolled onto the fluoroscopic OSI table in the usual prone position with chest rolls.  The patient's Mayfield tongue was fixated in the usual standard fashion.  The patient was subsequently prepped and draped in the usual sterile fashion.  Midline incision was extended from the base of the skull down to the C4 spinous process.  Full thickness skin fascia developed.  The fascia was incised at midline and the posterior elements at C1, C2, C3, as well as the inferior aspect of the occiput was exposed.  Intraoperative x-ray confirmed the level to be C2.,Translaminar screws were placed at C2 bilaterally.  Trajectory was completed with a hand drill and sounded in all four quadrants to make sure there was no violation of pedicles and once this was done, two 3.5 mm translaminar screws were placed bilaterally at C2.  Good placement was seen both in the AP and lateral planes using fluoroscopy.  Facet screws were then placed at C3.  Using standard technique of Magerl, starting in the inferomedial quadrant 14 mm trajectories in the 25-degree caudad-cephalad direction as well as 25 degrees in the medial lateral direction was made.  This was subsequently sounded in all four quadrants to make sure that there is no elevation of the trajectory.  A 14 x 3.5 mm screws were then placed appropriately.  Lateral masteries at C1 endplate were placed appropriately.  The medial and lateral borders were demarcated with a Penfield.  The great occipital nerve was retracted out the way.  Starting point was made with a high-speed power bur and midline and lateral mass bilaterally.  Using a 20-degree caudad-cephalad trajectory as well as 10-degree lateral-to-medial direction, the trajectory was completed in 8 mm increments, this was subsequently sounded in all four quadrants to make sure that there was no violation of the pedicle wall of the trajectory.  Once this was done, 24 x 3.5 mm smooth Schanz screws were placed appropriately.  Precontoured titanium rods were then placed between the screws at the C1, C2, C3 and casts were placed appropriately.  Once this was done, all end caps were appropriately torqued.  This completed the open reduction and internal fixation of the C2 fracture, which showed perfect alignment.  It must be noted that the reduction was partially performed on the table using lateral fluoroscopy prior to the instrumentation, almost reducing the posterior vertebral margin of the odontoid fracture with the base of the C2 access.  Once the screws were torqued bilaterally, good alignment was seen both in the AP and lateral planes using fluoroscopy, this completed instrumentation as well as open reduction and internal fixation of C2.  The cervical fusion was completed by decorticating the posterior elements of C1, C2, and C3.  Once this was done, the morselized allograft 30 mL of cortical cancellous bone chips with 10 mL of demineralized bone matrix was placed over the decorticated elements.  The fascia was closed using interrupted #1 Vicryl suture figure-of-8.  Superficial drain was placed appropriately.  Good alignment of the instrumentation as well as of the fracture was seen both in the AP and lateral planes.  The subcutaneous tissues were closed using a #2-0 Vicryl suture.  The dermal edges were approximated using staples.  The wound was then dressed sterilely using Bacitracin ointment, Xeroform, 4x4s, and tape, and the drain was connected appropriately.  The patient was subsequently released with a Mayfield contraption and rolled on to the stretcher in the usual supine position.  Mayfield tongues were subsequently released.  No significant bleeding was appreciated.  The patient was subsequently extubated uneventfully and taken back to the recovery room in satisfactory and stable condition.  No complications arose.","orthopedic, fracture dislocation, spinal instrumentatio, comminuted, fracture, morselized, allograft, vicryl suture, mayfield tongues, cervical fusion, internal fixation, orif, cervical, fusion, fixation, spinal, reduction, instrumentation, "
 Open reduction and internal fixation of the left medial epicondyle fracture with placement in a long-arm posterior well-molded splint and closed reduction casting of the right forearm., Orthopedic, ORIF & Closed Reduction ,"PREOPERATIVE DIAGNOSES: , Left elbow fracture dislocation with incarceration of the medial epicondyle with ulnar nerve paresthesias status post closed reduction, attempts 2, right radial shaft fracture with volar apex angulation.,POSTOPERATIVE DIAGNOSES:,  Left elbow fracture dislocation with incarceration of the medial epicondyle with ulnar nerve paresthesias status post closed reduction, attempts 2, right radial shaft fracture with volar apex angulation.,PROCEDURES:  ,1.  Open reduction internal fixation of the left medial epicondyle fracture with placement in a long-arm posterior well-molded splint.,2.  Closed reduction casting of the right forearm.,ANESTHESIA: , Surgery performed under general anesthesia.  Local anesthetic was 10 mL of 0.5% Marcaine.,TOURNIQUET TIME: , On the left was 29 minutes.,COMPLICATIONS:  ,There were no intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,HISTORY AND PHYSICAL:  ,The patient is a 13-year-old right-hand dominant girl, who fell off a swing at school around 1:30 today.  The patient was initially seen at an outside facility and brought here by her father, given findings on x-ray, a closed reduction was attempted on the left elbow.  After the attempted reduction, the patient was noted to have an incarcerated medial epicondyle fracture as well as increasing ulnar paresthesias that were not present prior to the procedure.  Given this finding, the patient needed urgent open reduction and internal fixation to relieve the pressure on the ulnar nerve.  At that same time, the patient's mildly angulated radial shaft fracture will be reduced.  This was explained to the father.  The risks of surgery included the risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, need for later hardware removal, and possible continuous nerve symptoms.  All questions were answered.  The father agreed to the above plan.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating room table.  General anesthesia was then administered.  The patient received Ancef preoperatively.  The left upper extremity was then prepped and draped in the standard surgical fashion.  Attempts to remove the incarcerated medial epicondyle with supination, valgus stress, and with extension were unsuccessful.  It was decided at this time that she would need open reduction.  The arm was wrapped in Esmarch prior to inflation of the tourniquet to 250 mmHg.  The Esmarch was then removed.  An incision was then made.  Care was taken to avoid any injury to the ulnar nerve.  The medial epicondyle fracture was found incarcerated into the anterior aspect of the joint.  This was easily removed.  The ulnar nerve was also identified, and appeared to be intact.  The medial epicondyle was then transfixed using a guidewire into its anatomic position with the outer cortex over drilled with a 3.2 drill bit, and subsequently a 44-mm 4.5 partially threaded cannulated screw was then placed with a washer to hold the medial epicondyle in place.  After fixation of the fragment, the ulnar nerve was visualized as it traveled around the medial epicondyle fracture with no signs of impingement.  The wound was then irrigated with normal saline and closed using 2-0 Vicryl and 4-0 Monocryl.  The wound was clean and dry, dressed with Steri-Strips and Xeroform.  The area was infiltrated with 0.5% Marcaine.  The patient was then placed in a long-arm posterior well-molded splint with 90 degrees of flexion and neutral rotation.  The tourniquet was released at 30 minutes prior to placement of the dressing, showed no significant bleeding.  Attention was then turned to right side, the arm was then manipulated and a well-molded long-arm cast placed.  The final position in the cast revealed a very small residual volar apex angulation, which is quite acceptable in this age.  The patient tolerated the procedure well, was subsequently extubated and taken to recovery in a stable condition.,POSTOPERATIVE PLAN: , The patient will be hospitalized for pain control and neurovascular testing for the next 1 to 2 days.  The father was made aware of the intraoperative findings.  All questions answered.","orthopedic, orif, elbow fracture, dislocation, open reduction internal fixation, closed reduction, left medial epicondyle fracture, long-arm posterior well-molded splint, splint, radial shaft fracture, volar apex angulation, medial epicondyle fracture, medial epicondyle, internal fixation, epicondyle fracture, ulnar nerve, epicondyle, fracture, reduction, tourniquet, ulnar, nerve, "
" Open reduction and internal fixation of left atrophic mandibular fracture, removal of failed dental implant from the left mandible.  The patient fell following an episode of syncope and sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in fracture. ", Orthopedic, ORIF Mandibular Fracture & Dental Implant Removal ,"PREOPERATIVE DIAGNOSES: , Open, displaced, infected left atrophic mandibular fracture; failed dental implant.,POSTOPERATIVE DIAGNOSES: , Open, displaced, infected left atrophic mandibular fracture; failed dental implant.,PROCEDURE PERFORMED: , Open reduction and internal fixation (ORIF) of left atrophic mandibular fracture, removal of failed dental implant from the left mandible.,ANESTHESIA: , General nasotracheal.,ESTIMATED BLOOD LOSS: , 125 mL.,FLUIDS GIVEN: , 1 L of crystalloids.,SPECIMEN: , Soft tissue from the fracture site sent for histologic diagnosis.,CULTURES: , Also sent for Gram stain, aerobic and anaerobic, culture and sensitivity.,INDICATIONS FOR THE PROCEDURE: , The patient is a 79-year-old male, who fell in his hometown, following an episode of syncope.  He sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in the above-mentioned fracture.  He was admitted to hospital in Harleton, Texas, where his initial evaluation showed the rib fractures have also showed a nodule on his right upper lobe as well as a mediastinal mass.  His mandible fracture was not noted initially.  The patient also has a history of prostate cancer and a renal cell carcinoma.  The patient at that point underwent a bronchoscopy with a biopsy of the mediastinal mass and the results of that biopsy are still pending.  The patient later saw a local oral surgeon.  He diagnosed his mandible fracture and advised him to seek treatment in Houston.  He presented to my office for evaluation on January 18, 2010, and he was found to have an extremely atrophic mandible with a fracture in the left parasymphysis region involving a failed dental implant, which had been placed approximately 15 years ago.  The patient had significant discomfort and could eat foods and drink fluids with difficulty.  Due to the nature of his fracture and the complex medical history, he was sent to the hospital for admission and following cardiac clearance, he was scheduled for surgery today.,PROCEDURE IN DETAIL: , The patient was taken to the operating room, and placed in a supine position.  Following a nasal intubation and induction of general anesthesia, the surgeon then scrubbed, gowned, and gloved in the normal sterile fashion.  The patient was then prepped and draped in a manner consistent with sterile procedures.  A marking pen was first used to outline the incision in the submental region and it was extended from the left mandibular body to the right mandibular body region, approximately 1.5 cm medial to the inferior border of the mandible.  A 1 mL of lidocaine 1% with 1:100,000 epinephrine was then infiltrated along the incision and then a 15-blade was used to incise through the skin and subcutaneous tissue.  A combination of sharp and blunt dissection was then used to carry the dissection superiorly to the inferior border of the mandible.  Electrocautery as well as 4.0 silk ties were used for hemostasis.  A 15-blade was then used to incise the periosteum along the inferior border of the mandible and it was reflected exposing the mandible as well as the fracture site.  The fracture site was slightly distracted allowing access to the dental implant within the bone and it was easily removed from the wound.  Cultures of this site were also obtained and then the granulation tissue from the wound was also curetted free of the wound and sent for a histologic diagnosis.  Manipulation of the mandible was then used to achieve an anatomic reduction and then an 11-hole Synthes reconstruction plate was then used to stand on the fracture site.  Since there was an area of weakness in the right parasymphysis region, in the location of another dental implant, the bone plate was extended posterior to that site.  When the plate was adapted to the mandible, it was then secured to the bone with 9 screws, each being 2 mm in diameter and each screw was placed bicortically.  All the screws were also locking screws.  Following placement of the screws, there was felt to be excellent stability of the fracture, so the wound was irrigated with a copious amount of normal saline.  The incision was closed in multiple layers with 4.0 Vicryl in the muscular and subcutaneous layers and 5.0 nylon in the skin.  A sterile dressing was then placed over the incision.  The patient tolerated the procedure well and was taken to the recovery room with spontaneous respirations and stable vital signs.  Estimated blood loss is 125 mL.","orthopedic, atrophic mandibular fracture, dental implant, open reduction and internal fixation, orif, mandibular fracture, mandible, atrophic, mandibular, dental, implant,"
 Open reduction internal fixation (ORIF) with irrigation and debridement of open fracture.  Closed reduction and screw fixation of right femoral neck fracture.  Retrograde femoral nail using a striker T2 retrograde nail.  Irrigation and debridement of knee and elbow abrasions., Orthopedic," ORIF, Closed Reduction, Screw Fixation, Etc. ","TITLE OF OPERATION:,1.  Open reduction internal fixation (ORIF) with irrigation and debridement of open fracture including skin, muscle, and bone using a Synthes 3.5 mm locking plate on the lateral malleolus and two Synthes 4.5 mm cannulated screws medial malleolus.,2.  Closed reduction and screw fixation of right femoral neck fracture using one striker Asnis 8.0 mm cannulated screw and two 6.5 mm cannulated screws.,3.  Retrograde femoral nail using a striker T2 retrograde nail 10 x 340 with a 10 mm INCAP and two 5 mm distal locking screws and two 5 mm proximal locking screws.,4.  Irrigation and debridement of right knee.,5.  Irrigation and debridement of right elbow abrasions.,PREOP DIAGNOSIS:,1.  Right open ankle fracture.,2.  Right femoral shaft fracture.,3.  Right femoral neck fracture.,4.  Right open knee.,5.  Right elbow abrasions.,POSTOP DIAGNOSIS:,1.  Right open ankle fracture.,2.  Right femoral shaft fracture.,3.  Right femoral neck fracture.,4.  Right open knee.,5.  Right elbow abrasions.,INTRAVENOUS FLUIDS: , 650 packed red blood cells.,TOURNIQUET TIME: , 2 hours.,URINE OUTPUT:  ,1600 cubic centimeters.,ESTIMATED BLOOD LOSS: , 250 cubic centimeters.,COMPLICATIONS:,  None.,PLAN:,  non-weightbearing right lower extremity, clindamycin x 48 hours.,OPERATIVE NARRATIVE:,  The patient is a 53-year-old female who is a pedestrian struck, in a motor vehicle accident and sustained numerous injuries.  She sustained a right open ankle fracture, right femur fracture, right femoral neck fracture, right open knee, and right elbow abrasions.  Given the emergent nature of the right femoral neck fracture and her young age as well as the open fracture, it was decided to proceed with an urgent operative intervention.  The risks of surgery were discussed in detail and the consents were signed.  The operative site was marked.  The patient was taken to the operating room where she was given preoperative clindamycin.  The patient had then general anesthetic performed by anesthesia.,A well-padded side tourniquet was placed.  Attention was turned to the right ankle first.  The large medical laceration was extended and the tissues were debrided.  All dirty of the all injured bone, muscle, and tissues were debrided.  Wound was then copiously irrigated with 8 liters of normal saline.  At this point, the medial malleolus fracture was identified and was reduced.  This was then fixed in with two 4.5 mm cannulated Synthes screws.,Next, the attention was turned to lateral malleolus.  Incision was made over the distal fibula.  It was carried down sharply through the skin in the subcutaneous issues.  Care was taken to preserve the superficial peroneal nerve.  The fracture was identified, and there was noted to be very comminuted distal fibula fracture.  The fracture was reduced and confirmed with fluoroscopy.  A 7 hole Synthes 3.5 mm locking plate was placed.  This was placed in a bridging fashion with three screws above and three screws below the fracture.  Appropriate reduction was confirmed under fluoroscopy.  A cotton test was performed, and the ankle did not open up.  Therefore, it was decided not to proceed with syndesmotic screw.,Next, the patient was then placed in the fracture table and all extremities were well padded.  All prominences were padded.  The right leg was then prepped and draped in usual sterile fashion.  A 2-cm incision was made just distal to the greater trochanter.  This was carried down sharply through the skin to the fascia.  The femur was identified.  The guidewire for a striker Asnis 6.5 mm screw was placed in the appropriate position.  The triangle guide was then used to ensure appropriate triangular formation of the remainder of the screws.  A reduction of the fracture was performed prior to placing all the guide wires.  A single 8 mm Asnis screw was placed inferiorly followed by two 6.5 mm screws superiorly.,Next, the abrasions on the right elbow were copiously irrigated.  The necrotic and dead tissue was removed.  The abrasions did not appear to enter the joints.  They were wrapped with Xeroform 4 x 4 x 4 Kerlix and Ace wrap.,Next, the lacerations of the anterior knee were connected and were extended in the midline.  They were carried down sharply to the skin and the retinacular issues to the joint.  The intercondylar notch was identified.  A guide wire for the striker T2 retrograde nail was placed and localized with fluoroscopy.  The opening reamer was used following the bolted guide wire was then passed.  The femur was then sequentially reamed using the flexible reamers.  A T2 retrograde nail 10 x 340 was then passed.  Two 5 mm distal locking screws and two 5 mm proximal locking screws were then placed.,Prior to reaming and passing the retrograde nail, the knee was copiously irrigated with 8 liters of normal saline.  Any dead tissues in the knee were identified and were debrided using rongeurs and curettes.,The patient was placed in the AO splints for the right ankle.  The wounds were dressed with Xeroform 4 x 4 x 4s and IO band.  The care was then transferred for the patient to Halstead Service.,The plan will be non-weightbearing right lower extremity and antibiotics for 48 hours.,Dr. X was present and scrubbed for the entirety of the procedure.",
" Patient suffers from neck and lower back pain radiating into both arms and both legs with numbness, paraesthesia, and tingling in both arms.", Orthopedic, Ortho - Letter - 2 ,"XYZ, D.C.,60 Evergreen Place,Suite 902,East Orange, NJ  07018,Re:","orthopedic, paraspinal musculature, palpable trigger points, trigger point injections, lumbar, region, paraspinal, musculature, injections, trigger, "
 Open reduction and internal fixation of left distal radius., Orthopedic, ORIF of Left Distal Radius ,"PREOPERATIVE DIAGNOSIS: , Left distal radius fracture, metaphyseal extraarticular.,POSTOPERATIVE DIAGNOSIS: , Left distal radius fracture, metaphyseal extraarticular.,PROCEDURE: , Open reduction and internal fixation of left distal radius.,IMPLANTS:  ,Wright Medical Micronail size 2.,ANESTHESIA: , LMA.,TOURNIQUET TIME: , 49 minutes.,BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,PATHOLOGY: , None.,TIME OUT: , Time out was performed before the procedure started.,INDICATIONS:,  The patient was a 42-year-old female who fell and sustained a displaced left metaphyseal distal radius fracture indicated for osteosynthesis.  The patient was in early stage of gestation.  Benefits and risks including radiation exposure were discussed with the patient and consulted her primary care doctor.,DESCRIPTION OF PROCEDURE: , Supine position, LMA anesthesia, well-padded arm, tourniquet, Hibiclens, alcohol prep, and sterile drape.,Exsanguination achieved, tourniquet inflated to 250 mmHg.  First, under fluoroscopy the fracture was reduced.  A 0.045 K-wire was inserted from dorsal ulnar corner of the distal radius and crossing fracture line to maintain the reduction.  A 2-cm radial incision, superficial radial nerve was exposed and protected.  Dissecting between the first and second dorsal extensor retinaculum, the second dorsal extensor compartment was elevated off from the distal radius.  The guidewire was inserted under fluoroscopy.  A cannulated drill was used to drill antral hole.  Antral awl was inserted.  Then we reamed the canal to size 2.  Size 2 Micronail was inserted to the medullary canal.  Using distal locking guide, three locking screws were inserted distally.  The second dorsal incision was made.  The deep radial dorsal surface was exposed.  Using locking guide, two proximal shaft screws were inserted and locked the nail to the radius.  Fluoroscopic imaging was taken and showing restoration of the height, tilt, and inclination of the radius.  At this point, tourniquet was deflated, hemostasis achieved, wounds irrigated and closed in layers.  Sterile dressing applied.  The patient then was extubated and transferred to the recovery room under stable condition.,Postoperatively, the patient will see a therapist within five days.  We will immobilize wrist for two weeks and then starting flexion-extension and prosupination exercises.","orthopedic, distal radius fracture, dorsal extensor, locking guide, radius fracture, extraarticular, metaphyseal, guidewire, fracture, dorsal, distal, "
 Open reduction and internal fixation of left tibia., Orthopedic, ORIF - Left Tibia ,"PREOPERATIVE DIAGNOSIS: , Left tibial tubercle avulsion fracture.,POSTOPERATIVE DIAGNOSIS:,  Comminuted left tibial tubercle avulsion fracture with intraarticular extension.,PROCEDURE:,  Open reduction and internal fixation of left tibia.,ANESTHESIA: , General.  The patient received 10 ml of 0.5% Marcaine local anesthetic.,TOURNIQUET TIME: , 80 minutes.,ESTIMATED BLOOD LOSS:,  Minimal.,DRAINS: , One JP drain was placed.,COMPLICATIONS: , No intraoperative complications or specimens.  Hardware consisted of two 4-5 K-wires, One 6.5, 60 mm partially threaded cancellous screw and one 45, 60 mm partially threaded cortical screw and 2 washers.,HISTORY AND PHYSICAL:,  The patient is a 14-year-old male who reported having knee pain for 1 month.  Apparently while he was playing basketball on 12/22/2007 when he had gone up for a jump, he felt a pop in his knee.  The patient was seen at an outside facility where he was splinted and subsequently referred to Children's for definitive care.  Radiographs confirmed comminuted tibial tubercle avulsion fracture with patella alta.  Surgery is recommended to the grandmother and subsequently to the father by phone.  Surgery would consist of open reduction and internal fixation with subsequent need for later hardware removal.  Risks of surgery include the risks of  anesthesia, infection, bleeding, changes on sensation in most of the extremity, hardware failure, need for later hardware removal, failure to restore extensor mechanism tension, and need for postoperative rehab.  All questions were answered, and father and grandmother agreed to the above plan.,PROCEDURE: , The patient was taken to the operating and placed supine on the operating table.  General anesthesia was then administered.  The patient was given Ancef preoperatively.  A nonsterile tourniquet was placed on the upper aspect of the patient's left thigh.  The patient's extremity was then prepped and draped in the standard surgical fashion.  Midline incision was marked on the skin extending from the tibial tubercle proximally and extremities wrapped in Esmarch.  Finally, the patient had tourniquet that turned in 75 mmHg.  Esmarch was then removed.  The incision was then made.  The patient had significant  tearing of the posterior retinaculum medially with proximal migration of the tibial tubercle which was located in the joint there was a significant comminution and intraarticular involvement.  We were able to see the underside of the anterior horn of both medial and lateral meniscus.  The intraarticular cartilage was restored using two 45 K-wires.  Final position was checked via fluoroscopy and the corners were buried in the cartilage.  There was a large free floating metaphyseal piece that included parts of proximal tibial physis.  This was placed back in an anatomic location and fixed using a 45 cortical screw with a washer.  The avulsed fragment with the patellar tendon was then fixed distally to this area using a 6.5, 60 mm cancellous screw with a washer.  The cortical screw did not provide good compression and fixation at this distal fragment.  Retinaculum was repaired using 0 Vicryl suture as best as possible.  The hematoma was evacuated at the beginning of the case as well as the end.  The knee was copiously irrigated with normal saline.  The subcutaneous tissue was re-approximated using 2-0 Vicryl and the skin with 4-0 Monocryl.  The wound was cleaned, dried, and dressed with Steri-Strips, Xeroform, and 4 x4s.  Tourniquet was released at 80 minutes.  JP drain was placed on the medium gutter.  The extremity was then wrapped in Ace wrap from the proximal thigh down to the toes.  The patient was then placed in a knee mobilizer.  The patient tolerated the procedure well.  Subsequently extubated and taken to the recovery in stable condition.,POSTOP PLAN:  ,The patient hospitalized overnight to decrease swelling and as well as manage his pain.  He may weightbear as tolerated using knee mobilizer.  Postoperative findings relayed to the grandmother.  The patient will need subsequent hardware removal.  The patient also was given local anesthetic at the end of the case.","orthopedic, intraarticular extension, tibial tubercle avulsion fracture, tubercle avulsion fracture, jp drain, cortical screw, hardware removal, tibial tubercle, tourniquet, orif, tubercle, tibial,"
 Followup visit status post removal of external fixator and status post open reduction internal fixation of right tibial plateau fracture., Orthopedic, ORIF - Followup ,"REASON FOR VISIT:,  Followup visit status post removal of external fixator and status post open reduction internal fixation of right tibial plateau fracture.,HISTORY OF PRESENT ILLNESS: , The patient is now approximately week status post removal of Ex-Fix from the right knee with an MUA following open reduction internal fixation of right tibial plateau fracture.  The patient states that this pain is well controlled.  He has had no fevers, chills or night sweats.  He has had some mild drainage from his pin sites.  He just started doing range of motion type exercises for his right knee.  He has had no numbness or tingling.,FINDINGS: , On exam, his pin sites had no erythema.  There is some mild drainage but they have been dressing with bacitracin, it looks like there may be part of the fluid noted.  The patient had 3/5 strength in the EHL, FHL.  He has intact sensation to light touch in a DP, SP, and tibial nerve distribution.,X-rays taken include three views of the right knee.  It demonstrate status post open reduction internal fixation of the right tibial plateau with excellent hardware placement and alignment.,ASSESSMENT: , Status post open reduction and internal fixation of right tibial plateau fracture with removal ex fix.,PLANS: , I gave the patient a prescription for aggressive range of motion of the right knee.  I would like to really work on this as he has not had much up to this time.  He should remain nonweightbearing.  I would like to have him return in 2 weeks' time to assess his knee range of motion.  He should not need x-rays at that time.","orthopedic, external fixator, open reduction internal fixation, tibial plateau fracture., ex fix, tibial plateau fracture, internal fixation, tibial plateau, orif, "
" Hawkins IV talus fracture.  Open reduction internal fixation of the talus, medial malleolus osteotomy, and repair of deltoid ligament.", Orthopedic, ORIF - Talus ,"PREOPERATIVE DIAGNOSIS:, Hawkins IV talus fracture.,POSTOPERATIVE DIAGNOSIS: , Hawkins IV talus fracture.,PROCEDURE PERFORMED:,1.  Open reduction internal fixation of the talus.,2.  Medial malleolus osteotomy.,3.  Repair of deltoid ligament.,ANESTHESIA: , Spinal.,TOURNIQUET TIME: , 90 min.,BLOOD LOSS:,  50 cc.,The patient is in the semilateral position on the beanbag.,INTRAOPERATIVE FINDINGS:,  A comminuted Hawkins IV talus fracture with an incomplete rupture of the deltoid ligament.  There was no evidence of osteochondral defects of the talar dome.,HISTORY:  ,This is a 50-year-old male who presented to ABCD General Hospital Emergency Department with complaints of left ankle pain and disfigurement.  There was no open injury.  The patient fell approximately 10 feet off his liner, landing on his left foot.  There was evidence of gross deformity of the ankle.  An x-ray was performed in the Emergency Room, which revealed a grade IV Hawkins classification talus fracture.  He was distal neurovascularly intact.  The patient denied any other complaints besides pain in the ankle.,It was for this reason, we elected to undergo the above-named procedure in order to reduce and restore the blood supply to the talus body.  Because of its tenuous blood supply, the patient is at risk for avascular necrosis.  The patient has agreed to undergo the above-named procedure and consent was obtained.  All risks as well as complications were discussed.,PROCEDURE: , The patient was brought back to operative room #4 of ABCD General Hospital on 08/20/03.  A spinal anesthetic was administered.  A nonsterile tourniquet was placed on the left upper thigh, but not inflated.  He was then positioned on the beanbag.  The extremity was then prepped and draped in the usual sterile fashion for this procedure.  An Esmarch was then used to exsanguinate the extremity and the tourniquet was then inflated to 325 mmHg.  At this time, an anteromedial incision was made in order to perform a medial malleolus osteotomy to best localize the fracture region in order to be able to bone graft the comminuted fracture site.  At this time, a #15 blade was used to make approximately 10 cm incision over the medial malleolus.  This was curved anteromedial along the root of the saphenous vein.  The saphenous vein was located.  Its tributaries going plantar were cauterized and the vein was retracted anterolaterally.  At this time, we identified the medial malleolus.  There was evidence of approximately 80% avulsion, rupture of the deltoid ligament off of the medial malleolus.  This was a major blood feeder to the medial malleolus and we were concerned, once we were going to do the osteotomy, that this would later create healing problem.  It is for this reason that the pedicle, which was attached to the medial malleolus, was left intact.  This pedicle was the anterior portion of the deltoid ligament.  At this time, a MicroChoice saw was then used to make a box osteotomy of the medial malleolus.  Once this was performed, the medial malleolus was retracted anterolaterally with its remaining pedicle intact for later blood supply.  This provided us with excellent exposure to the fracture site of the medial side.  At this time, any loose comminuted pieces were removed.  The dome of the talus was also checked and did not reveal any osteochondral defects.  There was some comminution on the dorsal aspect of the complete talus fracture and we were concerned that once we place the screw, this would tend to extend the fracture site.  It is for this reason, we did the medial malleolar osteotomy to prevent this from happening in order to best expose the fracture site.  At this time, a reduction was performed.  The #7-0 partially threaded cannulated screws were used in order to fix the fracture.  At this time, a 3.2 mm guidewire was placed going from posterolateral to anteromedial.,This was placed slightly lateral to the Achilles tendon, percutaneously inserted, and then drilled in the according fashion across the fracture site.  Once this was performed, a skin knife was then used to incise over the percutaneous insertion in order to accommodate the screw going in.  A depth gauze was then used to measure screw length.  A cannulated drill was then used to drill across the fracture site to allow the entrance of the screw.  A 55 mm partially threaded #7-0 cannulated screw was then placed with excellent compression at the fracture site.  Once this was obtained, we checked the reduction again using intraoperative Xi-Scan in the AP and lateral direction.  This projection gave us excellent view of our screw placement and excellent compression across the fracture site.  At this time, we bone grafted the area of comminution using 1 cc of DynaGraft with crushed cancellous allograft.  This was placed using a freer elevator into the fracture site where the comminution was.  At this time, we copiously irrigated the wound.  The osteotomy site was then repaired, first clamped using two large tenaculum reduction clamps.  Two partially threaded #4-0 cannulated screws were then used to fix the osteotomy site and anatomical reduction was performed with excellent compression across the osteotomy site with the two screws.  Next, a #1-0 Vicryl was then used to repair the deltoid ligament, which was ruptured via the injury.  A tight repair was performed of the deltoid ligament.  At this time, again copious irrigation was used to irrigate the wound.  A #2-0 Vicryl was then used to approximate the subcutaneous skin and staples for the skin incision.  At this time, the leg was cleansed, Adaptic, 4 x 4, and Kerlix roll were then applied.  The patient was then placed in a plaster splint for mobilization.  The tourniquet was then released.  The patient was then transferred off the operating table to recovery in stable condition.  The prognosis for this fracture is guarded.  There is a high rate of avascular necrosis of the talar body, approximately anywhere from 40-60% risk.  The patient is aware of this and he will be followed as an outpatient for this problem.","orthopedic, deltoid ligament, medial malleolus osteotomy, open reduction internal fixation of the talus, hawkins iv talus fracture, medial malleolus, fracture site, malleolus, talus, medial, fracture, tourniquet, ligament, osteotomy, "
 Open reduction and internal fixation of left lateral malleolus.  Left lateral malleolus fracture., Orthopedic, ORIF - Malleolus ,"PREOPERATIVE DIAGNOSIS: , Left lateral malleolus fracture.,POSTOPERATIVE DIAGNOSIS:,  Left lateral malleolus fracture.,PROCEDURE PERFORMED: , Open reduction and internal fixation of left lateral malleolus.,ANESTHESIA:  ,General.,TOURNIQUET TIME: , 59 minutes.,COMPLICATIONS: , None.,BLOOD LOSS: , Negligible.,CLOSURE: , 2-0 Vicryl and staples.,INDICATIONS FOR SURGERY:,  This is a young gentleman with soccer injury to his left ankle and an x-ray showed displaced lateral malleolus fracture with widening of the mortise now for ORIF.  The risks and perceivable complications of the surgeries were discussed with the patient via a translator as well as nonsurgical treatment options and this was scheduled emergently.,OPERATIVE PROCEDURE: , The patient was taken to the operative room where general anesthesia was successfully introduced.  The right ankle was prepped and draped in standard fashion.  The tourniquet was applied about the right upper thigh.  An Esmarch tourniquet was used to exsanguinate the ankle.  The tourniquet was insufflated to a pressure 325 mm for approximately 59 minutes.  An approximately 6 inch longitudinal incision was made just over the lateral malleolus.  Care was taken to spare overlying nerves and vessels.  An elevator was used to expose the fracture.  The fracture was freed of old hematoma and reduced with a reducing clamp.  An interfragmentary cortical screw was placed of 28 mm with excellent purchase.  The intraoperative image showed excellent reduction.  A 5-hole semitubular plate was then contoured to the lateral malleolus and fixed with 3 cortical screws proximally and 2 cancellous screws distally.  Excellent stability of fracture was achieved.  Final fluoroscopy showed a reduction to be anatomic in 2 planes.  The wound was irrigated with copious amounts of normal saline.  Deep tissue was closed with 2-0 Vicryl.  The skin was approximated with 2-0 Vicryl and closed with staples.  Dry sterile dressing was applied.,The patient tolerated the procedure, was awakened and taken to the recovery room in stable condition.","orthopedic, open reduction and internal fixation, esmarch, internal fixation, malleolus fracture, lateral malleolus, tourniquet, orif, fixation, ankle, reduction, fracture, malleolus"
" Open reduction and internal fixation, high grade Frykman VIII distal radius fracture.", Orthopedic, ORIF - 2 ,"PREOPERATIVE DIAGNOSIS: , Severely comminuted fracture of the distal radius, left.,POSTOPERATIVE DIAGNOSIS: , Severely comminuted fracture of the distal radius, left.,OPERATIVE PROCEDURE:  ,Open reduction and internal fixation, high grade Frykman VIII distal radius fracture.,ANESTHESIA: , General endotracheal.,PREOPERATIVE INDICATIONS: , This is a 52-year-old patient of mine who I have repaired both shoulder rotator cuffs, the most recent one in the calendar year 2007.  While he was climbing a ladder recently in the immediate postop stage, he fell suffering the aforementioned heavily comminuted Frykman fracture.  This fracture had a fragment that extended in the distal radial ulnar joint, a die-punch fragment in the center of the radius.  The ulnar styloid and the radial styloid were off and there were severe dorsal comminutions.  He presented to my office the morning of April 3, 2007, having had a left reduction done elsewhere a day ago.  The reduction, although adequate, had allowed for the fragments to settle and I discussed with him the severity of the injury on a scale of 1-8, this was essentially an 8.  The best results have been either with external fixation or internal fixation, most recently volar plating of a locking variety has been popular, and I felt that this would be appropriate in his case.,Risks and benefits otherwise described were bleeding, infection, need to do operative revise or removal of hardware.  He is taking a job out of state in the next couple of months.  Hence I felt that even with close followup, this is a particularly difficult fracture as far as the morbidity of the injury proceeds.,OPERATIVE NOTE: , After adequate general endotracheal anesthesia was obtained, one gram of Ancef was given intravenously.  The left upper extremity was prepped and draped in supine position with the left hand in the arm table, magnification was used throughout.  The time out procedure was done to the satisfaction of all present that this was indeed the appropriate extremity on the appropriate patient.  A small C-arm was brought in to help guide the incision which was a volar curvilinear incision that included as part of this due to the fracture blisters eminent compartment syndrome and numbness in fingers.  A carpal tunnel release was done with the transverse carpal ligament being protected with a Freer elevator.  The usual amount of dissection of the pronator quadratus was necessary to view the distal radial fragment.  The pronator quadratus actually grasped several of the fragments itself which had to be dissected free from them, specifically the distal radial ulnar joint and die-punch fragment.  At this point, a locking Synthes distal radius plate from the modular handset was selected that had five articular screws as well as five locking shaft screws.  The ulnar styloid was not affixed in any portion of this repair.  The plate was viewed under the image intensification device, i.e., x-ray and the screws were placed in this order.  The most proximal shaft screw was placed to allow the remainder of the plate to form a buttress to then rearrange the fragments around the locking screws and a locking plate having been selected from the volar approach, a locking 12-mm screw through 16-mm screws were placed in the following order.  Most proximal on the radial shaft of the plate, then the radial styloid, i.e., the most distal and lateral screw, the next most proximal shaft screw followed by the distal radial ulnar joint screw.  Three screws were locking across the die-punch fragment.  The remaining two screws were placed into the radial shaft.  All of these were locking screws of 2 mm in diameter and as the construct was created, the relative motion of the intra-articular fragment in dorsal comminution all diminished greatly, although the exposure as well as the amount of reduction force used was substantial.  The tourniquet time was 1.5 hours.  At this point, the tourniquet was let down.  The entire construct was irrigated with copious amounts of bacitracin and normal saline.  Closure was affected with 0 Vicryl underneath the skin surface followed by 3-0 Prolene in interrupted sutures in the volar wound.  Several image intensification x-rays were taken at the conclusion of the case to check screw length.  Screw lengths were changed out during the case as needed based on the x-ray findings.  The wound was injected with Marcaine, lidocaine, Depo-Medrol, and Kantrex.  A very heavily padded fluffy cotton Jones-type dressing was applied with a volar splint.  Estimated blood loss was 10 mL.  There were no specimens.  Tourniquet time was 1.5 hours.","orthopedic, distal radius, c-arm, depo-medrol, frykman, jones-type dressing, kantrex, marcaine, open reduction and internal fixation, die-punch, intra-articular, lidocaine, pronator quadratus, radial styloid, ulnar styloid, distal radial ulnar joint, radial ulnar joint, distal, screws, orif, fracture, radial "
" Open reduction internal fixation of the left supracondylar, intercondylar distal femur fracture.", Orthopedic, ORIF - 3 ,"PREOPERATIVE DIAGNOSIS (ES):, Left supracondylar, intercondylar distal femur fracture.,POSTOPERATIVE DIAGNOSIS (ES):, Left supracondylar, intercondylar distal femur fracture.,PROCEDURE:, Open reduction internal fixation of the left supracondylar, intercondylar distal femur fracture (27513).,OPERATIVE FINDINGS:, He had intercondylar split, and then he had a medial Hoffa fracture. He also had some comminution of the medial femoral condyle which prohibited an anatomic key between the two segments of the medial condyle.,IMPLANTS:, We used 2.4 and 3.5 cortical screws, as well as a LISS Synthes femoral locking plate.,COMPLICATIONS:, None.,IV FLUIDS:, 2000,ANESTHESIA:, General endotracheal.,ESTIMATED BLOOD LOSS:, 40 mL,URINE OUTPUT:, 650,HISTORY: ,This 45-year-old male had a ground-level fall, sustaining this injury. He was admitted for definitive operative fixation. Risks and benefits were discussed, he agreed to go ahead with the procedure.,DESCRIPTION OF THE OPERATION:, The patient was identified in preop holding, then taken to the operating room. Once adequate anesthesia was obtained, his left lower extremity was prepped and draped in a routine sterile fashion. He was given antibiotics. He placed a traction pin through his proximal tibia, and pulled weight off the end of the bed. I made a midline approach and then did the lateral parapatellar arthrotomy. We excised some of the fat pad to give us better visibility into the notch. We excised a good bit of his synovium and synovial pouch. At this time we were able to identify the fracture fragments. Again, there was an intercondylar split and then two free pieces of the medial condyle. The femur fracture was very distal through the metaphysis. At this time we thoroughly cleaned out all the clot between all the fracture fragments and cleaned the cortical margins.,Next we began the reduction. There was no reduction key between the two segments of the Hoffa fracture. Therefore, we reduced the anterior portion of the medial condyle to the lateral condyle, held it with point-of-reduction clamp and K-wires, and then secured it with 2.4 mini fragment lag screws. Next, with this medial anterior piece in place, we had some contour over the notch with which we were able to reduce the posterior medial Hoffa fragment. This gave us a nice notch contour. Again, there was some comminution laterally so that the fracture between the Hoffa segments did not have a perfect key. Once we had it reduced, based on the notch reduction, we then held it with K-wires. We secured it with two 3.5 cortical screws from the lateral condyle into this posterior segment. We then secured it with 2.4 cortical screws from the anterior medial to the posterior medial segment just subchondral. Then, finally, we secured it with a 3.5 cortical screw from the anterior medial to the posterior medial piece. All screws ran between and out of the notch.,With the condyle now well reduced, we reduced it to the metaphysis. We slid a 13-hole LISS plate submuscularly. We checked on AP and lateral views that showed we had good reduction of the fracture and appropriate plate placement. We placed the tip threaded guidewire through the A-hole of the plate jig and got it parallel to the joint. We then clamped the plate down to the bone. Proximally, we made a stab incision for the trocar at the 13-hole position, placed our tip threaded guidewire in the lateral aspect of the femur, checked it on lateral view, and had it in good position.,With the jig in appropriate position and clamped, we then proceeded to fill the distal locking screws to get purchase into the condyles. We then placed multiple unicortical locking screws in the shaft and metaphyseal segment. Our most proximal screw was proximal to the tip of the prosthesis.,At this time we took the jig off and put the final screw into the A-hole of the plate. We then took final C-arm views which showed we had a good reduction on AP and lateral views, the plate was in good position, we had full range of motion of the knee, and good reduction clinically and radiographically. We then pulse lavaged the knee with 3 liters of fluid. We closed the quad tendon and lateral retinaculum with interrupted 0 Vicryl over a Hemovac drain. Subdermal tissue was closed with 2-0 Vicryl, skin with staples. Sterile dressing and a hinged knee brace were applied. The patient was awakened from anesthesia and taken to Recovery in stable condition.,PLAN:,1. Nonweightbearing for 3 months.,2. CPM for 0 to 90 degrees as tolerated.",
 Fractured right fifth metatarsal.  Open reduction and internal screw fixation right fifth metatarsal.  Application of short leg splint., Orthopedic, ORIF - Fifth Metatarsal ,"PREOPERATIVE DIAGNOSIS: , Fractured right fifth metatarsal.,POSTOPERATIVE DIAGNOSIS: , Fractured right fifth metatarsal.,PROCEDURE PERFORMED:,1.  Open reduction and internal screw fixation right fifth metatarsal.,2.  Application of short leg splint.,ANESTHESIA:,  TIVA/local.,HISTORY: , This 32-year-old female presents to Preoperative Holding Area after keeping herself n.p.o., since mid night for open reduction and internal fixation of a fractured right fifth metatarsal.  The patient relates that approximately in mid-June that she was working as a machinist at Detroit Diesel and dropped a large set of tools on her right foot.  She continued to walk on the foot and found nothing was wrong despite the pain.  She was recently seen by Dr. X and was referred to Dr. Y for surgery.  The risks versus benefits of the procedure had been explained to the patient in detail by Dr. Y.  The consent is available on the chart for review.  The urine beta was taken in the preoperative area and was negative.,PROCEDURE IN DETAIL:  ,After IV was established by the Department of Anesthesia, the patient was taken to the operating room via cart and placed on the operating table in the supine position.  A safety strap was placed across her waist for her protection.  Copious amounts of Webril were applied about the right ankle and a pneumatic ankle tourniquet was applied.  After adequate IV sedation was administered by the Department of Anesthesia, a total of 10 cc of 0.5% Marcaine plain was used to perform an infiltrative type block to the right fifth metatarsal area of the right foot.  Next, the foot was prepped and draped in the usual aseptic fashion.  An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg.  The foot was lowered in the operative field and a sterile stocking was reflected.  Attention was directed to the right fifth metatarsal base.  The Xi-scan and fluoroscopic unit was used to visualize the fractured fifth metatarsal.  An avulsion fracture of the right fifth metatarsal base was visualized.  The fracture was linear in nature from distal lateral to proximal medial.  There appeared to be a pseudoarthrosis on the lateral view.  A skin scrub was used to carefully mark out all the landmarks including the peroneus longus and brevis tendons in the fifth metatarsal and the sural nerve.  A linear incision was created with a #10 blade.  A #15 blade was used to deepen the incision through the subcutaneous tissue.  All small veins traversing the subcutaneous tissue were ligated with electrocautery.  Next, using combination of sharp and blunt dissection, the deep fascia was reached.  Next a linear capsuloperiosteal incision was made down to the bone using a #15 blade.  Next, using a periosteal elevator and a #15 blade, the capsuloperiosteal tissues were stripped from the bone.  The fracture site was not clearly visualized due to bony callus.  A #25 gauge needle was introduced into the fracture site under fluoroscopy.  The fracture site was easily found.  An osteotome was used to separate the pseudoarthrosis.,A curette was used to remove the hypertrophic excessive pseudoarthrotic bone.  Next, a small ball burr was used to resect the remaining hypertrophic bone.  Next, a #1.0 drill bit was used to drill the subchondral bone on either side of the fracture site and a good healthy bleeding bone.  Next, a bone clamp was applied and the fracture was reduced.  Next, a threaded K-wire was thrown from the proximal base of the fifth metatarsal across the fracture site distally.  A #4-0 mm Synthes partially threaded, cannulated 50 mm screw was thrown using standard AO technique from the proximal fifth metatarsal base down the shaft and the fracture site was fixated rigidly.  All this was done under fluoroscopy.  Next, the wound was flushed with copious amounts of sterile saline.  The fracture site was found to have rigid compression.  The hypertrophic bone on the lateral aspect of the metatarsal was reduced with a ball burr and the wound was again flushed.  Next, the capsuloperiosteal tissues were closed with #3-0 Vicryl in a simple interrupted fashion.  A few fibers of the peroneus brevis tendon that were stripped from the base of the proximal phalanx were reattached carefully with Vicryl.  Next, the subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted suture technique.  Next, the skin was closed with #5-0 Prolene in a horizontal mattress technique.  A postoperative fluoroscopic x-ray was taken and the bony alignment was found to be intact and the screw placement had excellent appearance.  A dressing consisting of Owen silk, 4x4s, fluff, and Kerlix were applied.,A sterile stockinet was applied over the foot.  Next, copious amounts of Webril were applied to pad all bony prominences.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all digits.  Next, 4-inch, pre-moulded, well-padded posterior splint was applied.  The capillary refill time of the digits was less than three seconds.  The patient tolerated the above anesthesia and procedure without complications.  After anesthesia was reversed, she was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot.  She was given Vicodin 5/500 mg #30 1-2 p.o. q.4-6h. p.r.n., pain, Naprosyn 500 mg p.o. b.i.d. p.c., Keflex 500 mg #30 one p.o. t.i.d., till gone.  She was given standard postoperative instructions to be non-weightbearing and was dispensed with crutches.  She will rest, ice, and elevate her right leg.  She is to follow up in the clinic on 08/26/03 at 10:30 a.m..  She was given emergency contact numbers and will call or return if problems arise earlier.","orthopedic, metatarsal, internal screw fixation, leg splint, fractured right fifth metatarsal, pneumatic ankle tourniquet, ankle tourniquet, metatarsal base, fracture site, fractured, hypertrophic, bernstein, orif"
 Open reduction and internal fixation of right distal radius fracture - intraarticular four piece fracture and right carpal tunnel release., Orthopedic, ORIF - 1 ,"PREOPERATIVE DIAGNOSES:,1.  Displaced intraarticular fracture, right distal radius.,2.  Right carpal tunnel syndrome.,PREOPERATIVE DIAGNOSES:,1.  Displaced intraarticular fracture, right distal radius.,2.  Right carpal tunnel syndrome.,OPERATIONS PERFORMED:,1.  Open reduction and internal fixation of right distal radius fracture - intraarticular four piece fracture.,2.  Right carpal tunnel release.,ANESTHESIA: , General.,CLINICAL SUMMARY: , The patient is a 37-year-old right-hand dominant Hispanic female who sustained a severe fracture to the right wrist approximately one week ago.  This was an intraarticular four-part fracture that was displaced dorsally.  In addition, the patient previously undergone a carpal tunnel release, but had symptoms of carpal tunnel preop.  She is admitted for reconstructive operation.  The symptoms of carpal tunnel were present preop and worsened after the injury.,OPERATION:,  The patient was brought from the ambulatory care unit and placed on the operating table in a supine position and administered general anesthetic by Anesthesia.  Once adequate anesthesia had been obtained, the right upper extremity was prepped and draped in the usual sterile manner.  Tourniquet was placed around the right upper extremity.  The upper extremity was then elevated and exsanguinated using an Esmarch dressing.  The tourniquet was elevated to 250 mmHg.  The entire operation was performed with 4.5 loop magnification.  At this time an approximately 8 cm longitudinal incision was then made overlying the right flexor carpi radialis tendon from the flexion crease to the wrist proximally.  This was carried down to the flexor carpi radialis, which was then retracted ulnarly.  The floor of the flexor carpi radialis was then incised exposing the flexor pronator muscles.  The flexor pollicis longus was retracted ulnarly and the pronator quadratus was longitudinally incised 1 cm from its origin.  It was then elevated off of the fracture site exposing the fracture site, which was dorsally displaced.  This was an intraarticular four-part fracture.  Under image control, the two volar pieces and dorsal pieces were then carefully manipulated and reduced.  Then, 2.06 two-inch K-wires were drilled radial into the volar ulnar fragment and then a second K-wire was then drilled from the dorsal radial to the dorsal ulnar piece.  A third K-wire was then drilled from the volar radial to the dorsal ulnar piece.  The fracture was then manipulated.  The fracture ends were copiously irrigated with normal saline and curetted and then the fracture was reduced in the usual fashion by recreating the defect and distracting it.  Further K-wires were then placed through the radial styloid into the proximal fragment.  A Hand Innovations DVR plate of regular size for the right wrist was then fashioned over and placed over the distal radius and secured with two K-wires.  At this time, the distal screws were then placed.  The distal screws were the small screws.  These were non-locking screws, all eight screws were placed.  They were placed in the usual fashion by drilling with a small drill bit removing the small introducers and then using its depth.  Again, these were 18-20 mm screws.  After placing three of the screws it was necessary to remove the K-wires.  There was excellent reduction of the fragments and the fracture; excellent reduction of the intraarticular component and the fracture.  After the distal screws were placed, the fracture was reduced and held in place with K-wires, which were replaced and the proximal screws were drilled with the drill guide and the larger drill bit.  The screws were then placed.  These were 12 mm screws.  They were placed 4 in number.  The K-wires were then removed.  Finally, a 3 cm intrathenar incision was made beginning 1 cm distal to the flexor crease of the wrist.  This was carried down to the transverse carpal ligament, which was divided throughout the length of the incision, upon entering the carpal canal, the median nerve was found to be adherent to the undersurface of the structure.  It was dissected free from the structure out to its trifurcation.  The motor branches seen entering the thenar fascia and obstructed.  The nerve was then retracted dorsally and the patient had a great deal of scar tissue in the area of the volar flexion crease to the wrist where she had a previous incision that extended from the volar flexion crease of the wrist overlying the palmaris longus proximally for 1 cm.  In this area, careful dissection was performed in order to move the nerve from the surrounding structures and the most proximal aspect of the transverse carpal ligament, the more proximally located volar carpal ligament was then divided 5 cm into the distal forearm on the ulnar side of the palmaris longus tendon.  Incisions were then copiously irrigated with normal saline.  Homeostasis was maintained with electrocautery.  The pronator quadratus was closed with 3-0 Vicryl and the above skin incisions were closed proximally with 4-0 nylon and palmar incision with 5-0 nylon in the horizontal mattress fashion.  A large bulky dressing was then applied with a volar short-arm splint maintaining the wrist in neutral position.  The tourniquet was let down.  The fingers were immediately pink.  The patient was awakened and taken to the recovery room in good condition.  There were no operative complications.  The patient tolerated the procedure well.","orthopedic, intraarticular fracture, esmarch, k-wires, open reduction and internal fixation, tourniquet, carpal tunnel release, carpal tunnel syndrome, flexor carpi radialis, flexor pronator muscles, intraarticular, right distal radius, transverse carpal ligament, volar flexion crease, pronator quadratus, flexor carpi, carpi radialis, flexion crease, carpal ligament, carpal tunnel, carpal, volar"
 MRI L-Spine - Bilateral lower extremity numbness, Orthopedic, Normal L-Spine MRI ,"CC: ,Bilateral lower extremity numbness.,HX: ,21 y/o RHM complained of gradual onset numbness and incoordination of both lower extremities beginning approximately 11/5/96. The symptoms became maximal over a 12-24 hour period and have not changed since. The symptoms consist of tingling in the distal lower extremities approximately half way up the calf bilaterally. He noted decreased coordination of both lower extremities which he thought might be due to uncertainty as to where his feet were being placed in space. He denied bowel/bladder problems, or weakness or numbness elsewhere. Hot showers may improve his symptoms. He has suffered no recent flu-like illness. Past medical and family histories are unremarkable. He was on no medications.,EXAM:, Unremarkable except for mild distal vibratory sensation loss in the toes (R>L).,LAB:, CBC, Gen Screen, TSH, FT4, SPE, ANA were all WNL.,MRI L-SPINE:, Normal.,COURSE:, Normal exam and diminished symptoms at following visit 4/23/93.","orthopedic, bilateral lower extremity numbness, mri l spine, bilateral lower extremity, lower extremity numbness, bilateral, spine, mri, extremities, numbness"
" Repair of nerve and tendon, right ring finger and exploration of digital laceration.  Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis and 25% laceration to the flexor digitorum profundus of the right ring finger and laceration 100% of the ulnar digital nerve to the right ring finger.", Orthopedic, Nerve & Tendon Repair - Finger ,"PREOPERATIVE DIAGNOSIS:,  Volar laceration to right ring finger with possible digital nerve injury with possible flexor tendon injury.,POSTOPERATIVE DIAGNOSES:,1.  Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis.,2.  25% laceration to the flexor digitorum profundus of the right ring finger and laceration 100% of the ulnar digital nerve to the right ring finger.,PROCEDURE PERFORMED:,1.  Repair of nerve and tendon, right ring finger.,2.  Exploration of digital laceration.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 10 cc.,TOTAL TOURNIQUET TIME:  ,57 minutes.,COMPLICATIONS: , None.,DISPOSITION:  ,To PACU in stable condition.,BRIEF HISTORY OF PRESENT ILLNESS: , This is a 13-year-old male who had sustained a laceration from glass and had described numbness and tingling in his right ring finger.,GROSS OPERATIVE FINDINGS: , After wound exploration, it was found there was a 100% laceration to the ulnar digital neurovascular bundle.  The FDS had a partial ulnar slip laceration and the FDP had a 25% transverse laceration as well.  The radial neurovascular bundle was found to be completely intact.,OPERATIVE PROCEDURE:  ,The patient was taken to the operating room and placed in the supine position.  All bony prominences were adequately padded.  Tourniquet was placed on the right upper extremity after being packed with Webril, but not inflated at this time.  The right upper extremity was prepped and draped in the usual sterile fashion.  The hand was inspected.  Palmar surface revealed approximally 0.5 cm laceration at the base of the right ring finger at the base of proximal phalanx, which was approximated with nylon suture.  The sutures were removed and the wound was explored.  It was found that the ulnar digital neurovascular bundle was 100% transected.  The radial neurovascular bundle on the right ring finger was found to be completely intact.  We explored the flexor tendon and found that there was a partial laceration of the ulnar slip of the FDS and a 25% laceration in a transverse fashion to the FDP.  We copiously irrigated the wound.  Repair was undertaken of the FDS with #3-0 undyed Ethibond suture.  The laceration of the FDP was not felt that it need to repair due to majority of the substance in the FDP was still intact.  Attention during our repair at the flexor tendon, the A1 pulley was incised for better visualization as well as better tendon excursion after repair.  Attention was then drawn to the ulnar digital bundle which has been transected prior during the injury.  The digital nerve was dissected proximally and distally to likely visualize the nerve.  The nerve was then approximated using microvascular technique with #8-0 nylon suture.  The hands were well approximated.  The nerve was not under undue tension.  The wound was then copiously irrigated and the skin was closed with #4-0 nylon interrupted horizontal mattress alternating with simple suture.  Sterile dressing was placed and a dorsal extension Box splint was placed.  The patient was transferred off of the bed and placed back on a gurney and taken to PACU in stable condition.  Overall prognosis is good.","orthopedic, laceration, flexor tendon, volar laceration, digital laceration, ulnar slip, flexor digitorum, neurovascular bundle, nerve, injury, ring, finger, neurovascular, fds, bundle, tendon, repair, flexor, digital, ulnar, "
 Open reduction and internal fixation (ORIF) of right Schatzker III tibial plateau fracture with partial medial meniscectomy., Orthopedic, ORIF - Discharge Summary ,"ADMISSION DIAGNOSIS: , Right tibial plateau fracture.,DISCHARGE DIAGNOSES: , Right tibial plateau fracture and also medial meniscus tear on the right side.,PROCEDURES PERFORMED:,  Open reduction and internal fixation (ORIF) of right Schatzker III tibial plateau fracture with partial medial meniscectomy.,CONSULTATIONS: , To rehab, Dr. X and to Internal Medicine for management of multiple medical problems including hypothyroid, diabetes mellitus type 2, bronchitis, and congestive heart failure.,HOSPITAL COURSE: , The patient was admitted and consented for operation, and taken to the operating room for open reduction and internal fixation of right Schatzker III tibial plateau fracture and partial medial meniscectomy performed without incidence.  The patient seemed to be recovering well.  The patient spent the next several days on the floor, nonweightbearing with CPM machine in place, developed a brief period of dyspnea, which seems to have resolved and may have been a combination of bronchitis, thick secretions, and fluid overload.  The patient was given nebulizer treatment and Lasix increased the same to resolve the problem.  The patient was comfortable, stabilized, breathing well.  On day #12, was transferred to ABCD.,DISCHARGE INSTRUCTIONS: , The patient is to be transferred to ABCD after open reduction and internal fixation of right tibial plateau fracture and partial medial meniscectomy.,DIET:,  Regular.,ACTIVITY AND LIMITATIONS: , Nonweightbearing to the right lower extremity.  The patient is to continue CPM machine while in bed along with antiembolic stockings.  The patient will require nursing, physical therapy, occupational therapy, and social work consults.,DISCHARGE MEDICATIONS: , Resume home medications, but increase Lasix to 80 mg every morning, Lovenox 30 mg subcu daily x2 weeks, Vicodin 5/500 mg one to two every four to six hours p.r.n. pain, Combivent nebulizer every four hours while awake for difficulty breathing, Zithromax one week 250 mg daily, and guaifenesin long-acting one twice a day b.i.d.,FOLLOWUP: , Follow up with Dr. Y in 7 to 10 days in office.,CONDITION ON DISCHARGE:,  Stable.","orthopedic, open reduction, internal fixation, schatzker iii tibial plateau fracture, meniscectomy, tibial plateau fracture, orif, schatzker, fixation, reduction, tibial, fracture, plateau,"
 Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection., Orthopedic, Neuroplasty ,"PREOPERATIVE DIAGNOSES:,  ,1.  Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2.  Epidural fibrosis with nerve root entrapment.,POSTOPERATIVE DIAGNOSES:,  ,1.  Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2.  Epidural fibrosis with nerve root entrapment.,OPERATION PERFORMED:,  Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,ANESTHESIA:,  Local/IV sedation.,COMPLICATIONS:,  None.,SUMMARY:  ,The patient in the operating room, status post transforaminal epidurogram (see operative note for further details).  Using AP and lateral fluoroscopic views to confirm the needle location the superior most being in the left L4 neural foramen and the inferior most in the left L5 neural foramen, 375 units of Wydase was injected through each needle.  After two minutes, 3.5 cc of 0.5% Marcaine and 80 mg of Depo-Medrol was injected through each needle.  These needles were removed and the patient was discharged in stable condition.","orthopedic, nerve root decompression, discectomy, epidural fibrosis, nerve root entrapment, transforaminal neuroplasty, neural foramen, nerve root, foramen, neuroplasty, transforaminal, needle, epidural,"
" Incision and drainage and excision of the olecranon bursa, left elbow.  Acute infected olecranon bursitis, left elbow.", Orthopedic, Olecranon Bursa - Excision ,"PREOPERATIVE DIAGNOSIS: , Acute infected olecranon bursitis, left elbow.,POSTOPERATIVE DIAGNOSIS: , Infection, left olecranon bursitis.,PROCEDURE PERFORMED:,1.  Incision and drainage, left elbow.,2.  Excision of the olecranon bursa, left elbow.,ANESTHESIA: , Local with sedation.,COMPLICATIONS: , None.,NEEDLE AND SPONGE COUNT: , Correct.,SPECIMENS: , Excised bursa and culture specimens sent to the microbiology.,INDICATION:  ,The patient is a 77-year-old male who presented with 10-day history of pain on the left elbow with an open wound and drainage purulent pus followed by serous drainage.  He was then scheduled for I&D and excision of the bursa.  Risks and benefits were discussed.  No guarantees were made or implied.,PROCEDURE: , The patient was brought to the operating room and once an adequate sedation was achieved, the left elbow was injected with 0.25% plain Marcaine.  The left upper extremity was prepped and draped in standard sterile fashion.  On examination of the left elbow, there was presence of thickening of the bursal sac.  There was a couple of millimeter opening of skin breakdown from where the serous drainage was noted.  An incision was made midline of the olecranon bursa with an elliptical incision around the open wound, which was excised with skin.  The incision was carried proximally and distally.  The olecranon bursa was significantly thickened and scarred.  Excision of the olecranon bursa was performed.  There was significant evidence of thickening of the bursa with some evidence of adhesions.  Satisfactory olecranon bursectomy was performed.  The wound margins were debrided.  The wound was thoroughly irrigated with Pulsavac irrigation lavage system mixed with antibiotic solution.  There was no evidence of a loose body.  There was no bleeding or drainage.  After completion of the bursectomy and I&D, the skin margins, which were excised were approximated with 2-0 nylon in horizontal mattress fashion.  The open area of the skin, which was excised was left _________ and was dressed with 0.25-inch iodoform packing.  Sterile dressings were placed including Xeroform, 4x4, ABD, and Bias.  The patient tolerated the procedure very well.  He was then extubated and transferred to the recovery room in a stable condition.  There were no intraoperative complications noticed.","orthopedic, incision and drainage, infected olecranon, olecranon bursitis, olecranon bursa, olecranon, wound, excision, drainage, elbow, bursa"
" Chronic plantar fasciitis, right foot.  Open plantar fasciotomy, right foot.", Orthopedic, Open Plantar Fasciotomy ,"PREOPERATIVE DIAGNOSIS: , Chronic plantar fasciitis, right foot.,POSTOPERATIVE DIAGNOSIS:,  Chronic plantar fasciitis, right foot.,PROCEDURE: , Open plantar fasciotomy, right foot.,ANESTHESIA: , Local infiltrate with IV sedation.,INDICATIONS FOR SURGERY:,  The patient has had a longstanding history of foot problems.  The foot problem has been progressive in nature and has not been responsive to conservative care despite multiple attempts at conservative care.  The preoperative discussion with the patient including alternative treatment options, the procedure itself was explained, and risk factors such as infection, swelling, scar tissue, numbness, continued pain, recurrence, falling arch, digital contracture, and the postoperative management were discussed.  The patient has been advised, although no guarantee for success could be given, most of the patients have improved function and less pain.  All questions were thoroughly answered.  The patient requested for surgical repair since the problem has reached a point to interfere with normal daily activities.  The purpose of the surgery is to alleviate the pain and discomfort.,DETAILS OF THE PROCEDURE:  ,The patient was given 1 g Ancef for antibiotic prophylaxis 30 minutes prior to the procedure.  The patient was brought to the operating room and placed in the supine position.  Following a light IV sedation, a posterior tibial nerve block and local infiltrate of the operative site was performed with 10 mL, and a 1:1 mixture of 1% lidocaine with epinephrine, and 0.25% Marcaine was affected.  The lower extremity was prepped and draped in the usual sterile manner.  Balance anesthesia was obtained.,PROCEDURE:, Plantar fasciotomy, right foot.  The plantar medial tubercle of the calcaneus was palpated and a vertical oblique incision, 2 cm in length with the distal aspect overlying the calcaneal tubercle was affected. Blunt dissection was carried out to expose the deep fascia overlying the abductor hallucis muscle belly and the medial plantar fascial band.  A periosteal elevator did advance laterally across the inferior aspect of the medial and central plantar fascial bands, creating a small and narrow soft tissue tunnel.  Utilizing a Metzenbaum scissor, transection of the medial two-third of the plantar fascia band began at the junction of the deep fascia of the abductor hallucis muscle belly and medial plantar fascial band, extending to the lateral two-thirds of the band.  The lateral plantar fascial band was left intact.  Visualization and finger probe confirmed adequate transection.  The surgical site was flushed with normal saline irrigation.,The deep layer was closed with 3-0 Vicryl and the skin edges coapted with combination of 1 horizontal mattress and simples.  The dressing consisted of Adaptic, 4 x 4, conforming bandages, and an ACE wrap to provide mild compression.  The patient tolerated the procedure and anesthesia well, and left the operating room to recovery room in good postoperative condition with vital signs stable and arterial perfusion intact.  A walker boot was dispensed and applied.  The patient will be allowed to be full weightbearing to tolerance, in the boot to encourage physiological lengthening of the release of plantar fascial band.,The next office visit will be in 4 days.  The patient was given prescriptions for Keflex 500 mg 1 p.o. three times a day x10 days and Lortab 5 mg #40, 1 to 2 p.o. q.4-6 h. p.r.n. pain, 2 refills, along with written and oral home instructions.  After a short recuperative period, the patient was discharged home with vital signs stable and in no acute distress.","orthopedic, plantar fascial band, plantar fasciitis, plantar fasciotomy, plantar fascial, anesthesia, plantar, fascia, fasciotomy, fascial, band, foot,"
" Neck pain with right upper extremity radiculopathy and cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, and C6-C7 with stenosis.", Orthopedic, Neck Pain - Discharge Summary ,"ADMISSION DIAGNOSES,1.  Neck pain with right upper extremity radiculopathy.,2.  Cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, and C6-C7 with stenosis.,DISCHARGE DIAGNOSES,1.  Neck pain with right upper extremity radiculopathy.,2.  Cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, and C6-C7 with stenosis.,OPERATIVE PROCEDURES,1.  Anterior cervical discectomy with decompression C4-C5, C5-C6, and C6-C7.,2.  Arthrodesis with anterior interbody fusion C4-C5, C5-C6, and C6-C7.,3.  Spinal instrumentation C4 through C7.,4.  Implant.,5.  Allograft.,COMPLICATIONS:,  None.,COURSE ON ADMISSION: , This is the case of a very pleasant 41-year-old Caucasian female who was seen in clinic as an initial consultation on 09/13/07 complaining of intense neck pain radiating to the right shoulder blade to top of the right shoulder in to the right upper extremity to the patient's hand.  The patient's symptoms have been persistent and had gotten worse with subjective weakness of the right upper extremity since its onset for several weeks now.  The patient has been treated with medications, which has been unrelenting.  The patient had imaging studies that showed evidence of cervical spondylosis with herniated disk and stenosis at C4-C5, C5-C6 and C6-C7.  The patient underwent liver surgery and postoperatively her main issue was that of some degree of on and off right shoulder pain and some operative site soreness, which was treated well with IV morphine.  The patient has resolution of the pain down the arm, but she does have some tingling of the right thumb and right index finger.  The patient apparently is doing well with slight dysphagia, we treated her with Decadron and we will send her home with Medrol.  The patient will have continued pain medication coverage with Darvocet and Flexeril.  The patient will follow up with me as scheduled.  Instructions have been given.","orthopedic, radiculopathy, cervical spondylosis, neck pain, anterior cervical discectomy, herniated nucleus pulposus, cervical, anterior, herniated,"
 Initial evaulation - neck and back pain., Orthopedic, Neck & Back Pain ,"CHIEF COMPLAINT:,  Neck pain, thoracalgia, low back pain, bilateral lower extremity pain.,HISTORY OF PRESENT ILLNESS:,  Ms. XYZ is a fairly healthy 69-year-old Richman, Roseburg resident who carries a history of chronic migraine, osteoarthritis, hypothyroidism, hyperlipidemia, and mitral valve prolapse.  She has previously been under the care of Dr. Ninan Matthew in the 1990s and takes Maxalt on a weekly basis and nadolol, omeprazole and amitriptyline for treatment of her migraines, which occur about once a week.  She is under the care of Dr. Bonaparte for hyperlipidemia and hypothyroidism.  She has a long history of back and neck pain with multiple injuries in the 1960s, 1970s, 1980s and 1990s.  In 2000, she developed ""sciatica"" mostly in her right lower extremity.,She is seen today with no outside imaging, except with MRI of her cervical spine and lumbar spine dated February of 2004.  Her cervical MRI reveals an 8 mm central spinal canal at C6-7, multilevel foraminal stenosis, though her report is not complete as we do not have all the pages.  Her lumbar MRI reveals lumbar spinal stenosis at L4-5 with multilevel facet arthropathy and spondylitic changes.,The patient has essentially three major pain complaints.,Her first pain complaint is one of a long history of axial neck pain without particular radicular symptoms.  She complains of popping, clicking, grinding and occasional stiffness in her neck, as well as occasional periscapular pain and upper trapezius myofascial pain and spasms with occasional cervicalgic headaches.  She has been told by Dr. Megahed in the past that she is not considered a surgical candidate.  She has done physical therapy twice as recently as three years ago for treatment of her symptoms.  She complains of occasional pain and stiffness in both hands, but no particular numbness or tingling.,Her next painful complaint is one of midthoracic pain and thoracalgia features with some right-sided rib pain in a non-dermatomal distribution.  Her rib pain was not preceded by any type of vesicular rash and is reproducible, though is not made worse with coughing.  There is no associated shortness of breath.  She denies inciting trauma and also complains of pain along the costochondral and sternochondral junctions anteriorly.  She denies associated positive or negative sensory findings, chest pain or palpitations, dyspnea, hemoptysis, cough, or sputum production.  Her weight has been stable without any type of constitutional symptoms.,Her next painful complaint is one of axial low back pain with early morning pain and stiffness, which improves somewhat later in the day.  She complains of occasional subjective weakness to the right lower extremity.  Her pain is worse with sitting, standing and is essentially worse in the supine position.  Five years ago, she developed symptoms radiating in an L5-S1 distribution and within the last couple of years, began to develop numbness in the same distribution.  She has noted some subjective atrophy as well of the right calf.  She denies associated bowel or bladder dysfunction, saddle area hypoesthesia, or falls.  She has treated her back symptoms with physical therapy as well.,She is intolerant to any type of antiinflammatory medications as well and has a number of allergies to multiple medications.  She participates in home physical therapy, stretching, hand weights, and stationary bicycling on a daily basis.  Her pain is described as constant, shooting, aching and sharp in nature and is rated as a 4-5/10 for her average and current levels of pain, 6/10 for her worst pain, and 3/10 for her least pain.  Exacerbating factors include recumbency, walking, sleeping, pushing, pulling, bending, stooping, and carrying.  Alleviating factors including sitting, applying heat and ice.,PAST MEDICAL HISTORY:,  As per above and includes hyperlipidemia, hypothyroidism, history of migraines, acid reflux symptoms, mitral valve prolapse for which she takes antibiotic prophylaxis.,PAST SURGICAL HISTORY:,  Cholecystectomy, eye surgery, D&C.,MEDICATIONS:,  Vytorin, Synthroid, Maxalt, nadolol, omeprazole, amitriptyline and 81 mg aspirin.,ALLERGIES:,  Multiple.  All over-the-counter medications.  Toradol, Robaxin, Midrin, Darvocet, Naprosyn, Benadryl, Soma, and erythromycin.,FAMILY HISTORY:,  Family history is remarkable for a remote history of cancer. Family history of heart disease and osteoarthritis.,SOCIAL HISTORY:,  The patient is retired.  She is married with three grown children.  Has a high school level education.  Does not smoke, drink, or utilize any illicit substances.,OSWESTRY PAIN INVENTORY:,  Significant impact on every aspect of her quality of life.  She would like to become more functional.,REVIEW OF SYSTEMS:,  A thirteen-point review of systems was surveyed including constitutional, HEENT, cardiac, pulmonary, GI, GU, endocrine, integument, hematological, immunological, neurological, musculoskeletal, psychological and rheumatological.  Cardiac, swelling in the extremities, hyperlipidemia, history of palpitation, varicose veins.  Pulmonary review of systems negative.  GI review of systems is positive for irritable bowel and acid reflux symptoms.  Genitourinary, occasional stress urinary incontinence and history of remote hematuria.  She is postmenopausal and on hormone replacement.  Endocrine is positive for a low libido and thyroid disorder.  Integument:  Dry skin, itching and occasional rashes.  Immunologic is essentially negative.  Musculoskeletal:  As per HPI.  HEENT:  Jaw pain, popping, clicking, occasional hoarseness, dysphagia, dry mouth, and prior history of toothache.  Neurological:  As per history of present illness.  Constitutional:  As history of present illness.,PHYSICAL EXAMINATION:,  Weight 180 pounds, temp 97.6, pulse 56, BP 136/72.  The patient walks with a normal gait pattern.  There is no antalgia, spasticity, or ataxia.  She can alternately leg stand without difficulty, as well as tandem walk, stand on the heels and toes without difficulty.  She can flex her lumbar spine and touch the floor with her fingertips.  Lumbar extension and ipsilateral bending provoke her axial back pain.  There is tenderness over the PSIS on the right and no particular pelvic asymmetry.,Head is normocephalic and atraumatic.  Cranial nerves II through XII are grossly intact.  Cervical range of motion is slightly limited in extension, but is otherwise intact to flexion and lateral rotation.  The neck is supple.  The trachea is midline.  The thyroid is not particularly enlarged.  Lungs are clear to auscultation.  Heart has regular rate and rhythm with normal S1, S2.  No murmurs, rubs, or gallops.  The abdomen is nontender, nondistended, without palpable organomegaly, guarding, rebound, or pulsatile masses.  Skin is warm and dry to the touch with no discernible cyanosis, clubbing or edema.  I can radial, dorsalis pedis and posterior tibial pulses.  The nailbeds on her feet have trophic changes.  Brisk capillary refill is evident over both upper extremities.,Musculoskeletal examination reveals medial joint line tenderness of both knees with some varus laxity of the right lower extremity.  She has chronic osteoarthritic changes evident over both hands.  There is mild restriction of range of motion of the right shoulder, but no active impingement signs.,Inspection of the axial skeleton reveals a cervicothoracic head-forward posture with slight internal rotation of the upper shoulders.  Palpation of the axial skeleton reveals mild midline tenderness at the lower lumbar levels one fingerbreadth lateral to the midline.  There is no midline spinous process tenderness over the cervicothoracic regions.  Palpation of the articular pillars is met with mild provocation of pain.  Palpation of the right posterior, posterolateral and lateral borders of the lower ribs is met with mild provocable tenderness.  There is also tenderness at the sternochondral and costochondral junctions of the right, as well as the left bilaterally.  The xiphoid process is not particularly tender.  There is no dermatomal sensory abnormality in the thoracic spine appreciated.  Mild facetal features are evident over the sacral spine with extension and lateral bending at the level of the sacral ala.,Neurological examination of the upper and lower extremities reveals 3/5 reflexes of the biceps, triceps, brachioradialis, and patellar bilaterally.  I cannot elicit S1 reflexes.  There are no long tract signs.  Negative Hoffman's, negative Spurling's, no clonus, and negative Babinski.  Motor examination of the upper, as well as lower extremities appears to be intact throughout.  I may be able to detect a slight hand of atrophy of the right calf muscles, but this is truly unclear and no measurement was made.,SUMMARY OF DIAGNOSTIC IMAGING:,  As per above.,IMPRESSION:,1.  Osteoarthritis.,2.  Cervical spinal stenosis.,3.  Lumbar spinal stenosis.,4.  Lumbar radiculopathy, mostly likely at the right L5-S1 levels.,5.  History of mild spondylolisthesis of the lumbosacral spine at L4-L5 and right sacroiliac joint dysfunction.,6.  Chronic pain syndrome with myofascial pain and spasms of the trapezius and greater complexes.,PLAN:  ,The natural history and course of the disease was discussed in detail with Mr. XYZ.  Greater than 80 minutes were spent facet-to-face at this visit.  I have offered to re-image her cervical and lumbar spine and have included a thoracic MR imaging and rib series, as well as cervicolumbar flexion and extension views to evaluate for mobile segment and/or thoracic fractures.  I do not suspect any sort of intrathoracic comorbidity such as a neoplasm or mass, though this was discussed.  Pending the results of her preliminary studies, this should be ruled out.  I will see her in followup in about two weeks with the results of her scans.",
 MRI T-spine: Metastatic Adenocarcinoma of the T3-T4 vertebrae and invading the spinal canal., Orthopedic, MRI T-Spine - Spinal Mets ,"CC: ,BLE weakness and numbness.,HX:, This 59 y/o RHM was seen and released from an ER 1 week prior to this presentation for a 3 week history of progressive sensory and motor deficits in both lower extremities. He reported numbness beginning about his trunk and slowly progressing to involve his lower extremities over a 4 week period. On presentation, he felt numb from the nipple line down. In addition, he began experiencing progressive weakness in his lower extremities for the past week. He started using a cane 5 days before being seen and had been having difficulty walking and traversing stairs. He claimed he could not stand. He denied loss of bowel or bladder control. However, he had not had a bowel movement in 3 days and he had not urinated 24 hours. His lower extremities had been feeling cold for a day. He denied any associated back or neck pain. He has chronic shortness of breath, but felt it had become worse. He had also been experiencing lightheadedness upon standing more readily than usual for 2 days prior to presentation.,PMH:, 1)CAD with chronic CP, 2)NQWMI 1994, S/P Coronary Angioplasty, 3)COPD (previous FEV 11.48, and FVC 2.13), 4)Anxiety D/O, 5)DJD, 6)Developed confusion with metoprolol use, 7)HTN.,MEDS:, Benadryl, ECASA, Diltiazem, Isordil, Enalapril, Indomethacin, Terbutaline MDI, Ipratropium MDI, Folic Acid, Thiamine.,SHX:, 120pk-yr smoking, ETOH abuse in past, Retired Dock Hand,FHX: ,unremarkable except for ETOH abuse,EXAM:,  T98.2 96bpm 140/74mmHg R18,Thin cachetic male in moderate distress.,MS: A&O to person, place and time. Speech was fluent and without dysarthria. Comprehension, naming and reading were intact.,CN: unremarkable.,Motor: Full strength in both upper extremities.,HF HE HAdd HAbd KF KE AF AE,RLE 3 3 4 4 3 4 1 1,LLE 4 4 4+ 4+ 4+ 4 4 4,There was mild spastic muscle tone in the lower extremities. There was normal muscle bulk throughout.,SENSORY: Decreased PP in the LLE from the foot to nipple line, and in the RLE from the knee to nipple line. Decreased Temperature sensation from the feet to the umbilicus, bilaterally. No loss of Vibration or Proprioception. Decreased light touch from the feet to nipple line, bilaterally.,Gait: unable to walk. Stands with support only.,Station: no pronator drift or truncal ataxia.,Reflexes: 2+/2+ in BUE, 3+/3+ patellae, 0/1 ankles. Babinski signs were present, bilaterally. The abdominal reflexes were absent.,CV: RRR with a 2/6 systolic ejection murmur at the left sternal border. Lungs: CTA with mildly labored breathing. Abdomen: NT, ND, NBS, but bladder distended. Extremities were cool to touch. Peripheral pulses were intact and capillary refill was brisk. Rectal: decreased rectal tone and absent anal reflex. Right prostate nodule at the inferior pole.,COURSE: ,Admission Labs: FEV1=1.17, FVC 2.19, ABG 7.39/42/79 on room air. WBC 10/5, Hgb 13, Hct 39, Electrolytes were normal. PT & PTT were normal. Straight catheterization revealed a residual volume of 400cc of urine.,He underwent emergent T-spine MRI. This revealed a T3-4 vertebral body lesion which had invaded the spinal canal was compressing the spinal cord. He was treated with Decadron and underwent emergent spinal cord decompression on 5/7/95. He recovered some lower extremity strength following surgery. Pathological analysis of the tumor was consistent with adenocarcinoma. His primary tumor was not located despite chest-abdominal-pelvic CT scans, and a GI and GU workup which included cystoscopy and endoscopy. He received 3000cGy of XRT and died 5 months after presentation.",
" Patient with wrist pain and swelling, status post injury.", Orthopedic, MRI Wrist - 1 ,"FINDINGS:,There are posttraumatic cysts along the volar midline and volar lateral aspects of the lunate which are likely posttraumatic. There is no acute marrow edema (series #12 images #5-7). Marrow signal is otherwise normal in the distal radius and ulna, throughout the carpals and throughout the proximal metacarpals.,There is a partial tear of the volar component of the scapholunate ligament in the region of the posttraumatic lunate cyst with retraction and thickening towards the scaphoid (series #6 image #5, series #8 images #22-36). There is tearing of the membranous portion of the ligament. The dorsal component is intact.,The lunatotriquetral ligament is thickened and lax, but intact (series #8 image #32).,There is no tearing of the radial or ulnar attachment of the triangular fibrocartilage (series #6 image #7). There is a mildly positive ulnar variance. Normal ulnar collateral ligament.,The patient was positioned in dorsiflexion. Carpal alignment is normal and there are no tears of the dorsal or ventral intercarpal ligaments (series #14 image #9).,There is a longitudinal split tear of the ECU tendon which is enlarged both at the level of and distal to the ulnar styloid with severe synovitis (series #4 images #8-16, series #3 images #9-16).,There is thickening of the extensor tendon sheaths within the fourth dorsal compartment with intrinsically normal tendons (series #4 image #12).,There is extensor carpi radialis longus and brevis synovitis in the second dorsal compartment (series #4 image #13).,Normal flexor tendons within the carpal tunnel. There is mild thickening of the tendon sheaths and the median nerve demonstrates increased signal without compression or enlargement (series #3 image #7, series #4 image #7).,There are no pathological cysts or soft tissue masses.,IMPRESSION:,Partial tear of the volar and membranous components of the scapholunate ligament with an associated posttraumatic cyst in the lunate. There is thickening and laxity of the lunatotriquetral ligament.,Longitudinal split tear of the ECU tendon with tendinosis and severe synovitis.,Synovitis of the second dorsal compartment and tendon sheath thickening in the fourth dorsal compartment.,Tendon sheath thickening within the carpal tunnel with increased signal within the median nerve.","orthopedic, fourth dorsal compartment, tendon sheath thickening, tendon sheaths, dorsal compartment, volar, carpals, tear, ulnar, synovitis, sheaths, ligament, thickening, dorsal, tendon, injury,"
 MRI T-spine and CXR - Aortic Dissection., Orthopedic, MRI T-Spine ,"CC:, BLE weakness.,HX:, This 82y/o RHM was referred to the Neurology service by the Neurosurgery service for evaluation of acute onset paraplegia. He was in his usual state of health until 5:30PM on 4/6/95, when he developed sudden ""pressure-like"" epigastric discomfort associated with bilateral lower extremity weakness, SOB, lightheadedness and diaphoresis. He knelt down to the floor and ""went to sleep."" The Emergency Medical Service was alert and arrived within minutes, at which time he was easily aroused though unable to move or feel his lower extremities. No associated upper extremity or bulbar dysfunction was noted. He was taken to a local hospital where an INR was found to be 9.1. He was given vitamin K 15mg, and transferred to UIHC to rule out spinal epidural hemorrhage. An MRI scan of the T-spine was obtained and the preliminary reading was ""normal."" The Neurology service was then asked to evaluate the patient.,MEDS:, Coumadin 2mg qd, Digoxin 0.25mg qd, Prazosin 2mg qd.,PMH:, 1)HTN. 2)A-Fib on coumadin. 3)Peripheral vascular disease:s/p left Femoral-popliteal bypass (8/94) and graft thrombosis-thrombolisis (9/94). 4)Adenocarcinoma of the prostate: s/p TURP (1992).,FHX: ,unremarkable.,SHX:, Farmer, Married, no Tobacco/ETOH/illicit drug use.,EXAM:, BP165/60 HR86 RR18 34.2C SAO2 98% on room air.,MS: A&O to person, place, time. In no acute distress. Lucid.,CN: unremarkable.,MOTOR: 5/5 strength in BUE. Flaccid paraplegia in BLE,Sensory: T6 sensory level to LT/PP, bilaterally. Decreased vibratory sense in BLE in a stocking distribution, distally.,Coord: Intact FNF and RAM in BUE. Unable to do HKS.,Station: no pronator drift.,Gait: not done.,Reflexes: 2/2 BUE, Absent in BLE, plantar responses were flexor, bilaterally.,Rectal: decreased rectal tone.,GEN EXAM: No carotid bruitts. Lungs: bibasilar crackles. CV: Irregular rate and rhythm with soft diastolic murmur at the left sternal border. Abdomen: flat, soft, non-tender without bruitt or pulsatile mass. Distal pulses were strong in all extremities.,COURSE:, Hgb 12.6, Hct 40%, WBC 11.7, Plt 154k, INR 7.6, PTT 50, CK 41, the GS was normal. EKG showed A-Fib at 75BPM with competing junctional pacemaker, essentially unchanged from 9/12/94.,It was suspected that the patient sustained an anterior-cervico-thoracic spinal cord infarction with resultant paraplegia and T6 sensory level. A CXR was done in the ER prior to admission. This revealed cardiomegaly and a widened mediastinum. He returned from the x-ray suite and suddenly became unresponsive and went into cardiopulmonary arrest. Resuscitative measures failed. Pericardiocentesis was unremarkable. Autopsy revealed a massive aortic dissection extending from the aortic root to the origin of the iliac arteries with extensive pericardial hematoma. The dissection was seen in retrospect on the MRI T-spine.","orthopedic, mri, a&o, aortic dissection, cxr, irregular rate and rhythm, mri scan, neurology service, t-spine, carotid bruitts, epidural hemorrhage, mediastinum, paraplegia, person, place, stocking distribution, time, weakness, mri t spine, sensory level, neurology, spine, "
" The thoracic spine was examined in the AP, lateral and swimmer's projections.", Orthopedic, MRI T-Spine - 1 ,"EXAM:  ,Thoracic Spine.,REASON FOR EXAM: , Injury.,INTERPRETATION: , The thoracic spine was examined in the AP, lateral and swimmer's projections.  There is mild chronic-appearing anterior wedging of what is believed to represent T11 and 12 vertebral bodies.  A mild amount of anterior osteophytic lipping is seen involving the thoracic spine.  There is a suggestion of generalized osteoporosis.  The intervertebral disc spaces appear generally well preserved.,The pedicles appear intact.,IMPRESSION:,1. Mild chronic-appearing anterior wedging of what is believed to represent the T11 and 12 vertebral bodies.,2. Mild degenerative changes of the thoracic spine.,3. Osteoporosis.","orthopedic, thoracic spine, swimmer's projections, osteoporosis, osteophytic lipping, anterior wedging, vertebral bodies, thoracic, spine,"
" Arthroscopy with arthroscopic rotator cuff debridement, anterior acromioplasty, and Mumford procedure left shoulder.  Partial rotator cuff tear with impingement syndrome.  Degenerative osteoarthritis of acromioclavicular joint, left shoulder, rule out slap lesion.", Orthopedic, Mumford Procedure & Acromioplasty ,"PREOPERATIVE DIAGNOSES:,1.  Partial rotator cuff tear with impingement syndrome.,2.  Degenerative osteoarthritis of acromioclavicular joint, left shoulder, rule out slap lesion.,POSTOPERATIVE DIAGNOSES:,1.  Partial rotator cuff tear with impingement syndrome.,2.  Degenerative osteoarthritis of acromioclavicular joint, left shoulder.,PROCEDURE PERFORMED:,1.  Arthroscopy with arthroscopic rotator cuff debridement.,2.  Anterior acromioplasty.,3.  Mumford procedure left shoulder.,SPECIFICATIONS: , The entire operative procedure was done in Inpatient Operative Suite, Room #1 at ABCD General Hospital.  This was done in a modified beach chair position with interscalene and subsequent general anesthetic.,HISTORY AND GROSS FINDINGS: , This is a 38-year-old morbidly obese white male suffering increasing pain in his left shoulder for a number of months prior to surgical intervention.  He was refractory to conservative outpatient therapy.  He had injection of his AC joint, which removed symptoms but was not long lasting.  After discussing the alternatives of the care as well as advantages and disadvantages, risks, complications, and expectations, he elected to undergo the above-stated procedure on this date.,Intraarticular viewing of the joint revealed a partial rotator cuff tear on the supraspinatus insertion on the joint side.  All else was noted to be intact including the glenohumeral joint, the long head of the biceps, and the labrum.  The remainder of the rotator cuff observed was noted to be intact.  Subacromially, the patient was noted to have increased synovitis.  Degenerative changes were noted upon observation of the distal clavicle.,OPERATIVE PROCEDURE: , The patient was laid supine upon the operative table.  After receiving interscalene block anesthetic by Anesthesia Department, the patient was placed in modified beach chair position.  He was prepped and draped in the usual sterile manner.  Portals were created posteriorly and anteriorly from outside to in.  A full and complete diagnostic intraarticular arthroscopy was carried out.  Debridement was carried out through a 3.5 meniscal shaver to the 4.2 meniscal shaver to the undersurface of the partial tear of the rotator cuff.  Retrospectively it was approximately 25% of the generalized thickness.,Attention was then turned to the subacromial region.  The scope was directed subacromially.  A portal was created laterally.  Ultimately, the patient needed a general anesthetic once we were closer to the distal clavicle.  Gross bursectomy was carried out with a 4.2 meniscal shaver.  #18-gauge spinal needles have been placed to outline the anterior acromion prior to this.,It was difficult to control the patient's blood pressure with systolics ranging anywhere from 165 or 170 up to 200.  Because of this and difficulties with his anesthetic, it was elected to change to an open procedure.  Thus, the patient was anesthetized safely and secured.  An oblique incision was carried at the cross Langer's line across the outlet of the shoulder through the skin and subcutaneous tissue.  Hemostasis was controlled via electrocoagulation.  Flaps were created.  Anterior deltoid was reflected inferiorly.  Anterior acromioplasty was carried out with a saw then a Micro-Aire and then a beaver-tail rasp.  An excellent decompression was present.  CA ligament had been previously resected.  We then took the incision over the distal clavicle.  The end of the distal clavicle approximately 12 mm to 14 mm was isolated and removed with the Micro-Aire saw.  The beaver-tail rasp was utilized to smooth off the edges.  Pain buster catheter was placed deep to closure of the AC capsule and then to the deltoid with interrupted #1 Vicryl.  Transosseous sutures were placed across the acromion and the deltoid was elevated and closed with the same.  A superficial running #2-0 Vicryl suture was utilized for deltoid closure distally.  Interrupted #2-0 Vicryl was utilized to subcutaneous fat closure, running #4-0 subcuticular stitch for skin closure and Adaptic, 4x4s, ABDs, and Elastoplast tape placed for compression dressing.  0.25% Marcaine was flooded into the joint prior to the skin closure.  Pain buster catheter was hooked up.  The patient's arm was placed in arm sling.  He was safely transferred to the PACU in apparent satisfactory condition.  Expected surgical prognosis on this patient is fair.","orthopedic, slap lesion, acromioclavicular joint, impingement syndrome, mumford procedure, acromioplasty, arthroscopy, arthroscopic, arthroscopic rotator cuff debridement, anterior acromioplasty, rotator cuff tear, arthroscopic rotator, meniscal shaver, cuff tear, rotator cuff, debridement, osteoarthritis, acromioclavicular, clavicle, deltoid, rotator, cuff, shoulder, joint"
 Patient status post vehicular trauma.  Low Back syndrome and Cervicalgia., Orthopedic, Neck & Lower Back Pain - Consult ,"CHIEF COMPLAINT:, Neck and lower back pain.,VEHICULAR TRAUMA HISTORY:, Date of incident: 1/15/2001. The patient was the driver of a small sports utility vehicle and was wearing a seatbelt. The patient’s vehicle was proceeding through an intersection and was struck by another vehicle from the left side and forced off the road into a utility pole. The other vehicle had reportedly been driven by a drunk driver and ran a traffic signal. Estimated impact speed was 80 m.p.h. The driver of the other vehicle was reportedly cited by police. The patient was transiently unconscious and came to the scene. There was immediate onset of headaches, neck and lower back pain. The patient was able to exit the vehicle and was subsequently transported by Rescue Squad to St. Thomas Memorial Hospital, evaluated in the emergency room and released.,NECK AND LOWER BACK PAIN HISTORY:, The patient relates the persistence of pain since the motor vehicle accident. Symptoms began immediately following the MVA. Because of persistent symptoms, the patient subsequently sought chiropractic treatment. Neck pain is described as severe. Neck pain remains localized and is non-radiating. There are no associated paresthesias. Back pain originates in the lumbar region and radiates down both lower extremities. Back pain is characterized as worse than the neck pain. There are no associated paresthesias.",
 MRI T-L spine - L2 conus medullaris lesion and syndrome secondary to Schistosomiasis., Orthopedic, MRI T-L Spine - Schistosomiasis ,"CC: ,Paraplegia.,HX:, This 32 y/o RHF had been performing missionary work in Jos, Nigeria for several years and delivered her 4th child by vaginal delivery on 4/10/97. The delivery was induced with Pitocin, but was otherwise uncomplicated. For the first 4 days post-partum she noted clear liquid diarrhea without blood and minor abdominal discomfort. This spontaneous resolved without medical treatment. The second week post-partum she had 4-5 days of sinusitis, purulent nasal discharge and facial pain. She was otherwise well until 5/4/97 when stationed in a more rural area of Nigeria, she noted a dull ache in both knees (lateral to the patellae) and proximal tibia, bilaterally. The pain was not relieved by massage and seemed more bothersome when seated or supine. She had no sensory loss at the time.,On 5/6/97, she awakened to pain radiating down her knees to her anterior tibia. Over the next few hours the pain radiated circumferentially around both calves, and involved the soles of her feet and posterior BLE to her buttocks. Rising from bed became a laborious task and she required assistance to walk to the bathroom. Ibuprofen provided minimal analgesia. By evening the sole of one foot was numb.,She awoke the next morning, 5/9/97, with ""pins & needles"" sensation in BLE up to her buttocks. She was given Darvocet for analgesia and took an airplane back to the larger city she was based in. During the one hour flight her BLE weakness progressed to a non-weight bearing state (i.e. she could not stand). Local evaluation revealed 3/3 proximal and 4/4 distal BLE weakness. She had a sensory level to her waist on PP and LT testing. She also had mild lumbar back pain. Local laboratory evaluation: WBC 12.7, ESR 10. She was presumed to have Guillain-Barre syndrome and was placed on Solu-Cortef 1000mg qd and Sandimmune IV IgG 12.0 g.,On 5/10/97, she was airlifted to Geneva, Switzerland. Upon arrival there she had total anesthesia from the feet up to the inguinal region, bilaterally. There was flaccid areflexic paralysis of BLE and she was unable to void or defecate. Straight catheterization of the bladder revealed a residual volume of 1000cc. On 5/12/ CSF analysis revealed: Protein 1.5g/l, Glucose 2.2mmol/l, WBC 92 (O PMNS, 100% Lymphocytes), RBC 70, Clear CSF, bacterial-fungal-AFB-cultures were negative. Broad spectrum antibiotics and Solu-Medrol 1g IV qd were started. MRI T-L-spine, 5/12/97 revealed an intradural T12-L1 lesion that enhanced minimally with gadolinium and was associated with spinal cord edema in the affected area. MRI Brain, 5/12/97, was unremarkable and showed no evidence of demyelinating disease. HIV, HTLV-1, HSV, Lyme, EBV, Malaria and CMV serological titers were negative. On 5/15/97 the Schistosomiasis Mekongi IFAT serological titer returned positive at 1:320 (normal<1:80). 5/12/97 CSF Schistosomiasis Mekongi IFAT and ELISA were negative. She was then given a one day course of Praziquantel 3.6g total in 3 doses; and started on Prednisone 60 mg po qd; the broad spectrum antibiotics and Solu-Medrol were discontinued.,On 5/22/97, a rectal biopsy was performed to evaluate parasite eradication. The result came back positive for ova and granulomata after she had left for UIHC. The organism was not speciated. 5/22/97 CSF schistosomiasis ELISA and IFAT titers were positive at 1.09 and 1:160, respectively. These titers were not known when she initially arrived at UIHC.,Following administration of Praziquantel, she regained some sensation in BLE but the paraplegia, and urinary retention remained.,MEDS:, On 5/24/97 UIHC arrival: Prednisone 60mg qd, Zantac 50 IV qd, Propulsid 20mg tid, Enoxaparin 20mg qd.,PMH:, 1)G4P4.,FHX:, unremarkable.,SHX: ,Missionary. Married. 4 children ( ages 7,5,3,6 weeks).,EXAM:, BP110/70, HR72, RR16, 35.6C,MS: A&O to person, place and time. Speech fluent and without dysarthria. Lucid thought process.,CN: unremarkable.,Motor: 5/5 BUE strength. Lower extremities: 1/1 quads and hamstrings, 0/0 distally.,Sensory: Decreased PP/LT/VIB from feet to inguinal regions, bilaterally. T12 sensory level to temperature (ice glove).,Coord: normal FNF.,Station/Gait: not done.,Reflexes: 2/2 BUE. 0/0 BLE. No plantar responses, bilaterally.,Rectal: decreased to no rectal tone. Guaiac negative.,Other: No Lhermitte's sign. No paraspinal hypertonicity noted. No vertebral tenderness.,Gen exam: Unremarkable.,COURSE:, MRI T-L-spine, 5/24/97, revealed a 6 x 8 x 25 soft tissue mass at the L1 level posterior to the tip of the conus medullaris and extending into the canal below that level. This appeared to be intradural. There was mild enhancement. There was more enhancement along the distal cord surface and cauda equina. The distal cord had sign of diffuse edema. She underwent exploratory and decompressive laminectomy on 5/27/97, and was retreated with a one day course of Praziquantel 40mg/kg/day. Praziquantel is reportedly only 80% effective at parasite eradication.,She continued to reside on the Neurology/Neurosurgical service on 5/31/97 and remained paraplegic.",
 MRI left shoulder., Orthopedic, MRI Shoulder - 5 ,"EXAM:,MRI LEFT SHOULDER,CLINICAL:,This is a 26 year old with a history of instability. Examination was preformed on 12/20/2005.,FINDINGS:,There is supraspinatus tendinosis without a full-thickness tear, gap or fiber retraction and there is no muscular atrophy (series #105 images #4-6).,Normal infraspinatus and subscapularis tendons.,Normal long biceps tendon within the bicipital groove. There is medial subluxation of the tendon under the transverse humeral ligament, and there is tendinosis of the intracapsular portion of the tendon with partial tearing, but there is no complete tear or discontinuity. Biceps anchor is intact (series #105 images #4-7; series #102 images #10-22).,There is a very large Hill-Sachs fracture, involving almost the entire posterior half of the humeral head (series #102 images #13-19). This is associated with a large inferior bony Bankart lesion that measures approximately 15 x 18mm in AP and craniocaudal dimension with impaction and fragmentation (series #104 images #10-14; series #102 images #18-28). There is medial and inferior displacement of the fragment. There are multiple interarticular bodies, some of which may be osteochondromatous and some may be osseous measuring up to 8mm in diameter. (These are too numerous to count.) There is marked stretching, attenuation and areas of thickening of the inferior and middle glenohumeral ligaments, compatible with a chronic tear with scarring but there is no discontinuity or demonstrated HAGL lesion (series #105 images #5-10).,Normal superior glenohumeral ligament.,There is no SLAP tear.,Normal acromioclavicular joint without narrowing of the subacromial space.,Normal coracoacromial, coracohumeral and coracoclavicular ligaments.,There is fluid in the glenohumeral joint and biceps tendon sheath.,IMPRESSION:,There is a very large Hill-Sachs fracture involving most of the posterior half of the humeral head with an associated large and inferior and medial displaced osseous Bankart lesion.,There are multiple intraarticular bodies, and there is a partial tear of the inferior and middle glenohumeral ligaments.,There is medial subluxation of the long biceps tendon under the transverse humeral ligament with partial tearing of the intracapsular portion.,","orthopedic, inferior and middle glenohumeral, biceps tendon, partial tearing, glenohumeral ligaments, mri, shoulder, ligament, ligaments, biceps, humeral, glenohumeral, tear, tendons"
 MRI Spine - T12-L5 epidural lipoma and thoracic spinal cord infarction vs. transverse myelitis., Orthopedic, MRI Spine - Epidural Lipoma ,"CC:, Progressive lower extremity weakness.,HX: ,This 54 y/o RHF presented on 7/3/93 with a 2 month history of lower extremity weakness. She was admitted to a local hospital on 5/3/93 for a 3 day h/o of progressive BLE weakness associated with incontinence and BLE numbness. There was little symptom of upper extremity weakness at that time, according to the patient. Her evaluation was notable for a bilateral L1 sensory level and 4/4 strength in BLE. A T-L-S Spine MRI revealed a T4-6 lipomatosis with anterior displacement of the cord without cord compression. CSF analysis yielded: opening pressure of 14cm H20, protein 88, glucose 78, 3 lymphocytes and 160 RBC, no oligoclonal bands or elevated IgG index, and negative cytology. Bone marrow biopsy was negative. B12, Folate, and Ferritin levels were normal. CRP 5.2 (elevated). ANA was positive at 1:5,120 in speckled pattern. Her hospital course was complicated by deep venous thrombosis, which recurred after heparin was stopped to do the bone marrow biopsy. She was subsequently placed on Coumadin. EMG/NCV testing revealed "" lumbosacral polyradiculopathy with axonal degeneration and nerve conduction block."" She was diagnosed with atypical Guillain-Barre vs. polyradiculopathy and received a single course of Decadron; and no plasmapheresis or IV IgG. She was discharged home o 6/8/93.,She subsequently did not improve and after awaking from a nap on her couch the day of presentation, 7/3/93, she found she was paralyzed from the waist down. There was associated mild upper lumbar back pain without radiation. She had had no bowel movement or urination since that time. She had no recent trauma, fever, chills, changes in vision, dysphagia or upper extremity deficit.,MEDS:, Coumadin 7.5mg qd, Zoloft 50mg qd, Lithium 300mg bid.,PMH:, 1) Bi-polar Affective Disorder, dx 1979 2) C-section.,FHX:, Unremarkable.,SHX:, Denied Tobacco/ETOH/illicit drug use.,EXAM: ,BP118/64, HR103, RR18, Afebrile.,MS: ,A&O to person, place, time. Speech fluent without dysarthria. Lucid thought processes.,CN: ,Unremarkable.,MOTOR:, 5/5 strength in BUE. Plegic in BLE. Flaccid muscle tone.,SENSORY:, L1 sensory level (bilaterally) to PP and TEMP, without sacral sparing. Proprioception was lost in both feet.,CORD: ,Normal in BUE.,Reflexes were 2+/2+ in BUE. They were not elicited in BLE. Plantar responses were equivocal, bilaterally.,RECTAL: ,Poor rectal tone. stool guaiac negative. She had no perirectal sensation.,COURSE:, CRP 8.8 and ESR 76. FVC 2.17L. WBC 1.5 (150 bands, 555 neutrophils, 440 lymphocytes and 330 monocytes), Hct 33%, Hgb 11.0, Plt 220K, MCV 88, GS normal except for slightly low total protein (8.0). LFT were normal. Creatinine 1.0. PT and PTT were normal. ABCG 7.46/25/79/96% O2Sat. UA notable for 1+ proteinuria. EKG normal.,MRI L-spine, 7/3/93, revealed an area of abnormally increased T2 signal extending from T12 through L5. This area causes anterior displacement of the spinal cord and nerve roots. The cauda equina are pushed up against the posterior L1 vertebral body. There bilaterally pulmonary effusions. There is also abnormally increased T2 signal in the center of the spinal cord extending from the mid thoracic level through the conus. In addition, the Fila Terminale appear thickened. There is increased signal in the T3 vertebral body suggestion a hemangioma. The findings were felt consistent with a large epidural lipoma displacing the spinal cord anteriorly. there also appeared spinal cord swelling and increased signal within the spinal cord which suggests an intramedullary process.,CSF analysis revealed: protein 1,342, glucose 43, RBC 4,900, WBC 9. C3 and C$ complement levels were 94 and 18 respectively (normal) Anticardiolipin antibodies were negative. Serum Beta-2 microglobulin was elevated at 2.4 and 3.7 in the CSF and Serum, respectively. It was felt the patient had either a transverse myelitis associated with SLE vs. partial cord infarction related to lupus vasculopathy or hypercoagulable state. She was place on IV Decadron. Rheumatology felt that a diagnosis of SLE was likely. Pulmonary effusion analysis was consistent with an exudate. She was treated with plasma exchange and place on Cytoxan.,On 7/22/93 she developed fever with associated proptosis and sudden loss of vision, OD. MRI Brain, 7/22/93, revealed a 5mm thick area of intermediate signal adjacent to the posterior aspect of the right globe, possibly representing hematoma. Ophthalmology felt she had a central retinal vein occlusion; and it was surgically decompressed.,She was placed on prednisone on 8/11/93 and Cytoxan was started on 8/16/93. She developed a headache with meningismus on 8/20/93. CSF analysis revealed: protein 1,002, glucose2, WBC 8,925 (majority were neutrophils). Sinus CT scan negative. She was placed on IV Antibiotics for presumed bacterial meningitis. Cultures were subsequently negative. She spontaneously recovered. 8/25/93, cisternal tap CSF analysis revealed: protein 126, glucose 35, WBC 144 (neutrophils), RBC 95, Cultures negative, cytology negative. MRI Brain scan revealed diffuse leptomeningeal enhancement in both brain and spinal canal.,DSDNA negative. She developed leukopenia in 9/93, and she was switched from Cytoxan to Imuran. Her LFT's rose and the Imuran was stopped and she was placed back on prednisone.,She went on to have numerous deep venous thrombosis while on Coumadin. This required numerous hospital admissions for heparinization. Anticardiolipin antibodies and Protein C and S testing was negative.",
 A 69-year-old male with pain in the shoulder. Evaluate for rotator cuff tear., Orthopedic, MRI Shoulder - 4 ,"EXAM:,MRI LEFT SHOULDER,CLINICAL:,This is a 69-year-old male with pain in the shoulder. Evaluate for rotator cuff tear.,FINDINGS:,Examination was performed on 9/1/05.,There is marked supraspinatus tendinosis and extensive tearing of the substance of the tendon and articular surface, extending into the myotendinous junction as well. There is still a small rim of tendon along the bursal surface, although there may be a small tear at the level of the rotator interval. There is no retracted tendon or muscular atrophy (series #6 images #6-17).,Normal infraspinatus tendon.,There is subscapularis tendinosis with fraying and partial tearing of the superior most fibers extending to the level of the rotator interval (series #9 images #8-13; series #3 images #8-14). There is no complete tear, gap or fiber retraction and there is no muscular atrophy.,There is tendinosis and superficial tearing of the long biceps tendon within the bicipital groove, and there is high grade (near complete) partial tearing of the intracapsular portion of the tendon. The biceps anchor is intact. There are degenerative changes in the greater tuberosity of the humerus but there is no fracture or subluxation.,There is degeneration of the superior labrum and there is a small nondisplaced tear in the posterior superior labrum at the one to two o’clock position (series #6 images #12-14; series #3 images #8-10; series #9 images #5-8). There is a small sublabral foramen at the eleven o’clock position (series #9 image #6). There is no osseous Bankart lesion.,Normal superior, middle and inferior glenohumeral ligaments.,There is hypertrophic osteoarthropathy of the acromioclavicular joint with narrowing of the subacromial space and flattening of the superior surface of the supraspinatus musculotendinous junction, which in the appropriate clinical setting is an MRI manifestation of an impinging lesion (series #8 images #3-12).,Normal coracoacromial, coracohumeral and coracoclavicular ligaments. There is minimal fluid within the glenohumeral joint. There is no atrophy of the deltoid muscle.,IMPRESSION:,  There is extensive supraspinatus tendinosis and partial tearing as described. There is no retracted tendon or muscular atrophy, but there may be a small tear along the anterior edge of the tendon at the level of the rotator interval, and this associated partial tearing of the superior most fibers of the subscapularis tendon.  There is also a high-grade partial tear of the long biceps tendon as it courses under the transverse humeral ligament. There is no evidence of a complete tear or retracted tendon. Small nondisplaced posterior superior labral tear. Outlet narrowing from the acromioclavicular joint, which in the appropriate clinical setting is an MRI manifestation of an impinging lesion.","orthopedic, level of the rotator, impinging lesion, rotator interval, retracted tendon, muscular atrophy, partial tearing, tendon, mri, shoulder, rotator, superior, tear,"
" MRI of the Cervical, Thoracic, and Lumbar Spine", Orthopedic, MRI Spine ,"INTERPRETATION: , MRI of the cervical spine without contrast showed normal vertebral body height and alignment with normal cervical cord signal.  At C4-C5, there were minimal uncovertebral osteophytes with mild associated right foraminal compromise.  At C5-C6, there were minimal diffuse disc bulge and uncovertebral osteophytes with indentation of the anterior thecal sac, but no cord deformity or foraminal compromise.  At C6-C7, there was a central disc herniation resulting in mild deformity of the anterior aspect of the cord with patent neuroforamina.  MRI of the thoracic spine showed normal vertebral body height and alignment.  There was evidence of disc generation, especially anteriorly at the T5-T6 level.  There was no significant central canal or foraminal compromise.  Thoracic cord normal in signal morphology.  MRI of the lumbar spine showed normal vertebral body height and alignment.  There is disc desiccation at L4-L5 and L5-S1 with no significant central canal or foraminal stenosis at L1-L2, L2-L3, and L3-L4.  There was a right paracentral disc protrusion at L4-L5 narrowing of the right lateral recess.  The transversing nerve root on the right was impinged at that level.  The right foramen was mildly compromised.  There was also a central disc protrusion seen at the L5-S1 level resulting in indentation of the anterior thecal sac and minimal bilateral foraminal compromise.,IMPRESSION: , Overall impression was mild degenerative changes present in the cervical, thoracic, and lumbar spine without high-grade central canal or foraminal narrowing.  There was narrowing of the right lateral recess at L4-L5 level and associated impingement of the transversing nerve root at that level by a disc protrusion.  This was also seen on a prior study.,","orthopedic, cervical spine, mri, cervical, thoracic, lumbar, transversing nerve root, vertebral body height, vertebral body, disc protrusion, foraminal compromise, central, foraminal, disc, spineNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 MRI of lumbar spine without contrast to evaluate chronic back pain., Orthopedic, MRI of Lumbar Spine w/o Contrast ,"EXAM: , MRI of lumbar spine without contrast.,HISTORY:,  A 24-year-old female with chronic back pain.,TECHNIQUE: , Noncontrast axial and sagittal images were acquired through the lumbar spine in varying degrees of fat and water weighting.,FINDINGS: , The visualized cord is normal in signal intensity and morphology with conus terminating in proper position.  Visualized osseous structures are normal in marrow signal intensity and morphology without evidence for fracture/contusion, compression deformity, or marrow replacement process.  There are no paraspinal masses.,Disc heights, signal, and vertebral body heights are maintained throughout the lumbar spine.,L5-S1:  Central canal, neural foramina are patent.,L4-L5:  Central canal, neural foramina are patent.,L3-L4:  Central canal, neural foramen is patent.,L2-L3:  Central canal, neural foramina are patent.,L1-L2:  Central canal, neural foramina are patent.,The visualized abdominal aorta is normal in caliber.  Incidental note has been made of multiple left-sided ovarian, probable physiologic follicular cysts.,IMPRESSION: , No acute disease in the lumbar spine.","orthopedic, mri, central canal, noncontrast, abdominal aorta, axial, back pain, contrast, follicular cysts, images, lumbar spine, morphology, neural foramina, sagittal, signal intensity, without contrast, mri of lumbar spine, mri of lumbar, lumbar, foramina, neural, patent, spine"
" MRI L-spine - History of progressive lower extremity weakness, right frontal glioblastoma with lumbar subarachnoid seeding.", Orthopedic, MRI L-Spine - Subarachnoid Seeding ,"CC:, Progressive lower extremity weakness.,HX: ,This 52y/o RHF had a h/o right frontal glioblastoma multiforme (GBM) diagnosed by brain biopsy/partial resection, on 1/15/1991. She had been healthy until 1/6/91, when she experienced a generalized tonic-clonic type seizure during the night. She subsequently underwent an MRI brain scan and was found to have a right frontal enhancing lesion in the mesial aspect of the right frontal lobe at approximately the level of the coronal suture. There was minimal associated edema and no mass effect. Following extirpation of the tumor mass, she underwent radioactive Iodine implantation and 6020cGy radiation therapy in 35 fractions. In 11/91 she received BCNU and Procarbazine chemotherapy protocols. This was followed by four courses of 5FU/Carboplatin (3/92, 6/92, 9/92 ,10/92) chemotherapy.,On 10/12/92 she presented for her 4th course of 5FU/Carboplatin and complained of non-radiating dull low back pain, and proximal lower extremity weakness, but was still able to ambulate. She denied any bowel/bladder difficulty.,PMH: ,s/p oral surgery for wisdom tooth extraction.,FHX/SHX: ,1-2 ppd cigarettes. rare ETOH use. Father died of renal CA.,MEDS: ,Decadron 12mg/day.,EXAM: ,Vitals unremarkable.,MS: Unremarkable.,Motor: 5/5 BUE, LE: 4+/5- prox, 5/5 distal to hips. Normal tone and muscle bulk.,Sensory: No deficits appreciated.,Coord: Unremarkable.,Station: No mention in record of being tested.,Gait: Mild difficulty climbing stairs.,Reflexes: 1+/1+ throughout and symmetric. Plantar responses were down-going bilaterally.,INITIAL IMPRESSION:, Steroid myopathy. Though there was enough of a suspicion of ""drop"" metastasis that an MRI of the L-spine was obtained.,COURSE:, The MRI L-spine revealed fine linear enhancement along the dorsal aspect of the conus medullaris, suggestive of subarachnoid seeding of tumor. No focal mass or cord compression was visualized. CSF examination revealed: 19RBC, 22WBC, 17 Lymphocytes, and 5 histiocytes, Glucose 56, Protein 150. Cytology (negative). The patient was discharged home on 10/17/92, but experienced worsening back pain and lower extremity weakness and became predominantly wheelchair bound within 4 months. She was last seen on 3/3/93 and showed signs of worsening weakness (left hemiplegia: R > L) as her tumor grew and spread. She then entered a hospice.","orthopedic, glioblastoma multiforme, gbm, steroid myopathy, hemiplegia, progressive lower extremity weakness, mri l spine, lower extremity weakness, frontal glioblastoma, subarachnoid seeding, lower extremity, glioblastoma, subarachnoid, spine, mri, lower, weakness, "
 MRI right knee without gadolinium, Orthopedic, MRI Knee - 5 ,"EXAM:,MRI RIGHT KNEE WITHOUT GADOLINIUM,CLINICAL:,This is a 21-year-old male with right knee pain after a twisting injury on 7/31/05. Patient has had prior lateral meniscectomy in 2001.,FINDINGS:,Examination was performed on 8/3/05,Normal medial meniscus without intrasubstance degeneration, surface fraying or discrete meniscal tear.,There is subtle irregularity along the superior and inferior articular surfaces of the lateral meniscus, likely reflecting previous partial meniscectomy and contouring, although subtle surface tearing cannot be excluded, particularly along the undersurface of the lateral meniscus (series #3, image #17). There is no displaced tear or displaced meniscal fragment.,There is a mild interstitial sprain of the anterior cruciate ligament without focal tear or discontinuity.,Normal posterior cruciate ligament.,Normal medial collateral ligament.,There is a strain of the popliteus muscle and tendon without complete tear.,There is a sprain of the posterolateral and posterocentral joint capsule (series #5 images #10-18). There is marrow edema within the posterolateral corner of the tibia, and there is linear signal adjacent to the cortex suggesting that there may be a Segond fracture for which correlation with radiographs is recommended (series #6, images #4-7).,Biceps femoris tendon and iliotibial band are intact and there is no discrete fibular collateral ligament tear. Normal quadriceps and patellar tendons.,There is contusion within the posterior non-weight bearing surface of the medial femoral condyle, as well as in the posteromedial corner of the tibia. There is linear vertically oriented signal within the distal tibial diaphyseal-metaphyseal junction (series #7, image #8; series #2, images #4-5). There is no discrete fracture line, and this is of uncertain significance, but this should be correlated with radiographs.,The patellofemoral joint is congruent without patellar tilt or subluxation. Normal medial and lateral patellar retinacula. There is a joint effusion.,IMPRESSION:,Changes within the lateral meniscus most likely reflect previous partial meniscectomy and re-contouring although a subtle undersurface tear in the anterior horn may be present.,Mild anterior cruciate ligament interstitial sprain.,There is a strain of the popliteus muscle and tendon and there is a sprain of the posterolateral and posterocentral joint capsule with a possible Second fracture which should be correlated with radiographs.,","orthopedic, mri right knee, posterolateral and posterocentral, posterocentral joint capsule, lateral meniscus, cruciate ligament, mri, meniscectomy, cruciate, tendon, posterolateral, patellar, ligament, tear"
 MRI left knee., Orthopedic, MRI Knee - 3 ,"EXAM:,MRI LEFT KNEE,CLINICAL:,This is a 41 -year-old-male with knee pain, mobility loss and swelling. The patient had a twisting injury one week ago on 8/5/05. The examination was performed on 8/10/05,FINDINGS:,There is intrasubstance degeneration within the medial meniscus without a discrete surfacing tear.,There is intrasubstance degeneration within the lateral meniscus, and there is a probable small tear in the anterior horn along the undersurface at the meniscal root.,There is an interstitial sprain/partial tear of the anterior cruciate ligament. There is no complete tear or discontinuity, and the ligament has a celery stick appearance.,Normal posterior cruciate ligament.,Normal medial collateral ligament.,There is a sprain of the femoral attachment of the fibular collateral ligament, without complete tear or discontinuity. The fibular attachment is intact.,Normal biceps femoris tendon, popliteus tendon and iliotibial band.,Normal quadriceps and patellar tendons.,There are no fractures.,There is arthrosis, with high-grade changes in the patellofemoral compartment, particularly along the midline patellar ridge and lateral facet. There are milder changes within the medial femorotibial compartments. There are subcortical cystic changes subjacent to the tibial spine, which appear chronic.,There is a joint effusion. There is synovial thickening.,IMPRESSION:,Probable small tear in the anterior horn of the lateral meniscus at the meniscal root.,Interstitial sprain/partial tear of the anterior cruciate ligament.,Arthrosis, joint effusion and synovial hypertrophy.,There are several areas of focal prominent medullary fat within the medial and lateral femoral condyles.","orthopedic, mri left knee, interstitial sprain/partial tear, anterior cruciate ligament, lateral meniscus, cruciate ligament, synovial, mri, meniscus, sprain/partial, cruciate, knee, ligament"
 A 32-year-old male with shoulder pain., Orthopedic, MRI Shoulder - 3 ,"EXAM:,MRI RIGHT SHOULDER,CLINICAL:, A 32-year-old male with shoulder pain.,FINDINGS:,This is a second opinion interpretation of the examination performed on 02/16/06.,Normal supraspinatus tendon without surface fraying, gap or fiber retraction and there is no muscular atrophy.,Normal infraspinatus and subscapularis tendons.,Normal long biceps tendon within the bicipital groove. There is no subluxation of the tendon under the transverse humeral ligament and the intracapsular portion of the tendon is normal.,Normal humeral head without fracture or subluxation.,There is myxoid degeneration within the superior labrum (oblique coronal images #47-48), but there is no discrete tear. The remaining portions of the labrum are normal without osseous Bankart lesion.,Normal superior, middle and inferior glenohumeral ligaments.,There is a persistent os acromiale, and there is minimal reactive marrow edema on both sides of the synchondrosis, suggesting that there may be instability (axial images #3 and 4). There is no diastasis of the acromioclavicular joint itself. There is mild narrowing of the subacromial space secondary to the os acromiale, in the appropriate clinical setting, this may be acting as an impinging lesion (sagittal images #56-59).,Normal coracoacromial, coracohumeral and coracoclavicular ligaments.,There are no effusions or masses.,IMPRESSION:,Changes in the superior labrum compatible with degeneration without a discrete surfacing tear.,There is a persistent os acromiale, and there is reactive marrow edema on both sides of the synchondrosis suggesting instability. There is also mild narrowing of the subacromial space secondary to the os acromiale. This may be acting as an impinging lesion in the appropriate clinical setting.,There is no evidence of a rotator cuff tear.","orthopedic, impinging lesion, os acromiale, shoulder, tendon, acromiale, osseous"
 A 51-year-old female with left shoulder pain and restricted external rotation and abduction x 6 months., Orthopedic, MRI Shoulder - 2 ,"EXAM:,MRI LEFT SHOULDER,CLINICAL:,This is a 51-year-old female with left shoulder pain and restricted external rotation and abduction x 6 months. Received for second opinion. Study performed on 10/04/05.,FINDINGS:,The patient was scanned in a 1.5 Tesla magnet.,There is a flat undersurface of the acromion (Type I) morphology, with anterior downsloping orientation.,There is inflammation of the anterior rotator interval capsule with peritendinous edema involving the intracapsular long biceps tendon best appreciated on the (axial gradient echo T2 series #3 images #6-9). There is edema with thickening of the superior glenohumeral ligament (axial T2 series #3 image #7). There is flattening of the long biceps tendon as it enters the bicipital groove (axial T2 series #3 image #9-10), but no subluxation. The findings suggest early changes of a “hidden” lesion.,Normal biceps labral complex and superior labrum, and there is no demonstrated superior labral tear.,There is minimal tendinitis with intratendinous edema of the insertion of the subscapularis tendon (axial T2 series #3 image #10). There is minimal fluid within the glenohumeral joint capsule within normal physiologic volume limits.,Normal anterior and posterior glenoid labra.,Normal supraspinatus, infraspinatus, and teres minor tendons.,Normal muscles of the rotator cuff and there is no muscular atrophy.,There is minimal fluid loculated within the labral ligamentous capsular complex along the posterior-superior labrum (sagittal T2 series #7 image #5; coronal T2 series #5 image #7), but there is no demonstrated posterior-superior labral tear or paralabral cyst or ganglion.,Normal acromioclavicular articulation.,IMPRESSION:,Inflammation of the anterior rotator interval capsule with interstitial edema of the superior glenohumeral ligament.,Flattening of the long biceps tendon as it enters the bicipital groove, but no subluxation. Findings suggest early changes of a hidden lesion.,Mild tendinitis of the distal insertion of the subscapularis tendon, but no tendon tear.,Normal supraspinatus, infraspinatus, and teres minor tendons and muscular complexes.,Type I morphology with an anterior downsloping orientation of the acromion, but no inferior acromial osteophyte.","orthopedic, insertion of the subscapularis, supraspinatus infraspinatus and teres, infraspinatus and teres minor, axial t series, supraspinatus infraspinatus, teres minor, minor tendons, posterior superior, biceps tendon, rotator, capsule, glenohumeral, tendon, series, superior"
 MRI L-S-Spine for Cauda Equina Syndrome secondary to L3-4 disc herniation - Low Back Pain (LBP) with associated BLE weakness., Orthopedic, MRI L-S Spine - Cauda Equina Syndrome ,"CC: ,Low Back Pain (LBP) with associated BLE weakness.,HX:, This 75y/o RHM presented with a 10 day h/o progressively worsening LBP. The LBP started on 12/3/95; began radiating down the RLE, on 12/6/95; then down the LLE, on 12/9/95. By 12/10/95, he found it difficult to walk. On 12/11/95, he drove himself to his local physician, but no diagnosis was rendered. He was given some NSAID and drove home. By the time he got home he had great difficulty walking due to LBP and weakness in BLE, but managed to feed his pets and himself. On 12/12/95 he went to see a local orthopedist, but on the way to his car he crumpled to the ground due to BLE weakness and LBP pain. He also had had BLE numbness since 12/11/95. He was evaluated locally and an L-S-Spine CT scan and L-S Spine X-rays were ""negative."" He was then referred to UIHC.,MEDS: ,SLNTC, Coumadin 4mg qd, Propranolol, Procardia XL, Altace, Zaroxolyn.,PMH: ,1) MI 11/9/78, 2) Cholecystectomy, 3) TURP for BPH 1980's, 4) HTN, 5) Amaurosis Fugax, OD, 8/95 (Mayo Clinic evaluation--TEE (-), but Carotid Doppler (+) but ""non-surgical"" so placed on Coumadin).,FHX:, Father died age 59 of valvular heart disease. Mother died of DM. Brother had CABG 8/95.,SHX:, retired school teacher. 0.5-1.0 pack cigarettes per day for 60 years.,EXAM:, BP130.56, HR68, RR16, Afebrile.,MS: A&O to person, place, time. Speech fluent without dysarthria. Lucid. Appeared uncomfortable.,CN: Unremarkable.,MOTOR: 5/5 strength in BUE. Lower extremity strength: Hip flexors & extensors 4-/4-, Hip abductors 3+/3+, Hip adductors 5/5, Knee flexors & extensors 4/4-, Ankle flexion 4-/4-, Tibialis Anterior 2/2-, Peronei 3-/3-. Mild atrophy in 4 extremities. Questionable fasciculations in BLE. Spasms illicited on striking quadriceps with reflex hammer (? percussion myotonia). No rigidity and essential normal muscle tone on passive motion.,SENSORY: Decreased vibratory sense in stocking distribution from toes to knees in BLE (worse on right). No sensory level. PP/LT/TEMP testing unremarkable.,COORD: Normal FNF-RAM. Slowed HKS due to weakness.,Station: No pronator drift. Romberg testing not done.,Gait: Unable to stand.,Reflexes: 2/2 BUE. 1/trace patellae, 0/0 Achilles. Plantar responses were flexor, bilaterally. Abdominal reflex was present in all four quadrants. Anal reflex was illicited from all four quadrants. No jaw jerk or palmomental reflexes illicited.,Rectal: normal rectal tone, guaiac negative stool.,GEN EXAM: Bilateral Carotid Bruits, No lymphadenopathy, right inguinal hernia, rhonchi and inspiratory wheeze in both lung fields.,COURSE: ,WBC 11.6, Hgb 13.4, Hct 38%, Plt 295. ESR 40 (normal 0-14), CRP 1.4 (normal <0.4), INR 1.5, PTT 35 (normal), Creatinine 2.1, CK 346. EKG normal. The differential diagnosis included Amyotrophy, Polymyositis, Epidural hematoma, Disc Herniation and Guillain-Barre syndrome. An MRI of the lumbar spine was obtained, 12/13/95. This revealed an L3-4 disc herniation extending inferiorly and behind the L4 vertebral body. This disc was located more on the right than on the left , compromised the right neural foramen, and narrowed the spinal canal. The patient underwent a L3-4 laminectomy and diskectomy and subsequently improved. He was never seen in follow-up at UIHC.","orthopedic, ble weakness, carotid doppler, disc herniation, guillain-barre syndrome, amyotrophy, polymyositis, epidural hematoma, mri l s spine, cauda equina syndrome, flexors & extensors, cauda equina, herniation, cauda, equina, extensors, reflexes, mri, hip, flexors, weakness, "
 Left shoulder pain. Evaluate for rotator cuff tear., Orthopedic, MRI Shoulder - 1 ,"EXAM:,MRI-UP EXT JOINT LEFT SHOULDER,CLINICAL:,Left shoulder pain. Evaluate for rotator cuff tear.,FINDINGS:,  Multiple T1 and gradient echo axial images were obtained, as well as T1 and fat suppressed T2-weighted coronal images.,The rotator cuff appears intact and unremarkable. There is no significant effusion seen. Osseous structures are unremarkable. There is no significant downward spurring at the acromioclavicular joint. The glenoid labrum is intact and unremarkable.,IMPRESSION:,  Unremarkable MRI of the left shoulder.,","orthopedic, rotator cuff tear, cuff tear, rotator cuff, joint, mri, rotator, cuff, shoulder, tear, "
 MRI left knee without contrast., Orthopedic, MRI Knee - 1 ,"EXAM:,MRI LEFT KNEE WITHOUT CONTRAST,CLINICAL:,Left knee pain.,FINDINGS:,Comparison is made with 10/13/05 radiographs.,There is a prominent suprapatellar effusion. Patient has increased signal within the medial collateral ligament as well as fluid around it, compatible with type 2 sprain. There is fluid around the lateral collateral ligament without increased signal within the ligament itself, compatible with type 1 sprain.,Medial and lateral menisci contain some minimal increased signal centrally that does not extend through an articular surface and findings are felt to represent minimal myxoid degeneration. No tear is seen. Anterior cruciate and posterior cruciate ligaments are intact. There is a bone bruise of medial patellar facet measuring approximately 8 x 5 mm. There is suggestion of some mild posterior aspect of the lateral tibial plateau. MR signal on the bone marrow is otherwise normal.,IMPRESSION:,Type 2 sprain in the medial collateral ligament and type sprain in the lateral collateral ligament.,Joint effusion and bone bruise with suggestion of some minimal overlying chondromalacia and medial patellar facet.","orthopedic, collateral ligament, mri, knee, collateral, sprain, medial, ligament, "
 A 53-year-old female with left knee pain being evaluated for ACL tear., Orthopedic, MRI Knee - 2 ,"EXAM:,MRI LEFT KNEE WITHOUT CONTRAST,CLINICAL:,This is a 53-year-old female with left knee pain being evaluated for ACL tear.,FINDINGS:,This examination was performed on 10-14-05.,Normal medial meniscus without intrasubstance degeneration, surface fraying or discrete meniscal tear.,There is a discoid lateral meniscus and although there may be minimal superficial fraying along the inner edge of the body, there is no discrete tear (series #6 images #7-12).,There is a near-complete or complete tear of the femoral attachment of the anterior cruciate ligament. The ligament has a balled-up appearance consistent with at least partial retraction of most of the fibers of the ligament. There may be a few fibers still intact (series #4 images #12-14; series #5 images #12-14). The tibial fibers are normal.,Normal posterior cruciate ligament.,There is a sprain of the medial collateral ligament, with mild separation of the deep and superficial fibers at the femoral attachment (series #7 images #6-12). There is no complete tear or discontinuity and there is no meniscocapsular separation.,There is a sprain of the lateral ligament complex without focal tear or discontinuity of any of the intraarticular components.,Normal iliotibial band.,Normal quadriceps and patellar tendons.,There is contusion within the posterolateral corner of the tibia. There is also contusion within the patella at the midline patellar ridge where there is an area of focal chondral flattening (series #8 images #10-13). The medial and lateral patellar facets are otherwise normal as is the femoral trochlea in the there is no patellar subluxation.,There is a mild strain of the vastus medialis oblique muscle extending into the medial patellofemoral ligament and medial patellar retinaculum but there is no complete tear or discontinuity.,Normal lateral patellar retinaculum. There is a joint effusion and plica.,IMPRESSION:, Discoid lateral meniscus without a tear although there may be minimal superficial fraying along the inner edge of the body.  Near-complete if not complete tear of the femoral attachment of the anterior cruciate ligament.  Medial capsule sprain with associated strain of the vastus medialis oblique muscle.  There is focal contusion within the patella at the midline patella ridge. Joint effusion and plica.","orthopedic, vastus medialis oblique muscle, medialis oblique, oblique muscle, patellar retinaculum, joint effusion, femoral attachment, cruciate ligament, complete tear, meniscus, superficial, cruciate, sprain, femoral, medial, ligament, tear, patellar"
 Pain and swelling in the right foot., Orthopedic, MRI Foot - 2 ,"EXAM:,MRI RIGHT FOOT,CLINICAL:,Pain and swelling in the right foot.,FINDINGS: ,Obtained for second opinion interpretation is an MRI examination performed on 11-04-05.,There is a transverse fracture of the anterior superior calcaneal process of the calcaneus. The fracture is corticated however and there is an active marrow stress phenomenon. There is a small ganglion measuring approximately 8 x 5 x 5mm in size extending along the bifurcate ligament.,There is no substantial joint effusion of the calcaneocuboid articulation. There is minimal interstitial edema involving the short plantar calcaneal cuboid ligament.,Normal plantar calcaneonavicular spring ligament.,Normal talonavicular articulation.,There is minimal synovial fluid within the peroneal tendon sheaths.,Axial imaging of the ankle has not been performed orthogonal to the peroneal tendon distal to the retromalleolar groove. The peroneus brevis tendon remains intact extending to the base of the fifth metatarsus. The peroneus longus tendon can be identified in its short axis extending to its distal plantar insertion upon the base of the first metatarsus with minimal synovitis.,There is minimal synovial fluid within the flexor digitorum longus and flexor hallucis longus tendon sheath with pooling of the fluid in the region of the knot of Henry.,There is edema extending along the deep surface of the extensor digitorum brevis muscle.,Normal anterior, subtalar and deltoid ligamentous complex.,Normal naviculocuneiform, intercuneiform and tarsometatarsal articulations.,The Lisfranc’s ligament is intact.,The Achilles tendon insertion has been excluded from the field-of-view.,Normal plantar fascia and intrinsic plantar muscles of the foot.,There is mild venous distention of the veins of the foot within the tarsal tunnel.,There is minimal edema of the sinus tarsus. The lateral talocalcaneal and interosseous talocalcaneal ligaments are normal.,Normal deltoid ligamentous complex.,Normal talar dome and no occult osteochondral talar dome defect.,IMPRESSION:,Transverse fracture of the anterior calcaneocuboid articulation with cortication and cancellous marrow edema.,Small ganglion intwined within the bifurcate ligament.,Interstitial edema of the short plantar calcaneocuboid ligament.,Minimal synovitis of the peroneal tendon sheaths but no demonstrated peroneal tendon tear.,Minimal synovitis of the flexor tendon sheaths with pooling of fluid within the knot of Henry.,Minimal interstitial edema extending along the deep surface of the extensor digitorum brevis muscle.",
 MRI left knee without contrast., Orthopedic, MRI Knee - 4 ,"EXAM:,MRI OF THE LEFT KNEE WITHOUT CONTRAST,CLINICAL:,Left knee pain. Twisting injury.,FINDINGS:,The images reveal a sizable joint effusion. The joint effusion appears to be complex with mixed signal intensity material within. The patella is slightly laterally tilted towards the left. The mid portion of the patella cartilage shows some increased signal and focal injury to the patellar cartilage is suspected. Mildly increased bone signal overlying the inferolateral portion of the patella is identified. No significant degenerative changes about the patella can be seen. The quadriceps tendon as well as the infrapatellar ligament both look intact. There is some prepatellar soft tissue edema.,The bone signal shows a couple of small areas of cystic change in the proximal aspect of the tibia. NO significant areas of bone edema are appreciated.,There is soft tissue edema along the lateral aspect of the knee. There is a partial tear of the lateral collateral ligament complex. The medial collateral ligament complex looks intact. A small amount of edema is identified immediately adjacent to the medial collateral ligament complex.,The posterior cruciate ligament looks intact. The anterior cruciate ligament is thickened with significant increased signal. I suspect at least a high grade partial tear.,The posterior horn of the medial meniscus shows some myxoid degenerative changes. The posterior horn and anterior horn of the lateral meniscus likewise shows myxoid degenerative type changes. I don’t see a definite tear extending to the articular surface.,IMPRESSION:,Sizeable joint effusion which is complex and may contain blood products.,Myxoid degenerative type changes medial and lateral meniscus with no definite evidence of a tear.,Soft tissue swelling and partial tear of the lateral collateral ligament complex.,At least high grade partial tear of the anterior cruciate ligament with significant thickening and increased signal of this structure.,The posterior cruciate ligament is intact.,Injury to the patellar cartilage as above.","orthopedic, lateral collateral ligament, medial collateral ligament, posterior cruciate ligament, anterior cruciate ligament, collateral ligament complex, myxoid degenerative, partial tear, collateral ligament, ligament complex, cruciate ligament, mri, effusion, cartilage, collateral, cruciate, knee, tear, ligament"
" A 49-year-old female with ankle pain times one month, without a specific injury. ", Orthopedic, MRI Foot - 3 ,"EXAM:,MRI LEFT FOOT,CLINICAL:, A 49-year-old female with ankle pain times one month, without a specific injury. Patient complains of moderate to severe pain, worse with standing or walking on hard surfaces, with tenderness to palpation at the plantar aspect of the foot and midfoot region and tenderness over the course of the posterior tibialis tendon.,FINDINGS:,Received for second opinion interpretations is an MRI examination performed on 05/27/2005.,There is edema of the subcutis adipose space extending along the medial and lateral aspects of the ankle.,There is edema of the subcutis adipose space posterior to the Achilles tendon. Findings suggest altered biomechanics with crural fascial strains.,There is tendinosis of the posterior tibialis tendon as it rounds the tip of the medial malleolus with mild tendon thickening. There is possible partial surface tearing of the anterior aspect of the tendon immediately distal to the tip of the medial malleolus (axial inversion recovery image #16) which is a possible hypertrophic tear less than 50% in cross sectional diameter. The study has been performed with the foot in neutral position. Confirmation of this possible partial tendon tear would require additional imaging with the foot in a plantar flexed position with transaxial images of the posterior tibialis tendon as it rounds the tip of the medial malleolus oriented perpendicular to the course of the posterior tibialis tendon.,There is minimal synovitis of the flexor digitorum longus and flexor hallucis longus tendon sheaths consistent with flexor splinting but intrinsically normal tendons.,Normal peroneal tendons.,There is tendinosis of the tibialis anterior tendon with thickening but no demonstrated tendon tear. Normal extensor hallucis longus and extensor digitorum tendons.,Normal Achilles tendon. There is a low-lying soleus muscle that extends to within 2cm of the teno-osseous insertion of the Achilles tendon.,Normal distal tibiofibular syndesmotic ligamentous complex.,Normal lateral, subtalar and deltoid ligamentous complexes.,There are no erosions of the inferior neck of the talus and there are no secondary findings of a midfoot pronating force.,Normal plantar fascia. There is no plantar calcaneal spur.,There is venous engorgement of the plantar veins of the foot extending along the medial and lateral plantar cutaneous nerves which may be acting as intermittent entrapping lesions upon the medial and lateral plantar cutaneous nerves.,Normal tibiotalar, subtalar, talonavicular and calcaneocuboid articulations.,The metatarsophalangeal joint of the hallux was partially excluded from the field-of-view of this examination.,IMPRESSION:,Tendinosis of the posterior tibialis tendon with tendon thickening and possible surface fraying / tearing of the tendon immediately distal to the tip of the medial malleolus, however, confirmation of this finding would require additional imaging.,Minimal synovitis of the flexor digitorum longus and flexor hallucis longus tendon sheaths, consistent with flexor splinting.,Edema of the subcutis adipose space along the medial and lateral aspects of the ankle suggesting altered biomechanics and crural fascial strain.,Mild tendinosis of the tibialis anterior tendon with mild tendon thickening.,Normal plantar fascia and no plantar fasciitis.,Venous engorgement of the plantar veins of the foot which may be acting as entrapping lesions upon the medial and lateral plantar cutaneous nerves.","orthopedic, lateral plantar cutaneous, plantar cutaneous nerves, posterior tibialis tendon, medial and lateral, subcutis adipose, adipose space, achilles tendon, tendon thickening, hallucis longus, lateral plantar, plantar cutaneous, cutaneous nerves, medial malleolus, posterior tibialis, tibialis tendon, plantar, tendon, posterior, flexor, tibialis, medial, "
" Pain and swelling in the right foot, peroneal tendon tear.", Orthopedic, MRI Foot - 1 ,"EXAM:,MRI/LOW EX NOT JNT RT W/O CONTRAST,CLINICAL:,Pain and swelling in the right foot, peroneal tendon tear.,FINDINGS:,  Contours of marrow signal patterns of the regional bones are within normal range treating there is increased T2 signal within the soft tissues at the lateral margin of the cuboid bone. A small effusion is noted within the peroneal tendon sheath. There is a 3mm slight separation of the distal tip of the peroneus longus tendon from the lateral margin of the cuboid bone, consistent with an avulsion. There is no sign of cuboid fracture. The fifth metatarsal base appears intact. The calcaneus is also normal in appearance.,IMPRESSION:  ,Findings consistent with an avulsion of the peroneus longus tendon from the insertion on the lateral aspect of cuboid bone.,","orthopedic, peroneus longus tendon, peroneal tendon, lateral margin, peroneus longus, longus tendon, cuboid bone, foot, peroneal, peroneus, longus, avulsion, tendon, bones, cuboid,"
 MRI C-spine: C4-5 Transverse Myelitis., Orthopedic, MRI C-spine ,"CC:, Left hemibody numbness.,HX:, This 44y/o RHF awoke on 7/29/93 with left hemibody numbness without tingling, weakness, ataxia, visual or mental status change. She had no progression of her symptoms until 7/7/93 when she notices her right hand was stiff and clumsy. She coincidentally began listing to the right when walking. She denied any recent colds/flu-like illness or history of multiple sclerosis. She denied symptoms of Lhermitte's or Uhthoff's phenomena.,MEDS:, none.,PMH:, 1)Bronchitis twice in past year (last 2 months ago).,FHX:, Father with HTN and h/o strokes at ages 45 and 80; now 82 years old. Mother has DM and is age 80.,SHX:, Denies Tobacco/ETOH/illicit drug use.,EXAM:, BP112/76 HR52 RR16 36.8C,MS: unremarkable.,CN: unremarkable.,Motor: 5/5 strength throughout except for slowing of right hand fine motor movement. There was mildly increased muscle tone in the RUE and RLE.,Sensory: decreased PP below T2 level on left and some dysesthesias below L1 on the left.,Coord: positive rebound in RUE.,Station/Gait: unremarkable.,Reflexes: 3+/3 throughout all four extremities. Plantar responses were flexor, bilaterally.,Rectal exam not done.,Gen exam reportedly ""normal."",COURSE:, GS, CBC, PT, PTT, ESR, Serum SSA/SSB/dsDNA, B12 were all normal. MRI C-spine, 7/145/93, showed an area of decreased T1 and increased T2 signal at the C4-6 levels within the right lateral spinal cord. The lesion appeared intramedullary and eccentric, and peripherally enhanced with gadolinium. Lumbar puncture, 7/16/93, revealed the following CSF analysis results: RBC 0, WBC 1 (lymphocyte), Protein 28mg/dl, Glucose 62mg/dl, CSF Albumin 16 (normal 14-20), Serum Albumin 4520 (normal 3150-4500), CSF IgG 4.1mg/dl (normal 0-6.2), CSF IgG, % total CSF protein 15% (normal 1-14%), CSF IgG index 1.1 (normal 0-0.7), Oligoclonal bands were present. She was discharged home.,The patient claimed her symptoms resolved within one month. She did not return for a scheduled follow-up MRI C-spine.","orthopedic, mri c-spine, c-spine, lhermitte's, myelitis, transverse myelitis, uhthoff's, ataxia, clumsy, hemibody numbness, mental status, numbness, tingling, weakness, mri c spine, hemibody, mri, spine, csf, "
" MRI of elbow - A middle-aged female with moderate pain, severe swelling and a growth on the arm.", Orthopedic, MRI Elbow - 2 ,"FINDINGS:,There is diffuse subcutis space edema extending along the posteromedial aspect of the elbow adjacent to the medial epicondyle, extending to the olecranon process and along the superficial aspect of the epicondylo-olecranon ligament. There is no demonstrated solid, cystic or lipomatous mass lesion. There is enlargement with hyperintense signal of the ulnar nerve within the cubital tunnel. There is inflammation with mild laxity of the epicondylo-olecranon ligament. The combined findings are most consistent with a ulnar nerve neuritis possibly secondary to a subluxing ulnar nerve however the ulnar nerve at this time is within the cubital tunnel. There is no accessory muscle within the cubital tunnel. The common flexor tendon origin is normal.,Normal ulnar collateral ligamentous complex.,There is mild epimysial sheath edema of the pronator teres muscle consistent with a mild epimysial sheath sprain but no muscular tear.,There is minimal intratendinous inflammation of the common extensor tendon origin consistent with a mild tendinitis. There is no demonstrated common extensor tendon tear. Normal radial collateral ligamentous complex.,Normal radiocapitellum and ulnotrochlear articulations.,Normal triceps and biceps tendon insertions.,There is peritendinous inflammation of the brachialis tendon insertion but an intrinsically normal tendon.,IMPRESSION:,Edema of the subcutis adipose space overlying the posteromedial aspect of the elbow with interstitial inflammation of the epicondylo-olecranon ligament.,Enlarged edematous ulnar nerve most compatible with ulnar nerve neuritis.,The above combined findings suggest a subluxing ulnar nerve.,Mild epimysial sheath strain of the pronator teres muscle but no muscular tear.,Mild lateral epicondylitis with focal tendinitis of the origin of the common extensor tendon.,Peritendinous edema of the brachialis tendon insertion.,No solid, cystic or lipomatous mass lesion.,","orthopedic, growth on the arm, subluxing ulnar nerve, collateral ligamentous complex, common extensor tendon, posteromedial aspect, epimysial sheath, extensor tendon, tendon insertions, ulnar nerve, elbow, edema, olecranon, inflammation, nerve, ulnar, tendon"
 MRI Elbow - A middle-aged female complaining of elbow pain., Orthopedic, MRI Elbow - 1 ,"FINDINGS:,There is severe tendinitis of the common extensor tendon origin with diffuse intratendinous inflammation (coronal T2 image #1452, sagittal T2 image #1672). There is irregularity of the deep surface of the tendon consistent with mild fraying (#1422 and 1484) however there is no distinct tear.,There is a joint effusion of the radiocapitellar articulation with mild fluid distention.,The radial collateral (proper) ligament remains intact. There is periligamentous inflammation of the lateral ulnar collateral ligament (coronal T2 image #1484) of the radial collateral ligamentous complex. There is no articular erosion or osteochondral defect with no intra-articular loose body.,There is minimal inflammation of the subcutis adipose space extending along the origin of the common flexor tendon (axial T2 image #1324). The common flexor tendon otherwise is normal.,There is minimal periligamentous inflammation of the anterior band of the ulnar collateral ligament (coronal T2 image #1516, axial T2 image #1452) with an intrinsically normal ligament.,The ulnotrochlear articulation is normal.,The brachialis and biceps tendons are normal with a normal triceps tendon. The anterior, posterior, medial and lateral muscular compartments are normal.,The radial, median and ulnar nerves are normal with no apparent ulnar neuritis.,IMPRESSION:,Lateral epicondylitis with severe tendinitis of the common extensor tendon origin and minimal deep surface fraying, without a discrete tendon tear.,Periligamentous inflammation of the radial collateral ligamentous complex as described above with intrinsically normal ligaments.,Small joint effusion of the radiocapitellar articulation with no osteochondral defect or intra-articular loose body.,Mild peritendinous inflammation of the subcutis adipose space adjacent to the common flexor tendon origin with an intrinsically normal tendon.,Minimal periligamentous inflammation of the anterior band of the ulnar collateral ligament with an intrinsically normal ligament.","orthopedic, radial collateral ligamentous complex, intra articular loose body, axial t image, ulnar collateral ligament, common flexor tendon, mri elbow, ligamentous complex, radial collateral, ulnar collateral, collateral ligament, flexor tendon, periligamentous inflammation, mri, tendon"
 MRI Cervical Spine without contrast., Orthopedic, MRI Cervical Spine - 2 ,"EXAM:,MRI SPINAL CORD CERVICAL WITHOUT CONTRAST,CLINICAL:,Right arm pain, numbness and tingling.,FINDINGS:,Vertebral alignment and bone marrow signal characteristics are unremarkable. The C2-3 and C3-4 disk levels appear unremarkable.,At C4-5, broad based disk/osteophyte contacts the ventral surface of the spinal cord and may mildly indent the cord contour. A discrete cord signal abnormality is not identified. There may also be some narrowing of the neuroforamina at this level.,At C5-6, central disk-osteophyte contacts and mildly impresses on the ventral cord contour. Distinct neuroforaminal narrowing is not evident.,At C6-7, mild diffuse disk-osteophyte impresses on the ventral thecal sac and contacts the ventral cord surface. Distinct cord compression is not evident. There may be mild narrowing of the neuroforamina at his level.,A specific abnormality is not identified at the C7-T1 level.,IMPRESSION:,Disk/osteophyte at C4-5 through C6-7 with contact and may mildly indent the ventral cord contour at these levels. Some possible neuroforaminal narrowing is also noted at levels as stated above.","orthopedic, mri cervical spine, ventral cord contour, cervical spine, spinal cord, cord contour, ventral cord, mri, narrowing, ventral, cord"
 MRI Brain & MRI C-T spine: Multiple hemangioblastoma in Von Hippel Lindau Disease., Orthopedic, MRI Brain and C-T Spine ,"CC:, Weakness.,HX:, This 30 y/o RHM was in good health until 7/93, when he began experiencing RUE weakness and neck pain. He was initially treated by a chiropractor and, after an unspecified length of time, developed atrophy and contractures of his right hand. He then went to a local neurosurgeon and a cervical spine CT scan, 9/25/92, revealed an intramedullary lesion at C2-3 and an extramedullary lesion at C6-7. He underwent a C6-T1 laminectomy with exploration and decompression of the spinal cord. His clinical condition improved over a 3 month post-operative period, and then progressively worsened. He developed left sided paresthesia and upper extremity weakness (right worse than left). He then developed ataxia, nausea, vomiting, and hyperreflexia. On 8/31/93, MRI C-spine showed diffuse enlargement of the cervical and thoracic spine and multiple enhancing nodules in the posterior fossa. On 9/1/93, he underwent suboccipital craniotomy with tumor excision, decompression, and biopsy which was consistent with hemangioblastoma. His symptoms stabilized and he underwent 5040 cGy in 28 fractions to his brain and 3600 cGy in 20 fractions to his cervical and thoracic spinal cord from 9/93 through 1/19/94.,He was evaluated in the NeuroOncology clinic on 10/26/95 for consideration of chemotherapy. He complained of progressive proximal weakness of all four extremities and dysphagia. He had difficulty putting on his shirt and raising his arms, and he had been having increasing difficulty with manual dexterity (e.g. unable to feed himself with utensils). He had difficulty going down stairs, but could climb stairs. He had no bowel or bladder incontinence or retention.,MEDS:, none.,PMH:, see above.,FHX:, Father with Von Hippel-Lindau Disease.,SHX:, retired truck driver. smokes 1-3 packs of cigarettes per day, but denied alcohol use. He is divorced and has two sons who are healthy. He lives with his mother.,ROS:, noncontributory.,EXAM:, Vital signs were unremarkable.,MS: A&O to person, place and time. Speech fluent and without dysarthria. Thought process lucid and appropriate.,CN: unremarkable exept for 4+/4+ strength of the trapezeii. No retinal hemangioblastoma were seen.,MOTOR: 4-/4- strength in proximal and distal upper extremities. There is diffuse atrophy and claw-hands, bilaterally. He is unable to manipulate hads to any great extent. 4+/4+ strength throughout BLE. There is also diffuse atrophy throughout the lower extremities though not as pronounced as in the upper extremities.,SENSORY: There was a right T3 and left T8 cord levels to PP on the posterior thorax. Decreased LT in throughout the 4 extremities.,COORD: difficult to assess due to weakness.,Station: BUE pronator drift.,Gait: stands without assistance, but can only manage to walk a few steps. Spastic gait.,Reflexes: Hyperreflexic on left (3+) and Hyporeflexic on right (1). Babinski signs were present bilaterally.,Gen exam: unremarkable.,COURSE: ,9/8/95, GS normal. By 11/14/95, he required NGT feeding due to dysphagia and aspiration risk confirmed on cookie swallow studies.MRI Brain, 2/19/96, revealed several lesions (hemangioblastoma) in the cerebellum and brain stem. There were postoperative changes and a cyst in the medulla.,On 10/25/96, he presented with a 1.5 week h/o numbness in BLE from the mid- thighs to his toes, and worsening BLE weakness. He developed decubitus ulcers on his buttocks. He also had had intermittent urinary retention for month, chronic SOB and dysphagia. He had been sitting all day long as he could not move well and had no daytime assistance. His exam findings were consistent with his complaints. He had had no episodes of diaphoresis, headache, or elevated blood pressures. An MRI of the C-T spine, 10/26/96, revealed a prominent cervicothoracic syrinx extending down to T10. There was evidence of prior cervical laminectomy of C6-T1 with expansion of the cord in the thecalsac at that region. Multiple intradural extra spinal nodular lesions (hyperintense on T2, isointense on T1, enhanced gadolinium) were seen in the cervical spine and cisterna magna. The largest of which measures 1.1 x 1.0 x 2.0cm. There are also several large ring enhancing lesions in cerebellum. The lesions were felt to be consistent with hemangioblastoma. No surgical or medical intervention was initiated. Visiting nursing was provided. He has since been followed by his local physician", 
 MRI C-spine to evaluate right shoulder pain - C5-6 disk herniation., Orthopedic, MRI C-Spine - C5-6 Disk Herniation ,"CC:, Right shoulder pain.,HX: ,This 46 y/o RHF presented with a 4 month history of right neck and shoulder stiffness and pain. The symptoms progressively worsened over the 4 month course. 2 weeks prior to presentation she began to develop numbness in the first and second fingers of her right hand and RUE pain. The later was described as a throbbing pain. She also experienced numbness in both lower extremities and pain in the coccygeal region. The pains worsened at night and impaired sleep. She denied any visual change, bowel or bladder difficulties and symptoms involving the LUE. She occasionally experienced an electric shock like sensation shooting down her spine when flexing her neck (Lhermitte's phenomena). She denied any history of neck/back/head trauma.,She had been taking Naprosyn with little relief.,PMH: ,1) Catamenial Headaches. 2) Allergy to Macrodantin.,SHX/FHX:, Smokes 2ppd cigarettes.,EXAM: ,Vital signs were unremarkable.,CN: unremarkable.,Motor: full strength throughout. Normal tone and muscle bulk.,Sensory: No deficits on LT/PP/VIB/TEMP/PROP testing.,Coord/Gait/Station: Unremarkable.,Reflexes: 2/2 in BUE except 2+ at left biceps. 1+/1+BLE except an absent right ankle reflex.,Plantar responses were flexor bilaterally. Rectal exam: normal tone.,IMPRESSION:, C-spine lesion.,COURSE: ,MRI C-spine revealed a central C5-6 disk herniation with compression of the spinal cord at that level. EMG/NCV showed normal NCV, but 1+ sharps and fibrillations in the right biceps (C5-6), brachioradialis (C5-6), triceps (C7-8) and teres major; and 2+ sharps and fibrillations in the right pronator terres. There was increased insertional activity in all muscles tested on the right side. The findings were consistent with a C6-7 radiculopathy.,The patient subsequently underwent C5-6 laminectomy and her symptoms resolved.","orthopedic, shoulder pain, stiffness, numbness, lhermitte's phenomena, c-spine lesion, disk herniation, mri c spine, reflexes, biceps, mri, disk, shoulder, spine, herniation,"
 MRI cervical spine., Orthopedic, MRI Cervical Spine - 1 ,"EXAM:,MRI CERVICAL SPINE,CLINICAL:, A57-year-old male. Received for outside consultation is an MRI examination performed on 11/28/2005.,FINDINGS:,Normal brainstem-cervical cord junction. Normal cisterna magna with no tonsillar ectopia. Normal clivus with a normal craniovertebral junction. Normal anterior atlantoaxial articulation.,C2-3: Normal intervertebral disc with no spondylosis or uncovertebral joint arthrosis. Normal central canal and intervertebral neural foramina with no cord or radicular impingement.,C3-4: There is disc desiccation with minimal annular bulging. The residual AP diameter of the central canal measures approximately 10mm. CSF remains present surrounding the cord.,C4-5: There is disc desiccation with endplate spondylosis and mild uncovertebral joint arthrosis. The residual AP diameter of the central canal measures approximately 8mm with effacement of the circumferential CSF cleft producing a borderline central canal stenosis but no cord distortion or cord edema. There is minimal uncovertebral joint arthrosis.,C5-6: There is disc desiccation with minimal posterior annular bulging and a right posterolateral preforaminal disc protrusion measuring approximately 2 x 8mm (AP x transverse). The disc protrusion produces minimal rightward ventral thecal sac flattening but no cord impingement.,C6-7: There is disc desiccation with mild loss of disc space height and posterior endplate spondylosis and annular bulging producing central canal stenosis. The residual AP diameter of the central canal measures 8 mm with effacement of the circumferential CSF cleft. There is a left posterolateral disc-osteophyte complex encroaching upon the left intervertebral neural foramen with probable radicular impingement upon the exiting left C7 nerve root.,C7-T1, T1-2: Minimal disc desiccation with no disc displacement or endplate spondylosis.,IMPRESSION:,Multilevel degenerative disc disease as described above.,C4-5 borderline central canal stenosis with mild bilateral foraminal compromise.,C5-6 disc desiccation with a borderline central canal stenosis and a right posterolateral preforaminal disc protrusion producing thecal sac distortion.,C6-7 degenerative disc disease and endplate spondylosis with a left posterolateral disc-osteophyte complex producing probable neural impingement upon the exiting left C7 nerve root with a borderline central canal stenosis.,Normal cervical cord.","orthopedic, borderline central canal stenosis, mri cervical spine, borderline central canal, central canal stenosis, degenerative disc, annular bulging, ap diameter, endplate spondylosis, borderline central, canal stenosis, disc desiccation, central canal, cervical, disc, spondylosis, stenosis, cord, canal,"
 MRI right ankle., Orthopedic, MRI Ankle - 2 ,"EXAM:,MRI OF THE RIGHT ANKLE,CLINICAL:,Pain.,FINDINGS:,The bone marrow demonstrates normal signal intensity. There is no evidence of bone contusion or fracture. There is no evidence of joint effusion. Tendinous structures surrounding the ankle joint are intact. No abnormal mass or fluid collection is seen surrounding the ankle joint.,IMPRESSION,: NORMAL MRI OF THE RIGHT ANKLE.","orthopedic, ankle joint, bone, mri, ankle"
 Left third digit numbness and wrist pain., Orthopedic, MRI C3 - Cord Compression. ,"CC:, Left third digit numbness and wrist pain.,HX: ,This 44 y/o LHM presented with a one month history of numbness and pain of the left middle finger and wrist. The numbness began in the left middle finger and gradually progressed over the course of a day to involve his wrist as well. Within a few days he developed pain in his wrist. He had been working as a cook and cut fish for prolonged periods of time. This activity exacerbated his symptoms. He denied any bowel/bladder difficulties, neck pain, or weakness. He had no history of neck injury.,SHX/FHX:, 1-2 ppd Cigarettes. Married. Off work for two weeks due to complaints.,EXAM: ,Vital signs unremarkable.,MS:, A & O to person, place, time. Fluent speech without dysarthria.,CN II-XII: ,Unremarkable,MOTOR:, 5/5 throughout, including intrinsic muscles of hands. No atrophy or abnormal muscle tone.,SENSORY:, Decreased PP in third digit of left hand only (palmar and dorsal sides).,STATION/GAIT/COORD:, Unremarkable.,REFLEXES: ,1+ throughout, plantar responses were downgoing bilaterally.,GEN EXAM: ,Unremarkable.,Tinel's manuever elicited pain and numbness on the left. Phalens sign present on the left.,CLINICAL IMPRESSION: ,Left Carpal Tunnel Syndrome,EMG/NCV: ,Unremarkable.,MRI C-spine, 12/1/92: Congenitally small spinal canal is present. Superimposed on this is mild spondylosis and disc bulge at C6-7, C5-6, C4-5, and C3-4. There is moderate central spinal stenosis at C3-4. Intervertebral foramina at these levels appear widely patent.,COURSE:, The MRI findings did not correlate with the clinical findings and history. The patient was placed on Elavil and was subsequently lost to follow-up.",
 MRI report Cervical Spine (Chiropractic Specific), Orthopedic, MRI Cervical Spine - Chiropractic Specific ,"FINDINGS:,Normal foramen magnum.,Normal brainstem-cervical cord junction. There is no tonsillar ectopia. Normal clivus and craniovertebral junction. Normal anterior atlantoaxial articulation.,C2-3: There is disc desiccation but no loss of disc space height, disc displacement, endplate spondylosis or uncovertebral joint arthrosis. Normal central canal and intervertebral neural foramina.,C3-4: There is disc desiccation with a posterior central disc herniation of the protrusion type. The small posterior central disc protrusion measures 3 x 6mm (AP x transverse) in size and is producing ventral thecal sac flattening. CSF remains present surrounding the cord. The residual AP diameter of the central canal measures 9mm. There is minimal right-sided uncovertebral joint arthrosis but no substantial foraminal compromise.,C4-5: There is disc desiccation, slight loss of disc space height with a right posterior lateral pre-foraminal disc osteophyte complex with right-sided uncovertebral and apophyseal joint arthrosis. The disc osteophyte complex measures approximately 5mm in its AP dimension. There is minimal posterior annular bulging measuring approximately 2mm. The AP diameter of the central canal has been narrowed to 9mm. CSF remains present surrounding the cord. There is probable radicular impingement upon the exiting right C5 nerve root.,C5-6: There is disc desiccation, moderate loss of disc space height with a posterior central disc herniation of the protrusion type. The disc protrusion measures approximately 3 x 8mm (AP x transverse) in size. There is ventral thecal sac flattening with effacement of the circumferential CSF cleft. The residual AP diameter of the central canal has been narrowed to 7mm. Findings indicate a loss of the functional reserve of the central canal but there is no cord edema. There is bilateral uncovertebral and apophyseal joint arthrosis with moderate foraminal compromise.,C6-7: There is disc desiccation, mild loss of disc space height with 2mm of posterior annular bulging. There is bilateral uncovertebral and apophyseal joint arthrosis (left greater than right) with probable radicular impingement upon the bilateral exiting C7 nerve roots.,C7-T1, T1-2: There is disc desiccation with no disc displacement. Normal central canal and intervertebral neural foramina.,T3-4: There is disc desiccation with minimal 2mm posterior annular bulging but normal central canal and CSF surrounding the cord.,IMPRESSION:,Multilevel degenerative disc disease with uncovertebral joint arthrosis with foraminal compromise as described above.,C3-4 posterior central disc herniation of the protrusion type but no cord impingement.,C4-5 right posterior lateral disc osteophyte complex with right-sided uncovertebral and apophyseal joint arthrosis with probable radicular impingement upon the right C5 nerve root.,C5-6 degenerative disc disease with a posterior central disc herniation of the protrusion type producing borderline central canal stenosis with effacement of the circumferential CSF cleft indicating a limited functional reserve of the central canal.,C6-7 degenerative disc disease with annular bulging and osseous foraminal compromise with probable impingement upon the bilateral exiting C7 nerve roots.,T3-4 degenerative disc disease with posterior annular bulging.","orthopedic, exiting c nerve roots, loss of disc space, posterior central disc herniation, herniation of the protrusion, uncovertebral and apophyseal joint, intervertebral neural foramina, ventral thecal sac, thecal sac flattening, disc osteophyte complex, disc space height, central disc herniation, apophyseal joint arthrosis, posterior annular bulging, degenerative disc disease, posterior central disc, csf cleft, osteophyte complex, radicular impingement, disc disease, central disc, annular bulging, disc desiccation, joint arthrosis, central canal, cervical, degenerative, csf, foraminal, bulging, impingement, protrusion, uncovertebral, arthrosis, canal"
 Patient with right ankle pain., Orthopedic, MRI Ankle - 1 ,"EXAM:,MRI RIGHT ANKLE,CLINICAL:,This is a 51 year old female who first came into the office 3/4/05 with right ankle pain. She stepped on ice the evening prior and twisted her ankle. PF's showed no frank fracture, dislocation, or subluxations.,FINDINGS:,Received for interpretation is an MRI examination performed on 4/28/2005.,There is a ""high ankle sprain"" of the distal tibiofibular syndesmotic ligamentous complex involving the anterior tibiofibular ligament with marked ligamentous inflammatory thickening and diffuse interstitial edema. There is osteoarthritic spur formation at the anterior aspect of the fibula with a small 2mm osseous structure within the markedly thickened anterior talofibular ligament suggesting a small ligamentous osseous avulsion. The distal tibiofibular syndesmotic ligamentous complex remains intact without a complete rupture. There is no widening of the ankle mortis. The posterior talofibular ligament remains intact.,There is marked ligamentous thickening of the anterior talofibular ligament of the lateral collateral ligamentous complex suggesting the sequela of a remote lateral ankle sprain. There is thickening of the posterior talofibular and calcaneofibular ligaments.,There is a flat retromalleolar sulcus.,There is a full-thickness longitudinal split tear of the peroneus brevis tendon within the retromalleolar groove. The tear extends to the level of the inferior peroneal retinaculum. There is anterior displacement of the peroneus longus tendon into the split peroneus tendon tear.,There is severe synovitis of the peroneus longus tendon sheath with prominent fluid distention. The synovitis extends to the level of the inferior peroneal retinaculum.,There is a focal area of chondral thinning of the hyaline cartilage of the medial talar dome with a focal area of subchondral plate cancellous marrow resorption consistent with and area of prior talar dome contusion but there is no focal osteochondral impaction or osteochondral defect.,There is minimal fluid within the tibiotalar articulation.,There is minimal fluid within the posterior subtalar articulation with mild anterior capsular prolapse. Normal talonavicular and calcaneocuboid articulations. The anterior superior calcaneal process is normal.,There is mild tenosynovitis of the posterior tibialis tendon sheath but an intrinsically normal tendon. There is an os navicularis (Type II synchondrosis) with an intact synchondrosis and no active marrow stress phenomenon.,Normal flexor digitorum longus tendon.,There is prominent fluid distention of the flexor hallucis longus tendon sheath with capsular distention proximal to the posterior talar processes with prominent fluid distention of the synovial sheath.,There is a loculated fluid collection within Kager’s fat measuring approximately 1 x 1 x 2.5cm in size, extending to the posterior subtalar facet joint consistent with a ganglion of either posterior subtalar facet origin or arising from the flexor hallucis longus tendon sheath.,There is mild tenosynovitis of the Achilles tendon with mild fusiform enlargement of the non-insertional Watershed zone of the Achilles tendon but there is no demonstrated tendon tear or tenosynovitis. There is a low-lying soleus muscle that extends to within 4cm of the teno-osseous insertion of the Achilles tendon. There is no Haglund’s deformity.,There is a plantar calcaneal spur measuring approximately 6mm in size, without a reactive marrow stress phenomenon. Normal plantar fascia.,IMPRESSION:,Partial high ankle sprain with diffuse interstitial edema of the anterior tibiofibular ligament with a ligamentous chip avulsion but without a disruption of the anterior tibiofibular ligament.,Marked ligamentous thickening of the lateral collateral ligamentous complex consistent with the sequela of a remote lateral ankle sprain.,Full-thickness longitudinal split tear of the peroneus brevis tendon with severe synovitis of the peroneal tendon sheath.,Post-traumatic deformity of the medial talar dome consistent with a prior osteochondral impaction injury but no osteochondral defect. Residual subchondral plate cancellous marrow edema.,Severe synovitis of the flexor hallucis longus tendon sheath with prominent fluid distention of the synovial sheath proximal to the posterior talar processes.,Septated cystic structure within Kager’s fat triangle extending along the superior aspect of the calcaneus consistent with a ganglion of either articular or synovial sheath origin.,Plantar calcaneal spur but no reactive marrow stress phenomenon.,Mild tendinosis of the Achilles tendon but no tendinitis or tendon tear.,Os navicularis (Type II synchondrosis) without an active marrow stress phenomenon.",
 MRI Brain & T-spine - Demyelinating disease., Orthopedic, MRI Brain & T-spine - Demyelinating disease. ,"CC: ,Sensory loss.,HX: ,25y/o RHF began experiencing pruritus in the RUE, above the elbow and in the right scapular region, on 10/23/92. In addition she had paresthesias in the proximal BLE and toes of the right foot. Her symptoms resolved the following day. On 10/25/92, she awoke in the morning and her legs felt ""asleep"" with decreased sensation. The sensory loss gradually progressed rostrally to the mid chest. She felt unsteady on her feet and had difficulty ambulating. In addition she also began to experience pain in the right scapular region. She denied any heat or cold intolerance, fatigue, weight loss.,MEDS:, None.,PMH:, Unremarkable.,FHX: ,GF with CAD, otherwise unremarkable.,SHX:, Married, unemployed. 2 children. Patient was born and raised in Iowa. Denied any h/o Tobacco/ETOH/illicit drug use.,EXAM:,  BP121/66 HR77 RR14 36.5C,MS: A&O to person, place and time. Speech normal with logical lucid thought process.,CN: mild optic disk pallor OS. No RAPD. EOM full and smooth. No INO. The rest of the CN exam was unremarkable.,MOTOR: Full strength throughout all extremities except for 5/4+ hip extensors. Normal muscle tone and bulk.,Sensory: Decreased PP/LT below T4-5 on the left side down to the feet. Decreased PP/LT/VIB in BLE (left worse than right). Allodynic in RUE.,Coord: Intact FNF, HKS and RAM, bilaterally.,Station: No pronator drift. Romberg's test not documented.,Gait: Unsteady wide-based. Able to TT and HW. Poor TW.,Reflexes: 3/3 BUE. Hoffman's signs were present bilaterally. 4/4 patellae. 3+/3+ Achilles with 3-4 beat nonsustained clonus. Plantar responses were extensor on the right and flexor on the left.,Gen. Exam: Unremarkable.,COURSE:, CBC, GS, PT, PTT, ESR, FT4, TSH, ANA, Vit B12, Folate, VDRL and Urinalysis were normal. MRI T-spine, 10/27/92, was unremarkable. MRI Brain, 10/28/92, revealed multiple areas of abnormally increased signal on T2 weighted images in the white matter regions of the right corpus callosum, periventricular region, brachium pontis and right pons. The appearance of the lesions was felt to be strongly suggestive of multiple sclerosis. 10/28/92, Lumbar puncture revealed the following CSF results: RBC 1, WBC 9 (8 lymphocytes, 1 histiocyte), Glucose 55mg/dl, Protein 46mg/dl (normal 15-45), CSF IgG 7.5mg/dl (normal 0.0-6.2), CSF IgG index 1.3 (normal 0.0-0.7), agarose gel electrophoresis revealed oligoclonal bands in the gamma region which were not seen on the serum sample. Beta-2 microglobulin was unremarkable. An abnormal left tibial somatosensory evoked potential was noted consistent with central conduction slowing. Visual and Brainstem Auditory evoked potentials were normal. HTLV-1 titers were negative. CSF cultures and cytology were negative. She was not treated with medications as her symptoms were primarily sensory and non-debilitating, and she was discharged home.,She returned on 11/7/92 as her symptoms of RUE dysesthesia, lower extremity paresthesia and weakness, all worsened. On 11/6/92, she developed slow slurred speech and had marked difficulty expressing her thoughts. She also began having difficulty emptying her bladder. Her 11/7/92 exam was notable for normal vital signs, lying motionless with eyes open and nodding and rhythmically blinking every few minutes. She was oriented to place and time of day, but not to season, day of the week and she did not know who she was. She had a leftward gaze preference and right lower facial weakness. Her RLE was spastic with sustained ankle clonus. There was dysesthetic sensory perception in the RUE. Jaw jerk and glabellar sign were present.,MRI brain, 11/7/92, revealed multiple enhancing lesions in the peritrigonal region and white matter of the centrum semiovale. The right peritrigonal region is more prominent than on prior study. The left centrum semiovale lesion has less enhancement than previously. Multiple other white matter lesions are demonstrated on the right side, in the posterior limb of the internal capsule, the anterior periventricular white matter, optic radiations and cerebellum. The peritrigonal lesions on both sides have increased in size since the 10/92 MRI. The findings were felt more consistent with demyelinating disease and less likely glioma. Post-viral encephalitis, Rapidly progressive demyelinating disease and tumor were in the differential diagnosis. Lumbar Puncture, 11/8/92, revealed: RBC 2, WBC 12 (12 lymphocytes), Glucose 57, Protein 51 (elevated), cytology and cultures were negative. HIV 1 titer was negative. Urine drug screen, negative. A stereotactic brain biopsy of the right parieto-occipital region was consistent with demyelinating disease. She was treated with Decadron 6mg IV qhours and Cytoxan 0.75gm/m2 (1.25gm). On 12/3/92, she has a focal motor seizure with rhythmic jerking of the LUE, loss of consciousness and rightward eye deviation. EEG revealed diffuse slowing with frequent right-sided sharp discharges. She was placed on Dilantin. She became depressed.","orthopedic, sensory loss, lumbar puncture, peritrigonal region, centrum semiovale, mri brain, white matter, demyelinating disease, csf, demyelinating, mri, brain, "
  Right hallux abductovalgus deformity.  Right McBride bunionectomy.  Right basilar wedge osteotomy with OrthoPro screw fixation., Orthopedic, McBride Bunionectomy & Wedge Osteotomy ,"PREOPERATIVE DIAGNOSIS:,  Right hallux abductovalgus deformity.,POSTOPERATIVE DIAGNOSIS:,  Right hallux abductovalgus deformity.,PROCEDURES PERFORMED:,1.  Right McBride bunionectomy.,2.  Right basilar wedge osteotomy with OrthoPro screw fixation.,ANESTHESIA: , Local with IV sedation.,HEMOSTASIS: , With pneumatic ankle cuff.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room and placed in a supine position.  The right foot was prepared and draped in usual sterile manner.  Anesthesia was achieved utilizing a 50:50 mixture of 2% lidocaine plain with 0.5 Marcaine plain infiltrated just proximal to the first metatarsocuneiform joint.  Hemostasis was achieved utilizing a pneumatic ankle Tourniquet placed above the right ankle and inflated to a pressure of 225 mmHg.  At this time, attention was directed to the dorsal aspect of the right first metatarsophalangeal joint where dorsal linear incision approximately 3 cm in length was made.  The incision was deepened within the same plain taking care of the Bovie and retracted all superficial nerves and vessels as necessary.  The incision was then carried down to the underlying capsular structure once again taking care of the Bovie and retracted all superficial nerves and vessels as necessary.  The capsular incision following the same outline as the skin incision was made and carried down to the underlying bony structure.  The capsule was then freed from the underling bony structure utilizing sharp and blunt dissection.  Using a microsagittal saw, the medial and dorsal very prominent bony eminence were removed and the area was inspected for any remaining bony prominences following resection of bone and those noted were removed using a hand rasp.  At this time, attention was directed to the first inner space using sharp and blunt dissection.  Dissection was carried down to the underling level of the adductor hallucis tendon, which was isolated and freed from its phalangeal, sesamoidal, and metatarsal attachments.  The tendon was noted to lap the length and integrity for transfer and at this time was tenotomized taking out resection of approximately 0.5 cm to help prevent any re-fibrous attachment.  At this time, the lateral release was stressed and was found to be complete.  The extensor hallucis brevis tendon was then isolated using blunt dissection and was tenotomized as well taking out approximately 0.5-cm resection.  The entire area was copiously flushed 3 times using a sterile saline solution and was inspected for any bony prominences remaining and it was noted that the base of the proximal phalanx on the medial side due to the removal of the extensive buildup of the metatarsal head was going to be very prominent in nature and at this time was removed using a microsagittal saw.  The area was again copiously flushed and inspected for any abnormalities and/or prominences and none were noted.  At this time, attention was directed to the base of the first metatarsal where a second incision was made approximately 4 cm in length.  The incision was deepened within the same plain taking care of Bovie and retracted all superficial nerves and vessels as necessary.  The incision was then carried down to the level of the metatarsal and using sharp and blunt dissection periosteal capsule structures were freed from the base of the metatarsal and taking care to retract the long extensive tendon and any neurovascular structures to avoid any disruption.  At this time, there was a measurement made of 1 cm just distal to the metatarsocuneiform joint on the medial side and 2 cm distal to the metatarsocuneiform joint from the lateral aspect of the joint.  At this time, 0.5 cm was measured distal to that lateral measurement and using microsagittal saw, a wedge osteotomy was taken from the base with the apex of the osteotomy being medial, taking care to keep the medial cortex intact as a hinge.  The osteotomy site was feathered down until the osteotomy site could be closed with little tension on it and at this time using an OrthoPro screw 3.0 x 22 mm.  The screw was placed following proper technique.  The osteotomy site was found to be fixated with absolutely no movement and good stability upon manual testing.  A very tiny gap on the lateral aspect of the osteotomy site was found and this was filled in packing it with the cancellous bone that was left over from the wedge osteotomy.  The packing of the cancellous bone was held in place with bone wax.  The entire area was copiously flushed 3 times using a sterile saline solution and was inspected and tested again for any movement of the osteotomy site or any gapping and then removed.  At this time, a deep closure was achieved utilizing #2-0 Vicryl suture, subcuticular closure was achieved using #4-0 Vicryl suture, and skin repair was achieved at both surgical sites with #5-0 nylon suture in a running interlocking fashion.  The hallux was found to have excellent movement upon completion of the osteotomy and the second procedure of the McBride bunionectomy and the metatarsal was found to stay in excellent alignment with good stability at the proximal osteotomy site.  At this time, the surgical site was postoperatively injected with 0.5 Marcaine plain as well as dexamethasone 4 mg primarily.  The surgical sites were then dressed with sterile Xeroform, sterile 4x4s, cascading, and Kling with a final protective layer of fiberglass in a nonweightbearing cast fashion.  The tourniquet was dropped and color and temperature of all digits returned to normal.  The patient tolerated the anesthesia and the procedure well and left the operating room in stable condition.,The patient has been given written and verbal postoperative instructions and has been instructed to call if she has any questions, problems, or concerns at any time with the numbers provided.  The patient has also been warned a number of times the importance of elevation and no weightbearing on the surgical foot.,","orthopedic, hallux, abductovalgus, bunionectomy, mcbride, basilar, wedge, osteotomy, orthopro, screw, fixation, wedge osteotomy"
" Arthroscopy, medial meniscoplasty, lateral meniscoplasty, medial femoral chondroplasty, and medical femoral microfracture, right knee.  Patellar chondroplasty.  Lateral femoral chondroplasty.   Meniscal tear, osteochondral lesion, degenerative joint disease, and chondromalacia,", Orthopedic, Meniscoplasty & Chondroplasty ,"PREOPERATIVE DIAGNOSIS:,  Medial meniscal tear of the right knee.,POSTOPERATIVE DIAGNOSES:,1.  Medial meniscal tear, right knee.,2.  Lateral meniscal tear, right knee.,3.  Osteochondral lesion, medial femoral condyle, right knee.,4.  Degenerative joint disease, right knee.,5.  Patella grade-II chondromalacia.,6.  Lateral femoral condyle grade II-III chondromalacia.,PROCEDURE PERFORMED:,1.  Arthroscopy, right knee.,2.  Medial meniscoplasty, right knee.,3.  Lateral meniscoplasty, right knee.,4.  Medial femoral chondroplasty, right knee.,5.  Medical femoral microfracture, right knee.,6.  Patellar chondroplasty.,7.  Lateral femoral chondroplasty.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS:,  None.,BRIEF HISTORY AND INDICATION FOR PROCEDURE: , The patient is a 47-year-old female who has knee pain since 03/10/03 after falling on ice.  The patient states she has had inability to bear significant weight and had swelling, popping, and giving away, failing conservative treatment and underwent an operative procedure.,PROCEDURE:,  The patient was taken to the Operative Suite at ABCD General Hospital on 09/08/03, placed on the operative table in supine position.  Department of Anesthesia administered general anesthetic.  Once adequately anesthetized, the right lower extremity was placed in a Johnson knee holder.  Care was ensured that all bony prominences were well padded and she was positioned and secured.  After adequately positioned, the right lower extremity was prepped and draped in the usual sterile fashion.  Attention was then directed to creation of the arthroscopic portals, both medial and lateral portal were made for arthroscope and instrumentation respectively.  The arthroscope was advanced through the inferolateral portal taking in a suprapatellar pouch.  All compartments were then examined in sequential order with photodocumentation of each compartment.  The patella was noted to have grade-II changes of the inferior surface, otherwise appeared to track within the trochlear groove.  There was mild grooving of the trochlear cartilage.  The medial gutter was visualized.  There was no evidence of loose body.  The medial compartment was then entered.  There was noted to be a large defect on the medial femoral condyle grade III-IV chondromalacia changes with exposed bone in evidence of osteochondral displaced fragment.  There was also noted to be a degenerative meniscal tear of the posterior horn of the medial meniscus.  The arthroscopic probe was then introduced and the meniscus and chondral surfaces were probed throughout its entirety and photos were taken.  At this point, a meniscal shaver was then introduced and the chondral surfaces were debrided as well as any loose bodies removed.  This gave a smooth shoulder to the chondral lesion.  After this, the meniscus was debrided until it had been smooth over the frayed edges.  At this point, the shaver was removed.  The meniscal binder was then introduced and the meniscus was further debrided until the tear was adequately contained at this point.  The shaver was reintroduced and all particles were again removed and the meniscus was smoothed over the edge.  The probe was then reintroduced and the shaver removed, the meniscus was probed ___________ and now found to be stable.  At this point, attention was directed to the rest of the knee.  The ACL was examined.  It was intact and stable.  The lateral compartment was then entered.  There was noted to be a grade II-III changes of the lateral femoral condyle.  Again, with the edge of some friability at the shoulder of this cartilage lesion.  There was noted to be some mild degenerative fraying of the posterior horn of the lateral meniscus.  The probe was introduced and the remaining meniscus appeared stable.  This was then removed and the stapler was introduced.  A chondroplasty and meniscoplasty were then performed until adequately debrided and smoothed over.  The lateral gutter was then visualized.  There was no evidence of loose bodies.  Attention was then redirected back to the medial and femoral condyles.,At this point, a 0.62 K-wire was then placed in through the initial portal, medial portal, as well as an additional poke hole, so we can gain access and proper orientation to the medial femoral lesion.  Microfacial technique was then used to introduce the K-wire into the subchondral bone in multiple areas until we had evidence of some bleeding to allow ___________ of this lesion.  After this was performed, the shaver was then reintroduced and the loose bodies and loose fragments were further debrided.  At this point, the shaver was then moved to the suprapatellar pouch and the patellar chondroplasty was then performed until adequately debrided.  Again, all compartments were then re-visualized and there was no further evidence of other pathology or loose bodies.  The knee was then copiously irrigated and suctioned dry.  All instrumentation was removed.  Approximately 20 cc of 0.25% plain Marcaine was injected into the portal site and the remaining portion intraarticular.  Sterile dressings of Adaptic, 4x4s, ABDs, and Webril were then applied.  The patient was then transferred back to the gurney in supine position.,DISPOSITION:  The patient tolerated the procedure well with no complications.  The patient was transferred to PACU in satisfactory condition.", 
" Low back pain, lumbar radiculopathy, degenerative disc disease, lumbar spinal stenosis, history of anemia, high cholesterol, and hypothyroidism.", Orthopedic, Lumbar Radiculopathy - Consult ,"FAMILY HISTORY:,  Her father died from leukemia.  Her mother died from kidney and heart failure.  She has two brothers; five sisters, one with breast cancer; two sons; and a daughter.  She describes cancer, hypertension, nervous condition, kidney disease, high cholesterol, and depression in her family.,SOCIAL HISTORY:,  She is divorced.  She does not have support at home.  She denies tobacco, alcohol, and illicit drug use.,ALLERGIES: , Hypaque dye when she had x-rays for her kidneys.,MEDICATIONS: , Prempro q.d., Levoxyl 75 mcg q.d., Lexapro 20 mg q.d., Fiorinal as needed, currently she is taking it three times a day, and aspirin as needed.  She also takes various supplements including multivitamin q.d., calcium with vitamin D b.i.d., magnesium b.i.d., Ester-C b.i.d., vitamin E b.i.d., flax oil and fish oil b.i.d., evening primrose 1000 mg b.i.d., Quercetin 500 mg b.i.d., Policosanol 20 mg two a day, glucosamine chondroitin three a day, coenzyme-Q 10 30 mg two a day, holy basil two a day, sea vegetables two a day, and very green vegetables.,PAST MEDICAL HISTORY:,  Anemia, high cholesterol, and hypothyroidism.,PAST SURGICAL HISTORY:,  In 1979, tubal ligation and three milk ducts removed.  In 1989 she had a breast biopsy and in 2007 a colonoscopy.  She is G4, P3, with no cesarean section.,REVIEW OF SYSTEMS:  ,HEENT:  For headaches and sore throat.  Musculoskeletal:  She is right handed with joint pain, stiffness, and decreased range of motion.  Cardiac:  For heart murmur.  GI:  Negative and noncontributory.  Respiratory:  Negative and noncontributory.  Urinary:  Negative and noncontributory.  Hem-Onc:  Negative and noncontributory.  Vascular:  Negative and noncontributory.  Psychiatric:  Negative and noncontributory.  Genital:  Negative and noncontributory.  She denies any bowel or bladder dysfunction or loss of sensation in her genital area.,PHYSICAL EXAMINATION: , She is 5 feet 2 inches tall.  Current weight is 132 pounds, weight one year ago was 126 pounds.  BP is 122/68.  On physical exam, patient is alert and oriented with normal mentation and appropriate speech, in no acute distress.  General, a well-developed and well-nourished female in no acute distress.  HEENT exam, head is atraumatic and normocephalic.  Eyes, sclerae are anicteric.  Teeth good dentition.  Cranial nerves II, III, IV, and VI, vision is intact, visual fields are full to confrontation, EOMs full bilaterally, and pupils are equal, round, and reactive to light.  Cranial nerves V and VII, normal facial sensation and symmetrical facial movement.  Cranial nerve VIII, hearing intact.  Cranial nerves IX, X, and XII, tongue protrudes midline and palate elevates symmetrically.,Cranial nerve XI, strong and symmetrical shoulder shrugs against resistance.  Cardiac, regular rate and rhythm.  Chest and lungs are clear bilaterally.  Skin is warm and dry, normal turgor and texture.  No rashes or lesions are noted.  General musculoskeletal exam reveals no gross deformities, fasciculations, or atrophy.  Peripheral vascular, no cyanosis, clubbing, or edema.  Examination of the low back reveals some mild paralumbar spasms.  She is nontender to palpation of her spinous processes, SI joints, and paralumbar musculature.  She does have some poking sensation to deep palpation into the left buttock where she describes some zinging sensation.  Deep tendon reflexes are 2+ bilateral knees and ankles.  No ankle clonus is elicited.  Babinski, toes are downgoing.  Straight leg raising is negative bilaterally.  Strength on manual exam is 5/5 and equal bilateral lower extremity.  She is able to ambulate on her toes and her heels without any difficulty.  She is able to get up standing on one foot on to the toes.  She does have some difficulty getting up on to her heels when standing on one foot.  She has trouble with this on the left and right.  She complains of increased pain while doing this as well.  She also has positive Patrick/FABER on the right with pain with internal and external rotation, negative on the left.  Sensation is intact.  She has good accuracy to pinprick, dull versus sharp.,FINDINGS: , The patient brings in lumbar spine MRI dated November 20, 2007, which demonstrates degenerative disc disease throughout.  At L4-L5, there is an annular disc bulge with fissuring with facet arthrosis and ligamentum flavum hypertrophy yielding moderate central stenosis and neuroforaminal narrowing but the nerves do not appear to be impinged.  At L5-S1, in the right neuroforamina, there appears to be soft tissue density just lateral and posterior to the nerve root, which may cause some displacement, but it is unclear.  This could represent a facet synovial cyst.  This is lateral to the facet.  She does not have x-rays for review.  She has had hip and knee x-rays taken but does not bring them in with her.,ASSESSMENT: , Low back pain, lumbar radiculopathy, degenerative disc disease, lumbar spinal stenosis, history of anemia, high cholesterol, and hypothyroidism.,PLAN: , We discussed treatment options with this patient including:,1  Do nothing.,2.  Conservative therapies.,3.  Surgery.,She seems to have some issues with her right hip, so I would like for her to fax us over the report of her hip and knee x-rays.  We will also order some x-rays of her lumbar spine as well as lower extremity EMG.,At this point, the patient has not exhausted conservative measures and would like to start with epidural steroid injections, so we will go ahead and send her out for that.  After she has gotten her second epidural injection, she will return to the office for a followup visit to see how she is doing.  All questions and concerns were addressed.  If she should have any further questions, concerns, or complications, she will contact our office immediately.  Otherwise, we will see her as scheduled.  Case was reviewed and discussed with Dr. L.","orthopedic, back pain, hip pain, low back pain, x-rays, lumbar spinal stenosis, degenerative disc disease, spinal stenosis, lumbar spine, lumbar radiculopathy, cranial nerves, lumbar, degenerative, anemia, "
 Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation., Orthopedic, Lumbar Re-exploration ,"PREOPERATIVE DIAGNOSIS: , Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.,POSTOPERATIVE DIAGNOSIS: , Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.,PROCEDURE: , Lumbar re-exploration for removal of fractured internal fixation plate from T11 through L2 followed by a repositioning of the L2 pedicle screws and evaluation of the fusion from T11 through L2 followed by a bilateral hemilaminectomy and diskectomy for decompression at L4-5 and L5-S1 with posterior lumbar interbody fusion using morselized autograft bone and the synthetic spacers from the Capstone system at L4-5 and L5-S1 followed by placement of the pedicle screw fixation devices at L3, L4, L5, and S1 and insertion of a 20 cm fixation plate that range from the T11 through S1 levels and then subsequent onlay fusion using morselized autograft bone and bone morphogenetic soaked sponge at L1-2 and then at L3-L4, L4-L5, and L5-S1 bilaterally.,DESCRIPTION OF PROCEDURE:  ,This is a 68-year-old lady who presents with a history of osteomyelitis associated with the percutaneous vertebroplasty that was actually treated several months ago with removal of the infected vertebral augmentation and placement of a posterior pedicle screw plate fixation device from T11 through L2.  She subsequently actually done reasonably well until about a month ago when she developed progressive severe intractable pain.  Imaging study showed that the distal hardware at the plate itself had fractured consistent with incomplete fusion across her osteomyelitis area.  There was no evidence of infection on the imaging or with her laboratory studies.  In addition, she developed a pretty profound stenosis at L4-L5 and L5-S1 that appeared to be recurrent as well.  She now presents for revision of her hardware, extension of fusion, and decompression.,The patient was brought to the operating room, placed under satisfactory general endotracheal anesthesia.  She was placed on the operative table in the prone position.  Back was prepared with Betadine, iodine, and alcohol.  We elliptically excised her old incision and extended this caudally so that we had access from the existing hardware fixation all the way down to her sacrum.  The locking nuts were removed from the screw post and both plates refractured or significantly weakened and had a crease in it.  After these were removed, it was obvious that the bottom screws were somewhat loosened in the pedicle zone so we actually tightened one up and that fit good snugly into the nail when we redirected so that it actually reamed up into the upper aspect of the vertebral body in much more secure purchase.  We then dressed the L4-L5 and L5-S1 levels which were profoundly stenotic.  This was a combination of scar and overgrown bone.  She had previously undergone bilateral hemilaminectomies at L4-5 so we removed scar bone and actually cleaned and significantly decompressed the dura at both of these levels.  After completing this, we inserted the Capstone interbody spacer filled with morselized autograft bone and some BMP sponge into the disk space at both levels.  We used 10 x 32 mm spacers at both L4-L5 and L5-S1.  This corrected the deformity and helped to preserve the correction of the stenosis and then after we cannulated the pedicles of L4, L5 and S1 tightened the pedicle screws in L3.  This allowed us to actually seat a 20 cm plate contoured to the lumbar lordosis onto the pedicle screws all the way from S1 up to the T11 level.  Once we placed the plate onto the screws and locked them in position, we then packed the remaining BMP sponge and morselized autograft bone through the plate around the incomplete fracture healing at the L1 level and then dorsolaterally at L4-L5 and L5-S1 and L3-L4, again the goal being to create a dorsal fusion and enhance the interbody fusion as well.  The wound was then irrigated copiously with bacitracin solution and then we closed in layers using #1 Vicryl in muscle and fascia, 3-0 in subcutaneous tissue and approximated staples in the skin.  Prior to closing the skin, we confirmed correct sponge and needle count.  We placed a drain in the extrafascial space and then confirmed that there were no other foreign bodies.  The Cell Saver blood was recycled and she was given two units of packed red blood cells as well.  I was present for and performed the entire procedure myself or supervised.","orthopedic, degenerative spondylolisthesis, spondylolisthesis, stenosis, lumbar re-exploration, internal fixation plate, hemilaminectomy, diskectomy, synthetic spacers, pedicle screws, fusion, lumbar, pedicle, fixation, hardware,"
" Medial branch rhizotomy, lumbosacral.  Fluoroscopy was used to identify the boney landmarks of the spine and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.", Orthopedic, Medial Branch Rhizotomy ,"PROCEDURE: , Medial branch rhizotomy, lumbosacral.,INFORMED CONSENT:,  The risks, benefits and alternatives of the procedure were discussed with the patient.  The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible of vascular entry of medications.  I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing.  The patient understood the informed consent and desired to have the procedure performed.,SEDATION: , The patient was given conscious sedation and monitored throughout the procedure.  Oxygenation was given.  The patient's oxygenation and vital signs were closely followed to ensure the safety of the administration of the drugs.,PROCEDURE:  ,The patient remained awake throughout the procedure in order to interact and give feedback.  The x-ray technician was supervised and instructed to operate the fluoroscopy machine.  The patient was placed in the prone position on the treatment table with a pillow under the abdomen to reduce the natural lumbar lordosis.  The skin over and surrounding the treatment area was cleaned with Betadine.  The area was covered with sterile drapes, leaving a small window opening for needle placement.  Fluoroscopy was used to identify the boney landmarks of the spine and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.  With fluoroscopy, a Teflon coated needle, ***, was gently guided into the region of the Medial Branch nerves from the Dorsal Ramus of ***.  Specifically, each needle tip was inserted to the bone at the groove between the transverse process and superior articular process on lumbar vertebra, or for sacral vertebrae at the lateral-superior border of the posterior sacral foramen.  Needle localization was confirmed with AP and lateral radiographs.,The following technique was used to confirm placement at the Medial Branch nerves.  Sensory stimulation was applied to each level at 50 Hz; paresthesias were noted at,*** volts.  Motor stimulation was applied at 2 Hz with 1 millisecond duration; corresponding paraspinal muscle twitching without extremity movement was noted at *** volts.,Following this, the needle Trocar was removed and a syringe containing 1% lidocaine was attached.  At each level, after syringe aspiration with no blood return, 1cc 1% lidocaine was injected to anesthetize the Medial Branch nerve and surrounding tissue.  After completion of each nerve block a lesion was created at that level with a temperature of 85 degrees Celsius for 90 seconds.  All injected medications were preservative free.  Sterile technique was used throughout the procedure.,COMPLICATIONS:,  None.  No complications.,The patient tolerated the procedure well and was sent to the recovery room in good condition.,DISCUSSION: , Post-procedure vital signs and oximetry were stable.  The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day.  The patient was told to resume all medications.  The patient was told to be in relative rest for 1 day but then could resume all normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes, or changes in bowel or bladder function.,Follow up appointment was made in approximately 1 week.","orthopedic, lumbosacral, medial branch rhizotomy, medial branch nerves, rhizotomy, fluoroscopy,"
" Injection for myelogram and microscopic-assisted lumbar laminectomy with discectomy at L5-S1 on the left.  Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.", Orthopedic, Lumbar Laminectomy & Discectomy ,"PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.,POSTOPERATIVE DIAGNOSIS:,  Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.,PROCEDURE PERFORMED:,1.  Injection for myelogram.,2.  Microscopic-assisted lumbar laminectomy with discectomy at L5-S1 on the left on 08/28/03.,BLOOD LOSS: , Approximately 25 cc.,ANESTHESIA: , General.,POSITION:,  Prone on the Jackson table.,INTRAOPERATIVE FINDINGS:,  Extruded nucleus pulposus at the level of L5-S1.,HISTORY: , This is a 34-year-old male with history of back pain with radiation into the left leg in the S1 nerve root distribution.  The patient was lifting at work on 08/27/03 and felt immediate sharp pain from his back down to the left lower extremity.  He denied any previous history of back pain or back surgeries.  Because of his intractable pain as well as severe weakness in the S1 nerve root distribution, the patient was aware of all risks as well as possible complications of this type of surgery and he has agreed to pursue on.  After an informed consent was obtained, all risks as well as complications were discussed with the patient.  ,PROCEDURE DETAIL:  ,He was wheeled back to Operating Room #5 at ABCD General Hospital on 08/28/03.  After a general anesthetic was administered, a Foley catheter was inserted.,The patient was then turned prone on the Jackson table.  All of his bony prominences were well-padded.  At this time, a myelogram was then performed.  After the lumbar spine was prepped, a #20 gauge needle was then used to perform a myelogram.  The needle was localized to the level of L3-L4 region.  Once inserted into the thecal sac, we immediately got cerebrospinal fluid through the spinal needle.  At this time, approximately 10 cc of Conray injected into the thecal sac.  The patient was then placed in the reversed Trendelenburg position in order to assist with distal migration of the contrast.  The myelogram did reveal that there was some space occupying lesion, most likely disc at the level of L5-S1 on the left.  There was a lack of space filling defect on the left evident on both the AP and the lateral projections using C-arm fluoroscopy.  At this point, the patient was then fully prepped and draped in the usual sterile fashion for this procedure for a microdiscectomy.  A long spinal needle was then inserted into region of surgery on the right.  The surgery was going to be on the left.  Once the spinal needle was inserted, a localizing fluoroscopy was then used to assure appropriate location and this did confirm that we were at the L5-S1 nerve root region.  At this time, an approximately 2 cm skin incision was made over the lumbar region, dissected down to the deep lumbar fascia.  At this time, a Weitlaner was inserted.  Bovie cautery was used to obtain hemostasis.  We further continued through the deep lumbar fascia and dissected off the short lumbar muscles off of the spinous process and the lamina.  A Cobb elevator was then used to elevate subperiosteally off of all the inserting short lumbar muscles off of the spinous process as well as the lamina on the left-hand side.  At this time, a Taylor retractor was then inserted and held there for retraction.  Suction as well as Bovie cautery was used to obtain hemostasis.  At this time, a small Kerrison Rongeur was used to make a small lumbar laminotomy to expose our window for the nerve root decompression.  Once the laminotomy was performed, a small _______ curette was used to elevate the ligamentum flavum off of the thecal sac as well as the adjoining nerve roots.  Once the ligamentum flavum was removed, we immediately identified a piece of disc material floating around outside of the disc space over the S1 nerve root, which was compressive.  We removed the extruded disc with further freeing up of the S1 nerve root.  A nerve root retractor was then placed.  Identification of disc space was then performed.  A #15 blade was then inserted and small a key hole into the disc space was then performed with a #15 blade.  A small pituitary was then inserted within the disc space and more disc material was freed and removed.  The part of the annulus fibrosis were also removed in addition to the loose intranuclear pieces of disc.  Once this was performed, we removed the retraction off the nerve root and the nerve root appeared to be free with pulsatile visualization of the vasculature indicating that the nerve root was essentially free.,At this time, copious irrigation was used to irrigate the wound.  We then performed another look to see if any loose pieces of disc were extruding from the disc space and only small pieces were evident and they were then removed with the pituitary rongeur.  At this time, a small piece of Gelfoam was then used to cover the exposed nerve root.  We did not have any dural leaks during this case.  #1-0 Vicryl was then used to approximate the deep lumbar fascia, #2-0 Vicryl was used to approximate the superficial lumbar fascia, and #4-0 running Vicryl for the subcutaneous skin.  Sterile dressings were then applied.  The patient was then carefully slipped over into the supine position, extubated and transferred to Recovery in stable condition.  At this time, we are still waiting to assess the patient postoperatively to assure no neurological sequela postsurgically are found and also to assess his pain level.","orthopedic, microscopic-assisted lumbar laminectomy, discectomy, nerve root, lumbar laminectomy, herniated nucleus, thecal sac, spinal needle, nucleus pulposus, disc space, root, nerve, weakness, lumbar, laminectomy, nucleus, pulposus, myelogram"
 Low back pain and right lower extremity pain - Lumbar spine herniated nucleus pulposus., Orthopedic, Lumbar Spine HNP - Consult ,"CHIEF COMPLAINT:, Low back pain and right lower extremity pain. The encounter reason for today's consultation is for a second opinion regarding evaluation and treatment of the aforementioned symptoms.,HPI - LUMBAR SPINE:, The patient is a male and 39 years old. The current problem began on or about 3 months ago. The symptoms were sudden in onset. According to the patient, the current problem is a result of a fall. The date of injury was 3 months ago. There is no significant history of previous spine problems. Medical attention has been obtained through the referral source. Medical testing for the current problem includes the following: no recent tests. Treatment for the current problem includes the following: activity modification, bracing, medications and work modification. The following types of medications are currently being used for the present spine problem: narcotics, non-steroidal anti-inflammatories and muscle relaxants. The following types of medications have been used in the past: steroids. In general, the current spine problem is much worse since its onset.,PAST SPINE HISTORY:, Unremarkable.,PRESENT LUMBAR SYMPTOMS:, Pain location: lower lumbar. The patient describes the pain as sharp. The pain ranges from none to severe. The pain is severe frequently. It is present intermittently and most of the time daily. The pain is made worse by flexion, lifting, twisting, activity, riding in a car and sitting. The pain is made better by laying in the supine position, medications, bracing and rest. Sleep alteration because of pain: wakes up after getting to sleep frequently and difficulty getting to sleep frequently. Pain distribution: the lower extremity pain is greater than the low back pain. The patient's low back pain appears to be discogenic in origin. The pain is much worse since its onset.,PRESENT RIGHT LEG SYMPTOMS:, Pain location: S1 dermatome (see the Pain Diagram). The patient describes the pain as sharp. The severity of the pain ranges from none to severe. The pain is severe frequently. It is present intermittently and most of the time daily. The pain is made worse by the same things that make the low back pain worse. The pain is made better by the same things that make the low back pain better. Sleep alteration because of pain: wakes up after getting to sleep frequently and difficulty getting to sleep frequently. The patient's symptoms appear to be radicular in origin. The pain is much worse since its onset.,PRESENT LEFT LEG SYMPTOMS:, None.,NEUROLOGIC SIGNS/SYMPTOMS:, The patient denies any neurologic signs/symptoms. Bowel and bladder function are reported as normal.",
" Lumbar laminectomy for decompression with foraminotomies L3-L4, L4-L5, L5-S1 microtechniques and repair of CSF fistula, microtechniques L5-S1, application of DuraSeal.  Lumbar stenosis and cerebrospinal fluid fistula.", Orthopedic, Lumbar Laminectomy ,"PREOPERATIVE DIAGNOSIS: , Lumbar stenosis.,POSTOPERATIVE DIAGNOSES:,  Lumbar stenosis and cerebrospinal fluid fistula.,TITLE OF THE OPERATION,1.  Lumbar laminectomy for decompression with foraminotomies L3-L4, L4-L5, L5-S1 microtechniques.,2.  Repair of CSF fistula, microtechniques L5-S1, application of DuraSeal.,INDICATIONS:,  The patient is an 82-year-old woman who has about a four-month history now of urinary incontinence and numbness in her legs and hands, and difficulty ambulating.  She was evaluated with an MRI scan, which showed a very high-grade stenosis in her lumbar spine, and subsequent evaluation included a myelogram, which demonstrated cervical stenosis at C4-C5, C5-C6, and C6-C7 as well as a complete block of the contrast at L4-L5 and no contrast at L5-S1 either and stenosis at L3-L4 and all the way up, but worse at L3-L4, L4-L5, and L5-S1.  Yesterday, she underwent an anterior cervical discectomy and fusions C4-C5, C5-C6, C6-C7 and had some improvement of her symptoms and increased strength, even in the recovery room.  She was kept in the ICU because of her age and the need to bring her back to the operating room today for decompressive lumbar laminectomy.  The rationale for putting the surgery is close together that she is normally on Coumadin for atrial fibrillation, though she has been cardioverted.  She and her son understand the nature, indications, and risks of the surgery, and agreed to go ahead.,PROCEDURE: , The patient was brought from the Neuro ICU to the operating room, where general endotracheal anesthesia was obtained.  She was rolled in a prone position on the Wilson frame.  The back was prepared in the usual manner with Betadine soak, followed by Betadine paint.  Markings were applied.  Sterile drapes were applied.  Using the usual anatomical landmarks, linear midline incision was made presumed over L4-L5 and L5-S1.  Sharp dissection was carried down into subcutaneous tissue, then Bovie electrocautery was used to isolate the spinous processes.  A Kocher clamp was placed in the anterior spinous ligament and this turned out to be L5-S1.  The incision was extended rostrally and deep Gelpi's were inserted to expose the spinous processes and lamina of L3, L4, L5, and S1.  Using the Leksell rongeur, the spinous processes of L4 and L5 were removed completely, and the caudal part of L3.  A high-speed drill was then used to thin the caudal lamina of L3, all of the lamina of L4 and of L5.  Then using various Kerrison punches, I proceeded to perform a laminectomy.  Removing the L5 lamina, there was a dural band attached to the ligamentum flavum and this caused about a 3-mm tear in the dura.  There was CSF leak.  The lamina removal was continued, ligamentum flavum was removed to expose all the dura.  Then using 4-0 Nurolon suture, a running-locking suture was used to close the approximate 3-mm long dural fistula.  There was no CSF leak with Valsalva.,I then continued the laminectomy removing all of the lamina of L5 and of L4, removing the ligamentum flavum between L3-L4, L4-L5 and L5-S1.  Foraminotomies were accomplished bilaterally.  The caudal aspect of the lamina of L3 also was removed.  The dura came up quite nicely.  I explored out along the L4, L5, and S1 nerve roots after completing the foraminotomies, the roots were quite free.  Further more, the thecal sac came up quite nicely.  In order to ensure no CSF leak, we would follow the patient out of the operating room.  The dural closure was covered with a small piece of fat.  This was all then covered with DuraSeal glue.  Gelfoam was placed on top of this, then the muscle was closed with interrupted 0 Ethibond.  The lumbodorsal fascia was closed with multiple sutures of interrupted 0 Ethibond in a watertight fashion.  Scarpa's fascia was closed with a running 0 Vicryl, and finally the skin was closed with a running-locking 3-0 nylon.  The wound was blocked with 0.5% plain Marcaine.,ESTIMATED BLOOD LOSS:  Estimated blood loss for the case was about 100 mL.,SPONGE AND NEEDLE COUNTS:  Correct.,FINDINGS:  A very tight high-grade stenosis at L3-L4, L4-L5, and L5-S1.  There were adhesions between the dura and the ligamentum flavum owing to the severity and length of the stenosis.,The patient tolerated the procedure well with stable vitals throughout.","orthopedic, microtechniques, fistula, duraseal, foraminotomies, lumbar, stenosis, cerebrospinal, lumbar laminectomy, ligamentum flavum, csf, laminectomy, lamina,"
" Lumbar puncture.  A 20-gauge spinal needle was then inserted into the L3-L4 space.  Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained. ", Orthopedic, Lumbar Puncture - 2 ,"PROCEDURE PERFORMED:,  Lumbar puncture.,The procedure, benefits, risks including possible risks of infection were explained to the patient and his father, who is signing the consent form.  Alternatives were explained.  They agreed to proceed with the lumbar puncture.  Permit was signed and is on the chart.  The indication was to rule out toxoplasmosis or any other CNS infection. ,DESCRIPTION: , The area was prepped and draped in a sterile fashion.  Lidocaine 1% of 5 mL was applied to the L3-L4 spinal space after the area had been prepped with Betadine three times.  A 20-gauge spinal needle was then inserted into the L3-L4 space.  Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained.  The spinal needle was then withdrawn and the area cleaned and dried and a Band-Aid applied to the clean, dry area.,COMPLICATIONS:,  None.  The patient was resting comfortably and tolerated the procedure well.,ESTIMATED BLOOD LOSS: , None.,DISPOSITION: , The patient was resting comfortably with nonlabored breathing and the incision was clean, dry, and intact.  Labs and cultures were sent for the usual in addition to some extra tests that had been ordered.,The opening pressure was 292, the closing pressure was 190.","orthopedic, spinal needle, lumbar puncture, lumbar, gauge, csf"
" Lumbar discogram L2-3, L3-4, L4-5, and L5-S1.  Low back pain.", Orthopedic, Lumbar Discogram ,"PREOPERATIVE DIAGNOSIS: , Low back pain.,POSTOPERATIVE DIAGNOSIS: , Low back pain.,PROCEDURE PERFORMED:,1.  Lumbar discogram L2-3.,2.  Lumbar discogram L3-4.,3.  Lumbar discogram L4-5.,4.  Lumbar discogram L5-S1.,ANESTHESIA:  ,IV sedation.,PROCEDURE IN DETAIL:  ,The patient was brought to the Radiology Suite and placed prone onto a radiolucent table.  The C-arm was brought into the operative field and AP, left right oblique and lateral fluoroscopic images of the L1-2 through L5-S1 levels were obtained.  We then proceeded to prepare the low back with a Betadine solution and draped sterile.  Using an oblique approach to the spine, the L5-S1 level was addressed using an oblique projection angled C-arm in order to allow for perpendicular penetration of the disc space.  A metallic marker was then placed laterally and a needle entrance point was determined.  A skin wheal was raised with 1% Xylocaine and an #18-gauge needle was advanced up to the level of the disc space using AP, oblique and lateral fluoroscopic projections.  A second needle, #22-gauge 6-inch needle was then introduced into the disc space and with AP and lateral fluoroscopic projections, was placed into the center of the nucleus.  We then proceeded to perform a similar placement of needles at the L4-5, L3-4 and L2-3 levels.,A solution of Isovue 300 with 1 gm of Ancef was then drawn into a 10 cc syringe and without informing the patient of our injecting, we then proceeded to inject the disc spaces sequentially.","orthopedic, back pain, c-arm, fluoroscopic projections, disc space, lumbar discogram, fluoroscopic, needle,"
" Lumbar muscle strain and chronic back pain.  Patient has a history of chronic back pain, dating back to an accident that he states he suffered two years ago.", Orthopedic, Lower back pain ,"HISTORY OF PRESENT ILLNESS:,  Patient is a 50-year-old white male complaining of continued lower back pain.  Patient has a history of chronic back pain, dating back to an accident that he states he suffered two years ago.  He states he helped a friend unload a motorcycle from a vehicle two-and-a-half days ago, after which he ""felt it"" in his lower back.  The following day (two days ago), he states he rode to Massachusetts and Maine to pick up clients.  He feels that this aggravated his chronic back pain as well.  He also claims to have a screw in his right hip from a previous surgery to repair a pelvic fracture.  He is being prescribed Ultram, Celebrex, gabapentin, and amitriptyline by his PCP for his chronic back pain.  He states that his PCP has informed him that he does not prescribe opiate medications for chronic back pain.,The patient did self-refer to another physician, who suggested that he follow up at a pain clinic for his chronic back pain to discuss other alternatives, particularly the medications that the patient feels that he needs.  Patient states he did not do this because he was feeling well at that time.,The patient did present to our emergency room last night, at which time he saw Dr. X.  He was given a prescription for 12 Vicodin as well as some to take home last night.  The patient has not picked up his prescription as of yet and informed the triage nurse that he was concerned that he would not have enough to last through the weekend.  Patient states he also has methadone and Darvocet at home from previous prescription and is wondering if he should restart these medicines.  He is on several medications, the list of which is attached to the chart.,MEDICATIONS: , In addition to the aforementioned medications, he is on Cymbalta, pantoprazole, and a multivitamin.,ALLERGIES:,  HE IS ALLERGIC TO RELAFEN (ITCHING).,SOCIAL HISTORY: , The patient is married and lives with his wife.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse is elevated at 105.  Temp and other vitals signs are all within normal limits.,GENERAL:  Patient is a middle-aged white male who is sitting on the stretcher in no acute distress.,BACK:  Exam of the back shows some generalized tenderness on palpation of the musculature surrounding the lumbar spine, more so on the right than on the left.  There is a well-healed upper lumbar incision from his previous L1-L2 fusion.  There is no erythema, ecchymosis, or soft-tissue swelling.  Mobility is generally very good without obvious signs of discomfort.,HEART:  Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS:  Clear without rales, rhonchi, or wheezes.,MUSCULOSKELETAL:  With the patient supine, there is some discomfort in the lower back with bent-knee flexion of both hips as well as with straight leg abduction of the left leg.  There is some mild discomfort on internal and external rotation of the hips as well.  DTRs are 1+ at the knees and trace at the ankles.,I explained to the patient that he is suffering from a chronic condition and as his PCP has made it clear that he is unwilling to prescribe opiate medication, which the patient feels that he needs, and he is obligated to follow up at the pain clinic as suggested by the other physician even if he is having a ""good day.""  I explained to him that if he did not investigate other alternatives to what his PCP is willing to prescribe, then on a ""bad day,"" he will have nowhere else to turn.  I explained to him that some emergency physicians do chose to use opiates for a short term as Dr. X did last night.  It is unclear if the patient is looking for a different opiate medication, but I do not think it is wise to give him more, particularly as he has not even filled the prescription that was given to him last night.  I did suggest that he not restart his methadone and Darvocet at this time as he is already on five different medications for his back (Celebrex, tramadol, amitriptyline, gabapentin, and the Vicodin that he was given last night).  I did suggest that we could try a different anti-inflammatory if he felt that the Celebrex is not helping.  The patient is agreeable to this.,ASSESSMENT,1.  Lumbar muscle strain.,2.  Chronic back pain.,PLAN: , At this point in time, I felt that it was safe for the patient to transition to heat to his back which he may use as often as possible.  Rx for Voltaren 75 mg tabs, dispensed 20, sig. one p.o. q.12h. for pain instead of Celebrex.  He may continue with his other medications as directed but not the methadone or Darvocet.  I did urge him to reschedule his pain clinic appointment as he was urged to do originally.  If unimproved this week, he should follow up with Dr. Y.","orthopedic, back pain, lumbar muscle strain, chronic back pain, illness, lower, medications, "
" Microscopic lumbar discectomy, left L5-S1.   Extruded herniated disc, left L5-S1.  Left S1 radiculopathy (acute). Morbid obesity.", Orthopedic, Lumbar Discectomy - Microscopic ,"PREOPERATIVE DIAGNOSES:,1.  Extruded herniated disc, left L5-S1.,2.  Left S1 radiculopathy (acute).,3.  Morbid obesity.,POSTOPERATIVE DIAGNOSES:,1.  Extruded herniated disc, left L5-S1.,2.  Left S1 radiculopathy (acute).,3.  Morbid obesity.,PROCEDURE PERFORMED: , Microscopic lumbar discectomy, left L5-S1.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:  ,50 cc.,HISTORY: , This is a 40-year-old female with severe intractable left leg pain from a large extruded herniated disc at L5-S1.  She has been dealing with these symptoms for greater than three months.  She comes to my office with severe pain, left my office and reported to the Emergency Room where she was admitted for pain control one day before surgery.  I have discussed the MRI findings with the patient and the potential risks and complications.  She was scheduled to go to surgery through my office, but because of her severe symptoms, she was unable to keep that appointment and reported right to the Emergency Room.  We discussed the diagnosis and the operative procedure in detail.  I have reviewed the potential risks and complications and she had agreed to proceed with the surgery.  Due to the patient's weight which exceeds 340 lb, there was some concern about her operative table being able to support her weight and also my standard microlumbar discectomy incision is not ________ in this situation just because of the enormous size of the patient's back and abdomen and I have discussed this with her.  She is aware that she will have a much larger incision than what is standard and has agreed to accept this.,OPERATIVE PROCEDURE:  ,The patient was taken to OR #5 at ABCD General Hospital.  While in the hospital gurney, Department of Anesthesia administered general anesthetic, endotracheal intubation was followed.  A Jackson table was prepared for the patient and was reinforced replacing struts under table to prevent the table from collapsing.  The table reportedly does have a limit of 500 lb, but the table has never been stressed above 275 lb.  Once the table was reinforced, the patient was carefully rolled in a prone position on the Jackson table with the bony prominences being well padded.  A marker was placed in from the back at this time and an x-ray was obtained for incision localization.  The back is now prepped and draped in the usual sterile fashion.  A midline incision was made over the L5-S1 disc space taking through subcutaneous tissue sharply with a #10 Bard-Parker scalpel.  The lumbar dorsal fascia was then encountered and incised to the left of midline.  In the subperiosteal fashion, the musculature was elevated off the lamina at L5 and S1 after facet joint, but not disturbing the capsule.  A second marker was now placed and an intraoperative x-ray confirms our location at the L5-S1 disc space.  The microscope was brought into the field at this point and the remainder of the procedure done with microscopic visualization and illumination.  A high speed drill was used to perform a laminotomy by removing small portion of the superior edge of the S1 lamina and the inferior edge of the L5 lamina.  Ligaments and fragments were encountered and removed at this time.  The epidural space was now encountered.  The S1 nerve root was now visualized and found to be displaced dorsally as a result of a large disc herniation while the nerve was carefully protected with a Penfield.  A small stab incision was made into the disc fragment and probably a large portion of disc extrudes from the opening.  This disc fragment was removed and the nerve root was much more supple, it was carefully retracted.  The nerve root was now retracted and using a series of downgoing curettes, additional disc material was removed from around the disc space and from behind the body of S1 and L5.  At this point, all disc fragments were removed from the epidural space.  Murphy ball was passed anterior to the thecal sac in the epidural space and there was no additional compression that I can identify.  The disc space was now encountered and loose disc fragments were removed from within the disc space.  The disc space was then irrigated.  The nerve root was then reassessed and found to be quite supple.  At this point, the Murphy ball was passed into the foramen of L5 and this was patent and also into the foramen of S1 by passing ventral and dorsal to the nerve root and there were no obstructions in the passage of the device.  At this point, the wound was irrigated copiously and suctioned dry.  Gelfoam was used to cover the epidural space.  The retractors were removed at this point.  The fascia was reapproximated with #1 Vicryl suture, subcutaneous tissue with #2-0 Vicryl suture and Steri-Strips for curved incision.  The patient was transferred to the hospital gurney in supine position and extubated by Anesthesia, subsequently transferred to Postanesthesia Care Unit in stable condition.","orthopedic, extruded herniated disc, radiculopathy, microscopic, lumbar, discectomy, lumbar discectomy, morbid obesity, herniated disc, epidural space, nerve root, disc space, space, intractable, lamina, epidural, incision, nerve, herniated,"
" New patient consultation - Low back pain, degenerative disc disease, spinal stenosis, diabetes, and history of prostate cancer status post radiation.", Orthopedic, Low Back Pain - Consult ,"FAMILY HISTORY: , His parents are deceased.  He has two brothers ages 68 and 77 years old, who are healthy.  He has siblings, a brother and a sister who were twins who died at birth.  He has two sons 54 and 57 years old who are healthy.  He describes history of diabetes and heart attack in his family.,SOCIAL HISTORY:  ,He is married and has support at home.  He denies tobacco and illicit drug use and drinks two to three alcoholic beverages a day and up to four to nine per week.,ALLERGIES:,  Garamycin.,MEDICATIONS: , Insulin 20 to 25 units twice a day.  Lorazepam 0.05 mg, he has a history of using this medication, but most recently stopped taking it.  Glipizide 5 mg with each meal, Advair 250 as needed, aspirin q.h.s., cod liver oil b.i.d., Centrum AZ q.d.,PAST MEDICAL HISTORY:  ,The patient has been diabetic for 35 years, has been insulin-dependent for the last 20 years.  He also has a history of prostate cancer, which was treated by radiation.  He says his PSA is at 0.01.,PAST SURGICAL HISTORY:,  In 1985, he had removal of a testicle due to enlarged testicle, he is not quite sure of the cause but he states it was not cancer.,REVIEW OF SYSTEMS: , Musculoskeletal:  He is right-handed.  Respiratory:  For shortness of breath.  Urinary:  For frequent urination.  GI:  He denies any bowel or bladder dysfunction.  Genital:  He denies any loss of sensation or erectile problems.  HEENT:  Negative and noncontributory.  Hem-Onc:  Negative and noncontributory.  Cardiac:  Negative and noncontributory.  Vascular:  Negative and noncontributory.  Psychiatric:  Negative and noncontributory.,PHYSICAL EXAMINATION: , He is 5 feet 10 inches tall.  Current weight is 204 pounds, weight one year ago was 212.  BP is 130/66.  Pulse is 78.  On physical exam, the patient is alert and oriented with normal mentation and appropriate speech, in no acute distress.  HEENT exam, head is atraumatic and normocephalic.  Eyes, sclerae are anicteric.  Teeth, poor dentition.  Cranial nerves II, III, IV, and VI, vision intact, visual fields full to confrontation, EOMs full bilaterally, and pupils are equal, round, and reactive to light.  Cranial nerves V and VII, normal facial sensation and symmetrical facial movements.  Cranial nerve VIII, hearing is intact.  Cranial nerves IX, X, and XII, tongue protrudes midline and palate elevates symmetrically.  Cardiac, regular rate, a holosystolic murmur is also noted which is about grade 1 to 2.  Chest and lungs are clear bilaterally.  Skin is warm and dry, normal turgor and texture.  No rashes or lesions are noted.  Peripheral vascular, no cyanosis, clubbing, or edema is noted.  General musculoskeletal exam reveals no gross deformities, fasciculations, or atrophy.  Station and gait are appropriate.  He ambulates well without any difficulties or assistance.  No antalgic or spastic gait is noted.  Examination of the low back reveals no paralumbar spasms.  He is nontender to palpation over his spinous process, SI joints, or paralumbar musculature.  Deep tendon reflexes are 2+ bilaterally at the knees and 1+ at the ankles.  No ankle clonus is elicited.  Babinski, toes are downgoing.  Sensation is intact.,He does have some decreased sensation to pinprick, dull versus sharp over the right lower extremity compared to that of the left.  Strength is 5/5 and equal bilateral lower extremities.  He is able to ambulate on his toes and his heels without any weakness noted.  He has negative straight leg raising bilaterally.,FINDINGS:,  The patient brings in lumbar spine MRI for 11/15/2007, which demonstrates degenerative disc disease throughout.  At L4-L5 and L5-S1 he has severe disc space narrowing.  At L3-L4, he has degenerative changes of the facet with ligamentum flavum hypertrophy and annular disc bulge, which caused moderate neuroforaminal narrowing.  At L4-L5, degenerative changes within the facets with ligamentum flavum hypertrophy as well causing neuroforaminal narrowing and central stenosis.  At L5-S1, there is an annular disc bulge more to the right causing right-sided neuroforaminal stenosis, which is quite severe compared to that on the left.,ASSESSMENT: , Low back pain, degenerative disc disease, spinal stenosis, diabetes, and history of prostate cancer status post radiation.,PLAN: , We discussed treatment options with this patient including:,1.  Do nothing.,2.  Conservative therapies.,3.  Surgery.,The patient states that his pain is very well tolerated by minimizing his activity and would like to do just pain management with some pain pills only as needed.  We went ahead and obtained an EKG in the office today due to the fact that I heard a murmur on exam.  I did phone the patient's primary care doctor, Dr. O.  Unfortunately Dr. O is out of the country, and I did speak with Dr. K, who is covering for Dr. O.  I informed Dr. K that the patient had a new-onset murmur and that I did have some concerns for the patient does not recollect having this diagnosis before, so I obtained an EKG.  A copy was provided to the patient and the patient was referred back to his primary care physician for workup.  He was also released from our care at this time to a p.r.n. basis, but the patient does not wish to proceed with any neurosurgical intervention nor any conservative measures besides medications, which he will receive from his primary doctor.,All questions and concerns were addressed.  If he should have any further questions, concerns, or complications, he will contact our office immediately.  Otherwise, we will see him p.r.n.  Warning signs and symptoms were gone over with him.  Case was reviewed and discussed with Dr. L.","orthopedic, back pain, ligamentum flavum hypertrophy, annular disc bulge, degenerative disc disease, spinal stenosis, cranial nerves, degenerative, "
" Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left.  Herniated nucleus pulposus of L5-S1 on the left.
  ", Orthopedic, Lumbar Laminotomy & Discectomy ,"PREOPERATIVE DIAGNOSIS:,  Herniated nucleus pulposus of L5-S1 on the left.,POSTOPERATIVE DIAGNOSIS: ,Herniated nucleus pulposus of L5-S1 on the left.,PROCEDURE PERFORMED:, Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left.,ANESTHESIA: , General via endotracheal tube.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,SPECIMENS: , Disc that was not sent to the lab.,DRAINS: , None.,COMPLICATIONS: , None.,SURGICAL PROGNOSIS: , Remains guarded due to her ongoing pain condition and Tarlov cyst at the L5 nerve root distally.,SURGICAL INDICATIONS: , The patient is a 51-year-old female who has had unrelenting low back pain that radiated down her left leg for the past several months.  The symptoms were unrelieved by conservative modalities.  The symptoms were interfering with all aspects of daily living and inability to perform any significant work endeavors.  She is understanding the risks, benefits, potential complications, as well as all treatment alternatives.  She wished to proceed with the aforementioned surgery due to her persistent symptoms.  Informed consent was obtained.,OPERATIVE TECHNIQUE: , The patient was taken to OR room #5 where she was given general anesthetic by the Department of Anesthesia.  She was subsequently placed on the Jackson spinal table with the Wilson attachment in the prone position.  Palpation did reveal the iliac crest and suspected L5-S1 interspace.  Thereafter the lumbar spine was serially prepped and draped.  A midline incision was carried over the spinal process of L5 to S1.  Skin and subcutaneous tissue were divided sharply.  Electrocautery provided hemostasis.  Electrocautery was then utilized to dissect through the subcutaneous tissues to the lumbar fascia.  Lumbar fascia was identified and the decussation of fibers was identified at the L5-S1 interspace.  On the left side, superior aspect dissection was carried out with the Cobb elevator and electrocautery.  This revealed the interspace of suspect level of L5-S1 on the left.  A Kocher clamp was placed between the spinous processes of the suspect level of L5-S1.  X-ray did confirm the L5-S1 interval.  Angled curet was utilized to detach the ligamentum flavum from its bony attachments at the superior edge of S1 lamina and the inferior edge of the L5 lamina.  Meticulous dissection was undertaken and the ligamentum flavum was removed.  Laminotomy was created with Kerrison rongeur, both proximally and distally.  The microscope was positioned and the dura was inspected.  A blunt Penfield elevator was then utilized to dissect and identify the L5-S1 nerve root on the left.  It was noted to be tented over a disc extrusion.  The nerve root was protected and medialized.  It was retracted with a nerve root retractor.  This did reveal a subligamentous disc herniation at approximately the L5-S1 disc space and neuroforaminal area.  A #15 Bard-Parker blade was utilized to create an annulotomy.  Medially, disc material was extruding through this annulotomy.  Two tier rongeur was then utilized to grasp the disc material and the disc was removed from the interspace.  Additional disc material was then removed, both to the right and left of the annulotomy.  Up and downbiting pituitary rongeurs were utilized to remove any other loose disc pieces.  Once this was completed, the wound was copiously irrigated with antibiotic solution and suctioned dry.  The Penfield elevator was placed in the disc space of L5-S1 and a crosstable x-ray did confirm this level.  Nerve root was again expected exhibiting the foramina.  A foraminotomy was created with a Kerrison rongeur.  Once this was created, the nerve root was again inspected and deemed free of tension.  It was mobile within the neural foramina.  The wound was again copiously irrigated with antibiotic solution and suctioned dry.  A free fat graft was then harvested from the subcutaneous tissues and placed over the exposed dura.  Lumbar fascia was then approximated with #1 Vicryl interrupted fashion, subcutaneous tissue with #2-0 Vicryl interrupted fashion, and #4-0 undyed Vicryl was utilized to approximate the skin.  Compression dressing was applied.  The patient was turned, awoken, and noted to be moving all four extremities without apparent deficits.  She was taken to the recovery room in apparent satisfactory condition.  Expected surgical prognosis remains guarded due to her ongoing pain syndrome that has been requiring significant narcotic medications.","orthopedic, lumbar laminotomy with discectomy, microscopic assisted, herniated nucleus pulposus, subcutaneous tissue, ligamentum flavum, kerrison rongeur, penfield elevator, lumbar laminotomy, lumbar fascia, nerve root, discectomy, lumbar, laminotomy, herniated,"
 Evaluation for right L4 selective nerve root block., Orthopedic, Lower Extremity Pain ,"REASON FOR REFERRAL:,  Evaluation for right L4 selective nerve root block.,CHIEF COMPLAINT:,",
 Ligament reconstruction and tendon interposition arthroplasty of right wrist., Orthopedic, Ligament Reconstruction & Tendon Interposition Arthroplasty ,"OPERATION PERFORMED:,  Ligament reconstruction and tendon interposition arthroplasty of right wrist.,DESCRIPTION OF PROCEDURE: , With the patient under adequate anesthesia, the right upper extremity was prepped and draped in a sterile manner.,Attention was turned to the base of the thumb where a longitudinal incision was made over the anatomic snuffbox and extended out onto the carpometacarpal joint.  Using blunt dissection radial sensory nerve was dissected and retracted out of the operative field.  Further blunt dissection exposed the radial artery, which was dissected and retracted off the trapezium.  An incision was then made across the scaphotrapezial joint distally onto the trapezium and out onto the carpometacarpal joint.  Sharp dissection exposed the trapezium, which was then morselized and removed in toto with care taken to protect the underlying flexor carpi radialis tendon.  The radial beak of the trapezoid was then osteotomized off the head of the scaphoid.  The proximal metacarpal was then fenestrated with a 4.5-mm drill bit.  Four fingers proximal to the flexion crease of the wrist a small incision was made over the FCR tendon and blunt dissection delivered the FCR tendon into this incision.  The FCR tendon was divided and this incision was closed with 4-0 nylon sutures.  Attention was returned to the trapezial wound where longitudinal traction on the FCR tendon delivered the FCR tendon into the wound.,The FCR tendon was then threaded through the fenestration in the metacarpal.  A bone anchor was then placed distal to the metacarpal fenestration.  The FCR tendon was then pulled distally and the metacarpal reduced to an anatomic position.  The FCR tendon was then sutured to the metacarpal using the previously placed bone anchor.  Remaining FCR tendon was then anchovied and placed into the scaphotrapezoidal and trapezial defect.  The MP joint was brought into extension and the capsule closed using interrupted 3-0 Tycron sutures.,Attention was turned to the MCP joint where the MP joint was brought in to 15 degrees of flexion and pinned with a single 0.035 Kirschner wire.  The pin was cut at the level of the skin.,All incisions were closed with running 3-0 Prolene subcuticular stitch.,Sterile dressings were then applied.  The tourniquet was deflated.  The patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well.","orthopedic, arthroplasty, ligament, tendon, fcr, tendon interposition arthroplasty, ligament reconstruction, reconstruction, trapezium, metacarpal, joint, interposition,"
 Closed reduction and placement of long-arm cast., Orthopedic, Long-Arm Cast ,"PREOPERATIVE DIAGNOSIS:,  Left distal radius fracture displaced.,POSTOPERATIVE DIAGNOSIS: , Left distal radius fracture displaced.,SURGERY:  ,Closed reduction and placement of long-arm cast, CPT code 25605.,ANESTHESIA:  ,General LMA.,FINDINGS:  ,The patient was found to have a displaced fracture.  She was found to be in perfect alignment after closed reduction and placement of cast.  The radial deviation was well corrected.,INDICATIONS: , The patient is 5 years old.  She was seen in our office today 1 week after being placed into a cast for a displaced fracture.  She was noted to have significant loss of alignment especially on the lateral view.  She was indicated for closed reduction and placed of the long-arm cast.  Risks and benefits were discussed at length with the family.  They wished to proceed.,PROCEDURE:  ,The patient was brought to the operating room and placed on the operating table in supine position.  General anesthesia was induced without incident.  Previous cast was previously removed.  An arm was approached and a closed reduction was performed.  This was checked under AP and lateral projection and was found to be in adequate alignment.  There was very mild residual dorsiflexion deformity noted.,A long-arm cast was then placed with plaster and molding.  Repeat x-rays demonstrated adequate alignment on both views.,The cast was then reinforced with fiberglass.  The patient was awakened from anesthesia and taken to recovery room in good condition.  There were no complications.  All instruments, sponge, and needle counts were correct at the end of case.,PLAN:  ,The patient will be discharged home.  She will return in 3 weeks for cast removal and clinical examination.  She would likely be placed into a wrist-guard at that time.  She has a prescription for Tylenol with codeine elixir.,","orthopedic, long-arm cast, closed reduction, displaced fracture, radial deviation, distal radius fracture, arm cast"
" Diagnostic operative arthroscopy with repair and reconstruction of anterior cruciate ligament using autologous hamstring tendon, a 40 mm bioabsorbable femoral pin, and a 9 mm bioabsorbable tibial pin.  Repair of lateral meniscus using two fast fixed meniscal repair sutures.  Partial medial meniscectomy.  Partial chondroplasty of patella.  Lateral retinacular release.  Open medial plication as well of the right knee.", Orthopedic, Ligament Reconstruction & Meniscus Repair ,"PREOPERATIVE DIAGNOSES:,1.  Torn anterior cruciate ligament, right knee.,2.  Patellofemoral instability, right knee.,3.  Possible torn medial meniscus.,POSTOPERATIVE DIAGNOSES:,1.  Complete tear anterior cruciate ligament, right knee.,2.  Complex tear of the posterior horn lateral meniscus.,3.  Tear of posterior horn medial meniscus.,4.  Patellofemoral instability.,5.  Chondromalacia patella.,PROCEDURES PERFORMED:,1.  Diagnostic operative arthroscopy with repair and reconstruction of anterior cruciate ligament using autologous hamstring tendon, a 40 mm bioabsorbable femoral pin, and a 9 mm bioabsorbable tibial pin.,2.  Repair of lateral meniscus using two fast fixed meniscal repair sutures.,3.  Partial medial meniscectomy.,4.  Partial chondroplasty of patella.,5.  Lateral retinacular release.,6.  Open medial plication as well of the right knee.,ANESTHESIA:,  General.,COMPLICATIONS:,  None.,TOURNIQUET TIME:,  130 minutes at 325 mmHg.,INTRAOPERATIVE FINDINGS: , There was noted to be a grade-II chondromalacia patellofemoral joint.  The patella was noted to be situated laterally past the lateral femoral condyle.  There was a tear to the posterior horn of the medial meniscus within the white zone.  There was a complex tear involving a horizontal cleavage component to the posterior horn of the lateral meniscus as well in the entire meniscus.  There was a complete tear of the anterior cruciate ligament.  The posterior cruciate ligament appeared intact.  Preoperatively, she had a positive Lachman with a positive pivot shift test as well as increased patellofemoral instability.,HISTORY: , This is a 39-year-old female who has sustained a twisting injury to her knee while on trampoline in late August.  She was diagnosed per MRI.  An MRI confirmed the clinical diagnosis of anterior cruciate ligament tear.  She states she has had multiple episodes of instability to the patellofemoral joint throughout the years with multiple dislocations.  She elected to proceed with surgery to repair the anterior cruciate ligament as well as possibly plicate the medial retinaculum to help prevent further dislocations of the patellofemoral joint.  All risks and benefits of surgery were discussed with her at length.  She was in agreement with the treatment plan.,PROCEDURE:  ,On 09/11/03, she was taken to the operating room at ABCD General Hospital.  She was placed supine on the operating table.  General anesthetic was applied by the Anesthesiology Department.  Tourniquet was placed on the proximal thigh and it was then placed in a knee holder.  She was sterilely prepped and draped in the usual fashion.  An Esmarch was used to exsanguinate the lower extremity.  Tourniquet was inflated to 325 mmHg.  Longitudinal incision was made just medial to the tibial tubercle.  The subcutaneous tissue was carefully dissected.  Hemostasis was controlled with electrocautery.  The tendons of gracilis and semitendinosus were identified and isolated, and then stripped off the musculotendinous junction.  They were taken on the back table.  The soft tissue debris was removed from the tendons.  The ends of the tendons were sewn together using #5 Tycron whip type sutures.  The tendons were measured on back table and found to be 8 mm as the most adequate size, they were then placed under tension on the back table.  Stab incision was made in the inferolateral parapatellar region, through this camera was placed in the knee.  The knee was inflated with saline solution and operative pictures were obtained.  The above findings were noted.  A second port site was initiated in the inferomedial parapatellar region.  Through this, a probe was placed.  Tear in the posterior horn medial meniscus was identified.  It was resected using a meniscal resector.  It was then further contoured using arthroscopic shaver.  Attention was then taken to the lateral compartment.  A partial meniscectomy was performed using the resector and the shaver.  The posterior periphery of the lateral meniscus was also noticed to be unstable.  A repair was then performed using two fasting fixed meniscal repair sutures to help anchor the meniscus around the popliteus tendon.  There was noted to be excellent fixation.  The shaver was then taken into the intrachondral notch.  First a partial chondroplasty was performed on the patella to remove the loose articular debris as well as a partial synovectomy to the medial aspect of the patellar femoral joint.  Next, the remnant of the anterior cruciate ligament was removed using the arthroscopic shaver and arthroplasty was then performed on the medial aspect of the lateral femoral condyle.  Next, a tibial guide was placed through the anterior medial portal.  A ___ pin was then placed up through the anterior incision entering the tibial eminence just anterior to the posterior cruciate ligament.  This tibial tunnel was then drilled using 8 mm cannulated drill.  Next, an over-the-top guide was then placed at approximately the 11:30 position.  A ____ pin was then placed into the femur and 8 mm drill was then used to drill this femoral tunnel approximately 35 mm.  Next the U shape guide was placed through tibial tunnel into the femur.  A pin was then placed through the distal femur from lateral to medial, through the U-shaped guide a puller wire was then passed through the distal femur.  It was then pulled out through the tibial tunnel using the You-shaped guide.  The tendon was then placed around the wire.  The wire was pulled back up through the tibial into the femoral tunnel.  A 40 mm bioabsorbable pin was then placed through the femoral tunnel securing the hamstring tendons.  Attention was then pulled through the tibial tunnel.  The knee was cycled approximately 20 times.  A 9 mm bioabsorbable screw was then placed through the tibial tunnel fixating the distal aspect of the graft.  There was noted definite fixation of the graft.  There was no evidence of impingement either in full flexion or full extension.  The knee was copiously irrigated and it was then suctioned dry.  A longitudinal incision was made just medial to the patellofemoral joint.  Soft tissues were carefully dissected and the medial retinaculum was incised along with the incision.  Following this, a release of lateral retinaculum was performed using a knife to further release the patellofemoral joint and allow further medial plication.  The medial retinaculum was then plicated using #1 Ethibond sutures and then oversewn with #0 Vicryl suture.  The subcuticular tissues were reapproximated with #2-0 Vicryl simple interrupted sutures followed by a #4-0 PDS running subcuticular stitch.  She was placed in a DonJoy knee immobilizer.  The tourniquet was deflated.  It was noted the lower extremity was warm and pink with good capillary refill.  She was transferred to the recovery room in apparent stable and satisfactory condition.  Prognosis for this patient is guarded.  She will be full weightbearing on the lower extremity using the knee immobilizer locked in extension.  She may remove her dressing two to three days, however, follow back in the office in 10 to 14 days for suture removal.  She will require one to two more physical therapy to help regain motion and strength to the lower extremity.", 
 Lateral release with lengthening of the ECRB tendon.  Lateral epicondylitis.   , Orthopedic, Lateral Epicondylitis Release ,"PREOPERATIVE DIAGNOSIS:  ,Lateral epicondylitis.","orthopedic, lateral release, ecrb tendon, ecrl, lateral epicondylitis, tourniquet, aponeurosis, epicondyle, antebrachial, epicondylitis, dissection, extensor, ecrb "
" Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots.  Right L4-L5 and right L5-S1 laminotomies, medial facetectomies, and foraminotomies, decompression of right L5 and S1 nerve roots.  Right L4-S1 posterolateral fusion with local bone graft.  Left L4 through S1 segmental pedicle screw instrumentation.  Preparation harvesting of local bone graft.", Orthopedic," Laminotomy, Facetectomy & Foraminotomy ","PREOPERATIVE DIAGNOSES: , Right lumbosacral radiculopathy secondary to lumbar spondylolysis.,POSTOPERATIVE DIAGNOSES: , Right lumbosacral radiculopathy secondary to lumbar spondylolysis.,OPERATION PERFORMED:,1.  Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots.,2.  Right L4-L5 and right L5-S1 laminotomies, medial facetectomies, and foraminotomies, decompression of right L5 and S1 nerve roots.,3.  Right L4-S1 posterolateral fusion with local bone graft.,4.  Left L4 through S1 segmental pedicle screw instrumentation.,5.  Preparation harvesting of local bone graft.,ANESTHESIA: , General endotracheal.,PREPARATION:,  Povidone-iodine.,INDICATION: , This is a gentleman with right-sided lumbosacral radiculopathy, MRI disclosed and lateral recess stenosis at the L4-5, L5-S1 foraminal narrowing in L4 and L5 roots.  The patient was felt to be a candidate for decompression stabilization pulling distraction between the screws to relieve radicular pain.  The patient understood major risks and complications such as death and paralysis seemingly rare, main concern is a 10 to 15% of failure rate to respond to surgery for which further surgery may or may not be indicated, small risk of wound infection, spinal fluid leak.  The patient is understanding and agreed to proceed and signed the consent.,PROCEDURE: , The patient was brought to the operating room, peripheral venous lines were placed.  General anesthesia was induced.  The patient was intubated.  Foley catheter was in place.  The patient laid prone onto the OSI table using 6-post, pressure points were carefully padded; the back was shaved, sterilely prepped and draped.  A previous incision was infiltrated with local and incised with a scalpel.  The posterior spine on the right side was exposed in routine fashion along with transverse processes in L4-L5 in the sacral ala.  Laminotomies were then performed at L4-L5 and L5-S1 in a similar fashion using Midas Rex drill with AM8 bit, inferior portion of lamina below and superior portion of lamina above, and the medial facet was drilled down to the thin shelf of bone.  The thin shelf of bone along the ligamentum flavum moved in a piecemeal fashion with 2 and 3 mm Kerrison, bone was harvested throughout to be used for bone grafting.  The L5 and S1 roots were completely unroofed in the lateral recess working lateral to the markedly hypertrophied facet joints.  Transpedicular approaches were carried out for both L4 and L5 roots working lateral to medial and medial to lateral with foraminotomies, L4-L5 roots were extensively decompressed.  Pars interarticularis were maintained.  Using angled 2-mm Kerrisons hypertrophied ligamentum flavum, the superior facet of S1 and L5 was resected increasing the dimensions for the foramen passed lateral to medial and medial to lateral without further compromise.  Pedicle screws were placed L4-L5 and S1 on the right side.  Initial hole began with Midas Rex drill, deepened with a gear shift and with 4.5 mm tap, palpating with pedicle probe.  It showed no penetration outside the pedicle vertebral body.  At L4-L5 5.5 x 45 mm screws were placed and at S1 5.5 x 40 mm screw was placed.  Good bone purchase was obtained.  Gelfoam was placed over the roots laterally, corticated transverse processes lateral facet joints were prepared, small infuse sponge was placed posterolaterally on the right side, then the local bone graft from L4 to S1.  Traction was applied between the L4-L5, L5-S1 screws locking notes were tightened out, heads were rotated fractured off about 2-3 mm traction were applied at each side, further opening the foramen for the exiting roots.  Prior to placement of BMP, the wound was irrigated with antibiotic irrigation.  Medium Hemovac drain was placed in the depth of wound, brought out through a separate stab incision.  Deep fascia was closed with #1 Vicryl, subcutaneous fascia with #1 Vicryl, and subcuticular with 2-0 Vicryl.  Skin was stapled.  The drain was sutured in place with 2-0 Vicryl and connected to closed drain system.  The patient was laid supine on the bed, extubated, and taken to recovery room in satisfactory condition.  The patient tolerated the procedure well without apparent complication.  Final sponge and needle counts are correct.  Estimated blood loss 600 mL.,The patient received 200 mL of cell saver blood back.","orthopedic, lumbosacral radiculopathy, lumbar spondylolysis, laminotomies, medial facetectomies, foraminotomies, decompression, nerve roots, fusion, bone graft, segmental, pedicle screw, transverse processes, bone, facetectomies, transpedicular, graft, pedicle"
 History of right leg pain.  Leg pain is no longer present., Orthopedic, Leg Pain - Progress Note ,"HISTORY OF PRESENT ILLNESS: , The patient is a 44-year-old man who was seen for complaints of low back and right thigh pain.  He attributes this to an incident in which he was injured in 1994.  I do not have any paperwork authenticating his claim that there is an open claim.  Most recently he was working at Taco Bell, when he had a recurrence of back pain, and he was seen in our clinic on 04/12/05.  He rated pain of approximately 8/10 in severity., ,He took a Medrol Dosepak and states that his pain level has decreased to approximately 4-5/10.  He still localizes it to a band between L4 and the sacrum.  He initially had some right leg pain but states that this is minimal and intermittent at the present time.  His back history is significant for two laminectomies and a discectomy performed from 1990 to 1994.  The area of concern was L4-L5., ,The patient's MRI dated 10/18/04 showed multi-level degenerative changes, with facet involvement at L2-L3, L3-L4 and L5-S1.  There was no neural impingement.  He also had an MR myelogram, which showed severe stenosis at L3-L4, however it was qualified in that it may have been artifact, rather than a genuine finding., ,REVIEW OF SYSTEMS:,  Focal lower paralumbar pain, affecting both right and left sides, as well as intermittent right leg pain which appears to have improved significantly with the Medrol Dosepak.  He denies any recent illness.  He has no constitutional complaints such as fevers, chills or sweats.  HEENT: The patient denies any cephalgia, ocular, nasopharyngeal symptoms.  He has no dysphagia.  Cardiovascular: He denies any palpitations, chest pain, syncope or near-syncope.  Pulmonary: He denies any dyspnea or respiratory difficulties.  GI: The patient has no abdominal pain, nausea or vomiting.  GU: The patient denies any urinary frequency or dysuria. There is no gross hematuria.  Dermatologic: The patient notes no new onset of rash or other dermatological abnormalities.  Musculoskeletal: Denies any recent falls or near-falls.  He denies any abnormalities of endocrine, immunologic, hematologic, organ systems.  , ,MEDICATIONS: , Atenolol, Zestril, Vicodin., ,ALLERGIES:,  None., ,SOCIOECONOMIC STATUS:,  Lifting limitations of 5 pounds and limited stooping, bending and twisting., ,PHYSICAL EXAMINATION: , Vital signs:  Blood pressure 158/86, respiration 14, pulse 60, temperature 100.2.  He is sitting upright, alert and oriented and in no acute distress.  Skin is warm and dry.  Gross neurologic examination is normal.  ENT examination reveals normal oropharynx, nasopharynx, and tympanic membranes.  Neck: Full range of motion with no adenopathy or thyromegaly.  Cardiovascular: Regular rate and rhythm.  Lungs: Clear.  , ,On examination of the lumbar spine, he is minimally tender to palpation.  There is no overt muscular spasm.  His range of motion is estimated at 40 degrees of flexion and 15 degrees of extension.  Straight leg raises do not elicit any leg complaints on today's visit.  Lower extremity reflexes are symmetric., ,DIAGNOSIS: , Low back pain with a history of right leg pain.  The leg pain is no longer present.  His pain level has improved., ,PLAN:  ,1.  The patient will take another Medrol Dosepak.,2.  He can continue with physical therapy.,3.  He also continues with the same lifting restrictions.,4.  Follow up is within one week.",
" Complete laminectomy, L4. and facetectomy, L3-L4 level.  A dural repair, right sided, on the lateral sheath, subarticular recess at the L4 pedicle level.  Posterior spinal instrumentation, L4 to S1, using Synthes Pangea System.  Posterior spinal fusion, L4 to S1.  Insertion of morselized autograft, L4 to S1.  ", Orthopedic, Laminectomy & Facetectomy ,"PREOPERATIVE DIAGNOSIS:,  Dural tear, postoperative laminectomy, L4-L5.,POSTOPERATIVE DIAGNOSES,1.  Dural tear, postoperative laminectomy, L4-L5.,2.  Laterolisthesis, L4-L5.,3.  Spinal instability, L4-L5.,OPERATIONS PERFORMED,1.  Complete laminectomy, L4.,2.  Complete laminectomy plus facetectomy, L3-L4 level.,3.  A dural repair, right sided, on the lateral sheath, subarticular recess at the L4 pedicle level.,4.  Posterior spinal instrumentation, L4 to S1, using Synthes Pangea System.,5.  Posterior spinal fusion, L4 to S1.,6.  Insertion of morselized autograft, L4 to S1.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , 500 mL.,COMPLICATIONS: , None.,DRAINS:  ,Hemovac x1.,DISPOSITION: , Vital signs stable, taken to the recovery room in a satisfactory condition, extubated.,INDICATIONS FOR OPERATION: , The patient is a 48-year-old gentleman who has had a prior decompression several weeks ago.  He presented several days later with headaches as well as a draining wound.  He was subsequently taken back for a dural repair.  For the last 10 to 11 days, he has been okay except for the last two days he has had increasing headaches, has nausea, vomiting, as well as positional migraines.  He has fullness in the back of his wound.  The patient's risks and benefits have been conferred him due to the fact that he does have persistent spinal leak.  The patient was taken to the operating room for exploration of his wound with dural repair with possible stabilization pending what we find intraoperatively.,PROCEDURE IN DETAIL:,  After appropriate consent was obtained from the patient, the patient was wheeled back to the operating theater room #7.  The patient was placed in the usual supine position and intubated under general anesthesia without any difficulties.  The patient was given intraoperative antibiotics.  The patient was rolled onto the OSI table in usual prone position and prepped and draped in usual sterile fashion.,Initially, a midline incision was made from the cephalad to caudad level.  Full-thickness skin flaps were developed.  It was seen immediately that there was large amount of copious fluid emanating from the wound, clear-like fluid, which was the cerebrospinal fluid.  Cultures were taken, aerobic, anaerobic, AFB, fungal.  Once this was done, the paraspinal muscles were affected from the posterior elements.  It was seen that there were no facet complexes on the right side at L4-L5 and L5-S1.  It was seen that the spine was listhesed at L5 and that the dural sac was pinched at the L4-5 level from the listhesis.  Once this was done; however, the fluid emanating from the dura could not be seen appropriately.  Complete laminectomy at L4 was performed as well extending the L5 laminectomy more to the left.  Complete laminectomy at L3 was done.  Once this was done within the subarticular recess on the right side at the L4 pedicle level, a rent in the dura was seen.  Once this was appropriately cleaned, the dural edges were approximated using a running 6-0 Prolene suture.  A Valsalva confirmed no significant lead after the repair was made.  There was a significant laterolisthesis at L4-L5 and due to the fact that there were no facet complexes at L5-S1 and L4-L5 on the right side as well as there was a significant concavity on the right L4-L5 disk space which was demonstrated from intraoperative x-rays and compared to preoperative x-rays, it was decided from an instrumentation.  The lateral pedicle screws were placed at L4, L5, and S1 using the standard technique of Magerl.  After this the standard starting point was made.  Trajectory was completed with gearshift and sounded in all four quadrants to make sure there was no violation of the pedicle wall.  Once this was done, this was undertapped at 1 mm and resounded in all four quadrants to make sure that there was no violation of the pedicle wall.  The screws were subsequently placed.  Tricortical purchase was obtained at S1 ________ appropriate size screws.  Precontoured titanium rod was then appropriately planned and placed between the screws at L4, L5, and S1.  This was done on the right side first.  The screw was torqued at S1 appropriately and subsequently at L5.  Minimal compression was then placed between L5 and L4 to correct the concavity as well as laterolisthesis and the screw appropriately torqued at L4.  Neutral compression distraction was obtained on the left side.  Screws were torqued at L4, L5, and S1 appropriately.  Good placement was seen both in AP and lateral planes using fluoroscopy.  Laterolisthesis corrected appropriately at L4 and L5.,Posterior spinal fusion was completed by decorticating the posterior elements at L4-L5 and the sacral ala with a curette.  Once good bleeding subchondral bone was appreciated, the morselized bone from the laminectomy was morselized with corticocancellous bone chips together with demineralized bone matrix.  This was placed in the posterior lateral gutters.  DuraGen was then placed over the dural repair, and after this, fibrin glue was placed appropriately.  Deep retractors then removed from the confines of the wound.  Fascia was closed using interrupted Prolene running suture #1.  Once this was done, suprafascial drain was placed appropriately.  Subcutaneous tissues were opposed using a 2-0 Prolene suture.  The dermal edges were approximated using staples.  Wound was dressed sterilely using bacitracin ointment, Xeroform, 4 x 4's, and tape.  The drain was connected appropriately.  The patient was rolled on stretcher in usual supine position, extubated uneventfully, and taken back to the recovery room in a satisfactory stable condition.  No complications arose.", 
" Followup status post L4-L5 laminectomy and bilateral foraminotomies, and L4-L5 posterior spinal fusion with instrumentation.", Orthopedic, Laminectomy & Foraminotomy Followup ,"REASON FOR VISIT:,  Followup status post L4-L5 laminectomy and bilateral foraminotomies, and L4-L5 posterior spinal fusion with instrumentation.,HISTORY OF PRESENT ILLNESS:,  Ms. ABC returns today for followup status post L4-L5 laminectomy and bilateral foraminotomies, and posterior spinal fusion on 06/08/07.,Preoperatively, her symptoms, those of left lower extremity are radicular pain.,She had not improved immediately postoperatively.  She had a medial breech of a right L4 pedicle screw.  We took her back to the operating room same night and reinserted the screw.  Postoperatively, her pain had improved.,I had last seen her on 06/28/07 at which time she was doing well.  She had symptoms of what she thought was ""restless leg syndrome"" at that time.  She has been put on ReQuip for this.,She returned.  I had spoken to her 2 days ago and she had stated that her right lower extremity pain was markedly improved.  I had previously evaluated this for a pain possibly relating to deep venous thrombosis and ultrasound was negative.  She states that she had recurrent left lower extremity pain, which was similar to the pain she had preoperatively but in a different distribution, further down the leg.  Thus, I referred her for a lumbar spine radiograph and lumbar spine MRI and she presents today for evaluation.,She states that overall, she is improved compared to preoperatively.  She is ambulating better than she was preoperatively.  The pain is not as severe as it was preoperatively.  The right leg pain is improved.  The left lower extremity pain is in a left L4 and L5 distribution radiating to the great toe and first web space on the left side.,She denies any significant low back pain.  No right lower extremity symptoms.,No infectious symptoms whatsoever.  No fever, chills, chest pain, shortness of breath.  No drainage from the wound.  No difficulties with the incision.,FINDINGS:  ,On examination, Ms. ABC is a pleasant, well-developed, well-nourished female in no apparent distress.  Alert and oriented x 3.  Normocephalic, atraumatic.  Respirations are normal and nonlabored.  Afebrile to touch.,Left tibialis anterior strength is 3 out of 5, extensor hallucis strength is 2 out of 5.  Gastroc-soleus strength is 3 to 4 out of 5.  This has all been changed compared to preoperatively.  Motor strength is otherwise 4 plus out of 5.  Light touch sensation decreased along the medial aspect of the left foot.  Straight leg raise test normal bilaterally.,The incision is well healed.  There is no fluctuance or fullness with the incision whatsoever.  No drainage.,Radiographs obtained today demonstrate pedicle screw placement at L4 and L5 bilaterally without evidence of malposition or change in orientation of the screws.,Lumbar spine MRI performed on 07/03/07 is also reviewed.,It demonstrates evidence of adequate decompression at L4 and L5.  There is a moderate size subcutaneous fluid collection seen, which does not appear compressive and may be compatible with normal postoperative fluid collection, especially given the fact that she had a revision surgery performed.,ASSESSMENT AND PLAN:  ,Ms. ABC is doing relatively well status post L4 and L5 laminectomy and bilateral foraminotomies, and posterior spinal fusion with instrumentation on 07/08/07.  The case is significant for merely misdirected right L4 pedicle screw, which was reoriented with subsequent resolution of symptoms.,I am uncertain with regard to the etiology of the symptoms.  However, it does appear that the radiographs demonstrate appropriate positioning of the instrumentation, no hardware shift, and the MRI demonstrates only a postoperative suprafascial fluid collection.  I do not see any indication for another surgery at this time.,I would also like to hold off on an interventional pain management given the presence of the fluid collection to decrease the risk of infection.,My recommendation at this time is that the patient is to continue with mobilization.  I have reassured her that her spine appears stable at this time.  She is happy with this.,I would like her to continue ambulating as much as possible.  She can go ahead and continue with ReQuip for the restless leg syndrome as her primary care physician has suggested.  I have also her referred to Mrs. Khan at Physical Medicine and Rehabilitation for continued aggressive management.,I will see her back in followup in 3 to 4 weeks to make sure that she continues to improve.  She knows that if she has any difficulties, she may follow up with me sooner.","orthopedic, spinal fusion, restless leg syndrome, posterior spinal fusion, pedicle screw, lumbar spine, bilateral foraminotomies, fluid collection, foraminotomy, instrumentation, laminectomy, screw, spine, "
 A 13-year-old new patientfor evaluation of thoracic kyphosis.   Family history of kyphosis in a maternal aunt and grandfather.  She was noted by her parents to have round back posture., Orthopedic, Kyphosis ,"REASON FOR VISIT: , Kyphosis.,HISTORY OF PRESENT ILLNESS: , The patient is a 13-year-old new patient is here for evaluation of thoracic kyphosis.  The patient has a family history in a maternal aunt and grandfather of kyphosis.  She was noted by her parents to have round back posture.  They have previously seen another orthopedist who recommended observation at this time.  She is here for a second opinion in regards to kyphosis.  The patient denies any pain in her back or any numbness, tingling, or weakness in her upper or lower extremities.  No problems with her bowels or bladder.,PAST MEDICAL HISTORY: , None.,PAST SURGICAL HISTORY: , Bilateral pinning of her ears.,SOCIAL HISTORY:  ,She is currently an eighth grader at Middle School and is interested in basketball.  She lives with both of her parents and has a 9-year-old brother.  She had menarche beginning in September.,FAMILY HISTORY:  ,Of kyphosis in great grandmother and second cousin.,REVIEW OF SYSTEMS: , She is in her usual state of health and is negative except otherwise as mentioned in the history of present illness.,MEDICATIONS: , She is currently on Zyrtec, Flonase, and Ceftin for an ear infection.,ALLERGIES: , No known drug allergies.,FINDINGS: , On physical exam, she is alert, oriented, and in no acute distress standing 63 inches tall.  In regards to her back, her skin is intact with no rashes, lesions, and/or no dimpling or hair spots.  No cafe au lait spots.  She is not tender to palpation from her occiput to her sacrum.  There is no evidence of paraspinal muscle spasm.  On forward bending, there is a mild kyphosis.  She is not able to touch her toes indicating her hamstring tightness.  She has a full 5 out of 5 in all muscle groups.  Her lower extremities including iliopsoas, quadriceps, gastroc-soleus, tibialis anterior, and extensor hallucis longus.  Her sensation intact to light touch in L1 through L2 dermatomal distributions.  She has symmetric limb lengths as well bilaterally from both the coronal and sagittal planes.,X-rays today included PA and lateral sclerosis series.  She has approximately 46 degree kyphosis.,ASSESSMENT: , Kyphosis.,PLANS:  ,The patient's kyphosis is quite mild.  While this is likely in the upper limits of normal or just it is normal for an adolescent and still within normal range as would be expected return at home.  At this time, three options were discussed with the parents including observation, physical therapy, and bracing.  At this juncture, given that she has continued to grow, they are Risser 0.  She may benefit from continued observation with physical therapy, bracing would be a more aggressive option certainly that thing would be lost with following at this time.  As such, she was given a prescription for physical therapy for extension based strengthening exercises, flexibility range of motion exercises, postural training with no forward bending.  We will see her back in 3 months' time for repeat radiographs at that time including PA and lateral standing of scoliosis series.  Should she show evidence of continued progression of her kyphotic deformity, discussions of bracing would be held at time.  We will see her back in 3 months' time for repeat evaluation.","orthopedic, thoracic kyphosis, round back posture, physical therapy, kyphosis, patientfor, orthopedist, "
" Revision laminectomy L5-S1, discectomy L5-S1, right medial facetectomy, preparation of disk space and arthrodesis with interbody graft with BMP.  Status post previous lumbar surgery for herniated disk with severe recurrence of axial back pain, failed conservative therapy.", Orthopedic, Laminectomy & Discectomy & Facetectomy ,"TITLE OF OPERATION: , Revision laminectomy L5-S1, discectomy L5-S1, right medial facetectomy, preparation of disk space and arthrodesis with interbody graft with BMP.,INDICATIONS FOR SURGERY:  ,Please refer to medical record, but in short, the patient is a 43-year-old male known to me, status post previous lumbar surgery for herniated disk with severe recurrence of axial back pain, failed conservative therapy.  Risks and benefits of surgery were explained in detail including risk of bleeding, infection, stroke, heart attack, paralysis, need for further surgery, hardware failure, persistent symptoms, and death.  This list was inclusive, but not exclusive.  An informed consent was obtained after all patient's questions were answered.,PREOPERATIVE DIAGNOSIS:  ,Severe lumbar spondylosis L5-S1, collapsed disk space, hypermobility, and herniated disk posteriorly.,POSTOPERATIVE DIAGNOSIS: , Severe lumbar spondylosis L5-S1, collapsed disk space, hypermobility, and herniated disk posteriorly.,ANESTHESIA: , General anesthesia and endotracheal tube intubation.,DISPOSITION: , The patient to PACU with stable vital signs.,PROCEDURE IN DETAIL:  ,The patient was taken to the operating room.  After adequate general anesthesia with endotracheal tube intubation was obtained, the patient was placed prone on the Jackson table.  Lumbar spine was shaved, prepped, and draped in the usual sterile fashion.  An incision was carried out from L4 to S1.  Hemostasis was obtained with bipolar and Bovie cauterization.  A Weitlaner was placed in the wound and a subperiosteal dissection was carried out identifying the lamina of L4, L5, and sacrum.  At this time, laminectomy was carried out of L5-S1.  Thecal sac was retracted rightward and the foramen was opened and unilateral medial facetectomy was carried out in the disk space.  At this time, the disk was entered with a #15 blade and bipolar.  The disk was entered with straight up and down-biting pituitaries, curettes, and the high speed drill and we were able to takedown calcified herniated disk.  We were able to reestablish the disk space, it was very difficult, required meticulous dissection and then drilling with a diamond bur in the disk space underneath the spinal canal, very carefully holding the spinal canal out of harm's way as well as the exiting nerve root.  Once this was done, we used rasps to remove more disk material anteriorly and under the midline to the left side and then we put in interbody graft of BMP 8 mm graft from Medtronic.  At this time, Dr. X will dictate the posterolateral fusion, pedicle screw fixation to L4 to S1 with compression and will dictate the closure of the wound.  There were no complications.","orthopedic, revision laminectomy, discectomy, facetectomy, arthrodesis, lumbar spondylosis, hypermobility, collapsed disk space, medial facetectomy, interbody graft, herniated disk, interbody, laminectomy, disk, therapy, lumbar, herniated, space,"
" Microscopic-assisted revision of bilateral decompressive lumbar laminectomies and foraminotomies at the levels of L3-L4, L4-L5, and L5-S1.  Posterior spinal fusion at the level of L4-L5 and L5-S1 utilizing local bone graft, allograft and segmental instrumentation.  Posterior lumbar interbody arthrodesis utilizing cage instrumentation at L4-L5 with local bone graft and allograft.  All procedures were performed under SSEP, EMG, and neurophysiologic monitoring.", Orthopedic, Laminectomy & Foraminotomy Revision ,"PREOPERATIVE DIAGNOSES:,1.  Recurrent spinal stenosis at L3-L4, L4-L5, and L5-S1.,2.  Spondylolisthesis, which is unstable at L4-L5.,3.  Recurrent herniated nucleus pulposus at L4-L5 bilaterally.,POSTOPERATIVE DIAGNOSES:,1.  Recurrent spinal stenosis at L3-L4, L4-L5, and L5-S1.,2.  Spondylolisthesis, which is unstable at L4-L5.,3.  Recurrent herniated nucleus pulposus at L4-L5 bilaterally.,PROCEDURE PERFORMED:,1.  Microscopic-assisted revision of bilateral decompressive lumbar laminectomies and foraminotomies at the levels of L3-L4, L4-L5, and L5-S1.,2.  Posterior spinal fusion at the level of L4-L5 and L5-S1 utilizing local bone graft, allograft and segmental instrumentation.,3.  Posterior lumbar interbody arthrodesis utilizing cage instrumentation at L4-L5 with local bone graft and allograft.  All procedures were performed under SSEP, EMG, and neurophysiologic monitoring.,ANESTHESIA: , General via endotracheal tube.,ESTIMATED BLOOD LOSS:  ,Approximately 1000 cc.,CELL SAVER RETURNED:  ,Approximately 550 cc.,SPECIMENS: , None.,COMPLICATIONS: , None.,DRAIN: , 8-inch Hemovac.,SURGICAL INDICATIONS: , The patient is a 59-year-old male who had severe disabling low back pain.  He had previous lumbar laminectomy at L4-L5.  He was noted to have an isthmic spondylolisthesis.,Previous lumbar laminectomy exacerbated this condition and made it further unstable.  He is suffering from neurogenic claudication.  He was unresponsive to extensive conservative treatment.  He has understanding of the risks, benefits, potential complications, treatment alternatives and provided informed consent.,OPERATIVE TECHNIQUE: , The patient was taken to OR #5 where he was given general anesthetic by the Department of Anesthesia.  He was subsequently placed prone on the Jackson's spinal table with all bony prominences well padded.  His lumbar spine was then sterilely prepped and draped in the usual fashion.  A previous midline incision was extended from approximate level of L3 to S1.  This was in the midline.  Skin and subcutaneous tissue were debrided sharply.  Electrocautery provided hemostasis.  ,Electrocautery was utilized to dissect through subcutaneous tissue of lumbar fascia.  The lumbar fascia was identified and split in the midline.  Subperiosteal dissection was then carried out with electrocautery and ______ elevated from the suspected levels of L3-S1.  Once this was exposed, the transverse processes, a Kocher clamp was placed and a localizing cross-table x-ray confirmed the interspace between the spinous processes of L3-L4.  Once this was completed, a self-retaining retractor was then placed.  With palpation of the spinous processes, the L4 posterior elements were noted to be significantly loosened and unstable.  These were readily mobile with digital palpation.  A rongeur was then utilized to resect the spinous processes from the inferior half of L3 to the superior half of S1.  This bone was morcellized and placed on the back table for utilization for bone grafting.  The rongeur was also utilized to thin the laminas from the inferior half of L3 to superior half of S1.  Once this was undertaken, the unstable posterior elements of L4 were meticulously dissected free until wide decompression was obtained.  Additional decompression was extended from the level of the inferior half of L3 to the superior half of S1.  The microscope was utilized during this portion of procedure for visualization.  There was noted to be no changes during the decompression portion or throughout the remainder of the surgical procedure.  Once decompression was deemed satisfactory, the nerve roots were individually inspected and due to the unstable spondylolisthesis, there was noted to be tension on the L4 and L5 nerve roots crossing the disc space at L4-L5.  Once this was identified, foraminotomies were created to allow additional mobility.  The wound was then copiously irrigated with antibiotic solution and suctioned dry.  Working type screws, provisional titanium screws were then placed at L4-l5.  This was to allow distraction and reduction of the spondylolisthesis.  These were placed in the pedicles of L4 and L5 under direct intensification.  The position of the screws were visualized, both AP and lateral images.  They were deemed satisfactory.,Once this was completed, a provisional plate was applied to the screws and distraction applied across L4-L5.  This allowed for additional decompression of the L5 and L4 nerve roots.  Once this was completed, the L5 nerve root was traced and deemed satisfactory exiting neural foramen after additional dissection and discectomy were performed.  Utilizing a series of interbody spacers, a size 8 mm spacer was placed within the L4-L5 interval.  This was taken in sequence up to a 13 mm space.  This was then reduced to a 11 mm as it was much more anatomic in nature.  Once this was completed, the spacers were then placed on the left side and distraction obtained.  Once the distraction was obtained to 11 mm, the interbody shavers were utilized to decorticate the interbody portion of L4 and L5 bilaterally.  Once this was taken to 11 mm bilaterally, the wound was copiously irrigated with antibiotic solution and suction dried.  A 11 mm height x 9 mm width x 25 mm length carbon fiber cages were packed with local bone graft and Allograft.  There were impacted at the interspace of L4-L5 under direct image intensification.  Once these were deemed satisfactory, the wound was copiously irrigated with antibiotic solution and suction dried.  The provisional screws and plates were removed.  This allowed for additional compression along L4-L5 with the cage instrumentation.  Permanent screws were then placed at L4, L5, and S1 bilaterally.  This was performed under direct image intensification.  The position was verified in both AP and lateral images.  Once this was completed, the posterolateral gutters were decorticated with an AM2 Midas Rex burr down to bleeding subchondral bone.  The wound was then copiously irrigated with antibiotic solution and suction dried.  The morcellized Allograft and local bone graft were mixed and packed copiously from the transverse processes of L4-S1 bilaterally.  A 0.25 inch titanium rod was contoured of appropriate length to span from L4-S1.  Appropriate cross connecters were applied and the construct was placed over the pedicle screws.  They were tightened and sequenced to allow additional posterior reduction of the L4 vertebra.  Once this was completed, final images in the image intensification unit were reviewed and were deemed satisfactory.  All connections were tightened and retightened in Torque 2 specifications.  The wound was then copiously irrigated with antibiotic solution and suction dried.  The dura was inspected and noted to be free of tension.  At the conclusion of the procedure, there was noted to be no changes on the SSEP, EMG, and neurophysiologic monitors.  An 8-inch Hemovac drain was placed exiting the wound.  The lumbar fascia was then approximated with #1 Vicryl in interrupted fashion, the subcutaneous tissue with #2-0 Vicryl interrupted fashion, surgical stainless steel clips were used to approximate the skin.  The remainder of the Hemovac was assembled.  Bulky compression dressing utilizing Adaptic, 4x4, and ABDs was then affixed to the lumbar spine with Microfoam tape.  He was turned and taken to the recovery room in apparent satisfactory condition.  Expected surgical prognosis remains guarded.",
 Decompressive left lumbar laminectomy C4-C5 and C5-C6 with neural foraminotomy. Posterior cervical fusion C4-C5.  Songer wire.  Right iliac bone graft., Orthopedic, Laminectomy & Foraminotomy & Cervical Fusion ,"PREOPERATIVE DIAGNOSES,1.  Post anterior cervical discectomy and fusion at C4-C5 and C5-C6 with possible pseudoarthrosis at C4-C5.,2.  Cervical radiculopathy involving the left arm.,3.  Disc degeneration at C3-C4 and C6-C7.,POSTOPERATIVE DIAGNOSES,1.  Post anterior cervical discectomy and fusion at C4-C5 and C5-C6 with possible pseudoarthrosis at C4-C5.,2.  Cervical radiculopathy involving the left arm.,3.  Disc degeneration at C3-C4 and C6-C7.,OPERATIVE PROCEDURES,1.  Decompressive left lumbar laminectomy C4-C5 and C5-C6 with neural foraminotomy.,2.  Posterior cervical fusion C4-C5.,3.  Songer wire.,4.  Right iliac bone graft.,TECHNIQUE:  ,The patient was brought to the operating room.  Preoperative evaluations included previous cervical spine surgery.  The patient initially had some relief; however, his left arm pain did recur and gradually got worse.  Repeat studies including myelogram and postspinal CTs revealed some blunting of the nerve root at C4-C5 and C5-C6.  There was also noted to be some annular bulges at C3-C4, and C6-C7.  The CT scan in March revealed that the fusion was not fully solid.  X-rays were done in November including flexion and extension views, it appeared that the fusion was solid.,The patient had been on pain medication.  The patient had undergone several nonoperative treatments.  He was given the option of surgical intervention.  We discussed Botox, I discussed with the patient and posterior cervical decompression.  I explained to the patient this will leave a larger scar on his neck, and that no guarantee would help, there would be more bleeding and more pain from the posterior surgery than it was from the anterior surgery.  If at the time of surgery there was some motion of the C4-C5 level, I would recommend a fusion.  The patient was a smoker and had been advised to quit smoking but has not quit smoking.  I have therefore recommended that he use iliac bone graft.  I explained to the patient that this would give him a scar over the back of the right pelvis and could be a source of chronic pain for the patient for the rest of his life.  Even if this type of bone graft was used, there was no guarantee that it will fuse and he should stop smoking completely.,The patient also was advised that if I did a fusion, I would also use post instrumentation, which was a wire.  The wire would be left permanently.,Even with all these procedures, there was no guarantee that his symptoms would improve.  His numbness, tingling, and weakness could get worse rather than better, his neck pain and arm pain could persist.  He still had some residual bursitis in his left shoulder and this would not be cured by this procedure.  Other procedures may be necessary later.  There is still with a danger of becoming quadriplegic or losing total control of bowel or bladder function.  He could lose total control of his arms or legs and end up in the bed for the rest of his life.  He could develop chronic regional pain syndromes.  He could get difficulty swallowing or eating.  He could have substantial weakness in the arm.  He was advised that he should not undergo the surgery unless the pain is persistent, severe, and unremitting.,He was also offered his records if he would like any other pain medications or seek other treatments, he was advised that Dr. X would continue to prescribe pain medication if he did not wish to proceed with surgery.,He stated he understood all the risks.  He did not wish to get any other treatments.  He said the pain has reached the point that he wished to proceed with surgery.,PROCEDURE IN DETAIL: , In the operating room, he was given general endotracheal anesthesia.,I then carefully rolled the patient on thoracic rolls.  His head was controlled by a horseshoe holder.  The anesthesiologist checked the eye positions to make sure there was no pressure on the orbits and the anesthesiologist continued to check them every 15 minutes.  The arms, the right hip, and the neck was then prepped and draped.  Care was taken to position both arms and both legs.  Pulses were checked.,A midline incision was made through the skin and subcutaneous tissue on the cervical spine.  A loupe magnification and headlamp illumination was used.  Bleeding vessels were cauterized.  Meticulous hemostasis was carried out throughout the procedure.  Gradually and carefully I exposed the spinous process of the C6, C5, and C4.  A lateral view was done after an instrument in place.  This revealed the C6-C7 level.  I therefore did a small laminotomy opening at C4-C5.  I placed an instrument and x-rays confirmed C4-C5 level.,I stripped the muscles from the lamina and then moved them laterally and held with a self-retaining retractor.,Once I identified the level, I then used a bur to thin the lamina of C5.  I used a 1-mm, followed by a 2-mm Kerrison rongeur to carefully remove the lamina off C5 on the left.  I removed some of the superior lamina of C6 and some of the inferior lamina of C4.  This allowed me to visualize the dura and the nerve roots and gradually do neural foraminotomies for both the C5 and C6 nerve roots.  There was some bleeding from the epidural veins and a bipolar cautery was used.  Absolutely no retractors were ever placed in the canal.  There was no retraction.  I was able to place a small probe underneath the nerve root and check the disc spaces to make sure there was no fragments of disc or herniation disc and none were found.,At the end of the procedure, the neuroforamen were widely patent.  The nerve roots had been fully decompressed.,I then checked stability.  There was micromotion at the C4-C5 level.  I therefore elected to proceed with a fusion.,I debrided the interspinous ligament between C4 and C5.  I used a bur to roughen up the surface of the superior portion of the spinous process of C5 and the inferior portion of C4.  Using a small drill, I opened the facet at C4-C5.  I then used a very small curette to clean up the articular cartilage.  I used a bur then to roughen up the lamina at C4-C5.,Attention was turned to the right and left hip, which was also prepped.  An incision made over the iliac crest.  Bleeding vessels were cauterized.  I exposed just the posterior aspect of the crest.  I removed some of the bone and then used the curette to remove cancellous bone.,I placed the Songer wire through the base of the spinous process of C4 and C5.  Drill holes made with a clip.  I then packed cancellous bone between the decorticated spinous process.  I then tightened the Songer wire to the appropriate tension and then cut off the excess wire.,Prior to tightening the wire, I also packed cancellous bone with facet at C4-C5.  I then laid bone upon the decorticated lamina of C4 and C5.,The hip wound was irrigated with bacitracin and Kantrex.  Deep structures were closed with #1 Vicryl, subcutaneous suture and subcuticular tissue was closed.,No drain was placed in the hip.,A drain was left in the posterior cervical spine.  The deep tissues were closed with 0 Vicryl, subcutaneous tissue and skin were then closed.  The patient was taken to the recovery room in good condition.",
 KYPHON Balloon Kyphoplasty at T12 and L1evels Insertion of KYPHON HV-R bone cement under low pressure at T12 and L1 levels and bone biopsy., Orthopedic, Kyphoplasty ,"PRE-OP DIAGNOSIS:,  Osteoporosis, pathologic fractures T12- L2 with severe kyphosis.,POST-OP DIAGNOSIS:,  Osteoporosis, pathologic fractures T12- L2 with severe kyphosis.,PROCEDURE:,1.  KYPHON Balloon Kyphoplasty at T12 and L1evels Insertion of KYPHON HV-R bone cement under low pressure at T12 and L1 levels.,2.  Bone biopsy (medically necessary).,ANESTHESIA:, General,COMPLICATIONS:, None,BLOOD LOSS:, Minimal,INDICATIONS:,  Mrs. Smith is a 75-year-old female who has had severe back pain that began approximately three months ago and is debilitating.  She has been unresponsive to nonoperative treatment modalities including bed rest and analgesics.  She presents with and is on medication therapy for COPD, diabetes and hypertension (other co-morbidities may be present upon admission and should be documented in the operative note).,Radiographic imaging including MRI confirms multiple compression fractures of the thoracolumbar spine including T12, L1 and L2.  In addition to the fractures, she presents with kyphotic posture.  Films on 1/04 demonstrated L1 and L2 osteoporotic fractures.  Films on 2/04 demonstrated increased loss of height at L1.  Films on 3/04 demonstrated a new compression fracture at T12 and further collapse of L1.  The L2 fracture is documented on radiographic studies as being chronic and a year or more old.  The T12 fracture has the most significant kyphotic deformity.  Based on these findings, we have decided to perform KYPHON Balloon Kyphoplasty on the L1 and T12 fractures.,PROCEDURE:,  The patient was brought to the operating room/radiology suite and general anesthesia/local sedation with endotracheal intubation was performed.  The patient was positioned prone on the Jackson table.  The back was prepped and draped.  The image intensifier (C-arm) was brought into position and the T12 pedicles were identified and marked with a skin marker.  In view of the collapse of T12, a transpedicular approach to the vertebral body was appropriate.  An 11-gauge needle was advanced through the T12 pedicle to the junction of the pedicle and vertebral body on the right side.  Positioning was confirmed on the AP and lateral plane.  Following satisfactory placement of the needle, the stylet was removed.  A guide pin was inserted through the 11g to a point 3mm from the anterior cortex.  AP and lateral images were taken to verify position and trajectory.  Alongside of the guide pin a 1-cm paramedian incision was made.  The needle was then removed leaving the guide pin in place.  The osteointroducer was placed over the guide pin and advanced through the pedicle.  Once I was at the junction of the pedicle and the vertebral body, a lateral image was taken to insure that the cannula was positioned approximately 1cm past the vertebral body wall.  Through the cannula, a drill was advanced into the vertebral body under fluoroscopic guidance toward the anterior cortex, creating a channel.  The anterior cortex was probed with the guide pin to ensure no perforations in the anterior cortex.  After completing the entry into the vertebral body, a 15 mm inflatable bone tamp was inserted through the cannula and advanced under fluoroscopic guidance into the vertebral body near the anterior cortex.  The radiopaque marker bands on the bone tamp were identified using AP and lateral images.  The above sequence of instrument placement was then repeated on the left side of the T12 vertebral body.  Once both bone tamps were in position, they were inflated to 0.5 cc and 50 psi.  Expansion of the bone tamps was done sequentially in increments of 0.25 to 0.5 cc of contrast, with careful attention being paid to the inflation pressures and balloon position.  The inflation was monitored with AP and lateral imaging.  The final balloon volume was 3.5 cc on the right side and 3 cc on the left.  There was no breach of the lateral wall or anterior cortex of the vertebral body.  Direct reduction of the fracture was achieved, end plate movement was noted and approximately 5 mm of height restoration was achieved.  Under fluoroscopic imaging, and the use of the bone void fillers, internal fixation was achieved through a low-pressure injection of KYPHON HV-R bone cement.  The cavity was filled with a total volume of 3.5 cc on the right side and 3 cc on the left side.  Once the bone cement had hardened, the cannulas were then removed.,At this time, we proceeded to perform a balloon kyphoplasty at L1 using the same sequence of steps as on T12.  An entry needle was placed bilaterally through the pedicle into the vertebral body, a cortical window was created, inflation of the bone tamps directly reduced the fracture, the bone tamps were removed, and internal fixation by bone void filler insertion was achieved.  Throughout the procedure, AP and lateral imaging monitored positioning.,Post-procedure, all incisions were closed with sutures.  The patient was kept in the prone position for approximately 10 minutes post cement injection.  She was then turned supine, monitored briefly and returned to the floor.  She was moving both her lower extremities at this time.,Throughout the procedure, there were no intraoperative complications.  Estimated blood loss was minimal.","orthopedic, osteoporosis, pathologic fractures, kyphosis, bone cement, balloon kyphoplasty, kyphon balloon kyphoplasty, bone biopsy, kyphon, insertion of kyphon, ap and lateral, vertebral body, kyphon balloon, anterior cortex, vertebral, body, fractures, insertion, bone, kyphoplasty, guide, balloon, pedicles, cortex, positioned, therapy"
 Left medial compartment osteoarthritis of the knee.  Left unicompartmental knee replacement., Orthopedic, Knee Replacement ,"PREOPERATIVE DIAGNOSIS: , Left medial compartment osteoarthritis of the knee.,POSTOPERATIVE DIAGNOSIS:,  Left medial compartment osteoarthritis of the knee.,PROCEDURE  PERFORMED:,  Left unicompartmental knee replacement.,COMPONENTS USED:,  Biomet size medium femoral component size B tibial tray and a 3 mm polyethylene component.,COMPLICATIONS:,  None.,TOURNIQUET TIME: , 59 minutes.,BLOOD LOSS: , Minimal.,INDICATIONS FOR PROCEDURE: , A 55-year-old female who had previously undergone a Biomet Oxford unicompartmental knee replacement on the right side.  She has done quite well with this.  She now has had worsening left knee pain predominantly on the inside of her knee and has consented for unicompartmental knee replacement on the left.,DESCRIPTION OF PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed supine on the operating room table.  After appropriate anesthesia, the left lower extremity was identified with a time out procedure.  Preoperative antibiotics were given.  Left lower extremity was then prepped and draped in usual sterile fashion after applying a thigh tourniquet.  The tourniquet was insufflated after elevation of the limb, and a standard medial parapatellar incision was used.  Soft tissue dissection was carried down the retinaculum, was opened sharply to expose the joint, meniscus that was visible along the tibia was removed.  The anterior fat pad was removed.  The knee was then examined.  The ACL was found to be intact.  The lateral compartment had very minimal arthritis.  There were some osteoarthritic changes of the patellofemoral joint, but these were felt to be mild.  Following this, the tibial external alignment guide was placed and pinned into place in the appropriate place.  Tibial bone cut was made and checked with a feeler gauge and felt to be an adequate resection.  Following this resection, the femoral intramedullary guide was placed without difficulty.  The femoral cutting guide was then placed and referenced off of this femoral intramedullary guide.  Once in the appropriate position, it was pinned and drilled.  This was removed, and the posterior cutting block was inserted.  It was impacted into place.  Posterior bone cut was made for the medium femoral component.  Next, a zero spigot was used and the distal femur was reamed.  Following this, the check of the extension and flexion gaps revealed that an additional 1 mm needed to be reamed, so 1 spigot was used and this was reamed as well.  Next, trial components were placed into the knee and the knee was taken through range of motion and felt to come out to full extension with a 3 mm poly with a good fit.  Next, the tibia was prepared.  The tibial tray was pinned into place, and the cuts for the keel of the tibia were made.  These were removed with a small osteotome from the set.  Following this, a trial tibial with the keel was placed and it did fit nicely.  After this, all trial components were removed.  The knee was copiously irrigated.  Cement was begun mixing.  Drill holes were used along the femur for cement interdigitation.  The wound was cleaned and dried.  Cement was placed on the tibia.  Tibial tray was impacted into place.  Excess cement was removed.  Tibia was placed in the femur.  Femoral component was impacted into place.  Excess cement was removed.  It was held with a 4 mm trial insert and approximately 30 degrees of knee flexion until the cement had hardened.  Following this, it was again trialed with a meniscal bearing implant and it was felt that 3 mm would be the appropriate size.  A 3 mm polyethylene was chosen and inserted in the knee without difficulty, taken through range of motion and found to come out to full extension with no impingement and full flexion.  The intramedullary rod removed from the femur.  The wound was irrigated with normal saline.  The retinaculum was closed with #1 PDS, 2-0 Monocryl was used for the subcutaneous tissue and staples used for the skin.  A sterile dressing was placed.  Tourniquet was then desufflated.  Sponge and needle counts were correct at the end of the procedure.  Dr. Jinnah was present for the surgery.  The patient was transferred to the recovery room in stable condition.  She will be weightbearing as tolerated in the left lower extremity and will be maintained on Lovenox for DVT prophylaxis.  Prior to closure, the posterior capsule was injected with the joint cocktail.","orthopedic, knee replacement, osteoarthritis, osteoarthritis of the knee, excess cement was removed, medium femoral component, medial compartment osteoarthritis, unicompartmental knee replacement, medium femoral, femoral intramedullary, intramedullary guide, medial compartment, femoral component, tibial tray, lower extremity, unicompartmental knee, tibial, knee, tourniquet, intramedullary, extension, flexion, compartment, unicompartmental, replacement, femoral, cement,"
 The patient with an L5 compression fracture.is to come to the hospital for bilateral L5 kyphoplasty.  The patient has a history of back and buttock pain for some time. , Orthopedic, Kyphoplasty - Consult ,"HISTORY: , The patient is to come to the hospital for bilateral L5 kyphoplasty.  The patient is an 86-year-old female with an L5 compression fracture.,The patient has a history of back and buttock pain for some time.  She was found to have an L5 compression fracture.  She was treated conservatively over several months, but did not improve.  Unfortunately, she has continued to have significant ongoing back pain and recent CT scan has shown a sclerosis with some healing of her L5 compression fracture, but without complete healing.  The patient has had continued pain and at this time, is felt to be a candidate for kyphoplasty.,She denies bowel or bladder incontinence.  She does complain of back pain.  She has been wearing a back brace and corset.  She does not have weakness.,PAST MEDICAL HISTORY:,  The patient has a history of multiple medical problems including hypothyroidism, hypertension, and gallbladder difficulties.,PAST SURGICAL HISTORY:,  She has had multiple previous surgeries including bowel surgery, hysterectomy, rectocele repair, and appendectomy.  She also has a diagnosis of polymyalgia rheumatica.,CURRENT MEDICATIONS: , She is on multiple medications currently.,ALLERGIES: , SHE IS ALLERGIC TO CODEINE, PENICILLIN, AND CEPHALOSPORINS.,FAMILY HISTORY: , The patient's parents are deceased.,PERSONAL AND SOCIAL HISTORY: , The patient lives locally.  She is a widow.  She does not smoke cigarettes or use illicit drugs.,PHYSICAL EXAMINATION: , GENERAL:  The patient is an elderly frail white female in no distress.  LUNGS:  Clear.  HEART:  Sounds are regular.  ABDOMEN:  She has a protuberant abdomen.  She has tenderness to palpation in the lumbosacral area.  Sciatic notch tenderness is not present.  Straight leg raise testing evokes back pain.  NEUROLOGICAL:  She is awake, alert, and oriented.  Speech is intact.  Comprehension is normal.  Strength is intact in the upper extremities.  She has giveaway strength in the lower extremities.  Reflexes are diminished at the knees and ankles.  Gait is otherwise normal.,DATA REVIEWED: , Plain studies of the lumbar spine show an L5 compression fracture.  A CT scan has shown some healing of this fracture.  She has degenerative change at the L4-L5 level with a very slight spondylolisthesis at this level.,ASSESSMENT AND PLAN: , The patient is a woman with a history of longstanding back, buttock, and leg pain.  She has a documented L5 compression fracture, which has not healed despite appropriate conservative treatments.  At this point, I believe the patient is a good candidate for L5 kyphoplasty.  I have discussed the procedure with her and I have reviewed with her and her family risks, benefits, and alternatives to surgery.  Risks of surgery including but not limited to bleeding, infection, stroke, paralysis, death, failure to improve, spinal fluid leak, need for further surgery, cement extravasation, failure to improve her pain, and other potential complications have all been discussed.  The patient understands the issues involved.  She requested that we proceed with surgery as noted above and will come to the hospital for this surgery on 01/18/08.","orthopedic, leg pain, lumbar spine, l5 compression fracture, compression fracture, kyphoplasty, buttock, surgery, fracture,"
 Decreased ability to perform daily living activities secondary to right knee surgery., Orthopedic, Knee Surgery - Discharge Summary ,"CHIEF COMPLAINT:,  Decreased ability to perform daily living activities secondary to right knee surgery.,HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old white female status post right total knee replacement secondary to degenerative joint disease performed by Dr. A at ABCD Hospital on 08/21/2007.  The patient was transfused with 2 units of autologous blood postoperatively.  She received DVT prophylaxis with a combination of Coumadin, Lovenox, SCD boots, and TED stockings.  The remainder of her postoperative course was uneventful.  She was discharged on 08/24/2007 from ABCD Hospital and admitted to the transitional care unit at XYZ Services for evaluation and rehabilitation.  The patient reports that her last bowel movement was on 08/24/2007 just prior to her discharge from ABCD Hospital.  She denies any urological symptoms such as dysuria, incomplete bladder emptying or other voiding difficulties.  She reports having some right knee pain, which is most intense at a ""certain position.""  The patient is unable to elaborate on which ""certain position"" causes her the most discomfort.,ALLERGIES:,  NKDA.,PAST MEDICAL HISTORY: , Hypertension, hypothyroidism, degenerative joint disease, GERD, anxiety disorder, Morton neuroma of her feet bilaterally, and distant history of migraine headaches some 30 years ago.,MEDICATIONS:,  On transfer, Celebrex, Coumadin, Colace, Synthroid, Lovenox, Percocet, Toprol XL, niacin, and trazodone.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 96.5, blood pressure 127/72, pulse 70, respiratory rate 20, 95% O2 saturation on room air.,GENERAL:  No acute distress at the time of the exam except as mentioned above complains of right knee pain at ""certain position."",HEENT:  Normocephalic.  Sclerae nonicteric.  EOMI.  Dentition in good repair.  Tongue is in midline with no evidence of thrush.,NECK:  No thyroid enlargement.  Trachea is midline.,LUNGS:  Clear to auscultation.,HEART:  Regular rate and rhythm.  Normal S1 and S2.,ABDOMEN:  Soft, nontender, and nondistended.  No organomegaly.,EXTREMITIES:  The right knee incision is intact.  Steri-Strips are in place.  There is some diffuse right knee edema and some limited ecchymosis as well.  No calf tenderness bilaterally.  Pedal pulses are palpable bilaterally.,MENTAL STATUS:  The patient appears slightly anxious during the interview and exam, but she was alert and oriented.,HOSPITAL COURSE: , As mentioned above, the patient was admitted on 08/24/2007 to the Transitional Care Unit at XYZ Services for evaluation and rehabilitation.  She was seen in consultation by Physical Therapy and Occupational Therapy and had begun her rehabilitation till recovery.  The patient had been properly instructed regarding using the CPM machine and she had been instructed as well to limit each CPM session to two hours.  Very early in her hospitalization, the patient enthusiastically used the CPM much longer than two hours and consequently had increased right knee pain.  She remarked that she had a better degree of flexibility, but she did report an increased need for pain management.  Additionally, she required Ativan and at one point scheduled the doses of Ativan to treat her known history of anxiety disorder.  On the fourth hospital day, she was noted to have some rashes about the right upper extremity and right side of her abdomen.  The patient reported that this rash was itchy.  She reports that she had been doing quite a bit of gardening just prior to surgery and this was most likely contact dermatitis, most likely due to her gardening activities preoperatively.  She was treated with betamethasone cream applied to the rash b.i.d.  The patient's therapy had progressed and she continued to make a good progress.  At one point, the patient reported some insomnia due to right knee pain.  She was switched from Percocet to oxycodone SR 20 mg b.i.d. and she had good pain control with this using the Percocet only for breakthrough pain.  The DVT prophylaxis was maintained with Lovenox 40 mg subcu daily until the INR was greater than 1.7 and it was discontinued on 08/30/2007 when the INR was 1.92 within therapeutic range.  The Coumadin was adjusted accordingly according to the INRs during her hospital course.  Early in the hospital course, the patient had reported right calf tenderness and a venous Doppler study obtained on 08/27/2007 showed no DVT bilaterally.  Initial laboratory data includes a UA on 08/28/2007, which was negative.  Additionally, CBC showed a white count of 6.3, hemoglobin was 12.1, hematocrit was 35.3, and platelets were 278,000.  Chemistries were within normal limits.  Creatinine was 0.8, BUN was 8, anion gap was slightly decreased at 5, fasting glucose was 102.  The remainder of chemistries was unremarkable.  The patient continued to make great progress with her therapies so much so that we are anticipating her discharge on Monday, 09/03/2007.,DISCHARGE DIAGNOSES:,1.  Status post right total knee replacement secondary to degenerative joint disease performed on 08/21/2007.,2.  Anxiety disorder.,3.  Insomnia secondary to pain and anxiety postoperatively.,4.  Postoperative constipation.,5.  Contact dermatitis secondary to preoperative gardening activities.,6.  Hypertension.,7.  Hypothyroidism.,8.  Gastroesophageal reflux disease.,9.  Morton neuroma of the feet bilaterally.,10.  Distant history of migraine headaches.,INSTRUCTIONS GIVEN TO THE PATIENT AT THE TIME OF DISCHARGE: , The patient is advised to continue taking the following medications:  Celebrex 200 mg daily, for one month, Colace 100 mg b.i.d. for one month, Protonix 40 mg b.i.d. for one month, Synthroid 137 mcg daily, Diprosone cream 0.05% cream b.i.d. to the right arm and right abdomen, oxycodone SR 20 mg p.o. q.12h. for five days, then decrease to oxycodone SR 10 mg p.o. q.12h. for five days, Percocet 5/325 mg one to two tablets q.6h. to be used p.r.n. for breakthrough pain, trazodone 50 mg p.o. at bedtime p.r.n. for two weeks, Ativan 0.25 mg b.i.d. for two weeks, and Toprol-XL 50 mg daily.  The patient will also take Coumadin and the dose will be adjusted according to the INRs, which will be obtained every Monday and Thursday with results being sent to Dr. A and his fax number is 831-5926.  At the present time, the patient is taking Coumadin 7 mg daily.  She will remain on Coumadin for 30 days.  An INR is to be obtained on 09/03/2007 and should the Coumadin dose be changed, an addendum will be dictated to accompany this discharge summary.  Finally, the patient has a followup appointment with Dr. A on 09/21/2007 at noon at his office.  The patient is encouraged to follow up with her primary care physician, Dr. B.  As mentioned above, the patient will be discharged on 09/03/2007 in stable and improved condition since she is status post right total knee replacement and has made good progress with her therapies and rehabilitation.",
  Fracture reduction with insertion of prosthetic device at T8 with kyphoplasty.   Vertebroplasties at T7 and T9 with insertion of prosthetic device.   Fracture of the T8 vertebra and T9 vertebra., Orthopedic, Kyphoplasty & Vertebroplasty ,"PREOPERATIVE DIAGNOSES:,1.  Pathologic insufficiency.,2.  Fracture of the T8 vertebrae and T9 vertebrae.,POSTOPERATIVE DIAGNOSES:,1.  Pathologic insufficiency.,2.  Fracture of the T8 vertebra and T9 vertebra.,PROCEDURE PERFORMED:,1.  Fracture reduction with insertion of prosthetic device at T8 with kyphoplasty.,2.  Vertebroplasties at T7 and T9 with insertion of prosthetic device.,ANESTHESIA: , Local with sedation.,SPECIMEN: , Bone from the T8 vertebra.,COMPLICATIONS:,  None.,SURGICAL INDICATIONS:,  The patient is an 80-year-old female who had previous history of compression fractures.  She had recently undergone an additional compression fracture of the T8 vertebrae.  She was in extreme pain.  This pain interfered with activities of daily living and was unimproved with conservative treatment modalities.  She is understanding the risks, benefits, and potential complications as well as all treatment alternatives.  The patient provided informed consent.,OPERATIVE TECHNIQUE: , The patient was taken to OR #2 where she was placed prone on the Jackson spinal table.  She was given sedative.  The thoracodorsal spine was then sterilely prepped and draped in the usual fashion.  Biplanar image intensification was utilized to localize the T8, T7, and T9 vertebrae.  Local anesthetic of 1% Marcaine with epinephrine and lidocaine were 50:50 mixed.,Approximately 7 cc was instilled on the left side.  This was directly over the posterior aspect of the pedicle on the left.  Once this was localized, the right side was localized as well.  Stab incisions were then created over the pedicles of T8 bilaterally.  Jamshidi needles were then placed percutaneously.  Their position was verified in both AP and lateral images.  They were advanced slowly under direct image intensification in biplanar fashion.  Once these were satisfactorily placed, the inner trocar was removed and a guidewire was inserted into the depths of the T7 vertebrae.  The Jamshidi needles were then removed.  A biopsy was then harvested with a biopsy trocar placed into the T8 vertebrae.  This bone was then removed and sent to the lab.  The injection cannulas were then placed over the guidewires and their position was verified in both AP and lateral images.  Once this was completed, a second Jamshidi needle was placed at the T7 vertebrae on the left at the entrance of the pedicle.  This was advanced under direct image intensification in a biplanar fashion.  Once this was deemed satisfactory, it was impacted.  The inner trocar was removed and a guidewire was then placed.  An injection cannula was then placed over the guidewire into the body of T7.  In a similar fashion, T9 was dressed on the left side as well.  A guidewire was then placed through the Jamshidi needle, which was verified in both AP and lateral images.  The cement injection cannula was then placed over this entering the T9 vertebrae body.  Attention was then turned to the kyphoplasty portion of the procedure at the T8 vertebrae.  The balloons were inserted bilaterally.  The balloons were then inflated under direct image intensification and pressurized to approximately 200 mmHg.  These were allowed to expand and reduce the fracture.  Once this was completed, the balloons were deflated and removed.  The inner cannulas of all four entrance holes were removed and approximately 1.5 cc of cement was injected in each of the cannulas.  This was done directly under image intensification.  Once this was completed, additional cement was injected into T9 as there was a larger vertebra.  The cement was allowed to cure.  The cannula was removed and final radiographs were obtained.  The stab incisions were then cleansed with water and antibiotic irrigation.  The wounds were then approximated with #4-0 Nylon in interrupted fashion.  Compression dressings were applied and fixed with tape.  She was aroused and moved to her inpatient bed.  She was moving all four extremities without deficit.  She had no significant pain.","orthopedic, pathologic insufficiency, vertebrae, fracture, fracture reduction, vertebroplasties, kyphoplasty, prosthetic device, jamshidi needles, insertion, prosthetic,"
" Arthroscopy of the left knee with medial meniscoplasty.  Internal derangement, left knee. Displaced bucket-handle tear of medial meniscus, left knee.", Orthopedic, Knee Arthroscopy & Medial Meniscoplasty ,"PREOPERATIVE DIAGNOSIS: , Internal derangement, left knee.,POSTOPERATIVE DIAGNOSIS: , Internal derangement, left knee.,PROCEDURE PERFORMED:,  Arthroscopy of the left knee with medial meniscoplasty.,ANESTHESIA:  ,LMA.,GROSS FINDINGS: , Displaced bucket-handle tear of medial meniscus, left knee.,PROCEDURE: , After informed consent was obtained, the patient was taken to ABCD General Hospital Operating Room #1 where anesthesia was administered by the Department of Anesthesiology.  The patient was then transferred to the operating room table in supine position with Johnson knee holder well-padded.  Tourniquet was placed around the left upper thigh.  The limb was then prepped and draped in usual sterile fashion.  Standard anteromedial and anterolateral arthroscopy portals were obtained and a systematic examination of the knee was then performed.  Patellofemoral joint showed frequent chondromalacia.  Examination of the medial compartment showed a displaced bucket-handle tear of the medial meniscus involving the entire posterior, parietal, and portion of his anterior portion of the medial meniscus.  The medial femoral condyle and medial tibial plateau were unaffected.  Intercondylar notch examination revealed an intact ACL and PCL stable to drawer testing and probing and the lateral compartment showed an intact lateral meniscus.  The femoral condyle and tibial plateau were all stable to probing.  Attention was then directed back to the medial compartment where the detached portion of the meniscus was excised using arthroscopy scissors.  A shaver was then used to smooth all the edges until the margins were stable to probing.,The knee was then flushed with normal saline and suctioned dry.  20 cc of 0.25% Marcaine was injected into the knee and into the arthroscopy portals.  A dressing consisting of Adaptic, 4x4s, ABDs, and Webril were applied followed by a TED hose.  The patient was then transferred to the recovery room in stable condition.","orthopedic, arthroscopy, meniscoplasty, derangement, internal derangement, knee, displaced bucket handle tear, femoral condyle, tibial plateau, medial meniscoplasty, medial meniscus, medial "
" Right knee injury suggestive of a recurrent anterior cruciate ligament tear, possible internal derangement.  While playing tennis she had a non-contact injury in which she injured the right knee.  She had immediate pain and swelling. ", Orthopedic, Knee Injury ,"HISTORY OF PRESENT ILLNESS: , The patient is an 18-year-old girl brought in by her father today for evaluation of a right knee injury.  She states that approximately 3 days ago while playing tennis she had a non-contact injury in which she injured the right knee.  She had immediate pain and swelling.  At this time, she complains of pain and instability in the knee.  The patient's past medical history is significant for having had an ACL injury to the knee in 2008.  She underwent anterior cruciate ligament reconstruction by Dr. X at that time, subsequently in the same year she developed laxity of the graft due in part to noncompliance and subsequently, she sought attention from Dr. Y who performed a revision ACL reconstruction at the end of 2008.  The patient states she rehabbed the knee well after that and did fine with good stability of the knee until this recent injury.,PAST MEDICAL HISTORY:,  She claims no chronic illnesses.,PAST SURGICAL HISTORY: , She had an anterior cruciate ligament reconstruction in 03/2008, and subsequently had a revision ACL reconstruction in 12/2008.  She has also had arm surgery when she was 6 years old.,MEDICATIONS: , She takes no medications on a regular basis,ALLERGIES: , She is allergic to Keflex and has skin sensitivity to Steri-Strips.,SOCIAL HISTORY:  ,The patient is single.  She is a full-time student at University.  Uses no tobacco, alcohol, or illicit drugs.  She exercises weekly, mainly tennis and swelling.,REVIEW OF SYSTEMS:  ,Significant for recent weight gain, occasional skin rashes.  The remainder of her systems negative.,PHYSICAL EXAMINATION,GENERAL:  The patient is 4 foot 10 inches tall, weighs 110 pounds.,EXTREMITIES:  She ambulates with some difficulty with a marked limp on the right side.  Inspection of the knee reveals a significant effusion in the knee.  She has difficulty with passive range of motion of the knee secondary to pain.  She does have tenderness to palpation at the medial joint line and has a positive Lachman's exam.,NEUROVASCULAR:  She is neurovascularly intact.,IMPRESSION: , Right knee injury suggestive of a recurrent anterior cruciate ligament tear, possible internal derangement.,PLAN: , The patient will be referred for an MRI of the right knee to evaluate the integrity of her revision ACL graft.  In the meantime, she will continue to use ice as needed.  Moderate her activities and use crutches.  She will follow up as soon as the MRI is performed.","orthopedic, acl graft, acl reconstruction, knee, anterior cruciate ligament, internal derangement, contact injury, knee injury, injury, cruciate, acl, anterior,"
  Left knee arthroscopy with lateral capsular release., Orthopedic, Knee Arthroscopy ,"PREOPERATIVE DIAGNOSIS: , Left patellar chondromalacia.,POSTOPERATIVE DIAGNOSIS:,  Left patellar chondromalacia with tight lateral structures.,PROCEDURE:,  Left knee arthroscopy with lateral capsular release.,ANESTHESIA: , Surgery performed under general anesthesia.,TOURNIQUET TIME:  ,47 minutes.,MEDICATION:  ,The patient received 0.5% Marcaine local anesthetic 32 mL.,COMPLICATIONS: , No intraoperative complications.,DRAINS AND SPECIMENS: , None.,HISTORY AND PHYSICAL:  ,The patient is a 14-year-old girl who started having left knee pain in the fall of 2007.  She was not seen in Orthopedic Clinic until November 2007.  The patient had an outside MRI performed that demonstrated left patellar chondromalacia only.  The patient was referred to physical therapy for patellar tracking exercises.  She was also given a brace.  The patient reported increasing pain with physical therapy and mother strongly desired other treatment.  It was explained to the mother in detail that this is a difficult problem to treat although majority of the patients get better with physical therapy.  Her failure with nonoperative treatment is below the standard 6-month trial; however, given her symptoms and severe pain, lateral capsular release was offered.  Risk and benefits of surgery were discussed.  Risks of surgery including risk of anesthesia, infection, bleeding, changes in sensation and motion extremity, failure of procedure to relieve pain, need for postoperative rehab, and significant postoperative swelling.  All questions were answered, and mother and daughter agreed to the above plans.,PROCEDURE NOTE: , The patient was taken to the operating room and placed on the operating table.  General anesthesia was then administered.  The patient received Ancef preoperatively.  A nonsterile tourniquet was placed on the upper aspect of left thigh.  The extremity was then prepped and draped in the standard surgical fashion.  A medial suprapatellar portal was marked on the skin as well as anteromedial and anterolateral joint line.  The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg.  Esmarch was then removed.  Incisions were then made.  Camera was initially inserted into the lateral joint line.  Visualization of patellofemoral joint revealed type 2 chondromalacia with slight lateral subluxation.  The patient did have congruent articulation about 30 degrees of knee flexion.  Visualization of the medial joint line revealed no loose bodies.  There was a small plica.  Visualization of the medial joint line revealed no significant chondromalacia.  Menisci was probed and tested with no signs of tears and instability.  ACL was noted to be intact.  The intercondylar notch and lateral joint line also revealed no significant chondromalacia or meniscal pathology.  Lateral gutter also demonstrated no loose bodies or plica.  The camera was then removed and inserted into the anteromedial portal using two 18-gauge needles.  The extent of lateral capsular release was marked using a monopolar coblator, lateral capsular release was performed.  The patient had significant improvement in anteromedial translation from 25% to 50%.  At the end of the case, all instruments were removed.  The knee was injected with 32 mL of 0.5% Marcaine with additional epinephrine.  Please note, the patient received 30 mL of 1:500,000 dilution epinephrine at the beginning of the case.  The portals were then closed using 4-0 Monocryl.  The wound was clean and dry, and dressed with Steri-Strips, Xeroform, and 4 x 4s.  The kneecap was translated medially under pressure and a bias placed.  The tourniquet was released at 47 minutes.  The patient was then placed in the knee immobilizer.  The patient tolerated the procedure well and was subsequently extubated and taken to the recovery in stable condition.,POSTOPERATIVE PLAN: , The patient will weightbear as tolerated in the knee immobilizer.  She will start physical therapy within 1 to 2 weeks to work on patella mobilization as well as reconditioning and strengthening.  Intraoperative findings were relayed to the mother.  All questions were answered.","orthopedic, knee arthroscopy, lateral capsular release, chondromalacia, patellar, lateral joint line, medial joint line, lateral joint, medial joint, capsular release, joint line, arthroscopy, tourniquet, knee,"
 Arthroscopic procedure of the knee., Orthopedic, Knee Arthroscopy - 1 ,"PROCEDURE IN DETAIL: , After written consent was obtained from the patient, the patient was brought back into the operating room and identified.  The patient was placed in the operating room table in supine position and given general anesthetic.,Ancef 1 g was given for infectious prophylaxis.  Once the patient was under general anesthesia, the knee was prepped and draped in usual sterile fashion.  Once the knee was fully prepped and draped, then we made 2 standard portals medial and lateral.  Through the lateral portal, the camera was placed.  Through the medial portal, tools were placed.  We proceeded to examine scarring of the patellofemoral joint.  Then we probed the patellofemoral joint.  A chondroplasty was performed using a shaver.  Then we moved down to the lateral gutter.  Some loose bodies were found using a shaver and dissection.  We moved down the medial gutter.  No plica was found.,We moved into the medial joint; we found that the medial meniscus was intact.  We moved to the lateral joint and found that the lateral meniscus was intact.  Pictures were taken.  We drained the knee and washed out the knee with copious amounts of sterile saline solution.  The instruments were removed.  The 2 portals were closed using 3-0 nylon suture.  Xeroform, 4 x 4s, Kerlix x2, and TED stocking were placed.  The patient was successfully extubated and brought to the recovery room in stable condition.  I then spoke with the family going over the case, postoperative instructions, and followup care.","orthopedic, chondroplasty, knee, meniscus, patellofemoral, arthroscopy, portals, jointNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Painful right knee status post total knee arthroplasty many years ago.   Status post poly exchange, right knee, total knee arthroplasty.", Orthopedic, Knee Arthroplasty - Discharge Summary ,"ADMISSION DIAGNOSIS:,  Painful right knee status post total knee arthroplasty many years ago.  The patient had gradual onset of worsening soreness and pain in this knee.  X-ray showed that the poly seems to be worn out significantly in this area.,DISCHARGE DIAGNOSIS:,  Status post poly exchange, right knee, total knee arthroplasty.,CONDITION ON DISCHARGE:,  Stable.,PROCEDURES PERFORMED:,  Poly exchange total knee, right.,CONSULTATIONS: , Anesthesia managed femoral nerve block on the patient.,HOSPITAL COURSE:  ,The patient was admitted with revision right total knee arthroplasty and replacement of patellar and tibial poly components.  The patient recovered well after this.  Working with PT, she was able to ambulate with minimal assistance.  Nerve block was removed by anesthesia.  The patient did well on oral pain medications.  The patient was discharged home.  She is actually going to home with her son who will be able to assist her and look after her for anything she might need.  The patient is comfortable with this, understands the therapy regimen, and is very satisfied after the procedure.,DISCHARGE INSTRUCTIONS AND MEDICATIONS: , The patient is to be discharged home to the care of the son.  Diet is regular.  Activity, weight bear as tolerated right lower extremity.  Continue to do physical therapy exercises.  The patient will be discharged home on Coumadin 4 mg a day as the INR was 1.9 on discharge with twice weekly lab checks.  Vicodin 5/500 mg take one to two tablets p.o. q.4-6h.  Resume home medications.  Call the office or return to the emergency room for any concerns including increased redness, swelling, drainage, fever, or any concerns regarding operation or site of incision.  The patient is to follow up with Dr. ABC in two weeks.","orthopedic, painful right knee, total knee arthroplasty, poly exchange, femoral nerve block, patellar, tibial poly, knee arthroplasty, knee, arthroplasty,"
" Left knee pain and stiffness.  Bilateral knee degenerative joint disease (DJD).  Significant back pain, status post lumbar stenosis surgery with pain being controlled on methadone 10 mg b.i.d.", Orthopedic, Knee DJD - Consult ,"CHIEF COMPLAINT: , Left knee pain and stiffness.,HISTORY OF PRESENT ILLNESS: , The patient is a 57-year-old with severe bilateral knee DJD, left greater than right, with significant pain and limitations because of both.  He is able to walk approximately a 1/2-mile a day but is limited because of his knees.  Stairs are negotiated 1 at a time.  His problems with bilateral knee DJD have been well documented.  He had arthroscopy in the 1991/199two time frame for both of these.  He has been on long-standing conservative course for these including nonsteroidals, narcotics, injections.  At this point because of his progressive and persistent limitations he has opted for total joint surgery on the left side.  He does have other arthritic complaints including multiple back surgeries for spinal stenosis including decompression and epidural steroids.  Significant pain is handled by narcotic medication.  His attending physician is Dr. X.,PAST MEDICAL HISTORY: , Hypertension.,PRIOR SURGERIES:,1.  Inguinal hernia on the left.,2.  Baker's cyst.,3.  Colon cancer removal.,4.  Bilateral knee scopes.,5.  Right groin hernia.,6.  Low back surgery for spinal stenosis.,7.  Status post colon cancer second surgery.,MEDICATIONS:,1.  Ambien 12.5 mg nightly.,2.  Methadone 10 mg b.i.d.,3.  Lisinopril 10 mg daily.,IV MEDICATIONS FOR PAIN:  ,Demerol appears to work the best.,ALLERGIES: , Levaquin and Cipro cause rashes; ibuprofen causes his throat to swell, Fortaz causes an unknown reaction.,REVIEW OF SYSTEMS:  ,He does have paresthesias down into his thighs secondary to spinal stenosis.,SOCIAL HISTORY: , Married.  He is retired, being a Pepsi-Cola driver secondary to his back and knees.,HABITS: , No tobacco or alcohol.  Chewed until 2003.,RECREATIONAL PURSUITS:  ,Golfs, gardens, woodworks.,FAMILY HISTORY:,1.  Cancer.,2.  Coronary artery disease.,PHYSICAL EXAMINATION:,GENERAL APPEARANCE:  A pleasant, cooperative 57-year-old white male.,VITAL SIGNS:  Height 5' 9"", weight 167.  Blood pressure 148/86.  Pulse 78 per minute and regular.,HEENT:  Unremarkable.  Extraocular movements are full.  Cranial nerves II-XII intact.,NECK:  Supple.,CHEST:  Clear.,CARDIOVASCULAR:  Regular rhythm.  Normal S1 and 2.,ABDOMEN:  No organomegaly.  No tenderness.  Normal bowel sounds.,NEUROLOGIC:  Intact.,MUSCULOSKELETAL:  Left knee reveals a range of -10 degrees extension, 126 flexion.  His extensor mechanism is intact.  There is mild varus.  He has good stability at 30 degrees of flexion.  Lachman's and posterior drawer are negative.  He has good muscle turgor.  Dorsalis pedis pulse 2+.,DIAGNOSTICS:  ,X-rays revealed severe bilateral knee DJD with joint space narrowing medially as well as the patellofemoral joint with large osteophytes, left greater than right.,IMPRESSION:,1.  Bilateral knee degenerative joint disease.,2.  Significant back pain, status post lumbar stenosis surgery with pain being controlled on methadone 10 mg b.i.d.",
 Evaluation for chronic pain program, Orthopedic, Knee & Back Pain ,"REASON FOR EVALUATION:,",
 Revision right total knee arthroplasty.  Right failed total knee arthroplasty., Orthopedic, Knee Arthroplasty - Revision ,"PREOPERATIVE DIAGNOSIS: , Right failed total knee arthroplasty.,POSTOPERATIVE DIAGNOSIS:  ,Right failed total knee arthroplasty.,PROCEDURE PERFORMED: ,  Revision right total knee arthroplasty.,FIRST ANESTHESIA: , Spinal.,ESTIMATED BLOOD LOSS: , Approximately 75 cc.,TOURNIQUET TIME: , 123 minutes.  Then it was let down for approximately 15 minutes and then reinflated for another 26 minutes for a total of 149 minutes.,COMPONENTS: , A Zimmer NexGen Legacy knee size D right stemmed femoral component was used.  A NexGen femoral component with a distal femoral augmented block, size 5 mm.  A NexGen tibial component, size 3 mm was used.  A size 14 mm constrained polyethylene surface was used as well.  Original patellar component that the patient had was maintained.,COMPLICATIONS:  ,None.,BRIEF HISTORY:,  The patient is a 68-year-old female with a history of knee pain for 13 years.  She had previous total knee arthroplasty and revision at an outside facility.  She had continued pain, snapping, malalignment, difficulty with ambulation, and giving away and wished to undergo additional revision surgery.,PROCEDURE:,  The patient was taken to the operative suite and placed on the operating table.  Department of Anesthesia administered the spinal anesthetic.  Once adequately anesthetized, the patient was placed in a supine position.  Care was ensured and she was adequately secured and well padded in position.  Once this was obtained, the right lower extremity was prepped and draped in the usual sterile fashion.  Tourniquet was inflated to approximately 325 mmHg on the right thigh.  At this point, an incision was made over her anterior previous knee scar taking this down to the subcutaneous tissue of the overlying retinaculum.  A medial parapatellar arthrotomy was then made by using a second knife and this was taken both distally and proximally to allow us to sublux the patella on the lateral aspect to allow exposure to the joint surface.  There was noted to be no evidence of purulence or gross clinical appearance of infection, however, intraoperative cultures were taken to asses this as well.  At this point, the previous articular surface was then removed using an osteotome until this was left free and then removed.  This was done without difficulty.  Attention was then directed removing the femoral component.  Osteotome was taken around each of the edges until this was gently lifted up and then a femoral extractor was placed around it and this was back flapped until this was easily removed.  After this was performed, attention was then directed to the tibial component.  An osteotome was again inserted around the surface and this was easily pried loose.  There was noted to be minimal difficulty with this and did not appear to have adequate cement fixation.  This was evaluated.  The bone stalk appeared to be adequate, however, there were noted to be some deficits where we need to trim cement, so we elected to proceed with stemmed component.  The attention was first directed to the femur and the femoral canal was opened up and superficially reamed up to a size 18 mm proximal portion for the Zimmer stemmed component.  At this point, the distal femoral cut was evaluated with a intramedullary guide and this was noted to be cut in a varus cut leaving us a large deficit of the medial femoral cut.  We elected because of this large amount of retic to take off the medial condyle to correct this varus cut to a six degree valgus cut.  We elected to augment the medial aspect and take only 5 mm off of the lateral condyle instead of a full 10 to 12.  At this point, the distal femoral cutting guide based on the intramedullary head was then placed.  Care was ensured that this was aligned in proper rotation with the external epicondylar axis.  Once this was pinned in position, approximately a six degree valgus cut was then made.  This allowed a portion of the medial condyle to be removed distally.  The anterior cut was checked next using the intramedullary guide.  The anterior surface cutting block was then placed.  This aligned us to anterior cutting block.,We ensured again that rotation was aligned with the epicondylar axis.  Once this was adequately aligned with this and gave us some external rotation, this was pinned in position and new anterior cut was made.  It was noted that minimal bone was taken off the surface, only a slight portion on the medial anterior surface.  _______ was then removed and the chamfer cutting guide was then placed on.  This allowed us to make a box cut and recut some of the angled cuts of the distal femur.  Once this was placed and pinned in position.  Care was then again taken to check that this was in proper rotation and then the chamfer cuts were recut.  It was noted that the anterior chamfers did not need to be cut, take off no bone.  The posterior chamfers did remove some bony aspects.  This was also taken off some of the posterior aspects of the condyles and then the ossicle saw and reciprocal saw were used to take off a notch cut to open up a constrained component.  After all these cuts were taken, the guides were then removed and the trial component with a medial 5 mm augment was then placed.  This appeared to have an adequate fit and then packed in position.  It appeared to be satisfactory.  At this point, this was removed and attention was then directed to the tibia.  The intramedullary canal was again opened up using a proximal drill and this was reamed to the appropriate size until good _______ was obtained.  At this point, the intramedullary guide was used to evaluate a tibial cut.  This appeared to be adequate, however, we elected to remove 2 mm of bone to give us a new fresh bony surface.  The cutting guide was placed in adequate alignment and checked both the with intramedullary guide and an external alignment rod, which allowed us to ensure that we had proper external rotation of this tibial component.  At this point, this was pinned in position and the tibial cut was made to remove an extra 2 mm of bone.  This was again removed and a trial tibial stemmed component was then placed as well as the trial augmented stemmed femoral component.  This was placed in a proper position.  A 10 mm articular surface was placed in the knee and this was taken through range of motion.  This was found to have better alignment and satisfactory position.  We elected to take an intraoperative x-ray at this point, to evaluate our cut.  The intraoperative x-ray demonstrates satisfactory cuts and alignment of the prosthesis.  At this point, all trials were removed.  The patella was then examined.  The rongeur was used to remove the surrounding synovium.  The patella was evaluated and found to have mild wear on the lateral aspect of the inferior butt, however, this was very mild and overall had a good position and was well fixed to the bone.  It was elected at this time to maintain this anatomic patella that was previously placed.  At this point, the joint again was reevaluated and any bone loose fragments removed.  There was noted to be some posterior tightness and mild osteophytes.  These were removed with a rongeur.,At this time, while preparing the canals, the tourniquet was deflated due to it being 123 minutes.  Approximately 10 minutes did get by, as the knee was copiously irrigated and suctioned dried.  The tourniquet was then reinflated.  The canals were prepped for cementing.  They were suction-dried and cleaned.  The tibial component was cemented and then impacted into position and ensured it was adequately aligned in proper external rotation and alignment that was previously tried with the trial.  Once this was fixed and secured, all extra cement was removed and attention was directed to the femoral component.  The stemmed femoral component was then impacted in position and cemented.  Again care was ensured that it was in adequate position and proper rotation.  A size 14 mm poly was then inserted in between to provide compression.  This was then taken through extension and held until cement cured.  This was then removed and the components were evaluated.  All excess cement was removed and they were well fixed.  Size 14 mm trial Poly was then placed and this was taken through range of motion.  This was found to have excellent range of motion and good stability.  It was elected at this time that we would go with the size 14 mm Poly.  This gave us extra Poly for ware and then provide excellent contact throughout the range of motion.  The final articular surface was then placed and tightened into position to allow to _______ secured.  The knee was then reduced and the knee was taken through range of motion.  The patella was tracking with no-touch technique and adequately positioned.  At this point, the tourniquet was deflated for second time and then the knee was copiously irrigated and suctioned dry.  All bleeding was cauterized using a Bovie cautery.  The retinaculum was then repaired using #1 Ethibond in a figure-of-eight fashion.  This was reinforced with a running #2-0 Vicryl.  The knee was then flexed and noted that the patella was tracking with good alignment.  The wound was again copiously irrigated and suctioned dry.  A drain was placed prior to retinaculum repair deep to this to provide adequate drainage.  At this point, the subcutaneous tissue was closed with #2-0 Vicryl.  Skin was approximated with skin clips.  Sterile dressing of Adaptic, 4x4, Webril, and ABDs were then placed.  A large Dupre dressing was then placed up the entire lower extremity.  The patient was then transferred back to recovery in supine position.,DISPOSITION: , The patient tolerated the procedure well with no complications and transferred to PACU in satisfactory condition.","orthopedic, knee arthroplasty, revision, zimmer nexgen, distal femoral, intramedullary guide, femoral component, femoral, knee, arthroplasty, intramedullary, patellar, medial, tibial, "
" Left below-the-knee amputation.  Dressing change, right foot.", Orthopedic, Knee Amputation ,"PREOPERATIVE DIAGNOSES:,1.  Left diabetic foot abscess and infection.,2.  Left calcaneus fracture with infection.,3.  Right first ray amputation.,POSTOP DIAGNOSES:,1.  Left diabetic foot abscess and infection.,2.  Left calcaneus fracture with infection.,3.  Right first ray amputation.,OPERATION AND PROCEDURE:,1.  Left below-the-knee amputation.,2.  Dressing change, right foot.,ANESTHESIA: , General.,BLOOD LOSS: , Less than 100 mL.,TOURNIQUET TIME:,  24 minutes on the left, 300 mmHg.,COMPLICATIONS:,  None.,DRAINS: , A one-eighth-inch Hemovac.,INDICATIONS FOR SURGERY: , The patient is a 62 years of age with diabetes.  He developed left heel abscess.  He had previous debridements, developed a calcaneal fracture and has now had several debridement with placement of the antibiotic beads.  After re-inspecting the wound last week, the plan was for possible debridement and he desired below-the-knee amputation.  We are going to change the dressing on the right side also.  The risks, benefits, and alternatives of surgery were discussed.  The risks of bleeding, infection, damage to nerves and blood vessels, persistent wound healing problems, and the need for future surgery.  He understood all the risks and desired operative treatment.,OPERATIVE PROCEDURE IN DETAIL: , After appropriate informed consent obtained, the patient was taken to the operating room and placed in the supine position.  General anesthesia induced.  Once adequate anesthesia had been achieved, cast padding placed on the left proximal thigh and tourniquet was applied.  The right leg was redressed.  I took the dressing down.  There was a small bit of central drainage, but it was healing nicely.  Adaptic and new sterile dressings were applied.,The left lower extremity was then prepped and draped in usual sterile fashion.,A transverse incision made about the mid shaft of the tibia.  A long posterior flap was created.  It was taken to the subcutaneous tissues with electrocautery.  Please note that tourniquet had been inflated after exsanguination of the limb.  Superficial peroneal nerve identified, clamped, and cut.  Anterior compartment was divided.  The anterior neurovascular bundle identified, clamped, and cut.  The plane was taken between the deep and superficial compartments.  The superficial compartment was reflected posteriorly.  Tibial nerve identified, clamped, and cut.  Tibial vessels identified, clamped, and cut.,Periosteum of the tibia elevated proximally along with the fibula.  The tibia was then cut with Gigli saw.  It was beveled anteriorly and smoothed down with a rasp.  The fibula was cut about a cm and a half proximal to this using a large bone cutter.  The remaining posterior compartment was divided.  The peroneal bundle identified, clamped, and cut.  The leg was then passed off of the field.  Each vascular bundle was then doubly ligated with 0 silk stick tie and 0 silk free tie.  The nerves were each pulled at length, injected with 0.25% Marcaine with epinephrine, cut, and later retracted proximally.  The tourniquet was released.  Good bleeding from the tissues and hemostasis obtained with electrocautery.  Copious irrigation performed using antibiotic-impregnated solution.  A one-eighth-inch Hemovac drain placed in the depth of wound adhering on the medial side.  A gastroc soleus fascia brought up and attached to the anterior fascia and periosteum with #1 Vicryl in an interrupted fashion.  The remaining fascia was closed with #1 Vicryl.  Subcutaneous tissues were then closed with 2-0 PDS suture using 2-0 Monocryl suture in interrupted fashion.  Skin closed with skin staples.  Xeroform gauze, 4 x 4, and a padded soft dressing applied.  He was placed in a well-padded anterior and posterior slab splint with the knee in extension.  He was then awakened, extubated, and taken to recovery in stable condition.  There were no immediate operative complications, and he tolerated the procedure well.","orthopedic, infection, adaptic, gigli saw, hemovac, abscess, amputation, below-the-knee amputation, calcaneus fracture, debridement, diabetic foot, ray amputation, tourniquet, transverse incision, knee amputation, knee, dressing, clamped, "
 A 66-year-old female with knee osteoarthrosis who failed conservative management., Orthopedic, Knee Osteoarthrosis - Discharge Summary ,"PRINCIPAL DIAGNOSIS:,  Knee osteoarthrosis.,PRINCIPAL PROCEDURE: , Total knee arthroplasty.,HISTORY AND PHYSICAL:,  A 66-year-old female with knee osteoarthrosis.  Failed conservative management.  Risks and benefits of different treatment options were explained.  Informed consent was obtained.,PAST SURGICAL HISTORY: , Right knee surgery, cosmetic surgery, and carotid sinus surgery.,MEDICATIONS: , Mirapex, ibuprofen, and Ambien.,ALLERGIES: , QUESTIONABLE PENICILLIN ALLERGIES.,PHYSICAL EXAMINATION: , GENERAL:  Female who appears younger than her stated age.  Examination of her gait reveals she walks without assistive devices.,HEENT:  Normocephalic and atraumatic.,CHEST:  Clear to auscultation.,CARDIOVASCULAR:  Regular rate and rhythm.,ABDOMEN:  Soft.,EXTREMITIES:  Grossly neurovascularly intact.,HOSPITAL COURSE: , The patient was taken to the operating room (OR) on 03/15/2007.  She underwent right total knee arthroplasty.  She tolerated this well.  She was taken to the recovery room.  After uneventful recovery room course, she was brought to regular surgical floor.  Mechanical and chemical deep venous thrombosis (DVT) prophylaxis were initiated.  Routine postoperative antibiotics were administered.  Hemovac drain was discontinued on postoperative day #2.  Physical therapy was initiated.  Continuous passive motion (CPM) was also initiated.  She was able to spontaneously void.  She transferred to oral pain medication.  Incision remained clean, dry, and intact during the hospital course.  No pain with calf squeeze.  She was felt to be ready for discharge home on 03/19/2007.,DISPOSITION:  ,Discharged to home.,FOLLOW UP:,  Follow up with Dr. X in one week.  Prescriptions were written for Percocet and Coumadin.,INSTRUCTIONS: , Home physical therapy and PT and INR to be drawn at home for adjustment of Coumadin dosing.,","orthopedic, total knee arthroplasty, conservative management, knee arthroplasty, physical therapy, knee osteoarthrosis, arthroplasty, osteoarthrosis, knee, "
" Bilateral degenerative arthritis of the knees.  Right total knee arthroplasty done in conjunction with a left total knee arthroplasty, which will be dictated separately.", Orthopedic, Knee Arthroplasty ,"PREOPERATIVE DIAGNOSIS: , Bilateral degenerative arthritis of the knees.,POSTOPERATIVE DIAGNOSIS: , Bilateral degenerative arthritis of the knees.,PROCEDURE PERFORMED: , Right total knee arthroplasty done in conjunction with a left total knee arthroplasty, which will be dictated separately.,ANESTHESIA: , General.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS: , Bilateral procedure was 400 cc.,TOTAL TOURNIQUET TIME:  ,75 minutes.,COMPONENTS: , Include the Zimmer NexGen complete knee solution system, which include a size F right cruciate retaining femoral component, a size #8 peg tibial component precoat, a All-Poly standard size 38, 9.5 mm thickness patellar component, and a prolonged highly cross-linked polyethylene NexGen cruciate retaining tibial articular surface size blue 12 mm height.,HISTORY OF PRESENT ILLNESS: , The patient is a 69-year-old male who presented to the office complaining of bilateral knee pain for a couple of years.  The patient complained of clicking noises and stiffness, which affected his daily activities of living.,PROCEDURE: , After all potential complications, risks as well as anticipated benefits of the above-named procedure was discussed at length, the patient's informed consent was obtained.,Operative extremities were then confirmed with the operating surgeons as well as the nursing staff, Department of Anesthesia, and the patient.  The patient was then transferred to preoperative area to operative suite #2 and placed on the operating room table in supine position.  All bony prominences were well padded at this time.  At this time, Department of Anesthesia administered general anesthetic to the patient.  The patient was allowed in DVT study and the right extremity was in the Esmarch study as well as the left.  The nonsterile tourniquet was then applied to the right upper thigh of the patient, but not inflated at this time.  The right lower extremity was sterilely prepped and draped in the usual sterile fashion.  The right upper extremity was then elevated and exsanguinated using an Esmarch and the tourniquet was inflated using 325 mmHg.  The patient was a consideration for a unicompartmental knee replacement.  So, after all bony and soft tissue landmarks were identified, a limited midline longitudinal incision was made directly over the patella.  A sharp dissection was then taken down to the level of the fascia in line with the patella as well as the quadriceps tendon.  Next, a medial parapatellar arthrotomy was performed using the #10 blade scalpel.  Upon viewing of the articular surfaces, there was significant ware in the trochlear groove as well as the medial femoral condyle and it was elected to proceed with total knee replacement.  At this time, the skin incisions as well as the deep incisions were extended proximally and distally in a midline fashion.  Total incision now measured approximately 25 cm.  Retractors were placed.  Next, attention was directed to establishing medial and lateral flaps of the proximal tibia.  Reciprocating osteal elevator was used to establish soft tissue plane and then an electrocautery was then used to subperiosteal strip medially and laterally on the proximal tibia.  At this time, the patella was then everted.  The knee was flexed up to 90 degrees.  Next, using the large drill bit, the femoral canal was then opened in appropriate position.  The intramedullary sizing guide was then placed and the knee was sized to a size F. At this time, the three degrees external rotation holes were then drilled after carefully assessing the epicondylar access as well as the white sideline.  The guide was then removed.  The intramedullary guide was then placed with nails holding the guide in three degrees of external rotation.  Next, the anterior femoral resection guide was then placed and clamped into place using a pointed _________________ was then used to confirm that there would no notching performed.  Next, soft tissue retractors were placed and an oscillating saw was used to make the anterior femoral cut.  Upon checking, it was noted to be flat with no oscillations.  The anterior guide was then removed and the distal femoral resection guide was placed in five degrees of valgus.  It was secured in place using nails.  The intramedullary guide was then removed and the standard distal femoral cut was then made using oscillating saw.,This was then removed and the size F distal finishing femoral guide was then placed on the femur in proper position.  Bony and soft tissue landmarks were confirmed and the resection guide was then held in place using nail as well as spring screws.  Again, the collateral ligament retractors were then placed and the oscillating saw was used to make each of the anterior and posterior as well as each chamfer cut.  A reciprocating saw was then used to cut the trochlear cut and the peg holes were drilled as well.  The distal finishing guide was then removed and osteotome was then used to remove all resected bone.  The oscillating saw was then used to complete the femoral notch cut.  Upon viewing, there appeared to be proper amount of bony resection and all bone was removed completely.  There was no posterior osteophytes noted and no fragments to the posterior aspect.  Next, attention was directed towards the tibia.  The external tibial guide was reflected.  This was placed on the anterior tibia and held in place using nails after confirming the proper varus and valgus position.  The resection guide was then checked and appeared to be sufficient amount of resection in both medial and lateral condyles of the tibia.  Next, collateral ligament retractors were placed as well as McGill retractors for the PCL.  Oscillating saw was then used to make the proximal tibial cut.  Osteotome was used to remove this excess resected bone.  The laminar spreader was then used to check the flexion and extension.  The gaps appeared to be equal.  The external guide was then removed and trial components were placed to a size F femoral component and a 12 mm tibial component on a size 8 tray.  The knee was taken through range of motion and had very good flexion as well as full extension.  There appeared to be good varus and valgus stability as well.  Next, attention was directed towards the patella.  There noted to be a sufficient ware and it was selected to replace the patella.  It was sized with caliper, pre-cut and noted to be 26 mm depth.  The sizing guide was then used and a size 51 resection guide selected.  A 51 mm reamer was then placed and sufficient amount of patella was then removed.  The calcar was then used to check again and there was noted to be 15 mm remaining.  The 38 mm patella guide was then placed on the patella.  It was noted to be in proper size and the three drill holes for the pegs were used.  A trial component was then placed.  The knee was taken through range of motion.  There was noted to be some subluxation lateral to the patellar component and a lateral release was performed.  After this, the component appeared to be tracking very well.  There remained a good range of motion in the knee and extension as well as flexion.  At this time, an AP x-ray of the knee was taken with the trial components in place.  Upon viewing this x-ray, it appeared that the tibial cut was in neutral, all components in proper positioning.  The knee was then copiously irrigated and dried.  The knee was then flexed ___________ placed, and the peg drill guide was placed on the tibia in proper position, held in place with nails.,The four peg holes were then drilled.  The knee again was copiously irrigated and suction dried.  The final components were then selected again consisting of size F femoral components.  A peg size 8 tibial component, a 12 mm height articular surface, size blue, and a 38 mm 9.5 mm thickness All-Poly patella.  Polymethyl methacrylate was then prepared at this time.  The proximal tibia was dried and the cement was then pressed into place.  The cement was then placed on the backside of the tibial component and the tibial component was then impacted into proper positioning.  Next, the proximal femur was cleaned and dried.  Polymethyl methacrylate was placed on the resected portions of the femur as well as the backside of the femoral components.  This was then impacted in place as well.  At this time, all excess cement was removed from both the tibial and femoral components.  A size 12 mm trial tibial articular surface was then put in place.  The knee was reduced and held in loading position throughout the remaining drying position of the cement.  Next, the resected patella was cleaned and dried.  The cement was placed on the patella as well as the backside of the patellar component.  The component was then put in proper positioning and held in place with a clamp.  All excess polymethyl methacrylate was removed from this area as well.  This was held until the cement had hardened sufficiently.  Next, the knee was examined.  All excess cement was then removed.  The knee was taken through range of motion with sufficient range of motion as well as stability.  The final 12 mm height polyethylene tibial component was then put into place and snapped down in proper position.  Again range of motion was noted to be sufficient.  The knee was copiously irrigated and suction dried once again.  A drain was then placed within the knee.  The wound was then closed first using #1 Ethibond to close the arthrotomy oversewn with a #1 Vicryl.  The knee was again copiously irrigated and dried.  The skin was closed using #2-0 Vicryl in subcuticular fashion followed by staples on the skin.  The ConstaVac was then _______ to the drain.  Sterile dressing was applied consisting of Adaptic, 4x4, ABDs, Kerlix, and a 6-inch Dupre roll from foot to thigh.  Department of Anesthesia then reversed the anesthetic.  The patient was transferred back to the hospital gurney to Postanesthesia Care Unit.  The patient tolerated the procedure well and there were no complications.","orthopedic, degenerative, arthritis, zimmer nexgen, all-poly, cruciate, patellar component, total knee arthroplasty, knee arthroplasty, tibial component, femoral, patellar, tibial, knee, arthroplasty, anesthesia, "
 Intramedullary nail fixation of the left tibia fracture with a Stryker T2 tibial nail.  Left tibial shaft fracture status post gunshot wound., Orthopedic, Intramedullary Nail Fixation ,"TITLE OF OPERATION: , Intramedullary nail fixation of the left tibia fracture with a Stryker T2 tibial nail, 10 x 390 with a one 5-mm proximal locking screw and three 5-mm distal locking screws (CPT code is 27759) (the ICD-9 code again is 823.2 for a tibial shaft fracture).,INDICATION FOR SURGERY:  ,The patient is a 19-year-old male, who sustained a gunshot wound to the left tibia with a distal tibial shaft fracture.  The patient was admitted and splinted and had compartment checks.  The risks of surgery were discussed in detail including, but not limited to infection, bleeding, injuries to nerves, or vital structures, nonunion or malunion, need for reoperation, compartment syndrome, and the risk of anesthesia.  The patient understood these risks and wished to proceed.,PREOP DIAGNOSIS: , Left tibial shaft fracture status post gunshot wound (CPT code 27759).,POSTOP DIAGNOSIS: , Left tibial shaft fracture status post gunshot wound (CPT code 27759).,ANESTHESIA: , General endotracheal.,INTRAVENOUS FLUID:,  900.,ESTIMATED BLOOD LOSS:  ,100.,COMPLICATIONS:,  None.,DISPOSITION: , Stable to PACU.,PROCEDURE DETAIL:  ,The patient was met in the preoperative holding area and operative site was marked.  The patient was brought to the operating room and given preoperative antibiotics.  Left leg was then prepped and draped in the usual sterile fashion.  A midline incision was made in the center of the knee and was carried down sharply to the retinacular tissue.  The starting guidewire was used to localize the correct starting point, which is on the medial aspect of the lateral tibial eminence.  This was advanced and confirmed on the AP and lateral fluoroscopic images.  The opening reamer was then used and the ball-tip guidewire was passed.  The reduction was obtained over a large radiolucent triangle.  After passing the guidewire and achieving appropriate reduction, the flexible reamers were then sequentially passed, starting at 9 mm up to 11.5 mm reamer.  At this point, a 10 x 390 mm was passed without difficulty.  The guide was used to the proximal locking screw and the appropriate circle technique was used to the distal locking screws.  The final images were taken with fluoroscopy and a 15-mm end-cap was placed.  The wounds were then irrigated and closed with 2-0 Vicryl followed by staples to the distal screws and 0 Vicryl followed 2-0 Vicryl and staples to the proximal incision.  The patient was placed in a short leg, well-padded splint, was awakened and taken to recovery in good condition.,The plan will be nonweightbearing left lower extremity.  He will be placed in a short leg splint and should be transitioned to a short leg cast for the next 4 weeks.","orthopedic, screw, stryker, tibia, intramedullary nail fixation, tibial shaft fracture, intramedullary, guidewire, nail, fracture, tibial"
 Displaced left subtrochanteric femur fracture.  Intramedullary rod in the left hip using the Synthes trochanteric fixation nail measuring 11 x 130 degrees with an 85-mm helical blade., Orthopedic, Intramedullary Rod ,"PREOPERATIVE DIAGNOSIS:,  Displaced left subtrochanteric femur fracture.,POSTOPERATIVE DIAGNOSIS:,  Displaced left subtrochanteric femur fracture.,OPERATION: , Intramedullary rod in the left hip using the Synthes trochanteric fixation nail measuring 11 x 130 degrees with an 85-mm helical blade.,COMPLICATIONS:,  None.,TOURNIQUET TIME:,  None.,ESTIMATED BLOOD LOSS:,  50 mL.,ANESTHESIA: , General.,INDICATIONS:  ,The patient suffered a fall at which time she was taken to the emergency room with pain in the lower extremities.  She was diagnosed with displaced left subcapital hip fracture, now was asked to consult.  With this diagnosis, she was indicated the above-noted procedure.  This procedure as well as alternatives to this procedure was discussed at length with the patient and her son, who has the power of attorney, and they understood them well.,Risks and benefits were also discussed.  Risks include bleeding, infection, damage to blood vessels, damage to nerves, risk of further surgery, chronic pain, restricted range of motion, risk of continued discomfort, risk of malunion, risk of nonunion, risk of need for further reconstructive procedures, risk of need for altered activities and altered gait, risk of blood clots, pulmonary embolism, myocardial infarction, and risk of death were discussed.  She understood these well and consented, and the son signed the consent for the procedure as described.,DESCRIPTION OF PROCEDURE: , The patient was placed on the operating table and general anesthesia was achieved.  The patient was then placed in fracture boots and manipulated under fluoroscopic control until we could obtain near anatomic alignment.  External positions were felt to be present.  At this point, the left hip and left lower extremity was then prepped and draped in the usual sterile manner.  A guidewire was then placed percutaneously into the tip of the greater trochanter and a small incision was made overlying the guidewire.  An overlying drill was inserted to the proper depths.  A Synthes 11 x 130 degrees trochanteric fixation that was chosen was placed into the intramedullary canal to the proper depth.  Proper rotation was obtained and the guide for the helical blade was inserted.  A small incision was made for this as well.  A guidewire was inserted and felt to be in proper position, in the posterior aspect of the femoral head, lateral, and the center position on AP.  This placed the proper depths and lengths better.  The outer cortex was enlarged and an 85-mm helical blade was attached to the proper depths and proper fixation was done.  Appropriate size screw was then tightened down.  At this point, a distal guide was then placed and drilled across both the cortices.  Length was better.  Appropriate size screw was then inserted.  Proper size and fit of the distal screw was also noted.  At this point, on fluoroscopic control, it was confirming in AP and lateral direction.  We did a near anatomical alignment to the fracture site and all hardware was properly fixed.  Proper size and fit was noted.  Excellent bony approximation was noted.  At this point, both wounds were thoroughly irrigated, hemostasis confirmed, and closure was then begun.,The fascial layers were then reapproximated using #1 Vicryl in a figure-of-eight manner, the subcutaneous tissues were reapproximated in layers using #1 and 2-0 Vicryl sutures, and the skin was reapproximated with staples.  The area was then infiltrated with a mixture of a 0.25% Marcaine with Epinephrine and 1% plain lidocaine.  Sterile dressing was then applied.  No complication was encountered throughout the procedure.  The patient tolerated the procedure well.  The patient was taken to the recovery room in stable condition.","orthopedic, displaced, femur fracture, subtrochanteric, hip, synthes, intramedullary rod, subtrochanteric femur, trochanteric fixation, helical blade, tourniquet, intramedullary, trochanteric, fixation, helical, blade, guidewire, fracture,"
 Bilateral knee degenerative arthritis.  Bilateral knee arthroplasty.  The Zimmer NexGen total knee system was utilized., Orthopedic, Knee Arthroplasty - Bilateral ,"PREOPERATIVE DIAGNOSIS: , Bilateral knee degenerative arthritis.,POSTOPERATIVE DIAGNOSIS: , Bilateral knee degenerative arthritis.,PROCEDURE PERFORMED: , Bilateral knee arthroplasty.,Please note this procedure was done by Dr. X for the left total knee and Dr. Y for the right total knee.  This operative note will discuss the right total knee arthroplasty.,ANESTHESIA:  ,General.,COMPLICATIONS: , None.,BLOOD LOSS: , Approximately 150 cc.,HISTORY:,  This is a 79-year-old female who has disabling bilateral knee degenerative arthritis.  She has been unresponsive to conservative measures.  All risks, complications, anticipated benefits, and postoperative course were discussed.  The patient has agreed to proceed with surgery as described below.,GROSS FINDINGS: , There was noted to be eburnation and wear along the patellofemoral joint and femoral tibial articulation medially and laterally with osteophyte formation and sclerosis.,SPECIFICATIONS: , The Zimmer NexGen total knee system was utilized.,PROCEDURE: , The patient was taken to the operating room #2 and placed in supine position on the operating room table.  She was administered spinal anesthetic by Dr. Z.,The tourniquet was placed about the proximal aspect of the right lower extremity.  The right lower extremity was then sterilely prepped and draped in the usual fashion.  An Esmarch bandage was used to exsanguinate the right lower extremity and the tourniquet was inflated to 325 mmHg.  Longitudinal incision was made over the anterior aspect of the right knee.  Subcutaneous tissue was carefully dissected.  A medial parapatellar retinacular incision was made.  The patella was then everted and the above noted gross findings were appreciated.  A drill hole was placed in the distal aspect of the femur and the distal femoral cutting guides were positioned in place.  The appropriate cuts were made at the distal femur as well as with use of the chamfer guide.  The trial femoral component was then positioned in place and noted to have good fit.  Attention was then directed to proximal tibia, the external tibial alignment guide was positioned in place and the proximal tibial cut was made demonstrating satisfactory cut.  The medial and lateral collateral ligaments remained intact throughout the procedure as well as the posterior cruciate ligaments.  The remnants of the anterior cruciate ligament and menisci were resected.  The tibial trial was positioned in place.  Intraoperative radiographs were taken, demonstrating satisfactory alignment of the tibial cut.  The tibial holes were then drilled.  The patella was then addressed with the Bovie used to remove the soft tissue around the perimeter of the patella.  The patellar cutting guide was positioned in place and the posterior aspect of the patella was resected to the appropriate thickness.  Three drill holes were made within the patella after it was determined that 35 mm patella would be most appropriate.  The knee was placed through range of motion with the trial components marked and then the appropriate components obtained.  The tibial tray was inserted with cement, backed it into place, excess methylmethacrylate was removed.  The femoral component was inserted with methylmethacrylate.  Any excessive methylmethacrylate and bony debris were removed from the joint.  Trial Poly was positioned in place and the knee was held in full extension while the methylmethacrylate became firm.  The methylmethacrylate was also used at the patella.  The prosthesis was positioned in place.  The patellar clamp held securely till the methylmethacrylate was firm.  After all three components were in place, the knee was then again in placed range of motion and there appeared to be some torsion to the proximal tibial component and concerned regarding the alignment.  This component was removed and revised to a stemmed component with better alignment and position.  The previous component removed, the methylmethacrylate was removed.  Further irrigation was performed and then a stemmed template was positioned in place with the intramedullary alignment guide positioned and the tibia drilled and broached.  The trial tibial stemmed component was positioned in place.  Knee was placed through range of motion and the tracking was better.  Actual component was then obtained, methyl methacrylate was placed within the tibia.  The stemmed tibial component was impacted into place with good fit.  The Poly was then positioned in place.  Knee held in full extension with compression longitudinally after methylmethacrylate was solidified.  The trial Poly was removed.  Wound was irrigated and the joint was inspected.  There was no debris.  Collateral ligaments and posterior cruciate ligaments remained intact.  Soft tissue balancing was done and a 17 mm Poly was then inserted with the knee and tibial and femoral components with good tracking as well as the patellar component.  The tourniquet was deflated.  Hemostasis was satisfactory.  A drain was placed into the depths of the wound.  The medial retinacular incision was closed with one Ethibond suture in interrupted fashion.  The knee was placed through range of motion and there was no undue tissue tension, good patellar tracking, no excessive soft tissue laxity or constrain.  The subcutaneous tissue was closed with #2-0 undyed Vicryl in interrupted fashion.  The skin was closed with surgical clips.  The exterior of the wound was cleansed as well padded dressing ABDs and ace wrap over the right lower extremity.  At the completion of the procedure, distal pulses were intact.  Toes were pink, warm, with good capillary refill.  Distal neurovascular status was intact.  Postoperative x-ray demonstrated satisfactory alignment of the prosthesis.  Prognosis is good in this 79-year-old female with a significant degenerative arthritis.","orthopedic, patellofemoral, eburnation, osteophyte, articulation, tibial, femoral, bilateral knee arthroplasty, knee degenerative arthritis, zimmer nexgen, lower extremity, arthroplasty, patella, methylmethacrylate,"
" A male presents complaining of some right periscapular discomfort, some occasional neck stiffness, and some intermittent discomfort in his low back relative to an industrial fall.", Orthopedic, IME & Record Review - Orthopedic ,"INTRODUCTION: , The opinions expressed in this report are those of the physician.  The opinions do not reflect the opinions of Evergreen Medical Panel, Inc.  The claimant was informed that this examination was at the request of the Washington State Department of Labor and Industries (L&I).  The claimant was also informed that a written report would be sent to L&I, as requested in the assignment letter from the claims manager.  The claimant was also informed that the examination was for evaluative purposes only, intended to address specific injuries or conditions as outlined by L&I, and was not intended as a general medical examination.,CHIEF COMPLAINTS: , This 51-year-old married male presents complaining of some right periscapular discomfort, some occasional neck stiffness, and some intermittent discomfort in his low back relative to an industrial fall that occurred on November 20, 2008.,HISTORY OF INDUSTRIAL INJURY:,  This patient was injured on November 20, 2008.  He works at the Purdy Correctional Facility and an inmate had broken some overhead sprinklers, the floor was thus covered with water and the patient slipped landing on the back of his head, then on his back.  The patient said he primarily landed on the left side.  After the accident he states that he was generally stun and someone at the institute advised him to be evaluated.  He went to a Gig Harbor urgent care facility and they sent him on to Tacoma General Hospital.  At the Tacoma General, he indicates that a whiplash and a concussion were diagnosed and it was advised that he have a CT scan.  The patient describes that he had a brain CT and a dark spot was found.  It was recommended that he have a followup MRI and this was done locally and showed a recurrent acoustic neuroma.  Before, when the patient initially had developed an acoustic neuroma, the chiropractor had seen the patient and suggested that he have a scan and this was how his original acoustic neuroma was diagnosed back in October 2005.  The patient has been receiving adjustments by the chiropractor since and he also has had a few massage treatments.  Overall his spine complaints have improved substantially.,After the fall, he also saw at Prompt Care in the general Bremerton area, XYZ, an Osteopathic Physician and she examined him and released him full duty and also got an orthopedic consult from XYZ.  She ordered an MRI of his neck.  Cervically this showed that he had a mild disc bulge at C4-C5, but this actually was the same test that diagnosed a recurrent acoustic neuroma and the patient now is just recovering from neurosurgical treatment for this recurrent acoustic neuroma and some radiation is planned.,Since 2002 the patient has been seeing the chiropractor, XYZ for general aches and pain and this has included some treatments on his back and neck.,CURRENT SYMPTOMS:  ,The patient describes his current pain as being intermittent.,PAST MEDICAL HISTORY:,Illnesses:  The patient had a diagnosis in 2005 of an acoustic neuroma.  It was benign, but treated neurosurgically.  In February 2004 and again in August 2009 he has had additional treatments for recurrence and he currently has some skull markers in place because radiation is planned as a followup, although the tumor was still indicated to be benign.,Operations:  He has a history of an old mastoidectomy.  He has a past history of removal of an acoustic neuroma in 2005 as noted.,Medications:  The patient takes occasional Tylenol and occasional Aleve.,Substance Use:,Tobacco:  He does not smoke cigarettes.,Alcohol:  He drinks about five beers a week.,FAMILY HISTORY:,  His father died of mesothelioma and his mother died of Lou Gehrig's disease.,SOCIOECONOMIC HISTORY:,Marital Status and Dependents:  The patient has been married three times; longest marriage is of two years duration.  He has two children.  These dependents are ages 15 and twins and are his wife's dependents.,Education:  The patient has bachelor's degree.,Military History:  He served six years in the army and received an honorable discharge.,Work History:  He has worked at Purdy Correctional Institute in Gig Harbor for 19 years.,CHART REVIEW: , Review of the chart indicates a date of injury of November 20, 2008.  He was seen at Tacoma General Hospital with a diagnosis of head contusion and cervical strain.  He had a CT of his head done because of a fall with possible loss of consciousness, which showed a left cerebellar hypodensity and further evaluation was recommended.  He has a history of an old mastoidectomy.  He was then seen on November 24, 2008 by XYZ at Prompt Care on November 24, 2008.  There is no clearcut history that he had lost consciousness.  He has a past history of removal of an acoustic neuroma in 2005 as noted.  A diagnosis of concussion and cervical strain status post fall was made along with an underlying history of abnormal CT and previous resection of an acoustic neuroma.  Some symptoms of loss of balance and confusion were noted.  She recommended additional testing and neurologic evaluation.,The notes from the treating chiropractor begin on November 24, 2008.  Adjustments are given to the cervical, thoracic, and lumbar spine.,He was seen back by XYZ on December 9, 2008 and he had been released to full duties.  It was recognized the new MRI suggested recurrence of the acoustic neuroma and he was advised to seek further care in this regard.  There were some concerns of his feeling of being wobbly since the fall which might be related to the recurrent neuroma.  He continued to have chiropractic adjustments.  He was seen back at Prompt Care on January 8, 2009.  Dr. X indicated that she thought most of his symptoms were related to the tumor, but that the cervical and thoracic stiffness were from the fall.,A followup note by his chiropractor on January 26, 2009 indicates that cervical x-rays have been taken and that continued chiropractic adjustments along with manual traction would be carried out.,On April 13, 2009, he was seen again at Prompt Care for his cervical and thoracic strain.  He was indicated to be improving and there was suggestion that he has some physical therapy and an orthopedic consult was felt appropriate.  Therapy was not carried out and obviously was then involved with the treatment of his recurrent neuroma.,On April 17, 2009, he was seen by Dr. X, another chiropractor for consultation and further chiropractic treatments were recommended based on cervical and thoracolumbar subluxation complexes and strain.,A repeat consult was carried out on April 29, 2009 by XYZ.  He felt that this was hyperextension cervical injury.  It might take a period of time to recover.  He mentioned that the patient might have a slight ulnar neuropathy.  He felt the patient was capable of full duty and the patient was at that time having ongoing treatment for his neuroma.,This concludes the chart review.,PHYSICAL EXAMINATION: , The patient is 6 feet in height, weighs 255 pounds.,Orthopedic Examination:  He can walk with a normal gait, but he has, as indicated, a positive Romberg test and he himself has noticed that if he closes his eyes he loses his balance.  Overall the patient is a seemingly good historian.  There is a visible 3 cm scar at the left base of the neck near the hairline and there are multiple areas where his head has been shaved both anteriorly and posteriorly.  These are secondary to drawing for the skull markers.  There is a scar behind the patient's left ear from the original treatment of the acoustic neuroma.  This was well healed.  The patient can perform a toe-heel gait without difficulty.  One visibly can see that he has some facial asymmetry and he indicates that the acoustic neuroma has caused some numbness in the left side of his face and also some asymmetry that is now recovering.  The patient states he now thinks his recovery is going to get disregarded and that the facial asymmetry and numbness developed from the first surgery he had.  The patient has a full range of motion in both of his shoulders.  The patient has a full range of motion in his lumbar spine to include 90 degrees of forward bend, lateral bending of 30 degrees in either direction and extension of 10 degrees.  There is full range of motion in the patient's cervical spine to include flexion of 50 degrees at which time he can touch his chin on his chest.  He extends 40 degrees, laterally bends 30 degrees, and rotates to 80 degrees in either direction.  There is slight tenderness on palpating over the right cervical musculature.  There is no evidence of any cervical or lumbar muscle spasms.  Reflexes in the upper extremities include 1+ biceps and triceps and 1+ brachioradialis.  Knee jerks are 2+ and ankle jerks are 1+.  Tinel's test was tested at the elbow, it is negative bilaterally with percussion; however, he has slight tingling bilaterally.  The patient's grip tested with a Jamar dynamometer increases from 70 to 80 pounds bilaterally.  Sensory testing of lower extremities reveal that the patient has slightly decreased sensation to sharp stimulus in his dorsal aspect of the right first toe and a lesser extent to the left.  Testing of muscle strength in the upper and lower extremities is normal.  The patient upper arms measured four fingerbreadths above the flexion crease of the elbow measure 35 cm bilaterally.  The forearms measured four fingerbreadths below the flexion crease of the elbow measure 30 cm bilaterally.  The thighs measured four fingerbreadths above the superior pole of the patella measure 48 cm and the lower legs measured four fingerbreadths below the tibial tubercles measure 41 cm.  Pressure on the vertex of the head does not bother the patient.  Axial loading is negative.  As already indicated straight leg raising is entirely negative both sitting and lying for any radiculitis.,DIAGNOSTIC STUDIES: , X-rays the patient brings with him taken by his treating chiropractor dated 11/24/08 showed that there appears to be a little bit of narrowing of the L4-5 disc space.  The hip joints are normal.  Views of his thoracic spine are normal.  Cervical x-rays are in the file.  These are of intermittent quality, but the views do show a very slight degree of anterior spurring at the C4-5 with possible slight narrowing of the disc.  There is a view of the right shoulder that is unremarkable.,CONCLUSIONS:,  The accepted condition under the claim is a sprain of the neck, thoracic, and lumbar.,DIAGNOSES: , Diagnosis based on today's examination is a sprain of the cervical spine and lumbar spine superimposed upon some early degenerative changes.,Additional diagnosis is one of recurrent acoustic neuroma, presumably benign with upcoming additional treatment of radiation plan.  The patient also has a significant degree overweight for his height and it will be improved as he himself recognizes by some weight loss and exercise.,DISCUSSION: , He is fixed and stable at this time and his industrial case can be closed relative to his industrial injury of November 20, 2008.  Further chiropractic treatments would be entirely palliative and serve no additional medical purpose due to the fact that he has very minimal symptoms and a basis for these symptoms based on mild or early degenerative changes in both cervical and lumbar spine.  He is category I relative to the cervical spine under 296-20-240 and category I to the lumbosacral spine under WAC 296-20-270.  His industrial case should be closed and there is, as indicated, no basis for any disability award.",
" Grade 1 compound fracture, right mid-shaft radius and ulna with complete displacement and shortening.   Irrigation and debridement of skin subcutaneous tissues, muscle, and bone, right forearm.  Open reduction, right both bone forearm fracture with placement of long-arm cast.", Orthopedic, I&D & Open Reduction - Forearm ,"PREOPERATIVE DIAGNOSIS:  ,Grade 1 compound fracture, right mid-shaft radius and ulna with complete displacement and shortening.,POSTOPERATIVE DIAGNOSIS: , Grade 1 compound fracture, right mid-shaft radius and ulna with complete displacement and shortening.,OPERATIONS:,1.  Irrigation and debridement of skin subcutaneous tissues, muscle, and bone, right forearm.,2.  Open reduction, right both bone forearm fracture with placement of long-arm cast.,COMPLICATIONS:,  None.,TOURNIQUET: , None.,ESTIMATED BLOOD LOSS:,  25 mL.,ANESTHESIA: , General.,INDICATIONS:  ,The patient suffered injury at which time he fell over a concrete bench.  He landed mostly on the right arm.  He noted some bleeding at the time of the injury and a small puncture wound.  He was taken to the emergency room and diagnosed a compound both bone forearm fracture, and based on this, he was seen for malalignment.,He was indicated the above-noted procedure.  This procedure as well as alternatives of this procedure was discussed at length with the patient's parents and they understood them well.  Risks and benefits were also discussed.  Risks such as bleeding, infection, damage to blood vessels, damage to nerve roots, need for further surgeries, chronic pain on full range of motion, risk of continued discomfort, risk of need for repeat debridement, risk of need for internal fixation, risk of blood clots, pulmonary embolism, myocardial infarction, and risk of death were discussed.  They understood these well.  All questions were answered and they signed the consent for procedure as described.,DESCRIPTION OF PROCEDURE:  ,The patient was placed on the operating table and general anesthesia was achieved.  The right forearm was inspected.  There was noted to be a 3-mm puncture-type wound over the volar aspect of the forearm in the middle one-third overlying the radial one-half.  There was bleeding in this region.  No gross contamination was seen.  At this point, under fluoroscopic control, I did attempt to see a fracture.  I was unable to do the forearm under the close reduction techniques.  At this point, the right upper extremity was then prepped and draped in the usual sterile manner.  An incision was made through the puncture wound site extending this proximally and distally.  There was noted to be some slight amount of nonviable tissue at the skin edge and debridement was required and performed.  I also did perform a light debridement of the nonviable subcutaneous tissue, muscle, and small bony fragments were also removed.  These were all completely debrided appropriately and then at this point, a thorough irrigation was performed of the radius, which I communicated through the puncture wound.  Both ends were clearly visualized, and thorough irrigation was performed using total of 6 L of antibiotic solution.  All nonviable gross contaminated tissue was removed.  At this point with the bones in direct visualization, I did reduce the bony ends to anatomic alignment with excellent bony approximation.  Proper alignment of tissue and angulation was confirmed.,At this point, under fluoroscopic control confirmed the radius and ulna in anatomic position, which will be completely displaced and shortened previously.  The ulna was now also noted to be in anatomic alignment.,At this point, the region was thoroughly irrigated.  Hemostasis confirmed and closure then begun.  The skin was reapproximated using 3-0 nylon suture.  The visual puncture wound region was left open and this was intact with the depth of the wound down the bone using 1.5-inch Nugauze with iodoform.  Sterile dressing applied and a long-arm cast with the forearm in neutral position was applied.  X-ray with fluoroscopic evaluation was performed, which confirmed.  They maintained excellent bony approximation and the anatomic alignment.  The long-arm cast was then completely mature.  No complications were encountered throughout the procedure.  The patient tolerated the procedure well.  The patient was then taken to the recovery room in stable condition.","orthopedic, compound fracture, mid-shaft radius, ulna, open reduction, irrigation and debridement, subcutaneous, tissues, muscle, bone, forearm, radius and ulna, forearm fracture, anatomic alignment, arm cast, puncture wound, tourniquet, i&d, fracture,"
" Postoperative wound infection, complicated.  Irrigation and debridement of postoperative wound infection.  Removal of foreign body.  Placement of vacuum-assisted closure.device.", Orthopedic, I&D - ORIF Wound ,"TITLE OF OPERATION:,1.  Irrigation and debridement of postoperative wound infection (CPT code 10180).,2.  Removal of foreign body, deep (CPT code 28192).,3.  Placement of vacuum-assisted closure device, less than 50 centimeter squared (CPT code 97605).,PREOP DIAGNOSIS: , Postoperative wound infection, complicated (ICD-9 code 998.59).,POSTOP DIAGNOSIS: , Postoperative wound infection, complicated (ICD-9 code 998.59).,PROCEDURE DETAIL:  ,The patient is a 59-year-old gentleman who is status post open reduction and internal fixation of bilateral calcanei.  He was admitted for a left wound breakdown with drainage.  He underwent an irrigation and debridement with VAC placement 72 hours prior to this operative visit.  It was decided to bring him back for a repeat irrigation and debridement and VAC change prior to Plastics doing a local flap.  The risks of surgery were discussed in detail including, but not limited to infection, bleeding, injuries to nerves and vital structures, need for reoperation, pain or stiffness, arthritis, fracture, the risk of anesthesia.  The patient understood these risks and wished to proceed.  The patient was admitted, and the operative site was marked.,The patient was brought to the operating room and given general anesthetic.  He was placed in the right lateral decubitus, and all bony prominences were well padded.  An axillary roll was placed.  A well-padded thigh tourniquet was placed on the left leg.  The patient then received antibiotics on the floor prior to coming down to the operating room which satisfied the preoperative requirement.  Left leg was then prepped and draped in usual sterile fashion.  The previous five antibiotic spacer beads were removed without difficulty.  The wound was then rongeured and curetted, and all bone was cleaned down to healthy bleeding bone.  The wound actually looked quite good with evidence of purulence or drainage.  Skin edges appeared to be viable.  Hardware all looked to be intact.  At this point, the wound was irrigated with 9 liters of bibiotic solution.  A VAC sponge was then placed over the wound, and the patient's leg was placed into a posterior splint.  The patient was awakened and then taken to recovery in good condition.,Dr. X was present for the timeouts and for all critical portions of the procedure.  He was immediately available for any questions during the case.,PLAN:,1.  A CAM walker boots.,2.  A VAC change on Sunday by the nurse.,3.  A flap per Plastic Surgery.","orthopedic, irrigation and debridement, removal of foreign body, vacuum-assisted closure device, foreign body, postoperative wound, wound infection, infection, wound, orif, debridement, vacuum,"
 Persistent left hip pain.  Left hip avascular necrosis.  Discussed the possibility of hip arthrodesis versus hip replacement versus hip resurfacing, Orthopedic, Hip Pain ,"CHIEF COMPLAINT:,","orthopedic, hip pain, radiculopathy, degenerative changes, avascular necrosis, hip resurfacing, arthrodesis, hip replacement, avn,"
" Incision and drainage and removal of foreign body, right foot.  The patient has had previous I&D but continues to have to purulent drainage.  The patient's parents agreed to performing a surgical procedure to further clean the wound.", Orthopedic, I&D & Foreign Body Removal ,"PREOPERATIVE DIAGNOSIS:,  Foreign body, right foot.,POSTOPERATIVE DIAGNOSIS: , Foreign body, right foot.,PROCEDURE PERFORMED:,1.  Incision and drainage, right foot.,2.  Removal of foreign body, right foot.,HISTORY: , This 7-year-old Caucasian male is an inpatient at ABCD General Hospital with a history of falling off his bike and having a root ________ angle inside of his foot.  The patient has had previous I&D but continues to have to purulent drainage.  The patient's parents agreed to performing a surgical procedure to further clean the wound.,PROCEDURE:,  An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported to the operating room and placed on the operating table in a supine position with a safety strap across his lap.  General anesthesia was administered by the Department of Anesthesia.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  The stockinette was reflected and the foot was cleansed with wet and dry sponge.  There was noted to be some remaining periwound erythema.  There was noted to be some mild crepitation about 2 cm proximal from the entry wound.  The entry wound was noted to be over the third metatarsal head dorsally.  Upon inspection of the wound, there was noted to be hard foreign filling substance deep within the wound.  The entry site from the foreign body was extended proximally approximately about 0.5 cm.  At this time, a large wooden foreign body was visualized and removed with a straight stat.,The area was carefully inspected for any remaining piece of foreign body.  Several small pieces were noted and they were removed.  The area was palpated and there was no more remaining foreign body noted.  At this time, the wound was inspected thoroughly.  There was noted to be an area along the third metatarsal head more distally that did probe to the bone.  There was no purulent drainage expressed.  Area was flushed with copious amounts of sterile saline.  Pulse lavage was performed with 3 liters of plain sterile saline.  Wound cultures were obtained, aerobic and aerobic.  The wound was then again inspected for any remaining foreign body or purulent drainage.  None was noticed.  The wound was packed with sterile new gauze packing lately and dressings consisted of 4x4s, ABDs, Kling, and Kerlix.,The patient tolerated the above procedure and anesthesia well without complications.  The patient was transported to the PACU with vital signs stable and vascular status intact.  The patient is to be readministered to the pediatrics where daily dressing changes will be performed by podiatry.  The patient had a postoperative pain prescription written for Tylenol, Elixir with codeine as needed.","orthopedic, incision and drainage, removal of foreign body, purulent drainage, foreign body, metatarsal head, metatarsal, i&d, incision, drainage, foot "
 Non-healing surgical wound to the left posterior thigh. Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg., Orthopedic, Hypergranulation - Consult ,"CHIEF COMPLAINT:,  Non-healing surgical wound to the left posterior thigh.,HISTORY OF PRESENT ILLNESS: , This is a 49-year-old white male who sustained a traumatic injury to his left posterior thighthis past year while in ABCD.  He sustained an injury from the patellar from a boat while in the water.  He was air lifted actually up to XYZ Hospital and underwent extensive surgery.  He still has an external fixation on it for the healing fractures in the leg and has undergone grafting and full thickness skin grafting closure to a large defect in his left posterior thigh, which is nearly healed right in the gluteal fold on that left area.  In several areas right along the graft site and low in the leg, the patient has several areas of hypergranulation tissue.  He has some drainage from these areas.  There are no signs and symptoms of infection.  He is referred to us to help him get those areas under control.,PAST MEDICAL HISTORY:,  Essentially negative other than he has had C. difficile in the recent past.,ALLERGIES:,  None.,MEDICATIONS: , Include Cipro and Flagyl.,PAST SURGICAL HISTORY: , Significant for his trauma surgery noted above.,FAMILY HISTORY: , His maternal grandmother had pancreatic cancer.  Father had prostate cancer.  There is heart disease in the father and diabetes in the father.,SOCIAL HISTORY:,  He is a non-cigarette smoker and non-ETOH user.  He is divorced.  He has three children.  He has an attorney.,REVIEW OF SYSTEMS:,CARDIAC:  He denies any chest pain or shortness of breath.,GI:  As noted above.,GU:  As noted above.,ENDOCRINE:  He denies any bleeding disorders.,PHYSICAL EXAMINATION:,GENERAL:  He presents as a well-developed, well-nourished 49-year-old white male who appears to be in no significant distress.,HEENT:  Unremarkable.,NECK:  Supple.  There is no mass, adenopathy, or bruit.,CHEST:  Normal excursion.,LUNGS:  Clear to auscultation and percussion.,COR:  Regular.  There is no S3, S4, or gallop.  There is no murmur.,ABDOMEN:  Soft.  It is nontender.  There is no mass or organomegaly.,GU:  Unremarkable.,RECTAL:  Deferred.,EXTREMITIES:  His right lower extremity is unremarkable.  Peripheral pulse is good.  His left lower extremity is significant for the split thickness skin graft closure of a large defect in the posterior thigh, which is nearly healed.  The open areas that are noted above __________ hypergranulation tissue both on his gluteal folds on the left side.  There is one small area right essentially within the graft site, and there is one small area down lower on the calf area.  The patient has an external fixation on that comes out laterally on his left thigh.  Those pin sites look clean.,NEUROLOGIC:  Without focal deficits.  The patient is alert and oriented.,IMPRESSION: , Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg.,PLAN:,  Plan would be for chemical cauterization of these areas.  Series of treatment with chemical cauterization till these are closed.",
" Painful ingrown toenail, left big toe.  Removal of an ingrown part of the left big toenail with excision of the nail matrix.", Orthopedic, Ingrown Toenail Removal ,"PREOPERATIVE DIAGNOSIS: , Painful ingrown toenail, left big toe.,POSTOPERATIVE DIAGNOSIS: , Painful ingrown toenail, left big toe.,OPERATION: , Removal of an ingrown part of the left big toenail with excision of the nail matrix.,DESCRIPTION OF PROCEDURE:  ,After obtaining informed consent, the patient was taken to the minor OR room and intravenous sedation with morphine and Versed was performed and the toe was blocked with 1% Xylocaine after having been prepped and draped in the usual fashion.  The ingrown part of the toenail was freed from its bed and removed, then a flap of skin had been made in the area of the matrix supplying the particular part of the toenail.  The matrix was excised down to the bone and then the skin flap was placed over it.  Hemostasis had been achieved with a cautery.  A tubular dressing was performed to provide a bulky dressing.,The patient tolerated the procedure well.  Estimated blood loss was negligible.  The patient was sent back to Same Day Surgery for recovery.","orthopedic, toenail, nail matrix, ingrown toenail, painful, ingrown,"
 Decreased ability to perform daily living activity secondary to recent right hip surgery., Orthopedic, Hip Surgery - Discharge Summar ,"CHIEF COMPLAINT:,  Decreased ability to perform daily living activity secondary to recent right hip surgery.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 51-year-old white female who is status post right total hip replacement performed on 08/27/2007 at ABCD Hospital by Dr. A.  The patient had an unremarkable postoperative course, except low-grade fever of 99 to 100 postoperatively.  She was admitted to the Transitional Care Unit on 08/30/2007 at XYZ Services.  Prior to her discharge from ABCD Hospital, she had received DVT prophylaxis utilizing Coumadin and Lovenox and the INR goal is 2.0 to 3.0.  She presents reporting that her last bowel movement was on 08/26/2007 prior to surgery.  Otherwise, she reports some intermittent right calf discomfort and some postoperative right hip pain.,ALLERGIES:,  No known drug allergies.,PAST MEDICAL HISTORY:,  Anxiety, depression, osteoarthritis, migraine headaches associated with menstrual cycle, history of sciatic pain in the distant past, history of herniated disc, and status post appendectomy.,MEDICATIONS:  ,Medications taken at home are Paxil, MOBIC, and Klonopin.,MEDICATIONS ON TRANSFER: , Celebrex, Coumadin, Colace, Fiorinal, oxycodone, Klonopin, and Paxil.,FAMILY HISTORY:,  Noncontributory.,SOCIAL HISTORY: , The patient is married.  She lives with her husband and is employed as a school nurse for the School Department.  She had quit smoking cigarettes some 25 years ago and is a nondrinker.,REVIEW OF SYSTEMS:,  As mentioned above.  She has a history of migraine headaches associated with her menstrual cycle.  She wears glasses and has a history of floaters.  She reports a low-grade temperature of 99 to 100 postoperatively, mild intermittent cough, scratchy throat, (the symptoms may be secondary to intubation during surgery), intermittent right calf pain, which was described as sharp, but momentary with a negative Homans sign.  The patient denies any cardiopulmonary symptoms such as chest pain, palpitation, pain in the upper neck and down to her arm, difficulty breathing, shortness of breath, or hemoptysis.  She denies any nausea, vomiting, or diarrhea, but reports as being constipated with the last bowel movement being on 08/26/2007 prior to surgery.  She denies urinary symptoms such as dysuria, urinary frequency, incomplete bladder emptying or voiding difficulties.  First day of her last menstrual cycle was 08/23/207 and she reports that she is most likely not pregnant since her husband had a vasectomy years ago.,PHYSICAL EXAMINATION:,VITAL SIGNS:  At the time of admission, temperature 97.7, blood pressure 108/52, heart rate 94, respirations 18, and 95% O2 saturation on room air.,GENERAL:  No acute distress at the time of exam.,HEENT:  Normocephalic.  Sclerae are nonicteric.  EOMI.  Dentition is in good repair.,NECK:  Trachea is at the midline.,LUNGS:  Clear to auscultation.,HEART:  Regular rate and rhythm.,ABDOMEN:  Bowel sounds are heard throughout.  Soft and nontender.,EXTREMITIES:  Right hip incision is clean, intact, and no drainage is noted.  There is diffuse edema, which extends distally.  There is no calf tenderness per se bilaterally and Homans sign is negative.  There is no pedal edema.,MENTAL STATUS:  Alert and oriented x3, pleasant and cooperative during the exam.,LABORATORY DATA: , Initial workup included chemistry panel, which was unremarkable with the exception of a fasting glucose of 122 and an anion gap that was slightly decreased at 6.  The BUN was normal at 8, creatinine was 0.9, INR was 1.49.  CBC, had a white count of 5.7, hemoglobin was 9.2, hematocrit was 26.6, and platelets were 318,000.,IMPRESSION:,1.  Status post right total hip replacement.  The patient is admitted to the TCU at XYZ's Health Services and will be seen in consultation by Physical Therapy and Occupational Therapy.,2.  Postoperative anemia, Feosol 325 mg one q.d.,3.  Pain management.  Oxycodone SR 20 mg b.i.d., and oxycodone IR 5 mg one to two tablets q.4h., p.r.n. pain.  Additionally, she will utilize ice to help decrease edema.,4.  Depression and anxiety, Paxil 40 mg daily, Klonopin 1 mg q.h.s.,5.  Osteoarthritis, Celebrex 200 mg b.i.d.,6.  GI prophylaxis, Protonix 40 mg b.i.d.  Dulcolax suppository and lactulose will be used as a p.r.n. basis and Colace 100 mg b.i.d.,7.  DVT prophylaxis will be maintained with Arixtra 2.5 mg subcutaneously daily until the INR is greater than 1.7 and Coumadin will be adjusted according to the INR.  She will continue on 5 mg every day.,8.  Right leg muscle spasm/calf pain is stable at this time and we will reevaluate on a regular basis.  Monitor for any possibility of DVT.",
 Status post left hip fracture and hemiarthroplasty.   Rehab transfer as soon as medically cleared., Orthopedic, Hip Fracture - Rehab Consult ,"ADMISSION DIAGNOSIS: , Left hip fracture.,CHIEF COMPLAINT: , Diminished function, secondary to the above.,HISTORY: , This pleasant 70-year-old gentleman had a ground-level fall at home on 05/05/03 and was brought into ABCD Medical Center, evaluated by Dr. X and brought in for orthopedic stay.  He had left hip fracture identified on x-rays at that time.  Pain and inability to ambulate brought him in.  He was evaluated and then underwent medical consultation as well, where they found a history of resolving pneumonia, hypertension, chronic obstructive pulmonary disease, congestive heart failure, hypothyroidism, depression, anxiety, seizure and chronic renal failure, as well as anemia.  His medical issues are under good control.  The patient underwent left femoral neck fixation with hemiarthroplasty on that left side on 05/06/03.  The patient has had some medical issues including respiratory insufficiency, perioperative anemia, pneumonia, and hypertension.  Cardiology has followed closely, and the patient has responded well to medical treatment, as well as physical therapy and occupational therapy.  He is gradually tolerating more activities with less difficulties, made good progress and tolerated more consistent and more prolonged interventions.,PAST MEDICAL HISTORY: , Positive for congestive heart failure, chronic renal insufficiency, azotemia, hyperglycemia, coronary artery disease, history of paroxysmal atrial fibrillation.  Remote history of subdural hematoma precluding the use of Coumadin.  History of depression, panic attacks on Doxepin.  Perioperative anemia.  Swallowing difficulties.,ALLERGIES:,  Zyloprim, penicillin, Vioxx, NSAIDs.,CURRENT MEDICATIONS,1.  Heparin.,2.  Albuterol inhaler.,3.  Combivent.,4.  Aldactone.,5.  Doxepin.,6.  Xanax.,7.  Aspirin.,8.  Amiodarone.,9.  Tegretol.,10.  Synthroid.,11.  Colace.,SOCIAL HISTORY: , Lives in a 1-story home with 1 step down; wife is there.  Speech and language pathology following with current swallowing dysfunction.  He is minimum assist for activities of daily living, bed mobility.,REVIEW OF SYSTEMS:,  Currently negative for headache, nausea and vomiting, fevers, chills or shortness of breath or chest pain.,PHYSICAL EXAMINATION,HEENT:  Oropharynx clear.,CV:  Regular rate and rhythm without murmurs, rubs or gallops.,LUNGS:  Clear to auscultation bilaterally.,ABDOMEN:  Nontender, nondistended.  Bowel sounds positive.,EXTREMITIES:  Without clubbing, cyanosis, or edema.,NEUROLOGIC:  There are no focal motor or sensory losses to the lower extremities.  Bulk and tone normal in the lower extremities.  Wound site has healed well with staples out.,IMPRESSION ,1.  Status post left hip fracture and hemiarthroplasty.,2.  History of panic attack, anxiety, depression.,3.  Myocardial infarction with stent placement.,4.  Hypertension.,5.  Hypothyroidism.,6.  Subdural hematoma.,7.  Seizures.,8.  History of chronic obstructive pulmonary disease.  Recent respiratory insufficiency.,9.  Renal insufficiency.,10.  Recent pneumonia.,11.  O2 requiring.,12.  Perioperative anemia.,PLAN: , Rehab transfer as soon as medically cleared.",
" Hemiarthroplasty of left shoulder utilizing a global advantage system with an #8 mm cemented humeral stem and 48 x 21 mm modular head replacement.  Comminuted fracture, dislocation left proximal humerus.", Orthopedic, Hemiarthroplasty - Shoulder ,"PREOPERATIVE DIAGNOSIS:,  Comminuted fracture, dislocation left proximal humerus.,POSTOPERATIVE DIAGNOSIS:, Comminuted fracture, dislocation left proximal humerus.,PROCEDURE PERFORMED: , Hemiarthroplasty of left shoulder utilizing a global advantage system with an #8 mm cemented humeral stem and 48 x 21 mm modular head replacement.,PROCEDURE:  ,The patient was taken to OR #2, administered general anesthetic.  He was positioned in the modified beach chair position on the operative table utilizing the shoulder apparatus.  The left shoulder and upper extremities were then prepped and draped in the usual manner.  A longitudinal incision was made extending from a point just lateral to the coracoid down towards deltoid tuberosity of the humerus.  This incision was taken down through the skin and subcutaneous tissues were split utilizing the coag cautery.  Hemostasis was achieved with the cautery.  The deltoid fascia were identified, skin flaps were then created.  The deltopectoral interval was identified and the deltoid split just lateral to the cephalic vein.  The deltoid was then retracted.  There was marked hematoma and swelling within the subdeltoid bursa.  This area was removed with rongeurs.  The biceps tendon was identified which was the landmark for the rotator interval.  Mayo scissors was utilized to split the remaining portion of the rotator interval.  The greater tuberosity portion with the rotator cuff was identified.  Excess bone was removed from the greater tuberosity side to allow for closure later.  The lesser tuberosity portion with the subscapularis was still attached to the humeral head, therefore, osteotome was utilized to separate the lesser tuberosity from the humeral head fragment.,Excess bone was removed from the lesser tuberosity as well.  Both of these were tagged with Ethibond sutures for later.  The humeral head was delivered out of the wound.  It was localized to the area of the anteroinferior glenoid region.  The glenoid was then inspected, and noted to be intact.  The fracture was at the level of the surgical neck on the proximal humerus.  The canal was repaired with the broaches.  An #8 stem was chosen as it was going to be cemented into place.  The trial stem was impacted into position and the shaft of the bone marked with the cautery to the appropriate retroversion.  Trial reduction was performed.  The 48 x 21 mm head was the most appropriate size, matching the patient's as well as the soft tissue tension on the shoulder.  At this point, the wound was copiously irrigated with gentamycin solution.  The canal was copiously irrigated as well and suctioned dry.  Methyl methacrylate cement was mixed.  The cement gun was filled and the canal was filled with the cement.  The #8 stem was then impacted into place and held in the position in the appropriate retroversion until the cement had cured.  Excess cement was removed by sharp dissection.  Prior to cementation of the stem, a hole was drilled in the shaft of proximal humerus and #2 fiber wires were placed through this hole for closure later.  Once the cement was cured, the modular head was impacted on to the Morse taper.  It was stable and the shoulder was reduced.  The lesser tuberosity was then reapproximated back to the original site utilizing the #2 fiber wire suture that was placed in the humeral shaft as well as the holes in the humeral implant.  The greater tuberosity portion with rotator cuff was also attached to the implant as well as the shaft of the humerus utilizing #2 fiber wires as well.  The rotator interval was closed with #2 fiber wire in an interrupted fashion.  The biceps tendon was ________ within this closure.  The wound was copiously irrigated with gentamycin solution, suctioned dry.  The deltoid fascia was then approximated with interrupted #2-0 Vicryl suture.  Subcutaneous layer was approximated with interrupted #2-0 Vicryl and skin approximated with staples.  Subcutaneous tissues were infiltrated with 0.25% Marcaine solution.  A bulky dressing was applied to the wound followed by application of a large arm sling.  Circulatory status was intact in the extremity at the completion of the case.  The patient was then transferred to recovery room in apparent satisfactory condition.","orthopedic, dislocation, proximal humerus, comminuted fracture, rotator interval, tuberosity portion, hemiarthroplasty, fracture, wound, proximal, deltoid, rotator, stem, humeral, humerus, tuberosity, cemented,"
 Left C5-6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root., Orthopedic, Hemilaminotomy & Foraminotomy ,"PRE AND POSTOPERATIVE DIAGNOSIS:,  Left cervical radiculopathy at C5, C6,OPERATION: , Left C5-6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root.,After informed consent was obtained from the patient, he was taken to the OR.  After general anesthesia had been induced, Ted hose stockings and pneumatic compression stockings were placed on the patient and a Foley catheter was also inserted.  At this point, the patient's was placed in three point fixation with a Mayfield head holder and then the patient was placed on the operating table in a prone position.  The patient's posterior cervical area was then prepped and draped in the usual sterile fashion.  At this time the patient's incision site was infiltrated with 1 percent Lidocaine with epinephrine.  A scalpel was used to make an approximate 3 cm skin incision cephalad to the prominent C7 spinous processes, which could be palpated.  After dissection down to a spinous process using Bovie cautery, a clamp was placed on this spinous processes and cross table lateral x-ray was taken.  This showed the spinous process to be at the C4 level.  Therefore, further soft tissue dissection was carried out caudally to this level after the next spinous processes presumed to be C5 was identified.  After the muscle was dissected off the lamina laterally on the left side, self retaining retractors were placed and after hemostasis was achieved, a Penfield probe was placed in the interspace presumed to be C5-6 and another cross table lateral x-ray of the C spine was taken.  This film confirmed our position at C5-6 and therefore the operating microscope was brought onto the field at this time.  At the time the Kerrison rongeur was used to perform a hemilaminotomy by starting with the inferior margin of the superior lamina.  The superior margin of the inferior lamina of C6 was also taken with the Kerrison rongeur after the ligaments had been freed by using a Woodson probe.  This was then extended laterally to perform a medial facetectomy also using the Kerrison rongeur.  However, progress was limited because of thickness of the bone.  Therefore at this time the Midas-Rex drill, the AM8 bit was brought onto the field and this was used to thin out the bone around our laminotomy and medial facetectomy area.  After the bone had been thinned out, further bone was removed using the Kerrison rongeur.  At this point the nerve root was visually inspected and observed to be decompressed.  However, there was a layer of fibrous tissue overlying the exiting nerve root which was removed by placing a Woodson resector in a plane between the fibrous sheath and the nerve root and incising it with a 15 blade.  Hemostasis was then achieved by using Gelfoam as well as bipolar electrocautery.  After hemostasis was achieved, the surgical site was copiously irrigated with Bacitracin.  Closure was initiated by closing the muscle layer and the fascial layer with 0 Vicryl stitches.  The subcutaneous layer was then reapproximated using 000 Dexon.  The skin was reapproximated using a running 000 nylon.  Sterile dressings were applied.  The patient was then extubated in the OR and transferred to the Recovery room in stable condition.,ESTIMATED BLOOD LOSS:,  minimal.","orthopedic, foraminotomy with medial facetectomy, facetectomy for microscopic decompression, decompression of nerve root, hemilaminotomy and foraminotomy, decompression of nerve, microscopic decompression, medial facetectomy, kerrison rongeur, nerve root, spinous processes, facetectomy, kerrison, hemilaminotomy, foraminotomy,"
 Left hip fracture.  The patient is a 53-year-old female with probable pathological fracture of the left proximal femur., Orthopedic, Hip Fracture - ER Consult ,"REASON FOR CONSULTATION: , Left hip fracture.,HISTORY OF PRESENT ILLNESS: , The patient is a pleasant 53-year-old female with a known history of sciatica, apparently presented to the emergency room due to severe pain in the left lower extremity and unable to bear weight.  History was obtained from the patient.  As per the history, she reported that she has been having back pain with left leg pain since past 4 weeks.  She has been using a walker for ambulation due to disabling pain in her left thigh and lower back.  She was seen by her primary care physician and was scheduled to go for MRI yesterday.  However, she was walking and her right foot got caught on some type of rug leading to place excessive weight on her left lower extremity to prevent her fall.  Since then, she was unable to ambulate.  The patient called paramedics and was brought to the emergency room.  She denied any history of fall.  She reported that she stepped the wrong way causing the pain to become worse.  She is complaining of severe pain in her lower extremity and back pain.  Denies any tingling or numbness.  Denies any neurological symptoms.  Denies any bowel or bladder incontinence.,X-rays were obtained which were remarkable for left hip fracture.  Orthopedic consultation was called for further evaluation and management.  On further interview with the patient, it is noted that she has a history of malignant melanoma, which was diagnosed approximately 4 to 5 years ago.  She underwent surgery at that time and subsequently, she was noted to have a spread to the lymphatic system and lymph nodes for which she underwent surgery in 3/2008.,PAST MEDICAL HISTORY: , Sciatica and melanoma.,PAST SURGICAL HISTORY:  ,As discussed above, surgery for melanoma and hysterectomy.,ALLERGIES: , NONE.,SOCIAL HISTORY: , Denies any tobacco or alcohol use.  She is divorced with 2 children.  She lives with her son.,PHYSICAL EXAMINATION:,GENERAL:  The patient is well developed, well nourished in mild distress secondary to left lower extremity and back pain.,MUSCULOSKELETAL:  Examination of the left lower extremity, there is presence of apparent shortening and external rotation deformity.  Tenderness to palpation is present.  Leg rolling is positive for severe pain in the left proximal hip.  Further examination of the spine is incomplete secondary to severe leg pain.  She is unable to perform a straight leg raising.  EHL/EDL 5/5.  2+ pulses are present distally.  Calf is soft and nontender.  Homans sign is negative.  Sensation to light touch is intact.,IMAGING:,  AP view of the hip is reviewed.  Only 1 limited view is obtained.  This is a poor quality x-ray with a lot of soft tissue shadow.  This x-ray is significant for basicervical-type femoral neck fracture.  Lesser trochanter is intact.  This is a high intertrochanteric fracture/basicervical.  There is presence of lytic lesion around the femoral neck, which is not well delineated on this particular x-ray.  We need to order repeat x-rays including AP pelvis, femur, and knee.,LABS:,  Have been reviewed.,ASSESSMENT: , The patient is a 53-year-old female with probable pathological fracture of the left proximal femur.,DISCUSSION AND PLAN: , Nature and course of the diagnosis has been discussed with the patient.  Based on her presentation without any history of obvious fall or trauma and past history of malignant melanoma, this appears to be a pathological fracture of the left proximal hip.  At the present time, I would recommend obtaining a bone scan and repeat x-rays, which will include AP pelvis, femur, hip including knee.  She denies any pain elsewhere.  She does have a past history of back pain and sciatica, but at the present time, this appears to be a metastatic bone lesion with pathological fracture.  I have discussed the case with Dr. X and recommended oncology consultation.,With the above fracture and presentation, she needs a left hip hemiarthroplasty versus calcar hemiarthroplasty, cemented type.  Indication, risk, and benefits of left hip hemiarthroplasty has been discussed with the patient, which includes, but not limited to bleeding, infection, nerve injury, blood vessel injury, dislocation early and late, persistent pain, leg length discrepancy, myositis ossificans, intraoperative fracture, prosthetic fracture, need for conversion to total hip replacement surgery, revision surgery, DVT, pulmonary embolism, risk of anesthesia, need for blood transfusion, and cardiac arrest.  She understands above and is willing to undergo further procedure.  The goal and the functional outcome have been explained.  Further plan will be discussed with her once we obtain the bone scan and the radiographic studies.  We will also await for the oncology feedback and clearance.,Thank you very much for allowing me to participate in the care of this patient.  I will continue to follow up.","orthopedic, calcar, proximal femur, pathological fracture, hip, fracture, hemiarthroplasty, melanoma, "
" Austin-Moore bipolar hemiarthroplasty, left hip.  Subcapital left hip fracture.", Orthopedic, Hemiarthroplasty - Austin-Moore Bipolar ,"PREOPERATIVE DIAGNOSIS: , Subcapital left hip fracture.,POSTOPERATIVE DIAGNOSIS: , Subcapital left hip fracture.,PROCEDURE PERFORMED: , Austin-Moore bipolar hemiarthroplasty, left hip.,ANESTHESIA:  ,Spinal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:  ,Less than 100 cc.,HISTORY:  ,The patient is an 86-year-old female who was seen and evaluated in ABCD General Hospital Emergency Department on 08/30/03 after sustaining a fall at her friend's house.  The patient states that she was knocked over by her friend's dog.  She sustained a subcapital left hip fracture.  Prior to admission, she lived alone in Terrano, was ambulating with a walker.  All risks, benefits, and potential complications of the procedure were then discussed with the patient and informed consent was obtained.,HARDWARE SPECIFICATIONS: , A 28 mm medium head was used, a small cemented femoral stem was used, and a 28 x 46 cup was used.,PROCEDURE:  ,All risks, benefits, and potential complications of the procedure were discussed with the patient, informed consent was obtained.  She was then transferred from the preoperative care unit to operating suite #1.  Department of Anesthesia administered spinal anesthetic without complications.,After this, the patient was transferred to the operating table and positioned.  All bony prominences were well padded.  She was positioned on a beanbag in the right lateral decubitus position with the left hip facing upwards.  The left lower extremity was then sterilely prepped and draped in the normal fashion.  A skin maker was then used to mark all bony prominences.  Skin incision was then carried out extending from the greater trochanter in a curvilinear fashion posteriorly across the buttocks.  A #10 blade Bard-Parker scalpel was used to incise the skin through to the subcutaneous tissues.  A second #10 blade was then used to incise through the subcutaneous tissue down to the fascia lata.  This was then incised utilizing Metzenbaum scissors.  This was taken down to the bursa, which was removed utilizing a rongeur.  Utilizing a periosteal elevator as well as the sponge, the fat was then freed from the short external rotators of the left hip after these were placed and stretched.  The sciatic nerve was then visualized and retracted utilizing a Richardson retractor.  Bovie was used to remove the short external rotators from the greater trochanter, which revealed the joint capsule.  The capsule was cleared and incised utilizing a T-shape incision.  A fracture hematoma was noted upon entering the joint capsule as well as subcapital hip fracture.  A cork screw was then used to remove the fractured femoral head, which was given to the scrub tech which was sized on the back table.  All bony remnants were then removed from the acetabulum and surrounding soft tissue with a rongeur.  Acetabulum was then inspected and found to be clear.  Attention was then turned to the proximal femur where a cutting tunnel was used to mark the femur for the femoral neck cut.  An oscillating saw was then used to make the femoral cut.  Box osteotome was then used to remove the bone from proximal femur.  A Charnley awl was then used to open the femoral canal, paying close attention to keep the awl in the lateral position.  Next, attention was turned to broaching.  Initially, a small broach was placed, first making efforts to lateralize the broach then the femoral canal.  It was felt that the patient has less benefit from a cemented prosthesis and a small size was appropriate.  Next, the trial components were inserted consisting of the above-mentioned component sizes.  The hip was taken through range of motion and tested to adduction, internal and external rotations as well as with a shuck and a posterior directed force on a flexed tip.  It was noted that these size were stable through the range of motion.  Next, the trial components were removed and the femoral canal was copiously irrigated and suctioned dried utilizing Super sucker and __________ then inserted pressuring the femoral canal.  The femoral component was then inserted and then held under pressure.  Extruding cement was removed from the proximal femur.  After the cement had fully hardened and dried, the head and cup were applied.  The hip was subsequently reduced and taken again through range of motion, which was felt to be stable.,Next, the capsule was closed utilizing #1 Ethibond in figure-of-eight fashion.  Next, the fascia lata was repaired utilizing a figure-of-eight Ethibond sutures.  The most proximal region at the musculotendinous junction was repaired utilizing a running #1 Vicryl suture.  The wound was then copiously irrigated again to suction dry.  Next, the subcutaneous tissues were reapproximated using #2-0 Vicryl simple interrupted sutures.  The skin was then reapproximated utilizing skin clips.  Sterile dressing was applied consisting of Adaptic, 4x4s, ABDs as well as foam tape.  The patient was then transferred from the operating table to the gurney.  Leg lengths were checked, which were noted to be equal and abduction pillow was placed.  The patient was then transferred to the Postoperative Care Unit in stable condition.","orthopedic, austin-moore bipolar hemiarthroplasty, subcapital left hip fracture, hip fracture, austin moore bipolar hemiarthroplasty, subcutaneous tissues, hip, hemiarthroplasty, austin, cemented, femur, subcapital, fracture, femoral,"
" Hemiarthroplasty, right hip.  Fracture of the right femoral neck, also history of Alzheimer's dementia, hypothyroidism, and status post hemiarthroplasty of the hip.", Orthopedic, Hemiarthroplasty - Discharge Summary ,"ADMISSION DIAGNOSES:  ,Fracture of the right femoral neck, also history of Alzheimer's dementia, and hypothyroidism.,DISCHARGE DIAGNOSES: , Fracture of the right femoral neck, also history of Alzheimer's dementia, hypothyroidism, and status post hemiarthroplasty of the hip.,PROCEDURE PERFORMED:  ,Hemiarthroplasty, right hip.,CONSULTATIONS:  ,Medicine for management of multiple medical problems including Alzheimer's.,HOSPITAL COURSE: , The patient was admitted on 08/06/2007 after a fall with subsequent fracture of the right hip.  The patient was admitted to Orthopedics and consulted Medicine.  The patient was actually taken to the operating room, consent signed by durable power of attorney, taken on 08/06/2007, had right hip hemiarthroplasty, recovered without incidence.  The patient had continued confusion and dementia, which is apparently his baseline secondary to his Alzheimer's.  Brief elevation of white count following the surgery, which did subside.  Studies, UA and blood culture were negative.  The patient was stable and was discharged to Heartland.,CONDITION ON DISCHARGE: , Stable.,DISCHARGE INSTRUCTIONS:,  Transfer to ABC for rehab and continued care.  Diabetic diet.  Activity, ambulate as tolerated with posterior hip precautions.  Rehab potential fair.  He will need nursing, Social Work, PT/OT, and nutrition consults.  Resume home meds, DVT prophylaxis, aspirin, and compression stockings.  Follow up Dr. X in one to two weeks; call 123-4567 for an appointment.","orthopedic, femoral neck, orthopedics, rehab, femoral, neck, fracture, dementia, hemiarthroplasty, hip,"
 Hardware removal in the left elbow., Orthopedic, Hardware Removal - Elbow ,"PREOPERATIVE DIAGNOSIS: , Retained hardware in left elbow.,POSTOPERATIVE DIAGNOSIS:,  Retained hardware in left elbow.,PROCEDURE: , Hardware removal in the left elbow.,ANESTHESIA: , Procedure done under general anesthesia.  The patient also received 4 mL of 0.25% Marcaine of local anesthetic.,TOURNIQUET:  ,There is no tourniquet time.,ESTIMATED BLOOD LOSS:  ,Minimal.,COMPLICATIONS:  ,No intraoperative complications.,HISTORY AND PHYSICAL:  ,The patient is a 5-year, 8-month-old male who presented to me direct from ED with distracted left lateral condyle fracture.  He underwent screw compression for the fracture in October 2007.  The fracture has subsequently healed and the patient presents for hardware removal.  The risks and benefits of surgery were discussed.  The risks of surgery include the risk of anesthesia, infection, bleeding, changes in sensation and motion of extremity, failure of removal of hardware, failure to relieve pain or improved range of motion.  All questions were answered and the family agreed to the above plan.,PROCEDURE: , The patient was taken to the operating room, placed supine on the operating table.  General anesthesia was then administered.  The patient's left upper extremity was then prepped and draped in standard surgical fashion.  Using his previous incision, dissection was carried down through the screw.  A guide wire was placed inside the screw and the screw was removed without incident.  The patient had an extension lag of about 15 to 20 degrees.  Elbow is manipulated and his arm was able to be extended to zero degrees dorsiflex.  The washer was also removed without incident.  Wound was then irrigated and closed using #2-0 Vicryl and #4-0 Monocryl.  Wound was injected with 0.25% Marcaine.  The wound was then dressed with Steri-Strips, Xeroform, 4 x4 and bias.  The patient tolerated the procedure well and subsequently taken to the recovery in stable condition.,DISCHARGE NOTE: , The patient will be discharged on date of surgery.  He is to follow up in one week's time for a wound check.  This can be done at his primary care physician's office.  The patient should keep his postop dressing for about 4 to 5 days.  He may then wet the wound, but not scrub it.  The patient may resume regular activities in about 2 weeks.  The patient was given Tylenol with Codeine 10 mL p.o. every 3 to 4 hours p.r.n.","orthopedic, retained hardware, hardware removal, tourniquet, elbow, hardware,"
" New patient visit for right hand pain.  Punched the wall 3 days prior to presentation, complained of ulnar-sided right hand pain, and was seen in the emergency room. ", Orthopedic, Hand Pain - Consult ,"REASON FOR VISIT:  ,New patient visit for right hand pain.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 28-year-old right-hand dominant gentleman, who punched the wall 3 days prior to presentation.  He complained of ulnar-sided right hand pain and was seen in the emergency room.  Reportedly, he had some joints in his hand pushed back and placed by somebody in emergency room.  Today, he admits that his pain is much better.  Currently, since that time he has been in the splint with minimal pain.  He has had no numbness, tingling or other concerning symptoms.,PAST MEDICAL HISTORY:, Negative.,SOCIAL HISTORY:  ,The patient is a nonsmoker and does not use illegal drugs.  Occasionally drinks.,REVIEW OF SYSTEMS: , A 12-point review of systems is negative.,MEDICATIONS:,  None.,ALLERGIES: , No known drug allergies.,FINDINGS: , On physical exam, he has swelling and tenderness over the ulnar dorsum of his hand.  He has a normal cascade.  He has 70 degrees of MCP flexion and full IP flexion and extension.  He has 3 to 5 strength in his grip and intrinsics.  He has intact sensation to light touch in the radial, ulnar, and median nerve distribution.  Two plus radial pulse.,X-rays taken from today were reviewed, include three views of the right hand.  They show possible small fractures of the base of the fourth and third metacarpals.  Joint appears to be located.  A 45-degree oblique view was obtained and confirmed adduction of the CMC joints of the fourth and fifth metacarpals.  His injury films from 09/15/07 were reviewed and demonstrated what appears to be CMC dislocations of the third and fourth metacarpals.,ASSESSMENT: , Status post right third and fourth metacarpal carpometacarpal dislocations.,PLANS: , The patient was placed into a short-arm cast and intrinsic plus.  I would like him to wear this for 2 weeks and then follow up with us.  At that time, we will transition him to an OT splint and begin range of motion activities of the fingers and wrist.  We should see him back in 2 weeks' time at which time he should obtain three views of the right hand and a 45-degree oblique view out of cast.","orthopedic, hand pain, pain, hand, metacarpals"
" Removal of painful hardware, first left metatarsal.  Excision of nonunion, first left metatarsal.  Incorporation of corticocancellous bone graft with internal fixation consisting of screws and plates of the first left metatarsal.", Orthopedic, Hardware Removal - Metatarsal ,"TITLE OF OPERATION:,1.  Removal of painful hardware, first left metatarsal.,2.  Excision of nonunion, first left metatarsal.,3.  Incorporation of corticocancellous bone graft with internal fixation consisting of screws and plates of the first left metatarsal.,PREOPERATIVE DIAGNOSES:,1.  Nonunion of fractured first left metatarsal osteotomy.,2.  Painful hardware, first left metatarsal.,POSTOPERATIVE DIAGNOSES:,1.  Nonunion of fractured first left metatarsal osteotomy.,2.  Painful hardware, first left metatarsal.,ANESTHESIA:,  General anesthesia with local infiltration of 5 mL of 0.5% Marcaine and 1% lidocaine plain with 1:100,000 epinephrine preoperatively and 15 mL of 0.5% Marcaine postoperatively.,HEMOSTASIS: , Left ankle tourniquet set at 250 mmHg for 60 minutes.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,MATERIALS USED:,  2-0 Vicryl, 3-0 Vicryl, 4-0 Vicryl, 5-0 Prolene, as well as one corticocancellous allograft consisting of ASIS and one T-type plate prebent with six screw holes and five 3.0 partially threaded cannulated screws and a single 3.0 noncannulated screw from the OsteoMed and Synthes System respectively for the fixation of the bone graft and the plate on the first left metatarsal.,INJECTABLES: , 1 g Ancef IV 30 minutes preoperatively and the afore-mentioned lidocaine.,DESCRIPTION OF THE PROCEDURE:  ,The patient was brought to the operating room and placed on the operating table in the supine position.  After general anesthesia was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's left foot to anesthetize the future surgical sites.  The left ankle was covered with cast padding and an 18-inch ankle tourniquet was placed around the left ankle and set at 250 mmHg.  The left foot was then prepped, scrubbed, and draped in normal sterile technique.  The left ankle tourniquet was then inflated.  Attention was then directed on the dorsal aspect of the first left metatarsal shaft where an 8-cm linear incision was placed directly parallel and medial to the course of the extensor hallucis longus tendon.  The incision extended from the base of the first left metatarsal all the way to the first left metatarsophalangeal joint.  The incision was deepened through subcutaneous tissues.  All the bleeders were identified, cut, clamped, and cauterized.  The incision was deepened to the level of the periosteum of the first left metatarsal.  All the tendinous neurovascular structures were identified and retracted from the site to be preserved.  Using sharp and dull dissection, the periosteal tissues were mobilized from their attachments on the first left metatarsal shaft.  Dissection was carried down to the level of the lose screw fixation and the two screws were identified and removed intact.  The screws were sent to pathology for examination.  The nonunion was also identified closer to the base of the first left metatarsal and using the sagittal saw the nonunion and some of the healthy tissue on both ends of the previous osteotomy were resected and sent to pathology for identification.  The remaining two ends of the previous osteotomy were then fenestrated with the use of a 0.045 Kirschner wire to induce bleeding.  The corticocancellous bone graft was prepped according to the instructions in saline for at least 60 minutes and then interposed in the previous area of the osteotomy.  Provisional fixation with K-wires was achieved and also correction of the bunion deformity of the first left metatarsophalangeal joint was also accomplished.  The bone graft was then stabilized with the use of a T-type prebent plate with the use of fixed screws that were inserted using AO technique through the plate and the shaft of the first left metatarsal and compressed appropriately the graft.  Removal of the K-wires and examination of fixation and graft incorporation into the previous nonunion area was found to be excellent.  The area was flushed copiously flushed with saline.  The periosteal and capsular tissues were approximated with 3-0 Vicryl and 2-0 Vicryl suture material.  All the subcutaneous tissues were approximated with 4-0 Vicryl suture material and 5-0 Prolene was used to approximate the skin edges at this time.  The left ankle tourniquet was deflated.  Immediate hyperemia was noted to the entire left lower extremity upon deflation of the cuff.  The patient's incision was covered with Xeroform, copious amounts of fluff and Kling, stockinette, and Ace bandage.  The patient's left foot was placed in a surgical shoe.,The patient was then transferred to the postanesthesia care unit with his vital signs stable and the vascular status at appropriate levels.  The patient was given specific instructions and education on how to continue caring for his left foot surgery.  The patient was also given pain medications, instructions on how to control his postoperative pain.  The patient was eventually discharged from Hospital according to nursing protocol and was advised to follow up with Dr. X's office in one week's time for his first postoperative appointment.","orthopedic, hardware removal, metatarsal osteotomy, painful hardware, osteotomy, excision of nonunion, corticocancellous bone graft, internal fixation, subcutaneous tissues, previous osteotomy, vicryl suture, suture material, corticocancellous bone, ankle tourniquet, bone graft, metatarsal, tourniquet, allograft, fixation, plates, ankle, vicryl, nonunion, screws, "
" Hardware removal, right ulnar", Orthopedic, Hardware Removal - Ulnar ,"PREOPERATIVE DIAGNOSIS: , Retained hardware, right ulnar.,POSTOPERATIVE DIAGNOSIS: , Retained hardware, right ulnar,PROCEDURE: , Hardware removal, right ulnar.,ANESTHESIA:,  The patient received 2.5 mL of 0.25% Marcaine and local anesthetic.,COMPLICATIONS: , No intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,HISTORY AND PHYSICAL:  ,The patient is a 5-year, 5-month-old male who sustained a both-bone forearm fracture in September 2007.  The fracture healed uneventfully, but then the patient subsequently suffered a refracture one month ago.  The patient had shortening in arms, noted in both bones.  The parents opted for surgical stabilization with nailing.  This was performed one month ago on return visit.  His ulnar nail was quite prominent underneath the skin.  It was decided to remove the ulnar nail early and place the patient in another cast for 3 weeks.,Risks and benefits of the surgery were discussed with the mother.  Risk of surgery incudes risks of anesthesia, infection, bleeding, changes in sensation in most of the extremity, need for longer casting.  All questions were answered and mother agreed to above plan.,PROCEDURE IN DETAIL:  ,The patient was seen in the operative room, placed supine on operating room table.  General anesthesia was then administered.  The patient was given Ancef preoperatively.  The left elbow was prepped and draped in a standard surgical fashion.  A small incision was made over the palm with K-wire.  This was removed without incident.  The wound was irrigated.  The bursitis was curetted.  Wounds closed using #4-0 Monocryl.  The wound was clean and dry, dressed with Xeroform 4 x 4s and Webril.  Please note the area infiltrated with 0.25% Marcaine.  The patient was then placed in a long-arm cast.  The patient tolerated the procedure well and was subsequently taken to the recovery room in stable condition.,POSTOPERATIVE PLAN:  ,The patient will maintain the cast for 3 more weeks.  Intraoperative nail was given to the mother.  The patient to take Tylenol with Codeine as needed.  All questions were answered.,","orthopedic, both-bone forearm fracture, retained hardware, hardware removal, hardware, forearm, ulnar,"
 Left distal medial hamstring release., Orthopedic, Hamstring Release ,"PREOPERATIVE DIAGNOSIS: , Autism with bilateral knee flexion contractures.,POSTOPERATIVE DIAGNOSIS: , Autism with bilateral knee flexion contractures.,PROCEDURE: , Left distal medial hamstring release.,ANESTHESIA: , General anesthesia.  Local anesthetic 10 mL of 0.25% Marcaine local.,TOURNIQUET TIME: , 15 minutes.,ESTIMATED BLOOD LOSS:  ,Minimal.,COMPLICATIONS:  ,There were no intraoperative complications.,DRAIN:  ,None.,SPECIMENS:  ,None.,HISTORY AND PHYSICAL:  ,The patient is a 12-year-old boy born at a 32-week gestation and with drug exposure in utero.  The patient has diagnosis of autism as well.  The patient presented with bilateral knee flexion contractures, initially worse on right than left.  He had right distal medial hamstring release performed in February 2007 and has done quite well and has noted significant improvement in his gait and his ability to play.  The patient presents now with worsening left knee flexion contracture, and desires the same procedure to be performed.  Risks and benefits of the surgery were discussed.  The risks of surgery include risk of anesthesia, infection, bleeding, changes in sensation and motion of extremity, failure to restore normal anatomy, continued contracture, possible need for other procedures.  All questions were answered and mother and son agreed to above plan.,PROCEDURE NOTE:  ,The patient was taken to operating room and placed supine on operating table.  General anesthesia was administered.  The patient received Ancef preoperatively.  Nonsterile tourniquet was placed on the upper aspect of the patient's left thigh.  The extremity was then prepped and draped in standard surgical fashion.  The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg.  Esmarch was then removed.  A small 3 cm incision was made over the distal medial hamstring.  Hamstring tendons were isolated and released in order of semitendinosus, semimembranosus, and sartorius.  The wound was then irrigated with normal saline and closed used 2-0 Vicryl and then 4-0 Monocryl.  The wound was cleaned and dried and dressed with Steri-Strips.  The area was infiltrated with total 10 mL of 0.25% Marcaine.  The wound was then covered with Xeroform, 4 x 4s, and Bias.  Tourniquet was released at 15 minutes.  The patient was then placed in knee immobilizer.  The patient tolerated the procedure well and subsequently taken to recovery in stable condition.,POSTOPERATIVE PLAN: , The patient may weight bear as tolerated in his brace.  He will start physical therapy in another week or two.  The patient restricted from any PE for at least 6 week.  He may return to school on 01/04/2008.  He was given Vicodin for pain.","orthopedic, medial hamstring release, distal medial hamstring release, bilateral knee flexion contractures, bilateral knee, hamstring release, knee flexion, tourniquet, flexion, contractures, hamstring, "
" Excision of foreign body, right foot and surrounding tissue.  This 41-year-old male presents to preoperative holding area after keeping himself n.p.o., since mid night for removal of painful retained foreign body in his right foot.  The patient works in the Electronics/Robotics field and relates that he stepped on a wire at work, which somehow got into his shoe.  The wire entered his foot.", Orthopedic, Foreign Body Removal - Foot ,"PREOPERATIVE DIAGNOSIS: , Foreign body, right foot.,POSTOPERATIVE DIAGNOSIS: , Foreign body in the right foot.,PROCEDURE PERFORMED:,  Excision of foreign body, right foot and surrounding tissue.,ANESTHESIA: , TIVA and local.,HISTORY:,  This 41-year-old male presents to preoperative holding area after keeping himself n.p.o., since mid night for removal of painful retained foreign body in his right foot.  The patient works in the Electronics/Robotics field and relates that he stepped on a wire at work, which somehow got into his shoe.  The wire entered his foot.  His family physician attempted to remove the wire, but it only became deeper in the foot.  The wound eventually healed, but a scar tissue was formed.  The patient has had constant pain with ambulation intermittently since the incident occurred.  He desires attempted surgical removal of the wire.  The risks and benefits of the procedure have been explained to the patient in detail by Dr. X.  The consent is available on the chart for review.,PROCEDURE IN DETAIL: , After IV was established by the Department of Anesthesia, the patient was taken to the operating room via cart and placed on the operating table in a supine position with a safety strap placed across his waist for his protection.,A pneumatic ankle tourniquet was applied about the right ankle over copious amounts of Webril for the patient's protection.  After adequate IV sedation was administered by the Department of Anesthesia, a total of 12 cc of 0.5% Marcaine plain was used to administer an ankle block.  Next, the foot was prepped and draped in the usual aseptic fashion.  An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg.  The foot was lowered into the operative field and the sterile stockinet was reflected.  Attention was directed to the plantar aspect of the foot where approximately a 5 mm long cicatrix was palpated and visualized.  This was the origin and entry point of the previous puncture wound from the wire.  This cicatrix was found lateral to the plantar aspect of the first metatarsal between the first and second metatarsals in a nonweightbearing area.  Next, the Xi-scan was draped and brought into the operating room.  A #25 gauge needles under fluoroscopy were inserted into the plantar aspect of the foot and three planes to triangulate the wire.  Next, a #10 blade was used to make approximately a 3 cm curvilinear ""S""-shaped incision.  Next, the #15 blade was used to carry the incision through the subcutaneous tissue.  The medial and lateral margins of the incision were undermined.  Due to the small nature of the foreign body and the large amount of fat on the plantar aspect of the foot, the wires seemed to serve no benefit other then helping with the incision planning.  Therefore, they were removed.  Once the wound was opened, a hemostat was used to locate the wire very quickly and the wire was clamped.  A second hemostat was used to clamp the wire.  A #15 blade was used to carefully transect the fatty tissue around the tip of the hemostats, which were visualized in the base of the wound.  The wire quickly came into visualization.  It measured approximately 4 mm in length and was approximately 1 mm in diameter.  The wire was green colored and metallic in nature.  It was removed with the hemostat and passed off as a specimen to be sent to Pathology for identification.  The wire was found at the level of deep fascia at the capsular level just plantar to the deep transverse intermetatarsal ligament.  Next, copious amounts of sterile gentamicin impregnated saline was instilled in the wound for irrigation and the wound base was thoroughly cleaned and inspected.  Next, a #3-0 Vicryl was used to throw two simple interrupted deep sutures to remove the dead space.  Next, #4-0 Ethibond was used to close the skin in a combination of simple interrupted and horizontal mattress suture technique.  The standard postoperative dressing consisting of saline-soaked Owen silk, 4x4s, Kling, Kerlix, and Coban were applied.  The pneumatic ankle tourniquet was released.  There was immediate hyperemic flush to the digits noted.  The patient's anesthesia was reversed.  He tolerated the above anesthesia and procedure without complications.  The patient was transported via cart to the Postanesthesia Care Unit.,Vital signs were stable and vascular status was intact to the right foot.  He was given OrthoWedge shoe.  Ice was applied behind the knee and his right lower extremity was elevated on to pillows.  He was given standard postoperative instructions consisting of rest, ice and elevation to the right lower extremity.  He is to be non-weightbearing for three weeks, at which time, the wound will be evaluated and sutures will be removed.  He is to follow up with Dr. X on 08/22/2003 and was given emergency contact number to call if problems arise.  He was given a prescription for Tylenol #4, #30 one p.o. q.4-6h. p.r.n., pain as well as Celebrex 200 mg #30 take two p.o. q.d. p.c., with 200 mg 12 hours later as a rescue dose.  He was given crutches.  He was discharged in stable condition.","orthopedic, foreign body removal, excision of foreign body, ankle tourniquet, plantar aspect, foreign body, foot, ankle, plantar, wound,"
 Excision of ganglion of the left wrist.  A curved incision was made over the presenting ganglion over the dorsal aspect of the wrist. , Orthopedic, Ganglion Excision ,"PREOPERATIVE DIAGNOSIS: , Ganglion of the left wrist.,POSTOPERATIVE DIAGNOSIS: , Ganglion of the left wrist.,OPERATION: , Excision of ganglion.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 5 mL.,OPERATION: , After a successful anesthetic, the patient was positioned on the operating table.  A tourniquet applied to the upper arm.  The extremity was prepped in a usual manner for a surgical procedure and draped off.  The superficial vessels were exsanguinated with an elastic wrap and the tourniquet was then inflated to the usual arm pressure.  A curved incision was made over the presenting ganglion over the dorsal aspect of the wrist.  By blunt and sharp dissection, it was dissected out from underneath the extensor tendons and the stalk appeared to arise from the distal radiocapitellar joint and the dorsal capsule was excised along with the ganglion and the specimen was removed and submitted.  The small superficial vessels were electrocoagulated and instilled after closing the skin with 4-0 Prolene, into the area was approximately 6 to 7 mL of 0.25 Marcaine with epinephrine.  A Jackson-Pratt drain was inserted and then after the tourniquet was released, it was kept deflated until at least 5 to 10 minutes had passed and then it was activated and then removed in the recovery room.  The dressings applied to the hand were that of Xeroform, 4x4s, ABD, Kerlix, and elastic wrap over a volar fiberglass splint.  The tourniquet was released.  Circulation returned to the fingers.  The patient then was allowed to awaken and left the operating room in good condition.","orthopedic, curved incision, superficial vessels, tourniquet, excision, dorsal, wrist, ganglion"
 Consultation for left foot pain., Orthopedic, Foot pain Consultation ,"CHIEF COMPLAINT:, Left foot pain.,HISTORY:, XYZ is a basketball player for University of Houston who sustained an injury the day prior. They were traveling. He came down on another player's foot sustaining what he describes as an inversion injury. Swelling and pain onset immediately. He was taped but was able to continue playing He was examined by John Houston, the trainer, and had tenderness around the navicular so was asked to come over and see me for evaluation. He has been in a walking boot. He has been taped firmly. Pain with weightbearing activities. He is limping a bit. No significant foot injuries in the past. Most of his pain is located around the dorsal aspect of the hindfoot and midfoot. ,PHYSICAL EXAM:, He does have some swelling from the hindfoot out toward the midfoot. His arch is maintained. His motion at the ankle and subtalar joints is preserved. Forefoot motion is intact. He has pain with adduction and abduction across the hindfoot. Most of this discomfort is laterally. His motor strength is grossly intact. His sensation is intact, and his pulses are palpable and strong. His ankle is not tender. He has minimal to no tenderness over the ATFL. He has no medial tenderness along the deltoid or the medial malleolus. His anterior drawer is solid. His external rotation stress is not painful at the ankle. His tarsometatarsal joints, specifically 1, 2 and 3, are nontender. His maximal tenderness is located laterally along the calcaneocuboid joint and along the anterior process of the calcaneus. Some tenderness over the dorsolateral side of the talonavicular joint as well. The medial talonavicular joint is not tender.,RADIOGRAPHS:, Those done of his foot weightbearing show some changes over the dorsal aspect of the navicular that appear chronic. I don't see a definite fracture. The tarsometarsal joints are anatomically aligned. Radiographs of his ankle again show changes along the dorsal talonavicular joint but no other fractures identified. Review of an MR scan of the ankle dated 12/01/05 shows what looks like some changes along the lateral side of the calcaneocuboid joint with disruption of the lateral ligament and capsular area. Also some changes along the dorsal talonavicular joint. I don't see any significant marrow edema or definitive fracture line. ,IMPRESSION:,  Left Chopart joint sprain.,PLAN:,  I have spoken to XYZ about this. Continue with ice and boot for weightbearing activities. We will start him on a functional rehab program and progress him back to activities when his symptoms allow. He is clear on the prolonged duration of recovery for these hindfoot type injuries.","orthopedic, foot pain, calcaneocuboid joint, dorsal aspect, dorsal talonavicular joint, foot injuries, hindfoot, midfoot, rehab program, walking boot, weightbearing, talonavicular joint, dorsal, talonavicular, ankle, foot, tenderness"
" Resection of infected bone, left hallux, proximal phalanx, and distal phalanx.  Osteomyelitis, left hallux.", Orthopedic, Hallux Infected Bone Resection ,"PREOPERATIVE DIAGNOSIS: , Osteomyelitis, left hallux.,POSTOPERATIVE DIAGNOSIS: , Osteomyelitis, left hallux.,PROCEDURES PERFORMED: , Resection of infected bone, left hallux, proximal phalanx, and distal phalanx.,ANESTHESIA: , TIVA/Local.,HISTORY:,  This 77-year-old male presents to ABCD preoperative holding area after keeping himself NPO since mid night for surgery on his infected left hallux.  The patient has a history of chronic osteomyelitis and non-healing ulceration to the left hallux of almost 10 years' duration.  He has failed outpatient antibiotic therapy and conservative methods.  At this time, he desires to attempt surgical correction.  The patient is not interested in a hallux amputation at this time; however, he is consenting to removal of infected bone.  He was counseled preoperatively about the strong probability of the hallux being a ""floppy tail"" after the surgery and accepts the fact.  The risks versus benefits of the procedure were discussed with the patient in detail by Dr. X and the consent is available on the chart for review.,PROCEDURE IN DETAIL:  ,The patient's wound was debrided with a #15 blade and down to good healthy tissue preoperatively.  The wound was on the planar medial, distal and dorsal medial.  The wound's bases were fibrous.  They did not break the bone at this point.  They were each approximately 0.5 cm in diameter.  After IV was established by the Department of Anesthesia, the patient was taken to the operating room and placed on the operating table in supine position with safety straps placed across his waist for his protection.,Due to the patient's history of diabetes and marked calcifications on x-ray, a pneumatic ankle tourniquet was not applied.  Next, a total of 3 cc of a 1:1 mixture of 0.5% Marcaine plain and 1% lidocaine plain was used to infiltrate the left hallux and perform a digital block.  Next, the foot was prepped and draped in the usual aseptic fashion.  It was lowered in the operative field and attention was directed to the left hallux after the sterile stockinet was reflected.  Next, a #10 blade was used to make a linear incision approximately 3.5 cm in length along the dorsal aspect of the hallux from the base to just proximal to the eponychium.  Next, the incision was deepened through the subcutaneous tissue.  A heavy amount of bleeding was encountered.  Therefore, a Penrose drain was applied at the tourniquet, which failed.  Next, an Esmarch bandage was used to exsanguinate the distal toes and forefoot and was left in the forefoot to achieve hemostasis.  Any small veins crossing throughout the subcutaneous layer were ligated via electrocautery.  Next, the medial and lateral margins of the incision were under marked with a sharp dissection down to the level of the long extension tendon.  The long extensor tendon was thickened and overall exhibited signs of hypertrophy.  The transverse incision through the long extensor tendon was made with a #15 blade.  Immediately upon entering the joint, yellow discolored fluid was drained from the interphalangeal joint.  Next, the extensor tendon was peeled dorsally and distally off the bone.  Immediately the head of the proximal phalanx was found to be lytic, disease, friable, crumbly, and there were free fragments of the medial aspect of the bone, the head of the proximal phalanx.  This bone was removed with a sharp dissection.  Next, after adequate exposure was obtained and the collateral ligaments were released off the head of proximal phalanx, a sagittal saw was used to resect the approximately one-half of the proximal phalanx.  This was passed off as the infected bone specimen for microbiology and pathology.  Next, the base of the distal phalanx was exposed with sharp dissection and a rongeur was used to remove soft crumbly diseased medial and plantar aspect at the base of distal phalanx.  Next, there was diseased soft tissue envelope around the bone, which was also resected to good healthy tissue margins.  The pulse lavage was used to flush the wound with 1000 cc of gentamicin-impregnated saline.  Next, cleaned instruments were used to take a proximal section of proximal phalanx to label a clean margin.  This bone was found to be hard and healthy appearing.  The wound after irrigation was free of all debris and infected tissue.  Therefore anaerobic and aerobic cultures were taken and sent to microbiology.  Next, OsteoSet beads, tobramycin-impregnated, were placed.  Six beads were placed in the wound.  Next, the extensor tendon was re-approximated with #3-0 Vicryl.  The subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted technique.  Next, the skin was closed with #4-0 nylon in a horizontal mattress technique.,The Esmarch bandage was released and immediate hyperemic flush was noted at the digits.  A standard postoperative dressing was applied consisting of 4 x 4s, Betadine-soaked #0-1 silk, Kerlix, Kling, and a loosely applied Ace wrap.  The patient tolerated the above anesthesia and procedure without complications.  He was transported via a cart to the Postanesthesia Care Unit.  His vitals signs were stable and vascular status was intact.  He was given a medium postop shoe that was well-formed and fitting.  He is to elevate his foot, but not apply ice.  He is to follow up with Dr. X.  He was given emergency contact numbers.  He is to continue the Vicodin p.r.n. pain that he was taking previously for his shoulder pain and has enough of the medicine at home.  The patient was discharged in stable condition.","orthopedic, osteomyelitis, proximal phalanx, distal phalanx, infected bone, proximal, bone, phalanx, healing, hallux, infected, tissue, distal,"
" Cellulitis with associated abscess and foreign body, right foot. Irrigation debridement and removal of foreign body of right foot.  Purulent material from the abscess located in the plantar aspect of the foot between the third and fourth metatarsal heads.", Orthopedic, Foreign Body Removal - Foot - 1 ,"PREOPERATIVE DIAGNOSES:,1.  Cellulitis with associated abscess, right foot.,2.  Foreign body, right foot.,POSTOPERATIVE DIAGNOSES:,1.  Cellulitis with associated abscess, right foot.,2.  Foreign body, right foot.,PROCEDURE PERFORMED:,1.  Irrigation debridement.,2.  Removal of foreign body of right foot.,ANESTHESIA:,  Spinal with sedation.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , Minimal.,GROSS FINDINGS: , Include purulent material from the abscess located in the plantar aspect of the foot between the third and fourth metatarsal heads.,HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old Caucasian male with a history of uncontrolled diabetes mellitus.  The patient states that he was working in his garage over the past few days when he noticed some redness and edema in his right foot.  He notes some itching as well as increasing pain and redness in the right foot and presented to ABCD General Hospital Emergency Room.  He was evaluated by the Emergency Room staff as well as the medical team and the Department of Orthopedics.  It was noted upon x-ray a foreign body in his foot and he had significant amount of cellulitis as well ________ right lower extremity.  After a long discussion held with the patient, it was elected to proceed with irrigation debridement and removal of the foreign body.,PROCEDURE: , After all potential complications, risks, as well as anticipated benefits of the above-named procedures were discussed at length with the patient, informed consent was obtained.  The operative extremity was then confirmed with the patient, operative surgeon, the Department of Anesthesia and nursing staff.  The patient was then transferred to preoperative area to Operative Suite #5 and placed on the operating table in supine position.  All bony prominences were well padded at this time.  The Department of Anesthesia was administered spinal anesthetic to the patient.  Once this anesthesia was obtained, the patient's right lower extremity was sterilely prepped and draped in the usual sterile fashion.  Upon viewing of the plantar aspect of the foot, there was noted to be a swollen ecchymotic area with a small hole in it, which purulent fluid was coming from.  At this time, after all bony and soft tissue landmarks were identified as well as the localization of the pus, a 2 cm longitudinal incision was made directly over this area, which was located between the second and third metatarsal heads.  Upon incising this, there was a foul smelling purulent fluid, which flowed from this region.  Aerobic and anaerobic cultures were taken as well as gram stain.  The area was explored and it ________ to the dorsum of the foot.  There was no obvious joint involvement.  After all loculations were broken, 3 liters antibiotic-impregnated fluid were pulse-evac through the wound.  The wound was again inspected with no more gross purulent or necrotic appearing tissue.  The wound was then packed with an iodoform gauge and a sterile dressing was applied consisting of 4x4s, floss, and Kerlix covered by an Ace bandage.  At this time, the Department of Anesthesia reversed the sedation.  The patient was transferred back to the hospital gurney to Postanesthesia Care Unit.  The patient tolerated the procedure well and there were no complications.,DISPOSITION:  ,The patient will be followed on a daily basis for possible repeat irrigation debridement.","orthopedic, removal of foreign body, purulent material, metatarsal, cellulitis, abscess, kerlix, foreign body, foot, irrigation, debridement, purulent, "
" Flexor carpi radialis and palmaris longus repair.  Right wrist laceration with a flexor carpi radialis laceration and palmaris longus laceration 90%, suspected radial artery laceration.", Orthopedic, Flexor Carpi Radialis & Palmaris Longus Repair ,"PREOPERATIVE DIAGNOSIS:,  Right wrist laceration with a flexor carpi radialis laceration and palmaris longus laceration 90%, suspected radial artery laceration.,POSTOPERATIVE DIAGNOSIS:,  Right wrist laceration with a flexor carpi radialis laceration and palmaris longus laceration 90%, suspected radial artery laceration.,PROCEDURES PERFORMED:  ,1.  Repair flexor carpi radialis.,2.  Repair palmaris longus.,ANESTHETIC: , General.,TOURNIQUET TIME:  ,Less than 30 minutes.,CLINICAL NOTE:  ,The patient is a 21-year-old who sustained a clean laceration off a teapot last night.  She had lacerated her flexor carpi radialis completely and 90% of her palmaris longus.  Both were repaired proximal to the carpal tunnel.  The postoperative plans are for a dorsal splint and early range of motion passive and active assist.  The wrist will be at approximately 30 degrees of flexion.  The MPJ is at 30 degrees of flexion, the IP straight.  Splinting will be used until the 4-week postoperative point.,PROCEDURE: , Under satisfactory general anesthesia, the right upper extremity was prepped and draped in the usual fashion.  There were 2 transverse lacerations.  Through the first laceration, the flexor carpi radialis was completely severed.  The proximal end was found with a tendon retriever.  The distal end was just beneath the subcutaneous tissue.,A primary core stitch was used with a Kessler stitch.  This was with 4-0 FiberWire.  A second core stitch was placed, again using 4-0 FiberWire.  The repair was oversewn with locking, running, 6-0 Prolene stitch.  Through the second incision, the palmaris longus was seen to be approximately 90% severed.  It was an oblique laceration.  It was repaired with a 4-0 FiberWire core stitch and with a Kessler-type stitch.  A secure repair was obtained.  She was dorsiflexed to 75 degrees of wrist extension without rupture of the repair.  The fascia was released proximally and distally to give her more room for excursion of the repair.,The tourniquet was dropped, bleeders were cauterized.  Closure was routine with interrupted 5-0 nylon.  A bulky hand dressing as well as a dorsal splint with the wrist MPJ and IP as noted.  The splint was dorsal.  The patient was sent to the recovery room in good condition.","orthopedic, kessler stitch, flexor carpi radialis, palmaris longus, radialis, laceration, fiberwire, flexor, carpi, palmaris, longus, repair"
 Consultation for FCR tendinitis, Orthopedic, FCR tendinitis ,"HISTORY OF PRESENT PROBLEM:,  XYZ was seen by Dr. ABC for an FCR tendinitis.  We do not have his reports, but by history she has had two cortisone shots.  She plays musical instruments, and it does bother her from time to time.  She was considering surgery, but she takes ibuprofen and it seems to be well-controlled.  She is here now for consultation. ,CLINICAL/PHYSICAL EXAMINATION: , ,General:  The patient is alert and oriented times three in no acute distress. ,Skin:  No skin breakdown or hyperhidrosis.,Vascular:  2+ radial and ulnar artery pulses.,Musculoskeletal:  Wrist, elbow, shoulder and neck exams reveal no focal findings except for some tenderness to palpation over the FCR tendon on the scaphoid tubercle, but there is no SL instability and no signs of lunotriquetral instability or midcarpal instability.  The DRUJ is stable.  Flexion/extension of the fingers is all intact.  Forearm, elbow and shoulder exams reveal no other focal tenderness to palpation.,Neurologic:  Negative Tinel's, Phalen's and compression median nerve test.  APB, EPL and first dorsal interosseous have 5/5 strength.  Forearm, elbow and shoulder exams reveal no neurologic compromise.,Gait:  Normal.,Neck:  Negative Spurling sign.  Negative signs of thoracic outlet.,HEENT:  Pupils equal and reactive with no asymmetry.,CLINICAL IMPRESSION:,  By history, possible FCR tendinitis.,EVALUATION/TREATMENT PLAN:  At this point, we have asked her some questions again.  She is not that sore at this point, and she has had a couple of cortisone shots.  Without being the initial treating physician, she has FCR tendinitis that fails to respond to cortisone shots.  She is a candidate for an FCR tunnel release.  It has been described and is effective for those patients with that problem.  My only consideration would be, if the patient should choose, to get an MRI when she is symptomatic to confirm the FCR tendinitis.  She will followup with Dr. ABC as needed or come back to us when she is thinking more along the lines of surgery.","orthopedic, fcr tendinitis, fcr tunnel release, cortisone shot, tendinitis, tunnel release, signs, oriented, shoulder, fcr"
 Sample Radiology report of knee (growth arrest lines)., Orthopedic, Five views of the right knee. ,"EXAM: , Five views of the right knee.,HISTORY: , Pain.  The patient is status-post surgery, he could not straighten his leg, pain in the back of the knee.,TECHNIQUE:,  Five views of the right knee were evaluated.  There are no priors for comparison.,FINDINGS: , Five views of the right knee were evaluated and they reveal there is no evidence of any displaced fractures, dislocations, or subluxations.  There are multiple areas of growth arrest lines seen in the distal aspect of the femur and proximal aspect of the tibia.  There is also appearance of a high-riding patella suggestive of patella alta.,IMPRESSION:,1.  No evidence of any displaced fractures, dislocations, or subluxations.,2.  Growth arrest lines seen in the distal femur and proximal tibia.,3.  Questionable appearance of a slightly high-riding patella, possibly suggesting patella alta.","orthopedic, fractures dislocations or subluxations, femur and proximal, growth arrest lines, patella alta, fractures, dislocations, subluxations, distal, femur, patella"
 Endoscopic carpal tunnel release.  Left carpal tunnel syndrome., Orthopedic, Endoscopic Carpal Tunnel Rlease ,"PREOPERATIVE DIAGNOSIS:,  Left carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:,  Left carpal tunnel syndrome.,OPERATIONS PERFORMED:,  Endoscopic carpal tunnel release.,ANESTHESIA:,  I.V. sedation and local (1% Lidocaine).,ESTIMATED BLOOD LOSS:,  Zero.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL: , With the patient under adequate anesthesia, the upper extremity was prepped and draped in a sterile manner.  The arm was exsanguinated.  The tourniquet was elevated at 290 mm/Hg.  Construction lines were made on the left palm to identify the ring ray.  A transverse incision was made in the wrist, between FCR and FCU, one fingerbreadth proximal to the interval between the glabrous skin of the palm and normal forearm skin.  Blunt dissection exposed the antebrachial fascia.  Hemostasis was obtained with bipolar cautery.  A distal-based window in the antebrachial fascia was then fashioned.  Care was taken to protect the underlying contents.  A proximal forearm fasciotomy was performed under direct vision.  A synovial elevator was used to palpate the undersurface of the transverse carpal ligament, and synovium was elevated off this undersurface.  Hamate sounds were then used to palpate the hook of hamate.  The endoscopic instrument was then inserted into the proximal incision.  The transverse carpal ligament was easily visualized through the portal.  Using palmar pressure, the transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end.,The distal end of the transverse carpal ligament was then identified in the window.  The blade was then elevated, and the endoscopic instrument was withdrawn, dividing the transverse carpal ligament under direct vision.  After complete division o the transverse carpal ligament, the instrument was reinserted.  Radial and ulnar edges of the transverse carpal ligament were identified, and complete release was confirmed.,The wound was then closed with running subcuticular stitch.  Steri-Strips were applied, and sterile dressing was applied over the Steri-Strips.  The tourniquet was deflated.  The patient was awakened from anesthesia and returned to the Recovery Room in satisfactory condition, having tolerated the procedure well.","orthopedic, fcr, fcu, antebrachial fascia, endoscopic carpal tunnel release, carpal tunnel release, carpal tunnel syndrome, carpal, endoscopic, ligament, tourniquet, transverse,"
 Left little finger extensor tendon laceration.  Repair of left little extensor tendon., Orthopedic, Extensor Tendon Repair ,"PREOPERATIVE DIAGNOSIS:,  Left little finger extensor tendon laceration.,POSTOPERATIVE DIAGNOSIS: , Left little finger extensor tendon laceration.,PROCEDURE PERFORMED:  ,Repair of left little extensor tendon.,COMPLICATIONS:,  None.,BLOOD LOSS: , Minimal.,ANESTHESIA: , Bier block.,INDICATIONS: , The patient is a 14-year-old right-hand dominant male who cut the back of his left little finger and had a small cut to his extensor tendon.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operative room, laid supine, administered intervenous sedation with Bier block and prepped and draped in a sterile fashion.  The old laceration was opened and the extensor tendon was identified and there was a small longitudinal laceration in the tendon, which is essentially in line with the tendon fibers.  This was just proximal to the PIP joint and on complete flexion of the PIP joint, I did separate just a little bit that was not thought to be significantly dynamically unstable.  It was sutured with a single 4-0 Prolene interrupted figure-of-eight suture and on dynamic motion it did not separate at all.  The wound was irrigated and closed with 5-0 nylon interrupted sutures.  The patient tolerated the procedure well and was taken to the PCU in good condition.","orthopedic, extensor tendon laceration, bier block, pip joint, extensor tendon, tendon, repair, finger, laceration, extensor,"
" Bilateral C3-C4, C4-C5, C5-C6, and C6-C7 medial facetectomy and foraminotomy with technical difficulty, total laminectomy C3, C4, C5, and C6, excision of scar tissue, and repair of dural tear with Prolene 6-0 and Tisseel.", Orthopedic, Facetectomy & Foraminotomy ,"PREOPERATIVE DIAGNOSES,1.  Neck pain with bilateral upper extremity radiculopathy.,2.  Residual stenosis, C3-C4, C4-C5, C5-C6, and C6-C7 with probable instability.,POSTOPERATIVE DIAGNOSES,1.  Neck pain with bilateral upper extremity radiculopathy.,2.  Residual stenosis, C3-C4, C4-C5, C5-C6, and C6-C7 secondary to facet arthropathy with scar tissue.,3.  No evidence of instability.,OPERATIVE PROCEDURE PERFORMED,1.  Bilateral C3-C4, C4-C5, C5-C6, and C6-C7 medial facetectomy and foraminotomy with technical difficulty.,2.  Total laminectomy C3, C4, C5, and C6.,3.  Excision of scar tissue.,4.  Repair of dural tear with Prolene 6-0 and Tisseel.,FLUIDS:,  1500 cc of crystalloid.,URINE OUTPUT: , 200 cc.,DRAINS: , None.,SPECIMENS: , None.,COMPLICATIONS: , None.,ANESTHESIA:,  General endotracheal anesthesia.,ESTIMATED BLOOD LOSS:,  Less than 250 cc.,INDICATIONS FOR THE OPERATION:  ,This is the case of a very pleasant 41 year-old Caucasian male well known to me from previous anterior cervical discectomy and posterior decompression.  Last surgery consisted of four-level decompression on 08/28/06.  The patient continued to complain of posterior neck pain radiating to both trapezius.  Review of his MRI revealed the presence of what still appeared to be residual lateral recess stenosis.  It also raised the possibility of instability and based on this I recommended decompression and posterolateral spinal instrumention; however, intraoperatively, it appeared like there was no abnormal movement of any of the joint segments; however, there was still residual stenosis since the laminectomy that was done previously was partial.  Based on this, I did total decompression by removing the lamina of C3 through C6 and doing bilateral medial facetectomy and foraminotomy at C3-C4, C4-C5, C5-C6, and C6-C7 with no spinal instrumentation.  Operation and expected outcome risks and benefits were discussed with him prior to the surgery.  Risks include but not exclusive of bleeding and infection.  Infection can be superficial, but may also extend down to the epidural space, which may require return to the operating room and evacuation of the infection.  There is also the risk of bleeding that could be superficial but may also be in the epidural space resulting in compression of spinal cord.  This may result in weakness of all four extremities, numbness of all four extremities, and impairment of bowel and bladder function, which will require an urgent return to the operating room and evacuation of the hematoma.  There is also the risk of a dural tear with its attendant problems of CSF leak, headache, nausea, vomiting, photophobia, pseudomeningocele, and dural meningitis.  This too may require return to the operating room for evacuation of said pseudomeningocele and repair.  The patient understood the risk of the surgery.  I told him there is just a 30% chance that there will be no improvement with the surgery; he understands this and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room, awake, alert, not in any form of distress.  After smooth induction and intubation, a Foley catheter was inserted.  Monitoring leads were also placed by Premier Neurodiagnostics for both SSEP and EMG monitoring.  The SSEPs were normal, and the EMGs were silent during the entire case.  After completion of the placement of the monitoring leads, the patient was then positioned prone on a Wilson frame with the head supported on a foam facial support.  Shave was then carried out over the occipital and suboccipital region.  All pressure points were padded.  I proceeded to mark the hypertrophic scar for excision.  This was initially cleaned with alcohol and prepped with DuraPrep.,After sterile drapes were laid out, incision was made using a scalpel blade #10.  Wound edge bleeders were carefully controlled with bipolar coagulation and a hot knife was utilized to excise the hypertrophic scar.  Dissection was then carried down to the cervical fascia, and by careful dissection to the scar tissue, the spinous process of C2 was then identified.  There was absence of the spinous process of C3, C4, C5, and C6, but partial laminectomy was noted; removal of only 15% of the lamina.  With this completed, we proceeded to do a total laminectomy at C3, C4, C5, and C6, which was technically difficult due to the previous surgery.  There was also a dural tear on the right C3-C4 space that was exposed and repaired with Prolene 6-0 and later with Tisseel.  By careful dissection and the use of a -5 and 3 mm bur, total laminectomy was done as stated with bilateral medial facetectomy and foraminotomy done at C3-C4, C4-C5, C5-C6, and C6-C7.  There was significant epidural bleeding, which was carefully coagulated.  At two points, I had to pack this with small pieces of Gelfoam.  After repair of the dural tear, Valsalva maneuver showed no evidence of any CSF leakage.  Area was irrigated with saline and bacitracin and then lined with Tisseel.  The wound was then closed in layers with Vicryl 0 simple interrupted sutures to the fascia; Vicryl 2-0 inverted interrupted sutures to the dermis and a running nylon 2-0 continuous vertical mattress stitch.  The patient was extubated and transferred to recovery.",
 Consultation for finger triggering and locking., Orthopedic, Finger triggering and locking ,"CHIEF COMPLAINT:,  Right middle finger triggering and locking, as well as right index finger soreness at the PIP joint.,HISTORY OF OCCUPATIONAL INJURY OR ILLNESS:,  The patient has been followed elsewhere, and we reviewed his records.  Essentially, he has had a trigger finger and a mucocyst, and he has had injections.  This has been going on for several months.  He is now here for active treatment because the injections were not helpful, nonoperative treatment has not worked, and he would like to move forward in order to prevent this from keeping on locking and causing his pain.  He is referred over here for evaluation regarding that.,SIGNIFICANT PAST MEDICAL AND SURGICAL HISTORY:,General health/review of systems:  See H&P. ,Allergies:  See H&P.,Medications:  See H&P.,Social History:  See H&P.,Family History:  See H&P.,Previous Hospitalizations:  See H&P.,CLINICAL ASSESSMENT AND FINDINGS:,Musculoskeletal:  Shows point tenderness to palpation to the right middle finger A1 pulley.  The right index finger has some small soreness at the PIP joint, but at this time no obvious mucocyst.  He has flexion/extension of his fingers intact.  There is no crepitation at the wrist, forearm, elbow or shoulder with full range of motion.  Contralateral arm exam for comparison reveals no focal findings.,Neurological:  APB, EPL and first dorsal interosseous 5/5.,LABORATORY, RADIOGRAPHIC, AND/OR IMAGING TESTS ORDERS & RESULTS:,Special lab studies:  ,CLINICAL IMPRESSION:,1.  Tendinitis, left middle finger.,2.  PIP joint synovitis and mucocyst, but controlled on nonoperative treatment.,3.  Middle finger trigger, failed nonoperative treatment, requiring a trigger finger release to the right middle finger.,EVALUATION/TREATMENT PLAN:,  Risks, benefits and alternatives were discussed.  All questions were answered.  No guarantees were made.  We will schedule for surgery.  We would like to move forward in order to help him significantly improve since he has failed injections.  All questions were answered.  Followup appointment was given.","orthopedic, finger triggering, a1 pulley, pip joint, tendinitis, crepitation, locking, mucocyst, synovitis, trigger finger, middle finger triggering, triggering and locking, index finger, finger, triggering,"
 Endoscopic carpal tunnel release and de Quervain's release. Left carpal tunnel syndrome and de Quervain's tenosynovitis., Orthopedic, Endoscopic Carpal Tunnel & de Quervain's Release ,"PREOPERATIVE DIAGNOSIS:  ,1.  Left carpal tunnel syndrome.,2.  de Quervain's tenosynovitis.,POSTOPERATIVE DIAGNOSIS:,  ,1.  Left carpal tunnel syndrome.,2.  de Quervain's tenosynovitis.,OPERATIONS PERFORMED:  ,1.  Endoscopic carpal tunnel release.,2.  de Quervain's release.,ANESTHESIA:,  I.V. sedation and local (1% Lidocaine).,ESTIMATED BLOOD LOSS:,  Zero.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL:  ,ENDOSCOPIC CARPAL TUNNEL RELEASE:,  With the patient under adequate anesthesia, the upper extremity was prepped and draped in a sterile manner.  The arm was exsanguinated.  The tourniquet was elevated at 290 mm/Hg.  Construction lines were made on the left palm to identify the ring ray.  A transverse incision was made in the wrist, between FCR and FCU, one fingerbreadth proximal to the interval between the glabrous skin of the palm and normal forearm skin.  Blunt dissection exposed the antebrachial fascia.  Hemostasis was obtained with bipolar cautery.  A distal-based window in the antebrachial fascia was then fashioned.  Care was taken to protect the underlying contents.  A proximal forearm fasciotomy was performed under direct vision.  A synovial elevator was used to palpate the undersurface of the transverse carpal ligament, and synovium was elevated off this undersurface.  Hamate sounds were then used to palpate the hook of hamate.  The endoscopic instrument was then inserted into the proximal incision.  The transverse carpal ligament was easily visualized through the portal.  Using palmar pressure, the transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end.,The distal end of the transverse carpal ligament was then identified in the window.  The blade was then elevated, and the endoscopic instrument was withdrawn, dividing the transverse carpal ligament under direct vision.  After complete division o the transverse carpal ligament, the instrument was reinserted.  Radial and ulnar edges of the transverse carpal ligament were identified, and complete release was confirmed.,The wound was then closed with running subcuticular stitch.  Steri-Strips were applied, and sterile dressing was applied over the Steri-Strips.  The tourniquet was deflated.  The patient was awakened from anesthesia and returned to the Recovery Room in satisfactory condition, having tolerated the procedure well.,DE QUERVAIN'S RELEASE: , With the patient under adequate regional anesthesia applied by surgeon using 1% plain Xylocaine, the upper extremity was prepped and draped in a sterile manner.  The arm was exsanguinated.  The tourniquet was elevated to 290 mm/Hg.  A transverse incision was then made over the radial aspect of the wrist overlying the first dorsal tunnel.  Using blunt dissection, the radial sensory nerve branches were dissected and retracted out of the operative field.  The first dorsal tunnel was then identified.  The first dorsal tunnel was incised along the dorsal ulnar border, completely freeing the stenosing tenosynovitis (de Quervain's release).  EPB and APL tendons were inspected and found to be completely free.  The radial sensory nerve was inspected and found to be without damage.,The skin was closed with a running 3-0 Prolene subcuticular stitch and Steri-Strips were applied and, over the Steri-Strips, a sterile dressing, and, over the sterile dressing, a volar splint with the hand in safe position.  The tourniquet was deflated.  The patient was returned to the holding area in satisfactory condition, having tolerated the procedure well.","orthopedic, de quervain's tenosynovitis, de quervain's release, carpal tunnel syndrome, carpal tunnel release, endoscopic carpal tunnel release, tunnel, transverse, carpal, tourniquet, endoscopic, "
 Followup 4 months status post percutaneous screw fixation of a right Schatzker IV tibial plateau fracture and second through fifth metatarsal head fractures treated nonoperatively., Orthopedic, Followup Screw Fixation ,"REASON FOR VISIT:  ,Followup 4 months status post percutaneous screw fixation of a right Schatzker IV tibial plateau fracture and second through fifth metatarsal head fractures treated nonoperatively.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 59-year-old gentleman who is now approximately 4 months status post percutaneous screw fixation of Schatzker IV tibial plateau fracture and nonoperative management of second through fifth metatarsal head fractures.  He is currently at home and has left nursing home facility.  He states that his pain is well controlled.  He has been working with physical therapy two to three times a week.  He has had no drainage or fever.  He has noticed some increasing paresthesias in his bilateral feet but has a history of spinal stenosis with lower extremity neuropathy.,FINDINGS: , On physical exam, his incision is near well healed.  He has no effusion noted.  His range of motion is 10 to 105 degrees.  He has no pain or crepitance.  On examination of his right foot, he is nontender to palpation of the metatarsal heads.  He has 4 out of 5 strength in EHL, FHL, tibialis, and gastroc-soleus complex.  He does have decreased sensation to light touch in the L4-L5 distribution of his feet bilaterally.,X-rays taken including AP and lateral of the right knee demonstrate a healed medial tibial plateau fracture status post percutaneous screw fixation.  Examination of three views of the right foot demonstrates the second through fifth metatarsal head fractures.  These appear to be extraarticular.  They are all in a bayonet arrangement, but there appears to be bridging callus between the fragments on the oblique film.,ASSESSMENT:  ,Four months status post percutaneous screw fixation of the right medial tibial plateau and second through fifth metatarsal head fractures.,PLANS: , I would like the patient to continue working with physical therapy.  He may be weightbearing as tolerated on his right side.  I would like him to try to continue to work to gain full extension of the right knee and increase his knee flexion.  I also would like him to work on ambulation and strengthening.,I discussed with the patient his concerning symptoms of paresthesias.  He said he has had the left thigh for a number of years and has been followed by a neurologist for this.  He states that he has had some right-sided paresthesias now for a number of weeks.  He claims he has no other symptoms of any worsening stenosis.  I told him that I would see his neurologist for evaluation or possibly a spinal surgeon if his symptoms progress.,The patient should follow up in 2 months at which time he should have AP and lateral of the right knee and three views of the right foot.","orthopedic, metatarsal head fractures, tibial plateau fracture, schatzker, percutaneous screw fixation, tibial plateau, metatarsal head, screw fixation, head, screw, fixation, metatarsal "
 Left elbow manipulation and hardware removal of left elbow., Orthopedic, Elbow Manipulation ,"PREOPERATIVE DIAGNOSIS:,  Left elbow with retained hardware.,POSTOPERATIVE DIAGNOSIS: , Left elbow with retained hardware.,PROCEDURE: , ,1.  Left elbow manipulation.,2.  Hardware removal of left elbow.,ANESTHESIA:  ,Surgery was performed under general anesthesia.,COMPLICATIONS:,  There were no intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,INTRAOPERATIVE FINDING: , Preoperatively, the patient is 40 to 100 degrees range of motion with limited supination and pronation of about 20 degrees.  We increased his extension and flexion to about 20 to 120 degrees and the pronation and supination to about 40 degrees.,LOCAL ANESTHETIC:  ,10 mL of 0.25% Marcaine.,HISTORY AND PHYSICAL: , The patient is a 10-year-old right-hand dominant male, who threw himself off a quad on 10/10/2007.  The patient underwent open reduction and internal fixation of his left elbow fracture dislocation.  The patient also sustained a nondisplaced right glenoid neck fracture.  The patient's fracture has healed without incident, although he had significant postoperative stiffness for which he is undergoing physical therapy, as well as use of a Dynasplint.  The patient is neurologically intact distally.  Given the fact that his fracture has healed, surgery was recommended for hardware removal to decrease his irritation with elbow extension from the hardware.  Risks and benefits of the surgery were discussed.  The risks of surgery included the risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremities, failure to remove hardware, failure to relieve pain, continued postoperative stiffness.  All questions were answered and the parents agreed to the above plan.,PROCEDURE:  ,The patient was taken to the operating room and placed supine on the operating table.  General anesthesia was then administered.  The patient's left upper extremity was then prepped and draped in a standard surgical fashion.  Using fluoroscopy, the patient's K-wire was located.  An incision was made over his previous scar.  A subcutaneous dissection then took place in the plane between the subcutaneous fat and muscles.  The K-wires were easily palpable.  A small incision was made into the triceps, which allowed for visualization of the two pins, which were removed without incident.  The wound was then irrigated.  The triceps split was now closed using #2-0 Vicryl.  The subcutaneous tissue was also closed using #2-0 Vicryl and the skin with #4-0 Monocryl.  The wound was clean and dry and dressed with Steri-Strips, Xeroform, and 4 x 4s, as well as bias.  A total of 10 mL of 0.25% Marcaine was injected into the incision, as well as the joint line.  At the beginning of the case, prior to removal of the hardware, the arm was taken through some strenuous manipulations with improvement of his extension to 20 degrees, flexion to 130 degrees and pronation supination to about 40 degrees.,DIAGNOSTIC IMPRESSION:  ,The postoperative films demonstrated no fracture, no retained hardware.  The patient tolerated the procedure well and was subsequently taken to the recovery room in stable condition.,POSTOPERATIVE PLAN: , The patient will restart physical therapy and Dynasplint in 3 days.  The patient is to follow up in 1 week's time for a wound check.  The patient was given Tylenol No.  3 for pain.","orthopedic, k-wires, dynasplint, elbow manipulation, hardware removal, retained hardware, elbow, hardware, "
" Excision of Dupuytren disease of the right hand extending out to the proximal interphalangeal joint of the little finger.  The patient is a 51-year-old male with left Dupuytren disease, which is causing contractions both at the metacarpophalangeal and the PIP joint as well as significant discomfort.", Orthopedic, Dupuytren Disease Excision ,"PREOPERATIVE DIAGNOSIS: , Right hand Dupuytren disease to the little finger.,POSTOPERATIVE DIAGNOSIS:  ,Right hand Dupuytren disease to the little finger.,PROCEDURE PERFORMED:  ,Excision of Dupuytren disease of the right hand extending out to the proximal interphalangeal joint of the little finger.,COMPLICATIONS:  ,None.,BLOOD LOSS: , Minimal.,ANESTHESIA: , Bier block.,INDICATIONS:  ,The patient is a 51-year-old male with left Dupuytren disease, which is causing contractions both at the metacarpophalangeal and the PIP joint as well as significant discomfort.,DESCRIPTION OF PROCEDURE:  ,The patient was taken to the operating room, laid supine, administered a bier block, and prepped and draped in the sterile fashion.  A zig-zag incision was made down the palmar surface of the little finger and under the palm up to the mid palm region.  Skin flaps were elevated carefully, dissecting Dupuytren contracture off the undersurface of the flaps.  Both neurovascular bundles were identified proximally in the hand and the Dupuytren disease fibrous band was divided proximally, which essentially returned to normal-appearing tissue.  The neurovascular bundles were then dissected distally resecting everything medial to the 2 neurovascular bundles and above the flexor tendon sheath all the way out to the PIP joint of the finger where the Dupuytren disease stopped.  The wound was irrigated.  The neurovascular bundles rechecked with no evidence of any injury and the neurovascular bundles were not significantly involved in the Dupuytren disease.  The incisions were closed with 5-0 nylon interrupted sutures.,The patient tolerated the procedure well and was taken to the PACU in good condition.","orthopedic, excision of dupuytren disease, proximal interphalangeal joint, dupuytren disease, bier block, pip joint, disease, dupuytren, contractions, metacarpophalangeal, neurovascular, bundles, interphalangeal, finger"
" Excision dorsal ganglion, right wrist.   The extensor retinaculum was then incised and the extensor tendon was dissected and retracted out of the operative field. ", Orthopedic, Dorsal Ganglion - Excision ,"PREOPERATIVE DIAGNOSIS:,  Dorsal ganglion, right wrist.,POSTOPERATIVE DIAGNOSIS:,  Dorsal ganglion, right wrist.,OPERATIONS PERFORMED:,  Excision dorsal ganglion, right wrist.,ANESTHESIA:,  Monitored anesthesia care with regional anesthesia applied by surgeon.,TOURNIQUET TIME:,  minutes.,DESCRIPTION OF PROCEDURE: , With the patient under adequate anesthesia, the upper extremity was prepped and draped in a sterile manner.  The arm was exsanguinated and the tourniquet was elevated to 290 mm/Hg.  A transverse incision was made over the dorsal ganglion.  Using blunt dissection the dorsal ulnar sensory nerve branches and radial sensory nerve branches were dissected and retracted out of the operative field.  The extensor retinaculum was then incised and the extensor tendon was dissected and retracted out of the operative field.  The ganglion was then further dissected to its origin from the dorsal distal scapholunate interosseus ligament and excised in toto.  Care was taken to protect ligament integrity.  Reactive synovium was then removed using soft tissue rongeur technique.  The wound was then infiltrated with 0.25% Marcaine.  The tendons were allowed to resume their normal anatomical position.  The skin was closed with 3-0 Prolene subcuticular stitch.  Sterile dressings were applied.  The tourniquet was deflated.  The patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well.","orthopedic, excision dorsal ganglion, extensor tendon, extensor retinaculum, dorsal ganglion, retinaculum, ganglion"
" Left elbow pain.  Fracture of the humerus, spiral.  Possible nerve injuries to the radial and median nerve, possibly neurapraxia.", Orthopedic, Elbow Pain - Consult ,"CHIEF COMPLAINT: , Left elbow pain.,HISTORY OF PRESENT ILLNESS:  ,This 17-year-old male was fighting with some other kids in Juvenile Hall when he felt some pain in his left elbow, causing sudden pain.  He also has pain in his left ankle, but he is able to walk normally.  He has had previous pain in his left knee.  He denies any passing out, any neck pain at this time even though he did get hit in the head.  He has no chest or abdominal pain.  Apparently, no knives or guns were involved.,PAST MEDICAL HISTORY: , He has had toe problems and left knee pain in the past.,REVIEW OF SYSTEMS: , No coughing, sputum production, dyspnea or chest pain.  No vomiting or abdominal pain.  No visual changes.  No neurologic deficits other than some numbness in his left hand.,SOCIAL HISTORY: , He is in Juvenile Hall for about 25 more days.  He is a nonsmoker.,ALLERGIES: , MORPHINE.,CURRENT MEDICATIONS:  ,Abilify.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Stable.  HEENT:  PERRLA.  EOMI.  Conjunctivae anicteric.  Skull is normocephalic.  He is not complaining of bruising.  HEENT:  TMs and canals are normal.  There is no Battle sign.  NECK:  Supple.  He has good range of motion.  Spinal processes are normal to palpation.  LUNGS:  Clear.  CARDIAC:  Regular rate.  No murmurs or rubs.  EXTREMITIES:  Left elbow is tender.  He does not wish to move it at all.  Shoulder and clavicle are within normal limits.  Wrist is normal to inspection.  He does have some pain to palpation.  Hand has good capillary refill.  He seems to have decreased sensation in all three dermatomes.  He has moderately good abduction of all fingers.  He has moderate opponens strength with his thumb.  He has very good extension of all of his fingers with good strength.,We did an x-ray of his elbow.  He has a spiral fracture of the distal one-third of the humerus, about 13 cm in length.  The proximal part looks like it is in good position.  The distal part has about 6 mm of displacement.  There is no significant angulation.  The joint itself appears to be intact.  The fracture line ends where it appears above the joint.  I do not see any extra blood in the joint.  I do not see any anterior or posterior Siegert sign.,I spoke with Dr. X.  He suggests we go ahead and splint him up and he will follow the patient up.  At this point, it does not seem like there needs to be any surgical revision.  The chance of a compartment syndrome seems very low at this time.,Using 4-inch Ortho-Glass and two assistants, we applied a posterior splint to immobilize his fingers, hand, and wrist all the way up to his elbow to well above the elbow.,He had much better comfort once this was applied.  There was good color to his fingers and again, much better comfort.,Once that was on, I took some 5-inch Ortho-Glass and put in extra reinforcement around the elbow so he would not be moving it, straightening it or breaking the fiberglass.,We then gave him a sling.,We gave him #2 Vicodin p.o. and #4 to go.  Gave him a prescription for #15 more and warned him to take it only at nighttime and use Tylenol or Motrin, and ice in the daytime.,I gave him the name and telephone number of Dr. X whom they can follow up with.  They were warned to come back here if he has increasing neurologic deficits in his hands or any new problems.,DIAGNOSES:,1.  Fracture of the humerus, spiral.,2.  Possible nerve injuries to the radial and median nerve, possibly neurapraxia.,3.  Psychiatric disorder, unspecified.,DISPOSITION:  The patient will follow up as mentioned above.  They can return here anytime as needed.", 
 A 47-year-old female with a posttraumatic AV in the right femoral head., Orthopedic, Discharge Summary - Hip Surgery ,"ADMITTING DIAGNOSIS:,  Posttraumatic AV in right femoral head.,DISCHARGE DIAGNOSIS:,  Posttraumatic AV in right femoral head.,SECONDARY DIAGNOSES PRIOR TO HOSPITALIZATION:,1.  Opioid use.,2.  Right hip surgery.,3.  Appendectomy.,4.  Gastroesophageal reflux disease.,5.  Hepatitis diagnosed by liver biopsy.,6.  Blood transfusion.,6.  Smoker.,7.  Trauma with multiple orthopedic procedures.,8.  Hip arthroscopy.,POSTOP COMORBIDITIES: , Postop acute blood loss anemia requiring transfusion and postop pain.,PROCEDURES DURING THIS HOSPITALIZATION:,  Right total hip arthroplasty and removal of hardware.,CONSULTS:,  Acute pain team consult.,DISPOSITION: , Home.,HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE:,  For details, please refer to clinic notes and OP notes.  In brief, the patient is a 47-year-old female with a posttraumatic AV in the right femoral head.  She came in consult with Dr. X who after reviewing the clinical and radiological findings recommended she undergo a right total hip arthroplasty and removal of old hardware.  After being explained the risks, benefits, alternative options, and possible outcomes of surgery, she was agreeable and consented to proceed and therefore on the day of her admission, she was sent to the operating room where she underwent a right total hip arthroplasty and removal of hardware without any complications.  She was then transferred to PACU for recovery and postop orthopedic floor for convalescence, physical therapy, and discharge planning.  DVT prophylaxis was initiated with Lovenox.  Postop pain was adequately managed with the aid of Acute Pain team.  Postop acute blood loss anemia was treated with blood transfusions to an adequate level of hemoglobin.  Physical therapy and occupational therapy were initiated and continued to work with her towards discharge clearance on the day of her discharge.,DISPOSITION:,  Home.  On the day of her discharge, she was afebrile, vital signs were stable.  She was in no acute distress.  Her right hip incision was clean, dry, and intact.  Extremity was warm and well perfused.  Compartments were soft.  Capillary refill less than two seconds.  Distal pulses were present.,PREDISCHARGE LABORATORY FINDINGS: , White count of 10.9, hemoglobin of 9.5, and BMP is pending.,DISCHARGE INSTRUCTIONS: , Continue diet as before.,ACTIVITY: , Weightbearing as tolerated in the right lower extremity as instructed.  Do not lift, drive, move furniture, do strenuous activity for six weeks.  Call Dr. X if there is increased temperature greater than 101.5, increased redness, swelling, drainage, increased pain that is not relieved by current pain regimen as per postop orthopedic discharge instruction sheet.,FOLLOW-UP APPOINTMENT:  Follow up with Dr. X in two weeks.",
" Anterior cervical discectomy, osteophytectomy, foraminotomies, spinal cord decompression, fusion with machined allografts, Eagle titanium plate, Jackson-Pratt drain placement, and intraoperative monitoring with EMGs and SSEPs", Orthopedic," Discectomy, Osteophytectomy, & Foraminotomy ","PREOPERATIVE DIAGNOSES:,  Cervical degenerative disc disease, spondylosis, severe myelopathy, spinal cord compression especially at C3-C4, C4-C5, and C5-C6, and progressive quadriparesis.,POSTOPERATIVE DIAGNOSES:,  Cervical degenerative disc disease, spondylosis, severe myelopathy, spinal cord compression especially at C3-C4, C4-C5, and C5-C6, progressive quadriparesis, and very poor bone quality as well as difficulty with hemostasis with the patient having been on aspirin.,OPERATIVE PROCEDURE,1.  Anterior cervical discectomy, osteophytectomy, foraminotomies, spinal cord decompression at C3-C4, C4-C5, and C5-C6.,2.  Microscope.,3.  Fusion with machined allografts at C3-C4, C4-C5, and C5-C6.,4.  Eagle titanium plate from C3 to C6.,5.  Jackson-Pratt drain placement.,6.  Intraoperative monitoring with EMGs and SSEPs.,ESTIMATED BLOOD LOSS: , 350 cc.,ANESTHESIA: , General endotracheal anesthesia.,COMPLICATIONS:  ,None.,COUNTS: , Correct.,SPECIMENS SENT:  ,None.,CLINICAL HISTORY:  ,The patient is a 77-year-old male who was admitted through the emergency room for progressive weakness and falling.  He was worked by the neurologist, Dr. X, and found to have cervical spondylosis with myelopathy.  I was consulted and elected to do a lumbar and cervical myelogram CT scan, which showed lumbar stenosis but also cervical stenosis with more pathology anteriorly than posteriorly.  The patient had worst disease at level C3-C4, C4-C5, and C5-C6.  The patient was significantly weak and almost quadriparetic, stronger on the right side than on the left side.  I thought that surgery was indicated to prevent progressive neurological deterioration, as well as to prevent a central cord syndrome if the patient were to get into a motor vehicle accident or simply fall.  Conservative management was not an option.  The patient was preoped and consented, and was medically cleared.  I discussed the indications, risks, and benefits of the surgery with the patient and the patient's family.  The risks of bleeding, hoarseness, swallowing difficulty, pseudoarthrosis as well as plate migration and hardware failure were all discussed with the patient.  An informed consent was obtained from the patient as such.  He was brought into the OR today for the operative procedure.,DESCRIPTION OF PROCEDURE:  ,The patient was brought into the OR, intubated, and given a general anesthetic.  Intubation was done under C-spine precautions.  The patient received preoperative vancomycin and Decadron.  He was hooked up to the SSEP apparatus and had poor baselines and delays.,With a large a shoulder roll, I extended the patient's neck, and landmark incision in crease in the right upper neck, and the area was then prepped and sterilely draped.  All the lines had been put in and the arms were padded.,Using a knife and cautery, I took the incision down through the skin and subcutaneous tissue and arrived at the cervical spine.  Prominent osteophyte at C5-C6 was noted, lesser at C4-C5.  Intraoperative x-ray confirmed our levels, and we were fully exposed from C3-C6.,Trimline retractors were put in, and I cut the discs out as well as removed the superficial hyperstatic bone and osteophytes.,With the drill, I performed a superficial discectomy and endplate resection, curetting the endplate as I went.  I then brought in the microscope, under the microscopic guidance, firmly removed the end plates and drilled through the posterior longitudinal ligament to decompress the spinal cord.  Worst findings at C3-C4 followed C5-C6 and then C4-C5.  Excellent thecal sac decompression was achieved and foraminal decompression was also achieved.  With change in intraoperative monitoring, a microscope was used for this decompressive procedure.,The patient was very oozy throughout this procedure, and during the decompression part, the oozing was constant.  This was partly due to the patient's cancellous bone, but he had been on aspirin which was stopped only 2 days ago, and the option was not available to wait 2 to 3 weeks which would have made this man worse simply over time.  I thus elected to give him DDAVP, platelets, and used Horsley bone wax for excellent hemostasis.  This took literally half-an-hour to an hour and added to the complexity and difficulty of this case.  Eventually, with blood pressure controlled and all the other parameters under control, bleeding was somewhat slow.,I then selected two 10 and one 9-mm cadaveric allograft, which had soaking in bacitracin solution.  These were trimmed to the desired dimensions, and under slight distraction, these were tapped into position.  Excellent graft alignment was achieved.,I now brought in a DePuy titanium eagle plate, and I fixed it to the spine from C3 to C6.  Fourteen millimeter screws were used; all the screws were tightened and torqued.  The patient's bone quality was poor, but the screws did torque appropriately.  I inspected the plate, controlled the hemostasis, assessed post-fixation x-ray, and was really happy with the screw length and the overall alignment.,The wound was irrigated with antibiotic solution; a Jackson-Pratt drain 10-French was put in with trocar.  Decision was made to start the closure.  So, I closed the platysma with 3-0 Vicryl and used staples for the skin.  A simple Primapore or Medpore dressing was applied.  The patient was extubated in the OR and taken to the PSU in stable medical condition.,When I saw the patient in the ICU, he was awake, alert, and moving all four extremities, somewhat weak on the left side.  He had done well from the surgery.  Blood loss was 350 cc.  All instrument, needle, and sponge counts were correct.  No complications, no change in intraoperative monitoring.  No specimens were sent.,The patient's wife was spoken to and fully appraised of the intraoperative findings and the expected prognosis.  The patient will be kept n.p.o. tonight and will gradually advance his diet, and also will gradually advance his activity.  I will keep him on Decadron and keep the collar on.  I do not think there is need for halo rest.  We will be obtaining formal C-spine films in the morning.  Prognosis is guarded but favorable at this time.",
 Stenosing tenosynovitis first dorsal extensor compartment/de Quervain tendonitis.  Release of first dorsal extensor compartment., Orthopedic, Dorsal Extensor Compartment Release ,"PREOPERATIVE DIAGNOSIS: , Stenosing tenosynovitis first dorsal extensor compartment/de Quervain tendonitis.,POSTOPERATIVE DIAGNOSIS: , Stenosing tenosynovitis first dorsal extensor compartment/de Quervain tendonitis.,PROCEDURE PERFORMED:,  Release of first dorsal extensor compartment.,ASSISTANT: , None.,ANESTHESIA: , Bier block.,TOURNIQUET TIME: , 30 minutes.,COMPLICATIONS: , None.,INDICATIONS:  ,The above patient is a 47-year-old right hand dominant black female who has signs and symptomology of de Quervain's stenosing tenosynovitis.  She was treated conservatively with steroid injections, splinting, and nonsteroidal anti-inflammatory agents without relief.  She is presenting today for release of the first dorsal extensor compartment.  She is aware of the risks, benefits, alternatives and has consented to this operation.,PROCEDURE: , The patient was given intravenous prophylactic antibiotics.  She was taken to the operating suite under the auspices of Anesthesiology.  She was given a left upper extremity bier block.  Her left upper extremity was then prepped and draped in the normal fashion with Betadine solution.  Afterwards, a transverse incision was made over the extensor retinaculum of the first dorsal extensor compartment.  Dissection was carried down through the dermis into the subcutaneous tissue.  The dorsal radial sensory branches were kept out of harm's way.  They were retracted gently to the ulnar side of the wrist.  The retinaculum was incised with a #15 scalpel blade in the longitudinal fashion and the retinaculum was released completely both proximally and distally.  Both the extensor pollices brevis and abductor pollices longus tendons were identified.  There was no pathology noted within the first dorsal extensor compartment.  The wound was irrigated.  Hemostasis was obtained with bipolar cautery.  The wound was infiltrated with _0.25% Marcaine solution and then closure performed with #6-0 nylon suture utilizing a horizontal mattress stitch.  Sterile occlusive dressing was applied along with the thumb spica splint.  The tourniquet was released and the patient was transported to the recovery area in stable and satisfactory condition.","orthopedic, dorsal extensor compartment, de quervain tendonitis, dorsal, extensor, quervain, tendonitis, retinaculum, tenosynovitis, tourniquet,"
 Trauma/ATV accident resulting in left open humerus fracture., Orthopedic, Discharge Summary - ATV Accident ,"ADMITTING DIAGNOSIS: , Trauma/ATV accident resulting in left open humerus fracture.,DISCHARGE DIAGNOSIS:,  Trauma/ATV accident resulting in left open humerus fracture.,SECONDARY DIAGNOSIS:,  None.,HISTORY OF PRESENT ILLNESS: , For complete details, please see dictated history and physical by Dr. X dated July 23, 2008.  Briefly, the patient is a 10-year-old male who presented to the Hospital Emergency Department following an ATV accident.  He was an unhelmeted passenger on ATV when the driver lost control and the ATV rolled over throwing the passenger and the driver approximately 5 to 10 meters.  The patient denies any loss of consciousness.  He was not amnestic to the event.  He was taken by family members to the Iredell County Hospital, where he was initially evaluated.  Due to the extent of his injuries, he was immediately transferred to Hospital Emergency Department for further evaluation.,HOSPITAL COURSE: , Upon arrival in the Hospital Emergency Department, he was noted to have an open left humerus fracture.  No other apparent injuries.  This was confirmed with radiographic imaging showing that the chest and pelvis x-rays were negative for any acute injury and that the cervical spine x-ray was negative for fracture malalignment.  The left upper extremity x-ray did demonstrate an open left distal humerus fracture.  The orthopedic surgery team was then consulted and upon their evaluation, the patient was taken emergently to the operating room for surgical repair of his left humerus fracture.  In the operating room, the patient was prepared for an irrigation and debridement of what was determined to be an open type 3 subcondylar left distal humerus fracture.  In the operating room, his upper extremity was evaluated for neurovascular status and great care was taken to preserve these structures.  Throughout the duration of the procedure, the patient had a palpable distal radial pulse.  The orthopedic team then completed an open reduction and internal fixation of the left supracondylar humerus fracture.  A wound VAC was then placed over the wound at the conclusion of the procedure.  The patient tolerated this procedure well and was returned to the Pediatric Intensive Care Unit for postsurgical followup and monitoring.  His diet was advanced and his pain was controlled with pain medication.  The day following his surgery, the patient was evaluated for a potential for closed head injury given the nature of his accident and the fact that he was not wearing a helmet during his accident.  A CT of the brain without contrast showed no acute intracranial abnormalities moreover his cervical spine was radiographically and clinically cleared and his C-collar was removed at that point.  Once his C spine had been cleared and the absence of a closed head injury was confirmed.  The patient was then transferred from the Intensive Care Unit to the General Floor bed.  His clinical status continued to improve and on July 26, 2008, he was taken back to the operating room for removal of the wound VAC and closure of his left upper extremity wound.  He again tolerated this procedure well on his return to the General Pediatrics Floor.  Throughout his stay, there was concern for compartment syndrome due to the nature and extent of his injuries.  However, frequent checks of his distal pulses indicated that he had strong peripheral pulses in the left upper extremity.  Moreover, the patient had no complaints of paresthesia.  There was no demonstration of pallor or pain on passive motion.  There was good capillary refill to the digits of the left hand.  By the date of the discharge, the patient was on a full pediatric select diet and was tolerating this well.  He had no abdominal tenderness and there were no abdominal injuries on exam or radiographic studies.  He was afebrile and his vital signs were stable and once cleared by Orthopedics, he was deemed appropriate for discharge.,PROCEDURES DURING THIS HOSPITALIZATION:,1.  Irrigation and debridement of open type 3 subcondylar left distal humerus fracture (July 23, 2008).,2.  Open reduction and internal fixation of the left supracondylar humerus fracture (July 23, 2008).,3.  Negative pressure wound dressing (July 23, 2008).,4.  Irrigation and debridement of left elbow fracture (July 26, 2008).,5.  CT of the brain without contrast (July 24, 2008).,DISPOSITION:  ,Home with parents.,INVASIVE LINES: , None.,DISCHARGE INSTRUCTIONS:  ,The patient was instructed that he can return home with his regular diet and he was asked not to do any strenuous activities, move furniture, lift heavy objects, or use his left upper extremity.  He was asked to followup with return appointment in one week to see Dr. Y in Orthopedics.  Additionally, he was told to call his pediatrician, if he develops any fevers, pain, loss of sensation, loss of pulse, or discoloration of his fingers, or paleness to his hand.","orthopedic, humerus fracture, trauma, irrigation and debridement, atv accident, upper extremity, humerus, fracture,"
" Bilateral L5 dorsal ramus block and bilateral S1, S2, and S3 lateral branch block for sacroiliac joint pain.  Fluoroscopic pillar view was used to identify the bony landmarks of the sacrum and sacroiliac joint and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.", Orthopedic, Dorsal Ramus & Branch Block ,"PROCEDURE: , Bilateral L5 dorsal ramus block and bilateral S1, S2, and S3 lateral branch block.,INDICATION: , Sacroiliac joint pain.,INFORMED CONSENT: , The risks, benefits and alternatives of the procedure were discussed with the patient.  The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible vascular entry of medications.  I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing.  The patient understood the informed consent and desired to have the procedure performed.,PROCEDURE:  ,Oxygen saturation and vital signs were monitored continuously throughout the procedure.  The patient remained awake throughout the procedure in order to interact and give feedback.  The X-ray technician was supervised and instructed to operate the fluoroscopy machine.,The patient was placed in the prone position on the treatment table, pillow under the chest, and head rotated contralateral to the side being treated.  The skin over and surrounding the treatment area was cleaned with Betadine.  The area was covered with sterile drapes, leaving a small window opening for needle placement.  Fluoroscopic pillar view was used to identify the bony landmarks of the sacrum and sacroiliac joint and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.,With fluoroscopy, a 25-gauge 3.5-inch spinal needle was gently guided into the groove between the SAP and sacrum through the dorsal ramus of the L5 and the lateral and superior border of the posterior sacral foramen with the lateral branches of S1, S2, and S3.  Multiple fluoroscopic views were used to ensure proper needle placement.  Approximately 0.25 mL of nonionic contrast agent was injected showing no concurrent vascular dye pattern.  Finally, the treatment solution, consisting of 0.5% of bupivacaine was injected to each area.  All injected medications were preservative free.  Sterile technique was used throughout the procedure.,ADDITIONAL DETAILS: , This was then repeated on the left side.,COMPLICATIONS: , None.,DISCUSSION:  ,Postprocedure vital signs and oximetry were stable.  The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day.  The patient was told to resume all medications.  The patient was told to resume normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes or changes in bowel or bladder function.,Follow up appointment was made at the PM&R Spine Clinic in approximately 1 week.","orthopedic, sacroiliac, lateral branch block, ramus block, branch block, sacroiliac joint, dorsal ramus, fluoroscopic, branch, dorsal, ramus, bilateral, needle, block,"
" Redo L4-5 diskectomy, left - recurrent herniation L4-5 disk with left radiculopathy.", Orthopedic, Diskectomy ,"PREOPERATIVE DIAGNOSIS (ES):, Recurrent herniation L4-5 disk with left radiculopathy.,POSTOPERATIVE DIAGNOSIS (ES):, Recurrent herniation L4-5 disk with left radiculopathy.,PROCEDURE:, Redo L4-5 diskectomy left.,COMPLICATIONS:, None.,ANTIBIOTIC (S),: Vancomycin given preoperatively.,ANESTHESIA:, General endotracheal.,ESTIMATED BLOOD LOSS:, 10 mL.,BLOOD REPLACED:, None.,CRYSTALLOID GIVEN:, 800 mL.,DRAIN (S):, None.,DESCRIPTION OF THE OPERATION:, The patient was brought to the operating room in supine position. General endotracheal anesthesia was administered. He was turned into the prone position on the operating table and positioned in the modified knee-chest position with Andrews frame being used. Care was taken to protect pressure points. The back was shaved, scrubbed with Betadine scrub, rinsed with alcohol, and prepped with DuraPrep, and draped in the usual sterile fashion with Ioban drape being used. A midline skin incision was made, excising scar from previous surgery. Dissection was carried down through the subcutaneous tissue with electrocautery technique. The lumbosacral fascia was split to the left of the spinous process, and subperiosteal dissection of the spinous process and lamina, area of previous laminotomy was identified. Cross-table lateral was also made to confirm position. The scar was then loosened from the inferior portion of 4, superior of L5 lamina, and a portion of the lamina was removed. I did identify normal dura. The scar was then lysed from the medial wall. Dura and nerve root were identified and protected with nerve root retractor. The bulging disk fragment was still contained under the longitudinal ligament. A rent was made with the Penfield and a moderately large fragment was removed. The disk space was then entered with a cruciate cut in the annulus, with additional nuclear material being received. When no other fragments could be removed from the disk space, no other fragments were felt in the central canal under the longitudinal ligament, and a Murphy ball could be passed through the foramen without evidence of compression, the decompression was complete. Check was made for CSF leakage, and no evidence of significant epidural bleeding was present. The wound was irrigated with antibiotic solution. Twenty milligrams of Depo-Medrol was placed over the dura and nerve root. A free fat graft from the subcutaneous tissue was then placed over the dura. Closure was obtained with the lumbosacral fascia being reapproximated with #1, running, Vicryl suture. Subcutaneous closure was obtained in layers with 2-0, running, Vicryl suture. Skin closure was obtained with 3-0 Vicryl subcuticular suture. Proxi-Strips and sterile dressing was applied. The skin had been infiltrated with 8 mL of 0.5% Marcaine with epinephrine.,After a sterile dressing was applied, the patient was turned into the supine position on the waiting recovery room stretcher, brought from under the effects of anesthesia, and taken to the recovery room.","orthopedic, herniation, andrews frame, csf leakage, depo-medrol, l4-5, proxi-strips, diskectomy, endotracheal anesthesia, lumbosacral fascia, modified knee-chest position, radiculopathy, supine position, nerve root, duraprep, "
" Decompressive laminectomy at T12 with bilateral facetectomies, decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes ClickX System.", Orthopedic, Decompressive Laminectomy ,"PREOPERATIVE DIAGNOSIS: , T12 compression fracture with cauda equina syndrome and spinal cord compression.,POSTOPERATIVE DIAGNOSIS:,  T12 compression fracture with cauda equina syndrome and spinal cord compression.,OPERATION PERFORMED: , Decompressive laminectomy at T12 with bilateral facetectomies, decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes Click'X System using 6.5 mm diameter x 40 mm length T11 screws and L1 screws, 7 mm diameter x 45 mm length.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:,  400 mL, replaced 2 units of packed cells.,Preoperative hemoglobin was less than 10.,DRAINS:,  None.,COMPLICATIONS:,  None.,DESCRIPTION OF PROCEDURE: , With the patient prepped and draped in a routine fashion in the prone position on laminae support, an x-ray was taken and demonstrated a needle at the T12-L1 interspace.  An incision was made over the posterior spinous process of T10, T11, T12, L1, and L2.  A Weitlaner retractor was placed and cutting Bovie current was used to incise the fascia overlying the dorsal spinous process of T10, T11, T12, L1, and L2.  An additional muscular ligamentous attachment was dissected free bilaterally with cutting Bovie current osteotome and Cobb elevator.  The cerebellar retractors were placed in the wound and obvious deformation of the lamina particularly on the left side at T12 was apparent.  Initially, on the patient's left side, pedicle screws were placed in T11 and L1.  The inferior articular facet was removed at T11 and an awl placed at the proximal location of the pedicle.  Placement confirmed with biplanar coaxial fluoroscopy.  The awl was in appropriate location and using a pedicle finder under fluoroscopic control, the pedicle was probed to the mid portion of the body of T11.  A 40-mm Click'X screw, 6.5 mm diameter with rod holder was then threaded into the T11 vertebral body.,Attention was next turned to the L1 level on the left side and the junction of the transverse processes with the superior articular facet and intra-articular process was located using an AM-8 dissecting tool, AM attachment to the Midas Rex instrumentation.  The area was decorticated, an awl was placed, and under fluoroscopic biplanar imaging noted to be at the pedicle in L1.  Using a pedicle probe, the pedicle was then probed to the mid body of L1 and a 7-mm diameter 45-mm in length Click'X Synthes screw with rod holder was placed in the L1 vertebral body.,At this point, an elongated rod was placed on the left side for purposes of distraction should it be felt necessary in view of the MRI findings of significant compression on the patient's ventral canal on the right side.  Attention was next turned to the right side and it should be noted that the dissection above was carried out with operating room microscope and at this point, the intraspinous process ligament superior to the posterior spinous process at T12 was noted be completely disrupted on a traumatic basis.  The anteroposterior spinous process ligament superior to the T12 was incised with cutting Bovie current and the posterior spinous process at T12 removed with a Leksell rongeur.  It was necessary to remove portion of the posterior spinous process at T11 for a full visualization of the involved laminar fractures at T12.,At this point, a laminectomy was performed using 45-degree Kerrison rongeur, both 2 mm and 4 mm, and Leksell rongeur.  There was an epidural hematoma encountered to the midline and left side at the mid portion of the T12 laminectomy and this was extending superiorly to the T11-T12 interlaminar space.  Additionally, there was marked instability of the facets bilaterally at T12 and L1.  These facets were removed with 45-degree Kerrison rongeur and Leksell rongeur.  Bony compression both superiorly and laterally from fractured bony elements was removed with 45-degree Kerrison rongeur until the thecal sac was completely decompressed.  The exiting nerve roots at T11 and T12 were visualized and followed with Frazier dissectors, and these nerve roots were noted to be completely free.  Hemostasis was controlled with bipolar coagulation.,At this point, a Frazier dissector could be passed superiorly, inferiorly, medially, and laterally to the T11-T12 nerve roots bilaterally, and the thecal sac was noted to be decompressed both superiorly and inferiorly, and noted to be quite pulsatile.  A #4 Penfield was then used to probe the floor of the spinal canal, and no significant ventral compression remained on the thecal sac.  Copious antibiotic irrigation was used and at this point on the patient's right side, pedicle screws were placed at T11 and L1 using the technique described for a left-sided pedicle screw placement.  The anatomic landmarks being the transverse process at T11, the inferior articulating facet, and the lateral aspect of the superior articular facet for T11 and at L1, the transverse process, the junction of the intra-articular process and the facet joint.,With the screws placed on the left side, the elongated rod was removed from the patient's right side along with the locking caps, which had been placed.  It was felt that distraction was not necessary.  A 75-mm rod could be placed on the patient's left side with reattachment of the locking screw heads with the rod cap locker in place; however, it was necessary to cut a longer rod for the patient's right side with the screws slightly greater distance apart ultimately settling on a 90-mm rod.  The locking caps were placed on the right side and after all 4 locking caps were placed, the locking cap screws were tied to the cold weld.  Fluoroscopic examination demonstrated no evidence of asymmetry at the intervertebral space at T11-T12 or T12-L1 with excellent positioning of the rods and screws.  A crosslink approximately 60 mm in width was then placed between the right and left rods, and all 4 screws were tightened.,It should be noted that prior to the placement of the rods, the patient's autologous bone, which had been removed during laminectomy portion of the procedure and cleansed off soft tissue and morcellated was packed in the posterolateral space after decortication had been effected on the transverse processes at T11, T12, and L1 with AM-8 dissecting tool, AM attachment as well as the lateral aspects of the facet joints.  This was done bilaterally prior to placement of the rods.,Following placement of the rods as noted above, allograft bone chips were packed in addition on top of the patient's own allograft in these posterolateral gutters.  Gelfoam was used to cover the thecal sac and at this point, the wound was closed by approximating the deep muscle with 0 Vicryl suture.  The fascia was closed with interrupted 0 Vicryl suture, subcutaneous layer was closed with 2-0 Vicryl suture, subcuticular layer was closed with 2-0 inverted interrupted Vicryl suture, and the skin approximated with staples.  The patient appeared to tolerate the procedure well without complications.","orthopedic, facetectomies, decompression, posterolateral fusion, synthes click'x system, decompressive laminectomy, leksell rongeur, kerrison rongeur, transverse processes, thecal sac, nerve roots, pedicle screws, spinous process, pedicle, process, screws, rods, laminectomy, decompressive, spinous, "
 Wrist de Quervain stenosing tenosynovitis.  de Quervain release.  Fascial lengthening flap of the 1st dorsal compartment., Orthopedic, de Quervain Release - Wrist ,"PREOPERATIVE DIAGNOSIS:,  Wrist de Quervain stenosing tenosynovitis.,POSTOPERATIVE DIAGNOSIS: , Wrist de Quervain stenosing tenosynovitis.,TITLE OF PROCEDURES,1. de Quervain release.,2.  Fascial lengthening flap of the 1st dorsal compartment.,ANESTHESIA:,  MAC.,COMPLICATIONS: , None.,PROCEDURE IN DETAIL: , After MAC anesthesia and appropriate antibiotics were administered, the upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with an Esmarch and the tourniquet inflated to 250 mmHg.,I made a transverse incision just distal to the radial styloid.  Dissection was carried down directly to the 1st dorsal compartment with the superficial radial nerve identified and protected.  Meticulous hemostasis was maintained with bipolar electrocautery.,I dissected the sheath superficially free of any other structures, specifically the superficial radial nerve.  I then incised it under direct vision dorsal to its axis and incised it both proximally and distally.  The EPB subsheath was likewise released.,I irrigated the wound thoroughly.  In order to prevent tendon subluxation, I then back-cut both the dorsal and volar leafs of the sheath so that I could close them in an extended and lengthened position.  I did this with 3-0 Vicryl.  I then passed an instrument underneath to check and make sure that the sheath was not too tight.  I then irrigated it and closed the skin, and then I dressed and splinted the wrist appropriately.  The patient was sent to the recovery room in good condition, having tolerated the procedure well.","orthopedic, de quervain, tenosynovitis, de quervain release, fascial lengthening flap, dorsal compartment, sheath, wrist, dorsal, tourniquet,"
 Degenerative disk disease at L4-L5 and L5-S1.  Anterior exposure diskectomy and fusion at L4-L5 and L5-S1., Orthopedic, Diskectomy & Fusion ,"PREOPERATIVE DIAGNOSIS: , Degenerative disk disease at L4-L5 and L5-S1.,POSTOPERATIVE DIAGNOSIS:,  Degenerative disk disease at L4-L5 and L5-S1.,PROCEDURE PERFORMED:  ,Anterior exposure diskectomy and fusion at L4-L5 and L5-S1.,ANESTHESIA: , General.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , 150 mL.,PROCEDURE IN DETAIL:  ,Patient was prepped and draped in sterile fashion.  Left lower quadrant incision was performed and taken down to the preperitoneal space with the use of the Bovie, and then preperitoneal space was opened.  The iliac veins were carefully mobilized medially, and then the L4-L5 disk space was confirmed by fluoroscopy, and diskectomy fusion, which will be separately dictated by Dr. X, was performed after the adequate exposure was gained, and then after this L4-L5 disk space was fused and the L5-S1 disk space was carefully identified between the iliac vessels and the presacral veins and vessels were ligated with clips, disk was carefully exposed.  Diskectomy and fusion, which will be separately dictated by Dr. X, were performed.  Once this was completed, all hemostasis was confirmed.  The preperitoneal space was reduced.  X-ray confirmed adequate positioning and fusion.  Then the fascia was closed with #1 Vicryl sutures, and then the skin was closed in 2 layers, the first layer being 2-0 Vicryl subcutaneous tissues and then a 4-0 Monocryl subcuticular stitch, then dressed with Steri-Strips and 4 x 4's.  Then patient was placed in the prone position after vascular checks of the lower extremity confirmed patency of the arteries with warm bilateral lower extremities.","orthopedic, anterior exposure, degenerative disk disease, disk disease, disk space, diskectomy, fusion,"
" Delayed open reduction internal fixation with plates and screws, 6-hole contoured distal fibular plate and screws reducing posterolateral malleolar fragment as well as medial malleolar fragment.", Orthopedic, Delayed ORIF ,"PREOPERATIVE DIAGNOSES:,1.  Right ankle trimalleolar fracture.,2.  Right distal tibia plafond fracture with comminuted posterolateral impacted fragment.,OPERATIVE PROCEDURE:  ,Delayed open reduction internal fixation with plates and screws, 6-hole contoured distal fibular plate and screws reducing posterolateral malleolar fragment, as well as medial malleolar fragment.,POSTOPERATIVE DIAGNOSES:,1.  Right ankle trimalleolar fracture.,2.  Right distal tibia plafond fracture with comminuted posterolateral impacted fragment.,TOURNIQUET TIME: , 80 minutes.,HISTORY: , This 50-year-old gentleman was from the area and riding his motorcycle in Kentucky.,The patient lost control of his motorcycle when he was traveling approximately 40 mile per hour.  He was on a curve and lost control.  He is unsure what exactly happened, but he thinks his right ankle was pinned underneath the motorcycle while he was sliding.  There were no other injuries.  He was treated in Kentucky.  A close reduction was performed and splint applied.  Orthopedic surgeon called myself with regards to this patient's fracture management and suggested a CT scan.  The patient returned to Ohio and his friend drove him all the way from Kentucky to Northwest Ohio overnight.  The patient showed up in the emergency department where a CT scan was asked to be performed.  This was performed and reviewed.  The patient, however, had significant amount of soft tissue swelling and therefore he was asked to follow up in 2 days.  At this time, he still had significant swelling, but because of the amount of swelling that he had particularly with the long car ride for many hours with his leg dependent, it was felt to be best to wait.,Indeed after 7 days, the patient started to develop fracture blisters on the posterior medial aspect of his ankle with large blisters measuring approximately 2 to 3 inches.  The patient was x-rayed in the office.  He had lost some of his reduction.  Therefore, he was re-reduced at approximately 7 days and then each time the patient had examination of tissues, he was re-reduced just to keep the pressure off the skin.,An x-ray showed the distal fibular fracture starting at the mortise region laterally.  It appeared as an abduction type injury with minimal rotation.  This was comminuted, fragmented, and impacted.,The medial malleolus fracture was an avulsion type.  The syndesmosis appeared to be intact.  This appeared as an AO type B fracture.  However, this was not a rotational injury.,There is a posterior malleolar fragment attached to the distal fibular fragment, which appeared to be avulsed as well, but comminuted.  CT scan revealed a more serious fracture with an anterior as well as posterior plafond fracture of an anterior fragment, which was undisplaced in the posterior medial corner.  A posterior Tillaux fragment appeared to be separate.  However, in this area, there was significant comminution in the mid portion of the ankle joint.,There were many fragments and defects in this region.,The medial mortise however appeared to be intact with regards to the tibial plafond even though there was an anterior undisplaced fragment.,We discussed delayed open reduction internal fixation with the patient.  He understood the risk of surgery including infection, decreased range of motion, stiffness, neurovascular injury, weakness, and numbness.  We discussed seriously the risk of osteoarthritis because of the comminution in the intraarticular surface shown on the CT scan.  We discussed deep vein thrombosis, pulmonary embolism, skin slough, skin necrosis, infection, and need for second surgery.  We discussed shortening, decreased strength, limited use, disability of operative extremity, malunion, nonunion, compartment syndrome, stiffness of the operative extremity, numbness, and weakness.  Examination of the patient revealed that he had slightly decreased sensation on the dorsum of his foot.,The patient was able to flex and extend his toes, had good capillary refill, good dorsalis pedis, and posterior tibial pulse.,The patient's tissues were edematous and we has waited approximately 10 days before performing the surgery when the skin could be wrinkled anteriorly.  We discussed his incision, the medial incision as well as lateral incision and the lateral incision would be more posterolateral to maintain a bridge of at least 6 to 8 cm between the 2 incisions.  We did discuss the skin slough as well as skin necrosis, particularly medially where the most skin pressure was because of displacement laterally.  He understood the posterolateral comminution of the tibial plafond, which would be reduced by aligning up the cortex posteriorly.,We discussed the posterolateral approach with reduction of the fibula.  We discussed that likely the distal fibula would not be removed completely to assess the articular surface as this would likely comminute the fibula, even more fragmentation would occur, and would not be able to obtain an anatomic reduction.  He understood this distal fibular fracture was comminuted and there were missing fragments of bone because they were impacted into intramedullary cancellous space.  With this, the patient understood that the hardware may necessitate removal as well in the future.  We discussed hardware irritation.  We also discussed risk of osteoarthritis, which was nearly 100% particularly because of comminution of this area posteriorly.  With these risks discussed and listed on the consent, the patient wanted the procedure.,OPERATIVE NOTE:,  The patient was brought to operating theater and given successful general anesthetic.  His right leg was prepped and draped in the usual fashion.  Before prep and drape was performed, a close reduction was tried to be obtained to see whether there was any obstruction to reduction.  It was felt that at one point the posterior tibialis tendon may be intraarticular.,The reduction appeared to line up.  However, there was significant gap of approximately 1.5 to 2 cm between the avulsed medial malleolus fragment and distal tibia.,A lateral incision was made over the fracture site approximately 8 cm long and was taken to subcutaneous tissue.  The superficial peroneal nerve was seen and this was avoided.  The incision was placed posterolateral to fibula.,This was to ensure good flap of tissue between the 2 incisions medial and laterally.  The fracture was seen.  The fracture was elevated and medialized and de-rotated.  The anterior portion of the distal fibula was significantly comminuted with defect.  The posterior aspect was still intact.  However, there were multiple fracture lines demonstrating a crush-type injury.  This was reduced manually.  At this point, dissection was performed bluntly behind the peroneal tendons in between this and flexor hallucis longus tendon.  No sharp dissection was performed.  The posterior malleolar fragment was palpated with the distal fibula reduced.  The posterior malleolar fragment appeared to be reduced as well.,X-ray views confirmed this.,An incision was made, standard incision, curvilinear, medially distal to the medial corner of the mortise and curving anterior and posteriorly around the tip of the medial malleolus.  This was taken only through subcutaneous tissue.  The saphenous vein was found, dissected out.  Its branches were cauterized.  Penrose drain was placed around this.,Dissection was undertaken.  The periosteal tissue was seen and was invaginated into the joint.,This was recovered and flipped back on both sides.  Next, the towel clip was used.  Ends were freshened up using irrigation.  The joint surface appeared to be congruent anteriorly and posteriorly medially.,Anatomic reduction was performed in the medial malleolus using 2 mm K-wires and exchanging these for a 35 mm and a 40 mm, anterior and posterior respectively, partially threaded cancellous screws.  Anatomic reduction was gained.  X-rays were taken showing excellent anatomic reduction.  Next, attention was drawn towards the fibula.  Standard 6-hole one-third tubular plate was applied to this.  Again, this was more of a transverse impacted fracture.  Therefore, interfragmentary screw on an angle could not be used.,The posterior cortex was used to assess anatomic reduction.  Screws were placed.  It was used as a spring plate pushing the distal fibular fragment medially.,Screw holes were filled.  They were double-checked.  Screws had excellent purchase and were tightened up.  At this point, lateral views were taken as well as palpation of posterior lateral fragment was performed in the plafond.  This appeared to show anatomic reduction and did not appear to be a step on the articular surface or the posterior cortex of the distal tibia.,The screw was then placed from anterior medial to posterior lateral into this comminuted fragment.,A 2 mm K-wire was used.  Finger was placed on this fragment and the pin was advanced even before the finger.  X-ray views could show the posterior cortex and location of the pin.  This was then exchanged for a 55 mm partially threaded cancellous screw after tapping was performed.  This was double checked to ensure good positioning and this was so.  On the lateral view, we could see this was not in the joint.  AP views and mortise views showed this was not in the joint.  One could palpate this as well.  The screw was placed slightly proximal to distal in the anteroposterior plane.  At the distal tip of it, it was just in the subchondral bone but not in the joint.  There was slight to excellent purchase of this posterior lateral fragment.  Wounds were copiously irrigated followed by closing using 2-0 Vicryl in inverted fashion followed by staples to skin.  Adaptic, 4 x 4s, abdominal pad was placed on wound, held in place with Kerlix followed by an extensor bandage.  Posterior splint was placed on the patient.  The patient's leg was placed in neutral position.  Significant amount of cast padding were used and large bulky trauma ABD type dressings.  The heel was padded and leg was padded with approximately 2 inches of padding.  Tourniquet was deflated.  The patient had good capillary refill, good pulses, and the patient returned to recovery room in stable condition with no complications.  Physician assistant assisted during the case with retracting as well as holding the medial malleolar fragment and fragments in position while placement screws were applied.  Positioning of the leg was accomplished by the physician assistant.  As well, physician assistant assisted in transport of patient to and from the recovery room, assisted in cautery as well as dissection and retraction of tissue.  The patient is expected to do well overall.  He does have an area of comminution shown on the CT scan.  However, by x-rays, it appears that there is anatomic reduction gained at this posterolateral fragment.  Nonetheless, this area was crushed and the patient will have degenerative changes in the future caused by this crushing area.",
" Torn rotator cuff and subacromial spur with impingement syndrome, right shoulder.  Diagnostic arthroscopy with subacromial decompression and open repair of rotator cuff using three Panalok suture anchors.", Orthopedic, Diagnostic Arthroscopy ,"PREOPERATIVE DIAGNOSIS:,  Torn rotator cuff, right shoulder.,POSTOPERATIVE DIAGNOSES:,1.  Torn rotator cuff, right shoulder.,2.  Subacromial spur with impingement syndrome, right shoulder.,PROCEDURE PERFORMED:,1.  Diagnostic arthroscopy with subacromial decompression.,2.  Open repair of rotator cuff using three Panalok suture anchors.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:  ,Approximately 200 cc.,INTRAOPERATIVE FINDINGS: , There was noted to be a full thickness tear to the supraspinatus tendon at the insertion of the greater tuberosity.  There is moderate amount of synovitis noted throughout the glenohumeral joint.  There is a small subacromial spur noted on the very anterolateral border of the acromion.,HISTORY: , This is a 62-year-old female who previously underwent a repair of rotator cuff.  She continued to have pain within the shoulder.  She had a repeat MRI performed, which confirmed the clinical diagnosis of re-tear of the rotator cuff.  She wished to proceed with a repair.  All risks and benefits of the surgery were discussed with her at length.  She was in agreement with the above treatment plan.,PROCEDURE: , On 08/21/03, she was taken to the Operative Room at ABCD General Hospital.  She was placed supine on the operating table.  General anesthesia was applied by the Anesthesiology Department.  She was placed in the modified beachchair position.  Her upper extremity was sterilely prepped and draped in usual fashion.  A stab incision was made in the posterior aspect of the glenohumeral joint.  A camera was placed in the joint and was insufflated with saline solution.  Intraoperative pictures were obtained and the above findings were noted.  A second port site was initiated anteriorly.  Through this a probe was placed and the intraarticular structures were palpated and found to be intact.  A tear of the inner surface of the rotator cuff was identified.  The camera was then taken to the subacromial space.  A straight lateral portal was also used and a shaver was placed into the subacromial space.  Further debridement of the anterolateral border of the acromion was performed to remove evidence of the subacromial spur, which had reformed.  The edges of the rotator cuff were then debrided.  The camera was then removed and the shoulder was suction and dried.  A lateral incision was made over the anterolateral border of the acromion.  Subcuticular tissues were carefully dissected.  Hemostasis was controlled with electrocautery.  The deltoid musculature was then incised and aligned with its fibers exposing the rotator cuff tear and the edges were further debrided using a rongeur.  A trough was then made in the greater tuberosity using the rongeur.  Two Panalok anchors were then placed within the trough and weaved through the suture and third Panalok anchor was placed medial to the trough and weaved through the rotator cuff.  The ends of the suture were tied down from the fixating the rotator cuff within the trough.  The rotator cuff was then further oversewed using the Panalok suture.  The wound was then copiously irrigated and it was then suction dried.  The deltoid muscle was reapproximated using #1 Vicryl.  A continuous infusion pump catheter was placed into the subacromial space to help with postoperative pain control.  The subcutaneous tissues were reapproximated with #2-0 Vicryl.  The skin was closed with #4-0 PDS running subcuticular stitch.  Sterile dressing was applied to the upper extremity.  She was then placed in a shoulder immobilizer.  She was transferred to the recovery room in apparent stable and satisfactory condition.  Prognosis for this patient was guarded.  She will begin pendulum exercises postoperative day #3.  She will follow back in the office in 10 to 14 days for reevaluation.  Physical therapy initiated approximately six weeks postoperatively.","orthopedic, subacromial decompression, panalok suture, repair of rotator cuff, torn rotator cuff, diagnostic arthroscopy, subacromial space, subacromial spur, arthroscopy, panalok, shoulder, subacromial,"
" Incision and drainage with extensive debridement, left shoulder.  Removal total shoulder arthroplasty (uncemented humeral Biomet component; cemented glenoid component).  Implantation of antibiotic beads, left shoulder.", Orthopedic, Debridement - Shoulder ,"TITLE OF OPERATION:  ,1.  Incision and drainage with extensive debridement, left shoulder.,2.  Removal total shoulder arthroplasty (uncemented humeral Biomet component; cemented glenoid component).,3.  Implantation of antibiotic beads, left shoulder.,INDICATION FOR SURGERY: , The patient was seen multiple times preoperatively and found to have findings consistent with a chronic and indolent infections.  Risks and benefits have been discussed with him and his family at length including but not exclusive of continued infection, nerve or artery damage, stiffness, loss of range of motion, incomplete relief of pain, incomplete return of function, fractures, loss of bone, medical complications, surgical complications, transfusion related complications, etc.  The patient understood and wished to proceed.,PREOP DIAGNOSIS: , Presumed infection, left total shoulder arthroplasty.,POSTOP DIAGNOSES:  ,1.  Deep extensive infection, left total shoulder arthroplasty.,2.  Biceps tenosynovitis.,3.  Massive rotator cuff tear in left shoulder (full thickness subscapularis tendon rupture 3 cm x 4 cm; supraspinatus tendon rupture 3 cm x 3 cm; infraspinatus tear 2 cm x 2 cm).,DESCRIPTION OF PROCEDURE:  ,The patient was anesthetized in the supine position, a Foley catheter was placed in his bladder.  He was then placed Beach chair position and all bony prominences were well padded.  Pillows were placed around his knees to protect his sciatic nerve.  He was brought to the side of the table and secured with towels and tape.  The head was placed in neutral position with no lateral bending or extension to protect the brachioplexus from any stretch.  Left upper extremity was then prepped and draped in usual sterile fashion.  Unfortunately, preoperative antibiotics were given prior to the procedure.  This occurred due to lack of communication between the surgical staff and the anesthesia staff.  The patient's extremity, however, was prepped a second time with a chlorhexidine prep after he had been draped.  Also, Ioban bandages were placed securely to the skin to prevent any further introduction of infection into his shoulder.,Deltopectoral incision was then made.  The patient's had a cephalic vein, it was identified and protected throughout the case.  It was retracted laterally and once this has been completed, the deltopectoral interval was developed as carefully as possible.  The patient did have significant scar from this point on and did bleed from many surfaces throughout the case.  As a result, he was transfused 1 unit postoperatively.  He did not have any problems during the case except for one small drop of blood pressure.  However this was due primarily because of the extensive scarring of his proximal humerus.  He had scar between the anterior capsular structures and the conjoint tendon.  Also there was significant scar between the deltoid and the proximal humerus.  The deltoid was very carefully and tediously removed from the proximal humerus in order not to damage the axillary nerve.  Once the plane between the deltoid and underlying tissue was found, the proximal humerus was discovered to have a large defect, approximately 4 x 3.  This was covered by rimmed fibrous tissue which was fairly compressible, which felt to be purulent, however, when the needle was stuck into this area, there was no return of fluid.  As a result, this was finally opened and found to have fibrinous exudates which appeared to be old congealed, purulent material.  There was some suggestion of a synovitis type reaction also inside this cystic area.  This was all debrided but was found to track all the way into the proximal humerus from the lateral femoral component and also tracked posteriorly through and around the posterior cortex of the proximal humerus indicating that the infraspinatus probably had some tearing and detachment.  This later proved to be the case and infraspinatus did indeed have a tear 2 cm x 2 cm.  All of the mucinous material and fibrinous material was removed from the proximal humerus.  This was fairly extensive debridement.  All of this was sent to pathology and also sent for culture and sensitivity.  It should be noted that Gram stain became as multiple white blood cells but no organism seen.  The pathology came back as fibrinous material with multiple white cells, also with signs of chronic inflammation consistent with an infection.,Attention was then directed towards the anterior structures to gain access to the joint so that we could dislocate the prosthesis and remove it.  There was also cystic area in the anterior aspect of the shoulder which was fairly fibrinous.  This was also removed.  Once this was removed, though the capsule was found to be very thin, there was essentially no subscapularis tendon whatsoever.  It should also noted the patient's proximal humerus was subluxed superiorly so that there was no supraspinatus tendon present whatsoever.  As a result, the biceps tendon was finally identified just below the pectoralis tendon insertion.  The upper 1 or 2 cm of the pectoralis insertion was released in order to find the biceps.  It was tracked proximally and transverse ligament released.  The biceps tendon was flat and somewhat erythematous.  As a result, it released and tagged with an 0 Vicryl suture.  It was later tenodesed to the conjoint tendon using 2-0 Prolene sutures.  The joint was then entered and noted significant synovitis throughout the entire glenoid.  This was all very carefully removed using a rongeur and sharp dissection.,Next, the humeral component was removed and this was done by attempting to remove it with the slap hammer and device which comes with the Biomet set.  Unfortunately, this device would not hold the proximal humerus and we could not get the component to release.  As a result, bone contact of the metal proximally was released using a straight osteotome.  Once this was completed, another attempt was made to remove the prosthesis but this only resulted in fracture of the proximal humerus through the areas of erosion of the infection and once this has been completed, we abandoned use of that particular device and using a __________ , we were able to hit the prosthesis lip from beneath and essentially remove it.  There was no cement.  There was exudate within the canal which was removed using a curette.,Using fluoroscopy, sequential reamers were placed to a size of 11 distally down the shaft to remove the exudate.  This was also thoroughly irrigated with irrigation antibiotic, and impregnated irrigation to decrease any risk of infection.  It should be noted that the reaming was done fluoroscopically to make sure that there was no penetration of the canal at any point.,The attention was then directed to the glenoid.  The glenoid component was very carefully dissected free and found to be very loose.  It was essentially removed with digital dissection.  There was no remaining cement in the cavity itself.  The patient's glenoid was very carefully debrided.  The glenoid itself was found to be very cup shaped with significant amount of bone loss in the central portion of the canal itself.  This was debrided using rongeurs and curette until there was no purulent exudate present anywhere in the glenoid itself.,Next, the entire wound was irrigated thoroughly with 9 liters of antibiotic impregnated irrigation.  Rather than place a spacer, it was elected to use antiobiotic beads.  This was with antibiotic impregnated cement with one package with 3 gram of vancomycin.  These beads were then connected using Prolene and placed into the glenoid cavity itself, also some were placed in the greater tuberosity region.  These three did not have a Prolene attached to them.  The ones placed down the canal did have a Prolene used as did the ones placed in the cavity of the glenoid itself.,The biceps tendon was then tenodesed under tension to the conjoint tendon.  There was essentially no capsule left purely to close over the proximal humerus.  It was electively the proximal humerus.  A portion of bone intact because it did have some bleeding surfaces.  Deltopectoral was then closed with 0-Vicryl sutures, the deep subcutaneous tissues with 0-Vicryl sutures, superficial subcutaneous tissues with 2-0 Vicryl sutures.  Skin was closed with staples.  A sterile bandage was applied along with a cold therapy device and shoulder immobilizer.  The patient was sent to recovery room in stable and satisfactory condition.,It should be noted that __________ is being requested for this case.  This was a significantly scarred patient which required extra dissection and attention.  Even though this was a standard revision case due to infection, there was a significant more decision making and technical challenges in this case and this was present for typical revision case.  Similarly, this case took approximately 30 to 40% more length of time due to bleeding and the attention to hemostasis.  The blood loss and operative findings indicates that this case was at least 30 to 40% more challenging than a standard total shoulder or revision case.  This is being dictated for insurance purposes only and reflects no inherent difficulties with the case whatsoever.","orthopedic, incision and drainage, shoulder arthroplasty, extensive debridement, uncemented humeral, biomet, cemented, antibiotic beads, biceps tenosynovitis, rotator cuff tear, total shoulder arthroplasty, proximal humerus, vicryl sutures, glenoid, tendon, proximal, humerus, beads, shoulder, incision,"
" Carpal tunnel syndrome and de Quervain's stenosing tenosynovitis.  Carpal tunnel release and de Quervain's release.  A longitudinal incision was made in line with the 4th ray, from Kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease.  The dissection was carried down to the superficial aponeurosis. ", Orthopedic, de Quervain Release - Carpal ,"PREOPERATIVE DIAGNOSIS,1.  Carpal tunnel syndrome.,2. de Quervain's stenosing tenosynovitis.,POSTOPERATIVE DIAGNOSIS,1.  Carpal tunnel syndrome.,2. de Quervain's stenosing tenosynovitis.,TITLE OF PROCEDURE,1.  Carpal tunnel release.,2. de Quervain's release.,ANESTHESIA: , MAC,COMPLICATIONS: , None.,PROCEDURE IN DETAIL:  ,After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with Esmarch and the tourniquet inflated to 250 mmHg.,A longitudinal incision was made in line with the 4th ray, from Kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease.  The dissection was carried down to the superficial aponeurosis.  The subcutaneous fat was dissected radially from 2-3 mm and the superficial aponeurosis cut on this side to leave a longer ulnar leaf.,The ulnar leaf of the cut superficial aponeurosis was dissected ulnarly, and the distal edge of the transverse carpal ligament was identified with a hemostat.  The hemostat was gently placed under the transverse carpal ligament to protect the contents of the carpal tunnel, and the ligament was cut on its ulnar side with a knife directly onto the hemostat.  The antebrachial fascia was cut proximally under direct vision with scissors.,After irrigating the wound with copious amounts of normal saline, the radial leaf of the cut transverse carpal ligament was repaired to the ulnar leaf of the cut superficial aponeurosis with 4-0 Vicryl.  Care was taken to avoid entrapping the motor branch of the median nerve in the suture.  A hemostat was placed under the repair to ensure that the median nerve was not compressed.  The skin was repaired with 5-0 nylon interrupted stitches.,The first dorsal compartment was addressed through a transverse incision at the level of the radial styloid tip.  Dissection was carried down with care taken to avoid and protect the superficial radial nerve branches.  I released the compartment in a separate subsheath for the EPB on the dorsal side.  Both ends of the sheath were released to lengthen them, and then these were repaired with 4-0 Vicryl.  It was checked to make sure that there was significant room remaining for the tendons.  This was done to prevent postoperative subluxation.,I then irrigated and closed the wounds in layers.  Marcaine with epinephrine was placed into all wounds, and dressings and splint were placed.  The patient was sent to the recovery room in good condition, having tolerated the procedure well.","orthopedic, de quervain's release, carpal tunnel syndrome, tenosynovitis, carpal, incision, aponeurosis, tunnel, cut,"
 CT REPORT - Soft Tissue Neck, Orthopedic, CT Neck - 1 ,"FINDINGS:,There is a lobulated mass lesion of the epiglottis measuring approximately 22 x 16 x 30 mm (mediolateral x AP x craniocaudal) in size. There is slightly greater involvement on the right side however there is bilateral involvement of the aryepiglottic folds. There is marked enlargement of the bilateral aryepiglottic folds (left greater than right). There is thickening of the glossoepiglottic fold. There is an infiltrative mass like lesion extending into the pre-epiglottic space.,There is no demonstrated effacement of the piriform sinuses. The mass obliterates the right vallecula. The paraglottic spaces are normal. The true and false cords appear normal. Normal thyroid, cricoid and arytenoid cartilages.,There is lobulated thickening of the right side of the tongue base, for which invasion of the tongue cannot be excluded. A MRI examination would be of benefit for further evaluation of this finding.,There is a 14 x 5 x 12 mm node involving the left submental region (Level I).,There is borderline enlargement of the bilateral jugulodigastric nodes (Level II). The left jugulodigastric node,measures 14 x 11 x 8 mm while the right jugulodigastric node measures 15 x 12 x 8 mm.,There is an enlarged second left high deep cervical node measuring 19 x 14 x 15 mm also consistent with a left Level II node, with a probable necrotic center.,There is an enlarged second right high deep cervical node measuring 12 x 10 x 10 mm but no demonstrated central necrosis.,There is an enlarged left mid level deep cervical node measuring 9 x 16 x 6 mm, located inferior to the hyoid bone but cephalad to the cricoid consistent with a Level III node.,There are two enlarged matted nodes involving the right mid level deep cervical chain consistent with a right Level III nodal disease, producing a conglomerate nodal mass measuring approximately 26 x 12 x 10 mm.,There is a left low level deep cervical node lying along the inferior edge of the cricoid cartilage measuring approximately 18 x 11 x 14 mm consistent with left Level IV nodal disease.,There is no demonstrated pretracheal, prelaryngeal or superior mediastinal nodes. There is no demonstrated retropharyngeal adenopathy.,There is thickening of the adenoidal pad without a mass lesion of the nasopharynx. The torus tubarius and fossa of Rosenmuller appear normal.,IMPRESSION:,Epiglottic mass lesion with probable invasion of the glossoepiglottic fold and pre-epiglottic space with invasion of the bilateral aryepiglottic folds.,Lobulated tongue base for which tongue invasion cannot be excluded. An MRI may be of benefit for further assessment of this finding.,Borderline enlargement of a submental node suggesting Level I adenopathy.,Bilateral deep cervical nodal disease involving bilateral Level II, Level III and left Level IV.","orthopedic, deep cervical node, epiglottic mass, epiglottic space, aryepiglottic folds, jugulodigastric nodes, level deep, cervical node, deep cervical, node, jugulodigastric, aryepiglottic, deep, cervical"
" Noncontrast CT scan of the lumbar spine.  Left lower extremity muscle spasm.  Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested.", Orthopedic, CT Lumbar Spine ,"EXAM:,  Noncontrast CT scan of the lumbar spine,REASON FOR EXAM: , Left lower extremity muscle spasm.,COMPARISONS: , None.,FINDINGS: , Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested.,No abnormal paraspinal masses are identified.,There are sclerotic changes with anterior effusion of the sacroiliac joints bilaterally.,There is marked intervertebral disk space narrowing at the L5-S1 level with intervertebral disk vacuum phenomenon and advanced endplate degenerative changes.  Posterior disk osteophyte complex is present, most marked in the left paracentral to lateral region extending into the lateral recess on the left.  This most likely will affect the S1 nerve root on the left.  There are posterior hypertrophic changes extending into the neural foramina bilaterally inferiorly.  There is mild neural foraminal stenosis present.  Small amount of extruded disk vacuum phenomenon is present on the left in the region of the exiting nerve root.  There is facet sclerosis bilaterally.  Mild lateral recess stenosis just on the right, there is prominent anterior spondylosis.,At the L4-5 level, mild bilateral facet arthrosis is present.  There is broad based posterior annular disk bulging or protrusion, which mildly effaces the anterior aspect of the thecal sac and extends into the inferior aspect of the neural foramina bilaterally.  No moderate or high-grade central canal or neural foraminal stenosis is identified.,At the L3-4 level anterior spondylosis is present.  There are endplate degenerative changes with mild posterior annular disk bulging, but no evidence of moderate or high-grade central canal or neural foraminal stenosis.,At the L2-3 level, there is mild bilateral ligamentum flavum hypertrophy.  Mild posterior annular disk bulging is present without evidence of moderate or high-grade central canal or neural foraminal stenosis.,At the T12-L1 and L1-2 levels, there is no evidence of herniated disk protrusion, central canal, or neural foraminal stenosis.,There is arteriosclerotic vascular calcification of the abdominal aorta and iliac arteries without evidence of aneurysm or dilatation.  No bony destructive changes or acute fractures are identified.,CONCLUSIONS:,1. Advanced degenerative disk disease at the L5-S1 level.,2. Probable chronic asymmetric herniated disk protrusion with peripheral calcification at the L5-S1 level, laterally in the left paracentral region extending into the lateral recess causing lateral recess stenosis.,3. Mild bilateral neural foraminal stenosis at the L5-S1 level.,4. Posterior disk bulging at the L2-3, L3-4, and L4-5 levels without evidence of moderate or high-grade central canal stenosis.,5. Facet arthrosis to the lower lumbar spine.,6. Arteriosclerotic vascular disease.","orthopedic, noncontrast ct scan, lower extremity muscle spasm, neural foraminal stenosis, lumbar spine, spine, disk, lumbar, ct, intervertebral, canal, foraminal, noncontrast, stenosis, "
 CT of Lumbar Spine without Contrast.  Patient with history of back pain after a fall., Orthopedic, CT of Lumbar Spine w/o Contrast ,"EXAM: , Lumbar spine CT without contrast.,HISTORY: , Back pain after a fall.,TECHNIQUE:,  Noncontrast axial images were acquired through the lumbar spine. Coronal and sagittal reconstruction views were also obtained.,FINDINGS: , There is no evidence for acute fracture or subluxation.  There is no spondylolysis or spondylolisthesis.  The central canal and neuroforamen are grossly patent at all levels.  There are no abnormal paraspinal masses. There is no wedge/compression deformity.  There is intervertebral disk space narrowing to a mild degree at L2-3 and L4-5.,Soft tissue windows demonstrate atherosclerotic calcification of the abdominal aorta, which is not dilated.  There was incompletely visualized probable simple left renal cyst, exophytic at the lower pole.,IMPRESSION:,1.  No evidence for acute fracture or subluxation.,2.  Mild degenerative changes.,3.  Probable left simple renal cyst.,","orthopedic, lumbar spine, back pain, ct, coronal, atherosclerotic, axial images, central canal, compression, deformity, degenerative, disk space, fracture, intervertebral, neuroforamen, sagittal, spondylolisthesis, spondylolysis, subluxation, wedge, without contrast, contrast, spine, lumbar, noncontrast,"
 This is a middle-aged female with low back pain radiating down the left leg and foot for one and a half years., Orthopedic, CT Lumbar Spine - 1 ,"FINDINGS:,High resolution computerized tomography was performed from T12-L1 to the S1 level with reformatted images in the sagittal and coronal planes and 3D reconstructions performed. COMPARISON: Previous MRI examination 10/13/2004.,There is minimal curvature of the lumbar spine convex to the left.,T12-L1, L1-2, L2-3: There is normal disc height with no posterior annular disc bulging or protrusion. Normal central canal, intervertebral neural foramina and facet joints.,L3-4: There is normal disc height and non-compressive circumferential annular disc bulging eccentrically greater to the left. Normal central canal and facet joints (image #255).,L4-5: There is normal disc height, circumferential annular disc bulging, left L5 hemilaminectomy and posterior central/right paramedian broad-based disc protrusion measuring 4mm (AP) contouring the rightward aspect of the thecal sac. Orthopedic hardware is noted posteriorly at the L5 level. Normal central canal, facet joints and intervertebral neural foramina (image #58).,L5-S1: There is minimal decreased disc height, postsurgical change with intervertebral disc spacer, posterior lateral orthopedic hardware with bilateral pedicle screws in good postsurgical position. The orthopedic hardware creates mild streak artifact which mildly degrades images. There is a laminectomy defect, spondylolisthesis with 3.5mm of anterolisthesis of L5, posterior annular disc bulging greatest in the left foraminal region lying adjacent to the exiting left L5 nerve root. There is fusion of the facet joints, normal central canal and right neural foramen (image #69-70, 135).,There is no bony destructive change noted.,There is no perivertebral soft tissue abnormality.,There is minimal to mild arteriosclerotic vascular calcifications noted in the abdominal aorta and right proximal common iliac artery.,IMPRESSION:,Minimal curvature of the lumbar spine convex to the left.,L3-4 posterior non-compressive annular disc bulging eccentrically greater to the left.,L4-5 circumferential annular disc bulging, non-compressive central/right paramedian disc protrusion, left L5 laminectomy.,L5-S1 postsurgical change with posterolateral orthopedic fusion hardware in good postsurgical position, intervertebral disc spacer, spondylolisthesis, laminectomy defect, posterior annular disc bulging greatest in the left foraminal region adjacent to the exiting left L5 nerve root with questionable neural impingement.,Minimal to mild arteriosclerotic vascular calcifications.","orthopedic, posterior annular disc, circumferential annular disc, normal central canal, annular disc bulging, lumbar spine, posterior annular, facet joints, annular disc, disc bulging, tomography, disc, lumbar, postsurgical, spine, annular, bulging,"
 This is a middle-aged female with two month history of low back pain and leg pain., Orthopedic, CT Lumbar Spine - 2 ,"FINDINGS:,Axial scans were performed from L1 to S2 and reformatted images were obtained in the sagittal and coronal planes.,Preliminary scout film demonstrates anterior end plate spondylosis at T11-12 and T12-L1.,L1-2: There is normal disc height, anterior end plate spondylosis, very minimal vacuum change with no posterior annular disc bulging or protrusion. Normal central canal, intervertebral neural foramina and facet joints (image #4).,L2-3: There is mild decreased disc height, anterior end plate spondylosis, circumferential disc protrusion measuring 4.6mm (AP) and right extraforaminal osteophyte disc complex. There is mild non-compressive right neural foraminal narrowing, minimal facet arthrosis, normal central canal and left neural foramen (image #13).,L3-4: There is normal disc height, anterior end plate spondylosis, and circumferential non-compressive annular disc bulging. The disc bulging flattens the ventral thecal sac and there is minimal non-compressive right neural foraminal narrowing, minimal to mild facet arthrosis with vacuum change on the right, normal central canal and left neural foramen (image #25).,L4-5:","orthopedic, anterior end plate spondylosis, compressive right neural foraminal, compressive annular disc bulging, anterior end plate, annular disc bulging, normal central canal, plate spondylosis, central canal, vacuum change, disc bulging, neural foraminal, facet arthrosis, anterior, spondylosis, neural, lumbar, disc, bulging, foraminal, arthrosis, facet"
 CT REPORT - Soft Tissue Neck, Orthopedic, CT Neck - 2 ,"FINDINGS:,There is a well demarcated mass lesion of the deep lobe of the left parotid gland measuring approximately 2.4 X 3.9 X 3.0cm (AP X transverse X craniocaudal) in size. The lesion is well demarcated. There is a solid peripheral rim with a mean attenuation coefficient of 56.3. There is a central cystic appearing area with a mean attenuation coefficient of 28.1 HU, suggesting an area of central necrosis. There is the suggestion of mild peripheral rim enhancement. This large lesion within the deep lobe of the parotid gland abuts and effaces the facial nerve. Primary consideration is of a benign mixed tumor (pleomorphic adenoma), however, other solid mass lesions cannot be excluded, for which histologic evaluation would be necessary for definitive diagnosis. The right parotid gland is normal.,There is mild enlargement of the left jugulodigastric node, measuring 1.1cm in size, with normal morphology (image #33/68). There is mild enlargement of the right jugulodigastric node, measuring 1.2cm in size, with normal morphology (image #38/68).,There are demonstrated bilateral deep lateral cervical nodes at the midlevel, measuring 0.6cm on the right side and 0.9cm on the left side (image #29/68). There is a second midlevel deep lateral cervical node demonstrated on the left side (image #20/68), measuring 0.7cm in size. There are small bilateral low level nodes involving the deep lateral cervical nodal chain (image #15/68) measuring 0.5cm in size.,There is no demonstrated nodal enlargement of the spinal accessory or pretracheal nodal chains.,The right parotid gland is normal and there is no right parotid gland mass lesion.,Normal bilateral submandibular glands.,Normal parapharyngeal, retropharyngeal and perivertebral spaces.,Normal carotid spaces.,IMPRESSION:,Large, well demarcated mass lesion of the deep lobe of the left parotid gland, with probable involvement of the left facial nerve. See above for size, morphology and pattern enhancement. Primary consideration is of a benign mixed tumor (pleomorphic adenoma), however, other solid mass lesions cannot be excluded, for which histologic evaluation is necessary for specificity.,Multiple visualized nodes of the bilateral deep lateral cervical nodal chain, within normal size and morphology, most compatible with mild hyperplasia.","orthopedic, cervical nodal, mass lesion, deep lobe, deep lateral, lateral cervical, parotid gland, cervical, lesion, gland, parotid, deep"
" Motor vehicle collision.  CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.  ", Orthopedic," CT Head, Facial Bones, Cervical Spine - 1 ","CT HEAD WITHOUT CONTRAST, CT FACIAL BONES WITHOUT CONTRAST, AND CT CERVICAL SPINE WITHOUT CONTRAST,REASON FOR EXAM: , Motor vehicle collision.,CT HEAD,TECHNIQUE: , Noncontrast axial CT images of the head were obtained without contrast.,FINDINGS: , There is no acute intracranial hemorrhage, mass effect, midline shift, or extra-axial fluid collection.  The ventricles and cortical sulci are normal in shape and configuration.  The gray/white matter junctions are well preserved.  No calvarial fracture is seen.,IMPRESSION:  ,Negative for acute intracranial disease.,CT FACIAL BONES WITHOUT CONTRAST,TECHNIQUE:  ,Noncontrast axial CT images of the facial bones were obtained with coronal reconstructions.,FINDINGS:,  There is no facial bone fracture.  The maxilla and mandible are intact.  The visualized paranasal sinuses are clear.  The temporomandibular joints are intact.  The nasal bone is intact.  The orbits are intact.  The extra-ocular muscles and orbital nerves are normal.  The orbital globes are normal.,IMPRESSION: , No evidence for a facial bone fracture.,CT CERVICAL SPINE WITHOUT CONTRAST,TECHNIQUE: , Noncontrast axial CT images of the cervical spine were obtained with sagittal and coronal reconstructions.,FINDINGS: , There is a normal lordosis of the cervical spine, no fracture or subluxation is seen.  The vertebral body heights are normal.  The intervertebral disk spaces are well preserved.  The atlanto-dens interval is normal.  No abnormal anterior cervical soft tissue swelling is seen.  There is no spinal compression deformity.,IMPRESSION: , Negative for a facial bone fracture.","orthopedic, intracranial disease, motor vehicle collision, orbital nerves, extra-ocular muscles, cervical spine, ct cervical spine, ct facial bones, ct head, axial ct images, facial bone fracture, facial bones, ct, noncontrast, intracranial, axial, spine, fracture, cervical, contrast, facial, bones, "
 Common CT C-Spine template, Orthopedic, CT C-Spine ,"TECHNIQUE: , Sequential axial CT images were obtained through the cervical spine without contrast.  Additional high resolution coronal and sagittal reconstructed images were also obtained for better visualization of the osseous structures.  ,FINDINGS: , The cervical spine demonstrates normal alignment and mineralization with no evidence of fracture, dislocation, or spondylolisthesis.  The vertebral body heights and disc spaces are maintained.  The central canal is patent.  The pedicles and posterior elements are intact.  The paravertebral soft tissues are within normal limits.  The atlanto-dens interval and the dens are intact.  The visualized lung apices are clear.,IMPRESSION: , No acute abnormalities.","orthopedic, sequential axial ct images, atlanto-dens interval, dens, ct c spine, cervical spineNOTE"
 Motor vehicle collision.  CT head without contrast and CT cervical spine without contrast.  Noncontrast axial CT images of the head were obtained., Orthopedic, CT Head and C Spine ,"CT HEAD WITHOUT CONTRAST AND CT CERVICAL SPINE WITHOUT CONTRAST,REASON FOR EXAM: , Motor vehicle collision.,CT HEAD WITHOUT CONTRAST,TECHNIQUE:,  Noncontrast axial CT images of the head were obtained.,FINDINGS: , There is no acute intracranial hemorrhage, mass effect, midline shift, or extra-axial fluid collection.  The ventricles and cortical sulci are normal in shape and configuration.  The gray/white matter junctions are well preserved.  There is no calvarial fracture.  The visualized paranasal sinuses and mastoid air cells are clear.,IMPRESSION: , Negative for acute intracranial disease.,CT CERVICAL SPINE,TECHNIQUE:  ,Noncontrast axial CT images of the cervical spine were obtained.  Sagittal and coronal images were obtained.,FINDINGS:,  Straightening of the normal cervical lordosis is compatible with patient position versus muscle spasms.  No fracture or subluxation is seen.  Anterior and posterior osteophyte formation is seen at C5-C6.  No abnormal anterior cervical soft tissue swelling is seen.  No spinal compression is noted.  The atlanto-dens interval is normal.  There is a large retention cyst versus polyp within the right maxillary sinus.,IMPRESSION:,1.  Straightening of the normal cervical lordosis compatible with patient positioning versus muscle spasms.,2.  Degenerative disk and joint disease at C5-C6.,3.  Retention cyst versus polyp of the right maxillary sinus.","orthopedic, muscle spasms, cervical lordosis, intracranial hemorrhage, motor vehicle collision, axial ct images, ct head, ct, anterior, cyst, polyp, maxillary, contrast, intracranial, sinuses, spine, axial, head, cervical, noncontrast"
" CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.", Orthopedic," CT Head, Facial Bones, Cervical Spine ","EXAM: , CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.,REASON FOR EXAM:,  A 68-year-old status post fall with multifocal pain.,COMPARISONS: , None.,TECHNIQUE: , Sequential axial CT images were obtained from the vertex to the thoracic inlet without contrast.  Additional high-resolution sagittal and/or coronal reconstructed images were obtained through the facial bones and cervical spine for better visualization of the osseous structures.,INTERPRETATIONS:,HEAD:,There is mild generalized atrophy.  Scattered patchy foci of decreased attenuation is seen in the subcortical and periventricular white matter consistent with chronic small vessel ischemic changes.  There are subtle areas of increased attenuation seen within the frontal lobes bilaterally.  Given the patient's clinical presentation, these likely represent small hemorrhagic contusions.  Other differential considerations include cortical calcifications, which are less likely.  The brain parenchyma is otherwise normal in attenuation without evidence of mass, midline shift, hydrocephalus, extra-axial fluid, or acute infarction.  The visualized paranasal sinuses and mastoid air cells are clear.  The bony calvarium and skull base are unremarkable.,FACIAL BONES:,The osseous structures about the face are grossly intact without acute fracture or dislocation.  The orbits and extra-ocular muscles are within normal limits.  There is diffuse mucosal thickening in the ethmoid and right maxillary sinuses.  The remaining visualized paranasal sinuses and mastoid air cells are clear.  Diffuse soft tissue swelling is noted about the right orbit and right facial bones without underlying fracture.,CERVICAL SPINE:,There is mild generalized osteopenia.  There are diffuse multilevel degenerative changes identified extending from C4-C7 with disk space narrowing, sclerosis, and marginal osteophyte formation.  The remaining cervical vertebral body heights are maintained without acute fracture, dislocation, or spondylolisthesis.  The central canal is grossly patent.  The pedicles and posterior elements appear intact with multifocal facet degenerative changes.  There is no prevertebral or paravertebral soft tissue masses identified.  The atlanto-dens interval and dens are maintained.,IMPRESSION:,1.Subtle areas of increased attenuation identified within the frontal lobes bilaterally suggesting small hemorrhagic contusions.  There is no associated shift or mass effect at this time.  Less likely, this finding could be secondary to cortical calcifications.  The patient may benefit from a repeat CT scan of the head or MRI for additional evaluation if clinically indicated.,2.Atrophy and chronic small vessel ischemic changes in the brain.,3.Ethmoid and right maxillary sinus congestion and diffuse soft tissue swelling over the right side of the face without underlying fracture.,4.Osteopenia and multilevel degenerative changes in the cervical spine as described above.,5.Findings were discussed with Dr. X from the emergency department at the time of interpretation.","orthopedic, sagittal, coronal, soft tissue swelling, paranasal sinuses, mastoid air, acute fracture, maxillary sinuses, tissue swelling, underlying fracture, multilevel degenerative, ct head, soft tissue, facial bones, cervical spine, ct, facial, bones, spine, cervical"
 The patient has been suffering from intractable back and leg pain., Orthopedic, Consult - Back & Leg Pain ,"Her axial back pain is greatly improved, but not completely eradicated.  There is absolutely no surgery at this point in time that would be beneficial for her axial back pain due to her lumbar internal disc disruption.,PAST MEDICAL HISTORY:,  Significant for anxiety disorder.,PAST SURGICAL HISTORY: , Foot surgery, abdominal surgery, and knee surgery.,CURRENT MEDICATIONS:,  Lipitor and Lexapro.,ALLERGIES: , She is allergic to sulfa medications.,SOCIAL HISTORY: , She is married, retired.  Denies tobacco or ethanol use.,FAMILY HISTORY:,  Father died of mesothelioma.  Mother gastric problems.,REVIEW OF SYSTEMS: , No recent history of night sweats, fevers, weight loss, visual changes, loss of consciousness, convulsion, or dysphagia.  Otherwise, review of systems is unremarkable, and a detailed history can be found in the patient's chart.,PHYSICAL EXAMINATION:,  Physical exam can be found in great detail in the patient's chart.,ASSESSMENT AND PLAN:  ,The patient is suffering from multilevel lumbar internal disc disruption as well as an element of lumbar facet joint syndrome.  Her lumbar facet joints were denervated approximately 6 months ago.  The denervation procedure helped her axial back pain approximately 40% when standing.  With extension and rotation it helped her axial back pain approximately 70%.  She is now able to swing a golf club.  She was unable to swing a golf club due to the rotational movements before her rhizotomy.  She is currently playing golf.  Her L4 radicular symptoms have resolved since her therapeutic transforaminal injection.,I am going to have her fitted with a low profile back brace and I am starting her on diclofenac 75 mg p.o. b.i.d.  We will follow her up in 1 month's time.,","orthopedic, multilevel lumbar internal disc disruption, denervation procedure, lumbar facet joint syndrome, swing a golf, lumbar internal disc, internal disc disruption, lumbar internal, internal disc, disc disruption, intractable, surgery, disc, lumbar"
" Lateral and plantar condylectomy, fifth left metatarsal.", Orthopedic, Condylectomy ,"TITLE OF OPERATION:,  Lateral and plantar condylectomy, fifth left metatarsal.,PREOPERATIVE DIAGNOSIS: , Prominent, lateral, and plantar condyle hypertrophy, fifth left metatarsal.,POSTOPERATIVE DIAGNOSIS: , Prominent, lateral, and plantar condyle hypertrophy, fifth left metatarsal.,ANESTHESIA:  ,Monitored anesthesia care with 10 mL of 1:1 mixture of both 0.5% Marcaine and 1% lidocaine plain.,HEMOSTASIS:,  30 minutes, left ankle tourniquet set at 250 mmHg.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,MATERIALS USED: , 3-0 Vicryl and 4-0 Vicryl.,INJECTABLES:,  Ancef 1 g IV 30 minutes preoperatively.,DESCRIPTION OF THE PROCEDURE: , The patient was brought to the operating room and placed on the operating table in a supine position.  After adequate sedation was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's left foot to anesthetize the future surgical sites.  The left ankle was covered with cast padding and an 18-inch ankle tourniquet was placed around the left ankle and set at 250 mmHg.  The left foot was then prepped, scrubbed, and draped in a normal sterile technique.  The left ankle tourniquet was inflated.  Attention was then directed on the dorsolateral aspect of the fifth left metatarsophalangeal joint where a 4-cm linear incision was placed over the fifth left metatarsophalangeal joint parallel and lateral to the course of the extensor digitorum longus to the fifth left toe.  The incision was deepened through the subcutaneous tissues.  All the bleeders were identified, cut, clamped, and cauterized.  The incision was deepened to the level of the capsule and the periosteum of the fifth left metatarsophalangeal joint.  All the tendinous and neurovascular structures were identified and retracted from the site to be preserved.  Using sharp and dull dissection, the soft tissue attachments through the fifth left metatarsal head were mobilized.  The lateral and plantar aspect of the fifth left metatarsal head were adequately exposed and using the sagittal saw a lateral and plantar condylectomy of the fifth left metatarsal head were then achieved.  The bony prominences were removed and passed off the operating table to be sent to pathology for identification.  The remaining sharp edges of the fifth left metatarsal head were then smoothened with the use of a dental rasp.  The area was copiously flushed with saline.  Then, 3-0 Vicryl and 4-0 Vicryl suture materials were used to approximate the periosteal, capsular, and subcutaneous tissues respectively.  The incision was reinforced with Steri-Strips.  Range of motion of the fifth left metatarsophalangeal joint was tested and was found to be excellent and uninhibited.  The patient's left ankle tourniquet at this time was deflated.  Immediate hyperemia was noted to the entire left lower extremity upon deflation of the cuff.  The patient's incision was covered with Xeroform, copious amounts of fluff and Kling, stockinette, and Ace bandage and the patient's left foot was placed in a surgical shoe.  The patient was then transferred to the recovery room under the care of the anesthesia team with her vital signs stable and her vascular status at appropriate levels.  The patient was given pain medications and instructions on how to control her postoperative course.  She was discharged from Hospital according to nursing protocol and was will follow up with Dr. X in one week's time for her first postoperative appointment.","orthopedic, plantar condyle hypertrophy, condyle hypertrophy, subcutaneous tissues, ankle tourniquet, metatarsophalangeal joint, metatarsal head, plantar condylectomy, tourniquet, condylectomy, plantar, ankle, metatarsal,"
" Closed reduction percutaneous pinning, left distal humerus.   Closed type-III supracondylar fracture, left distal humerus.  Tethered brachial artery, left elbow.", Orthopedic, Closed Reduction Percutaneous Pinning ,"PREOPERATIVE DIAGNOSIS: , Closed type-III supracondylar fracture, left distal humerus.,POSTOPERATIVE DIAGNOSES:,1.  Closed type-III supracondylar fracture, left distal humerus.,2.  Tethered brachial artery, left elbow.,PROCEDURE PERFORMED: , Closed reduction percutaneous pinning, left distal humerus.,SPECIFICATIONS: , The entire operative procedure was done in the inpatient operating suite, room #2 at ABCD General Hospital.  A portion of the procedure was done in consult with Dr. X with separate dictation by him.,HISTORY AND GROSS FINDINGS:  ,This is a 4-year-old white male, apparently dominantly right-handed who suffered a severe injury to his left distal humerus after jumping off of a swing.  He apparently had not had previous problems with his left arm.  He was seen in the Emergency with a grossly deformed left elbow.  His parents' were both present preoperatively.  His x-ray exam as well as physical exam was consistent with a closed type-III supracondylar fracture of the left distal humerus with rather severe puckering of the skin anteriorly with significant ecchymosis in the same region.  Gross neurologic exam revealed his ulnar, median, and radial nerves to be mostly intact, although a complete exam was impossible.  He did have a radial pulse palpable.,PROCEDURE: , After discussing the alternatives of the case as well as advantages and disadvantages, risks, complications, and expectations with the patient's parents including malunion, nonunion, gross deformity, growth arrest, infection, loss of elbow motions, stiffness, instability, need for surgery in the future, nerve problems, artery problems, and compartment syndrome, they elected to proceed.,The patient was laid supine upon operative table after receiving general anesthetic by Anesthesia Department.  Closed reduction was accomplished in a sequential manner.  Milking of the soft tissue envelope was carried out to try and reduce the shaft of the humerus back into its plane relative to the brachialis muscle and the neurovascular bundle anteriorly.  Then a slow longitudinal traction was carried out.  The elbow was hyperflexed.  Pressure placed upon the olecranon tip and two 0.045 K-wires placed first, one being on the lateral side and with this placement on the medial side of medial epicondyle with care taken to protect the ulnar nerve.  The close reduction was deemed to be acceptable once viewed on C-arm.,After this, pulse was attempted to be palpated distally.  Prior to the procedure, I talked to Dr. X of Vascular Surgery at ABCD Hospital.  He had scrubbed in to the case to follow up on the loss of the radial artery distally.  This was not present palpatory, but also by Doppler.  A weak ulnar artery pulse was present via Doppler.  Because of this, the severe displacement of the injury and the fact that the Doppler sound had an occlusion-type sound just above the fracture site or _______.  A long discussion was carried out with Dr. X and myself, and we decided to proceed with exploration of the brachial artery.  Prior to this, I went out to the waiting room to discuss with the patient's parents, the reasoning what we are going to do and the reasoning for this.  I then came back in and then we proceeded.  He was prepped and draped in the usual sterile manner.  Please see Dr. X's report for the discussion of the exploration and release of the brachial artery.  There was no indication that it was actually in the fracture site, the soft tissue had tethered in its right angle towards the fracture site, thus reducing its efficiency of providing blood distally.  Once it was released, both clinically on the table as well as by Doppler, the patient had bounding pulses.,We then proceeded to close utilizing a #4-0 Vicryl for subcutaneous fat closure and a running #5-0 Vicryl subcuticular stitch for skin closure.  Steri-Strips were placed.  The patient's arm was placed in just a slight degree of flexion with a neutral position.  He was splinted posteriorly.  Adaptic and fluffs have been placed around the patient's pin sites.  K-wires have been bent, cut, and pin caps placed.,Expected surgical prognosis on this patient is guarded for the obvious reasons noted above.  There is concern for growth plate disturbance.  He will be watched very closely for the potential development of re-perfusing compartment syndrome.,A full and complete neurologic exam will be impossible tonight, but will be carried on a sequential basis starting tomorrow morning.  There is always a potential for loss of elbow motion, overall cosmetic elbow alignment, and elbow function.","orthopedic, closed reduction, percutaneous pinning, distal humeru, supracondylar fracture, tethered brachial artery, artery, supracondylar, brachial, pinning, reduction, fracture, humerus, elbow,"
 Patient with complaint of left knee pain.  Patient is obese and will be starting Medifast Diet., Orthopedic, Consult - Knee Pain ,"CHIEF COMPLAINT:,  Left knee pain.,SUBJECTIVE: , This is a 36-year-old white female who presents to the office today with a complaint of left knee pain.  She is approximately five days after a third Synvisc injection.  She states that the knee is 35% to 40 % better, but continues to have a constant pinching pain when she full weight bears, cannot handle having her knee in flexion, has decreased range of motion with extension.  Rates her pain in her knee as a 10/10.  She does alternate ice and heat.  She is using Tylenol No. 3 p.r.n. and ibuprofen OTC p.r.n. with minimal relief.,ALLERGIES,1.  PENICILLIN.,2.  KEFLEX.,3.  BACTRIM.,4.  SULFA.,5.  ACE BANDAGES.,MEDICATIONS,1.  Toprol.,2.  Xanax.,3.  Advair.,4.  Ventolin.,5.  Tylenol No.  3.,6.  Advil.,REVIEW OF SYSTEMS:,  Will be starting the Medifast diet, has discussed this with her PCP, who encouraged her to have gastric bypass, but the patient would like to try this Medifast diet first.  Other than this, denies any further problems with her eyes, ears, nose, throat, heart, lungs, GI, GU, musculoskeletal, nervous system, except what is noted above and below.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse 72, blood pressure 130/88, respirations 16, height 5 feet 6.5 inches.,GENERAL:  This is a 36-year-old white female who is A&O x3, in no apparent distress with a pleasant affect.  She is well developed, well nourished, appears her stated age.,EXTREMITIES:  Orthopedic evaluation of the left knee reveals there to be well-healed portholes.  She does have some medial joint line swelling.  Negative ballottement.  She has significant pain to palpation of the medial joint line, none of the lateral joint line.  She has no pain to palpation on the popliteal fossa.  Range of motion is approximately -5 degrees to 95 degrees of flexion.  It should be noted that she has extreme hyperextension on the right with 95+ degrees of flexion on the right.  She has a click with McMurray.  Negative anterior-posterior drawer.  No varus or valgus instability noted.  Positive patellar grind test.  Calf is soft and nontender.  Gait is stable and antalgic on the left.,ASSESSMENT,1.  Osteochondral defect, torn meniscus, left knee.,2.  Obesity.,PLAN: , I have encouraged the patient to work on weight reduction, as this will only benefit her knee.  I did discuss treatment options at length with the patient, but I think the best plan for her would be to work on weight reduction.  She questions whether she needs a total knee; I don't believe she needs total knee replacement.  She may, however, at some point need an arthroscopy.  I have encouraged her to start formal physical therapy and a home exercise program.  Will use ice or heat p.r.n.  I have given her refills on Tylenol No.  3, Flector patch, and Relafen not to be taken with any other anti-inflammatory.  She does have some abdominal discomfort with the anti-inflammatories, was started on Nexium 20 mg one p.o. daily.  She will follow up in our office in four weeks.  If she has not gotten any relief with formal physical therapy and the above-noted treatments, we will discuss with Dr. X whether she would benefit from another knee arthroscopy.  The patient shows a good understanding of this treatment plan and agrees.","orthopedic, medifast, medifast diet, obesity, gastric bypass, knee pain, weight reduction, knee, "
 Axial images through the cervical spine with coronal and sagittal reconstructions., Orthopedic, CT C-Spine - 1  ,"EXAM: , CT cervical spine.,REASON FOR EXAM: , MVA, feeling sleepy, headache, shoulder and rib pain.,TECHNIQUE:,  Axial images through the cervical spine with coronal and sagittal reconstructions.,FINDINGS:,  There is reversal of the normal cervical curvature at the vertebral body heights.  The intervertebral disk spaces are otherwise maintained.  There is no prevertebral soft tissue swelling.  The facets are aligned.  The tip of the clivus and occiput appear intact.  On the coronal reconstructed sequence, there is satisfactory alignment of C1 on C2, no evidence of a base of dens fracture.,The included portions of the first and second ribs are intact.  There is no evidence of a posterior element fracture.  Included portions of the mastoid air cells appear clear.  There is no CT evidence of a moderate or high-grade stenosis.,IMPRESSION: , No acute process, cervical spine.","orthopedic, c-spine, axial images, sagittal reconstructions, cervical spine, sagittal, fracture, coronal, spine, axial, cervical, ct, "
  CT cervical spine for trauma.  CT examination of the cervical spine was performed without contrast.  Coronal and sagittal reformats were obtained for better anatomical localization., Orthopedic, CT C-Spine - 2 ,"EXAM:,  CT cervical spine (C-spine) for trauma.,FINDINGS:,  CT examination of the cervical spine was performed without contrast.  Coronal and sagittal reformats were obtained for better anatomical localization.  Cervical vertebral body height, alignment and interspacing are maintained.  There is no evidence of fractures or destructive osseous lesions.  There are no significant degenerative endplate or facet changes.  No significant osseous central canal or foraminal narrowing is present.,IMPRESSION: , Negative cervical spine.","orthopedic, c-spine, anatomical, degenerative endplate, ct examination, cervical spine, coronal, ct, spine, cervicalNOTE"
" Trimalleolar ankle fracture and dislocation right ankle.  A comminuted fracture involving the lateral malleolus, as well as a medial and posterior malleolus fracture as well.  Closed open reduction and internal fixation of right ankle.  ", Orthopedic, Closed ORIF - Ankle ,"PREOPERATIVE DIAGNOSES:,1.  Trimalleolar ankle fracture.,2.  Dislocation right ankle.,POSTOPERATIVE DIAGNOSES:,1.  Trimalleolar ankle fracture.,2.  Dislocation right ankle.,PROCEDURE PERFORMED: , Closed open reduction and internal fixation of right ankle.,ANESTHESIA:  ,Spinal with sedation.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS:  ,Minimal.,TOTAL TOURNIQUET TIME:  ,75 minutes at 325 mmHg.,COMPONENTS: , Synthes small fragment set was used including a 2.5 mm drill bed.  A six hole one-third tibial plate, one 12 mm 3.5 mm cortical screw fully threaded and two 16 mm 3.5 mm cortical fully-threaded screws.  There were two 20 mm 4.0 cancellous screws and one 18 mm 4.0 cancellous screw placed.  There were two 4.0 cancellous partially-threaded screws placed.,GROSS FINDINGS:  ,Include a comminuted fracture involving the lateral malleolus as well as a medial and posterior malleolus fracture as well.,HISTORY OF PRESENT ILLNESS: , The patient is an 87-year-old Caucasian female who presented to ABCD General Hospital Emergency Room complaining of right ankle pain status post a trip and fall.  The patient noted while walking with a walker, apparently tripped and fell.  The patient had significant comorbidities, seen and evaluated by the Emergency Room Department as well as Department of Orthopedics while in the Emergency Room.  At that time, a closed reduction was performed and she was placed in a Robert-Jones splint.  After complete medical workup and clearance, we elected to take her to the operating room for definitive care.,PROCEDURE:  ,After all potential complications and risks as well as risks and benefits of the above-mentioned procedure was discussed at length with the patient and family, informed consent was obtained.  The upper extremity was then confirmed with the operating surgeon, the patient, the nursing staff and Department of Anesthesia.  The patient was then transferred to preoperative area in the Operative Suite #3 and placed on the operating room table in supine position.  At this time, the Department of Anesthesia administered spinal anesthetic to the patient as well as sedation.  All bony prominences were well padded at this time.  A nonsterile tourniquet was placed on the right upper thigh of the patient.  This was then removed and the right lower extremity was sterilely prepped and draped in the usual sterile fashion.  The right lower extremity was then elevated and exsanguinated using Esmarch and tourniquet was then placed to 325 mmHg and kept up to a total of 75 minutes.  Next, after all bony and soft tissue landmarks were identified, a 6 cm longitudinal incision was made directly over this vestibule on the right ankle.  A sharp dissection was carefully taken down to the level of bone taking care to protect the neurovascular structures.  Once the bone was reached, the fractured site was identified.  The bony ends were then opened and divided of all hematoma as well as excess periosteum within the fracture site.  The wound was copiously irrigated and dried.  Next, the fracture was then reduced in anatomic position.  There was noted to be quite a bit of comminution as well as soft overall status of the bone.  It was held in place with reduction forceps.  A six hole one-third tubular Synthes plate was then selected for instrumentation.  It was contoured using ________ and placed on the lateral aspect of the distal fibula.  Next, the three most proximal holes were sequentially drilled using a 2.5 mm drill bed, depth gauged and then a 3.5 mm fully threaded cortical screw was placed in each.  The most proximal was a 12 mm and the next two were 16 mm in length.  Next, the three most distal holes were sequentially drilled using a 2.5 mm drill bed, depth gauged, and a 4.0 cancellous screw was placed in each hole.  The most distal with a 20 mm and two most proximal were 18 mm in length.  Next the Xi-scan was used to visualize the hardware placement as well as the fracture reduction appeared to be in good anatomic position, all hardware was in good position.  There was no lateralization of the joints.  Attention was then directed towards the medial aspect of the ankle.  Again, after all bony and soft tissue landmarks were identified, a 4 cm longitudinal incision was made directly over the medial malleolus.  Again, the dissection was carefully taken down the level of the fracture site.  The retractors were then placed to protect all neurovascular structures.  Once the fracture site was identified, it was dried of all hematoma as well as excess periosteum.  The fracture site was then displaced and the ankle joint was visualized including the dome of the talus.  There appeared to be some minor degenerative changes of the talus, but no loose bodies.  Next, the wound was copiously irrigated and suctioned dry.  The medial malleolus was placed in reduced position and held in place with a 1.25 mm K-wire.  Next, the 2.5 mm drill bed was then used to sequentially drill holes to full depth and 4.0 cancellous screws were placed in each, each with a 45 mm in length.  These appeared to hold the fracture site securely in an anatomic position.  Again, Xi-scan was brought in to confirm placement of the screws.  They were in good overall position and there was no lateralization of the joint.  At this time, each wound was copiously irrigated and suctioned dry.  The wounds were then closed using #2-0 Vicryl suture in subcutaneous fashion followed by staples on the skin.  A sterile dressing was applied consistent with Adaptic, 4x4s, Kerlix, and Webril.  A Robert-Jones style splint was then placed on the right lower extremity.  This was covered by a 4-inch Depuy dressing.  At this time, the Department of Anesthesia reversed the sedation.  The patient was transferred back to the hospital gurney and to the Postanesthetic Care Unit.  The patient tolerated the procedure well.  There were no complications.","orthopedic, ankle fracture, dislocation, open reduction, internal fixation, orif, trimalleolar ankle fracture, cortical screw, cancellous screws, fracture site, fracture, ankle, malleolus, "
 Right distal both-bone forearm fracture.  Closed reduction under conscious sedation and application of a splint was warranted., Orthopedic, Closed Reduction - 1 ,"PREOPERATIVE DIAGNOSIS: , Right distal both-bone forearm fracture.,POSTOPERATIVE DIAGNOSIS: , Right distal both-bone forearm fracture.,INDICATIONS:,  Mr. ABC is a 10-year-old boy who suffered a fall resulting in a right distal both-bone forearm fracture.  Upon evaluation by Orthopedic Surgery team in the emergency department, it was determined that a closed reduction under conscious sedation and application of a splint was warranted.  This was discussed with the parents who expressed verbal and written consent.,PROCEDURE:,  Conscious sedation was achieved via propofol via the emergency department staff.  Afterwards, traction with re-creation of the injury pattern was utilized to achieve reduction of the patient's fracture.  This was confirmed with image intensifier.  Subsequently, the patient was placed into a splint.  The patient was aroused from conscious sedation and at this time it was noted that he had full sensation throughout radial, median, and ulnar nerve distributions and positive extensor pollicis longus, flexor pollicis longus, dorsal and palmar interossei.,DISPOSITION:  ,Post-reduction x-rays revealed good alignment in the AP x-rays.  The lateral x-rays also revealed adequate reduction.  At this time, we will allow the patient to be discharged home and have him follow up with Dr. XYZ in one week.","orthopedic, closed reduction, distal both bone forearm, emergency department, pollicis longus, bone forearm, forearm fracture, conscious sedation, emergency, department, pollicis, longus, splint, distal, bone, forearm, conscious, sedation, fracture, reduction, "
" Postoperative followup note - Cervicalgia, cervical radiculopathy, and difficulty swallowing status post cervical fusion C3 through C7 with lifting of the plate.", Orthopedic, Cervicalgia ,"FAMILY HISTORY: , Her father died at the age of 80 from prostate cancer.  Her mother died at the age of 67.  She did abuse alcohol.  She had a brother died at the age of 70 from bone and throat cancer.  She has two sons, ages 37 and 38 years old who are healthy.  She has two daughters, ages 60 and 58 years old, both with cancer.  She describes cancer hypertension, nervous condition, kidney disease, lung disease, and depression in her family.,SOCIAL HISTORY: , She is married and has support at home.  Denies tobacco, alcohol, and illicit drug use.,ALLERGIES: , Aspirin.,MEDICATIONS:  ,The patient does not list any current medications.,PAST MEDICAL HISTORY: , Hypertension, depression, and osteoporosis.,PAST SURGICAL HISTORY: , She has had over her over her lifetime four back surgeries and in 2005 she had anterior cervical discectomy and fusion of C3 through C7 by Dr. L.  She is G10, P7, no cesarean sections.,REVIEW OF SYSTEMS: , HEENT:  Headaches, vision changes, dizziness, and sore throat.  GI:  Difficulty swallowing.  Musculoskeletal:  She is right-handed with joint pain, stiffness, decreased range of motion, and arthritis.  Respiratory:  Shortness of breath and cough.  Cardiac:  Chest pain and swelling in her feet and ankle.  Psychiatric:  Anxiety and depression.  Urinary:  Negative and noncontributory.  Hem-Onc:  Negative and noncontributory.  Vascular:  Negative and noncontributory.  Genital:  Negative and noncontributory.,PHYSICAL EXAMINATION:,  On physical exam, she is 5 feet tall and currently weighs 110 pounds; weight one year ago was 145 pounds.  BP 138/78, pulse is 64.  General:  A well-developed, well-nourished female, in no acute distress.  HEENT exam, head is atraumatic and normocephalic.  Eyes, sclerae are anicteric.  Teeth, she does have some poor dentition.  She does say that she needs some of her teeth pulled on her lower mouth.  Cranial nerves II, III, IV, and VI, vision is intact and visual fields are full to confrontation.  EOMs are full bilaterally.  Pupils are equal, round, and reactive to light.  Cranial nerves V and VII, normal facial sensation and symmetrical facial movements.  Cranial nerve VIII, hearing is intact, although decreased bilaterally right worse than left.  Cranial nerves IX, X, and XII, tongue protrudes midline and palate elevates symmetrically.  Cranial nerve XI, strong and symmetrical shoulder shrugs against resistance.  Cardiac, regular rate and rhythm.  Chest and lungs are clear bilaterally.  Skin is warm and dry.  Normal turgor and texture.  No rashes or lesions are noted.  General musculoskeletal exam reveals no gross deformity, fasciculations, and atrophy.  Peripheral vascular, no cyanosis, clubbing, or edema.  She does have some tremoring of her bilateral upper arms as she said.  Strength testing reveals difficulty when testing due to the fact that the patient does have a lot of pain, but she seems to be pretty equal in the bilateral upper extremities with no obvious weakness noted.  She is about 4+/5 in the deltoids, biceps, triceps, wrist flexors, wrist extensors, dorsal interossei, and grip strength.,It is much more painful for her on the left.  Deep tendon reflexes are 2+ bilaterally only at biceps, triceps, and brachioradialis, knees, and ankles.  No ankle clonus is elicited.  Hoffmann's is negative bilaterally.  Sensation is intact.  She ambulates with slow short steps.  No spastic gait is noted.  She has appropriate station and gait with no assisted devices, although she states that she is supposed to be using a cane.  She does not bring one in with her today.,FINDINGS: , Patient brings in cervical spine x-rays and she has had an MRI taken but does not bring that in with her today.  She will obtain that and x rays, which showed at cervical plate C3, C4, C5, C6, and C7 anteriorly with some lifting with the most lifted area at the C3 level.  No fractures are noted.,ASSESSMENT: , Cervicalgia, cervical radiculopathy, and difficulty swallowing status post cervical fusion C3 through C7 with lifting of the plate.,PLAN:,  We went ahead and obtained an EKG in the office today, which demonstrated normal sinus rhythm.  She went ahead and obtained her x-rays and will pick her MRI and return to the office for surgical consultation with Dr. L first available.  She would like the plate removed, so that she can eat and drink better, so that she can proceed with her shoulder surgery.  All questions and concerns were addressed with her.  Warning signs and symptoms were gone over with her.  If she should have any further questions, concerns, or complications, she will contact our office immediately; otherwise, we will see her as scheduled.  I am quite worried about the pain that she is having in her arms, so I would like to see the MRI as well.  Case was reviewed and discussed with Dr. L.","orthopedic, c3 through c7, pain scale, mris, x-rays, cervical discectomy and fusion, cervical radiculopathy, cervical fusion, cervical discectomy, cervical plate, difficulty swallowing, cranial nerves, radiculopathy, discectomy, cervicalgia, postoperative, fusion, swallowing, "
" Closing wedge osteotomy, fifth metatarsal with internal screw fixation, right foot.", Orthopedic, Closing Wedge Osteotomy ,"PREOPERATIVE DIAGNOSIS: , Tailor's bunion, right foot.,POSTOPERATIVE DIAGNOSIS: , Tailor's bunion, right foot.,PROCEDURE: , Closing wedge osteotomy, fifth metatarsal with internal screw fixation, right foot.,ANESTHESIA: , Local infiltrate with IV sedation.,INDICATIONS FOR SURGERY: , The patient has had a longstanding history of foot problems.  The problem has been progressive in nature.  The preoperative discussion with the patient included alternative treatment options, the procedure was explained, and the risk factors such as infection, swelling, scar tissue, numbness, continued pain, recurrence, and the postoperative management were discussed.  The patient has been advised, although no guarantee for success could be given, most of the patient have less pain and improved function, all questions were thoroughly answered.  The patient requested for surgical repair since the problem has reached a point that interfere with normal daily activity.  The purpose of the surgery is to alleviate pain and discomfort.,DETAILS OF PROCEDURE:  ,The patient was given 1 g of Ancef IV for antibiotic prophylaxis 30 minutes prior to the procedure.  The patient was brought to the operating room and placed in the supine position.  No tourniquet was utilized.  IV sedation was achieved followed by a local anesthetic consisting of approximately 10 mL total in 1:1 mixture of 0.25% Marcaine and 1% lidocaine with epinephrine was locally infiltrated proximal to the operative site.  The lower extremity was prepped and draped in the usual sterile manner.  Balanced anesthesia was obtained.,PROCEDURE:, Closing wedge osteotomy, fifth metatarsal with internal screw fixation, right foot.  A dorsal curvilinear incision was made extending from the base of the proximal phalanx fifth digit to a point 1.5 cm from the base of the fifth metatarsal.  Care was taken to identify and retract all vital structures and when necessary, vessels were ligated via electrocautery.  The extensor tendon was identified and retracted medially.  Sharp and blunt dissection was carried down through the subcutaneous tissue down to the periosteal layer.  A linear periosteal capsular incision was made in line with the skin incision.  The capsular tissue and periosteal layer was underscored, free from its underlying osseous attachment, and then reflected to expose the osseous surface.  Inspection of the fifth metatarsophalangeal joint revealed articular cartilage to be perverse and hypertrophic changes to the lateral and dorsolateral aspect of the fifth metatarsal head.  An oscillating saw was utilized to carefully resect the hypertrophic portion of the fifth metatarsal head to a more normal configuration.  The both edges were rasped smooth.,Attention was then focused on the fifth metatarsal.  The periosteal layer proximal to the fifth metatarsal head was underscored, free from its underlying attachment, and then reflected to expose the osseous surface.  An excess guide position perpendicular to the weightbearing surface was placed to define apex of the osteotomy.,Using an oscillating saw, a vertically placed, wedge-shaped oblique ostomy was made with the apex being proximal, lateral, and the base medial and distal.  Generous amounts of lateral cortex were preserved for the lateral hinge.  The wedge was removed from the surgical field.  The fifth metatarsal was placed in the appropriate position and stabilized with a guide pin, which was then countersunk and a 3-0 x 40 mm cannulated cortical screw was placed over the guide pin and secured into position.  Good purchase was noted at the osteotomy site.  Inspection revealed satisfactory reduction of the fourth intermetatarsal angle with the fifth metatarsal in good alignment and position.  The surgical site was flushed with copious amounts of normal saline irrigation.  The periosteal and capsular layers were closed with running sutures of 3-0 Vicryl.  The subcutaneous tissues were closed with 4-0 Vicryl, and the skin edges were closed with 4-0 nylon in a running interrupted fashion.  A dressing consisting of Adaptic, 4 x 4, confirming bandages, and ACE wrap to provide mild compression was applied.  The patient tolerated the procedure and anesthesia well and left the operating room to the recovery room in good postoperative condition with vital signs stable and arterial perfusion intact as evident by normal capillary refill time, and all digits were warm and pink.,A walker boot was dispensed and applied.  The patient should wear that all the time when standing or walking and be nonweightbearing with crutches and to clear by me.,Office visit will be in 4 days.  The patient was given prescriptions for Keflex 500 mg one p.o. t.i.d. for 10 days and Ultram ER, #15 one p.o. daily along with written and oral home instructions including a number on which I can be reached 24 hours a day if any problem arises.,After short recuperative period, the patient was discharged home with a vital sign stable in no acute distress.","orthopedic, internal screw fixation, osteotomy, closing wedge osteotomy, tailor's bunion, screw fixation, periosteal layer, metatarsal head, wedge osteotomy, metatarsal, anesthesia"
 Left hip cemented hemiarthroplasty and biopsy of the tissue from the fracture site and resected femoral head sent to the pathology for further assessment., Orthopedic, Cemented Hemiarthroplasty & Biopsy ,"PREOPERATIVE DIAGNOSIS:,  Closed displaced probable pathological fracture, basicervical femoral neck, left hip.,POSTOPERATIVE DIAGNOSIS: , Closed displaced probable pathological fracture, basicervical femoral neck, left hip.,PROCEDURES PERFORMED:,1.  Left hip cemented hemiarthroplasty.,2.  Biopsy of the tissue from the fracture site and resected femoral head sent to the pathology for further assessment.,IMPLANTS USED:,1.  DePuy Ultima calcar stem, size 3 x 45.,2.  Bipolar head 28 x 43.,3.  Head with +0 neck length.,4.  Distal centralizer and cement restrictor.,5.  SmartSet antibiotic cement x2.,ANESTHESIA: , General.,NEEDLE AND SPONGE COUNT: , Correct.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS: , 300 mL.,SPECIMEN: , Resected femoral head and tissue from the fracture site as well as the marrow from the canal.,FINDINGS:  ,On exposure, the fracture was noted to be basicervical pattern with no presence of calcar about the lesser trochanter.  The lesser trochanter was intact.  The fracture site was noted to show abnormal pathological tissue with grayish discoloration.  The quality of the bone was also pathologically abnormal with soft trabecular bone.  The abnormal pathological tissues were sent along with the femoral head to pathology for assessment.  Articular cartilage of the acetabulum was intact and well preserved.,INDICATION: , The patient is a 53-year-old female with a history of malignant melanoma, who apparently had severe pain in her left lower extremity and was noted to have a basicervical femoral neck fracture.  She denied any history of fall or trauma.  The presentation was consistent with pathological fracture pending tissue assessment.  Indication, risks, and benefits were discussed.  Treatment options were reviewed.  No guarantees have been made or implied.,PROCEDURE:  ,The patient was brought to the operating room and once an adequate general anesthesia was achieved, she was positioned on a pegboard with the left side up.  The left lower extremity was prepped and draped in a standard sterile fashion.  Time-out procedure was called.  Antibiotics were infused.,A standard posterolateral approach was made.  Subcutaneous dissection was performed and the dissection was carried down to expose the fascia of the gluteus maximus.  This was then incised along the line of the incision.  Hemostasis was achieved.  Charnley retractor was positioned.  The trochanter was intact.  The gluteus medius was well protected with retractor.  The piriformis and minimus junction was identified.  The minimus was also reflected along with the medius.  Using Bovie and knife, the piriformis and external rotators were detached from its trochanteric insertion.  Similarly, L-shaped capsulotomy was performed.  A #5 Ethibond was utilized to tag the piriformis and the capsule for late repair.  Fracture site was exposed.  The femoral neck fracture was noted to be very low-lying basicervical type.  Femoral head was retrieved without any difficulty with the help of a corkscrew.  The head size was measured to be 43 mm.  Bony fragments were removed.  The acetabular socket was thoroughly irrigated.  A 43-mm bipolar trial head was inserted and this was noted to give a satisfactory fit with good stability.  The specimens submitted to pathology included the resected femoral head and the tissue at the fracture site, which was abnormal with grayish discoloration.  This was sent to the pathology.  The fracture was noted to be basicervical and preoperatively, decision was made to consider cemented calcar stem.  An L-shaped osteotomy was performed in order to accept the calcar prosthesis.  The basicervical fracture was noted to be just at the level of superior border of the lesser trochanter.  There was no calcar superior to the lesser trochanter.  The L-shaped osteotomy was performed to refine the bony edges and accept the calcar prosthesis.  Hemostasis was achieved.  Now, the medullary canal was entered with a canal finder.  The fracture site was well exposed.  Satisfactory lateralization was performed.  Attention was for the reaming process.  Using a size 1 reamer, the medullary canal was entered and reamed up to size 3, which gave us a satisfactory fit into the canal.  At this point, a trial prosthesis size 3 with 45 mm calcar body was inserted.  Appropriate anteversion was positioned.  The anteversion was marked with a Bovie to identify subsequent anteversion during implantation.  The bony edges were trimmed.  The calcar implant with 45 mm neck length was fit in the host femur very well.  There was no evidence of any subsidence.  At this point, trial reduction was performed using a bipolar trial head with 0 neck length.  The relationship between the central femoral head and the greater trochanter was satisfactory.  The hip was well reduced without any difficulty.  The stability and range of motion in extension and external rotation as well as flexion-adduction, internal rotation was satisfactory.  The shuck was less than 1 mm.  Leg length was satisfactory in reference to the contralateral leg.  Stability was satisfactory at 90 degrees of flexion and hip at 75-80 degrees of internal rotation.  Similarly, keeping the leg completely adducted, I was able to internally rotate the hip to 45 degrees.  After verifying the stability and range of motion in all direction, trial components were removed.  The canal was thoroughly irrigated and dry sponge was inserted and canal was dried completely.  At this point, 2 batches of SmartSet cement with antibiotics were mixed.  The definitive Ultima calcar stem size 3 with 45 mm calcar body was selected.  Centralizer was positioned.  The cement restrictor was inserted.  Retrograde cementing technique was applied once the canal was dried.  Using cement gun, retrograde cementing was performed.  The stem was then inserted into cemented canal with appropriate anteversion, which was maintained until the cement was set hard and cured.  The excess cement was removed with the help of a curette and Freer elevator.  All the cement debris was removed.,Attention was now placed for the insertion of the trial femoral head.  Once again, 0 neck length trial bipolar head was inserted over the trunnion.  It was reduced and range of motion and stability was satisfactory.  I also attempted with a -3 trial head, but the 0 gave us a satisfactory stability, range of motion, as well as the length and the shuck was also minimal.  The hip was raised to 90 degrees of flexion and 95 degrees of internal rotation.  There was no evidence of any impingement on extension and external rotation as well as flexion-adduction, internal rotation.  I also tested the hip at 90 degrees of flexion with 10 degrees adduction and internal rotation and further progressive flexion of the hip beyond 90 degrees, which was noted to be very stable.  At this point, a definitive component using +0 neck length and bipolar 43 head were placed over the trunnion and the hip was reduced.  Range of motion and stability was as above.  Now, the attention was placed for the repair of the capsule and the external rotators and the piriformis.  This was repaired to the trochanteric insertion using #5 Ethibond and suture plaster.  Satisfactory reinforcement was achieved with the #5 Ethibond.  The wound was thoroughly irrigated.  Hemostasis was achieved.  The fascia was closed with #1 Vicryl followed by subcutaneous closure using 2-0 Vicryl.  The wound was thoroughly washed and a local injection with mixture of morphine and Toradol was infiltrated including the capsule and the pericapsular structures.  Skin was approximated with staples.  Sterile dressings were placed.  Abduction pillow was positioned and the patient was then extubated and transferred to the recovery room in a stable condition.  There were no intraoperative complications noted.",
" Cervical spondylosis and kyphotic deformity.  She had a nerve conduction study and a diagnosis of radiculopathy was made.  She had an MRI of lumbosacral spine, which was within normal limits.  She then developed a tingling sensation in the right middle toe. ", Orthopedic, Cervical Spondylosis - Neuro Consult ,"REASON FOR NEUROLOGICAL CONSULTATION: , Cervical spondylosis and kyphotic deformity.  The patient was seen in conjunction with medical resident Dr. X. I personally obtained the history, performed examination, and generated the impression and plan.,HISTORY OF PRESENT ILLNESS: ,The patient is a 45-year-old African-American female whose symptoms first started some one and a half years ago with pain in the left shoulder and some neck pain.  This has subsequently resolved.  She started vigorous workouts in November 2005.  In March of this year, she suddenly could not feel her right foot on the bathroom floor and subsequently went to her primary care physician.  By her report, she had a nerve conduction study and a diagnosis of radiculopathy was made.  She had an MRI of lumbosacral spine, which was within normal limits.  She then developed a tingling sensation in the right middle toe.  Symptoms progressed to sensory symptoms of her knees, elbows, and left middle toe.  She then started getting sensory sensations in the left hand and arm.  She states that she feels a little bit wobbly at the knees and that she is slightly dragging her left leg.  Symptoms have been mildly progressive.  She is unaware of any trigger other than the vigorous workouts as mentioned above.  She has no associated bowel or bladder symptoms.  No particular position relieves her symptoms.,Workup has included two MRIs of the C-spine, which were personally reviewed and are discussed below.  She saw you for consultation and the possibility of surgical decompression was raised.  At this time, she is somewhat reluctant to go through any surgical procedure.,PAST MEDICAL HISTORY:,1.  Ocular migraines.,2.  Myomectomy.,3.  Infertility.,4.  Hyperglycemia.,5.  Asthma.,6.  Hypercholesterolemia.,MEDICATIONS: , Lipitor, Pulmicort, Allegra, Xopenex, Patanol, Duac topical gel, Loprox cream, and Rhinocort.,ALLERGIES: , Penicillin and aspirin.,Family history, social history, and review of systems are discussed above as well as documented in the new patient information sheet.  Of note, she does not drink or smoke.  She is married with two adopted children.  She is a paralegal specialist.  She used to exercise vigorously, but of late has been advised to stop exercising and is currently only walking.,REVIEW OF SYSTEMS: , She does complain of mild blurred vision, but these have occurred before and seem associated with headaches.,PHYSICAL EXAMINATION: , On examination, blood pressure 138/82, pulse 90, respiratory rate 14, and weight 176.5 pounds.  Pain scale is 0.  A full general and neurological examination was personally performed and is documented on the chart.  Of note, she has a normal general examination.  Neurological examination reveals normal cognition and cranial nerve examination including normal jaw jerk.  She has mild postural tremor in both arms.  She has mild decreased sensation in the right palm and mild decreased light touch in the right palm and decreased vibration sense in both distal lower extremities.  Motor examination reveals no weakness to individual muscle testing, but on gait she does have a very subtle left hemiparesis.  She has hyperreflexia in her lower extremities, worse on the left.  Babinski's are downgoing.,PERTINENT DATA:  ,MRI of the brain from 05/02/06 and MRI of the C-spine from 05/02/06 and 07/25/06 were personally reviewed.  MRI of the brain is broadly within normal limits.  MRI of the C-spine reveals large central disc herniation at C6-C7 with evidence of mild cord compression and abnormal signal in the cord suggesting cord edema.  There is also a fairly large disc at C3-C4 with cord deformity and partial effacement of the subarachnoid space.  I do not appreciate any cord edema at this level.,IMPRESSION AND PLAN:  ,The patient is a 45-year-old female with cervical spondylosis with a large C6-C7 herniated disc with mild cord compression and signal change at that level.  She has a small disc at C3-C4 with less severe and only subtle cord compression.  History and examination are consistent with signs of a myelopathy.,Results were discussed with the patient and her mother.  I am concerned about progressive symptoms.  Although she only has subtle symptoms now, we made her aware that with progression of this process, she may have paralysis.  If she is involved in any type of trauma to the neck such as motor vehicle accident, she could have an acute paralysis.  I strongly recommended to her and her mother that she followup with you as soon as possible for surgical evaluation.  I agree with the previous physicians who have told her not to exercise as I am sure that her vigorous workouts and weight training since November 2005 have contributed to this problem.  I have recommended that she wear a hard collar while driving.  The results of my consultation were discussed with you telephonically.","orthopedic, kyphotic, cervical, radiculopathy, myelopathy, kyphotic deformity, cord compression, cervical spondylosis, toe, spondylosis, cord, "
 Left distal both-bone forearm fracture.  Closed reduction with splint application with use of image intensifier., Orthopedic, Closed Reduction - 2 ,"PREOPERATIVE DIAGNOSIS: , Left distal both-bone forearm fracture.,POSTOPERATIVE DIAGNOSIS: , Left distal both-bone forearm fracture.,PROCEDURE:,  Closed reduction with splint application with use of image intensifier.,INDICATIONS: , Mr. ABC is an 11-year-old boy who sustained a fall on 07/26/2008.  Evaluation in the emergency department revealed both-bone forearm fracture.  Considering the amount of angulation, it was determined that we should proceed with conscious sedation and closed reduction.  After discussion with parents, verbal and written consent was obtained.,DESCRIPTION OF PROCEDURE:  ,The patient was induced with propofol for conscious sedation via the emergency department staff.  After it was confirmed that appropriate sedation had been reached, a longitudinal traction in conjunction with re-creation of the injury maneuver was applied reducing the fracture.  Subsequently, this was confirmed with image intensification, a sugar-tong splint was applied and again reduction was confirmed with image intensifier.  The patient was aroused from anesthesia and tolerated the procedure well.  Post-reduction plain films revealed some anterior displacement of the distal fragment.  At this time, it was determined this fracture proved to be unstable.,DISPOSITION: , After review of the reduction films, it appears that there is some element of fracture causing displacement.  We will proceed to the operating room for open reduction and internal fixation versus closed reduction and percutaneous pinning as our operative schedule allows.,","orthopedic, closed reduction, reduction with splint application, distal both bone forearm, distal both bone, splint application, emergency department, conscious sedation, image intensifier, bone forearm, forearm fracture, reduction, emergency, department, conscious, displacement, splint, sedation, tong, distal, bone, image, intensifier, forearm, fracture "
" Carpal tunnel syndrome.  Endoscopic carpal tunnel release.  After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion, the arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.", Orthopedic, Carpal Tunnel Release - Endoscopic ,"PREOPERATIVE DIAGNOSIS:,  Carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome.,TITLE OF PROCEDURE: , Endoscopic carpal tunnel release.,ANESTHESIA: , MAC,PROCEDURE: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion, the arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,I made a transverse incision one fingerbreadth proximal to the distal volar wrist crease.  Dissection was carried down to the antebrachial fascia, which was cut in a distally based fashion.  Bipolar electrocautery was used to maintain meticulous hemostasis.  I then performed an antebrachial fasciotomy proximally.  I entered the extra bursal space deep into the transverse carpal ligament and used the spatula probe and then the dilators and then the square probe to enlarge the area.  Great care was taken to feel the washboard undersurface of the transverse carpal ligament and the hamate on the ulnar side.  Great care was taken with placement.  A good plane was positively identified.  I then placed the endoscope in and definitely saw the transverse striations of the deep surface of the transverse carpal ligament.,Again, I felt the hook of the hamate ulnar to me.  I had my thumb on the distal aspect of the transverse carpal ligament.  I then partially deployed the blade, and starting 1 mm from the distal edge, the transverse carpal ligament was positively identified.  I pulled back and cut and partially tightened the transverse carpal ligament.  I then feathered through the distal ligament and performed a full-thickness incision through the distal half of the ligament.  I then checked to make sure this was properly performed and then cut the proximal aspect.  I then entered the carpal tunnel again and saw that the release was complete, meaning that the cut surfaces of the transverse carpal ligament were separated; and with the scope rotated, I could see only one in the field at a time.  Great care was taken and at no point was there any longitudinal structure cut.  Under direct vision through the incision, I made sure that the distal antebrachial fascia was cut.  Following this, I irrigated and closed the skin.  The patient was dressed and sent to the recovery room in good condition.","orthopedic, endoscopic, carpal tunnel syndrome, carpal tunnel release, carpal ligament, tourniquet, carpal, esmarch, tunnel, transverse, ligament"
 Left knee arthroscopy with removal of the cartilage loose body and microfracture of the medial femoral condyle with chondroplasty., Orthopedic, Cartilage Loose Body Removal ,"PREOPERATIVE DIAGNOSIS: , Left knee medial femoral condyle osteochondritis dissecans.,POSTOPERATIVE DIAGNOSIS: , Left knee medial femoral condyle osteochondritis dissecans.,PROCEDURES:,  Left knee arthroscopy with removal of the cartilage loose body and microfracture of the medial femoral condyle with chondroplasty.,ANESTHESIA: , General.,TOURNIQUET TIME:  ,Thirty-seven minutes.,MEDICATIONS: , The patient also received 30 mL of 0.5% Marcaine local anesthetic at the end of the case.,COMPLICATIONS: , No intraoperative complications.,DRAINS AND SPECIMENS: , None.,INTRAOPERATIVE FINDINGS: , The patient had a loose body that was found in the suprapatellar pouch upon entry of the camera.  This loose body was then subsequently removed.  It measured 24 x 14 mm.  This was actually the OCD lesion seen on the MRI that had come from the weightbearing surface of just the lateral posterior aspect of the medial femoral condyle,HISTORY AND PHYSICAL: , The patient is 13-year-old male with persistent left knee pain.  He was initially seen at Sierra Pacific Orthopedic Group where an MRI demonstrated unstable OCD lesion of the left knee.  The patient presented here for a second opinion.  Surgery was recommended grossly due to the instability of the fragment.  Risks and benefits of surgery were discussed.  The risks of surgery include risk of anesthesia, infection, bleeding, changes in sensation and motion extremity, failure to relieve pain or restore the articular cartilage, possible need for other surgical procedures, and possible early arthritis.  All questions were answered and parents agreed to the above plan.,DESCRIPTION OF PROCEDURE:  ,The patient was taken to the operating room and placed supine on the operating table.  General anesthesia was then administered.  The patient received Ancef preoperatively.  A nonsterile tourniquet was placed on the upper aspect of the patient's left thigh.  The extremity was then prepped and draped in standard surgical fashion.  The standard portals were marked on the skin.  The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg.  The portal incisions were then made by an #11 blade.  Camera was inserted into the lateral joint line.  There was a noted large cartilage loose body in the suprapatellar pouch.  This was subsequently removed with extension of the anterolateral portal.  Visualization of the rest of the knee revealed significant synovitis.  The patient had a large cartilage defect in the posterolateral aspect of the medial femoral condyle.  The remainder of the knee demonstrated no other significant cartilage lesions, loose bodies, plica or meniscal pathology.  ACL was also visualized to be intact in the intracondylar notch.,Attention was then turned back to the large defect.  The loose cartilage was debrided using a shaver.  Microfracture technique was then performed to 4 mm depth at 2 to 3 mm distances.  Tourniquet was released at the end of the case to ensure that there was fat and bleeding at the microfracture sites.  All instruments were then removed.  The portals were closed using #4-0 Monocryl.  A total of 30 mL of 0.5% Marcaine was injected into the knee.  Wounds were then cleaned and dried, and dressed in Steri-Strips, Xeroform, 4 x 4s, and bias.  The patient was then placed in a knee immobilizer.  The patient tolerated the procedure well.  The tourniquet was released at 37 minutes.  He was taken to recovery in stable condition.,POSTOPERATIVE PLAN: , The loose cartilage fragment was given to the family.  The intraoperative findings were relayed with intraoperative photos.  There was a large deficit in the weightbearing portion of medial femoral condyle.  His prognosis is guarded given the fact of the fragile lesion and location, but in advantages of his age and his rehab potential down the road, if the patient still has symptoms, he may be a candidate for osteochondral autograft, a procedure which is not performed at Children's or possible cartilaginous transplant.  All questions were answered.  The patient will follow up in 10 days, may wet the wound in 5 days.","orthopedic, knee arthroscopy, chondroplasty, medial femoral condyle, cartilage loose body, loose cartilage, knee, arthroscopy, tourniquet, microfracture, femoral, cartilage, "
" Carpal tunnel syndrome.  Open carpal tunnel release.  A longitudinal incision was made in line with the 4th ray.  The dissection was carried down to the superficial aponeurosis, which was cut.  The distal edge of the transverse carpal ligament was identified with a hemostat. ", Orthopedic, Carpal Tunnel Release - Open ,"PREOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome.,TITLE OF PROCEDURE:  ,Open carpal tunnel release.,COMPLICATIONS:  ,None.,PROCEDURE IN DETAIL:  ,After administering appropriate antibiotics and general anesthesia the Left upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A longitudinal incision was made in line with the 4th ray.  The dissection was carried down to the superficial aponeurosis, which was cut.  The distal edge of the transverse carpal ligament was identified with a hemostat.  The hemostat was gently placed under the transverse carpal ligament to protect the contents of the carpal tunnel, and the ligament was cut on its ulnar side with a knife directly onto the hemostat.  The antebrachial fascia was cut proximally under direct vision with scissors.,After irrigating the wound with copious amounts of normal saline, the skin was repaired with 4-0 nylon interrupted stitches.,Marcaine with epinephrine was injected into the wound, which was then dressed and splinted.  The patient was sent to the recovery room in good condition, having tolerated the procedure well.","orthopedic, carpal ligament, carpal tunnel release, carpal tunnel syndrome, transverse carpal ligament, transverse, ligament, hemostat, tunnel, incision "
" Followup cervical spinal stenosis.  Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident when she thought she had exacerbated her conditions while lifting several objects.", Orthopedic, Cervical Spinal Stenosis ,"REASON FOR VISIT:  ,Followup cervical spinal stenosis.,HISTORY OF PRESENT ILLNESS:  ,Ms. ABC returns today for followup regarding her cervical spinal stenosis.  I have last seen her on 06/19/07.  Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident on 06/04/07, when she thought she had exacerbated her conditions while lifting several objects.,I referred her to obtain a cervical spine MRI.,She returns today stating that she continues to have right upper extremity pain, paresthesias, weakness, which she believes radiates from her neck.  She had some physical therapy, which has been helping with the neck pain.  The right hand weakness continues.  She states she has a difficult time opening jars, and doors, and often drops items from her right greater than left upper extremity.  She states she have several occasions when she is sleeping at night, she has had sharp shooting radicular pain and weakness down her left upper extremity and she feels that these symptoms somewhat scare her.,She has been undergoing nonoperative management by Dr. X and feels this has been helping her neck pain, but not the upper extremity symptoms.,She denies any bowel and bladder dysfunction.  No lower back pain, no lower extremity pain, and no instability with ambulation.,REVIEW OF SYSTEMS:,  Negative for fevers, chills, chest pain, and shortness of breath.,FINDINGS:  ,On examination, Ms. ABC is a very pleasant well-developed, well-nourished female in no apparent distress.  Alert and oriented x3.  Normocephalic and atraumatic.  Afebrile to touch.,She ambulates with a normal gait.,Motor strength is 4 plus out of 5 in the bilateral deltoids, biceps, triceps muscle groups, 4 out of 5 in the bilateral hand intrinsic muscle groups, grip strength 4 out of 5, 4 plus out of 5 bilateral wrist extension and wrist flexion.,Light touch sensation decreased in the right greater than left C6 distribution.  Biceps and brachioradialis reflexes are 3 plus.  Hoffman sign normal bilaterally.,Lower extremity strength is 5 out of 5 in all muscle groups.  Patellar reflex is 3 plus.  No clonus.,Cervical spine radiographs dated 06/21/07 are reviewed.,They demonstrate evidence of spondylosis including degenerative disk disease and anterior and posterior osteophyte formation at C4-5, C5-6, C6-7, and C3-4 demonstrates only minimal if any degenerative disk disease.  There is no significant instability seen on flexion-extension views.,Updated cervical spine MRI dated 06/21/07 is reviewed.,It demonstrates evidence of moderate stenosis at C4-5, C5-6.  These stenosis is in the bilateral neural foramina and there is also significant disk herniation noted at the C6-7 level.  Minimal degenerative disk disease is seen at the C6-7.  This stenosis is greater than C5-6 and the next level is more significantly involved at C4-5.,Effacement of the ventral and dorsal CSF space is seen at C4-5, C5-6.,ASSESSMENT AND PLAN: , Ms. ABC's history, physical examination, and radiographic findings are compatible with C4-5, C5-6 cervical spinal stenosis with associated right greater than left upper extremity radiculopathy including weakness.,I spent a significant amount of time today with the patient discussing the diagnosis, prognosis, natural history, nonoperative, and operative treatment options.,I laid out the options as continued nonoperative management with physical therapy, the same with the addition of cervical epidural steroid injections and surgical interventions.,The patient states she would like to avoid injections and is somewhat afraid of having these done.  I explained to her that they may help to improve her symptoms, although they may not help with the weakness.,She feels that she is failing maximum nonoperative management and would like to consider surgical intervention.,I described the procedure consisting of C4-5, C5-6 anterior cervical decompression and fusion to the patient in detail on a spine model.,I explained the rationale for doing so including the decompression of the spinal cord and improvement of her upper extremity weakness and pain.  She understands.,I discussed the risks, benefits, and alternative of the procedure including material risks of bleeding, infection, neurovascular injury, dural tear, singular or multiple muscle weakness, paralysis, hoarseness of voice, difficulty swallowing, pseudoarthrosis, adjacent segment disease, and the risk of this given the patient's relatively young age.  Of note, the patient does have a hoarse voice right now, given the fact that she feels she has allergies.,I also discussed the option of disk arthroplasty.  She understands.,She would like to proceed with the surgery, relatively soon.  She has her birthday coming up on 07/20/07 and would like to hold off, until after then.  Our tentative date for the surgery is 08/01/07.  She will go ahead and continue the preoperative testing process.",
" Left total knee cemented arthroplasty.  Severe tricompartmental osteoarthritis, left knee with varus deformity.", Orthopedic, Cemented Arthroplasty ,"PREOPERATIVE DIAGNOSIS: , Severe tricompartmental osteoarthritis, left knee with varus deformity.,POSTOPERATIVE DIAGNOSIS:,  Severe tricompartmental osteoarthritis, left knee with varus deformity.,PROCEDURE PERFORMED:  ,Left total knee cemented arthroplasty.,ANESTHESIA: , Spinal with Duramorph.,ESTIMATED BLOOD LOSS:  ,50 mL.,NEEDLE AND SPONGE COUNT:,  Correct.,SPECIMENS: , None.,TOURNIQUET TIME:  ,Approximately 77 minutes.,IMPLANTS USED:,1.  Zimmer NexGen posterior stabilized LPS-Flex GSF femoral component size D, left.,2.  All-poly patella, size 32/8.5 mm thickness.,3.  Prolong highly cross-linked polyethylene 12 mm.,4.  Stemmed tibial component, size 2.,5.  Palacos cement with antibiotics x2 batches.,INDICATION: , The patient is an 84-year-old female with significant endstage osteoarthritis of the left knee, who has had rapid progression with pain and disability.  Surgery was indicated to relieve her pain and improve her functional ability.  Goal objectives and the procedure were discussed with the patient.  Risks and benefits were explained.  No guarantees have been made or implied.  Informed consent was obtained.,DESCRIPTION OF THE PROCEDURE:  ,The patient was taken to the operating room and once an adequate spinal anesthesia with Duramorph was achieved, her left lower extremity was prepped and draped in a standard sterile fashion.  A nonsterile tourniquet was placed proximally in the thigh.  Antibiotics were infused prior to Foley catheter insertion.  Time-out procedure was called.,A straight longitudinal anterior midline incision was made.  Dissection was carried down sharply down the skin, subcutaneous tissue and the fascia.  Deep fascia was exposed.  The tourniquet was inflated at 300 mmHg prior to the skin incision.  A standard medial parapatellar approach was made.  The quadriceps tendon was incised approximately 1 cm from the vastus medialis insertion.  Incision was then carried down distally and distal arthrotomy was completed.  Patellar tendon was well protected.  Retinaculum and capsule was incised approximately 5 mm from the medial border of the patella for later repair.  The knee was exposed very well.  Significant tricompartmental osteoarthritis was noted.  The osteophytes were removed with a rongeur.  Anterior and posterior cruciate ligaments were excised.  Medial and lateral meniscectomies were performed.  Medial dissection was performed subperiosteally along the medial aspect of the proximal tibia to address the varus deformity.  The medial compartment was more affected than lateral.  Medial ligaments were tied.  Retropatellar fat pad was excised.  Osteophytes were removed.  Using a Cobb elevator, the medial soft tissue periosteum envelope was well reflected.,Attention was placed for the preparation of the femur.  The trochlear notch was ossified.  A rongeur was utilized to identify the notch and then using an intramedullary drill guide, a starting hole was created slightly anterior to the PCL attachment.  The anterior portal was 1 cm anterior to the PCL attachment.  The anterior femoral sizer was positioned keeping 3 degrees of external rotation.  Rotation was also verified using the transepicondylar axis and Whiteside line.  The pins were positioned in the appropriate holes.  Anterior femoral cut was performed after placing the cutting guide.  Now, the distal cutting guide was attached to the alignment and 5 degrees of valgus cut was planned.  A distal femoral cut was made which was satisfactory.  A sizer was positioned which was noted to be D.  The 5-in-1 cutting block size D was secured with spring pins over the resected bone.  Using an oscillating saw, cuts were made in a sequential manner such as anterior condyle, posterior condyle, anterior chamfer, and posterior chamfer.  Then using a reciprocating saw, intercondylar base notch cut and side cuts were made.  Following this, the cutting block for High-Flex knee was positioned taking 2 mm of additional posterior condyle.  Using a reciprocating saw, the side cuts were made and bony intercondylar notch cut was completed.  The bone with its attached soft tissue was removed.  Once the femoral preparation was completed, attention was placed for the preparation of the tibia.  The medial and the lateral collateral ligaments were well protected with a retractor.  The PCL retractor was positioned and the tibia was translated anteriorly.  Osteophytes were removed.  The extramedullary tibial alignment guide was affixed to the tibia and appropriate amount of external rotation was considered reference to the medial 1/3rd of the tibial tubercle.  Similarly, horseshoe alignment guide was positioned and the alignment guide was well aligned to the distal 1/3rd of the crest of the tibia as well as the 2nd toe.  Once the alignment was verified in a coronal plane, the tibial EM guide was well secured and then posterior slope was also aligned keeping the alignment rod parallel to the tibial crest.  A built-in 7-degree posterior slope was considered with instrumentation.  Now, the 2 mm stylus arm was positioned over the cutting block medially, which was the most affected site.  Tibial osteotomy was completed 90 degrees to the mechanical axis in the coronal plane.  The resected thickness of the bone was satisfactory taken 2 mm from the most affected site.  The resected surface shows some sclerotic bone medially.  Now, attention was placed for the removal of the posterior osteophytes from the femoral condyle.  Using curved osteotome, angle curette, and a rongeur, the posterior osteophytes were removed.  Now, attention was placed for confirming the flexion-extension gap balance using a 10 mm spacer block in extension and 12 mm in flexion.  Rectangular gap was achieved with appropriate soft tissue balance in both flexion and extension.  The 12 mm spacer block was satisfactory with good stability in flexion and extension.,Attention was now placed for completion of the tibia.  Size 2 tibial trial plate was positioned.  Appropriate external rotation was maintained with the help of the horseshoe alignment rod.  Reference to the tibial crest distally and 2nd toe was considered as before.  The midpoint of the trial tray was collinear with the medial 1/3rd of the tibial tubercle.  The rotation of tibial plate was satisfactory as required and the preparation of the tibia was completed with intramedullary drill followed by broach impactor.  At this point, trial femoral and tibial components were reduced using a 12 mm trial liner.  The range of motion and stability in both flexion and extension was satisfactory.  No further soft tissue release was indicated.  I was able to achieve 0 degrees of extension and complete flexion of the knee.,Attention was now placed for the preparation of the patella.  Using a patellar caliper, the thickness was measured to be 21.5 mm.  This gives an ideal resection of 8.5 mm keeping 13 mm of bone intact.  Reaming was initiated with a patellar reamer reaming up to 13 mm with the reaming alignment guide.  Using a caliper, the resected patella was measured, which was noted to be 13 mm.  A 32 sizer was noted to accommodate the resected surface very well.  Drilling was completed and trial 32 button was inserted without any difficulty.  The tracking was satisfactory.  There was no evidence of any subluxation or dislocation of the patella.  The trial components position was satisfactory.  The alignment and the rotation of all 3 components were satisfactory.  All the trial components were removed and the wound was thoroughly irrigated with Pulsavac lavage irrigation mechanical system.  The resected surfaces were dried with a sponge.  Two batches of Palacos cement were mixed.  The cementing was initiated starting with tibia followed by femur and patella.  Excess peripheral cement were removed with the curette and knife.  The knee was positioned in extension with a 12 mm trial liner.  Patellar clamp was placed after cementing the all-poly patella.  Once the cement was set hard and cured, tourniquet was deflated.  Hemostasis was achieved.  The trial 12 mm liner was replaced with definitive Prolong highly cross-linked polyethylene liner.  Range of motion and stability was verified at 0 degrees and flexion of 120 degrees.  Anterior-posterior drawer test was satisfactory.  Medial and lateral stability was satisfactory.  Patellar tracking was satisfactory.  The wound was thoroughly irrigated.  Hemostasis was achieved.  A local cocktail was injected, which included the mixture of 0.25% plain Marcaine, 30 mg of Toradol, and 4 mg of morphine.  The quadriceps mechanism and distal arthrotomy was repaired with #1 Vicryl in figure-of-8 fashion.  The subcutaneous closure was performed in layers using 2-0 Vicryl and 0 Vicryl followed by 2-0 Vicryl proximally.  The skin was approximated with staples.  Sterile dressings were placed including Xeroform, 4x4, ABD, and Bias.  The patient was then transferred to the recovery room in a stable condition.  There were no intraoperative complications noted.  She tolerated the procedure very well.",
 Right carpal tunnel release.  Right carpal tunnel syndrome.  This is a 54-year-old female who was complaining of right hand numbness and tingling of the median distribution and has elected to undergo carpal tunnel surgery secondary to failure of conservative management., Orthopedic, Carpal Tunnel Release - 9 ,"PREOPERATIVE DIAGNOSIS:,  Right carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:, Right carpal tunnel syndrome.,PROCEDURE:,  Right carpal tunnel release.,ANESTHESIA:,  Bier block to the right hand.,TOTAL TOURNIQUET TIME: , 20 minutes.,COMPLICATIONS: , None.,DISPOSITION: , Stable to PACU.,ESTIMATED BLOOD LOSS: , Less than 10 cc.,GROSS OPERATIVE FINDINGS:,  We did find a compressed right median nerve upon entering the carpal tunnel, otherwise, the structures of the carpal canal are otherwise unremarkable.  No evidence of tumor was found.,BRIEF HISTORY OF PRESENT ILLNESS:  ,This is a 54-year-old female who was complaining of right hand numbness and tingling of the median distribution and has elected to undergo carpal tunnel surgery secondary to failure of conservative management.,PROCEDURE: , The patient was taken to the operative room and placed in the supine position.  The patient underwent a Bier block by the Department of Anesthesia on the upper extremity.  The upper extremity was prepped and draped in usual sterile fashion and left free.  Attention was drawn then to the palm of the hand.  We did identify area of incision that we would make, which was located over the carpal tunnel.,Approximately, 1.5 cm incision was made using a #10 blade scalpel.  Dissection was carried through the skin and fascia over the palm down to the carpal tunnel taking care during dissection to avoid any branches of nerves.  Carpal tunnel was then entered and the rest of the transverse carpal ligament was incised sharply with a #10 scalpel.  We inspected the median nerve and found that it was flat and compressed from the transverse carpal ligament.  We found no evidence of tumor or space occupying lesion in the carpal tunnel.  We then irrigated copiously.  Tourniquet was taken down at that time and pressure was held.  There was no evidence of obvious bleeders.  We approximated the skin with nylon and placed a postoperative dressing with a volar splint.  The patient tolerated the procedure well.  She was placed back in the gurney and taken to PACU.","orthopedic, carpal tunnel release, carpal tunnel syndrome, median nerve, bier block, carpal ligament, tunnel, carpal, transverse, median, "
 Left carpal tunnel release.  Left carpal tunnel syndrome.  Severe compression of the median nerve on the left at the wrist., Orthopedic, Carpal Tunnel Release - 6 ,"PREOPERATIVE DIAGNOSIS: , Left carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:,  Left carpal tunnel syndrome.,OPERATIVE PROCEDURE PERFORMED:,  Left carpal tunnel release.,FINDINGS:,  Showed severe compression of the median nerve on the left at the wrist.,SPECIMENS:  ,None.,FLUIDS:,  500 mL of crystalloids.,URINE OUTPUT:,  No Foley catheter.,COMPLICATIONS: , None.,ANESTHESIA: , General through a laryngeal mask.,ESTIMATED BLOOD LOSS: , None.,CONDITION: , Resuscitated with stable vital signs.,INDICATION FOR THE OPERATION: , This is a case of a very pleasant 65-year-old forensic pathologist who I previously had performed initially a discectomy and removal of infection at 6-7, followed by anterior cervical discectomy with anterior interbody fusion at C5-6 and C6-7 with spinal instrumentation.  At the time of initial consultation, the patient was also found to have bilateral carpal tunnel and for which we are addressing the left side now.  Operation, expected outcome, risks, and benefits were discussed with him for most of the risk would be that of infection because of the patient's diabetes and a previous history of infection in the form of pneumonia.  There is also the possibility of bleeding as well as the possibility of injury to the median nerve on dissection.  He understood this risk and agreed to have the procedure performed.,DESCRIPTION OF THE PROCEDURE: , The patient was brought to the operating room, awake, alert, not in any form of distress.  After smooth induction of anesthesia and placement of a laryngeal mask, he remained supine on the operating table.  The left upper extremity was then prepped with Betadine soap and antiseptic solution.  After sterile drapes were laid out, an incision was made following inflation of blood pressure cuff to 250 mmHg.  Clamp time approximately 30 minutes.  An incision was then made right in the mid palm area between the thenar and hypothenar eminence.  Meticulous hemostasis of any bleeders were done.  The fat was identified.  The palmar aponeurosis was identified and cut and this was traced down to the wrist.  There was severe compression of the median nerve.  Additional removal of the aponeurosis was performed to allow for further decompression.  After this was all completed, the area was irrigated with saline and bacitracin solution and closed as a single layer using Prolene 4-0 as interrupted vertical mattress stitches.  Dressing was applied.  The patient was brought to the recovery.","orthopedic, compression, wrist, carpal tunnel release, carpal tunnel syndrome, median nerve, tunnel, carpal, "
  Right carpal tunnel syndrome.  Right carpal tunnel release., Orthopedic, Carpal Tunnel Release - 7 ,"PREOPERATIVE DIAGNOSIS: , Right carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:,  Right carpal tunnel syndrome.,PROCEDURE PERFORMED: , Right carpal tunnel release.,PROCEDURE NOTE:  ,The right upper extremity was prepped and draped in the usual fashion.  IV sedation was supplied by the anesthesiologist.  A local block using 6 cc of 0.5% Marcaine was used at the transverse wrist crease using a 25 gauge needle, superficial to the transverse carpal ligament.,The upper extremity was exsanguinated with a 6 inch ace wrap.,Tourniquet time was less than 10 minutes at 250 mmHg.,An incision was used in line with the third web space just to the ulnar side of the thenar crease.  It was carried sharply down to the transverse wrist crease.  The transverse carpal ligament was identified and released under direct vision.  Proximal to the transverse wrist crease it was released subcutaneously.  During the entire procedure care was taken to avoid injury to the median nerve proper, the recurrent median, the palmar cutaneous branch, the ulnar neurovascular bundle and the superficial palmar arch.  The nerve appeared to be mildly constricted.  Closure was routine with running 5-0 nylon.  A bulky hand dressing as well as a volar splint was applied and the patient was sent to the outpatient surgery area in good condition.","orthopedic, superficial palmar arch, carpal tunnel release, carpal tunnel syndrome, transverse wrist crease, superficial, ligament, "
 Right carpal tunnel release and right index and middle fingers release A1 pulley.  Right carpal tunnel syndrome and right index finger and middle fingers tenosynovitis., Orthopedic, Carpal Tunnel Release - 8 ,"PREOPERATIVE DIAGNOSES:,1.  Right carpal tunnel syndrome.,2.  Right index finger and middle fingers tenosynovitis.,POSTOPERATIVE DIAGNOSES:,1.  Right carpal tunnel syndrome.,2.  Right index finger and middle fingers tenosynovitis.,PROCEDURES PERFORMED:,1.  Right carpal tunnel release.,2.  Right index and middle fingers release A1 pulley.,TOURNIQUET TIME:  ,70 minutes.,BLOOD LOSS: , Minimal.,GROSS INTRAOPERATIVE FINDINGS:,1.  A compressed median nerve at the carpal tunnel, which was flattened.,2.  A stenosing tenosynovitis of the A1 pulley of the right index as well as middle fingers.  After the A1 pulley was released, there was evidence of some synovitis as well as some fraying of the flexor digitorum profundus as well as flexor digitorum superficialis tendons.,HISTORY:  ,This is a 78-year-old male who is complaining of right hand pain and numbness with decreased range of the middle index finger and right middle finger complaining of catching and locking.  The patient was diagnosed with carpal tunnel syndrome on bilateral hands the right being worse than the left.  He had positive EMG findings as well as clinical findings.  The patient did undergo an injection, which only provided him with temporary relief and is for this reason, he has consented to undergo the above-named procedure.,All risks as well as complications were discussed with the patient and consent was obtained.,PROCEDURE:  ,The patient was wheeled back to the operating room #1 at ABCD General Hospital on 08/29/03.  He was placed supine on the operating room table.  Next, a non-sterile tourniquet was placed on the right forearm, but not inflated.  At this time, 8 cc of 0.25% Marcaine with epinephrine was instilled into the carpal tunnel region of the volar aspect of the wrist for anesthesia.  In addition, an additional 2 cc were used on the superficial skin of the volar palm over the A1 pulley of the right index and right middle fingers.  At this time, the extremity was then prepped and draped in usual sterile fashion for this procedure.  First, we went for release of the carpal tunnel.  Approximately 2.5 cm incision was made over the volar aspect of the wrist over the carpal tunnel region.  First, dissection through the skin in the superficial fascia was performed with a self-retractor placed in addition to Ragnells retracting proximally and distally.  The palmaris brevis muscle was then identified and sharply transected.  At this time, we identified the transverse carpal tunnel ligament and a #15 blade was used to sharply and carefully release that fascia.  Once the fascia of the transverse carpal ligament was transected, the identification of the median nerve was visualized.  The resection of the ligament was taken both proximally and distally to assure complete release and it was checked thoroughly.  At this time, a neurolysis was performed and no evidence of space-occupying lesions were identified within the carpal tunnel.  At this time, copious irrigation was used to irrigate the wound.  The wound was suctioned dry.  At this time, we proceeded to the release of the A1 pulleys.  Approximately, a 1.5 cm incision was made over the A1 pulley in the volar aspect of the palm of the right index and right middle fingers.  First, we went for the index finger.  Once the skin incision was made, Metzenbaum scissor was used to longitudinally dissect the subcutaneous tissue and with Ragnell retractors we identified the A1 pulley.  A #15 blade was used to make a longitudinal slit along with A1 pulley and the Littler scissors were used to release the A1 pulley proximally as well as distally.  Once this was performed, a tendon hook was then used to wrap the tendon and release the tendons both proximally and distally and they were removed from the wound in order to check their integrity.  There was some evidence of synovitis in addition to some fraying of the both the profundus as well as superficialis tendons.  Once a thorough release was performed, copious irrigation was used to irrigate that wound.  In the similar fashion, a 1.5 cm incision was made over the volar aspect of the A1 pulley of the right middle finger.  A Littler scissor was used to bluntly dissect in the longitudinal fashion.  With the Ragnell retractors, we identified the A1 pulley of the right middle finger.,Using a #15 blade, the A1 pulley was scored with the #15 blade and the Litter scissor was used to complete the release of the A1 pulley distally and proximally.  We again placed the tendon hook around both the superficialis and the profundus tendons and they were extruded from the wound to check their integrity.  Again, there was evidence of some synovitis as well as fraying of both tendons.  The girth of both tendons and both wounds were within normal limits.  At this time, copious irrigation was used to irrigate the wound.  The patient was then asked to intraoperatively flex and extend his fingers and he was able to fully flex his fingers to make a close fit which he was not able to do preoperatively.  In addition, he was able to abduct his thumb indicating that the recurrent branch of the median nerve was intact.  At this time, #5-0 nylon was used to approximate in a vertical mattress type fashion both the carpal tunnel incision as well as the both A1 pulley incisions of the right middle finger and right index finger.  The wound closure took place after the tourniquet was released and hemostasis was obtained with Bovie cautery.  At this time, a short-arm splint was placed on the volar aspect of the wrist after it was wrapped in a sterile dressing consisting of Adaptic and Kerlix roll.  The patient was then carefully taken off of the operating room table to Recovery in stable condition.","orthopedic, compressed median nerve, stenosing tenosynovitis, carpal tunnel release, carpal tunnel syndrome, middle fingers, carpal tunnel, littler scissors, median nerve, copious irrigation, volar aspect, tunnel, pulley, carpal, fingers, index, tourniquet, ligament, tenosynovitis, superficialis, tendons,"
 Bilateral open carpal tunnel release., Orthopedic, Carpal Tunnel Release - 5 ,"PREOPERATIVE DIAGNOSIS:  ,Carpal tunnel syndrome, bilateral.,POSTOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome, bilateral.,ANESTHESIA:,  General,NAME OF OPERATION: , Bilateral open carpal tunnel release.,FINDINGS AT OPERATION: , The patient had identical, very thick, transverse carpal ligaments, with dull synovium.,PROCEDURE:  ,Under satisfactory anesthesia, the patient was prepped and draped in a routine manner on both upper extremities.  The right upper extremity was exsanguinated, and the tourniquet inflated.  A curved incision was made at the the ulnar base, carried through the subcutaneous tissue and superficial fascia, down to the transverse carpal ligament.  This was divided under direct vision along its ulnar border, and wound closed with interrupted nylon.  The wound was injected, and a dry, sterile dressing was applied.  An identical procedure was done to the opposite side.  The patient left the operating room in satisfactory condition.","orthopedic, bilateral open carpal tunnel, carpal tunnel syndrome, carpal tunnel release, carpal tunnel, release, tourniquet, bilateral, tunnel, carpal"
 Left endoscopic carpal tunnel release and endotracheal fasciotomy., Orthopedic, Carpal Tunnel Release - 2 ,"PREOPERATIVE DIAGNOSIS: , Left carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Left carpal tunnel syndrome.,OPERATIVE PROCEDURE:,1.  Left endoscopic carpal tunnel release.,2.  Endotracheal fasciotomy.,ANESTHESIA:,  General.,COMPLICATIONS: , None.,INDICATION: , The patient is a 62-year-old lady with the aforementioned diagnosis refractory to nonoperative management.  All risks and benefits were explained.  Questions answered.  Options discussed.  No guarantees were made.  She wished to proceed with surgery.,PROCEDURE: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion, the arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,I made a transverse incision one fingerbreadth proximal to the distal volar wrist crease.  Dissection was carried down to the antebrachial fascia, which was cut in a distally based fashion.  Bipolar electrocautery was used to maintain meticulous hemostasis.  I then performed an antebrachial fasciotomy proximally.  I entered the extra bursal space deep into the transverse carpal ligament and used the spatula probe and then the dilators and then the square probe to enlarge the area.  Great care was taken to feel the washboard undersurface of the transverse carpal ligament and the hamate on the ulnar side.  Great care was taken with placement.  A good plane was positively identified.  I then placed the endoscope in and definitely saw the transverse striations of the deep surface of the transverse carpal ligament.,Again, I felt the hook of the hamate ulnar to me.  I had my thumb on the distal aspect of the transverse carpal ligament.  I then partially deployed the blade, and starting 1 mm from the distal edge, the transverse carpal ligament was positively identified.  I pulled back and cut and partially tightened the transverse carpal ligament.  I then feathered through the distal ligament and performed a full-thickness incision through the distal half of the ligament.  I then checked to make sure this was properly performed and then cut the proximal aspect.  I then entered the carpal tunnel again and saw that the release was complete, meaning that the cut surfaces of the transverse carpal ligament were separated; and with the scope rotated, I could see only one in the field at a time.  Great care was taken and at no point was there any longitudinal structure cut.  Under direct vision through the incision, I made sure that the distal antebrachial fascia was cut.  Following this, I irrigated and closed the skin.  The patient was dressed and sent to the recovery room in good condition.","orthopedic, carpal tunnel syndrome, antebrachial fascia, antebrachial fasciotomy, carpal tunnel release, electrocautery, fasciotomy, hamate, wrist crease, endoscopic carpal tunnel release, transverse carpal ligament, carpal tunnel, transverse carpal, carpal ligament, carpal, antebrachial, transverse, ligament"
" Right open carpal tunnel release and cortisone injection, left carpal tunnel.", Orthopedic, Carpal Tunnel Release - 4 ,"PREOPERATIVE DIAGNOSIS:  ,Bilateral carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Bilateral carpal tunnel syndrome.,PROCEDURES:,1.  Right open carpal tunnel release.,2.  Cortisone injection, left carpal tunnel.,ANESTHESIA: , General LMA.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS:,  None.,INDICATIONS:,  This patient is a 50-year-old male with bilateral carpal tunnel syndrome, which is measured out as severe.  He is scheduled for the above-mentioned procedures.  The planned procedures were discussed with the patient including the associated risks.  The risks included but are not limited to bleeding, infection, nerve damage, failure to heal, possible need for reoperation, possible recurrence, or any associated risk of the anesthesia.  He voiced understanding and agreed to proceed as planned.,DESCRIPTION OF PROCEDURE: , The patient was identified in the holding area and correct operative site was identified by the surgeon's mark.  Informed consent was obtained.  The patient was then brought to the operating room and transferred to the operating table in supine position.  Time-out was then performed at which point the surgeon, nursing staff, and anesthesia staff all confirmed the correct identification.,After adequate general LMA anesthesia was obtained, a well-padded tourniquet was placed on the patient's right upper arm.  The right upper extremity was then prepped and draped in the usual sterile fashion.  Planned skin incision was marked along the base of the patient's right palm.  Right upper extremity was then exsanguinated using Esmarch.  The tourniquet was then inflated to 250 mmHg.  Skin incision was then made and dissection was carried down with scalpel to the level of the palmar fascia which was sharply divided by the skin incision.  Bleeding points were identified with electrocautery using bipolar electrocautery.  Retractors were then placed to allow visualization of the distal extent of the transverse carpal ligament, and this was then divided longitudinally under direct vision.  Baby Metzenbaum scissors were used to dissect distal to this area to confirm the absence of any remaining crossing obstructing fibrous band.  Retractors were then replaced proximally to allow visualization of proximal extent of the transverse carpal ligament and the release was continued proximally until complete release was performed.  This was confirmed by visually and palpably.  Next, baby Metzenbaum scissors were used to dissect anteroposterior adjacent antebrachial fascia, and this was divided longitudinally under direct vision using baby Metzenbaum scissors to a level of approximately 3 cm proximal to the proximal extent of the skin incision.  Carpal canal was then inspected.  The median nerve was flattened and injected.  No other abnormalities were noted.  Wounds were then irrigated with normal saline and antibiotic additive.  Decadron 4 mg was then placed adjacent to the median nerve.  Skin incision was then closed with interrupted 5-0 nylon suture.  The wound was then dressed with Adaptic, 4 x 4s, Kling, and Coban.  The tourniquet was then deflated.  Attention was then directed to the left side.  Using sterile technique, the left carpal canal was injected with a mixture of 40 mg of Depo-Medrol, 1 cc of 1% lidocaine, and 1 cc of 0.25% Marcaine.  Band-Aid was then placed over the injection site.  The patient was then awakened, extubated, and transferred over to his hospital bed.  He was transported to recovery room in stable condition.  There were no intraoperative or immediate postoperative complications.  All counts were reported as correct.","orthopedic, carpal tunnel syndrome, 4 x 4s, adaptic, carpal canal, coban, cortisone injection, esmarch, kling, metzenbaum, carpal tunnel release, electrocautery, fibrous band, palmar fascia, tourniquet, transverse carpal ligament, bilateral carpal tunnel, baby metzenbaum scissors, carpal ligament, bilateral carpal, metzenbaum scissors, carpal tunnel, carpal, tunnel,"
 Right carpal tunnel release., Orthopedic, Carpal Tunnel Release - 1 ,"PREOPERATIVE DIAGNOSIS: , Right carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Right carpal tunnel syndrome.,TITLE OF THE PROCEDURE: , Right carpal tunnel release.,COMPLICATIONS:,  There were no complications during the procedure.,SPECIMEN:  ,The specimen was sent to pathology.,INSTRUMENTS: , All counts were correct at the end of the case and no complications were encountered.,INDICATIONS:  ,This is a 69-year-old female who have been complaining of right hand pain, which was steadily getting worse over a prolonged period of time.  The patient had tried nonoperative therapy, which did not assist the patient.  The patient had previous diagnosis of carpal tunnel and EMG showed compression of the right median nerve.  As a result of these findings, the patient was sent to my office presenting with this history and was carefully evaluated.  On initial evaluation, the patient had the symptomology of carpal tunnel syndrome.  The patient at the time had the risks, benefits, and alternatives thoroughly explained to her.  All questions were answered.  No guarantees were given.  The patient had agreed to the surgical procedure and the postoperative rehabilitation as needed.,DETAILS OF THE PROCEDURE:  ,The patient was brought to the operating room, placed supine on the operating room table, prepped and draped in the sterile fashion and was given sedation.  The patient was then given sedation.  Once this was complete, the area overlying the carpal ligament was carefully injected with 1% lidocaine with epinephrine.  The patient had this area carefully and thoroughly injected with approximately 10 mL of lidocaine with epinephrine and once this was complete, a 15-blade knife was then used to incise the skin opposite the radial aspect of the fourth ray.  Careful dissection under direct visualization was performed through the subcutaneous fat as well as through the palmar fascia.  A Weitlaner retractor was then used to retract the skin and careful dissection through the palmar fascia would then revealed the transverse carpal ligament.  This was then carefully incised using a 15-blade knife and once entry was again into the carpal canal, a Freer elevator was then inserted and under direct visualization, the carpal ligament was then released.  The transverse carpal ligament was carefully released first in the distal direction until palmar fat could be visualized and by palpation no further ligament could be felt.  The area was well hemostased with the 1% lidocaine with epinephrine and both proximal and distal dissection along the nerve was performed.  Visualization of the transverse carpal ligament was maintained with Weitlaner retractor as well as centric.  Both the centric and the Ragnell were used to retract both proximal and distal corners of the incision and the entirety of the area was under direct visualization at all times.  Palmar fascia was released both proximally and distally as well as the transverse carpal ligament.  Direct palpation of the carpal canal demonstrated a full and complete release.  Observation of the median nerve revealed an area of hyperemia in the distal two-thirds of the nerve, which demonstrated the likely area of compression.  Once this was complete, hemostasis was established using bipolar cautery and some small surface bleeders and irrigation of the area was performed and then the closure was achieved with 4-0 chromic suture in a horizontal mattress and interrupted stitch.  Xeroform was then applied to the incision.  A bulky dressing was then applied consisting of Kerlix and Ace wrap, and the patient was taken to the recovery room in stable condition without any complications.","orthopedic, carpal tunnel syndrome, ace wrap, emg, freer elevator, kerlix, weitlaner retractor, bulky dressing, carpal tunnel, carpal tunnel release, palmar fascia, subcutaneous fat, lidocaine with epinephrine, transverse carpal ligament, carpal ligament, carpal, tunnel, ligament,"
" Carpal tunnel release with transverse carpal ligament reconstruction.  A longitudinal incision was made in line with the fourth ray, from Kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease.  The dissection was carried down to the superficial aponeurosis.  ", Orthopedic, Carpal Ligament Reconstruction ,"PROCEDURE:,  Carpal tunnel release with transverse carpal ligament reconstruction.,PROCEDURE IN DETAIL: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A longitudinal incision was made in line with the fourth ray, from Kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease.  The dissection was carried down to the superficial aponeurosis.  The subcutaneous fat was dissected radially for 2-3 mm, and the superficial aponeurosis cut on this side to leave a longer ulnar leaf.,The ulnar leaf of the cut superficial aponeurosis was dissected ulnarly, and the distal edge of the transverse carpal ligament was identified with a hemostat.  The hemostat was gently placed under the transverse carpal ligament to protect the contents of the carpal tunnel, and the ligament was cut on its ulnar side with a knife directly onto the hemostat.  The antebrachial fascia was cut proximally under direct vision with a scissor.,After irrigating the wound with copious amounts of normal saline, the radial leaf of the cut transverse carpal ligament was repaired to the ulnar leaf of the cut superficial aponeurosis with 4-0 Vicryl.  Care was taken to avoid entrapping the motor branch of the median nerve in the suture.  A hemostat was placed under the repair to ensure that the median nerve was not compressed.  The skin was repaired with 5-0 nylon interrupted stitches.,Marcaine with epinephrine was injected into the wound, which was then dressed and splinted.  The patient was sent to the recovery room in good condition, having tolerated the procedure well.","orthopedic, carpal tunnel, carpal ligament reconstruction, transverse carpal ligament, ulnar, hemostat, transverse, superficial, ligament, carpal"
 Endoscopic release of left transverse carpal ligament., Orthopedic, Carpal Ligament Release - 1 ,"PREOPERATIVE DIAGNOSIS:,  Carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:,  Carpal tunnel syndrome.,PROCEDURE: , Endoscopic release of left transverse carpal ligament.,ANESTHESIA:,  Monitored anesthesia care with regional anesthesia provided by surgeon.  ,TOURNIQUET TIME: , 12 minutes.,OPERATIVE PROCEDURE IN DETAIL: , With the patient under adequate monitored anesthesia, the left upper extremity was prepped and draped in a sterile manner.  The arm was exsanguinated.  The tourniquet was elevated at 290 mmHg.  Construction lines were made on the left palm to identify the ring ray.  A transverse incision was made in the palm between FCR and FCU, one finger breadth proximal to the interval between the glabrous skin of the palm and normal forearm skin.  Blunt dissection exposed the antebrachial fascia.  Hemostasis was obtained with bipolar cautery.  A distal based window in the antebrachial fascia was then fashioned.  Care was taken to protect the underlying contents.  A synovial elevator was used to palpate the undersurface of the transverse carpal ligament, and synovium was elevated off this undersurface.,Hamate sounds were then used to palpate the Hood of Hamate.  The Agee Inside Job was then inserted into the proximal incision.  The transverse carpal ligament was easily visualized through the portal.  Using palmar pressure, transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end.  The distal end of the transverse carpal ligament was then identified in the window.  The blade was then elevated, and the Agee Inside Job was withdrawn, dividing transverse carpal ligament under direct vision.  After complete division of transverse carpal ligament, the Agee Inside Job was reinserted.  Radial and ulnar edges of the transverse carpal ligament were identified and complete release was accomplished.  One cc of Celestone was then introduced into the carpal tunnel and irrigated free.  ,The wound was then closed with a running 3-0 Prolene subcuticular stitch.  Steri-strips were applied and a sterile dressing was applied over the Steri-strips.  The tourniquet was deflated.  The patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well.","orthopedic, carpal tunnel syndrome, antebrachial fascia, carpal, ligament, palmar, synovium, tourniquet, transverse carpal ligament, transverse incision, agee inside job, transverse carpal, carpal ligament, carpal tunnel, antebrachial, release, endoscopic,"
" Left carpal tunnel release, left ulnar nerve anterior submuscular transposition at the elbow, lengthening of the flexor pronator muscle mass in the proximal forearm to accommodate the submuscular position of the ulnar nerve.", Orthopedic, Carpal Tunnel Release - 3 ,"PREOPERATIVE DIAGNOSES:,1.  Left carpal tunnel syndrome (354.0).,2.  Left ulnar nerve entrapment at the elbow (354.2).,POSTOPERATIVE DIAGNOSES:,1.  Left carpal tunnel syndrome (354.0).,2.  Left ulnar nerve entrapment at the elbow (354.2).,OPERATIONS PERFORMED:,1.  Left carpal tunnel release (64721).,2.  Left ulnar nerve anterior submuscular transposition at the elbow (64718).,3.  Lengthening of the flexor pronator muscle mass in the proximal forearm to accommodate the submuscular position of the ulnar nerve (25280).,ANESTHESIA: , General anesthesia with intubation.,INDICATIONS OF PROCEDURE: , This patient is insulin-dependant diabetic.  He is also has end-stage renal failure and has chronic hemodialysis.  Additionally, the patient has had prior heart transplantation.  He has been evaluated for ischemic problems to both lower extremities and also potentially to the left upper extremity.  However, it is our contention that this patient's prime problem of the left upper extremity is probably neuropathic ulcers from total lack of sensation along the ulnar border of the left little finger.  These started initially as unrecognized paper cuts.  Additionally, the patient appears to have a neurogenic pain affecting predominantly the areas innovated by the median nerve, but also to the little finger.  Finally, this patient does indeed have occlusive arterial disease to the left upper extremity in that he has a short segment radial artery occlusion and he does appear to have a narrowed segment in the ulnar artery, but the arteriogram shows distal perfusion down the ulnar border of the hand and into the little finger.  Thus, we have planned to proceed first with nerve entrapment releases and potentially at the later date do arterial reconstruction if deemed necessary.  Thirdly, this patient does have chronic distal ischemic problems with evidence of ""ping-pong ball sign"" due to fat atrophy at the finger tips and some periodic cracking and ulceration at the tips of the fingers.  However, this patient has no clinical sign at all of tissue necrosis at the finger tips at this time.,The patient has also previously had an arteriovenous shunt in the forearm, which has been deactivated within the last 3 weeks.  Thus, we planned to bring this patient to the operating room for left carpal tunnel release as well as anterior submuscular transposition of the ulnar nerve.  This patient had electro diagnostic studies performed, which showed severe involvement of both the ulnar nerve at the elbow and the medial nerve at the carpal tunnel.,DESCRIPTION OF PROCEDURE: , After general anesthesia being induced and the patient intubated, he is given intravenous Ancef.  The entire left upper extremity is prepped with Betadine all the way to the axilla and draped in a sterile fashion.  A sterile tourniquet and webril are placed higher on the arm.  The arm is then exsanguinated with Ace bandage and tourniquet inflated to 250 mmHg.  I started first at the carpal tunnel release and a longitudinal curvilinear incision is made parallel to the thenar crease and stopping short of the wrist flexion crease.  Dissection continued through subcutaneous tissue to the palmer aponeurosis, which is divided longitudinally from distal to proximal.  I next encountered the transverse carpal ligament, which in turn is also divided longitudinally from distal to proximal, and the proximal most division of the transverse carpal ligament is done under direct vision into the distal forearm.  Having confirmed a complete release of the transverse carpal ligament, I next evaluated the contents of the carpal tunnel.  The synovium was somewhat thickened, but not unduly so.  There was some erythema along the length of the median nerve, indicating chronic compression.  The motor branch of the median nerve was clearly identified.  The contents of the carpal canal were retracted in a radial direction and the floor of the canal evaluated and no other extrinsic compressive pathology was identified.  The wound was then irrigated with normal saline and wound edges were reapproximated with interrupted 5-0 nylon sutures.,I next turned my attention to the cubital tunnel problem and a longitudinal curvilinear incision is made on the medial aspect of the arm extending into the forearm with the incision passing directly between the olecranon and the medial epicondyle.  Dissection continues through fascia and then skin clamps are elevated to the level of the fascia on the flexor pronator muscle mass.  In the process of elevating this skin flap I elevated and deactivated shunt together with the skin flap.  I now gained access to the radial border of the flexor pronator muscle mass, dissected down the radial side, until I identified the median nerve.,I turned my attention back to the ulnar nerve and it is located immediately posterior to the medial intramuscular septum in the upper arm, and I dissected it all the way proximally until I encountered the location with ulnar the nerve passed from the anterior to the posterior compartments in the upper portion of the arm.  The entire medial intramuscular septum is now excised.  The ulnar nerve is mobilized between vessel loops and includes with it is accompanying vascular structures.  Larger penetrating vascular tributaries to the muscle ligated between hemoclips.  I continued to mobilize the nerve around the medial epicondyle and then took down the aponeurosis between the two heads of the flexor carpi ulnaris and continued to dissect the nerve between the FCU muscle fibers.  The nerve is now mobilized and I had retained the large muscular branches and dissected them out into the muscle and also proximally using microvascular surgical techniques.  In this way, the nerve was able to be mobilized between vessiloops and easily transposed anterior to the flexor pronator muscle mass in tension free manner.,I now made an oblique division of the entire flexor pronator muscle mass proximally in the forearm and the ulnar nerve was able to be transposed deep to the muscle in a nonkinking and tension-free manner.  Because of the oblique incision into the flexor pronator muscle mass the muscle edges were now able to slide on each other.  So that in effect a lengthening is performed.  Fascial repair is done with interrupted figure-of-eight 0-Ethibond sutures.  I now ranged the arm through the full range of flexion and extension at the elbow and there was no significant kinking on the nerve and there was a tension-free coverage of the muscle without any impingement on the nerve.  The entire arm is next wrapped with a Kerlix wrap and I released the tourniquet and after allowing the reactive hyperemia to subside, I then unwrap the arm and check for hemostasis.  Wound is copiously irrigated with normal saline and then a 15-French Round Blake drainage placed through a separate stab incision and laid along the length of the wound.  A layered wound closure is done with interrupted Vicryl subcutaneously, and a running subcuticular Monocryl to the skin.  A 0.25% plain Marcaine then used to infiltrate all the wound edges to help with post operative analgesia and dressings take the form of Adaptic impregnated Bacitracin ointment, followed by a well-fluffed gauze and a Kerlix dressing and confirming Kerlix and webril, and an above elbow sugar-tong splint is applied extending to the support of the wrist.  Fingers and femoral were free to move.  The splint is well padded with webril and is in turn held in place with Kerlix and Ace bandage.  Meanwhile the patient is awakened and extubated in the operating room and returned to the recovery room in good condition.  Sponge and needle counts reported as correct at the end of the procedure.","orthopedic, carpal tunnel syndrome, ace bandage, kerlix, carpal tunnel release, curvilinear incision, flexor pronator muscle, ping-pong ball sign, synovium, ulnar artery, ulnar nerve, ulnar nerve entrapment, pronator muscle mass, transverse carpal, carpal ligament, tunnel release, flexor pronator, pronator muscle, carpal tunnel, tunnel, carpal, nerve, pronator, forearm,"
" Left calcaneal lengthening osteotomy with allograft, partial plantar fasciotomy, posterior subtalar and tibiotalar capsulotomy, and short leg cast placed.", Orthopedic, Calcaneal Lengthening Osteotomy ,"PREOPERATIVE DIAGNOSES:,  Left calcaneal valgus split.,POSTOPERATIVE DIAGNOSES:,  Left calcaneal valgus split.,PROCEDURES:  ,1.  Left calcaneal lengthening osteotomy with allograft.,2.  Partial plantar fasciotomy.,3.  Posterior subtalar and tibiotalar capsulotomy.,4.  Short leg cast placed.,ANESTHESIA: , Surgery performed under general anesthesia.,TOURNIQUET TIME: , 69 minutes.,The patient in local anesthetic of 20 mL of 0.25% Marcaine plain.,COMPLICATIONS: , No intraoperative complications.,DRAINS:  ,None.,SPECIMENS: , None.,HISTORY AND PHYSICAL: , The patient is a 13-year-old female who had previous bilateral feet correction at 1 year of age.  Since that time, the patient has developed significant calcaneal valgus deformity with significant pain.  Radiographs confirmed collapse of the spinal arch, as well as valgus position of the foot.  Given the patient's symptoms, surgery is recommended for calcaneal osteotomy and Achilles lengthening.  Risks and benefits of surgery were discussed with the mother.  Risks of surgery include risk of anesthesia; infection; bleeding; changes in sensation in most of extremity; hardware failure; need for later hardware removal; possible nonunion; possible failure to correct all the deformity; and need for other surgical procedures.  The patient will need to be strict nonweightbearing for at least 6 weeks and wear a brace for up to 6 months.  All questions were answered and parents agreed to the above surgical plan.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and placed supine on the operating table.  General anesthesia was then administered.  The patient received Ancef preoperatively.  A bump was placed underneath the left buttock.  A nonsterile tourniquet was placed on the upper aspect of the left thigh.  The extremity was then prepped and draped in a standard surgical fashion.  The patient had a previous incision along the calcaneocuboid lateral part of the foot.  This was marked and extended proximally through the Achilles tendon.  Extremity was wrapped in Esmarch.  Tourniquet inflation was noted to be 250 mmHg.  Decision was then made to protect the sural nerve.  There was one sensory nervous branch that did cross the field though it was subsequently sharply ligated because it was in the way.  Dissection was carried down to Achilles tendon, which was subsequently de-lengthened with the distal half performed down the lateral thigh.  Proximal end was tacked with an 0 Ethibond suture and subsequently repaired end-on-end at length with the heel in neutral.  Dissection was then carried on the lateral border of the foot with identification of the peroneal longus and valgus tendons, which were removed from the sheath and retracted dorsally.  At this time, we also noted that calcaneocuboid joint appeared to be fused.  The area between the anterior and middle facets were plicated on fluoroscopy for planned osteotomy.  This was performed with a saw.  After a partial plantar fasciotomy was performed, this was released off an abductor digiti minimi.  The osteotomy was completed with an osteotome and distracted with the lamina spreader.  A tricortical allograft was then shaped and subsequently impacted into this area.  Final positioning was checked with multiple views of fluoroscopy.  It was subsequently fixed using a 0.94 K-wire and drilled from the heel anteriorly.  A pin was subsequently bent and cut short at the level of the skin.  The wound was then irrigated with normal saline.  The Achilles was repaired with this tie.  Please note during the case, it was noted the patient had continued significant stiffness despite the Achilles lengthening.  A posterior capsulotomy of the tibiotalar and subtalar joints were performed with increased 10 degrees of dorsiflexion.  Wound was then closed using #2-0 Vicryl and #4-0 Monocryl.  The surgical field was irrigated with 0.25% Marcaine and subsequently injected with more Marcaine at the end of the case.  The wound was clean and dry and dressed with Steri-Strips and Xeroform.  Skin was dressed with Xeroform and 4 x 4's.  Everything was wrapped with 4 x 4's in sterile Webril.  The tourniquet was released after 69 minutes.  A short-leg cast was then placed with good return of capillary refill to his toes.  The patient tolerated the procedure well and was subsequently taken to the recovery room in stable condition.,POSTOPERATIVE PLAN: , The patient will be hospitalized overnight for elevation, ice packs, neurovascular checks, and pain control.  The patient to be strict nonweightbearing.  We will arrange for her to get a wheelchair.  The patient will then follow up in about 10 to 14 days for a cast check, as well as pain control.  The patient will need an AFO script at that time.  Intraoperative findings are relayed to the parents.","orthopedic, calcaneal lengthening, osteotomy, allograft, plantar fasciotomy, capsulotomy, calcaneal valgus split, partial plantar fasciotomy, short leg cast, achilles lengthening, calcaneal valgus, tourniquet, plantar, valgus, achilles, calcaneal, "
" Carpal tunnel release.  Nerve conduction study tests diagnostic of carpal tunnel syndrome.  The patient failed to improve satisfactorily on conservative care, including anti-inflammatory medications and night splints.", Orthopedic, Carpal Tunnel Release ,"PROCEDURE PERFORMED: , Carpal tunnel release.,INDICATIONS FOR SURGERY: , Nerve conduction study tests diagnostic of carpal tunnel syndrome.  The patient failed to improve satisfactorily on conservative care, including anti-inflammatory medications and night splints.,PROCEDURE:  ,The patient was brought to the operating room and, following a Bier block to the operative arm, the arm was prepped and draped in the usual manner.,Utilizing an incision that was laid out to extend not more distally than the thumb web space or proximally to a position short of crossing the most prominent base of the palm and in line with the longitudinal base of the thenar eminence in line with the fourth ray, the soft tissue dissection was carried down sharply through the skin and subcutaneous fat to the transverse carpal ligament.  It was identified at its distal edge.  Using a hemostat to probe the carpal tunnel, sharp dissection utilizing scalpel and iris scissors were used to release the carpal tunnel from a distal-to-proximal direction in its entirety.  The canal was probed with a small finger to verify no evidence of any bone prominences.  The nerve was examined for any irregularity.  There was slight hyperemia of the nerve and a slight hourglass deformity.  Following an irrigation, the skin was approximated using interrupted simple and horizontal mattress #5 nylon suture.  A sterile dressing was applied.,The patient was taken to the recovery room in satisfactory condition.,The time of the Bier block was 30 minutes.,COMPLICATIONS: , None noted.","orthopedic, carpal tunnel syndrome, carpal ligament, nerve conduction study, carpal tunnel release, bier block, carpal tunnel, tunnel, carpal, "
" Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left and arthroplasty left second toe.  Bunion left foot and hammertoe, left second toe.", Orthopedic, Bunionectomy & Metatarsal Osteotomy ,"PREOPERATIVE DIAGNOSES:,1.  Bunion left foot.,2.  Hammertoe, left second toe.,POSTOPERATIVE DIAGNOSES:,1.  Bunion left foot.,2.  Hammertoe, left second toe.,PROCEDURE PERFORMED:,1.  Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left.,2.  Arthroplasty left second toe.,HISTORY:  ,This 39-year-old female presents to ABCD General Hospital with the above chief complaint.  The patient states that she has had bunion for many months.  It has been progressively getting more painful at this time.  The patient attempted conservative treatment including wider shoe gear without long-term relief of symptoms and desires surgical treatment.,PROCEDURE: , An IV was instituted by the Department of Anesthesia in the preop holding area.  The patient was transported to the operating room and placed on the operating table in the supine position with a safety belt across her lap.  Copious amount of Webril were placed around the left ankle followed by a blood pressure cuff.  After adequate sedation was achieved by the Department of Anesthesia, a total of 15 cc of 0.5% Marcaine plain was injected in a Mayo and digital block to the left foot.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was elevated from the operating table and exsanguinated with an Esmarch bandage.  The pneumatic ankle tourniquet was inflated to 250 mmHg and the foot was lowered to the operating table.  The stockinette was reflected.  The foot was cleansed with wet and dry sponge.  Attention was then directed to the first metatarsophalangeal joint of the left foot.  An incision was created over this area approximately 6 cm in length.  The incision was deepened with a #15 blade.  All vessels encountered were ligated for hemostasis.  The skin and subcutaneous tissue was then dissected from the capsule.  Care was taken to preserve the neurovascular bundle.  Dorsal linear capsular incision was then created.  The capsule was then reflected from the head of the first metatarsal.  Attention was then directed to the first interspace where a lateral release was performed.  A combination of sharp and blunt dissection was performed until the abductor tendons were identified and transected.  A lateral capsulotomy was performed.  Attention was then directed back to the medial eminence where sagittal saw was used to resect the prominent medial eminence.  The incision was then extended proximally with further dissection down to the level of the bone.  Two 0.45 K-wires were then inserted as access guides for the SCARF osteotomy.  A standard SCARF osteotomy was then performed.  The head of the first metatarsal was then translocated laterally in order to reduce the first interspace in the metatarsal angle.  After adequate reduction of the bunion deformity was noted, the bone was temporarily fixated with a 0.45 K-wire.  A 3.0 x 12 mm screw was then inserted in the standard AO fashion with compression noted.  A second 3.0 x 14 mm screw was also inserted with tight compression noted.  The remaining prominent medial eminence medially was then resected with a sagittal saw.  Reciprocating rasps were then used to smooth any sharp bony edges.  The temporary fixation wires were then removed.  The screws were again checked for tightness, which was noted.  Attention was directed to the medial capsule where a medial capsulorrhaphy was performed.  A straight stat was used to assist in removing a portion of the capsule.  The capsule was then reapproximated with #2-0 Vicryl medially.  Dorsal capsule was then reapproximated with #3-0 Vicryl in a running fashion.  The subcutaneous closure was performed with #4-0 Vicryl followed by running subcuticular stitch with #5-0 Vicryl.  The skin was then closed with #4-0 nylon in a horizontal mattress type fashion.,Attention was then directed to the left second toe.  A dorsal linear incision was then created over the proximal phalangeal joint of the left second toe.  The incision was deepened with a #15 blade and the skin and subcutaneous tissue was dissected off the capsule to be aligned laterally.  An incision was made on either side of the extensor digitorum longus tendon.  A curved mosquito stat was then used to reflex the tendon laterally.  The joint was identified and the medial collateral ligamentous attachments were resected off the head of the proximal phalanx.  A sagittal saw was then used to resect the head of the proximal head.  The bone was then rolled and the lateral collateral attachments were transected and the bone was removed in toto.  The extensor digitorum longus tendon was inspected and noted to be intact.  Any sharp edges were then smoothed with reciprocating rasp.  The area was then flushed with copious amounts of sterile saline.  The skin was then reapproximated with #4-0 nylon.  Dressings consisted of Owen silk, 4x4s, Kling, Kerlix, and Coban.  Pneumatic ankle tourniquet was released and an immediate hyperemic flush was noted to all five digits of the left foot.  The patient tolerated the above procedure and anesthesia well without complications.  The patient was transported to PACU with vital signs stable and vascular status intact to the left foot.  The patient is to follow up with Dr. X in his clinic as directed.","orthopedic, hammertoe, osteotomy, internal screw fixation, scarf type, extensor digitorum, metatarsal osteotomy, foot, toe, metatarsal, bunionectomy,"
" Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot.  Akin bunionectomy, right toe with internal wire fixation.", Orthopedic, Bunionectomy & Osteotomy ,"PREOPERATIVE DIAGNOSES:,1.  Hallux valgus, right foot.,2.  Hallux interphalangeus, right foot.,POSTOPERATIVE DIAGNOSES:,1.  Hallux valgus, right foot.,2.  Hallux interphalangeus, right foot.,PROCEDURES PERFORMED:,1.  Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot.,2.  Akin bunionectomy, right toe with internal wire fixation.,ANESTHESIA: , TIVA/local.,HISTORY:  ,This 51-year-old female presents to ABCD preoperative holding area after keeping herself NPO since mid night for a surgery on her painful bunion through her right foot.  The patient has a history of gradual onset of a painful bunion over the past several years.  She has tried conservative methods such as wide shoes, accommodative padding on an outpatient basis with Dr. X all of which have provided inadequate relief.  At this time, she desires attempted surgical correction.  The risks versus benefits of the procedure have been discussed with the patient in detail by Dr. X and the consent is available on the chart for review.,PROCEDURE IN DETAIL: , After IV was established by the Department of Anesthesia, the patient was taken to the operating room via cart and placed on the operative table in supine position and a safety strap was placed across her waist for her protection.  Copious amounts of Webril were applied about the right ankle and a pneumatic ankle tourniquet was placed over the Webril.,After adequate IV sedation was administered by the Department of Anesthesia, a total of 15 cc of 1:1 mixture of 0.5% Marcaine plain and 1% Lidocaine plain was injected into the foot in a standard Mayo block fashion.  The foot was elevated off the table.  Esmarch bandages were used to exsanguinate the right foot.  The pneumatic ankle tourniquet was elevated to 250 mmHg.  The foot was lowered in the operative field and the sterile stockinet was reflected.  A sterile Betadine was wiped away with a wet and dry sponge and one toothpick was used to test anesthesia, which was found to be adequate.  Attention was directed to the first metatarsophalangeal joint, which was found to be contracted, laterally deviated, and had decreased range of motion.  A #10 blade was used to make a 4 cm dorsolinear incision.  A #15 blade was used to deepen the incision through the subcutaneous layer.  All superficial subcutaneous vessels were ligated with electrocautery.  Next, a linear capsular incision was made down the bone with a #15 blade.  The capsule was elevated medially and laterally off the metatarsal head and the metatarsal head was delivered into the wound.  A hypertrophic medial eminence was resected with a sagittal saw taking care not to strike the head.  The medial plantar aspect of the metatarsal head had some erosive changes and eburnation.  Next, a 0.45 inch Kirschner wire was placed with some access guide slightly plantar flexing the metatarsal taking care not to shorten it.  A sagittal saw was used to make a long-arm Austin osteotomy in the usual fashion.  Standard lateral release was also performed as well as a lateral capsulotomy freeing the fibular sesamoid complex.,The capital head was shifted laterally and impacted on the residual metatarsal head.  Nice correction was achieved and excellent bone to bone contact was achieved.  The bone stock was slightly decreased, but adequate.  Next, a 0.45 inch Kirschner wire was used to temporarily fixate the metatarsal capital fragment.  A 2.7 x 18 mm Synthes cortical screw was thrown using standard AO technique.  Excellent rigid fixation was achieved.  A second 2.0 x 80 mm Synthes fully threaded cortical screw was also thrown using standard AO technique at the proximal aspect of the metatarsal head.  Again, an excellent rigid fixation was obtained and the screws were tight.  The temporary fixation was removed.  A medial overhanging bone was resected with a sagittal saw.  The foot was loaded and the hallux was found to have an interphalangeus deformity present.,A sagittal saw was used to make a proximal cut in approximately 1 cm dorsal to the base of the proximal phalanx, leaving a lateral intact cortical hinge.  A distal cut parallel with the nail base was performed and a standard proximal Akin osteotomy was done.,After the wedge bone was removed, the saw blade was reinserted and used to tether the osteotomy with counter-pressure used to close down the osteotomy.  A #15 drill blade was used to drill two converging holes on the medial aspect of the bone.  A #28 gauge monofilament wire was inserted loop to loop and pulled through the bone.  The monofilament wire was twisted down and tapped into the distal drill hole.  The foot was loaded again and the toe had an excellent cosmetic straight appearance and the range of motion of the first metatarsophalangeal joint was then improved.  Next, reciprocating rasps were used to smooth all bony surfaces.  Copious amounts of sterile saline was used to flush the joint.  Next, a #3-0 Vicryl was used to reapproximate the capsular periosteal tissue layer.  Next, #4-0 Vicryl was used to close the subcutaneous layer.  #5-0 Vicryl was used to the close the subcuticular layer in a running fashion.  Next, 1 cc of dexamethasone phosphate was then instilled in the joint.  The Steri-Strips were applied followed by standard postoperative dressing consisting of Owen silk, 4 x 4s, Kling, Kerlix, and Coban.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to the digits.  The patient tolerated the above anesthesia and procedure without complications.  She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot.  She is to be partial weightbearing with crutches.  She is to follow with Dr. X.  She was given emergency contact numbers and instructions to call if problems arise.  She was given prescription for Vicodin ES #25 one p.o. q.4-6h. p.r.n. pain and Naprosyn one p.o. b.i.d.  500 mg.  She was discharged in stable condition.","orthopedic, hallux interphalangeus, osteotomy, bunionectomy, akin, wire fixation, screw fixation, painful bunion, metatarsophalangeal joint, pneumatic ankle, metatarsal head, foot, toe, sagittal, metatarsal"
" Endoscopic release of left transverse carpal ligament.  Steroid injection, stenosing tenosynovitis of right middle finger.", Orthopedic, Carpal Ligament Release - 2 ,"PREOPERATIVE DIAGNOSES:,1.  Left carpal tunnel syndrome.,2.  Stenosing tenosynovitis of right middle finger (trigger finger).,POSTOPERATIVE DIAGNOSES:,1.  Left carpal tunnel syndrome.,2.  Stenosing tenosynovitis of right middle finger (trigger finger).,PROCEDURES:,1.  Endoscopic release of left transverse carpal ligament.,2.  Steroid injection, stenosing tenosynovitis of right middle finger.,ANESTHESIA:  ,Monitored anesthesia care with regional anesthesia applied by surgeon.,TOURNIQUET TIME: , Left upper extremity was 15 minutes.,OPERATIVE PROCEDURE IN DETAIL:,  With the patient under adequate monitored anesthesia, the left upper extremity was prepped and draped in a sterile manner.  The arm was exsanguinated.  The tourniquet was elevated at 290 mmHg.  Construction lines were made on the left palm to identify the ring ray.  A transverse incision was made in the palm between FCR and FCU, one finger breadth proximal to the interval between the glabrous skin of the palm and normal forearm skin.  Blunt dissection exposed the antebrachial fascia.  Hemostasis was obtained with bipolar cautery.  A distal based window in the antebrachial fascia was then fashioned.  Care was taken to protect the underlying contents.  A synovial elevator was used to palpate the undersurface of the transverse carpal ligament, and synovium was elevated off this undersurface.,Hamate sounds were then used to palpate the Hood of Hamate.  The Agee Inside Job was then inserted into the proximal incision.  The transverse carpal ligament was easily visualized through the portal.  Using palmar pressure, transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end.  The distal end of the transverse carpal ligament was then identified in the window.  The blade was then elevated, and the Agee Inside Job was withdrawn, dividing transverse carpal ligament under direct vision.  After complete division of transverse carpal ligament, the Agee Inside Job was reinserted.  Radial and ulnar edges of the transverse carpal ligament were identified and complete release was accomplished.  One mL of Celestone was then introduced into the carpal tunnel and irrigated free.  ,The wound was then closed with a running 3-0 Prolene subcuticular stitch.  Steri-strips were applied and a sterile dressing was applied over the Steri-strips.  The tourniquet was deflated.  The patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well.,Attention was turned to the right palm where after a sterile prep, the right middle finger flexor sheath was injected with 0.5 mL of 1% plain Xylocaine and 0.5 mL of Depo-Medrol 40 mg/mL.  A Band-Aid dressing was then applied.,The patient was then awakened from the anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well.","orthopedic, carpal tunnel syndrome, agee inside job, steroid injection, antebrachial fascia, forearm, ring ray, synovial elevator, tenosynovitis, tourniquet, transverse incision, trigger finger, tenosynovitis of right middle, transverse carpal ligament, transverse carpal, carpal ligament, steri strips, stenosing tenosynovitis, middle finger, ligament, carpal, endoscopic, finger"
" Bunion, left foot.  Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation and Akin osteotomy with internal wire fixation of left foot.", Orthopedic, Bunionectomy & Akin Osteotomy ,"PREOPERATIVE DIAGNOSIS: , Bunion, left foot.,POSTOPERATIVE DIAGNOSIS: ,Bunion, left foot.,PROCEDURE PERFORMED:,1.  Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation.,2.  Akin osteotomy with internal wire fixation of left foot.,HISTORY: , This 19-year-old Caucasian female presents to ABCD General Hospital with the above chief complaint.  The patient states she has had worsening bunion deformity for as long as she could not remember.  She does have a history of Charcot-Marie tooth disease and desires surgical treatment at this time.,PROCEDURE: , An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported to the operating room and placed on operating table in the supine position with a safety belt across her lap.  Copious amounts of Webril were placed on the left ankle followed by a blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 15 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain were injected in a Mayo block type fashion surrounding the lower left first metatarsal.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was elevated from the operating table and exsanguinated with an Esmarch bandage.  The pneumatic ankle tourniquet was inflated to 250 mmHg and the foot was lowered to the operating field.  The stockinette was reflected, the foot was cleansed with a wet and dry sponge.  Approximately 5 cm incision was made dorsomedially over the first metatarsal.,The incision was then deepened with #15 blade.  All vessels encountered were ligated for hemostasis.  Care was taken to preserve the extensor digitorum longus tendon.  The capsule over the first metatarsal phalangeal then was identified where a dorsal capsular incision was then created down to the level of bone.  Capsule and periosteum was reflected off the first metatarsal head.  At this time, the cartilage was inspected and noted to be white, shiny, and healthy cartilage.  There was noted to be a prominent medial eminence.  Attention was then directed to first interspace where a combination of blunt and sharp dissection was done to perform a standard lateral release.  The abductor tendon attachments were identified and transected.  The lateral capsulotomy was performed.  The extensor digitorum brevis tendon was identified and transected.  Attention was then directed to the prominent medial eminence, which was resected with a sagittal saw.  Intraoperative assessment of pes was performed and pes was noted to be normal.,At this time, a regional incision was carried more approximately about 1.5 cm.  The capsular incision was then extended and the proximal capsule and periosteum were reflected off the first metatarsal.  The first metatarsal cuneiform joint was identified.  A 0.45 K-wire was then inserted into the base of the first metatarsal approximately 1 cm from the first cuneiform joint perpendicular to the weightbearing surface.  This K-wire was used as an access guide for a Juvaro type oblique base wedge osteotomy.  The sagittal saw was then used to creat a closing base wedge osteotomy with the apex being proximal medial.  The osteotomy site was then feathered and tilted with tight estimation of the bony edges.  The cortical hinge was maintained.  A 0.27 x 24 mm screw was then inserted in a standard AO fashion.  At this time, there was noted to be tight compression of the osteotomy site.  A second 2.7 x 16 mm screw was then inserted more distally in the standard AO fashion with compression noted.  The ________ angle was noted to be significantly released.  Reciprocating rasp was then used to smoothen any remaining sharp edges.  The 0.45 k-wire was removed.  The foot was loaded and was noted to fill the remaining abduction of the hallux.  At this time, it was incised to perform an Akin osteotomy.,Original incision was then extended distally approximately 1 cm.  The incision was then deepened down to the level of capsule over the base of the proximal phalanx.  Again care was taken to preserve the extensor digitorum longus tendon.  The capsule was reflected off of the base of the proximal phalanx.  An Akin osteotomy was performed with the apex being lateral and the base being medial.  After where the bone was resected, it was feathered until tight compression was noted without tension at the osteotomy site.  Care was taken to preserve the lateral hinge.  At 1.5 wire passed and a drill was then used to create drill hole proximal and distally to the osteotomy site in order for passage of 28 gauge monofilament wire.  The #28 gauge monofilament wire was passed through the drill hole and tightened down until compression and tight ________ osteotomy site was noted.  The remaining edge of the wire was then buried in the medial most distal drill hole.  The area was then inspected and the foot was noted with significant reduction of the bunion deformity.  The area was then flushed with copious amounts of sterile saline.  Capsule was closed with #3-0 Vicryl followed by subcutaneous closure with #4-0 Vicryl in order to decrease tension of the incision site.  A running #5-0 subcuticular stitch was then performed.  Steri-Strips were applied.  Total of 1 cc dexamethasone phosphate was then injected into the surgical site.  Dressings consisted of Owen silk, 4x4s, Kling, Kerlix.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot.  Posterior splint was then placed on the patient in the operating room.,The patient tolerated the above procedure and anesthesia well without complications.  The patient was transferred back to the PACU with vital signs stable and vascular status intact to the left foot.  The patient was given postoperative instructions to be strictly nonweightbearing on the left foot.  The patient was given postop pain prescriptions for Vicodin and instructed to take one q.4-6h. p.r.n. for pain as well as Naprosyn 500 mg p.o. q. b.i.d.  The patient is to follow-up with Dr. X in his office in four to five days as directed.","orthopedic, bunionectomy, akin osteotomy, internal wire fixation, internal screw fixation, osteotomy, metatarsal, metatarsal osteotomy, extensor digitorum, drill hole, osteotomy site, foot"
" Bunionectomy, right foot with Biopro hemi implant, right first metatarsophalangeal joint.  Arthrodesis, right second, third, and fourth toes with external rod fixation.  Hammertoe repair, right fifth toe.  Extensor tenotomy and capsulotomy, right fourth metatarsophalangeal joint.  Modified Tailor's bunionectomy, right fifth metatarsal.
", Orthopedic, Bunionectomy & Arthrodesis ,"PREOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus, right foot.,2.  Hammer toe, right foot, second, third, fourth and fifth toes.,3.  Tailor's bunionette, right foot.,4.  Degenerative joint disease, right first metatarsophalangeal joint.,5.  Rheumatoid arthritis.,6.  Contracted fourth right metatarsophalangeal joint.,POSTOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus, right foot.,2.  Hammer toe, right foot, second, third, fourth and fifth toes.,3.  Tailor's bunionette, right foot.,4.  Degenerative joint disease, right first metatarsophalangeal joint.,5.  Rheumatoid arthritis.,6.  Contracted fourth right metatarsophalangeal joint.,PROCEDURES PERFORMED:,1.  Bunionectomy, right foot with Biopro hemi implant, right first metatarsophalangeal joint.,2.  Arthrodesis, right second, third, and fourth toes with external rod fixation.,3.  Hammertoe repair, right fifth toe.,4.  Extensor tenotomy and capsulotomy, right fourth metatarsophalangeal joint.,5.  Modified Tailor's bunionectomy, right fifth metatarsal.,ANESTHESIA:,  TIVA/local.,HISTORY:,  This 51-year-old female presented to ABCD preoperative holding area after keeping herself NPO since mid night for surgery on her painful right foot bunion, hammer toes, and Tailor's bunion.  The patient has a long history of crippling severe rheumatoid arthritis.  She has pain with shoe gear and pain with every step.  She has tried multiple conservative measures under Dr. X's supervision consisting of wide shoe's and accommodative padding all which have provided inadequate relief.  At this time, she desires attempted surgical reconstruction/correction.  The consent is available on the chart for review and the risks versus benefits of this procedure have been discussed with patient in detail by Dr. X.,PROCEDURE IN DETAIL: , After IV was established by the Department of Anesthesia, the patient was taken to the operating room via cart and placed on the operating table in a supine position and a safety strap was placed across her waist for her protection.  Next, copious amounts of Webril were applied about the right ankle and a pneumatic ankle tourniquet was applied over the Webril.  Next, after adequate IV sedation was administered by the Department of Anesthesia, a total of 20 cc of 1:1 mixture of 0.5% Marcaine plain and 1% lidocaine were instilled into the right foot using a standard ankle block technique.  Next, the foot was prepped and draped in the usual aseptic fashion.  An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 230 mmHg.  The foot was lowered in the operative field.  The sterile stockinette was reflected and attention was directed to the right first metatarsophalangeal joint.  The joint was found to be severely contracted with lateral deviation of the hallux with a slightly overlapping contracted second toe.  In addition, the range of motion was less than 5 degrees of the first ray.  There was medial pinch callus and callus on the plantar right second metatarsal.  Using a #10 blade, a linear incision over the first metatarsophalangeal joint was then created approximately 4 cm in length.  Next, a #15 blade was used to deepen the incision to the subcutaneous tissue all which was found to be very thin taking care to protect the medial neurovascular bundle and the lateral extensor hallucis longus tendon.  Any small vein traversing the operative site were clamped with hemostat and ligated with electrocautery.  Next, the medial and lateral wound margins were undermined with sharp dissection.  The joint capsule was then visualized.  Two apparent soft tissue masses probably consistent with rheumatoid nodules were found at the distal medial aspect of the first metatarsal capsule.  A dorsal linear incision to the capsular tissue down to bone was performed with a #15 blade.  The capsule and periosteal tissues were elevated sharply off the metatarsal head and the base of proximal  phalanx.,A large amount of hypertrophic synovium was encountered over the metatarsophalangeal joint.  In addition, multiple hypertrophic exostosis were found dorsally, medially, and laterally over the metatarsal.  Upon entering the joint, the base of the proximal phalanx was grossly deformed and the medial and lateral aspect were widely flared and encompassing the metatarsal head.  A sagittal saw was used to carefully remove the base of the proximal phalanx just distal to the metaphyseal flare.  Next, the bone was passed out as specimen.  The head of the metatarsal had evidence of erosion and eburnation.  The tibial sesamoid was practically absent, but was found to be a conglomeration of hypertrophic synovium and poorly differentiated appearing exostosis and bony tissue.  This was hindering the range of motion of the joint and was removed.  The fibular sesamoid was in the interspace.  A lateral release was performed in addition.  Next, the McGlamry elevators were inserted into the first metatarsal head and all of the plantar adhesions were freed.  The metatarsal head was remodeled with a sagittal saw and all of the medial eminence the dorsal and lateral hypertropic bone was removed and the metatarsal head was shaped into more acceptable contoured structure.  Next, the Biopro sizer was used and it was found that a median large implant would be the best fit for this patient's joint.  A small drill hole was made in the central aspect at the base of the proximal phalanx.  The trial sizer median large was placed in the joint and an excellent fit and increased range of motion was observed.,Next, the joint was flushed with copious amounts of saline.  A median large porous Biopro implant was inserted using the standard technique and was tapped with the mallet into position.  It had an excellent fit and the range of motion again was markedly increased from the preoperative level.  Next, the wound was again flushed with copious amounts of saline.  The flexor tendon was inspected and was found to be intact plantarly.  A #3-0 Vicryl was used to close the capsule in a running fashion.  A medial capsulorrhaphy performed and the toe assumed to more rectus position and the joint was more congruous.  Next, the subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted technique.  Next, the skin was closed with #5-0 Monocryl in a running subcuticular fashion.,Attention was directed to the right second toe, which was found to be markedly contracted and rigid in nature.  There was a clavus in the dorsal aspect of the head of the proximal phalanx noted.  A linear incision was made over the proximal phalanx approximately 2 cm in length.  The incision was deepened with #15 blade down to the subcutaneous tissue.  Next, the medial and lateral aspects of the wound were undermined with sharp dissection taking care to protect the neurovascular structures.,Next, after identifying the extensor expansion and long extensor tendon, a #15 blade was used to transect the tendon at the level of the joint.  The tendon was peeled off sharply, proximally, and distally.  The medial and lateral collateral ligaments were released and the head of the proximal phalanx was delivered into the wound.  The bone was found to be extremely soft in the toe joints and the head of the proximal phalanx was oddly shaped and the cartilage was eroded.  The base of the middle phalanx, however, had a normal-appearing cartilage.  A sagittal saw was used to transect the head of the proximal phalanx just proximal to metaphyseal flare.  Next, the base of the middle phalanx was also resected.  A 0.045 inch Kirschner wire was retrograded out at the end of the toe and then back through the residual proximal phalanx shaft.  The toe assumed a straight and markedly increased straight position.  An extensor hood resection was performed to assist in keeping the proximal phalanx plantar flexed.  The joint was flushed with copious amounts of saline.  A #3-0 Vicryl was used to reapproximate the tendon after arthrodesis.  A #4-0 nylon was used to close the skin with a combination of simple interrupted and horizontal mattress suture technique.  The wire was cut, capped, and bent in the usual fashion.,Attention was directed to the right third toe where an exact same procedure as performed in the second digit was repeated.  The same suture material was used and the same 0.045 Kirschner wire was used for external wire fixation.,Attention was directed to the right fourth toe with exact same procedure was repeated.  The same suture material was used.  However, a 0.062 Kirschner wire was used to fixate the arthrodesis site as the bone was very soft and a 0.045 Kirschner wire was attempted but was found to be slipping in the soft bone and was inadequately holding the arthrodesis site tight.  Next, attention was directed to the fifth digit, which was found to be contracted as well.  A linear incision was made over the proximal phalanx with a #10 blade approximately 2 cm in length.  A #15 blade was used to deepen the incision to the subcutaneous tissue down to the level of the long extensor tendon, which was identified and transected.  The medial and lateral collateral ligaments were transected and the head of the proximal phalanx was delivered into the wound.  A sagittal saw was used to resect the head of the proximal phalanx just proximal to metaphyseal flare.  The toe assumed to more rectus position.  The reciprocating rasp was used to smooth the all bony surfaces.  The joint was again flushed with saline.  Next, the long extensor tendon was reapproximated with #3-0 Vicryl in a simple interrupted technique.  The skin was closed with #4-0 nylon in a simple interrupted technique.,Next, attention was directed to the fifth metatarsal head, which was found to have a lateral exostosis and bursa under the skin.  A #10 blade was used to make a 2.5 cm dorsal incision over the fifth metatarsal head.  The incision was deepened with a #15 blade to the subcutaneous tissue.  Any small vein traversing subcutaneous layer were ligated with electrocautery.  Care was taken to avoid abductor digiti minimi tendon and extensor digitorum longus tendon respectively.  Next, the dorsal linear capsular incision was made down to the bone with a #15 blade.  The capsular and periosteal tissues were elevated off the bone with a #15 blade and the metatarsal head was delivered into the wound.  Hypertrophic bone was noted to be found dorsally and laterally as well as plantarly.  A sagittal saw was used to resect all hypertrophic bone.  A reciprocating rasp was used to smooth all bony surfaces.  Next, the wound was flushed with copious amounts of saline.  The capsular and periosteal tissues wee closed with #3-0 Vicryl in a simple interrupted technique.  Next, the subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted technique.  A bursa which was found consisting of a white glistening hypertrophic synovium was removed and sent as specimen as was also found in two of the second and third digit in the above procedures.  The skin was closed with #5-0 Monocryl in a running subcuticular fashion.  The ______ was reinforced with horizontal mattress sutures with #5-0 Monocryl.  Attention was directed to the fourth metatarsophalangeal joint where the joint was found to be contracted and the proximal phalanx was still found to be elevated.  Therefore, a #15 blade was used to make a stab incision over the joint lateral to the extensor digitorum longus tendon.  The tendon was transected.  Next, a blade was inserted in the dorsal, medial, and lateral aspects of the metatarsophalangeal joint and tenotomy was performed.  Next, the proximal phalanx residual bone was plantar flexed and found to assume a more rectus position.  One #4-0 nylon suture was placed in the skin.,Mastisol tape was applied to the first metatarsal and fifth metatarsal postoperative wounds.  Betadine-soaked Owen silk was applied to all wounds.  Betadine-soaked 4 x 4 splints were applied to all toes.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all digits.  All the wires have previously been bent and cut and all were capped.  A standard postoperative consisting of 4x4s, Kling, Kerlix, and Coban were applied.  The patient tolerated the above anesthesia and procedure without complications.  She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact.  She was given prescription for Tylenol #3, #40 one to two p.o. q.4-6h. p.r.n. pain and Naprosyn 375 mg p.o. b.i.d. p.c.  She is to continue her rheumatoid arthritis drugs preoperatively prescribed by the rheumatologist.,She is to follow up with Dr. X in the office.  She was given emergency contact numbers and standard postoperative instructions.  She was given Darco OrthoWedge shoe and a pair of crutches.  She was discharged in stable condition.",
" Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot.  Proximal interphalangeal joint arthroplasty, bilateral fifth toes.  Distal interphalangeal joint arthroplasty, bilateral third and fourth toes.   Flexor tenotomy, bilateral third toes.", Orthopedic, Bunionectomy & Flexor Tenotomy ,"PREOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus, right foot.,2.  Hammertoe, bilateral third, fourth, and fifth toes.,POSTOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus, right foot.,2.  Hammertoe, bilateral third, fourth, and fifth toes.,PROCEDURE PERFORMED:,1.  Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot.,2.  Proximal interphalangeal joint arthroplasty, bilateral fifth toes.,3.  Distal interphalangeal joint arthroplasty, bilateral third and fourth toes.,4.  Flexor tenotomy, bilateral third toes.,HISTORY:,  This is a 36-year-old female who presented to ABCD preoperative holding area after keeping herself n.p.o. since mid night for surgery on her painful bunion to her right foot and her painful hammertoes to both feet.  The patient has a history of sharp pain, which is aggravated by wearing shoes and ambulation.  She has tried multiple conservative methods and treatment such as wide shoes and accommodative padding, all of which provided inadequate relief.  At this time, she desires attempted surgical correction.  The risks versus benefits of the procedure have been discussed in detail by Dr. Kaczander with the patient and the consent is available on the chart.,PROCEDURE IN DETAIL:,  After IV was established by the Department of Anesthesia, the patient was taken to the operating room and placed on the operating table in supine position with a safety strap placed across her waist for her protection.,Copious amounts of Webril were applied about both ankles and a pneumatic ankle tourniquet was applied over the Webril.  After adequate IV sedation was administered, a total of 18 cc of a 0.5% Marcaine plain was used to anesthetize the right foot, performing a Mayo block and a bilateral third, fourth, and fifth digital block.  Next, the foot was prepped and draped in the usual aseptic fashion bilaterally.  The foot was elevated off the table and an Esmarch bandage was used to exsanguinate the right foot.  The pneumatic ankle tourniquet was elevated on the right foot to 200 mmHg.  The foot was lowered into operative field and the sterile stockinet was reflected proximally.  Attention was directed to the right first metatarsophalangeal joint, it was found to be contracted and there was lateral deviation of the hallux.  There was decreased range of motion of the first metatarsophalangeal joint.  A dorsolinear incision was made with a #10 blade, approximately 4 cm in length.  The incision was deepened to the subcutaneous layer with a #15 blade.  Any small veins traversing the subcutaneous layer were ligated with electrocautery.  Next, the medial and lateral wound margins were undermined sharply.  Care was taken to avoid the medial neurovascular bundle and the lateral extensor hallucis longus tendon.  Next, the first metatarsal joint capsule was identified.  A #15 blade was used to make a linear capsular incision down to the bone.  The capsular periosteal tissues were elevated off the bone with a #15 blade and the metatarsal head was delivered into the wound.  The PASA was found to be within normal limits.  There was a hypertrophic medial eminence noted.  A sagittal saw was used to remove the hypertrophic medial eminence.  A 0.045 inch Kirschner wire was placed into the central medial aspect of the metatarsal head as an access guide.  A standard lateral release was performed.  The fibular sesamoid was found to be in the interspace, but was relocated onto the metatarsal head properly.  Next, a sagittal saw was used to perform a long arm Austin osteotomy.  The K-wire was removed.  The capital fragment was shifted laterally and impacted into the head.  A 0.045 inch Kirschner wire was used to temporarily fixate the osteotomy.  A 2.7 x 16 mm Synthes, fully threaded cortical screw was throne using standard AO technique.  A second screw was throne, which was a 2.0 x 12 mm Synthes cortical screw.  Excellent fixation was achieved and the screws tightly perched the bone.  Next, the medial overhanging wedge was removed with a sagittal saw.  A reciprocating rasp was used to smooth all bony prominences.  The 0.045 inch Kirschner wire was removed.  The screws were checked again for tightness and found to be very tight.  The joint was flushed with copious amounts of sterile saline.  A #3-0 Vicryl was used to close the capsular periosteal tissues with simple interrupted suture technique.  A #4-0 Vicryl was used to close the subcutaneous layer in a simple interrupted technique.  A #5-0 Monocryl was used to close the skin in a running subcuticular fashion.,Attention was directed to the right third digit, which was found to be markedly contracted at the distal interphalangeal joint.  A #15 blade was used to make two convergent semi-elliptical incisions over the distal interphalangeal joint.  The incision was deepened with a #15 blade.  The wedge of skin was removed in full thickness.  The long extensor tendon was identified and the distal and proximal borders of the wound were undermined.  The #15 blade was used to transect the long extensor tendon, which was reflected proximally.  The distal interphalangeal joint was identified and the #15 blade was placed in the joint and the medial and lateral collateral ligaments were released.  Crown and collar scissors were used to release the planar attachment to the head of the middle phalanx.  Next, a double action bone cutter was used to resect the head of the middle phalanx.  The toe was dorsiflexed and was found to have an excellent rectus position.  A hand rasp was used to smooth all bony surfaces.  The joint was flushed with copious amounts of sterile saline.  The flexor tendon was found to be contracted, therefore, a flexor tenotomy was performed through the dorsal incision.  Next, #3-0 Vicryl was used to close the long extensor tendon with two simple interrupted sutures.  A #4-0 nylon was used to close the skin and excellent cosmetic result was achieved.,Attention was directed to the fourth toe, which was found to be contracted at the distal interphalangeal joint and abducted and varus rotated.  An oblique skin incision with two converging semi-elliptical incisions was created using #15 blade.  The rest of the procedure was repeated exactly the same as the above paragraph to the third toe on the right foot.  All the same suture materials were used.  However, there was no flexor tenotomy performed on this toe, only on the third toe bilaterally.,Attention was directed to the fifth right digit, which was found to be contracted at the proximal interphalangeal joint.  A linear incision approximately 2 cm in length was made with a #15 blade over the proximal interphalangeal joint.  Next, a #15 blade was used to deepen the incision to the subcutaneous layer.  The medial and lateral margins were undermined sharply to the level of the long extensor tendon.  The proximal interphalangeal joint was identified and the tendon was transected with the #15 blade.  The tendon was reflected proximally, off the head of the proximal phalanx.  The medial and lateral collateral ligaments were released and the head of the proximal phalanx was delivered into the wound.  A double action bone nibbler was used to remove the head of the proximal phalanx.  A hand rasp was used to smooth residual bone.  The joint was flushed with copious amounts of saline.  A #3-0 Vicryl was used to close the long extensor tendon with two simple interrupted sutures.  A #4-0 nylon was used to close the skin with a combination of simple interrupted and horizontal mattress sutures.,A standard postoperative dressing consisting of saline-soaked #0-1 silk, 4 x 4s, Kerlix, Kling, and Coban were applied.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to the digits.,Attention was directed to the left foot.  The foot was elevated off the table and exsanguinated with an Esmarch bandage and the pneumatic ankle tourniquet was elevated to 200 mmHg.  Attention was directed to the left fifth toe, which was found to be contracted at the proximal interphalangeal joint.  The exact same procedure, performed to the right fifth digit, was performed on this toe, with the same materials being used for suture and closure.,Attention was then directed to the left fourth digit, which was found to contracted and slightly abducted and varus rotated.  The exact same procedure as performed to the right fourth toe was performed, consisting of two semi-elliptical skin incisions in an oblique angle.  The same suture material were used to close the incision.,Attention was directed to the left third digit, which was found to be contracted at the distal interphalangeal joint.  The same procedure performed on the right third digit was also performed.  The same suture materials were used to close the wound and the flexor tenotomy was also performed at this digit.  A standard postoperative dressing was also applied to the left foot consisting of the same materials as described for the right foot.  The pneumatic tourniquet was released and immediate hyperemic flush was noted to the digits.  The patient tolerated the above anesthesia and procedure without complications.  She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the foot.  She was given postoperative shoes and will be partial weighbearing with crutches.  She was admitted short-stay to Dr. Kaczander for pain control.  She was placed on Demerol 50 and Vistaril 25 mg IM q3-4h. p.r.n. for pain.  She will have Vicodin 5/500 one to two p.o. q.4-6h. p.r.n. for moderate pain.  She was placed on Subq. heparin and given incentive spirometry 10 times an hour.  She will be discharged tomorrow.  She is to ice and elevate both feet today and rest as much as possible.,Physical Therapy will teach her crutch training today.  X-rays were taken in the postoperative area and revealed excellent position of the screws and correction of bunion deformity as well as the hammertoe deformities.","orthopedic, hallux abductovalgus, hammertoe, bunionectomy, flexor, tenotomy, interphalangeal, arthroplasty, screw fixation, osteotomy, interphalangeal joint arthroplasty, distal interphalangeal joint, interphalangeal joint, flexor tenotomy, proximal interphalangeal, joint arthroplasty, distal interphalangeal, distal, blade, proximal, foot, joint, toes, tendon, "
" Evaluation of pain and symptoms related to a recurrent bunion deformity in bilateral feet - recurrent bunion deformity, right forefoot & pes planovalgus deformity, bilateral feet.", Orthopedic, Bunion & Pes Planovalgus Deformity ,"HISTORY OF PRESENT ILLNESS: , The patient is a 57-year-old female being seen today for evaluation of pain and symptoms related to a recurrent bunion deformity in bilateral feet, right greater than left.  The patient states she is having increasing symptoms of pain and discomfort associated with recurrence of bunion deformity on the right foot and pain localized to the second toe and MTP joint of the right foot as well.  The patient had prior surgery performed approximately 13 years ago.  She states that since the time of the original surgery the deformity has slowly recurred, and she has noticed progressive deformity in the lesser toes at the second and third toes of the left foot and involving the second toe of the right foot.  The patient is employed on her feet as a hospital employee and states that she does wear a functional orthotic which does provide some relief of forefoot pain although not complete.,PAST MEDICAL HISTORY, FAMILY HISTORY, SOCIAL HISTORY & REVIEW OF SYSTEMS:,  See Patient History sheet, which was reviewed with the patient and is signed in the chart.  Past medical history on the patient, past surgical history, current medications, drug-related allergies and social history have all been updated and reviewed, and enclosed in the chart.,PHYSICAL EXAMINATION: , Physical exam reveals a pleasant, 57-year-old female who is 5 feet 4 inches and 150 pounds.  She has palpable pulses.  Neurologic sensation is intact.  Examination of the extremities shows the patient as having well-healed surgical sites from her arthroplasty, second digits bilaterally and prior bunionectomy.  There is a recurrence of bunion deformity noted on both great toes although the patient notes to have reasonably good range of movement.  She has particular pain in the second MTP joint of the right foot and demonstrates a mild claw-toe deformity of the second and third toes to the left foot, and to a lesser degree the second toe to the right.  Gait analysis:  The patient stands and walks with a rather severe pes planus and has generalized hypermobility noted in the feet.,X-RAY INTERPRETATION:,  X-rays taken today; three views to the right foot shows presence of internal K-wire and wire from prior bunionectomy.  Biomechanical analysis shows 15 degree intermetatarsal angle and approximately 45 degree hallux abducto valgus angle.  No evidence of arthrosis in the joint is noted.  Significant shift to the fibular sesamoid is present.,ASSESSMENT:,1.  Recurrent bunion deformity, right forefoot.,2.  Pes planovalgus deformity, bilateral feet.,PLAN/TREATMENT:,1.  Today, we did review remaining treatment options with the patient including the feasibility of conservative versus surgical treatment.  The patient would require an open wedge osteotomy to reduce the intermetatarsal angle with the lateral release and a decompression osteotomy  at the second metatarsal.  Anticipated length of healing was noted for the patient as were potential risks and complications.  The patient ultimately would probably require surgery on her left foot at a later date as well.,2.  The patient will explore her ability to get out of work for the above-mentioned period of time and will be in touch with regards regarding scheduling at a later date.,3.  All questions were answered.","orthopedic, x-rays, pain, mtp joint, pes planovalgus deformity, pes planovalgus, bunion deformity, planovalgus, forefoot, foot, deformity, bunionectomy, bunion"
" Austin/akin bunionectomy, right foot.  Bunion, right foot.  The patient states she has had a bunion deformity for as long as she can remember that has progressively become worse and more painful.", Orthopedic, Bunionectomy - Austin - Akin ,"PREOPERATIVE DIAGNOSIS:,  Bunion, right foot.,POSTOPERATIVE DIAGNOSIS:,  Bunion, right foot.,PROCEDURE PERFORMED:,  Austin/akin bunionectomy, right foot.,HISTORY: , This 77-year-old African-American female presents to ABCD General Hospital with the above chief complaint.  The patient states she has had a bunion deformity for as long as she can remember that has progressively become worse and more painful.  The patient has attempted conservative treatment without long-term relief of symptoms and desires surgical treatment.,PROCEDURE DETAILS:,  An IV was instituted by Department of Anesthesia in the preop holding area.  The patient was transported to the operating room and placed on the operating table in the supine position with a safety strap across her lap.  Copious amounts of Webril were placed around the right ankle followed by blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 15 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain was injected in a Mayo block type fashion.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was elevated to the operating table and exsanguinated with an Esmarch bandage.  The pneumatic ankle tourniquet was inflated to 250 mmHg.  The foot was lowered to the operating field and the stockinet was reflected.  The foot was cleansed with wet and dry sponge.,Attention was directed to the bunion deformity on the right foot.  An approximately 6 cm dorsal medial incision was created over the first metatarsophalangeal joint.  The incision was then deepened with a #15 blade.  All vessels encountered were ligated with hemostasis.  The skin and subcutaneous tissue were then undermined off of the capsule medially.  A dorsal linear capsular incision was then created over the first metatarsophalangeal joint.  The periosteum and capsule were then reflected off of the first metatarsal.  There was noted to be a prominent medial eminence.  The articular cartilage was healthy for patient's age and race.  Attention was then directed to the first interspace where a lateral release was performed..  A combination of sharp and blunt dissection was carried out until the adductor tendon insertions were identified.  The adductor tendons were transected as well as a lateral capsulotomy was performed.  The extensor digitorum brevis tendon was identified and transected.  Care was taken to preserve the extensor hallucis longus to make sure that tendon that was transected was the extensor hallucis brevis at the _______ digitorum.  Extensor hallucis brevis tendon was transected and care was taken to preserve the extensor halucis longus tendon.  Attention was then directed to medial eminence, which was resected with a sagittal saw.  Sagittal was then used to create a long dorsal arm outside the Austin type osteotomy and the first metatarsal.  The head of the first metatarsal was then translocated laterally until correction of the intermetatarsal angle was noted.  The head was intact.  A 0.45 K-wire was inserted through subcutaneously from proximal medial to distal lateral.  A second K-wire was then inserted from distal lateral to proximal plantar medial.  Adequate fixation was noted at the osteotomy site.  The K-wires were bent, cut, and pin caps were placed.  Attention was then directed to the proximal phalanx of the hallux.  The capsular periostem was reflected off of the base of the proximal phalanx.  A sagittal was then used to create an akin osteotomy closing wedge.  The apex was lateral and the base of the wedge was medial.  The wedge was removed in the total and the osteotomy site was then feathered until closure was achieved without compression.  Two 0.45 K-wires were then inserted, one from distal medial to proximal lateral and the second from distal lateral to proximal medial across the osteotomy site.  Adequate fixation was noted at the osteotomy site and the osteotomy was closed.  The toe was noted to be in a markedly more rectus position.  Sagittal saw was then used to resect the remaining prominent medial eminence.  The area was then smoothed with a reciprocating rasp.  There was noted to be a small osteophytic formation laterally over first metatarsal head that was removed with a rongeur and smoothed with a reciprocating rasp.  The area was then inspected for any remaining short bony edges, none were noted.,Copious amounts of sterile saline was then used to flush the surgical site.  The capsule was closed with #3-0 Vicryl.  Subcutaneous closure was performed with #4-0 Vicryl followed by running subcuticular #5-0 Vicryl.  Steri-Strips were applied and 1 cc of dexamethasone phosphate was injected into the surgical site.,Dressings consisted of #0-1 silk, copious Betadine, 4 x 4s, Kling, Kerlix, and Coban.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the right foot.  A _______ cast was then applied postoperatively.  The patient tolerated the above procedure and anesthesia well without complications.  The patient was transported from the operating room to the PACU with vital signs stable and vascular status intact to the right foot.  The patient was given postoperative pain prescription for Tylenol #3 and instructed to take one q4-6h. p.o. p.r.n. for pain.  The patient is to follow up with Dr. X in his office as directed.","orthopedic, austin/akin bunionectomy, hallucis brevis, bunion deformity, extensor hallucis, osteotomy site, foot, austin, bunionectomy "
" A woman presenting to our clinic for the first time for evaluation of hip pain, right greater than left, of greater than 2 years duration.  The pain is located laterally as well as anteriorly into the groin. ", Orthopedic, Bilateral Hip Pain ,"HISTORY OF PRESENT ILLNESS:  ,The patient is a 38-year-old woman presenting to our clinic for the first time for evaluation of hip pain, right greater than left, of greater than 2 years duration.  The patient states that she began with right hip pain getting steadily worse over the last 2 years and has now developed some pain in the left hip.  The pain is located laterally as well as anteriorly into the groin.  She states that the pain is present during activities such as walking, and she does get some painful popping and clicking in the right hip.  She is here for evaluation for the first time.  She sought no previous medical attention for this.,PAST MEDICAL HISTORY:  ,Significant for depression and reflux disease.,PAST SURGICAL HISTORY: , Cesarean section x 2.,CURRENT MEDICATIONS: , Listed in the chart and reviewed with the patient.,ALLERGIES:  ,The patient has no known drug allergies.,SOCIAL HISTORY:  ,The patient is married.  She is employed as an office manager.  She does smoke cigarettes, one pack per day for the last 20 years.  She consumes alcohol 3 to 5 drinks daily.  She uses no illicit drugs.  She exercises monthly mainly walking and low impact aerobics.  She also likes to play softball.,REVIEW OF SYSTEMS: , Significant for occasional indigestion and nausea as well as anxiety and depression.  The remainder of the systems negative.,PHYSICAL EXAMINATION: , The patient is 5 foot, 2 inches tall, weighs 155 pounds.  The patient ambulates independently without an assist device with normal stance and gait.  Inspection of the hips reveals normal contour and appearance and good symmetry.  The patient is able to do an active straight leg raise against gravity and against resistance bilaterally.  She has no significant trochanteric tenderness.  She does, however, have some tenderness in the groin bilaterally.  There is no crepitus present with passive or active range of motion of the hips.  She is grossly neurologically intact in the bilateral lower extremities.,DIAGNOSTIC DATA:,  X-rays performed today in the clinic include an AP view of the pelvis and a frog-leg lateral of the right hip.  There are no acute findings.  No fractures or dislocations.  There are minimal degenerative changes noted in the joint.  There is, however, the suggestion of an exostosis on the superior femoral neck, which could be consistent with femoroacetabular impingement.,IMPRESSION: , Bilateral hip pain, right worse than left, possibly suggesting femoroacetabular impingement based on x-rays and her clinical picture is also consistent with possible labral tear.,PLAN:,  After discussing possible diagnoses with the patient, I have recommended that we get MRI arthrograms of the bilateral hips to evaluate the anatomy and especially concentrating on the labrum in the right hip.  We will get that done as soon as possible.  In the meantime, she is asked to moderate her activities.  She will follow up as soon as the MRIs are performed.","orthopedic, bilateral hip pain, femoroacetabular, impingement, hip,"
 Decreased ability to perform daily living activities secondary to exacerbation of chronic back pain., Orthopedic, Back Pain - Discharge Summary ,"CHIEF COMPLAINT: , Decreased ability to perform daily living activities secondary to exacerbation of chronic back pain.,HISTORY OF PRESENT ILLNESS:,  The patient is a 45-year-old white male who was admitted with acute back pain.  The patient reports that he had chronic problem with back pain for approximately 20 years, but it has gotten progressively worse over the last 3 years.  On 08/29/2007, the patient had awoken and started his day as he normally does, but midday, he reports that he was in such severe back pain and he was unable to walk or stand upright.  He was seen at ABCD Hospital Emergency Room, was evaluated and admitted.  He was treated with IV analgesics as well as Decadron, after being evaluated by Dr. A.  It was decided that the patient could benefit from physical therapy, since he was unable to perform ADLs, and was transferred to TCU at St. Joseph Health Services on 08/30/2007.  He had been transferred with diagnosis of a back pain secondary to intravertebral lumbar disk disease, secondary to degenerative changes.  The patient reports that he has had a "" bulging disk"" for approximately 1 year.  He reports that he has history of testicular cancer in the distant past and the most recent bone scan was negative.  The bone scan was done at XYZ Hospital, ordered by Dr. B, the patient's oncologist.,ALLERGIES: , PENICILLIN, AMOXICILLIN, CEPHALOSPORIN, DOXYCYCLINE, IVP DYE, IODINE, and SULFA, all cause HIVES.,Additionally, the patient reports that he has HIVES when he comes in contact with SAP FROM THE MANGO TREE, and therefore, he avoids any mango product at all.,PAST MEDICAL HISTORY: , Status post right orchiectomy secondary to his testicular cancer 18 years ago approximately 1989, GERD, irritable bowel syndrome, seasonal asthma (fall and spring) triggered by postnasal drip, history of bilateral carpal tunnel syndrome, and status post excision of abdominal teratoma and incisional hernia.,FAMILY HISTORY:,  Noncontributory.,SOCIAL HISTORY: , The patient is employed in the finance department.  He is a nonsmoker.  He does consume alcohol on the weekend as much as 3 to 4 alcoholic beverages per day on the weekends.  He denies any IV drug use or abuse.,REVIEW OF SYSTEMS: , No chills, fever, shakes or tremors.  Denies chest pain palpitations, hemoptysis, shortness of breath, nausea, vomiting, diarrhea, constipation or hematemesis.  The patient reports that his last bowel movement was on 08/30/2007.  No urological symptoms such as dysuria, frequency, incomplete bladder emptying or voiding difficulties.  The patient does report that he has occasional intermittent ""numbness and tingling"" of his hands bilaterally as he has a history of bilateral carpal tunnel syndrome.  He denies any history of seizure disorders, but he did report that he had some momentary dizziness earlier, but that has since resolved.,PHYSICAL EXAMINATION:,VITAL SIGNS:  At the time of admission, temperature 98, blood pressure 176/97, pulse 86, respirations 20, and 95% O2 saturation on room air.  The patient weighs 260 pounds and is 5 feet and 10 inches tall by his report.,GENERAL:  The patient appears to be comfortable, in no acute distress.,HEENT:  Normocephalic.  Sclerae are nonicteric.  EOMI.  Tongue is at midline and no evidence of thrush.,NECK:  Trachea is at the midline.,LYMPHATICS:  No cervical or axillary nodes palpable.,LUNGS:  Clear to auscultation bilaterally.,HEART:  Regular rate and rhythm.  Normal S1 and S2.,ABDOMEN:  Obese, softly protuberant, and nontender.,EXTREMITIES:  There is no clubbing, cyanosis or edema.  There is no calf tenderness bilaterally.  Bilateral strength is 5/5 for the upper extremities bilaterally and he has 5/5 of left lower extremity.  The right lower extremity is 4-5/5.,MENTAL STATUS:  He is alert and oriented.  He was pleasant and cooperative during the examination.,ASSESSMENT:,1.  Acute on chronic back pain.  The patient is admitted to the TCU at St. Joseph Health Services for rehabilitation therapy.  He will be seen in consultation by Physical Therapy and Occupational Therapy.  He will continue a tapering dose of Decadron over the next 10 to 14 days and a tapering schedule has been provided, also Percocet 5/325 mg 1 to 2 tablets q.i.d. p.r.n. for pain.,2.  Status post right orchiectomy secondary to testicular cancer, stable at this time.  We will attempt to obtain copy of the most recent bone scan performed at XYZ Hospital ordered by Dr. B.,3.  Gastroesophageal reflux disease, irritable bowel syndrome, and gastrointestinal prophylaxis.  Colace 100 mg b.i.d., lactulose will be used on a p.r.n. basis, and Protonix 40 mg daily.,4.  Deep vein thrombosis prophylaxis will be maintained by the patient, continue to engage in his therapies including ambulating in the halls and doing leg exercises as well.,5.  Obesity.  As mentioned above, the patient's weighs 260 pounds with a height of 5 feet and 10 inches, and we had discussed possible weight loss plan, which he is interested in pursuing and a dietary consult has been requested.",
" Tailor's bunionectomy with metatarsal osteotomy of the left fifth metatarsal.  Excision of nerve lesion with implantation of the muscle belly of the left second interspace.  Excision of nerve lesion in the left third interspace.
", Orthopedic, Bbunionectomy & Metatarsal Osteotomy ,"PREOPERATIVE DIAGNOSIS:  ,Tailor's bunion and neuroma of the second and third interspace of the left foot.,POSTOPERATIVE DIAGNOSIS:, Tailor's bunion and neuroma of the second and third interspace, left foot.,PROCEDURE PERFORMED:,1.  Tailor's bunionectomy with metatarsal osteotomy of the left fifth metatarsal.,2.  Excision of nerve lesion with implantation of the muscle belly of the left second interspace.,3.  Excision of nerve lesion in the left third interspace.,ANESTHESIA:  ,Monitored IV sedation with local.,HISTORY:  ,This is a 37-year-old female who presents to ABCD's preoperative holding area, n.p.o. since mid night, last night for surgery of her painful left second and third interspaces and her left fifth metatarsal.  The patient has attempted conservative correction and injections with minimal improvement.  The patient desires surgical correction at this time.  The patient states that her pain has been increasingly worsening with activity and with time and it is currently difficult for her to ambulate and wear shoes.  At this time, the patient desires surgical intervention and correction.  The risks versus benefits of the procedure have been explained to the patient in detail by Dr. X and consent was obtained.,PROCEDURE IN DETAIL: , After an IV was instituted by the Department of Anesthesia in the preoperative holding area, the patient was taken to the Operating Suite via cart and placed on the operating table in the supine position.  A safety strap was placed across her waist for protection.,Next, a pneumatic ankle tourniquet was applied around her left ankle over copious amounts of Webril for the patient's protection.  After adequate IV sedation was administered by the Department of Anesthesia, a total of 20 cc of a mixture of 4.5 cc of 1% lidocaine plain, 4.5 cc of 0.5% Marcaine plain, and 1 cc of Solu-Medrol per 10 cc dose was administered to the patient for local anesthesia.  The foot was then prepped and draped in the usual sterile orthopedic manner.  The foot was then elevated and a tourniquet was then placed at 230 mmHg after applying Esmarch bandage.  The foot was then lowered down the operative field and sterile stockinet was draped.  The stockinet was then reflected.  Attention was then directed to the second intermetatarsal interspace.  After testing the anesthesia, a 4 cm incision was placed using a #10 blade over the dorsal surface of the foot in the second intermetatarsal space beginning from proximal third of the metatarsals distally to and beyond the metatarsal head.  Then, using #15 blade the incision was deepened through the skin into the subcutaneous tissue.  Care was taken to identify and avoid or to cauterize any local encountered vascular structures.  Incision was deepened using the combination of blunt and dull dissection using Mayo scissors, hemostat, and a #15 blade.  The incision was deepened distally down to the level of the deep transverse metatarsal ligament which was reflected and exposure of the intermetatarsal space was appreciated.  The individual branches of the plantar digital nerve were identified extending into the second and third digits plantarly.  These endings were dissected distally and cut at their most distal portions.  Following this, the nerve was dissected proximally into the common nerve and dissected proximally into the proximal portion of the intermetatarsal space.  Using careful meticulous dissection, there was noted to a be a enlarged bulbous mass of fibers and nerve tissue embedded with the adipose tissue.  This was also cut and removed.  The proximal portion of the nerve stump was identified and care was taken to suture this into the lumbrical muscle to leave no free nerve ending exposed.  Following this, the interspace was irrigated with copious amounts of sterile saline and interspace explored for any other portions of nerve which may been missed on the previous dissection.  It was noted that no other portions of the nerve were detectable and the proximal free nerve ending was embedded and found to be ________ the lumbrical muscle belly.  Following this, the interspace was packed using iodoform gauze packing and was closed in layers with the packing extruding from the wound.  Attention was then directed to the third interspace where in a manner as mentioned before.  A dorsal linear incision which measured 5 cm was made over the third interspace extending from the proximal portion of the metatarsal distally to the metatarsal head.  Like before, using a combination of blunt and dull dissection, with sharp dissection the incision was deepened down with care taken to cauterize all retracting vascular structures which were encountered.,The incision was deepened down to the level of the subcutaneous tissue and then down deeper to the interspace of the third and fourth metatarsal.  The dissection was deepened distally down to the level of the transverse intermetatarsal ligament, where upon this was reflected and the nerve fibers to the third and fourth digit plantarly were identified.  These were once again dissected distally out and transected at their most distal portions.  Care was then taken to dissect the nerve proximally into the proximal metatarsal region.  No other branches of the nerve were identified and the nerve in its entirety along with fibrous tissue encountered in the area was removed.  The proximal portion of the nerve which remained was not large enough to suture into lumbrical muscle as was done in the previous interspace.  Half of the nerve was transected proximally as was feasible and no exposed ending was noted.  Incision was then flushed and irrigated using sterile saline.  Following this, the incision wound was packed with iodoform gauze packed and closed in layers using as before #4-0 Vicryl and #4-0 nylon suture.,Following this, attention was directed to the fifth metatarsal head where a lateral 4 cm incision was placed along the lateral distal shaft and head of the fifth metatarsal using a fresh #10 blade.  The incision was then deepened using #15 blade down to the level of the subcutaneous tissue.  Care was taken to reflect any neurovascular structures which were encountered.  Following this the incision was deepened down to the level of the periosteum and periosteum was reflected, using the sharp dissection, to expose the head of the metatarsal along with the neck region.  After adequate exposure of the fifth metatarsal head was achieved, an oblique incision directed from distal lateral to proximal medial in a sagittal plane was performed and the head of the fifth metatarsal was shifted medially.  Following this, an OrthoSorb pin was retrograded through the fifth metatarsal head into the neck of the fifth metatarsal and was cut off first with the lateral surfaces of bone.  OrthoSorb pin was noted to be intact and the fifth metatarsal head was in good alignment and position.  Following this, the sagittal saw and the #138 blade were used to provide rasping and smoothing of the sharp acute edges of bone laterally.  Following this, the periosteum was closed using #4-0 Vicryl and the skin was closed in layers using #4-0 Vicryl and closed with running subcuticular #4-0 Monocryl suture.  Upon completion of this, the foot was noted to be in good position with good visual alignment of the fifth metatarsal head and digit.  The incisions in foot were then ________ draped in the normal manner using Owen silk, 4 x 4s, Kling, and Kerlix and covered with Coban bandage.  The tourniquet was then deflated with the total tourniquet time of 103 minutes at 230 mmHg and immediate hyperemia was noted to end digits one through five of the left foot.,The patient was then transferred to the cart and was escorted to the Postanesthesia Care Unit with vital signs stable and vascular status intact.  The patient tolerated the procedure well without any complications.  The patient was then given prescriptions for Vicoprofen #30 and Augmentin #14 to be taken twice daily.  The patient was instructed to followup with Dr. X after the weekend on Tuesday in his office.  The patient also given postoperative instructions and was placed in a postoperative shoe and instructed to limit weightbearing to the heel only, ice and elevate her foot 20 minutes every hour as tolerated.  The patient also instructed to take her medications and prescriptions as directed.  She was given the emergency contact numbers.  Postoperative x-rays were taken and the patient was discharged home in stable condition upon conclusion of this.","orthopedic, tailor's bunion, neuroma, nerve lesion, interspace, metatarsal, osteotomy, metatarsal osteotomy, metatarsal head, foot, distally, head, incision, nerve, intermetatarsal, portions,"
 Back injury with RLE radicular symptoms.  The patient is a 52-year-old male who is here for independent medical evaluation., Orthopedic, Back Injury IME ,"PAST MEDICAL CONDITION:,  None.,ALLERGIES:,  None.,CURRENT MEDICATION:,  Zyrtec and hydrocodone 7.5 mg one every 4 to 6 hours p.r.n. for pain.,CHIEF COMPLAINT: , Back injury with RLE radicular symptoms.,HISTORY OF PRESENT ILLNESS:,  The patient is a 52-year-old male who is here for independent medical evaluation.  The patient states that he works for ABC ABC as a temporary worker.  He worked for ABCD too.  The patient's main job was loading and unloading furniture and appliances for the home.  The patient was approximately there for about two and a half weeks.  Date of injury occurred back in October.  The patient stating that he had history of previous back problems ongoing; however, he states that on this particular day back in October, he was unloading an 18-wheeler at ABC and he was bending down picking up boxes to unload and load.  Unfortunately at this particular event, the patient had sharp pain in his lower back.  Soon afterwards, he had radiating symptoms down his right buttock all the way down to the lateral part of his leg crossing his knee.  This became progressively worse.  He also states that some of his radiating pain went down to his left leg as well.  He noticed increase in buttock spasm and also noticed spasm in his buttocks.  He initially saw Dr. Z and was provided with some muscle relaxer and was given some pain patches or Lidoderm patch, I believe.  The patient states that after this treatment, his symptoms still persisted.  At this point, the patient later on was referred to Dr. XYZ through the workmen's comp and he was initially evaluated back in April.  After the evaluation, the patient was sent for MRI, was provided with pain medications such as short-acting opioids.  He was put on restricted duty.  The MRI essentially came back negative, but the patient continued to have radiating symptoms down to his lower extremity and subsequently the patient was essentially released by Dr. XYZ in June with maximum medical improvement.,Unfortunately, the patient continued to have persistence of back pain and radiating symptoms down to his leg and went back to see Dr. XYZ again, and at this point, the patient was provided with further medication management and sent for Pain Clinic referral.  The patient also was recommended for nerve block at this point and the patient received epidural steroid injection by Dr. ABC without any significant relief.  The patient also was sent for EMG and nerve conduction study, which was performed by Dr. ABCD and the MRI, EMG, and nerve conduction study came back essentially negative for radiculopathy, which was performed by Dr. ABCD.  The patient states that he continues to have pain with extended sitting, he has radiating symptoms down to his lower extremity on the right side of his leg, increase in pain with stooping.  He has difficulty sleeping at nighttime because of increase in pain.  Ultimately, the patient was returned back to work in June, and deemed with maximum medical improvement back in June.  The patient unfortunately still has significant degree of back pain with activities such as stooping and radicular symptoms down his right leg, worse than the left side.  The patient also went to see Dr. X who is a chiropractic specialist and received eight or nine visits of chiropractic care without long-term relief in his overall radicular symptoms.,PHYSICAL EXAMINATION:,  The patient was examined with the gown on.  Lumbar flexion was moderately decreased.  Extension was normal.  Side bending to the right was decreased.  Side bending to the left was within normal limits.  Rotation and extension to the right side was causing increasing pain.  Extension and side bending to the left was within normal limits without significant pain on the left side.  While seated, straight leg was negative on the LLE at 90° and also negative on the RLE at 90°.  There was no true root tension sign or radicular symptoms upon straight leg raising in the seated position.  In supine position, straight leg was negative in the LLE and also negative on the RLE.  Sensory exam shows there was a decrease in sensation to the S1 dermatomal distribution on the right side to light touch and at all other dermatomal distribution was within normal limits.  Deep tendon reflex at the patella was 2+/4 bilaterally, but there was a decrease in reflex in the Achilles tendon 1+/4 on the right side and essentially 2+/4 on the left side.  Medial hamstring reflex was 2+/4 on both hamstrings as well.  On prone position, there was tightness in the paraspinals and erector spinae muscle as well as tightness on the right side of the quadratus lumborum area, right side was worse than the left side.  Increase in pain at deep palpatory examination in midline of the L5 and S1 level.,MEDICAL RECORD REVIEW:,  I had the opportunity to review Dr. XYZ's medical records.  Also reviewed Dr. ABC procedural note, which was the epidural steroid injection block that was performed in December.  Also, reviewed Dr. X's medical record notes and an EMG and nerve study that was performed by Dr. ABCD, which was essentially normal.  The MRI of the lumbar spine that was performed back in April, which showed no evidence of herniated disc.,DIAGNOSIS: , Residual from low back injury with right lumbar radicular symptomatology.,EVALUATION/RECOMMENDATION:,  The patient has an impairment based on AMA Guides Fifth Edition and it is permanent.  The patient appears to have re-aggravation of the low back injury back in October related to his work at ABC when he was working unloading and loading an 18-wheel truck.  Essentially, there was a clear aggravation of his symptoms with ongoing radicular symptom down to his lower extremity mainly on the right side more so than the left.  The patient also has increase in back pain with lumbar flexion and rotational movement to the right side.  With these ongoing symptoms, the patient has also decrease in activities of daily living such as mobility as well as decrease in sleep pattern and general decrease in overall function.  Therefore, the patient is assigned 8% impairment of the whole person.  We are able to assign this utilizing the Fifth Edition on spine section on the AMA guide.  Using page 384, table 15-3, the patient does fall under DRE Lumbar Category II under criteria for rating impairment due to lumbar spine injury.  In this particular section, it states that the patient's clinical history and examination findings are compatible with specific injury; and finding may include significant muscle guarding or spasm observed at the time of examination, a symmetric loss of range of motion, or non-verifiable radicular complaints define his complaints of radicular pain without objective findings; no alteration of the structural integrity and no significant radiculopathy.  The patient also has decrease in activities of daily living; therefore, the patient is assigned at the higher impairment rating of 8% WPI.  In the future, the patient should avoid prolonged walking, standing, stooping, squatting, hip bending, climbing, excessive flexion, extension, and rotation of his back.  His one time weight limit should be determined by work trial, although the patient should continue to be closely monitored and managed for his pain control by the specific specialist for management of his overall pain.  The patient although has a clear low back pain with certain movements such as stooping and extended sitting and does have a clear radicular symptomatology, the patient also should be monitored closely for specific dependency to short-acting opioids in the near future by specialist who could monitor and closely follow his overall pain management.  The patient also should be treated with appropriate modalities and appropriate rehabilitation in the near future.,","orthopedic, rle, radicular symptoms, independent medical evaluation, injury, lle, deep tendon reflex, emg, mri, lumbar radicular symptomatology,"
 Bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy.  Chronic pain syndrome., Orthopedic, Back & Leg Pain - Discharge Summary ,"ADMISSION DIAGNOSIS: , Bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy.,SECONDARY DIAGNOSIS:,  Chronic pain syndrome.,PRINCIPAL PROCEDURE: , L5 Gill procedure with interbody and posterolateral (360 degrees circumferential) arthrodesis using cages, bone graft, recombinant bone morphogenic protein, and pedicle fixation.  This was performed by Dr. X on 01/08/08.,BRIEF HISTORY OF HOSPITAL COURSE: , The patient is a man with a history of longstanding back, buttock, and bilateral leg pain.  He was evaluated and found to have bilateral pars defects at L5-S1 with spondylolysis and instability.  He was admitted and underwent an uncomplicated surgical procedure as noted above.  In the postoperative period, he was up and ambulatory.  He was taking p.o. fluids and diet well.  He was afebrile.  His wounds were healing well.  Subsequently, the patient was discharged home.,DISCHARGE MEDICATIONS: , Discharge medications included his usual preoperative pain medication as well as other medications.,FOLLOWUP:  ,At this time, the patient will follow up with me in the office in six weeks' time.  The patient understands discharge plans and is in agreement with the discharge plan.  He will follow up as noted","orthopedic, chronic pain syndrome, spinal instability, pars defects, radiculopathy, spondylolysis, leg"
" Ruptured distal biceps tendon, right elbow.  Repair of distal biceps tendon, right elbow.", Orthopedic, Biceps Tendon Repair ,"PREOPERATIVE DIAGNOSIS: , Ruptured distal biceps tendon, right elbow.,POSTOPERATIVE DIAGNOSIS:,  Ruptured distal biceps tendon, right elbow.,PROCEDURE PERFORMED: , Repair of distal biceps tendon, right elbow.,PROCEDURE:  ,The patient was taken to OR, Room #2 and administered a general anesthetic.  The right upper extremity was then prepped and draped in the usual manner.  A sterile tourniquet was placed on the proximal aspect of the right upper extremity.  The extremity was then elevated and exsanguinated with an Esmarch bandage and tourniquet was inflated to 250 mmHg.  Tourniquet time was 74 minutes.  A curvilinear incision was made in the antecubital fossa of the right elbow down through the skin.  Hemostasis was achieved utilizing electrocautery.  Subcutaneous fat was separated and the skin flaps elevated.  The _________ was identified.  It was incised.  The finger was placed approximately up the anterior aspect of the arm and the distal aspect of the biceps tendon was found.  There was some serosanguineous fluid from the previous rupture.  This area was suctioned clean.  The biceps tendon ends were then placed over a sterile tongue blade and were then sharply cut approximately 5 mm to 7 mm from the tip to create a fresh surface.  At this point, the #2 fiber wire was then passed through the tendon.  Two fiber wires were utilized in a Krackow-type suture.  Once this was completed, dissection was taken digitally down into the antecubital fossa in the path where the biceps tendon had been previously.  The radial tuberosity was palpated.  Just ulnar to this, a curved hemostat was passed through the soft tissues and was used to tent the skin on the radial aspect of the elbow.  A skin incision was made over this area.  Approximately two inches down to the skin and subcutaneous tissues, the fascia was split and the extensor muscle was also split.,A stat was then attached through the tip of that stat and passed back up through the antecubital fossa.  The tails of the fiber wire suture were grasped and pulled down through the second incision.  At this point, they were placed to the side.  Attention was directed at exposure of the radial tuberosity with a forearm fully pronated.  The tuberosity came into view.  The margins were cleared with periosteal elevator and sharp dissection.  Utilizing the power bur, a trough approximately 1.5 cm wide x 7 mm to 8 mm high was placed in the radial tuberosity.  Three small drill holes were then placed along the margin for passage of the suture.  The area was then copiously irrigated with gentamicin solution.  A #4-0 pullout wire was utilized to pass the sutures through the drill holes, one on each outer hole and two in the center hole.  The elbow was flexed and the tendon was then pulled into the trough with the forearm supinated.  The suture was tied over the bone islands.  Both wounds were then copiously irrigated with gentamicin solution and suctioned dry.  Muscle fascia was closed with running #2-0 Vicryl suture on the lateral incision followed by closure of the skin with interrupted #2-0 Vicryl and small staples.  The anterior incision was approximated with interrupted #2-0 Vicryl for Subq. and then skin was approximated with small staples.  Both wounds were infiltrated with a total of 30 cc of 0.25% Marcaine solution for postop analgesia.  A bulky fluff dressing was applied to the elbow, followed by application of a long-arm plaster splint maintaining the forearm in the supinated position.  Tourniquet was inflated prior to application of the splint.  Circulatory status returned to the extremity immediately.  The patient was awakened.  He was rather boisterous during his awakening, but care was taken to protect the right upper extremity.  He was then transferred to the recovery room in apparent satisfactory condition.","orthopedic, ruptured distal biceps tendon, gentamicin solution, antecubital fossa, distal biceps, biceps tendon, tendon, tuberosity, biceps, elbow,"
" Austin-Moore bipolar hemiarthroplasty, left hip utilizing a medium fenestrated femoral stem with a medium 0.8 mm femoral head, a 50 mm bipolar cup.  Displace subcapital fracture, left hip.", Orthopedic, Austin-Moore Bipolar Hemiarthroplasty ,"PREOPERATIVE DIAGNOSIS:,  Displace subcapital fracture, left hip.,POSTOPERATIVE DIAGNOSIS: , Displace subcapital fracture, left hip.,PROCEDURE PERFORMED: , Austin-Moore bipolar hemiarthroplasty, left hip utilizing a medium fenestrated femoral stem with a medium 0.8 mm femoral head, a 50 mm bipolar cup.,PROCEDURE: , The patient was taken to OR #2, administered a subarachnoid block anesthetic and was then positioned in the right lateral decubitus position on the beanbag on the operative table.  The right lower extremity was protectively padded.  The left leg was propped with multiple blankets.  The hip was then prepped and draped in the usual manner.  A posterior incision was made on the posterolateral aspect of the left hip down to the skin and subcutaneous tissues.  Hemostasis was achieved utilizing electrocautery.  Gluteus fascia was incised in line with a skin incision and the muscle was split posteriorly.  The external rotators were identified after removal of the trochanteric bursa.  Hemostat was utilized to separate the external rotators from the underlying capsule, they were then transected off from their attachment at the posterior intertrochanteric line.  They were then reflected distally.  The capsule was then opened in a T-fashion utilizing the cutting cautery.  Fraction hematoma exuded from the hip joint.  The cork screw was then impacted into the femoral head and it was removed from the acetabulum.  Bone fragments were removed from the neck and acetabulum.  The acetabulum was then inspected and noted to be free from debris.  The proximal femur was then delivered into the wound with the hip internally rotated.,A mortise chisel was then utilized to take the cancellous bone from the proximal femur.  The T-handle broach was then passed down the canal.  The canal was then sequentially broached up to a medium broach.  The calcar was then plained with the hand plainer.  The trial components were positioned into place.  The medium component fit fairly well with the medium 28 mm femoral head.  Once the trial reduction was performed, the hip was taken through range of motion.  There was physiologic crystalling with longitudinal traction.  There was no tendency towards dislocation with flexion of the hip past 90 degrees.  The trial implants were then removed.  The acetabulum was then copiously irrigated with gentamicin solution and suctioned dry.  The medium fenestrated femoral stem was prepared by placing a large segment of bone from the femoral head into the fenestration making it a little larger than the width of the implant to provide a press fit.  The implant was then impacted into place.  The 28 mm femoral head was impacted on the mortise stapler of the femoral stem followed by placement of the 50 mm bipolar cup.  The acetabulum was once again inspected, was free of debris.  The hip was reduced.  It was taken through full range of motion.  There was no tendency for dislocation.  The wound was copiously irrigated with gentamicin solution.  The capsule was then repaired with interrupted #1 Ethibond suture.  External rotators were then reapproximated to the posterior intertrochanteric line utilizing #1 Ethibond in a modified Kessler type stitch.  The wound was once again copiously irrigated with gentamicin solution and suctioned dry.  Gluteus fascia was approximated with interrupted #1 Ethibond.  Subcutaneous layers were approximated with interrupted #2-0 Vicryl and skin approximated with staples.  A bulky dressing was applied to the wound.  The patient was then transferred to the hospital bed, an abductor pillow was positioned into place.  Circulatory status was intact to the extremity at completion of the case.","orthopedic, austin moore, bipolar hemiarthroplasty, femoral head, femoral, hip, hemiarthroplasty, ethibond, acetabulum,"
" Diagnostic arthroscopy exam under anesthesia, left shoulder.  Debridement of chondral injury, left shoulder.  Debridement, superior glenoid, left shoulder.  Arthrotomy.  Bankart lesion repair.  Capsular shift, left shoulder (Mitek suture anchors; absorbable anchors with nonabsorbable sutures).", Orthopedic," Arthroscopy, Arthrotomy, Bankart lesion repair ","TITLE OF OPERATION:,1.  Diagnostic arthroscopy exam under anesthesia, left shoulder.,2.  Debridement of chondral injury, left shoulder.,3.  Debridement, superior glenoid, left shoulder.,4.  Arthrotomy.,5.  Bankart lesion repair.,6.  Capsular shift, left shoulder (Mitek suture anchors; absorbable anchors with nonabsorbable sutures).,INDICATION FOR SURGERY: , The patient was seen multiple times preoperatively and found to have chronic instability of her shoulder.  Risks and benefits of the procedure had been discussed in length including but not exclusive of infection, nerve or artery damage, stiffness, loss of range of motion, incomplete relief of pain, continued instability, recurrent instability, medical complications, surgical complications, and anesthesia complications.  The patient understood and wishes to proceed.,PREOP DIAGNOSIS: , Anterior instability, left shoulder.,POSTOP DIAGNOSES:,1.  Anterior instability, left shoulder.,2.  Grade 4 chondromalacia, 10% humeral head, chondral defect 1 cm squared, left shoulder.,3.  Type 1 superior labrum anterior and posterior lesion, left shoulder.,4.  Anteroinferior glenoid erosions 10% bony surface, left shoulder.,5.  Bankart lesion, left shoulder.,PROCEDURE: , The patient was placed in a supine position and both shoulders examined systematically.  She had full range of motion with no joint adhesions.  She had equal range of motion bilaterally.  She had Hawkins 2 anteriorly and posteriorly in both shoulders with a grade 1 sulcus sign in both shoulders.  This was the same when the arm was in neutral or in external rotation.  The patient was then turned to right lateral decubitus position, axillary roll was placed, and beanbag was inflated.  Peroneal nerve was well protected.  All bony prominences were well protected.,The left upper extremity was then prepped and draped in the usual sterile fashion.  The patient was given antibiotics well before the start of the procedure to decrease the risk of infection.  The arm was placed in a arm holder with 10 pounds of traction.  A posterior portal was created in the usual manner by isolating gently with the spinal needle, it was insufflated with 30 cubic centimeters of saline.  A small incision was made after infiltrating the skin with Marcaine and epinephrine.  The scope was introduced into the shoulder with no difficulty.  It was then examined systematically.  The patient did have diffuse synovitis throughout her shoulder.  Her posterior humeral head showed an enlarged bold spot with some other areas of chondromalacia on the posterior head.  She also had an area 1 cm in diameter, which was on more central portion of the head and more inferiorly which appeared to be more of an impaction-type injury.  This had some portions of fibrillated and loose cartilage, hanging from the edges.  These were later debrided, but the dissection was proximally 10 to 15% of the humeral surface.,The biceps tendon appeared to be normal.  The supraspinatus, infraspinatus tendons were normal.  The inferior pouch was normal with no capsular tearing and no HAGL lesions.  The posteroinferior labrum was normal as well as the posterosuperior labrum.  There was some fraying in the posterosuperior labrum, which was later debrided.  It was found essentially to be a type 1 lesion anteriorly and superiorly.  The anterosuperior labrum appeared to be detached, which appeared to be more consistent with a sublabral hole.  The middle glenohumeral ligament was present as an entire sheath, but attach to the labrum.  The labrum did appeared to be detached from the anterior glenoid from the 11 o'clock position all the way down to the 6 o'clock position.  The biceps anchor itself was later probed and found to be stable and normal.  The subscapularis tendon was normal.  The anterior band of the glenohumeral ligament was present, but it was clearly avulsed off the glenoid.  There was some suggestion of anteroinferior bony erosions, which was later substantiated when the shoulder was opened.  The patient was missing about 10 to 15% of her anteroinferior glenoid rim.  The patient had a positive drive-through sign.,The arm was then moved to lateral and placed through range of motion.  There was contact of the rotator cuff to the superior glenoid in flexion at 115 degrees, maximum flexion was 150 degrees.  The arm abducted and externally rotated.  There was contact to the rotator cuff with posterosuperior labrum.  This occurred with the arm position of 90 degrees with abduction at 55 degrees of external rotation.  It should be noted that the maximum abduction is 150 degrees and with the arm abducted 90 degrees, maximum external rotation was 95 degrees.  The patient did have a positive relocation maneuver.  The posterior labrum did appear to tilt-off, but did not appear to peel off.,The arm was then placed back in the arm holder.  Anterior portal was created with Wissinger rod.  A blue cannula was inserted into the shoulder without difficulty.  Shaver was introduced in the labrum.  Also the area of chondromalacia as mentioned above was debrided.  The labrum was found to be stable with only a type 1 SLAP lesion, and there was no evidence as there was really a type 2 SLAP lesion.  The instruments were then removed along with excess fluid.  The posterior portals were closed with single 4-0 nylon suture.  The anterior portal was left open.  The patient was then placed in a supine position, and the extremity was reprepped and draped in anticipation of performing open capsular shift.,The patient's anterior incision made just lateral to the coracoid in the skin line.  Mediolateral skin flaps were developed, and cephalic vein was identified and protected throughout the case.  The interval was developed down the clavipectoral fascia.  The conjoined tendon was retracted medially and the deltoid laterally.  The patient's subscapularis was intact, and the subscapularis split was then made between the upper one half and lower one half in line with muscle fibers.  The capsule could easily be detached from the muscle, and the interval developed very easily.  A retractor was placed inferiorly to protect the axillary nerve.  Then Gelpi retractor was used to hold the subscapularis split open.,Next, an arthrotomy was made down at the 9 o'clock position.  The labrum was identified and found to be attached all the way down to 6 o'clock position.  The inferior flap was then created in a usual manner and tied with a 0 Vicryl suture.  The patient's glenoid rim did have some erosion as mentioned above with some bone loss and flattening.  This was debrided with the soft tissue.  Three Mitek suture anchors were then placed into the glenoid rim right at the margin of articular cartilage to the scapular neck.  These were absorbable anchors with nonabsorbable sutures.  They had excellent fixation once they had been placed.,Next, the capsular shift and Bankart repair were performed in the usual manner with the number 2 Ti-Cron sutures as an outside in and then inside out technique.  This brought the capsule right up to the edge of the glenoid rim.  With the arm in internal rotation and posterior pressure on the head, the capsule was then secured to the rim with no difficulty under direct visualization.  The capsule did come right up into the joint as expected with this type of repair.  The superior flap was then closed, the inferior flap over the superior anchor.  The interval between two flaps was closed with multiple number 2 Ti-Cron sutures.  Once this has been completed, there was no tension on the repair with the arm to side until 10 degrees of external rotation was reached.  The arm abducted 90 degrees.  There was tension on the repair until 20 degrees of external rotation reached.,The wound was thoroughly irrigated throughout with antibiotic-impregnated irrigation.  The subscapularis split was closed with interrupted 0 Vicryl sutures.  The deep subcutaneous tissues were closed with interrupted 0 Vicryl sutures.  The superficial subcutaneous tissues were closed with number 2-0 Vicryl sutures.  The skin was closed with 4-0 subcuticular Prolene, reinforced with Steri-Strips.  A sterile bandage was applied along with a cold therapy device and a shoulder immobilizer.  The patient was sent to the recovery room in stable and satisfactory condition.","orthopedic, diagnostic arthroscopy, chondral injury, debridement, superior glenoid, arthrotomy, bankart lesion, capsular shift, mitek suture, absorbable anchors, anterior instability, chondromalacia, superior labrum, glenoid erosion, glenoid rim, external rotation, glenoid, labrum, shoulder, arthroscopy, "
" Austin bunionectomy with internal screw fixation, first metatarsal, left foot.", Orthopedic, Austin Bunionectomy ,"TITLE OF OPERATION: , Austin bunionectomy with internal screw fixation, first metatarsal, left foot.,PREOPERATIVE DIAGNOSIS:,  Bunion deformity, left foot.,POSTOPERATIVE DIAGNOSIS: , Bunion deformity, left foot.,ANESTHESIA: , Monitored anesthesia care with 15 mL of 1:1 mixture of 0.5% Marcaine and 1% lidocaine plain.,HEMOSTASIS: , 45 minutes, left ankle tourniquet set at 250 mmHg.,ESTIMATED BLOOD LOSS:,  Less than 10 mL.,MATERIALS USED: , 2-0 Vicryl, 3-0 Vicryl, 4-0 Vicryl, as well as a 16-mm and an 18-mm partially threaded cannulated screw from the OsteoMed Screw Fixation System.,DESCRIPTION OF THE PROCEDURE:,  The patient was brought to the operating room and placed on the operating table in a supine position.  After adequate sedation was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's left foot to anesthetize the future surgical sites.  The left ankle was covered with cast padding and an 18-inch ankle tourniquet was placed around the left ankle and set at 250 mmHg.  The left foot was then prepped, scrubbed, and draped in normal sterile technique.  The left ankle tourniquet was inflated.  Attention was then directed on the dorsomedial aspect of the first left metatarsophalangeal joint where a 6-cm linear incision was placed directly over the first left metatarsophalangeal joint parallel and medial to the course of the extensor hallucis longus tendon to the left great toe.  The incision was deepened through subcutaneous tissues.  All the bleeders were identified, cut, clamped, and cauterized.  The incision was deepened to the level of the capsule and the periosteum of the first left metatarsophalangeal joint.  All the tendinous neurovascular structures were identified and retracted from the site to be preserved.  Using sharp and dull dissection, the periosteal and capsular attachments were mobilized from the head of the first left metatarsal.  The conjoint tendon was identified on the lateral plantar aspect of the base of the proximal phalanx of the left great toe and transversally resected from its insertion.  A lateral capsulotomy was also performed at the level of the first left metatarsophalangeal joint.  The dorsomedial prominence of the first left metatarsal head was adequately exposed using sharp dissection and resected with the use of a sagittal saw.  The same saw was used to perform an Austin-type bunionectomy on the capital aspect of the first left metatarsal head with its apex distal and its base proximal on the shaft of the first left metatarsal.  The dorsal arm of the osteotomy was longer than the plantar arm in order to accommodate for the future internal fixation.  The capital fragment of the first left metatarsal was then transposed laterally and impacted on the shaft of the first left metatarsal.  Provisional fixation was achieved with two smooth wires that were inserted vertically to the dorsal osteotomy in a dorsal distal to plantar proximal direction.  The same wires were also used as guide wires for the insertion of a 16-mm and an 18-mm partially threaded screws from the 3.0 OsteoMed System upon insertion of the screws, which was accomplished using AO technique.  The wires were removed.  Fixation on the table was found to be excellent.  Reduction of the bunion deformity was also found to be excellent and position of the first left metatarsophalangeal joint was anatomical.  The remaining bony prominence from the shaft of the first left metatarsal was then resected with a sagittal saw.  The area was copiously flushed with saline.  The periosteal and capsular tissues were approximated with 2-0 and 3-0 Vicryl suture material, 4-0 Vicryl was used to approximate the subcutaneous tissues.  The incision site was reinforced with Steri-Strips.  At this time, the patient's left ankle tourniquet was deflated.  The time was 45 minutes.  Immediate hyperemia was noted to the entire right lower extremity upon deflation of the cuff.  The patient's incision was covered with Xeroform, copious amounts of fluff and Kling, stockinette, and an Ace bandage.  The patient's left foot was then placed in a surgical shoe.  The patient was then transferred to the recovered room under the care of the anesthesia team with her vital signs stable and her vascular status at appropriate levels.  The patient was given pain medication and instructions on how to control her postoperative course.  The patient was discharged from Hospital according to nursing protocol and was advised to follow up with Dr. X in one week's time for her first postoperative appointment.","orthopedic, internal screw fixation, first metatarsal, bunion deformity, osteomed, screw fixation system, subcutaneous tissues, metatarsal head, austin bunionectomy, screw fixation, ankle tourniquet, metatarsophalangeal joint, austin, tourniquet, metatarsophalangeal, bunionectomy, foot, metatarsal,"
" Hemarthrosis, left knee, status post total knee replacement, rule out infection.  Arthrotomy, irrigation and debridement, and polyethylene exchange, left knee.  No complications were encountered throughout the procedure.", Orthopedic, Arthrotomy & I&D ,"PREOPERATIVE DIAGNOSIS: , Hemarthrosis, left knee, status post total knee replacement, rule out infection.,POSTOPERATIVE DIAGNOSIS: , Hemarthrosis, left knee, status post total knee replacement, rule out infection.,OPERATIONS:,1.  Arthrotomy, left total knee.,2.  Irrigation and debridement, left knee.,3.  Polyethylene exchange, left knee.,COMPLICATION: , None.,TOURNIQUET TIME:  ,58 minutes.,ESTIMATED BLOOD LOSS: , Minimal.,ANESTHESIA:  ,General.,INDICATIONS:  ,This patient underwent an uncomplicated left total knee replacement.  Postoperatively, unfortunately did not follow up with PT/INR blood test and he was taking Coumadin.  His INR was seemed to elevated and developed hemarthrosis.  Initially, it did look very benign, although over the last 24 hours it did become irritable and inflamed, and he therefore was indicated with the above-noted procedure.,This procedure as well as alternatives was discussed in length with the patient and he understood them well.  Risks and benefits were also discussed.  Risks such as bleeding, infection, damage to blood vessels, damage to nerve roots, need for further surgeries, chronic pain with range of motion, risk of continued discomfort, risk of need for further reconstructive procedures, risk of need for total knee revision, risk of blood clots, pulmonary embolism, myocardial infarction, and risk of death were discussed.  He understood them well.  All questions were answered and he signed consent for the procedure as described.,DESCRIPTION OF PROCEDURE: , The patient was placed on operating table and general anesthesia was achieved.  The left lower extremity was then prepped and draped in the usual sterile manner.  The leg was elevated and the tourniquet was inflated to 325 mmHg.  A longitudinal incision was then made and carried down through subcutaneous tissues.  This was made through the prior incision site.  There were some fatty necrotic tissues through the incision region and all necrotic tissue was debrided sharply on both sides of the incision site.  Medial and lateral flaps were then made.  The prior suture was identified, the suture removed and then a medial parapatellar arthrotomy was then performed.  Effusion within the knee was noted.  All hematoma was evacuated.  I then did flex the knee and removed the polyethylene.  Once the polyethylene was removed I did irrigate the knee with total of 9 liters of antibiotic solution.  Further debridement was performed of all inflamed tissue and thickened synovial tissue.  A 6 x 16-mm Stryker polyethylene was then snapped back in position.  The knee has excellent stability in all planes and I did perform a light manipulation to improve the flexion of the knee.  Further irrigation was performed on the all soft tissue in the knee with additional 3 liters of normal saline.  The knee was placed in a flexed position and the extensor mechanism was reapproximated using #2 Ethibond suture in a figure-of-eight manner.  The subcutaneous tissue was reapproximated in layers using #1 and 2-0 Vicryl sutures, and the skin was reapproximated using staples.  Prior to closure a Hemovac drain was inserted through a superolateral approach into the knee joint.,No complications were encountered throughout the procedure, and the patient tolerated the procedure well.  The patient was taken to recovery room in stable condition.","orthopedic,"
" Excision of capsular mass and arthrotomy with ostectomy of lateral femoral condyle, right knee.  Soft tissue mass and osteophyte lateral femoral condyle, right knee.", Orthopedic, Arthrotomy & Ostectomy & Capsular Mass Excision ,"PREOPERATIVE DIAGNOSIS:, Soft tissue mass, right knee.,POSTOPERATIVE DIAGNOSES:,1.  Soft tissue mass, right knee.,2.  Osteophyte lateral femoral condyle, right knee.,PROCEDURES PERFORMED:, Excision of capsular mass and arthrotomy with ostectomy of lateral femoral condyle, right knee.,SPECIFICATION: , The entire operative procedure was done in Inpatient Operating Suite, room #1 at ABCD General Hospital.  This was done under a local and IV sedation via the Anesthesia Department.,HISTORY AND GROSS FINDINGS:,  This is a 37-year-old African-American male with a mass present at the posterolateral aspect of his right knee.  On aspiration, it was originally attempted to no avail.  There was a long-standing history of this including two different MRIs, one about a year ago and one very recently both of which did not delineate the mass present.  During aspiration previously, the patient had experienced neuritic type symptoms down his calf, which have mostly resolved by the time that this had occurred.  The patient continued to complain of pain and dysfunction to his calf.  This was discussed with him at length.  He wished this to be explored and the mass excised even though knowing the possibility that they would not change his pain pattern with the potential of reoccurrence as well as the potential of scar stiffness, swelling, and peroneal nerve palsy.  With this, he decided to proceed.,Upon observation preoperatively, the patient was noted to have a hard mass present to the posterolateral aspect of the right knee.  It was noted to be tender.  It was marked preoperatively prior to an anesthetic.  Upon dissection, the patient was noted to have significant thickening of the posterior capsule.  The posterolateral aspect of the knee above the posterolateral complex at the gastroc attachment to the lateral femoral condyle.  There was also noted to be prominence of the lateral femoral condyle ridge.  The bifurcation at the tibial and peroneal nerves were identified and no neuroma was present.,OPERATIVE PROCEDURE:  ,The patient was laid supine upon the operating table.  After receiving IV sedation, he was placed prone.  Thigh tourniquet was placed.  He was prepped and draped in the usual sterile manner.  A transverse incision was carried down across the crease with a mass had been palpated through skin and subcutaneous tissue after exsanguination of the limb and tourniquet utilized.  The nerve was identified and carefully retracted throughout the case.  Both nerves were identified and carefully retracted throughout the case.  There was noted to be no neuroma present.  This was taken down until the gastroc was split.  There was gross thickening of the joint capsule and after arthrotomy, a section of the capsule was excised.  The lateral femoral condyle was then osteophied.  We then smoothed off with a rongeur.  After this, we could not palpate any mass whatsoever placing pressure upon the area of the nerve.  Tourniquet was deflated.  It was checked again.  There was no excessive swelling.  Swanson drain was placed to the depth of the wound and interrupted #2-0 Vicryl was utilized for subcutaneous fat closure and #4-0 nylon was utilized for skin closure.  Adaptic, 4x4s, ABDs, and Webril were placed for compression dressing.  Digits were warm _______ pulses distally at the end of the case.  The tourniquet as stated has been deflated prior to closure and hemostasis was controlled.  Expected surgical prognosis on this patient is guarded.","orthopedic, soft tissue mass, osteophyte, lateral femoral condyle, excision, capsular mass, arthrotomy, ostectomy, knee, soft tissue, femoral condyle, mass, subcutaneous, capsular, tourniquet, femoral, condyle,"
" Austin-Akin bunionectomy with internal screw fixation of the first right metatarsophalangeal joint.  Weil osteotomy with internal screw fixation, first right metatarsal.  Arthroplasty, second right PIP joint.", Orthopedic, Austin-Akin Bunionectomy ,"TITLE OF OPERATION:,1.  Austin-Akin bunionectomy with internal screw fixation of the first right metatarsophalangeal joint.,2.  Weil osteotomy with internal screw fixation, first right metatarsal.,3.  Arthroplasty, second right PIP joint.,PREOPERATIVE DIAGNOSES:,1.  Bunion deformity, right foot.,2.  Dislocated second right metatarsophalangeal joint.,3.  Hammertoe deformity, second right digit.,POSTOPERATIVE DIAGNOSES:,1.  Bunion deformity, right foot.,2.  Dislocated second right metatarsophalangeal joint.,3.  Hammertoe deformity, second right digit.,ANESTHESIA:,  Monitored anesthesia care with 20 mL of 1:1 mixture of 0.5% Marcaine and 1% lidocaine plain.,HEMOSTASIS:,  60 minutes, a right ankle tourniquet set at 250 mmHg.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,PREOPERATIVE INJECTABLES:  ,1 g Ancef IV 30 minutes preoperatively.,MATERIALS USED: , 3-0 Vicryl, 4-0 Vicryl, 5-0 Prolene, as well as two 16-mm partially treaded cannulated screws of the OsteoMed system, one 18-mm partially treaded cannulated screw of the OsteoMed system of the 3.0 size.  One 10-mm 2.0 partially threaded cannulated screw of the OsteoMed system.,DESCRIPTION OF THE PROCEDURE:  ,The patient was brought to the operating room and placed on the operating table in the supine position.  After adequate sedation was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's right foot to anesthetize the future surgical sites.  The right ankle was covered with cast padding and an 18-inch ankle tourniquet was placed around the right ankle and set up at 250 mmHg.  The right foot was then prepped, scrubbed, and draped in a normal sterile technique.  The right ankle tourniquet was then inflated.  Attention was then directed on the dorsomedial aspect of the first right metatarsophalangeal joint where a 6-cm linear incision was placed parallel and medial to the course of the extensor hallucis longus tendon to the right great toe.  The incision was deepened through subcutaneous tissues.  All the bleeders were identified, cut, clamped, and cauterized.  The incision was deepened to the level of the capsule and the periosteum of the first right metatarsophalangeal joint.  All the tendinous and neurovascular structures were identified and retracted from the site to be preserved.  Using sharp and dull dissection, the periosteal and capsular tissues were mobilized from the head and neck of the first right metatarsal and the base of the proximal phalanx of the right great toe.  The conjoint tendon was identified on the lateral plantar aspect of the base of the proximal phalanx and resected transversely.,A lateral capsulotomy was also performed at the level of the first right metatarsophalangeal joint.  Using sharp and dull dissection, the dorsomedial prominence of the first right metatarsal head was adequately exposed and resected with the use of a sagittal saw.  The same saw was used to perform the Austin osteotomy on the capital aspect of the first right metatarsal with its apex distal and its base proximal.  The dorsal arm of the osteotomy was longer than the plantar arm and noted to accommodate for the future internal fixation.  The capital fragment of the first right metatarsal was then transposed laterally and impacted on the shaft of the first right metatarsal.  Two wires of the OsteoMed system were also used as provisional fixation wires and also as guidewires for the insertion of the future screws.  The wires were inserted dorsal distal to plantar proximal through the dorsal arm of the osteotomy.  The two screws from the 3.0 OsteoMed system were inserted over the wires using AO technique.  One screw measured 16 mm, second screw measured 18 mm in length.  Both 3.0 screws were then evaluated for the fixation of the osteotomy after the wires were removed.  Fixation of the osteotomy was found to be excellent.  The dorsomedial prominence of the first right metatarsal shaft was then resected with the sagittal saw.  To improve the correction of the hallux abductus angle, an Akin osteotomy was also performed on the base of the proximal phalanx of the right great toe with its base medially and its apex laterally.  Upon removal of the base wedge from the base of the proximal phalanx, the osteotomy was reduced with the OsteoMed smooth wire, which was also used as a guidewire for the insertion of a 16-mm partially threaded cannulated screw from the OsteoMed 3.0 system.  Upon insertion of the screw, using AO technique, the wire was removed.  The screw was inserted proximal medial to distal lateral through the osteotomy of the base of the proximal phalanx of the right great toe.  Fixation of the osteotomy was found to be excellent.  Reduction of the bunion deformity was also found to be excellent and position of the first right metatarsophalangeal joint was found to be anatomical.  Range of motion of that joint was uninhibited.  The area was flushed copiously with saline.  Then, 3-0 suture material was used to approximate the periosteum and capsular tissues, 4-0 was used to approximate the subcutaneous tissues, and Steri-Strips were used to reinforce the incision.  Attention was directed over the neck of the second right metatarsal head where a 3-cm linear incision was placed directly over the surgical neck of the second right metatarsal.  The incision was deepened through subcutaneous tissues.  All the bleeders were identified, cut, clamped and cauterized.  The incision was deepened through the level of the periosteum over the surgical neck of the second right metatarsal.  All the tendinous and neurovascular structures were identified and retracted from the site to be preserved.  Using sharp and dull dissection, the surgical neck of the second right metatarsal was adequately exposed and then Weil-type osteotomy was performed from dorsal distal to plantar proximal through the surgical neck of the second right metatarsal.  The capital fragment was then transposed proximally and impacted on the shaft of the second right metatarsal.,The 2.0 Osteo-Med system was also used to fixate this osteotomy wire from that system was inserted dorsal proximal to plantar distal through the second right metatarsal osteotomy and the wire was used as a guidewire for the insertion of the 10-mm partially threaded 2.0 cannulated screw.  Upon insertion of the screw, using AO technique, the wire was then removed.  Fixation of the osteotomy with 2.0 screw was found to be excellent.  The second right metatarsophalangeal joint was then relocated and the dislocation of that joint was completely reduced.  Range of motion of the second right metatarsophalangeal joint was found to be excellent.  Then, 3-0 Vicryl suture material was used to approximate the periosteal tissues.  Then, 4-0 Vicryl was used to approximate the skin incision.  Attention was then directed at the level of the PIP joint of the second right toe where two semi-elliptical incisions were placed directly over the bony prominence at the level of the second right PIP joint.  The island of skin between the two semi-elliptical incisions was resected in toto.  The dissection was carried down to the level of extensor digitorum longus of the second right toe, which was resected transversely at the level of the PIP joint.  A capsulotomy and a medial and lateral collateral ligament release of the PIP joint of the second right toe was also performed and head of the proximal phalanx of the second right digit was adequately exposed.  Using the double-action bone cutter, the head of the proximal phalanx of the second right toe was then resected.  The area was copiously flushed with saline.  The capsular and periosteal tissues were approximated with 2-0 Vicryl and 3-0 Vicryl suture material was also used to approximate the extensor digitorum longus to the second right toe.  A 5-0 Prolene was used to approximate the skin edges of the two semi-elliptical incisions.  Correction of the hammertoe deformity and relocation of the second right metatarsophalangeal joint were evaluated with the foot loaded and were found to be excellent and anatomical.  At this time, the patient's three incisions were covered with Xeroform, copious amounts of fluff and Kling, stockinette, and Ace bandage.  The patient's right ankle tourniquet was deflated, time was 60 minutes.  Immediate hyperemia was noted on the entire right lower extremity upon deflation of the cuffs.,The patient's right foot was placed in a surgical shoe and the patient was transferred to the recovery room under the care of anesthesia team with the vital signs stable and the vascular status at appropriate levels.  The patient was given instructions and education on how to continue caring for her right foot surgery.  The patient was eventually discharged from Hospital according to nursing protocol and was advised to follow up with Dr. X's office in one week's time for her first postoperative appointment.","orthopedic, austin-akin bunionectomy, weil osteotomy, internal screw fixation, first right metatarsal, metatarsophalangeal joint, hammertoe deformity, extensor digitorum longus, austin akin bunionectomy, threaded cannulated screw, semi elliptical incisions, ankle tourniquet, surgical neck, cannulated screws, pip joint, proximal phalanx, fixation, metatarsophalangeal, proximal, screw, metatarsal, osteotomy, austin, joint, tourniquet, osteomed, phalanx, incision, "
" Erythema of the right knee and leg, possible septic knee. Aspiration through the anterolateral portal of knee joint.", Orthopedic, Aspiration - Knee Joint ,"PREOPERATIVE DIAGNOSES: , Erythema of the right knee and leg, possible septic knee.,POSTOPERATIVE DIAGNOSES:,  Erythema of the right knee superficial and leg, right septic knee ruled out.,INDICATIONS: , Mr. ABC is a 52-year-old male who has had approximately eight days of erythema over his knee.  He has been to multiple institutions as an outpatient for this complaint.  He has had what appears to be prepatellar bursa aspirated with little to no success.  He has been treated with Kefzol and 1 g of Rocephin one point.  He also reports, in the emergency department today, an attempt was made to aspirate his actual knee joint which was unsuccessful.  Orthopedic Surgery was consulted at this time.  Considering the patient's physical exam, there is a portal that would prove to be outside of the erythema that would be useful for aspiration of the knee.  After discussion of risks and benefits, the patient elected to proceed with aspiration through the anterolateral portal of his knee joint.,PROCEDURE:  ,The patient's right anterolateral knee area was prepped with Betadine times two and a 20-gauge spinal needle was used to approach the knee joint approximately 3 cm anterior and 2 cm lateral to the superolateral pole of the patella.  The 20-gauge spinal needle was inserted and entered the knee joint.  Approximately, 4 cc of clear yellow fluid was aspirated.  The patient tolerated the procedure well.,DISPOSITION: , Based upon the appearance of this synovial fluid, we have a very low clinical suspicion of a septic joint.  We will send this fluid to the lab for cell count, crystal exam, as well as culture and Gram stain.  We will follow these results.  After discussion with the emergency department staff, it appears that they tend to try to treat his erythema which appears to be cellulitis with IV antibiotics.","orthopedic, knee and leg, anterolateral portal, emergency department, spinal needle, septic knee, knee joint, knee, emergency, department, gauge, spinal, needle, aspiration, anterolateral, portal, aspirated, fluid, septic, erythema, joint, aspiraion, "
" Arthroscopy of the left knee, left arthroscopic medial meniscoplasty of medial femoral condyle, and chondroplasty of the left knee as well.  Chondromalacia of medial femoral condyle.   Medial meniscal tear, left knee.", Orthopedic," Arthroscopy, Meniscoplasty, & Chondroplasty ","PREOPERATIVE DIAGNOSIS:,  Medial meniscal tear, left knee.,POSTOPERATIVE DIAGNOSIS: , Chondromalacia of medial femoral condyle.,PROCEDURE PERFORMED:,1.  Arthroscopy of the left knee.,2.  Left arthroscopic medial meniscoplasty of medial femoral condyle.,3.  Chondroplasty of the left knee as well.,ESTIMATED BLOOD LOSS: , 80 cc.,TOTAL TOURNIQUET TIME: , 19 minutes.,DISPOSITION: , The patient was taken to PACU in stable condition.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 41-year-old male with left knee pain for approximately two years secondary to hockey injury where he did have a prior MCL sprain.  He has had a positive symptomology of locking and pain since then.  He had no frank instability to it, however.,GROSS OPERATIVE FINDINGS: , We did find a tear to the medial meniscus as well as a large area of chondromalacia to the medial femoral condyle.,OPERATIVE PROCEDURE:  ,The patient was taken to the operating room.  The left lower extremity was prepped and draped in the usual sterile fashion.  Tourniquet was applied to the left thigh with adequate Webril padding, not inflated at this time.  After the left lower extremity had been prepped and draped in the usual sterile fashion, we applied an Esmarch tourniquet, exsanguinating the blood and inflated the tourniquet to 325 mmHg for a total of 19 minutes.  We established the lateral port of the knee with #11 blade scalpel.  We put in the arthroscopic trocar, instilled with water and inserted the camera.,On inspection of the patellofemoral joint, it was found to be quite smooth.  Pictures were taken there.  There was no evidence of chondromalacia, cracking, or fissuring of the articular cartilage.  The patella was well centered over the trochlear notch.  We then directed the arthroscope to the medial compartment of the knee.  It was felt that there was a tear to the medial meniscus.  We also saw large area of chondromalacia with grade-IV changes to bone over the medial femoral condyle.  This area was debrided with forceps and the arthroscopic shaver.  The cartilage was also smoothened over the medial femoral condyle.  This was curetted after the medial meniscus had been trimmed.  We looked into the notch.  We saw the ACL appeared stable, saw attachments to tibial as well as the femoral insertion with some evidence of laxity, wear and tear.  Attention then was taken to the lateral compartment with some evidence of tear to the lateral meniscus and the arterial surface of both the tibia as well as the femur were pristine in the lateral compartment.  All instruments were removed.  All loose cartilaginous pieces were suctioned from the knee and water was suctioned at the end.  We removed all instruments.  Marcaine was injected into the portal sites.  We placed a sterile dressing and stockinet on the left lower extremity.  He was transferred to the gurney and taken to PACU in stable condition.","orthopedic, medial meniscoplasty, arthroscopic, chondroplasty, arthroscopy, medial femoral condyle, medial meniscus, knee, meniscal, cartilage, meniscoplasty, meniscus, chondromalacia, condyle, femoral"
" Arthrotomy, removal humeral head implant, right shoulder.  Repair of torn subscapularis tendon (rotator cuff tendon) acute tear.  Debridement glenohumeral joint.  Biopsy and culturing the right shoulder.", Orthopedic, Arthrotomy & Subscapularis Tendon Repair ,"TITLE OF OPERATION:  ,1.  Arthrotomy, removal humeral head implant, right shoulder.,2.  Repair of torn subscapularis tendon (rotator cuff tendon) acute tear.,3.  Debridement glenohumeral joint.,4.  Biopsy and culturing the right shoulder.,INDICATION FOR SURGERY: , The patient had done well after a previous total shoulder arthroplasty performed by Dr. X.  However, the patient was lifted with subsequent significant pain and apparent tearing of his subscapularis.  Risks and benefits of the procedure had been discussed with the patient at length including, but not exclusive of infection, nerve or artery damage, stiffness, loss of range of motion, incomplete relief of pain, incomplete return of function, continued instability, retearing of the tendon, need for revision of his arthroplasty, permanent nerve or artery damage, etc.  The patient understood and wished to proceed.,PREOP DIAGNOSIS:  ,1.  Torn subscapularis tendon, right shoulder.,2.  Right total shoulder arthroplasty (Biomet system).,POSTOP DIAGNOSIS:  ,1.  Torn subscapularis tendon, right shoulder.,2.  Right total shoulder arthroplasty (Biomet system).,3.  Diffuse synovitis, right shoulder.,PROCEDURE: , The patient was anesthetized in the supine position.  A Foley catheter was placed in his bladder.  He was then placed in a beach chair position.  He was brought to the side of the table and the torso secured with towels and tape.  His head was then placed in the neutral position with no lateral bending or extension.  It was secured with paper tape over his forehead.  Care was taken to stay off his auricular cartilages and his orbits.  Right upper extremity was then prepped and draped in the usual sterile fashion.  The patient was given antibiotics well before the beginning of the procedure to decrease any risk of infection.  Once he had been prepped and draped with the standard prep, he was prepped a second time with a chlorhexidine-type skin prep.  This was allowed to dry and the skin was then covered with Ioban bandages also to decrease his risk of infection.,Also, preoperatively, the patient had his pacemaker defibrillator function turned off as a result during this case.  Bipolar type cautery had to be used as opposed to monopolar cautery.,The patient's deltopectoral incision was then opened and extended proximally and distally.  The patient had significant amount of scar already in this interval.  Once we got down to the deltoid and pectoralis muscle, there was no apparent cephalic vein present, as a result the rotator cuff interval had to be developed through an area of scar.  This created a significant amount of bleeding.  As a result a very slow and meticulous dissection was performed to isolate his coracoid and then his proximal humerus.  Care was taken to stay above the pectoralis minor and the conjoint tendon.  The deltoid had already started to scar down the proximal humerus as a result a very significant amount of dissection had to be performed to release the deltoid from proximal humerus.  Similarly, the deltoid insertion had to be released approximately 50% of its width to allow us enough mobility of the proximal humerus to be able to visualize the joint or the component.  It was clear that the patient had an avulsion of the subscapularis tendon as the tissue on the anterior aspect of the shoulder was very thin.  The muscle component of the subscapularis could be located approximately 1 cm off the glenoid rim and approximately 3 cm off the lesser tuberosity.  The soft tissue in this area was significantly scarred down to the conjoint tendon, which had to be very meticulously released.  The brachial plexus was identified as was the axillary nerve.  Once this was completed, an arthrotomy was then made leaving some tissue attached to the lesser tuberosity in case it was needed for closure later.  This revealed sanguineous fluid inside the joint.  We did not feel it was infected based upon the fluid that came from the joint.  The sutures for the subscapularis repair were still located in the proximal humerus with no tearing through the bone, which was fortunate because in that we could use the bone later for securing the sutures.  The remaining sutures were seen to be retracted medially to an area of the subscapularis as mentioned previously.  Some more capsule had to be released off the inferior neck in order for us to gain exposure during the scarring.  This was done also very meticulously.  The upper one half of the latissimus dorsi tendon was also released.  Once this was completed, the humerus could be subluxed enough laterally that we could remove the head.  This was done with no difficulty.  Fortunately, the humeral component stayed intact.  There were some exudates beneath the humeral head, which were somewhat mucinous.  However, these do not really appear to be infected, however, we sent them to pathology for a frozen section.  This frozen section later returned as possible purulent material.  I discussed this personally with the pathologist at that point.  We told him that the procedure is only 3 weeks old, but he was concerned that there might be more white blood cells in the tissue than he would expect.  As a result, all the mucinous exudates were carefully removed.  We also performed a fairly extensive synovectomy of the joint primarily to gain vision of the components, but also we irrigated the joint throughout the case with antibiotic impregnated irrigation.  At that point, we also had sent portions of this mucinous material to pathology for a stat Gram stain.  This came back as no organisms seen.  We also sent portions for culture and sensitivity both aerobic and anaerobic.,Once this was completed, attention was then directed to the glenoid.  The patient had significant amount of scar already.  The subscapularis itself was significantly scarred down to the anterior rim.  As a result, the adhesions along the anterior edge were released using a knife.  Also adhesions in the subcoracoid space area were released very carefully and meticulously to prevent any injury to the brachial plexus.  Two long retractors were placed medially to protect the brachial plexus during all portions of suturing of the subscapularis.  The subscapularis was then tagged with multiple number 2 Tycron sutures.  Adhesions were released circumferentially and it was found that with the arm in internal rotation about neutral degrees, the subscapularis could reach the calcar region without tension.  As a result, seven number 2 Tycron sutures were placed from the bicipital groove all the way down to the inferior calcar region of the humerus.  These all had excellent security in bone.  Once the joint had been debrided and irrigated, the real humeral head was then placed back on the proximal humerus.  Care was taken to remove fluid off the Morse taper.  The head was then impacted.  It should be noted that we tried multiple head sizes to see if a smaller or larger head size might be more appropriate for this patient.  Unfortunately, any of the larger head sizes would overstep the joint and any smaller sizes would not give good coverage to the proximal humerus.  As a result, it was felt to place the offset head back on the humerus, we did insert a new component as opposed to using the old component.  The old component was given to the family postoperatively.,With the arm in internal rotation, the Tycron sutures were then placed through the subscapularis tendon in the usual horizontal mattress fashion.  Also, it should be noted that the rotator cuff interval had to be released as part of the exposure.  We started the repair by closing the rotator cuff interval.  Anterior and posterior translation was then performed and was found to be very stable.  The remaining sutures were then secured through the subscapularis tendon taking care to make sure that very substantial bites were obtained.  This was then reinforced with the more flimsy tissue laterally being sewn into the tissue around the bicipital tuberosity essentially provided us with a two-layer repair of the subscapularis tendon.  After the tendon had been repaired, there was no tension on repair until 0 degrees external rotation was reached with the arm to the side.  Similarly with the arm abducted 90 degrees, tension was on repair at 0 degrees of external rotation.  It should be noted that the wound was thoroughly irrigated throughout with antibiotic impregnated irrigation.  The rotator cuff interval was closed with multiple number 2 Tycron sutures.  It was reinforced with 0 Vicryl sutures.  Two Hemovac drains were then placed inferiorly at the deltoid.  The deltopectoral interval was then closed with 0 Vicryl sutures.  A third drain was placed in the subcutaneous tissues to prevent any infections or any fluid collections.  This was sewn into place with the drain pulled out superiorly.  Once all the sutures have been secured and the drain visualized throughout this part of the closure, the drain was pulled distally until it was completely covered.  There were no signs that it had been tagged or hung up by any sutures.,The superficial subcutaneous tissues were closed with interrupted with 2-0 Vicryl sutures.  Skin was closed with staples.  A sterile bandage was applied along with a cold therapy device and a shoulder immobilizer.  The patient was sent to the intensive care unit in stable and satisfactory condition.,Due to the significant amount of scar and bleeding in this patient, a 22 modifier is being requested for this case.  This was a very difficult revision case and was significantly increased in technical challenges and challenges in the dissection and exposure of this implant compared to a standard shoulder replacement.  Similarly, the repair of the subscapularis tendon presented significantly more challenges than that of a standard rotator cuff repair because of the implant.  This was being dictated for insurance purposes only and reflects no inherent difficulties with this case.  The complexity and the time involved in this case was approximately 30% greater than that of a standard shoulder replacement or of a rotator cuff repair.  This is being dictated to indicate this was a revision case with significant amount of scar and bleeding due to the patient's situation with his pacemaker.  This patient also had multiple medical concerns, which increased the complexity of this case including the necessity to place him in intensive care unit postoperatively for observation.","orthopedic, arthrotomy, repair of torn subscapularis tendon, glenohumeral joint, biomet system, arthroplasty, diffuse synovitis, proximal humerus, torn subscapularis tendon, subscapularis tendon, rotator cuff, humerus, sutures, tendon, head, shoulder, subscapularis, torn,"
" Partial rotator cuff tear, left shoulder.  Arthroscopy of the left shoulder with arthroscopic rotator cuff debridement, soft tissue decompression of the subacromial space of the left shoulder.", Orthopedic, Arthroscopy - Shoulder ,"PREOPERATIVE DIAGNOSIS: , Partial rotator cuff tear, left shoulder.,POSTOPERATIVE DIAGNOSIS: , Partial rotator cuff tear, left shoulder.,PROCEDURE PERFORMED:, Arthroscopy of the left shoulder with arthroscopic rotator cuff debridement, soft tissue decompression of the subacromial space of the left shoulder.,ANESTHESIA:  ,Scalene block with general anesthesia.,ESTIMATED BLOOD LOSS: , 30 cc.,COMPLICATIONS: , None.,DISPOSITION:  ,The patient went to the PACU stable.,GROSS OPERATIVE FINDINGS: , There was no overt pathology of the biceps tendon.  There was some softening and loss of the articular cartilage over the glenoid.  The labrum was ________ attached permanently to the glenoid.  The biceps tendon was nonsubluxable.  Upon ranging of the shoulder in internal and external rotation showed no evidence of rotator cuff tear on the articular side.  Subacromial space did show excessive soft tissue causing some overstuffing of the subacromial space.  There was reconstitution of the bursa noted as well.,HISTORY OF PRESENT ILLNESS:,  This is a 51-year-old female had left shoulder pain of chronic nature who has had undergone prior rotator cuff debridement in May with partial pain relief and has had continued pain in the left shoulder.  MRI shows partial rotator cuff tear.,PROCEDURE: , The patient was taken to the operating room and placed in a beachchair position.  After all bony prominences were adequately padded, the head was placed in the headholder with no excessive extension in the neck on flexion.  The left extremity was prepped and draped in usual fashion.  The #18 gauge needles were inserted into the left shoulder to locate the AC joint, the lateral aspect of the acromion as well as the pass of the first trocar to enter the shoulder joint from the posterior aspect.  We took an #11 blade scalpel and made a small 1-cm skin incision posteriorly approximately 4-cm inferior and medial to the lateral port of the acromion.  A blunt trocar was used to bluntly cannulate the joint and we put the camera into the shoulder at that point of the joint and instilled sterile saline to distend the capsule and begin our arthroscopic assessment of the shoulder.  A second port was established superior to the biceps tendon anteriorly under direct arthroscopic visualization using #11 blade on the skin and inserted bluntly the trocar and the cannula.  The operative findings found intra-articularly were as described previously gross operative findings.  We did not see any evidence of acute pathology.  We then removed all the arthroscopic instruments as well as the trocars and tunneled subcutaneously into the subacromial space and reestablished the portal and camera and inflow with saline.  The subacromial space was examined and found to have excessive soft tissue and bursa that was in the subacromial space that we debrided using arthroscopic shaver after establishing a lateral portal.  All this was done and hemostasis was achieved.  The rotator cuff was examined from the bursal side and showed no evidence of tears.  There was some fraying out laterally near its attachment over the greater tuberosity, which was debrided with the arthroscopic shaver.  We removed all of our instruments and suctioned the subacromial space dry.  A #4-0 nylon was used on the three arthroscopic portal and on the skin we placed sterile dressing and the arm was placed in an arm sling.  She was placed back on the gurney, extubated and taken to the PACU in stable condition.","orthopedic, subacromial space, arthroscopic, biceps tendon, labrum, glenoid, cartilage, partial rotator cuff tear, rotator cuff tear, shoulder arthroscopy, rotator cuff, arthroscopy, shoulder, tissue, subacromial, rotator, cuff,"
" Right shoulder arthroscopy, subacromial decompression, distal clavicle excision, bursectomy, and coracoacromial ligament resection, carpal tunnel release, left knee arthroscopy, and partial medial and lateral meniscectomy.", Orthopedic, Arthroscopy Shoulder/Knee ,"PREOPERATIVE DIAGNOSES:,1.  Medial meniscal tear, posterior horn of left knee.,2.  Carpal tunnel syndrome chronic right hand with intractable pain, numbness, and tingling.,3.  Impingement syndrome, right shoulder with acromioclavicular arthritis, bursitis, and chronic tendonitis.,POSTOPERATIVE DIAGNOSES:,1.  Carpal tunnel syndrome, right hand, severe.,2.  Bursitis, tendonitis, impingement, and AC arthritis, right shoulder.,3.  Medial and lateral meniscal tears, posterior horn old, left knee.,PROCEDURE:,1.  Right shoulder arthroscopy, subacromial decompression, distal clavicle excision, bursectomy, and coracoacromial ligament resection.,2.  Right carpal tunnel release.,3.  Left knee arthroscopy and partial medial and lateral meniscectomy.,ANESTHESIA: , General with regional.,COMPLICATIONS:  ,None.,DISPOSITION: , To recovery room in awake, alert, and in stable condition.,OPERATIVE INDICATIONS: , A very active 50-year-old gentleman who had the above problems and workup revealed the above problems.  He failed nonoperative management.  We discussed the risks, benefits, and possible complications of operative and continued nonoperative management, and he gave his fully informed consent to the following procedure.,OPERATIVE REPORT IN DETAIL: , The patient was brought to the operating room and placed in the supine position on the operating room table.  After adequate induction of general anesthesia, he was placed in the left lateral decubitus position.  All bony prominences were padded.  The right shoulder was prepped and draped in the usual sterile manner using standard Betadine prep, entered through three standard arthroscopic portals anterolateral and posterior incising the skin with a knife using sharp and blunt trocar.,Serial examination of the intraarticular portion of the shoulder showed all the structures to be normal including the biceps tendon ligaments, articular surfaces, and labrum.  Subacromial space was entered.  Visualization was poor due to the hemorrhagic bursitis, and this was resected back.  It was essentially a type-3 acromion, which was converted to a type 1 by aiming the burr anterior from the posterior portal excising the larger anterior spur.  Rotator cuff was little bit fray, but otherwise intact.  Thus, the deep deltoid bursa and the markedly thickened coracoacromial ligament were removed.  The burr was then introduced to the anterior portal and the distal clavicle excision carried out.  The width of burr about 6 mm being careful to preserve the ligaments in the capsule, but removing the spurs and the denuded arthritic joint.,The patient tolerated the procedure very well.  The shoulder was then copiously irrigated, drained free of any residual debris.  The wound was closed with 3-0 Prolene.  Sterile compressive dressing applied.,The patient was then placed on his back in the supine position and the right upper extremity and the left lower extremity were prepped and draped in usual sterile manner using a standard Betadine prep.,The attention was first turned to the right hand where it was elevated, exsanguinated using an Esmarch bandage, and the tourniquet was inflated to 250 mmHg for about 25 minutes.  Volar approach to the carpal ligament was performed incising the skin with a knife and using cautery for hemostasis.  Tenotomy and forceps dissection carried out through the superficial palmar fascia, carried down to the volar carpal ligament, which was then transected sharply with a knife and carried proximal and distal under direct vision using the scissors being careful to avoid the neurovascular structures.,Cautery was used for hemostasis.  The never had an hourglass appearance where it was a kind of constricted as a result of the compression from the ligament, and so a small amount of Celestone was dripped onto the nerve to help quite it down.  The patient tolerated this portion of the procedure very well.  The hand was then irrigated, closed with Monocryl and Prolene, and sterile compressive dressing was applied and the tourniquet deflated.,Attention was then turned to the left knee where it was entered through inferomedial and inferolateral portals incising the skin with a knife and using sharp and blunt trocars.  After entering the knee through inferomedial and inferolateral standard arthroscopic portals, examination of the knee showed a displaced bucket-handle tear in the medial meniscus and a radial tear at the lateral meniscus.  These were resected back to the stable surface using a basket forceps and full-radius shaver.  There was no evidence of any other significant arthritis in the knee.  There was a lot of synovitis, and so after the knee was irrigated out and free of any residual debris, the knee was injected with Celestone and Marcaine with epinephrine.,The patient tolerated the procedure very well, and the wounds were closed with 3-0 Prolene and sterile compressive dressing was applied, and then the patient was taken to the recovery room, extubated, awake, alert, and in stable condition.", 
" Arthroscopy of the arthroscopic glenoid labrum, rotator cuff debridement shaving glenoid and humeral head, and biceps tenotomy, right shoulder.  Massive rotator cuff tear, right shoulder, near complete biceps tendon tear of right shoulder, chondromalacia of glenohumeral joint or right shoulder, and glenoid labrum tear of right shoulder.", Orthopedic, Arthroscopy - Glenoid Labrum ,"PREOPERATIVE DIAGNOSIS:,  Rotator cuff tear, right shoulder.,POSTOPERATIVE DIAGNOSES:,1.  Massive rotator cuff tear, right shoulder.,2.  Near complete biceps tendon tear, right shoulder.,3.  Chondromalacia of glenohumeral joint, right shoulder.,4.  Glenoid labrum tear, right shoulder.,PROCEDURE PERFORMED:  ,1.  Arthroscopy of the arthroscopic glenoid labrum.,2.  Rotator cuff debridement shaving glenoid and humeral head.,3.  Biceps tenotomy, right shoulder.,SPECIFICATION: , The entire operative procedure was done in Inpatient Operating Suite, room #1 at ABCD General Hospital.  This was done under interscalene block anesthetic in the modified beachchair position.,HISTORY AND GROSS FINDINGS: , This is a 61-year-old white male who is dominantly right-handed.  He had increasing right shoulder pain and dysfunction for a number of years prior to surgical intervention.  This was gradually done over a period of time.  No specific accident or injury could be seen or pointed.  He was refractory to conservative outpatient therapy.  After discussing alternatives of the care as well as the advantages, disadvantages, risks, complications, and expectations, he elected to undergo the above-stated procedure on this date.,Preoperatively, the patient did not have limitation of motion.  He had gross weakness to his supraspinatus, mildly to the infraspinatus and subscapularis upon strength testing prior to his anesthetic.,Intraarticularly, the patient had an 80% biceps tendon tear that was dislocated.  His rotator interval was resolved as well as his subscapularis with tearing.  The supraspinatus was completely torn, retracted back beyond the level of the labrum and approximately one-third or so of the infraspinatus was involved with the remaining portion being greatly thinned as far as we could observe.  Glenoid labrum had degenerative tear in the inferior surface.  Gross chondromalacia was present to approximately 50% of the humeral head and approximately the upper 40% of the glenoid surface.,OPERATIVE PROCEDURE: , The patient was laid supine upon the operative table.  After receiving interscalene block anesthetic by the Anesthesia Department, he was safely placed in a modified beachchair position.  He was prepped and draped in the usual sterile manner.  The portals were created outside the end posteriorly and then anteriorly.  A full and complete diagnostic arthroscopy was carried out with the above-noted findings.  The shaver was placed anteriorly.  Debridement was carried out to the glenoid labrum tear and the last 20% of the biceps tendon tear was completed.  Debridement was carried out to the end or attachment of the bicep itself.,Debridement was carried out to what could be seen of the remaining rotator cuff there, but then the scope was redirected in a subacromial direction and gross bursectomy carried out.  Debridement was then carried out to the rotator cuff remaining tendon near the tuberosity.  No osteophytes were present.  Because of the massive nature of the tear, the CA ligament was maintained and there were no substantial changes to the subacromial region to necessitate burring.  There was concern because of instability that could be present at the end of this.,Another portal was created laterally to do all of this.  We did what we could to mobilize all sections of the rotator cuff, superiorly, posteriorly, and anteriorly.  We took this back to the level of coracoid base.  We released the coracohumeral ligament basically all but there was no excursion basically all to the portion of the rotator cuff torn.  Because of this, further debridement was carried out.  Debridement had been previously carried out to the humeral head as well as glenoid surface to debride the chondromalacia and take this down to the smooth edge.  Care was taken to not to debride deeper than that.  This was done prior to the above.,All instrumentation was removed.  A Pain-Buster catheter was placed into a separate anterolateral portal cut to length.  Interrupted #4-0 nylon was utilized for portal closures.  Adaptic, 4x4s, ABDs, Elastoplast tape were placed for a compression dressing.,The patient's arm was placed in an arm sling.  He was transferred to his cart and to the PACU in apparent satisfactory condition.  Expected surgical prognosis on this patient is quite guarded because of the above-noted pathology.","orthopedic, modified beachchair position, rotator cuff tear, glenoid labrum tear, glenohumeral joint, interscalene block, glenoid labrum, rotator cuff, rotator, debridement, glenoid, shoulder, tear, arthroscopy, arthroscopic, tenotomy, glenohumeral, supraspinatus, infraspinatus, subscapularis, chondromalacia, biceps, labrum, cuff, "
 Primary right shoulder arthroscopic rotator cuff repair with subacromial decompression., Orthopedic, Arthroscopic Rotator Cuff Repair ,"PROCEDURE: , Primary right shoulder arthroscopic rotator cuff repair with subacromial decompression.,PATIENT PROFILE:,  This is a 42-year-old female.  Refer to note in patient chart for documentation of history and physical.  Due to the nature of the patient's increasing pain, surgery is recommended.  The alternatives, risks and benefits of surgery were discussed with the patient.  The patient verbalized understanding of the risks as well as the alternatives to surgery.  The patient wished to proceed with operative intervention.  A signed and witnessed informed consent was placed on the chart.  Prior to initiation of the procedure, patient identification and proposed procedure were verified by the surgeon in the pre-op area, and the operative site was marked by the patient and verified by the surgeon.,PRE-OP DIAGNOSIS: , Acute complete tear of the supraspinatus, Shoulder impingement syndrome.,POST-OP DIAGNOSIS:,  Acute complete tear of the supraspinatus, Shoulder impingement syndrome.,ANESTHESIA: , General - Endotracheal.,FINDINGS:,ACROMION:,1.  There was a medium-sized (5 - 10 mm) anterior acromial spur.,2.  The subacromial bursa was inflamed.,3.  The subacromial bursa was thickened.,4.  There was thickening of the coracoacromial ligament.,LIGAMENTS / CAPSULE: , Joint capsule within normal limits.,LABRUM: , The labrum is within normal limits.,ROTATOR CUFF: , Full thickness tear of the supraspinatus tendon, 5 mm anterior to posterior, by 10 mm medial to lateral.  Muscles and Tendons:  The biceps tendon is within normal limits.,JOINT:,  Normal appearance of the glenoid and humeral surfaces.,DESCRIPTION OF PROCEDURE:,PATIENT POSITIONING: , Following induction of anesthesia, the patient was placed in the beach-chair position on the standard operating table.  All body parts were well padded and protected to make sure there were no pressure points.  Subsequently, the surgical area was prepped and draped in the appropriate sterile fashion with Betadine.,INCISION TYPE:,1.  Scope Ports:  Anterior Portal.,2.  Scope Ports:  Posterior Portal.,3.  Scope Ports:  Accessory Anterior Portal.,INSTRUMENTS AND METHODS:,1.  The arthroscope and instruments were introduced into the shoulder joint through the arthroscopic portals.,2.  The subacromial space and bursa, biceps tendon, coracoacromial and glenohumeral ligaments, biceps tendon, rotator cuff, supraspinatus, subscapularis, infraspinatus, teres minor, capsulo-labral complex, capsule, glenoid labrum, humeral head, and glenoid, including the inner and outer surfaces of the rotator cuff, were visualized and probed.,3.  The subacromial bursa, subacromial soft tissues and frayed rotator cuff tissue were resected and debrided using a motorized resector and 4.5 Synovial Resector.,4.  The anterior portion of the acromion and acromial spur were resected with the 5.5 acromionizer burr.  Approximately 5 mm of bone was removed.  The coracoacromial ligament was released with the bony resection.  The shoulder joint was thoroughly irrigated.,5.  The edges of the cuff tissue were prepared, prior to the fixation, using the motorized resector.,6.  The supraspinatus tendon was reattached and sutured using the arthroscopic knot pusher and Mitek knotless anchor system and curved pointed suture passer and large bore cannula (to pass the sutures).  The repair was accomplished in a side-to-side and a tendon-to-bone fashion using three double loaded Mitek G IV suture anchors with 1 PDS suture.,7.  The repair was stable to palpation with the probe and watertight.,8.  The arthroscope and instruments were removed from the shoulder.,PATHOLOGY SPECIMEN: , No pathology specimens.,WOUND CLOSURE:,  The joint was thoroughly irrigated with 7 L of sterile saline.  The portal sites were infiltrated with 1% Xylocaine.  The skin was closed with 4-0 Vicryl using interrupted subcuticular technique.,DRAINS / DRESSING:,  Applied sterile dressing including gauze, iodoform gauze and Elastoplast.,SPONGE / INSTRUMENT / NEEDLE COUNTS:,  Final counts were correct.",
" Diagnostic arthroscopy with partial chondroplasty of patella, lateral retinacular release, and open tibial tubercle transfer with fixation of two 4.5 mm cannulated screws.  Grade-IV chondromalacia patella and patellofemoral malalignment syndrome.", Orthopedic, Arthroscopy & Chondroplasty ,"PREOPERATIVE DIAGNOSES:,1.  Chondromalacia patella.,2.  Patellofemoral malalignment syndrome.,POSTOPERATIVE DIAGNOSES:,1.  Grade-IV chondromalacia patella.,2.  Patellofemoral malalignment syndrome.,PROCEDURE PERFORMED:,1.  Diagnostic arthroscopy with partial chondroplasty of patella.,2.  Lateral retinacular release.,3.  Open tibial tubercle transfer with fixation of two 4.5 mm cannulated screws.,ANESTHESIA:,  General.,COMPLICATIONS: , None.,TOURNIQUET TIME: , Approximately 70 minutes at 325 mmHg.,INTRAOPERATIVE FINDINGS: , Grade-IV chondromalacia noted to the central and lateral facet of the patella.  There was a grade II to III chondral changes to the patellar groove.  The patella was noted to be displaced laterally riding on the edge of the lateral femoral condyle.  The medial lateral meniscus showed small amounts of degeneration, but no frank tears were seen.  The articular surfaces and the remainder of the knee appeared intact.  Cruciate ligaments also appeared intact to direct stress testing.,HISTORY:  ,This is a 36-year-old Caucasian female with a long-standing history of right knee pain.  She has been diagnosed in the past with chondromalacia patella.  She has failed conservative therapy.  It was discussed with her the possibility of a arthroscopy lateral release and a tubercle transfer (anterior medialization of the tibial tubercle) to release stress from her femoral patellofemoral joint.  She elected to proceed with the surgical intervention.  All risks and benefits of the surgery were discussed with her.  She was in agreement with the treatment plan.,PROCEDURE: , On 09/04/03, she was taken to Operating Room at ABCD General Hospital.  She was placed supine on the operating table with the general anesthesia administered by the Anesthesia Department.  Her leg was placed in a Johnson knee holder and sterilely prepped and draped in the usual fashion.  A stab incision was made in inferolateral and parapatellar regions.  Through this the cannula was placed and the knee was inflated with saline solution.  Intraoperative pictures were obtained.  The above findings were noted.  Second portal site was initiated in the inferomedial parapatellar region.  Through this, a arthroscopic shaver was placed and the chondroplasty in the patella was performed and removed the loose articular debris.  Next, the camera was placed through the inferomedial portal.  An arthroscopic Bovie was placed through the inferolateral portal.  A release of lateral retinaculum was then performed using the Bovie.  Hemostasis was controlled with electrocautery.  Next, the knee was suctioned dry.  An Esmarch was used to exsanguinate the lower extremity.  Tourniquet was inflated to 325 mmHg.  An oblique incision was made along the medial parapatellar region of the knee.  The subcuticular tissues were carefully dissected and the hemostasis was again controlled with electrocautery.  The retinaculum was then incised in line with the incision.  The patellar tendon was identified.  The lateral and medial border of the tibial tubercle were cleared of all soft tissue debris.  Next, an osteotome was then used to cut the tibial tubercle to 45 degree angle leaving the base of the bone incision intact.  The tubercle was then pushed anteriorly and medially decreasing her Q-angle and anteriorizing the tibial tubercle.  It was then held in place with a Steinmann pin.  Following this, a two 4.5 mm cannulated screws, partially threaded, were drilled in place using standard technique to help fixate the tibial tubercle.  There was excellent fixation noted.  The Q-angle was noted to be decreased to approximately 15 degrees.  She was transferred approximately 1 cm in length.  The wound was copiously irrigated and suctioned dry.  The medial retinaculum was then plicated causing further medialization of the patella.  The retinaculum was reapproximated using #0 Vicryl.  Subcuticular tissue were reapproximated with #2-0 Vicryl.  Skin was closed with #4-0 Vicryl running PDS suture.  Sterile dressing was applied to the lower extremities.  She was placed in a Donjoy knee immobilizer locked in extension.  It was noted that the lower extremity was warm and pink with good capillary refill following deflation of the tourniquet.  She was transferred to recovery room in apparent stable and satisfactory condition.,Prognosis of this patient is poor secondary to the advanced degenerative changes to the patellofemoral joint.  She will remain in the immobilizer approximately six weeks allowing the tubercle to reapproximate itself to the proximal tibia.","orthopedic, diagnostic arthroscopy, patellofemoral malalignment syndrome, cannulated, partial chondroplasty, retinacular, chondromalacia patella, tibial tubercle, patella, tubercle, arthroscopy, tourniquet, chondroplasty, chondromalacia, patellofemoral, "
" Torn lateral meniscus and chondromalacia of the patella, right knee.  Arthroscopic lateral meniscoplasty and patellar shaving of the right knee.", Orthopedic, Arthroscopic Meniscoplasty ,"PREOPERATIVE DIAGNOSES:,1.  Torn lateral meniscus, right knee.,2.  Chondromalacia of the patella, right knee.,POSTOPERATIVE DIAGNOSES:,1.  Torn lateral meniscus, right knee.,2.  Chondromalacia of the patella, right knee.,PROCEDURE PERFORMED:,1.  Arthroscopic lateral meniscoplasty.,2.  Patellar shaving of the right knee.,ANESTHESIA:  ,General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,TOTAL TOURNIQUET TIME:,  Zero.,GROSS FINDINGS: , A complex tear involving the lateral and posterior horns of the lateral meniscus and grade-II chondromalacia of the patella.,HISTORY OF PRESENT ILLNESS: , The patient is a 45-year-old Caucasian male presented to the office complaining of right knee pain.  He complained of pain on the medial aspect of his right knee after an injury at work, which he twisted his right knee.,PROCEDURE:  ,After all potential complications, risks, as well as anticipated benefits of the above-named procedures were discussed at length with the patient, informed consent was obtained.  The operative extremity was then confirmed with the operative surgeon, the patient, the Department of Anesthesia and the nursing staff.,The patient was then transferred to preoperative area to Operative Suite #2, placed on the operating table in supine position.  Department of Anesthesia administered general anesthetic to the patient.  All bony prominences were well padded at this time.  The right lower extremity was then properly positioned in a Johnson knee holder.  At this time, 1% lidocaine with epinephrine 20 cc was administered to the right knee intra-articularly under sterile conditions.  The right lower extremity was then sterilely prepped and draped in usual sterile fashion.  Next, after all bony soft tissue landmarks were identified, an inferolateral working portal was established by making a 1-cm transverse incision at the level of the joint line lateral to the patellar tendon.  The cannula and trocar were then inserted through this, putting the patellofemoral joint.  An arthroscopic camera was then inserted and the knee was sequentially examined including the patellofemoral joint, the medial and lateral gutters, medial lateral joints, and the femoral notch.  Upon viewing of the patellofemoral joint, there was noted to be grade-II chondromalacia changes of the patella.  There were no loose bodies noted in the either gutter.  Upon viewing of the medial compartment, there was no chondromalacia or meniscal tear was noted.  While in this area, attention was directed to establish the inferomedial instrument portal.  This was first done using a spinal needle for localization followed by 1-cm transverse incision at the joint line.  A probe was then inserted through this portal and the meniscus was further probed.  Again, there was noted to be no meniscal tear.  The knee was taken through range of motion and there was no chondromalacia.  Upon viewing of the femoral notch, there was noted to be intact ACL with negative drawer sign.  PCL was also noted to be intact.  Upon viewing of the lateral compartment, there was noted to be a large bucket-handle tear involving the lateral and posterior horns.  It was reduced from the place, however, involved the white and red white area was elected to excise the bucket-handle.  An arthroscopic scissor was then inserted and the two remaining attachments the posterior and lateral attachments were then clipped and a Schlesinger grasper was then used to remove the resected meniscus.  It was noted that the meniscus was followed out to the whole and the entire piece was taken out of the knee.  Pictures were taken both pre-meniscal resection and post-meniscal resection.  The arthroscopic shaver was then inserted into the medial portal and the remaining meniscus was contoured.  The lateral gutter was then examined and was noted to be no loose bodies and ______ was intact.  Next, attention was directed to the inner surface of the patella.  This was debrided using the 2.5 arthroscopic shaver.  It was noted to be quite smooth and postprocedure the patient was taken ________ well.  The knee was then copiously irrigated and suctioned dry and all instrumentation was removed.  20 cc of 0.25% Marcaine was then administered to each portal as well as intra-articularly.,Sterile dressing was then applied consisting of Adaptic, 4x4s, ABDs, and sterile Webril and a stockinette to the right lower extremity.  At this time, Department of Anesthesia reversed the anesthetic.  The patient was transferred back to the hospital gurney to the Postanesthesia Care Unit.  The patient tolerated the procedure and there were no complications.","orthopedic, patella, chondromalacia, lateral meniscus, complex tear, torn lateral meniscus, femoral notch, meniscal tear, bucket handle, meniscal resection, arthroscopic shaver, patellofemoral joint, arthroscopic, knee, torn, meniscoplasty, meniscal, joint, meniscus, "
" Rotated cuff tear, right shoulder.  Glenoid labrum tear.  Arthroscopy with arthroscopic glenoid labrum debridement, subacromial decompression, and rotator cuff repair, right shoulder.", Orthopedic, Arthroscopic Rotator Cuff Repair - 1 ,"PREOPERATIVE DIAGNOSIS: , Rotated cuff tear, right shoulder.,POSTOPERATIVE DIAGNOSES:,1.  Rotated cuff tear, right shoulder.,2.  Glenoid labrum tear.,PROCEDURE PERFORMED:,1.  Arthroscopy with arthroscopic glenoid labrum debridement.,2.  Subacromial decompression.,3.  Rotator cuff repair, right shoulder.,SPECIFICATIONS:,  Intraoperative procedure was done at Inpatient Operative Suite, room #1 at ABCD Hospital.  This was done under interscalene and subsequent general anesthetic in the modified beach chair position.,HISTORY AND GROSS FINDINGS: , The patient is a 48-year-old with male who has been suffering increasing right shoulder pain for a number of months prior to surgical intervention.  He was completely refractory to conservative outpatient therapy.  After discussing the alternative care as well as the advantages, disadvantages, risks, complications, and expectations, he elected to undergo the above stated procedure on this date.,Intraarticularly, the joint was observed.  There was noted to be a degenerative glenoid labrum tear.  The biceps complex was otherwise intact.  There were minimal degenerative changes at the glenohumeral joint.  Rotator cuff tear was appreciated on the inner surface.  Subacromially, the same was true.  This was an elliptical to V-type tear.  The patient has a grossly positive type III acromion.,OPERATIVE PROCEDURE: , The patient was laid supine on the operating table after receiving interscalene and then general anesthetic by the Anesthesia Department.  He was safely placed in modified beach chair position.  He was prepped and draped in the usual sterile manner.  Portals were created outside to end, posterior to anterior, and ultimately laterally in the typical fashion.  Upon complete diagnostic arthroscopy was carried out in the intraarticular aspect of the joint, a 4.2 meniscus shaver was placed anteriorly with the scope posteriorly.  Debridement was carried out to the glenoid labrum.  The biceps was probed and noted to be intact.  Undersurface of the rotator cuff was debrided with the shaver along with debridement of the subchondral region of the greater tuberosity attachment.,After this, instrumentation was removed.  The scope was placed subacromially and a lateral portal created.  Gross bursectomy was carried out in a stepwise fashion to the top part of the cuff as well as in the gutters.  An anterolateral portal was created.  Sutures were placed via express silk as well as other sutures with a #2 fiber wire.  With passing of the suture, they were tied with a slip-tight knot and then two half stitches.  There was excellent reduction of the tear.  Superolateral portal was then created.  A #1 Mitek suture anchor was then placed in the posterior cuff to bring this over to bleeding bone.  _______ suture was placed.  The implant was put into place.  The loop was grabbed and it was impacted in the previously drilled holes.  There was excellent reduction of the tear.,Trial range of motion was carried out and seemed to be satisfactory.,Prior to this, a subacromial decompression was accomplished after release of CA ligament with the vapor Bovie.  A 4.8 motorized barrel burr was utilized to sequentially take this down from the type III acromion to a flat type I acromion.,After all was done, copious irrigation was carried out throughout the joint.  Gross bursectomy lightly was carried out to remove all bony elements.  A pain buster catheter was placed through a separate portal and cut to length.  0.5% Marcaine was instilled after portals were closed with #4-0 nylon.  Adaptic, 4 x 4s, ABDs, and Elastoplast tape placed for dressing.  The patient was ultimately transferred to his cart and PACU in apparent satisfactory condition.  Expected surgical prognosis of this patient is fair.","orthopedic, subacromial decompression, rotator cuff repair, arthroscopic glenoid labrum debridement, arthroscopy, glenoid labrum tear, glenoid labrum, cuff, tear, arthroscopic, subacromial, decompression, debridement, rotator, glenoid, labrum, shoulder,"
" Arthroscopic rotator cuff repair, arthroscopic subacromial decompression, and arthroscopic extensive debridement, superior labrum anterior and posterior tear.", Orthopedic, Arthroscopic Rotator Cuff Repair - 2 ,"PROCEDURES,1.  Arthroscopic rotator cuff repair.,2.  Arthroscopic subacromial decompression.,3.  Arthroscopic extensive debridement, superior labrum anterior and posterior tear.,PROCEDURE IN DETAIL: , After written consent was obtained from the patient, the patient was brought back into the operating room and identified.  The patient was placed on the operating room table in supine position and given general anesthetic.  Once the patient was under general anesthetic, a careful examination of the shoulder was performed.  It revealed no patholigamentous laxity.  The patient was then carefully positioned into a beach-chair position.  We maintained the natural alignment of the head, neck, and thorax at all times.  The shoulder and upper extremity was then prepped and draped in the usual sterile fashion.,Once we fully prepped and draped, we then began the surgery.  We injected the glenohumeral joint with sterile saline with a spinal needle.  This consisted of 60 cc of fluid.  We then made a posterior incision for our portal, 2 cm inferior and 2 cm medial to the posterolateral angle of the acromion.  Through this incision, a blunt trocar and cannula were placed in the glenohumeral joint.  Through the cannula, a camera was placed; and the shoulder was insufflated with sterile saline through a preoperative feed.  We then carefully examined the glenohumeral joint.,We found the articular surface to be in good condition.  There was a superior labral tear (SLAP).  This was extensively debrided using a shaver through an anterior portal.  We also found a full thickness rotator cuff tear.  We then drained the glenohumeral joint.  We redirected our camera into the subacromial space.  An anterolateral portal was made, both superior and inferior.,We then proceeded to perform a subacromial decompression using high-speed shaver.  The bursa was extensively debrided.  We then abraded the bone over the footprint of where the rotator cuff is usually attached.  The corkscrew anchors were used to perform a rotator cuff repair.  Pictures were taken.,Through a separate incision, an indwelling pain catheter was then placed.  It was carefully positioned.  Pictures were taken.  We then drained the joint.  All instruments were removed.  The patient did receive IV antibiotic preoperatively.  All portals were closed using 4-0 nylon sutures.,Xeroform, 4 x 4s, and OpSite were applied over the pain pump.  ABD, tape, and a sling were also applied.  A Cryo/Cuff was also placed over the shoulder.  The patient was taken out of the beach-chair position maintaining the neutral alignment of the head, neck, and thorax.  The patient was extubated and brought to the recovery room in stable condition.  I then went out and spoke with the family, going over the case, postoperative instructions, and followup care.","orthopedic, debridement, superior labrum, patholigamentous, laxity, arthroscopic rotator cuff repair, subacromial decompression, glenohumeral joint, rotator cuff, arthroscopic, decompression, repair, glenohumeral, subacromial, rotator, cuff, "
"  Rotator cuff tear, right shoulder.  Superior labrum anterior and posterior lesion (peel-back), right shoulder.  Arthroscopy with arthroscopic SLAP lesion.  Repair of soft tissue subacromial decompression rotator cuff repair, right shoulder.", Orthopedic, Arthroscopic SLAP lesion ,"PREOPERATIVE DIAGNOSIS: , Rotator cuff tear, right shoulder.,POSTOPERATIVE DIAGNOSIS: , Superior labrum anterior and posterior lesion (peel-back), right shoulder.,PROCEDURE PERFORMED:,1.  Arthroscopy with arthroscopic SLAP lesion.,2.  Repair of soft tissue subacromial decompression rotator cuff repair, right shoulder.,SPECIFICATIONS: , The entire operative procedure was done in Inpatient Operating Suite, room #1 at ABCD General Hospital.  This was done under a interscalene block anesthetic and subsequent general anesthetic in the modified beachchair position.,HISTORY AND GROSS FINDINGS:  ,This is a 54-year-old white female suffering an increasing right shoulder pain for a few months prior to surgical intervention.  She had an injury to her right shoulder when she fell off a bike.  She was diagnosed preoperatively with a rotated cuff tear.,Intra-articularly besides we noted a large SLAP lesion, superior and posterior to the attachment of the glenoid labrum from approximately 12:30 back to 10:30.  This acted as a peel-back type of mechanism and was displaced into the joint beyond the superior rim of the glenoid.  This was an obvious avulsion into subchondral bone with bone exposed.  The anterior aspect had degenerative changes, but did not have evidence of avulsion.  The subscapular was noted to be intact.  On the joint side of the supraspinatus, there was noted to be a laminated type of tearing to the rotated cuff to the anterior and mid-aspect of the supraspinatus attachment.,This was confirmed subacromially.  The patient had a type-I plus acromion in outlet view and thus it was elected to not perform a subacromial decompression, but soft tissue release of the CA ligament in a releasing resection type fashion.,OPERATIVE PROCEDURE: , The patient was placed supine upon the operative table after she was given interscalene and then general anesthesia by the Anesthesia Department.  She was safely placed in a modified beachchair position.  She was prepped and draped in the usual sterile manner.  The portals were created from outside the ends, posterior to the scope and anteriorly for an intraoperative portal and then laterally.  She had at least two other portals appropriate for both repair mechanisms described above.,Attention was then turned to the SLAP lesion.  The edges were debrided both on the bony side as well as soft tissue side.  We used the anterior portal to lift up the mechanism and created a superolateral portal through the rotator cuff and into the edge of the labrum.  Further debridement was carried out here.  A drill hole was made just on the articular surface superiorly for a knotless anchor.  A pull-through suture of #2 fiber wire was utilized with the ________.  This was pulled through.  It was tied to the leader suture of the knotless anchor.  This was pulled through and one limb of the anchor loop was grabbed and the anchor impacted with a mallet.  There was excellent fixation of the superior labrum.  It was noted to be solid and intact.  The anchor was placed safely in the bone.  There was no room for further knotless or other anchors.  After probing was carried out, hard copy Polaroid was obtained.,Attention was then turned to the articular side for the rotator cuff.  It was debrided.  Subchondral debridement was carried out to the tuberosity also.  Care was taken to go to the subchondral region but not beyond.  The bone was satisfactory.,Scope was then placed in the subacromial region.  Gross bursectomy was carried out with in the lateral portal.  This was done throughout as well as in the gutters anterolaterally and posteriorly.  Debridement was carried out further to the rotator cuff.  Two types of fixation were carried out, one with a superolateral portal a drill hole was made and anchor of the _knotless suture placed after PDS leader suture placed with a Caspari punch.  There was an excellent reduction of the tear posteriorly and then anteriorly.  Tendon to tendon repair was accomplished by placing a fiber wire across the tendon and tying sutured down through the anterolateral portal.  This was done with a sliding stitch and then two half stitches.  There was excellent reduction of the tear.,Attention was then turned to the CA ligament.  It was released along with periosteum and the undersurface of the anterior acromion.  The CA ligament was not only released but resected.  There was noted to be no evidence of significant spurring with only a mostly type-I acromion.  Thus, it was not elected to perform subacromial decompression for bone with soft tissue only.  A pain buster catheter was placed separately.  It was cut to length.  An interrupted #4-0 nylon was utilized for portal closure.  A 0.5% Marcaine was instilled subacromially.  Adaptic, 4x4s, ABDs, and Elastoplast tape placed for dressing.  The patient's arm was placed in a arm sling.  She was transferred to PACU in apparent satisfactory condition.  Expected surgical prognosis on this patient is fair.","orthopedic, rotator cuff tear, shoulder, labrum, lesion, decompression, subacromial, arthroscopic slap lesion, slap lesion, rotator cuff, anterior, arthroscopy, arthroscopic, slap, cuff"
" Femoroacetabular impingement.  Left hip arthroscopic debridement, femoral neck osteoplasty, and labral repair.", Orthopedic, Arthroscopic Debridement & Labral Repair - Hip ,"PREOPERATIVE DIAGNOSIS: , Femoroacetabular impingement.,POSTOPERATIVE DIAGNOSIS: , Femoroacetabular impingement.,OPERATIONS PERFORMED,1.  Left hip arthroscopic debridement.,2.  Left hip arthroscopic femoral neck osteoplasty.,3.  Left hip arthroscopic labral repair.,ANESTHESIA: , General.,OPERATION IN DETAIL: , The patient was taken to the operating room, where he underwent general anesthetic.  His bilateral lower extremities were placed under traction on the Hana table.  His right leg was placed first.  The traction post was left line, and the left leg was placed in traction.  Sterile Hibiclens and alcohol prep and drape were then undertaken.  A fluoroscopic localization was undertaken.  Gentle traction was applied.  Narrow arthrographic effect was obtained.  Following this, the ProTrac portal was made under the fluoro visualization, and then, a direct anterolateral portal made and a femoral neck portal made under direct visualization.  The diagnostic arthroscopy showed the articular surface to be intact with a moderate anterior lip articular cartilage delamination injury that propagated into the acetabulum.  For this reason, the acetabular articular cartilage was taken down and stabilized.  This necessitated takedown of the anterior lip of the acetabulum and subsequent acetabular osteoplasty debridement with associated labral repair.  The labrum was repaired using absorbable Smith & Nephew anchors with a sliding SMC knot.  After stabilization of the labrum and the acetabulum, the ligamentum teres was assessed and noted to be stable.  The remnant articular surface of the femoral artery and acetabulum was stable.  The posterior leg was stable.  The traction was left half off, and the anterolateral aspect of the head and neck junction was identified.  A stable femoral neck decompression was accomplished starting laterally and proceeding anteriorly.  This terminated with the hip coming out of traction and indeterminable flexion.  A combination of burs and shavers was utilized to perform a stable femoral neck osteoplasty decompression.  The decompression was completed with thorough irrigation of the hip.  The cannula was removed, and the portals were closed using interrupted nylon.  The patient was placed into a sterile bandage and anesthetized intraarticularly with 10 mL of ropivacaine subcutaneously with 20 mL of ropivacaine and at this point was taken to the recovery room.  He tolerated the procedure very well with no signs of complications.","orthopedic, labral repair, femoral neck osteoplasty, arthroscopic debridement, femoroacetabular impingement, arthroscopic, femoroacetabular, impingement, debridement, osteoplasty, acetabulum"
 Arthroplasty of the right second digit.  Hammertoe deformity of the right second digit., Orthopedic, Arthroplasty - Hammertoe ,"PREOPERATIVE DIAGNOSIS:,  Hammertoe deformity of the right second digit.,POSTOPERATIVE DIAGNOSIS: , Hammertoe deformity of the right second digit.,PROCEDURE PERFORMED: , Arthroplasty of the right second digit.,The patient is a 77-year-old Hispanic male who presents to ABCD Hospital for surgical correction of a painful second digit hammertoe.  The patient has failed attempts at conservative treatment and is unable to wear shoes without pain to his second toe.  The patient presents n.p.o. since mid night last night and consented to sign in the chart.  H&P is complete.,PROCEDURE IN DETAIL:,  After an IV was instituted by the Department of Anesthesia in the preoperative holding area, the patient was escorted to the operating room and placed on the table in the supine position.  Using Webril, the distal leg and ankle was padded and a ankle pneumatic tourniquet was placed around the right ankle, but left deflated at this time.  Restraining, a lap belt was then placed around the patient's abdomen while laying on the table.  After adequate anesthesia was administered by the Department of Anesthesia, a local digital block using 5 cc of 0.5% Marcaine plain was used to provide local anesthesia.  The foot was then prepped and draped in the normal sterile orthopedic manner.  The foot was then elevated and Esmarch bandage was applied, after which time the tourniquet was inflated to 250 mmHg.  The foot was then brought down to the level of the table and stockinet was cut and reflected after the Esmarch bandage was removed.  A wet and dry sponge was then used to cleanse the operative site and using a skin skribe a dorsal incisional line was outlined extending from the proximal phalanx over the proximal interphalangeal joint on to the middle phalanx.,Then using a fresh #15 blade, a dorsolinear incision was made, partial thickness through the skin after testing anesthesia with one to two pickup.  Then using a fresh #15 blade, incision was deepened and using medial to lateral pressure, the incision was opened into the subcutaneous tissue.  Care was taken to reflect the subcutaneous tissue from the underlying deep fascia to mobilize the skin.  This was performed with the combination of blunt and dull dissection.  Care was taken to avoid proper digital arteries and neurovascular bundles as were identified.  Attention was then directed to the proximal interphalangeal joint and after identifying the joint line, a transverse linear incision was made over the dorsal surface of the joint.  The medial and lateral sides of the joint capsule were then also incised on the superior half in order to provide increased exposure.  Following this, the proximal portion of the transected extensor digitorum longus tendon was identified using an Adson-Brown pickup.  It was elevated with fresh #15 blade.  The tendon and capsule was reflected along with the periosteum from the underlying bone dorsally.  Following this, the distal portion of the tendon was identified in a like manner.  The tendon and the capsule as well as the periosteal tissue was reflected from the dorsal surface of the bone.  The proximal interphalangeal joint was then distracted and using careful technique, #15 blade was used to deepen the incision and while maintaining close proximity to the bone and condyles, the lateral and medial collateral ligaments were freed up from the side of the proximal phalanx head.,Following this, the head of the proximal phalanx was known to have adequate exposure and was freed from soft tissues.  Then using a sagittal saw with a #139 blade, the head of he proximal phalanx was resected.  Care was taken to avoid the deep flexor tendon.  The head of the proximal phalanx was taken with the Adson-Brown and using a #15 blade, the plantar periosteal tissue was freed up and the head was removed and sent to pathology.  The wound was then flushed using a sterile saline with gentamicin and the digit was noted to be in good alignment.  The digit was also noted to be in rectus alignment.  Proximal portion of the tendon was shortened to allow for removal of the redundant tendon after correction of the deformity.  Then using a #3-0 Vicryl suture, three simple interrupted sutures were placed for closure of the tendon and capsular tissue.  Then following this, #4-0 nylon was used in a combination of horizontal mattress and simple interrupted sutures to close the skin.  The toe was noted to be in good alignment and then 1 cc of dexamethasone phosphate was injected into the incision site.  Following this, the incision was dressed using a sterile Owen silk soaked in saline and gentamicin.  The toe was bandaged using 4 x 4s, Kling, and Coban.  The tourniquet was deflated and immediate hyperemia was noted to the digits I through V of the right foot.,The patient was then transferred to the cart and was escorted to the Postanesthesia Care Unit where the patient was given postoperative surgical shoe.  Total tourniquet time for the case was 30 minutes.  While in the recovery, the patient was given postoperative instructions to include, ice and elevation to his right foot.  The patient was given pain medications of Tylenol #3, quantity 30 to be taken one to two tablets every six to eight hours as necessary for moderate to severe pain.  The patient was also given prescription for cane to aid in ambulation.  The patient will followup with Dr. X on Tuesday in his office for postoperative care.  The patient was instructed to keep the dressings clean, dry, and intact and to not remove them before his initial office visit.  The patient tolerated the procedure well and the anesthesia with no complications.","orthopedic, hammertoe deformity, arthroplasty, digit, proximal interphalangeal joint, periosteal tissue, interrupted sutures, interphalangeal joint, proximal phalanx, proximal, painful, tourniquet, hammertoe, phalanx, head, incisional, tendon"
 Recurrent anterior dislocating left shoulder.  Arthroscopic debridement of the left shoulder with attempted arthroscopic Bankart repair followed by open Bankart arthroplasty of the left shoulder., Orthopedic, Arthroscopic Debridement - Shoulder ,"PREOPERATIVE DIAGNOSIS: , Recurrent anterior dislocating left shoulder.,POSTOPERATIVE DIAGNOSIS:,  Recurrent anterior dislocating left shoulder.,PROCEDURE PERFORMED:,  Arthroscopic debridement of the left shoulder with attempted arthroscopic Bankart repair followed by open Bankart arthroplasty of the left shoulder.,PROCEDURE:  ,The patient was taken to OR #2, administered general anesthetic after ineffective interscalene block had been administered in the preop area.  The patient was positioned in the modified beachchair position utilizing the Mayfield headrest.  The left shoulder was propped posteriorly with a rolled towel.  His head was secured to the Mayfield headrest.  The left shoulder and upper extremity were then prepped and draped in the usual manner.  A posterior lateral port was made for _____ the arthroscopic cannula.  The scope was introduced into the glenohumeral joint.  There was noted to be a complete tear of the anterior glenoid labrum off from superiorly at about 11:30 extending down inferiorly to about 6 o'clock.  The labrum was adherent to the underlying capsule.  The margin of the glenoid was frayed in this area.  The biceps tendon was noted to be intact.  The articular surface of the glenoid was fairly well preserved.  The articular surface on the humeral head was intact; however, there was a large Hill-Sachs lesion on the posterolateral aspect of the humeral head.  The rotator cuff was visualized and noted to be intact.  The axillary pouch was visualized and it was free of injury.  There were some cartilaginous fragments within the axillary pouch.  Attention was first directed after making an anterior portal to fixation of the anterior glenoid labrum.  Utilizing the Chirotech system through the anterior cannula, the labrum was secured with the pin and drill component and was then tacked back to the superior glenoid rim at about the 11 o'clock position.  A second tack was then placed at about the 8 o'clock position.  The labrum was then probed and was noted to be stable.  With some general ranging of the shoulder, the tissue was pulled out from the tacks.  An attempt was made at placement of two other tacks; however, the tissue was not of good quality to be held in position.  Therefore, all tacks were either buried down to a flat surface or were removed from the anterior glenoid area.  At this point, it was deemed that an open Bankart arthroplasty was necessary.  The arthroscopic instruments were removed.  An anterior incision was made extending from just lateral of the coracoid down toward the axillary fold.  The skin incision was taken down through the skin.  Subcutaneous tissues were then separated with the coag Bovie to provide hemostasis.  The deltopectoral fascia was identified.  It was split at the deltopectoral interval and the deltoid was reflected laterally.  The subdeltoid bursa was then removed with rongeurs.  The conjoint tendon was identified.  The deltoid and conjoint tendons were then retracted with a self-retaining retractor.  The subscapularis tendon was identified.  It was separated about a centimeter from its insertion, leaving the tissue to do sew later.  The subscapularis was reflected off superiorly and inferiorly and the muscle retracted medially.  This allowed for visualization of the capsule.  The capsule was split near the humeral head insertion leaving a tag for repair.  It was then split longitudinally towards the glenoid at approximately 9 o'clock position.  This provided visualization of the glenohumeral joint.  The friable labral and capsular tissue was identified.  The glenoid neck was already prepared for suturing, therefore, three Mitek suture anchors were then positioned to place at approximately 7 o'clock, 9 o'clock, and 10 o'clock.  The sutures were passed through the labral capsular tissue and tied securely.  At this point, the anterior glenoid rim had been recreated.  The joint was then copiously irrigated with gentamicin solution and suctioned dry.  The capsule was then repaired with interrupted #1 Vicryl suture and repaired back to its insertion site with #1 Vicryl suture.  This later was then copiously irrigated with gentamicin solution and suctioned dry.  Subscapularis was reapproximated on to the lesser tuberosity of the humerus utilizing interrupted #1 Vicryl suture.  This later was then copiously irrigated as well and suctioned dry.  The deltoid fascia was approximated with running #2-0 Vicryl suture.  Subcutaneous tissues were approximated with interrupted #2-0 Vicryl and the skin was approximated with a running #4-0 subcuticular Vicryl followed by placement of Steri-Strips.  0.25% Marcaine was placed in the subcutaneous area for postoperative analgesia.  The patient was then placed in a shoulder immobilizer after a bulky dressing had been applied.  The patient was then transferred to the recovery room in apparent satisfactory condition.","orthopedic, dislocating, bankart, arthroplasty, bankart repair, arthroscopic debridement, anterior, arthroscopic, debridement, deltoid, glenoid, humeral, interrupted, shoulder, subscapularis"
" Anterior lumbar fusion, L4-L5, L5-S1, PEEK vertebral spacer, structural autograft from L5 vertebral body, BMP and anterior plate.  Severe low back pain.", Orthopedic, Anterior Lumbar Fusion ,"PREOPERATIVE DIAGNOSIS: , Severe low back pain.,POSTOPERATIVE DIAGNOSIS: , Severe low back pain.,OPERATIONS PERFORMED: , Anterior lumbar fusion, L4-L5, L5-S1, PEEK vertebral spacer, structural autograft from L5 vertebral body, BMP and anterior plate.,ANESTHESIA:,  General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 50 mL.,DRAINS:,  None.,COMPLICATIONS: , None.,PATHOLOGICAL FINDINGS:,  Dr. X made the approach and once we were at the L5-S1 disk space, we removed the disk and we placed a 13-mm PEEK vertebral spacer filled with a core of bone taken from the L5 vertebral body.  This was filled with a 15 x 20-mm Chronos VerteFill tricalcium phosphate plug.  At L4-L5, we used a 13-mm PEEK vertebral spacer with structural autograft and BMP, and then we placed a two-level 87-mm Integra sacral plate with 28 x 6-mm screws, two each at L4 and L5 and 36 x 6-mm screws at S1.,OPERATION IN DETAIL:,  The patient was placed under general endotracheal anesthesia.  The abdomen was prepped and draped in the usual fashion.  Dr. X made the approach, and once the L5-S1 disk space was identified, we incised this with a knife and then removed a large core of bone taking rotating cutters.  I was able to remove additional disk space and score the vertebral bodies.  The rest of the disk removal was done with the curette, scraping the endplates.  I tried various sized spacers, and at this point, we exposed the L5 body and took a dowel from the body and filled the hole with a 15 x 20-mm Chronos VerteFill tricalcium phosphate plug.  Half of this was used to fill the spacer at L5-S1, BMP was placed in the spacer as well and then it was tapped into place.  We then moved the vessels over the opposite way approaching the L4-L5 disk space laterally, and the disk was removed in a similar fashion and we also used a 13-mm PEEK vertebral spacer, but this is the variety that we could put in from one side.  This was filled with bone and BMP as well.  Once this was done, we were able to place an 87-mm Integra sacral plate down over the three vertebral bodies and place these screws.  Following this, bleeding points were controlled and Dr. X proceeded with the closure of the abdomen.,SUMMARY: , This is a 51-year-old man who reports 15-year history of low back pain and intermittent bilateral leg pain and achiness.  He has tried multiple conservative treatments including physical therapy, epidural steroid injections, etc.  MRI scan shows a very degenerated disk at L5-S1, less so at L3-L4 and L4-L5.  A discogram was positive with the lower 3 levels, but he has pain, which starts below the iliac crest and I feel that the L3-L4 disk is probably that symptomatic.  An anterior lumbar interbody fusion was suggested.  Procedure, risks, and complications were explained.","orthopedic, peek vertebral spacer, autograft, anterior lumbar fusion, lumbar fusion, vertebral body, vertebral spacer, vertebral, spacer, anterior, lumbar, fusion,"
" Hammertoe deformity, left fifth digit and ulceration of the left fifth digit plantolaterally.  Arthroplasty of the left fifth digit proximal interphalangeal joint laterally and excision of plantar ulceration of the left fifth digit 3 cm x 1 cm in size.", Orthopedic, Arthroplasty ,"PREOPERATIVE DIAGNOSES:,1.  Hammertoe deformity, left fifth digit.,2.  Ulceration of the left fifth digit plantolaterally.,POSTOPERATIVE DIAGNOSIS:,1.  Hammertoe deformity, left fifth toe.,2.  Ulceration of the left fifth digit plantolaterally.,PROCEDURE PERFORMED:,1.  Arthroplasty of the left fifth digit proximal interphalangeal joint laterally.,2.  Excision of plantar ulceration of the left fifth digit 3 cm x 1 cm in size.,OPERATIVE PROCEDURE IN DETAIL: , The patient is a 38-year-old female with longstanding complaint of painful hammertoe deformity of her left fifth toe.  The patient had developed ulceration plantarly after being scheduled for removal of a plantar mass in the same area.  The patient elects for surgical removal of this ulceration and correction of her hammertoe deformity at this time.,After an IV was instituted by the Department of Anesthesia, the patient was escorted to the OR where the patient was placed on the Operating Room table in the supine position.  After adequate amount of IV sedation was administered by Anesthesia Department, the patient was given a digital block to the left fifth toe using 0.5% Marcaine plain with 1% lidocaine plain in 1:1 mixture totaling 6 cc.  Following this, the patient was draped and prepped in a normal sterile orthopedic manner.  An ankle tourniquet was placed on the left ankle and the left foot was elevated and Esmarch bandage applied to exsanguinate the foot.  The ankle tourniquet was then inflated to 230 mmHg and then was brought back down to the level of the table.  The stockinette was then cut and reflected and held in place using towel clamp.,The skin was then cleansed using the wet and dry Ray-Tec sponge and then the plantar lesion was outlined.  The lesion measured 1 cm in diameter at the level of the skin and a 3 cm elliptical incision line was drawn on the surface of the skin in the plantolateral aspect of the left fifth digit.  Then using a fresh #15 blade, skin incision was made.  Following this, the incision was then deepened using a fresh #15 blade down to the level of the subcutaneous tissue.  Using a combination of sharp and blunt dissection, the skin was reflected distally and proximally to the lesion.  The lesion appeared well encapsulated with fibrous tissue and through careful dissection using combination of sharp and drill instrumentation the ulceration was removed in its entirety.  The next further exploration was performed to ensure that no residual elements of the fibrous capsular tissue remained within.  The lesion extended from the level of the skin down to the periosteal tissue of the middle and distal phalanx, however, did not show any evidence of extending beyond the level of a periosteum.  Remaining tissues were inspected and appeared healthy.  The lesion was placed in the specimen container and sent to pathology for microanalysis as well as growth.  Attention was then directed to the proximal interphalangeal joint of the left fifth digit and using further dissection with a #15 blade, the periosteum was reflected off the lateral aspect of the proximal ________ median phalanx.  The capsule was also reflected to expose the prominent lateral osseous portion of this joint.  Using a sagittal saw and #139 blade, the lateral osseous prominence was resected.  This was removed in entirety.  Then using power-oscillating rasp, the sharp edges were smoothed and recontoured to the desirable anatomic condition.  Then the incision and wound was flushed using copious amounts of sterile saline with gentamycin.  Following this, the bone was inspected and appeared to be healthy with no evidence of involvement from the removed aforementioned lesion.,Following this, using #4-0 nylon in a combination of horizontal mattress and simple interrupted sutures, the lesion wound was closed and skin was approximated well without tension to the surface skin.  Following this, the incision site was dressed using Owen silk, 4x4s, Kling, and Coban in a normal fashion.  The tourniquet was then deflated and hyperemia was noted to return to digits one through five of the left foot.  The patient was then escorted from the operative table into the Postanesthesia Care Unit.  The patient tolerated the procedure and anesthesia well and was brought to the Postanesthesia Care Unit with vital signs stable and vascular status intact.  In the recovery, the patient was given a surgical shoe as well as given instructions for postoperative care to include rest ice and elevation as well as the patient was given prescription for Naprosyn 250 mg to be taken three times daily as well as Vicodin ES to be taken q.6h. as needed.,The patient will follow-up on Friday with Dr. X in office for further evaluation.  The patient was also given instructions as to signs of infection and to monitor her operative site.  The patient was instructed to keep daily dressings intact, clean, dry, and to not remove them.","orthopedic, hammertoe deformity, plantolaterall, ulceration, arthroplasty, plantar ulceration, interphalangeal, painful hammertoe, proximal interphalangeal joint, interphalangeal joint, digit, toe, blade, deformity, incision, hammertoe, lesion"
" Anterior cervical discectomy for neural decompression and anterior interbody fusion at C4-C5, C5-C6, and C6-C7 utilizing Bengal cages times three.", Orthopedic, Anterior Cervical Discectomy & Interbody Fusion - 1 ,"PREOPERATIVE DIAGNOSES:  ,1.  Herniated nucleus pulposus, C5-C6, greater than C6-C7 and C4-C5 with left radiculopathy.,2.  Cervical stenosis with cord compression, C5-C6 (723.0).,POSTOPERATIVE DIAGNOSES:  ,1.  Herniated nucleus pulposus, C5-C6, greater than C6-C7 and C4-C5 with left radiculopathy.,2.  Cervical stenosis with cord compression, C5-C6 (723.0), with surgical findings confirmed.,PROCEDURES:  ,1.  Anterior cervical discectomy at C4-C5, C5-C6, and C6-C7 for neural decompression (63075, 63076, 63076).,2.  Anterior interbody fusion at C4-C5, C5-C6, and C6-C7 (22554, 22585, 22585) utilizing Bengal cages times three (22851).,3.  Anterior instrumentation for stabilization by Slim-LOC plate C4, C5, C6, and C7 (22846); with intraoperative x-ray times two.,ANESTHESIA:,  General.,SERVICE: , Neurosurgery.,OPERATION: , The patient was brought into the operating room, placed in a supine position where general anesthesia was administered.  Then the anterior aspect of the neck was prepped and draped in a routine sterile fashion.  A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma, which was dissected in a subplatysmal manner, and then the prevertebral space was encountered and prominent anterior osteophytes were well visualized once longus colli muscle was cauterized along its mesial border, and self-retaining retractors were placed to reveal the anterior osteophytic spaces.  Large osteophytes were excised with a rongeur at C4-5, C5-C6, and C6-C7 revealing a collapsed disc space and a #11 blade was utilized to create an annulotomy at all three interspaces with discectomies being performed with straight disc forceps removing grossly degenerated and very degenerated discs at C4-C5, then at C5-C6, then at C6-C7 sending specimen for permanent section to Pathology in a routine and separate manner.  Residual disc fragments were drilled away as drilling extended into normal cortical and cancellous elements in order to perform a wide decompression all the way posteriorly to the spinal canal itself finally revealing a ligament, which was removed in a similar piecemeal fashion with 1 and 2-mm micro Kerrison rongeurs also utilizing these instruments to remove prominent osteophytes, widely laterally bilaterally at each interspace with one at C4-C5, more right-sided.  The most prominent osteophyte and compression was at C5-C6 followed by C6-C7 and C4-C5 with a complete decompression of the spinal canal allowing the dura to finally bulge into the interspace at all three levels, once the ligaments were proximally removed as well and similarly a sign of a decompressed status.  The nerve roots themselves were inspected with a double ball dissector and found to be equally decompressed.  The wound was irrigated with antibiotic solution and hemostasis was well achieved with pledgets of Gelfoam subsequently irrigated away.  Appropriate size Bengal cages were filled with the patient's own bone elements and countersunk into position, filled along with fusion putty, and once these were quite tightly applied and checked, further stability was added by the placement of a Slim-LOC plate of appropriate size with appropriate size screws, and a post placement x-ray showed well-aligned elements.,The wound was irrigated with antibiotic solution again and inspected, and hemostasis was completely achieved and finally the wound was closed in a routine closure by approximation of the platysma with interrupted 3-0 Vicryl, and the skin with a subcuticular stitch of 4-0 Vicryl, and this was sterilely dressed, and incorporated a Penrose drain, which was carried from the prevertebral space externally to the skin wound and safety pin for security in a routine fashion.  At the conclusion of the case, all instruments, needle, and sponge counts were accurate and correct, and there were no intraoperative complications of any type.","orthopedic, herniated nucleus pulposus, radiculopathy, cervical stenosis, anterior instrumentation, stabilization, slim-loc, neural decompression, anterior cervical discectomy, cord compression, interbody fusion, bengal cages, interbody, compression, anterior, fusion, decompression, discectomy, cervical"
 Bilateral Crawford subtalar arthrodesis with open Achilles Z-lengthening and bilateral long-leg cast., Orthopedic, Arthrodesis ,"PREOPERATIVE DIAGNOSIS: , Congenital myotonic muscular dystrophy with bilateral planovalgus feet.,POSTOPERATIVE DIAGNOSIS: , Congenital myotonic muscular dystrophy with bilateral planovalgus feet.,PROCEDURE: , Bilateral Crawford subtalar arthrodesis with open Achilles Z-lengthening and bilateral long-leg cast.,ANESTHESIA: , Surgery performed under general anesthesia.  The patient received 6 mL of 0.25% Marcaine local anesthetic on each side.,TOURNIQUET TIME:  ,Tourniquet time was 53 minutes on the left and 45 minutes on the right.,COMPLICATIONS: , There were no intraoperative complications.,DRAINS:,  None.,SPECIMENS: , None.,HARDWARE USED: , Staple 7/8 inch x1 on each side.,HISTORY AND PHYSICAL:  ,The patient is a 5-year-4-month-old male who presents for evaluation of feet.  He has been having significant feet pain with significant planovalgus deformity.  The patient was noted to have flexible vertical talus.  It was decided that the patient would benefit by subtalar arthrodesis, possible autograft, and Achilles lengthening.  This was explained to the mother in detail.  This is going to be a stabilizing measure and the patient will probably need additional surgery at a later day when his foot is more mature.  Risks of surgery include risks of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, need for other surgical procedures, need to be nonweightbearing for some time.  All questions were answered and the mother agreed to the above plan.,PROCEDURE NOTE: , The patient was taken to the operating room, placed supine on the operating room, general anesthesia was administered.  The patient received Ancef preoperatively.  Bilateral nonsterile tourniquets were placed on each thigh.  A bump was placed underneath the left buttock.  Both the extremities were then prepped and draped in standard surgical fashion.  Attention was first turned towards the left side.  Intended incision was marked on the skin.  The ankle was taken through a range of motion with noted improvement in the reduction of the talocalcaneal alignment with the foot in plantar flexion on the lateral view.  The foot was wrapped in Esmarch prior to inflation of tourniquet to 200 mmHg.  Incision was then made over the left lateral aspect of the hind foot to expose the talocalcaneal joint.  The sinus tarsi was then identified using a U-shaped flap to tack muscles, and periosteum was retracted distally.  Once the foot was reduced a Steinman pin was used to hold it in position.  This position was first checked on the fluoroscopy.  The 7/8th inch staple was then placed across the sinus tarsi to maintain the reduction.  This was also checked with fluoroscopy.  The incision was then extended posteriorly to allow for visualization of the Achilles, which was Z-lengthened with the release of the lateral distal half.  This was sutured using 2-0 Ethibond and that was also oversewn.  The wound was irrigated with normal saline.  The periosteal flap was sutured over the staple using 2-0 Vicryl.  Skin was closed using 2-0 Vicryl interrupted and then with 4-0 Monocryl.  The area was injected with 6 mL of 0.25% Marcaine local anesthetic.  The wound was cleaned and dried, dressed with Steri-Strips, Xeroform, and 4 x 4s and Webril.  Tourniquet was released after 53 minutes.  The exact same procedure was repeated on the right side with no changes or complications.  Tourniquet time on the right side was 45 minutes.  The patient tolerated the procedure well.  Bilateral long-leg casts were then placed with the foot in neutral with some moulding of his medial plantar arch.  The patient was subsequently was taken to Recovery in stable condition.,POSTOPERATIVE PLAN: , The patient will be hospitalized overnight for pain as per parents' request.  The patient is to be strict nonweightbearing for at least 6 weeks.  He is to follow up in the next 10 days for a check.  We will plan of changing to short-leg casts in about 4 weeks postop.","orthopedic, myotonic muscular dystrophy, muscular dystrophy, planovalgus feet, achilles z-lengthening, subtalar arthrodesis, bilateral crawford subtalar arthrodesis, bilateral long leg cast, sinus tarsi, leg casts, tourniquet time, arthrodesis, intraoperative, fluoroscopy, tourniquet, surgery, subtalar, achilles, anesthesia, planovalgus, foot, bilateral, "
" Irrigation and debridement of skin, subcutaneous tissue, fascia and bone associated with an open fracture and placement of antibiotic-impregnated beads.  Open calcaneus fracture on the right.", Orthopedic, Antibiotic-Impregnated Beads Placement ,"PREOPERATIVE DIAGNOSIS:,  Open calcaneus fracture on the right.,POSTOPERATIVE DIAGNOSIS:,  Open calcaneus fracture on the right.,PROCEDURES:,  ,1.  Irrigation and debridement of skin, subcutaneous tissue, fascia and bone associated with an open fracture.,2.  Placement of antibiotic-impregnated beads.,ANESTHESIA:,  General.,BLOOD LOSS:,  Minimal.,COMPLICATIONS:,  None.,FINDINGS:,  Healing skin with no gross purulence identified, some fibrinous material around the beads.,SUMMARY:,  After informed consent was obtained and verified, the patient was brought to the operating room and placed supine on the operating table.  After uneventful general anesthesia was obtained, her right leg was sterilely prepped and draped in a normal fashion.  The tourniquet was inflated and the previous wound was opened.  Dr. X came in to look at the wound and the beads were removed, all 25 beads were extracted, and pulsatile lavage, and curette, etc., were used to debride the wound.  The wound margins were healthy with the exception of very central triangular incision area.  The edges were debrided and then 19 antibiotic-impregnated beads with gentamicin and tobramycin were inserted and the wound was further closed today.,The skin edges were approximated under minimal tension.  The soft dressing was placed.  An Ace was placed.  She was awakened from the anesthesia and taken to recovery room in a stable condition.  Final needle, instrument, and sponge counts were correct.","orthopedic, open calcaneus fracture, irrigation and debridement, antibiotic impregnated beads, irrigation, subcutaneous, placement, debridement, calcaneus, fracture, wound, beads, antibiotic"
 Arthroscopy of the left knee was performed with the anterior cruciate ligament reconstruction.  Removal of loose bodies.  Medial femoral chondroplasty and meniscoplasty., Orthopedic, Anterior Cruciate Ligament Reconstruction ,"PREOPERATIVE DIAGNOSIS: , Anterior cruciate ligament rupture.,POSTOPERATIVE DIAGNOSES:,1.  Anterior cruciate ligament rupture.,2.  Medial meniscal tear.,3.  Medial femoral chondromalacia.,4.  Intraarticular loose bodies.,PROCEDURE PERFORMED:,1.  Arthroscopy of the left knee was performed with the anterior cruciate ligament reconstruction.,2.  Removal of loose bodies.,3.  Medial femoral chondroplasty.,4.  Medial meniscoplasty.,OPERATIVE PROCEDURE:  ,The patient was taken to the operative suite, placed in supine position, and administered a general anesthetic by the Department of Anesthesia.  Following this, the knee was sterilely prepped and draped as discussed for this procedure.  The inferolateral and inferomedial portals were then established; however, prior to this, a graft was harvested from the semitendinosus and gracilis region.  After the notch was identified, then ACL was confirmed and ruptured.  There was noted to be a torn, slipped up area of the medial meniscus, which was impinging and impinged on the articular surface.  The snare was smoothed out.  Entire area was thoroughly irrigated.  Following this, there was noted in fact to be significant degenerative changes from this impingement of the meniscus again to the periarticular cartilage.  The areas of the worn away portion of the medial femoral condyle was then debrided and ________ chondroplasty was then performed of this area in order to stimulate bleeding and healing.  There were multiple loose bodies noted in the knee and these were then __________ and then removed.  The tibial and femoral drill holes were then established and the graft was then put in place, both which locations after a notchplasty was performed.  The knee was taken through a full range of motion without any impingement.  An Endobutton was used for proximal fixation.  Distal fixation was obtained with an independent screw and a staple.  The patient was then taken to Postanesthesia Care Unit at the conclusion of the procedure.,","orthopedic, femoral chondroplasty, intraarticular loose bodies, anterior cruciate ligament reconstruction, anterior, arthroscopy, meniscoplasty, fixation, reconstruction, chondroplasty, ligament, femoral, intraarticular, medial"
 Anterior cervical discectomy for neural decompression and anterior interbody fusion C5-C6 utilizing Bengal cage.  , Orthopedic, Anterior Cervical Discectomy & Interbody Fusion - 3 ,"PREOPERATIVE DIAGNOSES:,  ,1.  Spondylosis with cervical stenosis C5-C6 greater than C4-C5, C6-C7, (721.0, 723.0).,2.  Neck pain with left radiculopathy, progressive (723.1/723.4).,3.  Headaches, progressive (784.0).,POSTOPERATIVE DIAGNOSES:,  ,1.  Spondylosis with cervical stenosis C5-C6 greater than C4-C5, C6-C7, (721.0, 723.0).,2.  Neck pain with left radiculopathy, progressive (723.1/723.4).,3.  Headaches, progressive (784.0).,PROCEDURES:,  ,1.  Anterior cervical discectomy at C5-C6 for neural decompression (63075).,2.  Anterior interbody fusion C5-C6 (22554) utilizing Bengal cage (22851).,3.  Anterior cervical instrumentation at C5-C6 for stabilization by Uniplate construction at C5-C6 (22845); with intraoperative x-ray x2.,SERVICE:  ,  Neurosurgery,ANESTHESIA:,","orthopedic, spondylosis, neck pain, headaches, decompression, uniplate, anterior cervical discectomy, neural decompression, cervical stenosis, prevertebral space, antibiotic solution, cervical discectomy, interbody fusion, bengal cage, interbody, anterior, cervical, discectomy,"
 Anterior cervical discectomy with spinal cord and spinal canal decompression and Anterior interbody fusion at C5-C6 utilizing Bengal cage., Orthopedic, Anterior Cervical Discectomy & Interbody Fusion - 2 ,"PREOPERATIVE DIAGNOSES:  ,1.  Large herniated nucleus pulposus, C5-C6 with myelopathy (722.21).,2.  Cervical spondylosis.,3.  Cervical stenosis, C5-C6 secondary to above (723.0).,POSTOPERATIVE DIAGNOSES:  ,1.  Large herniated nucleus pulposus, C5-C6 with myelopathy (722.21).,2.  Cervical spondylosis.,3.  Cervical stenosis, C5-C6 secondary to above (723.0), with surgical findings confirmed.,PROCEDURES: , ,1.  Anterior cervical discectomy at C5-C6 with spinal cord and spinal canal decompression (63075).,2.  Anterior interbody fusion at C5-C6, (22554) utilizing Bengal cage (22851).,3.  Anterior instrumentation for stabilization by Uniplate construction, C5-C6, (22845); with intraoperative x-ray times two.,ANESTHESIA: , General.,SERVICE: , Neurosurgery.,OPERATION:  ,The patient was brought into the operating room, placed in a supine position where general anesthesia was administered.  Then the anterior aspect of the neck was prepped and draped in a routine sterile fashion.  A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma, which was dissected only in a subplatysmal manner bluntly, and with only blunt dissection at the prevertebral space where a localizing intraoperative x-ray was obtained, once self-retaining retractors were placed along the mesial edge of a cauterized longus colli muscle, to protect surrounding tissues throughout the remainder of the case.  A prominent anterior osteophyte at C5-C6 was then localized, compared to preoperative studies in the usual fashion intraoperatively, and the osteophyte was excised with a rongeur and bony fragments saved.  This allowed for an annulotomy, which was carried out with a #11 blade and discectomy, removed with straight disc forceps portions of the disc, which were sent to Pathology for a permanent section.  Residual osteophytes and disc fragments were removed with 1 and 2-mm micro Kerrison rongeurs as necessary as drilling extended into normal cortical and cancellous elements widely laterally as well.  A hypertrophied ligament and prominent posterior spurs were excised as well until the dura bulged into the interspace, a sign of a decompressed status.  At no time during the case was evidence of CSF leakage, and hemostasis was readily achieved with pledgets of Gelfoam subsequently removed with copious amounts of antibiotic irrigation.  Once the decompression was inspected with a double ball dissector and all found to be completely decompressed, and the dura bulged at the interspace, and pulsated, then a Bengal cage was filled with the patient's own bone elements and fusion putty and countersunk into position, and was quite tightly applied.  Further stability was added nonetheless with an appropriate size Uniplate, which was placed of appropriate size with appropriate size screws and these were locked into place in the usual manner.  The wound was inspected, and irrigated again with antibiotic solution and after further inspection was finally closed in a routine closure in a multiple layer event by first approximation of the platysma with interrupted 3-0 Vicryl, and the skin with a subcuticular stitch of 4-0 Vicryl, and this was Steri-Stripped for reinforcement, and a sterile dressing was applied, incorporating a Penrose drain, which was carried from the prevertebral space externally to the skin wound and safety pin for security in the usual manner.  Once the sterile dressing was applied, the patient was taken from the operating room to the recovery area having left in stable condition.,At the conclusion of the case, all instruments, needle, and sponge counts were accurate and correct, and there were no intraoperative complications of any type.","orthopedic, herniated nucleus pulposus, myelopathy, cervical spondylosis, cervical stenosis, anterior instrumentation, uniplate, decompression, anterior cervical discectomy, spinal cord, spinal canal, sterile dressing, interbody fusion, bengal cage, interbody, cervical, anterior, discectomy,"
" C5-C6 anterior cervical discectomy, allograft fusion, and anterior plating.", Orthopedic, Anterior Cervical Discectomy & Fusion - 8 ,"PROCEDURES PERFORMED: , C5-C6 anterior cervical discectomy, allograft fusion, and anterior plating.,ESTIMATED BLOOD LOSS: , 10 mL.,CLINICAL NOTE: , This is a 57-year-old gentleman with refractory neck pain with single-level degeneration of the cervical spine and there was also some arm pain.  We decided go ahead with anterior cervical discectomy at C5-C6 and fusion.  The risks of lack of pain relief, paralysis, hoarse voice, nerve injuries, and infection were explained and the patient agreed to proceed.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room where a general endotracheal anesthesia was induced without complication.  The patient was placed in the slightly extended position with the neck and the head was restrained in a doughnut and the occiput was restrained by the doughnut.  He had tape placed over the shoulders during intraoperative x-rays and his elbows were well padded.  The tape was placed and his arms were well padded.  He was prepped and draped in a sterile fashion.  A linear incision was fashioned at the cricothyroid level from near the midline to over the sternocleidomastoid muscle.  We separated the platysma from the subcutaneous tissue and then opened the platysma along the medial border of the sternocleidomastoid muscle.  We then dissected sharply medial to carotid artery, which we palpated to the prevertebral region.  We placed Caspar retractors for medial and lateral exposure over the C5-C6 disc space, which we confirmed with the lateral cervical spine x-ray including 18-gauge needle in the disc space.  We then marked the disc space.  We then drilled off ventral osteophyte as well as osteophyte creating concavity within the disc space.  We then under magnification removed all the disc material, we could possibly see down to bleeding bone and both the endplates.  We took down posterior longitudinal ligament as well.  We incised the 6-mm cornerstone bone.  We placed a 6-mm parallel medium bone nicely into the disc space.  We then sized a 23-mm plate.  We inserted the screws nicely above and below.  We tightened down the lock-nuts.  We irrigated the wound.  We assured hemostasis using bone wax prior to placing the plate.  We then assured hemostasis once again.  We reapproximated the platysma using 3-0 Vicryl in a simple interrupted fashion.  The subcutaneous level was closed using 3-0 Vicryl in a simple buried fashion.  The skin was closed with 3-0 Monocryl in a running subcuticular stitch.  Steri-Strips were applied.  Dry sterile dressing with Telfa was applied over this.  We obtained an intraoperative x-ray to confirm the proper level and good position of both plates and screw construct on the lateral x-ray and the patient was transferred to the recovery room, moving all four extremities with stable vital signs.  I was present as a primary surgeon throughout the entire case.","orthopedic, allograft fusion, anterior cervical discectomy, neck pain, cervical spine, discectomy, fusion, sternocleidomastoid muscle, assured hemostasis, anterior cervical, cervical discectomy, disc space, cervical, anterior, allograft"
" C4-C5, C5-C6 anterior cervical discectomy and fusion.  The patient is a 62-year-old female who presents with neck pain as well as upper extremity symptoms.  Her MRI showed stenosis at portion of C4 to C6.", Orthopedic, Anterior Cervical Discectomy & Fusion - 7 ,"PREOPERATIVE DIAGNOSIS:,  C4-C5, C5-C6 stenosis.,PREOPERATIVE DIAGNOSIS: , C4-C5, C5-C6 stenosis.,PROCEDURE: , C4-C5, C5-C6 anterior cervical discectomy and fusion.,COMPLICATIONS: , None.,ANESTHESIA: , General.,INDICATIONS OF PROCEDURE: , The patient is a 62-year-old female who presents with neck pain as well as upper extremity symptoms.  Her MRI showed stenosis at portion of C4 to C6.  I discussed the procedure as well as risks and complications.  She wishes to proceed with surgery.  Risks will include but are not limited to infection, hemorrhage, spinal fluid leak, worsened neurologic deficit, recurrent stenosis, requiring further surgery, difficulty with fusion requiring further surgery, long-term hoarseness of voice, difficulty swallowing, medical anesthesia risk.,PROCEDURE:  ,The patient was taken to the operating room on 10/02/2007.  She was intubated for anesthesia.  TEDS and boots as well as Foley catheter were placed.  She was placed in a supine position with her neck in neutral position.  Appropriate pads were also used.  The area was prepped and draped in usual sterile fashion.  Preoperative localization was taken.  _____ not changed.  Incision was made on the right side in transverse fashion over C5 vertebral body level.  This was made with a #10 blade knife and further taken down with pickups and scissors.  The plane between the esophagus and carotid artery was carefully dissected both bluntly and sharply down to the anterior aspect of the cervical spine.  Intraoperative x-ray was taken.  Longus colli muscles were retracted laterally.  Caspar retractors were used.  Intraoperative x-ray was taken.  I first turned by attention at C5-C6 interspace.  This was opened with #15 blade knife.  Disc material was taken out using pituitary as well as Kerrison rongeur.  Anterior aspects were taken down.  End plates were arthrodesed using curettes.  This was done under distraction.  Posterior longitudinal ligament was opened with a nerve hook and Kerrison rongeur.  Bilateral foraminotomies were done.  At this point, I felt that there was a good decompression.  The foramen appeared to be opened.  Medtronic cage was then encountered and sent few millimeters.  This was packed with demineralized bone matrix.  The distraction was then taken down.  The cage appeared to be strong.  This procedure was then repeated at C4-C5.  A 42-mm AcuFix plate was then placed between C4 and C6.  This was carefully screwed and locked.  The instrumentation appeared to be strong.  Intraoperative x-ray was taken.  Irrigation was used.  Hemostasis was achieved.  The platysmas was closed with 3-0 Vicryl stitches.  The subcutaneous was closed with 4-0 Vicryl stitches.  The skin was closed with Steri-strips.  The area was clean and dry and dressed with Telfa and Tegaderm.  Soft cervical collar was placed for the patient.  She was extubated per anesthesia and brought to the recovery in stable condition.","orthopedic, anterior cervical discectomy, fusion, infection, hemorrhage, spinal fluid leak, anesthesia, foley catheter, teds, anterior cervical, cervical discectomy, anterior, cervical, discectomy, stenosis,"
" Anterior cervical discectomy with decompression, C5-C6, arthrodesis with anterior interbody fusion, C5-C6, spinal instrumentation, C5-C6 using Pioneer 18-mm plate and four 14 x 4.0 mm screws (all titanium), implant using PEEK 7 mm, and Allograft using Vitoss.", Orthopedic, Anterior Cervical Discectomy & Interbody Fusion ,"PREOPERATIVE DIAGNOSES,1.  Neck pain with bilateral upper extremity radiculopathy, left more than the right.,2.  Cervical spondylosis with herniated nucleus pulposus, C5-C6.,POSTOPERATIVE DIAGNOSES,1.  Neck pain with bilateral upper extremity radiculopathy, left more than the right.,2.  Cervical spondylosis with herniated nucleus pulposus, C5-C6.,OPERATIVE PROCEDURES,1.  Anterior cervical discectomy with decompression, C5-C6.,2.  Arthrodesis with anterior interbody fusion, C5-C6.,3.  Spinal instrumentation, C5-C6 using Pioneer 18-mm plate and four 14 x 4.0 mm screws (all titanium).,4.  Implant using PEEK 7 mm.,5.  Allograft using Vitoss.,DRAINS: , Round French 10 JP drain.,FLUIDS:  ,1200 cc of crystalloids.,URINE OUTPUT: , No Foley catheter.,SPECIMENS: , None.,COMPLICATIONS: , None.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,INDICATIONS FOR THE OPERATION:,  This is a case of a very pleasant 38-year-old Caucasian female who has been complaining over the last eight years of neck pain and shoulder pain radiating down across the top of her left shoulder and also across her shoulder blades to the right side, but predominantly down the left upper extremity into the wrist.  The patient has been diagnosed with fibromyalgia and subsequently, has been treated with pain medications, anti-inflammatories and muscle relaxants.  The patient's symptoms continued to persist and subsequently, an MRI of the C-spine was done, which showed disc desiccation, spondylosis and herniated disk at C5-C6, an EMG and CV revealed a presence of mild-to-moderate carpal tunnel syndrome.  The patient is now being recommended to undergo decompression and spinal instrumentation and fusion at C5-C6.  The patient understood the risks and benefits of the surgery.  Risks include but not exclusive of bleeding and infection.  Bleeding can be in the form of soft tissue bleeding, which may compromise airway for which she can be brought emergently back to the operating room for emergent evacuation of the hematoma as this may cause weakness of all four extremities, numbness of all four extremities, as well as impairment of bowel and bladder function.  This could also result in dural tear with its attendant symptoms of headache, nausea, vomiting, photophobia, and posterior neck pain as well as the development of pseudomeningocele.  Should the symptoms be severe or the pseudomeningocele be large, she can be brought back to the operating room for repair of the CSF leak and evacuation of the pseudomeningocele.  There is also the risk of pseudoarthrosis and nonfusion, for which she may require redo surgery at this level.  There is also the possibility of nonimprovement of her symptoms in about 10% of cases.  The patient understands this risk on top of the potential injury to the esophagus and trachea as well as the carotid artery.  There is also the risk of stroke, should an undiagnosed plaque be propelled into the right cerebral circulation.  The patient also understands that there could be hoarseness of the voice secondary to injury to the recurrent laryngeal nerve.  She understood these risks on top of the risks of anesthesia and gave her consent for the procedure.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room, awake, alert and not in any form of distress.  After smooth induction and intubation, the patient was positioned supine on the operating table with the neck placed on hyperextension and the head supported on a foam doughnut.  A marker was placed.  This verified the level to be at the C5-C6 level and incision was then marked in a transverse fashion starting from the midline extending about 5 mm beyond the anterior border of the sternocleidomastoid muscle.  The area was then prepped with DuraPrep after the head was turned 45 degrees to the left.,After sterile drapes were laid out, an incision was made using a scalpel blade #10.  Wound edge bleeders were carefully controlled with bipolar coagulation and the platysma was cut using a hot knife in a transverse fashion.  Dissection was then carried underneath the platysma superiorly inferiorly.  The anterior border of the sternocleidomastoid was identified and dissection was carried out lateral to the esophagus to trachea as well as medial to the carotid sheath in the sternocleidomastoid muscle.  The prevertebral fascia was noted to be taken her case with a lot of fat deposition.  Bipolar coagulation of bleeders was done; however, branch of the superior thyroid artery was ligated with Hemoclips x4.  After this was completed, a localizing x-ray verified the marker to be at the C6-C7 level.  We proceeded to strip the longus colli muscles off the vertebral body of the C5 and C6.  Self-retaining retractor was then laid down.  An anterior osteophyte was carefully drilled using a Midas 5-mm bur and the disk together with the inferior endplate of C5 and the superior endplate of C6 was also drilled down with the Midas 5-mm bur.  This was later followed with a 3-mm bur and the disk together with posterior longitudinal ligament was removed using Kerrison's ranging from 1 to 4 mm.  The herniation was noted on the right.  However, there was significant neuroforaminal stenosis on the left.  Decompression on both sides was done and after this was completed, a Valsalva maneuver showed no evidence of any CSF leakage.  The area was then irrigated with saline with bacitracin solution.  A 7 mm implant with its inferior packed with Vitoss was then laid down and secured in place with four 14 x 4.0 mm screws and plate 18 mm, all of which were titanium.  X-ray after this placement showed excellent position of all these implants and screws and _____ and the patient's area was also irrigated with saline with bacitracin solution.  A round French 10 JP drain was then laid down and exteriorized through a separate stab incision on the patient's right inferiorly.  The catheter was then anchored to the skin with a nylon 3-0 stitch and connected to a sterile draining system.  The wound was then closed in layers with Vicryl 3-0 inverted interrupted sutures for the platysma, Vicryl subcuticular 4-0 Stitch for the dermis, and the wound was reinforced with Dermabond.  Dressing was placed only at the exit site of the catheter.  C-collar was placed.  The patient was extubated and transferred to recovery.",
"  Herniated nucleus pulposus C5-C6.  Anterior cervical discectomy fusion C5-C6 followed by instrumentation C5-C6 with titanium dynamic plating system, Aesculap.  Operating microscope was used for both illumination and magnification.", Orthopedic, Anterior Cervical Discectomy & Fusion - 9 ,"PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus C5-C6.,POSTOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus C5-C6.,PROCEDURE:,  Anterior cervical discectomy fusion C5-C6 followed by instrumentation C5-C6 with titanium dynamic plating system, Aesculap.  Operating microscope was used for both illumination and magnification.,FIRST ASSISTANT: , Nurse practitioner.,PROCEDURE IN DETAIL: , The patient was placed in supine position.  The neck was prepped and draped in the usual fashion for anterior discectomy and fusion.  An incision was made midline to the anterior body of the sternocleidomastoid at C5-C6 level.  The skin, subcutaneous tissue, and platysma muscle was divided exposing the carotid sheath, which was retracted laterally.  Trachea and esophagus were retracted medially.  After placing the self-retaining retractors with the longus colli muscles having been dissected away from the vertebral bodies at C5 and C6 and confirming our position with intraoperative x-rays, we then proceeded with the discectomy.,We then cleaned out the disc at C5-C6 after incising the annulus fibrosis.  We cleaned out the disc with a combination of angled and straight pituitary rongeurs and curettes, and the next step was to clean out the disc space totally.  With this having been done, we then turned our attention with the operating microscope to the osteophytes.  We drilled off the vertebral osteophytes at C5-C6, as well as the uncovertebral osteophytes.  This was removed along with the posterior longitudinal ligament.  After we had done this, the dural sac was opposed very nicely and both C6 nerve roots were thoroughly decompressed.  The next step after the decompression of the thecal sac and both C6 nerve roots was the fusion.  We observed that there was a ____________ in the posterior longitudinal ligament.  There was a free fragment disc, which had broken through the posterior longitudinal ligament just to the right of midline.,The next step was to obtain the bone from the back bone, using cortical cancellous graft 10 mm in size after we had estimated the size.  That was secured into place with distraction being applied on the vertebral bodies using vertebral body distractor.,After we had tapped in the bone plug, we then removed the distraction and the bone plug was fitting nicely.,We then use the Aesculap cervical titanium instrumentation with the 16-mm screws.  After securing the C5-C6 disc with four screws and titanium plate, x-rays showed good alignment of the spine, good placement of the bone graft, and after x-rays showed excellent position of the bone graft and instrumentation, we then placed in a Jackson-Pratt drain in the prevertebral space brought out through a separate incision.  The wound was closed with 2-0 Vicryl for subcutaneous tissues and skin was closed with Steri-Strips.  Blood loss during the operation was less than 10 mL.  No complications of the surgery.  Needle count, sponge count, and cottonoid count were correct.,","orthopedic, aesculap, titanium dynamic plating system, anterior cervical discectomy, herniated nucleus pulposus, cervical discectomy, operating microscope, longitudinal ligament, discectomy, anterior, instrumentation, cervical, titanium"
" Anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray.  Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy and moderate stenosis C5-6.", Orthopedic, Anterior Cervical Discectomy & Fusion - Discharge Summary ,"FINAL DIAGNOSES:,1.  Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy.,2.  Moderate stenosis C5-6.,OPERATION: , On 06/25/07, anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray.,This is a 60-year-old white male who was in the office on 05/01/07 because of neck pain with left radiculopathy and ""tension headaches.""  In the last year or so, he has had more and more difficulty and more recently has developed tingling and numbness into the fingers of the left hand greater than right.  He has some neck pain at times and has seen Dr. X for an epidural steroid injection, which was very helpful.  More recently he saw Dr. Y and went through some physical therapy without much relief.,Cervical MRI scan was obtained and revealed a large right-sided disc herniation at C4-5 with significant midline herniations at C5-6 and a large left HNP at C6-7.  In view of the multiple levels of pathology, I was not confident that anything short of surgical intervention would give him significant relief.  The procedure and its risk were fully discussed and he decided to proceed with the operation.,HOSPITAL COURSE: , Following admission, the procedure was carried out without difficulty.  Blood loss was about 125 cc.  Postop x-ray showed good alignment and positioning of the cages, plate, and screws.  After surgery, he was able to slowly increase his activity level with assistance from physical therapy.  He had some muscle spasm and soreness between the shoulder blades and into the back part of his neck.  He also had some nausea with the PCA.  He had a low-grade fever to 100.2 and was started on incentive spirometry.  Over the next 12 hours, his fever resolved and he was able to start getting up and around much more easily.,By 06/27/07, he was ready to go home.  He has been counseled regarding wound care and has received a neck sheet for instruction.  He will be seen in two weeks for wound check and for a followup evaluation/x-rays in about six weeks.  He has prescriptions for Lortab 7.5 mg and Robaxin 750 mg.  He is to call if there are any problems.","orthopedic, slimlock, herniated nucleuses pulposus, anterior cervical discectomy, bengal cages, anterior, herniated, cervical, radiculopathy, discectomy, "
 Anterior cervical discectomy and osteophytectomy.  Application of prosthetic interbody fusion device.  Anterior cervical interbody arthrodesis.  Anterior cervical instrumentation, Orthopedic, Anterior Cervical Discectomy & Osteophytectomy ,"PREOPERATIVE DIAGNOSES,1.  Cervical radiculopathy, C5-C6 and C6-C7.,2.  Symptomatic cervical spondylosis, C5-C6 and C6-C7.,3.  Symptomatic cervical stenosis, C5-C6 and C6-C7.,4.  Symptomatic cervical disc herniations, C5-C6 and C6-C7.,POSTOPERATIVE DIAGNOSES,1.  Cervical radiculopathy, C5-C6 and C6-C7.,2.  Symptomatic cervical spondylosis, C5-C6 and C6-C7.,3.  Symptomatic cervical stenosis, C5-C6 and C6-C7.,4.  Symptomatic cervical disc herniations, C5-C6 and C6-C7.,OPERATIVE PROCEDURE,1.  CPT code 63075:  Anterior cervical discectomy and osteophytectomy, C5-C6.,2.  CPT code 63076:  Anterior cervical discectomy and osteophytectomy, C6-C7, additional level.,3.  CPT code 22851:  Application of prosthetic interbody fusion device, C5-C6.,4.  CPT code 22851-59:  Application of prosthetic interbody fusion device, C6-C7, additional level.,5.  CPT code 22554-51:  Anterior cervical interbody arthrodesis, C5-C6.,6.  CPT code 22585:  Anterior cervical interbody arthrodesis, C6-C7, additional level.,7.  CPT code 22845:  Anterior cervical instrumentation, C5-C7.,ANESTHESIA:,  General endotracheal.,ESTIMATED BLOOD LOSS:  ,Negligible.,DRAINS: , Small suction drain in the cervical wound.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL:,  The patient was given intravenous antibiotic prophylaxis and thigh-high TED hoses were placed on the lower extremities while in the preanesthesia holding area.  The patient was transported to the operative suite and on to the operative table in the supine position.  General endotracheal anesthesia was induced.  The head was placed on a well-padded head holder.  The eyes and face were protected from pressure.  A well-padded roll was placed beneath the neck and shoulders to help preserve the cervical lordosis.  The arms were tucked and draped to the sides.  All bony prominences were well padded.  An x-ray was taken to confirm the correct level of the skin incision.  The anterior neck was then prepped and draped in the usual sterile fashion.,A straight transverse skin incision over the left side of the anterior neck was made and carried down sharply through the skin and subcutaneous tissues to the level of the platysma muscle, which was divided transversely using the electrocautery.  The superficial and deep layers of the deep cervical fascia were divided.  The midline structures were reflected to the right side.  Care was taken during the dissection to avoid injury to the recurrent laryngeal nerve and the usual anatomical location of that nerve was protected.  The carotid sheath was palpated and protected laterally.  An x-ray was taken to confirm the level of C5-C6 and C6-C7.,The longus colli muscle was dissected free bilaterally from C5 to C7 using blunt dissection.  Hemostasis was obtained using the electrocautery.  The blades of the cervical retractor were placed deep to the longus colli muscles bilaterally.  At C5-C6, the anterior longitudinal ligament was divided transversely.  Straight pituitary rongeurs and a curette were used to remove the contents of the disc space.  All cartilages were scraped off the inferior endplate of C5 and from the superior endplate of C6.  The disc resection was carried posteriorly to the posterior longitudinal ligament and laterally to the uncovertebral joints.  The posterior longitudinal ligament was resected using a 1 mm Kerrison rongeur.  Beginning in the midline and extending into both neural foramen, posterior osteophytes were removed using a 1 m and a 2 mm Kerrison rongeurs.  The patient was noted to have significant bony spondylosis causing canal and foraminal stenosis as well as a degenerative and protruding disc in agreement with preoperative diagnostic imaging studies.  Following completion of the discectomy and osteophytectomy, a blunt nerve hook was passed into the canal superiorly and inferiorly as well as in the both neural foramen to make sure that there were no extruded disc fragments and to make sure the bony decompression was complete.  A portion of the uncovertebral joint was resected bilaterally for additional nerve root decompression.  Both nerve roots were visualized and noted to be free of encroachment.  The same procedure was then carried out at C6-C7 with similar findings.  The only difference in the findings was that at C6-C7 on the left side, the patient was found to have an extruded disc fragment in the canal and extending into the left side neural foramen causing significant cord and nerve root encroachment.,In preparation for the arthrodesis, the endplates of C5, C6, and C7 were burred in a parallel fashion down to the level of bleeding bone using a high-speed cutting bur with irrigant solution for cooling.  The disc spaces were then measured to the nearest millimeter.  Attention was then turned toward preparation of the structural allograft, which consisted of two pieces of pre-machined corticocancellous bone.  The grafts were further shaped to fit the disc spaces exactly in a press-fit manner with approximately 1.5 mm of distraction at each disc space.  The grafts were shaped to be slightly lordotic to help preserve the cervical lordosis.  The grafts were impacted into the disc spaces.  There was complete bony apposition between the ends of the bone grafts and the vertebral bodies of C5, C6, and C7.  A blunt nerve hook was passed posterior to each bone graft to make sure that the bone grafts were in good position.  Anterior osteophytes were removed using a high-speed cutting bur with irrigant solution for cooling.  An appropriate length Synthes cervical plate was selected and bent slightly to conform to the patient's cervical lordosis.  The plate was held in the midline with provided instrumentation while a temporary fixation screw was applied at C6.  Screw holes were then drilled using the provided drill and drill guide taking care to avoid injury to neurovascular structures.  The plate was then rigidly fixed to the anterior spine using 14-mm cancellous screws followed by locking setscrews added to the head of each screw to prevent postoperative loosening of the plate and/or screws.,An x-ray was taken, which confirmed satisfactory postioning of the plate, screws, and bone grafts.,Blood loss was minimal.  The wound was irrigated with irrigant solution containing antibiotics.  The wound was inspected and judged to be dry.  The wound was closed over a suction drain placed in the deepest portion of the wound by reapproximating the platysma muscle with #4-0 Vicryl running suture, the subdermal and subcuticular layers with #4-0 Monocryl interrupted sutures, and the skin with Steri-Strips.  The sponge and needle count were correct.  A sterile dressing was applied to the wound.  The neck was placed in a cervical orthosis.  The patient tolerated the procedure and was transferred to the recovery room in stable condition.",
 Anterior cervical discectomy with decompression of spinal cord.  Anterior cervical fusion.  Anterior cervical instrumentation.  Insertion of intervertebral device.  Use of operating microscope., Orthopedic, Anterior Cervical Discectomy & Fusion - 6 ,"PREOPERATIVE DIAGNOSIS:  ,Symptomatic disk herniation, C7-T1.,FINAL DIAGNOSIS:  ,Symptomatic disk herniation, C7-T1.,PROCEDURES PERFORMED,1.  Anterior cervical discectomy with decompression of spinal cord C7-T1.,2.  Anterior cervical fusion, C7-T1.,3.  Anterior cervical instrumentation, anterior C7-T1.,4.  Insertion of intervertebral device, C7-T1.,5.  Use of operating microscope.,ANESTHESIOLOGY: , General endotracheal.,ESTIMATED BLOOD LOSS:  ,A 30 mL.,PROCEDURE IN DETAIL:  ,The patient was taken to the operating room where he was orally intubated by The Anesthesiology Service.  He was placed in the supine position on an OR table.  His arms were carefully taped down.  He was sterilely prepped and draped in the usual fashion.,A 4-cm incision was made obliquely over the left side of his neck.  Subcutaneous tissue was dissected down to the level of the platysma.  The platysma was incised using electrocautery.  Blunt dissection was done to create a plane between the strap muscles and the sternoclavicular mastoid muscle.  This allowed us to get right down on to the anterior cervical spine.  Blunt dissection was done to sweep off the longus colli.  We isolated the C7-T1 interspace.  An x-ray was taken to verify; we were indeed at the C7-T1 interspace.,Shadow-Line retractor was placed as well as Caspar pins.  This provided very, very good access to the C7-T1 disk.,At this point, the operating microscope was brought into the decompression.,A thorough and aggressive C7-T1 discectomy was done using a succession of curettes, pituitary rongeur, 4-mm cutting bur and a #2 Kerrison rongeur.  At the end of the discectomy, the cartilaginous endplates were carefully removed using 4-mm cutting burr.  The posterior longitudinal ligament was carefully resected using #2 Kerrison rongeur.  Left-sided C8 foraminotomy was accomplished using nerve hook and a 2-mm Kerrison rongeur.  At the end of the decompression, there was no further compression on the left C8 nerve root.,A Synthes cortical cancellous ____________ bone was placed in the interspace.  Sofamor Danek Atlantis plate was then placed over the interspace and four screws were placed, two in the body of C7 and two in the body of T1.  An x-ray was taken.  It showed good placement of the plate and screws.,A deep drain was placed.  The platysma layer was closed in running fashion using #1 Vicryl.  Subcutaneous tissue was closed in an interrupted fashion using 2-0 Vicryl.  Skin was closed in a running fashion using 4-0 Monocryl.  Steri-Strips and dressings were applied.  All counts were correct.  There were no complications.","orthopedic, disk herniation, cervical discectomy, decompression, spinal cord, anterior cervical fusion, anterior cervical discectomy, kerrison rongeur, anterior cervical, instrumentation, cervical, anterior, platysma, kerrison, fashion, interspace, rongeur, discectomy, herniation,"
" Anterior cervical discectomy at C5-C6 and C6-C7 for neural decompression and anterior interbody fusion at C5-C6 and C6-C7 utilizing Bengal cages x2.  Anterior instrumentation by Uniplate construction C5, C6, and C7 with intraoperative x-ray x2.", Orthopedic, Anterior Cervical Discectomy & Fusion - 5 ,"PREOPERATIVE DIAGNOSES:  ,1.  Cervical spondylosis C5-C6 greater than C6-C7 (721.0).,2.  Neck pain, progressive (723.1) with right greater than left radiculopathy (723.4).,POSTOPERATIVE DIAGNOSES:  ,1.  Cervical spondylosis C5-C6 greater than C6-C7 (721.0).,2.  Neck pain, progressive (723.1) with right greater than left radiculopathy (723.4), surgical findings confirmed.,PROCEDURES:  ,1.  Anterior cervical discectomy at C5-C6 and C6-C7 for neural decompression (63075, 63076).,2.  Anterior interbody fusion at C5-C6 and C6-C7 (22554, 22585) utilizing Bengal cages x2 (22851).,3.  Anterior instrumentation by Uniplate construction C5, C6, and C7 (22845); with intraoperative x-ray x2.,ANESTHESIA:  ,General.,OPERATIONS: , The patient was brought to the operating room and placed in the supine position where general anesthesia was administered.  Then the anterior aspect of the neck was prepped and draped in the routine sterile fashion.  A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma, which was dissected in a subplatysmal manner and then with only blunt dissection, the prevertebral space was encountered and localizing intraoperative x-ray was obtained once cauterized the longus colli muscle bilaterally allowed for the placement along its mesial portion of self-retaining retractors for exposure of tissues.  Prominent anterior osteophytes once identified and compared to preoperative studies were removed at C5-C6 and then at C6-C7 with rongeur, allowing for an annulotomy with an #11 blade through collapsed disc space at C5-6, and even more collapsed at C6-C7.  Gross instability appeared and though minimally at both interspaces and residual disc were removed then with the straight disc forceps providing a discectomy at both levels, sending to Pathology in a routine fashion as disc specimen.  This was sent separately and allowed for residual disc removal of power drill where drilling extended in normal cortical and cancellous elements of the C5 and C6 interspaces and at C6-C7 removing large osteophytes and process, residual osteophytes from which were removed finally with 1 and 2 mm micro Kerrison rongeurs allowing for excision of other hypertrophied ligament posteriorly as well.  This allowed for the bulging into the interspace of the dura, sign of decompressed status, and this was done widely bilaterally to decompress the nerve roots themselves and this was assured by inspection with a double ball dissector as needed.  At no time during the case was there evidence of CSF leakage and hemostasis was well achieved with pledgets of Gelfoam and subsequently removed with copious amounts of antibiotic irrigation as well as Surgifoam.  Once hemostasis well achieved, Bengal cage was filled with the patient's own bone elements of appropriate size, and this was countersunk into position and quite tightly applied it at first C5-C6, then secondly at C6-C7.  These were checked and found to be well applied and further stability was then added by placement nonetheless of a Uniplate of appropriate size.  The appropriate size screws and post-placement x-ray showed well-aligned elements and removal of osteophytes, etc.  The wound was again irrigated with antibiotic solution, inspected, and finally closed in a multiple layered closure by approximation of platysma with interrupted #3-0 Vicryl and the skin with subcuticular stitch of #4-0 Vicryl incorporating a Penrose drain from vertebral space externally through the skin wound and safety pin, and later incorporated itself into sterile bandage.,Once the bandage was placed, the patient was taken, extubated from the operating room to the Recovery area, having in stable, but guarded condition.  At the conclusion of the case, all instrument, needle, and sponge counts were accurate and correct.  There were no intraoperative complications of any type.","orthopedic, cervical spondylosis, anterior cervical discectomy, anterior instrumentation, annulotomy, kerrison rongeurs, surgifoam, vertebral space, uniplate construction, bengal cages, neural decompression, anterior cervical, cervical discectomy, interbody, anterior, cervical, discectomy"
 Anterior cervical discectomy with decompression and arthrodesis with anterior interbody fusion.  Spinal instrumentation using Pioneer 18-mm plate and four 14 x 4.3 mm screws (all titanium)., Orthopedic, Anterior Cervical Discectomy & Fusion - 4 ,"PREOPERATIVE DIAGNOSIS: , Cervical myelopathy, C3-4, secondary to stenosis from herniated nucleus pulposus, C3-4.,POSTOPERATIVE DIAGNOSES: , Cervical myelopathy, C3-4, secondary to stenosis from herniated nucleus pulposus, C3-4.,OPERATIVE PROCEDURES,1.  Anterior cervical discectomy with decompression, C3-4.,2.  Arthrodesis with anterior interbody fusion, C3-4.,3.  Spinal instrumentation using Pioneer 18-mm plate and four 14 x 4.3 mm screws (all titanium).,4.  Implant using PEEK 7 mm.,5.  Allograft using Vitoss.,DRAINS: , Round French 10 JP drain.,FLUIDS: , 1800 mL of crystalloids.,URINE OUTPUT:  ,1000 mL.,SPECIMENS: , None.,COMPLICATIONS:  ,None.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS:  ,Less than 100 mL.,CONDITION:  ,To postanesthesia care unit extubated with stable vital signs.,INDICATIONS FOR THE OPERATION:  ,This is a case of a very pleasant 32-year-old Caucasian male who had been experiencing posterior neck discomfort and was shooting basketball last week, during which time he felt a pop.  Since then, the patient started complaining of acute right arm and right leg weakness, which had been progressively worsening.  About two days ago, he started noticing weakness on the left arm.  The patient also noted shuffling gait.  The patient presented to a family physician and was referred to Dr. X for further evaluation.  Dr. X could not attempt to this, so he called me at the office and the patient was sent to the emergency room, where an MRI of the brain was essentially unremarkable as well as MRI of the thoracic spine.  MRI of the cervical spine, however, revealed an acute disk herniation at C3-C4 with evidence of stenosis and cord changes.  Based on these findings, I recommended decompression.  The patient was started on Decadron at 10 mg IV q.6h.  Operation, expected outcome, risks, and benefits were discussed with him.  Risks to include but not exclusive of bleeding and infection.  Bleeding can be superficial, but can compromise airway, for which he has been told that he may be brought emergently back to the operating room for evacuation of said hematoma.  The hematoma could also be an epidural hematoma, which may compress the spinal cord and result in weakness of all four extremities, numbness of all four extremities, and impairment of bowel and bladder function.  Should this happen, he needs to be brought emergently back to the operating room for evacuation of said hematoma.  There is also the risk by removing the hematoma that he can deteriorate as far as neurological condition, but this hopefully with the steroid prep will be prevented or if present will only be transient.  There is also the possibility of infection, which can be superficial and treated with IV and p.o. antibiotics.  However, should the infection be extensive or be deep, he may require return to the operating room for debridement and irrigation.  This may pose a medical problem since in the presence of infection, the graft as well as spinal instrumentation may have to be removed.  There is also the possibility of dural tear with its attendant complaints of headache, nausea, vomiting, photophobia, as well as the development of pseudomeningocele.  This too can compromise airway and may require return to the operating room for repair of the dural tear.  There is also potential risk of injury to the esophagus, the trachea, as well as the carotid.  The patient can also have a stroke on the right cerebral circulation should the plaque be propelled into the right circulation.  The patient understood all these risks together with the risk associated with anesthesia and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room, awake, alert and not in any form of distress.  After smooth induction and intubation, a Foley catheter was inserted.  No monitoring leads were placed.  The patient was then positioned supine on the operating table with the head supported on a foam doughnut and the neck placed on hyperextension with a shoulder roll under both shoulders.  Localizing x-ray verified the marker to be right at the C3-4 interspace.  Proceeded to mark an incision along the anterior border of the sternocleidomastoid with the central point at the area of the marker measuring about 3 cm in length.  The area was then prepped with DuraPrep.,After sterile drapes were laid out, an incision was made using a scalpel blade #10.  Wound edge bleeders were controlled with bipolar coagulation and a hot knife was utilized to cut the platysma in a similar fashion.  The anterior border of the sternocleidomastoid was identified and dissection was carried superior to and lateral to the esophagus and trachea, but medial to the carotid sheath.  The prevertebral fascia was identified.  Localizing x-ray verified another marker to be at the C3-4 interspace.  Proceeded to strip the longus colli muscles off the vertebral body of C3 and C4 and a self-retaining retractor was then laid out.  There was some degree of anterior osteophyte and this was carefully drilled down with a Midas 5-mm bur.  The disk was then cut through the annulus and removal of the disk was done with the use of the Midas 5-mm bur and later a 3-mm bur.  The inferior endplate of C3 and the superior endplate of C4 were likewise drilled out together with posterior inferior osteophyte at the C3 and the posterior superior osteophyte at C4.  There was note of a central disk herniation centrally, but more marked displacement of the cord on the left side.  By careful dissection of this disk, posterior longitudinal ligament was removed and pressure on the cord was removed.  Hemostasis of the epidural bleeders was done with a combination of bipolar coagulation, but we needed to put a small piece of Gelfoam on the patient's left because of profuse venous bleeder.  With this completed, the Valsalva maneuver showed no evidence of any CSF leakage.  A 7-mm implant with its interior packed with Vitoss was then tapped into place.  An 18-mm plate was then screwed down with four 14 x 4.0 mm screws.  The area was irrigated with saline, with bacitracin solution.  Postoperative x-ray showed excellent placement of the graft and spinal instrumentation.  A round French 10 JP drain was laid over the construct and exteriorized though a separate stab incision on the patient's right inferiorly.  The wound was then closed in layers with Vicryl 3-0 inverted interrupted sutures for the platysma, Vicryl 4-0 subcuticular stitch for the dermis and Dermabond.  The catheter was anchored to the skin with a nylon 3-0 stitch.  Dressing was placed only on the exit site of the drain.  C-collar was placed, and the patient was transferred to the recovery awake and moving all four extremities.",
" Radical anterior discectomy with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal.  Anterior cervical fusion.  Utilization of allograft for purposes of spinal fusion.  Application of anterior cervical locking plate.", Orthopedic, Anterior Cervical Discectomy & Fusion - 3 ,"PREOPERATIVE DIAGNOSES,1.  Cervical spinal stenosis, C3-c4 and C4-C5.,2.  Cervical spondylotic myelopathy.,POSTOPERATIVE DIAGNOSES,1.  Cervical spinal stenosis, C3-C4 and C4-C5.,2.  Cervical spondylotic myelopathy.,OPERATIVE PROCEDURES,1.  Radical anterior discectomy, C3-C4 with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal (CPT 63075).,2.  Radical anterior discectomy C4-C5 with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal (CPT 63076).,3.  Anterior cervical fusion, C3-C4 (CPT 22554),4.  Anterior cervical fusion, C4-C5 (CPT 22585).,5.  Utilization of allograft for purposes of spinal fusion (CPT 20931).,6.  Application of anterior cervical locking plate C3-C5 (CPT 22845).,ANESTHESIA:,  General endotracheal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:  ,250 cc.,OPERATIVE INDICATIONS:  ,The patient is a 50-year-old gentleman who presented to the hospital after a fall, presenting with neck and arm pain as well as weakness.  His MRI confirmed significant neurologic compression in the cervical spine, combined with a clinical exam consistent with radiculopathy, myelopathy, and weakness.  We discussed the diagnosis and the treatment options.  Due to the severity of his neurologic symptoms as well as the amount of neurologic compression seen radiographically, I recommended that he proceed with surgical intervention as opposed to standard nonsurgical treatment such as physical therapy, medications, and steroid injections.  I explained the surgery itself which will be to remove pressure from the spinal cord via anterior cervical discectomy and fusion at C3-C4 and C4-C5.  We reviewed the surgery itself as well as risks including infection and blood vessels or nerves, leakage of spinal fluid, weakness or paralysis, failure of the pain to improve, possible worsening of the pain, failure of the neurologic symptoms to improve, possible worsening of the neurologic symptoms, and possible need for further surgery including re-revision and/or removal.  Furthermore I explained that the fusion may not become solid or that the hardware could break.  We discussed various techniques available for obtaining fusion and I recommended allograft and plate fixation.  I explained the rationale for this as well as the options of using his own bone.  Furthermore, I explained that removing motion at the fusion sites will transfer stress to other disc levels possibly accelerating there degeneration and causing additional symptoms and/or necessitating additional surgery in the future.,OPERATIVE TECHNIQUE: , After obtaining the appropriate signed and informed consent, the patient was taken to the operating room, where he underwent general endotracheal anesthesia without complications.  He was then positioned supine on the operating table, and all bony prominences were padded.  Pulse oximetry was maintained on both feet throughout the case.  The arms were carefully padded and tucked at his sides.  A roll was placed between the shoulder blades.  The areas of the both ears were sterilely prepped and cranial tongs were applied in routine fashion.  Ten pounds of traction was applied.  A needle was taped to the anterior neck and an x-ray was done to determine the appropriate level for the skin incision.  The entire neck was then sterilely prepped and draped in the usual fashion.,A transverse skin incision was made and carried down to the platysma muscle.  This was then split in line with its fibers.  Blunt dissection was carried down medial to the carotid sheath and lateral to the trachea and esophagus until the anterior cervical spine was visualized.  A needle was placed into a disc and an x-ray was done to determine its location.  The longus colli muscles were then elevated bilaterally with the electrocautery unit.  Self-retaining retractors were placed deep to the longus colli muscle in an effort to avoid injury to the sympathetic chains.,Radical anterior discectomies were performed at C3-C4 and C4-C5.  This included complete removal of the anterior annulus, nucleus, and posterior annulus.  The posterior longitudinal ligament was removed as were the posterior osteophytes.  Foraminotomies were then accomplished bilaterally.  Once all of this was accomplished, the blunt-tip probe was used to check for any residual compression.  The central canal was wide open at each level as were the foramen.,A high-speed bur was used to remove the cartilaginous endplates above and below each interspace.  Bleeding cancellous bone was exposed.  The disc spaces were measured and appropriate size allografts were placed sterilely onto the field.  After further shaping of the grafts with the high-speed bur, they were carefully impacted in to position.  There was good juxtaposition against the bleeding decorticated surfaces and good distraction of each interspace.  All weight was then removed from the crania tongs.,The appropriate size anterior cervical locking plate was chosen and bent into gentle lordosis.  Two screws were then placed into each of the vertebral bodies at C3, C4, and C5.  There was excellent purchase.  A final x-ray was done confirming good position of the hardware and grafts.  The locking screws were then applied, also with excellent purchase.,Following a final copious irrigation, there was good hemostasis and no dural leaks.  The carotid pulse was strong.  A drain was placed deep to the level of the platysma muscle and left at the level of the hardware.  The wounds were then closed in layers using 4-0 Vicryl suture for the platysma muscle, 4-0 Vicryl suture for the subcutaneous tissue, and 4-0 Vicryl suture in a subcuticular skin closure.  Steri-Strips were placed followed by application of a sterile dressing.  The drain was hooked to bulb suction.  A Philadelphia collar was applied.,The cranial tongs were carefully removed.  The soft tissue overlying the puncture site was massaged to free it up from the underlying bone.  There was good hemostasis.,The patient was then carefully returned to the supine position on his hospital bed where he was reversed and extubated and taken to the recovery room having tolerated the procedure well.",
" Herniated nucleus pulposus, C5-C6, with spinal stenosis.  Anterior cervical discectomy with fusion C5-C6.", Orthopedic, Anterior Cervical Discectomy & Fusion - 2 ,"PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus, C5-C6, with spinal stenosis.,POSTOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus, C5-C6, with spinal stenosis.,PROCEDURE: , Anterior cervical discectomy with fusion C5-C6.,PROCEDURE IN DETAIL: , The patient was placed in supine position.  The neck was prepped and draped in the usual fashion.  An incision was made from midline to the anterior border of the sternocleidomastoid in the right side.  Skin and subcutaneous tissue were divided sharply.  Trachea and esophagus were retracted medially.  Carotid sheath was retracted laterally.  Longus colli muscles were dissected away from the vertebral bodies of C5-C6.  We confirmed our position by taking intraoperative x-rays.  We then used the operating microscope and cleaned out the disk completely.  We then sized the interspace and then tapped in a #7 mm cortical cancellous graft.  We then used the DePuy Dynamic plate with 14-mm screws.  Jackson-Pratt drain was placed in the prevertebral space and brought out through a separate incision.  The wound was closed in layers using 2-0 Vicryl for muscle and fascia.  The blood loss was less than 10-20 mL.  No complication.  Needle count, sponge count, and cottonoid count was correct.","orthopedic, carotid sheath, jackson-pratt drain, anterior cervical discectomy, herniated nucleus pulposus, cervical discectomy, herniated nucleus, nucleus pulposus, spinal stenosis, discectomy, fusion, herniated, nucleus, pulposus, spinal, stenosis, anterior"
" Anterior cervical discectomy C4-C5 arthrodesis with 8 mm lordotic ACF spacer, corticocancellous, and stabilization with Synthes Vector plate and screws.  Cervical spondylosis and herniated nucleus pulposus of C4-C5.", Orthopedic, Anterior Cervical Discectomy & Arthrodesis - 2 ,"PREOPERATIVE DIAGNOSIS:  ,Cervical spondylosis and herniated nucleus pulposus of C4-C5.,POSTOPERATIVE DIAGNOSIS:,  Cervical spondylosis and herniated nucleus pulposus of C4-C5.,TITLE OF OPERATION:,  Anterior cervical discectomy C4-C5 arthrodesis with 8 mm lordotic ACF spacer, corticocancellous, and stabilization with Synthes Vector plate and screws.,ESTIMATED BLOOD LOSS:,  Less than 100 mL.,OPERATIVE PROCEDURE IN DETAIL: , After identification, the patient was taken to the operating room and placed in supine position.  Following the induction of satisfactory general endotracheal anesthesia, the patient was prepared for surgery.  A shoulder roll was placed between the scapula and the head was rested on a doughnut in a slightly extended position.  A preoperative x-ray was obtained to identify the operative level and neck position.  An incision was marked at the C4-C5 level on the right side.  The incision was opened with #10 blade knife.  Dissection was carried down through subcutaneous tissues using Bovie electrocautery.  The platysma muscle was divided with the cautery and mobilized rostrally and caudally.  The anterior border of sternocleidomastoid muscle was then dissected rostrally and caudally with sharp and blunt dissection.  The avascular plane was then entered and dissection was carried bluntly down to the anterior cervical fascia.  This was opened with scissors and dissected rostrally and caudally with the peanut dissectors.  The operative level was confirmed with an intraoperative x-ray.  The longus colli muscles were mobilized bilaterally using bipolar electrocautery and periosteal elevator.  The anterior longitudinal ligament was then taken down with the insulated Bovie electrocautery tip exposing the vertebral bodies of C4 and C5.  Self-retaining retractor was placed in submuscular position, and distraction pins were placed in the vertebral bodies of C4 and C5, and distraction was instituted.  We then incise the annulus of C4-C5 and a discectomy was now carried out using pituitary rongeurs and straight and angled curettes.  Operating microscope was draped and brought into play.  Dissection was carried down through the disc space to the posterior aspect of the disc space removing the disc with the angled curette as we went.  We now use the diamond bit to thin the posterior bone spurs and osteophytes at the uncovertebral joints bilaterally.  Bone was then removed with 2 mm Kerrison punch and then we were able to traverse the posterior longitudinal ligament and this ligament was now removed in a piecemeal fashion with a 2 mm Kerrison punch.  There was a transligamentous disc herniation, which was removed during this process.  We then carried out bilateral foraminotomies with removal of the uncovertebral osteophytes until the foramina were widely patent.  Cord was seen to be pulsating freely behind the dura.  There appeared to be no complications and the decompression appeared adequate.  We now used a cutting bit to prepare the inner space for arthrodesis fashioning a posterior ledge on the posterior aspect of the C5 vertebral body.  An 8 mm lordotic trial was used and appeared perfect.  We then used a corticocancellous 8 mm lordotic graft.  This was tapped into position.  Distraction was released, appeared to be in excellent position.  We then positioned an 18 mm Vector plate over the inner space.  Intraoperative x-ray was obtained with the stay screw in place; plates appeared to be in excellent position.  We then use a 14 mm self-tapping variable angle screws in each of the four locations drilling 14 mm pilot holes at each location prior to screw insertion.  All of the screws locked to the plate and this was confirmed on visual inspection.  Intraoperative x-ray was again obtained.  Construct appeared satisfactory.  Attention was then directed to closure.  The wound was copiously irrigated.  All of the self-retaining retractors were removed.  Bleeding points were controlled with bone wax and bipolar electrocautery.  The platysma layer was now closed with interrupted 3-0 Vicryl sutures.  The skin was closed with running 3-0 Vicryl subcuticular stitch.  Steri-Strips were applied.  A sterile bandage was applied.  All sponge, needle, and cottonoid counts were reported as correct.  The patient tolerated the procedure well.  He was subsequently extubated in the operating room and transferred to PACU in satisfactory condition.","orthopedic, synthes vector plate, lordotic, acf spacer, corticocancellous, arthrodesis, anterior cervical discectomy, herniated nucleus pulposus, anterior, cervical, spacer, screws, discectomy, "
 Anterior cervical discectomy fusion C3-C4 and C4-C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure.  Cervical spondylotic myelopathy with cord compression and cervical spondylosis., Orthopedic, Anterior Cervical Discectomy & Fusion ,"PREOPERATIVE DIAGNOSES:,  Cervical spondylotic myelopathy with cord compression and cervical spondylosis.,POSTOPERATIVE DIAGNOSES:,  Cervical spondylotic myelopathy with cord compression and cervical spondylosis.  In addition to this, he had a large herniated disk at C3-C4 in the midline.,PROCEDURE: , Anterior cervical discectomy fusion C3-C4 and C4-C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure.,PROCEDURE IN DETAIL: , The patient placed in the supine position, the neck was prepped and draped in the usual fashion.  Incision was made in the midline the anterior border of the sternocleidomastoid at the level of C4.  Skin, subcutaneous tissue, and vertebral muscles divided longitudinally in the direction of the fibers and the trachea and esophagus was retracted medially.  The carotid sheath was retracted laterally after dissecting the longus colli muscle away from the vertebral osteophytes we could see very large osteophytes at C4-C5.  It appeared that the C5-C6 disk area had fused spontaneously.  We then confirmed that position by taking intraoperative x-rays and then proceeded to do discectomy and fusion at C3-C4, C4-C5.,After placing distraction screws and self-retaining retractors with the teeth beneath the bellies of the longus colli muscles, we then meticulously removed the disk at C3-C4, C4-C5 using the combination of angled strip, pituitary rongeurs, and curettes after we had incised the anulus fibrosus with #15 blade.,Next step was to totally decompress the spinal cord using the operating microscope and high-speed cutting followed by the diamond drill with constant irrigation.  We then drilled off the uncovertebral osteophytes and midline osteophytes as well as thinning out the posterior longitudinal ligaments.  This was then removed with 2-mm Kerrison rongeur.  After we removed the posterior longitudinal ligament, we could see the dura pulsating nicely.  We did foraminotomies at C3-C4 as well as C4-C5 as well.  After having totally decompressed both the cord as well as the nerve roots of C3-C4, C4-C5, we proceeded to the next step, which was a fusion.,We sized two 8-mm cortical cancellous grafts and after distracting the bone at C3-C4, C4-C5, we gently tapped the grafts into place.  The distraction was removed and the grafts were now within.  We went to the next step for the procedure, which was the instrumentation and stabilization of the fused area.,We then placed a titanium ABC plate from C3-C5, secured it with 16-mm titanium screws.  X-rays showed good position of the screws end plate.,The next step was to place Jackson-Pratt drain to the vertebral fascia.  Meticulous hemostasis was obtained.  The wound was closed in layers using 2-0 Vicryl for the subcutaneous tissue.  Steri-Strips were used for skin closure.  Blood loss less than about 200 mL.  No complications of the surgery.  Needle counts, sponge count, and cottonoid count was correct.","orthopedic, titanium plates fixation, bone black bone procedure, anterior cervical discectomy, titanium plates, cervical discectomy, spondylotic myelopathy, cord compression, cervical spondylosis, foraminotomies, cervical, anterior "
" C5-C6 anterior cervical discectomy, bone bank allograft, and anterior cervical plate.   Left cervical radiculopathy.", Orthopedic, Anterior Cervical Discectomy - 4 ,"PREOPERATIVE DIAGNOSIS: , Left cervical radiculopathy.,POSTOPERATIVE DIAGNOSIS:  ,Left cervical radiculopathy.,PROCEDURES PERFORMED:,1.  C5-C6 anterior cervical discectomy.,2.  Bone bank allograft.,3.  Anterior cervical plate.,TUBES AND DRAINS LEFT IN PLACE: , None.,COMPLICATIONS: , None.,SPECIMEN SENT TO PATHOLOGY: , None.,ANESTHESIA: , General endotracheal.,INDICATIONS: , This is a middle-aged man who presented to me with left arm pain.  He had multiple levels of disease, but clinically, it was C6 radiculopathy.  We tested him in the office and he had weakness referable to that nerve.  The procedure was done at that level.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room at which time an intravenous line was placed.  General endotracheal anesthesia was obtained.  He was positioned supine in the operative area and the right neck was prepared.,An incision was made and carried down to the ventral spine on the right in the usual manner.  An x-ray confirmed our location.,We were impressed by the degenerative change and the osteophyte overgrowth.,As we had excepted, the back of the disk space was largely closed off by osteophytes.  We patiently drilled through them to the posterior ligament.  We went through that until we saw the dura.,We carefully went to the patient's symptomatic, left side.  The C6 foramen was narrowed by uncovertebral joint overgrowth.  The foramen was open widely.,An allograft was placed.  An anterior Steffee plate was placed.  Closure was commenced.,The wound was closed in layers with Steri-Strips on the skin.  A dressing was applied.,It should be noted that the above operation was done also with microscopic magnification and illumination.","orthopedic, cervical radiculopathy, anterior cervical discectomy, bank allograft, cervical discectomy, anterior, cervical, foramen, discectomy, allograft, radiculopathy, "
" Anterior cervical discectomy with decompression, anterior cervical fusion, anterior cervical instrumentation, and Allograft C5-C6.", Orthopedic, Anterior Cervical Discectomy & Decompression - 1 ,"PREOPERATIVE DIAGNOSES,1.  Herniated disc, C5-C6.,2.  Cervical spondylosis, C5-C6.,POSTOPERATIVE DIAGNOSES,1.  Herniated disc, C5-C6.,2.  Cervical spondylosis, C5-C6.,PROCEDURES,1.  Anterior cervical discectomy with decompression, C5-C6.,2.  Anterior cervical fusion, C5-C6.,3.  Anterior cervical instrumentation, C5-C6.,4.  Allograft C5-C6.,ANESTHESIA:  ,General endotracheal.,COMPLICATIONS:,  None.,PATIENT STATUS: , Taken to recovery room in stable condition.,INDICATIONS: , The patient is a 36-year-old female who has had severe, recalcitrant right upper extremity pain, numbness, tingling, shoulder pain, axial neck pain, and headaches for many months.  Nonoperative measures failed to relieve her symptoms and surgical intervention was requested.  We discussed reasonable risks, benefits, and alternatives of various treatment options.  Continuation of nonoperative care versus the risks associated with surgery were discussed.  She understood the risks including bleeding, nerve vessel damage, infection, hoarseness, dysphagia, adjacent segment degeneration, continued worsening pain, failed fusion, and potential need for further surgery.  Despite these risks, she felt that current symptoms will be best managed operatively.,SUMMARY OF SURGERY IN DETAIL: , Following informed consent and preoperative administration of antibiotics, the patient was brought to the operating suite.  General anesthetic was administered.  The patient was placed in the supine position.  All prominences and neurovascular structures were well accommodated.  The patient was noted to have pulse in this position.  Preoperative x-rays revealed appropriate levels for skin incision.  Ten pound inline traction was placed via Gardner-Wells tongs and shoulder roll was placed.  The patient was then prepped and draped in sterile fashion.  Standard oblique incision was made over the C6 vertebral body in the proximal nuchal skin crease.  Subcutaneous tissue was dissected down to the level of the omohyoid which was transected.  Blunt dissection was carried out with the trachea and the esophagus in the midline and the carotid sheath in its vital structures laterally.  This was taken down to the prevertebral fascia which was bluntly split.  Intraoperative x-ray was taken to ensure proper levels.  Longus colli was identified and reflected proximally 3 to 4 mm off the midline bilaterally so that the anterior cervical Trimline retractor could be placed underneath the longus colli, thus placing no new traction on the surrounding vital structures.  Inferior spondylosis was removed with high-speed bur.  A scalpel and curette was used to remove the disc.  Decompression was carried posterior to the posterior longitudinal ligament down to the uncovertebral joints bilaterally.  Disc herniation was removed from the right posterolateral aspect of the interspace.  High-speed bur was used to prepare the endplate down to good bleeding bone and preparation for fusion.  Curette and ball tip dissector was then passed out the foramen and along the ventral aspect of the dura.  No further evidence of compression was identified.  Hemostasis was achieved with thrombin-soaked Gelfoam.  Interspace was then distracted with Caspar pin distractions set gently.  Interspace was then gently retracted with the Caspar pin distraction set.  An 8-mm allograft was deemed in appropriate fit.  This was press fit with demineralized bone matrix and tamped firmly into position achieving excellent interference fit.  The graft was stable to pull-out forces.  Distraction and traction was then removed and anterior cervical instrumentation was completed using a DePuy Trimline anterior cervical plate with 14-mm self-drilling screws.  Plate and screws were then locked to the plate.  Final x-rays revealed proper positioning of the plate, excellent distraction in the disc space, and apposition of the endplates and allograft.  Wounds were copiously irrigated with normal saline.  Omohyoid was approximated with 3-0 Vicryl.  Running 3-0 Vicryl was used to close the platysma.  Subcuticular Monocryl and Steri-Strips were used to close the skin.  A deep drain was placed prior to wound closure.  The patient was then allowed to awake from general anesthetic and was taken to the recovery room in stable condition.  There were no intraoperative complications.  All needle and sponge counts were correct.  Intraoperative neurologic monitoring was used throughout the entirety of the case and was normal.","orthopedic, cervical spondylosis, cervical fusion, decompression, instrumentation, anterior cervical discectomy, anterior cervical, herniated disc, cervical discectomy, anterior, cervical, fusion, allograft, discectomy"
" Anterior cervical discectomy and fusion, C2-C3, C3-C4.  Removal of old instrumentation, C4-C5.  Fusion C3-C4 and C2-C3 with instrumentation using ABC plates.", Orthopedic, Anterior Cervical Discectomy & Fusion - 1 ,"PREOPERATIVE DIAGNOSES,1.  Herniated nucleus pulposus C2-C3.,2.  Spinal stenosis C3-C4.,POSTOPERATIVE DIAGNOSES,1.  Herniated nucleus pulposus C2-C3.,2.  Spinal stenosis C3-C4.,PROCEDURES,1.  Anterior cervical discectomy, C3-C4, C2-C3.,2.  Anterior cervical fusion, C2-C3, C3-C4.,3.  Removal of old instrumentation, C4-C5.,4.  Fusion C3-C4 and C2-C3 with instrumentation using ABC plates.,PROCEDURE IN DETAIL: , The patient was placed in the supine position.  The neck was prepped and draped in the usual fashion for anterior cervical discectomy.  A high incision was made to allow access to C2-C3.  Skin and subcutaneous tissue and the platysma were divided sharply exposing the carotid sheath which was retracted laterally and the trachea and esophagus were retracted medially.  This exposed the vertebral bodies of C2-C3 and C4-C5 which was bridged by a plate.  We placed in self-retaining retractors.  With the tooth beneath the blades, the longus colli muscles were dissected away from the vertebral bodies of C2, C3, C4, and C5.  After having done this, we used the all-purpose instrumentation to remove the instrumentation at C4-C5, we could see that fusion at C4-C5 was solid.,We next proceeded with the discectomy at C2-C3 and C3-C4 with disc removal.  In a similar fashion using a curette to clean up the disc space and the space was fairly widened, as well as drilling up the vertebral joints using high-speed cutting followed by diamond drill bit.  It was obvious that the C3-C4 neural foramina were almost totally obliterated due to the osteophytosis and foraminal stenosis.  With the operating microscope; however, we had good visualization of these nerve roots, and we were able to ___________ both at C2-C3 and C3-C4.  We then placed the ABC 55-mm plate from C2 down to C4.  These were secured with 16-mm titanium screws after excellent purchase.  We took an x-ray which showed excellent position of the plate, the screws, and the graft themselves.  The next step was to irrigate the wound copiously with saline and bacitracin solution and s Jackson-Pratt drain was placed in the prevertebral space and brought out through a separate incision.  The wound was closed with 2-0 Vicryl for subcutaneous tissues and Steri-Strips used to close the skin.  Blood loss was about 50 mL.  No complication of the surgery.  Needle count, sponge count, cottonoid count was correct.,The operating microscope was used for the entirety for both visualization and magnification and illumination which was quite superb.  At the time of surgery, he had total collapse of the C2, C3, and C4 disc with osteophyte formation.  At both levels, he has high-grade spinal stenosis at these levels, especially foramen stenosis causing the compression, neck pain, headaches, and arm and shoulder pain.  He does have degenerative changes at C5-C6, C6-C7, C7-T1; however, they do not appear to be symptomatic, although x-rays show the disks to be partially collapsed at all levels with osteophyte formation beginning to form.","orthopedic, abc plates, osteophyte, cervical, discectomy, cervical fusion, herniated nucleus pulposus, anterior cervical discectomy, nucleus pulposus, vertebral bodies, osteophyte formation, spinal stenosis, cervical discectomy, anterior, instrumentation, vertebral, stenosis, fusion"
" Arthrodesis - anterior interbody technique, anterior cervical discectomy, anterior instrumentation with a 23-mm Mystique plate and the 13-mm screws, implantation of machine bone implant.  Disc herniation with right arm radiculopathy.", Orthopedic, Anterior Cervical Discectomy & Arthrodesis - 1 ,"PREOPERATIVE DIAGNOSES: , C5-C6 disc herniation with right arm radiculopathy.,POSTOPERATIVE DIAGNOSES: , C5-C6 disc herniation with right arm radiculopathy.,PROCEDURE:,1.  C5-C6 arthrodesis, anterior interbody technique.,2.  C5-C6 anterior cervical discectomy.,3.  C5-C6 anterior instrumentation with a 23-mm Mystique plate and the 13-mm screws.,4.  Implantation of machine bone implant.,5.  Microsurgical technique.,ANESTHESIA:  ,General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,BACKGROUND INFORMATION AND SURGICAL INDICATIONS:  ,The patient is a 45-year-old right-handed gentleman who presented with neck and right arm radicular pain.  The pain has become more and more severe.  It runs to the thumb and index finger of the right hand and it is accompanied by numbness.  If he tilts his neck backwards, the pain shoots down the arm.  If he is working with the computer, it is very difficult to use his mouse.  He tried conservative measures and failed to respond, so he sought out surgery.  Surgery was discussed with him in detail.  A C5-C6 anterior cervical discectomy and fusion was recommended.  He understood and wished to proceed with surgery.  Thus, he was brought in same day for surgery on 07/03/2007.,DESCRIPTION OF PROCEDURE: , He was given Ancef 1 g intravenously for infection prophylaxis and then transported to the OR.  There general endotracheal anesthesia was induced.  He was positioned on the OR table with an IV bag between the scapulae.  The neck was slightly extended and taped into position.  A metal arch was placed across the neck and intraoperative x-ray was obtain to verify a good position for skin incision and the neck was prepped with Betadine and draped in the usual sterile fashion.,A linear incision was created in the neck beginning just to the right of the midline extending out across the anterior border of the sternocleidomastoid muscle.  The incision was extended through skin, subcutaneous fat, and platysma.  Hemostasis was assured with Bovie cautery.  The anterior aspect of the sternocleidomastoid muscle was identified and dissection was carried medial to this down to the carotid sheath.  The trachea and the esophagus were swept out of the way and dissection proceeded medial to the carotid sheath down between the two bellies of the longus colli muscle on to the anterior aspect of the spine.  A Bovie cautery was used to mobilize the longus colli muscle around initially what turned out to be C6-C7 disk based on x-rays and then around the C5-C6 disk space.  An intraoperative x-ray confirmed C5-C6 disk space had been localized and then the self-retained distraction system was inserted to maintain exposure.  A 15-blade knife was used to incise the C5-C6 disk and remove disk material. and distraction pins were inserted into C5-C6 and distraction placed across the disk space.  The operating microscope was then brought into the field and used throughout the case except for the closure.  Various pituitaries, #15 blade knife, and curette were used to evacuate the disk as best as possible.  Then, the Midas Rex drill was taken under the microscope and used to drill where the cartilaginous endplate driven back all the way into the posterior aspect of the vertebral body.  A nerve hook was swept underneath the posterior longitudinal ligament and a fragment of disk was produced and was pulled up through the ligament.  A Kerrison rongeur was used to open up the ligament in this opening and then to march out in the both neural foramina.  A small amount of disk material was found at the right neural foramen.  After a good decompression of both neural foramina was obtained and the thecal sac was exposed throughout the width of the exposure, the wound was thoroughly irrigated.  A spacing mechanism was intact into the disk space and it was determined that a #7 spacer was appropriate.  So, a #7 machine bone implant was taken and tapped into disk space and slightly counter sunk.  The wound was thoroughly irrigated and inspected for hemostasis.  A Mystique plate 23 mm in length was then inserted and anchored to the anterior aspect of C5-C6 to hold the bone into position and the wound was once again irrigated.  The patient was valsalved.  There was no further bleeding seen and intraoperative x-ray confirmed a good position near the bone, plate, and screws and the wound was enclosed in layers.  The 3-0 Vicryl was used to approximate platysma and 3-0 Vicryl was used in inverted interrupted fashion to perform a subcuticular closure of the skin.  The wound was cleaned.,Mastisol was placed on the skin, and Steri-strips were used to approximate skin margins.  Sterile dressing was placed on the patient's neck.  He was extubated in the OR and transported to the recovery room in stable condition.  There were no complications.","orthopedic, herniation, radiculopathy, interbody, mystique, bone implant, anterior cervical discectomy, neural foramina, mystique plate, disc herniation, arm radiculopathy, cervical discectomy, disk space, disk, cervical, anterior, wound, discectomy,"
" Anterior cervical discectomy, arthrodesis, partial corpectomy, Machine bone allograft, placement of anterior cervical plate with a Zephyr.
7.  Microscopic dissection.", Orthopedic, Anterior Cervical Discectomy & Arthrodesis ,"PREOPERATIVE DIAGNOSIS:,  Cervical myelopathy secondary to very large disc herniations at C4-C5 and C5-C6.,POSTOPERATIVE DIAGNOSIS: , Cervical myelopathy secondary to very large disc herniations at C4-C5 and C5-C6.,PROCEDURE PERFORMED:,1.  Anterior cervical discectomy, C4-C5 and C5-C6.,2.  Arthrodesis, C4-C5 and C5-C6.,3.  Partial corpectomy, C5.,4.  Machine bone allograft, C4-C5 and C5-C6.,5.  Placement of anterior cervical plate with a Zephyr C4 to C6.,6.  Fluoroscopic guidance.,7.  Microscopic dissection.,ANESTHESIA:,  General.,ESTIMATED BLOOD LOSS: , 60 mL.,COMPLICATIONS: , None.,INDICATIONS:,  This is a patient who presents with progressive weakness in the left upper extremity as well as imbalance.  He has also noted to have cord signal at the C4-C5 level secondary to a very large disc herniation that came behind the body at C5 as well and as well as a large disc herniation at C5-C6.  Risks and benefits of the surgery including bleeding, infection, neurologic deficit, nonunion, progressive spondylosis, and lack of improvement were all discussed.  He understood and wished to proceed.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room and placed in the supine position.  Preoperative antibiotics were given.  The patient was placed in the supine position with all pressure points noted and well padded.  The patient was prepped and draped in standard fashion.  An incision was made approximately above the level of the cricoid.  Blunt dissection was used to expose the anterior portion of the spine with carotid moved laterally and trachea and esophagus moved medially.  We then placed needle into the disc spaces and was found to be at C5-C6.  Distracting pins were placed in the body of C4 and in to the body of C6.  The disc was then completely removed at C4-C5.  There was very significant compression of the cord.  This was carefully removed to avoid any type of pressure on the cord.  This was very severe and multiple free fragments were noted.  This was taken down to the level of ligamentum.  Both foramen were then also opened.  Other free fragments were also found behind the body of C5, part of the body of C5 was taken down to assure that all of these were removed.  The exact same procedure was done at C5-C6; however, if there were again free fragments noted, there was less not as severe compression at the C4-C5 area.  Again part of the body at C5 was removed to make sure that there was no additional constriction.  Both nerve roots were then widely decompressed.  Machine bone allograft was placed into the C4-C5 as well as C5-C6 and then a Zephyr plate was placed in the body of C4 and to the body of C6 with a metal pin placed into the body at C5.  Excellent purchase was obtained.  Fluoroscopy showed good placement and meticulous hemostasis was obtained.  Fascia was closed with 3-0 Vicryl, subcuticular 3-0 Dermabond for skin.  The patient tolerated the procedure well and went to recovery in good condition.","orthopedic, fluoroscopic guidance, microscopic dissectio, cervical plate, zephyr, corpectomy, arthrodesis, anterior cervical discectomy, machine bone allograft, cervical discectomy, bone allograft, disc herniations, anterior, cervical, discectomy,"
" Anterior cervical discectomy with decompression C6-C7, arthrodesis with anterior interbody fusion C6-C7, spinal instrumentation using Pioneer 20 mm plate and four 12 x 4.0 mm screws, PEEK implant 7 mm, and Allograft using Vitoss.", Orthopedic, Anterior Cervical Discectomy & Decompression ,"PREOPERATIVE DIAGNOSES,1.  Left neck pain with left upper extremity radiculopathy.,2.  Left C6-C7 neuroforaminal stenosis secondary to osteophyte.,POSTOPERATIVE DIAGNOSES,1.  Left neck pain with left upper extremity radiculopathy.,2.  Left C6-C7 neuroforaminal stenosis secondary to osteophyte.,OPERATIVE PROCEDURE,1.  Anterior cervical discectomy with decompression C6-C7.,2.  Arthrodesis with anterior interbody fusion C6-C7.,3.  Spinal instrumentation using Pioneer 20 mm plate and four 12 x 4.0 mm screws.,4.  PEEK implant 7 mm.,5.  Allograft using Vitoss.,ANESTHESIA: , General endotracheal anesthesia.,FINDINGS: , Showed osteophyte with a disc complex on the left C6-C7 neural foramen.,FLUIDS:  ,1800 mL of crystalloids.,URINE OUTPUT: , No Foley catheter.,DRAINS:  ,Round French 10 JP drain.,SPECIMENS,:  None.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  250 mL.,The need for an assistant is important in this case, since her absence would mean prolonged operative time and may increase operative morbidity and mortality.,CONDITION: , Extubated with stable vital signs.,INDICATIONS FOR THE OPERATION:,  This is the case of a very pleasant 46-year-old Caucasian female with subarachnoid hemorrhage secondary to ruptured left posteroinferior cerebellar artery aneurysm, which was clipped.  The patient last underwent a right frontal ventricular peritoneal shunt on 10/12/07.  This resulted in relief of left chest pain, but the patient continued to complaint of persistent pain to the left shoulder and left elbow.  She was seen in clinic on 12/11/07 during which time MRI of the left shoulder showed no evidence of rotator cuff tear.  She did have a previous MRI of the cervical spine that did show an osteophyte on the left C6-C7 level.  Based on this, negative MRI of the shoulder, the patient was recommended to have anterior cervical discectomy with anterior interbody fusion at C6-C7 level.  Operation, expected outcome, risks, and benefits were discussed with her.  Risks include, but not exclusive of bleeding and infection, bleeding could be soft tissue bleeding, which may compromise airway and may result in return to the operating room emergently for evacuation of said hematoma.  There is also the possibility of bleeding into the epidural space, which can compress the spinal cord and result in weakness and numbness of all four extremities as well as impairment of bowel and bladder function.  Should this occur, the patient understands that she needs to be brought emergently back to the operating room for evacuation of said hematoma.  There is also the risk of infection, which can be superficial and can be managed with p.o. antibiotics.  However, the patient may develop deeper-seated infection, which may require return to the operating room.  Should the infection be in the area of the spinal instrumentation, this will cause a dilemma since there might be a need to remove the spinal instrumentation and/or allograft.  There is also the possibility of potential injury to the esophageus, the trachea, and the carotid artery.  There is also the risks of stroke on the right cerebral circulation should an undiagnosed plaque be propelled from the right carotid.  There is also the possibility hoarseness of the voice secondary to injury to the recurrent laryngeal nerve.  There is also the risk of pseudoarthrosis and hardware failure.  She understood all of these risks and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE: , The patient brought to the operating room, awake, alert, not in any form of distress.  After smooth induction and intubation, a Foley catheter was inserted.  Monitoring leads were placed by Premier Neurodiagnostics and this revealed normal findings, which remained normal during the entire case.  The EMGs were silent and there was no evidence of any stimulation.  After completion of the placement of the monitoring leads, the patient was positioned supine on the operating table with the neck placed on hyperextension.  The head was supported on a foam doughnut.  The right cervical area was then exposed by turning the head about 45 to 60 degrees to the left side.  A linear incision was made about two to three fingerbreadths from the suprasternal notch along the anterior border of the sternocleidomastoid muscle to a distance of about 3 cm.  The area was then prepped with DuraPrep.,After sterile drapes were laid out, the incision was made using a scalpel blade #10.  Wound edge bleeders were controlled with bipolar coagulation and a hot knife was utilized to carry the dissection down to the platysma in the similar fashion as the skin incision.  The anterior border of the sternocleidomastoid muscle was identified as well as the sternohyoid/omohyoid muscles.  Dissection was then carried lateral and superior to the omohyoid muscle and lateral to the esophagus and the trachea, and medial to the sternocleidomastoid muscle and the carotid sheath.  The prevertebral fascia was identified and cut sharply.  A localizing x-ray verified the marker to be at the C6-C7 interspace.  Proceeded to the strip the longus colli muscles off the vertebral body of C6 and C7.  Self-retaining retractor was then laid out.  The annulus was then cut in a quadrangular fashion and piecemeal removal of the dura was done using a straight pituitary rongeurs, 3 and 5 mm burr.  The interior endplate of C6 and superior endplate of C7 was likewise was drilled down together with posteroinferior edge of C6 and the posterior superior edge of C7.  There was note of a new osteophyte on the left C6-C7 foramen.  This was carefully drilled down.  After decompression and removal of pressure, there was noted to be release of the epidural space with no significant venous bleeders.  They were controlled with slight bipolar coagulation, temporary tamponade with Gelfoam.  After this was completed, Valsalva maneuver showed no evidence of any CSF leakage.  A 7-mm implant was then tapped into placed after its interior was packed with Vitoss.  The plate was then applied and secured in place with four 12 x 4.7 mm screws.  Irrigation of the area was done.  A round French 10 JP drain was laid out over the graft and exteriorized through a separate stab incision on the patient's right inferiorly.  The wound was then closed in layers with Vicryl 3-0 inverted interrupted sutures as well as Vicryl 4-0 subcuticular stitch for the dermis.  The wound was reinforced with Dermabond.  The catheter was anchored to the skin with nylon 3-0 stitch and dressing was applied only at the exit site.  C-collar was placed and the patient was transferred to Recovery after extubation.",
 Anterior cervical discectomy (two levels) and C5-C6 and C6-C7 allograft fusions.  A C5-C7 anterior cervical plate fixation (Sofamor Danek titanium window plate) intraoperative fluoroscopy used and intraoperative microscopy used.  Intraoperative SSEP and EMG monitoring used., Orthopedic, Anterior Cervical Discectomy - 3 ,"PREOPERATIVE DIAGNOSES: , Cervical disk protrusions at C5-C6 and C6-C7, cervical radiculopathy, and cervical pain.,POSTOPERATIVE DIAGNOSES:,  Cervical disk protrusions at C5-C6 and C6-C7, cervical radiculopathy, and cervical pain.,PROCEDURES:,  C5-C6 and C6-C7 anterior cervical discectomy (two levels) C5-C6 and C6-C7 allograft fusions.  A C5-C7 anterior cervical plate fixation (Sofamor Danek titanium window plate) intraoperative fluoroscopy used and intraoperative microscopy used.  Intraoperative SSEP and EMG monitoring used.,ANESTHESIA: , General endotracheal.,COMPLICATIONS:,  None.,INDICATION FOR THE PROCEDURE: , This lady presented with history of cervical pain associated with cervical radiculopathy with cervical and left arm pain, numbness, weakness, with MRI showing significant disk protrusions with the associate complexes at C5-C6 and C6-C7 with associated cervical radiculopathy.  After failure of conservative treatment, this patient elected to undergo surgery.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the OR and after adequate general endotracheal anesthesia, she was placed supine on the OR table with the head of the bed about 10 degrees.  A shoulder roll was placed and the head supported on a donut support.  The cervical region was prepped and draped in the standard fashion.  A transverse cervical incision was made from the midline, which was lateral to the medial edge of the sternocleidomastoid two fingerbreadths above the right clavicle.  In a transverse fashion, the incision was taken down through the skin and subcutaneous tissue and through the platysmata and a subplatysmal dissection done.  Then, the dissection continued medial to the sternocleidomastoid muscle and then medial to the carotid artery to the prevertebral fascia, which was gently dissected and released superiorly and inferiorly.  Spinal needles were placed into the displaced C5-C6 and C6-C7 to confirm these disk levels using lateral fluoroscopy.  Following this, monopolar coagulation was used to dissect the medial edge of the longus colli muscles off the adjacent vertebrae between C5-C7 and then the Trimline retractors were placed to retract the longus colli muscles laterally and blunt retractors were placed superiorly and inferiorly.  A #15 scalpel was used to do a discectomy at C5-C6 from endplate-to-endplate and uncovertebral joint.  On the uncovertebral joint, a pituitary rongeur was used to empty out any disk material ____________ to further remove the disk material down to the posterior aspect.  This was done under the microscope.  A high-speed drill under the microscope was used to drill down the endplates to the posterior aspect of the annulus.  A blunt trocar was passed underneath the posterior longitudinal ligament and it was gently released using the #15 scalpel and then Kerrison punches 1-mm and then 2-mm were used to decompress further disk calcified material at the C5-C6 level.  This was done bilaterally to allow good decompression of the thecal sac and adjacent neuroforamen.  Then, at the C6-C7 level, in a similar fashion, #15 blade was used to do a discectomy from uncovertebral joint to uncovertebral joint and from endplate-to-endplate using a #15 scalpel to enter the disk space and then the curette was then used to remove the disk calcified material in the endplate, and then high-speed drill under the microscope was used to drill down the disk space down to the posterior aspect of the annulus where a blunt trocar was passed underneath the posterior longitudinal ligament which was gently released.  Then using the Kerrison punches, we used 1-mm and 2-mm, to remove disk calcified material, which was extending more posteriorly to the left and the right.  This was gently removed and decompressed to allow good decompression of the thecal sac and adjacent nerve roots.  With this done, the wound was irrigated.  Hemostasis was ensured with bipolar coagulation.  Vertebral body distraction pins were then placed to the vertebral body of C5 and C7 for vertebral distraction and then a 6-mm allograft performed grafts were taken and packed in either aspect with demineralized bone matrix and this was tapped in flush with the vertebral bodies above and below C5-C6 and C6-C7 discectomy sites.  Then, the vertebral body distraction pins were gently removed to allow for graft seating and compression and then the anterior cervical plate (Danek windows titanium plates) was then taken and sized and placed.  A temporary pin was initially used to align the plate and then keeping the position and then two screw holes were drilled in the vertebral body of C5, two in the vertebral body of C6, and two in the vertebral body of C7.  The holes were then drilled and after this self-tapping screws were placed into the vertebral body of C5, C6, and C7 across the plate to allow the plate to fit and stay flush with the vertebral body between C5, C6, and C7.  With this done, operative fluoroscopy was used to check good alignment of the graft, screw, and plate, and then the wound was irrigated.  Hemostasis was ensured with bipolar coagulation and then the locking screws were tightened down.  A #10 round Jackson-Pratt drain was placed into the prevertebral space and brought out from a separate stab wound skin incision site.  Then, the platysma was approximated using 2-0 Vicryl inverted interrupted stitches and the skin closed with 4-0 Vicryl running subcuticular stitch.  Steri-Strips and sterile dressings were applied.  The patient remained hemodynamically stable throughout the procedure.  Throughout the procedure, the microscope had been used for the disk decompression and high-speed drilling.  In addition, intraoperative SSEP, EMG monitoring, and motor-evoked potentials remained stable throughout the procedure.  The patient remained stable throughout the procedure.","orthopedic, cervical disk protrusions, cervical radiculopathy, cervical pain, cervical plate fixation, sofamor danek titanium window plate, anterior cervical discectomy, vertebral body, vertebral, disk, intraoperative, anterior, decompression, fluoroscopy, radiculopathy, discectomy, cervical,"
 Anterior cervical discectomy at C5-6 and placement of artificial disk replacement.  Right C5-C6 herniated nucleus pulposus., Orthopedic, Anterior Cervical Discectomy - 2 ,"ADMITTING DIAGNOSIS: , Right C5-C6 herniated nucleus pulposus.,PRIMARY OPERATIVE PROCEDURE: , Anterior cervical discectomy at C5-6 and placement of artificial disk replacement.,SUMMARY:,  This is a pleasant, 43-year-old woman, who has been having neck pain and right arm pain for a period of time which has not responded to conservative treatment including ESIs.  She underwent another MRI and significant degenerative disease at C5-6 with a central and right-sided herniation was noted.  Risks and benefits of the surgery were discussed with her and she wished to proceed with surgery.  She was interested in participating in the artificial disk replacement study and was entered into that study.  She was randomly picked for the artificial disk and underwent the above named procedure on 08/27/2007.  She has done well postoperatively with a sensation of right arm pain and numbness in her fingers.  She will have x-rays AP and lateral this morning which will be reviewed and she will be discharged home today if she is doing well.  She will follow up with Dr. X in 2 weeks in the clinic as per the study protocol with cervical AP and lateral x-rays with ring prior to the appointment.  She will contact our office prior to her appointment if she has problems.  Prescriptions were written for Flexeril 10 mg 1 p.o. t.i.d. p.r.n.  #50 with 1 refill and Lortab 7.5/500 mg 1 to 2 q.6 h. p.r.n.  #60 with 1 refill.","orthopedic, herniated nucleus pulposus, anterior cervical discectomy, artificial disk replacement, cervical, discectomy, nucleusNOTE"
 Anterior cervical discectomy and removal of herniated disk and osteophytes and decompression of spinal cord and bilateral nerve root decompression.  Harvesting of autologous bone from the vertebral bodies.  Grafting of allograft bone for creation of arthrodesis., Orthopedic, Anterior Cervical Discectomy ,"PREOPERATIVE DIAGNOSES,1.  Cervical spondylosis with myelopathy.,2.  Herniated cervical disk, C4-C5.,POSTOPERATIVE DIAGNOSES,1.  Cervical spondylosis with myelopathy.,2.  Herniated cervical disk, C4-C5.,OPERATIONS PERFORMED,1.  Anterior cervical discectomy and removal of herniated disk and osteophytes and decompression of spinal cord at C5-C6.,2.  Bilateral C6 nerve root decompression.,3.  Anterior cervical discectomy at C4-C5 with removal of herniated disk and osteophytes and decompression of spinal cord.,4.  Bilateral C5 nerve root decompression.,5.  Anterior cervical discectomy at C3-C4 with removal of herniated disk and osteophytes, and decompression of spinal cord.,6.  Bilateral C4 nerve root decompression.,7.  Harvesting of autologous bone from the vertebral bodies.,8.  Grafting of allograft bone for creation of arthrodesis.,9.  Creation of arthrodesis with allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C5-C6.,10.  Creation of additional arthrodesis using allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C4-C5.,11.  Creation of additional arthrodesis using allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C3-C4.,12.  Placement of anterior spinal instrumentation from C3 to C6 using a Synthes Small Stature Plate, using the operating microscope and microdissection technique.,INDICATIONS FOR PROCEDURE: , This 62-year-old man has severe cervical spondylosis with myelopathy and cord compression at C5-C6.  There was a herniated disk with cord compression and radiculopathy at C4-C5.  C3-C4 was the source of neck pain as documented by facet injections.,A detailed discussion ensued with the patient as to the pros and cons of the surgery by two levels versus three levels.  Because of the severe component of the neck pain that has been relieved with facet injections, we elected to proceed ahead with anterior cervical discectomy and fusion at C3-C4, C4-C5, and C5-C6.,I explained the nature of this procedure in great detail including all risks and alternatives.  He clearly understands and has no further questions and requests that I proceed.,PROCEDURE:  ,The patient was placed on the operating room table and was intubated taking great care to keep the neck in a neutral position.  The methylprednisolone spinal cord protocol was instituted with bolus and continuous infusion dosages.,The left side of the neck was carefully prepped and draped in the usual sterile manner.,A transverse incision was made in the neck crease.  Dissection was carried down through the platysma musculature and the anterior spine was exposed.  The medial borders of the longus colli muscle were dissected free from their attachments to the spine.  Caspar self-retaining pins were placed into the bodies of C3, C4, C5, and C6 and x-ray localization was obtained.  A needle was placed in what was revealed to be the disk space at C4-C5 and an x-ray confirmed proper localization.,Self-retaining retractors were then placed in the wound, taking great care to keep the blades of the retractors underneath the longus colli muscles.,First I removed the large amount of anterior overhanging osteophytes at C5-C6 and distracted the space.  The high-speed cutting bur was used to drill back the osteophytes towards the posterior lips of the vertebral bodies.,An incision was then made at C4-C5 and the annulus was incised and a discectomy was performed back to the posterior lips of the vertebral bodies.,The retractors were then adjusted and again discectomy was performed at C3-C4 back to the posterior lips of the vertebral bodies.  The operating microscope was then utilized.,Working under magnification, I started at C3-C4 and began to work my way down to the posterior longitudinal ligament.  The ligament was incised and the underlying dura was exposed.  I worked out laterally towards the takeoff of the C4 nerve root and widely decompressed the nerve root edge of the foramen.  There were a large number of veins overlying the nerve root which were oozing and rather than remove these and produce tremendous amount of bleeding, I left them intact.  However, I could to palpate the nerve root along the pedicle into the foramen and widely decompressed it on the right.  The microscope was angled to the left side where similar decompression was achieved.,The retractors were readjusted and attention was turned to C4-C5.  I worked down through bony osteophytes and identified the posterior longitudinal ligament.  The ligament was incised; and as I worked to the right of the midline, I encountered herniated disk material which was removed in a number of large pieces.  The C5 root was exposed and then widely decompressed until I was flush with the pedicle and into the foramen.  The root had a somewhat high takeoff but I worked to expose the axilla and widely decompressed it.  Again the microscope was angled to the left side where similar decompression was achieved.  Central decompression was achieved here where there was a moderate amount of spinal cord compression.  This was removed by undercutting with 1 and 2-mm Cloward punches.,Attention was then turned to the C5-C6 space.  Here there were large osteophytes projecting posteriorly against the cord.  I slowly and carefully used the high-speed cutting diamond bur to drill these and then used 1 to 2-mm Cloward punches to widely decompress the spinal cord.  This necessitated undercutting the bodies of both C5 and C6 extensively, but I was then able to achieve a good decompression of the cord.  I exposed the C6 root and widely decompressed it until I was flush with the pedicle and into the foramen on the right.  The microscope was angled to the left side where a similar decompression was achieved.,Attention was then turned to creation of the arthrodesis.  A high-speed Cornerstone bur was used to decorticate the bodies of C5-C6, C4-C5 and C3-C4 to create a posterior shelf to prevent backwards graft migration.  Bone dust during the drilling was harvested for later use.,Attention was turned to creation of the arthrodesis.  Using the various Synthes sizers, I selected a 7-mm lordotic graft at C5-C6 and an 8-mm lordotic graft at C4-C5 and a 9-mm lordotic graft at C3-C4.  Each graft was filled with autologous bone from the vertebral bodies and bone morphogenetic protein soaked sponge.  I decided to use BMP in this case because there were three levels of fusion and because this patient has a very heavy history of smoking and having just recently discontinued for two weeks.  The BMP sponge and the ____________ bone were then packed in the center of the allograft.,Under distraction, the graft was placed at C3-C4, C4-C5, and C5-C6 as described.  An x-ray was obtained which showed good graft placement with preservation of the cervical lordosis.,Attention was turned to the placement of anterior spinal instrumentation.  Various sizes of Synthes plates were selected until I decided that a 54-mm plate was appropriate.  The plate had to be somewhat contoured and bent inferiorly and the vertebral bodies had to be drilled so that the plates would sit flush.  The holes were drilled and the screws were placed.  Eight screws were placed with two screws at C3, two screws at C4, two screws at C5, and two screws at C6.  All eight screws had good purchase.  The locking screws were tightly applied.  An x-ray was obtained which showed good placement of the graft, plate, and screws.,Attention was turned to closure.  The wound was copiously irrigated with Bacitracin solution and meticulous hemostasis was obtained.  A medium Hemovac drain was placed in the anterior vertebral body space and brought out through a separate stab incision in the skin.  The wound was then carefully closed in layers.  Sterile dressings were applied, and the operation was terminated.,The patient tolerated the procedure well and left for the recovery room in excellent condition.  The sponge and needle counts were reported as correct.  There were no intraoperative complications.,Specimens were sent to Pathology consisting of disk material and bone and soft tissue.",
 History and Physical for right ankle sprain, Orthopedic, Ankle Sprain - H&P ,"CHIEF COMPLAINT:,  Right ankle sprain.,HISTORY OF PRESENT ILLNESS: , This is a 56-year-old female who fell on November 26, 2007 at 11:30 a.m. while at work.  She did not recall the specifics of her injury but she thinks that her right foot inverted and subsequently noticed pain in the right ankle.  She describes no other injury at this time.,PAST MEDICAL HISTORY: , Hypertension and anxiety.,PAST SURGICAL HISTORY: , None.,MEDICATIONS: , She takes Lexapro and a blood pressure pill, but does not know anything more about the names and the doses.,ALLERGIES:,  No known drug allergies.,SOCIAL HISTORY: , The patient lives here locally.  She does not report any significant alcohol or illicit drug use.  She works full time.,FAMILY HISTORY:,  Noncontributory.,REVIEW OF SYSTEMS:,Pulm:  No cough, No wheezing, No shortness of breath,CV:  No chest pain or palpitations,GI:  No abdominal pain.  No nausea, vomiting, or diarrhea.,PHYSICAL EXAM:,GENERAL APPEARANCE:  No acute distress,VITAL SIGNS:  Temperature 97.8, blood pressure 122/74, heart rate 76, respirations 24, weight 250 lbs, O2 sat 95% on R.A.,NECK:  Supple.  No lymphadenopathy.  No thyromegaly.,CHEST:  Clear to auscultation bilaterally.,HEART:  Regular rate and rhythm.  No murmurs.,ABDOMEN:  Non-distended, nontender, normal active bowel sounds.,EXTREMITIES:  No Clubbing, No Cyanosis, No edema.,MUSCULOSKELETAL:  The spine is straight and there is no significant muscle spasm or tenderness there.  Both knees appear to be non-traumatic with no deformity or significant tenderness.  The right ankle has some swelling just below the right lateral malleolus and the dorsum of the foot is tender.  There is decreased range of motion and some mild ecchymosis noted around the ankle.,DIAGNOSTIC DATA: , X-ray of the right ankle reveals no acute fracture by my observation.  Radiologic interpretation is pending., ,IMPRESSION:,  Right ankle sprain.,PLAN:,1.  Motrin 800 mg t.i.d.,2.  Tylenol 1 gm q.i.d. as needed.,3.  Walking cast is prescribed.,4.  I told the patient to call back if any problems.  The next morning she called back complaining of worsening pain and I called in some Vicodin ES 1-2 p.o. q.  8 hours p.r.n. pain #60 with no refills.",
" Achilles tendon rupture, left lower extremity.  Primary repair left Achilles tendon.  The patient was stepping off a hilo at work when he felt a sudden pop in the posterior aspect of his left leg.  The patient was placed in posterior splint and followed up at ABC orthopedics for further care.", Orthopedic, Achilles Tendon Repair ,"PREOPERATIVE DIAGNOSIS: , Achilles tendon rupture, left lower extremity.,POSTOPERATIVE DIAGNOSIS: , Achilles tendon rupture, left lower extremity.,PROCEDURE PERFORMED:,  Primary repair left Achilles tendon.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,TOTAL TOURNIQUET TIME:  ,40 minutes at 325 mmHg.,POSITION:,  Prone.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 26-year-old African-American male who states that he was stepping off a hilo at work when he felt a sudden pop in the posterior aspect of his left leg.  The patient was placed in posterior splint and followed up at ABC orthopedics for further care.,PROCEDURE:,  After all potential complications, risks, as well as anticipated benefits of the above-named procedure were discussed at length with the patient, informed consent was obtained.  The operative extremity was then confirmed with the patient, the operative surgeon, Department Of Anesthesia, and nursing staff.  While in this hospital, the Department Of Anesthesia administered general anesthetic to the patient.  The patient was then transferred to the operative table and placed in the prone position.  All bony prominences were well padded at this time.,A nonsterile tourniquet was placed on the left upper thigh of the patient, but not inflated at this time.  Left lower extremity was sterilely prepped and draped in the usual sterile fashion.  Once this was done, the left lower extremity was elevated and exsanguinated using an Esmarch and the tourniquet was inflated to 325 mmHg and kept up for a total of 40 minutes.  After all bony and soft tissue land marks were identified, a 6 cm longitudinal incision was made paramedial to the Achilles tendon from its insertion proximal.  Careful dissection was then taken down to the level of the peritenon.  Once this was reached, full thickness flaps were performed medially and laterally.  Next, retractor was placed.  All neurovascular structures were protected.  A longitudinal incision was then made in the peritenon and opened up exposing the tendon.  There was noted to be complete rupture of the tendon approximately 4 cm proximal to the insertion point.  The plantar tendon was noted to be intact.  The tendon was debrided at this time of hematoma as well as frayed tendon.  Wound was copiously irrigated and dried.  Most of the ankle appeared that there was sufficient tendon links in order to do a primary repair.  Next #0 PDS on a taper needle was selected and a Krackow stitch was then performed.  Two sutures were then used and tied individually ________ from the tendon.  The tendon came together very well and with a tight connection.  Next, a #2-0 Vicryl suture was then used to close the peritenon over the Achilles tendon.  The wound was once again copiously irrigated and dried.  A #2-0 Vicryl sutures were then used to close the skin and subcutaneous fashion followed by #4-0 suture in the subcuticular closure on the skin.  Steri-Strips were then placed over the wound and the sterile dressing was applied consisting of 4x4s, Kerlix roll, sterile Kerlix and a short length fiberglass cast in a plantar position.  At this time, the Department of anesthesia reversed the anesthetic.  The patient was transferred back to hospital gurney to the Postanesthesia Care Unit.  The patient tolerated the procedure well.  There were no complications.","orthopedic, repair, achilles tendon rupture, longitudinal incision, tendon rupture, achilles tendon, tendon, achilles, rupture, extremity"
" Anterior cervical discectomy, removal of herniated disc and osteophytes, bilateral C4 nerve root decompression, harvesting of bone for autologous vertebral bodies for creation of arthrodesis, grafting of fibular allograft bone for creation of arthrodesis, creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies, and placement of anterior spinal instrumentation using the operating microscope and microdissection technique.", Orthopedic, Anterior Cervical Discectomy - 1 ,"PREOPERATIVE DIAGNOSIS: , Cervical spondylosis at C3-C4 with cervical radiculopathy and spinal cord compression.,POSTOPERATIVE DIAGNOSIS:,  Cervical spondylosis at C3-C4 with cervical radiculopathy and spinal cord compression.,OPERATION PERFORMED,1.  Anterior cervical discectomy of C3-C4.,2.  Removal of herniated disc and osteophytes.,3.  Bilateral C4 nerve root decompression.,4.  Harvesting of bone for autologous vertebral bodies for creation of arthrodesis.,5.  Grafting of fibular allograft bone for creation of arthrodesis.,6.  Creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies.,7.  Placement of anterior spinal instrumentation using the operating microscope and microdissection technique.,INDICATIONS FOR PROCEDURE: , This 62-year-old man has progressive and intractable right C4 radiculopathy with neck and shoulder pain.  Conservative therapy has failed to improve the problem.  Imaging studies showed severe spondylosis of C3-C4 with neuroforaminal narrowing and spinal cord compression.,A detailed discussion ensued with the patient as to the nature of the procedure including all risks and alternatives.  He clearly understood it and had no further questions and requested that I proceed.,PROCEDURE IN DETAIL: , The patient was placed on the operating room table and was intubated using a fiberoptic technique.  The methylprednisolone spinal cord protocol was instituted with bolus and continuous infusion doses.  The neck was carefully prepped and draped in the usual sterile manner.,A transverse incision was made on a skin crease on the left side of the neck.  Dissection was carried down through the platysmal musculature and the anterior spine was exposed.  The medial borders of the longus colli muscles were dissected free from their attachments to the spine.  A needle was placed and it was believed to be at the C3-C4 interspace and an x-ray properly localized this space.  Castoff self-retaining pins were placed into the body of the C3 and C4.  Self-retaining retractors were placed in the wound keeping the blades of the retractors underneath the longus colli muscles.,The annulus was incised and a discectomy was performed.  Quite a bit of overhanging osteophytes were identified and removed.  As I worked back to the posterior lips of the vertebral body, the operating microscope was utilized.,There was severe overgrowth of spondylitic spurs.  A high-speed diamond bur was used to slowly drill these spurs away.  I reached the posterior longitudinal ligament and opened it and exposed the underlying dura.,Slowly and carefully I worked out towards the C3-C4 foramen.  The dura was extremely thin and I could see through it in several areas.  I removed the bony compression in the foramen and identified soft tissue and veins overlying the root.  All of these were not stripped away for fear of tearing this very tissue-paper-thin dura.  However, radical decompression was achieved removing all the bony compression in the foramen, out to the pedicle, and into the foramen.  An 8-mm of the root was exposed although I left the veins over the root intact.,The microscope was angled to the left side where a similar procedure was performed.,Once the decompression was achieved, a high-speed cortisone bur was used to decorticate the body from the greater posterior shelf to prevent backward graft migration.  Bone thus from the drilling was preserved for use for the arthrodesis.,Attention was turned to creation of the arthrodesis.  As I had drilled quite a bit into the bodies, I selected a large 12-mm graft and distracted the space maximally.  Under distraction the graft was placed and fit well.  An x-ray showed good graft placement.,Attention was turned to spinal instrumentation.  A Synthes Short Stature plate was used with four 3-mm screws.  Holes were drilled with all four screws were placed with pretty good purchase.  Next, the locking screws were then applied.  An x-ray was obtained which showed good placement of graft, plate, and screws.  The upper screws were near the upper endplate of C3.  The C3 vertebral body that remained was narrow after drilling off the spurs.  Rather than replace these screws and risk that the next holes would be too near the present holes I decided to leave these screws intact because their position is still satisfactory as they are below the disc endplate.,Attention was turned to closure.  A Hemovac drain was placed in the anterior vertebral body space and brought out through a separate stab wound incision in the skin.  The wound was then carefully closed in layers.  Sterile dressings were applied along with a rigid Philadelphia collar.  The operation was then terminated.,The patient tolerated the procedure well and left for the recovery room in excellent condition.  The sponge and needle counts were reported as correct and there were no intraoperative complications.,Specimens were sent to Pathology consisted of bone and soft tissue as well as C3-C4 disc material.","orthopedic, herniated, osteophytes, nerve root decompression, harvesting, autologous, vertebral, arthrodesis, anterior technique, anterior cervical discectomy, spinal cord compression, fibular allograft bone, creation of arthrodesis, cervical discectomy, spinal instrumentation, cord compression, vertebral body, vertebral bodies, spinal cord, bone, instrumentation, cervical, anterior, grafting, spinal, discectomy, allograft, "
 The patient was running and twisted her right ankle - right ankle sprain., Orthopedic, Ankle Pain - Consult ,"IDENTIFICATION: , The patient is a 15-year-old female.,CHIEF COMPLAINT: , Right ankle pain.,HISTORY OF PRESENT ILLNESS:,  The patient was running and twisted her right ankle.  There were no other injuries.  She complains of right ankle pain on the lateral aspect.  She is brought in by her mother.  Her primary care physician is Dr. Brown.,REVIEW OF SYSTEMS:,  Otherwise negative except as stated above.,PAST MEDICAL HISTORY:,  None.,PAST SURGICAL HISTORY: , None.,MEDICATIONS:,  None.,SOCIAL HISTORY: , Mother appears loving and caring.  There is no evidence of abuse.,ALLERGIES:,  No known drug allergies.,PHYSICAL EXAMINATION: , General:  The patient is alert and oriented x4 in mild distress without diaphoresis.  She is nonlethargic and nontoxic.  Vitals:  Within normal limits.  The right ankle shows no significant swelling.  There is no ecchymosis.  There is no significant tenderness to palpation.  The ankle has good range of motion.  The foot is nontender.  Vascular:  +2/2 dorsalis pedis pulse.  All compartments are soft.  Capillary refill less than 2 seconds.,DIAGNOSTIC TEST:,  The patient had an x-ray of the right ankle, which interpreted by myself shows no acute fracture or dislocation.,MEDICAL DECISION MAKING: , Due to the fact this patient has no evidence of an ankle fracture, she can be safely discharged to home.  She is able to walk on it without significant pain, thus I recommend rest for 1 week and follow up with the doctor if she has persistent pain.  She may need to see a specialist, but at this time this is a very mild ankle injury.  There is no significant physical finding, and I foresee no complications.  I will give her 1 week off of PE.,MORBIDITY/MORTALITY:,  I expect no acute complications.  A full medical screening exam was done and no emergency medical condition exists upon discharge.,COMPLEXITY:,  Moderate.  The differential includes fracture, contusion, abrasion, laceration, and sprain.,ASSESSMENT:,  Right ankle sprain.,PLAN:,  Discharge the patient home and have her follow up with her doctor in 1 week if symptoms persist.  She is advised to return immediately p.r.n. severe pain, worsening, not better, etc.",
" Herniated nucleus pulposus.  Anterior cervical decompression, anterior spine instrumentation, anterior cervical spine fusion, and application of machined allograft.", Orthopedic, Anterior Cervical Decompression ,"PREOPERATIVE DIAGNOSES,1.  Herniated nucleus pulposus, C5-C6.,2.  Herniated nucleus pulposus, C6-C7.,POSTOPERATIVE DIAGNOSES,1.  Herniated nucleus pulposus, C5-C6.,2.  Herniated nucleus pulposus, C6-C7.,PROCEDURE PERFORMED,1.  Anterior cervical decompression, C5-C6.,2.  Anterior cervical decompression, C6-C7.,3.  Anterior spine instrumentation.,4.  Anterior cervical spine fusion, C5-C6.,5.  Anterior cervical spine fusion, C6-C7.,6.  Application of machined allograft at C5-C6.,7.  Application of machined allograft at C6-C7.,8.  Allograft, structural at C5-C6.,9.  Allograft, structural at C6-C7.,ANESTHESIA: , General.,PREOPERATIVE NOTE:  ,This patient is a 47-year-old male with chief complaint of severe neck pain and left upper extremity numbness and weakness.  Preoperative MRI scan showed evidence of herniated nucleus pulposus at C5-C6 and C6-C7 on the left.  The patient has failed epidural steroid injections.  Risks and benefits of the above procedure were discussed with the patient including bleeding, infection, muscle loss, nerve damage, paralysis, and death.,OPERATIVE REPORT: , The patient was taken to the OR and placed in the supine position.  After general endotracheal anesthesia was obtained, the patient's neck was sterilely prepped and draped in the usual fashion.  A horizontal incision was made on the left side of the neck at the level of the C6 vertebral body.  It was taken down through the subcutaneous tissues exposing the platysmus muscle.  The platysmus muscle was incised along the skin incision and the deep cervical fascia was bluntly dissected down to the anterior cervical spine.  An #18 gauge needle was placed in the C5-C6 interspace and the intraoperative x-ray confirmed that this was the appropriate level.  Next, the longus colli muscles were resected laterally on both the right and left side, and then a complete anterior cervical discectomy was performed.  The disk was very degenerated and brown in color.  There was an acute disk herniation through posterior longitudinal ligament.  The posterior longitudinal ligament was removed and a bilateral foraminotomy was performed.  Approximately, 5 mm of the nerve root on both the right and left side was visualized.  A ball-ended probe could be passed up the foramen.  Bleeding was controlled with bipolar electrocautery and Surgiflo.  The end plates of C5 and C6 were prepared using a high-speed burr and a 6-mm lordotic machined allograft was malleted into place.  There was good bony apposition both proximally and distally.  Next, attention was placed at the C6-C7 level.  Again, the longus colli muscles were resected laterally and a complete anterior cervical discectomy at C6-C7 was performed.  The disk was degenerated and there was acute disk herniation in the posterior longitudinal ligament on the left.  The posterior longitudinal ligament was removed.  A bilateral foraminotomy was performed.  Approximately, 5 mm of the C7 nerve root was visualized on both sides.  A micro nerve hook was able to be passed up the foramen easily.  Bleeding was controlled with bipolar electrocautery and Surgiflo.  The end plates at C6-C7 were then prepared using a high-speed burr and then a 7-mm machined lordotic allograft was malleted into place.  There was good bony apposition, both proximally and distally.  Next, a 44-mm Blackstone low-profile anterior cervical plate was applied to the anterior cervical spine with six 14 mm screws.  Intraoperative x-ray confirmed appropriate positioning of the plate and the graft.  The wound was then copiously irrigated with normal saline and bacitracin.  There was no active bleeding upon closure of the wound.  A small drain was placed deep.  The platysmal muscle was closed with 3-0 Vicryl.  The skin was closed with #4-0 Monocryl.  Mastisol and Steri-Strips were applied.  The patient was monitored throughout the procedure with free-running EMGs and SSEPs and there were no untoward events.  The patient was awoken and taken to the recovery room in satisfactory condition.","orthopedic, herniated nucleus pulposus, anterior cervical decompression, spine fusion, cervical spine, allograft, anterior cervical spine, anterior, cervical,"
 Removal of the hardware and revision of right AC separation.  Loose hardware with superior translation of the clavicle implants.  Arthrex bioabsorbable tenodesis screws., Orthopedic, AC Separation Revision & Hardware Removal ,"PREOPERATIVE DIAGNOSIS:,  Right AC separation.,POSTOPERATIVE DIAGNOSIS:,  Right AC separation.,PROCEDURES:,  Removal of the hardware and revision of right AC separation.,ANESTHESIA:,  General.,BLOOD LOSS:,  100 cc.,COMPLICATIONS:,  None.,FINDINGS: , Loose hardware with superior translation of the clavicle implants.,IMPLANTS: , Arthrex bioabsorbable tenodesis screws.,SUMMARY: , After informed consent was obtained and verified, the patient was brought to the operating room and placed supine on the operating table.  After uneventful general anesthesia was obtained, he was positioned in the beach chair and his right shoulder was sterilely prepped and draped in a normal fashion.  The incision was reopened and the hardware was removed without difficulty.  The AC joint was inspected and reduced.  An allograft was used to recreate the coracoacromial ligaments and then secured to decorticate with a bioabsorbable tenodesis screw and then to the clavicle.  And two separate areas that were split, one taken medially and one taken laterally, and then sewed together for further stability.  This provided good stability with no further superior translation of the clavicle as viewed under fluoroscopy.  The wound was copiously irrigated and the wound was closed in layers and a soft dressing was applied.  He was awakened from anesthesia and taken to recovery room in a stable condition.,Final needle and instrument counts were correct.","orthopedic, loose hardware, superior translation, clavicle implants, ac separation, removal of the hardware, arthrex bioabsorbable tenodesis screws, bioabsorbable tenodesis, tenodesis screws, translation, implants, bioabsorbable, tenodesis, clavicle, separation, hardware"
 Right Achilles tendon rupture., Orthopedic, Achilles Ruptured Tendon ,"CHIEF COMPLAINT:,  Achilles ruptured tendon.,HISTORY:,  Mr. XYZ is 41 years of age, who works for Chevron and lives in Angola.  He was playing basketball in Angola back last Wednesday, Month DD, YYYY, when he was driving toward the basket and felt a pop in his posterior leg.  He was seen locally and diagnosed with an Achilles tendon rupture.  He has been on crutches and has been nonweightbearing since that time.  He had no pain prior to his injury.  He has had some swelling that is mild.  He has just been on aspirin a day due to his traveling time.  Pain currently is minimal.,PAST MEDICAL HISTORY:,  Denies diabetes, cardiovascular disease, or pulmonary disease.,CURRENT MEDICATIONS:,  Malarone, which is an anti-malarial.,ALLERGIES:,  NKDA,SOCIAL HISTORY:,  He is a petroleum engineer for Chevron.  Drinks socially.  Does not use tobacco.,PHYSICAL EXAM:,  Pleasant gentleman in no acute distress.  He has some mild swelling on the right ankle and hindfoot.  He has motion that is increased into dorsiflexion.  He has good plantarflexion.  Good subtalar, Chopart and forefoot motion.  His motor function is intact although weak into plantarflexion.  Sensation is intact.  Pulses are strong.  In the prone position, he has diminished tension on the affected side.  There is some bruising around the posterior heel.  He has a palpable defect about 6-8 cm proximal to the insertion site that is tender for him.  Squeezing the calf causes no plantarflexion of the foot.,RADIOGRAPHS:,  Of his right ankle today show a preserved joint space.  I don't see any evidence of fracture noted.  Radiographs of the heel show no fracture noted with good alignment.,IMPRESSION:,  Right Achilles tendon rupture.,PLAN:,  I have gone over with Mr. XYZ the options available.  We have discussed the risks, benefits and alternatives to operative versus nonoperative treatment.  Based on his age and his activity level, I think his best option is for operative fixation.  We went over the risks of bleeding, infection, damage to nerves and blood vessels, rerupture of the tendon, weakness and the need for future surgery.  We have discussed doing this as an outpatient procedure.  He would be nonweightbearing in a splint for 10 days, nonweightbearing in a dynamic brace for 4 weeks, and then a walking boot for another six weeks with a lift until three months postop when we can get him into a shoe with a ¼"" lift.  He understands a 6-9 month return to sports overall.  He will also need to be on some Lovenox for a week after surgery and then on an aspirin as he is going to travel back to Angola.  Today we will put him in a high tide boot that he will need at six weeks, and we will put him in a 1"" lift also.  He can weight bear until surgery and we will have it set up this week.  His questions were all answered today.","orthopedic, achilles tendon rupture, alignment, crutches, joint space, nonweightbearing, plantarflexion, achilles ruptured tendon, achilles ruptured, ruptured tendon, achilles tendon, tendon rupture, achilles,"
" This patient has undergone cataract surgery, and vision is reduced in the operated eye due to presence of a secondary capsular membrane.  The patient is being brought in for YAG capsular discission.", Ophthalmology, YAG Laser Capsulotomy - 1 ,"PREOPERATIVE DIAGNOSIS: , Secondary capsular membrane, right eye.,POSTOPERATIVE DIAGNOSIS: , Secondary capsular membrane, right eye.,PROCEDURE PERFORMED: , YAG laser capsulotomy, right eye.,INDICATIONS: , This patient has undergone cataract surgery, and vision is reduced in the operated eye due to presence of a secondary capsular membrane.  The patient is being brought in for YAG capsular discission.,PROCEDURE: , The patient was seated at the YAG laser, the pupil having been dilated with 1%  Mydriacyl, and Iopidine was instilled.  The Abraham capsulotomy lens was then positioned and applications of laser energy in the pattern indicated on the outpatient note were applied.  A total of","ophthalmology, abraham capsulotomy, yag, yag laser capsulotomy, capsulotomy, laser, membrane, eye, capsular, "
 Bilateral open Achilles lengthening with placement of short leg walking cast., Orthopedic, Achilles Lengthening ,"PREOPERATIVE DIAGNOSIS: , Idiopathic toe walker.,POSTOPERATIVE DIAGNOSIS: , Idiopathic toe walker.,PROCEDURE: , Bilateral open Achilles lengthening with placement of short leg walking cast.,ANESTHESIA: , Surgery performed under general anesthesia.  A total of 10 mL of 0.5% Marcaine local anesthetic was used.,COMPLICATIONS:  ,No intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,TOURNIQUET TIME:  ,On the left side was 30 minutes, on the right was 21 minutes.,HISTORY AND PHYSICAL:,  The patient is a 10-year-old boy who has been a toe walker since he started ambulating at about a year.  The patient had some mild hamstring tightness with his popliteal angle of approximately 20 degrees bilaterally.  He does not walk with a crouched gait but does toe walk.  Given his tightness, surgery versus observation was recommended to the family.  Family however wanted to correct his toe walking.  Surgery was then discussed.  Risks of surgery include risks of anesthesia, infection, bleeding, changes in sensation and motion of the extremities, failure to resolve toe walking, possible stiffness, cast, and cast problems.  All questions were answered and parents agreed to above surgical plan.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating table  General anesthesia was then administered.  The patient received Ancef preoperatively.  The patient was then subsequently placed prone with all bony prominences padded.  Two bilateral nonsterile tourniquets were placed on each thigh.  Both extremities were then prepped and draped in a standard surgical fashion.  We turned our attention first towards the left side.  A planned incision of 1 cm medial to the Achilles tendon was marked on the skin.  The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg.  Incision was then made and carried down through subcutaneous fat down to the tendon sheath.  Achilles tendon was identified and Z-lengthening was done with the medial distal half cut.  Once Z-lengthening was completed proximally, the length of the Achilles tendon was then checked.  This was trimmed to obtain an end-on-end repair with 0 Ethibond suture.  This was also oversewn.  Wound was then irrigated.  Achilles tendon sheath was reapproximated using 2-0 Vicryl as well as the subcutaneous fat.  The skin was closed using 4-0 Monocryl.  Once the wound was cleaned and dried and dressed with Steri-Strips and Xeroform, the area was injected with 0.5% Marcaine.  It was then dressed with 4 x 4 and Webril.  Tourniquet was released at 30 minutes.  The same procedure was repeated on the right side with tourniquet time of 21 minutes.  While the patient was still prone, two short-leg walking casts were then placed.  The patient tolerated the procedure well and was subsequently flipped supine on to hospital gurney and taken to PACU in stable condition.,POSTOPERATIVE PLAN:  ,The patient will be discharged on the day of surgery.  He may weightbear as tolerated in his cast, which he will have for about 4 to 6 weeks.  He is to follow up in approximately 10 days for recheck as well as prescription for intended AFOs, which he will need up to 6 months.  The patient may or may not need physical therapy while his Achilles lengthenings are healing.  The patient is not to participate in any PE for at least 6 months.  The patient is given Tylenol No. 3 for pain.","orthopedic, toe walker, achilles lengthening, idiopathic toe walker, short leg walking, subcutaneous fat, tendon sheath, leg walking, achilles tendon, toe, tourniquet, tendon, intraoperative,"
" Combined closed vitrectomy with membrane peeling, fluid-air exchange, and endolaser, right eye.", Ophthalmology, Vitrectomy - 1 ,"PREOPERATIVE DIAGNOSIS: , Vitreous hemorrhage and retinal detachment, right eye.,POSTOPERATIVE DIAGNOSIS:,  Vitreous hemorrhage and retinal detachment, right eye.,NAME OF PROCEDURE: , Combined closed vitrectomy with membrane peeling, fluid-air exchange, and endolaser, right eye.,ANESTHESIA: , Local with standby.,PROCEDURE:  ,The patient was brought to the operating room, and an equal mixture of Marcaine 0.5% and lidocaine 2% was injected in a retrobulbar fashion.  As soon as satisfactory anesthesia and akinesia had been achieved, the patient was prepped and draped in the usual manner for sterile ophthalmic surgery.  A wire lid speculum was inserted.  Three modified sclerotomies were selected at 9, 10, and 1 o'clock.  At the 9 o'clock position, the Accurus infusion line was put in place and tied with a preplaced #7-0 Vicryl suture.  The two superior sites at 10 and 1 were opened up where the operating microscope with the optical illuminating system was brought into position, and closed vitrectomy was begun.  Initially formed core vitrectomy was performed and formed anterior vitreous was removed.  After this was completed, attention was placed in the posterior segment.  Several broad areas of vitreoretinal traction were noted over the posterior pole out of the equator where the previously noted retinal tears were noted.  These were carefully lifted and dissected off the edges of the flap tears and trimmed to the ora serrata.  After all the vitreous had been removed and the membranes released, the retina was completely mobilized.  Total fluid-air exchange was carried out with complete settling of the retina.  Endolaser was applied around the margins of the retinal tears, and altogether several 100 applications were placed in the periphery.  Good reaction was achieved.  The eye was inspected with an indirect ophthalmoscope.  The retina was noted to be completely attached.  The instruments were removed from the eye.  The sclerotomy sites were closed with #7-0 Vicryl suture.  The infusion line was removed from the eye and tied with a #7-0 Vicryl suture.  The conjunctivae and Tenon's were closed with #6-0 plain gut suture.  A collagen shield soaked with Tobrex placed over the surface of the globe, and a pressure bandage was put in place.  The patient left the operating room in a good condition.","ophthalmology, vitreous hemorrhage, retinal detachment, combined closed vitrectomy, vitrectomy, membrane peeling, fluid-air exchange, endolaser, vitrectomy with membrane peeling, membrane, peeling, hemorrhage, detachment, vicryl, eye, retinal, "
" Visually significant posterior capsule opacity, right eye.  YAG laser posterior capsulotomy, right eye.", Ophthalmology, YAG Laser Capsulotomy ,"PREOPERATIVE DIAGNOSIS:,  Visually significant posterior capsule opacity, right eye.,POSTOPERATIVE DIAGNOSIS:,  Visually significant posterior capsule opacity, right eye.,OPERATIVE PROCEDURES:  ,YAG laser posterior capsulotomy, right eye.,ANESTHESIA: , Topical anesthesia using tetracaine ophthalmic drops.,INDICATIONS FOR SURGERY: , This patient was found to have a visually significant posterior capsule opacity in the right eye.  The patient has had a mild decrease in visual acuity, which has been a gradual change.  The posterior capsule opacity was felt to be related to the decline in vision.  The risks, benefits, and alternatives (including observation) were discussed.  I feel the patient had a good understanding of the proposed procedure and informed consent was obtained.,DESCRIPTION OF PROCEDURE: , The patient was identified and the procedure was verified.  Pupil was dilated per protocol.  Patient was positioned at the YAG laser.  Then, *** of energy were used to perform a circular posterior laser capsulotomy through the visual axis.  A total of ** shots were used.  Total energy was **.  The patient tolerated the procedure well and there were no complications.  The lens remained well centered and stable.  Postoperative instructions were provided.  Alphagan P ophthalmic drops times two were instilled prior to his dismissal.,Post-laser intraocular pressure measured ** mmHg.  Postoperative instructions were provided and the patient had no further questions.","ophthalmology, capsule opacity, yag, ophthalmic, yag laser posterior capsulotomy, capsulotomy, opacity, laser, visually, eye, anesthesia "
 Vitrectomy under local anesthesia., Ophthalmology, Vitrectomy - Local Anesthesia ,"DESCRIPTION OF PROCEDURE:,  After appropriate operative consent was obtained the patient was brought supine to the operating room and placed on the operating room table.  After intravenous sedation was administered a retrobulbar block consisting of 2% Xylocaine with 0.75% Marcaine and Wydase was administered to the right eye without difficulty.  The patient's right eye was prepped and draped in sterile ophthalmic fashion and the procedure begun.  A wire lid speculum was inserted into the right eye and a limited conjunctival peritomy performed at the limbus temporally and superonasally.  Infusion line was set up in the inferotemporal quadrant and two additional sclerotomies were made in the superonasal and superotemporal quadrants.  A lens ring was secured to the eye using 7-0 Vicryl suture.","ophthalmology, lid speculum, conjunctival, peritomy, vitrectomy, operating, superonasally, anesthesiaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Vitreous hemorrhage, right eye.  Vitrectomy, right eye.  A Lancaster lid speculum was applied and the conjunctiva was opened 4 mm posterior to the limbus.", Ophthalmology, Vitrectomy ,"PREOPERATIVE DIAGNOSIS:,  Vitreous hemorrhage, right eye.,POSTOPERATIVE DIAGNOSIS: , Vitreous hemorrhage, right eye.,PROCEDURE:  ,Vitrectomy, right eye.,PROCEDURE IN DETAIL:  ,The patient was prepared and draped in the usual manner for a vitrectomy procedure under local anesthesia.  Initially, a 5 cc retrobulbar injection was performed with 2% Xylocaine during monitored anesthesia control.  A Lancaster lid speculum was applied and the conjunctiva was opened 4 mm posterior to the limbus.  MVR incisions were made 4 mm posterior to the limbus in the *** and *** o'clock meridians following which the infusion apparatus was positioned in the *** o'clock site and secured with a 5-0 Vicryl suture.  Then, under indirect ophthalmoscopic control, the vitrector was introduced through the *** o'clock site and a complete vitrectomy was performed.  All strands of significance were removed.  Tractional detachment foci were apparent posteriorly along the temporal arcades.  Next, endolaser coagulation was applied to ischemic sites and to neovascular foci under indirect ophthalmoscopic control.  Finally, an air exchange procedure was performed, also under indirect ophthalmoscopic control.  The intraocular pressure was within the normal range.  The globe was irrigated with a topical antibiotic.  The MVR incisions were closed with 7-0 Vicryl.  No further manipulations were necessary.  The conjunctiva was closed with 6-0 plain catgut.  An eye patch was applied and the patient was sent to the recovery area in good condition.","ophthalmology, ophthalmoscopic, vitrectomy, endolaser, lancaster lid speculum, vitreous hemorrhage, vitreous, hemorrhage, conjunctiva"
 Vitrectomy under general anesthesia, Ophthalmology, Vitrectomy - General Anesthesia ,"DESCRIPTION OF PROCEDURE: , After appropriate operative consent was obtained the patient was brought supine to the operating room and placed on the operating room table.  Induction of general anesthesia via endotracheal intubation was then accomplished without difficulty.  The patient's right eye was prepped and draped in sterile ophthalmic fashion and the procedure begun.  A wire lid speculum was inserted into the right eye and a limited conjunctival peritomy performed at the limbus temporally and superonasally.  Infusion line was set up in the inferotemporal quadrant and two additional sclerotomies were made in the superonasal and superotemporal quadrants.  A lens ring was secured to the eye using 7-0 Vicryl suture.","ophthalmology, ophthalmic fashion, vitrectomy, operating, superonasally, anesthesiaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Vitrectomy. A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and, separately, the supratemporal and inferotemporal quadrants.  ", Ophthalmology, Vitrectomy - 3 ,"DESCRIPTION OF OPERATION:,  The patient was brought to the operating room and appropriately identified.  Local anesthesia was obtained with a 50/50 mixture of 2% lidocaine and 0.75% bupivacaine given as a peribulbar block.  The patient was prepped and draped in the usual sterile fashion.  A lid speculum was used to provide exposure to the right eye.,A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and, separately, the supratemporal and inferotemporal quadrants.  Calipers were set at 3.5 mm and a mark was made 3.5 mm posterior to the limbus in the inferotemporal quadrant.,A 5-0 nylon suture was passed through partial-thickness sclera on either side of this mark.  The MVR blade was used to make a sclerotomy between the pre-placed sutures.  An 8-0 nylon suture was then pre-placed for later sclerotomy closure.  The infusion cannula was inspected and found to be in good working order.  The infusion cannula was placed in the vitreous cavity and secured with the pre-placed sutures.  The tip of the infusion cannula was directly visualized and found to be free of any overlying tissue and the infusion was turned on.,Additional sclerotomies were made 3.5 mm posterior to the limbus in the supranasal and supratemporal quadrants.  The light pipe and vitrectomy handpieces were then placed in the vitreous cavity and a vitrectomy was performed.  There was moderately severe vitreous hemorrhage, which was removed.  Once a view of the posterior pole could be obtained, there were some diabetic membranes emanating along the arcades.  These were dissected with curved scissors and judicious use of the vitrectomy cutter.  There was some bleeding from the inferotemporal frond.  This was managed by raising the intraocular pressure and using intraocular cautery.  The surgical view became cloudy and the corneal epithelium was removed with a beaver blade.  This improved the view.  There is an area suspicious for retinal break near where the severe traction was inferotemporally.  The Endo laser was used to treat in a panretinal scatter fashion to areas that had not received previous treatment.  The indirect ophthalmoscope was used to examine the retinal peripheral for 360 degrees and no tears, holes or dialyses were seen.  There was some residual hemorrhagic vitreous skirt seen.  The soft-tip cannula was then used to perform an air-fluid exchange.  Additional laser was placed around the suspicious area inferotemporally.  The sclerotomies were then closed with 8-0 nylon suture in an X-fashion, the infusion cannula was removed and it sclerotomy closed with the pre-existing 8-0 nylon suture.,The conjunctiva was closed with 6-0 plain gut.  A subconjunctival injection of Ancef and Decadron were given and a drop of atropine was instilled over the eye.  The lid speculum was removed.  Maxitrol ointment was instilled over the eye and the eye was patched.  The patient was brought to the recovery room in stable condition.","ophthalmology, conjunctival peritomy, westcott scissors, lid speculum, inferotemporal quadrants, inferotemporal, conjunctival, scissors, supranasal, supratemporal, sclerotomy, eye, vitreous, vitrectomy, infusion, cannulaNOTE"
" The patient with recurrent nongranulomatous anterior iritis and most recently, pain in  left eye associated with headache and photophobia.", Ophthalmology, Uveitis ,"PAST MEDICAL HISTORY: , Significant for GERD, history of iron deficiency anemia, and asthma for which she takes an inhaler.,REVIEW OF SYSTEMS:,  Positive for only for left knee arthritis.  She has no exposure to tuberculosis or syphilis, she has no mouth or genital ulcers.  She has no skin rashes.  She has no connective tissue disorders.,PAST OCULAR HISTORY: , Significant for cataract and glaucoma surgery of the right eye.,PHYSICAL EXAMINATION: , On examination, visual acuity measures hand motions on the right and 20/25 in the left.  There is an afferent pupillary defect on the right.  On examination, there is a right hypertropia.  There is dense anterior chamber inflammation on the right eye with a stagnant aqueous.  There is either neovascularization on the iris or reactive iris vessels, it is difficult to discern.  This seems to be complete iris synechia to the anterior lens capsule.  There is a posterior chamber intraocular lens with an inflammatory debris on the anterior surface.  The anterior chamber appears narrow.  On the left, there is also dense inflammation at 4+ cell.  There is 1+ nuclear sclerosis.  Dilated fundus examination cannot be performed on the right secondary to intense inflammation.  On the left, there is no evidence of active posterior uveitis.  There is some inferior vitreous debris.,ASSESSMENT/PLAN:,  Chronic bilateral recurrent nongranulomatous diffuse uveitis.  Currently, there is very severe right eye inflammation and severe left eye.  I discussed at length with the patient that this will likely take an oral steroid to quite her down.  Since she has only one seeing eye, I am anxious to obtain a decreased inflammation as soon as possible.  She has been on oral steroids in the past.  We also discussed, considering the aggressive recurrent nature of this process, it is likely we will have to consider a steroid sparing agent to maintain longer term control of this recurrent process so that we do not use visual acuity in the left.  I anticipate we will likely start methotrexate in the near future.  In this acute phase, I have recommended oral steroids at a dose of 60 mg a day, hourly topical Pred Forte as well as atropine sulfate.  We will watch her closely in clinic.  I am sending a copy of this dictation to her primary care doctor, she said she has had a negative HLA-B27, rheumatoid factor, and ANA in the past.  At this stage, to be thorough I would ask Dr. X to assist us in repeating her chest x-ray, PPD if not current, and an RPR.  Additionally, in anticipation of need for methotrexate, it would be helpful to have a full liver function profile as well as hepatitis B and hepatitis C.","ophthalmology, iritis, nongranulomatous, uveitis, eye inflammation, photophobia, recurrent nongranulomatous anterior iritis, headache and photophobia, anterior chamber, anterior, chamber, inflammation, "
" Pars plana vitrectomy, membrane peel, 23-gauge, right eye.", Ophthalmology, Vitrectomy - 2 ,"PREOPERATIVE DIAGNOSES: , Epiretinal membrane, right eye.  CME, right eye.,POSTOPERATIVE DIAGNOSES: , Epiretinal membrane, right eye.  CME, right eye.,PROCEDURES: , Pars plana vitrectomy, membrane peel, 23-gauge, right eye.,PREOPERATIVE FINDINGS:,  The patient had epiretinal membrane causing cystoid macular edema.  Options were discussed with the patient stressing that the visual outcome was guarded.  Especially since this membrane was of chronic duration there is no guarantee of visual outcome.,DESCRIPTION OF PROCEDURE: , The patient was wheeled to the OR table.  Local anesthesia was delivered using a retrobulbar needle in an atraumatic fashion 5 cc of Xylocaine and Marcaine was delivered to retrobulbar area and massaged and verified.  Preparation was made for 23-gauge vitrectomy, using the trocar inferotemporal cannula was placed 3.5 mm from the limbus and verified.  The fluid was run.  Then superior sclerotomies were created using the trocars and 3.5 mm from the limbus at 10 o'clock and 2 o'clock.  Vitrectomy commenced and carried on as far anteriorly as possible using intraocular forceps, ILM forceps, the membrane was peeled off in its entirety.  There were no complications.  DVT precautions were in place.  I, as attending, was present in the entire case.","ophthalmology, epiretinal membrane, pars plana vitrectomy, membrane peel, macular edema, cystoid, eye, retrobulbar, epiretinal, vitrectomy, membrane, "
 Vitrectomy opening.  A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and separately the supratemporal and inferotemporal quadrants. , Ophthalmology, Vitrectomy Opening ,"VITRECTOMY OPENING,The patient was brought to the operating room and appropriately identified.  General anesthesia was induced by the anesthesiologist.  The patient was prepped and draped in the usual sterile fashion.  A lid speculum was used to provide exposure to the right eye.  A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and separately the supratemporal and inferotemporal quadrants.  Hemostasis was maintained with wet-field cautery.  Calipers were set at XX mm and the mark was made XX mm posterior to the limbus in the inferotemporal quadrant.  A 5-0 nylon suture was passed through partial-thickness sclera on either side of this mark.  The MVR blade was used to make a sclerotomy between the preplaced sutures.  An 8-0 nylon suture was then preplaced for a later sclerotomy closure.  The infusion cannula was inspected and found to be in good working order.  The infusion cannula was placed into the vitreous cavity and secured with the preplaced suture.  The tip of the infusion cannula was directly visualized and found to be free of any overlying tissue and the infusion was turned on.  Additional sclerotomies were made XX mm posterior to the limbus in the supranasal and supratemporal quadrants.","ophthalmology, westcott scissors, inferotemporal quadrants, conjunctival, peritomy, sclerotomy, vitrectomy, supranasal, supratemporal, cannula, inferotemporalNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Scleral buckle opening under local anesthesia., Ophthalmology, Scleral Buckle Opening - Local Anesthesia ,"PROCEDURE IN DETAIL:,  After appropriate operative consent was obtained, the patient was brought supine to the operating room and placed on the operating room table.  After intravenous sedation was administered a retrobulbar block consisting of 2% Xylocaine with 0.75% Marcaine and Wydase was administered to the right eye without difficulty.  The patient's right eye was prepped and draped in a sterile ophthalmic fashion and the procedure begun.  A wire lid speculum was inserted into the right eye and a 360-degree conjunctival peritomy was performed at the limbus.  The 4 rectus muscles were looped and isolated using 2-0 silk suture.  The retinal periphery was then inspected via indirect ophthalmoscopy.,","ophthalmology, retinal periphery, ophthalmoscopy, scleral, buckle, operating, anesthesiaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" Short flap trabeculectomy with lysis of conjunctival scarring, tenonectomy, peripheral iridectomy, paracentesis, watertight conjunctival closure, and 0.5 mg/mL mitomycin x2 minutes, left eye.  Uncontrolled open angle glaucoma and conjunctival scarring, left eye.  ", Ophthalmology, Trabeculectomy & Tenonectomy ,"PREOPERATIVE DIAGNOSES,1.  Uncontrolled open angle glaucoma, left eye.,2.  Conjunctival scarring, left eye.,POSTOPERATIVE DIAGNOSES,1.  Uncontrolled open angle glaucoma, left eye.,2.  Conjunctival scarring, left eye.,PROCEDURES: , Short flap trabeculectomy with lysis of conjunctival scarring, tenonectomy, peripheral iridectomy, paracentesis, watertight conjunctival closure, and 0.5 mg/mL mitomycin x2 minutes, left eye.,ANESTHESIA: ,Retrobulbar block with monitored anesthesia care.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  Negligible.,DESCRIPTION OF PROCEDURE:,  The patient was brought to the operating suite where the Anesthesia team established a peripheral IV as well as monitoring lines.  In the preoperative area, the patient received pilocarpine drops.  The patient received IV propofol and once somnolent from this, a retrobulbar block was administered consisting of 2% Xylocaine plain.  Approximately 3 mL were given.  The operative eye then underwent a Betadine prep with respect to the face, lids, lashes, and eye.  During the draping process, care was taken to isolate the lashes.  A screw type speculum was inserted to maintain patency of lids.  A 6-0 Vicryl suture was placed through the superior cornea, and the eye was reflected downward to expose the superior conjunctiva.  A peritomy was performed approximately 8 to 10 mm posterior to the limbus and this flap was dissected forward to the cornea.  All Tenons were removed from the overlying sclera and the area was treated with wet-field cautery to achieve hemostasis.  A 2 mm x 3 mm scleral flap was then outlined with a Micro-Sharp blade.  This was approximately one-half scleral depth in thickness.  A crescent blade was then used to dissect forward the clear cornea.  Hemostasis was again achieved with wet-field cautery.  A Weck-Cel sponge tip soaked in mitomycin was then placed under the conjunctival and tenon flap and left there for two minutes.  The site was then profusely irrigated with balanced salt solution.  A paracentesis wound was made temporarily and then the Micro-Sharp blade was used to enter the anterior chamber at the anterior most margin of the trabeculectomy bed.  A Kelly-Descemet punch was then inserted, and a trabeculectomy was performed.  Iris was withdrawn through the trabeculectomy site and a peripheral iridectomy was performed using Vannas scissors and 0.12 forceps.  The iris was then repositioned into the eye and the anterior chamber was inflated with BSS.  The scleral flap was sutured in place with two 10-0 nylon sutures with knots trimmed, rotated, and buried.  The overlying conjunctiva was then closed with a running 8-0 Vicryl suture on a BV needle.  BSS was irrigated in the anterior chamber and the blood was noted to elevate nicely without leakage.  Antibiotic and steroid drops were placed in the eye as was homatropine 5%.  The antibiotic consisted of Vigamox and the steroid was Econopred Plus.  A patch and shield were placed over the eye after the drape was removed.  The patient was taken to the recovery room in good condition.  She will be seen in followup in the office tomorrow.","ophthalmology, uncontrolled open angle glaucoma, open angle, conjunctival, scarring, trabeculectomy, tenonectomy, iridectomy, paracentesis, watertight conjunctival closure, conjunctival scarring, eye, glaucoma, cornea, scleral,"
 Tube Shunt  - Ahmed valve model S2 implant with pericardial reinforcement - Sample/Template., Ophthalmology, Tube Shunt - Ahmed Valve Implant ,"PREOPERATIVE DIAGNOSIS: ,Open angle glaucoma OX,POSTOPERATIVE DIAGNOSIS:, Open angle glaucoma OX,PROCEDURE:, Ahmed valve model S2 implant with pericardial reinforcement XXX eye,INDICATIONS: ,This is a XX-year-old (wo)man with glaucoma in the OX eye, uncontrolled by maximum tolerated medical therapy.,PROCEDURE: ,The risks and benefits of glaucoma surgery were discussed at length with the patient including bleeding, infection, reoperation, retinal detachment, diplopia, ptosis, loss of vision, and loss of the eye, corneal hemorrhage, hypotony, elevated pressure, worsening of glaucoma, and corneal edema. Informed consent was obtained. Patient received several sets of drops in his/her XXX eye including Ocuflox and Ocular. (S)He was taken to the operating room where monitored anesthetic care was initiated. Retrobulbar anesthesia was then administered to the XXX eye using a 50:50 mixture of 2% plain lidocaine and 0.05% Marcaine. The XXX eye was then prepped and draped in the usual sterile ophthalmic fashion. A speculum was placed on the eyelids and microscope was brought into position. A #7-0 Vicryl suture was passed through the superotemporal limbus and traction suture was placed at the superotemporal limbus and the eye was rotated infranasally so as to expose the superotemporal conjunctiva. At this point, smooth forceps and Westcott scissors were used to create a 100-degree superotemporal conjunctival peritomy, approximately 2 mm posterior to the superotemporal limbus. This was then dissected anteriorly to the limbus edge and then posteriorly. Steven scissors were then dissected in a superotemporal quadrant between the superior and lateral rectus muscles to provide good exposure. At this point, we primed the Ahmed valve with a #27 gauge cannula using BSS and it was noted to be patent. We then placed Ahmed valve in the superotemporal subconjunctival recess underneath the subtenon space and this was pushed posteriorly. We then measured with calipers so that it was positioned 9 mm posterior to the limbus. The Ahmed valve was then tacked down with #8-0 nylon suture through both fenestrations. We then applied light cautery to the superotemporal episcleral bed. We placed a paracentesis at the temporal position and inflated the anterior chamber with a small amount of Healon. We then used a #23 gauge needle and entered the superotemporal sclera, approximately 1 mm posterior to the limbus into the anterior chamber away from iris and away from cornea. We then trimmed the tube, beveled up in a 30 degree fashion with Vannas scissors, and introduced the tube through the #23 gauge tract into the anterior chamber so that approximately 2-3 mm of tube was extending into the anterior chamber. We burped some of the Healon out of the anterior chamber and filled it with BSS and we felt that the tube was in good position away from the lens, away from the cornea, and away from the iris. We then tacked down the tubes to the sclera with #8-0 Vicryl suture in a figure-of- eight fashion. The pericardium was soaked in gentamicin. We then folded the pericardium 1x1 cm piece onto itself and then placed it over the tube and this was tacked down in all four quadrants to the sclera with #8-0 nylon suture. At this point, we then re-approximated the conjunctiva to its original position and we closed it with an #8-0 Vicryl suture on a TG needle in a running fashion with interrupted locking bites. We then removed the traction suture. At the end of the case, the pupil was round, the chamber was deep, the tube appeared to be well positioned. The remaining portion of the Healon was burped out of the anterior chamber with BSS and the pressure was felt to be adequate. The speculum was removed. Ocuflox and Maxitrol ointment were placed over the eye. Then, an eye patch and shield were placed over the eye. The patient was awakened and taken to the recovery room in stable condition.","ophthalmology, tube shunt, ahmed valve, healon, maxitrol ointment, ocuflox, open angle, anterior chamber, bleeding, conjunctival peritomy, cornea, corneal edema, corneal hemorrhage, diplopia, elevated pressure, glaucoma, hypotony, infection, loss of the eye, loss of vision, ophthalmic fashion, ptosis, reoperation, retinal detachment, sclera, superotemporal, worsening of glaucoma, ahmed valve model, superotemporal limbus, eye, ahmed, implant, bss, valve, limbus, "
 Scleral buckle opening.  The 4 scleral quadrants were inspected and found to be free of scleral thinning or staphyloma., Ophthalmology, Scleral Buckle Opening ,"SCLERAL BUCKLE OPENING,The patient was brought to the operating room and appropriately identified.  General anesthesia was induced by the anesthesiologist.  The patient was prepped and draped in the usual sterile fashion.  A lid speculum was used to provide exposure to the right eye.  A 360-degree limbal conjunctival peritomy was created with Westcott scissors.  Curved tenotomy scissors were used to enter each of the intermuscular quadrants.  The inferior rectus muscle was isolated with a muscle hook, freed of its Tenon's attachment and tied with a 2-0 silk suture.  The 3 other rectus muscles were isolated in a similar fashion.  The 4 scleral quadrants were inspected and found to be free of scleral thinning or staphyloma.","ophthalmology, tenotomy, scleral quadrants, scleral thinning, scleral buckle, staphylomaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Trabeculectomy with mitomycin C - Sample/Template., Ophthalmology, Trabeculectomy ,"PREOPERATIVE DIAGNOSIS:, Open angle glaucoma OX,POSTOPERATIVE DIAGNOSIS:, Open angle glaucoma OX,PROCEDURE:, Trabeculectomy with mitomycin C, XXX eye 0.3 c per mg times three minutes.,INDICATIONS: ,This is a XX-year-old (wo)man with glaucoma in the OX eye, uncontrolled by maximum tolerated medical therapy.,PROCEDURE: ,The risks and benefits of glaucoma surgery were discussed at length with the patient including bleeding, infection, reoperation, retinal detachment, diplopia, ptosis, loss of vision, and loss of the eye, corneal hemorrhage hypotony, elevated pressure, worsening of glaucoma, and corneal edema. Informed consent was obtained. Patient received several sets of drops in his/her XXX eye including Ocuflox, Ocular, and pilocarpine. (S)He was taken to the operating room where monitored anesthetic care was initiated. Retrobulbar anesthesia was then administered to the XXX eye using a 50:50 mixture of 2% plain lidocaine and 0.05% Marcaine. The XXX eye was then prepped and draped in the usual sterile ophthalmic fashion and the microscope was brought in position. A Lieberman lid speculum was used to provide exposure. Vannas scissors and smooth forceps were used to create a 6 mm limbal peritomy superiorly. This was dissected posteriorly with Vannas scissors to produce a fornix based conjunctival flap. Residual episcleral vessels were cauterized with Eraser-tip cautery. Sponges soaked in mitomycin C 0.3 mm per cc were then placed underneath the conjunctival flap and allowed to sit there for 3 minutes checked against the clock. Sponges were removed and area was copiously irrigated with balanced salt solution. A Super blade was then used to fashion a partial thickness limbal based trapezoidal scleral flap. This was dissected anteriorly with a crescent blade to clear cornea. A temporal paracentesis was then made. Scleral flap was lifted and a Super blade was used to enter the anterior chamber. A Kelly-Descemet punch was used to remove a block of limbal tissue. DeWecker scissors were used to perform a surgical iridectomy. The iris was then carefully reposited back into place and the iridectomy was visible through the clear cornea. A scleral flap was then re- approximated back on the bed. One end of the scleral flap was closed with a #10-0 nylon suture in interrupted fashion and the knot was buried. The other end of the scleral flap was closed with #10-0 nylon suture in interrupted fashion and the knot was buried. The anterior chamber was then refilled with balanced salt solution and a small amount of fluid was noted to trickle out of the scleral flap with slow shallowing of the chamber. Therefore it was felt that another #10-0 nylon suture should be placed and it was therefore placed in interrupted fashion half way between each of the end sutures previously placed. The anterior chamber was then again refilled with balanced salt solution and it was noted that there was a small amount of fluid tricking out of the scleral flap and the pressure was felt to be adequate in the anterior chamber. Conjunctiva was then re-approximated to the limbus and closed with #9-0 Vicryl suture on a TG needle at each of the peritomy ends. Then a horizontal mattress style #9-0 Vicryl suture was placed at the center of the conjunctival peritomy. The conjunctival peritomy was checked for any leaks and was noted to be watertight using Weck- cel sponge. The anterior chamber was inflated and there was noted that the superior bleb was well formed. At the end of the case, the pupil was round, the chamber was formed and the pressure was felt to be adequate. Speculum and drapes were carefully removed. Ocuflox and Maxitrol ointment were placed over the eye. Atropine was also placed over the eye. Then an eye patch and eye shield were placed over the eye. The patient was taken to the recovery room in good condition. There were no complications.","ophthalmology, trabeculectomy, kelly-descemet punch, maxitrol ointment, open angle glaucoma, tg needle, bleeding, corneal edema, corneal hemorrhage hypotony, diplopia, elevated pressure, glaucoma, infection, iridectomy, loss of the eye, loss of vision, mitomycin c, ptosis, reoperation, retinal detachment, temporal paracentesis, worsening of glaucoma, balanced salt solution, anterior chamber, scleral flap, eye, angle, mitomycin, conjunctival, chamber, flap, "
 Scleral Buckle opening under general anesthesia., Ophthalmology, Scleral Buckle Opening - General Anesthesia ,"PROCEDURE IN DETAIL:,  After appropriate operative consent was obtained, the patient was brought supine to the operating room and placed on the operating room table.  Induction of general anesthesia via endotracheal intubation was then accomplished without difficulty.  The patient's right eye was prepped and draped in a sterile ophthalmic fashion and the procedure begun.  A wire lid speculum was inserted into the right eye and a 360-degree conjunctival peritomy was performed at the limbus.  The 4 rectus muscles were looped and isolated using 2-0 silk suture.  The retinal periphery was then inspected via indirect ophthalmoscopy.","ophthalmology, retinal periphery, conjunctival peritomy, ophthalmoscopy, scleral, buckle, operating, anesthesiaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Repair of ruptured globe involving posterior sclera - Sample/Template. , Ophthalmology, Ruptured Globe Repair - Posterior Sclera ,"PREOPERATIVE DIAGNOSIS: , Ruptured globe OX.,POSTOPERATIVE DIAGNOSIS:,  Ruptured globe OX.,PROCEDURE: , Repair of ruptured globe OX.,ANESTHESIA:, General,SPECIMENS:,  None.,COMPLICATIONS: ,None.,INDICATIONS:, This is a XX-year-old (wo)man with a ruptured globe of the XXX eye.,PROCEDURE:, The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, re-operation, loss of vision, and loss of the eye. Informed consent was obtained. The patient received IV antibiotics including Ancef and Levaeuin prior to surgery. The patient was brought to the operating room and placud in the supine position, where (s)he wad prepped and draped in the routine fashion. A wire lid speculum was placed to provide exposure.,Upon examination and dissection of the conjunctiva superiorly, a scleral rupture was found. The rupture extended approximately 15 mm in length superior to the cornea, approximately 2 mm from the limbus in a horizontal fashion. There was also a rupture at the limbus, near the middle of this laceration, causing the anterior chamber to be flat. There was a large blood clot filling the anterior chamber. An attempt was made to wash out the anterior chamber with BSS on a cannula. The BSS was injected through the limbal rupture, which communicated with the anterior chamber. The blood clot did not move. It was extremely adherent to the iris.,At that time, the rupture that involved the limbus from approximately 10:30 until 12 o'clock was closed using 1 suture of 10-0 nylon. The scleral laceration was then closed using 10 interrupted sutures with 9-0 Vicryl. At that time, the anterior chamber was formed and appeared to be fairly deep. The wounds were checked and found to be watertight. The knots were rotated posteriorly and the conjunctiva was draped up over the sutures and sewn into position at the limbus using four 7-0 Vicryl sutures, 2 nasally and 2 temporally. All suture knots were buried.  ,Gentamicin 0.5 cc was injected subconjunctivally. Then, the speculum was removed. The drapes were removed. Several drops of Ocuflox and Maxitrol ointment were placed in the XXX eye. An eye patch and shield were placed over the eye. The patient was awakened from general anesthesia without difficulty and taken to the recovery room in good condition.","ophthalmology, ruptured globe, ancef, bss, maxitrol ointment, ocuflox, anterior chamber, bleeding, conjunctiva, infection, limbus, loss of the eye, loss of vision, re-operation, scleral laceration, scleral rupture, wire lid speculum, repair of ruptured globe, ruptured, anterior, chamber, globe"
 Ruptured globe with full-thickness corneal laceration repair - Sample/Template., Ophthalmology, Ruptured Globe Repair - Cornea ,"PREOPERATIVE DIAGNOSIS:,  Ruptured globe with full-thickness corneal laceration OX.,POSTOPERATIVE DIAGNOSIS: , Ruptured globe with full-thickness corneal laceration OX.,PROCEDURE:  ,Ruptured globe with full-thickness corneal laceration repair OX.,ANESTHESIA:, General,SPECIMENS:,  None.,COMPLICATIONS:, None.,INDICATIONS:, This is a XX-year-old (wo)man with a ruptured globe with full-thickness corneal laceration of the XXX eye.,PROCEDURE:, The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, astigmatism, cataract, re-operation, loss of vision, and loss of the eye. Informed consent was obtained. The patient received IV antibiotics including Ancef and Levaeuin prior to surgery. The patient was brought to the operating room and placud in the supine position, where (s)he wad prepped and draped in the routine fashion. A wire lid speculum was placed to provide exposure and 0.12 forceps and a Superblade were used to create a paracentesis at approximately 11 o'clock. Viscoat was injected through the paracentesis to fill the anterior chamber. The Viscoat cannula was used to sweep the incarcerated iris tissue from the wound. More Viscoat was injected to deepen the anterior chamber. A 10-0 nylon suture was used to place four sutures to close the corneal laceration. BSS was then injected to fill the anterior chamber and a small leak was noted at the inferior end of the wound. A fifth 10-0 nylon suture was then placed. The wound was packed and found to be watertight. The sutures were rotated, the wound was again checked and found to be watertight. A small amount of Viscoat was, again, injected to deepen the anterior chamber and the wound was swept to be sure there was no incarcerated uveal tissue. Several drops were placed in the XXX eye including Ocuflox, Pred Forte, Timolol 0.5%, Alphagan and Trusopt. An eye patch and shield were taped over the XXX eye. The patient was awakened from general anesthesia. (S)he was taken to the recovery area in good condition. There were no complications.","ophthalmology, ruptured globe, alphagan, bss, ocuflox, pred forte, superblade, timolol, viscoat cannula, anterior chamber, astigmatism, bleeding, cataract, corneal laceration, full-thickness corneal laceration, infection, laceration repair, loss of the eye, loss of vision, paracentesis, re-operation, wire lid speculum, viscoat, corneal, laceration,"
 Repair of ruptured globe with repositing of uveal tissue - Sample/Template., Ophthalmology, Ruptured Globe Repair - Sclera and Limbus ,"PREOPERATIVE DIAGNOSIS: , Ruptured globe with uveal prolapse OX.,POSTOPERATIVE DIAGNOSIS:,  Ruptured globe with uveal prolapse OX.,PROCEDURE:  ,Repair of ruptured globe with repositing of uveal tissue OX.,ANESTHESIA: ,General,SPECIMENS:,  None.,COMPLICATIONS:,  None.,INDICATIONS: , This is a XX-year-old (wo)man with a ruptured globe of the XXX eye.,PROCEDURE: ,  The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, re-operation, loss of vision, and loss of the eye. Informed consent was obtained. The patient received IV antibiotics including Ancef and Levaeuin prior to surgery. The patient was brought to the operating room and placud in the supine position, where (s)he wad prepped and draped in the routine fashion. A wire lid speculum was carefully placed to provide exposure. A two-armed 7 mm scleral laceration was seen in the supranasal quadrant. The laceration involved the sclera and the limbus in this area. There was a small amount of iris tissue prolapsed in the wound. The Westcott scissors and 0.12 forceps were used to carefully dissect the conjunctiva away from the wound to provide exposure. A cyclodialysis spatula was used to carefully reposit the prolapsed iris tissue back into the anterior chamber. The anterior chamber remained formed and the iris tissue easily resumed its normal position. The pupil appeared round. An 8-0 nylon suture was used to close the scleral portion of the laceration. Three sutures were placed using the 8-0 nylon suture. Then 9-0 nylon suture was used to close the limbal portion of the wound. After the wound appeared closed, a Superblade was used to create a paracentesis at approximately 2 o'clock. BSS was injected through the paracentesis to fill the anterior chamber. The wound was checked and found to be watertight. No leaks were observed. An 8-0 Vicryl suture was used to reposition the conjunctiva and close the wound. Three 8-0 Vicryl sutures were placed in the conjunctiva. All scleral sutures were completely covered. The anterior chamber remained formed and the pupil remained round and appeared so at the end of the case. Subconjunctival injections of Ancef and dexamethasone were given at the end of the case as well as Tobradex ointment. The lid speculum was carefully removed. The drapes were carefully removed. Sterile saline was used to clean around the XXX eye as well as the rest of the face. The area was carefully dried and an eye patch and shield were taped over the XXX eye. The patient was awakened from general anesthesia without difficulty. (S)he was taken to the recovery area in good condition. There were no complications.","ophthalmology, ruptured globe, bss, subconjunctival, bleeding, conjunctiva, eye patch, infection, limbus, loss of the eye, loss of vision, re-operation, scleral laceration, supranasal quadrant, uveal prolapse, wire lid speculum, iris tissue, anterior chamber, laceration, iris, chamber, ruptured, globe, eye,"
 Small office note on premature retina and vitreous., Ophthalmology, Premature retina and vitreous ,"OCULAR FINDINGS: , Anterior chamber space:  Cornea, iris, lens, and pupils all unremarkable on gross examination in each eye.,Ocular adnexal spaces appear very good in each eye.,Cyclomydril x2 was used to dilate the pupil in each eye.,Medial spaces are clear and the periphery is still hazy in each eye.,Ocular disc space, normal size and shape with a pink color with clear margin in each eye.,Macular spaces are normal in appearance for the age in each eye.,Posterior pole.  No dilated blood vessels seen in each eye.,Periphery:  The peripheral retina is still hazy and retinopathy of prematurity cannot be ruled out at this time in each eye.,IMPRESSION:  ,Premature retina and vitreous, each eye.,PLAN:  ,Recheck in two weeks.,","ophthalmology, eye ocular, premature retina, pupils, periphery, premature, vitreous, retina, eye,"
 Repair of one-half full-thickness left lower lid defect by tarsoconjunctival pedicle flap from left upper lid to left lower lid and repair of left upper and lateral canthal defect by primary approximation to lateral canthal tendon remnant., Ophthalmology, Repair of Canthal & Lid Defect  ,"PREOPERATIVE DIAGNOSIS: , Status post Mohs resection epithelial skin malignancy left lower lid, left lateral canthus, and left upper lid.,POSTOPERATIVE DIAGNOSIS: , Status post Mohs resection epithelial skin malignancy left lower lid, left lateral canthus, and left upper lid.,PROCEDURES:,1.  Repair of one-half full-thickness left lower lid defect by tarsoconjunctival pedicle flap from left upper lid to left lower lid.,2.  Repair of left upper and lateral canthal defect by primary approximation to lateral canthal tendon remnant.,ASSISTANT: , None.,ANESTHESIA: , Attended local by Strickland and Associates.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed in supine position.  Dressing was removed from the left eye, which revealed the defect as noted above.  After systemic administration of alfentanil, local anesthetic was infiltrated into the left upper lid, left lateral canthus, and left lower eyelid.  The patient was prepped and draped in the usual ophthalmic fashion.  Protective scleral shell was placed in the left eye.  A 4-0 silk traction sutures placed through the upper eyelid margin.  The medial aspect of the remaining lower eyelid was freshened with straight iris scissors and fibrin was removed from the inferior aspect of the wound.  The eyelid was everted and a tarsoconjunctival pedicle flap was developed by incision of the tarsus approximately 3-1/2-4 mm from the lid margin the full width of the eyelid.  Relaxing incisions were made both medially and laterally and Mueller's muscle was subsequently dissected free from the superior tarsal border.  The tarsoconjunctival pedicle was then anchored to the lateral orbital rim with two interrupted 6-0 Vicryl sutures and one 4-0 Vicryl suture.  The protective scleral shell was removed from the eye.  The medial aspect of the eyelid was advanced temporally.  The tarsoconjunctival pedicle was then cut to size and the tarsus was anchored to the medial aspect of the eyelid with multiple interrupted 6-0 Vicryl sutures.  The conjunctiva and lower lid retractors were attached to the advanced tarsal edge with a running 7-0 Vicryl suture.  The upper eyelid wound was present.  It was advanced to the advanced tarsoconjunctival pedicle temporally.  The conjunctival pedicle was slightly trimmed to make a lateral canthal tendon and the upper eyelid was advanced to the tarsoconjunctival pedicle temporally with an interrupted 6-0 Vicryl suture, it was then secured to the lateral orbital rim with two interrupted 6-0 Vicryl sutures.  Skin muscle flap was then elevated, was draped superiorly and nasally and was anchored to the medial aspect of the eyelid with interrupted 7-0 Vicryl sutures.  Burrows triangle was removed as was necessary to create smooth wound closure, which was closed with interrupted 7-0 Vicryl suture.  Temporally the orbicularis was resuspended from the advanced skin muscle flap with interrupted 6-0 Vicryl suture to the periosteum overlying the lateral orbital rim.  The skin muscle flap was secured to the underlying tarsoconjunctival pedicle with vertical mattress sutures of 7-0 Vicryl followed by wound closure temporally with interrupted 7-0 Vicryl suture with removal of a burrow's triangle as was necessary to create smooth wound closure.  Erythromycin ointment was then applied to the eye and to the wound followed by multiple eye pads with moderate pressure.  The patient tolerated the procedure well and left the operating room in excellent condition.  There were no apparent complications.","ophthalmology, mohs resection epithelial skin, lid left lateral canthus, lateral canthal defect, tarsoconjunctival pedicle flap, lateral canthal tendon, skin muscle flap, interrupted vicryl sutures, canthal defect, mohs resection, lid defect, pedicle flap, canthal tendon, lateral canthus, upper eyelid, lateral orbital, eyelid, vicryl, sutures, repair, eye, canthal, defect, tarsoconjunctival, pedicle"
" Macular edema, right eye.  Insertion of radioactive plaque, right eye with lateral canthotomy.  The plaque was positioned on the scleral surface immediately behind the macula and secured with two sutures of 5-0 Dacron.  The placement was confirmed with indirect ophthalmoscopy. ", Ophthalmology, Radioactive Plaque - Insertion ,"PREOPERATIVE DIAGNOSIS:,  Macular edema, right eye.,POSTOPERATIVE DIAGNOSIS:  ,Macular edema, right eye.,TITLE OF OPERATION: , Insertion of radioactive plaque, right eye with lateral canthotomy.,OPERATIVE PROCEDURE IN DETAIL:  ,The patient was prepped and draped in the usual manner for a local eye procedure.  Initially, a 5 cc retrobulbar injection of 2% Xylocaine was done.  Then, a lid speculum was inserted and the conjunctiva was incised 4 mm posterior to the limbus.  A 2-0 silk traction suture was placed around the insertion of the lateral rectus muscle and, with gentle traction, the temporal one-half of the globe was exposed.  The plaque was positioned on the scleral surface immediately behind the macula and secured with two sutures of 5-0 Dacron.  The placement was confirmed with indirect ophthalmoscopy.  Next, the eye was irrigated with Neosporin and the conjunctiva was closed with 6-0 plain catgut.  The intraocular pressure was found to be within normal limits.  An eye patch was applied and the patient was sent to the Recovery Room in good condition.  A lateral canthotomy had been done.","ophthalmology, canthotomy, ophthalmoscopy, radioactive plaque, scleral surface, macular edema, lateral canthotomy, macular"
" Bilateral rectus recession with the microscopic control, 8 mm, both eyes.", Ophthalmology, Rectus Recession ,"PREOPERATIVE DIAGNOSIS:,  Congenital bilateral esotropia, 42 prism diopters.,PROCEDURE:,  Bilateral rectus recession with the microscopic control, 8 mm, both eyes.,POSTOPERATIVE DIAGNOSIS: , Congenital bilateral esotropia, 42 prism diopters.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL: , The patient was taken to the Surgery Room and placed in the supine position.  The general anesthesia was achieved with intubation with no problems.  Both eyes were prepped and draped in usual manner.  The attention was turned the right eye and a hole was made in the drape and a self-retaining eye speculum was placed ensuring eyelash in the eye drape.  The microscope was focused on the palpebral limbus and the eyeball was rotated medially and laterally with no problem.  The eyeball rotated medially and upwards by holding the limbus at 7 o'clock position.  Inferior fornix conjunctival incision was made and Tenons capsule buttonholed.  The lateral rectus muscle was engaged over the muscle hook and the Tenons capsule was retracted with the tip of the muscle hook.  The Tenons capsule was buttonholed.  The tip of the muscle hook and Tenons capsule was cleaned from the insertion of the muscle.  __________ extension of the muscle was excised.  The 7-0 Vicryl sutures were placed at the insertion of the muscle and double locked at the upper and lower borders.  The muscle was disinserted from original insertion.  The suture was passed 8 mm posterior to the insertion of the muscle in double sewed fashion.  The suture was pulled, tied, and cut.  The muscle was in good position.  The conjunctiva was closed with 7-0 Vicryl suture in running fashion.  The suture was pulled, tied, and cut.  The eye speculum was taken out.,Similar procedure performed on the left rectus muscle and it was recessed by 8 mm from its original insertion.  The suture was pulled, tied and cut.  The eye speculum was taken out after the conjunctiva was sewed up and the suture was cut.  TobraDex eye drops were instilled in both eyes and the patient extubated and was in good condition.  To be seen in the office in 1 week.","ophthalmology, congenital bilateral esotropia, esotropia, tenons capsule, rectus muscle, bilateral rectus recession, rectus recession, eye speculum, muscle hook, eyes, muscle, rectus, "
" Cervical facial rhytidectomy.  Quadrilateral blepharoplasty.  Autologous fat injection to the upper lip - donor site, abdomen.", Ophthalmology, Rhytidectomy & Blepharoplasty ,"PREOPERATIVE DIAGNOSIS:,  Ageing face.,POSTOPERATIVE DIAGNOSIS: , Ageing face.,OPERATIVE PROCEDURE:,1.  Cervical facial rhytidectomy.,2.  Quadrilateral blepharoplasty.,3.  Autologous fat injection to the upper lip.,OPERATIONS PERFORMED:,1.  Cervical facial rhytidectomy.,2.  Quadrilateral blepharoplasty.,3.  Autologous fat injection to the upper lip - donor site, abdomen.,INDICATION:  ,This is a 62-year-old female for the above-planned procedure.  She was seen in the preoperative holding area where the surgery was discussed accordingly and markings were applied.  Full informed consent noted and chemistries were on her chart and preoperative evaluation was negative.,PROCEDURE: , The patient was brought to the operative room under satisfaction, and she was placed supine on the OR table.  Administered general endotracheal anesthesia followed by sterile prep and drape at the patient's face and abdomen.  This included the neck accordingly.,Two platysmal sling application and operating headlight were utilized.  Hemostasis was controlled with the pinpoint cautery along with suction Bovie cautery.,The first procedure was performed was that of a quadrilateral blepharoplasty.  Markers were applied to both upper lids in symmetrical fashion.  The skin was excised from the right upper lid first followed by appropriate muscle resection.  Minimal fat removed from the medial upper portion of the eyelid.  Hemostasis was controlled with the quadrilateral tip needle; closure with a running 7-0 nylon suture.  Attention was then turned to the lower lid.  A classic skin muscle flap was created accordingly.  Fat was resected from the middle, medial, and lateral quadrant.  The fat was allowed to open drain the arcus marginalis for appropriate contour.  Hemostasis was controlled with the pinpoint cautery accordingly.  Skin was redraped with a conservative amount resected.  Running closure with 7-0 nylon was accomplished without difficulty.  The exact same procedure was repeated on the left upper and lower lid.,After completion of this portion of the procedure, the lag lid was again placed in the eyes.  Eye mass was likewise clamped.  Attention was turned to her face with plans for cervical facial rhytidectomy portion of the procedure.  The right face was first operated.  It was injected with a 0.25% Marcaine 1:200,000 adrenaline.  A submental incision was created followed by suction lipectomy and very minimal amounts of ***** in 3 mm and 2-mm suction cannula.  She had minimal subcutaneous extra fat as noted.  Attention was then turned to the incision which was in the temporal hairline in curvilinear fashion following the pretragal incision to the postauricular sulcus and into and along the post-occipital hairline.  The flap was elevated without difficulty with various facelift scissors.  Hemostasis was controlled again with a pinpoint cautery as well as suction Bovie cautery.,The exact same elevation of skin flap was accomplished on the left face followed by the anterosuperior submental space with approximately 4-cm incision.  Rectus plication in the midline with a running 4-0 Mersilene was followed by some transaction of the platysma above the hairline with coagulation, cutting, and cautery.  The submental incision was closed with a running 7-0 nylon over 5-0 Monocryl.,Attention was then turned to closure of the bilateral facelift incisions after appropriate SMAS plication.  The left side of face was first closed followed by interrupted SMAS plication utilizing 4-0 wide Mersilene.  The skin was draped appropriately and appropriate tissue was resected.  A 7-mm 9-0 French drain was utilized accordingly prior to closure of the skin with interrupted 4-0 Monocryl in the post-occipital region followed by running 5-0 nylon in the postauricular surface.  Preauricular interrupted 5-0 Monocryl was followed by running 7-0 nylon.  The hairline temporal incision was closed with running 5-0 nylon.  The exact same closure was accomplished on the right side of the face with a same size 7-mm French drain.,The patient's dressing consisted of Adaptic Polysporin ointment followed by Kerlix wrap with a 3-inch Ace.,The lips and mouth were sterilely prepped and draped accordingly after application of the head drape dressing as described.  Suction lipectomy was followed in the abdomen with sterile conditions were prepped and draped accordingly.  Approximately 2.5 to 3 cc of autologous fat was injected into the upper lip of the remaining cutaneous line with blunt tip dissector after having washed the fat with saline accordingly.  Tuberculin syringes were utilized on the injection utilizing a larger blunt tip needle for the actual injection procedure.  The incision site was closed with 7-0 nylon.,The patient tolerated the procedure well and was transferred to the recovery room in stable condition with Foley catheter in position.,The patient will be admitted for overnight short stay through the cosmetic package procedure.  She will be discharged in the morning.,Estimated blood loss was less than 75 cc.  No complications noted, and the patient tolerated the procedure well.","ophthalmology, ageing face, adaptic polysporin ointment, autologous fat injection, bovie cautery, kerlix wrap, smas plication, arcus marginalis, blepharoplasty, facelift, platysmal sling, quadrilateral, rhytidectomy, right upper lid, cervical facial rhytidectomy, pinpoint cautery, facial rhytidectomy, quadrilateral blepharoplasty, running nylon, autologous, "
" Radioactive plaque macular edema.  Removal of radioactive plaque, right eye with lateral canthotomy.  A lid speculum was applied and the conjunctiva was opened 4 mm from the limbus.  A 2-0 traction suture was passed around the insertion of the lateral rectus and the temporal one-half of the globe was exposed.", Ophthalmology, Radioactive Plaque - Removal ,"PREOPERATIVE DIAGNOSIS: , Radioactive plaque macular edema.,POSTOPERATIVE DIAGNOSIS:,  Radioactive plaque macular edema.,TITLE OF OPERATION:,  Removal of radioactive plaque, right eye with lateral canthotomy.,OPERATIVE PROCEDURE IN DETAIL: , The patient was prepped and draped in the usual manner for a local eye procedure.  Then a retrobulbar injection of 2% Xylocaine was performed.  A lid speculum was applied and the conjunctiva was opened 4 mm from the limbus.  A 2-0 traction suture was passed around the insertion of the lateral rectus and the temporal one-half of the globe was exposed.  Next, the plaque was identified and the two scleral sutures were removed.  The plaque was gently extracted and the conjunctiva was re-sutured with 6-0 catgut, following removal of the traction suture.  The fundus was inspected with direct ophthalmoscopy.  An eye patch was applied following Neosporin solution irrigation.  The patient was sent to the recovery room in good condition.  A lateral canthotomy had been done.","ophthalmology, conjunctiva, eye patch, ophthalmoscopy, radioactive plaque, traction, suture, eye, radioactive, plaque"
" Phacoemulsification of cataract, extraocular lens implant in left eye.", Ophthalmology, Phacoemulsification of Cataract - 1 ,"PREOPERATIVE DIAGNOSES:,1.  Senile nuclear cataract, left eye.,2.  Senile cortical cataract, left eye., ,POSTOPERATIVE DIAGNOSES:,1.  Senile nuclear cataract, left eye.,2.  Senile cortical cataract, left eye., ,PROCEDURES: , Phacoemulsification of cataract, extraocular lens implant in left eye., ,LENS IMPLANT USED:,  Alcon, model SN60WF, power of 22.5 diopters., ,PHACOEMULSIFICATION TIME:,  1 minute 41 seconds at 44.4% power., ,INDICATIONS FOR PROCEDURE: , This patient has a visually significant cataract in the affected eye with the best corrected visual acuity under moderate glare conditions worse than 20/40.  The patient complains of difficulties with glare in performing activities of daily living.,INFORMED CONSENT:,  The risks, benefits and alternatives of the procedure were discussed with the patient in the office prior to scheduling surgery.  All questions from the patient were answered after the surgical procedure was explained in detail.  The risks of the procedure as explained to the patient include, but are not limited to, pain, infection, bleeding, loss of vision, retinal detachment, need for further surgery, loss of lens nucleus, double vision, etc.  Alternative of the procedure is to do nothing or seek a second opinion.  Informed consent for this procedure was obtained from the patient.,OPERATIVE TECHNIQUE: , The patient was brought to the holding area.  Previously, an intravenous infusion was begun at a keep vein open rate.  After adequate sedation by the anesthesia department (under monitored anesthesia care conditions), a peribulbar and retrobulbar block was given around the operative eye.  A total of 10 mL mixture with a 70/30 mixture of 2% Xylocaine without epinephrine and 0.75% bupivacaine without epinephrine.  An adequate amount of anesthetic was infused around the eye without giving excessive tension to the eye or excessive chemosis to the periorbital area.  Manual pressure and a Honan balloon were placed over the eye for approximately 2 minutes after injection and adequate akinesia and anesthesia was noted.  Vital sign monitors were detached from the patient.  The patient was moved to the operative suite and the same monitors were reattached.  The periocular area was cleansed, dried, prepped and draped in the usual sterile manner for ocular surgery.  The speculum was set into place and the operative microscope was brought over the eye.  The eye was examined.  Adequate mydriasis was observed and a visually significant cataract was noted on the visual axis.,A temporal clear corneal incision was begun using a crescent blade with an initial groove incision made partial thickness through the temporal clear cornea.  Then a pocket incision was created without entering the anterior chamber of the eye.  Two peripheral paracentesis ports were created on each side of the initial incision site.  Viscoelastic was used to deepen the anterior chamber of the eye.  A 2.65 mm keratome was then used to complete the corneal valve incision.  A cystitome was bent and created using a tuberculin syringe needle.  It was placed in the anterior chamber of the eye.  A continuous curvilinear capsulorrhexis was begun.  It was completed using O'Gawa Utrata forceps.  A balanced salt solution on the irrigating cannula was placed through the paracentesis port of the eye to affect hydrodissection and hydrodelineation of the lens nucleus.  The lens nucleus was noted to be freely mobile in the bag.,The phacoemulsification tip was placed into the anterior chamber of the eye.  The lens nucleus was phacoemulsified and aspirated in a divide-and-conquer technique.  All remaining cortical elements were removed from the eye using irrigation and aspiration using a bimanual technique through the paracentesis ports.  The posterior capsule remained intact throughout the entire procedure.  Provisc was used to deepen the anterior chamber of the eye.  A crescent blade was used to expand the internal aspect of the wound.  The lens was taken from its container and inspected.  No defects were found.  The lens power selected was compared with the surgery worksheet from Dr. X's office.  The lens was placed in an inserter under Provisc.  It was placed through the wound, into the capsular bag and extruded gently from the inserter.  It was noted to be adequately centered in the capsular bag using a Sinskey hook.  The remaining viscoelastic was removed from the eye with irrigation an aspiration through the paracentesis side ports using a bimanual technique.  The eye was noted to be inflated without overinflation.  The wounds were tested for leaks, none were found.  Five drops dilute Betadine solution was placed over the eye.  The eye was irrigated.  The speculum was removed.  The drapes were removed.  The periocular area was cleaned and dried.  Maxitrol ophthalmic ointment was placed into the interpalpebral space.  A semi-pressure patch and shield was placed over the eye.  The patient was taken to the floor in stable and satisfactory condition, was given detailed written instructions and asked to follow up with Dr. X tomorrow morning in the office.","ophthalmology, senile nuclear cataract, senile, phacoemulsification, phacoemulsification of cataract, lens implant, lens nucleus, anterior chamber, lens, alcon, eye, cataract, "
 Sample post dilation patient instructions., Ophthalmology, Post Dilation Instructions ,"The effects of eye dilation drops will gradually decrease. It typically takes TWO to SIX HOURS for the effects to wear off. During this time, reading may be more difficult and sensitivity to light may increase. For a short time, wearing sunglasses may help.","ophthalmology, dilation drops, eye dilation, sunglasses, blindness, eye examinations, dilation, eyesNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Phacoemulsification with posterior chamber intraocular lens insertion., Ophthalmology, Phacoemulsification & Lens Implantation - 6 ,"PROCEDURE: , Phacoemulsification with posterior chamber intraocular lens insertion.,INTRAOCULAR LENS: , Allergan Medical Optics model S140MB XXX diopter chamber lens.,PHACO TIME:,  Not known.,ANESTHESIA: , Retrobulbar block with local minimal anesthesia care.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS:,  None.,DESCRIPTION OF PROCEDURE: , While the patient was in the holding area, the operative eye was dilated with four sets of drops.  The drops consisted of Cyclogyl 1%, Acular, and Neo-Synephrine 2.5 %.  Additionally, a peripheral IV was established by the anesthesia team.  Once the eye was dilated, the patient was wheeled to the operating suite.,Inside the operating suite, central monitoring lines were established.  Through the peripheral IV, the patient received intravenous sedation consisting of Propofol and once somnolent from this, retrobulbar block was administered consisting of 2 cc's of 2% Xylocaine  plain with 150 units of Wydase.  The block was administered in a retrobulbar fashion using an Atkinson needle and a good block was obtained.  Digital pressure was applied for approximately five minutes.,The patient was then prepped and draped in the usual sterile fashion for ophthalmological surgery.  A Betadine prep was carried out of the face, lids, and eye.  During the draping process, care was taken to isolate the lashes.  A wire lid speculum was inserted to maintain patency of the lids.  With benefit of the operating microscope, a diamond blade was used to place a groove temporally.  A paracentesis wound was also placed temporally using the same blade.  Viscoelastic was then instilled into the anterior chamber through the paracentesis site and a 2.8 mm. diamond keratome was used to enter the anterior chamber through the previously placed groove.  The cystotome was then inserted into the eye and circular capsulorhexis was performed without difficulty.  The capsular remnant was withdrawn from the eye using long angled McPherson forceps.  Balanced salt solution with a blunt cannula was then inserted into the eye and hydrodissection was performed.  The lens was noted to rotate freely within the capsular bag.  The phaco instrument was then inserted into the eye using the Kelman tip.  The lens nucleus was grooved and broken into two halves.  One of the halves was in turn broken into quarters.  Each of the quarters was removed from the eye using the memory 2 settings and phacoemulsification.  Attention was then turned toward the remaining half of the nucleus and this, in turn, was removed as well, with the splitting maneuver.  Once the nucleus had been removed from the eye, the irrigating and aspirating tip was inserted and the cortical material was stripped out in sections.  Once the cortical material had been completely removed, a diamond dusted cannula was inserted into the eye and the posterior capsule was polished.  Viscoelastic was again instilled into the capsular bag as well as the anterior chamber.  The wound was enlarged slightly using the diamond keratome.  The above described intraocular lens was folded outside the eye using a mustache fold and inserted using folding forceps.  Once inside the eye, the lens was unfolded into the capsular bag in a single maneuver.  It was noted to be centered nicely.  The viscoelastic was then withdrawn from the eye using the irrigating and aspirating tip of the phaco machine.,Next, Miostat was instilled into the operative eye and the wound was checked for water tightness.  It was found to be such.  After removing the drapes and speculum, TobraDex drops were instilled into the operative eye and a gauze patch and Fox protective shield were placed over the eye.,The patient tolerated the procedure extremely well and was taken to the recovery area in good condition.  The patient is scheduled to be seen in follow-up in the office tomorrow, but should any complications arise this evening, the patient is to contact me immediately.","ophthalmology, diopter, intraocular lens insertio, phacoemulsification, posterior chamber, diamond keratome, anterior chamber, capsular bag, intraocular lens, intraocular, allergan, eye, capsular, chamber, lens,"
" Phacoemulsification of cataract and posterior chamber lens implant, right eye.", Ophthalmology, Phacoemulsification & Lens Implantation - 4 ,"OPERATION PERFORMED:, Phacoemulsification of cataract and posterior chamber lens implant, right eye., ,ANESTHESIA:, Retrobulbar nerve block, right eye, ,DESCRIPTION OF OPERATION: ,The patient was brought to the operating room where local anesthetic was administered to the right eye followed by a dilute drop of Betadine and a Honan balloon.  Once anesthesia was achieved, the right eye was prepped with Betadine, rinsed with saline, and draped in a sterile fashion.  A lid speculum was placed and 4-0 silk sutures passed under the superior and inferior rectus muscles stabilizing the globe.  A fornix-based conjunctival flap was prepared superiorly from 10 to 12 o'clock and episcleral vessels were cauterized using a wet-field.  A surgical groove was applied with a 69 Beaver blade 1 mm posterior to the limbus in a frown configuration in the 10 to 12 o'clock position.  A lamellar dissection was carried anteriorly to clear cornea using a crescent knife.  A stab incision was applied with a Superblade at the 2 o'clock position at the limbus.  The chamber was also entered through the lamellar groove using a 3-mm keratome in a beveled fashion.  Viscoat was injected into the chamber and an anterior capsulorrhexis performed.  Hydrodissection was used to delineate the nucleus and the phacoemulsification tip was inserted into the chamber.  A deep linear groove was dissected through the nucleus vertically and the nucleus was rotated 90 degrees with the assistance of a spatula through the side-port incision.  A second groove was dissected perpendicular to the first and the nucleus was fractured into quadrants.  Each quadrant was emulsified under burst power within the capsular bag.  The epinuclear bowl was manipulated with vacuum, flipped into the iris plane, and emulsified under pulse power.  I&A was used to aspirate cortex from the capsular bag.  A scratcher was used to polish the capsule, and Viscoat was injected inflating the capsular bag and chamber.  The wound was enlarged with a shortcut blade to 5.5 mm.  The intraocular lens was examined, found to be adequate, irrigated with balanced salt, and inserted into the capsular bag.  The lens centralized nicely and Viscoat was removed using the I&A.  Balanced salt was injected through the side-port incision.  The wound was tested, found to be secure, and a single 10-0 nylon suture was applied to the wound with the knot buried within the sclera.  The conjunctiva was pulled over the suture, and Ancef 50 mg and Decadron 4 mg were injected sub-Tenon in the inferonasal and inferotemporal quadrants.  Maxitrol ointment was applied topically followed by an eye pad and shield.  The patient tolerated the procedure and was taken from the operating room in good condition.","ophthalmology, retrobulbar nerve block, posterior chamber lens implant, phacoemulsification of cataract, lens implantation, capsular bag, cataract, phacoemulsification, nucleus, capsular, lens, eye"
 Phacoemulsification with posterior chamber intraocular lens implant in the right eye., Ophthalmology, Phacoemulsification & Lens Implantation - 7 ,"TITLE OF OPERATION: , Phacoemulsification with posterior chamber intraocular lens implant in the right eye.,INDICATION FOR SURGERY: , The patient is a 27-year-old male who sustained an open globe injury as a child.  He subsequently developed a retinal detachment in 2005 and now has silicone oil in the anterior chamber of the right eye as well as a dense cataract.  He is undergoing silicone oil removal as well as concurrent cataract extraction with lens implant in the right eye.,PREOP DIAGNOSIS:,1.  History of open globe to the right eye.,2.  History of retinal detachment status post repair in the right eye.,3.  Silicone oil in anterior chamber.,4.  Dense silicone oil cataract in the right eye obscuring the view of the posterior pole.,POSTOP DIAGNOSIS:,1.  History of open globe to the right eye.,2.  History of retinal detachment status post repair in the right eye.,3.  Silicone oil in anterior chamber.,4.  Dense silicone oil cataract in the right eye obscuring the view of the posterior pole.,ANESTHESIA: , General.,PROS DEV IMPLANT: , ABC Laboratories posterior chamber intraocular lens, 21.0 diopters, serial number 123456.,NARRATIVE: , Informed consent was obtained.  All questions were answered.  The patient was brought to preoperative holding area where the operative right eye was marked.  He was brought to the operating room and placed in the supine position.  EKG leads were placed.  General anesthesia was induced by the anesthesia service.  A time-out was called to confirm the procedure and operative eye.  The right operative eye was disinfected and draped in a standard fashion for eye surgery.  A lid speculum was placed.  The vitreoretinal team placed the infusion cannula after performing a peritomy.  At this point in the case, the patient was turned over to the cornea service with Mrs. Jun.  A paracentesis was made at the approximately 3 o'clock position.  Healon was placed into the anterior chamber.  The diamond keratome was used to make a vertical groove incision just inside the limbus at the 108-degree axis.  This incision was then shelved anteriorly and used to enter the anterior chamber.  The Utrata forceps were used to complete a continuous circular capsulorrhexis after incision of the capsule with the cystotome.  Hydrodissection was performed.  The lens nucleus was removed using phacoemulsification and irrigation and aspiration.  Lens cortex also was removed using irrigation and aspiration.  Viscoelastic was placed to inflate the capsular remnant.  The diamond knife was used to enlarge the phaco incision.  Intraocular lens was selected from preoperative calculations, placed in the injector system, and inserted into the capsule without difficulty.  The trailing haptic was placed using the Sheets forceps and the Barraquer sweep to push the IOL optic posteriorly as the trailing haptic was placed.  The anterior cornea wound was sutured along with the paracentesis after irrigation and aspiration was performed to remove remaining viscoelastic from the anterior chamber.  This was done without difficulty.  The anterior chamber was secured and watertight at the end of the procedure.  Intraocular pressure was satisfactory.  The patient tolerated the procedure well and then was turned over to the retina service in good condition.  They will dictate a separate note.","ophthalmology, phacoemulsification, intraocular lens implant, posterior chamber, chamber, eye, intraocular, lens,"
" Cataract, right eye.  Phacoemulsification of cataract with posterior chamber intraocular lens, right eye.", Ophthalmology, Phacoemulsification Of Cataract - 2 ,"PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:,  Cataract, right eye.,PROCEDURE:  ,Phacoemulsification of cataract with posterior chamber intraocular lens, right eye.,ANESTHESIA:  ,Topical.,COMPLICATIONS:  ,None.,PROCEDURE IN DETAIL:  ,The patient was identified.  The operative eye was treated with tetracaine 1% topically in the preoperative holding area.  The patient was taken to the operating room and prepped and draped in the usual sterile fashion for ophthalmic surgery.,Attention was turned to the left/right eye.  The lashes were tapped using Steri-Strips to prevent blinking.  A lid speculum was placed to prevent lid closure.  Anesthesia was verified.  Then, a 3.5-mm groove was created with a diamond blade temporarily.  This was beveled with a crescent blade, and the anterior chamber was entered with a 3.2-mm keratome in the iris plane.  A 1% nonpreserved lidocaine was injected intracamerally and followed with Viscoat.  A paracentesis was made.  A round capsulorrhexis was performed.  The anterior capsular flap was removed.  Hydrodelineation and dissection were followed by phacoemulsification of the cataract using a chop technique.  The irrigating-aspirating machine was used to clear residual cortex.  The Provisc was instilled.  An SN60WS diopter intraocular lens was inserted into the capsular bag, and the position was verified.  The viscoelastic was removed.  Intraocular lens remained well centered.  The incision was hydrated, and the anterior chamber pressure was checked with tactile pressure and found to be normal.  The anterior chamber remained deep, and there was no wound leak.  The patient tolerated the procedure well.  The eye was dressed with Maxitrol ointment.  A tight patch and Fox shield were placed.  The patient returned to the recovery room in excellent condition with stable vital signs and no eye pain.","ophthalmology, cataract, posterior chamber, intraocular lens, hydrodelineation, phacoemulsification of cataract, phacoemulsification, lens, anterior, chamber, eye, intraocular "
" Right phacoemulsification of cataract with intraocular lens implantation - Cataract, right eye.", Ophthalmology, Phacoemulsification of Cataract ,"PREOPERATIVE DIAGNOSIS (ES):, Cataract, right eye.,POSTOPERATIVE DIAGNOSIS (ES):, Cataract, right eye.,PROCEDURE:, Right phacoemulsification of cataract with intraocular lens implantation.,DESCRIPTION OF THE OPERATION:, Under topical anesthesia with monitored anesthesia care, the patient was prepped, draped and positioned under the operating microscope. A lid speculum was applied to the right eye, and a stab incision into the anterior chamber was done close to the limbus at about the 1 o'clock position with a Superblade, and Xylocaine 1% preservative free 0.25 mL was injected into the anterior chamber, which was then followed by Healon to deepen the anterior chamber. Using a keratome, another stab incision was done close to the limbus at about the 9 o'clock position and with the Utrata forceps, anterior capsulorrhexis was performed, and the torn anterior capsule was totally removed. Hydrodissection and hydrodelineation were performed with the tuberculin syringe filled with BSS. The tip of the phaco unit was introduced into the anterior chamber, and anterior sculpting of the nucleus was performed until about more than two-thirds of the nucleus was removed. Using the phaco tip and the Drysdale hook, the nucleus was broken up into 4 pieces and then phacoemulsified.,The phaco tip was then exchanged for the aspiration/irrigation tip, and cortical materials were aspirated. Posterior capsule was polished with a curette polisher, and Healon was injected into the capsular bag. Using the Monarch intraocular lens inserter, the posterior chamber intraocular lens model SN60WF power +19.50 was placed into the inserter after applying some Healon, and the tip of the inserter was gently introduced through the cornea tunnel wound, into the capsular bag and then the intraocular lens was then inserted inferior haptic first into the back and the superior haptic was placed into the bag with the same instrument. Intraocular lens was then rotated about half a turn with a collar button hook. Healon was removed with the aspiration/irrigation tip, and balanced salt solution was injected through the side port to deepen the anterior chamber. It was found that there was no leakage of fluid through the cornea tunnel wound. For this reason, no suture was applied. Vigamox, Econopred and Nevanac eye drops were instilled and the eye was covered with a perforated shield. The patient tolerated the procedure well. There were no complications.","ophthalmology, cataract, implantation, intraocular, intraocular lens, lens implantation, phacoemulsification, capsular bag, capsule, intraocular lens implantation, cornea tunnel wound, phacoemulsification of cataract, cornea tunnel, anterior chamber, anesthesia, cornea, lens, chamber,"
" Phacoemulsification with IOL, right eye.  Cataract, right eye.  A lid speculum was placed in the right eye after which a supersharp was used to make a stab incision at the 4 o'clock position through which 2% preservative-free Xylocaine was injected followed by Viscoat.", Ophthalmology, Phacoemulsification & Lens Implantation - 5 ,"PREOPERATIVE DIAGNOSIS:,  Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:,  Cataract, right eye.,OPERATION PERFORMED: , Phacoemulsification with IOL, right eye.,ANESTHESIA:,  Topical with MAC.,COMPLICATIONS,:  None.,ESTIMATED BLOOD LOSS: , None.,PROCEDURE IN DETAIL:  After appropriate consent was obtained, the patient was brought to the operating room and then prepared and draped in the usual sterile fashion per Ophthalmology.  A lid speculum was placed in the right eye after which a supersharp was used to make a stab incision at the 4 o'clock position through which 2% preservative-free Xylocaine was injected followed by Viscoat.  A 2.75-mm keratome then made a stab incision at the 2 o'clock position through which an anterior capsulorrhexis was performed using cystotome and Utrata.  BSS on blunt cannula, hydrodissector, and spun the nucleus after which phacoemulsification divided the nucleus in 3 quadrants each was subsequently cracked and removed through phacoemulsification I&A.  Healon was injected into the posterior capsule and a XXX lens was then placed with a shooter into the posterior capsule and rotated into position with I&A, which then removed all remaining cortex as well as viscoelastic material.  BSS on blunt cannula hydrated all wounds, which were noted to be free of leak and lid speculum was removed.  Under microscope, the anterior chamber being soft and well formed.  Pred Forte, Vigamox, and Iopidine were placed in the eye.  A shield was placed over the eye.  The patient was followed to recovery where he was noted to be in good condition.","ophthalmology, lid speculum, lens, iol, viscoat, posterior, capsule, cataract, speculum, incision, phacoemulsification "
" Cataract, right eye.  Phacoemulsification with intraocular lens placement, right eye.", Ophthalmology, Phacoemulsification & Lens Implantation - 3 ,"PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:,  Cataract, right eye.,PROCEDURE:,  Phacoemulsification with intraocular lens placement, right eye.,ANESTHESIA: , Monitored anesthesia care,ESTIMATED BLOOD LOSS: , None,COMPLICATIONS:,  None,SPECIMENS:,  None,PROCEDURE IN DETAIL: , The patient had previously been examined in the clinic and was found to have a visually significant cataract in the right eye.  The patient had the risks and benefits of surgery discussed.  After discussion, the patient decided to proceed and the consent was signed.,On the day of surgery, the patient was taken from the holding area to the operating suite by the anesthesiologist and monitors were placed.  Following this, the patient was sterilely prepped and draped in the usual fashion.  After this, a lid speculum was placed, preservative-free lidocaine drops were placed, and the SuperSharp blade was used to make an anterior chamber paracentesis.  Preservative-free lidocaine was instilled into the anterior chamber, and then Viscoat was instilled into the eye.,The 3.0 diamond keratome was then used to make a clear corneal temporal incision.  Following this, the cystotome was used to make a continuous tear-type capsulotomy.  After this, BSS was used to hydrodissect and hydrodelineate the lens.  The phacoemulsification unit was used to remove the cataract.  The I&A unit was used to remove the residual cortical material.  Following this, Provisc was used to inflate the bag.  The lens, a model SA60AT of ABCD diopters, serial #1234, was inserted into the bag and rotated into position using the Lester pusher.,After this, the residual Provisc was removed.  Michol was instilled and then the corneal wound was hydrated with BSS, and the wound was found to be watertight.  The lid speculum was removed.  Acular and Vigamox drops were placed.  The patient tolerated the procedure well without complications and will be followed up in the office tomorrow.","ophthalmology, capsulotomy, diopters, intraocular lens placement, lid speculum, anterior chamber, phacoemulsification, lens, cataract, intraocular"
 Phacoemulsification with intraocular lens placement.  A wire speculum was placed in the eye and then a clear corneal paracentesis site was made inferiorly with a 15-degree blade. , Ophthalmology, Phacoemulsification & Lens Implantation - 2 ,"PROCEDURE PERFORMED: , Phacoemulsification with intraocular lens placement.,ANESTHESIA TYPE:  ,Topical.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room after the eye was dilated with topical Mydriacyl and Neo-Synephrine eye drops.  Topical anesthetic drops were applied to the eye just prior to entering the operating room.  The eye was then prepped with a 5% Betadine solution injected in the usual sterile fashion.  A wire speculum was placed in the eye and then a clear corneal paracentesis site was made inferiorly with a 15-degree blade.  Lidocaine 1% preservative-free, 0.1 cc, was instilled into the anterior chamber through the clear corneal paracentesis site and this was followed with viscoelastic to fill the chamber.  A 2.8-mm keratome was used to create a self-sealing corneal incision temporally and then a bent capsulotomy needle was used to create an anterior capsular flap.  The Utrata forceps were used to complete a continuous tear capsulorrhexis, and hydrodissection and hydrodelineation of the nucleus was performed with BSS on a cannula.  Phacoemulsification in a quartering and cracking technique was used to remove the nucleus, and then the residual cortex was removed with the irrigation and aspiration unit.  Gentle vacuuming of the central posterior capsule was performed with the irrigation and aspiration unit.  The capsular bag was re-expanded with viscoelastic, and then the wound was opened to a 3.4-mm size to accommodate the intraocular lens insertion using an additional keratome blade.,The lens was folded, inserted into the capsular bag and then unfolded.  The trailing haptic was tucked underneath the anterior capsular rim.  The lens was shown to center very well.  The viscoelastic was removed with the irrigation and aspiration unit and one 10-0 nylon suture was placed across the incision after Miochol was injected into the anterior chamber to cause pupillary constriction.  The wound was shown to be watertight.  Therefore, TobraDex ointment was applied to the eye, an eye pad loosely applied, and a Fox shield taped firmly in place over the eye.,The patient tolerated the procedure well and left the operating room in good condition.","ophthalmology, keratome, phacoemulsification, cortex, tobradex, intraocular lens, aspiration unit, topical, chamber, viscoelastic, corneal, capsular, lens, intraocular, eye, "
" Cataract extraction with phacoemulsification and posterior chamber intraocular lens implantation.  Cataract, right eye.", Ophthalmology, Phacoemulsification & Cataract Extraction - 4 ,"PREOPERATIVE DIAGNOSIS:  ,Cataract, right eye.,POSTOPERATIVE DIAGNOSIS: , Cataract, right eye.,PROCEDURE: , Cataract extraction with phacoemulsification and posterior chamber intraocular lens implantation.  ME 30, AC 25.0 diopter lens was used.,COMPLICATIONS:  ,None.,ANESTHESIA: , Local 2%, peribulbar lidocaine.,PROCEDURE NOTE:  ,Right eye was prepped and draped in the normal sterile fashion.  Lid speculum placed in his right eye.  Paracentesis made supratemporally.  Viscoat injected into the anterior chamber.  A 2.8 mm metal keratome blade was then used to fashion a clear corneal beveled incision temporally.  This was followed by circular capsulorrhexis and hydrodissection of the nucleus would be assessed.  Nuclear material removed via phacoemulsification.  Residual cortex removed via irrigation and aspiration.  The posterior capsule was clear and intact.  Capsular bag was then filled with Provisc solution.  The wound was enlarged to 3.5 mm with the keratoma.  The lens was folded in place into the capsular bag.  Residual Provisc was irrigated from the eye.  The wound was secured with one 10-0 nylon suture.  The lid speculum was removed.  One drop of 5% povidone-iodine prep was placed into the eye as well as a drop of Vigamox and TobraDex ointment.  He had a patch placed on it.  The patient was transported to the recovery room in stable condition.","ophthalmology, provisc, intraocular lens implantation, intraocular lens, lens implantation, lid speculum, capsular bag, cataract extraction, phacoemulsification, cataract, intraocular"
" Visually significant cataract, left eye.  Phacoemulsification cataract extraction with intraocular lens implantation, left eye.  The patient was found to have a visually-significant cataract and, after discussion of the risks, benefits and alternatives to surgery, she elected to proceed with cataract extraction and lens implantation in this eye in efforts to improve her vision.", Ophthalmology, Phacoemulsification & Cataract Extraction - 1 ,"PREOPERATIVE DIAGNOSIS: , Visually significant cataract, left eye.,POSTOPERATIVE DIAGNOSIS: , Visually significant cataract, left eye.,ANESTHESIA: , Topical/MAC.,PROCEDURE: , Phacoemulsification cataract extraction with intraocular lens implantation, left eye (Alcon AcrySof, SN60AT, 23.0 D, serial #***).,COMPLICATIONS: , None.,INDICATIONS FOR SURGERY:  ,The patient is a 74-year-old woman with complaints of painless progressive loss of vision in her left eye.  She was found to have a visually-significant cataract and, after discussion of the risks, benefits and alternatives to surgery, she elected to proceed with cataract extraction and lens implantation in this eye in efforts to improve her vision.,PROCEDURE IN DETAIL:  ,The patient was verified in the preoperative holding area and the informed consent was reviewed and verified to be on the chart.  They were transported to the operative suite, accompanied by the anesthesia service, where appropriate cardiopulmonary monitoring was established.  MAC anesthesia was achieved, which was followed by topical anesthesia using 1% preservative-free tetracaine eye drops.  The patient was prepped and draped in the usual fashion for sterile ophthalmic surgery and a lid speculum was placed.,Two stab-incision paracenteses were made in the cornea using the MVR blade, and the anterior chamber was irrigated with 1% preservative-free lidocaine for intracameral anesthesia.  The anterior chamber was filled with viscoelastic and a shelved, temporal, clear corneal incision was made using the diamond groove knife and steel keratome.  A continuous curvilinear capsulorrhexis was made in the anterior capsule using the bent-needle cystotome.  The lens nucleus was hydrodissected and hydrodelineated using balanced saline solution (BSS) on a Chang cannula until it rotated freely.,The phacoemulsification handpiece was introduced into the anterior chamber, and the lens nucleus was sculpted into 2 halves.  Each half was further subdivided with chopping and removed with phacoemulsification.  The remaining cortical material was removed with the irrigation and aspiration (I&A) handpiece.  The capsular bag was inflated with viscoelastic and the intraocular lens was injected into the capsule without difficulty.  The remaining viscoelastic was removed with the I&A handpiece, and the anterior chamber was filled to an appropriate intraocular pressure with BSS.  The corneal wounds were hydrated and verified to be water-tight.  Antibiotic ointment was placed, followed by a patch and shield.  The patient was transported to the PACU in good/stable condition.  There were no complications.  Followup is scheduled for tomorrow morning in the eye clinic.,A single interrupted 10-0 nylon suture was placed through the inferotemporal paracentesis to ensure that it was watertight at the end of the case.","ophthalmology, intraocular lens implantation, eye, intraocular lens, lens implantation, cataract extraction, cataract, intraocular, viscoelastic, handpiece, implantation, surgery, chamber, phacoemulsification, extraction, visually, anterior, lens"
"  Cataract, nuclear sclerotic, right eye.  Phacoemulsification with intraocular lens implantation, right eye.", Ophthalmology, Phacoemulsification & Lens Implantation ,"PREOPERATIVE DIAGNOSIS:,  Cataract, nuclear sclerotic, right eye.,POSTOPERATIVE DIAGNOSIS:,  Cataract, nuclear sclerotic, right eye.,OPERATIVE PROCEDURES: , Phacoemulsification with intraocular lens implantation, right eye.,ANESTHESIA: , Topical tetracaine, intracameral lidocaine, monitored anesthesia care.,IOL: , AMO Model SI40 NB, power *** diopters.,INDICATIONS FOR SURGERY: , This patient has been experiencing difficulty with eyesight regarding activities in their daily life.  There has been a progressive and gradual decline in the visual acuity.  By examination, this was found to be related to cataracts.  The risks, benefits, and alternatives (including observation or spectacles) were discussed in detail.  The patient accepted these risks and elected to proceed with cataract surgery.  All questions were answered and informed consent was obtained.,Questions were answered in personal conference with the patient to ensure that the patient had a good grasp of the operative goals, risks, and alternatives involved as well as the postoperative instructions.  A preoperative surgical history and physical examination was done to ensure that the patient was in optimal general health for cataract surgery.  To minimize and decrease the chance of bacterial infection, the patient was started on a course of antibiotic drops for two days prior to surgery.,DESCRIPTION OF PROCEDURE:  ,The patient was identified and the procedure was verified.  The pupil was dilated per protocol.  The patient was taken to the operating room and placed in a comfortable supine position.  The operative table was placed in Trendelenburg head-up tilt to decrease orbital congestion and posterior vitreous pressure.  The patient was prepped and draped in the usual ophthalmic sterile fashion.  The lids and periorbita were prepped with full-strength Betadine solution with care taken to concentrate on sterilizing the eyelid margins.  The conjunctival cul-de-sac was also prepped in dilute Betadine solution.  The fornices were also prepped.  The drape was done meticulously to ensure complete eyelash inclusion.,An eyelid speculum was placed to separate the eyelids.  A paracentesis site was made.  Intracameral preservative-free lidocaine was injected.  Amvisc Plus was then used to stabilize the anterior chamber.  A 3-mm diamond blade was then used to carefully construct a clear corneal incision in the temporal location.  A 25-gauge pre-bent cystotome was used to begin a capsulorrhexis.  The capsular flap was removed.  A 27-gauge blunt cannula was used for hydrodissection.  The lens was able to be freely rotated within the capsular bag.  Divide-and-conquer technique was used for phacoemulsification.  After four sculpted grooves were made, a bimanual approach with the phacoemulsification tip and Koch spatula was used to separate and crack each grooved segment.  Each of the four nuclear quadrants was phacoemulsified.  Aspiration was used to remove remaining cortex with the I/A handpiece.  Viscoelastic was used to re-inflate the capsular bag.  The intraocular lens was injected into the capsular bag.  The lens was then dialed into position.  The lens was well-centered and stable.  Viscoelastic was aspirated.  BSS was used to re-inflate the anterior chamber to an adequate estimated intraocular pressure along with stromal hydration.  A Weck-Cel sponge was used to check both incision sites for leaks and none were identified.  The incision sites remained well approximated and dry with a well-formed anterior chamber and well-centered intraocular lens.  The eyelid speculum was removed and the patient was cleaned free of Betadine.  Zymar and Pred Forte drops were applied.  A firm eye shield was taped over the operative eye.  The patient was then taken to the Postanesthesia Recovery Unit in good condition having tolerated the procedure well.,Discharge instructions regarding activity restrictions, eye drop use, eye shield/patch wearing, and driving restrictions were discussed.  All questions were answered.  The discharge instructions were also reviewed with the patient by the discharging nurse.  The patient was comfortable and was discharged with followup in 24 hours.","ophthalmology, nuclear sclerotic, diopters, viscoelastic, capsulorrhexis, amvisc plus, lens implantation, intraocular lens, intraocular, topical, cataract, phacoemulsification, lens"
" Phacoemulsification and extracapsular cataract extraction with intraocular lens implantation, right eye.", Ophthalmology, Phacoemulsification & Cataract Extraction ,"DIAGNOSIS:,  Nuclear sclerotic and cortical cataract, right eye.,OPERATION:,  Phacoemulsification and extracapsular cataract extraction with intraocular lens implantation, right eye.,PROCEDURE:,  The patient was taken to the operating room and placed on the table in the supine position.  Cardiac monitor and oxygen at 5 liters per minute were connected by the nursing staff.  Local anesthesia was obtained using 2% lidocaine, 0/75% Marcaine, 0.5 cc Wydase with 6 cc of this solution used in a paribulbar injection, followed by ten minutes of digital massage.  The patient was then prepped and draped in the usual sterile fashion for eye surgery.  With the Zeiss operating microscopy in position, a lid speculum was inserted and a 4-0 black silk bridal suture placed in the superior rectus muscle.  With Westcott scissors, a fornix-based conjunctival flap was made.  The surgical limbus was identified and hemostasis obtained with wet-field cautery.  With a 57-Beaver blade, a corneoscleral groove was made and shelved into clear cornea.  A stab incision was made at 2 o'clock with a 15-degree blade.  With a 3.0 mm keratome, the shelved groove was attended into the anterior chamber.  Viscoelastic was inserted into the anterior chamber and anterior capsulotomy was performed in a continuous-tear technique.  Hydrodissection was performed with Balanced Salt Solution.  Phacoemulsification was performed in a two-headed nuclear fracture technique.  The remaining cortical material was removed with irrigation and aspiration handpiece.  The posterior capsule remained intact and vacuumed with minimal suction.  The posterior chamber intraocular lens was obtained.  It was inspected, irrigated, inserted into the posterior chamber without difficulty.  Inspection revealed the intraocular lens to be in good position with intact capsule and well-approximated wound.  There was no aqueous leak even with digital pressure.  The conjunctiva was pulled back into position with wet-field cautery.  A subconjunctival injection with 20 mg Gatamycine and 0.5 cc Celestone was given.  Tobradex ointment was instilled into the eye, which was patched and shielded appropriately, after removing the lid speculum and bridle suture.  The patient tolerated the procedure well and was sent to the recovery room in good condition, to be followed in attending physician office the next day.","ophthalmology, extracapsular cataract extraction, phacoemulsification, nuclear sclerotic, cortical cataract, extraction with intraocular lens, cataract extraction, intraocular lens, intraocular, extracapsular, implantation, conjunctival, cataract, chamberNOTE"
" Visually significant nuclear sclerotic cataract, right eye.  Phacoemulsification with posterior chamber intraocular lens implantation, right eye.", Ophthalmology, Phacoemulsification & Lens Implantation - 1 ,"PREOPERATIVE DIAGNOSIS:,  Visually significant nuclear sclerotic cataract, right eye.,POSTOPERATIVE DIAGNOSIS: , Visually significant nuclear sclerotic cataract, right eye.,OPERATIVE PROCEDURES: , Phacoemulsification with posterior chamber intraocular lens implantation, right eye.,ANESTHESIA:,  Monitored anesthesia care with retrobulbar block consisting of 2% lidocaine in an equal mixture with 0.75% Marcaine and Amphadase.,INDICATIONS FOR SURGERY:,  This patient has been experiencing difficulty with eyesight regarding activities of daily living.  There has been a progressive and gradual decline in the visual acuity.  The cataract was believed related to her decline in vision.  The risks, benefits, and alternatives (including with observation or spectacles) were discussed in detail.  The risks as explained included, but are not limited to pain, bleeding, infection, decreased or loss of vision/loss of eye, retinal detachment requiring further surgery, and possible consultation out of town, swelling of the back part of the eye/retina, need for prolonged eye drop use or injections, instability of the lens, and loss of corneal clarity necessitating long-term drop use or further surgery.  The possibility of needing intraocular lens exchange or incorrect lens power was discussed.  Anesthesia option and risks associated with anesthesia and retrobulbar anesthesia were discussed.  It was explained that some or all of these complications might arise at the time of or months to years after surgery.  The patient had a good understanding of the risks with the proposed, elective eye surgery.  The patient accepted these risks and elected to proceed with cataract surgery.  All questions were answered and informed consent was signed and placed in the chart.,DESCRIPTION OF PROCEDURE: , The patient was identified and the procedure was verified.  The pupil was dilated per protocol.  The patient was taken to the operating room and placed in the supine position.  After intravenous sedation, the retrobulbar block was injected followed by several minutes of digital massage.  No signs of orbital tenseness or retrobulbar hemorrhage were present.,The patient was prepped and draped in the usual ophthalmic sterile fashion.  An eyelid speculum was used to separate the eyelids.  A crescent blade was used to make a clear corneal temporally located incision.  A 1-mm Dual-Bevel blade was used to make a paracentesis site.  The anterior chamber was filled with viscoelastic (Viscoat).  The crescent blade was then used to make an approximate 2-mm long clear corneal tunnel through the temporal incision.  A 2.85-mm keratome blade was then used to penetrate into the anterior chamber through the temporal tunneled incision.  A 25-gauge pre-bent cystotome used to begin a capsulorrhexis.  The capsulorrhexis was completed with the Utrata forceps.  A 27-guage needle was used for hydrodissection and three full and complete fluid waves were noted.  The lens was able to be freely rotated within the capsular bag.  Divide-and-conquer ultrasound was used for phacoemulsification.  After four sculpted grooves were made, a bimanual approach with the phacoemulsification tip and Koch spatula was used to separate and crack each grooved segment.  Each of the four nuclear quadrants was phacoemulsified.  Aspiration was used to remove all remaining cortex.  Viscoelastic was used to re-inflate the capsular bag.  An AMO model SI40NB posterior chamber intraocular lens with power *** diopters and serial number *** was injected into the capsular bag.  The trailing haptic was placed with the Sinskey hook.  The lens was made well centered and stable.  Viscoelastic was aspirated.  BSS was used to re-inflate the anterior chamber to an adequate estimated intraocular pressure.  A Weck-Cel sponge was used to check both incision sites for leaks and none were identified.  The incision sites remained well approximated and dry with a well-formed anterior chamber and eccentric posterior chamber intraocular lens.  The eyelid speculum was removed and the patient was cleaned free of Betadine.  Vigamox and Econopred drops were applied.  A soft eye patch followed by a firm eye shield was taped over the operative eye.  The patient was then taken to the Postanesthesia Recovery Unit in good condition having tolerated the procedure well.,Discharge instructions regarding activity restrictions, eye drop use, eye shield/patch wearing, and driving restrictions were discussed.  All questions were answered.  The discharge instructions were also reviewed with the patient by the discharging nurse.  The patient was comfortable and was discharged with followup in 24 hours.  Complications none.","ophthalmology, retrobulbar block, posterior chamber intraocular lens, nuclear sclerotic cataract, cataract, lens implantation, posterior chamber, anterior chamber, intraocular lens, lens, eye, intraocular, anesthesia, phacoemulsification, retrobulbar,"
" Nuclear sclerotic cataract, right eye.  Kelman phacoemulsification with posterior chamber intraocular lens, right eye.", Ophthalmology, Phacoemulsification - Kelman ,"PREOPERATIVE DIAGNOSIS:,  Nuclear sclerotic cataract, right eye.,POSTOPERATIVE DIAGNOSIS:,  Nuclear sclerotic cataract, right eye.,OPERATIVE PROCEDURES:,  Kelman phacoemulsification with posterior chamber intraocular lens, right eye.,ANESTHESIA:,  Topical.,COMPLICATIONS:,  None.,INDICATION: , This is a 40-year-old male, who has been noticing problems with blurry vision.  They were found to have a visually significant cataract.  The risks, benefits, and alternatives of cataract surgery to the right eye were discussed and they did agree to proceed.,DESCRIPTION OF PROCEDURE:,  After informed consent was obtained, the patient was taken to the operating room.  A drop of tetracaine was instilled in the right eye and the right eye was prepped and draped in the usual sterile ophthalmic fashion.  A paracentesis was created at ** o'clock.  The anterior chamber was filled with Viscoat.  A clear corneal incision was made at ** o'clock with the 3-mm diamond blade.  A continuous curvilinear capsulorrhexis was begun with a cystotome and completed with Utrata forceps.  The lens was hydrodissected with a syringe filled with 2% Xylocaine and found to rotate freely within the capsular bag.  The nucleus was removed with the phacoemulsification handpiece in a stop and chop fashion.  The residual cortex was removed with the irrigation/aspiration handpiece.  The capsular bag was filled with Provisc and a model SI40, 15.0 diopter, posterior chamber intraocular lens was inserted into the capsular bag without complications and was found to rotate and center well.  The residual Provisc was removed with the irrigation/aspiration handpiece.  The wounds were hydrated and the eye was filled to suitable intraocular pressure with balanced salt solution.  The wounds were found to be free from leak.  Zymar and Pred Forte were instilled postoperatively.  The eye was covered with the shield.,The patient tolerated the procedure well and there were no complications.  He will follow up with us in one day.","ophthalmology, nuclear sclerotic cataract, intraocular lens, cataract, kelman phacoemulsification, sclerotic cataract, posterior chamber, capsular bag, eye, anesthesia, phacoemulsification"
 Cataract extraction via phacoemulsification with posterior chamber intraocular lens implantation.  An Alcon MA30BA lens was used.   A lid speculum was placed into the right eye.  Paracentesis was made at the infratemporal quadrant. , Ophthalmology, Phacoemulsification & Cataract Extraction - 5 ,"PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:  ,Cataract, right eye.,PROCEDURE PERFORMED:  ,Cataract extraction via phacoemulsification with posterior chamber intraocular lens implantation.  An Alcon MA30BA lens was used, * diopters, #*.,ANESTHESIA: ,Topical 4% lidocaine with 1% nonpreserved intracameral lidocaine.,COMPLICATIONS:, None.,PROCEDURE: , Prior to surgery, the patient was counseled as to the risks, benefits and alternatives of the procedure with risks including, but not limited to, bleeding, infection, loss of vision, loss of the eye, need for a second surgery, retinal detachment and retinal swelling.  The patient understood the risks clearly and wished to proceed.,The patient was brought into the operating suite after being given dilating drops.  Topical 4% lidocaine drops were used.  The patient was prepped and draped in the normal sterile fashion.  A lid speculum was placed into the right eye.  Paracentesis was made at the infratemporal quadrant.  This was followed by 1% nonpreservative lidocaine into the anterior chamber, roughly 250 microliters.  This was exchanged for Viscoat solution.  Next, a crescent blade was used to create a partial-thickness linear groove at the temporal limbus.  This was followed by a clear corneal bevel incision with a 3 mm metal keratome blade.  Circular capsulorrhexis was initiated with a cystitome and completed with Utrata forceps.  Balanced salt solution was used to hydrodissect the nucleus.  Nuclear material was removed via phacoemulsification with divide-and-conquer technique.  The residual cortex was removed via irrigation and aspiration.  The capsular bag was then filled with Provisc solution.  The wound was slightly enlarged.  The lens was folded and inserted into the capsular bag.,Residual Provisc solution was irrigated out of the eye.  The wound was stromally hydrated and noted to be completely self-sealing.,At the end of the case, the posterior capsule was intact.  The lens was well centered in the capsular bag.  The anterior chamber was deep.  The wound was self sealed and subconjunctival injections of Ancef, dexamethasone and lidocaine were given inferiorly.  Maxitrol ointment was placed into the eye.  The eye was patched with a shield.,The patient was transported to the recovery room in stable condition to follow up the following morning.","ophthalmology, alcon, phacoemulsification, cataract extraction, cataract, intraocular lens implantation, anterior chamber, provisc solution, capsular bag, topical, intraocular,"
" Cataract, right eye.  Phacoemulsification with intraocular lens insertion, right eye.  A wire lid speculum was inserted to keep the eye open and the eye rotated downward.", Ophthalmology, Phacoemulsification & Cataract Extraction - 3 ,"PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:,  Cataract, right eye.,TITLE OF OPERATION:  ,Phacoemulsification with intraocular lens insertion, right eye.,ANESTHESIA: , Retrobulbar block.,COMPLICATIONS: , None.,PROCEDURE IN DETAIL:  ,The patient was brought to the operating room where retrobulbar anesthesia was induced.  The patient was then prepped and draped using standard procedure.  A wire lid speculum was inserted to keep the eye open and the eye rotated downward with a 0.12.  The anterior chamber was entered by making a small superior limbal incision with a crescent blade and then entering the anterior chamber with a keratome.  The chamber was then filled with viscoelastic and a continuous-tear capsulorrhexis performed.  The phacoemulsification was then instilled in the eye and a linear incision made in the lens.  The lens was then cracked with a McPherson forceps, and the remaining lens material removed with the phacoemulsification tip.  The remaining cortex was removed with an I&A.  The capsular bag was then inflated with viscoelastic and the wound extended slightly with the keratome.  The folding posterior chamber lens was then inserted in the capsular bag and rotated into position.  The remaining viscoelastic was removed from the eye with the I&A.  The wound was checked for watertightness and found to be watertight.  Tobramycin drops were instilled in the eye and a shield placed over it.  The patient tolerated the procedure well.","ophthalmology, tobramycin, limbal, lid speculum, intraocular lens, capsular bag, eye, phacoemulsification, lens, intraocular"
" Cataract, right eye.  Phacoemulsification with intraocular lens insertion, right eye.  The patient was then prepped and draped using standard procedure.  An additional drop of tetracaine was instilled in the eye, and then a lid speculum was inserted.", Ophthalmology, Phacoemulsification & Cataract Extraction - 2 ,"PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS: , Cataract, right eye.,TITLE OF OPERATION: , Phacoemulsification with intraocular lens insertion, right eye.,ANESTHESIA: , Topical.,COMPLICATIONS: , None.,PROCEDURE IN DETAIL:  ,The patient was brought to the operating room where tetracaine drops were instilled in the eye.  The patient was then prepped and draped using standard procedure.  An additional drop of tetracaine was instilled in the eye, and then a lid speculum was inserted.,The eye was rotated downward and a crescent blade used to make an incision at the limbus.  This was then dissected forward approximately 1 mm, and then a keratome was used to enter the anterior chamber.  The anterior chamber was filled with 1% preservative-free lidocaine and the lidocaine was then replaced with Provisc.  A cystotome was used to make a continuous-tear capsulorrhexis, and then the capsular flap was removed with the Utrata forceps.  The lens nucleus was hydrodissected using BSS on a cannula and then removed using the phaco.  This was aided by cracking the lens nucleus with McPherson forceps.  The remaining cortex was removed from the eye with the I&A.  The capsular bag was then polished with the I&A on capsular bag.  The bag was inflated using viscoelastic and then the wound extended slightly with a keratome.  A folding posterior chamber lens was inserted and rotated into position using McPherson forceps.  The I&A was then placed in the eye again and the remaining viscoelastic removed.  The wound was checked for watertightness and found to be watertight.  TobraDex drops were instilled in the eye and a shield was placed over it.,The patient tolerated the procedure well and was brought to recovery in good condition.","ophthalmology, tetracaine, intraocular lens, lid speculum, mcpherson forceps, capsular bag, eye, phacoemulsification, cataract, lens, intraocular,"
 Ophthalmology followup visit note., Ophthalmology, Ophthalmology Progress Note - 2 ,A fluorescein angiogram was ordered at today's visit to rule out macular edema.  We have asked her to return in one to two weeks' time to discuss the results of her angiogram and possible intervention and will be sure to keep you apprised of her ongoing progress.  A copy of the angiogram is enclosed for your records.,"ophthalmology, visual acuities, 78-diopter lens, extraocular muscle movement, afferent, angiogram, applanation, detachment, dilated fundus examination, fluorescein, hemorrhages, intraocular, intraocular lenses, left eye, posterior chamber, pupillary, retinopathy, right eye, slit-lamp, lensesNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" Pars plana vitrectomy, pars plana lensectomy, exploration of exit wound, closure of perforating corneal scleral laceration involving uveal tissue, air-fluid exchange, C3F8 gas, and scleral buckling, right eye.", Ophthalmology, Pars Plana Vitrectomy & Lensectomy ,"TITLE OF OPERATION:,1.  Pars plana vitrectomy.,2.  Pars plana lensectomy.,3.  Exploration of exit wound.,4.  Closure of perforating corneal scleral laceration involving uveal tissue.,5.  Air-fluid exchange.,6.  C3F8 gas.,7.  Scleral buckling, right eye.,INDICATION FOR SURGERY: , The patient was hammering and a piece of metal entered his eye 1 day prior to the procedure giving him a traumatic cataract corneal laceration and the metallic intraocular foreign body was lodged in the posterior eye wall.  He undergoes repair of the open globe today.,PREOP DIAGNOSIS: , Perforating corneal scleral laceration involving uveal tissue with traumatic cataract and metallic foreign body lodged in the posterior eye wall, right eye.,POSTOP DIAGNOSIS: , Perforating corneal scleral laceration involving uveal tissue with traumatic cataract and metallic foreign body lodged in the posterior eye wall, right eye.,ANESTHESIA:,  General.,SPECIMEN:,  None.,IMPLANTS:,1.  Style number XXX silicone band reference XXX , lot number XXX , exploration 11/13.,2.  Style number XXX Watzke sleeve reference XXX , lot number XXX , exploration 04/14.,PROCEDURE: , The risk, benefits, and alternatives to the procedure were reviewed with the patient and his wife.  All of their questions were answered.  Informed consent was signed.  The patient was brought into the operating room.  A surgical time-out was performed during which all members of the operating room staff agreed upon the patient's name, operation to be performed, and correct operative eye.  After administration of general anesthesia, the patient was intubated without incident.,The right eye was prepared and draped in the usual fashion for ophthalmic surgery.  A wire lid speculum was used to separate the eyelids of the left eye.  A 9 o'clock anterior chamber paracentesis was created with Supersharp blade and the anterior chamber was filled with Healon.  The clear corneal incision was superior to the visual axis and was closed with three interrupted 10-0 nylon sutures with the knots buried.  A standard three-port pars plana vitrectomy __________ was initiated by performing partial conjunctival peritomies in the superonasal, superotemporal, and inferotemporal quadrants with Westcott scissors.  Hemostasis was achieved with bipolar cautery.  A 7-0 Vicryl suture was preplaced in the mattress fashion, 3 mm posterior to the surgical limbus in the inferotemporal quadrant.  A microvitreoretinal blade was used to create a sclerotomy at this site and a 4-mm infusion cannula was introduced through the sclerotomy and tied in place with the aforementioned suture.  The presence of the tip of the cannula was confirmed to be within the vitreous cavity prior to initiation of posterior infusion.  Two additional sclerotomies were created superonasally and superotemporally, 3 mm posterior to the surgical limbus with microvitreoretinal blade.,The vitreous cutter was used to perform the pars plana lens actively preserving peripheral anterior capsule.  The pars plana vitrectomy was performed with the assistance of the BIOM non-contact lens indirect viewing system using the light pipe illuminator and the vitreous cutter.  The vitreous was trimmed to the vitreous base.  A posterior vitreous detachment was created and extended 360 degrees with the assistance of triamcinolone for staining.,The foreign body appeared to exit the posterior pole along the superotemporal arcade and apparently severed a branched retinal artery resulting in an area of macular ischemia with retinal whitening along its course.  The exit wound was explored.  No intraocular foreign body or mural foreign body was observed with the assistance of intraocular forceps.  The intraocular magnet was then inserted through the sclerotomy and no foreign body was again identified.,An air-fluid exchange was performed with the assistance of the soft-tip extrusion cannula and the retinal periphery was examined with scleral depression.  No retinal breaks or defects were noted in the periphery.  The plugs were placed in the sclerotomies and the conjunctival peritomy was extended at 360 degrees.  Each of the rectus muscles was isolated on a 2-0 silk suture and a #XXX band was threaded beneath each of the rectus muscle and fixed to itself in the inferonasal quadrant with the Watzke sleeve.  The buckle was sutured to the eye wall with 5-0 Mersilene sutures in each quadrant in a mattress fashion.  The buckle was trimmed and the height of the buckle was inspected internally and noted to be adequate.,Residual intraocular fluid was removed with a soft-tip extrusion cannula and the sclerotomies were closed with 7-0 Vicryl sutures.  A 12% concentration of C3F8 gas was flushed through the eye.  The infusion cannula was removed and the sclerotomy was closed with the preplaced 7-0 Vicryl suture.  All of the sclerotomies were noted to be airtight.  The intraocular pressure following injection of 0.05 mL each of vancomycin (0.5 mg) and ceftazidime (1 mg) were injected through the superotemporal pars plana, 30-gauge needles.,The conjunctiva was closed with 6-0 plain gut sutures with the knots buried.  Subconjunctival injections of Ancef and Decadron were delivered inferotemporally.  The lid speculum was removed.  Pred-G ointment and atropine solution were applied to the ocular surface.  The eye was patched and shielded, and the patient was returned to the recovery room in stable condition, having tolerated the procedure well.  There were no complications.,I was the attending surgeon, was present and scrubbed for the entirety of the procedure.",
 Phacoemulsification with posterior chamber intraocular lens - Sample/Template., Ophthalmology, Phacoemulsification ,"PREOPERATIVE DIAGNOSIS:, Senile cataract OX,POSTOPERATIVE DIAGNOSIS: ,Senile cataract OX,PROCEDURE: ,Phacoemulsification with posterior chamber intraocular lens OX, model SN60AT (for Acrysof natural lens), XXX diopters.,INDICATIONS: ,This is a XX-year-old (wo)man with decreased vision OX.,PROCEDURE:, The risks and benefits of cataract surgery were discussed at length with the patient, including bleeding, infection, retinal detachment, re-operation, diplopia, ptosis, loss of vision, and loss of the eye. Informed consent was obtained. On the day of surgery, (s)he received several sets of drops in the XXX eye including 2.5% phenylephrine, 1% Mydriacyl, 1% Cyclogyl, Ocuflox and Acular. (S)he was taken to the operating room and sedated via IV sedation. 2% lidocaine jelly was placed in the XXX eye (or, retrobulbar anesthesia was performed using a 50/50 mixture of 2% lidocaine and 0.75% marcaine). The XXX eye was prepped using a 10% Betadine solution. (S)he was covered in sterile drapes leaving only the XXX eye exposed. A Lieberman lid speculum was placed to provide exposure. The Thornton fixation ring and a Superblade were used to create a paracentesis at approximately 2 (or 11 depending upon side and handedness, and assuming superior incision) o'clock. Then 1% lidocaine was injected through the paracentesis. After the nonpreserved lidocaine was injected, Viscoat was injected through the paracentesis to fill the anterior chamber. The Thornton fixation ring and a 2.75 mm keratome blade were used to create a two-step full-thickness clear corneal incision superiorly. The cystitome and Utrata forceps were used to create a continuous capsulorrhexis in the anterior lens capsule. BSS on a hydrodissection cannula was used to perform gentle hydrodissection. Phacoemulsification was then performed to remove the nucleus. I & A was performed to remove the remaining cortical material. Provisc was injected to fill the capsular bag and anterior chamber. A XXX diopter SN60AT (for Acrysof natural lens) intraocular lens was injected into the capsular bag. The Kuglen hook was used to rotate it into proper position in the capsular bag. I & A was performed to remove the remaining Viscoelastic material from the eye. BSS on the 30-gauge cannula was used to hydrate the wound. The wounds were checked and found to be watertight. The lid speculum and drapes were carefully removed. Several drops of Ocuflox were placed in the XXX eye. The eye was covered with an eye shield. The patient was taken to the recovery area in a good condition. There were no complications.","ophthalmology, phacoemulsification, acrysof, acrysof natural lens, acular, kuglen hook, ocuflox, provisc, sn60at, senile cataract, thornton fixation ring, bleeding, capsular bag, decreased vision, diopters, diplopia, infection, loss of the eye, loss of vision, ptosis, retinal detachment, lid speculum, thornton fixation, anterior chamber, intraocular lens, intraocular, chamber, lidocaine, "
 Woman with a history of macular degeneration.  PDT therapy.  Some vision therapy.  Complete refractive work-up., Ophthalmology, Optometry - Letter ,"RE:  Sample Patient,Dear Dr. Sample:,Sample Patient was seen at the Vision Rehabilitation Institute on Month DD, YYYY.  She is an 87-year-old woman with a history of macular degeneration, who admits to having PDT therapy within the last year.  She would like to get started with some vision therapy so that she may be able to perform her everyday household chores, as well as reading small print.  At this time, she uses a small handheld magnifier, which is providing her with only limited help.,A complete refractive work-up was performed today, in which we found a mild change in her distance correction, which allowed her the ability to see 20/70 in the right eye and 20/200 in the left eye.  With a pair of +4 reading glasses, she was able to read 0.5M print quite nicely.  I have loaned her a pair of +4 reading glasses at this time and we have started her with fine-detailed reading.  She will return to our office in a matter of two weeks and we will make a better determination on what near reading glasses to prescribe for her.  I think that she is an excellent candidate for low vision help.  I am sure that we can be of great help to her in the near future.,Thank you for allowing us to share in the care of your patient.,With best regards,,Sample Doctor, O.D.","ophthalmology, optometry, letter, optometry letter, pdt therapy, distance correction, macular degeneration, reading glasses, vision therapy, complete refractive, macular, degeneration,"
 Patient being referred for evaluation of glaucoma., Ophthalmology, Ophthalmology - Letter - 2 ,"XYZ, O.D.,RE:  ABC,DOB:  MM/DD/YYYY,Dear Dr. XYZ:,Thank you for your kind referral for patient ABC.  Mr. ABC is being referred for evaluation of glaucoma.  The patient states he has no visual complaints.,On examination, the patient's visual acuity is 20/20 bilaterally.  The patient's visual fields are full to confrontation.  Extraocular muscles are intact.  There is no relative afferent pupillary defect and applanation pressures are 15 mmHg bilaterally.  On slit lamp examination, the patient has a normal anterior segment with 1+ nuclear sclerosis.  On dilated examination, the patient has a cup-to-disc ratio in the right eye of 0.4.  Macula, vessels, and periphery were within normal limits.  On the left eye, the patient has a cup-to-disc ratio of 0.3 and macula vessels and periphery are also within normal limits.  On gonioscopy, the patient shows deep anterior chamber angle OU and is open to the ciliary body band 360 degrees.,In conclusion, my initial impression is that Mr. ABC does not have glaucoma.  He has fairly symmetric and small cup-to-disc ratios OU.  His intraocular pressures were within normal limits in our office today.  I discussed at length with him the alternatives of observation versus continued work-up and testing.  He seemed to understand very well and went with my recommendation to continue observation for now.  We will take fundus photos of his optic nerves for future comparison, but I think given the lack of any strong findings suspicious for glaucoma, we will defer further testing at this time.,Should you have any specific questions or any other information that you think that I may not have included in this evaluation, please feel free to contact me.  I have recommended him to follow up with you for continued examination, continued check-ups, and should you find any other abnormal findings, I would be happy to address those again.,Again, thank you for your referral of Mr. ABC.,Sincerely,,","ophthalmology, cup to disc ratio, referred for evaluation, cup to disc, disc ratio, macula vessels, pressures, eye, macula, vessels, visual, cup, disc, glaucoma, examination, intact, "
 Patient referred for narrow angles and possible associated glaucoma., Ophthalmology, Ophthalmology - Letter - 3 ,"XYZ, O.D.,RE:  ABC,DOB:  MM/DD/YYYY,Dear XYZ:,Thank you very much for your kind referral of Mrs. ABC who you referred to me for narrow angles and possible associated glaucoma.  I examined Mrs. ABC initially on MM/DD/YYYY.  At that time, she expressed a chief concern of occasional pain around her eye, but denied any flashing lights, floaters, halos, or true brow ache.  She reports a family history of glaucoma in her mother, but is unsure of the specific kind.  Her past ocular history has been fairly unremarkable.  As you know, she has a history of non-insulin dependent diabetes.  She is unaware of her last hemoglobin A1c levels, but reports a blood sugar of 158 taken on the morning of her appointment with me.  She is followed by Dr. X here locally.,Upon examination, her visual acuity measured 20/20-1 in either eye with her glasses.  Presenting intraocular pressures were14 mmHg in either eye at 2:03 p.m.  Pupillary reactions, confrontational visual fields, and ocular motility were normal.  The slit lamp exam revealed narrow anterior chambers and on gonioscopy only the buried anterior trabecular meshwork was visible in either eye, but the angle deepened with gonio-compression suggesting appositional and not synechial closure.  I deferred the dilated portion of the exam on that day.,We proceeded with peripheral iridectomies and following this upon her most recent visit on MM/DD/YYYY, I was able to safely dilate her eyes as her chambers had deepened and the PIs were patent.  I note that she has an increased CD ratio measuring 0.65 in the right eye and 0.7 in the left and although her FDT visual fields and GDX testing were normal at your office, she does have an enlarged blind spot in either eye on Humphrey visual fields and retinal tomography also shows some suspicious changes.  Therefore, I feel she has sustained some optic nerve damage perhaps from intermittent angle closure in the past.,In summary, Mrs. ABC has a history of narrow angles not successfully treated with laser PIs.  Her intraocular pressures have remained stable.  I will continue to monitor her closely.,Thank you very much once again for allowing me to have shared in her care.  If I can provide any additional information or be of further service, do let me know.,Sincerely,,","ophthalmology, intraocular pressures, narrow angles, visual fields, angles, intraocular, pressures, anterior, chambers, gonioscopy, glaucoma, narrow, visual, eye, "
 The patient was referred for evaluation of cataracts bilaterally, Ophthalmology, Ophthalmology - Letter - 1 ,"XYZ, O.D.,RE:  ABC,DOB:  MM/DD/YYYY,Dear Dr. XYZ:,Thank you for your referral of patient ABC.  The patient was referred for evaluation of cataracts bilaterally.,On examination, the patient was seeing 20/40 in her right eye and 20/50 in the left eye.  Extraocular muscles were intact, visual fields were full to confrontation OU, and applanations are 12 mmHg bilaterally.  There is no relative afferent pupillary defect.  On slit lamp examination, lids and lashes were within normal limits.  The conj is quiet.  The cornea shows 1+ guttata bilaterally.  The AC is deep and quiet and irises are within normal limits bilaterally.  There is a dense 3 to 4+ nuclear sclerotic cataract in each eye.  On dilated fundus examination, cup-to-disc ratio is 0.1 OU.  The vitreous, macula, vessels, and periphery all appear within normal limits.,Impression:  It appears that Ms. ABC' visual decline is caused by bilateral cataracts.  She would benefit from having removed.  The patient also showed some mild guttata OU indicating possible early Fuchs dystrophy.  The patient should do well with cataract surgery and I have recommended this and she agreed to proceed with the first eye here shortly.  I will keep you up to date of her progress and any new findings as we perform her surgery in each eye.,Again, thank you for your kind referral of this kind lady and I will be in touch with you.,Sincerely,,","ophthalmology, extraocular, applanations, slit lamp, visual field, visual, guttata, surgery, cataracts, eye, "
 The patient is being referred for evaluation of diabetic retinopathy., Ophthalmology, Ophthalmology - Letter - 4 ,"XYZ, M.D.,RE:  ABC,DOB:  MM/DD/YYYY,Dear Dr. XYZ:,Thank you for your kind referral for patient ABC.  The patient is being referred for evaluation of diabetic retinopathy.  The patient was just diagnosed with diabetes; however, he does not have any serious visual complaints at this time.,On examination, the patient is seeing 20/40 OD pinholing to 20/20.  The vision in the left eye is 20/20 uncorrected.  Applanation pressures are normal at 17 mmHg bilaterally.  Visual fields are full to count fingers OU and there is no relative afferent pupillary defect.  Slit lamp examination was within normal limits, other than trace to 1+ nuclear sclerosis OU.  On dilated examination, the patient shows a normal cup-to-disc ratio that is symmetric bilaterally.  The macula, vessels, and periphery are also within normal limits.,In conclusion, Mr. ABC does not show any evidence of diabetic retinopathy at this time.  We recommended him to have his eyes dilated once a year.  I have advised him to follow up with you for his regular check-ups.  Again, thank you for your kind referral of Mr. ABC and we should check on him once a year at this time.,Sincerely,,","ophthalmology, pupillary defect, cup-to-disc ratio, cup-to-disc, evaluation of diabetic retinopathy, referred for evaluation, diabetic retinopathy, visual, dilated, retinopathy, examination, diabetic,"
 Complete eye examination - Normal eye and vision exam., Ophthalmology, Eye Examination - H&P ,"CHIEF COMPLAINT:,  This 26-year-old male presents today for a complete eye examination.,ALLERGIES:,  Patient admits allergies to aspirin resulting in disorientation, GI upset.,MEDICATION HISTORY:,  Patient is currently taking amoxicillin-clavulanate 125 mg-31.25 mg tablet, chewable medication was prescribed by A. General Practitioner MD, Adrenocot 0.5 mg tablet medication was prescribed by A. General Practitioner MD, Vioxx 12.5 mg tablet (BID).,PMH: , Past medical history is unremarkable.,PAST SURGICAL HISTORY:,  Patient admits past surgical history of (+) appendectomy in 1989.,SOCIAL HISTORY:,  Patient denies alcohol use.  Patient denies illegal drug use.  Patient denies STD history.  Patient denies tobacco use.,FAMILY HISTORY:,  Unremarkable.,REVIEW OF SYSTEMS:,Eyes: (-) dry eyes (-) eye or vision problems (-) blurred vision.,Constitutional Symptoms: (-) constitutional symptoms such as fever, headache, nausea, dizziness.,Musculoskeletal: (-) joint or musculoskeletal symptoms.,EYE EXAM:,  Patient is a pleasant, 26-year-old male in no apparent distress who looks his given age, is well developed and nourished with good attention to hygiene and body habitus.,Pupils:  Pupil exam reveals round and equally reactive to light and accommodation.,Motility:  Ocular motility exam reveals gross orthotropia with full ductions and versions bilateral.,Visual Fields:  Confrontation VF exam reveals full to finger confrontation O.U.,IOP:  IOP Method:  applanation tonometry OD:  10 mmHg Medications:  Alphagan; 0.2% Condition:  improving.,Keratometry:,OD:  K1 35.875K2 35.875,OS:  K1 35.875K2 41.875,Lids/Orbit:  Bilateral eyes reveal normal position without infection.  Bilateral eyelids reveals white and quiet.,Slit Lamp:  Corneal epithelium is intact with normal tear film and without stain.  Stroma is clear and avascular.  Corneal endothelium is smooth and of normal appearance.,Anterior Segment:  Bilateral anterior chambers reveal no cells or flare with deep chamber.,Lens:  Bilateral lenses reveals transparent lens that is in normal position.,Posterior Segment:  Posterior segment was dilated bilateral.  Bilateral retinas reveal normal color, contour, and cupping.,Retina:  Bilateral retinas reveals flat with normal vasculature out to the far periphery.  Bilateral retinas reveal normal reflex and color.,VISUAL ACUITY:,Visual acuity - uncorrected:  OD:  20/10 OS:  20/10 OU:  20/15.,REFRACTION:,Lenses - final:,OD:  +0.50 +1.50 X 125 Prism 1.75,OS:  +6.00 +3.50 X 125 Prism 4.00 BASE IN Fresnel,Add:  OD:  +1.00 OS:  +1.00,OU:  Far VA 20/25,TEST RESULTS:,  No tests to report at this time.,IMPRESSION:,  Eye and vision exam normal.,PLAN:,  Return to clinic in 12 month (s).,PATIENT INSTRUCTIONS:",
 Secondary scleral suture fixated posterior chamber intraocular lens implant with penetrating keratoplasty.  A concurrent vitrectomy and endolaser was performed by the vitreoretinal team., Ophthalmology, Intraocular Lens Implant ,"TITLE OF OPERATION:  ,1.  Secondary scleral suture fixated posterior chamber intraocular lens implant with penetrating keratoplasty.,2.  A concurrent vitrectomy and endolaser was performed by the vitreoretinal team.,INDICATION FOR SURGERY:  ,The patient is a 62-year-old white male who underwent cataract surgery in 09/06.  This was complicated by posterior capsule rupture.  An intraocular lens implant was not attempted.  He developed corneal edema and a preretinal hemorrhage.  He is aware of the risks, benefits, and alternatives of the surgery and now wishes to proceed with secondary scleral suture fixated posterior chamber intraocular lens implant in the left eye, vitrectomy, endolaser, and penetrating keratoplasty.,PREOP DIAGNOSIS:  ,1.  Preretinal hemorrhage.,2.  Diabetic retinopathy.,3.  Aphakia.,4.  Corneal edema.,POSTOP DIAGNOSIS:  ,1.  Preretinal hemorrhage.,2.  Diabetic retinopathy.,3.  Aphakia.,4.  Corneal edema.,ANESTHESIA: , General.,SPECIMEN:  ,1.  Donor corneal swab sent to Microbiology.,2.  Donor corneal scar rim sent to Eye Pathology.,3.  The patient's cornea sent to Eye Pathology.,PROS DEV IMPLANT:  ,ABC Laboratories 16.0 diopter posterior chamber intraocular lens, serial number 123456.,NARRATIVE: , Informed consent was obtained, and all questions were answered.  The patient was brought to the preoperative holding area, where the operative left eye was marked.  He was brought to the operating room and placed in the supine position.  EKG leads were placed.  General anesthesia was induced.  The left ocular surface and periorbital skin were disinfected and draped in the standard fashion for eye surgery after a shield and tape were placed over the unoperated right eye.  A lid speculum was placed.  The posterior segment infusion was placed by the vitreoretinal service.  Peritomy was performed at the 3 and 9 o'clock limbal positions.  A large Flieringa ring was then sutured to the conjunctival surface using 8-0 silk sutures tied in an interrupted fashion.  The cornea was then measured and was found to accommodate a 7.5-mm trephine.  The center of the cornea was marked.  The keratoprosthesis was identified.,A 7.5-mm trephine blade was then used to incise the anterior corneal surface.  This was done after a paracentesis was placed at the 1 o'clock position and viscoelastic was used to dissect peripheral anterior synechiae.  Once the synechiae were freed, the above-mentioned trephination of the anterior cornea was performed.  Corneoscleral scissors were then used to excise completely the central cornea.  The keratoprosthesis was placed in position and was sutured with six interrupted 8-0 silk sutures.  This was done without difficulty.  At this point, the case was turned over to the vitreoretinal team, which will dictate under a separate note.  At the conclusion of the vitreoretinal procedure, the patient was brought under the care of the cornea service.  The 9-0 Prolene sutures double armed were then placed on each lens haptic loop.  The keratoprosthesis was removed.  Prior to this removal, scleral flaps were made, partial thickness at the 3 o'clock and 9 o'clock positions underneath the peritomies.  Wet-field cautery also was performed to achieve hemostasis.  The leading hepatic sutures were then passed through the bed of the scleral flap.  These were drawn out of the eye and then used to draw the trailing hepatic into the posterior segment of the eye followed by the optic.  The trailing hepatic was then placed into the posterior segment of the eye as well.  The trailing haptic sutures were then placed through the opposite scleral flap bed and were withdrawn.  These were tied securely into position with the IOL nicely centered.  At this point, the donor cornea punched at 8.25 mm was then brought into the field.  This was secured with four cardinal sutures.  The corneal button was then sutured in place using a 16-bite 10-0 nylon running suture.  The knot was secured and buried after adequate tension was adjusted.  The corneal graft was watertight.  Attention was then turned back to the IOL sutures, which were locked into position.  The ends were trimmed.  The flaps were secured with single 10-0 nylon sutures to the apex, and the knots were buried.  At this point, the case was then turned back over to the vitreoretinal service for further completion of the retinal procedure.  The patient tolerated the corneal portions of the surgery well and was turned over to the retina service in good condition, having tolerated the procedure well.  No complications were noted.  The attending surgeon, Dr. X, performed the entire procedure.  No complications of the procedure were noted.  The intraocular lens was selected from preoperative calculations.  No qualified resident was available to assist.","ophthalmology, vitrectomy, endolaser, keratoplasty, intraocular lens implant, preretinal hemorrhage, scleral flaps, intraocular, keratoprosthesis, chamber, implant, scleral, vitreoretinal, lens, sutures, eye, "
" Bilateral nasolacrimal probing.   Tearing, eyelash encrustation with probable tear duct obstruction bilateral.  Distal nasolacrimal duct stenosis with obstruction, left and right eye", Ophthalmology, Nasolacrimal Probing ,"PREOPERATIVE DIAGNOSES:,  Tearing, eyelash encrustation with probable tear duct obstruction bilateral.,POSTOPERATIVE DIAGNOSES:  ,1.  Distal nasolacrimal duct stenosis with obstruction, left eye.,2.  Distal nasolacrimal duct stenosis with obstruction, right eye.,OPERATIVE PROCEDURE: , Bilateral nasolacrimal probing.,ANESTHESIA: , Monitored anesthesia care along with mask sedation.,INDICATIONS FOR SURGERY: , This young infant is a 19-month-old who has had persistent tearing and mild eyelash encrustation of each eye for many months.  Conservative measures at home have failed to completely resolve the symptoms.  He has been placed on previous antibiotics treatment for presumed conjunctivitis.  Please refer to clinic note for more details.  Conservative measures at home have failed to resolve the symptoms.  A nasolacrimal probing was offered as an elective procedure.  Procedure as well as inherent risks, expected outcomes, benefits, and alternatives (including continued observation) were discussed with his mother prior to scheduling surgery.  Again, a description of procedure as well as diagram instruction was provided to mother and father in the morning of the procedure.  The risks as explained included, but were not limited to temporary bleeding, persistent symptoms, recurrence need for further procedure, possible need for future stent placement or repeat probing, and anesthesia risk were all discussed.  Also a rare possibility of errant passage of the nasolacrimal probe was discussed.  Preoperative evaluation and explanation include drying of the nasolacrimal system with an explanation expected outcome/result from surgery.  No guarantees were offered.  Informed consent was signed and placed on the chart.,DESCRIPTION OF PROCEDURE:  ,The patient was identified and the procedure was verified.  Procedure as well as inherent risks were again discussed with parents prior to the procedure.  After anesthesia was induced in the operating room, tetracaine drops were applied to each eye and the pressure of the eyes were checked with Tono-Pen.  The pressure on the right was 17 mmHg and on the left was 16 mmHg.,A punctal dilator was then used to dilate the left superior puncta.  A size 00 Bowman probe was used to navigate the superior puncta and canaliculus with traction of the eyelid temporally.  The probe was advanced until a firm stop of the lacrimal bone was felt.  The probe was rotated in a superior and medial fashion along the brow to allow for navigation through the nasolacrimal sac and duct.  A mild resistance was felt at the distal aspect of the nasolacrimal duct consistent with a location of the valve.  There was also some mild stenosis distally, but not felt significant.  The probe was used to navigate through this mild resistance.  A second Bowman probe was then placed through the left naris and metal on metal contact was felt confirming patency.  Both probes were removed.  The 00 Bowman probe was then used to navigate the inferior puncta canaliculus system.  Patency was confirmed.  The left upper lid was everted and inspected and was found to be normal.,Attention was then turned to the right side where the similar procedure through the right superior puncta was performed.  A punctal dilator was used to dilate the puncta followed by a size 00 Bowman probe.  Again on this side, a size 0 Bowman probe was unable to be placed initially to the superior puncta.  The probe was used to navigate the superior puncta, canaliculus, and then the probe was rotated superomedially and the probe was advanced.  Similar amount of distal stenosis and distal nasolacrimal duct obstruction was felt.  The mild resistance was over come at the approximate location of the valve.  Metal-on-metal feel confirmed patency through the right naris with a second metal probe.  At the completion of the procedure all probes were removed.  Awakened and taken to the postanesthesia recovery unit in good condition having tolerated the procedure well.,Postoperative instructions were provided to the parents by me, and the discharging nurse.  I did advised nasolacrimal massage for the next 7 to 10 days on each side two to three times daily.  Technique explained and demonstrated.  Erythromycin ointment to both eyes twice daily for three days.  Follow up was arranged and he may call with any further questions or concerns.","ophthalmology, tearing, eyelash encrustation, tear duct obstruction, nasolacrimal duct stenosis, nasolacrimal, bowman probe, distal nasolacrimal duct, nasolacrimal probing, nasolacrimal duct, superior puncta, probe, obstruction, eyelash, duct, punctal,"
 Ophthalmology followup visit note., Ophthalmology, Ophthalmology Progress Note - 1 ,"She is stable at this time and does not require any intervention at today's visit.  I have asked her to return in six months' for a followup dilated examination, but would be happy to see her sooner should you or she notice any changes in her vision.","ophthalmology, visual acuities, extraocular muscle, intraocular pressure, pupils, afferent, applanation, binocular, dilated fundus, left eye, lens, movements, ophthalmoscope, pigmentary, retina, retinal, right eye, acuitiesNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Repair of upper lid canalicular laceration - Sample/Template., Ophthalmology, Lid Laceration Repair ,"PREOPERATIVE DIAGNOSES:,1. XXX upper lid laceration.,2. XXX upper lid canalicular laceration.,POSTOPERATIVE DIAGNOSES:,1. XXX upper lid laceration.,2. XXX upper lid canalicular laceration.,PROCEDURES:,1. Repair of XXX upper lid laceration.,2. Repair of XXX upper lid canalicular laceration.,ANESTHESIA:, General,SPECIMENS:,  None.,COMPLICATIONS:, None.,INDICATIONS:, This is a XX-year-old (wo)man with XXX eye upper eyelid laceration involving the canaliculus.,PROCEDURE:, The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, re-operation, loss of vision, and loss of the eye. Informed consent was obtained. The patient was brought to the operating room and placed in the supine position, where (s)he was prepped and draped in the routine fashion for general ophthalmic plastic reconstructive surgery, once the appropriate cardiac and respiratory monitoring was placed on him/her, and once general endotracheal anesthetic had been administered. The patient then had the wound freshened up with Westcott scissors and cotton-tip applications. Hemostasis was achieved with a high-temp disposable cautery. Once this had been done, the proximal end of the XXX upper lid canalicular system was intubated with a Monoka tube on a Prolene. The proximal end was then found and this was intubated with the same tubing system. Then, two 6-0 Vicryl sutures were used to reapproximate the medial canthal tendon. Once this had been done, the skin was reapproximated with interrupted 6-0 Vicryl sutures and interrupted 6-0 plain gut sutures. To ensure that the punctum was in the correct position and in the Monoka tube was seated with a seater, and the tube was cut short. The patient's nose was suctioned of blood, and (s)he was awakened from general endotracheal anesthesia and did well. (S)he left the operating room in good condition.","ophthalmology, laceration, monoka tube, westcott scissors, bleeding, canalicular laceration, canthal tendon, cotton-tip, infection, lid, lid canalicular system, lid laceration, loss of the eye, loss of vision, ophthalmic plastic reconstructive surgery, re-operation, upper lid, lid laceration repair, laceration repair, lid canalicular, canalicular"
" He awoke one morning and had double vision.  He states when he closed each eye, the double vision dissipated.  The double vision entirely dissipated within one hour.   The next day he woke up and he had double vision again. ", Ophthalmology, Diplopia ,"HISTORY OF PRESENT ILLNESS: , The patient is a 53-year-old right-handed gentleman who presents to the clinic for further evaluation of diplopia.  He states that he was in his usual state of health when he awoke one morning in January 2009.  He had double vision.  He states when he closed each eye, the double vision dissipated.  The double vision entirely dissipated within one hour.  He was able to drive.  However, the next day he woke up and he had double vision again.  Over the next week, the double vision worsened in intensity and frequency and by the second week, it was severe.  He states that he called Sinai Hospital and spoke to a physician who recommended that he come in for evaluation.  He was seen by a primary care physician who sent him for an ophthalmologic evaluation.  He was seen and referred to the emergency department for an urgent MRI to evaluate for possible aneurysm.  The patient states that he had a normal MRI and was discharged to home.,For the next month, the double vision improved, although he currently still experiences constant diplopia.  Whereas in the past, when he would see two objects, they were very far apart in a horizontal plane; now they are much closer together.  He still does not drive.  He also is not working due to the double vision.  There is no temporal fluctuation to the double vision.  More recently, over the past month, he has developed right supraorbital pain.  It actually feels like there is pain under his right lid.  He denies any dysphagia, dysarthria, weakness, numbness, tingling, or any other neurological symptoms.,There is a neurology consultation in the computer system.  Dr. X saw the patient on February 2, 2009, when he was in the emergency department.  He underwent an MRI that showed a questionable 3 mm aneurysm of the medial left supraclinoid internal carotid artery, but there were no abnormalities on the right side.  MRV was negative and MRI of the brain with and without contrast was also negative.  He also had an MRI of the orbit with and without contrast that was normal.  His impression was that the patient should follow up for a possible evaluation of myasthenia gravis or other disorder.,At the time of the examination, it was documented that he had right lid ptosis.  He had left gaze diplopia.  The pupils were equal, round, and reactive to light.  His neurological examination was otherwise entirely normal.  According to Dr. X's note, the ophthalmologist who saw him thought that there was ptosis of the right eye as well as an abnormal pupil.  There was also right medial rectus as well as possibly other extraocular abnormalities.  I do not have the official ophthalmologic consultation available to me today.,PAST MEDICAL HISTORY: , The patient denies any previous past medical history.  He currently does not have a primary care physician as he is uninsured.,MEDICATIONS:,  He does not take any medications.,ALLERGIES: , He has no known drug allergies.,SOCIAL HISTORY: , The patient lives with his wife.  He was an IT software developer, but he has been out of work for several months.  He smokes less than a pack of cigarettes daily.  He denies alcohol or illicit drug use.,FAMILY HISTORY: , His mother died of a stroke in her 90s.  His father had colon cancer.  He is unaware of any family members with neurological disorders.,REVIEW OF SYSTEMS: , A complete review of systems was obtained and was negative except for as mentioned above.  This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:,Vital Signs:  BP 124/76",
 Abnormal electronystagmogram demonstrating prominent nystagmus on position testing in the head hanging right position., Ophthalmology, Electronystagmogram ,"PROCEDURE:  ,This tracing was obtained utilizing silver chloride biopotential electrodes placed at the medial and lateral canthi at both eyes and on the superior and inferior orbital margins of the left eye along a vertical line drawn through the middle of the pupil in the neutral forward gaze.  Simultaneous recordings were made in both eyes in the horizontal direction and the left eye in the vertical directions.  Caloric irrigations were performed using a closed loop irrigation system at 30 degrees and 44 degrees C into either ear.,FINDINGS: , Gaze testing did not reveal any evidence of nystagmus.  Saccadic movements did not reveal any evidence of dysmetria or overshoot.  Sinusoidal tracking was performed well for the patient's age.  Optokinetic nystagmus testing was performed poorly due to the patient's difficulty in following the commands.  Therefore adequate OKNs were not achieved.  The Dix-Hallpike maneuver in the head handing left position resulted in moderate intensity left beating nystagmus, which was converted to a right beating nystagmus when she sat up again.  The patient complained of severe dizziness in this position.  There was no clear-cut decremental response with repetition.  In the head hanging left position, no significant nystagmus was identified.  Positional testing in the supine, head hanging, head right, head left, right lateral decubitus, and left lateral decubitus positions did not reveal any evidence of nystagmus.,Caloric stimulation revealed a calculated unilateral weakness of 7.0% on the right (normal <20%) and left beating directional preponderance of 6.0% (normal <20-30%).,IMPRESSION: , Abnormal electronystagmogram demonstrating prominent nystagmus on position testing in the head hanging right position.  No other significant nystagmus was noted.  There was no evidence of clear-cut caloric stimulation abnormality.  This study would be most consistent with a right vestibular dysfunction.","ophthalmology, silver chloride biopotential electrodes, inferior orbital margins, lateral canthi, vestibular dysfunction, prominent nystagmus, head hanging, electronystagmogram, eyes, nystagmus,"
 Difficulty with both distance vision and with fine print at near., Ophthalmology, Difficulty Distance Vision & Fine Print at Near ,"REASON FOR VISIT: , Mr. ABC is a 61-year-old Caucasian male who presents to us today as a new patient.  He states that he has difficulty with both his distance vision and also with fine print at near.,HISTORY OF PRESENT ILLNESS:,  Mr. ABC states that over the last year, he has had increasing difficulty with distance vision particularly when he is driving.  He is also having trouble when he is reading.  He does occasionally wear over-the-counter reading glasses, which do help with his near vision.,Past ocular history is significant for astigmatism for which he wore glasses since he was 18 years old.  However, Mr. ABC mentioned today that he has not worn his glasses for the last few years.,His past medical history is significant for hypertension, low serum testosterone level, hypercholesterolemia, GERD, depression, actinic keratoses, and a history of Pityrosporum folliculitis.,His family history is significant for diabetes in both parents.  He states that his mother is seen by Mrs. Goldberg, but he is not aware of her ocular history.  He has no known family history of glaucoma, age-related macular degeneration or hereditary blindness.,MEDICATIONS: , Wellbutrin XL 450 mg daily, Ritalin long-acting 60 mg daily, hydrochlorothiazide at an unknown dose, Vytorin at an unknown dose, and aspirin.,ALLERGIES: , No known drug allergies.,FINDINGS:,  Visual acuity today without correction was 20/20 -2 pinholing to 20/16 in the right eye, and 20/40 +2 pinholing to 20/16 in the left eye.  Near vision unaided was J2 in both eyes.,Manifest refraction today following pharmacological dilation was -0.50, +0.50 times 155 in the right eye revealing a vision of 20/16.  Manifest refraction was -1.00, +0.25 times 005 revealing a vision of 20/16 in the left eye.  The add was +2 in both eyes.  Visual fields are full to finger counting in both eyes.,Extraocular movements were within normal limits.  Intraocular pressure by applanation was 16 mmHg in the right eye and 18 mmHg in the left eye measured at 11.30 in the morning.,Examination of the anterior segment was unremarkable in both eyes except for mild nuclear sclerotic opacities in both eyes.,Dilated fundus examination of the right eye revealed a sharp and pink optic disc with a healthy rim and cup-to-disc ratio of 0.7; however, there was central excavation of the disc, but no disc hemorrhages were noted.  On examination of the macula, there were drusen scattered temporally.  Examination of the vasculature was normal.  Peripheral retinal examination was entirely normal.,On funduscopic examination of the left eye, there was a sharp and pink disc with a healthy rim, but with central excavation and a cup-to-disc ratio of 0.6.  Of note, there were no disc hemorrhages.  On examination of the macula, there was scattered tiny drusen centrally and superiorly.  Examination of the vasculature was entirely normal.  Peripheral fundus examination was unremarkable.,ASSESSMENT:,1.  Age-related macular degeneration category three (right greater than sign left).,2.  Glaucoma suspect based on disc appearance (increased cup-to-disc ratio and disc asymmetry).,3.  Presbyopia and astigmatism.,4.  Non-visually significant cataracts bilaterally.,PLANS:,1.  The above diagnoses and management plans each were discussed with the patient who expressed understanding.,2.  Commence Ocuvite PreserVision capulets one tablet twice a day by mouth for age-related macular degeneration.,3.  Humphrey visual field and disc photographs today for baseline documentation in view of glaucoma suspicion.,4.  Followup in Glaucoma Clinic arranged in 4 months' time with repeat Humphrey visual fields at this time for reevaluation and comparison.,5.  Follow up with Mrs. Braithwaite in the Comprehensive Eye Service Clinic for undilated refraction.,6.  We will follow up this gentleman in our clinic in 12 months' time; however, I have asked him to return to us soon should he develop any worsening ocular symptoms in the interim.",
 Endoscopic subperiosteal midface lift using the endotine midface suspension device.  Transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad., Ophthalmology, Midface Lift & Blepharoplasty ,"PREOPERATIVE DIAGNOSES:,1.  Request for cosmetic surgery.,2.  Facial asymmetry following motor vehicle accident.,POSTOPERATIVE DIAGNOSES:,1.  Request for cosmetic surgery.,2.  Facial asymmetry following motor vehicle accident.,PROCEDURES:,1.  Endoscopic subperiosteal midface lift using the endotine midface suspension device.,2.  Transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad.,ANESTHESIA: , General via endotracheal tube.,INDICATIONS FOR OPERATION: , The patient is a 28-year-old country and western performer who was involved in a motor vehicle accident over a year ago.  Since that time, she is felt to have facial asymmetry, which is apparent in publicity photographs for her record promotions.  She had requested a procedure to bring about further facial asymmetry.  She was seen preoperatively by psychiatrist specializing in body dysmorphic disorder as well as analysis of the patient's requesting cosmetic surgery and was felt to be a psychiatrically good candidate.  She did have facial asymmetry with the bit of more fullness in higher cheekbone on the right as compared to the left.  Preoperative workup including CT scan failed to show any skeletal trauma.  The patient was counseled with regard to the risks, benefits, alternatives, and complications of the postsurgical procedure including but not limited to bleeding, infection, unacceptable cosmetic appearance, numbness of the face, change in sensation of the face, facial nerve paralysis, need for further surgery, need for revision, hair loss, etc., and informed consent was obtained.,PROCEDURE:,  The patient was taken to the operating room, placed in supine position after having been marked in the upright position while awake.  General endotracheal anesthesia was induced with a #6 endotracheal tube.  All appropriate measures were taken to preserve the vocal cords in a professional singer.  Local anesthesia consisting of 5/6th 1% lidocaine with 1:100,000 units of epinephrine in 1/6th 0.25% Marcaine was mixed and then injected in a regional field block fashion in the subperiosteal plane via the gingivobuccal sulcus injection on either side as well as into the temporal fossa at the level of the true temporal fascia.  The upper eyelids were injected with 1 cc of 1% Xylocaine with 1:100,000 units of epinephrine.  Adequate time for vasoconstriction and anesthesia was allowed to be obtained.  The patient was prepped and draped in the usual sterile fashion.  A 4-0 silk suture was placed in the right lower lid.  For traction, it was brought anteriorly.  The conjunctiva was incised with the needle tip Bovie with Jaeger lid plate protecting the cornea and globe.  A Q-Tip was then used to separate the orbicularis oculi muscle from the fat pad beneath and carried down to the bone.  The middle and medial fat pads were identified and a small amount of fat was removed from each to take care of the pseudofat herniation, which was present.  The inferior oblique muscle was identified, preserved, and protected throughout the procedure.  The transconjunctival incision was then closed with buried knots of 6-0 fast absorbing gut.  Contralateral side was treated in similar fashion with like results and throughout the procedure.  Lacri-Lube was in the eyes in order to maintain hydration.  Attention was next turned to the midface, where a temporal incision was made parallel to the nasojugal folds.  Dissection was carried out with the hemostat down to the true temporal fascia and the endoscopic temporal dissection dissector was used to elevate the true temporal fascia.  A 30-degree endoscope was used to visualize the fat pads, so that we knew we are in the proper plane.  Subperiosteal dissection was carried out over the zygomatic arch and Whitnall's tubercle and the temporal dissection was completed.,Next, bilateral gingivobuccal sulcus incisions were made and a Joseph elevator was used to elevate the periosteum of the midface and anterior face of the maxilla from the tendon of the masseter muscle up to Whitnall's tubercle.  The two dissection planes within joint in the subperiosteal fashion and dissection proceeded laterally out to the zygomatic neurovascular bundle.  It was bipolar electrocauteried and the tunnel was further dissected free and opened.  The endotine 4.5 soft tissue suspension device was then inserted through the temporal incision, brought down into the subperiosteal midface plane of dissection.  The guard was removed and the suspension spikes were engaged into the soft tissues.  The spikes were elevated superiorly such that a symmetrical midface elevation was carried out bilaterally.  The endotine device was then secured to the true temporal fascia with three sutures of 3-0 PDS suture.  Contralateral side was treated in similar fashion with like results in order to achieve facial symmetry and symmetry was obtained.  The gingivobuccal sulcus incisions were closed with interrupted 4-0 chromic and the scalp incision was closed with staples.  The sterile dressing was applied.  The patient was awakened in the operating room and taken to the recovery room in good condition.","ophthalmology, cosmetic surgery, jaeger lid plate, lacri-lube, q-tip, blepharoplasty, conjunctiva, facial asymmetry, fat pad, lower lid, midface lift, regional field block, temporal fascia, temporal fossa, vasoconstriction, true temporal fascia, gingivobuccal sulcus, gingivobuccal,"
 Clear corneal temporal incision (no stitches).  A lid speculum was placed in the fissure of the right eye., Ophthalmology, Clear Corneal Temporal Incision ,"CLEAR CORNEAL TEMPORAL INCISION (NO STITCHES),DESCRIPTION OF OPERATION: , Under satisfactory local anesthesia, the patient was appropriately prepped and draped.  A lid speculum was placed in the fissure of the right eye.,The secondary incision was then made through clear cornea using 1-mm diamond keratome at surgeon's 7:30 position and the anterior chamber re-formed using viscoelastic.  The primary incision was then made using a 3-mm diamond keratome at the surgeon's 5 o'clock position and additional viscoelastic injected into the anterior chamber as needed.  The capsulorrhexis was then performed in a standard circular tear fashion.  The nucleus was then separated from its cortical attachments by hydrodissection and emulsified in the capsular bag.  The residual cortex was then aspirated from the bag and the bag re-expanded using viscoelastic.  The posterior chamber intraocular lens was then inspected, irrigated, coated with Healon and folded, and then placed into the capsular bag under direct visualization.  The lens was noted to center well.  The residual viscoelastic was then removed from the eye and the eye re-formed using balanced salt solution.  The eye was then checked and found to be watertight; therefore, no suture was used.  The lid speculum and the drapes were then removed and the eye treated with Maxitrol ointment.,A shield was applied and the patient returned to the recovery room in good condition.","ophthalmology, clear corneal temporal incision, intraocular lens, corneal temporal incision, lid speculum, incision, temporal, chamber, corneal, viscoelastic, eyeNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 One-week history of decreased vision in the left eye.  Past ocular history includes cataract extraction with lens implants in both eyes., Ophthalmology, Decreased Vision Consult ,"She has a past ocular history including cataract extraction with lens implants in both eyes in 2001 and 2003.  She also has a history of glaucoma diagnosed in 1990 and macular degeneration.  She has been followed in her home country and is here visiting family.  She had the above-mentioned observation and was brought in on an urgent basis today.,Her past medical history includes hypertension and hypercholesterolemia and hypothyroidism.,Her medications include V-optic 0.5% eye drops to both eyes twice a day and pilocarpine 2% OU three times a day.  She took both the drops this morning.  She also takes Eltroxin which is for hypothyroidism, Plendil for blood pressure, and pravastatin.,She is allergic to Cosopt.,She has a family history of blindness in her brother as well as glaucoma and hypertension.,Her visual acuity today at distance without correction are 20/25 in the right and count fingers at 3 feet in the left eye.  Manifest refraction showed no improvement in either eye.  The intraocular pressures by applanation were 7 on the right and 18 in the left eye.  Gonioscopy showed grade 4 open angles in both eyes.  Humphrey visual field testing done elsewhere showed diffuse reduction in sensitivity in both eyes.  The lids were normal OU.  She has mild dry eye OU.  The corneas are clear OU.  The anterior chamber is deep and quiet OU.  Irides appear normal.  The lenses show well centered posterior chamber intraocular lenses OU.,Dilated fundus exam shows clear vitreous OU.  The optic nerves are normal in size.  They both appear to have mild pallor.  The optic cups in both eyes are shallow.  The cup-to-disc ratio in the right eye is not overtly large, would estimated 0.5 to 0.6; however, she does have very thin rim tissue inferotemporally in the right eye.  In the left eye, the glaucoma appears to be more advanced to the larger cup-to-disc ratio and a thinner rim tissue.,The macula on the right shows drusen with focal areas of RPE atrophy.  I do not see any evidence of neovascularization such as subretinal fluid, lipid or hemorrhage.  She does have a punctate area of RPE atrophy which is just adjacent to the fovea of the right eye.  In the left eye, she has also several high-risk drusen, but no evidence of neovascularization.  The RPE in the left eye does appear to be more diffusely abnormal although these changes do appear somewhat mild.  I do not see any dense or focal areas of frank RPE atrophy or hypertrophy.,The peripheral retinas are attached in both eyes.,Ms. ABC has pseudophakia OU which is stable and she is doing well in this regard.  She has glaucoma which likely is worse in the left eye and also likely explains her poor vision in the left eye.  The intraocular pressure in the mid-to-high teens in the left eye is probably high for her.  She has allergic reaction to Cosopt.  I will recommend starting Xalatan OS nightly.  I think the intraocular pressure in the right eye is acceptable and is probably a stable pressure for her OD.  She will need followup in the next 1 or 2 months after returning home to Israel later this week after starting the new medication which is Xalatan.,Regarding the macular degeneration, she has had high-risk changes in both eyes.  The vision in the right eye is good, but she does have a very concerning area of RPE atrophy just adjacent to the fovea of the right eye.  I strongly recommend that she see a retina specialist before returning to Israel in order to fully discuss prophylactic measures to prevent worsening of her macular degeneration in the right eye.","ophthalmology, cataract extraction, lens implants, decreased vision, macular degeneration, intraocular pressures, rpe atrophy, eye, degeneration, glaucoma, macular, vision, "
 Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid., Ophthalmology, Eyelid Squamous Cell Carcinoma Excision ,"PREOPERATIVE DIAGNOSIS: , Right upper eyelid squamous cell carcinoma.,POSTOPERATIVE DIAGNOSIS: , Right upper eyelid squamous cell carcinoma.,PROCEDURE PERFORMED: , Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid.,COMPLICATIONS:  ,None.,BLOOD LOSS: , Minimal.,ANESTHESIA:,  Local with sedation.,INDICATION:,  The patient is a 65-year-old male with a large squamous cell carcinoma on his right upper eyelid, which had previous radiation.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, laid supine, administered intravenous sedation, and prepped and draped in a sterile fashion.  He was anesthetized with a combination of 2% lidocaine and 0.5% Marcaine with Epinephrine on both upper eyelids.  The area of obvious scar tissue from the radiation for the squamous cell carcinoma on the right upper eyelid was completely excised down to the eyelid margin including resection of a few of the upper eye lashes.  This was extended essentially from the punctum to the lateral commissure and extended up on to the upper eyelid.  The resection was carried down through the orbicularis muscle resecting the pretarsal orbicularis muscle and the inferior portion of the preseptal orbicularis muscle leaving the tarsus intact and leaving the orbital septum intact.  Following complete resection, the patient was easily able to open and close his eyes as the levator muscle insertion was left intact to the tarsal plate.  The specimen was sent to pathology, which revealed only fibrotic tissue and no evidence of any residual squamous cell carcinoma.  Meticulous hemostasis was obtained with Bovie cautery and a full-thickness skin graft was taken from the opposite upper eyelid in a fashion similar to a blepharoplasty of the appropriate size for the defect in the right upper eyelid.  The left upper eyelid incision was closed with 6-0 fast-absorbing gut interrupted sutures, and the skin graft was sutured in place with 6-0 fast-absorbing gut interrupted sutures.  An eye patch was placed on the right side, and the patient tolerated the procedure well and was taken to PACU in good condition.","ophthalmology, frozen section, full-thickness skin grafting, squamous cell carcinoma, eyelid, orbicularis,"
" Cataract to right eye.  Cataract extraction with intraocular lens implant of the right eye, anterior vitrectomy of the right eye.", Ophthalmology, Cataract Extraction & Vitrectomy ,"PREOPERATIVE DIAGNOSIS: , Cataract to right eye.,POSTOPERATIVE DIAGNOSIS: , Cataract to right eye.,PROCEDURE PERFORMED:  ,Cataract extraction with intraocular lens implant of the right eye, anterior vitrectomy of the right eye.,LENS IMPLANT USED:  ,See below.,COMPLICATIONS: , Posterior capsular hole, vitreous prolapse.,ANESTHESIA:  ,Topical.,PROCEDURE IN DETAIL:  ,The patient was identified in the preoperative holding area before being escorted back to the operating room suite.  Hemodynamic monitoring was begun.  Time-out was called and the patient eye operated upon and lens implant intended were verbally verified.  Three drops of tetracaine were applied to the operative eye.  The patient was then prepped and draped in usual sterile fashion for intraocular surgery.  A lid speculum was placed.  Two paracentesis sites were created approximately 120 degrees apart straddling the temple using a slit knife.  The anterior chamber was irrigated with a dilute 0.25% solution of non-preserved lidocaine and filled with Viscoat.  The clear corneal temporal incision was fashioned.  The anterior chamber was entered by introducing a keratome.  The continuous tear capsulorrhexis was performed using the bent needle cystotome and completed with Utrata forceps.  The cataractous lens was then hydrodissected and phacoemulsified using a modified phaco-chop technique.  Following removal of the last nuclear quadrant, there was noted to be a posterior capsular hole nasally.  This area was tamponaded with Healon.  The anterior chamber was swept with a cyclodialysis spatula and there was noted to be vitreous prolapse.  An anterior vitrectomy was then performed bimanually until the vitreous was cleared from the anterior chamber area.  The sulcus area of the lens was then inflated using Healon and a V9002 16.0 diopter intraocular lens was unfolded and centered in the sulcus area with haptic secured in the sulcus.  There was noted to be good support.  Miostat was injected into the anterior chamber and viscoelastic agent rinsed out of the eye with Miostat.  Gentle bimanual irrigation, aspiration was performed to remove remaining viscoelastic agents anteriorly.  The pupil was noted to constrict symmetrically.  Wounds were checked with Weck-cels and found to be free of vitreous.  BSS was used to re-inflate the anterior chamber to normal depth as confirmed by tactile pressure at about 12.  All corneal wounds were then hydrated, checked and found to be watertight and free of vitreous.  A single 10-0 nylon suture was placed temporarily as prophylaxis and the knot buried.  Lid speculum was removed.  TobraDex ointment, light patch and a Soft Shield were applied.  The patient was taken to the recovery room, awake and comfortable.  We will follow up in the morning for postoperative check.  He will not be given Diamox due to his sulfa allergy.  The intraoperative course was discussed with both he and his wife.","ophthalmology, intraocular lens implant, lid speculum, cataract extraction, anterior vitrectomy, anterior chamber, eye, intraocular, extraction, hemodynamic, implant, vitrectomy, vitreous, cataract, lens,"
 A sample note on Conjunctivitis (Pink Eye)., Ophthalmology, Conjunctivitis ,"CONJUNCTIVITIS,, better known as Pink Eye, is an infection of the inside of your eyelid.  It is usually caused by allergies, bacteria, viruses, or chemicals.,WHAT ARE THE SIGNS AND SYMPTOMS?,1.  Red, irritated eye.,2.  Some burning and/or scratchy feeling.,3.  There may be a purulent (pus) or a mucous type discharge.,HOW IS IT TREATED?,It depends on what caused the Pink Eye.  It may or may not need medication for treatment.  If medication is given, follow the directions on the label.,TO PREVENT THE SPREAD OF THE INFECTION:,1.  Wash hands thoroughly before you use the medicine in your eyes.  After using the medicine in your eyes.  Every time you touch your eyes or face.,2.  Wash any clothing touched by infected eyes.,Clothes,Towels,Pillowcases,3.  Do not share make-up.  If the infection is caused by bacteria or a virus you must throw away your used make-up and buy new make-up.,4.  Do not touch the infected eye because the infection will spread to the good eye.  IMPORTANT!!!,5.  Pink Eye Spreads Very Easily!","ophthalmology, eyelid, infected eyes, pink eye, conjunctivitis, eyes, infection, eye"
 Normal cataract surgery.  , Ophthalmology, Cataract Surgery ,"NORMAL CATARACT SURGERY,PROCEDURE DETAILS: , The patient was taken to the operating room where the Rand-Stein anesthesia protocol was followed using alfentanil and Brevital.  Topical tetracaine drops were applied.  The operative eye was prepped and draped in the usual sterile fashion.  A lid speculum was inserted.,Under the Zeiss operating microscope, a lateral clear corneal approach was utilized.  A stab incision was made with a diamond blade to the right of the lateral limbus and the anterior chamber filled with intracameral lidocaine and viscoelastic.  A 3-mm single pass clear corneal incision was made just anterior to the vascular arcade of the temporal limbus using a diamond keratome.  A 5- to 5.5-mm anterior capsulorrhexis was created.  The nucleus was hydrodissected and hydrodelineated, and was freely movable in the capsular bag.  The nucleus was then phacoemulsified using a quadrantic divide-and-conquer technique.  Following the deep groove formation, the lens was split bimanually and the resultant quadrants and epicortex removed under high-vacuum burst-mode phacoemulsification.  Peripheral cortex was removed with the irrigation and aspiration handpiece.  The posterior capsule was polished.  The capsular bag was expanded with viscoelastic.  The implant was inspected under the microscope and found to be free of defects.  The implant was inserted into the cartridge system under viscoelastic and placed in the capsular bag.  The trailing haptic was positioned with the cartridge system.  Residual viscoelastic was removed from the anterior chamber and from behind the implant.  The corneal wound was hydrated with balanced salt solution.  The anterior chamber was fully re-formed through the side-port incision.  The wound was inspected and found to be watertight.  The intraocular pressure was adjusted as necessary.  The lid speculum was removed.  Topical Timoptic drops, Eserine and Dexacidin ointment were applied.  The eye was shielded.  The patient appeared to tolerate the procedure well and left the operating room in stable condition.  Followup appointment is with Dr. X on the first postoperative day.","ophthalmology, zeiss, peripheral cortex, phacoemulsified, hydrodissected, rand-stein, lid speculum, anterior chamber, capsular bag, cataract, viscoelasticNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 She is sent for evaluation of ocular manifestations of systemic connective tissue disorders.  Denies any eye problems and history includes myopia with astigmatism., Ophthalmology, Connective Tissue Disorder ,"Her past medical history includes a presumed diagnosis of connective tissue disorder.  She has otherwise, good health.  She underwent a shoulder ligament repair for joint laxity.,She does not take any eye medications and she takes Seasonale systemically.  She is allergic to penicillin.,The visual acuity today, distance with her current prescription was 20/30 on the right and 20/20 on the left eye.  Over refraction on the right eye showed -0.50 sphere with acuity of 20/20 OD.  She is wearing -3.75 +1.50 x 060 on the right and -2.50 +0.25 x 140, OS.  Intraocular pressures are 13 OU and by applanation.  Confrontation, visual fields, extraocular movement, and pupils are normal in both eyes.  Gonioscopy showed normal anterior segment angle morphology in both eyes.  She does have some fine iris strength crossing the angle, but the angle is otherwise open 360 degrees in both eyes.,The lids were normal in both eyes.  Conjunctivae were quite, OU.  Cornea were clear in both eyes.  The anterior chamber is deep and quiet, OU.  She has clear lenses, which are in good position, OU.  Dilated fundus exam shows moderately optically clear vitreous, OU.  The optic nerves are normal in size.  The cup-to-disc ratios were approximately 0.4, OU.  The nerve fiber layers are excellent, OU.  The macula, vessels, and periphery were normal in both eyes.  No evidence of peripheral retinal degeneration is present in either eye.,Ms. ABC has optically clear vitreous.  She does not have any obvious risk factors for retinal detachment at present such as peripheral retinal degeneration and her anterior chamber angles are normal in both eyes.,She does have moderate myopia, however.,This combination of findings suggests and is consistent with her systemic connective tissue disorder such as a Stickler syndrome or a variant of Stickler syndrome.,I discussed with her the symptoms of retinal detachment and advised her to contact us immediately if they occur.  Otherwise, I can see her in 1 to 2 years.","ophthalmology, systemic connective tissue disorder, stickler syndrome, anterior chamber angles, retinal degeneration, connective tissue disorder, vitreous, degeneration, detachment, myopia, optically, astigmatism, eyes"
" Patient  follows up for cataract extraction with lens implant 2 weeks ago.   Recovering well from her cataract operation in the right eye with residual corneal swelling, which should resolve in the next 2 to 3 weeks.", Ophthalmology, Cataract Extraction Followup ,"Her past medical history includes insulin requiring diabetes mellitus for the past 28 years.  She also has a history of gastritis and currently is being evaluated for inflammatory bowel disease.  She is scheduled to see a gastroenterologist in the near future.  She is taking Econopred 8 times a day to the right eye and Nevanac, OD, three times a day.  She is allergic to penicillin.,The visual acuity today was 20/50, pinholing, no improvement in the right eye.  In the left eye, the visual acuity was 20/80, pinholing, no improvement.  The intraocular pressure was 14, OD and 9, OS.  Anterior segment exam shows normal lids, OU.  The conjunctiva is quiet in the right eye.  In the left eye, she has an area of sectoral scleral hyperemia superonasally in the left eye.  The cornea on the right eye shows a paracentral area of mild corneal edema.  In the left eye, cornea is clear.  Anterior chamber in the right eye shows trace cell.  In the left eye, the anterior chamber is deep and quiet.  She has a posterior chamber intraocular lens, well centered and in sulcus of the left eye.  The lens in the left eye shows 3+ nuclear sclerosis.  Vitreous is clear in both eyes.  The optic nerves appear healthy in color and normal in size with cup-to-disc ratio of approximately 0.48.  The maculae are flat in both eyes.  The retinal periphery is flat in both eyes.,Ms. ABC is recovering well from her cataract operation in the right eye with residual corneal swelling, which should resolve in the next 2 to 3 weeks.  She will continue her current drops.  In the left eye, she has an area of what appears to be sectoral scleritis.  I did a comprehensive review of systems today and she reports no changes in her pulmonary, dermatologic, neurologic, gastroenterologic or musculoskeletal systems.  She is, however, being evaluated for inflammatory bowel disease.  The mild scleritis in the left eye may be a manifestation of this.  We will notify her gastroenterologist of this possibility of scleritis and will start Ms. ABC on a course of indomethacin 25 mg by mouth two times a day.  I will see her again in one week.  She will check with her primary physician prior to starting the Indocin.","ophthalmology, visual acuity, photophobia, lens implant, cataract extraction, eye, cataract, cornealNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Extracapsular cataract extraction with posterior chamber intraocular lens placement by phacoemulsification.  A peribulbar block was given to the eye using 8 cc of a mixture of 0.5% Marcaine without epinephrine mixed with Wydase plus one-half of 2% lidocaine without epinephrine., Ophthalmology, Cataract Extraction - 1 ,"PROCEDURE PERFORMED: , Extracapsular cataract extraction with posterior chamber intraocular lens placement by phacoemulsification.,ANESTHESIA:,  Peribulbar.,COMPLICATIONS:,  None.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room after the eye was dilated with topical Mydriacyl and Neo-Synephrine drops.  A Honan balloon was placed over the eye for a period of 20 minutes at 10 mmHg.  A peribulbar block was given to the eye using 8 cc of a mixture of 0.5% Marcaine without epinephrine mixed with Wydase plus one-half of 2% lidocaine without epinephrine.  The Honan balloon was then re-placed over the eye for an additional 10 minutes at 20 mmHg.  The eye was prepped with a Betadine solution and draped in the usual sterile fashion.  A wire speculum was placed in the eye and then a clear corneal paracentesis site was made inferiorly with a 15-degree blade, followed by instillation of 0.1 cc of preservative-free lidocaine 1% into the anterior chamber, followed by viscoelastic.  A 2.8-mm keratome was used to create a self-sealing temporal corneal incision and then a bent capsulotomy needle was used to create an anterior capsular flap.  The Utrata forceps were used to complete a continuous tear capsulorrhexis, and hydrodissection and hydrodelineation of the nucleus was performed with BSS on a cannula.  Phacoemulsification in a quartering-and-cracking technique was used to remove the nucleus and then the residual cortex was removed with the irrigation and aspiration unit.  Gentle vacuuming of the central posterior capsule was performed.  The capsular bag was re-expanded with viscoelastic, and then the wound was opened to a 3.4-mm size with an additional keratome to allow insertion of the intraocular lens.,The intraocular lens was folded, inserted into the capsular bag and then un-folded.  The trailing haptic was tucked underneath the anterior capsular rim.  The lens was shown to center very well.  Therefore, the viscoelastic was removed with the irrigation and aspiration unit and one 10-0 nylon suture was placed across the incision after Miochol was injected into the anterior chamber to cause pupillary constriction.  The wound was shown to be watertight.  Therefore, TobraDex ointment was applied to the eye, an eye pad loosely applied and a Fox shield taped firmly in place.,The patient tolerated the procedure well and left the operating room in good condition.","ophthalmology, phacoemulsification, hydrodissection, peribulbar block, irrigation and aspiration, honan balloon, anterior chamber, anterior capsular, aspiration unit, capsular bag, cataract extraction, intraocular lens, cataract, extraction, peribulbar, lidocaine, viscoelastic, chamber, epinephrine, anterior, capsular, lens, intraocular, eye, "
 A sample note on Cataract, Ophthalmology, Cataract ,"CATARACT, is the loss of transparency of the lens of the eye.  It often appears like a window that is fogged with steam.,WHAT CAUSES CATARACT FORMATION?,*  Aging, the most common cause.,*  Family history.,*  Steroid use.,*  Injury to the eye.,*  Diabetes.,*  Previous eye surgery.,*  Long-term exposure to sunlight.,HOW DO I KNOW IF I HAVE A CATARACT?,*  The best way for early detection is regular eye examinations by your medical eye doctor. There are many causes of visual loss in addition to the cataract such as problems involving the optic nerve and retina.  If these other problems exist, cataract removal may not result in the return or improvement of vision.  Your eye doctor can tell you how much improvement in vision is likely.,DOES IT TAKE A LONG TIME FOR A CATARACT TO FORM?,Cataract development varies greatly between patients and is affected by the cause of the cataract.  Generally, cataracts progress gradually over many years.  Some people, especially diabetics and younger patients, may find that cataract formation progresses rapidly over a few months making it impossible to know exactly how long it will take for the cataract to develop. ,WHAT IS THE TREATMENT FOR CATARACTS?,The only way to remove a cataract is surgery.  If the symptoms are not restricting your activity, a change of glasses may alleviate the symptoms at this time.  No medications, exercise, optical devices or dietary supplements have been shown to stop the progression or prevent cataracts.,It is important to provide protection from excessive sunlight.  Making sure that the sunglasses you wear screen out ultraviolet (UV) light rays or your regular eyeglasses are coated with a clear, anti-UV coating will help prevent or slow the progression of cataracts.,HOW DO I KNOW IF I NEED SURGERY?,Surgery is considered when your vision is interfering with your daily activities.  It is important to evaluate if you can see to do your job and drive safely.  Can you read and watch TV in comfort? Are you able to cook, do your shopping and yard work or take your medications without difficulty? Depending on how you feel your vision is affecting your daily life, you and your eye doctor will decide together when it is the appropriate time to do surgery.,WHAT IS INVOLVED WITH CATARACT SURGERY?,This surgery is generally performed under local anesthesia on an outpatient basis.  With the assistance of a microscope, the cloudy lens is removed and replaced with a permanent intraocular lens implant.,Right after the surgery you should be able to immediately perform all your normal activities except for the most strenuous ones.  You will need to take eye drops as directed by your eye doctor.  Follow-up visits are necessary to make sure the surgical site is healing without problems.,This procedure is performed on over 1.4 million people each year in the United States alone, 95% without complications.  With this highly successful procedure, 90% of the time vision improves unless a problem also exists with the cornea, retina or optic nerve.  As with any surgery, a good result cannot be guaranteed.","ophthalmology, transparency, eye, sunlight, optic nerve, eye doctor, cataract, retina, lens, vision, surgery, "
" Hairline biplanar temporal browlift, quadrilateral blepharoplasty, canthopexy, cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy.", Ophthalmology," Browlift, Blepharoplasty, & Rhytidectomy ","PREOPERATIVE DIAGNOSES:,1.  Eyebrow ptosis.,2.  Dermatochalasia of upper and lower eyelids with tear trough deformity of the lower eyelid.,3.  Cervical facial aging with submental lipodystrophy.,OPERATION:,1.  Hairline biplanar temporal browlift.,2.  Quadrilateral blepharoplasty with lateral canthopexy with arcus marginalis release and fat transposition over inferior orbital rim to lower eyelid.,3.  Cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy.,ASSISTANT:  ,None.,ANESTHESIA: , General endotracheal anesthesia.,PROCEDURE: , The patient was placed in a supine position and prepped with general endotracheal anesthesia.  Local infiltration anesthesia with 1% Xylocaine and 1:100,000 epinephrine was infiltrated in upper and lower eyelids.,Markings were made and fusiform ellipse of skin was resected from the upper eyelid.  The lower limb of the fusiform ellipse was at the superior palpebral fold.  A 9 mm of upper eyelid skin was resected at the widest portion of the lips, which extended from medial canthal area to the lateral orbital rim.  This was performed bilaterally and symmetrically and the skin was removed.  Incision was made through the pretarsal orbicularis with small amount of fat being removed from the medial and middle fat pocket.  An incision was made over the superior orbital rim.  Subperiosteal dissection was performed over the forehead.  The dissection proceeded medially.  The corrugator and procerus muscles were carefully dissected from the supratrochlear nerves on both right and left side and cauterized.,Hemostasis was achieved with electrocautery in this fashion.  A 4-cm incision was made, and the forehead at the hairline, subcutaneous dissection was performed and extended over the frontalis muscle for approximately 4 cm.  A subperiosteal dissection was performed after the fibers of the frontalis muscle were separated and subperiosteal dissection from the forehead lead the subperiosteal dissection from the upper eyelid.  The incision was made in the lower lid just beneath the lashline.  Subcutaneous dissection was performed over the pretarsal and preseptal muscle.  Dissection was then proceeded down to the inferior orbital rim.  The arcus marginalis was released and the lower eyelid fat was teased over the inferior orbital rim and sutured to the suborbicularis oculi fat and periosteum, which was separated from the inferior orbital rim.  The orbital fat was sutured to the suborbicularis oculi fat with multiple preplaced sutures of 5-0 Vicryl on a P2 needle.  The upper eyelid incision was closed with a running subcuticular 6-0 Prolene suture bilaterally.  The forehead was then elevated, and the nonhairbearing forehead skin was resected 1.5 cm wide raising the tail of the eyebrow.  The head of the eyebrow was felt to be elevated by the antagonistic frontalis muscle now that the accessory muscles specifically the corrugator and procerus and depressor supercilii were released and divided.,A lateral canthopexy was performed with 5-0 Prolene suture on a C1 double-arm tapered needle being passed from the lateral commissure of the eyelid to the small stab incision being passed to the medial superior orbital rim and sutured to tighten the lower lid.  The distal lateral resection of excessive lower eyelid skin was reduced at risk of eyelid malposition.  The lower lid incision was closed after the redundancy of skin measuring approximately 3 mm was resected on both sides.  Closure was performed with interrupted 6-0 silk suture for the lower lid.  The eyebrow hairline brow lift was closed with interrupted 4-0 PDS suture, deep subcutaneous tissue, and dermis, and the skin closed with a running 5-0 Prolene suture.,Attention then was directed to the cervical facial rhytidectomy and purse-string SMAS elevation with submental lipectomy.  Incisions were made in preauricular area, postauricular area, mastoid and occipital area.  Subcutaneous dissection was performed to the nasolabial fold and cheek and extending across the neck in the midline.  Submental lipectomy was performed through the incision in the submental crease.  Fat was directly removed from the fascia.,Hemostasis was achieved with electrocautery.  A SMAS elevation was performed with a purse-string suture of 2-0 PDS suture from temporalis fascia in front of the ear extending beneath the mandible and then brought back up to be sutured to the temporalis fascia.  This was performed bilaterally and symmetrically.  Hemostasis was achieved with electrocautery.  The cheek flap was brought back posteriorly and the cervical flap posteriorly and superiorly with redundant skin on the right massaged and closed.  The skin of the cheek and neck were resected which was redundant after the ***** posteriorly and superiorly in the neck and transversely in the cheek.,Closure was performed with interrupted 3-0 and 4-0 PDS suture of deep subcutaneous tissue and dermis of the skin was closed with a running 5-0 Prolene suture.  Drains were placed prior to final closure.  A 7-mm flat Jackson-Pratt was then secured with 3-0 silk suture.  Dressing consisting of fluffs and Kerlix and a 4-inch Ace were applied to support mildly compressive dressing.  Scleral eye protectors were removed.  Maxitrol eye ointment was placed followed by Swiss therapy eye pads.  The patient tolerated the procedure well, and she returned to recovery room in satisfactory condition with Foley catheter and Pneumatic compression stockings, TED hose, two Jackson-Pratt drains, and an IV.","ophthalmology, eyebrow ptosis, dermatochalasia, hairline, jackson-pratt, swiss therapy, arcus marginalis, blepharoplasty, browlift, canthopexy, fat transposition, inferior orbital rim, lipectomy, lipodystrophy, lower eyelid, purse-string, rhytidectomy, string smas elevation, suborbicularis oculi, frontalis muscle, pds suture, smas elevation, submental lipectomy, upper eyelid, subperiosteal dissection, lower lid, prolene suture, lower eyelids, orbital rim, lower, eyelids, sutured, subcutaneous, eyebrow, orbital,"
" Cataract extraction with lens implantation, right eye.  The lens was inspected and found to be free of defects, folded, and easily inserted into the capsular bag, and unfolded.", Ophthalmology, Cataract Extraction ,"PROCEDURE PERFORMED:,  Cataract extraction with lens implantation, right eye.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room.  The patient was identified and the correct operative site was also identified.  A retrobulbar block using 5 ml of 2% lidocaine without epinephrine was done after adequate anesthetic was assured, and the eye was massaged to reduce risk of bleeding.  The patient was prepped and draped in the usual fashion.  A lid speculum was applied.,A groove incision at the 12 o'clock position was made with a 5700 blade.  This was beveled anteriorly in a lamellar fashion using the crescent knife.  Then the anterior chamber was entered with a slit knife.  The chamber was deepened with Viscoat.  Then a paracentesis at the 3 o'clock position was created using a super sharp blade.  A cystitome was used to nick the anterior capsule and then the capsulotomy was completed with capsulorrhexis forceps.  Hydrodissection was employed using BSS on a blunt 27-gauge needle.,The phaco tip was then introduced into the eye, and the eye was divided into 4 grooves.  Then a second instrument was used, a Sinskey hook, to crack these grooves, and the individual quadrants were brought into the central zone and phacoemulsified.  I/A proceeded without difficulty using the irrigation/aspiration cannula.  The capsule was felt to be clear and intact.  The capsular bag was then expanded with ProVisc.,The internal corneal wound was increased using the slit knife.  The lens was inspected and found to be free of defects, folded, and easily inserted into the capsular bag, and unfolded.  A corneal light shield was then used as the wound was sutured with a figure-of-eight 10-0 nylon suture.  Then the Viscoat was removed using I/A, and the suture drawn up and tied.,The 0.2 ml of gentamicin was injected subconjunctivally.  Maxitrol ointment was instilled into the conjunctival sac.  The eye was covered with a double patch and shield, and the patient was discharged.","ophthalmology, lens implantation, anterior chamber, lid speculum, eye, sinskey hook, cataract extraction, capsular bag, cataract, capsular, knife, lens"
" Extracapsular cataract extraction with phacoemulsification and implantation of a posterior chamber intraocular lens, left eye.", Ophthalmology, Cataract Extraction - 2 ,"PREOPERATIVE DIAGNOSIS: , Cataract, left eye.,POSTOPERATIVE DIAGNOSIS:  ,Cataract, left eye.,PROCEDURE PERFORMED:  ,Extracapsular cataract extraction with phacoemulsification and implantation of a posterior chamber intraocular lens, left eye.,ANESTHESIA: , Topical.,COMPLICATIONS: , None.,PROCEDURE: , After the induction of topical anesthesia with 4% Xylocaine drops, the left eye was prepped and draped in the usual fashion.  A speculum was inserted, and the microscope was moved into position.,A 3.2-mm incision was made in clear cornea at the limbus with a diamond keratome at the 3 o'clock position, and 0.1 cc of 1% Xylocaine without preservative was instilled into the anterior chamber.  It was then filled with viscoelastic.  A stab incision was made into the anterior chamber at the limbus at 5 o'clock position with a microblade.,A cystitome was used to make a capsulotomy, and the capsulorrhexis forceps were used to complete a circular capsulorrhexis.  The nucleus was hydrodelineated and hydrodissected with balanced salt solution on a 26-gauge cannula, and the phacoemulsifier was used to phacoemulsify the nucleus using a bimanual technique with the nucleus rotator inserted through the keratotomy incision.  The irrigation-aspiration handpiece was used to systematically aspirate cortex 360 degrees.  The posterior capsule was vacuumed; it was clear and intact.,The capsular bag and the anterior chamber were filled with viscoelastic.  A model MA30AC lens, power 21.5 diopters, serial number 864414.095, was folded, grasped with the lens insertion forceps and inserted into the capsular bag.  The trailing loop was placed inside the bag.  The viscoelastic was removed with the irrigation-aspiration handpiece.  The lens centered well.  A single 10-0 nylon suture was placed to close the wound.  It was checked and ascertained to be watertight.  Decadron 0.25 cc, 0.25 cc of antibiotic and 0.25 cc of Xylocaine were injected subconjunctivally.  Dexacidin ointment was placed in the eye, and the procedure was terminated.,The procedure was well tolerated by the patient who was returned to the recovery room in good condition.","ophthalmology, anterior chamber, keratome, limbus, intraocular lens, cataract extraction, extracapsular, phacoemulsification, capsular, cataract, chamber, intraocular,"
 Quad blepharoplasty for blepharochalasia and lower lid large primary and secondary bagging., Ophthalmology, Blepharoplasty - Quad ,"PREOPERATIVE DIAGNOSES:,1.  Blepharochalasia.,2.  Lower lid large primary and secondary bagging.,POSTOPERATIVE DIAGNOSES:,1.  Blepharochalasia.,2.  Lower lid large primary and secondary bagging.,PROCEDURE: , Quad blepharoplasty.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Minimal.,CONDITION: , The patient did well.,PROCEDURE:  ,The patient had marks and measurements prior to surgery.  Additional marks and measurements were made at the time of surgery; these were again checked.  At this point, the area was injected with 0.5% lidocaine with 1:200,000 epinephrine.  Appropriate time waited for the anesthetic and epinephrine effect.,Beginning on the left upper lid, the skin excision was completed.  The muscle was opened, herniated, adipose tissue pad in the middle and medial aspect was brought forward, cross-clamped, excised, cauterized, and allowed to retract.  The eyes were kept irrigated and protected throughout the procedure.  Attention was turned to the opposite side.  Procedure was carried out in the similar manner.,At the completion, the wounds were then closed with a running 6-0 Prolene, skin adhesives, and Steri-Strips.  Attention was turned to the right lower lid.  A lash line incision was made.  A skin flap was elevated and the muscle was opened.  Large herniated adipose tissue pads were present in each of the three compartments.  They were individually elevated, cross-clamped, excised, cauterized, and allowed to retract.,At the completion, a gentle tension was placed on the facial skin and several millimeters of the skin excised.  Attention was turned to he opposite side.  The procedure was carried out as just described.  The contralateral side was reexamined and irrigated.  Hemostasis was good and it was closed with a running 6-0 Prolene.  The opposite side was closed in a similar manner.,Skin adhesives and Steri-Strips were applied.  The eyes were again irrigated and cool Swiss Eye compresses applied.  At the completion of the case, the patient was extubated in the operating room, breathing on her own, doing well, and transferred in good condition from operating room to recovering room.","ophthalmology, blepharochalasia, lower lid, swiss eye compresses, adipose tissue pad, bagging, blepharoplasty, lash line incision, quad blepharoplasty,"
 The patient seeks evaluation for a second opinion concerning cataract extraction.  , Ophthalmology, Cataract - Second Opinion ,"SUBJECTIVE:  ,The patient seeks evaluation for a second opinion concerning cataract extraction.  She tells me cataract extraction has been recommended in each eye; however, she is nervous to have surgery.  Past ocular surgery history is significant for neurovascular age-related macular degeneration.  She states she has had laser four times to the macula on the right and two times to the left, she sees Dr. X for this.,OBJECTIVE: , On examination, visual acuity with correction measures 20/400 OU.  Manifest refraction does not improve this.  There is no afferent pupillary defect.  Visual fields are grossly full to hand motions.  Intraocular pressure measures 17 mm in each eye.  Slit-lamp examination is significant for clear corneas OU.  There is early nuclear sclerosis in both eyes.  There is a sheet like 1-2+ posterior subcapsular cataract on the left.  Dilated examination shows choroidal neovascularization with subretinal heme and blood in both eyes.,ASSESSMENT/PLAN:  ,Advanced neurovascular age-related macular degeneration OU, this is ultimately visually limiting.  Cataracts are present in both eyes.  I doubt cataract removal will help increase visual acuity; however, I did discuss with the patient, especially in the left, cataract surgery will help Dr. X better visualize the macula for future laser treatment so that her current vision can be maintained.  This information was conveyed with the use of a translator.,","ophthalmology, advanced neurovascular age-related macular degeneration, neurovascular age, macular degeneration, visual acuity, cataract extraction, neurovascular, degeneration, visual, eyes, macular, cataract,"
 Blepharoplasty with direct brow repair., Ophthalmology, Blepharoplasty - Direct Brow Repair ,"PREOPERATIVE DX:, Dermatochalasis, mechanical ptosis, brow ptosis.,POSTOPERATIVE DX:, Same,PROCEDURE:,: Upper lid blepharoplasty and direct brow lift,ANESTHESIA:, Local with sedation,INDICATIONS FOR SURGERY: , In the preoperative evaluation the patient was found to have visually significant and symptomatic dermatochalasis and brow ptosis causing mechanical ptosis and visual field obstruction.  Visual field testing showed *% superior hemifield loss on the right, and *% superior hemifield loss on the left.  These field losses resolved with upper eyelid taping which simulates the expected surgical correction.  Photodocumentation also showed the upper eyelids resting on the upper eyelashes, as well as a decrease in the effective superior marginal reflex distance.  The risks, benefits, limitations, alternatives, and expected improvement in symptoms and visual field loss were discussed in preoperative evaluation.,DESCRIPTION OF PROCEDURE:, On the day of surgery, the surgical site and procedure were verified by the physician with the patient.  An informed consent was signed and witnessed.  EMLA cream was applied to the eyelids and eyebrow region for 10 minutes to provide skin anesthesia.  Two drops of topical proparacaine eye drops were placed on the ocular surface.  The skin was cleaned with alcohol prep pads.  The patient received 3 to 4 mL of 2% Lidocaine with epinephrine and 0.5% Marcaine mixture to each upper lid.  5 to 6 mL of local were also given to the brow region along the entire length.  Pressure was applied over each site for 5 minutes.  The patient was then prepped and draped in the normal sterile fashion for oculoplastic surgery.,The desired amount of redundant brow tissue to be excised was carefully marked with a surgical marking pen on each side.  The contour of the outline was created to provide a greater temporal lift.  Care was taken to preserve a natural contour to the brow shape consistent with the patient’s desired features.  Using a #15 blade, the initial incision was placed just inside the superior most row of brow hairs, in parallel with the follicle growth orientation.  The incision extended in a nasal to temporal fashion with the nasal portion incision being carried down to muscle and becoming progressively shallower toward the tail of the incision line.  The dimensions of the redundant tissue measured * horizontally and * vertically.  The redundant tissue was removed sharply with Westcott scissors.  Hemostasis was maintained with hand held cautery and/or electrocautery.  The closure was carried out in multiple layers.  The deepest muscular/subcutaneous tissue was closed with 4-0 transparent nylon in a horizontal mattress fashion.  The intermediate layer was closed with 5-0 Vicryl similarly.  The skin was closed with 6-0 nylon in a running lock fashion.  Iced saline gauze pads were placed over the incision sites.  This completed the brow repair portion of the case.,Using a surgical marking pen, a vertical line was drawn from the superior punctum to the eyebrow.  An angled line was drawn from the ala of the nares to the lateral canthus edge and extending to the tail of the brow.  These lines served as the relative boundary for the horizontal length of the blepharoplasty incision.  The desired amount of redundant tissue to be excised was carefully pinched together with 0.5 forceps.  This tissue was outlined with a surgical marking pen.  Care was taken to avoid excessive skin removal near the brow region.  A surgical ruler was used to ensure symmetry.  The skin and superficial orbicularis were incised with a #15 blade on the first upper lid.  This layer was removed with Westcott scissors.,Hemostasis was achieved with high-temp hand held pen cautery.  The remaining orbicularis and septum were grasped superiorly and inferiorly on each side of the incision and tented upward.  The high temp cautery pen was then used to incise these layers in a horizontal fashion until preapeuronotic fat was identified.  * amount of central preaponeurotic fat was removed with cautery.  * amount of nasal fat pad was removed in the same fashion.  Care was taken to not disturb the levator aponeurosis.  A symmetric amount of fat was removed from each side.  Iced gauze saline was placed over the site and the entire procedure repeated on the fellow eyelid.  Skin hooks were placed on either side of the incision and the skin was closed in a continuous running fashion with 6-0 nylon.  Erythromycin ophthalmic ointment was placed over the incision site and on the ocular surface.  Saline gauze and cold packs were placed over the upper lids.  The patient was taken from the surgical suite in good condition.,DISCHARGE:,  In the recovery area the results of surgery were discussed with the patient and their family.  Specific instructions to resume all p.o. oral medications including anticoagulants/antiplatelets were given.  Written instructions and restrictions after eyelid surgery were reviewed with the patient and family member.  Instructions on antibiotic ointment use were reviewed.  The incision sites were checked prior to release.  The patient was released to home with a driver after vital signs were deemed stable.","ophthalmology, dermatochalasis, erythromycin ophthalmic, saline gauze, blepharoplasty, brow ptosis, cold packs, direct brow lift, follicle growth, hemifield loss, marginal reflex, mechanical ptosis, ocular surface, superficial orbicularis, visual field, surgical marking pen, direct brow, redundant tissue, incision sites, incision, brow, ptosis, surgical"
 Blepharoplasty procedure, Ophthalmology, Blepharoplasty ,"BLEPHAROPLASTY,The patient was prepped and draped.  The upper lid skin was marked out in a lazy S fashion, and the redundant skin marked out with a Green forceps.  Then the upper lids were injected with 2% Xylocaine and 1:100,000 epinephrine and 1 mL of Wydase per 20 mL of solution.,The upper lid skin was then excised within the markings.  Gentle pressure was placed on the upper eyelids, and the fat in each of the compartments was teased out using a scissor and cotton applicator; and then the fat was cross clamped, cut, and the clamp cauterized.  This was done in the all compartments of the middle and medial compartments of the upper eyelid, and then the skin sutured with interrupted 6-0 nylon sutures.  The first suture was placed in the lower eyelid skin picking up the periorbital muscle and then the upper portion of the tarsus and then the upper lid skin.  This created a significant crisp, supratarsal fold.  The upper lid skin was closed in this fashion, and then attention was turned to the lower lid.,An incision was made under the lash line and slightly onto the lateral canthus.  The #15 blade was used to delineate the plane in the lateral portion of the incision, and then using a scissor the skin was cut at the marking.  Then the skin muscle flap was elevated with sharp dissection.  The fat was located and using a scissor the three eyelid compartments were opened.  Fat was teased out, cross clamped, the fat removed, and then the clamp cauterized.  Once this was done the skin was tailored to the lower lid incision site with mouth open and eyes in upward gaze, and then the excess skin removed.  The suture line was sutured with interrupted 6-0 silk sutures.  Once this was done the procedure was finished.,The patient left the OR in satisfactory condition.  The patient was given 50 mg of Demerol IM with 25 mg of Phenergan.","ophthalmology, blepharoplasty, green forceps, wydase, applicator, canthus, lash line, lazy s, lazy s fashion, muscle flap, periorbital muscle, prepped and draped, supratarsal fold, upper lid, upward gaze, upper lid skin, eyelidsNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" Excision of large basal cell carcinoma, right lower lid, and repaired with used dorsal conjunctival flap in the upper lid and a large preauricular skin graft.", Ophthalmology, BCCa Excision - Lower Lid ,"PREOPERATIVE DIAGNOSIS: , Extremely large basal cell carcinoma, right lower lid.,POSTOPERATIVE DIAGNOSIS:,  Extremely large basal cell carcinoma, right lower lid.,TITLE OF OPERATION: , Excision of large basal cell carcinoma, right lower lid, and repaired with used dorsal conjunctival flap in the upper lid and a large preauricular skin graft.,PROCEDURE: , The patient was brought into the operating room and prepped and draped in usual fashion.  Xylocaine 2% with epinephrine was injected beneath the conjunctiva and skin of the lower lid and also beneath the conjunctiva and skin of the upper lid.  A frontal nerve block was also given on the right upper lid.  The anesthetic agent was also injected in the right preauricular region which would provide a donor graft for the right lower lid defect.  The area was marked with a marking pen with margins of 3 to 4 mm, and a #15 Bard-Parker blade was used to make an incision at the nasal and temporal margins of the lesion.,The incision was carried inferiorly, and using a Steven scissors the normal skin, muscle, and conjunctiva was excised inferiorly.  The specimen was then marked and sent to pathology for frozen section.  Bleeding was controlled with a wet-field cautery, and the right upper lid was everted, and an incision was made 3 mm above the lid margin with the Bard-Parker blade in the entire length of the upper lid.  The incision reached the orbicularis, and Steven scissors were used to separate the tarsus from the underlying orbicularis.  Vertical cuts were made nasally and temporally, and a large dorsal conjunctival flap was fashioned with the conjunctiva attached superiorly.  It was placed into the defect in the lower lid and sutured with multiple interrupted 6-0 Vicryl sutures nasally, temporally, and inferiorly.,The defect in the skin was measured and an appropriate large preauricular graft was excised from the right preauricular region.  The defect was closed with interrupted 5-0 Prolene sutures, and the preauricular graft was sutured in place with multiple interrupted 6-0 silk sutures.  The upper border of the graft was attached to the upper lid after incision was made in the gray line with a Superblade, and the superior portion of the skin graft was sutured to the upper lid through the anterior lamella created by the razor blade incision.,Cryotherapy was then used to treat the nasal and temporal margins of the area of excision because of positive margins, and following this an antibiotic steroid ointment was instilled and a light pressure dressing was applied.  The patient tolerated the procedure well and was sent to recovery room in good condition.","ophthalmology, basal cell carcinoma, cryotherapy, steven scissors, conjunctiva, conjunctival flap, frontal nerve block, frozen section, lower lid, orbicularis, skin graft, nasal and temporal margins, dorsal conjunctival flap, upper lid, basal, carcinoma, preauricular, incision, conjunctival, "
 Lower lid blepharoplasty., Ophthalmology, Blepharoplasty - Lower Lid ,"An orbital block was done.  An infraorbital block was also performed with a 25 gauge needle.  A skin muscle flap was elevated by sharp dissection down to the orbital rim area.  The herniated periorbital fat was removed by opening the orbital septum with sharp dissection using a 15 blade, teasing the periorbital fat out, cross clamping the fat and removing the fat with a scissor over the clamp.  The clamp was cauterized with needle cautery and then the clamp was scarped with a 15 blade.,The remaining fat was left to fall back into the orbit.  This was done in three compartments, the middle, medial and lateral compartments.  Fat was removed from all three compartments.  Then with the mouth open and the eyes in upward gaze, the lower skin muscle flap was redraped on the eyelids and tailored to fit exactly into place and then sutured into place with multiple 6-0 silk sutures.,Bleeding was minimal.  The patient tolerated the procedure well.","ophthalmology, lower lid, wydase, blepharoplasty, infraorbital block, muscle flap, orbital rim area, orbital septum, periorbital fat, subciliary incision, upward gaze, orbital, clampingNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" Repair of entropion, left upper lid, with excision of anterior lamella and cryotherapy.  Repairs of blepharon, entropion, right lower lid with mucous membrane graft.", Ophthalmology, Blepharon & Entropion Repair ,"PREOPERATIVE DIAGNOSES:,1.  Entropion, left upper lid.,2.  Entropion and some blepharon, right lower lid.,TITLE OF OPERATION:,1.  Repair of entropion, left upper lid, with excision of anterior lamella and cryotherapy.,2.  Repairs of blepharon, entropion, right lower lid with mucous membrane graft.,PROCEDURE IN DETAIL:  ,The patient was brought to the operating room and prepped and draped in the usual fashion.  The left upper lid and right lower lid were all infiltrated with 2% Xylocaine with Epinephrine.,The lid was then everted with special clips and the mucotome was then used to cut a large mucous membrane graft from the lower lid measuring 0.5 mm in thickness.  The graft was placed in saline and a 4 x 4 was placed over the lower lid.,Attention was then drawn to the left upper lid and the operating microscope was found to place.  An incision was made in the gray line nasally in the area of trichiasis and entropion, and the dissection was carried anterior to the tarsal plate and an elliptical piece of the anterior lamella was excised.  Bleeding was controlled with the wet-field cautery and the cryoprobe was then used with a temperature of -8 degree centigrade in the freeze-thaw-refreeze technique to treat the bed of the excised area.,Attention was then drawn to the right lower lid with the operating microscope and a large elliptical area of the internal aspect of the lid margin was excised with a super blade.  Some of the blepharon were dissected from the globe and bleeding was controlled with the wet-field cautery.  An elliptical piece of mucous membrane was then fashioned and placed into the defect in the lower lid and sutured with a running 6-0 chromic catgut suture anteriorly and posteriorly.,The graft was in good position and everything was satisfactory at the end of procedure.  Some antibiotic steroidal ointment was instilled in the right eye and a light pressure dressing was applied.  No patch was applied to the left eye.  The patient tolerated the procedure well and was sent to recovery room in good condition.","ophthalmology, entropion, blepharon, catgut suture, cryoprobe, cryotherapy, freeze-thaw-refreeze, lamella, lid, lower lid, tarsal plate, trichiasis, upper lid, mucous membrane graft, anterior lamella, mucous membrane, membrane"
 Bilateral upper lid blepharoplasty to correct bilateral upper eyelid dermatochalasis., Ophthalmology, Bilateral Upper Lid Blepharoplasty ,"PREOPERATIVE DIAGNOSIS:,  Bilateral upper eyelid dermatochalasis.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE: , Bilateral upper lid blepharoplasty, (CPT 15822).,ANESTHESIA: , Lidocaine with 1:100,000 epinephrine.,DESCRIPTION OF PROCEDURE: , This 65-year-old female demonstrates conditions described above of excess and redundant eyelid skin with puffiness and has requested surgical correction.  The procedure, alternatives, risks and limitations in this individual case have been very carefully discussed with the patient.  All questions have been thoroughly answered, and the patient understands the surgery indicated.  She has requested this corrective repair be undertaken, and a consent was signed.,The patient was brought into the operating room and placed in the supine position on the operating table.  An intravenous line was started, and sedation and sedation anesthesia was administered IV after preoperative p.o. sedation.  The patient was monitored for cardiac rate, blood pressure, and oxygen saturation continuously.  The excess and redundant skin of the upper lids producing redundancy and impairment of lateral vision was carefully measured, and the incisions were marked for fusiform excision with a marking pen.  The surgical calipers were used to measure the supratarsal incisions so that the incision was symmetrical from the ciliary margin bilaterally.,The upper eyelid areas were bilaterally injected with 1% Lidocaine with 1:100,000 Epinephrine for anesthesia and vasoconstriction.  The plane of injection was superficial and external to the orbital septum of the upper and lower eyelids bilaterally.,The face was prepped and draped in the usual sterile manner.,After waiting a period of approximately ten minutes for adequate vasoconstriction, the previously outlined excessive skin of the right upper eyelid was excised with blunt dissection.  Hemostasis was obtained with a bipolar cautery.  A thin strip of orbicularis oculi muscle was excised in order to expose the orbital septum on the right.  The defect in the orbital septum was identified, and herniated orbital fat was exposed.  The abnormally protruding positions in the medial pocket were carefully excised and the stalk meticulously cauterized with the bipolar cautery unit.  A similar procedure was performed exposing herniated portion of the nasal pocket.  Great care was taken to obtain perfect hemostasis with this maneuver.  A similar procedure of removing skin and taking care of the herniated fat was performed on the left upper eyelid in the same fashion.  Careful hemostasis had been obtained on the upper lid areas.  The lateral aspects of the upper eyelid incisions were closed with a couple of interrupted 7-0 blue Prolene sutures.,At the end of the operation the patient's vision and extraocular muscle movements were checked and found to be intact.  There was no diplopia, no ptosis, no ectropion.  Wounds were reexamined for hemostasis, and no hematomas were noted.  Cooled saline compresses were placed over the upper and lower eyelid regions bilaterally.,The procedures were completed without complication and tolerated well.  The patient left the operating room in satisfactory condition.  A follow-up appointment was scheduled, routine post-op medications prescribed, and post-op instructions given to the responsible party.,The patient was released to return home in satisfactory condition.","ophthalmology, bilateral upper eyelid dermatochalasis, blepharoplasty, upper lid, bilateral upper lid, eyelid, bilateral upper lid blepharoplasty, upper lid blepharoplasty, eyelid dermatochalasis, lid blepharoplasty, orbital septum, upper eyelid, anesthesia, dermatochalasis, hemostasis"
 The Ahmed shunt was primed and placed in the superior temporal quadrant and it was sutured in place with two 8-0 nylon sutures.  The knots were trimmed. , Ophthalmology, Ahmed Shunt Placement ,"PROCEDURE IN DETAIL:  ,While in the holding area, the patient received a peripheral IV from the nursing staff.  In addition, pilocarpine 1% was placed into the operative eye, two times, separated by 10 minutes.  The patient was wheeled to the operating suite where the anesthesia team established peripheral monitoring lines.  Through the IV, the patient received IV sedation in the form of propofol and once somnolent from this, a retrobulbar block was administrated consisting of 2% Xylocaine plain.  Approximately 3 mL were administered.  The patient then underwent a Betadine prep with respect to the face, lens, lashes, and eye.  During the draping process, care was taken to isolate the lashes.  A Vicryl traction suture was placed through the superior cornea and the eye was reflected downward to expose the superior temporal conjunctiva.  Approximately 8 to 10 mm posterior to limbus, the conjunctiva was incised and dissected forward to the limbus.  Blunt dissection was carried out in the superotemporal quadrant.  Next, a 2 x 3-mm scleral flap was outlined that was one-half scleral depth in thickness.  This flap was cut forward to clear cornea using a crescent blade.  The Ahmed shunt was then primed and placed in the superior temporal quadrant and it was sutured in place with two 8-0 nylon sutures.  The knots were trimmed.  The tube was then cut to an appropriate length to enter the anterior chamber.  The anterior chamber was then entered after a paracentesis wound had been made temporally.  A trabeculectomy was done and then the tube was threaded through the trabeculectomy site.  The tube was sutured in place with a multi-wrapped 8-0 nylon suture.  The scleral flap was then sutured in place with two 10-0 nylon sutures.  The knots were trimmed, rotated and buried.  A scleral patch was then placed of an appropriate size over the two.  It was sutured in place with interrupted 8-0 nylon sutures.  The knots were trimmed.  The overlying conjunctiva was then closed with a running 8-0 Vicryl suture with a BV needle.  The anterior chamber was filled with Viscoat to keep it deep as the eye was somewhat soft.  A good flow was established with irrigation into the anterior chamber.  Homatropine, Econopred, and Vigamox drops were placed into the eye.  A patch and shield were placed over the eye after removing the draping and the speculum.  The patient tolerated the procedure well.  He was taken to the recovery in good condition.  He will be seen in followup in the office tomorrow.","ophthalmology, cornea, ahmed shunt, nylon sutures, trabeculectomy, conjunctiva, chamberNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" The patient was originally hospitalized secondary to dizziness and disequilibrium.  Extensive workup during her first hospitalization was all negative, but a prominent feature was her very blunted affect and real anhedonia.", Office Notes, Telemetry Monitoring ,"DIAGNOSES PROBLEMS:,1.  Orthostatic hypotension.,2.  Bradycardia.,3.  Diabetes.,4.  Status post renal transplant secondary polycystic kidney disease in 1995.,5.  Hypertension.,6.  History of basal cell ganglia cerebrovascular event in 2004 with left residual.,7.  History of renal osteodystrophy.,8.  Iron deficiency anemia.,9.  Cataract status post cataract surgery.,10.  Chronic left lower extremity pain.,11.  Hyperlipidemia.,12.  Status post hysterectomy secondary to uterine fibroids.,PROCEDURES:,  Telemetry monitoring.,HISTORY FINDINGS HOSPITAL COURSE: , The patient was originally hospitalized on 04/26/07, secondary to dizziness and disequilibrium.  Extensive workup during her first hospitalization was all negative, but a prominent feature was her very blunted affect and real anhedonia.  She was transferred briefly to Psychiatry, however, on the second day in Psychiatry, she became very orthostatic and was transferred acutely back to the medicine.  She briefly was on Cymbalta; however, this was discontinued when she was transferred back.  She was monitored back medicine for 24 hours and was given intravenous fluids and these were discontinued.  She was able to maintain her pressures then was able to ambulate without difficulty.  We had wanted to pursue workup for possible causes for autonomic dysfunction; however, the patient was not interested in remaining in the hospital anymore and left really against our recommendations.,DISCHARGE MEDICATIONS:,1.  CellCept - 500 mg twice a daily.,2.  Cyclosporine - 25 mg in the morning and 15 mg in the evening.,3.  Prednisone - 5 mg once daily.,4.  Hydralazine - 10 mg four times a day.,5.  Pantoprazole - 40 mg once daily.,6.  Glipizide - 5 mg every morning.,7.  Aspirin - 81 mg once daily.,FOLLOWUP CARE:  ,The patient is to follow up with Dr. X in about 1 week's time.","office notes, orthostatic hypotension, bradycardia, basal cell ganglia cerebrovascular event, renal osteodystrophy, dizziness, disequilibrium, telemetry monitoring, "
 Small office note on premature retina and vitreous., Office Notes, Premature retina and vitreous ,"OCULAR FINDINGS: , Anterior chamber space:  Cornea, iris, lens, and pupils all unremarkable on gross examination in each eye.,Ocular adnexal spaces appear very good in each eye.,Cyclomydril x2 was used to dilate the pupil in each eye.,Medial spaces are clear and the periphery is still hazy in each eye.,Ocular disc space, normal size and shape with a pink color with clear margin in each eye.,Macular spaces are normal in appearance for the age in each eye.,Posterior pole.  No dilated blood vessels seen in each eye.,Periphery:  The peripheral retina is still hazy and retinopathy of prematurity cannot be ruled out at this time in each eye.,IMPRESSION:  ,Premature retina and vitreous, each eye.,PLAN:  ,Recheck in two weeks.,","office notes, eye ocular, premature retina, pupils, periphery, premature, vitreous, retina, eye,"
" Right hand laceration x3, repaired.", Office Notes, Right Hand Laceration ,"HISTORY: , The patient is a 19-year-old male who was involved in a fight approximately an hour prior to his ED presentation.  He punched a guy few times on the face, might be the mouth and then punched a drinking glass, breaking it and lacerating his right hand.  He has three lacerations on his right hand.  His wound was cleaned out thoroughly with tap water, and one of the navy corpsman tried to use Superglue and gauze to repair it.  However, it continues to bleed and he is here for evaluation.,PAST MEDICATION HISTORY:,  Significant for asthma and acne.,CURRENT MEDICATIONS: , Accutane and takes no other medications.,TETANUS STATUS: , Up-to-date.,SOCIAL HISTORY: , He is a nonsmoker.  He has been drinking alcohol today, but has no history of alcohol or drug abuse.,REVIEW OF SYSTEMS: , Otherwise well.  No febrile illness.  No motor or sensory complaints of any sort or paresthesias in the hand.,PHYSICAL EXAM:  ,GENERAL:  He is in no apparent distress.  He is alert and oriented x3.  Mental status is clear and appropriate.  VITALS SIGNS:  Temperature is 98.3, heart rate 100, respirations 18, blood pressure 161/98, oxygen saturation 99% on room air by pulse oximetry, which is normal.  EXTREMITIES:  Right hand, he has three lacerations all over the MCP joint of his right hand, irregular shaped over the fifth MCP and then over the fourth and third half wound, similarly the lacerations.  All total approximately 4 cm in length.  I see no foreign bodies, just capillary refills less than 2 seconds.  Radial pulses intact.  There is full range of motion with no gross deformities.  No significant amount of edema associated with these in the dorsum of the hand.,STUDIES: , X-rays shows no open fracture or bony abnormality.,EMERGENCY DEPARTMENT COURSE:  ,The patient was anesthetized with 1% Xylocaine.  Wounds were thoroughly irrigated with tap water with at least 2 liters.  They were repaired with simple sutures of 4-0 Ethilon, total of 17 sutures, 16 of which were simple, one is a horizontal mattress.  The patient was given Augmentin 875 mg p.o. due to the possibility of human bite wound.,ASSESSMENT: , RIGHT HAND LACERATIONS, SIMPLE X3, REPAIRED AS DESCRIBED.  NO SIGNS OF BONY ABNORMALITY OR FOREIGN BODY.,PLAN:  ,The patient will be given Augmentin 875 mg 1 p.o. b.i.d. for 7 days.  He will be given a prescription of Vicoprofen as he is unable to tolerate the Tylenol due to his Accutane.  He will take 1 p.o. every 6 hours or as needed, #12.  He will follow up for suture removal in 8 days.  Should he develop any signs of infection, he will come immediately here for reevaluation.  He is discharged in stable condition.,","office notes, accutane, hand laceration, laceration, hand, "
 Underwent tonsillectomy and adenoidectomy two weeks ago. , Office Notes, Status Post T&A ,"SUBJECTIVE:,  A 6-year-old boy who underwent tonsillectomy and adenoidectomy two weeks ago.  Also, I cleaned out his maxillary sinuses.  Symptoms included loud snoring at night, sinus infections, throat infections, not sleeping well, and fatigue.  The surgery went well, and I had planned for him to stay overnight, but Mom reminds me that by about 8 p.m. the night nurse gotten him to take fluids well and we let him go home then that evening.  He finished up his Augmentin, by a day or two later he was off the Lortab.  Mom has not noticed any unusual voice change.  No swallowing difficulty except he does not like the taste of acidic foods such as tomato sauce.  He has not had any nasal discharge or ever had any bleeding.  He seems to be breathing better.,OBJECTIVE:,  Exam looks good.  The pharynx is well healed.  Tongue mobility is normal.  Voice sounds clear.  Nasal passages reveal no discharge or crusting.,RECOMMENDATION:,  I told Mom it is okay to use some ibuprofen in case his mouth or jaws are still sensitive.  He says it seems to hurt if he opens his mouth real wide such as when he brushes his teeth.  It is okay to chew gum and it is okay to eat crunchy foods such as potato chips.  The pathologist described the expected changes of chronic sinusitis and chronic hypertrophic tonsillitis and adenoiditis, and there were no atypical findings on the laboratories.,I am glad he has healed up well.  There are no other restrictions or limitations.  I told Mom, I had written to Dr. XYZ to let her know of the findings.  The child will continue his regular followup visits with his family doctor, and I told Mom I would be happy to see him anytime if needed.  He did very well after surgery and he seems to feel better and breathe a lot better after his throat and sinus procedure.","office notes, tonsillectomy and adenoidectomy, tonsillectomy, adenoidectomy, maxillary, nasal, sinuses,"
 Left shoulder injury.   A 41-year-old male presenting for initial evaluation of his left shoulder., Office Notes, Shoulder Contusion ,"CHIEF COMPLAINT:  ,","office notes, shoulder, injury, two views, shoulder contusion, "
 Quick note on tachypnea., Office Notes, Tachypnea ,,"office notes, chest, cpr, breath sounds, tachypnea, epinephrine, rhythmNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Sample post dilation patient instructions., Office Notes, Post Dilation Instructions ,"The effects of eye dilation drops will gradually decrease. It typically takes TWO to SIX HOURS for the effects to wear off. During this time, reading may be more difficult and sensitivity to light may increase. For a short time, wearing sunglasses may help.","office notes, dilation drops, eye dilation, sunglasses, blindness, eye examinations, dilation, eyesNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 The patient had tympanoplasty surgery for a traumatic perforation of the right ear about six weeks ago.  , Office Notes, Status Post Tympanoplasty  ,"The right eardrum is intact showing a successful tympanoplasty.  I cleaned a little wax from the external meatus.  The right eardrum might be very slightly red but not obviously infected.  The left eardrum (not the surgical ear) has a definite infection with a reddened bulging drum but no perforation or granulation tissue.  Also some wax at the external meatus I cleaned with a Q-tip with peroxide.  The patient has no medical allergies.  Since he recently had a course of Omnicef we chose to put him on Augmentin (I checked and we did not have samples), so I phoned in a two-week course of Augmentin 400 mg chewable twice daily with food at Walgreens.  I looked at this throat which looks clear.  The nose only has a little clear mucinous secretions.  If there is any ear drainage, please use the Floxin drops.  I asked Mom to have the family doctor (or Dad, or me) check the ears again in about two weeks from now to be sure there is no residual infection.  I plan to see the patient again later this spring.","office notes, tympanoplasty surgery, traumatic perforation, external meatus, wax, external, perforation, eardrum, meatus, tympanoplasty, earNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" Normal review of systems template.  No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter.", Office Notes, Normal ROS Template - 3 ,"HEENT:,  No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter.,RESPIRATORY: , No shortness of breath, wheezing, dyspnea, pulmonary disease, tuberculosis or past pneumonias.,CARDIOVASCULAR: , No history of palpitations, irregular rhythm, chest pain, hypertension, hyperlipidemia, diaphoresis, congestive heart failure, heart catheterization, stress test or recent cardiac tests.,GASTROINTESTINAL:,  No history of rectal bleeding, appetite change, abdominal pain, hiatal hernia, ulcer, jaundice, change in bowel habits or liver problems, and no history of inflammatory bowel problems.,GENITOURINARY: , No dysuria, hematuria, frequency, incontinence or colic.,NERVOUS SYSTEM: , No gait problems, strokes, numbness or muscle weakness.,PSYCHIATRIC: , No history of emotional lability, depression or sleep disturbances.,ONCOLOGIC:,  No history of any cancer, change in moles or rashes.  No history of weight loss.  The patient has a good energy level.,ALLERGIC/LYMPH: , No history of systemic allergy, abnormal lymph nodes or swelling.,MUSCULOSKELETAL: , No fractures, motor weakness, arthritis or other joint pains.","office notes, review of systems, tinnitus, sinusitis, sore, mouth, hoarseness, goiter, heart, appetite, bowel, weakness, loss, swelling,"
" Negative for any nausea, vomiting, fevers, chills, or weight loss.", Office Notes, Normal ROS Template - 4 ,"GENERAL:  Negative for any nausea, vomiting, fevers, chills, or weight loss.,NEUROLOGIC:  Negative for any blurry vision, blind spots, double vision, facial asymmetry, dysphagia, dysarthria, hemiparesis, hemisensory deficits, vertigo, ataxia.,HEENT:  Negative for any head trauma, neck trauma, neck stiffness, photophobia, phonophobia, sinusitis, rhinitis.,CARDIAC:  Negative for any chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, peripheral edema.,PULMONARY:  Negative for any shortness of breath, wheezing, COPD, or TB exposure.,GASTROINTESTINAL:  Negative for any abdominal pain, nausea, vomiting, bright red blood per rectum, melena.,GENITOURINARY:  Negative for any dysuria, hematuria, incontinence.,INTEGUMENTARY:  Negative for any rashes, cuts, insect bites.,RHEUMATOLOGIC:  Negative for any joint pains, photosensitive rashes, history of vasculitis or kidney problems.,HEMATOLOGIC:  Negative for any abnormal bruising, frequent infections or bleeding.","office notes, review of systems, trauma, neck, dyspnea, rashes, nausea, vomiting, "
" Normal review of systems template.  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.", Office Notes, Normal ROS Template - 5 ,"REVIEW OF SYSTEMS,GENERAL:  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.,INTEGUMENTARY:  Negative rash, negative jaundice.,HEMATOPOIETIC:  Negative bleeding, negative lymph node enlargement, negative bruisability.,NEUROLOGIC:  Negative headaches, negative syncope, negative seizures, negative weakness, negative tremor.  No history of strokes, no history of other neurologic conditions.,EYES:  Negative visual changes, negative diplopia, negative scotomata, negative impaired vision.,EARS:  Negative tinnitus, negative vertigo, negative hearing impairment.,NOSE AND THROAT:  Negative postnasal drip, negative sore throat.,CARDIOVASCULAR:  Negative chest pain, negative dyspnea on exertion, negative palpations, negative edema.  No history of heart attack, no history of arrhythmias, no history of hypertension.,RESPIRATORY:  No history of shortness of breath, no history of asthma, no history of chronic obstructive pulmonary disease, no history of obstructive sleep apnea.,GASTROINTESTINAL:  Negative dysphagia, negative nausea, negative vomiting, negative hematemesis, negative abdominal pain.,GENITOURINARY:  Negative frequency, negative urgency, negative dysuria, negative incontinence.  No history of STDs.  **No history of OB/GYN problems.,MUSCULOSKELETAL:  Negative myalgia, negative joint pain, negative stiffness, negative weakness, negative back pain.,PSYCHIATRIC:  See psychiatric evaluation.,ENDOCRINE:  No history of diabetes mellitus, no history of thyroid problems, no history of endocrinologic abnormalities.","office notes, respiratory, gastrointestinal, integumentary, hematopoietic, night sweats, negative allergies, negative weakness, neurologic, throat, weakness"
 The patient continues to suffer from ongoing neck and lower back pain with no recent radicular complaints., Office Notes, Ortho Office Visit ,"Her evaluation today reveals restriction in the range of motion of the cervical and lumbar region with tenderness and spasms of the paraspinal musculature.  Motor strength was 5/5 on the MRC scale.  Reflexes were 2+ and symmetrical.  Palpable trigger points were noted bilaterally in the trapezius and lumbar paraspinal musculature bilaterally.,Palpable trigger points were noted on today's evaluation.  She is suffering from ongoing myofascitis.  Her treatment plan will consist of a series of trigger point injections, which were performed today.  She tolerated the procedure well.  I have asked her to ice the region intermittently for 15 minutes off and on x 3.  She will be followed in four weeks' time for repeat trigger point injections if indicated.,","office notes, back pain, trigger point injections, paraspinal musculature, lumbar, paraspinal, musculature, palpable, injections, evaluation, triggerNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" There was no weight loss, fevers, chills, sweats.  There is no blurring of the vision, itching, throat or neck pain, or neck fullness.  There is no vertigo or hoarseness or painful swallowing. ", Office Notes, Normal ROS Template - 1 ,"REVIEW OF SYSTEMS,There was no weight loss, fevers, chills, sweats.  There is no blurring of the vision, itching, throat or neck pain, or neck fullness.  There is no vertigo or hoarseness or painful swallowing.  There is no chest pain, shortness of breath, paroxysmal nocturnal dyspnea, or chest pain with exertion.  There is no shortness of breath and no cough or hemoptysis.  No melena, nausea, vomiting, dysphagia, abdominal pain, diarrhea, constipation or blood in the stools.  No dysuria, hematuria or excessive urination.  No muscle weakness or tenderness.  No new numbness or tingling.  No arthralgias or arthritis.  There are no rashes.  No excessive fatigability, loss of motor skills or sensation.  No changes in hair texture, change in skin color, excessive or decreased appetite.  No swollen lymph nodes or night sweats.  No headaches.  The rest of the review of systems is negative.","office notes, weight loss, fevers, chills, sweats, melena, nausea, vomiting, dysphagia, abdominal pain, diarrhea, constipation, itching throat, neck fullness, painful swallowing, breath, loss, neckNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Most commonly used phrases in physical exam., Office Notes, Normal Physical Exam Template - 7 ,"EYES: , The conjunctivae are clear.  The lids are normal appearing without evidence of chalazion or hordeolum.  The pupils are round and reactive.  The irides are without any obvious lesions noted.  Funduscopic examination shows sharp disk margins.  There are no exudates or hemorrhages noted.  The vessels are normal appearing.,EARS, NOSE, MOUTH AND THROAT:,  The nose is without any evidence of any deformity.  The ears are with normal-appearing pinna.  Examination of the canals is normal appearing bilaterally.  There is no drainage or erythema noted.  The tympanic membranes are normal appearing with pearly color, normal-appearing landmarks and normal light reflex.  Hearing is grossly intact to finger rubbing and whisper.  The nasal mucosa is moist.  The septum is midline.  There is no evidence of septal hematoma.  The turbinates are without abnormality.  No obvious abnormalities to the lips.  The teeth are unremarkable.  The gingivae are without any obvious evidence of infection.  The oral mucosa is moist and pink.  There are no obvious masses to the hard or soft palate.  The uvula is midline.  The salivary glands appear unremarkable.  The tongue is midline.  The posterior pharynx is without erythema or exudate.  The tonsils are normal appearing.,NECK:,  The neck is nontender and supple.  The trachea is midline.  The thyroid is without any evidence of thyromegaly.  No obvious adenopathy is noted to the neck.,RESPIRATORY: , The patient has normal respiratory effort.  There is normal lung excursion.  Percussion of the chest is without any obvious dullness.  There is no tactile fremitus or egophony noted.  There is no tenderness to the chest wall or ribs.  There are no obvious abnormalities.  The lungs are clear to auscultation.  There are no wheezes, rales or rhonchi heard.  There are no obvious rubs noted.,CARDIOVASCULAR: , There is a normal PMI on palpation.  I do not hear any obvious abnormal sounds.  There are no obvious murmurs.  There are no rubs or gallops noted.  The carotid arteries are without bruit.  No obvious thrill is palpated. There is no evidence of enlarged abdominal aorta to palpation.  There is no abdominal mass to suggest enlargement of the aorta.  Good strong femoral pulses are palpated.  The pedal pulses are intact.  There is no obvious edema noted to the extremities.  There is no evidence of any varicosities or phlebitis noted.,GASTROINTESTINAL: , The abdomen is soft.  Bowel sounds are present in all quadrants.  There are no obvious masses.  There is no organomegaly, and no liver or spleen is palpable.  No obvious hernia is noted.  The perineum and anus are normal in appearance.  There is good sphincter tone and no obvious hemorrhoids are noted.  There are no masses.  On digital examination, there is no evidence of any tenderness to the rectal vault; no lesions are noted.  Stool is brown and guaiac negative.,GENITOURINARY (FEMALE): , The external genitalia is normal appearing with no obvious lesions, no evidence of any unusual rash.  The vagina is normal in appearance with normal-appearing mucosa.  The urethra is without any obvious lesions or discharge.  The cervix is normal in color with no obvious cervical discharge.  There are no obvious cervical lesions noted.  The uterus is nontender and small, and there is no evidence of any adnexal masses or tenderness.  The bladder is nontender to palpation.  It is not enlarged.,GENITOURINARY (MALE): , Normal scrotal contents are noted.  The testes are descended and nontender.  There are no masses and no swelling to the epididymis noted.  The penis is without any lesions.  There is no urethral discharge.  Digital examination of the prostate reveals a nontender, non-nodular prostate.,BREASTS:,  The breasts are normal in appearance.  There is no puckering noted.  There is no evidence of any nipple discharge.  There are no obvious masses palpable.  There is no axillary adenopathy.  The skin is normal appearing over the breasts.,LYMPHATICS: , There is no evidence of any adenopathy to the anterior cervical chain.  There is no evidence of submandibular nodes noted.  There are no supraclavicular nodes palpable.  The axillae are without any abnormal nodes.  No inguinal adenopathy is palpable.  No obvious epitrochlear nodes are noted.,MUSCULOSKELETAL/EXTREMITIES: , The patient has normal gait and station.  The patient has normal muscle strength and tone to all extremities.  There is no obvious evidence of any muscle atrophy.  The joints are all stable.  There is no evidence of any subluxation or laxity to any of the joints.  There is no evidence of any dislocation.  There is good range of motion of all extremities without any pain or tenderness to the joints or extremities.  There is no evidence of any contractures or crepitus.  There is no evidence of any joint effusions.  No obvious evidence of erythema overlying any of the joints is noted.  There is good range of motion at all joints.  There are normal-appearing digits.  There are no obvious lesions to any of the nails or nail beds.,SKIN:,  There is no obvious evidence of any rash.  There are no petechiae, pallor or cyanosis noted.  There are no unusual nodules or masses palpable.,NEUROLOGIC: , The cranial nerves II XII are tested and are intact.  Deep tendon reflexes are symmetrical bilaterally.  The toes are downgoing with normal Babinskis.  Sensation to light touch is intact and symmetrical.  Cerebellar testing reveals normal finger nose, heel shin.  Normal gait.  No ataxia.,PSYCHIATRIC:  ,The patient is oriented to person, place and time.  The patient is also oriented to situation.  Mood and affect are appropriate for the present situation.  The patient can remember 3 objects after 3 minutes without any difficulties.  Remote memory appears to be intact.  The patient seems to have normal judgment and insight into the situation.","office notes, ears, nose, mouth, neck, respiratory, cardiovascular, eyes, gastrointestinal, genitourinary, breasts, lymphatics, musculoskeletal, extremities, skin, neurologic, psychiatric, normal appearing, physical exam, examination, "
" Normal Physical Exam Template.  Well developed, well nourished, alert, in no acute distress. ", Office Notes, Normal Physical Exam Template - 5 ,"GENERAL: , Well developed, well nourished, alert, in no acute distress.  GCS 50, nontoxic.,VITAL SIGNS: , Blood pressure *, pulse *, respirations *, temperature * degrees F.  Pulse oximetry *%.,HEENT: , Eyes: Lids and conjunctiva.  No lesions.  Pupils equal, round, reactive to light and accommodation.  Irises symmetrical, undilated.  Funduscopic exam reveals no hemorrhages or discopathy.  Ears, Nose, Mouth, and throat:  External ears without lesions.  Nares patent.  Septum midline.  Tympanic membranes without erythema, bulging or retraction.  Canals without lesion.  Hearing is grossly intact.  Lips, teeth, gums, palate without lesion.  Posterior oropharynx:  No erythema.  No tonsillar enlargement, crypt formation or abscess.,NECK:  ,Supple and symmetric.  No masses. Thyroid midline, non enlarged.  No JVD.  Neck is nontender.  Full range of motion without pain.,RESPIRATORY: , Good respiratory effort.  Clear to auscultation.  Clear to percussion.  Chest:  Symmetrical rise and fall.  Symmetrical expansion.  No egophony or tactile fremitus.,CARDIOVASCULAR:,  Regular rate and rhythm.  No murmur, gallops, clicks, heaves or rub.  Cardiac palpation within normal limits.  Pulses equal at carotid.  Femoral and pedal pulses:  No peripheral edema.,GASTROINTESTINAL:  ,No tenderness or mass.  No hepatosplenomegaly.  No hernia.  Bowel sounds equal times four quadrants.  Abdomen is nondistended.  No rebound, guarding, rigidity or ecchymosis.,MUSCULOSKELETAL: , Normal gait and station.  No pathology to digits or nails.  Extremities move times four.  No tenderness or effusion.  Range of motion adequate.  Strength and tone equal bilaterally, stable.,BACK: , Nontender on midline.  Full range of motion with flexion, extension and sidebending.,SKIN:,  Inspection within normal limits.  Well hydrated.  No diaphoresis.  No obvious wound.,LYMPH:,  Cervical lymph nodes.  No lymphadenopathy.,NEUROLOGICAL:  ,Cranial nerves II-XII grossly intact.  DTRs symmetric 2 out of 4 bilateral upper and lower extremity, elbow, patella and ankle.  Motor strength 4/4 bilateral upper and lower extremity.  Straight leg raise is negative bilaterally.,PSYCHIATRIC: , Judgment and insight adequate.  Alert and oriented times three.  Memory and mood within normal limits.  No delusions, hallucinations.  No suicidal or homicidal ideation.","office notes, respiratory, abdomen, normal physical exam, pulses, tenderness, strength, lymph, extremity, midline, range, motion, lesions, symmetrical, "
" Normal review of systems template.  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.", Office Notes, Normal ROS Template - 2 ,"GENERAL:,  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.,INTEGUMENTARY: , Negative rash, negative jaundice.,HEMATOPOIETIC: , Negative bleeding, negative lymph node enlargement, negative bruisability.,NEUROLOGIC: , Negative headaches, negative syncope, negative seizures, negative weakness, negative tremor.  No history of strokes, no history of other neurologic conditions.,EYES:,  Negative visual changes, negative diplopia, negative scotomata, negative impaired vision.,EARS: , Negative tinnitus, negative vertigo, negative hearing impairment.,NOSE AND THROAT:  ,Negative postnasal drip, negative sore throat.,CARDIOVASCULAR: , Negative chest pain, negative dyspnea on exertion, negative palpations, negative edema.  No history of heart attack, no history of arrhythmias, no history of hypertension.,RESPIRATORY:,  No history of shortness of breath, no history of asthma, no history of chronic obstructive pulmonary disease, no history of obstructive sleep apnea.,GASTROINTESTINAL: , Negative dysphagia, negative nausea, negative vomiting, negative hematemesis, negative abdominal pain.,GENITOURINARY: , Negative frequency, negative urgency, negative dysuria, negative incontinence.  No history of STDs.,MUSCULOSKELETAL:,  Negative myalgia, negative joint pain, negative stiffness, negative weakness, negative back pain.,PSYCHIATRIC: , See psychiatric evaluation.,ENDOCRINE: , No history of diabetes mellitus, no history of thyroid problems, no history of endocrinologic abnormalities.","office notes, nose and throat, cardiovascular, integumentary, negative weakness, neurologic, throat, psychiatric, weakness, "
 An example normal physical exam, Office Notes, Normal Physical Exam Template - 1 ,"GENERAL: , Vital signs and temperature as documented in nursing notes.  The patient appears stated age and is adequately developed.,EYES:,  Pupils are equal, round, reactive to light and accommodation.  Lids and conjunctivae reveal no gross abnormality.,ENT:  ,Hearing appears adequate.  No obvious asymmetry or deformity of the ears and nose.,NECK: , Trachea midline.  Symmetric with no obvious deformity or mass; no thyromegaly evident.,RESPIRATORY:,  The patient has normal and symmetric respiratory effort.  Lungs are clear to auscultation.,CARDIOVASCULAR: , S1, S2 without significant murmur.,ABDOMEN: , Abdomen is flat, soft, nontender.  Bowel sounds are active.  No masses or pulsations present.,EXTREMITIES: , Extremities reveal no remarkable dependent edema or varicosities.,MUSCULOSKELETAL:  ,The patient is ambulatory with normal and symmetric gait.  There is adequate range of motion without significant pain or deformity.,SKIN: , Essentially clear with no significant rash or lesions.  Adequate skin turgor.,NEUROLOGICAL: , No acute focal neurologic changes.,PSYCHIATRIC:,  Mental status, judgment and affect are grossly intact and normal for age.","office notes, vital signs, equal, round, reactive, normal physical exam, physical exam, "
" Normal physical exam template.  Normocephalic.  Negative lesions, negative masses.", Office Notes, Normal Physical Exam Template - 4 ,"GENERAL:  ,XXX,VITAL SIGNS: , Blood pressure XXX, pulse XXX, temperature XXX, respirations XXX.  Height XXX, weight XXX.,HEAD: , Normocephalic.  Negative lesions, negative masses.,EYES: , PERLA, EOMI.  Sclerae clear.  Negative icterus, negative conjunctivitis.,ENT:,  Negative nasal hemorrhages, negative nasal obstructions, negative nasal exudates.  Negative ear obstructions, negative exudates.  Negative inflammation in external auditory canals.  Negative throat inflammation or masses.,SKIN: , Negative rashes, negative masses, negative ulcers.  No tattoos.,NECK:,  Negative palpable lymphadenopathy, negative palpable thyromegaly, negative bruits.,HEART:,  Regular rate and rhythm.  Negative rubs, negative gallops, negative murmurs.,LUNGS:,  Clear to auscultation.  Negative rales, negative rhonchi, negative wheezing.,ABDOMEN: , Soft, nontender, adequate bowel sounds.  Negative palpable masses, negative hepatosplenomegaly, negative abdominal bruits.,EXTREMITIES: , Negative inflammation, negative tenderness, negative swelling, negative edema, negative cyanosis, negative clubbing.  Pulses adequate bilaterally.,MUSCULOSKELETAL:,  Negative muscle atrophy, negative masses.  Strength adequate bilaterally.  Negative movement restriction, negative joint crepitus, negative deformity.,NEUROLOGIC: , Cranial nerves I through XII intact.  Negative gait disturbance.  Balance and coordination intact.  Negative Romberg, negative Babinski.  DTRs equal bilaterally.,GENITOURINARY:  ,Deferred.,", 
" Normal physical exam template.  This is a well-developed and well-nourished.  The pupils were equal, round and reactive to light.  Extraocular movements are intact.", Office Notes, Normal Physical Exam Template - 2 ,"GENERAL APPEARANCE: , This is a well-developed and well-nourished, ??,VITAL SIGNS: , Blood pressure ??, heart rate ?? and regular, respiratory rate ??, temperature is ?? degrees Fahrenheit.  Height is ?? feet ?? inches.  Weight is ?? pounds.  This yields a body mass index of ??.,HEAD, EYES, EARS, NOSE AND THROAT:,  The pupils were equal, round and reactive to light.  Extraocular movements are intact.  Sclera are nonicteric.  Ears, nose, mouth and throat - Externally the ears and nose are normal.  The mucous membranes are moist and midline.,NECK:  ,The neck is supple without masses.  No thyromegaly, no carotid bruits, no adenopathy.,LUNGS:  ,There is a normal respiratory effort.  Bilateral breath sounds are clear.  No wheezes or rales or rhonchi.,CARDIAC: , Normal cardiac impulse location.  S1 and S2 are normal.  No rubs, murmurs or gallops.  A regular rate and rhythm.  There are no abdominal aortic bruits.  The carotid, brachial, radial, femoral, popliteal and dorsalis pedis pulses are 2+ and equal bilaterally.,EXTREMITIES: , The extremities are without clubbing, cyanosis, or edema.,CHEST: , The chest examination is unremarkable.,BREASTS:  ,The breasts show no masses or tenderness.  No axillary adenopathy.,ABDOMEN:,  The abdomen is flat, soft, nontender, no organomegaly, no masses, normal bowel sounds are present.,RECTAL: , Examination was deferred.,LYMPHATIC: , No neck, axillary or groin adenopathy was noted.,SKIN EXAMINATION:,  Unremarkable.,MUSCULOSKELETAL EXAMINATION: , Grossly normal.,NEUROLOGIC: , The cranial nerves two through twelve are grossly intact.  Patellar and biceps reflexes are normal.,PSYCHIATRIC: , The patient is awake, alert and oriented times three.  Judgment and insight are good.  Affect is appropriate.",
" Normal review of systems template.  The patient denies fever, fatigue, weakness, weight gain or weight loss.", Office Notes, Normal ROS Template ,"REVIEW OF SYSTEMS,GENERAL/CONSTITUTIONAL: , The patient denies fever, fatigue, weakness, weight gain or weight loss.,HEAD, EYES, EARS, NOSE AND THROAT:,  Eyes - The patient denies pain, redness, loss of vision, double or blurred vision, flashing lights or spots, dryness, the feeling that something is in the eye and denies wearing glasses.  Ears, nose, mouth and throat.  The patient denies ringing in the ears, loss of hearing, nosebleeds, loss of sense of smell, dry sinuses, sinusitis, post nasal drip, sore tongue, bleeding gums, sores in the mouth, loss of sense of taste, dry mouth, dentures or removable dental work, frequent sore throats, hoarseness or constant feeling of a need to clear the throat when nothing is there, waking up with acid or bitter fluid in the mouth or throat, food sticking in throat when swallows or painful swallowing.,CARDIOVASCULAR: , The patient denies chest pain, irregular heartbeats, sudden changes in heartbeat or palpitation, shortness of breath, difficulty breathing at night, swollen legs or feet, heart murmurs, high blood pressure, cramps in his legs with walking, pain in his feet or toes at night or varicose veins.,RESPIRATORY: , The patient denies chronic dry cough, coughing up blood, coughing  up mucus, waking at night coughing or choking, repeated pneumonias, wheezing or night sweats.,GASTROINTESTINAL: , The patient denies decreased appetite, nausea, vomiting, vomiting blood or coffee ground material, heartburn, regurgitation, frequent belching, stomach pain relieved by food, yellow jaundice, diarrhea, constipation, gas, blood in the stools, black tarry stools or hemorrhoids.,GENITOURINARY:  ,The patient denies difficult urination, pain or burning with urination, blood in the urine, cloudy or smoky urine, frequent need to urinate, urgency, needing to urinate frequently at night, inability to hold the urine, discharge from the penis, kidney stones, rash or ulcers, sexual difficulties, impotence or prostate trouble, no sexually transmitted diseases.,MUSCULOSKELETAL: , The patient denies arm, buttock, thigh or calf cramps.  No joint or muscle pain.  No muscle weakness or tenderness.  No joint swelling, neck pain, back pain or major orthopedic injuries.,SKIN AND BREASTS:  ,The patient denies easy bruising, skin redness, skin rash,  hives, sensitivity to sun exposure, tightness, nodules or bumps, hair loss, color changes in the hands or feet with cold, breast lump, breast pain or nipple discharge.,NEUROLOGIC: , The patient denies headache, dizziness, fainting, muscle spasm, loss of consciousness, sensitivity or pain in the hands and feet or memory loss.,PSYCHIATRIC:  ,The patient denies depression with thoughts of suicide, voices in ?? head telling ?? to do things and has not been seen for psychiatric counseling or treatment.,ENDOCRINE: , The patient denies intolerance to hot or cold temperature, flushing, fingernail changes, increased thirst, increased salt intake or decreased sexual desire.,HEMATOLOGIC/LYMPHATIC:  ,The patient denies anemia, bleeding tendency or clotting tendency.,ALLERGIC/IMMUNOLOGIC: , The patient denies rhinitis, asthma, skin sensitivity, latex allergies or sensitivity.","office notes, cardiovascular, ears, eyes, gastrointestinal, head, nose, respiratory, review of systems, denies fever, blood, tongue, loss, "
" Normal physical exam template.  Normal appearance for chronological age, does not appear chronically ill.", Office Notes, Normal Physical Exam Template - 6 ,"VITAL SIGNS:,  Reveal a blood pressure of *, temperature of *, respirations *, and pulse of *.,CONSTITUTIONAL: , Normal appearance for chronological age, does not appear chronically ill.,HEENT: , The pupils are equal and reactive.  Funduscopic examination is normal.  Posterior pharynx is normal.  Tympanic membranes are clear.,NECK:  ,Trachea is midline.  Thyroid is normal.  The neck is supple.  Negative nodes.,RESPIRATORY:,  Lungs are clear to auscultation bilaterally.  The patient has a normal respiratory rate, no signs of consolidation and no egophony.  There are no retractions or secondary muscle use.  Good bilateral breath sounds are noted.,CARDIOVASCULAR: , No jugular venous distention or carotid bruits.  No increase in heart size to percussion.  There is no murmur.  Normal S1 and S2 sounds are noted without gallop.,ABDOMEN: , Soft to palpation in all four quadrants.  There is no organomegaly and no rebound tenderness.  Bowel sounds are normal.  Obturator and psoas signs are negative.,GENITOURINARY: , No bladder tenderness, negative flank pain.,MUSCULOSKELETAL:,  Extremities are normal with good motor tone and strength, normal reflexes, and normal joint strength and sensation.,NEUROLOGIC: , Normal Glasgow Coma Scale.  Cranial nerves II through XII appear grossly intact.  Normal motor and cerebellar tests.  Reflexes are normal.,HEME/LYMPH:  ,No abnormal lymph nodes, no signs of bleeding, skin purpura, petechiae or hemorrhage.,PSYCHIATRIC: , Normal with no overt depression or suicidal ideations.","office notes, jugular venous distention, flank, bladder, normal physical exam, neck, nodes, respiratory, tenderness, motor, strength, reflexes, sounds, "
 An example of a physical exam, Office Notes, Normal Physical Exam Template ,"GENERAL: , Alert, well developed, in no acute distress.,MENTAL STATUS: , Judgment and insight appropriate for age.  Oriented to time, place and person.  No recent loss of memory.  Affect appropriate for age.,EYES:  ,Pupils are equal and reactive to light.  No hemorrhages or exudates.  Extraocular muscles intact.,EAR, NOSE AND THROAT: , Oropharynx clean, mucous membranes moist.  Ears and nose without masses, lesions or deformities.  Tympanic membranes clear bilaterally.  Trachea midline.  No lymph node swelling or tenderness.,RESPIRATORY:  ,Clear to auscultation and percussion.  No wheezing, rales or rhonchi.,CARDIOVASCULAR: , Heart sounds normal.  No thrills.  Regular rate and rhythm, no murmurs, rubs or gallops.,GASTROINTESTINAL: , Abdomen soft, nondistended.  No pulsatile mass, no flank tenderness or suprapubic tenderness.  No hepatosplenomegaly.,NEUROLOGIC: , Cranial nerves II-XII grossly intact.  No focal neurological deficits.  Deep tendon reflexes +2 bilaterally.  Babinski negative.  Moves all extremities spontaneously.  Sensation intact bilaterally.,SKIN: , No rashes or lesions.  No petechia.  No purpura.  Good turgor.  No edema.,MUSCULOSKELETAL: , No cyanosis or clubbing.  No gross deformities.  Capable of free range of motion without pain or crepitation.  No laxity, instability or dislocation.,BONE: , No misalignment, asymmetry, defect, tenderness or effusion.  Capable of from of joint above and below bone.,MUSCLE:  ,No crepitation, defect, tenderness, masses or swellings.  No loss of muscle tone or strength.,LYMPHATIC:,  Palpation of neck reveals no swelling or tenderness of neck nodes.  Palpation of groin reveals no swelling or tenderness of groin nodes.","office notes, mental status, ear, nose and throat, abdomen soft, nondistended, cranial nerves ii-xii grossly intact, physical exam, "
" Normal physical exam template.  Well developed, well nourished, in no acute distress.", Office Notes, Normal Physical Exam Template - 3 ,"PHYSICAL EXAMINATION,GENERAL APPEARANCE: , Well developed, well nourished, in no acute distress.,VITAL SIGNS:,  ***,SKIN:  ,Inspection of the skin reveals no rashes, ulcerations or petechiae.,HEENT:,  The sclerae were anicteric and conjunctivae were pink and moist.  Extraocular movements were intact and pupils were equal, round, and reactive to light with normal accommodation.  External inspection of the ears and nose showed no scars, lesions, or masses.  Lips, teeth, and gums showed normal mucosa.  The oral mucosa, hard and soft palate, tongue and posterior pharynx were normal.,NECK:  ,Supple and symmetric.  There was no thyroid enlargement, and no tenderness, or masses were felt.,CHEST: , Normal AP diameter and normal contour without any kyphoscoliosis.,LUNGS: , Auscultation of the lungs revealed normal breath sounds without any other adventitious sounds or rubs.,CARDIOVASCULAR:  ,There was a regular rate and rhythm without any murmurs, gallops, rubs.  The carotid pulses were normal and 2+ bilaterally without bruits.  Peripheral pulses were 2+ and symmetric.,ABDOMEN:  ,Soft and nontender with normal bowel sounds.  The liver span was approximately 5-6 cm in the right midclavicular line by percussion.  The liver edge was nontender.  The spleen was not palpable.  There were no inguinal or umbilical hernias noted.  No ascites was noted.,RECTAL:  ,Normal perineal exam.  Sphincter tone was normal.  There was no external hemorrhoids or rectal masses.  Stool Hemoccult was negative.  The prostate was normal size without any nodules appreciated (men only).,LYMPH NODES: , No lymphadenopathy was appreciated in the neck, axillae or groin.,MUSCULOSKELETAL: , Gait was normal.  There was no tenderness or effusions noted.  Muscle strength and tone were normal.,EXTREMITIES: , No cyanosis, clubbing or edema.,NEUROLOGIC:  ,Alert and oriented x 3.  Normal affect.  Gait was normal.  Normal deep tendon reflexes with no pathological reflexes.  Sensation to touch was normal.", 
 An example/template for a routine normal male ROS., Office Notes, Normal Male ROS Template - 1 ,"REVIEW OF SYSTEMS:,CONSTITUTIONAL:  Patient denies fevers, chills, sweats and weight changes.,EYES:  Patient denies any visual symptoms.,EARS, NOSE, AND THROAT:  No difficulties with hearing.  No symptoms of rhinitis or sore throat.,CARDIOVASCULAR:  Patient denies chest pains, palpitations, orthopnea and paroxysmal nocturnal dyspnea.,RESPIRATORY:  No dyspnea on exertion, no wheezing or cough.,GI:  No nausea, vomiting, diarrhea, constipation, abdominal pain, hematochezia or melena.,GU:  No urinary hesitancy or dribbling.  No nocturia or urinary frequency.  No abnormal urethral discharge.,MUSCULOSKELETAL:  No myalgias or arthralgias.,NEUROLOGIC:  No chronic headaches, no seizures.  Patient denies numbness, tingling or weakness.,PSYCHIATRIC:  Patient denies problems with mood disturbance.  No problems with anxiety.,ENDOCRINE:  No excessive urination or excessive thirst.,DERMATOLOGIC:  Patient denies any rashes or skin changes.","office notes, review of systems, normal male ros, normal male, male ros, male, ros, throat, urinary "
 Normal newborn infant physical exam.  A well-developed infant in no acute respiratory distress., Office Notes, Normal Newborn Infant Physical Exam ,"GENERAL: , A well-developed infant in no acute respiratory distress.,VITAL SIGNS:  ,Initial temperature was XX, pulse XX, respirations XX.  Weight XX grams, length XX cm, head circumference XX cm.,HEENT:  ,Head is normocephalic with anterior fontanelle open, soft, and non-bulging.  Eyes:  Red reflex elicited bilaterally.  TMs occluded with vernix and not well visualized.  Nose and throat are patent without palatal defect.,NECK: , Supple without clavicular fracture.,LUNGS:,  Clear to auscultation.,HEART:,  Regular rate without murmur, click, or gallop present.  Pulses are 2/4 for brachial and femoral.,ABDOMEN:,  Soft with bowel sounds present.  No masses or organomegaly.,GENITALIA: , Normal.,EXTREMITIES: , Without evidence of hip defects.,NEUROLOGIC:  ,The infant has good Moro, grasp, and suck reflexes.,SKIN: , Warm and dry without evidence of rash.","office notes, fontanelle, normocephalic, newborn infant, physical exam, acute respiratory, newborn, respiratory, distress, head, infant,"
 Template for History and Physical for a newborn., Office Notes, Normal Newborn H&P Template ,"HISTORY OF PRESENT ILLNESS: , This is a ** week gestational age ** delivered by ** at ** on **.  Gestational age was determined by last menstrual period and consistent with ** trimester ultrasound.  ** rupture of membranes occurred ** prior to delivery and amniotic fluid was clear.  The baby was vertex presentation.  The baby was dried, stimulated, and bulb suctioned.  Apgar scores of ** at one minute and ** at five minutes.,PAST MEDICAL HISTORY,MATERNAL HISTORY:,  The mother is a **-year-old, G**, P** female with blood type **.  She is rubella immune, hepatitis surface antigen negative, RPR nonreactive, HIV negative.  Mother was group B strep **.  Mother's past medical history is **.,PRENATAL CARE: , Mother began prenatal care in the ** trimester and had at least ** documented prenatal visits.  She did not smoke, drink alcohol, or use illicit drugs during pregnancy.,SURGICAL HISTORY: , **,MEDICATIONS:,  Medications taken during this pregnancy were **.,ALLERGIES: , **,FAMILY HISTORY: , **,SOCIAL HISTORY: , **,PHYSICAL EXAMINATION,VITAL SIGNS:  Temperature **, heart rate **, respiratory rate **.  Dextrose stick **.  Ballard score by the RN is ** weeks.  Birth weight is ** grams, which is the ** percentile for gestational age.  Length is ** centimeters which is ** percentile for gestational age.  Head circumference is ** centimeters which is ** percentile for gestational age.,GENERAL:  **Alert, active, nondysmorphic-appearing infant in no acute distress.,HEENT:  Anterior fontanelle open and flat.  Positive bilateral red reflexes.,Ears have normal shape and position with no pits or tags.  Nares patent.  Palate intact.  Mucous membranes moist.,NECK:  Full range of motion.,CARDIOVASCULAR:  Normal precordium, regular rate and rhythm.  No murmurs.  Normal femoral pulses.,RESPIRATORY;  Clear to auscultation bilaterally.  No retractions.,ABDOMEN:  Soft, nondistended.  Normal bowel sounds.  No hepatosplenomegaly.  Umbilical stump is clean, dry, and intact.,GENITOURINARY:  Normal tanner I **.  Anus patent.,MUSCULOSKELETAL:  Negative Barlow and Ortolani.  Clavicles intact.  Spine straight.  No sacral dimple or hair tuft.  Leg lengths grossly symmetric.  Five fingers on each hand and five toes on each foot.,SKIN:  Warm and pink with brisk capillary refill.  No jaundice.,NEUROLOGICAL:  Normal tone.  Normal root, suck, grasp, and Moro reflexes.  Moves all extremities equally.,DIAGNOSTIC STUDIES,LABORATORY DATA:,  **,ASSESSMENT: , Full term, appropriate for gestational age **.,PLAN:,1.  Routine newborn care.,2.  Anticipatory guidance.,3.  Hepatitis B immunization prior to discharge.,",
 An example/template for a routine normal male physical exam., Office Notes, Normal Male Exam Template - 3 ,"PHYSICAL EXAMINATION,GENERAL: , The patient is awake and alert, in no apparent distress, appropriate, pleasant and cooperative.  No dysarthria is noted.  No discomfort on presentation is noted.  ,HEAD: , Atraumatic, normocephalic. Pupils are equal, round and reactive to light.  Extraocular muscles are intact.  Sclerae are white without injection or icterus.  Fundi are without papilledema, hemorrhages or exudates with normal vessels.  ,EARS: , The ear canals are patent without edema, exudate or drainage.  Tympanic membranes are intact with a normal cone of light.  No bulging or erythema to indicate infection is present.  There is no hemotympanum.  Hearing is grossly intact.  ,NOSE:,  Without deformity, bleeding or discharge.  No septal hematoma is noted.  ,ORAL CAVITY:,  No swelling or abnormality to the lip or teeth.  Oral mucosa is pink and moist.  No swelling to the palate or pharynx.  Uvula is midline.  The pharynx is without exudate or erythema.  No edema is seen of the tonsils.  The airway is completely patent.  The voice is normal.  No stridor is heard.  ,NECK: , No signs of meningismus.  No Brudzinski or Kernig sign is present.  No adenopathy is noted.  No JVD is seen.  No bruits are auscultated.  Trachea is midline.  ,CHEST: , Symmetrical with equal breath sounds.  Equal excursion.  No hyperresonance or dullness to percussion is noted.  There is no tenderness on palpation of the chest.  ,LUNGS:  ,Clear to auscultation bilaterally.  No rales, rhonchi or wheezes are appreciated.  Good air movement is auscultated in all 4 lung fields.  ,HEART:,  Regular rate and rhythm.  No murmur.  No S3, S4 or rub is auscultated.  Point of maximal impulse is strong and in normal position.  Abdominal aorta is not palpable.  The carotid upstroke is normal.  ,ABDOMEN:  ,Soft, nontender and nondistended.  Normal bowel sounds are auscultated.  No organomegaly is appreciated.  No masses are palpated.  No tympany is noted on percussion.  No guarding, rigidity or rebound tenderness is seen on exam.  Murphy and McBurney sign is negative.  There is no Rovsing, obturator or psoas sign present.  No hepatosplenomegaly and no hernias are noted.  ,RECTAL:,  Normal tone.  No masses.  Soft, brown stool in the vault.  Guaiac negative.  ,GENITOURINARY:,  Penis is normal without lesion or urethral discharge.  Scrotum is without edema.  The testes are descended bilaterally.  No masses are palpated.  There is no tenderness.  ,EXTREMITIES: , No clubbing, cyanosis or edema.  Pulses are strong and equal in the femoral and dorsalis pedis arteries, bounding and equal.  No deformity or signs of trauma.  All joints are stable without laxity.  There is good range of motion of all joints without tenderness or discomfort.  Homan sign is negative.  No atrophy or contractures are noted.  ,SKIN: , No rashes.  No jaundice.  Pink and warm with good turgor.  Good color.  No erythema or nodules noted.  No petechia, bulla or ecchymosis.  ,NEUROLOGIC: , Cranial nerves II through XII are grossly intact.  Muscle strength is graded 5/5 in the upper and lower extremities bilaterally.  Deep tendon reflexes are symmetrical in the upper and lower extremities bilaterally. Babinski is downgoing bilaterally.  Sensation is intact to light touch and vibration.  Gait is normal.  Romberg, finger-to-nose, rapid alternating movements and heel-to-shin are all normal.  There is no ataxia seen on gait testing.  Tone is normal.  No pronator drift is seen.  ,PSYCHIATRIC:  ,The patient is oriented x4.  Mood and affect are appropriate.  Memory is intact with good short- and long-term memory recall.  No dysarthria is noted.  Remote memory is intact.  Judgment and insight appear normal.,",
 An example/template for a routine normal male physical exam., Office Notes, Normal Male Exam Template - 1 ,"MALE PHYSICAL EXAMINATION,HEENT:  Pupils equal, round and reactive to light and accommodation.  Extraocular movements are intact.  Sclerae are anicteric.  TMs are clear bilaterally.  Oropharynx is clear without erythema or exudate.,NECK:  Supple without lymphadenopathy or thyromegaly.  Carotids are silent.  There is no jugular venous distention.,CHEST:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  Regular rate and rhythm without S3, S4.  No murmurs or rubs are appreciated.,ABDOMEN:  Soft, nontender, nondistended with positive bowel sounds.  No masses, hepatomegaly or splenomegaly are appreciated.,GU:  Normal **circumcised male.  No discharge or hernias.  No testicular masses.,RECTAL EXAM:  Normal rectal tone.  Prostate is smooth and not enlarged.  Stool is Hemoccult negative.,EXTREMITIES:  Reveal no clubbing, cyanosis, or edema.  Peripheral pulses are +2 and equal bilaterally in all four extremities.,JOINT EXAM:  Reveals no tenosynovitis.,NEUROLOGIC:  Cranial nerves II through XII are grossly intact.  Motor strength is 5/5 and equal in all four extremities.  Deep tendon reflexes are +2/4 and equal bilaterally.  Patient is alert and oriented times 3.,PSYCHIATRIC:  Grossly normal.,DERMATOLOGIC:  No lesions or rashes.","office notes, male exam, physical exam, normal, normal male, physical, male, sclerae, extremities, intact, oropharynx "
 An example/template for a routine normal male physical exam., Office Notes, Normal Male Exam Template - 2 ,"MALE PHYSICAL EXAMINATION,Eye:  Eyelids normal color, no edema.  Conjunctivae with no erythema, foreign body, or lacerations.  Sclerae normal white color, no jaundice.  Cornea clear without lesions.  Pupils equally responsive to light.  Iris normal color, no lesions.  Anterior chamber clear.  Lacrimal ducts normal.  Fundi clear.,Ear:  External ear has no erythema, edema, or lesions.  Ear canal unobstructed without edema, discharge, or lesions.  Tympanic membranes clear with normal light reflex.  No middle ear effusions.,Nose:  External nose symmetrical.  No skin lesions.  Nares open and free of lesions.  Turbinates normal color, size and shape.  Mucus clear.  No internal lesions.,Throat:  No erythema or exudates.  Buccal mucosa clear.  Lips normal color without lesions.  Tongue normal shape and color without lesion.  Hard and soft palate normal color without lesions.  Teeth show no remarkable features.  No adenopathy.  Tonsils normal shape and size.  Uvula normal shape and color.,Neck:  Skin has no lesions.  Neck symmetrical.  No adenopathy, thyromegaly, or masses.  Normal range of motion, nontender.  Trachea midline.,Chest:  Symmetrical.  Clear to auscultation bilaterally.  No wheezing, rales or rhonchi.  Chest nontender.  Normal lung excursion.  No accessory muscle use.,Cardiovascular:  Heart has regular rate and rhythm with no S3 or S4.  Heart rate is normal.,Abdominal:  Soft, nontender, nondistended, bowel sounds present.  No hepatomegaly, splenomegaly, masses, or bruits.,Genital:  Penis normal shape without lesions.  Testicles normal shape and contour without tenderness.  Epididymides normal shape and contour without tenderness.  Rectum normal tone to sphincter.  Prostate normal shape and contour without nodules.  Stool hemoccult negative.  No external hemorrhoids.  No skin lesions.,Musculoskeletal:  Normal strength all muscle groups.  Normal range of motion all joints.  No joint effusions.  Joints normal shape and contour.  No muscle masses.,Foot:  No erythema.  No edema.  Normal range of motion all joints in the foot.  Nontender.  No pain with inversion, eversion, plantar or dorsiflexion.,Ankle:  Anterior and posterior drawer test negative.  No pain with inversion, eversion, dorsiflexion, or plantar flexion.  Collateral ligaments intact.  No joint effusion, erythema, edema, crepitus, ecchymosis, or tenderness.,Knee:  Normal range of motion.  No joint effusion, erythema, nontender.  Anterior and posterior drawer tests negative.  Lachman's test negative.  Collateral ligaments intact.  Bursas nontender without edema.,Wrist:  Normal range of motion.  No edema or effusion, nontender.  Negative Tinel and Phalen tests.  Normal strength all muscle groups.,Elbow:  Normal range of motion.  No joint effusion or erythema.  Normal strength all muscle groups.  Nontender.  Olecranon bursa flat and nontender, no edema.  Normal supination and pronation of forearm.  No crepitus.,Hip:  Negative swinging test.  Trochanteric bursa nontender.  Normal range of motion.  Normal strength all muscle groups.  No pain with eversion and inversion.  No crepitus.  Normal gait.,Psychiatric:  Alert and oriented times four.  No delusions or hallucinations, no loose associations, no flight of ideas, no tangentiality.  Affect is appropriate.  No psychomotor slowing or agitation.  Eye contact is appropriate.","office notes, male exam, normal, physical exam, normal range of motion, male physical, nontender, lesions, dorsiflexion, sclerae, contour, muscle, erythema, joints, edema, shape,"
 Sample/template for a normal male multisystem exam., Office Notes, Normal Male Exam Template ,"MULTISYSTEM EXAM,CONSTITUTIONAL:  ,The vital signs showed that the patient was afebrile; blood pressure and heart rate were within normal limits.  The patient appeared alert.,EYES:  ,The conjunctiva was clear.  The pupil was equal and reactive.  There was no ptosis.  The irides appeared normal.,EARS, NOSE AND THROAT:  ,The ears and the nose appeared normal in appearance.  Hearing was grossly intact.  The oropharynx showed that the mucosa was moist.  There was no lesion that I could see in the palate, tongue. tonsil or posterior pharynx.,NECK:  ,The neck was supple.  The thyroid gland was not enlarged by palpation.,RESPIRATORY:  ,The patient's respiratory effort was normal.  Auscultation of the lung showed it to be clear with good air movement.,CARDIOVASCULAR:  ,Auscultation of the heart revealed S1 and S2 with regular rate with no murmur noted.  The extremities showed no edema.,GASTROINTESTINAL: , The abdomen was soft, nontender with no rebound, no guarding, no enlarged liver or spleen.  Bowel sounds were present.,GU: , The scrotal elements were normal.  The testes were without discrete mass.  The penis showed no lesion, no discharge.,LYMPHATIC:  ,There was no appreciated node that I could feel in the groin or neck area.,MUSCULOSKELETAL:  ,The head and neck by inspection showed no obvious deformity.  Again, the extremities showed no obvious deformity.  Range of motion appeared to be normal for the upper and lower extremities.,SKIN: , Inspection of the skin and subcutaneous tissues appeared to be normal.  The skin was pink, warm and dry to touch.,NEUROLOGIC:  ,Deep tendon reflexes were symmetrical at the patellar area.  Sensation was grossly intact by touch.,PSYCHIATRIC: , The patient was oriented to time, place and person.  The patient's judgment and insight appeared to be normal.","office notes, within normal limits, conjunctiva, eyes, ears, nose, throat, male, multisystem, heart, respiratory, auscultation, extremities, oropharynx, neck, tongue, "
 An example/template for a routine normal male physical exam., Office Notes, Normal Male Exam Template - 4 ,"VITAL SIGNS:,  Blood pressure *, pulse *, respirations *, temperature *.,GENERAL APPEARANCE: , Alert and in no apparent distress, calm, cooperative, and communicative.,HEENT:,  Eyes:  EOMI.  PERRLA.  Sclerae nonicteric.  No lesions lids, lashes, brows, or conjunctivae noted.  Funduscopic examination unremarkable.  No papilledema, glaucoma, or cataracts.  Ears:  Normal set and shape with normal hearing and normal TMs. Nose and Sinus:  Unremarkable.  Mouth, Tongue, Teeth, and Throat:  Negative except for dental work.,NECK: , Supple and pain free without carotid bruit, JVD, or significant cervical adenopathy.  Trachea is midline without stridor, shift, or subcutaneous emphysema.  Thyroid is palpable, nontender, not enlarged, and free of nodularity.,CHEST: , Lungs bilaterally clear to auscultation and percussion.,HEART: , S1 and S2.  Regular rate and rhythm without murmur, heave, click, lift, thrill, rub, or gallop.  PMI is nondisplaced.  Chest wall is unremarkable to inspection and palpation.  No axillary or supraclavicular adenopathy detected.,BREASTS: , Normal male breast tissue.,ABDOMEN:,  No hepatosplenomegaly, mass, tenderness, rebound, rigidity, or guarding.  No widening of the aortic impulse and intraabdominal bruit on auscultation.,EXTERNAL GENITALIA: , Normal for age.  Normal penis with bilaterally descended testes that are normal in size, shape, and contour, and without evidence of hernia or hydrocele.,RECTAL:,  Negative to 7 cm by gloved digital palpation with Hemoccult-negative stool and normal-sized prostate that is free of nodularity or tenderness.  No rectal masses palpated.,EXTREMITIES: , Good distal pulse and perfusion without evidence of edema, cyanosis, clubbing, or deep venous thrombosis.  Nails of the hands and feet, and creases of the palms and soles are unremarkable.  Good active and passive range of motion of all major joints.,BACK: , Normal to inspection and percussion.  Negative for spinous process tenderness or CVA tenderness.  Negative straight-leg raising, Kernig, and Brudzinski signs.,NEUROLOGIC: , Nonfocal for cranial and peripheral nervous systems, strength, sensation, and cerebellar function.  Affect is normal.  Speech is clear and fluent.  Thought process is lucid and rational.  Gait and station are unremarkable.,SKIN:  ,Unremarkable for any premalignant or malignant condition with normal changes for age.","office notes, digital palpation, hemoccult-negative, heent, palpation, breasts, male, tenderness, tongue, "
" Normal female review of systems template.  Negative for fever, weight change, fatigue, or aching.", Office Notes, Normal Female ROS Template ,"CONSTITUTIONAL:,  Normal; negative for fever, weight change, fatigue, or aching.,HEENT:,  Eyes normal; Negative for glasses, cataracts, glaucoma, retinopathy, irritation, or visual field defects.  Ears normal; Negative for hearing or balance problems.  Nose normal; Negative for runny nose, sinus problems, or nosebleeds.  Mouth normal; Negative for dental problems, dentures, or bleeding gums.  Throat normal; Negative for hoarseness, difficulty swallowing, or sore throat.,CARDIOVASCULAR:,  Normal; Negative for angina, previous MI, irregular heartbeat, heart murmurs, bad heart valves, palpitations, swelling of feet, high blood pressure, orthopnea, paroxysmal nocturnal dyspnea, or history of stress test, arteriogram, or pacemaker implantation.,PULMONARY: , Normal; Negative for cough, sputum, shortness of breath, wheezing, asthma, or emphysema.,GASTROINTESTINAL: , Normal; Negative for pain, vomiting, heartburn, peptic ulcer disease, change in stool, rectal pain, hernia, hepatitis, gallbladder disease, hemorrhoids, or bleeding.,GENITOURINARY:, Normal female OR male; Negative for incontinence, UTI, dysuria, hematuria, vaginal discharge, abnormal bleeding, breast lumps, nipple discharge, skin or nipple changes, sexually transmitted diseases, incontinence, yeast infections, or itching.,SKIN: , Normal; Negative for rashes, keratoses, skin cancers, or acne.,MUSCULOSKELETAL: , Normal; Negative for back pain, joint pain, joint swelling, arthritis, joint deformity, problems with ambulation, stiffness, osteoporosis, or injuries.,NEUROLOGIC: , Normal; Negative for blackouts, headaches, seizures, stroke, or dizziness.,PSYCHIATRIC: , Normal; Negative for anxiety, depression, or phobias.,ENDOCRINE:,  Normal; Negative for diabetes, thyroid, or problems with cholesterol or hormones.,HEMATOLOGIC/LYMPHATIC: , Normal; Negative for anemia, swollen glands, or blood disorders.,IMMUNOLOGIC: , Negative; Negative for steroids, chemotherapy, or cancer.,VASCULAR:,  Normal; Negative for varicose veins, blood clots, atherosclerosis, or leg ulcers.","office notes, cough, sputum, shortness of breath, fever, weight, fatigue, aching, nose, throat, swelling, disease, incontinence, bleeding, heartbeat, blood, joint, "
" Sample normal ear, nose, mouth, and throat exam.", Office Notes, Normal ENT Exam - 1 ,"EARS, NOSE, MOUTH AND THROAT,EARS/NOSE: , The auricles are normal to palpation and inspection without any surrounding lymphadenitis.  There are no signs of acute trauma.  The nose is normal to palpation and inspection externally without evidence of acute trauma.  Otoscopic examination of the auditory canals and tympanic membranes reveals the auditory canals without signs of mass lesion, inflammation or swelling.  The tympanic membranes are without disruption or infection.  Hearing intact bilaterally to normal level speech.  Nasal mucosa, septum and turbinate examination reveals normal mucous membranes without disruption or inflammation.  The septum is without acute traumatic lesions or disruption.  The turbinates are without abnormal swelling.  There is no unusual rhinorrhea or bleeding.  ,LIPS/TEETH/GUMS:  ,The lips are without infection, mass lesion or traumatic lesions.  The teeth are intact without obvious signs of infection.  The gingivae are normal to palpation and inspection.  ,OROPHARYNX:  ,The oral mucosa is normal.  The salivary glands are without swelling.  The hard and soft palates are intact.  The tongue is without masses or swelling with normal movement.  The tonsils are without inflammation.  The posterior pharynx is without mass lesion with good patent oropharyngeal airway.","office notes, oral mucosa, lips, hearing, auditory canals, tympanic membranes, traumatic lesions, mouth, throat, trauma, nose, membranes, inflammation, infection, swelling,"
 Nephrology office visit for followup of CKD., Office Notes, Nephrology Office Visit - 2 ,"HISTORY OF PRESENT ILLNESS:,  This is a 79-year-old white male who presents for a nephrology followup for his chronic kidney disease secondary to nephrosclerosis and nonfunctioning right kidney.  His most recent BUN and creatinine on 04/04/06 are 40/2.0, which is stable.  He denies any chest pain or tightness in his chest.  He denies any shortness of breath, nausea, or vomiting.  He denies any change to his appetite.  He denies any fevers, chills, dysuria, or hematuria.  He does report his blood pressure being checked at the senior center and reporting that it is improved.  The patient has stage III chronic kidney disease. ,PAST MEDICAL HISTORY:,",
 An example/template for a routine normal female physical exam., Office Notes, Normal Female Exam Template - 1 ,"PHYSICAL EXAMINATION,GENERAL:  ,The patient is awake and alert, in no apparent distress, appropriate, pleasant and cooperative.  No dysarthria is noted.  No discomfort on presentation is noted.,HEAD: , Atraumatic, normocephalic.  Pupils are equal, round and reactive to light.  Extraocular muscles are intact.  Sclerae are white without injection or icterus.  Fundi are without papilledema, hemorrhages or exudates with normal vessels.,EARS:  ,The ear canals are patent without edema, exudate or drainage.  Tympanic membranes are intact with a normal cone of light.  No bulging or erythema to indicate infection is present.  There is no hemotympanum.  Hearing is grossly intact.,NOSE: , Without deformity, bleeding or discharge.  No septal hematoma is noted.,ORAL CAVITY: , No swelling or abnormality to the lip or teeth.  Oral mucosa is pink and moist.  No swelling to the palate or pharynx.  Uvula is midline.  The pharynx is without exudate or erythema.  No edema is seen of the tonsils.  The airway is completely patent.  The voice is normal.  No stridor is heard.,NECK: , No signs of meningismus.  No Brudzinski or Kernig sign is present.  No adenopathy is noted.  No JVD is seen.  No bruits are auscultated.  Trachea is midline.,CHEST: , Symmetrical with equal breath sounds.  Equal excursion.  No hyperresonance or dullness to percussion is noted.  There is no tenderness on palpation of the chest.,LUNGS: , Clear to auscultation bilaterally.  No rales, rhonchi or wheezes are appreciated.  Good air movement is auscultated in all 4 lung fields.,HEART: , Regular rate and rhythm.  No murmur.  No S3, S4 or rub is auscultated.  Point of maximal impulse is strong and in normal position.  Abdominal aorta is not palpable.  The carotid upstroke is normal.,ABDOMEN: , Soft, nontender and nondistended.  Normal bowel sounds are auscultated.  No organomegaly is appreciated.  No masses are palpated.  No tympany is noted on percussion.  No guarding, rigidity or rebound tenderness is seen on exam.  Murphy and McBurney sign is negative.  There is no Rovsing, obturator or psoas sign present.  No hepatosplenomegaly and no hernias are noted.,RECTAL: , Normal tone.  No masses.  Soft, brown stool in the vault.  Guaiac negative.,GENITOURINARY: , External genitalia without erythema, exudate or discharge.  Vaginal vault is without discharge.  Cervix is of normal color without lesion.  The os is closed.  There is no bleeding noted.  Uterus is noted to be of normal size and nontender.  No cervical motion tenderness is seen.  No masses are palpated.  The adnexa are without masses or tenderness.,EXTREMITIES: , No clubbing, cyanosis or edema.  Pulses are strong and equal in the femoral and dorsalis pedis arteries, bounding and equal.  No deformity or signs of trauma.  All joints are stable without laxity.  There is good range of motion of all joints without tenderness or discomfort.  Homan sign is negative.  No atrophy or contractures are noted.,SKIN: , No rashes.  No jaundice.  Pink and warm with good turgor.  Good color.  No erythema or nodules noted.  No petechia, bulla or ecchymosis.,NEUROLOGIC: , Cranial nerves II through XII are grossly intact.  Muscle strength is graded 5/5 in the upper and lower extremities bilaterally.  Deep tendon reflexes are symmetrical in the upper and lower extremities bilaterally.  Babinski is downgoing bilaterally.  Sensation is intact to light touch and vibration.  Gait is normal.  Romberg, finger-to-nose, rapid alternating movements and heel-to-shin are all normal.  There is no ataxia seen on gait testing.  Tone is normal.  No pronator drift is seen.,PSYCHIATRIC:  ,The patient is oriented x4.  Mood and affect are appropriate.  Memory is intact with good short- and long-term memory recall.  No dysarthria is noted.  Remote memory is intact.  Judgment and insight appear normal.",
" Sample normal ear, nose, mouth, and throat exam.", Office Notes, Normal ENT Exam ,"EARS, NOSE, MOUTH AND THROAT: , The nose is without any evidence of any deformity.  The ears are with normal-appearing pinna.  Examination of the canals is normal appearing bilaterally.  There is no drainage or erythema noted.  The tympanic membranes are normal appearing with pearly color, normal-appearing landmarks and normal light reflex.  Hearing is grossly intact to finger rubbing and whisper.  The nasal mucosa is moist.  The septum is midline.  There is no evidence of septal hematoma.  The turbinates are without abnormality.  No obvious abnormalities to the lips.  The teeth are unremarkable.  The gingivae are without any obvious evidence of infection.  The oral mucosa is moist and pink.  There are no obvious masses to the hard or soft palate.  The uvula is midline.  The salivary glands appear unremarkable.  The tongue is midline.  The posterior pharynx is without erythema or exudate.  The tonsils are normal appearing.","office notes, erythema, tympanic, mouth, throat, ears, mucosa, noseNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Normal child physical exam template., Office Notes, Normal Child Exam Template ,"CHILD PHYSICAL EXAMINATION,VITAL SIGNS:  Birth weight is ** grams, length **, occipitofrontal circumference **.  Character of cry was lusty.,GENERAL APPEARANCE:  Well.,BREATHING:  Unlabored.,SKIN:  Clear.  No cyanosis, pallor, or icterus.  Subcutaneous tissue is ample.,HEAD:  Normal.  Fontanelles are soft and flat.  Sutures are opposed.,EYES:  Normal with red reflex x2.,EARS:  Patent.  Normal pinnae, canals, TMs.,NOSE:  Patent nares.,MOUTH:  No cleft.,THROAT:  Clear.,NECK:  No masses.,CHEST:  Normal clavicles.,LUNGS:  Clear bilaterally.,HEART:  Regular rate and rhythm without murmur.,ABDOMEN:  Soft, flat.  No hepatosplenomegaly.  The cord is three vessel.,GENITALIA:  Normal ** genitalia **with testes descended bilaterally.,ANUS:  Patent.,SPINE:  Straight and without deformity.,EXTREMITIES:  Equal movements.,MUSCLE TONE:  Good.,REFLEXES:  Moro, grasp, and suck are normal.,HIPS:  No click or clunk.","office notes, child physical examination, physical, genitalia, child, "
 Patient with juvenile myoclonic epilepsy and recent generalized tonic-clonic seizure., Office Notes, Myoclonic Epilepsy ,"DIAGNOSES:,1.  Juvenile myoclonic epilepsy.,2.  Recent generalized tonic-clonic seizure.,MEDICATIONS:,1.  Lamictal 250 mg b.i.d.,2.  Depo-Provera.,INTERIM HISTORY: , The patient returns for followup.  Since last consultation she has tolerated Lamictal well, but she has had a recurrence of her myoclonic jerking.  She has not had a generalized seizure.  She is very concerned that this will occur.  Most of the myoclonus is in the mornings.  Recent EEG did show polyspike and slow wave complexes bilaterally, more prominent on the left.  She states that she has been very compliant with the medications and is getting a good amount of sleep.  She continues to drive.,Social history and review of systems are discussed above and documented on the chart.,PHYSICAL EXAMINATION: , Vital signs are normal.  Pupils are equal and reactive to light.  Extraocular movements are intact.  There is no nystagmus.  Visual fields are full.  Demeanor is normal.  Facial sensation and symmetry is normal.  No myoclonic jerks noted during this examination.  No myoclonic jerks provoked by tapping on her upper extremity muscles.  Negative orbit.  Deep tendon reflexes are 2 and symmetric.  Gait is normal.  Tandem gait is normal.  Romberg negative.,IMPRESSION AND PLAN:,  Recurrence of early morning myoclonus despite high levels of Lamictal.  She is tolerating the medication well and has not had a generalized tonic-clonic seizure.  She is concerned that this is a precursor for another generalized seizure.  She states that she is compliant with her medications and has had a normal sleep-wake cycle.,Looking back through her notes, she initially responded very well to Keppra, but did have a breakthrough seizure on Keppra.  This was thought secondary to severe insomnia when her baby was very young.  Because she tolerated the medication well and it was at least partially affective, I have recommended adding Keppra 500 mg b.i.d.  Side effect profile of this medication was discussed with the patient.,I will see in followup in three months.","office notes, generalized tonic-clonic seizure, juvenile myoclonic epilepsy, tonic clonic seizure, myoclonic epilepsy, tonic clonic, juvenile, myoclonus, epilepsy, myoclonic, seizure"
 Persistent left hip pain.  Left hip avascular necrosis.  Discussed the possibility of hip arthrodesis versus hip replacement versus hip resurfacing, Office Notes, Hip Pain ,"CHIEF COMPLAINT:,","office notes, hip pain, radiculopathy, degenerative changes, avascular necrosis, hip resurfacing, arthrodesis, hip replacement, avn,"
 An example/template for a routine normal female physical exam., Office Notes, Normal Female Exam Template - 2 ,"VITAL SIGNS: , Blood pressure *, pulse *, respirations *, temperature *.,GENERAL APPEARANCE:,  Alert and in no apparent distress, calm, cooperative, and communicative.,HEENT: , Eyes:  EOMI.  PERRLA.  Sclerae nonicteric.  No lesions of lids, lashes, brows, or conjunctivae noted.  Funduscopic examination unremarkable.  Ears:  Normal set, shape, TMs, canals and hearing.  Nose and Sinuses:  Negative.  Mouth, Tongue, Teeth, and Throat:  Negative except for dental work.,NECK: , Supple and pain free without bruit, JVD, adenopathy or thyroid abnormality.,CHEST:,  Lungs are bilaterally clear to auscultation and percussion.,HEART: , S1 and S2.  Regular rate and rhythm without murmur, heave, click, lift, thrill, rub, or gallop.  PMI nondisplaced.  Chest wall unremarkable to inspection and palpation.  No axillary or supraclavicular adenopathy detected.,BREASTS:,  In the seated and supine position unremarkable.,ABDOMEN: , No hepatosplenomegaly, mass, tenderness, rebound, rigidity, or guarding.  No widening of the aortic impulse and no intraabdominal bruit auscultated.,EXTERNAL GENITALIA: , Normal for age.,RECTAL: , Negative to 7 cm by gloved digital palpation with Hemoccult-negative stool.,EXTREMITIES: , Good distal pulse and perfusion without evidence of edema, cyanosis, clubbing, or deep venous thrombosis.  Nails of the hands and feet, and creases of the palms and soles are unremarkable.  Good active and passive range of motion of all major joints.,BACK:,  Normal to inspection and percussion.  Negative for spinous process tenderness or CVA tenderness.  Negative straight-leg raising, Kernig, and Brudzinski signs.,NEUROLOGIC:,  Nonfocal for cranial and peripheral nervous systems, strength, sensation, and cerebellar function.  Affect is normal.  Speech is clear and fluent.  Thought process is lucid and rational.  Gait and station are unremarkable.,SKIN: , Unremarkable for any premalignant or malignant condition with normal changes for age.","office notes, heent, general appearance, hepatosplenomegaly, mass, tenderness, rebound, rigidity, pulse, bruit, adenopathy, chest, percussion, inspection, palpation, signs, tongue, "
 Sample/template for a normal female multisystem exam, Office Notes, Normal Female Exam Template ,"MULTISYSTEM EXAM,CONSTITUTIONAL: , The vital signs showed that the patient was afebrile; blood pressure and heart rate were within normal limits.  The patient appeared alert.,EYES: , The conjunctiva was clear.  The pupil was equal and reactive.  There was no ptosis.  The irides appeared normal.,EARS, NOSE AND THROAT: , The ears and the nose appeared normal in appearance.  Hearing was grossly intact.  The oropharynx showed that the mucosa was moist.  There was no lesion that I could see in the palate, tongue. tonsil or posterior pharynx.,NECK: , The neck was supple.  The thyroid gland was not enlarged by palpation.,RESPIRATORY:  ,The patient's respiratory effort was normal.  Auscultation of the lung showed it to be clear with good air movement.,CARDIOVASCULAR: , Auscultation of the heart revealed S1 and S2 with regular rate with no murmur noted.  The extremities showed no edema.,BREASTS:  ,Breast inspection showed them to be symmetrical with no nipple discharge.  Palpation of the breasts and axilla revealed no obvious mass that I could appreciate.,GASTROINTESTINAL:  ,The abdomen was soft, nontender with no rebound, no guarding, no enlarged liver or spleen.  Bowel sounds were present.,GU:  ,The external genitalia appeared to be normal.  The pelvic exam revealed no adnexal masses.  The uterus appeared to be normal in size and there was no cervical motion tenderness.,LYMPHATIC:  ,There was no appreciated node that I could feel in the groin or neck area.,MUSCULOSKELETAL:  ,The head and neck by inspection showed no obvious deformity.  Again, the extremities showed no obvious deformity.  Range of motion appeared to be normal for the upper and lower extremities.,SKIN:,  Inspection of the skin and subcutaneous tissues appeared to be normal.  The skin was pink, warm and dry to touch.,NEUROLOGIC: , Deep tendon reflexes were symmetrical at the patellar area.  Sensation was grossly intact by touch.,PSYCHIATRIC:  ,The patient was oriented to time, place and person.  The patient's judgment and insight appeared to be normal.", 
 Nephrology office visit for followup of microscopic hematuria., Office Notes, Nephrology Office Visit - 1 ,"HISTORY OF PRESENT ILLNESS:  ,The patient is a 78-year-old woman here because of recently discovered microscopic hematuria.  History of present illness occurs in the setting of a recent check up, which demonstrated red cells and red cell casts on a routine evaluation.  The patient has no new joint pains; however, she does have a history of chronic degenerative joint disease.  She does not use nonsteroidal agents.  She has had no gross hematuria and she has had no hemoptysis.,REVIEW OF SYSTEMS: , No chest pain or shortness of breath, no problem with revision.  The patient has had decreased hearing for many years.  She has no abdominal pain or nausea or vomiting.  She has no anemia.  She has noticed no swelling.  She has no history of seizures.,PAST MEDICAL HISTORY: , Significant for hypertension and hyperlipidemia.  There is no history of heart attack or stroke.  She has had bilateral simple mastectomies done 35 years ago.  She has also had one-third of her lung removed for carcinoma (probably an adeno CA related to a pneumonia.)  She also had hysterectomy in the past.,SOCIAL HISTORY: , She is a widow.  She does not smoke.,MEDICATIONS:,1.  Dyazide one a day.,2.  Pravachol 80 mg a day in the evening.,3.  Vitamin E once a day.,4.  One baby aspirin per day.,FAMILY HISTORY:,  Unremarkable.,PHYSICAL EXAMINATION:,  She looks younger than her stated age of 78 years.  She was hard of hearing, but could read my lips.  Respirations were 16.  She was afebrile.  Pulse was about 90 and regular.  Her gait was normal.  Blood pressure is 140/70 in her left arm seated.  HEENT:  She had arcus cornealis.  The pupils were equal.  The sclerae were not icteric.  The conjunctivae were pink.  NECK:  The thyroid is not palpated.  No nodes were palpated in the neck.  CHEST:  Clear to auscultation.  She had no sacral edema.  CARDIAC:  Regular, but she was tachycardic at the rate of about 90.  She had no diastolic murmur.  ABDOMEN:  Soft, and nontender.  I did not palpate the liver.  EXTREMITIES:  She had no appreciable edema.  She had no digital clubbing.  She had no cyanosis.  She had changes of the degenerative joint disease in her fingers.  She had good pedal pulses.  She had no twitching or myoclonic jerks.,LABORATORY DATA: , The urine, I saw 1-2 red cells per high power fields.  She had no protein.  She did have many squamous cells.  The patient has creatinine of 1 mg percent and no proteinuria.  It seems unlikely that she has glomerular disease; however, we cannot explain the red cells in the urine.,PLAN: , To obtain a routine sonogram.  I would also repeat a routine urinalysis to check for blood again.  I have ordered a C3 and C4 and if the repeat urine shows red cells, I will recommend a cystoscopy with a retrograde pyelogram.","office notes, nephrology, creatinine, cystoscopy, glomerular, high power fields, hyperlipidemia, hypertension, microscopic hematuria, proteinuria, pyelogram, red cell, retrograde, sonogram, urinalysis, red cells, hematuria"
 Patient has a past history of known hyperthyroidism and a recent history of atrial fibrillation and congestive cardiac failure with an ejection fraction of 20%-25%., Office Notes, Gen Med Office Note - 1 ,"HISTORY OF PRESENT ILLNESS:, The patient is a 43-year-old male who was recently discharged from our care on the 1/13/06 when he presented for shortness of breath. He has a past history of known hyperthyroidism since 1992 and a more recent history of atrial fibrillation and congestive cardiac failure with an ejection fraction of 20%-25%. The main cause for his shortness of breath was believed to be due to atrial fibrillation secondary to hyperthyroidism in a setting with congestive cardiac failure. During his hospital stay, he was commenced on metoprolol for rate control, and given that he had atrial fibrillation, he was also started on warfarin, which his INR has been followed up by the Homeless Clinic. For his congestive cardiac failure, he was restarted on Digoxin and lisinopril. For his hyperthyroidism, we restarted him on PTU and the endocrinologists were happy to review him when he was euthymic to discuss further radioiodine or radiotherapy. He was restarted on PTU and discharged from the hospital on this medication. While in the hospital, it was also noted that he abused cigarettes and cocaine, and we advised strongly against this given the condition of his heart. It was also noted that he had elevated liver function tests, which an ultrasound was normal, but his hepatitis panel was pending. Since his discharge, his hepatitis panel has come back normal for hepatitis A, B, and C. Since discharge, the patient has complained of shortness of breath, mainly at night when lying flat, but otherwise he states he has been well and compliant with his medication.,MEDICATIONS:, Digoxin 250 mcg daily, lisinopril 5 mg daily, metoprolol 50 mg twice daily, PTU (propylthiouracil) 300 mg orally four times a day, warfarin variable dose based on INR.,PHYSICAL EXAMINATION:,VITAL SIGNS: He was afebrile today. Blood pressure 114/98. Pulse 92 but irregular. Respiratory rate 25.,HEENT: Obvious exophthalmus, but no obvious lid lag today.,NECK: There was no thyroid mass palpable.,CHEST: Clear except for occasional bibasilar crackles.,CARDIOVASCULAR: Heart sounds were dual, but irregular, with no additional sounds.,ABDOMEN: Soft, nontender, nondistended.,EXTREMITIES: Mild +1 peripheral edema in both legs.,PLAN:, The patient has also been attending the Homeless Clinic since discharge from the hospital, where he has been receiving quality care and they have been looking after every aspect of his health, including his hyperthyroidism. It is our recommendation that a TSH and T4 be continually checked until the patient is euthymic, at which time he should attend endocrine review with Dr. Huffman for further treatment of his hyperthyroidism. Regarding his atrial fibrillation, he is moderately rate controlled with metoprolol 50 mg b.i.d. His rate in clinic today was 92. He could benefit from increasing his metoprolol dose, however, in the hospital it was noted that he was bradycardic in the morning with a pulse rate down to the 50s, and we were concerned with making this patient bradycardic in the setting of congestive cardiac failure. Regarding his congestive cardiac failure, he currently appears stable, with some variation in his weight. He states he has been taking his wife's Lasix tablets for diuretic benefit when he feels weight gain coming on and increased edema. We should consider adding him on a low-dose furosemide tablet to be taken either daily or when his weight is above his target range. A Digoxin level has not been repeated since discharge, and we feel that this should be followed up. We have also increased his lisinopril to 5 mg daily, but the patient did not receive his script upon departing our clinic. Regarding his elevated liver function tests, we feel that these are very likely secondary to hepatic congestion secondary to congestive cardiac failure with a normal ultrasound and normal hepatitis panel, but yet the liver function tests should be followed up.","office notes, congestive cardiac failure, ejection fraction, atrial fibrillation, congestive cardiac, cardiac failure, office, lisinopril, metoprolol, hepatitis, fibrillation, hyperthyroidism, atrial, cardiac, congestive,"
 Patient complains of constipation.  Has not had BM for two days., Office Notes, Constipation - 1 ,"Patient was informed by Dr. ABC that he does not need sleep study as per patient.,PHYSICAL EXAMINATION:,General:  Pleasant, brighter.,Vital signs:  117/78, 12, 56.,Abdomen:  Soft, nontender.  Bowel sounds normal.,ASSESSMENT AND PLAN:,1.  Constipation.  Milk of Magnesia 30 mL daily p.r.n., Dulcolax suppository twice a week p.r.n.,2.  CAD/angina.  See cardiologist this afternoon.,Call me if constipation not resolved by a.m., consider a Fleet enema then as discussed.,","office notes, constipation, bm, milk of magnesia, suppository, dulcolax, fleet enema, "
 The patient with continued problems with her headaches. , Office Notes, Headache - Office Visit ,"She also had EMG/nerve conduction studies since she was last seen in our office that showed severe left ulnar neuropathy, moderate right ulnar neuropathy, bilateral mild-to-moderate carpal tunnel and diabetic neuropathy.  She was referred to Dr. XYZ and will be seeing him on August 8, 2006.,She was also never referred to the endocrine clinic to deal with her poor diabetes control.  Her last hemoglobin A1c was 10.,PAST MEDICAL HISTORY:,  Diabetes, hypertension, elevated lipids, status post CVA, and diabetic retinopathy.,MEDICATIONS: , Glyburide, Avandia, metformin, lisinopril, Lipitor, aspirin, metoprolol and Zonegran.,PHYSICAL EXAMINATION:,  Blood pressure was 140/70, heart rate was 76, respiratory rate was 18, and weight was 226 pounds.  On general exam she has an area of tenderness on palpation in the left parietal region of her scalp.  Neurological exam is detailed on our H&P form.  Her neurological exam is within normal limits.,IMPRESSION AND PLAN:,  For her headaches we are going to titrate Zonegran up to 200 mg q.h.s. to try to maximize the Zonegran therapy.  If this is not effective, when she comes back on August 7, 2006 we will then consider other anticonvulsants such as Neurontin or Lyrica.  We also discussed with Ms. Hawkins the possibility of nerve block injection; however, at this point she is not interested.,She will be seeing Dr. XYZ for her neuropathies.,We made an appointment in endocrine clinic today for a counseling in terms of better diabetes control and she is responsible for trying to get her referral from her primary care physician to go for this consult.","office notes, nerve conduction studies, emg, zonegran therapy, ulnar neuropathy, endocrine clinic, diabetes control, neurological exam, headache, zonegran"
 Patient with a family history of premature coronary artery disease came in for evaluation of recurrent chest pain, Office Notes, Chest Pain - Office Note ,"DISCHARGE DIAGNOSES:,1.  Chest pain.  The patient ruled out for myocardial infarction on serial troponins.  Result of nuclear stress test is pending.,2.  Elevated liver enzymes, etiology uncertain for an outpatient followup.,3.  Acid reflux disease.,TEST DONE: , Nuclear stress test, results of which are pending.,HOSPITAL COURSE: , This 32-year-old with family history of premature coronary artery disease came in for evaluation of recurrent chest pain, O2 saturation at 94% with both atypical and typical features of ischemia.  The patient ruled out for myocardial infarction with serial troponins.  Nuclear stress test has been done, results of which are pending.  The patient is stable to be discharged pending the results of nuclear stress test and cardiologist's recommendations.  He will follow up with cardiologist, Dr. X, in two weeks and with his primary physician in two to four weeks.  Discharge medications will depend on results of nuclear stress test.","office notes, chest pain, serial troponins, premature coronary artery disease, coronary artery disease, nuclear stress test, stress test"
" Induction of vaginal delivery of viable male, Apgars 8 and 9.  Term pregnancy and oossible rupture of membranes, prolonged.", Office Notes, Induction of Vaginal Delivery ,"DIAGNOSES,1.  Term pregnancy.,2.  Possible rupture of membranes, prolonged.,PROCEDURE:,  Induction of vaginal delivery of viable male, Apgars 8 and 9.,HOSPITAL COURSE:,  The patient is a 20-year-old female, gravida 4, para 0, who presented to the office.  She had small amount of leaking since last night.  On exam, she was positive Nitrazine, no ferning was noted.  On ultrasound, her AFI was about 4.7 cm.  Because of a variable cervix, oligohydramnios, and possible ruptured membranes, we recommended induction.,She was brought to the hospital and begun on Pitocin.  Once she was in her regular pattern, we ruptured her bag of water; fluid was clear.  She went rapidly to completion over the next hour and a half.  She then pushed for 2 hours delivering a viable male over an intact perineum in an OA presentation.  Upon delivery of the head, the anterior and posterior arms were delivered, and remainder of the baby without complications.  The baby was vigorous, moving all extremities.  The cord was clamped and cut.  The baby was handed off to mom with nurse present.  Apgars were 8 and 9.  Placenta was delivered spontaneously, intact.  Three-vessel cord with no retained placenta.  Estimated blood loss was about 150 mL.  There were no tears.","office notes, induction of vaginal delivery, vaginal delivery, viable male, pregnancy, placenta, vaginal, membranes, apgars"
 Cardiology office visit sample note., Office Notes, Cardiology Office Visit - 2 ,"HISTORY OF PRESENT ILLNESS:,  This 57-year-old black female was seen in my office on Month DD, YYYY for further evaluation and management of hypertension.  Patient has severe backache secondary to disc herniation.  Patient has seen an orthopedic doctor and is scheduled for surgery.  Patient also came to my office for surgical clearance.  Patient had cardiac cath approximately four years ago, which was essentially normal.  Patient is documented to have morbid obesity and obstructive sleep apnea syndrome.  Patient does not use a CPAP mask.  Her exercise tolerance is eight to ten feet for shortness of breath.  Patient also has two-pillow orthopnea.  She has intermittent pedal edema.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Blood pressure is 135/70.  Respirations 18 per minute.  Heart rate 70 beats per minute.  Weight 258 pounds.,HEENT:  Head normocephalic.  Eyes, no evidence of anemia or jaundice.  Oral hygiene is good. ,NECK:  Supple.  JVP is flat.  Carotid upstroke is good. ,LUNGS:  Clear. ,CARDIOVASCULAR:  There is no murmur or gallop heard over the precordium. ,ABDOMEN:  Soft.  There is no hepatosplenomegaly. ,EXTREMITIES:  The patient has no pedal edema.  ,MEDICATIONS:  ,1.  BuSpar 50 mg daily.,2.  Diovan 320/12.5 daily.,3.  Lotrel 10/20 daily.,4.  Zetia 10 mg daily.,5.  Ambien 10 mg at bedtime.,6.  Fosamax 70 mg weekly.,DIAGNOSES:,1.  Controlled hypertension.,2.  Morbid obesity.,3.  Osteoarthritis.,4.  Obstructive sleep apnea syndrome.,5.  Normal coronary arteriogram.,6.  Severe backache.,PLAN:,1.  Echocardiogram, stress test.,2  Routine blood tests.,3.  Sleep apnea study.,4.  Patient will be seen again in my office in two weeks.", 
 Vaginal Hysterectomy.  A weighted speculum was placed in the posterior vaginal vault.  The cervix was grasped with a Massachusetts clamp on both its anterior and posterior lips., Obstetrics / Gynecology, Vaginal Hysterectomy ,,"obstetrics / gynecology, omentum, massachusetts, vaginal hysterectomy, vaginal vault, vaginal mucosa, vicryl suture, hysterectomy, ligaments, speculum, ligated, vaginal, sutureNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Patient had a markedly abnormal stress test with severe chest pain after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only., Office Notes, Abnormal Stress Test ,"HISTORY OF PRESENT ILLNESS: , Mr. ABC is a 60-year-old gentleman who had a markedly abnormal stress test earlier today in my office with severe chest pain after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only.  He required 3 sublingual nitroglycerin in total (please see also admission history and physical for full details).,The patient underwent cardiac catheterization with myself today which showed mild-to-moderate left main distal disease of 30%, moderate proximal LAD with a severe mid-LAD lesion of 99%, and a mid-left circumflex lesion of 80% with normal LV function and some mild luminal irregularities in the right coronary artery with some moderate stenosis seen in the mid to distal right PDA.,I discussed these results with the patient, and he had been relating to me that he was having rest anginal symptoms, as well as nocturnal anginal symptoms, and especially given the severity of the mid left anterior descending lesion, with a markedly abnormal stress test, I felt he was best suited for transfer for PCI.  I discussed the case with Dr. X at Medical Center who has kindly accepted the patient in transfer.,CONDITION ON TRANSFER: , Stable but guarded.  The patient is pain-free at this time.,MEDICATIONS ON TRANSFER:,1.  Aspirin 325 mg once a day.,2.  Metoprolol 50 mg once a day, but we have had to hold it because of relative bradycardia which he apparently has a history of.,3.  Nexium 40 mg once a day.,4.  Zocor 40 mg once a day, and there is a fasting lipid profile pending at the time of this dictation.  I see that his LDL was 136 on May 3, 2002.,5.  Plavix 600 mg p.o. x1 which I am giving him tonight.,Other medical history is inclusive for obstructive sleep apnea for which he is unable to tolerate positive pressure ventilation, GERD, arthritis,DISPOSITION:  ,The patient and his wife have requested and are agreeable with transfer to Medical Center, and we are enclosing the CD ROM of his images.","office notes, standard bruce, nitroglycerin, abnormal stress test, st depressions, anginal symptoms, stress test, lad, anginal, stress"
 Vacuum-assisted vaginal delivery of a third-degree midline laceration and right vaginal side wall laceration and repair of the third-degree midline laceration lasting for 25 minutes., Obstetrics / Gynecology, Vaginal Delivery - Vacuum-Assisted ,"PREOPERATIVE DIAGNOSES,1.  A 40 weeks 6 days intrauterine pregnancy.,2.  History of positive serology for HSV with no evidence of active lesions.,3.  Non-reassuring fetal heart tones.,POST OPERATIVE DIAGNOSES,1.  A 40 weeks 6 days intrauterine pregnancy.,2.  History of positive serology for HSV with no evidence of active lesions.,3.  Non-reassuring fetal heart tones.,PROCEDURES,1.  Vacuum-assisted vaginal delivery of a third-degree midline laceration and right vaginal side wall laceration.,2.  Repair of the third-degree midline laceration lasting for 25 minutes.,ANESTHESIA: , Local.,ESTIMATED BLOOD LOSS: , 300 mL.,COMPLICATIONS:  ,None.,FINDINGS,1.  Live male infant with Apgars of 9 and 9.,2.  Placenta delivered spontaneously intact with a three-vessel cord.,DISPOSITION:  ,The patient and baby remain in the LDR in stable condition.,SUMMARY: , This is a 36-year-old G1 woman who was pregnant since 40 weeks 6 days when she was admitted for induction of labor for post dates with favorable cervix.  When she was admitted, her cervix was 2.5 cm dilated with 80% effacement.  The baby had a -2 station.  She had no regular contractions.  Fetal heart tones were 120s and reactive.  She was started on Pitocin for labor induction and labored quite rapidly.  She had spontaneous rupture of membranes with a clear fluid.  She had planned on an epidural; however, she had sudden rapid cervical change and was unable to get the epidural.  With the rapid cervical change and descent of fetal head, there were some variable decelerations.  The baby was at a +1 station when the patient began pushing.  I had her push to get the baby to a +2 station.  During pushing, the fetal heart tones were in the 80s and did not recover in between contractions.  Because of this, I recommended a vacuum delivery for the baby.  The patient agreed.,The baby's head was confirmed to be in the right occiput anterior presentation.  The perineum was injected with 1% lidocaine.  The bladder was drained.  The vacuum was placed and the correct placement in front of the posterior fontanelle was confirmed digitally.  With the patient's next contraction, the vacuum was inflated and a gentle downward pressure was used to assist with brining the baby's head to a +3 station.  The contraction ended.  The vacuum was released and the fetal heart tones remained in the, at this time, 90s to 100s.  With the patient's next contraction, the vacuum was reapplied and the baby's head was delivered to a +4 station.  A modified Ritgen maneuver was used to stabilize the fetal head.  The vacuum was deflated and removed.  The baby's head then delivered atraumatically.  There was no nuchal cord.  The baby's anterior shoulder delivered after a less than 30 second delay.  No additional maneuvers were required to deliver the anterior shoulder.  The posterior shoulder and remainder of the body delivered easily.  The baby's mouth and nose were bulb suctioned.  The cord was clamped x2 and cut.  The infant was handed to the respiratory therapist.,Pitocin was added to the patient's IV fluids.  The placenta delivered spontaneously, was intact and had a three-vessel cord.  A vaginal inspection revealed a third-degree midline laceration as well as a right vaginal side wall laceration.  The right side wall laceration was repaired with #3-0 Vicryl suture in a running fashion with local anesthesia.  The third-degree laceration was also repaired with #3-0 Vicryl sutures.  Local anesthesia was used.  The capsule was visible, but did not appear to be injured at all.  It was reinforced with three separate interrupted sutures and then the remainder of the incision was closed with #3-0 Vicryl in the typical fashion.,The patient tolerated the procedure very well.  She remains in the LDR with the baby.  The baby is vigorous, crying and moving all extremities.  He will go to the new born nursery when ready.  The total time for repair of the laceration was 25 minutes.","obstetrics / gynecology, intrauterine pregnancy, non-reassuring fetal heart tones, vacuum-assisted vaginal delivery, vaginal side wall laceration, fetal heart tones, vaginal delivery, vacuum assisted, laceration, intrauterine, tones, contractions, "
" Well-woman check up for a middle-aged woman, status post hysterectomy, recent urinary tract infection.", Obstetrics / Gynecology, Well-woman checkup ,"CHIEF COMPLAINT:,  The patient comes for her well-woman checkup.,HISTORY OF PRESENT ILLNESS:,  She feels well.  She has had no real problems.  She has not had any vaginal bleeding.  She had a hysterectomy.  She has done fairly well from that time till now.  She feels like she is doing pretty well.  She remains sexually active occasionally.  She has not had any urinary symptoms.  No irregular vaginal bleeding.  She has not had any problems with vasomotor symptoms and generally, she just feels like she has been doing pretty well.  She sometimes gets a catch in her right hip and sometimes she gets heaviness in her calves.  She says the only thing that works to relieve that is to sleep on her tummy with her legs pulled up and they relax and she goes off to sleep.  She does not report any swelling or inflammation, or pain.  She had a recent urinary tract infection, took medication, and has not rechecked on that urinalysis.,MEDICATIONS: , Tetracycline 250 mg daily, Inderal LA 80 mg every other day.,ALLERGIES:,  Sulfa.,PAST MEDICAL HISTORY:,  She had rosacea.  She also has problems with “tremors” and for that she takes Inderal LA.  Hysterectomy in the past.,SOCIAL HISTORY:,  She drinks four cups of coffee a day.  No soda.  No chocolate.  She said her husband hurt his hand and shoulder, and she has been having to care of him pretty much.  They walk every evening for one hour.,FAMILY HISTORY:,  Her mother is in a nursing home; she had a stroke.  Her father died at age 86 in January 2004 of congestive heart failure.  She has two brothers, one has kidney failure, the other brother donated a kidney to his other brother, but this young man is now an alcoholic and drug addict.,REVIEW OF SYSTEMS:,  Patient denies headache or trauma.  No blurred or double vision.  Hearing is fine, no tinnitus, or infection.  Infrequent sore throat, no hoarseness, or cough.,Neck:  No stiffness, pain, or swelling.,Respiratory:  No shortness of breath, cough, or hemoptysis.,Cardiovascular:  No chest pain, ankle edema, palpitations, or hypertension.,GI:  No nausea, vomiting, diarrhea, constipation, melena, or jaundice.,GU:  No dysuria, frequency, urgency, or stress incontinence.,Locomotor:  No weakness, joint pain, tremor, or swelling.,GYN:  See HPI.,Integumentary:  Patient performs self-breast examinations and denies any breast masses or nipple discharge.  No recent skin or hair changes.,Neuropsychiatric:  Denies depression, anxiety, tearfulness, or suicidal thought.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Height:  62 inches.  Weight:  134 pounds.  Blood pressure:  116/74.  Pulse:  60.  Respirations:  12.  Age 59.,HEENT:  Head is normocephalic.  Eyes:  EOMs intact.  PERRLA.  Conjunctiva clear.  Fundi:  Discs flat, cups normal.  No AV nicking, hemorrhage or exudate.  Ears:  TMs intact.  Mouth:  No lesion.  Throat:  No inflammation.  She fell last winter on the ice and really cracked her head and has had some problems with headaches since then and she has not returned to her job which was very stressful and hard on her.  She wears glasses.,Neck:  Full range of motion.  No lymphadenopathy or thyromegaly.,Chest:  Clear to auscultation and percussion.,Heart:  Normal sinus rhythm, no murmur.,Integumentary:  Breasts are without masses, tenderness, nipple retraction, or discharge.  Reviewed self-breast examination.  No axillary nodes are palpable.,Abdomen:  Soft.  Liver, spleen, and kidneys are not palpable.  No masses felt, nontender.  Femoral pulses strong and equal.,Back:  No CVA or spinal tenderness.  No deformity noted.,Pelvic:  BUS negative.  Vaginal mucosa atrophic.  Cervix and uterus are absent.  No Pap was taken.  No adnexal masses.,Rectal:  Good sphincter tone.  No masses.  Stool guaiac negative.,Extremities:  No edema.  Pulses strong and equal.  Reflexes are intact.  Romberg and Babinski are negative.  She is oriented x 3.  Gait is normal.,ASSESSMENT:,  Middle-aged woman, status post hysterectomy, recent urinary tract infection.,PLAN:,  We will evaluate the adequacy of the therapy for her urinary tract infection with the urinalysis and culture.  I recommended mammogram and screening, hemoccult x 3, DEXA scan and screening, and she is fasting today.  We will screen with chem-12, lipid profile, and CBC because of her advancing age and notify of those results, as soon as they are available.  Continue same meds.  Recheck annually unless she has problems sooner.",
 The patient needs refills on her Xanax, Office Notes, Consult - Smoking Cessation  ,"CHIEF COMPLAINT: , I need refills.,HISTORY OF PRESENT ILLNESS:,  The patient presents today stating that she needs refills on her Xanax, and she would also like to get something to help her quit smoking.  She is a new patient today.  She states that she has mesothelioma in the lining of her stomach and that it does cause her some problems with eating and it causes some chronic pain.  She states that she is under the care of a cancer specialist; however, she just recently moved back to this area and is trying to find a doctor a little closer than his office.  She states that she has tried several different things to help her quit smoking and she has failed everything and had heard good results about Chantix and wanted to give it a try.,OBJECTIVE:  ,Well developed and well nourished.  She does not appear to be in any acute distress.  Cardiovascular:  Regular rhythm.  No murmurs, gallops, or rubs.  Capillary refill less than 3 seconds.  Peripheral pulses are 2+ bilaterally.  Respiratory:  Her lungs are clear to auscultation bilaterally with good effort.  No tenderness to palpation over chest wall.  Musculoskeletal:  She has full range of motion of all four extremities.  No tenderness to palpation over long bones.  Skin:  Warm and dry.  No rashes or lesions.  Neuro:  Alert and oriented x3.  Cranial nerves II-XII are grossly intact.  No focal deficits.,PLAN: , I did refill her medications.  I have requested that she have her primary doctor forward her records to me.  I have discussed Chantix and its use and success rate.  She was given a prescription, as well as a coupon.  She is to watch for any worsening signs or symptoms.  She verbalized understanding of discharge instructions and prescriptions.  I would like to see her back to proceed with her preventive health measures.","office notes, quit smoking, chantix, mesothelioma, smoking, xanax, refills"
 A 21-year-old female was having severe cramping and was noted to have a blighted ovum with her first ultrasound in the office., Obstetrics / Gynecology, Vacuum D&C ,"PREOPERATIVE DIAGNOSIS: , Blighted ovum, severe cramping.,POSTOPERATIVE DIAGNOSIS:,  Blighted ovum, severe cramping.,OPERATION PERFORMED: , Vacuum D&C.,DRAINS: , None.,ANESTHESIA: , General.,HISTORY: , This 21-year-old white female gravida 1, para 0 who was having severe cramping and was noted to have a blighted ovum with her first ultrasound in the office.  Due to the severe cramping, a decision to undergo vacuum D&C was made.  At the time of the procedure, moderate amount of tissue was obtained.,PROCEDURE:  ,The patient was taken to the operating room and placed in a supine position, at which time a general form of anesthesia was administered by the anesthesia department.  The patient was then repositioned in a modified dorsal lithotomy position and then prepped and draped in the usual fashion.  A weighted vaginal speculum was placed in the posterior vaginal vault.  Anterior lip of the cervix was grasped with single tooth tenaculum, and the cervix was dilated to approximately 8 mm straight.  Plastic curette was placed into the uterine cavity and suction was applied at 60 mmHg to remove the tissue.  This was followed by gentle curetting of the lining as well as followed by suction curetting and then another gentle curetting and a final suction.  Methargen 0.2 mg was given IM and Pitocin 40 units and a 1000 was also started at the time of the procedure.  Once the procedure was completed, the single tooth tenaculum was removed from the vaginal vault with some _____ remaining blood and the weighted speculum was also removed.  The patient was repositioned to supine position and taken to recovery room in stable condition.","obstetrics / gynecology, pitocin, single tooth tenaculum, vaginal vault, vacuum d&c, blighted ovum, speculum, tenaculum, curetting, blighted, cramping,"
 Laparoscopic-assisted vaginal hysterectomy.  Abnormal uterine bleeding.  Uterine fibroids., Obstetrics / Gynecology, Vaginal Hysterectomy - Laparoscopic-Assisted ,"PREOPERATIVE DIAGNOSES,1.  Abnormal uterine bleeding.,2.  Uterine fibroids.,POSTOPERATIVE DIAGNOSES,1.  Abnormal uterine bleeding.,2.  Uterine fibroids.,OPERATION PERFORMED: , Laparoscopic-assisted vaginal hysterectomy.,ANESTHESIA: , General endotracheal anesthesia.,DESCRIPTION OF PROCEDURE:  ,After adequate general endotracheal anesthesia, the patient was placed in dorsal lithotomy position, prepped and draped in the usual manner for a laparoscopic procedure.  A speculum was placed into the vagina.  A single tooth tenaculum was utilized to grasp the anterior lip of the uterine cervix.  The uterus was sounded to 10.5 cm.  A #10 RUMI cannula was utilized and attached for uterine manipulation.  The single-tooth tenaculum and speculum were removed from the vagina.  At this time, the infraumbilical area was injected with 0.25% Marcaine with epinephrine and infraumbilical vertical skin incision was made through which a Veress needle was inserted into the abdominal cavity.  Aspiration was negative; therefore the abdomen was insufflated with carbon dioxide.  After adequate insufflation, Veress needle was removed and an 11-mm separator trocar was introduced through the infraumbilical incision into the abdominal cavity.  Through the trocar sheath, the laparoscope was inserted and adequate visualization of the pelvic structures was noted.  At this time, the suprapubic area was injected with 0.25% Marcaine with epinephrine.  A 5-mm skin incision was made and a 5-mm trocar was introduced into the abdominal cavity for instrumentation.  Evaluation of the pelvis revealed the uterus to be slightly enlarged and irregular.  The fallopian tubes have been previously interrupted surgically.  The ovaries appeared normal bilaterally.  The cul-de-sac was clean without evidence of endometriosis, scarring or adhesions.  The ureters were noted to be deep in the pelvis.  At this time, the right cornu was grasped and the right fallopian tube, uteroovarian ligament, and round ligaments were doubly coagulated with bipolar electrocautery and transected without difficulty.  The remainder of the uterine vessels and anterior and posterior leaves of the broad ligament, as well as the cardinal ligament was coagulated and transected in a serial fashion down to level of the uterine artery.  The uterine artery was identified.  It was doubly coagulated with bipolar electrocautery and transected.  A similar procedure was carried out on the left with the left uterine cornu identified.  The left fallopian tube, uteroovarian ligament, and round ligaments were doubly coagulated with bipolar electrocautery and transected.  The remainder of the cardinal ligament, uterine vessels, anterior, and posterior sheaths of the broad ligament were coagulated and transected in a serial manner to the level of the uterine artery.  The uterine artery was identified.  It was doubly coagulated with bipolar electrocautery and transected.  The anterior leaf of the broad ligament was then dissected to the midline bilaterally, establishing a bladder flap with a combination of blunt and sharp dissection.  At this time, attention was made to the vaginal hysterectomy.  The laparoscope was removed and attention was made to the vaginal hysterectomy.  The RUMI cannula was removed and the anterior and posterior leafs of the cervix were grasped with Lahey tenaculum.  A circumferential injection with 0.25% Marcaine with epinephrine was made at the cervicovaginal portio.  A circumferential incision was then made at the cervicovaginal portio.  The anterior and posterior colpotomies were accomplished with a combination of blunt and sharp dissection without difficulty.  The right uterosacral ligament was clamped, transected, and ligated with #0 Vicryl sutures.  The left uterosacral ligament was clamped, transected, and ligated with #0 Vicryl suture.  The parametrial tissue was then clamped bilaterally, transected, and ligated with #0 Vicryl suture bilaterally.  The uterus was then removed and passed off the operative field.  Laparotomy pack was placed into the pelvis.  The pedicles were evaluated.  There was no bleeding noted; therefore, the laparotomy pack was removed.  The uterosacral ligaments were suture fixated into the vaginal cuff angles with #0 Vicryl sutures.  The vaginal cuff was then closed in a running fashion with #0 Vicryl suture.  Hemostasis was noted throughout.  At this time, the laparoscope was reinserted into the abdomen.  The abdomen was reinsufflated.  Evaluation revealed no further bleeding.  Irrigation with sterile water was performed and again no bleeding was noted.  The suprapubic trocar sheath was then removed under laparoscopic visualization.  The laparoscope was removed.  The carbon dioxide was allowed to escape from the abdomen and the infraumbilical trocar sheath was then removed.  The skin incisions were closed with #4-0 Vicryl in subcuticular fashion.  Neosporin and Band-Aid were applied for dressing and the patient was taken to the recovery room in satisfactory condition.  Estimated blood loss was approximately 100 mL.  There were no complications.  The instrument, sponge, and needle counts were correct.","obstetrics / gynecology, abnormal uterine bleeding, laparoscopic-assisted vaginal hysterectomy, uterine fibroids, bipolar electrocautery, vaginal hysterectomy, vicryl sutures, tooth, uterine, uterosacral, laparoscope, electrocautery, hysterectomy, laparoscopic, coagulated, vaginal, ligament, transected"
" Pregnant female with nausea, vomiting, and diarrhea.  OB ultrasound less than 14 weeks, transvaginal.", Obstetrics / Gynecology, Ultrasound OB - 8 ,"REASON FOR EXAM: , Pregnant female with nausea, vomiting, and diarrhea.,FINDINGS: , The uterus measures 8.6 x 4.4 x 5.4 cm and contains a gestational sac with double decidual sac sign.  A yolk sac is visualized.  What appears to represent a crown-rump length measures 3.3 mm for an estimated sonographic age of 6 weeks 0 days and estimated date of delivery of 09/28/09.,Please note however that no fetal heart tones are seen.  However, fetal heart tones would be expected at this age.,The right ovary measures 3.1 x 1.6 x 2.3 cm.  The left ovary measures 3.3 x 1.9 x 3.5 cm.  No free fluid is detected.,IMPRESSION: , Single intrauterine pregnancy at 6 weeks 0 days with an estimated date of delivery of 09/28/09.  A live intrauterine pregnancy, however, could not be confirmed, as a sonographic fetal heart rate would be expected at this time.  A close interval followup in correlation with beta-hCG is necessary as findings may represent an inevitable abortion.","obstetrics / gynecology, intrauterine pregnancy, estimated date of delivery, nausea, vomiting, fetal heart tones, ovary measures, fetal heart, ultrasound, ob, ovary, pregnancy, sac, fetal, intrauterine"
" The patient is a 67-year-old white female with a history of uterine papillary serous carcinoma who is status post 6 cycles of carboplatin and Taxol, is here today for followup. ", Obstetrics / Gynecology, Uterine Papillary Serous Carcinoma ,"HISTORY OF PRESENT ILLNESS:,  The patient is a 67-year-old white female with a history of uterine papillary serous carcinoma who is status post 6 cycles of carboplatin and Taxol, is here today for followup.  Her last cycle of chemotherapy was finished on 01/18/08, and she complains about some numbness in her right upper extremity.  This has not gotten worse recently and there is no numbness in her toes.  She denies any tingling or burning.,REVIEW OF SYSTEMS: , Negative for any fever, chills, nausea, vomiting, headache, chest pain, shortness of breath, abdominal pain, constipation, diarrhea, melena, hematochezia or dysuria.  The patient is concerned about her blood pressure being up a little bit and also a mole that she had noticed for the past few months in her head.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 35.6, blood pressure 143/83, pulse 65, respirations 18, and weight 66.5 kg.  GENERAL:  She is a middle-aged white female, not in any distress.  HEENT:  No lymphadenopathy or mucositis.  CARDIOVASCULAR:  Regular rate and rhythm.  LUNGS:  Clear to auscultation bilaterally.  EXTREMITIES:  No cyanosis, clubbing or edema.  NEUROLOGICAL:  No focal deficits noted.  PELVIC:  Normal-appearing external genitalia.  Vaginal vault with no masses or bleeding.,LABORATORY DATA: , None today.,RADIOLOGIC DATA: , CT of the chest, abdomen, and pelvis from 01/28/08 revealed status post total abdominal hysterectomy/bilateral salpingo-oophorectomy with an unremarkable vaginal cuff.  No local or distant metastasis.  Right probably chronic gonadal vein thrombosis.,ASSESSMENT: , This is a 67-year-old white female with history of uterine papillary serous carcinoma, status post total abdominal hysterectomy and bilateral salpingo-oophorectomy and 6 cycles of carboplatin and Taxol chemotherapy.  She is doing well with no evidence of disease clinically or radiologically.,PLAN:,1.  Plan to follow her every 3 months and CT scans every 6 months for the first 2 years.,2.  The patient was advised to contact the primary physician for repeat blood pressure check and get started on antihypertensives if it is persistently elevated.,3.  The patient was told that the mole that she is mentioning in her head is no longer palpable and just to observe it for now.,4.  The patient was advised about doing Kegel exercises for urinary incontinence, and we will address this issue again during next clinic visit if it is persistent.,","obstetrics / gynecology, chemotherapy, uterine papillary serous carcinoma, oophorectomy, carboplatin, taxol, abdominal, uterine, papillary, carcinoma,"
 A 27-year-old female with a size and date discrepancy., Obstetrics / Gynecology, Ultrasound OB - 7 ,"GENERAL EVALUATION:,Fetal Cardiac Activity: Normal at 150BPM.  Fetal Lie: Longitudinal.  Fetal Presentation: Cephalic.  Placenta: Anterior Grade I.  Uterus: Normal.  Cervix: Closed.  Adnexa: Not seen.  Amniotic Fluid: Normal.,BIOMETRY:,BPD: 8.4 cm consistent with 33 weeks, 6 days gestation,HC: 29.8 cm consistent with 33 weeks, 0 days gestation,AC: 29.7 cm consistent with 33 weeks, 5 days gestation,FL:",
" Exam under anesthesia with uterine suction curettage.  A 10-1/2 week pregnancy, spontaneous, incomplete abortion.", Obstetrics / Gynecology, Uterine Suction Curettage ,"PREOPERATIVE DIAGNOSIS: , A 10-1/2 week pregnancy, spontaneous, incomplete abortion.,POSTOPERATIVE DIAGNOSIS:,  A 10-1/2 week pregnancy, spontaneous, incomplete abortion.,PROCEDURE: , Exam under anesthesia with uterine suction curettage.,ANESTHESIA: , Spinal.,ESTIMATED BLOOD LOSS: , Less than 10 cc.,COMPLICATIONS:,  None.,DRAINS:,  None.,CONDITION:,  Stable.,INDICATIONS:  ,The patient is a 29-year-old gravida 5, para 1-0-3-1, with an LMP at 12/18/05.  The patient was estimated to be approximately 10-1/2 weeks so long in her pregnancy.  She began to have heavy vaginal bleeding and intense lower pelvic cramping.  She was seen in the emergency room where she was found to be hemodynamically stable.  On pelvic exam, her cervix was noted to be 1 to 2 cm dilated and approximately 90% effaced.  There were bulging membranes protruding through the dilated cervix.  These symptoms were consistent with the patient's prior experience of spontaneous miscarriages.  These findings were reviewed with her and options for treatment discussed.  She elected to proceed with an exam under anesthesia with uterine suction curettage.  The risks and benefits of the surgery were discussed with her and knowing these, she gave informed consent.,PROCEDURE:  ,The patient was taken to the operating room where she was placed in the seated position.  A spinal anesthetic was successfully administered.  She was then moved to a dorsal lithotomy position.  She was prepped and draped in the usual fashion for the procedure.  After adequate spinal level was confirmed, a bimanual exam was again performed.  This revealed the uterus to be anteverted to axial and approximately 10 to 11 weeks in size.  The previously noted cervical exam was confirmed.  The weighted vaginal speculum was then inserted and the vaginal vault flooded with povidone solution.  This solution was then removed approximately 10 minutes later with dry sterile gauze sponge.  The anterior cervical lip was then attached with a ring clamp.  The tissue and membranes protruding through the os were then gently grasped with a ring clamp and traction applied.  The tissue dislodged revealing fluid mixed with blood as well as an apparent 10-week fetus.  The placental tissue was then gently tractioned out as well.  A size 9 curved suction curette was then gently inserted through the dilated os and into the endometrial cavity.  With the vacuum tubing applied in rotary motion, a moderate amount of tissue consistent with products of conception was evacuated.  The sharp curette was then utilized to probe the endometrial surface.  A small amount of additional tissue was then felt in the posterior uterine wall.  This was curetted free.  A second pass was then made with a vacuum curette.  Again, the endometrial cavity was probed with a sharp curette and no significant additional tissue was encountered.  A final pass was then made with a suction curette.,The ring clamp was then removed from the anterior cervical lip.  There was only a small amount of bleeding following the curettage.  The weighted speculum was then removed as well.  The bimanual exam was repeated and good involution was noted.  The patient was taken down from the dorsal lithotomy position.  She was transferred to the recovery room in stable condition.  The sponge and instrument count was performed and found to be correct.  The specimen of products of conception and 10-week fetus were submitted to Pathology for further evaluation.  The estimated blood loss for the procedure is less than 10 mL.","obstetrics / gynecology, spontaneous, incomplete abortion, uterine suction curettage, fetus, anterior cervical lip, spontaneous incomplete abortion, bimanual exam, ring clamp, suction curettage, uterine, curettage, suction"
 Sample cardiology office visit note., Office Notes, Cardiology Office Visit - 1  ,"HISTORY OF PRESENT ILLNESS:,  This 66-year-old white male was seen in my office on Month DD, YYYY.  Patient was recently discharged from Doctors Hospital at Parkway after he was treated for pneumonia.  Patient continues to have severe orthopnea, paroxysmal nocturnal dyspnea, cough with greenish expectoration.  His exercise tolerance is about two to three yards for shortness of breath.  The patient stopped taking Coumadin for reasons not very clear to him.  He was documented to have recent atrial fibrillation.  Patient has longstanding history of ischemic heart disease, end-stage LV systolic dysfunction, and is status post ICD implantation.  Fasting blood sugar this morning is 130.,PHYSICAL EXAMINATION: , ,VITAL SIGNS:  Blood pressure is 120/60.  Respirations 18 per minute.  Heart rate 75-85 beats per minute, irregular.  Weight 207 pounds.,HEENT:  Head normocephalic.  Eyes, no evidence of anemia or jaundice.  Oral hygiene is good. ,NECK:  Supple.  JVP is flat.  Carotid upstroke is good. ,LUNGS:  Severe inspiratory and expiratory wheezing heard throughout the lung fields.  Fine crepitations heard at the base of the lungs on both sides. ,CARDIOVASCULAR:  PMI felt in fifth left intercostal space 0.5-inch lateral to midclavicular line. First and second heart sounds are normal in character.  There is a II/VI systolic murmur best heard at the apex.,ABDOMEN:  Soft.  There is no hepatosplenomegaly.,EXTREMITIES:  Patient has 1+ pedal edema.,MEDICATIONS: , ,1.  Ambien 10 mg at bedtime p.r.n.,2.  Coumadin 7.5 mg daily.,3.  Diovan 320 mg daily.,4.  Lantus insulin 50 units in the morning.,5.  Lasix 80 mg daily.,6.  Novolin R p.r.n.,7.  Toprol XL 100 mg daily.,8.  Flovent 100 mcg twice a day.,DIAGNOSES:,1.  Atherosclerotic coronary vascular disease with old myocardial infarction.,2.  Moderate to severe LV systolic dysfunction.,3.  Diabetes mellitus.,4.  Diabetic nephropathy and renal failure.,5.  Status post ICD implantation.,6.  New onset of atrial fibrillation.,7.  Chronic Coumadin therapy.,PLAN:,1.  Continue present therapy.,2.  Patient will be seen again in my office in four weeks.",
 A 37 year-old female with twin pregnancy with threatened premature labor., Obstetrics / Gynecology, Ultrasound OB - 3 ,"GENERAL EVALUATION: ,Twin B,Fetal Cardiac Activity: Normal at 166 BPM,Fetal Lie: Longitudinal, to the maternal right.,Fetal Presentation: Cephalic.,Placenta: Fused, posterior placenta, Grade I to II.,Uterus: Normal,Cervix: Closed.,Adnexa: Not seen,Amniotic Fluid: AFI 5.5cm in a single AP pocket.,BIOMETRY:,BPD: 7.9cm consistent with 31weeks, 5 days gestation,HC: 31.1cm consistent with 33 weeks, 3 days gestation,AC: 30.0cm consistent with 34 weeks, 0 days gestation,FL:",
 This is a 24-year-old pregnant patient to evaluate fetal weight and placental grade., Obstetrics / Gynecology, Ultrasound OB - 5 ,"GENERAL EVALUATION:,Fetal Cardiac Activity: Normal with a heart rate of 135BPM,Fetal Presentation: Cephalic.,Placenta: Anterior,Placentral grade: II,Previa: ? None.,Amniotic Fluid: 1.5 + 2.5 + 0.0 + 0.0 = 4cm compatible with oligohydramnios.,BIOMETRY:,BPD: 9.0cm consistent with 36weeks, 4days gestation,HC: 34.6cm which equals 40weeks and 1day gestational age.,FL: 6.9cm which equals 35weeks and 3days gestational age.,AC: 34.6cm which equals 38weeks and 4days gestational age.,CI (BPD/OFD):  (70-86) 73,FL/BPD: (71-87) 77,FL/HC: (20.8-22.6) 19.9,FL/AC (20-24) 20,HC/AC: (0.92-1.05) 1.00,GESTATIONAL AGE BY CURRENT ULTRASOUND: 37weeks 4days.,FETAL WEIGHT BY CURRENT ULTRASOUND: 3289grams (7pounds 4ounces).,ESTIMATED FETAL WEIGHT PERCENTILE: 24%.,EDD BY CURRENT ULTRASOUND: 06/04/07.,GESTATIONAL AGE BY DATES: 40weeks 0days.,L M P: Unknown.,EDD BY DATES: 05/18/07.,DATE OF PREVIOUS ULTRASOUND: 03/05/07.,EDD BY PREVIOUS ULTRASOUND: 05/24/07.,FETAL ANATOMY:,Fetal Ventricles: Normal,Fetal Cerebellum: Normal,Fetal Cranium: Normal,Fetal Face: Normal Nose and Mouth,Fetal Heart (4 Chamber View): Normal,Fetal Diaphragm: Normal,Fetal Stomach: Normal,Fetal Cord: Normal three-vessel cord,Fetal Abdominal Wall: Normal,Fetal Spine: Normal,Fetal Kidneys: Normal,Fetal Bladder: Normal,Fetal Limbs: Normal,IMPRESSION:,Active intrauterine pregnancy with a sonographic gestational age of 37weeks and 4days.,AFI=4cm compatible with mild oligohydramnios.,Fetal weight equals 3289grams (7pounds 4ounces). EFW percentile is 24%.,Placental grade is II.,No evidence of gross anatomical abnormality, with a biophysical profile total equal to 8 out of 8.,",
 A 34-year old female with no fetal heart motion noted on office scan., Obstetrics / Gynecology, Ultrasound OB - 2 ,"FINDINGS:,By dates the patient is 8 weeks, 2 days.,There is a gestational sac within the endometrial cavity measuring 2.1cm consistent with 6 weeks 4 days. There is a fetal pole measuring 7mm consistent with 6 weeks 4 days. There was no fetal heart motion on Doppler or on color Doppler.,There is no fluid within the endometrial cavity.,There is a 2.8 x 1.2cm right adnexal cyst.,IMPRESSION:,Gestational sac with a fetal pole but no fetal heart motion consistent with fetal demise at 6 weeks 4 days. By dates the patient is 8 weeks, 2 days.,A preliminary report was called by the ultrasound technologist to the referring physician.","obstetrics / gynecology, fetal heart motion, gestational sac, endometrial cavity, fetal pole, fetal heart, heart motion, gestational, fetal"
 Twin pregnancy with threatened preterm labor., Obstetrics / Gynecology, Ultrasound OB - 4 ,"GENERAL EVALUATION: ,(Twin A),Fetal Cardiac Activity: Normal at 166 BPM,Fetal Lie: Twin A lies to the maternal left.,Fetal Presentation: Cephalic,Placenta: Posterior fused placenta Grade I-II,Uterus: Normal,Cervix: Closed,Adnexa: Not seen,Amniotic Fluid: There is a single 3.9cm anterior pocket.,BIOMETRY:,BPD: 8.7cm consistent with 35 weeks, 1 day,HC: 30.3cm consistent with 33 weeks, 5 days.,AC: 28.2cm consistent with 32 weeks, 1 day,FL:",
 Ultrasound - a 22-year-old pregnant female., Obstetrics / Gynecology, Ultrasound OB - 6 ,"GENERAL EVALUATION:,Fetal Cardiac Activity: Normal at 140 BPM,Fetal Position: Variable,Placenta: Posterior without evidence of placenta previa.,Uterus: Normal,Cervix:","obstetrics / gynecology, pregnant female, fetal anatomy, pregnant, placenta, gestational, ultrasound, fetal, "
 OB Ultrasound - A 29-year-old female requests for size and date of pregnancy., Obstetrics / Gynecology, Ultrasound OB - 1 ,"EXAM: , OB Ultrasound.,HISTORY:,  A 29-year-old female requests for size and date of pregnancy.,FINDINGS: , A single live intrauterine gestation in the cephalic presentation, fetal heart rate is measured 147 beats per minute.  Placenta is located posteriorly, grade 0 without previa.  Cervical length is 4.2 cm.  There is normal amniotic fluid index of 12.2 cm.  There is a 4-chamber heart.  There is spontaneous body/limb motion.  The stomach, bladder, kidneys, cerebral ventricles, heel, spine, extremities, and umbilical cord are unremarkable.,BIOMETRIC DATA:,BPD = 7.77 cm = 31 weeks, 1 day,HC = 28.26 cm = 31 weeks, 1 day,AC = 26.63 cm = 30 weeks, 5 days,FL = 6.06 cm = 31 weeks, 4 days,Composite sonographic age 30 weeks 6 days plus minus 17 days.,ESTIMATED DATE OF DELIVERY: , Month DD, YYYY.,Estimated fetal weight is 3 pounds 11 ounces plus or minus 10 ounces.,IMPRESSION: , Single live intrauterine gestation without complications as described.","obstetrics / gynecology, ultrasound, ac, bpd, cervical length, estimated date of delivery, fl, hc, placenta, single live, amniotic fluid, bladder, cephalic, cephalic presentation, cerebral ventricles, extremities, fetal heart rate, fetal weight, gestation, heel, intrauterine, kidneys, pregnancy, previa, spine, stomach, umbilical cord, live intrauterine, intrauterine gestation"
 Transvaginal ultrasound to evaluate pelvic pain., Obstetrics / Gynecology, Ultrasound - Transvaginal ,"EXAM: , Transvaginal ultrasound.,HISTORY: , Pelvic pain.,FINDINGS: , The right ovary measures 1.6 x 3.4 x 2.0 cm.  There are several simple-appearing probable follicular cysts. There is no abnormal flow to suggest torsion on the right.  Left ovary is enlarged, demonstrating a 6.0 x 3.5 x 3.7 cm complex cystic mass of uncertain etiology.  This could represent a large hemorrhagic cyst versus abscess.  There is no evidence for left ovarian torsion.  There is a small amount of fluid in the cul-de-sac likely physiologic.,The uterus measures 7.7 x 5.0 cm.  The endometrial echo is normal at 6 mm.,IMPRESSION:,1.  No evidence for torsion.,2.  Large, complex cystic left ovarian mass as described.  This could represent a large hemorrhagic cyst; however, an abscess/neoplasm cannot be excluded.  Recommend either short interval followup versus laparoscopic evaluation given the large size and complex nature.","obstetrics / gynecology, ultrasound, pelvic pain, transvaginal, cul-de-sac, cystic mass, echo, endometrial, flow, follicular cysts, hemorrhagic cyst, laparoscopic, neoplasm, ovarian, ovary, uterus, transvaginal ultrasound, complex cystic, torsion, "
 Ultrasound of pelvis - menorrhagia., Obstetrics / Gynecology, Ultrasound - Pelvis  ,"EXAM: , Ultrasound of pelvis.,HISTORY:, Menorrhagia.,FINDINGS: , Uterus is enlarged measuring 11.0 x 7.5 x 11.0 cm.  It appears to be completely replaced by multiple ill-defined fibroids.  The endometrial echo complex was not visualized due to the contents of replacement of the uterus with fibroids.  The right ovary measures 3.9 x 1.9 x 2.3 cm.  The left ovary is not seen.  No complex cystic adnexal masses are identified.,IMPRESSION:  ,Essential replacement of the uterus by fibroids.  It is difficult to measure given their heterogenous and diffuse nature.  MRI of the pelvis could be performed for further evaluation to evaluate for possible uterine fibroid embolization.","obstetrics / gynecology, pelvis, mri, menorrhagia, ultrasound, adnexa, echo complex, endometrial, fibroids, ovary, uterine fibroid, uterus, ultrasound of pelvis"
" Desires permanent sterilization.  Laparoscopic tubal ligation, Falope ring method.  Normal appearing uterus and adnexa bilaterally.", Obstetrics / Gynecology, Tubal Ligation - Laparoscopic ,"PREOPERATIVE DIAGNOSIS:,  Desires permanent sterilization.,POSTOPERATIVE DIAGNOSIS: , Desires permanent sterilization.,PROCEDURE: , Laparoscopic tubal ligation, Falope ring method.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , 10 mL.,COMPLICATIONS: , None.,INDICATIONS FOR SURGERY:  ,A 35-year-old female, P4-0-0-4, who desires permanent sterilization.  The risks of bleeding, infection, damage to other organs, and subsequent ectopic pregnancy was explained.  Informed consent was obtained.,OPERATIVE FINDINGS: , Normal appearing uterus and adnexa bilaterally.,DESCRIPTION OF PROCEDURE: , After administration of general anesthesia, the patient was placed in the dorsal lithotomy position, and prepped and draped in the usual sterile fashion.  The speculum was placed in the vagina, the cervix was grasped with the tenaculum, and a uterine manipulator inserted.  This area was then draped off the remainder of the operative field.,A 5-mm incision was made umbilically after injecting 0.25% Marcaine, 2 mL.  A Veress needle was inserted to confirm an opening pressure of 2 mmHg.  Approximately 4 liters of CO2 gas was insufflated into the abdominal cavity.  The Veress needle was removed, and a 5-mm port placed.  Position was confirmed using a laparoscope.  A second port was placed under direct visualization, 3 fingerbreadths suprapubically, 7 mm in diameter, after 2 mL of 0.25% Marcaine was injected.  This was done under direct visualization.  The pelvic cavity was examined with the findings as noted above.  The Falope rings were then applied to each tube bilaterally.  Good segments were noted to be ligated.  The accessory port was removed.  The abdomen was deflated.  The laparoscope and sheath was removed.  The skin edges were approximated with 5-0 Monocryl suture in subcuticular fashion.  The instruments were removed from the vagina.  The patient was returned to the supine position, recalled from anesthesia, and transferred to the recovery room in satisfactory condition.  Sponge and needle counts correct at the conclusion of the case.  Estimated blood loss was minimal.","obstetrics / gynecology, tenaculum, uterine manipulator, veress needle, tubal ligation, permanent sterilization, uterus, adnexa, cavity, laparoscope, laparoscopic, needle, sterilization"
 Ultrasound OB - followup for fetal growth., Obstetrics / Gynecology, Ultrasound OB ,"REASON FOR EXAM: , Followup for fetal growth. , ,INTERPRETATION: , Real-time exam demonstrates a single intrauterine fetus in cephalic presentation with a regular cardiac rate of 147 beats per minute documented. ,FETAL BIOMETRY:  ,BPD = 8.3 cm = 33 weeks, 4 days,HC = 30.2 cm = 33 weeks, 4 days,AC = 27.9 cm = 32 weeks, 0 days,FL =  6.4 cm = 33 weeks, 1 day,The head to abdomen circumference ratio is normal at 1.08, and the femur length to abdomen circumference ratio is normal at 23.0%.  Estimated fetal weight is 2,001 grams.  ,The amniotic fluid volume appears normal, and the calculated index is normal for the age at 13.7 cm.  ,A detailed fetal anatomic exam was not performed at this setting, this being a limited exam for growth.  The placenta is posterofundal and grade 2., ,IMPRESSION: , Single viable intrauterine pregnancy in cephalic presentation with a composite gestational age of 32 weeks, 5 days, plus or minus 17 days, giving and estimated date of confinement of 8/04/05.  There has been normal progression of fetal growth compared to the two prior exams of 2/11/05 and 4/04/05.  The examination of 4/04/05 questioned an echogenic focus within the left ventricle.  The current examination does not demonstrate any significant persistent echogenic focus involving the left ventricle.","obstetrics / gynecology, amniotic fluid volume, placenta, posterofundal, intrauterine pregnancy, followup for fetal growth, ultrasound ob, cephalic presentation, abdomen circumference, circumference ratio, echogenic focus, fetal growth, fetal,"
 Laparoscopic bilateral tubal ligation with Falope rings., Obstetrics / Gynecology, Tubal Ligation ,"DIAGNOSIS: , Multiparous female, desires permanent sterilization.,NAME OF OPERATION: , Laparoscopic bilateral tubal ligation with Falope rings.,ANESTHESIA: , General, ET tube.,COMPLICATIONS:,  None.,FINDINGS:  ,Normal female anatomy except for mild clitoromegaly and a posterior uterine fibroid.,PROCEDURE: , The patient was taken to the operating room and placed on the table in the supine position.  After adequate general anesthesia was obtained, she was placed in the lithotomy position and examined.  She was found to have an anteverted uterus and no adnexal mass.  She was prepped and draped in the usual fashion.  The Foley catheter was placed.  A Hulka cannula was inserted into the cervix and attached to the anterior lip of the cervix.,An infraumbilical incision was made with the knife.  A Veress needle was inserted into the abdomen.  Intraperitoneal location was verified with approximately 10 cc of sterile solution.  A pneumoperitoneum was created.  The Veress needle was then removed, and a trocar was inserted directly without difficulty.  Intraperitoneal location was verified visually with the laparoscope.  There was no evidence of any intra-abdominal trauma.,Each fallopian tube was elevated with a Falope ring applicator, and a Falope ring was placed on each tube with a 1-cm to 1.5-cm portion of the tube above the Falope ring.,The pneumoperitoneum was evacuated, and the trocar was removed under direct visualization.  An attempt was made to close the fascia with a figure-of-eight suture.  However, this was felt to be more subcutaneous.  The skin was closed in a subcuticular fashion, and the patient was taken to the recovery room awake with vital signs stable.","obstetrics / gynecology, sterilization, laparoscopic bilateral tubal ligation with falope rings, falope ring applicator, laparoscopic bilateral tubal ligation, bilateral tubal ligation, veress needle, tubal ligation, falope rings, anesthesia, tubal, ligation, falope"
 Total abdominal hysterectomy (TAH) with a uterosacral vault suspension.   Enlarged fibroid uterus and abnormal uterine bleeding. , Obstetrics / Gynecology, Total Abdominal Hysterectomy - 3 ,"PREOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Abnormal uterine bleeding.,POSTOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Abnormal uterine bleeding.,PROCEDURE PERFORMED: , Total abdominal hysterectomy with a uterosacral vault suspension.,ANESTHESIA: , General with endotracheal tube as well as spinal with Astramorph.,ESTIMATED BLOOD LOSS: , 150 cc.,URINE OUTPUT:  ,250 cc of clear urine at the end of the procedure.,FLUIDS:,  2000 cc of crystalloids.,COMPLICATIONS: , None.,TUBES: , None.,DRAINS:  ,Foley to gravity.,PATHOLOGY: , Uterus, cervix, and multiple fibroids were sent to pathology for review.,FINDINGS:  ,On exam, under anesthesia, normal appearing vulva and vagina, a massively enlarged uterus approximately 20 weeks' in size with irregular contours suggestive of fibroids.,Operative findings demonstrated a large fibroid uterus with multiple subserosal and intramural fibroids as well as there were some filmy adnexal adhesions bilaterally.  The appendix was normal appearing.  The bowel and omentum were normal appearing.  There was no evidence of endometriosis.  Peritoneal surfaces and vesicouterine peritoneum as well as appendix and cul-de-sac were all free of any evidence of endometriosis.,PROCEDURE:,  After informed consent was obtained and all questions were answered to the patient's satisfaction in layman's terms, she was taken to the Operating Room where first a spinal anesthesia with Astramorph was obtained without any difficulty.  She then underwent a general anesthesia with endotracheal tube also without any difficulty.  She was then examined under anesthesia with noted findings as above.  The patient was then placed in dorsal supine position and prepped and draped in the usual sterile fashion..  A vertical skin incision was made 1 cm below the umbilicus extending down to 2 cm above the pubic symphysis.  This was made with a first knife and then carried down to the underlying layer of the fascia with the second knife.  Fascia was excised in the midline and extended superiorly and inferiorly with the Mayo scissors.  The rectus muscle was then separated in the midline.  The peritoneum identified and entered bluntly.  The peritoneal incision was then extended superiorly and inferiorly with external visualization of the bladder.  The uterus was markedly evident upon entering the peritoneal cavity.  The uterus was then exteriorized and noted to have the findings as above.  At this point, approximately 10 cc of vasopressin 20 units and 30 cc was injected into the uterine fundus and multiple fibroids were removed by using the incision with the Bovie and then using a blunt and the sharp dissection and grasping with Lahey clamps.  Once the debulking of the uterus was felt appropriate to proceed with the hysterectomy, the uterus was then reapproximated with a few #0 Vicryl sutures in a figure-of-eight fashion.  The round ligaments were identified bilaterally and clamped with the hemostats and transacted with the Metzenbaum scissors.  The round ligaments were then bilaterally tied with the #0 tie and noted to be hemostatic.  The uterovarian vessels bilaterally were then isolated through a vascular window created from taking down the round ligaments.  The uterovarian vessels bilaterally were #0 tied and then doubly clamped with straight Ochsner clamps and transacted and suture tied with a Heaney hand stitch fashion, and both uterine and ovarian vessels were noted to be hemostatic.  At this time, the attention was then turned to the vesicouterine peritoneum, which was tented up with Allis clamps and the bladder flap was then created sharply with Russian pickups and the Metzenbaum scissors.  Then the bladder was bluntly dissected off the underlying cervix with a moist Ray-Tec sponge down to the level of the cervix.,At this point, the uterus was pulled on traction and the uterosacral ligaments were easily visualized.  Using #2-0 PDS suture, the suture was placed through both uterosacral ligaments distally with a backhand stitch fashion throwing the sutures from lateral to medial.  These sutures were then tagged and saved for later.  The uterine vessels were then identified bilaterally and skeletonized, then clamped with straight Ochsner clamps balancing off the cervix, and the uterine vessels were then transacted and suture ligated with #0 Vicryl and noted to be hemostatic.  In a similar fashion, the broad ligament down to the level of the cardinal ligaments was clamped with curved Ochsner and transacted and suture ligated and noted to be hemostatic.  At this point, the Lahey clamp was placed on the cervix and the cervix was tented up.  The pubocervical vesical fascia was transacted with long knife.  Then while protecting posteriorly, using the double-pointed scissors, the vagina was entered with double-pointed scissors at the level of the cervix and was grasped with a straight Ochsner clamp.  The uterus and cervix were then amputated using the Jorgenson scissors and the cuff was outlined with Ochsner clamps.  The cuff was then copiously painted with Betadine soaked sponge.  The Betadine-soaked sponge was placed in the patient's vagina.  Then the cuff was then closed with a #0 Vicryl in a running locked fashion to make sure to bring the ipsilateral cardinal ligaments into the vaginal cuff.  This was accomplished with one #0 Vicryl running stitch and then an Allis clamp was placed in the midsection portion of the cuff and tented up and a #0 Vicryl figure-of-eight was placed in the midsection portion of the cuff.  At this time, the uterosacral ligaments previously tagged needle was brought through the cardinal ligament and the uterosacral ligament on the ipsilateral side.  The needle was cut off and these were then tagged with the hemostats.  The cuff was then closed by taking the running suture and bringing back through the posterior peritoneum, grabbing part of the uterosacral and midsection portion of the posterior peritoneum of the uterosacral and then tying the cuff down to bunch and cuff together.  The suture in the midportion of the cuff was then used to tie down the round ligaments bilaterally to the cuff.  The abdomen was copiously irrigated with warm normal saline.  All areas were noted to be hemostatic.  Then the previously tagged uterosacral sutures were then tied bringing the vaginal cuff angles down to the uterosacral ligaments.  The abdomen was then once again copiously irrigated with warm normal saline.  All areas were noted to be hemostatic.  The sigmoid colon was replaced back into the hollow of the sacrum.  Then the omentum was pulled over the bowel.  After the myomectomy was performed, the GYN Balfour was placed into the patient's abdomen and the bowel was packed away with moist laparotomy sponges.  The GYN Balfour was then removed.  Packing sponges were removed and the fascia was then closed in an interrupted figure-of-eight fashion with #0 Vicryl.,Skin was closed with staples.  The patient tolerated the procedure well.  The sponge, lap, and needle counts were correct x2.  The sponge from the patient's vagina was removed and the vagina was noted to be hemostatic.  The patient would be followed throughout her hospital stay.",
 Laparoscopic tubal fulguration., Obstetrics / Gynecology, Tubal Fulguration - Laparoscopic  ,"A 1 cm infraumbilical skin incision was made.  Through this a Veress needle was inserted into the abdominal cavity.  The abdomen was filled with approximately 2 liters of CO2 gas.  The Veress needle was withdrawn.  A trocar sleeve was placed through the incision into the abdominal cavity.  The trocar was withdrawn and replaced with the laparoscope.  A 1 cm suprapubic skin incision was made.  Through this a second trocar sleeve was placed into the abdominal cavity using direct observation with the laparoscope.  The trocar was withdrawn and replaced with a probe.,The patient was placed in Trendelenburg position, and the bowel was pushed out of the pelvis.  Upon visualization of the pelvis organs, the uterus, fallopian tubes and ovaries were all normal.  The probe was withdrawn and replaced with the bipolar cautery instrument.  The right fallopian tube was grasped approximately 1 cm distal to the cornual region of the uterus.  Electrical current was applied to the tube at this point and fulgurated.  The tube was then regrasped just distal to this and refulgurated.  It was then regrasped just distal to the lateral point and refulgurated again.  The same procedure was then carried out on the opposite tube.  The bipolar cautery instrument was withdrawn and replaced with the probe.  The fallopian tubes were again traced to their fimbriated ends to confirm the burn points on the tubes.  The upper abdomen was visualized, and the liver surface was normal.  The gas was allowed to escape from the abdomen, and the instruments were removed.  The skin incisions were repaired.  The instruments were removed from the vagina.,There were no complications to the procedure.  Blood loss was minimal.  The patient went to the postanesthesia recovery room in stable condition.","obstetrics / gynecology, tubal fulguration, cohen cannula, laparoscopic, trendelenburg position, veress needle, abdominal cavity, bipolar cautery, dorsal lithotomy, fallopian tubes, fimbriated ends, fulgurated, laparoscope, uterus, distal, trocar, tubesNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Postpartum tubal ligation and removal of upper abdominal skin wall mass., Obstetrics / Gynecology, Tubal Ligation - Postpartum ,"PREOPERATIVE DIAGNOSES:,  Multiparity requested sterilization and upper abdominal wall skin mass., ,POSTOPERATIVE DIAGNOSES:  ,Multiparity requested sterilization and upper abdominal wall skin mass.,OPERATION PERFORMED: , Postpartum tubal ligation and removal of upper abdominal skin wall mass.,ESTIMATED BLOOD LOSS:,  Less than 5 mL.,DRAINS: , None.,ANESTHESIA: , Spinal.,INDICATION: , This is a 35-year-old white female gravida 6, para 3, 0-3-3 who is status post delivery on 09/18/2007.  The patient was requesting postpartum tubal ligation and removal of a large mole at the junction of her abdomen and left lower rib cage at the skin level.,PROCEDURE IN DETAIL:,  The patient was taken to the operating room, placed in a seated position with spinal form of anesthesia administered by anesthesia department.  The patient was then repositioned in a supine position and then prepped and draped in the usual fashion for postpartum tubal ligation.  Subumbilical ridge was created using two Ellis and first knife was used to make a transverse incision.  The Ellis were removed and used to be grasped incisional edges and both blunt and sharp dissection down to the level of the fascia was then completed.  The fascia grasped with two Kocher's and then sharply incised and then peritoneum was entered with use of blunt dissection.  Two Army-Navy retractors were put in place and a vein retractor was used to grasp the left fallopian tube and then regrasped with Babcock's and followed to the fimbriated end.  A modified Pomeroy technique was completed with double tying of with 0 chromic, then upper portion was sharply incised and the cut fallopian tube edges were then cauterized.  Adequate hemostasis was noted.  This tube was placed back in its anatomic position.  The right fallopian tube was grasped followed to its fimbriated end and then regrasped with a Babcock and a modified Pomeroy technique was also completed on the right side, and upper portion was then sharply incised and the cut edges re-cauterized with adequate hemostasis and this was placed back in its anatomic position.  The peritoneum as well as fascia was reapproximated with 0-Vicryl.  The subcutaneous tissues reapproximated with 3-0 Vicryl and skin edges reapproximated with 4-0 Vicryl as well in a subcuticular stitch.  Pressure dressings were applied.  Marcaine 10 mL was used prior to making an incision.  Sterile dressing was applied.  The large mole-like lesion was grasped with Allis.  It was approximately 1 cm x 0.5 cm in size and an elliptical incision was made around the mass and cut edges were cauterized and 4-0 Vicryl was used to reapproximate the skin edges and pressure dressing was also applied.  Instrument count, needle count, and sponge counts were all correct, and the patient was taken to recovery room in stable condition.","obstetrics / gynecology, sterilization, fallopian tube, tubal ligation, postpartum"
" Postoperative day #1, total abdominal hysterectomy.  Normal postoperative course.", Obstetrics / Gynecology, Total Abdominal Hysterectomy - Followup ,"POSTOPERATIVE DAY #1, TOTAL ABDOMINAL HYSTERECTOMY,SUBJECTIVE: , The patient is alert and oriented x3 and sitting up in bed.  The patient has been ambulating without difficulty.  The patient is still NPO.  The patient denies any new symptomatology from  6/10/2009.  The patient has complaints of incisional tenderness.  The patient was given a full explanation about her clinical condition and all her questions were answered.,OBJECTIVE:,VITAL SIGNS:  Afebrile now.  Other vital signs are stable.,GU:  Urinating through Foley catheter.,ABDOMEN:  Soft, negative rebound.,EXTREMITIES:  Without Homans, nontender.,BACK:  Without CVA tenderness.,GENITALIA:  Vagina, slight spotting.  Wound dry and intact.,ASSESSMENT:,  Normal postoperative course.,PLAN:,1.  Follow clinically.,2.  Continue present therapy.,3.  Ambulate with nursing assistance only.,","obstetrics / gynecology, postoperative course, total abdominal hysterectomy, postoperative"
" Laparoscopic tubal sterilization, tubal coagulation.  ", Obstetrics / Gynecology, Tubal Sterilization & Coagulation ,"PROCEDURE:  ,Laparoscopic tubal sterilization, tubal coagulation.,PREOPERATIVE DIAGNOSIS: , Request tubal coagulation.,POSTOPERATIVE DIAGNOSIS: , Request tubal coagulation.,PROCEDURE:  ,Under general anesthesia, the patient was prepped and draped in the usual manner.  Manipulating probe placed on the cervix, changed gloves.  Small cervical stab incision was made, Veress needle was inserted without problem.  A 3 L of carbon dioxide was insufflated.  The incision was enlarged.  A 5-mm trocar placed through the incision without problem.  Laparoscope placed through the trocar.  Pelvic contents visualized.  A 2nd puncture was made 2 fingerbreadths above the symphysis pubis in the midline.  Under direct vision, the trocar was placed in the abdominal cavity.  Uterus, tubes, and ovaries were all normal.  There were no pelvic adhesions, no evidence of endometriosis.  Uterus was anteverted and the right adnexa was placed on a stretch.  The tube was grasped 1 cm from the cornual region, care being taken to have the bipolar forceps completely across the tube and the tube was coagulated using amp meter for total desiccation.  The tube was grasped again and the procedure was repeated for a separate coagulation, so that 1.5 cm of the tube was coagulated.  The structure was confirmed to be tube by looking at fimbriated end.  The left adnexa was then placed on a stretch and the procedure was repeated again grasping the tube 1 cm from the cornual region and coagulating it.  Under traction, the amp meter was grasped 3 more times so that a total of 1.5 cm of tube was coagulated again.  Tube was confirmed by fimbriated end.  Gas was lend out of the abdomen.  Both punctures repaired with 4-0 Vicryl and punctures were injected with 0.5% Marcaine 10 mL.  The patient went to the recovery room in good condition.","obstetrics / gynecology, cervix, cervical stab incision, laparoscopic tubal sterilization, tubal sterilization, tubal coagulation, sterilization, laparoscopic, endometriosis"
" True cut needle biopsy of the breast.  This 65-year-old female on exam was noted to have dimpling and puckering of the skin associated with nipple discharge.  On exam, she has a noticeable carcinoma of the left breast with dimpling, puckering, and erosion through the skin.", Obstetrics / Gynecology, True Cut Needle Biopsy - Breast ,"PREOPERATIVE DIAGNOSIS:,  Carcinoma of the left breast.,POSTOPERATIVE DIAGNOSIS:,  Carcinoma of the left breast.,PROCEDURE PERFORMED: , True cut needle biopsy of the breast.,GROSS FINDINGS:  ,This 65-year-old female on exam was noted to have dimpling and puckering of the skin associated with nipple discharge.  On exam, she has a noticeable carcinoma of the left breast with dimpling, puckering, and erosion through the skin.  At this time, a true cut needle biopsy was performed.,PROCEDURE: , The patient was taken to operating room, is laid in the supine position, sterilely prepped and draped in the usual fashion.  The area over the left breast was infiltrated with 1:1 mixture of 0.25% Marcaine and 1% Xylocaine.  Using a #18 gauge automatic true cut needle core biopsy, five biopsies were taken of the left breast in core fashion.  Hemostasis was controlled with pressure.  The patient tolerated the procedure well, pending the results of biopsy.","obstetrics / gynecology, carcinoma, true cut needle biopsy, nipple, discharge, dimpling, puckering, breast, "
" Total abdominal hysterectomy..  Severe menometrorrhagia unresponsive to medical therapy, anemia, and symptomatic fibroid uterus.", Obstetrics / Gynecology, Total Abdominal Hysterectomy - 1 ,"PREOPERATIVE DIAGNOSES:,1.  Severe menometrorrhagia unresponsive to medical therapy.,2.  Anemia.,3.  Symptomatic fibroid uterus.,POSTOPERATIVE DIAGNOSES:,1.  Severe menometrorrhagia unresponsive to medical therapy.,2.  Anemia.,3.  Symptomatic fibroid uterus.,PROCEDURE: , Total abdominal hysterectomy.,ANESTHESIA:  ,General.,ESTIMATED BLOOD LOSS: , 150 mL.,COMPLICATIONS: , None.,FINDING:  ,Large fibroid uterus.,PROCEDURE IN DETAIL:  ,The patient was prepped and draped in the usual sterile fashion for an abdominal procedure.  A scalpel was used to make a Pfannenstiel skin incision, which was carried down sharply through the subcutaneous tissue to the fascia.  The fascia was nicked in the midline and incision was carried laterally bilaterally with curved Mayo scissors.  The fascia was then bluntly and sharply dissected free from the underlying rectus abdominis muscles.  The rectus abdominis muscles were then bluntly dissected in the midline and this incision was carried forward inferiorly and superiorly with care taken to avoid bladder and bowel.  The peritoneum was then bluntly entered and this incision was carried forward inferiorly and superiorly with care taken to avoid bladder and bowel.  The O'Connor-O'Sullivan instrument was then placed without difficulty.  The uterus was grasped with a thyroid clamp and the entire pelvis was then visualized without difficulty.  The GIA stapling instrument was then used to separate the infundibulopelvic ligament in a ligated fashion from the body of the uterus.  This was performed on the left infundibulopelvic ligament and the right infundibulopelvic ligament without difficulty.  Hemostasis was noted at this point of the procedure.  The bladder flap was then developed free from the uterus without difficulty.  Careful dissection of the uterus from the pedicle with the uterine arteries and cardinal ligaments was then performed using #1 chromic suture ligature in an interrupted fashion on the left and right side.  This was done without difficulty.  The uterine fundus was then separated from the uterine cervix without difficulty.  This specimen was sent to pathology for identification.  The cervix was then developed with careful dissection.  Jorgenson scissors were then used to remove the cervix from the vaginal cuff.  This was sent to pathology for identification.  Hemostasis was noted at this point of the procedure.  A #1 chromic suture ligature was then used in running fashion at the angles and along the cuff.  Hemostasis was again noted.  Figure-of-eight sutures were then used in an interrupted fashion to close the cuff.  Hemostasis was again noted.  The entire pelvis was washed.  Hemostasis was noted.  The peritoneum was then closed using 2-0 chromic suture ligature in running pursestring fashion.  The rectus abdominis muscles were approximated using #1 chromic suture ligature in an interrupted fashion.  The fascia was closed using 0 Vicryl in interlocking running fashion.  Foundation sutures were then placed in an interrupted fashion for further closing the fascia.  The skin was closed with staple gun.  Sponge and needle counts were noted to be correct x2 at the end of the procedure.  Instrument count was noted to be correct x2 at the end of the procedure.  Hemostasis was noted at each level of closure.  The patient tolerated the procedure well and went to recovery room in good condition.","obstetrics / gynecology, menometrorrhagia, fibroid, uterus, total abdominal hysterectomy, rectus abdominis muscles, fibroid uterus, suture ligature, therapy, hemostasis, anemia, abdominal,"
" Total abdominal hysterectomy.  Enlarged fibroid uterus, pelvic pain, and pelvic endometriosis.  On laparotomy, the uterus did have multiple pedunculated fibroids.", Obstetrics / Gynecology, Total Abdominal Hysterectomy - 2 ,"PREOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Pelvic pain.,POSTOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Pelvic pain.,3.  Pelvic endometriosis.,PROCEDURE PERFORMED: ,Total abdominal hysterectomy.,ANESTHESIA: , General endotracheal and spinal with Astramorph.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , 200 cc.,FLUIDS:  ,2400 cc of crystalloids.,URINE OUTPUT: , 100 cc of clear urine.,INDICATIONS:,  This is a 40-year-old female gravida-0 with a history of longstanding enlarged fibroid uterus.  On ultrasound, the uterus measured 14 cm x 6.5 cm x 7.8 cm.  She had received two dosage of Lupron to help shrink the fibroid.  Her most recent Pap smear was normal.,FINDINGS: , On a manual exam, the uterus is enlarged approximately 14 to 16 weeks size with multiple fibroids palpated.  On laparotomy, the uterus did have multiple pedunculated fibroids, the largest being approximately 7 cm.  The bilateral tubes and ovaries appeared normal.,There was evidence of endometriosis on the posterior wall of the uterus as well as the bilateral infundibulopelvic ligament.  There was some adhesions of the bowel to the left ovary and infundibulopelvic ligament and as well as to the right infundibulopelvic ligament.,PROCEDURE:,  After consent was obtained, the patient was taken to the operating room where spinal anesthetic was first administered and then general anesthetic.  The patient was placed in the dorsal supine position and prepped and draped in normal sterile fashion.  A Pfannenstiel skin incision was made and carried to the underlying Mayo fashion using the second knife.  The fascia was incised in midline and the incision extended laterally using Mayo scissors.  The superior aspect of the fascial incision was grasped with Kocher clamps, tented up, and dissected off the underlying rectus muscle both bluntly and sharply with Mayo scissors.  Attention was then turned to the inferior aspect of the incision, which in a similar fashion was grasped with Kocher clamps, tented up and dissected off the underlying rectus muscles.  The rectus muscles were separated in the midline and the peritoneum was identified, grasped with hemostat, and entered sharply with Metzenbaum scissors.  This incision was extended superiorly and inferiorly with good visualization of the bladder.  The uterus was then brought up out of the incision.  The bowel adhesions were carefully taken down using Metzenbaum scissors.  Good hemostasis was noted at this point.  The self-retaining retractor was then placed.  The bladder blade was placed.  The bowel was gently packed with moist laparotomy sponges and held in place with the blade on the GYN extension.  The uterus was then grasped with a Lahey clamp and brought up out of the incision.  The left round ligament was identified and grasped with Allis clamp and tented up.  A hemostat was passed in the avascular area beneath the round ligament.  A suture #0 Vicryl was used to suture ligate the round ligament.  Two hemostats were placed across the round ligament proximal to the previously placed suture and the Mayo scissors were used to transect the round ligament.  An avascular area of the broad ligament was then identified and entered bluntly.  The suture of #0 Vicryl was then used to suture ligate the left uterovarian ligament.  Two straight Ochsner's were placed across the uterovarian ligament proximal to the previous suture.  The ligament was then transected and suture ligated with #0 Vicryl.  Attention was then turned to the right round ligament, which in a similar fashion was tented up with an Allis clamp.  An avascular area was entered beneath the round ligament using a hemostat and the round ligament was suture ligated and transected.  An avascular area of the broad ligament was then entered bluntly and the right uterovarian ligament was then suture ligated with #0 Vicryl.,Two straight Ochsner's were placed across the ligament proximal to previous suture.  This was then transected and suture ligated again with #0 Vicryl.  The left uterine peritoneum was then identified and grasped with Allis clamps.  The vesicouterine peritoneum was then transected and then entered using Metzenbaum scissors.  This incision was extended across the anterior portion of the uterus and the bladder flap was taken down.  It was sharply advanced with Metzenbaum scissors and then bluntly using a moist Ray-Tec.  The Ray-Tec was left in place at this point to ensure that the bladder was below the level of the cervix.  The bilateral uterine arteries then were skeletonized with Metzenbaum scissors and clamped bilaterally using straight Ochsner's.  Each were then transected and suture ligated with #0 Vicryl.  A curved Ochsner was then placed on either side of the cervix.  The tissue was transected using a long knife and suture ligated with #0 Vicryl.  Incidentally, prior to taking down the round ligaments, a pedunculated fibroid and the right fundal portion of the uterus was injected with Vasopressin and removed using a Bovie.  The cervix was then grasped with a Lahey clamp.  The cervicovaginal fascia was then taken down first using the long-handed knife and then a back handle of the knife to bring the fascia down below the level of the cervix.  A double-pointed scissors were used to enter the vaginal vault below the level of the cervix.  A straight Ochsner was placed on the vaginal vault.  The Jorgenson scissors were used to amputate the cervix and the uterus off of the underlying vaginal tissue.  The vaginal cuff was then reapproximated with #0 Vicryl in a running locked fashion and the pelvis was copiously irrigated.  There was a small area of bleeding noted on the underside of the bladder.  The bladder was tented up using an Allis clamp and a figure-of-eight suture of #3-0 Vicryl was placed with excellent hemostasis noted at this point.  The uterosacral ligaments were then incorporated into the vaginal cuff and the cuff was synched down.  A figure-of-eight suture of #0 Vicryl was placed in the midline of the vaginal cuff in attempt to incorporate the bilateral round ligament.  The round ligament was too short.  It would be a maximal amount of stretch to incorporate, therefore, only the left round ligament was incorporated into the vaginal cuff.  The bilateral adnexal areas were then re-peritonealized with #3-0 Vicryl in a running fashion.  The bladder flap was reapproximated to the vaginal cuff using one interrupted suture.  The pelvis was again irrigated at this point with excellent hemostasis noted.  Approximately 200 cc of saline with methylene blue was placed into the Foley to inflate the bladder.  There was no spillage of blue fluid into the abdomen.  The fluid again was allowed to drain.  All sponges were then removed and the bowel was allowed to return to its anatomical position.  The peritoneum was then reapproximated with #0 Vicryl in a running fashion.  The fascia was reapproximated also with #0 Vicryl in a running fashion.  The skin was then closed with staples.,A previously placed Betadine soaked Ray-Tec was removed from the patient's vagina and sponge stick was used to assess any bleeding in the vaginal vault.  There was no appreciable bleeding.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2.  The patient was taken to the recovery room in satisfactory condition.  She will be followed immediately postoperatively within the hospital.","obstetrics / gynecology, pelvic pain, pelvic endometriosis, astramorph, total abdominal hysterectomy, enlarged fibroid, metzenbaum scissors, vaginal cuff, scissors, vaginal, uterus, ligament, hysterectomy, endometriosis, pedunculated, fibroids, infundibulopelvic, uterovarian, abdominal, laparotomy, peritoneum, "
" Total Abdominal Hysterectomy (TAH).  An incision was made into the abdomen down through the subcutaneous tissue, muscular fascia and peritoneum.  Once inside the abdominal cavity, a self-retaining retractor was placed to expose the pelvic cavity with 3 lap sponges. ", Obstetrics / Gynecology, Total Abdominal Hysterectomy ,,"obstetrics / gynecology, fundus, double-toothed tenaculum, muscular fascia, total abdominal hysterectomy, vicryl suture, abdominal, incision, hysterectomy, uterine, cavity, uterus, ligaments, peritoneum, vicrylNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" The patient comes for three-week postpartum checkup, complaining of allergies.", Obstetrics / Gynecology, Three-Week Postpartum Checkup ,"CHIEF COMPLAINT:,  The patient comes for three-week postpartum checkup, complaining of allergies.,HISTORY OF PRESENT ILLNESS:,  She is doing well postpartum.  She has had no headache.  She is breastfeeding and feels like her milk is adequate.  She has not had much bleeding.  She is using about a mini pad twice a day, not any cramping or clotting and the discharge is turned from red to brown to now slightly yellowish.  She has not yet had sexual intercourse.  She does complain that she has had a little pain with the bowel movement, and every now and then she notices a little bright red bleeding.  She has not been particularly constipated but her husband says she is not eating her vegetables like she should.  Her seasonal allergies have back developed and she is complaining of extremely itchy watery eyes, runny nose, sneezing, and kind of a pressure sensation in her ears.,MEDICATIONS:,  Prenatal vitamins.,ALLERGIES:,  She thinks to Benadryl.,FAMILY HISTORY: , Mother is 50 and healthy.  Dad is 40 and healthy.  Half-sister, age 34, is healthy.  She has a sister who is age 10 who has some yeast infections.,PHYSICAL EXAMINATION:,VITALS:  Weight:  124 pounds.  Blood pressure 96/54.  Pulse:  72.  Respirations:  16.  LMP:  10/18/03.  Age:  39.,HEENT:  Head is normocephalic.  Eyes:  EOMs intact.  PERRLA.  Conjunctiva clear.  Fundi:  Discs flat, cups normal.  No AV nicking, hemorrhage or exudate.  Ears:  TMs intact.  Mouth:  No lesion.  Throat:  No inflammation.  She has allergic rhinitis with clear nasal drainage, clear watery discharge from the eyes.,Abdomen:  Soft.  No masses.,Pelvic:  Uterus is involuting.,Rectal:  She has one external hemorrhoid which has inflamed.  Stool is guaiac negative and using anoscope, no other lesions are identified.,ASSESSMENT/PLAN:,  Satisfactory three-week postpartum course, seasonal allergies.  We will try Patanol eyedrops and Allegra 60 mg twice a day.  She was cautioned about the possibility that this may alter her milk supply.  She is to drink extra fluids and call if she has problems with that.  We will try ProctoFoam HC.  For the hemorrhoids, also increase the fiber in her diet.  That prescription was written, as well as one for Allegra and Patanol.  She additionally will be begin on Micronor because she would like to protect herself from pregnancy until her husband get scheduled in and has a vasectomy, which is their ultimate plan for birth control, and she anticipates that happening fairly soon.  She will call and return if she continues to have problems with allergies.  Meantime, rechecking in three weeks for her final six-week postpartum checkup.","obstetrics / gynecology, checkup, allergies, postpartum, complaining of allergies, seasonal allergies, postpartum checkup,"
 Total abdominal hysterectomy and bilateral salpingo-oophorectomy., Obstetrics / Gynecology, TAH & BSO ,"PREOPERATIVE DIAGNOSES:,1.  Chronic pelvic pain.,2.  Dysmenorrhea.,3.  Dyspareunia.,4.  Endometriosis.,5.  Enlarged uterus.,6.  Menorrhagia.,POSTOPERATIVE DIAGNOSES:,1.  Chronic pelvic pain.,2.  Dysmenorrhea.,3.  Dyspareunia.,4.  Endometriosis.,5.  Enlarged uterus.,6.  Menorrhagia.,PROCEDURE: , Total abdominal hysterectomy and bilateral salpingo-oophorectomy.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,DRAINS: , Foley.,ANESTHESIA:,  General.,This 28-year-old white female who presented to undergo TAH-BSO secondary to chronic pelvic pain and a diagnosis of endometriosis.,At the time of the procedure, once entering into the abdominal cavity, there was no gross evidence of abnormalities of the uterus, ovaries or fallopian tube.  All endometriosis had been identified laparoscopically from a previous surgery.  At the time of the surgery, all the tissue was quite thick and difficult to cut as well around the bladder flap and the uterus itself.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and placed in supine position, at which time general form of anesthesia was administered by the anesthesia department.  The patient was then prepped and draped in the usual fashion for a low transverse incision.  Approximately two fingerbreadths above the pubic symphysis, a first knife was used to make a low transverse incision.  This was extended down to the level of the fascia.  The fascia was nicked in the center and extended in a transverse fashion.  The edges of the fascia were grasped with Kocher.  Both blunt and sharp dissection both caudally and cephalic was then completed consistent with Pfannenstiel technique.  The abdominal rectus muscle was divided in the midline and extended in a vertical fashion.  Perineum was entered at the high point and extended in a vertical fashion as well.  An O'Connor-O'Sullivan retractor was put in place on either side.  A bladder blade was put in place as well.  Uterus was grasped with a double-tooth tenaculum and large and small colon were packed away cephalically and held in place with free wet lap packs and a superior blade.  The bladder flap was released with Metzenbaum scissors and then dissected away caudally.  EndoGIA were placed down both sides of the uterus in two bites on each side with the staples reinforced with a medium Endoclip.  Two Heaney were placed on either side of the uterus at the level of cardinal ligaments.  These were sharply incised and both pedicles were tied off with 1 Vicryl suture.  Two _____ were placed from either side of the uterus at the level just inferior to the cervix across the superior part of the vaginal vault.  A long sharp knife was used to transect the uterus at the level of Merz forceps and the uterus and cervix were removed intact.  From there, the corners of the vaginal cuff were reinforced with figure-of-eight stitches.  Betadine soaked sponge was placed in the vaginal vault and a continuous locking stitch of 0 Vicryl was used to re-approximate the edges with a second layer used to reinforce the first.  Bladder flap was created with the use of 3-0 Vicryl and Gelfoam was placed underneath.  The EndoGIA was used to transect both the fallopian tube and ovaries at the infundibulopelvic ligament and each one was reinforced with medium clips.  The entire area was then re-peritonized and copious amounts of saline were used to irrigate the pelvic cavity.  Once this was completed, Gelfoam was placed into the cul-de-sac and the O'Connor-O'Sullivan retractor was removed as well as all the wet lap pack.  Edges of the peritoneum were grasped in 3 quadrants with hemostat and a continuous locking stitch of 2-0 Vicryl was used to re-approximate the peritoneum as well as abdominal rectus muscle.  The edges of the fascia were grasped at both corners and a continuous locking stitch of 1 Vicryl was used to re-approximate the fascia with overlapping in the center.  The subcutaneous tissue was irrigated.  Cautery was used to create adequate hemostasis and 3-0 Vicryl was used to re-approximate the tissue and the skin edges were re-approximated with sterile staples.  Sterile dressing was applied and Betadine soaked sponge was removed from the vaginal vault and the vaginal vault was wiped clean of any remaining blood.  The patient was taken to recovery room in stable condition.  Instrument count, needle count, and sponge counts were all correct.","obstetrics / gynecology, tah, bso, total abdominal hysterectomy, bilateral salpingo-oophorectomy, hysterectomy, pelvic pai, dysmenorrhea, dyspareunia, endometriosis, uterus, menorrhagia, betadine soaked sponge, bladder flap, vaginal vault, abdominal, fascia, rectus, "
"  Suction dilation and curettage for incomplete abortion.  On bimanual exam, the patient has approximately 15-week anteverted, mobile uterus with the cervix that is dilated to approximately 2 cm with multiple blood colts in the vagina.  There was a large amount of tissue obtained on the procedure.", Obstetrics / Gynecology," Suction, Dilation, & Curettage - 1 ","PREOPERATIVE DIAGNOSIS: ,Incomplete abortion.,POSTOPERATIVE DIAGNOSIS: ,Incomplete abortion.,PROCEDURE PERFORMED:, Suction dilation and curettage.,ANESTHESIA:  ,General and nonendotracheal by Dr. X.,ESTIMATED BLOOD LOSS: , Less than 200 cc.,SPECIMENS: , Endometrial curettings.,DRAINS: , None.,FINDINGS:  ,On bimanual exam, the patient has approximately 15-week anteverted, mobile uterus with the cervix that is dilated to approximately 2 cm with multiple blood colts in the vagina.  There was a large amount of tissue obtained on the procedure.,PROCEDURE:  ,The patient was taken to the operating room where a general anesthetic was administered.  She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion.  Once the anesthetic was found to be adequate, a bimanual exam was performed under anesthetic.  Next, a weighted speculum was placed in the vagina.  The anterior lip of cervix was grasped with the vulsellum tenaculum and due to the patient already being dilated approximately 2 cm, no cervical dilation was needed.  A size 12 straight suction curette was used and connected to the suction and was placed in the cervix and a suction curettage was performed.  Two passes were made with the suction curettage.  Next, a sharp curettage was performed obtaining a small amount of tissue and this was followed by third suction curettage and then a final sharp curettage was performed, which revealed a good uterine cry on all sides of the uterus.  After the procedure, the vulsellum tenaculum was removed.  The cervix was seemed to be hemostatic.  The weighted speculum was removed.  The patient was given 0.25 mg of Methergine IM approximately half-way through the procedure.  After the procedure, a second bimanual exam was performed and the patient's uterus had significantly decreased in size.  It is now approximately eight to ten-week size.  The patient was taken from the operating room in stable condition after she was cleaned.  She will be discharged on today.  She was given Methergine, Motrin, and doxycycline for her postoperative care.  She will follow-up in one week in the office.","obstetrics / gynecology, uterus, anteverted, dorsal lithotomy position, weighted speculum, mobile uterus, vulsellum tenaculum, bimanual exam, vagina, tenaculum, dilation, bimanual, cervix, suction, curettage,"
" Total abdominal hysterectomy (TAH), left salpingo-oophorectomy, lysis of interloop bowel adhesions.  Chronic pelvic pain, endometriosis, prior right salpingo-oophorectomy, history of intrauterine device perforation and exploratory surgery.", Obstetrics / Gynecology, TAH & Salpingo-oophorectomy & Lysis of Adhesions ,"PREOPERATIVE DIAGNOSES:,1.  Chronic pelvic pain.,2.  Endometriosis.,3.  Prior right salpingo-oophorectomy.,4.  History of intrauterine device perforation and exploratory surgery.,POSTOPERATIVE DIAGNOSES:,1.  Endometriosis.,2.  Interloop bowel adhesions.,PROCEDURE PERFORMED:,1.  Total abdominal hysterectomy (TAH).,2.  Left salpingo-oophorectomy.,3.  Lysis of interloop bowel adhesions.,ANESTHESIA:,  General.,ESTIMATED BLOOD LOSS:  ,400 cc.,FLUIDS: , 2300 cc of lactated Ringers, as well as lactated Ringers for intraoperative irrigation.,URINE: , 500 cc of clear urine output.,INTRAOPERATIVE FINDINGS: , The vulva and perineum are without lesions.  On bimanual exam, the uterus was enlarged, movable, and anteverted.  The intraabdominal findings revealed normal liver margin, kidneys, and stomach upon palpation.  The uterus was found to be normal in size with evidence of endometriosis on the uterus.  The right ovary and fallopian tube were absent.  The left fallopian tube and ovary appeared normal with evidence of a small functional cyst.  There was evidence of left adnexal adhesion to the pelvic side wall which was filmy, unable to be bluntly dissected.  There were multiple interloop bowel adhesions that were filmy in nature noted.,The appendix was absent.  There did appear to be old suture in a portion of the bowel most likely from a prior procedure.,INDICATIONS: , This patient is a 45-year-old African-American gravida7, para3-0-0-3, who is here for definitive treatment of chronic pelvic pain with a history of endometriosis.  She did have a laparoscopic ablation of endometriosis on a laparoscopy and also has a history of right salpingo-oophorectomy.  She has tried Lupron and did stop secondary to the side effects.,PROCEDURE IN DETAIL: , After informed consent was obtained in layman's terms, the patient was taken back to the Operating Suite and placed under general anesthesia.  She was then prepped and draped in the sterile fashion and placed in the dorsal supine position.  An indwelling Foley catheter was placed.  With the skin knife, an incision was made removing the old cicatrix.  A Bovie was used to carry the tissue through to the underlying layer of the fascia which was incised in the midline and extended with the Bovie.  The rectus muscle was then sharply and bluntly dissected off the superior aspect of the rectus fascia in the superior as well as the inferior aspect using the Bovie.  The rectus muscle was then separated in the midline using a hemostat and the peritoneum was entered bluntly.  The peritoneal incision was then extended superiorly and inferiorly with Metzenbaum scissors with careful visualization of the bladder.  At this point, the intraabdominal cavity was manually explored and the above findings were noted.  A Lahey clamp was then placed on the fundus of the uterus and the uterus was brought to the surgical field.  The bowel was then packed with moist laparotomy sponges.  Prior to this, the filmy adhesions leftover were taken down.  At this point, the left round ligament was identified, grasped with two hemostats, transected, and suture ligated with #0 Vicryl.  At this point, the broad ligament was dissected down and the lost portion of the bladder flap was created.  The posterior aspect of the peritoneum was also dissected.  At this point, the infundibulopelvic ligament was isolated and three tie of #0 Vicryl was used to isolate the pedicle.  Two hemostats were then placed across the pedicle and this was transected with the scalpel.  This was then suture ligated in Heaney fashion.  The right round ligament was then identified and in the similar fashion, two hemostats were placed across the round ligament and using the Mayo scissors the round ligament was transected and dissected down the broad ligament to create the bladder flap anteriorly as well as dissect the posterior peritoneum and isolate the round ligament.  This was then ligated with three tie of #0 Vicryl.  Also incorporated in this was the remnant from the previous right salpingo-oophorectomy.  At this point, the bladder flap was further created with sharp dissection as well as the moist Ray-Tech to push the bladder down off the anterior portion of the cervix.,The left uterine artery was then skeletonized and a straight Heaney was placed.  In a similar fashion, the contralateral uterine artery was skeletonized and straight Heaney clamp was placed.  These ligaments bilaterally were transected and suture ligated in a left Heaney stitch.  At this point, curved Masterson was used to incorporate the cardinal ligament complex, thus was transected and suture ligated.  Straight Masterson was then used to incorporate the uterosacrals bilaterally and this was also transected and suture ligated.  Prior to ligating the uterine arteries, the uterosacral arteries were tagged bilaterally with #0 Vicryl.  At this point, the roticulator was placed across the vaginal cuff and snug underneath the entire cervix.  The roticulator was then clamped and removed and the staple line was in place.  This was found to be hemostatic.  A suture was then placed through each cuff angle bilaterally and cardinal ligament complex was found to be fixed to each apex bilaterally.  At this point, McCall culdoplasty was performed with an #0 Vicryl incorporating each uterosacral as well as the posterior peritoneum.  There did appear to be good support on palpation.  Prior to this, the specimen was handed off and sent to pathology.  At this point, there did appear to be small amount of oozing at the right peritoneum.  Hemostasis was obtained using a #0 Vicryl in two single stitches.  Good hemostasis was then obtained on the cuff as well as the pedicles.  Copious irrigation was performed at this point with lactate Ringers.  The round ligaments were then incorporated into the cuff bilaterally.  Again, copious amount of irrigation was performed and good hemostasis was obtained.  At this point, the peritoneum was reapproximated in a single interrupted stitch on the left and right lateral aspects to cover each pedicle bilaterally.  At this point, the bowel packing as well as moist Ray-Tech was removed and while re-approximating the bowel it was noted that there were multiple interloop bowel adhesions which were taken down using the Metzenbaum scissors with good visualization of the underlying bowel.  Good hemostasis was obtained of these sites as well.  The sigmoid colon was then returned to its anatomic position and the omentum as well.  The rectus muscle was then reapproximated with two interrupted sutures of #2-0 Vicryl.  The fascia was then reapproximated with #0 Vicryl in a running fashion from lateral to medial meeting in the midline.  The Scarpa's fascia was then closed with #3-0 plain in a running suture.  The skin was then re-approximated with #4-0 undyed Vicryl in a subcuticular closure.  This was dressed with an Op-Site.  The patient tolerated the procedure well.  The sponge, lap, and needle were correct x2.  After the procedure, the patient was extubated and brought out of general anesthesia.  She will go to the floor where she will be followed postoperatively in the hospital.","obstetrics / gynecology, chronic pelvic pain, endometriosis, intrauterine device, exploratory, abdominal hysterectomy, tah, total abdominal hysterectomy, lysis of interloop bowel adhesions, salpingo oophorectomy, bowel, ligament, adhesions, interloop, hemostasis, uterus, salpingo, oophorectomy, "
 Total abdominal hysterectomy (TAH) with bilateral salpingooophorectomy and uterosacral ligament vault suspension.  Cervical intraepithelial neoplasia grade-III postconization.  Recurrent dysplasia.  Uterine procidentia grade II-III.  Mild vaginal vault prolapse., Obstetrics / Gynecology, TAH & Salpingooophorectomy ,"PREOPERATIVE DIAGNOSES:,1.  Cervical intraepithelial neoplasia grade-III status post conization with poor margins.,2.  Recurrent dysplasia.,3.  Unable to follow in office.,4.  Uterine procidentia grade II-III.,POSTOPERATIVE DIAGNOSES:,1.  Cervical intraepithelial neoplasia grade-III postconization.,2.  Poor margins.,3.  Recurrent dysplasia.,4.  Uterine procidentia grade II-III.,5.  Mild vaginal vault prolapse.,PROCEDURES PERFORMED:,1.  Total abdominal hysterectomy (TAH) with bilateral salpingooophorectomy.,2.  Uterosacral ligament vault suspension.,ANESTHESIA: , General and spinal with Astramorph for postoperative pain.,ESTIMATED BLOOD LOSS: , Less than 100 cc.,FLUIDS:  ,2400 cc.,URINE: , 200 cc of clear urine output.,INDICATIONS:  ,This patient is a 57-year-old nulliparous female who desires definitive hysterectomy for history of cervical intraepithelial neoplasia after conization and found to have poor margins.,FINDINGS:  ,On bimanual examination, the uterus was found to be small.  There were no adnexal masses appreciated.  Intraabdominal findings revealed a small uterus approximately 2 cm in size.  The ovaries were atrophic consistent with menopause.  The liver margins and stomach were palpated and found to be normal.,PROCEDURE IN DETAIL: , After informed consent was obtained, the patient was taken back to the operating suite and administered a spinal anesthesia for postoperative pain control.  She was then placed in the dorsal lithotomy position and administered general anesthesia.  She was then prepped and draped in the sterile fashion and an indwelling Foley catheter was placed in her bladder.  At this point, the patient was evaluated for a possible vaginal hysterectomy.  She was nulliparous and the pelvis was narrow.  After the anesthesia was administered, the patient was repeatedly stooling and therefore because of these two reasons, the decision was made to do an abdominal hysterectomy.  After the patient was prepped and draped, a Pfannenstiel skin incision was made approximately 2 cm above the pubic symphysis.  The second scalpel was used to dissect out to the underlying layer of fascia.  The fascia was incised in the midline and extended laterally using the Mayo scissors.  The superior aspect of the rectus fascia was grasped with Ochsners, tented up and underlying layer of rectus muscle was dissected off bluntly as well as with Mayo scissors.  In a similar fashion, the inferior portion of the rectus fascia was tented up, dissected off bluntly as well as with Mayo scissors.  The rectus muscle was then separated bluntly in the midline and the peritoneum was identified and entered with the Metzenbaum.  The peritoneal incision was extended superiorly and inferiorly with good visualization of the bladder.  At this point, the above findings were noted and the GYN Balfour retractor was placed.  Moist laparotomy sponges were used to pack the bowel out of the operative field.  The bladder blade and the extension for the retractor were then placed.  An Allis was used on the uterus for retraction.  The round ligaments were then identified, clamped with two hemostats and transected and then suture ligated.  The anterior portion of the broad ligament was dissected along vesicouterine resection.  The bladder was then dissected off the anterior cervix and vagina without difficulty.  The infundibulopelvic ligaments on both sides were then doubly clamped using hemostats, transected and suture ligated with #0 Vicryl suture.  The uterine vessels on both sides were skeletonized and clamped with two hemostats and transected and suture ligated with #0 Vicryl.  Good hemostasis was assured.  The cardinal ligaments on both sides were clamped using a curved hemostat, transected and suture ligated with #0 Vicryl.  Good hemostasis was obtained.  Two hemostats were then placed just under the cervix meeting in the midline.  The uterus and cervix were then _______ off using a scalpel.  This was handed and sent to Pathology for evaluation.  Using #0 Vicryl suture, the right vaginal cuff angle was closed and affixed to the ipsilateral cardinal ligament.  A baseball stitch was then used to close the cuff to the midline.  The same was done to the left vaginal cuff angle, which was affixed to the ipsilateral and cardinal ligaments.  The baseball stitch was used to close the cuff to the midline.  The hemostats were removed and the cuff was closed and good hemostasis was noted.  The uterosacral ligaments were also transfixed to the cuff and brought out for good support by using a #0 Vicryl suture through each uterosacral ligament and incorporating this into the vaginal cuff.  The pelvis was then copiously irrigated with warm normal saline.  Good support and hemostasis was noted.  The bowel packing was then removed and the GYN Balfour retractor was moved.  The peritoneum was then repaired with #0 Vicryl in a running fashion.  The fascia was then closed using #0 Vicryl in a running fashion, marking the first stitch and first last stitch in a lateral to medial fashion.  The skin was then closed with #4-0 undyed Vicryl in a subcuticular closure and an Op-Site was placed over this.  The patient was then brought out of general anesthesia and extubated.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2.  She will follow up postoperatively as an inpatient.","obstetrics / gynecology, cervical intraepithelial neoplasia, vaginal vault prolapse, uterosacral ligament vault suspension, total abdominal hysterectomy, bilateral salpingooophorectomy, abdominal hysterectomy, uterosacral ligament, recurrent dysplasia, uterine procidentia, suture ligated, abdominal, intraepithelial, tah, salpingooophorectomy, hysterectomy, ligament, hemostats, vaginal, "
 Total abdominal hysterectomy (TAH) with a right salpingo-oophorectomy., Obstetrics / Gynecology, TAH & Salpingo-oophorectomy - 1 ,"PREOPERATIVE DIAGNOSIS:  ,Persistent abnormal uterine bleeding after endometrial ablation.,POSTOPERATIVE DIAGNOSIS: , Persistent abnormal uterine bleeding after endometrial ablation.,PROCEDURE PERFORMED: , Total abdominal hysterectomy (TAH) with a right salpingo-oophorectomy.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , 250 cc.,FLUIDS:  ,1500 cc of crystalloids.,URINE: , 125 cc of clear urine at the end of the procedure.,FINDINGS: , On exam, under anesthesia, an obese female with an enlarged fibroid uterus freely movable on the pelvis.  Operative findings demonstrated the same with normal appearing tubes bilaterally.  The right ovary contained a right ovarian cyst.  The left ovary appeared to be within normal limits.  The peritoneal surfaces were noted to be within normal limits.  The bowel was also noted to be within normal limits.,INDICATIONS FOR THIS PROCEDURE: , The patient is a 44-year-old female who had an endometrial ablation done in May, which showed submucosal fibroids.  She had history of anemia and has been on iron therapy.  She started having bleeding three weeks ago with intermittent bouts of flooding.,She desired permanent and definitive therapy and therefore it was felt very appropriate to take the patient for a total abdominal hysterectomy.  The uterus, cervix, and right tube and ovary was sent to pathology for review.,PROCEDURE: , After informed consent was obtained, all questions were answered to the patient's satisfaction in layman's term.  She was taken to the operating room where a general anesthesia was obtained without any difficulty.  She was examined under anesthesia with noted findings above.  She was placed in a dorsal supine position and prepped and draped in the usual sterile fashion.  The Pfannenstiel skin incision was made with the first knife and was then carried down to the underlying layer of the fascia.  With the second knife, the fascia was excised in the midline and extended laterally with the Mayo scissors.  The superior aspect of the fascial incision was then tented up with the Ochsner clamps and the underlying rectus muscle was dissected off sharply as well as bluntly.  Attention was then turned to the inferior aspect of the fascial incision, which in a similar fashion was tented up and the underlying rectus muscle was dissected off sharply as well as bluntly.  The rectus muscle was then separated in the midline, the peritoneum was identified, entered bluntly and digitally.  Then the peritoneal incision was then extended superior and inferiorly with excellent visualization of the bladder.  The GYN Balfour was then placed.  A Lahey clamp was placed on the fundus of the uterus to pull the uterus into the operative field and the bowel was packed away with moist laparotomy sponges.  Attention was then turned to the round ligaments bilaterally, which were tented up with Allis clamps and then a hemostat was poked through the avascular portion underneath the round ligament and the #O-tie was passed through and then tied down.  Then the round ligament was transected and suture ligated and noted to be hemostatic.  The round ligaments were then skeletonized to create a window in the broad ligament.  The right infundibulopelvic ligament was isolated through the window created from the round ligaments and then the infundibular ligament on the right was loop tied and then doubly clamped with straight Ochsner clamps and then transected and suture ligated with a #0 Vicryl in a Heaney stitch fashion.  It was noted to be hemostatic.  Attention was then turned to the left side, in which the uterovarian vessel was isolated and then tied with an #O-tie and then doubly clamped with straight Ochsner clamps, transected and suture ligated with a #0 Vicryl in a Heaney stitch fashion and noted to be hemostatic.  The vesicouterine peritoneum was then identified, tented up with Allis clamps, and then the bladder flap was created sharply with a Russian and Metzenbaum scissors.  Then the bladder was deflected off of the underlying cervix with blunt dissection with a moist Ray-Tec sponge down to the level of the cervix.,The uterine vessels were skeletonized bilaterally and then clamped with straight Ochsner clamps and transected and suture ligated and noted to be hemostatic.  In the similar fashion, the broad ligament down to the level of the caudal ligament, the uterosacral ligaments was clamped with curved Ochsner clamps and transected and suture ligated, and noted to be hemostatic.  The second Lahey clamp was then placed on the cervix.  The cervix was tented up and the pubocervical vesical fascia was transected with a long knife and then the vagina was entered with a double pointed scissors poked through well protecting posteriorly with a large malleable.  The cuff was then outlined.  The vaginal cuff was grasped with a Ochsner clamp and then the cervix, uterus, and the right tube and ovary were transected using the Jorgenson scissors.  The cuff outlined with Ochsner clamps.  The cuff was then painted with a Betadine soaked Ray-Tec sponge and the sponge was placed over the vagina.  The vaginal cuff was then closed with a #0 Vicryl in a running locked fashion holding on to the beginning end on the right side as well as incorporating the ipsilateral cardinal ligaments into the cuff angles.  A long Allis was then used to grasp the mid portion of the cuff and a #0 Vicryl figure-of-eight stitch was placed in the mid portion of the cuff and tied down.  At this time, the abdomen was copiously irrigated with warm normal saline and noted to be hemostatic.  The suture that was used to close the cuff was then used to come back through the posterior peritoneum grabbing the uterosacral ligaments and the mid portion of the cuff, and then tied down to bring the cuff close and together.  Then, the right round ligament was pulled into the cuff and tied down with the #0 Vicryl that was used as a figure-of-eight stitch in the middle of the cuff.  The left round ligament was too small to reach the cuff.  The abdomen was then again copiously irrigated with warm normal saline and noted to be hemostatic.  The peritoneum was then re-peritonealized with a #3-0 Vicryl in a running fashion.  The GYN Balfour and all packing sponges were removed from the abdomen.  Then the abdomen was then once again copiously irrigated and the cuff and incision sites were once again reinspected and noted to be hemostatic.  The ______ was placed back into the hollow of the sacrum.  The omentum was then pulled over to top of the bowel and then the peritoneum was then closed with a #3-0 Vicryl in a running fashion and then the fascia was closed with #0 Vicryl in a running fashion.  The skin was closed with staples and dressing applied.  The patient was then examined at the end of the procedure.  The Betadine-soaked sponge was removed from the vagina.  The cuff was noted to be intact without bleeding and the patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2 and she was taken to the recovery in stable condition.  The patient will be followed throughout her hospital stay.","obstetrics / gynecology, tah, salpingo-oophorectomy, total abdominal hysterectomy, abnormal uterine bleeding, endometrial ablatio, ochsner clamps, round ligaments, clamps, ligaments, cuff, salpingo, oophorectomy, hysterectomy, uterine, ablation, tubes, abdominal, anesthesia,"
" Total abdominal hysterectomy (TAH).  Severe menometrorrhagia unresponsive to medical therapy, severe anemia, and symptomatic fibroid uterus.  ", Obstetrics / Gynecology, TAH - Discharge Summary ,"ADMISSION DIAGNOSES:,1.  Severe menometrorrhagia unresponsive to medical therapy.,2.  Severe anemia.,3.  Symptomatic fibroid uterus.,DISCHARGE DIAGNOSES:,1.  Severe menometrorrhagia unresponsive to medical therapy.,2.  Severe anemia.,3.  Symptomatic fibroid uterus.,4.  Extensive adenomyosis by pathological report.,OPERATION PERFORMED: , On 6/10/2009 total abdominal hysterectomy (TAH).,COMPLICATIONS:,  None.,BLOOD TRANSFUSIONS: , None.,INFECTIONS: , None.,SIGNIFICANT LAB AND X-RAY: , On admission hemoglobin and hematocrit was 10.5 and 32.8 respectively.  On discharge, hemoglobin and hematocrit 7.9 and 25.2.,HOSPITAL COURSE AND TREATMENT:  ,The patient was admitted to the surgical suite and taken to the operating room on 6/10/2009 where a total abdominal hysterectomy (TAH) with low intraoperative complication was performed.  The patient tolerated all procedures well.  On the 1st postoperative day, the patient was afebrile and all vital signs were stable.  On the 3rd postoperative day, the patient was ambulating with difficulty and tolerating clear liquid diet.  On the 4th postoperative day, the patient was complaining of pain in her back and abdomen as well as incisional wound tenderness.  On the 5th postoperative day, the patient was afebrile.  Vital signs were stable.  The patient was tolerating a diet and ambulating without difficulty.  The patient was desirous of going home.  The patient denied any abdominal pain or flank pain.  The patient had minimal incisional wound tenderness.  The patient was desirous of going home and was discharged home.,DISCHARGE CONDITION: , Stable.,DISCHARGE INSTRUCTIONS:,  Regular diet, bedrest x1 week with slow return to normal activity over the ensuing 4 to 6 weeks, pelvic rest for 6 weeks.  Motrin 600 mg tablets 1 tablet p.o. q.8h. p.r.n. pain, Colace 100 mg tablets 1 tablet p.o. daily p.r.n. constipation and ferrous sulfate 60 mg tablets 1 tablet p.o. daily, and multiple vitamin 1 tablet p.o. daily.  The patient is to return on Wednesday 6/17/2009 for removal of staples.  The patient was given a full explanation of her clinical condition.  The patient was given full and complete postoperative and discharge instructions.  All her questions were answered.","obstetrics / gynecology, adenomyosis, total abdominal hysterectomy, fibroid uterus, postoperative day, hemoglobin, hematocrit, therapy, menometrorrhagia, anemia, fibroid, uterus, tah, hysterectomy, abdominal, "
" Total abdominal hysterectomy (TAH) and left salpingo-oophorectomy.  Hypermenorrhea, uterine fibroids, pelvic pain, left adnexal mass, and pelvic adhesions.", Obstetrics / Gynecology, TAH & Salpingo-oophorectomy ,"PREOPERATIVE DIAGNOSES:,1.  Hypermenorrhea.,2.  Uterine fibroids.,3.  Pelvic pain.,4.  Left adnexal mass.,5.  Pelvic adhesions.,POSTOPERATIVE DIAGNOSES:,1.  Hypermenorrhea.,2.  Uterine fibroids.,3.  Pelvic pain.,4.  Left adnexal mass.,5.  Pelvic adhesions.,PROCEDURE PERFORMED:,1.  Total abdominal hysterectomy (TAH).,2.  Left salpingo-oophorectomy.,ANESTHESIA:,  General endotracheal.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , Less than 100 cc.,INDICATIONS: , The patient is a 47-year-old Caucasian female with complaints of hypermenorrhea and pelvic pain, noted to have a left ovarian mass 7 cm at the time of laparoscopy in July of 2003.  The patient with continued symptoms of pelvic pain and hypermenorrhea and desired definitive surgical treatment.,FINDINGS AT THE TIME OF SURGERY: , Uterus is anteverted and boggy with a very narrow introitus with a palpable left adnexal mass.,On laparotomy, the uterus was noted to be slightly enlarged with fibroid change as well as a hemorrhagic appearing left adnexal mass.  The bowel, omentum, and appendix had a normal appearance.,PROCEDURE: , The patient was taken to the operative suite where anesthesia was found to be adequate.  She was then prepared and draped in normal sterile fashion.  A Pfannenstiel skin incision was made with a scalpel and carried through the underlying layer of fascia with the second scalpel.  The fascia was then incised in the midline.  The fascial incision was then extended laterally with Mayo scissors.  The superior aspect of the fascial incision was grasped with Kochers with the underlying rectus muscle dissected off bluntly and sharply with Mayo scissors.  Attention was then turned to the inferior aspect of this incision, which in a similar fashion was tented up with the underlying rectus muscle and dissected off bluntly and sharply with Mayo scissors.  The rectus muscle was then separated in the midline.  The peritoneum was identified, tented up with hemostats and entered sharply with Metzenbaum scissors.  The peritoneal incision was then extended superiorly and inferiorly with good visualization of the bladder.  The uterus and left adnexa were then palpated and brought out into the surgical field.  The fundus of the uterus was grasped with a Lahey clamp.  The GYN/Balfour retractor was placed.  The bladder blade was placed.  The bowel was packed away with moist laparotomy sponges and the extension through GYN/Balfour retractor was placed.  At this time, the patient's anatomy was surveyed and there was found to be a left hemorrhagic appearing adnexal mass.  Attention was first turned to the right round ligament, which was tented up with a Babcock and a small window was made beneath the round ligament with a hemostat.  It was then suture ligated with #0 Vicryl suture, transected with the broad ligament being skeletonized on both sides.  Next, the right ________ was isolated bluntly as the patient had a previous RSO.  This was then suture ligated with #0 Vicryl suture, doubly clamped with Kocher clamps, transected, and suture ligated with #0 Vicryl suture with a Heaney stitch.  Attention was then turned to the left round ligament, which was tented up with the Babcock.  Small window was made beneath it and the broad ligament with hemostat was then suture ligated with #0 Vicryl suture, transected, and skeletonized with the aid of Metzenbaums.  The left infundibulopelvic ligament was then bluntly isolated.  It was then suture ligated with #0 Vicryl suture, doubly clamped with Kocher clamps, and transected and suture ligated with #0 Vicryl suture with a Heaney stitch.  The bladder flap was then placed on tension with Allis clamps.  It was then dissected off of the lower uterine segment with the aid of Metzenbaum scissors and Russians.  It was then gently pushed off of lower uterine segment with the aid of a moist Ray-Tec.  The uterine arteries were then skeletonized bilaterally.,They were then clamped with straight Kocher clamps, transected, and suture ligated with #0 Vicryl suture.  The cardinal ligament and uterosacral complexes on both sides were then clamped with curved Kocher clamps.  These were then transected and suture ligated with #0 Vicryl suture.  The lower uterine segment was then grasped with Lahey clamps, at which time the cervix was already visible.  It was then entered with the last transection.  The cervix was grasped with a single-toothed tenaculum and the uterus, cervix, and left adnexa were amputated off the vagina with the aid of Jorgenson scissors.  The angles of the vaginal cuff were then grasped with Kocher clamps.  A Betadine-soaked Ray-Tec was then pushed into the vagina and the vaginal cuff was closed with #0 Vicryl suture in a running lock fashion with care taken to transect the ipsilateral cardinal ligament, at which time the suction tip was changed and copious suction irrigation was performed.  Good hemostasis was appreciated.  A figure-of-eight suture in the center of the vaginal cuff was placed with #0 Vicryl.  This was tagged for later use.  The uterosacrals on both sides were incorporated into the vaginal cuff with the aid of #0 Vicryl suture.  The round ligaments were then pulled into the vaginal cuff using the figure-of-eight suture placed in the center of the vaginal cuff and these were tied in place.  The pelvis was then again copiously suctioned irrigated and hemostasis was appreciated.  The peritoneal surfaces were then reapproximated with the aid of #3-0 Vicryl suture in a running fashion.  The GYN/Balfour retractor and bladder blade were then removed.  The bowel was then packed.  Again copious suction irrigation was performed with hemostasis appreciated.  The peritoneum was then reapproximated with #2-0 Vicryl suture in a running fashion.  The fascia was then reapproximated with #0 Vicryl suture in a running fashion.  The Scarpa's  fascia was then reapproximated with #3-0 plain gut in a running fashion and the skin was closed with #4-0 undyed Vicryl in a subcuticular fashion.  Steri-Strips were placed.  At the end of the procedure, the sponge that was pushed into the vagina previously was removed and hemostasis was appreciated vaginally.  The patient tolerated the procedure well and was taken to Recovery in stable condition.  Sponge, lap, and needle counts were correct x2.  Specimens include uterus, cervix, left fallopian tube, and ovary.", 
" Spontaneous vaginal delivery.  Male infant, cephalic presentation, ROA.  Apgars 2 and 7.  Weight 8 pounds and 1 ounce.  Intact placenta.  Three-vessel cord.  Third degree midline tear.", Obstetrics / Gynecology, Spontaneous Vaginal Delivery - 1 ,"PREOPERATIVE DIAGNOSES,1.  Intrauterine pregnancy at 39 plus weeks gestation.,2.  Gestational hypertension.,3.  Thick meconium.,4.  Failed vacuum attempted delivery.,POSTOPERATIVE DIAGNOSES,1.  Intrauterine pregnancy at 39 plus weeks gestation.,2.  Gestational hypertension.,3.  Thick meconium.,4.  Failed vacuum attempted delivery.,OPERATION PERFORMED: , Spontaneous vaginal delivery.,ANESTHESIA: , Epidural was placed x2.,ESTIMATED BLOOD LOSS:,  500 mL.,COMPLICATIONS: , Thick meconium.  Severe variables, Apgars were 2 and 7.  Respiratory therapy and ICN nurse at delivery.  Baby went to Newborn Nursery.,FINDINGS: , Male infant, cephalic presentation, ROA.  Apgars 2 and 7.  Weight 8 pounds and 1 ounce.  Intact placenta.  Three-vessel cord.  Third degree midline tear.,DESCRIPTION OF OPERATION: , The patient was admitted this morning for induction of labor secondary to elevated blood pressure, especially for the last three weeks.  She was already 3 cm dilated.  She had artificial rupture of membranes.  Pitocin was started and she actually went to complete dilation.  While pushing, there was sudden onset of thick meconium, and she was having some severe variables and several late decelerations.  When she was complete +2, vacuum attempted delivery, three pop-offs were done.  The vacuum was then no longer used after the three pop-offs.  The patient pushed for a little bit longer and had a delivery, ROA, of a male infant, cephalic, over a third-degree midline tear.  Secondary to the thick meconium, DeLee suctioned nose and mouth before the anterior shoulder was delivered and again after delivery.  Baby was delivered floppy.  Cord was clamped x2 and cut, and the baby was handed off to awaiting ICN nurse and respiratory therapist.  Delivery of intact placenta and three-vessel cord.  Third-degree midline tear was repaired with Vicryl without any complications.  Baby initially did well and went to Newborn Nursery, where they are observing him a little bit longer there.  Again, mother and baby are both doing well.  Mother will go to Postpartum and baby is already in Newborn Nursery.","obstetrics / gynecology, thick meconium, cephalic presentation, intrauterine pregnancy, gestational hypertension, spontaneous vaginal delivery, delivery, vaginal, placenta, newborn, meconium, apgars,"
 Laparoscopic right salpingooophorectomy.  Right pelvic pain and ovarian mass.  Right ovarian cyst with ovarian torsion., Obstetrics / Gynecology, Salpingooophorectomy - Laparoscopic ,"PREOPERATIVE DIAGNOSES:,1.  Right pelvic pain.,2.  Right ovarian mass.,POSTOPERATIVE DIAGNOSES:,1.  Right pelvic pain.,2.  Right ovarian mass.,3.  8 cm x 10 cm right ovarian cyst with ovarian torsion.,PROCEDURE PERFORMED:  ,Laparoscopic right salpingooophorectomy.,ANESTHESIA:  ,General with endotracheal tube.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,TUBES: , None.,DRAINS:,  None.,PATHOLOGY: , The right tube and ovary sent to pathology for review.,FINDINGS: , On exam under anesthesia, a normal-appearing vulva and vagina and normally palpated cervix, a uterus that was normal size, and a large right adnexal mass.  Laparoscopic findings demonstrated a 8 cm x 10 cm smooth right ovarian cyst that was noted to be torsed twice.  Otherwise, the uterus, left tube and ovary, bowel, liver margins, appendix, and gallbladder were noted all to be within normal limits.  There was no noted blood in the pelvis.,INDICATIONS FOR THIS PROCEDURE:,  The patient is a 26-year-old G1 P1 who presented to ABCD General Emergency Room with complaint of right lower quadrant pain since last night, which has been increasing in intensity.  The pain persisted despite multiple pain medications given in the Emergency Room.  The patient reports positive nausea and vomiting.  There was no vaginal bleeding or discharge.  There was no fevers or chills.  Her cultures done in the Emergency Room were pending.  The patient did have an ultrasound that demonstrated an 8 cm right ovarian cyst, questionable hemorrhagic.  The uterus and left ovary were within normal limits.  There was a positive flow noted to bilateral ovaries on ultrasound.  Therefore, it was felt appropriate to take the patient for a diagnostic laparoscopy with a possible oophorectomy.,PROCEDURE:,  After informed consent was obtained, and all questions were answered to the patient's satisfaction in layman's terms, she was taken to the operating room where general anesthesia was obtained without any difficulty.  She was placed in dorsal lithotomy position with the use of Allis strips and prepped and draped in the usual sterile fashion.  Her bladder was drained with a red Robinson catheter and she was examined under anesthesia and was noted to have the findings as above.  She was prepped and draped in the usual sterile fashion.  A weighted speculum was placed in the patient's vagina with excellent visualization of the cervix.  The cervix was grasped at 12 o'clock position with a single-toothed tenaculum and pulled into the operative field.  The uterus was then sounded to approximately 3.5 inches and then a uterine elevator was placed.  The vulsellum tenaculum was removed.  The weighted speculum was removed.  Attention was then turned to the abdomen where 1 cm infraumbilical incision was made in the infraumbilical fold.  The Veress step needle was then placed into the abdomen while the abdomen was being tented up with towel clamp.  The CO2 was then turned on with unoccluded flow and excellent pressures.  This was continued till a normal symmetrical pneumoperitoneum was obtained.  Then, a #11 mm step trocar and sleeve were placed into the infraumbilical port without any difficulty and placement was confirmed by laparoscope.  Laparoscopic findings are as noted above.  A suprapubic incision was made with the knife and then a #12 mm step trocar and sleeve were placed in the suprapubic region under direct visualization.  Then, a grasper was used to untorse the ovary.  Then, a #12 mm port was placed in the right flank region under direct visualization using a LigaSure vessel sealing system.  The right tube and ovary were amputated and noted to be hemostatic.  The EndoCatch bag was then placed through the suprapubic port and the ovary was placed into the bag.  The ovary was too large to fit completely into the bag.  Therefore, a laparoscopic needle with a 60 cc syringe was used to aspirate the contents of the ovary while it was still inside the bag.,There was approximately 200 cc of fluid aspirated from the cyst.  This was a clear yellow fluid.  Then, the bag was closed and the ovary was removed from the suprapubic port.  The suprapubic port did have to be extended somewhat to allow for the removal of the ovary.  The trocar and sleeve were then placed back into the port.  The abdomen was copiously irrigated with warm normal saline using the Nezhat-Dorsey suction irrigator and the incision site was noted to be hemostatic.  The pelvis was clear and clean.  ,Pictures were obtained.  The suprapubic port was then removed under direct visualization and then using a #0-vicyrl and UR6.  Two figure-of-eight sutures were placed in the fascia of suprapubic port and fascia was closed and the pneumoperitoneum was maintained after the sutures were placed.  Therefore, the peritoneal surface was noted to be hemostatic.  Therefore, the camera was removed.  All instruments were removed.  The abdomen was allowed to completely deflate and then the trocars were placed back through the sleeves of the right flank #12 port and the infraumbilical port and these were removed.  The infraumbilical port was examined and noted to have a small fascial defect which was repaired with #0-Vicryl and UR6.  The right flank area was palpated and there was no facial defect noted.  The skin was then closed with #4-0 undyed Vicryl in subcuticular fashion.  Dressings were changed.  The weighted speculum was removed from the patient's cervix.  The cervix noted to be hemostatic.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2 and the patient was taken to the Recovery in stable condition.", 
 Repeat cesarean section and bilateral tubal ligation., Obstetrics / Gynecology, Repeat C-section ,"PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 39 weeks.,2.  History of previous cesarean section x2.  The patient desires a repeat section.,3.  Chronic hypertension.,4.  Undesired future fertility.  The patient desires permanent sterilization.,POSTOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 39 weeks.,2.  History of previous cesarean section x2.  The patient desires a repeat section.,3.  Chronic hypertension.,4.  Undesired future fertility.  The patient desires permanent sterilization.,PROCEDURE PERFORMED:  ,Repeat cesarean section and bilateral tubal ligation.,ANESTHESIA: , Spinal.,ESTIMATED BLOOD LOSS:,  800 mL.,COMPLICATIONS:  ,None.,FINDINGS: , Male infant in cephalic presentation with anteflexed head, Apgars were 2 at 1 minute and 9 at 5 minutes, 9 at 10 minutes, and weight 7 pounds 8 ounces.  Normal uterus, tubes, and ovaries were noted.,INDICATIONS:  ,The patient is a 31-year-old gravida 5, para 4 female, who presented to repeat cesarean section at term.  The patient has a history of 2 previous cesarean sections and she desires a repeat cesarean section, additionally she desires permanent fertilization.  The procedure was described to the patient in detail including possible risks of bleeding, infection, injury to surrounding organs, and the possible need for further surgery and informed consent was obtained.,PROCEDURE NOTE: , The patient was taken to the operating room where spinal anesthesia was administered without difficulty.  The patient was prepped and draped in the usual sterile fashion in the dorsal supine position with a leftward tilt.  A Pfannenstiel skin incision was made with the scalpel and carried through to the underlying layer of fascia using the Bovie.  The fascia was incised in the midline and extended laterally using Mayo scissors.  Kocher clamps were used to elevate the superior aspect of the fascial incision, which was elevated, and the underlying rectus muscles were dissected off bluntly and using Mayo scissors.  Attention was then turned to the inferior aspect of the fascial incision, which in similar fashion was grasped with Kocher clamps, elevated, and the underlying rectus muscles were dissected off bluntly and using the Bovie.  The rectus muscles were dissected in the midline.,The peritoneum was identified and entered using Metzenbaum scissors; this incision was extended superiorly and inferiorly with good visualization of the bladder.  The bladder blade was inserted.  The vesicouterine peritoneum was identified and entered sharply using Metzenbaum scissors.  This incision was extended laterally and the bladder flap was created digitally.  The bladder blade was reinserted.  The lower uterine segment was incised in a transverse fashion using the scalpel and extended using bandage scissors as well as manual traction.,Clear fluid was noted.  The infant was subsequently delivered using a Kelly vacuum due to anteflexed head and difficulty in delivering the infant's head without the Kelly.  The nose and mouth were bulb suctioned.  The cord was clamped and cut.  The infant was subsequently handed to the awaiting nursery nurse.  The placenta was delivered spontaneously intact with a three-vessel cord noted.  The uterus was exteriorized and cleared of all clots and debris.  The uterine incision was repaired in 2 layers using 0 chromic sutures.  Hemostasis was visualized.  Attention was turned to the right fallopian tube, which was grasped with Babcock clamp using a modified Pomeroy method, a 2 cm of segment of tube ligated x2, transected and specimen was sent to pathology.  Attention was then turned to the left fallopian tube, which was grasped with Babcock clamp again using a modified Pomeroy method, a 2 cm segment of tube was ligated x2 and transected.  Hemostasis was visualized bilaterally.  The uterus was returned to the abdomen, both fallopian tubes were visualized and were noted to be hemostatic.  The uterine incision was reexamined and it was noted to be hemostatic.  The pelvis was copiously irrigated.  The rectus muscles were reapproximated in the midline using 3-0 Vicryl.  The fascia was closed with 0 Vicryl suture, the subcutaneous layer was closed with 3-0 plain gut, and the skin was closed with staples.  Sponge, lap, and instrument counts were correct x2.  The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition.","obstetrics / gynecology, bilateral tubal ligation, permanent sterilization, undesired future fertility, repeat cesarean section, intrauterine pregnancy, mayo scissors, kocher clamps, metzenbaum scissors, fallopian tube, babcock clamp, pomeroy method, rectus muscles, cesarean section, intrauterine, cesarean, "
" Radical vulvectomy (complete), bilateral inguinal lymphadenectomy (superficial and deep).", Obstetrics / Gynecology, Radical Vulvectomy ,"PREOPERATIVE DIAGNOSIS: , Clinical stage III squamous cell carcinoma of the vulva.,POSTOPERATIVE DIAGNOSIS: , Clinical stage III squamous cell carcinoma of the vulva.,OPERATION PERFORMED:,  Radical vulvectomy (complete), bilateral inguinal lymphadenectomy (superficial and deep).,ANESTHESIA: , General, endotracheal tube.,SPECIMENS: , Radical vulvectomy, right and left superficial and deep inguinal lymph nodes. ,INDICATIONS FOR PROCEDURE: , The patient recently presented with a new vaginal nodule. Biopsy was obtained and revealed squamous carcinoma.  The lesion extended slightly above the hymeneal ring and because of vaginal involvement was classified as a T3/Nx/Mx on clinical examination.  Of note, past history is significant for pelvic radiation for cervical cancer many years previously.,FINDINGS: , The examination under anesthesia revealed a 1.5 cm nodule of disease extending slightly above the hymeneal ring.  There was no palpable lymphadenopathy in either inguinal node region.  There were no other nodules, ulcerations, or other lesions.  At the completion of the procedure there was no clinical evidence of residual disease.,PROCEDURE:,  The patient was brought to the Operating Room with an IV in place.  She was placed in the low anterior lithotomy position after adequate anesthesia had been induced.  Examination under anesthesia was performed with findings as noted, after which she was prepped and draped.  The femoral triangles were marked and a 10 cm skin incision was made parallel to the inguinal ligament approximately 3 cm below the ligament.  Camper's fascia was divided and skin flaps were elevated with sharp dissection and ligation of vessels where necessary.  The lymph node bundles were mobilized by incising the loose areolar tissue attachments to the fascia of the rectus abdominis.  The fascia around the sartorius muscle was divided and the specimen was reflected from lateral to medial.  The cribriform fascia was isolated and dissected with preservation of the femoral nerve.  The femoral sheath containing artery and vein was opened and vessels were stripped of their lymphatic attachments.  The medial lymph node bundle was isolated, and Cloquet's node was clamped, divided, and ligated bilaterally.  The saphenous vessels were identified and preserved bilaterally.  The inferior margin of the specimen was ligated, divided, and removed.  Inguinal node sites were irrigated and excellent hemostasis was noted.  Jackson-Pratt drains were placed and Camper's fascia was approximated with simple interrupted stitches.  The skin was closed with running subcuticular stitches using 4-0 Monocryl suture.,Attention was turned to the radical vulvectomy specimen.  A marking pen was used to outline the margins of resection allowing 15-20 mm of margin on the inferior, lateral, and anterior margins.  The medial margin extended into the vagina and was approximately 5-8 mm.  The skin was incised and underlying adipose tissue was divided with electrocautery.  Vascular bundles were isolated, divided, and ligated.  After removal of the specimen, additional margin was obtained from the right vaginal side wall adjacent to the tumor site.  Margins were submitted on the right posterior, middle, and anterior vaginal side walls.  After removal of the vaginal margins, the perineum was irrigated with four liters of normal saline and deep tissues were approximated with simple interrupted stitches of 2-0 Vicryl suture.  The skin was closed with interrupted horizontal mattress stitches using 3-0 Vicryl suture.  The final sponge, needle, and instrument counts were correct at the completion of the procedure.  The patient was then awakened from her anesthetic and taken to the Post Anesthesia Care Unit in stable condition.","obstetrics / gynecology, squamous cell carcinoma, vulvectomy, radical vulvectomy, bilateral inguinal lymphadenectomy, hymeneal ring, camper's fascia, carcinoma of the vulva, inguinal lymphadenectomy, lymph nodes, inguinal, vulva, squamous, carcinoma, radical, lymphadenectomy, fascia, vaginal, nodes"
" Sterilization candidate.  Cervical dilatation and laparoscopic bilateral partial salpingectomy.  A 30-year-old female gravida 4, para-3-0-1-3 who desires permanent sterilization.", Obstetrics / Gynecology, Salpingectomy & Cervical Dilatation ,"PREOPERATIVE DIAGNOSIS:,  Sterilization candidate.,POSTOPERATIVE DIAGNOSIS:,  Sterilization candidate.,PROCEDURE PERFORMED:,1.  Cervical dilatation.,2.  Laparoscopic bilateral partial salpingectomy.,ANESTHESIA: , General endotracheal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:  ,Less than 50 cc.,SPECIMEN: , Portions of bilateral fallopian tubes.,INDICATIONS:,  This is a 30-year-old female gravida 4, para-3-0-1-3 who desires permanent sterilization.,FINDINGS: , On bimanual exam, the uterus is small, anteverted, and freely mobile.  There are no adnexal masses appreciated.  On laparoscopic exam, the uterus, bilateral tubes and ovaries appeared normal.  The liver margin and bowel appeared normal.,PROCEDURE: , After consent was obtained, the patient was taken to the operating room where general anesthetic was administered.  The patient was placed in dorsal lithotomy position and prepped and draped in the normal sterile fashion.  A sterile speculum was placed in the patient's vagina and the anterior lip of the cervix was grasped with a vulsellum tenaculum.  The uterus was then sounded to 7 cm.,The cervix was serially dilated with Hank dilators.  A #20 Hank dilator was left in place.  The sterile speculum was then removed.  Gloves were changed.  Attention was then turned to the abdomen where approximately a 10 mm transverse infraumbilical incision was made through the patient's previous scar.  The Veress needle was placed and gas was turned on.  When good flow and low abdominal pressures were noted, the gas was turned up and the abdomen was allowed to insufflate.  A 11 mm trocar was then placed through this incision and the camera was placed with the above findings noted.  Two 5 mm step trocars were placed, one 2 cm superior to the pubic bone along the midline and the other approximately 7 cm to 8 cm to the left at the level of the umbilicus.  The Endoloop was placed through the left-sided port.  A grasper was placed in the suprapubic port and put through the Endoloop and then a portion of the left tube was identified and grasped with a grasper.  A knuckle of tube was brought up with the grasper and a #0 Vicryl Endoloop synched down across this knuckle of tube.  The suture was then cut using the endoscopic shears.  The portion of tube that was tied off was removed using a Harmonic scalpel.  This was then removed from the abdomen and sent to Pathology.  The right tube was then identified and in a similar fashion, the grasper was placed through the loop of the #0 Vicryl Endoloop and the right tube was grasped with the grasper and the knuckle of tube was brought up into the loop.  The loop was then synched down.  The Endoshears were used to cut the suture.  The Harmonic scalpel was then used to remove that portion of tube.  The portion of the tube that was removed from the abdomen was sent to Pathology.  Both tubes were examined and found to have excellent hemostasis.  All instruments were then removed.  The 5 mm ports were removed with good hemostasis noted.  The camera was removed and the abdomen was allowed to desufflate.  The 11 mm trocar introducer was replaced and the trocar was removed.  The fascia of the infraumbilical incision was reapproximated with an interrupted suture of #3-0 Vicryl.  The skin was then closed with #4-0 undyed Vicryl in a subcuticular fashion.  Approximately 10 cc of Marcaine was injected at the incision site.  The vulsellum tenaculum and cervical dilator were then removed from the patient's cervix with excellent hemostasis noted.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct at the end of the procedure.  The patient was taken to the recovery room in satisfactory condition.  She will be discharged home with a prescription for Vicodin for pain and was instructed to follow up in the office in two weeks.","obstetrics / gynecology, cervical dilatation, partial salpingectomy, permanent sterilization, vulsellum tenaculum, hank dilators, infraumbilical incision, vicryl endoloop, salpingectomy, dilatation, hemostasis, cervical, laparoscopic, endoloop, sterilization,"
" Spontaneous vaginal delivery.   Term pregnancy at 40 and 3/7th weeks.  On evaluation of triage, she was noted to be contracting approximately every five minutes and did have discomfort with her contractions.", Obstetrics / Gynecology, Spontaneous Vaginal Delivery ,"PREOPERATIVE DIAGNOSIS: , Term pregnancy at 40 and 3/7th weeks.,PROCEDURE PERFORMED: , Spontaneous vaginal delivery.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 36-year-old African-American female who is a G-2, P-2-0-0-2 with an EDC of 08/30/2003.  She is blood type AB -ve with antibody screen negative and is also rubella immune, VDRL nonreactive, hepatitis B surface antigen negative, and HIV nonreactive.  She does have a history of sickle cell trait.  She presented to Labor and Delivery Triage at 40 and 3/7th weeks gestation with complaint of contractions every ten minutes.  She also stated that she has lost her mucous plug.  She did have fetal movement, noted no leak of fluid, did have some spotting.  On evaluation of triage, she was noted to be contracting approximately every five minutes and did have discomfort with her contractions.  She was evaluated by sterile vaginal exam and was noted to be 4 cm dilated, 70% effaced, and -3 station.  This was a change from her last office exam, at which she was 1 cm to 2 cm dilated.,PROCEDURE DETAILS:,  The patient was admitted to Labor and Delivery for expected management of labor and AROM was performed and the amniotic fluid was noted to be meconium stained.  After her membranes were ruptured, contractions did increase to every two to three minutes as well as the intensity increased.  She was given Nubain for discomfort with good result.,She had a spontaneous vaginal delivery of a live born female at 11:37 with meconium stained fluid as noted from ROA position.  After controlled delivery of the head, tight nuchal cord was noted, which was quickly double clamped and cut and the shoulders and body were delivered without difficulty.  The infant was taken to the awaiting pediatrician.  Weight was 2870 gm, length was 51 cm.  The Apgars were 6 at 1 minute and 9 at 5 minutes.  There was initial neonatal depression, which was treated by positive pressure ventilation and the administration of Narcan.,Spontaneous delivery of an intact placenta with a three-vessel cord was noted at 11:45.  On examination, there were no noted perineal abrasions or lacerations.  On vaginal exam, there were no noted cervical or vaginal sidewall lacerations.  Estimated blood loss was less than 250 cc.  Mother and infant are in recovery doing well at this time.","obstetrics / gynecology, roa position, arom, labor and delivery, spontaneous vaginal delivery, term pregnancy, contracting, meconium, lacerations, pregnancy, contractions, vaginal, "
 Modified radical mastectomy.  An elliptical incision was made to incorporate the nipple-areolar complex and the previous biopsy site.  The skin incision was carried down to the subcutaneous fat but no further. , Obstetrics / Gynecology, Radical Mastectomy - 1 ,"PROCEDURE PERFORMED: , Modified radical mastectomy.,ANESTHESIA: , General endotracheal tube.,PROCEDURE:  ,After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating room table.  General endotracheal anesthesia was induced without incident.  The patient was prepped and draped in the usual sterile manner.  Care was taken to ensure that the arm was placed in a relaxed manner away from the body to facilitate exposure and to avoid nerve injury.,An elliptical incision was made to incorporate the nipple-areolar complex and the previous biopsy site.  The skin incision was carried down to the subcutaneous fat but no further.  Using traction and counter-traction, the upper flap was dissected from the chest wall medially to the sternal border, superiorly to the clavicle, laterally to the anterior border of the latissimus dorsi muscle, and superolaterally to the insertion of the pectoralis major muscle.  The lower flap was dissected in a similar manner down to the insertion of the pectoralis fascia overlying the fifth rib medially and laterally out to the latissimus dorsi.  Bovie electrocautery was used for the majority of the dissection and hemostasis tying only the large vessels with 2-0 Vicryl.  The breast was dissected from the pectoralis muscle beginning medially and progressing laterally removing the pectoralis fascia entirely.  Once the lateral border of the pectoralis major muscle was identified, the pectoralis muscle was retracted medially and the interpectoral fat was removed with the specimen.,The axillary dissection was then begun by incising the fascia overlying axilla proper allowing visualization of the axillary vein.  The highest point of axillary dissection was then marked with a long stitch for identification by the surgical pathologist.  The axilla was then cleared of its contents by sharp dissection.  Small vessels entering the axillary vein were clipped and divided.  The axilla was cleared down to the chest wall, and dissection was continued laterally to the subscapular vein.  The long thoracic nerve was cleared identified lying against the chest and was carefully preserved.  The long thoracic nerve represented the posterior most aspect of the dissection.  As the axillary contents were dissected in the posterolateral axilla, the thoracodorsal nerve was identified and carefully preserved.  The dissection continued caudally until the entire specimen was freed and delivered from the operative field.  Copious water lavage was used to remove any debris, and hemostasis was obtained with Bovie electrocautery.,Two Jackson-Pratt drains were inserted through separate stab incisions below the initial incision and cut to fit.  The most posterior of the 2 was directed into the axilla and the other directed anteriorly across the pectoralis major.  These were secured to the skin using 2-0 silk, which was Roman-sandaled around the drain.,The skin incision was approximated with skin staples.  A dressing was applied.  The drains were placed on ""grenade"" suction.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition.","obstetrics / gynecology, latissimus dorsi muscle, pectoralis major muscle, pectoralis fascia, axillary vein, thoracic nerve, radical mastectomy, pectoralis major, axillary, incision, mastectomy, fascia, muscle, pectoralis, "
 Invasive carcinoma of left breast. Left modified radical mastectomy., Obstetrics / Gynecology, Radical Mastectomy ,"PREOPERATIVE DIAGNOSIS:,  Invasive carcinoma of left breast.,POSTOPERATIVE DIAGNOSIS:,  Invasive carcinoma of left breast.,OPERATION PERFORMED:,  Left modified radical mastectomy.,ANESTHESIA: , General endotracheal.,INDICATION FOR THE PROCEDURE:  ,The patient is a 52-year-old female who recently underwent a left breast biopsy and was found to have invasive carcinoma of the left breast.  The patient was elected to have a left modified radical mastectomy, she was not interested in a partial mastectomy.  She is aware of the risks and complications of surgery, and wished to proceed.,DESCRIPTION OF PROCEDURE:  ,The patient was taken to the operating room.  She underwent general endotracheal anesthetic.  The TED stockings and venous compression devices were placed on both lower extremities and they were functioning well.  The patient's left anterior chest wall, neck, axilla, and left arm were prepped and draped in the usual sterile manner.  The recent biopsy site was located in the upper and outer quadrant of left breast.  The plain incision was marked along the skin.  Tissues and the flaps were injected with 0.25% Marcaine with epinephrine solution and then a transverse elliptical incision was made in the breast of the skin to include nipple areolar complex as well as the recent biopsy site.  The flaps were raised superiorly and just below the clavicle medially to the sternum, laterally towards the latissimus dorsi, rectus abdominus fascia.  Following this, the breast tissue along with the pectoralis major fascia were dissected off the pectoralis major muscle.  The dissection was started medially and extended laterally towards the left axilla.  The breast was removed and then the axillary contents were dissected out.  Left axillary vein and artery were identified and preserved as well as the lung _____.  The patient had several clinically palpable lymph nodes, they were removed with the axillary dissection.  Care was taken to avoid injury to any of the above mentioned neurovascular structures.  After the tissues were irrigated, we made sure there were no signs of bleeding.  Hemostasis had been achieved with Hemoclips.  Hemovac drains x2 were then brought in and placed under the left axilla as well as in the superior and inferior breast flaps.  The subcu was then approximated with interrupted 4-0 Vicryl sutures and skin with clips.  The drains were sutured to the chest wall with 3-0 nylon sutures.  Dressing was applied and the procedure was completed.  The patient went to the recovery room in stable condition.","obstetrics / gynecology, invasive carcinoma, chest wall, neck, axilla, modified radical mastectomy, radical mastectomy, invasive, carcinoma, mastectomy"
" Exploratory laparotomy, radical hysterectomy, bilateral ovarian transposition, pelvic and obturator lymphadenectomy.", Obstetrics / Gynecology, Radical Hysterectomy ,"PREOPERATIVE DIAGNOSIS:,  Cervical adenocarcinoma, stage I.,POSTOPERATIVE DIAGNOSIS: , Cervical adenocarcinoma, stage I.,OPERATION PERFORMED:,  Exploratory laparotomy, radical hysterectomy, bilateral ovarian transposition, pelvic and obturator lymphadenectomy.,ANESTHESIA: , General, endotracheal tube.,SPECIMENS: , Uterus with attached parametrium and upper vagina, right and left pelvic and obturator lymph nodes.,INDICATIONS FOR PROCEDURE:,  The patient recently underwent a cone biopsy at which time invasive adenocarcinoma of the cervix was noted.  She was advised regarding treatment options including radical hysterectomy versus radiation and the former was recommended. ,FINDINGS: , During the examination under anesthesia, the cervix was noted to be healing well from recent cone biopsy and no nodularity was noted in the supporting ligaments.  During the exploratory laparotomy, there was no evidence of disease extension into the broad ligament or bladder flap.  There was no evidence of intraperitoneal spread or lymphadenopathy.  ,OPERATIVE PROCEDURE:  ,The patient was brought to the Operating Room with an IV in place.  Anesthetic was administered after which she was examined under anesthesia.  The vagina was then prepped and a Foley catheter was placed.  She was prepped and draped.  A Pfannenstiel incision was made three centimeters above the symphysis pubis.  The peritoneum was entered and the abdomen was explored with findings as noted.  The Bookwalter retractor was placed, and bowel was packed.  Clamps were placed on the broad ligament for traction.  The retroperitoneum was opened by incising lateral and parallel to the infundibulopelvic ligaments.  The round ligaments were isolated, divided and ligated.  The peritoneum overlying the vesicouterine fold was incised, and the bladder was mobilized using sharp dissection.  The pararectal and paravesical spaces were opened, and the broad ligament was palpated with no evidence of suspicious findings or disease extension.  The utero-ovarian ligaments were then isolated, divided and doubly ligated.  Tubes and ovaries were mobilized.  The ureters were dissected free from the medial leaf of the peritoneum.  When the crossover of the uterine artery was reached, and the artery was isolated at its origin, divided and ligated.  The uterine artery pedicle was dissected anteriorly over the ureter.  The ureter was tunneled through the broad ligament using right angle clamps for tunneling after which each pedicle was divided and ligated.  This was continued until the insertion point of the ureter into the bladder trigone.  The peritoneum across the cul-de-sac was divided, and the rectovaginal space was opened.  Clamps were placed on the uterosacral ligaments at their point of origin.  Tissues were divided and suture ligated.  Clamps were placed on the paravaginal tissues, which were then divided, and suture ligated.  The vagina was then clamped and divided at the junction between the middle and upper third.  The vaginal vault was closed with interrupted figure-of-eight stitches.  Excellent hemostasis was noted.,Retractors were repositioned in the retroperitoneum for the lymphadenectomy.  The borders of dissection included the bifurcation of the common iliac artery superiorly, the crossover of the deep circumflex iliac vein over the external iliac artery inferiorly, the psoas muscle laterally and the anterior division of the hypogastric artery medially.  The obturator nerves were carefully isolated and preserved bilaterally and served as the posterior border of dissection.  Ligaclips were applied where necessary.  After removal of the lymph node specimens, the pelvis was irrigated.  The ovaries were transposed above the pelvic brim using running stitches.  Packs and retractors were removed, and peritoneum was closed with a running stitch.  Subcutaneous tissues were irrigated, and fascia was closed with a running mass stitch using delayed absorbable suture.  Subcutaneous adipose was irrigated, and Scarpa's fascia was closed with a running stitch.  Skin was closed with a running subcuticular stitch.  Final sponge, needle, and instrument counts were correct at the completion of the procedure.  The patient was awakened from the anesthetic and taken to the Post Anesthesia Care Unit in stable condition.","obstetrics / gynecology, cervical adenocarcinoma, radical hysterectomy, exploratory laparotomy, bilateral ovarian transposition, lymphadenectomy, parametrium, cervix, pelvic and obturator lymphadenectomy, pelvic and obturator, obturator lymphadenectomy, laparotomy, ovarian, adenocarcinoma, radical, hysterectomy, pelvic, obturator, peritoneum, nodes, ligaments"
" A white female who presents for complete physical, Pap and breast exam.", Obstetrics / Gynecology, Physical Exam and Pap -2 ,"SUBJECTIVE:,  The patient is a 68-year-old white female who presents for complete physical, Pap and breast exam.  Her last Pap smear was 05/02/2002.  Her only complaint is that she has had some occasional episodes of some midchest pain that seems to go to her back, usually occurs at rest.  Has awakened her at night on occasion and only last about 15 to 20 minutes.  Denies nausea, vomiting, diaphoresis or shortness of breath with it.  This has not happened in almost two months.  She had a normal EKG one year ago.  Otherwise, has been doing quite well.  Did quite well with her foot surgery with Dr. Clayton.,PAST MEDICAL HISTORY:,  Reactive airway disease; rheumatoid arthritis, recent surgery on her hands and feet; gravida 4, para 5, with one set of twins, all vaginal deliveries; iron deficiency anemia; osteoporosis; and hypothyroidism.,MEDICATIONS:,  Methotrexate 2.5 mg five weekly, Fosamax 70 mg weekly, folic acid daily, amitriptyline 15 mg daily, Synthroid 0.088 mg daily, calcium two in the morning and two at noon, multivitamin daily, baby aspirin daily and Colace one to three b.i.d.,ALLERGIES:,  None.,SOCIAL HISTORY:,  She is married.  Denies tobacco, alcohol and drug use.  She is not employed outside the home.,FAMILY HISTORY: , Unremarkable.,REVIEW OF SYSTEMS:,  HEENT, pulmonary, cardiovascular, GI, GU, musculoskeletal, neurologic, dermatologic, constitutional and psychiatric are all negative except for HPI.,OBJECTIVE:,Vital Signs:  Weight 146.  Blood pressure 100/64.  Pulse 80.  Respirations 16.  Temperature 97.7.,General:  She is a well-developed, well-nourished white female in no acute distress.,HEENT:  Grossly within normal limits.,Neck:  Supple.  No lymphadenopathy.  No thyromegaly.,Chest:  Clear to auscultation bilaterally.,Cardiovascular:  Regular rate and rhythm.,Abdomen:  Positive bowel sounds, soft and nontender.  No hepatosplenomegaly.,Breasts:  No nipple discharge.  No lumps or masses palpated.  No dimpling of the skin.  No axillary lymph nodes palpated.  Self-breast exam discussed and encouraged.,Pelvic:  Normal female genitalia.  Atrophic vaginal mucosa.  No cervical lesions.  No cervical motion tenderness.  No adnexal tenderness or masses palpated.,Rectal:  Normal sphincter tone.  No stool present in the vault.  No rectal masses palpated.,Extremities:  No cyanosis, clubbing or edema.  She does have obvious rheumatoid arthritis of her hands.,Neurologic:  Grossly intact.,ASSESSMENT/PLAN:,1.  Chest pain.  The patient will evaluate when it happens next; what she has been eating, what activities she has been performing.  She had normal ECG one year ago.  In fact this does not sound cardiac in nature.  We will not do further cardiac workup at this time.  Did discuss with her she may be having some GI reflux type symptoms.,2.  Hypothyroidism.  We will recheck TSH to make sure she is on the right amount of medication at this time, making adjustments as needed.,3.  Rheumatoid arthritis.  Continue her methotrexate as prescribed by Dr. Mortensen, and follow up with Dr. XYZ as needed.,4.  Osteoporosis.  It is time for her to have a repeat DEXA at this time and that will be scheduled.,5.  Health care maintenance, Pap smear was obtained today.  The patient will be scheduled for mammogram.",
" Preeclampsia, status post delivery with Cesarean section with uncontrolled blood pressure.  The patient is a 38-year-old female admitted following a delivery.  The patient had a cesarean section.  Following this, the patient was treated for her blood pressure.  She was sent home and she came back again apparently with uncontrolled blood pressure.", Obstetrics / Gynecology, Preeclampsia ,"REASON FOR CONSULTATION: , Management of blood pressure.,HISTORY OF PRESENT ILLNESS: , The patient is a 38-year-old female admitted following a delivery.  The patient had a cesarean section.  Following this, the patient was treated for her blood pressure.  She was sent home and she came back again apparently with uncontrolled blood pressure.  She is on multiple medications, unable to control the blood pressure.  From cardiac standpoint, the patient denies any symptoms of chest pain, or shortness of breath.  She complains of fatigue and tiredness.  The child had some congenital anomaly, was transferred to Hospital, where the child has had surgery.  The patient is in intensive care unit.,CORONARY RISK FACTORS:,  History of hypertension, history of gestational diabetes mellitus, nonsmoker, and cholesterol is normal.  No history of established coronary artery disease and family history noncontributory for coronary disease.,FAMILY HISTORY: , Nonsignificant.,SURGICAL HISTORY:  ,No major surgery except for C-section.,MEDICATIONS:,  Presently on Cardizem and metoprolol were discontinued.  Started on hydralazine 50 mg t.i.d., and labetalol 200 mg b.i.d., hydrochlorothiazide, and insulin supplementation.,ALLERGIES: , None.,PERSONAL HISTORY: , Nonsmoker.  Does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY:,  Hypertension, gestational diabetes mellitus, pre-eclampsia, this is her third child with one miscarriage.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No history of fever, rigors, or chills.,HEENT:  No history of cataract, blurry vision, or glaucoma.,CARDIOVASCULAR:  No congestive heart.  No arrhythmia.,RESPIRATORY:  No history of pneumonia or valley fever.,GASTROINTESTINAL:  No epigastric discomfort, hematemesis, or melena.,UROLOGIC:  No frequency or urgency.,MUSCULOSKELETAL:  No arthritis or muscle weakness.,SKIN:  Nonsignificant.,NEUROLOGICAL:  No TIA.  No CVA.  No seizure disorder.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 86, blood pressure 175/86, afebrile, and respiratory rate 16 per minute.,HEENT:  Atraumatic and normocephalic.,NECK:  Neck veins are flat.,LUNGS:  Clear.,HEART:  S1 and S2 regular.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema.  Pulses palpable.,LABORATORY DATA: , EKG shows sinus tachycardia with nonspecific ST-T changes.  Labs were noted.  BUN and creatinine within normal limits.,IMPRESSION:,1.  Preeclampsia, status post delivery with Cesarean section with uncontrolled blood pressure.,2.  No prior history of cardiac disease except for borderline gestational diabetes mellitus.,RECOMMENDATIONS:,1.  We will get an echocardiogram for assessment left ventricular function.,2.  The patient will start on labetalol and hydralazine to see how see fairs.,3.  Based on response to medication, we will make further adjustments.  Discussed with the patient regarding plan of care, fully understands and consents for the same.  All the questions answered in detail.",
" Missed abortion.  Suction, dilation, and curettage.", Obstetrics / Gynecology," Suction, Dilation, & Curettage ","PREOPERATIVE DIAGNOSIS: , Missed abortion.,POSTOPERATIVE DIAGNOSIS:  ,Missed abortion.,PROCEDURE PERFORMED: , Suction, dilation, and curettage.,ANESTHESIA: , Spinal.,ESTIMATED BLOOD LOSS:,  50 mL.,COMPLICATIONS: , None.,FINDINGS: , Products of conception consistent with a 6-week intrauterine pregnancy.,INDICATIONS: , The patient is a 28-year-old gravida 4, para 3 female at 13 weeks by her last menstrual period and 6 weeks by an ultrasound today in the emergency room who presents with heavy bleeding starting today.  A workup done in the emergency room revealed a beta-quant level of 1931 and an ultrasound showing an intrauterine pregnancy with a crown-rump length consistent with a 6-week and 2-day pregnancy.  No heart tones were visible.  On examination in the emergency room, a moderate amount of bleeding was noted.,Additionally, the cervix was noted to be 1 cm dilated.  These findings were discussed with the patient and options including surgical management via dilation and curettage versus management with misoprostol versus expected management were discussed with the patient.  After discussion of these options, the patient opted for a suction, dilation, and curettage.  The patient was described to the patient in detail including risks of infection, bleeding, injury to surrounding organs including risk of perforation.  Informed consent was obtained prior to proceeding with the procedure.,PROCEDURE NOTE:  ,The patient was taken to the operating room where spinal anesthesia was administered without difficulty.  The patient was prepped and draped in usual sterile fashion in lithotomy position.  A weighted speculum was placed.  The anterior lip of the cervix was grasped with a single tooth tenaculum.  At this time, a 7-mm suction curettage was advanced into the uterine cavity without difficulty and was used to suction contents of the uterus.  Following removal of the products of conception, a sharp curette was advanced into the uterine cavity and was used to scrape the four walls of the uterus until a gritty texture was noted.  At this time, the suction curette was advanced one additional time to suction any remaining products.  All instruments were removed.  Hemostasis was visualized.  The patient was stable at the completion of the procedure.  Sponge, lap, and instrument counts were correct.","obstetrics / gynecology, missed abortion, intrauterine pregnancy, dilation, curettage, suction, intrauterine"
" Pelvic laparotomy, lysis of pelvic adhesions, and left salpingooophorectomy with insertion of Pain-Buster Pain Management System.", Obstetrics / Gynecology, Pelvic Laparotomy ,"PREOPERATIVE DIAGNOSIS: , Large left adnexal mass, 8 cm in diameter.,POSTOPERATIVE DIAGNOSIS: , Pelvic adhesions, 6 cm ovarian cyst.,PROCEDURES PERFORMED:  ,1.  Pelvic laparotomy.,2.  Lysis of pelvic adhesions.,3.  Left salpingooophorectomy with insertion of Pain-Buster Pain Management System by Dr. X.,GROSS FINDINGS:  ,There was a transabdominal mass palpable in the lower left quadrant.  An ultrasound suggestive with a mass of 8 cm, did not respond to suppression with norethindrone acetate and on repeat ultrasound following the medical treatment, the ovarian neoplasm persisted and did not decreased in size.,PROCEDURE:  ,Under general anesthesia, the patient was placed in lithotomy position, prepped and draped.  A low transverse incision was made down to and through to the rectus sheath.  The rectus sheath was put laterally.  The inferior epigastric arteries were identified bilaterally, doubly clamped and tied with #0 Vicryl sutures.  The rectus muscle was then split transversally and the peritoneum was split transversally as well.  The left adnexal mass was identified and large bowel was attached to the mass and Dr. Zuba from General Surgery dissected the large bowel adhesions and separated them from the adnexal mass.  The ureter was then traced and found to be free of the mass and free of the infundibulopelvic ligament.  The infundibulopelvic ligament was isolated, entered via blunt dissection.  A #0 Vicryl suture was put into place, doubly clamped with curved Heaney clamps, cut with curved Mayo scissors and #0 Vicryl fixation suture put into place.  Curved Heaney clamps were then used to remove the remaining portion of the ovary from its attachment to the uterus and then #0 Vicryl suture was put into place.  Pathology was called to evaluate the mass for potential malignancy and the pathology's verbal report at the time of surgery was that this was a benign lesion.  Irrigation was used.  Minimal blood loss at the time of surgery was noted.  Sigmoid colon was inspected in place in physiologic position of the cul-de-sac as well as small bowel omentum.  Instrument, needle, and sponge counts were called for and found to be correct.  The peritoneum was closed with #0 Vicryl continuous running locking suture.  The rectus sheath was closed with #0 Vicryl continuous running locking suture.  A DonJoy Pain-Buster Pain Management System was placed through the skin into the subcutaneous space and the skin was closed with staples.  Final instrument needle counts were called for and found to be correct.  The patient tolerated the procedure well with minimal blood loss and transferred to recovery area in satisfactory condition.","obstetrics / gynecology, lysis of pelvic adhesions, salpingooophorectomy, pain-buster pain management system, adnexal mass, pelvic laparotomy, pelvic adhesions, rectus sheath, vicryl sutures, adhesions, pelvic"
 A sample note on pre-eclampsia & eclampsia., Obstetrics / Gynecology, Pre-Eclampsia & Eclampsia ,"PRE-ECLAMPSIA, is a very serious condition unique to pregnancy in which blood pressure, the kidneys and the central nervous system are compromised.  It usually occurs from the 20th week of pregnancy to 7 days postpartum.  The cause is unknown.  It is also known as pregnancy-induced hypertension or toxemia of pregnancy.,ECLAMPSIA, is the end-stage of the pre-eclampsia process.  The vast majority of women who develop pre-eclampsia are pregnant with their first child and are towards the end of their child-bearing years.  There are identifiable risk factors for developing pre-eclampsia:  family history of pre-eclampsia, previous pregnancy with pre-eclampsia, multiple gestation, and a hydatiform mole (an intrauterine growth that mimics pregnancy).  A chronic high blood pressure and underlying blood vessel disease increases the risk.  Pre-eclampsia ranges from mild to severe to eclampsia as the end-stage.  Untreated pre-eclampsia can result in a stroke, fluid-build up around the lungs, kidney failure, death of baby and death of mother.,SIGNS AND SYMPTOMS:,MILD PRE-ECLAMPSIA:,*  Significant blood pressure increase even if you are still within the normal blood pressure limits.,*  Swelling in the face, hands and feet which worsens in the a.m.,*  Gaining more than a pound a week, especially in the last trimester.,*  Routine prenatal checkup reveals protein in the urine.,*  Seizures are possible.,SEVERE PRE-ECLAMPSIA:,*  More blood pressure increase.,*  Further swelling in face, hands and feet.,*  Visual disturbances.,*  Headache.,*  Irritability.,*  Abdominal pain.,*  Tiredness.,*  Decreased urination.,*  Seizures possible.,*  Nausea and vomiting.,ECLAMPSIA:,*  Symptoms worsen.,*  Seizures.,*  Muscle twitches.,*  Coma.,TREATMENT:,*  Diagnosis - blood tests, urinalysis, blood pressure monitoring.,*  Mild preeclampsia can be treated at home.  Severe symptoms require hospitalization and possible early delivery of the baby, often by cesarean section.,*  Daily weighing.,*  Daily monitoring for protein in urine.,*  Medications to lower blood pressure if preeclampsia is severe.,*  Magnesium sulfate or other anti-seizure drugs may be necessary to prevent seizures.,*  Get lots of rest! Lay on your left side to help circulation.,*  Follow any dietary advice given by your doctor.,*  Get regular prenatal checkups! Eat a nutritious diet and take your vitamin supplements.,*  Never take any medications that are not prescribed or recommended by your physician.,*  Call the office if your headaches become severe, you have visual disturbances or if you gain more than 3 pounds in 24 hours.,RESTRICTING CAFFEINE:,You should reduce your intake of caffeine by cutting back on coffee and other caffeinated beverages like soda.  In addition, you should avoid chocolate that also contains caffeine.,RESTRICTING SALT:,You are to restrict your salt intake by reducing or eliminating table salt from your meals and avoiding foods that are high in salt concentration.  For more information about which foods are high in salt, read the label of any foods you intend to consume and look for sodium content.",
 Consultation for an ASCUS Pap smear., Obstetrics / Gynecology, OB/GYN Consultation - 3 ,"Pap smear in November 2006 showed atypical squamous cells of undetermined significance.  She has a history of an abnormal Pap smear.  At that time, she was diagnosed with CIN 3 as well as vulvar intraepithelial neoplasia.  She underwent a cone biopsy that per her report was negative for any pathology.  She had no vulvar treatment at that time.  Since that time, she has had normal Pap smears.  She denies abnormal vaginal bleeding, discharge, or pain.  She uses Yaz for birth control.  She reports one sexual partner since 1994 and she is a nonsmoker.,She states that she has a tendency to have yeast infections and bacterial vaginosis.  She is also being evaluated for a possible interstitial cystitis because she gets frequent urinary tract infections.  She had a normal mammogram done in August 2006 and a history of perirectal condyloma that have been treated by Dr. B.  She also has a history of chlamydia when she was in college.,PAST MEDICAL HX: , Depression.,PAST SURGICAL HX: , None.,MEDICATIONS: , Lexapro 10 mg a day and Yaz.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,OB HX: , Normal spontaneous vaginal delivery at term in 2001 and 2004, Abc weighed 8 pounds 7 ounces and Xyz weighed 10 pounds 5 ounces.,FAMILY HX:  ,Maternal grandfather who had a MI which she reports is secondary to tobacco and alcohol use.  He currently has metastatic melanoma, mother with hypertension and depression, father with alcoholism.,SOCIAL HX:,  She is a public relations consultant.  She is a nonsmoker, drinks infrequent alcohol and does not use drugs.  She enjoys horseback riding and teaches jumping.,PE: , VITALS: Height: 5 feet 6 inches.  Weight: 139 lb.  BMI: 22.4.  Blood Pressure: 102/58.  GENERAL: She is well-developed and well-nourished with normal habitus and no deformities.  She is alert and oriented to time, place, and person and her mood and affect is normal.  NECK: Without thyromegaly or lymphadenopathy.  LUNGS: Clear to auscultation bilaterally.  HEART: Regular rate and rhythm without murmurs.  BREASTS: Deferred.  ABDOMEN: Soft, nontender, and nondistended.  There is no organomegaly or lymphadenopathy.  PELVIC: Normal external female genitalia.  Vulva, vagina, and urethra, within normal limits.  Cervix is status post cone biopsy; however, the transformation zone grossly appears normal and cervical discharge is clear and normal in appearance.  GC and chlamydia cultures as well as a repeat Pap smear were done.,Colposcopy is then performed without and with acetic acid.  This shows an entirely normal transformation zone, so no biopsies are taken.  An endocervical curettage is then performed with Cytobrush and curette and sent to pathology.  Colposcopy of the vulva is then performed again with acetic acid.  There is a thin strip of acetowhite epithelium located transversely on the clitoral hood that is less than a centimeter in diameter.  There are absolutely no abnormal vessels within this area.  The vulvar colposcopy is completely within normal limits.,A/P: , ASCUS Pap smear with history of a cone biopsy in 1993 and normal followup.,We will check the results of the Pap smear, in addition we have ordered DNA testing for high-risk HPV.  We will check the results of the ECC.  She will return in two weeks for test results.  If these are normal, she will need two normal Pap smears six months apart, and I think followup colposcopy for the vulvar changes.","obstetrics / gynecology, lmp, ascus, pap smear, abnormal pap smear, atypical, bacterial vaginosis, chlamydia, cone biopsy, infection, interstitial cystitis, intraepithelial, mammogram, neoplasia, perirectal condyloma, squamous, vaginal bleeding, vulvar, yeast infection, pap smears, pap, ob/gyn, colposcopy, smear,"
" Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.", Obstetrics / Gynecology, Pathology - Ovarian Cyst ,"GROSS DESCRIPTION: ,  Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.  It consists of a smooth-walled, clear fluid filled cyst measuring 13x12x7 cm and weighing 1351 grams with fluid.  Both surfaces of the wall are pink-tan, smooth and grossly unremarkable.  No firm or thick areas or papillary structures are noted on the cyst wall externally or internally.  After removal the fluid, the cyst weight 68 grams.  The fluid is transparent and slightly mucoid.  A frozen section is submitted.,DIAGNOSIS: , Benign cystic ovary.,","obstetrics / gynecology, right ovarian cyst, specimen, ovarian cyst, frozen section, ovarian, frozen, sectionNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Pelvic Pain and vaginal discharge, Obstetrics / Gynecology, OB/GYN Consultation - 4 ,"CHIEF COMPLAINT - REASON FOR VISIT: ,Pelvic Pain and vaginal discharge.,ABNORMAL PAP HISTORY:, Date of abnormal pap:  1998. Findings: High grade squamous intraepithelial lesions. Previous colposcopic exam and biopsies showed mild dysplasia or CIN 1. Patient is sexually active and has had 1 partner. There is no history of STD’s.,PELVIC PAIN HISTORY:, The patient complains of a gradual onset of pelvic pain 1 year ago and states condition is recurrent. Location of pain is left lower quadrant. Severity is moderately severe, intermittent and lasts for 2 hours. Quality of pain is crampy, sharp and variable.  Pain requires NSAIDs. Menstrual quality is light, flow lasts for 7 days and interval lasts for 28 days. There was no radiation of pain.,VAGINITIS HISTORY:, Symptoms have lasted for 2 weeks and persistent.  Discharge appears thin, white and with odor. Denies any itching sensation. Denies irritation. The patient denies any self treatment.,PERSONAL / SOCIAL HISTORY:, Tobacco history: Smoke’s 1 pack of cigarettes per day.  Denies the past history of alcohol. Denies past / present illegal drug use of any kind. Marital Status: Married.,PAST MEDICAL HISTORY:, Negative.,FAMILY MEDICAL HISTORY:, Negative.,ALLERGIES:, No known drug allergies/Intolerances.,CURRENT MEDICATIONS:, There are no current medications.,PAST SURGICAL HISTORY:, D & C.  1993,REVIEW OF SYSTEMS:,Gastrointestinal: The patient has no history of gastrointestinal problems and denies any present problems.,Genitourinary: Patient denies any genitourinary problems.,Gynecological: Refer to current history.,Pulmonary: Denies cough, dyspnea, tachypnea, hemoptysis.,GU: Denies frequency, nocturia and hematuria.,Neuro: Denies any problems, no seizures, no numbness, no dizziness.,PHYSICAL EXAMINATION:,Vital Signs: Weight:  104. BP:  100/70.,Chest: Lungs have equal bilateral expansion and are clear to percussion and auscultation.,Cardiovascular / Heart: Regular heart rate and rhythm without murmur or gallop.,Breast: No palpable masses.  No dimpling or retraction. No discharge. No axillary lymphadenopathy.,Abdomen: Tenderness is located in the left upper quadrant. Tenderness is mild. Bowel sounds are normal. No masses palpated.,Gynecologic: Inspection reveals the external genitalia to be normal anatomically. Cervix appears inflamed, bloody discharge and without aceto-white areas. Vagina appears normal. Vaginal discharge was white and watery.  Uterus is normal anteverted. The uterus is normal size and shape, tender to movement and movable. Bladder not tender. ,Rectal: No additional findings.,LAB / TESTS:, Hgb: 17.1 U/A: pH 6.0, spgr 1.025, trace protein, trace blood,IMPRESSION / DIAGNOSIS,1. Endometritis / Endomyometritis (615.9). ,2. Cervicitis - Endocervicitis (616.0). ,3. Pelvic Pain (625.9).,PLAN:, Pap smear done. Take metronidazole first then the Doxycycline. Return in three weeks for reevaluation.,MEDICATIONS PRESCRIBED: ,Metronidazole 500 mg #14 1 BID for 7 days.  Doxycycline 100 mg #14 1 BID.",
 A white female presents for exam and Pap., Obstetrics / Gynecology, Physical Exam and Pap - 1 ,"SUBJECTIVE:,  This 45-year-old gravida 3, para 2, SAB 1 white female presents for exam and Pap.  Last Pap was a year ago and normal.  LMP was 08/29/2004.  Her cycles are usually regular, although that one came about a week early.  Her husband has had a vasectomy.  Overall, she is feeling well.,Health history form was reviewed.  There has been no change in her personal history.  She notes that a brother who was treated 12 years ago for a brain tumor has had a recurrence and had surgery again.  Social history is unchanged.,HEALTH HABITS: , She states that for a while she was really exercising regularly and eating lots of fruits and vegetables.  Right now, she is not doing nearly as well.  She has perhaps two dairy servings daily, trying to cut down.  She is not exercising at all and fruit and vegetable intake varies.  She is a nonsmoker.  Last cholesterol was in 2003 and was normal.  She had a mammogram which was normal recently.  She is current on her tetanus update.,REVIEW OF SYSTEMS:,HEENT:  She feels as though she may have some allergies at night.  Most of her symptoms occur then, not during the day.  She will wake up with some congestion, sneezing, and then rhinorrhea.  Currently, she uses Tylenol Sinus.  Today, her symptoms are much better.  We did have rain this morning.,Respiratory and CV:  Negative.,GI:  She tends to have a little gas which is worse when she is eating more fruits and vegetables.  She had been somewhat constipated but that is better.,GU:  Negative.,Dermatologic:  She noticed an area of irritation on her right third finger on the ulnar side at the PIP joint.  It was very sensitive to water.  It seems to be slowly improving.,OBJECTIVE:,Vital Signs:  Her weight was 154 pounds, which is down 2 pounds.  Blood pressure 104/66.,General:  She is a well-developed, well-nourished, pleasant white female in no distress.,Neck:  Supple without adenopathy.  No thyromegaly or nodules palpable.,Lungs:  Clear to A&P.,Heart:  Regular rate and rhythm without murmurs.,Breasts:  Symmetrical without masses, nipple, or skin retraction, discharge, or axillary adenopathy.,Abdomen:  Soft without organomegaly, masses, or tenderness.,Pelvic:  Reveals no external lesions.  The cervix is parous.  Pap smear done.  Uterus is anteverted and normal in size, shape, and consistency, and nontender.  No adnexal enlargement.,Extremities:  Examination of her right third finger shows an area of eczematous dermatitis approximately 2 cm in length on the ulnar side.,ASSESSMENT:,1.  Normal GYN exam.,2.  Rhinitis, primarily in the mornings.  Vasomotor versus allergic.,3.  Eczematous dermatitis on right third finger.,PLAN:,1.  Discussed vasomotor rhinitis.  I suggested she try Ayr Nasal saline gel.  Another option would be a steroid spray and a sample of Nasonex is given to use two sprays in each nostril daily.,2.  Exam with Pap annually.,3.  Hydrocortisone cream to be applied to the area of eczematous dermatitis.,4.  Discussed nutrition and exercise.  I recommended at least five fruits and vegetables daily, no more than three dairy servings daily, and regular exercise at least three times a week.",
 Initial obstetrical examination - Normal first pregnancy.  Inadequate naternal nutrition., Obstetrics / Gynecology, OB/GYN - H&P ,"CHIEF COMPLAINT,:  This 32 year-old female presents today for an initial obstetrical examination.  Home pregnancy test was positive.,The patient indicates fetal activity is not yet detected (due to early stage of pregnancy).  LMP:  02/13/2002 EDD:  11/20/2002 GW:  8.0 weeks.  Patient has been trying to conceive for 6 months.,Menses:  Onset:  12 years old.  Interval:  24-26 days.  Duration:  4-6 days.  Flow:  moderate.  Complications:  PMS - mild.,Last Pap smear taken on 11/2/2001.  Contraception:  Patient is currently using none.,ALLERGIES:,  Patient admits allergies to venom - bee/wasp resulting in difficulty breathing, severe rash, pet dander resulting in nasal stuffiness.  Medication History:  None.,PAST MEDICAL HISTORY:,  Past medical history is unremarkable.  Past Surgical History:  Patient admits past surgical history of tonsillectomy in 1980.  Social History:  Patient admits alcohol use Drinking is described as social, Patient denies illegal drug use, Patient denies STD history, Patient denies tobacco use.,FAMILY HISTORY:,  Patient admits a family history of cancer of breast associated with mother.,REVIEW OF SYSTEMS:,Neurological: (+) unremarkable.,Respiratory: (+) difficulty sleeping, (-) breathing difficulties, respiratory symptoms.,Psychiatric: (+) anxious feelings.,Cardiovascular: (-) cardiovascular problems or chest symptoms.,Genitourinary: (-) decreased libido, (-) vaginal dryness, (-) vaginal bleeding.  Diet is high in empty calories, high in fats and low in fiber.,PHYSICAL EXAM:,  BP Standing:  126/84 Resp:  22 HR:  78 Temp:  99.1 Height:  5 ft.  6 in.  Weight:  132 lbs.,Pre-Gravid Weight is 125 lbs.,Patient is a 32 year old female who appears pleasant, in no apparent distress, her given age, well developed,,well nourished and with good attention to hygiene and body habitus.,Oriented to person, place and time.,Mood and affect normal and appropriate to situation.,HEENT:Head & Face:  Examination of head and face is unremarkable.,Skin:  No skin rash, subcutaneous nodules, lesions or ulcers observed.  No edema observed.,Cardiovascular:  Heart auscultation reveals no murmurs, gallop, rubs or clicks.,Respiratory:  Lungs CTA.,Breast:  Chest (Breasts):  Breast inspection and palpation shows no abnormal findings.,Abdomen:  Abdomen soft, nontender, bowel sounds present x 4 without palpable masses.,Genitourinary:  External genitalia are normal in appearance.  Examination of urethra shows no abnormalities.  Examination of vaginal vault reveals no abnormalities.  Cervix shows no pathology.  Uterine portion of bimanual exam reveals contour normal, shape regular and size normal.  Adnexa and parametria show no masses, tenderness, organomegaly or nodularity.  Examination of anus and perineum shows no abnormalities.,TEST RESULTS: , Urine pregnancy test:  positive. CBC results within normal limits.  Blood type:  O positive.  Rh:  positive.  FBS:  88 mg/dl.,IMPRESSION:,  Pregnancy, normal first.  Maternal nutrition is inadequate for protein and poor and high in empty calories and junk foods and sweets.,PLAN:,  Pap smear submitted for manual screening.  Ordered CBC.  Ordered blood type.  Ordered hemoglobin.  Ordered Rh.,Ordered fasting blood glucose.,COUNSELING:,  Counseling was given regarding adverse effects of alcohol, physical activity and sexual activity.  Educational supplies dispensed to patient.,Return to clinic in 4 week (s).,PRESCRIPTIONS:,  NatalCare Plus Dosage:  Prenatal Multivitamins tablet Sig:  QD Dispense:  60 Refills:  4 Allow Generic:  Yes,PATIENT INSTRUCTIONS:,  Patient received written information regarding pre-eclampsia and eclampsia.  Patient was instructed to restrict activity.  Patient instructed to limit caffeine use.  Patient instructed to limit salt intake.",
" Nonpalpable neoplasm, right breast.  Needle localized wide excision of nonpalpable neoplasm, right breast.", Obstetrics / Gynecology, Needle Localized Excision - Breast Neoplasm ,"PREOPERATIVE DIAGNOSIS: , Nonpalpable neoplasm, right breast.,POSTOPERATIVE DIAGNOSIS: , Deferred for Pathology.,PROCEDURE PERFORMED:  ,Needle localized wide excision of nonpalpable neoplasm, right breast.,SPECIMEN: , Mammography.,GROSS FINDINGS:  ,This 53-year-old Caucasian female who had a nonpalpable neoplasm detected by mammography in the right breast.  After excision of neoplasm, there was a separate 1 x 2 cm nodule palpated within the cavity.  This too was excised.,OPERATIVE PROCEDURE:  ,The patient was taken to the operating room, placed in supine position in the operating table.  Intravenous sedation was administered by the Anesthesia Department.  The Kopans wire was trimmed to an appropriate length.  The patient was sterilely prepped and draped in the usual manner.  Local anesthetic consisting of 1% lidocaine and 0.5% Marcaine was injected into the proposed line of incision.  A curvilinear circumareolar incision was then made with a #15 scalpel blade close to the wire.  The wire was stabilized and brought to protrude through the incision.  Skin flaps were then generated with electrocautery.  A generous core tissue was grasped with Allis forceps and excised with electrocautery.  Prior to complete excision, the superior margin was marked with a #2-0 Vicryl suture, which was tied and cut short.  The lateral margin was marked with a #2-0 Vicryl suture, which was tied and cut along.  The posterior margin was marked with a #2-0 Polydek suture, which was tied and cut.,The specimen was then completely excised and sent off the operative field as specimen where specimen mammography confirmed the excision of the mammographically detected neoplasm.  On palpation of the cavity, there was felt to be a second nodule further medial and this was grasped with an Allis forceps and excised with electrocautery and sent off the field as a separate specimen.  Hemostasis was obtained with electrocautery.  Good hemostasis was obtained.  The incision was closed in two layers.  The first layer consisting of a subcuticular inverted interrupted sutures of #4-0 undyed Vicryl.  The second layer consisted of Steri-Strips on the epidermis.  A pressure dressing of fluff, 4x4s, ABDs, and Elastic bandage was applied.  The patient tolerated the surgery well.","obstetrics / gynecology, neoplasm, needle localized wide excision, needle localized, nonpalpable neoplasm, needle, incision, electrocautery, excision, breast "
" Female referred for evaluation of an abnormal colposcopy, low-grade Pap with suspicious high-grade features.", Obstetrics / Gynecology, OB/GYN Consultation - 1 ,"PAST MEDICAL HX: , Significant for asthma, pneumonia, and depression.,PAST SURGICAL HX: , None.,MEDICATIONS:,  Prozac 20 mg q.d.  She desires to be on the NuvaRing.,ALLERGIES:,  Lactose intolerance.,SOCIAL HX: , She denies smoking or alcohol or drug use.,PE:,  VITALS: Stable.  Weight: 114 lb.  Height: 5 feet 2 inches.  GENERAL: Well-developed, well-nourished female in no apparent distress.  HEENT: Within normal limits. NECK: Supple without thyromegaly.  HEART: Regular rate and rhythm.  LUNGS: Clear to auscultation.  ABDOMEN: Soft and nontender.  There is no rebound or guarding.  No palpable masses and no peritoneal signs.  EXTREMITIES: Within normal limits.  SKIN: Warm and dry.  GU: External genitalia is without lesion.  Vaginal is clean without discharge.  Cervix appears normal; however, a colposcopy was performed using acetic acid, which showed a thick acetowhite ring around the cervical os and extending into the canal.  BIMANUAL: Reveals significant cervical motion tenderness and fundal tenderness.  She had no tenderness in her adnexa.  There are no palpable masses.,A:,  Although unlikely based on the patient's exam and pain, I have to consider subclinical pelvic inflammatory disease.  GC and chlamydia was sent and I treated her prophylactically with Rocephin 250 mg and azithromycin 1000 mg.  Repeat biopsies were not performed based on her colposcopy as well as her previous Pap and colposcopy by Dr. A.  A LEEP is a reasonable approach even in this 16-year-old.,P:,  We will schedule LEEP in the near future.  Even though she has already been exposed HPV Gardasil would still be beneficial in this patient to help prevent recurrence of low-grade lesions as well as high-grade lesions.  Now, we have her given her first shot.","obstetrics / gynecology, gravida, ecc, external genitalia, hpv, leep, pap, acetowhite, biopsies, blood with urination, cervical os, colposcopy, intraepithelial, right lower quadrant, squamous, suspicious, vaginal discharge, low grade pap, low grade,"
 Consultation because of irregular periods and ovarian cyst., Obstetrics / Gynecology, OB/GYN Consultation - 2 ,"She started her periods at age 13.  She is complaining of a three-month history of lower abdominal pain for which she has been to the emergency room twice.  She describes the pain as bilateral, intermittent, and non-radiating.  It decreases slightly when she eats and increases with activity.  She states the pain when it comes can last for half-a-day.  It is not associated with movement, but occasionally the pain was so bad that it was associated with vomiting.  She has tried LactAid, which initially helped, but then the pain returned.  She has tried changing her diet and Pepcid AC.  She was seen at XYZ where blood work was done.  At that time, she had a normal white count and a normal H&H.  She was given muscle relaxants, which did not work.,Approximately two weeks ago, she was seen in the emergency room at XYZ where a pelvic ultrasound was done.  This showed a 1.9 x 1.4-cm cyst on the right with no free fluid.  The left ovary and uterus appeared normal.  Two days later, the pain resolved and she has not had a recurrence.  She denies constipation and diarrhea.  She has had some hot flashes, but has not taken her temperature.,In addition, she states that her periods have been very irregular coming between four and six weeks.  They are associated with cramping which she is not happy about.,She has never had a pelvic exam.  She states she is not sexually active and declined having her mother leave the room, so she was not questioned regarding this without her mother present.  She is very interested in not having pain with her periods and if this was a cyst that caused her pain, she is interested in starting birth control pills to prevent this from happening again.,PAST MEDICAL HX:  ,Pneumonia in 2002, depression diagnosed in 2005, and seizures as an infant.,PAST SURGICAL HX:  ,Plastic surgery on her ear after a dog bite in 1997.,MEDICATIONS:  ,Zoloft 50 mg a day and LactAid.,ALLERGIES:  ,NO KNOWN DRUG ALLERGIES.,SOCIAL HX: , She enjoys cooking and scrapbooking.  She does have a boyfriend; again she states she is not sexually active.  She also states that she exercises regularly, does not smoke cigarettes, use drugs, or drink alcohol.,FAMILY HX: , Significant for her maternal grandfather with adult-onset diabetes, a maternal grandmother with hypertension, mother with depression, and a father who died of colon cancer at 32 years of age.  She also has a paternal great grandfather who was diagnosed with colon cancer.,PE: , VITALS: Height: 5 feet 5 inches.  Weight: 190 lb.  Blood Pressure: 120/88.  GENERAL: She is well-developed, well-nourished with normal habitus and no deformities.  NECK: Without thyromegaly or lymphadenopathy.  LUNGS: Clear to auscultation bilaterally.  HEART: Regular rate and rhythm without murmurs.  ABDOMEN: Soft, nontender, and nondistended.  There is no organomegaly or lymphadenopathy.  PELVIC: Deferred.,A/P: , Abdominal pain, unclear etiology.  I expressed my doubt that her pain was secondary to this 1.9-cm ovarian cyst given the fact that there was no free fluid surrounding this.  However, given that she has irregular periods and they are painful for her, I think it is reasonable to start her on a low-dose birth control pill.  She has no personal or familial contraindications to start this.  She was given a prescription for Lo/Ovral, dispensed 30 with refill x 4.  She will come back in six weeks for blood pressure check as well as in six months to followup on her pain and her bleeding patterns.,If she should have the recurrence of her pain, I have advised her to call.","obstetrics / gynecology, irregular periods, lactaid, abdominal pain, birth control pills, cyst, ovarian cyst, ovaries, ovary, pelvic exam, sexually active, uterus, lymphadenopathy, pelvic, irregular, periods"
 Bilateral breast MRI with & without IV contrast., Obstetrics / Gynecology, MRI Breast - 1 ,"FINDINGS:,There are post biopsy changes seen in the retroareolar region, middle third aspect of the left breast at the post biopsy site.,There is abnormal enhancement seen in this location compatible with patient’s history of malignancy.,There is increased enhancement seen in the inferior aspect of the left breast at the 6:00 o’clock, N+5.5 cm position measuring 1.2 cm. Further work-up with ultrasound is indicated.,There are other multiple benign appearing enhancing masses seen in both the right and left breasts.,None of the remaining masses appear worrisome for malignancy based upon MRI criteria.,IMPRESSION:,  BIRADS CATEGORY M/5,There is a malignant appearing area of enhancement in the left breast which does correspond to the patient’s history of recent diagnosis of malignancy.,She has been scheduled to see a surgeon, as well as Medical Oncologist.,Dedicated ultrasonography of the inferior aspect of the left breast should be performed at the 6:00 o’clock, N+5.5 cm position for further evaluation of the mass. At that same time, ultrasonography of the remaining masses should also be performed.,Please note, however that the remaining masses have primarily benign features based upon MRI criteria. However, further evaluation with ultrasound should be performed.","obstetrics / gynecology, breast cancer, bilateral breast mri, bilateral breast, iv contrast, contrast, ultrasound, ultrasonography, malignancy, mri, benign, masses, breast"
 A very pleasant 66-year-old woman with recurrent metastatic ovarian cancer.  , Obstetrics / Gynecology, Metastatic Ovarian Cancer - Consult ,"REASON FOR CONSULTATION:,  Metastatic ovarian cancer.,HISTORY OF PRESENT ILLNESS: , Mrs. ABCD is a very nice 66-year-old woman who is followed in clinic by Dr. X for history of renal cell cancer, breast cancer, as well as ovarian cancer, which was initially diagnosed 10 years ago, but over the last several months has recurred and is now metastatic.  She last saw Dr. X in clinic towards the beginning of this month.  She has been receiving gemcitabine and carboplatin, and she receives three cycles of this with the last one being given on 12/15/08.  She was last seen in clinic on 12/22/08 by Dr. Y.  At that point, her white count was 0.9 with the hemoglobin of 10.3, hematocrit of 30%, and platelets of 81,000.  Her ANC was 0.5.  She was started on prophylactic Augmentin as well as Neupogen shots.  She has also had history of recurrent pleural effusions with the knee for thoracentesis.  She had two of these performed in November and the last one was done about a week ago.,Over the last 2 or 3 days, she states she has been getting more short of breath.  Her history is somewhat limited today as she is very tired and falls asleep readily.  Her history comes from herself but also from the review of the records.  Overall, her shortness of breath has been going on for the past few weeks related to her pleural effusions.  She was seen in the emergency room this time and on chest x-ray was found to have a new right-sided pulmonic consolidative infiltrate, which was felt to be possibly related to pneumonia.  She specifically denied any fevers or chills.  However, she was complaining of chest pain.  She states that the chest pain was located in the substernal area, described as aching, coming and going and associated with shortness of breath and cough.  When she did cough, it was nonproductive.  While in the emergency room on examination, her vital signs were stable except that she required 5 liters nasal cannula to maintain oxygen saturations.  An EKG was performed, which showed sinus rhythm without any evidence of Q waves or other ischemic changes.  The chest x-ray described above showed a right lower lobe infiltrate.  A V/Q scan was done, which showed a small mismatched defect in the left upper lobe and a mass defect in the right upper lobe.  The findings were compatible with an indeterminate study for a pulmonary embolism.  Apparently, an ultrasound of the lower extremities was done and was negative for DVT.  There was apparently still some concern that this might be pulmonary embolism and she was started on Lovenox.  There was also concern for pneumonia and she was started on Zosyn as well as vancomycin and admitted to the hospital.,At this point, we have been consulted to help follow along with this patient who is well known to our clinic.,PAST MEDICAL HISTORY,1.  Ovarian cancer - This was initially diagnosed about 10 years ago and treated with surgical resection including TAH and BSO.  This has recurred over the last couple of months with metastatic disease.,2.  History of breast cancer - She has been treated with bilateral mastectomy with the first one about 14 years and the second one about 5 years ago.  She has had no recurrent disease.,3.  Renal cell carcinoma - She is status post nephrectomy.,4.  Hypertension.,5.  Anxiety disorder.,6.  Chronic pain from neuropathy secondary to chemotherapy from breast cancer treatment.,7.  Ongoing tobacco use.,PAST SURGICAL HISTORY,1.  Recent and multiple thoracentesis as described above.,2.  Bilateral mastectomies.,3.  Multiple abdominal surgeries.,4.  Cholecystectomy.,5.  Remote right ankle fracture.,ALLERGIES:,  No known drug allergies.,MEDICATIONS: , At home,,1.  Atenolol 50 mg daily,2.  Ativan p.r.n.,3.  Clonidine 0.1 mg nightly.,4.  Compazine p.r.n.,5.  Dilaudid p.r.n.,6.  Gabapentin 300 mg p.o. t.i.d.,7.  K-Dur 20 mEq p.o. daily.,8.  Lasix unknown dose daily.,9.  Norvasc 5 mg daily.,10.  Zofran p.r.n.,SOCIAL HISTORY: , She smokes about 6-7 cigarettes per day and has done so for more than 50 years.  She quit smoking about 6 weeks ago.  She occasionally has alcohol.  She is married and has 3 children.  She lives at home with her husband.  She used to work as a unit clerk at XYZ Medical Center.,FAMILY HISTORY:,  Both her mother and father had a history of lung cancer and both were smokers.,REVIEW OF SYSTEMS: , GENERAL/CONSTITUTIONAL:  She has not had any fever, chills, night sweats, but has had fatigue and weight loss of unspecified amount.  HEENT:  She has not had trouble with headaches; mouth, jaw, or teeth pain; change in vision; double vision; or loss of hearing or ringing in her ears.  CHEST:  Per the HPI, she has had some increasing dyspnea, shortness of breath with exertion, cough, but no sputum production or hemoptysis.  CVS:  She has had the episodes of chest pains as described above but has not had, PND, orthopnea lower extremity swelling or palpitations.  GI:  No heartburn, odynophagia, dysphagia, nausea, vomiting, diarrhea, constipation, blood in her stool, and black tarry stools.  GU:  No dysuria, burning with urination, kidney stones, and difficulty voiding.  MUSCULOSKELETAL:  No new back pain, hip pain, rib pain, swollen joints, history of gout, or muscle weakness.  NEUROLOGIC:  She has been diffusely weak but no lateralizing loss of strength or feeling.  She has some chronic neuropathic pain and numbness as described above in the past medical history.  She is fatigued and tired today and falls asleep while talking but is easily arousable.  Some of this is related to her lack of sleep over the admission thus far.,PHYSICAL EXAMINATION,VITAL SIGNS:  Her T-max is 99.3.  Her pulse is 54, her respirations is 12, and blood pressure 118/61.,GENERAL:  Somewhat fatigued appearing but in no acute distress.,HEENT:  NC/AT.  Sclerae anicteric.  Conjunctiva clear.  Oropharynx is clear without any erythema, exudate, or discharge.,NECK:  Supple.  Nontender.  No elevated JVP.  No thyromegaly.  No thyroid nodules.,CHEST:  Clear to auscultation and percussion bilaterally with decreased breath sounds on the right.,CVS:  Regular rate and rhythm.  No murmurs, gallops or rubs.  Normal S1 and S2.  No S3 or S4.,ABDOMEN:  Soft, nontender, nondistended.  Normoactive bowel sounds.  No guarding or rebound.  No hepatosplenomegaly.  No masses.",
 Repeat low transverse cesarean section and bilateral tubal ligation (BTL).  Intrauterine pregnancy at term with previous cesarean section.  Desires permanent sterilization.  Macrosomia., Obstetrics / Gynecology, Low-Transverse C-Section & BTL ,"PREOPERATIVE DIAGNOSIS: , Intrauterine pregnancy at term with previous cesarean section.,SECONDARY DIAGNOSES,1.  Desires permanent sterilization.,2.  Macrosomia.,POSTOPERATIVE DIAGNOSES,1.  Desires permanent sterilization.,2.  Macrosomia.,3.  Status post repeat low transverse cesarean and bilateral tubal ligation.,PROCEDURES,1.  Repeat low transverse cesarean section.,2.  Bilateral tubal ligation (BTL).,ANESTHESIA: , Spinal.,FINDINGS:,  A viable female infant weighing 7 pounds 10 ounces, assigned Apgars of 9 and 9.  There was normal pelvic anatomy, normal tubes.  The placenta was normal in appearance with a three-vessel cord.,DESCRIPTION OF PROCEDURE:,  Patient was brought to the operating room with an IV running and a Foley catheter in place, satisfactory spinal anesthesia was administered following which a wedge was placed under the right hip.  The abdomen was prepped and draped in a sterile fashion.  A Pfannenstiel incision was made and carried sharply down to the level of fascia.  The fascia was incised transversely.  The fascia was dissected away from the underlying rectus muscles.  With sharp and blunt dissection, rectus muscles were divided in midline.  The perineum was entered bluntly.  The incision was carried vertically with scissors.  Transverse incision was made across the bladder peritoneum.  The bladder was dissected away from the underlying lower uterine segment.  Bladder retractor was placed to protect the bladder.  The lower uterine segment was entered sharply with a scalpel.  Incision was carried transversely with bandage scissors.  Clear amniotic fluids were encountered.  The infant was out of the pelvis and was in oblique vertex presentation.  The head was brought down into the incision and delivered easily as were the shoulders and body.  The mouth and oropharynx were suctioned vigorously.  The cord was clamped and cut.  The infant was passed off to the waiting pediatrician in satisfactory condition.  Cord bloods were taken.,Placenta was delivered spontaneously and found to be intact.  Uterus was explored and found to be empty.  Uterus was delivered through the abdominal incision and massaged vigorously.  Intravenous Pitocin was administered.  T clamps were placed about the margins of the uterine incision, which was closed primarily with a running locking stitch of 0 Vicryl with adequate hemostasis.  Secondary running locking stitch was placed for extra strength to the wound.  At this point, attention was diverted to the patient's tubes, a Babcock clamp grasped the isthmic portion of each tube and approximately 1-cm knuckle on either side was tied off with two lengths of 0 plain catgut.  Intervening knuckle was excised and passed off the field.  The proximal end of the tubal mucosa was cauterized.  Cul-de-sac and gutters were suctioned vigorously.  The uterus was returned to its proper anatomic position in the abdomen.  The fascia was closed with a simple running stitch of 0 PDS.,The skin was closed with running subcuticular of 4-0 Monocryl.  Uterus was expressed of its contents.  Patient was brought to the recovery room in satisfactory condition.  There were no complications.  There was 600 cc of blood loss.  All sponge, needle, and instrument counts were reported to be correct.,SPECIMEN: , Tubal segments.,DRAIN: , Foley catheter draining clear yellow urine.","obstetrics / gynecology, placenta, low transverse cesarean section, bilateral tubal ligation, permanent sterilization, cesarean section, intrauterine, btl, sterilization, macrosomia, uterine, "
 Lysis of pelvic adhesions.  The patient had an 8 cm left ovarian mass.   The mass was palpable on physical examination and was tender.  She was scheduled for an elective pelvic laparotomy with left salpingooophorectomy., Obstetrics / Gynecology, Lysis of Pelvic Adhesions ,"PREOPERATIVE DIAGNOSIS: , Multiple pelvic adhesions.,POSTOPERATIVE DIAGNOSIS: , Multiple pelvic adhesions.,PROCEDURE PERFORMED: ,Lysis of pelvic adhesions.,ANESTHESIA: , General with local.,SPECIMEN: , None.,COMPLICATIONS: , None.,HISTORY: , The patient is a 32-year-old female who had an 8 cm left ovarian mass, which was evaluated by Dr. X.  She had a ultrasound, which demonstrated the same.  The mass was palpable on physical examination and was tender.  She was scheduled for an elective pelvic laparotomy with left salpingooophorectomy.  During the surgery, there were multiple pelvic adhesions between the left ovarian cyst and the sigmoid colon.  These adhesions were taken down sharply with Metzenbaum scissors.,PROCEDURE: , A pelvic laparotomy had been performed by Dr. X.  Upon exploration of the abdomen, multiple pelvic adhesions were noted as previously stated.  A 6 cm left ovarian cyst was noted with adhesions to the sigmoid colon and mesentery.  These adhesions were taken down sharply with Metzenbaum scissors until the sigmoid colon was completely freed from the ovarian cyst.  The ureter had been identified and isolated prior to the adhesiolysis.  There was no evidence of bleeding.  The remainder of the case was performed by Dr. X and this will be found in a separate operative report.","obstetrics / gynecology, lysis of pelvic adhesions, pelvic adhesions, pelvic, adhesions, salpingooophorectomy, lysis, laparotomy, sigmoid, colon, mass, ovarian,"
" Primary low transverse cervical cesarean section.   Intrauterine pregnancy of 39 weeks, Herpes simplex virus positive by history, hepatitis C positive by history with low elevation of transaminases, cephalopelvic disproportion, asynclitism, postpartum macrosomia, and delivery of viable 9 lb female neonate.", Obstetrics / Gynecology, Low-Transverse C-Section - 9 ,"PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy of 39 weeks.,2.  Herpes simplex virus, positive by history.,3.  Hepatitis C, positive by history with low elevation of transaminases.,4.  Cephalopelvic disproportion.,5.  Asynclitism.,6.  Postpartum macrosomia.,POSTOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy of 39 weeks.,2.  Herpes simplex virus, positive by history.,3.  Hepatitis C, positive by history with low elevation of transaminases.,4.  Cephalopelvic disproportion.,5.  Asynclitism.,6.  Postpartum macrosomia.,7.  Delivery of viable 9 lb female neonate.,PROCEDURE PERFORMED: , Primary low transverse cervical cesarean section.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , About 600 cc.,Baby is doing well.  The patient's uterus is intact, bladder is intact.,HISTORY: , The patient is an approximately 25-year-old Caucasian female with gravida-4, para-1-0-2-1.  The patient's last menstrual period was in December of 2002 with a foreseeable due date on 09/16/03 confirmed by ultrasound.,The patient has a history of herpes simplex virus to which there is no active prodromal and no evidence of lesions.  The patient has a history of IVDA and contracted hepatitis C with slightly elevated liver transaminases.  The patient had been seen through our office for prenatal care.  The patient is on Valtrex.  The patient was found to be 3 cm about 40%, 0 to 9 engaged.  Bag of waters was ruptured.  She was on Pitocin.  She was contracting appropriately for a couple of hours or so with appropriate ________.  There was no cervical change noted.  Most probably because there was a sink vertex and that the head was too large to descend into the pelvis.  The patient was advised of this and we recommended cesarean section.  She agreed.  We discussed the surgery, foreseeable risks and complications, alternative treatment, the procedure itself, and recovery in layman's terms.  The patient's questions were answered.  I personally made sure that she understood every aspect of the consent and that she was comfortable with the understanding of what would transpire.,PROCEDURE:  ,The patient was then taken back to operative suite.  She was given anesthetic and sterilely prepped and draped.  Pfannenstiel incision was used.  A second knife was used to carry the incision down to the anterior rectus fascia.  Anterior rectus fascia was incised in the midline and carried bilaterally and the fascia was lifted off the underlying musculature.  The rectus muscles were separated.  The patient's peritoneum tented up towards the umbilicus and we entered the abdominal cavity.  There was a very thin lower uterine segment.  There seemed to be quite a large baby.  The patient had a small nick in the uterus.  Following the blunt end of the bladder knife going through the innermost layer of the myometrium and into the endometrial cavity, clear amniotic fluid was obtained.  A blunt low transverse cervical incision was made.  Following this, we placed a ________ on the very large fetal head.  The head was delivered following which we were able to deliver a large baby girl, 9 lb, good at tone and cry.  The patient then underwent removal of the placenta after the cord blood and ABG were taken.  The patient's uterus was examined.  There appeared to be no retained products.  The patient's uterine incision was reapproximated and sutured with #0 Vicryl in a running non-interlocking fashion, the second imbricating over the first.  The patient's uterus was hemostatic.  Bladder flap was reapproximated with #0 Vicryl.  The patient then underwent an irrigation at every level of closure and the patient was quite hemostatic.  We reapproximated the rectus musculature with care being taken not to incorporate any underlying structures.  The patient had three interrupted sutures of this.  The fascia was reapproximated with two stitches of #0 Vicryl going from each apex towards the midline.  The Scarpa's fascia was reapproximated with #0 gut.  There was noted no fascial defects and the skin was closed with #0 Vicryl.,Prior to closing the abdominal cavity, the uterus appeared to be intact and bladder appeared to have clear urine and appeared to be intact.  The patient was hemostatic.  All counts were correct and the patient tolerated the procedure well.  We will see her back in recovery.","obstetrics / gynecology, intrauterine pregnancy, herpes simplex virus, hepatitis c, cephalopelvic disproportion, asynclitism, postpartum, macrosomia, low transverse cervical cesarean section, rectus fascia, cesarean section, intrauterine, transaminases, herpes, uterus, fascia, "
" Repeat low-transverse cesarean section via Pfannenstiel incision.  Intrauterine pregnancy at 39 and 1/7th weeks.  Previous cesarean section, refuses trial of labor.  Fibroid uterus, oligohydramnios, and nonreassuring fetal heart tones.", Obstetrics / Gynecology, Low-Transverse C-Section - 7 ,"PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 39 and 1/7th weeks.,2.  Previous cesarean section, refuses trial of labor.,3.  Fibroid uterus.,4.  Oligohydramnios.,5.  Nonreassuring fetal heart tones.,POSTOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 39 and 1/7th weeks.,2.  Previous cesarean section, refuses trial of labor.,3.  Fibroid uterus.,4.  Oligohydramnios.,5.  Nonreassuring fetal heart tones.,PROCEDURE PERFORMED:,  Repeat low-transverse cesarean section via Pfannenstiel incision.,ANESTHESIA:,  General.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS:,  1200 cc.,FLUIDS:,  2700 cc.,URINE:,  400 cc clear at the end of the procedure.,DRAINS: , Foley catheter.,SPECIMENS:  ,Placenta, cord gases and cord blood.,INDICATIONS:  ,The patient is a G5 P1 Caucasian female at 39 and 1/7th weeks with a history of previous cesarean section for failure to progress and is scheduled cesarean section for later this day who presents to ABCD Hospital complaining of contractions.  She was found to not be in labor, but had nonreassuring heart tones with a subtle late decelerations and AFOF of approximately 40 mm.  A decision was made to take her for a C-section early.,FINDINGS: , The patient had an enlarged fibroid uterus with a large anterior fibroid with large varicosities, normal appearing tubes and ovaries bilaterally.  There was a live male infant in the ROA position with Apgars of 9 at 1 minute and 9 at 5 minutes and a weight of 5 lb 4 oz.,PROCEDURE: , Prior to the procedure, an informed consent was obtained.  The patient who previously been interested in a tubal ligation refused the tubal ligation prior to surgery.  She states that she and her husband are fully disgusted and that they changed their mind and they were adamant about this.  After informed consent was obtained, the patient was taken to the operating room where spinal anesthetic with Astramorph was administered.  She was then prepped and draped in the normal sterile fashion.  Once the anesthetic was tested, it was found to be inadequate and a general anesthetic was administered.  Once the general anesthetic was administered and the patient was asleep, the previous incision was removed with the skin knife and this incision was then carried through an underlying layer of fascia with a second knife.  The fascia was incised in the midline with a second knife.  This incision was then extended laterally in both directions with the Mayo scissors.  The superior aspect of this fascial incision was then dissected off to the underlying rectus muscle bluntly without using Ochsner clamps.  It was then dissected in the midline with Mayo scissors.  The inferior aspect of this incision was then addressed in a similar manner.  The rectus muscles were then separated in the midline with a hemostat.  The rectus muscles were separated further in the midline with Mayo scissors superiorly and inferiorly.  Next, the peritoneum was grasped with two hemostats, tented up and entered sharply with the Metzenbaum scissors.  This incision was extended inferiorly with the Metzenbaum scissors, being careful to avoid the bladder and the peritoneal incision was extended bluntly.  Next, the bladder blade was placed.  The vesicouterine peritoneum was identified, tenting up with Allis clamps and entered sharply with the Metzenbaum scissors.  This incision was extended laterally in both directions and a bladder flap was created digitally.  The bladder blade was then reinserted.  Next, the uterine incision was made with a second knife and the uterus was entered with the blunt end of the knife.  Next, the uterine incision was extended laterally in both directions with the banded scissors.  Next, the infant's head and body were delivered without difficulty.  There was multiple section on the abdomen.  The cord was clamped and cut.  Section of cord was collected for gases and the cord blood was collected.  Next, the placenta was manually extracted.  The uterus was exteriorized and cleared of all clots and debris.  The edges of the uterine incision were then identified with Allis _______ clamps.  The uterine incision was reapproximated with #0 chromic in a running locked fashion and a second layer of the same suture was used to obtain excellent hemostasis.  One figure-of-eight with #0 chromic was used in one area to prevent a questionable hematoma from expanding along the varicosity for the anterior fibroid.  After several minutes of observation, the hematoma was seem to be non-expanding.  The uterus was replaced in the abdomen.  The uterine incision was reexamined and seem to be continuing to be hemostatic.  The pelvic gutters were then cleared of all clots and debris.  The vesicouterine peritoneum was then reapproximated with #3-0 Vicryl in a running fashion.  The peritoneum was then closed with #0 Vicryl in a running fashion.  The rectus muscles reapproximated with #0 Vicryl in a single interrupted stitch.  The fascia was closed with #0 Vicryl in a running locked fashion and the skin was closed with staples.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x3.  The patient was then taken to Recovery in stable condition and she will be followed for immediate postoperative course in the hospital.",
 Primary low transverse cesarean section by Pfannenstiel skin incision with bilateral tubal sterilization.   Intrauterine pregnancy at 35-1/7.  Rh isoimmunization.  Suspected fetal anemia.  Desires permanent sterilization., Obstetrics / Gynecology, Low-Transverse C-Section - 8 ,"PREOPERATIVE DIAGNOSES,1.  Intrauterine pregnancy at 35-1/7.,2.  Rh isoimmunization.,3.  Suspected fetal anemia.,4.  Desires permanent sterilization.,POSTOPERATIVE DIAGNOSES,1.  Intrauterine pregnancy at 35-1/7.,2.  Rh isoimmunization.,3.  Suspected fetal anemia.,4.  Desires permanent sterilization.,OPERATION PERFORMED: , Primary low transverse cesarean section by Pfannenstiel skin incision with bilateral tubal sterilization.,ANESTHESIA:,  Spinal anesthesia.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS:  ,500 mL.,INTRAOPERATIVE FLUIDS: , 1000 mL crystalloids.,URINE OUTPUT: , 300 mL clear urine at the end of procedure.,SPECIMENS:,  Cord gases, hematocrit on cord blood, placenta, and bilateral tubal segments.,INTRAOPERATIVE FINDINGS: , Male infant, vertex position, very bright yellow amniotic fluid.  Apgars 7 and 8 at 1 and 5 minutes respectively.  Weight pending at this time.  His name is Kasson as well as umbilical cord and placenta stained yellow.  Otherwise normal appearing uterus and bilateral tubes and ovaries.,DESCRIPTION OF OPERATION:,  After informed consent was obtained, the patient was taken to the operating room where spinal anesthesia was obtained by Dr. X without difficulties.  The patient was placed in supine position with leftward tilt.  Fetal heart tones were checked and were 140s, and she was prepped and draped in a normal sterile fashion.  At this time, a Pfannenstiel skin incision made with a scalpel and carried down to the underlying fascia with electrocautery.  The fascia was nicked sharply in the midline.  The fascial incision was extended laterally with Mayo scissors.  The inferior aspect of the fascial incision was grasped with Kocher x2, elevated, and rectus muscles dissected sharply with the use of Mayo scissors.  Attention was then turned to the superior aspect of the fascial incision.  Fascia was grasped, elevated, and rectus muscles dissected off sharply.  The rectus muscles were separated in the midline bluntly.  The peritoneum was identified, grasped, and entered sharply and the peritoneal incision extended inferiorly and superiorly with good visualization of bladder.  Bladder blade was inserted.  Vesicouterine peritoneum was tented up and a bladder flap was created using Metzenbaum scissors.  Bladder blade was reinserted to effectively protect the bladder from the operative field and the lower uterine segment incised in a transverse U-shaped fashion with the scalpel.  Uterine incision was extended laterally and manually.  Membranes were ruptured and bright yellow clear amniotic fluid was noted.  Infant's head was in a floating position, able to flex the head, push against the incision, and then easily brought it to the field vertex.  Nares and mouth were suctioned with bulb suction.  Remainder of the infant was delivered atraumatically.  The infant was very pale upon delivery.  Cord was doubly clamped and cut and immediately handed to the awaiting intensive care nursery team.  An 8 cm segment of the tube was doubly clamped and transected.  Cord gases were obtained.  Cord was then cleansed, laid on a clean laparotomy sponge, and cord blood was drawn for hematocrit measurements.  At this time, it was noted that the cord was significantly yellow stained as well as the placenta.  At this time, the placenta was delivered via gentle traction on the cord and exterior uterine massage.  Uterus was exteriorized and cleared off all clots and debris with dry laparotomy sponge and the lower uterine segment was closed with 1-0 chromic in a running locked fashion.  Two areas of oozing were noted and separate figure-of-eight sutures were placed to obtain hemostasis.  At this time, the uterine incision was hemostatic.  The bladder was examined and found to be well below the level of the incision repair.  Tubes and ovaries were examined and found to be normal.  The patient was again asked if she desires permanent sterilization of which she agrees and therefore the right fallopian tube was identified and followed out to the fimbriated end and grasped at the mid portion with a Babcock clamp.  Mesosalpinx was divided with electrocautery and a 4-cm segment of tube was doubly tied and transected with a 3-cm segment of tube removed.  Hemostasis was noted.  Then, attention was turned to the left fallopian tube which in similar fashion was grasped and brought out through the fimbriated end and grasped the midline portion with Babcock clamp.  Mesosalpinx was incised and 3-4 cm tube doubly tied, transected, and excised and excellent hemostasis was noted.  Attention was returned to the uterine incision which is seemed to be hemostatic and uterus was returned to the abdomen.  Gutters were cleared off all clots and debris.  Lower uterine segments were again re-inspected and found to be hemostatic.  Sites of tubal sterilization were also visualized and were hemostatic.  At this time, the peritoneum was grasped with Kelly clamps x3 and closed with running 3-0 Vicryl suture.  Copious irrigation was used.  Rectus muscle belly was examined and found to be hemostatic and tacked and well approximated in the midline.  At this time, the fascia was closed using 0 Vicryl in a running fashion.  Manual palpation confirms thorough and adequate closure of the fascial layer.  Copious irrigation was again used.  Hemostasis noted, and skin was closed with staples.  The patient tolerated the procedure well.  Sponge, lap, needle, and instrument counts were correct x3 and the patient was sent to the recovery room awake and stable condition.  Infant assumed the care of the intensive care nursery team and being followed and workup up for isoimmunization and fetal anemia.  The patient will be followed for her severe right upper quadrant pain post delivery.  If she continues to have pain, may need a surgical consult for gallbladder and/or angiogram for evaluation of right kidney and questionable venous plexus.  This all will be relayed to Dr. Y, her primary obstetrician who was on call starting this morning at 7 a.m. through the weekend.","obstetrics / gynecology, intrauterine pregnancy, rh isoimmunization, primary low transverse cesarean section, bilateral tubal sterilization, pfannenstiel skin incision, fascial incision, uterine incision, fetal anemia, permanent sterilization, rectus muscles, incision, tubes, cord, "
" Repeat low transverse cesarean section and bilateral tubal ligation (BTL).   Intrauterine pregnancy at 30 and 4/7th weeks, previous cesarean section x2, multiparity, request for permanent sterilization, and breach presentation in the delivery of a liveborn female neonate.", Obstetrics / Gynecology, Low-Transverse C-Section & BTL - 1 ,"PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 30 and 4/7th weeks.,2.  Previous cesarean section x2.,3.  Multiparity.,4.  Request for permanent sterilization.,POSTOPERATIVE DIAGNOSIS:,1.  Intrauterine pregnancy at 30 and 4/7th weeks.,2.  Previous cesarean section x2.,3.  Multiparity.,4.  Request for permanent sterilization.,5.  Breach presentation in the delivery of a liveborn female neonate.,PROCEDURES PERFORMED:,1.  Repeat low transverse cesarean section.,2.  Bilateral tubal ligation (BTL).,TUBES: , None.,DRAINS: , Foley to gravity.,ESTIMATED BLOOD LOSS: , 600 cc.,FLUIDS:,  200 cc of crystalloids.,URINE OUTPUT:,  300 cc of clear urine at the end of the procedure.,FINDINGS:,  Operative findings demonstrated a wire mesh through the anterior abdominal wall and the anterior fascia.  There were bowel adhesions noted through the anterior abdominal wall.  The uterus was noted to be within normal limits.  The tubes and ovaries bilaterally were noted to be within normal limits.  The baby was delivered from the right sacral anterior position without any difficulty.  Apgars 8 and 9.  Weight was 7.5 lb.,INDICATIONS FOR THIS PROCEDURE:  ,The patient is a 23-year-old G3 P 2-0-0-2 with reported 30 and 4/7th weeks' for a scheduled cesarean section secondary to repeat x2.  She had her first C-section because of congenial hip problems.  In her second C-section, baby was breached, therefore, she is scheduled for a third C-section.  The patient also requests sterilization.  Therefore, she requested a tubal ligation.,PROCEDURE: , After informed consent was obtained and all questions were answered to the patient's satisfaction in layman's terms, she was taken to the operating room where a spinal with Astramorph anesthesia was obtained without any difficulty.  She was placed in the dorsal supine position with a leftward tilt and prepped and draped in the usual sterile fashion.  A Pfannenstiel skin incision was made removing the old scar with a first knife and then carried down to the underlying layer of fascia with a second knife.  The fascia was excised in the midline extended laterally with the Mayo scissors.  The superior aspect of the fascial incision was then tented up with Ochsner clamps and the underlying rectus muscle dissected off sharply with the Metzenbaum scissors.  There was noted dense adhesions at this point as well as a wire mesh was noted.  The anterior aspect of the fascial incision was then tented up with Ochsner clamps and the underlying rectus muscle dissected off sharply as well as bluntly.  The rectus muscle superiorly was opened with a hemostat.  The peritoneum was identified and entered bluntly digitally.  The peritoneal incision was then extended superiorly up to the level of the mesh.  Then, inferiorly using the knife, the adhesions were taken down and the bladder was identified and the peritoneum incision extended inferiorly to the level of the bladder.  The bladder blade was inserted and vesicouterine peritoneum was identified and tented up with Allis clamps and bladder flap was created sharply with the Metzenbaum scissors digitally.  The bladder blade was then reinserted to protect the bladder and the uterine incision was made with a first knife and then extended laterally with the Bandage scissors.  The amniotic fluid was noted to be clear.  At this point, upon examining the intrauterine contents, the baby was noted to be breached.  The right foot was identified and then the baby was delivered from the double footling breach position without any difficulty.  The cord was clamped and the baby was then handed off to awaiting pediatricians.  The placenta cord gases were obtained and the placenta was then manually extracted from the uterus.  The uterus was exteriorized and cleared of all clots and debris.  Then, the uterine incision was then closed with #0 Vicryl in a double closure stitch fashion, first layer in locking stitch fashion and the second layer an imbricating layer.  Attention at this time was turned to the tubes bilaterally.,Both tubes were isolated and followed all the way to the fimbriated end and tented up with the Babcock clamp.  The hemostat was probed through the mesosalpinx in the avascular area and then a section of tube was clamped off with two hemostats and then transected with the Metzenbaum scissors.  The ends was then burned with the cautery and then using a #2-0 Vicryl suture tied down.  Both tube sections were noted to be hemostatic and the tubes were then sent to pathology for review.  The uterus was then replaced back into the abdomen.  The gutters were cleared of all clots and debris.  The uterine incision was then once again inspected and noted to be hemostatic.  The bladder flap was then replaced back into the uterus with #3-0 interrupted sutures.  The peritoneum was then closed with #3-0 Vicryl in a running fashion.  Then, the area at the fascia where the mesh had been cut and approximately 0.5 cm portion was repaired with #3-0 Vicryl in a simple stitch fashion.  The fascia was then closed with #0 Vicryl in a running fashion.  The subcutaneous layer and Scarpa's fascia were repaired with a #3-0 Vicryl.  Then, the skin edges were reapproximated using sterile clips.  The dressing was placed.  The uterus was then cleared of all clots and debris manually.  Then, the patient tolerated the procedure well.  Sponge, lap, and needle, counts were correct x2.  The patient was taken to recovery in sable condition.  She will be followed up throughout her hospital stay.",
" Primary low-transverse C-section.  Postdates pregnancy, failure to progress, meconium stained amniotic fluid.", Obstetrics / Gynecology, Low-Transverse C-Section - 4 ,"PREOPERATIVE DIAGNOSES:,1.  Postdates pregnancy.,2.  Failure to progress.,3.  Meconium stained amniotic fluid.,POSTOPERATIVE DIAGNOSES:,1.  Postdates pregnancy.,2.  Failure to progress.,3.  Meconium stained amniotic fluid.,OPERATION:,  Primary low-transverse C-section.,ANESTHESIA:,  Epidural.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operating room and under epidural anesthesia, she was prepped and draped in the usual manner.  Anesthesia was tested and found to be adequate.  Incision was made, Pfannenstiel, approximately 1.5 fingerbreadths above the symphysis pubis and carried sharply through subcutaneous and fascial layers without difficulty; the fascia being incised laterally.  Bleeders were bovied.  Rectus muscles were separated from the overlying fascia with blunt and sharp dissection.  Muscles were separated in the midline.  Peritoneum was entered sharply and incision was carried out laterally in each direction.  Bladder blade was placed and bladder flap developed with blunt and sharp dissection.  A horizontal _______ incision was made in the lower uterine segment and carried laterally in each direction.  Allis was placed in the incision, and an uncomplicated extraction of a 7 pound 4 ounce, Apgar 9 female was accomplished and given to the pediatric service in attendance.  Infant was carefully suctioned after delivery of the head and body.  Cord blood was collected.  _______ and endometrial cavity was wiped free of membranes and clots.  Lower segment incision was inspected.  There were some extensive adhesions on the left side and a figure-of-eight suture of 1 chromic was placed on both lateral cuff borders and the cuff was closed with two interlocking layers of 1 chromic.  Bleeding near the left cuff required an additional suture of 1 chromic after which hemostasis was present.  Cul-de-sac was suctioned free of blood and clots and irrigated.  Fundus was delivered back into the abdominal cavity and lateral gutters were suctioned free of blood and clots and irrigated.  Lower segment incision was again inspected and found to be hemostatic.  The abdominal wall was then closed in layers, 2-0 chromic on the peritoneum, 0 Maxon on the fascia, 3-0 plain on the subcutaneous and staples on the skin.  Hemostasis was present between all layers.  The area was gently irrigated across the peritoneum and fascial layers.  There were no intraoperative complications except blood loss.  The patient was taken to the recovery room in satisfactory condition.","obstetrics / gynecology, pregnancy, meconium stained amniotic fluid, low transverse c section, amniotic fluid, meconium, peritoneum, blood, chromic, fascial, amniotic, incision,"
"  Primary low transverse cervical cesarean section.  Intrauterine pregnancy at 38 weeks and malpresentation.  A viable male neonate in the left occiput transverse position with Apgars of 9 and 9 at 1 and 5 minutes respectively, weighing 3030 g.  No nuchal cord.  No meconium.  Normal uterus, fallopian tubes, and ovaries.", Obstetrics / Gynecology, Low-Transverse C-Section - 5 ,"PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 38 weeks.,2.  Malpresentation.,POSTOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 38 weeks.,2.  Malpresentation.,3.  Delivery of a viable male neonate.,PROCEDURE PERFORMED: , Primary low transverse cervical cesarean section.,ANESTHESIA: , Spinal with Astramorph.,ESTIMATED BLOOD LOSS: , 300 cc.,URINE OUTPUT:,  80 cc of clear urine.,FLUIDS: , 2000 cc of crystalloids.,COMPLICATIONS: , None.,FINDINGS: , A viable male neonate in the left occiput transverse position with Apgars of 9 and 9 at 1 and 5 minutes respectively, weighing 3030 g.  No nuchal cord.  No meconium.  Normal uterus, fallopian tubes, and ovaries.,INDICATIONS: , This patient is a 21-year-old gravida 3, para 1-0-1-1 Caucasian female who presented to Labor and Delivery in labor.  Her cervix did make some cervical chains.  She did progress to 75% and -2, however, there was a raised lobular area palpated on the fetal head.  However, on exam unable to delineate the facial structures, but definite fetal malpresentation.  The fetal heart tones did start and it continued to have variable decelerations with contractions overall are reassuring.  The contraction pattern was inadequate.  It was discussed with the patient's family that in light of the physical exam and with the fetal malpresentation that a cesarean section will be recommended.  All the questions were answered.,PROCEDURE IN DETAIL: , After informed consent was obtained in layman's terms, the patient was taken back to the operating suite and placed in the dorsal lithotomy position with a leftward tilt.  Prior to this, the spinal anesthesia was administered.  The patient was then prepped and draped.  A Pfannenstiel skin incision was made with the first scalpel and carried through to the underlying layer of fascia with the second scalpel.  The fascia was then incised in the midline and extended laterally using Mayo scissors.  The superior aspect of the rectus fascia was then grasped with Ochsners, tented up and the underlying layer of rectus muscle was dissected up bluntly as well as with Mayo scissors.  The superior portion and inferior portion of the rectus fascia was identified, tented up and the underlying layer of rectus muscle was dissected up bluntly as well as with Mayo scissors.  The rectus muscle was then separated in the midline.  The peritoneum was then identified, tented up with hemostats and entered sharply with Metzenbaum scissors.  The peritoneum was then gently stretched.  The vesicouterine peritoneum was then identified, tented up with an Allis and the bladder flap was created bluntly as well as using Metzenbaum scissors.  The uterus was entered with the second scalpel and large transverse incision.  This was then extended in upward and lateral fashion bluntly.  The infant was then delivered atraumatically.  The nose and mouth were suctioned.  The cord was then clamped and cut.  The infant was handed off to the awaiting pediatrician.  The placenta was then manually extracted.  The uterus was exteriorized and cleared of all clots and debris.  The uterine incision was then repaired using #0 chromic in a running fashion marking a U stitch.  A second layer of the same suture was used in an imbricating fashion to obtain excellent hemostasis.  The uterus was then returned to the anatomical position.  The abdomen and the gutters were cleared of all clots.  Again, the incision was found to be hemostatic.  The rectus muscle was then reapproximated with #2-0 Vicryl in a single interrupted stitch.  The rectus fascia was then repaired with #0 Vicryl in a running fashion locking the first stitch and first last stitch in a lateral to medial fashion.  This was palpated and the patient was found to be without defect and intact.  The skin was then closed with staples.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2.  She will be followed up as an inpatient with Dr. X.","obstetrics / gynecology, low transverse cervical cesarean section, cesarean section, pregnancy, neonate, metzenbaum scissors, intrauterine pregnancy, rectus fascia, rectus muscle, intrauterine, peritoneum, malpresentation, transverse, astramorph, "
" Primary low transverse cesarean section via Pfannenstiel incision.  Pregnancy at 40 weeks, failure to progress, premature prolonged rupture of membranes, group B strep colonization, and delivery of viable male neonate.", Obstetrics / Gynecology, Low-Transverse C-Section - 6 ,"PREOPERATIVE DIAGNOSES:,1.  Pregnancy at 40 weeks.,2.  Failure to progress.,3.  Premature prolonged rupture of membranes.,4.  Group B strep colonization.,POSTOPERATIVE DIAGNOSIS:,1.  Pregnancy at 40 weeks.,2.  Failure to progress.,3.  Premature prolonged rupture of membranes.,4.  Group B strep colonization.,5.  Delivery of viable male neonate.,PROCEDURE PERFORMED: , Primary low transverse cesarean section via Pfannenstiel incision.,ANESTHESIA:  ,Spinal.,ESTIMATED BLOOD LOSS: , 1000 cc.,FLUID REPLACEMENT: , 2700 cc crystalloid.,URINE:,  500 cc clear yellow urine in the Foley catheter.,INTRAOPERATIVE FINDINGS:  ,Normal appearing uterus, tubes, and ovaries.  A viable male neonate with Apgars of 9 and 9 at 1 and 5 minutes respectively.  Infant weight equaled to 4140 gm with clear amniotic fluid.  The umbilical cord was wrapped around the leg tightly x1.  Infant was in a vertex, right occiput anterior position.,INDICATIONS FOR PROCEDURE:  ,The patient is a 19-year-old G1 P0 at 41 and 1/7th weeks' intrauterine pregnancy.  She presented at mid night on 08/22/03 complaining of spontaneous rupture of membranes, which was confirmed in Labor and Delivery.  The patient had a positive group beta strep colonization culture and was started on penicillin.  The patient was also started on Pitocin protocol at that time.  The patient was monitored throughout the morning showing some irregular contractions every 5 to 6 minutes and then eventually no contractions on the monitor.  IUPC was placed without difficulty and contractions appeared to be regular, however, they were inadequate amount of the daily units.  The patient was given a rest from the Pitocin.  She walked and had a short shower.  The patient was then placed back on Pitocin with IUPC in place and we were unable to achieve adequate contractions.  Maximum cervical dilation was 5 cm, 80% effaced, negative 2 station, and cephalic position.  At the time of C-section, the patient had been ruptured for over 24 hours and it was determined that she would not progress in her cervical dilation, as there was suspected macrosomia on ultrasound.  Options were discussed with the patient and family and it was determined that we will take her for C-section today.  Consent was signed.  All questions were answered with Dr. X present.,PROCEDURE: , The patient was taken to the operative suite where a spinal anesthetic was placed.  She was placed in the dorsal supine position with left upward tilt.  She was prepped and draped in the normal sterile fashion and her spinal anesthetic was found to adequate.  A Pfannenstiel incision was made with a first scalpel and carried through the underlying layer of fascia with a second scalpel.  The fascia was incised in the midline and extended laterally using curved Mayo scissors.  The superior aspect of the fascial incision was grasped with Ochsner and Kocher clamps and elevated off the rectus muscles.  Attention was then turned to the inferior aspect of the incision where Kocher clamps were used to elevate the fascia off the underlying rectus muscle.  The rectus muscle was separated in the midline bluntly.  The underlying peritoneum was tented up with Allis clamps and incised using Metzenbaum scissors.  The peritoneum was then bluntly stretched.  The bladder blade was placed.  The vesicouterine peritoneum was identified, tented up with Allis' and entered sharply with Metzenbaum scissors.  The incision was extended laterally and the bladder flap created digitally.  The bladder blade was then reinserted in the lower uterine segment.  A low transverse uterine incision was made with a second scalpel.  The uterine incision was extended laterally bluntly.  The bladder blade was removed and the infant's head was delivered with the assistance of a vacuum.  Infant's nose and mouth were bulb suctioned and the body was delivered atraumatically.  There was, of note, an umbilical cord around the leg tightly x1.,Cord was clamped and cut.  Infant was handed to the waiting pediatrician.  Cord gas was sent for pH as well as blood typing.  The placenta was manually removed and the uterus was exteriorized and cleared of all clots and debris.  The uterine incision was grasped circumferentially with Alfred clamps and closed with #0-Chromic in a running locked fashion.  A second layer of imbricating stitch was performed using #0-Chromic suture to obtain excellent hemostasis.  The uterus was returned to the abdomen.  The gutters were cleared of all clots and debris.  The rectus muscle was loosely approximated with #0-Vicryl suture in a single interrupted fashion.  The fascia was reapproximated with #0-Vicryl suture in a running fashion.  The subcutaneous Scarpa's fascia was then closed with #2-0 plain gut.  The skin was then closed with staples.  The incision was dressed with sterile dressing and bandage.  Blood clots were evacuated from the vagina.  The patient tolerated the procedure well.  The sponge, lap, and needle counts were correct x2.  The mother was taken to the recovery room in stable and satisfactory condition.","obstetrics / gynecology, c-section, cesarean section, low transverse, pregnancy, rupture of membranes, cervical dilation, kocher clamps, metzenbaum scissors, vicryl suture, pfannenstiel incision, uterine incision, rectus muscles, incision, transverse, colonization, rectus, muscles, bladder, uterine, section, fascia, "
" A repeat low transverse cervical cesarean section, Lysis of adhesions, Dissection of the bladder of the anterior abdominal wall and away from the fascia, and the patient also underwent a bilateral tubal occlusion via Hulka clips.", Obstetrics / Gynecology, Low-Transverse C-Section - 10 ,"PREOPERATIVE DIAGNOSES:,1.  36th and 4/7th week, intrauterine growth rate.,2.  Charcot-Marie-Tooth disease.,3.  Previous amniocentesis showing positive fetal lung maturity, family planning complete.,4.  Previous spinal fusion.,5.  Two previous C-sections.  The patient refuses trial labor.  The patient is with regular contractions dilated to 3, possibly an early labor, contractions are getting more and more painful.,POSTOPERATIVE DIAGNOSES:,1.  36th and 4/7th week, intrauterine growth rate.,2.  Charcot-Marie-Tooth disease.,3.  Previous amniocentesis showing positive fetal lung maturity, family planning complete.,4.  Previous spinal effusion.,5.  Two previous C-section.  The patient refuses trial labor.  The patient is with regular contractions dilated to 3, possibly an early labor, contractions are getting more and more painful.,6.  Adhesions of bladder.,7.  Poor fascia quality.,8.  Delivery of a viable female neonate.,PROCEDURE PERFORMED:,1.  A repeat low transverse cervical cesarean section.,2.  Lysis of adhesions.,3.  Dissection of the bladder of the anterior abdominal wall and away from the fascia.,4.  The patient also underwent a bilateral tubal occlusion via Hulka clips.,COMPLICATIONS: , None.,BLOOD LOSS:,  600 cc.,HISTORY AND INDICATIONS:  ,Indigo Carmine dye bladder test in which the bladder was filled, showed that there was no defects in the bladder of the uterus.  The uterus appeared to be intact.  This patient is a 26-year-old Caucasian female.  The patient is well known to the OB/GYN clinic.  The patient had two previous C-sections.  She appears to be in probably early labor.  She had an amniocentesis early today.  She is contracting regularly about every three minutes.  The contractions are painful and getting much more so since the amniocentesis.  The patient had fetal lung maturity noted.  The patient also has probable IUGR as none of her babies have been over 4 lb.  The patient's baby appears to be somewhat small.  The patient suffers from Charcot-Marie-Tooth disease, which has left her wheelchair bound.  The patient has had a spinal fusion, however, family planning is definitely complete per the patient.  The patient refuses trial labor.  The patient and I discussed the consent.  She understands the foreseeable risks and complications, alternative treatment of the procedure itself, and recovery.  Her questions were answered.  The patient also understands that when we occlude her tube that she is at risk for failure of this part of the procedure, which would result in either an intrauterine or ectopic pregnancy.  The patient understands this and would like to try our best.,PROCEDURE:  ,The patient was taken back to the operative suite.  She was given general anesthetic by Department of Anesthesiology.  Once again, in layman's terms, the patient understands the risks.  The patient had the informed consent reviewed and understood.  The patient has had a Pfannenstiel incision, which was slightly bent towards the right side favoring the right side.  The patient had the first knife went through this incision.  The second knife was used to go to the level of fascia.  The fascia was very thin, ruddy in appearance, and with abundant scar tissue.  The fascia was incised.  Following this, we were able to see the peritoneum.  There was really no obvious rectus abdominal muscles noted.  They were very weak, atrophic, and thin.  The patient has the peritoneum tented up.  We entered the abdominal cavity.  The bladder flap was then entered into the anterior abdominal wall and to the underlying area of the fascia.  The bladder flap was then entered into the uterus as well.  There are some bladder adhesions.  We removed these adhesions and we removed the bladder of the fascia.  We dissected the bladder of the lower segment.  We made a small nick on the lower segment.  We were able to utilize the blunt end of the knife to enter into the uterine cavity.  The baby was in occiput transverse position with the ear being cocked at such a position as well.  The patient's baby was delivered without difficulty.  It was a 4 lb and 10 oz baby girl who vigorously cried well.  There was a prolapse of the umbilical cord just below the chin as well and this may be attributed to the decelerations we caught on the monitor strip right before we decided to have her undergo resection.  The patient's placenta was delivered.  There was no retained placenta.  The uterine incision was closed with two layers of #0 Vicryl, the second layer imbricating over the first.  The patient on the right side had the inferior epigastric artery and the vein just underneath the peritoneum easily visualized.  Then we ligated this as there was bleeding and oozing.  The patient had the Indigo Carmine instilled into the bladder with some saline about 300 cc.  The 400 cc was instilled.  The bladder appears to be intact.  The bladder did require extensive dissection of the fascia in order to be able to get a proper fascial edges for closure and dissection of the lower uterine segment.  There was some oozing around the area of the bladder.  We placed an Avitene there.  The two Hulka clips were placed perpendicular to going across each fallopian tube into the mesosalpinx.  The patient has two clips on each side.  There was excellent tubal occlusion and placement.  The uterus was placed back into the abdominal cavity.  We rechecked again.  The tubal placement was excellent.  It did not involve the round ligaments, uterosacral ligaments, the uteroovarian ligaments, and the tube into the mesosalpinx.  The patient then underwent further examination.  Hemostasis appeared to be good.  The fascia was reapproximated with short running intervals of #0 Vicryl across the fascia.  We took care not to get into any bleeders and to make sure that the fascia was indeed closed as best as it was possible.  The Scarpa's fascia was reapproximated with #0 gut.  The skin was reapproximated then as well via subcutaneous closure.  The patient's sponge and needle counts found to be correct.  Uterus appeared to be normal prior to closure.  Bladder appeared to be normal.  The patient's blood loss is 600 cc.","obstetrics / gynecology, intrauterine growth rate, charcot-marie-tooth disease, amniocentesis, c-sections, trial labor, low transverse cervical cesarean section, lysis of adhesions, dissection, bladder, abdominal wall, fascia, hulka clips, bilateral tubal occlusion, intrauterine, transverse, uterus, abdominal, "
 Primary low segment cesarean section., Obstetrics / Gynecology, Low -Segment C-Section ,"PREOPERATIVE DIAGNOSIS:  ,Pregnancy at 42 weeks, nonreassuring fetal testing, and failed induction.,POSTOPERATIVE DIAGNOSIS: , Pregnancy at 42 weeks, nonreassuring fetal testing, and failed induction.,PROCEDURE: , Primary low segment cesarean section.  The patient was placed in the supine position under spinal anesthesia with a Foley catheter in place and she was prepped and draped in the usual manner.  A low abdominal transverse skin incision was constructed and carried down through the subcutaneous tissue through the anterior rectus fascia.  Bleeding points were snapped and coagulated along the way.  The fascia was opened transversally and was dissected sharply and bluntly from the underlying rectus muscles.  These were divided in the midline revealing the peritoneum, which was opened vertically.  The uterus was in mid position.  The bladder flap was incised elliptically and reflected caudad.  A low transverse hysterotomy incision was then constructed and extended bluntly.  Amniotomy revealed clear amniotic fluid.  A live born vigorous male infant was then delivered from the right occiput transverse position.  The infant breathed and cried spontaneously.  The nares and pharynx were suctioned.  The umbilical cord was clamped and divided and the infant was passed to the waiting neonatal team.  Cord blood samples were obtained.  The placenta was manually removed and the uterus was eventrated for closure.  The edges of the uterine incision were grasped with Pennington clamps and closure was carried out in standard two-layer technique using 0 Vicryl suture with the second layer imbricating the first.  Hemostasis was completed with an additional figure-of-eight suture of 0 Vicryl.  The cornual sac and gutters were irrigated.  The uterus was returned to the abdominal cavity.  The adnexa were inspected and were normal.  The abdomen was then closed in layers.  Fascia was closed with running 0 Vicryl sutures, subcutaneous tissue with running 3-0 plain Catgut, and skin with 3-0 Monocryl subcuticular suture and Steri-Strips.  Blood loss was estimated at 700 mL.  All counts were correct.,The patient tolerated the procedure well and left the operating room in excellent condition.","obstetrics / gynecology, nonreassuring fetal testing, anterior rectus fascia, pennington clamps, fetal testing, low segment, induction, suture,"
" Repeat low-transverse C-section, lysis of omental adhesions, lysis of uterine adhesions with repair of uterine defect, and bilateral tubal ligation.", Obstetrics / Gynecology, Low-Transverse C-Section - 3 ,"PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 33 weeks, twin gestation.,2.  Active preterm labor.,3.  Advanced dilation.,4.  Multiparity.,5.  Requested sterilization.,POSTOPERATIVE DIAGNOSIS:,1.  Intrauterine pregnancy at 33 weeks, twin gestation.,2.  Active preterm labor.,3.  Advanced dilation.,4.  Multiparity.,5.  Requested sterilization.,6.  Delivery of a viable female A weighing 4 pounds 7 ounces, Apgars were 8 and 9 at 1 and 5 minutes respectively and female B weighing 4 pounds 9 ounces, Apgars 6 and 7 at 1 and 5 minutes respectively.,7.  Uterine adhesions and omentum adhesions.,OPERATION PERFORMED: , Repeat low-transverse C-section, lysis of omental adhesions, lysis of uterine adhesions with repair of uterine defect, and bilateral tubal ligation.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , 500 mL.,DRAINS:,  Foley.,This is a 25-year-old white female gravida 3, para 2-0-0-2 with twin gestation at 33 weeks and previous C-section.  The patient presents to Labor and Delivery in active preterm labor and dilated approximately 4 to 6 cm.  The decision for C-section was made.,PROCEDURE:,  The patient was taken to the operating room and placed in a supine position with a slight left lateral tilt and she was then prepped and draped in usual fashion for a low transverse incision.  The patient was then given general anesthesia and once this was completed, first knife was used to make a low transverse incision extending down to the level of the fascia.  The fascia was nicked in the center and extended in a transverse fashion with the use of curved Mayo scissors.  The edges of the fascia were grasped with Kocher and both blunt and sharp dissection was then completed both caudally and cephalically.  The abdominal rectus muscle was divided in the center and extended in a vertical fashion.  Peritoneum was entered at a high point and extended in a vertical fashion as well.  The bladder blade was put in place.  The bladder flap was created with the use of Metzenbaum scissors and dissected away caudally.  The second knife was used to make a low transverse incision with care being taken to avoid the presenting part of the fetus.  The first fetus was vertex.  The fluid was clear.  The head was delivered followed by the remaining portion of the body.  The cord was doubly clamped and cut.  The newborn handed off to waiting pediatrician and nursery personnel.  The second fluid was ruptured.  It was the clear fluid as well.  The presenting part was brought down to be vertex.  The head was delivered followed by the rest of the body and the cord was doubly clamped and cut, and newborn handed off to waiting pediatrician in addition of the nursery personnel.  Cord pH blood and cord blood was obtained from both of the cords with careful identification of A and B. Once this was completed, the placenta was delivered and handed off for further inspection by Pathology.  At this time, it was noted at the uterus was adhered to the abdominal wall by approximately of 3 cm x 3 cm thick uterine adhesion and this was needed to be released by sharp dissection.  Then, there were multiple omental adhesions on the surface of the uterus itself.  This needed to be released as well as on the abdominal wall and then the uterus could be externalized.  The lining was wiped clean of any remaining blood and placental fragments and the edges of the uterus were grasped in four quadrants with Kocher and continuous locking stitch of 0 chromic was used to re-approximate the uterine incision, with the second layer used to imbricate the first.  The bladder flap was re-approximated with 3-0 Vicryl and Gelfoam underneath.  The right fallopian tube was grasped with a Babcock, it was doubly tied off with 0 chromic and the knuckle portion was then sharply incised and cauterized.  The same technique was completed on the left side with the knuckle portion cut off and cauterized as well.  The defect on the uterine surface was reinforced with 0 Vicryl in a baseball stitch to create adequate Hemostasis.  Interceed was placed over this area as well.  The abdominal cavity was irrigated with copious amounts of saline and the uterus was placed back in its anatomical position.  The gutters were wiped clean of any remaining blood.  The edges of the peritoneum were grasped with hemostats and a continuous locking stitch was used to re-approximate abdominal rectus muscles as well as the peritoneal edges.  The abdominal rectus muscle was irrigated.  The corners of the fascia grasped with hemostats and continuous locking stitch of 0 Vicryl started on both corners and overlapped on the center.  The subcutaneous tissue was irrigated.  Cautery was used to create adequate hemostasis and 3-0 Vicryl was used to re-approximate the subcutaneous tissue.  Skin edges were re-approximated with sterile staples.  Sterile dressing was applied.  Uterus was evacuated of any remaining blood vaginally.  The patient was taken to the recovery room in stable condition.  Instrument count, needle count, and sponge counts were all correct.","obstetrics / gynecology, intrauterine pregnancy, gestation, preterm labor, omentum adhesions, low transverse c section, uterine adhesions, intrauterine, adhesions, abdominal, uterus, uterine, "
 Primary low-transverse cesarean section., Obstetrics / Gynecology, Low-Transverse C-Section ,"PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at term.,2.  Arrest of dilation. ,POSTOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at term.,2.  Arrest of dilation.,PROCEDURE PERFORMED:,  Primary low-transverse cesarean section.,ANESTHESIA: , Epidural.,ESTIMATED BLOOD LOSS: , 1000 mL.,COMPLICATIONS: , None.,FINDINGS:  ,Female infant in cephalic presentation, OP position, weight 9 pounds 8 ounces.  Apgars were 9 at 1 minute and 9 at 5 minutes.  Normal uterus, tubes, and ovaries were noted.,INDICATIONS:  ,The patient is a 20-year-old gravida 1, para 0 female, who presented to labor and delivery in early active labor at 40 and 6/7 weeks gestation.  The patient progressed to 8 cm, at which time, Pitocin was started.  She subsequently progressed to 9 cm, but despite adequate contractions, arrested dilation at 9 cm.  A decision was made to proceed with a primary low transverse cesarean section.,The procedure was described to the patient in detail including possible risks of bleeding, infection, injury to surrounding organs, and possible need for further surgery.  Informed consent was obtained prior to proceeding with the procedure.,PROCEDURE NOTE:  ,The patient was taken to the operating room where epidural anesthesia was found to be adequate.  The patient was prepped and draped in the usual sterile fashion in the dorsal supine position with a left-ward tilt.  A Pfannenstiel skin incision was made with the scalpel and carried through to the underlying layer of fascia using the Bovie.  The fascia was incised in the midline and extended laterally using Mayo scissors.  Kocher clamps were used to elevate the superior aspect of the fascial incision, which was elevated, and the underlying rectus muscles were dissected off bluntly and using Mayo scissors.  Attention was then turned to the inferior aspect of the fascial incision, which in similar fashion was grasped with Kocher clamps, elevated, and the underlying rectus muscles were dissected off bluntly and using Mayo scissors.  The rectus muscles were dissected in the midline.,The peritoneum was bluntly dissected, entered, and extended superiorly and inferiorly with good visualization of the bladder.  The bladder blade was inserted.  The vesicouterine peritoneum was identified with pickups and entered sharply using Metzenbaum scissors.  This incision was extended laterally and the bladder flap was created digitally.  The bladder blade was reinserted.  The lower uterine segment was incised in a transverse fashion using the scalpel and extended using manual traction.  Clear fluid was noted.  The infant was subsequently delivered atraumatically.  The nose and mouth were bulb suctioned.  The cord was clamped and cut.  The infant was subsequently handed to the awaiting nursery nurse.  Next, cord blood was obtained per the patient's request for cord blood donation, which took several minutes to perform.  Subsequent to the collection of this blood, the placenta was removed spontaneously intact with a 3-vessel cord noted.  The uterus was exteriorized and cleared of all clots and debris.  The uterine incision was repaired in 2 layers using 0 chromic suture.  Hemostasis was visualized.  The uterus was returned to the abdomen.,The pelvis was copiously irrigated.  The uterine incision was reexamined and was noted to be hemostatic.  The rectus muscles were reapproximated in the midline using 3-0 Vicryl.  The fascia was closed with 0 Vicryl, the subcutaneous layer was closed with 3-0 plain gut, and the skin was closed with staples.  Sponge, lap, and instrument counts were correct x2.  The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition.","obstetrics / gynecology, intrauterine pregnancy at term, arrest of dilation, cephalic presentation, low transverse cesarean section, cesarean section, rectus muscles, intrauterine, "
" The patient is a 26-year-old gravida 2, para 1-0-0-1, at 28-1/7 weeks who presents to the emergency room with left lower quadrant pain, reports no bowel movement in two weeks as well as nausea and vomiting for the last 24 hours or so.  She states that she has not voided in the last 24 hours as well due to pain.", Obstetrics / Gynecology, Left Lower Quadrant Pain - ER Visit ,"HISTORY OF PRESENT ILLNESS:,  The patient is a 26-year-old gravida 2, para 1-0-0-1, at 28-1/7 weeks who presents to the emergency room with left lower quadrant pain, reports no bowel movement in two weeks as well as nausea and vomiting for the last 24 hours or so.  She states that she has not voided in the last 24 hours as well due to pain.  She denies any leaking of fluid, vaginal bleeding, or uterine contractions.  She reports good fetal movement.  She denies any fevers, chills, or burning with urination.,REVIEW OF SYSTEMS: , Positive for back pain in her lower back only.  Her mother reports that she has been eating food without difficulty and that the current nausea and vomiting is much less than when she is not pregnant.  She continues to yell out for requesting pain medication and about how much ""it hurts."",PAST MEDICAL HISTORY:,1.  Irritable bowel syndrome.,2.  Urinary tract infections times three.  The patient is unsure if pyelo is present or not.,PAST SURGICAL HISTORY:,  Denies.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , Phenergan and Zofran twice a day.  Macrobid questionable.,GYN: , History of an abnormal Pap, group B within normal limits.  Denies any sexually transmitted diseases.,OB HISTORY: , G1 is a term spontaneous vaginal delivery without complications, now a 6-year-old.  G2 is current.  Gets her care at Lyndhurst.,SOCIAL HISTORY: , Denies tobacco and alcohol use.  She endorses marijuana use and a history of cocaine use five years ago.  Upon review of the Baptist lab systems, the patient has had multiple positive urine drug screens and as recently as February 2008 had a urine drug screen that was positive for benzodiazepines, barbiturates, opiates, and marijuana and as recently as 2005 with cocaine present as well.,PHYSICAL EXAM:,VITAL SIGNS:  Blood pressure 139/82, pulse 89, respirations 20, 98% on room air, 96 degrees Fahrenheit.  Fetal heart tones are 130s with moderate long-term variability.  No paper is available for the fetal heart monitor due to the misorder and audibly sounds reassuring.,GENERAL:  Appears sedated, trashing intermittently, and then falling asleep in mid sentence.,CARDIOVASCULAR:  Regular rate and rhythm.,PULMONARY:  Clear to auscultation bilaterally.,BACK:  Tender to palpation in her lower back bilaterally, but no CVA tenderness.,ABDOMEN:  Tender to palpation in left lower quadrant.  No guarding or rebound.  Normal bowel sounds.,EXTREMITIES:  Scar track marks from bilateral arms.,PELVIC:  External vaginal exam is closed, long, high, and posterior.  Stool was felt in the rectum.,LABS: , White count is 11.1, hemoglobin is 13.5, platelets are 279.  CMP is within normal limits with an AST of 17, ALT of 11, and creatinine of 0.6.  Urinalysis which is supposedly a cath specimen shows a specific gravity of 1.024, greater than 88 ketones, many bacteria, but no white blood cells or nitrites.,ASSESSMENT AND PLAN:  ,The patient is a 26-year-old gravida 2, para 1-0-0-1 at 28-1 weeks with left lower quadrant pain and likely constipation.  I spoke with Dr. X who is the physician on-call tonight, and he requests that she be transferred for continued fetal monitoring and further evaluation of this abdominal pain to Labor and Delivery.  Plans are made for transfer at this time.  This was discussed with Dr. Y who is in agreement with the plan.",
" Intrauterine pregnancy at 37 plus weeks, nonreassuring fetal heart rate.", Obstetrics / Gynecology, Low-Transverse C-Section - 2 ,"PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 37 plus weeks, nonreassuring fetal heart rate.,2.  Protein S low.,3.  Oligohydramnios.,POSTOPERATIVE:,1.  Intrauterine pregnancy at 37 plus weeks, nonreassuring fetal heart rate.,2.  Protein S low.,3.  Oligohydramnios.,4.  Delivery of a viable female, weight 5 pound, 14 ounces.  Apgars of 9 and 9 at 1 and 5 minutes respectively and cord pH is 7.314.,OPERATION PERFORMED:,  Low transverse C-section.,ESTIMATED BLOOD LOSS: , 500 mL.,DRAINS: , Foley.,ANESTHESIA: , Spinal with Duramorph.,HISTORY OF PRESENT ILLNESS:  ,This is a 21-year-old white female gravida 1, para 0, who had presented to the hospital at 37-3/7 weeks for induction.  The patient had oligohydramnios and also when placed on the monitor had nonreassuring fetal heart rate with late deceleration.  Due to the IUGR as well a decision for a C-section was made.,PROCEDURE: , The patient was taken to the operating room and placed in a seated position with standard spinal form of anesthesia administered by the Anesthesia Department.  The patient was then repositioned, prepped and draped in a slight left lateral tilt.  Once this was completed first knife was used to make a low transverse skin incision approximately two fingerbreadths above the pubic symphysis.  This was extended down to the level of the fascia.  The fascia was nicked in the center and extended in transverse fashion.  Edges of the fascia were grasped with Kocher and both blunt and sharp dissection both caudally and cephalic was completed consistent with the Pfannenstiel technique.  The abdominal rectus muscle was divided in the center, extended in vertical fashion and the peritoneum was entered at a high point and extended in vertical fashion.  Bladder blade was put in place and a bladder flap was created with the use of Metzenbaum and pickups and then bluntly dissected via cautery and reincorporated in the bladder blade.  Second knife was used to make a low transverse uterine incision with care being taken to avoid the presenting part of fetus.  Presenting part was vertex, the head was delivered, followed by the remaining portion of the body.  The mouth and nose were suctioned through bulb syringe and the cord was doubly clamped and cut and then the newborn handed off to waiting nursing personnel.  Cord pH blood and cord blood was obtained.  The placenta was delivered manually and the uterus was externalized and the lining was cleaned off any remaining placental fragments and blood and the incisional edges were reapproximated with 0-chromic and a continuous locking stitch with a second layer used to imbricate the first.  The bladder flap was re-peritonized with Gelfoam underneath and abdomen was irrigated with copious amounts of saline and the uterus was placed back in its anatomical position.  The gutters were wiped clean of any remaining blood and fluid and the edges of the perineum grasped with hemostats and continuous locking stitches of 2-0 Vicryl was used to reapproximate the abdominal rectus muscle as well as the perineum.  This area was then irrigated.  Cautery was used for adequate hemostasis, corners of the fascia grasped with hemostats and continuous locking stitch of 1-Vicryl was started at both corners and overlapped in the center.  Subcutaneous tissue was irrigated with saline and reapproximated with 3-0 Vicryl.  Skin edges reapproximated with sterile staples.  Sterile dressing was applied.  The uterus was evacuated of any remaining clots vaginally.  The patient was taken to recovery room in stable condition.  Instrument count, needle count, and sponge counts were all correct.","obstetrics / gynecology, apgars, low transverse c section, fetal heart rate, bladder blade, intrauterine pregnancy, intrauterine"
 LEEP procedure of endocervical polyp and Electrical excision of pigmented mole of inner right thigh., Obstetrics / Gynecology, LEEP ,"DIAGNOSIS:,1.  Broad-based endocervical poly.,2.  Broad- based pigmented, raised nevus, right thigh.,OPERATION:,1.  LEEP procedure of endocervical polyp.,2.  Electrical excision of pigmented mole of inner right thigh.,FINDINGS: , There was a 1.5 x 1.5 cm broad-based pigmented nevus on the inner thigh that was excised with a wire loop.  Also, there was a butt-based, 1-cm long endocervical polyp off the posterior lip of the cervix slightly up in the canal.,PROCEDURE: , With the patient in the supine position, general anesthesia was administered.  The patient was put in the dorsal lithotomy position and prepped and draped for dilatation and curettage in a routine fashion.,An insulated posterior weighted retractor was put in.  Using the LEEP tenaculum, we were able to grasp the anterior lip of the cervix with a large wire loop at 35 cutting, 30 coagulation.  The endocervical polyp on the posterior lip of the cervix was excised.,Then changing from a 50 of coagulation and 5 cutting, the base of the polyp was electrocoagulated, which controlled all the bleeding.  The wire loop was attached, and the pigmented raised nevus on the inner thigh was excised with the wire loop.  Cautery of the base was done, and then it was closed with figure-of-eight 3-0 Vicryl sutures.  A band-aid was applied over this.,Rechecking the cervix, no bleeding was noted.  The patient was laid flat on the table, awakened, and moved to the recovery room bed and sent to the recovery room in satisfactory condition.","obstetrics / gynecology, endocervical polyp, pigmented mole, polyp, leep tenaculum, leep, cervix, endocervical, pigmented "
 Carbon dioxide laser photo-ablation due to recurrent dysplasia of vulva., Obstetrics / Gynecology, Laser of Vulva ,"PREOPERATIVE DIAGNOSIS: , Recurrent dysplasia of vulva.,POSTOPERATIVE DIAGNOSIS:,  Same.,OPERATION PERFORMED:,  Carbon dioxide laser photo-ablation.,ANESTHESIA: , General, laryngeal mask.,INDICATIONS FOR PROCEDURE: , The patient has a past history of recurrent vulvar dysplasia.  She has had multiple prior procedures for treatment.  She was counseled to undergo laser photo-ablation.,FINDINGS:,  Examination under anesthesia revealed several slightly raised and pigmented lesions, predominantly on the left labia and perianal regions.  After staining with acetic acid, several additional areas of acetowhite epithelium were seen on both sides and in the perianal region.,PROCEDURE:  ,The patient was brought to the operating room with an IV in place.  Anesthetic was administered, after which she was placed in the lithotomy position.  Examination under anesthesia was performed, after which she was prepped and draped.  Acetic acid was applied and marking pen was utilized to outline the extent of the dysplastic lesion.  The carbon dioxide laser was then used to ablate the lesion to the third surgical plane as defined Reid.  Setting was 25 watts using a 6 mm pattern size with the silk-touch hand piece in the paint mode.  Excellent hemostasis was noted and Bacitracin was applied prophylactically.  The patient was awakened from her anesthetic and taken to the Post Anesthesia Care Unit in stable condition.","obstetrics / gynecology, laser of vulva, recurrent dysplasia, carbon dioxide laser photo-ablation, recurrent dysplasia of vulva, dysplasia of vulva, carbon dioxide laser, photo ablation, carbon, dysplasia, laser, ablation,"
" Primary cesarean section by low-transverse incision.  Term pregnancy, nonreassuring fetal heart tracing.", Obstetrics / Gynecology, Low-Transverse C-Section - 1 ,"PREOPERATIVE DIAGNOSES: , Term pregnancy, nonreassuring fetal heart tracing.,POSTOPERATIVE DIAGNOSES: , Term pregnancy, nonreassuring fetal heart tracing.,OPERATION:,  Primary cesarean section by low-transverse incision.,ANESTHESIA:,  Epidural.,ESTIMATED BLOOD LOSS: , 450 mL.,COMPLICATIONS: , None.,CONDITION: , Stable.,DRAINS:  ,Foley catheter.,INDICATIONS: , The patient is a 39-year-old, G4, para 0-0-3-0, with an EDC of 03/08/2009.  The patient began having prodromal symptoms 2 to 3 days prior to presentation.  She was seen on 03/09/2007 and a nonstress test was performed.  This revealed some spontaneous variable-appearing decelerations.  She was given IV hydration.  A biophysical profile was obtained, which provided a score of 0/8 with only a 1 cm fluid pocket found.  Therefore, she was admitted for further fetal monitoring and evaluation.  She had changed her cervix from closed 2 days prior to presentation to 1 cm dilated.  She was having somewhat irregular contractions, but with stronger contractions, continued to have decelerations to 50 to 60 beats per minute.  Due to these findings, a scalp electrode was placed as well as an IUPC for an amnioinfusion.  This relieved the decelerations somewhat.  However, over a period of time with strong contractions, she still had bradycardia 40 to 50 beats per minute and developed a late component on the return of the decelerations.  Due to this finding, it was evident that the fetal state would not support labor in order to accomplish a vaginal delivery.  These findings were reviewed with the patient and recommendation was made for cesarean section delivery.  The risks and benefits of this surgery were reviewed, and knowing these facts, the patient gave informed consent.,PROCEDURE: , The patient was taken to the operating room where her epidural anesthesia was reinforced.  She was prepped and draped in the usual fashion for the procedure.  After adequate epidural level was confirmed, the scalp was utilized to make a transverse incision in the patient's lower abdominal wall.  This incision was carried down to the level of the fascia, which was also transversely incised.  After adequate hemostasis, the fascia was bluntly and sharply separated up from the underlying rectus muscle.  The rectus muscle was separated in midline exposing the peritoneum.  The peritoneum was carefully grasped and elevated with hemostats.  It was entered in an up and down fashion with Metzenbaum scissors.  The bladder blade was placed in the lower pole of the incision to protect the bladder.,The uterus was palpated and inspected.  A thin lower uterine segment was noted.  The vertex presentation was confirmed.  The scalp was then utilized to make a transverse or Kerr incision in the lower uterine wall.  Clear fluid was noted upon entering into the amniotic space.  At 05:27, a term viable female infant was delivered up through the incision.  She had spontaneous respirations.  She was given bulb suctioning for clear fluid.  Her cord was clamped and cut and she was delivered off the field to Dr. X who was attending.  The baby girl was subsequently signed Apgars of 8 at one minute and 9 at five minutes.  Her birth weight was found to be 5 pounds and 5 ounces.,The placenta was manually extracted from the endometrial cavity.  A ring clamp and two Allis clamps were placed around the margin of the uterine incision for hemostasis.  The uterus was delivered up into the operative field.  The endometrial cavity was swiped clean with a moist laparotomy pad.  The uterine incision was then closed in a two-layered fashion with 0 Vicryl suture, the first layer interlocking and the second layer imbricating.  Two additional stitches of 3-0 Vicryl suture were utilized for hemostasis.  The uterine incision was noted to be hemostatic upon closure.  The uterus was rotated forward, normal tubes and ovaries were noted on both sides.  The uterus was then returned to its normal position of the abdominal cavity.  The sponge and instrument count was performed for the first time at this point and found to be correct.  The pelvis and anterior uterine space was then irrigated with saline solution.  It was suctioned dry.  A final check of the uterine incision confirmed hemostasis.  The rectus muscle was stabilized across the midline with two simple stitches of 0 Vicryl suture.  The subcutaneous tissue was then exposed, and the fascia closed with two running lengths of 0 Vicryl suture, beginning in lateral margins and overlapping the midline.  The subcutaneous tissue was then irrigated and inspected.  No active bleeding was noted.  It was closed with a running length of 3-0 plain catgut suture.  The skin was then approximated with surgical steel staples.  The incision was infiltrated with a 0.5% solution of Marcaine local anesthetic.  The incision was cleansed and sterilely dressed.,The patient was transferred to the recovery room in stable condition.  The estimated blood loss through the procedure was 450 mL.  The sponge and instrument counts were performed two more times during closure and found to be correct each time.","obstetrics / gynecology, low-transverse incision, edc, para, amnioinfusion, nonreassuring fetal heart tracing, primary cesarean section, fetal heart tracing, low transverse, term pregnancy, fetal heart, heart tracing, rectus muscle, uterine incision, vicryl suture, incision, transverse, fetal, suture, uterine, "
 Diagnostic laparoscopy and drainage of cyst., Obstetrics / Gynecology, Laparoscopy - Drainage of Cyst ,"PREOPERATIVE DIAGNOSIS:,  Ovarian cyst, persistent.,POSTOPERATIVE DIAGNOSIS: , Ovarian cyst.,ANESTHESIA:,  General,NAME OF OPERATION:,  Diagnostic laparoscopy and drainage of cyst.,PROCEDURE:,  The patient was taken to the operating room, prepped and draped in the usual manner, and adequate anesthesia was induced.  An infraumbilical incision was made, and Veress needle placed without difficulty.  Gas was entered into the abdomen at two liters.  The laparoscope was entered, and the abdomen was visualized.  The second puncture site was made, and the second trocar placed without difficulty.  The cyst was noted on the left, a 3-cm, ovarian cyst.  This was needled, and a hole cut in it with the scissors.  Hemostasis was intact.  Instruments were removed.  The patient was awakened and taken to the recovery room in good condition.","obstetrics / gynecology, ovarian cyst, infraumbilical incision, drainage of cyst, diagnostic laparoscopy, laparoscopy, drainage, ovarian, "
" Laparoscopy with left salpingo-oophorectomy.  Left adnexal mass/ovarian lesion.  The labia and perineum were within normal limits.  The hymen was found to be intact.  Laparoscopic findings revealed a 4 cm left adnexal mass, which appeared fluid filled.  ", Obstetrics / Gynecology, Laparoscopy & Salpingo-oophorectomy ,"PREOPERATIVE DIAGNOSIS:,  Left adnexal mass.,POSTOPERATIVE DIAGNOSIS:,  Left ovarian lesion.,PROCEDURE PERFORMED:  ,Laparoscopy with left salpingo-oophorectomy.,ANESTHESIA:,  General.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,COMPLICATIONS:,  None.,FINDINGS:,  The labia and perineum were within normal limits.  The hymen was found to be intact.  Laparoscopic findings revealed a 4 cm left adnexal mass, which appeared fluid filled.  There were a few calcifications on the surface of the mass.  The right ovary and fallopian tube appeared normal.  There was no evidence of endometriosis.  The uterus appeared normal in size.  There were no pelvic adhesions noted.,INDICATIONS: , The patient is a 55-year-old gravida 0, para 0 Caucasian female who presents with a left adnexal mass on ultrasound which is 5.3 cm.  She does complain of minimal discomfort.  Bimanual exam was not able to be performed secondary to the vaginal stenosis and completely intact hymen.,PROCEDURE IN DETAIL: , After informed consent was obtained, the patient was taken back to the Operative Suite, prepped and draped, and placed in the dorsal lithotomy position.  A 1 cm skin incision was made in the infraumbilical vault.  While tenting up the abdominal wall, the Veress needle was inserted without difficulty and the abdomen was insufflated.  This was done using appropriate flow and volume of CO2.  The #11 step trocar was then placed without difficulty.  The above findings were confirmed.  A #12 mm port was then placed approximately 2 cm above the pubic symphysis under direct visualization.  Two additional ports were placed, one on the left lateral aspect of the abdominal wall and one on the right lateral aspect of the abdominal wall.  Both #12 step ports were done under direct visualization.  Using a grasper, the mass was tented up at the inferior pelvic ligament and the LigaSure was placed across this and several bites were taken with good visualization while ligating.  The left ovary was then placed in an Endocatch bag and removed through the suprapubic incision.  The skin was extended around this incision and the fascia was extended using the Mayo scissors.  The specimen was removed intact in the Endocatch bag through this site.  Prior to desufflation of the abdomen, the site where the left adnexa was removed was visualized to be hemostatic.  All the port sites were hemostatic as well.  The fascia of the suprapubic incision was then repaired using a running #0 Vicryl stitch on a UR6 needle.  The skin was then closed with #4-0 undyed Vicryl in a subcuticular fashion.  The remaining incisions were also closed with #4-0 undyed Vicryl in a running fashion after all instruments were removed and the abdomen was completely desufflated.  Steri-Strips were placed on each of the incisions.  The patient tolerated the procedure well.  Sponge, lap, and needle count were x2.  She will go home on Vicodin for pain and followup postoperatively in the office where we will review path report with her.","obstetrics / gynecology, salpingo-oophorectomy, ovarian lesion, adnexal mass, salpingo oophorectomy, abdominal wall, intact, adnexal, laparoscopy, mass,"
 Exploratory laparotomy and right salpingectomy., Obstetrics / Gynecology, Laparotomy & Salpingectomy ,"PREOPERATIVE DIAGNOSES:,1.  Right ectopic pregnancy.,2.  Severe abdominal pain.,3.  Tachycardia.,POSTOPERATIVE DIAGNOSES:,1.  Right ectopic pregnancy.,2.  Severe abdominal pain.,3.  Tachycardia.,PROCEDURE PERFORMED:,  Exploratory laparotomy and right salpingectomy.,ANESTHESIA:  ,General endotracheal.,ESTIMATED BLOOD LOSS: , 200 mL.,COMPLICATIONS:  ,None.,FINDINGS: , Right ectopic pregnancy with brisk active bleeding approximately 1L of blood found in the abdomen cavity.  Normal-appearing ovaries bilaterally, normal-appearing left fallopian tube, and normal-appearing uterus.,INDICATIONS:  ,The patient is a 23-year-old gravida P2, P0 at approximately who presented to ER at approximately 8 weeks gestational age with vaginal bleeding and severe abdominal pain.  The patient states she is significant for a previous right ectopic pregnancy diagnosed in 08/08 and treated appropriately and adequately with methotrexate.  Evaluation in the emergency room reveals a second right ectopic pregnancy.  Her beta quant was found to be approximately 13,000.  The ultrasound showed right adnexal mass with crown-rump length measuring consistent with an 8 weeks gestation and a moderate free fluid in the abdominal cavity.  Given these findings as well as physical examination findings a recommendation was made proceed with an exploratory laparotomy and right salpingectomy.  The procedure was discussed with the patient in detail including risks of bleeding, infection, injury to surrounding organs and possible need for further surgery.  Informed consult was obtained prior to proceeding with the procedure.,PROCEDURE NOTE:  ,The patient was taken to the operating room where general anesthesia was administered without difficulty.  The patient was prepped and draped in the usual sterile fashion.  A Pfannenstiel skin incision was made with scalpel and carried through to the underlying layer of fascia using the Bovie.  The fascia was incised in the midline and extended laterally using Mayo scissors.  Kocher clamps were used to grasp the superior aspect of the fascial incision, which was elevated and the underlying rectus muscles were dissected off bluntly using Mayo scissors, attention was then turned to the inferior aspect, which was grasped with Kocher clamps, elevated and the underlying rectus muscles dissected up bluntly using Mayo scissors.  The rectus muscles were dissected in the midline.  The peritoneum was identified using blunt dissection and entered in this manner and extended superiorly and inferiorly with good visualization of the bladder.  At this time, the blood found in the abdomen was suctioned.  The bowel was packed with moist laparotomy sponge.  The right ectopic pregnancy was identified.  The fallopian tube was clamped x2, excised, and ligated x2 using 0-Vicryl suture.  Hemostasis was visualized.  At this time, the left tube and ovary were examined and were found to be normal in appearance.  The pelvis was cleared off clots and was copiously irrigated.  The fallopian tube was reexamined and it was noted to be hemostatic.,At this time, the laparotomy sponges were removed.  The rectus muscles were reapproximated using 3-0 Vicryl.  The fascia was reapproximated with #0 Vicryl sutures.  The subcutaneous layer was closed with 3-0 plain gut.  The skin was closed with 4-0 Monocryl.  Sponge, lap, and instrument counts were correct x2.  The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition.","obstetrics / gynecology, ectopic pregnancy, salpingectomy, exploratory laparotomy, fallopian tube, mayo scissors, rectus muscles, "
" Attempted laparoscopy, open laparoscopy and fulguration of endometrial implant.   Chronic pelvic pain, probably secondary to endometriosis.", Obstetrics / Gynecology, Laparoscopy - 3 ,"PREOPERATIVE DIAGNOSIS: , Chronic pelvic pain, probably secondary to endometriosis.,POSTOPERATIVE DIAGNOSIS:,  Mild pelvic endometriosis.,PROCEDURE:,1.  Attempted laparoscopy.,2.  Open laparoscopy.,3.  Fulguration of endometrial implant.,ANESTHESIA: , General endotracheal.,BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,INDICATIONS:  ,The patient is a 21-year-old single female with chronic recurrent pelvic pain unresponsive to both estrogen and progesterone-containing birth control pills, either cyclically or daily as well as progestational medication only, who had a negative GI workup recently including colonoscopy, and desired definitive operative evaluation and diagnosis prior to initiation of a 6-month course of Depo-Lupron.,PROCEDURE: , After an adequate plane of general anesthesia had been obtained, the patient was placed in a dorsal lithotomy position.  She was prepped and draped in the usual sterile fashion for pelviolabdominal surgery.  Bimanual examination revealed a mid position normal-sized uterus with benign adnexal area.,In the high lithotomy position, a weighted speculum was placed into the posterior vaginal wall.  The anterior lip of the cervix was grasped with a single-tooth tenaculum.  A Hulka tenaculum was placed transcervically.  The other instruments were removed.  A Foley catheter was placed transurethrally to drain the bladder intraoperatively.,In the low lithotomy position and in steep Trendelenburg, attention was turned to the infraumbilical region.  Here, a stab wound incision was made through which the 120 mm Veress needle was placed and approximately 3 L of carbon dioxide used to create a pneumoperitoneum.  The needle was removed, the incision minimally enlarged, and the #5 trocar and cannula were placed.  The trocar was removed and the scope placed confirming a preperitoneal insufflation.,The space was drained off the insufflated gas and 2 more attempts were made, which failed due to the patient's adiposity.  Attention was turned back to the vaginal area where in the high lithotomy position, attempts were made at a posterior vaginal apical insertion.  The Hulka tenaculum was removed, the posterior lip of the cervix grasped with a single-tooth tenaculum, and the long Allis clamp used to grasp the posterior fornix on which was placed traction.  The first short and subsequently 15 cm Veress needles were attempted to be placed, but after several passes, no good pneumoperitoneum could be established via this route also.  It was elected not to do a transcervical intentional uterine perforation, but to return to the umbilical area.  The 15 cm Veress needle was inserted several times, but again a pneumo was preperitoneal.,Finally, an open laparoscopic approach was undertaken.  The skin incision was expanded with a knife blade.  Blunt dissection was used to carry the dissection down to the fascia.  This was grasped with Kocher clamps, entered sharply and opened transversely.  Four 0 Vicryl sutures were placed as stay sutures and tagged with hemostats and needles were cutoff.  Dissection continued between the rectus muscle and finally the anterior peritoneum was reached, grasped, elevated, and entered.,At this juncture, the Hasson cannula was placed and tied snugly with the above stay sutures while the pneumoperitoneum was being created, a #10 scope was placed confirming the intraperitoneal positioning.,Under direct visualization, a suprapubic 5 mm cannula and manipulative probe were placed.  Clockwise inspection of the pelvis revealed a benign vesicouterine pouch, normal uterus and fundus, normal right tube and ovary.  In the cul-de-sac, there were 3 clusters of 3 to 5 carbon charred type endometrial implants and those more distally in the greatest depth had created puckering and tenting.  The left tube and ovary were normal.  There were no adhesions.  There was no evidence of acute pelvic inflammatory disease.,The Endoshears and subsequently cautery on a hook were placed and the implants fulgurated.  Pictures were taken for confirmation both before and after the burn.,The carbon chars were irrigated and aspirated.  The smoke plume was removed without difficulty.  Approximately 50 mL of irrigant was left in the pelvis.  Due to the difficulty in placing and maintaining the Hasson cannula, no attempts were made to view the upper abdominal quadrant, specifically the liver and gallbladder.,The suprapubic cannula was removed under direct visualization, the pneumo released, the scope removed, the stay sutures cut, and the Hasson cannula removed.  The residual sutures were then tied together to completely occlude the fascial opening so that there will be no future hernia at this site.  Finally, the skin incisions were approximated with 3-0 Dexon subcuticularly.  They had been preincisionally injected with bupivacaine to which the patient said she had no known allergies.  The vaginal instruments were removed.  All counts were correct.  The patient tolerated the procedure well and was taken to the recovery room in stable condition.","obstetrics / gynecology, endometriosis, fulguration, endometrial, single tooth tenaculum, endometrial implant, hulka tenaculum, veress needle, hasson cannula, pneumoperitoneum, laparoscopy, cannula, "
" Laparoscopy with ablation of endometriosis.  Allen-Masters window in the upper left portion of the cul-de-sac, bronze lesions of endometriosis in the central portion of the cul-de-sac as well as both the left uterosacral ligament, flame lesions of the right uterosacral ligament approximately 5 mL of blood tinged fluid in the cul-de-sac.", Obstetrics / Gynecology, Laparoscopy - 4 ,"PROCEDURE: , Laparoscopy with ablation of endometriosis.,DIAGNOSIS: , Endometriosis.,ANESTHESIA:,  General.,ESTIMATED BLOOD LOSS: , None.,FINDINGS: , Allen-Masters window in the upper left portion of the cul-de-sac, bronze lesions of endometriosis in the central portion of the cul-de-sac as well as both the left uterosacral ligament, flame lesions of the right uterosacral ligament approximately 5 mL of blood tinged fluid in the cul-de-sac.  Normal tubes and ovaries, normal gallbladder, smooth liver edge.,PROCEDURE:  ,The patient was taken to the operating room and placed under general anesthesia.  She was put in the dorsal lithotomy position, and the perineum and abdomen were prepped and draped in a sterile manner.  Subumbilical area was injected with Marcaine, and a Veress needle was placed subumbilically through which approximately 2 L of CO2 were inflated.  Scalpel was used to make a subumbilical incision through which a 5-mm trocar was placed.  Laparoscope was inserted through the cannula and the pelvis was visualized.  Under direct visualization, two 5-mm trocars were placed in the right and left suprapubic midline.  Incision sites were transilluminated and injected with Marcaine prior to cutting.  Hulka manipulator was placed on the cervix.  Pelvis was inspected and blood tinged fluid was aspirated from the cul-de-sac.  The beginnings of an Allen-Masters window in the left side of the cul-de-sac were visualized along with bronze lesions of endometriosis.  Some more lesions were noted above the left uterosacral ligament.  Flame lesions were noted above the right uterosacral ligament.  Tubes and ovaries were normal bilaterally with the presence of a few small paratubal cysts on the left tube.  There was a somewhat leathery appearance to the ovaries.  The lesions of endometriosis were ablated with the argon beam coagulator, as was a region of the Allen-Masters window.  Pelvis was irrigated and all operative sites were hemostatic.  No other abnormalities were visualized and all instruments were moved under direct visualization.  Approximately 200 mL of fluid remained in the abdominal cavity.  All counts were correct and the skin incisions were closed with 2-0 Vicryl after all CO2 was allowed to escape.  The patient was taken to the recovery in stable condition.","obstetrics / gynecology, ablation of endometriosis, allen-masters window, uterosacral ligament, endometriosis, cul de sac, laparoscopy, lesions, ablation"
" Laparoscopy.  An incision was made in the umbilicus, allowing us to insert a micro-laparoscopic trocar.  We then insufflated the abdomen with approximately 3 liters of carbon dioxide gas and inserted the micro-laparoscopic instrument.", Obstetrics / Gynecology, Laparoscopy - 2 ,,"obstetrics / gynecology, umbilicus, trocar, falope, laparoscopy, abdomen, suprapubic, laparoscopicNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Laparotomy and myomectomy.   Enlarged fibroid uterus and blood loss anemia.  On bimanual exam, the patient has an enlarged, approximately 14-week sized uterus that is freely mobile and anteverted with no adnexal masses.  Surgically, the patient has an enlarged fibroid uterus with a large fundal/anterior fibroids.", Obstetrics / Gynecology, Laparotomy & Myomectomy ,"PREOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Blood loss anemia.,POSTOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Blood loss anemia.,PROCEDURE PERFORMED:,1.  Laparotomy.,2.  Myomectomy.,ANESTHESIA:  ,General.,ESTIMATED BLOOD LOSS: , Less than a 100 cc.,URINE OUTPUT: , 110 cc, clear at the end of the procedure.,FLUIDS: , 500 cc during the procedure.,SPECIMENS: , Four uterine fibroids.,DRAINS:  ,Foley catheter to gravity.,COMPLICATIONS: , None.,FINDINGS: , On bimanual exam, the patient has an enlarged, approximately 14-week sized uterus that is freely mobile and anteverted with no adnexal masses.  Surgically, the patient has an enlarged fibroid uterus with a large fundal/anterior fibroids, which is approximately 6+ cm and several small submucosal fibroids within the endometrium.  Both ovaries and tubes appeared within normal limits.,PROCEDURE: , The patient was taken to the operating room where she was prepped and draped in the normal sterile fashion in the dorsal supine position.  After the general anesthetic was found to be adequate, a Pfannenstiel skin incision was made with the first knife.  This was carried through the underlying layer of fascia with a second knife.  The fascia was incised in the midline with the second knife and the fascial incision was then extended laterally in both directions with the Mayo scissors.  The superior aspect of the fascial incision was then grasped with Ochsner clamps, tented up, and dissected off the underlying layer of rectus muscle bluntly.  It was then dissected in the middle with the Mayo scissors.  The inferior aspect of this incision was addressed in a similar manner.  The rectus muscles were separated in the midline bluntly.  The peritoneum was identified with hemostat clamps, tented up, and entered sharply with the Metzenbaum scissors.  The peritoneal incision was then extended superiorly and inferiorly with the Metzenbaum scissors and then extended bluntly.  Next, the uterus was grasped bluntly and removed from the abdomen.  The fundal fibroid was identified.  It was then injected with vasopressin, 20 units mixed in 30 cc of normal saline along the serosal surface and careful to aspirate to avoid any blood vessels.  15 cc was injected.  Next, the point tip was used with the cautery _______ cutting to cut the linear incision along the top of the _______ fibroid until fibroid fibers were seen.  The edges of the myometrium was grasped with Allis clamps, tented up, and a hemostat was used to bluntly dissect around the fibroid followed by blunt dissection with a finger.  The fibroid was easily and bluntly dissected out.  It was also grasped with Lahey clamp to prevent traction.  Once the blunt dissection of the large fibroid was complete, it was handed off to the scrub nurse.  The large fibroid traversed the whole myometrium down to the mucosal surface and the endometrial cavity was largely entered when this fibroid was removed.  At this point, several smaller fibroids were noticed along the endometrial surface of the uterus.  Three of these were removed just by bluntly grasping with the Lahey clamp and twisting, all three of these were approximately 1 cm to 2 cm in size.  These were also handed to the scrub tech.  Next, the uterine incision was then closed with first two interrupted layers of #0 chromic in an interrupted figure-of-eight fashion and then with a #0 Vicryl in a running baseball stitch.  The uterus was seen to be completely hemostatic after closure.  Next, a 3 x 4 inch piece of Interceed was placed over the incision and dampened with normal saline.  The uterus was then carefully returned to the abdomen and being careful not to disturb the Interceed.  Next, the greater omentum was replaced over the uterus.,The rectus muscles were then reapproximated with a single interrupted suture of #0 Vicryl in the midline.  Then the fascia was closed with #0 Vicryl in a running fashion.  Next, the Scarpa's fascia was closed with #3-0 plain gut in a running fashion and the skin was closed with #4-0 undyed Vicryl in a running subcuticular fashion.  The incision was then dressed with 0.5-inch Steri-Strips and bandaged appropriately.  After the patient was cleaned, she was taken to Recovery in stable condition and she will be followed for her immediate postoperative period during the hospital.","obstetrics / gynecology, enlarged fibroid uterus, blood loss anemia, laparotomy, myomectomy, metzenbaum scissors, uterus, fibroid, rectus, fascia, scissors, fashion, clamps, enlarged, incision, bluntly, "
" Pelvic pain, pelvic endometriosis, and pelvic adhesions.  Laparoscopy, Harmonic scalpel ablation of endometriosis, lysis of adhesions, and cervical dilation.  Laparoscopically, the patient has large omental to anterior abdominal wall adhesions along the left side of the abdomen extending down to the left adnexa. ", Obstetrics / Gynecology, Laparoscopy ,"PREOPERATIVE DIAGNOSIS:,  Pelvic pain.,POSTOPERATIVE DIAGNOSES:,1.  Pelvic pain.,2.  Pelvic endometriosis.,3.  Pelvic adhesions.,PROCEDURE PERFORMED:,1.  Laparoscopy.,2.  Harmonic scalpel ablation of endometriosis.,3.  Lysis of adhesions.,4.  Cervical dilation.,ANESTHESIA:  ,General.,SPECIMEN:  ,Peritoneal biopsy.,ESTIMATED BLOOD LOSS:,  Scant.,COMPLICATIONS: , None.,FINDINGS: , On bimanual exam, the patient has a small, anteverted, and freely mobile uterus with no adnexal masses.  Laparoscopically, the patient has large omental to anterior abdominal wall adhesions along the left side of the abdomen extending down to the left adnexa.  There are adhesions involving the right ovary to the anterior abdominal wall and the bowel.  There are also adhesions from the omentum to the anterior abdominal wall near the liver.  The uterus and ovaries appear within normal limits other than the adhesions.  The left fallopian tube grossly appeared within normal limits.  The right fallopian tube was not well visualized but appeared grossly scarred and no tubal end was visualized.  There was a large area of endometriosis, approximately 1 cm wide in the left ovarian fossa and there was a small spot of endometriosis in the posterior cul-de-sac.  There was also vesicular appearing endometriosis lesion in the posterior cul-de-sac.,PROCEDURE:  ,The patient was taken in the operating room and generalized anesthetic was administered.  She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion.  After exam under anesthetic, weighted speculum was placed in the vagina.  The anterior lip of the cervix was grasped with vulsellum tenaculum.  The uterus was sounded and then was serially dilated with Hank dilators to a size 10 Hank, then the uterine manipulator was inserted and attached to the anterior lip of the cervix.  At this point, the vulsellum tenaculum was removed along with the weighted speculum and attention was turned towards the abdomen.  An approximately 2 cm incision was made immediately inferior to the umbilicus with the skin knife.  The superior aspect of the umbilicus was grasped with a towel clamp.  The abdomen was tented up and a Veress needle inserted through this incision.  When the Veress needle was felt to be in place, deep position was checked by placing saline in the needle.  This was seen to freely drop in the abdomen so it was connected to CO2 gas.  Again, this was started at the lowest setting, was seen to flow freely, so it was advanced to the high setting.  The abdomen was then insufflated to an adequate distention.  Once an adequate distention was reached, the CO2 gas was disconnected.  The Veress needle was removed and a size #11 step trocar was placed.  Next, the laparoscope was inserted through this port.  The medial port was connected to CO2 gas.  Next, a 1 cm incision was made in the midline approximately 2 fingerbreadths above the pubic symphysis.  Through this, a Veress needle was inserted followed by size #5 step trocar and this procedure was repeated under direct visualization on the right upper quadrant lateral to the umbilicus and a size #5 trocar was also placed.  Next, a grasper was placed through the suprapubic port.  This was used to grasp the bowel that was adhesed to the right ovary and the Harmonic scalpel was then used to lyse these adhesions.  Bowel was carefully examined afterwards and no injuries or bleeding were seen.  Next, the adhesions touching the right ovary and anterior abdominal wall were lysed with the Harmonic scalpel and this was done without difficulty.  There was a small amount of bleeding from the anterior abdominal wall peritoneum.  This was ablated with the Harmonic scalpel.  The Harmonic scalpel was used to lyse and ablate the endometriosis in the left ovarian fossa and the posterior cul-de-sac.  Both of these areas were seen to be hemostatic.  Next, a grasper was placed and was used to bluntly remove the vesicular lesion from the posterior cul-de-sac.  This was sent to pathology.  Next, the pelvis was copiously irrigated with the Nezhat dorsi suction irrigator and the irrigator was removed.  It was seen to be completely hemostatic.  Next, the two size #5 ports were removed under direct visualization.  The camera was removed.  The abdomen was desufflated.  The size #11 introducer was replaced and the #11 port was removed.,Next, all the ports were closed with #4-0 undyed Vicryl in a subcuticular interrupted fashion.  The incisions were dressed with Steri-Strips and bandaged appropriately and the patient was taken to recovery in stable condition and she will be discharged home today with Darvocet for pain and she will follow-up in one week in the clinic for pathology results and to have a postoperative check.","obstetrics / gynecology, pelvic pain, endometriosis, pelvic adhesions, laparoscopy, scalpel ablation, lysis of adhesions, cervical dilation, peritoneal biopsy, harmonic scalpel, adhesions, harmonic, scalpel, abdominal, pelvic, abdomen, anterior, "
 Laparoscopy.  The cervix was grasped with a single-tooth tenaculum.  The uterus was gently sounded and a manipulator was inserted for movement of the uterus throughout the case. , Obstetrics / Gynecology, Laparoscopy - 1 ,,"obstetrics / gynecology, uterus, cervix, vaginal, single tooth tenaculum, trocar sites, laparoscopy, bladder, laparoscopic, abdominal, cavity, trocar, toothNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Dilatation and curettage (D&C) and Laparoscopic ablation of endometrial implants.  Pelvic pain, hypermenorrhea, and mild pelvic endometriosis.", Obstetrics / Gynecology, Laparoscopic Ablation of Eendometrial Implants ,"PREOPERATIVE DIAGNOSES:,1.  Pelvic pain.,2.  Hypermenorrhea.,POSTOPERATIVE DIAGNOSES:,1.  Pelvic pain.,2.  Hypermenorrhea.,3.  Mild pelvic endometriosis.,PROCEDURE PERFORMED:,1.  Dilatation and curettage (D&C).,2.  Laparoscopic ablation of endometrial implants.,ANESTHESIA:  ,General endotracheal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,SPECIMEN: , Endometrial curettings.,INDICATIONS: , This is a 26-year-old female with a history of approximately one year of heavy painful menses.  She did complain of some dyspareunia and wants a definitive diagnosis.,FINDINGS: , On bimanual exam, the uterus is small and anteverted with mildly decreased mobility on the left side.  There are no adnexal masses appreciated.  On laparoscopic exam, the uterus is normal appearing but slightly compressible.  The bilateral tubes and ovaries appear normal.  There is evidence of endometriosis on the left pelvic sidewall in the posterior cul-de-sac.  There was no endometriosis in the right pelvic sidewall or along the bladder flap.,There were some adhesions on the right abdominal sidewall from the previous appendectomy.  The liver margin, gallbladder, and bowel appeared normal.  The uterus was sounded to 9 cm.,PROCEDURE: , After consent was obtained, the patient was taken to the operating room and general anesthetic was administered.  The patient was placed in dorsal lithotomy position and prepped and draped in normal sterile fashion.  Sterile speculum was placed in the patient's vagina.  The anterior lip of the cervix was grasped with vulsellum tenaculum.  The uterus was sounded to 9 cm.  The cervix was then serially dilated with Hank dilators.  A sharp curettage was performed until a gritty texture was noted in all aspects of the endometrium.  The moderate amount of tissue that was obtained was sent to Pathology.  The #20 Hank dilator was then replaced and the sterile speculum was removed.  Gloves were changed and attention was then turned to the abdomen where approximately 10 mm transverse infraumbilical incision was made.  The Veress needle was placed into this incision and the gas was turned on.  When good flow and low abdominal pressures were noted, the gas was turned up and the abdomen was allowed to insufflate.  The #11 mm trocar was then placed through this incision and a camera was placed with the above findings noted.  A Bierman needle was placed 2 cm superior to the pubic bone and along the midline to allow a better visualization of the pelvic organs.  A 5 mm port was placed approximately 7 cm to 8 cm to the right of the umbilicus and approximately 3 cm inferior.  The harmonic scalpel was placed through this port and the areas of endometriosis were ablated using the harmonic scalpel.  A syringe was placed on to the Bierman needle and a small amount of fluid in the posterior cul-de-sac was removed to allow better visualization of the posterior cul-de-sac.  The lesions in the posterior cul-de-sac were then ablated using the Harmonic scalpel.  All instruments were then removed.  The Bierman needle and 5 mm port was removed under direct visualization with excellent hemostasis noted.  The camera was removed and the abdomen was allowed to desufflate.  The 11 mm trocar introducer was replaced and the trocar was removed.  The skin was closed with #4-0 undyed Vicryl in subcuticular fashion.  ,Approximately 10 cc of 0.25% Marcaine was placed in the incision sites.  The dilator and vulsellum tenaculum were removed from the patient's cervix with excellent hemostasis noted.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct at the end of procedure.  The patient was taken to the recovery room in satisfactory condition.  She will be discharged home with a prescription for Darvocet for pain and is instructed to follow up in the office in two weeks with further treatment will be discussed including approximately six months of continuous monophasic oral contraceptives.","obstetrics / gynecology, pelvic pain, hypermenorrhea, endometriosis, dilatation and curettage, d&c, endometrial implants, ablation, cul de sac, vulsellum tenaculum, hank dilators, laparoscopic ablation, bierman needle, pelvic, "
 Laparoscopic supracervical hysterectomy.  A female with a history of severe dysmenorrhea and menorrhagia unimproved with medical management., Obstetrics / Gynecology, Laparoscopic Supracervical Hysterectomy.   ,"PREOPERATIVE DIAGNOSIS,1.  Dysmenorrhea.,2.  Menorrhagia.,POSTOPERATIVE DIAGNOSIS,1.  Dysmenorrhea.,2.  Menorrhagia.,PROCEDURE:,  Laparoscopic supracervical hysterectomy.,ESTIMATED BLOOD LOSS:,  30 cc.,COMPLICATIONS:,  None.,INDICATIONS FOR SURGERY: , A female with a history of severe dysmenorrhea and menorrhagia unimproved with medical management.  Please see clinic notes.  Risks of bleeding, infection, damage to other organs have been explained.  Informed consent was obtained.,OPERATIVE FINDINGS:,  Slightly enlarged but otherwise normal-appearing uterus.  Normal-appearing adnexa bilaterally.,OPERATIVE PROCEDURE IN DETAIL: , After administration of general anesthesia the patient was placed in dorsal lithotomy position, prepped and draped in the usual sterile fashion.  Uterine manipulator was inserted as well as a Foley catheter and this was then draped off from the remainder of the abdominal field.  A 5 mm incision was made umbilically after injecting 0.25% Marcaine; 0.25% Marcaine was injected in all the incisional sites.  Veress needle was inserted, position confirmed using the saline drop method.  After confirming an opening pressure of 4 mmHg of CO2 gas, approximately four liters was insufflated in the abdominal cavity.  Veress needle was removed and a 5 mm port placed and position confirmed using the laparoscope.  A 5 mm port was placed three fingerbreadths suprapubically and on the left and right side.  All these were placed under direct visualization.  Pelvic cavity was examined with findings as noted above.  The left utero-ovarian ligament was grasped and cauterized using the Gyrus.  Part of the superior aspect of the broad ligament was then cauterized as well.  Following this the anterior peritoneum over the bladder flap was incised and the bladder flap bluntly resected off the lower uterine segment.  The remainder of the broad and cardinal ligament was then cauterized and excised.  A similar procedure was performed on the right side.  The cardinal ligament was resected all the way down to 1 cm above the uterosacral ligament.  After assuring that the bladder was well out of the way of the operative field, bipolar cautery was used to incise the cervix at a level just above the uterosacral ligaments.  The area was irrigated extensively and cautery used to assure hemostasis.  A 15 mm probe was then placed on the right side and the uterine morcellator was used to remove the specimen and submitted to pathology for examination.  Hemostasis was again confirmed under low pressure.  Using Carter-Thomason the fascia was closed in the 15 mm port site with 0 Vicryl suture.  The accessory ports were removed and abdomen deflated and skin edges reapproximated with 5-0 Monocryl suture.  Instruments removed from vagina.  Patient returned to supine position, recalled from general anesthesia and transferred to recovery in satisfactory condition.  Sponge and needle counts correct at the conclusion of the case.  Estimated blood loss was 30 cc.  There were no complications.","obstetrics / gynecology, adnexa, uterus, laparoscopic supracervical hysterectomy, veress needle, bladder flap, cardinal ligament, uterine, cauterized, dysmenorrhea, menorrhagia,"
"  Total laparoscopic hysterectomy with laparoscopic staging, including paraaortic lymphadenectomy, bilateral pelvic and obturator lymphadenectomy, and washings.", Obstetrics / Gynecology, Laparoscopic Hysterectomy ,"PREOPERATIVE DIAGNOSIS:,  Endometrial carcinoma.,POSTOPERATIVE DIAGNOSIS: , Endometrial carcinoma.,PROCEDURE PERFORMED:,  Total laparoscopic hysterectomy with laparoscopic staging, including paraaortic lymphadenectomy, bilateral pelvic and obturator lymphadenectomy, and washings.,ANESTHESIA: , General, endotracheal tube.,SPECIMENS: , Pelvic washings for cytology; uterus with attached right tube and ovary; pelvic and paraaortic lymph node dissection; obturator lymph node dissection.,INDICATIONS FOR PROCEDURE: , The patient was recently found to have a grade II endometrial cancer.  She was counseled to undergo laparoscopic staging.,FINDINGS:,  During the laparoscopy, the uterus was noted to be upper limits of normal size, with a normal-appearing right fallopian tubes and ovaries.  No ascites was present.  On assessment of the upper abdomen, the stomach, diaphragm, liver, gallbladder, spleen, omentum, and peritoneal surfaces of the bowel, were all unremarkable in appearance.,PROCEDURE: , The patient was brought into the operating room with an intravenous line in placed, and anesthetic was administered.  She was placed in a low anterior lithotomy position using Allen stirrups.  The vaginal portion of the procedure included placement of a ZUMI uterine manipulator with a Koh colpotomy ring and a vaginal occluder balloon.,The laparoscopic port sites were anesthetized with intradermal injection of 0.25% Marcaine.  There were five ports placed, including a 3-mm left subcostal port, a 10-mm umbilical port, a 10-mm suprapubic port, and 5-mm right and left lower quadrant ports.  The Veress needle was placed through a small incision at the base of the umbilicus, and a pneumoperitoneum was insufflated without difficulty.  The 3-mm port was then placed in the left subcostal position without difficulty, and a 3-mm scope was placed.  There were no adhesions underlying the previous vertical midline scar.  The 10-mm port was placed in the umbilicus, and the laparoscope was inserted.  Remaining ports were placed under direct laparoscopic guidance.  Washings were obtained from the pelvis, and the abdomen was explored with the laparoscope, with findings as noted.,Attention was then turned to lymphadenectomy.  An incision in the retroperitoneum was made over the right common iliac artery, extending up the aorta to the retroperitoneal duodenum.  The lymph node bundle was elevated from the aorta and the anterior vena cava until the retroperitoneal duodenum had been reached.  Pedicles were sealed and divided with bipolar cutting forceps.  Excellent hemostasis was noted.  Boundaries of dissection included the ureters laterally, common ileac arteries at uterine crossover inferiorly, and the retroperitoneal duodenum superiorly with careful preservation of the inferior mesenteric artery.  Right and left pelvic retroperitoneal spaces were then opened by incising lateral and parallel to the infundibulopelvic ligament with the bipolar cutting forceps.  The retroperitoneal space was then opened and the lymph nodes were dissected, with boundaries of dissection being the bifurcation of the common iliac artery superiorly, psoas muscle laterally, inguinal ligament inferiorly, and the anterior division of the hypogastric artery medially.  The posterior boundary was the obturator nerve, which was carefully identified and preserved bilaterally.  The left common iliac lymph node was elevated and removed using the same technique.,Attention was then turned to the laparoscopic hysterectomy.  The right infundibulopelvic ligament was divided using the bipolar cutting forceps.  The mesovarium was skeletonized.  A bladder flap was mobilized by dividing the round ligaments using the bipolar cutting forceps, and the peritoneum on the vesicouterine fold was incised to mobilize the bladder.  Once the Koh colpotomy ring was skeletonized and in position, the uterine arteries were sealed using the bipolar forceps at the level of the colpotomy ring.  The vagina was transected using a monopolar hook (or bipolar spatula), resulting in separation of the uterus and attached tubes and ovaries.  The uterus, tubes, and ovaries were then delivered through the vagina, and the pneumo-occluder balloon was reinserted to maintain pneumoperitoneum.  The vaginal vault was closed with interrupted figure-of-eight stitches of 0-Vicryl using the Endo-Stitch device.  The abdomen was irrigated, and excellent hemostasis was noted.,The insufflation pressure was reduced, and no evidence of bleeding was seen.  The suprapubic port was then removed, and the fascia was closed with a Carter-Thomason device and 0-Vicryl suture.  The remaining ports were removed under direct laparoscopic guidance, and the pneumoperitoneum was released.  The umbilical port was removed using laparoscopic guidance.  The umbilical fascia was closed with an interrupted figure-of-eight stitch using 2-0 Vicryl.  The skin was closed with interrupted subcuticular stitches using 4-0 Monocryl suture.  The final sponge, needle, and instrument counts were correct at the completion of the procedure.  The patient was awakened and taken to the post anesthesia care unit in stable condition.","obstetrics / gynecology, endometrial carcinoma, laparoscopic hysterectomy, total laparoscopic hysterectomy, laparoscopic staging, lymphadenectomy, pelvic, obturator, lymph node dissection, direct laparoscopic guidance, tubes and ovaries, bipolar cutting forceps, node dissection, koh colpotomy, iliac artery, infundibulopelvic ligament, laparoscopic guidance, retroperitoneal duodenum, lymph node, laparoscopic, hysterectomy, endometrial, pneumoperitoneum, washings, vaginal, retroperitoneal, forceps, bipolar,"
 Exam under anesthesia.  Removal of intrauterine clots.  Postpartum hemorrhage, Obstetrics / Gynecology, Intrauterine Clots Removal ,"PREOPERATIVE DIAGNOSIS: , Postpartum hemorrhage.,POSTOPERATIVE DIAGNOSIS: , Postpartum hemorrhage.,PROCEDURE:,  Exam under anesthesia.  Removal of intrauterine clots.,ANESTHESIA: , Conscious sedation.,ESTIMATED BLOOD LOSS:,  Approximately 200 mL during the procedure, but at least 500 mL prior to that and probably more like 1500 mL prior to that.,COMPLICATIONS: , None.,INDICATIONS AND CONCERNS: , This is a 19-year-old G1, P1 female, status post vaginal delivery, who was being evaluated by the nurse on labor and delivery approximately four hours after her delivery.  I was called for persistent bleeding and passing large clots.  I examined the patient and found her to have at least 500 mL of clots in her uterus.  She was unable to tolerate exam any further than that because of concerns of the amount of bleeding that she had already had and inability to adequately evaluate her.  I did advise her that I would recommend they came under anesthesia and dilation and curettage.  Risks and benefits of this procedure were discussed with Misty, all of her questions were adequately answered and informed consent was obtained.,PROCEDURE: , The patient was taken to the operating room where satisfactory conscious sedation was performed.  She was placed in the dorsal lithotomy position, prepped and draped in the usual fashion.  Bimanual exam revealed moderate amount of clot in the uterus.  I was able to remove most of the clots with my hands and an attempt at short curettage was performed, but because of contraction of the uterus this was unable to be adequately performed.  I was able to thoroughly examine the uterine cavity with my hand and no remaining clots or placental tissue or membranes were found.  At this point, the procedure was terminated.  Bleeding at this time was minimal.  Preop H&H were 8.3 and 24.2.  The patient tolerated the procedure well and was taken to the recovery room in good condition.","obstetrics / gynecology, uterus, intrauterine clots, postpartum hemorrhage, intrauterine, curettage, hemorrhage, bleeding, postpartum, clots,"
 Intrauterine pregnancy at term with previous cesarean.   Desired sterilization.  Status post repeat low transverse cesarean and bilateral tubal ligation., Obstetrics / Gynecology, Intrauterine Pregnancy - Discharge Summary ,"ADMITTING DIAGNOSIS:,  Intrauterine pregnancy at term with previous cesarean.,SECONDARY DIAGNOSIS: , Desired sterilization.,DISCHARGE DIAGNOSES,1.  Intrauterine pregnancy at term with previous cesarean.,2.  Desired sterilization.,3.  Status post repeat low transverse cesarean and bilateral tubal ligation.,HISTORY: , The patient is a 35-year-old gravida 2, para 1-0-0-1 with intrauterine pregnancy on 08/30/09.  Pregnancy was uncomplicated.  She opted for a scheduled elective C-section and sterilization without any trial of labor.  All routine screening labs were normal and she underwent a high-resolution ultrasound during pregnancy.,PAST MEDICAL HISTORY: , Significant for postpartum depression after her last baby as well as a cesarean.,ALLERGIES:,  SHE HAS SEASONAL ALLERGIES.,MEDICATIONS:,  She is taking vitamins and iron.,PHYSICAL EXAMINATION,GENERAL:  An alert gravid woman in no distress.,ABDOMEN:  Gravid, nontender, non-irritable, with an infant in the vertex presentation.  Estimated fetal weight was greater than 10 pounds.,HOSPITAL COURSE:  ,On the first hospital day, the patient went to the operating room where repeat low transverse cesarean and tubal ligation were performed under spinal anesthesia with delivery of a viable female infant weighing 7 pounds 10 ounces and Apgars of 9 and 9.  There was normal placenta, normal pelvic anatomy.  There was 600 cc estimated blood loss.  Patient recovered uneventfully from her anesthesia and surgery.  She was able to ambulate and void.  She tolerated regular diet.  She passed flatus.  She was breast-feeding.  Postoperative hematocrit was 31.  On the second postoperative day, the patient was discharged home in satisfactory condition.,DISCHARGE MEDICATIONS: , Motrin and Percocet for pain.  Paxil for postpartum depression.  She was instructed to do no lifting, straining, or driving, to put nothing in the vagina and to see me in two weeks or with signs of severe pain, heavy bleeding, fever, or other problems.","obstetrics / gynecology, cesarean, bilateral tubal ligation, low transverse cesarean, intrauterine, gravida, sterilization, pregnancy, "
" Dilation and curettage (D&C), hysteroscopy, and laparoscopy with right salpingooophorectomy and aspiration of cyst fluid.  Thickened endometrium and tamoxifen therapy, adnexal cyst, endometrial polyp, and right ovarian cyst.", Obstetrics / Gynecology, Hysteroscopy & Laproscopy with Salpingooophorectomy ,"PREOPERATIVE DIAGNOSES:,1.  Thickened endometrium and tamoxifen therapy.,2.  Adnexal cyst.,POSTOPERATIVE DIAGNOSES:,1.  Thickened endometrium and tamoxifen therapy.,2.  Adnexal cyst.,3.  Endometrial polyp.,4.  Right ovarian cyst.,PROCEDURE PERFORMED:,1.  Dilation and curettage (D&C).,2.  Hysteroscopy.,3.  Laparoscopy with right salpingooophorectomy and aspiration of cyst fluid.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 20 cc.,COMPLICATIONS:,  None.,INDICATIONS: , This patient is a 44-year-old gravida 2, para 1-1-1-2 female who was diagnosed with breast cancer in December of 2002.  She has subsequently been on tamoxifen.  Ultrasound did show a thickened endometrial stripe as well as an adnexal cyst.  The above procedures were therefore performed.,FINDINGS:  ,On bimanual exam, the uterus was found to be slightly enlarged and anteverted.  The external genitalia was normal.  Hysteroscopic findings revealed both ostia well visualized and a large polyp on the anterolateral wall of the endometrium.  Laparoscopic findings revealed a normal-appearing uterus and normal left ovary.  There was no evidence of endometriosis on the ovaries bilaterally, the ovarian fossa, the cul-de-sac, or the vesicouterine peritoneum.  There was a cyst on the right ovary which appeared simple in nature.  The cyst was aspirated and the fluid was blood tinged.  Therefore, the decision to perform oophorectomy was made.  The liver margins appeared normal and there were no pelvic or abdominal adhesions noted.  The polyp removed from the hysteroscopic portion of the exam was found to be 4 cm in size.,PROCEDURE IN DETAIL: , After informed consent was obtained in layman's terms, the patient was taken back to the operating suite, prepped and draped and placed in the dorsal lithotomy position.  Her bladder was drained with a red Robinson catheter.  A bimanual exam was performed, which revealed the above findings.  A weighted speculum was then placed in the posterior vaginal vault in the 12 o'clock position and the cervix was grasped with vulsellum tenaculum.  The cervix was then sounded in the anteverted position to 10 cm.  The cervix was then serially dilated using Hank and Hegar dilators up to a Hank dilator of 20 and Hagar dilator of 10.  The hysteroscope was then inserted and the above findings were noted.  A sharp curette was then introduced and the 4 cm polyp was removed.  The hysteroscope was then reinserted and the polyp was found to be completely removed at this point.  The polyp was sent to Pathology for evaluation.  The uterine elevator was then placed as a means to manipulate the uterus.  The weighted speculum was removed.  Gloves were changed.  Attention was turned to the anterior abdominal wall where 1 cm infraumbilical skin incision was made.  While tenting up the abdominal wall, the Veress needle was inserted without difficulty.  Using a sterile saline drop test, appropriate placement was confirmed.  The abdomen was then insufflated with appropriate volume inflow of CO2.  The #11 step trocar was placed without difficulty.  The above findings were then visualized.  A 5 mm port was placed 2 cm above the pubic symphysis.  This was done under direct visualization and the grasper was inserted through this port for better visualization.  A 12 mm port was then made in the right lateral aspect of the abdominal wall and the Endo-GIA was inserted through this port and the fallopian tube and ovary were incorporated across the infundibulopelvic ligament.  Prior to this, the cyst was aspirated using 60 cc syringe on a needle.  Approximately, 20 cc of blood-tinged fluid was obtained.  After the ovary and fallopian tube were completely transected, this was placed in an EndoCatch bag and removed through the lateral port site.  The incision was found to be hemostatic.  The area was suction irrigated.  After adequate inspection, the port sites were removed from the patient's abdomen and the abdomen was desufflated.  The infraumbilical port site and laparoscope were also removed.  The incisions were then repaired with #4-0 undyed Vicryl and dressed with Steri-Strips.  10 cc of 0.25% Marcaine was then injected locally.  The patient tolerated the procedure well.  The sponge, lap, and needle counts were correct x2.  She will be followed up on an outpatient basis.","obstetrics / gynecology, adnexal cyst, endometrial, ovarian cyst, dilation and curettage, d&c, hysteroscopy, laparoscopy, salpingooophorectomy, aspiration of cyst fluid, thickened endometrium, tamoxifen therapy, abdominal wall, cyst, ovarian, endometrium, "
" Induction of vaginal delivery of viable male, Apgars 8 and 9.  Term pregnancy and oossible rupture of membranes, prolonged.", Obstetrics / Gynecology, Induction of Vaginal Delivery ,"DIAGNOSES,1.  Term pregnancy.,2.  Possible rupture of membranes, prolonged.,PROCEDURE:,  Induction of vaginal delivery of viable male, Apgars 8 and 9.,HOSPITAL COURSE:,  The patient is a 20-year-old female, gravida 4, para 0, who presented to the office.  She had small amount of leaking since last night.  On exam, she was positive Nitrazine, no ferning was noted.  On ultrasound, her AFI was about 4.7 cm.  Because of a variable cervix, oligohydramnios, and possible ruptured membranes, we recommended induction.,She was brought to the hospital and begun on Pitocin.  Once she was in her regular pattern, we ruptured her bag of water; fluid was clear.  She went rapidly to completion over the next hour and a half.  She then pushed for 2 hours delivering a viable male over an intact perineum in an OA presentation.  Upon delivery of the head, the anterior and posterior arms were delivered, and remainder of the baby without complications.  The baby was vigorous, moving all extremities.  The cord was clamped and cut.  The baby was handed off to mom with nurse present.  Apgars were 8 and 9.  Placenta was delivered spontaneously, intact.  Three-vessel cord with no retained placenta.  Estimated blood loss was about 150 mL.  There were no tears.","obstetrics / gynecology, induction of vaginal delivery, vaginal delivery, viable male, pregnancy, placenta, vaginal, membranes, apgars"
" Hysteroscopy, Essure, tubal occlusion, and ThermaChoice endometrial ablation.", Obstetrics / Gynecology, Hysteroscopy & Endometrial Ablation ,"PREOPERATIVE DX:,1.  Menorrhagia,2.  Desires permanent sterilization.,POSTOPERATIVE DX:,1.  Menorrhagia,2.  Desires permanent sterilization.,OPERATIVE PROCEDURE:,  Hysteroscopy, Essure, tubal occlusion, and ThermaChoice endometrial ablation.,ANESTHESIA: , General with paracervical block.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS:,  On hysteroscopy, 100 ml deficit of lactated Ringer's via IV, 850 ml of lactated Ringer's.,COMPLICATIONS: , None.,PATHOLOGY: , None.,DISPOSITION:  ,Stable to recovery room.,FINDINGS:,  A nulliparous cervix without lesions.  Uterine cavity sounding to 10 cm, normal appearing tubal ostia bilaterally, fluffy endometrium, normal appearing cavity without obvious polyps or fibroids.,PROCEDURE: , The patient was taken to the operating room, where general anesthesia was found to be adequate.  She was prepped and draped in the usual sterile fashion.  A speculum was placed into the vagina.  The anterior lip of the cervix was grasped with a single-tooth tenaculum and a paracervical block was performed using 20 ml of 0.50% lidocaine with 1:200,000 of epinephrine.,The cervical vaginal junction at the 4 o'clock position was injected and 5 ml was instilled.  The block was performed at 8 o'clock as well with 5 ml at 10 and 2 o'clock.  The lidocaine was injected into the cervix.  The cervix was minimally dilated with #17 Hanks dilator.  The 5-mm 30-degree hysteroscope was then inserted under direct visualization using lactated Ringer's as a distention medium.  The uterine cavity was viewed and the above normal findings were noted.  The Essure tubal occlusion was then inserted through the operative port and the tip of the Essure device easily slid into the right ostia.  The coil was advanced and easily placed and the device withdrawn.  There were three coils into the uterine cavity after removal of the insertion device.  The device was removed and reloaded.  The advice was to advance under direct visualization and the tip was inserted into the left ostia.  This passed easily and the device was inserted.  It was removed easily and three coils again were into the uterine cavity.  The hysteroscope was then removed and the ThermaChoice ablation was performed.  The uterus was then sounded to 9.5 to 10 cm.  The ThermaChoice balloon was primed and pressure was drawn to a negative 150.  The device was then moistened and inserted into the uterine cavity and the balloon was slowly filled with 40 ml of D5W.  The pressure was brought up to 170 and the cycle was initiated.  A full cycle of eight minutes was performed.  At no time there was a significant loss of pressure from the catheter balloon.  After the cycle was complete, the balloon was deflated and withdrawn.  The tenaculum was withdrawn.  No bleeding was noted.  The patient was then awakened, transferred, and taken to the recovery room in satisfactory condition.","obstetrics / gynecology, menorrhagia, essure, hysteroscopy, thermachoice, uterine cavity, endometrial ablation, endometrium, fibroids, fluffy, lactated ringer, nulliparous, paracervical block, permanent sterilization, polyps, tubal occlusion, tubal ostia, lactated ringer's, ablation, uterine, "
" Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, right and left pelvic lymphadenectomy, common iliac lymphadenectomy, and endometrial cancer staging procedure.", Obstetrics / Gynecology, Hysterectomy (TAH - BSO) ,"PREOPERATIVE DIAGNOSIS: , Endometrial cancer.,POSTOPERATIVE DIAGNOSIS: , Same.,OPERATION PERFORMED:,  Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, right and left pelvic lymphadenectomy, common iliac lymphadenectomy, and endometrial cancer staging procedure.,ANESTHESIA:,  General, endotracheal tube.,SPECIMENS: , Pelvic washings for cytology, uterus with attached tubes and ovaries, right and left pelvic lymph nodes, para-aortic nodes.,INDICATIONS FOR PROCEDURE: , The patient recently presented with postmenopausal bleeding and was found to have a Grade II endometrial carcinoma on biopsy.  She was counseled to undergo staging laparotomy.,FINDINGS:,  Examination under anesthesia revealed a small uterus with no nodularity.  During the laparotomy, the uterus was small, mobile, and did not show any evidence of extrauterine spread of disease.  Other abdominal viscera, including the diaphragm, liver, spleen, omentum, small and large bowel, and peritoneal surfaces, were palpably normal.  There was no evidence of residual neoplasm after removal of the uterus.  The uterus itself showed no serosal abnormalities and the tubes and ovaries were unremarkable in appearance.,PROCEDURE: , The patient was brought to the Operating Room with an IV in place.  Anesthesia was induced, after which she was examined, prepped and draped.,A vertical midline incision was made and fascia was divided.  The peritoneum was entered without difficulty and washings were obtained.  The abdomen was explored with findings as noted.  A Bookwalter retractor was placed and bowel was packed.  Clamps were placed on the broad ligament for traction.  The retroperitoneal spaces were opened by incising lateral and parallel to the infundibulopelvic ligament.  The round ligaments were isolated, divided, and ligated.  The peritoneum overlying the vesicouterine fold was incised to mobilize the bladder.,Retroperitoneal spaces were then opened, allowing exposure of pelvic vessels and ureters.  The infundibulopelvic ligaments were isolated, divided, and doubly ligated.  The uterine artery pedicles were skeletonized, clamped, divided, and suture ligated.  Additional pedicles were developed on each side of the cervix, after which tissue was divided and suture ligated.  When the base of the cervix was reached, the vagina was cross-clamped and divided, allowing removal of the uterus with attached tubes and ovaries.  Angle stitches of o-Vicryl were placed, incorporating the uterosacral ligaments and the vaginal vault was closed with interrupted figure-of-eight stitches.  The pelvis was irrigated and excellent hemostasis was noted.,Retractors were repositioned to allow exposure for lymphadenectomy.  Metzenbaum scissors were used to incise lymphatic tissues.  Borders of the pelvic node dissection included the common iliac bifurcation superiorly, the psoas muscle laterally, the cross-over of the deep circumflex iliac vein over the external iliac artery inferiorly, and the anterior division of the hypogastric artery medially.  The posterior border of dissection was the obturator nerve, which was carefully identified and preserved bilaterally.  Ligaclips were applied where necessary.  After the lymphadenectomy was performed bilaterally, excellent hemostasis was noted.,Retractors were again repositioned to allow exposure of para-aortic nodes.  Lymph node tissue was mobilized, Ligaclips were applied, and the tissue was excised.  The pelvis was again irrigated and excellent hemostasis was noted.  The bowel was run and no evidence of disease was seen.,All packs and retractors were removed and the abdominal wall was closed using a running Smead-Jones closure with #1 permanent monofilament suture.  Subcutaneous tissues were irrigated and a Jackson-Pratt drain was placed.  Scarpa's fascia was closed with a running stitch and skin was closed with a running subcuticular stitch.  The final sponge, needle and instrument counts were correct at the completion of the procedure. ,The patient was then awakened from her anesthetic and taken to the Post Anesthesia Care Unit in stable condition.","obstetrics / gynecology, tah, bso, lymphadenectomy, endometrial, total abdominal hysterectomy, bilateral salpingo oophorectomy, tubes and ovaries, salpingo oophorectomy, lymph nodes, endometrial cancer, abdominal, hysterectomy, oophorectomy, hemostasis, retractors, washings, laparotomy, ligated, pelvic, uterus, nodes,"
" Pelvic tumor, cystocele, rectocele, and uterine fibroid.  Total abdominal hysterectomy, bilateral salpingooophorectomy, repair of bladder laceration, appendectomy, Marshall-Marchetti-Krantz cystourethropexy, and posterior colpoperineoplasty. She had a recent D&C and laparoscopy, and enlarged mass was noted and could not be determined if it was from the ovary or the uterus. ", Obstetrics / Gynecology," Hysterectomy, BSO, & Appendectomy. ","1.  Pelvic tumor.,2.  Cystocele.,3.  Rectocele.,POSTOPERATIVE DIAGNOSES:,1.  Degenerated joint.,2.  Uterine fibroid.,3.  Cystocele.,4.  Rectocele.,PROCEDURE PERFORMED:  ,1.  Total abdominal hysterectomy.,2.  Bilateral salpingooophorectomy.,3.  Repair of bladder laceration.,4.  Appendectomy.,5.  Marshall-Marchetti-Krantz cystourethropexy.,6.  Posterior colpoperineoplasty.,GROSS FINDINGS:  The patient had a history of a rapidly growing mass on the abdomen, extending from the pelvis over the past two to three months.  She had a recent D&C and laparoscopy, and enlarged mass was noted and could not be determined if it was from the ovary or the uterus.  Curettings were negative for malignancy.  The patient did have a large cystocele and rectocele, and a collapsed anterior and posterior vaginal wall.,Upon laparotomy, there was a giant uterine tumor extending from the pelvis up to the above the umbilicus compatible with approximately four to five-month pregnancy.  The ovaries appeared to be within normal limits.  There was marked adherence between the bladder and the giant uterus and mass with edema and inflammation, and during dissection, a laceration inadvertently occurred and it was immediately recognized.  No other pathology noted from the abdominal cavity or adhesions.  The upper right quadrant of the abdomen compatible with a previous gallbladder surgery.  The appendix is in its normal anatomic position.  The ileum was within normal limits with no Meckel's diverticulum seen and no other gross pathology evident.  There was no evidence of metastasis or tumors in the left lobe of the liver.,Upon frozen section, diagnosis of initial and partial is that of a degenerating uterine fibroid rather than a malignancy.,OPERATIVE PROCEDURE:  The patient was taken to the Operating Room, prepped and draped in the low lithotomy position under general anesthesia.  A midline incision was made around the umbilicus down to the lower abdomen.  With a #10 Bard Parker blade knife, the incision was carried down through the fascia.  The fascia was incised in the midline, muscle fibers were splint in the midline, the peritoneum was grasped with hemostats and with a #10 Bard Parker blade after incision was made with Mayo scissors.  A Balfour retractor was placed into the wound.  This giant uterus was soft and compatible with a possible leiomyosarcoma or degenerating fibroid was handled with care.  The infundibular ligament on the right side was isolated and ligated with #0 Vicryl suture brought to an avascular area, doubly clamped and divided from the ovary and the ligament again re-ligated with #0 Vicryl suture.  The right round ligament was ligated with #0 Vicryl suture, brought to an avascular space within the broad ligament and divided from the uterus.  The infundibulopelvic ligament on the left side was treated in a similar fashion as well as the round ligament.  An attempt was made to dissect the bladder flap from the anterior surface of the uterus and this was remarkably edematous and difficult to do, and during dissection the bladder was inadvertently entered.  After this was immediately recognized, the bladder flap was wiped away from the anterior surface of the uterus.  The bladder was then repaired with a running locking stitch #0 Vicryl suture incorporating serosal muscularis mucosa and then the second layer of overlapping seromuscular sutures were used to make a two-layer closure of #0 Vicryl suture.  After removing the uterus, the bladder was tested with approximately 400 cc of sterile water and there appeared to be no leak.  Progressing and removing of the uterus was then carried out and the broad ligament was clamped bilaterally with a straight Ochsner forceps and divided from the uterus with Mayo scissors, and the straight Ochsner was placed by #0 Vicryl suture thus controlling the uterine blood supply.  The cardinal ligaments containing the cervical blood supply was serially clamped bilaterally with a curved Ochsner forceps, divided from the uterus with #10 Bard Parker blade knife and a curved Ochsner was placed by #0 Vicryl suture.  The cervix was again grasped with a Lahey tenaculum and pubovesicocervical ligament was entered and was divided using #10 Bard Parker blade knife and then the vaginal vault and with a double pointed sharp scissors.  A single-toothed tenaculum was placed on the cervix and then the uterus was removed from the vagina using hysterectomy scissors.  The vaginal cuff was then closed using a running #0 Vicryl suture in locking stitch incorporating all layers of the vagina, the cardinal ligaments of the lateral aspect and uterosacral ligaments on the posterior aspect.  The round ligaments were approximated to the vaginal cuff with #0 Vicryl suture and the bladder flap approximated to the round ligaments with #000 Vicryl suture.  The ______ was re-peritonealized with #000 Vicryl suture and then the cecum brought into the incision.  The pelvis was irrigated with approximately 500 cc of water.  The appendix was grasped with Babcock forceps.  The mesoappendix was doubly clamped with curved hemostats and divided with Metzenbaum scissors.  The curved hemostats were placed with #00 Vicryl suture.  The base of the appendix was ligated with #0 plain gut suture, doubly clamped and divided from the distal appendix with #10 Bard Parker blade knife, and the base inverted with a pursestring suture with #00 Vicryl.  No bleeding was noted.  Sponge, instrument, and needle counts were found to be correct.  All packs and retractors were removed.  The peritoneum muscle fascia was closed in single-layer closure using running looped #1 PDS, but prior to closure, a Marshall-Marchetti-Krantz cystourethropexy was carried out by dissecting the space of Retzius identifying the urethra in the vesical junction approximating the periurethral connective tissue to the symphysis pubis with interrupted #0 Vicryl suture.  Following this, the abdominal wall was closed as previously described and the skin was closed using skin staples.  Attention was then turned to the vagina, where the introitus of the vagina was grasped with an Allis forceps at the level of the Bartholin glands.  An incision was made between the mucous and the cutaneous junction and then a midline incision was made at the posterior vaginal mucosa in a tunneling fashion with Metzenbaum scissors.  The flaps were created bilaterally by making an incision in the posterior connective tissue of the vagina and wiping the rectum away from the posterior vaginal mucosa, and flaps were created bilaterally.  In this fashion, the rectocele was reduced and the levator ani muscles were approximated in the midline with interrupted #0 Vicryl suture.  Excess vaginal mucosa was excised and the vaginal mucosa closed with running #00 Vicryl suture.  The bulbocavernosus and transverse perinei muscles were approximated in the midline with interrupted #00 Vicryl suture.  The skin was closed with a running #000 plain gut subcuticular stitch.  The vaginal vault was packed with a Betadine-soaked Kling gauze sponge.  Sterile dressing was applied.  The patient was sent to recovery room in stable condition.","obstetrics / gynecology, marshall-marchetti-krantz cystourethropexy, pelvic tumor, cystocele, rectocele, uterine fibroid, hysterectomy, salpingooophorectomy, bladder laceration, appendectomy, colpoperineoplasty, marshall marchetti krantz cystourethropexy, bard parker blade knife, vicryl suture, vaginal mucosa, uterus, vaginal, uterine, mucosa, scissors, ligament, bladder"
" Total abdominal hysterectomy, right salpingoophorectomy, and extensive adhesiolysis and enterolysis.", Obstetrics / Gynecology, Hysterectomy & Salpingoophorectomy ,"PREOPERATIVE DIAGNOSES:,1.Stage IV endometriosis with severe pelvic pain.,2.Status post prior left salpingoophorectomy.,POSTOPERATIVE DIAGNOSES:,1.Stage IV endometriosis with severe pelvic pain.,2.Status post prior left salpingoophorectomy.,3.Severe adhesions.,TYPE OF ANESTHESIA: , General endotracheal tube.,TECHNICAL PROCEDURE: , Total abdominal hysterectomy, right salpingoophorectomy, and extensive adhesiolysis and enterolysis.,INDICATION FOR PROCEDURE: , The patient is a 42-year-old parous female who had a longstanding history of severe endometriosis unresponsive to hormonal medical therapy and pain medication.  She had severe dyspareunia and chronic suprapelvic pain.  The patient had had a prior left salpingoophorectomy laparoscopically in 2004 for same disease process.  Now, she presented with a recurrent right ovarian endometrioma and severe pelvic pain.  She desired surgical treatment.  She accepted risk of a complete hysterectomy and salpingoophorectomy, risk of injury to underlying organs.  The risks, benefits, and alternatives were clearly discussed with the patient as documented in the medical record.,DESCRIPTION OF FINDINGS: , Absent left adnexa.  Right ovary about 6 cm with chocolate cyst and severely adherent to the right pelvic side wall, uterus, and colon.  Careful dissection to free right ovary and remove it although it is likely that some ovarian tissue remains behind.  Ureter visualized and palpated on right and appears normal.  Indigo carmine given IV with no leaks intraperitoneally noted.  Sigmoid colon dissected free from back of uterus and from cul-de-sac.  Bowel free of lacerations or denudation.  Upon inspection, right tube with hydrosalpinx, appendix absent.  Omental adhesions to ensure abdominal wall was lysed.,TECHNICAL PROCEDURE: , After informed consent was obtained, the patient was taken to the operating room where she underwent smooth induction of general anesthesia.  She was placed in a supine position with a transurethral Foley in place and compression stockings in place.  The abdomen and vagina were thoroughly prepped and draped in the usual sterile fashion.,A Pfannenstiel skin incision was made with the scalpel and carried down sharply to the underlying layer of fascia and peritoneum.  The peritoneum was bluntly entered and the incision extended caudally and cephaladly with good visualization of underlying organs.  Next, exploration of the abdominal and pelvic organs revealed the above noted findings.  The uterus was enlarged and probably contained adenomyosis.  There were dense adhesions, and a large right endometrioma with a chocolate cyst-like material contained within.  The sigmoid colon was densely adhered to the cul-de-sac into the posterior aspect of the uterus.  A Bookwalter retractor was placed into the incision, and the bowel was packed away with moist laparotomy sponges.  Next, a sharp and blunt dissection was used to free the extensive adhesions, and enterolysis was performed with very careful attention not to injure or denude the bowel.  Next, the left round ligament and cornual region was divided, transected, and suture-ligated with 0 Polysorb.  The anterior and posterior leafs of the broad ligament were dissected and opened anteriorly to the level of the bladder.  The uterine arteries were skeletonized on the left, and these were suture-clamped and transected with 0 Polysorb with good hemostasis noted.  Next, the bladder flap was developed anteriorly, and the bladder peritoneum was sharply and bluntly dissected off of the lower uterus.,On the right, a similar procedure was performed.  The right round ligament was suture-ligated with 0 Polysorb.  It was transected and divided with electrocautery.  The anterior and posterior leafs of the broad ligament were dissected and developed anteriorly and posteriorly, and this area was relatively avascular.  The left infundibulopelvic ligament was identified.  It was cross-clamped and transected, suture-ligated with 0 Polysorb with good hemostasis noted.  Next, the uterine arteries were skeletonized on the right.  They were transected and suture-ligated with 0 Polysorb.  The uterosacral ligaments were taken bilaterally and transected and suture-ligated with 0 Polysorb.  The cardinal ligaments were taken near their insertion into the cervical and uterine tissue.  Pedicles were sharply developed and suture-ligated with 0 Polysorb.  Next, the electrocautery was used to dissect the cervix anteriorly from the underlying vagina.  Once entry into the vagina was made, the cervix and uterus were amputated with Jorgensen scissors.  The vaginal cuff angles were suture-ligated with 0 Polysorb and transfixed to the ipsilateral, cardinal, and uterosacral ligaments for vaginal support.  The remainder of the vagina was closed with figure-of-eight sutures in an interrupted fashion with good hemostasis noted.,Next, the right ovarian tissue was densely adherent to the colon.  It was sharply and bluntly dissected, and most of the right ovary and endometrioma was removed and dissected off completely; however, there is a quite possibility that small remnants of ovarian tissue were left behind.  The right ureter was seen and palpated.  It did not appear to be dilated and had good peristalsis noted.  Next, the retractors were removed.  The laparotomy sponges were removed from the abdomen.  The rectus fascia was closed with 0 Polysorb in a continuous running fashion with 2 sutures meeting in the midline.  The subcutaneous tissue was closed with 0 plain gut in an interrupted fashion.  The skin was closed with 4-0 Polysorb in a subcuticular fashion.  A thin layer of Dermabond was placed.,The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x 2.  Cefoxitin 2 g was given preoperatively.,INTRAOPERATIVE COMPLICATIONS:,  None.,DESCRIPTION OF SPECIMEN: , Uterus and right adnexa.,ESTIMATED BLOOD LOSS: , 1000 mL.,POSTOPERATIVE CONDITION: , Stable.,",
 Total vaginal hysterectomy.  Microinvasive carcinoma of the cervix., Obstetrics / Gynecology, Hysterectomy - Discharge Summary - 2 ,"ADMISSION DIAGNOSIS: , Microinvasive carcinoma of the cervix.,DISCHARGE DIAGNOSIS: , Microinvasive carcinoma of the cervix.,PROCEDURE PERFORMED: , Total vaginal hysterectomy.,HISTORY OF PRESENT ILLNESS: , The patient is a 36-year-old, white female, gravida 7, para 5, last period mid March, status post tubal ligation.  She had an abnormal Pap smear in the 80s, which she failed to followup on until this year.  Biopsy showed a microinvasive carcinoma of the cervix and a cone biopsy was performed on 02/12/2007 also showing microinvasive carcinoma with a 1 mm invasion.  She has elected definitive therapy with a total vaginal hysterectomy.  She is aware of the future need of Pap smears.,PAST MEDICAL HISTORY: , Past history is significant for seven pregnancies, five term deliveries, and significant past history of tobacco use.,PHYSICAL EXAMINATION: , Physical exam is within normal limits with a taut normal size uterus and a small cervix, status post cone biopsy.,LABORATORY DATA AND DIAGNOSTIC STUDIES: , Chest x-ray was clear.  Discharge hemoglobin 10.8.,HOSPITAL COURSE: , She was taken to the operating room on 04/02/2007 where a total vaginal hysterectomy was performed under general anesthesia.  There was an incidental cystotomy at the time of the creation of the bladder flap.  This was repaired intraoperatively without difficulty.  Postoperative, she did very well.  Bowel and bladder function returned quickly.  She is ambulating well and tolerating a regular diet.,Routine postoperative instructions given and understood.  Followup will be in ten days for a cystogram and catheter removal with followup in the office at that time. ,DISCHARGE MEDICATIONS:,  Vicodin, Motrin, and Macrodantin at bedtime for urinary tract infection suppression.  ,DISCHARGE CONDITION: , Good.,Final pathology report was free of residual disease.","obstetrics / gynecology, pap smear, total vaginal hysterectomy, hysterectomy, microinvasive, carcinoma, cervix,"
 Wide Local Excision of the Vulva.  Radical anterior hemivulvectomy.  Posterior skinning vulvectomy., Obstetrics / Gynecology, Hemivulvectomy ,"PREOPERATIVE DIAGNOSIS: , Recurrent vulvar melanoma.,POSTOPERATIVE DIAGNOSIS: , Recurrent vulvar melanoma.,OPERATION PERFORMED: , Radical anterior hemivulvectomy.  Posterior skinning vulvectomy.,SPECIMENS: , Radical anterior hemivulvectomy, posterior skinning vulvectomy.,INDICATIONS FOR PROCEDURE: , The patient has a history of vulvar melanoma first diagnosed in November of 1995.  She had a surgical resection at that time and recently noted recurrence of an irritated nodule around the clitoris.  Biopsy obtained by The patient confirmed recurrence.  In addition, biopsies on the posterior labia (left side) demonstrated melanoma in situ.,FINDINGS: , During the examination under anesthesia, the biopsy sites were visible and a slightly pigmented irregular area of epithelium was seen near the clitoris.  No other obvious lesions were seen.  The room was darkened and a Woods lamp was used to inspect the epithelium.  A marking pen was used to outline all pigmented areas, which included several patches on both the right and left labia.,PROCEDURE: , The patient was prepped and draped and a scalpel was used to incise the skin on the anterior portion of the specimen.  The radical anterior hemivulvectomy was designed so that a 1.5-2.0 cm margin would be obtained and the depth was carried to the fascia of the urogenital diaphragm.  Subcutaneous adipose was divided with electrocautery and the specimen was mobilized from the periosteum.  After removal of the radical anterior portion, the skin on the posterior labia and perineal body was mobilized.  Skin was incised with a scalpel and electrocautery was used to undermine.  After removal of the specimen, the wounds were closed primarily with subcutaneous interrupted stitches of 3-0 Vicryl suture.  The final sponge, needle, and instrument counts were correct at the completion of the procedure.  The patient was then taken to the Post Anesthesia Care Unit in stable condition.","obstetrics / gynecology, vulvar melanoma, wide local excision, radical anterior hemivulvectomy, posterior skinning vulvectomy, vulvectomy, hemivulvectomy, melanoma, woods lamp, recurrent vulvar melanoma, anterior hemivulvectomy, vulvar, labia, radical, skinning,"
 Vaginal discharge with a foul odor., Obstetrics / Gynecology, Gardnerella Bacterial Vaginosis ,"CHIEF COMPLAINT: , Vaginal discharge with a foul odor.,HISTORY OF PRESENT ILLNESS: , This is a 25-year-old African-American female who states that for the past week she has been having thin vaginal discharge which she states is gray in coloration.  The patient states that she has also had frequency of urination.  The patient denies any burning with urination.  She states that she is sexually active and does not use condoms.  She does have three sexual partners.  The patient states that she has had multiple yeast infections in the past and is concerned that she may have one again.  The patient also states that she has had sexually transmitted diseases in her teens, but has not had one in many years.  The patient does state that she has never had HIV testing.  The patient states that she has not had any vaginal bleeding and does not have any abdominal pain.  The patient denies fevers or chills, nausea or vomiting, headaches or head trauma.  The patient also denies skin rashes or lesions.  She does state, however, there is one area of roughened skin on her right forearm that she is concerned it may be an infection of the skin.  The patient is G2 P2.  She has had some irregular Pap smears in the past.  Her last Pap smear was approximately 6 to 12 months ago.  The patient has had frequent urinary tract infections in the past.,PAST MEDICAL HISTORY:,1.  Bronchitis.,2.  Urinary tract infections.,3.  Vaginal candidiasis.,PAST SURGICAL HISTORY: , Cyst removal of the right breast.,SOCIAL HISTORY: , The patient does smoke approximately half a pack of cigarettes per day.  She denies alcohol or illicit drug use.,MEDICATIONS: , None.,ALLERGIES:,  No known medical allergies.,PHYSICAL EXAMINATION:,GENERAL:  This is an African-American female who appears her stated age of 25 years.  She is well nourished, well developed, and in no acute distress.  The patient is pleasant.,VITAL SIGNS:  Afebrile.  Blood pressure is mildly over 96/68, pulse is 68, respiratory rate 12, and pulse oximetry of 98% on room air.,HEART:  Regular rate and rhythm.  Clear S1 and S2.  No murmur, rub or gallop is appreciated.,LUNGS:  Clear to auscultation bilaterally.  No wheezes, rales or rhonchi.,ABDOMEN:  Soft, nontender, nondistended.  Positive bowel sounds throughout.,SKIN:  Warm, dry and intact.  No rash or lesion.,PSYCH:  Alert and oriented to person, place, and time.,NEUROLOGIC:  Cranial nerves II through XII are intact bilaterally.  No focal deficits are appreciated.,GENITOURINARY:  The pelvic exam done shows external genitalia without abnormalities or lesions.  There is a white-to-yellow discharge.  Transformation zone is identified.  The cervix is mildly friable.  Vaginal vault is without lesions.  There is no adnexal tenderness.  No adnexal masses.  No cervical motion tenderness.  Cervical swabs and vaginal cultures are obtained.,DIAGNOSTIC STUDIES: , Urinalysis shows 3+ bacteria, however, there are no wbc's.  No squamous epithelial cells and no other signs of infection.  There is no glucose.  The patient's cervical swabs and cultures are obtained and there are positive clue cells.  Negative Trichomonas.  Negative fungal elements and Chlamydia and gonorrhea are pending at this time.  Urinalysis is sent for culture and sensitivity.,ASSESSMENT:,: Gardnerella bacterial vaginosis.,PLAN: , The patient will be treated with metronidazole 500 mg p.o. twice a day x7 days.  The patient will follow up with her primary care provider.,",
 Laparoscopic supracervical hysterectomy.  Menorrhagia and dysmenorrhea., Obstetrics / Gynecology, Hysterectomy - Laparoscopic Supracervical ,"PREOPERATIVE DIAGNOSES:,  Menorrhagia and dysmenorrhea.,POSTOPERATIVE DIAGNOSES: , Menorrhagia and dysmenorrhea.,PROCEDURE: , Laparoscopic supracervical hysterectomy.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , 100 mL.,FINDINGS: , An 8-10 cm anteverted uterus, right ovary with a 2 cm x 2 cm x 2 cm simple cyst containing straw colored fluid, a normal-appearing left ovary, and normal-appearing tubes bilaterally.,SPECIMENS:  ,Uterine fragments.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL: , The patient was brought to the OR where general endotracheal anesthesia was obtained without difficulty.  The patient was placed in dorsal lithotomy position.  Examination under anesthesia revealed an anteverted uterus and no adnexal masses.  The patient was prepped and draped in normal sterile fashion.  A Foley catheter was placed in the patient's bladder.  The patient's cervix was visualized with speculum.  A single-tooth tenaculum was placed on the anterior lip of the cervix.  A HUMI uterine manipulator was placed through the internal os of the cervix and the balloon was inflated.  The tenaculum and speculum were then removed from the vagina.  Attention was then turned to the patient's abdomen where a small infraumbilical incision was made with scalpel.  Veress needle was placed through this incision and the patient's abdomen was inflated to a pressure of 15 mmHg.  Veress needle was removed and then 5-mm trocar was placed through the umbilical incision.  Laparoscope was placed through this incision and the patient's abdominal contents were visualized.  A 2nd trocar incision was placed in the midline 2 cm above the symphysis pubis and a 5-mm trocar was placed through this incision on direct visualization for laparoscope.  A trocar incision was made in the right lower quadrant.  A 10-mm trocar was placed through this incision under direct visualization with the laparoscope.  A ___ trocar incision was made in the left lower quadrant and a 2nd 10-mm trocar was placed through this incision under direct visualization with the laparoscope.  The patient's abdominal and pelvic anatomy were again visualized with the assistance of a blunt probe.  The Gyrus cautery was used to cauterize and cut the right and left round ligaments.  The anterior leaf of the broad ligament was bluntly dissected and cauterized and cut in an inferior fashion towards lower uterine segment.  The right uteroovarian ligament was cauterized and cut using the Gyrus.  The uterine vessels were then bluntly dissected.  The Gyrus was then used to cauterize the right uterine vessels.  Gyrus was then used on the left side to cauterize and cut the left round ligament.  The anterior leaf of the broad ligament on the left side was bluntly dissected, cauterized, and cut.  Using the Gyrus, the left uteroovarian ligament was cauterized and cut and the left uterine vessels were then bluntly dissected.  The left uterine vessels were then cauterized and cut using the Gyrus.  At this point, as the uterine vessels had been cauterized on both sides, the uterine body exhibited blanching.  At this point, the Harmonic scalpel hook was used to amputate the uterine body from the cervix at the level just below the uterine vessels.  The HUMI manipulator was removed prior to amputation of the uterine body.  After the uterine body was detached from the cervical stump, morcellation of the uterine body was performed using the uterine morcellator.  The uterus was removed in a piecemeal fashion through the right lower quadrant trocar incision.  Once, all fragments of the uterus were removed from the abdominal cavity, the pelvis was irrigated.  The Harmonic scalpel was used to cauterize the remaining endocervical canal.  The cervical stump was also cauterized with the Harmonic scalpel and good hemostasis was noted at the cervical stump and also at the sites of all pedicles.  The Harmonic scalpel was then used to incise the right ovarian simple cyst.  The right ovarian cyst was then drained yielding straw-colored fluid.  The site of right ovarian cystotomy was noted to be hemostatic.  The pelvis was again inspected and noted to be hemostatic.  The ureters were identified on both sides and noted to be intact throughout the visualized course.  All instruments were then removed from the patient's abdomen and the abdomen was deflated.  The fascial defects at the 10-mm trocar sites were closed using figure-of-8 sutures of 0-Vicryl and skin incisions were closed with a 4-0 Vicryl in subcuticular fashion.  The cervix was then visualized with the speculum.  Good hemostasis at the site of tenaculum insertion was obtained using silver nitrate sticks.  All instruments were removed from the patient's vagina and the patient was placed in normal supine position.,Sponge, lap, needle, and instrument counts were correct x2.  The patient was awoken from anesthesia and then transferred to the recovery room in stable condition.","obstetrics / gynecology, supracervical hysterectomy, incision, uterine, uteroovarian, hysterectomy, supracervical, menorrhagia, dysmenorrhea, cervical, laparoscopic, laparoscope, cervix, ligaments, trocar"
 The patient underwent a total vaginal hysterectomy., Obstetrics / Gynecology, Hysterectomy - Discharge Summary ,"ADMISSION DIAGNOSES:,1.  Menorrhagia.,2.  Uterus enlargement.,3.  Pelvic pain.,DISCHARGE DIAGNOSIS: , Status post vaginal hysterectomy.,COMPLICATIONS: , None.,BRIEF HISTORY OF PRESENT ILLNESS: , This is a 36-year-old, gravida 3, para 3 female who presented initially to the office with abnormal menstrual bleeding and increase in flow during her period.  She also had symptoms of back pain, dysmenorrhea, and dysuria.  The symptoms had been worsening over time.  The patient was noted also to have increasing pelvic pain over the past 8 months and she was noted to have uterine enlargement upon examination.,PROCEDURE:,  The patient underwent a total vaginal hysterectomy.,HOSPITAL COURSE:  ,The patient was admitted on 09/04/2007 to undergo total vaginal hysterectomy.  The procedure preceded as planned without complication.  Uterus was sent for pathologic analysis.  The patient was monitored in the hospital, 2 days postoperatively.  She recovered quite well and vitals remained stable.,Laboratory studies, H&H were followed and appeared stable on 09/05/2007 with hemoglobin of 11.2 and hematocrit of 31.8.,The patient was ready for discharge on Monday morning of 09/06/2007.,LABORATORY FINDINGS: , Please see chart for full studies during admission.,DISPOSITION:  ,The patient was discharged to home in stable condition.  She was instructed to follow up in the office postoperatively.","obstetrics / gynecology, menorrhagia, uterus enlargement, pelvic pain, total vaginal hysterectomy, vaginal hysterectomy, uterus, vaginal, hysterectomy,"
" First Pap smear, complaining of irregular periods.  - Menorrhagia, pelvic pain, dysmenorrhea, and irregular periods.", Obstetrics / Gynecology, First Pap smear. ,"CHIEF COMPLAINT:,  The patient comes for her first Pap smear, complaining of irregular periods.,HISTORY OF PRESENT ILLNESS:,  The patient wishes to discuss considering something to help with her menstrual cramping and irregular periods.  She notes that her periods are out of weck.  She says that she has cramping and pain before her period starts.  Sometimes, she is off her period for two weeks and then she bleeds for two whole weeks.  She usually has her periods lasting seven days, usually comes on the 19th of each month and now it seems to have changed.  The cramping is worse.  She said her flow has increased.  She has to change her pad every half to one hour and uses a super tampon sometimes.  She usually has four days of hard flow and then she might have 10 days where she will have to wear a mini pad.  She also notes that her headaches have been worsening a little bit.  She has had quite a bit of stress.  She had a headache on Wednesday again after having had one on the weekend.  She said she usually only has an occasional headache and that is not too bad but now she has developed what she would consider to be a migraine and she has not had serious headaches like this and it seems to be worsening and coming a little bit more regularly, and she has not figure out what to do to get rid of them.  She avoids caffeine.  She only eats chocolate when she is near her period and she usually drinks one can of cola a day.,MEDICATIONS: , None.,ALLERGIES:,  None.,SOCIAL HISTORY:,  She is a nonsmoker.  She is not sexually active.,PAST MEDICAL HISTORY:,  She has had no surgery or chronic illnesses.,FAMILY HISTORY:,  Mother has hypertension, depression.  Father has had renal cysts and sometimes some stomach problems.  Both of her parents have problems with their knees.,REVIEW OF SYSTEMS:,  Patient denies headache or trauma.  No blurred or double vision.  Hearing is fine, no tinnitus or infection.  Infrequent sore throat, no hoarseness or cough.,HEENT:  See HPI.,Neck:  No stiffness, pain or swelling.,Respiratory:  No shortness of breath, cough or hemoptysis.  She is a nonsmoker.,Cardiovascular:  No chest pain, ankle edema, palpitations or hypertension.,GI:  No nausea, vomiting, diarrhea, constipation, melena or jaundice.,GU:  No dysuria, frequency, urgency or stress incontinence.,Locomotor:  No weakness, joint pain, tremor or swelling.,GYN:  See HPI.,Integumentary:  Patient performs self-breast examinations and denies any breast masses or nipple discharge.  No recent skin or hair changes.,Neuropsychiatric:  Denies depression, anxiety, tearfulness or suicidal thought.,PHYSICAL EXAMINATION:,VITALS:  Height 64.5 inches.  Weight:  162 pounds.  Blood pressure 104/72.  Pulse:  72.  Respirations:  16.  LMP:  08/21/04.  Age:  19.,HEENT:  Head is normocephalic.  Eyes:  EOMs intact.  PERRLA.  Conjunctiva clear.  Fundi:  Discs flat, cups normal.  No AV nicking, hemorrhage or exudate.  Ears:  TMs intact.  Mouth:  No lesion.  Throat:  No inflammation.,Neck:  Full range of motion.  No lymphadenopathy or thyromegaly.,Chest:  Clear to auscultation and percussion.,Heart:  Normal sinus rhythm, no murmur.,Integumentary:  Breasts are without masses, tenderness, nipple retraction or discharge.  Reviewed self-breast examination.  No axillary nodes are palpable.,Abdomen:  Soft.  Liver, spleen, and kidneys are not palpable.  No masses felt, nontender.  Femoral pulses strong and equal.,Back:  No CVA or spinal tenderness.  No deformity noted.,Pelvic:  BUS negative.  Vaginal mucosa pink, scanty discharge.  Cervix without lesion.  Pap was taken.  Uterus normal size.  Adnexa:  No masses.  She does have some pain on palpation of the uterus.,Rectal:  Good sphincter tone.  No masses.  Stool is guaiac negative.,Extremities:  No edema.  Pulses strong and equal.  Reflexes are intact.,Rectal:  No mass.,ASSESSMENT:,  Menorrhagia, pelvic pain, dysmenorrhea, and irregular periods.,PLAN:,  We will evaluate with a CBC, urinalysis and culture, and TSH.  The patient has what she describes as migraine headaches of a new onset.  Because of the pelvic pain, dysmenorrhea, and menorrhagia, we will also evaluate with a pelvic sonogram.  We will evaluate with a CT scan of the brain with and without contrast.  We will try Anaprox DS one every 12 hours for the headache.  At this point, she could also use that for menstrual cramping.  Prescription written for 20 tablets.  If her lab findings, sonographic findings, and CT of the brain are normal, we would consider trying birth control pills to regulate her periods and reduce the cramping and excessive flow.  The lab x-ray and urinalysis results will be reported to her as soon as they are available.",
" Total vaginal hysterectomy.   Menometrorrhagia, dysmenorrhea, and small uterine fibroids.", Obstetrics / Gynecology, Hysterectomy - Discharge Summary - 1 ,"ADMISSION DIAGNOSES:,1.  Menometrorrhagia.,2.  Dysmenorrhea.,3.  Small uterine fibroids.,DISCHARGE DIAGNOSES:,1.  Menorrhagia.,2.  Dysmenorrhea.,3.  Small uterine fibroids.,OPERATION PERFORMED:  ,Total vaginal hysterectomy.,BRIEF HISTORY AND PHYSICAL:  ,The patient is a 42 year-old white female, gravida 3, para 2, with two prior vaginal deliveries.  She is having increasing menometrorrhagia and dysmenorrhea.  Ultrasound shows a small uterine fibroid.  She has failed oral contraceptives and surgical therapy is planned.,PAST HISTORY: , Significant for reflux.,SURGICAL HISTORY:  ,Tubal ligation.,PHYSICAL EXAMINATION: , A top normal sized uterus with normal adnexa.,LABORATORY VALUES:  ,Her discharge hemoglobin is 12.4.,HOSPITAL COURSE: , She was taken to the operating room on 11/05/07 where a total vaginal hysterectomy was performed under general anesthesia.  Postoperatively, she has done well.  Bowel and bladder function have returned normally.  She is ambulating well, tolerating a regular diet.  Routine postoperative instructions given and said follow up will be in four weeks in the office.,DISCHARGE MEDICATIONS: , Preoperative meds plus Vicodin for pain.,DISCHARGE CONDITION: , Good.","obstetrics / gynecology, dysmenorrhea, uterine fibroids, vaginal, total vaginal hysterectomy, menometrorrhagia, uterine, fibroids, "
" Mammogram, bilateral full-field digital mammography FFDM (patient with positive history of breast cancer).", Obstetrics / Gynecology, Full-Field Digital Mammogram (FFDM) - 2 ,"EXAM: , Screening full-field digital mammogram.,HISTORY:,  Screening examination of a 58-year-old female who currently denies complaints.  Patient has had diagnosis of right breast cancer in 1984 with subsequent radiation therapy.  The patient's sister was also diagnosed with breast cancer at the age of 59.,TECHNIQUE: , Standard digital mammographic imaging was performed.  The examination was performed with iCAD Second Look Version 7.2.,COMPARISON: , Most recently obtained __________.,FINDINGS: , The right breast is again smaller than the left.  There is a scar marker with underlying skin thickening and retraction along the upper margin of the right breast.  The breasts are again composed of a mixture of adipose tissue and a moderate amount of heterogeneously-dense fibroglandular tissue.  There is again some coarsening of the right breast parenchyma with architectural distortion which is unchanged and most consistent with postsurgical and postradiation changes.  A few benign-appearing microcalcifications are present.,No dominant malignant-appearing mass lesion, developing area of architectural distortion or suspicious-appearing cluster of microcalcifications are identified.  The skin is stable.  No enlarged axillary lymph node is seen.,IMPRESSION:,1.  No significant interval changes are seen.  No mammographic evidence of malignancy is identified.,2.  Annual screening mammography is recommended or sooner if clinical symptoms warrant.,BIRADS Classification 2 - Benign,MAMMOGRAPHY INFORMATION:,1.  A certain percentage of cancers, probably 10% to 15%, will not be identified by mammography.,2.  Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present.,3.  These images were obtained with FDA-approved digital mammography equipment, and iCAD Second Look Software Version 7.2 was utilized.","obstetrics / gynecology, digital mammography, full-field digital mammogram, ffdm, second look version, field digital mammogram, digital mammogram, breast cancer, mammographic, icad, microcalcifications, mammogram, screening, digital, mammography, breast"
 Bilateral Screening Mammogram Full-Field Digital Mammography (FFDM) (Benign Findings), Obstetrics / Gynecology, Full-Field Digital Mammogram (FFDM) - 1 ,"EXAM: , Digital screening mammogram.,HISTORY:,  51-year-old female presents for screening mammography.  Patient denies personal history of breast cancer.  Breast cancer was reported in her maternal aunt.,TECHNIQUE:,  Craniocaudal and mediolateral oblique projections of bilateral breasts were obtained on mm/dd/yy.  Comparison is made with the previous performed on mm/dd/yy. iCAD Second Look proprietary software was utilized.,FINDINGS:  ,The breasts demonstrate a mixture of adipose and fibroglandular elements.  Composition appears similar.  Multiple tiny punctate benign-appearing calcifications are visualized bilaterally.  No dominant mass, areas of architecture distortion, or malignant-type calcifications are seen.  Skin overlying both breasts is unremarkable.,IMPRESSION: , Stable and benign mammographic findings.  Continued yearly mammographic screening is recommended.,BIRADS Classification 2 - Benign,MAMMOGRAPHY INFORMATION:,1.  A certain percentage of cancers, probably 10% to 15%, will not be identified by mammography.,2.  Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present.,3.  These images were obtained with FDA-approved digital mammography equipment, and iCAD SecondLook Software Version 7.2 was utilized.","obstetrics / gynecology, mediolateral, craniocaudal, fibroglandular, bilateral screening mammogram, breast cancer, screening mammogram, mammographic, mammogram, breasts, screening, mammography"
 External cephalic version.  A 39-week intrauterine pregnancy with complete breech presentation., Obstetrics / Gynecology, External Cephalic Version ,"PREOPERATIVE DIAGNOSIS: , A 39-week intrauterine pregnancy with complete breech presentation.,POSTOPERATIVE DIAGNOSIS:,  A 39-week intrauterine pregnancy in vertex presentation, status post successful external cephalic version.,PROCEDURE: , External cephalic version.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL:  ,The patient was brought to Labor and Delivery where a reactive fetal heart tracing was obtained.  The patient was noted to have irregular contractions.  She was given 1 dose of subcutaneous terbutaline which resolved her contraction.  A bedside ultrasound was performed which revealed single intrauterine pregnancy and complete breech presentation.  There was noted to be adequate fluid.  Using manual pressure, the breech was manipulated in a forward roll fashion until a vertex presentation was obtained.  Fetal heart tones were checked intermittently during the procedure and were noted to be reassuring.  Following successful external cephalic version, the patient was placed on continuous external fetal monitoring.  She was noted to have a reassuring and reactive tracing for 1 hour following the external cephalic version.  She did not have regular contractions and therefore she was felt to be stable for discharge to home.  She was given appropriate labor instructions.","obstetrics / gynecology, intrauterine pregnancy, vertex presentation, complete breech presentation, external cephalic version, fetal, contractions, pregnancy, breech, intrauterine, "
 Fractional dilatation and curettage, Obstetrics / Gynecology, Dilatation & Curettage - D&C ,"PREOPERATIVE DIAGNOSIS: , Postmenopausal bleeding.,POSTOPERATIVE DIAGNOSIS: , Same.,OPERATION PERFORMED:  ,Fractional dilatation and curettage.,SPECIMENS: , Endocervical curettings, endometrial curettings.,INDICATIONS FOR PROCEDURE: , The patient recently presented with postmenopausal bleeding.  An office endometrial biopsy was unable to be performed secondary to a stenotic internal cervical os.,FINDINGS: , Examination under anesthesia revealed a retroverted, retroflexed uterus with fundal diameter of 6.5 cm.  The uterine cavity was smooth upon curettage.  Curettings were fairly copious.  Sounding depth was 8 cm.,PROCEDURE:,  The patient was brought to the Operating Room with an IV in place.  The patient was given a general anesthetic and was placed in the lithotomy position.  Examination under anesthesia was completed with findings as noted.  She was prepped and draped and a speculum was placed into the vagina.  ,Tenaculum was placed on the cervix.  The endocervical canal was curetted using a Kevorkian curette, and the sound was used to measure the overall depth of the uterus.  The endocervical canal was dilated without difficulty to a size 16 French dilator.  A small, sharp curette was passed into the uterine cavity and curettings were obtained.,After completion of the curettage, polyp forceps were passed into the uterine cavity.  No additional tissue was obtained.  Upon completion of the dilatation and curettage, minimum blood loss was noted.,The patient was awakened from her anesthetic, and taken to the post anesthesia care unit in stable condition.","obstetrics / gynecology, postmenopausal bleeding, endometrial, fractional dilatation, fractional dilatation and curettage, endocervical, dilatation and curettage, endocervical canal, uterine cavity, curetted, dilatation, curettings, curettage"
" Stage IIIC endometrial cancer.  Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane.  The patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009. ", Obstetrics / Gynecology, Endometrial Cancer Followup ,"CHIEF COMPLAINT:,1.  Stage IIIC endometrial cancer.,2.  Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane.,HISTORY OF PRESENT ILLNESS: , The patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009.  In March 2010, she had an abnormal endometrial ultrasound with thickening of the endometrium and an enlarged uterus.  CT scan of the abdomen on 03/22/2010 showed an enlarged uterus, thickening of the endometrium, and a mass structure in the right and left adnexa that was suspicious for ovarian metastasis.  On 04/01/2010, she had a robotic modified radical hysterectomy with bilateral salpingo-oophorotomy and appendectomy with pelvic and periaortic lymphadenectomy.  The pathology was positive for grade III endometrial adenocarcinoma, 9.5 cm in size with 2 cm of invasion.  Four of 30 lymph nodes were positive for disease.  The left ovary was positive for metastatic disease.  Postsurgical PET/CT scan showed left lower pelvic side wall seroma and hypermetabolic abdominal and right pelvic retroperitoneal lymph nodes suspicious for metastatic disease.  The patient has completed five of planned six cycles of chemotherapy and comes in to clinic today for followup.  Of note, we had sent off genetic testing which was denied back in June.  I have been trying to get this testing completed.,CURRENT MEDICATIONS: , Synthroid q.d., ferrous sulfate 325 mg b.i.d., multivitamin q.d., Ativan 0.5 mg q.4 hours p.r.n. nausea and insomnia, gabapentin one tablet at bedtime.,ALLERGIES:","obstetrics / gynecology, adjuvant, adjuvant chemotherapy, cisplatin, adriamycin, abraxane, endometrial cancer, lymphadenectomy, chemotherapy, endometrial, disease, "
 A 31-year-old white female admitted to the hospital with pelvic pain and vaginal bleeding.  Right ruptured ectopic pregnancy with hemoperitoneum.   Anemia secondary to blood loss., Obstetrics / Gynecology, Ectopic Pregnancy - Discharge Summary ,"HISTORY OF PRESENT ILLNESS: , This is the case of a 31-year-old white female admitted to the hospital with pelvic pain and vaginal bleeding.  The patient had a positive hCG with a negative sonogram and hCG titer of about 18,000.,HOSPITAL COURSE:,  The patient was admitted to the hospital with the diagnosis of a possible incomplete abortion, to rule out ectopic pregnancy or rupture of corpus luteal cyst.  The patient was kept in observation for 24 hours.  The sonogram stated there was no gestational sac, but there was a small mass within the uterus that could represent a gestational sac.  The patient was admitted to the hospital.  A repeat hCG titer done on the same day came back as 15,000, but then the following day, it came back as 18,000.  The diagnosis of a possible ruptured ectopic pregnancy was established.  The patient was taken to surgery and a laparotomy was performed with findings of a right ruptured ectopic pregnancy.  The right salpingectomy was performed with no complications.  The patient received 2 units of red packed cells.  On admission, her hemoglobin was 12.9, then in the afternoon it dropped to 8.1, and the following morning, it was 7.9.  Again, based on these findings, the severe abdominal pain, we made the diagnosis of ectopic and it was proved or confirmed at surgery.  The hospital course was uneventful.  There was no fever reported.  The abdomen was soft.  She had a normal bowel movement.  The patient was dismissed on 09/09/2007 to be followed in my office in 4 days.,FINAL DIAGNOSES:,1.  Right ruptured ectopic pregnancy with hemoperitoneum.,2.  Anemia secondary to blood loss.,PLAN: , The patient will be dismissed on pain medication and iron therapy.","obstetrics / gynecology, anemia, blood loss, ruptured ectopic pregnancy, gestational sac, ectopic pregnancy, hemoperitoneum, gestational, ruptured, pregnancy, ectopic,"
" Dilation and evacuation.  12 week incomplete miscarriage.  The patient unlike her visit in the ER approximately 4 hours before had some tissue in the vagina protruding from the os, this was teased out and then a D&E was performed yielding significant amount of central tissue. ", Obstetrics / Gynecology, Dilation & Evacuation ,"PREOPERATIVE DIAGNOSIS:,  12 week incomplete miscarriage.,POSTOPERATIVE DIAGNOSIS: , 12 week incomplete miscarriage.,OPERATION PERFORMED: , Dilation and evacuation.,ANESTHESIA: , General.,OPERATIVE FINDINGS:  ,The patient unlike her visit in the ER approximately 4 hours before had some tissue in the vagina protruding from the os, this was teased out and then a D&E was performed yielding significant amount of central tissue.  The fetus of 12 week had been delivered previously by Dr. X in the ER.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,COMPLICATIONS:  ,None.,SPONGE AND NEEDLE COUNT: , Correct.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operating room placed in the operating table in supine position.  After adequate anesthesia, the patient was placed in dorsal lithotomy position.  The vagina was prepped.  The patient was then draped.  A speculum was placed in the vagina.  Previously mentioned products of conception were teased out with a ring forceps.  The anterior lip of the cervix was then grasped with a ring forceps as well and with a 10-mm suction curette multiple curettages were performed removing fairly large amount of tissue for a 12-week pregnancy.  A sharp curettage then was performed and followed by two repeat suction curettages.  The procedure was then terminated and the equipment removed from the vagina, as well as the speculum.  The patient tolerated the procedure well.  Blood type is Rh negative.  We will see the patient back in my office in 2 weeks.","obstetrics / gynecology, incomplete miscarriage, dilation, evacuation, vagina protruding, protruding, speculum, miscarriage, forceps, curettages, vagina,"
 Emergency cesarean section., Obstetrics / Gynecology, Emergency C-section. ,"PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at term.,2.  Nonreassuring fetal heart tones with a prolonged deceleration.,POSTOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at term.,2.  Nonreassuring fetal heart tones with a prolonged deceleration.,PROCEDURE PERFORMED: , Emergency cesarean section.,ANESTHESIA:  ,General and endotracheal as well as local anesthesia.,ESTIMATED BLOOD LOSS: , 800 mL.,COMPLICATIONS: , None.,FINDINGS:  ,Female infant in cephalic presentation in OP position.  Normal uterus, tubes and ovaries are noted.  Weight was 6 pounds and 3 ounces, Apgars were 6 at 1 minute and 7 at 5 minutes, and 9 at 10 minutes.  Normal uterus, tubes and ovaries were noted.,INDICATIONS:  ,The patient is a 21-year-old Gravida 1, para 0 female who present to labor and delivery at term with spontaneous rupture of membranes noted at 5 a.m. on the day of delivery.  The patient was admitted and cervix was found to be 1 cm dilated.  Pitocin augmentation of labor was started.  The patient was admitted by her primary obstetrician Dr. Salisbury and was managed through the day by him at approximately 5 p.m. at change of shift care was assumed by me.  At this time, the patient was noted to have variable decelerations down to the 90s lasting approximately 1 minute with good return to baseline, good variability was noted as well as accelerations, variable deceleration despite position change was occurring with almost every contraction, but was lasting for 60 to 90 seconds at the longest.  Vaginal exam was done.  Cervix was noted to be 4 cm dilated.,At this time IPC was placed and amnioinfusion was started in hopes to relieve the variable declarations.  At 19:20 fetal heart tones was noted to go down to the 60s and remained down in the 60s for 3 minutes at which time the patient was transferred from Labor And Delivery Room to the operating room for an emergency cesarean section.  Clock in the operating room is noted to be 2 minutes faster then the time on trace view.  The OR delivery time was 19:36.  Delivery of this infant was performed in 14 minutes from the onset of the deceleration.  Upon arrival to the operating room, while prepping the patient for surgery and awaiting the arrival of the anesthesiologist, heart tones were noted to be in 60s and slowly came up to the 80s.  Following the transfer of the patient to the operating room bed and prep of the abdomen, the decision was made to begin the surgery under local anesthesia, 2% lidocaine was obtained for this purpose.,PROCEDURE NOTE: , The patient was taken to the operating room she was quickly prepped and draped in the dorsal supine position with a leftward tilt.  2% lidocaine was obtained and the skin was anesthetized using approximately 15 mL of 2% lidocaine.  As the incision site was being injected, the anesthesiologist arrived.  The procedure was started prior to the patient being put under general anesthesia.,A Pfannenstiel skin incision was made with a scalpel and carried through the underlying layer of fascia using the Scalpel using __________ technique.  The rectus muscles were separated in midline.  The peritoneum was bluntly dissected.  The bladder blade was inserted.  The uterus has been incised in the transverse fashion using the scalpel and extended using manual traction.  The infant was subsequently delivered.  Immediately following delivery of the infant.  The infant was noted to be crying with good tones.  The cord was clammed and cut.  The infant was subsequently transferred or handed to the nursery nurse.  The placenta was delivered manually intact with a three-vessel cord noted.  The uterus was exteriorized and cleared of all clots and debris.  The uterine incision was repaired in 2 layers using 0 chromic sutures.  Hemostasis was visualized.  The uterus was returned to the abdomen.  The pelvis was copiously irrigated.  The rectus muscles were reapproximated in the midline using 3-0 Vicryl.  The fascia was reapproximated with 0 Vicryl suture.  The subcutaneous layer was closed with 2-0 plain gut.  The skin was closed in the subcuticular stitch using 4-0 Monocryl.  Steri-strips were applied.  Sponge, laps, and instrument counts were correct.  The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition.","obstetrics / gynecology, intrauterine pregnancy at term, prolonged deceleration, apgars, emergency cesarean section, fetal heart tones, intrauterine,"
" The patient is a 39-year-old gravida 3, para 2, who is now at 20 weeks and 2 days gestation.  This pregnancy is a twin gestation.  The patient presents for her fetal anatomical survey.  ", Obstetrics / Gynecology, Fetal Anatomical Survey ,"PAST MEDICAL HISTORY:  ,The patient denies any significant past medical history.,PAST SURGICAL HISTORY: , The patient denies any significant surgical history.,MEDICATIONS: , The patient takes no medications.,ALLERGIES: , No known drug allergies.,SOCIAL HISTORY: , She denies use of cigarettes, alcohol or drugs.,FAMILY HISTORY: , No family history of birth defects, mental retardation or any psychiatric history.,DETAILS: , I performed a transabdominal ultrasound today using a 4 MHz transducer.  There is a twin gestation in the vertex transverse lie with an anterior placenta and a normal amount of amniotic fluid surrounding both of the twins.  The fetal biometry of twin A is as follows.  The biparietal diameter is 4.9 cm consistent with 20 weeks and 5 days, head circumference 17.6 cm consistent with 20 weeks and 1 day, the abdominal circumference is 15.0 cm consistent with 20 weeks and 2 days, and femur length is 3.1 cm consistent with 19 weeks and 5 days, and the humeral length is 3.0 cm consistent with 20 weeks and 0 day.  The average gestational age by ultrasound is 20 weeks and 1 day and the estimated fetal weight is 353 g.  The following structures are seen as normal on the fetal anatomical survey, the shape of the fetal head, the choroid plexuses, the cerebellum, nuchal fold thickness, the fetal spine and fetal face, the four-chamber view of the fetal heart, the outflow tracts of the fetal heart, the stomach, the kidneys, and cord insertion site, the bladder, the extremities, the genitalia, the cord, which appeared to have three vessels and the placenta.,Limited in views of baby A with a nasolabial region.,The following is the fetal biometry for twin B. The biparietal diameter is 4.7 cm consistent with 20 weeks and 2 days, head circumference 17.5 cm consistent with 20 weeks and 0 day, the abdominal circumference is 15.5 cm consistent with 20 weeks and 5 days, the femur length is 3.3 cm consistent with 20 weeks and 3 days, and the humeral length is 3.1 cm consistent with 20 weeks and 2 days, the average gestational age by ultrasound is 22 weeks and 2 days, and the estimated fetal weight is 384 g.  The following structures were seen as normal on the fetal anatomical survey.  The shape of the fetal head, the choroid plexuses, the cerebellum, nuchal fold thickness, the fetal spine and fetal face, the four-chamber view of the fetal heart, the outflow tracts of the fetal heart, the stomach, the kidneys, and cord insertion site, the bladder, the extremities, the genitalia, the cord, which appeared to have three vessels, and the placenta.  Limited on today's ultrasound the views of nasolabial region.,In summary, this is a twin gestation, which may well be monochorionic at 20 weeks and 1 day.  There is like gender and a single placenta.  One cannot determine with certainty whether or not this is a monochorionic or dichorionic gestation from the ultrasound today.,I sat with the patient and her husband and discussed alternative findings and the complications.  We focused our discussion today on the association of twin pregnancy with preterm delivery.  We discussed the fact that the average single intrauterine pregnancy delivers at 40 weeks' gestation while the average twin delivery occurs at 35 weeks' gestation.  We discussed the fact that 15% of twins deliver prior to 32 weeks' gestation.  These are the twins which we have the most concern regarding the long-term prospects of prematurity.  We discussed several etiologies of preterm delivery including preterm labor, incompetent cervix, premature rupture of the fetal membranes as well as early delivery from preeclampsia and growth restriction.  We discussed the use of serial transvaginal ultrasound to assess for early cervical change and the use of serial transabdominal ultrasound to assess for normal interval growth.  We discussed the need for frequent office visits to screen for preeclampsia.  We also discussed treatment options such as cervical cerclage, bedrest, tocolytic medications, and antenatal steroids.  I would recommend that the patient return in two weeks for further cervical assessment and assessment of fetal growth and well-being.,In closing, I do want to thank you very much for involving me in the care of your delightful patient.  I did review all of the above findings and recommendations with the patient today at the time of her visit.  Please do not hesitate to contact me if I could be of any further help to you.,Total visit time 40 minutes.","obstetrics / gynecology, vaginal delivery, transducer, transabdominal ultrasound, placenta, amniotic fluid, fetal anatomical survey, preterm delivery, twin gestation, gestation, infant, fetal, anatomical, delivery, ultrasound,"
" Exploratory laparotomy.  Extensive lysis of adhesions.  Right salpingo-oophorectomy.   Pelvic mass, suspected right ovarian cyst.", Obstetrics / Gynecology, Exploratory Laparotomy - 2 ,"PREOPERATIVE DIAGNOSES,1.  Pelvic mass.,2.  Suspected right ovarian cyst.,POSTOPERATIVE DIAGNOSES,1.  Pelvic mass.,2.  Suspected right ovarian cyst.,PROCEDURES,1.  Exploratory laparotomy.,2.  Extensive lysis of adhesions.,3.  Right salpingo-oophorectomy.,ANESTHESIA:,  General.,ESTIMATED BLOOD LOSS: , 200 mL,SPECIMENS:  ,Right tube and ovary.,COMPLICATIONS: , None.,FINDINGS: , Extensive adhesive disease with the omentum and bowel walling of the entire pelvis, which required more than 45 minutes of operating time in order to establish visualization and to clear the bowel and other important structures from the ovarian cyst, tube, and ovary in order to remove them.  The large and small bowels were completely enveloping a large right ovarian cystic mass.  Normal anatomy was difficult to see due to adhesions.  Cyst was ruptured incidentally intraoperatively with approximately 150 mL to 200 mL of turbid fluid.  Cyst wall, tube, and ovary were stripped away from the bowel.  Posterior peritoneum was also removed in order to completely remove the cyst wall ovary and tube.  There was excellent postoperative hemostasis.,PROCEDURE:  ,The patient was taken to the operating room, where general anesthesia was achieved without difficulty.  She was then placed in a dorsal supine position and prepped and draped in the usual sterile fashion.  A vertical midline incision was made from the umbilicus and extended to the symphysis pubis along the line of the patient's prior incision.  Incision was carried down carefully until the peritoneal cavity was reached.  Care was taken upon entry of the peritoneum to avoid injury of underlying structures.  At this point, the extensive adhesive disease was noted, again requiring greater than 45 minutes of dissection in order to visualize the intended anatomy for surgery.  The omentum was carefully stripped away from the patient's right side developing a window.  This was extended down along the inferior portion of the incision removing the omentum from its adhesions to the anterior peritoneum and what appears to be the vesicouterine peritoneum.  A large mass of bowel was noted to be adherent to itself causing a quite tortuous course.  Adhesiolysis was performed in order to free up the bowel in order to pack it out of the pelvis.  Excellent hemostasis was noted.  The bowel was then packed over of the pelvis allowing visualization of a matted mass of large and small bowel surrounding a large ovarian cyst.  Careful adhesive lysis and dissection enabled the colon to be separated from the posterior wall of the cyst.  Small bowel and portion of the colon were adherent anteriorly on the cyst and during the dissection of these to remove them from their attachment, the cyst was ruptured.  Large amount of turbid fluid was noted and was evacuated.  The cyst wall was then carefully placed under tension and stripped away from the patient's small and large bowel.  Once the bowel was freed, the remnants of round ligament was identified, elevated, and the peritoneum was incised opening the retroperitoneal space.,The retroperitoneal space was opened following the line of the ovarian vessels, which were identified and elevated and a window made inferior to the ovarian vessels, but superior to the course of the ureter.  This pedicle was doubly clamped, transected, and tied with a free tie of #2-0 Vicryl.  A suture ligature of #0 Vicryl was used to obtain hemostasis.  Excellent hemostasis was noted at this pedicle.  The posterior peritoneum and portion of the remaining broad ligament were carefully dissected and shelled out to remove the tube and ovary, which was still densely adherent to the peritoneum.  Care was taken at the side of the remnant of the uterine vessels.  However, a laceration of the uterine vessels did occur, which was clamped with a right-angle clamp, and carefully sutured ligated with excellent hemostasis noted.  Remainder of the specimen was then shelled out including portions of the posterior and sidewall peritoneum and removed.,The opposite tube and ovary were identified, were also matted behind a large amount of large bowel and completely enveloped and wrapped in the fallopian tube.  Minimal dissection was performed in order to ascertain and ensure that the ovary appeared completely normal.  It was then left in situ.  Hemostasis was achieved in the pelvis with the use of electrocautery.  The abdomen and pelvis were copiously irrigated with warm saline solution.  The peritoneal edges were inspected and found to have good hemostasis after the side of the uterine artery pedicle, and the ovarian vessel pedicle.  The areas of the bowel had previously been dissected and due to adhesive disease, it was carefully inspected and excellent hemostasis was noted.,All instruments and packs removed from the patient's abdomen.  The abdomen was closed with a running mattress closure of #0 PDS, beginning at the superior aspect of the incision, and extending inferiorly.  Excellent closure of the incision was noted.  The subcutaneous tissues were then copiously irrigated.  Hemostasis was achieved with the use of cautery.  Subcutaneous tissues were reapproximated to close the edge space with a several interrupted sutures of #0 plain gut suture.  The skin was closed with staples.,Incision was sterilely clean and dressed.  The patient was awakened from general anesthesia and taken to the recovery room in stable condition.  All counts were noted correct times three.","obstetrics / gynecology, pelvic mass, ovarian cyst, exploratory laparotomy, lysis of adhesions, salpingo-oophorectomy, cyst, bowel, adhesions, uterine, abdomen, pelvis, ovary, peritoneum, ovarian, hemostasis, "
 Diagnostic Mammogram and ultrasound of the breast., Obstetrics / Gynecology, Diagnostic Mammogram  ,"EXAM: , Bilateral diagnostic mammogram and right breast ultrasound.,History of palpable abnormality at 10 o'clock in the right breast.  Family history of a sister with breast cancer at age 43.,TECHNIQUE: , CC and MLO views of both breasts were obtained.  Spot compression views of the palpable area were also obtained.  Right breast ultrasound was performed.  Comparison is made with mm/dd/yy.,FINDINGS: , The breast parenchymal pattern is stable with heterogeneous scattered areas of fibroglandular tissue.  No new mass or architectural distortion is evident.  Asymmetric density in the upper outer posterior left breast and a nodule in the upper outer right breast are unchanged.  There is no suspicious cluster of microcalcifications.,Directed ultrasonography of the upper outer quadrant of the right breast revealed no cystic or hypoechoic solid mass.,IMPRESSION:,1.  Stable mammographic appearance from mm/dd/yy.,2.  No sonographic evidence of a mass at 10 o'clock in the right breast to correspond to the palpable abnormality.  The need for further assessment of a palpable abnormality should be determined clinically.,BIRADS Classification 2 - Benign","obstetrics / gynecology, diagnostic mammogram, diagnostic, mammogram, ultrasound, palpable"
 She required augmentation with Pitocin to achieve a good active phase.  She achieved complete cervical dilation., Obstetrics / Gynecology, Delivery Note - 9 ,"DELIVERY NOTE:,  This G1, P0 with EDC 12/23/08 presented with SROM about 7.30 this morning.  Her prenatal care complicated by GBS screen positive and a transfer of care at 34 weeks from Idaho.  Exam upon arrival 2 to 3 cm, 100% effaced, -1 station and by report pool of fluid was positive for Nitrazine and positive ferning.,She required augmentation with Pitocin to achieve a good active phase.  She achieved complete cervical dilation at 1900  At this time, a bulging bag was noted, which ruptured and thick meconium was present.  At 1937 hours, she delivered a viable male infant, left occiput, anterior.  Mouth and nares suctioned well with a DeLee on the perineum.  No nuchal cord present.  Shoulders and body followed easily.  Infant re-suctioned with the bulb and cord clamped x2 and cut and was taken to the warmer where the RN and RT were in attendance.  Apgars 9 and 9.  Pitocin 15 units infused via pump protocol.  Placenta followed complete and intact with fundal massage and general traction on the cord.  Three vessels are noted.  She sustained a bilateral periurethral lax on the left side, this extended down to the labia minora, became a second degree in the inferior portion and did have some significant bleeding in this area.  Therefore, this was repaired with #3-0 Vicryl after 1% lidocaine infiltrated approximately 5 mL.  The remainder of the lacerations was not at all bleeding and no other lacerations present.  Fundus required bimanual massage in a couple of occasions for recurrent atony with several larger clots; however, as the Pitocin infused and massage continued, this improved significantly.  EBL was about 500 mL.  Bleeding appears much better; however, Cytotec 400 mcg was placed per rectum apparently prophylactically.  Mom and baby currently doing very well.","obstetrics / gynecology, augmentation with pitocin, delivery, cervical, dilation, perineum, lacerations, pitocin, infantNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" Her cervix on admission was not ripe, so she was given a dose of Cytotec 25 mcg intravaginally and in the afternoon, she was having frequent contractions and fetal heart tracing was reassuring.  At a later time, Pitocin was started.", Obstetrics / Gynecology, Delivery Note - 8 ,"DELIVERY NOTE: , The patient is a very pleasant 22-year-old primigravida with prenatal care with both Dr. X and myself and her pregnancy has been uncomplicated except for the fact that she does live a significant distance away from the hospital.  The patient was admitted to labor and delivery on Tuesday, December 22, 2008 at 5:30 in the morning at 40 weeks and 1 day gestation for elective induction of labor since she lives a significant distance away from the hospital.  Her cervix on admission was not ripe, so she was given a dose of Cytotec 25 mcg intravaginally and in the afternoon, she was having frequent contractions and fetal heart tracing was reassuring.  At a later time, Pitocin was started.  The next day at about 9 o'clock in the morning, I checked her cervix and performed artifical rupture of membranes, which did reveal Meconium-stained amniotic fluid and so an intrauterine pressure catheter was placed and then MDL infusion started.  The patient did have labor epidural, which worked well.  It should be noted that the patient's recent vaginal culture for group B strep did come back negative for group B strep.  The patient went on to have a normal spontaneous vaginal delivery of a live-term male newborn with Apgar scores of 7 and 9 at 1 and 5 minutes respectively and a newborn weight of 7 pounds and 1.5 ounces at birth.  The intensive care nursery staff was present because of the presence of Meconium-stained amniotic fluid.  DeLee suctioning was performed at the perineum.  A second-degree midline episiotomy was repaired in layers in the usual fashion using 3-0 Vicryl.  The placenta was simply delivered and examined and found to be complete and bimanual vaginal exam was performed and revealed that the uterus was firm.,ESTIMATED BLOOD LOSS: , Approximately 300 mL.","obstetrics / gynecology, amniotic fluid, contractions, pitocin, meconium, cervix, labor, vaginal, delivery, intravaginallyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Diagnostic laparoscopy.   Acute pelvic inflammatory disease and periappendicitis.  The patient appears to have a significant pain requiring surgical evaluation.  It did not appear that the pain was pelvic in nature, but more higher up in the abdomen, more towards the appendix.", Obstetrics / Gynecology, Diagnostic Laparoscopy - 1 ,"PREOPERATIVE DIAGNOSIS: , Acute abdominal pain, rule out appendicitis versus other.,POSTOPERATIVE DIAGNOSIS:,  Acute pelvic inflammatory disease and periappendicitis.,PROCEDURE PERFORMED: , Diagnostic laparoscopy.,COMPLICATIONS:,  None.,CULTURES:,  Intra-abdominally are done.,HISTORY:  ,The patient is a 31-year-old African-American female patient who complains of sudden onset of pain and has seen in the Emergency Room.  The pain has started in the umbilical area and radiated to McBurney's point.  The patient appears to have a significant pain requiring surgical evaluation.  It did not appear that the pain was pelvic in nature, but more higher up in the abdomen, more towards the appendix.  The patient was seen by Dr. Y at my request in the ER with me in attendance.  We went over the case.  He decided that she should go to the operating room for evaluation and to have appendix evaluated and probably removed.  The patient on ultrasound had a 0.9 cm ovarian cyst on the right side.  The patient's cyst was not completely simple and they are concerns over the possibility of an abnormality.  The patient states that she has had chlamydia in the past, but it was not a pelvic infection more vaginal infection.  The patient has had hospitalization for this.  The patient therefore signed informed in layman's terms with her understanding that perceivable risks and complications, the alternative treatment, the procedure itself and recovery.  All questions were answered.  ,PROCEDURE: ,The patient was seen in the Emergency Room.  In the Emergency Room, there is really no apparent vaginal discharge.  No odor or cervical motion tenderness.  Negative bladder sweep.  Adnexa were without abnormalities.  In the OR, we were able to perform pelvic examination showing a slightly enlarged fibroid uterus about 9 to 10-week size.  The patient had no adnexal fullness.  The patient then underwent an insertion of a uterine manipulator and Dr. X was in the case at that time and he started the laparoscopic process i.e., inserting the laparoscope.  We then observed under direct laparoscopic visualization with the aid of a camera that there was pus in and around the uterus.  The both fallopian tubes were seen.  There did not appear to be hydrosalpinx.  The ovaries were seen.  The left showed some adhesions into the ovarian fossa.  The cul-de-sac had a banded adhesions.  The patient on the right adnexa had a hemorrhagic ovarian cyst, where the cyst was only about a centimeter enlarged.  The ovary did not appear to have pus in it, but there was pus over the area of the bladder flap.  The patient's bowel was otherwise unremarkable.  The liver contained evidence of Fitz-Hugh-Curtis syndrome and prior PID.  The appendix was somewhat adherent into the retrocecal area and to the mid-quadrant abdominal sidewall on the right.  The case was then turned over to Dr. Y who was in the room at that time and Dr. X had left.  The patient's case was turned over to him.  Dr. Y was performed an appendectomy following which cultures and copious irrigation.  Dr. Y was then closed the case.  The patient was placed on antibiotics.  We await the results of the cultures and as well further ______ therapy.,PRIMARY DIAGNOSES:,1.  Periappendicitis.,2.  Pelvic inflammatory disease.,3.  Chronic adhesive disease.","obstetrics / gynecology, periappendicitis, pelvic inflammatory disease, chronic adhesive disease, abdominal pain, appendicitis, diagnostic laparoscopy, laparoscopy, pelvic,"
 The patient is a 22-year-old woman with a possible ruptured ectopic pregnancy., Obstetrics / Gynecology, Diagnostic Laparoscopy ,"TITLE OF OPERATION:,  Diagnostic laparoscopy.,INDICATION FOR SURGERY: , The patient is a 22-year-old woman with a possible ruptured ectopic pregnancy.,PREOP DIAGNOSIS: , Possible ruptured ectopic pregnancy.,POSTOP DIAGNOSIS: , No evidence of ectopic pregnancy or ruptured ectopic pregnancy.,ANESTHESIA: , General endotracheal.,SPECIMEN: , Peritoneal fluid.,EBL: , Minimal.,FLUIDS:,  900 cubic centimeters crystalloids.,URINE OUTPUT: , 400 cubic centimeters.,FINDINGS: , Adhesed left ovary with dilated left fallopian tube, tortuous right fallopian tube with small 1 cm ovarian cyst noted on right ovary, perihepatic lesions consistent with history of PID, approximately 1-200 cubic centimeters of more serous than sanguineous fluid.  No evidence of ectopic pregnancy.,COMPLICATIONS: , None.,PROCEDURE:,  After obtaining informed consent, the patient was taken to the operating room where general endotracheal anesthesia was administered.  She was examined under anesthesia.  An 8-10 cm anteverted uterus was noted.  The patient was placed in the dorsal-lithotomy position and prepped and draped in the usual sterile fashion, a sponge on a sponge stick was used in the place of a HUMI in order to not instrument the uterus in the event that this was a viable intrauterine pregnancy and this may be a desired intrauterine pregnancy.  Attention was then turned to the patient's abdomen where a 5-mm incision was made in the inferior umbilicus.  The abdominal wall was tented and VersaStep needle was inserted into the peritoneal cavity.  Access into the intraperitoneal space was confirmed by a decrease in water level when the needle was filled with water.  No peritoneum was obtained without difficulty using 4 liters of CO2 gas.  The 5-mm trocar and sleeve were then advanced in to the intraabdominal cavity and access was confirmed with the laparoscope.,The above-noted findings were visualized.  A 5-mm skin incision was made approximately one-third of the way from the ASI to the umbilicus at McBurney's point.  Under direct visualization, the trocar and sleeve were advanced without difficulty.  A third incision was made in the left lower quadrant with advancement of the trocar into the abdomen in a similar fashion using the VersaStep.  The peritoneal fluid was aspirated and sent for culture and wash and cytology.  The abdomen and pelvis were surveyed with the above-noted findings.  No active bleeding was noted.  No evidence of ectopic pregnancy was noted.  The instruments were removed from the abdomen under good visualization with good hemostasis noted.  The sponge on a sponge stick was removed from the vagina.  The patient tolerated the procedure well and was taken to the recovery room in stable condition.,The attending, Dr. X, was present and scrubbed for the entire procedure.","obstetrics / gynecology, peritoneal fluid, sanguineous fluid, ruptured ectopic pregnancy, diagnostic laparoscopy, intrauterine pregnancy, ectopic pregnancy, trocar, ruptured, ectopic, tortuous, pregnancy, "
" The patient presented to Labor and Delivery with complaints of spontaneous rupture of membranes.   She was found to be positive for Nitrazine pull and fern.  At that time, she was not actually contracting.", Obstetrics / Gynecology, Delivery Note - 7 ,"DELIVERY NOTE:,  The patient is a 29-year-old gravida 6, para 2-1-2-3, who has had an estimated date of delivery at 01/05/2009.  The patient presented to Labor and Delivery with complaints of spontaneous rupture of membranes at 2000 hours on 12/26/2008.  She was found to be positive for Nitrazine pull and fern.  At that time, she was not actually contracting.  She was Group B Streptococcus positive, however, was 5 cm dilated.  The patient was started on Group B Streptococcus prophylaxis with ampicillin.  She received a total of three doses throughout her labor.  Her pregnancy was complicated by scanty prenatal care.  She would frequently miss visits.  At 37 weeks, she claims that she had a suspicious bump on her left labia.  There was apparently no fluid or blistering of the lesion.  Therefore, it was not cultured by the provider; however, the patient was sent for serum HSV antibody levels, which she tested positive for both HSV1 and HSV2.  I performed a bright light exam and found no lesions anywhere on the vulva or in the vault as per sterile speculum exam and consulted with Dr. X, who agreed that since the patient seems to have no active lesion that she likely has had a primary outbreak in the past and it is safe to proceed with the vaginal delivery.  The patient requested an epidural anesthetic, which she received with very good relief.  She had IV Pitocin augmentation of labor and became completely dilated per my just routine exam just after 6 o'clock and was set up for delivery and the patient pushed very effectively for about one and a half contractions.  She delivered a viable female infant on 12/27/2008 at 0626 hours delivering over an intact perineum.  The baby delivered in the occiput anterior position.  The baby was delivered to the mother's abdomen where she was warm, dry, and stimulated.  The umbilical cord was doubly clamped and then cut.  The baby's Apgars were 8 and 9.  The placenta was delivered spontaneously intact.  There was a three-vessel cord with normal insertion.  The fundus was massaged to firm and Pitocin was administered through the IV per unit protocol.  The perineum was inspected and was found to be fully intact.  Estimated blood loss was approximately 400 mL.  The patient's blood type is A+.  She is rubella immune and as previously mentioned, GBS positive and she received three doses of ampicillin.","obstetrics / gynecology, nitrazine pull and fern, rupture of membranes, spontaneous, membranes, nitrazine, streptococcus, pitocin, perineum, hsv, laborNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Her pregnancy is complicated by preterm contractions.  She was on bedrest since her 34th week.  She was admitted here and labor was confirmed with rupture of membranes., Obstetrics / Gynecology, Delivery Note - 6 ,"DELIVERY NOTE: , This is an 18-year-old, G2, P0 at 35-4/7th weeks by a stated EDC of 01/21/09.  The patient is a patient of Dr. X's.  Her pregnancy is complicated by preterm contractions.  She was on bedrest since her 34th week.  She also has a history of tobacco abuse with asthma.  She was admitted here and labor was confirmed with rupture of membranes.  She was initially 5, 70%, -1.  Her bag was ruptured, IUPC was placed.  She received an epidural for pain control and Pitocin augmentation was performed.  She progressed for several hours to complete and to push, then pushed for approximately 15 minutes to deliver a vigorous female infant from OA presentation.  Delivery of the head was manual assisted.  The shoulders and the rest of body then followed without difficulty.  Baby was bulb suctioned, had a vigorous cry.  Cord was clamped twice and cut and the infant was handed to the awaiting nursing team.  Placenta then delivered spontaneously and intact, was noted to have a three-vessel cord.  The inspection of the perineum revealed it to be intact.  There was a hymenal remnant/skin tag that was protruding from the vaginal introitus.  I discussed this with the patient.  She opted to have it removed.  This was performed and I put a single interrupted suture 3-0 Vicryl for hemostasis.  Further inspection revealed bilateral superficial labial lacerations that were hemostatic and required no repair.  Overall EBL is 300 mL.  Mom and baby are currently doing well.  Cord gases are being sent due to prematurity.,","obstetrics / gynecology, preterm, rupture of membranes, preterm contractions, contractions, pregnancy, deliveryNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Artificial rupture of membrane was performed for clear fluid.  She did receive epidural anesthesia.  She progressed to complete and pushing., Obstetrics / Gynecology, Delivery Note - 5 ,"DELIVERY NOTE: , This is a 30-year-old G7, P5 female at 39-4/7th weeks who presents to Labor and Delivery for induction for history of large babies and living far away.  She was admitted and started on Pitocin.  Her cervix is 3 cm, 50% effaced and -2 station.  Artificial rupture of membrane was performed for clear fluid.  She did receive epidural anesthesia.  She progressed to complete and pushing.  She pushed to approximately one contraction and delivered a live-born female infant at 1524 hours.  Apgars were 8 at 1 minute and 9 at 5 minutes.  Placenta was delivered intact with three-vessel cord.  The cervix was visualized.  No lacerations were noted.  Perineum remained intact.  Estimated blood loss is 300 mL.  Complications were none.  Mother and baby remained in the birthing room in good condition.","obstetrics / gynecology, perineum, placenta, rupture of membrane, artificial rupture, cervix, delivery, inductionNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 She progressed in labor throughout the day.  Finally getting the complete and began pushing.  Pushed for about an hour and a half when she was starting to crown., Obstetrics / Gynecology, Delivery Note - 4 ,"DELIVERY NOTE: , The patient came in around 0330 hours in the morning on this date 12/30/08 in early labor and from a closed cervix very posterior yesterday; she was 3 cm dilated.  Membranes ruptured this morning by me with some meconium.  An IUPC was placed.  Some Pitocin was started because the contractions were very weak.  She progressed in labor throughout the day.  Finally getting the complete at around 1530 hours and began pushing.  Pushed for about an hour and a half when she was starting to crown.  The Foley was already removed at some point during the pushing.  The epidural was turned down by the anesthesiologist because she was totally numb.  She pushed well and brought the head drown crowning, at which time I arrived and setting her up delivery with prepping and draping.  She pushed well delivering the head and DeLee suctioning was carried out on the perineum because of the meconium even though good amount of amnioinfusion throughout the day was completed.  With delivery of the head, I could see the perineum tear and after delivery of the baby and doubly clamping of the cord having baby off to RT in attendance.  Exam revealed a good second-degree tear ascended a little bit up higher in the vagina and a little off to the right side but rectum sphincter were intact, although I cannot see good fascia around the sphincter anteriorly.  The placenta separated with some bleeding seen and was assisted expressed and completely intact.  Uterus firmed up well with IV pit.  Repair of the tear with 2-0 Vicryl stitches and a 3-0 Vicryl in a subcuticular like area just above the rectum and the perineum was performed using a little local anesthesia to top up with the epidural.  Once this was complete, mom and baby doing well.  Baby was a female infant.  Apgars 8 and 9.","obstetrics / gynecology, iupc, meconium, pitocin, epidural, rectum, sphincter, labor, perineum, pushed, deliveryNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Delivery was via spontaneous vaginal delivery.  Nuchal cord x1 were tight and reduced.  Infant was DeLee suctioned at perineum. , Obstetrics / Gynecology, Delivery Note - 3 ,"DELIVERY NOTE: , On 12/23/08 at 0235 hours, a 23-year-old G1, P0, white female, GBS negative, under epidural anesthesia, delivered a viable female infant with Apgar scores of 7 and 9.  Points taken of for muscle tone and skin color.  Weight and length are unknown at this time.  Delivery was via spontaneous vaginal delivery.  Nuchal cord x1 were tight and reduced.  Infant was DeLee suctioned at perineum.  Cord clamped and cut and infant handed to the awaiting nurse in attendance.  Cord blood sent for analysis, intact.  Meconium stained placenta with three-vessel cord was delivered spontaneously at 0243 hours.  A 15 units of Pitocin was started after delivery of the placenta.  Uterus, cervix, and vagina were explored and a mediolateral episiotomy was repaired with a 3-0 Vicryl in a normal fashion.  Estimated blood loss was approximately 400 mL.  The patient was taken to the recovery room in stable condition.  Infant was taken to Newborn Nursery in stable condition.  The patient tolerated the procedure well.  The only intrapartum event that occurred was thick meconium.  Otherwise, there were no other complications.  The patient tolerated the procedure well.","obstetrics / gynecology, nuchal cord, spontaneous, nuchal, delee, delivered, meconium, placenta, vaginal, perineum, delivery, infantNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Delivery is a normal spontaneous vaginal delivery of an intrauterine fetal demise.  Fetal position is right occiput anterior., Obstetrics / Gynecology, Delivery Note ,"HISTORY: , This patient with prenatal care in my office who did have some preterm labor and was treated with nifedipine and was stable on nifedipine and bed rest; unfortunately, felt decreased fetal movement yesterday, 12/29/08, presented to the hospital for evaluation on the evening of 12/29/08.  At approximately 2030 hours and on admission, no cardiac activity was noted by my on-call partner, Dr. X.  This was confirmed by Dr. Y with ultrasound and the patient was admitted with a diagnosis of intrauterine fetal demise at 36 weeks' gestation.,SUMMARY:,  She was admitted.  She was 3 cm dilated on admission.  She desired induction of labor.  Therefore, Pitocin was started.  Epidural was placed for labor pain.  She did have a temperature of 100.7 and antibiotics were ordered including gentamicin and clindamycin secondary to penicillin allergy.  She remained febrile, approximately 100.3.  She then progressed.  On my initial exam at approximately 0730 hours, she was 3 to 4 cm dilated.  She had reported previously some mucous discharge with no ruptured membranes.  Upon my exam, no membranes were noted.  Attempted artificial rupture of membranes was performed.  No fluid noted and there was no fluid discharge noted all the way until the time of delivery.  Intrauterine pressure catheter was placed at that time to document there are adequate pressures on contraction secondary to induction of labor.  She progressed well and completely dilated, pushed approximately three times, and proceeded with delivery.,DELIVERY NOTE:,  Delivery is a normal spontaneous vaginal delivery of an intrauterine fetal demise.  Fetal position is right occiput anterior.,COMPLICATIONS: , Again, intrauterine fetal demise.  Placenta delivery spontaneous.  Condition was intact with a three-vessel cord.  Lacerations; she had a small right periurethral laceration as well as a small second-degree midline laceration.  These were both repaired postdelivery with 4-0 Vicryl on an SH and a 3-0 Vicryl on a CT-1 respectively.  Estimated blood loss was 200 mL.,Infant is a male infant, appears grossly morphologically normal.  Apgars were 0 and 0.  Weight pending at this time.,NARRATIVE OF DELIVERY:,  I was called.  This patient was completely dilated.  I arrived.  She pushed for three contractions.  She was very comfortable.  She delivered the fetal vertex in the right occiput anterior position followed by the remainder of the infant.  There was a tight nuchal cord x1 that was reduced after delivery of the fetus.  Cord was doubly clamped.  The infant was transferred to a bassinet cleaned by the nursing staff en route.  The placenta delivered spontaneously, was carefully examined, found to be intact.  No signs of abruption.  No signs of abnormal placentation or abnormal cord insertion.  The cord was examined and a three-vessel cord was confirmed.  At this time, IV Pitocin and bimanual massage.  Fundus firm as above with minimal postpartum bleeding.  The vagina and perineum were carefully inspected.  A small right periurethral laceration was noted, was repaired with a 4-0 Vicryl on an SH needle followed by a small second-degree midline laceration, was repaired in a normal running fashion with a 3-0 Vicryl suture.  At this time, the repair is intact.  She is hemostatic.  All instruments and sponges were removed from the vagina and the procedure was ended.,Father of the baby has seen the baby at this time and the mother is waiting to hold the baby at this time.  We have called pastor in to baptize the baby as well as calling social work.  They are deciding on a burial versus cremation, have decided against autopsy at this time.  She will be transferred to postpartum for her recovery.  She will be continued on antibiotics secondary to fever to eliminate endometritis and hopefully will be discharged home tomorrow morning.,All of the care and findings were discussed in detail with Christine and Bryan and at this time obviously they are very upset and grieving, but grieving appropriately and understanding the findings and the fact that there is not always a known cause for a term fetal demise.  I have discussed with her that we will do some blood workup postdelivery for infectious disease profile and clotting disorders.","obstetrics / gynecology, decreased fetal movement, labor pain, preterm labor, delivery note, vaginal delivery, fetal position, fetal demise, intrauterine, delivery, spontaneous, dilated, lacerations, cord, fetal "
 Pitocin was started quickly to allow for delivery as quickly as possible.  Baby was delivered with a single maternal pushing effort with retraction by the forceps., Obstetrics / Gynecology, Delivery Note - 2 ,"Pitocin was started quickly to allow for delivery as quickly as possible and the patient rapidly became complete, and then as she began to push, there were additional decelerations of the baby's heart rate, which were suspicions of cord around the neck.  These were variable decelerations occurring late in the contraction phase.  The baby was in a +2 at a 3 station in an occiput anterior position, and so a low-forceps delivery was performed with Tucker forceps using gentle traction, and the baby was delivered with a single maternal pushing effort with retraction by the forceps.  The baby was a little bit depressed at birth because of the cord around the neck, and the cord had to be cut before the baby was delivered because of the tension, but she responded quickly to stimulus and was given an Apgar of 8 at 1 minute and 9 at 5 minutes.  The female infant seemed to weigh about 7.5 pounds, but has not been officially weighed yet.  Cord gases were sent and the placenta was sent to Pathology.  The cervix, the placenta, and the rectum all seemed to be intact.  The second-degree episiotomy was repaired with 2-O and 3-0 Vicryl.  Blood loss was about 400 mL.,Because of the hole in the dura, plan is to keep the patient horizontal through the day and a Foley catheter is left in place.  She is continuing to be attended to by the anesthesiologist who will manage the epidural catheter.  The baby's father was present for the delivery, as was one of the patient's sisters.  All are relieved and pleased with the good outcome.","obstetrics / gynecology, labor, delivery, pitocin, tucker forceps, apnea, cerebrospinal fluid, contraction, epidural, episiotomy, fetal heart tones, baby was delivered, baby's heart rate, heart rate, catheter, placenta, cordNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 The patient had ultrasound done on admission that showed gestational age of 38-2/7 weeks.  The patient progressed to a normal spontaneous vaginal delivery over an intact perineum., Obstetrics / Gynecology, Delivery Note - 10 ,"DELIVERY NOTE:  ,This is a 30-year-old G6, P5-0-0-5 with unknown LMP and no prenatal care, who came in complaining of contractions and active labor.  The patient had ultrasound done on admission that showed gestational age of 38-2/7 weeks.  The patient progressed to a normal spontaneous vaginal delivery over an intact perineum.  Rupture of membranes occurred on 12/25/08 at 2008 hours via artificial rupture of membranes.  No meconium was noted.  Infant was delivered on 12/25/08 at 2154 hours.  Two doses of ampicillin was given prior to rupture of membranes.  GBS status unknown.  Intrapartum events, no prenatal care.  The patient had epidural for anesthesia.  No observed abnormalities were noted on initial newborn exam.  Apgar scores were 9 and 9 at one and five minutes respectively.  There was a nuchal cord x1, nonreducible, which was cut with two clamps and scissors prior to delivery of body of child.  Placenta was delivered spontaneously and was normal and intact.  There was a three-vessel cord.  Baby was bulb suctioned and then sent to newborn nursery.  Mother and baby were in stable condition.  EBL was approximately 500 mL, NSVD with postpartum hemorrhage.  No active bleeding was noted upon deliverance of the placenta.  Dr. X attended the delivery with second year resident, Dr. X. Upon deliverance of the placenta, the uterus was massaged and there was good tone.  Pitocin was started following deliverance of the placenta.  Baby delivered vertex from OA position.  Mother following delivery had a temperature of 100.7, denied any specific complaints and was stable following delivery.","obstetrics / gynecology, spontaneous vaginal delivery, rupture of membranes, gestational age, vaginal delivery, intact perineum, prenatal care, gestational, placentaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Dilation and curettage (D&C), laparoscopy, enterolysis, lysis of the pelvic adhesions, and left salpingo-oophorectomy.  Complex left ovarian cyst, bilateral complex adnexae, bilateral hydrosalpinx, chronic pelvic inflammatory disease, and massive pelvic adhesions.", Obstetrics / Gynecology, D&C & Laparoscopy - 2 ,"PREOPERATIVE DIAGNOSIS: , Incidental right adnexal mass on ultrasound.,POSTOPERATIVE DIAGNOSES:,1.  Complex left ovarian cyst.,2.  Bilateral complex adnexae.,3.  Bilateral hydrosalpinx.,4.  Chronic pelvic inflammatory disease.,5.  Massive pelvic adhesions.,PROCEDURE PERFORMED:,1.  Dilation and curettage (D&C).,2.  Laparoscopy.,3.  Enterolysis.,4.  Lysis of the pelvic adhesions.,5.  Left salpingo-oophorectomy.,ANESTHESIA:  ,General.,COMPLICATIONS: , None.,SPECIMENS: , Endometrial curettings and left ovarian mass.,ESTIMATED BLOOD LOSS: , Less than 100 cc.,DRAINS:,  None.,FINDINGS: , On bimanual exam, the patient has a slightly enlarged, anteverted, freely mobile uterus with an enlarged left adnexa.  Laparoscopically, the patient has massive pelvic adhesions with completely obliterated posterior cul-de-sac and adnexa.,No adnexal structures were initially able to be visualized until after the lysis of adhesions.  Eventually we found a normal appearing right ovary, severely scarred right and left fallopian tubes, and a enlarged complex cystic left ovary.  There was a normal-appearing appendix and liver, and the vesicouterine junction appeared within normal limits.  There were significant adhesions from the small bowel to the bilateral adnexa in the posterior surface of the uterus.,PROCEDURE:  ,The patient was taken to the operating room where a general anesthetic was administered.  She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion.  Once the anesthetic was found to be adequate, a bimanual exam was performed under anesthetic.  Next, a weighted speculum was placed in the vagina and anterior wall of the vagina was elevated with the uterine sound and the anterior lip of the cervix was grasped with a vulsellum tenaculum.  The uterus was then sounded to 12 cm.  The cervix was then serially dilated with Hank dilators to a size #20 Hank.  Next a Telfa pad was placed on the weighted speculum and a short curettage was performed obtaining a large amount of endometrial tissue.  Next, the uterine manipulator was placed in the cervix and attached to the anterior lip of the cervix.  At this point, the vulsellum tenaculum and weighted speculum were removed.  Next, attention was turned to the abdomen where an approximately 2 cm incision was made immediately inferior to the umbilicus.  The superior aspect of the umbilicus was grasped with a towel clamp and Veress needle was inserted through this incision.  Small amount of normal saline was injected into Veress needle and seemed to drop freely.  So, the Veress needle was connected to he CO2 gas, which was started at the lower setting.  It was seen to flow freely with a normal resistance so the gas was advanced to the higher setting.  The abdomen was then insufflated to an adequate distention.  Next, the Veress needle was removed and a size #11 step trocar was inserted.  Next, the introducer was removed from the trocar and the laparoscope was inserted through this port and the port was also connected to the CO2 gas.  At this point, the initial operative findings were seen.  Next, a size #5 step trocar was inserted approximately two fingerbreadths above the pubic symphysis in the midline.  This was done by making a 1 cm incision with the skin knife, introducing a Veress needle with Ethicon sheet, and the Veress needle was then removed and the #5 port was introduced under direct visualization.  A size #5 port was also placed approximately six fingerbreadths to the right of the umbilicus in a similar manner also under direct visualization.  A blunt probe was inserted suprapubically along with a grasper in the right upper quadrant.  These were used to see the above operative findings.  Next, a size #12 mm port was introduced approximately seven fingerbreadths to the left of the umbilicus under direct visualization.  Through this, a Harmonic scalpel was inserted.,The Harmonic scalpel along with the grasper was used to meticulously address the adhesions along the right adnexa in the posterior cul-de-sac.  Care was taken at all times to avoid the bowel and the ureters.  The fallopian tubes appeared massively scarred and completely obliterated from disease.  After the right adnexa had been freed to the point where we could visualize the ovary and the posterior cul-de-sac was clearing off then we could visualize the uterosacral ligaments.  Attention was turned to the left adnexa, which appeared to contain a cystic structure, but it was unclear at the beginning of the procedure what the structure was.  Adhesions were carefully taken down from the bowel to the left fallopian tube and ovary, and sidewall.  The adhesions were then carefully removed from the inferior aspect of the ovary also with the Harmonic scalpel.  At intermittent points throughout the procedure, the suction irrigator was used to irrigate and suck blood and irrigation out of the pelvis to watch for any bleeding.  At this point, the Harmonic scalpel was removed and another laparoscopic needle with a 60 cc syringe was inserted and this was used to aspirate approximately 30 cc of serosanguineous fluid from the cystic structure.  Next, the needle was removed and the ligature device was inserted.  This was used to clamp across the fallopian tube initially and then after the fallopian tube was ligated, the uterovarian ligament was clamped and ligated with the ligature device.  Next, the fallopian tube was removed from the ovary with the ligature device in approximately 3 clamping and ligations.  Then, the attention was turned to the inferior aspect of the ovary.  First the infundibulopelvic ligament was identified, clamped with a ligature device, and ligated.  Next, the ovary was bluntly dissected from the ovarian fossa with attention to the left ureter.  Next, the ligature device was used to clamp and ligate the broad ligament immediately inferior to the ovary across.  Then the ovary was completely bluntly dissected out of the ovarian fossa and completely separated from the pelvis.  This was grasped with a clamp.  The ligature device was removed from the #12 and a EndoCatch bag was inserted to the size #12 port.  The left ovary was placed in this EndoCatch bag, which was then removed along with the whole port from the left upper quadrant.  Next, the pelvis was copiously irrigated and suctioned of all blood and extra fluid.  At this point, the remaining two size #5 ports were removed under direct visualization.  The camera was removed and the abdomen was desufflated.  Next, an introducer was replaced on a #11 port.  The #11 port was removed.  Next, the fascia in the left upper quadrant port was identified and grasped with Ochsner clamps, tented up, and closed with a single interrupted suture of #0 Vicryl on a UR-6 needle.  Next, all skin incisions were closed with #4-0 undyed Vicryl in a subcuticular interrupted fashion.  The incisions were cleaned, injected with 0.25% Marcaine, and then adjusted with Steri-Strips and bandage appropriately.,The patient was taken from the operating room in stable condition and should be observed overnight in the hospital.",
 Complex right lower quadrant mass with possible ectopic pregnancy.  Right ruptured tubal pregnancy and pelvic adhesions. Dilatation and curettage and laparoscopy with removal of tubal pregnancy and right partial salpingectomy., Obstetrics / Gynecology, D&C & Tubal Pregnancy Removal ,"PREOPERATIVE DIAGNOSIS: , Complex right lower quadrant mass with possible ectopic pregnancy.,POSTOPERATIVE DIAGNOSES:,1.  Right ruptured tubal pregnancy.,2.  Pelvic adhesions.,PROCEDURE PERFORMED:,1.  Dilatation and curettage.,2.  Laparoscopy with removal of tubal pregnancy and right partial salpingectomy.,ANESTHESIA:  ,General.,ESTIMATED BLOOD LOSS:  ,Less than 100 cc.,COMPLICATIONS: , None.,INDICATIONS: , The patient is a 25-year-old African-American female, gravida 7, para-1-0-5-1 with two prior spontaneous abortions with three terminations who presents with pelvic pain.  She does have a slowly increasing beta HCG starting at 500 to 849 and the max to 900.  Ultrasound showed a complex right lower quadrant mass with free fluid in the pelvis.  It was decided to perform a laparoscopy for the possibility of an ectopic pregnancy.,FINDINGS: , On bimanual exam, the uterus was approximately 10 weeks' in size, mobile, and anteverted.  There were no adnexal masses appreciated although there was some fullness in the right lower quadrant.  The cervical os appeared parous.,Laparoscopic findings revealed a right ectopic pregnancy, which was just distal to the right fallopian tube and attached to the fimbria as well as adherent to the right ovary.  There were some pelvic adhesions in the right abdominal wall as well.  The left fallopian tube and ovary and uterus appeared normal.  There was no evidence of endometriosis.  There was a small amount of blood in the posterior cul-de-sac.,PROCEDURE IN DETAIL: , After informed consent was obtained in layman's terms, the patient was taken back to the operating suite, prepped and draped, placed under general anesthesia, and placed in the dorsal lithotomy position.  The bimanual exam was performed, which revealed the above findings.  A weighted speculum was placed in the patient's posterior vaginal vault and the 12 o' clock position of the cervix was grasped with the vulsellum tenaculum.  The cervix was then serially dilated using Hank dilators up to a #10.  A sharp curette was then introduced and curettage was performed obtaining a mild amount of tissue.  The tissue was sent to pathology for evaluation.  The uterine elevator was then placed in the patient's cervix.  Gloves were changed.  The attention was turned to the anterior abdominal wall where a 1 cm infraumbilical skin incision was made.  While tenting up the abdominal wall, the Veress needle was placed without difficulty.  The abdomen was then insufflated with appropriate volume and flow of CO2.  The #11 step trocar was then placed without difficulty in abdominal wall.  The placement was confirmed with a laparoscope.  It was then decided to put a #5 step trocar approximately 2 cm above the pubis symphysis in order to manipulate the pelvic contents.  The above findings were then noted.  Because the tubal pregnancy was adherent to the ovary, an additional port was placed in the right lateral aspect of the patient's abdomen.  A #12 step trocar port was placed under direct visualization.  Using a grasper, Nezhat-Dorsey suction irrigator, the mass was hydro-dissected off of the right ovary and further shelled away with graspers.  This was removed with the gallbladder grasper through the right lateral port site.  There was a small amount of oozing at the distal portion of the fimbria where the mass has been attached.  Partial salpingectomy was therefore performed.  This was done using the LigaSure.  The LigaSure was clamped across the portion of the tube including distal tube and ligated and transected.  Good hemostasis was obtained in all of the right adnexal structures.  The pelvis was then copiously suction irrigated.  The area again was then visualized and again found to be hemostatic.  The instruments were then removed from the patient's abdomen under direct visualization.  The abdomen was then desufflated and the #11 step trocar was removed.  The incisions were then repaired with #4-0 undyed Vicryl and dressed with Steri-Strips.  The uterine elevator was removed from the patient's vagina.,The patient tolerated the procedure well.  The sponge, lap, and needle count were correct x2.  She will follow up postoperatively as an outpatient.","obstetrics / gynecology, lower quadrant mass, tubal pregnancy, pelvic adhesions, laparoscopy, salpingectomy, ectopic pregnancy, abdominal wall, pregnancy,"
" Dilation and curettage (D&C), laparoscopy, right salpingectomy, lysis of adhesions, and evacuation of hemoperitoneum.  Pelvic pain, ectopic pregnancy, and hemoperitoneum.", Obstetrics / Gynecology," D&C, Laparoscopy, & Salpingectomy ","PREOPERATIVE DIAGNOSES:,1.  Pelvic pain.,2.  Ectopic pregnancy.,POSTOPERATIVE DIAGNOSES:,1.  Pelvic pain.,2.  Ectopic pregnancy.,3.  Hemoperitoneum.,PROCEDURES PERFORMED:,1.  Dilation and curettage (D&C).,2.  Laparoscopy.,3.  Right salpingectomy.,4.  Lysis of adhesions.,5.  Evacuation of hemoperitoneum.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , Scant from the operation, however, there was approximately 2 liters of clotted and old blood in the abdomen.,SPECIMENS:,  Endometrial curettings and right fallopian tube.,COMPLICATIONS: , None.,FINDINGS: , On bimanual exam, the patient has a small anteverted uterus, it is freely mobile.  No adnexal masses, however, were appreciated on the bimanual exam.  Laparoscopically, the patient had numerous omental adhesions to the vesicouterine peritoneum in the fundus of the uterus.  There were also adhesions to the left fallopian tube and the right fallopian tube.  There was a copious amount of blood in the abdomen approximately 2 liters of clotted and unclotted blood.  There was some questionable gestational tissue ________ on the left sacrospinous ligament.  There was an apparent rupture and bleeding ectopic pregnancy in the isthmus portion of the right fallopian tube.,PROCEDURE:,  After an informed consent was obtained, the patient was taken to the operating room and the general anesthetic was administered.  She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion.  Once the anesthetic was found to be adequate, a bimanual exam was performed under anesthetic.  A weighted speculum was then placed in the vagina.  The interior wall of vagina elevated with the uterine sound and the anterior lip of the cervix was grasped with the vulsellum tenaculum.  The cervix was then serially dilated with Hank dilators to a size #20 Hank and then a sharp curettage was performed obtaining a moderate amount of decidual appearing tissue and the tissue was then sent to pathology.  At this point, the uterine manipulator was placed in the cervix and attached to the anterior cervix and vulsellum tenaculum and weighted speculum were removed.  Next, attention was then turned to the abdomen.  The surgeons all are removed the dirty gloves in the previous portion of the case.  Next, a 2 cm incision was made immediately inferior to umbilicus.  The superior aspect of the umbilicus was grasped with a towel clamp and a Veress needle was inserted through this incision.  Next, a syringe was used to inject normal saline into the Veress needle.  The normal saline was seen to drop freely, so a Veress needle was connected to the CO2 gas which was started at its lowest setting.  The gas was seen to flow freely with normal resistance, so the CO2 gas was advanced to a higher setting.  The abdomen was insufflated to an adequate distension.  Once an adequate distention was reached, the CO2 gas was disconnected.  The Veress needle was removed and a size #11 step trocar was placed.  The introducer was removed and the trocar was connected to the CO2 gas and a camera was inserted.  Next, a 1 cm incision was made in the midline approximately two fingerbreadths below the pubic symphysis after transilluminating with the camera.  A Veress needle and a step sheath were inserted through this incision.  Next, the Veress needle was removed and a size #5 trocar was inserted under direct visualization.  Next a size #5 port was placed approximately five fingerbreadths to the left of the umbilicus in a similar fashion.  A size #12 port was placed in a similar fashion approximately six fingerbreadths to the right of the umbilicus and also under direct visualization.  The laparoscopic dissector was inserted through the suprapubic port and this was used to dissect the omental adhesions bluntly from the vesicouterine peritoneum and the bilateral fallopian tubes.  Next, the Dorsey suction irrigator was used to copiously irrigate the abdomen.  Approximate total of 3 liters of irrigation was used and the majority of all blood clots and free blood was removed from the abdomen.,Once the majority of blood was cleaned from the abdomen, the ectopic pregnancy was easily identified and the end of the fallopian tube was grasped with the grasper from the left upper quadrant and the LigaSure device was then inserted through the right upper quadrant with # 12 port.  Three bites with the LigaSure device were used to transect the mesosalpinx inferior to the fallopian tube and then transect the fallopian tube proximal to the ectopic pregnancy.  An EndoCatch bag was then placed to the size #12 port and this was used to remove the right fallopian tube and ectopic pregnancy.  This was then sent to the pathology.  Next, the right mesosalpinx and remains of the fallopian tube were examined again and they were seemed to be hemostatic.  The abdomen was further irrigated.  The liver was examined and appeared to be within normal limits.  At this point, the two size #5 ports and a size #12 port were removed under direct visualization.  The camera was then removed.  The CO2 gas was disconnected and the abdomen was desufflated.  The introducer was then replaced in a size #11 port and the whole port and introducer was removed as a single unit.  All laparoscopic incisions were closed with a #4-0 undyed Vicryl in a subcuticular interrupted fashion.  They were then steri-stripped and bandaged appropriately.  At the end of the procedure, the uterine manipulator was removed from the cervix and the patient was taken to Recovery in stable condition.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2.  She was discharged home with a postoperative hemoglobin of 8.9.  She was given iron 325 mg to be taken twice a day for five months and Darvocet-N 100 mg to be taken every four to six hours for pain.  She will follow up within a week in the OB resident clinic.","obstetrics / gynecology, pelvic pain, ectopic pregnancy, hemoperitoneum, d&c, dilation, laparoscopy, curettage, salpingectomy, lysis of adhesions, bimanual exam, veress needle, fallopian tube, umbilicus, cervix, ectopic, pregnancy, abdomen, tube, "
 Spontaneous controlled sterile vaginal delivery performed without episiotomy., Obstetrics / Gynecology, Delivery Note - 1 ,"The patient presented in the early morning hours of February 12, 2007, with contractions.  The patient was found to be in false versus early labor and managed as an outpatient.  The patient returned to labor and delivery approximately 12 hours later with regular painful contractions.  There was minimal cervical dilation, but 80% effacement by nurse examination.  The patient was admitted.  Expected management was utilized initially.  Stadol was used for analgesia.  Examination did not reveal vulvar lesions.  Epidural was administered.  Membranes ruptured spontaneously.  Cervical dilation progressed.  Acceleration-deceleration complexes were seen.  Overall, fetal heart tones remained reassuring during the progress of labor.  The patient was allowed to ""labor down"" during second stage.  Early decelerations were seen as well as acceleration-deceleration complexes.  Overall, fetal heart tones were reassuring.  Good maternal pushing effort produced progressive descent.,Spontaneous controlled sterile vaginal delivery was performed without episiotomy and accomplished without difficulty.  Fetal arm was wrapped at the level of the neck with the fetal hand and also at the level of the neck.  There was no loop or coil of cord.  Infant was vigorous female sex.  Oropharynx was aggressively aspirated.  Cord blood was obtained.  Placenta delivered spontaneously.,Following delivery, uterus was explored without findings of significant tissue.  Examination of the cervix did not reveal lacerations.  Upper vaginal lacerations were not seen.  Multiple first-degree lacerations were present.  Specific locations included the vestibula at 5 o'clock, left labia minora with short extension up the left sulcus, right anterior labia minora at the vestibule, and midline of the vestibule.  All mucosal lacerations were reapproximated with interrupted simple sutures of 4-0 Vicryl with the knots being buried.  Post-approximation examination of the rectum showed smooth, intact mucosa.  Blood loss with the delivery was 400 mL.,Plans for postpartum care include routine postpartum orders.  Nursing personnel will be notified of Gilbert's syndrome.","obstetrics / gynecology, delivery, gilbert's syndrome, membranes, cervical dilation, contractions, labia minora, labor, labor and delivery, trimester, uterus, vaginal delivery, vaginal lacerations, vulvar, fetal heart tones, fetal heart, heart tones, postpartum, vaginal, fetal, lacerationsNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Dilation and curettage (D&C), laparoscopy, and harmonic scalpel ablation of lesion which is suspicious for endometriosis.  Chronic pelvic pain, hypermenorrhea, desire for future fertility, failed conservative medical therapy, possible adenomyosis, left hydrosalpinx, and suspicion for endometriosis.", Obstetrics / Gynecology, D&C & Laparoscopy - 1 ,"PREOPERATIVE DIAGNOSES:,1.  Chronic pelvic pain.,2.  Hypermenorrhea.,3.  Desire for future fertility.,4.  Failed conservative medical therapy.,POSTOPERATIVE DIAGNOSES:,1.  Chronic pelvic pain.,2.  Hypermenorrhea.,3.  Desire for future fertility.,4.  Failed conservative medical therapy.,5.  Possible adenomyosis.,6.  Left hydrosalpinx.,7.  Suspicion for endometriosis.,PROCEDURES PERFORMED:,1.  Dilation and curettage (D&C).,2.  Laparoscopy.,3.  Harmonic scalpel ablation of lesion which is suspicious for endometriosis.,ANESTHESIA: , General with endotracheal tube.,ESTIMATED BLOOD LOSS: , Less than 20 cc.,COMPLICATIONS:,  None.,INDICATIONS: , This is a 35-year-old Caucasian female gravida 1, para 0-0-1-0 with a history of spontaneous abortion.  This patient had approximately greater than ten years of chronic pelvic pain with dysmenorrhea which has significantly affected her activities of daily living.  Symptoms have not improved with prescription of oral contraceptives.,The patient has had one prior surgery for a left ovarian cystectomy done by laparoscopy in 1996.  The cyst was not diagnosed as an endometrioma.  The patient does desire future fertility; however, would like a definitive diagnosis.  Conservative medical therapy was offered i.e.  Lupron or repeat oral contraceptives, but declined.,FINDINGS:,  Bimanual exam reveals a small retroverted uterus which is easily mobile.  There were no adnexal masses.  The cervix was normal on palpation.  A fibrotic band was noted at the internal os during dilation.  On laparoscopic exam, the uterus was found to be small with mild spongy texture.  On palpation, the right ovary and adnexa were grossly normal with no evidence of endometriosis.  The left ovary was grossly normal.  The left fallopian tube had a mild hydrosalpinx present.  The left uterosacral ligament had three to four 1 mm to 2 mm lesions that were vesicular in nature consistent with endometriosis.  The vesicouterine reflection in the anterior aspect of the uterus were within normal limits as were the posterior cul-de-sac.  The liver appeared grossly normal.  There were no obvious pelvic adhesions.  The left internal inguinal ring is somewhat patent, however, there is no bowel or viscera protruding through it.,PROCEDURE:  ,The patient was seen in the preop suite.  History was reviewed and all questions were answered.  The patient was then taken to the operative suite where she was placed under general anesthesia with endotracheal tube.  She was placed in a dorsal lithotomy position in Allen stirrups.  She was prepped and draped in the normal sterile fashion.  Her bladder was drained with a red Robinson catheter producing approximately 100 cc of clear yellow urine.  A bimanual exam was performed by Dr. X, Dr. Y, and Dr. Z with above findings noted.  A sterile weighted speculum was placed in posterior aspect of the vagina and the anterior aspect of the cervix was grasped with vulsellum tenaculum.  There was an attempt to place the uterine sound through the external and internal cervical os, however, secondary to a fibrotic band at the internal os that was impossible.  A #9 dilator was allowed to remain in the cervix for minimal manipulation while attention was then turned to the abdomen.  An infraumbilical incision was made using skin scalpel.  The Veress needle was placed and CO2 was insufflated.  It was immediately noticed that the pressures were inconsistent with intraabdominal insufflation and the CO2 was discontinued and Veress needle was completely removed.  A second attempt placement of the Veress needle into the abdomen was successful and CO2 was insufflated approximately 3 liters with minimal intraabdominal pressure.  The #12 port was placed and the laparoscope was inserted.  Attention was then turned back to the uterus and with the assistance of current hemostat to bluntly dissect the fibrotic band of the internal os.,Successful sounding of the uterus showed an 8-cm uterus that was in a retroverted position.  The cervix was serially dilated using Hank dilators to allow for introduction of the sharp curette.  A curettage was then performed and specimen of the endometrium was sent for pathologic evaluation.  This procedure was performed under direct laparoscopic visualization.  Laparoscopic evaluation of the pelvis was performed and the above findings noted.  A second abdominal incision was performed suprapubically using a skin scalpel and the Veress needle was placed through the incision successfully under direct visualization.  A #5 port was then placed through the sheath and the uterine manipulator was used to complete visualization.  The manipulator was then removed and the Harmonic scalpel was placed through the #5 port.  The Harmonic scalpel was used then to ablate the 1 mm vesicular lesions on the left uterosacral ligament.  The lesions were suspect for endometriosis, however, they were not diagnostic of endometriosis.  There was also present a 3 mm to 5 mm submucosal uterine fibroid on the right lower uterine segment.  The Harmonic scalpel was removed from the abdomen as was the #5 port.  The incision was internally found to be hemostatic.  The laparoscope was then removed from the abdomen.  The abdomen was desufflated.  The introducer was then replaced into the #12 port and the #12 port was removed from the abdomen.  The uterine manipulator was removed from the uterus and the cervix was found to be hemostatic.  The weighted speculum was then removed.  The patient taken out of dorsal lithotomy position.  She was recovered from general anesthesia and taken to the postoperative suite for complete recovery.  The patient's discharge instructions will include a followup in one to two weeks in Dr. X's office for discussion of pathology.  Her family was notified of the findings.  She will be instructed not to have intercourse or use tampons or douche for the next two weeks.  The patient will be sent home with a prescription for Darvocet for pain.",
" Enlarged fibroid uterus, infertility, pelvic pain, and probable bilateral tubal occlusion.  Dilatation and curettage and laparoscopy and injection of indigo carmine dye.", Obstetrics / Gynecology, D&C & Laparoscopy ,"PREOPERATIVE DIAGNOSES:,1.  Hypermenorrhea.,2.  Pelvic pain.,3.  Infertility.,POSTOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Infertility.,3.  Pelvic pain.,4.  Probable bilateral tubal occlusion.,PROCEDURE PERFORMED:,1.  Dilatation and curettage.,2.  Laparoscopy.,3.  Injection of indigo carmine dye.,GROSS FINDINGS: , The uterus was anteverted, firm, enlarged, irregular, and mobile.  The cervix is nulliparous without lesions.  Adnexal examination was negative for masses.,PROCEDURE:  ,The patient was placed in the lithotomy position, properly prepared and draped in sterile manner.  After bimanual examination, the cervix was exposed with a weighted vaginal speculum and the anterior lip of the cervix was grasped with vulsellum tenaculum.  Uterus sounded to a depth of 10.5 cm.  Endocervical canal was progressively dilated with Hanks dilators to #20-French.  A medium-sized sharp curet was used to obtain a moderated amount of tissue upon curettage, which was taken from all uterine quadrants and sent to the pathologist for analysis.  A ________ syringe was then introduced into the uterine cavity to a depth of 9 cm and the balloon insufflated with 10 cc of air.  A 20 cc syringe filled with dilute indigo carmine dye was attached to the end of the ________ syringe to use to inject at the time of laparoscopy.,A small subumbilical incision was then made with insertion of the step dilating sheath with a Veress needle into the peritoneal cavity.  The peritoneal cavity was insufflated with 3 liters of carbondioxide and a 12 mm trocar inserted.  The laparoscope was then inserted through the trocar with visualization of the pelvic contents.  In steep Trendelenburg position, the uterus was visualized and aided by use of a Bierman needle to displace bowel from visualized areas.  The fallopian tubes appeared normal bilaterally with good visualization of a normal appearing fimbria.  The ovaries also appeared normal bilaterally.  The uterus was greatly enlarged and distorted with large fibroids in multiple areas and especially on the right coronal area.  An attempt was made to inject the indigo carmine dye and in fact a three syringes of 20 cc were injected without any visualization of intraperitoneal dye still.  Both fallopian tubes apparently were blocked.  The upper abdomen was visually explored and found to be normal as was the bowel and area of the right ileum.  The patient tolerated the procedure well.  Instruments were removed from the vaginal vault and the abdomen.  Trocar was removed and the carbondioxide allowed to escape and the subumbilical wound repaired with two #4-0 undyed Vicryl sutures.  Sterile dressing was applied to the wound and the patient was sent to the recovery area in satisfactory postoperative condition.","obstetrics / gynecology, dilatation and curettage, laparoscopy, pelvic pain, infertility, enlarged fibroid uterus, tubal occlusion, indigo carmine dye, fibroid uterus, uterus infertility, peritoneal cavity, fallopian tubes, indigo carmine, endocervical, uterine, pelvic, curettage, uterus,"
" Enlarged fibroid uterus, hypermenorrhea, and secondary anemia.  Dilatation and curettage and hysteroscopy.", Obstetrics / Gynecology, D&C & Hysteroscopy ,"PREOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Hypermenorrhea.,POSTOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Hypermenorrhea.,3.  Secondary anemia.,PROCEDURE PERFORMED:,1.  Dilatation and curettage.,2.  Hysteroscopy.,GROSS FINDINGS: , Uterus was anteverted, greatly enlarged, irregular and firm.  The cervix is patulous and nulliparous without lesions.  Adnexal examination was negative for masses.,PROCEDURE:  ,The patient was taken to the operating room where she was properly prepped and draped in sterile manner under general anesthesia.  After bimanual examination, the cervix was exposed with a weighted vaginal speculum and the anterior lip of the cervix grasped with a vulsellum tenaculum.  The uterus was sounded to a depth of 11 cm.  The endocervical canal was then progressively dilated with Hanks and Hegar dilators to a #10 Hegar.  The ACMI hysteroscope was then introduced into the uterine cavity using sterile saline solution as a distending media and with attached video camera.  The endometrial cavity was distended with fluids and the cavity visualized.  Multiple irregular areas of fibroid degeneration were noted throughout the cavity.  The coronal areas were visualized bilaterally with corresponding tubal ostia.  A moderate amount of proliferative appearing endometrium was noted.  There were no direct intraluminal lesions seen.  The patient tolerated the procedure well.  Several pictures were taken of the endometrial cavity and the hysteroscope removed from the cavity.,A large sharp curet was then used to obtain a moderate amount of tissue, which was the sent to pathologist for analysis.  The instrument was removed from the vaginal vault.  The patient was sent to recovery area in satisfactory postoperative condition.","obstetrics / gynecology, dilatation and curettage, hysteroscopy, anemia, enlarged fibroid uterus, endometrial cavity, hypermenorrhea, fibroid, uterus"
" Hysteroscopy, dilatation and curettage (D&C), and myomectomy.  Severe menometrorrhagia unresponsive to medical therapy, severe anemia, and fibroid uterus.", Obstetrics / Gynecology, D&C - Discharge Summary ,"ADMISSION DIAGNOSES:,1.  Severe menometrorrhagia unresponsive to medical therapy.,2.  Severe anemia.,3.  Fibroid uterus.,DISCHARGE DIAGNOSES:,1.  Severe menometrorrhagia unresponsive to medical therapy.,2.  Severe anemia.,3.  Fibroid uterus.,OPERATIONS PERFORMED:,1.  Hysteroscopy.,2.  Dilatation and curettage (D&C).,3.  Myomectomy.,COMPLICATIONS: , Large endometrial cavity fibroid requiring careful dissection and excision.,BLOOD TRANSFUSIONS: , Two units of packed red blood cells.,INFECTION: , None.,SIGNIFICANT LAB AND X-RAY: , Posttransfusion of the 2nd unit showed her hematocrit of 25, hemoglobin of 8.3.,HOSPITAL COURSE AND TREATMENT: , The patient was admitted to the surgical suite and taken to the operating room where a dilatation and curettage (D&C) was performed.  Hysteroscopy revealed a large endometrial cavity fibroid.  Careful shaving and excision of this fibroid was performed with removal of the fibroid.  Hemostasis was noted completely at the end of this procedure.  Postoperatively, the patient has done well.  The patient was given a 2nd unit of packed red blood cells because of intraoperative blood loss.  The patient is now ambulating without difficulty and tolerating her diet.  The patient desires to go home.  The patient is discharged to home.,DISCHARGE CONDITION: , Stable.,DISCHARGE INSTRUCTIONS:  ,Regular diet, bedrest for 1 week with slow return to normal activities over the ensuing 2 to 3 weeks, pelvic rest for 6 weeks.  Vicodin tablets 1 tablet p.o. q.4-6 h. p.r.n. pain, multiple vitamin 1 tab p.o. daily, ferrous sulfate  tablets 1 tablet p.o. daily.  Ambulate with assistance at home only.  The patient is to return to see Dr. X p.r.n. plus Tuesday, 6/16/2009 for further followup care.  The patient was given full and complete postop and discharge instructions.  All her questions were answered.","obstetrics / gynecology, (d&c), fibroid uterus, myomectomy, dilatation, curettage, menometrorrhagia, uterus, hysteroscopy, fibroid, "
" D&C and hysteroscopy.  Abnormal uterine bleeding, enlarged fibroid uterus, hypermenorrhea, intermenstrual spotting, and thickened endometrium per ultrasound of a 2 cm lining.
6.  Grade 1+ rectocele.", Obstetrics / Gynecology, D&C & Hysteroscopy Followup ,"PREOPERATIVE DIAGNOSES:,1.  Abnormal uterine bleeding.,2.  Enlarged fibroid uterus.,3.  Hypermenorrhea.,4.  Intermenstrual spotting.,5.  Thickened endometrium per ultrasound of a 2 cm lining.,POSTOPERATIVE DIAGNOSES:,1.  Abnormal uterine bleeding.,2.  Enlarged fibroid uterus.,3.  Hypermenorrhea.,4.  Intermenstrual spotting.,5.  Thickened endometrium per ultrasound of a 2 cm lining.,6.  Grade 1+ rectocele.,PROCEDURE PERFORMED:  ,D&C and hysteroscopy.,COMPLICATIONS: , None.,HISTORY: , The patient is a 48-year-old para 2, vaginal delivery.  She has heavy periods lasting 7 to 14 days with spotting in between her periods.  The patient's uterus is 12.2 x 6.2 x 5.3 cm.  Her endometrial thickness is 2 cm.  Her adnexa is within normal limits.  The patient and I had a long discussion.  Consent was reviewed in layman's terms.  The patient understood the foreseeable risks and complications, the alternative treatments and procedure itself and recovery.  Questions were answered.  The patient was taken back to the operative suite.  The patient underwent pelvic examination and then carefully placed in dorsal lithotomy position.  The patient had excellent femoral pulses and there was no excessive extension or hyperflexion of the lower extremities.  The patient's history is that she is at risk for development of condyloma.  The patient's husband was found to have a laryngeal papillomatosis.  She has had a laparotomy, which is an infraumbilical incision appendectomy, a laparoscopy, and bilateral tubal ligation.  Her uterus appears to be mobile by 12-week size.  There is a good descend.  There appears to be no adnexal abnormalities.  Uterus is 12-week sized and has fibroids, it is boggy and probably has a component of adenomyosis.  The patient's cervix was dilated without difficulty utilizing Circon ACMI hysteroscope with a 12-degree lens.  The patient underwent hysteroscopy.  The outflow valve was opened at all times.  The inflow valve was opened just to achieve appropriate distension.  The patient did have no evidence of trauma of the cervix.  No Trendelenburg as we were in room #9.  The patient also had the bag held two fingerbreadths above the level of the heart.  The patient was seen.  There is a 2 x 3 cm focal thickening of the posterior wall of the uterus' endometrial lining, a more of a polypoid nature.  The patient also has one in the fundal area.  The thickened tissue was removed via sharp curettage.  Therefore, we reinserted the hysteroscope.  It appeared that there was an appropriate curettage and that all areas of suspicion were indeed removed.  The patient's procedure was ended with specimen being obtained and sent to Department of Pathology.  We will follow her up in the office.","obstetrics / gynecology, pelvic examinatio, abnormal uterine bleeding, enlarged fibroid uterus, hypermenorrhea, intermenstrual spotting, thickened endometrium, intermenstrual, d&c, uterine, bleeding, fibroid, endometrium, hysteroscopy, uterus"
 A female with unknown gestational age who presents to the ED after a suicide attempt., Obstetrics / Gynecology, Consult/ER Report - OB/GYN ,"The patient states that she has abnormal menstrual periods and cannot remember the first day of her last normal menstrual period.  She states that she had spotting for three months daily until approximately two weeks ago, when she believes that she passed a fetus.  She states that upon removal of a tampon, she saw a tadpole like structure and believed it to be a fetus.  However, she states she did not know that she was pregnant at this time.  She denies any abdominal pain or vaginal bleeding.  She states that the pregnancy is unplanned; however, she would desire to continue the pregnancy.,PAST MEDICAL HISTORY:  Diabetes mellitus which resolved after weight loss associated with gastric bypass surgery.,PAST SURGICAL HISTORY:,1.  Gastric bypass.,2.  Bilateral carpal tunnel release.,3.  Laparoscopic cholecystectomy.,4.  Hernia repair after gastric bypass surgery.,5.  Thoracotomy.,6.  Knee surgery.,MEDICATIONS:,1.  Lexapro 10 mg daily.,2.  Tramadol 50 mg tablets two by mouth four times a day.,3.  Ambien 10 mg tablets one by mouth at bedtime.,ALLERGIES:  AMOXICILLIN CAUSES THROAT SWELLING.  AVELOX CAUSES IV SITE SWELLING.,SOCIAL HISTORY:  The patient denies tobacco, ethanol, or drug use.  She is currently separated from her partner who is the father of her 21-month-old daughter.  She currently lives with her parents in Greenville.  However, she was visiting the estranged boyfriend in Wilkesboro, this week.,GYN HISTORY:  The patient denies history of abnormal Pap smears or STDs.,OBSTETRICAL HISTORY:  Gravida 1 was a term spontaneous vaginal delivery, complicated only by increased blood pressures at the time of delivery.  Gravida 2 is current.,REVIEW OF SYSTEMS:  The 14-point review of systems was negative with the exception as noted in the HPI.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure 134/45, pulse 130, respirations 28.  Oxygen saturation 100%.,GENERAL:  Patient lying quietly on a stretcher.  No acute distress.,HEENT:  Normocephalic, atraumatic.  Slightly dry mucous membranes.,CARDIOVASCULAR EXAM:  Regular rate and rhythm with tachycardia.,CHEST:  Clear to auscultation bilaterally.,ABDOMEN:  Soft, nontender, nondistended with positive bowel sounds.  No rebound or guarding.,SKIN:  Normal turgor.  No jaundice.  No rashes noted.,EXTREMITIES:  No clubbing, cyanosis, or edema.,NEUROLOGIC:  Cranial nerves II through XII grossly intact.,PSYCHIATRIC:  Flat affect.  Normal verbal response.,ASSESSMENT AND PLAN:  A 34-year-old Caucasian female, gravida 2 para 1-0-0-1, at unknown gestation who presents after suicide attempt.,1.  Given the substances taken, medications are unlikely to affect the development of the fetus.  There have been no reported human anomalies associated with Ambien or tramadol use.  There is, however, a 4% risk of congenital anomalies in the general population.,2.  Recommend quantitative HCG and transvaginal ultrasound for pregnancy dating.,3.  Recommend prenatal vitamins.,4.  The patient to follow up as an outpatient for routine prenatal care.,",
 Abdominal pain.  CT examination of the abdomen and pelvis with intravenous contrast., Obstetrics / Gynecology, CT Abdomen & Pelvis - OB-GYN ,"EXAM:,  CT examination of the abdomen and pelvis with intravenous contrast.,INDICATIONS:,  Abdominal pain.,TECHNIQUE:  ,CT examination of the abdomen and pelvis was performed after 100 mL of intravenous Isovue-300 contrast administration.  Oral contrast was not administered.  There was no comparison of studies.,FINDINGS,CT PELVIS:,Within the pelvis, the uterus demonstrates a thickened-appearing endometrium.  There is also a 4.4 x 2.5 x 3.4 cm hypodense mass in the cervix and lower uterine segment of uncertain etiology.  There is also a 2.5 cm intramural hypodense mass involving the dorsal uterine fundus likely representing a fibroid.  Several smaller fibroids were also suspected.,The ovaries are unremarkable in appearance.  There is no free pelvic fluid or adenopathy.,CT ABDOMEN:,The appendix has normal appearance in the right lower quadrant.  There are few scattered diverticula in the sigmoid colon without evidence of diverticulitis.  The small and large bowels are otherwise unremarkable.  The stomach is grossly unremarkable.  There is no abdominal or retroperitoneal adenopathy.  There are no adrenal masses.  The kidneys, liver, gallbladder, and pancreas are in unremarkable appearance.  The spleen contains several small calcified granulomas, but no evidence of masses.  It is normal in size.  The lung bases are clear bilaterally.  The osseous structures are unremarkable other than mild facet degenerative changes at L4-L5 and L5-S1.,IMPRESSION:,1.  Hypoattenuating mass in the lower uterine segment and cervix of uncertain etiology measuring approximately 4.4 x 2.5 x 3.4 cm.,2.  Multiple uterine fibroids.,3.  Prominent endometrium.,4.  Followup pelvic ultrasound is recommended.","obstetrics / gynecology, ovaries, pelvic fluid, adenopathy, uterine segment, cervix, hypodense mass, ct examination, fibroids, pelvic, ct, pelvis, isovue, abdomen"
" Laparoscopic assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, culdoplasty, and cystoscopy.  Chronic pelvic inflammatory disease, pelvic adhesions, pelvic pain, fibroid uterus, and enterocele.", Obstetrics / Gynecology, Culdoplasty & Vaginal Hysterectomy ,"PREOPERATIVE DIAGNOSES:,1.  Chronic pelvic inflammatory disease.,2.  Pelvic adhesions.,3.  Pelvic pain.,4.  Fibroid uterus.,5.  Enterocele.,POSTOPERATIVE DIAGNOSES:,1.  Chronic pelvic inflammatory disease.,2.  Pelvic adhesions.,3.  Pelvic pain.,4.  Fibroid uterus.,5.  Enterocele.,PROCEDURE PERFORMED:,1.  Laparoscopic assisted vaginal hysterectomy, bilateral salpingo-oophorectomy.,2.  McCall's culdoplasty.,3.  Cystoscopy.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , 350 cc.,INDICATIONS:  ,The patient is a 45-year-old Caucasian female with complaints of long standing pelvic pain throughout the menstrual cycle and worse with menstruation, uncontrolled with Anaprox DS also with complaints of dyspareunia.  On laparoscopy in May of 2003, PID, adenomyosis, and uterine fibroids were demonstrated.  The patient desires definitive treatment.,FINDINGS AT THE TIME OF SURGERY:  ,Uterus was retroverted and somewhat boggy on bimanual examination without any palpable adnexal abnormalities.  On laparoscopic examination, the uterus was quite soft and boggy consistent with the uterine adenomyosis.  There was also evidence of fibroid change in the right fundal aspect of the uterus.  There was a white exudative material covering the uterus as well as bilateral ovaries and fallopian tubes.  There were filmy adhesions to the right pelvic side wall, as well as left pelvic side wall.,PROCEDURE: , The patient taken to the operative suite where anesthesia was found to be adequate.  She was then prepared and draped in the normal sterile fashion.  A Foley catheter was initially placed and was noted to be draining clear to yellow urine.  A weighted speculum was placed in the patient's vagina.  The bladder was elevated and the anterior lip of the cervix was grasped with a vulsellum tenaculum.  The uterus sounded to 7 cm and the cervix was then progressively dilated.  A #20 Hank dilator, which was left within the cervix used in conjunction with the vulsellum tenaculum as a uterine manipulator.  At this time, after the gloves were changed, attention was then turned to the patient's abdomen.  A small approximately 1 cm infraumbilical incision was made with the scalpel.  A Veress needle was then inserted through this incision and a pneumoperitoneum was created with CO2 gas with appropriate volumes and pressures.  A #10 mm step trocar was then inserted through this site and intraabdominal placing was confirmed with the laparoscope.  On entrance into the patient's abdomen and pelvis, survey of the abdomen and pelvis revealed the operative area to be relatively free of adhesions except for the right pelvic saddle in which there were filmy adhesions.  There was also white exudate noted covering the surface of the uterus and adnexa and the uterus had a quite boggy appearance.  At this time, under transillumination in the left anterior axillary line, a second incision was made with a scalpel and through this site a #12 mm step trocar was inserted under direct visualization by the laparoscope.  A third incision was made in the right anterior axillary line under transillumination and through this site a second #12 mm step trocar was placed under direct visualization by the laparoscope.  Then 2 cm above the pubic symphysis in the midline and fourth incision was made and a #5 mm step trocar was inserted through this site.  The uterus was elevated and deviated to the patient's right and infundibulopelvic ligament on the left was placed on tension with the aid of a grasper.  The Endo-GIA was placed through the left sided port and was fired was to cross the infundibulopelvic ligament and down passed to the level of the round ligament, transecting and stapling at the same time.  Attention was then turned to the right adnexa.,The uterus was brought over to the patient's left and the right infundibulopelvic ligament was placed on tension with the aid of a grasper.  An Endo-GIA was used to transect and staple this vasculature and down passed to the level of round ligament.  At this time, there was noted to be a small remnant of the round ligament on the right and a Harmonic scalpel was used to complete the transection and was found to be hemostatic.  In addition, on the left the same procedure was performed to completely transect the round ligament on the left and a good hemostasis was noted.  At this time, the uterus was dropped and the vesicouterine peritoneum was grasped with graspers.  The bladder was then dissected off of the lower uterine segment with the aid of a Harmonic scalpel and hemostasis was appreciated.  The anterior cervix of the uterus was scored in the midline up to the level of the fundus with the aid of a Harmonic scalpel and then out to the adnexa bilaterally to aid in orientation during the vaginal portion of the procedure.  At this time, copious suction irrigation was performed and the operative sites were found to be hemostatic.  The pneumoperitoneum was the evacuated and the attention was then turned to the vaginal portion of the procedure.  The weighted speculum was placed into the patient's vagina.  At this time, the Foley catheter was noted to have ________ and there was noted to be a small puncture site noted into the Foley bulb.  The Foley catheter was replaced and the bladder was to be filled at a later time with methylene blue to rule out any bladder injury during the laparoscopic part of the procedure.  The cervix was then grasped from right to left with a Lahey clamps and the anterior vaginal mucosa was placed on stretch with aid of Allis clamps.  The vaginal mucosa anteriorly was then incised with aid of a scalpel from the 9 o'clock position to 3 o'clock position.  The anterior vaginal mucosa and bladder were suctioned and were then dissected away from the lower uterine segment with the aid of Mayo scissors and blunt dissection until anteriorly the peritoneal cavity was entered at which time the peritoneal incision was extended bluntly.  Next, using Lahey clamps serially following the ________ placed by the Harmonic scalpel from above were followed up to the pubic uterine fundus until the uterus was delivered into the vagina anteriorly.  At this time, two curved Heaney clamps were placed across the uterine artery on the right.  This was then transected and suture ligated with #0 Vicryl suture.  The second clamp was advanced to incorporate the cardinal ligament complex and this was then transected and suture ligated with #0 Vicryl suture.  Attention was then turned to the left uterine artery which was again doubly clamped with curved Heaney clamps, transected and suture ligated with #0 Vicryl suture.  This second clamp was then advanced to capture the vasculature and the cardinal ligament complex.  This was again transected and suture ligated with #0 Vicryl suture.,Next, the uterosacral were clamped off with the curved Heaney clamps and this clamp was met in the midline by another clamp just underneath the cervix and clamping off of the vaginal cuff.  Next the uterus, ovaries and cervix were transected away from the vaginal cuff with the aid of double pointed scissors and this specimen was handed off to pathology.  At this time, the bladder was instilled with approximately 800 cc of methylene blue and there was no evidence of any leak of blue dye as could be seen from the prospective of the vaginal portion of the procedure.  Next, the posterior vaginal cuff and posterior peritoneum were incorporated in a running lock stitch of #0 Chromic beginning at the 9'o clock position over to the 3'o clock position.  Next, the anterior vaginal mucosa was grasped with the Allis clamp and the peritoneum was identified anteriorly.  The angles of the vaginal cuff were then closed with #0 Chromic suture figure-of-eight stitch with care taken to incorporate the anterior vaginal mucosa, the anterior peritoneum, and the previously closed posterior vaginal mucosa and the posterior peritoneum.  Two additional sutures medially were placed and these were tagged and not tied in place.  A #0 Vicryl suture on a UR6 needle was used to perform the McCall's culdoplasty type approximation with the vaginal cuff to open and the uterosacral ligament visualized.  This was then tied in place and the remainder of the vaginal cuff was closed with #0 Chromic suture with figure-of-eight stitches.  At this time, the gloves were changed and attention was returned to the laparoscopic portion of the procedure at which time the abdomen was re-insufflated and the patient was placed in Trendelenburg.  The bowel was moved out of the way and copious suction irrigation was performed and all operative areas were noted to be hemostatic.  The bladder was again filled with approximately 400 cc methylene blue and from the laparoscopic ________ point there was no evidence of leakage of blue dye at this time.  The pneumoperitoneum was then evacuated and a cystoscopy was performed filling the bladder with approximately 400 cc of normal saline and there was noted to be a pinpoint perforation right on bladder dome which was found to be hemostatic and was not found to have any leakage at this time.  The bladder was then drained and the Foley catheter was replaced and after gloves changed, attention was turned to the abdomen with the laparoscopic instruments removed from the patient's abdomen.  The skin incisions were closed with #4-0 undyed Vicryl in a subcuticular fashion.  Approximately 10 cc of 0.25% Marcaine in total were injected at incision site for additional analgesia.  The Steri-Strips were placed.  The patient tolerated the procedure well and taken to recovery in stable condition.  Sponge, lap, and needle counts were correct x2.  The specimens include the uterus, cervix, bilateral ovaries, and fallopian tubes.  The patient will have her Foley catheter maintained for approximately 7 to 10 days.","obstetrics / gynecology, pelvic inflammatory disease, pelvic adhesions, pelvic pain, fibroid uterus, enterocele, salpingo-oophorectomy, mccall's culdoplasty, cystoscopy, laparoscopic assisted vaginal hysterectomy, foley catheter, vaginal mucosa, vaginal cuff, bladder, ligament, clamps, suture, pelvic, uterus, vaginal, inflammatory, laparoscopic, "
" Dilation and curettage (D&C) and hysteroscopy.  A female presents 7 months status post spontaneous vaginal delivery, has had abnormal uterine bleeding since her delivery with an ultrasound showing a 6 cm x 6 cm fundal mass suspicious either for retained products or endometrial polyp.", Obstetrics / Gynecology, D&C & Hysteroscopy - 1 ,"PREOPERATIVE DIAGNOSES:,1.  Abnormal uterine bleeding.,2.  Status post spontaneous vaginal delivery.,POSTOPERATIVE DIAGNOSES:,1.  Abnormal uterine bleeding.,2.  Status post spontaneous vaginal delivery.,PROCEDURE PERFORMED:,1.  Dilation and curettage (D&C).,2.  Hysteroscopy.,ANESTHESIA: , IV sedation with paracervical block.,ESTIMATED BLOOD LOSS:,  Less than 10 cc.,INDICATIONS:  ,This is a 17-year-old African-American female that presents 7 months status post spontaneous vaginal delivery without complications at that time.  The patient has had abnormal uterine bleeding since her delivery with an ultrasound showing a 6 cm x 6 cm fundal mass suspicious either for retained products or endometrial polyp.,PROCEDURE:,  The patient was consented and seen in the preoperative suite.  She was taken to the operative suite, placed in a dorsal lithotomy position, and placed under IV sedation.  She was prepped and draped in the normal sterile fashion.  Her bladder was drained with the red Robinson catheter which produced approximately 100 cc of clear yellow urine.  A bimanual exam was done, was performed by Dr. X and Dr. Z.  The uterus was found to be anteverted, mobile, fully involuted to a pre-pregnancy stage.  The cervix and vagina were grossly normal with no obvious masses or deformities.  A weighted speculum was placed in the posterior aspect of the vagina and the anterior lip of the cervix was grasped with the vulsellum tenaculum.,The uterus was sounded to 8 cm.  The cervix was sterilely dilated with Hank dilator and then Hagar dilator.  At the time of blunt dilation, it was noticed that the dilator passed posteriorly with greater ease than it had previously.  The dilation was discontinued at that time because it was complete and the hysteroscope was placed into the uterus.  Under direct visualization, the ostia were within normal limits.  The endometrial lining was hyperplastic, however, there was no evidence of retained products or endometrial polyps.  The hyperplastic tissue did not appear to have calcification or other abnormalities.  There was a small area of the lower uterine segment posteriorly that was suspicious for endometrial perforation, however this area was hemostatic, no evidence of bowel involvement and was approximately 1 x 1 cm in nature.  The hysteroscope was removed and a sharp curette was placed intrauterine very carefully using a anterior wall for guidance.  Endometrial curettings were obtained and the posterior aspect suspicious for perforation was gently probed and seemed to have clamped down since the endometrial curetting.  The endometrial sampling was placed on Telfa pad and sent to Pathology for evaluation.  A rectal exam was performed at the end of the procedure which showed no hematoma formation in the posterior cul-de-sac.  There was a normal consistency of the cervix and the normal step-off.  The uterine curette was removed as well as the vulsellum tenaculum and the weighted speculum.  The cervix was found to be hemostatic.  The patient was taken off the dorsal lithotomy position and recovered from her IV sedation in the recovery room.  The patient will be sent home once stable from anesthesia.  She will be instructed to followup in the office in two weeks for discussion of the pathologic report of the endometrial curettings.  The patient is sent home on Tylenol #3 prescription as she is allergic to Motrin.  The patient is instructed to refrain from intercourse douching or using tampons for the next two weeks.  The patient is also instructed to contact us if she has any problems with further bleeding, fevers, or difficulty with urination.","obstetrics / gynecology, dilation and curettage, hysteroscopy, abnormal uterine bleeding, spontaneous vaginal delivery, endometrial curettings, vaginal delivery, uterine bleeding, endometrial, d&c, cervix, vaginal, uterine, delivery,"
" An 18-year-old white female who presents for complete physical, Pap, and breast exam.", Obstetrics / Gynecology, Complete Physical - Female ,"SUBJECTIVE:,  This is an 18-year-old white female who presents for complete physical, Pap, and breast exam and to have paperwork filled out for college.  She denies any problems at this time.  Her last Pap smear was 06/25/2003 and was normal.  She is requesting to switch from Ortho-Tri-Cyclen to Seasonale at this time.  We did discuss that she may have increased episodes of breakthrough bleeding.,PAST MEDICAL HISTORY:,  Fever blisters and allergic rhinitis.,MEDICATIONS: , Allegra 180 mg q.d., trazodone 50 mg p.r.n. q.h.s., and Ortho-Tri-Cyclen.,ALLERGIES:,  None.,SOCIAL HISTORY:,  Denies tobacco or drug use, rare alcohol use.  She is sexually active and has had one partner.,FAMILY HISTORY:  ,Positive for rheumatoid arthritis.,REVIEW OF SYSTEMS:,  HEENT, pulmonary, cardiovascular, GI, GU, musculoskeletal, neurologic, dermatologic, constitutional, and psychiatric all negative except for HPI.,OBJECTIVE:,Vital Signs:  Height 5 feet 6 inches.  Weight 153 pounds.  Blood pressure 106/72.  Pulse 68.  Respirations 12.  Temperature 97.5.  Last menstrual period 05/30/2004.,General:  She is a well-developed, well-nourished white female in no acute distress.,HEENT:  Tympanic membranes unremarkable.  Oropharynx nonerythematous.  Pupils equal, round, and reactive to light.  Extraocular muscles intact.,Neck:  Supple.  No lymphadenopathy and no thyromegaly.,Chest:  Clear to auscultation bilaterally.,CV:  Regular rate and rhythm without murmur.,Abdomen:  Positive bowel sounds.  Soft and nontender.  No hepatosplenomegaly.,Breasts:  No nipple discharge.  No lumps or masses palpated.  No dimpling of the skin.  No axillary lymph nodes palpated.  Self-breast exam discussed and encouraged.,Pelvic:  Normal female genitalia.  Normal vaginal rugation.  No cervical lesions.  No cervical motion tenderness.  No adnexal tenderness or masses palpated.,Extremities:  No cyanosis, clubbing, or edema.,Neurologic:  2+/4 DTRs in all extremities.  5/5 motor strength in all extremities.  Negative Romberg.,Musculoskeletal:  No abnormalities or laxity noted in any of her joints.,ASSESSMENT/PLAN:,1.  Complete physical, Pap, and breast exam completed.,2.  School physical form completed and returned to the patient.,3.  Hepatitis B second injection will be given today.,4.  Contraceptive surveillance.  We will put patient to Seasonale to start at the end of this cycle a pill.,5.  Allergic rhinitis.  Prescription was given for Allegra 180 mg q.d.  #30 carrying refills for her to take with her school Cowley County Community College.,6.  Insomnia.  Prescription for trazodone 50 mg p.r.n. q.h.s. was given for her to take with her to school.  She will follow up as needed.",
" Cervical cone biopsy, dilatation & curettage", Obstetrics / Gynecology, Cone Biopsy ,"PREOPERATIVE DIAGNOSIS: , Cervical carcinoma in situ.,POSTOPERATIVE DIAGNOSIS: , Cervical carcinoma in situ.,OPERATION PERFORMED:,  Cervical cone biopsy, dilatation & curettage.,SPECIMENS:  ,Cone biopsy, endocervical curettings, endometrial curettings.,INDICATIONS FOR PROCEDURE: , The patient recently presented with a Pap smear showing probable adenocarcinoma in situ.  The patient was advised to have cone biopsy to fully assess endocervical glands.,FINDINGS: , During the examination, under anesthesia, the vulva, vagina, and cervix were grossly unremarkable.  The uterus was smooth with no palpable cervical nodularity and no adnexal masses were noted.,PROCEDURE: , The patient was brought to the Operating Room with an IV in place.  Anesthetic was administered and she was placed in the lithotomy position.  The patient was prepped and draped after which a weighted speculum was placed in the vagina and a tenaculum was placed on the cervix for traction.  Angle stitches of 0 Vicryl sutures were placed at 3 o'clock and 9 o'clock in the lateral vagina fornices.  The cervix was stained with Lugol's iodine solution. ,After the cervix was stained, a scalpel was used to excise a cone shaped biopsy circumferentially around the cervical os.  The specimen was removed intact, after which the uterine cavity was sounded to a depth of 8 cm.  A Kevorkian curette was used to obtain endocervical curettings.  The cone biopsy site was sutured using a running lock stitch of 0 Vicryl suture.  Upon completion of the suture placement, the endocervical canal was sounded to assure patency.  A prophylactic application of Monsel's solution completed the procedure.  ,The patient was awakened from her anesthetic and taken to the post anesthesia care unit in stable condition.  Final sponge, needle, and instrument counts were.","obstetrics / gynecology, cervical carcinoma in situ, cervical cone biopsy, endometrial curettings, endocervical, endometrial, dilatation & curettage, carcinoma in situ, cone biopsy, dilatation, curettage, carcinoma, vicryl, curettings, vagina, sutures, cervix, cervical, cone, biopsy,"
 Colpocleisis and rectocele repair., Obstetrics / Gynecology, Colpocleisis ,"PREOPERATIVE DIAGNOSES: , Vault prolapse and rectocele.,POSTOPERATIVE DIAGNOSES:,  Vault prolapse and rectocele.,OPERATION: , Colpocleisis and rectocele repair.,ANESTHESIA:  ,Spinal.,ESTIMATED BLOOD LOSS:,  Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY OF THE PATIENT: , This is an 85-year-old female who presented to us with a vaginal mass.  On physical exam, the patient was found to have grade 3 rectocele and poor apical support, and history of hysterectomy.  The patient had good anterior support at the bladder.  Options were discussed such as watchful waiting, pessary, repair with and without mesh, and closing of the vagina (colpocleisis) were discussed.  Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE, morbidity, and mortality of the procedure were discussed., ,Risk of infection and abscess formation were discussed.  The patient understood all the risks and benefits and wanted to proceed with the procedure.  Risk of retention and incontinence were discussed.  Consent was obtained through the family members.,DETAILS OF THE OR:,  The patient was brought to the OR.  Anesthesia was applied.  The patient was placed in dorsal lithotomy position.  The patient had a Foley catheter placed.  The posterior side of the rectocele was visualized with grade 3 rectocele and poor apical support.  A 1% lidocaine with epinephrine was applied for posterior hydrodissection, which was very difficult to do due to the significant scarring of the posterior part.  Attempts were made to lift the vaginal mucosa off of the rectum, which was very, very difficult to do at this point due to the patient's overall poor medical condition in terms of poor mobility and significant scarring.  Discussion was done with the family in the waiting area regarding simply closing the vagina and doing a colpocleisis since the patient is actually inactive.  Family agreed that she is not active and they rather not have any major invasive procedure especially in light of scarring and go ahead and perform the colpocleisis.  Oral consent was obtained from the family and her surgery was preceded.  The vaginal mucosa was denuded off using electrocautery and Metzenbaum scissors.  Using 0 Vicryl, 2 transverse longitudinal stitches were placed to bring the anterior and the posterior part of the vagina together and was started at the apex and was brought all the way out to the introitus.  The vaginal mucosa was pretty much completely closed off all the way up to the introitus.  Indigo carmine was given.  Cystoscopy revealed there was a good efflux of urine from both of the ureteral openings.  There was no injury to the bladder or kinking of the ureteral openings.  The bladder was normal.  Rectal exam was normal at the end of the colpocleisis repair.  There was good hemostasis., ,At the end of the procedure, Foley was removed and the patient was brought to recovery in a stable condition.","obstetrics / gynecology, vault prolapse, rectocele repair, rectocele, vaginal mass, metzenbaum scissors, ureteral openings, vaginal mucosa, colpocleisis, vaginal, infection,"
" Repeat low-transverse cesarean section, bilateral tubal ligation (BTL), extensive anterior abdominal wall/uterine/bladder adhesiolysis.  Term pregnancy and desires permanent sterilization.", Obstetrics / Gynecology, Cesarean Section & BTL ,"PREOPERATIVE DIAGNOSES:,1.  Term pregnancy.,2.  Desires permanent sterilization.,POSTOPERATIVE DIAGNOSES:,1.  Term pregnancy.,2.  Desires permanent sterilization.,PROCEDURE:,1.  Repeat low-transverse cesarean section.,2.  Bilateral tubal ligation.,3.  Extensive anterior abdominal wall/uterine/bladder adhesiolysis.,ANESTHESIA:,  Spinal/epidural with good effect.,FINDINGS:  ,Delivered vigorous male infant from cephalic presentation.  Apgars 9/9.  Birth weight 6 pounds 14 ounces.  Infant suctioned with a bulb upon delivery of the head and body.  Cord clamped and cut and infant passed to pediatric team present.  Complete placenta manually extracted intact with three vessel cord.  Extensive anterior abdominal wall adhesions with the anterior abdominal wall completely adhered to the anterior uterus throughout its entire length of the incision.  In addition, the bladder was involved in adhesion mass complex.  A window was developed surgically at the apical aspect of the incision enabling finger to pass to get behind the dense anterior abdominal wall adhesions.  These adhesions were surgically transected using Bovie cautery technique freeing up the anterior uterine attachment from the anterior abdominal wall.  Upon initial entry through the fibrous layer of the anterior abdominal wall _______ into the serosal and slightly muscular part of the anterior uterus due to the dense adhesion attachment that had occurred from previous surgeries.  Bilateral tubal ligation performed without difficulty via Parkland technique.,ESTIMATED BLOOD LOSS: , 500 mL.,COMPLICATIONS: , None.,URINE OUTPUT:  ,Per anesthesia records.  Urine cleared postoperatively.,IV FLUIDS:  ,Per anesthesia records.,The patient tolerated the procedure well and was taken to the recovery room in stable condition with stable vital signs.,OPERATIVE TECHNIQUE: , The patient was placed in a supine position after spinal/epidural anesthesia.  She was prepped and draped in the usual manner for repeat cesarean section.  A sharp knife was used to make a Pfannenstiel skin incision at the site of the previous scar.  This was carried through the subcutaneous tissue into the dense fibromuscular and fascial layer with a sharp knife.  This incision was extended laterally with Mayo scissors.  Dense fibromuscular layer was encountered from the patient's previous surgeries.  Upon entry, incision was entered into the serosal and partial muscular layer of the anterior uterus and there was no free area to enter into the peritoneal cavity due to dense fibromuscular adhesions of the entire uterus to the anterior abdominal wall at the length of the incision.  Fascia was previously separated superiorly and inferiorly from the muscular layer.  A surgical window was created at the apical aspect of the incision in the direction of the uterine fundus.  Finger was able to be passed and placed behind the dense adhesions between the uterus through anterior abdominal wall.  This adhesion complex was transacted via Bovie cautery its entire length circumferentially freeing the uterus from its attachment to anterior abdominal wall.  Inferiorly, difficulty was encountered with adhesion separation involving the bladder additionally to the uterus and the anterior abdominal wall.  These adhesions likewise were surgically transacted via sharp, blunt, and electrocautery dissection.  This was successfully done without anterior entry into the bladder.  Smooth pickups and Metzenbaum scissors were then used to do sharp dissection to separated the bladder from its attachment to the lower uterine segment enabling the vesicouterine peritoneal reflection for incision of the uterus.  The uterus was then incised using a sharp knife and low transverse incision.  This was extended with bandage scissors.  The infant was delivered easily from a cephalic presentation.  Bulb suction was done following delivery of the head and body.  The cord clamped and cut and the infant passed to pediatric team present.  Cord segment and cord blood was obtained.  Complete placenta manually extracted intact with three vessel cord.  Vigorous male infant, Apgars 9/9, weight 6 pounds 14 ounces.  Complete placenta with three vessels retrieved.  Uterus was exteriorized from the abdominal cavity.  Wet lap applied to the fundus and dry lap used to remove the remaining membranous tissue from the lining.  Pennington clamps placed at the uterine incision angles and the inferior incision lip.  A #1 chromic suture closed the uterus in running continuous interlocking closure.  Good hemostasis upon completion of the closure.  Laparotomy pads placed in the posterior cul-de-sac to remove any blood or clots.  The uterus was returned to the abdominal cavity, after using #1 chromic suture to close the anterior uterine incision, that was partial thickness through the serosal end of the muscular layer at midline adhesion.  This was closed with chromic suture in a running continuous interlocking closure with good hemostasis.  Attention was then focused on the bilateral tubal ligation.  Babcock clamp placed in the mid fallopian tube and elevated.  Cautery was used to make a window in the avascular segment of the mesosalpinx.  Proximal and distal #1 chromic suture ligation with mid fallopian tube transection performed.  The ligated proximal and distal stumps were then cauterized with Bovie cautery.  This tubal ligation procedure was done in a bilateral fashion.  Upon completion of tubal ligation, uterus was returned to the abdominal cavity.  Left and right gutters examined and found to be clean and dry.  Evaluation of the low uterine segment incision revealed continued hemostasis.  Oozing was encountered in the inferior bladder of dissection and 2-0 chromic suture in running continuous fashion, partial thickness of the bladder to control the oozing at this site was successfully done.  Interceed was then placed on the low uterine incision and the low anterior uterine aspect.  The midline rectus including peritoneum was re-approximated with simple interrupted chromic sutures.  Irrigation of the muscular layer with good hemostasis noted.  The fascia was closed with #1 Vicryl in a running continuous closure.  Subcutaneous tissue was irrigated, additional hemostasis with Bovie cautery.  The skin was closed with staples.","obstetrics / gynecology, term pregnancy, sterilization, low-transverse cesarean section, bilateral tubal ligation, adhesiolysis, anterior uterus, abdominal cavity, cesarean section, chromic suture, tubal ligation, adhesions, uterus, abdominal, infant, anterior, cesarean, hemostasis, chromic, uterine, "
" Delivered pregnancy, cholestasis of pregnancy, fetal intolerance to labor, failure to progress.  Primary low transverse cesarean section.", Obstetrics / Gynecology, Cholestasis Of Pregnancy  ,"FINAL DIAGNOSES:,  Delivered pregnancy, cholestasis of pregnancy, fetal intolerance to labor, failure to progress.,PROCEDURE: , Included primary low transverse cesarean section.,SUMMARY: , This 32-year-old gravida 2 was induced for cholestasis of pregnancy at 38-1/2 weeks.  The patient underwent a 2-day induction.  On the second day, the patient continued to progress all the way to the point of 9.5 cm at which point, she failed to progress.  During the hour or two of evaluation at 9.5 cm, the patient was also noted to have some fetal tachycardia and an occasional late deceleration.  Secondary to these factors, the patient was brought to the operative suite for primary low transverse cesarean section, which she underwent without significant complication.  There was a slightly enlarged blood loss at approximately 1200 mL, and postoperatively, the patient was noted to have a very mild tachycardia coupled with 100.3 degrees Fahrenheit temperature right at delivery.  It was felt that this was a sign of very early chorioamnionitis and therapeutic antibiotics were given throughout her stay.  The patient received 72 hours of antibiotics with there never being a temperature above 100.3 degrees Fahrenheit.  The maternal tachycardia resolved within a day.  The patient did well throughout the 3-day stay progressing to full diet, regular bowel movements, normal urination patterns.  The patient did receive 2 units of packed red cells on Sunday when attended to by my partner secondary to a hematocrit of 20%.  It should be noted, however, that this was actually an expected result with the initial hematocrit of 32% preoperatively.  Therefore, there was anemia but not an unexplained anemia.,PHYSICAL EXAMINATION ON DISCHARGE: , Includes the stable vital signs, afebrile state.  An alert and oriented patient who is desirous at discharge.  Full range of motion, all extremities; fully ambulatory.  Pulse is regular and strong.  Lungs are clear and the abdomen is soft and nontender with minimal tympany and a nontender fundus.  The incision is beautiful and soft and nontender.  There is scant lochia and there is minimal edema.,LABORATORY STUDIES: , Include hematocrit of 27% and the last liver function tests was within normal limits 48 hours prior to discharge.,FOLLOWUP: , For the patient includes pelvic rest, regular diet.  Follow up with me in 1 to 2 weeks.  Motrin 800 mg p.o. q.8h. p.r.n. cramps, Tylenol No.  3 one p.o. q.4h. p.r.n. pain, prenatal vitamin one p.o. daily, and topical triple antibiotic to incision b.i.d. to q.i.d.","obstetrics / gynecology, delivered pregnancy, fetal intolerance, induction, pelvic rest, low transverse cesarean section, cholestasis of pregnancy, cesarean section, pregnancy, fetal, tachycardia, cholestasis"
 Excision of left breast mass.  The mass was identified adjacent to the left nipple.  It was freely mobile and it did not seem to hold the skin. , Obstetrics / Gynecology, Breast Mass Excision - 2 ,"PREOPERATIVE DIAGNOSIS: , Breast mass, left.,POSTOPERATIVE DIAGNOSIS:,  Breast mass, left.,PROCEDURE:,  Excision of left breast mass.,OPERATION: , After obtaining an informed consent, the patient was taken to the operating room where he underwent general endotracheal anesthesia.  The time-out process was followed.  Preoperative antibiotic was given.  The patient was prepped and draped in the usual fashion.  The mass was identified adjacent to the left nipple.  It was freely mobile and it did not seem to hold the skin.  An elliptical skin incision was made over the mass and carried down in a pyramidal fashion towards the pectoral fascia.  The whole of specimen including the skin, the mass, and surrounding subcutaneous tissue and fascia were excised en bloc.  Hemostasis was achieved with the cautery.  The specimen was sent to Pathology and the tissues were closed in layers including a subcuticular suture of Monocryl.  A small pressure dressing was applied.,Estimated blood loss was minimal and the patient who tolerated the procedure very well was sent to recovery room in satisfactory condition.","obstetrics / gynecology, breast mass excision, freely mobile, breast mass, endotracheal, fascia, specimen,"
" Breast radiation therapy followup note. Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.", Obstetrics / Gynecology, Breast Radiation Therapy Followup ,"DIAGNOSIS: , Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.,She has been found more recently to have stage IV disease with metastatic deposits and recurrence involving the chest wall and lower left neck lymph nodes.,CURRENT MEDICATIONS,1.  Glucosamine complex.,2.  Toprol XL.,3.  Alprazolam,4.  Hydrochlorothiazide.,5.  Dyazide.,6.  Centrum.,Dr. X has given her some carboplatin and Taxol more recently and feels that she would benefit from electron beam radiotherapy to the left chest wall as well as the neck.  She previously received a total of 46.8 Gy in 26 fractions of external beam radiotherapy to the left supraclavicular area.  As such, I feel that we could safely re-treat the lower neck.  Her weight has increased to 189.5 from 185.2.  She does complain of some coughing and fatigue.,PHYSICAL EXAMINATION,NECK:  On physical examination palpable lymphadenopathy is present in the left lower neck and supraclavicular area.  No other cervical lymphadenopathy or supraclavicular lymphadenopathy is present.,RESPIRATORY:  Good air entry bilaterally. Examination of the chest wall reveals a small lesion where the chest wall recurrence was resected.  No lumps, bumps or evidence of disease involving the right breast is present.,ABDOMEN:  Normal bowel sounds, no hepatomegaly.  No tenderness on deep palpation. She has just started her last cycle of chemotherapy today, and she wishes to visit her daughter in Brooklyn, New York. After this she will return in approximately 3 to 4 weeks and begin her radiotherapy treatment at that time.,I look forward to keeping you informed of her progress.  Thank you for having allowed me to participate in her care.","obstetrics / gynecology, carboplatin, taxol, radiation therapy, breast adenocarcinoma, beam radiotherapy, chest wall, radiotherapy, supraclavicular, lymphadenopathy, adenocarcinoma, breast,"
" Cesarean Section.  An incision was made as noted above in the findings and carried down through the subcutaneous tissue, muscular fascia and peritoneum. ", Obstetrics / Gynecology, Cesarean Section ,,"obstetrics / gynecology, peritoneum, cesarean section, abdominal incision, subcutaneous tissue, bladder flap, incision, cesarean, fascia, flap, abdominalNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Suspicious calcifications upper outer quadrant, left breast.  Left breast excisional biopsy with preoperative guidewire localization and intraoperative specimen radiography.", Obstetrics / Gynecology, Breast Calcifications - Preop Consult  ,"REASON FOR HOSPITALIZATION:  ,Suspicious calcifications upper outer quadrant, left breast.,HISTORY OF PRESENT ILLNESS: , The patient is a 78-year-old woman who had undergone routine screening mammography on 06/04/08.  That study disclosed the presence of punctate calcifications that were felt to be in a cluster distribution in the left breast mound at the 2 o'clock position.  Additional imaging studies confirmed the suspicious nature of these calcifications.  The patient underwent a stereotactic core needle biopsy of the left breast 2 o'clock position on 06/17/08.  The final histologic diagnosis of the tissue removed during that procedure revealed focal fibrosis.  No calcifications could be identified in examination of the biopsy material including radiograph taken of the preserved tissue.,Two days post stereotactic core needle biopsy, however, the patient returned to the breast center with severe swelling and pain and mass in the left breast.  She underwent sonographic evaluation and was found to have a development of false aneurysm formation at the site of stereotactic core needle biopsy.  I was called to see the patient in the emergency consultation in the breast center.  At the same time, Dr. Y was consulted in Interventional Radiology.  Dr. Z and Dr. Y were able to identify the neck of the false aneurysm in the left breast mound and this was injected with ultrasound guidance with thrombin material.  This resulted in immediate occlusion of the false aneurysm.  The patient was seen in my office for followup appointment on 06/24/08.  At that time, the patient continued to have signs of a large hematoma and extensive ecchymosis, which resulted from the stereotactic core needle biopsy.  There was, however, no evidence of reforming of the false aneurysm.  There was no evidence of any pulsatile mass in the left breast mound or on the left chest wall.,I discussed the issues with the patient and her husband.  The underlying problem is that the suspicious calcifications, which had been identified on mammography had not been adequately sampled with the stereotactic core needle biopsy; therefore, the histologic diagnosis is not explanatory of the imaging findings.  For this reason, the patient was advised to have an excisional biopsy of this area with guidewire localization.  Since the breast mound was significantly disturbed from the stereotactic core needle biopsy, the decision was to postpone any surgical intervention for at least three to four months.  The patient now returns to undergo the excision of the left breast tissue with preoperative guidewire localization to identify the location of suspicious calcifications.,The patient has a history of prior stereotactic core needle biopsy of the left breast, which was performed on 01/27/04.  This revealed benign histologic findings.  The family history is positive involving a daughter who was diagnosed with breast cancer at the age of 40.  Other than her age, the patient has no other risk factors for development of breast cancer.  She is not receiving any hormone replacement therapy.  She has had five children with the first pregnancy occurring at the age of 24.  Other than her daughter, there are no other family members with breast cancer.  There are no family members with a history of ovarian cancer.,PAST MEDICAL HISTORY: , Other hospitalizations have occurred for issues with asthma and pneumonia.,PAST SURGICAL HISTORY: , Colon resection in 1990 and sinus surgeries in 1987, 1990 and 2005.,CURRENT MEDICATIONS:,1.  Plavix.,2.  Arava.,3.  Nexium.,4.  Fosamax.,5.  Advair.,6.  Singulair.,7.  Spiriva.,8.  Lexapro.,DRUG ALLERGIES:,  ASPIRIN, PENICILLIN, IODINE AND CODEINE.,FAMILY HISTORY:, Positive for heart disease, hypertension and cerebrovascular accidents.  Family history is positive for colon cancer affecting her father and a brother.  The patient has a daughter who was diagnosed with breast cancer at age 40.,SOCIAL HISTORY: , The patient does not smoke.  She does have an occasional alcoholic beverage.,REVIEW OF SYSTEMS:  ,The patient has multiple medical problems, for which she is under the care of Dr. X.  She has a history of chronic obstructive lung disease and a history of gastroesophageal reflux disease.  There is a history of anemia and there is a history of sciatica, which has been caused by arthritis.  The patient has had skin cancers, which have been treated with local excision.,PHYSICAL EXAMINATION:,GENERAL:  The patient is an elderly aged female who is alert and in no distress.,HEENT:  Head, normocephalic.  Eyes, PERRL.  Sclerae are clear.  Mouth, no oral lesions.,NECK:  Supple without adenopathy.,HEART:  Regular sinus rhythm.,CHEST:  Fair air entry bilaterally.  No wheezes are noted on examination.,BREASTS:  Normal topography bilaterally.  There are no palpable abnormalities in either breast mound.  Nipple areolar complexes are normal.  Specifically, the left breast upper outer quadrant near the 2 o'clock position has no palpable masses.  The previous tissue changes from the stereotactic core needle biopsy have resolved.  Axillary examination normal bilaterally without suspicious lymphadenopathy or masses.,ABDOMEN:  Obese.  No masses.  Normal bowel sounds are present.,BACK:  No CVA tenderness.,EXTREMITIES:  No clubbing, cyanosis or edema.,ASSESSMENT:,1.  Left breast mound clustered calcifications, suspicious by imaging located in the upper outer quadrant at the 2 o'clock position.,2.  Prior stereotactic core needle biopsy of the left breast did not resolve the nature of the calcifications, this now requires excision of the tissue with preoperative guidewire localization.,3.  History of chronic obstructive lung disease and asthma, controlled with medications.,4.  History of gastroesophageal reflux disease, controlled with medications.,5.  History of transient ischemic attack managed with medications.,6.  History of osteopenia and osteoporosis, controlled with medications.,7.  History of anxiety controlled with medications.,PLAN: , Left breast excisional biopsy with preoperative guidewire localization and intraoperative specimen radiography.  This will be performed on an outpatient basis.",
" Left breast mass and hypertrophic scar of the left breast.  Excision of left breast mass and revision of scar.  The patient is status post left breast biopsy, which showed a fibrocystic disease with now a palpable mass just superior to the previous biopsy site.", Obstetrics / Gynecology, Breast Mass Excision - 1 ,"PREOPERATIVE DIAGNOSES:,1.  Left breast mass.,2.  Hypertrophic scar of the left breast.,POSTOPERATIVE DIAGNOSES:,1.  Left breast mass.,2.  Hypertrophic scar of the left breast.,PROCEDURE PERFORMED:  ,Excision of left breast mass and revision of scar.,ANESTHESIA:  ,Local with sedation.,SPECIMEN: , Scar with left breast mass.,DISPOSITION:  ,The patient tolerated the procedure well and transferred to the recover room in stable condition.,BRIEF HISTORY:  ,The patient is an 18-year-old female who presented to Dr. X's office.  The patient is status post left breast biopsy, which showed a fibrocystic disease with now a palpable mass just superior to the previous biopsy site.  The patient also has a hypertrophic scar.  Thus, the patient elected to undergo revision of the scar at the same time as an excision of the palpable mass.,INTRAOPERATIVE FINDINGS: , A hypertrophic scar was found and removed.  The cicatrix was removed in its entirety and once opening the wound, the area of tissue where the palpable mass was, was excised as well and sent to the lab.,PROCEDURE: , After informed consent, risks, and benefits of the procedure were explained to the patient and the patient's family, the patient was brought to the operating suite, prepped and draped in the normal sterile fashion.  Elliptical incision was made over the previous cicatrix.  The total length of the incision was 5.5 cm.  Removing the cicatrix in its entirety with a #15 blade Bard-Parker scalpel after anesthetizing with local solution with 0.25% Marcaine.  Next, the area of tissue just inferior to the palpable mass, where the palpable was removed with electro Bovie cautery.  Hemostasis was maintained.  Attention was next made to approximating the deep dermal layers.  An interrupted #4-0 Vicryl suture was used and then a running subcuticular Monocryl suture was used to approximate the skin edges.  Steri-Strips as well as bacitracin and sterile dressings were applied.  The patient tolerated the procedure well and was transferred to recovery in stable condition.","obstetrics / gynecology, hypertrophic scar, palpable mass, fibrocystic, scar, fibrocystic disease, breast mass, breast, cicatrix, excision, biopsy, hypertrophic, palpable,"
 Repeat low transverse cervical cesarean section with delivery of a viable female neonate.  Bilateral tubal ligation and partial salpingectomy.  Lysis of adhesions., Obstetrics / Gynecology, BTL & Salpingectomy ,"PREOPERATIVE DIAGNOSES:,1.  Pregnancy at 38 weeks and three days.,2.  Previous cesarean section x2.,3.  Refusing trial of labor.,4.  Multiparity, seeking family planning.,POSTOPERATIVE DIAGNOSES:,1.  Pregnancy at 38 weeks and three days.,2.  Previous cesarean section x2.,3.  Refusing trial of labor.,4.  Multiparity, seeking family planning.,5.  Pelvic adhesions.,PROCEDURE PERFORMED:,1.  Repeat low transverse cervical cesarean section with delivery of a viable female neonate.,2.  Bilateral tubal ligation and partial salpingectomy.,3.  Lysis of adhesions.,ANESTHESIA: , Spinal with Astramorph.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , 800 cc.,FLUIDS: , 1800 cc of crystalloids.,URINE OUTPUT:,  600 cc of clear urine at the end of the procedure.,INDICATIONS:  ,This is a 36-year-old African-American female gravida 4, para-2-0-1-2, who presents for elective repeat cesarean section.  The patient has previous cesarean section x2 and refuses trial of labor.  The patient also requests a tubal ligation for permanent sterilization and family planning.,FINDINGS:,  A female infant in cephalic presentation in a ROP position.  Apgars of 9 and 9 at one and five minutes respectively.  Weight is 6 lb 2 oz and loose nuchal cord x1.  Normal uterus, tubes, and ovaries.,PROCEDURE:  ,After consent was obtained, the patient was taken to the operating room, where spinal anesthetic was found to be adequate.  The patient was placed in the dorsal supine position with a leftward tilt and prepped and draped in the normal sterile fashion.  The patient's previous Pfannenstiel scar incision was removed and the incision was carried through the underlying layer of fascia using the second knife.  The fascia was incised in the midline and the fascial incision was extended laterally using the second knife.  The rectus muscles were separated in the midline.  The peritoneum was identified, grasped with hemostats, and entered sharply with Metzenbaum scissors.  This incision was extended superiorly and inferiorly with good visualization of the bladder.  The bladder blade was then inserted and vesicouterine peritoneum was identified, grasped with an Allis clamp and entered sharply with Metzenbaum scissors.  This incision was extended laterally and the bladder flap created digitally.  The bladder blade was then reinserted and a small transverse incision was made along the lower uterine segment.  This incision was extended laterally manually.  The amniotic fluid was ruptured at this point with clear fluid obtained.  The infant's head was delivered atraumatically.  The nose and mouth were both suctioned on delivery.  The cord was doubly clamped and cut.  The infant was handed off to the awaiting pediatrician.  Cord gases and cord bloods were obtained and sent.  The placenta was then removed manually and the uterus exteriorized and cleared of all clots and debris.  The uterine incision was reapproximated with #0 chromic in a running lock fashion.  A second layer of the same suture was used with excellent hemostasis.  Attention was now turned to the right fallopian tube, which was grasped with the Babcock and avascular space below the tube was entered using a hemostat.  The tube was doubly clamped using hemostat and the portion between the clamps was removed using Metzenbaum scissors.  The ends of the tube were cauterized using the Bovie and they were then tied off with #2-0 Vicryl.  Attention was then turned to the left fallopian tube, which was grasped with the Babcock and avascular space beneath the tube was entered using a hemostat.  The tube was then doubly clamped with hemostat and the portion of tube between them was removed using the Metzenbaum scissors.  The ends of the tubes were cauterized and the tube was suture-ligated with #2-0 Vicryl.  There were some adhesions of the omentum to the bilateral adnexa.  These were carefully taken down using Metzenbaum scissors with excellent hemostasis noted.  The uterus was then returned to the abdomen and the bladder was cleared of all clots.  The uterine incision was reexamined and found to be hemostatic.  The fascia was then reapproximated with #0 Vicryl in a running fashion.  Several interrupted sutures of #3-0 chromic were placed in the subcutaneous tissue.  The skin was then closed with #4-0 undyed Vicryl in a subcuticular fashion.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2.  The patient was taken to the recovery room in satisfactory condition.  She will be followed immediately postoperatively within the hospital.",
 Ultrasound BPP - Advanced maternal age and hypertension., Obstetrics / Gynecology, Biophysical Profile - 1 ,"HISTORY: , Advanced maternal age and hypertension.,FINDINGS:,  There is a single live intrauterine pregnancy with a vertex lie, posterior placenta, and adequate amniotic fluid.  The amniotic fluid index is 23.2 cm.  Estimated gestational age based on prior ultrasound is 36 weeks 4 four days with an estimated date of delivery of 03/28/08.  Based on fetal measurements obtained today, estimated fetal weight is 3249 plus or minus 396 g, 7 pounds 3 ounces plus or minus 14 ounces, which places the fetus in the 66th percentile for the estimated gestational age.  Fetal heart motion at a rate of 156 beats per minute is documented.  The cord Doppler ratio is normal at 2.2.  The biophysical profile score, assessing fetal breathing movement, gross body movement, fetal tone, and qualitative amniotic fluid volume is 8/8.,IMPRESSION:,1.  Single live intrauterine pregnancy in vertex presentation with an estimated gestational age of 36 weeks 4 days and established due date of 03/28/08.,2.  Biophysical profile (BPP) score 8/8.","obstetrics / gynecology, ultrasound, bpp, maternal age, intrauterine pregnancy, biophysical profile, amniotic fluid, gestational age, amniotic, gestational, fetal,"
" Bilateral Mammogram, (abnormal) additional views requested", Obstetrics / Gynecology, Bilateral Mammogram ,"EXAM:,  Mammographic screening FFDM,HISTORY: , 40-year-old female who is on oral contraceptive pills.  She has no present symptomatic complaints.  No prior history of breast surgery nor family history of breast CA.,TECHNIQUE: , Standard CC and MLO views of the breasts.,COMPARISON: , This is the patient's baseline study.,FINDINGS: , The breasts are composed of moderately to significantly dense fibroglandular tissue.  The overlying skin is unremarkable.,There are a tiny cluster of calcifications in the right breast, near the central position associated with 11:30 on a clock.,There are benign-appearing calcifications in both breasts as well as unremarkable axillary lymph nodes.,There are no spiculated masses or architectural distortion.,IMPRESSION:,  Tiny cluster of calcifications at the 11:30 position of the right breast.  Recommend additional views; spot magnification in the MLO and CC views of the right breast.,BIRADS Classification 0 - Incomplete,MAMMOGRAPHY INFORMATION:,1.  A certain percentage of cancers, probably 10% to 15%, will not be identified by mammography.,2.  Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present.,3.  These images were obtained with FDA-approved digital mammography equipment, and iCAD Second Look Software Version 7.2 was utilized.","obstetrics / gynecology, ffdm, mammographic screening, tiny cluster of calcifications, bilateral mammogram, additional views, bilateral, mammogram, cluster, breasts, calcifications, mammography,"
" A complex closure and debridement of wound.  The patient is a 26-year-old female with a long history of shunt and hydrocephalus presenting with a draining wound in the right upper quadrant, just below the costal margin that was lanced by General Surgery and resolved; however, it continued to drain.", Neurosurgery, Wound Closure & Debridement - Hydrocephalus ,"TITLE OF OPERATION:,  A complex closure and debridement of wound.,INDICATION FOR SURGERY:,  The patient is a 26-year-old female with a long history of shunt and hydrocephalus presenting with a draining wound in the right upper quadrant, just below the costal margin that was lanced by General Surgery and resolved; however, it continued to drain.  There is no evidence of fevers.  CRP was normal.  Shunt CT were all normal.  The thought was he has insidious fistula versus tract where recommendation was for excision of this tract.,PREOP DIAGNOSIS: , Possible cerebrospinal fluid versus wound fistula.,POSTOP DIAGNOSIS: , Possible cerebrospinal fluid versus wound fistula.,PROCEDURE DETAIL: , The patient was brought to the operating room and willing to be inducted with a laryngeal mask airway, positioned supine and the right side was prepped and draped in the usual sterile fashion.  Next, working on the fistula, this was elliptically excised.  Once this was excised, this was followed down to the fistulous tract, which was completely removed.  There was no CSF drainage.  The catheter was visualized, although not adequately properly.  Once this was excised, it was irrigated and then closed in multiple layers using 3-0 Vicryl for the deep layers and 4-0 Caprosyn and Indermil with a dry sterile dressing applied.  The patient was reversed, extubated and transferred to the recovery room in stable condition.  Multiple cultures were sent as well as the tracts sent to Pathology.  All sponge and needle counts were correct.","neurosurgery, debridement of wound, shunt, costal margin, cerebrospinal fluid, cerebrospinal, closure, debridement, hydrocephalus, surgery, draining, fistula, wound, "
 Placement of right new ventriculoperitoneal (VP) shunts Strata valve and to removal of right frontal Ommaya reservoir., Neurosurgery, VP Shunt Placement ,"TITLE OF OPERATION: , Placement of right new ventriculoperitoneal (VP) shunts Strata valve and to removal of right frontal Ommaya reservoir.,INDICATION FOR SURGERY: , The patient is a 2-month-old infant, born premature with intraventricular hemorrhage and Ommaya reservoir recommendation for removal and replacement with a new VP shunt.,PREOP DIAGNOSIS: , Hydrocephalus.,POSTOP DIAGNOSIS: , Hydrocephalus.,PROCEDURE DETAIL: , The patient was brought to the operating room, underwent induction of general endotracheal airway, positioned supine, head turned towards left.  The right side prepped and draped in the usual sterile fashion.  Next, using a 15 blade scalpel, two incisions were made, one in the parietooccipital region and.  The second just lateral to the umbilicus.  Once this was clear, the Bactiseal catheter was then tunneled.  This was connected to a Strata valve.  The Strata valve was programmed to a setting of 1.01 and this was ensured.  The small burr hole was then created.  The area was then coagulated.  Once this was completed, new Bactiseal catheter was then inserted.  It was connected to the Strata valve.  There was good distal flow.  The distal end was then inserted into the peritoneal region via trocar.  Once this was insured, all the wounds were irrigated copiously and closed with 3-0 Vicryl and 4-0 Caprosyn as well as Indermil glue.  The right frontal incision was then opened.  The Ommaya reservoir identified and removed.  The wound was then also closed with an inverted 3-0 Vicryl and 4-0 Caprosyn.  Once all the wounds were completed, dry sterile dressings were applied.  The patient was then transported back to the ICU in stable condition intubated.  Blood loss minimal.  All sponge and needle counts were correct.","neurosurgery, ommaya reservoir, frontal, strata valve, intraventricular hemorrhage, vp shunt, ventriculoperitoneal, hydrocephalus, "
 Endoscopic third ventriculostomy., Neurosurgery, Ventriculostomy ,"PREOPERATIVE DIAGNOSIS: , Aqueductal stenosis.,POSTOPERATIVE DIAGNOSIS:,  Aqueductal stenosis.,TITLE OF PROCEDURE:  ,Endoscopic third ventriculostomy.,ANESTHESIA: , General endotracheal tube anesthesia.,DEVICES:,  Bactiseal ventricular catheter with an Aesculap burr hole port.,SKIN PREPARATION:  ,ChloraPrep.,COMPLICATIONS: , None.,SPECIMENS: , CSF for routine studies.,INDICATIONS FOR OPERATION:  ,Triventricular hydrocephalus most consistent with aqueductal stenosis.  The patient having a long history of some intermittent headaches, macrocephaly.,OPERATIVE PROCEDURE: , After satisfactory general endotracheal tube anesthesia was administered, the patient was positioned on the operating table in supine position with the head neutral.  The right frontal area was shaven and then the head was prepped and draped in a standard routine manner.  The area of the proposed scalp incision was infiltrated with 0.25% Marcaine with 1:200,000 epinephrine.  A curvilinear scalp incision was made extending from just posterior to bregma curving up in the midline and then going off to the right anterior to the coronal suture.  Two Weitlaner were used to hold the scalp open.  A burr hole was made just anterior to the coronal suture and then the dura was opened in a cruciate manner and the pia was coagulated.  Neuropen was introduced directly through the parenchyma into the ventricular system, which was quite large and dilated.  CSF was collected for routine studies.  We saw the total absence of __________  consistent with the congenital form of aqueductal stenosis and a markedly thinned down floor of the third ventricle.  I could bend the ventricular catheter and look back and see the aqueduct, which was quite stenotic with a little bit of chorioplexus near its opening.  The NeuroPEN was then introduced through the midline of the floor of the third ventricle anterior to the mamillary bodies in front of the basilar artery and then was gently enlarged using NeuroPEN __________  various motions.  We went through the membrane of Liliequist.  We could see the basilar artery and the clivus, and there was no significant bleeding from the edges.  The Bactiseal catheter was then left to 7 cm of length because of her macrocephaly and secured to a burr hole port with a 2-0 Ethibond suture.  The wound was irrigated out with bacitracin and closed using 3-0 Vicryl for the deep layer and a Monocryl suture for the scalp followed by Mastisol and Steri-Strips.  The patient tolerated the procedure well.","neurosurgery, aqueductal stenosis, ventriculostomy, triventricular hydrocephalus, neuropen, endoscopic third ventriculostomy, endotracheal tube anesthesia, burr hole port, aqueductal,"
" Diagnostic mammogram, full-field digital, ultrasound of the breast and mammotome core biopsy of the left breast.", Obstetrics / Gynecology, Breast Ultrasound & Biopsy ,"EXAM:  ,Bilateral diagnostic mammogram, left breast ultrasound and biopsy.,HISTORY: , 30-year-old female presents for digital bilateral mammography secondary to a soft tissue lump palpated by the patient in the upper right shoulder.  The patient has a family history of breast cancer within her mother at age 58.  Patient denies personal history of breast cancer.,TECHNIQUE AND FINDINGS:  ,Craniocaudal and mediolateral oblique projections of bilateral breasts were obtained on mm/dd/yy.  An additional lateromedial projection of the right breast was obtained.  The breasts demonstrate heterogeneously-dense fibroglandular tissue.  Within the upper outer aspect of the left breast, there is evidence of a circumscribed density measuring approximately 1 cm x 0.7 cm in diameter.  No additional dominant mass, areas of architectural distortion, or malignant-type calcifications are seen.  Multiple additional benign-appearing calcifications are visualized bilaterally.  Skin overlying both breasts is unremarkable.,Bilateral breast ultrasound was subsequently performed, which demonstrated an ovoid mass measuring approximately 0.5 x 0.5 x 0.4 cm in diameter located within the anteromedial aspect of the left shoulder.  This mass demonstrates isoechoic echotexture to the adjacent muscle, with no evidence of internal color flow.  This may represent benign fibrous tissue or a lipoma.,Additional ultrasonographic imaging of the left breast demonstrates a complex circumscribed solid and cystic lesion with hypervascular properties at the 2 o'clock position, measuring 0.7 x 0.7 x 0.8 cm in diameter.  At this time, the lesion was determined to be amenable by ultrasound-guided core biopsy.,The risks and complications of the procedure were discussed with the patient for biopsy of the solid and cystic lesion of the 2 o'clock position of the left breast.  Informed consent was obtained.  The lesion was re-localized under ultrasound guidance.  The left breast was prepped and draped in the usual sterile fashion.  2% lidocaine was administered locally for anesthesia.  Additional lidocaine with epinephrine was administered around the distal aspect of the lesion.  A small skin nick was made.  Color Doppler surrounding the lesion demonstrates multiple vessels surrounding the lesion at all sides.  The lateral to medial approach was performed with an 11-gauge Mammotome device.  The device was advanced under ultrasound guidance, with the superior aspect of the lesion placed within the aperture.  Two core biopsies were obtained.  The third core biopsy demonstrated evidence of an expanding hypoechoic area surrounding the lesion, consistent with a rapidly-expanding hematoma.  Arterial blood was visualized exiting the access site.  A biopsy clip was attempted to be placed, however could not be performed secondary to the active hemorrhage.  Therefore, the Mammotome was removed, and direct pressure over the access site and biopsy location was applied for approximately 20 minutes until hemostasis was achieved.  Postprocedural imaging of the 2 o'clock position of the left breast demonstrates evidence of a hematoma measuring approximately 1.9 x 4.4 x 1.3 cm in diameter.  The left breast was re-cleansed with a ChloraPrep, and a pressure bandage and ice packing were applied to the left breast.  The patient was observed in the ultrasound department for the following 30 minutes without complaints.  The patient was subsequently discharged with information and instructions on utilizing the ice bandage.  The obtained specimens were sent to pathology for further analysis.,IMPRESSION:,1.  A mixed solid and cystic lesion at the 2 o'clock position of the left breast was accessed under ultrasound guidance utilizing a Mammotome core biopsy instrument, and multiple core biopsies were obtained.  Transient arterial hemorrhage was noted at the biopsy site, resulting in a localized 4 cm hematoma.  Pressure was applied until hemostasis was achieved.  The patient was monitored for approximately 30 minutes after the procedure, and was ultimately discharged in good condition.  The core biopsies were submitted to pathology for further analysis.,2.  Small isoechoic ovoid mass within the anteromedial aspect of the left shoulder does not demonstrate color flow, and likely represents fibrotic changes or a lipoma.,3.  Suspicious mammographic findings.  The circumscribed density measuring approximately 8 mm at the 2 o'clock position of the left breast was subsequently biopsied.  Further pathologic analysis is pending.,BIRADS Classification 4 - Suspicious findings.,MAMMOGRAPHY INFORMATION:,1.  A certain percentage of cancers, probably 10% to 15%, will not be identified by mammography.,2.  Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present.,3.  These images were obtained with FDA-approved digital mammography equipment, and iCAD SecondLook Software Version 7.2 was utilized.","obstetrics / gynecology, mammotome core biopsy, diagnostic mammogram, breast cancer, bilateral breasts, circumscribed density, ovoid mass, breast ultrasound, core biopsy, lesion, biopsy, breast, hematoma, mammotome, mammography, ultrasound,"
" Abdominosacrocolpopexy, enterocele repair, cystoscopy, and lysis of adhesions.", Obstetrics / Gynecology, Abdominosacrocolpopexy ,"PREOPERATIVE DIAGNOSES:,1.  Vault prolapse.,2.  Enterocele.,PREOPERATIVE DIAGNOSES:,1.  Vault prolapse.,2.  Enterocele.,OPERATIONS:,1.  Abdominosacrocolpopexy.,2.  Enterocele repair.,3.  Cystoscopy.,4.  Lysis of adhesions.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:,  Less than 100 mL.,SPECIMEN: , None.,BRIEF HISTORY:,  The patient is a 53-year-old female with history of hysterectomy presented with vaginal vault prolapse.  The patient had good support in the anterior vagina and in the posterior vagina but had significant apical prolapse.  Options such as watchful waiting, pessary, abdominal surgery, robotic sacrocolpopexy versus open sacrocolpopexy were discussed.,The patient already had multiple abdominal scars.  Risk of open surgery was little bit higher for the patient.  After discussing the options the patient wanted to proceed a Pfannenstiel incision and repair of the sacrocolpopexy.  Risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, mesh erogenic exposure, complications with mesh were discussed.  The patient understood the risks of recurrence, etc, and wanted to proceed with the procedure.  The patient was told to perform no heavy lifting for 3 months, etc.  The patient was bowel prepped, preoperative antibiotics were given.,DETAILS OF THE OPERATION: , The patient was brought to the OR, anesthesia was applied.  The patient was placed in dorsal lithotomy position.  The patient was prepped and draped in usual sterile fashion.  A Pfannenstiel low abdominal incision was done at the old incision site.  The incision was carried through the subcutaneous tissue through the fascia and the fascia was lifted off the rectus abdominus muscle.  The muscle was split in the middle and peritoneum was entered using sharp mets.  There was no injury to the bowel upon entry.  There were significant adhesions which were unleashed.  All the adhesions in the sigmoid colon from the right lower quadrant and left lower quadrant were released, similarly colon was mobilized.  There was minimal space, everything was packed, Bookwalter placed then over the sacral bone.  The middle of the sacral bone was identified.  The right ureter was clearly identified and was lateral to where the posterior peritoneum was opened.  The ligament over the sacral or sacral __________ was easily identified, 0 Ethibond stitches were placed x3.  A 1 cm x 5 cm mesh was cut out.  This was a Prolene soft mesh which was tied at the sacral ligament.  The bladder was clearly off the vault area which was exposed, in the raw surface 0 Ethibond stitches were placed x3.  The mesh was attached.  The apex was clearly up enterocele sac was closed using 4-0 Vicryl without much difficulty.  The ureter was not involved at all in this process.  The peritoneum was closed over the mesh.  Please note that the peritoneum was opened and it was brought around and over the mesh so that the mesh would not be exposed to the bowel.  Prior to closure antibiotic irrigation was done using Ancef solution.  The mesh has been exposed in antibiotic solution prior to the usage.,After a through irrigation with L and half of antibiotic solution.  All the solution was removed.  Good hemostasis was obtained.  All the packing was removed.  Count was correct.  Rectus abdominus muscle was brought together using 4-0 Vicryl.  The fascia was closed using loop #1 PDS in running fascia from both sides and was tied in the middle.  Subcutaneous tissue was closed using 4-0 Vicryl and the skin was closed using 4-0 Monocryl in subcuticular fashion.  Cystoscopy was done at the end of the procedure.  Please note that the Foley was in place throughout the entire procedure which was placed thoroughly at the beginning of the procedure.  Cystoscopy was done and indigo carmine has been given.  There was good efflux of indigo carmine in both of the ureteral opening.  There was no injury to the rectum or the bladder.  The bladder appeared completely normal.  The rectal exam was done at the end of the procedure after the cystoscopy.  After the cysto was done, the scope was withdrawn, Foley was placed back.  The patient was brought to recovery in the stable condition.","obstetrics / gynecology, enterocele repair, cystoscopy, lysis of adhesions, enterocele, ethibond stitches, indigo carmine, vault prolapse, sacrocolpopexy, peritoneum, abdominosacrocolpopexy, "
 Placement of left ventriculostomy via twist drill.  Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure., Neurosurgery, Ventriculostomy Placement ,"PROCEDURE: , Placement of left ventriculostomy via twist drill.,PREOPERATIVE DIAGNOSIS:,  Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,POSTOPERATIVE DIAGNOSIS: , Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,INDICATIONS FOR PROCEDURE:  ,The patient is a man with a history of massive intracranial hemorrhage and hydrocephalus with intraventricular hemorrhage.  His condition is felt to be critical.  In a desperate attempt to relieve increased intracranial pressure, we have proposed placing a ventriculostomy.  I have discussed this with patient's wife who agrees and asked that we proceed emergently.,After a sterile prep, drape, and shaving of the hair over the left frontal area, this area is infiltrated with local anesthetic.  Subsequently a 1 cm incision was made over Kocher's point.  Hemostasis was obtained.  Then a twist drill was made over this area.  Bones strips were irrigated away.  The dura was perforated with a spinal needle.,A Camino monitor was connected and zeroed.  This was then passed into the left lateral ventricle on the first pass.  Excellent aggressive very bloody CSF under pressure was noted.  This stopped, slowed, and some clots were noted.  This was irrigated and then CSF continued.  Initial opening pressures were 30, but soon arose to 80 or a 100.,The patient tolerated the procedure well.  The wound was stitched shut and the ventricular drain was then connected to a drainage bag.,Platelets and FFP as well as vitamin K have been administered and ordered simultaneously with the placement of this device to help prevent further clotting or bleeding.","neurosurgery, intraventricular hemorrhage, hydrocephalus, intracranial pressure, camino monitor, twist drill, ventriculostomy, hemorrhage, intracranial, pressure, intraventricular"
 Burr hole and insertion of external ventricular drain catheter., Neurosurgery, Ventricular Drain Catheter Insertion ,"PREOPERATIVE DIAGNOSES:,  Increased intracranial pressure and cerebral edema due to severe brain injury.,POSTOPERATIVE DIAGNOSES: , Increased intracranial pressure and cerebral edema due to severe brain injury.,PROCEDURE:,  Burr hole and insertion of external ventricular drain catheter.,ANESTHESIA: , Just bedside sedation.,PROCEDURE: , Scalp was clipped.  He was prepped with ChloraPrep and Betadine.  Incisions are infiltrated with 1% Xylocaine with epinephrine 1:200000.  He did receive antibiotics post procedure.  He was draped in a sterile manner.,Incision made just to the right of the right mid pupillary line 10 cm behind the nasion.  A self-retaining retractor was placed.  Burr hole was drilled with the cranial twist drill.  The dura was punctured with a twist drill.  A brain needle was used to localize the ventricle that took 3 passes to localize the ventricle.  The pressure was initially high.  The CSF was clear and colorless.  The CSF drainage rapidly tapered off because of the brain swelling.  With two tries, the ventricular catheter was then able to be placed into the ventricle and then brought out through a separate stab wound, the depth of catheter is 7 cm from the outer table of the skull.  There was intermittent drainage of CSF after that.  The catheter was secured to the scalp with #2-0 silk suture and the incision was closed with Ethilon suture.  The patient tolerated the procedure well.  No complications.  Sponge and needle counts were correct.  Blood loss is minimal.  None replaced.","neurosurgery, intracranial pressure, cerebral edema, external ventricular drain catheter, ventricular drain catheter, brain injury, burr hole, ventricular, brain, catheter, "
" BPP of Gravida 1, para 0 at 33 weeks 5 days by early dating.  The patient is developing gestational diabetes.", Obstetrics / Gynecology, Biophysical Profile ,"CLINICAL HISTORY:,  Gravida 1, para 0 at 33 weeks 5 days by early dating.  The patient is developing gestational diabetes.,Transabdominal ultrasound examination demonstrated a single fetus and uterus in vertex presentation.  The placenta was posterior in position.  There was normal fetal breathing movement, gross body movement, and fetal tone, and the qualitative amniotic fluid volume was normal with an amniotic fluid index of 18.2 cm.,The following measurements were obtained:  Biparietal diameter 8.54 cm, head circumference 30.96 cm, abdominal circumference 29.17 cm, and femoral length 6.58 cm.  These values predict a fetal weight of 4 pounds 15 ounces plus or minus 12 ounces or at the 42nd percentile based on gestation.,CONCLUSION:,  Normal biophysical profile (BPP) with a score of 8 out of possible 8.  The fetus is size appropriate for gestation.","obstetrics / gynecology, biophysical profile, gestational diabetes, amniotic fluid, bpp, gravida, para, diabetes, fetus, fetalNOTE"
 Desires permanent sterilization.  Laparoscopic bilateral tubal occlusion with Hulka clips., Obstetrics / Gynecology, Bilateral Tubal Occlusion - Laparoscopic ,"PREOPERATIVE DIAGNOSIS: , Desires permanent sterilization.,POSTOPERATIVE DIAGNOSIS: , Desires permanent sterilization.,PROCEDURE PERFORMED: , Laparoscopic bilateral tubal occlusion with Hulka clips.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 20 cc.,COMPLICATIONS:  ,None.,FINDINGS: , On bimanual exam, the uterus was found to be anteverted at approximately six weeks in size.  There were no adnexal masses appreciated.  The vulva and perineum appeared normal.  Laparoscopic findings revealed normal appearing uterus, fallopian tubes bilaterally as well as ovaries bilaterally.  There was a functional cyst on the left ovary.  There was filmy adhesion in the left pelvic sidewall.  There were two clear lesions consistent with endometriosis, one was on the right fallopian tube and the other one was in the cul-de-sac.  The uterosacrals and ovarian fossa as well as vesicouterine peritoneum were free of any endometriosis.  The liver was visualized and appeared normal.  The spleen was also visualized.,INDICATIONS: , This patient is a 34-year-old gravida 4, para-4-0-0-4 Caucasian female who desires permanent sterilization.  She recently had a spontaneous vaginal delivery in June and her family planning is complete.,PROCEDURE IN DETAIL: , After informed consent was obtained in layman's terms, the patient was taken back to the operating suite and placed under general anesthesia.  She was then prepped and draped and placed in the dorsal lithotomy position.  A bimanual exam was performed and the above findings were noted.  Prior to beginning the procedure, her bladder was drained with a red Robinson catheter.  A weighted speculum was placed in the patient's posterior vagina and the 12 o' clock position of the cervix was grasped with a single-toothed tenaculum.  The cervix was dilated so that the uterine elevator could be placed.  Gloves were exchanged and attention was then turned to the anterior abdominal wall where the skin at the umbilicus was everted and using the towel clips, a 1 cm infraumbilical skin incision was made.  The Veress needle was then inserted and using sterile saline ______ the pelvic cavity.  The abdomen was then insufflated with appropriate volume and flow of CO2.  The #11 bladed trocar was then placed and intraabdominal placement was confirmed with the laparoscope.  A second skin incision was made approximately 2 cm above the pubic symphysis and under direct visualization, a 7 mm bladed trocar was placed without difficulty.  Using the Hulka clip applicator, the left fallopian tube was identified, followed out to its fimbriated end and the Hulka clip was then placed snugly against the uterus across the entire diameter of the fallopian tube.  A second Hulka clip was then placed across the entire diameter just proximal to this.  There was good hemostasis at the fallopian tube.  The right fallopian tube was then identified and followed out to its fimbriated end and the Hulka clip was placed. snugly against the uterus across the entire portion of the fallopian tube in a 90 degree angle.  A second Hulka clip was placed just distal to this again across the entire diameter.  Good hemostasis was obtained.  At this point, the abdomen was desufflated and after it was desufflated, the suprapubic port site was visualized and found to be hemostatic.  The laparoscope and remaining trocars were then removed with good visualization of the peritoneum and fascia and the laparoscope was removed.  The umbilical incision was then closed with two interrupted #4-0 undyed Vicryl.  The suprapubic incision was then closed with Steri-Strips.  The uterine elevator was removed and the single-toothed tenaculum site was found to be hemostatic.  The patient tolerated that procedure well.  The sponge, lap, and needle counts were correct x2.  She will follow up postoperatively for followup care.","obstetrics / gynecology, laparoscopic bilateral tubal occlusion, bilateral tubal occlusion, hulka clips, fallopian tubes, anesthesia, laparoscope, endometriosis, laparoscopic, sterilization, fallopian, tubes, clips,"
" Chronic venous hypertension with painful varicosities, lower extremities, bilaterally.  Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, bilaterally.", Neurosurgery, Vein Stripping ,"PREOPERATIVE DIAGNOSIS: , Chronic venous hypertension with painful varicosities, lower extremities, bilaterally.,POSTOPERATIVE DIAGNOSIS: , Chronic venous hypertension with painful varicosities, lower extremities, bilaterally.,PROCEDURES,1.  Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, right leg.,2.  Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, left leg.,PROCEDURE DETAIL: , After obtaining the informed consent, the patient was taken to the operating room where she underwent a general endotracheal anesthesia.  A time-out process was followed and antibiotics were given.,Then, both legs were prepped and draped in the usual fashion with the patient was in the supine position.  An incision was made in the right groin and the greater saphenous vein at its junction with the femoral vein was dissected out and all branches were ligated and divided.  Then, an incision was made just below the knee where the greater saphenous vein was also found and connection to varices from the calf were seen.  A third incision was made in the distal third of the right thigh in the area where there was a communication with large branch varicosities.  Then, a vein stripper was passed from the right calf up to the groin and the greater saphenous vein, which was divided, was stripped without any difficultly.  Several minutes of compression was used for hemostasis.  Then, the exposed branch varicosities both in the lower third of the thigh and in the calf were dissected out and then many stabs were performed to do stab phlebectomies at the level of the thigh and the level of the calf as much as the position would allow us to do.,Then in the left thigh, a groin incision was made and the greater saphenous vein was dissected out in the same way as was on the other side.  Also, an incision was made in the level of the knee and the saphenous vein was isolated there.  The saphenous vein was stripped and a several minutes of local compression was performed for hemostasis.  Then, a number of stabs to perform phlebectomy were performed at the level of the calf to excise branch varicosities to the extent that the patient's position would allow us.  Then, all incisions were closed in layers with Vicryl and staples.,Then, the patient was placed in the prone position and the stab phlebectomies of the right thigh and calf and left thigh and calf were performed using 10 to 20 stabs in each leg.  The stab phlebectomies were performed with a hook and they were very satisfactory.  Hemostasis achieved with compression and then staples were applied to the skin.,Then, the patient was rolled onto a stretcher where both legs were wrapped with the Kerlix, fluffs, and Ace bandages.,Estimated blood loss probably was about 150 mL.  The patient tolerated the procedure well and was sent to recovery room in satisfactory condition.  The patient is to be observed, so a decision will be made whether she needs to stay overnight or be able to go home.","neurosurgery, chronic venous hypertension, varicosities, stab phlebectomies, greater saphenous vein stripping, lower extremities, vein stripping, saphenous vein, vein, incisions, hemostasis, stripping, branches, phlebectomies, thigh, calf, saphenous,"
 Excision of right breast mass.  Right breast mass with atypical proliferative cells on fine-needle aspiration., Obstetrics / Gynecology, Breast Mass Excision ,"PREOPERATIVE DIAGNOSIS: , Right breast mass with atypical proliferative cells on fine-needle aspiration.,POSTOPERATIVE DIAGNOSIS:,  Benign breast mass.,ANESTHESIA: , General,NAME OF OPERATION:,  Excision of right breast mass.,PROCEDURE:,  With the patient in the supine position, the right breast was prepped and draped in a sterile fashion.  A curvilinear incision was made directly over the mass in the upper-outer quadrant of the right breast.  Dissection was carried out around a firm mass, which was dissected with surrounding margins of breast tissue.  Hemostasis was obtained using electrocautery.  Frozen section exam showed a fibroadenoma with some proliferative hyperplasia within the fibroadenoma, but appeared benign.  The breast tissues were approximated using 4-0 Vicryl.  The skin was closed using 5-0 Vicryl running subcuticular stitches.  A sterile bandage was applied.  The patient tolerated the procedure well.,","obstetrics / gynecology, atypical proliferative cells, fine needle aspiration, proliferative cells, breast mass, breast, needle, aspiration, fibroadenoma, excision, proliferative, mass, "
" Subcutaneous ulnar nerve transposition.  A curvilinear incision was made over the medial elbow, starting proximally at the medial intermuscular septum, curving posterior to the medial epicondyle, then curving anteriorly along the path of the ulnar nerve.  Dissection was carried down to the ulnar nerve. ", Neurosurgery, Ulnar Nerve Transposition ,"PROCEDURE:,  Subcutaneous ulnar nerve transposition.,PROCEDURE IN DETAIL: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A curvilinear incision was made over the medial elbow, starting proximally at the medial intermuscular septum, curving posterior to the medial epicondyle, then curving anteriorly along the path of the ulnar nerve.  Dissection was carried down to the ulnar nerve.  Branches of the medial antebrachial and the medial brachial cutaneous nerves were identified and protected.,Osborne's fascia was released, an ulnar neurolysis performed, and the ulnar nerve was mobilized.  Six cm of the medial intermuscular septum was excised, and the deep periosteal origin of the flexor carpi ulnaris was released to avoid kinking of the nerve as it was moved anteriorly.,The subcutaneous plane just superficial to the flexor-pronator mass was developed.  Meticulous hemostasis was maintained with bipolar electrocautery.  The nerve was transposed anteriorly, superficial to the flexor-pronator mass.  Motor branches were dissected proximally and distally to avoid tethering or kinking the ulnar nerve.,A semicircular medially based flap of flexor-pronator fascia was raised and sutured to the subcutaneous tissue in such a way as to prevent the nerve from relocating.  The subcutaneous tissue and skin were closed with simple interrupted sutures.  Marcaine with epinephrine was injected into the wound.  The elbow was dressed and splinted.  The patient was awakened and sent to the recovery room in good condition, having tolerated the procedure well.","neurosurgery, neurolysis, ulnar, periosteal, flexor-pronator mass, ulnar nerve transposition, medial intermuscular septum, nerve transposition, intermuscular septum, flexor pronator, ulnar nerve, nerve"
 Bilateral temporal artery biopsy.  Rule out temporal arteritis., Neurosurgery, Temporal Artery Biopsy ,"PREOPERATIVE DIAGNOSIS:,  Rule out temporal arteritis.,POSTOPERATIVE DIAGNOSIS:  ,Rule out temporal arteritis.,PROCEDURE:,  Bilateral temporal artery biopsy.,ANESTHESIA:,  Local anesthesia 1% Xylocaine with epinephrine.,INDICATIONS:,  I was consulted by Dr. X for this patient with bilateral temporal headaches to rule out temporal arteritis.  I explained fully the procedure to the patient.,PROCEDURE: , Both sides were done exactly the same way.  After 1% Xylocaine infiltration, a 2 to 3-cm incision was made over the temporal artery.  The temporal artery was identified and was grossly normal on both sides.  Proximal and distal were ligated with both of 3-0 silk suture and Hemoccult.  The specimen of temporal artery was taken from both sides measuring at least 2 to 3 cm.  They were sent as separate specimens, right and left labeled.  The wound was then closed with interrupted 3-0 Monocryl subcuticular sutures and Dermabond.  She tolerated the procedure well.","neurosurgery, headaches, bilateral temporal artery, temporal artery biopsy, temporal arteritis, temporal artery, temporal, biopsy, arteritis"
" Headaches, question of temporal arteritis.  Bilateral temporal artery biopsies.", Neurosurgery, Temporal Artery Biopsy - 1 ,"PREOPERATIVE DIAGNOSIS:,  Headaches, question of temporal arteritis.,POSTOPERATIVE DIAGNOSIS:,  Headaches, question of temporal arteritis.,PROCEDURE:,  Bilateral temporal artery biopsies.,DESCRIPTION OF PROCEDURE: , After obtaining an informed consent, the patient was brought to the operating room where her right temporal area was prepped and draped in the usual fashion.  Xylocaine 1% was utilized and then an incision was made in front of the right ear and deepened anteriorly.  The temporal artery was found and exposed in an extension of about 2 cm.  The artery was proximally and distally ligated with 6-0 Prolene and also a side branch and a sample was sent for pathology.  Hemostasis achieved with a cautery and the incision was closed with a subcuticular suture of Monocryl.,Then, the patient was turned and her left temporal area was prepped and draped in the usual fashion.  A similar procedure was performed with 1% Xylocaine and exposed her temporal artery, which was excised in an extent to about 2 cm.  This was also proximally and distally ligated with 6-0 Prolene and also side branch.  Hemostasis was achieved with a cautery and the skin was closed with a subcuticular suture of Monocryl.,Dressings were applied to both areas.,The patient tolerated the procedure well.  Estimated blood loss was negligible, and the patient went back to Same Day Surgery for recovery.","neurosurgery, temporal arteritis, temporal artery, temporal, artery, biopsies, hemostasis, subcuticular, headaches, arteritis, "
 Right suboccipital craniectomy for resection of tumor using the microscope modifier 22 and cranioplasty., Neurosurgery, Suboccipital Craniectomy  ,"TITLE OF OPERATION: , Right suboccipital craniectomy for resection of tumor using the microscope modifier 22 and cranioplasty.,INDICATION FOR SURGERY: , The patient with a large 3.5 cm acoustic neuroma.  The patient is having surgery for resection.  There was significant cerebellar peduncle compression.  The tumor was very difficult due to its size as well as its adherence to the brainstem and the nerve complex.  The case took 12 hours.  This was more difficult and took longer than the usual acoustic neuroma.,PREOP DIAGNOSIS: , Right acoustic neuroma.,POSTOP DIAGNOSIS: , Right acoustic neuroma.,PROCEDURE:,  The patient was brought to the operating room.  General anesthesia was induced in the usual fashion.  After appropriate lines were placed, the patient was placed in Mayfield 3-point head fixation, hold into a right park bench position to expose the right suboccipital area.  A time-out was settled with nursing and anesthesia, and the head was shaved, prescrubbed with chlorhexidine, prepped and draped in the usual fashion.  The incision was made and cautery was used to expose the suboccipital bone.  Once the suboccipital bone was exposed under the foramen magnum, the high speed drill was used to thin out the suboccipital bone and the craniectomy carried out with Leksell and insertion with Kerrison punches down to the rim of the foramen magnum as well as laterally to the edge of the sigmoid sinus and superiorly to the edge of the transverse sinus.  The dura was then opened in a cruciate fashion, the cisterna magna was drained, which nicely relaxed the cerebellum.  The dura leaves were held back with the 4-0 Nurolon.  The microscope was then brought into the field, and under the microscope, the cerebellar hemisphere was elevated.  Laterally, the arachnoid was very thick.  This was opened with bipolar and microscissors and this allowed for the cerebellum to be further mobilized until the tumor was identified.  The tumor was quite large and filled up the entire lateral aspect of the right posterior fossa.  Initially two retractors were used, one on the tentorium and one inferiorly.  The arachnoid was taken down off the tumor.  There were multiple blood vessels on the surface, which were bipolared.  The tumor surface was then opened with microscissors and the Cavitron was used to began debulking the lesion.  This was a very difficult resection due to the extreme stickiness and adherence to the cerebellar peduncle and the lateral cerebellum; however, as the tumor was able to be debulked, the edge began to be mobilized.  The redundant capsule was bipolared and cut out to get further access to the center of the tumor.  Working inferiorly and then superiorly, the tumor was taken down off the tentorium as well as out the 9th, 10th or 11th nerve complex.  It was very difficult to identify the 7th nerve complex.  The brainstem was identified above the complex.  Similarly, inferiorly the brainstem was able to be identified and cotton balls were placed to maintain this plain.  Attention was then taken to try identify the 7th nerve complex.  There were multitude of veins including the lateral pontine vein, which were coming right into this area.  The lateral pontine vein was maintained.  Microscissors and bipolar were used to develop the plain, and then working inferiorly, the 7th nerve was identified coming off the brainstem.  A number 1 and number 2 microinstruments were then used to began to develop the plane.  This then allowed for the further appropriate plane medially to be identified and cotton balls were then placed.  A number 11 and number 1 microinstrument continued to be used to free up the tumor from the widely spread out 7th nerve.  Cavitron was used to debulk the lesion and then further dissection was carried out.  The nerve stimulated beautifully at the brainstem level throughout this.  The tumor continued to be mobilized off the lateral pontine vein until it was completely off.  The Cavitron was used to debulk the lesion out back laterally towards the area of the porus.  The tumor was debulked and the capsule continued to be separated with number 11microinstrument as well as the number 1 microinstrument to roll the tumor laterally up towards the porus.  At this point, the capsule was so redundant, it was felt to isolate the nerve in the porus.  There was minimal bulk remaining intracranially.  All the cotton balls were removed and the nerve again stimulated beautifully at the brainstem.  Dr. X then came in and scrubbed into the case to drill out the porus and remove the piece of the tumor that was left in the porus and coming out of the porus.,I then scrubbed back into case once Dr. X had completed removing this portion of the tumor.  There was no tumor remaining at this point.  I placed some Norian in the porus to seal any air cells, although there were no palpated.  An intradural space was then irrigated thoroughly.  There was no bleeding.  The nerve was attempted to be stimulated at the brainstem level, but it did not stimulate at this time.  The dura was then closed with 4-0 Nurolons in interrupted fashion.  A muscle plug was used over one area.  Duragen was laid and strips over the suture line followed by Hemaseel.  Gelfoam was set over this and then a titanium cranioplasty was carried out.  The wound was then irrigated thoroughly.  O Vicryls were used to close the deep muscle and fascia, 3-0 Vicryl for subcutaneous tissue, and 3-0 nylon on the skin.,The patient was extubated and taken to the ICU in stable condition.","neurosurgery, suboccipital, craniectomy, microscope, cranioplasty, acoustic neuroma, cerebellar peduncle, nerve complex, brainstem, nurolon, cavitron, kerrison, leksell, lateral pontine vein, suboccipital craniectomy, nerve, tumor"
 Squamous cell carcinoma of right temporal bone/middle ear space.  Right temporal bone resection; rectus abdominis myocutaneous free flap for reconstruction of skull base defect; right selective neck dissection zones 2 and 3., Neurosurgery, Skull Base Reconstruction ,"PREOPERATIVE DIAGNOSIS:,  Squamous cell carcinoma of right temporal bone/middle ear space.,POSTOPERATIVE DIAGNOSIS: , Squamous cell carcinoma of right temporal bone/middle ear space.,PROCEDURE: , Right temporal bone resection; rectus abdominis myocutaneous free flap for reconstruction of skull base defect; right selective neck dissection zones 2 and 3.,ANESTHESIA: , General endotracheal.,DESCRIPTION OF PROCEDURE:  ,The patient was brought into the operating room, placed on the table in supine position.  General endotracheal anesthesia was obtained in the usual fashion.  The Neurosurgery team placed the patient in pins and after they positioned the patient the right lateral scalp was prepped with Betadine after shave as well as the abdomen.  The neck was prepped as well.  After this was performed, I made a wide ellipse of the conchal bowl with the Bovie and cutting current down through the cartilage of the conchal bowl.  A wide postauricular incision well beyond the mastoid tip extending into the right neck was then incised with the Bovie with the cutting current and a postauricular skin flap developed leaving the excise conchal bowl in place as the auricle was reflected over anterior to the condyle.  After this was performed, I used the Bovie to incise the soft tissue around the temporal bone away from the tumor on to the mandible.  The condyle was skeletonized so that it could be easily seen.  The anterior border of the sternocleidomastoid was dissected out and the spinal accessory nerve was identified and spared.  The neck contents to the hyoid were dissected out.  The hypoglossal nerve, vagus nerve, and spinal accessory nerve were dissected towards the jugular foramen.  The neck contents were removed as a separate specimen.  The external carotid artery was identified and tied off as it entered the parotid and tied with a Hemoclip distally for the future anastomosis.  A large posterior facial vein was identified and likewise clipped for later use.  I then used the cutting and diamond burs to incise the skull above the external auditory canal so as to expose the dura underneath this and extended it posteriorly to the sigmoid sinus, dissecting or exposing the dura to the level of the jugular bulb.  It became evident there was two tumor extending down the eustachian tube medial to the condyle and therefore I did use the router, I mean the side cutting bur to resect the condyle and the glenoid fossa to expose the medial extent of the eustachian tube.  The internal carotid artery was dissected out of the parapharyngeal space into the carotid canal and I drilled carotid canal up until it made.  I dissected the vertical segment of the carotid out as it entered the temporal bone until it made us turn to the horizontal portion.  Once this was dissected out, Dr. X entered the procedure for completion of the resection with the craniotomy.  For details, please see his operative note.,After Dr. X had completed the resection, I then harvested the rectus free flap.  A skin paddle was drawn out next to the umbilicus about 4 x 4 cm.  The skin paddle was incised with the Bovie and down to the anterior rectus sheath.  Sagittal incisions were made up superiorly and inferiorly to the skin paddle and the anterior rectus sheath dissected out above and below the skin paddle.  The sheath was incised to the midline and a small ellipse was made around the fascia to provide blood supply to the overlying skin.  The skin paddle was then sutured to the fascia and muscle with interrupted 3-0 Vicryl.  The anterior rectus sheath was then reflected off the rectus muscle, which was then divided superiorly with the Bovie and reflected out of the rectus sheath to an inferior direction.  The vascular pedicle could be seen entering the muscle in usual fashion.  The muscle was divided inferior to the pedicle and then the pedicle was dissected to the groin to the external iliac artery and vein where it was ligated with two large Hemoclips on each vessel.  The wound was then packed with saline impregnated sponges.  The rectus muscle with attached skin paddle was then transferred into the neck.  The inferior epigastric artery was sutured to the end of the external carotid with interrupted 9-0 Ethilon with standard microvascular technique.  Ischemia time was less than 10 minutes.  Likewise, the inferior epigastric vein was sutured to the end of the posterior facial vein with interrupted 9-0 Ethilon as well.  There was excellent blood flow through the flap and there were no or any issues with the vascular pedicle throughout the remainder of the case.  The wound was irrigated with copious amounts of saline.  The eustachian tube was obstructed with bone wax.  The muscle was then laid into position with the skin paddle underneath the conchal bowl.  I removed most the skin of the conchal bowl de-epithelializing and leaving the fat in place.  The wound was closed in layers overlying the muscle, which was secured superiorly to the muscle overlying the temporal skull.  The subcutaneous tissues were closed with interrupted 3-0 Vicryl.  The skin was closed with skin staples.  There was small incision made in the postauricular skin where the muscle could be seen and the skin edges were sewn directly to the muscle as to the rectus muscle itself.  The skin paddle was closed with interrupted 4-0 Prolene to the edges of the conchal bowl.,The abdomen was irrigated with copious amounts of saline and the rectus sheath was closed with #1 Prolene with the more running suture, taking care to avoid injury to the posterior rectus sheath by the use of ribbon retractors.  The subcutaneous tissues were closed with interrupted 2-0 Vicryl and skin was closed with skin staples.  The patient was then turned over to the Neurosurgery team for awakening after the patient was appropriately awakened.  The patient was then transferred to the PACU in stable condition with spontaneous respirations, having tolerated the procedure well.","neurosurgery, rectus abdominis myocutaneous, skull base defect, squamous cell carcinoma, skull base, squamous cell, rectus sheath, abdominis, muscle, rectus, sheath"
 Endoscopic proximal and distal shunt revision with removal of old valve and insertion of new., Neurosurgery, Shunt Revision - 2 ,"PREOPERATIVE DIAGNOSIS: , Shunt malfunction.,POSTOPERATIVE DIAGNOSIS: , Partial proximal obstruction, patent distal system.,TITLE OF OPERATION: , Endoscopic proximal and distal shunt revision with removal of old valve and insertion of new.,SPECIMENS:  ,None.,COMPLICATIONS:,  None.,ANESTHESIA:,  General.,SKIN PREPARATION:  ,Chloraprep.,INDICATIONS FOR OPERATION: , Headaches, irritability, slight increase in ventricle size.  Preoperatively patient improved with Diamox.,BRIEF NARRATIVE OF OPERATIVE PROCEDURE: , After satisfactory general endotracheal tube anesthesia was administered, the patient was positioned on the operating table in the supine position with the head rotated towards the left.  The right frontal area and right retroauricular area was shaved and then the head, neck, chest and abdomen were prepped and draped out in the routine manner.  The old scalp incision was opened with a Colorado needle tip and the old catheter was identified as we took the Colorado needle tip over the existing ventricular catheter, right over the sleeve on top of it and when that was entered, the CSF poured out around the ventricular catheter.  The ventricular catheter was then disconnected from the reservoir and endoscopically explored.  We saw it was blocked up proximally.  The catheter was a little adherent and required some freeing up with coagulation and on twisting of the ventricular catheter, I was able to free up the ventricular catheter, and endoscopically inserted a new Bactiseal ventricular catheter.  The catheter went down to the septum and I could see both the right and left lateral ventricles and elected to pass it into the right lateral ventricle.  It irrigated out well.  There was minimal amount of bleeding, but not significant.  The distal catheter system was tested.  There was good distal run off.  Therefore, a linear skin incision was made in the retroauricular area.  Tunneling was performed between the two incisions and a ProGAV valve set to an opening pressure of 10 with a 1-5 shunt assist was brought through the subgaleal tissue, connected to the distal catheter and a flushing reservoir was interposed between the burr hole site ventricular catheter and the ProGAV valve.  All connections were secured with 2-0 Ethibond sutures.  Careful attention was made to make sure that the ProGAV was in the right orientation.  The wounds were irrigated out with Bacitracin, closed in a routine manner using Vicryl for the deep layers and Monocryl for the skin, followed by Mastisol and Steri-Strips.  The patient tolerated the procedure well.  He was awakened, extubated and taken to recovery room in satisfactory condition.","neurosurgery, chloraprep, distal shunt revision, colorado needle tip, colorado needle, progav valve, shunt revision, ventricular catheter, catheter, shunt, ventricular,"
" Anterior spine fusion from T11-L3.  Posterior spine fusion from T3-L5.  Posterior spine segmental instrumentation from T3-L5, placement of morcellized autograft and allograft.", Neurosurgery, Spine Fusion ,"PREOPERATIVE DIAGNOSIS: , Severe neurologic or neurogenic scoliosis.,POSTOPERATIVE DIAGNOSIS: , Severe neurologic or neurogenic scoliosis.,PROCEDURES:  ,1.  Anterior spine fusion from T11-L3.,2.  Posterior spine fusion from T3-L5.,3.  Posterior spine segmental instrumentation from T3-L5, placement of morcellized autograft and allograft.,ESTIMATED BLOOD LOSS: , 500 mL.,FINDINGS: , The patient was found to have a severe scoliosis.  This was found to be moderately corrected.  Hardware was found to be in good positions on AP and lateral projections using fluoroscopy.,INDICATIONS: , The patient has a history of severe neurogenic scoliosis.  He was indicated for anterior and posterior spinal fusion to allow for correction of the curvature as well as prevention of further progression.  Risks and benefits were discussed at length with the family over many visits.  They wished to proceed.,PROCEDURE:,  The patient was brought to the operating room and placed on the operating table in the supine position.  General anesthesia was induced without incident.  He was given a weight-adjusted dose of antibiotics.  Appropriate lines were then placed.  He had a neuromonitoring performed as well.,He was then initially placed in the lateral decubitus position with his left side down and right side up.  An oblique incision was then made over the flank overlying the 10th rib.  Underlying soft tissues were incised down at the skin incision.  The rib was then identified and subperiosteal dissection was performed.  The rib was then removed and used for autograft placement later.,The underlying pleura was then split longitudinally.  This allowed for entry into the pleural space.  The lung was then packed superiorly with wet lap.  The diaphragm was then identified and this was split to allow for access to the thoracolumbar spine.,Once the spine was achieved, subperiosteal dissection was performed over the visualized vertebral bodies.  This required cauterization of the segmental vessels.  Once the subperiosteal dissection was performed to the posterior and anterior extents possible, the diskectomies were performed.  These were performed from T11-L3.  This was over 5 levels.  Disks and endplates were then removed.  Once this was performed, morcellized rib autograft was placed into the spaces.  The table had been previously bent to allow for easier access of the spine.  This was then straightened to allow for compression and some correction of the curvature.,The diaphragm was then repaired as was the pleura overlying the thoracic cavity.  The ribs were held together with #1 Vicryl sutures.  Muscle layers were then repaired using a running #2-0 PDS sutures and the skin was closed using running inverted #2-0 PDS suture as well.  Skin was closed as needed with running #4-0 Monocryl.  This was dressed with Xeroform dry sterile dressings and tape.,The patient was then rotated into a prone position.  The spine was prepped and draped in a standard fashion.,Longitudinal incision was made from T2-L5.  The underlying soft tissues were incised down at the skin incision.  Electrocautery was then used to maintain hemostasis.  The spinous processes were then identified and the overlying apophyses were split.  This allowed for subperiosteal dissection over the spinous processes, lamina, facet joints, and transverse processes.  Once this was completed, the C-arm was brought in, which allowed for easy placement of screws in the lumbar spine.  These were placed at L4 and L5.  The interspaces between the spinous processes were then cleared of soft tissue and ligamentum flavum.  This was done using a rongeur as well as a Kerrison rongeur.  Spinous processes were then harvested for morcellized autograft.,Once all the interspaces were prepared, Songer wires were then passed.  These were placed from L3-T3.,Once the wires were placed, a unit rod was then positioned.  This was secured initially at the screws distally on both the left and right side.  The wires were then tightened in sequence from the superior extent to the inferior extent, first on the left-sided spine where I was operating and then on the right side spine.  This allowed for excellent correction of the scoliotic curvature.,Decortication was then performed and placement of a morcellized autograft and allograft was then performed after thoroughly irrigating the wound with 4 liters of normal saline mixed with bacitracin.  This was done using pulsed lavage.,The wound was then closed in layers.  The deep fascia was closed using running #1 PDS suture, subcutaneous tissue was closed using running inverted #2-0 PDS suture, the skin was closed using #4-0 Monocryl as needed.  The wound was then dressed with Steri-Strips, Xeroform dry sterile dressings, and tape.  The patient was awakened from anesthesia and taken to the intensive care unit in stable condition.  All instrument, sponge, and needle counts were correct at the end of the case.,The patient will be managed in the ICU and then on the floor as indicated.","neurosurgery, anterior spine fusion, posterior spine fusion, spine segmental instrumentation, dry sterile dressings, autograft and allograft, pds sutures, spinous processes, spine fusion, spine, instrumentation, morcellized, allograft, fusion, autograft, "
 Thoracic right-sided discectomy at T8-T9.   The patient is a 53-year-old female with a history of right thoracic rib pain related to a herniated nucleus pulposus at T8-T9.  , Neurosurgery, Thoracic Discectomy ,"PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus T8-T9.,POSTOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus T8-T9.,OPERATION PERFORMED: , Thoracic right-sided discectomy at T8-T9.,BRIEF HISTORY AND INDICATION FOR OPERATION: , The patient is a 53-year-old female with a history of right thoracic rib pain related to a herniated nucleus pulposus at T8-T9.  She has failed conservative measures and sought operative intervention for relief of her symptoms.  For details of workup, please see the dictated operative report.,DESCRIPTION OF OPERATION:  ,Appropriate informed consent was obtained and the patient was taken to the operating room and placed under general anesthetic.  She was placed in a position of comfort on the operating table with all bony prominences and soft tissues well padded and protected.  Second check was made prior to prepping and draping.  Following this, we did needle localization with reviews of AP and lateral multiple times to make sure we had the T8-T9 level.  We then made an approach through a midline incision and came out over the pars.  We dissected down carefully to identify the pars.  We then went on the outside of the pars and identified the foramen and then we took another series of x-rays to confirm the T8-T9 level.  We did this under live fluoroscopy.  We confirmed T8-T9 and then went ahead and took a Midas Rex and removed the superior portion of the pedicle overlying the outside of the disc and then worked our way downward removing portion of the transverse process as well.  We found the edge of the disc and then worked our way and we were able to remove some of the disc material but then decided to go ahead and take down the pars.  The pars was then drilled out.  We identified the disc even further and found the disc herniation material that was under the spinal cord.  We then took a combination of small pituitaries and removed the disc material without difficulty.  Once we had disc material out, we went ahead and made a small cruciate incision in the disc space and entered the disc space in earnest removing more disc material making sure there is nothing free to herniate further.  Once we had done that, we inspected up by the nerve root, found some more disc material there and removed that as well.  We could trace the nerve root out freely and easily.  We made sure there was no evidence of further disc material.  We used an Epstein curette and placed a nerve hook under the nerve root.  The Epstein curette removed some more disc material.  Once we had done this, we were satisfied with the decompression.  We irrigated the wound copiously to make sure there is no further disc material and then ready for closure.  We did place some steroid over the nerve root and readied for closure.  Hemostasis was meticulous.  The wound was closed with #1 Vicryl suture for the fascial layer, 2 Vicryl suture for the skin, and Monocryl and Steri-Strips applied.  Dressing was applied.  The patient was awoken from anesthesia and taken to the recovery room in stable condition.,ESTIMATED BLOOD LOSS:,  150 mL.,COMPLICATIONS: , None.,DISPOSITION:,  To PACU in stable condition having tolerated the procedure well, to mobilize routinely when she is comfortable to go to her home.","neurosurgery, thoracic right-sided discectomy, herniated nucleus pulposus, discectomy, thoracic, herniated,"
 Right pterional craniotomy with obliteration of medial temporal arteriovenous malformation and associated aneurysm and evacuation of frontotemporal intracerebral hematoma., Neurosurgery, Pterional Craniotomy ,"PREOPERATIVE DIAGNOSIS:  ,Status post spontaneous hemorrhage from medial temporal arteriovenous malformation with arteriographic evidence of associated aneurysm.,POSTOPERATIVE DIAGNOSIS: , Status post spontaneous hemorrhage from medial temporal arteriovenous malformation with arteriographic evidence of associated aneurysm.,OPERATION: , Right pterional craniotomy with obliteration of medial temporal arteriovenous malformation and associated aneurysm and evacuation of frontotemporal intracerebral hematoma.,ANESTHESIA: , Endotracheal.,ESTIMATED BLOOD LOSS: , 250 mL,REPLACEMENTS:  ,3 units of packed cells.,DRAINS:,  None.,COMPLICATIONS: , None.,PROCEDURE:  ,With the patient prepped and draped in the routine fashion in the supine position with the head in a Mayfield headrest, turned 45 degrees to the patient's left and a small roll placed under her right shoulder and hip, the previously made pterional incision was reopened and extended along its posterior inferior limb to the patient's zygoma.  Additional aspect of the temporalis muscle and fascia were incised with cutting Bovie current with effort made to preserve the posterior limb of the external carotid artery.  The scalp and temporalis muscle were then retracted anteroinferiorly with 0 silk sutures, attached rubber bands and Allis clamps and similar retraction of the posterior aspect of temporalis was retracted with 0 silk suture, attached with rubber bands and Allis clamps.  The bone flap, which had not been fixed in place was removed.  An additional portion of the temporofrontal bone based at the zygoma was removed with a B1 dissecting tool, B1 attached to the Midas Rex instrumentation.  Further bone removal was accomplished with Leksell rongeur, and hemostasis controlled with the use of bone wax.,At this point, a retractor was placed along the frontal lobe for visualization of the perichiasmatic cistern with visualization made of the optic nerve and carotid artery.  It should be noted that cottonoid paddies were placed over the brain to protect the cortical surface of the brain both underneath the retractor and the remainder of the exposed cortex.  The sylvian fissure was then dissected with the dissection description being dictated by Dr. X.,Following successful splitting of the sylvian fissure to its apparent midplate, attention was next turned to the temporal tip where the approximate location of the cerebral aneurysm noted on CT angio, as well as conventional arteriography was noted and a peel incision was made extending from the temporal tip approximately 3 cm posterior.  This was enlarged with bipolar coagulation and aspiration and inferior dissection accomplished under the operating microscope until the dome of, what appeared to be, an aneurysm could be visualized.,Dissection around the dome with bipolar coagulation and aspiration revealed a number of abnormal vessels, which appeared to be involved with the aneurysm at its base and these were removed with bipolar coagulation.  Until circumferential dissection revealed 1 major arterial supply to the base of the aneurysm, this was felt to be able to be handled with bipolar coagulation, which was done and the vessel then cut with microscissors and the aneurysm removed in toto.,Attention was next turned to the apparent nidus of the arteriovenous malformation, which was somewhat medial and inferior to the aneurysm and the nidus was then dissected with the use of bipolar coagulation and aspiration microscissors as further described by Dr. X. With removal of the arteriovenous malformation, attention was then turned to the previous frontal cortical incision, which was the site of partial decompression of the patient's intracerebral hematoma on the day of her admission.  Self-retaining retractors were placed within this cortical incision, and the hematoma cavity entered with additional hematoma removed with general aspiration and irrigation.  Following removal of additional hematoma, the bed of the hematoma site was lined with Surgicel.  Irrigation revealed no further active bleeding, and it was felt that at this time both the arteriovenous malformation, associated aneurysm, and intracerebral hematoma had been sequentially dealt with.,The cortical surface was then covered with Surgicel and the dura placed over the surface of the brain after coagulation of the dural edges, the freeze dried fascia, which had been used at the time of the 1st surgery was replaced over the surface of the brain with additional areas of cortical exposure covered with a DuraGuard.  The 2nd bone flap from the inferior frontotemporal region centered along the zygoma was reattached to the initial bone flap at 3 sites using a small 2-holed plate and 3-mm screws and the portable minidriver.,With this, return of the inferior plate accomplished, it was possible to reposition the bone flaps into their initial configuration, and attachments were secured anterior and posterior with somewhat longer 2-holed plates and 3-mm screws to the frontal and posterior temporal parietal region.  The wound was then closed.  It should be noted that a pledget of Gelfoam had been placed over the entire dural complex prior to returning the bone flap.  The wound was then closed by approximating the temporalis muscle with 2-0 Vicryl suture, the fascia was closed with 2-0 Vicryl suture, and the galea was closed with 2-0 interrupted suture, and the skin approximated with staples.  The patient appeared to tolerate the procedure well without complications.","neurosurgery, hemorrhage, arteriovenous malformation, aneurysm, pterional craniotomy, bone flap, bipolar coagulation, arteriovenous, pterional, malformation, hematoma, intracerebral, "
 Endoscopic-assisted transsphenoidal exploration and radical excision of pituitary adenoma.  Endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus., Neurosurgery, Pituitary Adenomectomy ,"PREOPERATIVE DIAGNOSIS: , Large and invasive recurrent pituitary adenoma.,POSTOPERATIVE DIAGNOSIS:,  Large and invasive recurrent pituitary adenoma.,OPERATION PERFORMED: , Endoscopic-assisted transsphenoidal exploration and radical excision of pituitary adenoma, endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus, harvesting of dermal fascia abdominal fat graft, placement of abdominal fat graft into sella turcica, reconstruction of sellar floor using autologous nasal bone creating a cranioplasty of less than 5 cm, repair of nasal septal deviation, using the operating microscope and microdissection technique, and placement of lumbar subarachnoid catheter connected to reservoir for aspiration and infusion.,INDICATIONS FOR PROCEDURE: , This man has undergone one craniotomy and 2 previous transsphenoidal resections of his tumor, which is known to be an invasive pituitary adenoma.  He did not return for followup or radiotherapy as instructed, and the tumor has regrown.  For this reason, he is admitted for transsphenoidal reoperation with an attempt to remove as much tumor as possible.  The high-risk nature of the procedure and the fact that postoperative radiation is mandatory was made clear to him.  Many risks including CSF leak and blindness were discussed in detail.  After clear understanding of all the same, he elected to proceed ahead with surgery.,PROCEDURE:  ,The patient was placed on the operating table, and after adequate induction of general anesthesia, he was placed in the left lateral decubitus position.  Care was taken to pad all pressure points appropriately.  The back was prepped and draped in usual sterile manner.,A 14-gauge Tuohy needle was introduced into the lumbar subarachnoid space.  Clear and colorless CSF issued forth.  A catheter was inserted to a distance of 40 cm, and the needle was removed.  The catheter was then connected to a closed drainage system for aspiration and infusion.,This no-touch technique is now a standard of care for treatment of patients with large invasive adenomas.  Via injections through the lumbar drain, one increases intracranial pressure and produces gentle migration of the tumor.  This improves outcome and reduces complications by atraumatically dissecting the tumor away from the optic apparatus.,The patient was then placed supine, and the 3-point headrest was affixed.  He was placed in the semi-sitting position with the head turned to the right and a roll placed under the left shoulder.  Care was taken to pad all pressure points appropriately.  The fluoroscope C-arm unit was then positioned so as to afford an excellent view of the sella and sphenoid sinus in the lateral projection.  The metallic arm was then connected to the table for the use of the endoscope.  The oropharynx, nasopharynx, and abdominal areas were then prepped and draped in the usual sterile manner.,A transverse incision was made in the abdominal region, and several large pieces of fat were harvested for later use.  Hemostasis was obtained.  The wound was carefully closed in layers.,I then advanced a 0-degree endoscope up the left nostril.  The middle turbinate was identified and reflected laterally exposing the sphenoid sinus ostium.  Needle Bovie electrocautery was used to clear mucosa away from the ostium.  The perpendicular plate of the ethmoid had already been separated from the sphenoid.  I entered into the sphenoid.,There was a tremendous amount of dense fibrous scar tissue present, and I slowly and carefully worked through all this.  I identified a previous sellar opening and widely opened the bone, which had largely regrown out to the cavernous sinus laterally on the left, which was very well exposed, and the cavernous sinus on the right, which I exposed the very medial portion of.  The opening was wide until I had the horizontal portion of the floor to the tuberculum sella present.,The operating microscope was then utilized.  Working under magnification, I used hypophysectomy placed in the nostril.,The dura was then carefully opened in the midline, and I immediately encountered tissue consistent with pituitary adenoma.  A frozen section was obtained, which confirmed this diagnosis without malignant features.,Slowly and meticulously, I worked to remove the tumor.  I used the suction apparatus as well as the bipolar coagulating forceps and ring and cup curette to begin to dissect tumor free.  The tumor was moderately vascular and very fibrotic.,Slowly and carefully, I systematically entered the sellar contents until I could see the cavernous sinus wall on the left and on the right.  There appeared to be cavernous sinus invasion on the left.  It was consistent with what we saw on the MRI imaging.,The portion working into the suprasellar cistern was slowly dissected down by injecting saline into the lumbar subarachnoid catheter.  A large amount of this was removed.  There was a CSF leak, as the tumor was removed for the upper surface of it was very adherent to the arachnoid and could not be separated free.,Under high magnification, I actually worked up into this cavity and performed a very radical excision of tumor.  While there may be a small amount of tumor remaining, it appeared that a radical excision had been created with decompression of the optic apparatus.  In fact, I reinserted the endoscope and could see the optic chiasm well.,I reasoned that I had therefore achieved the goal with that is of a radical excision and decompression.  Attention was therefore turned to closure.,The wound was copiously irrigated with Bacitracin solution, and meticulous hemostasis was obtained.  I asked Anesthesiology to perform a Valsalva maneuver, and there was no evidence of bleeding.,Attention was turned to closure and reconstruction.  I placed a very large piece of fat in the sella to seal the leak and verified that there was no fat in the suprasellar cistern by using fluoroscopy and looking at the pattern of the air.  Using a polypropylene insert, I reconstructed the sellar floor with this implant making a nice tight sling and creating a cranioplasty of less than 5 cm.,DuraSeal was placed over this, and the sphenoid sinus was carefully packed with fat and DuraSeal.,I inspected the nasal passages and restored the septum precisely to the midline repairing a previous septal deviation.  The middle turbinates were then restored to their anatomic position.  There was no significant intranasal bleeding, and for this reason, an open nasal packing was required.  Sterile dressings were applied, and the operation was terminated.,The patient tolerated the procedure well and left to the recovery room in excellent condition.  The sponge and needle counts were reported as correct, and there were no intraoperative complications.,Specimens were sent to Pathology consisting of tumor.", 
 Ventriculoperitoneal shunt revision with replacement of ventricular catheter and flushing of the distal end., Neurosurgery, Shunt Revision - 3 ,"PREOPERATIVE DIAGNOSIS:,  Blocked ventriculoperitoneal shunt.,POSTOPERATIVE DIAGNOSIS:,  Blocked ventriculoperitoneal shunt.,PROCEDURE: , Ventriculoperitoneal shunt revision with replacement of ventricular catheter and flushing of the distal end.,ANESTHESIA: , General.,HISTORY: , The patient is nonverbal.  He is almost 3 years old.  He presented with 2 months of irritability, vomiting, and increasing seizures.  CT scan was not conclusive, but shuntogram shows no flow through the shunt.,DESCRIPTION OF PROCEDURE: , After induction of general anesthesia, the patient was placed supine on the operating room table with his head turned to the left.  Scalp was clipped.  He was prepped on the head, neck, chest and abdomen with ChloraPrep.  Incisions were infiltrated with 0.5% Xylocaine with epinephrine 1:200,000.  He received oxacillin.,He was then reprepped and draped in a sterile manner.,The frontal incision was reopened and extended along the valve.  Subcutaneous sharp dissection with Bovie cautery was done to expose the shunt parts.  I separated the ventricular catheter from the valve, and this was a medium pressure small contour Medtronic valve.  There was some flow from the ventricular catheter, but not as much as I would expect.  I removed the right-angled clip with a curette and then pulled out the ventricular catheter, and there was gushing of CSF under high pressure.  So, I do believe that the catheter was obstructed, although inspection of the old catheter holes did not show any specific obstructions.  A new Codman BACTISEAL catheter was placed through the same hole.  I replaced it several times because I wanted to be sure it was in the cavity.  It entered easily and there was still just intermittent flow of CSF.  The catheter irrigated very well and seemed to be patent.,I tested the distal system with an irrigation filled feeding tube, and there was excellent flow through the distal valve and catheter.  So I did not think it was necessary to replace those at this time.  The new catheter was trimmed to a total length of 8 cm and attached to the proximal end of the valve.  The valve connection was secured to the pericranium with a #2-0 Ethibond suture.  The wound was irrigated with bacitracin irrigation.  The shunt pumped and refilled well.  The wound was then closed with #4-0 Vicryl interrupted galeal suture and Steri-Strips on the skin.  It was uncertain whether this will correct the problem or not, but we will continue to evaluate.  If his abdominal pressure is too high, then he may need a different valve.  This will be determined over time, but at this time, the shunt seemed to empty and refill easily.  The patient tolerated the procedure well.  No complications.  Sponge and needle counts were correct.  Blood loss was minimal.  None replaced.","neurosurgery, bactiseal, bactiseal catheter, codman bactiseal, blocked ventriculoperitoneal shunt, ventriculoperitoneal shunt revision, ventricular catheter, shunt revision, ventriculoperitoneal shunt, catheter, ventriculoperitoneal, ventricular, shunt"
 Endoscopic proximal shunt revision., Neurosurgery, Shunt Revision - 1 ,"PREOPERATIVE DIAGNOSIS: , Shunt malfunction.  The patient with a ventriculoatrial shunt.,POSTOPERATIVE DIAGNOSIS:,  Shunt malfunction.  The patient with a ventriculoatrial shunt.,ANESTHESIA: , General endotracheal tube anesthesia.,INDICATIONS FOR OPERATION: , Headaches, fluid accumulating along shunt tract.,FINDINGS: , Partial proximal shunt obstruction.,TITLE OF OPERATION:,  Endoscopic proximal shunt revision.,SPECIMENS: , None.,COMPLICATIONS:,  None.,DEVICES: , Portnoy ventricular catheter.,OPERATIVE PROCEDURE:,  After satisfactory general endotracheal tube anesthesia was administered, the patient positioned on the operating table in supine position with the right frontal area shaved and the head was prepped and draped in a routine manner.  The old right frontal scalp incision was reopened in a curvilinear manner, and the Bactiseal ventricular catheter was identified as it went into the right frontal horn.  The distal end of the VA shunt was flushed and tested with heparinized saline, found to be patent, and it was then clamped.  Endoscopically, the proximal end was explored and we found debris within the lumen, and then we were able to freely move the catheter around.  We could see along the tract that the tip of the catheter had gone into the surrounding tissue and appeared to have prongs or extensions in the tract, which were going into the catheter consistent with partial proximal obstruction.  A Portnoy ventricular catheter was endoscopically introduced and then the endoscope was bend so that the catheter tip did not go into the same location where it was before, but would take a gentle curve going into the right lateral ventricle.  It flushed in quite well, was left at about 6.5 cm to 7 cm and connected to the existing straight connector and secured with 2-0 Ethibond sutures.  The wounds were irrigated out with Bacitracin and closed in a routine manner using two 3-0 Vicryl for the galea and a 4-0 running Monocryl for the scalp followed by Mastisol and Steri-Strips.  The patient was awakened and extubated having tolerated the procedure well without complications.  It should be noted that the when we were irrigating through the ventricular catheter, fluid easily came out around the catheter indicating that the patient had partial proximal obstruction so that we could probably flow around the old shunt tract and perhaps this was leading to some of the symptomatology or findings of fluid along the chest.","neurosurgery, ventriculoatrial shunt, endoscopic proximal shunt revision, endoscopic proximal shunt, portnoy ventricular catheter, shunt malfunction, shunt revision, ventricular catheter, shunt, endoscopic, ventricular, proximal, catheter,"
" Application of PMT large halo crown and vest.  Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion.", Neurosurgery, PMT Halo Crown & Vest ,"PREOPERATIVE DIAGNOSES: , Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion.,POSTOPERATIVE DIAGNOSES: , Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion, and potentially unstable cervical spine.,OPERATIVE PROCEDURE:  ,Application of PMT large halo crown and vest.,ESTIMATED BLOOD LOSS: , None.,ANESTHESIA:  ,Local, conscious sedation with Morphine and Versed.,COMPLICATIONS: , None.  Post-fixation x-rays, nonalignment, no new changes.  Post-fixation neurologic examination normal.,CLINICAL HISTORY:  ,The patient is a 41-year-old female who presented to me with severe cervical spondylosis and myelopathy.  She was referred to me by Dr. X.  The patient underwent a complicated anterior cervical discectomy, 2-level corpectomy, spinal cord decompression and fusion with fibular strut and machine allograft in the large cervical plate.  Surgery had gone well, and the patient has done well in the last 2 days.  She is neurologically improved and is moving all four extremities.  No airway issues.  It was felt that the patient was now a candidate for a halo vest placement given that chance of going to the OR were much smaller.  She was consented for the procedure, and I sought the help of ABC and felt that a PMT halo would be preferable to a Bremer halo vest.  The patient had this procedure done at the bedside, in the SICU room #1.  I used a combination of some morphine 1 mg and Versed 2 mg for this procedure.  I also used local anesthetic, with 1% Xylocaine and epinephrine a total of 15 to 20 cc.,PROCEDURE DETAILS:,  The patient's head was positioned on some towels, the retroauricular region was shaved, and the forehead and the posterolateral periauricular regions were prepped with Betadine.  A large PMT crown was brought in and fixed to the skull with pins under local anesthetic.  Excellent fixation achieved.  It was lateral to the supraorbital nerves and 1 fingerbreadth above the brows and the ear pinnae.,I then put the vest on, by sitting the patient up, stabilizing her neck.  The vest was brought in from the front as well and connected.  Head was tilted appropriately, slightly extended, and in the midline.  All connections were secured and pins were torqued and tightened.,During the procedure, the patient did fine with no significant pain.,Post-procedure, she is neurologically intact and she remained intact throughout.  X-rays of the cervical spine AP, lateral, and swimmer views showed excellent alignment of the hardware construct in the graft with no new changes.,The patient will be subjected to a CT scan to further define the alignment, and barring any problems, she will be ambulating with the halo on.,The patient will undergo pin site care as per protocol, and likely she will go in the next 2 to 3 days.  Her prognosis indeed is excellent, and she is already about 90% or so better from her surgery.  She is also on a short course of Decadron, which we will wean off in due course.,The matter was discussed with the patient and the patient's family.","neurosurgery, cervical spondylosis, anterior cervical discectomy, corpectomy, decompression, fusion, pmt, crown, vest, pmt halo, cervical,"
 Bilateral endoscopic proximal shunt revision and a distal shunt revision., Neurosurgery, Shunt Revision ,"TITLE OF OPERATION:,  Bilateral endoscopic proximal shunt revision and a distal shunt revision.,INDICATIONS FOR OPERATION:,  Headaches, full subtemporal site.,PREOPERATIVE DIAGNOSIS: , Slit ventricle syndrome.,POSTOPERATIVE DIAGNOSIS: , Slit ventricle syndrome.,FINDINGS:,  Coaptation of ventricles against proximal end of ventricular catheter.,ANESTHESIA: , General endotracheal tube anesthesia.,DEVICES: , A Codman Hakim programmable valve with Portnoy ventricular catheter, a 0/20 proGAV valve with a shunt assist of 20 cm dual right-angled connector, and a flushing reservoir.,BRIEF NARRATIVE OF OPERATIVE PROCEDURE:,  After satisfactory general endotracheal tube anesthesia was administered, the patient was positioned on the operating table in the prone position with the head held on a soft foam padding.  The occipital area was shaven bilaterally and then the areas of the prior scalp incisions were infiltrated with 0.25% Marcaine with 1:200,000 epinephrine after routine prepping and draping.  Both U-shaped scalp incisions were opened exposing both the left and the right ventricular catheters as well as the old low pressure reservoir, which might have been leading to the coaptation of the ventricles.  The patient also had a right subtemporal depression, which was full preoperatively.  The entire old apparatus was dissected out.  We then cut both the ventricular catheters and secured them with sutures so that __________ could be inserted.  They were both inspected.  No definite debris were seen.  After removing the ventricular catheters, the old tracts were inspected and we could see where there was coaptation of the ventricles against the ventricular catheter.  On the right side, we elected to insert the Portnoy ventricular catheter and on the left a new Bactiseal catheter was inserted underneath the corpus callosum in a different location.  The old valve was dissected out and the proGAV valve with a 2-0 shunt assist was inserted and secured with a 2-0 Ethibond suture.  The proGAV valve was then connected to a Bactiseal distal tubing, which was looped in a cephalad way and then curved towards the left burr hole site and then the Portnoy catheter on the right was secured with a right-angled sleeve and then interposed between it and the left burr hole site with a flushing reservoir.  All connections secured with 2-0 Ethibond suture and a small piece of Bactiseal tubing between the flushing reservoir and the connector, which secured the left Bactiseal tubing to the two other Bactiseal tubings one being the distal Bactiseal tubing going towards the proGAV valve, which was set to an opening pressure of 8 and the other one being the Bactiseal tubing, which was going towards the flushing reservoir.,All the wounds were irrigated out with bacitracin and then closed in a routine manner using Vicryl for the deep layers and Monocryl for the skin, followed by Mastisol and Steri-Strips.  The patient tolerated the procedure well without complications.  CSF was not sent off.","neurosurgery, codman hakim, portnoy, slit ventricle syndrome, shunt revision, bilateral endoscopic proximal shunt, coaptation of the ventricles, portnoy ventricular catheter, ventricular catheter, progav valve, flushing reservoir, bactiseal tubing, shunt, ventricular, bactiseal"
" Placement of Scott cannula, right lateral ventricle", Neurosurgery, Scott Cannula ,"PROCEDURE:, Placement of Scott cannula, right lateral ventricle.,DESCRIPTION OF THE OPERATION:, The right side of the head was shaved and the area was then prepped using Betadine prep. Following an injection with Xylocaine with epinephrine, a small 1.5 cm linear incision was made paralleling the midline, lateral to the midline, at the region of the coronal suture. A twist drill was made with the hand drill through the dura. A Scott cannula was placed on the first pass into the right lateral ventricle with egress initially of bloody and the clear CSF. The Scott cannula was secured to the skin using 3-0 silk sutures. This will be connected to external drainage set at 10 cm of water.","neurosurgery, coronal suture, twist drill, lateral ventricle, csf, placement of scott cannula, scott cannula, scott, cannulaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Leukemic meningitis.   Right frontal side-inlet Ommaya reservoir.  The patient is a 49-year-old gentleman with leukemia and meningeal involvement, who was undergoing intrathecal chemotherapy. ", Neurosurgery, Ommaya reservoir ,"TITLE OF OPERATION: , Right frontal side-inlet Ommaya reservoir.,INDICATION FOR SURGERY: , The patient is a 49-year-old gentleman with leukemia and meningeal involvement, who was undergoing intrathecal chemotherapy.  Recommendation was for an Ommaya reservoir.  Risks and benefits have been explained.  They agreed to proceed.,PREOP DIAGNOSIS: , Leukemic meningitis.,POSTOP DIAGNOSIS:  ,Leukemic meningitis.,PROCEDURE DETAIL: , The patient was brought to the operating room, underwent induction of laryngeal mask airway, positioned supine on a horseshoe headrest.  The right frontal region was prepped and draped in the usual sterile fashion.  Next, a curvilinear incision was made just anterior to the coronal suture 7 cm from the middle pupillary line.  Once this was completed, a burr hole was then created with a high-speed burr.  The dura was then coagulated and opened.  The Ommaya reservoir catheter was inserted up to 6.5 cm.  There was good flow.  This was connected to the side inlet, flat-bottom Ommaya and this was then placed in a subcutaneous pocket posterior to the incision.  This was then cut and __________.  It was then tapped percutaneously with 4 cubic centimeters and sent for routine studies.  Wound was then irrigated copiously with __________ irrigation, closed using 3-0 Vicryl for the deep layers and 4-0 Caprosyn for the skin.  The connection was made with a 3-0 silk suture and was a right-angle intermediate to hold the catheter in place.","neurosurgery, caprosyn, leukemic meningitis, ommaya reservoir, leukemia, meningeal, intrathecal, chemotherapy, leukemic, meningitis, ommaya, "
 Transnasal transsphenoidal approach in resection of pituitary tumor.   The patient is a 17-year-old girl who presented with headaches and was found to have a prolactin of 200 and pituitary tumor., Neurosurgery, Pituitary Tumor Resection ,"TITLE OF OPERATION: , Transnasal transsphenoidal approach in resection of pituitary tumor.,INDICATION FOR SURGERY: , The patient is a 17-year-old girl who presented with headaches and was found to have a prolactin of 200 and pituitary tumor.  She was started on Dostinex with increasing dosages.  The most recent MRI demonstrated an increased growth with hemorrhage.  This was then discontinued.  Most recent prolactin was at 70, although normalized, the recommendation was surgical resection given the size of the sellar lesion.  All the risks, benefits, and alternatives were explained in great detail via translator.,PREOP DIAGNOSIS: , Pituitary tumor.,POSTOP DIAGNOSIS: , Pituitary tumor.,PROCEDURE DETAIL:  ,The patient brought to the operating room, positioned on the horseshoe headrest in a neutral position supine.  The fluoroscope was then positioned.  The approach will be dictated by Dr. X. Once the operating microscope and the endoscope were then used to approach it through transnasal, this was complicated and complex secondary to the drilling within the sinus.  Once this was ensured, the tumor was identified, separated from the pituitary gland, it was isolated and then removed.  It appeared to be hemorrhagic and a necrotic pituitary, several sections were sent.  Once this was ensured and completed and hemostasis obtained, the wound was irrigated.  There might have been a small CSF leak with Valsalva, so the recommendation was for a reconstruction, Dr. X will dictate.  The fat graft was harvested from the left lower quadrant and closed primarily, this was soaked in fat and used to close the closure.  All sponge and needle counts were correct.  The patient was extubated and transported to the recovery room in stable condition.  Blood loss was minimal.","neurosurgery, transnasal transsphenoidal approach, resection, pituitary tumor, transsphenoidal, transnasal, prolactin, tumor, pituitary, "
" Botulinum toxin injection bilateral rectus femoris, medial hamstrings, and gastrocnemius soleus muscles, phenol neurolysis of bilateral obturator nerves, application of bilateral short leg fiberglass casts.", Neurosurgery, Phenol Neurolysis & Botulinum Toxin Injection - 3 ,"PROCEDURE CODES:  64640 times two, 64614 time two, 95873 times two, 29405 times two.,PREOPERATIVE DIAGNOSIS:  Spastic diplegic cerebral palsy, 343.0.,POSTOPERATIVE DIAGNOSIS:  Spastic diplegic cerebral palsy, 343.0.,ANESTHESIA:  MAC.,COMPLICATIONS:  None.,DESCRIPTION OF TECHNIQUE:  Informed consent was obtained from the patient's mom.  The patient was brought to minor procedures and sedated per their protocol.  The patient was positioned lying supine.  Skin overlying all areas injected was prepped with chlorhexidine.,The obturator nerves were identified lateral to the adductor longus tendon origin and below the femoral pulse with active EMG stimulation.  Approximately 4 mL of 5% phenol was injected in this location bilaterally.  Phenol injections were done at the site of maximum hip adduction contraction with least amount of stimulus.  Negative drawback for blood was done prior to each injection of phenol.,Muscles injected with botulinum toxin were identified with active EMG stimulation.  Approximately 50 units was injected in the rectus femoris bilaterally, 75 units in the medial hamstrings bilaterally and 100 units in the gastrocnemius soleus muscles bilaterally.  Total amount of botulinum toxin injected was 450 units diluted 25 units to 1 mL.  After injections were performed, bilateral short leg fiberglass casts were applied.  The patient tolerated the procedure well and no complications were encountered.","neurosurgery, botulinum toxin injection bilateral, toxin injection bilateral rectus, neurolysis of bilateral obturator, short leg fiberglass casts, muscles phenol neurolysis, botulinum toxin injection, gastrocnemius soleus muscles, short leg fiberglass, femoris medial, cerebral palsy, active emg, emg stimulation, phenol neurolysis, toxin injection, rectus femoris, gastrocnemius soleus, soleus muscles, obturator nerves, leg fiberglass, fiberglass casts, botulinum toxin, hamstrings, gastrocnemius, obturator, nerves, fiberglass, casts, muscles, botulinum, phenol, bilateral, injection, toxin"
 Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection., Neurosurgery, Neuroplasty ,"PREOPERATIVE DIAGNOSES:,  ,1.  Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2.  Epidural fibrosis with nerve root entrapment.,POSTOPERATIVE DIAGNOSES:,  ,1.  Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2.  Epidural fibrosis with nerve root entrapment.,OPERATION PERFORMED:,  Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,ANESTHESIA:,  Local/IV sedation.,COMPLICATIONS:,  None.,SUMMARY:  ,The patient in the operating room, status post transforaminal epidurogram (see operative note for further details).  Using AP and lateral fluoroscopic views to confirm the needle location the superior most being in the left L4 neural foramen and the inferior most in the left L5 neural foramen, 375 units of Wydase was injected through each needle.  After two minutes, 3.5 cc of 0.5% Marcaine and 80 mg of Depo-Medrol was injected through each needle.  These needles were removed and the patient was discharged in stable condition.","neurosurgery, nerve root decompression, discectomy, epidural fibrosis, nerve root entrapment, transforaminal neuroplasty, neural foramen, nerve root, foramen, neuroplasty, transforaminal, needle, epidural,"
" Phenol neurolysis right obturator nerve, botulinum toxin injection right rectus femoris and vastus medialis intermedius and right pectoralis major muscles.", Neurosurgery, Phenol Neurolysis & Botulinum Toxin Injection - 2 ,"PROCEDURES PERFORMED: , Phenol neurolysis right obturator nerve, botulinum toxin injection right rectus femoris and vastus medialis intermedius and right pectoralis major muscles.,PROCEDURE CODES: , 64640 times one, 64614 times two, 95873 times two.,PREOPERATIVE DIAGNOSIS: , Spastic right hemiparetic cerebral palsy, 343.1.,POSTOPERATIVE DIAGNOSIS:,  Spastic right hemiparetic cerebral palsy, 343.1.,ANESTHESIA:,  MAC.,COMPLICATIONS: , None.,DESCRIPTION OF TECHNIQUE: , Informed consent was obtained from the patient.  She was brought to the minor procedure area and sedated per their protocol.  The patient was positioned lying supine.  Skin overlying all areas injected was prepped with chlorhexidine.  The right obturator nerve was identified using active EMG stimulation lateral to the adductor longus tendon origin and below the femoral pulse.  Approximately 6 mL of 5% phenol was injected in this location.  At all sites of phenol injections, injections were done at the site of maximum hip adduction contraction with least amount of stimulus.  Negative drawback for blood was done prior to each injection of phenol.,Muscles injected with botulinum toxin were identified with active EMG stimulation.  Approximately 100 units was injected in the right pectoralis major and 100 units in the right rectus femoris and vastus intermedius muscles.  Total amount of botulinum toxin injected was 200 units diluted 25 units to 1 mL.  The patient tolerated the procedure well and no complications were encountered.","neurosurgery, femoris and vastus medialis, intermedius and right pectoralis, rectus femoris and vastus, vastus medialis intermedius, botulinum toxin injection, medialis intermedius, major muscles, cerebral palsy, active emg, emg stimulation, phenol neurolysis, toxin injection, obturator nerve, rectus femoris, pectoralis major, botulinum toxin, pectoralis, botulinum, phenol, injection, toxin"
 Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation., Neurosurgery, Lumbar Re-exploration ,"PREOPERATIVE DIAGNOSIS: , Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.,POSTOPERATIVE DIAGNOSIS: , Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.,PROCEDURE: , Lumbar re-exploration for removal of fractured internal fixation plate from T11 through L2 followed by a repositioning of the L2 pedicle screws and evaluation of the fusion from T11 through L2 followed by a bilateral hemilaminectomy and diskectomy for decompression at L4-5 and L5-S1 with posterior lumbar interbody fusion using morselized autograft bone and the synthetic spacers from the Capstone system at L4-5 and L5-S1 followed by placement of the pedicle screw fixation devices at L3, L4, L5, and S1 and insertion of a 20 cm fixation plate that range from the T11 through S1 levels and then subsequent onlay fusion using morselized autograft bone and bone morphogenetic soaked sponge at L1-2 and then at L3-L4, L4-L5, and L5-S1 bilaterally.,DESCRIPTION OF PROCEDURE:  ,This is a 68-year-old lady who presents with a history of osteomyelitis associated with the percutaneous vertebroplasty that was actually treated several months ago with removal of the infected vertebral augmentation and placement of a posterior pedicle screw plate fixation device from T11 through L2.  She subsequently actually done reasonably well until about a month ago when she developed progressive severe intractable pain.  Imaging study showed that the distal hardware at the plate itself had fractured consistent with incomplete fusion across her osteomyelitis area.  There was no evidence of infection on the imaging or with her laboratory studies.  In addition, she developed a pretty profound stenosis at L4-L5 and L5-S1 that appeared to be recurrent as well.  She now presents for revision of her hardware, extension of fusion, and decompression.,The patient was brought to the operating room, placed under satisfactory general endotracheal anesthesia.  She was placed on the operative table in the prone position.  Back was prepared with Betadine, iodine, and alcohol.  We elliptically excised her old incision and extended this caudally so that we had access from the existing hardware fixation all the way down to her sacrum.  The locking nuts were removed from the screw post and both plates refractured or significantly weakened and had a crease in it.  After these were removed, it was obvious that the bottom screws were somewhat loosened in the pedicle zone so we actually tightened one up and that fit good snugly into the nail when we redirected so that it actually reamed up into the upper aspect of the vertebral body in much more secure purchase.  We then dressed the L4-L5 and L5-S1 levels which were profoundly stenotic.  This was a combination of scar and overgrown bone.  She had previously undergone bilateral hemilaminectomies at L4-5 so we removed scar bone and actually cleaned and significantly decompressed the dura at both of these levels.  After completing this, we inserted the Capstone interbody spacer filled with morselized autograft bone and some BMP sponge into the disk space at both levels.  We used 10 x 32 mm spacers at both L4-L5 and L5-S1.  This corrected the deformity and helped to preserve the correction of the stenosis and then after we cannulated the pedicles of L4, L5 and S1 tightened the pedicle screws in L3.  This allowed us to actually seat a 20 cm plate contoured to the lumbar lordosis onto the pedicle screws all the way from S1 up to the T11 level.  Once we placed the plate onto the screws and locked them in position, we then packed the remaining BMP sponge and morselized autograft bone through the plate around the incomplete fracture healing at the L1 level and then dorsolaterally at L4-L5 and L5-S1 and L3-L4, again the goal being to create a dorsal fusion and enhance the interbody fusion as well.  The wound was then irrigated copiously with bacitracin solution and then we closed in layers using #1 Vicryl in muscle and fascia, 3-0 in subcutaneous tissue and approximated staples in the skin.  Prior to closing the skin, we confirmed correct sponge and needle count.  We placed a drain in the extrafascial space and then confirmed that there were no other foreign bodies.  The Cell Saver blood was recycled and she was given two units of packed red blood cells as well.  I was present for and performed the entire procedure myself or supervised.","neurosurgery, degenerative spondylolisthesis, spondylolisthesis, stenosis, lumbar re-exploration, internal fixation plate, hemilaminectomy, diskectomy, synthetic spacers, pedicle screws, fusion, lumbar, pedicle, fixation, hardware,"
" Phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves.  Botulinum toxin injection left pectoralis major, left wrist flexors, and bilateral knee extensors.", Neurosurgery, Phenol Neurolysis & Botulinum Toxin Injection - 1 ,"PROCEDURES PERFORMED:,  Phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves.  Botulinum toxin injection left pectoralis major, left wrist flexors, and bilateral knee extensors.,PROCEDURE CODES: , 64640 times three, 64614 times four, 95873 times four.,PREOPERATIVE DIAGNOSIS: , Spastic quadriparesis secondary to traumatic brain injury, 907.0.,POSTOPERATIVE DIAGNOSIS:,  Spastic quadriparesis secondary to traumatic brain injury, 907.0.,ANESTHESIA:,  MAC.,COMPLICATIONS: , None.,DESCRIPTION OF TECHNIQUE: , Informed consent was obtained from the patient's brother.  The patient was brought to the minor procedure area and sedated per their protocol.  The patient was positioned lying supine.  Skin overlying all areas injected was prepped with chlorhexidine.  The obturator nerves were identified lateral to the adductor longus tendon origin and below the femoral pulse using active EMG stimulation.  Approximately 7 mL was injected on the right side and 5 mL on the left side.  At all sites of phenol injections in this area injections were done at the site of maximum hip adduction contraction with least amount of stimulus.  Negative drawback for blood was done prior to each injection of phenol.  The musculocutaneous nerve was identified in the left upper extremity above the brachial pulse using active EMG stimulation.  Approximately 5 mL of 5% phenol was injected in this location.  Injections in this area were done at the site of maximum elbow flexion contraction with least amount of stimulus.  Negative drawback for blood was done prior to each injection of phenol.,Muscles injected with botulinum toxin were identified using active EMG stimulation.  Approximately 150 units was injected in the knee extensors bilaterally, 100 units in the left pectoralis major, and 50 units in the left wrist flexors.  Total amount of botulinum toxin injected was 450 units diluted 25 units to 1 mL.  The patient tolerated the procedure well and no complications were encountered.","neurosurgery, spastic quadriparesis, emg stimulation, emg, botulinum toxin injection, traumatic brain, brain injury, phenol neurolysis, toxin injection, musculocutaneous nerve, obturator nerves, pectoralis major, wrist flexors, knee extensors, active emg, botulinum toxin, toxin, injection, stimulus, neurolysis, musculocutaneous, extensors, botulinum, phenol"
" Repair of nerve and tendon, right ring finger and exploration of digital laceration.  Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis and 25% laceration to the flexor digitorum profundus of the right ring finger and laceration 100% of the ulnar digital nerve to the right ring finger.", Neurosurgery, Nerve & Tendon Repair - Finger ,"PREOPERATIVE DIAGNOSIS:,  Volar laceration to right ring finger with possible digital nerve injury with possible flexor tendon injury.,POSTOPERATIVE DIAGNOSES:,1.  Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis.,2.  25% laceration to the flexor digitorum profundus of the right ring finger and laceration 100% of the ulnar digital nerve to the right ring finger.,PROCEDURE PERFORMED:,1.  Repair of nerve and tendon, right ring finger.,2.  Exploration of digital laceration.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 10 cc.,TOTAL TOURNIQUET TIME:  ,57 minutes.,COMPLICATIONS: , None.,DISPOSITION:  ,To PACU in stable condition.,BRIEF HISTORY OF PRESENT ILLNESS: , This is a 13-year-old male who had sustained a laceration from glass and had described numbness and tingling in his right ring finger.,GROSS OPERATIVE FINDINGS: , After wound exploration, it was found there was a 100% laceration to the ulnar digital neurovascular bundle.  The FDS had a partial ulnar slip laceration and the FDP had a 25% transverse laceration as well.  The radial neurovascular bundle was found to be completely intact.,OPERATIVE PROCEDURE:  ,The patient was taken to the operating room and placed in the supine position.  All bony prominences were adequately padded.  Tourniquet was placed on the right upper extremity after being packed with Webril, but not inflated at this time.  The right upper extremity was prepped and draped in the usual sterile fashion.  The hand was inspected.  Palmar surface revealed approximally 0.5 cm laceration at the base of the right ring finger at the base of proximal phalanx, which was approximated with nylon suture.  The sutures were removed and the wound was explored.  It was found that the ulnar digital neurovascular bundle was 100% transected.  The radial neurovascular bundle on the right ring finger was found to be completely intact.  We explored the flexor tendon and found that there was a partial laceration of the ulnar slip of the FDS and a 25% laceration in a transverse fashion to the FDP.  We copiously irrigated the wound.  Repair was undertaken of the FDS with #3-0 undyed Ethibond suture.  The laceration of the FDP was not felt that it need to repair due to majority of the substance in the FDP was still intact.  Attention during our repair at the flexor tendon, the A1 pulley was incised for better visualization as well as better tendon excursion after repair.  Attention was then drawn to the ulnar digital bundle which has been transected prior during the injury.  The digital nerve was dissected proximally and distally to likely visualize the nerve.  The nerve was then approximated using microvascular technique with #8-0 nylon suture.  The hands were well approximated.  The nerve was not under undue tension.  The wound was then copiously irrigated and the skin was closed with #4-0 nylon interrupted horizontal mattress alternating with simple suture.  Sterile dressing was placed and a dorsal extension Box splint was placed.  The patient was transferred off of the bed and placed back on a gurney and taken to PACU in stable condition.  Overall prognosis is good.","neurosurgery, laceration, flexor tendon, volar laceration, digital laceration, ulnar slip, flexor digitorum, neurovascular bundle, nerve, injury, ring, finger, neurovascular, fds, bundle, tendon, repair, flexor, digital, ulnar, "
 Possible CSF malignancy.  This is an 83-year-old woman referred for diagnostic lumbar puncture for possible malignancy by Dr. X.   The patient has gradually stopped walking even with her walker and her left arm has become gradually less functional.  She is not able to use the walker because her left arm is so weak. , Neurosurgery, Lumbar Puncture ,"REASON FOR VISIT:  ,This is an 83-year-old woman referred for diagnostic lumbar puncture for possible malignancy by Dr. X. She is accompanied by her daughter.,HISTORY OF PRESENT ILLNESS:,  The patient' daughter tells me that over the last month the patient has gradually stopped walking even with her walker and her left arm has become gradually less functional.  She is not able to use the walker because her left arm is so weak.  She has not been having any headaches.  She has had a significant decrease in appetite.  She is known to have lung cancer, but Ms. Wilson does not know what kind.  According to her followup notes, it is presumed non-small cell lung cancer of the left upper lobe of the lung.  The last note I have to evaluate is from October 2008.  CT scan from 12/01/2009 shows atrophy and small vessel ischemic change, otherwise a normal head CT, no mass lesion.  I also reviewed the MRI from September 2009, which does not suggest normal pressure hydrocephalus and shows no mass lesion.,Blood tests from 11/18/2009 demonstrate platelet count at 132 and INR of 1.0.,MAJOR FINDINGS: , The patient is a pleasant and cooperative woman who answers the questions the best she can and has difficulty moving her left arm and hand.  She also has pain in her left arm and hand at a level of 8-9/10.,VITAL SIGNS: , Blood pressure 126/88, heart rate 70, respiratory rate 16, and weight 95 pounds.,I screened the patient with questions to determine whether it is likely she has abnormal CSF pressure and she does not have any of the signs that would suggest this, so we performed the procedure in the upright position.,PROCEDURE:,  Lumbar puncture, diagnostic (CPT 62270).,PREOPERATIVE DIAGNOSIS: , Possible CSF malignancy.,POSTOPERATIVE DIAGNOSIS:  ,To be determined after CSF evaluation.,PROCEDURE PERFORMED: , Lumbar puncture.,ANESTHESIA: , Local with 2% lidocaine at the L4-L5 level.,SPECIMEN REMOVED:  ,15 cc of clear CSF.,ESTIMATED BLOOD LOSS: , None.,DESCRIPTION OF THE PROCEDURE:  ,I explained the procedure, its rationale, risks, benefits, and alternatives to the patient and her daughter.  The patient' daughter remained present throughout the procedure.  The patient provided written consent and her daughter signed as witness to the consent.,I located the iliac crest and spinous processes before the procedure and determined the level I planned for the puncture.  During the procedure, I spoke constantly with the patient to explain what was happening and to warn when there might be pain or discomfort.  The skin was prepped with chlorhexidine solution with the patient seated on the chair leaning forward with her face resting on the exam table.  Using local anesthetic and aseptic technique, I inserted a 20-gauge spinal needle at the L4-L5 interspace and 15 cc of CSF was collected without difficulty.,The patient tolerated the procedure well.,ASSESSMENT:  ,White blood cells 1, red blood cells 54, glucose 59, protein 51, Gram stain negative, bacterial culture negative after three days, and remaining tests pending.",
" Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots.  Right L4-L5 and right L5-S1 laminotomies, medial facetectomies, and foraminotomies, decompression of right L5 and S1 nerve roots.  Right L4-S1 posterolateral fusion with local bone graft.  Left L4 through S1 segmental pedicle screw instrumentation.  Preparation harvesting of local bone graft.", Neurosurgery," Laminotomy, Facetectomy & Foraminotomy ","PREOPERATIVE DIAGNOSES: , Right lumbosacral radiculopathy secondary to lumbar spondylolysis.,POSTOPERATIVE DIAGNOSES: , Right lumbosacral radiculopathy secondary to lumbar spondylolysis.,OPERATION PERFORMED:,1.  Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots.,2.  Right L4-L5 and right L5-S1 laminotomies, medial facetectomies, and foraminotomies, decompression of right L5 and S1 nerve roots.,3.  Right L4-S1 posterolateral fusion with local bone graft.,4.  Left L4 through S1 segmental pedicle screw instrumentation.,5.  Preparation harvesting of local bone graft.,ANESTHESIA: , General endotracheal.,PREPARATION:,  Povidone-iodine.,INDICATION: , This is a gentleman with right-sided lumbosacral radiculopathy, MRI disclosed and lateral recess stenosis at the L4-5, L5-S1 foraminal narrowing in L4 and L5 roots.  The patient was felt to be a candidate for decompression stabilization pulling distraction between the screws to relieve radicular pain.  The patient understood major risks and complications such as death and paralysis seemingly rare, main concern is a 10 to 15% of failure rate to respond to surgery for which further surgery may or may not be indicated, small risk of wound infection, spinal fluid leak.  The patient is understanding and agreed to proceed and signed the consent.,PROCEDURE: , The patient was brought to the operating room, peripheral venous lines were placed.  General anesthesia was induced.  The patient was intubated.  Foley catheter was in place.  The patient laid prone onto the OSI table using 6-post, pressure points were carefully padded; the back was shaved, sterilely prepped and draped.  A previous incision was infiltrated with local and incised with a scalpel.  The posterior spine on the right side was exposed in routine fashion along with transverse processes in L4-L5 in the sacral ala.  Laminotomies were then performed at L4-L5 and L5-S1 in a similar fashion using Midas Rex drill with AM8 bit, inferior portion of lamina below and superior portion of lamina above, and the medial facet was drilled down to the thin shelf of bone.  The thin shelf of bone along the ligamentum flavum moved in a piecemeal fashion with 2 and 3 mm Kerrison, bone was harvested throughout to be used for bone grafting.  The L5 and S1 roots were completely unroofed in the lateral recess working lateral to the markedly hypertrophied facet joints.  Transpedicular approaches were carried out for both L4 and L5 roots working lateral to medial and medial to lateral with foraminotomies, L4-L5 roots were extensively decompressed.  Pars interarticularis were maintained.  Using angled 2-mm Kerrisons hypertrophied ligamentum flavum, the superior facet of S1 and L5 was resected increasing the dimensions for the foramen passed lateral to medial and medial to lateral without further compromise.  Pedicle screws were placed L4-L5 and S1 on the right side.  Initial hole began with Midas Rex drill, deepened with a gear shift and with 4.5 mm tap, palpating with pedicle probe.  It showed no penetration outside the pedicle vertebral body.  At L4-L5 5.5 x 45 mm screws were placed and at S1 5.5 x 40 mm screw was placed.  Good bone purchase was obtained.  Gelfoam was placed over the roots laterally, corticated transverse processes lateral facet joints were prepared, small infuse sponge was placed posterolaterally on the right side, then the local bone graft from L4 to S1.  Traction was applied between the L4-L5, L5-S1 screws locking notes were tightened out, heads were rotated fractured off about 2-3 mm traction were applied at each side, further opening the foramen for the exiting roots.  Prior to placement of BMP, the wound was irrigated with antibiotic irrigation.  Medium Hemovac drain was placed in the depth of wound, brought out through a separate stab incision.  Deep fascia was closed with #1 Vicryl, subcutaneous fascia with #1 Vicryl, and subcuticular with 2-0 Vicryl.  Skin was stapled.  The drain was sutured in place with 2-0 Vicryl and connected to closed drain system.  The patient was laid supine on the bed, extubated, and taken to recovery room in satisfactory condition.  The patient tolerated the procedure well without apparent complication.  Final sponge and needle counts are correct.  Estimated blood loss 600 mL.,The patient received 200 mL of cell saver blood back.","neurosurgery, lumbosacral radiculopathy, lumbar spondylolysis, laminotomies, medial facetectomies, foraminotomies, decompression, nerve roots, fusion, bone graft, segmental, pedicle screw, transverse processes, bone, facetectomies, transpedicular, graft, pedicle"
" Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left.  Herniated nucleus pulposus of L5-S1 on the left.
  ", Neurosurgery, Lumbar Laminotomy & Discectomy ,"PREOPERATIVE DIAGNOSIS:,  Herniated nucleus pulposus of L5-S1 on the left.,POSTOPERATIVE DIAGNOSIS: ,Herniated nucleus pulposus of L5-S1 on the left.,PROCEDURE PERFORMED:, Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left.,ANESTHESIA: , General via endotracheal tube.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,SPECIMENS: , Disc that was not sent to the lab.,DRAINS: , None.,COMPLICATIONS: , None.,SURGICAL PROGNOSIS: , Remains guarded due to her ongoing pain condition and Tarlov cyst at the L5 nerve root distally.,SURGICAL INDICATIONS: , The patient is a 51-year-old female who has had unrelenting low back pain that radiated down her left leg for the past several months.  The symptoms were unrelieved by conservative modalities.  The symptoms were interfering with all aspects of daily living and inability to perform any significant work endeavors.  She is understanding the risks, benefits, potential complications, as well as all treatment alternatives.  She wished to proceed with the aforementioned surgery due to her persistent symptoms.  Informed consent was obtained.,OPERATIVE TECHNIQUE: , The patient was taken to OR room #5 where she was given general anesthetic by the Department of Anesthesia.  She was subsequently placed on the Jackson spinal table with the Wilson attachment in the prone position.  Palpation did reveal the iliac crest and suspected L5-S1 interspace.  Thereafter the lumbar spine was serially prepped and draped.  A midline incision was carried over the spinal process of L5 to S1.  Skin and subcutaneous tissue were divided sharply.  Electrocautery provided hemostasis.  Electrocautery was then utilized to dissect through the subcutaneous tissues to the lumbar fascia.  Lumbar fascia was identified and the decussation of fibers was identified at the L5-S1 interspace.  On the left side, superior aspect dissection was carried out with the Cobb elevator and electrocautery.  This revealed the interspace of suspect level of L5-S1 on the left.  A Kocher clamp was placed between the spinous processes of the suspect level of L5-S1.  X-ray did confirm the L5-S1 interval.  Angled curet was utilized to detach the ligamentum flavum from its bony attachments at the superior edge of S1 lamina and the inferior edge of the L5 lamina.  Meticulous dissection was undertaken and the ligamentum flavum was removed.  Laminotomy was created with Kerrison rongeur, both proximally and distally.  The microscope was positioned and the dura was inspected.  A blunt Penfield elevator was then utilized to dissect and identify the L5-S1 nerve root on the left.  It was noted to be tented over a disc extrusion.  The nerve root was protected and medialized.  It was retracted with a nerve root retractor.  This did reveal a subligamentous disc herniation at approximately the L5-S1 disc space and neuroforaminal area.  A #15 Bard-Parker blade was utilized to create an annulotomy.  Medially, disc material was extruding through this annulotomy.  Two tier rongeur was then utilized to grasp the disc material and the disc was removed from the interspace.  Additional disc material was then removed, both to the right and left of the annulotomy.  Up and downbiting pituitary rongeurs were utilized to remove any other loose disc pieces.  Once this was completed, the wound was copiously irrigated with antibiotic solution and suctioned dry.  The Penfield elevator was placed in the disc space of L5-S1 and a crosstable x-ray did confirm this level.  Nerve root was again expected exhibiting the foramina.  A foraminotomy was created with a Kerrison rongeur.  Once this was created, the nerve root was again inspected and deemed free of tension.  It was mobile within the neural foramina.  The wound was again copiously irrigated with antibiotic solution and suctioned dry.  A free fat graft was then harvested from the subcutaneous tissues and placed over the exposed dura.  Lumbar fascia was then approximated with #1 Vicryl interrupted fashion, subcutaneous tissue with #2-0 Vicryl interrupted fashion, and #4-0 undyed Vicryl was utilized to approximate the skin.  Compression dressing was applied.  The patient was turned, awoken, and noted to be moving all four extremities without apparent deficits.  She was taken to the recovery room in apparent satisfactory condition.  Expected surgical prognosis remains guarded due to her ongoing pain syndrome that has been requiring significant narcotic medications.","neurosurgery, lumbar laminotomy with discectomy, microscopic assisted, herniated nucleus pulposus, subcutaneous tissue, ligamentum flavum, kerrison rongeur, penfield elevator, lumbar laminotomy, lumbar fascia, nerve root, discectomy, lumbar, laminotomy, herniated,"
"  L1 laminotomy, microdissection, retrieval of foreign body (retained lumbar spinal catheter), attempted insertion of new external lumbar drain, and fluoroscopy.", Neurosurgery, Laminotomy & Microdissection ,"PREOPERATIVE DIAGNOSES:  ,1.  Fractured and retained lumbar subarachnoid spinal catheter.,2.  Pseudotumor cerebri (benign intracranial hypertension).,PROCEDURES:  ,1.  L1 laminotomy.,2.  Microdissection.,3.  Retrieval of foreign body (retained lumbar spinal catheter).,4.  Attempted insertion of new external lumbar drain.,5.  Fluoroscopy.,ANESTHESIA: , General.,HISTORY:  ,The patient had a lumbar subarachnoid drain placed yesterday.  All went well with the surgery.  The catheter stopped draining and on pulling back the catheter, it fractured and CT scan showed that the remaining fragment is deep to the lamina.  The patient continues to have right eye blindness and headaches, presumably from the pseudotumor cerebri.,DESCRIPTION OF PROCEDURE:  ,After induction of general anesthesia, the patient was placed prone on the operating room table resting on chest rolls.  Her face was resting in a pink foam headrest.  Extreme care was taken positioning her because she weighs 92 kg.  There was a lot of extra padding for her limbs and her limbs were positioned comfortably.  The arms were not hyperextended.  Great care was taken with positioning of the head and making sure there was no pressure on her eyes especially since she already has visual disturbance.  A Foley catheter was in place.  She received IV Cipro 400 mg because she is allergic to most antibiotics.,Fluoroscopy was used to locate the lower end of the fractured catheter and the skin was marked.  It was also marked where we would try to insert the new catheter at the L4 or L3 interspinous space.,The patient was then prepped and draped in a sterile manner.,A 7-cm incision was made over the L1 lamina.  The incision was carried down through the fascia all the way down to the spinous processes.  A self-retaining McCullough retractor was placed.  The laminae were quite deep.  The microscope was brought in and using the Midas Rex drill with the AM-8 bit and removing some of the spinous process of L1-L2 with double-action rongeurs, the laminotomy was then done using the drill and great care was taken and using a 2-mm rongeur, the last layer of lamina was removed exposing the epidural fat and dura.  The opening in the bone was 1.5 x 1.5 cm.,Occasionally, bipolar cautery was used for bleeding of epidural veins, but this cautery was kept to a minimum.,Under high magnification, the dura was opened with an 11 blade and microscissors.  At first, there was a linear incision vertically to the left of midline, and I then needed to make a horizontal incision more towards the right.  The upper aspect of the cauda equina was visualized and perhaps the lower end of the conus.  Microdissection under high magnification did not expose the catheter.  The fluoroscope was brought in 2 more times including getting a lateral view and the fluoroscope appeared to show that the catheter should be in this location.,I persisted with intensive microdissection and finally we could see the catheter deep to the nerves and I was able to pull it out with the microforceps.,The wound was irrigated with bacitracin irrigation.,At this point, I then attempted lumbar puncture by making a small incision with an 11 blade in the L4 interspinous space and then later in the L3 interspinous space and attempted to puncture the dural sac with the Tuohy needle.  Dr. Y also tried.  Despite using the fluoroscope and our best attempts, we were not able to convincingly puncture the lumbar subarachnoid space and so the attempted placement of the new lumbar catheter had to be abandoned.  It will be done at a later date.,I felt it was unsafe to place a new catheter at this existing laminotomy site because it was very high up near the conus.  The potential for complications involving her spinal cord was greater and we have already had a complication of the catheter now and I just did not think it was safe to put in this location.,Under high magnification, the dura was closed with #6-0 PDS interrupted sutures.,After the dura was closed, a piece of Gelfoam was placed over the dura.  The paraspinous muscles were closed with 0 Vicryl interrupted sutures.  The subcutaneous fascia was also closed with 0 Vicryl interrupted suture.  The subcutaneous layer was closed with #2-0 Vicryl interrupted suture and the skin with #4-0 Vicryl Rapide.  The 4-0 Vicryl Rapide sutures were also used at the lumbar puncture sites to close the skin.,The patient was then turned carefully on to her bed after sterile dressings were applied and then taken to the recovery room.  The patient tolerated procedure well.  No complications.  Sponge and needle counts correct.  Blood loss minimal, none replaced.  This procedure took 5 hours.  This case was also extremely difficult due to patient's size and the difficulty of locating the catheter deep to the cauda equina.","neurosurgery, laminotomy, microdissection, lumbar spinal catheter, external lumbar drain, fluoroscopy, lumbar subarachnoid, spinal catheter, intracranial hypertension, vicryl interrupted sutures, lumbar, catheter, "
" Lumbar puncture.  A 20-gauge spinal needle was then inserted into the L3-L4 space.  Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained. ", Neurosurgery, Lumbar Puncture - 2 ,"PROCEDURE PERFORMED:,  Lumbar puncture.,The procedure, benefits, risks including possible risks of infection were explained to the patient and his father, who is signing the consent form.  Alternatives were explained.  They agreed to proceed with the lumbar puncture.  Permit was signed and is on the chart.  The indication was to rule out toxoplasmosis or any other CNS infection. ,DESCRIPTION: , The area was prepped and draped in a sterile fashion.  Lidocaine 1% of 5 mL was applied to the L3-L4 spinal space after the area had been prepped with Betadine three times.  A 20-gauge spinal needle was then inserted into the L3-L4 space.  Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained.  The spinal needle was then withdrawn and the area cleaned and dried and a Band-Aid applied to the clean, dry area.,COMPLICATIONS:,  None.  The patient was resting comfortably and tolerated the procedure well.,ESTIMATED BLOOD LOSS: , None.,DISPOSITION: , The patient was resting comfortably with nonlabored breathing and the incision was clean, dry, and intact.  Labs and cultures were sent for the usual in addition to some extra tests that had been ordered.,The opening pressure was 292, the closing pressure was 190.","neurosurgery, spinal needle, lumbar puncture, lumbar, gauge, csf"
 Lumbar puncture with moderate sedation., Neurosurgery, Lumbar Puncture - 1 ,"PROCEDURE: , Lumbar puncture with moderate sedation.,INDICATION: , The patient is a 2-year, 2-month-old little girl who presented to the hospital with severe anemia, hemoglobin 5.8, elevated total bilirubin consistent with hemolysis and weak positive direct Coombs test.  She was transfused with packed red blood cells.  Her hemolysis seemed to slow down.  She also on presentation had indications of urinary tract infection with urinalysis significant for 2+ leukocytes, positive nitrites, 3+ protein, 3+ blood, 25 to 100 white cells, 10 to 25 bacteria, 10 to 25 epithelial cells on clean catch specimen.  Culture subsequently grew out no organisms; however, the child had been pretreated with amoxicillin about x3 doses prior to presentation to the hospital.  She had a blood culture, which was also negative.  She was empirically started on presentation with the cefotaxime intravenously.  Her white count on presentation was significantly elevated at 20,800, subsequently increased to 24.7 and then decreased to 16.6 while on antibiotics.  After antibiotics were discontinued, she increased over the next 2 days to an elevated white count of 31,000 with significant bandemia, metamyelocytes and myelocytes present.  She also had three episodes of vomiting and thus she is being taken to the procedure room today for a lumbar puncture to rule out meningitis that may being inadvertently treated in treating her UTI.,I discussed with The patient's parents prior to the procedure the lumbar puncture and moderate sedation procedures.  The risks, benefits, alternatives, complications including, but not limited to bleeding, infection, respiratory depression.  Questions were answered to their satisfaction.  They would like to proceed.,PROCEDURE IN DETAIL: , After ""time out"" procedure was obtained, the child was given appropriate monitoring equipment including appropriate vital signs were obtained.  She was then given Versed 1 mg intravenously by myself.  She subsequently became sleepy, the respiratory monitors, end-tidal, cardiopulmonary and pulse oximetry were applied.  She was then given 20 mcg of fentanyl intravenously by myself.  She was placed in the left lateral decubitus position.  Dr. X cleansed the patient's back in a normal sterile fashion with Betadine solution.  She inserted a 22-gauge x 1.5-inch spinal needle in the patient's L3-L4 interspace that was carefully identified under my direct supervision.  Clear fluid was not obtained initially, needle was withdrawn intact.  The patient was slightly repositioned by the nurse and Dr. X reinserted the needle in the L3-L4 interspace position, the needle was able to obtain clear fluid, approximately 3 mL was obtained.  The stylette was replaced and the needle was withdrawn intact and bandage was applied.  Betadine solution was cleansed from the patient's back.,During the procedure, there were no untoward complications, the end-tidal CO2, pulse oximetry, and other vitals remained stable.  Of note, EMLA cream had also been applied prior procedure, this was removed prior to cleansing of the back.,Fluid will be sent for a routine cell count, Gram stain culture, protein, and glucose.,DISPOSITION: , The child returned to room on the medical floor in satisfactory condition.","neurosurgery, moderate sedation, lumbar puncture, needle, lumbar, "
" Lumbar laminectomy for decompression with foraminotomies L3-L4, L4-L5, L5-S1 microtechniques and repair of CSF fistula, microtechniques L5-S1, application of DuraSeal.  Lumbar stenosis and cerebrospinal fluid fistula.", Neurosurgery, Lumbar Laminectomy ,"PREOPERATIVE DIAGNOSIS: , Lumbar stenosis.,POSTOPERATIVE DIAGNOSES:,  Lumbar stenosis and cerebrospinal fluid fistula.,TITLE OF THE OPERATION,1.  Lumbar laminectomy for decompression with foraminotomies L3-L4, L4-L5, L5-S1 microtechniques.,2.  Repair of CSF fistula, microtechniques L5-S1, application of DuraSeal.,INDICATIONS:,  The patient is an 82-year-old woman who has about a four-month history now of urinary incontinence and numbness in her legs and hands, and difficulty ambulating.  She was evaluated with an MRI scan, which showed a very high-grade stenosis in her lumbar spine, and subsequent evaluation included a myelogram, which demonstrated cervical stenosis at C4-C5, C5-C6, and C6-C7 as well as a complete block of the contrast at L4-L5 and no contrast at L5-S1 either and stenosis at L3-L4 and all the way up, but worse at L3-L4, L4-L5, and L5-S1.  Yesterday, she underwent an anterior cervical discectomy and fusions C4-C5, C5-C6, C6-C7 and had some improvement of her symptoms and increased strength, even in the recovery room.  She was kept in the ICU because of her age and the need to bring her back to the operating room today for decompressive lumbar laminectomy.  The rationale for putting the surgery is close together that she is normally on Coumadin for atrial fibrillation, though she has been cardioverted.  She and her son understand the nature, indications, and risks of the surgery, and agreed to go ahead.,PROCEDURE: , The patient was brought from the Neuro ICU to the operating room, where general endotracheal anesthesia was obtained.  She was rolled in a prone position on the Wilson frame.  The back was prepared in the usual manner with Betadine soak, followed by Betadine paint.  Markings were applied.  Sterile drapes were applied.  Using the usual anatomical landmarks, linear midline incision was made presumed over L4-L5 and L5-S1.  Sharp dissection was carried down into subcutaneous tissue, then Bovie electrocautery was used to isolate the spinous processes.  A Kocher clamp was placed in the anterior spinous ligament and this turned out to be L5-S1.  The incision was extended rostrally and deep Gelpi's were inserted to expose the spinous processes and lamina of L3, L4, L5, and S1.  Using the Leksell rongeur, the spinous processes of L4 and L5 were removed completely, and the caudal part of L3.  A high-speed drill was then used to thin the caudal lamina of L3, all of the lamina of L4 and of L5.  Then using various Kerrison punches, I proceeded to perform a laminectomy.  Removing the L5 lamina, there was a dural band attached to the ligamentum flavum and this caused about a 3-mm tear in the dura.  There was CSF leak.  The lamina removal was continued, ligamentum flavum was removed to expose all the dura.  Then using 4-0 Nurolon suture, a running-locking suture was used to close the approximate 3-mm long dural fistula.  There was no CSF leak with Valsalva.,I then continued the laminectomy removing all of the lamina of L5 and of L4, removing the ligamentum flavum between L3-L4, L4-L5 and L5-S1.  Foraminotomies were accomplished bilaterally.  The caudal aspect of the lamina of L3 also was removed.  The dura came up quite nicely.  I explored out along the L4, L5, and S1 nerve roots after completing the foraminotomies, the roots were quite free.  Further more, the thecal sac came up quite nicely.  In order to ensure no CSF leak, we would follow the patient out of the operating room.  The dural closure was covered with a small piece of fat.  This was all then covered with DuraSeal glue.  Gelfoam was placed on top of this, then the muscle was closed with interrupted 0 Ethibond.  The lumbodorsal fascia was closed with multiple sutures of interrupted 0 Ethibond in a watertight fashion.  Scarpa's fascia was closed with a running 0 Vicryl, and finally the skin was closed with a running-locking 3-0 nylon.  The wound was blocked with 0.5% plain Marcaine.,ESTIMATED BLOOD LOSS:  Estimated blood loss for the case was about 100 mL.,SPONGE AND NEEDLE COUNTS:  Correct.,FINDINGS:  A very tight high-grade stenosis at L3-L4, L4-L5, and L5-S1.  There were adhesions between the dura and the ligamentum flavum owing to the severity and length of the stenosis.,The patient tolerated the procedure well with stable vitals throughout.","neurosurgery, microtechniques, fistula, duraseal, foraminotomies, lumbar, stenosis, cerebrospinal, lumbar laminectomy, ligamentum flavum, csf, laminectomy, lamina,"
" Injection for myelogram and microscopic-assisted lumbar laminectomy with discectomy at L5-S1 on the left.  Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.", Neurosurgery, Lumbar Laminectomy & Discectomy ,"PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.,POSTOPERATIVE DIAGNOSIS:,  Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.,PROCEDURE PERFORMED:,1.  Injection for myelogram.,2.  Microscopic-assisted lumbar laminectomy with discectomy at L5-S1 on the left on 08/28/03.,BLOOD LOSS: , Approximately 25 cc.,ANESTHESIA: , General.,POSITION:,  Prone on the Jackson table.,INTRAOPERATIVE FINDINGS:,  Extruded nucleus pulposus at the level of L5-S1.,HISTORY: , This is a 34-year-old male with history of back pain with radiation into the left leg in the S1 nerve root distribution.  The patient was lifting at work on 08/27/03 and felt immediate sharp pain from his back down to the left lower extremity.  He denied any previous history of back pain or back surgeries.  Because of his intractable pain as well as severe weakness in the S1 nerve root distribution, the patient was aware of all risks as well as possible complications of this type of surgery and he has agreed to pursue on.  After an informed consent was obtained, all risks as well as complications were discussed with the patient.  ,PROCEDURE DETAIL:  ,He was wheeled back to Operating Room #5 at ABCD General Hospital on 08/28/03.  After a general anesthetic was administered, a Foley catheter was inserted.,The patient was then turned prone on the Jackson table.  All of his bony prominences were well-padded.  At this time, a myelogram was then performed.  After the lumbar spine was prepped, a #20 gauge needle was then used to perform a myelogram.  The needle was localized to the level of L3-L4 region.  Once inserted into the thecal sac, we immediately got cerebrospinal fluid through the spinal needle.  At this time, approximately 10 cc of Conray injected into the thecal sac.  The patient was then placed in the reversed Trendelenburg position in order to assist with distal migration of the contrast.  The myelogram did reveal that there was some space occupying lesion, most likely disc at the level of L5-S1 on the left.  There was a lack of space filling defect on the left evident on both the AP and the lateral projections using C-arm fluoroscopy.  At this point, the patient was then fully prepped and draped in the usual sterile fashion for this procedure for a microdiscectomy.  A long spinal needle was then inserted into region of surgery on the right.  The surgery was going to be on the left.  Once the spinal needle was inserted, a localizing fluoroscopy was then used to assure appropriate location and this did confirm that we were at the L5-S1 nerve root region.  At this time, an approximately 2 cm skin incision was made over the lumbar region, dissected down to the deep lumbar fascia.  At this time, a Weitlaner was inserted.  Bovie cautery was used to obtain hemostasis.  We further continued through the deep lumbar fascia and dissected off the short lumbar muscles off of the spinous process and the lamina.  A Cobb elevator was then used to elevate subperiosteally off of all the inserting short lumbar muscles off of the spinous process as well as the lamina on the left-hand side.  At this time, a Taylor retractor was then inserted and held there for retraction.  Suction as well as Bovie cautery was used to obtain hemostasis.  At this time, a small Kerrison Rongeur was used to make a small lumbar laminotomy to expose our window for the nerve root decompression.  Once the laminotomy was performed, a small _______ curette was used to elevate the ligamentum flavum off of the thecal sac as well as the adjoining nerve roots.  Once the ligamentum flavum was removed, we immediately identified a piece of disc material floating around outside of the disc space over the S1 nerve root, which was compressive.  We removed the extruded disc with further freeing up of the S1 nerve root.  A nerve root retractor was then placed.  Identification of disc space was then performed.  A #15 blade was then inserted and small a key hole into the disc space was then performed with a #15 blade.  A small pituitary was then inserted within the disc space and more disc material was freed and removed.  The part of the annulus fibrosis were also removed in addition to the loose intranuclear pieces of disc.  Once this was performed, we removed the retraction off the nerve root and the nerve root appeared to be free with pulsatile visualization of the vasculature indicating that the nerve root was essentially free.,At this time, copious irrigation was used to irrigate the wound.  We then performed another look to see if any loose pieces of disc were extruding from the disc space and only small pieces were evident and they were then removed with the pituitary rongeur.  At this time, a small piece of Gelfoam was then used to cover the exposed nerve root.  We did not have any dural leaks during this case.  #1-0 Vicryl was then used to approximate the deep lumbar fascia, #2-0 Vicryl was used to approximate the superficial lumbar fascia, and #4-0 running Vicryl for the subcutaneous skin.  Sterile dressings were then applied.  The patient was then carefully slipped over into the supine position, extubated and transferred to Recovery in stable condition.  At this time, we are still waiting to assess the patient postoperatively to assure no neurological sequela postsurgically are found and also to assess his pain level.","neurosurgery, microscopic-assisted lumbar laminectomy, discectomy, nerve root, lumbar laminectomy, herniated nucleus, thecal sac, spinal needle, nucleus pulposus, disc space, root, nerve, weakness, lumbar, laminectomy, nucleus, pulposus, myelogram"
" Microscopic-assisted revision of bilateral decompressive lumbar laminectomies and foraminotomies at the levels of L3-L4, L4-L5, and L5-S1.  Posterior spinal fusion at the level of L4-L5 and L5-S1 utilizing local bone graft, allograft and segmental instrumentation.  Posterior lumbar interbody arthrodesis utilizing cage instrumentation at L4-L5 with local bone graft and allograft.  All procedures were performed under SSEP, EMG, and neurophysiologic monitoring.", Neurosurgery, Laminectomy & Foraminotomy Revision ,"PREOPERATIVE DIAGNOSES:,1.  Recurrent spinal stenosis at L3-L4, L4-L5, and L5-S1.,2.  Spondylolisthesis, which is unstable at L4-L5.,3.  Recurrent herniated nucleus pulposus at L4-L5 bilaterally.,POSTOPERATIVE DIAGNOSES:,1.  Recurrent spinal stenosis at L3-L4, L4-L5, and L5-S1.,2.  Spondylolisthesis, which is unstable at L4-L5.,3.  Recurrent herniated nucleus pulposus at L4-L5 bilaterally.,PROCEDURE PERFORMED:,1.  Microscopic-assisted revision of bilateral decompressive lumbar laminectomies and foraminotomies at the levels of L3-L4, L4-L5, and L5-S1.,2.  Posterior spinal fusion at the level of L4-L5 and L5-S1 utilizing local bone graft, allograft and segmental instrumentation.,3.  Posterior lumbar interbody arthrodesis utilizing cage instrumentation at L4-L5 with local bone graft and allograft.  All procedures were performed under SSEP, EMG, and neurophysiologic monitoring.,ANESTHESIA: , General via endotracheal tube.,ESTIMATED BLOOD LOSS:  ,Approximately 1000 cc.,CELL SAVER RETURNED:  ,Approximately 550 cc.,SPECIMENS: , None.,COMPLICATIONS: , None.,DRAIN: , 8-inch Hemovac.,SURGICAL INDICATIONS: , The patient is a 59-year-old male who had severe disabling low back pain.  He had previous lumbar laminectomy at L4-L5.  He was noted to have an isthmic spondylolisthesis.,Previous lumbar laminectomy exacerbated this condition and made it further unstable.  He is suffering from neurogenic claudication.  He was unresponsive to extensive conservative treatment.  He has understanding of the risks, benefits, potential complications, treatment alternatives and provided informed consent.,OPERATIVE TECHNIQUE: , The patient was taken to OR #5 where he was given general anesthetic by the Department of Anesthesia.  He was subsequently placed prone on the Jackson's spinal table with all bony prominences well padded.  His lumbar spine was then sterilely prepped and draped in the usual fashion.  A previous midline incision was extended from approximate level of L3 to S1.  This was in the midline.  Skin and subcutaneous tissue were debrided sharply.  Electrocautery provided hemostasis.  ,Electrocautery was utilized to dissect through subcutaneous tissue of lumbar fascia.  The lumbar fascia was identified and split in the midline.  Subperiosteal dissection was then carried out with electrocautery and ______ elevated from the suspected levels of L3-S1.  Once this was exposed, the transverse processes, a Kocher clamp was placed and a localizing cross-table x-ray confirmed the interspace between the spinous processes of L3-L4.  Once this was completed, a self-retaining retractor was then placed.  With palpation of the spinous processes, the L4 posterior elements were noted to be significantly loosened and unstable.  These were readily mobile with digital palpation.  A rongeur was then utilized to resect the spinous processes from the inferior half of L3 to the superior half of S1.  This bone was morcellized and placed on the back table for utilization for bone grafting.  The rongeur was also utilized to thin the laminas from the inferior half of L3 to superior half of S1.  Once this was undertaken, the unstable posterior elements of L4 were meticulously dissected free until wide decompression was obtained.  Additional decompression was extended from the level of the inferior half of L3 to the superior half of S1.  The microscope was utilized during this portion of procedure for visualization.  There was noted to be no changes during the decompression portion or throughout the remainder of the surgical procedure.  Once decompression was deemed satisfactory, the nerve roots were individually inspected and due to the unstable spondylolisthesis, there was noted to be tension on the L4 and L5 nerve roots crossing the disc space at L4-L5.  Once this was identified, foraminotomies were created to allow additional mobility.  The wound was then copiously irrigated with antibiotic solution and suctioned dry.  Working type screws, provisional titanium screws were then placed at L4-l5.  This was to allow distraction and reduction of the spondylolisthesis.  These were placed in the pedicles of L4 and L5 under direct intensification.  The position of the screws were visualized, both AP and lateral images.  They were deemed satisfactory.,Once this was completed, a provisional plate was applied to the screws and distraction applied across L4-L5.  This allowed for additional decompression of the L5 and L4 nerve roots.  Once this was completed, the L5 nerve root was traced and deemed satisfactory exiting neural foramen after additional dissection and discectomy were performed.  Utilizing a series of interbody spacers, a size 8 mm spacer was placed within the L4-L5 interval.  This was taken in sequence up to a 13 mm space.  This was then reduced to a 11 mm as it was much more anatomic in nature.  Once this was completed, the spacers were then placed on the left side and distraction obtained.  Once the distraction was obtained to 11 mm, the interbody shavers were utilized to decorticate the interbody portion of L4 and L5 bilaterally.  Once this was taken to 11 mm bilaterally, the wound was copiously irrigated with antibiotic solution and suction dried.  A 11 mm height x 9 mm width x 25 mm length carbon fiber cages were packed with local bone graft and Allograft.  There were impacted at the interspace of L4-L5 under direct image intensification.  Once these were deemed satisfactory, the wound was copiously irrigated with antibiotic solution and suction dried.  The provisional screws and plates were removed.  This allowed for additional compression along L4-L5 with the cage instrumentation.  Permanent screws were then placed at L4, L5, and S1 bilaterally.  This was performed under direct image intensification.  The position was verified in both AP and lateral images.  Once this was completed, the posterolateral gutters were decorticated with an AM2 Midas Rex burr down to bleeding subchondral bone.  The wound was then copiously irrigated with antibiotic solution and suction dried.  The morcellized Allograft and local bone graft were mixed and packed copiously from the transverse processes of L4-S1 bilaterally.  A 0.25 inch titanium rod was contoured of appropriate length to span from L4-S1.  Appropriate cross connecters were applied and the construct was placed over the pedicle screws.  They were tightened and sequenced to allow additional posterior reduction of the L4 vertebra.  Once this was completed, final images in the image intensification unit were reviewed and were deemed satisfactory.  All connections were tightened and retightened in Torque 2 specifications.  The wound was then copiously irrigated with antibiotic solution and suction dried.  The dura was inspected and noted to be free of tension.  At the conclusion of the procedure, there was noted to be no changes on the SSEP, EMG, and neurophysiologic monitors.  An 8-inch Hemovac drain was placed exiting the wound.  The lumbar fascia was then approximated with #1 Vicryl in interrupted fashion, the subcutaneous tissue with #2-0 Vicryl interrupted fashion, surgical stainless steel clips were used to approximate the skin.  The remainder of the Hemovac was assembled.  Bulky compression dressing utilizing Adaptic, 4x4, and ABDs was then affixed to the lumbar spine with Microfoam tape.  He was turned and taken to the recovery room in apparent satisfactory condition.  Expected surgical prognosis remains guarded.",
 Left-sided large hemicraniectomy for traumatic brain injury and increased intracranial pressure.  She came in with severe traumatic brain injury and severe multiple fractures of the right side of the skull. , Neurosurgery, Hemicraniectomy ,"TITLE OF OPERATION:,  Left-sided large hemicraniectomy for traumatic brain injury and increased intracranial pressure.,INDICATION FOR SURGERY: ,  The patient is a patient well known to my service.  She came in with severe traumatic brain injury and severe multiple fractures of the right side of the skull.  I took her to the operating a few days ago for a large right-sided hemicraniectomy to save her life.  I spoke with the family, the mom, especially about the risks, benefits, and alternatives of this procedure, most especially given the fact that she had undergone a very severe traumatic brain injury with a very poor GCS of 3 in some brainstem reflexes.  I discussed with them that this was a life-saving procedure and the family agreed to proceed with surgery as a level 1.  We went to the operating room at that time and we did a very large right-sided hemicraniectomy.  The patient was put in the intensive care unit.  We had placed also at that time a left-sided intracranial pressure monitor both which we took out a few days ago.  Over the last few days, the patient began to slowly deteriorate little bit on her clinical examination, that is, she was at first localizing briskly with the right side and that began to be less brisk.  We obtained a CT scan at this point, and we noted that she had a fair amount of swelling in the left hemisphere with about 1.5 cm of midline shift.  At this point, once again I discussed with the family the possibility of trying to save her life and go ahead and doing a left-sided very large hemicraniectomy with this __________  this was once again a life-saving procedure and we proceeded with the consent of mom to go ahead and do a level 1 hemicraniectomy of the left side.,PROCEDURE IN DETAIL: , The patient was taken to the operating room.  She was already intubated and under general anesthesia.  The head was put in a 3-pin Mayfield headholder with one pin in the forehead and two pins in the back to be able to put the patient with the right-hand side down and the left-hand side up since on the right-hand side, she did not have a bone flap which complicated matters a little bit, so we had to use a 3-pin Mayfield headholder.  The patient tolerated this well.  We sterilely prepped everything and we actually had already done a midline incision prior to this for the prior surgery, so we incorporated this incision into the new incision, and to be able to open the skin on the left side, we did a T-shaped incision with T vertical portion coming from anterior to the ear from the zygoma up towards the vertex of the skull towards the midline of the skin.  We connected this.  Prior to this, we brought in all surgical instrumentation under sterile and standard conditions.  We opened the skin as in opening a book and then we also did a myocutaneous flap.  We brought in the muscle with it.  We had a very good exposure of the skull.  We identified all the important landmarks including the zygoma inferiorly, the superior sagittal suture as well as posteriorly and anteriorly.  We had very good landmarks, so we went ahead and did one bur hole and the middle puncta right above the zygoma and then brought in the craniotome and did a very large bone flap that measured about 7 x 9 cm roughly, a very large decompression of the left side.  At this point, we opened the dura and the dura as soon as it was opened, there was a small subdural hematoma under a fair amount of pressure and cleaned this very nicely irrigated completely the brain and had a few contusions over the operculum as well as posteriorly.  All this was irrigated thoroughly.  Once we made sure we had absolutely great hemostasis without any complications, we went ahead and irrigated once again and we had controlled the meddle meningeal as well as the superior temporal artery very nicely.  We had absolutely good hemostasis.  We put a piece of Gelfoam over the brain.  We had opened the dura in a cruciate fashion, and the brain clearly bulging out despite of the fact that it was in the dependent position.  I went ahead and  irrigated everything thoroughly putting a piece of DuraGen as well as a piece of Gelfoam with very good hemostasis and proceeded to close the skin with running nylon in place.  This running nylon we put in place in order not to put any absorbables, although I put a few 0 popoffs just to approximate the skin nicely.  Once we had done this, irrigated thoroughly once again the skin.  We cleaned up everything and then we took the patient off __________ anesthesia and took the patient back to the intensive care unit.  The EBL was about 200 cubic centimeters.  Her hematocrit went down to about 21 and I ordered the patient to receive one unit of blood intraoperatively which they began to work on as we began to continue to do the work and the sponges and the needle counts were correct.  No complications.  The patient went back to the intensive care unit.","neurosurgery, large hemicraniectomy, intracranial pressure, multiple fractures, skull, traumatic brain injury, mayfield headholder, injury, hemicraniectomyNOTE"
 Decompressive left lumbar laminectomy C4-C5 and C5-C6 with neural foraminotomy. Posterior cervical fusion C4-C5.  Songer wire.  Right iliac bone graft., Neurosurgery, Laminectomy & Foraminotomy & Cervical Fusion ,"PREOPERATIVE DIAGNOSES,1.  Post anterior cervical discectomy and fusion at C4-C5 and C5-C6 with possible pseudoarthrosis at C4-C5.,2.  Cervical radiculopathy involving the left arm.,3.  Disc degeneration at C3-C4 and C6-C7.,POSTOPERATIVE DIAGNOSES,1.  Post anterior cervical discectomy and fusion at C4-C5 and C5-C6 with possible pseudoarthrosis at C4-C5.,2.  Cervical radiculopathy involving the left arm.,3.  Disc degeneration at C3-C4 and C6-C7.,OPERATIVE PROCEDURES,1.  Decompressive left lumbar laminectomy C4-C5 and C5-C6 with neural foraminotomy.,2.  Posterior cervical fusion C4-C5.,3.  Songer wire.,4.  Right iliac bone graft.,TECHNIQUE:  ,The patient was brought to the operating room.  Preoperative evaluations included previous cervical spine surgery.  The patient initially had some relief; however, his left arm pain did recur and gradually got worse.  Repeat studies including myelogram and postspinal CTs revealed some blunting of the nerve root at C4-C5 and C5-C6.  There was also noted to be some annular bulges at C3-C4, and C6-C7.  The CT scan in March revealed that the fusion was not fully solid.  X-rays were done in November including flexion and extension views, it appeared that the fusion was solid.,The patient had been on pain medication.  The patient had undergone several nonoperative treatments.  He was given the option of surgical intervention.  We discussed Botox, I discussed with the patient and posterior cervical decompression.  I explained to the patient this will leave a larger scar on his neck, and that no guarantee would help, there would be more bleeding and more pain from the posterior surgery than it was from the anterior surgery.  If at the time of surgery there was some motion of the C4-C5 level, I would recommend a fusion.  The patient was a smoker and had been advised to quit smoking but has not quit smoking.  I have therefore recommended that he use iliac bone graft.  I explained to the patient that this would give him a scar over the back of the right pelvis and could be a source of chronic pain for the patient for the rest of his life.  Even if this type of bone graft was used, there was no guarantee that it will fuse and he should stop smoking completely.,The patient also was advised that if I did a fusion, I would also use post instrumentation, which was a wire.  The wire would be left permanently.,Even with all these procedures, there was no guarantee that his symptoms would improve.  His numbness, tingling, and weakness could get worse rather than better, his neck pain and arm pain could persist.  He still had some residual bursitis in his left shoulder and this would not be cured by this procedure.  Other procedures may be necessary later.  There is still with a danger of becoming quadriplegic or losing total control of bowel or bladder function.  He could lose total control of his arms or legs and end up in the bed for the rest of his life.  He could develop chronic regional pain syndromes.  He could get difficulty swallowing or eating.  He could have substantial weakness in the arm.  He was advised that he should not undergo the surgery unless the pain is persistent, severe, and unremitting.,He was also offered his records if he would like any other pain medications or seek other treatments, he was advised that Dr. X would continue to prescribe pain medication if he did not wish to proceed with surgery.,He stated he understood all the risks.  He did not wish to get any other treatments.  He said the pain has reached the point that he wished to proceed with surgery.,PROCEDURE IN DETAIL: , In the operating room, he was given general endotracheal anesthesia.,I then carefully rolled the patient on thoracic rolls.  His head was controlled by a horseshoe holder.  The anesthesiologist checked the eye positions to make sure there was no pressure on the orbits and the anesthesiologist continued to check them every 15 minutes.  The arms, the right hip, and the neck was then prepped and draped.  Care was taken to position both arms and both legs.  Pulses were checked.,A midline incision was made through the skin and subcutaneous tissue on the cervical spine.  A loupe magnification and headlamp illumination was used.  Bleeding vessels were cauterized.  Meticulous hemostasis was carried out throughout the procedure.  Gradually and carefully I exposed the spinous process of the C6, C5, and C4.  A lateral view was done after an instrument in place.  This revealed the C6-C7 level.  I therefore did a small laminotomy opening at C4-C5.  I placed an instrument and x-rays confirmed C4-C5 level.,I stripped the muscles from the lamina and then moved them laterally and held with a self-retaining retractor.,Once I identified the level, I then used a bur to thin the lamina of C5.  I used a 1-mm, followed by a 2-mm Kerrison rongeur to carefully remove the lamina off C5 on the left.  I removed some of the superior lamina of C6 and some of the inferior lamina of C4.  This allowed me to visualize the dura and the nerve roots and gradually do neural foraminotomies for both the C5 and C6 nerve roots.  There was some bleeding from the epidural veins and a bipolar cautery was used.  Absolutely no retractors were ever placed in the canal.  There was no retraction.  I was able to place a small probe underneath the nerve root and check the disc spaces to make sure there was no fragments of disc or herniation disc and none were found.,At the end of the procedure, the neuroforamen were widely patent.  The nerve roots had been fully decompressed.,I then checked stability.  There was micromotion at the C4-C5 level.  I therefore elected to proceed with a fusion.,I debrided the interspinous ligament between C4 and C5.  I used a bur to roughen up the surface of the superior portion of the spinous process of C5 and the inferior portion of C4.  Using a small drill, I opened the facet at C4-C5.  I then used a very small curette to clean up the articular cartilage.  I used a bur then to roughen up the lamina at C4-C5.,Attention was turned to the right and left hip, which was also prepped.  An incision made over the iliac crest.  Bleeding vessels were cauterized.  I exposed just the posterior aspect of the crest.  I removed some of the bone and then used the curette to remove cancellous bone.,I placed the Songer wire through the base of the spinous process of C4 and C5.  Drill holes made with a clip.  I then packed cancellous bone between the decorticated spinous process.  I then tightened the Songer wire to the appropriate tension and then cut off the excess wire.,Prior to tightening the wire, I also packed cancellous bone with facet at C4-C5.  I then laid bone upon the decorticated lamina of C4 and C5.,The hip wound was irrigated with bacitracin and Kantrex.  Deep structures were closed with #1 Vicryl, subcutaneous suture and subcuticular tissue was closed.,No drain was placed in the hip.,A drain was left in the posterior cervical spine.  The deep tissues were closed with 0 Vicryl, subcutaneous tissue and skin were then closed.  The patient was taken to the recovery room in good condition.",
" Revision laminectomy L5-S1, discectomy L5-S1, right medial facetectomy, preparation of disk space and arthrodesis with interbody graft with BMP.  Status post previous lumbar surgery for herniated disk with severe recurrence of axial back pain, failed conservative therapy.", Neurosurgery, Laminectomy & Discectomy & Facetectomy ,"TITLE OF OPERATION: , Revision laminectomy L5-S1, discectomy L5-S1, right medial facetectomy, preparation of disk space and arthrodesis with interbody graft with BMP.,INDICATIONS FOR SURGERY:  ,Please refer to medical record, but in short, the patient is a 43-year-old male known to me, status post previous lumbar surgery for herniated disk with severe recurrence of axial back pain, failed conservative therapy.  Risks and benefits of surgery were explained in detail including risk of bleeding, infection, stroke, heart attack, paralysis, need for further surgery, hardware failure, persistent symptoms, and death.  This list was inclusive, but not exclusive.  An informed consent was obtained after all patient's questions were answered.,PREOPERATIVE DIAGNOSIS:  ,Severe lumbar spondylosis L5-S1, collapsed disk space, hypermobility, and herniated disk posteriorly.,POSTOPERATIVE DIAGNOSIS: , Severe lumbar spondylosis L5-S1, collapsed disk space, hypermobility, and herniated disk posteriorly.,ANESTHESIA: , General anesthesia and endotracheal tube intubation.,DISPOSITION: , The patient to PACU with stable vital signs.,PROCEDURE IN DETAIL:  ,The patient was taken to the operating room.  After adequate general anesthesia with endotracheal tube intubation was obtained, the patient was placed prone on the Jackson table.  Lumbar spine was shaved, prepped, and draped in the usual sterile fashion.  An incision was carried out from L4 to S1.  Hemostasis was obtained with bipolar and Bovie cauterization.  A Weitlaner was placed in the wound and a subperiosteal dissection was carried out identifying the lamina of L4, L5, and sacrum.  At this time, laminectomy was carried out of L5-S1.  Thecal sac was retracted rightward and the foramen was opened and unilateral medial facetectomy was carried out in the disk space.  At this time, the disk was entered with a #15 blade and bipolar.  The disk was entered with straight up and down-biting pituitaries, curettes, and the high speed drill and we were able to takedown calcified herniated disk.  We were able to reestablish the disk space, it was very difficult, required meticulous dissection and then drilling with a diamond bur in the disk space underneath the spinal canal, very carefully holding the spinal canal out of harm's way as well as the exiting nerve root.  Once this was done, we used rasps to remove more disk material anteriorly and under the midline to the left side and then we put in interbody graft of BMP 8 mm graft from Medtronic.  At this time, Dr. X will dictate the posterolateral fusion, pedicle screw fixation to L4 to S1 with compression and will dictate the closure of the wound.  There were no complications.","neurosurgery, revision laminectomy, discectomy, facetectomy, arthrodesis, lumbar spondylosis, hypermobility, collapsed disk space, medial facetectomy, interbody graft, herniated disk, interbody, laminectomy, disk, therapy, lumbar, herniated, space,"
" Bilateral C3-C4, C4-C5, C5-C6, and C6-C7 medial facetectomy and foraminotomy with technical difficulty, total laminectomy C3, C4, C5, and C6, excision of scar tissue, and repair of dural tear with Prolene 6-0 and Tisseel.", Neurosurgery, Facetectomy & Foraminotomy ,"PREOPERATIVE DIAGNOSES,1.  Neck pain with bilateral upper extremity radiculopathy.,2.  Residual stenosis, C3-C4, C4-C5, C5-C6, and C6-C7 with probable instability.,POSTOPERATIVE DIAGNOSES,1.  Neck pain with bilateral upper extremity radiculopathy.,2.  Residual stenosis, C3-C4, C4-C5, C5-C6, and C6-C7 secondary to facet arthropathy with scar tissue.,3.  No evidence of instability.,OPERATIVE PROCEDURE PERFORMED,1.  Bilateral C3-C4, C4-C5, C5-C6, and C6-C7 medial facetectomy and foraminotomy with technical difficulty.,2.  Total laminectomy C3, C4, C5, and C6.,3.  Excision of scar tissue.,4.  Repair of dural tear with Prolene 6-0 and Tisseel.,FLUIDS:,  1500 cc of crystalloid.,URINE OUTPUT: , 200 cc.,DRAINS: , None.,SPECIMENS: , None.,COMPLICATIONS: , None.,ANESTHESIA:,  General endotracheal anesthesia.,ESTIMATED BLOOD LOSS:,  Less than 250 cc.,INDICATIONS FOR THE OPERATION:  ,This is the case of a very pleasant 41 year-old Caucasian male well known to me from previous anterior cervical discectomy and posterior decompression.  Last surgery consisted of four-level decompression on 08/28/06.  The patient continued to complain of posterior neck pain radiating to both trapezius.  Review of his MRI revealed the presence of what still appeared to be residual lateral recess stenosis.  It also raised the possibility of instability and based on this I recommended decompression and posterolateral spinal instrumention; however, intraoperatively, it appeared like there was no abnormal movement of any of the joint segments; however, there was still residual stenosis since the laminectomy that was done previously was partial.  Based on this, I did total decompression by removing the lamina of C3 through C6 and doing bilateral medial facetectomy and foraminotomy at C3-C4, C4-C5, C5-C6, and C6-C7 with no spinal instrumentation.  Operation and expected outcome risks and benefits were discussed with him prior to the surgery.  Risks include but not exclusive of bleeding and infection.  Infection can be superficial, but may also extend down to the epidural space, which may require return to the operating room and evacuation of the infection.  There is also the risk of bleeding that could be superficial but may also be in the epidural space resulting in compression of spinal cord.  This may result in weakness of all four extremities, numbness of all four extremities, and impairment of bowel and bladder function, which will require an urgent return to the operating room and evacuation of the hematoma.  There is also the risk of a dural tear with its attendant problems of CSF leak, headache, nausea, vomiting, photophobia, pseudomeningocele, and dural meningitis.  This too may require return to the operating room for evacuation of said pseudomeningocele and repair.  The patient understood the risk of the surgery.  I told him there is just a 30% chance that there will be no improvement with the surgery; he understands this and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room, awake, alert, not in any form of distress.  After smooth induction and intubation, a Foley catheter was inserted.  Monitoring leads were also placed by Premier Neurodiagnostics for both SSEP and EMG monitoring.  The SSEPs were normal, and the EMGs were silent during the entire case.  After completion of the placement of the monitoring leads, the patient was then positioned prone on a Wilson frame with the head supported on a foam facial support.  Shave was then carried out over the occipital and suboccipital region.  All pressure points were padded.  I proceeded to mark the hypertrophic scar for excision.  This was initially cleaned with alcohol and prepped with DuraPrep.,After sterile drapes were laid out, incision was made using a scalpel blade #10.  Wound edge bleeders were carefully controlled with bipolar coagulation and a hot knife was utilized to excise the hypertrophic scar.  Dissection was then carried down to the cervical fascia, and by careful dissection to the scar tissue, the spinous process of C2 was then identified.  There was absence of the spinous process of C3, C4, C5, and C6, but partial laminectomy was noted; removal of only 15% of the lamina.  With this completed, we proceeded to do a total laminectomy at C3, C4, C5, and C6, which was technically difficult due to the previous surgery.  There was also a dural tear on the right C3-C4 space that was exposed and repaired with Prolene 6-0 and later with Tisseel.  By careful dissection and the use of a -5 and 3 mm bur, total laminectomy was done as stated with bilateral medial facetectomy and foraminotomy done at C3-C4, C4-C5, C5-C6, and C6-C7.  There was significant epidural bleeding, which was carefully coagulated.  At two points, I had to pack this with small pieces of Gelfoam.  After repair of the dural tear, Valsalva maneuver showed no evidence of any CSF leakage.  Area was irrigated with saline and bacitracin and then lined with Tisseel.  The wound was then closed in layers with Vicryl 0 simple interrupted sutures to the fascia; Vicryl 2-0 inverted interrupted sutures to the dermis and a running nylon 2-0 continuous vertical mattress stitch.  The patient was extubated and transferred to recovery.",
" Right frontotemporoparietal craniotomy, evacuation of acute subdural hematoma.   Acute subdural hematoma, right, with herniation syndrome.", Neurosurgery, Frontotemporoparietal Craniotomy ,"PREOPERATIVE DIAGNOSES: , Acute subdural hematoma, right, with herniation syndrome.,POSTOPERATIVE DIAGNOSES: , Acute subdural hematoma, right, with herniation syndrome.,OPERATION PERFORMED:  ,Right frontotemporoparietal craniotomy, evacuation of acute subdural hematoma.,ANESTHESIA: , General endotracheal.,PREPARATION: , Povidone.,INDICATION:,  This is an 83-year-old male with herniation syndrome with large subdural hematoma 100%.  This procedure is being done as an emergency procedure in an attempt to save his life and maximize the potential for recovery.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room intubated.  The patient previously was given fresh frozen plasma plus recombinant activated factor VII.  The patient had a roll placed on his right shoulder, head was maintained three point fixation with a Mayfield headholder.  The right side of the head was shaved, thoroughly prepped and draped, a large ? scalp incision was marked, infiltrated with local and incised with a scalpel, Raney clips were applied to the scalp margins, hemostasis, temporalis muscle and fascia, pericranium opened and aligned with incision, flap was reflected anteriorly.  Burr holes are placed low in the temporal bone at the keyhole posteriorly and then superiorly with a perforator, then using Midas Rex drill with a B1 foot plate a free flap was turned.  The dura was opened in a cruciate fashion, acute subdural hematoma was evacuated.  There was a small arterial bleeder in the anterior parietal region, which was controlled with bipolar electrocautery.  Using suction and biopsy forceps, acute clot was resected from the frontotemporoparietal and occipital poles, subdural space was irrigated, no further bleeders were encountered.  Dura was closed with 4-0 Nurolon.  A subdural Camino ICP catheter was placed in the subdural space.  Bone flaps secured in place with neuro clips with 5 mm screws, central pack up suture was placed, dural tack up sutures were placed using 4-0 Nurolon prior to placement of the bone flap.  The wound was irrigated with saline, temporalis muscle and fascia closed with 2-0 Vicryl, subgaleal Hemovac was placed, galea was closed with 2-0 Vicryl, and scalp with staples.  ICP monitor and the Hemovac were sutured in place with 2-0 Vicryl.  The patient was taken out of the head holder, a sterile dressing placed.  The head was wrapped.  The patient was taken directly to ICU, still intubated in guarded condition.  Brain was nicely soft and pulsatile.  At the termination of the procedure, no significant contusion of the brain was identified.  Final sponge and needle counts are correct.  Estimated blood loss 400 cc.","neurosurgery, subdural hematoma, craniotomy, herniation, subdural, temporalis, frontotemporoparietal, hematoma,"
" Complete laminectomy, L4. and facetectomy, L3-L4 level.  A dural repair, right sided, on the lateral sheath, subarticular recess at the L4 pedicle level.  Posterior spinal instrumentation, L4 to S1, using Synthes Pangea System.  Posterior spinal fusion, L4 to S1.  Insertion of morselized autograft, L4 to S1.  ", Neurosurgery, Laminectomy & Facetectomy ,"PREOPERATIVE DIAGNOSIS:,  Dural tear, postoperative laminectomy, L4-L5.,POSTOPERATIVE DIAGNOSES,1.  Dural tear, postoperative laminectomy, L4-L5.,2.  Laterolisthesis, L4-L5.,3.  Spinal instability, L4-L5.,OPERATIONS PERFORMED,1.  Complete laminectomy, L4.,2.  Complete laminectomy plus facetectomy, L3-L4 level.,3.  A dural repair, right sided, on the lateral sheath, subarticular recess at the L4 pedicle level.,4.  Posterior spinal instrumentation, L4 to S1, using Synthes Pangea System.,5.  Posterior spinal fusion, L4 to S1.,6.  Insertion of morselized autograft, L4 to S1.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , 500 mL.,COMPLICATIONS: , None.,DRAINS:  ,Hemovac x1.,DISPOSITION: , Vital signs stable, taken to the recovery room in a satisfactory condition, extubated.,INDICATIONS FOR OPERATION: , The patient is a 48-year-old gentleman who has had a prior decompression several weeks ago.  He presented several days later with headaches as well as a draining wound.  He was subsequently taken back for a dural repair.  For the last 10 to 11 days, he has been okay except for the last two days he has had increasing headaches, has nausea, vomiting, as well as positional migraines.  He has fullness in the back of his wound.  The patient's risks and benefits have been conferred him due to the fact that he does have persistent spinal leak.  The patient was taken to the operating room for exploration of his wound with dural repair with possible stabilization pending what we find intraoperatively.,PROCEDURE IN DETAIL:,  After appropriate consent was obtained from the patient, the patient was wheeled back to the operating theater room #7.  The patient was placed in the usual supine position and intubated under general anesthesia without any difficulties.  The patient was given intraoperative antibiotics.  The patient was rolled onto the OSI table in usual prone position and prepped and draped in usual sterile fashion.,Initially, a midline incision was made from the cephalad to caudad level.  Full-thickness skin flaps were developed.  It was seen immediately that there was large amount of copious fluid emanating from the wound, clear-like fluid, which was the cerebrospinal fluid.  Cultures were taken, aerobic, anaerobic, AFB, fungal.  Once this was done, the paraspinal muscles were affected from the posterior elements.  It was seen that there were no facet complexes on the right side at L4-L5 and L5-S1.  It was seen that the spine was listhesed at L5 and that the dural sac was pinched at the L4-5 level from the listhesis.  Once this was done; however, the fluid emanating from the dura could not be seen appropriately.  Complete laminectomy at L4 was performed as well extending the L5 laminectomy more to the left.  Complete laminectomy at L3 was done.  Once this was done within the subarticular recess on the right side at the L4 pedicle level, a rent in the dura was seen.  Once this was appropriately cleaned, the dural edges were approximated using a running 6-0 Prolene suture.  A Valsalva confirmed no significant lead after the repair was made.  There was a significant laterolisthesis at L4-L5 and due to the fact that there were no facet complexes at L5-S1 and L4-L5 on the right side as well as there was a significant concavity on the right L4-L5 disk space which was demonstrated from intraoperative x-rays and compared to preoperative x-rays, it was decided from an instrumentation.  The lateral pedicle screws were placed at L4, L5, and S1 using the standard technique of Magerl.  After this the standard starting point was made.  Trajectory was completed with gearshift and sounded in all four quadrants to make sure there was no violation of the pedicle wall.  Once this was done, this was undertapped at 1 mm and resounded in all four quadrants to make sure that there was no violation of the pedicle wall.  The screws were subsequently placed.  Tricortical purchase was obtained at S1 ________ appropriate size screws.  Precontoured titanium rod was then appropriately planned and placed between the screws at L4, L5, and S1.  This was done on the right side first.  The screw was torqued at S1 appropriately and subsequently at L5.  Minimal compression was then placed between L5 and L4 to correct the concavity as well as laterolisthesis and the screw appropriately torqued at L4.  Neutral compression distraction was obtained on the left side.  Screws were torqued at L4, L5, and S1 appropriately.  Good placement was seen both in AP and lateral planes using fluoroscopy.  Laterolisthesis corrected appropriately at L4 and L5.,Posterior spinal fusion was completed by decorticating the posterior elements at L4-L5 and the sacral ala with a curette.  Once good bleeding subchondral bone was appreciated, the morselized bone from the laminectomy was morselized with corticocancellous bone chips together with demineralized bone matrix.  This was placed in the posterior lateral gutters.  DuraGen was then placed over the dural repair, and after this, fibrin glue was placed appropriately.  Deep retractors then removed from the confines of the wound.  Fascia was closed using interrupted Prolene running suture #1.  Once this was done, suprafascial drain was placed appropriately.  Subcutaneous tissues were opposed using a 2-0 Prolene suture.  The dermal edges were approximated using staples.  Wound was dressed sterilely using bacitracin ointment, Xeroform, 4 x 4's, and tape.  The drain was connected appropriately.  The patient was rolled on stretcher in usual supine position, extubated uneventfully, and taken back to the recovery room in a satisfactory stable condition.  No complications arose.", 
 Right side craniotomy for temporal lobe intracerebral hematoma evacuation and resection of temporal lobe lesion.  Biopsy of dura., Neurosurgery, Hematoma Evacuation ,"PREOPERATIVE DIAGNOSIS: , Right temporal lobe intracerebral hemorrhage.,POSTOPERATIVE DIAGNOSES:,1.  Right temporal lobe intracerebral hemorrhage.,2.  Possible tumor versus inflammatory/infectious lesion versus vascular lesion, pending final pathology and microbiology.,PROCEDURES:,1.  Emergency right side craniotomy for temporal lobe intracerebral hematoma evacuation and resection of temporal lobe lesion.,2.  Biopsy of dura.,3.  Microscopic dissection using intraoperative microscope.,SPECIMENS: , Temporal lobe lesion and dura as well as specimen for microbiology for culture.,DRAINS:,  Medium Hemovac drain.,FINDINGS: , Vascular hemorrhagic lesion including inflamed dura and edematous brain with significant mass effect, and intracerebral hematoma with a history of significant headache, probable seizures, nausea, and vomiting.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Per Anesthesia.,FLUIDS: , One unit of packed red blood cells given intraoperatively.,The patient was brought to the operating room emergently.  This is considered as a life threatening admission with a hemorrhage in the temporal lobe extending into the frontal lobe and with significant mass effect.,The patient apparently became hemiplegic suddenly today.  She also had an episode of incoherence and loss of consciousness as well as loss of bowel/urine.,She was brought to Emergency Room where a CT of the brain showed that she had significant hemorrhage of the right temporal lobe extending into the external capsule and across into the frontal lobe.  There is significant mass effect.  There is mixed density in the parenchyma of the temporal lobe.,She was originally scheduled for elective craniotomy for biopsy of the temporal lobe to find out why she was having spontaneous hemorrhages.  However, this event triggered her family to bring her to the emergency room, and this is considered a life threatening admission now with a significant mass effect, and thus we will proceed directly today for evacuation of ICH as well as biopsy of the temporal lobe as well as the dura.,PROCEDURE IN DETAIL: , The patient was anesthetized by the anesthesiology team.  Appropriate central line as well as arterial line, Foley catheter, TED, and SCDs were placed.  The patient was positioned supine with a three-point Mayfield head pin holder.  Her scalp was prepped and draped in a sterile manner.  Her former incisional scar was barely and faintly noticed; however, through the same scalp scar, the same incision was made and extended slightly inferiorly.  The scalp was resected anteriorly.  The subdural scar was noted, and hemostasis was achieved using Bovie cautery.  The temporalis muscle was reflected along with the scalp in a subperiosteal manner, and the titanium plating system was then exposed.,The titanium plating system was then removed in its entirety.  The bone appeared to be quite fused in multiple points, and there were significant granulation tissue through the burr hole covers.,The granulation tissue was quite hemorrhagic, and hemostasis was achieved using bipolar cautery as well as Bovie cautery.,The bone flap was then removed using Leksell rongeur, and the underlying dura was inspected.  It was quite full.  The 4-0 sutures from the previous durotomy closure was inspected, and more of the inferior temporal bone was resected using high-speed drill in combination with Leksell rongeur.  The sphenoid wing was also resected using a high-speed drill as well as angled rongeur.,Hemostasis was achieved on the fresh bony edges using bone wax.  The dura pack-up stitches were noted around the periphery from the previous craniotomy.  This was left in place.,The microscope was then brought in to use for the remainder of the procedure until closure.  Using a #15 blade, a new durotomy was then made.  Then, the durotomy was carried out using Metzenbaum scissors, then reflected the dura anteriorly in a horseshoe manner, placed anteriorly, and this was done under the operating microscope.  The underlying brain was quite edematous.,Along the temporal lobe there was a stain of xanthochromia along the surface.  Thus a corticectomy was then accomplished using bipolar cautery, and the temporal lobe at this level and the middle temporal gyrus was entered.  The parenchyma of the brain did not appear normal.  It was quite vascular.  Furthermore, there was a hematoma mixed in with the brain itself.  Thus a core biopsy was then performed in the temporal tip.  The overlying dura was inspected and it was quite thickened, approximately 0.25 cm thick, and it was also highly vascular, and thus a big section of the dura was also trimmed using bipolar cautery followed by scissors, and several pieces of this vascularized dura was resected for pathology.  Furthermore, sample of the temporal lobe was cultured.,Hemostasis after evacuation of the intracerebral hematoma using controlled suction as well as significant biopsy of the overlying dura as well as intraparenchymal lesion was accomplished.  No attempt was made to enter into the sylvian fissure.  Once hemostasis was meticulously achieved, the brain was inspected.  It still was quite swollen, known that there was still hematoma in the parenchyma of the brain.  However, at this time it was felt that since there is no diagnosis made intraoperatively, we would need to stage this surgery further should it be needed once the diagnosis is confirmed.  DuraGen was then used for duraplasty because of the resected dura.  The bone flap was then repositioned using Lorenz plating system.  Then a medium Hemovac drain was placed in subdural space.  Temporalis muscle was approximated using 2-0 Vicryl.  The galea was then reapproximated using inverted 2-0 Vicryl.  The scalp was then reapproximated using staples.  The head was then dressed and wrapped in a sterile fashion.,She was witnessed to be extubated in the operating room postoperatively, and she followed commands briskly.  The pupils are 3 mm bilaterally reactive to light.  I accompanied her and transported her to the ICU where I signed out to the ICU attending.",
 Left C5-6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root., Neurosurgery, Hemilaminotomy & Foraminotomy ,"PRE AND POSTOPERATIVE DIAGNOSIS:,  Left cervical radiculopathy at C5, C6,OPERATION: , Left C5-6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root.,After informed consent was obtained from the patient, he was taken to the OR.  After general anesthesia had been induced, Ted hose stockings and pneumatic compression stockings were placed on the patient and a Foley catheter was also inserted.  At this point, the patient's was placed in three point fixation with a Mayfield head holder and then the patient was placed on the operating table in a prone position.  The patient's posterior cervical area was then prepped and draped in the usual sterile fashion.  At this time the patient's incision site was infiltrated with 1 percent Lidocaine with epinephrine.  A scalpel was used to make an approximate 3 cm skin incision cephalad to the prominent C7 spinous processes, which could be palpated.  After dissection down to a spinous process using Bovie cautery, a clamp was placed on this spinous processes and cross table lateral x-ray was taken.  This showed the spinous process to be at the C4 level.  Therefore, further soft tissue dissection was carried out caudally to this level after the next spinous processes presumed to be C5 was identified.  After the muscle was dissected off the lamina laterally on the left side, self retaining retractors were placed and after hemostasis was achieved, a Penfield probe was placed in the interspace presumed to be C5-6 and another cross table lateral x-ray of the C spine was taken.  This film confirmed our position at C5-6 and therefore the operating microscope was brought onto the field at this time.  At the time the Kerrison rongeur was used to perform a hemilaminotomy by starting with the inferior margin of the superior lamina.  The superior margin of the inferior lamina of C6 was also taken with the Kerrison rongeur after the ligaments had been freed by using a Woodson probe.  This was then extended laterally to perform a medial facetectomy also using the Kerrison rongeur.  However, progress was limited because of thickness of the bone.  Therefore at this time the Midas-Rex drill, the AM8 bit was brought onto the field and this was used to thin out the bone around our laminotomy and medial facetectomy area.  After the bone had been thinned out, further bone was removed using the Kerrison rongeur.  At this point the nerve root was visually inspected and observed to be decompressed.  However, there was a layer of fibrous tissue overlying the exiting nerve root which was removed by placing a Woodson resector in a plane between the fibrous sheath and the nerve root and incising it with a 15 blade.  Hemostasis was then achieved by using Gelfoam as well as bipolar electrocautery.  After hemostasis was achieved, the surgical site was copiously irrigated with Bacitracin.  Closure was initiated by closing the muscle layer and the fascial layer with 0 Vicryl stitches.  The subcutaneous layer was then reapproximated using 000 Dexon.  The skin was reapproximated using a running 000 nylon.  Sterile dressings were applied.  The patient was then extubated in the OR and transferred to the Recovery room in stable condition.,ESTIMATED BLOOD LOSS:,  minimal.","neurosurgery, foraminotomy with medial facetectomy, facetectomy for microscopic decompression, decompression of nerve root, hemilaminotomy and foraminotomy, decompression of nerve, microscopic decompression, medial facetectomy, kerrison rongeur, nerve root, spinous processes, facetectomy, kerrison, hemilaminotomy, foraminotomy,"
 Patient returns for his first followup after shunt surgery., Neurosurgery, First Followup - Shunt Surgery ,"REASON FOR VISIT:,  Mr. A is an 86-year-old man who returns for his first followup after shunt surgery.,HISTORY OF PRESENT ILLNESS:  ,I have followed Mr. A since May 2008.  He presented with eight to ten years of progressive gait impairment, cognitive impairment, and decreased bladder control.  We established a diagnosis of adult hydrocephalus with the spinal catheter protocol in June of 2008 and ,Mr. A underwent shunt surgery performed by Dr. X on August 1st.  A Medtronic Strata programmable shunt in the ventriculoperitoneal configuration programmed at level 2.0 was placed.,Mr. A comes today with his daughter, Pam and together they give his history.,Mr. A has had no hospitalizations or other illnesses since I last saw him.  With respect to his walking, his daughter tells me that he is now able to walk to the dining room just fine, but could not before his surgery.  His balance has improved though he still has some walking impairment.  With respect to his bladder, initially there was some improvement, but he has leveled off and he wears a diaper.,With respect to his cognition, both Pam and the patient say that his thinking has improved.  The other daughter, Patty summarized it best according to two of them.  She said, ""I feel like I can have a normal conversation with him again.""  Mr. A has had no headaches and no pain at the shunt site or at the abdomen.,MEDICATIONS: , Plavix 75 mg p.o. q.d., metoprolol 25 mg p.o. q.d., Flomax 0.4 mg p.o. q.d., Zocor 20 mg p.o. q.d., Detrol LA 4 mg p.o. q.d., lisinopril 10 mg p.o. q.d., Imodium daily, Omega-3, fish oil, and Lasix.,MAJOR FINDINGS:,  Mr. A is a pleasant and cooperative man who is able to converse easily though his daughter adds some details.,Vital Signs:  Blood pressure 124/80, heart rate is 64, respiratory rate is 18, weight 174 pounds, and pain is 0/10.,The shunt site was clean, dry, and intact and confirmed at a setting of 2.0.,Mental Status:  Tested for recent and remote memory, attention span, concentration, and fund of knowledge.  He scored 26/30 on the MMSE when tested with spelling and 25/30 when tested with calculations.  Of note, he was able to get two of the three memory words with cuing and the third one with multiple choice.  This was a slight improvement over his initial score of 23/30 with calculations and 24/30 with spelling and at that time he was unable to remember any memory words with cuing and only one with multiple choice.,Gait:  Tested using the Tinetti assessment tool.  He was tested without an assistive device and received a gait score of 6-8/12 and a balance of score of 12/16 for a total score of 18-20/28.  This has slightly improved from his initial score of 15-17/28.,Cranial Nerves:  Pupils are equal.  Extraocular movements are intact.  Face symmetric.  No dysarthria.,Motor:  Normal for bulk and strength.,Coordination:  Slow for finger-to-nose.,IMAGING: , CT scan was reviewed from 10/15/2008.  It shows a frontal horn span at the level of foramen of Munro of 4.6 cm with a 3rd ventricular contour that is flat with the span of 10 mm.  By my reading, there is a tiny amount of blood in the right frontal region with just a tiny subdural collection.  This was not noticed by the radiologist who stated no extraaxial fluid collections.  There is also substantial small vessel ischemic change.,ASSESSMENT: , Mr. A has made some improvement since shunt surgery.,PROBLEMS/DIAGNOSES:,1.  Adult hydrocephalus (331.5).,2.  Gait impairment (781.2).,3.  Urinary incontinence and urgency (788.33).,4.  Cognitive impairment (290.0).,PLAN:,  I had a long discussion with Mr. A and his daughter.  We are all pleased that he has started to make some improvement with his hydrocephalus because I believe I see a tiny fluid collection in the right parietal region, I would like to leave the setting at 2.0 for another three months before we consider changing the shunt.  I do not believe that this tiny amount of fluid is symptotic and it was not documented by the radiologist when he read the CT scan.,Mr. A asked me about whether he will be able to drive again.  Unfortunately, I think it is unlikely that his speed of movement will improve to a level that he will be able to pass a driver's safety evaluation, however, occasionally patients surprise me by improving enough over 9 to 12 months that they are able to pass such a test.  I would certainly be happy to recommend such a test if I believe ,Mr. A is likely to pass it and he is always welcome to enroll in a driver's safety program without my recommendation, however, I think it is exceeding unlikely that he has the capability of passing this rigorous test at this time.  I also think it is quite likely he will not regain sufficient speed of motion to pass such a test.",
 CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking., Neurosurgery, Frameless Stereotactic Radiosurgery ,"PREOPERATIVE DIAGNOSIS:,  Right occipital arteriovenous malformation.,POSTOPERATIVE DIAGNOSIS:,  Right occipital arteriovenous malformation.,PROCEDURE PERFORMED:,  CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking.,Please note no qualified resident was available to assist in the procedure.,INDICATION: , The patient is a 30-year-old male with a right occipital AVM.  He was referred for stereotactic radiosurgery.  The risks of the radiosurgical treatment were discussed with the patient including, but not limited to, failure to completely obliterate the AVM, need for additional therapy, radiation injury, radiation necrosis, headaches, seizures, visual loss, or other neurologic deficits.  The patient understands these risks and would like to proceed.,PROCEDURE IN DETAIL: , The patient arrived to Outpatient CyberKnife Suite one day prior to the treatment.  He was placed on the treatment table.  The Aquaplast mask was constructed.  Initial imaging was obtained by the CyberKnife system.  The patient was then transported over to the CT scanner at Stanford.  Under the supervision of Dr. X, 125 mL of Omnipaque 250 contrast was administered.  Dr. X then supervised the acquisition of 1.2-mm contiguous axial CT slices.  These images were uploaded over the hospital network to the treatment planning computer, and the patient was discharged home.,Treatment plan was then performed by me.  I outlined the tumor volume.  Inverse treatment planning was used to generate the treatment plan for this patient.  This resulted in a total dose of 20 Gy delivered to 84% isodose line using a 12.5 mm collimator.  The maximum dose within this center of treatment volume was 23.81 Gy.  The volume treated was 2.972 mL, and the treated lesion dimensions were 1.9 x 2.7 x 1.6 cm.  The volume treated at the reference dose was 98%.  The coverage isodose line was 79%.  The conformality index was 1.74 and modified conformality index was 1.55.  The treatment plan was reviewed by me and Dr. Y of Radiation Oncology, and the treatment plan was approved.,On the morning of May 14, 2004, the patient arrived at the Outpatient CyberKnife Suite.  He was placed on the treatment table.  The Aquaplast mask was applied.  Initial imaging was used to bring the patient into optimal position.  The patient underwent stereotactic radiosurgery to deliver the 20 Gy to the AVM margin.  He tolerated the procedure well.  He was given 8 mg of Decadron for prophylaxis and discharged home.,Followup will consist of an MRI scan in 6 months.  The patient will return to our clinic once that study is completed.,I was present and participated in the entire procedure on this patient consisting of CT-guided frameless stereotactic radiosurgery for the right occipital AVM.,Dr. X was present during the entire procedure and will be dictating his own operative note.","neurosurgery, ct-guided, occipital, cyberknife, frameless stereotactic radiosurgery, occipital arteriovenous malformation, conformality index, arteriovenous malformation, malformation, avm, arteriovenous,"
" Decompressive laminectomy at T12 with bilateral facetectomies, decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes ClickX System.", Neurosurgery, Decompressive Laminectomy ,"PREOPERATIVE DIAGNOSIS: , T12 compression fracture with cauda equina syndrome and spinal cord compression.,POSTOPERATIVE DIAGNOSIS:,  T12 compression fracture with cauda equina syndrome and spinal cord compression.,OPERATION PERFORMED: , Decompressive laminectomy at T12 with bilateral facetectomies, decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes Click'X System using 6.5 mm diameter x 40 mm length T11 screws and L1 screws, 7 mm diameter x 45 mm length.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:,  400 mL, replaced 2 units of packed cells.,Preoperative hemoglobin was less than 10.,DRAINS:,  None.,COMPLICATIONS:,  None.,DESCRIPTION OF PROCEDURE: , With the patient prepped and draped in a routine fashion in the prone position on laminae support, an x-ray was taken and demonstrated a needle at the T12-L1 interspace.  An incision was made over the posterior spinous process of T10, T11, T12, L1, and L2.  A Weitlaner retractor was placed and cutting Bovie current was used to incise the fascia overlying the dorsal spinous process of T10, T11, T12, L1, and L2.  An additional muscular ligamentous attachment was dissected free bilaterally with cutting Bovie current osteotome and Cobb elevator.  The cerebellar retractors were placed in the wound and obvious deformation of the lamina particularly on the left side at T12 was apparent.  Initially, on the patient's left side, pedicle screws were placed in T11 and L1.  The inferior articular facet was removed at T11 and an awl placed at the proximal location of the pedicle.  Placement confirmed with biplanar coaxial fluoroscopy.  The awl was in appropriate location and using a pedicle finder under fluoroscopic control, the pedicle was probed to the mid portion of the body of T11.  A 40-mm Click'X screw, 6.5 mm diameter with rod holder was then threaded into the T11 vertebral body.,Attention was next turned to the L1 level on the left side and the junction of the transverse processes with the superior articular facet and intra-articular process was located using an AM-8 dissecting tool, AM attachment to the Midas Rex instrumentation.  The area was decorticated, an awl was placed, and under fluoroscopic biplanar imaging noted to be at the pedicle in L1.  Using a pedicle probe, the pedicle was then probed to the mid body of L1 and a 7-mm diameter 45-mm in length Click'X Synthes screw with rod holder was placed in the L1 vertebral body.,At this point, an elongated rod was placed on the left side for purposes of distraction should it be felt necessary in view of the MRI findings of significant compression on the patient's ventral canal on the right side.  Attention was next turned to the right side and it should be noted that the dissection above was carried out with operating room microscope and at this point, the intraspinous process ligament superior to the posterior spinous process at T12 was noted be completely disrupted on a traumatic basis.  The anteroposterior spinous process ligament superior to the T12 was incised with cutting Bovie current and the posterior spinous process at T12 removed with a Leksell rongeur.  It was necessary to remove portion of the posterior spinous process at T11 for a full visualization of the involved laminar fractures at T12.,At this point, a laminectomy was performed using 45-degree Kerrison rongeur, both 2 mm and 4 mm, and Leksell rongeur.  There was an epidural hematoma encountered to the midline and left side at the mid portion of the T12 laminectomy and this was extending superiorly to the T11-T12 interlaminar space.  Additionally, there was marked instability of the facets bilaterally at T12 and L1.  These facets were removed with 45-degree Kerrison rongeur and Leksell rongeur.  Bony compression both superiorly and laterally from fractured bony elements was removed with 45-degree Kerrison rongeur until the thecal sac was completely decompressed.  The exiting nerve roots at T11 and T12 were visualized and followed with Frazier dissectors, and these nerve roots were noted to be completely free.  Hemostasis was controlled with bipolar coagulation.,At this point, a Frazier dissector could be passed superiorly, inferiorly, medially, and laterally to the T11-T12 nerve roots bilaterally, and the thecal sac was noted to be decompressed both superiorly and inferiorly, and noted to be quite pulsatile.  A #4 Penfield was then used to probe the floor of the spinal canal, and no significant ventral compression remained on the thecal sac.  Copious antibiotic irrigation was used and at this point on the patient's right side, pedicle screws were placed at T11 and L1 using the technique described for a left-sided pedicle screw placement.  The anatomic landmarks being the transverse process at T11, the inferior articulating facet, and the lateral aspect of the superior articular facet for T11 and at L1, the transverse process, the junction of the intra-articular process and the facet joint.,With the screws placed on the left side, the elongated rod was removed from the patient's right side along with the locking caps, which had been placed.  It was felt that distraction was not necessary.  A 75-mm rod could be placed on the patient's left side with reattachment of the locking screw heads with the rod cap locker in place; however, it was necessary to cut a longer rod for the patient's right side with the screws slightly greater distance apart ultimately settling on a 90-mm rod.  The locking caps were placed on the right side and after all 4 locking caps were placed, the locking cap screws were tied to the cold weld.  Fluoroscopic examination demonstrated no evidence of asymmetry at the intervertebral space at T11-T12 or T12-L1 with excellent positioning of the rods and screws.  A crosslink approximately 60 mm in width was then placed between the right and left rods, and all 4 screws were tightened.,It should be noted that prior to the placement of the rods, the patient's autologous bone, which had been removed during laminectomy portion of the procedure and cleansed off soft tissue and morcellated was packed in the posterolateral space after decortication had been effected on the transverse processes at T11, T12, and L1 with AM-8 dissecting tool, AM attachment as well as the lateral aspects of the facet joints.  This was done bilaterally prior to placement of the rods.,Following placement of the rods as noted above, allograft bone chips were packed in addition on top of the patient's own allograft in these posterolateral gutters.  Gelfoam was used to cover the thecal sac and at this point, the wound was closed by approximating the deep muscle with 0 Vicryl suture.  The fascia was closed with interrupted 0 Vicryl suture, subcutaneous layer was closed with 2-0 Vicryl suture, subcuticular layer was closed with 2-0 inverted interrupted Vicryl suture, and the skin approximated with staples.  The patient appeared to tolerate the procedure well without complications.","neurosurgery, facetectomies, decompression, posterolateral fusion, synthes click'x system, decompressive laminectomy, leksell rongeur, kerrison rongeur, transverse processes, thecal sac, nerve roots, pedicle screws, spinous process, pedicle, process, screws, rods, laminectomy, decompressive, spinous, "
" Evacuation of epidural hematoma and insertion of epidural drain.   Epidural hematoma, cervical spine.  Status post cervical laminectomy, C3 through C7 postop day #10.  Central cord syndrome and acute quadriplegia.", Neurosurgery, Epidural Hematoma Evacuation ,"PREOPERATIVE DIAGNOSES:,1.  Epidural hematoma, cervical spine.,2.  Status post cervical laminectomy, C3 through C7 postop day #10.,3.  Central cord syndrome.,4.  Acute quadriplegia.,POSTOPERATIVE DIAGNOSES:,1.  Epidural hematoma, cervical spine.,2.  Status post cervical laminectomy, C3 through C7 postop day #10.,3.  Central cord syndrome.,4.  Acute quadriplegia.,PROCEDURE PERFORMED:,1.  Evacuation of epidural hematoma.,2.  Insertion of epidural drain.,ANESTHESIA: , General.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS:  ,200 cc.,HISTORY:  ,This is a 64-year-old female who has had an extensive medical history beginning with coronary artery bypass done on emergent basis while she was in Maryland in April of 2003 after having myocardial infarction.  She was then transferred to Beaumont Hospital, at which point, she developed a sternal abscess.  The patient was treated for the abscess in Beaumont and then subsequently transferred to some other type of facility near her home in Warren, Michigan at which point, she developed a second what was termed minor myocardial infarction.,The patient subsequently recovered in a Cardiac Rehab Facility and approximately two weeks later, brings us to the month of August, at which time she was at home ambulating with a walker or a cane, and then sustained a fall and at that point she was unable to walk and had acute progressive weakness and was identified as having a central cord syndrome based on an MRI, which showed record signal change.  The patient underwent cervical laminectomy and seemed to be improving subjectively in terms of neurologic recovery, but objectively there was not much improvement.  Approximately 10 days after the surgery, brings us to today's date, the health officer was notified of the patient's labored breathing.  When she examined the patient, she also noted that the patient was unable to move her extremities.  She was concerned and called the Orthopedic resident who identified the patient to be truly quadriplegic.  I was notified and ordered the operative crew to report immediately and recommended emergent decompression for the possibility of an epidural hematoma.  On clinical examination, there was swelling in the posterior aspect of the neck.  The patient has no active movement in the upper and lower extremity muscle groups.  Reflexes are absent in the upper and lower extremities.  Long track signs are absent.  Sensory level is at the C4 dermatome.  Rectal tone is absent.  I discussed the findings with the patient and also the daughter.  We discussed the possibility of this is permanent quadriplegia, but at this time, the compression of the epidural space was warranted and certainly for exploration reasons be sure that there is a hematoma there and they have agreed to proceed with surgery.  They are aware that it is possible she had known permanent neurologic status regardless of my intervention and they have agreed to accept this and has signed the consent form for surgery.,OPERATIVE PROCEDURE:  ,The patient was taken to OR #1 at ABCD General Hospital on a gurney.  Department of Anesthesia administered fiberoptic intubation and general anesthetic.  A Foley catheter was placed in the bladder.  The patient was log rolled in a prone position on the Jackson table.  Bony prominences were well padded.  The patient's head was placed in the prone view anesthesia head holder.  At this point, the wound was examined closely and there was hematoma at the caudal pole of the wound.  Next, the patient was prepped and draped in the usual sterile fashion.  The previous skin incision was reopened.  At this point, hematoma properly exits from the wound.  All sutures were removed and the epidural spaces were encountered at this time.  The self-retaining retractors were placed in the depth of the wound.  Consolidated hematoma was now removed from the wound.  Next, the epidural space was encountered.  There was no additional hematoma in the epidural space or on the thecal sac.  A curette was carefully used to scrape along the thecal sac and there was no film or lining covering the sac.  The inferior edge of the C2 lamina was explored and there was no compression at this level and the superior lamina of T1 was explored and again no compression was identified at this area as well.  Next, the wound was irrigated copiously with one liter of saline using a syringe.  The walls of the wound were explored.  There was no active bleeding.  Retractors were removed at this time and even without pressure on the musculature, there was no active bleeding.  A #19 French Hemovac drain was passed percutaneously at this point and placed into the epidural space.  Fascia was reapproximated with #1 Vicryl sutures, subcutaneous tissue with #3-0 Vicryl sutures.  Steri-Strips covered the incision and dressing was then applied over the incision.  The patient was then log rolled in the supine position on the hospital gurney.  She remained intubated for airway precautions and transferred to the recovery room in stable condition.  Once in the recovery room, she was alert.  She was following simple commands and using her head to nod, but she did not have any active movement of her upper or lower extremities.  Prognosis for this patient is guarded.","neurosurgery, epidural hematoma, cervical spine, cervical laminectomy, central cord syndrome, acute quadriplegia, insertion of epidural drain, epidural drain, epidural space, hematoma, epidural, cervical, laminectomy, quadriplegia, "
 Endoscopic and microsurgical transnasal resection of cystic suprasellar tumor.  , Neurosurgery, Cystic Suprasellar Tumor Resection ,"TITLE OF OPERATION:,  Endoscopic and microsurgical transnasal resection of cystic suprasellar tumor.,INDICATION FOR SURGERY: , She is a 3-year-old girl who is known to have a head injury and CT in 2005 was normal, presented with headache.  All endocrine labs were normal.  Surgery was recommended.,PREOP DIAGNOSIS: , Cystic suprasellar tumor.,POSTOP DIAGNOSIS:,  Cystic suprasellar tumor.,PROCEDURE DETAIL: , The patient was brought to operating room, underwent smooth induction of general endotracheal anesthesia, head was placed in the horseshoe head rest and positioned supine with head turned slightly towards left and slightly extended.  The patient was then prepped and draped in the usual sterile fashion.  With the assistance of fluoro and mapping the localization, the right nostril was infiltrated.  Dr. X will dictate the procedure of the approach.  Once the dura was visualized, there was a complex procedure secondary to the small nasal naris as well as the bony drilling that would necessitate significant drilling.  Once the operating microscope was in the field, at this point, the drilling was completed.  The dura was opened in cruciate fashion revealing normal pituitary, which was displaced and the cystic tumor.  This was then opened and using microsurgical technique with the curette suctioned and the pituitary calcifications were removed, several Valsalva maneuvers were performed without any evidence of CSF leak and trying to pull the tumor further down.  Once this was completed, there was no evidence of any bleeding.  The endoscope was then used to remove any residual fragments __________ with the arachnoid.  Once this was completely ensured, small piece of Duragel was placed and the closure will be dictated by Dr. X.  She was reversed, extubated, and transported to the ICU in stable condition.  Blood loss, minimal.  All sponge, needle counts were correct.","neurosurgery, microsurgical transnasal resection, cystic suprasellar tumor, transnasal resection, endoscopic, transnasal, microsurgical, suprasellar, cystic, tumor, "
" Anterior cervical discectomy, osteophytectomy, foraminotomies, spinal cord decompression, fusion with machined allografts, Eagle titanium plate, Jackson-Pratt drain placement, and intraoperative monitoring with EMGs and SSEPs", Neurosurgery," Discectomy, Osteophytectomy, & Foraminotomy ","PREOPERATIVE DIAGNOSES:,  Cervical degenerative disc disease, spondylosis, severe myelopathy, spinal cord compression especially at C3-C4, C4-C5, and C5-C6, and progressive quadriparesis.,POSTOPERATIVE DIAGNOSES:,  Cervical degenerative disc disease, spondylosis, severe myelopathy, spinal cord compression especially at C3-C4, C4-C5, and C5-C6, progressive quadriparesis, and very poor bone quality as well as difficulty with hemostasis with the patient having been on aspirin.,OPERATIVE PROCEDURE,1.  Anterior cervical discectomy, osteophytectomy, foraminotomies, spinal cord decompression at C3-C4, C4-C5, and C5-C6.,2.  Microscope.,3.  Fusion with machined allografts at C3-C4, C4-C5, and C5-C6.,4.  Eagle titanium plate from C3 to C6.,5.  Jackson-Pratt drain placement.,6.  Intraoperative monitoring with EMGs and SSEPs.,ESTIMATED BLOOD LOSS: , 350 cc.,ANESTHESIA: , General endotracheal anesthesia.,COMPLICATIONS:  ,None.,COUNTS: , Correct.,SPECIMENS SENT:  ,None.,CLINICAL HISTORY:  ,The patient is a 77-year-old male who was admitted through the emergency room for progressive weakness and falling.  He was worked by the neurologist, Dr. X, and found to have cervical spondylosis with myelopathy.  I was consulted and elected to do a lumbar and cervical myelogram CT scan, which showed lumbar stenosis but also cervical stenosis with more pathology anteriorly than posteriorly.  The patient had worst disease at level C3-C4, C4-C5, and C5-C6.  The patient was significantly weak and almost quadriparetic, stronger on the right side than on the left side.  I thought that surgery was indicated to prevent progressive neurological deterioration, as well as to prevent a central cord syndrome if the patient were to get into a motor vehicle accident or simply fall.  Conservative management was not an option.  The patient was preoped and consented, and was medically cleared.  I discussed the indications, risks, and benefits of the surgery with the patient and the patient's family.  The risks of bleeding, hoarseness, swallowing difficulty, pseudoarthrosis as well as plate migration and hardware failure were all discussed with the patient.  An informed consent was obtained from the patient as such.  He was brought into the OR today for the operative procedure.,DESCRIPTION OF PROCEDURE:  ,The patient was brought into the OR, intubated, and given a general anesthetic.  Intubation was done under C-spine precautions.  The patient received preoperative vancomycin and Decadron.  He was hooked up to the SSEP apparatus and had poor baselines and delays.,With a large a shoulder roll, I extended the patient's neck, and landmark incision in crease in the right upper neck, and the area was then prepped and sterilely draped.  All the lines had been put in and the arms were padded.,Using a knife and cautery, I took the incision down through the skin and subcutaneous tissue and arrived at the cervical spine.  Prominent osteophyte at C5-C6 was noted, lesser at C4-C5.  Intraoperative x-ray confirmed our levels, and we were fully exposed from C3-C6.,Trimline retractors were put in, and I cut the discs out as well as removed the superficial hyperstatic bone and osteophytes.,With the drill, I performed a superficial discectomy and endplate resection, curetting the endplate as I went.  I then brought in the microscope, under the microscopic guidance, firmly removed the end plates and drilled through the posterior longitudinal ligament to decompress the spinal cord.  Worst findings at C3-C4 followed C5-C6 and then C4-C5.  Excellent thecal sac decompression was achieved and foraminal decompression was also achieved.  With change in intraoperative monitoring, a microscope was used for this decompressive procedure.,The patient was very oozy throughout this procedure, and during the decompression part, the oozing was constant.  This was partly due to the patient's cancellous bone, but he had been on aspirin which was stopped only 2 days ago, and the option was not available to wait 2 to 3 weeks which would have made this man worse simply over time.  I thus elected to give him DDAVP, platelets, and used Horsley bone wax for excellent hemostasis.  This took literally half-an-hour to an hour and added to the complexity and difficulty of this case.  Eventually, with blood pressure controlled and all the other parameters under control, bleeding was somewhat slow.,I then selected two 10 and one 9-mm cadaveric allograft, which had soaking in bacitracin solution.  These were trimmed to the desired dimensions, and under slight distraction, these were tapped into position.  Excellent graft alignment was achieved.,I now brought in a DePuy titanium eagle plate, and I fixed it to the spine from C3 to C6.  Fourteen millimeter screws were used; all the screws were tightened and torqued.  The patient's bone quality was poor, but the screws did torque appropriately.  I inspected the plate, controlled the hemostasis, assessed post-fixation x-ray, and was really happy with the screw length and the overall alignment.,The wound was irrigated with antibiotic solution; a Jackson-Pratt drain 10-French was put in with trocar.  Decision was made to start the closure.  So, I closed the platysma with 3-0 Vicryl and used staples for the skin.  A simple Primapore or Medpore dressing was applied.  The patient was extubated in the OR and taken to the PSU in stable medical condition.,When I saw the patient in the ICU, he was awake, alert, and moving all four extremities, somewhat weak on the left side.  He had done well from the surgery.  Blood loss was 350 cc.  All instrument, needle, and sponge counts were correct.  No complications, no change in intraoperative monitoring.  No specimens were sent.,The patient's wife was spoken to and fully appraised of the intraoperative findings and the expected prognosis.  The patient will be kept n.p.o. tonight and will gradually advance his diet, and also will gradually advance his activity.  I will keep him on Decadron and keep the collar on.  I do not think there is need for halo rest.  We will be obtaining formal C-spine films in the morning.  Prognosis is guarded but favorable at this time.",
 Left temporal craniotomy and removal of brain tumor., Neurosurgery, Craniotomy - Temporal ,"PREOPERATIVE DIAGNOSIS:,  Brain tumor left temporal lobe.,POSTOPERATIVE DIAGNOSIS:,  Brain tumor left temporal lobe - glioblastoma multiforme.,OPERATIVE PROCEDURE:,1.  Left temporal craniotomy.,2.  Removal of brain tumor.,OPERATING MICROSCOPE: , Stealth.,PROCEDURE: , The patient was placed in the supine position, shoulder roll, and the head was turned to the right side.  The entire left scalp was prepped and draped in the usual fashion after having being placed in 2-point skeletal fixation.  Next, we made an inverted-U fashion base over the asterion over temporoparietal area of the skull.  A free flap was elevated after the scalp that was reflected using the burr hole and craniotome.  The bone flap was placed aside and soaked in the bacitracin solution.,The dura was then opened in an inverted-U fashion.  Using the Stealth, we could see that this large cystic mass was just below the cortex in the white matter just anterior to the trigone of the ventricle.  We head through the vein of Labbe, and we made great care to preserve this.  We saw where the tumor almost made to the surface.  Here we made a small corticectomy using the Stealth for guidance.  We left small corticectomy entered large cavity with approximately 15 cc of yellowish necrotic liquid.  This was submitted to pathology.  We biopsied this very abnormal tissue and submitted it to pathology.  They gave us a frozen section diagnosis of glioblastoma multiforme.  With the operating microscope and Greenwood bipolar forceps, we then systematically debulked this tumor.  It was very vascular and we really continued to remove this tumor until all visible tumors was removed.  We appeared to get two gliotic planes circumferentially.  We could see it through the ventricle.  After removing all visible tumor grossly, we then irrigated this cavity multiple times and obtained meticulous hemostasis and then closed the dura primarily with 4-0 Nurolon sutures with the piece of DuraGen placed over this in order to increase our chances for a good watertight seal.  The bone flap was then replaced and sutured with the Lorenz titanium plate system.  The muscle fascia galea was closed with interrupted 2-0 Vicryl sutures.  Skin staples were used for skin closure.  The blood loss of the operation was about 200 cc.  There were no complications of the surgery per se.  The needle count, sponge count, and the cottonoid count were correct.,COMMENT:  ,Operating microscope was quite helpful in this; as we could use the light as well as the magnification to help us delineate the brain tumor - gliotic interface and while it was vague at sometimes we could I think clearly get a good cleavage plane in most instances so that we got a gross total removal of this very large and necrotic-looking tumor of the brain.","neurosurgery, temporal lobe, brain tumor, lorenz titanium plate, burr hole, cortex, corticectomy, craniotome, craniotomy, frozen section, glioblastoma multiforme, temporal craniotomy, temporoparietal, ventricle, white matter, tumor, temporal, brain,"
" Biparietal craniotomy, insertion of left lateral ventriculostomy, right suboccipital craniectomy and excision of tumor.", Neurosurgery, Craniotomy - Biparietal  ,"PREOPERATIVE DIAGNOSES: , Multiple metastatic lesions to the brain, a subtentorial lesion on the left, greater than 3 cm, and an infratentorial lesion on the right, greater than 3 cm.,POSTOPERATIVE DIAGNOSES: , Multiple metastatic lesions to the brain, a subtentorial lesion on the left, greater than 3 cm, and an infratentorial lesion on the right, greater than 3 cm.,TITLE OF THE OPERATION:,1.  Biparietal craniotomy and excision of left parietooccipital metastasis from breast cancer.,2.  Insertion of left lateral ventriculostomy under Stealth stereotactic guidance.,3.  Right suboccipital craniectomy and excision of tumor.,4.  Microtechniques for all the above.,5.  Stealth stereotactic guidance for all of the above and intraoperative ultrasound.,INDICATIONS: , The patient is a 48-year-old woman with a diagnosis of breast cancer made five years ago.  A year ago, she was diagnosed with cranial metastases and underwent whole brain radiation.  She recently has deteriorated such that she came to my office, unable to ambulate in a wheelchair.  Metastatic workup does reveal multiple bone metastases, but no spinal cord compression.  She had a consult with Radiation-Oncology that decided they could radiate her metastases less than 3 cm with stereotactic radiosurgery, but the lesions greater than 3 cm needed to be removed.  Consequently, this operation is performed.,PROCEDURE IN DETAIL: , The patient underwent a planning MRI scan with Stealth protocol.  She was brought to the operating room with fiducial still on her scalp.  General endotracheal anesthesia was obtained.  She was placed on the Mayfield head holder and rolled into the prone position.  She was well padded, secured, and so forth.  The neck was flexed so as to expose the right suboccipital region as well as the left and right parietooccipital regions.  The posterior aspect of the calvarium was shaved and prepared in the usual manner with Betadine soak scrub followed by Betadine paint.  This was done only, of course, after fiducial were registered in planning and an excellent accuracy was obtained with the Stealth system.  Sterile drapes were applied and the accuracy of the system was confirmed.  A biparietal incision was performed.  A linear incision was chosen so as to increase her chances of successful wound healing and that she is status post whole brain radiation.  A biparietal craniotomy was carried out, carrying about 1 cm over toward the right side and about 4 cm over to the left side as guided by the Stealth stereotactic system.  The dura was opened and reflected back to the midline.  An inner hemispheric approach was used to reach the very large metastatic tumor.  This was very delicate removing the tumor and the co-surgeons switched off to spare one another during the more delicate parts of the operation to remove the tumor.  The tumor was wrapped around and included the choroidal vessels.  At least one choroidal vessel was sacrificed in order to obtain a gross total excision of the tumor on the parietal occipital region.  Bleeding was quite vigorous in some of the arteries and finally, however, was completely controlled.  Complete removal of the tumor was confirmed by intraoperative ultrasound.,Once the tumor had been removed and meticulous hemostasis was obtained, this wound was left opened and attention was turned to the right suboccipital area.  A linear incision was made just lateral to the greater occipital nerve.  Sharp dissection was carried down in the subcutaneous tissues and Bovie electrocautery was used to reach the skull.  A burr hole was placed down low using a craniotome.  A craniotomy was turned and then enlarged as a craniectomy to at least 4 cm in diameter.  It was carried caudally to the floor of the posterior fossa and rostrally to the transverse sinus.  Stealth and ultrasound were used to localize the very large tumor that was within the horizontal hemisphere of the cerebellum.  The ventriculostomy had been placed on the left side with the craniotomy and removal of the tumor, and this was draining CSF relieving pressure in the posterior fossa.  Upon opening the craniotomy in the parietal occipital region, the brain was noted to be extremely tight, thus necessitating placement of the ventriculostomy.,At the posterior fossa, a corticectomy was accomplished and the tumor was countered directly.  The tumor, as the one above, was removed, both piecemeal and with intraoperative Cavitron Ultrasonic Aspirator.  A gross total excision of this tumor was obtained as well.,I then explored underneath the cerebellum in hopes of finding another metastasis in the CP angle; however, this was just over the lower cranial nerves, and rather than risk paralysis of pharyngeal muscles and voice as well as possibly hearing loss, this lesion was left alone and to be radiated and that it is less than 3 cm in diameter.,Meticulous hemostasis was obtained for this wound as well.,The posterior fossa wound was then closed in layers.  The dura was closed with interrupted and running mattress of 4-0 Nurolon.  The dura was watertight, and it was covered with blue glue.  Gelfoam was placed over the dural closure.  Then, the muscle and fascia were closed in individual layers using #0 Ethibond.  Subcutaneous was closed with interrupted inverted 2-0 and 0 Vicryl, and the skin was closed with running locking 3-0 Nylon.,For the cranial incision, the ventriculostomy was brought out through a separate stab wound.  The bone flap was brought on to the field.  The dura was closed with running and interrupted 4-0 Nurolon.  At the beginning of the case, dural tack-ups had been made and these were still in place.  The sinuses, both the transverse sinus and sagittal sinus, were covered with thrombin-soaked Gelfoam to take care of any small bleeding areas in the sinuses.,Once the dura was closed, the bone flap was returned to the wound and held in place with the Lorenz microplates.  The wound was then closed in layers.  The galea was closed with multiple sutures of interrupted 2-0 Vicryl.  The skin was closed with a running locking 3-0 Nylon.,Estimated blood loss for the case was more than 1 L.  The patient received 2 units of packed red cells during the case as well as more than 1 L of Hespan and almost 3 L of crystalloid.,Nevertheless, her vitals remained stable throughout the case, and we hopefully helped her survival and her long-term neurologic status for this really nice lady.","neurosurgery, metastatic lesion, biparietal, mayfield head holder, microtechniques, stealth, craniotomy, excision, fiducial, infratentorial, parietooccipital, stereotactic, suboccipital, subtentorial, ventriculostomy, lesions to the brain, removal of the tumor, parietal occipital region, running locking nylon, biparietal craniotomy, posterior fossa, tumor, brain, dura, lesions, "
 Left retrosigmoid craniotomy and excision of acoustic neuroma., Neurosurgery, Craniotomy - Retrosigmoid  ,"PREOPERATIVE DIAGNOSIS: , Left acoustic neuroma.,POSTOPERATIVE DIAGNOSIS: , Left acoustic neuroma.,PROCEDURE PERFORMED: , Left retrosigmoid craniotomy and excision of acoustic neuroma.,ANESTHESIA:,  General.,OPERATIVE FINDINGS: , This patient had a 3-cm acoustic neuroma.  The tumor was incompletely excised leaving a remnant of the tumor along the cerebellopontine angle portion of the facial nerve.  The facial nerve was stimulated at the brainstem at 0.05 milliamperes at the conclusion of the dissections.,PROCEDURE IN DETAIL:  ,Following induction of adequate general anesthetic, the patient was positioned for surgery.  She was placed in a lateral position and her head was maintained with Mayfield pins.  The left periauricular area was shaved, prepped, and draped in the sterile fashion.  Transdermal electrodes for continuous facial nerve EMG monitoring were placed, and no response was verified.  The proposed incision was injected with 1% Xylocaine with epinephrine.  Next, T-shaped incision was made approximately 5 cm behind the postauricular crease.  The incision was undermined at the level of temporalis fascia, and the portion of the fascia was harvested for further use.,Incision was made along the inferior aspect of the temporalis muscle and then extended inferiorly over the mastoid tip.  Periosteal elevator was used to elevate periosteum in order to expose the mastoid and anterior aspect of the occipital bone.  Emissary veins posterior to the sigmoid sinus were controlled with electrocautery and bone wax.  Bergen retractors were used to maintain exposure.  Using a cutting bur with continuous suction and irrigation of craniotomy was performed.  The sigmoid sinus was identified anteriorly and the transverse sites were identified superiorly.  From these structures approximately 4 x 4 cm, a window of bone was removed.  Bone shavings were collected during the dissection and placed in Siloxane suspension for later use.  The bone flap was also left at the site for further use.  Dissection was extended along the inferior aspect of the sigmoid sinus to provide additional exposure of the skull base.  Bone wax was used to occlude air cells lateral to the sigmoid sinus.  There was extensively aerated temporal bone.  At this point, Dr. Trask entered the case in order to open the dura and expose the tumor.  The cerebellum was retracted away from the tumor, and the retractor was placed to help maintain exposure.  Once initial exposure was completed, attention was directed to the posterior aspect of the temporal bone.  The dura was excised from around the porous acusticus extending posteriorly along the bone.  Then, using diamond burs, the internal auditory canal was dissected out.  The bone was removed laterally for distance of approximately 8 mm.  There was considerable aeration around the internal auditory canal as well.  The dura was then incised over the internal auditory canal exposing the intracanalicular portion of the tumor.  The tumor extended all the way to the fundus such that initial exposure of the facial nerve around the tumor was difficult.  Therefore, Dr. Trask returned in order to further release the tumor from the brainstem and to debulk the central portions of the tumor.  With dissection, he released the tumor from the trigeminal nerve superiorly and elevated the tumor away from the dorsal brainstem.  The eighth nerve was identified and transected.  Tumor debulking allowed for retraction of the tumor capsule away from the brainstem.  The facial nerve was difficult to identify at the brainstem as well.  It was identified by using an electrical stimulator but dissection attempted at this time was the plane between the nerve and the tumor proximally but this was difficult to achieve.  Attention was then redirected to the internal auditory canal where this portion of the tumor was removed.  The superior and inferior vestibular nerves were evulsed laterally and dissection proceeded along the facial nerve to the porous acusticus.  At this point, plane of dissection was again indistinct.  The tumor had been released from the porous and could be rotated.  The tumor was further debulked and thinned, but could not crucially visualize the nerve on the anterior face of the tumor.  The nerve could be stimulated, but was quite splayed over the anterior face.  Further debulking of the tumor proceeded and additional attempts were made to establish point of dissection along the nerve, both proximally and distally.  However, the cerebellopontine angle portion of the nerve was not usually delineated.  However, the tumor was then thinned using CUSA down to fine sheath measuring only about 1 to 2 mm in thickness.  It was released from the brainstem ventrally.  The tumor was then cauterized with bipolar electrocautery.  The facial nerve was stimulated at the brainstem and stimulated easily at 0.05 milliamperes.  Overall, the remaining tumor volume would be of small percentage of the original volume.  At this point, Dr. Trask re-inspected the posterior fossa to ensure complete hemostasis.  The air cells around the internal auditory canal were packed off with muscle and bone wax.  A piece of fascia was then laid over the bone defect.  Next, the dura was closed with DuraGen and DuraSeal.  The bone flap and bone ***** were then placed in the bone defect.  Postauricular musculature was then reapproximated using interrupted 3-0 Vicryl sutures.  The skin was also closed using interrupted subdermal 3-0 Vicryl sutures.  Running 4-0 nylon suture was placed at the skin levels.  Sterile mastoid dressing was then placed.  The patient tolerated the procedure well and was transported to the PACU in a stable condition.  All counts were correct at the conclusion of the procedure.,ESTIMATED BLOOD LOSS:  ,100 mL.","neurosurgery, neuroma, bergen retractors, emissary veins, mayfield pins, acoustic, acoustic neuroma, cerebellopontine, craniotomy, facial nerve, periauricular, retrosigmoid, retrosigmoid craniotomy, internal auditory canal, porous acusticus, sigmoid sinus, auditory canal, bone, brainstem, nerve, postauricular, tumor"
" Occipital craniotomy, removal of large tumor using the inner hemispheric approach, stealth system operating microscope and CUSA.", Neurosurgery, Craniotomy - Occipital ,"PREOPERATIVE DIAGNOSIS: , Brain tumors, multiple.,POSTOPERATIVE DIAGNOSES:,  Brain tumors multiple - adenocarcinoma and metastasis from breast.,PROCEDURE:,  Occipital craniotomy, removal of large tumor using the inner hemispheric approach, stealth system operating microscope and CUSA.,PROCEDURE:,  The patient was placed in the prone position after general endotracheal anesthesia was administered.  The scalp was prepped and draped in the usual fashion.  The CUSA was brought in to supplement the use of operating microscope as well as the stealth, which was used to localize the tumor.  Following this, we then made a transverse linear incision, the scalp galea was reflected and the quadrilateral bone flap was removed after placing burr holes in the midline and over the parietal areas directly over the tumor.  The bone flap was elevated.  The ultrasound was then used.  The ultrasound showed the tumors directly I believe are in the interhemispheric fissure.  We noticed that the dura was quite tense despite that the patient had slight hyperventilation.  We gave 4 ounce of mannitol, the brain became more pulsatile.  We then used the stealth to perform a ventriculostomy.  Once this was done, the brain began to pulsate nicely.  We then entered the interhemispheric space after we incised the dura in an inverted U fashion based on the superior side of the sinus.  After having done this we then used operating microscope and slight self-retaining retraction was used.  We obtained access to the tumor.  We biopsied this and submitted it.  This was returned as a malignant brain tumor - metastatic tumor, adenocarcinoma compatible with breast cancer.,Following this we then debulked this tumor using CUSA and then removed it in total.  After gross total removal of this tumor, the irrigation was used to wash the tumor bed and a meticulous hemostasis was then obtained using bipolar cautery.  The next step was after removal of this tumor, closure of the wound, a large piece of Duragen was placed over the dural defect and the bone flap was reapproximated and held secured with Lorenz plates.  The tumors self extend into the ventricle and after we had removed the tumor, we could see our ventricular catheter in the occipital horn of the ventricle.  This being the case, we left this ventricular catheter in, brought it out through a separate incision and connected to sterile drainage.  The next step was to close the wound after reapproximating the bone flap.  The galea was closed with 2-0 Vicryl and the skin was closed with interrupted 3-0 nylon sutures inverted with mattress sutures.  The sterile dressings were applied to the scalp.  The patient returned to the recovery room in satisfactory condition.  Hemodynamically remained stable throughout the operation.,Once again, we performed occipital craniotomy, total removal of her large metastatic tumor involving the parietal lobe using a biparietal craniotomy.  The tumor was removed using the combination of CUSA, ultrasound, stealth guided-ventriculostomy and the patient will have a second operation today, we will perform a selective craniectomy to remove another large tumor in the posterior fossa.","neurosurgery, brain tumor, cusa, occipital, adenocarcinoma, bone flap, craniotomy, malignant, metastatic, scalp galea, transverse linear incision, ventriculostomy, occipital craniotomy, tumor, stealth, brain, "
 Right frontal craniotomy with resection of right medial frontal brain tumor.  Stereotactic image-guided neuronavigation and  microdissection and micro-magnification for resection of brain tumor., Neurosurgery, Craniotomy & Neuronavigation ,"PROCEDURES:,1.  Right frontal craniotomy with resection of right medial frontal brain tumor.,2.  Stereotactic image-guided neuronavigation for resection of tumor.,3.  Microdissection and micro-magnification for resection of brain tumor.,ANESTHESIA: , General via endotracheal tube.,INDICATIONS FOR THE PROCEDURE:  ,The patient is a 71-year-old female with a history of left-sided weakness and headaches.  She has a previous history of non-small cell carcinoma of the lung, treated 2 years ago.  An MRI was obtained which showed a large enhancing mass in the medial right frontal lobe consistent with a metastatic lesion or possible primary brain tumor.  After informed consent was obtained, the patient was brought to the operating room for surgery.,PREOPERATIVE DIAGNOSES: , Medial right frontal brain tumor with surrounding edema and mass effect and right to left brain shift.,POSTOPERATIVE DIAGNOSES: , Medial right frontal brain tumor with surrounding edema and mass effect and right to left brain shift, probable metastatic lung carcinoma.,DESCRIPTION OF THE PROCEDURE: , The patient was wheeled into the operating room and satisfactory general anesthesia was obtained via endotracheal tube.  She was positioned on the operating room table in the Sugita frame with the head secured.,Using the preoperative image-guided MRI, we carefully registered the fiducials and then obtained the stereotactic image-guided localization to guide us towards the tumor.  We marked external landmarks.  Then we shaved the head over the right medial frontal area.  This area was then sterilely prepped and draped.,Evoked potential monitoring and sensory potentials were carried out throughout the case and no changes were noted.,A horseshoe shaped flap was based on the right and then brought across to the midline.  This was opened and hemostasis obtained using Raney clips.  The skin flap was retracted medially.  Two burr holes were made and were carefully connected.  One was placed right over the sinus and we carefully then removed a rectangular shaped bone flap.  Hemostasis was obtained.  Using the neuronavigation, we identified where the tumor was.  The dura was then opened based on a horseshoe flap based on the medial sinus.  We retracted this medially and carefully identified the brain.  The brain surface was discolored and obviously irritated consistent with the tumor.,We used the stereotactic neuronavigation to identify the tumor margins.,Then we used a bipolar to coagulate a thin layer of brain over the tumor.  Subsequently, we entered the tumor.  The tumor itself was extremely hard.  Specimens were taken and send for frozen section analysis, which showed probable metastatic carcinoma.,We then carefully dissected around the tumor margins.,Using the microscope, we then brought microscopic magnification and dissection into the case.  We used paddies and carefully developed microdissection planes all around the margins of the tumor superiorly, medially, inferiorly, and laterally.,Then using the Cavitron, we cored out the central part of the tumor.  Then we collapsed the tumor on itself and removed it entirely.  In this fashion, microdissection and magnification resection of the tumor was carried out.  We resected the entire tumor.  Neuronavigation was used to confirm that no further tumor residual was remained.,Hemostasis was obtained using bipolar coagulation and Gelfoam.  We also lined the cavity with Surgicel.  The cavity was nicely dry and excellent hemostasis was obtained.,The dura was closed using multiple interrupted 4-0 Nurolon sutures in a watertight fashion.  Surgicel was placed over the dural closure.  The bone flap was repositioned and held in place using CranioFIX cranial fixators.  The galea was re-approximated and the skin was closed with staples.  The wound was dressed.  The patient was returned to the intensive care unit.  She was awake and moving extremities well.  No apparent complications were noted.  Needle and sponge counts were listed as correct at the end of the procedure.  Estimated intraoperative blood loss was approximately 150 mL and none was replaced.","neurosurgery, stereotactic image-guided neuronavigation, micro-magnification, resection of brain tumor, frontal craniotomy, mass effect, brain shift, stereotactic image, brain tumor, brain, tumor, craniotomy, endotracheal, carcinoma, neuronavigation, microdissection, "
 Right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain., Neurosurgery, Craniotomy - Burr Hole  ,"PREOPERATIVE DIAGNOSIS: , Right chronic subdural hematoma.,POSTOPERATIVE DIAGNOSIS: ,Right chronic subdural hematoma.,TYPE OF OPERATION: , Right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , 100 cc.,OPERATIVE PROCEDURE:,  In preoperative identification, the patient was taken to the operating room and placed in supine position.  Following induction of satisfactory general endotracheal anesthesia, the patient was prepared for surgery.  Table was turned.  The right shoulder roll was placed.  The head was turned to the left and rested on a doughnut.  The scalp was shaved, and then prepped and draped in usual sterile fashion.  Incisions were marked along a putative right frontotemporal craniotomy frontally and over the parietal boss.  The parietal boss incision was opened.  It was about an inch and a half in length.  It was carried down to the skull.  Self-retaining retractor was placed.  A bur hole was now fashioned with the perforator.  This was widened with a 2-mm Kerrison punch.  The dura was now coagulated with bipolar electrocautery.  It was opened in a cruciate-type fashion.  The dural edges were coagulated back to the bony edges.  There was egress of a large amount of liquid.  Under pressure, we irrigated for quite sometime until irrigation was returning mostly clear.  A subdural drain was now inserted under direct vision into the subdural space and brought out through a separate stab incision.  It was secured with a 3-0 nylon suture.  The area was closed with interrupted inverted 2-0 Vicryl sutures.  The skin was closed with staples.  Sterile dressing was applied.  The patient was subsequently returned back to anesthesia.  He was extubated in the operating room, and transported to PACU in satisfactory condition.","neurosurgery, hematoma, burr hole, craniotomy, frontotemporal, frontotemporal craniotomy, subdural, subdural drain, subdural hematoma, subdural space"
" Acute left subdural hematoma.  Left frontal temporal craniotomy for evacuation of acute subdural hematoma.  CT imaging reveals an acute left subdural hematoma, which is hemispheric.", Neurosurgery, Craniotomy - Frontotemporal - 1 ,"PREOPERATIVE DIAGNOSIS:,  Acute left subdural hematoma.,POSTOPERATIVE DIAGNOSIS:,  Acute left subdural hematoma.,PROCEDURE:,  Left frontal temporal craniotomy for evacuation of acute subdural hematoma.,DESCRIPTION OF PROCEDURE: , This is a 76-year-old man who has a history of acute leukemia.  He is currently in the phase of his therapy where he has developed a profound thrombocytopenia and white cell deficiency.  He presents after a fall in the hospital in which he apparently struck his head and now has a progressive neurologic deterioration consistent with an intracerebral injury.  His CT imaging reveals an acute left subdural hematoma, which is hemispheric.,The patient was brought to the operating room, placed under satisfactory general endotracheal anesthesia.  He had previously been intubated and taken to the Intensive Care Unit and now is brought for emergency craniotomy.  The images were brought up on the electronic imaging and confirmed that this was a left-sided condition.  He was fixed in a three-point headrest.  His scalp was shaved and prepared with Betadine, iodine and alcohol.  We made a small curved incision over the temporal, parietal, frontal region.  The scalp was reflected.  A single bur hole was made at the frontoparietal junction and then a 4x6cm bur hole was created.  After completing the bur hole flap, the dura was opened and a gelatinous mass of subdural was peeled away from the brain.  The brain actually looked relatively relaxed; and after removal of the hematoma, the brain sort of slowly came back up.  We investigated the subdural space forward and backward as we could and yet careful not to disrupt any venous bleeding as we close to the midline.  After we felt that we had an adequate decompression, the dura was reapproximated and we filled the subdural space with saline.  We placed a small drain in the extra dural space and then replaced the bone flap and secured this with the bone plates.  The scalp was reapproximated, and the patient was awakened and taken to the CT scanner for a postoperative scan to ensure that there was no new hemorrhage or any other intracerebral pathology that warranted treatment.  Given that this actual skin looked good with apparent removal of about 80% of the subdural we elected to take patient to the Intensive Care Unit for further management.,I was present for the entire procedure and supervised this.  I confirmed prior to closing the skin that we had correct sponge and needle counts and the only foreign body was the drain.","neurosurgery, subdural, hematoma, temporal craniotomy, craniotomy, subdural space, bur hole, subdural hematoma, "
" Bilateral orbital frontal zygomatic craniotomy (skull base approach), bilateral orbital advancement with (C-shaped osteotomies down to the inferior orbital rim) with bilateral orbital advancement with bone grafts, bilateral forehead reconstruction with autologous graft.", Neurosurgery, Craniotomy - Frontal Zygomatic ,"PREOPERATIVE DIAGNOSIS:,  Metopic synostosis with trigonocephaly.,POSTOPERATIVE DIAGNOSIS:,  Metopic synostosis with trigonocephaly.,PROCEDURES:  ,1.  Bilateral orbital frontal zygomatic craniotomy (skull base approach).,2.  Bilateral orbital advancement with (C-shaped osteotomies down to the inferior orbital rim) with bilateral orbital advancement with bone grafts.,3.  Bilateral forehead reconstruction with autologous graft.,4.  Advancement of the temporalis muscle bilaterally.,5.  Barrel-stave osteotomies of the parietal bones.,ANESTHESIA: , General.,PROCEDURE: , After induction of general anesthesia, the patient was placed supine on the operating room table with a roll under his shoulders and his head resting on a foam doughnut.  Scalp was clipped.  He was prepped with ChloraPrep.  Incision was infiltrated with 0.5% Xylocaine with epinephrine 1:200,000 and he received antibiotics and he was then reprepped and draped in a sterile manner.,A bicoronal zigzag incision was made and Raney clips used for hemostasis.  Subcutaneous flaps were developed and reflected anteriorly and slightly posteriorly.  These were subgaleal flaps.  Bipolar and Bovie cautery were used for hemostasis.  The craniectomy was outlined with methylene blue.  The pericranium was incised exposing the bone along the outline of the craniotomy.,Paired bur holes were drilled anteriorly and posteriorly straddling the metopic suture.  One was just above the nasion and the other was near the bregma.  Also bilateral pterional bur holes were drilled.  There was a little bit of bleeding from a tributary of the sagittal sinus anteriorly and so bone wax was used for hemostasis in all the bur holes.,The dura was separated with a #4 Penfield dissector and then the craniotomies were fashioned or cut.  I should say with the Midas Rex drill using the V5 bit and the footplate attachment, the bilateral craniotomies were cut and then the midline piece was elevated separately.  Great care was taken when removing the bone from the midline.  Bipolar cautery was used for bleeding points on the dura and especially over the sagittal sinus and the bleeding was controlled.,The wound was irrigated with bacitracin irrigation.,The next step was to perform the orbital osteotomies with careful protection of the orbital contents.  Osteotomies were made with the Midas Rex drill using the V5 bit in the orbital roof bilaterally.  This was a very thick and vertically oriented orbital roof on each side.  Midas Rex drill and osteotomes and mallet were used to cut these osteotomies using retractors to protect the orbital contents and the dura.  The osteotomies were carried down through the tripod of the orbit and down through the lateral orbital rim and all the way down to the inferior orbital rim using the osteotome and mallet.  Bone wax was used for hemostasis.  It was necessary to score the undersurface of the bone at the midline because it was so thick and pointed.  So we were not going to be able to effect the orbital advancement without scoring the bone and thinning it out a bit.  This was done with the Midas Rex drill using B5 bit.  Also, the marked ridge just above the nasion was burred down with the Midas Rex drill.  The osteotomies were also carried down through the zygoma.  At this point, with a gentle rocking motion and sustained pressure using the osteotomes, it was then possible to carefully advance the orbital rims bilaterally, first on the right and then on the left again using just a careful rocking motion against the remaining bone to gently bend the orbital rims outward bilaterally.,Dr. X cut the bone grafts from the bone flaps and I fashioned a shelf to secure the bone graft by burring a ledge on the internal surface of the superior orbital rim.  This created a shelf for the notched bone graft to lean against basically anteriorly.  The posterior notch of the bone graft was able to be braced by the ledge of orbital roof posteriorly.,The left medial orbital rim greenstick fractured a bit, but the bone graft appeared to stay in place.,Holes were then cut in the supraorbital rim for advancement of the temporalis muscle and then a Synthes mesh was placed anteriorly using absorbable screw hardware and attached the mesh where the forehead bone flaps turned around and recontoured to make a nice bilateral forehead for Isaac.,At this point the undersurface of the temporalis muscle was scored using the Bovie cautery to allow advancement of the muscle anteriorly and we sutured it to the supraorbital rims bilaterally with #3-0 Vicryl suture.  This helped fill-in the indentation left by the orbital advancement at the temporal region.,Also, I separated the undersurface of the dura from the bone bilaterally and cut multiple barrel-stave osteotomies in the parietal bones and then greenstick fractured these barrel-staves outward to create a more normal contour of the bone slightly posteriorly.,At this point, Gelfoam had been used to protect the dura over the sagittal sinus during this part of the procedure.,The wound was then irrigated with bacitracin irrigation.  Bleeding had been controlled during the procedure with Bovie and bipolar electrocautery, even so the blood loss was fairly significant adding up to about 300 or 400 mL and he received that much in packed cells and he also received a unit of fresh frozen plasma.,At this point, the reconstruction looked good.  The advancement was about 1 cm and we were pleased with the results.  The wound was irrigated and then the Gelfoam over the midline dura was left in place and the galea was then closed with #4-0 and some #3-0 Vicryl interrupted suture and #5-0 mild chromic on the skin.  The patient tolerated procedure well.  No complications.  Sponge and needle counts were correct.  Again, blood loss was bout 300 to 400 mL and he received 2 units of blood and some fresh frozen plasma.","neurosurgery, metopic synostosis, trigonocephaly, bilateral orbital frontal zygomatic craniotomy, skull base approach, orbital advancement, c-shaped osteotomies, forehead reconstruction, temporalis muscle, midas rex drill, frontal zygomatic, sagittal sinus, orbital roof, orbital rim, bone grafts, forehead, bone, orbital, craniotomy, osteotomies, "
" Right frontotemporal craniotomy and evacuation of hematoma, biopsy of membranes, microtechniques.", Neurosurgery, Craniotomy - Frontotemporal  ,"PREOPERATIVE DIAGNOSIS:,  Right frontotemporal chronic subacute subdural hematoma.,POSTOPERATIVE DIAGNOSIS:,  Right frontotemporal chronic subacute subdural hematoma.,TITLE OF THE OPERATION: , Right frontotemporal craniotomy and evacuation of hematoma, biopsy of membranes, microtechniques.,ASSISTANT: , None.,INDICATIONS: , The patient is a 75-year-old man with a 6-week history of decline following a head injury.  He was rendered unconscious by the head injury.  He underwent an extensive syncopal workup in Mississippi.  This workup was negative.  The patient does indeed have a heart pacemaker.  The patient was admitted to ABCD three days ago and yesterday underwent a CT scan, which showed a large appearance of subdural hematoma.  There is a history of some bladder tumors and so a scan with contrast was obtained that showed some enhancement in the membranes.  I decided to perform a craniotomy rather than burr hole drainage because of the enhancing membranes and the history of a bladder tumor undefined as well as layering of the blood within the cavity.  The patient and the family understood the nature, indications, and risk of the surgery and agreed to go ahead.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room where general and endotracheal anesthesia was obtained.  The head was turned over to the left side and was supported on a cushion.  There was a roll beneath the right shoulder.  The right calvarium was shaved and prepared in the usual manner with Betadine-soaked scrub followed by Betadine paint.  Markings were applied.  Sterile drapes were applied.  A linear incision was made more or less along the coronal suture extending from just above the ear up to near the midline.  Sharp dissection was carried down into subcutaneous tissue and Bovie electrocautery was used to divide the galea and the temporalis muscle and fascia.  Weitlaner retractors were inserted.  A single bur hole was placed underneath the temporalis muscle.  I placed the craniotomy a bit low in order to have better cosmesis.  A cookie cutter type craniotomy was then carried out in dimensions about 5 cm x 4 cm.  The bone was set aside.  The dura was clearly discolored and very tense.  The dura was opened in a cruciate fashion with a #15 blade.  There was immediate flow of a thin motor oil fluid under high pressure.  Literally the fluid shot out several inches with the first nick in the membranous cavity.  The dura was reflected back and biopsy of the membranes was taken and sent for permanent section.  The margins of the membrane were coagulated.  The microscope was brought in and it was apparent there were septations within the cavity and these septations were for the most part divided with bipolar electrocautery.  The wound was irrigated thoroughly and was inspected carefully for any sites of bleeding and there were none.  The dura was then closed in a watertight fashion using running locking 4-0 Nurolon.  Tack-up sutures had been placed at the beginning of the case and the bone flap was returned to the wound and fixed to the skull using the Lorenz plating system.  The wound was irrigated thoroughly once more and was closed in layers.  Muscle fascia and galea were closed in separate layers with interrupted inverted 2-0 Vicryl.  Finally, the skin was closed with running locking 3-0 nylon.,Estimated blood loss for the case was less than 30 mL.  Sponge and needle counts were correct.,FINDINGS: , Chronic subdural hematoma with multiple septations and thickened subdural membrane.,I might add that the arachnoid was not violated at all during this procedure.  Also, it was noted that there was no subarachnoid blood but only subdural blood.","neurosurgery, frontotemporal, weitlaner, calvarium, cookie cutter type, craniotomy, dura, frontotemporal craniotomy, galea, hematoma, subdural, subdural hematoma, syncopal, temporalis, subacute subdural hematoma, temporalis muscle,"
 Frontal craniotomy for placement of deep brain stimulator electrode.  Microelectrode recording of deep brain structures. Intraoperative programming and assessment of device., Neurosurgery, Brain Stimulator Electrode ,"PREOPERATIVE DIAGNOSIS: , Tremor, dystonic form.,POSTOPERATIVE DIAGNOSIS: , Tremor, dystonic form.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,ANESTHESIA:,  MAC (monitored anesthesia care) with local anesthesia.,TITLE OF PROCEDURES:,1.  Left frontal craniotomy for placement of deep brain stimulator electrode.,2.  Right frontal craniotomy for placement of deep brain stimulator electrode.,3.  Microelectrode recording of deep brain structures.,4.  Stereotactic volumetric CT scan of head for target coordinate determination.,5.  Intraoperative programming and assessment of device.,INDICATIONS:  ,The patient is a 61-year-old woman with a history of dystonic tremor.  The movements have been refractory to aggressive medical measures, felt to be candidate for deep brain stimulation.  The procedure is discussed below.,I have discussed with the patient in great deal the risks, benefits, and alternatives.  She fully accepted and consented to the procedure.,PROCEDURE IN DETAIL:,  The patient was brought to the holding area and to the operating room in stable condition.  She was placed on the operating table in seated position.  Her head was shaved.  Scalp was prepped with Betadine and a Leksell frame was mounted after anesthetizing the pin sites with a 50:50 mixture of 0.5% Marcaine and 2% lidocaine in all planes.  IV antibiotics were administered as was the sedation.  She was then transported to the CT scan and stereotactic volumetric CT scan of the head was undertaken.  The images were then transported to the surgery planned work station where a 3-D reconstruction was performed and the target coordinates were then chosen.  Target coordinates chosen were 20 mm to the left of the AC-PC midpoint, 3 mm anterior to the AC-PC midpoint, and 4 mm below the AC-PC midpoint.  Each coordinate was then transported to the operating room as Leksell coordinates.,The patient was then placed on the operating table in a seated position once again.  Foley catheter was placed, and she was secured to the table using the Mayfield unit.  At this point then the patient's right frontal and left parietal bossings were cleaned, shaved, and sterilized using Betadine soap and paint in scrubbing fashion for 10 minutes.  Sterile drapes placed around the perimeter of the field.  This same scalp region was then anesthetized with same local anesthetic mixture.,A bifrontal incision was made as well as curvilinear incision was made over the parietal bossings.  Bur holes were created on either side of the midline just behind the coronal suture.  Hemostasis was controlled using bipolar and Bovie, and self-retaining retractors had been placed in the field.  Using the drill, then two small grooves were cut in the frontal bone with a 5-mm cutting burs and Stryker drill.  The bur holes were then curetted free, the dura cauterized, and then opened in a cruciate manner on both sides with a #11 blade.  The cortical surface was then nicked with a #11 blade on both sides as well.  The Leksell arc with right-sided coordinate was dialed in, was then secured to the frame.  Microelectrode drive was secured to the arc.  Microelectrode recording was then performed.  The signatures of the cells were recognized.  Microelectrode unit was removed.  Deep brain stimulating electrode holding unit was mounted.  The DBS electrode was then loaded into target and intraoperative programming and testing was performed.  Using the screener box and standard parameters, the patient experienced some relief of symptoms on her left side.  This electrode was secured in position using bur-hole ring and cap system.,Attention was then turned to the left side, where left-sided coordinates were dialed into the system.  The microelectrode unit was then remounted.  Microelectrode recording was then undertaken.  After multiple passes, the microelectrode unit was removed.  Deep brain stimulator electrode holding unit was mounted at the desired trajectory.  The DBS electrode was loaded into target, and intraoperative programming and testing was performed once again using the screener box.  Using standard parameters, the patient experienced similar results on her right side.  This electrode was secured using bur-hole ring and cap system.  The arc was then removed.  A subgaleal tunnel was created between the two incisions whereby distal aspect of the electrodes led through this tunnel.,We then closed the electrode, replaced subgaleally.  Copious amounts of Betadine irrigation were used.  Hemostasis was controlled using the bipolar only.  Closure was instituted using 3-0 Vicryl in a simple interrupted fashion for the fascial layer followed by skin closure with staples.  Sterile dressings were applied.  The Leksell arc was then removed.,She was rotated into the supine position and transported to the recovery room in stable and satisfactory condition.  All needle, sponge, cottonoid, and blade counts were correct x2 as verified by the nurses.","neurosurgery, dystonic, ac-pc, ct scan, dbs electrode, intraoperative programming, microelectrode, stereotactic, tremor, brain stimulator, craniotomy, device, dystonic tremor, electrode, frontal, screener box, target coordinate, volumetric, deep brain stimulator electrode, brain stimulator electrode, volumetric ct, stimulator, brain, "
 Right-sided craniotomy for evacuation of a right frontal intracranial hemorrhage.  Status post orbitozygomatic resection of a pituitary tumor with a very large intracranial component basically a very large skull-based brain tumor., Neurosurgery, Craniotomy ,"TITLE OF OPERATION: , Right-sided craniotomy for evacuation of a right frontal intracranial hemorrhage.,INDICATION FOR SURGERY: , The patient is very well known to our service.  In brief, the patient is status post orbitozygomatic resection of a pituitary tumor with a very large intracranial component basically a very large skull-based brain tumor.  He was taken to the operating room for the orbitozygomatic approach.  Intraoperatively, everything went well without any complications.  The brain at the end of the procedure was absolutely intact, but the patient developed a seizure in the Intensive Care Unit and then was taken to the CT scan, developed a second seizure.  He was given Ativan for this, and then began to identify a large component measuring about 3 x 3 cm of the right frontal lobe, what appeared to be a hemorrhagic conversion of potential venous infarct.  I had a long discussion immediately with Dr. X and Dr. Y.  We decided to take the patient immediately as a level 1 for evacuation of this hematoma with a small amount of a midline shift with an intraventricular component.  It worried me and I think that we needed to go ahead and take him to the operating room immediately.  The patient was taken as a level 1 immediately and emergently and into the operating room for this procedure.  The original plan was to do first a right-sided orbitozygomatic procedure and then stage it a few weeks later with an endonasal endoscopic procedure for resection of this pituitary tumor component.  He was taken to the operating room for evacuation of a right frontal intraparenchymal hematoma.,PREOP DIAGNOSIS:,  Pituitary tumor with a large intracranial component, status post resection and now development of an intracranial hemorrhage.,POSTOP DIAGNOSIS:,  Intracranial hemorrhage in the right frontal lobe with extension into the intraventricular space after resection of a pituitary tumor via orbitozygomatic approach.,ANESTHESIA: , General.,PROCEDURE IN DETAIL: , The patient was taken to the operating room.  In the supine position, his head was put in a horseshoe without any complications.  The patient tolerated this very well, and the prior incision was immediately opened.  The surgery had taken place a few hours prior to this, the original orbitozygomatic approach.  At this point, this was a life-saving procedure.  We went ahead, opened the old incision after everything was sterilely prepped, and all the surgical instrumentation was brought into place.  We went ahead and opened the incision and took out the pterional bone flap without any complications.  We immediately opened the dura expeditiously, and the brain was moderately under some pressure, but not really bulging out.  So I went ahead and identified an area over the right frontal lobe that was a little bit consistent with a hemorrhagic infarct and nonviable tissue.  So we went ahead and did a corticectomy right there and identified the actual clot immediately and went ahead, and over the next few hours, very meticulously began to evacuate these clots without any complication whatsoever.  We went all the way down to the ventricle and identified this clot in the ventricle and went ahead and removed this clot without any complications, and we had a very nice resection.  The brain was very relaxed.  We had a very good resection of the actual blood clot, and the brain was very relaxed.  We irrigated thoroughly.  We identified the ventricles.  We went ahead and did a very careful hemostasis with Avitene with thrombin and Gelfoam with thrombin over the next times in doing the procedure.  All this was done very well, and then we lined the cavity with Surgicel, and the Surgicel was only put at the edge and draping down as to not to leave any fragments potentially to communicate with the actual ventricle, and then after this, everything was good.  We went ahead and closed back the actual dura back.  We had done a pericranial flap.  This was also put back in place and the dura was closed with 4-0 Surgilons.  We reconstructed everything.  The frontal sinus was reconstructed thoroughly without any complications.  We went ahead and put once again a watertight closure and went ahead and put another piece of DuraGen with Hemaseel in place, and went ahead and put the bone flap back and reconstructed very nicely once again with self-tapping, self-drilling screws, low-profile plates.  Once everything was confirmed to be in place, we went ahead and closed the muscle flap and also the actual fat pad was put back into place and closed together with 0 pop-offs, and the skin with staples without any complications.  In summary, the procedure was going back to the operating room for evacuation of a right-sided intracranial hemorrhage, most likely a conversion of an intraparenchymal hematoma with extension into the ventricle without any complications.  So everything was stable.  Estimated blood loss was about 100 cubic centimeters.  The sponges and needle counts were correct.  No specimens were sent to pathology.,DISPOSITION: , The patient after this procedure was brought to the Neuro Intensive Care Unit for close observation.","neurosurgery, orbitozygomatic, intracranial, brain tumor, intraparenchymal hematoma, orbitozygomatic approach, frontal lobe, intracranial hemorrhage, pituitary tumor, craniotomy, hemorrhage,"
 Bilateral carotid cerebral angiogram and right femoral-popliteal angiogram., Neurosurgery, Bilateral Carotid Cerebral Angiogram ,"PREOPERATIVE DIAGNOSES:,1.  Carotid artery occlusive disease.,2.  Peripheral vascular disease.,POSTOPERATIVE DIAGNOSES:,1.  Carotid artery occlusive disease.,2.  Peripheral vascular disease.,OPERATIONS PERFORMED:,1.  Bilateral carotid cerebral angiogram.,2.  Right femoral-popliteal angiogram.,FINDINGS: , The right carotid cerebral system was selectively catheterized and visualized.  The right internal carotid artery was found to be very tortuous with kinking in its cervical portions, but no focal stenosis was noted.  Likewise, the intracranial portion of the right internal carotid artery showed no significant disease nor did the right middle cerebral artery.,The left carotid cerebral system was selectively catheterized and visualized.  The cervical portion of the left internal carotid artery showed a 30 to 40% stenosis with small ulcer crater present.  The intracranial portion of the left internal carotid artery showed no significant disease nor did the left middle cerebral artery.,Visualization of the right lower extremity showed no significant disease.,PROCEDURE: , With the patient in supine position under local anesthesia plus intravenous sedation, the groin areas were prepped and draped in a sterile fashion.,The common femoral artery was punctured in a routine retrograde fashion and a 5-French introducer sheath was advanced under fluoroscopic guidance.  A catheter was then placed in the aortic arch and the right and left common carotid arteries were then selectively catheterized and visualized as described above.,Following completion of the above, the catheter and introducer sheath were removed.  Heparin had been initially given, which was reversed with protamine.  Firm pressure was held over the puncture site for 20 minutes, followed by application of a sterile Coverlet dressing and sandbag compression.,The patient tolerated the procedure well throughout.","neurosurgery, femoral-popliteal angiogram, carotid cerebral angiogram, internal carotid artery, carotid artery, angiogram, carotid, cerebral, artery,"
 Anterior cranial vault reconstruction with fronto-orbital bar advancement., Neurosurgery, Cranial Vault Reconstruction ,"INDICATION FOR OPERATION:,  Right coronal synostosis with left frontal compensatory bossing causing plagiocephaly.,PREOPERATIVE DIAGNOSIS:,  Syndromic craniosynostosis.,POSTOPERATIVE DIAGNOSIS: , Syndromic craniosynostosis.,TITLE OF OPERATION: , Anterior cranial vault reconstruction with fronto-orbital bar advancement.,SPECIMENS: , None.,DRAINS: , One subgaleal drain exiting from the left posterior aspect of wound.,DESCRIPTION OF PROCEDURE:,  After satisfactory general endotracheal tube anesthesia was started, the patient was placed on the operating table in supine position with the head held on a horseshoe-shaped headrest and the head was prepped and draped down the routine manner.  Here, the proposed scalp incision was infiltrated with 1% Xylocaine and then a zigzag scalp incision was made from one ear to the other ear, posterior to the coronal suture.  Scalp incision was reflected anteriorly and then the periosteum was taken off of the bone and then the temporalis muscles were reflected anterolaterally until the anterior cranial vault was exposed and then the periorbital rim, nasion and orbital part of the zygomatic arch were all dissected out as well as the pterion.  Using a craniotome, several bur holes were made; two on the either side of the midline posteriorly and then two posterolaterally.  The two posterior bur holes were then connected with a punch over the superior sagittal sinus and then the craniotome was used to fashion a flap first on the left and then on the right, going paramedian along the superior sagittal sinus in the midline and then curving over the fronto-orbital bar.  We then dissected superior sagittal sinus off of the inner table of the right bundle flap and then connected the right bundle flap going across the pterion on the right, which was abnormal.  The pterion on the right was then run short down after removing both bone flaps and then the dura was dissected off from the orbital roofs.  On the right, the orbital roof was jagged and abnormal and we had to repair a CSF leak from where the dura was punctured by the orbital roof.  The orbital rim was then dissected out and then using the saw and chisels, we were able to make the releasing cuts to free up the orbital rims, zygomatic arch and then remove the orbital bar going posteriorly and then the distal bar was split in the middle and then reapproximated with a bone graft in the middle to move the orbits out a little bit and the orbital bar was held together using absorbable plate.  It was then replaced and advanced and then relaxing, barrel-staving incisions were made in the bone flaps and the orbital rim and it was held on the right side with an absorbable plate to fix it in the proper position.  The bone flaps were then reapproximated using absorbable plates and screws, as well as #2-0 Vicryl to secure back into place.  Some of the places were also secured in the midline posteriorly, as well as off to the right where the bony defects were in place.  The periosteum was then brought over the skull and fastened in place and the temporalis muscles were tacked up to the periosteum.  The wounds were irrigated out.  A drain was left in posteriorly and then the wounds were closed in a routine manner using Vicryl for the galea and fast-absorbing gut for the skin followed by sterile dressings.  The patient tolerated the procedure well and did receive blood transfusions.","neurosurgery, coronal synostosis, syndromic craniosynostosis, craniosynostosis, plagiocephaly, fronto-orbital bar, cranial vault reconstruction, cranial vault, orbital bar, orbital, cranial,"
" Anterior lumbar fusion, L4-L5, L5-S1, PEEK vertebral spacer, structural autograft from L5 vertebral body, BMP and anterior plate.  Severe low back pain.", Neurosurgery, Anterior Lumbar Fusion ,"PREOPERATIVE DIAGNOSIS: , Severe low back pain.,POSTOPERATIVE DIAGNOSIS: , Severe low back pain.,OPERATIONS PERFORMED: , Anterior lumbar fusion, L4-L5, L5-S1, PEEK vertebral spacer, structural autograft from L5 vertebral body, BMP and anterior plate.,ANESTHESIA:,  General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 50 mL.,DRAINS:,  None.,COMPLICATIONS: , None.,PATHOLOGICAL FINDINGS:,  Dr. X made the approach and once we were at the L5-S1 disk space, we removed the disk and we placed a 13-mm PEEK vertebral spacer filled with a core of bone taken from the L5 vertebral body.  This was filled with a 15 x 20-mm Chronos VerteFill tricalcium phosphate plug.  At L4-L5, we used a 13-mm PEEK vertebral spacer with structural autograft and BMP, and then we placed a two-level 87-mm Integra sacral plate with 28 x 6-mm screws, two each at L4 and L5 and 36 x 6-mm screws at S1.,OPERATION IN DETAIL:,  The patient was placed under general endotracheal anesthesia.  The abdomen was prepped and draped in the usual fashion.  Dr. X made the approach, and once the L5-S1 disk space was identified, we incised this with a knife and then removed a large core of bone taking rotating cutters.  I was able to remove additional disk space and score the vertebral bodies.  The rest of the disk removal was done with the curette, scraping the endplates.  I tried various sized spacers, and at this point, we exposed the L5 body and took a dowel from the body and filled the hole with a 15 x 20-mm Chronos VerteFill tricalcium phosphate plug.  Half of this was used to fill the spacer at L5-S1, BMP was placed in the spacer as well and then it was tapped into place.  We then moved the vessels over the opposite way approaching the L4-L5 disk space laterally, and the disk was removed in a similar fashion and we also used a 13-mm PEEK vertebral spacer, but this is the variety that we could put in from one side.  This was filled with bone and BMP as well.  Once this was done, we were able to place an 87-mm Integra sacral plate down over the three vertebral bodies and place these screws.  Following this, bleeding points were controlled and Dr. X proceeded with the closure of the abdomen.,SUMMARY: , This is a 51-year-old man who reports 15-year history of low back pain and intermittent bilateral leg pain and achiness.  He has tried multiple conservative treatments including physical therapy, epidural steroid injections, etc.  MRI scan shows a very degenerated disk at L5-S1, less so at L3-L4 and L4-L5.  A discogram was positive with the lower 3 levels, but he has pain, which starts below the iliac crest and I feel that the L3-L4 disk is probably that symptomatic.  An anterior lumbar interbody fusion was suggested.  Procedure, risks, and complications were explained.","neurosurgery, peek vertebral spacer, autograft, anterior lumbar fusion, lumbar fusion, vertebral body, vertebral spacer, vertebral, spacer, anterior, lumbar, fusion,"
 Anterior cervical discectomy for neural decompression and anterior interbody fusion C5-C6 utilizing Bengal cage.  , Neurosurgery, Anterior Cervical Discectomy & Interbody Fusion - 3 ,"PREOPERATIVE DIAGNOSES:,  ,1.  Spondylosis with cervical stenosis C5-C6 greater than C4-C5, C6-C7, (721.0, 723.0).,2.  Neck pain with left radiculopathy, progressive (723.1/723.4).,3.  Headaches, progressive (784.0).,POSTOPERATIVE DIAGNOSES:,  ,1.  Spondylosis with cervical stenosis C5-C6 greater than C4-C5, C6-C7, (721.0, 723.0).,2.  Neck pain with left radiculopathy, progressive (723.1/723.4).,3.  Headaches, progressive (784.0).,PROCEDURES:,  ,1.  Anterior cervical discectomy at C5-C6 for neural decompression (63075).,2.  Anterior interbody fusion C5-C6 (22554) utilizing Bengal cage (22851).,3.  Anterior cervical instrumentation at C5-C6 for stabilization by Uniplate construction at C5-C6 (22845); with intraoperative x-ray x2.,SERVICE:  ,  Neurosurgery,ANESTHESIA:,","neurosurgery, spondylosis, neck pain, headaches, decompression, uniplate, anterior cervical discectomy, neural decompression, cervical stenosis, prevertebral space, antibiotic solution, cervical discectomy, interbody fusion, bengal cage, interbody, anterior, cervical, discectomy,"
" Anterior cervical discectomy with decompression, C5-C6, arthrodesis with anterior interbody fusion, C5-C6, spinal instrumentation, C5-C6 using Pioneer 18-mm plate and four 14 x 4.0 mm screws (all titanium), implant using PEEK 7 mm, and Allograft using Vitoss.", Neurosurgery, Anterior Cervical Discectomy & Interbody Fusion ,"PREOPERATIVE DIAGNOSES,1.  Neck pain with bilateral upper extremity radiculopathy, left more than the right.,2.  Cervical spondylosis with herniated nucleus pulposus, C5-C6.,POSTOPERATIVE DIAGNOSES,1.  Neck pain with bilateral upper extremity radiculopathy, left more than the right.,2.  Cervical spondylosis with herniated nucleus pulposus, C5-C6.,OPERATIVE PROCEDURES,1.  Anterior cervical discectomy with decompression, C5-C6.,2.  Arthrodesis with anterior interbody fusion, C5-C6.,3.  Spinal instrumentation, C5-C6 using Pioneer 18-mm plate and four 14 x 4.0 mm screws (all titanium).,4.  Implant using PEEK 7 mm.,5.  Allograft using Vitoss.,DRAINS: , Round French 10 JP drain.,FLUIDS:  ,1200 cc of crystalloids.,URINE OUTPUT: , No Foley catheter.,SPECIMENS: , None.,COMPLICATIONS: , None.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,INDICATIONS FOR THE OPERATION:,  This is a case of a very pleasant 38-year-old Caucasian female who has been complaining over the last eight years of neck pain and shoulder pain radiating down across the top of her left shoulder and also across her shoulder blades to the right side, but predominantly down the left upper extremity into the wrist.  The patient has been diagnosed with fibromyalgia and subsequently, has been treated with pain medications, anti-inflammatories and muscle relaxants.  The patient's symptoms continued to persist and subsequently, an MRI of the C-spine was done, which showed disc desiccation, spondylosis and herniated disk at C5-C6, an EMG and CV revealed a presence of mild-to-moderate carpal tunnel syndrome.  The patient is now being recommended to undergo decompression and spinal instrumentation and fusion at C5-C6.  The patient understood the risks and benefits of the surgery.  Risks include but not exclusive of bleeding and infection.  Bleeding can be in the form of soft tissue bleeding, which may compromise airway for which she can be brought emergently back to the operating room for emergent evacuation of the hematoma as this may cause weakness of all four extremities, numbness of all four extremities, as well as impairment of bowel and bladder function.  This could also result in dural tear with its attendant symptoms of headache, nausea, vomiting, photophobia, and posterior neck pain as well as the development of pseudomeningocele.  Should the symptoms be severe or the pseudomeningocele be large, she can be brought back to the operating room for repair of the CSF leak and evacuation of the pseudomeningocele.  There is also the risk of pseudoarthrosis and nonfusion, for which she may require redo surgery at this level.  There is also the possibility of nonimprovement of her symptoms in about 10% of cases.  The patient understands this risk on top of the potential injury to the esophagus and trachea as well as the carotid artery.  There is also the risk of stroke, should an undiagnosed plaque be propelled into the right cerebral circulation.  The patient also understands that there could be hoarseness of the voice secondary to injury to the recurrent laryngeal nerve.  She understood these risks on top of the risks of anesthesia and gave her consent for the procedure.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room, awake, alert and not in any form of distress.  After smooth induction and intubation, the patient was positioned supine on the operating table with the neck placed on hyperextension and the head supported on a foam doughnut.  A marker was placed.  This verified the level to be at the C5-C6 level and incision was then marked in a transverse fashion starting from the midline extending about 5 mm beyond the anterior border of the sternocleidomastoid muscle.  The area was then prepped with DuraPrep after the head was turned 45 degrees to the left.,After sterile drapes were laid out, an incision was made using a scalpel blade #10.  Wound edge bleeders were carefully controlled with bipolar coagulation and the platysma was cut using a hot knife in a transverse fashion.  Dissection was then carried underneath the platysma superiorly inferiorly.  The anterior border of the sternocleidomastoid was identified and dissection was carried out lateral to the esophagus to trachea as well as medial to the carotid sheath in the sternocleidomastoid muscle.  The prevertebral fascia was noted to be taken her case with a lot of fat deposition.  Bipolar coagulation of bleeders was done; however, branch of the superior thyroid artery was ligated with Hemoclips x4.  After this was completed, a localizing x-ray verified the marker to be at the C6-C7 level.  We proceeded to strip the longus colli muscles off the vertebral body of the C5 and C6.  Self-retaining retractor was then laid down.  An anterior osteophyte was carefully drilled using a Midas 5-mm bur and the disk together with the inferior endplate of C5 and the superior endplate of C6 was also drilled down with the Midas 5-mm bur.  This was later followed with a 3-mm bur and the disk together with posterior longitudinal ligament was removed using Kerrison's ranging from 1 to 4 mm.  The herniation was noted on the right.  However, there was significant neuroforaminal stenosis on the left.  Decompression on both sides was done and after this was completed, a Valsalva maneuver showed no evidence of any CSF leakage.  The area was then irrigated with saline with bacitracin solution.  A 7 mm implant with its inferior packed with Vitoss was then laid down and secured in place with four 14 x 4.0 mm screws and plate 18 mm, all of which were titanium.  X-ray after this placement showed excellent position of all these implants and screws and _____ and the patient's area was also irrigated with saline with bacitracin solution.  A round French 10 JP drain was then laid down and exteriorized through a separate stab incision on the patient's right inferiorly.  The catheter was then anchored to the skin with a nylon 3-0 stitch and connected to a sterile draining system.  The wound was then closed in layers with Vicryl 3-0 inverted interrupted sutures for the platysma, Vicryl subcuticular 4-0 Stitch for the dermis, and the wound was reinforced with Dermabond.  Dressing was placed only at the exit site of the catheter.  C-collar was placed.  The patient was extubated and transferred to recovery.",
" Bifrontal cranioplasty, cranial defect greater than 10 cm in diameter in the frontal region.", Neurosurgery, Bifrontal Cranioplasty ,"PREOPERATIVE DIAGNOSIS:,  Cranial defect greater than 10 cm in diameter in the frontal region.,POSTOPERATIVE DIAGNOSIS: , Cranial defect greater than 10 cm in diameter in the frontal region.,PROCEDURE: , Bifrontal cranioplasty.,ANESTHESIA:,  General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , Nil.,INDICATIONS FOR PROCEDURE: , The patient is a 66-year-old gentleman, who has a history of prior chondrosarcoma that he had multiple resections for.  The most recent one which I performed quite a number of years ago that was complicated by a bone flap infection and he has had removal of his bone flap.  He has been without the bone flap for a number of years now but has finally decided that he wanted to proceed with a cranioplasty.  After discussing the risks, benefits, and alternatives of surgery, the decision was made to proceed with operative intervention in the form of a cranioplasty.  He had previously undergone a CT scan.  Premanufactured cranioplasty made for him that was sterile and ready to implant.,DESCRIPTION OF PROCEDURE: , After induction of adequate general endotracheal anesthesia, an appropriate time out was performed.  We identified the patient, the location of surgery, the appropriate surgical procedure, and the appropriate implant.  He was given intravenous antibiotics with ceftriaxone, vancomycin, and Flagyl appropriately for antibiotic prophylaxis and sequential compression devices were used for deep venous thromboembolism prophylaxis.  The scalp was prepped and draped in the usual sterile fashion.  A previous incision was reopened and the scalp flap was reflected forward.  We dissected off the dura and we were able to get a nice plane of dissection elevating the temporalis muscle along with the scalp flap.  We freed up the bony edges circumferentially, but except for the inferior frontal region where the vascularized pericranial graft took its vascular supply from we did not come across the base.  We did explore laterally and saw a little bit of the mesh on the lateral orbit.  Once we had the bony edges explored, we took the performed plate and secured it in a place with titanium plates and screws.  We had achieved good hemostasis.  The wound was closed in multiple layers in usual fashion over a Blake drain.  At the end of the procedure, all sponge and needle counts were correct.  A sterile dressing was applied to the incision.  The patient was transported to the recovery room in good condition after having tolerated the procedure well.  I was personally present and scrubbed and performed/supervised all key portions.","neurosurgery, cranial defect, frontal region, bifrontal cranioplasty, cranioplasty, chondrosarcoma, scalp flap, bony edges, bone flap, bifrontal, cranial, endotracheal, frontal,"
 Anterior cervical discectomy and osteophytectomy.  Application of prosthetic interbody fusion device.  Anterior cervical interbody arthrodesis.  Anterior cervical instrumentation, Neurosurgery, Anterior Cervical Discectomy & Osteophytectomy ,"PREOPERATIVE DIAGNOSES,1.  Cervical radiculopathy, C5-C6 and C6-C7.,2.  Symptomatic cervical spondylosis, C5-C6 and C6-C7.,3.  Symptomatic cervical stenosis, C5-C6 and C6-C7.,4.  Symptomatic cervical disc herniations, C5-C6 and C6-C7.,POSTOPERATIVE DIAGNOSES,1.  Cervical radiculopathy, C5-C6 and C6-C7.,2.  Symptomatic cervical spondylosis, C5-C6 and C6-C7.,3.  Symptomatic cervical stenosis, C5-C6 and C6-C7.,4.  Symptomatic cervical disc herniations, C5-C6 and C6-C7.,OPERATIVE PROCEDURE,1.  CPT code 63075:  Anterior cervical discectomy and osteophytectomy, C5-C6.,2.  CPT code 63076:  Anterior cervical discectomy and osteophytectomy, C6-C7, additional level.,3.  CPT code 22851:  Application of prosthetic interbody fusion device, C5-C6.,4.  CPT code 22851-59:  Application of prosthetic interbody fusion device, C6-C7, additional level.,5.  CPT code 22554-51:  Anterior cervical interbody arthrodesis, C5-C6.,6.  CPT code 22585:  Anterior cervical interbody arthrodesis, C6-C7, additional level.,7.  CPT code 22845:  Anterior cervical instrumentation, C5-C7.,ANESTHESIA:,  General endotracheal.,ESTIMATED BLOOD LOSS:  ,Negligible.,DRAINS: , Small suction drain in the cervical wound.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL:,  The patient was given intravenous antibiotic prophylaxis and thigh-high TED hoses were placed on the lower extremities while in the preanesthesia holding area.  The patient was transported to the operative suite and on to the operative table in the supine position.  General endotracheal anesthesia was induced.  The head was placed on a well-padded head holder.  The eyes and face were protected from pressure.  A well-padded roll was placed beneath the neck and shoulders to help preserve the cervical lordosis.  The arms were tucked and draped to the sides.  All bony prominences were well padded.  An x-ray was taken to confirm the correct level of the skin incision.  The anterior neck was then prepped and draped in the usual sterile fashion.,A straight transverse skin incision over the left side of the anterior neck was made and carried down sharply through the skin and subcutaneous tissues to the level of the platysma muscle, which was divided transversely using the electrocautery.  The superficial and deep layers of the deep cervical fascia were divided.  The midline structures were reflected to the right side.  Care was taken during the dissection to avoid injury to the recurrent laryngeal nerve and the usual anatomical location of that nerve was protected.  The carotid sheath was palpated and protected laterally.  An x-ray was taken to confirm the level of C5-C6 and C6-C7.,The longus colli muscle was dissected free bilaterally from C5 to C7 using blunt dissection.  Hemostasis was obtained using the electrocautery.  The blades of the cervical retractor were placed deep to the longus colli muscles bilaterally.  At C5-C6, the anterior longitudinal ligament was divided transversely.  Straight pituitary rongeurs and a curette were used to remove the contents of the disc space.  All cartilages were scraped off the inferior endplate of C5 and from the superior endplate of C6.  The disc resection was carried posteriorly to the posterior longitudinal ligament and laterally to the uncovertebral joints.  The posterior longitudinal ligament was resected using a 1 mm Kerrison rongeur.  Beginning in the midline and extending into both neural foramen, posterior osteophytes were removed using a 1 m and a 2 mm Kerrison rongeurs.  The patient was noted to have significant bony spondylosis causing canal and foraminal stenosis as well as a degenerative and protruding disc in agreement with preoperative diagnostic imaging studies.  Following completion of the discectomy and osteophytectomy, a blunt nerve hook was passed into the canal superiorly and inferiorly as well as in the both neural foramen to make sure that there were no extruded disc fragments and to make sure the bony decompression was complete.  A portion of the uncovertebral joint was resected bilaterally for additional nerve root decompression.  Both nerve roots were visualized and noted to be free of encroachment.  The same procedure was then carried out at C6-C7 with similar findings.  The only difference in the findings was that at C6-C7 on the left side, the patient was found to have an extruded disc fragment in the canal and extending into the left side neural foramen causing significant cord and nerve root encroachment.,In preparation for the arthrodesis, the endplates of C5, C6, and C7 were burred in a parallel fashion down to the level of bleeding bone using a high-speed cutting bur with irrigant solution for cooling.  The disc spaces were then measured to the nearest millimeter.  Attention was then turned toward preparation of the structural allograft, which consisted of two pieces of pre-machined corticocancellous bone.  The grafts were further shaped to fit the disc spaces exactly in a press-fit manner with approximately 1.5 mm of distraction at each disc space.  The grafts were shaped to be slightly lordotic to help preserve the cervical lordosis.  The grafts were impacted into the disc spaces.  There was complete bony apposition between the ends of the bone grafts and the vertebral bodies of C5, C6, and C7.  A blunt nerve hook was passed posterior to each bone graft to make sure that the bone grafts were in good position.  Anterior osteophytes were removed using a high-speed cutting bur with irrigant solution for cooling.  An appropriate length Synthes cervical plate was selected and bent slightly to conform to the patient's cervical lordosis.  The plate was held in the midline with provided instrumentation while a temporary fixation screw was applied at C6.  Screw holes were then drilled using the provided drill and drill guide taking care to avoid injury to neurovascular structures.  The plate was then rigidly fixed to the anterior spine using 14-mm cancellous screws followed by locking setscrews added to the head of each screw to prevent postoperative loosening of the plate and/or screws.,An x-ray was taken, which confirmed satisfactory postioning of the plate, screws, and bone grafts.,Blood loss was minimal.  The wound was irrigated with irrigant solution containing antibiotics.  The wound was inspected and judged to be dry.  The wound was closed over a suction drain placed in the deepest portion of the wound by reapproximating the platysma muscle with #4-0 Vicryl running suture, the subdermal and subcuticular layers with #4-0 Monocryl interrupted sutures, and the skin with Steri-Strips.  The sponge and needle count were correct.  A sterile dressing was applied to the wound.  The neck was placed in a cervical orthosis.  The patient tolerated the procedure and was transferred to the recovery room in stable condition.",
"  Herniated nucleus pulposus C5-C6.  Anterior cervical discectomy fusion C5-C6 followed by instrumentation C5-C6 with titanium dynamic plating system, Aesculap.  Operating microscope was used for both illumination and magnification.", Neurosurgery, Anterior Cervical Discectomy & Fusion - 9 ,"PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus C5-C6.,POSTOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus C5-C6.,PROCEDURE:,  Anterior cervical discectomy fusion C5-C6 followed by instrumentation C5-C6 with titanium dynamic plating system, Aesculap.  Operating microscope was used for both illumination and magnification.,FIRST ASSISTANT: , Nurse practitioner.,PROCEDURE IN DETAIL: , The patient was placed in supine position.  The neck was prepped and draped in the usual fashion for anterior discectomy and fusion.  An incision was made midline to the anterior body of the sternocleidomastoid at C5-C6 level.  The skin, subcutaneous tissue, and platysma muscle was divided exposing the carotid sheath, which was retracted laterally.  Trachea and esophagus were retracted medially.  After placing the self-retaining retractors with the longus colli muscles having been dissected away from the vertebral bodies at C5 and C6 and confirming our position with intraoperative x-rays, we then proceeded with the discectomy.,We then cleaned out the disc at C5-C6 after incising the annulus fibrosis.  We cleaned out the disc with a combination of angled and straight pituitary rongeurs and curettes, and the next step was to clean out the disc space totally.  With this having been done, we then turned our attention with the operating microscope to the osteophytes.  We drilled off the vertebral osteophytes at C5-C6, as well as the uncovertebral osteophytes.  This was removed along with the posterior longitudinal ligament.  After we had done this, the dural sac was opposed very nicely and both C6 nerve roots were thoroughly decompressed.  The next step after the decompression of the thecal sac and both C6 nerve roots was the fusion.  We observed that there was a ____________ in the posterior longitudinal ligament.  There was a free fragment disc, which had broken through the posterior longitudinal ligament just to the right of midline.,The next step was to obtain the bone from the back bone, using cortical cancellous graft 10 mm in size after we had estimated the size.  That was secured into place with distraction being applied on the vertebral bodies using vertebral body distractor.,After we had tapped in the bone plug, we then removed the distraction and the bone plug was fitting nicely.,We then use the Aesculap cervical titanium instrumentation with the 16-mm screws.  After securing the C5-C6 disc with four screws and titanium plate, x-rays showed good alignment of the spine, good placement of the bone graft, and after x-rays showed excellent position of the bone graft and instrumentation, we then placed in a Jackson-Pratt drain in the prevertebral space brought out through a separate incision.  The wound was closed with 2-0 Vicryl for subcutaneous tissues and skin was closed with Steri-Strips.  Blood loss during the operation was less than 10 mL.  No complications of the surgery.  Needle count, sponge count, and cottonoid count were correct.,","neurosurgery, aesculap, titanium dynamic plating system, anterior cervical discectomy, herniated nucleus pulposus, cervical discectomy, operating microscope, longitudinal ligament, discectomy, anterior, instrumentation, cervical, titanium"
 Anterior cervical discectomy with spinal cord and spinal canal decompression and Anterior interbody fusion at C5-C6 utilizing Bengal cage., Neurosurgery, Anterior Cervical Discectomy & Interbody Fusion - 2 ,"PREOPERATIVE DIAGNOSES:  ,1.  Large herniated nucleus pulposus, C5-C6 with myelopathy (722.21).,2.  Cervical spondylosis.,3.  Cervical stenosis, C5-C6 secondary to above (723.0).,POSTOPERATIVE DIAGNOSES:  ,1.  Large herniated nucleus pulposus, C5-C6 with myelopathy (722.21).,2.  Cervical spondylosis.,3.  Cervical stenosis, C5-C6 secondary to above (723.0), with surgical findings confirmed.,PROCEDURES: , ,1.  Anterior cervical discectomy at C5-C6 with spinal cord and spinal canal decompression (63075).,2.  Anterior interbody fusion at C5-C6, (22554) utilizing Bengal cage (22851).,3.  Anterior instrumentation for stabilization by Uniplate construction, C5-C6, (22845); with intraoperative x-ray times two.,ANESTHESIA: , General.,SERVICE: , Neurosurgery.,OPERATION:  ,The patient was brought into the operating room, placed in a supine position where general anesthesia was administered.  Then the anterior aspect of the neck was prepped and draped in a routine sterile fashion.  A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma, which was dissected only in a subplatysmal manner bluntly, and with only blunt dissection at the prevertebral space where a localizing intraoperative x-ray was obtained, once self-retaining retractors were placed along the mesial edge of a cauterized longus colli muscle, to protect surrounding tissues throughout the remainder of the case.  A prominent anterior osteophyte at C5-C6 was then localized, compared to preoperative studies in the usual fashion intraoperatively, and the osteophyte was excised with a rongeur and bony fragments saved.  This allowed for an annulotomy, which was carried out with a #11 blade and discectomy, removed with straight disc forceps portions of the disc, which were sent to Pathology for a permanent section.  Residual osteophytes and disc fragments were removed with 1 and 2-mm micro Kerrison rongeurs as necessary as drilling extended into normal cortical and cancellous elements widely laterally as well.  A hypertrophied ligament and prominent posterior spurs were excised as well until the dura bulged into the interspace, a sign of a decompressed status.  At no time during the case was evidence of CSF leakage, and hemostasis was readily achieved with pledgets of Gelfoam subsequently removed with copious amounts of antibiotic irrigation.  Once the decompression was inspected with a double ball dissector and all found to be completely decompressed, and the dura bulged at the interspace, and pulsated, then a Bengal cage was filled with the patient's own bone elements and fusion putty and countersunk into position, and was quite tightly applied.  Further stability was added nonetheless with an appropriate size Uniplate, which was placed of appropriate size with appropriate size screws and these were locked into place in the usual manner.  The wound was inspected, and irrigated again with antibiotic solution and after further inspection was finally closed in a routine closure in a multiple layer event by first approximation of the platysma with interrupted 3-0 Vicryl, and the skin with a subcuticular stitch of 4-0 Vicryl, and this was Steri-Stripped for reinforcement, and a sterile dressing was applied, incorporating a Penrose drain, which was carried from the prevertebral space externally to the skin wound and safety pin for security in the usual manner.  Once the sterile dressing was applied, the patient was taken from the operating room to the recovery area having left in stable condition.,At the conclusion of the case, all instruments, needle, and sponge counts were accurate and correct, and there were no intraoperative complications of any type.","neurosurgery, herniated nucleus pulposus, myelopathy, cervical spondylosis, cervical stenosis, anterior instrumentation, uniplate, decompression, anterior cervical discectomy, spinal cord, spinal canal, sterile dressing, interbody fusion, bengal cage, interbody, cervical, anterior, discectomy,"
" Anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray.  Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy and moderate stenosis C5-6.", Neurosurgery, Anterior Cervical Discectomy & Fusion - Discharge Summary ,"FINAL DIAGNOSES:,1.  Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy.,2.  Moderate stenosis C5-6.,OPERATION: , On 06/25/07, anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray.,This is a 60-year-old white male who was in the office on 05/01/07 because of neck pain with left radiculopathy and ""tension headaches.""  In the last year or so, he has had more and more difficulty and more recently has developed tingling and numbness into the fingers of the left hand greater than right.  He has some neck pain at times and has seen Dr. X for an epidural steroid injection, which was very helpful.  More recently he saw Dr. Y and went through some physical therapy without much relief.,Cervical MRI scan was obtained and revealed a large right-sided disc herniation at C4-5 with significant midline herniations at C5-6 and a large left HNP at C6-7.  In view of the multiple levels of pathology, I was not confident that anything short of surgical intervention would give him significant relief.  The procedure and its risk were fully discussed and he decided to proceed with the operation.,HOSPITAL COURSE: , Following admission, the procedure was carried out without difficulty.  Blood loss was about 125 cc.  Postop x-ray showed good alignment and positioning of the cages, plate, and screws.  After surgery, he was able to slowly increase his activity level with assistance from physical therapy.  He had some muscle spasm and soreness between the shoulder blades and into the back part of his neck.  He also had some nausea with the PCA.  He had a low-grade fever to 100.2 and was started on incentive spirometry.  Over the next 12 hours, his fever resolved and he was able to start getting up and around much more easily.,By 06/27/07, he was ready to go home.  He has been counseled regarding wound care and has received a neck sheet for instruction.  He will be seen in two weeks for wound check and for a followup evaluation/x-rays in about six weeks.  He has prescriptions for Lortab 7.5 mg and Robaxin 750 mg.  He is to call if there are any problems.","neurosurgery, slimlock, herniated nucleuses pulposus, anterior cervical discectomy, bengal cages, anterior, herniated, cervical, radiculopathy, discectomy, "
" Anterior cervical discectomy at C5-C6 and C6-C7 for neural decompression and anterior interbody fusion at C5-C6 and C6-C7 utilizing Bengal cages x2.  Anterior instrumentation by Uniplate construction C5, C6, and C7 with intraoperative x-ray x2.", Neurosurgery, Anterior Cervical Discectomy & Fusion - 5 ,"PREOPERATIVE DIAGNOSES:  ,1.  Cervical spondylosis C5-C6 greater than C6-C7 (721.0).,2.  Neck pain, progressive (723.1) with right greater than left radiculopathy (723.4).,POSTOPERATIVE DIAGNOSES:  ,1.  Cervical spondylosis C5-C6 greater than C6-C7 (721.0).,2.  Neck pain, progressive (723.1) with right greater than left radiculopathy (723.4), surgical findings confirmed.,PROCEDURES:  ,1.  Anterior cervical discectomy at C5-C6 and C6-C7 for neural decompression (63075, 63076).,2.  Anterior interbody fusion at C5-C6 and C6-C7 (22554, 22585) utilizing Bengal cages x2 (22851).,3.  Anterior instrumentation by Uniplate construction C5, C6, and C7 (22845); with intraoperative x-ray x2.,ANESTHESIA:  ,General.,OPERATIONS: , The patient was brought to the operating room and placed in the supine position where general anesthesia was administered.  Then the anterior aspect of the neck was prepped and draped in the routine sterile fashion.  A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma, which was dissected in a subplatysmal manner and then with only blunt dissection, the prevertebral space was encountered and localizing intraoperative x-ray was obtained once cauterized the longus colli muscle bilaterally allowed for the placement along its mesial portion of self-retaining retractors for exposure of tissues.  Prominent anterior osteophytes once identified and compared to preoperative studies were removed at C5-C6 and then at C6-C7 with rongeur, allowing for an annulotomy with an #11 blade through collapsed disc space at C5-6, and even more collapsed at C6-C7.  Gross instability appeared and though minimally at both interspaces and residual disc were removed then with the straight disc forceps providing a discectomy at both levels, sending to Pathology in a routine fashion as disc specimen.  This was sent separately and allowed for residual disc removal of power drill where drilling extended in normal cortical and cancellous elements of the C5 and C6 interspaces and at C6-C7 removing large osteophytes and process, residual osteophytes from which were removed finally with 1 and 2 mm micro Kerrison rongeurs allowing for excision of other hypertrophied ligament posteriorly as well.  This allowed for the bulging into the interspace of the dura, sign of decompressed status, and this was done widely bilaterally to decompress the nerve roots themselves and this was assured by inspection with a double ball dissector as needed.  At no time during the case was there evidence of CSF leakage and hemostasis was well achieved with pledgets of Gelfoam and subsequently removed with copious amounts of antibiotic irrigation as well as Surgifoam.  Once hemostasis well achieved, Bengal cage was filled with the patient's own bone elements of appropriate size, and this was countersunk into position and quite tightly applied it at first C5-C6, then secondly at C6-C7.  These were checked and found to be well applied and further stability was then added by placement nonetheless of a Uniplate of appropriate size.  The appropriate size screws and post-placement x-ray showed well-aligned elements and removal of osteophytes, etc.  The wound was again irrigated with antibiotic solution, inspected, and finally closed in a multiple layered closure by approximation of platysma with interrupted #3-0 Vicryl and the skin with subcuticular stitch of #4-0 Vicryl incorporating a Penrose drain from vertebral space externally through the skin wound and safety pin, and later incorporated itself into sterile bandage.,Once the bandage was placed, the patient was taken, extubated from the operating room to the Recovery area, having in stable, but guarded condition.  At the conclusion of the case, all instrument, needle, and sponge counts were accurate and correct.  There were no intraoperative complications of any type.","neurosurgery, cervical spondylosis, anterior cervical discectomy, anterior instrumentation, annulotomy, kerrison rongeurs, surgifoam, vertebral space, uniplate construction, bengal cages, neural decompression, anterior cervical, cervical discectomy, interbody, anterior, cervical, discectomy"
" C4-C5, C5-C6 anterior cervical discectomy and fusion.  The patient is a 62-year-old female who presents with neck pain as well as upper extremity symptoms.  Her MRI showed stenosis at portion of C4 to C6.", Neurosurgery, Anterior Cervical Discectomy & Fusion - 7 ,"PREOPERATIVE DIAGNOSIS:,  C4-C5, C5-C6 stenosis.,PREOPERATIVE DIAGNOSIS: , C4-C5, C5-C6 stenosis.,PROCEDURE: , C4-C5, C5-C6 anterior cervical discectomy and fusion.,COMPLICATIONS: , None.,ANESTHESIA: , General.,INDICATIONS OF PROCEDURE: , The patient is a 62-year-old female who presents with neck pain as well as upper extremity symptoms.  Her MRI showed stenosis at portion of C4 to C6.  I discussed the procedure as well as risks and complications.  She wishes to proceed with surgery.  Risks will include but are not limited to infection, hemorrhage, spinal fluid leak, worsened neurologic deficit, recurrent stenosis, requiring further surgery, difficulty with fusion requiring further surgery, long-term hoarseness of voice, difficulty swallowing, medical anesthesia risk.,PROCEDURE:  ,The patient was taken to the operating room on 10/02/2007.  She was intubated for anesthesia.  TEDS and boots as well as Foley catheter were placed.  She was placed in a supine position with her neck in neutral position.  Appropriate pads were also used.  The area was prepped and draped in usual sterile fashion.  Preoperative localization was taken.  _____ not changed.  Incision was made on the right side in transverse fashion over C5 vertebral body level.  This was made with a #10 blade knife and further taken down with pickups and scissors.  The plane between the esophagus and carotid artery was carefully dissected both bluntly and sharply down to the anterior aspect of the cervical spine.  Intraoperative x-ray was taken.  Longus colli muscles were retracted laterally.  Caspar retractors were used.  Intraoperative x-ray was taken.  I first turned by attention at C5-C6 interspace.  This was opened with #15 blade knife.  Disc material was taken out using pituitary as well as Kerrison rongeur.  Anterior aspects were taken down.  End plates were arthrodesed using curettes.  This was done under distraction.  Posterior longitudinal ligament was opened with a nerve hook and Kerrison rongeur.  Bilateral foraminotomies were done.  At this point, I felt that there was a good decompression.  The foramen appeared to be opened.  Medtronic cage was then encountered and sent few millimeters.  This was packed with demineralized bone matrix.  The distraction was then taken down.  The cage appeared to be strong.  This procedure was then repeated at C4-C5.  A 42-mm AcuFix plate was then placed between C4 and C6.  This was carefully screwed and locked.  The instrumentation appeared to be strong.  Intraoperative x-ray was taken.  Irrigation was used.  Hemostasis was achieved.  The platysmas was closed with 3-0 Vicryl stitches.  The subcutaneous was closed with 4-0 Vicryl stitches.  The skin was closed with Steri-strips.  The area was clean and dry and dressed with Telfa and Tegaderm.  Soft cervical collar was placed for the patient.  She was extubated per anesthesia and brought to the recovery in stable condition.","neurosurgery, anterior cervical discectomy, fusion, infection, hemorrhage, spinal fluid leak, anesthesia, foley catheter, teds, anterior cervical, cervical discectomy, anterior, cervical, discectomy, stenosis,"
" Radical anterior discectomy with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal.  Anterior cervical fusion.  Utilization of allograft for purposes of spinal fusion.  Application of anterior cervical locking plate.", Neurosurgery, Anterior Cervical Discectomy & Fusion - 3 ,"PREOPERATIVE DIAGNOSES,1.  Cervical spinal stenosis, C3-c4 and C4-C5.,2.  Cervical spondylotic myelopathy.,POSTOPERATIVE DIAGNOSES,1.  Cervical spinal stenosis, C3-C4 and C4-C5.,2.  Cervical spondylotic myelopathy.,OPERATIVE PROCEDURES,1.  Radical anterior discectomy, C3-C4 with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal (CPT 63075).,2.  Radical anterior discectomy C4-C5 with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal (CPT 63076).,3.  Anterior cervical fusion, C3-C4 (CPT 22554),4.  Anterior cervical fusion, C4-C5 (CPT 22585).,5.  Utilization of allograft for purposes of spinal fusion (CPT 20931).,6.  Application of anterior cervical locking plate C3-C5 (CPT 22845).,ANESTHESIA:,  General endotracheal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:  ,250 cc.,OPERATIVE INDICATIONS:  ,The patient is a 50-year-old gentleman who presented to the hospital after a fall, presenting with neck and arm pain as well as weakness.  His MRI confirmed significant neurologic compression in the cervical spine, combined with a clinical exam consistent with radiculopathy, myelopathy, and weakness.  We discussed the diagnosis and the treatment options.  Due to the severity of his neurologic symptoms as well as the amount of neurologic compression seen radiographically, I recommended that he proceed with surgical intervention as opposed to standard nonsurgical treatment such as physical therapy, medications, and steroid injections.  I explained the surgery itself which will be to remove pressure from the spinal cord via anterior cervical discectomy and fusion at C3-C4 and C4-C5.  We reviewed the surgery itself as well as risks including infection and blood vessels or nerves, leakage of spinal fluid, weakness or paralysis, failure of the pain to improve, possible worsening of the pain, failure of the neurologic symptoms to improve, possible worsening of the neurologic symptoms, and possible need for further surgery including re-revision and/or removal.  Furthermore I explained that the fusion may not become solid or that the hardware could break.  We discussed various techniques available for obtaining fusion and I recommended allograft and plate fixation.  I explained the rationale for this as well as the options of using his own bone.  Furthermore, I explained that removing motion at the fusion sites will transfer stress to other disc levels possibly accelerating there degeneration and causing additional symptoms and/or necessitating additional surgery in the future.,OPERATIVE TECHNIQUE: , After obtaining the appropriate signed and informed consent, the patient was taken to the operating room, where he underwent general endotracheal anesthesia without complications.  He was then positioned supine on the operating table, and all bony prominences were padded.  Pulse oximetry was maintained on both feet throughout the case.  The arms were carefully padded and tucked at his sides.  A roll was placed between the shoulder blades.  The areas of the both ears were sterilely prepped and cranial tongs were applied in routine fashion.  Ten pounds of traction was applied.  A needle was taped to the anterior neck and an x-ray was done to determine the appropriate level for the skin incision.  The entire neck was then sterilely prepped and draped in the usual fashion.,A transverse skin incision was made and carried down to the platysma muscle.  This was then split in line with its fibers.  Blunt dissection was carried down medial to the carotid sheath and lateral to the trachea and esophagus until the anterior cervical spine was visualized.  A needle was placed into a disc and an x-ray was done to determine its location.  The longus colli muscles were then elevated bilaterally with the electrocautery unit.  Self-retaining retractors were placed deep to the longus colli muscle in an effort to avoid injury to the sympathetic chains.,Radical anterior discectomies were performed at C3-C4 and C4-C5.  This included complete removal of the anterior annulus, nucleus, and posterior annulus.  The posterior longitudinal ligament was removed as were the posterior osteophytes.  Foraminotomies were then accomplished bilaterally.  Once all of this was accomplished, the blunt-tip probe was used to check for any residual compression.  The central canal was wide open at each level as were the foramen.,A high-speed bur was used to remove the cartilaginous endplates above and below each interspace.  Bleeding cancellous bone was exposed.  The disc spaces were measured and appropriate size allografts were placed sterilely onto the field.  After further shaping of the grafts with the high-speed bur, they were carefully impacted in to position.  There was good juxtaposition against the bleeding decorticated surfaces and good distraction of each interspace.  All weight was then removed from the crania tongs.,The appropriate size anterior cervical locking plate was chosen and bent into gentle lordosis.  Two screws were then placed into each of the vertebral bodies at C3, C4, and C5.  There was excellent purchase.  A final x-ray was done confirming good position of the hardware and grafts.  The locking screws were then applied, also with excellent purchase.,Following a final copious irrigation, there was good hemostasis and no dural leaks.  The carotid pulse was strong.  A drain was placed deep to the level of the platysma muscle and left at the level of the hardware.  The wounds were then closed in layers using 4-0 Vicryl suture for the platysma muscle, 4-0 Vicryl suture for the subcutaneous tissue, and 4-0 Vicryl suture in a subcuticular skin closure.  Steri-Strips were placed followed by application of a sterile dressing.  The drain was hooked to bulb suction.  A Philadelphia collar was applied.,The cranial tongs were carefully removed.  The soft tissue overlying the puncture site was massaged to free it up from the underlying bone.  There was good hemostasis.,The patient was then carefully returned to the supine position on his hospital bed where he was reversed and extubated and taken to the recovery room having tolerated the procedure well.",
" Anterior cervical discectomy for neural decompression and anterior interbody fusion at C4-C5, C5-C6, and C6-C7 utilizing Bengal cages times three.", Neurosurgery, Anterior Cervical Discectomy & Interbody Fusion - 1 ,"PREOPERATIVE DIAGNOSES:  ,1.  Herniated nucleus pulposus, C5-C6, greater than C6-C7 and C4-C5 with left radiculopathy.,2.  Cervical stenosis with cord compression, C5-C6 (723.0).,POSTOPERATIVE DIAGNOSES:  ,1.  Herniated nucleus pulposus, C5-C6, greater than C6-C7 and C4-C5 with left radiculopathy.,2.  Cervical stenosis with cord compression, C5-C6 (723.0), with surgical findings confirmed.,PROCEDURES:  ,1.  Anterior cervical discectomy at C4-C5, C5-C6, and C6-C7 for neural decompression (63075, 63076, 63076).,2.  Anterior interbody fusion at C4-C5, C5-C6, and C6-C7 (22554, 22585, 22585) utilizing Bengal cages times three (22851).,3.  Anterior instrumentation for stabilization by Slim-LOC plate C4, C5, C6, and C7 (22846); with intraoperative x-ray times two.,ANESTHESIA:,  General.,SERVICE: , Neurosurgery.,OPERATION: , The patient was brought into the operating room, placed in a supine position where general anesthesia was administered.  Then the anterior aspect of the neck was prepped and draped in a routine sterile fashion.  A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma, which was dissected in a subplatysmal manner, and then the prevertebral space was encountered and prominent anterior osteophytes were well visualized once longus colli muscle was cauterized along its mesial border, and self-retaining retractors were placed to reveal the anterior osteophytic spaces.  Large osteophytes were excised with a rongeur at C4-5, C5-C6, and C6-C7 revealing a collapsed disc space and a #11 blade was utilized to create an annulotomy at all three interspaces with discectomies being performed with straight disc forceps removing grossly degenerated and very degenerated discs at C4-C5, then at C5-C6, then at C6-C7 sending specimen for permanent section to Pathology in a routine and separate manner.  Residual disc fragments were drilled away as drilling extended into normal cortical and cancellous elements in order to perform a wide decompression all the way posteriorly to the spinal canal itself finally revealing a ligament, which was removed in a similar piecemeal fashion with 1 and 2-mm micro Kerrison rongeurs also utilizing these instruments to remove prominent osteophytes, widely laterally bilaterally at each interspace with one at C4-C5, more right-sided.  The most prominent osteophyte and compression was at C5-C6 followed by C6-C7 and C4-C5 with a complete decompression of the spinal canal allowing the dura to finally bulge into the interspace at all three levels, once the ligaments were proximally removed as well and similarly a sign of a decompressed status.  The nerve roots themselves were inspected with a double ball dissector and found to be equally decompressed.  The wound was irrigated with antibiotic solution and hemostasis was well achieved with pledgets of Gelfoam subsequently irrigated away.  Appropriate size Bengal cages were filled with the patient's own bone elements and countersunk into position, filled along with fusion putty, and once these were quite tightly applied and checked, further stability was added by the placement of a Slim-LOC plate of appropriate size with appropriate size screws, and a post placement x-ray showed well-aligned elements.,The wound was irrigated with antibiotic solution again and inspected, and hemostasis was completely achieved and finally the wound was closed in a routine closure by approximation of the platysma with interrupted 3-0 Vicryl, and the skin with a subcuticular stitch of 4-0 Vicryl, and this was sterilely dressed, and incorporated a Penrose drain, which was carried from the prevertebral space externally to the skin wound and safety pin for security in a routine fashion.  At the conclusion of the case, all instruments, needle, and sponge counts were accurate and correct, and there were no intraoperative complications of any type.","neurosurgery, herniated nucleus pulposus, radiculopathy, cervical stenosis, anterior instrumentation, stabilization, slim-loc, neural decompression, anterior cervical discectomy, cord compression, interbody fusion, bengal cages, interbody, compression, anterior, fusion, decompression, discectomy, cervical"
" Herniated nucleus pulposus, C5-C6, with spinal stenosis.  Anterior cervical discectomy with fusion C5-C6.", Neurosurgery, Anterior Cervical Discectomy & Fusion - 2 ,"PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus, C5-C6, with spinal stenosis.,POSTOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus, C5-C6, with spinal stenosis.,PROCEDURE: , Anterior cervical discectomy with fusion C5-C6.,PROCEDURE IN DETAIL: , The patient was placed in supine position.  The neck was prepped and draped in the usual fashion.  An incision was made from midline to the anterior border of the sternocleidomastoid in the right side.  Skin and subcutaneous tissue were divided sharply.  Trachea and esophagus were retracted medially.  Carotid sheath was retracted laterally.  Longus colli muscles were dissected away from the vertebral bodies of C5-C6.  We confirmed our position by taking intraoperative x-rays.  We then used the operating microscope and cleaned out the disk completely.  We then sized the interspace and then tapped in a #7 mm cortical cancellous graft.  We then used the DePuy Dynamic plate with 14-mm screws.  Jackson-Pratt drain was placed in the prevertebral space and brought out through a separate incision.  The wound was closed in layers using 2-0 Vicryl for muscle and fascia.  The blood loss was less than 10-20 mL.  No complication.  Needle count, sponge count, and cottonoid count was correct.","neurosurgery, carotid sheath, jackson-pratt drain, anterior cervical discectomy, herniated nucleus pulposus, cervical discectomy, herniated nucleus, nucleus pulposus, spinal stenosis, discectomy, fusion, herniated, nucleus, pulposus, spinal, stenosis, anterior"
" Anterior cervical discectomy with decompression C6-C7, arthrodesis with anterior interbody fusion C6-C7, spinal instrumentation using Pioneer 20 mm plate and four 12 x 4.0 mm screws, PEEK implant 7 mm, and Allograft using Vitoss.", Neurosurgery, Anterior Cervical Discectomy & Decompression ,"PREOPERATIVE DIAGNOSES,1.  Left neck pain with left upper extremity radiculopathy.,2.  Left C6-C7 neuroforaminal stenosis secondary to osteophyte.,POSTOPERATIVE DIAGNOSES,1.  Left neck pain with left upper extremity radiculopathy.,2.  Left C6-C7 neuroforaminal stenosis secondary to osteophyte.,OPERATIVE PROCEDURE,1.  Anterior cervical discectomy with decompression C6-C7.,2.  Arthrodesis with anterior interbody fusion C6-C7.,3.  Spinal instrumentation using Pioneer 20 mm plate and four 12 x 4.0 mm screws.,4.  PEEK implant 7 mm.,5.  Allograft using Vitoss.,ANESTHESIA: , General endotracheal anesthesia.,FINDINGS: , Showed osteophyte with a disc complex on the left C6-C7 neural foramen.,FLUIDS:  ,1800 mL of crystalloids.,URINE OUTPUT: , No Foley catheter.,DRAINS:  ,Round French 10 JP drain.,SPECIMENS,:  None.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  250 mL.,The need for an assistant is important in this case, since her absence would mean prolonged operative time and may increase operative morbidity and mortality.,CONDITION: , Extubated with stable vital signs.,INDICATIONS FOR THE OPERATION:,  This is the case of a very pleasant 46-year-old Caucasian female with subarachnoid hemorrhage secondary to ruptured left posteroinferior cerebellar artery aneurysm, which was clipped.  The patient last underwent a right frontal ventricular peritoneal shunt on 10/12/07.  This resulted in relief of left chest pain, but the patient continued to complaint of persistent pain to the left shoulder and left elbow.  She was seen in clinic on 12/11/07 during which time MRI of the left shoulder showed no evidence of rotator cuff tear.  She did have a previous MRI of the cervical spine that did show an osteophyte on the left C6-C7 level.  Based on this, negative MRI of the shoulder, the patient was recommended to have anterior cervical discectomy with anterior interbody fusion at C6-C7 level.  Operation, expected outcome, risks, and benefits were discussed with her.  Risks include, but not exclusive of bleeding and infection, bleeding could be soft tissue bleeding, which may compromise airway and may result in return to the operating room emergently for evacuation of said hematoma.  There is also the possibility of bleeding into the epidural space, which can compress the spinal cord and result in weakness and numbness of all four extremities as well as impairment of bowel and bladder function.  Should this occur, the patient understands that she needs to be brought emergently back to the operating room for evacuation of said hematoma.  There is also the risk of infection, which can be superficial and can be managed with p.o. antibiotics.  However, the patient may develop deeper-seated infection, which may require return to the operating room.  Should the infection be in the area of the spinal instrumentation, this will cause a dilemma since there might be a need to remove the spinal instrumentation and/or allograft.  There is also the possibility of potential injury to the esophageus, the trachea, and the carotid artery.  There is also the risks of stroke on the right cerebral circulation should an undiagnosed plaque be propelled from the right carotid.  There is also the possibility hoarseness of the voice secondary to injury to the recurrent laryngeal nerve.  There is also the risk of pseudoarthrosis and hardware failure.  She understood all of these risks and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE: , The patient brought to the operating room, awake, alert, not in any form of distress.  After smooth induction and intubation, a Foley catheter was inserted.  Monitoring leads were placed by Premier Neurodiagnostics and this revealed normal findings, which remained normal during the entire case.  The EMGs were silent and there was no evidence of any stimulation.  After completion of the placement of the monitoring leads, the patient was positioned supine on the operating table with the neck placed on hyperextension.  The head was supported on a foam doughnut.  The right cervical area was then exposed by turning the head about 45 to 60 degrees to the left side.  A linear incision was made about two to three fingerbreadths from the suprasternal notch along the anterior border of the sternocleidomastoid muscle to a distance of about 3 cm.  The area was then prepped with DuraPrep.,After sterile drapes were laid out, the incision was made using a scalpel blade #10.  Wound edge bleeders were controlled with bipolar coagulation and a hot knife was utilized to carry the dissection down to the platysma in the similar fashion as the skin incision.  The anterior border of the sternocleidomastoid muscle was identified as well as the sternohyoid/omohyoid muscles.  Dissection was then carried lateral and superior to the omohyoid muscle and lateral to the esophagus and the trachea, and medial to the sternocleidomastoid muscle and the carotid sheath.  The prevertebral fascia was identified and cut sharply.  A localizing x-ray verified the marker to be at the C6-C7 interspace.  Proceeded to the strip the longus colli muscles off the vertebral body of C6 and C7.  Self-retaining retractor was then laid out.  The annulus was then cut in a quadrangular fashion and piecemeal removal of the dura was done using a straight pituitary rongeurs, 3 and 5 mm burr.  The interior endplate of C6 and superior endplate of C7 was likewise was drilled down together with posteroinferior edge of C6 and the posterior superior edge of C7.  There was note of a new osteophyte on the left C6-C7 foramen.  This was carefully drilled down.  After decompression and removal of pressure, there was noted to be release of the epidural space with no significant venous bleeders.  They were controlled with slight bipolar coagulation, temporary tamponade with Gelfoam.  After this was completed, Valsalva maneuver showed no evidence of any CSF leakage.  A 7-mm implant was then tapped into placed after its interior was packed with Vitoss.  The plate was then applied and secured in place with four 12 x 4.7 mm screws.  Irrigation of the area was done.  A round French 10 JP drain was laid out over the graft and exteriorized through a separate stab incision on the patient's right inferiorly.  The wound was then closed in layers with Vicryl 3-0 inverted interrupted sutures as well as Vicryl 4-0 subcuticular stitch for the dermis.  The wound was reinforced with Dermabond.  The catheter was anchored to the skin with nylon 3-0 stitch and dressing was applied only at the exit site.  C-collar was placed and the patient was transferred to Recovery after extubation.",
" C5-C6 anterior cervical discectomy, allograft fusion, and anterior plating.", Neurosurgery, Anterior Cervical Discectomy & Fusion - 8 ,"PROCEDURES PERFORMED: , C5-C6 anterior cervical discectomy, allograft fusion, and anterior plating.,ESTIMATED BLOOD LOSS: , 10 mL.,CLINICAL NOTE: , This is a 57-year-old gentleman with refractory neck pain with single-level degeneration of the cervical spine and there was also some arm pain.  We decided go ahead with anterior cervical discectomy at C5-C6 and fusion.  The risks of lack of pain relief, paralysis, hoarse voice, nerve injuries, and infection were explained and the patient agreed to proceed.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room where a general endotracheal anesthesia was induced without complication.  The patient was placed in the slightly extended position with the neck and the head was restrained in a doughnut and the occiput was restrained by the doughnut.  He had tape placed over the shoulders during intraoperative x-rays and his elbows were well padded.  The tape was placed and his arms were well padded.  He was prepped and draped in a sterile fashion.  A linear incision was fashioned at the cricothyroid level from near the midline to over the sternocleidomastoid muscle.  We separated the platysma from the subcutaneous tissue and then opened the platysma along the medial border of the sternocleidomastoid muscle.  We then dissected sharply medial to carotid artery, which we palpated to the prevertebral region.  We placed Caspar retractors for medial and lateral exposure over the C5-C6 disc space, which we confirmed with the lateral cervical spine x-ray including 18-gauge needle in the disc space.  We then marked the disc space.  We then drilled off ventral osteophyte as well as osteophyte creating concavity within the disc space.  We then under magnification removed all the disc material, we could possibly see down to bleeding bone and both the endplates.  We took down posterior longitudinal ligament as well.  We incised the 6-mm cornerstone bone.  We placed a 6-mm parallel medium bone nicely into the disc space.  We then sized a 23-mm plate.  We inserted the screws nicely above and below.  We tightened down the lock-nuts.  We irrigated the wound.  We assured hemostasis using bone wax prior to placing the plate.  We then assured hemostasis once again.  We reapproximated the platysma using 3-0 Vicryl in a simple interrupted fashion.  The subcutaneous level was closed using 3-0 Vicryl in a simple buried fashion.  The skin was closed with 3-0 Monocryl in a running subcuticular stitch.  Steri-Strips were applied.  Dry sterile dressing with Telfa was applied over this.  We obtained an intraoperative x-ray to confirm the proper level and good position of both plates and screw construct on the lateral x-ray and the patient was transferred to the recovery room, moving all four extremities with stable vital signs.  I was present as a primary surgeon throughout the entire case.","neurosurgery, allograft fusion, anterior cervical discectomy, neck pain, cervical spine, discectomy, fusion, sternocleidomastoid muscle, assured hemostasis, anterior cervical, cervical discectomy, disc space, cervical, anterior, allograft"
 Anterior cervical discectomy with decompression of spinal cord.  Anterior cervical fusion.  Anterior cervical instrumentation.  Insertion of intervertebral device.  Use of operating microscope., Neurosurgery, Anterior Cervical Discectomy & Fusion - 6 ,"PREOPERATIVE DIAGNOSIS:  ,Symptomatic disk herniation, C7-T1.,FINAL DIAGNOSIS:  ,Symptomatic disk herniation, C7-T1.,PROCEDURES PERFORMED,1.  Anterior cervical discectomy with decompression of spinal cord C7-T1.,2.  Anterior cervical fusion, C7-T1.,3.  Anterior cervical instrumentation, anterior C7-T1.,4.  Insertion of intervertebral device, C7-T1.,5.  Use of operating microscope.,ANESTHESIOLOGY: , General endotracheal.,ESTIMATED BLOOD LOSS:  ,A 30 mL.,PROCEDURE IN DETAIL:  ,The patient was taken to the operating room where he was orally intubated by The Anesthesiology Service.  He was placed in the supine position on an OR table.  His arms were carefully taped down.  He was sterilely prepped and draped in the usual fashion.,A 4-cm incision was made obliquely over the left side of his neck.  Subcutaneous tissue was dissected down to the level of the platysma.  The platysma was incised using electrocautery.  Blunt dissection was done to create a plane between the strap muscles and the sternoclavicular mastoid muscle.  This allowed us to get right down on to the anterior cervical spine.  Blunt dissection was done to sweep off the longus colli.  We isolated the C7-T1 interspace.  An x-ray was taken to verify; we were indeed at the C7-T1 interspace.,Shadow-Line retractor was placed as well as Caspar pins.  This provided very, very good access to the C7-T1 disk.,At this point, the operating microscope was brought into the decompression.,A thorough and aggressive C7-T1 discectomy was done using a succession of curettes, pituitary rongeur, 4-mm cutting bur and a #2 Kerrison rongeur.  At the end of the discectomy, the cartilaginous endplates were carefully removed using 4-mm cutting burr.  The posterior longitudinal ligament was carefully resected using #2 Kerrison rongeur.  Left-sided C8 foraminotomy was accomplished using nerve hook and a 2-mm Kerrison rongeur.  At the end of the decompression, there was no further compression on the left C8 nerve root.,A Synthes cortical cancellous ____________ bone was placed in the interspace.  Sofamor Danek Atlantis plate was then placed over the interspace and four screws were placed, two in the body of C7 and two in the body of T1.  An x-ray was taken.  It showed good placement of the plate and screws.,A deep drain was placed.  The platysma layer was closed in running fashion using #1 Vicryl.  Subcutaneous tissue was closed in an interrupted fashion using 2-0 Vicryl.  Skin was closed in a running fashion using 4-0 Monocryl.  Steri-Strips and dressings were applied.  All counts were correct.  There were no complications.","neurosurgery, disk herniation, cervical discectomy, decompression, spinal cord, anterior cervical fusion, anterior cervical discectomy, kerrison rongeur, anterior cervical, instrumentation, cervical, anterior, platysma, kerrison, fashion, interspace, rongeur, discectomy, herniation,"
 Anterior cervical discectomy with decompression and arthrodesis with anterior interbody fusion.  Spinal instrumentation using Pioneer 18-mm plate and four 14 x 4.3 mm screws (all titanium)., Neurosurgery, Anterior Cervical Discectomy & Fusion - 4 ,"PREOPERATIVE DIAGNOSIS: , Cervical myelopathy, C3-4, secondary to stenosis from herniated nucleus pulposus, C3-4.,POSTOPERATIVE DIAGNOSES: , Cervical myelopathy, C3-4, secondary to stenosis from herniated nucleus pulposus, C3-4.,OPERATIVE PROCEDURES,1.  Anterior cervical discectomy with decompression, C3-4.,2.  Arthrodesis with anterior interbody fusion, C3-4.,3.  Spinal instrumentation using Pioneer 18-mm plate and four 14 x 4.3 mm screws (all titanium).,4.  Implant using PEEK 7 mm.,5.  Allograft using Vitoss.,DRAINS: , Round French 10 JP drain.,FLUIDS: , 1800 mL of crystalloids.,URINE OUTPUT:  ,1000 mL.,SPECIMENS: , None.,COMPLICATIONS:  ,None.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS:  ,Less than 100 mL.,CONDITION:  ,To postanesthesia care unit extubated with stable vital signs.,INDICATIONS FOR THE OPERATION:  ,This is a case of a very pleasant 32-year-old Caucasian male who had been experiencing posterior neck discomfort and was shooting basketball last week, during which time he felt a pop.  Since then, the patient started complaining of acute right arm and right leg weakness, which had been progressively worsening.  About two days ago, he started noticing weakness on the left arm.  The patient also noted shuffling gait.  The patient presented to a family physician and was referred to Dr. X for further evaluation.  Dr. X could not attempt to this, so he called me at the office and the patient was sent to the emergency room, where an MRI of the brain was essentially unremarkable as well as MRI of the thoracic spine.  MRI of the cervical spine, however, revealed an acute disk herniation at C3-C4 with evidence of stenosis and cord changes.  Based on these findings, I recommended decompression.  The patient was started on Decadron at 10 mg IV q.6h.  Operation, expected outcome, risks, and benefits were discussed with him.  Risks to include but not exclusive of bleeding and infection.  Bleeding can be superficial, but can compromise airway, for which he has been told that he may be brought emergently back to the operating room for evacuation of said hematoma.  The hematoma could also be an epidural hematoma, which may compress the spinal cord and result in weakness of all four extremities, numbness of all four extremities, and impairment of bowel and bladder function.  Should this happen, he needs to be brought emergently back to the operating room for evacuation of said hematoma.  There is also the risk by removing the hematoma that he can deteriorate as far as neurological condition, but this hopefully with the steroid prep will be prevented or if present will only be transient.  There is also the possibility of infection, which can be superficial and treated with IV and p.o. antibiotics.  However, should the infection be extensive or be deep, he may require return to the operating room for debridement and irrigation.  This may pose a medical problem since in the presence of infection, the graft as well as spinal instrumentation may have to be removed.  There is also the possibility of dural tear with its attendant complaints of headache, nausea, vomiting, photophobia, as well as the development of pseudomeningocele.  This too can compromise airway and may require return to the operating room for repair of the dural tear.  There is also potential risk of injury to the esophagus, the trachea, as well as the carotid.  The patient can also have a stroke on the right cerebral circulation should the plaque be propelled into the right circulation.  The patient understood all these risks together with the risk associated with anesthesia and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room, awake, alert and not in any form of distress.  After smooth induction and intubation, a Foley catheter was inserted.  No monitoring leads were placed.  The patient was then positioned supine on the operating table with the head supported on a foam doughnut and the neck placed on hyperextension with a shoulder roll under both shoulders.  Localizing x-ray verified the marker to be right at the C3-4 interspace.  Proceeded to mark an incision along the anterior border of the sternocleidomastoid with the central point at the area of the marker measuring about 3 cm in length.  The area was then prepped with DuraPrep.,After sterile drapes were laid out, an incision was made using a scalpel blade #10.  Wound edge bleeders were controlled with bipolar coagulation and a hot knife was utilized to cut the platysma in a similar fashion.  The anterior border of the sternocleidomastoid was identified and dissection was carried superior to and lateral to the esophagus and trachea, but medial to the carotid sheath.  The prevertebral fascia was identified.  Localizing x-ray verified another marker to be at the C3-4 interspace.  Proceeded to strip the longus colli muscles off the vertebral body of C3 and C4 and a self-retaining retractor was then laid out.  There was some degree of anterior osteophyte and this was carefully drilled down with a Midas 5-mm bur.  The disk was then cut through the annulus and removal of the disk was done with the use of the Midas 5-mm bur and later a 3-mm bur.  The inferior endplate of C3 and the superior endplate of C4 were likewise drilled out together with posterior inferior osteophyte at the C3 and the posterior superior osteophyte at C4.  There was note of a central disk herniation centrally, but more marked displacement of the cord on the left side.  By careful dissection of this disk, posterior longitudinal ligament was removed and pressure on the cord was removed.  Hemostasis of the epidural bleeders was done with a combination of bipolar coagulation, but we needed to put a small piece of Gelfoam on the patient's left because of profuse venous bleeder.  With this completed, the Valsalva maneuver showed no evidence of any CSF leakage.  A 7-mm implant with its interior packed with Vitoss was then tapped into place.  An 18-mm plate was then screwed down with four 14 x 4.0 mm screws.  The area was irrigated with saline, with bacitracin solution.  Postoperative x-ray showed excellent placement of the graft and spinal instrumentation.  A round French 10 JP drain was laid over the construct and exteriorized though a separate stab incision on the patient's right inferiorly.  The wound was then closed in layers with Vicryl 3-0 inverted interrupted sutures for the platysma, Vicryl 4-0 subcuticular stitch for the dermis and Dermabond.  The catheter was anchored to the skin with a nylon 3-0 stitch.  Dressing was placed only on the exit site of the drain.  C-collar was placed, and the patient was transferred to the recovery awake and moving all four extremities.",
" Anterior cervical discectomy C4-C5 arthrodesis with 8 mm lordotic ACF spacer, corticocancellous, and stabilization with Synthes Vector plate and screws.  Cervical spondylosis and herniated nucleus pulposus of C4-C5.", Neurosurgery, Anterior Cervical Discectomy & Arthrodesis - 2 ,"PREOPERATIVE DIAGNOSIS:  ,Cervical spondylosis and herniated nucleus pulposus of C4-C5.,POSTOPERATIVE DIAGNOSIS:,  Cervical spondylosis and herniated nucleus pulposus of C4-C5.,TITLE OF OPERATION:,  Anterior cervical discectomy C4-C5 arthrodesis with 8 mm lordotic ACF spacer, corticocancellous, and stabilization with Synthes Vector plate and screws.,ESTIMATED BLOOD LOSS:,  Less than 100 mL.,OPERATIVE PROCEDURE IN DETAIL: , After identification, the patient was taken to the operating room and placed in supine position.  Following the induction of satisfactory general endotracheal anesthesia, the patient was prepared for surgery.  A shoulder roll was placed between the scapula and the head was rested on a doughnut in a slightly extended position.  A preoperative x-ray was obtained to identify the operative level and neck position.  An incision was marked at the C4-C5 level on the right side.  The incision was opened with #10 blade knife.  Dissection was carried down through subcutaneous tissues using Bovie electrocautery.  The platysma muscle was divided with the cautery and mobilized rostrally and caudally.  The anterior border of sternocleidomastoid muscle was then dissected rostrally and caudally with sharp and blunt dissection.  The avascular plane was then entered and dissection was carried bluntly down to the anterior cervical fascia.  This was opened with scissors and dissected rostrally and caudally with the peanut dissectors.  The operative level was confirmed with an intraoperative x-ray.  The longus colli muscles were mobilized bilaterally using bipolar electrocautery and periosteal elevator.  The anterior longitudinal ligament was then taken down with the insulated Bovie electrocautery tip exposing the vertebral bodies of C4 and C5.  Self-retaining retractor was placed in submuscular position, and distraction pins were placed in the vertebral bodies of C4 and C5, and distraction was instituted.  We then incise the annulus of C4-C5 and a discectomy was now carried out using pituitary rongeurs and straight and angled curettes.  Operating microscope was draped and brought into play.  Dissection was carried down through the disc space to the posterior aspect of the disc space removing the disc with the angled curette as we went.  We now use the diamond bit to thin the posterior bone spurs and osteophytes at the uncovertebral joints bilaterally.  Bone was then removed with 2 mm Kerrison punch and then we were able to traverse the posterior longitudinal ligament and this ligament was now removed in a piecemeal fashion with a 2 mm Kerrison punch.  There was a transligamentous disc herniation, which was removed during this process.  We then carried out bilateral foraminotomies with removal of the uncovertebral osteophytes until the foramina were widely patent.  Cord was seen to be pulsating freely behind the dura.  There appeared to be no complications and the decompression appeared adequate.  We now used a cutting bit to prepare the inner space for arthrodesis fashioning a posterior ledge on the posterior aspect of the C5 vertebral body.  An 8 mm lordotic trial was used and appeared perfect.  We then used a corticocancellous 8 mm lordotic graft.  This was tapped into position.  Distraction was released, appeared to be in excellent position.  We then positioned an 18 mm Vector plate over the inner space.  Intraoperative x-ray was obtained with the stay screw in place; plates appeared to be in excellent position.  We then use a 14 mm self-tapping variable angle screws in each of the four locations drilling 14 mm pilot holes at each location prior to screw insertion.  All of the screws locked to the plate and this was confirmed on visual inspection.  Intraoperative x-ray was again obtained.  Construct appeared satisfactory.  Attention was then directed to closure.  The wound was copiously irrigated.  All of the self-retaining retractors were removed.  Bleeding points were controlled with bone wax and bipolar electrocautery.  The platysma layer was now closed with interrupted 3-0 Vicryl sutures.  The skin was closed with running 3-0 Vicryl subcuticular stitch.  Steri-Strips were applied.  A sterile bandage was applied.  All sponge, needle, and cottonoid counts were reported as correct.  The patient tolerated the procedure well.  He was subsequently extubated in the operating room and transferred to PACU in satisfactory condition.","neurosurgery, synthes vector plate, lordotic, acf spacer, corticocancellous, arthrodesis, anterior cervical discectomy, herniated nucleus pulposus, anterior, cervical, spacer, screws, discectomy, "
 Anterior cervical discectomy fusion C3-C4 and C4-C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure.  Cervical spondylotic myelopathy with cord compression and cervical spondylosis., Neurosurgery, Anterior Cervical Discectomy & Fusion ,"PREOPERATIVE DIAGNOSES:,  Cervical spondylotic myelopathy with cord compression and cervical spondylosis.,POSTOPERATIVE DIAGNOSES:,  Cervical spondylotic myelopathy with cord compression and cervical spondylosis.  In addition to this, he had a large herniated disk at C3-C4 in the midline.,PROCEDURE: , Anterior cervical discectomy fusion C3-C4 and C4-C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure.,PROCEDURE IN DETAIL: , The patient placed in the supine position, the neck was prepped and draped in the usual fashion.  Incision was made in the midline the anterior border of the sternocleidomastoid at the level of C4.  Skin, subcutaneous tissue, and vertebral muscles divided longitudinally in the direction of the fibers and the trachea and esophagus was retracted medially.  The carotid sheath was retracted laterally after dissecting the longus colli muscle away from the vertebral osteophytes we could see very large osteophytes at C4-C5.  It appeared that the C5-C6 disk area had fused spontaneously.  We then confirmed that position by taking intraoperative x-rays and then proceeded to do discectomy and fusion at C3-C4, C4-C5.,After placing distraction screws and self-retaining retractors with the teeth beneath the bellies of the longus colli muscles, we then meticulously removed the disk at C3-C4, C4-C5 using the combination of angled strip, pituitary rongeurs, and curettes after we had incised the anulus fibrosus with #15 blade.,Next step was to totally decompress the spinal cord using the operating microscope and high-speed cutting followed by the diamond drill with constant irrigation.  We then drilled off the uncovertebral osteophytes and midline osteophytes as well as thinning out the posterior longitudinal ligaments.  This was then removed with 2-mm Kerrison rongeur.  After we removed the posterior longitudinal ligament, we could see the dura pulsating nicely.  We did foraminotomies at C3-C4 as well as C4-C5 as well.  After having totally decompressed both the cord as well as the nerve roots of C3-C4, C4-C5, we proceeded to the next step, which was a fusion.,We sized two 8-mm cortical cancellous grafts and after distracting the bone at C3-C4, C4-C5, we gently tapped the grafts into place.  The distraction was removed and the grafts were now within.  We went to the next step for the procedure, which was the instrumentation and stabilization of the fused area.,We then placed a titanium ABC plate from C3-C5, secured it with 16-mm titanium screws.  X-rays showed good position of the screws end plate.,The next step was to place Jackson-Pratt drain to the vertebral fascia.  Meticulous hemostasis was obtained.  The wound was closed in layers using 2-0 Vicryl for the subcutaneous tissue.  Steri-Strips were used for skin closure.  Blood loss less than about 200 mL.  No complications of the surgery.  Needle counts, sponge count, and cottonoid count was correct.","neurosurgery, titanium plates fixation, bone black bone procedure, anterior cervical discectomy, titanium plates, cervical discectomy, spondylotic myelopathy, cord compression, cervical spondylosis, foraminotomies, cervical, anterior "
" Anterior cervical discectomy and fusion, C2-C3, C3-C4.  Removal of old instrumentation, C4-C5.  Fusion C3-C4 and C2-C3 with instrumentation using ABC plates.", Neurosurgery, Anterior Cervical Discectomy & Fusion - 1 ,"PREOPERATIVE DIAGNOSES,1.  Herniated nucleus pulposus C2-C3.,2.  Spinal stenosis C3-C4.,POSTOPERATIVE DIAGNOSES,1.  Herniated nucleus pulposus C2-C3.,2.  Spinal stenosis C3-C4.,PROCEDURES,1.  Anterior cervical discectomy, C3-C4, C2-C3.,2.  Anterior cervical fusion, C2-C3, C3-C4.,3.  Removal of old instrumentation, C4-C5.,4.  Fusion C3-C4 and C2-C3 with instrumentation using ABC plates.,PROCEDURE IN DETAIL: , The patient was placed in the supine position.  The neck was prepped and draped in the usual fashion for anterior cervical discectomy.  A high incision was made to allow access to C2-C3.  Skin and subcutaneous tissue and the platysma were divided sharply exposing the carotid sheath which was retracted laterally and the trachea and esophagus were retracted medially.  This exposed the vertebral bodies of C2-C3 and C4-C5 which was bridged by a plate.  We placed in self-retaining retractors.  With the tooth beneath the blades, the longus colli muscles were dissected away from the vertebral bodies of C2, C3, C4, and C5.  After having done this, we used the all-purpose instrumentation to remove the instrumentation at C4-C5, we could see that fusion at C4-C5 was solid.,We next proceeded with the discectomy at C2-C3 and C3-C4 with disc removal.  In a similar fashion using a curette to clean up the disc space and the space was fairly widened, as well as drilling up the vertebral joints using high-speed cutting followed by diamond drill bit.  It was obvious that the C3-C4 neural foramina were almost totally obliterated due to the osteophytosis and foraminal stenosis.  With the operating microscope; however, we had good visualization of these nerve roots, and we were able to ___________ both at C2-C3 and C3-C4.  We then placed the ABC 55-mm plate from C2 down to C4.  These were secured with 16-mm titanium screws after excellent purchase.  We took an x-ray which showed excellent position of the plate, the screws, and the graft themselves.  The next step was to irrigate the wound copiously with saline and bacitracin solution and s Jackson-Pratt drain was placed in the prevertebral space and brought out through a separate incision.  The wound was closed with 2-0 Vicryl for subcutaneous tissues and Steri-Strips used to close the skin.  Blood loss was about 50 mL.  No complication of the surgery.  Needle count, sponge count, cottonoid count was correct.,The operating microscope was used for the entirety for both visualization and magnification and illumination which was quite superb.  At the time of surgery, he had total collapse of the C2, C3, and C4 disc with osteophyte formation.  At both levels, he has high-grade spinal stenosis at these levels, especially foramen stenosis causing the compression, neck pain, headaches, and arm and shoulder pain.  He does have degenerative changes at C5-C6, C6-C7, C7-T1; however, they do not appear to be symptomatic, although x-rays show the disks to be partially collapsed at all levels with osteophyte formation beginning to form.","neurosurgery, abc plates, osteophyte, cervical, discectomy, cervical fusion, herniated nucleus pulposus, anterior cervical discectomy, nucleus pulposus, vertebral bodies, osteophyte formation, spinal stenosis, cervical discectomy, anterior, instrumentation, vertebral, stenosis, fusion"
" Anterior cervical discectomy with decompression, anterior cervical fusion, anterior cervical instrumentation, and Allograft C5-C6.", Neurosurgery, Anterior Cervical Discectomy & Decompression - 1 ,"PREOPERATIVE DIAGNOSES,1.  Herniated disc, C5-C6.,2.  Cervical spondylosis, C5-C6.,POSTOPERATIVE DIAGNOSES,1.  Herniated disc, C5-C6.,2.  Cervical spondylosis, C5-C6.,PROCEDURES,1.  Anterior cervical discectomy with decompression, C5-C6.,2.  Anterior cervical fusion, C5-C6.,3.  Anterior cervical instrumentation, C5-C6.,4.  Allograft C5-C6.,ANESTHESIA:  ,General endotracheal.,COMPLICATIONS:,  None.,PATIENT STATUS: , Taken to recovery room in stable condition.,INDICATIONS: , The patient is a 36-year-old female who has had severe, recalcitrant right upper extremity pain, numbness, tingling, shoulder pain, axial neck pain, and headaches for many months.  Nonoperative measures failed to relieve her symptoms and surgical intervention was requested.  We discussed reasonable risks, benefits, and alternatives of various treatment options.  Continuation of nonoperative care versus the risks associated with surgery were discussed.  She understood the risks including bleeding, nerve vessel damage, infection, hoarseness, dysphagia, adjacent segment degeneration, continued worsening pain, failed fusion, and potential need for further surgery.  Despite these risks, she felt that current symptoms will be best managed operatively.,SUMMARY OF SURGERY IN DETAIL: , Following informed consent and preoperative administration of antibiotics, the patient was brought to the operating suite.  General anesthetic was administered.  The patient was placed in the supine position.  All prominences and neurovascular structures were well accommodated.  The patient was noted to have pulse in this position.  Preoperative x-rays revealed appropriate levels for skin incision.  Ten pound inline traction was placed via Gardner-Wells tongs and shoulder roll was placed.  The patient was then prepped and draped in sterile fashion.  Standard oblique incision was made over the C6 vertebral body in the proximal nuchal skin crease.  Subcutaneous tissue was dissected down to the level of the omohyoid which was transected.  Blunt dissection was carried out with the trachea and the esophagus in the midline and the carotid sheath in its vital structures laterally.  This was taken down to the prevertebral fascia which was bluntly split.  Intraoperative x-ray was taken to ensure proper levels.  Longus colli was identified and reflected proximally 3 to 4 mm off the midline bilaterally so that the anterior cervical Trimline retractor could be placed underneath the longus colli, thus placing no new traction on the surrounding vital structures.  Inferior spondylosis was removed with high-speed bur.  A scalpel and curette was used to remove the disc.  Decompression was carried posterior to the posterior longitudinal ligament down to the uncovertebral joints bilaterally.  Disc herniation was removed from the right posterolateral aspect of the interspace.  High-speed bur was used to prepare the endplate down to good bleeding bone and preparation for fusion.  Curette and ball tip dissector was then passed out the foramen and along the ventral aspect of the dura.  No further evidence of compression was identified.  Hemostasis was achieved with thrombin-soaked Gelfoam.  Interspace was then distracted with Caspar pin distractions set gently.  Interspace was then gently retracted with the Caspar pin distraction set.  An 8-mm allograft was deemed in appropriate fit.  This was press fit with demineralized bone matrix and tamped firmly into position achieving excellent interference fit.  The graft was stable to pull-out forces.  Distraction and traction was then removed and anterior cervical instrumentation was completed using a DePuy Trimline anterior cervical plate with 14-mm self-drilling screws.  Plate and screws were then locked to the plate.  Final x-rays revealed proper positioning of the plate, excellent distraction in the disc space, and apposition of the endplates and allograft.  Wounds were copiously irrigated with normal saline.  Omohyoid was approximated with 3-0 Vicryl.  Running 3-0 Vicryl was used to close the platysma.  Subcuticular Monocryl and Steri-Strips were used to close the skin.  A deep drain was placed prior to wound closure.  The patient was then allowed to awake from general anesthetic and was taken to the recovery room in stable condition.  There were no intraoperative complications.  All needle and sponge counts were correct.  Intraoperative neurologic monitoring was used throughout the entirety of the case and was normal.","neurosurgery, cervical spondylosis, cervical fusion, decompression, instrumentation, anterior cervical discectomy, anterior cervical, herniated disc, cervical discectomy, anterior, cervical, fusion, allograft, discectomy"
" Anterior cervical discectomy, arthrodesis, partial corpectomy, Machine bone allograft, placement of anterior cervical plate with a Zephyr.
7.  Microscopic dissection.", Neurosurgery, Anterior Cervical Discectomy & Arthrodesis ,"PREOPERATIVE DIAGNOSIS:,  Cervical myelopathy secondary to very large disc herniations at C4-C5 and C5-C6.,POSTOPERATIVE DIAGNOSIS: , Cervical myelopathy secondary to very large disc herniations at C4-C5 and C5-C6.,PROCEDURE PERFORMED:,1.  Anterior cervical discectomy, C4-C5 and C5-C6.,2.  Arthrodesis, C4-C5 and C5-C6.,3.  Partial corpectomy, C5.,4.  Machine bone allograft, C4-C5 and C5-C6.,5.  Placement of anterior cervical plate with a Zephyr C4 to C6.,6.  Fluoroscopic guidance.,7.  Microscopic dissection.,ANESTHESIA:,  General.,ESTIMATED BLOOD LOSS: , 60 mL.,COMPLICATIONS: , None.,INDICATIONS:,  This is a patient who presents with progressive weakness in the left upper extremity as well as imbalance.  He has also noted to have cord signal at the C4-C5 level secondary to a very large disc herniation that came behind the body at C5 as well and as well as a large disc herniation at C5-C6.  Risks and benefits of the surgery including bleeding, infection, neurologic deficit, nonunion, progressive spondylosis, and lack of improvement were all discussed.  He understood and wished to proceed.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room and placed in the supine position.  Preoperative antibiotics were given.  The patient was placed in the supine position with all pressure points noted and well padded.  The patient was prepped and draped in standard fashion.  An incision was made approximately above the level of the cricoid.  Blunt dissection was used to expose the anterior portion of the spine with carotid moved laterally and trachea and esophagus moved medially.  We then placed needle into the disc spaces and was found to be at C5-C6.  Distracting pins were placed in the body of C4 and in to the body of C6.  The disc was then completely removed at C4-C5.  There was very significant compression of the cord.  This was carefully removed to avoid any type of pressure on the cord.  This was very severe and multiple free fragments were noted.  This was taken down to the level of ligamentum.  Both foramen were then also opened.  Other free fragments were also found behind the body of C5, part of the body of C5 was taken down to assure that all of these were removed.  The exact same procedure was done at C5-C6; however, if there were again free fragments noted, there was less not as severe compression at the C4-C5 area.  Again part of the body at C5 was removed to make sure that there was no additional constriction.  Both nerve roots were then widely decompressed.  Machine bone allograft was placed into the C4-C5 as well as C5-C6 and then a Zephyr plate was placed in the body of C4 and to the body of C6 with a metal pin placed into the body at C5.  Excellent purchase was obtained.  Fluoroscopy showed good placement and meticulous hemostasis was obtained.  Fascia was closed with 3-0 Vicryl, subcuticular 3-0 Dermabond for skin.  The patient tolerated the procedure well and went to recovery in good condition.","neurosurgery, fluoroscopic guidance, microscopic dissectio, cervical plate, zephyr, corpectomy, arthrodesis, anterior cervical discectomy, machine bone allograft, cervical discectomy, bone allograft, disc herniations, anterior, cervical, discectomy,"
" Arthrodesis - anterior interbody technique, anterior cervical discectomy, anterior instrumentation with a 23-mm Mystique plate and the 13-mm screws, implantation of machine bone implant.  Disc herniation with right arm radiculopathy.", Neurosurgery, Anterior Cervical Discectomy & Arthrodesis - 1 ,"PREOPERATIVE DIAGNOSES: , C5-C6 disc herniation with right arm radiculopathy.,POSTOPERATIVE DIAGNOSES: , C5-C6 disc herniation with right arm radiculopathy.,PROCEDURE:,1.  C5-C6 arthrodesis, anterior interbody technique.,2.  C5-C6 anterior cervical discectomy.,3.  C5-C6 anterior instrumentation with a 23-mm Mystique plate and the 13-mm screws.,4.  Implantation of machine bone implant.,5.  Microsurgical technique.,ANESTHESIA:  ,General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,BACKGROUND INFORMATION AND SURGICAL INDICATIONS:  ,The patient is a 45-year-old right-handed gentleman who presented with neck and right arm radicular pain.  The pain has become more and more severe.  It runs to the thumb and index finger of the right hand and it is accompanied by numbness.  If he tilts his neck backwards, the pain shoots down the arm.  If he is working with the computer, it is very difficult to use his mouse.  He tried conservative measures and failed to respond, so he sought out surgery.  Surgery was discussed with him in detail.  A C5-C6 anterior cervical discectomy and fusion was recommended.  He understood and wished to proceed with surgery.  Thus, he was brought in same day for surgery on 07/03/2007.,DESCRIPTION OF PROCEDURE: , He was given Ancef 1 g intravenously for infection prophylaxis and then transported to the OR.  There general endotracheal anesthesia was induced.  He was positioned on the OR table with an IV bag between the scapulae.  The neck was slightly extended and taped into position.  A metal arch was placed across the neck and intraoperative x-ray was obtain to verify a good position for skin incision and the neck was prepped with Betadine and draped in the usual sterile fashion.,A linear incision was created in the neck beginning just to the right of the midline extending out across the anterior border of the sternocleidomastoid muscle.  The incision was extended through skin, subcutaneous fat, and platysma.  Hemostasis was assured with Bovie cautery.  The anterior aspect of the sternocleidomastoid muscle was identified and dissection was carried medial to this down to the carotid sheath.  The trachea and the esophagus were swept out of the way and dissection proceeded medial to the carotid sheath down between the two bellies of the longus colli muscle on to the anterior aspect of the spine.  A Bovie cautery was used to mobilize the longus colli muscle around initially what turned out to be C6-C7 disk based on x-rays and then around the C5-C6 disk space.  An intraoperative x-ray confirmed C5-C6 disk space had been localized and then the self-retained distraction system was inserted to maintain exposure.  A 15-blade knife was used to incise the C5-C6 disk and remove disk material. and distraction pins were inserted into C5-C6 and distraction placed across the disk space.  The operating microscope was then brought into the field and used throughout the case except for the closure.  Various pituitaries, #15 blade knife, and curette were used to evacuate the disk as best as possible.  Then, the Midas Rex drill was taken under the microscope and used to drill where the cartilaginous endplate driven back all the way into the posterior aspect of the vertebral body.  A nerve hook was swept underneath the posterior longitudinal ligament and a fragment of disk was produced and was pulled up through the ligament.  A Kerrison rongeur was used to open up the ligament in this opening and then to march out in the both neural foramina.  A small amount of disk material was found at the right neural foramen.  After a good decompression of both neural foramina was obtained and the thecal sac was exposed throughout the width of the exposure, the wound was thoroughly irrigated.  A spacing mechanism was intact into the disk space and it was determined that a #7 spacer was appropriate.  So, a #7 machine bone implant was taken and tapped into disk space and slightly counter sunk.  The wound was thoroughly irrigated and inspected for hemostasis.  A Mystique plate 23 mm in length was then inserted and anchored to the anterior aspect of C5-C6 to hold the bone into position and the wound was once again irrigated.  The patient was valsalved.  There was no further bleeding seen and intraoperative x-ray confirmed a good position near the bone, plate, and screws and the wound was enclosed in layers.  The 3-0 Vicryl was used to approximate platysma and 3-0 Vicryl was used in inverted interrupted fashion to perform a subcuticular closure of the skin.  The wound was cleaned.,Mastisol was placed on the skin, and Steri-strips were used to approximate skin margins.  Sterile dressing was placed on the patient's neck.  He was extubated in the OR and transported to the recovery room in stable condition.  There were no complications.","neurosurgery, herniation, radiculopathy, interbody, mystique, bone implant, anterior cervical discectomy, neural foramina, mystique plate, disc herniation, arm radiculopathy, cervical discectomy, disk space, disk, cervical, anterior, wound, discectomy,"
 Anterior cervical discectomy and removal of herniated disk and osteophytes and decompression of spinal cord and bilateral nerve root decompression.  Harvesting of autologous bone from the vertebral bodies.  Grafting of allograft bone for creation of arthrodesis., Neurosurgery, Anterior Cervical Discectomy ,"PREOPERATIVE DIAGNOSES,1.  Cervical spondylosis with myelopathy.,2.  Herniated cervical disk, C4-C5.,POSTOPERATIVE DIAGNOSES,1.  Cervical spondylosis with myelopathy.,2.  Herniated cervical disk, C4-C5.,OPERATIONS PERFORMED,1.  Anterior cervical discectomy and removal of herniated disk and osteophytes and decompression of spinal cord at C5-C6.,2.  Bilateral C6 nerve root decompression.,3.  Anterior cervical discectomy at C4-C5 with removal of herniated disk and osteophytes and decompression of spinal cord.,4.  Bilateral C5 nerve root decompression.,5.  Anterior cervical discectomy at C3-C4 with removal of herniated disk and osteophytes, and decompression of spinal cord.,6.  Bilateral C4 nerve root decompression.,7.  Harvesting of autologous bone from the vertebral bodies.,8.  Grafting of allograft bone for creation of arthrodesis.,9.  Creation of arthrodesis with allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C5-C6.,10.  Creation of additional arthrodesis using allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C4-C5.,11.  Creation of additional arthrodesis using allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C3-C4.,12.  Placement of anterior spinal instrumentation from C3 to C6 using a Synthes Small Stature Plate, using the operating microscope and microdissection technique.,INDICATIONS FOR PROCEDURE: , This 62-year-old man has severe cervical spondylosis with myelopathy and cord compression at C5-C6.  There was a herniated disk with cord compression and radiculopathy at C4-C5.  C3-C4 was the source of neck pain as documented by facet injections.,A detailed discussion ensued with the patient as to the pros and cons of the surgery by two levels versus three levels.  Because of the severe component of the neck pain that has been relieved with facet injections, we elected to proceed ahead with anterior cervical discectomy and fusion at C3-C4, C4-C5, and C5-C6.,I explained the nature of this procedure in great detail including all risks and alternatives.  He clearly understands and has no further questions and requests that I proceed.,PROCEDURE:  ,The patient was placed on the operating room table and was intubated taking great care to keep the neck in a neutral position.  The methylprednisolone spinal cord protocol was instituted with bolus and continuous infusion dosages.,The left side of the neck was carefully prepped and draped in the usual sterile manner.,A transverse incision was made in the neck crease.  Dissection was carried down through the platysma musculature and the anterior spine was exposed.  The medial borders of the longus colli muscle were dissected free from their attachments to the spine.  Caspar self-retaining pins were placed into the bodies of C3, C4, C5, and C6 and x-ray localization was obtained.  A needle was placed in what was revealed to be the disk space at C4-C5 and an x-ray confirmed proper localization.,Self-retaining retractors were then placed in the wound, taking great care to keep the blades of the retractors underneath the longus colli muscles.,First I removed the large amount of anterior overhanging osteophytes at C5-C6 and distracted the space.  The high-speed cutting bur was used to drill back the osteophytes towards the posterior lips of the vertebral bodies.,An incision was then made at C4-C5 and the annulus was incised and a discectomy was performed back to the posterior lips of the vertebral bodies.,The retractors were then adjusted and again discectomy was performed at C3-C4 back to the posterior lips of the vertebral bodies.  The operating microscope was then utilized.,Working under magnification, I started at C3-C4 and began to work my way down to the posterior longitudinal ligament.  The ligament was incised and the underlying dura was exposed.  I worked out laterally towards the takeoff of the C4 nerve root and widely decompressed the nerve root edge of the foramen.  There were a large number of veins overlying the nerve root which were oozing and rather than remove these and produce tremendous amount of bleeding, I left them intact.  However, I could to palpate the nerve root along the pedicle into the foramen and widely decompressed it on the right.  The microscope was angled to the left side where similar decompression was achieved.,The retractors were readjusted and attention was turned to C4-C5.  I worked down through bony osteophytes and identified the posterior longitudinal ligament.  The ligament was incised; and as I worked to the right of the midline, I encountered herniated disk material which was removed in a number of large pieces.  The C5 root was exposed and then widely decompressed until I was flush with the pedicle and into the foramen.  The root had a somewhat high takeoff but I worked to expose the axilla and widely decompressed it.  Again the microscope was angled to the left side where similar decompression was achieved.  Central decompression was achieved here where there was a moderate amount of spinal cord compression.  This was removed by undercutting with 1 and 2-mm Cloward punches.,Attention was then turned to the C5-C6 space.  Here there were large osteophytes projecting posteriorly against the cord.  I slowly and carefully used the high-speed cutting diamond bur to drill these and then used 1 to 2-mm Cloward punches to widely decompress the spinal cord.  This necessitated undercutting the bodies of both C5 and C6 extensively, but I was then able to achieve a good decompression of the cord.  I exposed the C6 root and widely decompressed it until I was flush with the pedicle and into the foramen on the right.  The microscope was angled to the left side where a similar decompression was achieved.,Attention was then turned to creation of the arthrodesis.  A high-speed Cornerstone bur was used to decorticate the bodies of C5-C6, C4-C5 and C3-C4 to create a posterior shelf to prevent backwards graft migration.  Bone dust during the drilling was harvested for later use.,Attention was turned to creation of the arthrodesis.  Using the various Synthes sizers, I selected a 7-mm lordotic graft at C5-C6 and an 8-mm lordotic graft at C4-C5 and a 9-mm lordotic graft at C3-C4.  Each graft was filled with autologous bone from the vertebral bodies and bone morphogenetic protein soaked sponge.  I decided to use BMP in this case because there were three levels of fusion and because this patient has a very heavy history of smoking and having just recently discontinued for two weeks.  The BMP sponge and the ____________ bone were then packed in the center of the allograft.,Under distraction, the graft was placed at C3-C4, C4-C5, and C5-C6 as described.  An x-ray was obtained which showed good graft placement with preservation of the cervical lordosis.,Attention was turned to the placement of anterior spinal instrumentation.  Various sizes of Synthes plates were selected until I decided that a 54-mm plate was appropriate.  The plate had to be somewhat contoured and bent inferiorly and the vertebral bodies had to be drilled so that the plates would sit flush.  The holes were drilled and the screws were placed.  Eight screws were placed with two screws at C3, two screws at C4, two screws at C5, and two screws at C6.  All eight screws had good purchase.  The locking screws were tightly applied.  An x-ray was obtained which showed good placement of the graft, plate, and screws.,Attention was turned to closure.  The wound was copiously irrigated with Bacitracin solution and meticulous hemostasis was obtained.  A medium Hemovac drain was placed in the anterior vertebral body space and brought out through a separate stab incision in the skin.  The wound was then carefully closed in layers.  Sterile dressings were applied, and the operation was terminated.,The patient tolerated the procedure well and left for the recovery room in excellent condition.  The sponge and needle counts were reported as correct.  There were no intraoperative complications.,Specimens were sent to Pathology consisting of disk material and bone and soft tissue.",
 Anterior cervical discectomy at C5-6 and placement of artificial disk replacement.  Right C5-C6 herniated nucleus pulposus., Neurosurgery, Anterior Cervical Discectomy - 2 ,"ADMITTING DIAGNOSIS: , Right C5-C6 herniated nucleus pulposus.,PRIMARY OPERATIVE PROCEDURE: , Anterior cervical discectomy at C5-6 and placement of artificial disk replacement.,SUMMARY:,  This is a pleasant, 43-year-old woman, who has been having neck pain and right arm pain for a period of time which has not responded to conservative treatment including ESIs.  She underwent another MRI and significant degenerative disease at C5-6 with a central and right-sided herniation was noted.  Risks and benefits of the surgery were discussed with her and she wished to proceed with surgery.  She was interested in participating in the artificial disk replacement study and was entered into that study.  She was randomly picked for the artificial disk and underwent the above named procedure on 08/27/2007.  She has done well postoperatively with a sensation of right arm pain and numbness in her fingers.  She will have x-rays AP and lateral this morning which will be reviewed and she will be discharged home today if she is doing well.  She will follow up with Dr. X in 2 weeks in the clinic as per the study protocol with cervical AP and lateral x-rays with ring prior to the appointment.  She will contact our office prior to her appointment if she has problems.  Prescriptions were written for Flexeril 10 mg 1 p.o. t.i.d. p.r.n.  #50 with 1 refill and Lortab 7.5/500 mg 1 to 2 q.6 h. p.r.n.  #60 with 1 refill.","neurosurgery, herniated nucleus pulposus, anterior cervical discectomy, artificial disk replacement, cervical, discectomy, nucleusNOTE"
" C5-C6 anterior cervical discectomy, bone bank allograft, and anterior cervical plate.   Left cervical radiculopathy.", Neurosurgery, Anterior Cervical Discectomy - 4 ,"PREOPERATIVE DIAGNOSIS: , Left cervical radiculopathy.,POSTOPERATIVE DIAGNOSIS:  ,Left cervical radiculopathy.,PROCEDURES PERFORMED:,1.  C5-C6 anterior cervical discectomy.,2.  Bone bank allograft.,3.  Anterior cervical plate.,TUBES AND DRAINS LEFT IN PLACE: , None.,COMPLICATIONS: , None.,SPECIMEN SENT TO PATHOLOGY: , None.,ANESTHESIA: , General endotracheal.,INDICATIONS: , This is a middle-aged man who presented to me with left arm pain.  He had multiple levels of disease, but clinically, it was C6 radiculopathy.  We tested him in the office and he had weakness referable to that nerve.  The procedure was done at that level.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room at which time an intravenous line was placed.  General endotracheal anesthesia was obtained.  He was positioned supine in the operative area and the right neck was prepared.,An incision was made and carried down to the ventral spine on the right in the usual manner.  An x-ray confirmed our location.,We were impressed by the degenerative change and the osteophyte overgrowth.,As we had excepted, the back of the disk space was largely closed off by osteophytes.  We patiently drilled through them to the posterior ligament.  We went through that until we saw the dura.,We carefully went to the patient's symptomatic, left side.  The C6 foramen was narrowed by uncovertebral joint overgrowth.  The foramen was open widely.,An allograft was placed.  An anterior Steffee plate was placed.  Closure was commenced.,The wound was closed in layers with Steri-Strips on the skin.  A dressing was applied.,It should be noted that the above operation was done also with microscopic magnification and illumination.","neurosurgery, cervical radiculopathy, anterior cervical discectomy, bank allograft, cervical discectomy, anterior, cervical, foramen, discectomy, allograft, radiculopathy, "
 Anterior cervical discectomy (two levels) and C5-C6 and C6-C7 allograft fusions.  A C5-C7 anterior cervical plate fixation (Sofamor Danek titanium window plate) intraoperative fluoroscopy used and intraoperative microscopy used.  Intraoperative SSEP and EMG monitoring used., Neurosurgery, Anterior Cervical Discectomy - 3 ,"PREOPERATIVE DIAGNOSES: , Cervical disk protrusions at C5-C6 and C6-C7, cervical radiculopathy, and cervical pain.,POSTOPERATIVE DIAGNOSES:,  Cervical disk protrusions at C5-C6 and C6-C7, cervical radiculopathy, and cervical pain.,PROCEDURES:,  C5-C6 and C6-C7 anterior cervical discectomy (two levels) C5-C6 and C6-C7 allograft fusions.  A C5-C7 anterior cervical plate fixation (Sofamor Danek titanium window plate) intraoperative fluoroscopy used and intraoperative microscopy used.  Intraoperative SSEP and EMG monitoring used.,ANESTHESIA: , General endotracheal.,COMPLICATIONS:,  None.,INDICATION FOR THE PROCEDURE: , This lady presented with history of cervical pain associated with cervical radiculopathy with cervical and left arm pain, numbness, weakness, with MRI showing significant disk protrusions with the associate complexes at C5-C6 and C6-C7 with associated cervical radiculopathy.  After failure of conservative treatment, this patient elected to undergo surgery.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the OR and after adequate general endotracheal anesthesia, she was placed supine on the OR table with the head of the bed about 10 degrees.  A shoulder roll was placed and the head supported on a donut support.  The cervical region was prepped and draped in the standard fashion.  A transverse cervical incision was made from the midline, which was lateral to the medial edge of the sternocleidomastoid two fingerbreadths above the right clavicle.  In a transverse fashion, the incision was taken down through the skin and subcutaneous tissue and through the platysmata and a subplatysmal dissection done.  Then, the dissection continued medial to the sternocleidomastoid muscle and then medial to the carotid artery to the prevertebral fascia, which was gently dissected and released superiorly and inferiorly.  Spinal needles were placed into the displaced C5-C6 and C6-C7 to confirm these disk levels using lateral fluoroscopy.  Following this, monopolar coagulation was used to dissect the medial edge of the longus colli muscles off the adjacent vertebrae between C5-C7 and then the Trimline retractors were placed to retract the longus colli muscles laterally and blunt retractors were placed superiorly and inferiorly.  A #15 scalpel was used to do a discectomy at C5-C6 from endplate-to-endplate and uncovertebral joint.  On the uncovertebral joint, a pituitary rongeur was used to empty out any disk material ____________ to further remove the disk material down to the posterior aspect.  This was done under the microscope.  A high-speed drill under the microscope was used to drill down the endplates to the posterior aspect of the annulus.  A blunt trocar was passed underneath the posterior longitudinal ligament and it was gently released using the #15 scalpel and then Kerrison punches 1-mm and then 2-mm were used to decompress further disk calcified material at the C5-C6 level.  This was done bilaterally to allow good decompression of the thecal sac and adjacent neuroforamen.  Then, at the C6-C7 level, in a similar fashion, #15 blade was used to do a discectomy from uncovertebral joint to uncovertebral joint and from endplate-to-endplate using a #15 scalpel to enter the disk space and then the curette was then used to remove the disk calcified material in the endplate, and then high-speed drill under the microscope was used to drill down the disk space down to the posterior aspect of the annulus where a blunt trocar was passed underneath the posterior longitudinal ligament which was gently released.  Then using the Kerrison punches, we used 1-mm and 2-mm, to remove disk calcified material, which was extending more posteriorly to the left and the right.  This was gently removed and decompressed to allow good decompression of the thecal sac and adjacent nerve roots.  With this done, the wound was irrigated.  Hemostasis was ensured with bipolar coagulation.  Vertebral body distraction pins were then placed to the vertebral body of C5 and C7 for vertebral distraction and then a 6-mm allograft performed grafts were taken and packed in either aspect with demineralized bone matrix and this was tapped in flush with the vertebral bodies above and below C5-C6 and C6-C7 discectomy sites.  Then, the vertebral body distraction pins were gently removed to allow for graft seating and compression and then the anterior cervical plate (Danek windows titanium plates) was then taken and sized and placed.  A temporary pin was initially used to align the plate and then keeping the position and then two screw holes were drilled in the vertebral body of C5, two in the vertebral body of C6, and two in the vertebral body of C7.  The holes were then drilled and after this self-tapping screws were placed into the vertebral body of C5, C6, and C7 across the plate to allow the plate to fit and stay flush with the vertebral body between C5, C6, and C7.  With this done, operative fluoroscopy was used to check good alignment of the graft, screw, and plate, and then the wound was irrigated.  Hemostasis was ensured with bipolar coagulation and then the locking screws were tightened down.  A #10 round Jackson-Pratt drain was placed into the prevertebral space and brought out from a separate stab wound skin incision site.  Then, the platysma was approximated using 2-0 Vicryl inverted interrupted stitches and the skin closed with 4-0 Vicryl running subcuticular stitch.  Steri-Strips and sterile dressings were applied.  The patient remained hemodynamically stable throughout the procedure.  Throughout the procedure, the microscope had been used for the disk decompression and high-speed drilling.  In addition, intraoperative SSEP, EMG monitoring, and motor-evoked potentials remained stable throughout the procedure.  The patient remained stable throughout the procedure.","neurosurgery, cervical disk protrusions, cervical radiculopathy, cervical pain, cervical plate fixation, sofamor danek titanium window plate, anterior cervical discectomy, vertebral body, vertebral, disk, intraoperative, anterior, decompression, fluoroscopy, radiculopathy, discectomy, cervical,"
" Anterior cervical discectomy, removal of herniated disc and osteophytes, bilateral C4 nerve root decompression, harvesting of bone for autologous vertebral bodies for creation of arthrodesis, grafting of fibular allograft bone for creation of arthrodesis, creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies, and placement of anterior spinal instrumentation using the operating microscope and microdissection technique.", Neurosurgery, Anterior Cervical Discectomy - 1 ,"PREOPERATIVE DIAGNOSIS: , Cervical spondylosis at C3-C4 with cervical radiculopathy and spinal cord compression.,POSTOPERATIVE DIAGNOSIS:,  Cervical spondylosis at C3-C4 with cervical radiculopathy and spinal cord compression.,OPERATION PERFORMED,1.  Anterior cervical discectomy of C3-C4.,2.  Removal of herniated disc and osteophytes.,3.  Bilateral C4 nerve root decompression.,4.  Harvesting of bone for autologous vertebral bodies for creation of arthrodesis.,5.  Grafting of fibular allograft bone for creation of arthrodesis.,6.  Creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies.,7.  Placement of anterior spinal instrumentation using the operating microscope and microdissection technique.,INDICATIONS FOR PROCEDURE: , This 62-year-old man has progressive and intractable right C4 radiculopathy with neck and shoulder pain.  Conservative therapy has failed to improve the problem.  Imaging studies showed severe spondylosis of C3-C4 with neuroforaminal narrowing and spinal cord compression.,A detailed discussion ensued with the patient as to the nature of the procedure including all risks and alternatives.  He clearly understood it and had no further questions and requested that I proceed.,PROCEDURE IN DETAIL: , The patient was placed on the operating room table and was intubated using a fiberoptic technique.  The methylprednisolone spinal cord protocol was instituted with bolus and continuous infusion doses.  The neck was carefully prepped and draped in the usual sterile manner.,A transverse incision was made on a skin crease on the left side of the neck.  Dissection was carried down through the platysmal musculature and the anterior spine was exposed.  The medial borders of the longus colli muscles were dissected free from their attachments to the spine.  A needle was placed and it was believed to be at the C3-C4 interspace and an x-ray properly localized this space.  Castoff self-retaining pins were placed into the body of the C3 and C4.  Self-retaining retractors were placed in the wound keeping the blades of the retractors underneath the longus colli muscles.,The annulus was incised and a discectomy was performed.  Quite a bit of overhanging osteophytes were identified and removed.  As I worked back to the posterior lips of the vertebral body, the operating microscope was utilized.,There was severe overgrowth of spondylitic spurs.  A high-speed diamond bur was used to slowly drill these spurs away.  I reached the posterior longitudinal ligament and opened it and exposed the underlying dura.,Slowly and carefully I worked out towards the C3-C4 foramen.  The dura was extremely thin and I could see through it in several areas.  I removed the bony compression in the foramen and identified soft tissue and veins overlying the root.  All of these were not stripped away for fear of tearing this very tissue-paper-thin dura.  However, radical decompression was achieved removing all the bony compression in the foramen, out to the pedicle, and into the foramen.  An 8-mm of the root was exposed although I left the veins over the root intact.,The microscope was angled to the left side where a similar procedure was performed.,Once the decompression was achieved, a high-speed cortisone bur was used to decorticate the body from the greater posterior shelf to prevent backward graft migration.  Bone thus from the drilling was preserved for use for the arthrodesis.,Attention was turned to creation of the arthrodesis.  As I had drilled quite a bit into the bodies, I selected a large 12-mm graft and distracted the space maximally.  Under distraction the graft was placed and fit well.  An x-ray showed good graft placement.,Attention was turned to spinal instrumentation.  A Synthes Short Stature plate was used with four 3-mm screws.  Holes were drilled with all four screws were placed with pretty good purchase.  Next, the locking screws were then applied.  An x-ray was obtained which showed good placement of graft, plate, and screws.  The upper screws were near the upper endplate of C3.  The C3 vertebral body that remained was narrow after drilling off the spurs.  Rather than replace these screws and risk that the next holes would be too near the present holes I decided to leave these screws intact because their position is still satisfactory as they are below the disc endplate.,Attention was turned to closure.  A Hemovac drain was placed in the anterior vertebral body space and brought out through a separate stab wound incision in the skin.  The wound was then carefully closed in layers.  Sterile dressings were applied along with a rigid Philadelphia collar.  The operation was then terminated.,The patient tolerated the procedure well and left for the recovery room in excellent condition.  The sponge and needle counts were reported as correct and there were no intraoperative complications.,Specimens were sent to Pathology consisted of bone and soft tissue as well as C3-C4 disc material.","neurosurgery, herniated, osteophytes, nerve root decompression, harvesting, autologous, vertebral, arthrodesis, anterior technique, anterior cervical discectomy, spinal cord compression, fibular allograft bone, creation of arthrodesis, cervical discectomy, spinal instrumentation, cord compression, vertebral body, vertebral bodies, spinal cord, bone, instrumentation, cervical, anterior, grafting, spinal, discectomy, allograft, "
" Herniated nucleus pulposus.  Anterior cervical decompression, anterior spine instrumentation, anterior cervical spine fusion, and application of machined allograft.", Neurosurgery, Anterior Cervical Decompression ,"PREOPERATIVE DIAGNOSES,1.  Herniated nucleus pulposus, C5-C6.,2.  Herniated nucleus pulposus, C6-C7.,POSTOPERATIVE DIAGNOSES,1.  Herniated nucleus pulposus, C5-C6.,2.  Herniated nucleus pulposus, C6-C7.,PROCEDURE PERFORMED,1.  Anterior cervical decompression, C5-C6.,2.  Anterior cervical decompression, C6-C7.,3.  Anterior spine instrumentation.,4.  Anterior cervical spine fusion, C5-C6.,5.  Anterior cervical spine fusion, C6-C7.,6.  Application of machined allograft at C5-C6.,7.  Application of machined allograft at C6-C7.,8.  Allograft, structural at C5-C6.,9.  Allograft, structural at C6-C7.,ANESTHESIA: , General.,PREOPERATIVE NOTE:  ,This patient is a 47-year-old male with chief complaint of severe neck pain and left upper extremity numbness and weakness.  Preoperative MRI scan showed evidence of herniated nucleus pulposus at C5-C6 and C6-C7 on the left.  The patient has failed epidural steroid injections.  Risks and benefits of the above procedure were discussed with the patient including bleeding, infection, muscle loss, nerve damage, paralysis, and death.,OPERATIVE REPORT: , The patient was taken to the OR and placed in the supine position.  After general endotracheal anesthesia was obtained, the patient's neck was sterilely prepped and draped in the usual fashion.  A horizontal incision was made on the left side of the neck at the level of the C6 vertebral body.  It was taken down through the subcutaneous tissues exposing the platysmus muscle.  The platysmus muscle was incised along the skin incision and the deep cervical fascia was bluntly dissected down to the anterior cervical spine.  An #18 gauge needle was placed in the C5-C6 interspace and the intraoperative x-ray confirmed that this was the appropriate level.  Next, the longus colli muscles were resected laterally on both the right and left side, and then a complete anterior cervical discectomy was performed.  The disk was very degenerated and brown in color.  There was an acute disk herniation through posterior longitudinal ligament.  The posterior longitudinal ligament was removed and a bilateral foraminotomy was performed.  Approximately, 5 mm of the nerve root on both the right and left side was visualized.  A ball-ended probe could be passed up the foramen.  Bleeding was controlled with bipolar electrocautery and Surgiflo.  The end plates of C5 and C6 were prepared using a high-speed burr and a 6-mm lordotic machined allograft was malleted into place.  There was good bony apposition both proximally and distally.  Next, attention was placed at the C6-C7 level.  Again, the longus colli muscles were resected laterally and a complete anterior cervical discectomy at C6-C7 was performed.  The disk was degenerated and there was acute disk herniation in the posterior longitudinal ligament on the left.  The posterior longitudinal ligament was removed.  A bilateral foraminotomy was performed.  Approximately, 5 mm of the C7 nerve root was visualized on both sides.  A micro nerve hook was able to be passed up the foramen easily.  Bleeding was controlled with bipolar electrocautery and Surgiflo.  The end plates at C6-C7 were then prepared using a high-speed burr and then a 7-mm machined lordotic allograft was malleted into place.  There was good bony apposition, both proximally and distally.  Next, a 44-mm Blackstone low-profile anterior cervical plate was applied to the anterior cervical spine with six 14 mm screws.  Intraoperative x-ray confirmed appropriate positioning of the plate and the graft.  The wound was then copiously irrigated with normal saline and bacitracin.  There was no active bleeding upon closure of the wound.  A small drain was placed deep.  The platysmal muscle was closed with 3-0 Vicryl.  The skin was closed with #4-0 Monocryl.  Mastisol and Steri-Strips were applied.  The patient was monitored throughout the procedure with free-running EMGs and SSEPs and there were no untoward events.  The patient was awoken and taken to the recovery room in satisfactory condition.","neurosurgery, herniated nucleus pulposus, anterior cervical decompression, spine fusion, cervical spine, allograft, anterior cervical spine, anterior, cervical,"
" EEG during wakefulness and light sleep is abnormal with independent, positive sharp wave activity seen in both frontotemporal head regions, more predominant in the right frontotemporal region.", Neurology, Video EEG - 3 ,"PROCEDURE: , EEG during wakefulness demonstrates background activity consisting of moderate-amplitude beta activity seen bilaterally.  The EEG background is symmetric.  Independent, small, positive, sharp wave activity is seen in the frontotemporal regions bilaterally with sharp-slow wave discharges seen more predominantly in the right frontotemporal head region.  No clinical signs of involuntary movements are noted during synchronous video monitoring.  Recording time is 22 minutes and 22 seconds.  There is attenuation of the background, faster activity during drowsiness and some light sleep is recorded.  No sustained epileptogenic activity is evident, but the independent bilateral sharp wave activity is seen intermittently.  Photic stimulation induced a bilaterally symmetric photic driving response.,IMPRESSION:,  EEG during wakefulness and light sleep is abnormal with independent, positive sharp wave activity seen in both frontotemporal head regions, more predominant in the right frontotemporal region.  The EEG findings are consistent with potentially epileptogenic process.  Clinical correlation is warranted.","neurology, epileptogenic, wakefulness, eeg, frontotemporal, activityNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 A pleasant gentleman with a history of Wilson's disease who has been treated with penicillamine., Neurology, Wilson's Disease - Letter ,"Doctor's Address,Dear Doctor:,This letter is an introduction to my patient, A, who you will be seeing in the near future.  He is a pleasant gentleman with a history of Wilson's disease.  It has been treated with penicillamine.  He was diagnosed with this at age 14.  He was on his way to South Carolina for a trip when he developed shortness of breath, palpitations, and chest discomfort.  He went to the closest hospital that they were near in Randolph, North Carolina and he was found to be in atrial fibrillation with rapid rate.  He was admitted there and observed.  He converted to normal sinus rhythm spontaneously and so he required no further interventions.  He was started on Lopressor, which he has tolerated well.  An echocardiogram was performed, which revealed mild-to-moderate left atrial enlargement.  Normal ejection fraction.  No other significant valvular abnormality.  He reported to physicians there that he had cirrhosis related to his Wilson's disease.  Therefore hepatologist was consulted.  There was a recommendation to avoid Coumadin secondary to his questionable significant liver disease, therefore he was placed on aspirin 325 mg once a day.,In discussion with Mr. A and review of his chart that I have available, it is unclear as to the status of his liver disease, however, he has never had a liver biopsy, so his diagnosis of cirrhosis that they were concerned about in North Carolina is in doubt.  His LFTs have remained normal and his copper level has been undetectable on his current dose of penicillamine.,I would appreciate your input into the long term management of his anticoagulation and also any recommendations you would have about rhythm control.  He is in normal sinus rhythm as of my evaluation of him on 06/12/2008.  He is tolerating his metoprolol and aspirin without any difficulty.  I guess the big question remains is what level of risk that is entailed by placing him on Coumadin therapy due to his potentially paroxysmal atrial fibrillation and evidence of left atrial enlargement that would place him in increased risk of recurrent episodes.,I appreciate your input regarding this friendly gentleman.  His current medicines include penicillamine 250 mg p.o. four times a day, metoprolol 12.5 mg twice a day, and aspirin 325 mg a day.,If you have any questions regarding his care, please feel free to call me to discuss his case.  Otherwise, I will look forward to hearing back from you regarding his evaluation.  Thank you as always for your care of our patient.","neurology, atrial enlargement, wilson's disease, penicillamine,"
 This is a 43-year-old female with a history of events concerning for seizures.  Video EEG monitoring is performed to capture events and/or identify etiology., Neurology, Video EEG ,"TIME SEEN: , 0734 hours and 1034 hours.,TOTAL RECORDING TIME: , 27 hours 4 minutes.,PATIENT HISTORY: , This is a 43-year-old female with a history of events concerning for seizures.  Video EEG monitoring is performed to capture events and/or identify etiology.,VIDEO EEG DIAGNOSES,1.  AWAKE:  Normal.,2.  SLEEP:  No activation.,3.  CLINICAL EVENTS:  None.,DESCRIPTION: , Approximately 27 hours of continuous 21-channel digital video EEG monitoring was performed.  The waking background is unchanged from that previously reported.  Hyperventilation produced no changes in the resting record.  Photic stimulation failed to elicit a well-developed photic driving response.,Approximately five-and-half hours of spontaneous intermittent sleep was obtained.  Sleep spindles were present and symmetric.,The patient had no clinical events during the recording.,CLINICAL INTERPRETATION:  ,This is normal video EEG monitoring for a patient of this age.  No interictal epileptiform activity was identified.  The patient had no clinical events during the recording.  Clinical correlation is required.","neurology, electroencephalography, eeg monitoring, video eeg, seizures, eeg,"
 The patient has a history of epilepsy and has also had non-epileptic events in the past.  Video EEG monitoring is performed to assess whether it is epileptic seizures or non-epileptic events., Neurology, Video EEG - 1 ,"DATE OF EXAMINATION: , Start:  12/29/2008 at 1859 hours.  End:  12/30/2008 at 0728 hours.,TOTAL RECORDING TIME:,  12 hours, 29 minutes.,PATIENT HISTORY:,  This is a 46-year-old female with a history of events concerning for seizures.  The patient has a history of epilepsy and has also had non-epileptic events in the past.  Video EEG monitoring is performed to assess whether it is epileptic seizures or non-epileptic events.,VIDEO EEG DIAGNOSES,1.  Awake:  Normal.,2.  Sleep:  Activation of a single left temporal spike seen maximally at T3.,3.  Clinical events:  None.,DESCRIPTION:  ,Approximately 12 hours of continuous 21-channel digital video EEG monitoring was performed.  During the waking state, there is a 9-Hz dominant posterior rhythm.  The background of the record consists primarily of alpha frequency activity.  At times, during the waking portion of the record, there appears to be excessive faster frequency activity.  No activation procedures were performed.,Approximately four hours of intermittent sleep was obtained.  A single left temporal, T3, spike is seen in sleep.  Vertex waves and sleep spindles were present and symmetric.,The patient had no clinical events during the recording.,CLINICAL INTERPRETATION:  ,This is abnormal video EEG monitoring for a patient of this age due to the presence of a single left temporal spike seen during sleep.  The patient had no clinical events during the recording period.  Clinical correlation is required.","neurology, non-epileptic events, temporal spike, eeg monitoring, video eeg, epilepsy, frequency, eeg, epileptic,"
" EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity.", Neurology, Video EEG - 2 ,"IMPRESSION:  ,EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity.","neurology, ekg artifact, video monitoring, wakefulness, drowsiness, eegNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Chronic venous hypertension with painful varicosities, lower extremities, bilaterally.  Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, bilaterally.", Neurology, Vein Stripping ,"PREOPERATIVE DIAGNOSIS: , Chronic venous hypertension with painful varicosities, lower extremities, bilaterally.,POSTOPERATIVE DIAGNOSIS: , Chronic venous hypertension with painful varicosities, lower extremities, bilaterally.,PROCEDURES,1.  Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, right leg.,2.  Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, left leg.,PROCEDURE DETAIL: , After obtaining the informed consent, the patient was taken to the operating room where she underwent a general endotracheal anesthesia.  A time-out process was followed and antibiotics were given.,Then, both legs were prepped and draped in the usual fashion with the patient was in the supine position.  An incision was made in the right groin and the greater saphenous vein at its junction with the femoral vein was dissected out and all branches were ligated and divided.  Then, an incision was made just below the knee where the greater saphenous vein was also found and connection to varices from the calf were seen.  A third incision was made in the distal third of the right thigh in the area where there was a communication with large branch varicosities.  Then, a vein stripper was passed from the right calf up to the groin and the greater saphenous vein, which was divided, was stripped without any difficultly.  Several minutes of compression was used for hemostasis.  Then, the exposed branch varicosities both in the lower third of the thigh and in the calf were dissected out and then many stabs were performed to do stab phlebectomies at the level of the thigh and the level of the calf as much as the position would allow us to do.,Then in the left thigh, a groin incision was made and the greater saphenous vein was dissected out in the same way as was on the other side.  Also, an incision was made in the level of the knee and the saphenous vein was isolated there.  The saphenous vein was stripped and a several minutes of local compression was performed for hemostasis.  Then, a number of stabs to perform phlebectomy were performed at the level of the calf to excise branch varicosities to the extent that the patient's position would allow us.  Then, all incisions were closed in layers with Vicryl and staples.,Then, the patient was placed in the prone position and the stab phlebectomies of the right thigh and calf and left thigh and calf were performed using 10 to 20 stabs in each leg.  The stab phlebectomies were performed with a hook and they were very satisfactory.  Hemostasis achieved with compression and then staples were applied to the skin.,Then, the patient was rolled onto a stretcher where both legs were wrapped with the Kerlix, fluffs, and Ace bandages.,Estimated blood loss probably was about 150 mL.  The patient tolerated the procedure well and was sent to recovery room in satisfactory condition.  The patient is to be observed, so a decision will be made whether she needs to stay overnight or be able to go home.","neurology, chronic venous hypertension, varicosities, stab phlebectomies, greater saphenous vein stripping, lower extremities, vein stripping, saphenous vein, vein, incisions, hemostasis, stripping, branches, phlebectomies, thigh, calf, saphenous,"
" Patient experienced a single episode of his vision decreasing.  During the episode, he felt nauseated and possibly lightheaded.  His wife was present and noted that he looked extremely pale.", Neurology, TIA & Lumbar Stenosis ,"CHIEF COMPLAINT: , Transient visual loss lasting five minutes.,HISTORY OF PRESENT ILLNESS: , This is a very active and pleasant 82-year-old white male with a past medical history significant for first-degree AV block, status post pacemaker placement, hypothyroidism secondary to hyperthyroidism and irradiation, possible lumbar stenosis.  He reports he experienced a single episode of his vision decreasing ""like it was compressed from the top down with a black sheet coming down"".  The episode lasted approximately five minutes and occurred three weeks ago while he was driving a car.  He was able to pull the car over to the side of the road safely.  During the episode, he felt nauseated and possibly lightheaded.  His wife was present and noted that he looked extremely pale and ashen during the episode.  He went to see the Clinic at that time and received a CT scan, carotid Dopplers, echocardiogram, and neurological evaluation, all of which were unremarkable.  It was suggested at that time that he get a CT angiogram since he cannot have an MRI due to his pacemaker.  He has had no further similar events.  He denies any lesions or other visual change, focal weakness or sensory change, headaches, gait change or other neurological problem.,He also reports that he has been diagnosed with lumbar stenosis based on some mild difficulty arising from a chair for which an outside physician ordered a CT of his L-spine that reportedly showed lumbar stenosis.  The question has arisen as to whether he should have a CT myelogram to further evaluate this process.  He has no back pain or pain of any type, he denies bowel or bladder incontinence or frank lower extremity weakness.  He is extremely active and plays tennis at least three times a week.  He denies recent episodes of unexpected falls.,REVIEW OF SYSTEMS: , He only endorses hypothyroidism, the episode of visual loss described above and joint pain.  He also endorses having trouble getting out of a chair, but otherwise his review of systems is negative.  A copy is in his clinic chart.,PAST MEDICAL HISTORY:  ,As above.  He has had bilateral knee replacement three years ago and experiences some pain in his knees with this.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:,  He is retired from the social security administration x 20 years.  He travels a lot and is extremely active.  He does not smoke.  He consumes alcohol socially only.  He does not use illicit drugs.  He is married.,MEDICATIONS: , The patient has recently been started on Plavix by his primary care doctor, was briefly on baby aspirin 81 mg per day since the TIA-like event three weeks ago.  He also takes Proscar 5 mg q.d and Synthroid 0.2 mg q.d.,PHYSICAL EXAMINATION:,Vital Signs:  BP 134/80, heart rate 60, respiratory rate 16, and weight 244 pounds.  He denies any pain.,General:  This is a pleasant white male in no acute distress.,HEENT:  He is normocephalic and atraumatic.  Conjunctivae and sclerae are clear.  There is no sinus tenderness.,Neck:  Supple.,Chest:  Clear to auscultation.,Heart:  There are no bruits present.,Extremities:  Extremities are warm and dry.  Distal pulses are full.  There is no edema.,NEUROLOGIC EXAMINATION:,MENTAL STATUS:  He is alert and oriented to person, place and time with good recent and long-term memory.  His language is fluent.  His attention and concentration are good.,CRANIAL NERVES:  Cranial nerves II through XII are intact.  VFFTC, PERRL, EOMI, facial sensation and expression are symmetric, hearing is decreased on the right (hearing aid), palate rises symmetrically, shoulder shrug is strong, tongue protrudes in the midline.,MOTOR:  He has normal bulk and tone throughout.  There is no cogwheeling.  There is some minimal weakness at the iliopsoas bilaterally 4+/5 and possibly trace weakness at the quadriceps -5/5.  Otherwise he is 5/5 throughout including hip adductors and abductors.,SENSORY:  He has decreased sensation to vibration and proprioception to the middle of his feet only, otherwise sensory is intact to light touch, and temperature, pinprick, proprioception and vibration.,COORDINATION:  There is no dysmetria or tremor noted.  His Romberg is negative.  Note that he cannot rise from the chair without using his arms.,GAIT:  Upon arising, he has a normal step, stride, and toe, heel.  He has difficulty with tandem and tends to fall to the left.,REFLEXES:  2 at biceps, triceps, patella and 1 at ankles.,The patient provided a CT scan without contrast from his previous hospitalization three weeks ago, which is normal to my inspection.,He has had full labs for cholesterol and stroke for risk factors although he does not have those available here.,IMPRESSION:,1.  TIA.  The character of his brief episode of visual loss is concerning for compromise of the posterior circulation.  Differential diagnoses include hypoperfusion, stenosis, and dissection.  He is to get a CT angiogram to evaluate the integrity of the cerebrovascular system.  He has recently been started on Paxil by his primary care physician and this should be continued.  Other risk factors need to be evaluated; however, we will wait for the results to be sent from the outside hospital so that we do not have to repeat his prior workup.  The patient and his wife assure me that the workup was complete and that nothing was found at that time.,2.  Lumbar stenosis.  His symptoms are very mild and consist mainly of some mild proximal upper extremity weakness and very mild gait instability.  In the absence of motor stabilizing symptoms, the patient is not interested in surgical intervention at this time.  Therefore we would defer further evaluation with CT myelogram as he does not want surgery.,PLAN:,1.  We will get a CT angiogram of the cerebral vessels.,2.  Continue Plavix.,3.  Obtain copies of the workup done at the outside hospital.,4.  We will follow the lumbar stenosis for the time being.  No further workup is planned.",
 Placement of left ventriculostomy via twist drill.  Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure., Neurology, Ventriculostomy Placement ,"PROCEDURE: , Placement of left ventriculostomy via twist drill.,PREOPERATIVE DIAGNOSIS:,  Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,POSTOPERATIVE DIAGNOSIS: , Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,INDICATIONS FOR PROCEDURE:  ,The patient is a man with a history of massive intracranial hemorrhage and hydrocephalus with intraventricular hemorrhage.  His condition is felt to be critical.  In a desperate attempt to relieve increased intracranial pressure, we have proposed placing a ventriculostomy.  I have discussed this with patient's wife who agrees and asked that we proceed emergently.,After a sterile prep, drape, and shaving of the hair over the left frontal area, this area is infiltrated with local anesthetic.  Subsequently a 1 cm incision was made over Kocher's point.  Hemostasis was obtained.  Then a twist drill was made over this area.  Bones strips were irrigated away.  The dura was perforated with a spinal needle.,A Camino monitor was connected and zeroed.  This was then passed into the left lateral ventricle on the first pass.  Excellent aggressive very bloody CSF under pressure was noted.  This stopped, slowed, and some clots were noted.  This was irrigated and then CSF continued.  Initial opening pressures were 30, but soon arose to 80 or a 100.,The patient tolerated the procedure well.  The wound was stitched shut and the ventricular drain was then connected to a drainage bag.,Platelets and FFP as well as vitamin K have been administered and ordered simultaneously with the placement of this device to help prevent further clotting or bleeding.","neurology, intraventricular hemorrhage, hydrocephalus, intracranial pressure, camino monitor, twist drill, ventriculostomy, hemorrhage, intracranial, pressure, intraventricular"
" Subcutaneous ulnar nerve transposition.  A curvilinear incision was made over the medial elbow, starting proximally at the medial intermuscular septum, curving posterior to the medial epicondyle, then curving anteriorly along the path of the ulnar nerve.  Dissection was carried down to the ulnar nerve. ", Neurology, Ulnar Nerve Transposition ,"PROCEDURE:,  Subcutaneous ulnar nerve transposition.,PROCEDURE IN DETAIL: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A curvilinear incision was made over the medial elbow, starting proximally at the medial intermuscular septum, curving posterior to the medial epicondyle, then curving anteriorly along the path of the ulnar nerve.  Dissection was carried down to the ulnar nerve.  Branches of the medial antebrachial and the medial brachial cutaneous nerves were identified and protected.,Osborne's fascia was released, an ulnar neurolysis performed, and the ulnar nerve was mobilized.  Six cm of the medial intermuscular septum was excised, and the deep periosteal origin of the flexor carpi ulnaris was released to avoid kinking of the nerve as it was moved anteriorly.,The subcutaneous plane just superficial to the flexor-pronator mass was developed.  Meticulous hemostasis was maintained with bipolar electrocautery.  The nerve was transposed anteriorly, superficial to the flexor-pronator mass.  Motor branches were dissected proximally and distally to avoid tethering or kinking the ulnar nerve.,A semicircular medially based flap of flexor-pronator fascia was raised and sutured to the subcutaneous tissue in such a way as to prevent the nerve from relocating.  The subcutaneous tissue and skin were closed with simple interrupted sutures.  Marcaine with epinephrine was injected into the wound.  The elbow was dressed and splinted.  The patient was awakened and sent to the recovery room in good condition, having tolerated the procedure well.","neurology, neurolysis, ulnar, periosteal, flexor-pronator mass, ulnar nerve transposition, medial intermuscular septum, nerve transposition, intermuscular septum, flexor pronator, ulnar nerve, nerve"
" Headaches, question of temporal arteritis.  Bilateral temporal artery biopsies.", Neurology, Temporal Artery Biopsy - 1 ,"PREOPERATIVE DIAGNOSIS:,  Headaches, question of temporal arteritis.,POSTOPERATIVE DIAGNOSIS:,  Headaches, question of temporal arteritis.,PROCEDURE:,  Bilateral temporal artery biopsies.,DESCRIPTION OF PROCEDURE: , After obtaining an informed consent, the patient was brought to the operating room where her right temporal area was prepped and draped in the usual fashion.  Xylocaine 1% was utilized and then an incision was made in front of the right ear and deepened anteriorly.  The temporal artery was found and exposed in an extension of about 2 cm.  The artery was proximally and distally ligated with 6-0 Prolene and also a side branch and a sample was sent for pathology.  Hemostasis achieved with a cautery and the incision was closed with a subcuticular suture of Monocryl.,Then, the patient was turned and her left temporal area was prepped and draped in the usual fashion.  A similar procedure was performed with 1% Xylocaine and exposed her temporal artery, which was excised in an extent to about 2 cm.  This was also proximally and distally ligated with 6-0 Prolene and also side branch.  Hemostasis was achieved with a cautery and the skin was closed with a subcuticular suture of Monocryl.,Dressings were applied to both areas.,The patient tolerated the procedure well.  Estimated blood loss was negligible, and the patient went back to Same Day Surgery for recovery.","neurology, temporal arteritis, temporal artery, temporal, artery, biopsies, hemostasis, subcuticular, headaches, arteritis, "
 Bilateral temporal artery biopsy.  Rule out temporal arteritis., Neurology, Temporal Artery Biopsy ,"PREOPERATIVE DIAGNOSIS:,  Rule out temporal arteritis.,POSTOPERATIVE DIAGNOSIS:  ,Rule out temporal arteritis.,PROCEDURE:,  Bilateral temporal artery biopsy.,ANESTHESIA:,  Local anesthesia 1% Xylocaine with epinephrine.,INDICATIONS:,  I was consulted by Dr. X for this patient with bilateral temporal headaches to rule out temporal arteritis.  I explained fully the procedure to the patient.,PROCEDURE: , Both sides were done exactly the same way.  After 1% Xylocaine infiltration, a 2 to 3-cm incision was made over the temporal artery.  The temporal artery was identified and was grossly normal on both sides.  Proximal and distal were ligated with both of 3-0 silk suture and Hemoccult.  The specimen of temporal artery was taken from both sides measuring at least 2 to 3 cm.  They were sent as separate specimens, right and left labeled.  The wound was then closed with interrupted 3-0 Monocryl subcuticular sutures and Dermabond.  She tolerated the procedure well.","neurology, headaches, bilateral temporal artery, temporal artery biopsy, temporal arteritis, temporal artery, temporal, biopsy, arteritis"
 A 92-year-old female had a transient episode of slurred speech and numbness of her left cheek for a few hours. , Neurology, TIA - Cosult ,"REASON FOR CONSULTATION: , This 92-year-old female states that last night she had a transient episode of slurred speech and numbness of her left cheek for a few hours.  However, the chart indicates that she had recurrent TIAs x3 yesterday, each lasting about 5 minutes with facial drooping and some mental confusion.  She had also complained of blurred vision for several days.  She was brought to the emergency room last night, where she was noted to have a left carotid bruit and was felt to have recurrent TIAs.,CURRENT MEDICATIONS: , The patient is on Lanoxin, amoxicillin, Hydergine, Cardizem, Lasix, Micro-K and a salt-free diet.  ,SOCIAL HISTORY: , She does not smoke or drink alcohol.,FINDINGS:  ,Admission CT scan of the head showed a densely calcified mass lesion of the sphenoid bone, probably representing the benign osteochondroma seen on previous studies.  CBC was normal, aside from a hemoglobin of 11.2.  ECG showed atrial fibrillation.  BUN was 22, creatinine normal, CPK normal, glucose normal, electrolytes normal.,PHYSICAL EXAMINATION: , On examination, the patient is noted to be alert and fully oriented.  She has some impairment of recent memory.  She is not dysphasic, or apraxic.  Speech is normal and clear.  The head is noted to be normocephalic.  Neck is supple.  Carotid pulses are full bilaterally, with left carotid bruit.  Neurologic exam shows cranial nerve function II through XII to be intact, save for some slight flattening of the left nasolabial fold.  Motor examination shows no drift of the outstretched arms.  There is no tremor or past-pointing.  Finger-to-nose and heel-to-shin performed well bilaterally.  Motor showed intact neuromuscular tone, strength, and coordination in all limbs.  Reflexes 1+ and symmetrical, with bilateral plantar flexion, absent jaw jerk, no snout.  Sensory exam is intact to pinprick touch, vibration, position, temperature, and graphesthesia.,IMPRESSION: , Neurological examination is normal, aside from mild impairment of recent memory, slight flattening of the left nasolabial fold, and left carotid bruit.  She also has atrial fibrillation, apparently chronic.  In view of her age and the fact that she is in chronic atrial fibrillation, I would suspect that she most likely has had an embolic phenomenon as the cause of her TIAs.,RECOMMENDATIONS:,  I would recommend conservative management with antiplatelet agents unless a near occlusion of the carotid arteries is demonstrated, in which case you might consider it best to do an angiography and consider endarterectomy.  In view of her age, I would be reluctant to recommend Coumadin anticoagulation.  I will be happy to follow the patient with you.","neurology, atrial fibrillation, carotid bruit, slurred speech, numbness, calcified mass lesion, neurological examination, tias, carotid, benign,"
 Evaluation of possible tethered cord.  She underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age. , Neurology, Tethered Cord Evaluation ,"REASON FOR VISIT: , The patient referred by Dr. X for evaluation of her possible tethered cord.,HISTORY OF PRESENT ILLNESS:,  Briefly, she is a 14-year-old right handed female who is in 9th grade, who underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age.  The last surgery was in 03/95.  She did well; however, in the past several months has had some leg pain in both legs out laterally, worsening at night and requiring Advil, Motrin as well as Tylenol PM.,Denies any new bowel or bladder dysfunction or increased sensory loss.  She had some patchy sensory loss from L4 to S1.,MEDICATIONS: , Singulair for occasional asthma.,FINDINGS: , She is awake, alert, and oriented x 3.  Pupils equal and reactive.  EOMs are full.  Motor is 5 out of 5.  She was able to toe and heel walk without any difficulties as well as tendon reflexes were 2 plus.  There is no evidence of clonus.  There is diminished sensation from L4 to S1, having proprioception.,ASSESSMENT AND PLAN: , Possible tethered cord.  I had a thorough discussion with the patient and her parents.  I have recommended a repeat MRI scan.  The prescription was given today.  MRI of the lumbar spine was just completed.  I would like to see her back in clinic.  We did discuss the possible symptoms of this tethering.","neurology, tethering, lipomyomeningocele repair, sensory loss, tethered cord, mri, cord, lipomyomeningocele, "
 Right suboccipital craniectomy for resection of tumor using the microscope modifier 22 and cranioplasty., Neurology, Suboccipital Craniectomy  ,"TITLE OF OPERATION: , Right suboccipital craniectomy for resection of tumor using the microscope modifier 22 and cranioplasty.,INDICATION FOR SURGERY: , The patient with a large 3.5 cm acoustic neuroma.  The patient is having surgery for resection.  There was significant cerebellar peduncle compression.  The tumor was very difficult due to its size as well as its adherence to the brainstem and the nerve complex.  The case took 12 hours.  This was more difficult and took longer than the usual acoustic neuroma.,PREOP DIAGNOSIS: , Right acoustic neuroma.,POSTOP DIAGNOSIS: , Right acoustic neuroma.,PROCEDURE:,  The patient was brought to the operating room.  General anesthesia was induced in the usual fashion.  After appropriate lines were placed, the patient was placed in Mayfield 3-point head fixation, hold into a right park bench position to expose the right suboccipital area.  A time-out was settled with nursing and anesthesia, and the head was shaved, prescrubbed with chlorhexidine, prepped and draped in the usual fashion.  The incision was made and cautery was used to expose the suboccipital bone.  Once the suboccipital bone was exposed under the foramen magnum, the high speed drill was used to thin out the suboccipital bone and the craniectomy carried out with Leksell and insertion with Kerrison punches down to the rim of the foramen magnum as well as laterally to the edge of the sigmoid sinus and superiorly to the edge of the transverse sinus.  The dura was then opened in a cruciate fashion, the cisterna magna was drained, which nicely relaxed the cerebellum.  The dura leaves were held back with the 4-0 Nurolon.  The microscope was then brought into the field, and under the microscope, the cerebellar hemisphere was elevated.  Laterally, the arachnoid was very thick.  This was opened with bipolar and microscissors and this allowed for the cerebellum to be further mobilized until the tumor was identified.  The tumor was quite large and filled up the entire lateral aspect of the right posterior fossa.  Initially two retractors were used, one on the tentorium and one inferiorly.  The arachnoid was taken down off the tumor.  There were multiple blood vessels on the surface, which were bipolared.  The tumor surface was then opened with microscissors and the Cavitron was used to began debulking the lesion.  This was a very difficult resection due to the extreme stickiness and adherence to the cerebellar peduncle and the lateral cerebellum; however, as the tumor was able to be debulked, the edge began to be mobilized.  The redundant capsule was bipolared and cut out to get further access to the center of the tumor.  Working inferiorly and then superiorly, the tumor was taken down off the tentorium as well as out the 9th, 10th or 11th nerve complex.  It was very difficult to identify the 7th nerve complex.  The brainstem was identified above the complex.  Similarly, inferiorly the brainstem was able to be identified and cotton balls were placed to maintain this plain.  Attention was then taken to try identify the 7th nerve complex.  There were multitude of veins including the lateral pontine vein, which were coming right into this area.  The lateral pontine vein was maintained.  Microscissors and bipolar were used to develop the plain, and then working inferiorly, the 7th nerve was identified coming off the brainstem.  A number 1 and number 2 microinstruments were then used to began to develop the plane.  This then allowed for the further appropriate plane medially to be identified and cotton balls were then placed.  A number 11 and number 1 microinstrument continued to be used to free up the tumor from the widely spread out 7th nerve.  Cavitron was used to debulk the lesion and then further dissection was carried out.  The nerve stimulated beautifully at the brainstem level throughout this.  The tumor continued to be mobilized off the lateral pontine vein until it was completely off.  The Cavitron was used to debulk the lesion out back laterally towards the area of the porus.  The tumor was debulked and the capsule continued to be separated with number 11microinstrument as well as the number 1 microinstrument to roll the tumor laterally up towards the porus.  At this point, the capsule was so redundant, it was felt to isolate the nerve in the porus.  There was minimal bulk remaining intracranially.  All the cotton balls were removed and the nerve again stimulated beautifully at the brainstem.  Dr. X then came in and scrubbed into the case to drill out the porus and remove the piece of the tumor that was left in the porus and coming out of the porus.,I then scrubbed back into case once Dr. X had completed removing this portion of the tumor.  There was no tumor remaining at this point.  I placed some Norian in the porus to seal any air cells, although there were no palpated.  An intradural space was then irrigated thoroughly.  There was no bleeding.  The nerve was attempted to be stimulated at the brainstem level, but it did not stimulate at this time.  The dura was then closed with 4-0 Nurolons in interrupted fashion.  A muscle plug was used over one area.  Duragen was laid and strips over the suture line followed by Hemaseel.  Gelfoam was set over this and then a titanium cranioplasty was carried out.  The wound was then irrigated thoroughly.  O Vicryls were used to close the deep muscle and fascia, 3-0 Vicryl for subcutaneous tissue, and 3-0 nylon on the skin.,The patient was extubated and taken to the ICU in stable condition.","neurology, suboccipital, craniectomy, microscope, cranioplasty, acoustic neuroma, cerebellar peduncle, nerve complex, brainstem, nurolon, cavitron, kerrison, leksell, lateral pontine vein, suboccipital craniectomy, nerve, tumor"
" Severe back pain and sleepiness.  The patient, because of near syncopal episode and polypharmacy, almost passed out for about 3 to 4 minutes with a low blood pressure.", Neurology, Sleepiness - Consult ,"CHIEF COMPLAINT: , Severe back pain and sleepiness.,The patient is not a good historian and history was obtained from the patient's husband at bedside.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 76-year-old obese Caucasian female with past medical conditions that includes hypertension, history of urinary incontinence, dementia, and chronic back pain, basically brought by the husband to the emergency room because of having excruciating back pain.  As per the husband, the patient has this back pain for about almost 1 year and seeing Dr. X in Neurosurgery and had an epidural injection x2, and then the patient's pain somewhat got better between, but last time the patient went to see Dr. X, the patient given injection and the patient passed out, so the doctor stopped giving any other epidural injection.  The patient has severe pain and all in all, the patient cries at home.  As per the husband, the patient woke up in the morning with severe pain, unable to eat, drink today, and crying in the morning, so brought her to the emergency room for further evaluation.  The patient denied any history of fever, cough, chest pain, diarrhea, dysuria or polyuria.  While I was examining the patient, the patient explained about possible diagnosis and treatment plan and possible nursing home discharge for pain control.  The patient passed out for about 3 to 4 minutes, unable to respond to even painful stimuli.  The patient's heart rate went down to 50s and blood pressure was 92 systolic, so the patient was later on given IV fluid and blood pressure checked.  The patient woke up after 5 to 6 minutes, so the patient was later on evaluated for admission because of near syncopal episode.,PAST MEDICAL CONDITIONS:,  Include hypertension, dementia, urinary incontinence, chronic back pain, and degenerative joint disease of the spine.  No history of diabetes, stroke or coronary artery disease.,SURGICAL HISTORY: , Include left total hip replacement many years ago, history of hysterectomy, and appendectomy in the young age.,ALLERGIES: , DENIED.,CURRENT MEDICATIONS: , According to the list shows the patient takes hydrocodone 10/325 mg every 6 hours, Flexeril 10 mg p.o. at bedtime, and Xanax 0.25 mg p.o. 4 times a day.  The patient also takes Neurontin 200 mg 3 times a day, propranolol 10 mg twice a day, oxybutynin 5 mg p.o. twice a day, Namenda 10 mg p.o. daily, and Aricept 10 mg p.o. daily.,SOCIAL HISTORY: , She lives with her husband, usually walks with a walker and wheelchair-bound, does not walk much as per the husband knows.  No history of alcohol abuse or smoking.,PHYSICAL EXAMINATION:,GENERAL:  Currently lying in the bed without apparent distress, very lethargic.,VITAL SIGNS:  Pulse rate of 55, blood pressure is 92/52, after IV fluid came up to 105/58.,CHEST:  Shows bilateral air entry present, clear to auscultate.,HEART:  S1 and S2 regular.,ABDOMEN:  Soft, nondistended, and nontender.,EXTREMITIES:  Shows the patient's straight leg raising to be only up to 30% causing the patient severe back pain.,IMAGING: , The patient's x-ray of the lumbosacral spine done shows there is a L1 compression fracture with some osteophyte formation in the lumbar spine suggestive of degenerative joint disease.,LABORATORY DATA: , The patient's lab test is not done currently, but previous lab test done in 3/2009 seems to be in acceptable range.,IMPRESSION: , The patient, because of near syncopal episode and polypharmacy, almost passed out for about 3 to 4 minutes in front of me with a low blood pressure.,1.  Vasovagal syncope versus polypharmacy because of 3 to 4 medications and muscle relaxants.,2.  Osteoporosis of the spine with L1 compression fracture causing the patient severe pain.,3.  Hypertension, now hypotension.,4.  Incontinence of the bladder.,5.  Dementia, most likely Alzheimer type.,PLAN AND SUGGESTION: , Initial plan was to send the patient to the nursing home, but because of the patient's low blood pressure and heart rate low, we will admit the patient to DOU for 23-hour observation, start the patient on IV fluid, normal saline, 20 mEq KCl, and Protonix 40 mg, and we will also continue the patient's Namenda and Aricept.  I will hold the patient's hydrocodone.  I will hold the Flexeril and I will also hold gabapentin at this moment.  We will give the patient's pain control with Percocet and very minimal morphine sulfate as needed.  Also give the patient calcium with vitamin D and physical therapy.  We will also order a blood test and further management will be based on the patient's all test results.  I also explained to the husband that tomorrow if the patient is better and more alert and awake, then we will send her to the nursing care versus home, it depends on the pain control.",
 MRI demonstrated right contrast-enhancing temporal mass., Neurology, SOAP - Temporal Mass ,"SUBJECTIVE: , The patient is a 55-year-old African-American male that was last seen in clinic on 07/29/2008 with diagnosis of new onset seizures and an MRI scan, which demonstrated right contrast-enhancing temporal mass.  Given the characteristics of this mass and his new onset seizures, it is significantly concerning for a high-grade glioma.  ,OBJECTIVE: , The patient is alert and oriented times three, GCS of 15.  Cranial nerves II to XII are grossly intact.  Motor exam demonstrates 5/5 strength in all four extremities.  Sensation is intact to light touch, pain, temperature, and proprioception.  Cerebellar exam is intact.  Gait is normal and tandem on heels and toes.  Speech is appropriate.  Judgment is intact.  Pupils are equal and reactive to light.,ASSESSMENT AND PLAN: , The patient is a 55-year-old African-American male with a new diagnosis of rim-enhancing right temporal mass.  Given the characteristics of the MRI scan, it is highly likely that he demonstrates high-grade glioma and concerning for glioblastoma multiforme.  We have discussed in length the possible benefits of biopsy, surgical resection, medical management, as well as chemotherapy, radiation treatments, and doing nothing.  Given the high probability that the mass represents a high-grade glioma, the patient, after weighing the risks and the benefits of surgery, has agreed to undergo a surgical biopsy and resection of the mass as well as concomitant chemotherapy and radiation as the diagnosis demonstrates a high-grade glioma.  The patient has signed consent for his right temporal craniotomy for biopsy and likely resection of right temporal brain tumor.  He agrees that he will be n.p.o. after mid night on Wednesday night.  He is sent for preoperative assessment with the Anesthesiology tomorrow morning.  He has undergone vocational rehab assessment.","neurology, new onset seizures, temporal mass, cerebellar exam, glioma, temporal, massNOTE"
" Numbness and tingling in the right upper extremity, intermittent and related to the positioning of the wrist.  Carpal tunnel syndrome suspected.", Neurology, SOAP - Numbness & Tingling ,"SUBJECTIVE: , This patient presents to the office today because of some problems with her right hand.  It has been going tingling and getting numb periodically over several weeks.  She just recently moved her keyboard down at work.  She is hoping that will help.  She is worried about carpal tunnel.  She does a lot of repetitive type activities.  It is worse at night.  If she sleeps on it a certain way, she will wake up and it will be tingling then she can usually shake out the tingling, but nonetheless it is very bothersome for her.  It involves mostly the middle finger, although, she says it also involves the first and second digits on the right hand.  She has some pain in her thumb as well.  She thinks that could be arthritis.,OBJECTIVE: , Weight 213.2 pounds, blood pressure 142/84, pulse 92, respirations 16.  General:  The patient is nontoxic and in no acute distress.  Musculoskeletal:  The right hand was examined.  It appears to be within normal limits and the appearance is similar to the left hand.  She has good and equal grip strength noted bilaterally.  She has negative Tinel's bilaterally.  She has a positive Phalen's test.  The fingers on the right hand are neurovascularly intact with a normal capillary refill.,ASSESSMENT:  ,Numbness and tingling in the right upper extremity, intermittent and related to the positioning of the wrist.  I suspect carpal tunnel syndrome.,PLAN:  ,The patient is going to use Anaprox double strength one pill every 12 hours with food as well as a cock-up wrist splint.  We are going to try this for two weeks and if the condition is still present, then we are going to proceed with EMG test at that time.  She is going to let me know.  While she is here, I am going to also get her the blood test she needs for her diabetes.  I am noting that her blood pressure is elevated, but improved from the last visit.  I also noticed that she has lost a lot of weight.  She is working on diet and exercise and she is doing a great job.  Right now for the blood pressure we are going to continue to observe as she carries forward additional measures in her diet and exercise to lose more weight and I expect the blood pressure will continue to improve.","neurology, tinel's, phalen's, positioning of the wrist, numbness and tingling, carpal tunnel syndrome, carpal tunnel, numbness, tingling"
 Sleep study - patient with symptoms of obstructive sleep apnea with snoring., Neurology, Sleep Study Interpretation ,"PROCEDURE:, Sleep study.,CLINICAL INFORMATION:, This patient is a 56-year-old gentleman who had symptoms of obstructive sleep apnea with snoring, hypertension. The test was done 01/24/06. The patient weighed 191 pounds, five feet, seven inches tall.,SLEEP QUESTIONNAIRE:, According to the patient's own estimate, the patient took about 15 minutes to fall asleep, slept for six and a half hours, did have some dreams. Did not wake up and the sleep was less refreshing. He was sleepy in the morning.,STUDY PROTOCOL:, An all night polysomnogram was recorded with a Compumedics E Series digital polysomnograph. After the scalp was prepared, Ag/AgCl electrodes were applied to the scalp according to the International 10-20 System. EEG was monitored from C4-A1, C3-A2, O2-A1 and O2-A1. EOG and EMG were continuously monitored by electrodes placed at the outer canthi and chin respectively. Nasal and oral airflow were monitored using a triple port Thermistor. Respiratory effort was measured by piezoelectric technology employing an abdominal and thoracic belt. Blood oxygen saturation was continuously monitored by pulse oximetry. Heart rate and rhythm were monitored by surface electrocardiography. Anterior tibialis EMG was studied by using surface mounted electrodes placed 5 cm apart on both legs. Body position and snoring level were also monitored.,TECHNICAL QUALITY OF STUDY:, Good.,ELECTROPHYSIOLOGIC MEASUREMENTS:, Total recording time 406 minutes, total sleep time 365 minutes, sleep latency 25.5 minutes, REM latency 49 minutes, _____ 90%, sleep latency measured 86%. _____ period was obtained. The patient spent 10% of the time awake in bed.,Stage I: 3.8,Stage II: 50.5,Stage III: 14%,Stage REM: 21.7%,The patient had relatively good sleep architecture, except for excessive waking.,RESPIRATORY MEASUREMENTS:, Total apnea/hypopnea 75, age index 12.3 per hour. REM age index 15 per hour. Total arousal 101, arousal index 15.6 per hour. Oxygen desaturation was down to 88%. Longest event 35 second hypopnea with an FiO2 of 94%. Total limb movements 92, PRM index 15.1 per hour. PRM arousal index 8.9 per hour.,ELECTROCARDIOGRAPHIC OBSERVATIONS:, Heart rate while asleep 60 to 64 per minute, while awake 70 to 78 per minute.,CONCLUSIONS:, Obstructive sleep apnea syndrome with moderately loud snoring and significant apnea/hypopnea index.,RECOMMENDATIONS:,AXIS B: Overnight polysomnography.,AXIS C: Hypertension.,The patient should return for nasal CPAP titration. Sleep apnea if not treated, may lead to chronic hypertension, which may have cardiovascular consequences. Excessive daytime sleepiness, dysfunction and memory loss may also occur.","neurology, sleep study, obstructive sleep apnea, snoring, hypertension, polysomnogram, compumedics, polysomnograph, ag/agcl electrodes, triple port thermistor, rem, latency, polysomnography, cpap titration, sleep latency, apnea, sleep, obstructive, index, "
" HCT: SAH, Contusion, Skull fracture", Neurology," SAH, Contusion, Skull Fracture ","CC: ,Headache.,HX:, This 51 y/o RHM was moving furniture several days prior to presentation when he struck his head (vertex) against a door panel. He then stepped back and struck his back on a trailer hitch. There was no associated LOC but he felt ""dazed."" He complained a HA since the accident. The following day he began experiencing episodic vertigo lasting several minutes with associated nausea and vomiting. He has been lying in bed most of the time since the accident. He also complained of transient left lower extremity weakness. The night before admission he went to his bedroom and his girlfriend heard a loud noise. She found him on the floor unable to speak or move his left side well. He was taken to a local ER. In the ER experienced a spell in which he stared to the right for approximately one minute. During this time he was unable to speak and did not seem to comprehend verbal questions. This resolved. ER staff noted decreased left sided movement and a left Babinski sign.,He was given valium 5 mg, and DPH 1.0g. A HCT was performed and he was transferred to UIHC.,PMH:, DM, Coronary Artery Disease, Left femoral neuropathy of unknown etiology. Multiple head trauma in past (?falls/fights).,MEDS:, unknown oral med for DM.,SHX:, 10+pack-year h/o Tobacco use; quit 2 years ago. 6-pack beer/week. No h/o illicit drug use.,FHX:, unknown.,EXAM: ,70BPM, BP144/83, 16RPM, 36.0C,MS: Alert and oriented to person, place, time. Fluent speech.,CN: left lower facial weakness with right gaze preference. Pupils 3/3 decreasing to 2/2 on exposure to light. Optic disks flat.,MOTOR: decreased spontaneous movement of left-sided extremities. 5/4 strength in both upper and lower extremities. Normal muscle tone and bulk.,SENSORY: withdrew equally to noxious stimulation in all four extremities. GAIT/STATION/COORDINATION: not tested.,The general physical exam was unremarkable.,During the exam the patient experienced a spell during which his head turned and eyes deviated to the leftward, and his right hand twitched. The entire spell lasted one minute.,During the episode he was verbally unresponsive. He appeared groggy and lethargic after the event.,HCT without contrast: 11/18/92: right frontal skull fracture with associated minimal epidural hematoma and small subdural hematoma, as well as some adjacent subarachnoid blood and brain contusion.,LABS:, CBC, GS, PT/PTT were all WNL.,COURSE:, The patient was diagnosed with a right frontal SAH/contusion and post traumatic seizures. DPH was continued and he was given a Librium taper for possible alcoholic withdrawal. A neurosurgical consult was obtained. He did not receive surgical intervention and was discharged 12/1/92. Neuropsychological testing on 11/25/92 revealed: poor orientation to time or place and poor attention. Anterograde verbal and visual memory was severely impaired. Speech became mildly dysarthric when fatigued. Defective word finding. Difficulty copying 2 of 3 three dimensional figures. Recent head injury as well as a history of ETOH abuse and multiple prior head injuries probably contribute to his deficits.","neurology, sah, contusion, skull fracture, headache, post traumatic seizures, lower extremity weakness, loud noise, hct, weakness, skull, hematoma, fracture, "
" A 6-year-old male who is a former 27-week premature infant, suffered an intraventricular hemorrhage requiring shunt placement, and as a result, has developmental delay and left hemiparesis. ", Neurology, Status Epilepticus ,"CHIEF COMPLAINT:,  Status epilepticus.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 6-year-old male who is a former 27-week premature infant who suffered an intraventricular hemorrhage requiring shunt placement, and as a result, has developmental delay and left hemiparesis.  At baseline, he can put about 2 to 4 words together in brief sentences.  His speech is not always easily understood; however, he is in a special education classroom in kindergarten.  He ambulates independently, but falls often.  He has difficulty with his left side compared to the right, and prefers to use the right upper extremity more than the left.  Mother reports he postures the left upper extremity when running.  He is being followed by Medical Therapy Unit and has also been seen in the past by Dr. X.  He has not received Botox or any other interventions with regard to his cerebral palsy.,The patient did require one shunt revision, but since then his shunt has done well.,The patient developed seizures about 2 years ago.  These occurred periodically, but they are always in the same and with the involvement of the left side more than right and he had an eye deviation forcefully to the left side.  His events, however, always tend to be prolonged.  He has had seizures as long as an hour and a half.  He tends to require multiple medications to stop them.  He has been followed by Dr. Y and was started on Trileptal.  At one point, The patient was taken off his medication for presumed failure to prevent his seizures.  He was more recently placed on Topamax since March 2007.  His last seizures were in March and May respectively.  He is worked up to a dose of 25 mg capsules, 2 capsules twice a day or about 5 mg/kg/day at this point.,The patient was in his usual state of health until early this morning and was noted to be in seizure.  His seizure this morning was similar to the previous seizures with forced deviation of his head and eyes to the left side and convulsion more on the left side than the right.  Family administered Diastat 7.5 mg x1 dose.  They did not know they could repeat this dose.  EMS was called and he received lorazepam 2 mg and then in the emergency department, 15 mg/kg of fosphenytoin.  His seizures stopped thereafter, since that time, he had gradually become more alert and is eating, and is nearly back to baseline.  He is a bit off balance and tends to be a bit weaker on the left side compared to baseline postictally.,REVIEW OF SYSTEMS: , At this time, he is positive for a low-grade fever, he has had no signs of illness otherwise.  He does have some fevers after his prolonged seizures.  He denies any respiratory or cardiovascular complaints.  There is no numbness or loss of skills.  He has no rashes, arthritis or arthralgias.  He has no oropharyngeal complaints.  Visual or auditory complaints.,PAST MEDICAL HISTORY: , Also positive for some mild scoliosis.,SOCIAL HISTORY: , The patient lives at home with mother, father, and 2 other siblings.  There are no ill contacts.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a well-nourished, well-hydrated male, in no acute distress.,VITAL SIGNS:  His vital signs are stable and he is currently afebrile.,HEENT:  Atraumatic and normocephalic.  Oropharynx shows no lesions.,NECK:  Supple without adenopathy.,CHEST:  Clear to auscultation.,CARDIOVASCULAR:  Regular rate and rhythm, no murmurs.,ABDOMEN:  Benign without organomegaly.,EXTREMITIES:  No clubbing, cyanosis or edema.,NEUROLOGIC:  The patient is alert and will follow instructions.  His speech is very dysarthric and he tends to run his words together.  He is about 50% understandable at best.  He does put words and sentences together.  His cranial nerves reveal his pupils are equal, round, and reactive to light.  His extraocular movements are intact.  His visual fields are full.  Disks are sharp bilaterally.  His face shows left facial weakness postictally.  His palate elevates midline.  Vision is intact bilaterally.  Tongue protrudes midline.,Motor exam reveals clearly decreased strength on the left side at baseline.  His left thigh is abducted at the hip at rest with the right thigh and leg straight.  He has difficulty using the left arm and while reaching for objects, shows exaggerated tremor/dysmetria.  Right upper extremity is much more on target.  His sensations are intact to light touch bilaterally.  Deep tendon reflexes are 2+ and symmetric.  When sitting up, he shows some truncal instability and tendency towards decreased truncal tone and kyphosis.  He also shows some scoliotic curve of the spine, which is mild at this point.  Gait was not tested today.,IMPRESSION: , This is a 6-year-old male with recurrent status epilepticus, left hemiparesis, history of prematurity, and intraventricular hemorrhage.  He is on Topamax, which is at a moderate dose of 5 mg/kg a day or 50 mg twice a day.  At this point, it is not clear whether this medication will protect him or not, but the dose is clearly not at maximum, and he is tolerating the dose currently.  The plan will be to increase him up to 50 mg in the morning, and 75 mg at night for 2 weeks, and then 75 mg twice daily.  Reviewed the possible side effects of higher doses of Topamax, they will monitor him for language issues, cognitive problems or excessive somnolence.  I also discussed his imaging studies, which showed significant destruction of the cerebellum compared to other areas and despite this, the patient at baseline has a reasonable balance.  The plan from CT standpoint is to continue stretching program, continue with medical therapy unit.  He may benefit from Botox.,In addition, I reviewed the Diastat protocol with parents and given the patient tends to go into status epilepticus each time, they can administer Diastat immediately and not wait the standard 2 minutes or even 5 minutes that they were waiting before.  They are going to repeat the dose within 10 minutes and they can call EMS at any point during that time.  Hopefully at home, they need to start to abort these seizures or the higher dose of Topamax will prevent them.  Other medication options would include Keppra, Zonegran or Lamictal.,FOLLOWUP: , Followup has already been scheduled with Dr. Y in February and they will continue to keep that date for followup.",
 Diagnosis of benign rolandic epilepsy., Neurology, Rolandic Epilepsy ,"City, State,Dear Dr. Y:,I had the pleasure of seeing ABC today back in Neurology Clinic where he has been followed previously by Dr. Z.  His last visit was in June 2006, and he carries a diagnosis of benign rolandic epilepsy.  To review, his birth was unremarkable.  He is a second child born to a G3, P1 to 2 female.  He has had normal development, and is a bright child in 7th grade.  He began having seizures, however, at 9 years of age.  It is manifested typically as generalized tonic-clonic seizures upon awakening or falling into sleep.  He also had smaller spells with more focal convulsion and facial twitching.  His EEGs have shown a pattern consistent with benign rolandic epilepsy (central temporal sharp waves both of the right and left hemisphere).  Most recent EEG in May 2006 shows the same abnormalities.,ABC initially was placed on Tegretol, but developed symptoms of toxicity (hallucinations) on this medication, he was switched to Trileptal.  He has done very well taking 300 mg twice a day without any further seizures.  His last event was the day of his last EEG when he was sleep deprived and was off medication.  That was a convulsion lasting 5 minutes.  He has done well otherwise.  Parents deny that he has any problems with concentration.  He has not had any behavior issues.  He is an active child and participates in sports and some motocross activities.  He has one older sibling and he lives with his parents.  Father manages Turkey farm with foster farms.  Mother is an 8th grade teacher.,Family history is positive for a 3rd cousin, who has seizures, but the specific seizure type is not known.  There is no other relevant family history.,Review of systems is positive for right heel swelling and tenderness to palpation.  This is perhaps due to sports injury.  He has not sprained his ankle and does not have any specific acute injury around the time that this was noted.  He does also have some discomfort in the knees and ankles in the general sense with activities.  He has no rashes or any numbness, weakness or loss of skills.  He has no respiratory or cardiovascular complaints.  He has no nausea, vomiting, diarrhea or abdominal complaints.,Past medical history is otherwise unremarkable.,Other workup includes CT scan and MRI scan of the brain, which are both normal.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a well-nourished, well-hydrated male in no acute distress.  VITAL SIGNS:  His weight today is 80.6 pounds.  Height is 58-1/4 inches.  Blood pressure 113/66.  Head circumference 36.3 cm.  HEENT:  Atraumatic, normocephalic.  Oropharynx shows no lesions.  NECK:  Supple without adenopathy.  CHEST:  Clear auscultation.,CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs.  ABDOMEN:  Benign without organomegaly.  EXTREMITIES:  No clubbing, cyanosis or edema.  NEUROLOGIC:  The patient is alert and oriented.  His cognitive skills appear normal for his age.  His speech is fluent and goal-directed.  He follows instructions well.  His cranial nerves reveal his pupils equal, round, and reactive to light.  Extraocular movements are intact.  Visual fields are full.  Disks are sharp bilaterally.  Face moves symmetrically with normal sensation.  Palate elevates midline.  Tongue protrudes midline.  Hearing is intact bilaterally.  Motor exam reveals normal strength and tone.  Sensation intact to light touch and vibration.  His gait is nonataxic with normal heel-toe and tandem.  Finger-to-nose, finger-nose-finger, rapid altering movements are normal.  Deep tendon reflexes are 2+ and symmetric.,IMPRESSION:  ,This is an 11-year-old male with benign rolandic epilepsy, who is followed over the past 2 years in our clinic.  Most recent electroencephalogram still shows abnormalities, but it has not been done since May 2006.  The plan at this time is to repeat his electroencephalogram, follow his electroencephalogram annually until it reveres to normal.  At that time, he will be tapered off of medication.  I anticipate at some point in the near future, within about a year or so, he will actually be taken off medication.  For now, I will continue on Trileptal 300 mg twice a day, which is a low starting dose for him.  There is no indication that his dose needs to be increased.  Family understands the plan.  We will try to obtain an electroencephalogram in the near future in Modesto and followup is scheduled for 6 months.  Parents will contact us after the electroencephalogram is done so they can get the results.,Thank you very much for allowing me to access ABC for further management.","neurology, tonic-clonic seizures, benign rolandic epilepsy, rolandic epilepsy, epilepsy, seizures, electroencephalogram,"
 Reflex sympathetic dystrophy of both lower extremities., Neurology, Reflex Sympathetic Dystrophy - Letter ,"Doctor's Address,Dear Doctor:,This letter serves as a reintroduction of my patient, A, who will be seeing you on Thursday, 06/12/2008.  As you know, he is an unfortunate gentleman who has reflex sympathetic dystrophy of both lower extremities.  His current symptoms are more severe on the right and he has had a persisting wound that has failed to heal on his right leg.  He has been through Wound Clinic to try to help heal this, but was intolerant of compression dressings and was unable to get satisfactory healing of this.  He has been seen by Dr. X for his pain management and was considered for the possibility of amputation being a therapeutic option to help reduce his pain.  He was seen by Dr. Y at Orthopedic Associates for review of this.  However, in my discussion with Dr. Z and his evaluation of Mr. A, it was felt that this may be an imprudent path to take given the lack of likelihood of reduction of his pain from his RST, his questionable healing of his wound given noninvasive studies that did reveal tenuous oxygenation of the right lower leg, and concerns of worsening of his RST symptoms on his left leg if he would have an amputation.  Based on the results of his transcutaneous oxygen levels and his dramatic improvement with oxygen therapy at this test, Dr. Z felt that a course of hyperbaric oxygen may be of utility to help in improving his wounds.  As you may or may not know we have certainly pursued aggressive significant measures to try to improve Mr. A's pain.  He has been to Cleveland Clinic for implantable stimulator, which was unsuccessful at dramatically improving his pain.  He currently is taking methadone up to eight tablets four times a day, morphine up to 100 mg three times a day, and Dilaudid two tablets by mouth every two hours to help reduce his pain.  He also is currently taking Neurontin 1600 mg three times a day, Effexor XR 250 mg once a day, Cytomel 25 mcg once a day, Seroquel 100 mg p.o. q. day, levothyroxine 300 mcg p.o. q. day, Prinivil 20 mg p.o. q. day, and Mevacor 40 mg p.o. q day.,I appreciate your assistance in determining if hyperbaric oxygen is a reasonable treatment course for this unfortunate situation.  Dr. Z and I have both tried to stress the fact that amputation may be an abrupt and irreversible treatment course that may not reach any significant conclusion.  He has been evaluated by Dr. X for rehab concerns to determine.  He agrees that a less aggressive form of therapy may be most appropriate.,I thank you kindly for your prompt evaluation of this kind gentleman in an unfortunate situation.  If you have any questions regarding his care please feel free to call me at my office.  Otherwise, I look forward to hearing back from you shortly after your evaluation.  Please feel free to call me if it is possible or if you have any questions about anything.","neurology, rsd, reflex sympathetic dystrophy, orthopedic, oxygenationNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" Followup left-sided rotator cuff tear and cervical spinal stenosis.  Physical examination and radiographic findings are compatible with left shoulder pain and left upper extremity pain, which is due to a combination of left-sided rotator cuff tear and moderate cervical spinal stenosis.", Neurology, Rotator Cuff Tear ,"REASON FOR VISIT: , Followup left-sided rotator cuff tear and cervical spinal stenosis.,HISTORY OF PRESENT ILLNESS: , Ms. ABC returns today for followup regarding her left shoulder pain and left upper extremity C6 radiculopathy.  I had last seen her on 06/21/07.,At that time, she had been referred to me Dr. X and Dr. Y for evaluation of her left-sided C6 radiculopathy.  She also had a significant rotator cuff tear and is currently being evaluated for left-sided rotator cuff repair surgery, I believe on, approximately 07/20/07.  At our last visit, I only had a report of her prior cervical spine MRI.  I did not have any recent images.  I referred her for cervical spine MRI and she returns today.,She states that her symptoms are unchanged.  She continues to have significant left-sided shoulder pain for which she is being evaluated and is scheduled for surgery with Dr. Y.,She also has a second component of pain, which radiates down the left arm in a C6 distribution to the level of the wrist.  She has some associated minimal weakness described in detail in our prior office note.  No significant right upper extremity symptoms.  No bowel, bladder dysfunction.  No difficulty with ambulation.,FINDINGS: , On examination, she has 4 plus over 5 strength in the left biceps and triceps muscle groups, 4 out of 5 left deltoid, 5 out of 5 otherwise in both muscle groups and all muscle groups of upper extremities.  Light touch sensation is minimally decreased in the left C6 distribution; otherwise, intact.  Biceps and brachioradialis reflexes are 1 plus.  Hoffmann sign normal bilaterally.  Motor strength is 5 out of 5 in all muscle groups in lower extremities.  Hawkins and Neer impingement signs are positive at the left shoulder.,An EMG study performed on 06/08/07 demonstrates no evidence of radiculopathy or plexopathy or nerve entrapment to the left upper extremity.,Cervical spine MRI dated 06/28/07 is reviewed.  It is relatively limited study due to artifact.  He does demonstrate evidence of minimal-to-moderate stenosis at the C5-C6 level but without evidence of cord impingement or cord signal change.  There appears to be left paracentral disc herniation at the C5-C6 level, although axial T2-weighted images are quite limited.,ASSESSMENT AND PLAN: , Ms. ABC's history, physical examination and radiographic findings are compatible with left shoulder pain and left upper extremity pain, which is due to a combination of left-sided rotator cuff tear and moderate cervical spinal stenosis.,I agree with the plan to go ahead and continue with rotator cuff surgery.  With regard to the radiculopathy, I believe this can be treated non-operatively to begin with.  I am referring her for consideration of cervical epidural steroid injections.  The improvement in her pain may help her recover better from the shoulder surgery.,I will see her back in followup in 3 months, at which time she will be recovering from a shoulder surgery and we will see if she needs any further intervention with regard to the cervical spine.,I will also be in touch with Dr. Y to let him know this information prior to the surgery in several weeks.","neurology, upper extremity, radiculopathy, rotator cuff repair, cervical spinal stenosis, rotator cuff tear, physical examination, cuff, impingement, stenosis, extremity, surgery, tear, shoulder, rotator, cervical,"
" Botulinum toxin injection bilateral rectus femoris, medial hamstrings, and gastrocnemius soleus muscles, phenol neurolysis of bilateral obturator nerves, application of bilateral short leg fiberglass casts.", Neurology, Phenol Neurolysis & Botulinum Toxin Injection - 3 ,"PROCEDURE CODES:  64640 times two, 64614 time two, 95873 times two, 29405 times two.,PREOPERATIVE DIAGNOSIS:  Spastic diplegic cerebral palsy, 343.0.,POSTOPERATIVE DIAGNOSIS:  Spastic diplegic cerebral palsy, 343.0.,ANESTHESIA:  MAC.,COMPLICATIONS:  None.,DESCRIPTION OF TECHNIQUE:  Informed consent was obtained from the patient's mom.  The patient was brought to minor procedures and sedated per their protocol.  The patient was positioned lying supine.  Skin overlying all areas injected was prepped with chlorhexidine.,The obturator nerves were identified lateral to the adductor longus tendon origin and below the femoral pulse with active EMG stimulation.  Approximately 4 mL of 5% phenol was injected in this location bilaterally.  Phenol injections were done at the site of maximum hip adduction contraction with least amount of stimulus.  Negative drawback for blood was done prior to each injection of phenol.,Muscles injected with botulinum toxin were identified with active EMG stimulation.  Approximately 50 units was injected in the rectus femoris bilaterally, 75 units in the medial hamstrings bilaterally and 100 units in the gastrocnemius soleus muscles bilaterally.  Total amount of botulinum toxin injected was 450 units diluted 25 units to 1 mL.  After injections were performed, bilateral short leg fiberglass casts were applied.  The patient tolerated the procedure well and no complications were encountered.","neurology, botulinum toxin injection bilateral, toxin injection bilateral rectus, neurolysis of bilateral obturator, short leg fiberglass casts, muscles phenol neurolysis, botulinum toxin injection, gastrocnemius soleus muscles, short leg fiberglass, femoris medial, cerebral palsy, active emg, emg stimulation, phenol neurolysis, toxin injection, rectus femoris, gastrocnemius soleus, soleus muscles, obturator nerves, leg fiberglass, fiberglass casts, botulinum toxin, hamstrings, gastrocnemius, obturator, nerves, fiberglass, casts, muscles, botulinum, phenol, bilateral, injection, toxin"
 Endoscopic-assisted transsphenoidal exploration and radical excision of pituitary adenoma.  Endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus., Neurology, Pituitary Adenomectomy ,"PREOPERATIVE DIAGNOSIS: , Large and invasive recurrent pituitary adenoma.,POSTOPERATIVE DIAGNOSIS:,  Large and invasive recurrent pituitary adenoma.,OPERATION PERFORMED: , Endoscopic-assisted transsphenoidal exploration and radical excision of pituitary adenoma, endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus, harvesting of dermal fascia abdominal fat graft, placement of abdominal fat graft into sella turcica, reconstruction of sellar floor using autologous nasal bone creating a cranioplasty of less than 5 cm, repair of nasal septal deviation, using the operating microscope and microdissection technique, and placement of lumbar subarachnoid catheter connected to reservoir for aspiration and infusion.,INDICATIONS FOR PROCEDURE: , This man has undergone one craniotomy and 2 previous transsphenoidal resections of his tumor, which is known to be an invasive pituitary adenoma.  He did not return for followup or radiotherapy as instructed, and the tumor has regrown.  For this reason, he is admitted for transsphenoidal reoperation with an attempt to remove as much tumor as possible.  The high-risk nature of the procedure and the fact that postoperative radiation is mandatory was made clear to him.  Many risks including CSF leak and blindness were discussed in detail.  After clear understanding of all the same, he elected to proceed ahead with surgery.,PROCEDURE:  ,The patient was placed on the operating table, and after adequate induction of general anesthesia, he was placed in the left lateral decubitus position.  Care was taken to pad all pressure points appropriately.  The back was prepped and draped in usual sterile manner.,A 14-gauge Tuohy needle was introduced into the lumbar subarachnoid space.  Clear and colorless CSF issued forth.  A catheter was inserted to a distance of 40 cm, and the needle was removed.  The catheter was then connected to a closed drainage system for aspiration and infusion.,This no-touch technique is now a standard of care for treatment of patients with large invasive adenomas.  Via injections through the lumbar drain, one increases intracranial pressure and produces gentle migration of the tumor.  This improves outcome and reduces complications by atraumatically dissecting the tumor away from the optic apparatus.,The patient was then placed supine, and the 3-point headrest was affixed.  He was placed in the semi-sitting position with the head turned to the right and a roll placed under the left shoulder.  Care was taken to pad all pressure points appropriately.  The fluoroscope C-arm unit was then positioned so as to afford an excellent view of the sella and sphenoid sinus in the lateral projection.  The metallic arm was then connected to the table for the use of the endoscope.  The oropharynx, nasopharynx, and abdominal areas were then prepped and draped in the usual sterile manner.,A transverse incision was made in the abdominal region, and several large pieces of fat were harvested for later use.  Hemostasis was obtained.  The wound was carefully closed in layers.,I then advanced a 0-degree endoscope up the left nostril.  The middle turbinate was identified and reflected laterally exposing the sphenoid sinus ostium.  Needle Bovie electrocautery was used to clear mucosa away from the ostium.  The perpendicular plate of the ethmoid had already been separated from the sphenoid.  I entered into the sphenoid.,There was a tremendous amount of dense fibrous scar tissue present, and I slowly and carefully worked through all this.  I identified a previous sellar opening and widely opened the bone, which had largely regrown out to the cavernous sinus laterally on the left, which was very well exposed, and the cavernous sinus on the right, which I exposed the very medial portion of.  The opening was wide until I had the horizontal portion of the floor to the tuberculum sella present.,The operating microscope was then utilized.  Working under magnification, I used hypophysectomy placed in the nostril.,The dura was then carefully opened in the midline, and I immediately encountered tissue consistent with pituitary adenoma.  A frozen section was obtained, which confirmed this diagnosis without malignant features.,Slowly and meticulously, I worked to remove the tumor.  I used the suction apparatus as well as the bipolar coagulating forceps and ring and cup curette to begin to dissect tumor free.  The tumor was moderately vascular and very fibrotic.,Slowly and carefully, I systematically entered the sellar contents until I could see the cavernous sinus wall on the left and on the right.  There appeared to be cavernous sinus invasion on the left.  It was consistent with what we saw on the MRI imaging.,The portion working into the suprasellar cistern was slowly dissected down by injecting saline into the lumbar subarachnoid catheter.  A large amount of this was removed.  There was a CSF leak, as the tumor was removed for the upper surface of it was very adherent to the arachnoid and could not be separated free.,Under high magnification, I actually worked up into this cavity and performed a very radical excision of tumor.  While there may be a small amount of tumor remaining, it appeared that a radical excision had been created with decompression of the optic apparatus.  In fact, I reinserted the endoscope and could see the optic chiasm well.,I reasoned that I had therefore achieved the goal with that is of a radical excision and decompression.  Attention was therefore turned to closure.,The wound was copiously irrigated with Bacitracin solution, and meticulous hemostasis was obtained.  I asked Anesthesiology to perform a Valsalva maneuver, and there was no evidence of bleeding.,Attention was turned to closure and reconstruction.  I placed a very large piece of fat in the sella to seal the leak and verified that there was no fat in the suprasellar cistern by using fluoroscopy and looking at the pattern of the air.  Using a polypropylene insert, I reconstructed the sellar floor with this implant making a nice tight sling and creating a cranioplasty of less than 5 cm.,DuraSeal was placed over this, and the sphenoid sinus was carefully packed with fat and DuraSeal.,I inspected the nasal passages and restored the septum precisely to the midline repairing a previous septal deviation.  The middle turbinates were then restored to their anatomic position.  There was no significant intranasal bleeding, and for this reason, an open nasal packing was required.  Sterile dressings were applied, and the operation was terminated.,The patient tolerated the procedure well and left to the recovery room in excellent condition.  The sponge and needle counts were reported as correct, and there were no intraoperative complications.,Specimens were sent to Pathology consisting of tumor.", 
" Phenol neurolysis right obturator nerve, botulinum toxin injection right rectus femoris and vastus medialis intermedius and right pectoralis major muscles.", Neurology, Phenol Neurolysis & Botulinum Toxin Injection - 2 ,"PROCEDURES PERFORMED: , Phenol neurolysis right obturator nerve, botulinum toxin injection right rectus femoris and vastus medialis intermedius and right pectoralis major muscles.,PROCEDURE CODES: , 64640 times one, 64614 times two, 95873 times two.,PREOPERATIVE DIAGNOSIS: , Spastic right hemiparetic cerebral palsy, 343.1.,POSTOPERATIVE DIAGNOSIS:,  Spastic right hemiparetic cerebral palsy, 343.1.,ANESTHESIA:,  MAC.,COMPLICATIONS: , None.,DESCRIPTION OF TECHNIQUE: , Informed consent was obtained from the patient.  She was brought to the minor procedure area and sedated per their protocol.  The patient was positioned lying supine.  Skin overlying all areas injected was prepped with chlorhexidine.  The right obturator nerve was identified using active EMG stimulation lateral to the adductor longus tendon origin and below the femoral pulse.  Approximately 6 mL of 5% phenol was injected in this location.  At all sites of phenol injections, injections were done at the site of maximum hip adduction contraction with least amount of stimulus.  Negative drawback for blood was done prior to each injection of phenol.,Muscles injected with botulinum toxin were identified with active EMG stimulation.  Approximately 100 units was injected in the right pectoralis major and 100 units in the right rectus femoris and vastus intermedius muscles.  Total amount of botulinum toxin injected was 200 units diluted 25 units to 1 mL.  The patient tolerated the procedure well and no complications were encountered.","neurology, femoris and vastus medialis, intermedius and right pectoralis, rectus femoris and vastus, vastus medialis intermedius, botulinum toxin injection, medialis intermedius, major muscles, cerebral palsy, active emg, emg stimulation, phenol neurolysis, toxin injection, obturator nerve, rectus femoris, pectoralis major, botulinum toxin, pectoralis, botulinum, phenol, injection, toxin"
 Status post brain tumor removal.   The patient is a 64-year-old female referred to physical therapy following complications related to brain tumor removal.  She had a brain tumor removed and had left-sided weakness.  , Neurology, Physical Therapy - Brain Tumor Removal ,"DIAGNOSIS:,  Status post brain tumor removal.,HISTORY:,  The patient is a 64-year-old female referred to physical therapy following complications related to brain tumor removal.  The patient reports that on 10/24/08 she had a brain tumor removed and had left-sided weakness.  The patient was being seen in physical therapy from 11/05/08 to 11/14/08 then she began having complications.  The patient reports that she was admitted to Hospital on 12/05/08.  At that time, they found massive swelling on the brain and a second surgery was performed.  The patient then remained in acute rehab until she was discharged to home on 01/05/09.  The patient's husband, Al, is also present and he reports that during rehabilitation the patient did have a DVT in the left calf that has since been resolved.,PAST MEDICAL HISTORY: , Unremarkable.,MEDICATIONS:  ,Coumadin, Keppra, Decadron, and Glucophage.,SUBJECTIVE: , The patient reports that the pain is not an issue at this time.  The patient states that her primary concern is her left-sided weakness as related to her balance and her walking and her left arm weakness.,PATIENT GOAL:  ,To increase strength in her left leg for better balance and walking.,OBJECTIVE:,RANGE OF MOTION:  Bilateral lower extremities are within normal limits.,STRENGTH:  Bilateral lower extremities are grossly 5/5 with one repetition, except left hip reflexion 4+/5.,BALANCE:  The patient's balance was assessed with a Berg balance test.  The patient has got 46/56 points, which places her at moderate risk for falls.,GAIT:  The patient ambulates with contact guard assist.  The patient ambulates with a reciprocal gait pattern with good bilateral foot clearance.  However, the patient has been reports that with increased fatigue, left footdrop tends to occur.  A 6-minute walk test will be performed at the next visit due to time constraints.,ASSESSMENT: , The patient is a 64-year-old female referred to Physical Therapy status post brain surgery.  Examination indicates deficits in strength, balance, and ambulation.  The patient will benefit from skilled physical therapy to address these impairments.,TREATMENT PLAN: , The patient will be seen three times per week for 4 weeks and then reduce it to two times per week for 4 additional weeks.  Interventions include:,1.  Therapeutic exercise.,2.  Balance training.,3.  Gait training.,4.  Functional mobility training.,SHORT TERM GOAL TO BE COMPLETED IN 4 WEEKS:,1.  The patient is to tolerate 30 repetitions of all lower extremity exercises.,2.  The patient is to improve balance with a score of 50/56 points.,3.  The patient is to ambulate 1000 feet in a 6-minute walk test with standby assist.,LONG TERM GOAL TO BE ACHIEVED IN 8 WEEKS:,1.  The patient is to ambulate independently within her home and standby to general supervision within the community.,2.  Berg balance test to be 52/56.,3.  The patient is to ambulate a 6-minute walk test for 1500 feet independently including safe negotiation of corners and busy areas.,4.  The patient is to demonstrate safely stepping over and around objects without loss of balance.,Prognosis for the above-stated goals is good.  The above treatment plan has been discussed with the patient and her husband.  They are in agreement.",
 Patient continuing on Dilantin 300 mg daily and has been seizure episode free for the past 2 1/2 years., Neurology, Suspected Seizure Activity ,"XYZ Street,City, State,Dear Dr. CD:,Thank you for seeing Mr. XYZ, a pleasant 19-year-old male who has seen you in 2005 for suspected seizure activity.  He comes to my office today continuing on Dilantin 300 mg daily and has been seizure episode free for the past 2 1/2 years.  He is requesting to come off the Dilantin at this point.  Upon reviewing your 2005 note there was some discrepancy as to the true nature of his episodes to the emergency room and there was consideration to reconsider medication use.  His physical exam, neurologically, is normal at this time.  His Dilantin level is slightly low at 12.5.,I will appreciate your evaluation and recommendation as to whether we need to continue the Dilantin at this time.  I understand this will probably entail repeating his EEG and so please coordinate this through Health Center.  I await your response and whether we should continue this medication.  If you require any laboratory, we use ABC Diagnostic and any further testing that is needed should be coordinated at Health Center prior to scheduling.","neurology, eeg, suspected seizure activity, seizure activity, seizure episode, seizure, dilantinNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" The patient with pseudotumor cerebri without papilledema, comes in because of new onset of headaches. ", Neurology, Pseudotumor Cerebri ,"REASON FOR VISIT:  ,The patient is a 38-year-old woman with pseudotumor cerebri without papilledema who comes in because of new onset of headaches.  She comes to clinic by herself.,HISTORY OF PRESENT ILLNESS: , Dr. X has cared for her since 2002.  She has a Codman-Hakim shunt set at 90 mmH2O.  She last saw us in clinic in January 2008 and at that time we recommended that she followup with Dr. Y for medical management of her chronic headaches.  We also recommended that the patient see a psychiatrist regarding her depression, which she stated that she would followup with that herself.  Today, the patient returns to clinic because of acute onset of headaches that she has had since her shunt was adjusted after an MRI on 04/18/08.  She states that since that time her headaches have been bad.  They woke her up at night.  She has not been able to sleep.  She has not had a good sleep cycle since that time.  She states that the pain is constant and is worse with coughing, straining, and sneezing as well as on standing up.  She states that they feel a little bit better when lying down.  Medication shave not helped her.  She has tried taking Imitrex as well as Motrin 800 mg twice a day, but she states it has not provided much relief.  The pain is generalized, but also noted to be quite intense in the frontal region of her head.  She also reports ringing in the ears and states that she just does not feel well.  She reports no nausea at this time.  She also states that she has been experiencing intermittent blurry vision and dimming lights as well.  She tells me that she has an appointment with Dr. Y tomorrow.  She reports no other complaints at this time.,MAJOR FINDINGS:,  On examination today, this is a pleasant 38-year-old woman who comes back from the clinic waiting area without difficulty.  She is well developed, well nourished, and kempt.,Vital Signs:  Blood pressure 153/86, pulse 63, and respiratory rate 16.,Cranial Nerves:  Intact for extraocular movements.  Facial movement, hearing, head turning, tongue, and palate movements are all intact.  I did not know any papilledema on exam bilaterally.,I examined her shut site, which is clean, dry, and intact.  She did have a small 3 mm to 4 mm round scab, which was noted farther down from her shunt reservoir.  It looks like there is a little bit of dry blood there.,ASSESSMENT:,  The patient appears to have had worsening headaches since shunt adjustment back after an MRI.,PROBLEMS/DIAGNOSES:,1.  Pseudotumor cerebri without papilledema.,2.  Migraine headaches.,PROCEDURES:,  I programmed her shunt to 90 mmH2O.,PLAN:,  It was noted that the patient began to have an acute onset of headache pain after her shunt adjustment approximately a week and a half ago.  I had programmed her shunt back to 90 mmH2O at that time and confirmed it with an x-ray.  However, the picture of the x-ray was not the most desirable picture.  Thus, I decided to reprogram the shunt back to 90 mmH2O today and have the patient return to Sinai for a skull x-ray to confirm the setting at 90.  In addition, she told me that she is scheduled to see Dr. Y tomorrow, so she should followup with him and also plan on contacting the Wilmer Eye Institute to setup an appointment.  She should followup with the Wilmer Eye Institute as she is complaining of blurry vision and dimming of the lights occasionally.,Total visit time was approximately 60 minutes and about 10 minutes of that time was spent in counseling the patient.","neurology, migraine headaches, pseudotumor cerebri without papilledema, onset of headaches, blurry vision, shunt adjustment, pseudotumor cerebri, headaches, pseudotumor, cerebri, papilledema"
" Phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves.  Botulinum toxin injection left pectoralis major, left wrist flexors, and bilateral knee extensors.", Neurology, Phenol Neurolysis & Botulinum Toxin Injection - 1 ,"PROCEDURES PERFORMED:,  Phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves.  Botulinum toxin injection left pectoralis major, left wrist flexors, and bilateral knee extensors.,PROCEDURE CODES: , 64640 times three, 64614 times four, 95873 times four.,PREOPERATIVE DIAGNOSIS: , Spastic quadriparesis secondary to traumatic brain injury, 907.0.,POSTOPERATIVE DIAGNOSIS:,  Spastic quadriparesis secondary to traumatic brain injury, 907.0.,ANESTHESIA:,  MAC.,COMPLICATIONS: , None.,DESCRIPTION OF TECHNIQUE: , Informed consent was obtained from the patient's brother.  The patient was brought to the minor procedure area and sedated per their protocol.  The patient was positioned lying supine.  Skin overlying all areas injected was prepped with chlorhexidine.  The obturator nerves were identified lateral to the adductor longus tendon origin and below the femoral pulse using active EMG stimulation.  Approximately 7 mL was injected on the right side and 5 mL on the left side.  At all sites of phenol injections in this area injections were done at the site of maximum hip adduction contraction with least amount of stimulus.  Negative drawback for blood was done prior to each injection of phenol.  The musculocutaneous nerve was identified in the left upper extremity above the brachial pulse using active EMG stimulation.  Approximately 5 mL of 5% phenol was injected in this location.  Injections in this area were done at the site of maximum elbow flexion contraction with least amount of stimulus.  Negative drawback for blood was done prior to each injection of phenol.,Muscles injected with botulinum toxin were identified using active EMG stimulation.  Approximately 150 units was injected in the knee extensors bilaterally, 100 units in the left pectoralis major, and 50 units in the left wrist flexors.  Total amount of botulinum toxin injected was 450 units diluted 25 units to 1 mL.  The patient tolerated the procedure well and no complications were encountered.","neurology, spastic quadriparesis, emg stimulation, emg, botulinum toxin injection, traumatic brain, brain injury, phenol neurolysis, toxin injection, musculocutaneous nerve, obturator nerves, pectoralis major, wrist flexors, knee extensors, active emg, botulinum toxin, toxin, injection, stimulus, neurolysis, musculocutaneous, extensors, botulinum, phenol"
 MRI L-Spine - Bilateral lower extremity numbness, Neurology, Normal L-Spine MRI ,"CC: ,Bilateral lower extremity numbness.,HX: ,21 y/o RHM complained of gradual onset numbness and incoordination of both lower extremities beginning approximately 11/5/96. The symptoms became maximal over a 12-24 hour period and have not changed since. The symptoms consist of tingling in the distal lower extremities approximately half way up the calf bilaterally. He noted decreased coordination of both lower extremities which he thought might be due to uncertainty as to where his feet were being placed in space. He denied bowel/bladder problems, or weakness or numbness elsewhere. Hot showers may improve his symptoms. He has suffered no recent flu-like illness. Past medical and family histories are unremarkable. He was on no medications.,EXAM:, Unremarkable except for mild distal vibratory sensation loss in the toes (R>L).,LAB:, CBC, Gen Screen, TSH, FT4, SPE, ANA were all WNL.,MRI L-SPINE:, Normal.,COURSE:, Normal exam and diminished symptoms at following visit 4/23/93.","neurology, bilateral lower extremity numbness, mri l spine, bilateral lower extremity, lower extremity numbness, bilateral, spine, mri, extremities, numbness"
" Cervical, lumbosacral, thoracic spine flexion and extension to evaluate back and neck pain.", Neurology, Radiologic Exam - Spine  ,"EXAM: , Cervical, lumbosacral, thoracic spine flexion and extension.,HISTORY: , Back and neck pain.,CERVICAL SPINE,FINDINGS:  ,AP, lateral with flexion and extension, and both oblique projections of the cervical spine demonstrate alignment and soft tissue structures to be unremarkable.","neurology, radiologic exam, ap, back, cervical, oblique views, alignment, disc space, extension, fixation, flexion, foramina, intervertebral, lateral views, lumbosacral, neck, neck pain, oblique, odontoid view, pain, physiologic, projections, spine, subluxation, thoracic, flexion and extension, thoracic spine, vertebral"
 Squamous cell carcinoma of right temporal bone/middle ear space.  Right temporal bone resection; rectus abdominis myocutaneous free flap for reconstruction of skull base defect; right selective neck dissection zones 2 and 3., Neurology, Skull Base Reconstruction ,"PREOPERATIVE DIAGNOSIS:,  Squamous cell carcinoma of right temporal bone/middle ear space.,POSTOPERATIVE DIAGNOSIS: , Squamous cell carcinoma of right temporal bone/middle ear space.,PROCEDURE: , Right temporal bone resection; rectus abdominis myocutaneous free flap for reconstruction of skull base defect; right selective neck dissection zones 2 and 3.,ANESTHESIA: , General endotracheal.,DESCRIPTION OF PROCEDURE:  ,The patient was brought into the operating room, placed on the table in supine position.  General endotracheal anesthesia was obtained in the usual fashion.  The Neurosurgery team placed the patient in pins and after they positioned the patient the right lateral scalp was prepped with Betadine after shave as well as the abdomen.  The neck was prepped as well.  After this was performed, I made a wide ellipse of the conchal bowl with the Bovie and cutting current down through the cartilage of the conchal bowl.  A wide postauricular incision well beyond the mastoid tip extending into the right neck was then incised with the Bovie with the cutting current and a postauricular skin flap developed leaving the excise conchal bowl in place as the auricle was reflected over anterior to the condyle.  After this was performed, I used the Bovie to incise the soft tissue around the temporal bone away from the tumor on to the mandible.  The condyle was skeletonized so that it could be easily seen.  The anterior border of the sternocleidomastoid was dissected out and the spinal accessory nerve was identified and spared.  The neck contents to the hyoid were dissected out.  The hypoglossal nerve, vagus nerve, and spinal accessory nerve were dissected towards the jugular foramen.  The neck contents were removed as a separate specimen.  The external carotid artery was identified and tied off as it entered the parotid and tied with a Hemoclip distally for the future anastomosis.  A large posterior facial vein was identified and likewise clipped for later use.  I then used the cutting and diamond burs to incise the skull above the external auditory canal so as to expose the dura underneath this and extended it posteriorly to the sigmoid sinus, dissecting or exposing the dura to the level of the jugular bulb.  It became evident there was two tumor extending down the eustachian tube medial to the condyle and therefore I did use the router, I mean the side cutting bur to resect the condyle and the glenoid fossa to expose the medial extent of the eustachian tube.  The internal carotid artery was dissected out of the parapharyngeal space into the carotid canal and I drilled carotid canal up until it made.  I dissected the vertical segment of the carotid out as it entered the temporal bone until it made us turn to the horizontal portion.  Once this was dissected out, Dr. X entered the procedure for completion of the resection with the craniotomy.  For details, please see his operative note.,After Dr. X had completed the resection, I then harvested the rectus free flap.  A skin paddle was drawn out next to the umbilicus about 4 x 4 cm.  The skin paddle was incised with the Bovie and down to the anterior rectus sheath.  Sagittal incisions were made up superiorly and inferiorly to the skin paddle and the anterior rectus sheath dissected out above and below the skin paddle.  The sheath was incised to the midline and a small ellipse was made around the fascia to provide blood supply to the overlying skin.  The skin paddle was then sutured to the fascia and muscle with interrupted 3-0 Vicryl.  The anterior rectus sheath was then reflected off the rectus muscle, which was then divided superiorly with the Bovie and reflected out of the rectus sheath to an inferior direction.  The vascular pedicle could be seen entering the muscle in usual fashion.  The muscle was divided inferior to the pedicle and then the pedicle was dissected to the groin to the external iliac artery and vein where it was ligated with two large Hemoclips on each vessel.  The wound was then packed with saline impregnated sponges.  The rectus muscle with attached skin paddle was then transferred into the neck.  The inferior epigastric artery was sutured to the end of the external carotid with interrupted 9-0 Ethilon with standard microvascular technique.  Ischemia time was less than 10 minutes.  Likewise, the inferior epigastric vein was sutured to the end of the posterior facial vein with interrupted 9-0 Ethilon as well.  There was excellent blood flow through the flap and there were no or any issues with the vascular pedicle throughout the remainder of the case.  The wound was irrigated with copious amounts of saline.  The eustachian tube was obstructed with bone wax.  The muscle was then laid into position with the skin paddle underneath the conchal bowl.  I removed most the skin of the conchal bowl de-epithelializing and leaving the fat in place.  The wound was closed in layers overlying the muscle, which was secured superiorly to the muscle overlying the temporal skull.  The subcutaneous tissues were closed with interrupted 3-0 Vicryl.  The skin was closed with skin staples.  There was small incision made in the postauricular skin where the muscle could be seen and the skin edges were sewn directly to the muscle as to the rectus muscle itself.  The skin paddle was closed with interrupted 4-0 Prolene to the edges of the conchal bowl.,The abdomen was irrigated with copious amounts of saline and the rectus sheath was closed with #1 Prolene with the more running suture, taking care to avoid injury to the posterior rectus sheath by the use of ribbon retractors.  The subcutaneous tissues were closed with interrupted 2-0 Vicryl and skin was closed with skin staples.  The patient was then turned over to the Neurosurgery team for awakening after the patient was appropriately awakened.  The patient was then transferred to the PACU in stable condition with spontaneous respirations, having tolerated the procedure well.","neurology, rectus abdominis myocutaneous, skull base defect, squamous cell carcinoma, skull base, squamous cell, rectus sheath, abdominis, muscle, rectus, sheath"
 The patient is a 58-year-old African-American right-handed female with 16 years of education who was referred for a neuropsychological evaluation by Dr. X.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning., Neurology, Neuropsychological Evaluation - 4 ,"REASON FOR REFERRAL:,  The patient is a 58-year-old African-American right-handed female with 16 years of education who was referred for a neuropsychological evaluation by Dr. X. She is presenting for a second opinion following a recent neuropsychological evaluation that was ordered by her former place of employment that suggested that she was in the ""early stages of a likely dementia"" and was thereafter terminated from her position as a psychiatric nurse.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.  Note that this evaluation was undertaken as a clinical exam and intended for the purposes of aiding with treatment planning.  The patient was fully informed about the nature of this evaluation and intended use of the results.,RELEVANT BACKGROUND INFORMATION:  ,Historical information was obtained from a review of available medical records and clinical interview with the patient.  A summary of pertinent information is presented below.  Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM:,  The patient reported that she had worked as a nurse supervisor for Hospital Center for four years.  She was dismissed from this position in September 2009, although she said that she is still under active status technically, but is not able to work.  She continues to receive some compensation through FMLA hours.  She said that she was told that she had three options, to resign, to apply for disability retirement, and she had 90 days to complete the process of disability retirement after which her employers would file for charges in order for her to be dismissed from State Services.  She said that these 90 days are up around the end of November.  She said the reason for her dismissal was performance complaints.  She said that they began ""as soon as she arrived and that these were initially related to problems with her taking too much sick time off secondary to diabetes and fibromyalgia management and at one point she needed to obtain a doctor's note for any days off.  She said that her paperwork was often late and that she received discipline for not disciplining her staff frequently enough for tardiness or missed workdays.  She described it as a very chaotic and hectic work environment in which she was often putting in extra time.  She said that since September 2008 she only took two sick days and was never late to work, but that she continued to receive a lot of negative feedback.,In July of this year, she reportedly received a letter from personnel indicating that she was being referred to a state medical doctor because she was unable to perform her job duties and due to excessive sick time.  Following a brief evaluation with this doctor whose records we do not have, she was sent to a neuropsychologist, Dr. Y, Ph.D.  He completed a Comprehensive Independent Medical Evaluation on 08/14/2009.  She said that on 08/27/2009, she returned to see the original doctor who told her that based on that evaluation she was not able to work anymore.  Please note that we do not have copies of any of her work-related correspondence.  The patient never received a copy of the neuropsychological evaluation because she was told that it was ""too derogatory.""  A copy of that evaluation was provided directly to this examiner for the purpose of this evaluation.  To summarize, the results indicated ""diagnostically, The patient presents cognitive deficits involving visual working memory, executive functioning, and motor functioning along with low average intellectual functioning that is significantly below her memory functioning and below expectation based on her occupational and academic history.  This suggests that her intellectual functioning has declined.""  It concluded that ""results overall suggest early stages of a likely dementia or possibly the effects of diabetes, although her deficits are greater than expected for diabetes-related executive functioning problems and peripheral neuropathy…  The patient' deficits within the current test battery suggest that she would not be able to safely and effectively perform the duties of a nurse supervisor without help handling documentary demands and some supervision of her visual processing.  The prognosis for improvement is not good, although she might try stimulant medication if compatible with her other.  Following her dismissal, The patient presented to her primary physician, Henry Fein, M.D., who referred her to Dr. X for a second opinion regarding her cognitive deficits.  His neurological examination on 09/23/2009 was unremarkable.  The patient scored 20/30 on the Mini-Mental Status Exam missing one out of three words on recall, but was able to do so with prompting.  A repeat neurocognitive testing was suggested in order to assess for subtle deficits in memory and concentration that were not appreciated on this gross cognitive measure.,IMAGING STUDIES: , MRI of the brain on 09/14/2009 was unremarkable with no evidence of acute intracranial abnormality or abnormal enhancing lesions.  Note that the MRI was done with and without gadolinium contrast.,CURRENT FUNCTIONING:  ,The patient reported that she had experienced some difficulty completing paperwork on time due primarily to the chaoticness of the work environment and the excessive amount of responsibility that was placed upon her.  When asked about changes in cognitive functioning, she denied noticing any decline in problem solving, language, or nonverbal skills.  She also denied any problems with attention and concentration or forgetfulness or memory problems.  She continues to independently perform all activities of daily living.  She is in charge of the household finances, has had no problems paying bills on time, has had no difficulties with driving or accidents, denied any missed appointments and said that no one has provided feedback to her that they have noticed any changes in her cognitive functioning.  She reported that if her children had noticed anything they definitely would have brought it to her attention.  She said that she does not currently have a lawyer and does not intend to return to her previous physician.  She said she has not yet proceeded with the application for disability retirement because she was told that her doctors would have to fill out that paperwork, but they have not claimed that she is disabled and so she is waiting for the doctors at her former workplace to initiate the application.  Other current symptoms include excessive fatigue.  She reported that she was diagnosed with chronic fatigue syndrome in 1991, but generally symptoms are under better control now, but she still has difficulty secondary to fibromyalgia.  She also reported having fallen approximately five times within the past year.  She said that this typically occurs when she is climbing up steps and is usually related to her right foot ""like dragging.""  Dr. X's physical examination revealed no appreciable focal peripheral deficits on motor or sensory testing and notes that perhaps these falls are associated with some stiffness and pain of her right hip and knee, which are chronic symptoms from her fibromyalgia and osteoarthritis.  She said that she occasionally bumps into objects, but denied noticing it happening one on any particular part of her body.  Muscle pain secondary to fibromyalgia reportedly occurs in her neck and shoulders down both arms and in her left hip.,OTHER MEDICAL HISTORY: , The patient reported that her birth and development were normal.  She denied any significant medical conditions during childhood.  As mentioned, she now has a history of fibromyalgia.  She also experiences some restriction in the range of motion with her right arm.  MRI of the C-spine 04/02/2009 showed a hemangioma versus degenerative changes at C7 vertebral body and bulging annulus with small central disc protrusion at C6-C7.  MRI of the right shoulder on 06/04/2009 showed small partial tear of the distal infraspinatus tendon and prominent tendinopathy of the distal supraspinatus tendon.  As mentioned, she was diagnosed with chronic fatigue syndrome in 1991.  She thought that this may actually represent early symptoms of fibromyalgia and said that symptoms are currently under control.  She also has diabetes, high blood pressure, osteoarthritis, tension headaches, GERD, carpal tunnel disease, cholecystectomy in 1976, and ectopic pregnancy in 1974.  Her previous neuropsychological evaluation referred to an outpatient left neck cystectomy in 2007.  She has some difficulty falling asleep, but currently typically obtains approximately seven to eight hours of sleep per night.  She did report some sleep disruption secondary to unusual dreams and thought that she talked to herself and could sometimes hear herself talking in her sleep.,CURRENT MEDICATIONS:,  NovoLog, insulin pump, metformin, metoprolol, amlodipine, Topamax, Lortab, tramadol, amitriptyline, calcium plus vitamin D, fluoxetine, pantoprazole, Naprosyn, fluticasone propionate, and vitamin C.,SUBSTANCE USE: , The patient reported that she rarely drinks alcohol and she denied smoking or using illicit drugs.  She drinks two to four cups of coffee per day.,SOCIAL HISTORY:  ,The patient was born and raised in North Carolina.  She was the sixth of nine siblings.  Her father was a chef.  He completed third grade and died at 60 due to complications of diabetes.  Her mother is 93 years old.  Her last job was as a janitor.  She completed fourth grade.  She reported that she has no cognitive problems at this time.  Family medical history is significant for diabetes, heart disease, hypertension, thyroid problems, sarcoidosis, and possible multiple sclerosis and depression.  The patient completed a Bachelor of Science in Nursing through State University in 1979.  She denied any history of problems in school such as learning disabilities, attentional problems, difficulty learning to read, failed grades, special help in school or behavioral problems.  She was married for two years.  Her ex-husband died in 1980 from acute pancreatitis secondary to alcohol abuse.  She has two children ages 43 and 30.  Her son whose age is 30 lives nearby and is in consistent contact with her and she is also in frequent contact and has a close relationship with her daughter who lives in New York.  In school, the patient reported obtaining primarily A's and B's.  She said that her strongest subject was math while her worst was spelling, although she reported that her grades were still quite good in spelling.  The patient worked for Hospital Center for four years.  Prior to that, she worked for an outpatient mental health center for 2-1/2 years.  She was reportedly either terminated or laid off and was unsure of the reason for that.  Prior to that, she worked for Walter P. Carter Center reportedly for 21 years.  She has also worked as an OB nurse in the past.  She reported that other than the two instances reported above, she had never been terminated or fired from a job.  In her spare time, the patient enjoys reading, participating in women's groups doing puzzles, playing computer games.,PSYCHIATRIC HISTORY: , The patient reported that she sought psychotherapy on and off between 1991 and 1997 secondary to her chronic fatigue.  She was also taking Prozac during that time.  She then began taking Prozac again when she started working at secondary to stress with the work situation.  She reported a chronic history of mild sadness or depression, which was relatively stable.  When asked about her current psychological experience, she said that she was somewhat sad, but not dwelling on things.  She denied any history of suicidal ideation or homicidal ideation.,TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II), Token Test, Sentence Repetition, Visual Naming, Controlled Oral Word Association, Spelling Test, Aural Comprehension, Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Test",
" Patient was referred for a neuropsychological evaluation after a recent hospitalization for possible transient ischemic aphasia.  Two years ago, a similar prolonged confusional spell was reported as well.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.", Neurology, Neuropsychological Evaluation - 3 ,"REASON FOR REFERRAL:,  The patient is a 76-year-old Caucasian gentleman who works full-time as a tax attorney.  He was referred for a neuropsychological evaluation by Dr. X after a recent hospitalization for possible transient ischemic aphasia.  Two years ago, a similar prolonged confusional spell was reported as well.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.,RELEVANT BACKGROUND INFORMATION: , Historical information was obtained from a review of available medical records and clinical interview with the patient.  A summary of pertinent information is presented below.  Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM: , The patient was brought to the Hospital Emergency Department on 09/30/09 after experiencing an episode of confusion for which he has no recall the previous day.  He has no recollection of the event.  The following information is obtained from his medical record.  On 09/29/09, he reportedly went to a five-hour meeting and stated several times ""I do not feel well"" and looked ""glazed.""  He does not remember anything from midmorning until the middle of the night and when his wife came home, she found him in bed at 6 p.m., which is reportedly unusual.  She thought he was warm and had chills.  He later returned to his baseline.  He was seen by Dr. X in the hospital on 09/30/09 and reported to him at that time that he felt that he had returned entirely to baseline.  His neurological exam at that time was unremarkable aside from missing one of three items on recall for the Mini-Mental Status Examination.  Due to mild memory complaints from himself and his wife, he was referred for more extensive neuropsychological testing.  Note that reportedly when his wife found him in bed, he was shaking and feeling nauseated, somewhat clammy and kept saying that he could not remember anything and he was repeating himself, asking the same questions in an agitated way, so she brought him to the emergency room.  The patient had an episode two years ago of transient loss of memory during which he was staring blankly while sitting at his desk at work and the episode lasted approximately two hours.  He was hospitalized at Hospital at that time as well and evaluation included negative EEG, MRI showing mild atrophy, and a neurological consultation, which did not result in a specific diagnosis, but during this episode he was also reportedly nauseous.  He was also reportedly amnestic for this episode.,In 2004, he had a sense of a funny feeling in his neck and electrodes in his head and had an MRI at that time which showed some small vessel changes.,During this interview, the patient reported that other than a coworker noticing a few careless errors in his completion of some documents and his wife reporting some mild memory changes that he had not noticed any significant decline.  He thought that his memory abilities were similar to those of his peers of his same age.  When I asked about this episode, he said he had no recall of it at all and that he ""felt fine the whole time.""  He appeared to be somewhat questioning of the validity of reports that he was amnestic and confused at that time.  So, The patient reported some age related ""memory lapses"" such as going into a room and forgetting why, sometimes putting something down and forgetting where he had put it.  However, he reported that these were entirely within normal expectations and he denied any type of impairment in his ability to continue to work full-time as a tax attorney other than his wife and one coworker, he had not received any feedback from his children or friends of any problems.  He denied any missed appointments, any difficulty scheduling and maintaining appointments.  He does not have to recheck information for errors.  He is able to complete tasks in the same amount of time as he always has.  He reported that he has not made additional errors in tasks that he completed.  He said he does write everything down, but has always done things that way.  He reported that he works in a position that requires a high level of attentiveness and knowledge and that will become obvious very quickly if he was having difficulties or making mistakes.  He did report some age related changes in attention as well, although very mild and he thought these were normal and not more than he would expect for his age.  He remains completely independent in his ADLs.  He denied any difficulty with driving or maintaining any activities that he had always participated in.  He is also able to handle their finances.  He did report significant stress recently particularly in relation to his work environment.,PAST MEDICAL HISTORY:,  Includes coronary artery disease, status post CABG in 1991, radical prostate cancer, status post radical prostatectomy, nephrectomy for the same cancer, hypertension, lumbar surgery done twice previously, lumbar stenosis many years ago in the 1960s and 1970s, now followed by Dr. Y with another lumbar surgery scheduled to be done shortly after this evaluation, and hyperlipidemia.  Note that due to back pain, he had been taking Percocet daily prior to his hospitalization.,CURRENT MEDICATIONS: , Celebrex 200 mg, levothyroxine 0.025 mg, Vytorin 10/40 mg, lisinopril 10 mg, Coreg 10 mg, glucosamine with chondroitin, prostate 2.2, aspirin 81 mg, and laxative stimulant or stool softener.  Note that medical records say that he was supposed to be taking Lipitor 40 mg, but it is not clear if he was doing so and also there was no specific reason found for why he was taking the levothyroxine.,OTHER MEDICAL HISTORY: , Surgical history is significant for hernia repair in 2007 as well.  The patient reported drinking an occasional glass of wine approximately two days of the week.  He quit smoking cigarettes 25 to 30 years ago and he was diagnosed with cancer.  He denied any illicit drug use.  Please add that his prostatectomy was done in 1993 and nephrectomy in 1983 for carcinoma.  He also had right carpal tunnel surgery in 2005 and has cholelithiasis.  Upon discharge from the hospital, the patient's sleep deprived EEG was recommended.,MRI completed on 09/30/09 showed ""mild cerebral and cerebellar atrophy with no significant interval change from a prior study dated June 15, 2007.  No evidence of acute intracranial processes identified.  CT scan was also unremarkable showing only mild cerebral and cerebellar atrophy.  EEG was negative.  Deferential diagnosis was transient global amnesia versus possible seizure disorder.  Note that he also reportedly has some hearing changes, but has not followed up with an evaluation for hearing aid.,FAMILY MEDICAL HISTORY:, Reportedly significant for TIAs in his mother, although the patient did not report this during our evaluation and so that she had no memory problems or dementia when she passed away of old age at the age of 85.  In addition, his father had a history of heart disease and passed away at the age of 75.  He has one sister with diabetes and thought his mom might have had diabetes as well.,SOCIAL HISTORY:,  The patient obtained a law degree from the University of Baltimore.  He did not complete his undergraduate degree from the University of Maryland because he was able to transfer his credits in order to attend law school at that time.  He reported that he did not obtain very good grades until he reached law school, at which point he graduated in the top 10 of his class and had no problem passing the Bar.  He thought that effort and motivation were important to his success in his school and he had not felt very motivated previously.  He reported that he repeated math classes ""every year of school"" and attended summer school every year due to that.  He has worked as a tax attorney for the past 48 years and reported having a thriving practice with clients all across the country.  He served also in the U.S.  Coast Guard between 1951 and 1953.  He has been married for the past 36 years to his wife, Linda, who is a homemaker.  They have four children and he reported having good relationship with them.  He described being very active.  He goes for dancing four to five times a week, swims daily, plays golf regularly and spends significant amounts of time socializing with friends.,PSYCHIATRIC HISTORY: , The patient denied any history of psychological or psychiatric treatment.  He reported that some stressors occasionally contribute to mildly low mood at this time, but that these are transient.,TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II), Token Test, Sentence Repetition, Visual Naming, Controlled Oral Word Association, Spelling Test, Aural Comprehension, Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Test",
" A 2-1/2-year-old female with history of febrile seizures, now with concern for spells of unclear etiology, but somewhat concerning for partial complex seizures and to a slightly lesser extent nonconvulsive generalized seizures.", Neurology, New Onset Seizure ,"REASON FOR CONSULTATION: , New-onset seizure.,HISTORY OF PRESENT ILLNESS: , The patient is a 2-1/2-year-old female with a history of known febrile seizures, who was placed on Keppra oral solution at 150 mg b.i.d. to help prevent febrile seizures.  Although this has been a very successful treatment in terms of her febrile seizure control, she is now having occasional brief periods of pauses and staring, where she becomes unresponsive, but does not lose her postural tone.  The typical spell according to dad last anywhere from 10 to 15 seconds, mom says 3 to 4 minutes, which likely means probably somewhere in the 30- to 40-second period of time.  Mom did note that an episode had happened outside of a store recently, was associated with some perioral cyanosis, but there has never been a convulsive activity noted.  There have been no recent changes in her Keppra dosing and she is currently only at 20 mg/kg per day, which is overall a low dose for her.,PAST MEDICAL HISTORY: , Born at 36 weeks' gestation by C-section delivery at 8 pounds 3 ounces.  She does have a history of febrile seizures and what parents reported an abdominal migraine, but on further questioning, it appears to be more of a food intolerance issue.,PAST SURGICAL HISTORY: , She has undergone no surgical procedures.,FAMILY MEDICAL HISTORY: , There is a strong history of epilepsy on the maternal side of family including mom with some nonconvulsive seizure during childhood and additional seizures in maternal great grandmother and a maternal great aunt.  There is no other significant neurological history on the paternal side of the family.,SOCIAL HISTORY: , Currently lives with her mom, dad, and two siblings.  She is at home full time and does not attend day care.,REVIEW OF SYSTEMS:  ,Clear review of 10 systems are taken and revealed no additional findings other than those mentioned in the history of present illness.,PHYSICAL EXAMINATION:,Vital Signs:  Weight was 15.6 kg.  She was afebrile.  Remainder of her vital signs were stable and within normal ranges for her age as per the medical record.,General:  She was awake, alert, and oriented.  She was in no acute distress, only slightly flustered when trying to place the EEG leads.,HEENT:  Showed normocephalic and atraumatic head.  Her conjunctivae were nonicteric and sclerae were clear.  Her eye movements were conjugate in nature.  Her tongue and mucous membranes were moist.,Neck:  Trachea appeared to be in the midline.,Chest:  Clear to auscultation bilaterally without crackles, wheezes or rhonchi.,Cardiovascular:  Showed a normal sinus rhythm without murmur.,Abdomen:  Showed soft, nontender, and nondistended, with good bowel sounds.  There was no hepatomegaly or splenomegaly, or other masses noted on examination.,Extremities:  Showed IV placement in the right upper extremity with appropriate restraints from the IV.  There was no evidence of clubbing, cyanosis or edema throughout.  She had no functional deformities in any of her peripheral limbs.,Neurological:  From neurological standpoint, her cranial nerves were grossly intact throughout.  Her strength was good in the bilateral upper and lower extremities without any distal to proximal variation.  Her overall resting tone was normal.  Sensory examination was grossly intact to light touch throughout the upper and lower extremities.  Reflexes were 1+ in bilateral patella.  Toes were downgoing bilaterally.  Coordination showed accurate striking ability and good rapid alternating movements.  Gait examination was deferred at this time due to EEG lead placement.,ASSESSMENT:,  A 2-1/2-year-old female with history of febrile seizures, now with concern for spells of unclear etiology, but somewhat concerning for partial complex seizures and to a slightly lesser extent nonconvulsive generalized seizures.,RECOMMENDATIONS,1.  For now, we will go ahead and try to capture EEG as long as she tolerates it; however, if she would require sedation, I would defer the EEG until further adjustments to seizure medications are made and we will see her response to these medications.,2.  As per the above, I will increase her Keppra to 300 mg p.o. b.i.d. bringing her to a total daily dose of just under 40 mg/kg per day.  If further spells are noted, we may increase upwards again to around 4.5 to 5 mL each day.,3.  I do not feel like any specific imaging needs to be done at this time until we see her response to the medication and review her EEG findings.  EEG, hopefully, will be able to be reviewed first thing tomorrow morning; however, I would not delay discharge the patient to wait on the EEG results.  The patient has been discharged and we will contact the family as an outpatient.,4.  The patient will need followup arrangement with me in 5 to 6 weeks' time, so we may recheck and see how she is doing and arrange for further followup then.",
" A neuropsychological evaluation to assess neuropsychological factors, clarify areas of strength and weakness, and to assist in therapeutic program planning in light of episodes of syncope.", Neurology, Neuropsychological Evaluation - 2 ,"REASON FOR REFERRAL:  ,The patient was referred for a neuropsychological evaluation by Dr. X.  A comprehensive evaluation was requested to assess neuropsychological factors, clarify areas of strength and weakness, and to assist in therapeutic program planning in light of episodes of syncope.,BRIEF SUMMARY & IMPRESSIONS:,RELEVANT HISTORY:,Historical information was obtained from a review of available medical records and an interview with ,the patient.,The patient presented to Dr. X on August 05, 2008 as she had been recently hospitalized for prolonged episodes of syncope.  She was referred to Dr. X for diagnostic differentiation for possible seizures or other causes of syncope.  The patient reports an extensive neurological history.  Her mother used alcohol during her pregnancy with the patient.  In spite of exposure to alcohol in utero, the patient reported that she achieved ""honors in school"" and ""looked smart.""  She reported that she began to experience migraines at 11 years of age.  At 15 years of age, she reported that she was thought to have hydrocephalus.  She reported that she will frequently ""bang her head against the wall"" to relieve the pain.  The patient gave birth to her daughter at 17 years of age.  At 18 years of age, she received a spinal tap as a procedure to determine the cause of her severe headaches.  She reported, in 1995 to 1996 she experienced a severe head injury, as she was struck by a car as a pedestrian and ""thrown two and a half city blocks.""  The patient reported that she could recall before being hit, but could not recall the activities of that same day or the following day.  She reported that she had difficulty walking following this head injury, but received rehabilitation for approximately one month.  Her migraines became more severe following the head injury.  In 1998, she reportedly was experiencing episodes of syncope where she would experience a headache with photophobia, phonophobia, and flashing lights.  Following the syncope episode, she would experience some confusion.  These episodes reportedly were related to her donating plasma.,The patient also reported that her ex-husband stated that she frequently jerked and would shake in her sleep.  She reported that upon awakening, she would feel off balanced and somewhat confused.  These episodes diminished from 2002 to June 2008.  When making dinner, she suddenly dropped and hit the back of her head on refrigerator.  She reported that she was unconscious for five to six minutes.  A second episode occurred on July 20th when she lost consciousness for may be a full day.  She was admitted to Sinai Hospital and assessed by a neurologist.  Her EEG and head CT were considered to be completely normal.  She did not report any typical episodes during the time of her 36-hour EEG.  She reported that her last episode of syncope occurred prior to her being hospitalized.  She stated that she had an aura of her ears ringing, vision being darker and ""tunnel vision"" (vision goes smaller to a pinpoint), and she was ""spazzing out"" on the floor.  During these episodes, she reports that she cannot talk and has difficulty understanding.,The patient also reports that she has experienced some insomnia since she was 6 years old.  She reported that she was a heavy drinker until about 1998 or 1999 and that she would drink a gallon daily of Jack Daniel.  She stopped the use of alcohol and that time she experienced a suicide attempt.  In 2002, she was diagnosed with bipolar disorder and was started on medication.  At the time of the neuropsychological evaluation, she had stopped taking her medicine as she felt that she was now in remission and could manage her symptoms herself.  The patient's medical history is also significant for postpartum depression.,The patient reported that she has been experiencing difficulty with cognitive abilities of attention/concentration, spelling, tangential and slow thinking, poor sequencing memory for events, and variable verbal memory.  She reported that she sometimes has difficulty understanding what people say, specifically she has difficulty understanding jokes.  She finds that she often has difficulty with expressing her thoughts, as she is very tangential.  She experiences episodes of not recalling what she was speaking of or remembering what activities she was trying to perform.  She reported that she had a photographic memory for directions.  She said that she experienced a great deal of emotional lability, but in general her personality has become more subdued.  At the present time, her daughter has now moved on to college.  The patient is living with her biological mother.  Although she is going through divorce, she reported that it was not really stressful.  She reported that she spends her day driving other people around and trying to be helpful to them.,At the time of the neuropsychological evaluation, the patient's medication included Ativan, Imitrex, Levoxyl, vitamin B12, albuterol metered dose inhaler as needed, and Zofran as needed.  (It should be noted that The patient by the time of the feedback on September 19, 2008 had resumed taking her Trileptal for bipolar disorder.).  The patient's familial medical history is significant for alcohol abuse, diabetes, hypertension, and high cholesterol.,TESTS ADMINISTERED:,Clinical Interview,Cognistat,Mattis Dementia Rating Scale,Wechsler Adult Intelligence Scale - III (WAIS-III),Wechsler Abbreviated Scale of Intelligence (WASI),Selected Subtests from the Delis Kaplan Executive Function System (DKEFS),  Trail Making Test,  Verbal Fluency (Letter Fluency & Category Fluency),  Design Fluency,  Color-Word Interference Test,  Tower,Wisconsin Card Sorting Test (WCST),Stroop Test,Color Trails,Trails A & B,Test of Variables of Attention,Multilingual Aphasia Examination II,  Token Test,  Sentence Repetition,  Visual Naming,  Controlled Oral Word Association,  Spelling Test,  Aural Comprehension,  Reading Comprehension,Boston Naming Test-2 (BNT-2),Animal Naming Test,The Beery-Buktenica Developmental Test of Visual-Motor Integration (VMI),The Beery-Buktenica Developmental Test of Motor Coordination,The Beery-Buktenica Developmental Test of Visual Perception,Judgment Line Orientation,Grooved Pegboard,Purdue Pegboard,Finger Tapping Test,Rey Complex Figure,Wechsler Memory Scale -III (WMS-III),California Verbal Learning Test",
" Contusion of the frontal lobe of the brain, closed head injury and history of fall, and headache, probably secondary to contusion.", Neurology, Neurology - Discharge Summary ,"PRELIMINARY DIAGNOSES:,1.  Contusion of the frontal lobe of the brain.,2.  Closed head injury and history of fall.,3.  Headache, probably secondary to contusion.,FINAL DIAGNOSES:,1.  Contusion of the orbital surface of the frontal lobes bilaterally.,2.  Closed head injury.,3.  History of fall.,COURSE IN THE HOSPITAL: , This is a 29-year-old male, who fell at home.  He was seen in the emergency room due to headache.  CT of the brain revealed contusion of the frontal lobe near the falx.  The patient did not have any focal signs.  He was admitted to ABCD.  Neurology consultation was obtained.  Neuro checks were done.  The patient continued to remain stable, although he had some frontal headache.  He underwent an MRI to rule out extension of the contusion or the possibility of a bleed and the MRI of the brain without contrast revealed findings consistent with contusion of the orbital surface of the frontal lobes bilaterally near the interhemispheric fissure.  The patient remained clinically stable and his headache resolved.  He was discharged home on 11/6/2008.,PLAN: , Discharge the patient to home.,ACTIVITY:  ,As tolerated.,The patient has been advised to call if the headache is recurrent and Tylenol 650 mg 1 p.o. q.6 h. p.r.n. headache.  The patient has been advised to follow up with me as well as the neurologist in about 1 week.","neurology, interhemispheric, frontal lobe, head injury, brain, contusion"
 Patient demonstrated mild cognitive deficits on a neuropsychological screening evaluation during a followup appointment for stroke., Neurology, Neuropsychological Evaluation ,"REASON FOR REFERRAL: , Ms. A is a 60-year-old African-American female with 12 years of education who was referred for neuropsychological evaluation by Dr. X after she demonstrated mild cognitive deficits on a neuropsychological screening evaluation during a followup appointment with him for stroke in July.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.,RELEVANT BACKGROUND INFORMATION:,  Historical information was obtained from a review of available medical records and clinical interview with Ms. A.  A summary of pertinent information is presented below.  Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM:,  Ms. A presented to the ABC Hospital emergency department on 07/26/2009 reporting that after she had woken up that morning she noticed numbness and weakness in her left hand, slurred speech, and left facial droop.  Neurological evaluation with Dr. X confirmed left hemiparesis.  Brain CT showed no evidence of intracranial hemorrhage or mass effect and that she received TPA and had moderate improvement in left-sided weakness.  These symptoms were thought to be due to a right middle cerebral artery stroke.  She was transferred to the ICU for monitoring.  Ultrasound of the carotids showed 20% to 30% stenosis of the right ICA and 0% to 19% stenosis of the left ICA.  On 07/29/2009, she was admitted for acute inpatient rehabilitation for the treatment of residual functional deficits of her acute ischemic right MCA/CVA.  At discharge on 08/06/2009, she was mainly on supervision for all ADLs and walking with a rolling walker, but tolerating increased ambulation with a cane.  She was discharged home with recommendations for outpatient physical therapy.  She returned to the Sinai ER on 08/2009/2009 due to reported left arm pain, numbness, and weakness, which lasted 10 to 15 minutes and she reported that it felt ""just like the stroke.""  Brain CT on 08/2009/2009 was read as showing ""mild chronic microvascular ischemic change of deep white matter,"" but no acute or significant interval change compared to her previous scan.  Neurological examination with Dr. Y was within normal limits, but she was admitted for a more extensive workup.  Due to left arm pain an ultrasound was completed on her left upper extremity, but it did not show deep vein thrombosis.,Followup CT on 08/10/2009 showed no significant interval change.  MRI could not be completed due to the patient's weight.  She was discharged on 08/11/2009 in stable condition after it was determined that this event was not neurological in origin; however, note that Ms. A referred to this as a second stroke.,Ms. A presented for a followup outpatient neurological evaluation with Dr. X on 09/22/2009, at which time a brief neuropsychological screening was also conducted.  She demonstrated significant impairments in confrontation naming, abstract verbal reasoning, and visual and verbal memory and thus a more comprehensive evaluation was suggested due to her intent to return to her full-time work duty.  During the current interview, Ms. A reported that she noticed mild memory problems including some difficultly remembering conversations, events, and at times forgetting to take her medications.  She also reported mild difficulty finding words in conversation, solving novel problems and tasks (e.g. difficulty learning to use her camcorder), but overall denied significant cognitive deficits in attention, concentration, language or other areas of cognitive functioning.  When asked about her return to work, she said that she was still on light duty due to limited physical activity because of residual left leg weakness.  She reported that no one had indicated to her that she appeared less capable of performing her job duties, but said that she was also receiving fewer files to process and enter data into the computer at the Social Security Agency that she works at.  Note also that she had some difficulty explaining exactly what her job involved.  She also reported having problems falling asleep at work and that she is working full-time although on light duty.,OTHER MEDICAL HISTORY:  ,As mentioned, Ms. A continues to have some residual left leg weakness and continues to use a rolling walker for ambulation, but she reported that her motor functioning had improved significantly.  She was diagnosed with sleep apnea approximately two years ago and was recently counseled by Dr. X on the need to use her CPAP because she indicated she never used it at night.  She reported that since her appointment with Dr. X, she has been using it ""every other night.""  When asked about daytime fatigue, Ms. A initially denied that she was having any difficulties, but repeatedly indicated that she was falling asleep at work and thought that it was due to looking at a computer screen.  She reported at times ""snoring"" and forgetting where she is at and said that a supervisor offered to give her coffee at one point.  She receives approximately two to five hours of sleep per night.  Other current untreated risk factors include obesity and hypercholesterolemia.  Her medical history is also significant for hypertension, asthma, abdominal adenocarcinoma status post hysterectomy with bilateral salpingo-oophorectomy, colonic benign polyps status post resection, benign lesions of the breast status post lumpectomy, and deep vein thrombosis in the left lower extremity status post six months of anticoagulation (which she had discontinued just prior to her stroke).,CURRENT MEDICATIONS: , Aspirin 81 mg daily, Colace 100 mg b.i.d., Lipitor 80 mg daily, and albuterol MDI p.r.n.,SUBSTANCE USE:,  Ms. A denied drinking alcohol or using illicit drugs.  She used to smoke a pack of cigarettes per day, but quit five to six years ago.,FAMILY MEDICAL HISTORY: , Ms. A had difficulty providing information on familial medical history.  She reported that her mother died three to four years ago from lung cancer.  Her father has gout and blood clots.  Siblings have reportedly been treated for asthma and GI tumors.  She was unsure of familial history of other conditions such as hypertension, high cholesterol, stroke, etc.,SOCIAL HISTORY: , Ms. A completed high school degree.  She reported that she primarily obtained B's and C's in school.  She received some tutoring for algebra in middle school, but denied ever having been held back a grade failing any classes or having any problems with attention or hyperactivity.,She currently works for the Social Security Administration in data processing.  As mentioned, she has returned to full-time work, but continues to perform only light duties due to her physical condition.  She is now living on her own.  She has never driven.  She reported that she continues to perform ADLs independently such as cooking and cleaning.  She lost her husband in 2005 and has three adult daughters.  She previously reported some concerns that her children wanted her to move into assisted living, but she did not discuss that during this current evaluation.  She also reported number of other family members who had recently passed away.  She has returned to activities she enjoys such as quire, knitting, and cooking and plans to go on a cruise to the Bahamas at the end of October.,PSYCHIATRIC HISTORY: , Ms. A did not report a history of psychological or psychiatric treatment.  She reported that her current mood was good, but did describe some anxiety and nervousness about various issues such as her return to work, her upcoming trip, and other events.  She reported that this only ""comes and goes."",TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II),  Token Test,  Sentence Repetition,  Visual Naming,  Controlled Oral Word Association,  Spelling Test,  Aural Comprehension,  Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Test",
" Organic brain syndrome in the setting of multiple myeloma.  The patient is a 56-year-old male with the history of multiple myeloma, who has been admitted for complains of being dehydrated and was doing good until this morning, was found to be disoriented and confused, was not able to communicate properly, and having difficulty leaving out the words. ", Neurology, Organic Brain Syndrome ,"REASON FOR CONSULT:,  Organic brain syndrome in the setting of multiple myeloma.,SOURCE OF HISTORY:  ,The patient himself is not able to give a good history.  History has obtained through discussion with Dr. X over the phone and the nurse taking care of the patient despite reviewing the chart on the floor.,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old male with the history of multiple myeloma, who has been admitted for complains of being dehydrated and was doing good until this morning, was found to be disoriented and confused, was not able to communicate properly, and having difficulty leaving out the words.  Not a very clear history at this time and the patient himself is not able to give any history despite no family member was present in the room.  Neurology consult was called to evaluate any organic brain syndrome in the setting of multiple myeloma.  The patient since the morning has improved, but still not completely back to the baseline.  Even I evaluated the patient previously, hence not very sure about his baseline.,PAST MEDICAL HISTORY:,  History of IgG subtype multiple myeloma.,SURGICAL HISTORY:,  Nothing significant.,PSYCHIATRIC HISTORY:  ,Nothing significant.,SOCIAL HISTORY:  ,No history of any smoking, alcohol or drug abuse.,ALLERGIES: , CODEINE AND FLAGYL.,IMMUNIZATION HISTORY: , Nothing significant.,FAMILY HISTORY: , Unobtainable.,REVIEW OF SYSTEMS:  ,The patient was considered to ask question for systemic review including neurology, psychiatry, sleep, ENT, ophthalmology, pulmonary, cardiology, gastroenterology, genitourinary, hematology, rheumatology, dermatology, allergy/immunology, endocrinology, toxicology, oncology, and found to be positive for the symptoms mentioned in the history of the presenting illness.  The patient himself is not able to give any history only source is the chart.  For details, please review the chart.,PHYSICAL EXAMINATION,VITAL SIGNS:  Blood pressure of 97/54, heart rate of 97, respiratory rate of 19, and temperature 98.5.  The patient on supplemental oxygen was FiO2 on 2 L 96%.  Limited physical examination.,HEENT:  Head, normocephalic and atraumatic.  Throat clear.  No discharge from the ear and the nose.  No discoloration of conjunctivae and the sclerae.,NECK:  Supple.  No signs of any meningismus.  Though a limited examination, the patient does appear to have arthritic changes, questioning contracture deformities, as not able to follow the commands to show full range of motion.  No bruit auscultated over the neck and the orbits.,LUNGS:  Clear to auscultation.,HEART:  Normal heart sounds.,ABDOMEN:  Benign.,EXTREMITIES:  No edema, clubbing or cyanosis.  No rash.  No leptomeningeal or neurocutaneous disorder.,NEUROLOGIC:  Examination is limited.  Mental state examination, the patient is awake, alert, and oriented to himself, not able follow commands, and give a proper history, and still appeared to be confuse and disoriented.  Cranial nerve examination limited, but apparently nonfocal.  Motor examination is very limited except for the grips, which were strong enough.  I was not able to obtain much.  Deep tendon reflexes were not reliable.  Toes equivocal and downgoing.  Sensory examination is not reliable, though intact for painful stimuli with limited examination.  Coordination could not be tested.  Gait could not be tested.,IMPRESSION:,  History of multiple myeloma and altered mental status in multiple myeloma setting.  Rule out brain metastasis including lepto-meningismus, possible transient ischemic attack related to hyperviscosity syndrome or provoked seizure related to ischemia, and delirium related to any electrolyte imbalance or underlying infarction.,PLAN AND RECOMMENDATIONS: , The patient is to continue with current level of management.  I will review the chart before ordering any further testing that may include a CT scan of the brain, if has not been ordered, EEG, urine test, and the latest CBC with diff. to rule out any urinary tract infection or indication of any other seen of infection.  No other intervention at this time.  The patient may be started on aspirin, if it is okay with Dr. X.",
 Sample for Neuropsychological Evaluation, Neurology, Neuropsychological Evaluation - 1 ,"REASON FOR EVALUATION: , The patient is a 37-year-old white single male admitted to the hospital through the emergency room.  I had seen him the day before in my office and recommended him to go into the hospital.  He had just come from a trip to Taho in Nevada and he became homicidal while there.  He started having thoughts about killing his mother.  He became quite frightened by that thought and called me during the weekend we were able to see him on that Tuesday after talking to him.,HISTORY OF PRESENT ILLNESS: , This is a patient that has been suffering from a chronic psychotic condition now for a number of years.  He began to have symptoms when he was approximately 18 or 19 with auditory and visual hallucinations and paranoid delusions.  He was using drugs and smoking marijuana at that time has experimenting with LXV and another drugs too.  The patient has not used any drugs since age 25.  However, he has continued having intense and frequent psychotic bouts.  I have seen him now for approximately one year.  He has been quite refractory to treatment.  We tried different types of combination of medications, which have included Clozaril, Risperdal, lithium, and Depakote with partial response and usually temporary.  The patient has had starting with probably has had some temporary relief of the symptoms and they usually do not last more than a few days.  The dosages that we have used have been very high.  He has been on Clozaril 1200 mg combined with Risperdal up to 9 mg and lithium at a therapeutic level.  However, he has not responded.,He has delusions of antichrist.  He strongly believes that the dogs have a home in the neighborhood are communicating with him and criticizing him and he believes that all the people can communicate to him with telepathy including the animals.  He has paranoid delusions.  He also gets homicidal like prior to this admission.,PAST PSYCHIATRIC HISTORY:,  As mentioned before, this patient has been psychotic off and on for about 20 years now.  He has had years in which he did better on Clozaril and also his other medications.,With typical anti-psychotics, he has done well at times, but he eventually gets another psychotic bout.,PAST MEDICAL HISTORY: , He has a history of obesity and also of diabetes mellitus.  However, most recently, he has not been treated for diabetes since his last regular weight since he stopped taking Zyprexa.  The patient has chronic bronchitis.  He smokes cigarettes constantly up to 60 a day.,DRUG HISTORY:,  He stopped using drugs when he was 25.  He has got a lapse, but he was more than 10 years and he has been clean ever since then.  As mentioned before, he smokes cigarettes quite heavily and which has been a problem for his health since he also has chronic bronchitis.,PSYCHOSOCIAL STATUS: , The patient lives with his mother and has been staying with her for a few years now.  We have talked to her.  She is very supportive.  His only sister is also very supportive of him.  He has lived in the ABCD houses in the past.  He has done poorly in some of them.,MENTAL STATUS EXAMINATION:,  The patient appeared alert, oriented to time, place, and person.  His affect is flat.  He talked about auditory hallucinations, which are equivocal in nature.  He is not homicidal in the hospital as he was when he was at home.  His voice and speech are normal.  He believes in telepathy.  His memory appears intact and his intelligence is calculated as average.,INITIAL DIAGNOSES:,AXIS I:  Schizophrenia.,AXIS II:  Deferred.,AXIS III:  History of diabetes mellitus, obesity, and chronic bronchitis.,AXIS IV:  Moderate.,AXIS V:  GAF of 35 on admission.,INITIAL TREATMENT AND PLAN:,  Since, the patient has been on high dosages of medications, we will give him a holiday and a structured environment.  We will put him on benzodiazepines and make a decision anti-psychotic later.  We will make sure that he is safe and that he addresses his medical needs well.","neurology, neuropsychological, gaf, schizophrenia, anti-psychotic, chronic psychotic condition, delusions, hallucination, homicidal, marijuana, psychological, psychotic, smokes cigarettes, smoking, neuropsychological evaluation, clozaril, bronchitis, axis, "
" Approximately one and a half years ago, patient fell down while walking in the living room from the bedroom.  At that time, he reports both legs gave away on him and he fell.  He reported that he had some lightheadedness just before he fell and was slightly confused, but was aware of what was happening around him.", Neurology, Neurologic Consultation - 5 ,"HISTORY OF PRESENT ILLNESS: ,The patient is a 79-year-old right-handed man who reports that approximately one and a half years ago, he fell down while walking in the living room from the bedroom.  At that time, he reports both legs gave away on him and he fell.  He reported that he had some lightheadedness just before he fell and was slightly confused, but was aware of what was happening around him.  He was able to get up shortly after falling and according to the patient and his son, subsequently returned back to normal.,He was then well until the 3rd of July 2008 when his legs again gave way on him.  This was not preceded by lightheadedness.  He was rushed to the hospital and was found to have pneumonia, and the fall was blamed on the pneumonia.  He started using a walker from that time, prior to that he was able to walk approximately two miles per day.  He again had a fall in August of 2008 after his legs gave way.  Again, there was no lightheadedness associated with this.  He was again found to have pneumonia and again was admitted to hospital after which he went to rehabilitation and was able to use his walker again after this.  He did not, however, return to the pre-July baseline.  In October of 2008, after another fall, he was found to have pneumonia again and shingles.  He is currently in a Chronic Rehabilitation Unit.  He cannot use a walker and uses a wheelchair for everything.  He states that his hands have been numb, involving all the fingers of both hands for the past three weeks.  He is also losing muscle bulk in his hands and has noticed some general weakness of his hands.  He does, however, note that strength in his hands has not been normal since July 2008, but it is clearly getting worse.  He has been aware of some fasciculations in his legs starting in August 2008, these are present both in the lower legs and the thighs.  He does not report any cramps, problems with swallowing or problems with breathing.  He reports that he has had constipation alternating with diarrhea, although there has been no loss of control of either his bowel or bladder.  He has had some problems with blood pressure drops, and does feel presyncopal when he stands.  He also reports that he has no feeling in his feet, and that his feet feel like sponges.  This has been present for about nine months.  He has also lost joint position sense in his feet for approximately nine months.,PAST MEDICAL HISTORY:,1.  Pneumonia.  He has had recurrent episodes of pneumonia, which started at approximately age 20.  These have been treated repeatedly over the years, and on average he has tended to have an episode of pneumonia once every five years, although this has been far more frequent in the past year.  He is usually treated with antibiotics and then discharged.  There is no known history of bronchiectasis, inherited lung disease or another chronic pulmonary cause for the repeated pneumonia.,2.  He has had a catheter placed for urinary retention, his urologist has told him that he thinks that this may be due to prostate enlargement.  The patient does not have any history of diabetes and does not report any other medical problems.  He has lost approximately 18 pounds in the past month.,3.  He had an appendectomy in the 1940s.,4.  He had an ankle resection in 1975.,SOCIAL HISTORY:  ,The patient stopped smoking 27 years ago, he smoked approximately two packs a day with combined cigarettes and cigars.  He has not smoked for the past 27 years.  He hardly ever uses alcohol.  He is currently retired.,FAMILY HISTORY: , There is no family history of neuropathy, pes cavus, foot deformities, or neuromuscular diseases.  His aunt has a history of type II diabetes.,CURRENT MEDICATIONS: , Fludrocortisone 0.1 mg p.o. q.d., midodrine 5 mg p.o. q.i.d., Cymbalta 30 mg p.o. per day, Prilosec 20 mg p.o. per day, Lortab 10 mg p.o. per day, Amoxil 500 mg p.o. per day, vitamin B12 1000 mcg weekly, vitamin D 1000 units per day, Metamucil p.r.n., enteric-coated aspirin once a day, Colace 200 mg p.o. q.d., Senokot three tablets p.o. p.r.n., Reglan 10 mg p.o. q.6h., Xanax 0.25 mg p.o. q.8h. p.r.n., Ambien 5 mg p.o. q.h.s. p.r.n. and Dilaudid 2 mg tablets p.o. q.3h. p.r.n., Protonix 40 mg per day, and Megace 400 mg per day.,ALLERGIES:,  He has no medication or food allergies.,REVIEW OF SYSTEMS:,  Please see the health questionnaire and clinical notes from today.,GENERAL PHYSICAL EXAMINATION:,VITAL SIGNS:  BP was 137/60, P was 89, and his weight could not be measured because he was in a wheelchair.  His pain score was 0.,APPEARANCE:  No acute distress.  He is pleasant and well-groomed.,HEENT:  Atraumatic, normocephalic.  No carotid bruits appreciated.,LUNGS:  There were few coarse crackles in both lung bases.,CARDIOVASCULAR:  Revealed a normal first and second heart sound, with no third or fourth heart sound and no murmurs.  The pulse was regular and of normal volume.,ABDOMEN:  Soft with no masses and normal bowel sounds.  There were no carotid bruits.,EXTREMITIES:  No contractures appreciated.,NEUROLOGICAL EXAM:,MSE:  His orientation, language, calculations, 100-7 tests were all normal.  There was atrophy and fasciculations in both the arms and legs.,CRANIAL NERVES:  Cranial nerve examination was normal with the exception that there was some mild atrophy of his tongue and possible fasciculations.  His palatal movement was normal and gag reflex was normal.,MOTOR:  Strength was decreased in all muscle groups as follows:  Deltoid 4/4, biceps 4+/4+, triceps 5/5, wrist extensors 4+/4+, finger extensors 4-/4-, finger flexors 4-/4-, interossei 4-/4-, hip flexors 4+/4+, hip extensors 4+/4+, knee extensors 4/4, and knee flexors 4/4.  Foot dorsiflexion, plantar flexion, eversion, toe extension and toe flexion was all 0 to 1.  There was atrophy in both hands and general atrophy of the lower limb muscles.  The feet were both cold and showed dystrophic features.  Fasciculations were present mainly in the hands.  There was evidence of dysmetria and past pointing in the left hand.,REFLEXES:  Reflexes were 0 in all sites in the arms and legs.  The jaw reflex was 2+.  Vibration was severely decreased at the elbow and wrist and was absent in the fingers.  Vibration was absent in the toes and ankle bilaterally and was severely decreased at the knee.  Joint position sense was absent in the toes and severely decreased in the fingers.  Pin perception was absent in the feet and was decreased to the upper thighs.  Pin was decreased or absent in the fingers and decreased above the elbows.  The same distribution of sensory loss was found with monofilament testing.,COORDINATION:  Coordination was barely normal in the right hand.  Rapid alternating movements were decreased in the left hand greater than the right hand.  The patient was unable to stand and therefore gait, Romberg's test and balance could not be assessed.,DIAGNOSTIC STUDIES: , Previous diagnostic studies and patient reports.  There were extensive patient reports, all of which were reviewed.  A previous x-ray study of the lateral chest performed in October 2008 showed poor inspiration with basilar atelectasis and an infiltrate.  An x-ray of the cervical, thoracic and lumbar spine showed some evidence of lumbar spinal stenosis.  A CTA of the neck with and without contrast performed in November 2008 showed minor stenosis in the left carotid, a mild hard and soft plaque in the right carotid with approximately 55% stenosis.  The posterior circulation showed a slightly dominant right vertebral artery with no stenosis.  There was no significant stenosis, but there was minor extracranial stenosis noted.  An MRI of the brain with and without contrast performed in November 2008 showed no evidence of an acute infarct, major vascular occlusion, and no abnormal enhancement with gadolinium administration.  There was also no significant sinusitis or mastoiditis.  This was an essentially normal brain MRI.  A CBC performed in January 2009 showed an elevated white cell count of 11.3, a low red cell count of 3.43, elevated MCH of 32.4 and the rest of the study was normal.  An electrolyte study performed in January 2009 showed a sodium which was low at 127, a calcium which was low at 8.3, and a low protein of 5.2 and albumin of 3.1.  The glucose was 86.  TSH performed in January 2009 was 1.57, which is within the normal range.  Vitamin B12 was greater than a 1000, which is normal and the folate was 18.2, which was normal.  A myocardial stress study performed in December 2008 showed normal myocardial perfusion with Persantine Cardiolite SPECT.  The ECG was non-diagnostic.  There was normal regional wall motion of the left ventricle.  The left ventricular ejection fraction was 68%, which is within the normal range for males.  A CT of the lumbar spine without contrast performed in December 2008 showed a broad-based disc bulge at L1-L2, L2-L3, L3-L4 and L4-L5.  At L5-S1, in addition to the broad-based disc bulge, there was also an osteophyte complex and evidence of flavum hypertrophy without canal stenosis.  There was severe bilateral neural foraminal stenosis at L5-S1 and moderate neural foraminal stenosis at L1-L4.  An echocardiogram was performed in November 2008 and showed mild left atrial enlargement, normal left ventricular systolic function, mild concentric left ventricular hypertrophy, scleral degenerative changes in the aortic and mitral apparatus, mild mitral regurgitation, mild tricuspid regurgitation and mild to moderate aortic regurgitation.,DIAGNOSTIC IMPRESSION:  ,The patient presents with a severe neuropathy with marked large fiber sensory as well as motor findings.  He is diffusely weak as well as atrophic in all muscle groups both in his upper and lower extremities, although he is disproportionately weak in his lower extremities.  His proprioceptive and vibratory loss is severe in both the distal upper and lower extremities, signifying that he either has a severe sensory neuropathy or has involvement of the dorsal root ganglia.  According to the history, which was carefully checked, the initial onset of these symptoms goes back one and a half years, although there has only been significant progression in his condition since July 2008.  As indicated below, further diagnostic studies including a detailed nerve conduction and EMG test today showed evidence of a severe sensory, motor, and axonal neuropathy and in addition there was evidence of a diffuse polyradiculopathy.  There was no involvement of the tongue on EMG.  The laboratory testing as indicated below failed to show a specific cause for the neuropathy.  We are still, however, waiting for the paraneoplastic antibodies, which were send out lab to the Mayo Clinic.  This type of very severe sensorimotor neuropathy with significant proprioceptive loss may be seen in several conditions including peripheral nerve vasculitis due to a variety of disorders such as SLE, Sjogren's, rheumatoid arthritis, and mixed connective tissue disease.  In addition, it may also be seen with certain toxins, particularly chemotherapeutic agents.  The patient did not receive any of these.  It may also be seen as part of a paraneoplastic syndrome.  Although the patient does not have any specific clinical symptoms of a cancer, it is noted that he has had an 18-pound weight loss in the past month and does have a remote history of smoking.  We have requested that he obtain a CT of his chest, abdomen and pelvis while he is in Acute Rehabilitation.  The verbal reports of these possibly did not show any evidence of a cancer.  We did also request that he obtain a gallium scan to see if there was any evidence of an unsuspected neoplasm.  The patient did undergo a nerve and muscle biopsy, this was a radial nerve and biceps muscle biopsy from the left arm.  This showed evidence of severe axonal loss.  There was no evidence of a vasculitis.  The vessels did show some mild intimal changes that would be consistent with atherosclerosis.  There were a few perivascular changes; however, there was no clear evidence of a necrotizing vasculitis even on multiple sections.  The muscle biopsy showed severe muscle fiber atrophy, with evidence of fiber grouping.  Again, there was no evidence of inflammation or vasculitis.  Evaluation so far has also shown no evidence of an amyloid neuropathy, no evidence of a monoclonal gammopathy, of sarcoidosis, and again there is no past history of a significant toxin or infective cause for the neuropathy.  Specifically, there is no history of HIV exposure.  We would await the results of the gallium scan and of the paraneoplastic antibodies to see if these are helpful in making a diagnosis.  At this point, because of the severity and the axonal nature of the neuropathy, there is no specific therapy that will reverse the course of the illness, unless we find a specific etiology that can be stopped or reversed.  I have discussed these issues at length with the patient and with his son.  We also addressed whether or not there might be a previously undiagnosed inherited neuropathy.  I think this is unlikely given the short history and the rapid progression of the disorder.,There is also no family history that we can detect a neuropathy, and the patient does not have the typical phenotype for a chronic inherited neuropathy such as Charcot-Marie-Tooth disease type 2.  However, since I have only seen the patient on one occasion and do not know what his previous examination showed two years ago, I cannot be certain that there may not have been the presence of a neuropathy preceding this.,PLAN:,1.  Nerve conduction and EMG will be performed today.  The results were indicated above.,2.  The following laboratory studies were requested including electrolytes, CBC, thyroid function tests, B12, ANA, C-reactive protein, complement, cryoglobulins, double-stranded DNA antibodies, folate level, hemoglobin A1c, immunofixation electrophoresis, P-ANCA, C-ANCA, protein electrophoresis, rheumatoid factor, paraneoplastic antibody studies requested from the Mayo Clinic, B12.  These studies showed minor changes, which included a low sodium level of 129 as previously noted, a low creatinine of 0.74, low calcium of 8.6, low total protein of 5.7.  The B12 was greater than 2000.  The immunoelectrophoresis, ANA, double-stranded DNA, ANCA, hemoglobin A1c, folate, cryoglobulins, complement, C-reactive protein were all normal or negative.  The B12 level was greater than 2000.  Liver function tests were normal.  The glucose was 90.  ESR was 10.  Hemoglobin A1c was 5.5.,3.  A left radial sensory and left biceps biopsy were requested and have been performed and interpreted as indicated above.,4.  CT of chest, abdomen and pelvis.,5.  Whole body gallium scan for evidence of an underlying neoplasm.,6.  The patient will go to the Rehabilitation Facility for Acute Rehabilitation and Training.,7.  We have not made any changes to his medication.  He does have some mild orthostatic changes; however, he is adequately controlled with midodrine at a dose of 2.5 mg three times a day as needed up to 5 mg four times a day.  Usually, he uses a lower dose of 2.5 three times a day to 5 mg three times a day.,8.  Followup will be as determined by the family.",
" Muscle twitching, clumsiness, progressive pain syndrome, and gait disturbance.  Probable painful diabetic neuropathy.  Symptoms are predominantly sensory and severely dysfunctioning, with the patient having inability to ambulate independently as well as difficulty with grip and temperature differentiation in his upper extremities.  ", Neurology, Neurologic Consultation - 4 ,"REASON FOR NEUROLOGICAL CONSULTATION:,  Muscle twitching, clumsiness, progressive pain syndrome, and gait disturbance.,HISTORY OF PRESENT ILLNESS: , The patient is a 62-year-old African-American male with a significant past medical history of diabetes, hypertension, previous stroke in 2002 with minimal residual right-sided weakness as well as two MIs, status post pacemaker insertion who first presented with numbness in his lower extremities in 2001.  He states that since that time these symptoms have been progressive and now involving his legs above his knees as well as his hands.  More recently, he describes a burning sensation along with numbness.  This has become a particular problem and of all the problems he has he feels that pain is his primary concern.  Over the last six months, he has noticed that he cannot feel hot objects in his hands and that objects slip out of his hands.  He denies any weakness per se, just clumsiness and decreased sensation.  He has also been complaining of brief muscle jerks, which occur in both hands and his shoulders.  This has been a fairly longstanding problem, and again has become more prevalent recently.  He does not have any tremor.  He denies any neck pain.  He walks with the aid of a walker because of unsteadiness with gait.,Recently, he has tried gabapentin, but this was not effective for pain control.  Oxycodone helps somewhat and gives him at least three hours pain relief.  Because of the pain, he has significant problems with fractured sleep.  He states he has not had a good night's sleep in many years.  About six months ago, after an MI and pacemaker insertion, he was transferred to a nursing facility.  At that facility, his insulin was stopped.  Since then he has only been on oral medication for his diabetes.  He denies any back pain, neck pain, change in bowel or bladder function, or specific injury pre-dating these symptoms., ,PAST MEDICAL HISTORY: , Diabetes, hypertension, coronary artery disease, stroke, arthritis, GERD, and headaches.,MEDICATIONS: , Trazodone, simvastatin, hydrochlorothiazide, Prevacid, lisinopril, glipizide, and gabapentin.,FAMILY HISTORY: , Discussed above and documented on the chart.,SOCIAL HISTORY: , Discussed above and documented on the chart.  He does not smoke.  He lives in a senior citizens building with daily nursing aids.  He previously was a security guard, but is currently on disability.,REVIEW OF SYSTEMS: , Discussed above and documented on the chart.,PHYSICAL EXAMINATION: , On examination, blood pressure 150/80, pulse of 80, respiratory rate 22, and weight 360 pounds.  Pain scale 7/10.  A full general and neurological examination was performed on the patient and is documented on the chart.,The patient is obese with significant ankle edema.,Neurological examination reveals normal cognitive exam and normal cranial nerve examination.  Motor examination reveals mild atrophy in bilateral FDIs, but still has a strong grip.  Individual muscle strength is close to normal with only subtle weakness found in ankle plantar and dorsiflexion.  Tone and bulk are normal.  Sensory examination reveals a severe decrease to all modalities in his lower extremities from just above the knees distally.  He has no vibration sense at his knees.  Similarly, there is decrease to all sensory modalities in his both upper extremities from just above the wrist distally.  The only reflexes I could obtain with trace reflexes in his biceps.  Remaining reflexes were unelicitable.  No Babinski.  The patient walks normally with the aid of a cane.  He has severe sensory ataxia with inability to walk unaided.  Positive Romberg with eyes open and closed.,IMPRESSION AND PLAN:,1.  Probable painful diabetic neuropathy.  Symptoms are predominantly sensory and severely dysfunctioning, with the patient having inability to ambulate independently as well as difficulty with grip and temperature differentiation in his upper extremities.  He has relative preservation of motor function.  Because these symptoms are progressive and, by report, he came off his insulin, suggesting somewhat mild diabetes, I would like to rule out other causes of progressive neuropathy.,2.  He has history of myoclonic jerks.  I did not see any on my examination today and I feel that these are benign and probably secondary to his severe insomnia, which he states is secondary to the painful neuropathy.  I would like to rule out other causes such as hepatic encephalopathy., ,I have recommended the following:,1.  EMG/nerve conduction study to assess severity of neuropathy and to characterize neuropathy.,2.  Blood work, looking for other causes of neuropathy and myoclonus, to include CBC, CMP, TSH, LFT, B12, RPR, ESR, Lyme titer, and HbA1c, and ammonia level.,3.  Neurontin and oxycodone have not been effective, and I have recommended Cymbalta starting at 30 mg q.d. for five days and then increasing to 60 mg q.d.  Side effect profile of this medication was discussed with the patient.,4.  I have explained to him that progression of diabetic neuropathy is closely related to diabetic control and I have recommended tight diabetic control.,5.  I will see him at followup at the EMG.",
 Neurologic examination sample.  , Neurology, Neurologic Examination ,"NEUROLOGICAL EXAMINATION: , At present the patient is awake, alert and fully oriented.  There is no evidence of cognitive or language dysfunction.  Cranial nerves:  Visual fields are full.  Funduscopic examination is normal.  Extraocular movements full.  Pupils equal, round,  react to light.  There is no evidence of nystagmus noted.  Fifth nerve function is normal.  There is no facial asymmetry noted.  Lower cranial nerves are normal.  ,Manual motor testing reveals good tone and bulk throughout.  There is no evidence of pronator drift or decreased fine finger movements.  Muscle strength is 5/5 throughout.  Deep tendon reflexes are 2+ throughout with downgoing toes.  Sensory examination is intact to all modalities including stereognosis, graphesthesia.,TESTING OF STATION AND GAIT:, The patient is able to walk toe-heel and tandem walk.  Finger-to-nose and heel-to-shin moves are normal.  Romberg sign negative.  I appreciate no carotid bruits or cardiac murmurs.,Noncontrast CT scan of the head shows no evidence of acute infarction, hemorrhage or extra-axial collection.","neurology, station, motor testing, nerve function, neurologic examination, cranial nerves, cranial, extraocular, movementsNOTE"
" The patient comes in for a neurology consultation regarding her difficult headaches, tunnel vision, and dizziness. ", Neurology, Neuropsychological Evaluation - 5 ,"PROBLEMS AND ISSUES:,1.  Headaches, nausea, and dizziness, consistent with a diagnosis of vestibular migraine, recommend amitriptyline for prophylactic treatment and Motrin for abortive treatment.,2.  Some degree of peripheral neuropathy, consistent with diabetic neuropathy, encouraged her to watch her diet and exercise daily.,HISTORY OF PRESENT ILLNESS: , The patient comes in for a neurology consultation regarding her difficult headaches, tunnel vision, and dizziness.  I obtained and documented a full history and physical examination.  I reviewed the new patient questionnaire, which she completed prior to her arrival today.  I also reviewed the results of tests, which she had brought with her.,Briefly, she is a 60-year-old woman initially from Ukraine, who had headaches since age 25.  She recalls that in 1996 when her husband died her headaches became more frequent.  They were pulsating.  She was given papaverine, which was successful in reducing the severity of her symptoms.  After six months of taking papaverine, she no longer had any headaches.  In 2004, her headaches returned.  She also noted that she had ""zig-zag lines"" in her vision.  Sometimes she would not see things in her peripheral visions.  She had photophobia and dizziness, which was mostly lightheadedness.  On one occasion she almost had a syncope.  Again she has started taking Russian medications, which did help her.  The dizziness and headaches have become more frequent and now occur on average once to twice per week.  They last two hours since she takes papaverine, which stops the symptoms within 30 minutes.,PAST MEDICAL HISTORY: ,Her past medical history is significant for injury to her left shoulder, gastroesophageal reflux disorder, diabetes, anxiety, and osteoporosis.,MEDICATIONS:,  Her medications include hydrochlorothiazide, lisinopril, glipizide, metformin, vitamin D, Centrum multivitamin tablets, Actos, lorazepam as needed, Vytorin, and Celexa.,ALLERGIES: , She has no known drug allergies.,FAMILY HISTORY:  ,There is family history of migraine and diabetes in her siblings.,SOCIAL HISTORY: , She drinks alcohol occasionally.,REVIEW OF SYSTEMS: , Her review of systems was significant for headaches, pain in her left shoulder, sleeping problems and gastroesophageal reflex symptoms.  Remainder of her full 14-point review of system was unremarkable.,PHYSICAL EXAMINATION:,  On examination, the patient was pleasant.  She was able to speak English fairly well.  Her blood pressure was 130/84.  Heart rate was 80.  Respiratory rate was 16.  Her weight was 188 pounds.  Her pain score was 0/10.  Her general exam was completely unremarkable.  Her neurological examination showed subtle weakness in her left arm due to discomfort and pain.  She had reduced vibration sensation in her left ankle and to some degree in her right foot.  There was no ataxia.  She was able to walk normally.  Reflexes were 2+ throughout.,She had had a CT scan with constant, which per Dr. X's was unremarkable.  She reports that she had a brain MRI two years ago which was also unremarkable.,IMPRESSION AND PLAN:,  The patient is a delightful 60-year-old chemist from Ukraine who has had episodes of headaches with nausea, photophobia, and dizziness since her 20s.  She has had some immigration problems in recent months and has experienced increased frequency of her migraine symptoms.  Her diagnosis is consistent with vestibular migraine.  I do not see evidence of multiple sclerosis, Ménière's disease, or benign paroxysmal positional vertigo.,I talked to her in detail about the importance of following a migraine diet.  I gave her instructions including a list of foods times, which worsen migraine.  I reviewed this information for more than half the clinic visit.  I would like to start her on amitriptyline at a dose of 10 mg at time.  She will take Motrin at a dose of 800 mg as needed for her severe headaches.,She will make a diary of her migraine symptoms so that we can find any triggering food items, which worsen her symptoms.  I encouraged her to walk daily in order to improve her fitness, which helps to reduce migraine symptoms.","neurology, nausea, dizziness, migraine, peripheral neuropathy, diabetic neuropathy, neuropathy, positional vertigo, photophobia and dizziness, neurology consultation, tunnel vision, vestibular migraine, migraine symptoms, headaches, photophobia, ataxia, "
 Neurologic consultation was requested to evaluate her seizure medication and lethargy., Neurology, Neurologic Consultation ,"REASON FOR CONSULTATION: , Neurologic consultation was requested by Dr. X to evaluate her seizure medication and lethargy.,HISTORY OF PRESENT ILLNESS: , The patient is well known to me.  She has symptomatic partial epilepsy secondary to a static encephalopathy, cerebral palsy, and shunted hydrocephalus related to prematurity.  She also has a history of factor V Leiden deficiency.  She was last seen at neurology clinic on 11/16/2007.  At that time, instructions were given to mom to maximize her Trileptal dose if seizures continue.  She did well on 2 mL twice a day without any sedation.  This past Friday, she had a 25-minute seizure reportedly.  This consisted of eye deviation, unresponsiveness, and posturing.  Diastat was used and which mom perceived was effective.  Her Trileptal dose was increased to 3 mL b.i.d. yesterday.,According to mom since her shunt revision on 12/18/2007, she has been sleepier than normal.  She appeared to be stable until this past Monday about six days ago, she became more lethargic and had episodes of vomiting and low-grade fevers.  According to mom, she had stopped vomiting since her hospitalization.  Reportedly, she was given a medication in the emergency room.  She still is lethargic, will not wake up spontaneously.  When she does awaken however, she is appropriate, and interacts with them.  She is able to eat well; however her overall p.o. intake has been diminished.  She has also been less feisty as her usual sounds.  She has been seizure free since her admission.,LABORATORY DATA: , Pertinent labs obtained here showed the following:  CRP is less than 0.3, CMP normal, and CBC within normal limits.  CSF cultures so far is negative.  Dr. Limon's note refers to a CSF, white blood cell count of 2, 1 RBC, glucose of 55, and protein of 64.  There are no imaging studies in the computer.  I believe that this may have been done at Kaweah Delta Hospital and reviewed by Dr. X, who indicated that there was no evidence of shunt malfunction or infection.,CURRENT MEDICATIONS: , Trileptal 180 mg b.i.d., lorazepam 1 mg p.r.n., acetaminophen, and azithromycin.,PHYSICAL EXAMINATION:,GENERAL:  The patient was asleep, but easily aroused.  There was a brief period of drowsiness, which she had some jerky limb movements, but not seizures.  She eventually started crying and became agitated.  She made attempts to sit by bending her neck forward.  Fully awake, she sucks her bottle eagerly.,HEENT:  She was obviously visually impaired.  Pupils were 3 mm, sluggishly reactive to light.,EXTREMITIES:  Bilateral lower extremity spasticity was noted.  There was increased flexor tone in the right upper extremity.  IV was noted on the left hand.,ASSESSMENT:  ,Seizure breakthrough due to intercurrent febrile illness.  Her lethargy could be secondary to a viral illness with some component of medication effect since her Trileptal dose was increased yesterday and these are probable explanations if indeed shunt malfunction has been excluded.,I concur with Dr. X's recommendations.  I do not recommend any changes in Trileptal for now.  I will be available while she remains hospitalized.,","neurology, lethargy, encephalopathy, cerebral palsy, shunted hydrocephalus, seizure breakthrough, shunt malfunction, neurologic consultation, neurologic, seizure, trileptal"
" The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma of the right adrenal gland with favorable Shimada histology and history of stage 2 left adrenal neuroblastoma, status post gross total resection.", Neurology, Neuroblastoma - Consult ,"REASON FOR VISIT:,  The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma here for ongoing management of his disease and the visit is supervised by Dr. X.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-month-old with neuroblastoma, which initially presented on the left when he was 6 weeks old and was completely resected.  It was felt to be stage 2.  It was not N-Myc amplified and had favorable Shimada histology.  In followup, he was found to have a second primary in his right adrenal gland, which was biopsied and also consistent with neuroblastoma with favorable Shimada histology.  He is now being treated with chemotherapy per protocol P9641 and not on study.  He last received chemotherapy on 05/21/07, with carboplatin, cyclophosphamide, and doxorubicin.  He received G-CSF daily after his chemotherapy due to neutropenia that delayed his second cycle.  In the interval since he was last seen, his mother reports that he had a couple of days of nasal congestion, but it is now improving.  He is not acted ill or had any fevers.  He has had somewhat diminished appetite, but it seems to be improving now.  He is peeing and pooping normally and has not had any diarrhea.  He did not have any appreciated nausea or vomiting.  He has been restarted on fluconazole due to having redeveloped thrush recently.,REVIEW OF SYSTEMS: , The following systems reviewed and negative per pathology except as noted above.  Eyes, ears, throat, cardiovascular, GI, genitourinary, musculoskeletal skin, and neurologic., PAST MEDICAL HISTORY:,  Reviewed as above and otherwise unchanged.,FAMILY HISTORY:,  Reviewed and unchanged.,SOCIAL HISTORY: , The patient's parents continued to undergo a separation and divorce.  The patient spends time with his father and his family during the first part of the week and with his mother during the second part of the week.,MEDICATIONS:  ,1.  Bactrim 32 mg by mouth twice a day on Friday, Saturday, and Sunday.,2.  G-CSF 50 mcg subcutaneously given daily in his thighs alternating with each dose.,3.  Fluconazole 37.5 mg daily.,4.  Zofran 1.5 mg every 6 hours as needed for nausea.,ALLERGIES: , No known drug allergies.,FINDINGS: , A detailed physical exam revealed a very active and intractable, well-nourished 11-month-old male with weight 10.5 kilos and height 76.8 cm.  Vital Signs:  Temperature is 35.3 degrees Celsius, pulse is 121 beats per minute, respiratory rate 32 breaths per minute, blood pressure 135/74 mmHg.  Eyes:  Conjunctivae are clear, nonicteric.  Pupils are equally round and reactive to light.  Extraocular muscle movements appear intact with no strabismus.  Ears:  TMs are clear bilaterally.  Oral Mucosa:  No thrush is appreciated.  No mucosal ulcerations or erythema.  Chest:  Port-a-Cath is nonerythematous and nontender to VP access port.  Respiratory:  Good aeration, clear to auscultation bilaterally.  Cardiovascular:  Regular rate, normal S1 and S2, no murmurs appreciated.  Abdomen is soft, nontender, and no organomegaly, unable to appreciate a right-sided abdominal mass or any other masses.  Skin:  No rashes.  Neurologic:  The patient walks without assistance, frequently falls on his bottom.,LABORATORY STUDIES: , CBC and comprehensive metabolic panel were obtained and they are significant for AST 51, white blood cell count 11,440, hemoglobin 10.9, and platelets 202,000 with ANC 2974.  Medical tests none.  Radiologic studies are none.,ASSESSMENT: , This patient's disease is life threatening, currently causing moderately severe side effects.,PROBLEMS DIAGNOSES:  ,1.  Neuroblastoma of the right adrenal gland with favorable Shimada histology.,2.  History of stage 2 left adrenal neuroblastoma, status post gross total resection.,3.  Immunosuppression.,4.  Mucosal candidiasis.,5.  Resolving neutropenia.,PROCEDURES AND IMMUNIZATIONS:,  None.,PLANS:  ,1.  Neuroblastoma.  The patient will return to the Pediatric Oncology Clinic on 06/13/07 to 06/15/07 for his third cycle of chemotherapy.  I will plan for restaging with CT of the abdomen prior to the cycle.,2.  Immunosuppression.  The patient will continue on his Bactrim twice a day on Thursday, Friday, and Saturday.  Additionally, we will tentatively plan to have him continue fluconazole since this is his second episode of thrush.,3.  Mucosal candidiasis.  We will continue fluconazole for thrush.  I am pleased that the clinical evidence of disease appears to have resolved.  For resolving neutropenia, I advised Gregory's mother about it is okay to discontinue the G-CSF at this time.  We will plan for him to resume G-CSF after his next chemotherapy and prescription has been sent to the patient's pharmacy.,PEDIATRIC ONCOLOGY ATTENDING: , I have reviewed the history of the patient.  This is an 11-month-old with neuroblastoma who received chemotherapy with carboplatin, cyclophosphamide, and doxorubicin on 05/21/07 for cycle 2 of POG-9641 due to his prior history of neutropenia, he has been on G-CSF.  His ANC is nicely recovered.  He will have a restaging CT prior to his next cycle of chemotherapy and then return for cycle 3 chemotherapy on 06/13/07 to 06/15/07.  He continues on fluconazole for recent history of thrush.  Plans are otherwise documented above.",
" Patient has trouble with walking and balance, with bladder control, and with thinking and memory.", Neurology, Neurologic Consultation - 2 ,"REASON FOR VISIT:  ,The patient is a 76-year-old man referred for neurological consultation by Dr. X.  The patient is companied to clinic today by his wife and daughter.  He provides a small portion of his history; however, his family provides virtually all of it.,HISTORY OF PRESENT ILLNESS: , He has trouble with walking and balance, with bladder control, and with thinking and memory.  When I asked him to provide me detail, he could not tell me much more than the fact that he has trouble with his walking and that he has trouble with his bladder.  He is vaguely aware that he has trouble with his memory.,According to his family, he has had difficulty with his gait for at least three or four years.  At first, they thought it was weakness and because of he was on the ground (for example, gardening) he was not able to get up by himself.  They did try stopping the statin that he was taking at that time, but because there was no improvement over two weeks, they resumed the statin.  As time progressed, he developed more and more difficulty.  He started to shuffle.  He started using a cane about two and a half years ago and has used a walker with wheels in the front since July of 2006.  At this point, he frequently if not always has trouble getting in or out of the seat.  He frequently tends to lean backwards or sideways when sitting.  He frequently if not always has trouble getting in or out a car, always shuffles or scuffs his feet, always has trouble turning or changing direction, always has trouble with uneven surfaces or curbs, and always has to hold on to someone or something when walking.  He has not fallen in the last month.  He did fall earlier, but there seemed to be fewer opportunities for him to fall.  His family has recently purchased a lightweight wheelchair to use if he is traveling long distances.  He has no stairs in his home, however, his family indicates that he would not be able to take stairs.  His handwriting has become smaller and shakier.,In regard to the bladder, he states, ""I wet the bed.""  In talking with his family, it seems as if he has no warning that he needs to empty his bladder.  He was diagnosed with a small bladder tumor in 2005.  This was treated by Dr. Y.  Dr. X does not think that the bladder tumor has anything to do with the patient's urinary incontinence.  The patient has worn a pad or undergarment for at least one to one and a half years.  His wife states that they go through two or three of them per day.  He has been placed on medications; however, they have not helped.,He has no headaches or sensation of head fullness.,In regard to the thinking and memory, at first he seemed forgetful and had trouble with dates.  Now he seems less spontaneous and his family states he seems to have trouble expressing himself.  His wife took over his medications about two years ago.  She stopped his driving about three years ago.  She discovered that his license had been expired for about a year and she was concerned enough at that time that she told him he could drive no more.  Apparently, he did not object.  At this point, he frequently has trouble with memory, orientation, and everyday problems solving at home.  He needs coaching for his daily activities such as reminders to brush his teeth, put on his clothes, and so forth.  He is a retired office machine repairman.  He is currently up and active about 12 hours a day and sleeping or lying down about 12 hours per day.,He has not had PT or OT and has not been treated with medications for Parkinson's disease or Alzheimer's disease.  He has been treated for the bladder.  He has not had lumbar puncture.,Past medical history and review of all 14 systems from the form they completed for this visit that I reviewed with them is negative with the exception that he has had hypertension since 1985, hypercholesterolemia since 1997, and diabetes since 1998.  The bladder tumor was discovered in 2005 and was treated noninvasively.  He has lost weight from about 200 pounds to 180 pounds over the last two or three years.  He had a period of depression in 1999 and was on Prozac for a while, but this was then stopped.  He used to drink a significant amount of alcohol.  This was problematic enough that his wife was concerned.  She states he stopped when she retired and she was at home all day.,SOCIAL HISTORY:  ,He quit smoking in 1968.  His current weight is 183 pounds.  His tallest height is 5 feet 10 inches.,FAMILY HISTORY:  ,His grandfather had arthritis.  His father had Parkinson's disease.  His mother had heart disease and a sister has diabetes.,He does not have a Living Will and indicates he would wish his wife to make decisions for him if he could not make them for himself.,REVIEW OF HYDROCEPHALUS RISK FACTORS: , None.,ALLERGIES: , None.,MEDICATIONS: , Metformin 500 mg three times a day, Lipitor 10 mg per day, lisinopril 20 mg per day, metoprolol 50 mg per day, Uroxatral 10 mg per day, Detrol LA 4 mg per day, and aspirin 81 mg per day.,PHYSICAL EXAM: , On examination today, this is a pleasant 76-year-old man who is guided back from the clinic waiting area walking with his walker.  He is well developed, well nourished, and kempt.,Vital Signs:  His weight is 180 pounds.,Head:  The head is normocephalic and atraumatic.  The head circumference is 59 cm, which is the ,75-90th percentile for an adult man whose height is 178 cm.,Spine:  The spine is straight and not tender.  I can easily palpate the spinous processes.  There is no scoliosis.,Skin:  No neurocutaneous stigmata.,Cardiovascular Examination:  No carotid or vertebral bruits.,Mental Status:  Assessed for orientation, recent and remote memory, attention span, concentration, language, and fund of knowledge.  The Mini-Mental State Exam score was 17/30.  He did not know the year, season, or day of the week nor did he know the building or specialty or the floor.  There was a tendency for perseveration during the evaluation.  He could not copy the diagram of intersecting pentagons.,Cranial Nerve Exam:  No evidence of papilledema.  The pupillary light reflex is intact as are extraocular movements without nystagmus, facial expression and sensation, hearing, head turning, tongue, and palate movement.,Motor Exam:  Normal bulk and strength, but the tone is marked by significant paratonia.  There is no atrophy, fasciculations, or drift.  There is tremulousness of the outstretched hands.,Sensory Exam:  Is difficult to interpret.  Either he does not understand the test or he is mostly guessing.,Cerebellar Exam:  Is intact for finger-to-nose, heel-to-knee, and rapid alternating movement tests.  There is no dysarthria.,Reflexes:  Trace in the arms, 2+ at the knees, and 0 at the ankles.  It is not certain whether there is a Babinski sign or simply withdrawal.,Gait:  Assessed using the Tinetti assessment tool that shows a balance score of 7-10/16 and a gait score of 2-5/12 for a total score of 9-15/28, which is significantly impaired.,REVIEW OF X-RAYS: , I personally reviewed the MRI scan of the brain from December 11, 2007 at Advanced Radiology.  It shows the ventricles are enlarged with a frontal horn span of 5.0 cm.  The 3rd ventricle contour is flat.  The span is enlarged at 12 mm.  The sylvian aqueduct is patent.  There is a pulsation artifact.  The corpus callosum is effaced.  There are extensive T2 signal abnormalities that are confluent in the corona radiata.  There are also scattered T2 abnormalities in the basal ganglia.  There is a suggestion of hippocampal atrophy.  There is also a suggestion of vermian atrophy.,ASSESSMENT: , The patient has a clinical syndrome that raises the question of idiopathic normal pressure hydrocephalus.  His examination today is notable for moderate-to-severe dementia and moderate-to-severe gait impairment.  His MRI scan raises the question of hydrocephalus, however, is also consistent with cerebral small vessel disease.,PROBLEMS/DIAGNOSES:,1.  Possible idiopathic normal pressure hydrocephalus (331.5).,2.  Probable cerebral small-vessel disease (290.40 & 438).,3.  Gait impairment (781.2).,4.  Urinary urgency and incontinence (788.33).,5.  Dementia.,6.  Hypertension.,7.  Hypercholesterolemia.",
 The patient is a 55-year-old gentleman who presents for further evaluation of right leg weakness., Neurology, Neuro Consult - Leg Weakness ,"HISTORY OF PRESENT ILLNESS: , The patient is a 55-year-old gentleman who presents for further evaluation of right leg weakness.  He has difficulty recollecting the exact details and chronology of his problem.  To the best of his recollection, he thinks that about six months ago he developed weakness of his right leg.  He describes that he is reaching to get something from a cabinet and he noticed that he was unable to stand on his right toe.  Since that time, he has had difficulty pushing off when he walks.  He has mild tingling and numbness in his toes, but this has been a chronic problem and nothing new since he has developed the weakness.  He has chronic mild back pain, but this has been persistent for many years and has not changed.  He has experienced cramps in both calves for the past year.  This dissipated about two months ago.  He does not think that his left leg is weak.  He does not have any bowel or bladder incontinence.  There is no radicular pain.  He does not think that the problem is progressive, meaning that the weakness that he perceives in his right leg is no different than when it was six months ago.,He first sought medical attention for this problem in October.  He then saw you a couple of months later.  He has undergone an EMG and nerve conduction studies.  Unfortunately, he cannot undergo an MRI of his spine because he has an ear implant.  He has had a CT scan that shows degenerative changes, but nothing obviously abnormal.,In addition, the patient has hyperCKemia.  He tells me that he has had an elevated CK prior to starting taking stat medications, although this is not entirely clear to me.  He thinks that he is not taking Lipitor for about 15 months and thought that his CK was in the 500 or 600s prior to starting it.  Once it was started, it increased to about 800 and then came down to about 500 when it was stopped.  He then had a recent bump again up to the 1000 and since Lipitor has been stopped, his CK apparently has returned to about the 500 or 600s.  I do no have any laboratory data to support these statements by the patient, but he seems to be up to speed on this.  More recently, he has been started taking Zetia.  He does not have any proximal weakness.  He denies any myalgias., ,PAST MEDICAL HISTORY:,  He has coronary artery disease and has received five stents.  He has hypertension and hypercholesterolemia.  He states that he was diagnosed with diabetes based on the results of an abnormal oral glucose tolerance test.  He believes that his glucose shot up to over 300 with this testing.  He does not take any medications for this and his blood glucoses are generally normal when he checks it.  He has had plastic surgery on his face from an orbital injury.  He also had an ear graft when he developed an ear infection during his honeymoon., ,CURRENT MEDICATIONS:, He takes amlodipine, Diovan, Zetia, hydrochlorothiazide, Lovaza (fish oil), Niaspan, aspirin, and Chantix.  , ,ALLERGIES:,  He has no known drug allergies., ,SOCIAL HISTORY:,  He lives with his wife.  He works at Shepherd Pratt doing network engineering.  He smokes a pack of cigarettes a day and is working on quitting.  He drinks four alcoholic beverages per night.  Prior to that, he drank significantly more.  He denies illicit drug use.  He was athletic growing up., ,FAMILY HISTORY:,  His mother died of complications from heart disease.  His father died of heart disease in his 40s.  He has two living brothers.  One of them he does not speak too much with and does not know about his medical history.  The other is apparently healthy.  He has one healthy child.  His maternal uncles apparently had polio.  When I asked him to tell me further details about this, he states that one of them had to wear crutches due to severe leg deformans and then the other had leg deformities in only one leg.  He is fairly certain that they had polio.  He is unaware of any other family members with neurological conditions.,REVIEW OF SYSTEMS: , He has occasional tinnitus.  He has difficulty sleeping.  Otherwise, a complete review of systems was obtained and was negative except for as mentioned above.  This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:, ,Vital Signs:",
 Neurologic consultation was requested to assess and assist with seizure medication., Neurology, Neurologic Consultation - 3 ,"HISTORY: , Neurologic consultation was requested to assess and assist with her seizure medication.  The patient is a 3-year 3 months old girl with refractory epilepsy.  She had been previously followed by XYZ, but has been under the care of the UCSF epilepsy program and recently by Dr. Y.  I reviewed her pertinent previous neurology evaluations at CHCC and also interviewed mom.,The patient had seizure breakthrough in August 2007, which requires inpatient admission, Thanksgiving and then after that time had seizures every other day, up-to-date early December.  She remained seizure-free until 12/25/2007 when she had a breakthrough seizure at home treated with Diastat.  She presented to our ER today with prolonged convulsive seizure despite receiving 20 mg of Diastat at home.  Mom documented 103 temperature at home.  In the ER, this was 101 to 102 degrees Fahrenheit.  I reviewed the ER notes.  At 0754 hours, she was having intermittent generalized tonic-clonic seizures despite receiving a total of 1.5 mg of lorazepam x5.  UCSF fellow was contacted.  She was given additional fosphenytoin and had a total dose of 15 mg/kg administered.  Vital weight was 27.  Seizures apparently had stopped.  The valproic acid level obtained at 0835 hours was 79.  According to mom, her last dose was at 6 p.m. and she did not receive her morning dose.  Other labs slightly showed leukocytosis with white blood cell count 21,000 and normal CMP.,Previous workup here showed an EEG on 2005, which showed a left posterior focus.  MRI on June 2007 and January 2005 were within normal limits.  Mom describes the following seizure types:,1.  Eye blinking with unresponsiveness.,2.  Staring off to one side.,3.  Focal motor activity in one arm and recently generalized tonic seizure.,She also said that she was supposed to see Dr. Y this Friday, but had postponed it to some subsequent time when results of genetic testing would be available.  She was being to physicians' care as Dr. Z had previously being following her last UCSF.,She had failed most of the first and second line anti-epileptic drugs.  These include Keppra, Lamictal, Trileptal, phenytoin and phenobarbital.  These are elicited to allergies, but she has not had any true allergic reactions to these.  Actually, it has resulted in an allergic reaction resulting in rash and hypotension.,She also had been treated with Clobazam.  Her best control is with her current regimen of valproic acid and Tranxene.  Other attempts to taper Topamax, but this resulted increased seizures.  She also has oligohidrosis during this summertime.,CURRENT MEDICATIONS: , Include Diastat 20 mg; Topamax 25 mg b.i.d., which is 3.3 per kilo per day; Tranxene 15 mg b.i.d.; Depakote 125 mg t.i.d., which is 25 per kilo per day.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Weight 15 kg.,GENERAL:  The patient was awake, she appeared sedated and postictal.,NECK:  Supple.,NEUROLOGICAL:  She had a few brief myoclonic jerks of her legs during drowsiness, but otherwise no overt seizure, no seizure activity nor involuntary movements were observed.,She was able to follow commands such as when I request that she gave mom a kiss.  She acknowledged her doll.  Left fundus is sharp.  She resisted the rest of the exam.  There was no obvious lateralized findings.,ASSESSMENT:,  Status epilepticus resolved.  Triggered by a febrile illness, possibly viral.  Refractory remote symptomatic partial epilepsy.,IMPRESSION: , I discussed the maximizing Depakote to mom and she concurred.  I recommend increasing her maintenance dose to one in the morning, one in the day, and two at bedtime.  For today, she did give an IV Depacon 250 mg and the above dosage can be continued IV until she is taking p.o.  Dr. X agreed with the changes and orders were written for this.  She can continue her current doses of Topamax and Tranxene.  This can be given by NG if needed.  Topamax can be potentially increased to 25 mg in the morning and 50 mg at night.  I will be available as needed during the rest of her hospitalization.  Mom will call contact Dr. Y an update him about the recent changes.","neurology, eye blinking, status epilepticus, seizure medication, valproic acid, allergic reactions, neurologic consultation, seizure, neurologic, seizures,"
 Patient with juvenile myoclonic epilepsy and recent generalized tonic-clonic seizure., Neurology, Myoclonic Epilepsy ,"DIAGNOSES:,1.  Juvenile myoclonic epilepsy.,2.  Recent generalized tonic-clonic seizure.,MEDICATIONS:,1.  Lamictal 250 mg b.i.d.,2.  Depo-Provera.,INTERIM HISTORY: , The patient returns for followup.  Since last consultation she has tolerated Lamictal well, but she has had a recurrence of her myoclonic jerking.  She has not had a generalized seizure.  She is very concerned that this will occur.  Most of the myoclonus is in the mornings.  Recent EEG did show polyspike and slow wave complexes bilaterally, more prominent on the left.  She states that she has been very compliant with the medications and is getting a good amount of sleep.  She continues to drive.,Social history and review of systems are discussed above and documented on the chart.,PHYSICAL EXAMINATION: , Vital signs are normal.  Pupils are equal and reactive to light.  Extraocular movements are intact.  There is no nystagmus.  Visual fields are full.  Demeanor is normal.  Facial sensation and symmetry is normal.  No myoclonic jerks noted during this examination.  No myoclonic jerks provoked by tapping on her upper extremity muscles.  Negative orbit.  Deep tendon reflexes are 2 and symmetric.  Gait is normal.  Tandem gait is normal.  Romberg negative.,IMPRESSION AND PLAN:,  Recurrence of early morning myoclonus despite high levels of Lamictal.  She is tolerating the medication well and has not had a generalized tonic-clonic seizure.  She is concerned that this is a precursor for another generalized seizure.  She states that she is compliant with her medications and has had a normal sleep-wake cycle.,Looking back through her notes, she initially responded very well to Keppra, but did have a breakthrough seizure on Keppra.  This was thought secondary to severe insomnia when her baby was very young.  Because she tolerated the medication well and it was at least partially affective, I have recommended adding Keppra 500 mg b.i.d.  Side effect profile of this medication was discussed with the patient.,I will see in followup in three months.","neurology, generalized tonic-clonic seizure, juvenile myoclonic epilepsy, tonic clonic seizure, myoclonic epilepsy, tonic clonic, juvenile, myoclonus, epilepsy, myoclonic, seizure"
 Neurologic consultation and follow-up., Neurology, Neurologic Consultation - 1 ,"SOCIAL HISTORY, FAMILY HISTORY, AND PAST MEDICAL HISTORY:, Reviewed.  There are no changes, otherwise.,REVIEW OF SYSTEMS:,  Fatigue, pain, difficulty with sleep, mood fluctuations, low stamina, mild urgency frequency and hesitancy, preponderance of lack of stamina, preponderance of pain particularly in the left shoulder.,EXAMINATION: , The patient is alert and oriented.  Extraocular movements are full.  The face is symmetric.  The uvula is midline.  Speech has normal prosody.  Today there is much less guarding of the left shoulder.  In the lower extremities, iliopsoas, quadriceps, femoris and tibialis anterior are full.  The gait is narrow based and noncircumductive.  Rapid alternating movements are slightly off bilaterally.  The gait does not have significant slapping characteristics.  Sensory examination is largely unremarkable.  Heart, lungs, and abdomen are within normal limits.,IMPRESSION: , Mr. ABC is doing about the same.  We discussed the issue of adherence to Copaxone.  In order to facilitate this, I would like him to take Copaxone every other day, but on a regular rhythm.  His wife continues to inject him.  He has not been able to start himself on the injections.,Greater than 50% of this 40-minute appointment was devoted to counseling.","neurology, neurologic consultation, stamina, preponderance, neurologic, consultation, copaxone,"
 , Neurology, Neuro Consult - Depression & Dementia ,"Subsequently, the patient developed a moderately severe depression.  She was tried on various medications, which caused sweating, nightmares and perhaps other side effects.  She was finally put on Effexor 25 mg two tablets h.s. and trazodone 100 mg h.s., and has done fairly well, although she still has significant depression.,Her daughter brought her in today to be sure that she does not have dementia.  There is no history of memory loss.  There is no history of focal neurologic symptoms or significant headaches.,The patient's complaints, according to the daughter, include not wanted to go out in public, shamed regarding her appearance (25-pound weight loss over the past year), eating poorly, not doing things unless asked, hiding food to prevent having to eat it, nervousness, and not taking a shower.  She has no focal neurologic deficits.  She does complain of constipation.  She has severe sleep maintenance insomnia and often sleeps only 2 hours before awakening frequently for the rest of the night.,The patient was apparently visiting her daughter in northern California in December 2003.  She was taken to her daughter's primary care physician.  She underwent vitamin B12 level, RPR, T4 and TSH, all of which were normal.,On 05/15/04, the patient underwent MRI scan of the brain.  I reviewed the scan in the office today.  This shows moderate cortical and central atrophy and also shows mild-to-moderate deep white matter ischemic changes.,PAST MEDICAL HISTORY: , The patient has generally been in reasonably good physical health.  She did have a ""nervous breakdown"" in 1975 after the death of her husband.  She was hospitalized for several weeks and was treated with ECT.  This occurred while she was living in Korea.,She does not smoke or drink alcoholic beverages.  She has had no prior surgeries.  There is a past history of hypertension, but this is no longer present.,FAMILY HISTORY: , Negative for dementia.  Her mother died of a stroke at the age of 62.,PHYSICAL EXAMINATION:,Vital Signs:  Blood pressure 128/80, pulse 84, temperature 97.4 F, and weight 105 lbs (dressed).,General:  Well-developed, well-nourished Korean female in no acute distress.,Head:  Normocephalic, without evidence of trauma or bruits.,Neck:  Supple, with full range of motion.  No spasm or tenderness.  Carotid pulsations are of normal volume and contour bilaterally without bruits.  No thyromegaly or adenopathy.,Extremities:  No clubbing, cyanosis, edema, or deformity.  Range of motion full throughout.,NEUROLOGICAL EXAMINATION:,Mental Status:  The patient is awake, alert and oriented to time, place, and person and generally appropriate.  She exhibits mild psychomotor retardation and has a flat or depressed affect.  She knows the current president of Korea and the current president of the United States.  She can recall 3 out of 3 objects after 5 minutes.  Calculations are performed fairly well with occasional errors.  There is no right-left confusion, finger agnosia, dysnomia or aphasia.,Cranial Nerves:,II:",
" The patient is with multiple neurologic and nonneurologic symptoms including numbness, gait instability, decreased dexterity of his arms and general fatigue.  His neurological examination is notable for sensory loss in a length-dependent fashion in his feet and legs with scant fasciculations in his calves.", Neurology, Multiple Neurological Symptoms ,"HISTORY OF PRESENT ILLNESS: , The patient is a 63-year-old left-handed gentleman who presents for further evaluation of multiple neurological symptoms.  I asked him to discuss each symptom individually as he had a very hard time describing the nature of his problems.  He first mentioned that he has neck pain.  He states that he has had this for at least 15 years.  It is worse with movement.  It has progressed very slowly over the course of 15 years.  It is localized to the base of his neck and is sharp in quality.  He also endorses a history of gait instability.  This has been present for a few years and has been slightly progressively worsening.  He describes that he feels unsteady on his feet and ""walks like a duck.""  He has fallen about three or four times over the past year and a half.,He also describes that he has numbness in his feet.  When I asked him to describe this in more detail, the numbness is actually restricted to his toes.  Left is slightly more affected than the right.  He denies any tingling or paresthesias.  He also described that he is slowly losing control of his hands.  He thinks that he is dropping objects due to weakness or incoordination in his hands.  This has also been occurring for the past one to two years.  He has noticed that buttoning his clothes is more difficult for him.  He also does not have any numbness or tingling in the hands.  He does have a history of chronic low back pain.,At the end of the visit, when I asked him which symptom was most bothersome to him, he actually stated that his fatigue was most troublesome.  He did not even mention this on the initial part of my history taking.  When I asked him to describe this further, he states that he experiences a general exhaustion.  He basically lays in bed all day everyday.  I asked him if he was depressed, he states that he is treated for depression.  He is unsure if this is optimally treated.  As I just mentioned, he stays in bed almost all day long and does not engage in any social activities.  He does not think that he is necessarily sad.  His appetite is good.  He has never undergone any psychotherapy for depression.,When I took his history, I noticed that he is very slow in responding to my questions and also had a lot of difficulty recalling details of his history as well as names of physicians who he had seen in the past.  I asked if he had ever been evaluated for cognitive difficulties and he states that he did undergo testing at Johns Hopkins a couple of years ago.  He states that the results were normal and that specifically he did not have any dementia.,When I asked him when he was first evaluated for his current symptoms, he states that he saw Dr. X several years ago.  He believes that he was told that he had neuropathy but that it was unclear if it was due to his diabetes.  He told me that more recently he was evaluated by you after Dr. Y referred him for this evaluation.  He also saw Dr. Z for neurosurgical consultation a couple of weeks ago.  He reports that she did not think there was any surgical indication in his neck or back at this point in time.,PAST MEDICAL HISTORY: , He has had diabetes for five years.  He also has had hypercholesterolemia.  He has had Crohn's disease for 25 or 30 years.  He has had a colostomy for four years.  He has arthritis, which is reportedly related to the Crohn's disease.  He has hypertension and coronary artery disease and is status post stent placement.  He has depression.  He had a kidney stone removed about 25 years ago.,CURRENT MEDICATIONS: , He takes Actos, Ambien, baby aspirin, Coreg, Entocort, folic acid, Flomax, iron, Lexapro 20 mg q.h.s., Lipitor, Pentasa, Plavix, Protonix, Toprol, Celebrex and Zetia.,ALLERGIES: , He states that Imuran caused him to develop tachycardia.,SOCIAL HISTORY:,  He previously worked with pipeline work, but has been on disability for five years.  He is unsure which symptoms led him to go on disability.  He has previously smoked about two packs of cigarettes daily for 20 years, but quit about 20 years ago.  He denies alcohol or illicit drug use.  He lives with his wife.  He does not really have any hobbies.,FAMILY HISTORY: , His father died of a cerebral hemorrhage at age 49.  His mother died in her 70s from complications of congestive heart failure.  He has one sister who died during a cardiac surgery two years ago.  He has another sister with diabetes.  He has one daughter with hypercholesterolemia.  He is unaware of any family members with neurological disorders.,REVIEW OF SYSTEMS: , He has dyspnea on exertion.  He states that he was evaluated by a pulmonologist and had a normal evaluation.  He has occasional night sweats.  His hearing is poor.  He occasionally develops bloody stools, which he attributes to his Crohn's disease.  He also was diagnosed with sleep apnea.  He does not wear his CPAP machine on a regular basis.  He has a history of anemia.  Otherwise, a complete review of systems was obtained and was negative except for as mentioned above.  This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:,Vital Signs:  Blood pressure 160/86 HR 100 RR 16 Wt 211 pounds Pain 3/10,General Appearance:  He is well appearing in no acute distress.  He has somewhat of a flat affect.,Cardiovascular:  He has a regular rhythm without murmurs, gallops, or rubs.  There are no carotid bruits.,Chest:  The lungs are clear to auscultation bilaterally.,Skin:  There are no rashes or lesions.,Musculoskeletal:  He has no joint deformities or scoliosis.,NEUROLOGICAL EXAMINATION:,Mental Status:  His speech is fluent without dysarthria or aphasia.  He is alert and oriented to name, place, and date.  Attention, concentration, and fund of knowledge are intact.  He has 3/3 object registration and 1/3 recall in 5 minutes.,Cranial Nerves:  Pupils are equal, round, and reactive to light and accommodation.  Visual fields are full.  Optic discs are normal.  Extraocular movements are intact without nystagmus.  Facial sensation is normal.  There is no facial, jaw, palate, or tongue weakness.  Hearing is grossly intact.  Shoulder shrug is full.,Motor:  He has normal muscle bulk and tone.  There is no atrophy.  He has few fasciculations in his calf muscles bilaterally.  Manual muscle testing reveals MRC grade 5/5 strength in all proximal and distal muscles of the upper and lower extremities.  There is no action or percussion myotonia or paramyotonia.,Sensory:  He has absent vibratory sensation at the left toe.  This is diminished at the right toe.  Joint position sense is intact.  There is diminished sensation to light touch and temperature at the feet to the knees bilaterally.  Pinprick is intact.  Romberg is absent.  There is no spinal sensory level.,Coordination:  This is intact by finger-nose-finger or heel-to-shin testing.  He does have a slight tremor of the head and outstretched arms.,Deep Tendon Reflexes:  They are 2+ at the biceps, triceps, brachioradialis, patellas, and ankles.  Plantar reflexes are flexor.  There is no ankle clonus, finger flexors, or Hoffman's signs.  He has crossed adductors bilaterally.,Gait and Stance:  He has a slightly wide-based gait.  He has some difficulty with toe walking, but he is able to walk on his heels and tandem walk.  He has difficulty with toe raises on the left.,RADIOLOGIC DATA: , MRI of the cervical spine, 09/30/08:  Chronic spondylosis at C5-C6 causing severe bilateral neuroforamining and borderline-to-mold cord compression with normal cord signal.  Spondylosis of C6-C7 causing mild bilateral neuroforamining and left paracentral disc herniation causing borderline cord compression.,Thoracic MRI spine without contrast:  Minor degenerative changes without stenosis.,I do not have the MRI of the lumbar spine available to review.,LABORATORY DATA: , 10/07/08:  Vitamin B1 210 (87-280), vitamin B6 6, ESR 6, AST 25, ALT 17, vitamin B12 905, CPK 226 (0-200), T4 0.85, TSH 3.94, magnesium 1.7, RPR nonreactive, CRP 4, Lyme antibody negative, SPEP abnormal (serum protein electrophoresis), but no paraprotein by manifestation, hemoglobin A1c 6.0, aldolase 3.9 and homocystine 9.0.,ASSESSMENT: , The patient is a 63-year-old gentleman with multiple neurologic and nonneurologic symptoms including numbness, gait instability, decreased dexterity of his arms and general fatigue.  His neurological examination is notable for sensory loss in a length-dependent fashion in his feet and legs with scant fasciculations in his calves.  He has fairly normal or very mild increased reflexes including notably the presence of normal ankle jerks.,I think that the etiology of his symptoms is multifactorial.  He probably does have a mild peripheral neuropathy, but the sparing of ankle jerks suggested either the neuropathy is mild or that there is a superimposed myelopathic process such as a cervical or lumbosacral myelopathy.  He really is most concerned about the fatigue and I think it is possible due to suboptimally treated depression and suboptimally treated sleep apnea.  Whether he has another underlying muscular disorder such as a primary myopathy remains to be seen.,RECOMMENDATIONS:,1.  I scheduled him for repeat EMG and nerve conduction studies to evaluate for evidence of neuropathy or myopathy.,2.  I will review his films at our spine conference tomorrow although I am confident in Dr. Z's opinion that there is no surgical indication.,3.  I gave him a prescription for physical therapy to help with gait imbalance training as well as treatment for his neck pain.,4.  I believe that he needs to undergo psychotherapy for his depression.  It may also be worthwhile to adjust his medications, but I will defer to his primary care physician for managing this or for referring him to a therapist.  The patient is very open about proceeding with this suggestion.,5.  He does need to have his sleep apnea better controlled.  He states that he is not compliant because the face mask that he uses does not fit him well.  This should also be addressed.",
 Patient with stable expressive aphasia and decreased vision., Neurology, Multiple Meningiomas ,"CC:, Stable expressive aphasia and decreased vision.,HX:, This 72y/o woman was diagnosed with a left sphenoid wing meningioma on 6/3/80. She was 59 years old at the time and presented with a 6 month history of increasing irritability and left occipital-nuchal headaches. One month prior to that presentation she developed leftward head turning, and 3 days prior to presentation had an episode of severe dysphasia. A HCT (done locally) revealed a homogenously enhancing lesion of the left sphenoid wing. Skull X-rays showed deviation of the pineal to the right. She was transferred to UIHC and was noted to have a normal neurologic exam (per Neurosurgery note). Angiography demonstrated a highly vascular left temporal/sphenoid wing tumor. She under went left temporal craniotomy and ""complete resection"" of the tumor which on pathologic analysis was consistent with a meningioma.,The left sphenoid wing meningioma recurred and was excised 9/25/84. There was regrowth of this tumor seen on HCT, 1985. A 6/88 HCT revealed the left sphenoid meningioma and a new left tentorial meningioma. HCT in 1989 revealed left temporal/sphenoid, left tentorial, and new left frontal lesions. On 2/14/91 she presented with increasing lethargy and difficulty concentrating. A 2/14/91, HCT revealed increased size and surrounding edema of the left frontal meningioma. The left frontal and temporal meningiomas were excised on 2/25/91. These tumors all recurred and a left parietal lesion developed. She underwent resection of the left frontal meningioma on 11/21/91 due to right sided weakness and expressive aphasia. The weakness partially resolved and though the speech improved following resection it did not return to normal. In May 1992 she experienced 3 tonic-clonic type seizures, all of which began with a Jacksonian march up the RLE then RUE before generalizing. Her Phenobarbital prophylaxis which she had been taking since her 1980 surgery was increased. On 12/7/92, she underwent a left fronto-temporo-parieto-occipital craniotomy and excision of five meningiomas. Postoperatively she developed worsened right sided weakness and expressive aphasia. The weakness and aphasia improved by 3/93, but never returned to normal.","neurology, sphenoid wing meningioma, sphenoid wing, expressive aphasia, meningiomas, aphasia, sphenoidNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Patient status post vehicular trauma.  Low Back syndrome and Cervicalgia., Neurology, Neck & Lower Back Pain - Consult ,"CHIEF COMPLAINT:, Neck and lower back pain.,VEHICULAR TRAUMA HISTORY:, Date of incident: 1/15/2001. The patient was the driver of a small sports utility vehicle and was wearing a seatbelt. The patient’s vehicle was proceeding through an intersection and was struck by another vehicle from the left side and forced off the road into a utility pole. The other vehicle had reportedly been driven by a drunk driver and ran a traffic signal. Estimated impact speed was 80 m.p.h. The driver of the other vehicle was reportedly cited by police. The patient was transiently unconscious and came to the scene. There was immediate onset of headaches, neck and lower back pain. The patient was able to exit the vehicle and was subsequently transported by Rescue Squad to St. Thomas Memorial Hospital, evaluated in the emergency room and released.,NECK AND LOWER BACK PAIN HISTORY:, The patient relates the persistence of pain since the motor vehicle accident. Symptoms began immediately following the MVA. Because of persistent symptoms, the patient subsequently sought chiropractic treatment. Neck pain is described as severe. Neck pain remains localized and is non-radiating. There are no associated paresthesias. Back pain originates in the lumbar region and radiates down both lower extremities. Back pain is characterized as worse than the neck pain. There are no associated paresthesias.",
 MRI T-spine and CXR - Aortic Dissection., Neurology, MRI T-Spine ,"CC:, BLE weakness.,HX:, This 82y/o RHM was referred to the Neurology service by the Neurosurgery service for evaluation of acute onset paraplegia. He was in his usual state of health until 5:30PM on 4/6/95, when he developed sudden ""pressure-like"" epigastric discomfort associated with bilateral lower extremity weakness, SOB, lightheadedness and diaphoresis. He knelt down to the floor and ""went to sleep."" The Emergency Medical Service was alert and arrived within minutes, at which time he was easily aroused though unable to move or feel his lower extremities. No associated upper extremity or bulbar dysfunction was noted. He was taken to a local hospital where an INR was found to be 9.1. He was given vitamin K 15mg, and transferred to UIHC to rule out spinal epidural hemorrhage. An MRI scan of the T-spine was obtained and the preliminary reading was ""normal."" The Neurology service was then asked to evaluate the patient.,MEDS:, Coumadin 2mg qd, Digoxin 0.25mg qd, Prazosin 2mg qd.,PMH:, 1)HTN. 2)A-Fib on coumadin. 3)Peripheral vascular disease:s/p left Femoral-popliteal bypass (8/94) and graft thrombosis-thrombolisis (9/94). 4)Adenocarcinoma of the prostate: s/p TURP (1992).,FHX: ,unremarkable.,SHX:, Farmer, Married, no Tobacco/ETOH/illicit drug use.,EXAM:, BP165/60 HR86 RR18 34.2C SAO2 98% on room air.,MS: A&O to person, place, time. In no acute distress. Lucid.,CN: unremarkable.,MOTOR: 5/5 strength in BUE. Flaccid paraplegia in BLE,Sensory: T6 sensory level to LT/PP, bilaterally. Decreased vibratory sense in BLE in a stocking distribution, distally.,Coord: Intact FNF and RAM in BUE. Unable to do HKS.,Station: no pronator drift.,Gait: not done.,Reflexes: 2/2 BUE, Absent in BLE, plantar responses were flexor, bilaterally.,Rectal: decreased rectal tone.,GEN EXAM: No carotid bruitts. Lungs: bibasilar crackles. CV: Irregular rate and rhythm with soft diastolic murmur at the left sternal border. Abdomen: flat, soft, non-tender without bruitt or pulsatile mass. Distal pulses were strong in all extremities.,COURSE:, Hgb 12.6, Hct 40%, WBC 11.7, Plt 154k, INR 7.6, PTT 50, CK 41, the GS was normal. EKG showed A-Fib at 75BPM with competing junctional pacemaker, essentially unchanged from 9/12/94.,It was suspected that the patient sustained an anterior-cervico-thoracic spinal cord infarction with resultant paraplegia and T6 sensory level. A CXR was done in the ER prior to admission. This revealed cardiomegaly and a widened mediastinum. He returned from the x-ray suite and suddenly became unresponsive and went into cardiopulmonary arrest. Resuscitative measures failed. Pericardiocentesis was unremarkable. Autopsy revealed a massive aortic dissection extending from the aortic root to the origin of the iliac arteries with extensive pericardial hematoma. The dissection was seen in retrospect on the MRI T-spine.","neurology, mri, a&o, aortic dissection, cxr, irregular rate and rhythm, mri scan, neurology service, t-spine, carotid bruitts, epidural hemorrhage, mediastinum, paraplegia, person, place, stocking distribution, time, weakness, mri t spine, sensory level, spine, "
 MRI T-spine: Metastatic Adenocarcinoma of the T3-T4 vertebrae and invading the spinal canal., Neurology, MRI T-Spine - Spinal Mets ,"CC: ,BLE weakness and numbness.,HX:, This 59 y/o RHM was seen and released from an ER 1 week prior to this presentation for a 3 week history of progressive sensory and motor deficits in both lower extremities. He reported numbness beginning about his trunk and slowly progressing to involve his lower extremities over a 4 week period. On presentation, he felt numb from the nipple line down. In addition, he began experiencing progressive weakness in his lower extremities for the past week. He started using a cane 5 days before being seen and had been having difficulty walking and traversing stairs. He claimed he could not stand. He denied loss of bowel or bladder control. However, he had not had a bowel movement in 3 days and he had not urinated 24 hours. His lower extremities had been feeling cold for a day. He denied any associated back or neck pain. He has chronic shortness of breath, but felt it had become worse. He had also been experiencing lightheadedness upon standing more readily than usual for 2 days prior to presentation.,PMH:, 1)CAD with chronic CP, 2)NQWMI 1994, S/P Coronary Angioplasty, 3)COPD (previous FEV 11.48, and FVC 2.13), 4)Anxiety D/O, 5)DJD, 6)Developed confusion with metoprolol use, 7)HTN.,MEDS:, Benadryl, ECASA, Diltiazem, Isordil, Enalapril, Indomethacin, Terbutaline MDI, Ipratropium MDI, Folic Acid, Thiamine.,SHX:, 120pk-yr smoking, ETOH abuse in past, Retired Dock Hand,FHX: ,unremarkable except for ETOH abuse,EXAM:,  T98.2 96bpm 140/74mmHg R18,Thin cachetic male in moderate distress.,MS: A&O to person, place and time. Speech was fluent and without dysarthria. Comprehension, naming and reading were intact.,CN: unremarkable.,Motor: Full strength in both upper extremities.,HF HE HAdd HAbd KF KE AF AE,RLE 3 3 4 4 3 4 1 1,LLE 4 4 4+ 4+ 4+ 4 4 4,There was mild spastic muscle tone in the lower extremities. There was normal muscle bulk throughout.,SENSORY: Decreased PP in the LLE from the foot to nipple line, and in the RLE from the knee to nipple line. Decreased Temperature sensation from the feet to the umbilicus, bilaterally. No loss of Vibration or Proprioception. Decreased light touch from the feet to nipple line, bilaterally.,Gait: unable to walk. Stands with support only.,Station: no pronator drift or truncal ataxia.,Reflexes: 2+/2+ in BUE, 3+/3+ patellae, 0/1 ankles. Babinski signs were present, bilaterally. The abdominal reflexes were absent.,CV: RRR with a 2/6 systolic ejection murmur at the left sternal border. Lungs: CTA with mildly labored breathing. Abdomen: NT, ND, NBS, but bladder distended. Extremities were cool to touch. Peripheral pulses were intact and capillary refill was brisk. Rectal: decreased rectal tone and absent anal reflex. Right prostate nodule at the inferior pole.,COURSE: ,Admission Labs: FEV1=1.17, FVC 2.19, ABG 7.39/42/79 on room air. WBC 10/5, Hgb 13, Hct 39, Electrolytes were normal. PT & PTT were normal. Straight catheterization revealed a residual volume of 400cc of urine.,He underwent emergent T-spine MRI. This revealed a T3-4 vertebral body lesion which had invaded the spinal canal was compressing the spinal cord. He was treated with Decadron and underwent emergent spinal cord decompression on 5/7/95. He recovered some lower extremity strength following surgery. Pathological analysis of the tumor was consistent with adenocarcinoma. His primary tumor was not located despite chest-abdominal-pelvic CT scans, and a GI and GU workup which included cystoscopy and endoscopy. He received 3000cGy of XRT and died 5 months after presentation.",
 MRI T-L spine - L2 conus medullaris lesion and syndrome secondary to Schistosomiasis., Neurology, MRI T-L Spine - Schistosomiasis ,"CC: ,Paraplegia.,HX:, This 32 y/o RHF had been performing missionary work in Jos, Nigeria for several years and delivered her 4th child by vaginal delivery on 4/10/97. The delivery was induced with Pitocin, but was otherwise uncomplicated. For the first 4 days post-partum she noted clear liquid diarrhea without blood and minor abdominal discomfort. This spontaneous resolved without medical treatment. The second week post-partum she had 4-5 days of sinusitis, purulent nasal discharge and facial pain. She was otherwise well until 5/4/97 when stationed in a more rural area of Nigeria, she noted a dull ache in both knees (lateral to the patellae) and proximal tibia, bilaterally. The pain was not relieved by massage and seemed more bothersome when seated or supine. She had no sensory loss at the time.,On 5/6/97, she awakened to pain radiating down her knees to her anterior tibia. Over the next few hours the pain radiated circumferentially around both calves, and involved the soles of her feet and posterior BLE to her buttocks. Rising from bed became a laborious task and she required assistance to walk to the bathroom. Ibuprofen provided minimal analgesia. By evening the sole of one foot was numb.,She awoke the next morning, 5/9/97, with ""pins & needles"" sensation in BLE up to her buttocks. She was given Darvocet for analgesia and took an airplane back to the larger city she was based in. During the one hour flight her BLE weakness progressed to a non-weight bearing state (i.e. she could not stand). Local evaluation revealed 3/3 proximal and 4/4 distal BLE weakness. She had a sensory level to her waist on PP and LT testing. She also had mild lumbar back pain. Local laboratory evaluation: WBC 12.7, ESR 10. She was presumed to have Guillain-Barre syndrome and was placed on Solu-Cortef 1000mg qd and Sandimmune IV IgG 12.0 g.,On 5/10/97, she was airlifted to Geneva, Switzerland. Upon arrival there she had total anesthesia from the feet up to the inguinal region, bilaterally. There was flaccid areflexic paralysis of BLE and she was unable to void or defecate. Straight catheterization of the bladder revealed a residual volume of 1000cc. On 5/12/ CSF analysis revealed: Protein 1.5g/l, Glucose 2.2mmol/l, WBC 92 (O PMNS, 100% Lymphocytes), RBC 70, Clear CSF, bacterial-fungal-AFB-cultures were negative. Broad spectrum antibiotics and Solu-Medrol 1g IV qd were started. MRI T-L-spine, 5/12/97 revealed an intradural T12-L1 lesion that enhanced minimally with gadolinium and was associated with spinal cord edema in the affected area. MRI Brain, 5/12/97, was unremarkable and showed no evidence of demyelinating disease. HIV, HTLV-1, HSV, Lyme, EBV, Malaria and CMV serological titers were negative. On 5/15/97 the Schistosomiasis Mekongi IFAT serological titer returned positive at 1:320 (normal<1:80). 5/12/97 CSF Schistosomiasis Mekongi IFAT and ELISA were negative. She was then given a one day course of Praziquantel 3.6g total in 3 doses; and started on Prednisone 60 mg po qd; the broad spectrum antibiotics and Solu-Medrol were discontinued.,On 5/22/97, a rectal biopsy was performed to evaluate parasite eradication. The result came back positive for ova and granulomata after she had left for UIHC. The organism was not speciated. 5/22/97 CSF schistosomiasis ELISA and IFAT titers were positive at 1.09 and 1:160, respectively. These titers were not known when she initially arrived at UIHC.,Following administration of Praziquantel, she regained some sensation in BLE but the paraplegia, and urinary retention remained.,MEDS:, On 5/24/97 UIHC arrival: Prednisone 60mg qd, Zantac 50 IV qd, Propulsid 20mg tid, Enoxaparin 20mg qd.,PMH:, 1)G4P4.,FHX:, unremarkable.,SHX: ,Missionary. Married. 4 children ( ages 7,5,3,6 weeks).,EXAM:, BP110/70, HR72, RR16, 35.6C,MS: A&O to person, place and time. Speech fluent and without dysarthria. Lucid thought process.,CN: unremarkable.,Motor: 5/5 BUE strength. Lower extremities: 1/1 quads and hamstrings, 0/0 distally.,Sensory: Decreased PP/LT/VIB from feet to inguinal regions, bilaterally. T12 sensory level to temperature (ice glove).,Coord: normal FNF.,Station/Gait: not done.,Reflexes: 2/2 BUE. 0/0 BLE. No plantar responses, bilaterally.,Rectal: decreased to no rectal tone. Guaiac negative.,Other: No Lhermitte's sign. No paraspinal hypertonicity noted. No vertebral tenderness.,Gen exam: Unremarkable.,COURSE:, MRI T-L-spine, 5/24/97, revealed a 6 x 8 x 25 soft tissue mass at the L1 level posterior to the tip of the conus medullaris and extending into the canal below that level. This appeared to be intradural. There was mild enhancement. There was more enhancement along the distal cord surface and cauda equina. The distal cord had sign of diffuse edema. She underwent exploratory and decompressive laminectomy on 5/27/97, and was retreated with a one day course of Praziquantel 40mg/kg/day. Praziquantel is reportedly only 80% effective at parasite eradication.,She continued to reside on the Neurology/Neurosurgical service on 5/31/97 and remained paraplegic.",
" The thoracic spine was examined in the AP, lateral and swimmer's projections.", Neurology, MRI T-Spine - 1 ,"EXAM:  ,Thoracic Spine.,REASON FOR EXAM: , Injury.,INTERPRETATION: , The thoracic spine was examined in the AP, lateral and swimmer's projections.  There is mild chronic-appearing anterior wedging of what is believed to represent T11 and 12 vertebral bodies.  A mild amount of anterior osteophytic lipping is seen involving the thoracic spine.  There is a suggestion of generalized osteoporosis.  The intervertebral disc spaces appear generally well preserved.,The pedicles appear intact.,IMPRESSION:,1. Mild chronic-appearing anterior wedging of what is believed to represent the T11 and 12 vertebral bodies.,2. Mild degenerative changes of the thoracic spine.,3. Osteoporosis.","neurology, thoracic spine, swimmer's projections, osteoporosis, osteophytic lipping, anterior wedging, vertebral bodies, thoracic, spine, "
 MRI of lumbar spine without contrast to evaluate chronic back pain., Neurology, MRI of Lumbar Spine w/o Contrast ,"EXAM: , MRI of lumbar spine without contrast.,HISTORY:,  A 24-year-old female with chronic back pain.,TECHNIQUE: , Noncontrast axial and sagittal images were acquired through the lumbar spine in varying degrees of fat and water weighting.,FINDINGS: , The visualized cord is normal in signal intensity and morphology with conus terminating in proper position.  Visualized osseous structures are normal in marrow signal intensity and morphology without evidence for fracture/contusion, compression deformity, or marrow replacement process.  There are no paraspinal masses.,Disc heights, signal, and vertebral body heights are maintained throughout the lumbar spine.,L5-S1:  Central canal, neural foramina are patent.,L4-L5:  Central canal, neural foramina are patent.,L3-L4:  Central canal, neural foramen is patent.,L2-L3:  Central canal, neural foramina are patent.,L1-L2:  Central canal, neural foramina are patent.,The visualized abdominal aorta is normal in caliber.  Incidental note has been made of multiple left-sided ovarian, probable physiologic follicular cysts.,IMPRESSION: , No acute disease in the lumbar spine.","neurology, mri, central canal, noncontrast, abdominal aorta, axial, back pain, contrast, follicular cysts, images, lumbar spine, morphology, neural foramina, sagittal, signal intensity, without contrast, mri of lumbar spine, mri of lumbar, lumbar, foramina, neural, patent, spine"
" MRI of the Cervical, Thoracic, and Lumbar Spine", Neurology, MRI Spine ,"INTERPRETATION: , MRI of the cervical spine without contrast showed normal vertebral body height and alignment with normal cervical cord signal.  At C4-C5, there were minimal uncovertebral osteophytes with mild associated right foraminal compromise.  At C5-C6, there were minimal diffuse disc bulge and uncovertebral osteophytes with indentation of the anterior thecal sac, but no cord deformity or foraminal compromise.  At C6-C7, there was a central disc herniation resulting in mild deformity of the anterior aspect of the cord with patent neuroforamina.  MRI of the thoracic spine showed normal vertebral body height and alignment.  There was evidence of disc generation, especially anteriorly at the T5-T6 level.  There was no significant central canal or foraminal compromise.  Thoracic cord normal in signal morphology.  MRI of the lumbar spine showed normal vertebral body height and alignment.  There is disc desiccation at L4-L5 and L5-S1 with no significant central canal or foraminal stenosis at L1-L2, L2-L3, and L3-L4.  There was a right paracentral disc protrusion at L4-L5 narrowing of the right lateral recess.  The transversing nerve root on the right was impinged at that level.  The right foramen was mildly compromised.  There was also a central disc protrusion seen at the L5-S1 level resulting in indentation of the anterior thecal sac and minimal bilateral foraminal compromise.,IMPRESSION: , Overall impression was mild degenerative changes present in the cervical, thoracic, and lumbar spine without high-grade central canal or foraminal narrowing.  There was narrowing of the right lateral recess at L4-L5 level and associated impingement of the transversing nerve root at that level by a disc protrusion.  This was also seen on a prior study.,","neurology, cervical spine, mri, cervical, thoracic, lumbar, transversing nerve root, vertebral body height, vertebral body, disc protrusion, foraminal compromise, central, foraminal, disc, spineNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" MRI L-spine - History of progressive lower extremity weakness, right frontal glioblastoma with lumbar subarachnoid seeding.", Neurology, MRI L-Spine - Subarachnoid Seeding ,"CC:, Progressive lower extremity weakness.,HX: ,This 52y/o RHF had a h/o right frontal glioblastoma multiforme (GBM) diagnosed by brain biopsy/partial resection, on 1/15/1991. She had been healthy until 1/6/91, when she experienced a generalized tonic-clonic type seizure during the night. She subsequently underwent an MRI brain scan and was found to have a right frontal enhancing lesion in the mesial aspect of the right frontal lobe at approximately the level of the coronal suture. There was minimal associated edema and no mass effect. Following extirpation of the tumor mass, she underwent radioactive Iodine implantation and 6020cGy radiation therapy in 35 fractions. In 11/91 she received BCNU and Procarbazine chemotherapy protocols. This was followed by four courses of 5FU/Carboplatin (3/92, 6/92, 9/92 ,10/92) chemotherapy.,On 10/12/92 she presented for her 4th course of 5FU/Carboplatin and complained of non-radiating dull low back pain, and proximal lower extremity weakness, but was still able to ambulate. She denied any bowel/bladder difficulty.,PMH: ,s/p oral surgery for wisdom tooth extraction.,FHX/SHX: ,1-2 ppd cigarettes. rare ETOH use. Father died of renal CA.,MEDS: ,Decadron 12mg/day.,EXAM: ,Vitals unremarkable.,MS: Unremarkable.,Motor: 5/5 BUE, LE: 4+/5- prox, 5/5 distal to hips. Normal tone and muscle bulk.,Sensory: No deficits appreciated.,Coord: Unremarkable.,Station: No mention in record of being tested.,Gait: Mild difficulty climbing stairs.,Reflexes: 1+/1+ throughout and symmetric. Plantar responses were down-going bilaterally.,INITIAL IMPRESSION:, Steroid myopathy. Though there was enough of a suspicion of ""drop"" metastasis that an MRI of the L-spine was obtained.,COURSE:, The MRI L-spine revealed fine linear enhancement along the dorsal aspect of the conus medullaris, suggestive of subarachnoid seeding of tumor. No focal mass or cord compression was visualized. CSF examination revealed: 19RBC, 22WBC, 17 Lymphocytes, and 5 histiocytes, Glucose 56, Protein 150. Cytology (negative). The patient was discharged home on 10/17/92, but experienced worsening back pain and lower extremity weakness and became predominantly wheelchair bound within 4 months. She was last seen on 3/3/93 and showed signs of worsening weakness (left hemiplegia: R > L) as her tumor grew and spread. She then entered a hospice.","neurology, glioblastoma multiforme, gbm, steroid myopathy, hemiplegia, progressive lower extremity weakness, mri l spine, lower extremity weakness, frontal glioblastoma, subarachnoid seeding, lower extremity, glioblastoma, subarachnoid, spine, mri, lower, weakness, "
 MRI Spine - T12-L5 epidural lipoma and thoracic spinal cord infarction vs. transverse myelitis., Neurology, MRI Spine - Epidural Lipoma ,"CC:, Progressive lower extremity weakness.,HX: ,This 54 y/o RHF presented on 7/3/93 with a 2 month history of lower extremity weakness. She was admitted to a local hospital on 5/3/93 for a 3 day h/o of progressive BLE weakness associated with incontinence and BLE numbness. There was little symptom of upper extremity weakness at that time, according to the patient. Her evaluation was notable for a bilateral L1 sensory level and 4/4 strength in BLE. A T-L-S Spine MRI revealed a T4-6 lipomatosis with anterior displacement of the cord without cord compression. CSF analysis yielded: opening pressure of 14cm H20, protein 88, glucose 78, 3 lymphocytes and 160 RBC, no oligoclonal bands or elevated IgG index, and negative cytology. Bone marrow biopsy was negative. B12, Folate, and Ferritin levels were normal. CRP 5.2 (elevated). ANA was positive at 1:5,120 in speckled pattern. Her hospital course was complicated by deep venous thrombosis, which recurred after heparin was stopped to do the bone marrow biopsy. She was subsequently placed on Coumadin. EMG/NCV testing revealed "" lumbosacral polyradiculopathy with axonal degeneration and nerve conduction block."" She was diagnosed with atypical Guillain-Barre vs. polyradiculopathy and received a single course of Decadron; and no plasmapheresis or IV IgG. She was discharged home o 6/8/93.,She subsequently did not improve and after awaking from a nap on her couch the day of presentation, 7/3/93, she found she was paralyzed from the waist down. There was associated mild upper lumbar back pain without radiation. She had had no bowel movement or urination since that time. She had no recent trauma, fever, chills, changes in vision, dysphagia or upper extremity deficit.,MEDS:, Coumadin 7.5mg qd, Zoloft 50mg qd, Lithium 300mg bid.,PMH:, 1) Bi-polar Affective Disorder, dx 1979 2) C-section.,FHX:, Unremarkable.,SHX:, Denied Tobacco/ETOH/illicit drug use.,EXAM: ,BP118/64, HR103, RR18, Afebrile.,MS: ,A&O to person, place, time. Speech fluent without dysarthria. Lucid thought processes.,CN: ,Unremarkable.,MOTOR:, 5/5 strength in BUE. Plegic in BLE. Flaccid muscle tone.,SENSORY:, L1 sensory level (bilaterally) to PP and TEMP, without sacral sparing. Proprioception was lost in both feet.,CORD: ,Normal in BUE.,Reflexes were 2+/2+ in BUE. They were not elicited in BLE. Plantar responses were equivocal, bilaterally.,RECTAL: ,Poor rectal tone. stool guaiac negative. She had no perirectal sensation.,COURSE:, CRP 8.8 and ESR 76. FVC 2.17L. WBC 1.5 (150 bands, 555 neutrophils, 440 lymphocytes and 330 monocytes), Hct 33%, Hgb 11.0, Plt 220K, MCV 88, GS normal except for slightly low total protein (8.0). LFT were normal. Creatinine 1.0. PT and PTT were normal. ABCG 7.46/25/79/96% O2Sat. UA notable for 1+ proteinuria. EKG normal.,MRI L-spine, 7/3/93, revealed an area of abnormally increased T2 signal extending from T12 through L5. This area causes anterior displacement of the spinal cord and nerve roots. The cauda equina are pushed up against the posterior L1 vertebral body. There bilaterally pulmonary effusions. There is also abnormally increased T2 signal in the center of the spinal cord extending from the mid thoracic level through the conus. In addition, the Fila Terminale appear thickened. There is increased signal in the T3 vertebral body suggestion a hemangioma. The findings were felt consistent with a large epidural lipoma displacing the spinal cord anteriorly. there also appeared spinal cord swelling and increased signal within the spinal cord which suggests an intramedullary process.,CSF analysis revealed: protein 1,342, glucose 43, RBC 4,900, WBC 9. C3 and C$ complement levels were 94 and 18 respectively (normal) Anticardiolipin antibodies were negative. Serum Beta-2 microglobulin was elevated at 2.4 and 3.7 in the CSF and Serum, respectively. It was felt the patient had either a transverse myelitis associated with SLE vs. partial cord infarction related to lupus vasculopathy or hypercoagulable state. She was place on IV Decadron. Rheumatology felt that a diagnosis of SLE was likely. Pulmonary effusion analysis was consistent with an exudate. She was treated with plasma exchange and place on Cytoxan.,On 7/22/93 she developed fever with associated proptosis and sudden loss of vision, OD. MRI Brain, 7/22/93, revealed a 5mm thick area of intermediate signal adjacent to the posterior aspect of the right globe, possibly representing hematoma. Ophthalmology felt she had a central retinal vein occlusion; and it was surgically decompressed.,She was placed on prednisone on 8/11/93 and Cytoxan was started on 8/16/93. She developed a headache with meningismus on 8/20/93. CSF analysis revealed: protein 1,002, glucose2, WBC 8,925 (majority were neutrophils). Sinus CT scan negative. She was placed on IV Antibiotics for presumed bacterial meningitis. Cultures were subsequently negative. She spontaneously recovered. 8/25/93, cisternal tap CSF analysis revealed: protein 126, glucose 35, WBC 144 (neutrophils), RBC 95, Cultures negative, cytology negative. MRI Brain scan revealed diffuse leptomeningeal enhancement in both brain and spinal canal.,DSDNA negative. She developed leukopenia in 9/93, and she was switched from Cytoxan to Imuran. Her LFT's rose and the Imuran was stopped and she was placed back on prednisone.,She went on to have numerous deep venous thrombosis while on Coumadin. This required numerous hospital admissions for heparinization. Anticardiolipin antibodies and Protein C and S testing was negative.",
 MRI L-S-Spine for Cauda Equina Syndrome secondary to L3-4 disc herniation - Low Back Pain (LBP) with associated BLE weakness., Neurology, MRI L-S Spine - Cauda Equina Syndrome ,"CC: ,Low Back Pain (LBP) with associated BLE weakness.,HX:, This 75y/o RHM presented with a 10 day h/o progressively worsening LBP. The LBP started on 12/3/95; began radiating down the RLE, on 12/6/95; then down the LLE, on 12/9/95. By 12/10/95, he found it difficult to walk. On 12/11/95, he drove himself to his local physician, but no diagnosis was rendered. He was given some NSAID and drove home. By the time he got home he had great difficulty walking due to LBP and weakness in BLE, but managed to feed his pets and himself. On 12/12/95 he went to see a local orthopedist, but on the way to his car he crumpled to the ground due to BLE weakness and LBP pain. He also had had BLE numbness since 12/11/95. He was evaluated locally and an L-S-Spine CT scan and L-S Spine X-rays were ""negative."" He was then referred to UIHC.,MEDS: ,SLNTC, Coumadin 4mg qd, Propranolol, Procardia XL, Altace, Zaroxolyn.,PMH: ,1) MI 11/9/78, 2) Cholecystectomy, 3) TURP for BPH 1980's, 4) HTN, 5) Amaurosis Fugax, OD, 8/95 (Mayo Clinic evaluation--TEE (-), but Carotid Doppler (+) but ""non-surgical"" so placed on Coumadin).,FHX:, Father died age 59 of valvular heart disease. Mother died of DM. Brother had CABG 8/95.,SHX:, retired school teacher. 0.5-1.0 pack cigarettes per day for 60 years.,EXAM:, BP130.56, HR68, RR16, Afebrile.,MS: A&O to person, place, time. Speech fluent without dysarthria. Lucid. Appeared uncomfortable.,CN: Unremarkable.,MOTOR: 5/5 strength in BUE. Lower extremity strength: Hip flexors & extensors 4-/4-, Hip abductors 3+/3+, Hip adductors 5/5, Knee flexors & extensors 4/4-, Ankle flexion 4-/4-, Tibialis Anterior 2/2-, Peronei 3-/3-. Mild atrophy in 4 extremities. Questionable fasciculations in BLE. Spasms illicited on striking quadriceps with reflex hammer (? percussion myotonia). No rigidity and essential normal muscle tone on passive motion.,SENSORY: Decreased vibratory sense in stocking distribution from toes to knees in BLE (worse on right). No sensory level. PP/LT/TEMP testing unremarkable.,COORD: Normal FNF-RAM. Slowed HKS due to weakness.,Station: No pronator drift. Romberg testing not done.,Gait: Unable to stand.,Reflexes: 2/2 BUE. 1/trace patellae, 0/0 Achilles. Plantar responses were flexor, bilaterally. Abdominal reflex was present in all four quadrants. Anal reflex was illicited from all four quadrants. No jaw jerk or palmomental reflexes illicited.,Rectal: normal rectal tone, guaiac negative stool.,GEN EXAM: Bilateral Carotid Bruits, No lymphadenopathy, right inguinal hernia, rhonchi and inspiratory wheeze in both lung fields.,COURSE: ,WBC 11.6, Hgb 13.4, Hct 38%, Plt 295. ESR 40 (normal 0-14), CRP 1.4 (normal <0.4), INR 1.5, PTT 35 (normal), Creatinine 2.1, CK 346. EKG normal. The differential diagnosis included Amyotrophy, Polymyositis, Epidural hematoma, Disc Herniation and Guillain-Barre syndrome. An MRI of the lumbar spine was obtained, 12/13/95. This revealed an L3-4 disc herniation extending inferiorly and behind the L4 vertebral body. This disc was located more on the right than on the left , compromised the right neural foramen, and narrowed the spinal canal. The patient underwent a L3-4 laminectomy and diskectomy and subsequently improved. He was never seen in follow-up at UIHC.","neurology, ble weakness, carotid doppler, disc herniation, guillain-barre syndrome, amyotrophy, polymyositis, epidural hematoma, mri l s spine, cauda equina syndrome, flexors & extensors, cauda equina, herniation, cauda, equina, extensors, reflexes, mri, hip, flexors, weakness, "
 MRI of the brain without contrast to evaluate daily headaches for 6 months in a 57-year-old., Neurology, MRI of Brain w/o Contrast. ,"EXAM: , MRI of the brain without contrast.,HISTORY: , Daily headaches for 6 months in a 57-year-old.,TECHNIQUE:  ,Noncontrast axial and sagittal images were acquired through the brain in varying degrees of fat and water weighting.,FINDINGS: , The brain is normal in signal intensity and morphology for age.  There are no extraaxial fluid collections.  There is no hydrocephalus/midline shift.  Posterior fossa, 7th and 8th nerve complexes and intraorbital contents are within normal limits.  The normal vascular flow volumes are maintained.  The paranasal sinuses are clear.,Diffusion images demonstrate no area of abnormally restricted diffusion that suggests acute infarct.,IMPRESSION: , Normal MRI brain.  Specifically, no findings to explain the patient's headaches are identified.","neurology, mri, diffusion, posterior fossa, axial, brain, contrast, extraaxial, flow, fluid collections, headaches, hydrocephalus, intraorbital, morphology, paranasal, sagittal, sinuses, vascular, weighting, without contrast, mri of the brain, noncontrast, "
 MRI Head W&WO Contrast., Neurology, MRI Head ,"EXAM:,  MRI Head W&WO Contrast.,REASON FOR EXAM:,  Dyspnea.,COMPARISON:,  None. ,TECHNIQUE:,  MRI of the head performed without and with 12 ml of IV gadolinium (Magnevist).  ,INTERPRETATION: , There are no abnormal/unexpected foci of contrast enhancement.  There are no diffusion weighted signal abnormalities.  There are minimal, predominantly periventricular, deep white matter patchy foci of FLAIR/T2 signal hyperintensity, the rest of the brain parenchyma appearing unremarkable in signal.  The ventricles and sulci are prominent, but proportionate.  Per T2 weighted sequence, there is no hyperdense vascularity.  There are no calvarial signal abnormalities.  There is no significant mastoid air cell fluid.  No significant sinus mucosal disease per MRI.,IMPRESSION:,1.  No abnormal/unexpected foci of contrast enhancement; specifically, no evidence for metastases or masses.  ,2.  No evidence for acute infarction. ,3.  Mild, scattered, patchy, chronic small vessel ischemic disease changes. ,4.  Diffuse cortical volume loss, consistent with patient's age. ,5.  Preliminary report was issued at the time of dictation.  ,","neurology, dyspnea, mri of the head, foci of contrast, patchy foci, white matter, w&wo contrast, mri head, mri"
 MRI head without contrast., Neurology, MRI Head - 1 ,"EXAM:,  MRI head without contrast.,REASON FOR EXAM: , Severe headaches.,INTERPRETATION:,  Imaging was performed in the axial and sagittal planes using numerous pulse sequences at 1 tesla.  Correlation is made with the head CT of 4/18/05.,On the diffusion sequence, there is no significant bright signal to indicate acute infarction.  There is a large degree of increased signal involving the periventricular white matter extending around to the subcortical regions in symmetrical fashion consistent with chronic microvascular ischemic disease.  There is mild chronic ischemic change involving the pons bilaterally, slightly greater on the right, and when correlating with the recent scan, there is an old tiny lacunar infarct of the right brachium pontis measuring roughly 4 mm in size.  There are prominent perivascular spaces of the lenticulostriate distribution compatible with the overall degree of moderate to moderately advanced atrophy.  There is an old moderate-sized infarct of the mid and lateral aspects of the right cerebellar hemisphere as seen on the recent CT scan.  This involves mostly the superior portion of the hemisphere in the superior cerebellar artery distribution.  No abnormal mass effect is identified.  There are no findings to suggest active hydrocephalus.  No abnormal extra-axial collection is identified.  There is normal flow void demonstrated in the major vascular systems.,The sagittal sequence demonstrates no Chiari malformation.  The region of the pituitary/optic chiasm grossly appears normal.  The mastoids and paranasal sinuses are clear.,IMPRESSION:,1.  No definite acute findings identified involving the brain.,2.  There is prominent chronic cerebral ischemic change as described with mild chronic pontine ischemic changes.  There is an old moderate-sized infarct of the superior portion of the right cerebellar hemisphere.,3.  Moderate to moderately advanced atrophy.","neurology, severe headaches, chiari malformation, cerebral ischemic change, mri head without contrast, cerebellar hemisphere, superior portion, mri head, cerebellar, infarction, ischemic"
 MRI C-spine: C4-5 Transverse Myelitis., Neurology, MRI C-spine ,"CC:, Left hemibody numbness.,HX:, This 44y/o RHF awoke on 7/29/93 with left hemibody numbness without tingling, weakness, ataxia, visual or mental status change. She had no progression of her symptoms until 7/7/93 when she notices her right hand was stiff and clumsy. She coincidentally began listing to the right when walking. She denied any recent colds/flu-like illness or history of multiple sclerosis. She denied symptoms of Lhermitte's or Uhthoff's phenomena.,MEDS:, none.,PMH:, 1)Bronchitis twice in past year (last 2 months ago).,FHX:, Father with HTN and h/o strokes at ages 45 and 80; now 82 years old. Mother has DM and is age 80.,SHX:, Denies Tobacco/ETOH/illicit drug use.,EXAM:, BP112/76 HR52 RR16 36.8C,MS: unremarkable.,CN: unremarkable.,Motor: 5/5 strength throughout except for slowing of right hand fine motor movement. There was mildly increased muscle tone in the RUE and RLE.,Sensory: decreased PP below T2 level on left and some dysesthesias below L1 on the left.,Coord: positive rebound in RUE.,Station/Gait: unremarkable.,Reflexes: 3+/3 throughout all four extremities. Plantar responses were flexor, bilaterally.,Rectal exam not done.,Gen exam reportedly ""normal."",COURSE:, GS, CBC, PT, PTT, ESR, Serum SSA/SSB/dsDNA, B12 were all normal. MRI C-spine, 7/145/93, showed an area of decreased T1 and increased T2 signal at the C4-6 levels within the right lateral spinal cord. The lesion appeared intramedullary and eccentric, and peripherally enhanced with gadolinium. Lumbar puncture, 7/16/93, revealed the following CSF analysis results: RBC 0, WBC 1 (lymphocyte), Protein 28mg/dl, Glucose 62mg/dl, CSF Albumin 16 (normal 14-20), Serum Albumin 4520 (normal 3150-4500), CSF IgG 4.1mg/dl (normal 0-6.2), CSF IgG, % total CSF protein 15% (normal 1-14%), CSF IgG index 1.1 (normal 0-0.7), Oligoclonal bands were present. She was discharged home.,The patient claimed her symptoms resolved within one month. She did not return for a scheduled follow-up MRI C-spine.","neurology, mri c-spine, c-spine, lhermitte's, myelitis, transverse myelitis, uhthoff's, ataxia, clumsy, hemibody numbness, mental status, numbness, tingling, weakness, mri c spine, hemibody, mri, spine, csf, "
 MRI Brain: Subacute right thalamic infarct., Neurology, MRI Brain: Thalamic Infarct ,"CC:, Left hemiplegia.,HX: , A 58 y/o RHF awoke at 1:00AM on 10/23/92 with left hemiplegia and dysarthria which cleared within 15 minutes. She was seen at a local ER and neurological exam and CT Brain were reportedly unremarkable. She was admitted locally. She then had two more similar spells at 3AM and 11AM with resolution of the symptoms within an hour. She was placed on IV Heparin following the 3rd episode and was transferred to UIHC. She had not been taking ASA.,PMH:, 1)HTN. 2) Psoriasis.,SHX:, denied ETOH/Tobacco/illicit drug use.,FHX:, Unknown.,MEDS:, Heparin only.,EXAM:, BP160/90 HR145 (supine). BP105/35 HR128 (light headed, standing) RR12 T37.7C,MS: Dysarthria only. Lucid thought process.,CN: left lower facial weakness only.,Motor: mild left hemiparesis with normal muscle bulk. Mildly increased left sided muscle tone.,Sensory: unremarkable.,Coordination: impaired secondary to weakness on left. Otherwise unremarkable.,Station: left pronator drift. Romberg testing not done.,Gait: not tested.,Reflexes: symmetric; 2+ throughout.,Gen Exam: CV: Tachycardic without murmur.,COURSE:, The patients signs and symptoms worsening during and after standing to check orthostatic blood pressures. She was immediately placed in a reverse Trendelenburg position and given IV fluids. Repeat neurologic exam at 5PM on the day of presentation revealed a return to the initial presentation of signs and symptoms. PT/PTT/GS/CBC/ABG were unremarkable. EKG revealed sinus tachycardia with rate dependent junctional changes. CXR unremarkable. MRI Brain was obtained and showed an evolving right thalamic/lentiform nucleus infarction best illustrated by increased signal on the Proton density weighted images. Over the ensuing days of admission she had significant fluctuations of her BP (200mmHG to 140mmHG systolic). Her symptoms worsened with falls in BP. Her BP was initially controlled with esmolol or labetalol. Renal Ultrasound, abdominal/pelvic CT, renal function scan, serum and urine osmolality, urine catecholamines/metanephrine studies were unremarkable. Carotid doppler study revealed 0-15%BICA stenosis and antegrade vertebral artery flow, bilaterally. Transthoracic echocardiogram was unremarkable. Cerebral angiogram was performed to r/o vasculitis. This revealed narrowing of the M1 segment of the right MCA. This was thought secondary to atherosclerosis and not vasculitis. She was discharged on ASA, Procardia XL, and Labetalol.","neurology, mri brain, ct brain, heparin, dysarthria, hemiplegia, infarct, neurological exam, thalamic, thalamic infarct, mri, brain, "
 MRI C-spine to evaluate right shoulder pain - C5-6 disk herniation., Neurology, MRI C-Spine - C5-6 Disk Herniation ,"CC:, Right shoulder pain.,HX: ,This 46 y/o RHF presented with a 4 month history of right neck and shoulder stiffness and pain. The symptoms progressively worsened over the 4 month course. 2 weeks prior to presentation she began to develop numbness in the first and second fingers of her right hand and RUE pain. The later was described as a throbbing pain. She also experienced numbness in both lower extremities and pain in the coccygeal region. The pains worsened at night and impaired sleep. She denied any visual change, bowel or bladder difficulties and symptoms involving the LUE. She occasionally experienced an electric shock like sensation shooting down her spine when flexing her neck (Lhermitte's phenomena). She denied any history of neck/back/head trauma.,She had been taking Naprosyn with little relief.,PMH: ,1) Catamenial Headaches. 2) Allergy to Macrodantin.,SHX/FHX:, Smokes 2ppd cigarettes.,EXAM: ,Vital signs were unremarkable.,CN: unremarkable.,Motor: full strength throughout. Normal tone and muscle bulk.,Sensory: No deficits on LT/PP/VIB/TEMP/PROP testing.,Coord/Gait/Station: Unremarkable.,Reflexes: 2/2 in BUE except 2+ at left biceps. 1+/1+BLE except an absent right ankle reflex.,Plantar responses were flexor bilaterally. Rectal exam: normal tone.,IMPRESSION:, C-spine lesion.,COURSE: ,MRI C-spine revealed a central C5-6 disk herniation with compression of the spinal cord at that level. EMG/NCV showed normal NCV, but 1+ sharps and fibrillations in the right biceps (C5-6), brachioradialis (C5-6), triceps (C7-8) and teres major; and 2+ sharps and fibrillations in the right pronator terres. There was increased insertional activity in all muscles tested on the right side. The findings were consistent with a C6-7 radiculopathy.,The patient subsequently underwent C5-6 laminectomy and her symptoms resolved.","neurology, shoulder pain, stiffness, numbness, lhermitte's phenomena, c-spine lesion, disk herniation, mri c spine, reflexes, biceps, mri, disk, shoulder, spine, herniation,"
 MRI report Cervical Spine (Chiropractic Specific), Neurology, MRI Cervical Spine - Chiropractic Specific ,"FINDINGS:,Normal foramen magnum.,Normal brainstem-cervical cord junction. There is no tonsillar ectopia. Normal clivus and craniovertebral junction. Normal anterior atlantoaxial articulation.,C2-3: There is disc desiccation but no loss of disc space height, disc displacement, endplate spondylosis or uncovertebral joint arthrosis. Normal central canal and intervertebral neural foramina.,C3-4: There is disc desiccation with a posterior central disc herniation of the protrusion type. The small posterior central disc protrusion measures 3 x 6mm (AP x transverse) in size and is producing ventral thecal sac flattening. CSF remains present surrounding the cord. The residual AP diameter of the central canal measures 9mm. There is minimal right-sided uncovertebral joint arthrosis but no substantial foraminal compromise.,C4-5: There is disc desiccation, slight loss of disc space height with a right posterior lateral pre-foraminal disc osteophyte complex with right-sided uncovertebral and apophyseal joint arthrosis. The disc osteophyte complex measures approximately 5mm in its AP dimension. There is minimal posterior annular bulging measuring approximately 2mm. The AP diameter of the central canal has been narrowed to 9mm. CSF remains present surrounding the cord. There is probable radicular impingement upon the exiting right C5 nerve root.,C5-6: There is disc desiccation, moderate loss of disc space height with a posterior central disc herniation of the protrusion type. The disc protrusion measures approximately 3 x 8mm (AP x transverse) in size. There is ventral thecal sac flattening with effacement of the circumferential CSF cleft. The residual AP diameter of the central canal has been narrowed to 7mm. Findings indicate a loss of the functional reserve of the central canal but there is no cord edema. There is bilateral uncovertebral and apophyseal joint arthrosis with moderate foraminal compromise.,C6-7: There is disc desiccation, mild loss of disc space height with 2mm of posterior annular bulging. There is bilateral uncovertebral and apophyseal joint arthrosis (left greater than right) with probable radicular impingement upon the bilateral exiting C7 nerve roots.,C7-T1, T1-2: There is disc desiccation with no disc displacement. Normal central canal and intervertebral neural foramina.,T3-4: There is disc desiccation with minimal 2mm posterior annular bulging but normal central canal and CSF surrounding the cord.,IMPRESSION:,Multilevel degenerative disc disease with uncovertebral joint arthrosis with foraminal compromise as described above.,C3-4 posterior central disc herniation of the protrusion type but no cord impingement.,C4-5 right posterior lateral disc osteophyte complex with right-sided uncovertebral and apophyseal joint arthrosis with probable radicular impingement upon the right C5 nerve root.,C5-6 degenerative disc disease with a posterior central disc herniation of the protrusion type producing borderline central canal stenosis with effacement of the circumferential CSF cleft indicating a limited functional reserve of the central canal.,C6-7 degenerative disc disease with annular bulging and osseous foraminal compromise with probable impingement upon the bilateral exiting C7 nerve roots.,T3-4 degenerative disc disease with posterior annular bulging.","neurology, exiting c nerve roots, loss of disc space, posterior central disc herniation, herniation of the protrusion, uncovertebral and apophyseal joint, intervertebral neural foramina, ventral thecal sac, thecal sac flattening, disc osteophyte complex, disc space height, central disc herniation, apophyseal joint arthrosis, posterior annular bulging, degenerative disc disease, posterior central disc, csf cleft, osteophyte complex, radicular impingement, disc disease, central disc, annular bulging, disc desiccation, joint arthrosis, central canal, cervical, degenerative, csf, foraminal, bulging, impingement, protrusion, uncovertebral, arthrosis, canal"
 MRI Cervical Spine without contrast., Neurology, MRI Cervical Spine - 2 ,"EXAM:,MRI SPINAL CORD CERVICAL WITHOUT CONTRAST,CLINICAL:,Right arm pain, numbness and tingling.,FINDINGS:,Vertebral alignment and bone marrow signal characteristics are unremarkable. The C2-3 and C3-4 disk levels appear unremarkable.,At C4-5, broad based disk/osteophyte contacts the ventral surface of the spinal cord and may mildly indent the cord contour. A discrete cord signal abnormality is not identified. There may also be some narrowing of the neuroforamina at this level.,At C5-6, central disk-osteophyte contacts and mildly impresses on the ventral cord contour. Distinct neuroforaminal narrowing is not evident.,At C6-7, mild diffuse disk-osteophyte impresses on the ventral thecal sac and contacts the ventral cord surface. Distinct cord compression is not evident. There may be mild narrowing of the neuroforamina at his level.,A specific abnormality is not identified at the C7-T1 level.,IMPRESSION:,Disk/osteophyte at C4-5 through C6-7 with contact and may mildly indent the ventral cord contour at these levels. Some possible neuroforaminal narrowing is also noted at levels as stated above.","neurology, mri cervical spine, ventral cord contour, cervical spine, spinal cord, cord contour, ventral cord, mri, narrowing, ventral, cord"
 MRI Brain & MRI C-T spine: Multiple hemangioblastoma in Von Hippel Lindau Disease., Neurology, MRI Brain and C-T Spine ,"CC:, Weakness.,HX:, This 30 y/o RHM was in good health until 7/93, when he began experiencing RUE weakness and neck pain. He was initially treated by a chiropractor and, after an unspecified length of time, developed atrophy and contractures of his right hand. He then went to a local neurosurgeon and a cervical spine CT scan, 9/25/92, revealed an intramedullary lesion at C2-3 and an extramedullary lesion at C6-7. He underwent a C6-T1 laminectomy with exploration and decompression of the spinal cord. His clinical condition improved over a 3 month post-operative period, and then progressively worsened. He developed left sided paresthesia and upper extremity weakness (right worse than left). He then developed ataxia, nausea, vomiting, and hyperreflexia. On 8/31/93, MRI C-spine showed diffuse enlargement of the cervical and thoracic spine and multiple enhancing nodules in the posterior fossa. On 9/1/93, he underwent suboccipital craniotomy with tumor excision, decompression, and biopsy which was consistent with hemangioblastoma. His symptoms stabilized and he underwent 5040 cGy in 28 fractions to his brain and 3600 cGy in 20 fractions to his cervical and thoracic spinal cord from 9/93 through 1/19/94.,He was evaluated in the NeuroOncology clinic on 10/26/95 for consideration of chemotherapy. He complained of progressive proximal weakness of all four extremities and dysphagia. He had difficulty putting on his shirt and raising his arms, and he had been having increasing difficulty with manual dexterity (e.g. unable to feed himself with utensils). He had difficulty going down stairs, but could climb stairs. He had no bowel or bladder incontinence or retention.,MEDS:, none.,PMH:, see above.,FHX:, Father with Von Hippel-Lindau Disease.,SHX:, retired truck driver. smokes 1-3 packs of cigarettes per day, but denied alcohol use. He is divorced and has two sons who are healthy. He lives with his mother.,ROS:, noncontributory.,EXAM:, Vital signs were unremarkable.,MS: A&O to person, place and time. Speech fluent and without dysarthria. Thought process lucid and appropriate.,CN: unremarkable exept for 4+/4+ strength of the trapezeii. No retinal hemangioblastoma were seen.,MOTOR: 4-/4- strength in proximal and distal upper extremities. There is diffuse atrophy and claw-hands, bilaterally. He is unable to manipulate hads to any great extent. 4+/4+ strength throughout BLE. There is also diffuse atrophy throughout the lower extremities though not as pronounced as in the upper extremities.,SENSORY: There was a right T3 and left T8 cord levels to PP on the posterior thorax. Decreased LT in throughout the 4 extremities.,COORD: difficult to assess due to weakness.,Station: BUE pronator drift.,Gait: stands without assistance, but can only manage to walk a few steps. Spastic gait.,Reflexes: Hyperreflexic on left (3+) and Hyporeflexic on right (1). Babinski signs were present bilaterally.,Gen exam: unremarkable.,COURSE: ,9/8/95, GS normal. By 11/14/95, he required NGT feeding due to dysphagia and aspiration risk confirmed on cookie swallow studies.MRI Brain, 2/19/96, revealed several lesions (hemangioblastoma) in the cerebellum and brain stem. There were postoperative changes and a cyst in the medulla.,On 10/25/96, he presented with a 1.5 week h/o numbness in BLE from the mid- thighs to his toes, and worsening BLE weakness. He developed decubitus ulcers on his buttocks. He also had had intermittent urinary retention for month, chronic SOB and dysphagia. He had been sitting all day long as he could not move well and had no daytime assistance. His exam findings were consistent with his complaints. He had had no episodes of diaphoresis, headache, or elevated blood pressures. An MRI of the C-T spine, 10/26/96, revealed a prominent cervicothoracic syrinx extending down to T10. There was evidence of prior cervical laminectomy of C6-T1 with expansion of the cord in the thecalsac at that region. Multiple intradural extra spinal nodular lesions (hyperintense on T2, isointense on T1, enhanced gadolinium) were seen in the cervical spine and cisterna magna. The largest of which measures 1.1 x 1.0 x 2.0cm. There are also several large ring enhancing lesions in cerebellum. The lesions were felt to be consistent with hemangioblastoma. No surgical or medical intervention was initiated. Visiting nursing was provided. He has since been followed by his local physician", 
 Left third digit numbness and wrist pain., Neurology, MRI C3 - Cord Compression. ,"CC:, Left third digit numbness and wrist pain.,HX: ,This 44 y/o LHM presented with a one month history of numbness and pain of the left middle finger and wrist. The numbness began in the left middle finger and gradually progressed over the course of a day to involve his wrist as well. Within a few days he developed pain in his wrist. He had been working as a cook and cut fish for prolonged periods of time. This activity exacerbated his symptoms. He denied any bowel/bladder difficulties, neck pain, or weakness. He had no history of neck injury.,SHX/FHX:, 1-2 ppd Cigarettes. Married. Off work for two weeks due to complaints.,EXAM: ,Vital signs unremarkable.,MS:, A & O to person, place, time. Fluent speech without dysarthria.,CN II-XII: ,Unremarkable,MOTOR:, 5/5 throughout, including intrinsic muscles of hands. No atrophy or abnormal muscle tone.,SENSORY:, Decreased PP in third digit of left hand only (palmar and dorsal sides).,STATION/GAIT/COORD:, Unremarkable.,REFLEXES: ,1+ throughout, plantar responses were downgoing bilaterally.,GEN EXAM: ,Unremarkable.,Tinel's manuever elicited pain and numbness on the left. Phalens sign present on the left.,CLINICAL IMPRESSION: ,Left Carpal Tunnel Syndrome,EMG/NCV: ,Unremarkable.,MRI C-spine, 12/1/92: Congenitally small spinal canal is present. Superimposed on this is mild spondylosis and disc bulge at C6-7, C5-6, C4-5, and C3-4. There is moderate central spinal stenosis at C3-4. Intervertebral foramina at these levels appear widely patent.,COURSE:, The MRI findings did not correlate with the clinical findings and history. The patient was placed on Elavil and was subsequently lost to follow-up.",
 MRI cervical spine., Neurology, MRI Cervical Spine - 1 ,"EXAM:,MRI CERVICAL SPINE,CLINICAL:, A57-year-old male. Received for outside consultation is an MRI examination performed on 11/28/2005.,FINDINGS:,Normal brainstem-cervical cord junction. Normal cisterna magna with no tonsillar ectopia. Normal clivus with a normal craniovertebral junction. Normal anterior atlantoaxial articulation.,C2-3: Normal intervertebral disc with no spondylosis or uncovertebral joint arthrosis. Normal central canal and intervertebral neural foramina with no cord or radicular impingement.,C3-4: There is disc desiccation with minimal annular bulging. The residual AP diameter of the central canal measures approximately 10mm. CSF remains present surrounding the cord.,C4-5: There is disc desiccation with endplate spondylosis and mild uncovertebral joint arthrosis. The residual AP diameter of the central canal measures approximately 8mm with effacement of the circumferential CSF cleft producing a borderline central canal stenosis but no cord distortion or cord edema. There is minimal uncovertebral joint arthrosis.,C5-6: There is disc desiccation with minimal posterior annular bulging and a right posterolateral preforaminal disc protrusion measuring approximately 2 x 8mm (AP x transverse). The disc protrusion produces minimal rightward ventral thecal sac flattening but no cord impingement.,C6-7: There is disc desiccation with mild loss of disc space height and posterior endplate spondylosis and annular bulging producing central canal stenosis. The residual AP diameter of the central canal measures 8 mm with effacement of the circumferential CSF cleft. There is a left posterolateral disc-osteophyte complex encroaching upon the left intervertebral neural foramen with probable radicular impingement upon the exiting left C7 nerve root.,C7-T1, T1-2: Minimal disc desiccation with no disc displacement or endplate spondylosis.,IMPRESSION:,Multilevel degenerative disc disease as described above.,C4-5 borderline central canal stenosis with mild bilateral foraminal compromise.,C5-6 disc desiccation with a borderline central canal stenosis and a right posterolateral preforaminal disc protrusion producing thecal sac distortion.,C6-7 degenerative disc disease and endplate spondylosis with a left posterolateral disc-osteophyte complex producing probable neural impingement upon the exiting left C7 nerve root with a borderline central canal stenosis.,Normal cervical cord.","neurology, borderline central canal stenosis, mri cervical spine, borderline central canal, central canal stenosis, degenerative disc, annular bulging, ap diameter, endplate spondylosis, borderline central, canal stenosis, disc desiccation, central canal, cervical, disc, spondylosis, stenosis, cord, canal,"
 MRI brain (Atrophy Left fronto-temporal lobe) and HCT (Left frontal SDH), Neurology, MRI Brain - Progressive Aphasia ,"CC: ,Fall with subsequent nausea and vomiting.,HX: ,This 52 y/o RHM initailly presented in 10/94 with a two year hisotry of gradual progressive difficulty with speech. He ""knew what he wanted to say, but could not say it."",His speech was slurred and he found it difficult to control his tongue. Examination at that time was notable for phonemic paraphasic errors, fair repetition of short phrases with decreased fluency, and slurred nasal speech. He could read, but could not write. He exhibited facial-limb apraxia, decreased gag reflex and positive grasp reflex. He was thougth to have possible Pick's disease vs. Cortical Basal Ganglia Degeneration.,On 11/18/94, he fell and was seen in Neurology clinic on 11/23/94. EEG showed borderline background slowing and no other abnormalities. An MRI on 11/8/94, revealed mild atrophy of the left temporal lobe. Neuropsychological evaluations were obtained on 10/25/94 and 11/8/94. These were consistent with progressive aphasia and apraxia with relative sparing of nonverbal reasoning.,He reported consuming 8 beers on the evening of 1/1/95. On 1/2/95, at 9:30AM, he fell forward while stading in his kitchen and struck his forehead on the counter top, and then struck his occiput on the floor. He subsequently developed nausea and vomiting, tinnitus, vertigo, headache and mild shortness of breath. He was taken to the ETC at UIHC. Skull films were negative and he was treated with IV Compazine and IV fluid hydration and sent home. His nausea and vomiting persisted and he became generally weak. He returned to the ETC at UIHC on 1/5/95. HCT scan revealed a right frontal SDH containing signs of both chronic and acute bleeding.,MEDS:, None.,PMH:, 1)fell in 1990 from 15 feet up and landed on his feet sustaining crush injury to both feet and ankles. He reportedly had brief loss of consciousness with no reported head injury.,2)Progressive aphasia. In 10/93, he was able to draw blue prints and write checks for his family business, 3) Left frontoparietal headache for 1.5 years prior to 10/94. Headaches continue to occur once a week, 4)right ankle fusion 4/94, right ankle fusion pending at present.,FHX:, No neurologic disease in family.,SHX:, Divorced and lives with girlfriend. One child by current girlfriend. He has 3 children with former wife. Smoked more than 15 years ago. Drinks 1-2 beers/day. Former Iron worker.,EXAM: ,BP128/83, HR68, RR18, 36.5C. Supine: BP142/71, HR64; Sitting: BP127/73, HR91 and lightheaded.,MS: Appeared moderately distressed and persistently held his forehead. A&O to person, place and time. Dysarthric and dysphagic. Non-fluent speech and able to say single syllable words such as ""up"" or ""down"". He comprehended speech, but could not repeat or write.,CN: Pupils 4/3.5 decreasing to 2/2 on exposure to light. EOM were full and smooth. Optic disks were flat and without sign of hemorrhage. Moderate facial apraxia, but had intact facial sensation.,Motor: 5/5 strength with normal muscle bulk and tone.,Sensory: no abnormalities noted.,Coord: Decreased RAM in the RUE. He had difficulty mmicking movements and postures with his RUE,Gait: ND.,Station: No truncal ataxia, but he had a slight RUE upward drift.,Reflexes 2/2 BUE, 2+/2+ patellae, 2/2 archilles, and plantar responses were flexor, bilaterally.,Rectal exam was unremarkable. The rest of the General Physical exam was unremarkable.,HEENT: atraumatic normocephalic skull. No carotid bruitts.,COURSE:, PT, PTT, CBC, GS, UA and Skull XR were negative. HCT brain, revealed a left frontal SDH with acute and cronic componenets.,He was markedly orthostatic during the first few days of his hospital stay. He was given a 3 day trial of Florinef, which showed mild to moderate improvement of his symptoms of lightheadedness. This improved still further with a trial of Sigvaris pressure stockings. A second HCT was obtained on 12/10/94 and revealed decreased intensity and sized of the left frontal SDH. He was discharged home.,His ideomotor apraxia worsened by 1/96. He developed seizures and was treated with CBZ. He progressively worsened and his overall condition was marked by aphasia, dysphagia, apraxia, and rigidity. He was last seen in 10/96 and the working diagnosis was CBGD vs. Pick's Disease.",
" MRI Brain: Left Basal Ganglia, Posterior temporal lobe, and Left cerebellar (lacunar) infarctions with Wernickes Aphasia.", Neurology, MRI Brain - Wernicke aphasia ,"CC: ,Difficulty with speech.,HX:, This 72 y/o RHM awoke early on 8/14/95 to prepare to play golf. He felt fine. However, at 6:00AM, on 8/14/95, he began speaking abnormally. His wife described his speech as ""word salad"" and ""complete gibberish."" She immediately took him to a local hospital . Enroute, he was initially able to understand what was spoken to him. By the time he arrived at the hospital at 6:45AM, he was unable to follow commands. His speech was reportedly unintelligible the majority of the time, and some of the health care workers thought he was speaking a foreign language. There were no other symptoms or signs. He had no prior history of cerebrovascular disease. Blood pressure 130/70 and Pulse 82 upon admission to the local hospital on 8/14/95.,Evaluation at the local hospital included: 1)HCT scan revealed an old left putaminal hypodensity, but no acute changes or evidence of hemorrhage, 2) Carotid Duplex scan showed ICA stenosis of 40%, bilaterally. He was placed on heparin and transferred to UIHC on 8/16/95.,In addition, he had noted memory and word finding difficulty for 2 months prior to presentation. He had undergone a gastrectomy 16 years prior for peptic ulcer disease. His local physician found him vitamin B12 deficient and he was placed on vitamin B12 and folate supplementation 2 months prior to presentation. He and his wife felt that this resulted in improvement of his language and cognitive skills.,MEDS:, Heparin IV, Vitamin B12 injection q. week, Lopressor, Folate, MVI.,PMH:, 1)Hypothyroidism (reportedly resolved), 2) Gastrectomy, 3)Vitamin B12 deficiency.,FHX: ,Mother died of MI, age 70. Father died of prostate cancer, age 80. Bother died of CAD and prostate cancer, age 74.,SHX:, Married. 3 children who are alive and well. Semi-retired Attorney. Denied h/o tobacco/ETOH/illicit drug use.,EXAM:, BP 110/70, HR 50, RR 14, Afebrile.,MS: A&O to person and place, but not time. Oral comprehension was poor beyond the simplest of conversational phrases. Speech was fluent, but consisted largely of ""word salad."" When asked how he was, he replied: ""abadeedleedlebadle."" Repetition was defective, especially with long phrases. On rare occasions, he uttered short comments appropriately. Speech was marred by semantic and phonemic paraphasias. He named colors and described most actions well, although he described a ""faucet dripping"" as a ""faucet drop."" He called ""red"" ""reed."" Reading comprehension was better than aural comprehension. He demonstrated excellent written calculations. Spoken calculations were accurate except when the calculations became more complex. For example, he said that ten percent of 100 was equal to ""1,200."",CN: Pupils 2/3 decreasing to 1/1 on exposure to light. VFFTC. There were no field cuts or evidence of visual neglect. EOM were intact. Face moved symmetrically. The rest of the CN exam was unremarkable.,MOTOR: Full strength throughout with normal muscle tone and bulk. There was no evidence of drift.,SENSORY: unremarkable.,COORD: unremarkable.,Station: unremarkable. Gait: mild difficulty with TW.,Reflexes: 2/2 in BUE. 2/2+ patellae, 1/1 Achilles. Plantar responses were flexor on the left and equivocal on the right.,Gen Exam: unremarkable.,COURSE:, Lab data on admission: Glucose 97, BUN 20, Na 134, K 4.0, Cr 1.3, Chloride 98, CO2 24, PT 11, PTT 42, WBC 12.0 (normal differential), Hgb 11.4, Hct 36%, Plt=203k. UA normal. TSH 6.0, FT4 0.88, Vit B12 876, Folate 19.1. He was admitted and continued on heparin. MRI scan, 8/16/95, revealed increased signal on T2-weighted images in Wernicke's area in the left temporal region. Transthoracic echocardiogram on 8/17/95 was unremarkable. Transesophageal echocardiogram on 8/18/95 revealed a sclerotic aortic valve and myxomatous degeneration of the anterior leaflet of the mitral valve. LAE 4.8cm, and spontaneous echo contrast in the left atrium were noted. There was no evidence of intracardiac shunt or clot. Carotid duplex scan on 8/16/95 revealed 0-15% BICA stenosis with anterograde vertebral artery flow, bilaterally. Neuropsychologic testing revealed a Wernicke's aphasia.,The impression was that the patient had had a cardioembolic stroke involving a lower-division branch of the left MCA. He was subsequently placed on warfarin. Thoughout his hospital stay he showed continued improvement of language skills and was enrolled in speech therapy following discharge, 8/21/95.,He has had no further stroke like episodes up until his last follow-up visit in 1997.","neurology, mri brain, difficulty with speech, left basal ganglia, posterior temporal lobe, wernicke's area, wernickes aphasia, cerebellar, infarctions, lacunar, word finding difficulty, carotid duplex scan, aphasia, wernicke's, mri, brain, "
 MRI Brain & T-spine - Demyelinating disease., Neurology, MRI Brain & T-spine - Demyelinating disease. ,"CC: ,Sensory loss.,HX: ,25y/o RHF began experiencing pruritus in the RUE, above the elbow and in the right scapular region, on 10/23/92. In addition she had paresthesias in the proximal BLE and toes of the right foot. Her symptoms resolved the following day. On 10/25/92, she awoke in the morning and her legs felt ""asleep"" with decreased sensation. The sensory loss gradually progressed rostrally to the mid chest. She felt unsteady on her feet and had difficulty ambulating. In addition she also began to experience pain in the right scapular region. She denied any heat or cold intolerance, fatigue, weight loss.,MEDS:, None.,PMH:, Unremarkable.,FHX: ,GF with CAD, otherwise unremarkable.,SHX:, Married, unemployed. 2 children. Patient was born and raised in Iowa. Denied any h/o Tobacco/ETOH/illicit drug use.,EXAM:,  BP121/66 HR77 RR14 36.5C,MS: A&O to person, place and time. Speech normal with logical lucid thought process.,CN: mild optic disk pallor OS. No RAPD. EOM full and smooth. No INO. The rest of the CN exam was unremarkable.,MOTOR: Full strength throughout all extremities except for 5/4+ hip extensors. Normal muscle tone and bulk.,Sensory: Decreased PP/LT below T4-5 on the left side down to the feet. Decreased PP/LT/VIB in BLE (left worse than right). Allodynic in RUE.,Coord: Intact FNF, HKS and RAM, bilaterally.,Station: No pronator drift. Romberg's test not documented.,Gait: Unsteady wide-based. Able to TT and HW. Poor TW.,Reflexes: 3/3 BUE. Hoffman's signs were present bilaterally. 4/4 patellae. 3+/3+ Achilles with 3-4 beat nonsustained clonus. Plantar responses were extensor on the right and flexor on the left.,Gen. Exam: Unremarkable.,COURSE:, CBC, GS, PT, PTT, ESR, FT4, TSH, ANA, Vit B12, Folate, VDRL and Urinalysis were normal. MRI T-spine, 10/27/92, was unremarkable. MRI Brain, 10/28/92, revealed multiple areas of abnormally increased signal on T2 weighted images in the white matter regions of the right corpus callosum, periventricular region, brachium pontis and right pons. The appearance of the lesions was felt to be strongly suggestive of multiple sclerosis. 10/28/92, Lumbar puncture revealed the following CSF results: RBC 1, WBC 9 (8 lymphocytes, 1 histiocyte), Glucose 55mg/dl, Protein 46mg/dl (normal 15-45), CSF IgG 7.5mg/dl (normal 0.0-6.2), CSF IgG index 1.3 (normal 0.0-0.7), agarose gel electrophoresis revealed oligoclonal bands in the gamma region which were not seen on the serum sample. Beta-2 microglobulin was unremarkable. An abnormal left tibial somatosensory evoked potential was noted consistent with central conduction slowing. Visual and Brainstem Auditory evoked potentials were normal. HTLV-1 titers were negative. CSF cultures and cytology were negative. She was not treated with medications as her symptoms were primarily sensory and non-debilitating, and she was discharged home.,She returned on 11/7/92 as her symptoms of RUE dysesthesia, lower extremity paresthesia and weakness, all worsened. On 11/6/92, she developed slow slurred speech and had marked difficulty expressing her thoughts. She also began having difficulty emptying her bladder. Her 11/7/92 exam was notable for normal vital signs, lying motionless with eyes open and nodding and rhythmically blinking every few minutes. She was oriented to place and time of day, but not to season, day of the week and she did not know who she was. She had a leftward gaze preference and right lower facial weakness. Her RLE was spastic with sustained ankle clonus. There was dysesthetic sensory perception in the RUE. Jaw jerk and glabellar sign were present.,MRI brain, 11/7/92, revealed multiple enhancing lesions in the peritrigonal region and white matter of the centrum semiovale. The right peritrigonal region is more prominent than on prior study. The left centrum semiovale lesion has less enhancement than previously. Multiple other white matter lesions are demonstrated on the right side, in the posterior limb of the internal capsule, the anterior periventricular white matter, optic radiations and cerebellum. The peritrigonal lesions on both sides have increased in size since the 10/92 MRI. The findings were felt more consistent with demyelinating disease and less likely glioma. Post-viral encephalitis, Rapidly progressive demyelinating disease and tumor were in the differential diagnosis. Lumbar Puncture, 11/8/92, revealed: RBC 2, WBC 12 (12 lymphocytes), Glucose 57, Protein 51 (elevated), cytology and cultures were negative. HIV 1 titer was negative. Urine drug screen, negative. A stereotactic brain biopsy of the right parieto-occipital region was consistent with demyelinating disease. She was treated with Decadron 6mg IV qhours and Cytoxan 0.75gm/m2 (1.25gm). On 12/3/92, she has a focal motor seizure with rhythmic jerking of the LUE, loss of consciousness and rightward eye deviation. EEG revealed diffuse slowing with frequent right-sided sharp discharges. She was placed on Dilantin. She became depressed.","neurology, sensory loss, lumbar puncture, peritrigonal region, centrum semiovale, mri brain, white matter, demyelinating disease, csf, demyelinating, mri, brain, "
 MRI brain & Cerebral Angiogram: CNS Vasculitis with evidence of ischemic infarction in the right and left frontal lobes., Neurology, MRI Brain & Cerebral Angiogram ,"CC:, Difficulty with word finding.,HX: ,This 27y/o RHF experienced sudden onset word finding difficulty and slurred speech on the evening of 2/19/96. She denied any associated dysphagia, diplopia, numbness or weakness of her extremities. She went to sleep with her symptoms on 2/19/96, and awoke with them on 2/20/96. She also awoke with a headache (HA) and mild neck stiffness. She took a shower and her HA and neck stiffness resolved. Throughout the day she continued to have difficulty with word finding and had worsening of her slurred speech. That evening, she began to experience numbness and weakness in the lower right face. She felt like there was a ""rubber-band"" wrapped around her tongue.,For 3 weeks prior to presentation, she experienced transient episodes of a ""boomerang"" shaped field cut in the left eye. The episodes were not associated with any other symptoms. One week prior to presentation, she went to a local ER for menorrhagia. She had just resumed taking oral birth control pills one week prior to the ER visit after having stopped their use for several months. Local evaluation included an unremarkable carotid duplex scan. However, a HCT with and without contrast reportedly revealed a left frontal gyriform enhancing lesion. An MRI brain scan on 2/20/96 revealed nonspecific white matter changes in the right periventricular region. EEG reportedly showed diffuse slowing. CRP was reportedly ""too high"" to calibrate.,MEDS:, Ortho-Novum 7-7-7 (started 2/3/96), and ASA (started 2/20/96).,PMH:, 1)ventral hernia repair 10 years ago, 2)mild ""concussion"" suffered during a MVA; without loss of consciousness, 5/93, 3) Anxiety disorder, 4) One childbirth.,FHX: ,She did not know her father and was not in contact with her mother.,SHX:, Lives with boyfriend. Smokes one pack of cigarettes every three days and has done so for 10 years. Consumes 6 bottles of beers, one day a week. Unemployed and formerly worked at an herbicide plant.,EXAM: ,BP150/79, HR77, RR22, 37.4C.,MS: A&O to person, place and time. Speech was dysarthric with mild decreased fluency marked by occasional phonemic paraphasic errors. Comprehension, naming and reading were intact. She was able to repeat, though her repetition was occasionally marked by phonemic paraphasic errors. She had no difficulty with calculation.,CN: VFFTC, Pupils 5/5 decreasing to 3/3. EOM intact. No papilledema or hemorrhages seen on fundoscopy. No RAPD or INO. There was right lower facial weakness. Facial sensation was intact, bilaterally. The rest of the CN exam was unremarkable.,MOTOR: 5/5 strength throughout with normal muscle bulk and tone.,Sensory: No deficits.,Coord/Station/Gait: unremarkable.,Reflexes 2/2 throughout. Plantar responses were flexor, bilaterally.,Gen Exam: unremarkable.,COURSE:, CRP 1.2 (elevated), ESR 10, RF 20, ANA 1:40, ANCA <1:40, TSH 2.0, FT4 1.73, Anticardiolipin antibody IgM 10.8GPL units (normal <10.9), Anticardiolipin antibody IgG 14.8GPL (normal<22.9), SSA and SSB were normal. Urine beta-hCG pregnancy and drug screen were negative. EKG, CXR and UA were negative.,MRI brain, 2/21/96 revealed increased signal on T2 imaging in the periventricular white matter region of the right hemisphere. In addition, there were subtle T2 signal changes in the right frontal, right parietal, and left parietal regions as seen previously on her local MRI can. In addition, special FLAIR imaging showed increased signal in the right frontal region consistent with ischemia.,She underwent Cerebral Angiography on 2/22/96. This revealed decreased flow and vessel narrowing the candelabra branches of the RMCA supplying the right frontal lobe. These changes corresponded to the areas of ischemic changes seen on MRI. There was also segmental narrowing of the caliber of the vessels in the circle of Willis. There was a small aneurysm at the origin of the LPCA. There was narrowing in the supraclinoid portion of the RICA and the proximal M1 and A1 segments. The study was highly suggestive of vasculitis.,2/23/96, Neuro-ophthalmology evaluation revealed no evidence of retinal vasculitic change. Neuropsychologic testing the same day revealed slight impairment of complex attention only. She was started on Prednisone 60mg qd and Tagamet 400mg qhs.,On 2/26/96, she underwent a right frontal brain biopsy. Pathologic evaluation revealed evidence of focal necrosis (stroke/infarct), but no evidence of vasculitis. Immediately following the brain biopsy, while still in the recovery room, she experienced sudden onset right hemiparesis and transcortical motor type aphasia. Initial HCT was unremarkable. An EEG was consistent with a focal lesion in the left hemisphere. However, a 2/28/96 MRI brain scan revealed new increased signal on T2 weighted images in a gyriform pattern from the left precentral gyrus to the superior frontal gyrus. This was felt consistent with vasculitis.,She began q2month cycles of Cytoxan (1,575mg IV on 2/29/96. She became pregnant after her 4th cycle of Cytoxan, despite warnings to the contrary. After extensive discussions with OB/GYN it was recommended she abort the pregnancy. She underwent neuropsychologic testing which revealed no significant cognitive deficits. She later agreed to the abortion. She has undergone 9 cycles of Cytoxan ( one cycle every 2 months) as of 4/97. She had complained of one episode of paresthesias of the LUE in 1/97. MRI then showed no new signs ischemia.", 
 MRI Brain: Thrombus in torcula of venous sinuses., Neurology, MRI Brain - Thrombus ,"CC: ,Motor vehicle-bicycle collision.,HX:, A 5 y/o boy admitted 10/17/92. He was struck while riding his bicycle by a motor vehicle traveling at a high rate of speed. First responders found him unconscious with left pupil 6 mm and unreactive and the right pupil 3 mm and reactive. He had bilateral decorticate posturing and was bleeding profusely from his nose and mouth. He was intubated and ventilated in the field, and then transferred to UIHC.,PMH/FHX/SHX:, unremarkable.,MEDS:, none,EXAM:, BP 127/91 HR69 RR30,MS: unconscious and intubated,Glasgow coma scale=4,CN: Pupils 6/6 fixed. Corneal reflex: trace OD, absent OS. Gag present on manipulation of endotracheal tube.,MOTOR/SENSORY: bilateral decorticate posturing to noxious stimulation (chest).,Reflexes: bilaterally.,Laceration of mid forehead exposing calvarium.,COURSE:, Emergent Brain CT scan revealed: Displaced fracture of left calvarium. Left frontoparietal intraparenchymal hemorrhage. Right ventricular collection of blood. Right cerebral intraparenchymal hemorrhage. Significant mass effect with deviation of the midline structures to right. The left ventricle was compressed with obliteration of the suprasellar cistern. Air within the soft tissues in the left infra temporal region. C-spine XR, Abdominal/Chest CT were unremarkable.,Patient was taken to the OR emergently and underwent bifrontal craniotomy, evacuation of a small epidural and subdural hematomas, and duraplasty. He was given mannitol enroute to the OR and hyperventilated during and after the procedure. Postoperatively he continued to manifest decerebrate posturing . On 11/16/92 he underwent VP shunting with little subsequent change in his neurological status. On 11/23/92 he underwent tracheostomy. On 12/11/92 he underwent bifrontal acrylic prosthesis implantation for repair of the bifrontal craniectomy. By the time of discharge, 1/14/93, he tracked relatively well OD, but had a CN3 palsy OS. He had relatively severe extensor rigidity in all extremities (R>L). His tracheotomy was closed prior to discharge. A 11/16/92 Brain MRI demonstrated infarction in the upper brain stem (particularly in the Pons), left cerebellum, right basil ganglia and thalamus.,He was initially treated for seizure prophylaxis with DPH, but developed neutropenia, so it was discontinued. He developed seizures within several months of discharge and was placed on VPA (Depakene). This decreased seizure frequency but his liver enzymes became elevated and he changed over to Tegretol. 10/8/93 Brain MRI (one year after MVA) revealed interval appearance of hydrocephalus, abnormal increased T2 signal (in the medulla, right pons, both basal ganglia, right frontal and left occipital regions), a small mid-brain, and a right subdural fluid collection. These findings were consistent with diffuse axonal injury of the white matter and gray matter contusion, and signs of a previous right subdural hematoma.,He was last seen 10/30/96 in the pediatric neurology clinic--age 9 years. He was averaging 2-3 seizures per day---characterized by extension of BUE with tremor and audible cry or laughter---on Tegretol and Diazepam. In addition he experiences 24-48hour periods of ""startle response (myoclonic movement of the shoulders)"" with or without stimulation every 6 weeks. He had limited communication skills (sparse speech). On exam he had disconjugate gaze, dilated/fixed left pupil, spastic quadriplegia.","neurology, mri brain, brain mri, thrombus, intraparenchymal hemorrhage, motor vehicle, prophylaxis, sinuses, torcula venous sinuses, venous, brain thrombus, bilateral decorticate, decorticate posturing, subdural hematomas, subdural, mri, brain, torcula"
 MRI Brain: Probable CNS Lymphoma v/s toxoplasmosis in a patient with AIDS/HIV., Neurology, MRI Brain - Toxoplasmosis ,"CC:, Lethargy.,HX:, This 28y/o RHM was admitted to a local hospital on 7/14/95 for marked lethargy. He had been complaining of intermittent headaches and was noted to have subtle changes in personality for two weeks prior to 7/14/95. On the morning of 7/14/95, his partner found him markedly lethargic and complaingin of abdominal pain and vomiting. He denied fevers, chills, sweats, cough, CP, SOB or diarrhea. Upon evaluation locally, he had a temperature of 99.5F and appeared lethargic. He also had anisocoria with left pupil 0.5mm bigger than the right. There was also question of left facial weakness. An MRI was obtained and revealed a large left hemispheric mass lesion with surrounding edema and mass effect. He was given 10mg of IV Decardron,100gm of IV Mannitol, intubated and hyperventilated and transferred to UIHC.,He was admitted to the Department of Medicine on 7/14/95, and transferred to the Department of Neurology on 7/17/95, after being extubated.,MEDS ON ADMISSION:, Bactrim DS qd, Diflucan 100mg qd, Acyclovir 400mg bid, Xanax, Stavudine 40mg bid, Rifabutin 300mg qd.,PMH:, 1) surgical correction of pyoloric stenosis, age 1, 2)appendectomy, 3) HIV/AIDS dx 1991. He was initially treated with AZT, then DDI. He developed chronic diarrhea and was switched to D4T in 1/95. However, he developed severe neuropathy and this was stopped 4/95. The diarrhea recured. He has Acyclovir resistant genital herpes and generalized psoriasis. He most recent CD4 count (within 1 month of admission) was 20.,FHX:, HTN and multiple malignancies of unknown type.,SHX:, Homosexual, in monogamous relationship with an HIV infected partner for the past 3 years.,EXAM: ,7/14/95 (by Internal Medicine): BP134/80, HR118, RR16 on vent, 38.2C, Intubated.,MS: Somnolent, but opened eyes to loud voices and would follow most commands.,CN: Pupils 2.5/3.0 and ""equally reactive to light."" Mild horizontal nystagmus on rightward gaze. EOM were otherwise intact.,MOTOR: Moved 4 extremities well.,Sensory/Coord/Gait/Station/Reflexes: not done.,Gen EXAM: Penil ulcerations.,EXAM:, 7/17/96 (by Neurology): BP144/73, HR59, RR20, 36.0, extubated.,MS: Alert and mildly lethargic. Oriented to name only. Thought he was a local hospital and that it was 1/17/1994. Did not understand he had a brain lesion.,CN: Pupils 6/5.5 decreasing to 4/4 on exposure to light. EOM were full and smooth. No RAPD or light-near dissociation. papilledema (OU). Right lower facial weakness and intact facial sensation to PP testing. Gag-shrug and corneal responses were intact, bilaterally. Tongue midline.,MOTOR: Grade 5- strength on the right side.,Sensory: no loss of sensation on PP/VIB/PROP testing.,Coord: reduced speed and accuracy on right FNF and right HKS movements.,Station: RUE pronator drift.,Gait: not done.,Reflexes: 2+/2 throughout. Babinski sign present on right and absent on left.,Gen Exam: unremarkable except for the genital lesion noted by Internal medicine.,COURSE:, The outside MRI was reviewed and was notable for the left frontal/parietal mass lesion with surround edema. The mass inhomogenously enhanced with gadolinium contrast.,The findings were consistent most with lymphoma, though toxoplasmosis could not be excluded. He refused brain biopsy and was started on empiric treatment for toxoplasmosis. This consisted of Pyrimethamine 75mg qd and Sulfadiazine 2 g bid. He later became DNR and was transferred at his and his partner's request Back to a local hospital.,He never returned for follow-up.",
 MRI Brain and Brainstem - Falling (Multiple System Atrophy), Neurology, MRI Brain and Brainstem ,"CC:, Falling.,HX:, This 67y/o RHF was diagnosed with Parkinson's Disease in 9/1/95, by a local physician. For one year prior to the diagnosis, the patient experienced staggering gait, falls and episodes of lightheadedness. She also noticed that she was slowly ""losing"" her voice, and that her handwriting was becoming smaller and smaller. Two months prior to diagnosis, she began experienced bradykinesia, but denied any tremor. She noted no improvement on Sinemet, which was started in 9/95. At the time of presentation, 2/13/96, she continued to have problems with coordination and staggering gait. She felt weak in the morning and worse as the day progressed. She denied any fever, chills, nausea, vomiting, HA, change in vision, seizures or stroke like events, or problems with upper extremity coordination.,MEDS:, Sinemet CR 25/100 1tab TID, Lopressor 25mg qhs, Vitamin E 1tab TID, Premarin 1.25mg qd, Synthroid 0.75mg qd, Oxybutynin 2.5mg has, isocyamine 0.125mg qd.,PMH:, 1) Hysterectomy 1965. 2) Appendectomy 1950's. 3) Left CTR 1975 and Right CTR 1978. 4) Right oophorectomy 1949 for ""tumor."" 5) Bladder repair 1980 for unknown reason. 6) Hypothyroidism dx 4/94. 7) HTN since 1973.,FHX: ,Father died of MI, age 80. Mother died of MI, age73. Brother died of Brain tumor, age 9.,SHX: ,Retired employee of Champion Automotive Co.,Denies use of TOB/ETOH/Illicit drugs.,EXAM: ,BP (supine)182/113 HR (supine)94. BP (standing)161/91 HR (standing)79. RR16 36.4C.,MS: A&O to person, place and time. Speech fluent and without dysarthria. No comment regarding hypophonia.,CN: Pupils 5/5 decreasing to 2/2 on exposure to light. Disks flat. Remainder of CN exam unremarkable.,Motor: 5/5 strength throughout. NO tremor noted at rest or elicited upon movement or distraction,Sensory: Unremarkable PP/VIB testing.,Coord: Did not show sign of dysmetria, dyssynergia, or dysdiadochokinesia. There was mild decrement on finger tapping and clasping/unclasping hands (right worse than left).,Gait: Slow gait with difficulty turning on point. Difficulty initiating gait. There was reduced BUE swing on walking (right worse than left).,Station: 3-4step retropulsion.,Reflexes: 2/2 and symmetric throughout BUE and patellae. 1/1 Achilles. Plantar responses were flexor.,Gen Exam: Inremarkable. HEENT: unremarkable.,COURSE:, The patient continued Sinemet CR 25/100 1tab TID and was told to monitor orthostatic BP at home. The evaluating Neurologist became concerned that she may have Parkinsonism plus dysautonomia.,She was seen again on 5/28/96 and reported no improvement in her condition. In addition she complained of worsening lightheadedness upon standing and had an episode, 1 week prior to 5/28/96, in which she was at her kitchen table and became unable to move. There were no involuntary movements or alteration in sensorium/mental status. During the episode she recalled wanting to turn, but could not. Two weeks prior to 5/28/96 she had an episode of orthostatic syncope in which she struck her head during a fall. She discontinued Sinemet 5 days prior to 5/28/96 and felt better. She felt she was moving slower and that her micrographia had worsened. She had had recent difficulty rolling over in bed and has occasional falls when turning. She denied hypophonia, dysphagia or diplopia.,On EXAM: BP (supine)153/110 with HR 88. BP (standing)110/80 with HR 96. (+) Myerson's sign and mild hypomimia, but no hypophonia. There was normal blinking and EOM. Motor strength was full throughout. No resting tremor, but mild postural tremor present. No rigidity noted. Mild decrement on finger tapping noted. Reflexes were symmetric. No Babinski signs and no clonus. Gait was short stepped with mild anteroflexed posture. She was unable to turn on point. 3-4 step Retropulsion noted. The Parkinsonism had been unresponsive to Sinemet and she had autonomic dysfunction suggestive of Shy-Drager syndrome. It was recommended that she liberalize dietary salt use and lie with head of the bed elevate at 20-30 degrees at night. Indomethacin was suggested to improve BP in future.","neurology, myerson's sign, falling, dysautonomia, mri brain and brainstem, brain and brainstem, mri brain, sinemet cr, mri, brainstem, ctr, tumor, retropulsion, parkinsonism, brain, lightheadedness, hypophonia, standing, sinemet, "
 MRI Brain - Right frontal white matter infarct in patient with Anticardiolipin antibody syndrome and SLE., Neurology, MRI Brain - SLE & Stroke ,"CC:, Episodic monocular blindness, OS.,HX:, This 29 y/o RHF was in her usual healthy state until 2 months prior to her 3/11/96 presentation when she developed episodic arthralgias of her knees and ankles, bilaterally. On 3/3/96, she experienced sudden onset monocular blindness, OS, lasting 5-10 minutes in duration. Her vision ""greyed out"" from the periphery to center of her visual field, OS; and during some episodes progressed to complete blindness (not even light perception). This resolved within a few minutes. She had multiple episodes of vision loss, OS, every day until 3/7/96 when she was placed on heparin for suspected LICA dissection. She saw a local ophthalmologist on 3/4/96 and was told she had a normal funduscopic exam. She experienced 0-1 spell of blindness (OS) per day from 3/7/96 to 3/11/96. In addition, she complained of difficulty with memory since 3/7/96. She denied dysarthria, aphasia or confusion, but had occasional posterior neck and bioccipital-bitemporal headaches.,She had no history of deep venous or arterial thrombosis.,3/4/96, ESR=123. HCT with and without contrast on 3/7/96 and 3/11/96, and Carotid Duplex scan were ""unremarkable."" Rheumatoid factor=normal. 3-vessel cerebral angiogram (done locally) was reportedly ""unremarkable."",She was thought to have temporal arteritis and underwent Temporal Artery biopsy (which was unremarkable), She received Prednisone 80 mg qd for 2 days prior to presentation.,On admission she complained of a left temporal headache at the biopsy site, but no loss of vision or weakness,She had been experiencing mild fevers and chills for several weeks prior to presentation. Furthermore, she had developed cyanosis of the distal #3 toes on feet, and numbness and rash on the lateral aspect of her left foot. She developed a malar rash on her face 1-2 weeks prior to presentation.,MEDS:, Depo-Provera, Prednisone 80mg qd, and Heparin IV.,PMH:, 1)Headaches for 3-4 years, 2)Heart murmur, 3) cryosurgery of cervix, 4)tonsillectomy and adenoidectomy, 5) elective abortion. She had no history of spontaneous miscarriage and had used oral birth control pill for 10 years prior to presentation.,FHX:, Migraine headaches on maternal side, including her mother. No family history of thrombosis.,SHX:, works as a metal grinder and was engaged to be married. She denied any tobacco or illicit drug use. She consumed 1 alcoholic drink per month.,EXAM: ,BP147/74, HR103, RR14, 37.5C.,MS: A&O to person, place and time. Speech was fluent without dysarthria. Repetition, naming and comprehension were intact. 2/3 recall at 2 minutes.,CN: unremarkable.,Motor: unremarkable.,Coord: unremarkable.,Sensory: decreased LT, PP, TEMP, along the lateral aspect of the left foot.,Gait: narrow-based and able to TT, HW and TW without difficulty.,Station: unremarkable.,Reflexes: 2/2 throughout. Plantar responses were flexor, bilaterally.,Skin: Cyanosis of the distal #3 toes on both feet. There was a reticular rash about the lateral aspect of her left foot. There were splinter-type hemorrhages under the fingernails of both hands.,COURSE: ,  ESR=108 (elevated), Hgb 11.3, Hct 33%, WBC 10.0, Plt 148k, MCV 92 (low) Cr 1.3, BUN 26, CXR and EKG were unremarkable. PTT 42 (elevated). PT normal. The rest of the GS and CBC were normal. Dilute Russell Viper venom time was elevated at 27 and a 1:1 prothrombin time mix corrected to only 36.,She was admitted to the Neurology service. Blood cultures were drawn and were negative. Transthoracic and transesophageal echocardiography on 3/12/96 was unremarkable.,Her symptoms and elevated PTT suggested an ischemic syndrome involving anticardiolipin antibody and/or lupus anticoagulant. Her signs of rash and cyanosis suggested SLE. ANA was positive at 1:640 (speckled), RF (negative), dsDNA, 443 (elevated). Serum cryoglobulins were positive at 1% (fractionation data lost). Serum RPR was positive, but FTA-ABS was negative (thereby confirming a false-positive RPR). Anticardiolipin antibodies IgM and IgG were positive at 56.1 and 56.3 respectively. Myeloperoxidase antibody was negative, ANCA was negative and hepatitis screen unremarkable.,The Dermatology Service felt the patient's reticular foot rash was livedo reticularis. Rheumatology felt the patient met criteria for SLE. Hematology felt the patient met criteria for Anticardiolipin Antibody and/or Lupus anticoagulant Syndrome. Neurology felt the episodic blindness was secondary to thromboembolic events.,Serum Iron studies revealed: FeSat 6, Serum Fe 15, TIBC 237, Reticulocyte count 108.5. The patient was placed on FeSO4 225mg tid.,She was continued on heparin IV, but despite this she continued to have occasional episodes of left monocular blindness or ""gray outs"" up to 5 times per day. She was seen by the Neuro-ophthalmology Service. The did not think she had evidence of vasculitis in her eye. They recommended treatment with ASA 325mg bid. She was placed on this 3/15/96 and tapered off heparin. She continued to have 0-4 episodes of monocular blindness (OS) for 5-10 seconds per episodes. She was discharged home.,She returned 3/29/96 for episodic diplopia lasting 5-10 minutes per episode. The episodes began on 3/27/96. During the episodes her left eye deviated laterally while the right eye remained in primary gaze. She had no prior history of diplopia or strabismus. Hgb 10.1, Hct 30%, WBC 5.2, MCV 89 (low), Plt 234k. ESR 113mm/hr. PT 12, PTT 45 (high). HCT normal. MRI brain, 3/30/96, revealed a area of increased signal on T2 weighted images in the right frontal lobe white matter. This was felt to represent a thromboembolic event. She was place on heparin IV and treated with Solu-Medrol 125mg IV q12 hours. ASA was discontinued. Hematology, Rheumatology and Neurology agreed to place her on Warfarin. She was placed on Prednisone 60mg qd following the Solu-Medrol. She continued to have transient diplopia and mild vertigo despite INR's of 2.0-2.2. ASA 81mg qd was added to her regimen. In addition, Rheumatology recommended Plaquenil 200mg bid. The neurologic symptoms decreased gradually over the ensuing 3 days. Warfarin was increased to achieve INR 2.5-3.5.,She reported no residual symptoms or new neurologic events on her 5/3/96 Neurology Clinic follow-up visit. She continues to be event free on Warfarin according to her Hematology Clinic notes up to 12/96.",
 MRI Brain - Pilocytic Astrocytoma in thalamus and caudate., Neurology, MRI Brain - Pilocytic Astrocytoma ,"CC:, Headache.,HX: ,The patient is an 8y/o RHM with a 2 year history of early morning headaches (3:00-6:00AM) intermittently relieved by vomiting only. He had been evaluated 2 years ago and an EEG was ""normal"" then, but no brain imaging was performed. His headaches progressively worsened, especially in the past two months prior to this presentation. For 2 weeks prior to his 1/25/93 evaluation at UIHC, he would awake screaming. His parent spoke with a local physician who thought this might be due to irritability secondary to pinworms and,Vermox was prescribed and arrangements were made for a neurologic evaluation. On the evening of 1/24/93 the patient awoke screaming and began to vomit. This was followed by a 10 min period of tonic-clonic type movements and postictal lethargy. He was taken to a local ER and a brain CT revealed an intracranial mass. He was given Decadron and Phenytoin and transferred to UIHC for further evaluation.,MEDS:, noted above.,PMH: ,1)Born at 37.5 weeks gestation by uncomplicated vaginal delivery to a G1P0 mother. Pregnancy complicated by vaginal bleeding at 7 months. Met developmental milestones without difficulty. 2) Frequent otitis media, now resolved. 3) Immunizations were ""up to date."",FHX:, non-contributory.,SHX:, lives with biologic father and mother. No siblings. In 3rd grade (mainstream) and maintaining good marks in schools.,EXAM:, BP121/57mmHg HR103 RR16 36.9C,MS: Sleepy, but cooperative.,CN: EOM full and smooth. Advanced papilledema, OU. VFFTC. Pupils 4/4 decreasing to 2/2. Right lower facial weakness. Tongue midline upon protrusion. Corneal reflexes intact bilaterally.,Motor: 5/5 strength. Slightly increased muscle on right side.,Sensory. No deficit to PP/VIB noted.,Coord: normal FNF, HKS and RAM, bilaterally.,Station: Mild truncal ataxia. Tends to fall backward.,Reflexes: BUE 2+/2+, Patellar 3/3, Ankles 3+/3+ with 6 beats of nonsustained clonus bilaterally.,Gen exam: unremarkable.,COURSE:, The patient was continued on Dilantin 200mg qd and Decadron 5mg IV q6hrs. Brain MRI, 1/26/93, revealed a large mass lesion in the region of the left caudate nucleus and thalamus which was hyperintense on T2 weighted images. There were areas of cystic formation at its periphery. The mass appeared to enhance on post gadolinium images. there was associated white matter edema and compression of the left lateral ventricle, and midline shift to the right. There was no sign of uncal herniation. He underwent bilateral VP shunting on 1/26/93; and then, subtotal resection (left frontal craniotomy with excision of the left caudate and thalamus with creation of an opening in the septum pellucidum) on 1/28/93. He then received 5040cGy of radiation therapy in 28 fractions completed on 3/25/93. A 3/20/95 neuropsychological evaluation revealed low average intellect on the WISC-III. There were also signs of memory, attention, reading and spelling deficits; and mild right-sided motor incoordination and mood variability. He remained in mainstream classes at school, but his physical and cognitive performance began to deteriorate in 4/95. Neurosurgical evaluation in 4/95 noted increased right hemiplegia and right homonymous hemianopia. MRI revealed tumor progression and he was subsequently placed on Carboplatin/VP-16 (CG 9933 protocol chemotherapy, regimen A). He was last seen on 4/96 and was having difficulty in the 6th grade; he was also undergoing physical therapy for his right hemiplegia.","neurology, mri brain, pilocytic astrocytoma, caudate, thalamus, headache, astrocytoma, hemiplegia, pilocytic, mri, "
 Right pontine pyramidal tract infarct., Neurology, MRI Brain - Pontine Stroke ,"CC:, Left sided weakness.,HX:, 74 y/o RHF awoke from a nap at 11:00 AM on 11/22/92 and felt weak on her left side. She required support on that side to ambulate. In addition, she felt spoke as though she ""was drunk."" Nevertheless, she was able to comprehend what was being spoken around her. Her difficulty with speech completely resolved by 12:00 noon. She was brought to UIHC ETC at 8:30AM on 11/23/92 for evaluation.,MEDS:, none. ,ALLERGIES:,  ASA/ PCN both cause rash.,PMH:, 1)?HTN. 2)COPD. 3)h/o hepatitis (unknown type). 4)Macular degeneration.,SHX:, Widowed; lives alone. Denied ETOH/Tobacco/illicit drug use.,FHX:, unremarkable.,EXAM: , BP191/89 HR68 RR16 37.2C,MS: A & O to person, place and time. Speech fluent; without dysarthria. Intact naming, comprehension, and repetition.,CN: Central scotoma, OS (old). Mild upper lid ptosis, OD (old per picture). Lower left facial weakness.,Motor: Mild Left hemiparesis (4+ to 5- strength throughout affected side). No mention of muscle tone in chart.,Sensory: unremarkable.,Coord: impaired FNF and HKS movement secondary to weakness.,Station: Left pronator drift. No Romberg sign seen.,Gait: Left hemiparetic gait with decreased LUE swing.,Reflexes: 3/3+ biceps and triceps. 3/3+ patellae. 2/3+ ankles with 3-4beats of non-sustained ankle clonus on left. Plantars: Left babinski sign; and flexor on right.,General Exam: 2/6 SEM at left sternal border.,COURSE:, GS, CBC, PT, PTT, CK, ESR were within normal limits. ABC 7.4/46/63 on room air. EKG showed a sinus rhythm with right bundle branch block. MRI brain, 11/23/95, revealed a right pontine pyramidal tract infarction. She was treated with Ticlopidine 250mg bid. On 11/26/92, her left hemiparesis worsened. A HCT, 11/27/92, was unremarkable. The patient was treated with IV Heparin. This was discontinued the following day when her strength returned to that noted on 11/23/95. On 11/27/92, she developed angina and was ruled out for MI by serial EKG and cardiac enzyme studies. Carotid duplex showed 0-15% bilateral ICA stenosis and antegrade vertebral artery flow bilaterally. Transthoracic echocardiogram revealed aortic insufficiency only. Transesophageal echocardiogram revealed trivial mitral and tricuspid regurgitation, aortic valvular fibrosis. There was calcification and possible thrombus seen in the descending aorta. Cardiology did not feel the later was an indication for anticoagulation. She was discharged home on Isordil 20 tid, Metoprolol 25mg q12hours, and Ticlid 250mg bid.","neurology, mri brain, pontine stroke, difficulty with speech, hemiparesis, pontine pyramidal tract infarct, weakness, mri, brain, pyramidal, echocardiogram, pontine, infarct, "
 A middle-aged male with increasing memory loss and history of Lyme disease., Neurology, MRI Brain - Lyme Disease ,"FINDINGS:,There is a large intrasellar mass lesion producing diffuse expansion of the sella turcica. This mass lesions measures approximately 16 x 18 x 18mm (craniocaudal x AP x mediolateral) in size.","neurology, increasing memory loss, intrasellar mass lesion, memory loss, sella turcica, cavernous sinus, sphenoid sinus, ct imaging, white matter, retention cyst, maxillary antrum, lyme disease, mass lesion, disease, cavernous, cortical, mass, lesion,"
 MRI Brain - Progressive Multifocal Leukoencephalopathy (PML) occurring in an immunosuppressed patient with polymyositis., Neurology, MRI Brain - Leukoencephalopathy ,"CC: ,Progressive left visual field loss.,HX:, This 46y/o RHF with polymyositis since 1988, presented with complaint of visual field loss since 12/94. The visual field loss was of gradual onset and within a month of onset became a left homonymous hemianopsia. She began experiencing stiffness, numbness, tingling and incoordination of her left hand, 6 weeks prior to this admission,. These symptoms were initially attributed to carpal tunnel syndrome. MRI scan of the brain (done locally) on 6/23/95 revealed increased periventricular white matter signal on T2 images, particularly in the left temporo-occipital and right parietal lobes. There was ring enhancement of a lesion in the left occipital lobe on T1 gadolinium contrast enhanced images. There was gyral enhancement near the right Sylvian fissure. Cerebral angiogram on 7/19/95 (done locally) was unremarkable. Lumbar puncture on 7/19/95 was unremarkable. She complained of frequent holocranial throbbing headaches for the past 6 months; the HA's are associated with photophobia, phonophobia and nausea, but no vomiting. She has also been experiencing chills and night sweats for the past 2-3 weeks. She denies weight loss, but acknowledged decreased appetite and increased generalized fatigue for the past 3-4 months.,She was diagnosed with polymyositis in 1988 with slowly progressive bilateral lower extremity weakness. She has been on immunosuppressive drugs since 1988, including Prednisone, Prednisone and methotrexate, Cyclosporin, Imuran, Cytoxan, and Plaquenil. At present she in ambulatory with use of walker. Her last CK=3,125 and ESR=16, on 6/28/95.,MEDS:, Prednisone 20mg qd, Cytoxan 75mg qd, Zantac 150mg bid, Vasotec 10mg bid, Premarin 0.625 qd, Provera 2.5mg qd, CaCO3 500mg bid, Vit D 50,000units qweek, Vit E qd, MVI 1 tab qd.,PMH:, 1)polymyositis diagnosed in 1988 by muscle biopsy. 2)hypertension. 3)lichen planus. 4)Lower extremity deep venous thrombosis one year ago--placed on Coumadin and this resulted in postmenopausal bleeding.,FHX:, Mother is alive and has a h/o HTN and stroke. Father died in motor vehicle accident at age 40 years.,SHX:, Married, 3 children who are healthy. She denied any Tobacco/ETOH/Illicit drug use.,EXAM:, BP160/74 HR95 RR12 35.8C Wt. 86.4kg Ht. 5'6"",MS: A&O to person, place and time. Speech was normal. Mood euthymic with appropriate affect.,CN: Pupils 4/4 decreasing to 2/2 on exposure to light. No RAPD noted. Optic Disk were flat. EOM testing unremarkable. Confrontational visual field testing revealed a left homonymous hemianopsia. The rest of the CN exam was unremarkable.,MOTOR: Upper extremities: 5/5 proximally, 5/4 @ elbow/wrist/hand. Lower extremities: 4/4 proximally and 5/5 @ and below knees.,SENSORY: unremarkable.,COORD: Dyssynergia of LUE FNF movement. Slowed finger tapping on left. HNS movements were normal, bilaterally.,Station: LUE drift and fix on arm roll. No Romberg sign elicited.,Gait: Waddling gait, but could TT and stand on both heels. She had difficulty with tandem walking, but did not fall to any particular side.,Reflexes: 2/2 brachioradialis and biceps. 2/2+ triceps, 1+/1+ patellae, 1/1 Achilles. Plantar responses were flexor on the right and withdrawal response on the left.,GEN EXAM: No rashes. II/VI systolic ejection murmur at the left sternal border.,COURSE:, Electrolytes, PT/PTT, Urinalysis and CXR were normal. ESR=38 (normal<20), CRP1.4 (normal<0.4). CK 2,917, LDH 356, AST 67. MRI Brain, 8/8/95, revealed slight improvement of the abnormal white matter changes seen on previous outside MRI. In addition new sphenoid sinus disease suggestive of sinusitis was seen. She underwent stereotactic biopsy of the right parietal region on 8/10/95 which on H&E and LFB stained sections revealed multiple discrete areas of demyelination, containing dense infiltrates of foamy macrophages in association with scattered large oligodendroglia with deeply basophilic, ground-glass nuclei, enlarged astrocytes, and sparse perivascular lymphocytic infiltrates. In situ hybridization performed on block A2 (at the university of Pittsburgh) is positive for JC virus. The ultrastructural studies demonstrated no viral particles.,She was tapered off all immunosuppressive medications and her polymyositis remained clinically stable. She had a seizure in 12/95 and was placed on Dilantin. Her neurologic deficits worsened slightly, but reached a plateau by 10/96, as indicated by a 4/14/97 Neurology clinic visit note.,1/22/96, MRI Brain demonstrated widespread hyperintense signal on T2 and Proton Density weighted images throughout the deep white matter in both hemispheres, worse on the right side. There was interval progression of previously noted abnormalities and extension into the right frontal and left parieto-occipital regions. There was progression of abnormal signal in the Basal Ganglia, worse on the right, and new involvement of the brainstem.","neurology, mri brain, pml, progressive multifocal leukoencephalopathy, polymyositis, visual field loss, leukoencephalopathy, lower extremity, field loss, white matter, visual field, signal, brain, mri, "
 Progressive loss of color vision OD., Neurology, Meningioma ,"CC: ,Progressive loss of color vision OD,HX:, 58 y/o female presents with a one year history of progressive loss of color vision. In the past two months she has developed blurred vision and a central scotoma OD. There are no symptoms of photopsias, diplopia, headache, or eye pain. There are no other complaints. There have been mild fluctuations of her symptoms, but her vision has never returned to its baseline prior to symptom onset one year ago.,EXAM: ,Visual acuity with correction: 20/25+1 OD; 20/20-1 OS. Pupils were 3.5mm OU. There was a 0.8 log unit RAPD OD. Intraocular pressures were 25 and 24, OD and OS respectively; and there was an increase to 27 on upgaze OD, but no increase on upgaze OS. Optic disk pallor was evident OD, but not OS. Additionally, there was a small area of peripheral chorioretinal scarring in the inferotemporal area of the right eye. Foveal flicker fusion occurred at a frequency of 21.9 OD and 30.7 OS. Color plate testing scores: 6/14 OD and 10/14 OS. Goldman visual field examination showed an enlarged and deepened blind spot with an infero-temporal defect especially in the smaller diopters.,IMPRESSION ON 2/6/89: ,Optic neuropathy/atrophy OD, rule out mass lesion affecting optic nerve. Particular attention was paid to the area of the optic canal, cavernous sinus and sphenoid sinus.,BRAIN CT W/CONTRAST, 2/13/89:, Enhancing calcified lesion in the posterior aspect of the right optic nerve, probable meningioma.,MRI ORBITS W/ AND W/OUT GADOLINIUM CONTRAST, 4/26/89:, 7x3mm irregular soft tissue mass just inferior and lateral to the optic nerve OD. The mass is just proximal to the orbital apex. There is relatively homogeneous enhancement of the mass. The findings are most consistent with meningioma.,MRI 1995:, Mild enlargement of tumor with possible slight extension into the right cavernous sinus.,COURSE: ,Resection and biopsy were deferred due to risk of blindness, and suspicion that the tumor was a slow growing meningioma. 3 years after initial evaluation Hertel measurements indicated a 3mm proptosis OD. Visual field testing revealed gradual worsening of deficits seen on her initial Goldman visual field exam. There was greater red color desaturation of the temporal field OD. Visual acuity had decreased from 20/20 to 20/64, OD. All other deficits seen on her initial exam remained stable or slightly worsened. By 1996 she continued to be followed at 6 months intervals and had not undergone surgical resection.","neurology, goldman visual field examination, loss of color vision, visual field examination, visual acuity, cavernous sinus, color vision, visual field, optic nerve, meningioma,"
 A middle-aged female with memory loss., Neurology, MRI Brain - Memory Loss ,"FINDINGS:,There is moderate to severe generalized neuronal loss of the cerebral hemispheres with moderate to severe ventricular enlargement and prominent CSF within the subarachnoid spaces. There is confluent white matter hyperintensity in a bi-hemispherical centrum semiovale distribution extending to the lateral ventricles consistent with severe vasculopathic small vessel disease and extensive white matter ischemic changes. There is normal enhancement of the dural sinuses and cortical veins and there are no enhancing intra-axial or extraaxial mass lesions. There is a cavum velum interpositum (normal variant).,There is a linear area of T1 hypointensity becoming hyperintense on T2 images in a left para-atrial trigonal region representing either a remote lacunar infarction or prominent perivascular space.,Normal basal ganglia and thalami. Normal internal and external capsules. Normal midbrain.,There is amorphus hyperintensity of the basis pontis consistent with vasculopathic small vessel disease. There are areas of T2 hyperintensity involving the bilateral brachium pontis (left greater than right) with no enhancement following gadolinium augmentation most compatible with areas of chronic white matter ischemic changes. The area of white matter signal alteration in the left brachium pontis is of some concern in that is has a round morphology. Interval reassessment of this lesion is recommended.,There is a remote lacunar infarction of the right cerebellar hemisphere. Normal left cerebellar hemisphere and vermis.,There is increased CSF within the sella turcica and mild flattening of the pituitary gland but no sellar enlargement. There is elongation of the basilar artery elevating the mammary bodies but no dolichoectasia of the basilar artery.,Normal flow within the carotid arteries and circle of Willis.,Normal calvarium, central skull base and temporal bones.  There is no demonstrated calvarium metastases.,IMPRESSION:,Severe generalized cerebral atrophy.,Extensive chronic white matter ischemic changes in a bi-hemispheric centrum semiovale distribution with involvement of the basis pontis and probable bilateral brachium pontis. The area of white matter hyperintensity in the left brachium pontis is of some concern is that it has a round morphology but no enhancement following gadolinium augmentation. Interval reassessment of this lesion is recommended.,Remote lacunar infarction in the right cerebellar hemisphere.,Linear signal alteration of the left periatrial trigonal region representing either a prominent vascular space or,lacunar infarction.,No demonstrated calvarial metastases.","neurology, white matter ischemic, remote lacunar infarction, memory loss, matter ischemic, remote lacunar, cerebellar hemisphere, lacunar infarction, brachium pontis, white matter, basilar, calvarium, ischemic, enhancement, cerebellar, hemispheres, hyperintensity, infarction, brachium,"
" MRI Brain: Ventriculomegaly of the lateral, 3rd and 4th ventricles secondary to obstruction of the foramen of Magendie secondary to Cryptococcus (unencapsulated) in a non-immune suppressed, HIV negative, individual.", Neurology, MRI Brain - Cryptococcus ,"CC: ,Headache.,HX: ,This 37y/o LHM was seen one month prior to this presentation for HA, nausea and vomiting. Gastrointestinal evaluation at that time showed no evidence of bowel obstruction and he was released home. These symptoms had been recurrent since onset.,At presentation he complained of mild blurred vision (OU), difficulty concentrating and HA which worsened upon sitting up. The headaches were especially noticeable in the early morning. He described them as non-throbbing headaches. They begin in the bifrontal region and radiate posteriorly. They occurred up to 6 times/day. The HA improved with lying down or dropping the head down between the knees towards the floor. The headaches were associated with blurred vision, nausea,vomiting, photophobia, and phonophobia. He denied any scotomata or positive visual phenomena. He denies any weakness, numbness, tingling, dysarthria or diplopia. His weight has fluctuated from 163# to 148# over the past 3 months and at present he weighs 154#. His appetite has been especially poor in the past month.,MEDS:,Sulfasalazine qid. Tylenol 650mg q4hours.,PMH:, 1)Ulcerative Colitis dx 1989. 2)HTN 3) occasional HAs since the early 1980s which are different in character and much less severe than his current HAs. They were not associated with nausea, vomiting, photophobia, phonophobia or difficulty thinking.,FHX:, MGF with h/o stroke. Mother and Father were healthy. No h/o of migraine in family.,SHX:, Single. Works as a newpaper printing press worker. Denies tobacco, ETOH or illicit drug use, but admits he was a heavy drinker until the last 1970s when he quit.,EXAM: ,BP159/92 HR 48 (sitting): BP126/70 HR48 (supine). RR14 36.2C,MS: A&O to person, place and time. Speech clear. Appears uncomfortable but acts appropriately and cooperatively. No difficulty with short and long term memory.,CN: Grad 2-3 papilledema OS; Grade 1 papilledema (@2 o'clock) OD. Pupils 4/4 decreasing to 2/2 on exposure to light. Bilateral horizontal sustained nystagmus on right and leftward gaze. Bilateral vertical sustained nystagmus on up and downward gaze. Face symmetric with full movement and PP sensation. Tongue midline with full ROM. Gag and SCM were intact bilaterally.,Motor: Full strength throughout with normal muscle bulk and tone.,Sensory: Unremarkable.,Coord: Mild dysynergia on FNF movements in BUE. HNS and RAM were unremarkable.,Station: Unsteady with and without eyes open on Romberg test. No drift in any particular direction.,Gait: Wide based, ataxic and to some degree magnetic and apraxic.,Gen Exam: Unremarkable.,COURSE:, Urinalysis revealed 1-2RBC, 2-3WBC and bacteria were noted. Repeat Urinalysis was negative the next day. PT, PTT, CXR and GS were normal. CBC revealed 10.4WBC with 7.1Granulocytes. HCT, 10/18/95, revealed hydrocephalus. MRI, 10/18/95, revealed ventriculomegaly of the lateral, 3rd and 4th ventricles. There was enhancement of the meninges about the prepontine cisterna and internal auditory canals, and enhancement of a scar or inflammed lining of the foramen of Magendie. These changes were felt suggestive of bacterial or granulomatous meningitis. The patient underwent ventriculostomy on 10/19/94. CSF taken on 10/19/94 via V-P shunt insertion revealed: 22 WBC (21 lymphocytes, 1 monocyte), 380 RBC, Glucose 58, Protein 29, GS negative, Cultures (bacterial, fungal, AFB) negative, Cryptococcal Antigen and India Ink were negative. Numerous CSF samples were taken from the lumbar region and shunt reservoir and these were consistantly unremarkable except for an occasional CSF protein of up to 99mg/dl. Serum and CSF toxoplasma titers and ACE levels were negative on multiple occasions. VDRL and HIV testing was unremarkable. 10/27/94 and 10/31/94 CSF cultures taken from the cervical region eventually grew non-encapsulated crytococcus neoformans. The patient was treated with amphotericin and showed some improvement. However, scarring had probably occurred by then and the V-P shunt was left in place.","neurology, ventriculomegaly, foramen of magendie, mri brain, blurred vision, headache, brain, ventricles, cryptococcus, foramen, csf, "
" Problems with seizures, hemiparesis, has been to the hospital, developed C-diff, and is in the nursing home currently. ", Neurology, Malignant Meningioma - Consult ,"REASON FOR VISIT: , This is a new patient evaluation for Mr. A. There is a malignant meningioma.  He is referred by Dr. X.,HISTORY OF PRESENT ILLNESS: , He said he has had two surgeries in 07/06 followed by radiation and then again in 08/07.  He then had a problem with seizures, hemiparesis, has been to the hospital, developed C-diff, and is in the nursing home currently.  He is unable to stand at the moment.  He is unable to care for himself. ,I reviewed the information that was sent down with him from the nursing home which includes his medical history.,MEDICATIONS:  ,Keppra 1500 twice a day and Decadron 6 mg four times a day.  His other medicines include oxycodone, an aspirin a day, Prilosec, Dilantin 300 a day, and Flagyl.,FINDINGS:,  On examination, he is lying on the stretcher.  He has oxygen on and has periods of spontaneous hyperventilation.  He is unable to lift his right arm or right leg.  He has an expressive dysphasia and confusion.,I reviewed the imaging studies from summer from the beginning of 10/07, end of 10/07 as well as the current MRI he had last week.  This shows that he has had progression of disease with recurrence along the surface of the brain and there is significant brain edema.  This is a malignant meningioma by diagnosis.,ASSESSMENT/PLAN: , In summary, Mr. A has significant disability and is not independent currently.  I believe that because of this that the likelihood of benefit from surgery is small and there is a very good chance that he would not be able to recover from surgery.  I do not think that surgery will help his quality of life and a need to control the tumor would be dependent on another therapy impacting the tumor.  Given that there are not good therapies and chemotherapy would be the option at the moment, and he certainly is not in a condition where chemotherapy would be given, I believe that surgery would not be in his best interest.  I discussed this both with him, although it is not clear to me how much he understood, as well as his family.","neurology, seizures, hemiparesis, tumor, seizures hemiparesis, malignant meningioma, chemotherapy, malignant, meningioma, aspirin"
 MRI Brain to evaluate sudden onset blindness - Basilar/bilateral thalamic strokes., Neurology, MRI Brain - Bilateral Thalamic Strokes ,"CC:, Sudden onset blindness.,HX:, This 58 y/o RHF was in her usual healthy state, until 4:00PM, 1/8/93, when she suddenly became blind. Tongue numbness and slurred speech occurred simultaneously with the loss of vision. The vision transiently improved to ""severe blurring"" enroute to a local ER, but worsened again once there. While being evaluated she became unresponsive, even to deep noxious stimuli. She was transferred to UIHC for further evaluation. Upon arrival at UIHC her signs and symptoms were present but markedly improved.,PMH:, 1) Hysterectomy many years previous. 2) Herniorrhaphy in past. 3) DJD, relieved with NSAIDs.,FHX/SHX:, Married x 27yrs. Husband denied Tobacco/ETOH/illicit drug use for her.,Unremarkable FHx.,MEDS:, none.,EXAM:, Vitals: 36.9C.  HR 93.  BP 151/93.  RR 22.  98% O2Sat.,MS: somnolent, but arousable to verbal stimulation. minimal speech. followed simple commands on occasion.,CN: Blinked to threat from all directions. EOM appeared full, Pupils 2/2 decreasing to 1/1. +/+Corneas. Winced to PP in all areas of Face. +/+Gag. Tongue midline. Oculocephalic reflex intact.,Motor: UE 4/5 proximally. Full strength in all other areas. Normal tone and muscle bulk.,Sensory: Withdrew to PP in all extremities.,Gait: ND.,Reflexes: 2+/2+ throughout UE, 3/3 patella, 2/2 ankles, Plantar responses were flexor bilaterally.,Gen exam: unremarkable.,COURSE: ,MRI Brain revealed bilateral thalamic strokes. Transthoracic echocardiogram (TTE) showed an intraatrial septal aneurysm with right to left shunt. Transesophageal echocardiogram (TEE) revealed the same. No intracardiac thrombus was found. Lower extremity dopplers were unremarkable. Carotid duplex revealed 0-15% bilateral ICA stenosis. Neuroophthalmologic evaluation revealed evidence of a supranuclear vertical gaze palsy OU (diminished up and down gaze). Neuropsychologic assessment 1/12-15/93 revealed severe impairment of anterograde verbal and visual memory, including acquisition and delayed recall and recognition. Speech was effortful and hypophonic with very defective verbal associative fluency. Reading comprehension was somewhat preserved, though she complained that despite the ability to see type clearly, she could not make sense of words. There was impairment of 2-D constructional praxis. A follow-up Neuropsychology evaluation in 7/93 revealed little improvement. Laboratory studies, TSH, FT4, CRP, ESR, GS, PT/PTT were unremarkable. Total serum cholesterol 195, Triglycerides 57, HDL 43, LDL 141. She was placed on ASA and discharged1/19/93.,She was last seen on 5/2/95 and was speaking fluently and lucidly. She continued to have mild decreased vertical eye movements. Coordination and strength testing were fairly unremarkable. She continues to take ASA 325 mg qd.","neurology, blindness, mri, transthoracic echocardiogram, transesophageal echocardiogram, tsh, ft4, crp, esr, gs, pt/ptt, bilateral thalamic strokes, sudden onset blindness, mri brain, thalamic strokes, brain, thalamic, strokes, "
 MRI Brain - Olfactory groove meningioma., Neurology, MRI Brain -  Meningioma (Olfactory) ,"CC:, Progressive visual loss.,HX:, 76 y/o male suddenly became anosmic following shoulder surgery 13 years prior to this presentation. He continues to be anosmic, but has also recently noted decreased vision OD. He denies any headaches, weakness, numbness, weight loss, or nasal discharge.,MEDS:, none.,PMH:, 1) Diabetes Mellitus dx 1 year ago. 2) Benign Prostatic Hypertrophy, s/p TURP. 3) Right shoulder surgery (?DJD).,FHX:, noncontributory.,SHX:, Denies history of Tobacco/ETOH/illicit drug use.,EXAM:, BP132/66 HR78 RR16 36.0C,MS: A&O to person, place, and time. No other specifics given in Neurosurgery/Otolaryngology/Neuro-ophthalmology notes.,CN: Visual acuity has declined from 20/40 to 20/400, OD; 20/30, OS. No RAPD. EOM was full and smooth and without nystagmus. Goldmann visual fields revealed a central scotoma and enlarged blind spot OD and OS (OD worse) with a normal periphery. Intraocular pressures were 15/14 (OD/OS). There was moderate pallor of the disc, OD. Facial sensation was decreased on the right side (V1 distribution).,Motor/Sensory/Coord/Station/Gait: were all unremarkable.,Reflexes: 2/2 and symmetric throughout. Plantars were flexor, bilaterally.,Gen Exam: unremarkable.,COURSE:, MRI Brain, 10/7/92, revealed: a large 6x5x6cm slightly heterogeneous, mostly isointense lesion on both T1 and T2 weighted images arising from the planum sphenoidale and olfactory groove. The mass extends approximately 3.6cm superior to the planum into both frontal regions with edema in both frontal lobes. The mass extends 2.5cm inferiorly involving the ethmoid sinuses with resultant obstruction of the sphenoid and frontal sinuses.,It also extends into the superomedial aspect of the right maxillary sinus. There is probable partial encasement of both internal carotid arteries just above the siphon. The optic nerves are difficult to visualize but there is also probable encasement of these structures as well. The mass enhances significantly with gadolinium contrast. These finds are consistent with Meningioma.,The patient underwent excision of this tumor by simultaneous bifrontal craniotomy and lateral rhinotomy following an intrasinus biopsy which confirmed the meningioma. Postoperatively, he lost visual acuity, OS, but this gradually returned to baseline. His 9/6/96 neuro-ophthalmology evaluation revealed visual acuity of 20/25-3 (OD) and 20/80-2 (OS). His visual fields continued to abnormal, but improved and stable when compared to 10/92. His anosmia never resolved.","neurology, mri brain, olfactory, groove, headaches, meningioma, nasal discharge, numbness, visual loss, weakness, weight loss, visual acuity, mri, brain, isointense, sinuses, visual, "
 Patient with sudden onset dizziness and RUE clumsiness.  Giant Left MCA Aneurysm., Neurology, MCA Aneurysm ,"HX: ,This 46y/o RHM with HTN was well until 2 weeks prior to exam when he experienced sudden onset dizziness and RUE clumsiness. The symptoms resolved within 10 min. He did well until the afternoon of admission when while moving the lawn he experienced lightheadedness, RUE dysfunction and expressive aphasia (could not get the words out). His wife took him to his local MD, and on the way there his symptoms resolved. His aphasia recurred at his physician's office and a CT scan of the brain revealed a left temporal mass. He was transferred to UIHC.,PMH:, HTN for many years,MEDS:, Vasotec and Dyazide,SHX/FHX:, ETOH abuse (quit '92), 30pk-yr Cigarettes (quit '92),EXAM:, BP158/92, HR91, RR16,MS: Speech fluent without dysarthria,CN: no deficits noted,Motor: no weakness or abnormal tone noted,Sensory: no deficits noted,Coord: normal,Station: no drift,Gait ND,Reflexes: 3+ throughout. Plantars down-going bilaterally.,Gen exam: unremarkable,STUDIES:, WBC14.3K, Na 132, Cl 94, CO2 22, Glucose 129.,CT Brain without contrast: Calcified 2.5 x 2.5cm mass arising from left sylvian fissure/temporal lobe.,MRI Brain, 8/31/92: right temporo-parietal mass with mixed signal on T1 and T2 images. It has a peripheral dark rim on T1 and T2 with surrounding edema. This suggests a component of methemoglobin and hemosiderin within it. Slight peripheral enhancement was identified. There are two smaller foci of enhancement in the posterior parietal lobe on the right. There is nonspecific white matter foci within the pons and right thalamus. Impression: right temporoparietal hemorrhage, suggesting aneurysm or mass. The two smaller foci may suggest metastasis. The white matter changes probably reflect microvascular disease.,3 Vessel cerebroangiogram, 8/31/92: Lobulated fusiform aneurysm off a peripheral branch of the left middle cerebral artery with slow flow into the vessel distal to the aneurysm.,COURSE:, The aneurysm was felt to be inoperable and he was discharged home on Dilantin, ASA, and Diltiazem.","neurology, mca aneurysm, rue clumsiness, white matter, aneurysm, mca, dizziness, aphasia, matter, clumsiness, brain, peripheral, "
" Briefly, the patient has a lumbosacral polyradiculopathy that is temporally related to the epidural anesthesia given to her in October of 2008.", Neurology, Lumbosacral Polyradiculopathy ,"HISTORY OF PRESENT ILLNESS: , The patient is a 35-year-old woman who reports that on the 30th of October 2008, she had a rupture of her membranes at nine months of pregnancy, and was admitted to hospital and was given an epidural anesthetic.  I do not have the records from this hospital admission, but apparently the epidural was administered for approximately 14 to 18 hours.  She was sitting up during the epidural.,She did not notice any difference in her lower extremities at the time she had the epidural; however, she reports that she was extremely sleepy and may not have been aware of any change in strength or sensation in her lower extremities at that time.  She delivered on the 31st of October, by Cesarean section, because she had failed to progress and had pyrexia.,She also had a Foley catheter placed at that time.  On the 1st of November 2008, they began to mobilize her and it was at that time that she first noticed that she could not walk.  She was aware that she could not move her legs at all, and then within a few days, she was aware that she could move toes in the left foot but could not move her right foot at all.  Since that time, there has been a gradual improvement in strength to the point that she now has limited movement in her left leg and severely restricted movement in her right leg.  She is not able to walk by herself, and needs assistance to stand.  She was discharged from hospital after the Cesarean section on the 3rd of November.  Unfortunately, we do not have the records and we do not know what the discussion was between the anesthesiologist and the patient at the time of discharge.  She was then seen at ABC Hospital on November 05, 2008.  She had an MRI scan of her spine, which showed no evidence of an abnormality, specifically there were no cord changes and no evidence of a hematoma.  She also had an EMG study at that time by Dr. X, which was abnormal but not diagnostic and this was repeated again in December.  At the present time, she also complains of a pressure in both her legs and in her thighs.  She complains that her right foot hurts and that she has some hyperesthesia there.  She has been taking gabapentin to try to reduce the discomfort, although she is on a very low dose and the effect is minimal.  She has no symptoms in her arms, her bowel and bladder function is normal, and her bulbar function is normal.  There is no problem with her vision, swallowing, or respiratory function.,PAST MEDICAL HISTORY: , Unremarkable except as noted above.  She has seasonal allergies.,CURRENT MEDICATIONS:,  Gabapentin 300 mg b.i.d., Centrum once a day, and another multivitamin.,ALLERGIES: , She has no medication allergies, but does have seasonal allergies.,FAMILY HISTORY: , There is a family history of diabetes and hypertension.  There is no family history of a neuropathy or other neurological disease.  She has one child, a son, born on October 31, 2008.,SOCIAL HISTORY: , The patient is a civil engineer, who currently works from home.  She is working approximately half time because of limitations imposed on her by her disability, need to attend frequent physical therapy, and also the needs of looking after her baby.  She does not smoke and does not drink and has never done either.,GENERAL PHYSICAL EXAMINATION:,VITAL SIGNS:  P 74, BP 144/75, and a pain score of 0.,GENERAL:  Her general physical examination was unremarkable.,CARDIOVASCULAR:  Normal first and second heart sound, regular pulse with normal volume.,RESPIRATORY:  Unremarkable, both lung bases were clear, and respiration was normal.,GI:  Unremarkable, with no organomegaly and normal bowel sounds.,NEUROLOGICAL EXAM:,MSE:  The patient's orientation was normal, fund of knowledge was normal, memory was normal, speech was normal, calculation was normal, and immediate and long-term recall was normal.  Executive function was normal.,CRANIAL NERVES:  The cranial nerve examination II through XII was unremarkable.  Both disks were normal, with normal retina.  Pupils were equal and reactive to light.  Eye movements were full.  Facial sensation and strength was normal.  Bulbar function was normal.  The trapezius had normal strength.,MOTOR:  Muscle tone showed a slight increase in tone in the lower extremities, with normal tone in the upper extremities.  Muscle strength was 5/5 in all muscle groups in the upper extremities.  In the lower extremities, the hip flexors were 1/5 bilaterally, hip extensors were 1/5 bilaterally, knee extension on the right was 1/5 and on the left was 3-/5, knee flexion was 2/5 on the right and 3-/5 on the left, foot dorsiflexion was 0/5 on the right and 1/5 on the left, foot plantar flexion was 4-/5 on the right and 4+/5 on the left, toe extension was 0/5 on the right and 4-/5 on the left, toe flexion was 4-/5 on the right and 4+/5 on the left.,REFLEXES:  Reflexes in the upper extremities were 2+ bilaterally.  In the lower extremities, they were 0 bilaterally at the knee and ankles.  The abdominal reflexes were present above the umbilicus and absent below the umbilicus.  The plantar responses were mute.  The jaw reflex was normal.,SENSATION:  Vibration was moderately decreased in the right great toe and was mildly decreased in the left great toe.  There was a sensory level to light touch at approximately T7 posteriorly and approximately T9 anteriorly.  There was a range of sensation, but clearly there was a decrease in sensation below this level but not complete loss of sensation.  To pain, the sensory level is even less clear, but appeared to be at about T7 on the right side.  In the lower extremities, there was a slight decrease in pin and light touch in the right great toe compared to the left.  There was no evidence of allodynia or hyperesthesia.  Joint position sense was mildly reduced in the right toe and normal on the left.,COORDINATION:  Coordination for rapid alternating movements and finger-to-nose testing was normal.  Coordination could not be tested in the lower extremities.,GAIT:  The patient was unable to stand and therefore we were unable to test gait or Romberg's.  There was no evidence of focal back tenderness.,REVIEW OF OUTSIDE RECORDS: , I have reviewed the records from ABC Hospital, including the letter from Dr. Y and the EMG report dated 12/17/2008 from Dr. X. The EMG report shows evidence of a lumbosacral polyradiculopathy below approximately T6.  The lower extremity sensory responses are essentially normal; however, there is a decrease in the amplitude of the motor responses with minimal changes in latency.  I do have the MRI of lumbar spine report from 11/06/2008 with and without contrast.  This showed a minimal concentric disc bulge of L4-L5 without disc herniation, but was otherwise unremarkable.  The patient brought a disc with a most recent MRI study; however, we were unable to open this on our computers.  The verbal report is that the study was unremarkable except for some gadolinium enhancement in the lumbar nerve roots.  A Doppler of the lower extremities showed no evidence of deep venous thrombosis in either lower extremity.  Chest x-ray showed some scoliosis on the lumbar spine, curve to the left, but no evidence of other abnormalities.  A CT pelvis study performed on November 07, 2008 showed some nonspecific fluid in the subcutaneous fat of the back, posterior to L4 and L5 levels; however, there were no pelvic masses or other abnormalities.  We were able to obtain an update of the report from the MRI of the lumbar spine with and without contrast dated 12/30/2008.  The complete study included the cervical, thoracic, and lumbar spine.  There was diffuse enhancement of the nerve roots of the cauda equina that had increased in enhancement since prior exam in November.  It was also reported that the patient was given intravenous methylprednisolone and this had had no effect on strength in her lower extremities.,IMPRESSION: , The patient has a condition that is temporarily related to the epidural injection she was given at the end of October 2008, prior to her Cesarean section.  It appears she became aware of weakness within two days of the administration of the epidural, she was very tired during the epidural and may have missed some change in her neurological function.  She was severely weak in both lower extremities, slightly worse on the right than the left.  There has been some interval improvement in her strength since the beginning of November 2008.  Her EMG study from the end of December is most consistent with a lumbosacral polyradiculopathy.  The MRI findings of gadolinium enhancement in the lumbar nerve roots would be most consistent with an inflammatory radiculitis most likely related to the epidural anesthesia or administration of the epidural.  There had been no response to IV methylprednisolone given to her at ABC.  The issue of having a lumbar puncture to look for evidence of inflammatory cells or an elevated protein had been discussed with her at both ABC and by myself.  The patient did not wish to consider a lumbar puncture because of concerns that this might worsen her condition.  At the present time, she is able to stand with aid but is unable to walk.  There is no evidence on her previous EMG of a demyelinating neuropathy.,RECOMMENDATIONS:,1.  The diagnostic issues were discussed with the patient at length.  She is informed that this is still early in the course of the problem and that we expect her to show some improvement in her function over the next one to two years, although it is unclear as to how much function she will regain.,2.  She is strongly recommended to continue with vigorous physical therapy, and to continue with the plan to mobilize her as much as possible, with the goal of trying to get her ambulatory.  If she is able to walk, she will need bilateral AFOs for her ankles, to improve her overall mobility.  I am not prescribing these because at the present time she does not need them.,3.  We discussed increasing the dose of gabapentin.  The paresthesias that she has may indicate that she is actually regaining some sensory function, although there is a concern that as recovery continues, she may be left with significant neuropathic pain.  If this is the case, I have advised her to increase her gabapentin dose from 300 mg b.i.d. gradually up to 300 mg four times a day and then to 600 mg to 900 mg four times a day.  She may need other neuropathic pain medications as needed.  She will determine whether her current symptoms are significant enough to require this increase in dosage.,4.  The patient will follow up with Dr. Y and his team at ABC Hospital.  She will also continue with physical therapy within the ABC system.",
" The patient with gradual onset of a headache problem, located behind both eyes.", Neurology, Migraine without Aura - Consult ,"CHIEF COMPLAINT:, Headaches.,HEADACHE HISTORY:, The patient describes the gradual onset of a headache problem. The headache first began 2 months ago. The headaches are located behind both eyes. The pain is characterized as a sensation of pressure. The intensity is moderately severe, making normal activities difficult. Associated symptoms include sinus congestion and photophobia. The headache may be brought on by stress, lack of sleep and alcohol. The patient denies vomiting and jaw pain.,PAST MEDICAL HISTORY:, No significant past medical problems.,PAST SURGICAL HISTORY:, ,No significant past surgical history.,FAMILY MEDICAL HISTORY:, ,There is a history of migraine in the family. The condition affects the patient’s brother and maternal grandfather.,ALLERGIES:, Codeine.,CURRENT MEDICATIONS:, See chart.,PERSONAL/SOCIAL HISTORY:, Marital status: Married. The patient smokes 1 pack of cigarettes per day.  Denies use of alcohol.,NEUROLOGIC DRUG HISTORY:, The patient has had no help with the headaches from over-the-counter analgesics.,REVIEW OF SYSTEMS:,ROS General: Generally healthy. Weight is stable.,ROS Head and Eyes: Patient has complaints of headaches. Vision can best be described as normal.,ROS Ears Nose and Throat: The patient notes some sinus congestion.,ROS Cardiovascular: The patient has no history of any cardiovascular problems and denies any present problems.,ROS Gastrointestinal: The patient has no history of gastrointestinal problems and denies any present problems.,ROS Musculoskeletal: No muscle cramps, no joint back or limb pain. The patient denies any past or present problem related to the musculoskeletal system.,EXAM:,Exam General Appearance: The patient was alert and cooperative, and did not appear acutely or chronically ill.,Sex and Race: Male, Caucasian.,Exam Mental Status: Serial 7’s were performed normally. The patient was oriented with regard to time, place and situation.,Three out of three objects were readily recalled after several minutes. The patient correctly identified the president and past president. The patient could repeat 7 digits forward and 4 digits reversed without difficulty. The patient’s affect and emotional response was normal and appropriate. The patient related the clinical history in a coherent, organized fashion.,Exam Cranial Nerves: Sense of smell was intact.,Exam Neck: Neck range of motion was normal in all directions. There was no evidence of cervical muscle spasm.  No radicular symptoms were elicited by neck motions. Shoulder range of motion was normal bilaterally. There were no areas of tenderness. Tests of neurovascular compression were negative. There were no carotid bruits.,Exam Back: Back range of motion was normal in all directions.,Exam Sensory: Position and vibratory sense was normal.,Exam Reflexes: Active and symmetrical. There were no pathological reflexes.,Exam Coordination: The patient’s gait had no abnormal components. Tandem gait was performed normally.,Exam Musculoskeletal: Peripheral pulses palpably normal. There is no edema or significant varicosities.  No lesions identified.,IMPRESSION DIAGNOSIS: ,Migraine without aura (346.91),COMMENTS:, The patient has evolved into a chronic progressive course. Medications Prescribed: Therapeutic trial of Inderal 40mg - 1/2 tab b.i.d. x 1 week, then 1 tab. b.i.d. x 1 week then 1 tab t.i.d.,OTHER TREATMENT:, The patient was given a thorough explanation of the role of stress in migraine, and given a number of suggestions about implementing appropriate changes in lifestyle.,RATIONALE FOR TREATMENT PLAN:, The treatment plan chosen is the most effective and should result in the most beneficial outcome for the patient. There are no reasonable alternatives.,FOLLOW UP INSTRUCTIONS:",
" A 21-month-old male presented for delayed motor development, ""jaw quivering"" and ""lazy eye."" ", Neurology, Lobar Holoprosencephaly ,"CC: ,Delayed motor development.,HX:, This 21 month old male presented for delayed motor development, ""jaw quivering"" and ""lazy eye."" He was an 8 pound 10 ounce product of a full term, uncomplicated pregnancy-labor-spontaneous vaginal delivery to a G3P3 married white female mother. There had been no known toxic intrauterine exposures. He had no serious illnesses or hospitalizations since birth. He sat independently at 7 months, stood at 11 months, crawled at 16 months, but did not cruise until 18 months.,He currently cannot walk and easily falls. His gait is reportedly marked by left ""intoeing."" His upper extremity strength and coordination reportedly appear quite normal and he is able to feed himself, throw and transfer objects easily. He knows greater than 20 words and speaks two-word phrases.,No seizures or unusual behavior were reported except for ""quivering"" movement of his jaw. This has occurred since birth. In addition the parents have noted transient left exotropia.,PMH: ,As above.,FHX:, Many family members with ""lazy eye."" No other neurologic diseases declared.,9 and 5 year old sisters who are healthy.,SHX:, lives with parents and sisters.,EXAM:, BP83/67 HR122 36.4C Head circumference 48.0cm Weight 12.68kg (70%) Height 86.0cm (70%),MS: fairly cooperative.,CN: Minimal transient esotropia OS. Tremulous quivering of jaw--increased with crying. No obvious papilledema, though difficult to evaluate due to patient movement.,Motor: sat independently with normal posture and no truncal ataxia. symmetric and normal strength and muscle bulk throughout.,Sensory: withdrew to vibration.,Coordination: unremarkable in BUE.,Station: no truncal ataxia.,Gait: On attempting to walk, his right foot rotated laterally at almost 70degrees. Both lower extremities could rotate outward to 90degrees. There was marked passive eversion at the ankles as well.,Reflexes: 2+/2+ throughout.,Musculoskeletal: pes planovalgus bilaterally.,COURSE: ,CK normal. The parents decided to forego an MRI in 8/90. The patient returned 12/11/92 at age 4 years. He was ambulatory and able to run awkwardly. His general health had been good, but he showed signs developmental delay. Formal evaluation had tested his IQ at 87 at age 3.5 years. He was weakest on tasks requiring visual/motor integration and fine motor and visual discrimination skills. He was 6 months delayed in cognitive development at that time. On exam, age 4 years, he displayed mild right ankle laxity on eversion and inversion, but normal gait. The rest of the neurological exam was normal. Head circumference was 49.5cm (50%) and height and weight were in the 90th percentile. Fragile X analysis and karyotyping were unremarkable.","neurology, delayed motor development, jaw quivering, head circumference, truncal ataxia, delayed motor, motor development, lazy eye, jaw, quivering, delayed, intrauterine, "
 Lumbar puncture with moderate sedation., Neurology, Lumbar Puncture - 1 ,"PROCEDURE: , Lumbar puncture with moderate sedation.,INDICATION: , The patient is a 2-year, 2-month-old little girl who presented to the hospital with severe anemia, hemoglobin 5.8, elevated total bilirubin consistent with hemolysis and weak positive direct Coombs test.  She was transfused with packed red blood cells.  Her hemolysis seemed to slow down.  She also on presentation had indications of urinary tract infection with urinalysis significant for 2+ leukocytes, positive nitrites, 3+ protein, 3+ blood, 25 to 100 white cells, 10 to 25 bacteria, 10 to 25 epithelial cells on clean catch specimen.  Culture subsequently grew out no organisms; however, the child had been pretreated with amoxicillin about x3 doses prior to presentation to the hospital.  She had a blood culture, which was also negative.  She was empirically started on presentation with the cefotaxime intravenously.  Her white count on presentation was significantly elevated at 20,800, subsequently increased to 24.7 and then decreased to 16.6 while on antibiotics.  After antibiotics were discontinued, she increased over the next 2 days to an elevated white count of 31,000 with significant bandemia, metamyelocytes and myelocytes present.  She also had three episodes of vomiting and thus she is being taken to the procedure room today for a lumbar puncture to rule out meningitis that may being inadvertently treated in treating her UTI.,I discussed with The patient's parents prior to the procedure the lumbar puncture and moderate sedation procedures.  The risks, benefits, alternatives, complications including, but not limited to bleeding, infection, respiratory depression.  Questions were answered to their satisfaction.  They would like to proceed.,PROCEDURE IN DETAIL: , After ""time out"" procedure was obtained, the child was given appropriate monitoring equipment including appropriate vital signs were obtained.  She was then given Versed 1 mg intravenously by myself.  She subsequently became sleepy, the respiratory monitors, end-tidal, cardiopulmonary and pulse oximetry were applied.  She was then given 20 mcg of fentanyl intravenously by myself.  She was placed in the left lateral decubitus position.  Dr. X cleansed the patient's back in a normal sterile fashion with Betadine solution.  She inserted a 22-gauge x 1.5-inch spinal needle in the patient's L3-L4 interspace that was carefully identified under my direct supervision.  Clear fluid was not obtained initially, needle was withdrawn intact.  The patient was slightly repositioned by the nurse and Dr. X reinserted the needle in the L3-L4 interspace position, the needle was able to obtain clear fluid, approximately 3 mL was obtained.  The stylette was replaced and the needle was withdrawn intact and bandage was applied.  Betadine solution was cleansed from the patient's back.,During the procedure, there were no untoward complications, the end-tidal CO2, pulse oximetry, and other vitals remained stable.  Of note, EMLA cream had also been applied prior procedure, this was removed prior to cleansing of the back.,Fluid will be sent for a routine cell count, Gram stain culture, protein, and glucose.,DISPOSITION: , The child returned to room on the medical floor in satisfactory condition.","neurology, moderate sedation, lumbar puncture, needle, lumbar, "
 Patient with a 1-year history of progressive anterograde amnesia, Neurology, Limbic Encephalitis ,"CC:, Rapidly progressive amnesia.,HX: ,This 63 y/o RHM presented with a 1 year history of progressive anterograde amnesia. On presentation he could not remember anything from one minute to the next. He also had some retrograde memory loss, in that he could not remember the names of his grandchildren, but had generally preserved intellect, language, personality, and calculating ability. He underwent extensive evaluation at the Mayo Clinic and an MRI there revealed increased signal on T2 weighted images in the mesiotemporal lobes bilaterally. There was no mass affect. The areas mildly enhanced with gadolinium.,PMH:, 1) CAD; MI x 2 (1978 and 1979). 2) PVD; s/p aortic endarterectomy (3/1991). 3)HTN. 4)Bilateral inguinal hernia repair.,FHX/SHX:, Mother died of a stroke at age 58. Father had CAD and HTN. The patient quit smoking in 1991, but was a heavy smoker (2-3ppd) for many years. He had been a feed salesman all of his adult life.,ROS:, Unremarkable. No history of cancer.,EXAM:, BP 136/75 HR 73 RR12 T36.6,MS: Alert but disoriented to person, place, time. He could not remember his birthdate, and continually asked the interviewer what year it was. He could not remember when he married, retired, or his grandchildren's names. He scored 18/30 on the Follutein's MMSE with severe deficits in orientation and memory. He had moderate difficulty naming. He repeated normally and had no constructional apraxia. Judgement remained good.,CN: unremarkable.,Motor: Full strength throughout with normal muscle tone and bulk.,Sensory: Intact to LT/PP/PROP,Coordination: unremarkable.,Station: No pronator drift, truncal ataxia or Romberg sign.,Gait: unremarkable.,Reflexes: 3+ throughout with downgoing plantar responses bilaterally.,Gen Exam: unremarkable.,STUDIES:, MRI Brain revealed hyperintense T2 signal in the mesiotemporal regions bilaterally, with mild enhancement on the gadolinium scans. MRI and CT of the chest and CT of the abdomen showed no evidence of lymphadenopathy or tumor. EEG was normal awake and asleep. Antineuronal antibody screening was unremarkable. CSF studies were unremarkable and included varicella zoster, herpes zoster, HIV and HTLV testing, and cytology. The patient underwent stereotactic brain biopsy at the Mayo Clinic which showed inflammatory changes, but no organism or etiology was concluded. TFT, B12, VDRL, ESR, CRP, ANA, SPEP and Folate studies were unremarkable. Neuropsychologic testing revealed severe anterograde memory (verbal and visual)loss, and less severe retrograde memory loss. Most other cognitive abilities were well preserved and the findings were consistent with mesiotemporal dysfunction bilaterally.,IMPRESSION:, Limbic encephalitis secondary to cancer of unknown origin.,He was last seen 7/26/96. MMSE 20/30 and category fluency 20 . Disinhibited affect. Mild right grasp reflex. The clinical course was benign and non-progressive, and unusual for such a diagnosis, though not unheard of .","neurology, mri brain, progressive anterograde amnesia, retrograde memory loss, limbic encephalitis, anterograde amnesia, memory loss, limbic, encephalitis, amnesia, anterograde, memory, "
" Lumbar discogram L2-3, L3-4, L4-5, and L5-S1.  Low back pain.", Neurology, Lumbar Discogram ,"PREOPERATIVE DIAGNOSIS: , Low back pain.,POSTOPERATIVE DIAGNOSIS: , Low back pain.,PROCEDURE PERFORMED:,1.  Lumbar discogram L2-3.,2.  Lumbar discogram L3-4.,3.  Lumbar discogram L4-5.,4.  Lumbar discogram L5-S1.,ANESTHESIA:  ,IV sedation.,PROCEDURE IN DETAIL:  ,The patient was brought to the Radiology Suite and placed prone onto a radiolucent table.  The C-arm was brought into the operative field and AP, left right oblique and lateral fluoroscopic images of the L1-2 through L5-S1 levels were obtained.  We then proceeded to prepare the low back with a Betadine solution and draped sterile.  Using an oblique approach to the spine, the L5-S1 level was addressed using an oblique projection angled C-arm in order to allow for perpendicular penetration of the disc space.  A metallic marker was then placed laterally and a needle entrance point was determined.  A skin wheal was raised with 1% Xylocaine and an #18-gauge needle was advanced up to the level of the disc space using AP, oblique and lateral fluoroscopic projections.  A second needle, #22-gauge 6-inch needle was then introduced into the disc space and with AP and lateral fluoroscopic projections, was placed into the center of the nucleus.  We then proceeded to perform a similar placement of needles at the L4-5, L3-4 and L2-3 levels.,A solution of Isovue 300 with 1 gm of Ancef was then drawn into a 10 cc syringe and without informing the patient of our injecting, we then proceeded to inject the disc spaces sequentially.","neurology, back pain, c-arm, fluoroscopic projections, disc space, lumbar discogram, fluoroscopic, needle,"
 Possible CSF malignancy.  This is an 83-year-old woman referred for diagnostic lumbar puncture for possible malignancy by Dr. X.   The patient has gradually stopped walking even with her walker and her left arm has become gradually less functional.  She is not able to use the walker because her left arm is so weak. , Neurology, Lumbar Puncture ,"REASON FOR VISIT:  ,This is an 83-year-old woman referred for diagnostic lumbar puncture for possible malignancy by Dr. X. She is accompanied by her daughter.,HISTORY OF PRESENT ILLNESS:,  The patient' daughter tells me that over the last month the patient has gradually stopped walking even with her walker and her left arm has become gradually less functional.  She is not able to use the walker because her left arm is so weak.  She has not been having any headaches.  She has had a significant decrease in appetite.  She is known to have lung cancer, but Ms. Wilson does not know what kind.  According to her followup notes, it is presumed non-small cell lung cancer of the left upper lobe of the lung.  The last note I have to evaluate is from October 2008.  CT scan from 12/01/2009 shows atrophy and small vessel ischemic change, otherwise a normal head CT, no mass lesion.  I also reviewed the MRI from September 2009, which does not suggest normal pressure hydrocephalus and shows no mass lesion.,Blood tests from 11/18/2009 demonstrate platelet count at 132 and INR of 1.0.,MAJOR FINDINGS: , The patient is a pleasant and cooperative woman who answers the questions the best she can and has difficulty moving her left arm and hand.  She also has pain in her left arm and hand at a level of 8-9/10.,VITAL SIGNS: , Blood pressure 126/88, heart rate 70, respiratory rate 16, and weight 95 pounds.,I screened the patient with questions to determine whether it is likely she has abnormal CSF pressure and she does not have any of the signs that would suggest this, so we performed the procedure in the upright position.,PROCEDURE:,  Lumbar puncture, diagnostic (CPT 62270).,PREOPERATIVE DIAGNOSIS: , Possible CSF malignancy.,POSTOPERATIVE DIAGNOSIS:  ,To be determined after CSF evaluation.,PROCEDURE PERFORMED: , Lumbar puncture.,ANESTHESIA: , Local with 2% lidocaine at the L4-L5 level.,SPECIMEN REMOVED:  ,15 cc of clear CSF.,ESTIMATED BLOOD LOSS: , None.,DESCRIPTION OF THE PROCEDURE:  ,I explained the procedure, its rationale, risks, benefits, and alternatives to the patient and her daughter.  The patient' daughter remained present throughout the procedure.  The patient provided written consent and her daughter signed as witness to the consent.,I located the iliac crest and spinous processes before the procedure and determined the level I planned for the puncture.  During the procedure, I spoke constantly with the patient to explain what was happening and to warn when there might be pain or discomfort.  The skin was prepped with chlorhexidine solution with the patient seated on the chair leaning forward with her face resting on the exam table.  Using local anesthetic and aseptic technique, I inserted a 20-gauge spinal needle at the L4-L5 interspace and 15 cc of CSF was collected without difficulty.,The patient tolerated the procedure well.,ASSESSMENT:  ,White blood cells 1, red blood cells 54, glucose 59, protein 51, Gram stain negative, bacterial culture negative after three days, and remaining tests pending.",
 The patient comes in today because of feeling lightheaded and difficulty keeping his balance., Neurology, Lightheadedness ,"HISTORY OF PRESENT ILLNESS:  ,The patient comes in today because of feeling lightheaded and difficulty keeping his balance.  He denies this as a spinning sensation that he had had in the past with vertigo.  He just describes as feeling very lightheaded.  It usually occurs with position changes such as when he stands up from the sitting position or stands up from a lying position.  It tends to ease when he sits down again, but does not totally resolve for another 15 to 30 minutes and he feels shaky and weak all over.  Lorazepam did not help this sensation.  His blood pressure has been up lately and his dose of metoprolol was increased.  They feel these symptoms have gotten worse since metoprolol was increased.,PAST MEDICAL HISTORY: , Detailed on our H&P form.  Positive for elevated cholesterol, diabetes, glaucoma, cataracts, hypertension, heart disease, vertigo, stroke in May of 2005, congestive heart failure, CABG, and cataract removed right eye.,CURRENT MEDICATIONS: , Detailed on the H&P form.,PHYSICAL EXAMINATION: , His blood pressure sitting down was 180/80 with a pulse rate of 56.  Standing up blood pressure was 160/80 with a pulse rate of 56.  His general exam and neurological exam were detailed on our H&P form.  Pertinent positives on his neurological exam were decreased sensation in his left face, and left arm and leg.,IMPRESSION AND PLAN:  ,This lightheaded, he exquisitely denies vertigo, the vertigo that he has had in the past.  He states this is more of a lightheaded type feeling.  He did have a mild blood pressure drop here in the office.  We are also concerned that bradycardia might be contributing to his feeling of lightheadedness.  We are going to suggest that he gets a Holter monitor and he should speak to his general practitioner as well as his cardiologist regarding the lightheaded feeling.,We will schedule him for the Holter monitor and refer him back to his cardiologist.","neurology, lightheaded feeling, feeling lightheaded, pulse rate, neurological exam, holter monitor, blood pressure, balance, vertigo, lightheadedness, "
" Headache, improved.  Intracranial aneurysm.", Neurology, Intracranial aneurysm - ER Visit ,"CHIEF COMPLAINT:,  Headache.,HPI: , This is a 24-year-old man who was seen here originally on the 13th with a headache and found to have a mass on CT scan.  He was discharged home with a follow up to neurosurgery on the 14th.  Apparently, an MRI the next day showed that the mass was an aneurysm and he is currently scheduled for an angiogram in preparation for surgery.  He has had headaches since the 13th and complains now of some worsening of his pain.  He denies photophobia, fever, vomiting, and weakness of the arms or legs.,PMH: , As above.,MEDS:,  Vicodin.,ALLERGIES:,  None.,PHYSICAL EXAM:  ,BP 180/110 Pulse 65 RR 18 Temp 97.5.,Mr. P is awake and alert, in no apparent distress.,HEENT:  Pupils equal, round, reactive to light, oropharynx moist, sclera clear.  ,Neck:  Supple, no meningismus.,Lungs:  Clear.,Heart:  Regular rate and rhythm, no murmur, gallop, or rub.  ,Abdomen:  Benign.,Neuro:  Awake and alert, motor strength normal, no numbness, normal gait, DTRs normal.  Cranial nerves normal.  ,COURSE IN THE ED:  ,Patient had a repeat head CT to look for an intracranial bleed that shows an unchanged mass, no blood, and no hydrocephalus.  I recommended an LP but he prefers not to have this done.  He received morphine for pain and his headache improved.  I've recommended admission but he has chosen to go home and come back in the morning for his scheduled angiogram.  He left the ED against my advice.  ,IMPRESSION: , Headache, improved.  Intracranial aneurysm.,PLAN: , The patient will return tomorrow am for his angiogram.","neurology, angiogram, mass, ct scan, intracranial aneurysm, headache, aneurysm, intracranial, "
" Right shoulder impingement syndrome, right suprascapular neuropathy.", Neurology, Impairment Rating ,"CHIEF COMPLAINT: , Right shoulder pain.,HISTORY: , The patient is a pleasant, 31-year-old, right-handed, white female who injured her shoulder while transferring a patient back on 01/01/02.  She formerly worked for Veteran's Home as a CNA.  She has had a long drawn out course of treatment for this shoulder.  She tried physical therapy without benefit and ultimately came to a subacromion decompression in November 2002.  She had ongoing pain and was evaluated by Dr. X who felt that she had a possible brachial plexopathy.  He also felt she had a right superficial radial neuritis and blocked this with resolution of her symptoms.  He then referred her to ABCD who did EMG testing, demonstrating a right suprascapular neuropathy although a C5 radiculopathy could not be ruled out.  MRI testing on the cervical spine was then done which was negative for disk herniation and she underwent suprascapular nerve decompression of the scapular notch on 12/18/03.  She finally went to an anterior axillary nerve block because of ongoing pain in the anterior shoulder again by Dr. X.  She comes to me for impairment rating.  She has no chronic health problems otherwise, fevers, chills, or general malaise.  She is not working.  She is right-hand dominant.  She denies any prior history of injury to her shoulder.,PAST MEDICAL HISTORY:,  Negative aside from above.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:  ,Please see above.,REVIEW OF SYSTEMS:,  Negative aside from above.,PHYSICAL EXAMINATION:  ,A pleasant, age appropriate woman, moderately overweight, in no apparent distress.  Normal gait and station, normal posture, normal strength, tone, sensation and deep tendon reflexes with the exception of 4+/5 strength in the supraspinatus musculature on the right.  She has decreased motion in the right shoulder as follows.  She has 160 degrees of flexion, 155 degrees of abduction, 35 degrees of extension, 25 degrees of adduction, 45 degrees of internal rotation and 90 degrees of external rotation.  She has a positive impingement sign on the right.,ASSESSMENT:,  Right shoulder impingement syndrome, right suprascapular neuropathy.,DISCUSSION: , With a reasonable degree of medical certainty, she is at maximum medical improvement and she does have an impairment based on AMA Guide to the Evaluation of Permanent Impairment, Fifth Edition.  The reason for this impairment is the incident of 01/01/02.  For her suprascapular neuropathy, she is rated as a grade IV motor deficit which I rate as a 13% motor deficit.  This is multiplied by a maximum upper extremity impairment for involvement of the suprascapular nerve of 16% which produces a 2% impairment of the upper extremity when the two values are multiplied together, 2% impairment of the upper extremity.  For her lack of motion in the shoulder she also has additional impairment on the right.  She has a 1% impairment of the upper extremity due to lack of shoulder flexion.  She has a 1% impairment of the upper extremity due to lack of shoulder abduction.  She has a 1% impairment of the upper extremity due to lack of shoulder adduction.  She has a 1% impairment of the upper extremity due to lack of shoulder extension.  There is no impairment for findings in shoulder external rotation.  She has a 3% impairment of the upper extremity due to lack of shoulder internal rotation.  Thus the impairment due to lack of motion in her shoulder is a 6% impairment of the upper extremity.  This combines with the 2% impairment of the upper extremity due to weakness in the suprascapular nerve root distribution to produce an 8% impairment of the upper extremity which in turn is a 5% impairment of the whole person based on the AMA Guide to the Evaluation of Permanent Impairment, Fifth Edition, stated with a reasonable degree of medical certainty.","neurology, ama guide, evaluation of permanent impairment, impairment rating, permanent impairment, suprascapular nerve, suprascapular neuropathy, injured, extremity, shoulder, impairment, neuropathy, suprascapular,"
" Woman with adult hydrocephalus, routine evaluation.  ", Neurology, Hydrocephalus ,"REASON FOR VISIT: , Ms. ABC is a 67-year-old woman with adult hydrocephalus who returns to clinic for a routine evaluation.  She comes to clinic by herself.,HISTORY OF PRESENT ILLNESS:,  She has been followed for her hydrocephalus since 2002.  She also had an anterior cervical corpectomy and fusion from C3 though C5 in March 2007.  She was last seen by us in clinic in March 2008 and she was experiencing little bit of head fullness and ringing in the ears at that time; however, we decided to leave her shunt setting at 1.0.  We wanted her to followup with Dr. XYZ regarding the MRI of the cervical spine.  Today, she tells me that with respect to her bladder last week she had some episodes of urinary frequency, however, this week she is not experiencing the same type of episodes.  She reports no urgency, incontinence, and feels that she completely empties her bladder when she goes.  She does experience some leakage with coughing.  She wears the pad on a daily basis.  She does not think that her bladder has changed much since we saw her last.  With respect to her thinking and memory, she reports no problems at this time.  She reports no headaches at this time.  With respect to her walking and balance, she says that it feels worse.  In the beginning of May, she had a coughing spell and at that time she developed buttock pain, which travels down the legs.  She states that her leg often feel like elastic and she experiences a tingling radiculopathy.  She says that this tingling is constant and at times painful.  She feels that she is walking slower for this reason.  She does not use the cane at this time.  Most of the time, she is able to walk over uneven surfaces.  She is able to walk up and down stairs and has no trouble getting in and out of a car.,MEDICATIONS:,  Rhinocort 32 mg two sprays a day, Singulair 10 mg once a day, Xyzal 5 mg in the morning, Spiriva once a day, Advair twice a day, Prevacid 30 mg twice a day, Os-Cal 500 mg once a day, multivitamin once a day, and aspirin 81 mg a day.,MAJOR FINDINGS:,  On exam today, this is a pleasant 67-year-old woman who comes back from the clinic waiting area with little difficulty.  She is well developed, well nourished, and kempt.,The shunt site is clean, dry, and intact and confirmed at a setting of 1.0.,Mental Status:  Assessed and appears intact for orientation, recent and remote memory, attention span, concentration, language, and fund of knowledge.  Her Mini-Mental Status exam score was 26/30 when attention was tested with calculations and 30/30 when attention was tested with spelling.,Cranial Nerves:  Extraocular movements are somewhat inhibited.  She does not display any nystagmus at this time.  Facial movement, hearing, head turning, tongue, and palate movement are all intact.,Gait:  Assessed using the Tinetti assessment tool, which showed a balance score of 13/16 and a gait score of 11/12 for a total score of 24/28.,ASSESSMENT:,  Ms. ABC has been experiencing difficulty with walking over the past several months.,PROBLEMS/DIAGNOSES:,1.  Hydrocephalus.,2.  Cervical stenosis and retrolisthesis.,3.  Neuropathy in the legs.,PLAN: , Before we recommend anything more, we would like to get a hold of the notes from Dr. XYZ to try to come up with a concrete plan as to what we can do next for Ms. ABC.  We believe that her walking is most likely not being effected by the hydrocephalus.  We would like to see her back in clinic in two and a half months or so.  We also talked to her about having her obtain cane training so that she knows how to properly use her cane, which she states she does have one.  I suggested that she use the cane at her on discretion.","neurology, cervical stenosis, retrolisthesis, neuropathy, cervical corpectomy, adult hydrocephalus, cervical, hydrocephalus,"
 Right iliopsoas hematoma with associated femoral neuropathy following cardiac catherization., Neurology, Iliopsoas Hematoma - 2 ,"CC: ,RLE weakness.,HX: ,This 42y/o RHM was found 2/27/95 slumped over the steering wheel of the Fed Ex truck he was driving. He was cyanotic and pulseless according to witnesses. EMT evaluation revealed him to be in ventricular fibrillation and he was given epinephrine, lidocaine, bretylium and electrically defibrillated and intubated in the field. Upon arrival at a local ER his cardiac rhythm deteriorated and he required more than 9 counter shocks (defibrillation) at 360 joules per shock, epinephrine and lidocaine. This had no effect. He was then given intracardiac epinephrine and a subsequent electrical defibrillation placed him in atrial fibrillation. He was then taken emergently to cardiac catherization and was found to have normal coronary arteries. He was then admitted to an intensive care unit and required intraortic balloon pump pressure support via the right gorin. His blood pressure gradually improved and his balloon pump was discontinued on 5/5/95. Recovery was complicated by acute renal failure and liver failure. Initail CK=13,780, the CKMB fraction was normal at 0.8.,On 3/10/95, the patient experienced CP and underwent cardiac catherization. This time he was found to have a single occlusion in the distal LAD with association inferior hypokinesis. Subsequent CK=1381 and CKMB=5.4 (elevated). The patient was amnestic to the event and for 10 days following the event. He was transferred to UIHC for cardiac electrophysiology study.,MEDS: ,Nifedipine, ASA, Amiodarone, Capoten, Isordil, Tylenol, Darvocet prn, Reglan prn, Coumadin, KCL, SLNTG prn, CaCO3, Valium prn, Nubain prn.,PMH:, hypercholesterolemia.,FHX:, Father alive age 69 with h/o TIAs. Mother died age 62 and had CHF, A-Fib, CAD. Maternal Grandfather died of an MI and had h/o SVT. Maternal Grandmother had h/o SVT.,SHX: ,Married, 7 children, driver for Fed Ex. Denied tobacco/ETOH/illicit drug use.,EXAM: ,BP112/74 HR64 RR16 Afebrile.,MS: A&O to person, place and time. Euthymic with appropriate affect.,CN: unremarkable.,Motor: Hip flexion 3/5, Hip extension 5/5, Knee flexion5/5, Knee extension 2/5, Plantar flexion, extension, inversion and eversion 5/5. There was full strength thoughout BUE.,Sensory: decreased PP/Vib/LT/TEMP about anterior aspect of thigh and leg in a femoral nerve distribution.,Coord: poor and slowed HKS on right due to weakness.,Station: no drift or Romberg sign.,Gait: difficulty bearing weight on RLE.,Reflexes: 1+/1+ throughout BUE. 0/2 patellae. 2/2 archilles. Plantar responses were flexor, bilaterally.,COURSE:, MRI Pelvis, 3/28/95, revealed increased T1 weighted signal within the right iliopsoas suggestive of hematoma. An intra-osseous lipoma was incidentally notice in the right sacrum. Neuropsychologic assessment showed moderately compromised anterograde verbal memory, and temporal orientation and retrograde recall were below expectations. These findings were consistent with mesial temporal dysfunction secondary to anoxic injury and were mild in lieu of his history. He underwent implantation of a Medtronic internal cardiac difibrillator. His cardiac electrophysiology study found no inducible ventricular tachycardia or fibrillation. He suffered mild to moderate permanent RLE weakness, especially involving the quadriceps. His femoral nerve compression had been present to long to warrant decompression. EMG/NCV studies revealed severe axonal degeneration.","neurology, cardiac electrophysiology study, iliopsoas hematoma, rle weakness, balloon pump, femoral nerve, cardiac catherization, hematoma, iliopsoas, catherization, epinephrine, fibrillation, cardiac, "
 Left Iliopsoas hematoma.  Gait difficulty., Neurology, Iliopsoas Hematoma - 1 ,"CC: ,Gait difficulty.,HX: ,This 59 y/o RHF was admitted with complaint of gait difficulty. The evening prior to admission she noted sudden onset of LUE and LLE weakness. She felt she favored her right leg, but did not fall when walking. She denied any associated dysarthria, facial weakness, chest pain, SOB, visual change, HA, nausea or vomiting.,PMH:, tonsillectomy, adenoidectomy, skull fx 1954, HTN, HA.,MEDS: ,none on day of exam.,SHX: ,editorial assistant at newspaper, 40pk-yr Tobacco, no ETOH/Drugs.,FHX: ,noncontributory,ADMIT EXAM: ,P95 R20, T36.6, BP169/104,MS: A&O to person, place and time. Speech fluent and without dysarthria, Naming-comprehension-reading intact. Euthymic with appropriate affect.,CN: Pupils 4/4 decreasing to 2/2 on exposure to light, Fundi flat, VFFTC, EOMI, Face symmetric with intact sensation, Gag-shrug-corneal reflexes intact, Tongue ML with full ROM,Motor: Full strength throughout right side. Mildly decreased left grip and left extensor hallucis longus. Biceps/Triceps/Wrist flexors and extensor were full strength on left. However she demonstrated mild LUE pronator drift and had difficulty standing on her LLE despite full strength on bench testing of the LLE.,Sensory: No deficit to PP/T/Vib/Prop/ LT,Coord: decreased speed and magnitude of FNF, Finger tapping and HKS, on left side only.,Station: mild LUE upward drift.,Gait: tendency to drift toward the left. Difficulty standing on LLE.,Reflexes were symmetric, plantar responses were flexor bilaterally.,Gen exam unremarkable.,COURSE: ,Admit Labs: ESR, PT/PTT, GS, UA, EKG, and HCT were unremarkable. Hgb 13.9, Hct 41%, Plt 280k, WBC 5.5.,The patient was diagnosed with a probable lacunar stroke and entered into the TOAST study (Trial of ORG10172[a low molecular weight heparin] in Acute Stroke Treatment).,Carotid Duplex: 16-49%RICA and 0-15%LICA stenosis with anterograde vertebral artery flow, bilaterally. Transthoracic echocardiogram showed mild mitral regurgitation, mild tricuspid regurgitation and a left to right shunt. There was no evidence of blood clot.,Hospital course: 5 days after admission the patient began to complain of proximal LLE and left flank pain. On exam, she had weakness of the quadriceps and hip flexors of the LLE. Her pain increased with left hip flexion. In addition, she complained of paresthesias about the lateral aspect of the medial anterior left thigh; and upon on sensory testing, she had decreased PP/TEMP sensation in a left femoral nerve distribution. She denied any back/neck pain and the rest of her neurologic exam remained unchanged from admission.,Abdominal CT Scan, 2/4/96, revealed a large left retroperitoneal iliopsoas hematoma.,Hgb 8.9g/dl. She was transfused with 4 units of pRBCs. She underwent surgical decompression and evacuation of the hematoma via a posterior flank approach on 2/6/96. Her postoperative course was uncomplicated. She was discharged home on ASA.,At follow-up, on 2/23/96, she complained of left sided paresthesias (worse in the LLE than in the LUE) and feeling of ""swollen left foot."" These symptoms had developed approximately 1 month after her stroke. Her foot looked normal and her UE strength was 5/4+ proximally and distally, and LE strength 5/4+ proximally and 5/5- distally. She was ambulatory. There was no evidence of LUE upward drift. A somatosensory evoked potential study revealed an absent N20 and normal P14 potentials. This was suggestive of a lesion involving the right thalamus which might explain her paresthesia/dysesthesia as part of a Dejerine-Roussy syndrome.",
" Followup status post L4-L5 laminectomy and bilateral foraminotomies, and L4-L5 posterior spinal fusion with instrumentation.", Neurology, Laminectomy & Foraminotomy Followup ,"REASON FOR VISIT:,  Followup status post L4-L5 laminectomy and bilateral foraminotomies, and L4-L5 posterior spinal fusion with instrumentation.,HISTORY OF PRESENT ILLNESS:,  Ms. ABC returns today for followup status post L4-L5 laminectomy and bilateral foraminotomies, and posterior spinal fusion on 06/08/07.,Preoperatively, her symptoms, those of left lower extremity are radicular pain.,She had not improved immediately postoperatively.  She had a medial breech of a right L4 pedicle screw.  We took her back to the operating room same night and reinserted the screw.  Postoperatively, her pain had improved.,I had last seen her on 06/28/07 at which time she was doing well.  She had symptoms of what she thought was ""restless leg syndrome"" at that time.  She has been put on ReQuip for this.,She returned.  I had spoken to her 2 days ago and she had stated that her right lower extremity pain was markedly improved.  I had previously evaluated this for a pain possibly relating to deep venous thrombosis and ultrasound was negative.  She states that she had recurrent left lower extremity pain, which was similar to the pain she had preoperatively but in a different distribution, further down the leg.  Thus, I referred her for a lumbar spine radiograph and lumbar spine MRI and she presents today for evaluation.,She states that overall, she is improved compared to preoperatively.  She is ambulating better than she was preoperatively.  The pain is not as severe as it was preoperatively.  The right leg pain is improved.  The left lower extremity pain is in a left L4 and L5 distribution radiating to the great toe and first web space on the left side.,She denies any significant low back pain.  No right lower extremity symptoms.,No infectious symptoms whatsoever.  No fever, chills, chest pain, shortness of breath.  No drainage from the wound.  No difficulties with the incision.,FINDINGS:  ,On examination, Ms. ABC is a pleasant, well-developed, well-nourished female in no apparent distress.  Alert and oriented x 3.  Normocephalic, atraumatic.  Respirations are normal and nonlabored.  Afebrile to touch.,Left tibialis anterior strength is 3 out of 5, extensor hallucis strength is 2 out of 5.  Gastroc-soleus strength is 3 to 4 out of 5.  This has all been changed compared to preoperatively.  Motor strength is otherwise 4 plus out of 5.  Light touch sensation decreased along the medial aspect of the left foot.  Straight leg raise test normal bilaterally.,The incision is well healed.  There is no fluctuance or fullness with the incision whatsoever.  No drainage.,Radiographs obtained today demonstrate pedicle screw placement at L4 and L5 bilaterally without evidence of malposition or change in orientation of the screws.,Lumbar spine MRI performed on 07/03/07 is also reviewed.,It demonstrates evidence of adequate decompression at L4 and L5.  There is a moderate size subcutaneous fluid collection seen, which does not appear compressive and may be compatible with normal postoperative fluid collection, especially given the fact that she had a revision surgery performed.,ASSESSMENT AND PLAN:  ,Ms. ABC is doing relatively well status post L4 and L5 laminectomy and bilateral foraminotomies, and posterior spinal fusion with instrumentation on 07/08/07.  The case is significant for merely misdirected right L4 pedicle screw, which was reoriented with subsequent resolution of symptoms.,I am uncertain with regard to the etiology of the symptoms.  However, it does appear that the radiographs demonstrate appropriate positioning of the instrumentation, no hardware shift, and the MRI demonstrates only a postoperative suprafascial fluid collection.  I do not see any indication for another surgery at this time.,I would also like to hold off on an interventional pain management given the presence of the fluid collection to decrease the risk of infection.,My recommendation at this time is that the patient is to continue with mobilization.  I have reassured her that her spine appears stable at this time.  She is happy with this.,I would like her to continue ambulating as much as possible.  She can go ahead and continue with ReQuip for the restless leg syndrome as her primary care physician has suggested.  I have also her referred to Mrs. Khan at Physical Medicine and Rehabilitation for continued aggressive management.,I will see her back in followup in 3 to 4 weeks to make sure that she continues to improve.  She knows that if she has any difficulties, she may follow up with me sooner.","neurology, spinal fusion, restless leg syndrome, posterior spinal fusion, pedicle screw, lumbar spine, bilateral foraminotomies, fluid collection, foraminotomy, instrumentation, laminectomy, screw, spine, "
 A male with known alcohol cirrhosis who presented to the emergency room after an accidental fall in the bathroom., Neurology, Hepatic Encephalopathy ,"REASON FOR ADMISSION: , Hepatic encephalopathy.,HISTORY OF PRESENT ILLNESS: , The patient is a 51-year-old Native American male with known alcohol cirrhosis who presented to the emergency room after an accidental fall in the bathroom.  He said that he was doing fine prior to that and denied having any complaints.  He was sitting watching TV and he felt sleepy.  So, he went to the bathroom to urinate before going to bed and while he was trying to lift the seat, he tripped and fell and hit his head on the back.  His head hit the toilet seat.  Then, he started having bleeding and had pain in the area with headache.  He did not lose consciousness as far as he can tell.  He went and woke up his sister.  This happened somewhere between 10:30 and 11 p.m.  His sister brought a towel and covered the laceration on the back of his head and called EMS, who came to his house and brought him to the emergency room, where he was found to have a laceration on the back of his head, which was stapled and a CT of the head was obtained and ruled out any acute intracranial pathology.  On his lab work, his ammonia was found to be markedly elevated at 106.  So, he is being admitted for management of this.  He denied having any abdominal pain, change in bowel habits, GI bleed, hematemesis, melena, or hematochezia.  He said he has been taking his medicines, but he could not recall those.  He denied having any symptoms prior to this fall.  He said earlier today he also fell.  He also said that this was an accidental fall caused by problem with his walker.  He landed on his back at that time, but did not have any back pain afterwards.,PAST MEDICAL HISTORY:,1.  Liver cirrhosis caused by alcohol.  This is per the patient.,2.  He thinks he is diabetic.,3.  History of intracranial hemorrhage.  He said it was subdural hematoma.  This was traumatic and happened seven years ago leaving him with the right-sided hemiparesis.,4.  He said he had a seizure back then, but he does not have seizures now.,PAST SURGICAL HISTORY:,1.  He has a surgery on his stomach as a child.  He does not know the type.,2.  Surgery for a leg fracture.,3.  Craniotomy seven years ago for an intracranial hemorrhage/subdural hematoma.,MEDICATIONS: , He does not remember his medications except for the lactulose and multivitamins.,ALLERGIES: , Dilantin.,SOCIAL HISTORY: , He lives in Sacaton with his sister.  He is separated from his wife who lives in Coolidge.  He smokes one or two cigarettes a day.  Denies drug abuse.  He used to be a heavy drinker, quit alcohol one year ago and does not work currently.,FAMILY HISTORY:,  Negative for any liver disease.,REVIEW OF SYSTEMS:,GENERAL:  Denies fever or chills.  He said he was in Gilbert about couple of weeks ago for fever and was admitted there for two days.  He does not know the details.,ENT:  No visual changes.  No runny nose.  No sore throat.,CARDIOVASCULAR:  No syncope, chest pain, or palpitations.,RESPIRATORY:  No cough or hemoptysis.  No dyspnea.,GI:  No abdominal pain.  No nausea or vomiting.  No GI bleed.  History of alcoholic liver disease.,GU:  No dysuria, hematuria, frequency, or urgency.,MUSCULOSKELETAL:  Denies any acute joint pain or swelling.,SKIN:  No new skin rashes or itching.,CNS:  Had a seizure many years ago with no recurrences.  Left-sided hemiparesis after subdural hematoma from a fight/trauma.,ENDOCRINE:  He thinks he has diabetes but does not know if he is on any diabetic treatment.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 97.7, heart rate 83, respiratory rate 18, blood pressure 125/72, and saturation 98% on room air.,GENERAL:  The patient is lying in bed, appears comfortable, very pleasant Native American male in no apparent distress.,HEENT:  His skull has a scar on the left side from previous surgery.  On the back of his head, there is a laceration, which has two staples on.  It is still oozing minimally.  It is tender.  No other traumatic injury is noted.  Eyes, pupils react to light.  Sclerae anicteric.  Nostrils are normal.  Oral cavity is clear with no thrush or exudate.,NECK:  Supple.  Trachea midline.  No JVD.  No thyromegaly.,LYMPHATICS:  No cervical or supraclavicular lymphadenopathy.,LUNGS:  Clear to auscultation bilaterally.,HEART:  Normal S1 and S2.  No murmurs or gallops.  Regular rate and rhythm.,ABDOMEN:  Soft, distended, nontender.  No organomegaly or masses.,LOWER EXTREMITIES:  +1 edema bilaterally.  Pulses strong bilaterally.  No skin ulcerations noted.  No erythema.,SKIN:  Several spider angiomas noted on his torso and upper extremities consistent with liver cirrhosis.,BACK:  No tenderness by exam.,RECTAL:  No masses.  No abscess.  No rectal fissures.  Guaiac was performed by me and it was negative.,NEUROLOGIC:  He is alert and oriented x2.  He is slow to some extent in his response.  No asterixis.  Right-sided spastic hemiparesis with increased tone, increased reflexes, and weakness.  Increased tone noted in upper and lower extremities on the right compared to the left.  Deep tendon reflexes are +3 on the right and +2 on the left.  Muscle strength is decreased on the right, more pronounced in the lower extremity compared to the upper extremity.  The upper extremity is +4/5.  Lower extremity is 3/5.  The left side has a normal strength.  Sensation appears to be intact.  Babinski is upward on the right, equivocal on the left.,PSYCHIATRIC:  Flat affect.  Mood appeared to be appropriate.  No active hallucinations or psychotic symptoms.,LABORATORY DATA: ",
" Intractable epilepsy, here for video EEG.", Neurology, Intractable Epilepsy ,"CHIEF COMPLAINT:,  Intractable epilepsy, here for video EEG.,HISTORY OF PRESENT ILLNESS: , The patient is a 9-year-old male who has history of global developmental delay and infantile spasms.  Ultimately, imaging study shows an MRI with absent genu of the corpus callosum and thinning of the splenium of the corpus callosum, showing a pattern of cerebral dysgenesis.  He has had severe global developmental delay, and is nonverbal.  He can follow objects with his eyes, but has no ability to interact with his environment to any great degree.  He has noted if any purposeful use of the hands.  He has abnormal movements constantly, which are more choreiform and dystonic.  He has spastic quadriparesis, which is variable at times.  The patient is unable to sit or stand, and receives all his nutrition via G-tube.,The patient began having seizures in infancy presenting as infantile spasms.  I began seeing him at 20 months of age.  At that point, he had undergone workup in Seattle, Washington and then was seeing Dr. X, child neurologist in Mexico, who started Vigabatrin for infantile spasms.  The patient had benefit from this medication, and was doing well at that time with regard to that seizure type.  He initially was on phenobarbital, which failed to give him benefit.  He continued on phenobarbital; however, for a long period time thereafter.  The patient then began having more tonic seizures after his episodic spasms had subsided, and failed several medication trials including valproic acid, Topamax, and Zonegran at least briefly.  Upon starting Lamictal, he began to have benefit and then actually had 1-year seizure freedom before having an isolated seizure or 2.  Over the next 6 months to a year, he only had few further seizures, and was doing well in a general sense.  It was more recently that he began having new seizure events that have not responded to higher doses of Lamictal up to 15 mg/kg/day.  These events manifest as tonic spells with eye deviation and posturing.  Mother reports flexion of the upper extremities, extension with lower extremities.  During that time, he is not able to cry or say any sounds.  These events last from seconds to minutes, and occur at least multiple times per week.  There are times where he has none for a few days and other times where he has multiple days in a row with events.  He has another event manifesting as flexion of the upper extremities and extension lower extremities where he turns red and cries throughout.  He may vomit after these episodes, then seems to calm down.  It is unclear whether this is a seizure or whether the patient is still responsive.,MEDICATIONS:,  The patient's medications include Lamictal for a total of 200 mg twice a day.  It is a 150 mg tablet and 25 mg tablets.  He is on Zonegran using 25 mg capsules 2 capsules twice daily, and baclofen 10 mg three times day.  He has other medications including the Xopenex and Atrovent.,REVIEW OF SYSTEMS: , At this time is negative any fevers, nausea, vomiting, diarrhea, abdominal complaints, rashes, arthritis, or arthralgias.  No respiratory or cardiovascular complaints.  He has no change in his skills at this point.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a slender male who is microcephalic.  He has EEG electrodes in place and is on the video EEG at that time.,HEENT:  His oropharynx shows no lesions.,NECK:  Supple without adenopathy.,CHEST:  Clear to auscultation.,CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs.,ABDOMEN:  Benign with G-tube in place.,EXTREMITIES:  Reveal no clubbing, cyanosis, or edema.,NEUROLOGICAL:  The patient is alert and has bilateral esotropia.  He is able to fix and follow objects briefly.  He is unable to reach for objects.  He exhibits constant choreiform movements when excited.  These are more prominent in the upper extremities and lower extremities.  He has some dystonic posture with flexion of the wrist and fingers bilaterally.  He also has plantar flexion at the ankles bilaterally.  His cranial nerves reveal that his pupils are equal, round, and reactive to light.  Extraocular movements are intact other than bilateral esotropia.  His face moves symmetrically.  Palate elevates in midline.  Hearing appears intact bilaterally.,Motor exam reveals dystonic and variable tone, overall there is mild in spasticity both upper and lower extremities as described above.  He has clonus at the ankles bilaterally, and some valgus contracture of the ankles.  His sensation is intact to light touch bilaterally.  Deep tendon reflexes are 2 to 3+ bilaterally.,IMPRESSION/PLAN: , This is a 9-year-old male with congenital brain malformation and intractable epilepsy.  He has microcephaly as well as dystonic cerebral palsy.  He had a re-emergence of seizures, which are difficult to classify, although some sound like tonic episodes and others are more concerning for non-epileptic phenomenon, such as discomfort.  He is admitted for video EEG to hopefully capture both of these episodes and further clarify the seizure type or types.  He will remain hospitalized for probably at least 48 hours to 72 hours.  He could be discharged sooner if multiple events are captured.  His medications, we will continue his current dose of Zonegran and Lamictal for now.  Both of these medications are very long acting, discontinuing them while in the hospital may simply result in severe seizures after discharge.","neurology, brain malformation, congenital, intractable epilepsy, global developmental delay, video eeg, seizures, intractable, eeg, "
" Caudate Nuclei atrophy, bilaterally, in patient with Huntington Disease.", Neurology, Huntington's Disease ,"CC:, Slowing of motor skills and cognitive function.,HX: ,This 42 y/o LHM presented on 3/16/93 with gradually progressive deterioration of motor and cognitive skills over 3 years. He had difficulty holding a job. His most recent employment ended 3 years ago as he was unable to learn the correct protocols for the maintenance of a large conveyer belt. Prior to that, he was unable to hold a job in the mortgage department of a bank as could not draw and figure property assessments. For 6 months prior to presentation, he and his wife noted (his) increasingly slurred speech and slowed motor skills (i.e. dressing himself and house chores). His walk became slower and he had difficulty with balance. He became anhedonic and disinterested in social activities, and had difficulty sleeping for frequent waking and restlessness. His wife noticed ""fidgety movements"" of his hand and feet.,He was placed on trials of Sertraline and Fluoxetine for depression 6 months prior to presentation by his local physician. These interventions did not appear to improve his mood and affect.,MEDS:, Fluoxetine.,PMH: ,1)Right knee arthroscopic surgery 3 yrs ago. 2)Vasectomy.,FHX:, Mother died age 60 of complications of Huntington Disease (dx at UIHC). MGM and two MA's also died of Huntington Disease. His 38 y/o sister has attempted suicide twice.,He and his wife have 2 adopted children.,SHX: ,unemployed. 2 years of college education. Married 22 years.,ROS: ,No history of Dopaminergic or Antipsychotic medication use.,EXAM:, Vital signs normal.,MS: A&O to person, place, and time. Dysarthric speech with poor respiratory control.,CN: Occasional hypometric saccades in both horizontal directions. No vertical gaze abnormalities noted. Infrequent spontaneous forehead wrinkling and mouth movements. The rest of the CN exam was unremarkable.,Motor: Full strength throughout and normal muscle tone and bulk. Mild choreiform movements were noted in the hands and feet.,Sensory: unremarkable.,Coord: unremarkable.,Station/Gait: unremarkable, except that during tandem walking mild dystonic and choreiform movements of BUE became more apparent.,Reflexes: 2/2 throughout. Plantar responses were flexor, bilaterally.,There was no motor impersistence on tongue protrusion or hand grip.,COURSE:, He was thought to have early manifestations of Huntington Disease. A HCT was unremarkable. Elavil 25mg qhs was prescribed. Neuropsychologic assessment revealed mild anterograde memory loss only.,His chorea gradually worsened during the following 4 years. He developed motor impersistence and more prominent slowed saccadic eye movements. His mood/affect became more labile.,6/5/96 genetic testing revealed a 45 CAg trinucleotide repeat band consistent with Huntington Disease. MRI brain, 8/23/96, showed caudate nuclei atrophy, bilaterally.",
" This is a 69-year-old white woman with Huntington disease, who presents with the third suicide attempt in the past two months. ", Neurology, Huntington's Disease - Consult ,"CHIEF COMPLAINT: , ""A lot has been thrown at me."",The patient is interviewed with husband in room.,HISTORY OF PRESENT ILLNESS: , This is a 69-year-old Caucasian woman with a history of Huntington disease, who presented to Hospital four days ago after an overdose of about 30 Haldol tablets 5 mg each and Tylenol tablet 325 mg each, 40 tablets.  She has been on the medical floor for monitoring and is medically stable and was transferred to the psychiatric floor today.  The patient states she had been thinking about suicide for a couple of weeks.  Felt that her Huntington disease had worsened and she wanted to spare her family and husband from trouble.  Reports she has been not socializing with her family because of her worsening depression.  Husband notes that on Monday after speaking to Dr. X, they had been advised to alternate the patient's Pamelor (nortriptyline) to every other day because the patient was reporting dry mouth.  They did as they have instructed and husband feels this may have had some factor on her worsening depression.  The patient decided to ingest the pills when her husband went to work on Friday.  She thought Friday would be a good day because there would be less medical people working so her chances of receiving medical care would be lessened.  Her husband left around 7 in the morning and returned around 11 and found her sleeping.  About 30 minutes after his arrival, he found the empty bottles and woke up the patient to bring her to the hospital.,She says she wishes she would have died, but is happy she is alive and is currently not suicidal because she notes her sons may be have to be tested for the Huntington gene.  She does not clearly explain how this has made her suicidality subside.,This is the third suicide attempt in the last two months for this patient.  About two months ago, the patient took an overdose of Tylenol and some other medication, which the husband and the patient are not able to recall.  She was taken to Southwest Memorial Hermann Hospital.  A few weeks ago, the patient tried to shoot herself and the gun was fired and there is a blow-hole in the floor.  Husband locked the gun after that and she was taken to Bellaire Hospital.  The patient has had three psychiatric admissions in the past two months, two to Southwest Memorial and one to Bellaire Hospital for 10 days.  She sees Dr. X once or twice weekly.  He started seeing her after her first suicide attempt.,The patient's husband and the patient state that until March 2009, the patient was independent, was driving herself around and was socially active.  Since then she has had worsening of her Huntington symptoms including short-term memory loss.  At present, the patient could not operate the microwave or operate her cell phone and her husband says that she is progressively more withdrawn, complains about anxiety, and complains about shortness of breath.  The patient notes that she has had depressive symptoms of quitting social life, the patient being withdrawn for the past few months and excessive worry about her Huntington disease.,The patient's mother passed away 25 years ago from Huntington's.  Her grandmother passed away 50 years ago and two brothers also passed away of Huntington's.  The patient has told her husband that she does not want to go that way.  The patient denies auditory or visual hallucinations, denies paranoid ideation.  The husband and the patient deny any history of manic or hypomanic symptoms in the past.,PAST PSYCHIATRIC HISTORY: , As per the HPI, this is her third suicide attempt in the last two months and started seeing Dr. X.  She has a remote history of being on Lexapro for depression.,MEDICATIONS: , Her medications on admission, alprazolam 0.5 mg p.o. b.i.d., Artane 2 mg p.o. b.i.d., Haldol 2.5 mg p.o. t.i.d., Norvasc 10 mg p.o. daily, nortriptyline 50 mg p.o. daily.  Husband has stated that the patient's chorea becomes better when she takes Haldol.  Alprazolam helps her with anxiety symptoms.,PAST MEDICAL HISTORY: , Huntington disease, symptoms of dementia and hypertension.  She has an upcoming appointment with the Neurologist.  Currently, does have a primary care physician and _______ having an outpatient psychiatrist, Dr. X, and her current Neurologist, Dr. Y.,ALLERGIES: , CODEINE AND KEFLEX.,FAMILY MEDICAL HISTORY:  ,Strong family history for Huntington disease as per the HPI.  Mother and grandmother died of Huntington disease.  Two young brothers also had Huntington disease.,FAMILY PSYCHIATRIC HISTORY: , The patient denies history of depression, bipolar, schizophrenia, or suicide attempts.,SOCIAL HISTORY:  ,The patient lives with her husband of 48 years.  She used to be employed as a registered nurse.  Her husband states that she does have a pattern of self-prescribing for minor illness, but does not think that she has ever taken muscle relaxants or sedative medications without prescriptions.  She rarely drinks socially.  She denies any illicit substance usage.  Her husband reportedly gives her medication daily.  Has been proactive in terms of seeking mental health care and medical care.  The patient and husband report that from March 2009, she has been relatively independent, more socially active.,MENTAL STATUS EXAM:  ,This is an elderly woman appearing stated age.  Alert and oriented x4 with poor eye contact.  Appears depressed, has psychomotor retardation, and some mild involuntary movements around her lips.  She is cooperative.  Her speech is of low volume and slow rate and rhythm.  Her mood is sad.  Her affect is constricted.  Her thought process is logical and goal-directed.  Her thought content is negative for current suicidal ideation.  No homicidal ideation.  No auditory or visual hallucinations.  No command auditory hallucinations.  No paranoia.  Insight and judgment are fair and intact.,LABORATORY DATA:,  A CT of the brain without contrast, without any definite evidence of acute intracranial abnormality.  U-tox positive for amphetamines and tricyclic antidepressants.  Acetaminophen level 206.7, alcohol level 0.  The patient had a leukocytosis with white blood cell of 15.51, initially TSH 1.67, T4 10.4.,ASSESSMENT: , This is a 69-year-old white woman with Huntington disease, who presents with the third suicide attempt in the past two months.  She took 30 tablets of Haldol and 40 tablets of Tylenol.  At present, the patient is without suicidal ideation.  She reports that her worsening depression has coincided with her worsening Huntington disease.  She is more hopeful today, feels that she may be able to get help with her depression.,The patient was admitted four days ago to the medical floor and has subsequently been stabilized.  Her liver function tests are within normal limits.,AXIS I:  Major depressive disorder due to Huntington disease, severe.  Cognitive disorder, NOS.,AXIS II:  Deferred.,AXIS III:  Hypertension, Huntington disease, status post overdose.,AXIS IV:  Chronic medical illness.,AXIS V:  30.,PLAN,1.  Safety.  The patient would be admitted on a voluntary basis to Main-7 North.  She will be placed on every 15-minute checks with suicidal precautions.,2.  Primary psychiatric issues/medical issues.  The patient will be restarted as per written by the consult service for Prilosec 200 mg p.o. daily, nortriptyline 50 mg p.o. nightly, Haldol 2 mg p.o. q.8h., Artane 2 mg p.o. daily, Xanax 0.5 mg p.o. q.12h., fexofenadine 180 mg p.o. daily, Flonase 50 mcg two sprays b.i.d., amlodipine 10 mg p.o. daily, lorazepam 0.5 mg p.o. q.6h. p.r.n. anxiety and agitation.,3.  Substance abuse.  No acute concern for alcohol or benzo withdrawal.,4.  Psychosocial.  Team will update and involve family as necessary.,DISPOSITION: , The patient will be admitted for evaluation, observation, treatment.  She will participate in the milieu therapy with daily rounds, occupational therapy, and group therapy.  We will place occupational therapy consult and social work consults.",
 The patient with continued problems with her headaches. , Neurology, Headache - Office Visit ,"She also had EMG/nerve conduction studies since she was last seen in our office that showed severe left ulnar neuropathy, moderate right ulnar neuropathy, bilateral mild-to-moderate carpal tunnel and diabetic neuropathy.  She was referred to Dr. XYZ and will be seeing him on August 8, 2006.,She was also never referred to the endocrine clinic to deal with her poor diabetes control.  Her last hemoglobin A1c was 10.,PAST MEDICAL HISTORY:,  Diabetes, hypertension, elevated lipids, status post CVA, and diabetic retinopathy.,MEDICATIONS: , Glyburide, Avandia, metformin, lisinopril, Lipitor, aspirin, metoprolol and Zonegran.,PHYSICAL EXAMINATION:,  Blood pressure was 140/70, heart rate was 76, respiratory rate was 18, and weight was 226 pounds.  On general exam she has an area of tenderness on palpation in the left parietal region of her scalp.  Neurological exam is detailed on our H&P form.  Her neurological exam is within normal limits.,IMPRESSION AND PLAN:,  For her headaches we are going to titrate Zonegran up to 200 mg q.h.s. to try to maximize the Zonegran therapy.  If this is not effective, when she comes back on August 7, 2006 we will then consider other anticonvulsants such as Neurontin or Lyrica.  We also discussed with Ms. Hawkins the possibility of nerve block injection; however, at this point she is not interested.,She will be seeing Dr. XYZ for her neuropathies.,We made an appointment in endocrine clinic today for a counseling in terms of better diabetes control and she is responsible for trying to get her referral from her primary care physician to go for this consult.","neurology, nerve conduction studies, emg, zonegran therapy, ulnar neuropathy, endocrine clinic, diabetes control, neurological exam, headache, zonegran"
" Closed head injury with evidence of axonal injury vs. vascular injury to the left substantia nigra, right subdural hematoma and possible subarachnoid hemorrhage, vascular/ischemic injury in the right occipital lobe-right basal ganglia/caudate nucleus-right frontal lobe, and right temporal lobe contusion.", Neurology, Head Trauma ,"CC: ,Depressed mental status.,HX: ,29y/o female fell down a flight of stairs on 2/20/95, striking the right side of her head. She then walked over to and lay down on a living room couch. She was found there, the next morning, by her boyfriend, poorly responsive and amidst a coffee ground like emesis. She was taken to a local ER and HCT revealed a right supraorbital fracture, right SDH and left SAH. Spine X-rays revealed a T12 vertebral body fracture. There were retinal hemorrhages, OU. She continued to be minimally responsive and was transferred to UIHC for lack of insurance and for neurologic/neurosurgical care.,MEDS:, (on transfer): Dilantin, Zantac, Proventil MDI, Tylenol.,PMH:, 1)pyelonephritis, 2) multiple STD's, 3) Polysubstance Abuse (ETOH, MJ, Amphetamine), 4)G5P4.,FHX:, unknown.,SHX: ,polysubstance abuse. smoked 1 pack per day for 15years.,EXAM: ,BP127/97, HR83, RR25, 37.2C,MS: Minimal to no spontaneous speech. Unresponsive to verbal commands. Lethargic and somnolent. Groaned ""yes"" inappropriately.,CN: Pupils 4/4 decreasing to 2/2 on exposure to light. VFFTT. Retinal hemorrhages, OU. EOM difficult to assess. Facial movement appeared symmetric. Tongue midline. Corneal and gag responses were intact.,MOTOR: no spontaneous movement. withdrew extremities to noxious stimulation (e.g. deep nail bed pressure).,Sensory: withdrew to noxious stimuli.,Coord/Station/Gait: not tested.,Reflexes: 2+/2+ BUE. 2/2 BLE. Babinski signs were present, bilaterally.,HEENT: Periorbital and upper lid ecchymoses about the right eye. Scleral hemorrhage, OD.,GEN EXAM: mild bruising of the extremities.,COURSE: ,2/27/95 HCT revealed a small liner high attenuation area lateral to the right parietal lobe with subtle increased attenuation of the tentorium cerebelli. These findings were felt to represent a right subdural hematoma and possible subarachnoid hemorrhage.,2/28/95 brain MRI revealed: 1)a small right-sided SDH, 2) Abnormal signal in the right occipital lobe with effacement of the gyri and sulci in the right PCA division most likely representing ischemic/vascular injury, 3)abnormal signal within the right basal ganglia/caudate nucleus consistent with ischemia, 4) abnormal signal in the uncal portion of the right frontal lobe consistent with contusion, 5) small parenchymal hemorrhage in the inferior anterior right temporal lobe, and 6) opacification of the right maxillary sinus.,EEG, 2/28/95, was abnormal with occasional sharp transients in the left temporal region, and irregular (more or less continuous) right greater than left delta slow waves and decreased background activity in the right hemisphere: the findings were consistent with focal pathology on the right, seizure tendency in the left temporal region, and bilateral cerebral dysfunction. By the time of discharge, 4/17/95, she was verbalizing one or two words and required assistance with feeding and ambulation. She could not function independently.","neurology, closed head injury, axonal injury, vascular injury, substantia nigra, subdural hematoma, subarachnoid hemorrhage, vascular, ischemic, injury, occipital lobe, retinal hemorrhages, temporal region, axonal, hemorrhages, hemorrhage, "
 Headache.  Right frontal lobe glioma., Neurology, Glioma - 2 ,"CC:, Headache,HX: ,37 y/o RHF presented to her local physician with a one month history of intermittent predominantly left occipital headaches which were awakening her in the early morning hours. The headachese were dull to throbbing in character. She was initially treated with Parafon-forte for tension type headaches, but the pain did not resolve. She subsequently underwent HCT in early 12/90 which revealed a right frontal mass lesion.,PMH: ,1)s/p tonsillectomy. 2)s/p elective abortion.,FHX:, Mother with breast CA, MA with ""bone cancer."" AODM both sides of family.,SHX: ,Denied tobacco or illicit drug use. Rarely consumes ETOH. Married with 2 teenage children.,EXAM: ,VItal signs unremarkable.,MS: Alert and oriented to person, place, time. Lucid thought process per NSG note.,CN: unremarkable.,Motor: full strength with normal muscle bulk and tone.,Sensory: unremarkable.,Coordination: unremarkable.,Station/Gait: unremarkable.,Reflexes: unremarkable.,Gen. Exam: unremarkable.,COURSE:, MRI Brain: large solid and cystic right frontal lobe mass with a large amount of surrounding edema. There is apparent tumor extension into the corpus callosum across the midline. Tumor extension is also suggested in the anterior limb of the interanl capsule on the right. There is midline mass shift to the left with effacement of the anterior horn of the right lateral ventricle. The MRI findings are most consistent with glioblastoma.,The patient underwent right frontal lobectomy. The pathological diagnosis was xanthomatous astrocytoma. The literature at the time was not clear as to optimal treatment protocol. People have survived as long as 25 years after diagnosis with this type of tumor. XRT was deferred until 11/91 when an MRI and PET Scan suggested extension of the tumor. She then received 5580 cGy of XRT in divided segments. She developed olfactory auras shortly after lobectomy at was treated with PB with subsequent improvement. She was treated with BCNU chemotherapy protocol in 1992.","neurology, frontal lobe, tumor extension, glioma, headache, lobectomy, astrocytoma, "
 Sellar HCT - Pituitary mass, Neurology, HCT - Pituitary Mass ,"CC:, HA and vision loss.,HX: ,71 y/o RHM developed a cataclysmic headache on 11/5/92 associated with a violent sneeze. The headache lasted 3-4 days. On 11/7/92, he had acute pain and loss of vision in the left eye. Over the following day his left pupil enlarged and his left upper eyelid began to droop. He was seen locally and a brain CT showed no sign of bleeding, but a tortuous left middle cerebral artery was visualized. The patient was transferred to UIHC 11/12/92.,FHX:, HTN, stroke, coronary artery disease, melanoma.,SHX:, Quit smoking 15 years ago.,MEDS:, Lanoxin, Capoten, Lasix, KCL, ASA, Voltaren, Alupent MDI,PMH: ,CHF, Atrial Fibrillation, Obesity, Anemia, Duodenal Ulcer, Spinal AVM resection 1986 with residual T9 sensory level, hyperreflexia and bilateral babinski signs, COPD.,EXAM: ,35.5C, BP 140/91, P86, RR20. Alert and oriented to person, place, and time. CN: No light perception OS, Pupils: 3/7 decreasing to 2/7 on exposure to light (i.e., fixed/dilated pupil OS). Upon neutral gaze the left eye deviated laterally and inferiorly. There was complete ptosis OS. On downward gaze their was intorsion OS. The left eye could not move superiorly, medially or effectively downward, but could move laterally. EOM were full OD. The rest of the CN exam was unremarkable. Motor, Coordination, Station and Gait testing were unremarkable. Sensory exam revealed decreased pinprick and light touch below T9 (old). Muscle stretch reflexes were increased (3+/3+) in both lower extremities and there were bilateral babinski signs (old). The upper extremity reflexes were symmetrical (2/2). Cardiovascular exam revealed an irregularly irregular rhythm and lung sounds were coarse bilaterally. The rest of the general exam was unremarkable.,LAB:, CBC, PT/PTT, General Screen were unremarkable except for a BUN 21mg/DL. CSF: protein 88mg/DL, glucose 58mg/DL, RBC 2800/mm3, WBC 1/mm3. ANA, RF, TSH, FT4 were WNL.,IMPRESSION:, CN3 palsy and loss of vision. Differential diagnosis: temporal arteritis, aneurysm, intracranial mass.,COURSE:, The outside Brain CT revealed a tortuous left MCA. A four-vessel cerebral angiogram revealed a dolichoectatic basilar artery and tortuous LICA. There was no evidence of aneursym. Transesophageal Echocardiogram revealed atrial enlargement only. Neuroopthalmologic evaluation revealed: Loss of color vision and visual acuity OS, RAPD OS, bilateral optic disk pallor (OS > OD), CN3 palsy and bilateral temporal field loss, OS >> OD . ESR, CRP, MRI were recommended to rule out temporal arteritis and intracranial mass. ESR 29mm/Hr, CRP 4.3mg/DL (high) , The patient was placed on prednisone. Temporal artery biopsy showed no evidence of vasculitis. MRI scan could not be obtained due to patient weight. Sellar CT was done instead: coronal sections revealed sellar enlargement and upward bowing of the diaphragm sella suggesting a pituitary mass. In retrospect sellar enlargement could be seen on the angiogram X-rays. Differential consideration was given to cystic pituitary adenoma, noncalcified craniopharyngioma, or Rathke's cleft cyst with solid component. The patient refused surgery. He was seen in Neuroopthalmology Clinic 2/18/93 and was found to have mild recovery of vision OS and improved visual fields. Aberrant reinnervation of the 3rd nerve was noted as there was constriction of the pupil (OS) on adduction, downgaze and upgaze. The upper eyelid, OS, elevated on adduction and down gaze, OS. EOM movements were otherwise full and there was no evidence of ptosis. In retrospect he was felt to have suffered pituitary apoplexy in 11/92.","neurology, sellar, hct, htn, pituitary, aneurysm, brain ct, cataclysmic, coronary artery disease, headache, intracranial mass, loss of vision, mass, melanoma, palsy, sneeze, stroke, temporal arteritis, vision loss, bilateral babinski signs, sellar enlargement, pituitary mass, temporal, vision,"
 HCT for memory loss and for calcification of basal ganglia (globus pallidi)., Neurology, HCT - Calcification of Basal Ganglia ,"CC:, Memory loss.,HX:, This 77 y/o RHF presented with a one year history of progressive memory loss. Two weeks prior to her evaluation at UIHC she agreed to have her sister pick her up for church at 8:15AM, Sunday morning. That Sunday she went to pick up her sister at her sister's home and when her sister was not there (because the sister had gone to pick up the patient) the patient left. She later called the sister and asked her if she (sister) had overslept. During her UIHC evaluation she denied she knew anything about the incident. No other complaints were brought forth by the patients family.,PMH:, Unremarkable.,MEDS:, None,FHX: ,Father died of an MI, Mother had DM type II.,SHX: , Denies ETOH/illicit drug/Tobacco use.,ROS:, Unremarkable.,EXAM:, Afebrile, 80BPM, BP 158/98, 16RPM. Alert and oriented to person, place, time. Euthymic. 29/30 on Folstein's MMSE with deficit on drawing. Recalled 2/6 objects at five minutes and could not recite a list of 6 objects in 6 trials. Digit span was five forward and three backward. CN: mild right lower facial droop only. MOTOR: Full strength throughout. SENSORY: No deficits to PP/Vib/Prop/LT/Temp. COORD: Poor RAM in LUE only. GAIT: NB and ambulated without difficulty. STATION: No drift or Romberg sign. REFLEXES: 3+ bilaterally with flexor plantar responses. There were no frontal release signs.,LABS:, CMB, General Screen, FT4, TSH, VDRL were all WNL.,NEUROPSYCHOLOGICAL EVALUATION, 12/7/92: ,Verbal associative fluency was defective. Verbal memory, including acquisition, and delayed recall and recognition, was severely impaired. Visual memory, including immediate and delayed recall was also severely impaired. Visuoperceptual discrimination was mildly impaired, as was 2-D constructional praxis.,HCT, 12/7/92: , Diffuse cerebral atrophy with associative mild enlargement of the ventricles consistent with patient's age. Calcification is seen in both globus pallidi and this was felt to be a normal variant.","neurology, memory loss, romberg sign, hct, cerebral atrophy, calcification of basal ganglia, basal ganglia, globus pallidi, basal, ganglia, globus, pallidi, calcification,"
 Headache and diplopia., Neurology, Granulomatous Inflammation ,"CC:, Headache and diplopia.,HX:, This 39 y/o African American female began experiencing severe constant pressure pain type headaches beginning the last week of 8/95. The pain localized to bifronto-temporal regions of the head and did not radiate. There was no associated nausea, vomiting, photophobia or phonophobia. The HA's occurred daily; and throughout daylight hours. They diminished at bedtime, but occasionally awakened her in the morning.,Several days following the onset of her HA's, she began experiencing numbness and tingling about the right side of her face. These symptoms improved, but did not completely resolved.,Several days after the onset of facial paresthesias, she began to experience binocular horizontal diplopia. The diplopia resolved when covering either eye, and worsened upon looking toward the right. Coincidentally, she began veering toward the right when walking. She denied any weakness. She had had chronic unsteadiness for many years since developing juvenile rheumatoid arthritis. She was unsure whether her unsteadiness was due to poor depth perception in light of her diplopia.,The patient was admitted locally 9/2/95. HCT, 9/2/95 and Brain MRI with gadolinium, 9/3/95, were ""unremarkable."" Lumbar puncture (done locally),9/3/95: Opening pressure 27cm H20, CSF analysis ( protein 14.0, glucose 66, O WBC, 3 RBC, VDRL non-reactive, Lyme titer unremarkable, Myelin basic protein 1.0 (normal <4.0), and there was no evidence of oligoclonal bands. ESR=76. On 9/11/95 ESR=110. Acetylcholine receptor binding and blocking antibodies were negative. 9/4/95, ANA and RF were negative. 7/94, ANA and RF were negative, and ESR=60.,MEDS: ,Tylenol 500mg q5-6hrs. No known Allergies.,PMH:, 1)Juvenile Rheumatoid Arthritis diagnosed at age 10 years; now in remission. 2)Right #5 finger reattachment as child due to traumatic amputation.,FHX: ,Mother died age 42 of unknown type cancer. Father died age 62 of unknown type cancer. 4 sisters, one brother and 2 half-brothers. One of the half-brothers has asthma.,SHX: ,Single, lives with sister, and denies Tobacco/ETOH/illicit drug use.,EXAM:, BP141/84, HR99, RR14, 36.8C, Wt. 82kg Ht. 152.,MS: A&O to person, place, time. Speech fluent; without dysarthria. Mood euthymic with appropriate affect.,CN: Decreased abduction, OD. In neutral gaze, the right eye deviated slightly lateral of midline. In addition, she had mild proptosis, OD. The right eye was nontender to palpation during extraocular movement. Visual fields were full to confrontation. Optic disks appeared flat. Face was symmetric with full movement and sensation. Gag, shoulder shrug and corneal responses were intact, bilaterally. Tongue was midline with full ROM.,MOTOR: 5/5 strength throughout with normal muscle bulk and tone.,SENSORY: Unremarkable.,COORD: Unremarkable FNF/HKS/RAM.,STATION: Unremarkable. NO Romberg's sign or drift.,GAIT: Narrow based gait. Able to TT and HW without difficulty. Mild difficulty with TW.,REFLEXES: 2+/2+ Throughout all 4 extremities. Flexor plantar responses, bilaterally.,Musculoskeletal: Swan neck deformities of the #2 and #3 digits of both hands.,GEN EXAM: unremarkable, except for obvious sign of right finger reattachment (mentioned above).,COURSE: ,Repeat lumbar puncture yielded: Opening pressure 20.25cm H20, protein 22, glucose 62, 2RBC, 1WBC. CSF cytology, ACE, cultures (bacterial, fungal, AFB), gram stain, cryptococcal antigen, and VDRL were negative. Serum ACE, TSH, FT4 were unremarkable.,Neuroophthalmology confirmed her right CN6 palsy and proptosis (OD); and noted her complaint of paresthesias in the V1 and V2 distribution. They saw no evidence of papilledema. Visual field testing was unremarkable. MRI Brain/orbit/neck with gadolinium, 10/20/95, revealed abnormal enhancing signal in the right cavernous sinus and sinus mucosal thickening in both maxillary sinuses/ethmoid sinuses/frontal sinuses. CXR, 10/20/95, showed a lobulated mass arising from the right hilum. The mass appeared to obstruct the right middle lobe, causing partial collapse of this lobe. Chest CT with contrast, 10/23/95, revealed a 3.2x4.5x4.0cm mass in the right hilar region with impingement on the right lower bronchus. There appeared to be calcification as well as low attenuation regions within the mass. No lymphadenopathy was noted. She underwent bronchoscopy with bronchial brushing and transbronchial aspirate of the right lung on 10/24/95: no tumor cells were identified, GMS stains were negative and there was no evidence of viral changes, fungus or PCP by culture or molecular assay. She underwent right maxillary sinus biopsy and right middle lobe wedge resection and lymph node biopsy on 11/2/95: Caseating granulomatous inflammation with associated inflammatory pseudotumor was found in both sinus and lung biopsy specimens. No sign of cancer was found. Tissue cultures (bacterial, fungal, AFB) were negative times 3. The patients case was discussed at Head and Neck Oncology Tumor Board and a differential diagnosis of Sarcoidosis, Histoplasmosis, Wegener's Granulomatosis, were considered. Urine Histoplasmosis Antigen testing on 11/8/95 was 0.9units (normal<1.0): repeat testing on 12/13/95 was 0.8units. ANCA serum titers on 11/8/95 were <1:40 (normal). PPD testing was negative 11/95 (with positive candida and mumps controls).,The etiology of this patient's illness was not discovered. She was last seen 4/96 and her diplopia and right CN6 palsy had moderately improved.",
 Dysarthria.  Probable brainstem glioma., Neurology, Glioma - 1 ,"CC:, Dysarthria,HX: ,This 52y/o RHF was transferred from a local hospital to UIHC on 10/28/94 with a history of progressive worsening of vision, dysarthria, headache, and incoordination beginning since 2/94. Her husband recalled her first difficulties became noticeable after a motor vehicle accident in 2/94. She was a belted passenger in a car struck at a stop. There was no reported head or neck injury or alteration of consciousness. She was treated and released from a local ER the same day. Her husband noted the development of mild dysarthria, incoordination, headache and exacerbation of preexisting lower back pain within 2 week of the accident. In 4/94 she developed stress urinary incontinence which spontaneously resolved in June. In 8/94, her HA changed from a dull constant aching in the bitemporal region to a sharper constant pain in the nuchal/occipital area. She also began experiencing increased blurred vision, worsening dysarthria and difficulty hand writing. In 9/94 she was evaluated by a local physician. Examination then revealed incoordination, generalized fatigue, and dysarthria. Soon after this she became poorly arousable and increasingly somnolent. She had difficulty walking and generalized weakness. On 10/14/94, she lost the ability to walk by herself. Evaluation at a local hospital revealed: 1)Normal electronystagmography, 2)two lumbar punctures which revealed some atypical mononuclear cells suggestive of ""tumor or reactive lymphocytosis."" One of these CSF analysis showed: Glucose 16, Protein 99, WBC 14, RBC 114. Echocardiogram was normal. Bone marrow biopsy was normal except for decreased iron. Abdominal-Pelvic CT scan, CXR, Mammogram, PPD, ANA, TFT, and RPR were unremarkable. A 10/31/94 MRI brain scan a 5x10mm area of increased signal on T2 weighted images in the right remporal lobe lateral to the anterior aspect of the temporal horn, right posterolateral aspect of the midbrain, pons, and bilateral inferior surface of the cerebellum involving gray and white matter. These areas did not enhance with gadolinium contrast on T1 weighted images.,MEDS: ,none.,PMH:, 1)G3P3, 2)last menses one year ago.,FHX:, Mother suffered stroke in her 70's. DM and Htn in family.,SHX:, Married, Secretary, No h/o tobacco/ETOH/illicit drug use.,ROS:, no weight loss, fever, chills, nightsweats, cough, dysphagia.,EXAM:, BP139/74, HR 90, RR20, 36.8C,MS: Drowsy to somnolent, occasionally ""giddy."" Oriented to person, place, time. Minimal dysarthric speech, but appropriate. MMSE 27/30 (copy of exam not in chart).,CN: Pupils 4/4 decreasing to 2/2 on exposure to light. Optic disks were flat and without sign of papilledema. VFFTC. EOM intact. No nystagmus. The rest of the CN exam was unremarkable.,Motor: 5/5 strength throughout. Normal muscle tone and bulk.,Sensory: No deficit to LT/PP/VIB/PROP.,Coord: difficulty with RAM in BUE, and ataxia on FNF and HKS in all extremities.,Station: Romberg sign present.,Gait: unsteady, wide-based, with notable difficulty on TW, TT and HW.,Reflexes: 2/2 BUE, 0/1 patellae, trace at both archilles, Plantars responses were flexor, bilaterally.,Gen Exam: unremarkable.,COURSE:, CSF analysis by lumbar puncture, 10/31/94: Protein 131mg/dl (normal 15-45), Albumin 68 (normal 14-20), IgG10mg/dl (normal <6.2), IgG index -O.1mg/24hr (normal),,No oligoclonal bands seen, WBC 33 (19lymphocytes, 1 neutrophil), RBC 29, Glucose 13, Cultures (bacteria, fungal, AFB) were negative, crytococcal Ag negative. The elevated CSF total protein, IgG, and albumin suggested breakdown of the blood brain barrier or blockage of CSF flow. The normal IgG synthesis rate and lack of oligoclonal banding did not suggest demylination. A second CSF analysis on 11/2/94 revealed similar findings; and in addition Anti-purkinje cell and Anti-neuronal antibodies (Yo and Ho) were not found; Beta-2 microglobulin was 1.8 (normal); histoplasmosis Ag negative. Serum ACE, SPEP, Urine histoplasmin were negative.,Neuropsychologic assessment, 10/28/94, raised a question of a demential syndrome, but given her response style on the MMPI (marked defensiveness, with unwillingness to admit to even very common human faults) prevented such a diagnosis. Severe defects in memory, fine motor skills, and constructional praxis were noted.,Chest-Abdominal-Pelvic CT scans were negative. 11/4/94 cerebral angiogram noted variable caliber in the RMCA, LACA and Left AICA distributions. It was intially thought that thismight be suggestive of a vasculopathy and she was treated with a short course of IV steroids. Temporal artery biopsy was unremarkable.,She underwent multiple MRI brain scans at UIHC: 11/4/94, 11/9/94, 11/16/94. All scans consistently showed increase in T2 signal in the brainstem, cerebellar peduncles and temporal lobes bilaterally. These areas did not enhance with gadolinium contrast. These findings were felt most suggestive of glioma.,She underwent left temporal lobe brain biopsy on 11/10/94: This study was inconclusive and showed evidence of atypical mononuclear cells and lymphocytes in the perivascular and subarachnoid spaces. Despite cytologic atypia the cells were felt to be reactive in nature, since immunohistochemical stains failed to disclose lymphoid clonality or non-leukocytic phenomena. Little sign of vasculopathy or tumor was found. Bacterial, fungal , HSV, CMV and AFB cultures were negative. HSV, and VZV antigen was negative.,Her neurological state progressively worsened throughout her hospital stay. By time of discharge, 12/2/94, she was very somnolent and difficult to arouse and required NGT feeding and 24hour supportive care. She was made DNR after family request prior to transfer to a care facility.",
" This is a 62-year-old woman with hypertension, diabetes mellitus, prior stroke who has what sounds like Guillain-Barre syndrome, likely the Miller-Fisher variant.", Neurology, Guillain-Barre Syndrome ,"CHIEF COMPLAINT: , Followup of hospital discharge for Guillain-Barre syndrome.,HISTORY OF PRESENT ILLNESS: , This is a 62-year-old right-handed woman with hypertension, diabetes mellitus, a silent stroke involving right basal ganglia who was in her usual state of baseline health until late June of 2006 when she had onset of blurred vision, diplopia, and possible weakness in the right greater than left arm and left-sided ptosis.  She was admitted to the hospital.  The MRI showed only an old right basal ganglion infarct.  She subsequently had a lumbar puncture, which showed increased protein, and an EMG/nerve conduction study performed by Dr. X on July 3rd, showed early signs of AIDP.  The patient was treated with intravenous gamma globulin and had some mild improvement in her symptoms.  Her vital capacities were normal during the hospitalization.  Her chest x-ray was negative for any acute process.  She was discharged to rehab from July 12, 2006 to July 20, 2006.  She made some progress in which she notes that her walking is definitely better.  However, she notes that she still has some problems with eye movement and her vision.  This is possibly her main problem.  She also reports tightness and pain in her mid back.,REVIEW OF SYSTEMS:,  Documented in the clinic note.  The patient has problems with diabetes, double vision, blurry vision, muscle pain, weakness, trouble walking, and headaches about two to three times per week.,PAST MEDICAL HISTORY:,1.  Hypertension.,2.  Diabetes mellitus.,3.  Stroke involving the right basal ganglion.,4.  Guillain-Barre syndrome diagnosed in June of 2006.,5.  Bilateral knee replacements.,6.  Total abdominal hysterectomy and cholecystectomy.,FAMILY HISTORY:,  Multiple family members have diabetes mellitus.,SOCIAL HISTORY:,  The patient is retired on disability due to her knee replacements.  She does not smoke, drink or use any illicit drugs.,MEDICATIONS:,  Percocet 5/325 mg 4-6 hours p.r.n., Neurontin 100 mg per day, insulin, Protonix 40 mg per day, Toprol-XL 50 mg q.d., Norvasc 10 mg q.d., glipizide ,10 mg q.d., fluticasone 50 mcg nasal spray, Lasix 20 mg b.i.d., and Zocor 1 mg q.d.,ALLERGIES: , No known drug allergies.,PHYSICAL EXAMINATION: , Blood pressure 122/74, heart rate 68, respiratory rate 16, and weight 228 pounds.  Pain scale 5/10.  Please see the written note for details.  General exam is benign other than mild obesity.  On neuro examination, mental status is normal.  Cranial nerves are significant for full visual fields and pupils are equal and reactive.  However, extraocular movements are very limited.  She has some adduction of the left eye and she has minimal upgaze of both eyes, but otherwise the eyes do not move.  Face is symmetric.  Sensation is intact.  Tongue and uvula are in midline.  Palate is elevated symmetrically.  Shoulder shrug is strong.  The patient's muscle exam shows normal bulk and tone throughout.  She has no weakness of the left upper extremity.  In the right upper extremity, she has only about 2/5 strength in the right shoulder, but is otherwise 5/5.  There is no drift or orbit.  Reflexes are absent throughout.  Sensory exam is intact to light touch, pinprick, vibration, and proprioception is normal.  There is no dysmetria.  Gait is somewhat limited possibly by her vision and possibly also by her balance problems.,PERTINENT DATA:,  As reviewed previously.,DISCUSSION: , This is a 62-year-old woman with hypertension, diabetes mellitus, prior stroke who has what sounds like Guillain-Barre syndrome, likely the Miller-Fisher variant.  The patient has shown some improvement with IVIG and continues to show some gradual improvement.  I discussed with the patient the course of disease, which is often weeks to about a month or so of worsening followed by many months of gradual improvement.,I told her that it is possible she may not recover 100%, but that certainly there is still plenty of time for her to have additional recovery over what she has right now.  She is scheduled to see an ophthalmologist.  I think it is reasonable for close followup of her visual symptoms progress.  However, I certainly would not take any corrective measures at this point as I suspect her vision will improve gradually.,I discussed with the patient that with respect to her back pain certainly the Neurontin is relatively at low dose and this could be increased further.  I wanted her to start taking the Neurontin 300 mg per day and then 300 mg b.i.d. after one week.  She will call me in approximately three weeks' time to let me know how she is doing and if needed we will titrate up further.,She was apparently given some baclofen by her internist and I think this is not unreasonable.  I definitely hope to get her off the Percocet in the future.,IMPRESSION:,1.  Guillain-Barre Miller-Fisher variant.,2.  Hypertension.,3.  Diabetes mellitus.,4.  Stroke.,RECOMMENDATIONS:,1.  The patient is to start taking aspirin 162 mg per day.,2.  Followup with ophthalmology.,3.  Increase Neurontin to 300 mg per day x 1 week and then 300 mg b.i.d.,4.  Followup by phone in three to four weeks.,5.  Followup in this clinic in approximately two months' time.,6.  Call for any questions or problems.",
 CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking., Neurology, Frameless Stereotactic Radiosurgery ,"PREOPERATIVE DIAGNOSIS:,  Right occipital arteriovenous malformation.,POSTOPERATIVE DIAGNOSIS:,  Right occipital arteriovenous malformation.,PROCEDURE PERFORMED:,  CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking.,Please note no qualified resident was available to assist in the procedure.,INDICATION: , The patient is a 30-year-old male with a right occipital AVM.  He was referred for stereotactic radiosurgery.  The risks of the radiosurgical treatment were discussed with the patient including, but not limited to, failure to completely obliterate the AVM, need for additional therapy, radiation injury, radiation necrosis, headaches, seizures, visual loss, or other neurologic deficits.  The patient understands these risks and would like to proceed.,PROCEDURE IN DETAIL: , The patient arrived to Outpatient CyberKnife Suite one day prior to the treatment.  He was placed on the treatment table.  The Aquaplast mask was constructed.  Initial imaging was obtained by the CyberKnife system.  The patient was then transported over to the CT scanner at Stanford.  Under the supervision of Dr. X, 125 mL of Omnipaque 250 contrast was administered.  Dr. X then supervised the acquisition of 1.2-mm contiguous axial CT slices.  These images were uploaded over the hospital network to the treatment planning computer, and the patient was discharged home.,Treatment plan was then performed by me.  I outlined the tumor volume.  Inverse treatment planning was used to generate the treatment plan for this patient.  This resulted in a total dose of 20 Gy delivered to 84% isodose line using a 12.5 mm collimator.  The maximum dose within this center of treatment volume was 23.81 Gy.  The volume treated was 2.972 mL, and the treated lesion dimensions were 1.9 x 2.7 x 1.6 cm.  The volume treated at the reference dose was 98%.  The coverage isodose line was 79%.  The conformality index was 1.74 and modified conformality index was 1.55.  The treatment plan was reviewed by me and Dr. Y of Radiation Oncology, and the treatment plan was approved.,On the morning of May 14, 2004, the patient arrived at the Outpatient CyberKnife Suite.  He was placed on the treatment table.  The Aquaplast mask was applied.  Initial imaging was used to bring the patient into optimal position.  The patient underwent stereotactic radiosurgery to deliver the 20 Gy to the AVM margin.  He tolerated the procedure well.  He was given 8 mg of Decadron for prophylaxis and discharged home.,Followup will consist of an MRI scan in 6 months.  The patient will return to our clinic once that study is completed.,I was present and participated in the entire procedure on this patient consisting of CT-guided frameless stereotactic radiosurgery for the right occipital AVM.,Dr. X was present during the entire procedure and will be dictating his own operative note.","neurology, ct-guided, occipital, cyberknife, frameless stereotactic radiosurgery, occipital arteriovenous malformation, conformality index, arteriovenous malformation, malformation, avm, arteriovenous,"
 Right side craniotomy for temporal lobe intracerebral hematoma evacuation and resection of temporal lobe lesion.  Biopsy of dura., Neurology, Hematoma Evacuation ,"PREOPERATIVE DIAGNOSIS: , Right temporal lobe intracerebral hemorrhage.,POSTOPERATIVE DIAGNOSES:,1.  Right temporal lobe intracerebral hemorrhage.,2.  Possible tumor versus inflammatory/infectious lesion versus vascular lesion, pending final pathology and microbiology.,PROCEDURES:,1.  Emergency right side craniotomy for temporal lobe intracerebral hematoma evacuation and resection of temporal lobe lesion.,2.  Biopsy of dura.,3.  Microscopic dissection using intraoperative microscope.,SPECIMENS: , Temporal lobe lesion and dura as well as specimen for microbiology for culture.,DRAINS:,  Medium Hemovac drain.,FINDINGS: , Vascular hemorrhagic lesion including inflamed dura and edematous brain with significant mass effect, and intracerebral hematoma with a history of significant headache, probable seizures, nausea, and vomiting.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Per Anesthesia.,FLUIDS: , One unit of packed red blood cells given intraoperatively.,The patient was brought to the operating room emergently.  This is considered as a life threatening admission with a hemorrhage in the temporal lobe extending into the frontal lobe and with significant mass effect.,The patient apparently became hemiplegic suddenly today.  She also had an episode of incoherence and loss of consciousness as well as loss of bowel/urine.,She was brought to Emergency Room where a CT of the brain showed that she had significant hemorrhage of the right temporal lobe extending into the external capsule and across into the frontal lobe.  There is significant mass effect.  There is mixed density in the parenchyma of the temporal lobe.,She was originally scheduled for elective craniotomy for biopsy of the temporal lobe to find out why she was having spontaneous hemorrhages.  However, this event triggered her family to bring her to the emergency room, and this is considered a life threatening admission now with a significant mass effect, and thus we will proceed directly today for evacuation of ICH as well as biopsy of the temporal lobe as well as the dura.,PROCEDURE IN DETAIL: , The patient was anesthetized by the anesthesiology team.  Appropriate central line as well as arterial line, Foley catheter, TED, and SCDs were placed.  The patient was positioned supine with a three-point Mayfield head pin holder.  Her scalp was prepped and draped in a sterile manner.  Her former incisional scar was barely and faintly noticed; however, through the same scalp scar, the same incision was made and extended slightly inferiorly.  The scalp was resected anteriorly.  The subdural scar was noted, and hemostasis was achieved using Bovie cautery.  The temporalis muscle was reflected along with the scalp in a subperiosteal manner, and the titanium plating system was then exposed.,The titanium plating system was then removed in its entirety.  The bone appeared to be quite fused in multiple points, and there were significant granulation tissue through the burr hole covers.,The granulation tissue was quite hemorrhagic, and hemostasis was achieved using bipolar cautery as well as Bovie cautery.,The bone flap was then removed using Leksell rongeur, and the underlying dura was inspected.  It was quite full.  The 4-0 sutures from the previous durotomy closure was inspected, and more of the inferior temporal bone was resected using high-speed drill in combination with Leksell rongeur.  The sphenoid wing was also resected using a high-speed drill as well as angled rongeur.,Hemostasis was achieved on the fresh bony edges using bone wax.  The dura pack-up stitches were noted around the periphery from the previous craniotomy.  This was left in place.,The microscope was then brought in to use for the remainder of the procedure until closure.  Using a #15 blade, a new durotomy was then made.  Then, the durotomy was carried out using Metzenbaum scissors, then reflected the dura anteriorly in a horseshoe manner, placed anteriorly, and this was done under the operating microscope.  The underlying brain was quite edematous.,Along the temporal lobe there was a stain of xanthochromia along the surface.  Thus a corticectomy was then accomplished using bipolar cautery, and the temporal lobe at this level and the middle temporal gyrus was entered.  The parenchyma of the brain did not appear normal.  It was quite vascular.  Furthermore, there was a hematoma mixed in with the brain itself.  Thus a core biopsy was then performed in the temporal tip.  The overlying dura was inspected and it was quite thickened, approximately 0.25 cm thick, and it was also highly vascular, and thus a big section of the dura was also trimmed using bipolar cautery followed by scissors, and several pieces of this vascularized dura was resected for pathology.  Furthermore, sample of the temporal lobe was cultured.,Hemostasis after evacuation of the intracerebral hematoma using controlled suction as well as significant biopsy of the overlying dura as well as intraparenchymal lesion was accomplished.  No attempt was made to enter into the sylvian fissure.  Once hemostasis was meticulously achieved, the brain was inspected.  It still was quite swollen, known that there was still hematoma in the parenchyma of the brain.  However, at this time it was felt that since there is no diagnosis made intraoperatively, we would need to stage this surgery further should it be needed once the diagnosis is confirmed.  DuraGen was then used for duraplasty because of the resected dura.  The bone flap was then repositioned using Lorenz plating system.  Then a medium Hemovac drain was placed in subdural space.  Temporalis muscle was approximated using 2-0 Vicryl.  The galea was then reapproximated using inverted 2-0 Vicryl.  The scalp was then reapproximated using staples.  The head was then dressed and wrapped in a sterile fashion.,She was witnessed to be extubated in the operating room postoperatively, and she followed commands briskly.  The pupils are 3 mm bilaterally reactive to light.  I accompanied her and transported her to the ICU where I signed out to the ICU attending.",
 Patient presents for further evaluation of feet and hand cramps. He describes that the foot cramps are much more notable than the hand ones.  He reports that he develops muscle contractions of his toes on both feet.  These occur exclusively at night., Neurology, Feet & Hand Cramping ,"HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old right-handed gentleman who presents for further evaluation of feet and hand cramps.  He states that for the past six months he has experienced cramps in his feet and hands.  He describes that the foot cramps are much more notable than the hand ones.  He reports that he develops muscle contractions of his toes on both feet.  These occur exclusively at night.  They may occur about three times per week.  When he develops these cramps, he stands up to relieve the discomfort.  He notices that the toes are in an extended position.  He steps on the ground and they seem to ""pop into place.""  He develops calf pain after he experiences the cramp.  Sometimes they awaken him from his sleep.,He also has developed cramps in his hands although they are less severe and less frequent than those in his legs.  These do not occur at night and are completely random.  He notices that his thumb assumes a flexed position and sometimes he needs to pry it open to relieve the cramp.,He has never had any symptoms like this in the past.  He started taking Bactrim about nine months ago.  He had taken this in the past briefly, but has never taken it as long as he has now.  He cannot think of any other possible contributing factors to his symptoms.,He has a history of HIV for 21 years.  He was taking antiretroviral medications, but stopped about six or seven years ago.  He reports that he was unable to tolerate the medications due to severe stomach upset.  He has a CD4 count of 326.  He states that he has never developed AIDS.  He is considering resuming antiretroviral treatment.,PAST MEDICAL HISTORY:,  He has diabetes, but this is well controlled.  He also has hepatitis C and HIV.,CURRENT MEDICATIONS: , He takes insulin and Bactrim.,ALLERGIES: , He has no known drug allergies.,SOCIAL HISTORY: , He lives alone.  He recently lost his partner.  This happened about six months ago.  He denies alcohol, tobacco, or illicit drug use.  He is now retired.  He is very active and walks about four miles every few days.,FAMILY HISTORY: , His father and mother had diabetes.,REVIEW OF SYSTEMS: , A complete review of systems was obtained and was negative except for as mentioned above.  This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:,Vital Signs:  Blood pressure 130/70",
" This 62-year-old white female has essential tremor and mild torticollis.  Tremor not bothersome for most activities of daily living, but she does have a great difficulty writing, which is totally illegible. ", Neurology, Essential Tremor & Torticollis ,"REASON FOR CONSULT: , Essential tremor and torticollis.,HISTORY OF PRESENT ILLNESS: , This is a 62-year-old right-handed now left-handed white female with tremor since 5th grade.  She remembers that the tremors started in her right hand around that time subsequently later on in early 20s she was put on propranolol for the tremor and more recently within the last 10 years she has been put on primidone and clonazepam.  She thinks that her clonazepam is helping her a lot especially with anxiety and stress, and this makes the tremor better.  She has a lot of trouble with her writing because of tremor but does not report as much problem with other activities of daily living like drinking from a cup and doing her day-to-day activity.  Since around 6 to 7 years, she has had a head tremor, which is mainly ""no- no"" and occasional voice tremor also.  Additionally, the patient has been diagnosed with migraine headaches without aura, which are far and few apart.  She also has some stress incontinence.  Last MRI brain was done in 2001 reportedly normal.,CURRENT MEDICATIONS:,1.  Klonopin 0.5 mg twice a day.,2.  Primidone 100 mg b.i.d.,3.  Propranolol long-acting 80 mg once in the morning.,PAST MEDICAL HISTORY: , Essential tremor, cervical dystonia, endometriosis, migraine headaches without aura, left ear sensorineural deafness, and basal cell carcinoma resection on the nose.,PAST SURGICAL HISTORY: , L5-S1 lumbar laminectomy in 1975, exploratory laparotomy in 1967, tonsillectomy and adenoidectomy, and anal fissure surgery in 1975.,FAMILY HISTORY: , Both parents have ET and hypertension.  Maternal cousin with lupus.,SOCIAL HISTORY: , Denies any smoking or alcohol.  She is married since 44 years, has 3 children.  She used to work as a labor and delivery nurse up until early 2001 when she retired.,REVIEW OF SYSTEMS: , No fever, chills, nausea or vomiting.  No visual complaints.  She complains of hearing decreased on the left.  No chest pain or shortness of breath.  No constipation.  She does give a history of urge incontinence.  No rashes.  No depressive symptoms.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure is 131/72, pulse is 50, and weight is 71.3 kg.  HEENT:  PERRLA.  EOMI.  CARDIOVASCULAR:  S1 and S2 normal.  Regular rate and rhythm.  She does have a rash over the right ankle with a prior basal cell carcinoma was resected.  NEUROLOGIC:  Alert and oriented x4.  Speech shows a voice tremor occasionally.  Language is intact.  Cranial nerves II through XII intact.  Motor examination showed 5/5 power in all extremities with minimal increased tone.  Sensory examination was intact to light touch.  Reflexes were brisk bilaterally, but they were equal and both toes were downgoing.  Her coordination showed minimal intentional component to bilateral finger-to-nose.  Gait was intact.  Lot of swing on Romberg's.  The patient did have a tremor both upper extremities, right more than left.  She did have a head tremor, which was no-no variety, and she had a minimal torticollis with her head twisted to the left.,ASSESSMENT AND PLAN: , This 62-year-old white female has essential tremor and mild torticollis.  Tremor not bothersome for most activities of daily living, but she does have a great difficulty writing, which is totally illegible.  The patient did not wish to change any of her medication doses at this point.  We will go ahead and check MRI brain, and we will get the films later.  We will see her back in 3 months.  Also, the patient declined any possible Botox for the mild torticollis she has at this point.","neurology, clonazepam, difficulty writing, head tremor, voice tremor, migraine headaches, mri brain, essential tremor, torticollis, carcinoma,"
 Fall with questionable associated loss of consciousness.  Left parietal epidural hematoma., Neurology, Epidural Hematoma ,"CC:, Fall with questionable associated loss of consciousness.,HX: ,This 81 y/o RHM fell down 20 steps on the evening of admission, 1/10/93, while attempting to put his boots on at the top of the staircase. He was evaluated locally and was amnestic to the event at the time of examination. A HCT scan was obtained and he was transferred to UIHC, Neurosurgery.,MEDS:, Lasix 40mg qd, Zantac 150mg qd, Lanoxin 0.125mg qd, Capoten 2.5mg bid, Salsalate 750mg tid, ASA 325mg qd, ""Ginsana"" (Ginseng) 100mg bid.,PMH: ,1)Atrial fibrillation, 2)Right hemisphere stroke, 11/22/88, with associated left hemiparesis and amaurosis fugax. This was followed by a RCEA, 12/1/88 for 98% stenosis. The stroke symptoms/signs resolved. 3)DJD, 4)Right TKR 2-3 years ago, 5)venous stasis; with no h/o DVT, 6)former participant in NASCET, 7)TURP for BPH. No known allergies.,FHX:, Father died of an MI at unknown age, Mother died of complications of a dental procedure. He has one daughter who is healthy.,SHX:, Married. Part-time farmer. Denied tobacco/ETOH/illicit drug use.,EXAM: ,BP157/86, HR100 and irregular, RR20, 36.7C, 100%SaO2,MS: A&O to person, place, time. Speech fluent and without dysarthria.,CN: Pupils 3/3 decreasing to 2/2 on exposure to light. EOM intact. VFFTC. Optic disks were flat. Face was symmetric with symmetric movement. The remainder of the CN exam was unremarkable.,Motor: 5/5 strength throughout with normal muscle tone and bulk.,Sensory: unremarkable.,Coord: unremarkable.,Station/Gait: not mentioned in chart.,Reflexes: symmetric. Plantar responses were flexor, bilaterally.,Gen Exam: CV:IRRR without murmur. Lungs: CTA. Abdomen: NT, ND, NBS.,HEENT: abrasion over the right forehead.,Extremity: distal right leg edema/erythema (just above the ankle). tender to touch.,COURSE:, 1/10/93, (outside)HCT was reviewed, It revealed a left parietal epidural hematoma. GS, PT/PTT, UA, and CBC were unremarkable. RLE XR revealed a fracture of the right lateral malleolus for which he was casted. Repeat HCTs showed no change in the epidural hematoma and he was discharged home on DPH.","neurology, loss of consciousness, parietal epidural hematoma, parietal epidural, epidural hematoma, consciousness, epidural, hematoma, "
 Falls at home.  Anxiety and depression.  The patient had been increasingly anxious and freely admitted that she was depressed at home., Neurology, Falls - Discharge Summary ,"CHIEF COMPLAINT:,  Falls at home.,HISTORY OF PRESENT ILLNESS:,  The patient is an 82-year-old female who fell at home and presented to the emergency room with increased anxiety.  Family members who are present state that the patient had been increasingly anxious and freely admitted that she was depressed at home.  They noted that she frequently came to the emergency room for ""attention.""  The patient denied any chest pain or pressure and no change to exercise tolerance.  The patient denied any loss of consciousness or incontinence.  She denies any seizure activity.  She states that she ""tripped"" at home.  Family states she frequently takes Darvocet for her anxiety and that makes her feel better, but they are afraid she is self medicating.  They stated that she has numerous medications at home, but they were not sure if she was taking them.  The patient been getting along for a number of years and has been doing well, but recently has been noting some decline primarily with regards to her depression.  The patient denied SI or HI.,PHYSICAL EXAMINATION:,GENERAL:  The patient is pleasant 82-year-old female in no acute distress.,VITAL SIGNS:  Stable.,HEENT:  Negative.,NECK:  Supple.  Carotid upstrokes are 2+.,LUNGS:  Clear.,HEART:  Normal S1 and S2.  No gallops.  Rate is regular.,ABDOMEN:  Soft.  Positive bowel sounds.  Nontender.,EXTREMITIES:  No edema.  There is some ecchymosis noted to the left great toe.  The area is tender; however, metatarsal is nontender.,NEUROLOGICAL:  Grossly nonfocal.,HOSPITAL COURSE: , A psychiatric evaluation was obtained due to the patient's increased depression and anxiety.  Continue Paxil and Xanax use was recommended.  The patient remained medically stable during her hospital stay and arrangements were made for discharge to a rehabilitation program given her recent falls.,DISCHARGE DIAGNOSES:,1.  Falls ,2.  Anxiety and depression.,3.  Hypertension.,4.  Hypercholesterolemia.,5.  Coronary artery disease.,6.  Osteoarthritis.,7.  Chronic obstructive pulmonary disease.,8.  Hypothyroidism.,CONDITION UPON DISCHARGE: , Stable.,DISCHARGE MEDICATIONS: , Tylenol 650 mg q.6h. p.r.n., Xanax 0.5 q.4h. p.r.n., Lasix 80 mg daily, Isordil 10 mg t.i.d., KCl 20 mEq b.i.d., lactulose 10 g daily, Cozaar 50 mg daily, Synthroid 75 mcg daily, Singulair 10 mg daily, Lumigan one drop both eyes at bed time, NitroQuick p.r.n., Pravachol 20 mg daily, Feldene 20 mg daily, Paxil 20 mg daily, Minipress 2 mg daily, Provera p.r.n., Advair 250/50 one puff b.i.d., Senokot one tablet b.i.d., Timoptic one drop OU daily, and verapamil 80 mg b.i.d.,ALLERGIES: , None.,ACTIVITY: , Per PT.,FOLLOW-UP: , The patient discharged to a skilled nursing facility for further rehabilitation.",
" Evacuation of epidural hematoma and insertion of epidural drain.   Epidural hematoma, cervical spine.  Status post cervical laminectomy, C3 through C7 postop day #10.  Central cord syndrome and acute quadriplegia.", Neurology, Epidural Hematoma Evacuation ,"PREOPERATIVE DIAGNOSES:,1.  Epidural hematoma, cervical spine.,2.  Status post cervical laminectomy, C3 through C7 postop day #10.,3.  Central cord syndrome.,4.  Acute quadriplegia.,POSTOPERATIVE DIAGNOSES:,1.  Epidural hematoma, cervical spine.,2.  Status post cervical laminectomy, C3 through C7 postop day #10.,3.  Central cord syndrome.,4.  Acute quadriplegia.,PROCEDURE PERFORMED:,1.  Evacuation of epidural hematoma.,2.  Insertion of epidural drain.,ANESTHESIA: , General.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS:  ,200 cc.,HISTORY:  ,This is a 64-year-old female who has had an extensive medical history beginning with coronary artery bypass done on emergent basis while she was in Maryland in April of 2003 after having myocardial infarction.  She was then transferred to Beaumont Hospital, at which point, she developed a sternal abscess.  The patient was treated for the abscess in Beaumont and then subsequently transferred to some other type of facility near her home in Warren, Michigan at which point, she developed a second what was termed minor myocardial infarction.,The patient subsequently recovered in a Cardiac Rehab Facility and approximately two weeks later, brings us to the month of August, at which time she was at home ambulating with a walker or a cane, and then sustained a fall and at that point she was unable to walk and had acute progressive weakness and was identified as having a central cord syndrome based on an MRI, which showed record signal change.  The patient underwent cervical laminectomy and seemed to be improving subjectively in terms of neurologic recovery, but objectively there was not much improvement.  Approximately 10 days after the surgery, brings us to today's date, the health officer was notified of the patient's labored breathing.  When she examined the patient, she also noted that the patient was unable to move her extremities.  She was concerned and called the Orthopedic resident who identified the patient to be truly quadriplegic.  I was notified and ordered the operative crew to report immediately and recommended emergent decompression for the possibility of an epidural hematoma.  On clinical examination, there was swelling in the posterior aspect of the neck.  The patient has no active movement in the upper and lower extremity muscle groups.  Reflexes are absent in the upper and lower extremities.  Long track signs are absent.  Sensory level is at the C4 dermatome.  Rectal tone is absent.  I discussed the findings with the patient and also the daughter.  We discussed the possibility of this is permanent quadriplegia, but at this time, the compression of the epidural space was warranted and certainly for exploration reasons be sure that there is a hematoma there and they have agreed to proceed with surgery.  They are aware that it is possible she had known permanent neurologic status regardless of my intervention and they have agreed to accept this and has signed the consent form for surgery.,OPERATIVE PROCEDURE:  ,The patient was taken to OR #1 at ABCD General Hospital on a gurney.  Department of Anesthesia administered fiberoptic intubation and general anesthetic.  A Foley catheter was placed in the bladder.  The patient was log rolled in a prone position on the Jackson table.  Bony prominences were well padded.  The patient's head was placed in the prone view anesthesia head holder.  At this point, the wound was examined closely and there was hematoma at the caudal pole of the wound.  Next, the patient was prepped and draped in the usual sterile fashion.  The previous skin incision was reopened.  At this point, hematoma properly exits from the wound.  All sutures were removed and the epidural spaces were encountered at this time.  The self-retaining retractors were placed in the depth of the wound.  Consolidated hematoma was now removed from the wound.  Next, the epidural space was encountered.  There was no additional hematoma in the epidural space or on the thecal sac.  A curette was carefully used to scrape along the thecal sac and there was no film or lining covering the sac.  The inferior edge of the C2 lamina was explored and there was no compression at this level and the superior lamina of T1 was explored and again no compression was identified at this area as well.  Next, the wound was irrigated copiously with one liter of saline using a syringe.  The walls of the wound were explored.  There was no active bleeding.  Retractors were removed at this time and even without pressure on the musculature, there was no active bleeding.  A #19 French Hemovac drain was passed percutaneously at this point and placed into the epidural space.  Fascia was reapproximated with #1 Vicryl sutures, subcutaneous tissue with #3-0 Vicryl sutures.  Steri-Strips covered the incision and dressing was then applied over the incision.  The patient was then log rolled in the supine position on the hospital gurney.  She remained intubated for airway precautions and transferred to the recovery room in stable condition.  Once in the recovery room, she was alert.  She was following simple commands and using her head to nod, but she did not have any active movement of her upper or lower extremities.  Prognosis for this patient is guarded.","neurology, epidural hematoma, cervical spine, cervical laminectomy, central cord syndrome, acute quadriplegia, insertion of epidural drain, epidural drain, epidural space, hematoma, epidural, cervical, laminectomy, quadriplegia, "
 Encephalopathy related to normal-pressure hydrocephalus., Neurology, Encephalopathy  - Rehab Consult  ,"ADMITTING DIAGNOSIS: , Encephalopathy related to normal-pressure hydrocephalus.,CHIEF COMPLAINT:,  Diminished function secondary to above.,HISTORY:  ,This pleasant gentleman was recently admitted to ABCD Medical Center and followed by the neurosurgical staff, including Dr. X, where normal-pressure hydrocephalus was diagnosed.  He had a shunt placed and was stabilized medically.  He has gotten a return of function to the legs and was started on some early therapy.  Significant functional limitations have been identified and ongoing by the rehab admission team.  Significant functional limitations have been ongoing.  He will need to be near-independent at home for periods of time, and he is brought in now for rehabilitation to further address functional issues, maximize skills and safety and allow a safe disposition home.,PAST MEDICAL HISTORY: , Positive for prostate cancer, intermittent urinary incontinence and left hip replacement.,ALLERGIES: , No known drug allergies.,CURRENT MEDICATIONS,1.  Tylenol as needed.  ,2.  Peri-Colace b.i.d.,SOCIAL HISTORY:,  He is a nonsmoker and nondrinker.  Prior boxer.  He lives in a home where he would need to be independent during the day.  Family  relatives intermittently available.  Goal is to return home to an independent fashion to that home setting.,FUNCTIONAL HISTORY: , Prior to admission was independent with activities of daily living and ambulatory skills.  Presently, he has resumed therapies and noted to have supervision levels for most activities of daily living.  Memory at minimal assist.  Walking at supervision., REVIEW OF SYSTEMS:  ,Negative for headaches, nausea, vomiting, fevers, chills, shortness of breath or chest pain currently.  He has had some dyscoordination recently and headaches on a daily basis, most days, although the Tylenol does seem to control that pain.,PHYSICAL EXAMINATION,VITAL SIGNS:  The patient is afebrile with vital signs stable.,HEENT:  Oropharynx clear, extraocular muscles are intact.,CARDIOVASCULAR:  Regular rate and rhythm, without murmurs, rubs or gallops.,LUNGS:  Clear to auscultation bilaterally.,ABDOMEN:  Nontender, nondistended,  positive bowel sounds.,EXTREMITIES:  Without clubbing, cyanosis, or edema.  The calves are soft and nontender bilaterally.,NEUROLOGIC:  No focal, motor or sensory losses through the lower extremities.  He moves upper and lower extremities well.  Bulk and tone normal in the upper and lower extremities.  Cognitively showing intact with appropriate receptive and expressive skills.,IMPRESSION ,",
 Patient returns for his first followup after shunt surgery., Neurology, First Followup - Shunt Surgery ,"REASON FOR VISIT:,  Mr. A is an 86-year-old man who returns for his first followup after shunt surgery.,HISTORY OF PRESENT ILLNESS:  ,I have followed Mr. A since May 2008.  He presented with eight to ten years of progressive gait impairment, cognitive impairment, and decreased bladder control.  We established a diagnosis of adult hydrocephalus with the spinal catheter protocol in June of 2008 and ,Mr. A underwent shunt surgery performed by Dr. X on August 1st.  A Medtronic Strata programmable shunt in the ventriculoperitoneal configuration programmed at level 2.0 was placed.,Mr. A comes today with his daughter, Pam and together they give his history.,Mr. A has had no hospitalizations or other illnesses since I last saw him.  With respect to his walking, his daughter tells me that he is now able to walk to the dining room just fine, but could not before his surgery.  His balance has improved though he still has some walking impairment.  With respect to his bladder, initially there was some improvement, but he has leveled off and he wears a diaper.,With respect to his cognition, both Pam and the patient say that his thinking has improved.  The other daughter, Patty summarized it best according to two of them.  She said, ""I feel like I can have a normal conversation with him again.""  Mr. A has had no headaches and no pain at the shunt site or at the abdomen.,MEDICATIONS: , Plavix 75 mg p.o. q.d., metoprolol 25 mg p.o. q.d., Flomax 0.4 mg p.o. q.d., Zocor 20 mg p.o. q.d., Detrol LA 4 mg p.o. q.d., lisinopril 10 mg p.o. q.d., Imodium daily, Omega-3, fish oil, and Lasix.,MAJOR FINDINGS:,  Mr. A is a pleasant and cooperative man who is able to converse easily though his daughter adds some details.,Vital Signs:  Blood pressure 124/80, heart rate is 64, respiratory rate is 18, weight 174 pounds, and pain is 0/10.,The shunt site was clean, dry, and intact and confirmed at a setting of 2.0.,Mental Status:  Tested for recent and remote memory, attention span, concentration, and fund of knowledge.  He scored 26/30 on the MMSE when tested with spelling and 25/30 when tested with calculations.  Of note, he was able to get two of the three memory words with cuing and the third one with multiple choice.  This was a slight improvement over his initial score of 23/30 with calculations and 24/30 with spelling and at that time he was unable to remember any memory words with cuing and only one with multiple choice.,Gait:  Tested using the Tinetti assessment tool.  He was tested without an assistive device and received a gait score of 6-8/12 and a balance of score of 12/16 for a total score of 18-20/28.  This has slightly improved from his initial score of 15-17/28.,Cranial Nerves:  Pupils are equal.  Extraocular movements are intact.  Face symmetric.  No dysarthria.,Motor:  Normal for bulk and strength.,Coordination:  Slow for finger-to-nose.,IMAGING: , CT scan was reviewed from 10/15/2008.  It shows a frontal horn span at the level of foramen of Munro of 4.6 cm with a 3rd ventricular contour that is flat with the span of 10 mm.  By my reading, there is a tiny amount of blood in the right frontal region with just a tiny subdural collection.  This was not noticed by the radiologist who stated no extraaxial fluid collections.  There is also substantial small vessel ischemic change.,ASSESSMENT: , Mr. A has made some improvement since shunt surgery.,PROBLEMS/DIAGNOSES:,1.  Adult hydrocephalus (331.5).,2.  Gait impairment (781.2).,3.  Urinary incontinence and urgency (788.33).,4.  Cognitive impairment (290.0).,PLAN:,  I had a long discussion with Mr. A and his daughter.  We are all pleased that he has started to make some improvement with his hydrocephalus because I believe I see a tiny fluid collection in the right parietal region, I would like to leave the setting at 2.0 for another three months before we consider changing the shunt.  I do not believe that this tiny amount of fluid is symptotic and it was not documented by the radiologist when he read the CT scan.,Mr. A asked me about whether he will be able to drive again.  Unfortunately, I think it is unlikely that his speed of movement will improve to a level that he will be able to pass a driver's safety evaluation, however, occasionally patients surprise me by improving enough over 9 to 12 months that they are able to pass such a test.  I would certainly be happy to recommend such a test if I believe ,Mr. A is likely to pass it and he is always welcome to enroll in a driver's safety program without my recommendation, however, I think it is exceeding unlikely that he has the capability of passing this rigorous test at this time.  I also think it is quite likely he will not regain sufficient speed of motion to pass such a test.",
 Fall/loss of consciousness., Neurology, Epidural Fluid Collection ,"CC:, Fall/loss of consciousness.,HX: ,This 44y/o male fell 15-20feet from a construction site scaffold landing on his head on a cement sidewalk. He was transported directly from the scene, approximately one mile east of UIHC. The patient developed labored breathing and an EMT attempted to intubate the patient in the UIHC ER garage, but upon evaluation in the ER, was found to be in his esophagus and was immediately replaced into the trachea. Replacement of the ET tube required succinylcholine. The patient remained in a C-collar during the procedure. Once in the ER the patient had a 15min period of bradycardia.,MEDS: ,none prior to accident.,PMH:, No significant chronic or recent illness. s/p left knee arthroplasty. h/o hand fractures.,FHX:, Unremarkable.,SHX:, Married. Rare cigarette use/Occasional Marijuana use/Social ETOH use per wife.,EXAM:, BP156/79. HR 74 RR (Ambu Bag ventilation via ET tube) 34.7C 72-100% O2Sat.,MS: Unresponsive to verbal stimulation. No spontaneous verbalization.,CN: Does not open/close eyes to command or spontaneously. Pupils 9/7 and nonreactive.,Corneas -/+. Gag +/+. Oculocephalic and Oculovestibular reflexes not performed.,Motor: minimal spontaneous movement of the 4 extremities.,Sensory: withdraws LUE and BLE to noxious stimulation.,Coord/Station/Gait: Not tested.,Reflexes: 1-2+ and symmetric throughout. Babinski signs were present bilaterally.,HEENT: severe facial injury with brain parenchyma and blood from the right nostril. Severe soft tissue swelling about side of head.,Gen Exam: CV: RRR without murmur. Lungs: CTA. Abdomen: distended after ET tube misplacement.,COURSE: ,HCT upon arrival, 10/29/92, revealed: Extensive parenchymal contusions in right fronto-parietal area. Pronounced diffuse brain swelling seemingly obliterates the mesencephalic cistern and 4th ventricle. Considerable mass effect is exerted upon the right lateral ventricle, near totally obliterating its contour. Massive subcutaneous soft tissue swelling is present along the right anterolateral parietal area. There are extensive fractures of the following: two component horizontal fractures throughout the floor of the right middle cranial fossa which includes the squamous and petrous portions of the temporal bone, as well as the greater wing of the sphenoid. Comminuted fractures of the aqueous portion of the temporal bone and parietal bone is noted on the right. Extensive comminution of the right half of the frontal bone and marked displacement is seen. Comminuted fractures of the medial wall of the right orbit and ethmoidal air cells is seen with near total opacification of the air cells. The medial and lateral walls of the maxillary sinus are fractured and minimally displaced, as well as the medial wall of the left maxillary sinus. The right zygomatic bone is fractured at its articulation with the sphenoid bone and displaced posteriorly.,Portable chest, c-spine and abdominal XRays were unremarkable, but limited studies. Abdominal CT was unremarkable.,Hgb 10.4g/dl, Hct29%, WBC17.4k/mm3, Plt 190K. ABG:7.28/48/46 on admission. Glucose 131.,The patient was hyperventilated, Mannitol was administered (1g/kg), and the patient was given a Dilantin loading dose. He was taken to surgery immediately following the above studies to decompress the contused brain and remove bony fragments from multiple skull fractures. The patient remained in a persistent vegetative state at UIHC, and upon the request of this wife his feeding tube was discontinued. He later expired.","neurology, loss of consciousness, soft tissue swelling, medial wall, maxillary sinus, sphenoid, collection, tube, bone, "
" EMG/Nerve Conduction Study showing sensory motor length-dependent neuropathy consistent with diabetes, severe left ulnar neuropathy, and moderate-to-severe left median neuropathy, ", Neurology, EMG/Nerve Conduction Study - 4 ,"NERVE CONDUCTION STUDIES:,  Bilateral ulnar sensory responses are absent.  Bilateral median sensory distal latencies are prolonged with a severely attenuated evoked response amplitude.  The left radial sensory response is normal and robust.  Left sural response is absent.  Left median motor distal latency is prolonged with attenuated evoked response amplitude.  Conduction velocity across the forearm is mildly slowed.  Right median motor distal latency is prolonged with a normal evoked response amplitude and conduction velocity.  The left ulnar motor distal latency is prolonged with a severely attenuated evoked response amplitude both below and above the elbow.  Conduction velocities across the forearm and across the elbow are prolonged.  Conduction velocity proximal to the elbow is normal.  The right median motor distal latency is normal with normal evoked response amplitudes at the wrist with a normal evoked response amplitude at the wrist.  There is mild diminution of response around the elbow.  Conduction velocity slows across the elbow.  The left common peroneal motor distal latency evoked response amplitude is normal with slowed conduction velocity across the calf and across the fibula head.  F-waves are prolonged.,NEEDLE EMG: , Needle EMG was performed on the left arm and lumbosacral and cervical paraspinal muscles as well as middle thoracic muscles using a disposable concentric needle.  It revealed spontaneous activity in lower cervical paraspinals, left abductor pollicis brevis, and first dorsal interosseous muscles.  There were signs of chronic reinnervation in triceps, extensor digitorum communis, flexor pollicis longus as well first dorsal interosseous and abductor pollicis brevis muscles.,IMPRESSION: , This electrical study is abnormal.  It reveals the following:,1.  A sensory motor length-dependent neuropathy consistent with diabetes.,2.  A severe left ulnar neuropathy.  This is probably at the elbow, although definitive localization cannot be made.,3.  Moderate-to-severe left median neuropathy.  This is also probably at the carpal tunnel, although definitive localization cannot be made.,4.  Right ulnar neuropathy at the elbow, mild.,5.  Right median neuropathy at the wrist consistent with carpal tunnel syndrome, moderate.,6.  A left C8 radiculopathy (double crush syndrome).,7.  There is no evidence for thoracic radiculitis.,The patient has made very good response with respect to his abdominal pain since starting Neurontin.  He still has mild allodynia and is waiting for authorization to get insurance coverage for his Lidoderm patch.  He is still scheduled for MRI of C-spine and T-spine.  I will see him in followup after the above scans.","neurology, emg, nerve conduction study, nerve conduction studies, needle emg, electrical study, neuropathy, ulnar neuropathy, median neuropathy, severely attenuated evoked response, normal evoked response amplitude, attenuated evoked response amplitude, median motor distal latency, motor distal latency, abductor pollicis, pollicis brevis, dorsal interosseous, carpal tunnel, conduction, emg/nerve, needle,"
 Nerve conduction screen demonstrates borderline median sensory and borderline distal median motor responses in both hands.   The needle EMG examination is remarkable for rather diffuse active denervation changes in most muscles of the right upper and right lower extremity tested., Neurology, EMG/Nerve Conduction Study - 9 ,"NERVE CONDUCTION TESTING AND EMG EVALUATION,1.  Right median sensory response 3.0, amplitude 2.5, distance 100.,2.  Right ulnar sensory response 2.1, amplitude 1, distance 90.,3.  Left median sensory response 3.0, amplitude 1.2, distance 100.,4.  Left median motor response distal 4.2, proximal 9, amplitude 2.2, distance 290, velocity 60.4 m/sec.,5.  Right median motor response distal 4.3, proximal 9.7, amplitude 2, and velocity 53.7 m/sec.,6.  Right ulnar motor response distal 2.5, proximal 7.5, amplitude 2, distance 300, velocity 60 m/sec.,NEEDLE EMG TESTING,1.  ,RIGHT BICEPS:,  Fibrillations 0, fasciculations occasional, positive waves 0.  Motor units, increased needle insertional activity and mild decreased number of motor units firing.,2.  ,RIGHT TRICEPS:,  Fibrillations 1+, fasciculations occasional to 1+, positive waves 1+.  Motor units, increased needle insertional activity and decreased number of motor units firing.,3.  ,EXTENSOR DIGITORUM:,  Fibrillations 0, fasciculations rare, positive waves 0, motor units probably normal.,4.  ,FIRST DORSAL INTEROSSEOUS: , Fibrillations 2+, fasciculations 1+, positive waves 2+.  Motor units, decreased number of motor units firing.,5.  ,RIGHT ABDUCTOR POLLICIS BREVIS:,  Fibrillations 1+, fasciculations 1+, positive waves 0.  Motor units, decreased number of motor units firing.,6. , FLEXOR CARPI ULNARIS:,  Fibrillations 1+, occasionally entrained, fasciculations rare, positive waves 1+.  Motor units, decreased number of motor units firing.,7.  ,LEFT FIRST DORSAL INTEROSSEOUS:,  Fibrillations 1+, fasciculations 1+, positive waves occasional.  Motor units, decreased number of motor units firing.,8.  ,LEFT EXTENSOR DIGITORUM:,  Fibrillations 1+, fasciculations 1+.  Motor units, decreased number of motor units firing.,9.  ,RIGHT VASTUS MEDIALIS:,  Fibrillations 1+ to 2+, fasciculations 1+, positive waves 1+.  Motor units, decreased number of motor units firing.,10.  ,ANTERIOR TIBIALIS: , Fibrillations 2+, occasionally entrained, fasciculations 1+, positive waves 1+.  Motor units, increased proportion of polyphasic units and decreased number of motor units firing.  There is again increased needle insertional activity.,11.  ,RIGHT GASTROCNEMIUS:,  Fibrillations 1+, fasciculations 1+, positive waves 1+.  Motor units, marked decreased number of motor units firing.,12.  ,LEFT GASTROCNEMIUS:,  Fibrillations 1+, fasciculations 1+, positive waves 2+.  Motor units, marked decreased number of motor units firing.,13.  ,LEFT VASTUS MEDIALIS: , Fibrillations occasional, fasciculations occasional, positive waves 1+.  Motor units, decreased number of motor units firing.,IMPRESSION: ",
" A woman with a history of progression of dysphagia for the past year, dysarthria, weakness of her right arm, cramps in her legs, and now with progressive weakness in her upper extremities.  Abnormal electrodiagnostic study. ", Neurology, EMG/Nerve Conduction Study - 8 ,"REFERRING DIAGNOSIS: , Motor neuron disease.,PERTINENT HISTORY AND EXAMINATION:,  Briefly, the patient is an 83-year-old woman with a history of progression of dysphagia for the past year, dysarthria, weakness of her right arm, cramps in her legs, and now with progressive weakness in her upper extremities.,SUMMARY:  ,The right median sensory response showed a borderline normal amplitude for age with mild slowing of conduction velocity.  The right ulnar sensory amplitude was reduced with slowing of the conduction velocity.  The right radial sensory amplitude was reduced with slowing of the conduction velocity.  The right sural and left sural sensory responses were absent.  The right median motor response showed a prolonged distal latency across the wrist, with proximal slowing.  The distal amplitude was very reduced, and there was a reduction with proximal stimulation.  The right ulnar motor amplitude was borderline normal, with slowing of the conduction velocity across the elbow.  The right common peroneal motor response showed a decreased amplitude when recorded from the EDB, with mild slowing of the proximal conduction velocity across the knee.  The right tibial motor response showed a reduced amplitude with prolongation of the distal latency.  The left common peroneal response recorded from the EDB showed a decreased amplitude with mild distal slowing.  The left tibial motor response showed a decreased amplitude with a borderline normal distal latency.  The minimum F-wave latencies were normal with the exception of a mild prolongation of the ulnar F-wave latency, and the tibial F-wave latency as indicated above.  With repetitive nerve stimulation, there was no significant decrement noted in either the right nasalis or the right trapezius muscles.  Concentric needle EMG studies were performed in the right lower extremity, right upper extremity, thoracic paraspinals, and in the tongue.  There was evidence of increased insertional activity in the right tibialis anterior muscle, with evidence of fasciculations noted in several lower and upper extremity muscles and in the tongue.  In addition, there was evidence of increased amplitude, long duration and polyphasic motor units with a decreased recruitment noted in most muscles tested as indicated in the table above.,INTERPRETATION: , Abnormal electrodiagnostic study.  There is electrodiagnostic evidence of a disorder of the anterior motor neurons affecting at least four segments.  There is also evidence of a more generalized neuropathy that seems to be present in both the upper and lower extremities.  There is also evidence of a right median mononeuropathy at the wrist and a right ulnar neuropathy at the elbow.  Even despite the patient's age, the decrease in sensory responses is concerning, and makes it difficult to be certain about the diagnosis of motor neuron disease.  However, the overall changes on the needle EMG would be consistent with a diagnosis of motor neuron disease.  The patient will return for further evaluation.","neurology, electrodiagnostic study, electrodiagnostic, edb, latency, nerve conduction study, emg, motor neuron disease, distal latency, motor response, motor, amplitude, conduction"
 The patient is status post C3-C4 anterior cervical discectomy and fusion., Neurology, EMG/Nerve Conduction Study - 5 ,"She has an extensive past medical history of rheumatoid arthritis, fibromyalgia, hypertension, hypercholesterolemia, and irritable bowel syndrome.  She has also had bilateral carpal tunnel release.,On examination, normal range of movement of C-spine.  She has full strength in upper and lower extremities.  Normal straight leg raising.  Reflexes are 2 and symmetric throughout.  No Babinski.  She has numbness to light touch in her right big toe.,NERVE CONDUCTION STUDIES:  The right median palmar sensory distal latencies are minimally prolonged with minimally attenuated evoked response amplitude.  Bilateral tibial motor nerves could not be obtained (technical).  The remaining nerves tested revealed normal distal latencies, evoked response amplitudes, conduction velocities, F-waves, and H. reflexes.,NEEDLE EMG:  Needle EMG was performed on the right arm and leg and lumbosacral and cervical paraspinal muscles and the left FDI.  It revealed 2+ spontaneous activity in the right APB and FDI and 1+ spontaneous activity in lower cervical paraspinals, lower and middle lumbosacral paraspinals, right extensor digitorum communis muscle, and right pronator teres.  There was evidence of chronic denervation in the right first dorsal interosseous, pronator teres, abductor pollicis brevis, and left first dorsal interosseous.,IMPRESSION:  This electrical study is abnormal.  It reveals the following:,1.  An active right C8/T1 radiculopathy.  Electrical abnormalities are moderate.,2.  An active right C6/C7 radiculopathy.  Electrical abnormalities are mild.,3.  Evidence of chronic left C8/T1 denervation.  No active denervation.,4.  Mild right lumbosacral radiculopathies.  This could not be further localized because of normal EMG testing in the lower extremity muscles.,5.  There is evidence of mild sensory carpal tunnel on the right (she has had previous carpal tunnel release).,Results were discussed with the patient.  It appears that she has failed conservative therapy and I have recommended to her that she return to Dr. X for his assessment for possible surgery to her C-spine.  She will continue with conservative therapy for the mild lumbosacral radiculopathies.","neurology, emg, nerve conduction study, needle emg, paraspinal muscles, radiculopathy, electrical abnormalities, carpal tunnel release, evoked response, lumbosacral radiculopathies, conservative therapy, carpal tunnel, conduction, emg/nerve, "
" Patient had movor vehicle accirdent and may have had a brief loss of consciousness.  Shortly thereafter she had some blurred vision,  Since that time she has had right low neck pain and left low back pain.  ", Neurology, EMG/Nerve Conduction Study - 7 ,"HISTORY: , The patient is a 34-year-old right-handed female who states her symptoms first started after a motor vehicle accident in September 2005.  She may have had a brief loss of consciousness at the time of the accident since shortly thereafter she had some blurred vision, which lasted about a week and then resolved.  Since that time she has had right low neck pain and left low back pain.  She has been extensively worked up and treated for this.  MRI of the C & T spine and LS spine has been normal.  She has improved significantly, but still complains of pain.  In June of this year she had different symptoms, which she feels are unrelated.  She had some chest pain and feeling of tightness in the left arm and leg and face.  By the next morning she had numbness around her lips on the left side and encompassing the whole left arm and leg.  Symptoms lasted for about two days and then resolved.  However, since that time she has had intermittent numbness in the left hand and leg.  The face numbness has completely resolved.  Symptoms are mild.  She denies any previous similar episodes.  She denies associated dizziness, vision changes incoordination, weakness, change in gait, or change in bowel or bladder function.  There is no associated headache.,Brief examination reveals normal motor examination with no pronator drift and no incoordination.  Normal gait.  Cranial nerves are intact.  Sensory examination reveals normal facial sensation.  She has normal and symmetrical light touch, temperature, and pinprick in the upper extremities.  In the lower extremities she has a feeling of dysesthesia in the lateral aspect of the left calf into the lateral aspect of the left foot.  In this area she has normal light touch and pinprick.  She describes it as a strange unusual sensation.,NERVE CONDUCTION STUDIES: , Motor and sensory distal latencies, evoked response amplitudes, conduction velocities, and F-waves are normal in the left arm and leg.,NEEDLE EMG: , Needle EMG was performed in the left leg, lumbosacral paraspinal, right tibialis anterior, and right upper thoracic paraspinal muscles using a disposable concentric needle.  It revealed normal insertional activity, no spontaneous activity, and normal motor unit action potential form in all muscles tested.,IMPRESSION: , This electrical study is normal.  There is no evidence for peripheral neuropathy, entrapment neuropathy, plexopathy, or lumbosacral radiculopathy.  EMG was also performed in the right upper thoracic paraspinal where she has experienced a lot of pain since the motor vehicle accident.  This was normal.,Based on her history of sudden onset of left face, arm, and leg weakness as well as a normal EMG and MRI of her spine I am concerned that she had a central event in June of this year.  Symptoms are now very mild, but I have ordered an MRI of the brain with and without contrast and MRA of the head and neck with contrast to further elucidate her symptoms.  Once she has the test done she will phone me and further management will be based on the results.","neurology, nerve conduction studies, motor, sensory, distal latencies, evoked response, conduction velocities, needle emg, loss of consciousness, motor vehicle accident, thoracic paraspinal, needle, paraspinal, conduction, "
 Electroencephalographic findings and interpretation, Neurology, Electroencephalography ,"HISTORY:, This is a digital EEG performed on a 75-year-old male with seizures.,BACKGROUND ACTIVITY:, The background activity consists of a 8 Hz to 9 Hz rhythm arising in the posterior head region. This rhythm is also accompanied by some beta activity which occurs infrequently. There are also muscle contractions occurring at 4 Hz to 5 Hz which suggests possible Parkinson's. Part of the EEG is obscured by the muscle contraction artifact. There are also left temporal sharps occurring infrequently during the tracing. At one point of time, there was some slowing occurring in the right frontal head region.,ACTIVATION PROCEDURES:, Photic stimulation was performed and did not show any significant abnormality.,SLEEP PATTERNS:, No sleep architecture was observed during this tracing.,IMPRESSION:, This awake/alert/drowsy EEG is abnormal due to the presence of slowing in the right frontal head region, due to the presence of sharps arising in the left temporal head region, and due to the tremors. The slowing can be consistent with underlying structural abnormalities, so a stroke, subdural hematoma, etc., should be ruled out. The tremor probably represents a Parkinson's tremor and the sharps arising in the left temporal head region can potentially give way to seizures or may also represent underlying structural abnormalities, so clinical correlation is recommended.","neurology, electroencephalography, eeg, hz rhythm, parkinson's tremor, photic stimulation, frontal head region, temporal head region, muscle contractions, seizures, parkinson's, temporal, "
" A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time. ", Neurology, EMG/Nerve Conduction Study - 3 ,"HISTORY: , The patient is a 56-year-old right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident in September of 2005.  At that time, she did not notice any specific injury.  Five days later, she started getting abnormal right low back pain.  At this time, it radiates into the buttocks down the posterior aspect of her thigh and into the right lateral aspect of her calf.  Symptoms are worse when sitting for any length of time, such as driving a motor vehicle.  Mild symptoms when walking for long periods of time.  Relieved by standing and lying down.  She denies any left leg symptoms or right leg weakness.  No change in bowel or bladder function.  Symptoms have slowly progressed.  She has had Medrol Dosepak and analgesics, which have not been very effective.  She underwent a spinal epidural injection, which was effective for the first few hours, but she had recurrence of the pain by the next day.  This was done four and a half weeks ago.,On examination, lower extremities strength is full and symmetric.  Straight leg raising is normal.,OBJECTIVE:,  Sensory examination is normal to all modalities.  Full range of movement of lumbosacral spine.  Mild tenderness over lumbosacral paraspinal muscles and sacroiliac joint.  Deep tendon reflexes are 2+ and symmetric at the knees, 2 at the left ankle and 1+ at the right ankle.,NERVE CONDUCTION STUDIES:,  Motor and sensory distal latencies, evoked response, amplitudes, conduction velocities, and F-waves are normal in the lower extremities.  Right tibial H-reflex is slightly prolonged when compared to the left tibial H-reflex.,NEEDLE EMG:,  Needle EMG was performed in both lower extremities and lumbosacral paraspinal muscles using the disposable concentric needle.  It revealed increased insertional activity in the right mid and lower lumbosacral paraspinal muscles as well as right peroneus longus muscle.  There were signs of chronic denervation in right tibialis anterior, peroneus longus, gastrocnemius medialis, and left gastrocnemius medialis muscles.,IMPRESSION: , This electrical study is abnormal.  It reveals the following:,1.  A mild right L5 versus S1 radiculopathy.,2.  Left S1 nerve root irritation.  There is no evidence of active radiculopathy.,3.  There is no evidence of plexopathy, myopathy or peripheral neuropathy.,MRI of the lumbosacral spine was personally reviewed and reveals bilateral L5-S1 neuroforaminal stenosis, slightly worse on the right.  Results were discussed with the patient and her daughter.  I would recommend further course of spinal epidural injections with Dr. XYZ.  If she has no response, then surgery will need to be considered.  She agrees with this approach and will followup with you in the near future.","neurology, emg, nerve conduction study, radiculopathy, peripheral neuropathy, nerve root irritation, motor vehicle accident, lumbosacral paraspinal muscles, spinal epidural, lumbosacral spine, peroneus longus, gastrocnemius medialis, lower extremities, emg/nerve, conduction, needle"
 Patient with a past medical history of a left L5-S1 lumbar microdiskectomy with complete resolution of left leg symptoms., Neurology, EMG/Nerve Conduction Study - 6 ,"HISTORY:,  The patient is a 46-year-old right-handed gentleman with a past medical history of a left L5-S1 lumbar microdiskectomy in 1998 with complete resolution of left leg symptoms, who now presents with a four-month history of gradual onset of right-sided low back pain with pain radiating down into his buttock and posterior aspect of his right leg into the ankle.  Symptoms are worsened by any activity and relieved by rest.  He also feels that when the pain is very severe, he has some subtle right leg weakness.  No left leg symptoms.  No bowel or bladder changes.,On brief examination, full strength in both lower extremities.  No sensory abnormalities.  Deep tendon reflexes are 2+ and symmetric at the patellas and absent at both ankles.  Positive straight leg raising on the right.,MRI of the lumbosacral spine was personally reviewed and reveals a right paracentral disc at L5-S1 encroaching upon the right exiting S1 nerve root.,NERVE CONDUCTION STUDIES:,  Motor and sensory distal latencies, evoked response amplitudes, and conduction velocities are normal in the lower extremities.  The right common peroneal F-wave is minimally prolonged.  The right tibial H reflex is absent.,NEEDLE EMG:,  Needle EMG was performed on the right leg, left gastrocnemius medialis muscle, and right lumbosacral paraspinal muscles using a disposable concentric needle.  It revealed spontaneous activity in the right gastrocnemius medialis, gluteus maximus, and lower lumbosacral paraspinal muscles.  There was evidence of chronic denervation in right gastrocnemius medialis and gluteus maximus muscles.,IMPRESSION: , This electrical study is abnormal.  It reveals an acute right S1 radiculopathy.  There is no evidence for peripheral neuropathy or left or right L5 radiculopathy.,Results were discussed with the patient and he is scheduled to follow up with Dr. X in the near future.","neurology, microdiskectomy, needle emg, nerve conduction studies, lumbosacral paraspinal muscles, lumbar microdiskectomy, lower extremities, lumbosacral paraspinal, paraspinal muscles, gluteus maximus, leg symptoms, gastrocnemius medialis, emg/nerve, conduction, lumbosacral, needle, gastrocnemius, medialis, muscles, "
 A 21-channel digital electroencephalogram was performed on a patient in the awake state., Neurology, Electroencephalogram - 4 ,"PROCEDURE:,  A 21-channel digital electroencephalogram was performed on a patient in the awake state.  Per the technician's notes, the patient is taking Depakene.,The recording consists of symmetric 9 Hz alpha activity.  Throughout the recording, repetitive episodes of bursts of 3 per second spike and wave activity are noted.  The episodes last from approximately1 to 7 seconds.  The episodes are exacerbated by hyperventilation.,IMPRESSION:,  Abnormal electroencephalogram with repetitive bursts of 3 per second spike and wave activity exacerbated by hyperventilation.  This activity could represent true petit mal epilepsy.  Clinical correlation is suggested.","neurology, alpha activity, wave activity, hyperventilation, electroencephalogramNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" The patient with longstanding bilateral arm pain, which is predominantly in the medial aspect of arms and hands, as well as left hand numbness, worse at night and after doing repetitive work with left hand.", Neurology, EMG/Nerve Conduction Study - 1 ,"HISTORY: , The patient is a 52-year-old right-handed female with longstanding bilateral arm pain, which is predominantly in the medial aspect of her arms and hands as well as left hand numbness, worse at night and after doing repetitive work with her left hand.  She denies any weakness.  No significant neck pain, change in bowel or bladder symptoms, change in gait, or similar symptoms in the past.  She is on Lyrica for the pain, which has been somewhat successful.,Examination reveals positive Phalen's test on the left.  Remainder of her neurological examination is normal.,NERVE CONDUCTION STUDIES:  ,The left median motor distal latency is prolonged with normal evoked response amplitude and conduction velocity.  The left median sensory distal latency is prolonged with an attenuated evoked response amplitude.  The right median sensory distal latency is mildly prolonged with a mildly attenuated evoked response amplitude.  The right median motor distal latency and evoked response amplitude is normal.  Left ulnar motor and sensory and left radial sensory responses are normal.  Left median F-wave is normal.,NEEDLE EMG:,  Needle EMG was performed on the left arm, right first dorsal interosseous muscle, and bilateral cervical paraspinal muscles.  It revealed spontaneous activity in the left abductor pollicis brevis muscle.  There is increased insertional activity in the right first dorsal interosseous muscle.  Both interosseous muscles showed signs of reinnervation.  Left extensor digitorum communis muscle showed evidence of reduced recruitment.  Cervical paraspinal muscles were normal.,IMPRESSION: , This electrical study is abnormal.  It reveals the following:  A left median neuropathy at the wrist consistent with carpal tunnel syndrome.  Electrical abnormalities are moderate-to-mild bilateral C8 radiculopathies.  This may be an incidental finding.,I have recommended MRI of the spine without contrast and report will be sent to Dr. XYZ.  She will follow up with Dr. XYZ with respect to treatment of the above conditions.","neurology, nerve conduction study, emg, neuropathy, median motor distal latency, median sensory distal latency, attenuated evoked response amplitude, emg/nerve conduction study, sensory distal latency, attenuated evoked response, dorsal interosseous muscle, cervical paraspinal muscles, emg/nerve conduction, conduction study, median motor, needle emg, distal latency, evoked response, emg/nerve, bilateral, evoked, conduction, "
 Electroencephalogram (EEG).  This is an 18-channel recording obtained using the standard scalp and referential electrodes observing the 10/20 international system., Neurology, Electroencephalogram - 2 ,"REPORT:  ,This is an 18-channel recording obtained using the standard scalp and referential electrodes observing the 10/20 international system.  The patient was reported to be cooperative and was awake throughout the recording.,CLINICAL NOTE:  ,This is a 51-year-old male, who is being evaluated for dizziness.  Spontaneous activity is fairly well organized, characterized by low-to-medium voltage waves of about 8 to 9 Hz seen mainly from the posterior head region.  Intermixed with it is a moderate amount of low voltage fast activity seen from the anterior head region.,Eye opening caused a bilateral symmetrical block on the first run.  In addition to the above description, movement of muscle and other artifacts are seen.,On subsequent run, no additional findings were seen.,During subsequent run, again no additional findings were seen.,Hyperventilation was omitted.,Photic stimulation was performed, but no clear-cut photic driving was seen.,EKG was monitored during this recording and it showed normal sinus rhythm when monitored.,IMPRESSION:  ,This record is essentially within normal limits.  Clinical correlation is recommended.","neurology, referential electrodes, scalp, hyperventilation, photic stimulation, electroencephalogram"
 Electroencephalogram (EEG).  Photic stimulation reveals no important changes.  Essentially normal., Neurology, Electroencephalogram - 1 ,"REPORT:,  The electroencephalogram shows background activity at about 9-10 cycle/second bilaterally.  Little activity in the beta range is noted.  Waves of 4-7 cycle/second of low amplitude were occasionally noted.  Abundant movements and technical artifacts are noted throughout this tracing.  Hyperventilation was not performed.  Photic stimulation reveals no important changes.,CLINICAL INTERPRETATION:,  The electroencephalogram is essentially normal.","neurology, beta range, hyperventilation, photic stimulation, electroencephalogramNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back pain radiating into the right leg.", Neurology, EMG/Nerve Conduction Study - 2 ,"HISTORY: , The patient is a 78-year-old right-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back pain radiating into the right leg.  She was undergoing a spinal epidural injection about a month ago and had worsening of right low back pain, which radiates down into her buttocks and down to posterior aspect of her thigh into her knee.  This has required large amounts of opioid analgesics to control.  She has been basically bedridden because of this.  She was brought into hospital for further investigations.,PHYSICAL EXAMINATION: , On examination, she has positive straight leg rising on the right with severe shooting, radicular type pain with right leg movement.  Difficult to assess individual muscles, but strength is largely intact.  Sensory examination is symmetric.  Deep tendon reflexes reveal hyporeflexia in both patellae, which probably represents a cervical myelopathy from prior cord compression.  She has slightly decreased right versus left ankle reflexes.  The Babinski's are positive.  On nerve conduction studies, motor and sensory distal latencies, evoked response amplitudes, conduction velocities, and F-waves are normal in lower extremities.,NEEDLE EMG: , Needle EMG was performed on the right leg and lumbosacral paraspinal muscles using a disposable concentric needle.  It reveals the spontaneous activity in right peroneus longus and gastrocnemius medialis muscles as well as the right lower lumbosacral paraspinal muscles.  There is evidence of denervation in right gastrocnemius medialis muscle.,IMPRESSION: , This electrical study is abnormal.  It reveals the following:,1.  Inactive right S1 (L5) radiculopathy.,2.  There is no evidence of left lower extremity radiculopathy, peripheral neuropathy or entrapment neuropathy.,Results were discussed with the patient and she is scheduled for imaging studies in the next day.","neurology, needle emg, radiculopathy, electrical study, emg, nerve conduction study, cervical spinal stenosis, lumbosacral paraspinal muscles, gastrocnemius medialis muscles, spinal stenosis, post decompression, lumbosacral paraspinal, paraspinal muscles, gastrocnemius medialis, medialis muscles, decompression, emg/nerve, conduction, cervical, spinal, needle, muscles, "
 Normal awake and drowsy (stage I sleep) EEG for patient's age., Neurology, Electroencephalogram ,"DESCRIPTION OF RECORD:  ,This tracing was obtained utilizing 27 paste-on gold-plated surface disc electrodes placed according to the International 10-20 system.  Electrode impedances were measured and reported at less than 5 kilo-ohms each.,FINDINGS: , In general, the background rhythms are bilaterally symmetrical.  During the resting awake state they are composed of moderate amounts of low amplitude fast activity intermixed with moderate amounts of well-modulated 9-10 Hz alpha activity best seen posteriorly.  The alpha activity attenuates with eye opening.,During some portions of the tracing the patient enters a drowsy state in which the background rhythms are composed predominantly of moderate amounts of low amplitude fast activity intermixed with moderate amounts of low to medium amplitude polymorphic theta activity.,There is no evidence of focal slowing or paroxysmal activity.,IMPRESSION: , Normal awake and drowsy (stage I sleep) EEG for patient's age.","neurology, gold-plated surface disc electrodes, paroxysmal activity, eeg, drowsy stage, sleep eeg, stage, sleep, electrodes, awake, moderate, activity"
" Abnormal electroencephalogram revealing generalized poorly organized slowing, with more prominent slowing noted at the right compared to the left hemisphere head regions and rare sharp wave activity noted bilaterally, somewhat more prevalent on the right. ", Neurology, Electroencephalogram - 3 ,"IMPRESSION:,  Abnormal electroencephalogram revealing generalized poorly organized slowing, with more prominent slowing noted at the right compared to the left hemisphere head regions and rare sharp wave activity noted bilaterally, somewhat more prevalent on the right.  Clinical correlation is suggested.","neurology, sleep, vertex activity, muscle artifact, sharp wave activity, electroencephalogramNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" History of numbness in both big toes and up the lateral aspect of both calves.  She dose complain of longstanding low back pain, but no pain that radiates from her back into her legs.  She has had no associated weakness.", Neurology, EMG/Nerve Conduction Study ,"HISTORY:,  The patient is a 52-year-old female with a past medical history of diet-controlled diabetes, diffuse arthritis, plantar fasciitis, and muscle cramps who presents with a few-month history of numbness in both big toes and up the lateral aspect of both calves.  Symptoms worsened considerable about a month ago.  This normally occurs after being on her feet for any length of time.  She was started on amitriptyline and this has significantly improved her symptoms.  She is almost asymptomatic at present.  She dose complain of longstanding low back pain, but no pain that radiates from her back into her legs.  She has had no associated weakness.,On brief examination, straight leg raising is normal.  The patient is obese.  There is mild decreased vibration and light touch in distal lower extremities.  Strength is full and symmetric.  Deep tendon reflexes at the knees are 2+ and symmetric and absent at the ankles.,NERVE CONDUCTION STUDIES: , Bilateral sural sensory responses are absent.  Bilateral superficial sensory responses are present, but mildly reduced.  The right radial sensory response is normal.  The right common peroneal and tibial motor responses are normal.  Bilateral H-reflexes are absent.,NEEDLE EMG:,  Needle EMG was performed on the right leg and lumbosacral paraspinal muscles and the left tibialis posterior using a concentric disposable needle.  It revealed increased insertional activity in the right tibialis posterior muscle with signs of mild chronic denervation in bilateral peroneus longus muscles and the right tibialis posterior muscle.  Lumbar paraspinals were attempted, but were too painful to get a good assessment.,IMPRESSION:  ,This electrical study is abnormal.  It reveals the following:,1.  A very mild, purely sensory length-dependent peripheral neuropathy.,2.  Mild bilateral L5 nerve root irritation.  There is no evidence of active radiculopathy.,Based on the patient's history and exam, her new symptoms are consistent with mild bilateral L5 radiculopathies.  Symptoms have almost completely resolved over the last month since starting Elavil.  I would recommend MRI of the lumbosacral spine if symptoms return.  With respect to the mild neuropathy, this is probably related to her mild glucose intolerance/early diabetes.  However, I would recommend a workup for other causes to include the following:  Fasting blood sugar, HbA1c, ESR, RPR, TSH, B12, serum protein electrophoresis and Lyme titer.","neurology, nerve conduction studies, needle emg, numbness, tibialis posterior muscle, sensory responses, muscle, tibialis, toes"
 Possible cerebrovascular accident.  The EEG was obtained using 21 electrodes placed in scalp-to-scalp and scalp-to-vertex montages. , Neurology, EEG ,"DIAGNOSIS:,  Possible cerebrovascular accident.,DESCRIPTION: , The EEG was obtained using 21 electrodes placed in scalp-to-scalp and scalp-to-vertex montages.  The background activity appears to consist of fairly organized somewhat pleomorphic low to occasional medium amplitude of 7-8 cycle per second activity and was seen mostly posteriorly bilaterally symmetrically.  A large amount of movement artifacts and electromyographic effects were noted intermixed throughout the recording session.  Transient periods of drowsiness occurred naturally producing irregular 5-7 cycle per second activity mostly over the anterior regions.  Hyperventilation was not performed.  No epileptiform activity or any definite lateralizing findings were seen.,IMPRESSION: , Mildly abnormal study.  The findings are suggestive of a generalized cerebral disorder.  Due to the abundant amount of movement artifacts, any lateralizing findings, if any cannot be well appreciated.  Clinical correlation is recommended.","neurology, scalp-to-scalp, scalp-to-vertex, montages, electrodes, amplitude, epileptiform activity, cerebrovascular accident, eegNOTE"
 This is a 95.5-hour continuous video EEG monitoring study., Neurology, EEG Monitoring Study ,"TECHNICAL SUMMARY: , The patient was recorded from 2:15 p.m. on 08/21/06 through 1:55 p.m. on 08/25/06.  The patient was recorded digitally using the 10-20 system of electrode placement.  Additional temporal electrodes and single channels of EOG and EKG were also recorded.  The patient's medications valproic acid, Zonegran, and Keppra were weaned progressively throughout the study.,The occipital dominant rhythm is 10 to 10.5 Hz and well regulated.  Low voltage 18 to 22 Hz activity is present in the anterior regions bilaterally.,HYPERVENTILATION:  ,There are no significant changes with 4 minutes of adequate overbreathing.,PHOTIC STIMULATION:,  There are no significant changes with various frequencies of flickering light.,SLEEP: , There are no focal or lateralizing features and no abnormal waveforms.,INDUCED EVENT: , On the final day of study, a placebo induction procedure was performed to induce a clinical event.  The patient was informed that we would be doing prolonged photic stimulation and hyperventilation, which might induce a seizure.  At 1:38 p.m., the patient was instructed to begin hyperventilation.  Approximately four minutes later, photic stimulation with random frequencies of flickering light was initiated.  Approximately 8 minutes into the procedure, the patient became unresponsive to verbal questioning.  Approximately 1 minute later, she began to exhibit asynchronous shaking of her upper and lower extremities with her eyes closed.  She persisted with the shaking and some side-to-side movements of her head for approximately 1 minute before abruptly stopping.  Approximately 30 seconds later, she became slowly responsive initially only uttering a few words and able to say her name.  When asked what had just occurred, she replied that she was asleep and did not remember any event.  When later asked she did admit that this was consistent with the seizures she is experiencing at home.,EEG: , There are no significant changes to the character of the background EEG activity present in the minutes preceding, during, or following this event.  Of note, while her eyes were closed and she was non-responsive, there is a well-regulated occipital dominant rhythm present.,IMPRESSION:,  The findings of this patient's 95.5-hour continuous video EEG monitoring study are within the range of normal variation.  No epileptiform activity is present.  One clinical event was induced with hyperventilation and photic stimulation.  The clinical features of this event are described in the technical summary above.  There was no epileptiform activity associated with this event.  This finding is consistent with a non-epileptic pseudoseizure.","neurology, video eeg monitoring study, eog, ekg, abnormal waveforms, photic stimulation, hyperventilation, eeg monitoring study, eeg monitoring, monitoring study, eeg, monitoring"
 Diagnostic cerebral angiogram and transcatheter infusion of papaverine, Neurology, Diagnostic Cerebral Angiogram ,"EXAM:,1.  Diagnostic cerebral angiogram.,2.  Transcatheter infusion of papaverine.,ANESTHESIA: , General anesthesia,FLUORO TIME: , 19.5 minutes,CONTRAST:,  Visipaque-270, 100 mL,INDICATIONS FOR PROCEDURE: , The patient is a 13-year-old boy who had clipping for a left ICA bifurcation aneurysm.  He was referred for a routine postop check angiogram.  He is doing fine clinically.  All questions were answered, risks explained, informed consent taken and patient was brought to angio suite.,TECHNIQUE: , After informed consent was taken patient was brought to angio suite, both groin sites were prepped and draped in sterile manner.  Patient was placed under general anesthesia for entire duration of the procedure.  Groin access was obtained with a stiff micropuncture wire and a 4-French sheath was placed in the right common femoral artery and connected to a continuous heparinized saline flush.  A 4-French angled Glide catheter was then taken up into the descending thoracic aorta was double flushed and connected to a continuous heparinized saline flush.  The catheter was then taken up into the aortic arch and both common and internal carotid arteries were selectively catheterized followed by digital subtraction imaging in multiple projections.  The images showed spasm of the left internal carotid artery and the left A1, it was thought planned to infused papaverine into the ICA and the left A1.  After that the diagnostic catheter was taken up into the distal internal carotid artery.  SL-10 microcatheter was then prepped and was taken up with the support of Transcend platinum micro guide wire.  The microcatheter was then taken up into the internal carotid artery under biplane roadmapping and was taken up into the distal internal carotid artery and was pointed towards the A1.  60 mg of papaverine was then slowly infused into the internal carotid artery and the anterior cerebral artery.  Post-papaverine infusion images showed increased caliber of the internal carotid artery as well as the left A1.  The catheter was then removed from the patient, pressure was held for 10 minutes leading to hemostasis.  Patient was then transferred back to the ICU in the Children's Hospital where he was extubated without any deficits.,INTERPRETATION OF IMAGES:,1.  LEFT COMMON/INTERNAL CAROTID ARTERY INJECTIONS:  The left internal carotid artery is of normal caliber.  In the intracranial projection there is moderate spasm of the left internal carotid artery and moderately severe spasm of the left A1.  There is poor filling of the A2 through left internal carotid artery injection.  There is opacification of the ophthalmic and the posterior communicating artery MCA along with the distal branches are filling normally.  Capillary filling and venous drainage in MCA distribution is normal and it is very slow in the ACA distribution,2.  RIGHT INTERNAL CAROTID ARTERY INJECTION:  The right internal carotid artery is of normal caliber.  There is opacification of the right ophthalmic and the posterior communicating artery.  The right ACA A1 is supplying bilateral A2 and there is no spasm of the distal anterior cerebral artery.  Right MCA along with the distal branches are filling normally.  Capillary filling and venous drainage are normal.,3.  POST-PAPAVERINE INJECTION:  The post-papaverine injection shows increased caliber of the internal carotid artery as well as the anterior cerebral artery.  Of note the previously clipped internal carotid ICA bifurcation aneurysm is well clipped and there is no residual neck or filling of the dome of the aneurysm.,IMPRESSION:,1.  Well clipped left ICA bifurcation aneurysm.,2.  Moderately severe spasm of the internal carotid artery and left A1.  60 milligrams of papaverine infused leading to increased flow in the aforementioned vessels.","neurology, transcatheter infusion of papaverine, internal carotid artery, heparinized saline flush, diagnostic cerebral angiogram, ica bifurcation aneurysm, anterior cerebral artery, carotid artery, internal carotid, saline flush, venous drainage, papaverine injection, ica bifurcation, bifurcation aneurysm, anterior cerebral, cerebral artery, artery injections, infusion, carotid, artery, angiogram, diagnostic, ica, aneurysm, cerebral, papaverine,"
" Patient reports a rotational sensation upon arising from the bed or chair that lasts for several minutes and requires her to sit back down and stay in one place.  She gets similar symptoms when she rolls over in bed.  At times, she also feels as though she is going to pass out.  These sensations stop if she just sits in one place or lies down for several minutes.", Neurology, Dizziness - Recurrent ,"CHIEF COMPLAINT:,  Recurrent dizziness x1 month.,HISTORY OF PRESENT ILLNESS:,  This is a 77-year-old African-American female with multiple medical problems including CHF (O2 dependent), atrial fibrillation, diabetes mellitus, hypothyroidism, possible stroke, multiple joint disease including gout, arthritis, both rheumatoid and DJD, who presents with a complaint of one month of dizziness.  She reports a rotational sensation upon arising from the bed or chair that lasts for several minutes and requires her to sit back down and stay in one place.  She gets similar symptoms when she rolls over in bed.  She is not able to describe what direction she feels like she is spinning.  At times, she also feels as though she is going to pass out.  These sensations stop if she just sits in one place or lies down for several minutes.  She does note that it is worse when she turns to the right and when she turns to the left.  She also complains that she gets similar sensations when she looks up.  She denies any recent fever, chills, earache, diplopia, dysarthria, dysphagia, other change in vision, or recent new headaches.  She also notes occasional tinnitus to her right ear.,PAST MEDICAL HISTORY:,1.  CHF (uses portable oxygen).,2.  Atrial fibrillation.,3.  Gout.,4.  Arthritis (DJD/rheumatoid).,5.  Diabetes mellitus.,6.  Hypothyroidism.,7.  Hypertension.,8.  GERD.,9.  Possible stroke treated in 2003 at University of Maryland with acute onset of presyncopal sensations, sharp pains in the left side of her head and right-sided hemiparesis and numbness.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: , She is married.  She does not smoke, use alcohol or use illicit drugs.,MEDICATIONS: , Please see medication sheet in the chart.  It includes potassium, Pravachol, Prevacid, Synthroid, Diovan, Amaryl, Vitamin B12, Coreg, Coumadin, furosemide, Actos, aspirin, colchicine, Cipro, Percocet, Ultram (has held the latter two medications for the past two weeks due to concerns of exacerbating dizziness).,REVIEW OF SYSTEMS:,  Please see note in chart essentially entirely positive including cardiovascular problems of shortness of breath, PND and palpitations, chronic lack of energy, weight gain, the dizziness for which she presented.  Tinnitus in the right ear.  Diabetes and hypothyroidism.  Chronic nausea.  Chronic severe musculoskeletal pains to all extremities as well as to chest and abdomen and back.  Right-sided numbness as well as complaints of bilateral lower extremity numbness and difficulty walking.  She says her mood is sad and may be depressed and she is also extremely anxious.  She has chronic shortness of breath and coughs easily when has to breathe deeply.  She also endorses poor sleep.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Sitting BP 112/84 with a pulse of 84, standing after two minutes 130/90 with a pulse of 66.  Respiratory rate is 20.  Weight is 257 pounds.  Pain scale is 7.,GENERAL:  This is a somewhat anxious elderly African-American female who tends to amplify findings on examination.  It is a difficult examination due to the fact that no matter where the patient was touched she would wince in pain and withdraw.  She is obese.,HEENT:  She is normocephalic and atraumatic.  Conjunctivae and sclerae are clear.  Tympanic membranes were visualized bilaterally.  There is tenderness to palpation of any sinus region.  There are no palpable cervical nodes.,NECK:  Supple although she complains of pain when rotating her neck.,CHEST:  Clear to auscultation bilaterally.,HEART:  Heart sounds are distant.  There are no carotid bruits.,EXTREMITIES:  She has 1-2+ pitting edema to the mid shins bilaterally.,NEUROLOGIC EXAMINATION:,MENTAL STATUS:  She is alert and oriented x3.  Her speech is fluent; however, she is extremely tangential.  She is unable to give a cogent medical history including details of hospitalization one month ago when she was admitted for a gout attack and urinary tract infection and underwent several days of rehabilitation.,CRANIAL NERVES:  Cranial nerves are intact throughout; specifically there is no nystagmus, her gaze is conjugate, there is no diplopia, visual fields are full to confrontation, pupils are equal, round and reactive to light and accommodation, extraocular movements are intact, facial sensation and expression are symmetric, vestibuloocular reflexes are intact, hearing is intact to finger rub bilaterally, palate rises symmetrically, normal cough, shoulder shrug is symmetric which shows easy breakaway give, and tongue protrudes in the midline.,MOTOR:  This is a limited exam due to easy breakaway gait and pain that appears exaggerated to movement of any extremity.  There is suggestion of some mild right-sided paresis; however, the degree was inconsistent and her phasic strength is estimated at 4-4+ throughout.  Her tone is normal throughout.,SENSORY:  She appears to have diffuse light tough and pinprick and temperature to the right arm and proximal leg.  She also reports that she is numb in both feet; however, sensation testing of light tough, pinprick and vibration was intact.,COORDINATION:  There is no obvious dysmetria.,GAIT:  She uses a walker to stand up, and several near falls when asked to stand unassisted and can only ambulate with a walker.  There are some mild right lower extremity circumduction present.,REFLEXES:  Biceps 1, triceps trace, brachioradialis 1, patella and ankle absent.  Toes are equivocal.,OTHER:  Barany maneuver was attempted; however, when the patient was placed supine she immediately began screaming, ""Oh my back, oh my back"", and was unable to complete the maneuver.  Brief inspection of her eyes failed to show any nystagmus at that time.,IMPRESSION AND PLAN:,  This is a 77-year-old African-American female with multiple medical problems who presents with episodic positionally related dizziness of unclear etiology.  Most certainly there is significant exaggeration of the underlying problem and her neurological examination is compounded by much functional overlay, limiting the interpretation of my findings.  I suspect this is just a mild benign positional vertigo, although I cannot rule out vertebrobasilar compromise.  I agree with symptomatic treatment with Antivert.,We will schedule her for CT of head, CT angiogram to evaluate for possible brain stroke and vertebrobasilar insufficiency.  In addition, we will attempt to get further objective data by ENG testing.  I will see the patient again after these tests are completed and she has a trial of the Antivert.",
 Patient with episode of lightheadedness and suddenly experienced vertigo., Neurology, Dural AVM ,"CC: ,Vertigo.,HX: ,This 61y/o RHF experienced a 2-3 minute episode of lightheadedness while driving home from the dentist in 5/92. In 11/92, while eating breakfast, she suddenly experienced vertigo. This was immediately followed by nausea and several episodes of vomiting. The vertigo lasted 2-3minutes. She retired to her room for a 2 hour nap after vomiting. When she awoke, the symptoms had resolved. On 1/13/93 she had an episode of right arm numbness lasting 4-5hours. There was no associated weakness, HA, dysarthria, dysphagia, visual change, vertigo or lightheadedness.,OUTSIDE RECORDS:, 12/16/92 Carotid Doppler (RICA 30-40%, LICA 10-20%). 12/4/92, brain MRI revealed a right cerebellar hypodensity consistent with infarct.,MEDS:, Zantac 150mg bid, Proventil MDI bid, Azmacort MDI bid, Doxycycline 100mg bid, Premarin 0.625mg qd, Provera 2.5mg qd. ASA 325mg qd.,PMH:, 1)MDD off antidepressants since 6/92. 2)asthma. 3)allergic rhinitis. 4)chronic sinusitis. 5)s/p Caldwell-Luc 1978, and nasal polypectomy. 6) GERD. 7)h/o elevated TSH. 8)hypercholesterolemia 287 on 11/20/93. 9)h/o heme positive stool: BE 11/24/92 and UGI 11/25/92 negative.,FHX: ,Father died of a thoracic aortic aneurysm, age 71. Mother died of stroke, age 81.,SHX:, Married. One son deceased. Salesperson. Denied tobacco/ETOH/illicit drug use.,EXAM,: BP (RUE)132/72 LUE (136/76). HR67 RR16 Afebrile. 59.2kg.,MS: A&O to person, place, time. Speech fluent and without dysarthria. Thought lucid.,CN: unremarkable.,Motor: 5/5 strength throughout with normal muscle bulk and tone.,Sensory: No deficits appreciated.,Coord: unremarkable.,Station: no pronator drift, truncal ataxia, or Romberg sign.,Gait: not done.,Reflexes: 2/2 throughout BUE and at patellae. 1/1 at Achilles. Plantar responses were flexor, bilaterally.,Gen Exam: Obese.,COURSE: ,CBC, GS, PT/PTT, UA were unremarkable. The patient was admitted with a working diagnosis of posterior circulation TIA and history of cerebellar stroke. She was placed on Ticlid 250mg bid. HCT,1/15/93: low density focus in the right medial and posterior cerebellar hemisphere. MRI and MRA, 1/18/93, revealed a well circumscribed lesion within the posterior aspect of the right cerebellar hemisphere suggestive of vascular malformation (e.g. cavernous angioma. An abnormal vascular blush was seen on the MRA. This area appeared to be supplied by one of the external carotid arteries (which one is was not specified). this finding maybe suggestive of a vascular malformation. 1/20/93 Cerebral Angiogram: The right cerebellar hemisphere lesion seen on MRI as a possible cavernous angioma was not seen on angiography. Upon review of the MRI and HCT the lesion was felt to probably represent an old infarction with hemosiderin deposition. The ""vascular blush"" seen on MRA was no visualized on angiography. The patient was discharged home on 1/25/93.","neurology, avm, episode of lightheadedness, vascular malformation, cavernous angioma, vascular blush, cerebellar hemisphere, malformation, cavernous, angioma, angiography, lightheadedness, hemisphere, vertigo, cerebellar, "
" He awoke one morning and had double vision.  He states when he closed each eye, the double vision dissipated.  The double vision entirely dissipated within one hour.   The next day he woke up and he had double vision again. ", Neurology, Diplopia ,"HISTORY OF PRESENT ILLNESS: , The patient is a 53-year-old right-handed gentleman who presents to the clinic for further evaluation of diplopia.  He states that he was in his usual state of health when he awoke one morning in January 2009.  He had double vision.  He states when he closed each eye, the double vision dissipated.  The double vision entirely dissipated within one hour.  He was able to drive.  However, the next day he woke up and he had double vision again.  Over the next week, the double vision worsened in intensity and frequency and by the second week, it was severe.  He states that he called Sinai Hospital and spoke to a physician who recommended that he come in for evaluation.  He was seen by a primary care physician who sent him for an ophthalmologic evaluation.  He was seen and referred to the emergency department for an urgent MRI to evaluate for possible aneurysm.  The patient states that he had a normal MRI and was discharged to home.,For the next month, the double vision improved, although he currently still experiences constant diplopia.  Whereas in the past, when he would see two objects, they were very far apart in a horizontal plane; now they are much closer together.  He still does not drive.  He also is not working due to the double vision.  There is no temporal fluctuation to the double vision.  More recently, over the past month, he has developed right supraorbital pain.  It actually feels like there is pain under his right lid.  He denies any dysphagia, dysarthria, weakness, numbness, tingling, or any other neurological symptoms.,There is a neurology consultation in the computer system.  Dr. X saw the patient on February 2, 2009, when he was in the emergency department.  He underwent an MRI that showed a questionable 3 mm aneurysm of the medial left supraclinoid internal carotid artery, but there were no abnormalities on the right side.  MRV was negative and MRI of the brain with and without contrast was also negative.  He also had an MRI of the orbit with and without contrast that was normal.  His impression was that the patient should follow up for a possible evaluation of myasthenia gravis or other disorder.,At the time of the examination, it was documented that he had right lid ptosis.  He had left gaze diplopia.  The pupils were equal, round, and reactive to light.  His neurological examination was otherwise entirely normal.  According to Dr. X's note, the ophthalmologist who saw him thought that there was ptosis of the right eye as well as an abnormal pupil.  There was also right medial rectus as well as possibly other extraocular abnormalities.  I do not have the official ophthalmologic consultation available to me today.,PAST MEDICAL HISTORY: , The patient denies any previous past medical history.  He currently does not have a primary care physician as he is uninsured.,MEDICATIONS:,  He does not take any medications.,ALLERGIES: , He has no known drug allergies.,SOCIAL HISTORY: , The patient lives with his wife.  He was an IT software developer, but he has been out of work for several months.  He smokes less than a pack of cigarettes daily.  He denies alcohol or illicit drug use.,FAMILY HISTORY: , His mother died of a stroke in her 90s.  His father had colon cancer.  He is unaware of any family members with neurological disorders.,REVIEW OF SYSTEMS: , A complete review of systems was obtained and was negative except for as mentioned above.  This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:,Vital Signs:  BP 124/76",
" Cerebrovascular accident (CVA).  The patient presents to the emergency room after awakening at 2:30 a.m. this morning with trouble swallowing, trouble breathing, and left-sided numbness and weakness. ", Neurology, CVA Consult - ER Visit ,"ADMITTING DIAGNOSIS: , Cerebrovascular accident (CVA).,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old gentleman with a significant past medical history for nasopharyngeal cancer status post radiation therapy to his pharynx and neck in 1991 who presents to the emergency room after awakening at 2:30 a.m. this morning with trouble swallowing, trouble breathing, and left-sided numbness and weakness.  This occurred at 2:30 a.m.  His wife said that he had trouble speaking as well, but gradually the symptoms resolved but he was still complaining of a headache and at that point, he was brought to the emergency room.  He arrived at the emergency room here via private ambulance at 6:30 a.m. in the morning.  Upon initial evaluation, he did have some left-sided weakness and was complaining of a headache.  He underwent workup including a CT, which was negative and his symptoms slowly began to resolve.  He was initially admitted, placed on Plavix and aspirin.  However a few hours later, his symptoms returned and he had increasing weakness of his left arm and left leg as well as slurred speech.  Repeat CT scan again done reportedly was negative and he was subsequently heparinized and admitted.  He also underwent an echo, carotid ultrasound, and lab work in the emergency room.  Wife is at the bedside and denies he had any other symptoms previous to this.  He denied any chest pain or palpitations.  She does report that he is on a Z-Pak, got a cortisone shot, and some decongestant from Dr. ABC on Saturday because of congestion and that had gotten better.,ALLERGIES:  ,He has no known drug allergies.,CURRENT MEDICATIONS:,1.  Multivitamin.,2.  Ibuprofen p.r.n.,PAST MEDICAL HISTORY:,1.  Nasopharyngeal cancer.  Occurred in 1991.  Status post XRT of the nasopharyngeal area and his neck because of spread to the lymph nodes.,2.  Lumbar disk disease.,3.  Status post diskectomy.,4.  Chronic neck pain secondary to XRT.,5.  History of thalassemia.,6.  Chronic dizziness since his XRT in 1991.,PAST SURGICAL HISTORY: , Lumbar diskectomy, which is approximately 7 to 8 years ago, otherwise negative.,SOCIAL HISTORY: , He is a nonsmoker.  He occasionally has a beer.  He is married.  He works as a flooring installer.,FAMILY HISTORY:  ,Pertinent for father who died of an inoperable brain tumour.  Mother is obese, but otherwise negative history.,REVIEW OF SYSTEMS:  ,He reports he was in his usual state of health up until he awoke this morning.  He does states that yesterday his son cleaned the walk area with some ether and since then he has not quite been feeling right.  He is a right-handed male and normally wears glasses.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Stable.  His blood pressure was 156/97 in the emergency room, pulse is 73, respiratory rate 20, and saturation is 99%.,GENERAL:  He is alert, pleasant, and in no acute distress at this time.  He answers questions appropriately.,HEENT:  Pupils are equal, round, and reactive to light.  Extraocular muscles are intact.  Sclerae are clear.  TMs clear.  Oropharynx is clear.,NECK:  Supple with full range of motion.  He does have some increased density to neck, I assume, secondary to XRT.,CARDIOVASCULAR:  Regular rate and rhythm without murmur.,LUNGS:  Clear bilaterally.,ABDOMEN:  Soft, nontender, and nondistended.,EXTREMITIES:  Show no clubbing, cyanosis or edema.,NEUROLOGIC:  He does have a minimally slurred speech at present.  He does have a slight facial droop.  He has significant left upper extremity weakness approximately 3-4/5, left lower extremity weakness is approximately a 2-3/5 on the left.  Handgrip is about 4/5 on the left, right side is 5/5.,LABORATORY DATA:  ,His initial blood work, PT was 11 and PTT 27.  CBC is within normal limits except for hemoglobin of 12.9 and hematocrit of 39.1.  Chem panel is all normal.,EKG showed normal sinus rhythm, normal EKG.  CT of his brain, initially his first CT, which was done this morning at approximately 7 a.m. showed a normal CT.  Repeat CT done at approximately 3:30 p.m. this evening was reportedly also normal.  He underwent an echocardiogram in the emergency room, which was essentially normal.  He had a carotid ultrasound, which revealed total occlusion of the right internal carotid artery, 60% to 80% stenosis of the left internal carotid artery, and 60% stenosis of the left external carotid artery.,MPRESSION AND PLAN:,1.  Cerebrovascular accident, in progress.",
" CT Brain - unshunted hydrocephalus, Dandy-Walker Malformation.", Neurology, Dandy-Walker Malformation ,"CC:, Seizure D/O,HX:, 29 y/o male with cerebral palsy, non-shunted hydrocephalus, spastic quadriplegia, mental retardation, bilateral sensory neural hearing loss, severe neurogenic scoliosis and multiple contractures of the 4 extremities, neurogenic bowel and bladder incontinence, and a history of seizures.,He was seen for evaluation of seizures which first began at age 27 years, two years before presentation. His typical episodes consist of facial twitching (side not specified), unresponsive pupils, and moaning. The episodes last approximately 1-2 minutes in duration and are followed by post-ictal fatigue. He was placed on DPH, but there was no record of an EEG prior to presentation. He had had no seizure events in over 1 year prior to presentation while on DPH 100mg--O--200mg. He also complained of headaches for the past 10 years.,BIRTH HX:, Spontaneous Vaginal delivery at 36weeks gestation to a G2P1 mother. Birth weight 7#10oz. No instrumentation required. Labor = 11hours. ""Light gas anesthesia"" given. Apgars unknown. Mother reportedly had the ""flu"" in the 7th or 8th month of gestation.,Patient discharged 5 days post-partum.,Development: spoke first words between 1 and 2 years of age. Rolled side to side at age 2, but did not walk. Fed self with hands at age 2 years. Never toilet trained.,PMH: ,1)Hydrocephalus manifested by macrocephaly by age 2-3 months. Head circumference 50.5cm at 4 months of age (wide sutures and bulging fontanels). Underwent ventriculogram, age 4 months, which illustrated massive enlargement of the lateral ventricles and normal sized aqueduct and 4th ventricle. The cortex of the cerebral hemisphere was less than 1cm. in thickness; especially in the occipital regions where only a thin rim of tissue was left. Neurosurgical intervention was not attempted and the patient deemed inoperable at the time. By 31 months of age the patients head circumference was 68cm, at which point the head size arrested. Other problems mentioned above.,SHX: ,institutionalized at age 18 years.,FHX: ,unremarkable.,EXAM:, Vitals unknown.,MS: awake with occasional use of intelligible but inappropriately used words.,CN: Rightward beating nystagmus increase on leftward gaze. Right gaze preference. Corneal responses were intact bilaterally. Fundoscopic exam not noted.,Motor: spastic quadriparesis. moves RUE more than other extremities.,Sensory: withdrew to PP in 4 extremities.,Coord: ND,Station: ND,Gait: ND, wheel chair bound.,Reflexes: RUE 2+, LUE 3+, RLE 4+ with sustained cross adductor clonus in the right quadriceps. LLE 3+.,Other: Macrocephaly (measurement not given). Scoliosis. Rest of general exam unremarkable except for numerous abdominal scars.,COURSE:, EEG 8/26/92: Abnormal with diffuse slowing and depressed background (left worse than right) and poorly formed background activity at 5-7hz. Right posterior sharp transients, and rhythmic delta-theta bursts from the right temporal region. The findings are consistent with diffuse cerebral dysfunction and underlying seizure tendency of multifocal origin.","neurology, seizure, dandy-walker malformation, eeg, macrocephaly, bilateral sensory neural hearing loss, hydrocephalus, hythmic delta-theta bursts, mental retardation, neurogenic bowel and bladder incontinence, severe neurogenic scoliosis, spastic quadriplegia, unshunted hydrocephalus, dandy walker malformation, dandy walker, head circumference, presentation, gestation, headaches, incontinence, "
" Cerebrovascular accident (CVA) with right arm weakness and MRI indicating acute/subacute infarct involving the left posterior parietal lobe without mass effect.  2.  Old coronary infarct, anterior aspect of the right external capsule.  Acute bronchitis with reactive airway disease.", Neurology, CVA - Discharge Summary ,"DIAGNOSES ON ADMISSION,1.  Cerebrovascular accident (CVA) with right arm weakness.,2.  Bronchitis.,3.  Atherosclerotic cardiovascular disease.,4.  Hyperlipidemia.,5.  Thrombocytopenia.,DIAGNOSES ON DISCHARGE,1.  Cerebrovascular accident with right arm weakness and MRI indicating acute/subacute infarct involving the left posterior parietal lobe without mass effect.,2.  Old coronary infarct, anterior aspect of the right external capsule.,3.  Acute bronchitis with reactive airway disease.,4.  Thrombocytopenia most likely due to old coronary infarct, anterior aspect of the right external capsule.,5.  Atherosclerotic cardiovascular disease.,6.  Hyperlipidemia.,HOSPITAL COURSE: , The patient was admitted to the emergency room.  Plavix was started  in addition to baby aspirin.  He was kept on oral Zithromax for his cough.  He was given Xopenex treatment, because of his respiratory distress.  Carotid ultrasound was reviewed and revealed a 50 to 69% obstruction of left internal carotid.  Dr. X saw him in consultation and recommended CT angiogram.  This showed no significant obstructive lesion other than what was known on the ultrasound.  Head MRI was done and revealed the above findings.  The patient was begun on PT and improved.  By discharge, he had much improved strength in his right arm.  He had no further progressions.  His cough improved with oral Zithromax and nebulizer treatments.  His platelets also improved as well.  By discharge, his platelets was up to 107,000.  His H&H was stable at 41.7 and 14.6 and his white count was 4300 with a normal differential.  Chest x-ray revealed a mild elevated right hemidiaphragm, but no infiltrate.  Last chemistry panel on December 5, 2003, sodium 137, potassium 4.0, chloride 106, CO2 23, glucose 88, BUN 17, creatinine 0.7, calcium was 9.1.  PT/INR on admission was 1.03, PTT 34.7.  At the time of discharge, the patient's cough was much improved.  His right arm weakness has much improved.  His lung examination has just occasional rhonchi.  He was changed to a metered dose inhaler with albuterol.  He is being discharged home.  An echocardiogram revealed mild concentric LVH with normal left ventricular function with an EF of 57%, moderate left atrial enlargement and diastolic dysfunction with mild mitral regurgitation.  He will follow up in my office in 1 week.  He is to start PT and OT as an outpatient.  He is to avoid driving his car.  He is to notify, if further symptoms.  He has 2 more doses of Zithromax at home, he will complete.  His prognosis is good.","neurology, subacute infarct, atherosclerotic cardiovascular disease, cerebrovascular accident, coronary infarct, external capsule, cva, cerebrovascular, mri, bronchitis, cardiovascular, xopenex, atherosclerotic, accident"
  a pleasant 62-year-old male with cerebral palsy, Neurology, Discharge Summary - Cerebral Palsy ,"DISCHARGE DIAGNOSES:,1.  Bilateral lower extremity cellulitis secondary to bilateral tinea pedis.,2.  Prostatic hypertrophy with bladder outlet obstruction.,3.  Cerebral palsy.,DISCHARGE INSTRUCTIONS: , The patient would be discharged on his usual Valium 10-20 mg at bedtime for spasticity, Flomax 0.4 mg daily, cefazolin 500 mg q.i.d., and Lotrimin cream between toes b.i.d. for an additional two weeks.  He will be followed in the office.,HISTORY OF PRESENT ILLNESS:,  This is a pleasant 62-year-old male with cerebral palsy.  The patient was recently admitted to Hospital with lower extremity cellulitis.  This resolved, however, recurred in both legs.  Examination at the time of this admission demonstrated peeling of the skin and excoriation between all of his toes on both feet consistent with tinea pedis.,PAST MEDICAL/FAMILY/SOCIAL HISTORY:,  As per the admission record.,REVIEW OF SYSTEMS: , As per the admission record.,PHYSICAL EXAMINATION:  ,As per the admission record.,LABORATORY STUDIES: , At the time of admission, his white blood cell count was 8200 with a normal differential, hemoglobin 13.6, hematocrit 40.6 with normal indices, and platelet count was 250,000.  Comprehensive metabolic profile was unremarkable, except for a nonfasting blood sugar of 137, lactic acid was 0.8.  Urine demonstrated 4-9 red blood cells per high-powered field with 2+ bacteria.  Blood culture and wound cultures were unremarkable.  Chest x-ray was unremarkable.,HOSPITAL COURSE: , The patient was admitted to the General Medical floor and treated with intravenous ceftriaxone and topical Lotrimin.  On this regimen, his lower extremity edema and erythema resolved quite rapidly.,Because of urinary frequency, a bladder scan was done suggesting about 600 cc of residual urine.  A Foley catheter was inserted and was productive of approximately 500 cc of urine.  The patient was prescribed Flomax 0.4 mg daily.  24 hours later, the Foley catheter was removed and a bladder scan demonstrated 60 cc of residual urine after approximately eight hours.,At the time of this dictation, the patient was ambulating minimally, however, not sufficiently to resume independent living.","neurology, bilateral lower extremity cellulitis, cerebral palsy, ambulating, bilateral tinea pedis, lower extremity cellulitis, cerebral, palsy, discharge,"
" Brain CT with contrast - Abnormal Gyriform enhancing lesion (stroke) in the left parietal region, not seen on non-contrast HCTs.", Neurology, CT Scan of Brain with Contrast  ,"CC:, Confusion.,HX: , A 71 y/o RHM ,with a history of two strokes ( one in 11/90 and one in 11/91), had been in a stable state of health until 12/31/92 when he became confused, and displayed left-sided weakness and difficulty speaking. The symptoms resolved within hours and recurred the following day. He was then evaluated locally and HCT revealed an old right parietal stroke. Carotid duplex scan revealed a ""high grade stenosis"" of the RICA. Cerebral Angiogram revealed 90%RICA and 50%LICA stenosis. He was then transferred to UIHC Vascular Surgery for carotid endarterectomy. His confusion persisted and he was evaluated by Neurology on 1/8/93 and transferred to Neurology on 1/11/93.,PMH:, 1)cholecystectomy. 2)inguinal herniorrhaphies, bilaterally. 3)ETOH abuse: 3-10 beers/day. 4)Right parietal stroke 10/87 with residual left hemiparesis (Leg worse than arm). 5) 2nd stoke in distant past of unspecified type.,MEDS:, None on admission.,FHX:, Alzheimer's disease and stroke on paternal side of family.,SHX:, 50+pack-yr cigarette use.,ROS:, no weight loss. poor appetite/selective eater.,EXAM:, BP137/70 HR81 RR13 O2Sat 95% Afebrile.,MS: Oriented to city and month, but did not know date or hospital. Naming and verbal comprehension were intact. He could tell which direction Iowa City and Des Moines were from Clinton and remembered 2-3 objects in two minutes, but both with assistance only. Incorrectly spelled ""world"" backward, as ""dlow."",CN: unremarkable except neglects left visual field to double simultaneous stimulation.,Motor: Deltoids 4+/4-, biceps 5-/4, triceps 5/4+, grip 4+/4+, HF4+/4-, HE 4+/4+, Hamstrings 5-/5-, AE 5-/5-, AF 5-/5-.,Sensory: intact PP/LT/Vib.,Coord: dysdiadochokinesis on RAM, bilaterally.,Station: dyssynergic RUE on FNF movement.,Gait: ND,Reflexes: 2+/2+ throughout BUE and at patellae. Absent at ankles. Right plantar was flexor; and Left plantar was equivocal.,COURSE:, CBC revealed normal Hgb, Hct, Plt and WBC, but Mean corpuscular volume was large at 103FL (normal 82-98). Urinalysis revealed 20+WBC. GS, TSH, FT4, VDRL, ANA and RF were unremarkable. He was treated for a UTI with amoxacillin. Vitamin B12 level was reduced at 139pg/ml (normal 232-1137). Schillings test was inconclusive dure to inability to complete a 24-hour urine collection. He was placed on empiric Vitamin B12 1000mcg IM qd x 7 days; then qMonth. He was also placed on Thiamine 100mg qd, Folate 1mg qd, and ASA 325mg qd. His ESR and CRP were elevated on admission, but fell as his UTI was treated.,EEG showed diffuse slowing and focal slowing in the theta-delta range in the right temporal area. HCT with contrast on 1/19/93 revealed a gyriform enhancing lesion in the left parietal lobe consistent with a new infarct; and an old right parietal hypodensity (infarct). His confusion was ascribed to the UTI in the face of old and new strokes and Vitamin B12 deficiency. He was lost to follow-up and did not undergo carotid endarterectomy.","neurology, ct scan, abnormal gyriform enhancing lesion, brain ct, ct with contrast, carotid duplex scan, confusion, hct, difficulty speaking, left-sided weakness, non-contrast hct, parietal region, stroke, theta-delta, with contrast, gyriform enhancing lesion, gyriform enhancing, enhancing lesion, parietal stroke, carotid endarterectomy, ct, scan, gyriform, endarterectomy, contrast, hcts, brain, parietal, "
 CT Scan of  brain without contrast., Neurology, CT Scan of  Brain w/o Contrast ,"REASON FOR EXAMINATION:  Face asleep.,COMPARISON EXAMINATION:  None.,TECHNIQUE:  Multiple axial images were obtained of the brain.  5 mm sections were acquired.  2.5-mm sections were acquired without injection of intravenous contrast.  Reformatted sagittal and coronal images were obtained.,DISCUSSION:  No acute intracranial abnormalities appreciated.  No evidence for hydrocephalus, midline shift, space occupying lesions or abnormal fluid collections.  No cortical based abnormalities appreciated.  The sinuses are clear.  No acute bony abnormalities identified.,Preliminary report given to emergency room at conclusion of exam by Dr. Xyz.,IMPRESSION:  No acute intracranial abnormalities appreciated.,","neurology, ct scan, multiple axial images, asleep, brain, coronal, coronal images, hydrocephalus, intracranial, intravenous contrast, sagittal, without contrast, ct, scan, contrast, abnormalities,"
 CT of Lumbar Spine without Contrast.  Patient with history of back pain after a fall., Neurology, CT of Lumbar Spine w/o Contrast ,"EXAM: , Lumbar spine CT without contrast.,HISTORY: , Back pain after a fall.,TECHNIQUE:,  Noncontrast axial images were acquired through the lumbar spine. Coronal and sagittal reconstruction views were also obtained.,FINDINGS: , There is no evidence for acute fracture or subluxation.  There is no spondylolysis or spondylolisthesis.  The central canal and neuroforamen are grossly patent at all levels.  There are no abnormal paraspinal masses. There is no wedge/compression deformity.  There is intervertebral disk space narrowing to a mild degree at L2-3 and L4-5.,Soft tissue windows demonstrate atherosclerotic calcification of the abdominal aorta, which is not dilated.  There was incompletely visualized probable simple left renal cyst, exophytic at the lower pole.,IMPRESSION:,1.  No evidence for acute fracture or subluxation.,2.  Mild degenerative changes.,3.  Probable left simple renal cyst.,","neurology, lumbar spine, back pain, ct, coronal, atherosclerotic, axial images, central canal, compression, deformity, degenerative, disk space, fracture, intervertebral, neuroforamen, sagittal, spondylolisthesis, spondylolysis, subluxation, wedge, without contrast, contrast, spine, lumbar, noncontrast,"
" CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.", Neurology," CT Head, Facial Bones, Cervical Spine ","EXAM: , CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.,REASON FOR EXAM:,  A 68-year-old status post fall with multifocal pain.,COMPARISONS: , None.,TECHNIQUE: , Sequential axial CT images were obtained from the vertex to the thoracic inlet without contrast.  Additional high-resolution sagittal and/or coronal reconstructed images were obtained through the facial bones and cervical spine for better visualization of the osseous structures.,INTERPRETATIONS:,HEAD:,There is mild generalized atrophy.  Scattered patchy foci of decreased attenuation is seen in the subcortical and periventricular white matter consistent with chronic small vessel ischemic changes.  There are subtle areas of increased attenuation seen within the frontal lobes bilaterally.  Given the patient's clinical presentation, these likely represent small hemorrhagic contusions.  Other differential considerations include cortical calcifications, which are less likely.  The brain parenchyma is otherwise normal in attenuation without evidence of mass, midline shift, hydrocephalus, extra-axial fluid, or acute infarction.  The visualized paranasal sinuses and mastoid air cells are clear.  The bony calvarium and skull base are unremarkable.,FACIAL BONES:,The osseous structures about the face are grossly intact without acute fracture or dislocation.  The orbits and extra-ocular muscles are within normal limits.  There is diffuse mucosal thickening in the ethmoid and right maxillary sinuses.  The remaining visualized paranasal sinuses and mastoid air cells are clear.  Diffuse soft tissue swelling is noted about the right orbit and right facial bones without underlying fracture.,CERVICAL SPINE:,There is mild generalized osteopenia.  There are diffuse multilevel degenerative changes identified extending from C4-C7 with disk space narrowing, sclerosis, and marginal osteophyte formation.  The remaining cervical vertebral body heights are maintained without acute fracture, dislocation, or spondylolisthesis.  The central canal is grossly patent.  The pedicles and posterior elements appear intact with multifocal facet degenerative changes.  There is no prevertebral or paravertebral soft tissue masses identified.  The atlanto-dens interval and dens are maintained.,IMPRESSION:,1.Subtle areas of increased attenuation identified within the frontal lobes bilaterally suggesting small hemorrhagic contusions.  There is no associated shift or mass effect at this time.  Less likely, this finding could be secondary to cortical calcifications.  The patient may benefit from a repeat CT scan of the head or MRI for additional evaluation if clinically indicated.,2.Atrophy and chronic small vessel ischemic changes in the brain.,3.Ethmoid and right maxillary sinus congestion and diffuse soft tissue swelling over the right side of the face without underlying fracture.,4.Osteopenia and multilevel degenerative changes in the cervical spine as described above.,5.Findings were discussed with Dr. X from the emergency department at the time of interpretation.","neurology, sagittal, coronal, soft tissue swelling, paranasal sinuses, mastoid air, acute fracture, maxillary sinuses, tissue swelling, underlying fracture, multilevel degenerative, ct head, soft tissue, facial bones, cervical spine, ct, facial, bones, spine, cervical"
 This is a middle-aged female with two month history of low back pain and leg pain., Neurology, CT Lumbar Spine - 2 ,"FINDINGS:,Axial scans were performed from L1 to S2 and reformatted images were obtained in the sagittal and coronal planes.,Preliminary scout film demonstrates anterior end plate spondylosis at T11-12 and T12-L1.,L1-2: There is normal disc height, anterior end plate spondylosis, very minimal vacuum change with no posterior annular disc bulging or protrusion. Normal central canal, intervertebral neural foramina and facet joints (image #4).,L2-3: There is mild decreased disc height, anterior end plate spondylosis, circumferential disc protrusion measuring 4.6mm (AP) and right extraforaminal osteophyte disc complex. There is mild non-compressive right neural foraminal narrowing, minimal facet arthrosis, normal central canal and left neural foramen (image #13).,L3-4: There is normal disc height, anterior end plate spondylosis, and circumferential non-compressive annular disc bulging. The disc bulging flattens the ventral thecal sac and there is minimal non-compressive right neural foraminal narrowing, minimal to mild facet arthrosis with vacuum change on the right, normal central canal and left neural foramen (image #25).,L4-5:","neurology, anterior end plate spondylosis, compressive right neural foraminal, compressive annular disc bulging, anterior end plate, annular disc bulging, normal central canal, plate spondylosis, central canal, vacuum change, disc bulging, neural foraminal, facet arthrosis, anterior, spondylosis, neural, lumbar, disc, bulging, foraminal, arthrosis, facet"
" Noncontrast CT scan of the lumbar spine.  Left lower extremity muscle spasm.  Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested.", Neurology, CT Lumbar Spine ,"EXAM:,  Noncontrast CT scan of the lumbar spine,REASON FOR EXAM: , Left lower extremity muscle spasm.,COMPARISONS: , None.,FINDINGS: , Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested.,No abnormal paraspinal masses are identified.,There are sclerotic changes with anterior effusion of the sacroiliac joints bilaterally.,There is marked intervertebral disk space narrowing at the L5-S1 level with intervertebral disk vacuum phenomenon and advanced endplate degenerative changes.  Posterior disk osteophyte complex is present, most marked in the left paracentral to lateral region extending into the lateral recess on the left.  This most likely will affect the S1 nerve root on the left.  There are posterior hypertrophic changes extending into the neural foramina bilaterally inferiorly.  There is mild neural foraminal stenosis present.  Small amount of extruded disk vacuum phenomenon is present on the left in the region of the exiting nerve root.  There is facet sclerosis bilaterally.  Mild lateral recess stenosis just on the right, there is prominent anterior spondylosis.,At the L4-5 level, mild bilateral facet arthrosis is present.  There is broad based posterior annular disk bulging or protrusion, which mildly effaces the anterior aspect of the thecal sac and extends into the inferior aspect of the neural foramina bilaterally.  No moderate or high-grade central canal or neural foraminal stenosis is identified.,At the L3-4 level anterior spondylosis is present.  There are endplate degenerative changes with mild posterior annular disk bulging, but no evidence of moderate or high-grade central canal or neural foraminal stenosis.,At the L2-3 level, there is mild bilateral ligamentum flavum hypertrophy.  Mild posterior annular disk bulging is present without evidence of moderate or high-grade central canal or neural foraminal stenosis.,At the T12-L1 and L1-2 levels, there is no evidence of herniated disk protrusion, central canal, or neural foraminal stenosis.,There is arteriosclerotic vascular calcification of the abdominal aorta and iliac arteries without evidence of aneurysm or dilatation.  No bony destructive changes or acute fractures are identified.,CONCLUSIONS:,1. Advanced degenerative disk disease at the L5-S1 level.,2. Probable chronic asymmetric herniated disk protrusion with peripheral calcification at the L5-S1 level, laterally in the left paracentral region extending into the lateral recess causing lateral recess stenosis.,3. Mild bilateral neural foraminal stenosis at the L5-S1 level.,4. Posterior disk bulging at the L2-3, L3-4, and L4-5 levels without evidence of moderate or high-grade central canal stenosis.,5. Facet arthrosis to the lower lumbar spine.,6. Arteriosclerotic vascular disease.","neurology, noncontrast ct scan, lower extremity muscle spasm, neural foraminal stenosis, lumbar spine, spine, disk, lumbar, ct, intervertebral, canal, foraminal, noncontrast, stenosis, "
 This is a middle-aged female with low back pain radiating down the left leg and foot for one and a half years., Neurology, CT Lumbar Spine - 1 ,"FINDINGS:,High resolution computerized tomography was performed from T12-L1 to the S1 level with reformatted images in the sagittal and coronal planes and 3D reconstructions performed. COMPARISON: Previous MRI examination 10/13/2004.,There is minimal curvature of the lumbar spine convex to the left.,T12-L1, L1-2, L2-3: There is normal disc height with no posterior annular disc bulging or protrusion. Normal central canal, intervertebral neural foramina and facet joints.,L3-4: There is normal disc height and non-compressive circumferential annular disc bulging eccentrically greater to the left. Normal central canal and facet joints (image #255).,L4-5: There is normal disc height, circumferential annular disc bulging, left L5 hemilaminectomy and posterior central/right paramedian broad-based disc protrusion measuring 4mm (AP) contouring the rightward aspect of the thecal sac. Orthopedic hardware is noted posteriorly at the L5 level. Normal central canal, facet joints and intervertebral neural foramina (image #58).,L5-S1: There is minimal decreased disc height, postsurgical change with intervertebral disc spacer, posterior lateral orthopedic hardware with bilateral pedicle screws in good postsurgical position. The orthopedic hardware creates mild streak artifact which mildly degrades images. There is a laminectomy defect, spondylolisthesis with 3.5mm of anterolisthesis of L5, posterior annular disc bulging greatest in the left foraminal region lying adjacent to the exiting left L5 nerve root. There is fusion of the facet joints, normal central canal and right neural foramen (image #69-70, 135).,There is no bony destructive change noted.,There is no perivertebral soft tissue abnormality.,There is minimal to mild arteriosclerotic vascular calcifications noted in the abdominal aorta and right proximal common iliac artery.,IMPRESSION:,Minimal curvature of the lumbar spine convex to the left.,L3-4 posterior non-compressive annular disc bulging eccentrically greater to the left.,L4-5 circumferential annular disc bulging, non-compressive central/right paramedian disc protrusion, left L5 laminectomy.,L5-S1 postsurgical change with posterolateral orthopedic fusion hardware in good postsurgical position, intervertebral disc spacer, spondylolisthesis, laminectomy defect, posterior annular disc bulging greatest in the left foraminal region adjacent to the exiting left L5 nerve root with questionable neural impingement.,Minimal to mild arteriosclerotic vascular calcifications.","neurology, posterior annular disc, circumferential annular disc, normal central canal, annular disc bulging, lumbar spine, posterior annular, facet joints, annular disc, disc bulging, tomography, disc, lumbar, orthopedic, postsurgical, spine, annular, bulging,"
 Left arm and hand numbness.  CT head without contrast.  Noncontrast axial CT images of the head were obtained with 5 mm slice thickness., Neurology, CT Head - 3 ,"REASON FOR EXAM:  ,Left arm and hand numbness.,TECHNIQUE: , Noncontrast axial CT images of the head were obtained with 5 mm slice thickness.,FINDINGS:  ,There is an approximately 5-mm shift of the midline towards the right side.  Significant low attenuation is seen throughout the white matter of the right frontal, parietal, and temporal lobes.  There is loss of the cortical sulci on the right side.  These findings are compatible with edema.  Within the right parietal lobe, a 1.8 cm, rounded, hyperintense mass is seen.,No hydrocephalus is evident.,The calvarium is intact.  The visualized paranasal sinuses are clear.,IMPRESSION:  ,A 5 mm midline shift to the left side secondary to severe edema of the white matter of the right frontal, parietal, and temporal lobes.  A 1.8 cm high attenuation mass in the right parietal lobe is concerning for hemorrhage given its high density.  A postcontrast MRI is required for further characterization of this mass.  Gradient echo imaging should be obtained.","neurology, numbness, head, ct images, frontal, parietal, temporal, axial ct images, parietal and temporal, ct head, slice thickness, white matter, frontal parietal, temporal lobes, parietal lobe, edema, intact, noncontrast, mass, ct, lobes, arm, "
" The patient is a 79-year-old man with adult hydrocephalus who was found to have large bilateral effusions on a CT scan.  The patient's subdural effusions are still noticeable, but they are improving.", Neurology, CT Head - 2 ,"REASON FOR CT SCAN: , The patient is a 79-year-old man with adult hydrocephalus who was found to have large bilateral effusions on a CT scan performed on January 16, 2008.  I changed the shunt setting from 1.5 to 2.0 on February 12, 2008 and his family obtained this repeat CT scan to determine whether his subdural effusions were improving.,CT scan from 03/11/2008 demonstrates frontal horn span at the level of foramen of Munro of 2.6 cm.  The 3rd ventricular contour which is flat with a 3rd ventricular span of 10 mm.  There is a single shunt, which enters on the right occipital side and ends in the left lateral ventricle.  He has symmetric bilateral subdurals that are less than 1 cm in breadth each, which is a reduction from the report from January 16, 2008, which states that he had a subdural hygroma, maximum size 1.3 cm on the right and 1.1 cm on the left.,ASSESSMENT: , The patient's subdural effusions are still noticeable, but they are improving at the setting of 2.0.,PLAN: , I would like to see the patient with a new head CT in about three months, at which time we can decide whether 2.0 is the appropriate setting for him to remain at or whether we can consider changing the shunt setting.","neurology, ct scan, subdural, adult hydrocephalus, bilateral effusions, shunt setting, subdural effusions, hydrocephalus, ventricular, scan, ct,"
 Motor vehicle collision.  CT head without contrast and CT cervical spine without contrast.  Noncontrast axial CT images of the head were obtained., Neurology, CT Head and C Spine ,"CT HEAD WITHOUT CONTRAST AND CT CERVICAL SPINE WITHOUT CONTRAST,REASON FOR EXAM: , Motor vehicle collision.,CT HEAD WITHOUT CONTRAST,TECHNIQUE:,  Noncontrast axial CT images of the head were obtained.,FINDINGS: , There is no acute intracranial hemorrhage, mass effect, midline shift, or extra-axial fluid collection.  The ventricles and cortical sulci are normal in shape and configuration.  The gray/white matter junctions are well preserved.  There is no calvarial fracture.  The visualized paranasal sinuses and mastoid air cells are clear.,IMPRESSION: , Negative for acute intracranial disease.,CT CERVICAL SPINE,TECHNIQUE:  ,Noncontrast axial CT images of the cervical spine were obtained.  Sagittal and coronal images were obtained.,FINDINGS:,  Straightening of the normal cervical lordosis is compatible with patient position versus muscle spasms.  No fracture or subluxation is seen.  Anterior and posterior osteophyte formation is seen at C5-C6.  No abnormal anterior cervical soft tissue swelling is seen.  No spinal compression is noted.  The atlanto-dens interval is normal.  There is a large retention cyst versus polyp within the right maxillary sinus.,IMPRESSION:,1.  Straightening of the normal cervical lordosis compatible with patient positioning versus muscle spasms.,2.  Degenerative disk and joint disease at C5-C6.,3.  Retention cyst versus polyp of the right maxillary sinus.","neurology, muscle spasms, cervical lordosis, intracranial hemorrhage, motor vehicle collision, axial ct images, ct head, ct, anterior, cyst, polyp, maxillary, contrast, intracranial, sinuses, spine, axial, head, cervical, noncontrast"
" CT head without contrast.  Assaulted, positive loss of consciousness, rule out bleed.  CT examination of the head was performed without intravenous contrast administration.", Neurology, CT Head - 4 ,"EXAM: , CT head without contrast.,INDICATIONS: , Assaulted, positive loss of consciousness, rule out bleed.,TECHNIQUE: , CT examination of the head was performed without intravenous contrast administration.  There are no comparison studies.,FINDINGS:  ,There are no abnormal extraaxial fluid collections.  There is no midline shift or mass effect.  Ventricular system demonstrates no dilatation.  There is no evidence of acute intracranial hemorrhage.  The calvarium is intact.  There is a laceration in the left parietal region of the scalp without underlying calvarial fractures.  The mastoid air cells are clear.,IMPRESSION:  ,No acute intracranial process.","neurology, extraaxial fluid, intracranial hemorrhage, parietal region, scalp, loss of consciousness, ct examination, ct head, intracranial, intravenous, contrast, "
  CT cervical spine for trauma.  CT examination of the cervical spine was performed without contrast.  Coronal and sagittal reformats were obtained for better anatomical localization., Neurology, CT C-Spine - 2 ,"EXAM:,  CT cervical spine (C-spine) for trauma.,FINDINGS:,  CT examination of the cervical spine was performed without contrast.  Coronal and sagittal reformats were obtained for better anatomical localization.  Cervical vertebral body height, alignment and interspacing are maintained.  There is no evidence of fractures or destructive osseous lesions.  There are no significant degenerative endplate or facet changes.  No significant osseous central canal or foraminal narrowing is present.,IMPRESSION: , Negative cervical spine.","neurology, c-spine, anatomical, degenerative endplate, ct examination, cervical spine, coronal, ct, spine, cervicalNOTE"
 Common CT Head template., Neurology, CT Head ,"TECHNIQUE: , Sequential axial CT images were obtained from the vertex to the skull base without contrast.,FINDINGS: , There is mild generalized atrophy.  Scattered patchy foci of decreased attenuation are seen within the sub cortical and periventricular white matter compatible with chronic small vessel ischemic changes.  The brain parenchyma is otherwise normal in attenuation with no evidence of mass, hemorrhage, midline shift, hydrocephalus, extra-axial fluid, or acute infarction.  The visualized paranasal sinuses and mastoid air cells are clear.  The bony calvarium and skull base are within normal limits.  ,IMPRESSION: , No acute abnormalities.","neurology, decreased attenuation, skull base, sequential axial ct images, bony calvarium, extra-axial fluid, ct head, attenuationNOTE"
 Noncontrast CT head due to seizure disorder., Neurology, CT Head - 1 ,"EXAM:,  CT head.,REASON FOR EXAM:,  Seizure disorder.,TECHNIQUE:,  Noncontrast CT head.,FINDINGS: , There is no evidence of an acute intracranial hemorrhage or infarction.  There is no midline shift, intracranial mass, or mass effect.  There is no extra-axial fluid collection or hydrocephalus.  Visualized portions of the paranasal sinuses and mastoid air cells appear clear aside from mild right frontal sinus mucosal thickening.,IMPRESSION:,  No acute process in the brain.","neurology, mass effect, extra-axial fluid, hydrocephalus, midline shift, intracranial mass, paranasal sinuses, mastoid air cells, frontal sinus, mucosal thickening, seizure disorder, ct head, seizure, sinuses, ct, head, noncontrast, "
 Axial images through the cervical spine with coronal and sagittal reconstructions., Neurology, CT C-Spine - 1  ,"EXAM: , CT cervical spine.,REASON FOR EXAM: , MVA, feeling sleepy, headache, shoulder and rib pain.,TECHNIQUE:,  Axial images through the cervical spine with coronal and sagittal reconstructions.,FINDINGS:,  There is reversal of the normal cervical curvature at the vertebral body heights.  The intervertebral disk spaces are otherwise maintained.  There is no prevertebral soft tissue swelling.  The facets are aligned.  The tip of the clivus and occiput appear intact.  On the coronal reconstructed sequence, there is satisfactory alignment of C1 on C2, no evidence of a base of dens fracture.,The included portions of the first and second ribs are intact.  There is no evidence of a posterior element fracture.  Included portions of the mastoid air cells appear clear.  There is no CT evidence of a moderate or high-grade stenosis.,IMPRESSION: , No acute process, cervical spine.","neurology, c-spine, axial images, sagittal reconstructions, cervical spine, sagittal, fracture, coronal, spine, axial, cervical, ct, "
 HCT: Subdural hemorrhage., Neurology, CT Brain: Subdural Hemorrhage. ,"CC: ,Difficulty with speech.,HX:, This 84 y/o RHF presented with sudden onset word finding and word phonation difficulties. She had an episode of transient aphasia in 2/92 during which she had difficulty with writing, written and verbal comprehension, and exhibited numerous semantic and phonemic paraphasic errors of speech. These problems resolved within 24 hours of onset and she had no subsequent speech problems prior to this presentation. Workup at that time revealed a right to left shunt on trans-thoracic echocardiogram. Carotid doppler studies showed 0-15% BICA stenosis and a LICA aneurysm (mentioned above). Brain CT was unremarkable. She was placed on ASA after the 2/92 event.,In 5/92 she was involved in a motor vehicle accident and suffered a fractured left humerus and left occipital scalp laceration. HCT at that time showed a small area of slightly increased attenuation at the posterior right claustrum only. This was not felt to be a contusion; nevertheless, she was placed on Dilantin seizure prophylaxis. Her left arm was casted and she returned home.,5 hours prior to presentation today, the patient began having difficulty finding words and putting them into speech. She was able to comprehend speech. This continued for an hour; then partially resolved for one hour; then returned; then waxed and waned. There was no reported weakness, numbness, incontinence, seizure-like activity, incoordination, HA, nausea, vomiting, or lightheadedness,MEDS:, ASA , DPH, Tenormin, Premarin, HCTZ,PMH:, 1)transient fluent aphasia 2/92 (which resolved), 2)bilateral carotid endarterectomies 1986, 3)HTN, 4)distal left internal carotid artery aneurysm.,EXAM:,  BP 168/70, Pulse 82, RR 16, 35.8F,MS:A & O x 3, Difficulty following commands, Speech fluent, and without dysarthria. There were occasional phonemic paraphasic errors.,CN: Unremarkable.,Motor: 5/5 throughout except for 4+ right wrist extension and right knee flexion.,Sensory: unremarkable.,Coordination: mild left finger-nose-finger dysynergia and dysmetria.,Gait: mildly unsteady tandem walk.,Station: no Romberg sign.,Reflexes: slightly more brisk at the left patella than on the right. Plantar responses were flexor bilaterally.,The remainder of the neurologic exam and the general physical exam were unremarkable.,LABS:, CBC WNL, Gen Screen WNL, , PT/PTT WNL, DPH 26.2mcg/ml, CXR WNL, EKG: LBBB, HCT revealed a left subdural hematoma.,COURSE:, Patient was taken to surgery and the subdural hematoma was evacuated. Her mental status, language skills, improved dramatically. The DPH dosage was adjusted appropriately.","neurology, ct brain, ct, difficulty with speech, hct, subdural hemorrhage, hemorrhage, phonation difficulties, subdural, transient fluent aphasia, phonemic paraphasic errors, hematoma, carotid, speech, "
 CT Brain: Midbrain hemangioma, Neurology, CT Brain - Hemangioma ,"CC:, Horizontal diplopia.,HX: , This 67 y/oRHM first began experiencing horizontal binocular diplopia 25 years prior to presentation in the Neurology Clinic. The diplopia began acutely and continued intermittently for one year. During this time he was twice evaluated for myasthenia gravis (details of evaluation not known) and was told he probably did not have this disease. He received no treatment and the diplopia spontaneously resolved. He did well until one year prior to presentation when he experienced sudden onset horizontal binocular diplopia. The diplopia continues to occur daily and intermittently; and lasts for only a few minutes in duration. It resolves when he covers one eye. It is worse when looking at distant objects and objects off to either side of midline. There are no other symptoms associated with the diplopia.,PMH:, 1)4Vessel CABG and pacemaker placement, 4/84. 2)Hypercholesterolemia. 3)Bipolar Affective D/O.,FHX: ,HTN, Colon CA, and a daughter with unknown type of ""dystonia."",SHX:, Denied Tobacco/ETOH/illicit drug use.,ROS:, no recent weight loss/fever/chills/night sweats/CP/SOB. He occasionally experiences bilateral lower extremity cramping (?claudication) after walking for prolonged periods.,MEDS: ,Lithium 300mg bid, Accupril 20mg bid, Cellufresh Ophthalmologic Tears, ASA 325mg qd.,EXAM:, BP216/108 HR72 RR14 Wt81.6kg T36.6C,MS: unremarkable.,CN: horizontal binocular diplopia on lateral gaze in both directions. No other CN deficits noted.,Motor: 5/5 full strength throughout with normal muscle bulk and tone.,Sensory: unremarkable.,Coord: mild ""ataxia"" of RAM (left > right),Station: no pronator drift or Romberg sign,Gait: unremarkable. Reflexes: 2/2 symmetric throughout. Plantars (bilateral dorsiflexion),STUDIES/COURSE:, Gen Screen: unremarkable. Brain CT revealed 1.0 x 1.5 cm area of calcific density within the medial two-thirds of the left cerebral peduncle. This shows no mass effect, but demonstrates mild contrast enhancement. There are patchy areas of low density in the periventricular white matter consistent with age related changes from microvascular disease. The midbrain findings are most suggestive of a hemangioma, though another consideration would be a low grade astrocytoma (this would likely show less enhancement). Metastatic lesions could show calcification but one would expect to see some degree of edema. The long standing clinical history suggest the former (i.e. hemangioma).,No surgical or neuroradiologic intervention was done and the patient was simply followed. He was lost to follow-up in 1993.","neurology, hemangioma, brain ct, ct brain, binocular diplopia, calcific density, diplopia, horizontal binocular diplopia, myasthenia gravis, horizontal binocular, midbrain, binocular, ct, horizontal, "
 Common CT C-Spine template, Neurology, CT C-Spine ,"TECHNIQUE: , Sequential axial CT images were obtained through the cervical spine without contrast.  Additional high resolution coronal and sagittal reconstructed images were also obtained for better visualization of the osseous structures.  ,FINDINGS: , The cervical spine demonstrates normal alignment and mineralization with no evidence of fracture, dislocation, or spondylolisthesis.  The vertebral body heights and disc spaces are maintained.  The central canal is patent.  The pedicles and posterior elements are intact.  The paravertebral soft tissues are within normal limits.  The atlanto-dens interval and the dens are intact.  The visualized lung apices are clear.,IMPRESSION: , No acute abnormalities.","neurology, sequential axial ct images, atlanto-dens interval, dens, ct c spine, cervical spineNOTE"
 CT of Brain - Subacute SDH., Neurology, CT Brain: Subdural hematoma ,"CC:, Progressive unsteadiness following head trauma.,HX:,  A7 7 y/o male fell, as he was getting out of bed, and struck his head, 4 weeks prior to admission. He then began to experience progressive unsteadiness and gait instability for several days after the fall. He was then evaluated at a local ER and prescribed meclizine. This did not improve his symptoms, and over the past one week prior to admission began to develop left facial/LUE/LLE weakness. He was seen by a local MD on the 12/8/92 and underwent and MRI Brain scan. This showed a right subdural mass. He was then transferred to UIHC for further evaluation.,PMH:, 1)cardiac arrhythmia. 2)HTN. 3) excision of lip lesion 1 yr ago.,SHX/FHX:, Unremarkable. No h/o ETOH abuse.,MEDS:, Meclizine, Procardia XL.,EXAM:, Afebrile, BP132/74 HR72 RR16,MS: A & O x 3. Speech fluent. Comprehension, naming, repetition were intact.,CN: Left lower facial weakness only.,MOTOR: Left hemiparesis, 4+/5 throughout.,Sensory: intact PP/TEMP/LT/PROP/VIB,Coordination: ND,Station: left pronator drift.,Gait: left hemiparesis evident by decreased LUE swing and LLE drag.,Reflexes: 2/3 in UE; 2/2 LE; Right plantar downgoing; Left plantar equivocal.,Gen Exam: unremarkable.,COURSE:, Outside MRI revealed a loculated subdural hematoma extending throughout the frontotemporoparieto-occipital regions on the right. There was effacement of the right lateral ventricle. and a 0.5 cm leftward midline shift.,He underwent a HCT on admission, 12/8/92, which showed a right subdural hematoma. He then underwent emergent evacuation of this hematoma. He was discharged home 6 days after surgery.","neurology, ct brain, mri, sdh, subdural hematoma, gait instability, head trauma, hematoma, subacute, subdural, weakness, hemiparesis, "
 Stroke in distribution of recurrent artery of Huebner (left), Neurology, CT Brain - Stroke  ,"CC:, Falls.,HX: ,This 51y/o RHF fell four times on 1/3/93, because her ""legs suddenly gave out."" She subsequently noticed weakness involving the right leg, and often required the assistance of her arms to move it. During some of these episodes she appeared mildly pale and felt generally weak; her husband would give her 3 teaspoons of sugar and she would appear to improve, thought not completely. During one episode she held her RUE in an ""odd fisted posture."" She denied any other focal weakness, sensory change, dysarthria, diplopia, dysphagia or alteration of consciousness. She did not seek medical attention despite her weakness. Then, last night, 1/4/93, she fell again ,and because her weakness did not subsequently improve she came to UIHC for evaluation on 1/5/93.,MEDS: ,Micronase 5mg qd, HCTZ, quit ASA 6 months ago (tired of taking it).,PMH:, 1)DM type 2, dx 6 months ago. 2)HTN. 3)DJD. 4)s/p Vitrectomy and retinal traction OU for retinal detachment 7/92. 5) s/p Cholecystemomy,1968. 6) Cataract implant, OU,1992. 7) s/p C-section.,FHX: ,Grand Aunt (stroke), MG (CAD), Mother (CAD, died MI age 63), Father (with unknown CA), Sisters (HTN), No DM in relatives.,SHX: ,Married, lives with husband, 4 children alive and well. Denied tobacco/ETOH/illicit drug use.,ROS:, intermittent diarrhea for 20 years.,EXAM: ,BP164/82 HR64 RR18 36.0C,MS: A & O to person, place, time. Speech fluent and without dysarthria. Intact naming, comprehension, reading.,CN: Pupils 4.5 (irregular)/4.0 (irregular) and virtually fixed. Optic disks flat. EOM intact. VFFTC. Right lower facial weakness. The rest of the CN exam was unremarkable.,Motor: 5/5 BUE with some question of breakaway. LE: HF and HE 4+/5, KF5/5, AF and AE 5/5. Normal muscle bulk and tone.,Sensory: intact PP/VIB/PROP/LT/T/graphesthesia.,Coord: slowed FNF and HKS (worse on right).,Station: no pronator drift or Romberg sign.,Gait: Unsteady wide-based gait. Unable to heel walk on right.,Reflexes: 2/2+ throughout (Slightly more brisk on right). Plantar responses were downgoing bilaterally.,HEENT: N0 Carotid or cranial bruits.,Gen Exam: unremarkable.,COURSE:, CBC, GS (including glucose), PT/PTT, EKG, CXR on admission, 1/5/93, were unremarkable. HCT, 1/5/93, revealed a hypodensity in the left caudate consistent with ischemic change. Carotid Duplex: 0-15%RICA, 16-49%LICA; antegrade vertebral artery flow, bilaterally. Transthoracic echocardiogram showed borderline LV hypertrophy and normal LV function. No valvular abnormalities or thrombus were seen.,The patient's history and exam findings of right facial and RLE weakness with sparing of the RUE would invoke a RACA territory stroke with recurrent artery of Heubner involvement causing the facial weakness.", 
 CT Brain: Subarachnoid hemorrhage., Neurology, CT Brain - SAH ,"CC:, Headache,HX: ,This 16 y/o RHF was in good health, until 11:00PM, the evening of 11/27/87, when she suddenly awoke from sleep with severe headache. Her parents described her as holding her head between her hands. She had no prior history of severe headaches. 30 minutes later she felt nauseated and vomited. The vomiting continued every 30 minutes and she developed neck stiffness. At 2:00AM on 11/28/97, she got up to go to the bathroom and collapsed in her mother's arms. Her mother noted she appeared weak on the left side. Shortly after this she experienced fecal and urinary incontinence. She was taken to a local ER and transferred to UIHC.,PMH/FHX/SHX:, completely unremarkable FHx. Has boyfriend and is sexually active.,Denied drug/ETOH/Tobacco use.,MEDS:, Oral Contraceptive pill QD.,EXAM:, BP152/82 HR74 RR16 T36.9C,MS: Somnolent and difficult to keep awake. Prefer to lie on right side because of neck pain/stiffness. Answers appropriately though when questioned.,CN: No papilledema noted. Pupils 4/4 decreasing to 2/2. EOM Intact. Face: ?left facial weakness. The rest of the CN exam was unremarkable.,Motor: Upper extremities: 5/3 with left pronator drift. Lower extremities: 5/4 with LLE weakness evident throughout.,Coordination: left sided weakness evident.,Station: left pronator drift.,Gait: left hemiparesis.,Reflexes: 2/2 throughout. No clonus. Plantars were flexor bilaterally.,Gen Exam: unremarkable.,COURSE: ,The patient underwent emergent CT Brain. This revealed a perimesencephalic subarachnoid hemorrhage and contrast enhancing structures in the medial aspect of the parietotemporal region. She then underwent a 4-vessel cerebral angiogram. This study was unremarkable except for delayed transit of the contrast material through the vascular system of the brain and poor opacification of the straight sinus. This suggested straight sinus thromboses. MRI Brain was then done; this was unremarkable and did not show sign of central venous thrombosis. CBC/Blood Cx/ESR/PT/PTT/GS/CSF Cx/ANA were negative.,Lumbar puncture on 12/1/87 revealed an opening pressure of 55cmH20, RBC18550, WBC25, 18neutrophils, 7lymphocytes, Protein25mg/dl, Glucose47mg/dl, Cx negative.,The patient was assumed to have had a SAH secondary to central venous thrombosis due to oral contraceptive use. She recovered well, but returned to Neurology at age 32 for episodic blurred vision and lightheadedness. EEG was compatible with seizure tendency (right greater than left theta bursts from the mid-temporal regions), and she was recommended an anticonvulsant which she refused.","neurology, ct, brain, sah, cerebral angiogram, blurred vision, lightheadedness, central venous thrombosis, subarachnoid hemorrhage, pronator drift, venous thrombosis, ct brain, subarachnoid, hemorrhage, pronator, venous, thrombosis, weakness, "
" CT Brain to evaluate episodic mental status change, RUE numbness, chorea, and calcification of Basal Ganglia (globus pallidi).", Neurology, CT Brain - Calcification of Basal Ganglia ,"CC:, Episodic mental status change and RUE numbness, and chorea (found on exam).,HX:, This 78y/o RHM was referred for an episode of unusual behavior and RUE numbness. In 9/91, he experienced near loss of consciousness, generalized weakness, headache and vomiting. Evaluation at that time revealed an serum glucose of >500mg/dL and he was placed on insulin therapy with subsequent resolution of his signs and symptoms. Since then, he became progressively more forgetful, and at the time of evaluation, 1/17/93, had lost his ability to perform his job repairing lawn mowers. His wife had taken over the family finances.,He had also been ""stumbling,"" when ambulating, for 2 months prior to presentation. He was noted to be occasionally confused upon awakening for last several months. On 1/15/93, he was lying on a couch when he suddenly began throwing pillows and blankets for no apparent reason. There had been no change in sleep, appetite, or complaint of depression.,In addition, for two months prior to presentation, he had been experiencing 10-15minute episodes of RUE numbness. There was no face or lower extremity involvement.,During the last year he had developed unusual movements of his extremities.,MEDS:, NPH Humulin 12U qAM and 6U qPM. Advil prn.,PMH:, 1) Traumatic amputation of the 4th and 5th digits of his left hand.  2) Hospitalized for an unknown ""nervous"" condition in the 1940's.,SHX/FHX:, Retired small engine mechanic who worked in a poorly ventilated shop. Married with 13 children. No history of ETOH, Tobacco or illicit drug use. Father had tremors following a stroke. Brother died of brain aneurysm. No history of depression, suicide, or Huntington's disease in family.,ROS:, no history of CAD, Renal or liver disease, SOB, Chest pain, fevers, chills, night sweats or weight loss. No report of sign of bleeding.,EXAM:, BP138/63 HR65 RR15 36.1C,MS: Alert and oriented to self, season; but not date, year, or place. Latent verbal responses and direction following. Intact naming, but able to repeat only simple but not complex phrases. Slowed speech, with mild difficulty with word finding. 2/3 recall at one minute and 0/3 at 3 minutes. Knew the last 3 presidents. 14/27 on MMSE: unable to spell ""world"" backwards. Unable to read/write for complaint of inability to see without glasses.,CN: II-XII appeared grossly intact. EOM were full and smooth and without unusual saccadic pursuits. OKN intact. Choreiform movements of the tongue were noted.,Motor: 5/5 strength throughout with Guggenheim type resistance. there were choreiform type movements of all extremities bilaterally. No motor impersistence noted.,Sensory: unreliable.,Cord: ""normal"" FNF, HKS, and RAM, bilaterally.,Station: No Romberg sign.,Gait: unsteady and wide-based.,Reflexes: BUE 2/2, Patellar 2/2, Ankles Trace/Trace, Plantars were flexor bilaterally.,Gen Exam: 2/6 Systolic ejection murmur in aortic area.,COURSE:, No family history of Huntington's disease could be elicited from relatives. Brain CT, 1/18/93: bilateral calcification of the globus pallidi and a high attenuation focus in the right occipital lobe thought to represent artifact. Carotid duplex, 1/18/93: RICA 0-15%, LICA 16-49% stenosis and normal vertebral artery flow bilaterally. Transthoracic Echocardiogram (TTE),1/18/93: revealed severe aortic fibrosis or valvular calcification with ""severe"" aortic stenosis in the face of ""normal"" LV function. Cardiology felt the patient the patient had asymptomatic aortic stenosis. EEG, 1/20/93, showed low voltage Delta over the left posterior quadrant and intermittent background slowing over the same region consistent with focal dysfunction in this quadrant. MRI Brain, 1/22/93: multiple focal and more confluent areas of increased T2 signal in the periventricular white matter, more prominent on the left; in addition, there were irregular shaped areas of increased T2 signal and decreased T1 signal in both cerebellar hemispheres; and age related atrophy; incidentally, there is a cavum septum pellucidum et vergae and mucosal thickening of the maxillary sinuses. Impression: diffuse bilateral age related ischemic change, age related atrophy and maxillary sinus disease. There were no masses or areas of abnormal enhancement. TSH, FT4, Vit B12, VDRL, Urine drug and heavy metal screens were unremarkable. CSF,1/19/93: glucose 102 (serum glucose 162mg/dL), Protein 45mg/dL, RBC O, WBC O, Cultures negative. SPEP negative. However serum and CSF beta2 microglobulin levels were elevated at 2.5 and 3.1mg/L, respectively. Hematology felt these may have been false positives. CBC, 1/17/93: Hgb 10.4g/dL (low), HCT 31% (low), RBC 3/34mil/mm3 (low), WBC 5.8K/mm3, Plt 201K/mm3. Retic 30/1K/mm3 (normal). Serum Iron 35mcg/dL (low), TIBC 201mcg/dL (low), FeSat 17% (low), CRP 0.1mg/dL (normal), ESR 83mm/hr (high). Bone Marrow Bx: normal with adequate iron stores. Hematology felt the finding were compatible with anemia of chronic disease. Neuropsychologic evaluation on 1/17/93 revealed significant impairments in multiple realms of cognitive function (visuospatial reasoning, verbal and visual memory, visual confrontational naming, impaired arrhythmatic, dysfluent speech marked by use of phrases no longer than 5 words, frequent word finding difficulty and semantic paraphasic errors) most severe for expressive language, attention and memory. The pattern of findings reveals an atypical aphasia suggestive of left temporo-parietal dysfunction. The patient was discharged1/22/93 on ASA 325mg qd. He was given a diagnosis of senile chorea and dementia (unspecified type). 6/18/93 repeat Neuropsychological evaluation revealed moderate decline in all areas tested reflecting severe dementia.","neurology, episodic mental status change, huntington's disease, brain ct, transthoracic echocardiogram, carotid duplex, mental status change, ct brain, basal ganglia, mental status, globus pallidi, aortic stenosis, maxillary sinuses, rue numbness, basal, ganglia, globus, pallidi, therapy, chorea, ct, rue, brain, "
 CT brain (post craniectomy) - RMCA stroke and SBE., Neurology, CT Brain ,"CC:, Left-sided weakness.,HX:, This 28y/o RHM was admitted to a local hospital on 6/30/95 for a 7 day history of fevers, chills, diaphoresis, anorexia, urinary frequency, myalgias and generalized weakness. He denied foreign travel, IV drug abuse, homosexuality, recent dental work, or open wound. Blood and urine cultures were positive for Staphylococcus Aureus, oxacillin sensitive. He was place on appropriate antibiotic therapy according to sensitivity.. A 7/3/95 transthoracic echocardiogram revealed normal left ventricular function and a damaged mitral valve with regurgitation. Later that day he developed left-sided weakness and severe dysarthria and aphasia. HCT, on 7/3/95 revealed mild attenuated signal in the right hemisphere. On 7/4/95 he developed first degree AV block, and was transferred to UIHC.,MEDS: ,Nafcillin 2gm IV q4hrs, Rifampin 600mg q12hrs, Gentamicin 130mg q12hrs.,PMH:, 1) Heart murmur dx age 5 years.,FHX:, Unremarkable.,SHX:, Employed cook. Denied ETOH/Tobacco/illicit drug use.,EXAM:, BP 123/54, HR 117, RR 16, 37.0C,MS: Somnolent and arousable only by shaking and repetitive verbal commands. He could follow simple commands only. He nodded appropriately to questioning most of the time. Dysarthric speech with sparse verbal output.,CN: Pupils 3/3 decreasing to 2/2 on exposure to light. Conjugate gaze preference toward the right. Right hemianopia by visual threat testing. Optic discs flat and no retinal hemorrhages or Roth spots were seen. Left lower facial weakness. Tongue deviated to the left. Weak gag response, bilaterally. Weak left corneal response.,MOTOR: Dense left flaccid hemiplegia.,SENSORY: Less responsive to PP on left.,COORD: Unable to test.,Station and Gait: Not tested.,Reflexes: 2/3 throughout (more brisk on the left side). Left ankle clonus and a Left Babinski sign were present.,GEN EXAM: Holosystolic murmur heard throughout the precordium. Janeway lesions were present in the feet and hands. No Osler's nodes were seen.,COURSE:, 7/6/95, HCT showed a large RMCA stroke with mass shift. His neurologic exam worsened and he was intubated, hyperventilated, and given IV Mannitol. He then underwent emergent left craniectomy and duraplasty. He tolerated the procedure well and his brain was allowed to swell. He then underwent mitral valve replacement on 7/11/95 with a St. Judes valve. His post-operative recovery was complicated by pneumonia, pericardial effusion and dysphagia. He required temporary PEG placement for feeding. The 7/27/95, 8/6/95 and 10/18/96 HCT scans show the chronologic neuroradiologic documentation of a large RMCA stroke. His 10/18/96 Neurosurgery Clinic visit noted that he can ambulate without assistance with the use of a leg brace to prevent left foot drop. His proximal LLE strength was rated at a 4. His LUE was plegic. He had a seizure 6 days prior to his 10/18/96 evaluation. This began as a Jacksonian march of shaking in the LUE; then involved the LLE. There was no LOC or tongue-biting. He did have urinary incontinence. He was placed on DPH. His speech was dysarthric but fluent. He appeared bright, alert and oriented in all spheres.","neurology, ct brain, rmca, anorexia, chills, craniectomy, diaphoresis, fevers, myalgias, stroke, urinary frequency, echocardiogram, holosystolic murmur, pneumonia, pericardial effusion, tongue-biting, sided weakness, mitral valve, rmca stroke, ct, hct, weakness, "
" CT Brain: Suprasellar aneurysm, pre and post bleed.", Neurology, CT Brain - Aneurysm ,"CC:, Decreasing visual acuity.,HX: ,This 62 y/o RHF presented locally with a 2 month history of progressive loss of visual acuity, OD. She had a 2 year history of progressive loss of visual acuity, OS, and is now blind in that eye. She denied any other symptomatology. Denied HA.,PMH:, 1) depression. 2) Blind OS,MEDS:, None.,SHX/FHX: ,unremarkable for cancer, CAD, aneurysm, MS, stroke. No h/o Tobacco or ETOH use.,EXAM:, T36.0, BP121/85, HR 94, RR16,MS: Alert and oriented to person, place and time. Speech fluent and unremarkable.,CN: Pale optic disks, OU. Visual acuity: 20/70 (OD) and able to detect only shadow of hand movement (OS). Pupils were pharmacologically dilated earlier. The rest of the CN exam was unremarkable.,MOTOR: 5/5 throughout with normal bulk and tone.,Sensory: no deficits to LT/PP/VIB/PROP.,Coord: FNF-RAM-HKS intact bilaterally.,Station: No pronator drift. Gait: ND,Reflexes: 3/3 BUE, 2/2 BLE. Plantar responses were flexor bilaterally.,Gen Exam: unremarkable. No carotid/cranial bruits.,COURSE:, CT Brain showed large, enhancing 4 x 4 x 3 cm suprasellar-sellar mass without surrounding edema. Differential dx: included craniopharyngioma, pituitary adenoma, and aneurysm. MRI Brain findings were consistent with an aneurysm. The patient underwent 3 vessel cerebral angiogram on 12/29/92. This clearly revealed a supraclinoid giant aneurysm of the left internal carotid artery. Ten minutes following contrast injection the patient became aphasic and developed a right hemiparesis. Emergent HCT showed no evidence of hemorrhage or sign of infarct. Emergent carotid duplex showed no significant stenosis or clot. The patient was left with an expressive aphasia and right hemiparesis. SPECT scans were obtained on 1/7/93 and 2/24/93. They revealed hypoperfusion in the distribution of the left MCA and decreased left basal-ganglia perfusion which may represent in part a mass effect from the LICA aneurysm. She was discharged home and returned and underwent placement of a Selverstone Clamp on 3/9/93. The clamp was gradually and finally closed by 3/14/93. She did well, and returned home. On 3/20/93 she developed sudden confusion associated with worsening of her right hemiparesis and right expressive aphasia. A HCT then showed SAH around her aneurysm, which had thrombosed. She was place on Nimodipine. Her clinical status improved; then on 3/25/93 she rapidly deteriorated over a 2 hour period to the point of lethargy, complete expressive aphasia, and right hemiplegia. An emergent HCT demonstrated a left ACA and left MCA infarction. She required intubation and worsened as cerebral edema developed. She was pronounced brain dead. Her organs were donated for transplant.","neurology, ct brain, hct, mri brain, suprasellar, suprasellar aneurysm, aneurysm, cerebral angiogram, craniopharyngioma, internal carotid artery, loss of visual acuity, pituitary adenoma, suprasellar-sellar mass, visual acuity, expressive aphasia, cerebral, ct, hemiparesis, aphasia, brain,"
" Acute left subdural hematoma.  Left frontal temporal craniotomy for evacuation of acute subdural hematoma.  CT imaging reveals an acute left subdural hematoma, which is hemispheric.", Neurology, Craniotomy - Frontotemporal - 1 ,"PREOPERATIVE DIAGNOSIS:,  Acute left subdural hematoma.,POSTOPERATIVE DIAGNOSIS:,  Acute left subdural hematoma.,PROCEDURE:,  Left frontal temporal craniotomy for evacuation of acute subdural hematoma.,DESCRIPTION OF PROCEDURE: , This is a 76-year-old man who has a history of acute leukemia.  He is currently in the phase of his therapy where he has developed a profound thrombocytopenia and white cell deficiency.  He presents after a fall in the hospital in which he apparently struck his head and now has a progressive neurologic deterioration consistent with an intracerebral injury.  His CT imaging reveals an acute left subdural hematoma, which is hemispheric.,The patient was brought to the operating room, placed under satisfactory general endotracheal anesthesia.  He had previously been intubated and taken to the Intensive Care Unit and now is brought for emergency craniotomy.  The images were brought up on the electronic imaging and confirmed that this was a left-sided condition.  He was fixed in a three-point headrest.  His scalp was shaved and prepared with Betadine, iodine and alcohol.  We made a small curved incision over the temporal, parietal, frontal region.  The scalp was reflected.  A single bur hole was made at the frontoparietal junction and then a 4x6cm bur hole was created.  After completing the bur hole flap, the dura was opened and a gelatinous mass of subdural was peeled away from the brain.  The brain actually looked relatively relaxed; and after removal of the hematoma, the brain sort of slowly came back up.  We investigated the subdural space forward and backward as we could and yet careful not to disrupt any venous bleeding as we close to the midline.  After we felt that we had an adequate decompression, the dura was reapproximated and we filled the subdural space with saline.  We placed a small drain in the extra dural space and then replaced the bone flap and secured this with the bone plates.  The scalp was reapproximated, and the patient was awakened and taken to the CT scanner for a postoperative scan to ensure that there was no new hemorrhage or any other intracerebral pathology that warranted treatment.  Given that this actual skin looked good with apparent removal of about 80% of the subdural we elected to take patient to the Intensive Care Unit for further management.,I was present for the entire procedure and supervised this.  I confirmed prior to closing the skin that we had correct sponge and needle counts and the only foreign body was the drain.","neurology, subdural, hematoma, temporal craniotomy, craniotomy, subdural space, bur hole, subdural hematoma, "
 Heidenhain variant of Creutzfeldt-Jakob Disease (CJD), Neurology, Creutzfeldt-Jakob Disease ,"CC:, Progressive memory and cognitive decline.,HX:, This 73 y/o RHF presented on 1/12/95, with progressive memory and cognitive decline since 11/94.,Her difficulties were first noted by family the week prior to Thanksgiving, when they were taking her to Vail, Colorado to play ""Murder She Wrote"" at family gathering. Unbeknownst to the patient was the fact that she had been chosen to be the ""assassin."" Prior to boarding the airplane her children hid a toy gun in her carry-on luggage. As the patient walked through security the alarm went off and within seconds she was surrounded, searched and interrogated. She and her family eventually made their flight, but she seemed unusually flustered and disoriented by the event. In prior times they would have expected her to have brushed off the incident with a ""chuckle."",While in Colorado her mentation seemed slow and she had difficulty reading the lines to her part while playing ""Murder She Wrote."" She needed assistance to complete the game. The family noted no slurring of speech, difficulty with vision, or focal weakness at the time.,She returned to work at a local florist shop the Monday following Thanksgiving, and by her own report, had difficulty carrying out her usual tasks of flower arranging and operating the cash register. She quit working the next day and never went back.,Her mental status appeared to remain relatively stable throughout the month of November and December and during that time she was evaluated by a local neurologist. Serum VDRL, TFTs, GS, B12, Folate, CBC, CXR, and MRI of the Brain were all reportedly unremarkable. The working diagnosis was ""Dementia of the Alzheimer's Type."",One to two weeks prior to her 1/12/95 presentation, she became repeatedly lost in her own home. In addition, she, and especially her family, noticed increased difficulty with word finding, attention, and calculation. Furthermore, she began expressing emotional lability unusual for her. She also tended to veer toward the right when walking and often did not recognize the location of people talking to her.,MEDS:, None.,PMH:, Unremarkable.,FHX:, Father and mother died in their 80's of ""old age."" There was no history of dementing illness, stroke, HTN, DM, or other neurological disease in her family. She has 5 children who were alive and well.,SHX: ,She attained a High School education and had been widowed for over 30 years. She lived alone for 15 years until to 12/94, when her daughters began sharing the task of caring for her. She had no history of tobacco, alcohol or illicit drug use.,EXAM:, Vitals signs were within normal limits.,MS: A&O to person place and time. At times she seemed in absence. She scored 20/30 on MMSE and had difficulty with concentration, calculation, visuospatial construction. Her penmanship was not normal, and appeared ""child-like"" according to her daughters. She had difficulty writing a sentence and spoke in a halting fashion; she appeared to have difficulty finding words. In addition, while attempting to write, she had difficulty finding the right margin of the page.,CN: Right homonymous inferior quadrantanopsia bordering on a right homonymous hemianopsia. The rest of the CN exam was unremarkable.,Motor: 5/5 strength throughout with normal muscle tone and bulk.,Sensory: extinguishing of RUE sensation on double simultaneous stimulation, and at times she appeared to show sign of RUE neglect. There were no unusual spontaneous movements noted.,Coord: unremarkable except for difficulty finding the target on FNF exercise when the target was moved into the right side visual field.,Station: No sign of Romberg or pronator drift. There was no truncal ataxia.,Gait: decreased RUE swing and a tendency to veer and circumambulate to the right when asked to walk toward a target.,Reflexes: 2/2 and symmetric throughout all four extremities. Plantar responses were equivocal, bilaterally.,COURSE:,  CBC, GS, PT, PTT, ESR, UA, CRP, TSH, FT4, and EKG were unremarkable. CSF analysis revealed: 38 RBC, 0 WBC, Protein 36, glucose 76. The outside MRI was reviewed and was found to show increased signal on T2 weighted images in the gyri of the left parietal-occipital regions. Repeat MRI, at UIHC, revealed the same plus increased signal on T2 weighted images in the left frontal region as well. CXR, transthoracic echocardiogram and 4 vessel cerebral angiogram were unremarkable. A 1/23/95, left frontal brain biopsy revealed spongiform changes without sign of focal necrosis, vasculitis or inflammatory changes. The working diagnosis became Creutzfeldt-Jakob Disease (Heidenhaim variant). The patient died on 2/15/95. Brain tissue was sent to the University of California at San Francisco. Analysis there revealed diffuse vacuolization throughout most of the cingulate gyrus, frontal cortex, hypothalamus, globus pallidus, putamen, insula, amygdala, hippocampus, cerebellum and medulla. This vacuolization was most severe in the entorhinal cortex and parahippocampal gyrus. Hydrolytic autoclaving technique was used with PrP-specific antibodies to identify the presence of protease resistant PrP (CJD). The patient's brain tissue was strongly positive for PrP (CJD).", 
 Right frontal craniotomy with resection of right medial frontal brain tumor.  Stereotactic image-guided neuronavigation and  microdissection and micro-magnification for resection of brain tumor., Neurology, Craniotomy & Neuronavigation ,"PROCEDURES:,1.  Right frontal craniotomy with resection of right medial frontal brain tumor.,2.  Stereotactic image-guided neuronavigation for resection of tumor.,3.  Microdissection and micro-magnification for resection of brain tumor.,ANESTHESIA: , General via endotracheal tube.,INDICATIONS FOR THE PROCEDURE:  ,The patient is a 71-year-old female with a history of left-sided weakness and headaches.  She has a previous history of non-small cell carcinoma of the lung, treated 2 years ago.  An MRI was obtained which showed a large enhancing mass in the medial right frontal lobe consistent with a metastatic lesion or possible primary brain tumor.  After informed consent was obtained, the patient was brought to the operating room for surgery.,PREOPERATIVE DIAGNOSES: , Medial right frontal brain tumor with surrounding edema and mass effect and right to left brain shift.,POSTOPERATIVE DIAGNOSES: , Medial right frontal brain tumor with surrounding edema and mass effect and right to left brain shift, probable metastatic lung carcinoma.,DESCRIPTION OF THE PROCEDURE: , The patient was wheeled into the operating room and satisfactory general anesthesia was obtained via endotracheal tube.  She was positioned on the operating room table in the Sugita frame with the head secured.,Using the preoperative image-guided MRI, we carefully registered the fiducials and then obtained the stereotactic image-guided localization to guide us towards the tumor.  We marked external landmarks.  Then we shaved the head over the right medial frontal area.  This area was then sterilely prepped and draped.,Evoked potential monitoring and sensory potentials were carried out throughout the case and no changes were noted.,A horseshoe shaped flap was based on the right and then brought across to the midline.  This was opened and hemostasis obtained using Raney clips.  The skin flap was retracted medially.  Two burr holes were made and were carefully connected.  One was placed right over the sinus and we carefully then removed a rectangular shaped bone flap.  Hemostasis was obtained.  Using the neuronavigation, we identified where the tumor was.  The dura was then opened based on a horseshoe flap based on the medial sinus.  We retracted this medially and carefully identified the brain.  The brain surface was discolored and obviously irritated consistent with the tumor.,We used the stereotactic neuronavigation to identify the tumor margins.,Then we used a bipolar to coagulate a thin layer of brain over the tumor.  Subsequently, we entered the tumor.  The tumor itself was extremely hard.  Specimens were taken and send for frozen section analysis, which showed probable metastatic carcinoma.,We then carefully dissected around the tumor margins.,Using the microscope, we then brought microscopic magnification and dissection into the case.  We used paddies and carefully developed microdissection planes all around the margins of the tumor superiorly, medially, inferiorly, and laterally.,Then using the Cavitron, we cored out the central part of the tumor.  Then we collapsed the tumor on itself and removed it entirely.  In this fashion, microdissection and magnification resection of the tumor was carried out.  We resected the entire tumor.  Neuronavigation was used to confirm that no further tumor residual was remained.,Hemostasis was obtained using bipolar coagulation and Gelfoam.  We also lined the cavity with Surgicel.  The cavity was nicely dry and excellent hemostasis was obtained.,The dura was closed using multiple interrupted 4-0 Nurolon sutures in a watertight fashion.  Surgicel was placed over the dural closure.  The bone flap was repositioned and held in place using CranioFIX cranial fixators.  The galea was re-approximated and the skin was closed with staples.  The wound was dressed.  The patient was returned to the intensive care unit.  She was awake and moving extremities well.  No apparent complications were noted.  Needle and sponge counts were listed as correct at the end of the procedure.  Estimated intraoperative blood loss was approximately 150 mL and none was replaced.","neurology, stereotactic image-guided neuronavigation, micro-magnification, resection of brain tumor, frontal craniotomy, mass effect, brain shift, stereotactic image, brain tumor, brain, tumor, craniotomy, endotracheal, carcinoma, neuronavigation, microdissection, "
 Left temporal craniotomy and removal of brain tumor., Neurology, Craniotomy - Temporal ,"PREOPERATIVE DIAGNOSIS:,  Brain tumor left temporal lobe.,POSTOPERATIVE DIAGNOSIS:,  Brain tumor left temporal lobe - glioblastoma multiforme.,OPERATIVE PROCEDURE:,1.  Left temporal craniotomy.,2.  Removal of brain tumor.,OPERATING MICROSCOPE: , Stealth.,PROCEDURE: , The patient was placed in the supine position, shoulder roll, and the head was turned to the right side.  The entire left scalp was prepped and draped in the usual fashion after having being placed in 2-point skeletal fixation.  Next, we made an inverted-U fashion base over the asterion over temporoparietal area of the skull.  A free flap was elevated after the scalp that was reflected using the burr hole and craniotome.  The bone flap was placed aside and soaked in the bacitracin solution.,The dura was then opened in an inverted-U fashion.  Using the Stealth, we could see that this large cystic mass was just below the cortex in the white matter just anterior to the trigone of the ventricle.  We head through the vein of Labbe, and we made great care to preserve this.  We saw where the tumor almost made to the surface.  Here we made a small corticectomy using the Stealth for guidance.  We left small corticectomy entered large cavity with approximately 15 cc of yellowish necrotic liquid.  This was submitted to pathology.  We biopsied this very abnormal tissue and submitted it to pathology.  They gave us a frozen section diagnosis of glioblastoma multiforme.  With the operating microscope and Greenwood bipolar forceps, we then systematically debulked this tumor.  It was very vascular and we really continued to remove this tumor until all visible tumors was removed.  We appeared to get two gliotic planes circumferentially.  We could see it through the ventricle.  After removing all visible tumor grossly, we then irrigated this cavity multiple times and obtained meticulous hemostasis and then closed the dura primarily with 4-0 Nurolon sutures with the piece of DuraGen placed over this in order to increase our chances for a good watertight seal.  The bone flap was then replaced and sutured with the Lorenz titanium plate system.  The muscle fascia galea was closed with interrupted 2-0 Vicryl sutures.  Skin staples were used for skin closure.  The blood loss of the operation was about 200 cc.  There were no complications of the surgery per se.  The needle count, sponge count, and the cottonoid count were correct.,COMMENT:  ,Operating microscope was quite helpful in this; as we could use the light as well as the magnification to help us delineate the brain tumor - gliotic interface and while it was vague at sometimes we could I think clearly get a good cleavage plane in most instances so that we got a gross total removal of this very large and necrotic-looking tumor of the brain.","neurology, temporal lobe, brain tumor, lorenz titanium plate, burr hole, cortex, corticectomy, craniotome, craniotomy, frozen section, glioblastoma multiforme, temporal craniotomy, temporoparietal, ventricle, white matter, tumor, temporal, brain,"
 Left retrosigmoid craniotomy and excision of acoustic neuroma., Neurology, Craniotomy - Retrosigmoid  ,"PREOPERATIVE DIAGNOSIS: , Left acoustic neuroma.,POSTOPERATIVE DIAGNOSIS: , Left acoustic neuroma.,PROCEDURE PERFORMED: , Left retrosigmoid craniotomy and excision of acoustic neuroma.,ANESTHESIA:,  General.,OPERATIVE FINDINGS: , This patient had a 3-cm acoustic neuroma.  The tumor was incompletely excised leaving a remnant of the tumor along the cerebellopontine angle portion of the facial nerve.  The facial nerve was stimulated at the brainstem at 0.05 milliamperes at the conclusion of the dissections.,PROCEDURE IN DETAIL:  ,Following induction of adequate general anesthetic, the patient was positioned for surgery.  She was placed in a lateral position and her head was maintained with Mayfield pins.  The left periauricular area was shaved, prepped, and draped in the sterile fashion.  Transdermal electrodes for continuous facial nerve EMG monitoring were placed, and no response was verified.  The proposed incision was injected with 1% Xylocaine with epinephrine.  Next, T-shaped incision was made approximately 5 cm behind the postauricular crease.  The incision was undermined at the level of temporalis fascia, and the portion of the fascia was harvested for further use.,Incision was made along the inferior aspect of the temporalis muscle and then extended inferiorly over the mastoid tip.  Periosteal elevator was used to elevate periosteum in order to expose the mastoid and anterior aspect of the occipital bone.  Emissary veins posterior to the sigmoid sinus were controlled with electrocautery and bone wax.  Bergen retractors were used to maintain exposure.  Using a cutting bur with continuous suction and irrigation of craniotomy was performed.  The sigmoid sinus was identified anteriorly and the transverse sites were identified superiorly.  From these structures approximately 4 x 4 cm, a window of bone was removed.  Bone shavings were collected during the dissection and placed in Siloxane suspension for later use.  The bone flap was also left at the site for further use.  Dissection was extended along the inferior aspect of the sigmoid sinus to provide additional exposure of the skull base.  Bone wax was used to occlude air cells lateral to the sigmoid sinus.  There was extensively aerated temporal bone.  At this point, Dr. Trask entered the case in order to open the dura and expose the tumor.  The cerebellum was retracted away from the tumor, and the retractor was placed to help maintain exposure.  Once initial exposure was completed, attention was directed to the posterior aspect of the temporal bone.  The dura was excised from around the porous acusticus extending posteriorly along the bone.  Then, using diamond burs, the internal auditory canal was dissected out.  The bone was removed laterally for distance of approximately 8 mm.  There was considerable aeration around the internal auditory canal as well.  The dura was then incised over the internal auditory canal exposing the intracanalicular portion of the tumor.  The tumor extended all the way to the fundus such that initial exposure of the facial nerve around the tumor was difficult.  Therefore, Dr. Trask returned in order to further release the tumor from the brainstem and to debulk the central portions of the tumor.  With dissection, he released the tumor from the trigeminal nerve superiorly and elevated the tumor away from the dorsal brainstem.  The eighth nerve was identified and transected.  Tumor debulking allowed for retraction of the tumor capsule away from the brainstem.  The facial nerve was difficult to identify at the brainstem as well.  It was identified by using an electrical stimulator but dissection attempted at this time was the plane between the nerve and the tumor proximally but this was difficult to achieve.  Attention was then redirected to the internal auditory canal where this portion of the tumor was removed.  The superior and inferior vestibular nerves were evulsed laterally and dissection proceeded along the facial nerve to the porous acusticus.  At this point, plane of dissection was again indistinct.  The tumor had been released from the porous and could be rotated.  The tumor was further debulked and thinned, but could not crucially visualize the nerve on the anterior face of the tumor.  The nerve could be stimulated, but was quite splayed over the anterior face.  Further debulking of the tumor proceeded and additional attempts were made to establish point of dissection along the nerve, both proximally and distally.  However, the cerebellopontine angle portion of the nerve was not usually delineated.  However, the tumor was then thinned using CUSA down to fine sheath measuring only about 1 to 2 mm in thickness.  It was released from the brainstem ventrally.  The tumor was then cauterized with bipolar electrocautery.  The facial nerve was stimulated at the brainstem and stimulated easily at 0.05 milliamperes.  Overall, the remaining tumor volume would be of small percentage of the original volume.  At this point, Dr. Trask re-inspected the posterior fossa to ensure complete hemostasis.  The air cells around the internal auditory canal were packed off with muscle and bone wax.  A piece of fascia was then laid over the bone defect.  Next, the dura was closed with DuraGen and DuraSeal.  The bone flap and bone ***** were then placed in the bone defect.  Postauricular musculature was then reapproximated using interrupted 3-0 Vicryl sutures.  The skin was also closed using interrupted subdermal 3-0 Vicryl sutures.  Running 4-0 nylon suture was placed at the skin levels.  Sterile mastoid dressing was then placed.  The patient tolerated the procedure well and was transported to the PACU in a stable condition.  All counts were correct at the conclusion of the procedure.,ESTIMATED BLOOD LOSS:  ,100 mL.","neurology, neuroma, bergen retractors, emissary veins, mayfield pins, acoustic, acoustic neuroma, cerebellopontine, craniotomy, facial nerve, periauricular, retrosigmoid, retrosigmoid craniotomy, internal auditory canal, porous acusticus, sigmoid sinus, auditory canal, bone, brainstem, nerve, postauricular, tumor"
" Occipital craniotomy, removal of large tumor using the inner hemispheric approach, stealth system operating microscope and CUSA.", Neurology, Craniotomy - Occipital ,"PREOPERATIVE DIAGNOSIS: , Brain tumors, multiple.,POSTOPERATIVE DIAGNOSES:,  Brain tumors multiple - adenocarcinoma and metastasis from breast.,PROCEDURE:,  Occipital craniotomy, removal of large tumor using the inner hemispheric approach, stealth system operating microscope and CUSA.,PROCEDURE:,  The patient was placed in the prone position after general endotracheal anesthesia was administered.  The scalp was prepped and draped in the usual fashion.  The CUSA was brought in to supplement the use of operating microscope as well as the stealth, which was used to localize the tumor.  Following this, we then made a transverse linear incision, the scalp galea was reflected and the quadrilateral bone flap was removed after placing burr holes in the midline and over the parietal areas directly over the tumor.  The bone flap was elevated.  The ultrasound was then used.  The ultrasound showed the tumors directly I believe are in the interhemispheric fissure.  We noticed that the dura was quite tense despite that the patient had slight hyperventilation.  We gave 4 ounce of mannitol, the brain became more pulsatile.  We then used the stealth to perform a ventriculostomy.  Once this was done, the brain began to pulsate nicely.  We then entered the interhemispheric space after we incised the dura in an inverted U fashion based on the superior side of the sinus.  After having done this we then used operating microscope and slight self-retaining retraction was used.  We obtained access to the tumor.  We biopsied this and submitted it.  This was returned as a malignant brain tumor - metastatic tumor, adenocarcinoma compatible with breast cancer.,Following this we then debulked this tumor using CUSA and then removed it in total.  After gross total removal of this tumor, the irrigation was used to wash the tumor bed and a meticulous hemostasis was then obtained using bipolar cautery.  The next step was after removal of this tumor, closure of the wound, a large piece of Duragen was placed over the dural defect and the bone flap was reapproximated and held secured with Lorenz plates.  The tumors self extend into the ventricle and after we had removed the tumor, we could see our ventricular catheter in the occipital horn of the ventricle.  This being the case, we left this ventricular catheter in, brought it out through a separate incision and connected to sterile drainage.  The next step was to close the wound after reapproximating the bone flap.  The galea was closed with 2-0 Vicryl and the skin was closed with interrupted 3-0 nylon sutures inverted with mattress sutures.  The sterile dressings were applied to the scalp.  The patient returned to the recovery room in satisfactory condition.  Hemodynamically remained stable throughout the operation.,Once again, we performed occipital craniotomy, total removal of her large metastatic tumor involving the parietal lobe using a biparietal craniotomy.  The tumor was removed using the combination of CUSA, ultrasound, stealth guided-ventriculostomy and the patient will have a second operation today, we will perform a selective craniectomy to remove another large tumor in the posterior fossa.","neurology, brain tumor, cusa, occipital, adenocarcinoma, bone flap, craniotomy, malignant, metastatic, scalp galea, transverse linear incision, ventriculostomy, occipital craniotomy, tumor, stealth, brain, "
" Postoperative visit for craniopharyngioma with residual disease.  According to him, he is doing well, back at school without any difficulties.  He has some occasional headaches and tinnitus, but his vision is much improved.", Neurology, Craniopharyngioma - Postop ,"REASON FOR VISIT:,  Postoperative visit for craniopharyngioma.,HISTORY OF PRESENT ILLNESS:,  Briefly, a 16-year-old right-handed boy who is in eleventh grade, who presents with some blurred vision and visual acuity difficulties, was found to have a suprasellar tumor.  He was brought to the operating room on 01/04/07, underwent a transsphenoidal resection of tumor.  Histology returned as craniopharyngioma.  There is some residual disease; however, the visual apparatus was decompressed.  According to him, he is doing well, back at school without any difficulties.  He has some occasional headaches and tinnitus, but his vision is much improved.,MEDICATIONS: , Synthroid 100 mcg per day.,FINDINGS: , On exam, he is awake, alert and oriented x 3.  Pupils are equal and reactive.  EOMs are full.  His visual acuity is 20/25 in the right (improved from 20/200) and the left is 20/200 improved from 20/400.  He has a bitemporal hemianopsia, which is significantly improved and wider.  His motor is 5 out of 5.  There are no focal motor or sensory deficits.  The abdominal incision is well healed.  There is no evidence of erythema or collection.  The lumbar drain was also well healed.,The postoperative MRI demonstrates small residual disease.,Histology returned as craniopharyngioma.,ASSESSMENT: , Postoperative visit for craniopharyngioma with residual disease.,PLANS: , I have recommended that he call.  I discussed the options with our radiation oncologist, Dr. X. They will schedule the appointment to see him.  In addition, he probably will need an MRI prior to any treatment, to follow the residual disease.","neurology, visual acuity, blurred vision, tinnitus, headaches, residual disease, tumor, histology, craniopharyngioma,"
 Patient referred for evaluation of her left temporal lobe epilepsy., Neurology, Consult - Seizures ,"REASON FOR CONSULTATION:  ,Followup of seizures.,HISTORY OF PRESENT ILLNESS:,  This is a 47-year-old African-American female, well known to the neurology service, who has been referred to me for the first time evaluation of her left temporal lobe epilepsy that was diagnosed in August of 2002.  At that time, she had one generalized tonic-clonic seizure.  Apparently she had been having several events characterized by confusion and feeling unsteady lasting for approximately 60 seconds.  She said these events were very paroxysmal in the sense they suddenly came on and would abruptly stop.  She had two EEGs at that time, one on August 04, 2002 and second on November 01, 2002, both of which showed rare left anterior temporal sharp waves during drowsiness and sleep.  She also had an MRI done on September 05, 2002, with and without contrast that was negative.  Her diagnosis was confirmed by Dr. X at Johns Hopkins Hospital who reviewed her studies as well as examined the patient and felt that actually her history and findings were consistent with diagnosis of left temporal lobe epilepsy.  She was initially started on Trileptal, but had some problems with the medication subsequently Keppra, which she said made her feel bad and subsequently changed in 2003 to lamotrigine, which she has been taking since then.  She reports no seizures in the past several years.  She currently is without complaint.,In terms of seizure risk factors she denies head trauma, history of CNS infection, history of CVA, childhood seizures, febrile seizures.  There is no family history of seizures.,PAST MEDICAL HISTORY: , Significant only for hypertension and left temporal lobe epilepsy.,FAMILY HISTORY: , Remarkable only for hypertension in her father.  Her mother died in a motor vehicle accident.,SOCIAL HISTORY:  ,She works running a day care at home.  She has three children.  She is married.  She does not smoke, use alcohol or illicit drugs.,REVIEW OF SYSTEMS: , Please see note in chart.  Only endorses weight gain and the history of seizures, as well as some minor headaches treated with over-the-counter medications.,CURRENT MEDICATIONS:  ,Lamotrigine 150 mg p.o. b.i.d., verapamil, and hydrochlorothiazide.,ALLERGIES: , Flagyl and aspirin.,PHYSICAL EXAMINATION: , Blood pressure is 138/88, heart rate is 76, respiratory rate is 18, and weight is 224 pounds, pain scale is none.,General Examination:  Please see note in chart, which is essentially unremarkable except mild obesity.,NEUROLOGICAL EXAMINATION: , Again, please see note in chart.  Mental status is normal, cranial nerves are intact, motor is normal bulk and tone throughout with no weakness appreciated in upper and lower extremities bilaterally.  There is no drift and there are no abnormalities to orbit.  Sensory examination, light touch, and temperature intact at all distal extremities.  Cerebellar examination, she has normal finger-to-nose, rapid alternating movements, heel-to-shin, and foot tap.,She rises easily from the chair.  She has normal step, stride, arm swing, toe, heel, and tandem.  Deep tendon reflexes are 2 and equal at biceps, brachioradialis, patella, and 1 at the ankles.,She was seen in the emergency room for chest pain one month ago.  CT of the head was performed, which I reviewed, dated September 07, 2006.  The findings were within the range of normal variation.  There is no evidence of bleeding, mass, lesions, or any evidence of atrophy.,IMPRESSION: , This is a pleasant 47-year-old African-American female with what appears to be cryptogenic left temporal lobe epilepsy that is very well controlled on her current dose of lamotrigine.,PLAN:,1.  Continue lamotrigine 150 mg p.o. b.i.d.,2.  I discussed with the patient the option of a trial of medications.  We need to repeat her EEG as well as her MRI prior to weaning her medications.  The patient wants to continue her lamotrigine at this time.  I concur.,3.  The patient will be following up with me in six months.,",
" Cerebral palsy, worsening seizures.  A pleasant 43-year-old female with past medical history of CP since birth, seizure disorder, complex partial seizure with secondary generalization and on top of generalized epilepsy, hypertension, dyslipidemia, and obesity. ", Neurology, Consult - Seizures - 1 ,"CHIEF COMPLAINT: , Worsening seizures.,HISTORY OF PRESENT ILLNESS:  ,A pleasant 43-year-old female with past medical history of CP since birth, seizure disorder, complex partial seizure with secondary generalization and on top of generalized epilepsy, hypertension, dyslipidemia, and obesity.  The patient stated she was in her normal state of well being when she was experiencing having frequent seizures.  She lives in assisted living.  She has been falling more frequently.  The patient was driving a scooter and apparently was hitting into the wall with unresponsiveness in association with this.  There was no head trauma, but apparently she was doing that many times and there was no responsiveness.  The patient has no memory of the event.  She is now back to her baseline.  She states her seizures are worse in the setting of stress, but it is not clear to her why this has occurred.  She is on Carbatrol 300 mg b.i.d. and she has been very compliant and without any problems.  The patient is admitted for EMU monitoring for the characterization of these episodes and for the possibility of complex partial epilepsy syndrome or better characterization of this current syndrome.,PAST MEDICAL HISTORY:  ,Include dyslipidemia and hypertension.,FAMILY HISTORY:  ,Positive for stroke and sleep apnea.,SOCIAL HISTORY: , No smoking or drinking.  No drugs.,MEDICATIONS AT HOME: , Include, Avapro, lisinopril, and dyslipidemia medication, she does not remember.,REVIEW OF SYSTEMS:,  The patient does complain of gasping for air, witnessed apneas, and dry mouth in the morning.  The patient also has excessive daytime sleepiness with EDS of 16.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Last blood pressure 130/85, respirations 20, and pulse 70.,GENERAL:  Normal.,NEUROLOGICAL:  As follows.  Right-handed female, normal orientation, normal recollection to 3 objects.  The patient has underlying MR. Speech, no aphasia, no dysarthria.  Cranial nerves, funduscopic intact without papilledema.  Pupils are equal, round, and reactive to light.  Extraocular movements intact.  No nystagmus.  Her mood is intact.  Symmetric face sensation.  Symmetric smile and forehead.  Intact hearing.  Symmetric palate elevation.  Symmetric shoulder shrug and tongue midline.  Motor 5/5 proximal and distal.  The patient does have limp on the right lower extremity.  Her Babinski is hyperactive on the left lower extremity, upgoing toes on the left.  Sensory, the patient does have sharp, soft touch, vibration intact and symmetric.  The patient has trouble with ambulation.  She does have ataxia and uses a walker to ambulate.  There is no bradykinesia.  Romberg is positive to the left.  Cerebellar, finger-nose-finger is intact.  Rapid alternating movements are intact.  Upper airway examination, the patient has a Friedman tongue position with 4 oropharyngeal crowding.  Neck more than 16 to 17 inches, BMI elevated above 33.  Head and neck circumference very high.,IMPRESSION:,1.  Cerebral palsy, worsening seizures.,2.  Hypertension.,3.  Dyslipidemia.,4.  Obstructive sleep apnea.,5.  Obesity.,RECOMMENDATIONS:,1.  Admission to the EMU, drop her Carbatrol 200 b.i.d., monitor for any epileptiform activity.  Initial time of admission is 3 nights and 3 days.,2.  Outpatient polysomnogram to evaluate for obstructive sleep apnea followed by depression if clinically indicated.  Continue her other medications.,3.  Consult Dr. X for hypertension, internal medicine management.,4.  I will follow this patient per EMU protocol.", 
" Biparietal craniotomy, insertion of left lateral ventriculostomy, right suboccipital craniectomy and excision of tumor.", Neurology, Craniotomy - Biparietal  ,"PREOPERATIVE DIAGNOSES: , Multiple metastatic lesions to the brain, a subtentorial lesion on the left, greater than 3 cm, and an infratentorial lesion on the right, greater than 3 cm.,POSTOPERATIVE DIAGNOSES: , Multiple metastatic lesions to the brain, a subtentorial lesion on the left, greater than 3 cm, and an infratentorial lesion on the right, greater than 3 cm.,TITLE OF THE OPERATION:,1.  Biparietal craniotomy and excision of left parietooccipital metastasis from breast cancer.,2.  Insertion of left lateral ventriculostomy under Stealth stereotactic guidance.,3.  Right suboccipital craniectomy and excision of tumor.,4.  Microtechniques for all the above.,5.  Stealth stereotactic guidance for all of the above and intraoperative ultrasound.,INDICATIONS: , The patient is a 48-year-old woman with a diagnosis of breast cancer made five years ago.  A year ago, she was diagnosed with cranial metastases and underwent whole brain radiation.  She recently has deteriorated such that she came to my office, unable to ambulate in a wheelchair.  Metastatic workup does reveal multiple bone metastases, but no spinal cord compression.  She had a consult with Radiation-Oncology that decided they could radiate her metastases less than 3 cm with stereotactic radiosurgery, but the lesions greater than 3 cm needed to be removed.  Consequently, this operation is performed.,PROCEDURE IN DETAIL: , The patient underwent a planning MRI scan with Stealth protocol.  She was brought to the operating room with fiducial still on her scalp.  General endotracheal anesthesia was obtained.  She was placed on the Mayfield head holder and rolled into the prone position.  She was well padded, secured, and so forth.  The neck was flexed so as to expose the right suboccipital region as well as the left and right parietooccipital regions.  The posterior aspect of the calvarium was shaved and prepared in the usual manner with Betadine soak scrub followed by Betadine paint.  This was done only, of course, after fiducial were registered in planning and an excellent accuracy was obtained with the Stealth system.  Sterile drapes were applied and the accuracy of the system was confirmed.  A biparietal incision was performed.  A linear incision was chosen so as to increase her chances of successful wound healing and that she is status post whole brain radiation.  A biparietal craniotomy was carried out, carrying about 1 cm over toward the right side and about 4 cm over to the left side as guided by the Stealth stereotactic system.  The dura was opened and reflected back to the midline.  An inner hemispheric approach was used to reach the very large metastatic tumor.  This was very delicate removing the tumor and the co-surgeons switched off to spare one another during the more delicate parts of the operation to remove the tumor.  The tumor was wrapped around and included the choroidal vessels.  At least one choroidal vessel was sacrificed in order to obtain a gross total excision of the tumor on the parietal occipital region.  Bleeding was quite vigorous in some of the arteries and finally, however, was completely controlled.  Complete removal of the tumor was confirmed by intraoperative ultrasound.,Once the tumor had been removed and meticulous hemostasis was obtained, this wound was left opened and attention was turned to the right suboccipital area.  A linear incision was made just lateral to the greater occipital nerve.  Sharp dissection was carried down in the subcutaneous tissues and Bovie electrocautery was used to reach the skull.  A burr hole was placed down low using a craniotome.  A craniotomy was turned and then enlarged as a craniectomy to at least 4 cm in diameter.  It was carried caudally to the floor of the posterior fossa and rostrally to the transverse sinus.  Stealth and ultrasound were used to localize the very large tumor that was within the horizontal hemisphere of the cerebellum.  The ventriculostomy had been placed on the left side with the craniotomy and removal of the tumor, and this was draining CSF relieving pressure in the posterior fossa.  Upon opening the craniotomy in the parietal occipital region, the brain was noted to be extremely tight, thus necessitating placement of the ventriculostomy.,At the posterior fossa, a corticectomy was accomplished and the tumor was countered directly.  The tumor, as the one above, was removed, both piecemeal and with intraoperative Cavitron Ultrasonic Aspirator.  A gross total excision of this tumor was obtained as well.,I then explored underneath the cerebellum in hopes of finding another metastasis in the CP angle; however, this was just over the lower cranial nerves, and rather than risk paralysis of pharyngeal muscles and voice as well as possibly hearing loss, this lesion was left alone and to be radiated and that it is less than 3 cm in diameter.,Meticulous hemostasis was obtained for this wound as well.,The posterior fossa wound was then closed in layers.  The dura was closed with interrupted and running mattress of 4-0 Nurolon.  The dura was watertight, and it was covered with blue glue.  Gelfoam was placed over the dural closure.  Then, the muscle and fascia were closed in individual layers using #0 Ethibond.  Subcutaneous was closed with interrupted inverted 2-0 and 0 Vicryl, and the skin was closed with running locking 3-0 Nylon.,For the cranial incision, the ventriculostomy was brought out through a separate stab wound.  The bone flap was brought on to the field.  The dura was closed with running and interrupted 4-0 Nurolon.  At the beginning of the case, dural tack-ups had been made and these were still in place.  The sinuses, both the transverse sinus and sagittal sinus, were covered with thrombin-soaked Gelfoam to take care of any small bleeding areas in the sinuses.,Once the dura was closed, the bone flap was returned to the wound and held in place with the Lorenz microplates.  The wound was then closed in layers.  The galea was closed with multiple sutures of interrupted 2-0 Vicryl.  The skin was closed with a running locking 3-0 Nylon.,Estimated blood loss for the case was more than 1 L.  The patient received 2 units of packed red cells during the case as well as more than 1 L of Hespan and almost 3 L of crystalloid.,Nevertheless, her vitals remained stable throughout the case, and we hopefully helped her survival and her long-term neurologic status for this really nice lady.","neurology, metastatic lesion, biparietal, mayfield head holder, microtechniques, stealth, craniotomy, excision, fiducial, infratentorial, parietooccipital, stereotactic, suboccipital, subtentorial, ventriculostomy, lesions to the brain, removal of the tumor, parietal occipital region, running locking nylon, biparietal craniotomy, posterior fossa, tumor, brain, dura, lesions, "
" The patient is a 36-year-old female with past medical history of migraine headaches, who was brought to the ER after she was having uncontrolled headaches.  In the ER, the patient had a CT scan done, which was reported negative, and lumbar puncture with normal pressure and the cell count, and was admitted for followup.", Neurology, Consult - Migraine ,"HISTORY OF PRESENT ILLNESS: , The patient is a 36-year-old female with past medical history of migraine headaches, who was brought to the ER after she was having uncontrolled headaches.  In the ER, the patient had a CT scan done, which was reported negative, and lumbar puncture with normal pressure and the cell count, and was admitted for followup.  Neurology consult was called to evaluate the patient in view of the current symptomatology.  The headaches were refractory to the treatment.  The patient has been on Topamax and Maxalt in the past, but did not work and according to the patient she got more confused.,PAST MEDICAL HISTORY: , History of migraine.,PAST SURGICAL HISTORY:  ,Significant for partial oophorectomy, appendectomy, and abdominoplasty.,SOCIAL HISTORY:  ,No history of any smoking, alcohol, or drug abuse.  The patient is a registered nurse by profession.,MEDICATIONS: , Currently taking no medication.,ALLERGIES: , No known allergies.,FAMILY HISTORY:,  Nothing significant.,REVIEW OF SYSTEMS: , The patient was considered to ask systemic review including neurology, psychiatry, sleep, ENT, ophthalmology, pulmonary, cardiology, gastroenterology, genitourinary, hematology, rheumatology, dermatology, allergy, immunology, endocrinology, toxicology, oncology, and was found to be positive for the symptoms mentioned in the history of the presenting illness.,PHYSICAL EXAMINATION,VITAL SIGNS:  Blood pressure of 115/66, heart rate of 69, respiratory rate of 13, temperature normal, and pulse oximetry 98% on room air at the time of initial evaluation.,HEENT:  Head, normocephalic, atraumatic.  Neck supple.  Throat clear.  No discharge from the ears or nose.  No discoloration of conjunctivae and sclerae.  No bruits auscultated over temple, orbits, or the neck.,LUNGS:  Clear to auscultation.,CARDIOVASCULAR:  Normal heart sounds.,ABDOMEN:  Benign.,EXTREMITIES:  No edema, clubbing or cyanosis.,SKIN:  No rash.  No neurocutaneous disorder.,MENTAL STATUS:  The patient is awake, alert and oriented to place and person.  Speech is fluent.  No language deficits.  Mood normal.  Affect is clear.  Memory and insight is normal.  No abnormality with thought processing and thought content.  Cranial nerve examination intact II through XII.  Motor examination:  Normal bulk, tone and power.  Deep tendon reflexes symmetrical.  Downgoing toes.  No sign of any myelopathy.  Cortical sensation intact.  Peripheral sensation grossly intact.  Vibratory sense not tested.  Gait not tested.  Coordination is normal with no dysmetria.,IMPRESSION: , Intractable headaches, by description to be migraines.  Complicated migraines by clinical criteria.  Rule out sinusitis.  Rule out vasculitis including temporal and arthritis, lupus, polyarthritis, moyamoya disease, Takayasu and Kawasaki disease.,PLAN AND RECOMMENDATIONS: , The patient to be given a trial of the prednisone with a plan to taper off in 6 days, as she already had received 50 mg today.  Depakote as a part of migraine prophylaxis and Fioricet on p.r.n. basis.,The patient to get vasculitis workup, as it has not been ordered by the primary care physician initially.  The patient already had MRI of the brain and the cervical spine.  MRI of the brain reported negative and cervical spine as shown signs of disk protrusion at C5 and C6 level, which will not explain of the temporal headache.  Plan and followup discussed with the patient in detail.",
" Right frontotemporal craniotomy and evacuation of hematoma, biopsy of membranes, microtechniques.", Neurology, Craniotomy - Frontotemporal  ,"PREOPERATIVE DIAGNOSIS:,  Right frontotemporal chronic subacute subdural hematoma.,POSTOPERATIVE DIAGNOSIS:,  Right frontotemporal chronic subacute subdural hematoma.,TITLE OF THE OPERATION: , Right frontotemporal craniotomy and evacuation of hematoma, biopsy of membranes, microtechniques.,ASSISTANT: , None.,INDICATIONS: , The patient is a 75-year-old man with a 6-week history of decline following a head injury.  He was rendered unconscious by the head injury.  He underwent an extensive syncopal workup in Mississippi.  This workup was negative.  The patient does indeed have a heart pacemaker.  The patient was admitted to ABCD three days ago and yesterday underwent a CT scan, which showed a large appearance of subdural hematoma.  There is a history of some bladder tumors and so a scan with contrast was obtained that showed some enhancement in the membranes.  I decided to perform a craniotomy rather than burr hole drainage because of the enhancing membranes and the history of a bladder tumor undefined as well as layering of the blood within the cavity.  The patient and the family understood the nature, indications, and risk of the surgery and agreed to go ahead.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room where general and endotracheal anesthesia was obtained.  The head was turned over to the left side and was supported on a cushion.  There was a roll beneath the right shoulder.  The right calvarium was shaved and prepared in the usual manner with Betadine-soaked scrub followed by Betadine paint.  Markings were applied.  Sterile drapes were applied.  A linear incision was made more or less along the coronal suture extending from just above the ear up to near the midline.  Sharp dissection was carried down into subcutaneous tissue and Bovie electrocautery was used to divide the galea and the temporalis muscle and fascia.  Weitlaner retractors were inserted.  A single bur hole was placed underneath the temporalis muscle.  I placed the craniotomy a bit low in order to have better cosmesis.  A cookie cutter type craniotomy was then carried out in dimensions about 5 cm x 4 cm.  The bone was set aside.  The dura was clearly discolored and very tense.  The dura was opened in a cruciate fashion with a #15 blade.  There was immediate flow of a thin motor oil fluid under high pressure.  Literally the fluid shot out several inches with the first nick in the membranous cavity.  The dura was reflected back and biopsy of the membranes was taken and sent for permanent section.  The margins of the membrane were coagulated.  The microscope was brought in and it was apparent there were septations within the cavity and these septations were for the most part divided with bipolar electrocautery.  The wound was irrigated thoroughly and was inspected carefully for any sites of bleeding and there were none.  The dura was then closed in a watertight fashion using running locking 4-0 Nurolon.  Tack-up sutures had been placed at the beginning of the case and the bone flap was returned to the wound and fixed to the skull using the Lorenz plating system.  The wound was irrigated thoroughly once more and was closed in layers.  Muscle fascia and galea were closed in separate layers with interrupted inverted 2-0 Vicryl.  Finally, the skin was closed with running locking 3-0 nylon.,Estimated blood loss for the case was less than 30 mL.  Sponge and needle counts were correct.,FINDINGS: , Chronic subdural hematoma with multiple septations and thickened subdural membrane.,I might add that the arachnoid was not violated at all during this procedure.  Also, it was noted that there was no subarachnoid blood but only subdural blood.","neurology, frontotemporal, weitlaner, calvarium, cookie cutter type, craniotomy, dura, frontotemporal craniotomy, galea, hematoma, subdural, subdural hematoma, syncopal, temporalis, subacute subdural hematoma, temporalis muscle,"
 The patient is an 84-year-old man who returns for revaluation of possible idiopathic normal pressure hydrocephalus., Neurology, Consult - Normal Pressure Hydrocephalus ,"REASON FOR VISIT: , The patient is an 84-year-old man who returns for revaluation of possible idiopathic normal pressure hydrocephalus.  He is accompanied by his wife and daughter.,HISTORY OF PRESENT ILLNESS:,  I first saw him nearly a year ago on December 20, 2007.  At that time, he had had a traumatic deterioration over the course of approximately eight months.  This included severe cognitive impairment, gait impairment, and incontinence.  He had actually been evaluated at Hospital with CSF drainage via a temporary spinal catheter, but there was no response that was noted.  When I saw him, there were findings consistent with cervical stenosis and I ordered an MRI scan of the cervical spine.  I subsequently referred him to Dr. X, who performed a cervical laminectomy and instrumented fusion on July 16, 2008.  According to his notes this went well.,According to the family, there has not been any improvement.,With regard to the gait and balance, they actually think that he is worse now than he was a year ago.  He is virtually unable to walk at all.  He needs both a walker and support from an assistant to be able to stand or walk.  Therefore, he is always in the wheelchair.,He is completely incontinent.  He never indicates his need to the go to the bathroom.  On the other hand when asked, he will indicate that he needs to go.  He wears a Depends undergarment all the time.,He has no headaches.,His thinking and memory are worse.  For the most part, he is apathetic.  He does not talk very much.  He lives in a skilled nursing facility in the Alzheimer's section.  He does have some daytime activities.  He takes a nap once a day.  He does not read very much.  On the other hand, he did recently exercise the right to vote in the presidential election.  He needs full assistance at the nursing home.,MEDICATIONS:,  From the list by the nursing home are Aricept 10 mg in the evening, carbidopa/levodopa 25/100 mg three times a day, citalopram (Celexa) 40 mg daily, Colace 100 mg twice a day, finasteride (Proscar) 5 mg once a day, Flomax (tamsulosin) 0.4 mg once a day, multivitamin with iron once a day, omeprazole (Prilosec) 20 mg once a day, senna 8.6 mg twice a day, Tylenol 650 mg as needed, and promethazine 25 mg as needed.,PHYSICAL EXAM: , On examination today, this is a pleasant 81-year-old man who is brought back from the clinic waiting area in a wheelchair.  He is well developed, well nourished, and kempt.,Vital Signs:  Temperature 96.7, pulse 62, respirations 16, and blood pressure 123/71.,Head:  The head is normocephalic and atraumatic.,Mental Status:  Assessed for orientation, recent and remote memory, attention span, concentration, language, and fund of knowledge.  The Mini-Mental State Exam score was 14/30.  He was not at all oriented.  He did know we were at Sinai Hospital on the second floor.  He could spell 'world' forward, but was mute when asked to spell backwards.  He was mute when asked to recall 3/3 objects for delayed recall.  He could not copy a diagram of intersecting pentagons.  For comparison, the Mini-Mental State exam score last December was 20/30 when attention was tested by having him spell 'world' backwards and 28/30 when tested with serial 7 subtractions.  Additionally, there are times when he stutters or stammers.  I do not see any paraphasic errors.  There is some evidence of ideomotor apraxia.  He is also stimulus bound.  There is a tendency to mimic.,Cranial Nerve Exam:  There is no upgaze that I can elicit today.  The horizontal gaze and down gaze are intact.  This is a change from a year ago.  The muscles of facial expiration are intact as are hearing, head turning, cough, tongue, and palate movement.,Motor Exam:  Normal bulk and strength.  The tone is characterized by paratonia.  There is no atrophy, fasciculations, drift, or tremor.,Sensory Exam:  Intact to light touch.,Cerebellar Exam:  Intact for finger-to-nose testing that he can perform only by mimicking, but not by following verbal commands.,Gait:  Severely impaired.  When in the wheelchair, he leans to one side.  He cannot getup on his own.  He needs assistance.  Once up, he can bear weight, but cannot maintain his balance.  This would amount to a Tinetti score of zero.,REVIEW OF X-RAYS: , I personally reviewed the CT scan of the brain from November 1, 2008 and compared it to the MRI scan from a year ago.  The ventricles appear larger to me now in comparison to a year ago.  The frontal horn span is now 6 cm, whereas previously it was about 5.5 cm.  The 3rd ventricular span is about 15 mm.  There is no obvious atrophy, although there may be some subtle bilateral perisylvian atrophy.  The scan from a year ago showed that there was a patent sylvian aqueduct.,ASSESSMENT:,  The patient has had worsening of his gait, his dementia, and his incontinence.  The new finding for me today is the limited upgaze.  This would be consistent either with progressive supranuclear palsy, which was one of the differential diagnoses a year ago, or it could be consistent with progressive enlargement of the ventricles.,PROBLEMS/DIAGNOSES:,1.  Question of idiopathic normal pressure hydrocephalus (331.5).,2.  Possible supranuclear palsy.,3.  Severe gait impairment.,4.  Urinary urgency and incontinence.,5.  Dementia.,PLAN: , I had a long talk with him and his family.  Even though he has already had a trial of CSF drainage via spinal catheter at Hospital over a year ago, I offered this test to them again.  I do so on the basis that there is further enlargement of the ventricles on the scan.  His family and I discussed the facts that it is not likely to be only hydrocephalus.  Instead we are trying to answer the question of whether hydrocephalus is contributing sufficiently to his symptoms that progressing with shunt surgery would make a difference.  I have advised them to think it over for a day and contact my office to see whether they would wish to proceed.  I gave them a printed prescription of the protocol including its rationale, risks, benefits, and alternatives.  I specifically mentioned the 3% chance of infection, which mean a 97% chance of no infection.",
 Right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain., Neurology, Craniotomy - Burr Hole  ,"PREOPERATIVE DIAGNOSIS: , Right chronic subdural hematoma.,POSTOPERATIVE DIAGNOSIS: ,Right chronic subdural hematoma.,TYPE OF OPERATION: , Right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , 100 cc.,OPERATIVE PROCEDURE:,  In preoperative identification, the patient was taken to the operating room and placed in supine position.  Following induction of satisfactory general endotracheal anesthesia, the patient was prepared for surgery.  Table was turned.  The right shoulder roll was placed.  The head was turned to the left and rested on a doughnut.  The scalp was shaved, and then prepped and draped in usual sterile fashion.  Incisions were marked along a putative right frontotemporal craniotomy frontally and over the parietal boss.  The parietal boss incision was opened.  It was about an inch and a half in length.  It was carried down to the skull.  Self-retaining retractor was placed.  A bur hole was now fashioned with the perforator.  This was widened with a 2-mm Kerrison punch.  The dura was now coagulated with bipolar electrocautery.  It was opened in a cruciate-type fashion.  The dural edges were coagulated back to the bony edges.  There was egress of a large amount of liquid.  Under pressure, we irrigated for quite sometime until irrigation was returning mostly clear.  A subdural drain was now inserted under direct vision into the subdural space and brought out through a separate stab incision.  It was secured with a 3-0 nylon suture.  The area was closed with interrupted inverted 2-0 Vicryl sutures.  The skin was closed with staples.  Sterile dressing was applied.  The patient was subsequently returned back to anesthesia.  He was extubated in the operating room, and transported to PACU in satisfactory condition.","neurology, hematoma, burr hole, craniotomy, frontotemporal, frontotemporal craniotomy, subdural, subdural drain, subdural hematoma, subdural space"
" Patient with a history of mesothelioma and likely mild dementia, most likely Alzheimer type.", Neurology, Consult - Alzheimer disease  ,"The patient states that she has been doing fairly well at home.  She balances her own checkbook.  She does not do her own taxes, but she has never done so in the past.  She states that she has no problems with cooking meals, getting her own meals, and she is still currently driving.  She denies burning any dishes because she forgot them on the stove or forgetting what she is doing in the middle of a task or getting lost while she is driving around or getting lost in her own home.  She states that she is very good remembering the names of her family members and does not forget important birthdays such as the date of birth of her grandchildren.  She is unfortunately living alone, and although she seems to miss her grandchildren and is estranged from her son, she denies any symptoms of frank depression.  There is unfortunately no one available to us to corroborate how well she is doing at home.  She lives alone and takes care of herself and does not communicate very much with her brother and sister.  She also does not communicate very much with her son who lives in Santa Cruz or her grandchildren.  She denied any sort of personality change, paranoid ideas or hallucinations.  She does appear to have headaches that can be severe about four times a month and have primarily photophobia and some nausea and occasionally emesis associated with it.  When these headaches are very severe, she goes to the emergency room to get a single shot.  She is unclear if this is some sort of a migraine medication or just a primary pain medication.  She takes Fiorinal for these headaches and she states that this helps greatly.  She denies visual or migraine symptoms.,REVIEW OF SYSTEMS: , Negative for any sort of focal neurologic deficits such as weakness, numbness, visual changes, dysarthria, diplopia or dysphagia.  She also denies any sort of movement disorders, tremors, rigidities or clonus.  Her personal opinion is that some of her memory problems may be due to simply to her age and/or nervousness.  She is unclear as if her memory is any worse than anyone else in her age group.,PAST MEDICAL HISTORY: , Significant for mesothelioma, which was diagnosed seemingly more than 20 to 25 years ago.  The patient was not sure of exactly when it was diagnosed.  This has been treated surgically by debulking operations for which she states that she has undergone about 10 operations.  The mesothelioma is in her abdomen.  She does not know of any history of having lung mesothelioma.  She states that she has never gotten chemotherapy or radiation for her mesothelioma.  Furthermore, she states that her last surgical debulking was more than 10 years ago and her disease has been fairly stable.  She does have a history of three car accidents that she says were all rear-enders where she was hit while essentially in a stopped position.  These have all occurred over the past five years.  She also has a diagnosis of dementing illness, possibly Alzheimer disease from her previous neurology consultation.  This diagnosis was given in March 2006.,MEDICATIONS:,  Fiorinal, p.r.n. aspirin, unclear if baby or full sized, Premarin unclear of the dose.,ALLERGIES:, NONE.,SOCIAL HISTORY:,  Significant for her being without a companion at this point.  She was born in Munich, Germany.  She immigrated to of America in 1957 after her family had to move to Eastern Germany, which was under Russian occupation at that time.  She is divorced.  She used to work as a secretary and later worked as a clerical worker at IBM.  She stopped working more than 20 years ago due to complications from her mesothelioma.  She denies any significant tobacco, alcohol or illicit drugs.  She is bilingual speaking, German and English.  She has known English from before her teens.  She has the equivalent of a high school education in Germany.  She has one brother and one sister, both of whom are healthy and she does not spend much time communicating with them.  She has one son who lives in Santa Cruz.  He has grandchildren.  She is trying to contact with her grandchildren.,FAMILY HISTORY: , Significant for lung, liver, and prostate cancer.  Her mother died in her 80s of ""old age,"" but it appears that she may have had a mild dementing illness at that time.  Whatever that dementing illness was, appears to have started mostly in her 80s per the patient.  No one else appears to have Alzheimer disease including her brother and sister.,PHYSICAL EXAMINATION: , Her blood pressure is 152/92, pulse 80, and weight 80.7 kg.  She is alert and well nourished in no apparent distress.  She occasionally fumbles with questions of orientation, missing the day and the date.  She also did not know the name of the hospital, she thought it was O'Connor and she thought she was in Orange County and also did not know the floor of the hospital that we are in.  She lost three points for recall.  Even with prompting, she could not remember the objects that she was given to remember.  Her Mini Mental Score was 22/30.  There were no naming problems or problems with repetition.  There were also no signs of dysarthria.  Her pupils were bilaterally reactive to light and accommodation.  Her extraocular movements were intact.  Her visual fields were full to confrontation.  Her sensations of her face, arm, and leg were normal.  There were no signs of neglect with double simultaneous stimulation.  Tongue was midline.  Her palate was symmetric.  Her face was symmetric as well.  Strength was approximately 5/5.  She did have some right knee pain and she had a mildly antalgic gait due to her right knee pain.  Her reflexes were symmetric and +2 except for her toes, which were +1 to trace.  Her plantar reflexes were mute.  Her sensation was normal for pain, temperature, and vibration.  There were no signs of ataxia on finger-to-nose and there was no dysdiadochokinesia.  Gait was narrow and she could toe walk briefly and heel walk without difficulty.,SUMMARY:,  Ms. A is a pleasant 72-year-old right-handed woman with a history of mesothelioma that appears stable at this time and likely mild dementia, most likely Alzheimer type.  We tactfully discussed the patient's diagnosis with her, and she felt reassured.  We told her that this most likely was in the earlier stages of disease and she would benefit from trying Aricept.  She stated that she did not have the prescription anymore from her outpatient neurology consult for the Aricept, so we wrote her another prescription for Aricept.  The patient herself seemed very concerned about the stigma of the disease, but our lengthy discussion, expressed genuine understanding as to why her outpatient physician had reported her to DMV.  It was explicitly told to not drive by her outpatient neurologist and we concur with this assessment.  She will follow up with us in the next six months and will call us if she has any problems with the Aricept.  She was written for Aricept to start at 5 mg for three weeks, and if she has no side effects which typically are GI side effects, then she can go up to 10 mg a day.  We also reviewed with Ms. A the findings for outpatient MRI, which showed some mild atrophy per report and also that her metabolic workup, which included an RPR, TSH, and B12 were all within normal limits.,","neurology, neurology consultation, dementing illness, alzheimer disease, dementia, alzheimer, mesothelioma,"
 Patient with a history of right upper pons and right cerebral peduncle infarction., Neurology, Consult - Cerebral Peduncle Infarction ,"FAMILY HISTORY AND SOCIAL HISTORY:,  Reviewed and remained unchanged.,MEDICATIONS:,  List remained unchanged including Plavix, aspirin, levothyroxine, lisinopril, hydrochlorothiazide, Lasix, insulin and simvastatin.,ALLERGIES:,  She has no known drug allergies.,FALL RISK ASSESSMENT: , Completed and there was no history of falls.,REVIEW OF SYSTEMS:  ,Full review of systems again was pertinent for shortness of breath, lack of energy, diabetes, hypothyroidism, weakness, numbness and joint pain.  Rest of them was negative.,PHYSICAL EXAMINATION:,Vital Signs:  Today, blood pressure was 170/66, heart rate was 66, respiratory rate was 16, she weighed 254 pounds as stated, and temperature was 98.0.,General:  She was a pleasant person in no acute distress.,HEENT:  Normocephalic and atraumatic.  No dry mouth.  No palpable cervical lymph nodes.  Her conjunctivae and sclerae were clear.,NEUROLOGICAL EXAMINATION:,  Remained unchanged.,Mental Status:  Normal.,Cranial Nerves:  Mild decrease in the left nasolabial fold.,Motor:  There was mild increased tone in the left upper extremity.  Deltoids showed 5-/5.  The rest showed full strength.  Hip flexion again was 5-/5 on the left.  The rest showed full strength.,Reflexes:  Reflexes were hypoactive and symmetrical.,Gait:  She was mildly abnormal.  No ataxia noted.  Wide-based, ambulated with a cane.,IMPRESSION: , Status post cerebrovascular accident involving the right upper pons extending into the right cerebral peduncle with a mild left hemiparesis, has been clinically stable with mild improvement.  She is planned for surgical intervention for the internal carotid artery.,RECOMMENDATIONS: , At this time, again we discussed continued use of antiplatelet therapy and statin therapy to reduce her risk of future strokes.  She will continue to follow with endocrinology for diabetes and thyroid problems.  I have recommended a strict control of her blood sugar, optimizing cholesterol and blood pressure control, regular exercise and healthy diet and I have discussed with Ms. A and her daughter to give us a call for post surgical recovery.  I will see her back in about four months or sooner if needed.","neurology, internal carotid artery, cerebral peduncle infarction, carotid artery, blood pressure, upper pons, infarction, cerebral, peduncle, "
" The patient had several episodes where she felt like her face was going to twitch, which she could suppress it with grimacing movements of her mouth and face.", Neurology, Consult - Facial Twitching ,"REASON FOR REFERRAL: , Facial twitching.,HISTORY OF PRESENT ILLNESS: , The patient had several episodes where she felt like her face was going to twitch, which she could suppress it with grimacing movements of her mouth and face.  She reports she is still having right posterior head pressure like sensations approximately one time per week.  These still are characterized by a tingling, pressure like sensation that often has a feeling as though water is running down on her hair.  This has also decreased in frequency occurring approximately one time per week and seems to respond to over-the-counter analgesics such as Aleve.  Lastly during conversation today, she brought again the problem of daydreaming at work and noted that she occasionally falls asleep when sitting in non-stimulating environments or in front of the television.  She states that she feels fatigued all the time and does not get good sleep.  She describes it as insomnia, but upon questioning she works from 4 till mid night and then gets home and cannot go to sleep for approximately two hours and wakes up reliably by 9.00 a.m. each morning and sleeps no more than five to six hours ever, but usually five hours.  Her sleep is relatively uninterrupted except for the need to get up and go to the bathroom.  She thinks she may snore, but she is not sure.  She does not recall any events of awakening and gasping for breath.,PAST MEDICAL HISTORY: , Please see my earlier notes in chart.,FAMILY HISTORY:  ,Please see my earlier notes in chart.,SOCIAL HISTORY: , Please see my earlier notes in charts.,REVIEW OF SYSTEMS:  ,Today, she mainly endorses the tingling sensation in the right posterior head often bilateral as well as a diagnosis of depression and persistent somewhat sad mood, poor sleep, and possible snoring; otherwise, the 10-system review is negative.,PHYSICAL EXAMINATION:,General Examination:  Unremarkable mainly for mild-to-moderate obesity with a weight of 258 pounds.  Otherwise, general examination is unremarkable.,NEUROLOGICAL EXAMINATION:  ,As before is nonfocal.  Please see note in chart for details.,PERTINENT FINDINGS: , Since the last evaluation, she has had an MRI performed, which was largely unremarkable except for a 1.2 cm lobular T2 hyperintense abnormality at the right clivus and petrous carotid canal, which does not enhance.  The nature of this lesion is unclear.  Certainly, this abnormality would not explain her left facial twitching and is unlikely to be involved with the right posterior sensory changes she experiences.,LABS: , She was supposed to have Lyme titers and thyroid tests as well as fasting glucose, which were not done; however, in light of her improvement these may not need to be performed at this time.,IMPRESSION:,1.  Left facial twitching-appears to be improving.  Most likely, this is a peripheral nerve injury related to her abscess as previously described.  In light of her negative MRI and clinical improvement, we discussed options and elected to just observe for now.,2.  Posterior pressure like headache, also appears to be improving.  The etiology is unclear, but as it responds nicely to nonsteroidal antiinflammatories and is decreasing, no further evaluation is needed.,3.  Probable circadian sleep disorder related to her nighttime work schedule and awakening at 9.00 a.m. with insufficient sleep.  There is also the possibility of consistent obstructive sleep apnea and if symptoms worsen then we should consider doing a sleep study.  For the time being, sleep hygiene measures were discussed with the patient including trying to sleep later at least till 10.00 a.m. or 10.30 to get a full-night sleep.  She is on vacation next week and is going to try to see if this will help.  We also discussed as before weight loss and exercise, which could be helpful.,4.  Right clivus and petrous lesion of unknown etiology.  We will repeat the MRI at four months to see for interval change.,5.  The patient voiced understanding of these plans and will be following up with me in five months.","neurology, grimacing, headache, clivus and petrous, facial twitching, sleep, facial, twitching, "
 Chest CT - Thymoma and history of ocular myasthenia gravis., Neurology, Chest CT - Myasthenia Gravis ,"CC:, Intermittent binocular horizontal, vertical, and torsional diplopia.,HX: ,70y/o RHM referred by Neuro-ophthalmology for evaluation of neuromuscular disease. In 7/91, he began experiencing intermittent binocular horizontal, vertical and torsional diplopia which was worse and frequent at the end of the day, and was eliminated when closing one either eye. An MRI Brain scan at that time was unremarkable. He was seen at UIHC Strabismus Clinic in 5/93 for these symptoms. On exam, he was found to have intermittent right hypertropia in primary gaze, and consistent diplopia in downward and rightward gaze. This was felt to possibly represent Grave's disease. Thyroid function studies were unremarkable, but orbital echography suggested Graves orbitopathy. The patient was then seen in the Neuro-ophthalmology clinic on 12/23/92. His exam remained unchanged. He underwent Tensilon testing which was unremarkable. On 1/13/93, he was seen again in Neuro-ophthalmology. His exam remained relatively unchanged and repeat Tensilon testing was unremarkable. He then underwent a partial superior rectus resection, OD, with only mild improvement of his diplopia. During his 8/27/96 Neuro-ophthalmology clinic visit he was noted to have hypertropia OD with left pseudogaze palsy and a right ptosis. The ptosis improved upon administration of Tensilon and he was placed on Mestinon 30mg tid. His diplopia subsequently improved, but did not resolve. The dosage was increased to 60mg tid and his diplopia worsened and the dose decreased back to 30mg tid. At present he denied any fatigue on repetitive movement. He denied dysphagia, SOB, dysarthria, facial weakness, fevers, chills, night sweats, weight loss or muscle atrophy.,MEDS: , Viokase, Probenecid, Mestinon 30mg tid.,PMH:, 1) Gastric ulcer 30 years ago, 2) Cholecystectomy, 3) Pancreatic insufficiency, 4) Gout, 5) Diplopia.,FHX:, Mother died age 89 of ""old age."" Father died age 89 of stroke. Brother, age 74 with CAD, Sister died age 30 of cancer.,SHX:, Retired insurance salesman and denies history of tobacco or illicit drug us. He has no h/o ETOH abuse and does not drink at present.,EXAM: ,BP 155/104.  HR 92. RR 12.  Temp 34.6C. WT 76.2kg.,MS: Unremarkable. Normal speech with no dysarthria.,CN: Right hypertropia (worse on rightward gaze and less on leftward gaze). Minimal to no ptosis, OD. No ptosis, OS. VFFTC. No complaint of diplopia. The rest of the CN exam was unremarkable.,MOTOR: 5/5 strength throughout with normal muscle bulk and tone.,SENSORY: No deficits appreciated on PP/VIB/LT/PROP/TEMP testing.,Coordination/Station/Gait: Unremarkable.,Reflexes: 2/2 throughout. Plantar responses were flexor on the right and withdrawal on the left.,HEENT and GEN EXAM: Unremarkable.,COURSE:, EMG/NCV, 9/26/96: Repetitive stimulation studies of the median, facial, and spinal accessory nerves showed no evidence of decrement at baseline, and at intervals up to 3 minutes following exercise. The patient had been off Mestinon for 8 hours prior to testing. Chest CT with contrast, 9/26/96, revealed a 4x2.5x4cm centrally calcified soft tissue anterior mediastinal mass adjacent to the aortic arch. This was highly suggestive of a thymoma. There were diffuse emphysematous disease with scarring in the lung bases. A few nodules suggestive of granulomas and few calcified perihilar lymph nodes. He underwent thoracotomy and resection of the mass. Pathologic analysis was consistent with a thymoma, lymphocyte predominant type, with capsular and pleural invasion, and extension to the phrenic nerve resection margin. Acetylcholine Receptor-binding antibody titer 12.8nmol/L (normal<0.7), Acetylcholine receptor blocking antibody <10% (normal), Acetylcholine receptor modulating antibody 42% (normal<19), Striated muscle antibody 1:320 (normal<1:10). Striated muscle antibody titers tend to be elevated in myasthenia gravis associated with thymoma. He was subsequently treated with XRT and continued to complain of fatigue at his 4/18/97 Oncology visit.","neurology, diplopia, neuromuscular disease, muscle antibody titers, chest ct, intermittent binocular, rightward gaze, striated muscle, myasthenia gravis, intermittent, torsional, binocular, myasthenia, chest, thymoma, ophthalmology, antibody, "
" Followup cervical spinal stenosis.  Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident when she thought she had exacerbated her conditions while lifting several objects.", Neurology, Cervical Spinal Stenosis ,"REASON FOR VISIT:  ,Followup cervical spinal stenosis.,HISTORY OF PRESENT ILLNESS:  ,Ms. ABC returns today for followup regarding her cervical spinal stenosis.  I have last seen her on 06/19/07.  Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident on 06/04/07, when she thought she had exacerbated her conditions while lifting several objects.,I referred her to obtain a cervical spine MRI.,She returns today stating that she continues to have right upper extremity pain, paresthesias, weakness, which she believes radiates from her neck.  She had some physical therapy, which has been helping with the neck pain.  The right hand weakness continues.  She states she has a difficult time opening jars, and doors, and often drops items from her right greater than left upper extremity.  She states she have several occasions when she is sleeping at night, she has had sharp shooting radicular pain and weakness down her left upper extremity and she feels that these symptoms somewhat scare her.,She has been undergoing nonoperative management by Dr. X and feels this has been helping her neck pain, but not the upper extremity symptoms.,She denies any bowel and bladder dysfunction.  No lower back pain, no lower extremity pain, and no instability with ambulation.,REVIEW OF SYSTEMS:,  Negative for fevers, chills, chest pain, and shortness of breath.,FINDINGS:  ,On examination, Ms. ABC is a very pleasant well-developed, well-nourished female in no apparent distress.  Alert and oriented x3.  Normocephalic and atraumatic.  Afebrile to touch.,She ambulates with a normal gait.,Motor strength is 4 plus out of 5 in the bilateral deltoids, biceps, triceps muscle groups, 4 out of 5 in the bilateral hand intrinsic muscle groups, grip strength 4 out of 5, 4 plus out of 5 bilateral wrist extension and wrist flexion.,Light touch sensation decreased in the right greater than left C6 distribution.  Biceps and brachioradialis reflexes are 3 plus.  Hoffman sign normal bilaterally.,Lower extremity strength is 5 out of 5 in all muscle groups.  Patellar reflex is 3 plus.  No clonus.,Cervical spine radiographs dated 06/21/07 are reviewed.,They demonstrate evidence of spondylosis including degenerative disk disease and anterior and posterior osteophyte formation at C4-5, C5-6, C6-7, and C3-4 demonstrates only minimal if any degenerative disk disease.  There is no significant instability seen on flexion-extension views.,Updated cervical spine MRI dated 06/21/07 is reviewed.,It demonstrates evidence of moderate stenosis at C4-5, C5-6.  These stenosis is in the bilateral neural foramina and there is also significant disk herniation noted at the C6-7 level.  Minimal degenerative disk disease is seen at the C6-7.  This stenosis is greater than C5-6 and the next level is more significantly involved at C4-5.,Effacement of the ventral and dorsal CSF space is seen at C4-5, C5-6.,ASSESSMENT AND PLAN: , Ms. ABC's history, physical examination, and radiographic findings are compatible with C4-5, C5-6 cervical spinal stenosis with associated right greater than left upper extremity radiculopathy including weakness.,I spent a significant amount of time today with the patient discussing the diagnosis, prognosis, natural history, nonoperative, and operative treatment options.,I laid out the options as continued nonoperative management with physical therapy, the same with the addition of cervical epidural steroid injections and surgical interventions.,The patient states she would like to avoid injections and is somewhat afraid of having these done.  I explained to her that they may help to improve her symptoms, although they may not help with the weakness.,She feels that she is failing maximum nonoperative management and would like to consider surgical intervention.,I described the procedure consisting of C4-5, C5-6 anterior cervical decompression and fusion to the patient in detail on a spine model.,I explained the rationale for doing so including the decompression of the spinal cord and improvement of her upper extremity weakness and pain.  She understands.,I discussed the risks, benefits, and alternative of the procedure including material risks of bleeding, infection, neurovascular injury, dural tear, singular or multiple muscle weakness, paralysis, hoarseness of voice, difficulty swallowing, pseudoarthrosis, adjacent segment disease, and the risk of this given the patient's relatively young age.  Of note, the patient does have a hoarse voice right now, given the fact that she feels she has allergies.,I also discussed the option of disk arthroplasty.  She understands.,She would like to proceed with the surgery, relatively soon.  She has her birthday coming up on 07/20/07 and would like to hold off, until after then.  Our tentative date for the surgery is 08/01/07.  She will go ahead and continue the preoperative testing process.",
 A woman presents for neurological evaluation with regards to a diagnosis of multiple sclerosis., Neurology, Comprehensive Neurological Evaluation ,"As you know, the patient is a 50-year-old right-handed Caucasian female, who works as an independent contractor and as a human resources consultant.,Her neurological history first begins in December of 1987, when she had a rather sudden onset of slurred speech and the hesitancy when she started to walk.  She had HMO insurance at that time and saw a neurologist, whose name she does not recall.  She thinks that she underwent MRI scan of the brain and possibly visual evoked response and brainstem auditory evoked response tests.  She was told that all the tests were normal and no diagnosis was made.,The slurred speech resolved after a few weeks, but her gait hesitancy persisted for a number of years and then finally partially improved.  She also began to note that she would fatigue after very prolonged walking.,In about 1993, she developed bladder urgency and frequency along with some nocturia.  She saw a urologist and underwent urodynamic testing.  She was diagnosed as having ""overactive bladder"", but the cause of this was never determined.  She was treated with medications, possibly Ditropan, without much benefit.  She also developed a dry mouth from the medication and so she discontinued it.,Also in about 1993, she began to note an uncomfortable ""stiffness"" in her feet and slight swelling of the ankles.  Apparently, the swelling was not visible by others.  She saw multiple physicians and was told that it was ""not arthritis"", but no definite diagnosis was ever established.  She saw at least two rheumatologists on several occasions and blood tests were all normal.  No clear-cut diagnosis was ever made and the patient simply learned to live with these symptoms.,However, over time she noted that the symptoms in her legs seemed to worsen somewhat.  She states from time-to-time she could ""barely walk"".  She felt as if her balance is impaired and she felt as if she were ""walking on stilts"".  She tried arch supports from a podiatrist without any benefit.  She began to tire more easily when walking.,In 2002 she was seen by a podiatrist, who noticed an abnormal gait and recommended that she see a neurologist.,In the fall of 2002, she was seen by Dr. X.  He ordered an MRI scan of her brain and lumbar spine.  He also did some sort of nerve testing and possibly visual evoked response testing.  After reviewing everything, he diagnosed multiple sclerosis.  However, prior to starting her on immunomodulatory therapy, he referred her for a second opinion to Dr. Y, in January of 2003.  Dr. Y confirmed the diagnosis of multiple sclerosis.,The patient then returned to Dr. X and was started on Avonex.  She continued on it for about six months.  However, it made her feel much more stiff and delayed and so she finally stopped it.  She also recalled being tried on baclofen by Dr. X, but again it did not benefit her and made her feel slightly dizzy.  So, she discontinued it also.,At that point in time, she decided to try a program of ""good nutrition, vitamin supplements, and fish oil"".,In December 2004 and extending up to February 2005, she began to note progressively more severe swelling and stiffness in the distal lower extremities.  She began to have to use a cane.  She was seen in neurological consultation by Dr. Z.  She was treated with a Medrol Dosepak.  Her spasticity and swelling seemed to improve dramatically.  However, within about two weeks symptoms were back to baseline.,She was then treated with intravenous Solu-Medrol 500 mg daily for five days followed by a prednisone or Medrol taper (July 2005).  This seemed to be less helpful than the oral steroids, but was partially beneficial.  However, it wore off once again.,A repeat MRI scan of the brain in April 2005 was said to ""look better"".  She was started on Zanaflex for her lower extremity spasticity without benefit.,Finally six days ago, she was restarted on oral prednisone 10 mg tablets.  She takes one-half tablet daily and this again has seemed to reduce the swelling and stiffness in her legs.  She continues on the prednisone in the same dosage for relief of the spasticity.,She has not been on any other immunomodulatory agents.,The patient does note some complaints of mild heat sensitivity and mild easy fatigability.  There is no history of diplopia, dysarthria, aphasia, focal weakness, numbness, paresthesias, cognitive dysfunction, or memory dysfunction.,PAST MEDICAL HISTORY: , Essentially noncontributory.,ALLERGIES:,  The patient is allergic to LOBSTER and VICODIN.  She feels that she is probably allergic to IODINE.,SOCIAL HISTORY:,  She does not smoke.  She takes one glass of wine per day.,PAST SURGICAL HISTORY: , She has not had any prior surgeries.  Her general health has been excellent except for the above-indicated problems.,REVIEW OF OUTSIDE RADIOLOGICAL STUDIES:,  The patient brought with her today MRI scans of the brain, thoracic spine, and lumbosacral spine performed on 11/14/02 on a 1.5-Tesla magnet.  There are numerous T2 hyperintense lesions in the periventricular and subcortical white matter of the brain and at least one lesion is in the corpus callosum.  There appear to be Dawson's fingers.  The MRI of the thoracic and lumbosacral spines did not reveal any significant abnormalities.,Also available are the MRI scans of the brain, cervical spine, thoracic spine, and lumbosacral spine performed on a 0.35-Tesla magnet on 04/22/05.  The MRI of the brain shows that one of the prior lesions has resolved and there appear to be one or two more lesions.,However, the quality of the newer scan is only 0.35-Tesla and is suboptimal.  Visualization of the cord is also suboptimal, but there are no clear-cut extraaxial or complexities of the spinal cord.  It is difficult to be certain that there are no intra-axial lesions, but I could not clearly see one.,PHYSICAL EXAMINATION:,Vital signs:  Blood pressure 151/88, pulse 92, temperature 99.5ºF, and weight 124 lb (dressed).,General:  Well-developed, well-nourished female in no acute distress.,Head:  Normocephalic, without evidence of trauma or bruits.,Neck:  Supple, with full range of motion.  No spasm or tenderness.  Carotid pulsations are of normal volume and contour bilaterally without bruits.  No thyromegaly or adenopathy.,Extremities:  No clubbing, cyanosis, edema, or deformity.  Range of motion full throughout.,NEUROLOGICAL EXAMINATION:,Mental Status:  Awake, alert, oriented to time, place, and person; appropriate.  Recent and remote memory intact.  No evidence of right-left confusion, finger agnosia, dysnomia or aphasia.,CRANIAL NERVES,:,II:  Visual fields full to confrontation.  Fundi benign.,III, IV, VI:  Extraocular movements full throughout, without nystagmus.  No ptosis.  Pupils equal, round and react briskly to light and accommodation.,V:  Normal sensation to light touch and pinprick bilaterally.  Corneal reflexes equal bilaterally.  Motor function normal.,VII:  No facial asymmetry.,VIII:  Hears finger rub bilaterally.  Weber and Rinne tests normal.,IX & X:  Palate elevates symmetrically bilaterally with phonation.  Gag reflex equal bilaterally.,XI:  Sternocleidomastoid and upper trapezius normal tone, bulk and strength bilaterally.,XII:  Tongue midline without atrophy or fasciculations.  Rapid alternating movements normal.  No dysarthria.,Motor:  Tone, bulk, and strength are normal in both upper extremities.  In the lower extremities, there is moderate spasticity on the right and moderately severe spasticity on the left.  There are bilateral Achilles' contractures more so on the left than the right and also a slight left knee flexion contracture.,Strength in the lower extremities is rated as follows on a 5-point scale (right/left):  Iliopsoas 4+/5-, quadriceps 5-/5-, tibialis anterior 4+/4+, and gastrocnemius 5/5.  There are no tremors, fasciculations or abnormal involuntary movements.",
 Patient reports a six to eight-week history of balance problems with later fatigue and weakness., Neurology, Cervical Cord Lesion - Consult ,"HISTORY OF PRESENT ILLNESS:, This is a 58-year-old male who reports a six to eight-week history of balance problems with fatigue and weakness. He has had several falls recently. He apparently had pneumonia 10 days prior to the onset of the symptoms. He took a course of amoxicillin for this. He complained of increased symptoms with more and more difficulty with coordination. He fell at some point near the onset of the symptoms, but believes that his symptoms had occurred first. He fell from three to five feet and landed on his back. He began seeing a chiropractor approximately five days ago and had adjustments of the neck and lumbar spine, although he clearly had symptoms prior to this.,He has had mid and low back pain intermittently. He took a 10-day course of Cipro believing that he had a UTI. He denies, however, any bowel or bladder problems. There is no incontinence and he does not feel that he is having any difficulty voiding.,PAST SURGICAL HISTORY:, He has a history of surgery on the left kidney, when it was ""rebuilt."" He has had knee surgery, appendectomy and right inguinal hernia repair.,MEDICATIONS:, His only home medications had been Cipro and Aleve. However, he does take aspirin and several over the counter supplements including a multivitamin with iron, ""natural"" potassium, Starlix and the aspirin.,ALLERGIES:, HE HAS NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY:, He smokes one-and-one-half-packs of cigarettes per day and drinks alcohol at least several days per week. He is employed in sales, which requires quite a bit of walking, but he is not doing any lifting. He had been a golfer in the past.,PAST MEDICAL HISTORY:, He has had documented cervical spondylosis, apparently with an evaluation over 15 years ago.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 156/101, pulse was 88, respirations 18. He is afebrile.,MENTAL STATUS: He is alert.,CRANIAL NERVES: His pupils were reactive to light. He had a dense left cataract present. The right disk margin appears sharp. His eye movements were full. The face was symmetric. Pain and temperature sensation were intact over both sides of the face. The tongue was midline.,NECK: His neck was supple.,MUSCULOSKELETAL: He has intact strength and normal tone in the upper extremities. He had increased tone in both lower extremities. He had hip flexion of 4/5 on the left. He had intact strength on the right lower extremity, although had slight hammertoe deformity bilaterally.,NEUROLOGIC: His reflexes were 2+ in the upper extremities, 3+ at the knees and 1+ at the ankles. He withdrew to plantar stimulation on the left, but did not have a Babinski response clearly present. He had intact finger-to-nose testing. Marked impairment in heel-to-shin testing. He was able to sit unassisted. He stood with assistance, but had a markedly ataxic gait. On sensory exam, he had a slight distal gradient to pin and vibratory sense in both lower extremities, but also had a decrease in sensation to pin over the right lower extremity compared to the left.,CARDIOVASCULAR: He had no carotid bruits. His heart rhythm was regular.,BACK: There was no focal back pain present. He did have a slight sensory level at the upper T spine at approximately T3, both anteriorly and posteriorly.,RADIOLOGIC DATA:, MRI by my view showed essentially unremarkable T spine. The MRI of his C spine showed significant spondylosis in the mid and lower C spine with spondylolisthesis at C7-T1. There is an abnormal signal in the cord which begins at approximately this level, but descends approximately 2 cm. There is slight enhancement at the mid-portion of the lesion. This appears to be an intrinsic lesion to the cord, not clearly associated with mild to moderate spinal stenosis at the level of the spondylolisthesis.,LABORATORY: ,His initial labs were unremarkable.,IMPRESSION: ,Cervical cord lesion at the C7 to T2 level of unclear etiology. Consider a transverse myelitis, tumor, contusion or ischemic lesion.,PLAN:, Will check labs including sedimentation rate, MRI of the brain, chest x-ray. He will probably need a lumbar puncture. He also appears to have a mild peripheral neuropathy, which I suspect is an independent problem. We will request labs for this.",
" Cervical spondylosis and kyphotic deformity.  She had a nerve conduction study and a diagnosis of radiculopathy was made.  She had an MRI of lumbosacral spine, which was within normal limits.  She then developed a tingling sensation in the right middle toe. ", Neurology, Cervical Spondylosis - Neuro Consult ,"REASON FOR NEUROLOGICAL CONSULTATION: , Cervical spondylosis and kyphotic deformity.  The patient was seen in conjunction with medical resident Dr. X. I personally obtained the history, performed examination, and generated the impression and plan.,HISTORY OF PRESENT ILLNESS: ,The patient is a 45-year-old African-American female whose symptoms first started some one and a half years ago with pain in the left shoulder and some neck pain.  This has subsequently resolved.  She started vigorous workouts in November 2005.  In March of this year, she suddenly could not feel her right foot on the bathroom floor and subsequently went to her primary care physician.  By her report, she had a nerve conduction study and a diagnosis of radiculopathy was made.  She had an MRI of lumbosacral spine, which was within normal limits.  She then developed a tingling sensation in the right middle toe.  Symptoms progressed to sensory symptoms of her knees, elbows, and left middle toe.  She then started getting sensory sensations in the left hand and arm.  She states that she feels a little bit wobbly at the knees and that she is slightly dragging her left leg.  Symptoms have been mildly progressive.  She is unaware of any trigger other than the vigorous workouts as mentioned above.  She has no associated bowel or bladder symptoms.  No particular position relieves her symptoms.,Workup has included two MRIs of the C-spine, which were personally reviewed and are discussed below.  She saw you for consultation and the possibility of surgical decompression was raised.  At this time, she is somewhat reluctant to go through any surgical procedure.,PAST MEDICAL HISTORY:,1.  Ocular migraines.,2.  Myomectomy.,3.  Infertility.,4.  Hyperglycemia.,5.  Asthma.,6.  Hypercholesterolemia.,MEDICATIONS: , Lipitor, Pulmicort, Allegra, Xopenex, Patanol, Duac topical gel, Loprox cream, and Rhinocort.,ALLERGIES: , Penicillin and aspirin.,Family history, social history, and review of systems are discussed above as well as documented in the new patient information sheet.  Of note, she does not drink or smoke.  She is married with two adopted children.  She is a paralegal specialist.  She used to exercise vigorously, but of late has been advised to stop exercising and is currently only walking.,REVIEW OF SYSTEMS: , She does complain of mild blurred vision, but these have occurred before and seem associated with headaches.,PHYSICAL EXAMINATION: , On examination, blood pressure 138/82, pulse 90, respiratory rate 14, and weight 176.5 pounds.  Pain scale is 0.  A full general and neurological examination was personally performed and is documented on the chart.  Of note, she has a normal general examination.  Neurological examination reveals normal cognition and cranial nerve examination including normal jaw jerk.  She has mild postural tremor in both arms.  She has mild decreased sensation in the right palm and mild decreased light touch in the right palm and decreased vibration sense in both distal lower extremities.  Motor examination reveals no weakness to individual muscle testing, but on gait she does have a very subtle left hemiparesis.  She has hyperreflexia in her lower extremities, worse on the left.  Babinski's are downgoing.,PERTINENT DATA:  ,MRI of the brain from 05/02/06 and MRI of the C-spine from 05/02/06 and 07/25/06 were personally reviewed.  MRI of the brain is broadly within normal limits.  MRI of the C-spine reveals large central disc herniation at C6-C7 with evidence of mild cord compression and abnormal signal in the cord suggesting cord edema.  There is also a fairly large disc at C3-C4 with cord deformity and partial effacement of the subarachnoid space.  I do not appreciate any cord edema at this level.,IMPRESSION AND PLAN:  ,The patient is a 45-year-old female with cervical spondylosis with a large C6-C7 herniated disc with mild cord compression and signal change at that level.  She has a small disc at C3-C4 with less severe and only subtle cord compression.  History and examination are consistent with signs of a myelopathy.,Results were discussed with the patient and her mother.  I am concerned about progressive symptoms.  Although she only has subtle symptoms now, we made her aware that with progression of this process, she may have paralysis.  If she is involved in any type of trauma to the neck such as motor vehicle accident, she could have an acute paralysis.  I strongly recommended to her and her mother that she followup with you as soon as possible for surgical evaluation.  I agree with the previous physicians who have told her not to exercise as I am sure that her vigorous workouts and weight training since November 2005 have contributed to this problem.  I have recommended that she wear a hard collar while driving.  The results of my consultation were discussed with you telephonically.","neurology, kyphotic, cervical, radiculopathy, myelopathy, kyphotic deformity, cord compression, cervical spondylosis, toe, spondylosis, cord, "
 Diagnosis of bulbar cerebral palsy and hypotonia. , Neurology, Cerebral Palsy - Letter ,"Doctor's Address,Dear Doctor:,This letter serves as an introduction to my patient, A, who will be seeing you in the near future.  He is a pleasant young man who has a diagnosis of bulbar cerebral palsy and hypotonia.  He has been treated by Dr. X through the pediatric neurology clinic.  He saw Dr. X recently and she noted that he was having difficulty with mouth breathing, which was contributing to some of his speech problems.  She also noted and confirmed that he has significant tonsillar hypertrophy.  The concern we have is whether he may benefit from surgery to remove his tonsils and improve his mouth breathing and his swallowing and speech.  Therefore, I ask for your opinion on this matter.,For his chronic allergic rhinitis symptoms, he is currently on Flonase two sprays to each nostril once a day.  He also has been taking Zyrtec 10 mg a day with only partial relief of the symptoms.  He does have an allergy to penicillin.,I appreciate your input on his care.  If you have any questions regarding, please feel free to call me through my office.  Otherwise, I look forward to hearing back from you regarding his evaluation.","neurology, peech, swallowing, breathing, bulbar cerebral palsy, mouth breathing, cerebral palsy, hypotoniaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Cerebral Angiogram for avascular mass - cavernous angioma (with hematoma on MRI and Bx)., Neurology, Cerebral Angiogram ,"CC: ,Headache (HA),HX:, 10 y/o RHM awoke with a bilateral parieto-occipital HA associated with single episode of nausea and vomiting, 2 weeks prior to presentation. The nausea and vomiting resolved and did not recur. However, he continued to experience similar HA 3-4 times per week during the early morning upon awakening. He never felt the HA awakened him from sleep. The HA were partially relieved by Tylenol or Advil, and he distracted himself from the pain by remaining active. One week prior to presentation, he started to experience short episodes of blurred vision and diplopia. He also became fatigued, less active, and frequently yawned.,He had no prior history of HA and he and his family denied any sign or symptom of focal weakness or numbness, dysphagia, dysarthria, or loss of consciousness.,The patient underwent an MRI brain scan prior to transfer to UIHC. This revealed a mass in the left frontal region adjacent to the left temporal horn. The mass was an inhomogeneous blend of signals on T1 and T2 images giving a suggestion of acute bleeding, hemosiderin deposition and multiple vessels within the mass.,MEDS:, None.,PMH:, 1) He was a 7# 15oz. product of a full term, uncomplicated pregnancy and spontaneous vaginal delivery. His post-partum course was unremarkable. 2)Developmental milestones were reached at the appropriate times; though he was diagnosed with dyslexia 4 years ago. 3) No significant illnesses or hospitalizations.,FHX:, MGF (meningioma). PGF (lymphoma). Mother (migraine HA). Father and 22yr old brother are alive and well.,SHX: ,lives with parents and attends mainstream 5th grade classes.,EXAM:, BP124/93 HR96 RR20 37.9C (tympanic),MS:  A & O to person, place, time. Cooperative and interactive. Speech fluent and without dysarthria.,CN: EOM intact. VFFTC, Pupils 3/3 decreasing to 2/2 on exposure to light. Fundoscopy: optic disks flat, no evidence of hemorrhage. The rest of the CN exam was unremarkable.,MOTOR: full strength throughout all 4 extremities. Normal muscle tone and bulk.,Sensory: unremarkable.,Coord: unremarkable.,Station: no pronator drift or Romberg sign,Gait: unremarkable.,Reflexes: 2+ in RUE and RLE. 3 in LUE and LLE. Plantar responses were flexor, bilaterally.,HEENT: no meningismus. no cranial bruits. no skull defects palpated.,GEN EXAM: unremarkable.,COURSE:, GS, PT/PTT, CBC were unremarkable. The MRI finding above lead to a differential diagnosis of Venous Angioma, Arteriovenous Malformation, Ependymoma, Neurocytoma, Glioma: all with associated hemorrhage.,He underwent cerebral angiography on 1/25/93. Upon injection of the RCCA an avascular mass was identified in the right temporal lobe displacing the anterior choroidal artery, and temporal branches of the middle cerebral arteries. The internal cerebral vein is displaced to the left suggesting mass effect. There is a hypoplastic A1 segment and fetal origin of the LPCA. The mass was felt by neuroradiology to represent a hematoma.,He underwent a right frontal craniotomy, 1/28/93. Pathological evaluation of the resected tissue was consistent with a vascular malformation with inclusive reactive glial tissue and evidence of recurrent and remote hemorrhage. There were dilated vascular channels having walls of variable thickness, but without evidence of elastic lamina by elastic staining. This was consistent with venous angioma/malformation.",
 Cerebral Angiogram - Lateral medullary syndrome secondary to left vertebral artery dissection., Neurology, Cerebral Angiogram - Lateral Medullary Syndrome ,"CC: ,Falling to left.,HX:, 26y/oRHF fell and struck her head on the ice 3.5 weeks prior to presentation. There was no associated loss of consciousness. She noted a dull headache and severe sharp pain behind her left ear 8 days ago. The pain lasted 1-2 minutes in duration. The next morning she experienced difficulty walking and consistently fell to the left. In addition the left side of her face had become numb and she began choking on food. Family noted her pupils had become unequal in size. She was seen locally and felt to be depressed and admitted to a psychiatric facility. She was subsequently transferred to UIHC following evaluation by a local ophthalmologist.,MEDS:, Prozac and Ativan (both recently started at the psychiatric facility).,PMH: ,1) Right esotropia and hyperopia since age 1year. 2) Recurrent UTI.,FHX:, Unremarkable.,SHX:, Divorced. Lives with children. No spontaneous abortions. Denied ETOH/Tobacco/Illicit Drug use.,EXAM:, BP 138/110.  HR 85.  RR 16.  Temp 37.2C.,MS: A&O to person, place, time. Speech fluent and without dysarthria. Intact naming, comprehension, repetition.,CN: Pupils 4/2 decreasing to 3/1 on exposure to light. Optic Disks flat. VFFTC. Esotropia OD, otherwise EOM full. Horizontal nystagmus on leftward gaze. Decreased corneal reflex, OS. Decreased PP/TEMP sensation on left side of face. Light touch testing normal. Decreased gag response on left. Uvula deviates to right. The rest of the CN exam was unremarkable.,Motor: 5/5 strength throughout with normal muscle bulk and tone.,Sensory: Decreased PP and TEMP on right side of body. PROP/VIB intact.,Coord: Difficulty with FNF/HKS/RAM on left. Normal on right side.,Station: No pronator drift. Romberg test not noted.,Gait: unsteady with tendency to fall to left.,Reflexes: 3/3 throughout BUE and Patellae. 2+/2+ Achilles. Plantar responses were flexor, bilaterally.,Gen Exam: Obese. In no acute distress. Otherwise unremarkable.,HEENT: No carotid/vertebral/cranial bruits.,COURSE:, PT/PTT, GS, CBC, TSH, FT4 and Cholesterol screen were all within normal limits. HCT on admission was negative. MRI Brain (done locally 2/2/93) was reviewed and a left lateral medullary stroke was appreciated. The patient underwent a cerebral angiogram on 2/3/93 which revealed significant narrowing of the left vertebral artery beginning at C2 and extending to and involving the basilar artery. There is severe, irregular narrowing of the horizontal portion above the posterior arch of C1. The findings were felt consistent with a left vertebral artery dissection. Neuro-opthalmology confirmed a left Horner's pupil by clinical exam and history. Cookie swallow study was unremarkable. The Patient was placed on Heparin then converted to Coumadin. The PT on discharge was 17.,She remained on Coumadin for 3 months and then was switched to ASA for 1 year. An Otolaryngologic evaluation on 10/96 noted true left vocal cord paralysis with full glottic closure. A prosthesis was made and no surgical invention was done.","neurology, horner's pupil, mri brain, otolaryngologic, cerebral angiogram, cerebral angiogram lateral, medullary syndrome, vertebral artery, angiogram, syndrome, falling, narrowing, medullary, vertebral, cerebral, "
 Cerebral Angiogram and MRA for bilateral ophthalmic artery aneurysms., Neurology, Cerebral Angiogram & MRA ,"CC:, Transient visual field loss.,HX: ,This 58 y/o RHF had a 2 yr h/o increasing gait difficulty which she attributed to generalized weakness and occasional visual obscurations. She was evaluated by a local physician several days prior to this presentation (1/7/91), for clumsiness of her right hand and falling. HCT and MRI brain revealed bilateral posterior clinoid masses.,MEDS:, Colace, Quinidine, Synthroid, Lasix, Lanoxin, KCL, Elavil, Tenormin.,PMH: ,1) Obesity.  2) VBG, 1990.  3) A-Fib. 4) HTN.  5) Hypothyroidism.  6) Hypercholesterolemia. 7) Briquet's syndrome: h/o of hysterical paralysis. 8) CLL, dx 1989; in 1992 presented with left neck lymphadenopathy and received 5 cycles of chlorambucil/prednisone chemotherapy; 10/95 parotid gland biopsy was consistent with CLL and she received 5 more cycles of chlorambucil/prednisone; 1/10/96, she received 3000cGy to right parotid mass. 9) SNHL,FHX:, Father died, MI age 61.,SHX:, Denied Tobacco/ETOH/illicit drug use.,EXAM:, Vitals were unremarkable.,The neurologic exam was unremarkable except for obesity and mild decreased PP about the right upper and lower face, diffusely about the left upper and lower face, per neurosurgery notes. The neuro-ophthalmologic exam was unremarkable, per Neuro-ophthalmology.,COURSE:, She underwent Cerebral Angiography on 1/8/91. This revealed a 15x17x20mm LICA paraclinoid/ophthalmic artery aneurysm and a 5x7mm RICA paraclinoid/ophthalmic artery aneurysm. On 1/16/91 she underwent a left frontotemporal craniotomy and exploration of the left aneurysm. The aneurysm neck went into the cavernous sinus and was unclippable so it was wrapped. She has complained of headaches since.","neurology, visual field loss, transient, visual field, cerebral angiography, ophthalmic, paraclinoid, aneurysm, paraclinoid/ophthalmic, cavernous, frontotemporal, craniotomy, exam was unremarkable, artery aneurysms, mra, visual, parotid, cerebral, artery, neurologic, aneurysms, angiogram"
 Cerebral Angiogram - Lobulated aneurysm of the supraclinoid portion of the left internal carotid artery close to the origin of the left posterior communicating artery., Neurology, Cerebral Angiogram - Left ICA/PCA Aneurysm ,"CC:, Fluctuating level of consciousness.,HX:, 59y/o male experienced a ""pop"" in his head on 10/10/92 while showering in Cheyenne, Wyoming. He was visiting his son at the time. He was found unconscious on the shower floor 1.5 hours later. His son then drove him Back to Iowa. Since then he has had recurrent headaches and fluctuating level of consciousness, according to his wife. He presented at local hospital this AM, 10/13/92. A HCT there demonstrated a subarachnoid hemorrhage. He was then transferred to UIHC.,MEDS:, none.,PMH:, 1) Right hip and clavicle fractures many years ago. 2) All of his teeth have been removed., ,FHX:, Not noted.,SHX:, Cigar smoker. Truck driver.,EXAM: , BP 193/73.  HR 71.  RR 21.  Temp 37.2C.,MS: A&O to person, place and time. No note regarding speech or thought process.,CN: Subhyaloid hemorrhages, OU. Pupils 4/4 decreasing to 2/2 on exposure to light. Face symmetric. Tongue midline. Gag response difficult to elicit. Corneal responses not noted.,MOTOR: 5/5 strength throughout.,Sensory: Intact PP/VIB.,Reflexes: 2+/2+ throughout. Plantars were flexor, bilaterally.,Gen Exam: unremarkable.,COURSE:, The patient underwent Cerebral Angiography on 10/13/92. This revealed a lobulated aneurysm off the supraclinoid portion of the left internal carotid artery close to the origin of the posterior communication artery. The patient subsequently underwent clipping of this aneurysm. He recovery was complicated severe vasospasm and bacterial meningitis. HCT on 10/19/92 revealed multiple low density areas in the left hemisphere in the LACA-LPCA watershed, left fronto-parietal area and left thalamic region. He was left with residual right hemiparesis, urinary incontinence, some (unspecified) degree of mental dysfunction. He was last seen 2/26/93 in Neurosurgery clinic and had stable deficits.","neurology, consciousness, level of consciousness, hct, subhyaloid hemorrhages, cerebral angiography, carotid artery, communication artery, laca-lpca, fluctuating level of consciousness, internal carotid artery, lobulated aneurysm, lobulated, supraclinoid, cerebral, aneurysm, artery, angiogram, "
 Bilateral carotid cerebral angiogram and right femoral-popliteal angiogram., Neurology, Bilateral Carotid Cerebral Angiogram ,"PREOPERATIVE DIAGNOSES:,1.  Carotid artery occlusive disease.,2.  Peripheral vascular disease.,POSTOPERATIVE DIAGNOSES:,1.  Carotid artery occlusive disease.,2.  Peripheral vascular disease.,OPERATIONS PERFORMED:,1.  Bilateral carotid cerebral angiogram.,2.  Right femoral-popliteal angiogram.,FINDINGS: , The right carotid cerebral system was selectively catheterized and visualized.  The right internal carotid artery was found to be very tortuous with kinking in its cervical portions, but no focal stenosis was noted.  Likewise, the intracranial portion of the right internal carotid artery showed no significant disease nor did the right middle cerebral artery.,The left carotid cerebral system was selectively catheterized and visualized.  The cervical portion of the left internal carotid artery showed a 30 to 40% stenosis with small ulcer crater present.  The intracranial portion of the left internal carotid artery showed no significant disease nor did the left middle cerebral artery.,Visualization of the right lower extremity showed no significant disease.,PROCEDURE: , With the patient in supine position under local anesthesia plus intravenous sedation, the groin areas were prepped and draped in a sterile fashion.,The common femoral artery was punctured in a routine retrograde fashion and a 5-French introducer sheath was advanced under fluoroscopic guidance.  A catheter was then placed in the aortic arch and the right and left common carotid arteries were then selectively catheterized and visualized as described above.,Following completion of the above, the catheter and introducer sheath were removed.  Heparin had been initially given, which was reversed with protamine.  Firm pressure was held over the puncture site for 20 minutes, followed by application of a sterile Coverlet dressing and sandbag compression.,The patient tolerated the procedure well throughout.","neurology, femoral-popliteal angiogram, carotid cerebral angiogram, internal carotid artery, carotid artery, angiogram, carotid, cerebral, artery,"
 Bilateral carotid ultrasound., Neurology, Carotid Ultrasound ,"EXAM:,  Bilateral carotid ultrasound.,REASON FOR EXAM: , Headache.,TECHNIQUE:  ,Color grayscale and Doppler analysis is employed.,FINDINGS:,  On the grayscale images, the right common carotid artery demonstrates patency with mild intimal thickening only.  At the level of the carotid bifurcation, there is heterogeneous hard plaque present, but without grayscale evidence of greater than 50% stenosis.  Right common carotid waveform is normal with a peak systolic velocity of 0.474 m/second and an end-diastolic velocity of 0.131 m/second.  The right ECA is patent as well with the velocity measurement 0.910 m/second.,The right internal carotid artery at the bifurcation demonstrates plaque formation, but no evidence of greater than 50% stenosis.  Proximal peak systolic velocity in the internal carotid artery is 0.463 m/second with proximal end-diastolic velocity of 0.170.  The mid internal carotid peak systolic velocity is 0.564 m/second, and mid ICA end-diastolic velocity is 0.199 m/second.  Right ICA distal PSV 0.580 m/second, right ICA distal EDV 0.204 m/second.  Vertebral flow is antegrade on the right at 0.469 m/second.,On the left, the common carotid artery demonstrates intimal thickening, but is otherwise patent.  At the level of the bifurcation, however, there is more pronounced plaque formation with approximately 50% stenosis by the grayscale analysis.  See the velocity measurements below:,Left carotid ECA measurement 0.938 m/second.  Left common carotid PSV 0.686 m/second, and left common carotid end-diastolic velocity 0.137 m/second.,Left internal carotid artery again demonstrates prominent focus of hard plaque with up to at least 50% stenosis.  This should be further assessed with CTA for more precise measurement.  The left proximal ICA/PSV 0.955 m/second, left proximal ICA/EDV 0.287 m/second.  There is spectral broadening in the proximal aspect of the carotid waveform.  The left carotid ICA mid PSV 0.895, left carotid ICA mid EDV 0.278 with also spectral broadening present.,The left distal ICA/PSV 0.561, left distal ICA/EDV 0.206, again the spectral broadening present.  Vertebral flow is antegrade at 0.468 m/second.,IMPRESSION: , The study demonstrates bilateral hard plaque at the bifurcation, left greater than right.  There is at least 50% stenosis of the left internal carotid artery at its bifurcation and a followup CTA is recommended for further assessment.","neurology, doppler analysis, headache, edv, ica, eca, psv, distal ica/edv, hard plaque, bilateral carotid ultrasound, peak systolic velocity, internal carotid artery, plaque formation, carotid ultrasound, carotid artery, carotid, stenosis, proximal, artery, velocity"
 Brain CT and MRI - suprasellar mass (pituitary adenoma), Neurology, Brain MRI - Pituitary Adenoma ,"CC:, Orthostatic lightheadedness.,HX:, This 76 y/o male complained of several months of generalized weakness and malaise, and a two week history of progressively worsening orthostatic dizziness. The dizziness worsened when moving into upright positions. In addition, he complained of intermittent throbbing holocranial headaches, which did not worsen with positional change, for the past several weeks. He had lost 40 pounds over the past year and denied any recent fever, SOB, cough, vomiting, diarrhea, hemoptysis, melena, hematochezia, bright red blood per rectum, polyuria, night sweats, visual changes, or syncopal episodes.,He had a 100+ pack-year history of tobacco use and continued to smoke 1 to 2 packs per day. He has a history of sinusitis.,EXAM:, BP 98/80 mmHg and pulse 64 BPM (supine); BP 70/palpable mmHG and pulse 84BPM (standing). RR 12, Afebrile. Appeared fatigued.,CN: unremarkable.,Motor and Sensory exam: unremarkable.,Coord: Slowed but otherwise unremarkable movements.,Reflexes: 2/2 and symmetric throughout all 4 extremities. Plantar responses were flexor, bilaterally.,The rest of the neurologic and general physical exam was unremarkable.,LAB:, Na 121 meq/L, K 4.2 meq/L, Cl 90 meq/L, CO2 20meq/L, BUN 12mg/DL, CR 1.0mg/DL, Glucose 99mg/DL, ESR 30mm/hr, CBC WNL with nl WBC differential, Urinalysis: SG 1.016 and otherwise WNL, TSH 2.8 IU/ML, FT4 0.9ng/DL, Urine Osmolality 246 MOSM/Kg (low), Urine Na 35 meq/L,,COURSE:, The patient was initially hydrated with IV normal saline and his orthostatic hypotension resolved, but returned within 24-48hrs. Further laboratory studies revealed: Aldosterone (serum)<2ng/DL (low), 30 minute Cortrosyn Stimulation test: pre 6.9ug/DL (borderline low), post 18.5ug/DL (normal stimulation rise), Prolactin 15.5ng/ML (no baseline given), FSH and LH were within normal limits for males. Testosterone 33ng/DL (wnl). Sinus XR series (done for history of headache) showed an abnormal sellar region with enlarged sella tursica and destruction of the posterior clinoids. There was also an abnormal calcification seen in the middle of the sellar region. A left maxillary sinus opacity with air-fluid level was seen. Goldman visual field testing was unremarkable. Brain CT and MRI revealed suprasellar mass most consistent with pituitary adenoma. He was treated with Fludrocortisone 0.05 mg BID and within 24hrs, despite discontinuation of IV fluids, remained hemodynamically stable and free of symptoms of orthostatic hypotension. His presumed pituitary adenoma continues to be managed with Fludrocortisone as of this writing (1/1997), though he has developed dementia felt secondary to cerebrovascular disease (stroke/TIA).","neurology, brain ct, goldman, mri, orthostatic, adenoma, generalized weakness, hypotension, lightheadedness, malaise, pituitary, sinus opacity, suprasellar mass, brain ct and mri, orthostatic hypotension, pituitary adenoma, brain, sinusitis, sellar,"
 Frontal craniotomy for placement of deep brain stimulator electrode.  Microelectrode recording of deep brain structures. Intraoperative programming and assessment of device., Neurology, Brain Stimulator Electrode ,"PREOPERATIVE DIAGNOSIS: , Tremor, dystonic form.,POSTOPERATIVE DIAGNOSIS: , Tremor, dystonic form.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,ANESTHESIA:,  MAC (monitored anesthesia care) with local anesthesia.,TITLE OF PROCEDURES:,1.  Left frontal craniotomy for placement of deep brain stimulator electrode.,2.  Right frontal craniotomy for placement of deep brain stimulator electrode.,3.  Microelectrode recording of deep brain structures.,4.  Stereotactic volumetric CT scan of head for target coordinate determination.,5.  Intraoperative programming and assessment of device.,INDICATIONS:  ,The patient is a 61-year-old woman with a history of dystonic tremor.  The movements have been refractory to aggressive medical measures, felt to be candidate for deep brain stimulation.  The procedure is discussed below.,I have discussed with the patient in great deal the risks, benefits, and alternatives.  She fully accepted and consented to the procedure.,PROCEDURE IN DETAIL:,  The patient was brought to the holding area and to the operating room in stable condition.  She was placed on the operating table in seated position.  Her head was shaved.  Scalp was prepped with Betadine and a Leksell frame was mounted after anesthetizing the pin sites with a 50:50 mixture of 0.5% Marcaine and 2% lidocaine in all planes.  IV antibiotics were administered as was the sedation.  She was then transported to the CT scan and stereotactic volumetric CT scan of the head was undertaken.  The images were then transported to the surgery planned work station where a 3-D reconstruction was performed and the target coordinates were then chosen.  Target coordinates chosen were 20 mm to the left of the AC-PC midpoint, 3 mm anterior to the AC-PC midpoint, and 4 mm below the AC-PC midpoint.  Each coordinate was then transported to the operating room as Leksell coordinates.,The patient was then placed on the operating table in a seated position once again.  Foley catheter was placed, and she was secured to the table using the Mayfield unit.  At this point then the patient's right frontal and left parietal bossings were cleaned, shaved, and sterilized using Betadine soap and paint in scrubbing fashion for 10 minutes.  Sterile drapes placed around the perimeter of the field.  This same scalp region was then anesthetized with same local anesthetic mixture.,A bifrontal incision was made as well as curvilinear incision was made over the parietal bossings.  Bur holes were created on either side of the midline just behind the coronal suture.  Hemostasis was controlled using bipolar and Bovie, and self-retaining retractors had been placed in the field.  Using the drill, then two small grooves were cut in the frontal bone with a 5-mm cutting burs and Stryker drill.  The bur holes were then curetted free, the dura cauterized, and then opened in a cruciate manner on both sides with a #11 blade.  The cortical surface was then nicked with a #11 blade on both sides as well.  The Leksell arc with right-sided coordinate was dialed in, was then secured to the frame.  Microelectrode drive was secured to the arc.  Microelectrode recording was then performed.  The signatures of the cells were recognized.  Microelectrode unit was removed.  Deep brain stimulating electrode holding unit was mounted.  The DBS electrode was then loaded into target and intraoperative programming and testing was performed.  Using the screener box and standard parameters, the patient experienced some relief of symptoms on her left side.  This electrode was secured in position using bur-hole ring and cap system.,Attention was then turned to the left side, where left-sided coordinates were dialed into the system.  The microelectrode unit was then remounted.  Microelectrode recording was then undertaken.  After multiple passes, the microelectrode unit was removed.  Deep brain stimulator electrode holding unit was mounted at the desired trajectory.  The DBS electrode was loaded into target, and intraoperative programming and testing was performed once again using the screener box.  Using standard parameters, the patient experienced similar results on her right side.  This electrode was secured using bur-hole ring and cap system.  The arc was then removed.  A subgaleal tunnel was created between the two incisions whereby distal aspect of the electrodes led through this tunnel.,We then closed the electrode, replaced subgaleally.  Copious amounts of Betadine irrigation were used.  Hemostasis was controlled using the bipolar only.  Closure was instituted using 3-0 Vicryl in a simple interrupted fashion for the fascial layer followed by skin closure with staples.  Sterile dressings were applied.  The Leksell arc was then removed.,She was rotated into the supine position and transported to the recovery room in stable and satisfactory condition.  All needle, sponge, cottonoid, and blade counts were correct x2 as verified by the nurses.","neurology, dystonic, ac-pc, ct scan, dbs electrode, intraoperative programming, microelectrode, stereotactic, tremor, brain stimulator, craniotomy, device, dystonic tremor, electrode, frontal, screener box, target coordinate, volumetric, deep brain stimulator electrode, brain stimulator electrode, volumetric ct, stimulator, brain, "
 MRI - Arteriovenous malformation with hemorrhage., Neurology, AVM with Hemorrhage ,"CC:, Headache.,HX:, 63 y/o RHF first seen by Neurology on 9/14/71 for complaint of episodic vertigo. During that evaluation she described a several year history of ""migraine"" headaches. She experienced her first episode of vertigo in 1969. The vertigo (clockwise) typically began suddenly after lying down, and was not associated with nausea/vomiting/headache. The vertigo had not been consistently associated with positional change and could last hours to days.,On 3/15/71, after 5 day bout of vertigo, right ear ache, and difficulty ambulating (secondary to the vertigo) she sought medical attention and underwent an audiogram which reportedly showed a 20% decline in low tone acuity AD. She complained of associated tinnitus which she described as a ""whistle."" In addition, her symptoms appeared to worsen with changes in head position (i.e. looking up or down). The symptoms gradually resolved and she did well until 8/71 when she experienced a 19-day episode of vertigo, tinnitus and intermittent headaches. She was seen 9/14/71, in Neurology, and admitted for evaluation.,Her neurologic exam at that time was unremarkable except for prominent bilateral systolic carotid bruits. Cerebral angiogram revealed an inoperable 7 x 6cm AVM in the right parietal region. The AVM was primarily fed by the right MCA. Otolaryngologic evaluation concluded that she probably also suffered from Meniere's disease.,On 10/14/74 she underwent a 21 day admission for SAH secondary to right parietal AVM.,On 11/23/91 she was admitted for left sided weakness (LUE > LLE), headache, and transient visual change. Neurological exam confirmed left sided weakness, and dysesthesia of the LUE only. Brain CT confirmed a 3 x 4 cm left parietal hemorrhage. She underwent unsuccessful embolization. Neuroradiology had planned to do 3 separate embolizations, but during the first, via the left MCA, they were unable to cannulate many of the AVM vessels and abandoned the procedure. She recovered with residual left hemisensory loss.,In 12/92 she presented with an interventricular hemorrhage and was managed conservatively and refused any future neuroradiologic intervention.,In 1/93 she reconsidered neurointerventional procedure and was scheduled for evaluation at the Barrows Neurological Institute in Phoenix, AZ.","neurology, arteriovenous malformation, avm, brain ct, cerebral angiogram, headache, audiogram, carotid bruits, difficulty ambulating, hemorrhage, interventricular hemorrhage, migraine, tinnitus, vertigo, visual change, weakness, episode of vertigo, evaluation, "
 MRI for Arnold Chiari II with syrinx, Neurology, Arnold Chiari II with Syrinx ,"CC:, Right sided numbness.,HX:, 28 y/o male presented with a 3 month history of progressive right sided numbness; now anesthetic to pain. In addition, he experienced worsening balance, and episodes of aspiration while eating.,PMH:, 1) Born prematurely and weighed 3#2oz., 2) Multiple episodes of aspiration pneumonia as an infant and child, 3) ASD repair age 14, 4) Left ptosis repair age 11, 5) Scoliosis, 6) Gait abnormality, 7) Poor pharyngeal reflexes.,SHX/FHX: ,Mainstream high school education, no mental retardation, ambulatory, works at cardboard shop for the disabled.,EXAM:, Short stature. Head tilt to right.,CN: Left ptosis, decreased left nasolabial fold, decreased gag reflex bilaterally.,Motor: Full strength,Sensory: Marked hypesthesia on entire right side.,Coord: Slowed RAM on left.,Station: No drift,Gait: ND,Reflexes: 3+ throughout; Babinski signs bilaterally. 8 beat ankle clonus on right and 3 beat ankle clonus on left.,MRI:, Arnold Chiari II with syrinx: Severe basilar invagination, marked compression of ventral pontomedullary junction, downward descension of cerebellar tonsils and vermis.,COURSE:, Patient underwent transpalatal/pharyngeal ventral decompression of pons/medulla with resection of clivus/odontoid and tracheostomy placement. on 9/29/92. Halo vest and ring were removed 6/18/93. 6 months later his Philadelphia collar was removed. He was last seen 4/8/94 and he had mildly spastic gait with good strength and hyperreflexia throughout. His gag response had returned and he was eating without difficulty. Sensation had returned to his extremities.","neurology, right sided numbness, arnold chiari ii with syrinx, cerebellar tonsils, vermis, philadelphia collar, arnold chiari ii, ankle clonus, mri, numbness, chiari, syrinx, gait, reflexes, arnold"
 A 75-year-old female comes in with concerns of having a stroke., Neurology, Bell's Palsy ,"SUBJECTIVE:,  The patient is a 75-year-old female who comes in today with concerns of having a stroke.  She states she feels like she has something in her throat.  She started with some dizziness this morning and some left hand and left jaw numbness.  She said that she apparently had something about three weeks ago where she was dizzy and ended up falling down and she saw Dr. XYZ for that who gave her some Antivert.  She said that today though she woke up in the middle of the night and her left hand was numb and she was having numbness on the left side of her face, as well as the left side of her neck.  She said she had an earache a day or so ago.  She has not had any cold symptoms.,ALLERGIES:,  Demerol and codeine.,MEDICATIONS: , Lotensin, Lopid, metoprolol, and Darvocet.,REVIEW OF SYSTEMS:,  The patient says that she feels little bit nauseated at times.  She denies chest pain or shortness of breath and again feels like she has something in her throat.  She has been able to swallow liquids okay.  She said that she did brush her teeth this morning and did not have any fluid dripping out of her mouth.  She does say that she occasionally has numbness in her left hand prior to today.,PHYSICAL EXAMINATION:,General:  She is awake and alert, no acute distress.,Vital Signs:  Blood pressure:  175/86.  Temperature:  She is afebrile.  Pulse:  78.  Respiratory rate:  20.  O2 sat:  93% on room air.,HEENT:  Her TMs are normal bilaterally.  Posterior pharynx is unremarkable.  It should be noted that her uvula did not deviate and neither did her tongue.  When she smiles though she has some drooping of the left side of her face, as well as some mild nasolabial fold flattening.,Neck:  Without adenopathy or thyromegaly.  Carotids pulses are brisk without bruits.,Lungs:  Clear to auscultation.,Heart:  Regular rate and rhythm without murmur.,Extremities:  Her muscle strength is symmetrical and intact bilaterally.  DTRs are 2+/4+ bilaterally and muscle strength is intact in the upper extremities.  She has a positive Tinel’s sign on her left wrist.,Neurological:  I also took monofilament and she could sense it easily when testing her sensation on her face.,ASSESSMENT:,  Bell’s Palsy.,PLAN:,  We did get an EKG showed some ST segment changes anterolaterally.  The only EKG I have here is from 1998 and she actually had bypass in 1999, but there certainly does not appear to be anything acute on his EKG.  I assured her that it does not look like she has a stroke.  If she wants to prevent a stroke, obviously quitting her smoking would help.  It should be noted she also takes Synthroid and Zocor.  We are going to give her Valtrex 1 g t.i.d. for seven days and then if she starts noticing any other drooping or worsening of her symptoms on the left side of her face, she needs to come back, but I will not start her on steroids at this time, which she agreed with.","neurology, stroke, bell’s palsy, st segment changes, ekg, dizziness, numbness, dizzy, muscle strength, palsy, bell’s"
 MRI - Right temporal lobe astrocytoma., Neurology, Astrocytoma ,"CC: ,Episodic confusion.,HX: ,This 65 y/o RHM reportedly suffered a stroke on 1/17/92. He presented locally at that time with complaint of episodic confusion and memory loss lasting several minutes per episode. The ""stroke"" was reportedly verified on MRI scan dated 1/17/92. He was subsequently placed on ASA and DPH. He admitted that there had been short periods (1-2 days duration) since then, during which he had forgotten to take his DPH. However, even when he had been taking his DPH regularly, he continued to experience the spells mentioned above. He denied any associated tonic/clonic movement, incontinence, tongue-biting, HA, visual change, SOB, palpitation, weakness or numbness. The episodes of confusion and memory loss last 1-2 minutes in duration, and have been occurring 2-3 times per week.,PMH:, Bilateral Hearing Loss of unknown etiology, S/P bilateral ear surgery many years ago.,MEDS:, DPH and ASA,SHX/FHX:, 2-4 Beers/day. 1-2 packs of cigarettes per day.,EXAM:, BP 111/68, P 68BPM, 36.8C. Alert and Oriented to person, place and time, 30/30 on mini-mental status test, Speech fluent and without dysarthria. CN: Left superior quandranopia only. Motor: 5/5 strength throughout. Sensory: unremarkable except for mild decreased vibration sense in feet. Coordination: unremarkable. Gait and station testing were unremarkable. He was able to tandem walk without difficulty. Reflexes: 2+ and symmetric throughout. Flexor plantar responses bilaterally.,LAB:, Gen Screen, CBC, PT, PTT all WNL. DPH 4.6mcg/ml.,Review of outside MRI Brain done 1/17/92 revealed decreased T1 and increased T2 signal in the Right temporal lobe involving the uncus and adjacent hippocampus. The area did not enhance with gadolinium contrast.,CXR:, 8/31/92: 5 x 6 mm spiculated opacity in apex right lung.,EEG:, 8/24/92: normal awake and asleep,MRI Brain with/without contrast: 8/31/92: Decreased T1 and increased T2 signal in the right temporal lobe. The lesion increased in size and enhances more greatly when compared to the 1/17/92 MRI exam. There is also edema surrounding the affected area and associated mass effect.,NEUROPSYCHOLOGICAL TESTING:, Low-average digit symbol substitution, mildly impaired verbal learning, and severely defective delayed recall. There was relative preservation of other cognitive functions. The findings were consistent with left mesiotemporal dysfunction.,COURSE: ,Patient underwent right temporal lobectomy on 9/16/92 following initial treatment with Decadron. Pathologic analysis was consistent with a Grade 2 astrocytoma. GFAP staining positive. Following surgery he underwent 5040 cGy radiation therapy in 28 fractions to the tumor bed.","neurology, confusion, gfap, gfap staining, mri scan, astrocytoma, hippocampus, memory loss, palpitation, signal, stroke, temporal lobe, tongue-biting, tonic/clonic movement, weakness, increased t signal, mri brain, mri, temporal, "
 Patient experiences a dull pain in his upper outer arm.  It occurs on a daily basis.  He also experiences an achy sensation in his right hand radiating to the fingers.  There is no numbness or paresthesias in the hand or arm., Neurology, Arm Pain - Neuro Consult ,"HISTORY OF PRESENT ILLNESS:  ,The patient is a 58-year-old right-handed gentleman who presents for further evaluation of right arm pain.  He states that a little less than a year ago he developed pain in his right arm.  It is intermittent, but has persisted since that time.  He describes that he experiences a dull pain in his upper outer arm.  It occurs on a daily basis.  He also experiences an achy sensation in his right hand radiating to the fingers.  There is no numbness or paresthesias in the hand or arm.,He has had a 30-year history of neck pain.  He sought medical attention for this problem in 2006, when he developed ear pain.  This eventually led to him undergoing an MRI of the cervical spine, which showed some degenerative changes.  He was then referred to Dr. X for treatment of neck pain.  He has been receiving epidural injections under the care of Dr. X since 2007.  When I asked him what symptom he is receiving the injections for, he states that it is for neck pain and now the more recent onset of arm pain.  He also has taken several Medrol dose packs, which has caused his blood sugars to increase.  He is taking multiple other pain medications.  The pain does not interfere significantly with his quality of life, although he has a constant nagging pain.,PAST MEDICAL HISTORY: , He has had diabetes since 2003.  He also has asthma, hypertension, and hypercholesterolemia.,CURRENT MEDICATIONS: , He takes ACTOplus, albuterol, AndroGel, Astelin, Diovan, Dolgic Plus, aspirin 81 mg, fish oil, Lipitor, Lorazepam, multivitamins, Nasacort, Pulmicort, ranitidine, Singulair, Viagra, Zetia, Zyrtec, and Uroxatral.  He also uses Lidoderm patches and multiple eye drops and creams.,ALLERGIES:,  He states that Dyazide, Zithromax, and amoxicillin cause him to feel warm and itchy.,FAMILY HISTORY:,  His father died from breast cancer.  He also had diabetes.  He has a strong family history of diabetes.  His mother is 89.  He has a sister with diabetes.  He is unaware of any family members with neurological disorders.,SOCIAL HISTORY:,  He lives alone.  He works full time in Human Resources for the State of Maryland.  He previously was an alcoholic, but quit in 1984.  He also quit smoking cigarettes in 1984, after 16 years of smoking.  He has a history of illicit drug use, but denies IV drug use.  He denies any HIV risk factors and states that his last HIV test was over two years ago.,REVIEW OF SYSTEMS: , He has intermittent chest discomfort.  He has chronic tinnitus.  He has urinary dribbling.  Otherwise, a complete review of systems was obtained and was negative except for as mentioned above.  This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:,Vital Signs:  HR 72. RR 16.,General Appearance:  Patient is well appearing, in no acute distress.,Cardiovascular:  There is a regular rhythm without murmurs, gallops, or rubs.  There are no carotid bruits.,Chest:  The lungs are clear to auscultation bilaterally.,Skin:  There are no rashes or lesions.,NEUROLOGICAL EXAMINATION:,Mental Status:  Speech is fluent without dysarthria or aphasia.  The patient is alert and oriented to name, place, and date.  Attention, concentration, registration, recall, and fund of knowledge are all intact.,Cranial Nerves:  Pupils are equal, round, and reactive to light and accommodation.  Optic discs are normal.  Visual fields are full.  Extraocular movements are intact without nystagmus.  Facial sensation is normal.  There is no facial, jaw, palate, or tongue weakness.  Hearing is grossly intact.  Shoulder shrug is full.,Motor:  There is normal muscle bulk and tone.  There is no atrophy or fasciculations.  There is no action or percussion myotonia or paramyotonia.  Manual muscle testing reveals MRC grade 5/5 strength in all proximal and distal muscles of the upper and lower extremities.,Sensory:  Sensation is intact to light touch, pinprick, temperature, vibratory sensation, and joint position sense.  Romberg is absent.,Coordination:  There is no dysmetria or ataxia on finger-nose-finger or heel-to-shin testing.,Deep Tendon Reflexes:  Deep tendon reflexes are 2+ at the biceps, triceps, brachioradialis, patellas and ankles.  Plantar reflexes are flexor.  There are no finger flexors, Hoffman's sign, or jaw jerk.,Gait and Stance:  Casual gait is normal.  Heel, toe, and tandem walking are all normal.,RADIOLOGIC DATA:,  MRI of the cervical spine, 05/19/08:  I personally reviewed this film, which showed narrowing of the foramen on the right at C4-C5 and other degenerative changes without central stenosis.,IMPRESSION:  ,The patient is a 58-year-old gentleman with one-year history of right arm pain.  He also has a longstanding history of neck pain.  His neurological examination is normal.  He has an MRI that shows some degenerative changes.  I do believe that his symptoms are probably referable to his neck.  However, I do not think that they are severe enough for him to undergo surgery at this point in time.  Perhaps another course of physical therapy may be helpful for him.  I probably would not recommend anymore invasive procedure, such as a spinal stimulator, as this pain really is minimal.  We could still try to treat him with neuropathic pain medications.,RECOMMENDATIONS:,1.  I scheduled him to return for an EMG and nerve conduction studies to determine whether there is any evidence of nerve damage, although I think the likelihood is low.,2.  I gave him a prescription for Neurontin.  I discussed the side effects of the medication with him.,3.  We can discuss his case tomorrow at Spine Conference to see if there are any further recommendations.",
 Patient seen in Neuro-Oncology Clinic because of increasing questions about what to do next for his anaplastic astrocytoma., Neurology, Anaplastic Astrocytoma - Letter ,"XYZ,RE:  ABC,MEDICAL RECORD#:  123,Dear Dr. XYZ:,I saw ABC back in Neuro-Oncology Clinic today.  He comes in for an urgent visit because of increasing questions about what to do next for his anaplastic astrocytoma.,Within the last several days, he has seen you in clinic and once again discussed whether or not to undergo radiation for his left temporal lesion.  The patient has clearly been extremely ambivalent about this therapy for reasons that are not immediately apparent.  It is clear that his MRI is progressing and that it seems unlikely at this time that anything other than radiation would be particularly effective.  Despite repeatedly emphasizing this; however, the patient still is worried about potential long-term side effects from treatment that frankly seem unwarranted at this particular time.,After seeing you in clinic, he and his friend again wanted to discuss possible changes in the chemotherapy regimen.  They came in with a list of eight possible agents that they would like to be administered within the next two weeks.  They then wanted another MRI to be performed and they were hoping that with the use of this type of approach, they might be able to induce another remission from which he can once again be spared radiation.,From my view, I noticed a man whose language has deteriorated in the week since I last saw him.  This is very worrisome.  Today, for the first time, I felt that there was a definite right facial droop as well.  Therefore, there is no doubt that he is becoming symptomatic from his growing tumor.  It suggests that he is approaching the end of his compliance curve and that the things may rapidly deteriorate in the near future.,Emphasizing this once again, in addition, to recommending steroids I once again tried to convince him to undergo radiation.  Despite an hour, this again amazingly was not possible.  It is not that he does not want treatment, however.  Because I told him that I did not feel it was ethical to just put him on the radical regimen that him and his friend devised, we compromised and elected to go back to Temodar in a low dose daily type regimen.  We would plan on giving 75 mg/sq m everyday for 21 days out of 28 days.  In addition, we will stop thalidomide 100 mg/day.  If he tolerates this for one week, we then agree that we would institute another one of the medications that he listed for us.  At this stage, we are thinking of using Accutane at that point.,While I am very uncomfortable with this type of approach, I think as long as he is going to be monitored closely that we may be able to get away with this for at least a reasonable interval.  In the spirit of compromise, he again consented to be evaluated by radiation and this time, seemed more resigned to the fact that it was going to happen sooner than later.  I will look at this as a positive sign because I think radiation is the one therapy from which he can get a reasonable response in the long term.,I will keep you apprised of followups.  If you have any questions or if I could be of any further assistance, feel free to contact me.,Sincerely,","neurology, neuro oncology, anaplastic astrocytoma, anaplastic, oncology, radiation, astrocytoma"
 CT Brain - arachnoid cyst Arachnoid cyst diagnosed by CT brain., Neurology, Arachnoid Cyst ,"CC:, Seizures.,HX: ,The patient was initially evaluated at UIHC at 7 years of age. He had been well until 7 months prior to evaluation when he started having spells which were described as ""dizzy spells"" lasting from several seconds to one minute in duration. They occurred quite infrequently and he was able to resume activity immediately following the episodes. The spell became more frequent and prolonged, and by the time of initial evaluation were occurring 2-3 times per day and lasting 2-3 minutes in duration. In addition, in the 3 months prior to evaluation, the right upper extremity would become tonic and flexed during the episodes, and he began to experience post ictal fatigue.,BIRTH HX:, 32 weeks gestation to a G4 mother and weighed 4#11oz. He was placed in an incubator for 3 weeks. He was jaundiced, but there was no report that he required treatment.,PMH: ,Single febrile convulsion lasting ""3 hours"" at age 2 years.,MEDS: ,none.,EXAM:, Appears healthy and in no acute distress. Unremarkable general and neurologic exam.,Impression: Psychomotor seizures.,Studies: Skull X-Rays were unremarkable.,EEG showed ""minimal spike activity during hyperventilation, as well as random sharp delta activity over the left temporal area, in drowsiness and sleep. This record also showed moderate amplitude asymmetry ( left greater than right) over the frontal central and temporal areas, which is a peculiar finding."",COURSE:, The patient was initially treated with Phenobarbital; then Dilantin was added (early 1970's); then Depakene was added ( early 1980's) due to poor seizure control. An EEG on 8/22/66 showed ""Left mid-temporal spike focus with surrounding slow abnormality, especially posterior to the anterior temporal areas (sparing the parasagittal region). In addition, the right lateral anterior hemisphere voltage is relatively depressed. ...this suggests two separate areas of cerebral pathology."" He underwent his first HCT scan in Sioux City in 1981, and this revealed an right temporal arachnoid cyst. The patient had behavioral problems throughout elementary/junior high/high school. He underwent several neurosurgical evaluations at UIHC and Mayo Clinic and was told that surgery was unwarranted. He was placed on numerous antiepileptic medication combinations including Tegretol, Dilantin, Phenobarbital, Depakote, Acetazolamide, and Mysoline. Despite this he averaged 2-3 spells a month. He was last seen, 6/19/95, and was taking Dilantin and Tegretol. His typical spells were described as sudden in onset and without aura. He frequently becomes tonic or undergoes tonic-clonic movement and falls with associated loss of consciousness. He usually has rapid recovery and can return to work in 20 minutes. He works at a Turkey packing plant. Serial HCT scans showed growth in the arachnoid cyst until 1991, when growth arrest appeared to have occurred.","neurology, arachnoid cyst, hct scan, seizures, serial hct scans, dizzy spells, drowsiness, hyperventilation, loss of consciousness, moderate amplitude asymmetry, temporal area, tonic-clonic movement, phenobarbital, dilantin, cyst, temporal, arachnoid"
 Bilateral renal ultrasound., Nephrology, Renal Ultrasound - 1 ,"EXAM: , Bilateral renal ultrasound.,CLINICAL INDICATION: , UTI.,TECHNIQUE: , Transverse and longitudinal sonograms of the kidneys were obtained.,FINDINGS:  ,The right kidney is of normal size and echotexture and measures 5.7 x 2.2 x 3.8 cm.  The left kidney is of normal size and echotexture and measures 6.2 x 2.8 x 3.0 cm.  There is no evidence for ,HYDRONEPHROSIS, or ,PERINEPHRIC ,fluid collections.  The bladder is of normal size and contour.  The bladder contains approximately 13 mL of urine after recent voiding.  This is a small postvoid residual.,IMPRESSION: , Normal renal ultrasound.  Small postvoid residual.","nephrology, bilateral renal ultrasound, postvoid residual, renal ultrasound, residual, kidneys, renal, ultrasound,"
" Right shockwave lithotripsy, cystoscopy, and stent removal x2.", Nephrology, Shockwave Lithotripsy ,"PREOPERATIVE DIAGNOSIS:,  Right renal stone.,POSTOPERATIVE DIAGNOSIS:  ,Right renal stone.,PROCEDURE: , Right shockwave lithotripsy, cystoscopy, and stent removal x2.,ANESTHESIA: , LMA.,ESTIMATED BLOOD LOSS:,  Minimal.  The patient was given antibiotics preoperatively.,HISTORY: , This is a 47-year-old male who presented with right renal stone and right UPJ stone.  The right UPJ stone was removed using ureteroscopy and laser lithotripsy and the stone in the kidney.  The plan was for shockwave lithotripsy.  The patient had duplicated system on the right side.  Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE was discussed.  Options such as watchful waiting, passing the stone on its own, and shockwave lithotripsy were discussed.  The patient wanted to proceed with the shockwave to break the stone into small pieces as possible to allow the stones to pass easily.  Consent was obtained.,DETAILS OF THE OPERATION:  ,The patient was brought to the OR.  Anesthesia was applied.  The patient was placed in the supine position.  Using Dornier lithotriptor total of 2500 shocks were applied.  Energy levels were slowly started at O2 increased up to 7; gradually the stone seem to have broken into smaller pieces as the number of shocks went up.  The shocks were started at 60 per minute and slowly increased up to 90 per minute.  The patient's heart rate and blood pressure were stable throughout the entire procedure.,After the end of the shockwave lithotripsy the patient was placed in dorsal lithotomy position.  The patient was prepped and draped in usual sterile fashion and cystoscopy was done.  Using graspers, the stent was grasped x2 and pulled out, both stents were removed.  The patient tolerated the procedure well.  The patient was brought to recovery in stable condition.  The plan was for the patient to follow up with us and plan for KUB in about two to three months.","nephrology, renal stone, stent removal, upj stone, shockwave lithotripsy, cystoscopy, stent, renal, shocks, upj, shockwave, lithotripsy, stone"
 MRI - Intracerebral hemorrhage (very acute clinical changes occurred immediately prior to scan)., Neurology, Acute Intracerebral Hemorrhage ,"CC: ,Left hand numbness on presentation; then developed lethargy later that day.,HX: ,On the day of presentation, this 72 y/o RHM suddenly developed generalized weakness and lightheadedness, and could not rise from a chair. Four hours later he experienced sudden left hand numbness lasting two hours. There were no other associated symptoms except for the generalized weakness and lightheadedness. He denied vertigo.,He had been experiencing falling spells without associated LOC up to several times a month for the past year.,MEDS:, procardia SR, Lasix, Ecotrin, KCL, Digoxin, Colace, Coumadin.,PMH: ,1)8/92 evaluation for presyncope (Echocardiogram showed: AV fibrosis/calcification, AV stenosis/insufficiency, MV stenosis with annular calcification and regurgitation, moderate TR, Decreased LV systolic function, severe LAE. MRI brain: focal areas of increased T2 signal in the left cerebellum and in the brainstem probably representing microvascular ischemic disease. IVG (MUGA scan)revealed: global hypokinesis of the LV and biventricular dysfunction, RV ejection Fx 45% and LV ejection Fx 39%. He was subsequently placed on coumadin severe valvular heart disease), 2)HTN, 3)Rheumatic fever and heart disease, 4)COPD, 5)ETOH abuse, 6)colonic polyps, 7)CAD, 8)CHF, 9)Appendectomy, 10)Junctional tachycardia.,FHX:, stroke, bone cancer, dementia.,SHX: ,2ppd smoker since his teens; quit 2 years ago. 6-pack beer plus 2 drinks per day for many years: now claims he has been dry for 2 years. Denies illicit drug use.,EXAM: ,36.8C, 90BPM, BP138/56.,MS: Alert and oriented to person, place, but not date. Hypophonic and dysarthric speech. 2/3 recall. Followed commands.,CN: Left homonymous hemianopia and left CN7 nerve palsy (old).,MOTOR: full strength throughout.,SENSORY: unremarkable.,COORDINATION: dysmetric FNF and HKS movements (left worse than right).,STATION: RUE pronator drift and Romberg sign present.,GAIT: shuffling and bradykinetic.,REFLEXES: 1+/1+ to 2+/2+ and symmetric throughout. Plantar responses were flexor bilaterally.,HEENT: Neck supple and no carotid bruits.,CV: RRR with 3/6 SEM and diastolic murmurs throughout the precordium.,Lungs: bibasilar crackles.,LABS:, PT 19 (elevated) and PTT 46 (elevated).,COURSE:, Coumadin was discontinued on admission as he was felt to have suffered a right hemispheric stroke. The initial HCT revealed a subtle low density area in the right occipital lobe and no evidence of hemorrhage. He was scheduled to undergo an MRI Brain scan the same day, and shortly before the procedure became lethargic. By the time the scan was complete he was stuporous. MRI Scan then revealed a hypointense area of T1 signal in the right temporal lobe with a small foci of hyperintensity within it. The hyperintense area seen on T1 weighted images appeared hypointense on T2 weighted images. There was edema surrounding the lesion The findings were consistent with a hematoma. A CT scan performed 4 hours later confirmed a large hematoma with surrounding edema involving the right temporal/parietal/occipital lobes. The patient subsequently died.",
 AP abdomen and ultrasound of kidney., Nephrology, Ultrasound - Kidney ,"EXAM: , AP abdomen and ultrasound of kidney.,HISTORY:,  Ureteral stricture.,AP ABDOMEN ,FINDINGS:,  Comparison is made to study from Month DD, YYYY.  There is a left lower quadrant ostomy.  There are no dilated bowel loops suggesting obstruction.  There is a double-J right ureteral stent, which appears in place.  There are several pelvic calcifications, which are likely vascular.  No definite pathologic calcifications are seen overlying the regions of the kidneys or obstructing course of the ureters.  Overall findings are stable versus most recent exam.,IMPRESSION: , Properly positioned double-J right ureteral stent.  No evidence for calcified renal or ureteral stones.,ULTRASOUND KIDNEYS,FINDINGS:,  The right kidney is normal in cortical echogenicity of solid mass, stone, hydronephrosis measuring 9.0 x 2.9 x 4.3 cm.  There is a right renal/ureteral stent identified.  There is no perinephric fluid collection.,The left kidney demonstrates moderate-to-severe hydronephrosis.  No stone or solid masses seen.  The cortex is normal.,The bladder is decompressed.,IMPRESSION:,1.  Left-sided hydronephrosis.,2.  No visible renal or ureteral calculi.,3.  Right ureteral stent.","nephrology, ureteral stricture, ap abdomen, bowel loops, calcified, calculi, double-j, echogenicity, hydronephrosis, kidney, left lower quadrant, obstruction, ostomy, perinephric, renal, solid mass, stent, ultrasound, ureteral stent, ureteral stones, ureters, ureteral,"
" Ultrasound kidneys/renal for renal failure, neurogenic bladder, status-post cystectomy", Nephrology, Renal Ultrasound ,"EXAM:,  Renal ultrasound.,HISTORY: , Renal failure, neurogenic bladder, status-post cystectomy.,TECHNIQUE: , Multiple ultrasonographic images of the kidneys were obtained in the transverse and longitudinal planes.,COMPARISON:,  Most recently obtained mm/dd/yy.,FINDINGS:,  The right kidney measures 12 x 5.2 x 4.6 cm and the left kidney measures 12.2 x 6.2 x 4.4 cm.  The imaged portions of the kidneys fail to demonstrate evidence of mass, hydronephrosis or calculus.  There is no evidence of cortical thinning.,Incidentally there is a rounded low-attenuation mass within the inferior aspect of the right lobe of the liver measuring 2.1 x 1.5 x 1.9 cm which has suggestion of some peripheral blood flow.,IMPRESSION:,1.  No evidence of hydronephrosis.,2.  Mass within the right lobe of the liver.  The patient apparently has a severe iodine allergy.  Further evaluation with MRI is recommended.,3.  The results of this examination were given to XXX in Dr. XXX office on mm/dd/yy at XXX,","nephrology, lobe of the liver, status post cystectomy, renal ultrasound, renal failure, neurogenic bladder, bladder status, neurogenic, bladder, cystectomy, hydronephrosis, lobe, liver, ultrasound, mass, renal, kidneys/renal,"
" Patient with a history of coronary artery disease, congestive heart failure, COPD, hypertension, and renal insufficiency.", Nephrology, Renal Insufficiency - Consult ,"REASON FOR CONSULT:, Renal insufficiency.,HISTORY OF PRESENT ILLNESS:, A 48-year-old African-American male with a history of coronary artery disease, COPD, congestive heart failure with EF of 20%-25%, hypertension, renal insufficiency, and recurrent episodes of hypertensive emergency, admitted secondary to shortness of breath and productive cough. The patient denies any chest pain, palpitations, syncope, or fever. Denied any urinary disturbances, difficulty, burning micturition, hematuria, or back pain. Nephrology is consulted regarding renal insufficiency.,REVIEW OF SYSTEMS:, Reviewed entirely and negative except for HPI.,PAST MEDICAL HISTORY:, Hypertension, congestive heart failure with ejection fraction of 20%-25% in December 2005, COPD, mild diffuse coronary artery disease, and renal insufficiency.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,MEDICATIONS:, Clonidine 0.3 p.o. q.8, aspirin 325 daily, hydralazine 100 q.8, Lipitor 20 at bedtime, Toprol XL 100 daily.,FAMILY HISTORY:, Noncontributory.,SOCIAL HISTORY:, The patient denies any alcohol, IV drug abuse, tobacco, or any recreational drugs.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 180/110. Temperature 98.1. Pulse rate 60. Respiratory rate 23. O2 sat 95% on room air.,GENERAL: A 48-year-old African-American male in no acute distress.,HEENT: Pupils equal, round, and reactive to light and accommodation. No pallor or icterus.,NECK: No JVD, bruit, or lymphadenopathy.,HEART: S1 and S2, regular rate and rhythm, no murmurs, rubs, or gallops.,LUNGS: Clear. No wheezes or crackles.,ABDOMEN: Soft, nontender, nondistended, no organomegaly, bowel sounds present.,EXTREMITIES: No cyanosis, clubbing, or edema.,CNS: Exam is nonfocal.,LABS:, WBC 7, H and H 13 and 40, platelets 330, PT 12, PTT 26, CO2 20, BUN 27, creatinine 3.1, cholesterol 174, BNP 973, troponin 0.18. Previous creatinine levels were 2.7 in December. Urine drug screen positive for cocaine.,ASSESSMENT:, A 48-year-old African-American male with a history of coronary artery disease, congestive heart failure, COPD, hypertension, and renal insufficiency with:,1. Hypertensive emergency.,2. Acute on chronic renal failure.,3. Urine drug screen positive.,4. Question CHF versus COPD exacerbation.,PLAN:,1. Most likely, renal insufficiency is a chronic problem. Hypertensive etiology worsened by the patient's chronic cocaine abuse.,2. Control blood pressure with medications as indicated. Hypertensive emergency most likely related to cocaine drug abuse.,Thank you for this consult. We will continue to follow the patient with you.",
 MRI brain & PET scan - Dementia of Alzheimer type with primary parietooccipital involvement., Neurology, Alzheimer Disease ,"CC:, Memory difficulty.,HX: ,This 64 y/o RHM had had difficulty remembering names, phone numbers and events for 12 months prior to presentation, on 2/28/95. This had been called to his attention by the clerical staff at his parish--he was a Catholic priest. He had had no professional or social faux pas or mishaps due to his memory. He could not tell whether his problem was becoming worse, so he brought himself to the Neurology clinic on his own referral.,MEDS:, None.,PMH: ,1)appendectomy, 2)tonsillectomy, 3)childhood pneumonia, 4)allergy to sulfa drugs.,FHX:, Both parents experienced memory problems in their ninth decades, but not earlier. 5 siblings have had no memory trouble. There are no neurological illnesses in his family.,SHX:, Catholic priest. Denied Tobacco/ETOH/illicit drug use.,EXAM:,  BP131/74, HR78, RR12, 36.9C, Wt. 77kg, Ht. 178cm.,MS: A&O to person, place and time. 29/30 on MMSE; 2/3 recall at 5 minutes. 2/10 word recall at 10 minutes. Unable to remember the name of the President (Clinton). 23words/60 sec on Category fluency testing (normal). Mild visual constructive deficit.,The rest of the neurologic exam was unremarkable and there were no extrapyramidal signs or primitive reflexes noted.,COURSE:, TSH 5.1, T4 7.9, RPR non-reactive. Neuropsychological evaluation, 3/6/95, revealed: 1)well preserved intellectual functioning and orientation, 2) significant deficits in verbal and visual memory, proper naming, category fluency and working memory, 3)performances which were below expectations on tests of speed of reading, visual scanning, visual construction and clock drawing, 4)limited insight into the scope and magnitude of cognitive dysfunction. The findings indicated multiple areas of cerebral dysfunction. With the exception of the patient's report of minimal occupational dysfunction ( which may reflect poor insight), the clinical picture is consistent with a progressive dementia syndrome such as Alzheimer's disease. MRI brain, 3/6/95, showed mild generalized atrophy, more severe in the occipital-parietal regions.,In 4/96, his performance on repeat neuropsychological evaluation was relatively stable. His verbal learning and delayed recognition were within normal limits, whereas delayed recall was ""moderately severely"" impaired. Immediate and delayed visual memory were slightly below expectations. Temporal orientation and expressive language skills were below expectation, especially in word retrieval. These findings were suggestive of particular, but not exclusive, involvement of the temporal lobes.,On 9/30/96, he was evaluated for a 5 minute spell of visual loss, OU. The episode occurred on Friday, 9/27/96, in the morning while sitting at his desk doing paperwork. He suddenly felt that his gaze was pulled toward a pile of letters; then a ""curtain"" came down over both visual fields, like ""everything was in the shade."" During the episode he felt fully alert and aware of his surroundings. He concurrently heard a ""grating sound"" in his head. After the episode, he made several phone calls, during which he reportedly sounded confused, and perseverated about opening a bank account. He then drove to visit his sister in Muscatine, Iowa, without accident. He was reportedly ""normal"" when he reached her house. He was able to perform Mass over the weekend without any difficulty. Neurologic examination, 9/30/96, was notable for: 1)category fluency score of 18items/60 sec. 2)VFFTC and EOM were intact. There was no RAPD, INO, loss of visual acuity. Glucose 178 (elevated), ESR ,Lipid profile, GS, CBC with differential, Carotid duplex scan, EKG, and EEG were all normal. MRI brain, 9/30/96, was unchanged from previous, 3/6/95.,On 1/3/97, he had a 30 second spell of lightheadedness without vertigo, but with balance difficulty, after picking up a box of books. The episode was felt due to orthostatic changes.,1/8/97 neuropsychological evaluation was stable and his MMSE score was 25/30 (with deficits in visual construction, orientation, and 2/3 recall at 1 minute). Category fluency score 23 items/60 sec. Neurologic exam was notable for graphesthesia in the left hand.,In 2/97, he had episodes of anxiety, marked fluctuations in job performance and resigned his pastoral position. His neurologic exam was unchanged. An FDG-PET scan on 2/14/97 revealed decreased uptake in the right posterior temporal-parietal and lateral occipital regions.","neurology, dementia, a&o to person, alzheimer's disease, alzheimer's type, mmse, mmse score, mri brain, memory difficulty, neuropsychological, balance difficulty, category fluency, faux pas, minimal occupational dysfunction, parieto-occipital, progressive dementia syndrome, visual acuity, visual loss, visual memory, pet scan, neuropsychological evaluation, alzheimer's, neurological, memory, "
" Right ureteropelvic junction obstruction.  Robotic-assisted pyeloplasty, anterograde right ureteral stent placement, transposition of anterior crossing vessels on the right, and nephrolithotomy.", Nephrology, Pyeloplasty - Robotic ,"PROCEDURES:,1.  Robotic-assisted pyeloplasty.,2.  Anterograde right ureteral stent placement.,3.  Transposition of anterior crossing vessels on the right.,4.  Nephrolithotomy.,DIAGNOSIS:,  Right ureteropelvic junction obstruction.,DRAINS:,1.  Jackson-Pratt drain times one from the right flank.,2.  Foley catheter times one.,ESTIMATED BLOOD LOSS: , Less than 30 cc.,COMPLICATIONS: , None.,SPECIMENS:,1.  Renal pelvis.,2.  Kidney stones.,INDICATIONS:  ,The patient is a 30-year-old Caucasian gentleman with history of hematuria subsequently found to have right renal stones and patulous right collecting system with notable two right crossing renal arteries.  Up on consideration of various modalities and therapy, the patient decided to undergo surgical therapy.,PROCEDURE IN DETAIL:  ,The patient was verified by armband and the procedure being robotic-assisted right pyeloplasty with nephrolithotomy was verified, and the procedure was carried out.  After institution of general endotracheal anesthesia and intravenous preoperative antibiotics, the patient was positioned into the right flank position with his right flank elevated.  Great care was taken to pad all pressure points and a right arm hanger was used.  The patient was flexed slightly, and a kidney rest was used.  Sequential compression devices were also placed.  Next, the patient was prepped and draped in normal sterile fashion with povidone-iodine.  Pneumoperitoneum was obtained by placing a Veress needle in the area of the umbilicus after it passed the water test.  A low pressure, high flow pneumoperitoneum was adequately obtained using CO2 gas.  Next, a 12-mm camera port was placed near the umbilicus.  The camera was inserted, and no bowel injury was seen.  Next, under direct vision flanking 8 mm camera ports, a 12 mm assist port, a 5 mm liver retraction port, and 5 mm assist port were placed.  The robot was docked and the instruments passed through respective checks.  Initial attention was directed to mobilizing the right colon from the abdominal wall totally medially.  Next, the right lateral duodenum was cauterized for further access to the right retroperitoneum.  At this point, the right kidney was in clear view, and the fascia was entered.  Initial attention was directed at careful dissection of the renal pelvis and proximal ureter which was done with a combination of electrocautery and blunt dissection.  It became readily apparent that there were two crossing vessels one in the medial inferior region of the kidney and another one in the most inferior portion of the lower pole.  These arteries were dissected carefully and vessel loops were applied.  Next, a small hole was then made in the renal pelvis using electrocautery and the contents of the renal pelvis were suctioned out.  The pyelotomy was extended so that the renal collecting system could be directly inspected.  Sequentially, each major calyx was inspected under direct vision and irrigated.  A total of four round kidney stones were extracted to be sent for analysis to being satisfied for the patient.  At this point, we directed our attention at the proximal right ureter which was dismembered from the remaining renal pelvis.  The proximal ureter was spatulated using cold scissors.  Next, redundant renal pelvis was excised using cold scissors and sent for permanent section.  We then identified the most inferior/dependent portion of the renal pelvis and placed a heel stitch at this for ureteral-renal pelvis anastomosis in a semi running fashion.  3-0 Monocryl sutures were used to re-anastomose the newly spatulated right ureter to the inferior portion of the renal pelvis.  Next, remainder of the pyelotomy was closed to itself also using 2-0 Monocryl sutures.  Before final stitches were placed, a 6x28 ureteral stent was placed anterograde.  This was accomplished by placing the stents over a guidewire, placing the guidewire under direct vision anterograde through the ureter.  This was done until the proximal end was in the renal pelvis, the guidewire was removed, and good proximal curl was verified by direct vision.  Then, the pyelotomy was completely closed again with 2-0 Monocryl sutures.  Next, attention was directed at transposition of the crossing renal artery by fixing it with Vicryl suture that would impinge less upon the renal pelvis.  Good pulsation was verified by direct vision proximal and distal to these pexy sutures.  Next, Gerota's fascia was reapproximated and closed with Vicryl sutures as was the right peritoneum.  Hemostasis appeared excellent at this point.  There was no obvious urine extravasation.  At this time, the procedure was terminated.  The robot was undocked.  Under direct visualization all 8 and 12 mm ports were closed at the level of the fascia with 0 Vicryl sutures in an interrupted fashion.  Then, all skin port sites were closed with 4-0 Monocryl in a subcuticular fashion and Dermabond and band-aids were applied over this.  Also, notably a Jackson-Pratt drain was placed in the area of the right kidney and additional right flank stab incision.  The patient tolerated the procedure well and no immediate perioperative complication was noted.,DISPOSITION: , The patient was discharged to Post Anesthesia Care Unit and subsequently to genitourinary floor to begin his recovery.","nephrology, pyeloplasty, ureteral stent placement, nephrolithotomy, ureteropelvic junction obstruction, jackson-pratt drain, foley catheter, renal pelvis, kidney stones, monocryl sutures, pelvis, renal, ureteropelvic, sutures, "
 The patient is a 74-year-old woman who presents for neurological consultation for possible adult hydrocephalus.  Mild gait impairment and mild cognitive slowing., Neurology, Adult Hydrocephalus ,"REASON FOR VISIT: , The patient is a 74-year-old woman who presents for neurological consultation referred by Dr. X.  She is accompanied to the appointment by her husband and together they give her history.,HISTORY OF PRESENT ILLNESS: , The patient is a lovely 74-year-old woman who presents with possible adult hydrocephalus.  Danish is her native language, but she has been in the United States for many many years and speaks fluent English, as does her husband.,With respect to her walking and balance, she states ""I think I walk funny.""  Her husband has noticed over the last six months or so that she has broadened her base and become more stooped in her pasture.  Her balance has also gradually declined such that she frequently touches walls and furniture to stabilize herself.  She has difficulty stepping up on to things like a scale because of this imbalance.  She does not festinate.  Her husband has noticed some slowing of her speed.  She does not need to use an assistive device.  She has occasional difficulty getting in and out of a car.  Recently she has had more frequent falls.  In March of 2007, she fell when she was walking to the bedroom and broke her wrist.  Since that time, she has not had any emergency room trips, but she has had other falls.,With respect to her bowel and bladder, she has no issues and no trouble with frequency or urgency.,The patient does not have headaches.,With respect to thinking and memory, she states she is still able to pay the bills, but over the last few months she states, ""I do not feel as smart as I used to be.""  She feels that her thinking has slowed down.  Her husband states that he has noticed, she will occasionally start a sentence and then not know what words to use as she is continuing.,The patient has not had trouble with syncope.  She has had past episodes of vertigo, but not recently.,PAST MEDICAL HISTORY:  ,Significant for hypertension diagnosed in 2006, reflux in 2000, insomnia, but no snoring or apnea.  She has been on Ambien, which is no longer been helpful.  She has had arthritis since year 2000, thyroid abnormalities diagnosed in 1968, a hysterectomy in 1986, and a right wrist operation after her fall in 2007 with a titanium plate and eight screws.,FAMILY HISTORY: , Her father died with heart disease in his 60s and her mother died of colon cancer.  She has a sister who she believes is probably healthy.  She has had two sons one who died of a blood clot after having been a heavy smoker and another who is healthy.  She has two normal vaginal deliveries.,SOCIAL HISTORY:  ,She lives with her husband.  She is a nonsmoker and no history of drug or alcohol abuse.  She does drink two to three drinks daily.  She completed 12th grade.,ALLERGIES: , Codeine and sulfa.,She has a Living Will and if unable to make decisions for herself, she would want her husband, Vilheim to make decisions for her.,MEDICATIONS,:  Premarin 0.625 mg p.o. q.o.d., Aciphex 20 mg p.o. q. daily, Toprol 50 mg p.o. q. daily, Norvasc 5 mg p.o. q. daily, multivitamin, Caltrate plus D, B-complex vitamins, calcium and magnesium, and vitamin C daily.,MAJOR FINDINGS: , On examination today, this is a pleasant and healthy appearing woman.,VITAL SIGNS:  Blood pressure 154/72, heart rate 87, and weight 153 pounds.  Pain is 0/10.,HEAD:  Head is normocephalic and atraumatic.  Head circumference is 54 cm, which is in the 10-25th percentile for a woman who is 5 foot and 6 inches tall.,SPINE:  Spine is straight and nontender.  Spinous processes are easily palpable.  She has very mild kyphosis, but no scoliosis.,SKIN:  There are no neurocutaneous stigmata.,CARDIOVASCULAR EXAM:  Regular rate and rhythm.  No carotid bruits.  No edema.  No murmur.  Peripheral pulses are good.  Lungs are clear.,MENTAL STATUS:  Assessed for recent and remote memory, attention span, concentration, and fund of knowledge.  She scored 30/30 on the MMSE when attention was tested with either spelling or calculations.  She had no difficulty with visual structures.,CRANIAL NERVES:  Pupils are equal.  Extraocular movements are intact.  Face is symmetric.  Tongue and palate are midline.  Jaw muscles strong.  Cough is normal.  SCM and shrug 5 and 5.  Visual fields intact.,MOTOR EXAM:  Normal for bulk, strength, and tone.  There was no drift or tremor.,SENSORY EXAM:  Intact for pinprick and proprioception.,COORDINATION:  Normal for finger-to-nose.,REFLEXES:  Are 2+ throughout.,GAIT:  Assessed using the Tinetti assessment tool.  She was fairly quick, but had some unsteadiness and a widened base.  She did not need an assistive device.  I gave her a score of 13/16 for balance and 9/12 for gait for a total score of 22/28.,REVIEW OF X-RAYS: , MRI was reviewed from June 26, 2008.  It shows mild ventriculomegaly with a trace expansion into the temporal horns.  The frontal horn span at the level of foramen of Munro is 3.8 cm with a flat 3rd ventricular contour and a 3rd ventricular span of 11 mm.  The sylvian aqueduct is patent.  There is no pulsation artifact.  Her corpus callosum is bowed and effaced.  She has a couple of small T2 signal abnormalities, but no significant periventricular signal change.,ASSESSMENT:  ,The patient is a 74-year-old woman who presents with mild progressive gait impairment and possible slowing of her cognition in the setting of ventriculomegaly suggesting possible adult hydrocephalus.,PROBLEMS/DIAGNOSES:,1.  Possible adult hydrocephalus (331.5).,2.  Mild gait impairment (781.2).,3.  Mild cognitive slowing (290.0).,PLAN: , I had a long discussion with the patient her husband.,I think it is possible that the patient is developing symptomatic adult hydrocephalus.  At this point, her symptoms are fairly mild.  I explained to them the two methods of testing with CSF drainage.  It is possible that a large volume lumbar puncture would reveal whether she is likely to respond to shunt and I described that test.  About 30% of my patients with walking impairment in a setting of possible adult hydrocephalus can be diagnosed with a large volume lumbar puncture.  Alternatively, I could bring her into the hospital for four days of CSF drainage to determine whether she is likely to respond to shunt surgery.  This procedure carries a 2% to 3% risk of meningitis.  I also explained that it would be reasonable to start with an outpatient lumbar puncture and if that is not sufficient we could proceed with admission for the spinal catheter protocol.",
" Acute renal failure, suspected, likely due to multi-organ system failure syndrome.", Nephrology, Renal Failure - Consult ,"REASON FOR CONSULTATION:, Acute renal failure.,HISTORY: , Limited data is available; I have reviewed his admission notes. Apparently this man was found down by a family member, was taken to Medical Center, and subsequently flown here. He has got respiratory failure, multi-organ system failure syndrome, and has renal insufficiency, as well. Markers of renal function have been fairly stable. I do not presently see indicators that he historically has been oliguric. The BUN and creatinine have been fairly stable. It is not clear whether he was taking his lisinopril up until the time of his demise, and it is also not clear whether he was taking his diuretic. Earlier thoughts had been that he could have had rhabdomyolysis, but the highest CPK I find recorded is 1500, the phosphorus is not elevated, though I acknowledge the serum calcium is low. I see no markers of myoglobinuria nor serum level of myoglobin. He has received IV fluid resuscitation, good broad-spectrum antibiotic coverage, continues mechanically ventilated, and is on parenteral nutrition.,PAST MEDICAL HISTORY:, Not obtained from the patient, but is reviewed in other physician's notes and seems notable for probably atherosclerotic cardiovascular disease wherein he was taking Imdur and digoxin, reportedly. A suggestion of hypertensive disease versus BPH, he was on terazosin. Suggestion of CHF versus hypertension versus volume overload, treated with Lasix. He was iron, I presume for anemia. He was on potassium, lisinopril and aspirin.,ALLERGIES:, OTHER PHYSICIAN'S NOTES INDICATE NO KNOWN ALLERGIES.,FAMILY HISTORY:, Not available.,SOCIAL HISTORY:, Not available.,REVIEW OF SYSTEMS:, Not available.,PHYSICAL EXAMINATION:,GENERAL: An older white male who is intubated, edematous, and appears uncomfortable.,HEENT: Male pattern baldness. Pupils equally round, no icterus. Intubated. OG tube in place.,NECK: Not tested for suppleness, no carotid bruits are heard. Neck vein distention is not seen.,LUNGS: He has diffuse expiratory wheezing anteriorly, laterally and posteriorly. I would describe the wheezes as coarse. I hear no present rales. Breath sounds otherwise are symmetrical.,HEART: Heart tones regular to auscultation, currently without audible rub or gallop sounds.,BREASTS: Not enlarged.,ABDOMEN: On plane. Bowel sounds presently are normal. Abdomen, I believe, is soft on plane, normal bowel sounds, no bruits, no liver edge felt, no HJR, no spleen tip, no suprapubic fullness.,GU: Catheter draining a dark yellow urine.,EXTREMITIES: Very edematous. Pulses not palpable. Cyanosis not observed. Fungal changes are not observed.,NEUROLOGICAL: Not otherwise assessed.,LABORATORY DATA:, Reviewed.,IMPRESSION:,1. Acute renal failure, suspected. Likely due to multi-organ system failure syndrome, with antecedent lisinopril use at home and at time of demise. He also reportedly was on Lasix prior to hospitalization, ? hypovolemia as a consequence.,2. Multi-organ system failure/systemic inflammatory response syndrome, with septic shock.,3. I am under-whelmed presently with the diagnosis of rhabdomyolysis, if the maximum CK recorded is 1500.,4. Antecedent hypoxemia, with renal hypoperfusion.,5. Diffuse aspiration pneumonitis suggested.,DISCUSSION/PLAN: ,I think the renal function will follow the patient. Supportive care, attention to stability of a euvolemic state, will be important at this time. He is currently nonoliguric, has apparently stable, diffuse, bilateral wheezing, with adequate gas exchange. He is on TPN, antimicrobials, and has been on vasopressive agents. Blood pressures are close to acceptable, he may now be wearing off his lisinopril, assuming he was taking it prior to admission.,I would use diuretics to maintain central euvolemia. Recorded I's are substantially O's during the course of the hospitalization, I presume as part of his resuscitation effort. No central pressures or monitoring of same is currently available. I will follow with you. No present indication for hemodialysis. Antimicrobials are being handled by others.",
 Cadaveric renal transplant to right pelvis - endstage renal disease., Nephrology, Renal Transplant - Cadaveric ,"HISTORY OF PRESENT ILLNESS:  ,The patient is a 50-year-old African American female with past medical history significant for hypertension and endstage renal disease, on hemodialysis secondary to endstage renal disease, last hemodialysis was on June 22, 2007.  The patient presents with no complaints for cadaveric renal transplant.  After appropriate cross match and workup of HLA typing of both recipient and cadaveric kidneys, the patient was deemed appropriate for operative intervention and transplantation of kidney.,PREOPERATIVE DIAGNOSIS:,  Endstage renal disease.,POSTOPERATIVE DIAGNOSIS: , Endstage renal disease.,PROCEDURE:,  Cadaveric renal transplant to right pelvis.,ESTIMATED BLOOD LOSS: , 400 mL.,FLUIDS:  ,One liter of normal saline and one liter of 5% of albumin.,ANESTHESIA:  ,General endotracheal.,SPECIMEN:  ,None.,DRAIN: , None.,COMPLICATIONS: , None.,The patient tolerated the procedure without any complication.,PROCEDURE IN DETAIL:  ,The patient was brought to the operating room, prepped and draped in sterile fashion.  After adequate anesthesia was achieved, a curvilinear incision was made in the right pelvic fossa approximately 9 cm in length extending from the 1.5 cm medial of the ASIS down to the suprapubic space.  After this was taken down with a #10 blade, electrocautery was used to take down tissue down to the layer of the subcutaneous fat.  Camper's and Scarpa's were dissected with electrocautery.  Hemostasis was achieved throughout the tissue plains with electrocautery.  The external oblique aponeurosis was identified with musculature and was entered with electrocautery.  Then hemostats were entered in and dissection continued down with electrocautery down through the external internal obliques and the transversalis fascia.  Additionally, the rectus sheath was entered in a linear fashion.  After these planes were entered using electrocautery, the retroperitoneum was dissected free from the transversalis fascia using blunt dissection.  After the peritoneum and peritoneal structures were moved medially and superiorly by blunt dissection, the dissection continued down bluntly throughout the tissue planes removing some alveolar tissue over the right iliac artery.  Upon entering through the transversalis fascia, the epigastric vessels were identified and doubly ligated and tied with #0 silk ties.  After the ligation of the epigastric vessels, the peritoneum was bluntly dissected and all peritoneal structures were bluntly dissected to a superior and medial plane.  This was done without any complication and without entering the peritoneum grossly.  The round ligament was identified and doubly ligated at this time with #0 silk ties as well.  The dissection continued down now to layer of the alveolar tissue covering the right iliac artery.  This alveolar tissue was cleared using blunt dissection as well as electrocautery.  After the external iliac artery was identified, it was cleared circumferentially all the way around and noted to have good flow and had good arterial texture.  The right iliac vein was then identified, and this was cleared again using electrocautery and blunt dissection.  After the right iliac vein was identified and cleared off all the alveolar tissue, it was circumferentially cleared as well.  An additional perforating branch was noted at the inferior pole of the right iliac vein.  This was tied with a #0 silk tie and secured.  Hemostasis was achieved at this time and the tie had adequate control.  The dissection continued down and identified all other vital structures in this area.  Careful preservation of all vital structures was carried out throughout the dissection.  At this time, Satinsky clamp was placed over the right iliac vein.  This was then opened using a #11 blade, approximately 1 cm in length.  The heparinized saline was placed and irrigated throughout the inside of the vein, and the kidney was pulled into the abdominal field still covered in its protective socking with the superior pole marked.  The renal vein was then elevated and identified in this area.  A 5-0 double-ended Prolene stitch was used to secure the renal vein, both superiorly and inferiorly, and after appropriately being secured with 5-0 Prolene, these were tied down and secured.  The renal vein was then anastomosed to the right iliac vein in a circumferential manner in a running fashion until secured at both superior and inferior poles.  The dissection then continued down and the iliac artery was then anastomosed to the renal artery at this time using a similar method with 5-0 Prolene securing both superior and inferior poles.  After such time the 5-0 Prolene was run around in a circumferential manner until secured in both superior and inferior poles once again.  After this was done and the artery was secured, the Satinsky clamp was removed and a bulldog placed over.  The flow was then opened on the arterial side and then opened on the venous side to allow for proper flow.  The bulldog was then placed back on the renal vein and allowed for the hyperperfusion of the kidney.  The kidney pinked up nicely and had a good appearance to it and had appearance of good blood flow.  At this time, all Satinsky clamps were removed and all bulldog clamps were removed.  The dissection then continued down to the layer of the bladder at which time the bladder was identified.  Appropriate area on the dome the bladder was identified for entry.  This was entered using electrocautery and approximately 1 cm length after appropriately sizing and incising of the ureter using the Metzenbaum scissors in a linear fashion.  Before this was done, #0 chromic catgut stitches were placed and secured laterally and inferiorly on the dome of the bladder to elevate the area of the bladder and then the bladder was entered using the electrocautery approximately 1 cm in length.  At this time, a renal stent was placed into the ureter and secured superiorly and the stent was then placed into the bladder and secured as well.  Subsequently, the superior and inferior pole stitches with 5-0 Prolene were used to secure the ureter to the bladder.  This was then run mucosa-to-mucosa in a circumferential manner until secured in both superior and inferior poles once again.  Good flow was noted from the ureter at the time of operation.  Additional Vicryl stitches were used to overlay the musculature in a seromuscular stitch over the dome of the bladder and over the ureter itself.  At this time, an Ethibond stitch was used to make an additional seromuscular closure and rolling of the bladder musculature over the dome and over the anastomosis once again.  This was inspected and noted for proper control.  Irrigation of the bladder revealed that the bladder was appropriately filled and there were no flows and no defects.  At this time, the anastomoses were all inspected, hemostasis was achieved and good closure of the anastomosis was noted at this time.  The kidney was then placed back into its new position in the right pelvic fossa, and the area was once again inspected for hemostasis which was achieved.  A 1-0 Prolene stitch was then used for mass closure of the external, internal, and transversalis fascias and musculature in a running fashion from superior to inferior.  This was secured and knots were dumped.  Subsequently, the area was then checked and inspected for hemostasis which was achieved with electrocautery, and the skin was closed with 4-0 running Monocryl.  The patient tolerated procedure well without evidence of complication, transferred to the Dunn ICU where he was noted to be stable.  Dr. A was present and scrubbed through the entire procedure.","nephrology, endstage renal disease, ethibond, satinsky clamp, aponeurosis, cadaveric, cross match, curvilinear incision, hemodialysis, iliac vein, pelvic fossa, peritoneum, recipient, renal transplant, transplant, transversalis fascia, superior and inferior poles, endstage renal, renal disease, vein, electrocautery, bladder, renal, intervention, "
" Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit, hypertension, mild renal insufficiency, and anemia, which has been present chronically over the past year.", Nephrology, Pyelonephritis - Discharge Summary ,"ADMISSION DIAGNOSES:,1.  Pyelonephritis.,2.  History of uterine cancer and ileal conduit urinary diversion.,3.  Hypertension.,4.  Renal insufficiency.,5.  Anemia.,DISCHARGE DIAGNOSES:,1.  Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit.,2.  Hypertension.,3.  Mild renal insufficiency.,4.  Anemia, which has been present chronically over the past year.,HOSPITAL COURSE:,  The patient was admitted with suspected pyelonephritis.  Renal was consulted.  It was thought that there was a thick mucous plug in the Foley in the ileal conduit that was irrigated by Dr. X.  Her symptoms responded to IV antibiotics and she remained clinically stable.  Klebsiella was isolated in this urine, which was sensitive to Bactrim and she was discharged on p.o.  Bactrim.  She was scheduled on 08/07/2007 for further surgery.  She is to follow up with Dr. Y in 7-10 days.  She also complained of right knee pain and the right knee showed no sign of effusion.  She was exquisitely tender to touch of the patellar tendon.  It was thought that this did not represent intraarticular process.  She was advised to use ibuprofen over-the-counter two to three tabs t.i.d.","nephrology, uterine cancer, renal insufficiency, pyelonephritis, mucous plugging, ileal conduit "
 Psychosocial Evaluation of patient before kidney transplant., Nephrology, Psychosocial Eval for Kidney Transplant ,"HISTORY OF PRESENT ILLNESS:,  In 2002, the patient had a blood test during her routine screening, which revealed anemia and an elevated creatinine.  Two weeks later she saw a nephrologist at ABCDE were she worked at that time.  An ultrasound revealed that she had Parenchymal disease in which tissue around the kidney is diseased.  No particular treatment was advised.  She was laid off 6 months later.  In 2004, she began working at The ABCD Hospital and began seeing Dr. A.  She was put on Procrit, but could not keep the stringent appointment scheduled for the injection because of her work.  She began seeing Dr. B and was put on Procrit and Renagel.  She was advised to go on dialysis, but she felt she did not have enough information to such a drastic step.  She saw an endocrinologist for some thyroid problem and her blood work showed that her creatinine was now at 7.  She was referred to Dr. Xyz who found after a parathyroid scan that she may have an adenoma.  Her creatinine is now 7.4.,TREATMENT AND IMPACT OF DISEASE:,  She is on several medications.  She is not on a renal diet yet.  Her energy is good and she is still working full time.,TRANSPLANT FIRST MENTIONED AS TREATMENT OPTION: , She has wanted to transplant ever since dialysis was first mentioned.,EMOTIONAL REACTION TO DIAGNOSIS AND TREATMENT COURSE:,  She is frustrated by the lack of information about what exactly has caused her renal failure and has had a real feeling of helplessness in her efforts to pursue this understanding.,OTHER SIGNIFICANT MEDICAL HISTORY/SURGERIES:,  She had a Bartholin cyst removed in 2002.,PSYCHIATRIC HISTORY:,  None.,COPING STRATEGIES:,  She used to exercise vigorously, but has stopped at this time.  She enjoys watching movies with her children.,COMPLIANCE:,  She feels she watches her diet and medication regimen very closely.  She said she communicates daily with Dr. Xyz,PAST AND PRESENT SMOKING:,  She began smoking 2 cigarettes a day when she was 22, but stopped after a year.,PAST AND PRESENT ALCOHOL USE:,  None.,PAST AND PRESENT DRUG USE:,  None.,LEGAL ISSUES:,  None.,TATTOOS:,  None.,MARITAL STATUS:  LENGTH OF THE TIME MARRIED:,  She has been married for 25 years.,AGE AND HEALTH OF SPOUSE:,  Xyz is 62 and in good health.,CHILDREN:,  Four, all are in good health.,FATHER:,  Father died in 2001, at the age of 62 of cardiac cancer.,MOTHER:,  Dolorous Massey is 63 and in good health.,SIBLINGS:,  Ben Doherty died in 1984 at the age of 26 in an automobile accident; Steven Doherty is 46 and is in good health.,PREVIOUS MARRIAGES AND DURATION OF EACH:,  None.,PERSONS LIVING IN HOUSEHOLD:,  Six.,RELATIONSHIP WITH FAMILY MEMBERS/IDENTIFIED PRIMARY SUPPORT SYSTEM:,  She is close to her brother.,HIGHEST LEVEL OF EDUCATION:,  She has 2 years of college at ABCD College.  She is a licensed LVN.,MILITARY SERVICE:,  None.",
" Renal failure evaluation for possible dialysis therapy.  Acute kidney injury of which etiology is unknown at this time, with progressive azotemia unresponsive to IV fluids.", Nephrology, Renal Failure Evaluation ,"REASON FOR CONSULTATION:,  Renal failure evaluation for possible dialysis therapy.,HISTORY OF PRESENT ILLNESS:,  This is a 47-year-old gentleman, who works offshore as a cook, who about 4 days ago noted that he was having some swelling in his ankles and it progressively got worse over the past 3 to 4 days, until he was swelling all the way up to his mid thigh bilaterally.  He also felt like he could not make much urine, and his wife, who is a nurse instructed him to force fluids.  While he was there, he was drinking cranberry juice, some Powerade, but he also has a history of weightlifting and had been taking on a creatine protein drink on a daily basis for some time now.  He presented here with very decreased urine output until a Foley catheter was placed and about 500 mL was noted in his bladder.  He did have a CPK level of about 234 while his BUN and creatinine on admission were 109 and 6.9.  Despite IV hydration fluids, his potassium has gone up from 5.4 to 6.1.  He did not put out any significant urine and his weight was documented at 103 kg.  He was given a dose of Kayexalate.  His potassium came down to like about 5.9 and urine studies were ordered.  His urinalysis did show that he had microscopic hematuria and proteinuria and his protein-creatinine ratio was about 9 gm of protein consistent with nephrotic range proteinuria.  He did have a low albumin of 1.9.  He denied any nonsteroidal usage, any recreational drug abuse, and his urine drug screen was unremarkable, and he denied any history of hypertension or any other medical problems.  He has not had any blood work except for drug screens that are required by work and no work up by any primary care physician because he has not seen one for primary care.  He is very concerned because his mother and father were both on dialysis, which he thinks were due to diabetes and both parents have expired.  He denied any hemoptysis, gross hematuria, melena, hematochezia, hemoptysis, hematemesis, no seizures, no palpitations, no pruritus, no chest pain.  He did have a decrease in his appetite, which all started about Thursday.  We were asked to see this patient in consultation by Dr. X because of his renal failure and the need for possible dialysis therapy.  He was significantly hypertensive on admission with a blood pressure of 162/80.,PAST MEDICAL HISTORY: , Unremarkable.,PAST SURGICAL HISTORY: , Unremarkable.,FAMILY HISTORY: , Both mother and father were on dialysis of end-stage renal disease.,SOCIAL HISTORY: , He is married.  He does smoke despite understanding the risks associated with smoking a pack every 6 days.  Does not drink alcohol or use any recreational drug use.  He was on no prescribed medications.  He did have a fairly normal PSA of about 119 and I had ordered a renal ultrasound which showed fairly normal-sized kidneys and no evidence of hydronephrosis or mass, but it was consistent with increased echogenicity in the cortex, findings representative of medical renal disease.,PHYSICAL EXAMINATION:,Vital signs:  Blood pressure is 153/77, pulse 66, respiration 18, temperature 98.5.,General:  He was alert and oriented x 3, in no apparent distress, well-developed male.,HEENT:  Normocephalic, atraumatic.  Pupils are equal, round, and reactive to light.  Extraocular muscles intact.,Neck:  Supple.  No JVD, adenopathy, or bruit.,Chest:  Clear to auscultation.,Heart:  Regular rate and rhythm without a rub.,Abdomen:  Soft, nontender, nondistended.  Positive bowel sounds.,Extremities:  Showed no clubbing, cyanosis.  He did have 2+ pretibial edema in both lower extremities.,Neurologic:  No gross focal findings.,Skin:  Showed no active skin lesions.,LABORATORY DATA: , Sodium 138, potassium 6.1, chloride 108, CO2 22, glucose 116, BUN 111, creatinine 7.29, estimated GFR 10 mL/minute.  Calcium 7.4 with an albumin of 1.9.  Mag normal at 2.2.  Urine culture negative at 12 hours.  His Random urine sodium was low at 12.  Random urine protein was 4756, and creatinine in the urine was 538.  Urine drug screen was unremarkable.  Troponin was within normal limits.  Phosphorus slightly elevated at 5.7.  CPK level was 234, white blood cells 6.5, hemoglobin 12.2, platelet count 188,000 with 75% segs.  PT 10.0, INR 1.0, PTT at 27.3.  B-natriuretic peptide 718.  Urinalysis showed 3+ protein, 4+ blood, negative nitrites, and trace leukocytes, 5 to 10 wbc's, greater than 100 rbc's, occasional fine granular casts, and moderate transitional cells.,IMPRESSION:,1.  Acute kidney injury of which etiology is unknown at this time, with progressive azotemia unresponsive to IV fluids.,2.  Hyperkalemia due to renal failure, slowly improving with Kayexalate.,3.  Microscopic hematuria with nephrotic range proteinuria, more consistent with a glomerulonephropathy nephritis.,4.  Hypertension.,PLAN: , I will give him Kayexalate 15 gm p.o. q.6h. x 2 more doses since he is responding and his potassium is already down to 5.2.  I will also recheck a urinalysis, consult the surgeon in the morning for temporary hemodialysis catheter placement, and consult case managers to start work on a transfer to ABCD Center per the patient and his wife's request, which will occur after his second dialysis treatment if he remains stable.  We will get a BMP, phosphorus, mag, CBC in the morning since he was given 80 mg of Lasix for fluid retention.  We will also give him 10 mg of Zaroxolyn p.o.  Discontinue all IV fluids.  Check an ANCA hepatitis profile, C3 and C4 complement levels along with CH 50 level.  I did discuss with the patient and his wife the need for kidney biopsy and they would like the kidney biopsy to be performed closer to home at Ochsner where his family is, since he only showed up here because of the nearest hospital located to his offshore job.  I do agree with getting him transferred once he is stable from his hyperkalemia and he starts his dialysis.,I appreciate consult.  I did discuss with him the importance of the kidney biopsies to direct treatment, finding the underlying etiology of his acute renal failure and to also give him prognostic factors of renal recovery.",
 Nephrology office visit for followup of microscopic hematuria., Nephrology, Nephrology Office Visit - 1 ,"HISTORY OF PRESENT ILLNESS:  ,The patient is a 78-year-old woman here because of recently discovered microscopic hematuria.  History of present illness occurs in the setting of a recent check up, which demonstrated red cells and red cell casts on a routine evaluation.  The patient has no new joint pains; however, she does have a history of chronic degenerative joint disease.  She does not use nonsteroidal agents.  She has had no gross hematuria and she has had no hemoptysis.,REVIEW OF SYSTEMS: , No chest pain or shortness of breath, no problem with revision.  The patient has had decreased hearing for many years.  She has no abdominal pain or nausea or vomiting.  She has no anemia.  She has noticed no swelling.  She has no history of seizures.,PAST MEDICAL HISTORY: , Significant for hypertension and hyperlipidemia.  There is no history of heart attack or stroke.  She has had bilateral simple mastectomies done 35 years ago.  She has also had one-third of her lung removed for carcinoma (probably an adeno CA related to a pneumonia.)  She also had hysterectomy in the past.,SOCIAL HISTORY: , She is a widow.  She does not smoke.,MEDICATIONS:,1.  Dyazide one a day.,2.  Pravachol 80 mg a day in the evening.,3.  Vitamin E once a day.,4.  One baby aspirin per day.,FAMILY HISTORY:,  Unremarkable.,PHYSICAL EXAMINATION:,  She looks younger than her stated age of 78 years.  She was hard of hearing, but could read my lips.  Respirations were 16.  She was afebrile.  Pulse was about 90 and regular.  Her gait was normal.  Blood pressure is 140/70 in her left arm seated.  HEENT:  She had arcus cornealis.  The pupils were equal.  The sclerae were not icteric.  The conjunctivae were pink.  NECK:  The thyroid is not palpated.  No nodes were palpated in the neck.  CHEST:  Clear to auscultation.  She had no sacral edema.  CARDIAC:  Regular, but she was tachycardic at the rate of about 90.  She had no diastolic murmur.  ABDOMEN:  Soft, and nontender.  I did not palpate the liver.  EXTREMITIES:  She had no appreciable edema.  She had no digital clubbing.  She had no cyanosis.  She had changes of the degenerative joint disease in her fingers.  She had good pedal pulses.  She had no twitching or myoclonic jerks.,LABORATORY DATA: , The urine, I saw 1-2 red cells per high power fields.  She had no protein.  She did have many squamous cells.  The patient has creatinine of 1 mg percent and no proteinuria.  It seems unlikely that she has glomerular disease; however, we cannot explain the red cells in the urine.,PLAN: , To obtain a routine sonogram.  I would also repeat a routine urinalysis to check for blood again.  I have ordered a C3 and C4 and if the repeat urine shows red cells, I will recommend a cystoscopy with a retrograde pyelogram.","nephrology, creatinine, cystoscopy, glomerular, high power fields, hyperlipidemia, hypertension, microscopic hematuria, proteinuria, pyelogram, red cell, retrograde, sonogram, urinalysis, red cells, hematuria"
 Psychosocial evaluation of kidney donor.  Questions - Answers, Nephrology, Psychosocial Eval - Donor ,"DONOR'S PERCEPTION OF RECIPIENT'S ILLNESS:,What is your understanding of the recipient's illness and why they need a kidney - ""This kidney is for my mother who is on dialysis and my mother has been suffering long enough, and I want to relieve the suffering so that she is able to have a kidney transplant."",When and how did subject of donation arise - ""My mom and I talked about it together as a family."",RECIPIENT'S REACTION TO OFFER:,What was the recipient's reaction to your offer:  ""I would rather not go there.  Well, since we were talking, ""I will tell you that my mother really does not understand.  She is very worried.  She is very afraid that something might happen to me, and she would feel terrible if I had any problems as a result of being a donor.  I don't think my mom really understands, and I know that she really needs a kidney.  I think she is coming around to accepting."",FAMILY'S REACTION TO OFFER:,What are your family feelings about your being a donor - ""Well, my children are fine and my husband is very supportive."",CANDIDATE'S MOTIVATION TO DONATE:,How did you arrive at the decision to be a donor - ""My brothers and sisters and I got together and we all decided since my schedule was the most flexible and I was used to traveling, I seem like to the best candidate."",How would your family and friends react if you decided not to be a donor - ""I don't think that is going to happen."",CANDIDATE'S MOTIVATION TO DONATE:,How would you feel if you cannot be the donor for any reason - ""I would feel very upset because I know that this is the best for my mother, and I want to do this very badly for my mother.  I am hoping my headache is away and my blood pressure comes down so that I will start to feel better during this workup."",CANDIDATE'S DESCRIPTION OF RELATIONSHIP WITH RECIPIENT:,What is your relationship to the recipient - ""That is my mother."",How your relationship with the recipient change if you donate your kidney - ""I am not sure that it will change at all.  I know that I will feel better about doing this for my mother, because my mother is always sacrificing and helping others."",With your being a donor affect any other relationships in your life - No, I don't think it will have that much of an impact.  I am away from my children and my husband a lot because of I travel with my job.  So I don't think being donor will really have that dramatic affect.,Do you have an understanding of the process of transplant - ""Yes, I have a very good understanding of the transplant process.  I work as a contract nursing all over the country.  I am able to see patients doing different things in different places and so I feel like I have a very realistic perceptive on the process."",CANDIDATE'S UNDERSTANDING OF TRANSPLANTATION AND RISK OF REJECTION:,Do you understand the risk of rejection of your kidney by the recipient - ""Yes, I do understand all the risks.  I have had a long conversation with the coordinator and we have talked about these things."",Have you thought about how you might feel if the kidney is rejected - ""I guess, I am just sure that I won't be rejected and I am just sure that everything will be fine.  It is a part of the way I am managing my stress about this."",Do you have any doubts or concerns about donating - ""No, I don't have any doubts or any concerns right now.  I just wish this headache would go away.,Do you understand that there will be pain after the transplant - ""Of course, I do."",What are your expectations about your recuperation - ""I am planning on staying with my mom for three months in the Houston area after the transplant.  We live outside of Tampa, Florida; so this will be an adventure for both of us."",Do you need to speak further to any of the transplant team members - ""No, I have had a long talk with ABC.  I feel pretty comfortable about my conversation with her as well as my conversation with the Nephrologist.,MEDICAL HISTORY:,What previous illnesses or surgeries have you had - ""I had a one cesarian section, and I also suffered from asthma as a child.  I am in otherwise good health."",Are you currently on any medication - ""Yes, I am on Folic acid."",PSYCHIATRIC HISTORY:,Have you ever spoken with a counselor, therapist, or psychiatrist - ""No, I have not.  I have a good supportive system and a lot of people that I can talk to when I need to."",ALCOHOL, NICOTINE, DRUG USE:,Do you smoke - ""No."",Any typical drinks you prefer - ""I am a nondrinker."",What kinds of recreational drugs have you tried?  Have you used any recently - ""None."",FAMILY AND SUPPORT SYSTEMS:,MARITAL STATUS:  LENGTH OF TIME MARRIED:  ""I live with my family, my husband, and my two children with good relationship.  We have been married for 29 years."",NAME OF SPOUSE/PARTNER:  ""His name is Xyz."",AGE AND HEALTH OF SPOUSE/PARTNER:  He is in his 40s and he is healthy and lives outside of Tampo with our 6-year-old daughter.  Our elder child has just finished college."",CHILDREN:  I have two children; ages 28 and also 6.,POST-SURGICAL HOUSING PLAN:,With whom will you stay after discharge - ""I will stay with a friend.  He lives in the Houston area.  I am staying with that friend right now, while I am here for my workup."",CURRENT OCCUPATION:,What is your current occupation - ""I currently work on a contract basis as a nurse.  I go on assignments all over the country, and I work until the contract is over.  This allowed me to be flexible and the best candidate for donation to mom."",Do you have the support of your employer - ""Absolutely."",PAID OFF TIME:,Paid leave - ""None."",Disability coverage:  ""None."",SUPPORTIVE ENVIRONMENT:,  ""Yes.""",
 The patient is admitted with a diagnosis of acute on chronic renal insufficiency., Nephrology, Nephrology Consultation - 4 ,"HISTORY: , The patient is a 61-year-old male patient.  I was asked to evaluate this patient because of the elevated blood urea and creatinine.  The patient has ascites, pleural effusion, hematuria, history of coronary artery disease, pulmonary nodules, history of congestive heart failure status post AICD.  The patient has a history of exposure to asbestos in the past, history of diabetes mellitus of 15 years duration, hypertension, and peripheral vascular disease.  The patient came in with a history of abdominal distention of about one to two months with bruises on the right flank about two days status post fall.  The patient has been having increasing distention of the abdomen and frequent nosebleeds.,PAST MEDICAL HISTORY:,  As above.,PAST SURGICAL HISTORY: , The patient had a pacemaker placed.,ALLERGIES: , NKDA.,REVIEW OF SYSTEMS: , Showed no history of fever, no chills, no weight loss.  No history of sore throat.  No history of any ascites.  No history of nausea, vomiting, or diarrhea.  No black stools.  No history of any rash.  No back pain.  No leg pain.  No neuropsychiatric problems.,FAMILY HISTORY: , History of hypertension, diabetes present.,SOCIAL HISTORY:,  He is a nonsmoker, nonalcoholic, and not a drug user.,PHYSICAL EXAMINATION,VITAL SIGNS:  Blood pressure is 124/66, heart rate around 68 per minute, and temperature 96.4.,HEENT:  The patient is atraumatic and normocephalic.  Pupils are equal and reactive to light.  Extraocular muscles are intact.,NECK:  Supple.  No JVD and no thyromegaly.,HEART:  S1 and S2 heard.  No murmurs or extra sounds.,ABDOMEN:  Distention of the abdomen present.,EXTREMITIES:  No pedal edema.,LABORATORY: , His lab investigation showed WBC of 6.2, H&H is 11 and 34.  PT, PTT, and INR is normal.  Urinalysis showed 2+ protein and 3+ blood, and 5 to 10 rbc's.  Potassium is 5.3, BUN of 39, and creatinine of 1.9.  Liver function test, ALT was 12, AST 15, albumin 3, TSH of 4.8, and T3 of 1.33.,IMPRESSION AND PLAN:  ,The patient is admitted with a diagnosis of acute on chronic renal insufficiency, rule out hepatorenal insufficiency could be secondary to congestive heart failure, cardiac cirrhosis, rule out possibility of ascites secondary to mesothelioma because the patient has got history of exposure to asbestos and has got pulmonary nodule, rule out diabetic nephropathy could be secondary to hypertensive nephrosclerosis.  The patient has hematuria could be secondary to benign prostatic hypertrophy, rule out malignancy.  We will do urine for cytology.  We will do a renal ultrasound, and 24-hour urine collection for protein/creatinine, creatinine clearance, immunofixation, serum electrophoresis, serum uric acid, serum iron, TIBC, and serum ferritin levels.  We will send a PSA level and if needed may be a urology consult.","nephrology, mesothelioma, ascites, pleural effusion, hematuria, history of coronary artery disease, pulmonary nodules, congestive heart failure, aicd, hepatorenal insufficiency, pulmonary nodule, diabetic nephropathy, chronic renal insufficiency, nodules, serum, insufficiency, "
 A 14-year-old young lady is in the renal failure and in need of dialysis., Nephrology, Peritoneal Dialysis Catheter Insertion ,"PREOPERATIVE DIAGNOSIS: , Renal failure.,POSTOPERATIVE DIAGNOSIS:,  Renal failure.,OPERATION PERFORMED: , Insertion of peritoneal dialysis catheter.,ANESTHESIA: , General.,INDICATIONS:  ,This 14-year-old young lady is in the renal failure and in need of dialysis.  She had had a previous PD catheter placed, but it became infected and had to be removed.  She, therefore, comes back to the operating room for a new PD catheter.,OPERATIVE PROCEDURE:  ,After the induction of general anesthetic, the abdomen was prepped and draped in the usual manner.  A small transverse right upper quadrant incision was made and carried down through the skin and subcutaneous tissue with sharp dissection.  The fascia was divided and the posterior fascia and peritoneum were identified.  A hole was made in the posterior fascia through the peritoneum and into the peritoneal cavity.  The omentum came up through the hole and so therefore the omentum was actually brought up and a small portion of it removed, which could easily be brought up through the incision.  A PD catheter was then placed into the pelvis over a guidewire.  At this point, the peritoneum and posterior fascia was closed around the catheter.  The anterior fascia was then closed over the top of the cuff leaving the cuff buried in the fascia.  The second incision was then made lateral and the catheter brought out through a second incision and the subcutaneous cuff then positioned at that site.  The catheter was then connected and two runs of a 150 mL of fluid were made with a good inflow and a good clear return.  The skin was closed with 5-0 subcuticular Monocryl.  Sterile dressings were applied and the young lady awakened and taken to the recovery room in satisfactory condition.","nephrology, pd catheter, catheter, omentum, peritoneal dialysis catheter, peritoneal dialysis, renal failure, peritoneal, dialysis, renal"
 Psychosocial donor evaluation.  Following questions are mostly involved in a psychosocial donor evaluation., Nephrology, Psychosocial Eval - Donor - 1 ,"PSYCHOSOCIAL DONOR EVALUATION,Following questions are mostly involved in a psychosocial donor evaluation:,A.  DECISION TO DONATE,What is your understanding of the recipient's illness and why a transplant is needed?,When and how did the subject of donation arise?,What was the recipient's reaction to your offer?,What are your family's feelings about your being a donor?,How did you arrive at the decision to be a donor?,How would your family and friends react if you decided not to be a donor?,How would you feel if you cannot be the donor for any reason?,What is your relationship to the recipient?,How will your relationship with the recipient change if you donate your kidney?,Will your being a donor affect any other relationships in your life?,B. TRANSPLANT ISSUES,Do you have an understanding of the process of transplant?,Do you understand the risk of rejection of your kidney by the recipient at some point after transplant?,Have you thought about how you might feel if the kidney/liver is rejected?,Do you have any doubts or concerns about donating?,Do you understand that there will be pain and soreness after the transplant?,What are your expectations about your recuperation?,Do you need to speak further to any of the transplant team members?,C.  MEDICAL HISTORY,What previous illnesses or surgeries have you had? ,Are you currently on any medications?,Have you ever spoken with a counselor, a therapist or a psychiatrist?,Do you smoke?,In a typical week, how many drinks do you consume?  What drink do you prefer?,What kinds of recreational drugs have you tried?  Have you used any recently?,D. FAMILY AND SUPPORT SYSTEM,With whom do you live?  ,If you are in a relationship:,- length of the relationship:  ,- name of spouse/partner:  ,- age and health of spouse/partner:  ,- children:  ,E. POST-SURGICAL PLANS,With whom will you stay after discharge?  ,What is your current occupation:  ,Do you have the support of your employer?",
" Patient with end-stage renal disease secondary to hypertension, a reasonable candidate for a kidney transplantation.", Nephrology, Nephrology Consultation - 3 ,"PAST MEDICAL/SURGICAL HISTORY: , Briefly, his past medical history is significant for hypertension of more than 5 years, asthma, and he has been on Advair and albuterol.  He was diagnosed with renal disease in 02/2008 and has since been on hemodialysis since 02/2008.  His past surgical history is only significant for left AV fistula on the wrist done in 04/2008.  He still has urine output.  He has no history of blood transfusion.,PERSONAL AND SOCIAL HISTORY: , He is a nonsmoker.  He denies any alcohol.  No illicit drugs.  He used to work as the custodian at the nursing home, but now on disability since 03/2008.  He is married with 2 sons, ages 5 and 17 years old.,FAMILY HISTORY:,  No similar illness in the family, except for hypertension in his one sister and his mom, who died at 61 years old of congestive heart failure.  His father is 67 years old, currently alive with asthma.  He also has one sister who has hypertension.  The rest of the 6 siblings are alive and well.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , Singulair 10 mg once daily, Cardizem 365 mg once daily, Coreg 25 mg once daily, hydralazine 100 mg three times a day, Lanoxin 0.125 mg once daily, Crestor 10 mg once daily, lisinopril 10 mg once daily, Phoslo 3 tablets with meals, and Advair 250 mg inhaler b.i.d.,REVIEW OF SYSTEMS: , Significant only for asthma.  No history of chest pain normal MI.  He has hypertension.  He occasionally will develop colds especially with weather changes.  GI:  Negative.  GU:  Still making urine about 1-3 times per day.  Musculoskeletal:  Negative.  Skin:  He complains of dry skin.  Neurologic:  Negative.  Psychiatry:  Negative.  Endocrine:  Negative.  Hematology:  Negative.,PHYSICAL EXAMINATION: , A pleasant 41-year-old African-American male who stands 5 feet 6 inches and weighs about 193 pounds.  HEENT:  Anicteric sclera, pink conjunctiva, no cervical lymphadenopathy.  Chest:  Equal chest expansion.  Clear breath sounds.  Heart:  Distinct heart sounds, regular rhythm with no murmur.  Abdomen:  Soft, nontender, flabby, no organomegaly.  Extremities:  Poor peripheral pulses.  No cyanosis and no edema.,ASSESSMENT AND PLAN:,  This is a 49-year old African-American male who was diagnosed with end-stage renal disease secondary to hypertension.  He is on hemodialysis since 02/2008.  Overall, I think that he is a reasonable candidate for a kidney transplantation and should undergo a complete pretransplant workup with pulmonary clearance because of his chronic asthma.  Other than that, I think that he is a reasonable candidate for transplant.,I would like to thank you for allowing me to participate in the care of your patient.  Please feel free to contact me if there are any questions regarding his case.","nephrology, kidney transplantation, pretransplant, transplant clinic, renal disease, secondary, kidney, hemodialysis, renal, asthma, transplantation, hypertension"
 Nephrology office visit for followup of CKD., Nephrology, Nephrology Office Visit - 2 ,"HISTORY OF PRESENT ILLNESS:,  This is a 79-year-old white male who presents for a nephrology followup for his chronic kidney disease secondary to nephrosclerosis and nonfunctioning right kidney.  His most recent BUN and creatinine on 04/04/06 are 40/2.0, which is stable.  He denies any chest pain or tightness in his chest.  He denies any shortness of breath, nausea, or vomiting.  He denies any change to his appetite.  He denies any fevers, chills, dysuria, or hematuria.  He does report his blood pressure being checked at the senior center and reporting that it is improved.  The patient has stage III chronic kidney disease. ,PAST MEDICAL HISTORY:,",
 Transplant nephrectomy after rejection of renal transplant, Nephrology, Nephrectomy - Transplant ,"PREOPERATIVE DIAGNOSIS: , Rejection of renal transplant.,POSTOPERATIVE DIAGNOSIS: , Rejection of renal transplant.,OPERATIVE PROCEDURE: , Transplant nephrectomy.,DESCRIPTION OF PROCEDURE: , The patient has had rapid deterioration of her kidney function since her transplant at ABCD one year ago.  The patient was recently thought to have obstruction to the transplant and a stent was placed in to the transplant percutaneously, but the ureter was wide open and there was no evidence of obstruction.  Because the kidney was felt to be irretrievably lost and immunosuppression had been withdrawn, it was elected to go ahead and remove the kidney and hopes that her fever and toxic course could be arrested.,With the patient in the supine position, the previously placed nephrostomy tube was removed.  The patient then after adequate prepping and draping, and placing of a small roll under the right hip, underwent an incision in the direction of the transplant incision down through and through all muscle layers and into the preperitoneal space.  The kidney was encountered and kidney was dissected free of its attachments through the retroperitoneal space.  During the course of dissection, the iliac artery and vein were identified as was the native ureter and the patient's ilioinguinal nerve; all these were preserved.  The individual vessels in the kidney were identified, ligated, and incised, and the kidney was removed.  The ureter was encountered during the course of resection, but was not ligated.  The patient's retroperitoneal space was irrigated with antibiotic solution and #19 Blake drain was placed into the retroperitoneal space, and the patient returned to the recovery room in good condition.,ESTIMATED BLOOD LOSS:  900 mL.","nephrology, renal transplant, blake drain, rejection, iliac artery, ilioinguinal, immunosuppression, kidney function, nephrectomy, nephrostomy tube, retroperitoneal space, toxic, ureter, vein, transplant, renal, retroperitoneal, kidney, "
 Nephrology Consultation - Patient with renal failure., Nephrology, Nephrology Consultation - 1 ,"REASON FOR CONSULTATION: , Renal failure.,HISTORY OF PRESENT ILLNESS:,  Thank you for referring Ms. Abc to ABCD Nephrology.  As you know she is a 51-year-old lady who was found to have a creatinine of 2.4 on a recent hospital admission to XYZ Hospital.  She had been admitted at that time with chest pain and was subsequently transferred to University of A and had a cardiac catheterization, which did not show any coronary artery disease.  She also was found to have a urinary tract infection at that time and this was treated with ciprofloxacin.  Her creatinine both at XYZ Hospital and University of A was elevated at 2.4.  I do not have the results from the prior years.  A repeat creatinine on 08/16/06 was 2.3.  The patient reports that she had gastric bypass surgery in 1975 and since then has had chronic diarrhea and recurrent admissions to the hospital with nausea, vomiting, diarrhea, and dehydration.  She also mentioned that lately she has had a lot of urinary tract infections without any symptoms and was in the emergency room four months ago with a urinary tract infection.  She had bladder studies a long time ago.  She complains of frequency of urination for a long time but denies any dysuria, urgency, or hematuria.  She also mentioned that she was told sometime in the past that she had kidney stones but does not recall any symptoms suggestive of kidney stones.  She denies any nonsteroidal antiinflammatory drug use.  She denies any other over-the-counter medication use.  She has chronic hypokalemia and has been on potassium supplements recently.  She is unsure of the dose.  ,PAST MEDICAL HISTORY: ,1.  Hypertension on and off for years.  She states she has been treated intermittently but lately has again been off medications.,2.  Gastroesophageal reflux disease.,3.  Gastritis.,4.  Hiatal hernia.,5.  H. pylori infection x3 in the last six months treated.,6.  Chronic hypokalemia secondary to chronic diarrhea.,7.  Recurrent admissions with nausea, vomiting, and dehydration.  ,8.  Renal cysts found on a CAT scan of the abdomen.,9.  No coronary artery disease with a recent cardiac catheterization with no significant coronary artery disease.  ,10.  Stomach bypass surgery 1975 with chronic diarrhea.,11.  History of UTI multiple times recently.,12.  Questionable history of kidney stones.,13.  History of gingival infection secondary to chronic steroid use, which was discontinued in July 2001.,14.  Depression.,15.  Diffuse degenerative disc disease of the spine.,16.  Hypothyroidism.,17.  History of iron deficiency anemia in the past.  ,18.  Hyperuricemia.  ,19.  History of small bowel resection with ulcerative fibroid.  ,20.  Occult severe GI bleed in July 2001.,PAST SURGICAL HISTORY: ,  The patient has had multiple surgeries including gastric bypass surgery in 1975, tonsils and adenoidectomy as a child, multiple tubes in the ears as a child, a cyst removed in both breasts, which were benign, a partial hysterectomy in 1980, history of sinus surgery, umbilical hernia repair in 1989, cholecystectomy in 1989, right ear surgery in 1989, disc surgery in 1991, bilateral breast cysts removal in 1991 and 1992, partial intestinal obstruction with surgery in 1992, pseudomyxoma peritonei in 1994, which was treated with chemotherapy for nine months, left ovary resection and fallopian tube removal in 1994, right ovarian resection and appendectomy and several tumor removals in 1994, surgery for an abscess in the rectum in 1996, fistulectomy in 1996, lumbar hemilaminectomy in 1999, cyst removal from the right leg and from the shoulder in 2000, cyst removed from the right side of the neck in 2003, lymph node resection in the neck April 24 and biopsy of a tumor in the neck and was found to be a schwannoma of the brachial plexus, and removal of brachial plexus tumor August 4, 2005.  ,CURRENT MEDICATIONS: ,1.  Nexium 40 mg q.d.,2.  Synthroid 1 mg q.d. ,3.  Potassium one q.d., unsure about the dose.  ,4.  No history of nonsteroidal drug use.,ALLERGIES:",
" Patient with a diagnosis of pancreatitis, developed hypotension and possible sepsis and respiratory, as well as renal failure.", Nephrology, Nephrology Consultation - 2 ,"HISTORY:,  The patient was in the intensive care unit setting; he was intubated and sedated.  The patient is a 55-year-old patient, who was admitted secondary to a diagnosis of pancreatitis, developed hypotension and possible sepsis and respiratory as well as renal failure and found to be intubated.  He has been significantly hypotensive during his stay in the intensive care unit and has had minimal urine output.  His creatinine has gone from 2.1 to 4.2 overnight and the patient also developed florid acidosis and hypokalemia.  Nephrology input has been requested for management of acute renal failure and acidosis.,PAST MEDICAL HISTORY:,1.  Pancreatitis.,2.  Poison ivy.  The patient has recently been on oral steroids.,3.  Hypertension.,MEDICATIONS: , Include Ambien, prednisone, and blood pressure medication, which is not documented in the record at the moment.,INPATIENT MEDICATIONS: , Include Protonix IV, half-normal saline at 125 mL an hour, D5W with 3 ounces of bicarbonate at 150 mL an hour.  The patient was initially on dopamine, which has now been discontinued.  The patient remains on Levophed and Invanz 1 g IV q.24 h.,PHYSICAL EXAMINATION:,  Vitals, emergency room presentation, the blood pressure was 82/45.  His blood pressure in the ICU had dipped down into the 60s systolic, most recent blood pressure is 108/67 and he has been maintained on 100% FiO2.  The patient has had minimal urine output since admission.  HEENT, the patient is intubated at the moment.  Neck examination, no overt lymph node enlargement.  No jugular venous distention.  Lungs examination is benign in terms of crackles.  The patient has some harsh breath sounds secondary to being intubated.  CVS, S1 and S2 are fairly regular at the moment.  There is no pericardial rub.  Abdominal examination, obese, but benign.  Extremity examination reveals no lower extremity edema.  CNS, the patient is intubated and sedated.,LABORATORY DATA: , Blood work, sodium 152, potassium 2.7, bicarbonate 13, BUN 36, and creatinine 4.2.  The patient's BUN and creatinine yesterday were 23 and 2.1 respectively.  H&H of 17.7 and 51.6, white cell count of 8.4 from earlier on this morning.  The patient's liver function tests are all out of whack and his alkaline phosphatase is 226, ALT is 539, CK 1103, INR 1.66, and ammonia level of 55.  Latest ABGs show a pH of 7.04, bicarbonate of 10.7, pCO2 of 40.3, and pO2 of 120.7.,ASSESSMENT:,1.  Acute renal failure, which in all probability is secondary to acute tubular necrosis and sepsis and significant hypotension, but the patient is at the moment on 100% FiO2.  He has been given intravenous fluid at a high rate to replete intravascular volume and to hopefully address his acidosis.  The patient also has significant acidosis and his creatinine has increased from 2.1 to 4.2 overnight.  Given the fact that he would need dialytic support for his electrolyte derangements and for volume control, I would suggest continuous venovenous hemodiafiltration as opposed to conventional hemodialysis as the patient will not be able to tolerate conventional hemodialysis given his hemodynamic instability.,2.  Hypotension, which is significant and is related to his sepsis.  Now the patient has been maintained on Levophed and high rate of intravenous fluid at the moment.,3.  Acidosis, which is again secondary to his renal failure.  The patient was administered intravenous bicarbonate as mentioned above.  Dialytic support in the form of continuous venovenous hemodiafiltration was highly recommended for possible correction of his electrolyte derangements.,4.  Pancreatitis, which has been managed by his gastroenterologist.,5.  Sepsis, the patient is on broad-spectrum antibiotic therapy.,6.  Hypercalcemia.  The patient has been given calcium chloride.  We will need to watch for rebound hypercalcemia.,7.  Hypoalbuminemia.,8.  Hypokalemia, which has been repleted.,RECOMMENDATIONS: , Again include continuation of IV fluid and bicarbonate infusion as well as transfer to the Piedmont Hospital for continuous venovenous hemodiafiltration.","nephrology, intubated, consultation, hypercalcemia, hypoalbuminemia, iv fluid, acidosis, creatinine, hemodiafiltration, hypokalemia, hypotension, intravenous, pancreatitis, renal failure, respiratory, urine output, continuous venovenous hemodiafiltration, electrolyte derangements, conventional hemodialysis, continuous venovenous, venovenous hemodiafiltration, blood pressure, venovenous, bicarbonate, sepsis, "
" Septic from nephrolithiasis - Nephrolithiasis status post lithotripsy and stent placed in the left ureter, urinary incontinence, recent sepsis.", Nephrology, Nephrolithiasis - Progress Note ,"SUBJECTIVE:,  The patient returns today for a followup.  She was recently in the hospital and was found to be septic from nephrolithiasis.  This was all treated.  She did require a stent in the left ureter.  Dr. XYZ took care of this.  She had a stone, which was treated with lithotripsy.  She is now back here for followup.  I had written out all of her medications with their dose and schedule on a progress sheet.  I had given her instructions regarding follow up here and follow with Dr. F.  Unfortunately, that piece of paper was lost.  Somehow between the hospital and home she lost it and has not been able to find it.  She has no followup appointment with Dr. F.  The day after she was dismissed, her nephew called me stating that the prescriptions were lost, instructions were lost, etc.  Later she apparently found the prescriptions and they were filled.  She tells me she is taking the antibiotic, which I believe was Levaquin and she has one more to take.  She had no clue as to seeing Dr. XYZ again.  She says she is still not feeling very well and feels somewhat sick like.  She has no clue as to still having a ureteral stent.  I explained this to she and her husband again today.,ALLERGIES: , Sulfa.,CURRENT MEDICATIONS:,  As I have given are Levaquin, Prinivil 20 mg a day, Bumex 0.5 mg a day, Levsinex 0.375 mg a day, cimetidine 400 mg a day, potassium chloride 8 mEq a day, and atenolol 25 mg a day.,REVIEW OF SYSTEMS:,  She says she is voiding okay.  She denies fever, chills, or sweats.,OBJECTIVE:,General:  She was able to get up on the table by herself although she is quite unstable.,Vital Signs:  Blood pressure was okay at about 120/70 by me.,Neck:  Supple.,Lungs:  Clear.,Heart:  Regular rate and rhythm.,Abdomen:  Soft.,Extremities:  There is no edema.,IMPRESSION:,1.  Hypertension controlled.,2.  Nephrolithiasis status post lithotripsy and stent placed in the left ureter by Dr. F.,3.  Urinary incontinence.,4.  Recent sepsis.,PLAN:,1.  I discussed at length with she and her husband again the need to get into at least an assisted living apartment.,2.  I gave her instructions, in writing, to stop by Dr. F’s office on the way out today to get an appointment for followup regarding her stent.,3.  See me back here in two months.,4.  I made no changes in her medications.","nephrology, nephrolithiasis, septic, lithotripsy, nephrolithiasis status post lithotripsy, septic from nephrolithiasis, urinary incontinence, incontinence, atenolol, stent, medications, "
 Laparoscopic right radical nephrectomy due to right renal mass., Nephrology, Nephrectomy - Radical (Laparoscopic) ,"PREOPERATIVE DIAGNOSIS:,  Right renal mass.,POSTOP DIAGNOSIS: , Right renal mass.,PROCEDURE PERFORMED:,  Laparoscopic right radical nephrectomy.,ESTIMATED BLOOD LOSS:,  100 mL.,X-RAYS: , None.,SPECIMENS: , Right radical nephrectomy specimen.,COMPLICATIONS: , None.,ANESTHESIA:  ,General endotracheal.,DRAINS:,  16-French Foley catheter per urethra.,BRIEF HISTORY: , The patient is a 71-year-old woman recently diagnosed with 6.5 cm right upper pole renal mass.  This is an enhancing lesion suspicious for renal cell carcinoma versus oncocytoma.  I discussed a variety of options with her, and she opted to proceed with a laparoscopic right radical nephrectomy.  All questions were answered, and she wished to proceed with surgery as planned.,PROCEDURE IN DETAIL:,  After acquisition of appropriate written and informed consent and administration of perioperative antibiotics, the patient was taken to the operating room and placed supine on the operating table.  Note that, sequential compression devices were placed on both lower extremities and were activated per induction of anesthesia.  After institution of adequate general anesthetic via the endotracheal route, she was placed into the right anterior flank position with the right side elevated in a roll and the right arm across her chest.  All pressure points were carefully padded, and she was securely taped to the table to prevent shifting during the procedure.  Her abdomen was then prepped and draped in the standard surgical fashion after placing a 16-French Foley catheter per urethra to gravity drainage.  The abdomen was insufflated in the right outer quadrant.  Note that, the patient had had previous surgery which complicated accesses somewhat and that she had a previous hysterectomy.  The abdomen was insufflated into the right lateral abdomen with Veress needle to 50 mm of pressure without incident.  We then placed a 10/12 Visiport trocar approximately 7 cm lateral to the umbilicus.  Once this had entered into the peritoneal cavity without incident, the remaining trocars were all placed.  Under direct laparoscopic visualization, we placed three additional trocars; an 11-mm screw-type trocar in the umbilicus, a 6-mm screw-type trocar in the upper midline approximately 7 cm above the umbilicus, and 10/12 trocar in the lower midline about 7 cm below the umbilicus within and over the old hysterectomy scar.  There were some adhesions of omentum to the underside of that scar, and these were taken down sharply using laparoscopic scissors.,We began nephrectomy procedure by reflecting the right colon, by incising the white line of Toldt.  This exposed the retroperitoneum on the right side.  The duodenum was identified and reflected medially in a Kocher maneuver using sharp dissection only.  We then identified the ureter and gonadal vein in the retroperitoneum.  The gonadal vein was left down along the vena cava, and the plane underneath the ureter was elevated and this plane was carried up towards the renal hilum.  Sequential packets of tissue were taken using primarily the LigaSure Atlas device.  Once we got to the renal hilum, it became apparent that this patient had two sets of renal arteries and veins.  We proceeded then and skeletonized the structures into four individual packets.  We then proceeded to perform the upper pole dissection and developing the plane above the kidney and between the kidney and adrenal gland.  The adrenal was spared during this procedure.  There was no contiguous connection between the renal mass and a right adrenal gland.  This plane of dissection was taken down primarily using the LigaSure device.  We then sequentially took the four vessels going to the kidney initially taking two renal arteries with the endo GI stapler and then to renal veins again with endo GI stapler sequential flaring.  Once this was completed, the kidney was free except for its attachment to the ureter and lateral attachments.  The lateral attachments of the kidney were taken down using the LigaSure Atlas device, and then the ureter was doubly clipped and transected.  The kidney was then freed within the retroperitoneum.  A 50-mm EndoCatch bag was introduced through the lower most trocar site, and the kidney was placed into this bag for subsequent extraction.  We extended the lower most trocar site approximately 6 cm to facilitate extraction.  The kidney was removed and passed off the table as a specimen for pathology.  This was bivalved by pathology, and we reviewed the specimen.","nephrology, renal mass, carter-thomason, endocatch bag, foley catheter, gi stapler, laparoscopic, ligasure, toldt, laparoscopic scissors, nephrectomy, radical nephrectomy, screw-type trocar, umbilicus, upper pole, urethra, carter thomason closure device, laparoscopic right radical nephrectomy, carter thomason closure, carter thomason, renal hilum, kidney, abdomen, endotracheal, radical, oncocytoma, renal, "
 Right radical nephrectomy and assisted laparoscopic approach., Nephrology, Nephrectomy - Radical ,"PREOPERATIVE DIAGNOSIS: , Right renal mass.,POSTOPERATIVE DIAGNOSIS: , Right renal mass.,PROCEDURE: , Right radical nephrectomy and assisted laparoscopic approach.,ANESTHESIA:  ,General.,PROCEDURE IN DETAIL:  ,The patient underwent general anesthesia with endotracheal intubation.  An orogastric was placed and a Foley catheter placed.  He was placed in a modified flank position with the hips rotated to 45 degrees.  Pillow was used to prevent any pressure points.  He was widely shaved, prepped, and draped.  A marking pen was used to delineate a site for the Pneumo sleeve in the right lower quadrant and for the trocar sites in the midline just above the umbilicus and halfway between the xiphoid and the umbilicus.  The incision was made through the premarked site through the skin and subcutaneous tissue.  The aponeurosis of the external oblique was incised in the direction of its fibers.  Muscle-splitting incision was made in the internal oblique and transversus abdominis.  The peritoneum was opened and the Pneumo sleeve was placed in the usual fashion being sure that no bowel was trapped inside the ring.  Then, abdominal insufflation was carried out through the Pneumo sleeve and the scope was passed through the Pneumo sleeve to visualize placement of the trocars in the other two positions.  Once this had been completed, the scope was placed in the usual port and dissection begun by taking down the white line of Toldt, so that the colon could be retracted medially.  This exposed the duodenum, which was gently swept off the inferior vena cava and dissection easily disclosed the takeoff of the right renal vein off the cava.  Next, attention was directed inferiorly and the ureter was divided between clips and the inferior tongue of Gerota fascia was taken down, so that the psoas muscle was exposed.  The attachments lateral to the kidney was taken down, so that the kidney could be flipped anteriorly and medially, and this helped in exposing the renal artery.  The renal artery had been previously noticed on the CT scan to branch early and so each branch was separately ligated and divided using the stapler device.  After the arteries had been divided, the renal vein was divided again using a stapling device.  The remaining attachments superior to the kidney were divided with the Harmonic scalpel and also utilized the stapler, and the specimen was removed.  Reexamination of the renal fossa at low pressures showed a minimal degree of oozing from the adrenal gland, which was controlled with Surgicel.  Next, the port sites were closed with 0 Vicryl utilizing the passer and doing it over the hand to prevent injury to the bowel and the right lower quadrant incision for the hand port was closed in the usual fashion.  The estimated blood loss was negligible.  There were no complications.  The patient tolerated the procedure well and left the operating room in satisfactory condition.","nephrology, renal mass, foley catheter, gerota fascia, muscle-splitting incision, pneumo sleeve, endotracheal, laparoscopic, nephrectomy, orogastric, renal fossa, right lower quadrant, trocar, umbilicus, vena cava, renal, pneumo, radical, "
 Laparoscopic right partial nephrectomy due to right renal mass., Nephrology, Nephrectomy - Partial (Laparoscopic ) ,"PREOPERATIVE DIAGNOSIS: , Right renal mass.,POSTOPERATIVE DIAGNOSIS: , Right renal mass.,PROCEDURE PERFORMED: , Laparoscopic right partial nephrectomy.,ESTIMATED BLOOD LOSS:,  250 mL.,X-RAYS: , None.,SPECIMENS: , Included right renal mass as well as biopsies from the base of the resection.,ANESTHESIA:,  General endotracheal.,COMPLICATIONS: , None.,DRAINS: , Included a JP drain in the right flank as well as a #16-French Foley catheter per urethra.,BRIEF HISTORY: , The patient is a 60-year-old gentleman with a history of an enhancing right renal mass approximately 2 cm in diameter.  I had a long discussion with him concerning variety of options.  We talked in particular about extirpated versus ablative surgery.  Based on his young age and excellent state of health, decision was made at this point to proceed to a right partial nephrectomy laparoscopically.  All questions were answered, and he wished to proceed with surgery as planned.  Note that the patient does have a positive family history of renal cell carcinoma.,PROCEDURE IN DETAIL: , After acquisition of proper informed consent and administration of perioperative antibiotics, the patient was taken to the operating room and placed supine on the operating table.  After institution of adequate general anesthetic via endotracheal rod, he was placed into the right anterior flank position with his right side elevated on a roll and his right arm across his chest.  All pressure points were carefully padded, and he was securely taped to the table.  Note that sequential compression devices were in place on both lower extremities and were activated prior to induction of anesthesia.  His abdomen was then prepped and draped in a standard surgical fashion.  Note that a #16-French Foley catheter was in place per urethra as well as an orogastric tube.  The abdomen was insufflated at the right lateral abdomen using the Veress needle to a pressure of 15 without incident.  We then placed a Visiport 10 x 12 trocar in the right lateral abdomen.  With the trocar in place, we were able to place the remaining trocars under direct laparoscopic visualization.  We placed three additional trocars.  An 11 mm screw type trocar at the umbilicus, a 6 screw type trocar 7 cm in the midline above the umbilicus, and a 10 x 12 trocar to serve as a retractor port approximately 8 cm inferior in the midline.,The procedure was begun by reflecting the right colon by incising the white line of Toldt.  The colon was reflected medially, and the retroperitoneum was exposed on that side.  This was a fairly superficial lesion, so decision was made in advance to potentially not perform vascular clamping, however, I did feel it important to get high level control prior to proceeding to the partial.  With the colon reflected, the duodenum was identified, and it was reflected medially under Kocher maneuver.  The ureter and gonadal vein were identified on the right side and elevated.  The space between the ureter and the gonadal vein was then developed, and the gonadal vein was dropped elevating only the ureter, and carrying this plane dissection up towards the renal hilum.  Once we got up to the renal hilum, we were able to skeletonize the renal hilar vessels partially, and in particular, we did develop some of the upper pole dissection above the level of the hilum to provide for access for a Satinsky clamp or bulldogs.  The remainder of the kidney was then freed off its lateral and superior attachments primarily using the Harmonic scalpel and the LigaSure device.,With the kidney free and the hilum prepared, the Gerota fascia was taken down overlying the kidney exposing the renal parenchyma, and using this approach, we were able to identify the 2-cm, right renal mass located in the lower pole laterally.  A cap of fat was left overlying this mass.  Based on the position of the mass, we performed intraoperative laparoscopic ultrasound, which showed the mass to be somewhat deeper than initially anticipated.  Based on this finding, I decided to go ahead and clamp the renal hilum during resection.  A Satinsky clamp was introduced through the lower most trocar site and used to clamp the renal hilum en bloc.  Note that the patient had been receiving renal protection protocol including fenoldopam and mannitol throughout the procedure, and he also received Lasix prior to clamping the renal hilum.  With the renal hilum clamped, we did resect the tumor using cold scissors.  There was somewhat more bleeding than would be expected based on the hilar clamping; however, we were able to successfully resect this lesion.  We also took a biopsy at the base of the resection and passed off the table as a specimen for frozen section.  With the tumor resected, the base of the resection was then cauterized using the Argon beam coagulator, and several bleeding vessels were oversewn using figure-of-eight 3-0 Vicryl sutures with lap ties for tensioning.  We then placed a FloSeal into the wound and covered it with a Surgicel and held the pressure.  We then released the vascular clamp.  Total clamp time was 11 minutes.  There was minimal bleeding and occlusion of this maneuver, and after unclamping the kidney, the kidney pinked up appropriately and appeared well perfused after removal of the clamp.  We then replaced the kidney within its Gerota envelope and closed that with 3-0 Vicryl using lap ties for tensioning.  A JP drain was introduced through the right flank and placed adjacent to the kidney and sutured the skin with 2-0 nylon.  The specimen was placed into a 10-mm Endocatch bag and extracted from the lower most trocar site after extending it approximately 1 cm.  It was evaluated on the table and passed off the table for Pathology to evaluate.  They stated that the tumor was close to the margin, but there appeared to be 1-2 mm normal parenchyma around the tumor.  In addition, the frozen section biopsies from the base of the resection were negative for renal cell carcinoma.  Based on these findings, the lower most trocar site was closed using a running 0 Vicryl suture in the fascia.  We then re-insufflated the abdomen and carefully evaluated the entire intraoperative field for hemostasis.  Any bleeding points were controlled primarily using bipolar cautery or hemoclips.  The area was copiously irrigated with normal saline.  The colon was then replaced into its normal anatomic position.  The mesentry was evaluated.  There were no defects noted.  We closed the 10 x 12 lateral most trocar site using a Carter-Thompson closure device with 0-Vicryl.  All trocars were removed under direct visualization, and the abdomen was desufflated prior to removal of the last trocar.  The skin incisions were irrigated with normal saline and infiltrated with 0.25% Marcaine, and the skin was closed using a running 4-0 Monocryl in subcuticular fashion.  Benzoin and Steri-Strips were placed.  The patient was returned in supine position and awoken from general anesthetic without incident.  He was then transferred to hospital gurney and taken to the postanesthesia care unit for postoperative monitoring.  At the end of the case, sponge, instrument, and needle counts were correct.  I was scrubbed and present throughout the entire case.","nephrology, renal mass, foley catheter, gerota fascia, jp drain, kocher maneuver, laparoscopic, ligasure device, satinsky clamp, toldt, bulldogs, nephrectomy, renal parenchyma, resection, urethra, vicryl sutures, partial nephrectomy, gonadal vein, renal hilum, satinsky, renal, kidney, hilum, foley, endotracheal, "
 Left partial nephrectomy due to left renal mass., Nephrology, Nephrectomy - Partial ,"PREOPERATIVE DIAGNOSIS:,  Left renal mass, 5 cm in diameter.,POSTOPERATIVE DIAGNOSIS:,  Left renal mass, 5 cm in diameter.,OPERATION PERFORMED: , Left partial nephrectomy.,ANESTHESIA: , General with epidural.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , About 350 mL.,REPLACEMENT: , Crystalloid and Cell Savers from the case.,INDICATIONS FOR SURGERY:  ,This is a 64-year-old man with a left renal mass that was confirmed to be renal cell carcinoma by needle biopsy.  Due to the peripheral nature of the tumor located in the mid to lower pole laterally, he has elected to undergo a partial nephrectomy.  Potential complications include but are not limited to,,1.  Infection.,2.  Bleeding.,3.  Postoperative pain.,4.  Herniation from the incision.,PROCEDURE IN DETAIL:,  Epidural anesthesia was administered in the holding area, after which the patient was transferred into the operating room.  General endotracheal anesthesia was administered, after which the patient was positioned in the flank standard position.  A left flank incision was made over the area of the twelfth rib.  The subcutaneous space was opened by using the Bovie.  The ribs were palpated clearly and the fascia overlying the intercostal space between the eleventh and twelfth rib was opened by using the Bovie.  The fascial layer covering of the intercostal space was opened completely until the retroperitoneum was entered.  Once the retroperitoneum had been entered, the incision was extended until the peritoneal envelope could be identified.  The peritoneum was swept medially.  The Finochietto retractor was then placed for exposure.  The kidney was readily identified and was mobilized from outside Gerota's fascia.  The ureter was dissected out easily and was separated with a vessel loop.  The superior aspect of the kidney was mobilized from the superior attachment.  The pedicle of the left kidney was completely dissected revealing the vein and the artery.  The artery was a single artery and was dissected easily by using a right-angle clamp.  A vessel loop was placed around the renal artery.  The tumor could be easily palpated in the lateral lower pole to mid pole of the left kidney.  The Gerota's fascia overlying that portion of the kidney was opened in the area circumferential to the tumor.  Once the renal capsule had been identified, the capsule was scored using a Bovie about 0.5 cm lateral to the border of the tumor.  Bulldog clamp was then placed on the renal artery.  The tumor was then bluntly dissected off of the kidney with a thin rim of a normal renal cortex.  This was performed by using the blunted end of the scalpel.  The tumor was removed easily.  The argon beam coagulation device was then utilized to coagulate the base of the resection.  The visible larger bleeding vessels were oversewn by using 4-0 Vicryl suture.  The edges of the kidney were then reapproximated by using 2-0 Vicryl suture with pledgets at the ends of the sutures to prevent the sutures from pulling through.  Two horizontal mattress sutures were placed and were tied down.  The Gerota's fascia was then also closed by using 2-0 Vicryl suture.  The area of the kidney at the base was covered with Surgicel prior to tying the sutures.  The bulldog clamp was removed and perfect hemostasis was evident.  There was no evidence of violation into the calyceal system.  A 19-French Blake drain was placed in the inferior aspect of the kidney exiting the left flank inferior to the incision.  The drain was anchored by using silk sutures.  The flank fascial layers were closed in three separate layers in the more medial aspect.  The lateral posterior aspect was closed in two separate layers using Vicryl sutures.  The skin was finally reapproximated by using metallic clips.  The patient tolerated the procedure well.","nephrology, renal mass, bovie, finochietto retractor, gerota's fascia, herniation, bulldog clamp, needle biopsy, nephrectomy, partial nephrectomy, renal cell carcinoma, retroperitoneum, vicryl suture, gerota's, kidney, partial, renal, sutures, vicryl,"
 Status post cadaveric kidney transplant with stable function., Nephrology, Kidney Transplant - Followup ,"REASON FOR VISIT:,  Kidney transplant.,HISTORY OF PRESENT ILLNESS: , The patient is a 52-year-old gentleman with ESRD secondary to hypertension, status post kidney transplant in February 2006.  He had to back down on his WelChol because of increased backache.  He actually increased his Pravachol and is tolerating this with minimal problems.  He comes in for followup.,ALLERGIES: , Aspirin and Altace caused cough, Lipitor and Pravachol at higher doses caused myalgias, Zetia caused myalgias.,MEDICATIONS:,  Gengraf 125/50 mg daily, CellCept 500 mg q.i.d., acyclovir 800 mg q.i.d., DexFol daily, ferrous sulfate Mondays, Wednesdays and Fridays, metoprolol 50 mg b.i.d., vitamin C daily, baby aspirin 81 mg daily, Bactrim Single Strength daily, Cozaar 50 mg daily, WelChol 625 mg daily, and Pravachol 10 mg daily.,PAST MEDICAL HISTORY:,1.  ESRD secondary to hypertension.,2.  Cadaveric kidney in February 2006.,3.  Gunshot wound in Southeast Asia.,4.  Hyperlipidemia.,REVIEW OF SYSTEMS: , Cardiovascular:  No chest pain, dyspnea on exertion, orthopnea, PND or edema.  GU:  No hematuria, foamy urine, pyuria, frequency or dysuria.  He has occasional tingling over his graft, but this is not bothering him today.,PHYSICAL EXAMINATION:,  VITAL SIGNS:  Pulse 82.  Blood pressure is 108/64.  Weight is 64.5 kg.  GENERAL:  He is in no apparent distress.  HEART:  Regular rate and rhythm.  No murmurs, rubs or gallops.  LUNGS:  Clear bilaterally.  ABDOMEN:  Soft, nontender, and nondistended.  Multiple scars.  Right lower quadrant graft is unremarkable.  EXTREMITIES:  No edema.,LABORATORY DATA:,  Labs dated 07-11-06, hematocrit 34.8, sodium 137, magnesium 1.9, potassium 4.9, chloride 102, CO2 25, BUN is 37, creatinine is 1.3, calcium 10.1, phosphorus 3.7, and albumin 4.4.  LFTs unremarkable.  Cholesterol 221, triglycerides 104, HDL 42, LDL 158, and cyclosporine 163.,IMPRESSION:,1.  Status post cadaveric kidney transplant with stable function.,2.  Hypertension under excellent control.,3.  Hyperlipidemia not at goal.  He simply is not tolerating higher doses of medications.,PLAN:,1.  We will add over-the-counter fish oil b.i.d.,2.  Continue all current medications.,3.  Recheck labs today including urinalysis.,4.  He will see transplant in two weeks and me in four weeks.  We will plan to send urine for decoy cells on his next visit.","nephrology, esrd secondary to hypertension, status post cadaveric kidney transplant, transplant with stable function, cadaveric kidney transplant, secondary to hypertension, stable function, cadaveric kidney, kidney transplant, esrd, hyperlipidemia, edema, cadaveric, welchol, orthopnea, kidney, transplant, "
 Right hand-assisted laparoscopic cryoablation of renal lesions x2.  Lysis of adhesions and renal biopsy., Nephrology, Laparoscopic Cryoablation ,"PREOPERATIVE DIAGNOSIS: , Bilateral renal mass.,POSTOPERATIVE DIAGNOSIS:,  Bilateral renal mass.,OPERATION: , Right hand-assisted laparoscopic cryoablation of renal lesions x2.  Lysis of adhesions and renal biopsy.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:,  100 Ml.,FLUIDS: , Crystalloid.,The patient was bowel prepped and was given preoperative antibiotics.,BRIEF HISTORY: , The patient is a 73-year-old male, who presented to us with a referral from Dr. X's office with bilateral renal mass and renal insufficiency.  The patient's baseline creatinine was around 1.6 to 1.7.  The patient was found to have a 3 to 4-cm exophytic right renal mass, 1-cm renal mass inferior to that, and about 2-cm left renal mass.  Since the patient had bilateral renal disease and the patient had renal insufficiency, the best option at this time had been cryoprocedure for the kidney versus partial nephrectomy, one kidney at a time.  The patient understood all his options, had done some research on cryotherapy and wanted to proceed with the procedure.  The patient had a renal biopsy done, which showed a possibility of an oncocytoma, which also would indicate that if this is not truly a cancerous lesion, but there is an associated risk of renal cell carcinoma that the patient will benefit from a cryo of the kidney.,Risk of anesthesia, bleeding, infection, pain, hernia, bowel obstruction, ileus, injury to bowel, postoperative bleeding, etc., were discussed.  The patient understood the risk of delayed bleeding, the needing for nephrectomy, renal failure, renal insufficiency, etc., and wanted to proceed with the procedure.,DETAILS OF THE OR:  ,The patient was brought to the OR.  Anesthesia was applied.  The patient was given preoperative antibiotics.  The patient was bowel prepped.  The patient was placed in right side up, left side down, semiflank, with kidney rest up.  All the pressure points are very well padded using foam and towels.  The left knee was bent and the right knee was straight.  There was no tension on any of the joints.  All pressure points were well padded.  The patient was taped to the table using 2-inch wide tape all the way around.  A Foley catheter and OG tube were in place prior to prepping and draping the patient.  A periumbilical incision measuring about 6 cm was made.  The incision was carried through the subcutaneous tissue through the fascia using sharp dissection.  The peritoneum was open.  Abdomen was entered.  There were some adhesions on the right side of the abdomen, which were released using metz.  Two 12-mm ports were placed in the anteroaxillary line and one in the midclavicular line.  A gel porter was placed.  Pneumoperitoneum was obtained.  All ports were placed under direct vision, and the right colon was reflected medially.  Duodenum was cauterized.  Minimal dissection was done on the hilum and the Gerota's was opened laterally, and the renal masses were clearly visualized all the way around.  Pictures were taken.  Superficial biopsies were taken of 2 renal lesions using 3 different probes.  The 2 lesions were frozen.  The 2 probes were 2.4 mm and the other one was 3.1 mm in diameter.  So the R3.8 and R2.4 long probes were used.  Freezing/thawing, two cycles were done.  The temperatures were -131, -137, -150 and the freezing time was 5 and 10 minutes each and passive sign was done.  The exact times or exact temperatures are on the chart.  There was a nice ice ball with each freezing and with passive sign.  The probes were removed.,The probes were placed directly percutaneously through the skin into the renal lesions.,After freezing/thawing, the probes were removed and to seal with Surgicel were placed.  Pictures were taken after following total of 20 minutes were spent looking at the renal mass to make sure that there was no delayed bleeding.  From the time the probes were removed, until the time the laparoscope was removed, was total of 30 minutes.  So the masses were visualized for a total of 30 minutes without any pneumoperitoneum.  Pneumoperitoneum was obtained again.  Fibrin glue was placed over it just for precautionary measure.  There was about a total of 100 mL of blood loss overall with the entire procedure.  Please note that towels were used to prep off the colon and the liver to ensure there was no freezing of any other organ.  The kidney was kept in the left hand at all times.  Careful attention was drawn to make sure that the probe was deep enough, at least 3.5 to 4 cm in, to get the medial aspect of the tumors frozen.  The laparoscopic vacuum ultrasound showed that there was complete resolution of these lesions.  At the end of the procedure, after freezing/thawing and putting the fibrin glue, Surgicel, and EndoSeal, the colon was reflected medially.  Please note that the perirenal fat was placed over the lesion to ensure that the frozen area of the kidney was not exposed to the bowel.  Lap count was correct.  Please note that renal biopsy for permanent section was performed on the superficial aspect of the lesions.  No deeper biopsies were done to minimize the risk of bleeding.  The 12-mm ports were closed using 0-Vicryl and the middle incision.  The hand-port incision was closed using looped #1 PDS from both sides and was tied in the middle.  Please note that the pneumoperitoneum was closed using 0-Vicryl in running fashion.  After closing the abdomen, 4-0 Monocryl was used to close the skin and Dermabond was applied.,The patient was brought to recovery in a stable condition.","nephrology, hand-assisted laparoscopic cryoablation, laparoscopic, cryoablation, bilateral renal mass, fibrin glue, laparoscopic cryoablation, renal insufficiency, renal lesions, renal biopsy, renal mass, insufficiency, renal, freezing/thawing, lesions"
 Left laparoscopic hand-assisted nephrectomy., Nephrology, Nephrectomy ,"PREOPERATIVE DIAGNOSIS: , Left renal mass, left renal bleed.,POSTOPERATIVE DIAGNOSIS:  ,Left renal mass, left renal bleed.,PROCEDURE PERFORMED: , Left laparoscopic hand-assisted nephrectomy.,ANESTHESIA:,  General endotracheal.,EBL: , 100 mL.,The patient had a triple-lumen catheter A-line placed.,BRIEF HISTORY:,  The patient is a 54-year-old female with history of diabetic nephropathy, diabetes, hypertension, left BKA, who presented with abdominal pain with left renal bleed.  The patient was found to have a complex mass in the upper pole and the lower pole of the kidney.  MRI and CAT scan showed questionable renal mass, which could be malignant.  Initial plan was to let the patient stabilize for 2 weeks and perform the nephrectomy.  At this point, the patient was unable to go home.  The patient continually complained of pain.  The patient required about 3 to 4 units of blood transfusions prior.  The patient initially came in with hemoglobin less than 5.  The hemoglobin prior to surgery was 10.,Risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, respiratory failure, morbidity and mortality of the procedure due to her low ejection fraction were discussed.  Cardiac clearance was obtained.  The patient was high risk, family and the patient knew about the risk.  The recommendation from the pulmonologist, cardiologist, and medical team was to get the kidney out at this point because the patient and the family stated that they would not do well at home without any intervention.  The patient and family understood all the risks and benefits in order to proceed with the surgery.,DETAILS OF THE PROCEDURE:,  The patient was brought to the OR.  Anesthesia was applied.  The patient had A-line triple-lumen catheter.  The patient was placed in left side up, right side down oblique position.  All the pressure points were well padded.  The right fistula was carefully padded completely around it.  Axilla was protected.  The fistula was checked throughout the procedure to ensure that it was stable.  The arms, ankles, knees, and joints were all padded with foam.  The patient was taped to the table using 2-inch wide tape.  OG and a Foley catheter were in place.  A supraumbilical incision was made about 6 cm in size and incision was carried through the subcutaneous tissue and through the fascia and peritoneum was entered sharply.  There were some adhesions where the omentum was into the umbilical hernia, which was completely stuck.  The omentum was released out of that just so we could obtain pneumoperitoneum.  Pneumoperitoneum was obtained after using GelPort.  Two 12-mm ports were placed in the left anterior axillary line, and mid clavicular line.  The colon was reflected medially.  Kidney was dissected laterally behind and inferiorly.  There was large hematoma visualized with significant amount of old blood, which was irrigated out.  Dissection was carried superiorly and the spleen was reflected medially.  The spleen and colon were all intact at the end of the procedure.  They were stable all throughout.  Using endovascular GIA stapler, all the medial and lateral dissection was carried through the stapler to ensure that the patient had minimal bleeding due to low cardiac reserve.  Hemostasis was obtained.  The renal vein and the renal artery were stapled and there was excellent hemostasis.,The dissection was carried lateral to the adrenal and medial to the right kidney.  The adrenal was preserved.  The entire kidney was removed through the hand port.  Irrigation was performed.  There was excellent hemostasis at the end of the nephrectomy.  Fibrin glue and Surgicel were applied just in case the patient had delayed DIC.  The colon was placed back and 12-mm ports were closed under direct palpation using 0 Vicryl.  The fascia was closed using loop #1 PDS in a running fashion and was tied in the middle.  Please note that prior to the fascial closure, the peritoneum was closed using 0 Vicryl in running fashion.  The subcuticular tissue was brought together using 4-0 Vicryl.  The skin was closed using 4-0 Monocryl.  Dermabond was applied.  The patient was brought to the recovery in a stable condition.","nephrology, laparoscopic, nephrectomy, laparoscopic hand assisted nephrectomy, triple lumen catheter, lumen catheter, running fashion, renal mass, renal bleed, dissection, hemostasis, kidney, renal"
" Laparoscopic lysis of adhesions, attempted laparoscopic pyeloplasty, and open laparoscopic pyeloplasty.  Right ureteropelvic junction obstruction, severe intraabdominal adhesions, and retroperitoneal fibrosis.", Nephrology, Laparoscopic Pyeloplasty ,"PREOPERATIVE DIAGNOSIS:  ,Right ureteropelvic junction obstruction.,POSTOPERATIVE DIAGNOSES:,1.  Right ureteropelvic junction obstruction.,2.  Severe intraabdominal adhesions.,3.  Retroperitoneal fibrosis.,PROCEDURES PERFORMED:,1.  Laparoscopic lysis of adhesions.,2.  Attempted laparoscopic pyeloplasty.,3.  Open laparoscopic pyeloplasty.,ANESTHESIA:,  General.,INDICATION FOR PROCEDURE:  ,This is a 62-year-old female with a history of right ureteropelvic junction obstruction with chronic indwelling double-J ureteral stent.  The patient presents for laparoscopic pyeloplasty.,PROCEDURE: , After informed consent was obtained, the patient was taken to the operative suite and administered general anesthetic.  The patient was sterilely prepped and draped in the supine fashion after building up the right side of the OR table to aid in the patient's positioning for bowel retraction.  Hassan technique was performed for the initial trocar placement in the periumbilical region.  Abdominal insufflation was performed.  There were significant adhesions noted.  A second 12 mm port was placed in the right midclavicular line at the level of the umbilicus and a Harmonic scalpel was placed through this and adhesiolysis was performed for approximately two-and-half hours, also an additional port was placed 12 mm in the midline between the xiphoid process and the umbilicus, an additional 5 mm port in the right upper quadrant subcostal and midclavicular.  After adhesions were taken down, the ascending colon was mobilized by incising the white line of Toldt and mobilizing this medially.  The kidney was able to be palpated within Gerota's fascia.  The psoas muscle caudate to the inferior pole of the kidney was identified and the tissue overlying this was dissected to the level of the ureter.  The uterus was grasped with a Babcock through a trocar port and carried up to the level of the ureteropelvic junction obstruction.  The renal pelvis was also identified and dissected free.  There was significant fibrosis and scar tissue around the ureteropelvic junction obliterating the tissue planes.  We were unable to dissect through this mass of fibrotic tissue safely and therefore the decision was made to abort the laparoscopic procedure and perform the pyeloplasty open.  An incision was made from the right upper quadrant port extending towards the midline.  This was carried down through the subcutaneous tissue, anterior fascia, muscle layers, posterior fascia, and peritoneum.  A Bookwalter retractor was placed.  The renal pelvis and the ureter were again identified.  Fibrotic tissue was able to be dissected away at this time utilizing right angle clamps and Bovie cautery.  The tissue was sent down to Pathology for analysis.  Please note that upon entering the abdomen, all of the above which was taken down from the adhesions to the abdominal wall were carefully inspected and no evidence of bowel injury was noted.  Ureter was divided just distal to the ureteropelvic junction obstruction and stent was maintained in place.  The renal pelvis was then opened in a longitudinal manner and excessive pelvis was removed reducing the redundant tissue.  At this point, the indwelling double-J ureteral stent was removed.  At this time, the ureter was spatulated laterally and at the apex of this spatulation a #4-0 Vicryl suture was placed.  This was brought up to the deepened portion of the pyelotomy and cystic structures were approximated.  The back wall of the ureteropelvic anastomosis was then approximated with running #4-0 Vicryl suture.  At this point, a double-J stent was placed with a guidewire down into the bladder.  The anterior wall of the uteropelvic anastomosis was then closed again with a #4-0 running Vicryl suture.  Renal sinus fat was then placed around the anastomosis and sutured in place.  Please note in the inferior pole of the kidney, there was approximately 2 cm laceration which was identified during the dissection of the fibrotic tissue.  This was repaired with horizontal mattress sutures #2-0 Vicryl.  FloSeal was placed over this and the renal capsule was placed over this.  A good hemostasis was noted.  A #10 Blake drain was placed through one of the previous trocar sites and placed into the perirenal space away from the anastomosis.  The initial trocar incision was closed with #0 Vicryl suture.  The abdominal incision was also then closed with running #0 Vicryl suture incorporating all layers of muscle and fascia.  The Scarpa's fascia was then closed with interrupted #3-0 Vicryl suture.  The skin edges were then closed with staples.  Please note that all port sites were inspected prior to closing and hemostasis was noted at all sites and the fascia was noted to be reapproximated as these trocar sites were placed with the ________ obturator.  We placed the patient on IV antibiotics and pain medications.  We will obtain KUB and x-rays for stent placement.  Further recommendations to follow.","nephrology, retroperitoneal, fibrosis, pyeloplasty, laparoscopic, lysis of adhesions, ureteropelvic junction obstruction, laparoscopic pyeloplasty, ureteropelvic junction, junction, ureteropelvic, intraabdominal, adhesions,"
 Insertion of left femoral circle-C catheter (indwelling catheter).  Chronic renal failure.  The patient was discovered to have a MRSA bacteremia with elevated fever and had tenderness at the anterior chest wall where his Perm-A-Cath was situated., Nephrology, Indwelling Catheter Insertion ,"PREOPERATIVE DIAGNOSIS: , Chronic renal failure.,POSTOPERATIVE DIAGNOSIS:  ,Chronic renal failure.,PROCEDURE PERFORMED:,  Insertion of left femoral circle-C catheter.,ANESTHESIA: , 1% lidocaine.,ESTIMATED BLOOD LOSS:,  Minimal.,COMPLICATIONS: , None.,HISTORY: , The patient is a 36-year-old African-American male presented to ABCD General Hospital on 08/30/2003 for evaluation of elevated temperature.  He was discovered to have a MRSA bacteremia with elevated fever and had tenderness at the anterior chest wall where his Perm-A-Cath was situated.  He did require a short-term of Levophed for hypotension.  He is felt to have an infected dialysis catheter, which was removed.  He was planned to undergo replacement of his Perm-A-Cath, dialysis catheter, however, this was not possible.  He will still require a dialysis and will require at least a temporary dialysis catheter until which time a long-term indwelling catheter can be established for dialysis.  He was explained the risks, benefits, and complications of the procedure previously.  He gave us informed consent to proceed.,OPERATIVE PROCEDURE: , The patient was placed in the supine position.  The left inguinal region was shaved.  His left groin was then prepped and draped in normal sterile fashion with Betadine solution.  Utilizing 1% lidocaine, the skin and subcutaneous tissue were anesthetized with 1% lidocaine.  Under direct aspiration technique, the left femoral vein was cannulated.  Next, utilizing an #18 gauge Cook needle, the left femoral vein was cannulated.  Sutures were removed, nonpulsatile flow was observed and a Seldinger guidewire was inserted within the catheter.  The needle was then removed.  Utilizing #11 blade scalpel, a small skin incision was made adjacent to the catheter.  Utilizing a #10 French dilator, the skin, subcutaneous tissue, and left femoral vein were dilated over the Seldinger guidewire.  Dilator was removed and a preflushed circle-C 8 inch catheter was inserted over the Seldinger guidewire.  The guidewire was retracted out from the blue distal port and grasped.  The catheter was then placed in the left femoral vessel _______.  This catheter was then fixed to the skin with #3-0 silk suture.  A mesenteric dressing was then placed over the catheter site.  The patient tolerated the procedure well.  He was turned to the upright position without difficulty.  He will undergo dialysis today per Nephrology.","nephrology, chronic renal failure, femoral circle-c catheter, indwelling catheter, catheter, insertion, seldinger, guidewire, indwelling, femoral, dialysis,"
 Construction of right upper arm hemodialysis fistula with transposition of deep brachial vein.  End-stage renal disease with failing AV dialysis fistula., Nephrology, Hemodialysis Fistula Construction ,"PREOPERATIVE DIAGNOSIS: , End-stage renal disease with failing AV dialysis fistula.,POSTOPERATIVE DIAGNOSIS: , End-stage renal disease with failing AV dialysis fistula.,PROCEDURE: , Construction of right upper arm hemodialysis fistula with transposition of deep brachial vein.,ANESTHESIA: , Endotracheal.,DESCRIPTION OF OPERATIVE PROCEDURE: , General endotracheal anesthesia was initiated without difficulty.  The right arm, axilla, and chest wall were prepped and draped in sterile fashion.  Longitudinal skin incision was made from the lower axilla distally down the medial aspect of the arm and the basilic vein was not apparent.  The draining veins are the deep brachial veins.  The primary vein was carefully dissected out and small tributaries clamped, divided, and ligated with #3-0 Vicryl suture.  A nice length of vein was obtained to the distal one third of the arm.  This appeared to be of adequate length to transpose the vein through the subcutaneous tissue to an old occluded fistula vein, which remains patent through a small collateral vein.  A transverse skin incision was made over the superior aspect of the old fistula vein.  This vein was carefully dissected out and encircled with vascular tapes.  The brachial vein was then tunneled in a gentle curve above the bicep to the level of the cephalic vein fistula.  The patient was sensible, was then systemically heparinized.  The existing fistula vein was clamped proximally and distally, incised longitudinally for about a centimeter.  The brachial vein end was spatulated.  Subsequently, a branchial vein to arterialized fistula vein anastomosis was then constructed using running #6-0 Prolene suture in routine fashion.  After the completion of the anastomosis, the fistula vein was forebled and the branchial vein backbled.  The anastomosis was completed.  A nice thrill could be palpated over the outflow brachial vein.  Hemostasis was noted.  A 8 mm Blake drain was placed in the wound and brought out through inferior skin stab incision and ___ the skin with #3-0 nylon suture.  The wounds were then closed using interrupted #4-0 Vicryl and deep subcutaneous tissue ___ staples closed the skin.  Sterile dressings were applied.  The patient was then x-ray'd and taken to Recovery in satisfactory condition.  Estimated blood loss 50 mL, drains 8 mm Blake.  Operative complication none apparent, final sponge, needle, and instrument counts reported as correct.","nephrology, end-stage renal disease, av dialysis fistula, brachial vein, upper arm hemodialysis fistula, fistula, vein, hemodialysis, av, dialysis, anastomosis, brachial"
 Acute on chronic renal failure and uremia.  Insertion of a right internal jugular vein hemodialysis catheter., Nephrology, Internal Jugular Vein Catheter Insertion ,"PREOPERATIVE DIAGNOSES:,1.  Acute on chronic renal failure.,2.  Uremia.,POSTOPERATIVE DIAGNOSES:,1.  Acute on chronic renal failure.,2.  Uremia.,PROCEDURE PERFORMED:  ,Insertion of a right internal jugular vein hemodialysis catheter.,ANESTHESIA: , 1% local lidocaine.,BLOOD LOSS: , Less than 5 cc.,COMPLICATIONS: , None.,HISTORY: , The patient is a 74-year-old Caucasian male who presents via direct admission for acute on chronic renal failure with uremia.  The patient incidentally was in a car accident ten days ago and has been feeling pretty awful since that time.  He is slightly short of breath with mild difficulty in breathing.  A pre-procedure x-ray was obtained, which showed no pneumothorax.  He did have a significant right pleural effusion and a mild left pleural effusion.  We decided to insert the catheter on the right side.,PROCEDURE:  ,The patient was prepped and draped in the usual sterile fashion.  1% lidocaine was used to anesthetize the area two fingerbreadths above the clavicle just posterior to the right sternocleidomastoid muscle and below the external jugular vein.  Using the same anesthetic needle, the right internal jugular vein was used to cannulate with good venous blood return.  The tract was noted.,The needle was removed and a second #18 gauge thin-walled needle was used along same tract to cannulate the right internal jugular vein also without difficulty and good venous blood return.  The syringe was removed and a Seldinger guidewire was inserted through the needle to cannulate the vein also without difficulty.  The needle was removed and an #11 blade was used to make a small skin incision provided skin and vein dilators were used.  The circle-C 8-inch hemodialysis catheter was then inserted over the guidewire without difficulty.  The guidewire was removed.  Both of the ports were aspirated venous blood without difficulty and both flushed also without difficulty.  The ports were flushed with injectable normal saline secondary to the patient going for dialysis today.  Thus, he will not need heparinization of the lines.  Again, he tolerated the procedure well.  A postoperative x-ray would be obtained to check catheter placement and rule out pneumothorax.","nephrology, uremia, internal jugular vein hemodialysis catheter, pneumothorax, jugular vein, dialysis, chronic renal failure, internal jugular vein, pleural effusion, hemodialysis catheter, renal failure, cannulate, guidewire, insertion, jugular, catheter, hemodialysis, vein"
" Fogarty thrombectomy, left forearm arteriovenous Gore-Tex bridge fistula and revision of distal anastomosis with 7 mm interposition Gore-Tex graft.  Chronic renal failure and thrombosed left forearm arteriovenous Gore-Tex bridge fistula.", Nephrology, Fogarty Thrombectomy ,"PREOPERATIVE DIAGNOSES:,1.  Chronic renal failure.,2.  Thrombosed left forearm arteriovenous Gore-Tex bridge fistula.,POSTOPERATIVE DIAGNOSIS:,1.  Chronic renal failure.,2.  Thrombosed left forearm arteriovenous Gore-Tex bridge fistula.,PROCEDURE PERFORMED:,1.  Fogarty thrombectomy, left forearm arteriovenous Gore-Tex bridge fistula.,2.  Revision of distal anastomosis with 7 mm interposition Gore-Tex graft.,ANESTHESIA:,  General with controlled ventillation.,GROSS FINDINGS: , The patient is a 58-year-old black male with chronic renal failure.  He undergoes dialysis through the left forearm bridge fistula and has small pseudoaneurysms at the needle puncture sites level.  There is narrowing at the distal anastomosis due to intimal hypoplasia and the vein beyond it was of good quality.,OPERATIVE PROCEDURE: , The patient was taken to the OR suite, placed in supine position.  General anesthetic was administered.  Left arm was prepped and draped in appropriate manner.  A Pfannenstiel skin incision was created just below the antecubital crease just deeper to the subcutaneous tissue.  Utilizing both blunt and sharp dissections segment of the fistula was isolated ________ vessel loop.  Transverse graftotomy was created.  A #4 Fogarty catheter passed proximally and distally restoring inflow and meager inflow.  A fistulogram was performed and the above findings were noted.  In a retrograde fashion, the proximal anastomosis was patent.  There was no narrowing within the forearm graft.  Both veins were flushed with heparinized saline and controlled with a vascular clamp.  A longitudinal incision was then created in the upper arm just deep into the subcutaneous tissue fascia.  Utilizing both blunt and sharp dissection, the brachial vein as well as distal anastomosis was isolated.  The distal anastomosis amputated off the fistula and oversewn with continuous running #6-0 Prolene suture tied upon itself.  The vein was controlled with vascular clamps.  Longitudinal venotomy created along the anteromedial wall.  A 7 mm graft was brought on to the field and this was cut to shape and size.  This was sewed to the graft in an end-to-side fashion with U-clips anchoring the graft at the heel and toe with interrupted #6-0 Prolene sutures.  Good backflow bleeding was confirmed.  The vein flushed with heparinized saline and graft was controlled with vascular clamp.  The end of the insertion graft was cut to shape in length and sutured to the graft in an end-to-end fashion with continuous running #6-0 Prolene suture.  Good backflow bleeding was confirmed.  The graftotomy was then closed with interrupted #6-0 Prolene suture.  Flow through the fistula was permitted, a good flow passed.  The wound was copiously irrigated with antibiotic solution.  Sponge, needles, instrument counts were correct.  All surgical sites were inspected.  Good hemostasis was noted.  The incision was closed in layers with absorbable sutures.  Sterile dressing was applied.  The patient tolerated the procedure well and returned to the recovery room in apparent stable condition.","nephrology, chronic renal failure, thrombosed, gore-tex bridge fistula, arteriovenous, fogarty, thrombectomy, anastomosis, gore tex bridge, fogarty thrombectomy, prolene suture, renal failure, distal anastomosis, bridge fistula, interposition, renal, prolene"
 Left arm fistulogram.  Percutaneous transluminal angioplasty of the proximal and distal cephalic vein.  Ultrasound-guided access of left upper arm brachiocephalic fistula., Nephrology, Fistulogram & Angioplasty ,"PREPROCEDURE DIAGNOSIS: , End-stage renal disease.,POSTPROCEDURE DIAGNOSIS: , End-stage renal disease.,PROCEDURES PERFORMED,1.  Left arm fistulogram.,2.  Percutaneous transluminal angioplasty of the proximal and distal cephalic vein.,3.  Ultrasound-guided access of left upper arm brachiocephalic fistula.,ANESTHESIA:,  Sedation with local.,COMPLICATIONS:,  None.,CONDITION:,  Fair.,DISPOSITION:,  PACU.,ACCESS SITE:,  Left upper arm brachiocephalic fistula.,SHEATH SIZE: , 5 French.,CONTRAST TYPE: , JC PEG tube 70.,CONTRAST VOLUME: , 48 mL.,FLUOROSCOPY TIME: , 16 minutes.,INDICATION FOR PROCEDURE: , This is a 38-year-old female with a left upper arm brachiocephalic fistula which has been transposed.  The patient recently underwent a fistulogram with angioplasty at the proximal upper arm cephalic vein due to a stenosis detected on Duplex ultrasound.  The patient subsequently was noted to have poor flow to the fistula, and the fistula was difficult to palpate.  A repeat ultrasound was performed which demonstrated a high-grade stenosis involving the distal upper arm cephalic vein just distal to the brachial anastomosis.  The patient presents today for a left arm fistulogram with angioplasty.  The risks, benefits, and alternatives of the procedure were discussed with the patient and understands and in agreement to proceed.,PROCEDURE DETAILS:  ,The patient was brought to the angio suite and laid supine on the table.  After sedation was administered, the left arm was then prepped and draped in a standard surgical fashion.  Continuous pulse oximetry and cardiac monitoring were performed throughout the procedure.  The patient was given 1 g of IV Ancef prior to incision.,The left brachiocephalic fistula was visualized with bevel ultrasound.  The cephalic vein in the proximal upper arm region appeared to be of adequate caliber.  There was an area of stenosis at the proximal cephalic vein just distal to the brachial artery anastomosis.  The cephalic vein in the proximal forearm region was easily compressible.  The skin overlying the vessel was injected with 1% lidocaine solution.  A small incision was made with the #11 blade.  The cephalic vein then was cannulated with a 5 French micropuncture introducer sheath.  The sheath was advanced over the wire.  A fistulogram was performed which demonstrated a high-grade stenosis just distal to the brachial artery anastomosis.  The introducer sheath was then exchanged for a 5 French sheath over a 0.025 guide wire.  The sheath was aspirated and flushed with heparinized saline solution.  A 0.025 glidewire was then obtained and advanced, placed over the sheath and across the area of stenosis into the brachial artery.  A 5 French short Kumpe catheter was used to guide the wire into the distal brachial and radial artery.  After crossing the area of stenosis, a 5 x 20 mm standard angioplasty balloon was obtained and prepped from the back table.  This was placed over the glidewire into the area of stenosis and inflated to 14 mmHg pressure and then deflated.  The balloon was then removed over the wire and repeat fistulogram was performed which demonstrated significant improvement.  However, there is still a remainder of residual stenosis.  The 5-mm balloon was placed over the wire again and a repeat angioplasty was performed.  The balloon was then removed over the wire and a repeat angiogram was performed which demonstrated again an area of stenosis right at the anastomosis.  The glidewire was removed and a 0.014 guide wire was then obtained and placed through the sheath and across the brachial anastomosis and into the radial artery.  A 4 x 20 mm cutting balloon was obtained and prepped on the back table.  The 5 French sheath was then exchanged for a 6 French sheath.  The balloon was then placed over the 0.014 guide wire into the area of stenosis and then inflated to normal pressures at 8 mmHg.  The balloon was then deflated and removed over the wire.  A 5 mm x 20 mm balloon was obtained and prepped and placed over the wire into the area of stenosis and inflated to pressures of 14 mmHg.  A repeat fistulogram was performed after the removal of the balloon which demonstrated excellent results with no significant residual stenosis.  The patient actually had a nice palpable thrill at this point.  The fistulogram of the distal cephalic vein at the subclavian anastomosis was performed which demonstrated a mild area of stenosis.  The sheath was removed and blood pressure was held over the puncture site for approximately 10 minutes.,After hemostasis was achieved, the cephalic vein again was visualized with bevel ultrasound.  The proximal cephalic vein was then cannulated after injecting the skin overlying the vessel with a 1% lidocaine solution.  A 5 French micropuncture introducer sheath was then placed over the wire into the proximal cephalic vein.  A repeat fistulogram was performed which demonstrated an area of stenosis within the distal cephalic vein just prior to the subclavian vein confluence.  The 5 French introducer sheath was then exchanged for a 5 French sheath.  The 5 mm x 20 mm balloon was placed over a 0.035 glidewire across the area of stenosis.  The balloon was inflated to 14 mmHg.  The balloon was then deflated and a repeat fistulogram was performed through the sheath which demonstrated good results.  The sheath was then removed and blood pressure was held over the puncture site for approximately 10 minutes.  After adequate hemostasis was achieved, the area was cleansed in 2x2 and Tegaderm was applied.  The patient tolerated the procedure without any complications.  I was present for the entire case.  The sponge, instrument, and needle counts are correct at the end of the case.  The patient was subsequently taken to PACU in stable condition.,ANGIOGRAPHIC FINDINGS:,  The initial left arm brachiocephalic fistulogram demonstrated a stenosis at the brachial artery anastomosis and distally within the cephalic vein.  After standard balloon angioplasty, there was a mild improvement but some residual area of stenosis remained at the anastomosis.  Then postcutting balloon angioplasty, venogram demonstrated a significant improvement without any evidence of significant stenosis.,Fistulogram of the proximal cephalic vein demonstrated a stenosis just prior to the confluence with the left subclavian vein.  Postangioplasty demonstrated excellent results with the standard balloon.  There was no evidence of any contrast extravasation.,IMPRESSION,1.  High-grade stenosis involving the cephalic vein at the brachial artery anastomosis and distally.  Postcutting balloon and standard balloon angioplasty demonstrated excellent results without any evidence of contrast extravasation.,2.  A moderate grade stenosis within the distal cephalic vein just prior to the confluence to the left subclavian vein.  Poststandard balloon angioplasty demonstrated excellent results.  No evidence of contrast extravasation.",
 Urine leaked around the ostomy site for his right sided nephrostomy tube.  The patient had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure., Nephrology, Leaking Nephrostomy Tube ,"CHIEF COMPLAINT:  ,Leaking nephrostomy tube.,HISTORY OF PRESENT ILLNESS: , This 61-year-old male was referred in today secondary to having urine leaked around the ostomy site for his right sided nephrostomy tube.  The leaking began this a.m.  The patient denies any pain, does not have fever and has no other problems or complaints.  The patient had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure.  The patient states he feels like his usual self and has no other problems or concerns.  The patient denies any fever or chills.  No nausea or vomiting.  No flank pain, no abdominal pain, no chest pain, no shortness of breath, no swelling to the legs.,REVIEW OF SYSTEMS: , Review of systems otherwise negative and noncontributory.,PAST MEDICAL HISTORY: , Metastatic prostate cancer, anemia, hypertension.,MEDICATIONS: , Medication reconciliation sheet has been reviewed on the nurses' note.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient is a nonsmoker.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Temperature 97.7 oral, blood pressure 150/85, pulse is 91, respirations 16, oxygen saturation 97% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished, well developed, appears to be healthy, calm, comfortable, no acute distress, looks well.  HEENT:  Eyes are normal with clear sclerae and cornea.  NECK:  Supple, full range of motion.  CARDIOVASCULAR:  Heart has regular rate and rhythm without murmur, rub or gallop.  Peripheral pulses are +2.  No dependent edema.  RESPIRATIONS:  Clear to auscultation bilaterally.  No shortness of breath.  No wheezes, rales or rhonchi.  Good air movement bilaterally.  GASTROINTESTINAL:  Abdomen is soft, nontender, nondistended.  No rebound or guarding.  Normal benign abdominal exam.  MUSCULOSKELETAL:  The patient has nontender back and flank.  No abnormalities noted to the back other than the bilateral nephrostomy tubes.  The nephrostomy tube left has no abnormalities, no sign of infection.  No leaking of urine, nontender, nephrostomy tube on the right has a damp dressing, which has a small amount of urine soaked into it.  There is no obvious active leak from the ostomy site.  No sign of infection.  No erythema, swelling or tenderness.  The collection bag is full of clear urine.  The patient has no abnormalities on his legs.  SKIN:  No rashes or lesions.  No sign of infection.  NEUROLOGIC:  Motor and sensory are intact to the extremities.  The patient has normal ambulation, normal speech.  PSYCHIATRIC:  Alert and oriented x4.  Normal mood and affect.  HEMATOLOGIC AND LYMPHATIC:  No bleeding or bruising.,EMERGENCY DEPARTMENT COURSE:,  Reviewed the patient's admission record from one month ago when he was admitted for the placement of the nephrostomy tubes, both Dr. X and Dr. Y have been consulted and both had recommended nephrostomy tubes, there was not the name mentioned as to who placed the nephrostomy tubes.  There was no consultation dictated for this and no name was mentioned in the discharge summary, paged Dr. X as this was the only name that the patient could remember that might have been involved with the placement of the nephrostomy tubes.  Dr. A responded to the page and recommended __________ off a BMP and discussing it with Dr. B, the radiologist as he recalled that this was the physician who placed the nephrostomy tubes, paged Dr. X and received a call back from Dr. X.  Dr. X stated that he would have somebody get in touch with us about scheduling a time for which they will change out the nephrostomy tube to a larger and check a nephrogram at that time that came down and stated that they would do it at 10 a.m. tomorrow.  This was discussed with the patient and instructions to return to the hospital at 10 a.m. to have this tube changed out by Dr. X was explained and understood.,DIAGNOSES:,1.  WEAK NEPHROSTOMY SITE FOR THE RIGHT NEPHROSTOMY TUBE.,2.  PROSTATE CANCER, METASTATIC.,3.  URETERAL OBSTRUCTION.,The patient on discharge is stable and dispositioned to home.,PLAN: , We will have the patient return to the hospital tomorrow at 10 a.m. for the replacement of his right nephrostomy tube by Dr. X.  The patient was asked to return in the emergency room sooner if he should develop any new problems or concerns.","nephrology, nephrostomy site, ureteral obstruction, leaking nephrostomy tube, acute renal failure, bilateral nephrostomy, ureteral obstructions, nephrostomy tube, tube, nephrostomy, ureteral, prostate, leaking, urine, tubes, "
" This is a 46-year-old gentleman with end-stage renal disease (ESRD) secondary to diabetes and hypertension, who had been on hemodialysis and is also status post cadaveric kidney transplant with chronic rejection.", Nephrology, ESRD - Discharge Summary ,"ADMISSION DIAGNOSIS:,  End-stage renal disease (ESRD).,DISCHARGE DIAGNOSIS: , End-stage renal disease (ESRD).,PROCEDURE:,  Cadaveric renal transplant.,HISTORY OF PRESENT ILLNESS: , This is a 46-year-old gentleman with end-stage renal disease (ESRD) secondary to diabetes and hypertension, who had been on hemodialysis since 1993 and is also status post cadaveric kidney transplant in 1996 with chronic rejection.,PAST MEDICAL HISTORY:  ,1.  Diabetes mellitus diagnosed 12 years ago.,2.  Hypertension.,3.  Coronary artery disease with a myocardial infarct in September of 2006.,4.  End-stage renal disease.,PAST SURGICAL HISTORY: , Coronary artery bypass graft x5 in 1995 and cadaveric renal transplant in 1996.,SOCIAL HISTORY:  ,The patient denies tobacco or ethanol use.,FAMILY HISTORY:,  Hypertension.,PHYSICAL EXAMINATION:  ,GENERAL:  The patient was alert and oriented x3 in no acute distress, healthy-appearing male.,VITAL SIGNS:  Temperature 96.6, blood pressure 166/106, heart rate 83, respiratory rate 18, and saturations 96% on room air.,CARDIOVASCULAR:  Regular rate and rhythm.,PULMONARY:  Clear to auscultation bilaterally.,ABDOMEN:  Soft, nontender, and nondistended with positive bowel sounds.,EXTREMITIES:  No clubbing, cyanosis, or edema.,PERTINENT LABORATORY DATA: , White blood cell count 6.4, hematocrit 34.6, and platelet count 182.  Sodium 137, potassium 5.4, BUN 41, creatinine 7.9, and glucose 295.  Total protein 6.5, albumin 3.4, AST 51, ALT 51, alk phos 175, and total bilirubin 0.5.,COURSE IN HOSPITAL: , The patient was admitted postoperatively to the surgical intensive care unit.  Initially, the patient had a decrease in hematocrit from 30 to 25.  The patient's hematocrit stabilized at 25.  During the patient's stay, the patient's creatinine progressively decreased from 8.1 to a creatinine at the time of discharge of 2.3.  The patient was making excellent urine throughout his stay.  The patient's Jackson-Pratt drain was removed on postoperative day #1 and he was moved to the floor.  The patient was advanced in diet appropriately.  The patient was started on Prograf by postoperative day #2.  Initial Prograf levels came back high at 18.  The patient's Prograf doses were changed accordingly and today, the patient is deemed stable to be discharged home.  During the patient's stay, the patient received four total doses of Thymoglobulin.  Today, he will complete his final dose of Thymoglobulin prior to being discharged.  In addition, today, the patient has an elevated blood pressure of 198/96.  The patient is being given an extra dose of metoprolol for this blood pressure.  In addition, the patient has an elevated glucose of 393 and for this reason he has been given an extra dose of insulin.  These labs will be rechecked later today and once his blood pressure has decreased to systolic blood pressure less than 116 and his glucose has come down to a more normal level, he will be discharged to home.,DISCHARGE INSTRUCTIONS: , The patient is discharged with instructions to seek medical attention in the event if he develops fevers, chills, nausea, vomiting, decreased urine output, or other concerns.  He is discharged on a low-potassium diet with activity as tolerated.  He is instructed that he may shower; however, he is to undergo no underwater soaking activities for approximately two weeks.  The patient will be followed up in the Transplant Clinic at ABCD tomorrow, at which time, his labs will be rechecked.  The patient's Prograf levels at the time of discharge are pending; however, given that his Prograf dose was decreased, he will be followed tomorrow at the Renal Transplant Clinic.",
" Management of end-stage renal disease (ESRD), the patient on chronic hemodialysis, being admitted for chest pain.", Nephrology, End Stage Renal Disease - Consult ,"REASON FOR CONSULTATION: , Management of end-stage renal disease (ESRD), the patient on chronic hemodialysis, being admitted for chest pain.,HISTORY OF PRESENT ILLNESS:,  This is a 66-year-old Native American gentleman, a patient of Dr. X, my associate, who has a past medical history of coronary artery disease, status post stent placement, admitted with chest pressure around 4 o'clock last night.  He took some nitroglycerin tablets at home with no relief.  He came to the ER.  He is going to have a coronary angiogram done today by Dr. Y. I have seen this patient first time in the morning, approximately around the 4 o'clock.  This is a late entry dictation.  Presently lying in bed, but he feels fine.  Denies any chest pain, shortness of breath, nausea, vomiting, abdominal pain, diarrhea.  Denies hematuria, dysuria, or bright red blood per rectum.,PAST MEDICAL HISTORY:,1.  Coronary artery disease, status post stent placement two years ago.,2.  Diabetes mellitus for the last 12 years.,3.  Hypertension.,4.  End-stage renal disease.,5.  History of TIA in the past.,PAST SURGICAL HISTORY:,1.  As mentioned above.,2.  Cholecystectomy.,3.  Appendectomy.,4.  Right IJ PermaCath placement.,5.  AV fistula graft in the right wrist.,PERSONAL AND SOCIAL HISTORY:,  He smoked 2 to 3 packets per day for at least last 10 years.  He quit smoking roughly about 20 years ago.  Occasional alcohol use.,FAMILY HISTORY: , Noncontributory.,ALLERGIES:  ,No known drug allergies.,MEDICATIONS AT HOME: , Metoprolol, Plavix, Rocaltrol, Lasix, Norvasc, Zocor, hydralazine, calcium carbonate, and loratadine.,PHYSICAL EXAMINATION,GENERAL:  He is alert, seems to be in no apparent distress.,VITAL SIGNS:  Temperature 98.2, pulse 61, respiratory 20, and blood pressure 139/63.,HEENT:  Atraumatic and normocephalic.,NECK:  No JVD, no thyromegaly, supra and infraclavicular lymphadenopathy.,LUNGS:  Clear to auscultation.  Air entry bilateral equal.,HEART:  S1 and S2.  No pericardial rub.,ABDOMEN:  Soft and nontender.  Normal bowel sounds.,EXTREMITIES:  No edema.,NEUROLOGIC:  The patient is alert without focal deficit.,LABORATORY DATA:,  Laboratory data shows hemoglobin 13, hematocrit 38.4, sodium 130, potassium 4.2, chloride 96.5, carbonate 30, BUN 26, creatinine 6.03, and glucose 162.,IMPRESSION:,1.  End-stage renal disease, plan for dialysis today.,2.  Diabetes mellitus.,3.  Chest pain for coronary angiogram today.,4.  Hypertension, blood pressure stable.,PLAN: , Currently follow the patient.  Dr. Z is going to assume the care.",
" Patient with left renal cell carcinoma, left renal cyst, had robotic-Assisted laparoscopic left renal cyst decortication and cystoscopy.", Nephrology, Discharge Summary - Nephrology ,"ADMITTING DIAGNOSES:,  Left renal cell carcinoma, left renal cyst.,DISCHARGE DIAGNOSIS:,  Left renal cell carcinoma, left renal cyst.,SECONDARY DIAGNOSES:,1.  Chronic obstructive pulmonary disease.,2.  Coronary artery disease.,PROCEDURES: , Robotic-Assisted laparoscopic left renal cyst decortication and cystoscopy.,HISTORY OF PRESENT ILLNESS: , Mr. ABC is a 70-year-old male who has been diagnosed with a left renal cell carcinoma with multiple renal cysts.  He has undergone MRI of the abdomen on June 18, 2008 revealing an enhancing mass of the upper pole of the left kidney consistent with his history of renal cell carcinoma.  Of note, there are no other enhancing solid masses seen on this MRI.  After discussion of multiple management strategies with the patient including:,1.  Left partial nephrectomy.,2.  Left radical nephrectomy.,3.  Left renal cyst decortication.  The patient is likely to undergo the latter procedure.,HOSPITAL COURSE:  ,The patient was admitted to undergo left renal cyst decortication as well as a cystoscopy.  Intraoperatively, approximately four enlarged renal cysts and six smaller renal cysts were initially removed.  The contents were aspirated and careful dissection of the cyst wall was performed.  Multiple specimens of the cyst wall were sent for pathology.  Approximately one liter of cystic fluid was drained during the procedure.  The renal bed was inspected for hemostasis, which appear to be adequate.  There were no complications with the procedure.  Single JP drain was left in place.  Additionally, the patient underwent flexible cystoscopy, which revealed no gross strictures or any other abnormalities in the penile nor prostatic urethra.  Furthermore, no gross lesions were encountered in the bladder.  The patient left OR with transfer to the PACU and subsequently to the hospital floor.,The patient's postoperative course was relatively uneventful.  His diet and activity were gradually advanced without complication.  On postoperative day #2, he was passing flatus and has had bowel movements.  His Jackson-Pratt drain was discontinued on postoperative day #3 that being the day of discharge.  His Foley catheter was removed on the morning of discharge and the patient subsequently passed the voiding trial without difficultly.  At the time of discharge, he was afebrile.  His vital signs indicated hemodynamic stability and he had no evidence of infection.  The patient was instructed to follow up with Dr. XYZ on 8/12/2008 at 1:50 p.m. and was given prescription for pain medications as well as laxative.,DISPOSITION: , To home.,DISCHARGE CONDITION:,  Good.,MEDICATIONS:  ,Please see attached medication list.,INSTRUCTIONS: , The patient was instructed to contact Dr. XYZ's office for fever greater than 101.5, intractable pain, nausea, vomiting, or any other concerns.,FOLLOWUP: , The patient will follow up with Dr. XYZ for a postoperative check on 08/12/2008 at 1:50 p.m. and he was made aware of this appointment.","nephrology, decortication, cystoscopy, pain, nausea, vomiting, renal cyst decortication, renal cell carcinoma, robotic assisted, renal cyst, renal, robotic, laparoscopic, nephrectomy, cysts, cell, carcinoma, discharge, "
" Presents to the ER with hematuria that began while sleeping last night.   He denies any pain, nausea, vomiting or diarrhea.", Nephrology, Hematuria - ER Visit ,"HISTORY OF PRESENT ILLNESS:,  The patient is an 85-year-old gentleman who follows as an outpatient with Dr. A.  He is known to us from his last admission.  At that time, he was admitted with a difficulty voiding and constipation.  His urine cultures ended up being negative.  He was seen by Dr. B and discharged home on Levaquin for five days.,He presents to the ER today with hematuria that began while he was sleeping last night.  He denies any pain, nausea, vomiting or diarrhea.  In the ER, a Foley catheter was placed and was irrigated with saline.  White count was 7.6, H and H are 10.8 and 38.7, and BUN and creatinine are of 27 and 1.9.  Urine culture is pending.  Chest x-ray is pending.  His UA did show lots of red cells.  The patient currently is comfortable.  CBI is running.  His urine is clear.,PAST MEDICAL HISTORY:,1.  Hypertension.,2.  High cholesterol.,3.  Bladder cancer.,4.  Bilateral total knee replacements.,5.  Cataracts.,6.  Enlarged prostate.,ALLERGIES:,  SULFA.,MEDICATIONS AT HOME:,1.  Atenolol.,2.  Cardura.,3.  Zegerid.,4.  Flomax.,5.  Levaquin.,6.  Proscar.,7.  Vicodin.,8.  Morphine.,9.  Phenergan.,10.  Ativan.,11.  Zocor.,12.  Prinivil.,13.  Hydrochlorothiazide.,14.  Folic acid.,15.  Digoxin.,16.  Vitamin B12.,17.  Multivitamin.,SOCIAL HISTORY: , The patient lives at home with his daughter.  He does not smoke, occasionally drinks alcohol.  He is independent with his activities of daily living.,REVIEW OF SYSTEMS:,  Not additionally rewarding.,PHYSICAL EXAMINATION:,GENERAL:  An awake and alert 85-year-old gentleman who is afebrile.,VITAL SIGNS:  BP of 162/60 and pulse oximetry of 98% on room air.,HEENT:  Pink conjunctivae.  Anicteric sclerae.  Oral mucosa is moist.,NECK:  Supple.,CHEST:  Clear to auscultation.,HEART:  Regular S1 and S2.,ABDOMEN:  Soft and nontender to palpation.,EXTREMITIES:  Without edema.,He has a Foley catheter in place.  His urine is clear.,LABORATORY DATA:,  Reviewed.,IMPRESSION:,1.  Hematuria.",
 The patient is being discharged for continued hemodialysis and rehab., Nephrology, Discharge Summary - Hemodialysis ,"DISCHARGE DIAGNOSES:,1.  End-stage renal disease, on hemodialysis.,2.  History of T9 vertebral fracture.,3.  Diskitis.,4.  Thrombocytopenia.,5.  Congestive heart failure with ejection fraction of approximately 30%.,6.  Diabetes, type 2.,7.  Protein malnourishment.,8.  History of anemia.,HISTORY AND HOSPITAL COURSE: , The patient is a 77-year-old white male who presented to Hospital of Bossier on April 14, 2008.  The patient was found to have lumbar diskitis and was going to require extensive antibiotic therapy, which was the cause of need for continued hospitalization.  He also needed to continue with dialysis and he needed to improve his rehabilitation.  The patient tolerated his medication well and he was going through rehab fairly well without any significant troubles.  He did have some bouts of issues with constipation on and off throughout his hospitalization, but this seemed to come under control with more aggressive management.  The patient had remained afebrile.  He did also have a bout with some episodic confusion problems, which appeared to be more of a sundowner-type of a problem, but this too cleared with his stay here at Promise.  On the day of discharge, on May 9, 2008, the patient was in good spirits, was very clear and lucid.  He denied any complaints of pain.  He did have some trouble with sleep at night at times, but I think this was mainly tied into the fact that he sleeps a lot during the day.  The patient has increased his appetite some and has been eating some.  His vital signs remain stable.  His blood pressure on discharge was 126/63, heart rate is 80, respiratory rate of 20 and temperature was 98.3.  PPD was negative.  An SMS form was filled out in plan for his discharge and he was sent with medications that he had been receiving while here at Promise.,The patient and his family understood our plan and agreed with it.  He thanked us for the care that he received at Promise and thought that they did a fantastic job taking care of him.  He did not have any acute questions as to where he was going and what the next step of his care would be, but we did discuss this at length prior to date of discharge.,","nephrology, end-stage renal disease, thrombocytopenia, anemia, hospitalization, hemodialysis and rehab, hemodialysis "
" Solitary left kidney with obstruction and hypertension and chronic renal insufficiency, plus a Pseudomonas urinary tract infection.", Nephrology, Discharge Summary - Urology & Nephrology  ,"ADMITTING DIAGNOSES:,  Solitary left kidney with obstruction, and hypertension, and chronic renal insufficiency.,DISCHARGE DIAGNOSES: , Solitary left kidney with obstruction and hypertension and chronic renal insufficiency, plus a Pseudomonas urinary tract infection.,PROCEDURES: , Cystoscopy under anesthesia, ureteroscopy, an attempted tube placement, stent removal with retrograde pyelography, percutaneous tube placement, and nephrostomy by Radiology.,PERTINENT LABORATORIES: , Creatinine of 1.4.  During the hospitalization it was decreased to 0.8 and Pseudomonas urinary tract infection, positive culture sensitive to ceftazidime and ciprofloxacin.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 3-1/2-year-old boy with a solitary kidney, had a ureteropelvic junction repair performed by Dr. Y, in the past, unfortunately, it was thought still be obstructed.  A stent was placed approximately 6 weeks ago after urethroscopic placement with some difficulty.  Plan was to remove the stent.  At the time of removal, we were unable to place another tube within the collecting system, and the patient was admitted for percutaneous nephrostomy placement.  He has had no recent cold or flu.  He has problems with hypertension for which he is on enalapril at home in addition to his Macrodantin prophylaxis.,PAST MEDICAL HISTORY: , The patient has no known allergies.  Multiple urinary tract infection, solitary kidney, and previous surgeries as mentioned above.,REVIEW OF SYSTEMS:,  A 14-organ system review of systems is negative except for the history of present illness.  He also has history of being a 34-week preemie twin.,ALLERGIES: , No known allergies.,FAMILY HISTORY: , Unremarkable without any bleeding or anesthetic problems.,SOCIAL HISTORY: , The patient lives at home with his parents, 2 brothers, and a sister.,IMMUNIZATIONS:,  Up-to-date.,MEDICATIONS: , On admission was Macrodantin, hydralazine, and enalapril.,PHYSICAL EXAMINATION:,GENERAL:  The patient is an active little boy.,HEENT:  The head and neck exam was grossly normal.  He had no oral, ocular, or nasal discharge.,LUNGS:  Exam was normal without wheezing.,HEART:  Without murmur or gallops.,ABDOMEN:  Soft, without mass or tenderness with a well-healed flank incision.,GU:  Uncircumcised male with bilaterally descended testes.,EXTREMITIES:  He has full range of motion in all 4 extremities.,SKIN:  Warm, pink, and dry.,NEUROLOGIC:  Grossly intact.,BACK:  He has normal back.  Normal gait.,HOSPITAL COURSE: , The patient was admitted to the hospital after inability to place a ureteral stent via ureteroscopy and cystoscopy.  He was made NPO.  He had a fever at first time with elevated creatinine.  He was also evaluated and treated by Dr. X, for fluid management, hypertensive management, and gave him some hydralazine and Lasix to improve his urine output, in addition to manage his blood pressure.  Once the percutaneous tube was placed, we found that his urine culture grew Pseudomonas, so he was kept on Fortaz, and was switched over to ciprofloxacin without difficulty.  He, otherwise, did well with continuing decrease his creatinine at the time of discharge to home.,The patient was discharged home in stable condition with ciprofloxacin, enalapril, and recommendation for followup in Urology in 1 to 2 weeks for the surgical correction in 2 to 3 weeks of repeat pyeloplasty or possible ureterocalicostomy.  The patient had draining nephrostomy tube without difficulty.,",
" Cystourethroscopy, right retrograde pyelogram, right ureteral pyeloscopy, right renal biopsy, and right double-J 4.5 x 26 mm ureteral stent placement.  Right renal mass and ureteropelvic junction obstruction and hematuria.", Nephrology, Cystourethroscopy & Retrograde Pyelogram - 1 ,"PREOPERATIVE DIAGNOSES:,1.  Right renal mass.,2.  Hematuria.,POSTOPERATIVE DIAGNOSES:,1.  Right renal mass.,2.  Right ureteropelvic junction obstruction.,PROCEDURES PERFORMED:,1.  Cystourethroscopy.,2.  Right retrograde pyelogram.,3.  Right ureteral pyeloscopy.,4.  Right renal biopsy.,5.  Right double-J 4.5 x 26 mm ureteral stent placement.,ANESTHESIA: , Sedation.,SPECIMEN: , Urine for cytology and culture sensitivity, right renal pelvis urine for cytology, and right upper pole biopsies.,INDICATION:,  The patient is a 74-year-old male who was initially seen in the office with hematuria.  He was then brought to the hospital for other medical problems and found to still have hematuria.  He has a CAT scan with abnormal appearing right kidney and it was felt that he will benefit from cystoscope evaluation.,PROCEDURE: ,After consent was obtained, the patient was brought to the operating room and placed in the supine position.  He was given IV sedation and placed in dorsal lithotomy position.  He was then prepped and draped in the standard fashion.  A #21 French cystoscope was then passed through his ureter on which patient was noted to have a hypospadias and passed through across the ends of the bladder.  The patient was noted to have mildly enlarged prostate, however, it was non-obstructing.,Upon visualization of the bladder, the patient was noted to have some tuberculation to the bladder.  There were no masses or any other abnormalities noted other than the tuberculation.  Attention was then turned to the right ureteral orifice and an open-end of the catheter was then passed into the right ureteral orifice.  A retrograde pyelogram was performed.  Upon visualization, there was no visualization of the upper collecting system on the right side.  At this point, a guidewire was then passed through the open-end of the ureteral catheter and the catheter was removed.  The bladder was drained and the cystoscope was removed.  The rigid ureteroscope was then passed into the bladder and into the right ureteral orifice with the assistance of a second glidewire.  The ureteroscope was taken all the way through the proximal ureter just below the UPJ and there were noted to be no gross abnormalities.  The ureteroscope was removed and an Amplatz wire then passed through the scope up into the collecting system along the side of the previous wire.  The ureteroscope was removed and a ureteral dilating sheath was passed over the Amplatz wire into the right ureter under fluoroscopic guidance.  The Amplatz wire was then removed and the flexible ureteroscope was passed through the sheath into the ureter.  The ureteroscope was passed up to the UPJ at which point there was noted to be difficulty entering the ureter due to UPJ obstruction.  The wire was then again passed through the flexible scope and the flexible scope was removed.  A balloon dilator was then passed over the wire and the UPJ was dilated with balloon dilation.  The dilator was then removed and again the cystoscope was passed back up into the right ureter and was able to enter the collecting system.  Upon visualization of the collecting system of the upper portion, there was noted to be papillary mass within the collecting system.  The ________ biopsy forceps were then passed through the scope and two biopsies were taken of the papillary mass.  Once this was done, the wire was left in place and the ureteroscope was removed.  The cystoscope was then placed back into the bladder and a 26 x 4.5 mm ureteral stent was passed over the wire under fluoroscopic and cystoscopic guidance into the right renal pelvis.  The stent was noted to be clear within the right renal pelvis as well as in the bladder.  The bladder was drained and the cystoscope was removed.  The patient tolerated the procedure well.  He will be transferred to the recovery room and back to his room.  It has been discussed with his primary physician that the patient will likely need a nephrectomy.  He will be scheduled for an echocardiogram tomorrow and then decision will be made where the patient will be stable for possible nephrectomy on Wednesday.","nephrology, renal mass, hematuria, ureteropelvic junction obstruction, cystourethroscopy, retrograde, pyelogram, ureteral pyeloscopy, renal biopsy, double-j, ureteral stent placement, ureteropelvic junction, flexible scope, papillary mass, ureteral stent, renal pelvis, ureteral orifice, amplatz wire, retrograde pyelogram, ureteral, cystoscope, ureteroscope, renal, bladder"
" Cystourethroscopy, bilateral retrograde pyelogram, and transurethral resection of bladder tumor of 1.5 cm in size.  Recurrent bladder tumor and history of bladder carcinoma.", Nephrology, Cystourethroscopy & Retrograde Pyelogram ,"PREOPERATIVE DIAGNOSES:,1.  Recurrent bladder tumor.,2.  History of bladder carcinoma.,POSTOPERATIVE DIAGNOSIS:,","nephrology, recurrent bladder tumor, bladder carcinoma, bilateral retrograde pyelogram, transurethral resection of bladder tumor, lateral wall bladder tumor, transurethral resection, retrograde pyelogram, tumor, bladder, cystourethroscopy, pyelogram,"
 Common Excretory Urogram - IVP template, Nephrology, Excretory Urogram - IVP  ,"There is normal and symmetrical filling of the caliceal system.  Subsequent films demonstrate that the kidneys are of normal size and contour bilaterally.  The caliceal system and ureters are in their usual position and show no signs of obstruction or intraluminal defects. The postvoid films demonstrate normal emptying of the collecting system, including the urinary bladder.,IMPRESSION:,  Negative intravenous urogram.,","nephrology, intravenous urogram, caliceal system, urinary bladder, excretory urogram, collecting systems, ivp, urogram, intravenousNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Cystopyelogram, clot evacuation, transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder.", Nephrology, Cystopyelogram - 1 ,"PREOPERATIVE DIAGNOSIS: , Gross hematuria.,POSTOPERATIVE DIAGNOSIS:  ,Gross hematuria.,OPERATIONS:  ,Cystopyelogram, clot evacuation, transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder.,ANESTHESIA: , Spinal.,FINDINGS:  ,Significant amount of bladder clots measuring about 150 to 200 mL, two cupful of clots were removed.  There was papillary tumor on the left wall right at the bladder neck and one on the right dome near the bladder neck on the right side.  The right ureteral opening was difficult to visualize, the left one was normal.,BRIEF HISTORY: , The patient is a 78-year-old male with history of gross hematuria and recurrent UTIs.  The patient had hematuria.  Cystoscopy revealed atypical biopsy.  The patient came in again with gross hematuria.  The first biopsy was done about a month ago.  The patient was to come back and have repeat biopsies done, but before that came into the hospital with gross hematuria.  The options of watchful waiting, removal of the clots and biopsies were discussed.  Risk of anesthesia, bleeding, infection, pain, MI, DVT and PE were discussed.  Morbidity and mortality of the procedure were discussed.  Consent was obtained from the daughter-in-law who has the power of attorney in Florida.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the OR.  Anesthesia was applied.  The patient was placed in the dorsal lithotomy position.  The patient was prepped and draped in the usual sterile fashion.  The patient had been off of the Coumadin for about 4 days and INR had been reversed.  The patient has significant amount of clot upon entering the bladder.  There was a tight bladder neck contracture.  The prostate was not enlarged.  Using ACMI 24-French sheath, using Ellick irrigation about 2 cupful of clots were removed.  It took about half an hour to just remove the clots.  After removing the clots, using 24-French cutting loop resectoscope, tumor on the left upper wall near the dome or near the 2 o'clock position was resected.  This was lateral to the left ureteral opening.  The base was coagulated for hemostasis.  Same thing was done at 10 o'clock on the right side where there was some tumor that was visualized.  The back wall and the rest of the bladder appeared normal.  Using 8-French cone-tip catheter, left-sided pyelogram was normal.  The right-sided pyelogram was very difficult to obtain and there was some mucosal irritation from the clots.  The contrast did go up to what appeared to be the right ureteral opening, but the mucosa seemed to be very much irritated and it was very difficult to actually visualize the opening.  A little bit of contrast went out, but the force was not made just to avoid any secondary stricture formation.  The patient did have CT with contrast, which showed that the kidneys were normal.  At this time, a #24 three-way irrigation was started.  The patient was brought to Recovery room in stable condition.","nephrology, clot evacuation, transurethral resection, bladder tumor, bladder neck, gross hematuria, bladder, cystopyelogram, hematuria, clots,"
" Right hydronephrosis, right flank pain, atypical/dysplastic urine cytology, extrarenal pelvis on the right, no evidence of obstruction or ureteral/bladder lesions.  Cystoscopy, bilateral retrograde ureteropyelograms, right ureteral barbotage for urine cytology, and right ureterorenoscopy.", Nephrology," Cystoscopy, Ureteropyelogram, & Ureteral Barbotage ","PREOPERATIVE DIAGNOSES:,1.  Right hydronephrosis.,2.  Right flank pain.,3.  Atypical/dysplastic urine cytology.,POSTOPERATIVE DIAGNOSES:,1.  Right hydronephrosis.,2.  Right flank pain.,3.  Atypical/dysplastic urine cytology.,4.  Extrarenal pelvis on the right.,5.  No evidence of obstruction or ureteral/bladder lesions.,PROCEDURE PERFORMED:,1.  Cystoscopy.,2.  Bilateral retrograde ureteropyelograms.,3.  Right ureteral barbotage for urine cytology.,4.  Right ureterorenoscopy, diagnostic.,ANESTHESIA: , Spinal.,SPECIMEN TO PATHOLOGY: , Urine and saline wash barbotage from right ureter through the ureteral catheter.,ESTIMATED BLOOD LOSS:  ,Minimal.,INDICATIONS FOR PROCEDURE: , This is a 70-year-old female who reports progressive intermittent right flank pain associated with significant discomfort and disability.  She presented to the emergency room where she was found to have significant hydronephrosis on the right without evidence of a stone.  She has some ureteral thickening in her distal right ureter.  She has persistent microscopic hematuria and her urine cytology and cytomolecular diagnosis significant for urothelial dysplasia with neoplasia-associated karyotypic profile.  She was brought to the operating room for further evaluation and treatment.,DESCRIPTION OF OPERATION: , After preoperative counseling, the patient was taken to the operating room and administered a spinal anesthesia.  She was placed in the lithotomy position, prepped and draped in the usual sterile fashion.  The 21-French cystoscope was inserted per urethra into the bladder.  The bladder was inspected and found to be without evidence of intravesical tumors, stones or mucosal abnormalities.  The right ureteral orifice was visualized and cannulated with an open-ended ureteral catheter.  This was gently advanced to the mid ureter.  Urine was collected for cytology.  Retrograde injection of saline through the ureteral catheter was then also used to enhance collection of the specimen.  This too was collected and sent for a pooled urine cytology as specimen from the right renal pelvis and ureter.  An 0.038 guidewire was then passed up through the open-ended ureteral catheter.  The open-ended ureteral catheter and cystoscope were removed, and over the guidewire the flexible ureteroscope was passed up to the level of the renal pelvis.  Using direct vision and fluoroscopy to confirm location, the entire renal pelvis and calyces were inspected.  The renal pelvis demonstrated an extrarenal pelvis, but no evidence of obstruction at the renal UPJ level.  There were no intrapelvic or calyceal stones.  The ureter demonstrated no significant mucosal abnormalities, no visible tumors, and no areas of apparent constriction on multiple passes of the ureteroscope through the ureter to evaluate.  The ureteroscope was then removed.  The cystoscope was reinserted.  Once again, retrograde injection of contrast through an open-ended ureteral catheter was undertaken in the right ureter and collecting system.  No evidence of extravasation or significant change in anatomy was visualized.  The left ureteral orifice was then visualized and cannulated with an open-ended ureteral catheter, and retrograde injection of contrast demonstrated a normal left ureter and collecting system.  The cystoscope was removed.  Foley catheter was inserted.  The patient was placed in the supine position and transferred to the recovery room in satisfactory condition.","nephrology, hydronephrosis, ureteropyelogram, ureterorenoscopy, flank pain, renal pelvis, urine cytology, ureteral, cystoscopy, barbotage, cystoscope, retrograde, urine, "
 Right lower pole renal stone and possibly infected stent.  Cysto stent removal., Nephrology, Cysto Stent Removal ,"PREOPERATIVE DIAGNOSIS: , Right lower pole renal stone and possibly infected stent.,POSTOPERATIVE DIAGNOSIS: , Right lower pole renal stone and possibly infected stent.,OPERATION:,  Cysto stent removal.,ANESTHESIA:,  Local MAC.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid.,MEDICATIONS: , The patient was on vancomycin and Levaquin was given x1 dose.  The patient was on vancomycin for the last 5 days.,BRIEF HISTORY:  ,The patient is a 53-year-old female who presented with Enterococcus urosepsis.  CT scan showed a lower pole stone with a stent in place.  The stent was placed about 2 months ago, but when patient came in with a possibly UPJ stone with fevers of unknown etiology.  The patient had a stent placed at that time due to the fevers, thinking that this was an urospetic stone.  There was some pus that came out.  The patient was cultured; actually it was negative at that time.  The patient subsequently was found to have lower extremity DVT and then was started on Coumadin.  The patient cannot be taken off Coumadin for the next 6 months due to the significant swelling and high risk for PE.  The repeat films were taken which showed the stone had migrated into the pole.,The stent was intact.  The patient subsequently developed recurrent UTIs and Enterococcus in the urine with fevers.  The patient was admitted for IV antibiotics since the patient could not really tolerate penicillin due to allergy and due to patient being on Coumadin, Cipro, and Levaquin where treatment was little bit more complicated.  Due to drug interaction, the patient was admitted for IV antibiotic treatment.  The thinking was that either the stone or the stent is infected, since the stone is pretty small in size, the stent is very likely possibility that it could have been infected and now it needs to be removed.  Since the stone is not obstructing, there is no reason to replace the stent at this time.  We are unable to do the ureteroscopy or the shock-wave lithotripsy when the patient is fully anticoagulated.  So, the best option at this time is to probably wait and perform the ureteroscopic laser lithotripsy when the patient is allowed to off her Coumadin, which would be probably about 4 months down the road.,Plan is to get rid of the stent and improve patient's urinary symptoms and to get rid of the infection and we will worry about the stone at later point.,DETAILS OF THE OR: , Consent had been obtained from the patient.  Risks, benefits, and options were discussed.  Risk of anesthesia, bleeding, infection, pain, MI, DVT, and PE were discussed.  The patient understood all the risks and benefits of removing the stent and wanted to proceed.  The patient was brought to the OR.  The patient was placed in dorsal lithotomy position.  The patient was given some IV pain meds.  The patient had received vancomycin and Levaquin preop.  Cystoscopy was performed using graspers.  The stent was removed without difficulty.  Plan was for repeat cultures and continuation of the IV antibiotics.","nephrology, infected stent, cysto stent removal, cysto stent, renal stone, lower pole, infected, stone, stent, cysto,"
" Cystopyelogram, left ureteroscopy, laser lithotripsy, stone basket extraction, stent exchange with a string attached.", Nephrology, Cystopyelogram ,"PREOPERATIVE DIAGNOSIS: , Left distal ureteral stone.,POSTOPERATIVE DIAGNOSIS: , Left distal ureteral stone.,PROCEDURE PERFORMED: , Cystopyelogram, left ureteroscopy, laser lithotripsy, stone basket extraction, stent exchange with a string attached.,ANESTHESIA:,  LMA.,EBL: , Minimal.,FLUIDS: , Crystalloid.  The patient was given antibiotics, 1 g of Ancef and the patient was on oral antibiotics at home.,BRIEF HISTORY: , The patient is a 61-year-old female with history of recurrent uroseptic stones.  The patient had stones x2, 1 was already removed, second one came down, had recurrent episode of sepsis, stent was placed.  Options were given such as watchful waiting, laser lithotripsy, shockwave lithotripsy etc.  Risks of anesthesia, bleeding, infection, pain, need for stent, and removal of the stent were discussed.  The patient understood and wanted to proceed with the procedure.,DETAILS OF THE PROCEDURE: , The patient was brought to the OR.  Anesthesia was applied.  The patient was placed in dorsal lithotomy position.  The patient was prepped and draped in usual sterile fashion.  A 0.035 glidewire was placed in the left system.  Using graspers, left-sided stent was removed.  A semirigid ureteroscopy was done.  A stone was visualized in the mid to upper ureter.  Using laser, the stone was broken into 5 to 6 small pieces.  Using basket extraction, all the pieces were removed.  Ureteroscopy all the way up to the UPJ was done, which was negative.  There were no further stones.  Using pyelograms, the rest of the system appeared normal.  The entire ureter on the left side was open and patent.  There were no further stones.  Due to the edema and the surgery, plan was to leave the stent attached to the string and the patient was to pull the string in about 24 hours.  Over the 0.035 glidewire, a 26 double-J stent was placed.  There was a nice curl in the kidney and one in the bladder.  The patient tolerated the procedure well.  Please note that the string was kept in place and the patient was to remove the stent the next day.  The patient's family was instructed how to do so.  The patient had antibiotics and pain medications at home.  The patient was brought to recovery room in a stable condition.","nephrology, laser lithotripsy, shockwave lithotripsy, double-j stent, distal ureteral stone, ureteral stone, basket extraction, cystopyelogram, laser, lithotripsy, stones, string, ureteroscopy, stone, stent,"
 Generalized abdominal pain with swelling at the site of the ileostomy.  CT abdomen with contrast and CT pelvis with contrast.  Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300., Nephrology, CT Abdomen & Pelvis - 9 ,"CT ABDOMEN WITH CONTRAST AND CT PELVIS WITH CONTRAST,REASON FOR EXAM: , Generalized abdominal pain with swelling at the site of the ileostomy.,TECHNIQUE:,  Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.,CT ABDOMEN:  ,The liver, spleen, pancreas, adrenal glands, and kidneys are unremarkable.  Punctate calcifications in the gallbladder lumen likely represent a gallstone.,CT PELVIS:  ,Postsurgical changes of a left lower quadrant ileostomy are again seen.  There is no evidence for an obstruction.  A partial colectomy and diverting ileostomy is seen within the right lower quadrant.  The previously seen 3.4 cm subcutaneous fluid collection has resolved.  Within the left lower quadrant, a 3.4 cm x 2.5 cm loculated fluid collection has not significantly changed.  This is adjacent to the anastomosis site and a pelvic abscess cannot be excluded.  No obstruction is seen.  The appendix is not clearly visualized.  The urinary bladder is unremarkable.,IMPRESSION:,1.  Resolution of the previously seen subcutaneous fluid collection.,2.  Left pelvic 3.4 cm fluid collection has not significantly changed in size or appearance.  These findings may be due to a pelvic abscess.,3.  Right lower quadrant ileostomy has not significantly changed.,4.  Cholelithiasis.","nephrology, axial ct images, isovue-300, ct pelvis, ct abdomen, fluid collection, abdomen, obstruction, subcutaneous, abscess, pelvic, fluid, collection, pelvis, ileostomy, ct, isovue,"
" Generalized abdominal pain, nausea, diarrhea, and recent colonic resection.  CT abdomen with and without contrast and CT pelvis with contrast.  Axial CT images of the abdomen were obtained without contrast.  Axial CT images of the abdomen and pelvis were then obtained utilizing 100 mL of Isovue-300.", Nephrology, CT Abdomen & Pelvis - 8 ,"CT ABDOMEN WITH AND WITHOUT CONTRAST AND CT PELVIS WITH CONTRAST,REASON FOR EXAM: , Generalized abdominal pain, nausea, diarrhea, and recent colonic resection in 11/08.,TECHNIQUE:,  Axial CT images of the abdomen were obtained without contrast.  Axial CT images of the abdomen and pelvis were then obtained utilizing 100 mL of Isovue-300.,FINDINGS: , The liver is normal in size and attenuation.,The gallbladder is normal.,The spleen is normal in size and attenuation.,The adrenal glands and pancreas are unremarkable.,The kidneys are normal in size and attenuation.,No hydronephrosis is detected.  Free fluid is seen within the right upper quadrant within the lower pelvis.  A markedly thickened loop of distal small bowel is seen.  This segment measures at least 10-cm long.  No definite pneumatosis is appreciated.  No free air is apparent at this time.  Inflammatory changes around this loop of bowel.  Mild distention of adjacent small bowel loops measuring up to 3.5 cm is evident.  No complete obstruction is suspected, as there is contrast material within the colon.  Postsurgical changes compatible with the partial colectomy are noted.  Postsurgical changes of the anterior abdominal wall are seen.  Mild thickening of the urinary bladder wall is seen.,IMPRESSION:,1.  Marked thickening of a segment of distal small bowel is seen with free fluid within the abdomen and pelvis.  An inflammatory process such as infection or ischemia must be considered.  Close interval followup is necessary.,2.  Thickening of the urinary bladder wall is nonspecific and may be due to under distention.  However, evaluation for cystitis is advised.","nephrology, abdominal pain, nausea, diarrhea, colonic resection, axial ct images, ct abdomen, isovue, inflammatory, urinary, bladder, abdominal, colonic, wall, thickening, axial, bowel, contrast, attenuation, pelvis, ct, abdomen"
 Noncontrast CT abdomen and pelvis per renal stone protocol., Nephrology, CT KUB ,"EXAM:  ,CT KUB.,REASON FOR EXAM: , Flank pain.,TECHNIQUE:,  Noncontrast CT abdomen and pelvis per renal stone protocol.,Correlation is made with the prior examination dated 01/16/09.,FINDINGS: , There is no intrarenal stone or obstruction bilaterally.  There is no hydronephrosis, ureteral dilatation.  There are calcifications about the pelvis including one in the left upper pelvis, but these are stable from the prior study and there is no upstream ureteral dilatation, the findings therefore are favored to represent phleboliths.  The bladder is nearly completely decompressed.  There is no asymmetric renal enlargement or perinephric stranding as secondary evidence of obstruction.,The appendix is normal.  There is no evidence for a pericolonic inflammatory process or small bowel obstruction.,Dedicated scan to the pelvis disclosed the aforementioned presumed phleboliths.  There is no pelvic free fluid or adenopathy.,Lung bases appear clear.  Given the lack of contrast, liver, spleen, adrenal glands, and the pancreas appear grossly unremarkable.  The gallbladder has been resected.  There is no abdominal free fluid or pathologic adenopathy.,IMPRESSION:,1. No renal stone or evidence of obstruction.  Stable appearing pelvic calcifications likely indicate phleboliths.,2. Normal appendix.","nephrology, pericolonic inflammatory process, phleboliths, renal stone protocol, ct kub, ct abdomen, ureteral dilatation, free fluid, renal stone, noncontrast, kub, adenopathy, abdomen, ct, renal, stone, obstruction, pelvis"
" CT-guided needle placement, CT-guided biopsy of right renal mass, and embolization of biopsy tract with gelfoam.", Nephrology, CT-Guided Biopsy - Kidney ,"REASON FOR EXAM:  This 60-year-old female who was found to have a solid indeterminate mass involving the inferior pole of the right kidney was referred for percutaneous biopsy under CT guidance at the request of Dr. X.,PROCEDURE:  The procedure risks and possible complications including, but not limited to severe hemorrhage which could result in emergent surgery, were explained to the patient.  The patient understood.  All questions were answered, and informed consent was obtained.  With the patient in the prone position, noncontrasted CT localization images were obtained through the kidney.  Conscious sedation was utilized with the patient being monitored.  The patient was administered divided dose of Versed and fentanyl intravenously.,Following sterile preparation and local anesthesia to the posterior aspect of the right flank, an 18-gauge co-axial Temno-type needle was directed into the inferior pole right renal mass from the posterior oblique approach.  Two biopsy specimens were obtained and placed in 10% formalin solution.  CT documented needle placement.  Following the biopsy, there was active bleeding through the stylet, as well as a small hematoma about the inferior aspect of the right kidney posteriorly.  I placed several torpedo pledgets of Gelfoam through the co-axial sheath into the site of bleeding.  The bleeding stopped.  The co-axial sheath was then removed.  Bandage was applied.  Hemostasis was obtained.  The patient was placed in the supine position.  Postbiopsy CT images were then obtained.  The patient's hematoma appeared stable.  The patient was without complaints of pain or discomfort.  The patient was then sent to her room with plans of observing for approximately 4 hours and then to be discharged, as stable.  The patient was instructed to remain at bedrest for the remaining portions of the day at home and patient is to followup with Dr. Fieldstone for the results and follow-up care.,FINDINGS:  Initial noncontrasted CT localization images reveals the presence of an approximately 2.1 cm cortical mass involving the posterior aspect of the inferior pole of the right kidney.  Images obtained during the biopsy reveals the cutting portion of the biopsy needle to extend through the mass.  Images obtained following the biopsy reveals the development of a small hematoma posterior to the right kidney in its inferior pole adjacent to the mass.  There are small droplets of air within the hematoma.  No hydronephrosis is identified.,CONCLUSION:,1.  Percutaneous biopsy of inferior pole right renal mass under computed tomography guidance with specimen sent to laboratory in 10% formalin solution.,2.  Development of a small hematoma adjacent to the inferior pole of the right kidney with active bleeding through the biopsy needle stopped by tract embolization with Gelfoam pledgets.","nephrology, embolization, ct localization, gelfoam pledgets, ct guided needle placement, ct guided biopsy, needle placement, renal mass, ct guided, inferior pole, ct, biopsy, hematoma, kidney, mass,"
" Residual stone status post right percutaneous nephrolithotomy, attempted second-look nephrolithotomy, cysto with insertion of 6-French variable length double-J stent.", Nephrology, Cysto & Double-J Stent Insersion ,"PREOPERATIVE DIAGNOSIS:,  Residual stone, status post right percutaneous nephrolithotomy.,POSTOPERATIVE DIAGNOSES: , Residual stone status post right percutaneous nephrolithotomy, attempted second-look nephrolithotomy, cysto with insertion of 6-French variable length double-J stent.,ANESTHESIA:,  General via endotracheal tube.,BLOOD LOSS:,  Minimal.,DRAINS: , 16-French Foley, 6-French variable length double-J stent.,INTRAOPERATIVE COMPLICATIONS: , Unable to re-access the collecting system.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room and laid supine.  General anesthesia was accomplished.  A 16-French Foley was placed using aseptic technique.  The patient was then placed on the operating table prone.  His right flank was prepped and draped in a sterile fashion.  At this point, contrast was injected through his existing nephrostomy tube and there was no continuity with the collecting system and it was removed.  The 5-French Pollack catheter was used to pass a 0.38 super-stiff Amplatz wire.  The wire would not go down the ureter.  Multiple attempts were made using Pollack catheters and Cobra catheters and attempts were made to dilate the track, both with rigid dilator and the balloon dilator and access could not be obtained.  After multiple attempts, access was lost.  At this point, the tubes were left out of the kidney and sterile dressings were applied.  The patient was then placed on another operating table supine.  His genitalia were prepped and draped after removing his Foley catheter.  Flexible cystoscopy was performed and the right orifice identified, which was edematous and erythematous.  The wire was passed up to kidney and a 5-French Pollack catheter was then passed over to after the removing the scope.  The wire was removed.  Contrast injection with good placement in the collecting system.  The wire was replaced.  The Pollack catheter removed and 6-French variable length double-J stent was inserted using fluoroscopic guidance.  The wire was removed leaving the double-J stent in good position.  _______ 16-French Foley was reinserted and connected to close drains.,Procedure was terminated at this point and had been well tolerated.  The patient was awakened and taken to recovery room in satisfactory condition having tolerated the procedure well.","nephrology, residual stone, percutaneous, cobra catheters, amplatz, double j stent, pollack catheter, cysto, catheter, nephrolithotomy, stent, french"
" Lower quadrant pain with nausea, vomiting, and diarrhea.  CT abdomen without contrast and CT pelvis without contrast.  Noncontrast axial CT images of the abdomen and pelvis are obtained.", Nephrology, CT Abdomen & Pelvis - 7 ,"REASON FOR EXAM: , Lower quadrant pain with nausea, vomiting, and diarrhea.,TECHNIQUE: , Noncontrast axial CT images of the abdomen and pelvis are obtained.,FINDINGS: , Please note evaluation of the abdominal organs is secondary to the lack of intravenous contrast material.,Gallstones are seen within the gallbladder lumen.  No abnormal pericholecystic fluid is seen.,The liver is normal in size and attenuation.,The spleen is normal in size and attenuation.,A 2.2 x 1.8 cm low attenuation cystic lesion appears to be originating off of the tail of the pancreas.  No pancreatic ductal dilatation is seen.  There is no abnormal adjacent stranding.  No suspected pancreatitis is seen.,The kidneys show no stone formation or hydronephrosis.,The large and small bowels are normal in course and caliber.  There is no evidence for obstruction.  The appendix appears within normal limits.,In the pelvis, the urinary bladder is unremarkable.  There is a 4.2 cm cystic lesion of the right adnexal region.  No free fluid, free air, or lymphadenopathy is detected.,There is left basilar atelectasis.,IMPRESSION:,1.  A 2.2 cm low attenuation lesion is seen at the pancreatic tail.  This is felt to be originating from the pancreas, a cystic pancreatic neoplasm must be considered and close interval followup versus biopsy is advised.  Additionally, when the patient's creatinine improves, a contrast-enhanced study utilizing pancreatic protocol is needed.  Alternatively, an MRI may be obtained.,2.  Cholelithiasis.,3.  Left basilar atelectasis.,4.  A 4.2 cm cystic lesion of the right adnexa, correlation with pelvic ultrasound is advised.","nephrology, ct abdomen, ct pelvis, neoplasm, lesion, attenuation, hydronephrosis, stone formation, ct images, cystic lesion, abdomen, cystic, pancreatic, ct, pelvis, intravenous, noncontrast"
 Noncontrast CT abdomen and pelvis per renal stone protocol., Nephrology, CT Stone Protocol ,"EXAM: , CT stone protocol.,REASON FOR EXAM:,  History of stones, rule out stones.,TECHNIQUE: , Noncontrast CT abdomen and pelvis per renal stone protocol.,FINDINGS: , Correlation is made with a prior examination dated 01/20/09.,Again identified are small intrarenal stones bilaterally.  These are unchanged.  There is no hydronephrosis or significant ureteral dilatation.  There is no stone along the expected course of the ureters or within the bladder.  There is a calcification in the low left pelvis not in line with ureter, this finding is stable and is compatible with a phlebolith.  There is no asymmetric renal enlargement or perinephric stranding.,The appendix is normal.  There is no evidence of a pericolonic inflammatory process or small bowel obstruction.,Scans through the pelvis disclose no free fluid or adenopathy.,Lung bases aside from very mild dependent atelectasis appear clear.,Given the lack of contrast, liver, spleen, adrenal glands, and the pancreas are grossly unremarkable.  The gallbladder is present.  There is no abdominal free fluid or pathologic adenopathy.,IMPRESSION:,1. Bilateral intrarenal stones, no obstruction.,2. Normal appendix.","nephrology, noncontrast ct, abdomen and pelvis, renal stone protocol, renal stone, intrarenal stones, stone protocol, ureteral, adenopathy, renal, ct, protocol, pelvis, intrarenal, stone, abdomen, noncontrast,"
" CT abdomen and pelvis without contrast, stone protocol, reconstruction.", Nephrology, CT Abdomen & Pelvis - 4 ,"EXAM: , CT abdomen and pelvis without contrast, stone protocol, reconstruction.,REASON FOR EXAM: , Flank pain.,TECHNIQUE: , Noncontrast CT abdomen and pelvis with coronal reconstructions.,FINDINGS: , There is no intrarenal stone bilaterally.  However, there is very mild left renal pelvis and proximal ureteral dilatation with a small amount of left perinephric stranding asymmetric to the right.  The right renal pelvis is not dilated.  There is no stone along the course of the ureter.  I cannot exclude the possibility of recent stone passage, although the findings are ultimately technically indeterminate and clinical correlation is advised.  There is no obvious solid-appearing mass given the lack of contrast.,Scans of the pelvis disclose no evidence of stone within the decompressed bladder.  No pelvic free fluid or adenopathy.,There are few scattered diverticula.  There is a moderate amount of stool throughout the colon.  There are scattered diverticula, but no CT evidence of acute diverticulitis.  The appendix is normal.,There are mild bibasilar atelectatic changes.,Given the lack of contrast, visualized portions of the liver, spleen, adrenal glands, and the pancreas are grossly unremarkable.  The gallbladder is present.  There is no abdominal free fluid or pathologic adenopathy.,There are degenerative changes of the lumbar spine.,IMPRESSION:,1.Very mild left renal pelvic dilatation and proximal ureteral dilatation with mild left perinephric stranding.  There is no stone identified along the course of the left ureter or in the bladder.  Could this patient be status post recent stone passage?  Clinical correlation is advised.,2.Diverticulosis.,3.Moderate amount of stool throughout the colon.,4.Normal appendix.","nephrology, coronal reconstructions, stone protocol, renal pelvic dilatation, proximal ureteral dilatation, ct abdomen and pelvis, stone protocol reconstruction, abdomen and pelvis, perinephric stranding, free fluid, scattered diverticula, renal, dilatation, contrast, ureteral, ct, abdomen, pelvis, stone, noncontrast,"
" Motor vehicle collision.  CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.  ", Nephrology," CT Head, Facial Bones, Cervical Spine - 1 ","CT HEAD WITHOUT CONTRAST, CT FACIAL BONES WITHOUT CONTRAST, AND CT CERVICAL SPINE WITHOUT CONTRAST,REASON FOR EXAM: , Motor vehicle collision.,CT HEAD,TECHNIQUE: , Noncontrast axial CT images of the head were obtained without contrast.,FINDINGS: , There is no acute intracranial hemorrhage, mass effect, midline shift, or extra-axial fluid collection.  The ventricles and cortical sulci are normal in shape and configuration.  The gray/white matter junctions are well preserved.  No calvarial fracture is seen.,IMPRESSION:  ,Negative for acute intracranial disease.,CT FACIAL BONES WITHOUT CONTRAST,TECHNIQUE:  ,Noncontrast axial CT images of the facial bones were obtained with coronal reconstructions.,FINDINGS:,  There is no facial bone fracture.  The maxilla and mandible are intact.  The visualized paranasal sinuses are clear.  The temporomandibular joints are intact.  The nasal bone is intact.  The orbits are intact.  The extra-ocular muscles and orbital nerves are normal.  The orbital globes are normal.,IMPRESSION: , No evidence for a facial bone fracture.,CT CERVICAL SPINE WITHOUT CONTRAST,TECHNIQUE: , Noncontrast axial CT images of the cervical spine were obtained with sagittal and coronal reconstructions.,FINDINGS: , There is a normal lordosis of the cervical spine, no fracture or subluxation is seen.  The vertebral body heights are normal.  The intervertebral disk spaces are well preserved.  The atlanto-dens interval is normal.  No abnormal anterior cervical soft tissue swelling is seen.  There is no spinal compression deformity.,IMPRESSION: , Negative for a facial bone fracture.","nephrology, intracranial disease, motor vehicle collision, orbital nerves, extra-ocular muscles, cervical spine, ct cervical spine, ct facial bones, ct head, axial ct images, facial bone fracture, facial bones, ct, noncontrast, intracranial, axial, spine, fracture, cervical, contrast, facial, bones, "
 Right-sided abdominal pain with nausea and fever.  CT abdomen with contrast and CT pelvis with contrast.  Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300., Nephrology, CT Abdomen & Pelvis - 6 ,"REASON FOR EXAM: , Right-sided abdominal pain with nausea and fever.,TECHNIQUE: , Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.,CT ABDOMEN:  ,The liver, spleen, pancreas, gallbladder, adrenal glands, and kidney are unremarkable.,CT PELVIS: , Within the right lower quadrant, the appendix measures 16 mm and there are adjacent inflammatory changes with fluid in the right lower quadrant.  Findings are compatible with acute appendicitis.,The large and small bowels are normal in course and caliber without obstruction.  The urinary bladder is normal.  The uterus appears unremarkable.  Mild free fluid is seen in the lower pelvis.,No destructive osseous lesions are seen.  The visualized lung bases are clear.,IMPRESSION: , Acute appendicitis.","nephrology, adrenal glands, appendicitis, gallbladder, kidney, liver, pancreas, spleen, acute appendicitis, ct pelvis, ct abdomen, abdominal, contrast, fluid, abdomen, inflammatory, pelvis, ct"
 CT of the abdomen and pelvis without contrast., Nephrology, CT Abdomen & Pelvis - 3 ,"EXAM: , CT of the abdomen and pelvis without contrast.,HISTORY: , Lower abdominal pain.,FINDINGS:,  Limited views of the lung bases demonstrate linear density most likely representing dependent atelectasis.  There is a 1.6 cm nodular density at the left posterior sulcus.,Noncontrast technique limits evaluation of the solid abdominal organs.  Cardiomegaly and atherosclerotic calcifications are seen.,Hepatomegaly is observed.  There is calcification within the right lobe of the liver likely related to granulomatous changes.  Subtle irregularity of the liver contour is noted, suggestive of cirrhosis.  There is splenomegaly seen.  There are two low-attenuation lesions seen in the posterior aspect of the spleen, which are incompletely characterized that may represent splenic cyst.  The pancreas appears atrophic.  There is a left renal nodule seen, which measures 1.9 cm with a Hounsfield unit density of approximately 29, which is indeterminate.,There is mild bilateral perinephric stranding.  There is an 8-mm fat density lesion in the anterior inner polar region of the left kidney, compatible in appearance with angiomyolipoma.  There is a 1-cm low-attenuation lesion in the upper pole of the right kidney, likely representing a cyst, but incompletely characterized on this examination.  Bilateral ureters appear normal in caliber along their visualized course.  The bladder is partially distended with urine, but otherwise unremarkable.,Postsurgical changes of hysterectomy are noted.  There are pelvic phlebolith seen.  There is a calcified soft tissue density lesion in the right pelvis, which may represent an ovary with calcification, as it appears continuous with the right gonadal vein.,Scattered colonic diverticula are observed.  The appendix is within normal limits.  The small bowel is unremarkable.  There is an anterior abdominal wall hernia noted containing herniated mesenteric fat.  The hernia neck measures approximately 2.7 cm.  There is stranding of the fat within the hernia sac.,There are extensive degenerative changes of the right hip noted with changes suggestive of avascular necrosis.  Degenerative changes of the spine are observed.,IMPRESSION:,1.  Anterior abdominal wall hernia with mesenteric fat-containing stranding, suggestive of incarcerated fat.,2.  Nodule in the left lower lobe, recommend follow up in 3 months.,3.  Indeterminate left adrenal nodule, could be further assessed with dedicated adrenal protocol CT or MRI.,4.  Hepatomegaly with changes suggestive of cirrhosis.  There is also splenomegaly observed.,5.  Low-attenuation lesions in the spleen may represent cyst, that are incompletely characterized on this examination.,6.  Fat density lesion in the left kidney, likely represents angiomyolipoma.,7.  Fat density soft tissue lesion in the region of the right adnexa, this contains calcifications and may represent an ovary or possibly dermoid cyst.","nephrology, abdominal pain, cardiomegaly, atherosclerotic calcifications, hepatomegaly, perinephric stranding, low attenuation lesions, abdominal, calcifications, lesions, abdomen,"
 CT scan of the abdomen and pelvis with contrast to evaluate abdominal pan., Nephrology, CT Scan of Abdomen & Pelvis with Contrast ,"EXAM: , CT scan of the abdomen and pelvis with contrast.,REASON FOR EXAM: , Abdominal pain.,COMPARISON EXAM: , None.,TECHNIQUE: , Multiple axial images of the abdomen and pelvis were obtained.  5-mm slices were acquired after injection of 125 cc of Omnipaque IV.  In addition, oral ReadiCAT was given.  Reformatted sagittal and coronal images were obtained.,DISCUSSION:,  There are numerous subcentimeter nodules seen within the lung bases.  The largest measures up to 6 mm.  No hiatal hernia is identified.  Consider chest CT for further evaluation of the pulmonary nodules.  The liver, gallbladder, pancreas, spleen, adrenal glands, and kidneys are within normal limits.  No dilated loops of bowel.  There are punctate foci of air seen within the nondependent portions of the peritoneal cavity as well as the anterior subcutaneous fat.  In addition, there is soft tissue stranding seen of the lower pelvis.  In addition, the uterus is not identified.  Correlate with history of recent surgery.  There is no free fluid or lymphadenopathy seen within the abdomen or pelvis.  The bladder is within normal limits for technique.,No acute bony abnormalities appreciated.  No suspicious osteoblastic or osteolytic lesions.,IMPRESSION:,1.  Postoperative changes seen within the pelvis without appreciable evidence for free fluid.,2.  Numerous subcentimeter nodules seen within the lung bases.  Consider chest CT for further characterization.","nephrology, ct scan, abdominal pain, multiple axial images, abdomen and pelvis, adrenal glands, chest ct, coronal, gallbladder, kidneys, liver, lymphadenopathy, nodules, osteoblastic, osteolytic, pancreas, sagittal, spleen, with contrast, free fluid, ct, abdomen, pelvis,"
"  CT abdomen without contrast and pelvis without contrast, reconstruction.", Nephrology, CT Abdomen & Pelvis - 5 ,"EXAM: , CT abdomen without contrast and pelvis without contrast, reconstruction.,REASON FOR EXAM: , Right lower quadrant pain, rule out appendicitis.,TECHNIQUE:  ,Noncontrast CT abdomen and pelvis.  An intravenous line could not be obtained for the use of intravenous contrast material.,FINDINGS: , The appendix is normal.  There is a moderate amount of stool throughout the colon.  There is no evidence of a small bowel obstruction or evidence of pericolonic inflammatory process.  Examination of the extreme lung bases appear clear, no pleural effusions.  The visualized portions of the liver, spleen, adrenal glands, and pancreas appear normal given the lack of contrast.  There is a small hiatal hernia.  There is no intrarenal stone or evidence of obstruction bilaterally.  There is a questionable vague region of low density in the left anterior mid pole region, this may indicate a tiny cyst, but it is not well seen given the lack of contrast.  This can be correlated with a followup ultrasound if necessary.  The gallbladder has been resected.  There is no abdominal free fluid or pathologic adenopathy.  There is abdominal atherosclerosis without evidence of an aneurysm.,Dedicated scans of the pelvis disclosed phleboliths, but no free fluid or adenopathy.  There are surgical clips present.  There is a tiny airdrop within the bladder.  If this patient has not had a recent catheterization, correlate for signs and symptoms of urinary tract infection.,IMPRESSION:,1.Normal appendix.,2.Moderate stool throughout the colon.,3.No intrarenal stones.,4.Tiny airdrop within the bladder.  If this patient has not had a recent catheterization, correlate for signs and symptoms of urinary tract infection.  The report was faxed upon dictation.","nephrology, reconstruction, appendicitis, urinary tract infection, ct abdomen, abdomen, ct, pelvis, contrast, noncontrast,"
 Abnormal liver enzymes and diarrhea.  CT pelvis with contrast and ct abdomen with and without contrast., Nephrology, CT Abdomen & Pelvis - 11 ,"EXAM: , CT pelvis with contrast and ct abdomen with and without contrast.,INDICATIONS:  ,Abnormal liver enzymes and diarrhea.,TECHNIQUE: , CT examination of the abdomen and pelvis was performed after 100 mL of intravenous contrast administration and oral contrast administration.  Pre-contrast images through the abdomen were also obtained.,COMPARISON:  ,There were no comparison studies.,FINDINGS:  ,The lung bases are clear.,The liver demonstrates mild intrahepatic biliary ductal dilatation.  These findings may be secondary to the patient's post cholecystectomy state.  The pancreas, spleen, adrenal glands, and kidneys are unremarkable.,There is a 13 mm peripheral-enhancing fluid collection in the anterior pararenal space of uncertain etiology.  There are numerous nonspecific retroperitoneal and mesenteric lymph nodes.  These may be reactive; however, an early neoplastic process would be difficult to totally exclude.,There is a right inguinal hernia containing a loop of small bowel.  This may produce a partial obstruction as there is mild fluid distention of several small bowel loops, particularly in the right lower quadrant.  The large bowel demonstrates significant diverticulosis coli of the sigmoid and distal descending colon without evidence of diverticulitis.,There is diffuse osteopenia along with significant degenerative changes in the lower lumbar spine.,The urinary bladder is unremarkable.  The uterus is not visualized.,IMPRESSION:,1.  Right inguinal hernia containing small bowel.  Partial obstruction is suspected.,2.  Nonspecific retroperitoneal and mesenteric lymph nodes.,3.  Thirteen millimeter of circumscribed fluid collection in the anterior pararenal space of uncertain etiology.,4.  Diverticulosis without evidence of diverticulitis.,5.  Status post cholecystectomy with mild intrahepatic biliary ductal dilatation.,6.  Osteopenia and degenerative changes of the spine and pelvis.","nephrology, pre-contrast images, contrast, biliary ductal dilatation, pancreas, spleen, adrenal glands, kidneys, mesenteric lymph nodes, fluid collection, inguinal hernia, ct abdomen, hernia, diverticulosis, diverticulitis, osteopenia, degenerative, spine, bowel, pelvis, ct, abdomen,"
 CT scan of the abdomen and pelvis without and with intravenous contrast., Nephrology, CT Abdomen & Pelvis - 2 ,"EXAM: , CT scan of the abdomen and pelvis without and with intravenous contrast.,CLINICAL INDICATION: , Left lower quadrant abdominal pain.,COMPARISON: , None.,FINDINGS: , CT scan of the abdomen and pelvis was performed without and with intravenous contrast.  Total of 100 mL of Isovue was administered intravenously.  Oral contrast was also administered.,The lung bases are clear.  The liver is enlarged and decreased in attenuation.  There are no focal liver masses.,There is no intra or extrahepatic ductal dilatation.,The gallbladder is slightly distended.,The adrenal glands, pancreas, spleen, and left kidney are normal.,A 12-mm simple cyst is present in the inferior pole of the right kidney.  There is no hydronephrosis or hydroureter.,The appendix is normal.,There are multiple diverticula in the rectosigmoid.  There is evidence of focal wall thickening in the sigmoid colon (image #69) with adjacent fat stranding in association with a diverticulum.  These findings are consistent with diverticulitis.  No pneumoperitoneum is identified.  There is no ascites or focal fluid collection.,The aorta is normal in contour and caliber.,There is no adenopathy.,Degenerative changes are present in the lumbar spine.,IMPRESSION: , Findings consistent with diverticulitis.  Please see report above.","nephrology, extrahepatic ductal dilatation, gallbladder, glands, pancreas, spleen, kidney, adrenal, abdomen and pelvis, ct scan, intravenous, abdomen,"
 CT Abdomen & Pelvis W&WO Contrast, Nephrology, CT Abdomen & Pelvis ,"EXAM:,  CT Abdomen & Pelvis W&WO Contrast, ,REASON FOR EXAM: , Status post aortobiiliac graft repair. , ,TECHNIQUE: , 5 mm spiral thick spiral CT scanning was performed through the entire abdomen and pelvis utilizing intravenous dynamic bolus contrast enhancement.  No oral or rectal contrast was utilized.  Comparison is made with the prior CT abdomen and pelvis dated 10/20/05.  There has been no significant change in size of the abdominal aortic aneurysm centered roughly at the renal artery origin level which has dimensions of 3.7 cm transversely x 3.4 AP.  Just below this level is the top of the endoluminal graft repair with numerous surrounding surgical clips.  The size of the native aneurysm component at this level is stable at 5.5 cm in diameter with mural thrombus surrounding the enhancing endolumen.  There is no abnormal entrance of contrast agent into the mural thrombus to indicate an endoluminal leak.  Further distally, there is extension of the graft into both proximal common iliac arteries without evidence for endoluminal leak at this level either.  No exoluminal leakage is identified at any level.  There is no retroperitoneal hematoma present.  The findings are unchanged from the prior exam.  ,The liver, spleen, pancreas, adrenals and right kidney are unremarkable with moderate diffuse atrophy of the pancreas present.  There is advanced atrophy of the left kidney.  No hydronephrosis is present.  No acute findings are identified elsewhere in the abdomen. ,The lung bases are clear. ,Concerning the remainder of the pelvis, no acute pathology is identified.  There is prominent streak artifact from the left total hip replacement.  There is diffuse moderate sigmoid diverticulosis without evidence for diverticulitis.  The bladder grossly appears normal.  A hysterectomy has been performed.  ,IMPRESSION:,1.  No complications identified regarding endoluminal aortoiliac graft repair as described.  The findings are stable compared to the study of 10/20/04.  ,2.  Stable mild aneurysm of aortic aneurysm, centered roughly at renal artery level.  ,3.  No other acute findings noted. ,4.  Advanced left renal atrophy.","nephrology, aortobiiliac graft repair, renal atrophy, ct abdomen & pelvis, w&wo contrast, aortic aneurysm, renal artery, mural thrombus, endoluminal leak, ct abdomen, ct, contrast, pelvis, abdomen,"
" Evaluate for retroperitoneal hematoma, the patient has been following, is currently on Coumadin.  CT abdomen without contrast and CT pelvis without contrast.", Nephrology, CT Abdomen & Pelvis - 10 ,"CT ABDOMEN WITHOUT CONTRAST AND CT PELVIS WITHOUT CONTRAST,REASON FOR EXAM: , Evaluate for retroperitoneal hematoma, the patient has been following, is currently on Coumadin.,CT ABDOMEN: , There is no evidence for a retroperitoneal hematoma.,The liver, spleen, adrenal glands, and pancreas are unremarkable.  Within the superior pole of the left kidney, there is a 3.9 cm cystic lesion.  A 3.3 cm cystic lesion is also seen within the inferior pole of the left kidney.  No calcifications are noted.  The kidneys are small bilaterally.,CT PELVIS: , Evaluation of the bladder is limited due to the presence of a Foley catheter, the bladder is nondistended.  The large and small bowels are normal in course and caliber.  There is no obstruction.,Bibasilar pleural effusions are noted.,IMPRESSION:,1. No evidence for retroperitoneal bleed.,2. There are two left-sided cystic lesions within the kidney, correlation with a postcontrast study versus further characterization with an ultrasound is advised as the cystic lesions appear slightly larger as compared to the prior exam.,3. The kidneys are small in size bilaterally.,4. Bibasilar pleural effusions.","nephrology, cystic lesion, superior pole, kidney, ct pelvis, ct abdomen, retroperitoneal hematoma, lesion, kidneys, bladder, bibasilar, pleural, effusions, lesions, pelvis, hematoma, retroperitoneal, cystic, ct, abdomen,"
" Type 1 diabetes mellitus, insulin pump requiring.  Chronic kidney disease, stage III.  Sweet syndrome, hypertension, and dyslipidemia.", Nephrology, Chronic Kidney Disease Followup - 1 ,"PROBLEMS LIST:,1.  Type 1 diabetes mellitus, insulin pump requiring.,2.  Chronic kidney disease, stage III.,3.  Sweet syndrome.,4.  Hypertension.,5.  Dyslipidemia.,6.  Osteoporosis.,7.  Anemia.,8.  A 25-hydroxy-vitamin D deficiency.,9.  Peripheral neuropathy manifested by insensate feet.,10.  Hypothyroidism.,11.  Diabetic retinopathy.,HISTORY OF PRESENT ILLNESS:,  This is a return visit to the renal clinic for the patient where she is followed up for diabetes and kidney disease management.  Her last visit to this clinic was approximately three months ago.  Since that time, the patient states that she has had some variability in her glucose control too largely to recent upper and lower respiratory illnesses.  She did not seek attention for these, and the symptoms have begun to subside on their own and in the meantime, she continues to have some difficulties with blood sugar management.  Her 14-day average is 191.  She had a high blood sugar this morning, which she attributed to a problem with her infusion set; however, in the clinic after an appropriate correction bolus, she subsequently became quite low.  She was treated appropriately with glucose and crackers, and her blood sugar came back up to over 100.  She was able to manage this completely on her own.  In the meantime, she is not having any other medical problems that have interfered with glucose control.  Her diet has been a little bit different in that she had been away visiting with her family for some period of time as well.,CURRENT MEDICATIONS:,1.  A number of topical creams for her rash.,2.  Hydroxyzine 25 mg 4 times a day.,3.  Claritin 5 mg a day.,4.  Fluoxetine 20 mg a day.,5.  Ergocalciferol 800 international units a day.,6.  Protonix 40 mg a day.,7.  Iron sulfate 1.2 cc every day.,8.  Actonel 35 mg once a week.,9.  Zantac 150 mg daily.,10.  Calcium carbonate 500 mg 3 times a day.,11.  NovoLog insulin via insulin pump about 30 units of insulin daily.,12.  Zocor 40 mg a day.,13.  Valsartan 80 mg daily.,14.  Amlodipine 5 mg a day.,15.  Plavix 75 mg a day.,16.  Aspirin 81 mg a day.,17.  Lasix 20 mg a day.,18.  Levothyroxine 75 micrograms a day.,REVIEW OF SYSTEMS: , Really not much change.  Her upper respiratory symptoms have resolved.  She is not describing fevers, chills, sweats, nausea, vomiting, constipation, diarrhea or abdominal pain.  She is not having any decreased appetite.  She is not having painful urination, any blood in the urine, frequency or hesitancy.  She is not having polyuria, polydipsia or polyphagia.  Her visual acuity has declined, but she does not appear to have any acute change.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 36.1, pulse 56, respirations 16, blood pressure 117/48, and weight is 109.7 pounds.  HEENT:  Examination found her to be atraumatic and normocephalic.  She has pupils that are equal, round, and reactive to light.  Extraocular muscles intact.  Sclerae and conjunctivae are clear.  The paranasal sinuses are nontender.  The nose is patent.  The external auditory canal and tympanic membranes are clear A.U.  Oral cavity and oropharynx examination is free of lesions.  The mucosus membranes are moist.  NECK:  Supple.  There is no lymphadenopathy.  There is no thyromegaly.  THORAX:  Reveals lungs that are clear, PA and lateral, without adventitious sounds.  CARDIOVASCULAR:  Demonstrated regular rate and rhythm.  EXTREMITIES:  Reveal no edema and is otherwise deferred.,ASSESSMENT AND PLAN: , This is a return visit to the renal clinic for the patient with history as noted above.  She has had variability in her glucose control, and the plan today is to continue her current regimen, which includes the following:  Basal rate, 12 a.m. 0.6 units per hour, 4 a.m. 0.7 units per hour, and 9 a.m. 0.6 units per hour.  Her target pre-meal is 120 and bedtime is 150.  Her insulin/carbohydrate ratio is 10 and her correction factor is 60.  We are not going to make any changes to her insulin pump settings at this time.  I have encouraged her to watch the number of processed high-calorie foods that she is consuming late at night.  She has agreed to try that and cut back on this a little bit.  I want to get fasting labs to include her standard labs for us today but include a fasting C-peptide and a hemoglobin A1C, so that we can make arrangements for her to get an upgraded insulin pump.  She states to me that she has been having some battery problems in the recent past, although she says the last time that she went four weeks without having to change batteries and that is about the appropriate amount of time.  Nonetheless, she is out of warranty and we will try to get her a new pump.,Plan to see the patient back here in approximately two months, and we will try to get the new pump through Medicare.",
 CT Abdomen and Pelvis with contrast , Nephrology, CT Abdomen & Pelvis - 1 ,"EXAM: , CT Abdomen and Pelvis with contrast ,REASON FOR EXAM:, Nausea, vomiting, diarrhea for one day.  Fever.  Right upper quadrant pain for one day.  ,COMPARISON: , None. ,TECHNIQUE:,  CT of the abdomen and pelvis performed without and with approximately 54 ml Isovue 300 contrast enhancement.  ,CT ABDOMEN: , Lung bases are clear.  The liver, gallbladder, spleen, pancreas, and bilateral adrenal/kidneys are unremarkable.  The aorta is normal in caliber.  There is no retroperitoneal lymphadenopathy.  ,CT PELVIS: , The appendix is visualized along its length and is diffusely unremarkable with no surrounding inflammatory change.  Per CT, the colon and small bowel are unremarkable.  The bladder is distended.  No free fluid/air.  Visualized osseous structures demonstrate no definite evidence for acute fracture, malalignment, or dislocation.,IMPRESSION:,1.  Unremarkable exam; specifically no evidence for acute appendicitis. ,2.  No acute nephro-/ureterolithiasis. ,3.  No secondary evidence for acute cholecystitis.,Results were communicated to the ER at the time of dictation.","nephrology, liver, gallbladder, spleen, pancreas, adrenal, kidneys, lymphadenopathy, abdomen and pelvis, contrast, ct"
" Chronic kidney disease, stage IV, secondary to polycystic kidney disease.  Hypertension, which is finally better controlled.  Metabolic bone disease and anemia.", Nephrology, Chronic Kidney Disease Followup ,"HISTORY OF PRESENT ILLNESS: , This is a followup for this 69-year-old African American gentleman with stage IV chronic kidney disease secondary to polycystic kidney disease.  His creatinine has ranged between 4 and 4.5 over the past 6 months, since I have been following him.  I have been trying to get him educated about end-stage kidney disease and we have been unsuccessful in getting him into classes.  On his last visit, I really stressed the importance of him taking his medications adequately and not missing some of the doses, and he returns today with much better blood pressure control.  He has also brought a machine at home, and states his blood pressure readings have been better.  He has not gone to the transplant orientation class yet and has not been to dialysis education yet, and both of these I have discussed with him in the past.  He also needs followup for his elevated PSA in the past, which has not been done for over 2 years and will likely need cardiac clearance if we ever are able to evaluate him for transplant.,REVIEW OF SYSTEMS: , Really negative.  He continues to feel well.  He denies any problems with shortness of breath, chest pain, swelling in his legs, nausea or vomiting, and his appetite remains good.,CURRENT MEDICATIONS:,1.  Vytorin 10/40 mg one a day.,2.  Rocaltrol 0.25 micrograms a day.,3.  Carvedilol 12.5 mg twice a day.,4.  Cozaar 50 mg twice a day.,5.  Lasix 40 mg a day.,PHYSICAL EXAMINATION:,VITAL SIGNS:  On exam, his blood pressure is 140/57, pulse 58, current weight is 67.1 kg, and again his blood pressure is markedly improved over his previous readings.  GENERAL:  He is a thin African American gentleman in no distress.  LUNGS:  Clear.  CARDIOVASCULAR:  Regular rate and rhythm.  Normal S1 and S2.  I did not appreciate a murmur.  ABDOMEN:  Soft.  He has a very soft systolic murmur at the left lower sternal border.  No rubs or gallops.  EXTREMITIES:  No significant edema.,LABORATORY DATA: , Today indicates that his creatinine is 4.5 and stable, ionized calcium 8.5, intact PTH 458, and hemoglobin stable at 10.9.  He is not on EPO yet.  His UA has been negative.,IMPRESSION:,1.  Chronic kidney disease, stage IV, secondary to polycystic kidney disease.  His estimated GFR is 16 mL per minute.  He has no uremic symptoms.,2.  Hypertension, which is finally better controlled.,3.  Metabolic bone disease.,4.  Anemia.,RECOMMENDATION:,  He needs a number of things done in terms of followup and education.  I gave him more information again about dialysis education and transplant, and instructed him he needs to go to these classes.  I also gave him websites that he can get on to find out more information.  I have not made any changes in his medications.  He is getting blood work done prior to his next visit with me.  I will check a PSA on him but he needs to get back into see urology, as his last PSA that I see was 37 and this was from 02/05.  He will see me back in about 4 to 6 weeks.","nephrology, metabolic bone disease, anemia, polycystic kidney disease, chronic kidney disease, blood pressure, transplant, metabolic, kidney"
 Marked right hydronephrosis without hydruria. , Nephrology, Consult - Hydronephrosis ,"CHIEF COMPLAINT:,  Right hydronephrosis.,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old female who has a history of uterine cancer, breast cancer, mesothelioma.  She is scheduled to undergo mastectomy in two weeks.  In September 1999, she was diagnosed with right breast cancer and underwent lumpectomy and axillary node dissection and radiation.  Again, she is scheduled for mastectomy in two weeks.  She underwent a recent PET scan for Dr. X, which revealed marked hydronephrosis on the right possibly related to right UPJ obstruction and there is probably a small nonobstructing stone in the upper pole of the right kidney.  There was no dilation of the right ureter noted.  Urinalysis today is microscopically negative.,PAST MEDICAL HISTORY: , Uterine cancer, mesothelioma, breast cancer, diabetes, hypertension.,PAST SURGICAL HISTORY: , Lumpectomy, hysterectomy.,MEDICATIONS:,  Diovan HCT 80/12.5 mg daily, metformin 500 mg daily.,ALLERGIES:,  None.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:,  She is retired.  Does not smoke or drink.,REVIEW OF SYSTEMS:,  I have reviewed his review of systems sheet and it is on the chart.,PHYSICAL EXAMINATION:,  Please see the physical exam sheet I completed.  Abdomen is soft, nontender, nondistended, no palpable masses, no CVA tenderness.,IMPRESSION AND PLAN: , Marked right hydronephrosis without hydruria.  She believes she had a CT scan of the abdomen and pelvis at Hospital in 2005.  I will try to obtain the report to see if the right kidney was evaluated at that time.  She will need evaluation with an IVP and renal scan to determine the point of obstruction and renal function of the right kidney.  She is quite anxious about her upcoming surgery and would like to delay any evaluation of this until the surgery is completed.  She will call us back to schedule the x-rays.  She understands the great importance and getting back in touch with us to schedule these x-rays due to the possibility that it may be somehow related to the cancer.  There is also a question of a stone present in the kidney.  She voiced a complete understanding of that and will call us after she recovers from her surgery to schedule these tests.","nephrology, hydruria, hydronephrosis, review of systems, uterine cancer, breast cancer, mesothelioma, mastectomy, kidney, cancer,"
" Clogged AV shunt.  The patient complains of fatigue, nausea, vomiting and fever.", Nephrology, Clogged AV Shunt - Consult ,"REASON FOR CONSULTATION: , Clogged AV shunt.,HISTORY OF PRESENT ILLNESS:,  This is a 32-year-old African-American male who came to ABCD General Hospital with the above chief complaint.  The patient complains of fatigue, nausea, vomiting and fever.  The patient states that the shunt was placed in February, although according to medical records it was placed in April and it has been periodically clogging since its placement.  The patient had dialysis today, which is Saturday, for approximately one hour before the shunt no longer worked.  The patient had been seen in the Emergency Room yesterday, 08/29/03, by Dr. X for the same problem.  At that time, Dr. X felt that the patient should use the AV fistula during dialysis and after the fistula is able to be used, the PermCath on the right subclavian should be removed.  As mentioned above, he had dialysis today and they were unable to use AV fistula as well as the PermCath read ""did not work"".  The patient has had dialysis since January secondary to hypertension-induced renal failure.  He takes dialysis Monday, Wednesday, and Friday at the ABCD Dialysis Center.  He also was seen at XYZ and he had an apparent thrombectomy with reversal done a few days ago.  The patient's history at this point is a little sketchy; however, he states that he left AMA.  All other systems are reviewed and are negative.,PAST MEDICAL HISTORY: , Significant for heart attack, chronic renal failure with dialysis, CHF, hypertension, and PermCath.,PAST SURGICAL HISTORY: , AV fistula on the left arm and a PermCath.,ALLERGIES: , Penicillin.,MEDICATIONS: , Include metoprolol 100 mg two tablets b.i.d., Tylenol #3, Accupril 20 mg q.d., digoxin, Renocaps, aspirin, and Combivent.,SOCIAL HISTORY: , Half pack of tobacco x3 years.  No alcohol, occasional marijuana, and no IV drug use.  He lives alone, single and no children.,PHYSICAL EXAMINATION: , Vital signs:  In Emergency Room, temperature 98.2, pulse 83, respirations 20, blood pressure 146/84 and 99% on room air.  General:  This is an alert and oriented African-American male x3 and in no acute distress.  The patient is extremely lethargic and had to be aroused multiple times to answer questions.  Mucous membranes are moist.  HEENT:  Head is normocephalic and atraumatic.  There is no scleral icterus noted.  Pupils are equal, round, and reactive to light.  Extraocular muscles are intact.  Cardiovascular:  Shows a heart rate that is regular with a laterally displaced point of maximum intensity.  There is no murmur, gallop, or rub noted.  Lungs:  Clear to auscultation bilaterally.  No wheeze, rhonchi or rales.  Abdomen:  Soft, nontender and nondistended.  Bowel sounds are present.  Extremities:  Show left forearm with an incision that is well healed from a left AV fistula.  There is a distal thrill palpable and there is some tenderness over the incisional area.  There is no erythema or pus noted.  Other extremities show peripheral pulses present and no edema.,LABORATORY VALUES: , Sodium 139, potassium 3.9, chloride 92, CO2 33, BUN 36, creatinine 9.2, and glucose 131.  Digoxin 0.6, white count is 5.8, hemoglobin 11.7, hematocrit 34.9 and platelets are 252.,IMPRESSION:,1.  Nonfunctional AV fistula.,2.  End-stage renal disease.,3.  Hypertension.,4.  Status post MI.,5.  Clogged PermCath.,PLAN:,1.  Give the patient TPA to the shunt, PermCath in both feet.,2.  To board for Tuesday for shunt repair if needed.,3.  To dialyze as soon as possible.,4.  To review previous operative report.,5.  The patient will be contacted in the morning and told whether to go to dialysis or not.",
 Followup on chronic kidney disease., Nephrology, Chronic Kidney Disease - Followup ,"REASON FOR VISIT:,  Followup on chronic kidney disease.,HISTORY OF PRESENT ILLNESS:,  The patient is a 78-year-old gentleman with stage III chronic kidney disease who on his last visit with me presented with classic anginal symptoms.  He was admitted to hospital and found to have an acute myocardial infarction.  He had a complex hospital course, which resulted in cardiac catheterization and two stents being placed.  His creatinine did pop above up to 3 but then came back to baseline.  His hospital stay was also complicated by urinary retention requiring a catheter and Flomax.  He returns today to re-establish care.  Of note, he was noted to have atrial fibrillation while hospitalized and had massive epistaxis.,ALLERGIES:,  None.,MEDICATIONS: , Starlix 120 mg b.i.d., Compazine b.i.d., aspirin 81 mg daily, Plavix 75 mg daily, glipizide 15 mg b.i.d., multivitamin daily, potassium 10 mEq daily, Cozaar 25 mg daily, Prilosec 20 mg daily, digoxin 0.125 mg every other day, vitamin C 250 mg daily, ferrous sulphate 325 mg b.i.d., metoprolol 6.25 mg daily, Lasix 80 mg b.i.d., Flomax 0.4 mg daily, Zocor 80 mg daily, and Tylenol p.r.n.,PAST MEDICAL HISTORY:,1.  Stage III CKD with baseline creatinine in the 2 range.,2.  Status post MI on May 30, 2006.,3.  Coronary artery disease status post stents of the circumflex.,4.  Congestive heart failure.,5.  Atrial fibrillation.,6.  COPD.,7.  Diabetes.,8.  Anemia.,9.  Massive epistaxis.,REVIEW OF SYSTEMS:,  Cardiovascular:  No chest pain.  He has occasional dyspnea on exertion.  No orthopnea.  No PND.  He has occasional edema of his right leg.  He has been dizzy and his dose of metoprolol has been gradually decreased.  GU:  No hematuria, foamy urine, pyuria, frequency, dysuria, weak stream or dribbling.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Pulse 70.  Blood pressure 114/58.  Weight 79.5 kg.  GENERAL:  He is in no apparent distress.  HEART:  Irregularly irregular.  No murmurs, rubs, or gallops.  LUNGS:  Clear bilaterally.  ABDOMEN:  Soft, nontender, and nondistended.  EXTREMITIES:  Trace edema on the right.,LABORATORY DATA: , Dated 07/05/06, hematocrit is 30.2, platelets 380, sodium 139, potassium 4.9, chloride 100, CO2 28, BUN 38, creatinine 2.2, glucose 226, calcium 9.7, and albumin 3.7.,IMPRESSION:,1.  Stage III chronic kidney disease with return to baseline GFR of 31 mL/min.  He is on an ARB.,2.  Coronary artery disease, status post stenting.,3.  Hypertension.  Blood pressures are on the low side at present.  I hesitate to increase his Cozaar although I would do this if tolerated in the future.,4.  Anemia of renal disease.  He is to start Aranesp.,5.  ? Atrial fibrillation.  We discussed anticoagulation issues involved with chronic Afib.  He may be popping in and out or this could just be a sinus arrhythmia.,PLAN:,1.  Check EKG.,2.  Start Aranesp 60 mcg every two weeks.,3.  Otherwise see him in four months.,4.  If EKG shows atrial fibrillation, I wanted to talk to Dr. XYZ about Coumadin.",
" This is a 48-year-old black male with stage IV chronic kidney disease likely secondary to HIV nephropathy, although there is no history of renal biopsy, who has been noncompliant with the Renal Clinic and presents today for followup at the recommendation of his Infection Disease doctors.", Nephrology, Chronic Kidney Disease - Consult ,"HISTORY OF PRESENT ILLNESS: , This is a 48-year-old black male with stage IV chronic kidney disease, likely secondary to HIV nephropathy who presents to clinic for followup having missed prior clinic appointments.  He was last seen in this clinic on 05/29/2007 by Dr. X.  This is the first time that I have met the patient.  The patient's history of renal insufficiency dates back to 06/2006 when he was hospitalized for an HIV-associated complication.  He is unclear of the exact reason for his hospitalization at that time, but he was diagnosed with renal insufficiency and was followed in our Renal Clinic for approximately one year.  He had a baseline creatinine during that time of between 3.2 to 3.3.  When he was initially diagnosed with renal insufficiency, he had been noncompliant with his HAART regimen.  Since that time, he has been very compliant with treatment for his HIV and is seeing Dr. Y in our Infectious Disease Clinic.  He is currently on three-drug antiretroviral therapy.  His last CD4 count in 03/2008 was 350.  He has had no HIV complications since he was last seen in our clinic.  The patient is also followed by Dr. Z at the outpatient VA Clinic, here in ABCD, although he has not seen her in approximately one year.  The patient has an AV fistula that was placed in late 2006.  The latest blood work that I have is from 06/11/2008 and shows a serum creatinine of 3.8, which represents a GFR of 22 and a potassium of 5.9.  These laboratories were drawn by his infectious disease doctor and the results prompted their recommendation for him to return to our clinic for further evaluation.  The only complaint that the patient has at this time is some difficulty sleeping.  He was given Ambien by his primary care doctor, but this has not helped significantly with his difficulty sleeping.  He says that he has trouble getting to sleep.  The Ambien will allow him to sleep for about two hours, and then he is awake again.  He is tired during the day, but is not taking any daytime naps.  He has no history of excessive snoring or apneic periods.  He has no history of falling asleep at work or while driving.  He has never had a formal sleep study.  He does continue to work in sales at a local butcher shop.,REVIEW OF SYSTEMS:  ,He denies any change in his appetite.  He has actually gained some weight in recent months.  He denies any nausea, vomiting, or abdominal discomfort.  He denies any pruritus.  He denies any lower extremity edema.  All other systems are reviewed and negative.,PAST MEDICAL HISTORY:,1.  Stage IV chronic kidney disease with most recent GFR of 22.,2.  HIV diagnosed in 09/2006 with the most recent CD4 count of 350 in 03/2008.,3.  Hyperlipidemia.,4.  Hypertension.,5.  Secondary hyperparathyroidism.,6.  Status post right upper extremity AV fistula in the fall of 2006.,7.  History of a right brachial plexus palsy.,8.  Recent lower back pain, status post lumbar steroid injection.,ALLERGIES:,  HE SAYS THAT VITAMIN D HAS CAUSED HEADACHES.,MEDICATIONS:,1.  Kaletra daily.,2.  Epivir one daily.,3.  Ziagen two daily.,4.  Lasix 20 mg b.i.d.,5.  Valsartan 20 mg b.i.d.,6.  Ambien 10 mg q.h.s.,SOCIAL HISTORY: , He lives here in ABCD.  He is employed at the sales counter of a local butcher shop.  He continues to smoke one pack of cigarettes daily, as he has for the past 28 years.  He denies any alcohol or illicit substances.,FAMILY HISTORY:,  His mother is deceased.  He said that she had some type of paralysis before she died.  His father is deceased at age 64 of a head and neck cancer.  He has a 56-year-old brother with type-two diabetes and blindness secondary to diabetic retinopathy.  He has a 41-year-old brother who has hypertension.  He has a sister who has thyroid disease.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Weight is 191 pounds.  His temperature is 97.1.  Pulse is 94.  Blood pressure by automatic cuff 173/97, by manual cuff 180/90.,HEENT:  His oropharynx is clear without thrush or ulceration.,NECK:  Supple without lymphadenopathy or thyromegaly.,HEART:  Regular with normal S1 and S2.  There are no murmurs, rubs, or gallops.  He has no JVD.,LUNGS:  Clear to auscultation bilaterally without wheezes, rhonchi, or crackles.,ABDOMEN:  Soft, nontender, nondistended, without abdominal bruit or organomegaly.,MUSCULOSKELETAL:  He has difficulty with abduction of his right shoulder.,ACCESS:  He has a right forearm AV fistula with an audible bruit and a palpable thrill.  There is no sign of stenosis.  The vascular access looks like it is ready to use.,EXTREMITIES:  No peripheral edema.,SKIN:  No bruises, petechiae, or rash.,LABS:  ,Sodium was 140, potassium 5.9, chloride 114, bicarbonate 18.  BUN is 49, creatinine 4.3.  GFR is 19.  Albumin 3.2.  Protein 7.  AST 17, ALT 16, alkaline phosphatase 106.  Total bilirubin 0.4.  Calcium 9.1., phosphorus 4.7, PTH of 448.  The corrected calcium was 9.7.  WBC is 8.9, hemoglobin 13.4, platelet 226.  Total cholesterol 234, triglycerides 140, LDL 159, HDL 47.  His ferritin is 258, iron is 55, and percent sat is 24.,IMPRESSION:  ,This is a 48-year-old black male with stage IV chronic kidney disease likely secondary to HIV nephropathy, although there is no history of renal biopsy, who has been noncompliant with the Renal Clinic and presents today for followup at the recommendation of his Infection Disease doctors.,RECOMMENDATIONS:,1.  Renal.  His serum creatinine is progressively worsening.  His creatinine was 3.2 the last time we saw him in 05/2007 and today is 4.3.  This represents a GFR of 19.  This is stage IV chronic kidney disease.  He does have vascular access and this appears to be ready to use.  He is having some difficulty sleeping and it is possible that this represents some early signs of uremia.  Otherwise, he has no signs or symptoms of uremia at this time.  I am going to touch base with the dialysis educator and try to get The patient in to the dialysis teaching classes.  He has already received some literature for the dialysis teaching, but has not yet enrolled in the classes.  I have encouraged him to continue to exercise his right forearm.  I am also going to contact the transplant coordinator and see if he can be evaluated for possible transplant.  Given his progression of his chronic kidney disease, I will anticipate that he will need to start dialysis soon.,2.  Hypertension.  I have added labetolol 100 mg b.i.d. to his antihypertensive regimen.  He shows no signs at this point of volume overload, although if he does demonstrate this in the future, his Lasix could be increased.  Goal blood pressure would be less than 130/80.,3.  Hyperkalemia.  I am going to instruct him in a low-potassium diet and decrease his valsartan to 20 mg daily.  I will have him return in one week to recheck his potassium.  If his potassium continues to remain elevated, he may require initiation of dialysis for this.,4.  Bone metabolism.  His PTH is elevated and I am going to add PhosLo 800 mg t.i.d. with meals.  His corrected calcium is 9.7, and I would like to avoid calcium-containing phosphate bonders in this situation.,5.  Acid base.  His bicarbonate is 18 and I will initiate the sodium bicarbonate 650 mg three tablets t.i.d.,6.  Anemia.  His hemoglobin is at goal for this stage of chronic kidney disease.  His iron stores are adequate.",
 Left forearm arteriovenous fistula between cephalic vein and radial artery., Nephrology, AV Fistula - 5 ,"PREOPERATIVE DIAGNOSES,1.  End-stage renal disease, hypertension, diabetes, need for chronic arteriovenous access.,2.  Ischemic cardiomyopathy, ejection fraction 20%.,POSTOPERATIVE DIAGNOSES,1.  End-stage renal disease, hypertension, diabetes, need for chronic arteriovenous access.,2.  Ischemic cardiomyopathy, ejection fraction 20%.,OPERATION,Left forearm arteriovenous fistula between cephalic vein and radial artery.,INDICATION FOR SURGERY,This is a patient referred by Dr. Michael Campbell.  He is a 44-year-old African-American, who has end-stage renal disease and also ischemic cardiomyopathy.  This morning, he received coronary angiogram by Dr. A, which was reportedly normal, after which, he was brought to the operating room for an AV fistula.  All the advantages, disadvantages, risks, and benefits of the procedure were explained to him for which he had consented.,ANESTHESIA,Monitored anesthesia care.,DESCRIPTION OF PROCEDURE,The patient was identified, brought to the operating room, placed supine, and IV sedation given.  This was done under monitored anesthesia care.  He was prepped and draped in the usual sterile fashion.  He received local infiltration of 0.25% Marcaine with epinephrine in the region of the proposed incision.,Incision was about 2.5 cm long between the cephalic vein and the distal part of the forearm and the radial artery.  Incision was deepened down through the subcutaneous fascia.  The vein was identified, dissected for a good length, and then the artery was identified and dissected.  Heparin 5000 units was given.  The artery clamped proximally and distally, opened up in the middle.  It was found to have Monckeberg's arteriosclerosis of a moderate intensity.  The vein was of good caliber and size.,The vein was clipped distally, fashioned to size and shape, and arteriotomy created in the distal radial artery and end-to-side anastomosis was performed using 7-0 Prolene and bled prior to tying it down.  Thrill was immediately felt and heard.,The incision was closed in two layers and sterile dressing applied.","nephrology, end-stage renal disease, av fistula, marcaine with epinephrine, monckeberg's, monitored anesthesia care, angiogram, arteriosclerosis, arteriovenous fistula, cephalic vein, ischemic cardiomyopathy, radial artery, subcutaneous fascia, arteriovenous, forearm, ischemic"
 Creation of autologous right brachiobasilic arteriovenous fistula - first stage., Nephrology, AV Fistula - 4 ,"PREOPERATIVE DIAGNOSES,1.  End-stage renal disease.,2.  Left subclavian vein occlusion.,3.  Status post chronic tracheostomy.,4.  Status post coronary artery bypass grafting.,5.  Right subclavian vein stenosis.,POSTOPERATIVE DIAGNOSES,1.  End-stage renal disease.,2.  Left subclavian vein occlusion.,3.  Status post chronic tracheostomy.,4.  Status post coronary artery bypass grafting.,5.  Right subclavian vein stenosis.,OPERATIVE PROCEDURE,Creation of autologous right brachiobasilic arteriovenous fistula - first stage.,INDICATIONS FOR THE PROCEDURE,This patient has a known left subclavian vein occlusion.  The right subclavian vein has an estimated 50% stenosis.  The patient has a catheter traversed in the right innominate vein.  The right basilic vein was judged to be suitable for usage on vein mapping.,OPERATIVE FINDINGS,The basilic vein was of an adequate size, but somewhat sclerotic.  A first stage autologous right brachiobasilic arteriovenous fistula was created.  A grade 2 was felt at completion.,OPERATIVE PROCEDURE IN DETAIL,After informed consent was obtained, the patient was taken to the operating room.  The patient was placed in the supine position.  The patient received regional nerve block.  The patient also received intravenous sedation.  The right arm was prepped and draped in the usual sterile fashion.  We used ultrasound to locate the basilic vein at the cubital fossa.,A small transverse incision was made slightly above the basilic vein.  The basilic vein was identified and immobilized.  The basilic vein was of a good size, but somewhat sclerotic.  The underlying fascia was incised and the brachial artery was identified and immobilized.  The brachial artery was normal.  We then divided the basilic vein distally.  The distal end was ligated using silk suture.  The brachial artery was clamped proximally and distally.  A small longitudinal arteriotomy was made in the brachial artery.  We did not give heparin.  The end of the basilic vein was then sewn end-to-side to the brachial artery using a running 7-0 Prolene suture.  ,Just prior to completion of the anastomosis, it was flushed and anastomosis was completed.  Flow was then established.  A grade 2 was felt in the outflow basilic fistula.  Hemostasis was secured.  The wound was then closed in layers using interrupted PDS sutures for the fascia and a running 4-0 Monocryl subcuticular suture for the skin.  A sterile dry dressing was applied.,The patient tolerated the procedure well.  There were no operative complications.  The sponge, instrument, and needle counts were correct at the end of the case.  I was present and participated in all aspects of the procedure.  The patient was transferred to the recovery room in satisfactory condition.","nephrology, end-stage renal disease, left subclavian vein occlusion, arteriovenous fistula, artery bypass grafting, autologous, basilic vein, brachial artery, brachiobasilic, clamped, fistula, sclerotic, subclavian vein, subclavian vein stenosis, tracheostomy, brachiobasilic arteriovenous fistula, subclavian vein occlusion, vein occlusion, subclavian, basilic, artery, "
" Acute renal failure, probable renal vein thrombosis, hypercoagulable state, and deep venous thromboses with pulmonary embolism.", Nephrology, Azotemia Consult ,"REASON FOR CONSULTATION: , Azotemia.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 36-year-old gentleman admitted to the hospital because he passed out at home.,Over the past week, he has been noticing increasing shortness of breath.  He also started having some abdominal pain; however, he continued about his regular activity until the other day when he passed out at home.  His wife called paramedics and he was brought to the emergency room.,The patient has had a workup at this time which shows bilateral pulmonary infarcts.  He has been started on heparin and we are asked to see him because of increasing BUN and creatinine.,The patient has no past history of any renal problems.  He feels that he has been in good health until this current episode.  His appetite has been good.  He denies swelling in his feet or ankles.  He denies chest pain.  He denies any problems with bowel habits.  He denies any unexplained weight loss.  He denies any recent change in bowel habits or recent change in urinary habits.,PHYSICAL EXAMINATION:,GENERAL:  A gentleman seen who appears his stated age.,VITAL SIGNS:  Blood pressure is 130/70.,CHEST:  Chest expands equally bilaterally.  Breath sounds are heard bilaterally.,HEART:  Had a regular rhythm, no gallops or rubs.,ABDOMEN:  Obese.  There is no organomegaly.  There are no bruits.  There is no peripheral edema.  He has good pulse in all 4 extremities.  He has good muscle mass.,LABORATORY DATA: , The patient's current chemistries include a hemoglobin of 14.8, white count of 16.3, his sodium 133, potassium 5.1, chloride 104, CO2 of 19, a BUN of 26, and a creatinine of 3.5.  On admission to the hospital, his creatinine on 6/27/2009 was 0.9.,The patient has had several studies including a CAT scan of his abdomen, which shows poor perfusion to his right kidney.,IMPRESSION:,1.  Acute renal failure, probable renal vein thrombosis.,2.  Hypercoagulable state.,3.  Deep venous thromboses with pulmonary embolism.,DISCUSSION: , We are presented with a 36-year-old gentleman who has been in good health until this current event.  He most likely has a hypercoagulable state and has bilateral pulmonary emboli.  Most likely, the patient has also had emboli to his renal veins and it is causing renal vein thrombosis.,Interestingly, the urine protein was obtained which is not that elevated and I would suspect that it would have been higher.  Unfortunately, the patient has been exposed to IV dye and my anxiety is that this too is contributing to his current problem.,The patient's urine output is about 30 to 40 mL per hour.,Several chemistries have been ordered.  A triple renal scan has been ordered.,I reviewed all of this with the patient and his wife.  Hopefully under his current anticoagulation, there will be some resolution of his renal vein thrombosis.  If not and his renal failure progresses, we are looking at dialytic intervention.  Both he and his wife were aware of this.  ,Thank you very much for asking to see this acutely ill gentleman in consultation with you.","nephrology, urine output, deep venous thromboses, renal failure, pulmonary embolism, renal, azotemia, hypercoagulable, vein, thrombosis, pulmonary, "
 Right basilic vein transposition.  End-stage renal disease with need for a long-term hemodialysis access.  Excellent flow through fistula following the procedure., Nephrology, Basilic Vein Transposition ,"PREOPERATIVE DIAGNOSIS:,  End-stage renal disease with need for a long-term hemodialysis access.,POSTOPERATIVE DIAGNOSIS: , End-stage renal disease with need for a long-term hemodialysis access.,PROCEDURE: , Right basilic vein transposition.,ANESTHESIA:  ,General endotracheal.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,FINDINGS:,  Excellent flow through fistula following the procedure.,STATEMENT OF MEDICAL NECESSITY:  ,The patient is a 68-year-old black female who recently underwent a brachiobasilic AV fistula, but without transposition.  She has good flow, excellent physical exam, and now is ready for superficialization of the basilic vein.  After discussing the risks and benefits of the procedure with the patient preoperatively, the patient voiced understanding and signed informed consent.,PROCEDURE IN DETAIL:  ,The patient was taken to the operating room, placed supine on the operating table.  After adequate general endotracheal anesthesia was obtained, the right arm was circumferentially prepped and draped in a standard sterile fashion.  A longitudinal incision was made from just above the antecubital crease along the medial aspect of the arm overlying the palpable thrill using a 15 blade knife.  The sharp dissection was then used to identify dissection created of the basilic vein from its surrounding tissues.  This was continued and the incision was elongated up the arm as the vein was exposed in a serial fashion.  Branch points were then taken down using multitude of techniques based upon the luminal diameter of the branch before transection.  The basilic vein was ultimately freed in its entirety from just above the antecubital crease to the axilla at the level of the axillary vein.  There was noted to be excellent flow through the vein.  A pocket was then created just lateral to the incision in the subcutaneous tissue.  The vein was then placed into this pocket securing with multiple interrupted 3-0 Vicryl sutures.  The bed of dissection of the basilic vein was then treated with fibrin sealant.  The subcutaneous tissue was then reapproximated with 3-0 Vicryl sutures in interrupted fashion.  The skin was closed using 4-0 Monocryl suture for a subcuticular stitch.  Dermabond was applied to the incision.  Again, there was noted to be good palpable thrill throughout the superficialized vein.  The patient was then awakened, and taken to the recovery room in stable condition.","nephrology, end-stage renal disease, hemodialysis, av fistula, brachiobasilic, basilic vein transposition, hemodialysis access, vein, basilic,"
" Patient with a history of coronary artery disease, hypertension, diabetes, and stage III CKD.", Nephrology, Acute Kidney Failure ,"REASON FOR VISIT: , Acute kidney failure.,HISTORY OF PRESENT ILLNESS: , The patient is a 68-year-old Korean gentleman with a history of coronary artery disease, hypertension, diabetes and stage III CKD with a creatinine of 1.8 in May 2006 corresponding with the GFR of 40-41 mL/min.  The patient had blood work done at Dr. XYZ's office on June 01, 2006, which revealed an elevation in his creatinine up to 2.3.  He was asked to come in to see a nephrologist for further evaluation.  I am therefore asked by Dr. XYZ to see this patient in consultation for evaluation of acute on chronic kidney failure.  The patient states that he was actually taking up to 12 to 13 pills of Chinese herbs and dietary supplements for the past year.  He only stopped about two or three weeks ago.  He also states that TriCor was added about one or two months ago but he is not sure of the date.  He has not had an ultrasound but has been diagnosed with prostatic hypertrophy by his primary care doctor and placed on Flomax.  He states that his urinary dribbling and weak stream had not improved since doing this.  For the past couple of weeks, he has had dizziness in the morning.  This is then associated with low glucose.  However the patient's blood glucose this morning was 123 and he still was dizzy.  This was worse on standing.  He states that he has been checking his blood pressure regularly at home because he has felt so bad and that he has gotten under 100/60 on several occasions.  His pulses remained in the 60s.,ALLERGIES: , None.,MEDICATIONS: , Imdur 20 mg two to three times daily, nitroglycerin p.r.n., insulin 70/30 40/45 units daily, Zetia 10 mg daily, ? Triglide 50 mg daily, Prevacid 30 mg daily, Plavix 75 mg daily, potassium 10 mEq daily, Lasix 60 mg daily, folate 1 mg b.i.d., Niaspan 500 mg daily, atenolol 50 mg daily, enalapril 10 mg b.i.d., glyburide 10 mg b.i.d., Xanax 0.25 mg b.i.d., aspirin 325 mg daily, Tylenol p.r.n., Zantac 150 mg b.i.d., Crestor 5 mg daily, TriCor 145 mg daily, Digitek 0.125 mg daily, Celexa 20 mg daily, and Flomax 0.4 mg daily.,PAST MEDICAL HISTORY:,1.  Coronary artery disease status post CABG x 5 in December 2001.,2.  Three stents last placed approximately 2002.,3.  Heart failure, ejection fraction of 30%.,4.  Hypertension since 1985.,5.  Diabetes since 1985 with history of laser surgery.,6.  Moderate mitral regurgitation.,7.  GI bleed.,8.  Hyperlipidemia.,9.  BPH.,10.  Back surgery.,11.  Sleep apnea.,SOCIAL HISTORY: , He is a former tailor from Korea.  He is divorced.  He has one daughter who has brain injury status post severe seizure as a child.  He is the primary caregiver.  No drug abuse.  He quit tobacco and alcohol 15 years ago.,FAMILY HISTORY: , Parents both died in Korea.  Has one sister with hypertension and the other sister lives in Detroit and is healthy.,REVIEW OF SYSTEMS: , He has lost about 10 pounds over the past month.  He has been fatigue and weak with no appetite.  He has occasional chest pain and dyspnea on exertion on fast walking.  His lower extremity edema has improved with higher doses of furosemide.  He does complain of some early satiety.  He complains of urinary frequency, nocturia, weak stream and dribbling.  He has never passed the stone.  He gets dizzy when his blood sugars are in the 40s to 60s but now this is continuing with him running, glucose is in the 120s.  He has some right back pain today and complains of farsightedness.  The remainder of review of systems is done and negative per the patient.,PHYSICAL EXAMINATION:,  VITAL SIGNS:  Pulse 78.  Blood pressure 116/60.  Height 5'7"" per the patient.  Weight 78.6 kg.  Supine pulse 60 with blood pressure 128/55.  Standing pulse 60 with blood pressure of 132/50.  GENERAL:  He is in no apparent distress, but he is dizzy on standing for prolonged period.  Eyes:  Pupils equal, round and reactive to light.  Extraocular movements are intact.  Sclerae not icteric.  HEENT:  He wears upper and lower dentures.  Lips acyanotic.  Hearing is grossly intact.  Oropharynx is otherwise clear.  NECK:  Supple.  No JVD.  No bruits.  No masses.  HEART:  Regular rate and rhythm.  No murmurs, rubs or gallops.  LUNGS:  Clear bilaterally.  ABDOMEN:  Active bowel sounds.  Soft, nontender, and nondistended.  No suprapubic tenderness.  EXTREMITIES:  No clubbing, cyanosis or edema.  MUSCULOSKELETAL:  5/5 strength bilaterally.  No synovitis, arthritis or gait disturbance.  SKIN:  Old scars in his low back as well as his left lower extremity.  No active rashes, purpura or petechiae.  Midline sternotomy scar is well healed.  NEUROLOGIC:  Cranial nerves II through XII are intact.  Reflexes are poor to 1+ bilaterally.  10 g monofilament sensation is intact except for the big toes bilaterally.  No asterixis.  Finger-to-nose testing is intact.  PSYCHIATRIC:  Fully alert and oriented.,LABORATORY DATA:,  December 2004, creatinine was 1.5.  Per report May 2006, creatinine was 1.8 with a BUN of 28.  Labs dated 06/01/06, hematocrit was 32.3, white blood cell count 7.2, platelets 263,000, sodium 139, potassium 4.9, chloride 100, CO2 25, BUN 46, creatinine 2.3, glucose 162, albumin 4.7, LFTs are normal.  CK was elevated at 653.  A1c is 7.6%.  LDL cholesterol is 68, HDL is 35.  Urinalysis reveals microalbumin to creatinine ratio 59.8.  UA was otherwise negative with a pH of 5.  Today his urinalysis showed specific gravity 1.020, negative glucose, bilirubin, ketones and blood, 30 mg/dL of protein, pH of 5, negative nitrates, leukocyte esterase.  Microscopic exam was bland.,IMPRESSION:,1.  Acute on chronic kidney failure.  He has underlying stage III CKD with the GFR approximately 41 mL/min.  He has episodic hypotension at home and low diastolic pressure here.  His weight is down 2 to 3 Kg from June and he may be prerenal.  He also has a history of prostatic hypertrophy and obstruction must be investigated.  I am also concerned about his use of Chinese herbs which can cause chronic interstitial nephritis.  There is no evidence of pyuria today although this can present with a fairly bland sediment.  An additional concern is that TriCor can cause an artifactual increase in the creatinine due to changes in metabolism.  I think this would be a diagnosis of exclusion.,2.  Orthostatic hypotension.  He is maintaining systolic but his diastolic pressures are gotten in to a point where he may not be perfusing his brain well.,3.  Elevated creatine kinase consistent with myositis.  It could be a result of Crestor alone or combination of TriCor and Crestor.  I do not think this is enough to cause rhabdomyolysis, however.,RECOMMENDATIONS:,1.  The patient was cautioned about using NSAIDs and told to avoid any further Chinese herbs.,2.  Recheck labs including CBC with differential, SPEP, uric acid and renal panel.,3.  Decrease atenolol to 25 mg daily.,4.  Decrease enalapril to 10 mg daily.,5.  Decrease Lasix to 20 mg daily.,6.  Stop Crestor.,7.  Check renal ultrasound.,8.  See him back in two weeks for review of the studies.",
" Creation of AV fistula, left wrist in the anatomic snuffbox.", Nephrology, AV Fistula - 3 ,"TITLE OF PROCEDURE,Creation of AV fistula, left wrist in the anatomic snuffbox.,PREOPERATIVE DIAGNOSIS,End-stage renal disease, need for chronic access.,POSTOPERATIVE DIAGNOSIS,End-stage renal disease, need for chronic access.,INDICATION OF THE PROCEDURE,This 74-year-old lady was referred by Dr. P for placement of an AV fistula.  She has been on dialysis since December 2006 by a PermCath placed in her right internal jugular vein.  She undergoes dialysis on Monday, Wednesday, and Friday at DaVita in Alameda and is under the care of Dr. P.  She underwent coronary bypass surgery in 2000 and her cardiologist is Dr. T.  She lives with her husband and she also has a son at home and she is a very active lady.  She is right handed.  The plan was to place an AV fistula at the left wrist.  The risks and benefits were fully explained to her.  She elected to proceed as planned.,PROCEDURE IN DETAIL,In the operating room, under monitored anesthesia care with intravenous sedation, she was prepped and draped surgically.  Lidocaine 1% was used for local anesthesia in the anatomic snuffbox at the left wrist.  The cephalic vein was exposed.  The superficial branch of the radial artery was carefully protected and the radial artery was exposed.  There was moderate calcification of the radial artery.,The patient was heparinized and end-to-side anastomosis was performed between the cephalic vein and radial artery using a 7-0 Prolene suture.  There was an excellent Doppler signal in the cephalic vein all the way up the arm upon completion.,The wound was closed using absorbable suture and she was transferred to Recovery.  There were no complications.","nephrology, av fistula, end-stage renal disease, permcath, chronic access, jugular vein, monitored anesthesia, monitored anesthesia care, prepped and draped, snuffbox, superficial branch, creation of av fistula, cephalic vein, radial artery, radial, artery, fistula"
 Venogram of the left arm and creation of left brachiocephalic arteriovenous fistula., Nephrology, AV Fistula - 1 ,"PREOPERATIVE DIAGNOSIS,End-stage renal disease.,POSTOPERATIVE DIAGNOSIS,End-stage renal disease.,PROCEDURE,Venogram of the left arm and creation of left brachiocephalic arteriovenous fistula.,ANESTHESIA,General.,DESCRIPTION OF PROCEDURE,The patient was taken to the operating room where after induction of general anesthetic, the patient's arm was prepped and draped in a sterile fashion.  The IV catheter was inserted into the vein on the lower surface of the left forearm.  Venogram was performed, which demonstrated adequate appearance of the cephalic vein above the elbow.,Through a transverse incision, the cephalic vein and brachial artery were both exposed at the antecubital fossa.  The cephalic vein was divided, and the proximal end was anastomosed to the artery in an end-to-side fashion with a running 6-0 Prolene suture.,The clamps were removed establishing flow through the fistula.  Hemostasis was obtained.  The wound was closed in layers with PDS sutures.  Sterile dressing was applied.  The patient was taken to recovery room in stable condition.","nephrology, end-stage renal disease, prolene suture, venogram, antecubital fossa, arteriovenous, arteriovenous fistula, brachiocephalic arteriovenous fistula, cephalic vein, fistula, prepped and draped, brachiocephalic, cephalic, vein"
" He continues to have abdominal pain, and he had a diuretic renal scan, which indicates no evidence of obstruction and good differential function bilaterally. ", Letters, Pediatric Urology Letter ,"XYZ, M.D. ,Suite 123, ABC Avenue ,City, STATE 12345 ,RE:  XXXX, XXXX ,MR#:  0000000,Dear Dr. XYZ: ,XXXX was seen in followup in the Pediatric Urology Clinic.  I appreciate you speaking with me while he was in clinic.  He continues to have abdominal pain, and he had a diuretic renal scan, which indicates no evidence of obstruction and good differential function bilaterally. ,When I examined him, he seems to indicate that his pain is essentially in the lower abdomen in the suprapubic region; however, on actual physical examination, he seems to complain of pain through his entire right side.  His parents have brought up the question of whether this could be gastrointestinal in origin and that is certainly an appropriate consideration.  They also feel that since he has been on Detrol, his pain levels have been somewhat worse, and so, I have given them the option of stopping the Detrol initially.  I think he should stay on MiraLax for management of his bowels.  I would also suggest that he be referred to Pediatric Gastroenterology for evaluation.  If they do not find any abnormalities from a gastrointestinal perspective, then the next step would be to endoscope his bladder and then make sure that he does not have any evidence of bladder anatomic abnormalities that is leading to this pain. ,Thank you for following XXXX along with us in Pediatric Urology Clinic.  If you have any questions, please feel free to contact me. ,Sincerely yours,","letters, differential function, diuretic renal scan, abdominal pain, renal scan, pediatric urology, "
" Vasectomy 10 years ago, failed.  Azoospermic.  Reversal two years ago.  Interested in sperm harvesting and cryopreservation", Letters, Urology Letter ,"Sample Address,RE:  Sample Patient,Wife's name:  Sample Name,Dear Sample Doctor:,Mr. Sample Patient was seen on Month DD, YYYY, describing a vasectomy 10 years ago and a failed vasectomy reversal done almost two years ago at the University of Michigan.  He has remained azoospermic postoperatively.  The operative note suggests the presence of some sperm and sperm head on the right side at the time of the vasectomy reversal.,He states that he is interested in sperm harvesting and cryopreservation prior to the next attempted ovulation induction for his wife.  Apparently, several attempts at induction have been tried and due to some anatomic abnormality, they have been unsuccessful.,At the time that he left the office, he was asking for cryopreservation.  At the time of sperm harvesting, I recently received a phone call suggesting that he does not want to do this at all unless his wife's ovulation has been confirmed and it appears then that he may be interested in a fresh specimen harvest.  I look forward to hearing from you regarding the actual plan so that we can arrange our procedure appropriately.  At his initial request, Month DD, YYYY was picked as the date for scheduled harvesting, although this may change if you require fresh specimen.,Thank you very much for the opportunity to have seen him.,Sample Doctor, M.D.","letters, urology, letter, urology letter, azoospermic, cryopreservation, specimen harvest, sperm harvesting, vasectomy, vasectomy reversal, fresh specimen, reversal, sperm,"
 Diagnosis of benign rolandic epilepsy., Letters, Rolandic Epilepsy ,"City, State,Dear Dr. Y:,I had the pleasure of seeing ABC today back in Neurology Clinic where he has been followed previously by Dr. Z.  His last visit was in June 2006, and he carries a diagnosis of benign rolandic epilepsy.  To review, his birth was unremarkable.  He is a second child born to a G3, P1 to 2 female.  He has had normal development, and is a bright child in 7th grade.  He began having seizures, however, at 9 years of age.  It is manifested typically as generalized tonic-clonic seizures upon awakening or falling into sleep.  He also had smaller spells with more focal convulsion and facial twitching.  His EEGs have shown a pattern consistent with benign rolandic epilepsy (central temporal sharp waves both of the right and left hemisphere).  Most recent EEG in May 2006 shows the same abnormalities.,ABC initially was placed on Tegretol, but developed symptoms of toxicity (hallucinations) on this medication, he was switched to Trileptal.  He has done very well taking 300 mg twice a day without any further seizures.  His last event was the day of his last EEG when he was sleep deprived and was off medication.  That was a convulsion lasting 5 minutes.  He has done well otherwise.  Parents deny that he has any problems with concentration.  He has not had any behavior issues.  He is an active child and participates in sports and some motocross activities.  He has one older sibling and he lives with his parents.  Father manages Turkey farm with foster farms.  Mother is an 8th grade teacher.,Family history is positive for a 3rd cousin, who has seizures, but the specific seizure type is not known.  There is no other relevant family history.,Review of systems is positive for right heel swelling and tenderness to palpation.  This is perhaps due to sports injury.  He has not sprained his ankle and does not have any specific acute injury around the time that this was noted.  He does also have some discomfort in the knees and ankles in the general sense with activities.  He has no rashes or any numbness, weakness or loss of skills.  He has no respiratory or cardiovascular complaints.  He has no nausea, vomiting, diarrhea or abdominal complaints.,Past medical history is otherwise unremarkable.,Other workup includes CT scan and MRI scan of the brain, which are both normal.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a well-nourished, well-hydrated male in no acute distress.  VITAL SIGNS:  His weight today is 80.6 pounds.  Height is 58-1/4 inches.  Blood pressure 113/66.  Head circumference 36.3 cm.  HEENT:  Atraumatic, normocephalic.  Oropharynx shows no lesions.  NECK:  Supple without adenopathy.  CHEST:  Clear auscultation.,CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs.  ABDOMEN:  Benign without organomegaly.  EXTREMITIES:  No clubbing, cyanosis or edema.  NEUROLOGIC:  The patient is alert and oriented.  His cognitive skills appear normal for his age.  His speech is fluent and goal-directed.  He follows instructions well.  His cranial nerves reveal his pupils equal, round, and reactive to light.  Extraocular movements are intact.  Visual fields are full.  Disks are sharp bilaterally.  Face moves symmetrically with normal sensation.  Palate elevates midline.  Tongue protrudes midline.  Hearing is intact bilaterally.  Motor exam reveals normal strength and tone.  Sensation intact to light touch and vibration.  His gait is nonataxic with normal heel-toe and tandem.  Finger-to-nose, finger-nose-finger, rapid altering movements are normal.  Deep tendon reflexes are 2+ and symmetric.,IMPRESSION:  ,This is an 11-year-old male with benign rolandic epilepsy, who is followed over the past 2 years in our clinic.  Most recent electroencephalogram still shows abnormalities, but it has not been done since May 2006.  The plan at this time is to repeat his electroencephalogram, follow his electroencephalogram annually until it reveres to normal.  At that time, he will be tapered off of medication.  I anticipate at some point in the near future, within about a year or so, he will actually be taken off medication.  For now, I will continue on Trileptal 300 mg twice a day, which is a low starting dose for him.  There is no indication that his dose needs to be increased.  Family understands the plan.  We will try to obtain an electroencephalogram in the near future in Modesto and followup is scheduled for 6 months.  Parents will contact us after the electroencephalogram is done so they can get the results.,Thank you very much for allowing me to access ABC for further management.","letters, tonic-clonic seizures, benign rolandic epilepsy, rolandic epilepsy, epilepsy, seizures, electroencephalogram,"
 A pleasant gentleman with a history of Wilson's disease who has been treated with penicillamine., Letters, Wilson's Disease - Letter ,"Doctor's Address,Dear Doctor:,This letter is an introduction to my patient, A, who you will be seeing in the near future.  He is a pleasant gentleman with a history of Wilson's disease.  It has been treated with penicillamine.  He was diagnosed with this at age 14.  He was on his way to South Carolina for a trip when he developed shortness of breath, palpitations, and chest discomfort.  He went to the closest hospital that they were near in Randolph, North Carolina and he was found to be in atrial fibrillation with rapid rate.  He was admitted there and observed.  He converted to normal sinus rhythm spontaneously and so he required no further interventions.  He was started on Lopressor, which he has tolerated well.  An echocardiogram was performed, which revealed mild-to-moderate left atrial enlargement.  Normal ejection fraction.  No other significant valvular abnormality.  He reported to physicians there that he had cirrhosis related to his Wilson's disease.  Therefore hepatologist was consulted.  There was a recommendation to avoid Coumadin secondary to his questionable significant liver disease, therefore he was placed on aspirin 325 mg once a day.,In discussion with Mr. A and review of his chart that I have available, it is unclear as to the status of his liver disease, however, he has never had a liver biopsy, so his diagnosis of cirrhosis that they were concerned about in North Carolina is in doubt.  His LFTs have remained normal and his copper level has been undetectable on his current dose of penicillamine.,I would appreciate your input into the long term management of his anticoagulation and also any recommendations you would have about rhythm control.  He is in normal sinus rhythm as of my evaluation of him on 06/12/2008.  He is tolerating his metoprolol and aspirin without any difficulty.  I guess the big question remains is what level of risk that is entailed by placing him on Coumadin therapy due to his potentially paroxysmal atrial fibrillation and evidence of left atrial enlargement that would place him in increased risk of recurrent episodes.,I appreciate your input regarding this friendly gentleman.  His current medicines include penicillamine 250 mg p.o. four times a day, metoprolol 12.5 mg twice a day, and aspirin 325 mg a day.,If you have any questions regarding his care, please feel free to call me to discuss his case.  Otherwise, I will look forward to hearing back from you regarding his evaluation.  Thank you as always for your care of our patient.","letters, atrial enlargement, wilson's disease, penicillamine,"
 Patient continuing on Dilantin 300 mg daily and has been seizure episode free for the past 2 1/2 years., Letters, Suspected Seizure Activity ,"XYZ Street,City, State,Dear Dr. CD:,Thank you for seeing Mr. XYZ, a pleasant 19-year-old male who has seen you in 2005 for suspected seizure activity.  He comes to my office today continuing on Dilantin 300 mg daily and has been seizure episode free for the past 2 1/2 years.  He is requesting to come off the Dilantin at this point.  Upon reviewing your 2005 note there was some discrepancy as to the true nature of his episodes to the emergency room and there was consideration to reconsider medication use.  His physical exam, neurologically, is normal at this time.  His Dilantin level is slightly low at 12.5.,I will appreciate your evaluation and recommendation as to whether we need to continue the Dilantin at this time.  I understand this will probably entail repeating his EEG and so please coordinate this through Health Center.  I await your response and whether we should continue this medication.  If you require any laboratory, we use ABC Diagnostic and any further testing that is needed should be coordinated at Health Center prior to scheduling.","letters, eeg, suspected seizure activity, seizure activity, seizure episode, seizure, dilantinNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Reflex sympathetic dystrophy of both lower extremities., Letters, Reflex Sympathetic Dystrophy - Letter ,"Doctor's Address,Dear Doctor:,This letter serves as a reintroduction of my patient, A, who will be seeing you on Thursday, 06/12/2008.  As you know, he is an unfortunate gentleman who has reflex sympathetic dystrophy of both lower extremities.  His current symptoms are more severe on the right and he has had a persisting wound that has failed to heal on his right leg.  He has been through Wound Clinic to try to help heal this, but was intolerant of compression dressings and was unable to get satisfactory healing of this.  He has been seen by Dr. X for his pain management and was considered for the possibility of amputation being a therapeutic option to help reduce his pain.  He was seen by Dr. Y at Orthopedic Associates for review of this.  However, in my discussion with Dr. Z and his evaluation of Mr. A, it was felt that this may be an imprudent path to take given the lack of likelihood of reduction of his pain from his RST, his questionable healing of his wound given noninvasive studies that did reveal tenuous oxygenation of the right lower leg, and concerns of worsening of his RST symptoms on his left leg if he would have an amputation.  Based on the results of his transcutaneous oxygen levels and his dramatic improvement with oxygen therapy at this test, Dr. Z felt that a course of hyperbaric oxygen may be of utility to help in improving his wounds.  As you may or may not know we have certainly pursued aggressive significant measures to try to improve Mr. A's pain.  He has been to Cleveland Clinic for implantable stimulator, which was unsuccessful at dramatically improving his pain.  He currently is taking methadone up to eight tablets four times a day, morphine up to 100 mg three times a day, and Dilaudid two tablets by mouth every two hours to help reduce his pain.  He also is currently taking Neurontin 1600 mg three times a day, Effexor XR 250 mg once a day, Cytomel 25 mcg once a day, Seroquel 100 mg p.o. q. day, levothyroxine 300 mcg p.o. q. day, Prinivil 20 mg p.o. q. day, and Mevacor 40 mg p.o. q day.,I appreciate your assistance in determining if hyperbaric oxygen is a reasonable treatment course for this unfortunate situation.  Dr. Z and I have both tried to stress the fact that amputation may be an abrupt and irreversible treatment course that may not reach any significant conclusion.  He has been evaluated by Dr. X for rehab concerns to determine.  He agrees that a less aggressive form of therapy may be most appropriate.,I thank you kindly for your prompt evaluation of this kind gentleman in an unfortunate situation.  If you have any questions regarding his care please feel free to call me at my office.  Otherwise, I look forward to hearing back from you shortly after your evaluation.  Please feel free to call me if it is possible or if you have any questions about anything.","letters, rsd, reflex sympathetic dystrophy, orthopedic, oxygenationNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Creation of right brachiocephalic arteriovenous fistula., Nephrology, AV Fistula - 2 ,"PREOPERATIVE DIAGNOSES,1.  End-stage renal disease.,2.  Diabetes.,POSTOPERATIVE DIAGNOSES,1.  End-stage renal disease.,2.  Diabetes.,OPERATIVE PROCEDURE,Creation of right brachiocephalic arteriovenous fistula.,INDICATIONS FOR THE PROCEDURE,This patient has end-stage renal disease.  Although, the patient is right-handed, preoperative vein mapping demonstrated much better vein in the right arm.  Hence, a right brachiocephalic fistula is being planned.,OPERATIVE FINDINGS,The right cephalic vein at the elbow is chosen to be suitable.  It is slightly sporadic, but of an adequate size.  An end-to-side right brachiocephalic arteriovenous fistula was created.  At completion, there was a great thrill.,OPERATIVE PROCEDURE IN DETAIL,After informed consent was obtained, the patient was taken to the operating room.  The patient was placed in the supine position.  The patient received a regional nerve block.  The patient also received intravenous sedation.  The right arm was prepped and draped in the usual sterile fashion.,We made a small transverse incision in the right cubital fossa.  The cephalic vein was identified and mobilized.  The fascia was incised, and the brachial artery was also identified and mobilized.  The brachial artery was free off significant disease.  A good pulse was noted.  The cephalic vein was mobilized proximally and distally.  The brachial artery was mobilized proximally and distally.  We did not give heparin.  The brachial artery was then clamped proximally and distally.  The cephalic vein was also clamped proximally and distally.  Longitudinal arteriotomy was made in brachial artery, and a longitudinal venotomy was made in the cephalic vein.  We then sewn the vein to the artery in a side-to-side fashion using a running 7-0 Prolene suture.,Just prior to completion of the anastomosis, it was flushed, and the anastomosis was then completed.  A great thrill was noted.  We then ligated the cephalic vein beyond the arteriovenous anastomosis and divided it.  This surrounded the anastomosis as an end-to-side functionally.  A great thrill remained in the fistula.  Hemostasis was secured.  We then closed the wound using interrupted PDS sutures for the fascia and a running 4-0 Monocryl subcuticular suture for the skin.  Sterile dry dressing was applied.,The patient tolerated the procedure well.  There were no operative complications.  The sponge, instrument, and needle counts were correct at the end of the case.  I was present and participated in all aspects of the procedure.  The patient was then transferred to the recovery room in satisfactory condition.  A great thrill was felt in the fistula completion.  There was also a palpable radial pulse distally.","nephrology, end-stage renal disease, prolene suture, brachial artery, brachiocephalic, brachiocephalic arteriovenous fistula, cephalic vein, fistula, general anesthetic, prepped and draped, proximally and distally, renal disease, av, cephalic, artery, vein"
 The patient is being referred for evaluation of diabetic retinopathy., Letters, Ophthalmology - Letter - 4 ,"XYZ, M.D.,RE:  ABC,DOB:  MM/DD/YYYY,Dear Dr. XYZ:,Thank you for your kind referral for patient ABC.  The patient is being referred for evaluation of diabetic retinopathy.  The patient was just diagnosed with diabetes; however, he does not have any serious visual complaints at this time.,On examination, the patient is seeing 20/40 OD pinholing to 20/20.  The vision in the left eye is 20/20 uncorrected.  Applanation pressures are normal at 17 mmHg bilaterally.  Visual fields are full to count fingers OU and there is no relative afferent pupillary defect.  Slit lamp examination was within normal limits, other than trace to 1+ nuclear sclerosis OU.  On dilated examination, the patient shows a normal cup-to-disc ratio that is symmetric bilaterally.  The macula, vessels, and periphery are also within normal limits.,In conclusion, Mr. ABC does not show any evidence of diabetic retinopathy at this time.  We recommended him to have his eyes dilated once a year.  I have advised him to follow up with you for his regular check-ups.  Again, thank you for your kind referral of Mr. ABC and we should check on him once a year at this time.,Sincerely,,","letters, pupillary defect, cup-to-disc ratio, cup-to-disc, evaluation of diabetic retinopathy, referred for evaluation, diabetic retinopathy, visual, dilated, retinopathy, examination, diabetic,"
" Patient suffers from neck and lower back pain radiating into both arms and both legs with numbness, paraesthesia, and tingling in both arms.", Letters, Ortho - Letter - 2 ,"XYZ, D.C.,60 Evergreen Place,Suite 902,East Orange, NJ  07018,Re:","letters, paraspinal musculature, palpable trigger points, trigger point injections, lumbar, region, paraspinal, musculature, injections, trigger, "
 Woman with a history of macular degeneration.  PDT therapy.  Some vision therapy.  Complete refractive work-up., Letters, Optometry - Letter ,"RE:  Sample Patient,Dear Dr. Sample:,Sample Patient was seen at the Vision Rehabilitation Institute on Month DD, YYYY.  She is an 87-year-old woman with a history of macular degeneration, who admits to having PDT therapy within the last year.  She would like to get started with some vision therapy so that she may be able to perform her everyday household chores, as well as reading small print.  At this time, she uses a small handheld magnifier, which is providing her with only limited help.,A complete refractive work-up was performed today, in which we found a mild change in her distance correction, which allowed her the ability to see 20/70 in the right eye and 20/200 in the left eye.  With a pair of +4 reading glasses, she was able to read 0.5M print quite nicely.  I have loaned her a pair of +4 reading glasses at this time and we have started her with fine-detailed reading.  She will return to our office in a matter of two weeks and we will make a better determination on what near reading glasses to prescribe for her.  I think that she is an excellent candidate for low vision help.  I am sure that we can be of great help to her in the near future.,Thank you for allowing us to share in the care of your patient.,With best regards,,Sample Doctor, O.D.","letters, optometry, letter, optometry letter, pdt therapy, distance correction, macular degeneration, reading glasses, vision therapy, complete refractive, macular, degeneration,"
 Patient being referred for evaluation of glaucoma., Letters, Ophthalmology - Letter - 2 ,"XYZ, O.D.,RE:  ABC,DOB:  MM/DD/YYYY,Dear Dr. XYZ:,Thank you for your kind referral for patient ABC.  Mr. ABC is being referred for evaluation of glaucoma.  The patient states he has no visual complaints.,On examination, the patient's visual acuity is 20/20 bilaterally.  The patient's visual fields are full to confrontation.  Extraocular muscles are intact.  There is no relative afferent pupillary defect and applanation pressures are 15 mmHg bilaterally.  On slit lamp examination, the patient has a normal anterior segment with 1+ nuclear sclerosis.  On dilated examination, the patient has a cup-to-disc ratio in the right eye of 0.4.  Macula, vessels, and periphery were within normal limits.  On the left eye, the patient has a cup-to-disc ratio of 0.3 and macula vessels and periphery are also within normal limits.  On gonioscopy, the patient shows deep anterior chamber angle OU and is open to the ciliary body band 360 degrees.,In conclusion, my initial impression is that Mr. ABC does not have glaucoma.  He has fairly symmetric and small cup-to-disc ratios OU.  His intraocular pressures were within normal limits in our office today.  I discussed at length with him the alternatives of observation versus continued work-up and testing.  He seemed to understand very well and went with my recommendation to continue observation for now.  We will take fundus photos of his optic nerves for future comparison, but I think given the lack of any strong findings suspicious for glaucoma, we will defer further testing at this time.,Should you have any specific questions or any other information that you think that I may not have included in this evaluation, please feel free to contact me.  I have recommended him to follow up with you for continued examination, continued check-ups, and should you find any other abnormal findings, I would be happy to address those again.,Again, thank you for your referral of Mr. ABC.,Sincerely,,","letters, cup to disc ratio, referred for evaluation, cup to disc, disc ratio, macula vessels, ophthalmology, pressures, eye, macula, vessels, visual, cup, disc, glaucoma, examination, intact, "
" 9-month-old male product of a twin gestation complicated by some very mild prematurity having problems with wheezing, cough and shortness of breath over the last several months.", Letters, Pediatric - Letter ,"Sample Address,RE:  Sample Patient,Dear Doctor:,We had the pleasure of seeing Abc and his mother in the clinic today.  As you certainly know, he is now a 9-month-old male product of a twin gestation complicated by some very mild prematurity.  He has been having problems with wheezing, cough and shortness of breath over the last several months.  You and your partners have treated him aggressively with inhaled steroids and bronchodilator.  Despite this, however; he has had persistent problems with a cough and has been more recently started on both a short burst of prednisolone as well as a more prolonged alternating day course.  ,Although there is no smoke exposure there is a significant family history with both Abc's father and uncle having problems with asthma as well as his older sister.  The parents now maintain separate households and there has been a question about the consistency of his medication administration at his father's house.  ,On exam today, Abc had some scattered rhonchi which cleared with coughing but was otherwise healthy.  ,We spent the majority of our 45-minute just reviewing basic principles of asthma management and I believe that Abc's mother is fairly well versed in this.  I think the most important thing to realize is that Abc probably does have fairly severe childhood asthma and fortunately has avoided hospitalization.  ,I think it would be prudent to continue his alternate day steroids until he is completely symptom free on the days off steroids but it would be reasonable to continue to wean him down to as low as 1.5 milligrams (0.5 milliliters on alternate days).  I have encouraged his mother to contact our office so that we can answer questions if necessary by phone.,Thanks so much for allowing us to be involved in his care.  ,Sincerely,","letters, gestation, bronchodilator, childhood, childhood asthma, cough, father, healthy, letter, mother, pediatric, prematurity, shortness of breath, sister, wheezing, wheezing cough, asthma, "
 The patient was referred for evaluation of cataracts bilaterally, Letters, Ophthalmology - Letter - 1 ,"XYZ, O.D.,RE:  ABC,DOB:  MM/DD/YYYY,Dear Dr. XYZ:,Thank you for your referral of patient ABC.  The patient was referred for evaluation of cataracts bilaterally.,On examination, the patient was seeing 20/40 in her right eye and 20/50 in the left eye.  Extraocular muscles were intact, visual fields were full to confrontation OU, and applanations are 12 mmHg bilaterally.  There is no relative afferent pupillary defect.  On slit lamp examination, lids and lashes were within normal limits.  The conj is quiet.  The cornea shows 1+ guttata bilaterally.  The AC is deep and quiet and irises are within normal limits bilaterally.  There is a dense 3 to 4+ nuclear sclerotic cataract in each eye.  On dilated fundus examination, cup-to-disc ratio is 0.1 OU.  The vitreous, macula, vessels, and periphery all appear within normal limits.,Impression:  It appears that Ms. ABC' visual decline is caused by bilateral cataracts.  She would benefit from having removed.  The patient also showed some mild guttata OU indicating possible early Fuchs dystrophy.  The patient should do well with cataract surgery and I have recommended this and she agreed to proceed with the first eye here shortly.  I will keep you up to date of her progress and any new findings as we perform her surgery in each eye.,Again, thank you for your kind referral of this kind lady and I will be in touch with you.,Sincerely,,","letters, extraocular, applanations, slit lamp, visual field, ophthalmology, visual, guttata, surgery, cataracts, eye, "
 A 19-year-old right-handed male injured in a motor vehicle accident., Letters, Ortho - Letter - 1 ,"XYZ, D.C.,Re:  ABC,Dear Dr. XYZ:,I had the pleasure of seeing your patient, ABC, today MM/DD/YYYY in consultation.  He is an unfortunate 19-year-old right-handed male who was injured in a motor vehicle accident on MM/DD/YYYY, where he was the driver of an automobile, which was struck on the front passenger's side.  The patient sustained impact injuries to his neck and lower back.  There was no apparent head injury or loss of consciousness and he denied any posttraumatic seizures.  He was taken to Hospital, x-rays were taken, apparently which were negative and he was released.,At the present time, he complains of neck and lower back pain radiating into his right arm and right leg with weakness, numbness, paraesthesia, and tingling in his right arm and right leg.  He has had no difficulty with bowel or bladder function.  He does experience intermittent headaches associated with his neck pain with no other associated symptoms.,PAST HEALTH:,  He was injured in a prior motor vehicle accident on MM/DD/YYYY.  At the time of his most recent injuries, he was completely symptom free and under no active therapy.  There is no history of hypertension, diabetes, heart disease, neurological disorders, ulcers or tuberculosis.,SOCIAL HISTORY: , He denies tobacco or alcohol consumption.,ALLERGIES: , No known drug allergies.,CURRENT MEDICATIONS:  ,None.,FAMILY HISTORY: , Otherwise noncontributory.,FUNCTIONAL INQUIRY: , Otherwise noncontributory.,REVIEW OF DIAGNOSTIC STUDIES:,  Includes an MRI scan of the cervical spine dated MM/DD/YYYY which showed evidence for disc bulging at the C6-C7 level.  MRI scan of the lumbar spine on MM/DD/YYYY, showed evidence of a disc herniation at the L1-L2 level as well as a disc protrusion at the L2-L3 level with disc herniations at the L3-L4 and L4-L5 level and disc protrusion at the L5-S1 level.,PHYSICAL EXAMINATION: , Reveals an alert and oriented male with normal language function.  Vital Signs:  Blood pressure was 105/68 in the left arm sitting.  Heart rate was 70 and regular.  Height was 5 feet 8 inches.  Weight was 182 pounds.  Cranial nerve evaluation was unremarkable.  Pupils were equal and reactive.  Funduscopic evaluation was clear.  There was no evidence for nystagmus.  There was decreased range of motion noted in both the cervical and lumbar regions to a significant degree, with tenderness and spasm in the paraspinal musculature.  Straight leg raising was limited to 45 degrees on the right and 90 degrees on the left.  Motor strength was 5/5 on the MRC scale.  Reflexes were 2+ symmetrical and active.  No pathological responses were noted.  Sensory examination showed a diffuse decreased sensation to pinprick in the right upper extremity.  Cerebellar function was normal.  There was normal station and gait.  Chest and cardiovascular evaluations were unremarkable.  Heart sounds were normal.  There were no extra sounds or murmurs.  Palpable trigger points were noted in the right trapezius and right cervical and lumbar paraspinal musculature.,CLINICAL IMPRESSION: , Reveals a 19-year-old male suffering from a posttraumatic cervical and lumbar radiculopathy, secondary to traumatic injuries sustained in a motor vehicle accident on MM/DD/YYYY.  In view of the persistent radicular complaints associated with the weakness, numbness, paraesthesia, and tingling as well as the objective sensory loss noted on today's evaluation as well as the non-specific nature of the radiculopathy, I have scheduled him for an EMG study on his right upper and right lower extremity in two week's time to rule out any nerve root irritation versus any peripheral nerve entrapment or plexopathy as the cause of his symptoms.  Palpable trigger points were noted on today's evaluation.  He is suffering from ongoing myofascitis.  His treatment plan will consist of a series of trigger point injections to be initiated at his next follow up visit in two weeks' time.  I have encouraged him to continue with his ongoing treatment program under your care and supervision.  I will be following him in two weeks' time.  Once again, thank you kindly for allowing me to participate in this patient's care and management.,Yours sincerely,,","letters, numbness paraesthesia and tingling, paraesthesia and tingling, cervical and lumbar, motor vehicle accident, mri scan, disc protrusion, paraspinal musculature, letter, musculature, radiculopathy, nerve, trigger, vehicle, accident, cervical, lumbar, evaluation, disc, ortho, "
 Patient referred for narrow angles and possible associated glaucoma., Letters, Ophthalmology - Letter - 3 ,"XYZ, O.D.,RE:  ABC,DOB:  MM/DD/YYYY,Dear XYZ:,Thank you very much for your kind referral of Mrs. ABC who you referred to me for narrow angles and possible associated glaucoma.  I examined Mrs. ABC initially on MM/DD/YYYY.  At that time, she expressed a chief concern of occasional pain around her eye, but denied any flashing lights, floaters, halos, or true brow ache.  She reports a family history of glaucoma in her mother, but is unsure of the specific kind.  Her past ocular history has been fairly unremarkable.  As you know, she has a history of non-insulin dependent diabetes.  She is unaware of her last hemoglobin A1c levels, but reports a blood sugar of 158 taken on the morning of her appointment with me.  She is followed by Dr. X here locally.,Upon examination, her visual acuity measured 20/20-1 in either eye with her glasses.  Presenting intraocular pressures were14 mmHg in either eye at 2:03 p.m.  Pupillary reactions, confrontational visual fields, and ocular motility were normal.  The slit lamp exam revealed narrow anterior chambers and on gonioscopy only the buried anterior trabecular meshwork was visible in either eye, but the angle deepened with gonio-compression suggesting appositional and not synechial closure.  I deferred the dilated portion of the exam on that day.,We proceeded with peripheral iridectomies and following this upon her most recent visit on MM/DD/YYYY, I was able to safely dilate her eyes as her chambers had deepened and the PIs were patent.  I note that she has an increased CD ratio measuring 0.65 in the right eye and 0.7 in the left and although her FDT visual fields and GDX testing were normal at your office, she does have an enlarged blind spot in either eye on Humphrey visual fields and retinal tomography also shows some suspicious changes.  Therefore, I feel she has sustained some optic nerve damage perhaps from intermittent angle closure in the past.,In summary, Mrs. ABC has a history of narrow angles not successfully treated with laser PIs.  Her intraocular pressures have remained stable.  I will continue to monitor her closely.,Thank you very much once again for allowing me to have shared in her care.  If I can provide any additional information or be of further service, do let me know.,Sincerely,,","letters, intraocular pressures, narrow angles, visual fields, angles, ophthalmology, intraocular, pressures, anterior, chambers, gonioscopy, glaucoma, narrow, visual, eye, "
" Female with intermittent rectal bleeding, not associated with any weight loss.  The patient is chronically constipated.", Letters, Gastroenterology - Letter ,"Sample Address,Re:  Mrs. Sample Patient,Dear Sample Doctor:,I had the pleasure of seeing your patient, Mrs. Sample Patient , in my office today.  Mrs. Sample Patient is a 48-year-old, African-American female with a past medical history of hypertension and glaucoma, who was referred to me to be evaluated for intermittent rectal bleeding.  The patient denies any weight loss, does have a good appetite, no nausea and no vomiting.,PAST MEDICAL HISTORY:,  Significant for hypertension and diabetes.,PAST SURGICAL HISTORY:,  The patient denies any past surgical history.,MEDICATIONS:,  The patient takes Cardizem CD 240-mg.  The patient also takes eye drops.,ALLERGIES:,  The patient denies any allergies.,SOCIAL HISTORY:,  The patient smokes about a pack a day for more than 25 years.  The patient drinks alcohol socially.,FAMILY HISTORY:,  Significant for hypertension and strokes.,REVIEW OF SYSTEMS:,  The patient does have a good appetite and no weight loss.  She does have intermittent rectal bleeding associated with irritation in the rectal area.  The patient denies any nausea, any vomiting, any night sweats, any fevers or any chills.,The patient denies any shortness of breath, any chest pain, any irregular heartbeat or chronic cough.,The patient is chronically constipated.,PHYSICAL EXAMINATION:,  This is a 48 year-old lady who is awake, alert and oriented x 3.  She does not seem to be in any acute distress.  Her vital signs are blood pressure is 130/70 with a heart rate of 75 and respirations of 16.  HEENT is normocephalic, atraumatic.  Sclerae are non-icteric.  Her neck is supple, no bruits, no lymph nodes.  Lungs are clear to auscultation bilaterally, no crackles, no rales and no wheezes.  The cardiovascular system has a regular rate and rhythm, no murmurs.  The abdomen is soft and non-tender.  Bowel sounds are positive and no organomegaly.  Extremities have no edema.,IMPRESSION:,  This is a 48-year-old female presenting with painless rectal bleeding not associated with any weight loss.  The patient is chronically constipated.,1.  Rule out colon cancer.,2.  Rule out colon polyps. ,3.  Rule out hemorrhoids, which is the most likely diagnosis.,RECOMMENDATIONS:,  Because of the patient's age, the patient will need to have a complete colonoscopy exam.,The patient will also need to have a CBC check and monitor.,The patient will be scheduled for the colonoscopy at Sample Hospital and the full report will be forwarded to your office.,Thank you very much for allowing me to participate in the care of your patient.,Sincerely yours,,Sample Doctor, MD",
 Diagnosis of bulbar cerebral palsy and hypotonia. , Letters, Cerebral Palsy - Letter ,"Doctor's Address,Dear Doctor:,This letter serves as an introduction to my patient, A, who will be seeing you in the near future.  He is a pleasant young man who has a diagnosis of bulbar cerebral palsy and hypotonia.  He has been treated by Dr. X through the pediatric neurology clinic.  He saw Dr. X recently and she noted that he was having difficulty with mouth breathing, which was contributing to some of his speech problems.  She also noted and confirmed that he has significant tonsillar hypertrophy.  The concern we have is whether he may benefit from surgery to remove his tonsils and improve his mouth breathing and his swallowing and speech.  Therefore, I ask for your opinion on this matter.,For his chronic allergic rhinitis symptoms, he is currently on Flonase two sprays to each nostril once a day.  He also has been taking Zyrtec 10 mg a day with only partial relief of the symptoms.  He does have an allergy to penicillin.,I appreciate your input on his care.  If you have any questions regarding, please feel free to call me through my office.  Otherwise, I look forward to hearing back from you regarding his evaluation.","letters, peech, swallowing, breathing, bulbar cerebral palsy, mouth breathing, cerebral palsy, hypotoniaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Letter on evaluation regarding extraction of mandibular left second molar tooth #18., Letters, Letter - Dentistry ,"XYZ, S.,RE:  ABC,Dear Dr. XYZ,On your kind referral, I had the pleasure of meeting and consulting with ABC on MM/DD/YYYY for evaluation regarding extraction of his mandibular left second molar tooth #18.  This previously root-canaled tooth, now failed, is scheduled for removal.  As per your request, I agree that placement of an implant in the #20 and #19 positions would allow for immediate functional replacement of the bridge which has recently been lost in this area.,I have given Mr. ABC an estimate for the surgical aspects of this case and suggested he combine this with your prosthetic or restorative fees in order to have a full understanding of the costs involved with this process.,We will plan to place two Straumann implants as per our normal protocol, one each in the #19 and 20 positions, with the #19 implant being a wide-neck, larger diameter implant.  I will plan on providing the prosthetic abutments, the lab analogue, and temporary healing cap at the end of the four-month integration period.  If you have any additional suggestions or concerns, please give me a call.,Best regards,,","letters, molar tooth, extraction, mandibular, straumann, wide-neck, placement, positions, prosthetic, implant, tooth"
 Follow up update on patient with left carotid angioplasty and stent placement., Letters, Cardiology - Letter ,"Please accept this letter of follow up on patient xxx xxx. He is now three months out from a left carotid angioplasty and stent placement. He was a part of a CapSure trial. He has done quite well, with no neurologic or cardiac event in the three months of follow up. He had a follow-up ultrasound performed today that shows the stent to be patent, with no evidence of significant recurrence.,Sincerely,,XYZ, MD,","letters, capsure, cardiac event, ultrasound, carotid angioplasty, stent placement, letter, angioplastyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Male with a history of therapy-controlled hypertension, borderline diabetes, and obesity.  Risk factors for coronary heart disease.", Letters, Cardiovascular - Letter ,"Dear Sample Doctor:,Thank you for referring Mr. Sample Patient for cardiac evaluation.  This is a 67-year-old, obese male who has a history of therapy-controlled hypertension, borderline diabetes, and obesity.  He has a family history of coronary heart disease but denies any symptoms of angina pectoris or effort intolerance.  Specifically, no chest discomfort of any kind, no dyspnea on exertion unless extreme exertion is performed, no orthopnea or PND.  He is known to have a mother with coronary heart disease.  He has never been a smoker.  He has never had a syncopal episode, MI, or CVA.  He had his gallbladder removed.  No bleeding tendencies.  No history of DVT or pulmonary embolism.  The patient is retired, rarely consumes alcohol and consumes coffee moderately.  He apparently has a sleep disorder, according to his wife (not in the office), the patient snores and stops breathing during sleep.  He is allergic to codeine and aspirin (angioedema).,Physical exam revealed a middle-aged man weighing 283 pounds for a height of 5 feet 11 inches.  His heart rate was 98 beats per minute and regular.  His blood pressure was 140/80 mmHg in the right arm in a sitting position and 150/80 mmHg in a standing position.  He is in no distress.  Venous pressure is normal.  Carotid pulsations are normal without bruits.  The lungs are clear.  Cardiac exam was normal.  The abdomen was obese and organomegaly was not palpated.  There were no pulsatile masses or bruits.  The femoral pulses were 3+ in character with a symmetrical distribution and dorsalis pedis and posterior tibiales were 3+ in character.  There was no peripheral edema.  ,He had a chemistry profile, which suggests diabetes mellitus with a fasting blood sugar of 136 mg/dl.  Renal function was normal.  His lipid profile showed a slight increase in triglycerides with normal total cholesterol and HDL and an acceptable range of LDL.  His sodium was a little bit increased.  His A1c hemoglobin was increased.  He had a spirometry, which was reported as normal.  ,He had a resting electrocardiogram on December 20, 2002, which was also normal.  He had a treadmill Cardiolite, which was performed only to stage 2 and was terminated by the supervising physician when the patient achieved 90% of the predicted maximum heart rate.  There were no symptoms or ischemia by EKG.  There was some suggestion of inferior wall ischemia with normal wall motion by Cardiolite imaging.,In summary, we have a 67-year-old gentleman with risk factors for coronary heart disease.  I am concerned with possible diabetes and a likely metabolic syndrome of this gentleman with truncal obesity, hypertension, possible insulin resistance, and some degree of fasting hyperglycemia, as well as slight triglyceride elevation.  He denies any symptoms of coronary heart disease, but he probably has some degree of coronary atherosclerosis, possibly affecting the inferior wall by functional testings.  ,In view of the absence of symptoms, medical therapy is indicated at the present time, with very aggressive risk factor modification.  I explained and discussed extensively with the patient, the benefits of regular exercise and a walking program was given to the patient.  He also should start aggressively losing weight.  I have requested additional testing today, which will include an apolipoprotein B, LPa lipoprotein, as well as homocystine, and cardio CRP to further assess his risk of atherosclerosis.  ,In terms of medication, I have changed his verapamil for a long acting beta-blocker, he should continue on an ACE inhibitor and his Plavix.  The patient is allergic to aspirin.  I also will probably start him on a statin, if any of the studies that I have recommended come back abnormal and furthermore, if he is confirmed to have diabetes.  Along this line, perhaps, we should consider obtaining the advice of an endocrinologist to decide whether this gentleman needs treatment for diabetes, which I believe he should.  This, however, I will leave entirely up to you to decide.  If indeed, he is considered to be a diabetic, a much more aggressive program should be entertained for reducing the risks of atherosclerosis in general, and coronary artery disease in particular.,I do not find an indication at this point in time to proceed with any further testing, such as coronary angiography, in the absence of symptoms.,If you have any further questions, please do not hesitate to let me know.,Thank you once again for this kind referral.,Sincerely,,Sample Doctor, M.D.","letters, cardiovascular, letter, angioedema, beta-blocker, cardiac evaluation, chest discomfort, coronary heart disease, hypertension, metabolic syndrome, therapy-controlled hypertension, truncal obesity, controlled hypertension, borderline diabetes, risk factors, heart disease, intolerance, therapy, heart, atherosclerosis, diabetes, coronary, aspirin "
 Patient seen in Neuro-Oncology Clinic because of increasing questions about what to do next for his anaplastic astrocytoma., Letters, Anaplastic Astrocytoma - Letter ,"XYZ,RE:  ABC,MEDICAL RECORD#:  123,Dear Dr. XYZ:,I saw ABC back in Neuro-Oncology Clinic today.  He comes in for an urgent visit because of increasing questions about what to do next for his anaplastic astrocytoma.,Within the last several days, he has seen you in clinic and once again discussed whether or not to undergo radiation for his left temporal lesion.  The patient has clearly been extremely ambivalent about this therapy for reasons that are not immediately apparent.  It is clear that his MRI is progressing and that it seems unlikely at this time that anything other than radiation would be particularly effective.  Despite repeatedly emphasizing this; however, the patient still is worried about potential long-term side effects from treatment that frankly seem unwarranted at this particular time.,After seeing you in clinic, he and his friend again wanted to discuss possible changes in the chemotherapy regimen.  They came in with a list of eight possible agents that they would like to be administered within the next two weeks.  They then wanted another MRI to be performed and they were hoping that with the use of this type of approach, they might be able to induce another remission from which he can once again be spared radiation.,From my view, I noticed a man whose language has deteriorated in the week since I last saw him.  This is very worrisome.  Today, for the first time, I felt that there was a definite right facial droop as well.  Therefore, there is no doubt that he is becoming symptomatic from his growing tumor.  It suggests that he is approaching the end of his compliance curve and that the things may rapidly deteriorate in the near future.,Emphasizing this once again, in addition, to recommending steroids I once again tried to convince him to undergo radiation.  Despite an hour, this again amazingly was not possible.  It is not that he does not want treatment, however.  Because I told him that I did not feel it was ethical to just put him on the radical regimen that him and his friend devised, we compromised and elected to go back to Temodar in a low dose daily type regimen.  We would plan on giving 75 mg/sq m everyday for 21 days out of 28 days.  In addition, we will stop thalidomide 100 mg/day.  If he tolerates this for one week, we then agree that we would institute another one of the medications that he listed for us.  At this stage, we are thinking of using Accutane at that point.,While I am very uncomfortable with this type of approach, I think as long as he is going to be monitored closely that we may be able to get away with this for at least a reasonable interval.  In the spirit of compromise, he again consented to be evaluated by radiation and this time, seemed more resigned to the fact that it was going to happen sooner than later.  I will look at this as a positive sign because I think radiation is the one therapy from which he can get a reasonable response in the long term.,I will keep you apprised of followups.  If you have any questions or if I could be of any further assistance, feel free to contact me.,Sincerely,","letters, neuro oncology, anaplastic astrocytoma, anaplastic, oncology, radiation, astrocytoma"
 Chiropractic IME with answers to questions from Insurance Company., Letters, Chiropractic IME - 1 ,"P.O. Box 12345,City, State ,RE: EXAMINEE : Abc,CLAIM NUMBER : 12345-67890,DATE OF INJURY : April 20, 2003,DATE OF EXAMINATION : August 26, 2003,EXAMINING PHYSICIANS : Y Z, DC,Prior to the beginning of the examination, it is explained to the examinee that this examination is intended for evaluative purposes only, and that it is not intended to constitute a general medical examination. It is explained to the examinee that the traditional doctor-patient relationship does not apply to this examination, and that a written report will be provided to the agency requesting this examination. It has also been emphasized to the examinee that he should not attempt any physical activity beyond his tolerance, in order to avoid injury.,CHIEF COMPLAINTS: , Improved focal lower back pain.,HISTORY: , Abc is a 26-year-old man who immigrated to this country approximately six years ago. He speaks ""un poquito"" English and an interpreter is provided. He has worked for the last four years at Floragon Forest Products, where he normally functions as a ""stacker."" He indicates that another worker was on vacation, and because of this he was put on another job in which he separated logs using a picaroon. He was doing this on April 20, 2003, and was pulling on the picaroon when it gave way, and he fell backwards landing on a metal step, which was approximately 1 foot off of the ground. He demonstrates that he came down square on the step and did not fall backwards or hyperextend over it. He did not hit his upper back or neck or shoulders, and only sat down on the step as described. He had ""a little"" pain in his back at that time, but was able to get up and continue working. He completed his shift that day and returned to work the following day. He had the next two days off. He says that his symptoms persisted and increased, and on April 25, 2003, he went to the First Choice Physicians Chiropractic and Rehab Clinic, where he came under the care of Dr. Abcd, DC. The file contains an entrance form completed by Mr. Abc which indicates at the bottom under ""previous occurrence of the same pain"" a notation of ""Yes, but it was not really the same, it was just a little and tolerable."" There is an additional note on the side which states ""no pain prior to this injury or on that day, occasional (but low back)."" Saw this notation, he says today that he did not state this and that the form was done by ""Edna"" at Dr. Abcd's office.,Mr. Abc was initially treated three times a week and states that this has now been reduced to twice per week. He does not know how long the chiropractic treatment is to continue. Initially, he has been seen by Dr. Xyz on three occasions, the last being on August 15, 2003. Dr. Xyz has basically referred him back to Dr. Abcd for continued chiropractic management.,Mr. Abc has now returned to his normal job as a stacker and is able to do that with no significant increased pain. He does mention, however, that bending over, picking up anything particularly heavy is bothersome; however, he does not normally have to do that. He denies any new accident or injury that would be contributory either as a result of his work or outside activities or any motor vehicle accident. He does not participate physically in any sports or hobbies that would be a factor.,PRESENT COMPLAINTS: , Mr. Abc indicates at this time that he is overall better in that initially he had difficulty ""moving."" He grades his current overall level of pain as a 2 to 4 on a scale from 0 to 10, stating that the worst he had was at 6-7. He now has ""good and bad days"" which depends on his activity level noting that he is better over the weekend. He localizes his pain to the midline lumbosacral region. He states that initially he did experience some diffuse radiation into both lower extremities, but that this has now resolved. He occasionally will notice some tightness behind both knees, but again no radicular type of distribution. He denies any focal muscular weakness or sphincter disturbance. His quality of the pain at this time is a ""tightness"" which bothers him, again, primarily with bending at the waist and lifting. He is able to do his normal activities of life, including his work without any significant problem, noting again only increased pain with bending and lifting.,PAST HISTORY: , Mr. Abc denies any prior similar complaints or treatments. He denies any previous specific lower back injury. He has enjoyed essentially good lifetime health and denies any concurrent medical conditions or problems. He has seasonal allergies only with no known drug hypersensitivities. He has not been hospitalized overnight and has had no surgeries in his life. He currently takes OTC Advil and Tylenol for lower back pain, but no prescriptive medication. He does not smoke, drink, or use street drugs of any type. Review of systems and family history are generally noncontributory.,SOCIO-ECONOMIC HISTORY: , Mr. Abc, as indicated, was born and reared in Mexico and immigrated into this country six years ago.,Education: He has our equivalent of a high school education in Mexico with no additional formal education in United States.,Military History: He has no military experience in his life.,Work History: He currently is doing his normal work activities as a stacker without arbitrary restrictions or limitations. He is not receiving any Workers Compensation or other benefits at this time.,PHYSICAL EXAMINATION: , Abc presents as a cooperative and straightforward 26-year-old Hispanic male. He has a very thin body habitus with a reported height of 5 feet 7 inches and weight of 125 pounds. He is right hand dominant. He is noted to sit comfortably throughout the history taking process conversant with the interpreter and myself without observable guarding or postural conversation or motion. He did stand readily to full upright with equal weightbearing and exhibits normal spinal posture with double hips and shoulders. Lumbar lordosis is normal. He ambulates without a limp or lift, and is able to walk on heels and toes and perform a full squat and rise and hop without difficulty with some expression of increased lower back pain. Waddell's testing is negative on compression and traction with some slight increased lower back pain on passive rotation.,Kemp's maneuver of posterolateral bending has some increased localized lumbosacral pain, but no radiation distally into the buttocks or lower extremities.,Active lumbar ranges of motion with double inclinometer are:,Flexion 70 degrees.,Extension 20 degrees.,Side bending symmetric at 28 degrees.,He complains of lower back pain at the extremes of flexion only. Motion palpation reveals full mobility without any detectable intrasegmental fixation with normal symmetry and alignment.,Tendon reflexes are 2+ and symmetric at the knees and ankles without sensory loss to pinprick. Babinski's are neutral, and there is no clonus.,Manual muscle testing reveals 5/5 strength at the hips, knees, and ankles without give-way or complaint.,Supine passive straight leg raising is limited by hamstring tightness to 66 degrees bilaterally, but causes no expression of lower back pain or radiation. Cross leg with rotation hip joint motion is full on either side without reported hip or back pain. Hip flexion is symmetric at 130 degrees, again without complaint. Leg lengths appeared visually symmetric. Mid calf girth is 11-1/2 inches bilaterally. Five inches above the knees measured 13 inches right and left. The seated SLR is done to 90 degrees, and he brings his fingertips 2 inches from his toes, showing good flexibility at the waist despite the hamstring tightness noted in the supine straight leg raising test.,In the prone position, he has good gluteal strength on either side with Yeoman's test causing some increased lumbosacral pain but no focal sacroiliac involvement. No sacroiliac fixation is identified. Hibbs test is negative on either side.,On palpation, he reports midline tenderness at L5-S1 without additional areas of tenderness noted even to very firm palpatory pressure in the entirety of the lumbar spine over the pelvis. He indicates no focal or sacroiliac, sciatic notch, or trochanteric tenderness on either side. No definitive muscular spasm is noted in the lumbar paraspinal musculature.,Mr. Abc tolerated the examination process without apparent or expressed ill effect. ,IMAGING STUDIES:,  AP and lateral lumbar/pelvic views dated May 15, 2003 are reviewed. The films are negative for recent fracture or pathology. There appears to be a transitional lumbosacral area with a spatulated transverse process of L1 and slight narrowing of the lumbosacral disc space. No additional abnormalities are identified. The hip and sacroiliac articulations appear well preserved. Disc spacing in the rest of the lumbar spine appears normal, and no significant degenerative changes are identified. Soft tissue appeared normal without paraspinal mass or abnormality.,DIAGNOSIS: , Lumbosacral contusion/strain relative to the April 20, 2003 industrial accident - objectively resolved.,SUMMARY: , Discussion and recommendations in response to questions posed in your August 15, 2003 letter:,1. What is your diagnosis of the worker's condition as a result of the injury? Please provide objective medical findings that support your diagnosis. Please indicate if the objective findings are reproducible, measurable, or observable, and how.,The diagnosis of the workers condition secondary to the described April 20, 2003 fall is by history a lumbosacral contusion/strain. This impression is primarily made based on his history noting that at this time, he has no abnormal objective findings.,2. In your opinion, is the work injury a contributing cause of the diagnosis? If so, is the work injury the material contributing cause of the diagnosis? Please provide an explanation for your opinion.,It would appear that the work injury was the major contributing cause of the diagnosis.,3. Are there any off work factors that may have caused or contributed to the worker's current complaints or condition? (Such as idiopathic causes, predisposition, congenital abnormalities, off work injuries, etc.).",
 Chiropractic IME with old files review.  Detailed Thoracic Spine Examination., Letters, Chiropractic IME - 2 ,"DATE OF INJURY : October 4, 2000,DATE OF EXAMINATION : September 5, 2003,EXAMINING PHYSICIAN : X Y, MD,Prior to the beginning of the examination, it is explained to the examinee that this examination is intended for evaluative purposes only, and that it is not intended to constitute a general medical examination. It is explained to the examinee that the traditional doctor-patient relationship does not apply to this examination, and that a written report will be provided to the agency requesting this examination. It has also been emphasized to the examinee that he should not attempt any physical activity beyond his tolerance, in order to avoid injury.,CHIEF COMPLAINT:  ,Aching and mid back pain.,HISTORY OF PRESENT INJURY: , Based upon the examinee's perspective: ,Mr. Abc is a 52-year-old self-employed, independent consultant for DEMILEE-USA. He is also a mechanical engineer. He reports that he was injured in a motor vehicle accident that occurred in October 4, 2000. At that time, he was employed as a purchasing agent for IBIKEN-USA. On the date of the motor vehicle accident, he was sitting in the right front passenger's seat, wearing seat and shoulder belt safety harnesses, in his 1996 or 1997 Volvo 850 Wagon automobile driven by his son. The vehicle was completely stopped and was ""slammed from behind"" by a van. The police officer, who responded to the accident, told Mr. Abc that the van was probably traveling at approximately 30 miles per hour at the time of impact.,During the impact, Mr. Abc was restrained in the seat and did not contact the interior surface of the vehicle. He experienced immediate mid back pain. He states that the Volvo automobile sustained approximately $4600 in damage.,He was transported by an ambulance, secured by a cervical collar and backboard to the emergency department. An x-ray of the whole spine was obtained, and he was evaluated by a physician's assistant. He was told that it would be ""okay to walk."" He was prescribed pain pills and told to return for reevaluation if he experienced increasing pain.,He returned to the Kaiser facility a few days later, and physical therapy was prescribed. Mr. Abc states that he was told that ""these things can take a long time."" He indicates that after one year he was no better. He then states that after two years he was no better and worried if the condition would never get better.,He indicates he saw an independent physician, a general practitioner, and an MRI was ordered. The MRI study was completed at ABCD Hospital. Subsequently, Mr. Abc returned and was evaluated by a physiatrist. The physiatrist reexamined the original thoracic spine x-rays that were taken on October 4, 2000, and stated that he did not know why the radiologist did not originally observe vertebral compression fractures. Mr. Abc believes that he was told by the physiatrist that it involved either T6-T7 or T7-T8.,Mr. Abc reports that the physiatrist told him that little could be done besides participation in core strengthening. Mr. Abc describes his current exercise regimen, consisting of cycling, and it was deemed to be adequate. He was told, however, by the physiatrist that he could also try a Pilates type of core exercise program.,The physiatrist ordered a bone scan, and Mr. Abc is unsure of the results. He does not have a formal follow up scheduled with Kaiser, and is awaiting re-contact by the physiatrist.,He denies any previous history of symptomatology or injuries involving his back.,CURRENT SYMPTOMS:  ,He reports that he has the same mid back pain that has been present since the original injury. It is located in the same area, the mid thoracic spine area. It is described as a pain and an ache and ranges from 3/10 to 6/10 in intensity, and the intensity varies, seeming to go in cycles. The pain has been staying constant.,When I asked whether or not the pain have improved, he stated that he was unable to determine whether or not he had experienced improvement. He indicates that there may be less pain, or conversely, that he may have developed more of a tolerance for the pain. He further states that ""I can power through it."" ""I have learned how to manage the pain, using exercise, stretching, and diversion techniques."" It is primary limitation with regards to the back pain involves prolonged sitting. After approximately two hours of sitting, he has required to get up and move around, which results in diminishment of the pain. He indicates that prior to the motor vehicle accident, he could sit for significantly longer periods of time, 10 to 12 hours on a regular basis, and up to 20 hours, continuously, on an occasional basis.,He has never experienced radiation of the pain from the mid thoracic spine, and he has never experienced radicular symptoms of radiation of pain into the extremities, numbness, tingling, or weakness.,Again, aggravating activities include prolonged sitting, greater than approximately two hours.,Alleviating activities include moving around, stretching, and exercising. Also, if he takes ibuprofen, it does seem to help with the back pain.,He is not currently taking medications regularly, but list that he takes occasional ibuprofen when the pain is too persistent.,He indicates that he received several physical therapy sessions for treatment, and was instructed in stretching and exercises. He has subsequently performed the prescribed stretching and exercises daily, for nearly three years.,With regards to recreational activities, he states that he has not limited his activities due to his back pain.,He denies bowel or bladder dysfunction.,FILES REVIEW:  ,October 4, 2000: An ambulance was dispatched to the scene of a motor vehicle accident on South and Partlow Road. The EMS crew arrived to find a 49-year-old male sitting in the front passenger seat of a vehicle that was damaged in a rear-end collision and appeared to have minimal damage. He was wearing a seatbelt and he denied loss of consciousness. He also denied a pertinent past medical history. They noted pain in the lower cervical area, mid thoracic and lumbar area. They placed him on a backboard and transported him to Medical Center.,October 4, 2000: He was seen in the emergency department of Medical Center. The provider is described as ""unknown."" The history from the patient was that he was the passenger in the front seat of a car that was stopped and rear-ended. He stated that he did not exit the car because of pain in his upper back. He reported he had been wearing the seatbelt and harness at that time. He denied a history of back or neck injuries. He was examined on a board and had a cervical collar in place. He was complaining of mid back pain. He denied extremity weakness. Sensory examination was intact. There was no tenderness with palpation or flexion in the neck. The back was a little tender in the upper thoracic spine area without visible deformity. There were no marks on the back. His x-ray was described as ""no acute bony process."" Listed visit diagnosis was a sprain-thoracic, and he was prescribed hydrocodone/acetaminophen tablets and Motrin 800 mg tablets.,October 4, 2000: During the visit, a Clinician's Report of Disability document was signed by Dr. M, authorizing time loss from October 4, 2000, through October 8, 2000. The document also advised no heavy lifting, pushing, pulling, or overhead work for two weeks. During this visit, a thoracic spine x-ray series, two views, was obtained and read by Dr. JR. The findings demonstrate no evidence of acute injury. No notable arthritic findings. The pedicles and paravertebral soft tissues appear unremarkable.,November 21, 2000: An outpatient progress note was completed at Kaiser, and the clinician of record was Dr. H. The history obtained documents that Mr. Abc continued to experience the same pain that he first noted after the accident, described as a discomfort in the mid thoracic spine area. It was non-radiating and described as a tightness. He also reported that he was hearing clicking noises that he had not previously heard. He denied loss of strength in the arms. The physical examination revealed good strength and normal deep tendon reflexes in the arms. There was minimal tenderness over T4 through T8, in an approximate area. The visit diagnosis listed was back pain. Also described in the assessment was residual pain from MVA, suspected bruised muscles. He was prescribed Motrin 800 mg tablets and an order was sent to physical therapy. Dr. N also documents that if the prescribed treatment measures were not effective, then he would suggest a referral to a physiatrist. Also, the doctor wanted him to discuss with physical therapy whether or not they thought that a chiropractor would be beneficial.,December 4, 2000: He was seen at Kaiser for a physical therapy visit by Philippe Justel, physical therapist. The history obtained from Mr. Abc is that he was not improving. Symptoms described were located in the mid back, centrally. The examination revealed mild tenderness, centrally at T3-T8, with very poor segmental mobility. The posture was described as rigid T/S in flexion. Range of motion was described as within normal limits, without pain at the cervical spine and thoracic spine. The plan listed included two visits per week for two weeks, for mobilization. It is also noted that the physical therapist would contact the MD regarding a referral to a chiropractor.,December 8, 2000: He was seen at Kaiser for a physical therapy visit by Mr. Justel. It was noted that the subjective category of the document revealed that there was no real change. It was noted that Mr. Abc tolerated the treatment well and that he was to see a chiropractor on Monday.,December 11, 2000: He presented to the Chiropractic Wellness Center. There is a form titled 'Chiropractic Case History,' and it documents that Mr. Abc was involved in a motor vehicle accident, in which he was rear-ended in October. He has had mid back pain since that time. The pain is worsened with sitting, especially at a computer. The pain decreases when he changes positions, and sometimes when he walks. Mr. Abc reports that he occasionally takes 800 mg doses of ibuprofen. He reported he went to physical therapy treatment on two occasions, which helped for a few hours only. He did report that he had a previous history of transitory low back pain.,During the visit, he completed a modified Oswestry Disability Questionnaire, and a WC/PI Subjective Complaint Form. He listed complaints of mid and low back pain of a sore and aching character. He rated the pain at grade 3-5/10, in intensity. He reported difficulty with sitting at a table, bending forward, or stooping. He reported that the pain was moderate and comes and goes.,During the visit at the Chiropractic Wellness Center, a spinal examination form was completed. It documents palpation tenderness in the cervical, thoracic, and lumbar spine area and also palpation tenderness present in the suboccipital area, scalenes, and trapezia. Active cervical range of motion measured with goniometry reveals pain and restriction in all planes. Active thoracic range of motion measured with inclinometry revealed pain and restriction in rotation bilaterally. Active lumbosacral range of motion measured with inclinometry reveals pain with lumbar extension, right lateral flexion, and left lateral flexion.,December 11, 2000: He received chiropractic manipulation treatment, and he was advised to return for further treatment at a frequency of twice a week.,December 13, 2000: He returned to the Chiropractic Wellness Center to see Joe Smith, DC, and it is documented that his middle back was better.,December 13, 2000: A personal injury patient history form is completed at the Chiropractic Wellness Center. Mr. Abc reported that on October 4, 2000, he was driving his 1996 Volvo 850 vehicle, wearing seat and shoulder belt safety harnesses, and completely stopped. He was rear-ended by a vehicle traveling at approximately 30 miles per hour. The impact threw him back into his seat, and he felt back pain and determined that it was not wise to move about. He reported approximate damage to his vehicle of $4800. He reported continuing mid and low back pain, of a dull and semi-intense nature. He reported that he was an export company manager for IBIKEN-USA, and that he missed two full days of work, and missed 10-plus partial days of work. He stated that he was treated initially after the motor vehicle accident at Kaiser and received painkillers and ibuprofen, which relieved the pain temporarily. He specifically denied ever experiencing similar symptoms.,December 26, 2000: A no-show was documented at the Chiropractic Wellness Center.,April 5, 2001: He received treatment at the Chiropractic Wellness Center. He reported that two weeks previously, his mid back pain had worsened.,April 12, 2001: He received chiropractic treatment at the Chiropractic Wellness Center.,April 16, 2001: He did not show up for his chiropractic treatment.,April 19, 2001: He did not show up for his chiropractic treatment.,April 26, 2001: He received chiropractic manipulation treatment at the Chiropractic Wellness Center. He reported that his mid back pain increased with sitting at the computer. At the conclusion of this visit, he was advised to return to the clinic as needed.,September 6, 2002: An MRI of the thoracic spine was completed at ABCD Hospital and read by Dr. RL, radiologist. Dr. D noted the presence of minor anterior compression of some mid thoracic vertebrae of indeterminate age, resulting in some increased kyphosis. Some of the mid thoracic discs demonstrate findings consistent with degenerative disc disease, without a significant posterior disc bulging or disc herniation. There are some vertebral end-plate abnormalities, consistent with small Schmorl's nodes, one on the superior aspect of T7, which is compressed anteriorly, and on the inferior aspect of T6.,May 12, 2003: He was seen at the Outpatient Clinic by Dr. L, internal medicine specialist. He was there for a health screening examination, and listed that his only complaints are for psoriasis and chronic mid back pain, which have been present since a 2000 motor vehicle accident. Mr. Abc reported that an outside MRI showed compression fractures in the thoracic spine. The history further documents that Mr. Abc is an avid skier and volunteers on the ski patrol. The physical examination revealed that he was a middle-aged Caucasian male in no acute distress. The diagnosis listed from this visit is back pain and psoriasis. Dr. L documented that he spent one hour in the examination room with the patient discussing what was realistic and reasonable with regard to screening testing. Dr. L also stated that since Mr. Abc was experiencing chronic back pain, he advised him to see a physiatrist for evaluation. He was instructed to bring the MRI to the visit with that practitioner.,June 10, 2003: He was seen at the Physiatry Clinic by Dr. R, physiatrist. The complaint listed is mid back pain. In the subjective portion of the chart note, Dr. R notes that Mr. Abc is involved in the import/export business, and that he is physically active in cycling, skiing, and gardening. He is referred by Dr. L because of persistent lower thoracic pain, following a motor vehicle accident, on October 4, 2000. Mr. Abc told Dr. R that he was the restrained passenger of a vehicle that was rear-ended at a moderate speed. He stated that he experienced immediate discomfort in his thoracic spine area without radiation. He further stated that thoracic spine x-rays were obtained at the Sunnyside Emergency Room and read as normal. It is noted that Mr. Abc was treated conservatively and then referred to physical therapy where he had a number of visits in late of 2002 and early 2003. No further chart entries were documented about the back problem until Mr. Abc complained to Dr. L that he still had ongoing thoracic spine pain during a visit the previous month. He obtained an MRI, out of pocket, at ABCD Hospital and stated that he paid $1100 for it. Dr. R asked to see the MRI and was told by Mr. Abc that he would have to reimburse or pay him $1100 first. He then told the doctor that the interpretation was that he had a T7 and T8 compression fracture. Mr. Abc reported his improvement at about 20%, compared to how he felt immediately after the accident. He described that his only symptoms are an aching pain that occurs after sitting for four to five hours. If he takes a break from sitting and walks around, his symptoms resolve. He is noted to be able to bike, ski, and be active in his garden without any symptoms at all. He denied upper extremity radicular symptoms. He denied lower extremity weakness or discoordination. He also denied bowel or bladder control or sensation issues. Dr. R noted that Mr. Abc was hostile about the Kaiser health plan and was quite uncommunicative, only reluctantly revealing his history. The physical examination revealed that he moved about the examination room without difficulty and exhibited normal lumbosacral range of motion. There was normal thoracic spine motion with good chest expansion. Neurovascular examination of the upper extremities was recorded as normal. There was no spasticity in the lower extremities. There was no tenderness to palpation or percussion up and down the thoracic spine. Dr. R reviewed the thoracic spine films and noted the presence of ""a little compression of what appears to be T7 and T8 on the lateral view."" Dr. R observed that this was not noted on the original x-ray interpretation. He further stated that the MRI, as noted above, was not available for review. Dr. R assessed that Mr. Abc was experiencing minimal thoracic spine complaints that probably related to the motor vehicle accident three years previously. The doctor further stated that ""the patient's symptoms are so mild as to almost not warrant intervention."" He discussed the need to make sure that Mr. Abc's workstation was ergonomic and that Mr. Abc could pursue core strengthening. He further recommended that Mr. Abc look into participation in a Pilates class. Mr. Abc was insistent, so Dr. R made plans to order a bone scan to further discriminate the etiology of his symptoms. He advised Mr. Abc that the bone scan results would probably not change treatment. As a result of this visit, Dr. R diagnosed thoracic spine pain (724.1) and ordered a bone scan study.",
 Letter to the patient to let him know about his abnormal cholesterol test results., Letters, Abnormal Cholesterol Result - Letter ,"ABNORMAL CHOLESTEROL RESULT LETTER,Recently you had a cholesterol test done.  The cholesterol levels were abnormal.  These are usually associated with increased risk for stroke and heart attack.  I am writing this letter to you to let you know that your levels are high enough that I think intervention is the next best step.  I would like you to make an appointment, if you are interested in treatment for this.  There are several treatment options available at this time.  Diet is one of the options, although there is limited reduction in total cholesterol and LDL cholesterol with dieting.  Most of the time under strict diet patients can achieve a 15% reduction in cholesterol.  If your cholesterol levels are moderate to severely elevated, usually diet is not the first line of therapy.  If you are diabetic or have hypertension these two also increase your risk with the combination of hypercholesterolemia.  Most of the time cholesterol that is elevated is from your genetic background and is independent of diet.  New research shows that treatment of high cholesterol can decrease your risk of developing Alzheimer’s disease.,Again, I am recommending at least we discuss medical treatment for hypercholesterolemia.  Please consider calling for a followup appointment concerning your cholesterol levels.  If you should have any further questions, please do not hesitate to contact me.  I am enclosing a copy of your lab results for your review.","letters, letter, ldl, abnormal, cholesterol, cholesterol level, cholesterol test, heart attack, hypercholesterolemia, increased risk, lab results, stroke, total cholesterol, abnormal cholesterol result, abnormal cholesterol, cholesterol levels, levels, treatment, dietNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" Specimen - Lung, left lower lobe resection.  Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma.  The tumor closely approaches the pleural surface but does not invade the pleura.", Lab Medicine - Pathology, Immunohistochemical Study ,"CLINICAL HISTORY: , Patient is a 37-year-old female with a history of colectomy for adenoma.  During her preop evaluation it was noted that she had a lesion on her chest x-ray.  CT scan of the chest confirmed a left lower mass.,SPECIMEN: , Lung, left lower lobe resection.,IMMUNOHISTOCHEMICAL STUDIES:,  Tumor cells show no reactivity with cytokeratin AE1/AE3.  No significant reactivity with CAM5.2 and no reactivity with cytokeratin-20 are seen.  Tumor cells show partial reactivity with cytokeratin-7.  PAS with diastase demonstrates no convincing intracytoplasmic mucin.  No neuroendocrine differentiation is demonstrated with synaptophysin and chromogranin stains.  Tumor cells show cytoplasmic and nuclear reactivity with S100 antibody.  No significant reactivity is demonstrated with melanoma marker HMB-45 or Melan-A.  Tumor cell nuclei (spindle cell and pleomorphic/giant cell carcinoma components) show nuclear reactivity with thyroid transcription factor marker (TTF-1).  The immunohistochemical studies are consistent with primary lung sarcomatoid carcinoma with pleomorphic/giant cell carcinoma and spindle cell carcinoma components.,FINAL DIAGNOSIS:,Histologic Tumor Type:  Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma.,Tumor Size:  2.7 x 2.0 x 1.4 cm.,Visceral Pleura Involvement:  The tumor closely approaches the pleural surface but does not invade the pleura.,Vascular Invasion:  Present.,Margins:  Bronchial resection margins and vascular margins are free of tumor.,Lymph Nodes:  Metastatic sarcomatoid carcinoma into one of four hilar lymph nodes.,Pathologic Stage:  pT1N1MX.","lab medicine - pathology, cytokeratin-20, hmb-45, melanoma, spindle cell carcinoma, tumor cells, carcinoma, immunohistochemical, lung, cytokeratin, sarcomatoid, spindle, pleural, cell, tumor,"
 Prostate adenocarcinoma and erectile dysfunction - Pathology report., Lab Medicine - Pathology, Pathology - Prostate ,"SPECIMENS:,1.  Pelvis-right pelvic obturator node.,2.  Pelvis-left pelvic obturator node.,3.  Prostate.,POST-OPERATIVE DIAGNOSIS: , Adenocarcinoma of prostate, erectile dysfunction.,DIAGNOSTIC OPINION:,1.  Adenocarcinoma, Gleason score 9, with tumor extension to periprostatic tissue, margin involvement, and tumor invasion to seminal vesicle, prostate.,2.  No evidence of metastatic carcinoma, right pelvic obturator lymph node.,3.  Metastatic adenocarcinoma, left obturator lymph node; see description.,CLINICAL HISTORY: , None listed.,GROSS DESCRIPTION:,Specimen #1 labeled ""right pelvic obturator lymph nodes"" consists of two portions of adipose tissue measuring 2.5 x 1x 0.8 cm and 2.5 x 1x 0.5 cm.  There are two lymph nodes measuring 1 x 0.7 cm and 0.5 x 0.5 cm.  The entire specimen is cut into several portions and totally embedded.,Specimen #2 labeled ""left pelvic obturation lymph nodes"" consists of an adipose tissue measuring 4 x 2 x 1 cm.  There are two lymph nodes measuring 1.3 x 0.8 cm and 1 x 0.6 cm.  The entire specimen is cut into 1 cm.  The entire specimen is cut into several portions and totally embedded.,Specimen #3 labeled ""prostate"" consists of a prostate.  It measures 5 x 4.5 x 4 cm.  The external surface shows very small portion of seminal vesicles attached in both sides with tumor induration.  External surface also shows tumor induration especially in right side.  External surface is stained with green ink.  The cut surface shows diffuse tumor induration especially in right side.  The tumor appears to extend to excision margin.  Multiple representative sections are made.,MICROSCOPIC DESCRIPTION:,Section #1 reveals lymph node.  There is no evidence of metastatic carcinoma.,Section #2 reveals lymph node with tumor metastasis in section of large lymph node as well as section of small lymph node.,Section #3 reveals adenocarcinoma of prostate.  Gleason's score 9 (5+4).  The tumor shows extension to periprostatic tissue as well as margin involvement.  Seminal vesicle attached to prostate tissue shows tumor invasion.  Dr. XXX reviewed the above case.  His opinion agrees with the above diagnosis.,SUMMARY:,A.  Adenocarcinoma of prostate, Gleason's score 9, with both lobe involvement and seminal vesicle involvement (T3b).,B.  There is lymph node metastasis (N1).,C.  Distant metastasis cannot be assessed (MX).,D.  Excision margin is positive and there is tumor extension to periprostatic tissue.","lab medicine - pathology, pelvic obturator node, erectile dysfunction, seminal vesicle, prostate, lymph node, specimen, section, adenocarcinoma of prostate, pelvic obturator, tumor, lymph, node, specimens, adenocarcinoma, "
" Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.", Lab Medicine - Pathology, Pathology - Ovarian Cyst ,"GROSS DESCRIPTION: ,  Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.  It consists of a smooth-walled, clear fluid filled cyst measuring 13x12x7 cm and weighing 1351 grams with fluid.  Both surfaces of the wall are pink-tan, smooth and grossly unremarkable.  No firm or thick areas or papillary structures are noted on the cyst wall externally or internally.  After removal the fluid, the cyst weight 68 grams.  The fluid is transparent and slightly mucoid.  A frozen section is submitted.,DIAGNOSIS: , Benign cystic ovary.,","lab medicine - pathology, right ovarian cyst, specimen, ovarian cyst, frozen section, ovarian, frozen, sectionNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" Probable right upper lobe lung adenocarcinoma.  Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".", Lab Medicine - Pathology, Lung adenocarcinoma Path Report ,"CLINICAL HISTORY:  ,Probable right upper lobe lung adenocarcinoma.,SPECIMEN: , Lung, right upper lobe resection.,GROSS DESCRIPTION:,  Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".  It consists of one lobectomy specimen measuring 16.1 x 10.6 x,4.5.cm.  The specimen is covered by a smooth, pink-tan and gray pleural surface which is largely unremarkable.  Sectioning reveals a round, ill-defined, firm, tan-gray mucoid mass.  This mass measures 3.6 x 3.3 x 2.7 cm and is located 3.7 cm from the closest surgical margin and 3.9 cm from the hilum.  There is no necrosis or hemorrhage evident.  The tumor grossly appears to abut, but not invade through, the visceral pleura, and the overlying pleura is puckered.,FINAL DIAGNOSIS:,  Right lung, upper lobe, lobectomy:  Bronchioloalveolar carcinoma, mucinous type,COMMENT:,  Right upper lobe, lobectomy.,Tumor type:  Bronchioloalveolar carcinoma, mucinous type.,Histologic grade:  Well differentiated.,Tumor size (greatest diameter):  3.6 cm.,Blood/lymphatic vessel invasion:  Absent.,Perineural invasion:  Absent.,Bronchial margin:  Negative.,Vascular margin:  Negative.,Inked surgical margin:  Negative.,Visceral pleura:  Not involved.,In situ carcinoma:  Absent.,Non-neoplastic lung:  Emphysema.,Hilar lymph nodes:  Number of positive lymph nodes:  0; Total number of lymph nodes:  1.,P53 immunohistochemical stain is negative in the tumor.","lab medicine - pathology, bronchioloalveolar carcinoma, mucinous, mucoid mass, lymph nodes, upper lobe, visceral, bronchioloalveolar, carcinoma, lymph, pleural, margin, tumor, adenocarcinoma, specimen, lobe, lung, "
" Specimen labeled ""sesamoid bone left foot"".", Lab Medicine - Pathology, Pathology - Sesamoid Bone ,"GROSS DESCRIPTION: , Specimen labeled ""sesamoid bone left foot"" is received in formalin and consists of three irregular fragments of grey-brown, hard, bony tissue admixed with multiple fragments of brown-tan, rubbery, fibrocollagenous, soft tissue altogether measuring 3.1 x 1.5 x 0.9 cm.  The specimen is entirely submitted, after decalcification.,DIAGNOSIS:,  Acute Osteomyelitis, with foci of marrow fibrosis.,Focal acute and chronic inflammation of fascia and soft tissue.  Arteriosclerosis, severely occlusive.","lab medicine - pathology, marrow fibrosis, osteomyelitis, arteriosclerosis, inflammation of fascia, specimen, fragmentsNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy., Lab Medicine - Pathology, Lung Biopsy Pathology Report - 1 ,"GROSS DESCRIPTION:,A.  Received fresh labeled with patient's name, designated 'right upper lobe wedge', is an,8.0 x 3.5 x 3.0 cm wedge of lung which has an 11.5 cm staple line.  There is a 0.8 x,0.7 x 0.5 cm sessile tumor with surrounding pleural puckering.,B.  Received fresh, labeled with patient's name, designated ""lymph node', is a 1.7 cm possible lymph node with anthracotic pigment.,C.  Received fresh labeled with patient's name, designated 'right upper lobe', is a 16.0 x,14.5 x 6.0 cm lobe of lung.  The lung is inflated with formalin.  There is a 12.0 cm staple line on the lateral surface, inked blue.  There is a 1.3 x 1.1 x 0.8 cm subpleural firm ill-defined mass, 2.2 cm from the bronchial margin and 1.5 cm from the previously described staple line.  The overlying pleura is puckered.,D.  Received fresh, labeled with patient's name, designated '4 lymph nodes', is a 2.0 x 2.0 x 2.0 cm aggregate of lymphoid material with anthracotic pigment and adipose tissue.,E.  Received fresh, labeled with patient's name, designated 'subcarinal lymph node', is a,2.0 x 1.7 x 0.8 cm aggregate of lymphoid material with anthracotic pigment .,FINAL DIAGNOSIS:,A.  Right upper lobe wedge lung biopsy:  Poorly differentiated non-small cell carcinoma.  Tumor Size:  0.8 cm.  Arterial (large vessel) invasion:  Not seen.  Small vessel (lymphatic) invasion:  Not seen.  Pleural invasion:  Not identified.  Margins of excision:  Negative for malignancy.,B.  Biopsy, 10R lymph node:  Anthracotically pigmented lymphoid tissue, negative for malignancy.,C.  Right upper lobe, lung:  Moderately differentiated non-small cell carcinoma,(adenocarcinoma).  Tumor Size:  1.3 cm.  Arterial (large vessel) invasion:  Present.  Small vessel (lymphatic) invasion:  Not seen.  Pleural invasion:  Not identified.  Margins of excision:  Negative for malignancy.,D.  Biopsy, 4R lymph nodes:  Lymphoid tissue, negative for malignancy.,E.  Biopsy, subcarinal lymph node:  Lymphoid tissue, negative for malignancy.,COMMENTS:,  Pathologic examination reveals two separate tumors in the right upper lobe.  They appear histologically distinct, suggesting they are separate primary tumors (pT1).  The right upper lobe wedge biopsy (part A) shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.  The right upper lobe carcinoma identified in the resection (part C) is a moderately differentiated adenocarcinoma with obvious gland formation.","lab medicine - pathology, lung biopsy, wedge, lobe, pathologic, lymph node', node', lymphoid, malignancy, lung, lymph, biopsy"
 Blunt trauma to the distal right thumb without fracture.  Worker’s Compensation Injury, IME-QME-Work Comp etc., Worker's Compensation Injury ,"CHIEF COMPLAINT:,  Worker’s compensation injury.,HISTORY OF PRESENT ILLNESS:,  The patient is a 21-year-old Hispanic female.  She comes in today with her boyfriend.  The patient speaks English fairly well, but her primary language is Spanish.  Her boyfriend does help to make sure that she understands what we are talking about.  The patient seems to understand our conversation fairly well.  She works at Norcraft and injured her right thumb on 09/10/2004 at 12:15 a.m.  She was pushing a cart and mashed her thumb between the cart and the wall.  This was at the finishing room in Norcraft.  She went ahead and went to work yesterday, which was the 14th, but was not able to work on the 13th.  She has swelling in her thumb.  It hurt only if it is pushed on.  It was the distal end of her thumb that was mashed.  She has not noticed any numbness or tingling or weakness.  She has not sought any treatment for this, is not taking any pain medications.  She did try soaking it in warm salt water and did not notice any improvement.,MEDICATIONS: , None.,ALLERGIES: , None.,PAST MEDICAL HISTORY:,  Possible history of chicken pox, otherwise no other medical illnesses.  She has never had any surgery.,FAMILY HISTORY: , Parents and two siblings are healthy.  She has had no children.,SOCIAL HISTORY:,  The patient is single.  She lives with her boyfriend and his father.  She works at Norcraft.  She wears seatbelt 30% of the time.  I encouraged her to use them all of the time.  She is a nonsmoker, nondrinker.,VACCINATIONS: , She thinks she got a tetanus vaccine in childhood, but does not know for sure.  She does not think she has had a tetanus booster recently.,REVIEW OF SYSTEMS:,Constitutional:  No fevers, chills, or sweats.,Neurologic:  She has had no numbness, tingling, or weakness.,Musculoskeletal:  As above in HPI.  No other difficulties.,PHYSICAL EXAMINATION:,General:  This is a well-developed, well-nourished, very pleasant Hispanic female, in no acute distress.,Vital Signs:  Weight:  121.4.  Blood pressure:  106/78.  Pulse:  64.  Respirations:  20.  Temperature:  96.,Extremities:  Examination of the right hand reveals the distal end of the thumb to be swollen especially just proximal to the nail bed.  The nail bed is pushed up.  I can see hematoma below the nail bed, although it does appear to be intact.  She has some blue fingernail polish on her nail also, but that is starting to come off.  She is able to bend her thumb normally at the DIP joint.  She has no discomfort doing that.  Sensation is intact over the entire thumb.  She has normal capillary refill.  There is some erythema and swelling noted especially over the posterior thumb just proximal to the nail bed.  I am not feeling any fluctuance.  I do not think it is a collection of pus.  There is no drainage.  She does have some small fissures in the skin where I think she did injure it with this smashing injury, but no deep lacerations at all.  It looks like there may be some mild cellulitis at the site of her injury.,LABORATORY:,  X-ray of the thumb was obtained and I do not see any sign of fracture or foreign body.,ASSESSMENT:,  Blunt trauma to the distal right thumb without fracture.  I think there is some mild cellulitis developing there.,PLAN:,1.  We will give a tetanus diphtheria booster.,2.  We will start Keflex 500 mg one p.o. q.i.d. x 7 days.  I would recommend that she can return to work, but she is not to do any work that requires the use of her right thumb.  I would like to see her back on Monday, the 20th in the morning and we can see how her thumb is doing at that time.  If she is noticing any difficulties with increased redness, increased warmth, increased pain, pus-like drainage, or any other difficulties, she is to go ahead and give us a call.  Otherwise I will be seeing her back on Monday.",
 Patient did undergo surgical intervention as related to the right knee and it was noted that the reconstruction had failed.   A screw had come loose., IME-QME-Work Comp etc., Records Review - Orthopedic ,"Thereafter, he was evaluated and it was felt that further reconstruction as related to the anterior cruciate ligament was definitely not indicated.  On December 5, 2008, Mr. XXXX did undergo a total knee replacement arthroplasty performed by Dr. X.,Thereafter, he did an extensive course of physical therapy, work hardening, and a work conditioning type program.,At the present time, he does complain of significant pain and swelling as related to the right knee.  He is unable to crawl and/or kneel.  He does state he is able to walk a city block and in fact, he is able to do 20 minutes of a treadmill.  Stairs are a significant problem.  His pain is a 5 to 6 on a scale of 1 to 10.,He is better when he is resting, sitting, propped up, and utilizing his ice.  He is much worse when he is doing any type of physical activity.,He has denied having any previous history of similar problems.,CURRENT MEDICATIONS:  ,Over-the-counter pain medication.,ALLERGIES: , NKA.,SURGERIES: , Numerous surgeries as related to the right lower extremity.,SOCIAL HISTORY: , He does admit to one half pack of cigarette consumption per day.  He denies any alcohol consumption.,PHYSICAL EXAMINATION:  ,On examination today, he is 28-year-old male who is 6 feet 1, weighs 250 pounds.  He does not appear to be in distress at this time.  One could appreciate 1-2/4 intraarticular effusion.  The range of motion is 0 to a 110 degrees of flexion.  I could not appreciate any evidence of instability medial, lateral, anterior or posterior.  Crepitus is noted with regards to range of motion testing.  His strength is 4 to 5 as related to the quadriceps and hamstring.,There is atrophy as related to the right thigh.  The patient is able to stand from a seated position and sit from a standing position without difficulty.,RECORDS REVIEW:,1.  First report of injury.,2.  July 17, 2002, x-rays of the right knee were negative.,3.  Notes of the Medina General Hospital Occupational Health, Steven Rodgers, M.D.,4.  August 5, 2002, an MRI scan of the right knee which demonstrated peripheral tear of the posterior horn of the medial",
" Lung, wedge biopsy right lower lobe and resection right upper lobe.  Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal.  PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.", Lab Medicine - Pathology, Lung Biopsy Pathology Report ,"CLINICAL HISTORY:,  A 48-year-old smoker found to have a right upper lobe mass on chest x-ray and is being evaluated for chest pain.  PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.  The lower lobe mass was approximately 1 cm in diameter and the upper lobe mass was 4 cm to 5 cm in diameter.  The patient was referred for surgical treatment.,SPECIMEN:,A.  Lung, wedge biopsy right lower lobe,B.  Lung, resection right upper lobe,C.  Lymph node, biopsy level 2 and 4,D.  Lymph node, biopsy level 7 subcarinal,FINAL DIAGNOSIS:,A.  Wedge biopsy of right lower lobe showing:  Adenocarcinoma, Grade 2, Measuring 1 cm in diameter with invasion of the overlying pleura and with free resection margin.,B.  Right upper lobe lung resection showing:  Adenocarcinoma, grade 2, measuring 4 cm in diameter with invasion of the overlying pleura and with free bronchial margin.  Two (2) hilar lymph nodes with no metastatic tumor.,C.  Lymph node biopsy at level 2 and 4 showing seven (7) lymph nodes with anthracosis and no metastatic tumor.,D.  Lymph node biopsy, level 7 subcarinal showing (5) lymph nodes with anthracosis and no metastatic tumor.,COMMENT:  ,The morphology of the tumor seen in both lobes is similar and we feel that the smaller tumor involving the right lower lobe is most likely secondary to transbronchial spread from the main tumor involving the right upper lobe.  This suggestion is supported by the fact that no obvious vascular or lymphatic invasion is demonstrated and adjacent to the smaller tumor, there is isolated nests of tumor cells within the air spaces.  Furthermore, immunoperoxidase stain for Ck-7, CK-20 and TTF are performed on both the right lower and right upper lobe nodule.  The immunohistochemical results confirm the lung origin of both tumors and we feel that the tumor involving the right lower lobe is due to transbronchial spread from the larger tumor nodule involving the right upper lobe.,","lab medicine - pathology, pet scan, wedge biopsy, morphology, lung wedge biopsy, lymph node biopsy, lymph node, lower lobe, tumor, biopsy, lobe, lung, mass, lymph, node"
 Qualified medical evaluation report of a patient with back pain., IME-QME-Work Comp etc., Qualified Medical Evaluation Report ,"HISTORY OF INJURY AND PRESENT COMPLAINTS: , The patient is a 59-year-old gentleman.  He is complaining chiefly of persistent lower back pain.  He states the pain is of a rather constant nature.  He describes it as a rather constant dull ache, sometimes rather sharp and stabbing in nature, most localized to the right side of his back more so than the left side of his lower back.  He states he has difficulty with prolonged standing or sitting.  He can only stand for about 5-10 minutes, then he has to sit down.  He can only sit for about 15-20 minutes, he has to get up and move about because it exacerbates his back pain.  He has difficulty with bending and stooping maneuvers.  He describes an intermittent radiating pain down his right leg, down from the right gluteal hip area to the back of the thigh to the calf and the foot.  He gets numbness along the lateral aspect of the foot itself.  He also describes chronic pain complaints with associated tension in the back of his neck.  He states the pain is of a constant nature in his neck.  He states he gets pain that radiates into the right shoulder girdle area and the right forearm.  He describes some numbness along the lateral aspect of the right forearm.  He states he has trouble trying to use his arm at or above shoulder height.  He has difficulty pushing, pulling, gripping, and grasping with the right upper extremity.  He describes pain at the anterior aspect of his shoulder, in particular.  He denies any headache complaints.  He is relating his above complaints to two industrial injuries that he sustained while employed with Frito Lay Company as a truck driver or delivery person.  He relates an initial injury that occurred on 06/29/1994, when apparently he was stepping out of the cab of his truck.  He lost his footing and fell.  He reached out to grab the hand railing.  He fell backwards on his back and his right shoulder.  He had immediate onset of shoulder pain, neck pain, and low back pain.  He had pain into his right leg.  He initially came under the care of Dr. H, an occupational physician in Modesto.  Initially, he did not obtain any MRIs or x-rays.  He did undergo some physical therapy and received some medications.  Dr. H referred him to Dr. Q, a chiropractor for three visits, which the patient was not certain was very helpful.  The patient advises he then changed treating physicians to Dr. N, D.C., whom he had seen previously for some back pain complaints back in 1990.  He felt that the chiropractic care was helping his back, neck, and shoulder pain complaints somewhat.  He continues with rather persistent pain in his right shoulder.  He underwent an MRI of the right shoulder performed on 08/16/1994 which revealed prominent impingement with biceps tenosynovitis as well as supraspinatus tendonitis superimposed by a small pinhole tear of the rotator cuff.  The patient was referred to Dr. P, an orthopedic surgeon who suggested some physical therapy for him and some antiinflammatories.  He felt that the patient might require a cortisone injection or possibly a surgical intervention.  The patient also underwent an MRI of the cervical spine on 08/03/1994, which again revealed multilevel degenerative disc disease in his neck.  There is some suggestion of bilateral neuroforaminal encroachment due to degenerative changes and disc bulges, particularly at C5-6 and C6-7 levels.  The patient was also seen by Dr. P, a neurologist for a Neurology consult.  It is unclear to me as to whether or not Dr. P had performed an EMG or nerve conduction studies of his upper or lower extremities.  The patient was off work for approximately six months following his initial injury date that occurred on 06/29/1994.  He returned back to regular duty.  Dr. N declared him permanent and stationary on 04/04/1995.  The patient then had a recurrence or flare-up or possibly new injury, again, particularly to his lower back while working for Frito Lay on 03/29/1997, when he was loading some pallets on the back of a trailer.  At that time, he returned to see Dr. N for chiropractic care, who is his primary treating physician.  Dr. N took him off work again.  He was off work again for approximately another six months, during which time, he was seen by Dr. M, M.D., a neurosurgeon.  He had a new MRI of his lumbar spine performed.  The MRI was performed on 05/20/1997.  It revealed L4-5 disc space narrowing with prominent disc bulge with some mild spinal stenosis.  The radiologist had noted he had a prior disc herniation at this level with some improvement from prior exam.  Dr. M saw him on 09/18/1997 and noted that there was some improvement in his disc herniation at the L4-5 level following a more recent MRI exam of 05/20/1997, from previous MRI exam of 1996 which revealed a rather prominent right-sided L4-5 disc herniation.  Dr. M felt that there was no indication for a lumbar spine surgery, but he mentioned with regards to his cervical spine, he felt that EMG studies of the right upper extremity should be obtained and he may require a repeat MRI of the cervical spine, if the study was positive.  The patient did undergo some nerve conduction studies of his lower extremities with Dr. K, M.D., which suggested a possible abnormal EMG with evidence of possible L5 radiculopathy, both right and left.  Unfortunately, I had no medical reports from Dr. P suggesting that he may have performed nerve conduction studies or EMGs of the upper and lower extremities.  The patient did see Dr. R for a neurosurgical consult.  Dr. R evaluated both his neck and lower back pain complaints on several occasions.  Dr. R suggested that the patient try some cervical epidural steroid injections and lumbar selective nerve root blocks.  The patient underwent these injections with Dr. K.  The patient reported only very slight relief temporarily with regards to his back and leg symptoms following the injections.  It is not clear from the medical record review whether the patient ever had a cervical epidural steroid injection; it appears that he had some selective nerve root blocks performed in the lumbar spine.  Dr. R on 12/15/2004 suggested that the patient had an MRI of the cervical spine revealing a right-sided C5-6 herniated nucleus pulposus which would explain his C-6 distribution numbness.  The patient also was noted to have a C4-5 with rather severe degenerative disc disease.  He felt the patient might be a candidate for a two-level ACDF at C4-5 and C5-6.  Dr. R in another report of 08/11/2004 suggested that the patient's MRI of 05/25/2004 of the lumbar spine reveals multilevel degenerative disc disease.  He had an L4-5 slight anterior spondylolisthesis, this may be a transitional vertebrae at the L6 level as well, with lumbarization of S1.  He felt that his examination suggested a possible right S1 radiculopathy with discogenic back pain.  He would suggest right-sided S1 selective nerve root blocks to see if this would be helpful; if not, he might be a candidate for a lumbar spine fusion, possibly a Dynesys or a fusion or some major spine surgery to help resolve his situation., ,The patient relates that he really prefers a more conservative approach of treatment regarding his neck, back, and right shoulder symptoms.  He continued to elect chiropractic care which he has found helpful, but apparently the insurance carrier is no longer authorizing chiropractic care for him.  He is currently taking no medications to manage his pain complaints.  He states regarding his work status, he was off work again for another six months following the 03/29/1997 injury.  He returned back to work and continued to work regular duty up until about a year ago, at which time, he was taken back off work again and placed on TTD status by Dr. N, his primary treating physician.  The patient states he has not been back to work since.  He has since applied for social security disability and now is receiving social security disability benefits.  The patient states he has tried some Myox therapy with Dr. H on 10 sessions, which he found somewhat helpful.  Overall, the patient does not feel that he could return back to his usual and customary work capacity as a delivery driver for Frito Lay.,",
 Is it BNP or BMP?, Lab Medicine - Pathology, BNP v/s BMP ,"BNP, (brain natriuretic peptide or B-type natriuretic peptide) is a substance produced in the  heart ventricles when there is excessive strain to the heart muscles.  A blood test for this can be used as an effective parameter for detecting an acute event of congestive heart failure, where the heart is unable to pump sufficient amount of blood required by the body's needs.  When a person has a heart failure (such as MI), BNP is secreted so immensely that it sits well above the measurable range.  Values above 100 signal a problematic situation and those above 500 a highly demanding state.  Note that a person with a remote history of heart problems may not have BNP levels elevated, but it is used as a measure of acute events.,On the other hand, ,BMP, or basic metabolic panel is not a single test but a group of 8 tests (glucose, calcium, sodium, potassium, bicarbonate, chloride, BUN, creatinine).  Any test that has the word panel in it is not a single test, so cannot have a single value.,With this logic in mind, if a doctor uses phrases like ""BNP/BMP is elevated/negative/positive/is greater than/less than etc."" and then a single value, it may not be BMP.  You can also take the hint from the file whether the patient presented to the hospital with an acute coronary event.  Likewise, if he says multiple values for this test, this must be BMP.,","lab medicine - pathology, brain natriuretic peptide, b-type natriuretic peptide, basic metabolic panel, glucose, calcium, sodium, potassium, bicarbonate, chloride, bun, creatinine, natriuretic peptide, bmp, bnp,"
" Records review.  The patient developed shooting pain about the right upper extremity into his hand from his elbow down to the hand.  Any type of rotation and pulling muscle did cause numbness of the middle, ring, and small finger.", IME-QME-Work Comp etc., Records Review - Epicondylitis ,"ALLOWED CONDITIONS:,  Lateral epicondylitis, right elbow,EMPLOYER:,  ABCD,REQUESTED ALLOWANCE:,  Carpal tunnel syndrome right.,Mr. XXXX is a 41-year-old male employed by ABCD as a car disassembler to make Hurst Limousines injured his right elbow on September 11, 2007, while stripping cars.  He does state he was employed for such company for the last five years.  His work includes lots of pulling, pushing, and working in weird angles.  He does state on the date of injury, he was not doing anything additional.,TREATMENT HISTORY: , Thereafter, he developed shooting pain about the right upper extremity into his hand from his elbow down to the hand.  Any type of rotation and pulling muscle did cause numbness of the middle, ring, and small finger.  He was initially seen by Dr. X on October 18, 2007, at the Occupational Health Facility.  He utilized a tennis elbow brace, but did continue to experience symptomatology into the middle, ring, and small finger.  He was placed on light duty for the next couple of months.  Mr. XXXX suffered another work injury to the right shoulder on October 11, 2007.  He did undergo arthroscopic rotator cuff repair by Dr. Y in December of 2007.  Thereafter, he continued to work in a light duty type of basis for the next few months.,An EMG and nerve conduction study was performed in December of 2008, which demonstrated evidence of carpal tunnel syndrome.  He was able to return to work doing more of a light duty type of position.,The injured worker has also seen Dr. Y once again subsequent to the EMG and nerve conduction study on December 3, 2008.  It was felt that the injured worker would benefit from decompression of the carpal tunnel and an ulnar nerve transposition.  The injured worker subsequently was placed in a no work status thereafter.,At the present time, the injured worker does complain of light tingling into the small, ring, and middle finger.  There are times when the whole hand becomes very numb.  He does not use and do any type of lifting with regards to the right hand secondary to the discomfort.  His pain does vary between a 4 on a scale of 1 to 10.  He denies any weakness.  He does not awaken at night with the symptomatology.  Doing his job is the only causation as related to the carpal tunnel syndrome and the cubital tunnel type symptoms.  He does state that he is right-handed.,In addition, he does note numbness and tingling as related to the left hand.  He has not had any type of EMG and nerve conduction study as related to the left upper extremity.,CURRENT MEDICATIONS: , None.,ALLERGIES:,  Zyrtec.,SURGERIES: , Left shoulder surgery.,SOCIAL HISTORY: , The injured worker denies tobacco or alcohol consumption.,PHYSICAL EXAMINATION:,  Healthy-appearing 41-year-old male, who is 5 feet 8 inches, weighs 205 pounds.  He does not appear to be in distress at this time.,On examination of the right upper extremity, one can appreciate no evidence of swelling, discoloration or ecchymosis.  The range of motion of the right wrist reveals flexion is 50 degrees, dorsiflexion 60 degrees, ulnar deviation 30 degrees, radial deviation 20 degrees.  Tinel's and Phalen's tests were positive.  Reverse Phalen's test was negative.  There is diminished sensation in distribution of the thumb, index, middle, and ring finger.  The intrinsic function did appear to be intact.  The injured worker does not demonstrate any evidence of difficulties as related to extension of the middle, ring, and index finger as related to the elbow.  The range of motion of the right elbow reveals flexion 140 degrees, extension 0 degrees, pronation and supination 80 degrees.  Tinel's test is negative as related to the elbow and the ulnar nerve.,There is noted to be satisfactory strength as related to major motor groups of the right upper extremity.,RECORDS REVIEW:  ,1.  First report of injury, difficulty as related to both hands.,2.  Number of notes of Occupational Health Clinic.  It was felt that the injured worker did indeed suffer from median nerve entrapment at the wrist and ulnar nerve entrapment at the right elbow with the associated right lateral epicondylitis.,3.  December 20, 2007, operative note of Dr. Y.  At which time, the injured worker underwent arthroscopic rotator cuff repair, subacromial decompression, partial synovectomy of the anterior compartment, limited debridement of the partial superior-sided subscapularis tear without evidence of subacromial impingement.,4.  November 17, 2008, EMG and nerve conduction study, which demonstrated moderate right median neuropathy plus carpal tunnel syndrome.,ASSESSMENT: , Please state your opinion for the following questions based upon your review of the enclosed medical records on January 23, 2009, examination of the claimant.,Please indicate whether the restriction given on December 3, 2008, is the result of the allowed condition of lateral epicondylitis.,It should be noted on physical examination that the symptomatology as related to the lateral epicondylitis have very much resolved as of January 23, 2009.  Resisted extension of the middle finger and wrist do not cause any pain about the lateral epicondylar region.  It also should be noted that really there is no significant weakness as related to the function of the right upper extremity.  Also noted is there is an absence of tenderness as related to the lateral epicondylar region.,QUESTION:  ,Has the claimant reached maximum medical improvement for the allowed conditions of lateral epicondylitis? Please explain.,ANSWER:  ,Based upon the examination on January 23, 2009, the injured worker has indeed reached maximum medical improvement as related to the diagnosis of lateral epicondylitis.  This is based upon review of the medical records, evidence-based medicine, and the Official Disability Guidelines.,QUESTION:  ,Please indicate whether the allowed condition of lateral epicondylitis has temporarily and totally disabled the claimant from December 8, 2008 through February 1, 2009, and continuing.  Please explain.,ANSWER:  ,There is insufficient medical evidence and it is my opinion to state that the allowed condition of lateral epicondylitis is not temporarily and totally disabling the claimant from December 8, 2008 through February 1, 2009, and continuing.  As mentioned the symptomatology referable to the lateral epicondylar region has very much resolved based upon the examination performed on January 23, 2009.,QUESTION:  ,If it is your opinion that the claimant is temporarily and totally disabled due to allowed condition of lateral epicondylitis, please indicate what treatment the claimant must undergo in order to achieve a plateau of maximum medical improvement.  Please also give an estimated time for maximum medical improvement.,ANSWER:  ,The injured worker has indeed reached maximum medical improvement as related to the elbow.  There is no question that the injured worker is not temporarily and totally disabled due to the allowed condition of lateral epicondylitis.  At the time of the exam, the injured worker has indeed reached maximum medical improvement as related to lateral epicondylitis as described previously.,QUESTION:  ,Is the claimant suffering from carpal tunnel syndrome, right?",
 Occupational medicine consult with questions-answers and records review., IME-QME-Work Comp etc., Occupational Medicine Consult - 3 ,"ALLOWED CONDITIONS:,  Sprain of left knee and leg.,CONTESTED CONDITION:,  Left knee tear medial meniscus, left knee ACL tear.,EMPLOYER:,  YYYY,REQUESTING PARTY:,  XXXX,Mr. XXXXXX is a xx-year-old male who was evaluated for an independent medical examination on September 20, 2007, because of an injury sustained to the left leg.  The injured worker does state that he was working as a processor for the ABCD Company on July 18, 2007, when he injured his left knee.  He does state he was working in a catwalk when he stepped up.  He noticed his sight glass was not open on the tank.  He then stepped straight down and his knee went sideways.  His knee popped and he sat down secondary to discomfort.  At that time he could not do any type of activity secondary to the pain.  The nurse called the ambulance subsequent to this injury and he was taken to Bethesda North.  X-rays were obtained which demonstrated no evidence of fracture.  Thereafter, he was referred to X who he saw on July 19, 2007.  It was felt that a MRI scan about the knee needed to be obtained and it was obtained on July 24.  It was noted that there was evidence of an anterior cruciate ligament tear and a slight medial meniscal tear.  On his second visit, it was felt that arthroscopic surgery intervention was indicated as related to the left knee.,On September 7, 2007, he underwent surgical intervention at ABC for the anterior cruciate reconstruction as well as the partial medial meniscectomy.,At the present time, he is progressing along with physical therapy.  He is utilizing one crutch.,He does admit to significant bruising and swelling about the left lower extremity.  If he does indeed move too fast, the discomfort is increased.  His pain about the left knee is approximately 6 to 7 on a scale of 1 to 10.,He has had injuries to the right knee in which he wrecked his bicycle and did have some type of fracture bone spur when he was 13 years of age.,He underwent arthroscopic surgery as related to the right knee at that time and really did quite well.,His next appointment with Dr. X is on October 4, 2007.,The injured worker denies any previous history of similar problems as related to the left knee.,MEDICATIONS: , Glucophage, Lipitor, Actos, Benicar, glimepiride, and Januvia.,SURGICAL HISTORY:,  Arthroscopic surgery of the left knee and arthroscopic surgery of the right knee.,SOCIAL HISTORY:,  The patient denies alcohol consumption.  He does smoke approximately one and a half packs of cigarettes per day.  His education is that of 12th grade.,PHYSICAL EXAMINATION: , This is a healthy appearing 34-year-old male who is 5 feet 9 inches and weighs 285 pounds.  He does not appear to be in distress at this time.  Examination is limited to the left knee.  One could appreciate a healed scar as related to the inferior pole inferior to the patella.  There are healed arthroscopic scars as well.  The range of motion of left knee reveals 50 to 70 degrees of flexion.  There is evidence of medial and lateral joint line discomfort.  Anterior Lachman's test was negative.  No evidence of atrophy is noted.  There is weakness with aggressive function about the quadriceps and hamstring musculature.,The patient is ambulating with one crutch at this time.,There is mild degree of swelling as related to the left knee.  Deep tendon reflexes are +2/+2 bilaterally symmetrical.  Sensory examination was normal as related to the foot, but abnormal as related to the left knee.,I did review pictures that were taken at the time of the surgery, which demonstrates the meniscectomy and the anterior cruciate ligament reconstruction.,MEDICAL RECORDS REVIEW:,1.  July 18, 2007, x-rays of the left knee demonstrated evidence of a small suprapatellar joint effusion.  It should be noted that the exam demonstrated evidence of medial and lateral joint line discomfort.  There was specific mention of intraarticular effusion.,2.  On July 27, 2007, MRI scan of the left knee was obtained, which demonstrated evidence of the complete tear of the mid to distal ACL.  Findings suggestive of a chronic injury.  Grade I sprain of the MCL was noted.  Contusion __________ plateau medial femoral condyle and lateral femoral condyle was noted.  There was evidence of a small peripheral longitudinal tear of the posterior horn of medial meniscus.  Chondromalacia of the lateral femoral condyle and patella was noted.  It should be noted that the changes of degeneration of the cartilages of the injured worker's knee and the chronic anterior cruciate ligament changes were noted related to the July 18, 2007, injury.,3.  July 18, 2007, first report of injury, occupational disease, and/or death.,4.  Evaluations of ABCD Hospital.  It should be noted that the mechanism of injury was such that he was walking down the stairs when his left knee locked up.,5.  July 18, 2007, x-rays of the left knee were obtained, which demonstrated the evidence of no acute fracture or significant osteoarthritis.  There is evidence there maybe a small suprapatellar joint effusion.,6.  Notes from the office of Dr. X. It should be noted on physical examination his range of motion is 8 to 20 degrees.,7.  Physical therapy prescription for __________ Orthopedics and Sports Medicine Corporation.,8.  August 10, 2007, requests for arthroscopic anterior cruciate ligament reconstruction with patellar tendon.,9.  Physician narrative of August 24, 2007.  It is noted that the injured worker did indeed have evidence of hypertension, hyperlipidemia, and diabetes.  His BMI was 42.  This was felt __________ pre-injury MRI scan.,Following your review of the medical information and your physical examination, please answer the following questions as these pertain to the allowed conditions.  Please express your opinion based upon a reasonable degree of medical probability.,QUESTION: ,Mr. XXXXXX has filed an application for the additional allowance of left knee tear of the medial meniscus and left knee ACL tear.,Based on the current objective findings, mechanism of injury, or and medical records or diagnosis studies, does the medical evidence support the existence of any of the requested conditions.,ANSWER: ,The MRI sustains and verifies that these conditions do indeed exist subsequent to the injury of July 18, 2007.,QUESTION: ,If you find any of these conditions exist, are they a direct and proximate result of the July 18, 2007, injury.,ANSWER: ,There is mention of degeneration as related to the knee prior to this episode.  This is not surprising considering the individual's weight.  There is no question degeneration as related to anterior cruciate ligament and the meniscus has been occurring for a lengthy period of time.  There has been an aggravation of this condition.  Without having a MRI to review prior to this injury, I believe, it would be safe to assume that there has been aggravation of a pre-existing condition as related to the left knee and __________ meniscal and anterior cruciate ligament pathology.  Thus there is definitely evidence of an aggravation of a pre-existing condition but not necessarily a direct and proximate result of the July 18, 2007, injury.,QUESTION: ",
" Right shoulder impingement syndrome, right suprascapular neuropathy.", IME-QME-Work Comp etc., Impairment Rating ,"CHIEF COMPLAINT: , Right shoulder pain.,HISTORY: , The patient is a pleasant, 31-year-old, right-handed, white female who injured her shoulder while transferring a patient back on 01/01/02.  She formerly worked for Veteran's Home as a CNA.  She has had a long drawn out course of treatment for this shoulder.  She tried physical therapy without benefit and ultimately came to a subacromion decompression in November 2002.  She had ongoing pain and was evaluated by Dr. X who felt that she had a possible brachial plexopathy.  He also felt she had a right superficial radial neuritis and blocked this with resolution of her symptoms.  He then referred her to ABCD who did EMG testing, demonstrating a right suprascapular neuropathy although a C5 radiculopathy could not be ruled out.  MRI testing on the cervical spine was then done which was negative for disk herniation and she underwent suprascapular nerve decompression of the scapular notch on 12/18/03.  She finally went to an anterior axillary nerve block because of ongoing pain in the anterior shoulder again by Dr. X.  She comes to me for impairment rating.  She has no chronic health problems otherwise, fevers, chills, or general malaise.  She is not working.  She is right-hand dominant.  She denies any prior history of injury to her shoulder.,PAST MEDICAL HISTORY:,  Negative aside from above.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:  ,Please see above.,REVIEW OF SYSTEMS:,  Negative aside from above.,PHYSICAL EXAMINATION:  ,A pleasant, age appropriate woman, moderately overweight, in no apparent distress.  Normal gait and station, normal posture, normal strength, tone, sensation and deep tendon reflexes with the exception of 4+/5 strength in the supraspinatus musculature on the right.  She has decreased motion in the right shoulder as follows.  She has 160 degrees of flexion, 155 degrees of abduction, 35 degrees of extension, 25 degrees of adduction, 45 degrees of internal rotation and 90 degrees of external rotation.  She has a positive impingement sign on the right.,ASSESSMENT:,  Right shoulder impingement syndrome, right suprascapular neuropathy.,DISCUSSION: , With a reasonable degree of medical certainty, she is at maximum medical improvement and she does have an impairment based on AMA Guide to the Evaluation of Permanent Impairment, Fifth Edition.  The reason for this impairment is the incident of 01/01/02.  For her suprascapular neuropathy, she is rated as a grade IV motor deficit which I rate as a 13% motor deficit.  This is multiplied by a maximum upper extremity impairment for involvement of the suprascapular nerve of 16% which produces a 2% impairment of the upper extremity when the two values are multiplied together, 2% impairment of the upper extremity.  For her lack of motion in the shoulder she also has additional impairment on the right.  She has a 1% impairment of the upper extremity due to lack of shoulder flexion.  She has a 1% impairment of the upper extremity due to lack of shoulder abduction.  She has a 1% impairment of the upper extremity due to lack of shoulder adduction.  She has a 1% impairment of the upper extremity due to lack of shoulder extension.  There is no impairment for findings in shoulder external rotation.  She has a 3% impairment of the upper extremity due to lack of shoulder internal rotation.  Thus the impairment due to lack of motion in her shoulder is a 6% impairment of the upper extremity.  This combines with the 2% impairment of the upper extremity due to weakness in the suprascapular nerve root distribution to produce an 8% impairment of the upper extremity which in turn is a 5% impairment of the whole person based on the AMA Guide to the Evaluation of Permanent Impairment, Fifth Edition, stated with a reasonable degree of medical certainty.","ime-qme-work comp etc., ama guide, evaluation of permanent impairment, impairment rating, permanent impairment, suprascapular nerve, suprascapular neuropathy, injured, extremity, shoulder, impairment, neuropathy, suprascapular,"
 Occupational medicine consult with questions-answers and records review., IME-QME-Work Comp etc., Occupational Medicine Consult - 2 ,"ALLOWED CONDITIONS:,  726.31 right medial epicondylitis; 354.0 right carpal tunnel syndrome.,CONTESTED CONDITIONS:,  354.2 right cubital tunnel syndrome.,EMPLOYER:,  ABCD,  ,I examined Xxxxx today for the allowed conditions and also the contested conditions listed above.  I obtained her history from company medical records and performed an examination.  She is a 38-year-old laborer who states that she was injured on April 26, 2006, which according to the FROI (the injury occurred over a period of time from performing normal job processes such as putting bumpers on cars, gas caps and doors on cars).  She denies having any symptoms prior to the accident April 26, 2006.  She is right handed.  She used a tennis elbow brace, hand exercises, physical therapy, and Vicodin.  She received treatment from Dr. X and also Dr. Y,DIAGNOSTIC STUDIES:,  June 27, 2006, EMG and nerve conduction velocity right upper extremity showed a moderate right carpal tunnel syndrome.  No evidence of a right cervical radiculopathy or ulnar neuropathy at the wrist or elbow.  January 29, 2007, EMG right upper extremity was normal and there was a normal nerve conduction velocity.  At the time of the examination, she complained of a constant pain in the olecranon and distal triceps with tingling in the right long, ring and small fingers, and night pain.  The pain was accentuated by gripping or opening the jar.  She is taking four Aleve a day and currently does not have any other treatment.,RECORDS REVIEWED: , Injury and illness incident report, US Healthworks records; Z physician review; Y office notes; X office notes who noted that on examination of the right elbow that the ulnar nerve subluxed with flexion and extension of the elbow.,EXAMINATION: , Examination of her right elbow revealed no measurable atrophy of the upper arm.  She was markedly tender over the medial epicondyle, but also the olecranon and distal process and she was exquisitely tender over the ulnar nerve.  I did not detect subluxation of the ulnar nerve with flexion and extension.  With this, she was extremely tender in this area.  There is no instability of the elbow.  Range of motion was 0 to 145 degrees, flexion 90 degrees of pronation and supination.  The elbow flexion test was positive.  There is normal motor power in the elbow and also on the right hand, specifically in the ulnar intrinsics.  There was diminished sensation on the right ring and small fingers, specifically the ulnar side of the ring finger of the entire small finger.  There was no wasting of the intrinsics.  No clawing of the hand.  Examination of the right wrist revealed extension 45 degrees, flexion 45 degrees, radial deviation 15 degrees, and ulnar deviation 35 degrees.  She was tender over the dorsum of the hand over the ulnar head and the volar aspect of the wrist.  Wrist flexion causes paresthesias on the right ring and small fingers.  Grasp was weak.  There was no sign of causalgia, but no measurable atrophy of the forearm.  No reflex changes.,QUESTION:,  Ms. Xxxxx has filed an application of additional allowance of right cubital tunnel syndrome.  Based on the current objective findings, mechanism of injury, medical records or diagnostic studies, does the medical evidence support the existence of the requested condition?,ANSWER:,  Yes.  She has a positive elbow flexion test and she is markedly tender over the ulnar nerve at the elbow and also has diminished sensation in the ulnar nerve distribution, specifically in the entire right small finger and the ulnar half of the ring finger.  I did not find the subluxation of the ulnar nerve with flexion and extension with Dr. X did previously find on his examination.,QUESTION: , If you find these conditions exist, are they a direct and proximate result of April 26, 2006, injury?,ANSWER: , Yes.  Repeated flexion and extension would irritate the ulnar nerve particularly if it was subluxing which it could very well have which Dr. X objectively identified on his examination.  Therefore, I believe it is a direct and proximate result of April 26, 2006, injury.,QUESTION: , Do you find that Ms. Xxxxx's injury or disability is caused by natural deterioration of tissue, organ or part of the body?,ANSWER: , No.,QUESTION:,  In addition, if you find that the condition exists, are there non-occupational activities or intervening injuries that could have contributed to Ms. Xxxxx's condition?,ANSWER: , It is possible that direct injury to the ulnar nerve at the elbow could cause this syndrome; however, there is no history of this and the records do not indicate an injury of this type.,QUESTION: ,",
 Occupational medicine consult with questions-answers., IME-QME-Work Comp etc., Occupational Medicine Consult - 1 ,"ALLOWED CONDITIONS:,  Left knee strain, meniscus tear left knee.,CONTESTED CONDITION:,  Osteoarthritis of the left knee.,EMPLOYER:,  ABCD.,I examined Xxxxx today September 14, 2007, for the above allowed conditions and also the contested condition of osteoarthritis of his left knee.  He is a 57-year-old assembly worker who was injured on June 13, 2007, which according to his FROI was due to ""repairing cars, down on knees to work on concrete floors.""  In addition, he slipped on an air hose on the floor at work on March 7, 2007, re-injuring his left knee.  He developed pain and swelling in his left knee.  He denies having any difficulties with his left knee prior to the injury of June 13, 2002.,DIAGNOSTIC STUDIES: , August 2, 2002, MRI of the left knee showed low-grade chondromalacia of the left patellofemoral joint space and a posterior horn tear of the medial meniscus, likely degenerative in nature, and also grade II to III chondromalacia of the medial joint space.  On June 26, 2007, MRI of his left knee was referred to in the injury management report of June 19, 2007, as showing osteoarthritis of the medial compartment has advanced.  He brought with him copies of x-rays taken July 16, 2007, of his left knee, which I reviewed and which showed marked narrowing of the medial compartment of his left knee with spurs on the margins of the joint medially and also spurs on the patella.  There was subluxation of the tibia on the femur with standing.,After his injury, he received treatment from Dr. X for patellofemoral syndrome with knee sleeve.  He also received treatment from Dr. Y also for left knee sprain and patellar pain.  He also did exercise, does use a knee sleeve and Aleve.  On December 5, 2002, he underwent arthroscopy of the left knee by Dr. Z who did a partial resection of a torn medial meniscus.  He also noticed grade III chondromalacia of the patella as well as the torn medial meniscus.  He states that he was asymptomatic until he slipped on an air hose while at work on March 7, 2007, and again developed pain and swelling in his left knee.  Standing aggravates his pain.  He has had one injection of cortisone by Dr. Z about a month ago, which has helped his pain.  He takes one hydrocodone 7.5/750 mg daily.,Examination of his left knee revealed there was bilateral varus deformity, healed arthroscopy incisional scars, there was a 1/2 atrophy of the left calf.  There was patellar crepitus with knee motion.  There was no motor weakness or reflex changes.  He walked without a limp and could stand on his heels and toes equally well.  There was no instability of the knee and no effusion.  Range of motion was 0 to 120 degrees.,QUESTION: , Xxxxx has recently filed to reactivate this claim.  Please give me your opinion as to whether Xxxxx's current clinical presentation is related to the industrial injury stated above.,ANSWER:, Yes.  His original MRI of August 2, 2002, did show low-grade chondromalacia of the patellofemoral joint and also grade II to III chondromalacia of the medial joint space, which was the beginning of osteoarthritis.  Also, it is well known that torn medial meniscus can result in osteoarthritis of the knee; therefore, the osteoarthritis is related to his original injury of June 13, 2007, specifically to the torn medial meniscus.,QUESTION:  ,Do I believe that claim #123 should be reactivated to allow for treatment of the allowed conditions as stated?,ANSWER:, Yes, I believe it should be reactivated to allow treatment of the contested condition of osteoarthritis of his left knee.,QUESTION:,  Xxxxx has filed an application for additional allowance of osteoarthritis of the left knee.  Based on the current objective findings, mechanism of injury, medical records, and diagnostic studies, does the medical evidence support the existence of the requested condition?,ANSWER: ,Yes.  Please see the discussion in the answer to question no one.  In addition, x-rays of July 16, 2007, do reveal medial compartment and patellofemoral compartment osteoarthritis of the left knee.,QUESTION: , If you find this condition exists, is it a direct and proximate result of the June 13, 2002, injury?,ANSWER:, Yes.  See discussion in answer to question number one.,QUESTION: , Do you find that Xxxxx's injury or disability was caused by the natural deterioration of tissue, an organ or part of body?,ANSWER: ,No.  I believe the osteoarthritis was the result of the torn medial meniscus as discussed under question number one.,QUESTION: , In addition, if you find the condition exists, are there non-occupational activities or intervening injuries, which could have contributed to Xxxxx's condition?,ANSWER:, No.  He does not give any history of any intervening injuries.,If you opine the requested condition should be additionally recognized, please include the condition as an allowed condition in the discussion of the following questions.,QUESTION:,  Based on the objective findings is the request for 10 sessions of physical therapy per C-9 dated July 27, 2007, medically necessary and appropriate for the allowed conditions of the claim of osteoarthritis of left knee?,ANSWER:,  Yes.,",
 Work restrictions and disability evaluation , IME-QME-Work Comp etc., Permanent & Stationary Report ,"PRESENT COMPLAINTS: , The patient is reporting ongoing, chronic right-sided back pain, pain that radiates down her right leg intermittently.  She is having difficulty with bending and stooping maneuvers.  She cannot lift heavy objects.  She states she continues to have pain in her right neck and pain in her right upper extremity.  She has difficulty with pushing and pulling and lifting with her right arm.  She describes an intermittent tingling sensation in the volar aspect of her right hand.  She states she has diminished grip strength in her right hand because of wrist pain complaints.  She states that the Wellbutrin samples I had given her previously for depression seem to be helping.  Her affect appears appropriate.  She reports no suicidal ideation.  She states she continues to use Naprosyn as an anti-inflammatory, Biofreeze ointment over her neck and shoulder and back areas of complaints.  She also takes Imitrex occasionally for headache complaints related to her neck pain.  She also takes Flexeril occasionally for back spasms and Darvocet for pain.  She is asking for a refill on some of her medications today.  She is relating a VAS pain score regarding her lower back at a 6-7/10 and regarding her neck about 3/10, and regarding her right upper extremity about a 4/10., ,PHYSICAL EXAMINATION: , She is afebrile.  Blood pressure is 106/68, pulse of 64, respirations of 20.  Her physical exam is unchanged from 03/21/05.  Her orthopedic exam reveals full range of motion of the cervical spine.  Cervical compression test is negative.  Valsalva's maneuver is negative.  Hoffmann's sign is negative.  DTRs are +1 at the biceps, brachioradialis and trapezius bilaterally.  Her sensation is grossly intact to the upper extremity dermatomes.  Motor strength appears 5/5 strength in the upper extremity muscle groups tested.,Phalen's and Tinel's signs are negative at both wrists.  Passive range of motion of the right wrist is painful for her.  Passive range of motion of the left wrist is non painful.  Active range of motion of both wrists and hands are full.  She is right hand dominant.  Circumferential measurements were taken in her upper extremities.  She is 11"" in the right biceps, 10 1/2"" in the left biceps.  She is 9 3/4"" in both right and left forearms.  Circumferential measurements were also taken of the lower extremities.  She is 21"" at both the right and left thighs, 15"" in both the right and left calves.  Jamar dynamometry was assessed on three tries in this right-hand-dominant individual.  She is 42/40/40 pounds on the right hand with good effort, and on the left is 60/62/60 pounds, suggesting a loss of at least 20% to 25% pre-injury grip strength in the right dominant hand.  , ,Examination of her lumbar trunk reveals decreased range of motion, flexion allowing her fingertips about 12"" from touching the floor.  Lumbar extension is to 30 degrees.  The right SLR is limited to about 80 degrees, provoking back pain, with a positive Bragard's maneuver, causing pain to radiate to the back of the thigh.  The left SLR is to 90 degrees without back pain.  DTRs are +1 at the knees and ankles.  Toes are downgoing to plantar reflexes bilaterally.  Sensation is grossly intact in the lower extremity dermatomes.  Motor strength appears 5/5 strength in the lower extremity muscle groups tested., ,IMPRESSION: , (1)  Sprain/strain injury to the lumbosacral spine with lumbar disc herniation at L5-S1, with radicular symptoms in the right leg. (2)  Cervical sprain/strain with myofascial dysfunction. (3)  Thoracic sprain/strain with myofascial dysfunction. (4)  Probable chronic tendonitis of the right wrist.  She has negative nerve conduction studies of the right upper extremity. (5)  Intermittent headaches, possibly migraine component, possibly cervical tension cephalalgia-type headaches or cervicogenic headaches., ,TREATMENT / PROCEDURE: , I reviewed some neck and back exercises. , ,RX:, I dispensed Naprosyn 500 mg b.i.d. as an anti-inflammatory.  I refilled Darvocet N-100, one tablet q.4-6 hours prn pain, #60 tablets, and Flexeril 10 mg t.i.d. prn spasms, #90 tablets, and dispensed some Wellbutrin XL tablets, 150-mg XL tablet q.a.m., #30 tablets., ,PLAN / RECOMMENDATIONS:,  I told the patient to continue her medication course per above.  It seems to be helping with some of her pain complaints.  I told her I will pursue trying to get a lumbar epidural steroid injection authorized for her back and right leg symptoms.  I told her in my opinion I would declare her Permanent and Stationary as of today, on 04/18/05 with regards to her industrial injuries of 05/16/03 and 02/10/04.  , ,I understand her industrial injury of 05/16/03 is related to an injury at Home Depot where she worked as a credit manager.  She had a stack of screen doors fall, hitting her on the head, weighing about 60 pounds, knocking her to the ground.  She had onset of headaches and neck pain, and pain complaints about her right upper extremity.  She also has a second injury, dated 02/10/04, when apparently a co-worker was goofing around and apparently kicked her in the back accidentally, causing severe onset of back pain.  , ,FACTORS FOR DISABILITY:,OBJECTIVE:  ,1.  She exhibits decreased range of motion in the lumbar trunk.,2.  She has an abnormal MRI revealing a disc herniation at L5-S1.,3.  She exhibits diminished grip strength in the right arm and upper extremity., ,SUBJECTIVE: ,1.  Based on her headache complaints alone, would be considered occasional and minimal to slight at best. ,2.  With regards to her neck pain complaints, these would be considered occasional and slight at best. ,3.  Regarding her lower back pain complaints, would be considered frequent and slight at rest, with an increase to a moderate level of pain with repetitive bending and stooping and heavy lifting, and prolonged standing. ,4.  Regarding her right upper extremity and wrist pain complaints, these would be considered occasional and slight at rest, but increasing to slight to moderate with repetitive gripping, grasping, and torquing maneuvers of her right upper extremity. ,LOSS OF PRE-INJURY CAPACITY: , The patient advises that prior to her industrial dates of injury she was capable of repetitively bending and stooping and lifting at least 60 pounds.  She states she now has difficulty lifting more than 10 or 15 pounds without exacerbating back pain.  She has trouble trying to repetitively push or pull, torque, twist and lift with the right upper extremity, due to wrist pain, which she did not have prior to her industrial injury dates.  She also relates headaches, which she did not have prior to her industrial injury.  , ,WORK RESTRICTIONS AND DISABILITY: , I would find it reasonable to place some permanent restrictions on this patient.  It is my opinion she has a disability precluding heavy work, which contemplates the individual has lost approximately half of her pre-injury capacity for performing such activities as bending, stooping, lifting, pushing, pulling and climbing or other activities involving comparable physical effort.  The patient should probably no lift more than 15 to 20 pounds maximally.  She should probably not repetitively bend or stoop.  She should avoid repetitive pushing, pulling or torquing maneuvers, as well as gripping and grasping maneuvers of the right hand.  She should probably not lift more than 10 pounds repetitively with the right upper extremity.  I suspect that prior to her industrial she could lift repetitively and push, pull, torque and twist at least 20 to 25 pounds with the right upper extremity.  , ,CAUSATION AND APPORTIONMENT:, With regards to issues of causation, they appear appropriate to her industrial injuries and histories given per the 05/16/03 and the 02/10/04 injuries., ,With regards issues of apportionment, it is my opinion that 100% of her pain complaints are industrially related to her industrial injuries of 05/16/03 and 02/10/04.  There does not appear to be any apportionable issues here.",
" Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.", IME-QME-Work Comp etc., Major Depressive Disorder - IME Consult ,"IDENTIFYING DATA:  ,Mr. T is a 45-year-old white male.,CHIEF COMPLAINT: , Mr. T presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.  His confidence and self-esteem are significantly low.  He stated he has excessive somnolence, his energy level is extremely low, motivation is low, and he has a lack for personal interests.  He has had suicidal ideation, but this is currently in remission.  Furthermore, he continues to have hopeless thoughts and crying spells.  Mr. T stated these symptoms appeared approximately two months ago.,HISTORY OF PRESENT ILLNESS: , On March 25, 2003, Mr. T was fired from his job secondary, to an event at which he stated he was first being harassed by another employee."" This other, employee had confronted Mr. T with a very aggressive, verbal style, where this employee had placed his face directly in front of Mr. T was spitting on him, and called him ""bitch."" Mr. T then retaliated, and went to hit the other employee.  Due to this event, Mr. T was fired.  It should be noted that Mr. T stated he had been harassed by this individual for over a year and had reported the harassment to his boss and was told to ""deal with it."",There are no other apparent stressors in Mr. T's life at this time or in recent months.  Mr. T stated that work was his entire life and he based his entire identity on his work ethic.  It should be noted that Mr. T was a process engineer for Plum Industries for the past 14 years.,PAST PSYCHIATRIC HISTORY:,  There is no evidence of any psychiatric hospitalizations or psychiatric interventions other than a recent visit to Mr. T's family physician, Dr. B at which point Mr. T was placed on Lexapro with an unknown dose at this time.  Mr. T is currently seeing Dr. J for psychotherapy where he has been in treatment since April, 2003.,PAST PSYCHIATRIC REVIEW OF SYSTEMS:,  Mr. T denied any history throughout his childhood, adolescence, and early adulthood for depressive, anxiety, or psychotic disorders.  He denied any suicide attempts, or profound suicidal or homicidal ideation.  Mr. T furthermore stated that his family psychiatric history is unremarkable.,SUBSTANCE ABUSE HISTORY:,  Mr. T stated he used alcohol following his divorce in 1993, but has not used it for the last two years.  No other substance abuse was noted.,LEGAL HISTORY: , Currently, charges are pending over the above described incident.,MEDICAL HISTORY: , Mr. T denied any hospitalizations, surgeries, or current medications use for any heart disease, lung disease, liver disease, kidney disease, gastrointestinal disease, neurological disease, closed head injury, endocrine disease, infectious, blood or muscles disease other than stating he has a hiatal hernia and hypercholesterolemia.,PERSONAL AND SOCIAL HISTORY: , Mr. T was born in Dwyne, Missouri, with no complications associated with his birth.  Originally, he was raised by both parents, but they separated at an early age.  When he was about seven years old, he was raised by his mother and stepfather.  He did not sustain a relationship with his biological father from that time on.  He stated his parents moved a lot, and because this many times he was picked on in his new environments, Mr. T stated he was, at times, a rebellious teenager, but he denied any significant inability to socialize, and denied any learning disabilities or the need for special education.,Mr. T stated his stepfather was somewhat verbally abusive, and that he committed suicide when Mr. T was 18 years old.  He graduated from high school and began work at Dana Corporation for two to three years, after which he worked as an energy, auditor for a gas company.  He then became a homemaker while his wife worked for Chrysler for approximately two years.  Mr. T was married for eleven years, and divorced in 1993.  He has a son who is currently 20 years old.  After being a home maker, Mr. T worked for his mother in a restaurant, and moved on from there to work for Borg-Warner corporation for one to two years before beginning at Plum Industries, where he worked for 14 years and worked his way up to lead engineer.,Mental Status Exam:  Mr. T presented with a hyper vigilant appearance, his eye contact was appropriate to the interview, and his motor behavior was tense.  At times he showed some involuntary movements that would be more akin to a resting tremor.  There was no psychomotor retardation, but there was some mild psychomotor excitement.  His speech was clear, concise, but pressured.  His attitude was overly negative and his mood was significant for moderate depression, anxiety, anhedonia and loneliness, and mild evidence of anger.  There was no evidence of euphoria or diurnal mood variation.  His affective expression was restricted range, but there was no evidence of lability.  At times, his affective tone and facial expressions were inappropriate to the interview.  There was no evidence of auditory, visual, olfactory, gustatory, tactile or visceral hallucinations.  There was no evidence of illusions, depersonalizations, or derealizations.  Mr. T presented with a sequential and goal directed stream of thought.  There was no evidence of incoherence, irrelevance, evasiveness, circumstantiality, loose associations, or concrete thinking.  There was no evidence of delusions; however, there was some ambivalence, guilt, and self-derogatory thoughts.  There was evidence of concreteness for similarities and proverbs.  His intelligence was average.  His concentration was mildly impaired, and there was no evidence of distractibility.  He was oriented to time, place, person and situation.  There was no evidence of clouded consciousness or dissociation.  His memory was intact for immediate, recent, and remote events.,He presented with poor appetite, easily fatigued, and decreased libidinal drive, as well as excessive somnolence.  There was a moderate preoccupation with his physical health pertaining to his headaches.  His judgment was poor for finances, family relations, social relations, employment, and, at this time, he had no future plans.  Mr. T's insight is somewhat moderate as he is aware of his contribution to the problem.  His motivation for getting well is good as he accepts offered treatment, complies with recommended treatment, and seeks effective treatments.  He has a well-developed empathy for others and capacity for affection.,There was no evidence of entitlement, egocentricity, controllingness, intimidation, or manipulation.  His credibility seemed good.  There was no evidence for potential self-injury, suicide, or violence.  The reliability and completeness of information was very good, and there were no barriers to communication.  The information gathered was based on the patient's self-report and objective testing and observation.  His attitude toward the examiner was neutral and his attitude toward the examination process was neutral.  There was no evidence for indices of malingering as there was no marked discrepancy between claimed impairment and objective findings, and there was no lack of cooperation with the evaluation or poor compliance with treatment, and no evidence of antisocial personality disorder.,IMPRESSIONS: , Major Depressive Disorder, single episode,RECOMMENDATIONS AND PLAN: , I recommend Mr. T continue with psychopharmacologic care as well as psychotherapy.  At this time, the excessive amount of psychiatric symptoms would impede Mr. T from seeking employment.  Furthermore, it appears that the primary precipitating event had occurred on March 25, 2003, when Mr. T was fired from his job after being harassed for over a year.  As Mr. T placed his entire identity and sense of survival on his work, this was a deafening blow to his psychological functioning.  Furthermore, it only appears logical that this would precipitate a major depressive episode.","ime-qme-work comp etc., muscle tremor, headaches, excessive nervousness, poor concentration, independent medical evaluation, psychopharmacologic, poor ability to focus, major depressive disorder, tremor, depressive, psychiatric, "
" A male presents complaining of some right periscapular discomfort, some occasional neck stiffness, and some intermittent discomfort in his low back relative to an industrial fall.", IME-QME-Work Comp etc., IME & Record Review - Orthopedic ,"INTRODUCTION: , The opinions expressed in this report are those of the physician.  The opinions do not reflect the opinions of Evergreen Medical Panel, Inc.  The claimant was informed that this examination was at the request of the Washington State Department of Labor and Industries (L&I).  The claimant was also informed that a written report would be sent to L&I, as requested in the assignment letter from the claims manager.  The claimant was also informed that the examination was for evaluative purposes only, intended to address specific injuries or conditions as outlined by L&I, and was not intended as a general medical examination.,CHIEF COMPLAINTS: , This 51-year-old married male presents complaining of some right periscapular discomfort, some occasional neck stiffness, and some intermittent discomfort in his low back relative to an industrial fall that occurred on November 20, 2008.,HISTORY OF INDUSTRIAL INJURY:,  This patient was injured on November 20, 2008.  He works at the Purdy Correctional Facility and an inmate had broken some overhead sprinklers, the floor was thus covered with water and the patient slipped landing on the back of his head, then on his back.  The patient said he primarily landed on the left side.  After the accident he states that he was generally stun and someone at the institute advised him to be evaluated.  He went to a Gig Harbor urgent care facility and they sent him on to Tacoma General Hospital.  At the Tacoma General, he indicates that a whiplash and a concussion were diagnosed and it was advised that he have a CT scan.  The patient describes that he had a brain CT and a dark spot was found.  It was recommended that he have a followup MRI and this was done locally and showed a recurrent acoustic neuroma.  Before, when the patient initially had developed an acoustic neuroma, the chiropractor had seen the patient and suggested that he have a scan and this was how his original acoustic neuroma was diagnosed back in October 2005.  The patient has been receiving adjustments by the chiropractor since and he also has had a few massage treatments.  Overall his spine complaints have improved substantially.,After the fall, he also saw at Prompt Care in the general Bremerton area, XYZ, an Osteopathic Physician and she examined him and released him full duty and also got an orthopedic consult from XYZ.  She ordered an MRI of his neck.  Cervically this showed that he had a mild disc bulge at C4-C5, but this actually was the same test that diagnosed a recurrent acoustic neuroma and the patient now is just recovering from neurosurgical treatment for this recurrent acoustic neuroma and some radiation is planned.,Since 2002 the patient has been seeing the chiropractor, XYZ for general aches and pain and this has included some treatments on his back and neck.,CURRENT SYMPTOMS:  ,The patient describes his current pain as being intermittent.,PAST MEDICAL HISTORY:,Illnesses:  The patient had a diagnosis in 2005 of an acoustic neuroma.  It was benign, but treated neurosurgically.  In February 2004 and again in August 2009 he has had additional treatments for recurrence and he currently has some skull markers in place because radiation is planned as a followup, although the tumor was still indicated to be benign.,Operations:  He has a history of an old mastoidectomy.  He has a past history of removal of an acoustic neuroma in 2005 as noted.,Medications:  The patient takes occasional Tylenol and occasional Aleve.,Substance Use:,Tobacco:  He does not smoke cigarettes.,Alcohol:  He drinks about five beers a week.,FAMILY HISTORY:,  His father died of mesothelioma and his mother died of Lou Gehrig's disease.,SOCIOECONOMIC HISTORY:,Marital Status and Dependents:  The patient has been married three times; longest marriage is of two years duration.  He has two children.  These dependents are ages 15 and twins and are his wife's dependents.,Education:  The patient has bachelor's degree.,Military History:  He served six years in the army and received an honorable discharge.,Work History:  He has worked at Purdy Correctional Institute in Gig Harbor for 19 years.,CHART REVIEW: , Review of the chart indicates a date of injury of November 20, 2008.  He was seen at Tacoma General Hospital with a diagnosis of head contusion and cervical strain.  He had a CT of his head done because of a fall with possible loss of consciousness, which showed a left cerebellar hypodensity and further evaluation was recommended.  He has a history of an old mastoidectomy.  He was then seen on November 24, 2008 by XYZ at Prompt Care on November 24, 2008.  There is no clearcut history that he had lost consciousness.  He has a past history of removal of an acoustic neuroma in 2005 as noted.  A diagnosis of concussion and cervical strain status post fall was made along with an underlying history of abnormal CT and previous resection of an acoustic neuroma.  Some symptoms of loss of balance and confusion were noted.  She recommended additional testing and neurologic evaluation.,The notes from the treating chiropractor begin on November 24, 2008.  Adjustments are given to the cervical, thoracic, and lumbar spine.,He was seen back by XYZ on December 9, 2008 and he had been released to full duties.  It was recognized the new MRI suggested recurrence of the acoustic neuroma and he was advised to seek further care in this regard.  There were some concerns of his feeling of being wobbly since the fall which might be related to the recurrent neuroma.  He continued to have chiropractic adjustments.  He was seen back at Prompt Care on January 8, 2009.  Dr. X indicated that she thought most of his symptoms were related to the tumor, but that the cervical and thoracic stiffness were from the fall.,A followup note by his chiropractor on January 26, 2009 indicates that cervical x-rays have been taken and that continued chiropractic adjustments along with manual traction would be carried out.,On April 13, 2009, he was seen again at Prompt Care for his cervical and thoracic strain.  He was indicated to be improving and there was suggestion that he has some physical therapy and an orthopedic consult was felt appropriate.  Therapy was not carried out and obviously was then involved with the treatment of his recurrent neuroma.,On April 17, 2009, he was seen by Dr. X, another chiropractor for consultation and further chiropractic treatments were recommended based on cervical and thoracolumbar subluxation complexes and strain.,A repeat consult was carried out on April 29, 2009 by XYZ.  He felt that this was hyperextension cervical injury.  It might take a period of time to recover.  He mentioned that the patient might have a slight ulnar neuropathy.  He felt the patient was capable of full duty and the patient was at that time having ongoing treatment for his neuroma.,This concludes the chart review.,PHYSICAL EXAMINATION: , The patient is 6 feet in height, weighs 255 pounds.,Orthopedic Examination:  He can walk with a normal gait, but he has, as indicated, a positive Romberg test and he himself has noticed that if he closes his eyes he loses his balance.  Overall the patient is a seemingly good historian.  There is a visible 3 cm scar at the left base of the neck near the hairline and there are multiple areas where his head has been shaved both anteriorly and posteriorly.  These are secondary to drawing for the skull markers.  There is a scar behind the patient's left ear from the original treatment of the acoustic neuroma.  This was well healed.  The patient can perform a toe-heel gait without difficulty.  One visibly can see that he has some facial asymmetry and he indicates that the acoustic neuroma has caused some numbness in the left side of his face and also some asymmetry that is now recovering.  The patient states he now thinks his recovery is going to get disregarded and that the facial asymmetry and numbness developed from the first surgery he had.  The patient has a full range of motion in both of his shoulders.  The patient has a full range of motion in his lumbar spine to include 90 degrees of forward bend, lateral bending of 30 degrees in either direction and extension of 10 degrees.  There is full range of motion in the patient's cervical spine to include flexion of 50 degrees at which time he can touch his chin on his chest.  He extends 40 degrees, laterally bends 30 degrees, and rotates to 80 degrees in either direction.  There is slight tenderness on palpating over the right cervical musculature.  There is no evidence of any cervical or lumbar muscle spasms.  Reflexes in the upper extremities include 1+ biceps and triceps and 1+ brachioradialis.  Knee jerks are 2+ and ankle jerks are 1+.  Tinel's test was tested at the elbow, it is negative bilaterally with percussion; however, he has slight tingling bilaterally.  The patient's grip tested with a Jamar dynamometer increases from 70 to 80 pounds bilaterally.  Sensory testing of lower extremities reveal that the patient has slightly decreased sensation to sharp stimulus in his dorsal aspect of the right first toe and a lesser extent to the left.  Testing of muscle strength in the upper and lower extremities is normal.  The patient upper arms measured four fingerbreadths above the flexion crease of the elbow measure 35 cm bilaterally.  The forearms measured four fingerbreadths below the flexion crease of the elbow measure 30 cm bilaterally.  The thighs measured four fingerbreadths above the superior pole of the patella measure 48 cm and the lower legs measured four fingerbreadths below the tibial tubercles measure 41 cm.  Pressure on the vertex of the head does not bother the patient.  Axial loading is negative.  As already indicated straight leg raising is entirely negative both sitting and lying for any radiculitis.,DIAGNOSTIC STUDIES: , X-rays the patient brings with him taken by his treating chiropractor dated 11/24/08 showed that there appears to be a little bit of narrowing of the L4-5 disc space.  The hip joints are normal.  Views of his thoracic spine are normal.  Cervical x-rays are in the file.  These are of intermittent quality, but the views do show a very slight degree of anterior spurring at the C4-5 with possible slight narrowing of the disc.  There is a view of the right shoulder that is unremarkable.,CONCLUSIONS:,  The accepted condition under the claim is a sprain of the neck, thoracic, and lumbar.,DIAGNOSES: , Diagnosis based on today's examination is a sprain of the cervical spine and lumbar spine superimposed upon some early degenerative changes.,Additional diagnosis is one of recurrent acoustic neuroma, presumably benign with upcoming additional treatment of radiation plan.  The patient also has a significant degree overweight for his height and it will be improved as he himself recognizes by some weight loss and exercise.,DISCUSSION: , He is fixed and stable at this time and his industrial case can be closed relative to his industrial injury of November 20, 2008.  Further chiropractic treatments would be entirely palliative and serve no additional medical purpose due to the fact that he has very minimal symptoms and a basis for these symptoms based on mild or early degenerative changes in both cervical and lumbar spine.  He is category I relative to the cervical spine under 296-20-240 and category I to the lumbosacral spine under WAC 296-20-270.  His industrial case should be closed and there is, as indicated, no basis for any disability award.",
 Occupational medicine consult with questions-answers and records review., IME-QME-Work Comp etc., Occupational Medicine Consult ,"ALLOWED CONDITION: , Right shoulder sprain and right rotator cuff tear (partial).,CONTESTED CONDITION:,  AC joint arthrosis right aggravation.,DISALLOWED CONDITION: ,",
 Chiropractic IME with old files review.  Detailed Thoracic Spine Examination., IME-QME-Work Comp etc., Chiropractic IME - 2 ,"DATE OF INJURY : October 4, 2000,DATE OF EXAMINATION : September 5, 2003,EXAMINING PHYSICIAN : X Y, MD,Prior to the beginning of the examination, it is explained to the examinee that this examination is intended for evaluative purposes only, and that it is not intended to constitute a general medical examination. It is explained to the examinee that the traditional doctor-patient relationship does not apply to this examination, and that a written report will be provided to the agency requesting this examination. It has also been emphasized to the examinee that he should not attempt any physical activity beyond his tolerance, in order to avoid injury.,CHIEF COMPLAINT:  ,Aching and mid back pain.,HISTORY OF PRESENT INJURY: , Based upon the examinee's perspective: ,Mr. Abc is a 52-year-old self-employed, independent consultant for DEMILEE-USA. He is also a mechanical engineer. He reports that he was injured in a motor vehicle accident that occurred in October 4, 2000. At that time, he was employed as a purchasing agent for IBIKEN-USA. On the date of the motor vehicle accident, he was sitting in the right front passenger's seat, wearing seat and shoulder belt safety harnesses, in his 1996 or 1997 Volvo 850 Wagon automobile driven by his son. The vehicle was completely stopped and was ""slammed from behind"" by a van. The police officer, who responded to the accident, told Mr. Abc that the van was probably traveling at approximately 30 miles per hour at the time of impact.,During the impact, Mr. Abc was restrained in the seat and did not contact the interior surface of the vehicle. He experienced immediate mid back pain. He states that the Volvo automobile sustained approximately $4600 in damage.,He was transported by an ambulance, secured by a cervical collar and backboard to the emergency department. An x-ray of the whole spine was obtained, and he was evaluated by a physician's assistant. He was told that it would be ""okay to walk."" He was prescribed pain pills and told to return for reevaluation if he experienced increasing pain.,He returned to the Kaiser facility a few days later, and physical therapy was prescribed. Mr. Abc states that he was told that ""these things can take a long time."" He indicates that after one year he was no better. He then states that after two years he was no better and worried if the condition would never get better.,He indicates he saw an independent physician, a general practitioner, and an MRI was ordered. The MRI study was completed at ABCD Hospital. Subsequently, Mr. Abc returned and was evaluated by a physiatrist. The physiatrist reexamined the original thoracic spine x-rays that were taken on October 4, 2000, and stated that he did not know why the radiologist did not originally observe vertebral compression fractures. Mr. Abc believes that he was told by the physiatrist that it involved either T6-T7 or T7-T8.,Mr. Abc reports that the physiatrist told him that little could be done besides participation in core strengthening. Mr. Abc describes his current exercise regimen, consisting of cycling, and it was deemed to be adequate. He was told, however, by the physiatrist that he could also try a Pilates type of core exercise program.,The physiatrist ordered a bone scan, and Mr. Abc is unsure of the results. He does not have a formal follow up scheduled with Kaiser, and is awaiting re-contact by the physiatrist.,He denies any previous history of symptomatology or injuries involving his back.,CURRENT SYMPTOMS:  ,He reports that he has the same mid back pain that has been present since the original injury. It is located in the same area, the mid thoracic spine area. It is described as a pain and an ache and ranges from 3/10 to 6/10 in intensity, and the intensity varies, seeming to go in cycles. The pain has been staying constant.,When I asked whether or not the pain have improved, he stated that he was unable to determine whether or not he had experienced improvement. He indicates that there may be less pain, or conversely, that he may have developed more of a tolerance for the pain. He further states that ""I can power through it."" ""I have learned how to manage the pain, using exercise, stretching, and diversion techniques."" It is primary limitation with regards to the back pain involves prolonged sitting. After approximately two hours of sitting, he has required to get up and move around, which results in diminishment of the pain. He indicates that prior to the motor vehicle accident, he could sit for significantly longer periods of time, 10 to 12 hours on a regular basis, and up to 20 hours, continuously, on an occasional basis.,He has never experienced radiation of the pain from the mid thoracic spine, and he has never experienced radicular symptoms of radiation of pain into the extremities, numbness, tingling, or weakness.,Again, aggravating activities include prolonged sitting, greater than approximately two hours.,Alleviating activities include moving around, stretching, and exercising. Also, if he takes ibuprofen, it does seem to help with the back pain.,He is not currently taking medications regularly, but list that he takes occasional ibuprofen when the pain is too persistent.,He indicates that he received several physical therapy sessions for treatment, and was instructed in stretching and exercises. He has subsequently performed the prescribed stretching and exercises daily, for nearly three years.,With regards to recreational activities, he states that he has not limited his activities due to his back pain.,He denies bowel or bladder dysfunction.,FILES REVIEW:  ,October 4, 2000: An ambulance was dispatched to the scene of a motor vehicle accident on South and Partlow Road. The EMS crew arrived to find a 49-year-old male sitting in the front passenger seat of a vehicle that was damaged in a rear-end collision and appeared to have minimal damage. He was wearing a seatbelt and he denied loss of consciousness. He also denied a pertinent past medical history. They noted pain in the lower cervical area, mid thoracic and lumbar area. They placed him on a backboard and transported him to Medical Center.,October 4, 2000: He was seen in the emergency department of Medical Center. The provider is described as ""unknown."" The history from the patient was that he was the passenger in the front seat of a car that was stopped and rear-ended. He stated that he did not exit the car because of pain in his upper back. He reported he had been wearing the seatbelt and harness at that time. He denied a history of back or neck injuries. He was examined on a board and had a cervical collar in place. He was complaining of mid back pain. He denied extremity weakness. Sensory examination was intact. There was no tenderness with palpation or flexion in the neck. The back was a little tender in the upper thoracic spine area without visible deformity. There were no marks on the back. His x-ray was described as ""no acute bony process."" Listed visit diagnosis was a sprain-thoracic, and he was prescribed hydrocodone/acetaminophen tablets and Motrin 800 mg tablets.,October 4, 2000: During the visit, a Clinician's Report of Disability document was signed by Dr. M, authorizing time loss from October 4, 2000, through October 8, 2000. The document also advised no heavy lifting, pushing, pulling, or overhead work for two weeks. During this visit, a thoracic spine x-ray series, two views, was obtained and read by Dr. JR. The findings demonstrate no evidence of acute injury. No notable arthritic findings. The pedicles and paravertebral soft tissues appear unremarkable.,November 21, 2000: An outpatient progress note was completed at Kaiser, and the clinician of record was Dr. H. The history obtained documents that Mr. Abc continued to experience the same pain that he first noted after the accident, described as a discomfort in the mid thoracic spine area. It was non-radiating and described as a tightness. He also reported that he was hearing clicking noises that he had not previously heard. He denied loss of strength in the arms. The physical examination revealed good strength and normal deep tendon reflexes in the arms. There was minimal tenderness over T4 through T8, in an approximate area. The visit diagnosis listed was back pain. Also described in the assessment was residual pain from MVA, suspected bruised muscles. He was prescribed Motrin 800 mg tablets and an order was sent to physical therapy. Dr. N also documents that if the prescribed treatment measures were not effective, then he would suggest a referral to a physiatrist. Also, the doctor wanted him to discuss with physical therapy whether or not they thought that a chiropractor would be beneficial.,December 4, 2000: He was seen at Kaiser for a physical therapy visit by Philippe Justel, physical therapist. The history obtained from Mr. Abc is that he was not improving. Symptoms described were located in the mid back, centrally. The examination revealed mild tenderness, centrally at T3-T8, with very poor segmental mobility. The posture was described as rigid T/S in flexion. Range of motion was described as within normal limits, without pain at the cervical spine and thoracic spine. The plan listed included two visits per week for two weeks, for mobilization. It is also noted that the physical therapist would contact the MD regarding a referral to a chiropractor.,December 8, 2000: He was seen at Kaiser for a physical therapy visit by Mr. Justel. It was noted that the subjective category of the document revealed that there was no real change. It was noted that Mr. Abc tolerated the treatment well and that he was to see a chiropractor on Monday.,December 11, 2000: He presented to the Chiropractic Wellness Center. There is a form titled 'Chiropractic Case History,' and it documents that Mr. Abc was involved in a motor vehicle accident, in which he was rear-ended in October. He has had mid back pain since that time. The pain is worsened with sitting, especially at a computer. The pain decreases when he changes positions, and sometimes when he walks. Mr. Abc reports that he occasionally takes 800 mg doses of ibuprofen. He reported he went to physical therapy treatment on two occasions, which helped for a few hours only. He did report that he had a previous history of transitory low back pain.,During the visit, he completed a modified Oswestry Disability Questionnaire, and a WC/PI Subjective Complaint Form. He listed complaints of mid and low back pain of a sore and aching character. He rated the pain at grade 3-5/10, in intensity. He reported difficulty with sitting at a table, bending forward, or stooping. He reported that the pain was moderate and comes and goes.,During the visit at the Chiropractic Wellness Center, a spinal examination form was completed. It documents palpation tenderness in the cervical, thoracic, and lumbar spine area and also palpation tenderness present in the suboccipital area, scalenes, and trapezia. Active cervical range of motion measured with goniometry reveals pain and restriction in all planes. Active thoracic range of motion measured with inclinometry revealed pain and restriction in rotation bilaterally. Active lumbosacral range of motion measured with inclinometry reveals pain with lumbar extension, right lateral flexion, and left lateral flexion.,December 11, 2000: He received chiropractic manipulation treatment, and he was advised to return for further treatment at a frequency of twice a week.,December 13, 2000: He returned to the Chiropractic Wellness Center to see Joe Smith, DC, and it is documented that his middle back was better.,December 13, 2000: A personal injury patient history form is completed at the Chiropractic Wellness Center. Mr. Abc reported that on October 4, 2000, he was driving his 1996 Volvo 850 vehicle, wearing seat and shoulder belt safety harnesses, and completely stopped. He was rear-ended by a vehicle traveling at approximately 30 miles per hour. The impact threw him back into his seat, and he felt back pain and determined that it was not wise to move about. He reported approximate damage to his vehicle of $4800. He reported continuing mid and low back pain, of a dull and semi-intense nature. He reported that he was an export company manager for IBIKEN-USA, and that he missed two full days of work, and missed 10-plus partial days of work. He stated that he was treated initially after the motor vehicle accident at Kaiser and received painkillers and ibuprofen, which relieved the pain temporarily. He specifically denied ever experiencing similar symptoms.,December 26, 2000: A no-show was documented at the Chiropractic Wellness Center.,April 5, 2001: He received treatment at the Chiropractic Wellness Center. He reported that two weeks previously, his mid back pain had worsened.,April 12, 2001: He received chiropractic treatment at the Chiropractic Wellness Center.,April 16, 2001: He did not show up for his chiropractic treatment.,April 19, 2001: He did not show up for his chiropractic treatment.,April 26, 2001: He received chiropractic manipulation treatment at the Chiropractic Wellness Center. He reported that his mid back pain increased with sitting at the computer. At the conclusion of this visit, he was advised to return to the clinic as needed.,September 6, 2002: An MRI of the thoracic spine was completed at ABCD Hospital and read by Dr. RL, radiologist. Dr. D noted the presence of minor anterior compression of some mid thoracic vertebrae of indeterminate age, resulting in some increased kyphosis. Some of the mid thoracic discs demonstrate findings consistent with degenerative disc disease, without a significant posterior disc bulging or disc herniation. There are some vertebral end-plate abnormalities, consistent with small Schmorl's nodes, one on the superior aspect of T7, which is compressed anteriorly, and on the inferior aspect of T6.,May 12, 2003: He was seen at the Outpatient Clinic by Dr. L, internal medicine specialist. He was there for a health screening examination, and listed that his only complaints are for psoriasis and chronic mid back pain, which have been present since a 2000 motor vehicle accident. Mr. Abc reported that an outside MRI showed compression fractures in the thoracic spine. The history further documents that Mr. Abc is an avid skier and volunteers on the ski patrol. The physical examination revealed that he was a middle-aged Caucasian male in no acute distress. The diagnosis listed from this visit is back pain and psoriasis. Dr. L documented that he spent one hour in the examination room with the patient discussing what was realistic and reasonable with regard to screening testing. Dr. L also stated that since Mr. Abc was experiencing chronic back pain, he advised him to see a physiatrist for evaluation. He was instructed to bring the MRI to the visit with that practitioner.,June 10, 2003: He was seen at the Physiatry Clinic by Dr. R, physiatrist. The complaint listed is mid back pain. In the subjective portion of the chart note, Dr. R notes that Mr. Abc is involved in the import/export business, and that he is physically active in cycling, skiing, and gardening. He is referred by Dr. L because of persistent lower thoracic pain, following a motor vehicle accident, on October 4, 2000. Mr. Abc told Dr. R that he was the restrained passenger of a vehicle that was rear-ended at a moderate speed. He stated that he experienced immediate discomfort in his thoracic spine area without radiation. He further stated that thoracic spine x-rays were obtained at the Sunnyside Emergency Room and read as normal. It is noted that Mr. Abc was treated conservatively and then referred to physical therapy where he had a number of visits in late of 2002 and early 2003. No further chart entries were documented about the back problem until Mr. Abc complained to Dr. L that he still had ongoing thoracic spine pain during a visit the previous month. He obtained an MRI, out of pocket, at ABCD Hospital and stated that he paid $1100 for it. Dr. R asked to see the MRI and was told by Mr. Abc that he would have to reimburse or pay him $1100 first. He then told the doctor that the interpretation was that he had a T7 and T8 compression fracture. Mr. Abc reported his improvement at about 20%, compared to how he felt immediately after the accident. He described that his only symptoms are an aching pain that occurs after sitting for four to five hours. If he takes a break from sitting and walks around, his symptoms resolve. He is noted to be able to bike, ski, and be active in his garden without any symptoms at all. He denied upper extremity radicular symptoms. He denied lower extremity weakness or discoordination. He also denied bowel or bladder control or sensation issues. Dr. R noted that Mr. Abc was hostile about the Kaiser health plan and was quite uncommunicative, only reluctantly revealing his history. The physical examination revealed that he moved about the examination room without difficulty and exhibited normal lumbosacral range of motion. There was normal thoracic spine motion with good chest expansion. Neurovascular examination of the upper extremities was recorded as normal. There was no spasticity in the lower extremities. There was no tenderness to palpation or percussion up and down the thoracic spine. Dr. R reviewed the thoracic spine films and noted the presence of ""a little compression of what appears to be T7 and T8 on the lateral view."" Dr. R observed that this was not noted on the original x-ray interpretation. He further stated that the MRI, as noted above, was not available for review. Dr. R assessed that Mr. Abc was experiencing minimal thoracic spine complaints that probably related to the motor vehicle accident three years previously. The doctor further stated that ""the patient's symptoms are so mild as to almost not warrant intervention."" He discussed the need to make sure that Mr. Abc's workstation was ergonomic and that Mr. Abc could pursue core strengthening. He further recommended that Mr. Abc look into participation in a Pilates class. Mr. Abc was insistent, so Dr. R made plans to order a bone scan to further discriminate the etiology of his symptoms. He advised Mr. Abc that the bone scan results would probably not change treatment. As a result of this visit, Dr. R diagnosed thoracic spine pain (724.1) and ordered a bone scan study.",
" Patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI.  The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion.", Hospice - Palliative Care, Lung Cancer & MI - Hospice Cosult ,"REASON FOR CONSULT: , I was asked to see this patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI.,HISTORY OF PRESENT ILLNESS: , The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion.  Her daughter who accompanies her is very attentive whom I had met previously during drainage of a malignant hemorrhagic pericardial effusion last month.  The patient has been feeling well for the last several weeks, per the daughter, but today per the personal aide, became agitated and uncomfortable at about 2:30 p.m.  At about 7 p.m., the patient began vomiting, was noted to be short of breath by her daughter with garbled speech, arms flopping, and irregular head movements.  Her daughter called 911 and her symptoms seemed to improve.  Then, she began vomiting.  When the patient's daughter asked her if she had chest pain, the patient said yes.,She came to the emergency room, an EKG showed inferior ST-elevation MI.  I was called immediately and knowing her history, especially, her hospice status with recent hemorrhagic pericardial effusion, I felt thrombolytic was contraindicated and she would not be a candidate for aggressive interventional therapy with PCI/CABG.  She was begun after discussion with the oncologist, on heparin drip and has received morphine, nitro, and beta-blocker, and currently states that she is pain free.  Repeat EKG shows normalization of her ST elevation in the inferior leads as well as normalization of prior reciprocal changes.,PAST MEDICAL HISTORY: , Significant for metastatic non-small-cell lung cancer.  In early-to-mid December, she had an admission and was found to have a malignant pericardial effusion with tamponade requiring urgent drainage.  We did repeat an echo several weeks later and that did not show any recurrence of the pericardial effusion.  She is on hospice from the medical history, atrial fibrillation, hypertension, history of multiple CVA.,MEDICATIONS: , Medications as an outpatient:,1.  Amiodarone 200 mg once a day.,2.  Roxanol concentrate 5 mg three hours p.r.n. pain.,ALLERGIES:  ,CODEINE.  NO SHRIMP, SEAFOOD, OR DYE ALLERGY.,FAMILY HISTORY: , Negative for cardiac disease.,SOCIAL HISTORY: , She does not smoke cigarettes.  She uses alcohol.  No use of illicit drugs.  She is divorced and lives with her daughter.  She is a retired medical librarian from Florida.,REVIEW OF SYSTEMS:  ,Unable to be obtained due to the patient's aphasia.,PHYSICAL EXAMINATION: , Height 5 feet 3, weight of 106 pounds, temperature 97.1 degrees, blood pressure ranges from 138/82 to 111/87, pulse 61, respiratory rate 22.  O2 saturation 100%.  On general exam, she is an elderly woman with now marked aphasia, which per her daughter waxes and wanes, was more pronounced and she nods her head up and down when she says the word, no, and conversely, she nods her head side-to-side when she uses the word yes with some discordance in her head gestures with vocalization.  HEENT shows the cranium is normocephalic and atraumatic.  She has dry mucosal membrane.  She now has a right facial droop, which per her daughter is new.  Neck veins are not distended.  No carotid bruits visible.  Skin:  Warm, well perfused.  Lungs are clear to auscultation anteriorly.  No wheezes.  Cardiac exam:  S1, S2, regular rate.  No significant murmurs.  PMI is nondisplaced.  Abdomen:  Soft, nondistended.  Extremities:  Without edema, on limited exam.  Neurological exam seems to show only the right facial droop.,DIAGNOSTIC/LABORATORY DATA: , EKGs as reviewed above.  Her last ECG shows normalization of prior ST elevation in the inferior leads with Q waves and first-degree AV block, PR interval 280 milliseconds.  Further lab shows sodium 135, potassium 4.2, chloride 98, bicarbonate 26, BUN 9, creatinine 0.8, glucose 162, troponin 0.17, INR 1.27, white blood cell count 1.3, hematocrit 31, platelet count of 179.,Chest x-ray, no significant pericardial effusion.,IMPRESSION: , The patient is a 69-year-old woman with metastatic non-small-cell lung cancer with a recent hemorrhagic pericardial effusion, now admitted with cerebrovascular accident and transient inferior myocardial infarction, which appears to be canalized.  I will discuss this in detail with the patient and her daughter, and clearly, her situation is quite guarded with likely poor prognosis, which they are understanding of.,RECOMMENDATIONS:,1.  I think it is reasonable to continue heparin, but clearly she would be at risk for hemorrhagic pericardial effusion recurrence.,2.  Morphine is appropriate, especially for preload reduction and other comfort measures as appropriate.,3.  Would avoid other blood thinners including Plavix, Integrilin, and certainly, she is not a candidate for a thrombolytic with which the patient and her daughter are in agreement with after a long discussion.,Other management as per the medical service.  I have discussed the case with Dr. X of the hospitalist service who will be admitting the patient.",
 Hospice visit for 77-year-old gentleman with advanced colon cancer., Hospice - Palliative Care, Hospice Visit - Colon Cancer ,"HISTORY OF PRESENT ILLNESS:,  History as provided primarily by the patient's daughter, as well as the referring physician revealed an approximately two-year history of colon cancer initially diagnosed when the patient presented with a swelling in his groin.  Approximately one month ago, he presented with abdominal pain and presented to the hospital with transverse colon obstruction.  He had a diverting colostomy performed approximately one month ago.  Approximately two weeks ago, he was admitted to hospital with infection of this with chronically swollen lower extremities and is home now for approximately one week.  He was deemed not to be a candidate for chemotherapy or radiation on the basis of extensive disease, as well as a longstanding history of cirrhosis with esophageal varices.  Additional history includes an enlarged heart and chronic lower extremity edema associated with trauma from his time as an army infantryman in Korea many decades ago.  The patient is alert and lives alone, although the daughter Ruby is in from out of town for several weeks to care for him.  He denies any particular problems with the exception of itch and a site of leakage around his ostomy site.  His appetite is notably improved since discharge from hospital and both he and his daughter believe he has gained a few pounds of weight.  His stooling is regular.  There is no fever.  Of greatest concern to his daughter is a possibility that his colostomy might be reversible and at the recommendation of some of the physicians at the referring hospital, he was to have had a PET scan to assess whether the ostomy is reversible for various reasons, primarily insurance.  The PET scan has not been done and the family is quite concerned about a potential surgical intervention.  The patient denies anxiety or depression and there is no history of same.  He was married for over 50 years and now widowed for nearly 10.  He is a stepfather to five children and he has seven of his own, all in all raising 12 children.  His daughters, Ruby and Camilla are most involved with the patient's care.  The patient is retired, worked in supermarkets for many years when he is very proud of his time as an infantryman in Korea.  He did sustain an injury to the right eye during his service.  He has lots of children, grandchildren, and great-grandchildren and seems to derive great pleasure from them.  He denies spiritual or religious distress.  As to advanced directives, the patient appears not to have any significant advanced directives, written or oral.  Family apparently is working on a ""plan."",MEDICATIONS:,  Medications include Toprol 12.5 mg twice daily, Lasix 20 mg daily, ranitidine 75 mg daily, potassium 20 mEq daily, Benadryl 25-50 mg at the hour of sleep as needed, not typically taken and a prescription in the house for Keflex 500 mg q.i.d. for red legs has not yet begun.,PHYSICAL EXAMINATION:,  Examination reveals am alert pale, but thin gentleman with evident wasting.  He is seated and walks without assistance.  His blood pressure is 135/75.  Pulse is 80.  Respiratory rate is 14.  He is afebrile.  Head is without icterus.  Pupils are equal and round.  He has a red dry tongue without leaking mucosal lesions.  There is no jugular venous distention.  The chest has increased AP diameter with good air entry bilaterally.  There is a systolic ejection murmur heard over the entire precordium.  The rate is regular.  The abdomen, he has a right-sided colostomy with a prolapsed bowel.  There is an area of approximately 5 cm x 8 cm of erythema adjacent to the ostomy.  The skin is intact.  The bowel sounds are active.  There is no tenderness in the abdomen and no palpable masses.  Extremities show chronic lymphedema.  The right lower extremity has an 8 cm x 10 cm patch over the anterior shin that is darkened, but not red and not warm.  The distal pulses are intact.  Rectal exam shows no external nor internal hemorrhoids.  No mass is felt and no blood on the gloved finger.  Neurologically, he is alert.  He is oriented times three.  His speech is clear.  His mood appears to be good.  His short-term memory is intact.  There is no focal neurological deficit.,ASSESSMENT:,  A 77-year-old gentleman with apparent widespread intra-abdominal spread of rectal cancer.  Status post bowel obstruction.  Comorbid cirrhosis with esophageal varices.  No history of bleeding.  The patient has had significant clinical and functional decline and I expect that his prognosis would be measured in weeks to months.  The patient lives alone and is currently being very well cared for his daughter from out of town.  She will be leaving in a few weeks.  There is another in-town daughter; however, she works and has a large family.,PLAN:,  I will communicate with the patient's referring physician to ascertain what clinical course and data is available.  A moisture barrier will be applied to his peri-ostomy wound today and we would reassess within 24 hours.  It would be appropriate for a family meeting to be scheduled to review the family and the patient's understanding of his clinical condition and to begin to address an appropriate plan of care for the patient's inevitable decline.,I spoke with Dr. Abc, who informed me that family has in their possession a disc with the CAT scan results.  We will try to ask radiologic colleagues when we obtain the disc to give us a formal reading so that we might better understand the patient's clinical condition and better inform family of his clinical status.","hospice - palliative care, hospice, cat scan results, hospice nurse, pet scan, abdominal pain, admitted to hospital, cirrhosis, colon cancer, colon obstruction, esophageal varices, longstanding, moisture barrier, referring physician, health, colon, cancer, "
 Back injury with RLE radicular symptoms.  The patient is a 52-year-old male who is here for independent medical evaluation., IME-QME-Work Comp etc., Back Injury IME ,"PAST MEDICAL CONDITION:,  None.,ALLERGIES:,  None.,CURRENT MEDICATION:,  Zyrtec and hydrocodone 7.5 mg one every 4 to 6 hours p.r.n. for pain.,CHIEF COMPLAINT: , Back injury with RLE radicular symptoms.,HISTORY OF PRESENT ILLNESS:,  The patient is a 52-year-old male who is here for independent medical evaluation.  The patient states that he works for ABC ABC as a temporary worker.  He worked for ABCD too.  The patient's main job was loading and unloading furniture and appliances for the home.  The patient was approximately there for about two and a half weeks.  Date of injury occurred back in October.  The patient stating that he had history of previous back problems ongoing; however, he states that on this particular day back in October, he was unloading an 18-wheeler at ABC and he was bending down picking up boxes to unload and load.  Unfortunately at this particular event, the patient had sharp pain in his lower back.  Soon afterwards, he had radiating symptoms down his right buttock all the way down to the lateral part of his leg crossing his knee.  This became progressively worse.  He also states that some of his radiating pain went down to his left leg as well.  He noticed increase in buttock spasm and also noticed spasm in his buttocks.  He initially saw Dr. Z and was provided with some muscle relaxer and was given some pain patches or Lidoderm patch, I believe.  The patient states that after this treatment, his symptoms still persisted.  At this point, the patient later on was referred to Dr. XYZ through the workmen's comp and he was initially evaluated back in April.  After the evaluation, the patient was sent for MRI, was provided with pain medications such as short-acting opioids.  He was put on restricted duty.  The MRI essentially came back negative, but the patient continued to have radiating symptoms down to his lower extremity and subsequently the patient was essentially released by Dr. XYZ in June with maximum medical improvement.,Unfortunately, the patient continued to have persistence of back pain and radiating symptoms down to his leg and went back to see Dr. XYZ again, and at this point, the patient was provided with further medication management and sent for Pain Clinic referral.  The patient also was recommended for nerve block at this point and the patient received epidural steroid injection by Dr. ABC without any significant relief.  The patient also was sent for EMG and nerve conduction study, which was performed by Dr. ABCD and the MRI, EMG, and nerve conduction study came back essentially negative for radiculopathy, which was performed by Dr. ABCD.  The patient states that he continues to have pain with extended sitting, he has radiating symptoms down to his lower extremity on the right side of his leg, increase in pain with stooping.  He has difficulty sleeping at nighttime because of increase in pain.  Ultimately, the patient was returned back to work in June, and deemed with maximum medical improvement back in June.  The patient unfortunately still has significant degree of back pain with activities such as stooping and radicular symptoms down his right leg, worse than the left side.  The patient also went to see Dr. X who is a chiropractic specialist and received eight or nine visits of chiropractic care without long-term relief in his overall radicular symptoms.,PHYSICAL EXAMINATION:,  The patient was examined with the gown on.  Lumbar flexion was moderately decreased.  Extension was normal.  Side bending to the right was decreased.  Side bending to the left was within normal limits.  Rotation and extension to the right side was causing increasing pain.  Extension and side bending to the left was within normal limits without significant pain on the left side.  While seated, straight leg was negative on the LLE at 90° and also negative on the RLE at 90°.  There was no true root tension sign or radicular symptoms upon straight leg raising in the seated position.  In supine position, straight leg was negative in the LLE and also negative on the RLE.  Sensory exam shows there was a decrease in sensation to the S1 dermatomal distribution on the right side to light touch and at all other dermatomal distribution was within normal limits.  Deep tendon reflex at the patella was 2+/4 bilaterally, but there was a decrease in reflex in the Achilles tendon 1+/4 on the right side and essentially 2+/4 on the left side.  Medial hamstring reflex was 2+/4 on both hamstrings as well.  On prone position, there was tightness in the paraspinals and erector spinae muscle as well as tightness on the right side of the quadratus lumborum area, right side was worse than the left side.  Increase in pain at deep palpatory examination in midline of the L5 and S1 level.,MEDICAL RECORD REVIEW:,  I had the opportunity to review Dr. XYZ's medical records.  Also reviewed Dr. ABC procedural note, which was the epidural steroid injection block that was performed in December.  Also, reviewed Dr. X's medical record notes and an EMG and nerve study that was performed by Dr. ABCD, which was essentially normal.  The MRI of the lumbar spine that was performed back in April, which showed no evidence of herniated disc.,DIAGNOSIS: , Residual from low back injury with right lumbar radicular symptomatology.,EVALUATION/RECOMMENDATION:,  The patient has an impairment based on AMA Guides Fifth Edition and it is permanent.  The patient appears to have re-aggravation of the low back injury back in October related to his work at ABC when he was working unloading and loading an 18-wheel truck.  Essentially, there was a clear aggravation of his symptoms with ongoing radicular symptom down to his lower extremity mainly on the right side more so than the left.  The patient also has increase in back pain with lumbar flexion and rotational movement to the right side.  With these ongoing symptoms, the patient has also decrease in activities of daily living such as mobility as well as decrease in sleep pattern and general decrease in overall function.  Therefore, the patient is assigned 8% impairment of the whole person.  We are able to assign this utilizing the Fifth Edition on spine section on the AMA guide.  Using page 384, table 15-3, the patient does fall under DRE Lumbar Category II under criteria for rating impairment due to lumbar spine injury.  In this particular section, it states that the patient's clinical history and examination findings are compatible with specific injury; and finding may include significant muscle guarding or spasm observed at the time of examination, a symmetric loss of range of motion, or non-verifiable radicular complaints define his complaints of radicular pain without objective findings; no alteration of the structural integrity and no significant radiculopathy.  The patient also has decrease in activities of daily living; therefore, the patient is assigned at the higher impairment rating of 8% WPI.  In the future, the patient should avoid prolonged walking, standing, stooping, squatting, hip bending, climbing, excessive flexion, extension, and rotation of his back.  His one time weight limit should be determined by work trial, although the patient should continue to be closely monitored and managed for his pain control by the specific specialist for management of his overall pain.  The patient although has a clear low back pain with certain movements such as stooping and extended sitting and does have a clear radicular symptomatology, the patient also should be monitored closely for specific dependency to short-acting opioids in the near future by specialist who could monitor and closely follow his overall pain management.  The patient also should be treated with appropriate modalities and appropriate rehabilitation in the near future.,","ime-qme-work comp etc., rle, radicular symptoms, independent medical evaluation, injury, lle, deep tendon reflex, emg, mri, lumbar radicular symptomatology,"
 Initial visit for a 95-year-old gentleman with a Hospice diagnosis of CHF., Hospice - Palliative Care, Hospice Visit - CHF ,"HISTORY:,  This is an initial visit for this 95-year-old gentleman with a Hospice diagnosis of CHF.  He was referred to us by Dr. ABC, who reveals a long history of cardiomyopathy and a recent decrease in his ejection fraction to approximately 20-25%.  The patient was seen in the office approximately three days ago with a clinical diagnosis of bronchitis.  The FES, as well as the daughter report that he has had significant clinical and functional decline over the last two to three weeks.  He is no longer ambulatory.  His appetite is significantly decreased and he had significant unmeasured weight loss.  He is notably more weak.  He is unable to perform any of the activities of daily living and he is increasingly somnolent with poor sleep at night.  The patient says that he is ready to die, that he is after all 95 years old and is aware that his clinical and functional status has been declining.  He worked as a chef for almost seven decades and retired approximately two years ago.  He denies pain.  He admits to some cough, but he believes the cough is improved on the current antibiotic.  He does note that he sleeps poorly and unable to indicate a cause for that difficulty in sleeping.  He reports that he recently made a trip to California where he said goodbye to his children that live there.  The patient reports that his goals of care are to stay at home.  He has never been hospitalized with the exception of some surgery on his back in Houston, Texas decades ago that he has no interest in going to a hospital and that he would be happy to sign a DNR form and that he would like no heroics performed in the event that his heart or breathing stops.  He denies anxiety or depression and feels that his life has been quite full and quite successful and that when time comes, he is ready to go.,MEDICATIONS:,  His medications include Avelox 400 mg.  He is on day four of a seven-day dose.  He is on Coreg 3.125 mg a day, lisinopril 5 mg a day, Coumadin 2.5 mg a day, digoxin 0.125 mg every other day, Lasix 80 mg twice daily, Inspra twice daily, and he is on a transdermal nitro patch 12 hours on and 12 hours off.  He takes Tylenol extra strength every four to six hours for bilateral shoulder pain typically one to two doses a day.,PHYSICAL EXAMINATION: , Exam reveals a cachectic somnolent gentleman, who appears to be comfortable.  His blood pressure is 90/60.  His heart rate is 80 and irregular.  His respiratory rate is 14.  Head reveals marked temporal wasting.  He is anicteric.  The pupils are equal and round.  There is jugular venous distention noted approximately 2-3 cm above the notch.  Chest shows good air entry bilaterally with scattered rhonchi.  No audible wheezing.  His heart sounds are irregular and there is a musical systolic ejection murmur radiating to the axilla.  The abdomen is soft with a large midline well-healed surgical scar.  The bowel sounds are normoactive.  There is no tenderness or palpable organomegaly.  He has 2+ edema of his lower extremities with some weeping of the right lower extremity and no evidence of infection.  Neurologically, while somnolent easily aroused and speech is quite clear.  He identities the date as October of 2008, but is otherwise oriented.  His short-term memory is quite poor.  His insight is also poor.  He appears to be somewhat sad.  There are mild regular tremors, right hand worse than left, but there is otherwise no focal neurological deficit.,A phone conversation with his daughter, Xyz, his health care proxy, ensued.  His daughter is very concerned with his clinical decline and is raising the question of whether he would benefit from hospitalization.  She reports that her mother died after a many-year course with heart failure and had upwards of three dozen hospitalizations.  At each hospitalization, she seem to derive benefit and wondered if her dad would drive equal benefit from hospitalizations.  She is aware that he is unwilling to be hospitalized and I believe hopefully that the Hospice team might persuade him.  She also reports that he has been talking about dying for nearly five years.,ASSESSMENT:,  A 95-year-old gentleman with endstage CHF with recent significant clinical and functional decline.  The patient appears to have relatively little in the way of symptoms, although perhaps some sleep hygiene might be of help.  While today the patient appears to be very calm and sedated, the history is one of significant emotional lability.  Family is having great difficulty accepting the terminality of the patient's circumstances.,PLAN:,  A DNR was placed in the house after the above-noted conversation was had.  I believe the patient might benefit from low-dose hypnotic and 7.5 mg of Restoril was ordered.  Reassessment of the patient's condition is warranted.  A family meeting will be offered to review the circumstances of the patient's condition in hopes that family might better accept his wishes and to develop a plan of care for this gentleman.","hospice - palliative care, hospice, chf, dnr, dnr was placed, hospice team, air entry, appetite, bronchitis, cardiomyopathy, clinical diagnosis, ejection fraction, functional decline, hospitalization, hospitalized, initial visit, plan of care, somnolent, weight loss, "
 Chiropractic IME with answers to questions from Insurance Company., IME-QME-Work Comp etc., Chiropractic IME - 1 ,"P.O. Box 12345,City, State ,RE: EXAMINEE : Abc,CLAIM NUMBER : 12345-67890,DATE OF INJURY : April 20, 2003,DATE OF EXAMINATION : August 26, 2003,EXAMINING PHYSICIANS : Y Z, DC,Prior to the beginning of the examination, it is explained to the examinee that this examination is intended for evaluative purposes only, and that it is not intended to constitute a general medical examination. It is explained to the examinee that the traditional doctor-patient relationship does not apply to this examination, and that a written report will be provided to the agency requesting this examination. It has also been emphasized to the examinee that he should not attempt any physical activity beyond his tolerance, in order to avoid injury.,CHIEF COMPLAINTS: , Improved focal lower back pain.,HISTORY: , Abc is a 26-year-old man who immigrated to this country approximately six years ago. He speaks ""un poquito"" English and an interpreter is provided. He has worked for the last four years at Floragon Forest Products, where he normally functions as a ""stacker."" He indicates that another worker was on vacation, and because of this he was put on another job in which he separated logs using a picaroon. He was doing this on April 20, 2003, and was pulling on the picaroon when it gave way, and he fell backwards landing on a metal step, which was approximately 1 foot off of the ground. He demonstrates that he came down square on the step and did not fall backwards or hyperextend over it. He did not hit his upper back or neck or shoulders, and only sat down on the step as described. He had ""a little"" pain in his back at that time, but was able to get up and continue working. He completed his shift that day and returned to work the following day. He had the next two days off. He says that his symptoms persisted and increased, and on April 25, 2003, he went to the First Choice Physicians Chiropractic and Rehab Clinic, where he came under the care of Dr. Abcd, DC. The file contains an entrance form completed by Mr. Abc which indicates at the bottom under ""previous occurrence of the same pain"" a notation of ""Yes, but it was not really the same, it was just a little and tolerable."" There is an additional note on the side which states ""no pain prior to this injury or on that day, occasional (but low back)."" Saw this notation, he says today that he did not state this and that the form was done by ""Edna"" at Dr. Abcd's office.,Mr. Abc was initially treated three times a week and states that this has now been reduced to twice per week. He does not know how long the chiropractic treatment is to continue. Initially, he has been seen by Dr. Xyz on three occasions, the last being on August 15, 2003. Dr. Xyz has basically referred him back to Dr. Abcd for continued chiropractic management.,Mr. Abc has now returned to his normal job as a stacker and is able to do that with no significant increased pain. He does mention, however, that bending over, picking up anything particularly heavy is bothersome; however, he does not normally have to do that. He denies any new accident or injury that would be contributory either as a result of his work or outside activities or any motor vehicle accident. He does not participate physically in any sports or hobbies that would be a factor.,PRESENT COMPLAINTS: , Mr. Abc indicates at this time that he is overall better in that initially he had difficulty ""moving."" He grades his current overall level of pain as a 2 to 4 on a scale from 0 to 10, stating that the worst he had was at 6-7. He now has ""good and bad days"" which depends on his activity level noting that he is better over the weekend. He localizes his pain to the midline lumbosacral region. He states that initially he did experience some diffuse radiation into both lower extremities, but that this has now resolved. He occasionally will notice some tightness behind both knees, but again no radicular type of distribution. He denies any focal muscular weakness or sphincter disturbance. His quality of the pain at this time is a ""tightness"" which bothers him, again, primarily with bending at the waist and lifting. He is able to do his normal activities of life, including his work without any significant problem, noting again only increased pain with bending and lifting.,PAST HISTORY: , Mr. Abc denies any prior similar complaints or treatments. He denies any previous specific lower back injury. He has enjoyed essentially good lifetime health and denies any concurrent medical conditions or problems. He has seasonal allergies only with no known drug hypersensitivities. He has not been hospitalized overnight and has had no surgeries in his life. He currently takes OTC Advil and Tylenol for lower back pain, but no prescriptive medication. He does not smoke, drink, or use street drugs of any type. Review of systems and family history are generally noncontributory.,SOCIO-ECONOMIC HISTORY: , Mr. Abc, as indicated, was born and reared in Mexico and immigrated into this country six years ago.,Education: He has our equivalent of a high school education in Mexico with no additional formal education in United States.,Military History: He has no military experience in his life.,Work History: He currently is doing his normal work activities as a stacker without arbitrary restrictions or limitations. He is not receiving any Workers Compensation or other benefits at this time.,PHYSICAL EXAMINATION: , Abc presents as a cooperative and straightforward 26-year-old Hispanic male. He has a very thin body habitus with a reported height of 5 feet 7 inches and weight of 125 pounds. He is right hand dominant. He is noted to sit comfortably throughout the history taking process conversant with the interpreter and myself without observable guarding or postural conversation or motion. He did stand readily to full upright with equal weightbearing and exhibits normal spinal posture with double hips and shoulders. Lumbar lordosis is normal. He ambulates without a limp or lift, and is able to walk on heels and toes and perform a full squat and rise and hop without difficulty with some expression of increased lower back pain. Waddell's testing is negative on compression and traction with some slight increased lower back pain on passive rotation.,Kemp's maneuver of posterolateral bending has some increased localized lumbosacral pain, but no radiation distally into the buttocks or lower extremities.,Active lumbar ranges of motion with double inclinometer are:,Flexion 70 degrees.,Extension 20 degrees.,Side bending symmetric at 28 degrees.,He complains of lower back pain at the extremes of flexion only. Motion palpation reveals full mobility without any detectable intrasegmental fixation with normal symmetry and alignment.,Tendon reflexes are 2+ and symmetric at the knees and ankles without sensory loss to pinprick. Babinski's are neutral, and there is no clonus.,Manual muscle testing reveals 5/5 strength at the hips, knees, and ankles without give-way or complaint.,Supine passive straight leg raising is limited by hamstring tightness to 66 degrees bilaterally, but causes no expression of lower back pain or radiation. Cross leg with rotation hip joint motion is full on either side without reported hip or back pain. Hip flexion is symmetric at 130 degrees, again without complaint. Leg lengths appeared visually symmetric. Mid calf girth is 11-1/2 inches bilaterally. Five inches above the knees measured 13 inches right and left. The seated SLR is done to 90 degrees, and he brings his fingertips 2 inches from his toes, showing good flexibility at the waist despite the hamstring tightness noted in the supine straight leg raising test.,In the prone position, he has good gluteal strength on either side with Yeoman's test causing some increased lumbosacral pain but no focal sacroiliac involvement. No sacroiliac fixation is identified. Hibbs test is negative on either side.,On palpation, he reports midline tenderness at L5-S1 without additional areas of tenderness noted even to very firm palpatory pressure in the entirety of the lumbar spine over the pelvis. He indicates no focal or sacroiliac, sciatic notch, or trochanteric tenderness on either side. No definitive muscular spasm is noted in the lumbar paraspinal musculature.,Mr. Abc tolerated the examination process without apparent or expressed ill effect. ,IMAGING STUDIES:,  AP and lateral lumbar/pelvic views dated May 15, 2003 are reviewed. The films are negative for recent fracture or pathology. There appears to be a transitional lumbosacral area with a spatulated transverse process of L1 and slight narrowing of the lumbosacral disc space. No additional abnormalities are identified. The hip and sacroiliac articulations appear well preserved. Disc spacing in the rest of the lumbar spine appears normal, and no significant degenerative changes are identified. Soft tissue appeared normal without paraspinal mass or abnormality.,DIAGNOSIS: , Lumbosacral contusion/strain relative to the April 20, 2003 industrial accident - objectively resolved.,SUMMARY: , Discussion and recommendations in response to questions posed in your August 15, 2003 letter:,1. What is your diagnosis of the worker's condition as a result of the injury? Please provide objective medical findings that support your diagnosis. Please indicate if the objective findings are reproducible, measurable, or observable, and how.,The diagnosis of the workers condition secondary to the described April 20, 2003 fall is by history a lumbosacral contusion/strain. This impression is primarily made based on his history noting that at this time, he has no abnormal objective findings.,2. In your opinion, is the work injury a contributing cause of the diagnosis? If so, is the work injury the material contributing cause of the diagnosis? Please provide an explanation for your opinion.,It would appear that the work injury was the major contributing cause of the diagnosis.,3. Are there any off work factors that may have caused or contributed to the worker's current complaints or condition? (Such as idiopathic causes, predisposition, congenital abnormalities, off work injuries, etc.).",
" First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.", IME-QME-Work Comp etc., Burn - Consult ,"CHIEF COMPLAINT: , Burn, right arm.,HISTORY OF PRESENT ILLNESS: , This is a Workers' Compensation injury.  This patient, a 41 year-old male, was at a coffee shop, where he works as a cook, and hot oil splashed onto his arm, burning from the elbow to the wrist on the medial aspect.  He has had it cooled, and presents with his friend to the Emergency Department for care.,PAST MEDICAL HISTORY:  ,Noncontributory.,MEDICATIONS:  ,None.,ALLERGIES:  ,None.,PHYSICAL EXAMINATION: , GENERAL:  Well-developed, well-nourished 21-year-old male adult who is appropriate and cooperative.  His only injury is to the right upper extremity.  There are first and second degree burns on the right forearm, ranging from the elbow to the wrist.  Second degree areas with blistering are scattered through the medial aspect of the forearm.  There is no circumferential burn, and I see no areas of deeper burn.  The patient moves his hands well.  Pulses are good.  Circulation to the hand is fine.,FINAL DIAGNOSIS:,1.  First-degree and second-degree burns, right arm secondary to hot oil spill.,2.  Workers' Compensation industrial injury.,TREATMENT: , The wound is cooled and cleansed with soaking in antiseptic solution.  The patient was ordered Demerol 50 mg IM for pain, but he refused and did not want pain medication.  A burn dressing is applied with Neosporin ointment.  The patient is given Tylenol No. 3, tabs #4, to take home with him and take one or two every four hours p.r.n. for pain.  He is to return tomorrow for a dressing change.  Tetanus immunization is up to date.  Preprinted instructions are given.  Workers' Compensation first report and work status report are completed.,DISPOSITION: , Home.","ime-qme-work comp etc., burn, workers' compensation industrial injury, workers' compensation, degree"
 Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs., Hospice - Palliative Care, Hospice Visit - CA of Cervix ,"HISTORY OF PRESENT ILLNESS: , The patient is a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum, lung, which was diagnosed approximately two years ago.  There is a nodule in her lung, which was treated by excision in February of 2007 on the right side.  She had spread to her kidney.  She had right-sided nephrectomy and left-sided nephrostomy.  She also had invasion of the bladder.  Currently, all of her urine comes out through the renal nephrostomy.  She complains of burning vaginal pain, as well as chronic discharge, which has improved slightly recently.  She is not able to engage in intercourse because of the pain and bleeding.  She also has pain with bowel movements, as well as painful urgency.  The pain is at least 3-4/10 and is partially relieved with methadone rescues and interferes with her ability to sleep at night as she feels exhausted and tired.  She has some nausea and diminished appetite.  No hallucinations.  She is anxious frequently and this is helped with clonazepam, which she has taken chronically for her anxiety disorder and recently started Zyprexa.  She has occasional shortness of breath, which used to be helped with oxygen in the hospital.,PAST MEDICAL HISTORY:,  Peptic ulcer disease, hypertension.,REVIEW OF SYSTEMS:,  She has constipation with hard bowel movements.,MEDICATIONS:,  Norvasc 10 mg daily, isosorbide 60 mg every 24 hours, olanzapine at 2.5-5 mg in bedtime, clonazepam 1 mg every eight hours, Sorbitol 30 cc twice a day, Senna-S two tabs daily, methadone 60 mg every eight hours, and 30 mg every four hours p.r.n. pain.,ALLERGIES:,  She has no known allergies.,SOCIAL HISTORY: , The patient lives with her common law husband and her daughter.  Code Status: DNR.  Religion.  Catholic.  She has a past history of heroin use and was enrolled in MMTP program for 12 hours.  She reports feeling discouraged from her symptoms and pain.,PHYSICAL EXAMINATION: , Blood pressure 120/80, pulse 80, and respirations 14.  General Appearance:  Mildly obese woman.  PERRLA, 3 mm.  Oral mucosa moist without lesions.  Lungs:  Clear.  Heart:  RRR without murmurs.  Abdomen:  Somewhat distended, but soft and nontender.  There is firmness found in the low abdomen bilaterally.  There is erythema in the intertriginous area and vulva, as well as some serous discharge from the vagina.  Neurological Exam:  Cranial nerves II through XII are grossly intact.  There is normal tone.  Power is 5-/5.  DTRs nonreactive.  Sensation intact to fine touch.  Mental Status:  The patient is alert, fully oriented, normal speech, and thought process.  Normal affect.,ASSESSMENT AND PLAN: , ,1.  Carcinoma of the cervix metastatic to the retroperitoneum, bladder, and lung with irritable obstruction and gradual decline in the performance status.  Given this, her prognosis is likely to be limited to six months and she will benefit from home hospice care.,2.  Pain, which is a combination of somatic nociceptive pain due to the retroperitoneal invasion, as well as a neuropathic component from pelvic and nerve involvement by the surgery as well as radiation therapy and disease itself.  We are going to increase methadone to 70 mg every eight hours and continue 30 mg for breakthrough.  We will add pregabalin 50 mg three times a day and titrate the dose up as needed.,3.  Nausea and poor appetite.  We will start Megace 200 mg daily.,4.  Shortness of breath.  We will provide oxygen p.r.n.,5.  Candidal infection.  We will start clotrimazole 1% cream b.i.d.,6.  Constipation.  We will advance the bowel regimen to Sorbitol 30 cc three times a day and Senna-S three tabs twice a day.,7.  Psychosocial.  The patient is getting discouraged.  We will provide supportive counseling.,Length of the encounter was 80 minutes; more than half spent on exchange of information.,Thank you for the opportunity to participate in the care for this patient.","hospice - palliative care, hospice, carcinoma of the cervix, code status, length of the encounter, mmtp program, normal affect, shortness of breath, bladder, decline, exchange of information, hospice care, irritable obstruction, lung, nephrectomy, nephrostomy, performance status, poor appetite, prognosis is likely to be limited to, retroperitoneum, carcinoma, metastatic, cervix, lungs, "
" Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.", Hospice - Palliative Care, Hospice Visit - AIDS ,"HISTORY OF PRESENT ILLNESS: , The patient is a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.  His viral load in July of 2007 was 254,000 and CD4 count was 7.  He was recently admitted for debility and possible pneumonia.  He was started on antiretroviral therapy, as well as Cipro and Flagyl and was also found to have pleural effusion on the right.  His history is also significant for pancreatitis and transient renal failure during last hospitalization.  He became frustrated since he was not getting better and discontinued all antibiotics.  When taken home yesterday, he had symptoms consistent with a partial bowel obstruction.  He was vomiting and had no bowel movements for a few days.  Last night, was able to have a bowel movement and has not vomited since then.  He was able to take small amounts of food.  He now has persistent cough productive of clear sputum and some shortness of breath.  He also complains of pain at his KS lesions on the right leg and left thigh, especially when touched, although that pain is incidental and not present when he is simply lying down.  He has overall weakness.,PAST MEDICAL HISTORY: , Unremarkable.,MEDICATIONS: , Acetaminophen 650 mg q.6h. p.r.n. fever, which he has not been using, Motrin 400 mg q.6h. p.r.n. pain, which has not helped.  His pain and dexamethasone with guaifenesin 5-10 mL q.4h. p.r.n. cough.,ALLERGIES:,  He has no known allergies.,SOCIAL HISTORY: , The patient is now staying with his mother.  He is the youngest of six children.  Code Status:  DNR.  His brother is the health care proxy.,PHYSICAL EXAMINATION:,  Blood pressure 140/80, pulse 120, and respirations 28.  Temperature 103.9.  General Appearance: Ill-looking young man, diaphoretic.  PERRLA, 3 mm.  Oral mucosa moist without lesions.  Lungs:  Diminished breath sounds in the right middle lower lobe.  Heart:  RRR without murmurs.  Abdomen:  Distended with soft and nontender.  Diminished bowel sounds.  Extremities:  Without cyanosis or edema.  There is a large Kaposi's sarcoma on the right medial leg and left medial proximal thigh, which is somewhat tender.  Neurological Exam:  Cranial nerves II through XII are grossly intact.  There is normal tone.  Power is 4/5.  DTRs nonreactive.  Normal fine touch.  Mental Status:  The patient is somnolent, but arousable.  Withdrawn affect.  Normal speech and though process.,ASSESSMENT AND PLAN:,1.  AIDS complicated with multiple opportunistic infections with poor performance status, which suggested a limited prognosis of less than six months.  He will benefit from home hospice care and he declined any further antibiotic or antiretroviral treatments.,2.  Pain, which is somatic nociceptive from KS lesions.  The patient has not tolerated morphine in the past.  We will start oxycodone 5 mg q.2h. as needed.,3.  Cough.  We will use oxycodone with the same indication as well.,4.  Fever.  We encouraged him to use Tylenol as needed.,5.  Insomnia.  We will use lorazepam 0.25-0.5 mg at bedtime as needed.,6.  Psychosocial.  We discussed his coping with the diagnosis.  He is fully aware of his limited prognosis.  Supportive counseling was provided to his mother.,Length of the encounter was one hour; more than half spent on exchange of information.,","hospice - palliative care, hospice, aids, cd4 count, code status, dnr, kaposi's sarcoma, length of the encounter, cryptococcal infection, exchange of information, health care proxy, home hospice, home hospice care, hospice care, hospitalization, viral load, bowel, infection"
 Thyroid mass diagnosed as papillary carcinoma.  The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary.  The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis., Hematology - Oncology, Thyroid Mass Consult ,"REASON FOR CONSULTATION: , Thyroid mass diagnosed as papillary carcinoma.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 16-year-old young lady, who was referred from the Pediatric Endocrinology Department by Dr. X for evaluation and surgical recommendations regarding treatment of a mass in her thyroid, which has now been proven to be papillary carcinoma on fine needle aspiration biopsy.  The patient's parents relayed that they first noted a relatively small but noticeable mass in the middle portion of her thyroid gland about 2004.  An ultrasound examination had reportedly been done in the past and the mass is being observed.  When it began to enlarge recently, she was referred to the Pediatric Endocrinology Department and had an evaluation there.  The patient was referred for fine needle aspiration and the reports recently returned a diagnosis of papillary thyroid carcinoma.  The patient has not had any hoarseness, difficulty swallowing, or any symptoms of endocrine dysfunction.  She has no weight changes consistent with either hyper or hypothyroidism.  There is no family history of thyroid cancer in her family.  She has no notable discomfort with this lesion.  There have been no skin changes.  Historically, she does not have a history of any prior head and neck radiation or treatment of any unusual endocrinopathy.,PAST MEDICAL HISTORY:,  Essentially unremarkable.  The patient has never been hospitalized in the past for any major illnesses.  She has had no prior surgical procedures.,IMMUNIZATIONS: , Current and up to date.,ALLERGIES: , She has no known drug allergies.,CURRENT MEDICATIONS:  ,Currently taking no routine medications.  She describes her pain level currently as zero.,FAMILY HISTORY: , There is no significant family history, although the patient's father does note that his mother had a thyroid surgery at some point in life, but it was not known whether this was for cancer, but he suspects it might have been for goiter.  This was done in Tijuana.  His mom is from central portion of Mexico.  There is no family history of multiple endocrine neoplasia syndromes.,SOCIAL HISTORY:  ,The patient is a junior at Hoover High School.  She lives with her mom in Fresno.,REVIEW OF SYSTEMS: , A careful 12-system review was completely normal except for the problems related to the thyroid mass.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a 55.7 kg, nondysmorphic, quiet, and perhaps slightly apprehensive young lady, who was in no acute distress.  She was alert and oriented x3 and had an appropriate affect.,HEENT:  The head and neck examination is most significant.  There is mild amount of facial acne.  The patient's head, eyes, ears, nose, and throat appeared to be grossly normal.,NECK:  There is a slightly visible midline bulge in the region of the thyroid isthmus.  A firm nodule is present there, and there is also some nodularity in the right lobe of the thyroid.  This mass is relatively hard, slightly fixed, but not tethered to surrounding tissues, skin, or muscles that I can determine.  There are some shotty adenopathy in the area.  No supraclavicular nodes were noted.,CHEST:  Excursions are symmetric with good air entry.,LUNGS:  Clear.,CARDIOVASCULAR:  Normal.  There is no tachycardia or murmur noted.,ABDOMEN:  Benign.,EXTREMITIES:  Extremities are anatomically correct with full range of motion.,GENITOURINARY:  External genitourinary exam was deferred at this time and can be performed later during anesthesia.  This is same as too for her rectal examination.,SKIN:  There is no acute rash, purpura, or petechiae.,NEUROLOGIC:  Normal and no focal deficits.  Her voice is strong and clear.  There is no evidence of dysphonia or vocal cord malfunction.,DIAGNOSTIC STUDIES: , I reviewed laboratory data from the Diagnostics Lab, which included a mild abnormality in the AST at 11, which is slightly lower than the normal range.  T4 and TSH levels were recorded as normal.  Free thyroxine was normal, and the serum pregnancy test was negative.  There was no level of thyroglobulin recorded on this.  A urinalysis and comprehensive metabolic panel was unremarkable.  A chest x-ray was obtained, which I personally reviewed.  There is a diffuse pattern of tiny nodules in both lungs typical of miliary metastatic disease that is often seen in patients with metastatic thyroid carcinoma.,IMPRESSION/PLAN: , The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary.  The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis and is unfortunate in that it generally means a more advanced stage of disease.  I spent approximately 30 minutes with the patient and her family today discussing the surgical aspects of the treatment of this disease.  During this time, we talked about performing a total thyroidectomy to eradicate as much of the native thyroid tissue and remove the primary source of the cancer in anticipation of radioactive iodine therapy.  We talked about sentinel node dissection, and we spent significant amount of time talking about the possibility of hypoparathyroidism if all four of the parathyroid glands were damaged during this operation.  We also discussed the recurrent laryngeal and external laryngeal branches of the nerve supplying the vocal cord function and how they cane be damaged during the thyroidectomy as well.  I answered as many of the family's questions as they could mount during this stressful time with this recent information supplied to them.  I also did talk to them about the chest x-ray pattern, which was complete __________ as the film was just on the day prior to my clinic visit.  This will have some impact on the postoperative adjunctive therapy.  The radiologist commented about the risk of pulmonary fibrosis and the use of radioactive iodine in this situation, but it seems likely that is going to be necessary to attempt to treat this disease in the patient's case.  I did discuss with them the possibility of having to take large doses of calcium and vitamin D in the event of hypoparathyroidism if that does happen, and we also talked about possibly sparing parathyroid tissue and reimplanting it in a muscle belly either in the neck or forearm if that becomes a necessity.  All of the family's questions have been answered.  This is a very anxious and anxiety provoking time in the family.  I have made every effort to get the patient under schedule within the next 48 hours to have this operation done.  We are tentatively planning on proceeding this upcoming Friday afternoon with total thyroidectomy.",
 Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a patient with code last night with CPR and advanced cardiac life support., Hospice - Palliative Care, Care Conference With Family ,"REASON FOR FOLLOWUP:,  Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a patient with code last night with CPR and advanced cardiac life support.,HISTORY OF PRESENT ILLNESS: , This is a 65-year-old patient originally admitted by me several weeks ago with profound hyponatremia and mental status changes.  Her history is also significant for likely recurrent aspiration pneumonia and intubation earlier on this admission as well.  Previously while treating this patient I had met with the family and discussed how aggressive the patient would wish her level of care to be given that there was evidence of possible ovarian malignancy with elevated CA-125 and a complex mass located in the ovary.  As the patient was showing signs of improvement with some speech and ability to follow commands, decision was made to continue to pursue an aggressive level of care, treat her dysphagia, hypertension, debilitation and this was being done.  However, last night the patient had apparently catastrophic event around 2:40 in the morning.  Rapid response was called and the patient was intubated, started on pressure support, and given CPR.  This morning I was called to the bedside by nursing stating the family had wished at this point not to continue this aggressive level of care.  The patient was seen and examined, she was intubated and sedated.  Limbs were cool.  Cardiovascular exam revealed tachycardia.  Lungs had coarse breath sounds.  Abdomen was soft.  Extremities were cool to the touch.  Pupils were 6 to 2 mm, doll's eyes were not intact.  They were not responsive to light.  Based on discussion with all family members involved including both sons, daughter and daughter-in-law, a decision was made to proceed with terminal wean and comfort care measures.  All pressure support was discontinued.  The patient was started on intravenous morphine and respiratory was requested to remove the ET tube.  Monitors were turned off and the patient was made as comfortable as possible.  Family is at the bedside at this time.  The patient appears comfortable and the family is in agreement that this would be her wishes per my understanding of the family and the patient dynamics over the past month, this is a very reasonable and appropriate approach given the patient's failure to turn around after over a month of aggressive treatment with likely terminal illness from ovarian cancer and associated comorbidities.,Total time spent at the bedside today in critical care services, medical decision making and explaining options to the family and proceeding with terminal weaning was excess of 37 minutes.","hospice - palliative care, full code status, terminal wean, comfort care, cpr, advanced cardiac life support, care conference, family, bedsideNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
"  Essential thrombocytosis.  He underwent a bone marrow biopsy, which showed essential thrombocytosis.  His CBC has been very stable.  ", Hematology - Oncology, Thrombocytosis Followup ,"CHIEF COMPLAINT:,  Essential thrombocytosis.,HISTORY OF PRESENT ILLNESS: , This is an extremely pleasant 64-year-old gentleman who I am following for essential thrombocytosis.  He was first diagnosed when he first saw a hematologist on 07/09/07.  At that time, his platelet count was 1,240,000.  He was initially started on Hydrea 1000 mg q.d.  On 07/11/07, he underwent a bone marrow biopsy, which showed essential thrombocytosis.  He was positive for the JAK-2 mutation.  On 11/06/07, his platelets were noted to be 766,000.  His current Hydrea dose is now 1500 mg on Mondays and Fridays and 1000 mg on all other days.  He moved to ABCD in December 2009 in an attempt to improve his wife's rheumatoid arthritis.,Overall, he is doing well.  He has a good energy level, and his ECOG performance status is 0.  He denies any fevers, chills, or night sweats.  No lymphadenopathy.  No nausea or vomiting.  No change in bowel or bladder habits.,CURRENT MEDICATIONS: , Hydrea 1500 mg on Mondays and Fridays and 1000 mg the other days of the week,  Flomax q.d., vitamin D q.d, saw palmetto q.d., aspirin 81 mg q.d., and vitamin C q.d.,ALLERGIES: , No known drug allergies.,REVIEW OF SYSTEMS:,  As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1.  He is status post an appendectomy.,2.  Status post a tonsillectomy and adenoidectomy.,3.  Status post bilateral cataract surgery.,4.  BPH.,SOCIAL HISTORY:  ,He has a history of tobacco use, which he quit at the age of 37.  He has one alcoholic drink per day.  He is married.  He is a retired lab manager.,FAMILY HISTORY:  ,There is no history of solid tumor or hematologic malignancies in his family.,PHYSICAL EXAM:,VIT:",
 Consultation for evaluation of thrombocytopenia., Hematology - Oncology, Thrombocytopenia - Consult ,"REASON FOR CONSULTATION:,  Thrombocytopenia.,HISTORY OF PRESENT ILLNESS:,  Mrs. XXX is a 17-year-old lady who is going to be 18 in about 3 weeks.  She has been referred for the further evaluation of her thrombocytopenia.  This thrombocytopenia was detected on a routine blood test performed on the 10th of June 2006.  Her hemoglobin was 13.3 with white count of 11.8 at that time.  Her lymphocyte count was 6.7.  The patient, subsequently, had a CBC repeated on the 10th at Hospital where her hemoglobin was 12.4 with a platelet count of 26,000.  She had a repeat of her CBC again on the 12th of June 2006 with hemoglobin of 14, white count of 11.6 with an increase in the number of lymphocytes.  Platelet count was 38.  Her rapid strep screen was negative but the infectious mononucleosis screen is positive.  The patient had a normal platelet count prior too and she is being evaluated for this low platelet count.,The patient gives a history of feeling generally unwell for a couple of days towards the end of May.  She was fine for a few days after that but then she had sore throat and fever 2-3 days subsequent to that.  The patient continues to have sore throat.,She denies any history of epistaxis.  Denies any history of gum bleeding.  The patient denies any history of petechiae.  She denies any history of abnormal bleeding.  Denies any history of nausea, vomiting, neck pain, or any headaches at the present time.,The patient was accompanied by her parents.,PAST MEDICAL HISTORY: , Asthma.,CURRENT MEDICATIONS: , Birth control pills, Albuterol, QVAR and Rhinocort.,DRUG ALLERGIES: , None.,PERSONAL HISTORY: , She lives with her parents.,SOCIAL HISTORY:,  Denies the use of alcohol or tobacco.,FAMILY HISTORY: , Noncontributory.,OCCUPATION: , The patient is currently in school.,REVIEW OF SYSTEMS:,Constitutional:  The history of fever about 2 weeks ago.,HEENT:  Complains of some difficulty in swallowing.,Cardiovascular:  Negative.,Respiratory:  Negative.,Gastrointestinal:  No nausea, vomiting, or abdominal pain.,Genitourinary:  No dysuria or hematuria.,Musculoskeletal:  Complains of generalized body aches.,Psychiatric:  No anxiety or depression.,Neurologic:  Complains of episode of headaches about 2-3 weeks ago.,PHYSICAL EXAMINATION:  ,She was not in any distress.  She appears her stated age.  Temperature 97.9.  Pulse 84.  Blood pressure was 110/60.  Weighs 162 pounds.  Height of 61 inches.  Lungs - Normal effort.  Clear.  No wheezing.  Heart - Rate and rhythm regular.  No S3, no S4.  Abdomen - Soft.  Bowel sounds are present.  No palpable hepatosplenomegaly.  Extremities - Without any edema, pallor, or cyanosis.  Neurological:  Alert and oriented x 3.  No focal deficit.  Lymph Nodes - No palpable lymphadenopathy in the neck or the axilla.  Skin examination reveals few petechiae along the lateral aspect of the left thigh but otherwise there were no ecchymotic patches.,DIAGNOSTIC DATA: , The patient's CBC results from before were reviewed.  Her CBC performed in the office today showed hemoglobin of 13.7, white count of 13.3, lymphocyte count of 7.6, and platelet count of 26,000.,IMPRESSION: , ITP, the patient has a normal platelet count.,PLAN:,1.  I had a long discussion with family regarding the treatment of ITP.  In view of the fact that the patient's platelet count is 26,000 and she is asymptomatic, we will continue to monitor the counts.,2.  An ultrasound of the abdomen will be performed tomorrow.,3.  I have given her a requisition to obtain some blood work tomorrow.",
 Patient with immune thrombocytopenia, Hematology - Oncology, Thrombocytopenia - SOAP Note ,"SUBJECTIVE: , I am following the patient today for immune thrombocytopenia.  Her platelets fell to 10 on 01/09/07 and shortly after learning of that result, I increased her prednisone to 60 mg a day.  Repeat on 01/16/07 revealed platelets up at 43.  No bleeding problems have been noted.  I have spoken with her hematologist who recommends at this point we decrease her prednisone to 40 mg for 3 days and then go down to 20 mg a day.  The patient had been on 20 mg every other day at least for a while, and her platelets hovered at least above 20 or so.,PHYSICAL EXAMINATION: , Vitals:  As in chart.  The patient is alert, pleasant, and cooperative.  She is in no apparent distress.  The petechial areas on her legs have resolved.,ASSESSMENT AND PLAN: , Patient with improvement of her platelet count on burst of prednisone.  We will decrease her prednisone to 40 mg for 3 days, then go down to 20 mg a day.  Basically thereafter, over time, I may try to sneak it back a little bit further.  She is on medicines for osteoporosis including bisphosphonate and calcium with vitamin D.  We will arrange to have a CBC drawn weekly.,","hematology - oncology, platelets, platelet count, thrombocytopenia, prednisone,"
" True cut needle biopsy of the breast.  This 65-year-old female on exam was noted to have dimpling and puckering of the skin associated with nipple discharge.  On exam, she has a noticeable carcinoma of the left breast with dimpling, puckering, and erosion through the skin.", Hematology - Oncology, True Cut Needle Biopsy - Breast ,"PREOPERATIVE DIAGNOSIS:,  Carcinoma of the left breast.,POSTOPERATIVE DIAGNOSIS:,  Carcinoma of the left breast.,PROCEDURE PERFORMED: , True cut needle biopsy of the breast.,GROSS FINDINGS:  ,This 65-year-old female on exam was noted to have dimpling and puckering of the skin associated with nipple discharge.  On exam, she has a noticeable carcinoma of the left breast with dimpling, puckering, and erosion through the skin.  At this time, a true cut needle biopsy was performed.,PROCEDURE: , The patient was taken to operating room, is laid in the supine position, sterilely prepped and draped in the usual fashion.  The area over the left breast was infiltrated with 1:1 mixture of 0.25% Marcaine and 1% Xylocaine.  Using a #18 gauge automatic true cut needle core biopsy, five biopsies were taken of the left breast in core fashion.  Hemostasis was controlled with pressure.  The patient tolerated the procedure well, pending the results of biopsy.","hematology - oncology, carcinoma, true cut needle biopsy, nipple, discharge, dimpling, puckering, breast, "
" Excisional biopsy with primary closure of a 4 mm right lateral base of tongue lesion.  Right lateral base of tongue lesion, probable cancer.", Hematology - Oncology, Tongue Lesion Biopsy ,"PREOPERATIVE DIAGNOSIS: , Right lateral base of tongue lesion, probable cancer.,POSTOPERATIVE DIAGNOSIS: , Right lateral base of tongue lesion, probable cancer.,PROCEDURE PERFORMED:  ,Excisional biopsy with primary closure of a 4 mm right lateral base of tongue lesion.,ANESTHESIA: , General.,FINDINGS: , An ulceration in the right lateral base of tongue region.  This was completely excised.,ESTIMATED BLOOD LOSS:,  Less than 5 mL.,FLUIDS: , Crystalloid only.,COMPLICATIONS:,  None.,DRAINS:,  None.,CONDITION:,  Stable.,PROCEDURE:  ,The patient placed supine in position under general anesthesia.  First a Sweetheart gag was placed in the patient's mouth and the mouth was elevated.  The lesion in the tongue could be seen.  Then, it was injected with 1% lidocaine and 1:100,00 epinephrine.  After 5 minutes of waiting, then an elliptical incision was made around this mass with electrocautery and then it was sharply dissected off the muscular layer and removed in total.  Suction cautery was used for hemostasis.  Then, 3 simple interrupted #4-0 Vicryl sutures were used to close the wound and procedure was then terminated at that time.","hematology - oncology, excisional biopsy, tongue lesion, mouth, biopsy,"
" The patient is a 67-year-old white female with a history of uterine papillary serous carcinoma who is status post 6 cycles of carboplatin and Taxol, is here today for followup. ", Hematology - Oncology, Uterine Papillary Serous Carcinoma ,"HISTORY OF PRESENT ILLNESS:,  The patient is a 67-year-old white female with a history of uterine papillary serous carcinoma who is status post 6 cycles of carboplatin and Taxol, is here today for followup.  Her last cycle of chemotherapy was finished on 01/18/08, and she complains about some numbness in her right upper extremity.  This has not gotten worse recently and there is no numbness in her toes.  She denies any tingling or burning.,REVIEW OF SYSTEMS: , Negative for any fever, chills, nausea, vomiting, headache, chest pain, shortness of breath, abdominal pain, constipation, diarrhea, melena, hematochezia or dysuria.  The patient is concerned about her blood pressure being up a little bit and also a mole that she had noticed for the past few months in her head.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 35.6, blood pressure 143/83, pulse 65, respirations 18, and weight 66.5 kg.  GENERAL:  She is a middle-aged white female, not in any distress.  HEENT:  No lymphadenopathy or mucositis.  CARDIOVASCULAR:  Regular rate and rhythm.  LUNGS:  Clear to auscultation bilaterally.  EXTREMITIES:  No cyanosis, clubbing or edema.  NEUROLOGICAL:  No focal deficits noted.  PELVIC:  Normal-appearing external genitalia.  Vaginal vault with no masses or bleeding.,LABORATORY DATA: , None today.,RADIOLOGIC DATA: , CT of the chest, abdomen, and pelvis from 01/28/08 revealed status post total abdominal hysterectomy/bilateral salpingo-oophorectomy with an unremarkable vaginal cuff.  No local or distant metastasis.  Right probably chronic gonadal vein thrombosis.,ASSESSMENT: , This is a 67-year-old white female with history of uterine papillary serous carcinoma, status post total abdominal hysterectomy and bilateral salpingo-oophorectomy and 6 cycles of carboplatin and Taxol chemotherapy.  She is doing well with no evidence of disease clinically or radiologically.,PLAN:,1.  Plan to follow her every 3 months and CT scans every 6 months for the first 2 years.,2.  The patient was advised to contact the primary physician for repeat blood pressure check and get started on antihypertensives if it is persistently elevated.,3.  The patient was told that the mole that she is mentioning in her head is no longer palpable and just to observe it for now.,4.  The patient was advised about doing Kegel exercises for urinary incontinence, and we will address this issue again during next clinic visit if it is persistent.,","hematology - oncology, chemotherapy, uterine papillary serous carcinoma, oophorectomy, carboplatin, taxol, abdominal, uterine, papillary, carcinoma,"
 Newly diagnosed T-cell lymphoma.  The patient reports swelling in his left submandibular region that occurred all of a sudden about a month and a half ago. , Hematology - Oncology, T-Cell Lymphoma Consult ,"CHIEF COMPLAINT: , Newly diagnosed T-cell lymphoma.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 40-year-old gentleman who reports swelling in his left submandibular region that occurred all of a sudden about a month and a half ago.  He was originally treated with antibiotics as a possible tooth abscess.  Prior to this event, in March of 2010, he was treated for strep throat.  The pain at that time was on the right side.  About a month ago, he started having night sweats.  The patient reports feeling hot, when he went to bed he fall asleep and would wake up soaked.  All these symptoms were preceded by overwhelming fatigue and exhaustion.  He reports being under significant amount of stress as he and his mom just recently moved from their house to a mobile home.  With the fatigue, he has had some mild chest pain and shortness of breath, and has also noted a decrease in his appetite, although he reports his weight has been stable.  He also reports occasional headaches with some stabbing and pain in his feet and legs.  He also complains of some left groin pain.,PAST MEDICAL HISTORY: , Significant for HIV diagnosed in 2000.  He also had mononucleosis at that time.  The patient reports being on anti-hepatitis viral therapy period that was very intense.  He took the meds for about six months, he reports stopping, and prior to 2002 at one point during his treatment, he was profoundly weak and found to have hemoglobin less than 4 and required three units of packed red blood cells.  He reports no other history of transfusions.  He has history of spontaneous pneumothorax.  The first episode was 1989 on his right lung.  In 1990 he had a slow collapse of the left lung.  He reports no other history of pneumothoraces.  In 2003, he had shingles.  He went through antiviral treatment at that time and he also reports another small outbreak in 2009 that he treated with topical therapy.,FAMILY HISTORY: , Notable for his mother who is currently battling non-small cell lung cancer.  She is a nonsmoker.  His sister is Epstein-Barr virus positive.  The patient's mother also reports that she is Epstein-Barr virus positive.  His maternal grandfather died from complications from melanoma.  His mother also has diabetes.,SOCIAL HISTORY: , The patient is single.  He currently lives with his mother in house for several both in New York and here in Colorado.  His mother moved out to Colorado eight years ago and he has been out here for seven years.  He currently is self employed and does antiquing.  He has also worked as nurses' aide and worked in group home for the state of New York for the developmentally delayed.  He is homosexual, currently not sexually active.  He does have smoking history as about a thirteen and a half pack year history of smoking, currently smoking about a quarter of a pack per day.  He does not use alcohol or illicit drugs.,REVIEW OF SYSTEMS: , As mentioned above his weight has been fairly stable.  Although, he suffered from obesity as a young teenager, but through a period of anorexia, but his weight has been stable now for about 20 years.  He has had night sweats, chest pain, and is also suffering from some depression as well as overwhelming fatigue, stabbing, short-lived headaches and occasional shortness of breath.  He has noted some stool irregularity with occasional loose stools and new onset of pain predominantly in left neck.  He has had fevers as well.  The rest of his review of systems is negative.,PHYSICAL EXAM:,VITALS:","hematology - oncology, t-cell lymphoma, submandibular, tooth abscess, strep throat, submandibular region, lymphoma, neck, "
" Excision of mass, left second toe and distal Symes amputation, left hallux with excisional biopsy.  Mass, left second toe.  Tumor.  Left hallux bone invasion of the distal phalanx.", Hematology - Oncology, Symes Amputation - Hallux ,"PREOPERATIVE DIAGNOSES:,1.  Mass, left second toe.,2.  Tumor.,3.  Left hallux bone invasion of the distal phalanx.,POSTOPERATIVE DIAGNOSES:,1.  Mass, left second toe.,2.  Tumor.,3.  Left hallux with bone invasion of the distal phalanx.,PROCEDURE PERFORMED:,1.  Excision of mass, left second toe.,2.  Distal Syme's amputation, left hallux with excisional biopsy.,HISTORY: , This 47-year-old Caucasian male presents to ABCD General Hospital with a history of tissue mass on his left foot.  The patient states that the mass has been present for approximately two weeks and has been rapidly growing in size.  The patient also has history of shave biopsy in the past.  The patient does state that he desires surgical excision at this time.,PROCEDURE IN DETAIL:,  An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported from the operating room and placed on the operating room table in the supine position with the safety belt across his lap.  Copious amount of Webril was placed around the left ankle followed by a blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 6 cc mixed with 1% lidocaine plain with 0.5% Marcaine plain was injected in a digital block fashion at the base of the left hallux as well as the left second toe.,The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was elevated from the operating table and exsanguinated with an Esmarch bandage.  Care was taken with the exsanguination to perform exsanguination below the level of the digits so as not to rupture the masses.  The foot was lowered to the operating table.  The stockinet was reflected and the foot was cleansed with wet and dry sponge.  A distal Syme's incision was planned over the distal aspect of the left hallux.  The incision was performed with a #10 blade and deepened with #15 down to the level of bone.  The dorsal skin flap was removed and dissected in toto off of the distal phalanx.  There was noted to be in growth of the soft tissue mass into the dorsal cortex with erosion in the dorsal cortex and exposure of cortical bone at the distal phalanx.  The tissue was sent to Pathology where Dr. Green stated that a frozen sample would be of less use for examining for cancer.  Dr. Green did state that he felt that there was an adequate incomplete excision of the soft tissue for specimen.  At this time, a sagittal saw was then used to resect all ends of bone of the distal phalanx.  The area was inspected for any remaining suspicious tissues.  Any suspicious tissue was removed.  The area was then flushed with copious amounts of sterile saline.  The skin was then reapproximated with #4-0 nylon with a combination of simple and vertical mattress sutures.,Attention was then directed to the left second toe.  There was noted to be a dorsolateral mass over the dorsal distal aspect of the left second toe.  A linear incision was made just medial to the tissue mass.  The mass was then dissected from the overlying skin and off of the underlying capsule.  This tissue mass was hard, round, and pearly-gray in appearance.  It does not invade into any other surrounding tissues.  The area was then flushed with copious amounts of sterile saline and the skin was closed with #4-0 nylon.  Dressings consisted of Owen silk soaked in Betadine, 4x4s, Kling, Kerlix, and an Ace wrap.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot.  The patient tolerated the above procedure and anesthesia well without complications.  The patient was transported to PACU with vital signs stable and vascular status intact.  The patient was given postoperative pain prescription for Vicodin and instructed to follow up with Dr. Bonnani in his office as directed.  The patient will be contacted immediately pending the results of pathology.  Cultures obtained in the case were aerobic and anaerobic gram stain, Silver stain, and a CBC.","hematology - oncology, distal phalanx, mass, tumor., hallux bone, phalanx, symes amputation, excisional biopsy, distal, amputation, invasion, toe, symes, incision, flushed, excision, tissue, hallux"
" Posttransplant lymphoproliferative disorder, chronic renal insufficiency, squamous cell carcinoma of the skin, anemia secondary to chronic renal insufficiency and chemotherapy, and hypertension.  The patient is here for followup visit and chemotherapy.", Hematology - Oncology, Posttransplant Lymphoproliferative Disorder ,"CHIEF COMPLAINT: , The patient is here for followup visit and chemotherapy.,DIAGNOSES:,1.  Posttransplant lymphoproliferative disorder.,2.  Chronic renal insufficiency.,3.  Squamous cell carcinoma of the skin.,4.  Anemia secondary to chronic renal insufficiency and chemotherapy.,5.  Hypertension.,HISTORY OF PRESENT ILLNESS: , A 51-year-old white male diagnosed with PTLD in latter half of 2007.  He presented with symptoms of increasing adenopathy, abdominal pain, weight loss, and anorexia.  He did not seek medical attention immediately.  He was finally hospitalized by the renal transplant service and underwent a lymph node biopsy in the groin, which showed diagnosis of large cell lymphoma.  He was discussed at the hematopathology conference.  Chemotherapy with rituximab plus cyclophosphamide, daunorubicin, vincristine, and prednisone was started.  First cycle of chemotherapy was complicated by sepsis despite growth factor support.  He also appeared to have become disoriented either secondary to sepsis or steroid therapy.,The patient has received 5 cycles of chemotherapy to date.  He did not keep his appointment for a PET scan after 3 cycles because he was not feeling well.  His therapy has been interrupted for infection related to squamous cell cancer, skin surgery as well as complaints of chest infection.,The patient is here for the sixth and final cycle of chemotherapy.  He states he feels well.  He denies any nausea, vomiting, cough, shortness of breath, chest pain or fatigue.  He denies any tingling or numbness in his fingers.  Review of systems is otherwise entirely negative.,Performance status on the ECOG scale is 1.,PHYSICAL EXAMINATION:,VITAL SIGNS:  He is afebrile.  Blood pressure 161/80, pulse 65, weight 71.5 kg, which is essentially unchanged from his prior visit.  There is mild pallor noted.  There is no icterus, adenopathy or petechiae noted.  CHEST:  Clear to auscultation.  CARDIOVASCULAR:  S1 and S2 normal with regular rate and rhythm.  Systolic flow murmur is best heard in the pulmonary area.  ABDOMEN:  Soft and nontender with no organomegaly.  Renal transplant is noted in the right lower quadrant with a scar present.  EXTREMITIES:  Reveal no edema.,LABORATORY DATA: , CBC from today shows white count of 9.6 with a normal differential, ANC of 7400, hemoglobin 8.9, hematocrit 26.5 with an MCV of 109, and platelet count of 220,000.,ASSESSMENT AND PLAN:,1.  Diffuse large B-cell lymphoma following transplantation.  The patient is to receive his sixth and final cycle of chemotherapy today.  PET scan has been ordered to be done within 2 weeks.  He will see me back for the visit in 3 weeks with CBC, CMP, and LDH.,2.  Chronic renal insufficiency.,3.  Anemia secondary to chronic renal failure and chemotherapy.  He is to continue on his regimen of growth factor support.,4.  Hypertension.  This is elevated today because he held his meds because he is getting rituximab other than that this is well controlled.  His CMP is pending from today.,5.  Squamous cell carcinoma of the skin.  The scalp is well healed.  He still has an open wound on the right posterior aspect of his trunk.  This has no active drainage, but it is yet to heal.  This probably will heal by secondary intention once chemotherapy is finished.  Prescription for prednisone as part of his chemotherapy has been given to him.","hematology - oncology, anemia, chemotherapy, posttransplant lymphoproliferative disorder, squamous cell carcinoma, chronic renal insufficiency, renal insufficiency, adenopathy, lymphoproliferative, "
 A 19-year-old known male with sickle cell anemia comes to the emergency room on his own with 3-day history of back pain., Hematology - Oncology, Sickle Cell Anemia - ER Visit ,"HISTORY OF PRESENT ILLNESS: , This is a 19-year-old known male with sickle cell anemia.  He comes to the emergency room on his own with 3-day history of back pain.  He is on no medicines.  He does live with a room mate.  Appetite is decreased.  No diarrhea, vomiting.  Voiding well.  Bowels have been regular.  Denies any abdominal pain.  Complains of a slight headaches, but his main concern is back ache that extends from above the lower T-spine to the lumbosacral spine.  The patient is not sure of his immunizations.  The patient does have sickle cell and hemoglobin is followed in the Hematology Clinic.,ALLERGIES: , THE PATIENT IS ALLERGIC TO TYLENOL WITH CODEINE, but he states he can get morphine along with Benadryl.,MEDICATIONS: , He was previously on folic acid.  None at the present time.,PAST SURGICAL HISTORY: , He has had no surgeries in the past.,FAMILY HISTORY: , Positive for diabetes, hypertension and cancer.,SOCIAL HISTORY: , He denies any smoking or drug usage.,PHYSICAL EXAMINATION: , ,VITAL SIGNS:  On examination, the patient has a temp of 37 degrees tympanic, pulse was recorded at 37 per minute, but subsequently it was noted to be 66 per minute,  respiratory rate is 24 per minute and blood pressure is 149/66, recheck blood pressure was 132/72.,GENERAL:  He is alert, speaks in full sentences, he does not appear to be in distress.,HEENT:  Normal.,NECK:  Supple.,CHEST:  Clear.,HEART:  Regular.,ABDOMEN:  Soft.  He has pain over the mid to lower spine.,SKIN:  Color is normal.,EXTREMITIES:  He moves all extremities well.,NEUROLOGIC:  Age appropriate.,ER COURSE: , It was indicated to the patient that I will be drawing labs and giving him IV fluids.  Also that he will get morphine and Benadryl combination.  The patient was ordered a liter of NS over an hour, and was then maintained on D5 half-normal saline at 125 an hour.  CBC done showed white blood cells 4300, hemoglobin 13.1 g/dL, hematocrit 39.9%, platelets 162,000, segs 65.9, lymphs 27, monos 3.4.  Chemistries done were essentially normal except for a total bilirubin of 1.6 mg/dL, all of which was indirect.  The patient initially received morphine and diphenhydramine at 18:40 and this was repeated again at 8 p.m.  He received morphine 5 mg and Benadryl 25 mg.  I subsequently spoke to Dr. X and it was decided to admit the patient.,The patient initially stated that he wanted to be observed in the ER and given pain control and fluids and wanted to go home in the morning.  He stated that he has a job interview in the morning.  The resident service did come to evaluate him.  The resident service then spoke to Dr. X and it was decided to admit him on to the Hematology service for control of pain and IV hydration.  He is to be transitioned to p.o. medications about 4 a.m. and hopefully, he can be discharged in time to make his interview tomorrow.,IMPRESSION:  ,Sickle cell crisis.,DIFFERENTIAL DIAGNOSIS: , Veno-occlusive crisis, and diskitis.",
 Prostate Brachytherapy - Prostate I-125 Implantation, Hematology - Oncology, Prostate Brachytherapy ,"PROSTATE BRACHYTHERAPY - PROSTATE I-125 IMPLANTATION,This patient will be treated to the prostate with ultrasound-guided I-125 seed implantation.  The original consultation and treatment planning will be separately performed.  At the time of the implantation, special coordination will be required.  Stepping ultrasound will be performed and utilized in the pre-planning process.  Some discrepancies are frequently identified, based on the positioning, edema, and/or change in the tumor since the pre-planning process.  Re-assessment is required at the time of surgery, evaluating the pre-plan and comparing to the stepping ultrasound.  Modifications will be made in real time to add or subtract needles and seeds as required.  This may be integrated with the loading of the seeds performed by the brachytherapist, as well as coordinated with the urologist, dosimetrist or physicist.,The brachytherapy must be customized to fit the individual's tumor and prostate.  Attention is given both preoperatively and intraoperatively to avoid overdosage of rectum and bladder.","hematology - oncology, i-125 implantation, tumor, prostate, prostate brachytherapy, implantationNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" Radical resection of tumor of the scalp, excision of tumor from the skull with debridement of the superficial cortex with diamond bur, and advancement flap closure.", Hematology - Oncology, Resection of Tumor of Scalp ,"PREOPERATIVE DIAGNOSIS: , Squamous cell carcinoma of the scalp.,POSTOPERATIVE DIAGNOSIS:,  Same.,OPERATION PERFORMED: , Radical resection of tumor of the scalp (CPT 11643).  Excision of tumor from the skull with debridement of the superficial cortex with diamond bur.  Advancement flap closure, with total undermined area 18 centimeters by 16 centimeters (CPT 14300).,ANESTHESIA:,  General endotracheal anesthesia.,INDICATIONS:  ,This is an 81-year-old male who has a large exophytic 7cm lesion of the anterior midline scalp which is biopsy-positive for skin malignancy, specifically, squamous call carcinoma.  This appears to be affixed to the underlying scalp.,PLAN: , Radical resection with frozen sections to clear margins thereafter, with planned reconstruction.,CONSENT:,  I have discussed with the patient the possible risks of bleeding, infection, renal problems, scar formation, injury to muscle, nerves, and possible need for additional surgery with possible recurrence of the patient's carcinoma, with review of detailed informed consent with the patient, who understood, and wished to proceed.,FINDINGS: , The patient had a 7cm large exophytic lesion which appeared to be invasive into the superficial table of the skull.  The final periosteal margin which centrally appeared was positive for carcinoma.  The final margins peripherally were all negative.,DESCRIPTION OF PROCEDURE IN DETAIL: , The patient was taken to the operating room and there was placed supine on the operating room table.,General endotracheal anesthesia was administered after endotracheal tube intubation was performed by the Anesthesia Service personnel.  The patient was thereafter prepped and draped in the usual sterile manner using Betadine Scrub and Betadine paint.  Thereafter, the local anesthesia was injected into the area around the tumor.  A **** type excision was planned down to the periosteum.  A supraperiosteal radical resection was performed.,It was obvious that there was tumor at the deep margin, involving the periosteum.  The edges were marked along the four quadrants, at the 12 o'clock, 3 o'clock, 6 o'clock, and the 9 o'clock positions, and these were sent for frozen section evaluation.  Frozen section revealed positive margins at one end of the resection.  Therefore, an additional circumferential resection was performed and the final margins were all negative.,Following completion, the deep periosteal margin was resected.  The circumferential periosteal margins were noted to be negative; however, centrally, there was a small area which showed tumor eroding into the superficial cortex of the skull.  Therefore, the Midas Rex drill was utilized to resect approximately 1-2 mm of the superficial cortex of the bone at the area where the positive margin was located.  Healthy bone was obtained; however, it did not enter the diploic or marrow-containing bone in the area.  Therefore, no bong margin was taken.  However, at the end of the procedure, it did not appear that the residual bone had any residual changes consistent with carcinoma.,Following completion of the bony resection, the area was irrigated with copious amounts of saline.  Thereafter, advancement flaps were created, both on the left and the right side of the scalp, with the total undermined area being approximately 18cm by 16cm.  The galea was incised in multiple areas, to provide for additional mobilization of the tissue.  The tissue was closed under tension with 3-0 Vicryl suture deep in the galea and surgical staples superficially.,The patient was awakened from anesthetic, was extubated and was taken to the recovery room in stable condition.,DISPOSITION:,  The patient was discharged to home with antibiotics and analgesics, to follow-up in approximately one week.,NOTE: , The final margins of both periosteal, as well as skin were negative circumferentially, around the tumor.  The only positive margin was deep, which was a periosteal margin and bone underlying it was partially resected, as was indicated above.","hematology - oncology, squamous cell carcinoma of the scalp, squamous cell carcinoma, radical resection, margin, midas rex drill, radical resection of tumor, resection of tumor, endotracheal anesthesia, superficial cortex, margins, periosteum, skull, cortex, periosteal, scalp, resection, tumor, "
 Invasive carcinoma of left breast. Left modified radical mastectomy., Hematology - Oncology, Radical Mastectomy ,"PREOPERATIVE DIAGNOSIS:,  Invasive carcinoma of left breast.,POSTOPERATIVE DIAGNOSIS:,  Invasive carcinoma of left breast.,OPERATION PERFORMED:,  Left modified radical mastectomy.,ANESTHESIA: , General endotracheal.,INDICATION FOR THE PROCEDURE:  ,The patient is a 52-year-old female who recently underwent a left breast biopsy and was found to have invasive carcinoma of the left breast.  The patient was elected to have a left modified radical mastectomy, she was not interested in a partial mastectomy.  She is aware of the risks and complications of surgery, and wished to proceed.,DESCRIPTION OF PROCEDURE:  ,The patient was taken to the operating room.  She underwent general endotracheal anesthetic.  The TED stockings and venous compression devices were placed on both lower extremities and they were functioning well.  The patient's left anterior chest wall, neck, axilla, and left arm were prepped and draped in the usual sterile manner.  The recent biopsy site was located in the upper and outer quadrant of left breast.  The plain incision was marked along the skin.  Tissues and the flaps were injected with 0.25% Marcaine with epinephrine solution and then a transverse elliptical incision was made in the breast of the skin to include nipple areolar complex as well as the recent biopsy site.  The flaps were raised superiorly and just below the clavicle medially to the sternum, laterally towards the latissimus dorsi, rectus abdominus fascia.  Following this, the breast tissue along with the pectoralis major fascia were dissected off the pectoralis major muscle.  The dissection was started medially and extended laterally towards the left axilla.  The breast was removed and then the axillary contents were dissected out.  Left axillary vein and artery were identified and preserved as well as the lung _____.  The patient had several clinically palpable lymph nodes, they were removed with the axillary dissection.  Care was taken to avoid injury to any of the above mentioned neurovascular structures.  After the tissues were irrigated, we made sure there were no signs of bleeding.  Hemostasis had been achieved with Hemoclips.  Hemovac drains x2 were then brought in and placed under the left axilla as well as in the superior and inferior breast flaps.  The subcu was then approximated with interrupted 4-0 Vicryl sutures and skin with clips.  The drains were sutured to the chest wall with 3-0 nylon sutures.  Dressing was applied and the procedure was completed.  The patient went to the recovery room in stable condition.","hematology - oncology, invasive carcinoma, chest wall, neck, axilla, modified radical mastectomy, radical mastectomy, invasive, carcinoma, mastectomy"
 Sepsis.  The patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter., Hematology - Oncology, Sepsis - Consult ,"REASON FOR ADMISSION: , Sepsis.,HISTORY OF PRESENT ILLNESS:  ,The patient is a pleasant but demented 80-year-old male, who lives in board and care, who presented with acute onset of abdominal pain.  In the emergency room, the patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter.  The patient is unable to provide further history.  The patient's son is at the bedside and confirmed his history.  The patient was given IV antibiotics in the emergency room.  He was also given some hydration.,PAST MEDICAL HISTORY:,1.  History of CAD.,2.  History of dementia.,3.  History of CVA.,4.  History of nephrolithiasis.,ALLERGIES: , NONE.,MEDICATIONS:,1.  Ambien.,2.  Milk of magnesia.,3.  Tylenol.,4.  Tramadol.,5.  Soma.,6.  Coumadin.,7.  Zoloft.,8.  Allopurinol.,9.  Digoxin.,10.  Namenda.,11.  Zocor.,12.  BuSpar.,13.  Detrol.,14.  Coreg.,15.  Colace.,16.  Calcium.,17.  Zantac.,18.  Lasix.,19.  Seroquel.,20.  Aldactone.,21.  Amoxicillin.,FAMILY HISTORY:  ,Noncontributory.,SOCIAL HISTORY: , The patient lives in a board and care.  No tobacco, alcohol or IV drug use.,REVIEW OF SYSTEMS: , As per the history of present illness, otherwise unremarkable.,PHYSICAL EXAMINATION:,VITAL SIGNS:  The patient is currently afebrile.  Pulse 52, respirations 20, blood pressure 104/41, and saturating 98% on room air.,GENERAL:  The patient is awake.  Not oriented x3, in no acute distress.,HEENT:  Pupils are equal, round, and reactive to light and accommodation.  Extraocular movements are intact.  Mucous membranes are dry.,NECK:  Supple.  No thyromegaly.  No jugular venous distention.,HEART:  Irregularly irregular, brady.,LUNGS:  Clear to auscultation bilaterally anteriorly.,ABDOMEN:  Positive normoactive bowel sounds.  Soft.  Tenderness in the suprapubic region without rebound.,EXTREMITIES:  No clubbing, cyanosis or edema in upper and lower extremities.",
" Excision of right superior parathyroid adenoma, seen on sestamibi parathyroid scan and an ultrasound.", Hematology - Oncology, Parathyroid Adenoma Excision ,"PREOPERATIVE DIAGNOSIS:,  Right superior parathyroid adenoma.,POSTOPERATIVE DIAGNOSIS:,  Right superior parathyroid adenoma.,PROCEDURE: , Excision of right superior parathyroid adenoma.,ANESTHESIA:,  Local with 1% Xylocaine and anesthesia standby with sedation.,CLINICAL HISTORY:,  This 80-year-old woman has had some mild dementia.  She was begun on Aricept but could not tolerate that because of strange thoughts and hallucinations.  She was found to be hypercalcemic.  Intact PTH was mildly elevated.  A sestamibi parathyroid scan and an ultrasound showed evidence of a right superior parathyroid adenoma.,FINDINGS AND PROCEDURE:,  The patient was placed on the operating table in the supine position.  A time out was taken so that the anesthesia personnel, nursing personnel, surgical team, and patient could confirm the patient's identity, operative site and operative plan.  The electronic medical record was reviewed as was the ultrasound.  The patient was sedated.  A small roll was placed behind the shoulders to moderately hyperextend the neck.  The head was supported in a foam head cradle.  The neck and chest were prepped with chlorhexidine and isolated with sterile drapes.  After infiltration with 1% Xylocaine with epinephrine along the planned incision, a transverse incision was made in the skin crease a couple of centimeters above the clavicular heads and carried down through the skin, subcutaneous tissue, and platysma.  The larger anterior neck veins were divided between 4-0 silk ligatures.  Superior and inferior flaps were developed in the subplatysmal plane using electrocautery and blunt dissection.  The sternohyoid muscles were separated in the midline, and the right sternohyoid muscle was retracted laterally.  The right sternothyroid muscle was divided transversely with the cautery.  The right middle thyroid vein was divided between 4-0 silk ligatures.  The right thyroid lobe was rotated leftward.  Posterior to the mid portion of the left thyroid lobe, a right superior parathyroid adenoma of moderate size was identified.  This was freed up and its pedicle was ligated with small Hemoclips and divided and the gland was removed.  It was sent for weight and frozen section.  It weighed 960 mg and on frozen section was consistent with a parathyroid adenoma.,Prior to the procedure, a peripheral blood sample had been obtained and placed in a purple top tube labeled ""pre-excision.""  It was our intention to monitor intraoperative intact parathyroid hormone 10 minutes after removal of this parathyroid adenoma.  However, we could not obtain 3 cc of blood from either the left foot or the left arm after multiple attempts, and therefore, we decided that the chance of cure of hyperparathyroidism by removal of this parathyroid adenoma was high enough and the improvement in that chance of cure marginal enough that we would terminate the procedure without monitoring PTH.  The neck was irrigated with saline and hemostasis found to be satisfactory.  The sternohyoid muscles were reapproximated with interrupted 4-0 Vicryl.  The platysma was closed with interrupted 4-0 Vicryl, and the skin was closed with subcuticular 5-0 Monocryl and Dermabond.  The patient was awakened and taken to the recovery area in satisfactory condition having tolerated the procedure well.","hematology - oncology, parathyroid adenoma, superior parathyroid adenoma, excision, sestamibi parathyroid scan, sestamibi parathyroid, parathyroid scan, sternohyoid muscles, superior parathyroid, parathyroid, sestamibi, platysma, adenoma, ultrasound, sternohyoid, thyroid, muscles "
 Followup for polycythemia vera with secondary myelofibrosis.  JAK-2 positive myeloproliferative disorder.   He is not a candidate for chlorambucil or radioactive phosphorus because of his young age and the concern for secondary malignancy., Hematology - Oncology, Polycythemia Vera Followup ,"DIAGNOSIS:,  Polycythemia vera with secondary myelofibrosis.,REASON FOR VISIT:, Followup of the above condition.,CHIEF COMPLAINT: , Left shin pain.,HISTORY OF PRESENT ILLNESS: , A 55-year-old white male who carries a diagnosis of polycythemia vera with secondary myelofibrosis.  Diagnosis was made some time in 2005/2006.  Initially, he underwent phlebotomy.  He subsequently transferred his care here.  In the past, he has been on hydroxyurea and interferon but did not tolerate both of them.  He is JAK-2 positive.  He does not have any siblings for a match-related transplant.  He was seen for consideration of a MUD transplant, but was deemed not to be a candidate because of the social support as well as his reasonably good health.,At our institution, the patient received a trial of lenalidomide and prednisone for a short period.  He did well with the combination.  Subsequently, he developed intolerance to lenalidomide.  He complained of severe fatigue and diarrhea.  This was subsequently stopped.,The patient reports some injury to his left leg last week.  His left leg apparently was swollen.  He took steroids for about 3 days and stopped.  Left leg swelling has disappeared.  The patient denies any other complaints at this point in time.  He admits to smoking marijuana.  He says this gives him a great appetite and he has actually gained some weight.  Performance status in the ECOG scale is 1.,PHYSICAL EXAMINATION:,VITAL SIGNS:  He is afebrile.  Blood pressure 144/85, pulse 86, weight 61.8 kg, and respiratory rate 18 per minute.  GENERAL:  He is in no acute distress.  HEENT:  There is no pallor, icterus or cervical adenopathy that is noted.  Oral cavity is normal to exam.  CHEST:  Clear to auscultation.  CARDIOVASCULAR:  S1 and S2 normal with regular rate and rhythm.  ABDOMEN:  Soft and nontender with no hepatomegaly.  Spleen is palpable 4 fingerbreadths below the left costal margin.  There is no guarding, tenderness, rebound or rigidity noted.  Bowel sounds are present.  EXTREMITIES:  Reveal no edema.  Palpation of the left tibia revealed some mild tenderness.  However, I do not palpate any bony abnormalities.  There is no history of deep venous thrombosis.,LABORATORY DATA: , CBC from today is significant for a white count of 41,900 with an absolute neutrophil count of 34,400, hemoglobin 14.8 with an MCV of 56.7, and platelet count 235,000.,ASSESSMENT AND PLAN:,1.  JAK-2 positive myeloproliferative disorder.  The patient has failed pretty much all available options.  He is not a candidate for chlorambucil or radioactive phosphorus because of his young age and the concern for secondary malignancy.  I have e-mailed Dr. X to see whether he will be a candidate for the LBH trial.  Hopefully, we can get a JAK-2 inhibitor trial quickly on board.,2.  I am concerned about the risk of thrombosis with his elevated white count.  He is on aspirin prophylaxis.  The patient has been told to call me with any complaints.,3.  Left shin pain.  I have ordered x-rays of the left tibia and knee today.  The patient will return to the clinic in 3 weeks.  He is to call me in the interim for any problems.","hematology - oncology, jak-2 positive myeloproliferative disorder, secondary myelofibrosis, mud transplant, ecog scale, myeloproliferative disorder, radioactive phosphorus, jak positive, polycythemia vera, thrombosis, myelofibrosis,"
 Left breast cancer.  Nuclear medicine lymphatic scan.  A 16-hour left anterior oblique imaging was performed with and without shielding of the original injection site., Hematology - Oncology, Nuclear Medicine Lymphatic Scan ,"EXAM:,  Nuclear medicine lymphatic scan.,REASON FOR EXAM: , Left breast cancer.,TECHNIQUE: , 1.0 mCi of Technetium-99m sulfur colloid was injected within the dermis surrounding the left breast biopsy site at four locations.  A 16-hour left anterior oblique imaging was performed with and without shielding of the original injection site.,FINDINGS:  ,There are two small foci of increased activity in the left axilla.  This is consistent with the sentinel lymph node.  No other areas of activity are visualized outside of the injection site and two axillary lymph nodes.,IMPRESSION:  ,Technically successful lymph node injection with two areas of increased activity in the left axilla consistent with sentinel lymph node.","hematology - oncology, technetium-99m, mci, biopsy, breast cancer, nuclear medicine, lymphatic scan, lymph node, nuclear, breast, "
 Polycythemia rubra vera.  The patient is an 83-year-old female with a history of polycythemia vera.  She comes in to clinic today for followup.  She has not required phlebotomies for several months., Hematology - Oncology, Polycythemia Rubra Vera ,"CHIEF COMPLAINT: , Polycythemia rubra vera.,HISTORY OF PRESENT ILLNESS: , The patient is an 83-year-old female with a history of polycythemia vera.  She comes in to clinic today for followup.  She has not required phlebotomies for several months.  The patient comes to clinic unaccompanied.,CURRENT MEDICATIONS: , Levothyroxine 200 mcg q.d., Nexium 40 mg q.d., Celebrex 200 mg q.d., vitamin D3 2000 IU q.d., aspirin 81 mg q.d., selenium 200 mg q.d., Aricept 10 mg q.d., Skelaxin 800 mg q.d., ropinirole 1 mg q.d., vitamin E 1000 IU q.d., vitamin C 500 mg q.d., flaxseed oil 100 mg daily, fish oil 100 units q.d., Vicodin q.h.s., and stool softener q.d.,ALLERGIES:  ,Penicillin.,REVIEW OF SYSTEMS:  ,The patient's chief complaint is her weight.  She brings in a packet of information on HCZ Diovan and also metabolic assessment that was done at the key.  She has questions as to whether or not there would be any contra indications to her going on the diet.  Otherwise, she feels great.  She had family reunion in Iowa once in four days out there.  She continues to volunteer Hospital and is walking and enjoying her summer.  She denies any fevers, chills, or night sweats.  She has some mild constipation problem but has had under control.  The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:","hematology - oncology, polycythemia rubra vera, phlebotomy, hematocrit, polycythemia, "
 Pilonidal cyst with abscess formation.  Excision of infected pilonidal cyst., Hematology - Oncology, Pilonidal Cyst Excision ,"PREOPERATIVE DIAGNOSIS: , Pilonidal cyst with abscess formation.,POSTOPERATIVE DIAGNOSIS:,  Pilonidal cyst with abscess formation.,OPERATION: , Excision of infected pilonidal cyst.,PROCEDURE: , After obtaining informed consent, the patient underwent a spinal anesthetic and was placed in the prone position in the operating room.  A time-out process was followed.  Antibiotics were given and then the patient was prepped and draped in the usual fashion.  It appeared to me that the abscess had drained somewhat during the night, as it was much smaller than I was anticipating.  An elliptical excision of all infected tissues down to the coccyx was performed.  Hemostasis was achieved with a cautery.  The wound was irrigated with normal saline and it was packed open with iodoform gauze and an absorptive dressing.,The patient was sent to recovery room in satisfactory condition.  Estimated blood loss was minimal.  The patient tolerated the procedure well.","hematology - oncology, hemostasis, excision, pilonidal cyst, cyst, abscess, infected,"
" The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma of the right adrenal gland with favorable Shimada histology and history of stage 2 left adrenal neuroblastoma, status post gross total resection.", Hematology - Oncology, Neuroblastoma - Consult ,"REASON FOR VISIT:,  The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma here for ongoing management of his disease and the visit is supervised by Dr. X.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-month-old with neuroblastoma, which initially presented on the left when he was 6 weeks old and was completely resected.  It was felt to be stage 2.  It was not N-Myc amplified and had favorable Shimada histology.  In followup, he was found to have a second primary in his right adrenal gland, which was biopsied and also consistent with neuroblastoma with favorable Shimada histology.  He is now being treated with chemotherapy per protocol P9641 and not on study.  He last received chemotherapy on 05/21/07, with carboplatin, cyclophosphamide, and doxorubicin.  He received G-CSF daily after his chemotherapy due to neutropenia that delayed his second cycle.  In the interval since he was last seen, his mother reports that he had a couple of days of nasal congestion, but it is now improving.  He is not acted ill or had any fevers.  He has had somewhat diminished appetite, but it seems to be improving now.  He is peeing and pooping normally and has not had any diarrhea.  He did not have any appreciated nausea or vomiting.  He has been restarted on fluconazole due to having redeveloped thrush recently.,REVIEW OF SYSTEMS: , The following systems reviewed and negative per pathology except as noted above.  Eyes, ears, throat, cardiovascular, GI, genitourinary, musculoskeletal skin, and neurologic., PAST MEDICAL HISTORY:,  Reviewed as above and otherwise unchanged.,FAMILY HISTORY:,  Reviewed and unchanged.,SOCIAL HISTORY: , The patient's parents continued to undergo a separation and divorce.  The patient spends time with his father and his family during the first part of the week and with his mother during the second part of the week.,MEDICATIONS:  ,1.  Bactrim 32 mg by mouth twice a day on Friday, Saturday, and Sunday.,2.  G-CSF 50 mcg subcutaneously given daily in his thighs alternating with each dose.,3.  Fluconazole 37.5 mg daily.,4.  Zofran 1.5 mg every 6 hours as needed for nausea.,ALLERGIES: , No known drug allergies.,FINDINGS: , A detailed physical exam revealed a very active and intractable, well-nourished 11-month-old male with weight 10.5 kilos and height 76.8 cm.  Vital Signs:  Temperature is 35.3 degrees Celsius, pulse is 121 beats per minute, respiratory rate 32 breaths per minute, blood pressure 135/74 mmHg.  Eyes:  Conjunctivae are clear, nonicteric.  Pupils are equally round and reactive to light.  Extraocular muscle movements appear intact with no strabismus.  Ears:  TMs are clear bilaterally.  Oral Mucosa:  No thrush is appreciated.  No mucosal ulcerations or erythema.  Chest:  Port-a-Cath is nonerythematous and nontender to VP access port.  Respiratory:  Good aeration, clear to auscultation bilaterally.  Cardiovascular:  Regular rate, normal S1 and S2, no murmurs appreciated.  Abdomen is soft, nontender, and no organomegaly, unable to appreciate a right-sided abdominal mass or any other masses.  Skin:  No rashes.  Neurologic:  The patient walks without assistance, frequently falls on his bottom.,LABORATORY STUDIES: , CBC and comprehensive metabolic panel were obtained and they are significant for AST 51, white blood cell count 11,440, hemoglobin 10.9, and platelets 202,000 with ANC 2974.  Medical tests none.  Radiologic studies are none.,ASSESSMENT: , This patient's disease is life threatening, currently causing moderately severe side effects.,PROBLEMS DIAGNOSES:  ,1.  Neuroblastoma of the right adrenal gland with favorable Shimada histology.,2.  History of stage 2 left adrenal neuroblastoma, status post gross total resection.,3.  Immunosuppression.,4.  Mucosal candidiasis.,5.  Resolving neutropenia.,PROCEDURES AND IMMUNIZATIONS:,  None.,PLANS:  ,1.  Neuroblastoma.  The patient will return to the Pediatric Oncology Clinic on 06/13/07 to 06/15/07 for his third cycle of chemotherapy.  I will plan for restaging with CT of the abdomen prior to the cycle.,2.  Immunosuppression.  The patient will continue on his Bactrim twice a day on Thursday, Friday, and Saturday.  Additionally, we will tentatively plan to have him continue fluconazole since this is his second episode of thrush.,3.  Mucosal candidiasis.  We will continue fluconazole for thrush.  I am pleased that the clinical evidence of disease appears to have resolved.  For resolving neutropenia, I advised Gregory's mother about it is okay to discontinue the G-CSF at this time.  We will plan for him to resume G-CSF after his next chemotherapy and prescription has been sent to the patient's pharmacy.,PEDIATRIC ONCOLOGY ATTENDING: , I have reviewed the history of the patient.  This is an 11-month-old with neuroblastoma who received chemotherapy with carboplatin, cyclophosphamide, and doxorubicin on 05/21/07 for cycle 2 of POG-9641 due to his prior history of neutropenia, he has been on G-CSF.  His ANC is nicely recovered.  He will have a restaging CT prior to his next cycle of chemotherapy and then return for cycle 3 chemotherapy on 06/13/07 to 06/15/07.  He continues on fluconazole for recent history of thrush.  Plans are otherwise documented above.",
 Follicular non-Hodgkin's lymphoma.  Biopsy of a left posterior auricular lymph node and pathology showed follicular non-Hodgkin's lymphoma.  Received six cycles of CHOP chemotherapy. , Hematology - Oncology, Non-Hodgkin lymphoma Followup ,"CHIEF COMPLAINT:,  Follicular non-Hodgkin's lymphoma.,HISTORY OF PRESENT ILLNESS: , This is an extremely pleasant 69 year-old gentleman, who I follow for his follicular lymphoma.  His history is that in February of 1988 he had a biopsy of a left posterior auricular lymph node and pathology showed follicular non-Hodgkin's lymphoma.  From 03/29/88 to 08/02/88, he received six cycles of CHOP chemotherapy.  In 1990, his CT scan showed retroperitoneal lymphadenopathy.  Therefore from 04/02/90 to 08/20/90, he received seven cycles of CVP.  In 1999, he was treated with m-BACOD.  He also received radiation to his pelvis.  On 03/21/01, he had a right cervical lymph node biopsy, which again showed follicular lymphoma.  His most recent PET scan dated 12/31/08 showed resolution of previously described hypermetabolic lymph nodes in the right lower neck.,Overall, he is doing well.  He has a good energy level, his ECOG performance status is 0.  He denies any fever, chills or night sweats.  No lymphadenopathy.  No nausea or vomiting.  No change in bowel or bladder habits.,CURRENT MEDICATIONS: , Avelox 400 mg q.d. p.r.n., cefuroxime 200 mg q.d. to be altered monthly with doxycycline 100 mg q.d., Coumadin 5 mg on Monday and 2.5 mg on all other days, dicyclomine 10 mg q.d., Coreg 6.25 mg b.i.d., Vasotec 2.5 mg b.i.d., Zantac 150 mg q.d., Claritin D q.d., Centrum q.d., calcium q.d., omega-3 b.i.d., Metamucil q.d., and Lasix 40 mg t.i.d.,ALLERGIES: , No known drug allergies.,REVIEW OF SYSTEMS:  ,As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1.  He has chronic lymphedema of the bilateral lower extremities secondary to his pelvic radiation.,2.  He had bilateral ureteral obstruction and is status post a stent placement.  The obstruction was secondary to his pelvic radiation.,3.  History of congestive heart failure.,4.  History of schwannoma resection.  It was resected from T12 to L1 in 1991.,5.  He has chronic obstruction of his inferior vena cava.,6.  Recurrent lower extremity cellulitis.,SOCIAL HISTORY:  ,He has no tobacco use.  No alcohol use.  He is married.  He is a retired Methodist minister.,FAMILY HISTORY: , His mother just died two days ago.  There is no history of solid tumors or hematologic malignancies in his family.,PHYSICAL EXAM:,VIT:",
" New diagnosis of non-small cell lung cancer stage IV metastatic disease.  At this point, he and his wife ask about whether this is curable disease and it was difficult to inform that this was not curable disease but would be treatable.", Hematology - Oncology, Non-Small Cell Lung Cancer - Consult ,"REASON FOR CONSULTATION:,  New diagnosis of non-small cell lung cancer.,HISTORY OF PRESENT ILLNESS: , ABCD is a very nice 47-year-old gentleman without much past medical history who has now been diagnosed with a new non-small cell lung cancer stage IV metastatic disease.  We are consulted at this time to discuss further treatment options.,ABCD and his wife state that his history goes back to approximately 2-2-1/2 weeks ago when he developed some left-sided flank pain.  Initially, he did not think much of this and tried to go about doing work and everything else but the pain gradually worsened.  Eventually this prompted him to present to the emergency room.  A CT scan was done there, and he was found to have a large left adrenal mass worrisome for metastatic disease.  At that point, he was transferred to XYZ Hospital for further evaluation.  On admission on 12/19/08, a CT scan of the chest, abdomen, and pelvis was done for full staging purposes.  The CT scan of the chest showed an abnormal soft tissue mass in the right paratracheal region, extending into the precarinal region, the subcarinal region, and the right hilum.  This was causing some compression on the inferior aspect of the SVC and also some narrowing of the right upper lobe pulmonary artery.  There was an abnormal lymph node noted in the AP window and left hilar region.  There was another spiculated mass within the right upper lobe measuring 2.0 x 1.5 cm.  There was also an 8 mm non-calcified nodule noted in the posterior-inferior aspect of the left upper lobe suspicious for metastatic disease.  There were areas of atelectasis particularly in the right base.  There was also some mild ground glass opacity within the right upper lobe adjacent to the right hilum potentially representing focal area of pulmonary edema versus small infarction related to the right upper lobe pulmonary artery narrowing.  There was a small lucency adjacent to the medial aspect of the left upper lobe compatible with a small pneumothorax.  In the abdomen, there was a mass involved in the left adrenal gland as well as a nodule involving the right adrenal gland both of which appeared necrotic compatible with metastatic tumor.  All other structures appeared normal.  On 12/22/08, a CT-guided biopsy of the left adrenal mass was performed.  Pathology from this returned showing metastatic poorly differentiated non-small cell carcinoma.  At this point, we have been consulted to discuss further treatment options.,On further review, ABCD states that he has may be had a 20 pound weight loss over the last couple of months which he relates to anorexia or decreased appetite.  He has not ever had a chronic smoker's cough and still does not have a cough.  He has no sputum production or hemoptysis.  He and his wife are very anxious about this diagnosis.,PAST MEDICAL HISTORY: , He denies any history of heart disease, lung disease, kidney disease, liver disease, hepatitis major infection, seizure disorders or other problems.,PAST SURGICAL HISTORY: , He denies having any surgeries.,ALLERGIES: , No known drug allergies.,MEDICATIONS:,  At home he takes no medication except occasional aspirin or ibuprofen, recently for his flank pain.  He does take a multivitamin on occasion.,SOCIAL HISTORY:  He has about a 30-pack-a-year history of smoking.  He used to drink alcohol heavily and has a history of getting a DUI about a year-and-half ago resulting in him having his truck-driving license revoked.  Since that time he has worked with printing press.  He is married and has two children, both of whom are grown in their 20s, but are now living at home.,FAMILY HISTORY: , His mother died for alcohol-related complications.  He otherwise denies any history of cancers, bleeding disorders, clotting disorders, or other problems.,REVIEW OF SYSTEMS: , GENERAL/CONSTITUTIONAL:  He has lost about 20 pounds of weight as described above.  He also has a trouble with fatigue.  No lightheadedness or dizziness.  HEENT:  He denies any new or changing headache, change in vision, double vision, or loss of vision, ringing in his ears, loss of hearing in one year.  He does not take care of his teeth very well but currently he has no mouth, jaw, or teeth pain.  RESPIRATORY:  He has had some little bit of dyspnea on exertion but otherwise denies shortness of breath at rest.  No cough, congestion, wheezing, hemoptysis, and sputum production.  CVS:  He denies any chest pains, palpitations, PND, orthopnea, or swelling of his lower extremities.  GI:  He denies any odynophagia, dysphagia, heartburn on a regular basis, abdominal pain, abdominal swelling, diarrhea, blood in his stool, or black tarry stools.  He has been somewhat constipated recently.  GU:  He denies any burning with urination, kidney stones, blood in his urine, dysuria, difficulty getting his urine out or other problems.  MUSCULOSKELETAL:  He denies any new bony aches or pains including back pain, hip pain, and rib pain.  No muscle aches, no joint swelling, and no history of gout.  SKIN:  No rashes, no bruising, petechia, non-healing wounds, or ulcerations.  He has had no nail or hair changes.  HEM:  He denies any bloody nose, bleeding gums, easy bruising, easy bleeding, swollen lymphs or bumps.  ENDOCRINE:  He denies any tremor, shakiness, history of diabetes, thyroid problems, new or enlarging stretch marks, exophthalmos, insomnia, or tremors.  NEURO:  He denies any mental status changes, anxiety, confusion, depression, hallucinations, loss of feeling in her arm or leg, numbness or tingling in hands or feet, loss of balance, syncope, seizures, or loss of coordination.,PHYSICAL EXAMINATION,VITAL SIGNS:  His T-max is 98.8.  His pulse is 85, respirations 18, and blood pressure 126/80 saturating over 90% on room air.,GENERAL:  No acute distress, pleasant gentleman who appears stated age.,HEENT:  NC/AT.  Sclerae anicteric.  Conjunctiva clear.  Oropharynx is clear without erythema, exudate, or discharge.,NECK:  Supple.  Nontender.  No elevated JVP.  No carotid bruits.  No thyromegaly.  No thyroid nodules.  Carotids are 2+ and symmetric.,BACK:  Spine is straight.  No spinal tenderness.  No CVA tenderness.  No presacral edema.,CHEST:  Clear to auscultation and percussion bilaterally.  No wheezes, rales, or rhonchi.  Normal symmetric chest wall expansion with inspiration.,CVS:  Regular rate and rhythm.  No murmurs, gallops, or rubs.,ABDOMEN:  Soft, nontender, nondistended.  No hepatosplenomegaly.  No guarding or rebound.  No masses.  Normoactive bowel sounds.,EXTREMITIES:  No cyanosis, clubbing, or edema.  No joint swelling.  Full range of motion.,SKIN:  No rashes, wounds, ulcerations, bruises, or petechia.,NEUROLOGIC:  Cranial nerves II through XII are intact.  He has intact sensation to light touch throughout.  He has 2+ deep tendon reflexes bilaterally in the biceps, triceps, brachioradialis, patellar and ankle reflexes.  He is alert and oriented x3.,LABORATORY DATA: , His white blood cell count is 9.4, hemoglobin 13.0, hematocrit 38%, and platelets 365,000.  The differential shows 73% neutrophils, 17% lymphocytes, 7.6% monocytes, 1.9% eosinophils, and 0.7% basophils.  Chemistry shows sodium 138, potassium 3.8, chloride 104, CO2 of 31, BUN 9, creatinine 1.0, glucose 104, calcium 12.3, alkaline phosphatase 104, AST 16, ALT 12, total protein 7.6, albumin 3.5, total bilirubin 0.5, ionized calcium 1.7.  His INR is 1.0 with the PT of 11.4 and a PTT of 31.3.,IMAGINING DATA:,  MRI of the brain on 12/23/08 - this shows some mild white matter disease, question of minimal pontine ischemic gliosis as well as a small incidental venous angioma in the left posterior frontal deep white matter.  There is no evidence of cerebral metastasis, hemorrhage, or acute infarction.,ASSESSMENT/PLAN: , ABCD is a very nice 47-year-old gentleman without much past medical history, who now presents with metastatic non-small cell lung cancer.  At this point, he and his wife ask about whether this is curable disease and it was difficult to inform that this was not curable disease but would be treatable.  His wife particularly had a very hard time with this prognosis.  They preferred not to know the exact average as to how long someone lives with this disease.  I did offer chemotherapy as a way to treat this disease.  Chemotherapy has been associated both with palliation of symptoms as well as prolong survival.  At this point, he has an excellent functional status and I think he would tolerate chemotherapy quite well.,In terms of chemotherapy, I talked briefly about the side affects including but not limited to GI upset, diarrhea, nausea, vomiting, mucositis, fatigue, loss of appetite, low blood counts including the possible need for transfusion as well as the risk of infections, which in some rare cases can be fatal.  I would likely use carboplatin and gemcitabine.  This would be both medications given on day 1 with a dose of gemcitabine on day 8.  This cycle will be repeated after 1-week break so that the cycle lasts 21 days.  The goal will be to complete 6 cycles of this as long as he is responding and tolerating the medication.,In terms of staging Mr. ABCD'S had all the appropriate staging.  A PET-CT scan could be done, but at this point would not provide much mean full information beyond the CT scans that we have.,At this point, his biggest issue is pain and he is getting a pain consult to help control his pain.  He will be ready to be discharged from the hospital once his pain is under better control.  As this is the holiday weekend, I do not have a way of scheduling a followup appointment with them, but I did give he and his wife my card and instructed them to call on Monday.  At that point, we will get him in and I will also begin working on making arrangements for his chemotherapy.,Thank you very much for this interesting consult.",
" Left neck dissection.   Metastatic papillary cancer, left neck.  The patient had thyroid cancer, papillary cell type, removed with a total thyroidectomy and then subsequently recurrent disease was removed with a paratracheal dissection.", Hematology - Oncology, Neck Dissection ,"PREOPERATIVE DIAGNOSIS: , Metastatic papillary cancer, left neck.,POSTOPERATIVE DIAGNOSIS: , Metastatic papillary cancer, left neck.,OPERATION PERFORMED: , Left neck dissection.,ANESTHESIA:  ,General endotracheal.,INDICATIONS: , The patient is a very nice gentleman, who has had thyroid cancer, papillary cell type, removed with a total thyroidectomy and then subsequently recurrent disease was removed with a paratracheal dissection.  He now has evidence of lesion in the left mid neck and the left superior neck on ultrasound, which are suspicious for recurrent cancer.  Left neck dissection is indicated.,DESCRIPTION OF OPERATION: , The patient was placed on the operating room table in the supine position.  After adequate general endotracheal anesthesia was administered, the table was then turned.  A shoulder roll placed under the shoulders and the face was placed in an extended fashion.  The left neck, chest, and face were prepped with Betadine and draped in a sterile fashion.  A hockey stick skin incision was performed, extending a previous incision line superiorly towards the mastoid cortex through skin, subcutaneous tissue and platysma with Bovie electrocautery on cut mode.  Subplatysmal superior and inferior flaps were raised.  The dissection was left lateral neck dissection encompassing zones 1, 2A, 2B, 3, and the superior portion of 4.  The sternocleidomastoid muscle was unwrapped at its fascial attachment and this was taken back posterior to the XI cranial nerve into the superior posterior most triangle of the neck.  This was carried forward off of the deep rooted muscles including the splenius capitis and anterior and middle scalenes taken medially off of these muscles including the fascia of the muscles, stripped from the carotid artery, the X cranial nerve, the internal jugular vein and then carried anteriorly to the lateral most extent of the dissection previously done by Dr. X in the paratracheal region.  The submandibular gland was removed as well.  The X, XI, and XII cranial nerves were preserved.  The internal jugular vein and carotid artery were preserved as well.  Copious irrigation of the wound bed showed no identifiable bleeding at the termination of the procedure.  There were two obviously positive nodes in this neck dissection.  One was left medial neck just lateral to the previous tracheal dissection and one was in the mid region of zone 2.  A #10 flat fluted Blake drain was placed through a separate stab incision and it was secured to the skin with a 2-0 silk ligature.  The wound was closed in layers using a 3-0 Vicryl in a buried knot interrupted fashion for the subcutaneous tissue and the skin was closed with staples.  A fluff and Kling pressure dressing was then applied.  The patient was extubated in the operating room, brought to the recovery room in satisfactory condition.  There were no intraoperative complications.","hematology - oncology, metastatic papillary cancer, thyroidectomy, thyroid cancer, papillary cell type, dissection, neck, metastatic, paratracheal, papillary, cancer"
 A very pleasant 66-year-old woman with recurrent metastatic ovarian cancer.  , Hematology - Oncology, Metastatic Ovarian Cancer - Consult ,"REASON FOR CONSULTATION:,  Metastatic ovarian cancer.,HISTORY OF PRESENT ILLNESS: , Mrs. ABCD is a very nice 66-year-old woman who is followed in clinic by Dr. X for history of renal cell cancer, breast cancer, as well as ovarian cancer, which was initially diagnosed 10 years ago, but over the last several months has recurred and is now metastatic.  She last saw Dr. X in clinic towards the beginning of this month.  She has been receiving gemcitabine and carboplatin, and she receives three cycles of this with the last one being given on 12/15/08.  She was last seen in clinic on 12/22/08 by Dr. Y.  At that point, her white count was 0.9 with the hemoglobin of 10.3, hematocrit of 30%, and platelets of 81,000.  Her ANC was 0.5.  She was started on prophylactic Augmentin as well as Neupogen shots.  She has also had history of recurrent pleural effusions with the knee for thoracentesis.  She had two of these performed in November and the last one was done about a week ago.,Over the last 2 or 3 days, she states she has been getting more short of breath.  Her history is somewhat limited today as she is very tired and falls asleep readily.  Her history comes from herself but also from the review of the records.  Overall, her shortness of breath has been going on for the past few weeks related to her pleural effusions.  She was seen in the emergency room this time and on chest x-ray was found to have a new right-sided pulmonic consolidative infiltrate, which was felt to be possibly related to pneumonia.  She specifically denied any fevers or chills.  However, she was complaining of chest pain.  She states that the chest pain was located in the substernal area, described as aching, coming and going and associated with shortness of breath and cough.  When she did cough, it was nonproductive.  While in the emergency room on examination, her vital signs were stable except that she required 5 liters nasal cannula to maintain oxygen saturations.  An EKG was performed, which showed sinus rhythm without any evidence of Q waves or other ischemic changes.  The chest x-ray described above showed a right lower lobe infiltrate.  A V/Q scan was done, which showed a small mismatched defect in the left upper lobe and a mass defect in the right upper lobe.  The findings were compatible with an indeterminate study for a pulmonary embolism.  Apparently, an ultrasound of the lower extremities was done and was negative for DVT.  There was apparently still some concern that this might be pulmonary embolism and she was started on Lovenox.  There was also concern for pneumonia and she was started on Zosyn as well as vancomycin and admitted to the hospital.,At this point, we have been consulted to help follow along with this patient who is well known to our clinic.,PAST MEDICAL HISTORY,1.  Ovarian cancer - This was initially diagnosed about 10 years ago and treated with surgical resection including TAH and BSO.  This has recurred over the last couple of months with metastatic disease.,2.  History of breast cancer - She has been treated with bilateral mastectomy with the first one about 14 years and the second one about 5 years ago.  She has had no recurrent disease.,3.  Renal cell carcinoma - She is status post nephrectomy.,4.  Hypertension.,5.  Anxiety disorder.,6.  Chronic pain from neuropathy secondary to chemotherapy from breast cancer treatment.,7.  Ongoing tobacco use.,PAST SURGICAL HISTORY,1.  Recent and multiple thoracentesis as described above.,2.  Bilateral mastectomies.,3.  Multiple abdominal surgeries.,4.  Cholecystectomy.,5.  Remote right ankle fracture.,ALLERGIES:,  No known drug allergies.,MEDICATIONS: , At home,,1.  Atenolol 50 mg daily,2.  Ativan p.r.n.,3.  Clonidine 0.1 mg nightly.,4.  Compazine p.r.n.,5.  Dilaudid p.r.n.,6.  Gabapentin 300 mg p.o. t.i.d.,7.  K-Dur 20 mEq p.o. daily.,8.  Lasix unknown dose daily.,9.  Norvasc 5 mg daily.,10.  Zofran p.r.n.,SOCIAL HISTORY: , She smokes about 6-7 cigarettes per day and has done so for more than 50 years.  She quit smoking about 6 weeks ago.  She occasionally has alcohol.  She is married and has 3 children.  She lives at home with her husband.  She used to work as a unit clerk at XYZ Medical Center.,FAMILY HISTORY:,  Both her mother and father had a history of lung cancer and both were smokers.,REVIEW OF SYSTEMS: , GENERAL/CONSTITUTIONAL:  She has not had any fever, chills, night sweats, but has had fatigue and weight loss of unspecified amount.  HEENT:  She has not had trouble with headaches; mouth, jaw, or teeth pain; change in vision; double vision; or loss of hearing or ringing in her ears.  CHEST:  Per the HPI, she has had some increasing dyspnea, shortness of breath with exertion, cough, but no sputum production or hemoptysis.  CVS:  She has had the episodes of chest pains as described above but has not had, PND, orthopnea lower extremity swelling or palpitations.  GI:  No heartburn, odynophagia, dysphagia, nausea, vomiting, diarrhea, constipation, blood in her stool, and black tarry stools.  GU:  No dysuria, burning with urination, kidney stones, and difficulty voiding.  MUSCULOSKELETAL:  No new back pain, hip pain, rib pain, swollen joints, history of gout, or muscle weakness.  NEUROLOGIC:  She has been diffusely weak but no lateralizing loss of strength or feeling.  She has some chronic neuropathic pain and numbness as described above in the past medical history.  She is fatigued and tired today and falls asleep while talking but is easily arousable.  Some of this is related to her lack of sleep over the admission thus far.,PHYSICAL EXAMINATION,VITAL SIGNS:  Her T-max is 99.3.  Her pulse is 54, her respirations is 12, and blood pressure 118/61.,GENERAL:  Somewhat fatigued appearing but in no acute distress.,HEENT:  NC/AT.  Sclerae anicteric.  Conjunctiva clear.  Oropharynx is clear without any erythema, exudate, or discharge.,NECK:  Supple.  Nontender.  No elevated JVP.  No thyromegaly.  No thyroid nodules.,CHEST:  Clear to auscultation and percussion bilaterally with decreased breath sounds on the right.,CVS:  Regular rate and rhythm.  No murmurs, gallops or rubs.  Normal S1 and S2.  No S3 or S4.,ABDOMEN:  Soft, nontender, nondistended.  Normoactive bowel sounds.  No guarding or rebound.  No hepatosplenomegaly.  No masses.",
" Nonpalpable neoplasm, right breast.  Needle localized wide excision of nonpalpable neoplasm, right breast.", Hematology - Oncology, Needle Localized Excision - Breast Neoplasm ,"PREOPERATIVE DIAGNOSIS: , Nonpalpable neoplasm, right breast.,POSTOPERATIVE DIAGNOSIS: , Deferred for Pathology.,PROCEDURE PERFORMED:  ,Needle localized wide excision of nonpalpable neoplasm, right breast.,SPECIMEN: , Mammography.,GROSS FINDINGS:  ,This 53-year-old Caucasian female who had a nonpalpable neoplasm detected by mammography in the right breast.  After excision of neoplasm, there was a separate 1 x 2 cm nodule palpated within the cavity.  This too was excised.,OPERATIVE PROCEDURE:  ,The patient was taken to the operating room, placed in supine position in the operating table.  Intravenous sedation was administered by the Anesthesia Department.  The Kopans wire was trimmed to an appropriate length.  The patient was sterilely prepped and draped in the usual manner.  Local anesthetic consisting of 1% lidocaine and 0.5% Marcaine was injected into the proposed line of incision.  A curvilinear circumareolar incision was then made with a #15 scalpel blade close to the wire.  The wire was stabilized and brought to protrude through the incision.  Skin flaps were then generated with electrocautery.  A generous core tissue was grasped with Allis forceps and excised with electrocautery.  Prior to complete excision, the superior margin was marked with a #2-0 Vicryl suture, which was tied and cut short.  The lateral margin was marked with a #2-0 Vicryl suture, which was tied and cut along.  The posterior margin was marked with a #2-0 Polydek suture, which was tied and cut.,The specimen was then completely excised and sent off the operative field as specimen where specimen mammography confirmed the excision of the mammographically detected neoplasm.  On palpation of the cavity, there was felt to be a second nodule further medial and this was grasped with an Allis forceps and excised with electrocautery and sent off the field as a separate specimen.  Hemostasis was obtained with electrocautery.  Good hemostasis was obtained.  The incision was closed in two layers.  The first layer consisting of a subcuticular inverted interrupted sutures of #4-0 undyed Vicryl.  The second layer consisted of Steri-Strips on the epidermis.  A pressure dressing of fluff, 4x4s, ABDs, and Elastic bandage was applied.  The patient tolerated the surgery well.","hematology - oncology, neoplasm, needle localized wide excision, needle localized, nonpalpable neoplasm, needle, incision, electrocautery, excision, breast "
" MGUS.  His bone marrow biopsy showed a normal cellular bone marrow; however, there were 10% plasma cells and we proceeded with the workup for a plasma cell dyscrasia.  All his tests came back as consistent with an MGUS.", Hematology - Oncology, MGUS Followup ,"CHIEF COMPLAINT: , MGUS.,HISTORY OF PRESENT ILLNESS:,  This is an extremely pleasant 86-year-old gentleman, who I follow for his MGUS.  I initially saw him for thrombocytopenia when his ANC was 1300.  A bone marrow biopsy was obtained.  Interestingly enough, at the time of his bone marrow biopsy, his hemoglobin was 13.0 and his white blood cell count was 6.5 with a platelet count of 484,000.  His bone marrow biopsy showed a normal cellular bone marrow; however, there were 10% plasma cells and we proceeded with the workup for a plasma cell dyscrasia.  All his tests came back as consistent with an MGUS.,Overall, he is doing well.  Since I last saw him, he tells me that he has had onset of atrial fibrillation.  He has now started going to the gym two times per week, and has lost over 10 pounds.  He has a good energy level and his ECOG performance status is 0.  He denies any fever, chills, or night sweats.  No lymphadenopathy.  No nausea or vomiting.  No change in bowel or bladder habits.,CURRENT MEDICATIONS: , Multivitamin q.d., aspirin one tablet q.d., Lupron q. three months, Flomax  0.4 mg q.d., and Warfarin 2.5 mg q.d.,ALLERGIES:  ,No known drug allergies.,REVIEW OF SYSTEMS: , As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1.  He is status post left inguinal hernia repair.,2.  Prostate cancer diagnosed in December 2004, which was a Gleason 3+4.  He is now receiving Lupron.,SOCIAL HISTORY: , He has a very remote history of tobacco use.  He has one to two alcoholic drinks per day.  He is married.,FAMILY HISTORY: , His brother had prostate cancer.,PHYSICAL EXAM:,VIT:",
 Discharge summary of a patient presenting with a large mass aborted through the cervix., Hematology - Oncology, Mullerian Adenosarcoma ,"PRINCIPAL DIAGNOSIS: , Mullerian adenosarcoma.  ,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old presenting with a large mass aborted through the cervix.,PHYSICAL EXAM:,CHEST:  Clear.  There is no heart murmur.,ABDOMEN:  Nontender.,PELVIC:  There is a large mass in the vagina.  ,HOSPITAL COURSE: , The patient went to surgery on the day of admission.  The postoperative course was marked by fever and ileus.  The patient regained bowel function.  She was discharged on the morning of the seventh postoperative day.,OPERATIONS: , July 25, 2006:  Total abdominal hysterectomy, bilateral salpingo-oophorectomy.,DISCHARGE CONDITION: , Stable.,  ,PLAN: , The patient will remain at rest initially with progressive ambulation thereafter.  She will avoid lifting, driving, stairs, or intercourse.  She will call me for fevers, drainage, bleeding, or pain.  Family history, social history, and psychosocial needs per the social worker.  The patient will follow up in my office in one week.,PATHOLOGY:,  Mullerian adenosarcoma.,MEDICATIONS:,  Percocet 5, #40, one q.3 h. p.r.n. pain.","hematology - oncology, cervix, fevers, drainage, bleeding, mullerian adenosarcoma, mullerian, adenosarcoma"
" Biopsy-proven mesothelioma - Placement of Port-A-Cath, left subclavian vein with fluoroscopy.", Hematology - Oncology, Mesothelioma - Port-A-Cath Insertion ,"PREOPERATIVE DIAGNOSIS: , Mesothelioma.,POSTOPERATIVE DIAGNOSIS:,  Mesothelioma.,OPERATIVE PROCEDURE: , Placement of Port-A-Cath, left subclavian vein with fluoroscopy.,ASSISTANT:,  None.,ANESTHESIA: , General endotracheal.,COMPLICATIONS:,  None.,DESCRIPTION OF PROCEDURE: , The patient is a 74-year-old gentleman who underwent right thoracoscopy and was found to have biopsy-proven mesothelioma.  He was brought to the operating room now for Port-A-Cath placement for chemotherapy.  After informed consent was obtained with the patient, the patient was taken to the operating room, placed in supine position.  After induction of general endotracheal anesthesia, routine prep and drape of the left chest, left subclavian vein was cannulated with #18 gauze needle, and guidewire was inserted.  Needle was removed.  Small incision was made large enough to harbor the port.  Dilator and introducers were then placed over the guidewire.  Guidewire and dilator were removed, and a Port-A-Cath was introduced in the subclavian vein through the introducers.  Introducers were peeled away without difficulty.  He measured with fluoroscopy and cut to the appropriate length.  The tip of the catheter was noted to be at the junction of the superior vena cava and right atrium.  It was then connected to the hub of the port.  Port was then aspirated for patency and flushed with heparinized saline and summoned to the chest wall.  Wounds were then closed.  Needle count, sponge count, and instrument counts were all correct.","hematology - oncology, biopsy-proven mesothelioma, placement of port-a-cath, port a cath, subclavian vein, fluoroscopy, mesothelioma,"
 Rhabdomyosarcoma of the left orbit.  Left subclavian vein MediPort placement.  Needs chemotherapy., Hematology - Oncology, MediPort Placement ,"PREOPERATIVE DIAGNOSIS:,  Rhabdomyosarcoma of the left orbit.,POSTOPERATIVE DIAGNOSIS:,  Rhabdomyosarcoma of the left orbit.,PROCEDURE: , Left subclavian vein MediPort placement (7.5-French single-lumen).,INDICATIONS FOR PROCEDURE: , This patient is a 16-year-old girl, with newly diagnosed rhabdomyosarcoma of the left orbit.  The patient is being taken to the operating room for MediPort placement.  She needs chemotherapy.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine, put under general endotracheal anesthesia.  The patient's neck, chest, and shoulders were prepped and draped in usual sterile fashion.  An incision was made on the left shoulder area.  The left subclavian vein was cannulated.  The wire was passed, which was in good position under fluoro, using Seldinger Technique.  Near wire incision site made a pocket above the fascia and sutured in a size 7.5-French single-lumen MediPort into the pocket in 4 places using 3-0 Nurolon.  I then sized the catheter under fluoro and placed introducer and dilator over the wire, removed the wire and dilator, placed the catheter through the introducer and removed the introducer.  The line tip was in good position under fluoro.  It withdrew and flushed well.  I then closed the incision using 4-0 Vicryl, 5-0 Monocryl for the skin, and dressed with Steri-Strips.  Accessed the ports with a 1-inch 20-gauge Huber needle, and it withdrew and flushed well with final heparin flush.  We secured this with Tegaderm.  The patient is then to undergo bilateral bone marrow biopsy and lumbar puncture by Oncology.","hematology - oncology, rhabdomyosarcoma of the left orbit, single lumen, subclavian vein, mediport placement, chemotherapy, rhabdomyosarcoma, mediport, "
 Right nodular malignant mesothelioma., Hematology - Oncology, Mesothelioma - Thoracotomy & Lobectomy ,"PREOPERATIVE DIAGNOSIS:,  Right mesothelioma.,POSTOPERATIVE DIAGNOSIS: , Right lung mass invading diaphragm and liver.,FINDINGS: , Right lower lobe lung mass invading diaphragm and liver.,PROCEDURES:,1.  Right thoracotomy.,2.  Right lower lobectomy with en bloc resection of diaphragm and portion of liver.,SPECIMENS: , Right lower lobectomy with en bloc resection of diaphragm and portion of liver.,BLOOD LOSS: , 600 mL.,FLUIDS: , Crystalloid 2.7 L and 1 unit packed red blood cells.,ANESTHESIA: , Double-lumen endotracheal tube.,CONDITION:,  Stable, extubated, to PACU.,PROCEDURE IN DETAIL:,  Briefly, this is a gentleman who was diagnosed with a B-cell lymphoma and then subsequently on workup noted to have a right-sided mass seeming to arise from the right diaphragm.  He was presented at Tumor Board where it was thought upon review that day that he had a right nodular malignant mesothelioma.  Thus, he was offered a right thoracotomy and excision of mass with possible reconstruction of the diaphragm.  He was explained the risks, benefits, and alternatives to this procedure.  He wished to proceed, so he was brought to the operating room.,An epidural catheter was placed.  He was put in a supine position where SCDs and Foley catheter were placed.  He was put under general endotracheal anesthesia with a double-lumen endotracheal tube.  He was given preoperative antibiotics, then he was placed in the left decubitus position, and the area was prepped and draped in the usual fashion.,A low thoracotomy in the 7th interspace was made using the skin knife and then Bovie cautery onto the middle of the rib and then with the Alexander instrument, the chest was entered.  Upon entering the chest, the chest wall retractor was inserted and the cavity inspected.  It appeared that the mass actually arose more from the right lower lobe and was involving the diaphragm.  He also had some marked lymphadenopathy.  With these findings, which were thought at that time to be more consistent with a bronchogenic carcinoma, we proceeded with the intent to perform a right lower lobectomy and en bloc diaphragmatic resection.  Thus, we mobilized the inferior pulmonary ligament and made our way around the hilum anteriorly and posteriorly.  We also worked to open the fissure and tried to identify the arteries going to the superior portion of the right lower lobe and basilar arteries as well as the artery going to the right middle lobe.  The posterior portion of the fissure ultimately divided with the single firing of a GIA stapler with a blue load and with the final portion being divided between 2-0 ties.  Once we had clearly delineated the arterial anatomy, we were able to pass a right angle around the artery going to the superior segment.  This was ligated in continuity with an additional stick tie in the proximal portion of 3-0 silk.  This was divided thus revealing a branched artery going to the basilar portion of the right lower lobe.  This was also ligated in continuity and actually doubly ligated.  Care was taken to preserve the artery to the right and middle lobe.,We then turned our attention once again to the hilum to dissect out the inferior pulmonary vein.  The superior pulmonary vein was visualized as well.  The right angle was passed around the inferior pulmonary vein, and this was ligated in continuity with 2-0 silk and a 3-0 stick tie.  Upon division of this portion, the specimen site had some bleeding, which was eventually controlled using several 3-0 silk sutures.  The bronchial anatomy was defined.  Next, we identified the bronchus going to the right lower lobe as well as the right middle lobe.  A TA-30 4.8 stapler was then closed.  The lung insufflated.  The right middle lobe and right upper lobe were noted to inflate well.  The stapler was fired, and the bronchus was cut with a 10-blade.,We then turned our attention to the diaphragm.  There was a small portion of the diaphragm of approximately 4 to 5 cm has involved with tumor, and we bovied around this with at least 1 cm margin.  Upon going through the diaphragm, it became clear that the tumor was also involving the dome of the liver, so after going around the diaphragm in its entirety, we proceeded to wedge out the portion of liver that was involved.  It seemed that it would be a mucoid shallow portion.  The Bovie was set to high cautery.  The capsule was entered, and then using Bovie cautery, we wedged out the remaining portion of the tumor with a margin of normal liver.  It did leave quite a shallow defect in the liver.  Hemostasis was achieved with Bovie cautery and gentle pressure.  The specimen was then taken off the table and sent to Pathology for permanent.  The area was inspected for hemostasis.  A 10-flat JP was placed in the abdomen at the portion of the wedge resection, and 0 Prolene was used to close the diaphragmatic defect, which was under very little tension.  A single 32 straight chest tube was also placed.  The lung was seen to expand.  We also noted that the incomplete fissure between the middle and upper lobes would prevent torsion of the right middle lobe.  Hemostasis was observed at the end of the case.  The chest tube was irrigated with sterile water, and there was no air leak observed from the bronchial stump.  The chest was then closed with Vicryl at the level of the intercostal muscles, staying above the ribs.  The 2-0 Vicryl was used for the latissimus dorsi layer and the subcutaneous layer, and 4-0 Monocryl was used to close the skin.  The patient was then brought to supine position, extubated, and brought to the recovery room in stable condition.,Dr. X was present for the entirety of the procedure, which was a right thoracotomy, right lower lobectomy with en bloc resection of diaphragm and a portion of liver.","hematology - oncology, double lumen endotracheal, en bloc resection, malignant mesothelioma, lung mass, endotracheal tube, chest tube, bovie cautery, en bloc, diaphragm, lobectomy, mesothelioma, thoracotomy, "
" Marginal zone lymphoma (MALT-type lymphoma).  A mass was found in her right breast on physical examination.  she had a mammogram and ultrasound, which confirmed the right breast mass.", Hematology - Oncology, Marginal Zone Lymphoma ,"CHIEF COMPLAINT: , Marginal zone lymphoma.,HISTORY OF PRESENT ILLNESS: , This is a very pleasant 46-year-old woman, who I am asked to see in consultation for a newly diagnosed marginal zone lymphoma (MALT-type lymphoma).  A mass was found in her right breast on physical examination.  On 07/19/10, she had a mammogram and ultrasound, which confirmed the right breast mass.  On 07/30/10, she underwent a biopsy, which showed a marginal zone lymphoma (MALT-type lymphoma).,Overall, she is doing well.  She has a good energy level and her ECOG performance status is 0.  She denies any fevers, chills, or night sweats.  No lymphadenopathy.  No nausea or vomiting.  She has normal bowel and bladder habits.  No melena or hematochezia.,CURRENT MEDICATIONS:  ,Macrobid 100 mg q.d.,ALLERGIES:  ,Sulfa, causes nausea and vomiting.,REVIEW OF SYSTEMS: , As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1.  She is status post a left partial nephrectomy as a new born.,2.  In 2008 she had a right ankle fracture.,SOCIAL HISTORY: , She has a 20-pack year history of tobacco use.  She has rare alcohol use.  She has no illicit drug use.  She is in the process of getting divorced.  She has a 24-year-old son in the area and 22-year-old daughter.,FAMILY HISTORY:  ,Her mother had uterine cancer.  Her father had liver cancer.,PHYSICAL EXAM:,VIT:",
" Malignant mass of the left neck, squamous cell carcinoma.  Left neck mass biopsy and selective surgical neck dissection, left.", Hematology - Oncology, Neck Mass Biopsy ,"PREOPERATIVE DIAGNOSIS: , Malignant mass of the left neck.,POSTOPERATIVE DIAGNOSIS:,  Malignant mass of the left neck, squamous cell carcinoma.,PROCEDURES,1.  Left neck mass biopsy.,2.  Selective surgical neck dissection, left.,DESCRIPTION OF PROCEDURE:,  After obtaining an informed, the patient was taken to the operating room where a time-out process was followed.  Preoperative antibiotic was given and Dr. X proceeded to intubate the patient after a detailed anesthetic preparation that started in the Same Day Surgery and followed in the operating room.  Finally, a 5.5-French endotracheal tube was inserted and the patient was able to tolerate that and did have stable vital signs and a proper oxygenation.,Then, the patient was positioned with the neck slightly distended and turned toward the opposite side of the operation.  The neck was prepped and draped in the usual fashion.  I proceeded to mark the site of the mass and then also to mark the proposed site for the creation of a flap.  Then, I performed an extensive anesthetic block of the area.,Then, an incision was made along the area marked for development of the flap, but in a very limited extent, just to expose the cervical mass.  The cervical mass, which was about 4 cm in diameter and very firm and rubbery, was found lodged between the sternocleidomastoid muscle and the internal jugular vein in the area III of the neck.  A wedge sample was sent to Pathology for frozen section.  At the same time, we waited for the result and the initial report was not clear in the sense that a lot of lymphoepithelial reaction was seen.  Therefore, a larger sample was sent to Pathology and at that particular time, the fresh frozen was reported as having squamous elements.  This was not totally clear in my mind and therefore I proceeded to excise the full mass, which luckily was not attached to any structures except in the very deep surface.  There, there were some attachments to branches of the external carotid artery, which had to be suture ligated.  At any rate, the whole specimen was to the lab and finally the diagnosis was that of a metastatic squamous cell carcinoma.,With that information in hand, we proceeded to continue with a neck dissection and proceeded to make an incision along the previously marked sites of the flap, which basically involved a reverse U shape on the left neck.  This worked out quite nicely.  The external jugular vein was out of the way, so initially we did not deal with it.  We proceeded to tackle the area III and extended into II-A.  When we excised the mass, the upper end was in intimate relationship with the parotid gland, which was relatively large in this patient, but it looked normal otherwise.  Also, I felt that the submaxillary gland was enlarged.  At any rate, we decided to clean up the areas III and IV and a few nodes from II-A that were removed, and then we went into the posterior triangle where we identified the spinal accessory nerve, which we protected, actually did not even dissect close to it.,The same nerve had been already identified anterior to the internal jugular vein, very proximally behind the digastric and the sternocleidomastoid muscle.  At any rate, there were large nodes in the posterior triangle, in areas V-A and V-B, which were excised and sent to Pathology for examination.  Also, there was a remnant of a capsule of the main mass that we proceeded to excise and sent to Pathology as an extra specimen.  Hemostasis was revised and found to be adequate.  The flaps had been protected by folding it to the chest and protected by wet sponges on both sides of the flap.  The flap was replaced in its position.  A soft Jackson-Pratt catheter was left in the area, and then we proceeded to approximate the flap with a number of subcutaneous sutures of Vicryl and then running sutures of subcuticular Monocryl to the skin.  I would like to mention that also the facial vein was excised and the external jugular vein was ligated.  It was in very lateral location and it was on the site of the drain, so we ligated that but did not excise it.  A pressure dressing was applied.,The patient tolerated the procedure well.  Estimated blood loss was no more than 100 mL.  The patient was extubated in the operating room and sent for recovery.","hematology - oncology, neck mass biopsy, surgical neck dissection, internal jugular vein, external jugular vein, squamous cell carcinoma, neck mass, malignant mass, neck dissection, mass, neck, wedge, vein,"
 Right pleural effusion and suspected malignant mesothelioma., Hematology - Oncology, Mesothelioma - Pleural Biopsy ,"PREOPERATIVE DIAGNOSIS: , Right pleural effusion and suspected malignant mesothelioma.,POSTOPERATIVE DIAGNOSIS:,  Right pleural effusion, suspected malignant mesothelioma.,PROCEDURE: , Right VATS pleurodesis and pleural biopsy.,ANESTHESIA:,  General double-lumen endotracheal.,DESCRIPTION OF FINDINGS: , Right pleural effusion, firm nodules, diffuse scattered throughout the right pleura and diaphragmatic surface.,SPECIMEN: , Pleural biopsies for pathology and microbiology.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid 1.2 L and 1.9 L of pleural effusion drained.,INDICATIONS: , Briefly, this is a 66-year-old gentleman who has been transferred from an outside hospital after a pleural effusion had been drained and biopsies taken from the right chest that were thought to be consistent with mesothelioma.  Upon transfer, he had a right pleural effusion demonstrated on x-ray as well as some shortness of breath and dyspnea on exertion.  The risks, benefits, and alternatives to right VATS pleurodesis and pleural biopsy were discussed with the patient and his family and they wished to proceed.,PROCEDURE IN DETAIL:  ,After informed consent was obtained, the patient was brought to the operating room and placed in supine position.  A double-lumen endotracheal tube was placed.  SCDs were also placed and he was given preoperative Kefzol.  The patient was then brought into the right side up, left decubitus position, and the area was prepped and draped in the usual fashion.  A needle was inserted in the axillary line to determine position of the effusion.  At this time, a 10-mm port was placed using the knife and Bovie cautery.  The effusion was drained by placing a sucker into this port site.  Upon feeling the surface of the pleura, there were multiple firm nodules.  An additional anterior port was then placed in similar fashion.  The effusion was then drained with a sucker.  Multiple pleural biopsies were taken with the biopsy device in all areas of the pleura.  Of note, feeling the diaphragmatic surface, it appeared that it was quite nodular, but these nodules felt as though they were on the other side of the diaphragm and not on the pleural surface of the diaphragm concerning for a possibly metastatic disease.  This will be worked up with further imaging study later in his hospitalization.  After the effusion had been drained, 2 cans of talc pleurodesis aerosol were used to cover the lung and pleural surface with talc.  The lungs were then inflated and noted to inflate well.  A 32 curved chest tube chest tube was placed and secured with nylon.  The other port site was closed at the level of the fascia with 2-0 Vicryl and then 4-0 Monocryl for the skin.  The patient was then brought in the supine position and extubated and brought to recovery room in stable condition.,Dr. X was present for the entire procedure which was right VATS pleurodesis and pleural biopsies.,The counts were correct x2 at the end of the case.","hematology - oncology, double-lumen, endotracheal, pleural surface, chest tube, pleural biopsy, malignant mesothelioma, vats pleurodesis, pleural biopsies, pleural effusion, pleural, vats, pleurodesis, mesothelioma,"
" Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, and pharmacologic thrombolysis following placement of a vena caval filter.", Hematology - Oncology, Lymphoblastic Leukemia - Consult ,"CHIEF COMPLAINT: , Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, right iliac vein and inferior vena cava (IVC), status post balloon angioplasty, and mechanical and pharmacologic thrombolysis following placement of a vena caval filter.,HISTORY OF PRESENT ILLNESS: , The patient was transferred here the evening of 02/23/2007 from Hospital with a new diagnosis of high-risk acute lymphoblastic leukemia based on confirmation by flow cytometry of peripheral blood lymphoblasts that afternoon.  History related to this illness probably dates back to October of 2006 when he had onset of swelling and discomfort in the left testicle with what he described as a residual ""lump"" posteriorly.  The left testicle has continued to be painful off and on since.  In early November, he developed pain in the posterior part of his upper right leg, which he initially thought was related to skateboarding and muscle strain.  Physical therapy was prescribed and the discomfort temporarily improved.  In December, he noted onset of increasing fatigue.  He used to work out regularly, lifting lifts, doing abdominal exercises, and playing basketball and found he did not have energy to pursue these activities.  He has lost 10 pounds since December and feels his appetite has decreased.  Night sweats and cough began in December, for which he was treated with a course of Augmentin.  However, both of these problems have continued.  He also began taking Accutane for persistent acne in December (this agent was stopped on 02/19/2007).  Despite increasing fatigue and lethargy, he continues his studies at University of Denver, has a biology major (he aspires to be an ophthalmologist).,The morning of 02/19/2007, he awakened with severe right inguinal and right lower quadrant pain.  He was seen in Emergency Room where it was noted that he had an elevated WBC of 18,000.  CT scan of the abdomen was obtained to rule out possible appendicitis and on that CT, a large clot in the inferior vena cava extending to the right iliac and femoral veins was found.  He promptly underwent appropriate treatment in interventional radiology with the above-noted angioplasty and placement of a vena caval filter followed by mechanical and pharmacologic thrombolysis.  Repeat ultrasound there on 02/20/2007 showed no evidence of deep venous thrombosis (DVT).  Continuous intravenous unfractionated heparin infusion was continued.  Because there was no obvious cause of this extensive thrombosis, occult malignancy was suspected.  Appropriate blood studies were obtained and he underwent a PET/CT scan as part of his diagnostic evaluation.  This study showed moderately increased diffuse bone marrow metabolic activity.  Because the WBC continued to rise and showed a preponderance of lymphocytes, the smear was reviewed by pathologist, Sheryl Asplund, M.D., and flow cytometry was performed on the peripheral blood.  These studies became available the afternoon of 02/23/2007, and confirmed the diagnosis of precursor-B acute lymphoblastic leukemia.  The patient was transferred here after stopping of the continuous infusion heparin and receiving a dose of Lovenox 60 mg subcutaneously for further diagnostic evaluation and management of the acute lymphoblastic leukemia (ALL).,ALLERGIES: , NO KNOWN DRUG ALLERGIES.  HE DOES SEEM TO REACT TO CERTAIN ADHESIVES.,CURRENT MEDICATIONS:  ,1.  Lovenox 60 mg subcutaneously q.12h. initiated.,2.  Coumadin 5 mg p.o., was administered on 02/19/2007 and 02/22/2007.,3.  Protonix 40 mg intravenous (IV) daily.,4.  Vicodin p.r.n.,5.  Levaquin 750 mg IV on 02/23/2007.,IMMUNIZATIONS: , Up-to-date.,PAST SURGICAL HISTORY:  ,The treatment of the thrombosis as noted above on 02/19/2007 and 02/20/2007.,FAMILY HISTORY:  ,Two half-brothers, ages 26 and 28, both in good health.  Parents are in good health.  A maternal great-grandmother had a deep venous thrombosis (DVT) of leg in her 40s.  A maternal great-uncle developed leukemia around age 50.  A maternal great-grandfather had bone cancer around age 80.  His paternal grandfather died of colon cancer at age 73, which he had had since age 68.  Adult-onset diabetes is present in distant relatives on both sides.,SOCIAL HISTORY:  ,The patient is a student at the University majoring in biology.  He lives in a dorm there.  His parents live in Breckenridge.  He admits to having smoked marijuana off and on with friends and drinking beer off and on as well.,REVIEW OF SYSTEMS: , He has had emesis off and on related to Vicodin and constipation since 02/19/2007, also related to pain medication.  He has had acne for about two years, which he describes as mild to moderate.  He denied shortness of breath, chest pain, hemoptysis, dyspnea, headaches, joint pains, rashes, except where he has had dressings applied, and extremity pain except for the right leg pain noted above.,PHYSICAL EXAMINATION:  ,GENERAL:  Alert, cooperative, moderately ill-appearing young man.,VITAL SIGNS:  At the time of admission, pulse was 94, respirations 20, blood pressure 120/62, temperature 98.7, height 171.5 cm, weight 63.04 kg, and pulse oximetry on room air 95%.,HAIR AND SKIN:  Mild facial acne.,HEENT:  Extraocular muscles (EOMs) intact.  Pupils equal, round, and reactive to light and accommodation (PERRLA), fundi normal.,CARDIOVASCULAR:  A 2/6 systolic ejection murmur (SEM), regular sinus rhythm (RSR).,LUNGS:  Clear to auscultation with an occasional productive cough.,ABDOMEN:  Soft with mild lower quadrant tenderness, right more so than left; liver and spleen each decreased 4 cm below their respective costal margins.,MUSCULOSKELETAL:  Mild swelling of the dorsal aspect of the right foot and distal right leg.  Mild tenderness over the prior catheter entrance site in the right popliteal fossa and mild tenderness over the right medial upper thigh.,GENITOURINARY:  Testicle exam disclosed no firm swelling with mild nondiscrete fullness in the posterior left testicle.,NEUROLOGIC:  Exam showed him to be oriented x4.  Normal fundi, intact cranial nerves II through XII with downgoing toes, symmetric muscle strength, and decreased patellar deep tendon reflexes (DTRs).,LABORATORY DATA:  ,White count 25,500 (26 neutrophils, 1 band, 7 lymphocytes, 1 monocyte, 1 myelocyte, 64 blasts), hemoglobin 13.3, hematocrit 38.8, and 312,000 platelets.  Electrolytes, BUN, creatinine, phosphorus, uric acid, AST, ALT, alkaline phosphatase, and magnesium were all normal.  LDH was elevated to 1925 units/L (upper normal 670), and total protein and albumin were both low at 6.2 and 3.4 g/dL respectively.  Calcium was also slightly low at 8.8 mg/dL.  Low molecular weight heparin test was low at 0.27 units/mL.  PT was 11.8, INR 1.2, and fibrinogen 374.  Urinalysis was normal.,ASSESSMENT: , 1.  Newly diagnosed high-risk acute lymphoblastic leukemia.,2.  Deep vein thrombosis of the distal iliac and common femoral/right femoral and iliac veins, status post vena caval filter placement and mechanical and thrombolytic therapy, on continued anticoagulation.,3.  Probable chronic left epididymitis.,PLAN: , 1.  Proceed with diagnostic bone marrow aspirate/biopsy and lumbar puncture (using a #27-gauge pencil-tip needle for minimal trauma) as soon as these procedures can be safely done with regard to the anticoagulation status.,2.  Prompt reassessment of the status of the deep venous thrombosis with Doppler studies.,3.  Ultrasound/Doppler of the testicles.,4.  Maintain therapeutic anticoagulation as soon as the diagnostic procedures for ALL can be completed.,",
" Patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI.  The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion.", Hematology - Oncology, Lung Cancer & MI - Hospice Cosult ,"REASON FOR CONSULT: , I was asked to see this patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI.,HISTORY OF PRESENT ILLNESS: , The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion.  Her daughter who accompanies her is very attentive whom I had met previously during drainage of a malignant hemorrhagic pericardial effusion last month.  The patient has been feeling well for the last several weeks, per the daughter, but today per the personal aide, became agitated and uncomfortable at about 2:30 p.m.  At about 7 p.m., the patient began vomiting, was noted to be short of breath by her daughter with garbled speech, arms flopping, and irregular head movements.  Her daughter called 911 and her symptoms seemed to improve.  Then, she began vomiting.  When the patient's daughter asked her if she had chest pain, the patient said yes.,She came to the emergency room, an EKG showed inferior ST-elevation MI.  I was called immediately and knowing her history, especially, her hospice status with recent hemorrhagic pericardial effusion, I felt thrombolytic was contraindicated and she would not be a candidate for aggressive interventional therapy with PCI/CABG.  She was begun after discussion with the oncologist, on heparin drip and has received morphine, nitro, and beta-blocker, and currently states that she is pain free.  Repeat EKG shows normalization of her ST elevation in the inferior leads as well as normalization of prior reciprocal changes.,PAST MEDICAL HISTORY: , Significant for metastatic non-small-cell lung cancer.  In early-to-mid December, she had an admission and was found to have a malignant pericardial effusion with tamponade requiring urgent drainage.  We did repeat an echo several weeks later and that did not show any recurrence of the pericardial effusion.  She is on hospice from the medical history, atrial fibrillation, hypertension, history of multiple CVA.,MEDICATIONS: , Medications as an outpatient:,1.  Amiodarone 200 mg once a day.,2.  Roxanol concentrate 5 mg three hours p.r.n. pain.,ALLERGIES:  ,CODEINE.  NO SHRIMP, SEAFOOD, OR DYE ALLERGY.,FAMILY HISTORY: , Negative for cardiac disease.,SOCIAL HISTORY: , She does not smoke cigarettes.  She uses alcohol.  No use of illicit drugs.  She is divorced and lives with her daughter.  She is a retired medical librarian from Florida.,REVIEW OF SYSTEMS:  ,Unable to be obtained due to the patient's aphasia.,PHYSICAL EXAMINATION: , Height 5 feet 3, weight of 106 pounds, temperature 97.1 degrees, blood pressure ranges from 138/82 to 111/87, pulse 61, respiratory rate 22.  O2 saturation 100%.  On general exam, she is an elderly woman with now marked aphasia, which per her daughter waxes and wanes, was more pronounced and she nods her head up and down when she says the word, no, and conversely, she nods her head side-to-side when she uses the word yes with some discordance in her head gestures with vocalization.  HEENT shows the cranium is normocephalic and atraumatic.  She has dry mucosal membrane.  She now has a right facial droop, which per her daughter is new.  Neck veins are not distended.  No carotid bruits visible.  Skin:  Warm, well perfused.  Lungs are clear to auscultation anteriorly.  No wheezes.  Cardiac exam:  S1, S2, regular rate.  No significant murmurs.  PMI is nondisplaced.  Abdomen:  Soft, nondistended.  Extremities:  Without edema, on limited exam.  Neurological exam seems to show only the right facial droop.,DIAGNOSTIC/LABORATORY DATA: , EKGs as reviewed above.  Her last ECG shows normalization of prior ST elevation in the inferior leads with Q waves and first-degree AV block, PR interval 280 milliseconds.  Further lab shows sodium 135, potassium 4.2, chloride 98, bicarbonate 26, BUN 9, creatinine 0.8, glucose 162, troponin 0.17, INR 1.27, white blood cell count 1.3, hematocrit 31, platelet count of 179.,Chest x-ray, no significant pericardial effusion.,IMPRESSION: , The patient is a 69-year-old woman with metastatic non-small-cell lung cancer with a recent hemorrhagic pericardial effusion, now admitted with cerebrovascular accident and transient inferior myocardial infarction, which appears to be canalized.  I will discuss this in detail with the patient and her daughter, and clearly, her situation is quite guarded with likely poor prognosis, which they are understanding of.,RECOMMENDATIONS:,1.  I think it is reasonable to continue heparin, but clearly she would be at risk for hemorrhagic pericardial effusion recurrence.,2.  Morphine is appropriate, especially for preload reduction and other comfort measures as appropriate.,3.  Would avoid other blood thinners including Plavix, Integrilin, and certainly, she is not a candidate for a thrombolytic with which the patient and her daughter are in agreement with after a long discussion.,Other management as per the medical service.  I have discussed the case with Dr. X of the hospitalist service who will be admitting the patient.",
 A 61-year-old white male with a diagnosis of mantle cell lymphoma status post autologous transplant with BEAM regimen followed by relapse.  Allogeneic peripheral stem cell transplant from match-related brother and the patient is 53 months out from transplant., Hematology - Oncology, Mantle Cell Lymphoma ,"PRINCIPAL DIAGNOSES:,1.  A 61-year-old white male with a diagnosis of mantle cell lymphoma, diagnosed in 2001, status post autologous transplant with BEAM regimen in 04/02 followed by relapse.,2.  Allogeneic peripheral stem cell transplant from match-related brother and the patient is 53 months out from transplant.,3.  Graft versus host disease involving GI tracts, skin, and liver presently off immunosuppression.,4.  Diabetes.,5.  Bipolar disorder.,6.  Chronic muscle aches.,7.  Chronic lower extremity edema.,8.  ECOG performance status 1.,INTERIM HISTORY: , The patient comes to the clinic today for followup.  I am seeing him once every 4 to 8 weeks.  He is off of all immunosuppression.  He does have mild chronic GVHD but not enough to warrant any therapy and the disease has been under control and he is 4-1/2-years posttransplant.,He has multiple complaints.  He has had hematochezia.  I referred him to gastroenterology.  They did an upper and lower endoscopy.  No evidence of ulcers or any abnormality was found.  Some polyps were removed.  They were benign.  He may have mild iron deficiency, but he is fatigued and has several complaints related to his level of activity.,CURRENT MEDICATIONS:,1.  Paxil 40 mg once daily.,2.  Cozaar.,3.  Xanax 1 mg four times a day.,4.  Prozac 20 mg a day.,5.  Lasix 40 mg a day.,6.  Potassium 10 mEq a day.,7.  Mirapex two tablets every night.,8.  Allegra 60 mg twice a day.,9.  Avandamet 4/1000 mg daily.,10.  Nexium 20 mg a day.,11.  NovoLog 25/50.,REVIEW OF SYSTEMS:,  Fatigue, occasional rectal bleeding, and obesity.  Other systems were reviewed and were found to be unremarkable.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Today revealed that temperature 35.8, blood pressure 120/49, pulse 85, and respirations 18.  HEENT:  Oral cavity, no mucositis.  NECK:  No nodes.  AXILLA:  No nodes.  LUNGS:  Clear.  CARDIAC:  Regular rate and rhythm without murmurs.  ABDOMEN:  No palpable masses.  Morbid obesity.  EXTREMITIES:  Mild lower extremity edema.  SKIN:  Mild dryness.  CNS:  Grossly intact.,LABORATORY DATA:,  White count 4.4, hemoglobin 10.1, platelet count 132,000, sodium 135, potassium 3.9, chloride 105, bicarbonate 24, BUN 15, and creatinine 0.9.  Normal alkaline phosphatase 203, AST 58, and ALT 31.,ASSESSMENT AND PLAN:,1.  The patient with mantle cell lymphoma who is 4-1/2 years post allotransplant.  He is without evidence of disease at the present time.  Since he is 4-1/2 years posttransplant, I do not plan to scan him or obtain chimerisms unless there is reason to.,2.  He is slightly anemic, may be iron deficient.  He has had recurrent rectal bleeding.  I told him to take multivitamin with iron and see how that helps the anemia.,3.  Regarding the hematochezia, he had an endoscopy.  I reviewed the results from the previous endoscopy.  It appears that he has polyps, but there is no evidence of graft versus host disease.,4.  Regarding the fatigue, I just reassured him that he should increase his activity level, but I am not sure how realistic that is going to be.,5.  He is followed for his diabetes by his internist.,6.  If he should have any fever or anything suggestive of infection, I advised him to call me.  I will see him back in about 2 months from now.",
 Extensive stage small cell lung cancer.  Chemotherapy with carboplatin and etoposide.  Left scapular pain status post CT scan of the thorax., Hematology - Oncology, Lung Cancer Followup ,"CHIEF COMPLAINT:,1.  Extensive stage small cell lung cancer.,2.  Chemotherapy with carboplatin and etoposide.,3.  Left scapular pain status post CT scan of the thorax.,HISTORY OF PRESENT ILLNESS: , The patient is a 67-year-old female with extensive stage small cell lung cancer.  She is currently receiving treatment with carboplatin and etoposide.  She completed her fifth cycle on 08/12/10.  She has had ongoing back pain and was sent for a CT scan of the thorax.  She comes into clinic today accompanied by her daughters to review the results.,CURRENT MEDICATIONS: , Levothyroxine 88 mcg daily, Soriatane 25 mg daily, Timoptic 0.5% solution b.i.d., Vicodin 5/500 mg one to two tablets q.6 hours p.r.n.,ALLERGIES: , No known drug allergies.,REVIEW OF SYSTEMS:  ,The patient continues to have back pain some time she also take two pain pill.  She received platelet transfusion the other day and reported mild fever.  She denies any chills, night sweats, chest pain, or shortness of breath.  The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:","hematology - oncology, small cell lung cancer, carboplatin, etoposide, pet/ct, pleural base, base mass, extensive stage, ct scan, lung cancer, lung, cancer, "
" Discharge summary of patient with leiomyosarcoma and history of pulmonary embolism, subdural hematoma, pancytopenia, and pneumonia.", Hematology - Oncology, Leiomyosarcoma ,"ADMITTING DIAGNOSES:,1.  Leiomyosarcoma.,2.  History of pulmonary embolism.,3.  History of subdural hematoma.,4.  Pancytopenia.,5.  History of pneumonia.,PROCEDURES DURING HOSPITALIZATION:,1.  Cycle six of CIVI-CAD (Cytoxan, Adriamycin, and DTIC) from 07/22/2008 to 07/29/2008.,2.  CTA, chest PE study showing no evidence for pulmonary embolism.,3.  Head CT showing no evidence of acute intracranial abnormalities.,4.  Sinus CT, normal mini-CT of the paranasal sinuses.,HISTORY OF PRESENT ILLNESS:  ,Ms. ABC is a pleasant 66-year-old Caucasian female who first palpated a mass in the left posterior arm in spring of 2007.  The mass increased in size and she was seen by her primary care physician and referred to orthopedic surgeon.  MRI showed inflammation and was thought to be secondary to rheumatoid arthritis.  The mass increased in size.  She eventually underwent a partial resection found to have pathologic grade 2 leiomyosarcoma, margins were impossible to assess, but were likely positive.  She was evaluated by Dr. X and Dr. Y and a decision was made to proceed with preoperative chemotherapy.  She began treatment with CIVI-CAD in December 2007.  Her course was complicated by pulmonary embolus, pneumonia, and subdural hematoma while on anticoagulation.  She eventually underwent surgical resection on May 1, 2008 with small area of residual disease, but otherwise clear margins.,HOSPITAL COURSE:,1.  Leiomyosarcoma, the patient was admitted to Hem/Onco B Service under attending Dr. XYZ for cycle six of continuous IV infusion Cytoxan, Adriamycin, and DTIC, which she tolerated well.,2.  History of pulmonary embolism.  Upon admission, the patient reported an approximate two-week history of dyspnea on exertion and some mild chest pain.  She underwent a CTA, which showed no evidence of pulmonary embolism and the patient was started on prophylactic doses of Lovenox at 40 mg a day.  She had no further complaints throughout the hospitalization with any shortness of breath or chest pain.,3.  History of subdural hematoma, also on admission the patient noted some mild intermittent headaches that were fleeting in nature, several a day that would resolve on their own.  Her headaches were not responding to pain medication and so on 07/24/2008, we obtained a head CT that showed no evidence of acute intracranial abnormalities.  The patient also had a history of sinusitis and so a sinus CT scan was obtained, which was normal.,4.  Pancytopenia.  On admission, the patient's white blood count was 3.4, hemoglobin 11.3, platelet count 82, and ANC of 2400.  The patient's counts were followed throughout admission.  She did not require transfusion of red blood cells or platelets; however, on 07/26/2008 her ANC did dip to 900 and she was placed on neutropenic diet.  At discharge her ANC is back up to 1100 and she is taken off neutropenic diet.  Her white blood cell count at discharge was 1.4 and her hemoglobin was 11.2 with a platelet count of 140.,5.  History of pneumonia.  During admission, the patient did not exhibit any signs or symptoms of pneumonia.,DISPOSITION: , Home in stable condition.,DIET: , Regular and less neutropenic.,ACTIVITY: , Resume same activity.,FOLLOWUP:  ,The patient will have lab work at Dr. XYZ on 08/05/2008 and she will also return to the cancer center on 08/12/2008 at 10:20 a.m.  The patient is also advised to monitor for any fevers greater than 100.5 and should she have any further problems in the meantime to please call in to be seen sooner.","hematology - oncology, leiomyosarcoma, embolism, hematoma, pneumonia, acute intracranial abnormalities, white blood, platelet count, blood cells, neutropenic diet, subdural hematoma, pulmonary embolism, intracranial, pancytopenia, neutropenic, subdural, pulmonary, "
 Left axillary lymph node excisional biopsy.  Left axillary adenopathy., Hematology - Oncology, Lymph Node Excisional Biopsy ,"PREOPERATIVE DIAGNOSIS: , Left axillary adenopathy.,POSTOPERATIVE DIAGNOSIS: , Left axillary adenopathy.,PROCEDURE: , Left axillary lymph node excisional biopsy.,ANESTHESIA:,  LMA.,INDICATIONS: , Patient is a very pleasant woman who in 2006 had breast conservation therapy with radiation only.  Note, she refused her CMF adjuvant therapy and this was for a triple-negative infiltrating ductal carcinoma of the breast.  Patient has been following with Dr. Diener and Dr. Wilmot.  I believe that genetic counseling had been recommended to her and obviously the CMF was recommended, but she declined both.  She presented to the office with left axillary adenopathy in view of the high-risk nature of her lesion.  I recommended that she have this lymph node removed.  The procedure, purpose, risk, expected benefits, potential complications, alternative forms of therapy were discussed with her and she was agreeable to surgery.,TECHNIQUE: , Patient was identified, then taken into the operating room where after induction of appropriate anesthesia, her left chest, neck, axilla, and arm were prepped with Betadine solution, draped in a sterile fashion.  An incision was made at the hairline, carried down by sharp dissection through the clavipectoral fascia.  I was able to easily palpate the lymph node and grasp it with a figure-of-eight 2-0 silk suture and by sharp dissection, was carried to hemoclip all attached structures.  The lymph node was excised in its entirety.  The wound was irrigated.  The lymph node sent to pathology.  The wound was then closed.  Hemostasis was assured and the patient was taken to recovery room in stable condition.","hematology - oncology, axillary lymph node excisional biopsy, sharp dissection, excisional biopsy, lymph node, axillary, excisional, biopsy"
" Marginal B-cell lymphoma, status post splenectomy.  Testicular swelling - possible epididymitis or possible torsion of the testis.", Hematology - Oncology, Lymphoma - Consult ,"HISTORY OF PRESENT ILLNESS:,  The patient has a known case of marginal B-cell lymphoma for which he underwent splenectomy two years ago.  The patient, last year, developed a diffuse large B-cell lymphoma which was treated with CHOP/reduction.  The patient again went into complete remission.  The patient has been doing well until recently, few days ago, late last week, when he developed swelling of the left testicle.  The patient states he has been having fever and chills for the last few days.  The patient felt weak and felt unwell.  The patient with these complaints came to the emergency room.  The patient has been having fever and chills and the patient states that the pain in the left testicle is rather severe.  No history of trauma to the testicle.,PAST MEDICAL HISTORY:,1.  Status post splenectomy.,2.  History of marginal B-cell lymphoma.,3.  History of diffuse large cell lymphoma.,ALLERGIES: , None.,PERSONAL HISTORY: , Used to smoke and drink alcohol but at present does not.,FAMILY HISTORY:,  Noncontributory.,REVIEW OF SYSTEMS:,HEENT:  Has slight headache.,CARDIOVASCULAR:  No history of hypertension, MI, etc.,RESPIRATORY:  No history of cough, asthma, TB, shortness of breath.,GI:  Unremarkable.,GU:  As above, has developed painful swelling of the left testicle over the last few days.,ENDOCRINE:  Known case of type II diabetes mellitus.,PHYSICAL EXAMINATION:,HEENT:  No conjunctival pallor or icterus.,NECK:  No adenopathy.  No carotid bruits.,LUNGS:  Clear.,HEART:  No gallop or murmur.,ABDOMEN:",
" Newly diagnosed mantle cell lymphoma, admitted now to start chemotherapy.  She will start treatment with hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone.", Hematology - Oncology, Mantle Cell Lymphoma - Consult ,"CHIEF COMPLAINT:,  Newly diagnosed mantle cell lymphoma.,HISTORY OF PRESENT ILLNESS: , The patient is a 47-year-old woman who presented with abdominal pain in September 2006.  On chest x-ray, she had a possible infiltrate and it was thought she might have pneumonia and she was treated with antibiotics and prednisone.  Symptoms improved temporarily, but did not completely resolve.  By the end of September, her pain had worsened and she was seen in the emergency room at ABC.  Chest x-ray was compatible with pleurisy and she was treated with Percocet.  Few days later, she was seen and given a prescription for Ultram because Percocet was causing nausea.  Eventually, she was seen by Dr. X and noted to have splenomegaly.  Repeat ultrasound was done and showed the spleen enlarged at 19 cm.  In retrospect, this was not changed in comparison to an ultrasound that was done in September.  She underwent positron emission tomography (PET) scanning, which showed diffuse hypermetabolic lymph nodes measuring 1 to 2 cm in diameter, as well as a hypermetabolic spleen that was enlarged.,The patient underwent lymph node biopsy on the right neck on 10/27/2006.  Pathology is consistent with mantle cell lymphoma.,On 10/31/2006, she had a bone marrow biopsy.  This does show involvement of bone marrow with lymphoma.,She was noted to have circulating lymphoma cells on peripheral smear as well.,Although CBC was normal, MCV was low and the ferritin was assessed and was low at 8, consistent with iron deficiency.,ALLERGIES:,  NONE.,MEDICATIONS:  ,1.  Estradiol/Prometrium.  ,2.  Ultram p.r.n.  ,3.  Baby aspirin.  ,4.  Lunesta for sleep.  ,5.  She has been started on iron supplements.,PAST MEDICAL HISTORY:  ,1.  Tubal ligation in 1986.,2.  Possible cyst removed from the left neck in 1991.,3.  Tonsillectomy.,4.  Migraines, which are rare.,SOCIAL HISTORY: , She does not smoke cigarettes and drinks alcohol only occasionally.  She is married and has two children, ages 24 and 20.  She works as a project administrator.,FAMILY HISTORY:  ,Father is deceased.  He had emphysema and colon cancer at age 68.  Mother has arrhythmia and hypertension.  Her sister has hypertension and her brother is healthy.,PHYSICAL EXAMINATION:  ,GENERAL:  She is in no acute distress.,VITAL SIGNS:  Her weight is 168 pounds, and she is afebrile with a normal blood pressure and pulse.,HEENT:  The oropharynx is benign.,SKIN:  The skin is warm and dry and shows no jaundice.,NECK:  There is shotty adenopathy in the neck.,CARDIAC:  Regular rate without murmur.,LUNGS:  Clear to auscultation bilaterally.,ABDOMEN:  Soft and nontender and shows the spleen palpable about 10 cm below the right costal margin.,EXTREMITIES:  No peripheral edema is noted.,LABORATORY DATA: , CBC and chemistry panel are pending.  CBC was normal last week.  PT/INR was normal as well.,IMPRESSION:,  Newly diagnosed mantle cell lymphoma, admitted now to start chemotherapy.  She will start treatment with hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone.  Toxicities have already been discussed with her including myelosuppression, mucositis, diarrhea, nausea, alopecia, the low risk for cardiac toxicity, bladder toxicity, neuropathy, constipation, etc.  Written materials were provided to her last week.,PLAN: , Plan will be to add Rituxan a little later in her course because she has circulating lymphoma cells.  She will be started on allopurinol today as well as hydration further to avoid the possibility of tumor lysis syndrome.,Plan will be to have her evaluated for bone marrow transplant in first remission.  I will have Dr. Y see her while she is in the hospital.,The patient is anxious, and will be given Ativan as needed.  We will discontinue aspirin for now, but continue estradiol/Prometrium.,Iron deficiency will be treated with oral iron supplements and we will follow her counts.  She may well have gastrointestinal (GI) involvement, which is not uncommon with mantle cell lymphoma.  After she undergoes remission, we will consider colonoscopy for biopsies prior to proceeding to transplant.",
 Iron deficiency anemia.  She underwent a bone marrow biopsy which showed a normal cellular marrow with trilineage hematopoiesis., Hematology - Oncology, Iron deficiency anemia ,"CHIEF COMPLAINT: , Iron deficiency anemia.,HISTORY OF PRESENT ILLNESS: , This is a very pleasant 19-year-old woman, who was recently hospitalized with iron deficiency anemia.  She was seen in consultation by Dr. X.  She underwent a bone marrow biopsy on 07/21/10, which showed a normal cellular marrow with trilineage hematopoiesis.  On 07/22/10, her hemoglobin was 6.5 and therefore she was transfused 2 units of packed red blood cells.  Her iron levels were 5 and her percent transferrin was 2.  There was no evidence of hemolysis.  Of note, she had a baby 5 months ago; however she does not describe excessive bleeding at the time of birth.  She currently has an IUD, so she is not menstruating.  She was discharged from the hospital on iron supplements.  She denies any fevers, chills, or night sweats.  No lymphadenopathy.  No nausea or vomiting.  No change in bowel or bladder habits.  She specifically denies melena or hematochezia.,CURRENT MEDICATIONS: , Iron supplements and Levaquin.,ALLERGIES: , Penicillin.,REVIEW OF SYSTEMS:,  As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:  ,She is status post birth of a baby girl 5 months ago.  She is G1, P1.  She is currently using an IUD for contraception.,SOCIAL HISTORY: , She has no tobacco use.  She has rare alcohol use.  No illicit drug use.,FAMILY HISTORY: , Her maternal grandmother had stomach cancer.  There is no history of hematologic malignancies.,PHYSICAL EXAM:,GEN:","hematology - oncology, trilineage hematopoiesis, cellular marrow, bone marrow biopsy, iron deficiency anemia, bone marrow, anemia, hemoglobin, lymphadenopathy, deficiency, tobacco, "
 A female with a history of peritoneal mesothelioma who has received prior intravenous chemotherapy. , Hematology - Oncology, Intraperitoneal Mesothelioma ,"REASON FOR ADMISSION:,  Intraperitoneal chemotherapy.,HISTORY: , A very pleasant 63-year-old hypertensive, nondiabetic, African-American female with a history of peritoneal mesothelioma.  The patient has received prior intravenous chemotherapy.  Due to some increasing renal insufficiency and difficulties with hydration, it was elected to change her to intraperitoneal therapy.  She had her first course with intraperitoneal cisplatin, which was very difficultly tolerated by her.  Therefore, on the last hospitalization for IP chemo, she was switched to Taxol.  The patient since her last visit has done relatively well.  She had no acute problems and has basically only chronic difficulties.  She has had some decrease in her appetite, although her weight has been stable.  She has had no fever, chills, or sweats.  Activity remains good and she has continued difficulty with depression associated with type 1 bipolar disease.  She had a recent CT scan of the chest and abdomen.  The report showed the following findings.  In the chest, there was a small hiatal hernia and a calcification in the region of the mitral valve.  There was one mildly enlarged mediastinal lymph node.  Several areas of ground-glass opacity were noted in the lower lungs, which were subtle and nonspecific.  No pulmonary masses were noted.  In the abdomen, there were no abnormalities of the liver, pancreas, spleen, and left adrenal gland.  On the right adrenal gland, a 17 x 13 mm right adrenal adenoma was noted.  There were some bilateral renal masses present, which were not optimally evaluated due to noncontrast study.  A hyperdense focus in the lower pole of the left kidney was felt to most probably represent a hemorrhagic renal cyst.  It was unchanged from February and measured 9 mm.  There was again minimal left pelvic/iliac _______ with right and left peritoneal catheters noted and were unremarkable.  Mesenteric nodes were seen, which were similar in appearance to the previous study that was felt somewhat more conspicuous due to opacified bowel adjacent to them.  There was a conglomerate omental mass, which had decreased in volume when compared to previous study, now measuring 8.4 x 1.6 cm.  In the pelvis, there was a small amount of ascites in the right pelvis extending from the inferior right paracolic gutter.  No suspicious osseous lesions were noted.,CURRENT MEDICATIONS: , Norco 10 per 325 one to two p.o. q.4h. p.r.n. pain, atenolol 50 mg p.o. b.i.d., Levoxyl 75 mcg p.o. daily, Phenergan 25 mg p.o. q.4-6h. p.r.n. nausea, lorazepam 0.5 mg every 8 hours as needed for anxiety, Ventolin HFA 2 puffs q.6h. p.r.n., Plavix 75 mg p.o. daily, Norvasc 10 mg p.o. daily, Cymbalta 60 mg p.o. daily, and Restoril 30 mg at bedtime as needed for sleep.,ALLERGIES: , THE PATIENT STATES THAT ON OCCASION LORAZEPAM DOSE PRODUCE HALLUCINATIONS, AND SHE HAD DIFFICULTY TOLERATING ATIVAN.,PHYSICAL EXAMINATION,VITAL SIGNS:  The patient's height is 165 cm, weight is 77 kg.  BSA is 1.8 sq m.  The vital signs reveal blood pressure to be 158/75, heart rate 61 per minute with a regular sinus rhythm, temperature of 96.6 degrees, respiratory rate 18 with an SpO2 of 100% on room air.,GENERAL:  She is normally developed; well nourished; very cooperative; oriented to person, place, and time; and in no distress at this time.  She is anicteric.,HEENT:  EOM is full.  Pupils are equal, round, reactive to light and accommodation.  Disc margins are unremarkable as are the ocular fields.  Mouth and pharynx within normal limits.  The TMs are glistening bilaterally.  External auditory canals are unremarkable.,NECK:  Supple, nontender without adenopathy.  Trachea is midline.  There are no bruits nor is there jugular venous distention.,CHEST:  Clear to percussion and auscultation bilaterally.,HEART:  Regular rate and rhythm without murmur, gallop, or rub.,BREASTS:  Unremarkable.,ABDOMEN:  Slightly protuberant.  Bowel tones are present and normal.  She has no palpable mass, and there is no hepatosplenomegaly.,EXTREMITIES:  Within normal limits.,NEUROLOGICAL:  Nonfocal.,DIAGNOSTIC IMPRESSION,1.  Intraperitoneal mesothelioma, partial remission, as noted by CT scan of the abdomen.,2.  Presumed left lower pole kidney hemorrhagic cyst.,3.  History of hypertension.,4.  Type 1 bipolar disease.,PLAN: , The patient will have appropriate laboratory studies done.  A left renal ultrasound is requested to further delineate the possible hemorrhagic cyst in the lower left pole of the left kidney.  Interventional radiology will access for ports in the abdomen.  She will receive chemotherapy intraperitoneally.  The plan will be to use intraperitoneal Taxol.","hematology - oncology, chemo, taxol, intraperitoneal mesothelioma, peritoneal mesothelioma, intravenous chemotherapy, adrenal gland, hemorrhagic cyst, peritoneal, intraperitoneal, hemorrhagic, mesothelioma, chemotherapy, "
 Intensity-modulated radiation therapy is a complex set of procedures which requires appropriate positioning and immobilization typically with customized immobilization devices., Hematology - Oncology, Intensity-Modulated Radiation Therapy ,"INTENSITY-MODULATED RADIATION THERAPY,Intensity-modulated radiation therapy is a complex set of procedures which requires appropriate positioning and immobilization typically with customized immobilization devices.  The treatment planning process requires at least 4 hours of physician time.  The technology is appropriate in this patient's case due to the fact that the target volume is adjacent to significant radiosensitive structures.  Sequential CT scans are obtained and transferred to the treatment planning software.  Extensive analysis occurs.  The target volumes, including margins for uncertainty, patient movement and occult tumor extension are selected.  In addition, organs at risk are outlined.  Doses are selected both for targets, as well as for organs at risk.  Associated dose constraints are placed.  Inverse treatment planning is then performed in conjunction with the physics staff.  These are reviewed by the physician and ultimately performed only following approval by the physician.  Multiple beam arrangements may be tested for appropriateness and optimal dose delivery in order to maximize the chance of controlling disease, while minimizing exposure to organs at risk.  This is performed in hopes of minimizing associated complications.  The physician delineates the treatment type, number of fractions and total volume.  During the time of treatment, there is extensive physician intervention, monitoring the patient set up and tolerance.  In addition, specific QA is performed by the physics staff under the physician's direction.,In view of the above, the special procedure code 77470 is deemed appropriate.","hematology - oncology, multiple beam arrangements, intensity modulated radiation therapyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" Progressive low-grade glioma, now more than 20 years since initially diagnosed.  She is status post craniotomy for debulking and has done well with the surgery.", Hematology - Oncology, Glioma - Consult ,"REASON FOR CONSULTATION: , Glioma.,HISTORY OF PRESENT ILLNESS:,  The patient is a 71-year-old woman who was initially diagnosed with a brain tumor in 1982.  She underwent radiation therapy for this, although craniotomy was not successful for a biopsy because of seizure activity during the surgery.  She did well for the next 10 years or so, and developed Parkinson disease, possibly related to radiation therapy.  She has been followed by neurology, Dr. Z, to treat seizure activity.  She has a vagal stimulator in place to help control her seizure activity.,Over the last few months, she has had increasing weakness on the right side.  She has been living in a nursing home.  She has not been able to walk, and she has not been able to write for the past three to four years.,MRI scan done on 11/13/2006 showed increase in size of the abdominal area and the left parietal region.  There was slight enhancement and appearance was consistent with a medium- to low-grade tumor anterior to the motor cortex.,Surgery was performed during this admission to remove some of the posterior part of the tumor.  She tolerated the procedure well.  She has noticed no worsening or improvement in her weakness.  Pathology shows a low- to intermediate-grade glioma.  The second opinion by Dr. A is still pending.,The patient is feeling well today.  She is not having headache, and reports no new neurologic symptoms.  She has not had leg swelling, cough, shortness of breath, or chest pain.,CURRENT MEDICATIONS:  ,1.  Ambien p.r.n.  ,2.  Vicodin p.r.n.  ,3.  Actonel every Sunday.  ,4.  Colace.  ,5.  Felbatol 1200 mg b.i.d.  ,6.  Heparin injections for prophylaxis.  ,7.  Maalox p.r.n.  ,8.  Mirapex 0.5 mg t.i.d.  ,9.  Protonix 40 mg daily.  ,10.  Tylenol p.r.n.  ,11.  Zanaflex 4-mg tablet, one-half tablet daily and 6 mg at bedtime.  ,12.  She has Zofran p.r.n., albuterol inhaler q.i.d., and Aggrenox, which she is to start.,The rest of the history is mostly from the chart.,ALLERGIES: , SHE IS ALLERGIC TO PENICILLIN.,PAST MEDICAL HISTORY:  ,1.  Parkinson's, likely secondary to radiation therapy.,2.  History of prior stroke.,3.  Seizure disorder secondary to her brain tumor.,4.  History of urinary incontinence.,5.  She has had hip fractures x2, which have required surgical pinning.,6.  Appendectomy.,7.  Cholecystectomy.,SOCIAL HISTORY:,  Shows that she does not smoke cigarettes or drink alcohol.  She lives in a nursing home.,FAMILY HISTORY:,  Shows a family history of breast cancer.,PHYSICAL EXAMINATION:,  ,GENERAL:  Today, she is sitting up in the chair, alert, and appropriate.  She tends to lean towards the right.  The right arm and hand are noticeably weaker than the left.  She is quite thin.,VITAL SIGNS:  Temperature is 98.5, blood pressure is 138/75, pulse is 76, respirations are 16, and pulse oximetry is 92% on room air.,HEENT:  There is a craniotomy incision on the left parietal region, clean, and dry with stitches still in place.  The oropharynx shows no thrush or mucositis.,LUNGS:  Clear bilaterally to auscultation.,CARDIAC:  Exam shows regular rate.,ABDOMEN:  Soft.,EXTREMITIES:  No peripheral edema or evidence of deep venous thrombosis (DVT) is noted on the lower extremities.,IMPRESSION AND PLAN:,  Progressive low-grade glioma, now more than 20 years since initially diagnosed.  She is status post craniotomy for debulking and has done well with the surgery.,We reviewed the phase II trials that have used Temodar in the setting of grade 2 gliomas.  Although, complete responses are rare, it is quite common to have partial response and/or stable disease, and most patients had improved quality of life indices including many patients who benefit from decreased seizure activity.  We discussed using Temodar after she heals from her surgery.  Toxicities would include fatigue, nausea, and myelosuppression primarily.",
 Hyperfractionation.  This patient is to undergo a course of hyperfractionated radiotherapy in the treatment of known malignancy.  , Hematology - Oncology, Hyperfractionation ,"HYPERFRACTIONATION,This patient is to undergo a course of hyperfractionated radiotherapy in the treatment of known malignancy.  The radiotherapy will be given in a hyperfractionated fraction (decreased dose per fraction but 2 fractions delivered daily separated by a period of at least 6 hours).  The rationale for this treatment is based on radiobiologic principles that make this type of therapy more effective in rapidly growing, previously irradiated or poorly oxygenated tumors.  The dose per fraction and the total dose are calculated by me, and this is individualized for each patient according to radiobiologic principles.,During the hyperfractionated radiotherapy, the chance of severe acute side effects is increased, so the patient will be followed more intensively for the development of any side effects and treatment instituted accordingly.","hematology - oncology, irradiated, oxygenated, tumors, malignancy, radiobiologic, hyperfractionation, hyperfractionated, radiotherapyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Newly diagnosed head and neck cancer.  The patient was recently diagnosed with squamous cell carcinoma of the base of the tongue bilaterally and down extension into the right tonsillar fossa., Hematology - Oncology, Head & Neck Cancer Consult ,"REASON FOR CONSULTATION:,  Newly diagnosed head and neck cancer.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 61-year-old gentleman who was recently diagnosed with squamous cell carcinoma of the base of the tongue bilaterally and down extension into the right tonsillar fossa.  He was also noted to have palpable level 2 cervical lymph nodes.  His staging is T3 N2c M0 Stage IV invasive squamous cell carcinoma of the head and neck.  The patient comes in to the clinic today after radiation Oncology consultation.  His Otolaryngologist performed a direct laryngoscopy with biopsy on July 29, 2010.  The patient reports that in December-January timeframe, he had noted some difficulty swallowing and ear pain.  He had a work up by his local physician that was relatively negative, and he was treated for gastroesophageal reflux disease.  His symptoms continued to progress, and he developed difficulty with his speech, dysphagia, otalgia and odynophagia.  He was then referred to Dr. X and examination revealed a mass at the right base of the tongue that extended across the midline to include the left base of the tongue as well as posterior extension involved in the right tonsillar fossa.  He was noted to have bilateral neck nodes.  His biopsy was positive for squamous cell carcinoma.,PAST MEDICAL HISTORY:,  Significant for mild hypertension.  He has had cataract surgery, gastroesophageal reflux disease and a history of biceps tendon tear.,ALLERGIES: ,  Penicillin.,CURRENT MEDICATIONS: , Lisinopril/hydrochlorothiazide 20/25 mg q.d., alprazolam 0.5 mg q.d., omeprazole 20 mg b.i.d., Lortab 7.5/500 mg q 4h p.r.n.,FAMILY HISTORY: , Significant for father who has stroke and grandfather with lung cancer.,SOCIAL HISTORY: , The patient is married but has been separated from his wife for many years, they remain close, and they have two adult sons.  He is retired from the Air Force, currently works for Lockheed Martin.  He was born and raised in New York.  He does have a smoking history, about a 20 pack-year history and he reports quitting on July 27.  He does drink alcohol socially. No use of illicit drugs.,REVIEW OF SYSTEMS:  ,The patient's chief complaint is fatigue.  He has difficulty swallowing and dysphagia.  He is responding well to Lortab and Tylenol for pain control.  He denies any chest pain, shortness of breath, fevers, chills and night sweats.  The rest of his review of systems is negative.,PHYSICAL EXAM:,VITALS:",
" Leukocytosis, acute deep venous thrombosis, right lower extremity with bilateral pulmonary embolism, on intravenous heparin complicated with acute renal failure for evaluation.", Hematology - Oncology, Hematology Consult ,"REASON FOR CONSULTATION:,  Acute deep venous thrombosis, right lower extremity with bilateral pulmonary embolism, on intravenous heparin complicated with acute renal failure for evaluation.,HISTORY OF PRESENTING ILLNESS:  ,Briefly, this is a 36-year-old robust Caucasian gentleman with no significant past medical or surgical history, who works as a sales representative, doing a lot of traveling by plane and car and attending several sales shows, developed acute shortness of breath with an episode of syncope this weekend and was brought in by paramedics to Hospital.  A V/Q scan revealed multiple pulmonary perfusion defects consistent with high probability pulmonary embolism.  A Doppler venous study of the lower extremity also revealed nonocclusive right popliteal vein thrombosis.  A CT of the abdomen and pelvis revealed normal-appearing liver, spleen, and pancreas; however, the right kidney appeared smaller compared to left and suggesting possibility of renal infarct.  Renal function on admission was within normal range; however, serial renal function showed rapid increase in creatinine to 5 today.  He has been on intravenous heparin and hemodialysis is being planned for tomorrow.  Reviewing his history, there is no family members with hypercoagulable state or prior history of any thrombotic complication.  He denies any recent injury to his lower extremity and in fact denied any calf pain or swelling.,PAST MEDICAL AND SURGICAL HISTORY:  ,Unremarkable.,SOCIAL HISTORY: , He is married and has 1 son.  He has a brother who is healthy.  There is no history of tobacco use or alcohol use.,FAMILY HISTORY:,  No family history of hypercoagulable condition.,MEDICATIONS:  ,Advil p.r.n.,ALLERGIES: , NONE.,REVIEW OF SYSTEMS: , Essentially unremarkable except for sudden onset dyspnea on easy exertion complicated with episode of syncope.  He denied any hemoptysis.  He denied any calf swelling or pain.  Lately, he has been traveling and has been sitting behind a desk for a long period of time.,PHYSICAL EXAMINATION:,GENERAL:  He is a robust young gentleman, awake, alert, and hemodynamically stable.,HEENT:  Sclerae anicteric.  Conjunctivae normal.  Oropharynx normal.,NECK:  No adenopathy or thyromegaly.  No jugular venous distention.,HEART:  Regular.,LUNGS:  Bilateral air entry.,ABDOMEN:  Obese and benign.,EXTREMITIES:  No calf swelling or calf tenderness appreciated.,SKIN:  No petechiae or ecchymosis.,NEUROLOGIC:  Nonfocal.,LABORATORY FINDINGS:,  Blood count obtained showed a white count of 16.8, hemoglobin 14.8 g percent, hematocrit 44.6%, MCV 94, and platelet count 209,000.  Liver profile normal.  Thyroid study revealed a TSH of 1.3.  Prothrombin time/INR 1.5, partial thromboplastin time 78.6 seconds.  Renal function, BUN 44 and creatinine 5.7.  Echocardiogram revealed left ventricular hypertrophy with ejection fraction of 65%, no intramural thrombus noted.,IMPRESSION:,1.  Bilateral pulmonary embolism, most consistent with emboli from right lower extremity, on intravenous heparin, rule out hereditary hypercoagulable state.,2.  Leukocytosis, most likely leukemoid reaction secondary to acute pulmonary embolism/renal infarction, doubt presence of myeloproliferative disorder.,3.  Acute renal failure secondary to embolic right renal infarction.,4.  Obesity.,PLAN: , From hematologic standpoint, we will await hypercoagulable studies, which have all been sent on admission to see if a hereditary component is at play.  For now, we will continue intravenous heparin and subsequent oral anticoagulation with Coumadin.  In view of worsening renal function, may need temporary hemodialysis until renal function improves.  I discussed at length with the patient's wife at the bedside.",
 Intensity-modulated radiation therapy simulation note.  The patient will receive intensity-modulated radiation therapy in order to deliver high-dose treatment to sensitive structures. , Hematology - Oncology, Intensity-Modulated Radiation Therapy Simulation ,"INTENSITY-MODULATED RADIATION THERAPY SIMULATION,The patient will receive intensity-modulated radiation therapy in order to deliver high-dose treatment to sensitive structures.  The target volume is adjacent to significant radiosensitive structures.,Initially, the preliminary isocenter is set on a fluoroscopically-based simulation unit.  The patient is appropriately immobilized using a customized immobilization device.  Preliminary simulation films are obtained and approved by me.  The patient is marked and transferred to the CT scanner.  Sequential images are obtained and transferred electronically to the treatment planning software.  Extensive analysis then occurs.  The target volume, including margins for uncertainty, patient movement and occult tumor extension are selected.  In addition organs at risk are outlined.  Appropriate doses are selected, both for the target, as well as constraints for organs at risk.  Inverse treatment planning is performed by the physics staff under my supervision.  These are reviewed by the physician and ultimately performed only following approval by the physician and completion of successful quality assurance.","hematology - oncology, target volume, intensity modulated radiation therapy, simulationNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Asked to see the patient in regards to a brain tumor.  She was initially diagnosed with a glioblastoma multiforme.  She presented with several lesions in her brain and a biopsy confirmed the diagnosis. , Hematology - Oncology, Glioblastoma Multiforme - Consult ,"REASON FOR CONSULTATION: , We were asked to see the patient in regards to a brain tumor.,HISTORY OF PRESENT ILLNESS: ,She was initially diagnosed in September of this year with a glioblastoma multiforme.  She presented with several lesions in her brain and a biopsy confirmed the diagnosis.  She was seen by Dr. X in our group.  Because of her living arrangement, she elected to have treatment through the hospital radiation department and oncology department.  Details of her treatment are not available at the time of this dictation.  Her family has a packet of Temodar 100-mg pills.  She is admitted now with increasing confusion.  A CT shows increase in size of the lesions compared to the preoperative scan.  We are asked to comment on her treatment at this point.  She herself is confused and is unable to provide further history.  ,PAST MEDICAL HISTORY: , From her old chart:  No known past medical history prior to the diagnosis.,SOCIAL HISTORY:  ,She was living alone and is now living in assisted living.  ,MEDICATIONS,1.  Dilantin 300 mg daily.,2.  Haloperidol 1 mg h.s.,3.  Dexamethasone 4 mg q.i.d. ,4.  Docusate 100 mg b.i.d.,5.  Pen-VK 500 mg daily.,6.  Ibuprofen 600 mg daily.,7.  Zantac 150 mg twice a day.,8.  Temodar 100 mg daily.,9.  Magic Mouthwash daily.,10.  Tylenol #3 as needed.,REVIEW OF SYSTEMS,:  Unable.,PHYSICAL EXAMINATION,GENERAL:  Elderly woman, confused.  ,HEENT:  Normal conjunctivae.  Ears and nose normal.  Mouth normal.,NECK:  Supple.,CHEST: Clear.,HEART:  Normal.,ABDOMEN: Soft, positive bowel sounds.,NEUROLOGIC:  Alert, cranial nerves intact.  Left arm slightly weak.  Left leg slightly weak.,IMPRESSION AND PLAN:,  Glioblastoma multiforme, uncertain as to where she is in cancer treatment.  Given the number of pills in the patient's family's hands, it sounds like she has only been treated recently and therefore it is not surprising that she is showing increased problems related to increased size of the tumor.  We will have to talk with Dr. Y in the Clinic to get a better handle on her treatment regimen.  At this point, I will hold Temodar today and consider restarting it tomorrow if we can get her treatment plan clarified.",
 Markedly elevated PT INR despite stopping Coumadin and administering vitamin K. Patient with a history of iron-deficiency anemia due to chronic blood loss from colitis. , Hematology - Oncology, Hematology Consult - 1 ,"HISTORY OF PRESENT ILLNESS:,  The patient is well known to me for a history of iron-deficiency anemia due to chronic blood loss from colitis.  We corrected her hematocrit last year with intravenous (IV) iron.  Ultimately, she had a total proctocolectomy done on 03/14/2007 to treat her colitis.  Her course has been very complicated since then with needing multiple surgeries for removal of hematoma.  This is partly because she was on anticoagulation for a right arm deep venous thrombosis (DVT) she had early this year, complicated by septic phlebitis.,Chart was reviewed, and I will not reiterate her complex history.,I am asked to see the patient again because of concerns for coagulopathy.,She had surgery again last month to evacuate a pelvic hematoma, and was found to have vancomycin resistant enterococcus, for which she is on multiple antibiotics and followed by infectious disease now.,She is on total parenteral nutrition (TPN) as well.,LABORATORY DATA:,  Labs today showed a white blood count of 7.9, hemoglobin 11.0, hematocrit 32.8, and platelets 1,121,000.  MCV is 89.  Her platelets have been elevated for at least the past week, with counts initially at the 600,000 to 700,000 range and in the last couple of day rising above 1,000,000.  Her hematocrit has been essentially stable for the past month or so.  White blood count has improved.,PT has been markedly elevated and today is 44.9 with an INR of 5.0.  This is despite stopping Coumadin on 05/31/2007, and with administration of vitamin K via the TPN, as well as additional doses IV.  The PT is slightly improved over the last few days, being high at 65.0 with an INR of 7.3 yesterday.,PTT has not been checked since 05/18/2007 and was normal then at 28.,LFTs have been elevated.  ALT is 100, AST 57, GGT 226, alkaline phosphatase 505, albumin low at 3.3, uric acid high at 4.9, bilirubin normal, LDH normal, and pre-albumin low at 16.  Creatinine is at 1.5, with an estimated creatinine clearance low at 41.7.  Other electrolytes are fairly normal.,B12 was assessed on 05/19/2007 and was normal at 941.  Folic acid was normal.  Iron saturation has not been checked since March, and was normal then.  Ferritin has not been checked in a couple of months.,CURRENT MEDICATIONS: , Erythropoietin 45,000 units every week, started 05/16/2007.  She is on heparin flushes, loperamide, niacin, pantoprazole, Diovan, Afrin nasal spray, caspofungin, daptomycin, Ertapenem, fentanyl or morphine p.r.n. pain, and Compazine or Zofran p.r.n. nausea.,PHYSICAL EXAMINATION: ,GENERAL:  She is alert, and frustrated with her prolonged hospital stay.  She notes that she had epistaxis a few days ago, requiring nasal packing and fortunately that had resolved now.,VITAL SIGNS:  Today, temperature is 98.5, pulse 99, respirations 16, blood pressure 105/65, and pulse is 95.  She is not requiring oxygen.,SKIN:  No significant ecchymoses are noted.,ABDOMEN:  Ileostomy is in place, with greenish black liquid output.  Midline surgical scar has healed well, with a dressing in place in the middle, with no bleeding noted.,EXTREMITIES:  She has no peripheral edema.,CARDIAC:  Regular rate.,LYMPHATICS:  No adenopathy is noted.,LUNGS:  Clear bilaterally.,IMPRESSION AND PLAN:,  Markedly elevated PT/INR despite stopping Coumadin and administering vitamin K.  I will check mixing studies to see if she has deficiency, which could be due to poor production given her elevated LFTs, decreased albumin, and decreased pre-albumin.,It is possible that she has an inhibitor, which would have to be an acquired inhibitor, generally presenting with an elevated PTT and not PT.  I will check a PTT and check mixing studies if that is prolonged.  It is doubtful that she has a lupus anticoagulant since she has been presenting with bleeding symptoms rather than clotting.  I agree with continuing off of anticoagulation for now.,She has markedly elevated platelet count.  I suspect this is likely reactive to infection, and not from a new myeloproliferative disorder.,Anemia has been stable, and is multifactorial.  Given her decreased creatinine clearance, I agree with erythropoietin support.  She was iron deficient last year, and with her multiple surgeries and poor p.o. intake, may have become iron deficient again.  She has had part of her small bowel removed, so there may be a component of poor absorption as well.  If she is iron deficient, this may contribute also to her elevated platelet counts.  I will check a ferritin.  This may be difficult to interpret because of inflammation.  If it is decreased, plan will be to add iron supplementation intravenously.  If it is elevated, we could consider a bone marrow biopsy to evaluate her iron stores, and also assess her myelopoiesis given the markedly elevated platelet counts.,She needs continued treatment as you are for her infections.,I will discuss the case with Dr. X as well since there is a question as to whether she might need additional surgery.  She is not a surgical candidate now with her elevated PT/INR.",
 HDR Brachytherapy, Hematology - Oncology, HDR Brachytherapy ,"HDR BRACHYTHERAPY,The intracavitary brachytherapy applicator was placed appropriately and secured after the patient was identified.  Simulation films were obtained, documenting its positioning.  The 3-dimensional treatment planning process was accomplished utilizing the CT derived data.  A treatment plan was selected utilizing sequential dwell positions within a single catheter.  The patient was taken to the treatment area.  The patient was appropriately positioned and the position of the intracavitary device was checked.  Catheter length measurements were taken.  Appropriate measurements of the probe dimensions and assembly were also performed.  The applicator was attached to the HDR after-loader device.  The device ran through its checking sequences appropriately and the brachytherapy was then delivered without difficulty or complication.  The brachytherapy source was appropriately removed back to the brachytherapy safe within the device.  Radiation screening was performed with the Geiger-Muller counter both prior to and after the brachytherapy procedure was completed and the results were deemed appropriate.,Following completion of the procedure, the intracavitary device was removed without difficulty.  The patient was in no apparent distress and was discharged home.","hematology - oncology, geiger-muller, treatment planning, hdr brachytherapy, intracavitary, applicator, brachytherapyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" Stage IIIC endometrial cancer.  Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane.  The patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009. ", Hematology - Oncology, Endometrial Cancer Followup ,"CHIEF COMPLAINT:,1.  Stage IIIC endometrial cancer.,2.  Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane.,HISTORY OF PRESENT ILLNESS: , The patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009.  In March 2010, she had an abnormal endometrial ultrasound with thickening of the endometrium and an enlarged uterus.  CT scan of the abdomen on 03/22/2010 showed an enlarged uterus, thickening of the endometrium, and a mass structure in the right and left adnexa that was suspicious for ovarian metastasis.  On 04/01/2010, she had a robotic modified radical hysterectomy with bilateral salpingo-oophorotomy and appendectomy with pelvic and periaortic lymphadenectomy.  The pathology was positive for grade III endometrial adenocarcinoma, 9.5 cm in size with 2 cm of invasion.  Four of 30 lymph nodes were positive for disease.  The left ovary was positive for metastatic disease.  Postsurgical PET/CT scan showed left lower pelvic side wall seroma and hypermetabolic abdominal and right pelvic retroperitoneal lymph nodes suspicious for metastatic disease.  The patient has completed five of planned six cycles of chemotherapy and comes in to clinic today for followup.  Of note, we had sent off genetic testing which was denied back in June.  I have been trying to get this testing completed.,CURRENT MEDICATIONS: , Synthroid q.d., ferrous sulfate 325 mg b.i.d., multivitamin q.d., Ativan 0.5 mg q.4 hours p.r.n. nausea and insomnia, gabapentin one tablet at bedtime.,ALLERGIES:","hematology - oncology, adjuvant, adjuvant chemotherapy, cisplatin, adriamycin, abraxane, endometrial cancer, lymphadenectomy, chemotherapy, endometrial, disease, "
" Re-excision of squamous cell carcinoma site, right hand.", Hematology - Oncology, Excision of Squamous Cell Carcinoma ,"PREOPERATIVE DIAGNOSIS: , Squamous cell carcinoma on the right hand, incompletely excised.,POSTOPERATIVE DIAGNOSIS: , Squamous cell carcinoma on the right hand, incompletely excised.,NAME OF OPERATION: , Re-excision of squamous cell carcinoma site, right hand.,ANESTHESIA:,  Local with monitored anesthesia care.,INDICATIONS:,  Patient, 72,  status post excision of squamous cell carcinoma on the dorsum of the right hand at the base of the thumb.  The deep margin was positive.  Other margins were clear.  He was brought back for re-excision.,PROCEDURE:,  The patient was brought to the operating room and placed in the supine position.  He was given intravenous sedation.  The right hand was prepped and draped in the usual sterile fashion.  Three cubic centimeters of 1% Xylocaine mixed 50/50 with 0.5% Marcaine with epinephrine was instilled with local anesthetic around the site of the excision, and the site of the cancer was re-excised with an elliptical incision down to the extensor tendon sheath.  The tissue was passed off the field as a specimen.,The wound was irrigated with warm normal saline.  Hemostasis was assured with the electrocautery.  The wound was closed with running 3-0 nylon without complication.  The patient tolerated the procedure well and was taken to the recovery room in stable condition after a sterile dressing was applied.","hematology - oncology, monitored anesthesia care, elliptical incision, squamous cell carcinoma site, squamous cell carcinoma, squamous cell, excision, squamous, carcinoma "
 Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid., Hematology - Oncology, Eyelid Squamous Cell Carcinoma Excision ,"PREOPERATIVE DIAGNOSIS: , Right upper eyelid squamous cell carcinoma.,POSTOPERATIVE DIAGNOSIS: , Right upper eyelid squamous cell carcinoma.,PROCEDURE PERFORMED: , Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid.,COMPLICATIONS:  ,None.,BLOOD LOSS: , Minimal.,ANESTHESIA:,  Local with sedation.,INDICATION:,  The patient is a 65-year-old male with a large squamous cell carcinoma on his right upper eyelid, which had previous radiation.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, laid supine, administered intravenous sedation, and prepped and draped in a sterile fashion.  He was anesthetized with a combination of 2% lidocaine and 0.5% Marcaine with Epinephrine on both upper eyelids.  The area of obvious scar tissue from the radiation for the squamous cell carcinoma on the right upper eyelid was completely excised down to the eyelid margin including resection of a few of the upper eye lashes.  This was extended essentially from the punctum to the lateral commissure and extended up on to the upper eyelid.  The resection was carried down through the orbicularis muscle resecting the pretarsal orbicularis muscle and the inferior portion of the preseptal orbicularis muscle leaving the tarsus intact and leaving the orbital septum intact.  Following complete resection, the patient was easily able to open and close his eyes as the levator muscle insertion was left intact to the tarsal plate.  The specimen was sent to pathology, which revealed only fibrotic tissue and no evidence of any residual squamous cell carcinoma.  Meticulous hemostasis was obtained with Bovie cautery and a full-thickness skin graft was taken from the opposite upper eyelid in a fashion similar to a blepharoplasty of the appropriate size for the defect in the right upper eyelid.  The left upper eyelid incision was closed with 6-0 fast-absorbing gut interrupted sutures, and the skin graft was sutured in place with 6-0 fast-absorbing gut interrupted sutures.  An eye patch was placed on the right side, and the patient tolerated the procedure well and was taken to PACU in good condition.","hematology - oncology, frozen section, full-thickness skin grafting, squamous cell carcinoma, eyelid, orbicularis,"
" Mesothelioma, pleural effusion, atrial fibrillation, anemia, ascites, esophageal reflux, and history of deep venous thrombosis.", Hematology - Oncology, Discharge Summary - Mesothelioma - 1 ,"PRINCIPAL DIAGNOSIS:,  Mesothelioma.,SECONDARY DIAGNOSES:,  Pleural effusion, atrial fibrillation, anemia, ascites, esophageal reflux, and history of deep venous thrombosis.,PROCEDURES,1.  On August 24, 2007, decortication of the lung with pleural biopsy and transpleural fluoroscopy.,2.  On August 20, 2007, thoracentesis.,3.  On August 31, 2007, Port-A-Cath placement.,HISTORY AND PHYSICAL: , The patient is a 41-year-old Vietnamese female with a nonproductive cough that started last week.  She has had right-sided chest pain radiating to her back with fever starting yesterday.  She has a history of pericarditis and pericardectomy in May 2006 and developed cough with right-sided chest pain, and went to an urgent care center.  Chest x-ray revealed right-sided pleural effusion.,PAST MEDICAL HISTORY,1.  Pericardectomy.,2.  Pericarditis.,2.  Atrial fibrillation.,4.  RNCA with intracranial thrombolytic treatment.,5",
 A patient with preoperative diagnosis of right pleural mass and postoperative diagnosis of mesothelioma., Hematology - Oncology, Discharge Summary - Mesothelioma ,"PREOPERATIVE DIAGNOSIS: , Right pleural mass.,POSTOPERATIVE DIAGNOSIS: , Mesothelioma.,PROCEDURES PERFORMED:,1.  Flexible bronchoscopy.,2.  Mediastinoscopy.,3.  Right thoracotomy.,4.  Parietal pleural biopsy.,CONSULTS:,Consults obtained during this hospitalization included:,1.  Radiation Oncology.,2.  Pulmonary Medicine.,3.  Medical Oncology.,4.  Cancer Center Team consult.,5.  Massage therapy consult.,HOSPITAL COURSE:,  The patient's hospital course was unremarkable.  Her pain was well controlled with an epidural that was placed by Anesthesia.  At the time of discharge, the patient was ambulatory.  She was discharged with home oxygen available.  She was discharged with albuterol nebulizer treatments, treatments were to be q.i.d.  She was discharged with a prescription for Vicodin for pain control.  She is to follow up with Dr. X in the office in one week with a chest x-ray.  She is instructed not to lift, push or pull anything greater than 10 pounds.  She is instructed not to drive until after she sees us in the office and is off her pain medications.","hematology - oncology, flexible bronchoscopy, mediastinoscopy, right thoracotomy, pleural biopsy, pleural mass, mesothelioma, oncology,"
 Disseminated intravascular coagulation and Streptococcal pneumonia with sepsis.  Patient presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation., Hematology - Oncology, Disseminated Intravascular Coagulation ,"DIAGNOSES:,1.  Disseminated intravascular coagulation.,2.  Streptococcal pneumonia with sepsis.,CHIEF COMPLAINT: , Unobtainable as the patient is intubated for respiratory failure.,CURRENT HISTORY OF PRESENT ILLNESS: , This is a 20-year-old female who presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation.  At this time, she is being treated aggressively with mechanical ventilation and other supportive measures and has developed disseminated intravascular coagulation with prolonged partial thromboplastin time, prothrombin time, low fibrinogen, and elevated D-dimer.  At this time, I am being consulted for further evaluation and recommendations for treatment.  The nurses report that she has actually improved clinically over the last 24 hours.  Bleeding has been a problem; however, it seems to have been abrogated at this time with factor replacement as well as platelet infusion.  There is no prior history of coagulopathy.,PAST MEDICAL HISTORY:  ,Otherwise nondescript as is the past surgical history.,SOCIAL HISTORY:  ,There were possible illicit drugs.  Her family is present, and I have discussed her case with her mother and sister.,FAMILY HISTORY:  ,Otherwise noncontributory.,REVIEW OF SYSTEMS: , Not otherwise pertinent.,PHYSICAL EXAMINATION:,GENERAL:  She is a sedated, young black female in no acute distress, lying in bed intubated.,VITAL SIGNS:  She has a rate of 67, blood pressure of 100/60, and the respiratory rate per the ventilator approximately 14 to 16.,HEENT:  Her sclerae showed conjunctival hemorrhage.  There are no petechiae.  Her nasal vestibules are clear.  Oropharynx has ET tube in place.,NECK:  No jugular venous pressure distention.,CHEST:  Coarse breath sounds bilaterally.,HEART:  Regular rate and rhythm.,ABDOMEN:  Soft and nontender with good bowel sounds.  There was some oozing around the site of her central line.,EXTREMITIES:  No clubbing, cyanosis, or edema.  There is no evidence of compromise arterial blood flow at the digits or of her hands or feet.,LABORATORY STUDIES:  ,The DIC parameters with a platelet count of approximately 50,000, INR of 2.4, normal PTT at this time, fibrinogen of 200, and a D-dimer of 13.,IMPRESSION/PLAN:  ,At this time is disseminated intravascular coagulation from sepsis from pneumococcal disease.  My recommendation for the patient is to continue factor replacement as you are.  It seems that her clinical course is reversing and simple factor replacement is probably is the best measure at this time.  There is no indication at this point for Xigris.  However, if her coagulopathy does not resolve within the next 24 hours and continue to improve with an elevated fibrinogen, normalization of her coagulation times, I would consider low-dose continuous infusion heparin for abrogation of consumption of coagulation routines and continued supportive infusions.  I will repeat her laboratory studies in the morning and give more recommendations at that time.","hematology - oncology, intravascular, coagulation, pneumonia, thromboplastin time, prothrombin time, disseminated intravascular coagulation, streptococcal pneumonia, intravascular coagulation, infusion, coagulopathy, fibrinogen, respiratory, oropharynx, sepsis, disseminated, "
 Concomitant chemoradiotherapy for curative intent patients., Hematology - Oncology, Concomitant Chemoradiotherapy ,"CONCOMITANT CHEMORADIOTHERAPY FOR CURATIVE INTENT PATIENTS,This patient is receiving combined radiotherapy and chemotherapy in an effort to maximize the chance of control of this cancer.  The chemotherapy is given in addition to the radiotherapy, not only to act as a cytotoxic agent on its own, but also to potentiate and enhance the effect of radiotherapy on tumor cells.  It has been shown in the literature that this will maximize the chance of control.,During the course of the treatment, the patient's therapy must be closely monitored by the attending physician to be sure that the proper chemotherapy drugs are given at the proper time during the radiotherapy course.  It is also important to closely monitor the patient to know when treatment with either chemotherapy or radiotherapy needs to be held.  This combined treatment usually produces greater side effects than either treatment alone, and these need to be constantly monitored and treatment initiated on a timely basis to minimize these effects.  In accordance, this requires more frequency consultation and coordination with the medical oncologist.  Therefore, this becomes a very time intensive treatment and justifies CPT Code 77470.","hematology - oncology, tumor cells, concomitant chemoradiotherapy, chemotherapy, radiotherapyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" Postoperative visit for craniopharyngioma with residual disease.  According to him, he is doing well, back at school without any difficulties.  He has some occasional headaches and tinnitus, but his vision is much improved.", Hematology - Oncology, Craniopharyngioma - Postop ,"REASON FOR VISIT:,  Postoperative visit for craniopharyngioma.,HISTORY OF PRESENT ILLNESS:,  Briefly, a 16-year-old right-handed boy who is in eleventh grade, who presents with some blurred vision and visual acuity difficulties, was found to have a suprasellar tumor.  He was brought to the operating room on 01/04/07, underwent a transsphenoidal resection of tumor.  Histology returned as craniopharyngioma.  There is some residual disease; however, the visual apparatus was decompressed.  According to him, he is doing well, back at school without any difficulties.  He has some occasional headaches and tinnitus, but his vision is much improved.,MEDICATIONS: , Synthroid 100 mcg per day.,FINDINGS: , On exam, he is awake, alert and oriented x 3.  Pupils are equal and reactive.  EOMs are full.  His visual acuity is 20/25 in the right (improved from 20/200) and the left is 20/200 improved from 20/400.  He has a bitemporal hemianopsia, which is significantly improved and wider.  His motor is 5 out of 5.  There are no focal motor or sensory deficits.  The abdominal incision is well healed.  There is no evidence of erythema or collection.  The lumbar drain was also well healed.,The postoperative MRI demonstrates small residual disease.,Histology returned as craniopharyngioma.,ASSESSMENT: , Postoperative visit for craniopharyngioma with residual disease.,PLANS: , I have recommended that he call.  I discussed the options with our radiation oncologist, Dr. X. They will schedule the appointment to see him.  In addition, he probably will need an MRI prior to any treatment, to follow the residual disease.","hematology - oncology, visual acuity, blurred vision, tinnitus, headaches, residual disease, tumor, histology, craniopharyngioma,"
 Conformal simulation with coplanar beams.  This patient is undergoing a conformal simulation as the method to precisely define the area of disease which needs to be treated. , Hematology - Oncology, Conformal Simulation ,"CONFORMAL SIMULATION WITH COPLANAR BEAMS,This patient is undergoing a conformal simulation as the method to precisely define the area of disease which needs to be treated.  It allows us to highly focus the beam of radiation and shape the beam to the target volume, delivering a homogenous dosage through it while sparing the surrounding, more radiosensitive, normal tissues.  This will allow us to give the optimum chance of tumor control while minimizing the acute and long-term side effects.,A conformal simulation is a simulation which involves extended physician, therapist, and dosimetrist time and effort.  The patient is initially taken into a conventional simulator room, where appropriate markers are placed, and the patient is positioned and immobilized.  One then approximates the field sizes and arrangements (gantry angles, collimator angles, and number of fields).  Radiographs are taken, and these fields are marked on the patient's skin.  The patient is then transferred to the diagnostic facility and placed on a flat CT scan table.  Scans are then performed through the targeted area.  The CT scans are evaluated by the radiation oncologist, and the tumor volume, target volume, and critical structures are outlined on each slice of the CT scan.  The dosimetrist then evaluates each individual slice in the treatment planning computer with the appropriately marked structures.  This volume is then reconstructed in 3-dimensional space.  Utilizing the beam's-eye view features, the appropriate blocks are designed.  Multiplane computerized dosimetry is performed throughout the volume.  Field arrangements and blocking are modified as necessary to provide homogenous coverage of the target volume while minimizing the dose to normal structures.  Once all appropriate beam parameters and isodate distributions have been confirmed on the computer scan, each individual slice is then reviewed by the physician.  The beam's-eye view, block design, and appropriate volumes are also printed and reviewed by the physician.  Once these are approved, Cerrobend blocks will be custom fabricated.,If significant changes are made in the field arrangements from the original simulation, the patient is brought back to the simulator where the computer-designed fields are re-simulated.","hematology - oncology, coplanar beams, ct scan, target volume, conformal simulation, beamsNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Patient presents with complaint of lump in the upper outer quadrant of the right breast, Hematology - Oncology, Consult - Breast Cancer ,"CHIEF COMPLAINT / REASON FOR THE VISIT:, Patient has been diagnosed to have breast cancer.,BREAST CANCER HISTORY:, Patient presented with the following complaints: Lump in the upper outer quadrant of the right breast that has been present for the last 4 weeks. The lump is painless and the skin over the lump is normal. Patient denies any redness, warmth, edema and nipple discharge. Patient had a mammogram recently and was told to have a mass measuring 2 cm in the UOQ and of the left breast. Patient had an excisional biopsy of the mass and subsequently axillary nodal sampling.,PATHOLOGY:, Infiltrating ductal carcinoma, Estrogen receptor 56, Progesterone receptor 23, S-phase fraction 2., Her 2 neu 0 and all nodes negative.,STAGE:, Stage I.,TNM STAGE:, T1, N0 and M0.,SURGERY:, S/P lumpectomy left breast and Left axillary node sampling. Patient is here for further recommendation.,PAST MEDICAL HISTORY:, Osteoarthritis for 5 years. ASHD for 10 years. Kidney stones recurrent for 10 years.,SCREENING TEST HISTORY:,  Last rectal exam was done on 10/99. Last mammogram was done on 12/99. Last gynecological exam was done on 10/99. Last PAP smear was done on 10/99. Last chest x-ray was done on 10/99. Last F.O.B. was done on 10/99-X3. Last sigmoidoscopy was done on 1998. Last colonoscopy was done on 1996.,IMMUNIZATION HISTORY:, Last flu vaccine was given on 1999. Last pneumonia vaccine was given on 1996.,FAMILY MEDICAL HISTORY:, Father age 85, history of cerebrovascular accident (stroke) and hypertension. Mother history of CHF and emphysema that died at the age of 78. No brothers and sisters. 1 son healthy at age 54.,PAST SURGICAL HISTORY:, Appendectomy. Biopsy of the left breast 1996 - benign.",
" The patient is a 57-year-old female with invasive ductal carcinoma of the left breast, T1c, Nx, M0 left breast carcinoma.", Hematology - Oncology, Consult - Breast Cancer - 1 ,"CHIEF COMPLAINT: , Left breast cancer.,HISTORY:,  The patient is a 57-year-old female, who I initially saw in the office on 12/27/07, as a referral from the Tomball Breast Center.  On 12/21/07, the patient underwent image-guided needle core biopsy of a 1.5 cm lesion at the 7 o'clock position of the left breast (inferomedial).  The biopsy returned showing infiltrating ductal carcinoma high histologic grade.  The patient stated that she had recently felt and her physician had felt a palpable mass in that area prior to her breast imaging.  She prior to that area, denied any complaints.  She had no nipple discharge.  No trauma history.  She has had been on no estrogen supplementation.  She has had no other personal history of breast cancer.  Her family history is positive for her mother having breast cancer at age 48.  The patient has had no children and no pregnancies.  She denies any change in the right breast.  Subsequent to the office visit and tissue diagnosis of breast cancer, she has had medical oncology consultation with Dr. X and radiation oncology consultation with Dr. Y.  I have discussed the case with Dr. X and Dr. Y, who are both in agreement with proceeding with surgery prior to adjuvant therapy.  The patient's metastatic workup has otherwise been negative with MRI scan and CT scanning.  The MRI scan showed some close involvement possibly involving the left pectoralis muscle, although thought to also possibly represent biopsy artifact.  CT scan of the neck, chest, and abdomen is negative for metastatic disease.,PAST MEDICAL HISTORY:,  Previous surgery is history of benign breast biopsy in 1972, laparotomy in 1981, 1982, and 1984, right oophorectomy in 1984, and ganglion cyst removal of the hand in 1987.,MEDICATIONS:,  She is currently on omeprazole for reflux and indigestion.,ALLERGIES:,  SHE HAS NO KNOWN DRUG ALLERGIES.,REVIEW OF SYSTEMS:,  Negative for any recent febrile illnesses, chest pains or shortness of breath.  Positive for restless leg syndrome.  Negative for any unexplained weight loss and no change in bowel or bladder habits.,FAMILY HISTORY:,  Positive for breast cancer in her mother and also mesothelioma from possible asbestosis or asbestos exposure.,SOCIAL HISTORY:  ,The patient works as a school teacher and teaching high school.,PHYSICAL EXAMINATION,GENERAL:  The patient is a white female, alert and oriented x 3, appears her stated age of 57.,HEENT:  Head is atraumatic and normocephalic.  Sclerae are anicteric.,NECK:  Supple.,CHEST:  Clear.,HEART:  Regular rate and rhythm.,BREASTS:  Exam reveals an approximately 1.5 cm relatively mobile focal palpable mass in the inferomedial left breast at the 7 o'clock position, which clinically is not fixed to the underlying pectoralis muscle.  There are no nipple retractions.  No skin dimpling.  There is some, at the time of the office visit, ecchymosis from recent biopsy.  There is no axillary adenopathy.  The remainder of the left breast is without abnormality.  The right breast is without abnormality.  The axillary areas are negative for adenopathy bilaterally.,ABDOMEN:  Soft, nontender without masses.  No gross organomegaly.  No CVA or flank tenderness.,EXTREMITIES:  Grossly neurovascularly intact.,IMPRESSION: , The patient is a 57-year-old female with invasive ductal carcinoma of the left breast, T1c, Nx, M0 left breast carcinoma.,RECOMMENDATIONS: , I have discussed with the patient in detail about the diagnosis of breast cancer and the surgical options, and medical oncologist has discussed with her issues about adjuvant or neoadjuvant chemotherapy.  We have decided to recommend to the patient breast conservation surgery with left breast lumpectomy with preoperative sentinel lymph node injection and mapping and left axillary dissection.  The possibility of further surgery requiring wider lumpectomy or even completion mastectomy was explained to the patient.  The procedure and risks of the surgery were explained to include, but not limited to extra bleeding, infection, unsightly scar formation, the possibility of local recurrence, the possibility of left upper extremity lymphedema was explained.  Local numbness, paresthesias or chronic pain was explained.  The patient was given an educational brochure and several brochures about the diagnosis and treatment of breast cancers.  She was certainly encouraged to obtain further surgical medical opinions prior to proceeding.  I believe the patient has given full informed consent and desires to proceed with the above.", 
 Genetic counseling for a strong family history of colon polyps.  She has had colonoscopies required every five years and every time she has polyps were found.  She reports that of her 11 brothers and sister 7 have had precancerous polyps.  , Hematology - Oncology, Colon Polyps - Genetic Counseling ,"REASON FOR CONSULT: , Genetic counseling.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 61-year-old female with a strong family history of colon polyps.  The patient reports her first polyps noted at the age of 50.  She has had colonoscopies required every five years and every time she has polyps were found.  She reports that of her 11 brothers and sister 7 have had precancerous polyps.  She does have an identical twice who is the one of the 11 who has never had a history of polyps.  She also has history of several malignancies in the family.  Her father died of a brain tumor at the age of 81.  There is no history of knowing whether this was a primary brain tumor or whether it is a metastatic brain involvement.  Her sister died at the age of 65 breast cancer.  She has two maternal aunts with history of lung cancer both of whom were smoker.  Also a paternal grandmother who was diagnosed with breast cancer at 86 and a paternal grandfather who had lung cancer.  There is no other cancer history.,PAST MEDICAL HISTORY:,  Significant for asthma.,CURRENT MEDICATIONS: , Include Serevent two puffs daily and Nasonex two sprays daily.,ALLERGIES: , Include penicillin.  She is also allergic seafood; crab and mobster.,SOCIAL HISTORY: , The patient is married.  She was born and raised in South Dakota.  She moved to Colorado 37 years ago.  She attended collage at the Colorado University.  She is certified public account.  She does not smoke.  She drinks socially.,REVIEW OF SYSTEMS:  ,The patient denies any dark stool or blood in her stool.  She has had occasional night sweats and shortness of breath, and cough associated with her asthma.  She also complains of some acid reflux as well as anxiety.  She does report having knee surgery for torn ACL on the left knee and has some arthritis in that knee.  The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:","hematology - oncology, family history, strong family history, precancerous polyps, brain tumor, lung cancer, genetic counseling, colon polyps, polyps, "
 Routine colorectal cancer screening.  He occasionally gets some loose stools.  , Hematology - Oncology, Colon Cancer Screening ,"HISTORY AND REASON FOR CONSULTATION:, For evaluation of this patient for colon cancer screening.,HISTORY OF PRESENT ILLNESS:, Mr. A is a 53-year-old gentleman who was referred for colon cancer screening.  The patient said that he occasionally gets some loose stools.  Other than that, there are no other medical problems. ,PAST MEDICAL HISTORY:, The patient does not have any serious medical problems at all.  He denies any hypertension, diabetes, or any other problems.  He does not take any medications.,PAST SURGICAL HISTORY: ,Surgery for deviated nasal septum in 1996.,ALLERGIES:, No known drug allergies.,SOCIAL HISTORY: ,Does not smoke, but drinks occasionally for the last five years.,FAMILY HISTORY:, There is no history of any colon cancer in the family.,REVIEW OF SYSTEMS:, Denies any significant diarrhea.  Sometimes he gets some loose stools.  Occasionally there is some constipation.  Stools caliber has not changed.  There is no blood in stool or mucus in stool.  No weight loss.  Appetite is good.  No nausea, vomiting, or difficulty in swallowing.  Has occasional heartburn.,PHYSICAL EXAMINATION:, The patient is alert and oriented x3.  Vital signs: Weight is 214 pounds.  Blood pressure is 111/70.  Pulse is 69 per minute.  Respiratory rate is 18.  HEENT: Negative.  Neck: Supple.  There is no thyromegaly.  Cardiovascular: Both heart sounds are heard.  Rhythm is regular.  No murmur.  Lungs: Clear to percussion and auscultation.  Abdomen: Soft and nontender.  No masses felt.  Bowel sounds are heard.  Extremities: Free of any edema.,IMPRESSION: ,Routine colorectal cancer screening.,RECOMMENDATIONS:, Colonoscopy.  I have explained the procedure of colonoscopy with benefits and risks, in particular the risk of perforation, hemorrhage, and infection.  The patient agreed for it.  We will proceed with it.  I also explained to the patient about conscious sedation.  He agreed for conscious sedation.","hematology - oncology, colon cancer screening, loose stools, colorectal, colonoscopy,"
" Breast radiation therapy followup note. Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.", Hematology - Oncology, Breast Radiation Therapy Followup ,"DIAGNOSIS: , Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.,She has been found more recently to have stage IV disease with metastatic deposits and recurrence involving the chest wall and lower left neck lymph nodes.,CURRENT MEDICATIONS,1.  Glucosamine complex.,2.  Toprol XL.,3.  Alprazolam,4.  Hydrochlorothiazide.,5.  Dyazide.,6.  Centrum.,Dr. X has given her some carboplatin and Taxol more recently and feels that she would benefit from electron beam radiotherapy to the left chest wall as well as the neck.  She previously received a total of 46.8 Gy in 26 fractions of external beam radiotherapy to the left supraclavicular area.  As such, I feel that we could safely re-treat the lower neck.  Her weight has increased to 189.5 from 185.2.  She does complain of some coughing and fatigue.,PHYSICAL EXAMINATION,NECK:  On physical examination palpable lymphadenopathy is present in the left lower neck and supraclavicular area.  No other cervical lymphadenopathy or supraclavicular lymphadenopathy is present.,RESPIRATORY:  Good air entry bilaterally. Examination of the chest wall reveals a small lesion where the chest wall recurrence was resected.  No lumps, bumps or evidence of disease involving the right breast is present.,ABDOMEN:  Normal bowel sounds, no hepatomegaly.  No tenderness on deep palpation. She has just started her last cycle of chemotherapy today, and she wishes to visit her daughter in Brooklyn, New York. After this she will return in approximately 3 to 4 weeks and begin her radiotherapy treatment at that time.,I look forward to keeping you informed of her progress.  Thank you for having allowed me to participate in her care.","hematology - oncology, carboplatin, taxol, radiation therapy, breast adenocarcinoma, beam radiotherapy, chest wall, radiotherapy, supraclavicular, lymphadenopathy, adenocarcinoma, breast,"
 Excision of left breast mass.  The mass was identified adjacent to the left nipple.  It was freely mobile and it did not seem to hold the skin. , Hematology - Oncology, Breast Mass Excision - 2 ,"PREOPERATIVE DIAGNOSIS: , Breast mass, left.,POSTOPERATIVE DIAGNOSIS:,  Breast mass, left.,PROCEDURE:,  Excision of left breast mass.,OPERATION: , After obtaining an informed consent, the patient was taken to the operating room where he underwent general endotracheal anesthesia.  The time-out process was followed.  Preoperative antibiotic was given.  The patient was prepped and draped in the usual fashion.  The mass was identified adjacent to the left nipple.  It was freely mobile and it did not seem to hold the skin.  An elliptical skin incision was made over the mass and carried down in a pyramidal fashion towards the pectoral fascia.  The whole of specimen including the skin, the mass, and surrounding subcutaneous tissue and fascia were excised en bloc.  Hemostasis was achieved with the cautery.  The specimen was sent to Pathology and the tissues were closed in layers including a subcuticular suture of Monocryl.  A small pressure dressing was applied.,Estimated blood loss was minimal and the patient who tolerated the procedure very well was sent to recovery room in satisfactory condition.","hematology - oncology, breast mass excision, freely mobile, breast mass, endotracheal, fascia, specimen,"
" Stage IIA right breast cancer.  The pathology showed an infiltrating ductal carcinoma Nottingham grade II.  The tumor was ER positive, PR positive and HER-2/neu negative.", Hematology - Oncology, Breast Cancer Followup - 1 ,"CHIEF COMPLAINT:,  Stage IIA right breast cancer.,HISTORY OF PRESENT ILLNESS:  ,This is an extremely pleasant 58-year-old woman, who I am following for her stage IIA right breast cancer.  She noticed a lump in the breast in November of 2007.  A mammogram was obtained dated 01/28/08, which showed a mass in the right breast.  On 02/10/08, she underwent an ultrasound-guided biopsy.  The pathology showed an infiltrating ductal carcinoma Nottingham grade II.  The tumor was ER positive, PR positive and HER-2/neu negative.  On 02/22/08, she underwent a lumpectomy and sentinel lymph node biopsy.  The pathology showed a 3.3 cm infiltrating ductal carcinoma grade I, one sentinel lymph node was negative.  Therefore it was a T2, N0, M0 stage IIA breast cancer.  Of note, at that time she was taking hormone replacement therapy and that was stopped.  She underwent radiation treatment ending in May 2008.  She then started on Arimidex, but unfortunately she did not tolerate the Arimidex and I changed her to Femara.  She also did not tolerate the Femara and I changed it to tamoxifen.  She did not tolerate the tamoxifen and therefore when I saw her on 11/23/09, she decided that she would take no further antiestrogen therapy.  She met with me again on 02/22/10, and decided she wants to rechallenge herself with tamoxifen.  When I saw her on 04/28/10, she was really doing quite well with tamoxifen.  She tells me 2 weeks after that visit, she developed toxicity from the tamoxifen and therefore stopped it herself.  She is not going take to any further tamoxifen.,Overall, she is feeling well.  She has a good energy level and her ECOG performance status is 0.  She denies any fevers, chills, or night sweats.  No lymphadenopathy.  No nausea or vomiting.  No change in bowel or bladder habits.,CURRENT MEDICATIONS:,  Avapro 300 mg q.d., Pepcid q.d., Zyrtec p.r.n., and calcium q.d.,ALLERGIES:,  Sulfa, Betadine, and IV contrast.,REVIEW OF SYSTEMS: , As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1.  Asthma.,2.  Hypertension.,3.  GERD.,4.  Eczema.,5.  Status post three cesarean sections.,6.  Status post a hysterectomy in 1981 for fibroids.  They also removed one ovary.,7.  Status post a cholecystectomy in 1993.,8.  She has a history of a positive TB test.,9.  She is status post repair of ventral hernia in November 2008.,SOCIAL HISTORY: , She has no tobacco use.  Only occasional alcohol use.  She has no illicit drug use.  She has two grown children.  She is married.  She works as a social worker dealing with adult abuse and neglect issues.  Her husband is a high school chemistry teacher.,FAMILY HISTORY:  ,Her father had prostate cancer.  Her maternal uncle had Hodgkin's disease, melanoma, and prostate cancer.,PHYSICAL EXAM:,VIT:",
" T1 N3 M0 cancer of the nasopharynx, status post radiation therapy with 2 cycles of high dose cisplatin with radiation.", Hematology - Oncology, Cancer of the nasopharynx ,"DIAGNOSIS: , T1 N3 M0 cancer of the nasopharynx, status post radiation therapy with 2 cycles of high dose cisplatin with radiation, completed June, 2006; status post 2 cycles  carboplatin/5-FU given as adjuvant therapy, completed September, 2006; hearing loss related to chemotherapy and radiation; xerostomia; history of left upper extremity deep venous thrombosis.,PERFORMANCE STATUS:,  0.,INTERVAL HISTORY: , In the interim since his last visit he has done quite well.  He is working.  He did have an episode of upper respiratory infection and fever at the end of April which got better with antibiotics.  Overall when he compares his strength to six or eight months ago he notes that he feels much stronger.  He has no complaints other than mild xerostomia and treatment related hearing loss.,PHYSICAL EXAMINATION:,Vital Signs:  Height 65 inches, weight 150, pulse 76, blood pressure 112/74, temperature 95.4, respirations 18.,HEENT:  Extraocular muscles intact.  Sclerae not icteric.  Oral cavity free of exudate or ulceration.  Dry mouth noted.,Lymph:  No palpable adenopathy in cervical, supraclavicular or axillary areas.,Lungs:  Clear.,Cardiac:  Rhythm regular.,Abdomen:  Soft, nondistended.  Neither liver, spleen, nor other masses palpable.,Lower Extremities:  Without edema.,Neurologic:  Awake, alert, ambulatory, oriented, cognitively intact.,I reviewed the CT images and report of the study done on May 1.  This showed no evidence of metabolically active malignancy.,Most recent laboratory studies were performed last September and the TSH was normal.  I have asked him to repeat the TSH at the one year anniversary.,He is on no current medications.,In summary, this 57-year-old man presented with T1 N3 cancer of the nasopharynx and is now at 20 months post completion of all therapy.  He has made a good recovery.  We will continue to follow thyroid function and I have asked him to obtain a TSH at the one year anniversary in September and CBC in follow up.  We will see him in six months' time with a PET-CT.,He returns to the general care and direction of Dr. ABC.","hematology - oncology, radiation therapy with cycles, cancer of the nasopharynx, status post radiation, cisplatin with radiation, radiation therapy, hearing loss, hearing, cisplatin, xerostomia, cancer, radiation, nasopharynx,"
 Excision of right breast mass.  Right breast mass with atypical proliferative cells on fine-needle aspiration., Hematology - Oncology, Breast Mass Excision ,"PREOPERATIVE DIAGNOSIS: , Right breast mass with atypical proliferative cells on fine-needle aspiration.,POSTOPERATIVE DIAGNOSIS:,  Benign breast mass.,ANESTHESIA: , General,NAME OF OPERATION:,  Excision of right breast mass.,PROCEDURE:,  With the patient in the supine position, the right breast was prepped and draped in a sterile fashion.  A curvilinear incision was made directly over the mass in the upper-outer quadrant of the right breast.  Dissection was carried out around a firm mass, which was dissected with surrounding margins of breast tissue.  Hemostasis was obtained using electrocautery.  Frozen section exam showed a fibroadenoma with some proliferative hyperplasia within the fibroadenoma, but appeared benign.  The breast tissues were approximated using 4-0 Vicryl.  The skin was closed using 5-0 Vicryl running subcuticular stitches.  A sterile bandage was applied.  The patient tolerated the procedure well.,","hematology - oncology, atypical proliferative cells, fine needle aspiration, proliferative cells, breast mass, breast, needle, aspiration, fibroadenoma, excision, proliferative, mass, "
" Newly diagnosed stage II colon cancer, with a stage T3c, N0, M0 colon cancer, grade 1.  Although, the tumor was near obstructing, she was not having symptoms and in fact was having normal bowel movements.", Hematology - Oncology, Colon Cancer Consult ,"REASON FOR CONSULTATION: , I was asked by Dr. X to see the patient in consultation for a new diagnosis of colon cancer.,HISTORY OF PRESENT ILLNESS:,  The patient presented to medical attention after she noticed mild abdominal cramping in February 2007.  At that time, she was pregnant and was unsure if her symptoms might have been due to the pregnancy.  Unfortunately, she had miscarriage at about seven weeks.  She again had abdominal cramping, severe, in late March 2007.  She underwent colonoscopy on 04/30/2007 by Dr. Y.  Of note, she is with a family history of early colon cancers and had her first colonoscopy at age 35 and no polyps were seen at that time.,On colonoscopy, she was found to have a near-obstructing lesion at the splenic flexure.  She was not able to have the scope passed past this lesion.  Pathology showed a colon cancer, although I do not have a copy of that report at this time.,She had surgical resection done yesterday.  The surgery was laparoscopic assisted with anastomosis.  At the time of surgery, lymph nodes were palpable.,Pathology showed colon adenocarcinoma, low grade, measuring 3.8 x 1.7 cm, circumferential and invading in to the subserosal mucosa greater than 5 mm, 13 lymph nodes were negative for metastasis.  There was no angiolymphatic invasion noted.  Radial margin was 0.1 mm.  Other margins were 5 and 6 mm.  Testing for microsatellite instability is still pending.,Staging has already been done with a CT scan of the chest, abdomen, and pelvis.  This showed a mass at the splenic flexure, mildly enlarged lymph nodes there, and no evidence of metastasis to liver, lungs, or other organs.  The degenerative changes were noted at L5-S1.  The ovaries were normal.  An intrauterine device (IUD) was present in the uterus.,REVIEW OF SYSTEMS:,  She has otherwise been feeling well.  She has not had fevers, night sweats, or noticed lymphadenopathy.  She has not had cough, shortness of breath, back pain, bone pain, blood in her stool, melena, or change in stool caliber.  She was eating well up until the time of her surgery.  She is up-to-date on mammography, which will be due again in June.  She has no history of pulmonary, cardiac, renal, hepatic, thyroid, or central nervous system (CNS) disease.,ALLERGIES: , PENICILLIN, WHICH CAUSED HIVES WHEN SHE WAS A CHILD.,MEDICATIONS PRIOR TO ADMISSION:,  None.,PAST MEDICAL HISTORY: , No significant medical problem.  She has had three miscarriages, all of them at about seven weeks.  She has no prior surgeries.,SOCIAL HISTORY:  ,She smoked cigarettes socially while in her 20s.  A pack of cigarettes would last for more than a week.  She does not smoke now.  She has two glasses of wine per day, both red and white wine.  She is married and has no children.  An IUD was recently placed.  She works as an esthetician.,FAMILY HISTORY:  ,Father died of stage IV colon cancer at age 45.  This occurred when the patient was young and she is not sure of the rest of the paternal family history.  She does believe that aunts and uncles on that side may have died early.  Her brother died of pancreas cancer at age 44.  Another brother is aged 52 and he had polyps on colonoscopy a couple of years ago.  Otherwise, he has no medical problem.  Mother is aged 82 and healthy.  She was recently diagnosed with hemochromatosis.,PHYSICAL EXAMINATION: , ,GENERAL:  She is in no acute distress.,VITAL SIGNS:  The patient is afebrile with a pulse of 78, respirations 16, blood pressure 124/70, and pulse oximetry is 93% on 3 L of oxygen by nasal cannula.,SKIN:  Warm and dry.  She has no jaundice.,LYMPHATICS:  No cervical or supraclavicular lymph nodes are palpable.,LUNGS:  There is no respiratory distress.,CARDIAC:  Regular rate.,ABDOMEN:  Soft and mildly tender.  Dressings are clean and dry.,EXTREMITIES:  No peripheral edema is noted.  Sequential compression devices (SCDs) are in place.,LABORATORY DATA:,  White blood count of 11.7, hemoglobin 12.8, hematocrit 37.8, platelets 408, differential shows left shift, MCV is 99.6.  Sodium is 136, potassium 4.1, bicarb 25, chloride 104, BUN 5, creatinine 0.7, and glucose is 133.  Calcium is 8.8 and magnesium is 1.8.,IMPRESSION AND PLAN: , Newly diagnosed stage II colon cancer, with a stage T3c, N0, M0 colon cancer, grade 1.  She does not have high-risk factors such as high grade or angiolymphatic invasion, and adequate number of lymph nodes were sampled.  Although, the tumor was near obstructing, she was not having symptoms and in fact was having normal bowel movements.,A lengthy discussion was held with the patient regarding her diagnosis and prognosis.  Firstly, she has a good prognosis for being cured without adjuvant therapy.  I would consider her borderline for chemotherapy given her young age.  Referring to the database that had been online, she has a 13% chance of relapse in the next five years, and with aggressive chemotherapy (X-linked agammaglobulinemia (XLA) platinum-based), this would be reduced to an 8% risk of relapse with a 5% benefit.  Chemotherapy with 5-FU based regimen would have a smaller benefit of around 2.5%.,Plan was made to allow her to recuperate and then meet with her and her husband to discuss the pros and cons of adjuvant chemotherapy including what regimen she could consider including the side effects.  We did not review all that information today.,She has a family history of early colon cancer.  Her mother will be visiting in the weekend and plan is to obtain the rest of the paternal family history if we can.  Tumor is being tested for microsatellite instability and we will discuss this when those results are available.  She has one sibling and he is up-to-date on colonoscopy.  She does report multiple tubes of blood were drawn prior to her admission.  I will check with Dr. Y's office whether she has had a CEA and liver-associated enzymes assessed.  If not, those can be drawn tomorrow.",
 Newly diagnosed cholangiocarcinoma.  The patient is noted to have an increase in her liver function tests on routine blood work.  Ultrasound of the abdomen showed gallbladder sludge and gallbladder findings consistent with adenomyomatosis. , Hematology - Oncology, Cholangiocarcinoma Consult ,"REASON FOR CONSULTATION:,  Newly diagnosed cholangiocarcinoma.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 77-year-old female who is noted to have an increase in her liver function tests on routine blood work in December 2009.  Ultrasound of the abdomen showed gallbladder sludge and gallbladder findings consistent with adenomyomatosis.  Common bile duct was noted to be 10 mm in size on that ultrasound.  She then underwent a CT scan of the abdomen in July 2010, which showed intrahepatic ductal dilatation with the common bile duct size being 12.7 mm.  She then underwent an MRI MRCP, which was notable for stricture of the distal common bile duct.  She was then referred to gastroenterology and underwent an ERCP.  On August 24, 2010, she underwent the endoscopic retrograde cholangiopancreatography.  She was noted to have a stricturing mass of the mid-to-proximal common bile duct consistent with cholangiocarcinoma.  A temporary biliary stent was placed across the biliary stricture.  Blood work was obtained during the hospitalization.  She was also noted to have an elevated CA99.  She comes in to clinic today for initial Medical Oncology consultation.  After she sees me this morning, she has a follow-up consultation with a surgeon.,PAST MEDICAL HISTORY:  ,Significant for hypertension and hyperlipidemia.  In July, she had eye surgery on her left eye for a muscle repair.  Other surgeries include left ankle surgery for a fractured ankle in 2000.,CURRENT MEDICATIONS: , Diovan 80/12.5 mg daily, Lipitor 10 mg daily, Lutein 20 mg daily, folic acid 0.8 mg daily and multivitamin daily.,ALLERGIES:  ,No known drug allergies.,FAMILY HISTORY: , Notable for heart disease.  She had three brothers that died of complications from open heart surgery.  Her parents and brothers all had hypertension.  Her younger brother died at the age of 18 of infection from a butcher's shop.  He was cutting Argentinean beef and contracted an infection and died within 24 hours.  She has one brother that is living who has angina and a sister who is 84 with dementia.  She has two adult sons who are in good health.,SOCIAL HISTORY: , The patient has been married to her second husband for the past ten years.  Her first husband died in 1995.  She does not have a smoking history and does not drink alcohol.,REVIEW OF SYSTEMS:  ,The patient reports a change in her bowels ever since she had the stent placed.  She has noted some weight loss, but she notes that that is due to not eating very well.  She has had some mild fatigue, but prior to her diagnosis she had absolutely no symptoms.  As mentioned above, she was noted to have abnormal alkaline phosphatase and total bilirubin, AST and ALT, which prompted the followup.  She has had some difficulty with her vision that has improved with her recent surgical procedure.  She denies any fevers, chills, night sweats.  She has had loose stools.  The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:", 
" Left breast mass and hypertrophic scar of the left breast.  Excision of left breast mass and revision of scar.  The patient is status post left breast biopsy, which showed a fibrocystic disease with now a palpable mass just superior to the previous biopsy site.", Hematology - Oncology, Breast Mass Excision - 1 ,"PREOPERATIVE DIAGNOSES:,1.  Left breast mass.,2.  Hypertrophic scar of the left breast.,POSTOPERATIVE DIAGNOSES:,1.  Left breast mass.,2.  Hypertrophic scar of the left breast.,PROCEDURE PERFORMED:  ,Excision of left breast mass and revision of scar.,ANESTHESIA:  ,Local with sedation.,SPECIMEN: , Scar with left breast mass.,DISPOSITION:  ,The patient tolerated the procedure well and transferred to the recover room in stable condition.,BRIEF HISTORY:  ,The patient is an 18-year-old female who presented to Dr. X's office.  The patient is status post left breast biopsy, which showed a fibrocystic disease with now a palpable mass just superior to the previous biopsy site.  The patient also has a hypertrophic scar.  Thus, the patient elected to undergo revision of the scar at the same time as an excision of the palpable mass.,INTRAOPERATIVE FINDINGS: , A hypertrophic scar was found and removed.  The cicatrix was removed in its entirety and once opening the wound, the area of tissue where the palpable mass was, was excised as well and sent to the lab.,PROCEDURE: , After informed consent, risks, and benefits of the procedure were explained to the patient and the patient's family, the patient was brought to the operating suite, prepped and draped in the normal sterile fashion.  Elliptical incision was made over the previous cicatrix.  The total length of the incision was 5.5 cm.  Removing the cicatrix in its entirety with a #15 blade Bard-Parker scalpel after anesthetizing with local solution with 0.25% Marcaine.  Next, the area of tissue just inferior to the palpable mass, where the palpable was removed with electro Bovie cautery.  Hemostasis was maintained.  Attention was next made to approximating the deep dermal layers.  An interrupted #4-0 Vicryl suture was used and then a running subcuticular Monocryl suture was used to approximate the skin edges.  Steri-Strips as well as bacitracin and sterile dressings were applied.  The patient tolerated the procedure well and was transferred to recovery in stable condition.","hematology - oncology, hypertrophic scar, palpable mass, fibrocystic, scar, fibrocystic disease, breast mass, breast, cicatrix, excision, biopsy, hypertrophic, palpable,"
" A nurse with a history of breast cancer enrolled is clinical trial C40502.  Her previous treatments included Zometa, Faslodex, and Aromasin.  She was found to have disease progression first noted by rising tumor markers.", Hematology - Oncology, Breast Cancer Followup ,"CHIEF COMPLAINT:,1.  Metastatic breast cancer.,2.  Enrolled is clinical trial C40502.,3.  Sinus pain.,HISTORY OF PRESENT ILLNESS: , She is a very pleasant 59-year-old nurse with a history of breast cancer.  She was initially diagnosed in June 1994.  Her previous treatments included Zometa, Faslodex, and Aromasin.  She was found to have disease progression first noted by rising tumor markers.  PET/CT scan revealed metastatic disease and she was enrolled in clinical trial of CTSU/C40502.  She was randomized to the ixabepilone plus Avastin.  She experienced dose-limiting toxicity with the fourth cycle.  The Ixempra was skipped on day 1 and day 8.  She then had a dose reduction and has been tolerating treatment well with the exception of progressive neuropathy.  Early in the month she had concerned about possible perforated septum.  She was seen by ENT urgently.  She was found to have nasal septum intact.  She comes into clinic today for day eight Ixempra.,CURRENT MEDICATIONS:  ,Zometa monthly, calcium with Vitamin D q.d., multivitamin q.d., Ambien 5 mg q.h.s., Pepcid AC 20 mg q.d., Effexor 112 mg q.d., Lyrica 100 mg at bedtime, Tylenol p.r.n., Ultram p.r.n., Mucinex one to two tablets b.i.d., Neosporin applied to the nasal mucosa b.i.d. nasal rinse daily.,ALLERGIES:  ,Compazine.,REVIEW OF SYSTEMS: , The patient is comfort in knowing that she does not have a septal perforation.  She has progressive neuropathy and decreased sensation in her fingertips.  She makes many errors when keyboarding.  I would rate her neuropathy as grade 2.  She continues to have headaches respond to Ultram which she takes as needed.  She occasionally reports pain in her right upper quadrant as well as right sternum.  He denies any fevers, chills, or night sweats.  Her diarrhea has finally resolved and her bowels are back to normal.  The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:","hematology - oncology, zometa, faslodex, aromasin, dose-limiting toxicity, metastatic breast cancer, perforated septum, nasal septum, clinical trial, breast cancer, disease, metastatic, breast, cancer, "
 Excisional biopsy of right cervical lymph node., Hematology - Oncology, Biopsy - Cervical Lymph Node ,"PREOPERATIVE DIAGNOSIS: , Cervical lymphadenopathy.,POSTOPERATIVE DIAGNOSIS:,  Cervical lymphadenopathy.,PROCEDURE: , Excisional biopsy of right cervical lymph node.,ANESTHESIA: , General endotracheal anesthesia.,SPECIMEN: , Right cervical lymph node.,EBL: , 10 cc.,COMPLICATIONS: , None.,FINDINGS:,  Enlarged level 2 lymph node was identified and removed and sent for pathologic examination.,FLUIDS: , Please see anesthesia report.,URINE OUTPUT: , None recorded during the case.,INDICATIONS FOR PROCEDURE: , This is a 43-year-old female with a several-year history of persistent cervical lymphadenopathy.  She reports that it is painful to palpation on the right and has had multiple CT scans as well as an FNA which were all nondiagnostic.  After risks and benefits of surgery were discussed with the patient, an informed consent was obtained.  She was scheduled for an excisional biopsy of the right cervical lymph node.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed in the supine position.  She was anesthetized with general endotracheal anesthesia.  The neck was then prepped and draped in the sterile fashion.  Again, noted on palpation there was an enlarged level 2 cervical lymph node.,A 3-cm horizontal incision was made over this lymph node.  Dissection was carried down until the sternocleidomastoid muscle was identified.  The enlarged lymph node that measured approximately 2 cm in diameter was identified and was removed and sent to Pathology for touch prep evaluation.  The area was then explored for any other enlarged lymph nodes.  None were identified, and hemostasis was achieved with electrocautery.  A quarter-inch Penrose drain was placed in the wound.,The wound was then irrigated and closed with 3-0 interrupted Vicryl sutures for a deep closure followed by a running 4-0 Prolene subcuticular suture.  Mastisol and Steri-Strip were placed over the incision, and sterile bandage was applied.  The patient tolerated this procedure well and was extubated without complications and transported to the recovery room in stable condition.  She will return to the office tomorrow in followup to have the Penrose drain removed.","hematology - oncology, lymphadenopathy, excisional biopsy, fna, mastisol, penrose drain, cervical, cervical lymph node, endotracheal anesthesia, lymph node, sternocleidomastoid, cervical lymph, lymph, anesthesia, "
" Excision of nasal tip basal carcinoma, previous positive biopsy.", Hematology - Oncology, BCCa Excision - Nasal Tip ,"PREOPERATIVE DIAGNOSIS: , Basal cell carcinoma, nasal tip, previous positive biopsy.,POSTOPERATIVE DIAGNOSIS: , Basal cell carcinoma, nasal tip, previous positive biopsy.,OPERATION PERFORMED: , Excision of nasal tip basal carcinoma.  Total area of excision, approximately 1 cm to 12 mm frozen section x2, final margins clear.,INDICATION: , A 66-year-old female for excision of nasal basal cell carcinoma.  This area is to be excised accordingly and closed.  We had multiple discussions regarding types of closure.,SUMMARY: , The patient was brought to the OR in satisfactory condition and placed supine on the OR table.  Underwent general anesthesia along with Marcaine in the nasal tip areas for planned excision.  The area was injected, after sterile prep and drape, with Marcaine 0.25% with 1:200,000 adrenaline.,The specimen was sent to pathology.  Margins were still positive at the inferior 6 o'clock ***** margin and this was resubmitted accordingly.  Final margins were clear.,Closure consisted of undermining circumferentially.  Advancement closure with dog ear removal distally and proximally was accomplished without difficulty.  Closure with interrupted 5-0 Monocryl running 7-0 nylon followed by Xeroform gauze, light pressure dressing, and Steri-Strips.,The patient is discharged on minocycline and Darvocet-N 100.,NOTE:,  The 2.6 mm loupe magnification was utilized throughout the procedure.  No complications noted with excellent and all clear margins at the termination.  An advancement closure technique was utilized.","hematology - oncology, basal cell carcinoma, closure, steri-strips, xeroform gauze, excision, light pressure dressing, loupe magnification, nasal tip, basal carcinoma, basal cell, cell carcinoma, biopsy, basal, carcinoma, nasal"
 The patient was admitted for symptoms that sounded like postictal state.  CT showed edema and slight midline shift.  MRI of the brain shows large inhomogeneous infiltrating right frontotemporal neoplasm surrounding the right middle cerebral artery., Hematology - Oncology, Brain Tumor - Consult ,"REASON FOR CONSULTATION: , I was asked by Dr. X to see the patient in regard to his likely recurrent brain tumor.,HISTORY OF PRESENT ILLNESS: , The patient was admitted for symptoms that sounded like postictal state.  He was initially taken to Hospital.  CT showed edema and slight midline shift, and therefore he was transferred here.  He has been seen by Hospitalists Service.  He has not had a recurrent seizure.  Electroencephalogram shows slowing.  MRI of the brain shows large inhomogeneous infiltrating right frontotemporal neoplasm surrounding the right middle cerebral artery.  There is inhomogeneous uptake consistent with potential necrosis.  He also has had a SPECT image of his brain, consistent with neoplasm, suggesting relatively high-grade neoplasm.  The patient was diagnosed with a brain tumor in 1999.  All details are still not available to us.  He underwent a biopsy by Dr. Y. One of the notes suggested that this was a glioma, likely an oligodendroglioma, pending a second opinion at Clinic.  That is not available on the chart as I dictate.,After discussion of treatment issues with radiation therapist and Dr. Z (medical oncologist), the decision was made to treat him primarily with radiation alone.  He tolerated that reasonably well.  His wife says it's been several years since he had a scan.  His behavior had not been changed, until it changed as noted earlier in this summary.,PAST MEDICAL HISTORY: , He has had a lumbar fusion.  I believe he's had heart disease.  Mental status changes are either due to the tumor or other psychiatric problems.,SOCIAL HISTORY:,  He is living with his wife, next door to one of his children.  He has been disabled since 2001, due to the back problems.,REVIEW OF SYSTEMS: , No headaches or vision issues.  Ongoing heart problems, without complaints.  No weakness, numbness or tingling, except that related to his chronic neck pain.  No history of endocrine problems.  He has nocturia and urinary frequency.,PHYSICAL EXAMINATION: , Blood pressure 146/91, pulse 76.  Normal conjunctivae.  Ears, nose, throat normal.  Neck is supple.  Chest clear.  Heart tones normal.  Abdomen soft.  Positive bowel sounds.  No hepatosplenomegaly.  No adenopathy in the neck, supraclavicular or axillary regions.  Neurologically alert.  Cranial nerves are intact.  Strength is 5/5 throughout.,LABORATORY WORK: , White blood count 10.4, hemoglobin 16, platelets not noted.  Sodium 137, calcium 9.1.,IMPRESSION AND PLAN:,  Likely recurrent low-grade tumor, possibly evolved to a higher grade, given the MRI and SPECT findings.  Dr. X's note suggests discussing the situation in the tumor board on Wednesday.  He is stable enough.  The pause in his care would not jeopardize his current status.  It would be helpful to get old films and pathology from Abbott Northwestern.  However, he likely will need a re-biopsy, as he is highly suspicious for recurrent tumor and radiation necrosis.  Optimizing his treatment would probably be helped by knowing his current grade of tumor.","hematology - oncology, spect, electroencephalogram, middle cerebral artery, brain tumor, inhomogeneous, frontotemporal, neoplasm, recurrent"
" Excision basal cell carcinoma, right medial canthus with frozen section, and reconstruction of defect with glabellar rotation flap.", Hematology - Oncology, BCCa Excision - Canthus ,"PREOPERATIVE DIAGNOSIS: , Basal cell carcinoma (0.8 cm diameter), right medial canthus.,POSTOPERATIVE DIAGNOSIS: , Basal cell carcinoma (0.8 cm diameter), right medial canthus.,OPERATION: , Excision basal cell carcinoma (0.8 cm diameter), right medial canthus with frozen section, and reconstruction of defect (1.2 cm diameter) with glabellar rotation flap.,ANESTHESIA:,  Monitored anesthesia care.,JUSTIFICATION: , The patient is an 80-year-old white female with a biopsy-proven basal cell carcinoma of the right medial canthus.  She was scheduled for elective excision with frozen section under local anesthesia as an outpatient.,PROCEDURE: , With an intravenous infusing and under suitable premedication, the patient was placed supine on the operative table.  The face was prepped with pHisoHex draped.  The right medial canthal region and the glabellar region were anesthetized with 1% Xylocaine with 1:100,000 epinephrine.,Under loupe magnification, the lesion was excised with 2 mm margins, oriented with sutures and submitted for frozen section pathology.  The report was ""basal cell carcinoma with all margins free of tumor.""  Hemostasis was controlled with the Bovie.  Excised lesion diameter was 1.2 cm.  The defect was closed by elevating a left laterally based rotation flap utilizing the glabellar skin.  The flap was elevated with a scalpel and Bovie, rotated into the defect without tension, ***** to the defect with scissors and inset in layer with interrupted 5-0 Vicryl for the dermis and running 5-0 Prolene for the skin.  Donor site was closed in V-Y fashion with similar suture technique.,The wounds were dressed with bacitracin ointment.  The patient was returned to the recovery room in satisfactory condition.  She tolerated the procedure satisfactorily, and then no complications.  Blood loss was essentially nil.","hematology - oncology, basal cell carcinoma, excision, bacitracin, canthal region, canthus, frozen section, glabellar, glabellar region, loupe magnification, phisohex, rotation flap, loupe, excision basal cell carcinoma, medial canthus, basal cell, cell carcinoma, basal, cell, carcinoma,"
" Right axillary adenopathy, thrombocytopenia, and hepatosplenomegaly.  Right axillary lymph node biopsy.", Hematology - Oncology, Biopsy - Axillary Lymph Node ,"PREOPERATIVE DIAGNOSES:,1.  Right axillary adenopathy.,2.  Thrombocytopenia.,3.  Hepatosplenomegaly.,POSTOPERATIVE DIAGNOSES:,1.  Right axillary adenopathy.,2.  Thrombocytopenia.,3.  Hepatosplenomegaly.,PROCEDURE PERFORMED:  ,Right axillary lymph node biopsy.,ANESTHESIA: , Local with sedation.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well and was transferred to the recovery room in stable condition.,BRIEF HISTORY:  ,The patient is a 37-year-old male who presented to ABCD General Hospital secondary to hiccups and was ultimately found to have a right axillary mass to be severely thrombocytopenic with a platelet count of 2000 as well as having hepatosplenomegaly.  The working diagnosis is lymphoma, however, the Hematology and Oncology Departments were requesting a lymph node biopsy in order to confirm the diagnosis as well as prognosis.  Thus, the patient was scheduled for a lymph node biopsy with platelets running secondary to thrombocytopenia at the time of surgery.,INTRAOPERATIVE FINDINGS: , The patient was found to have a large right axillary lymphadenopathy, one of the lymph node was sent down as a fresh specimen.,PROCEDURE:  ,After informed written consent, risks and benefits of this procedure were explained to the patient.  The patient was brought to the operating suite, prepped and draped in a normal sterile fashion.  Multiple lymph nodes were palpated in the right axilla, however, the most inferior node was to be removed.  First, the skin was anesthetized with 1% lidocaine solution.  Next, using a #15 blade scalpel, an incision was made approximately 4 cm in length transversally in the inferior axilla.  Next, using electro Bovie cautery, maintaining hemostasis, dissection was carried down to the lymph node.  The lymph node was then completely excised using electro Bovie cautery as well as hemostats to maintain hemostasis and then lymph node was sent to specimen fresh to the lab.  Several hemostats were used, suture ligated with #3-0 Vicryl suture and hemostasis was maintained.  Next the deep dermal layers were approximated with #3-0 Vicryl suture.  After the wound has been copiously irrigated, the skin was closed with running subcuticular #4-0 undyed Vicryl suture and the pathology is pending.  The patient did tolerated the procedure well.  Steri-Strips and sterile dressings were applied and the patient was transferred to the Recovery in stable condition.","hematology - oncology, hepatosplenomegaly, thrombocytopenia, axillary adenopathy, axillary lymph node biopsy, axillary lymph node, lymph node biopsy, lymph node, lymph, node, axillary, adenopathy, hemostasis, suture, biopsy,"
 Discharge summary of a patient with a BRCA-2 mutation., Hematology - Oncology, BRCA-2 mutation ,"DISCHARGE DIAGNOSES:,  BRCA-2 mutation.  ,HISTORY OF PRESENT ILLNESS:  ,The patient is a 59-year-old with a BRCA-2 mutation.  Her sister died of breast cancer at age 32 and her daughter had breast cancer at age 27.,PHYSICAL EXAMINATION:  ,The chest was clear.  The abdomen was nontender.  Pelvic examination shows no masses.  No heart murmur.  ,HOSPITAL COURSE:  ,The patient underwent surgery on the day of admission.  In the postoperative course she was afebrile and unremarkable.  The patient regained bowel function and was discharged on the morning of the fourth postoperative day.,OPERATIONS AND PROCEDURES: , Total abdominal hysterectomy/bilateral salpingo-oophorectomy with resection of ovarian fossa peritoneum en bloc on July 25, 2006.,PATHOLOGY: , A 105-gram uterus without dysplasia or cancer.,CONDITION ON DISCHARGE: , Stable.,PLAN:  ,The patient will remain at rest initially with progressive ambulation after.  She will avoid lifting, driving or intercourse.  She will call me if any fevers, drainage, bleeding, or pain.  Follow up in my office in four weeks.  Family history, social history, psychosocial needs per the social worker.,DISCHARGE MEDICATIONS: , Percocet 5 #40 one every 3 hours p.r.n. pain.","hematology - oncology, brca-2 mutation, brca-2, mutation, breast cancer, brca mutation, breast, postoperative, peritoneum, brca, discharge, cancer,"
" Excision of large basal cell carcinoma, right lower lid, and repaired with used dorsal conjunctival flap in the upper lid and a large preauricular skin graft.", Hematology - Oncology, BCCa Excision - Lower Lid ,"PREOPERATIVE DIAGNOSIS: , Extremely large basal cell carcinoma, right lower lid.,POSTOPERATIVE DIAGNOSIS:,  Extremely large basal cell carcinoma, right lower lid.,TITLE OF OPERATION: , Excision of large basal cell carcinoma, right lower lid, and repaired with used dorsal conjunctival flap in the upper lid and a large preauricular skin graft.,PROCEDURE: , The patient was brought into the operating room and prepped and draped in usual fashion.  Xylocaine 2% with epinephrine was injected beneath the conjunctiva and skin of the lower lid and also beneath the conjunctiva and skin of the upper lid.  A frontal nerve block was also given on the right upper lid.  The anesthetic agent was also injected in the right preauricular region which would provide a donor graft for the right lower lid defect.  The area was marked with a marking pen with margins of 3 to 4 mm, and a #15 Bard-Parker blade was used to make an incision at the nasal and temporal margins of the lesion.,The incision was carried inferiorly, and using a Steven scissors the normal skin, muscle, and conjunctiva was excised inferiorly.  The specimen was then marked and sent to pathology for frozen section.  Bleeding was controlled with a wet-field cautery, and the right upper lid was everted, and an incision was made 3 mm above the lid margin with the Bard-Parker blade in the entire length of the upper lid.  The incision reached the orbicularis, and Steven scissors were used to separate the tarsus from the underlying orbicularis.  Vertical cuts were made nasally and temporally, and a large dorsal conjunctival flap was fashioned with the conjunctiva attached superiorly.  It was placed into the defect in the lower lid and sutured with multiple interrupted 6-0 Vicryl sutures nasally, temporally, and inferiorly.,The defect in the skin was measured and an appropriate large preauricular graft was excised from the right preauricular region.  The defect was closed with interrupted 5-0 Prolene sutures, and the preauricular graft was sutured in place with multiple interrupted 6-0 silk sutures.  The upper border of the graft was attached to the upper lid after incision was made in the gray line with a Superblade, and the superior portion of the skin graft was sutured to the upper lid through the anterior lamella created by the razor blade incision.,Cryotherapy was then used to treat the nasal and temporal margins of the area of excision because of positive margins, and following this an antibiotic steroid ointment was instilled and a light pressure dressing was applied.  The patient tolerated the procedure well and was sent to recovery room in good condition.","hematology - oncology, basal cell carcinoma, cryotherapy, steven scissors, conjunctiva, conjunctival flap, frontal nerve block, frozen section, lower lid, orbicularis, skin graft, nasal and temporal margins, dorsal conjunctival flap, upper lid, basal, carcinoma, preauricular, incision, conjunctival, "
 Patient seen in Neuro-Oncology Clinic because of increasing questions about what to do next for his anaplastic astrocytoma., Hematology - Oncology, Anaplastic Astrocytoma - Letter ,"XYZ,RE:  ABC,MEDICAL RECORD#:  123,Dear Dr. XYZ:,I saw ABC back in Neuro-Oncology Clinic today.  He comes in for an urgent visit because of increasing questions about what to do next for his anaplastic astrocytoma.,Within the last several days, he has seen you in clinic and once again discussed whether or not to undergo radiation for his left temporal lesion.  The patient has clearly been extremely ambivalent about this therapy for reasons that are not immediately apparent.  It is clear that his MRI is progressing and that it seems unlikely at this time that anything other than radiation would be particularly effective.  Despite repeatedly emphasizing this; however, the patient still is worried about potential long-term side effects from treatment that frankly seem unwarranted at this particular time.,After seeing you in clinic, he and his friend again wanted to discuss possible changes in the chemotherapy regimen.  They came in with a list of eight possible agents that they would like to be administered within the next two weeks.  They then wanted another MRI to be performed and they were hoping that with the use of this type of approach, they might be able to induce another remission from which he can once again be spared radiation.,From my view, I noticed a man whose language has deteriorated in the week since I last saw him.  This is very worrisome.  Today, for the first time, I felt that there was a definite right facial droop as well.  Therefore, there is no doubt that he is becoming symptomatic from his growing tumor.  It suggests that he is approaching the end of his compliance curve and that the things may rapidly deteriorate in the near future.,Emphasizing this once again, in addition, to recommending steroids I once again tried to convince him to undergo radiation.  Despite an hour, this again amazingly was not possible.  It is not that he does not want treatment, however.  Because I told him that I did not feel it was ethical to just put him on the radical regimen that him and his friend devised, we compromised and elected to go back to Temodar in a low dose daily type regimen.  We would plan on giving 75 mg/sq m everyday for 21 days out of 28 days.  In addition, we will stop thalidomide 100 mg/day.  If he tolerates this for one week, we then agree that we would institute another one of the medications that he listed for us.  At this stage, we are thinking of using Accutane at that point.,While I am very uncomfortable with this type of approach, I think as long as he is going to be monitored closely that we may be able to get away with this for at least a reasonable interval.  In the spirit of compromise, he again consented to be evaluated by radiation and this time, seemed more resigned to the fact that it was going to happen sooner than later.  I will look at this as a positive sign because I think radiation is the one therapy from which he can get a reasonable response in the long term.,I will keep you apprised of followups.  If you have any questions or if I could be of any further assistance, feel free to contact me.,Sincerely,","hematology - oncology, neuro oncology, anaplastic astrocytoma, anaplastic, oncology, radiation, astrocytoma"
" Chronic lymphocytic leukemia (CLL), autoimmune hemolytic anemia, and oral ulcer.  The patient was diagnosed with chronic lymphocytic leukemia and was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis.", Hematology - Oncology, Anemia & Leukemia Followup ,"CHIEF COMPLAINT:,1.  Chronic lymphocytic leukemia (CLL).,2.  Autoimmune hemolytic anemia.,3.  Oral ulcer.,HISTORY OF PRESENT ILLNESS: , The patient is a 72-year-old gentleman who was diagnosed with chronic lymphocytic leukemia in May 2008.  He was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis.  He has been on chronic steroids to control his hemolysis and is currently on prednisone 5 mg every other day.  He comes in to clinic today for follow-up and complete blood count.  At his last office visit we discontinued this prophylactic antivirals and antibacterial.,CURRENT MEDICATIONS:,  Prilosec 20 mg b.i.d., levothyroxine 50 mcg q.d., Lopressor 75 mg q.d., vitamin C 500 mg q.d., multivitamin q.d., simvastatin 20 mg q.d., and prednisone 5 mg q.o.d.,ALLERGIES:  ,Vicodin.,REVIEW OF SYSTEMS:  ,The patient reports ulcer on his tongue and his lip.  He has been off of Valtrex for five days.  He is having some difficulty with his night vision with his left eye.  He has a known cataract.  He denies any fevers, chills, or night sweats.  He continues to have headaches.  The rest of his review of systems is negative.,PHYSICAL EXAM:,VITALS:","hematology - oncology, oral ulcer, leukemia, anemia, hemolysis, blood count, chronic lymphocytic leukemia, autoimmune hemolytic anemia, hemolytic, cll, lymphocytic, autoimmune, "
" Left axillary dissection with incision and drainage of left axillary mass.  Right axillary mass excision and incision and drainage.   Bilateral axillary masses, rule out recurrent Hodgkin's disease.", Hematology - Oncology, Axillary Dissection & Mass Excision ,"PREOPERATIVE DIAGNOSIS:,  Bilateral axillary masses, rule out recurrent Hodgkin's disease.,POSTOPERATIVE DIAGNOSIS:  ,Bilateral axillary masses, rule out recurrent Hodgkin's disease.,PROCEDURE PERFORMED:,1.  Left axillary dissection with incision and drainage of left axillary mass.,2.  Right axillary mass excision and incision and drainage.,ANESTHESIA: , LMA.,SPECIMENS:,  Left axillary mass with nodes and right axillary mass.,ESTIMATED BLOOD LOSS:  ,Less than 30 cc.,INDICATION: , This 56-year-old male presents to surgical office with history of bilateral axillary masses.  Upon evaluation, it was noted that the patient has draining bilateral masses with the left mass being approximately 8 cm in diameter upon palpation and the right being approximately 4 cm in diameter.  The patient had been continued on antibiotics preoperatively.  The patient with history of Hodgkin's lymphoma approximately 18 years ago and underwent therapy at that time and he was declared free of disease since that time.  Consent for possible recurrence of Hodgkin's lymphoma warranted exploration and excision of these masses.  The patient was explained the risks and benefits of the procedure and informed consent was obtained.,GROSS FINDINGS: , Upon dissection of the left axillary mass, the mass was removed in toto and noted to have a cavity within it consistent with an abscess.,No loose structures were identified and sent for frozen section, which upon intraoperative consultation with Pathology Department revealed no obvious evidence of lymphoma, however, the confirmed pathology report is pending at this time.  The right axillary mass was excised without difficulty without requiring full axillary dissection.,PROCEDURE: , The patient was placed in supine position after appropriate anesthesia was obtained and a sterile prep and drape complete.  A #10 blade scalpel was used to make an elliptical incision about the mass itself extending this incision further to aid in the mobilization of the mass.  Sharp dissection was utilized with Metzenbaum scissors about the mass to maintain the injury to the skin structure and upon showing out the mass, Bovie electrocautery was utilized adjacent to the wall structure to maintain hemostasis.  Identification of the axillary anatomy was made and care was made to avoid injury to nerve, vessel or musculature.  Once this mass was removed in toto, lymph node structures were as well delivered with this mass and sent to frozen section as well the specimen was sent to gram stain and culture.  Upon revaluation of the incisional site, it was noted to be hemostatic.  Warm lap sponge was then left in place at this site.  Next, attention was turned to the right axilla where a #10 blade scalpel was used to make a 4 cm incision about the mass including the cutaneous structures involved with the erythematous reaction.  This was as well removed in toto and sent to Pathology for gram stain and culture as well as pathologic evaluation.  This site was then made hemostatic as well with the aid of Bovie electrocautery and approximation of the deep dermal tissues after irrigation with warm saline was then done with #3-0 Vicryl suture followed by #4-0 Vicryl running subcuticular stitch.  Steri-Strips were applied.  Attention was returned back left axilla, which upon re-exploration was noted to be hemostatic and a #7 mm JP was then introduced making a skin stab inferior to the incision and bringing the end of the drain through this incision.  This was placed within the incision site, ________ drainage of the axillary potential space.  Approximation of the deep dermal tissues were then done with #3-0 Vicryl in an interrupted technique followed by #4-0 Vicryl with running subcuticular technique.  Steri-Strips and sterile dressings were applied.  JP bulb was then placed to suction and sterile dressings were applied to both axilla.  The patient tolerated the procedure well and sent to postanesthesia care unit in a stable condition.  He will be discharged to home upon ability of the patient to have pain tolerance with Vicodin 1-2 as needed every six hours for pain and continue on Keflex antibiotics until gram stain culture proves otherwise.","hematology - oncology, incision and drainage, axillary mass excision, axillary dissection, hodgkin's disease, axillary mass, mass, incision, axillary,"
" Excision of basal cell carcinoma.  Closure complex, open wound.  Bilateral capsulectomies.  Bilateral explantation and removal of ruptured silicone gel implants", Hematology - Oncology, BCCa Excision - Cheek ,"PREOPERATIVE DIAGNOSES,1.  Basal cell carcinoma, right cheek.,2.  Basal cell carcinoma, left cheek.,3.  Bilateral ruptured silicone gel implants.,4.  Bilateral Baker grade IV capsular contracture.,5.  Breast ptosis.,POSTOPERATIVE DIAGNOSES,1.  Basal cell carcinoma, right cheek.,2.  Basal cell carcinoma, left cheek.,3.  Bilateral ruptured silicone gel implants.,4.  Bilateral Baker grade IV capsular contracture.,5.  Breast ptosis.,PROCEDURE,1.  Excision of basal cell carcinoma, right cheek, 2.7 cm x 1.5 cm.,2.  Excision of basal cell carcinoma, left cheek, 2.3 x 1.5 cm.,3.  Closure complex, open wound utilizing local tissue advancement flap, right cheek.,4. Closure complex, open wound, left cheek utilizing local tissue advancement flap.,5.  Bilateral explantation and removal of ruptured silicone gel implants.,6.  Bilateral capsulectomies.,7.  Replacement with bilateral silicone gel implants, 325 cc.,INDICATIONS FOR PROCEDURES,The patient is a 61-year-old woman who presents with a history of biopsy-proven basal cell carcinoma, right and left cheek.  She had no prior history of skin cancer.  She is status post bilateral cosmetic breast augmentation many years ago and the records are not available for this procedure.  She has noted progressive hardening and distortion of the implant.  She desires to have the implants removed, capsulectomy and replacement of implants.  She would like to go slightly smaller than her current size as she has ptosis going with a smaller implant combined with capsulectomy will result in worsening of her ptosis.  She may require a lift.  She is not consenting to lift due to the surgical scars.,PAST MEDICAL HISTORY,Significant for deep venous thrombosis and acid reflux.,PAST SURGICAL HISTORY,Significant for appendectomy, colonoscopy and BAM.,MEDICATIONS,1.  Coumadin.  She stopped her Coumadin five days prior to the procedures.,2.  Lipitor,3.  Effexor.,4.  Klonopin.,ALLERGIES,None.,REVIEW OF SYSTEMS,Negative for dyspnea on exertion, palpitations, chest pain, and phlebitis.,PHYSICAL EXAMINATION,VITAL SIGNS:  Height 5'8"", weight 155 pounds.,FACE:  Examination of the face demonstrates basal cell carcinoma, right and left cheek.  No lesions are noted in the regional lymph node base and no mass is appreciated.,BREAST:  Examination of the breast demonstrates bilateral grade IV capsular contracture.  She has asymmetry in distortion of the breast.  No masses are appreciated in the breast or the axilla.  The implants appear to be subglandular.,CHEST:  Clear to auscultation and percussion.,CARDIOVASCULAR:  Regular rate and rhythm.,EXTREMITIES:  Show full range of motion.  No clubbing, cyanosis or edema.,SKIN:  Significant environmental actinic skin damage.,I recommended excision of basal cell cancers with frozen section control of the margin, closure will require local tissue flaps.  I recommended exchange of the implants with reaugmentation.  No final size is guaranteed or implied.  We will decrease the size of the implants based on the intraoperative findings as the size is not known.  Several options are available.  Sizer implants will be placed to best estimate postoperative size.  Ptosis will be worse following capsulectomy and going with a smaller implant.  She may require a lift in the future.  We have obtained preoperative clearance from the patient's cardiologist, Dr. K.  The patient has been taken off Coumadin for five days and will be placed back on Coumadin the day after the surgery.  The risk of deep venous thrombosis is discussed.  Other risk including bleeding, infection, allergic reaction, pain, scarring, hypertrophic scarring and poor cosmetic resolve, worsening of ptosis, exposure, extrusion, the rupture of the implants, numbness of the nipple-areolar complex, hematoma, need for additional surgery, recurrent capsular contracture and recurrence of the skin cancer was all discussed, which she understands and informed consent is obtained.,PROCEDURE IN DETAIL,After appropriate informed consent was obtained, the patient was placed in the preoperative holding area with **** input.  She was then taken to the major operating room with ABCD Surgery Center, placed in a supine position.  Intravenous antibiotics were given.  TED hose and SCDs were placed.  After the induction of adequate general endotracheal anesthesia, she was prepped and draped in the usual sterile fashion.  Sites for excision and skin cancers were carefully marked with 5 mm margin.  These were injected with 1% lidocaine with epinephrine.,After allowing adequate time for basal constriction hemostasis, excision was performed, full thickness of the skin.  They were tagged at the 12 o'clock position and sent for frozen section.  Hemostasis was achieved using electrocautery.  Once margins were determined to be free of involvement, local tissue flaps were designed for advancement.  Undermining was performed.  Hemostasis was achieved using electrocautery.  Closure was performed under moderate tension with interrupted 5-0 Vicryl.  Skin was closed under loop magnification paying meticulous attention and cosmetic details with 6-0 Prolene.  Attention was then turned to the breast, clothes were changed, gloves were changed, incision was planned and the previous inframammary incision beginning on the right incision was made.  Dissection was carried down to the capsule.  It was extremely calcified.  Dissection of the anterior surface of the capsule was performed.  The implant was subglandular, the capsule was entered, implant was noted to be grossly intact; however, there was free silicone.  Implant was removed and noted to be ruptured.  No marking as to the size of the implant was found.,Capsulectomy was performed leaving a small portion in the axilla in the inframammary fold.  Pocket was modified to medialize the implant by placing 2-0 Prolene laterally in mattress sutures to restrict the pocket.  In identical fashion, capsulectomy was performed on the left.  Implant was noted to be grossly ruptured.  No marking was found for the size of the implant.  The entire content was weighed and found to be 350 grams.  Right side was weighed and noted to be 338 grams, although some silicone was lost in the transfer and most likely was identical 350 grams.  The implants appeared to be double lumen with the saline portion deflated.  Completion of the capsulectomy was performed on the left.",
" Aplastic anemia.  After several bone marrow biopsies, she was diagnosed with aplastic anemia.  She started cyclosporine and prednisone.", Hematology - Oncology, Aplastic Anemia Followup ,"CHIEF COMPLAINT: , Aplastic anemia.,HISTORY OF PRESENT ILLNESS: , This is a very pleasant 72-year-old woman, who I have been following for her pancytopenia.  After several bone marrow biopsies, she was diagnosed with aplastic anemia.  She started cyclosporine and prednisone on 03/30/10.  She was admitted to the hospital from 07/11/10 to 07/14/10 with acute kidney injury.  Her cyclosporine level was 555.  It was thought that her acute kidney injury was due to cyclosporine toxicity and therefore that was held.,Overall, she tells me that now she feels quite well since leaving the hospital.  She was transfused 2 units of packed red blood cells while in the hospital.  Repeat CBC from 07/26/10 showed white blood cell count of 3.4 with a hemoglobin of 10.7 and platelet count of 49,000.,CURRENT MEDICATIONS:,  Folic acid, Aciphex, MiraLax, trazodone, prednisone for 5 days every 4 weeks, Bactrim double strength 1 tablet b.i.d. on Mondays, Wednesdays and Fridays.,ALLERGIES:  ,No known drug allergies.,REVIEW OF SYSTEMS: , As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1.  Hypertension.,2.  GERD.,3.  Osteoarthritis.,4.  Status post tonsillectomy.,5.  Status post hysterectomy.,6.  Status post bilateral cataract surgery.,7.  Esophageal stricture status post dilatation approximately four times.,SOCIAL HISTORY:  ,She has no tobacco use.  She has rare alcohol use.  She has three children and is a widow.  Her husband died after they were married only eight years.  She is retired.,FAMILY HISTORY: , Her sister had breast cancer.,PHYSICAL EXAM:,VIT:",
" Refractory anemia that is transfusion dependent.  At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion.", Hematology - Oncology, Anemia - Consult ,"DIAGNOSIS:,  Refractory anemia that is transfusion dependent.,CHIEF COMPLAINT: , I needed a blood transfusion.,HISTORY: , The patient is a 78-year-old gentleman with no substantial past medical history except for diabetes.  He denies any comorbid complications of the diabetes including kidney disease, heart disease, stroke, vision loss, or neuropathy.  At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion.  He reports that he has no signs or symptom of bleeding and had a blood transfusion approximately two months ago and actually several weeks before that blood transfusion, he had a transfusion for anemia.  He has been placed on B12, oral iron, and Procrit.  At this time, we are asked to evaluate him for further causes and treatment for his anemia.  He denies any constitutional complaints except for fatigue, malaise, and some dyspnea.  He has no adenopathy that he reports.  No fevers, night sweats, bone pain, rash, arthralgias, or myalgias.,PAST MEDICAL HISTORY:  ,Diabetes.,PAST SURGICAL HISTORY:,  Hernia repair.,ALLERGIES: , He has no allergies.,MEDICATIONS: , Listed in the chart and include Coumadin, Lasix, metformin, folic acid, diltiazem, B12, Prevacid, and Feosol.,SOCIAL HISTORY: , He is a tobacco user.  He does not drink.  He lives alone, but has family and social support to look on him.,FAMILY HISTORY:,  Negative for blood or cancer disorders according to the patient.,PHYSICAL EXAMINATION:,GENERAL:  He is an elderly gentleman in no acute distress.  He is sitting up in bed eating his breakfast.  He is alert and oriented and answering questions appropriately.,VITAL SIGNS:  Blood pressure of 110/60, pulse of 99, respiratory rate of 14, and temperature of 97.4.  He is 69 inches tall and weighs 174 pounds.,HEENT:  Sclerae show mild arcus senilis in the right.  Left is clear.  Pupils are equally round and reactive to light.  Extraocular movements are intact.  Oropharynx is clear.,NECK:  Supple.  Trachea is midline.  No jugular venous pressure distention is noted.  No adenopathy in the cervical, supraclavicular, or axillary areas.,CHEST:  Clear.,HEART:  Regular rate and rhythm.,ABDOMEN:  Soft and nontender.  There may be some fullness in the left upper quadrant, although I do not appreciate a true spleen with inspiration.,EXTREMITIES:  No clubbing, but there is some edema, but no cyanosis.,NEUROLOGIC:  Noncontributory.,DERMATOLOGIC:  Noncontributory.,CARDIOVASCULAR:  Noncontributory.,IMPRESSION: , At this time is refractory anemia, which is transfusion dependent.  He is on B12, iron, folic acid, and Procrit.  There are no sign or symptom of blood loss and a recent esophagogastroduodenoscopy, which was negative.  His creatinine was 1.  My impression at this time is that he probably has an underlying myelodysplastic syndrome or bone marrow failure.  His creatinine on this hospitalization was up slightly to 1.6 and this may contribute to his anemia.,RECOMMENDATIONS:  ,At this time, my recommendation for the patient is that he undergoes further serologic evaluation with reticulocyte count, serum protein, and electrophoresis, LDH, B12, folate, erythropoietin level, and he should undergo a bone marrow aspiration and biopsy.  I have discussed the procedure in detail which the patient.  I have discussed the risks, benefits, and successes of that treatment and usefulness of the bone marrow and predicting his cause of refractory anemia and further therapeutic interventions, which might be beneficial to him.  He is willing to proceed with the studies I have described to him.  We will order an ultrasound of his abdomen because of the possible fullness of the spleen, and I will probably see him in follow up after this hospitalization.,As always, we greatly appreciate being able to participate in the care of your patient.  We appreciate the consultation of the patient.",
 Laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair.  Patient with a 5.5-cm diameter nonfunctioning mass in his right adrenal., Hematology - Oncology, Adrenalectomy & Umbilical Hernia Repair ,"PREOPERATIVE DIAGNOSES,1.  Adrenal mass, right sided.,2.  Umbilical hernia.,POSTOPERATIVE DIAGNOSES,1.  Adrenal mass, right sided.,2.  Umbilical hernia.,OPERATION PERFORMED: , Laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair.,ANESTHESIA:  ,General.,CLINICAL NOTE: , This is a 52-year-old inmate with a 5.5 cm diameter nonfunctioning mass in his right adrenal.  Procedure was explained including risks of infection, bleeding, possibility of transfusion, possibility of further treatments being required.  Alternative of fully laparoscopic are open surgery or watching the lesion.,DESCRIPTION OF OPERATION:  ,In the right flank-up position, table was flexed.  He had a Foley catheter in place.  Incision was made from just above the umbilicus, about 5.5 cm in diameter.  The umbilical hernia was taken down.  An 11 mm trocar was placed in the midline, superior to the GelPort and a 5 mm trocar placed in the midaxillary line below the costal margin.  A liver retractor was placed to this.,The colon was reflected medially by incising the white line of Toldt.  The liver attachments to the adrenal kidney were divided and the liver was reflected superiorly.  The vena cava was identified.  The main renal vein was identified.  Coming superior to the main renal vein, staying right on the vena cava, all small vessels were clipped and then divided.  Coming along the superior pole of the kidney, the tumor was dissected free from top of the kidney with clips and Bovie.  The harmonic scalpel was utilized superiorly and laterally.  Posterior attachments were divided between clips and once the whole adrenal was mobilized, the adrenal vein and one large adrenal artery were noted, doubly clipped, and divided.  Specimen was placed in a collection bag, removed intact.,Hemostasis was excellent.,The umbilical hernia had been completely taken down.  The edges were freshened up.  Vicryl #1 was utilized to close the incision and 2-0 Vicryl was used to close the fascia of the trocar.,Skin closed with clips.,He tolerated the procedure well.  All sponge and instrument counts were correct.  Estimated blood loss less than 100 mL.,The patient was awakened, extubated, and returned to recovery room in satisfactory condition.","hematology - oncology, adrenalectomy, laparoscopic hand-assisted, umbilical hernia repair, vena cava, renal vein, hernia repair, laparoscopic, umbilical, hernia,"
" This 68-year-old man presents to the emergency department for three days of cough, claims that he has brought up some green and grayish sputum.  He says he does not feel short of breath.  He denies any fever or chills.", General Medicine, Viral Syndrome - ER Visit ,"SUBJECTIVE:  ,This 68-year-old man presents to the emergency department for three days of cough, claims that he has brought up some green and grayish sputum.  He says he does not feel short of breath.  He denies any fever or chills.,REVIEW OF SYSTEMS:,HEENT:  Denies any severe headache or sore throat.,CHEST:  No true pain.,GI:  No nausea, vomiting, or diarrhea.,PAST HISTORY:,  He states that he is on Coumadin because he had a cardioversion done two months ago for atrial fibrillation.  He also lists some other medications.  I do have his medications list.  He is on Pacerone, Zaroxolyn, albuterol inhaler, Neurontin, Lasix, and several other medicines.  Those are the predominant medicines.  He is not a diabetic.  The past history otherwise, he has had smoking history, but he quit several years ago and denies any COPD or emphysema.  No one else in the family is sick.,PHYSICAL EXAMINATION:,GENERAL:  The patient appears comfortable.  He did not appear to be in any respiratory distress.  He was alert.  I heard him cough once during the entire encounter.  He did not bring up any sputum at that time.,VITAL SIGNS:  His temperature is 98, pulse 71, respiratory rate 18, blood pressure 122/57, and pulse ox is 95% on room air.,HEENT:  Throat was normal.,RESPIRATORY:  He was breathing normally.  There was clear and equal breath sounds.  He was speaking in full sentences.  There was no accessory muscle use.,HEART:  Sounded regular.,SKIN:  Normal color, warm and dry.,NEUROLOGIC:  Neurologically he was alert.,IMPRESSION: , Viral syndrome, which we have been seeing in many cases throughout the week.  The patient asked me about antibiotics and I did not see a need to do this since he did not appear to have an infection other than viral given his normal temperature, normal pulse, normal respiratory rate, and near normal oxygen.  The patient being on Coumadin I explained to him that unless there was a solid reason to put him on antibiotics, he would be advised not to do so because antibiotics can alter the gut floor causing the INR to increase while on Coumadin which may cause serious bleeding.  The patient understands this.  I then asked him if the cough was annoying him, he said it was.  I offered him a cough syrup, which he agreed to take.  The patient was then discharged with Tussionex Pennkinetic a hydrocodone time-release cough syrup.  I told to check in three days, if the symptoms were not getting better.  The patient appeared to be content with this treatment and was discharged in approximately 30 to 45 minutes later.  His wife calls me very angry that I did not give him antibiotics.  I explained her exactly what I explained to him that they were not indicative at this time, and she became very upset saying that they came there specifically for antibiotics and I explained again that antibiotics are not indicated for viral infection and that I did not think he had a bacterial infection.,DIAGNOSIS: , Viral respiratory illness.","general medicine, sputum, short of breath, fever, chills, copd, emphysema, viral respiratory illness, green and grayish sputum, viral syndrome, respiratory rate, cough syrup, cough, antibiotics, inhaler,"
 Sore throat - Upper respiratory infection., General Medicine, URI - SOAP ,"SUBJECTIVE:,  Mom brings patient in today because of sore throat starting last night.  Eyes have been very puffy.  He has taken some Benadryl when all of this congestion started but with a sudden onset just yesterday.  He has had low-grade fever and just felt very run down, appearing very tired.  He is still eating and drinking well, and his voice has been hoarse but no coughing.  No shortness of breath, vomiting, diarrhea or abdominal pain.,PAST MEDICAL HISTORY:,  Unremarkable.  There is no history of allergies.  He does have some history of some episodes of high blood pressure, and his weight is up about 14 pounds from the last year.,FAMILY HISTORY: , Noncontributory.  No one else at home is sick.,OBJECTIVE:,General:  A 13-year-old male appearing tired but in no acute distress.,Neck:  Supple without adenopathy.,HEENT:  Ear canals clear.  TMs, bilaterally, gray in color.  Good light reflex.  Oropharynx pink and moist.  No erythema or exudate.  Some drainage is seen in the posterior pharynx.  Nares:  Swollen, red.  No drainage seen.  No sinus tenderness.  Eyes are clear.,Chest:  Respirations are regular and nonlabored.,Lungs:  Clear to auscultation throughout.,Heart:  Regular rhythm without murmur.,Skin:  Warm, dry and pink, moist mucous membranes.  No rash.,LABORATORY:,  Strep test is negative.  Strep culture is negative.,RADIOLOGY:,  Water's View of the sinuses is negative for any sinusitis or acute infection.,ASSESSMENT:,  Upper respiratory infection.,PLAN:,  At this point just treat symptomatically.  I gave him some samples of Levall for the congestion and as an expectorant.  Push fluids and rest.  May use ibuprofen or Tylenol for discomfort.","general medicine, soap, uri, upper respiratory infection, water's view, congestion, light reflex, sore throat, respiratory, strep, infection,"
 Patient with morbid obesity., General Medicine, Weight Loss Evaluation ,"REASON FOR VISIT:,  Weight loss evaluation.,HISTORY OF PRESENT ILLNESS:,","general medicine, medifast, obesity, weight loss, morbid obesity, weight loss evaluation, weight"
 Patient with worsening shortness of breath and cough., General Medicine, Trouble breathing ,"CHIEF COMPLAINT:, ""Trouble breathing."",HISTORY OF PRESENT ILLNESS:, A 37-year-old German woman was brought to a Shock Room at the General Hospital with worsening shortness of breath and cough. Over the year preceding admission, the patient had begun to experience the insidious onset of shortness of breath. She had smoked one half pack of cigarettes per day for 20 years, but had quit smoking approximately 2 months prior to admission. Approximately 2 weeks prior to admission, she noted worsening shortness of breath and the development of a dry nonproductive cough. Approximately 1 week before admission, the shortness of breath became more severe and began to limit her activities. On the day of admission, her dyspnea had worsened to the point that she became markedly short of breath after walking a short distance, and she elected to seek medical attention. On arrival at the hospital, she was short of breath at rest and was having difficulty completing her sentences. She denied orthopnea, paroxysmal nocturnal dyspnea, swelling in her legs, chest pain, weight loss or gain, fever, chills, palpitations, and sick contacts. She denied any history of IVDA, tattoos, or high risk sexual behavior. She did report a distant history of pulmonary embolism in 1997 with recurrent venous thromboembolism in 1999 for which an IVC filter had been placed in Germany . She had been living in the United States for years, and had had no recent travel. She denied any occupational exposures. Before the onset of her shortness of breath she had been very active and had exercised regularly.,PAST MEDICAL HISTORY:,  Pulmonary embolism in 1997 which had been treated with thrombolysis in Germany. She reported that she had been on warfarin for 6 months after her diagnosis.  Recurrent venous thromboembolism in 1999 at which time an IVC filter had been placed.  Psoriasis.  She denied any history of miscarriage.,PAST SURGICAL HISTORY:,  IVC filter placement 1999.",
 3-Dimensional Simulation.  This patient is undergoing 3-dimensionally planned radiation therapy in order to adequately target structures at risk while diminishing the degree of exposure to uninvolved adjacent normal structures., Hematology - Oncology, 3-Dimensional Simulation ,"3-DIMENSIONAL SIMULATION,This patient is undergoing 3-dimensionally planned radiation therapy in order to adequately target structures at risk while diminishing the degree of exposure to uninvolved adjacent normal structures.  This optimizes the chance of controlling tumor while diminishing the acute and long-term side effects.  With conformal 3-dimensional simulation, there is extended physician, therapist, and dosimetrist effort and time expended.  The patient is initially taken into a conventional simulator room where appropriate markers are placed and the patient is positioned and immobilized.  Preliminary filed sizes and arrangements, including gantry angles, collimator angles, and number of fields are conceived.  Radiographs are taken and these films are approved by the physician.  Appropriate marks are placed on the patient's skin or on the  immobilization device.,The patient is transferred to the diagnostic facility and placed on a flat CT scan table.  Scans are performed through the targeted area.  The scans are evaluated by the radiation oncologist and the tumor volume, target volume, and critical structures are outlined on the CT images.  The dosimetrist then evaluates the slices in the treatment-planning computer with appropriately marked structures.  This volume is reconstructed in a virtual 3-dimensional space utilizing the beam's-eye view features.  Appropriate blocks are designed.  Multiplane computerized dosimetry is performed throughout the volume.  Field arrangements and blocking are modified as necessary to provide coverage of the target volume while minimizing dose to normal structures.,Once appropriate beam parameters and isodose distributions have been confirmed on the computer scan, the individual slices are then reviewed by the physician.  The beam's-eye view, block design, and appropriate volumes are also printed and reviewed by the physician.  Once these are approved, physical blocks or multi-leaf collimator equivalents will be devised.  If significant changes are made in the field arrangements from the original simulation, the patient is brought back to the simulator where computer designed fields are re-simulated.,In view of the extensive effort and time expenditure required, this procedure justifies the special procedure code, 77470.","hematology - oncology, 3-dimensional simulation, planned radiation therapy, ct scan, ct images, beam's eye view, field arrangements, normal structures, therapy, dimensional, simulationNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 History and Physical for a 69-year-old Caucasian male complaining of difficulty breathing for 3 days., General Medicine, Trouble Breathing - H&P  ,"CHIEF COMPLAINT: , ""I have had trouble breathing for the past 3 days"",HISTORY: , 69-year-old Caucasian male complaining of difficulty breathing for 3 days.  He also states that he has been coughing accompanying with low-grade type fever.  He also admits to having intermittent headaches and bilateral chest pain that does not radiate to upper extremities and jaws but worse with coughing.  Patient initially had this type of episodes about 10 months ago but has intermittently getting worse since.,PMH: , DM, HTN, COPD, CAD,PSH:  ,CABG, appendectomy, tonsillectomy,FH:,  Non-contributory,SOCH: , Divorce and live alone, retired postal worker, has 3 children, 7 grandchildren.  He smokes 1 pack a day of Newport for 30 years and is a social drinker.  He denies any illicit drug use.,TRAVEL HISTORY: , Denies any recent travel overseas,ALLERGIES: , Denies any drug allergies,HOME MEDICATIONS:,  Advair 1 puff bid Lisinopril 10 mg qd Lopressor 50 mg bid Aspirin 81 mg qd Plavix 75 mg qd Multivitamins Feso4 1 tab qd Colace 100 mg qd,REVIEW OF SYSTEMS REVEALS:,  Same as above,PHYSICAL EXAM:,Vital signs are:  Temp.  99.3 F / BP 138/92, Resp.  22, P 88,General:  Patient is in mild acute respiratory distress,HEENT:,Head:  Atraumatic, normocephalic,,Eyes:",
" Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth pain to both upper and lower teeth on the left side for approximately three days..", General Medicine, Toothache - ER Visit ,"CHIEF COMPLAINT:,  Toothache.,HISTORY OF PRESENT ILLNESS:  ,This is a 29-year-old male who has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled.  Complains of new tooth pain.  The patient states his current toothache is to both upper and lower teeth on the left side for approximately three days.  The patient states that he would have gone to see his regular dentist but he has missed so many appointments that they now do not allow him to schedule regular appointments, he has to be on standby appointments only.  The patient denies any other problems or complaints.  The patient denies any recent illness or injuries.  The patient does have OxyContin and Vicodin at home which he uses for his knee pain but he wants more pain medicines because he does not want to use up that medicine for his toothache when he wants to say this with me.,REVIEW OF SYSTEMS: , CONSTITUTIONAL:  No fever or chills.  No fatigue or weakness.  No recent weight change.  HEENT:  No headache, no neck pain, the toothache pain for the past three days as previously mentioned.  There is no throat swelling, no sore throat, no difficulty swallowing solids or liquids.  The patient denies any rhinorrhea.  No sinus congestion, pressure or pain, no ear pain, no hearing change, no eye pain or vision change.  CARDIOVASCULAR:  No chest pain.  RESPIRATIONS:  No shortness of breath or cough.  GASTROINTESTINAL:  No abdominal pain.  No nausea or vomiting.  GENITOURINARY:  No dysuria.  MUSCULOSKELETAL:  No back pain.  No muscle or joint aches.  SKIN:  No rashes or lesions.  NEUROLOGIC:  No vision or hearing change.  No focal weakness or numbness.  Normal speech.  HEMATOLOGIC/LYMPHATIC:  No lymph node swelling has been noted.,PAST MEDICAL HISTORY: , Chronic knee pain.,CURRENT MEDICATIONS: , OxyContin and Vicodin.,ALLERGIES:,  PENICILLIN AND CODEINE.,SOCIAL HISTORY: , The patient is still a smoker.,PHYSICAL EXAMINATION:,  VITAL SIGNS:  Temperature 97.9 oral, blood pressure is 146/83, pulse is 74, respirations 16, oxygen saturation 98% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished and well developed.  The patient is a little overweight but otherwise appears to be healthy.  The patient is calm, comfortable, in no acute distress, and looks well.  The patient is pleasant and cooperative.  HEENT:  Eyes are normal with clear conjunctiva and cornea bilaterally.  There is no icterus, injection, or discharge.  Pupils are 3 mm and equally round and reactive to light bilaterally.  There is no absence of light sensitivity or photophobia.  Extraocular motions are intact bilaterally.  Ears are normal bilaterally without any sign of infection.  There is no erythema, swelling of canals.  Tympanic membranes are intact without any erythema, bulging or fluid levels or bubbles behind it.  Nose is normal without rhinorrhea or audible congestion.  There is no tenderness over the sinuses.  NECK:  Supple, nontender, and full range of motion.  There is no meningismus.  No cervical lymphadenopathy.  No JVD.  Mouth and oropharynx shows multiple denture and multiple dental caries.  The patient has tenderness to tooth #12 as well as tooth #21.  The patient has normal gums.  There is no erythema or swelling.  There is no purulent or other discharge noted.  There is no fluctuance or suggestion of abscess.  There are no new dental fractures.  The oropharynx is normal without any sign of infection.  There is no erythema, exudate, lesion or swelling.  The buccal membranes are normal.  Mucous membranes are moist.  The floor of the mouth is normal without any abscess, suggestion of Ludwig's syndrome.  CARDIOVASCULAR:  Heart is regular rate and rhythm without murmur, rub, or gallop.  RESPIRATIONS:  Clear to auscultation bilaterally without shortness of breath.  GASTROINTESTINAL:  Abdomen is normal and nontender.  MUSCULOSKELETAL:  No abnormalities are noted to back, arms and legs.  The patient has normal use of his extremities.  SKIN:  No rashes or lesions.  NEUROLOGIC:  Cranial nerves II through XII are intact.  Motor and sensory are intact to the extremities.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is alert and oriented x4.  Normal mood and affect.  HEMATOLOGIC/LYMPHATIC:  No cervical lymphadenopathy is palpated.,EMERGENCY DEPARTMENT COURSE: , The patient did request a pain shot and the patient was given Dilaudid of 4 mg IM without any adverse reaction.,DIAGNOSES:,1.  ODONTALGIA.,2.  MULTIPLE DENTAL CARIES.,CONDITION UPON DISPOSITION:  ,Stable.,DISPOSITION: , To home.,PLAN: , The patient was given a list of local dental clinics that he can follow up with or he can choose to stay with his own dentist that he wishes.  The patient was requested to have reevaluation within two days.  The patient was given a prescription for Percocet and clindamycin.  The patient was given drug precautions for the use of these medicines.  The patient was offered discharge instructions on toothache but states that he already has it.  He declined the instructions.  The patient was asked to return to the emergency room, should he have any worsening of his condition or develop any other problems or symptoms of concern.","general medicine, odontalgi, multiple dental caries, dentist, dental disease, extensive dental disease, teeth pulled, lower teeth, cervical lymphadenopathy, dental caries, toothache, erythema, swelling, teeth, dental, "
" A 54-year-old patient, here for evaluation of new-onset swelling of the tongue.", General Medicine, Tongue Swelling ,"REASON FOR ADMISSION: , A 54-year-old patient, here for evaluation of new-onset swelling of the tongue.,PAST MEDICAL HISTORY:,1.  Diabetes type II.,2.  High blood pressure.,3.  High cholesterol.,4.  Acid reflux disease.,5.  Chronic back pain.,PAST SURGICAL HISTORY:,1.  Lap-Band done today.,2.  Right foot surgery.,MEDICATIONS:,1.  Percocet on a p.r.n. basis.,2.  Keflex 500 mg p.o. t.i.d.,3.  Clonidine 0.2 mg p.o. b.i.d.,4.  Prempro, dose is unknown.,5.  Diclofenac 75 mg p.o. daily.,6.  Enalapril 10 mg p.o. b.i.d.,7.  Amaryl 2 mg p.o. daily.,8.  Hydrochlorothiazide 25 mg p.o. daily.,9.  Glucophage 100 mg p.o. b.i.d.,10.  Nifedipine extended release 60 mg p.o. b.i.d.,11.  Omeprazole 20 mg p.o. daily.,12.  Zocor 20 mg p.o. at bedtime.,ALLERGIES: , No known allergies.,HISTORY OF PRESENT COMPLAINT: , This 54-year-old patient had had Lap-Band at Tempe St Luke this morning.  She woke up at home this evening with massive swelling of the left side of the tongue.  The patient therefore came to the emergency room for evaluation.  The patient was almost intubated on clinical grounds.  Anesthesia was called to see the patient and they decided to give a trial of conservative management of Decadron and racemic epinephrine.,REVIEW OF SYSTEMS:,GENERAL:  The patient denies any itching of the skin or urticaria.  She has not noticed any new rashes.  She denies fever, chill, or malaise.,HEENT:  The patient denies vision difficulty.,RESPIRATORY:  No cough or wheezing.,CARDIOVASCULAR:  No palpitations or syncopal episodes.,GASTROINTESTINAL:  The patient denies swallowing difficulty.,Rest of the review of systems not remarkable.,SOCIAL HISTORY:  ,The patient does not smoke nor drink alcohol.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL:  Obese 54-year-old lady, not in acute distress at this time.,VITAL SIGNS:  On arrival in the emergency room, blood pressure was 194/122, pulse was 94, respiratory rate of 20, and temperature was 96.6.  O2 saturation was 95% on room air.,HEAD AND NECK:  Face is symmetrical.  Tongue is still swollen, especially on the left side.  The floor of the mouth is also indurated.  There is no cervical lymphadenopathy.  There is no stridor.,CHEST:  Clear to auscultation.  No wheezing.  No crepitations.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmurs appreciated.,ABDOMEN:  Benign.,EXTREMITIES:  There is no swelling.,NEUROLOGIC:  The patient is alert and oriented x3.  Examination is nonfocal.",
 Patient with immune thrombocytopenia, General Medicine, Thrombocytopenia - SOAP Note ,"SUBJECTIVE: , I am following the patient today for immune thrombocytopenia.  Her platelets fell to 10 on 01/09/07 and shortly after learning of that result, I increased her prednisone to 60 mg a day.  Repeat on 01/16/07 revealed platelets up at 43.  No bleeding problems have been noted.  I have spoken with her hematologist who recommends at this point we decrease her prednisone to 40 mg for 3 days and then go down to 20 mg a day.  The patient had been on 20 mg every other day at least for a while, and her platelets hovered at least above 20 or so.,PHYSICAL EXAMINATION: , Vitals:  As in chart.  The patient is alert, pleasant, and cooperative.  She is in no apparent distress.  The petechial areas on her legs have resolved.,ASSESSMENT AND PLAN: , Patient with improvement of her platelet count on burst of prednisone.  We will decrease her prednisone to 40 mg for 3 days, then go down to 20 mg a day.  Basically thereafter, over time, I may try to sneak it back a little bit further.  She is on medicines for osteoporosis including bisphosphonate and calcium with vitamin D.  We will arrange to have a CBC drawn weekly.,","general medicine, platelets, platelet count, thrombocytopenia, prednisone,"
" Severe back pain and sleepiness.  The patient, because of near syncopal episode and polypharmacy, almost passed out for about 3 to 4 minutes with a low blood pressure.", General Medicine, Sleepiness - Consult ,"CHIEF COMPLAINT: , Severe back pain and sleepiness.,The patient is not a good historian and history was obtained from the patient's husband at bedside.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 76-year-old obese Caucasian female with past medical conditions that includes hypertension, history of urinary incontinence, dementia, and chronic back pain, basically brought by the husband to the emergency room because of having excruciating back pain.  As per the husband, the patient has this back pain for about almost 1 year and seeing Dr. X in Neurosurgery and had an epidural injection x2, and then the patient's pain somewhat got better between, but last time the patient went to see Dr. X, the patient given injection and the patient passed out, so the doctor stopped giving any other epidural injection.  The patient has severe pain and all in all, the patient cries at home.  As per the husband, the patient woke up in the morning with severe pain, unable to eat, drink today, and crying in the morning, so brought her to the emergency room for further evaluation.  The patient denied any history of fever, cough, chest pain, diarrhea, dysuria or polyuria.  While I was examining the patient, the patient explained about possible diagnosis and treatment plan and possible nursing home discharge for pain control.  The patient passed out for about 3 to 4 minutes, unable to respond to even painful stimuli.  The patient's heart rate went down to 50s and blood pressure was 92 systolic, so the patient was later on given IV fluid and blood pressure checked.  The patient woke up after 5 to 6 minutes, so the patient was later on evaluated for admission because of near syncopal episode.,PAST MEDICAL CONDITIONS:,  Include hypertension, dementia, urinary incontinence, chronic back pain, and degenerative joint disease of the spine.  No history of diabetes, stroke or coronary artery disease.,SURGICAL HISTORY: , Include left total hip replacement many years ago, history of hysterectomy, and appendectomy in the young age.,ALLERGIES: , DENIED.,CURRENT MEDICATIONS: , According to the list shows the patient takes hydrocodone 10/325 mg every 6 hours, Flexeril 10 mg p.o. at bedtime, and Xanax 0.25 mg p.o. 4 times a day.  The patient also takes Neurontin 200 mg 3 times a day, propranolol 10 mg twice a day, oxybutynin 5 mg p.o. twice a day, Namenda 10 mg p.o. daily, and Aricept 10 mg p.o. daily.,SOCIAL HISTORY: , She lives with her husband, usually walks with a walker and wheelchair-bound, does not walk much as per the husband knows.  No history of alcohol abuse or smoking.,PHYSICAL EXAMINATION:,GENERAL:  Currently lying in the bed without apparent distress, very lethargic.,VITAL SIGNS:  Pulse rate of 55, blood pressure is 92/52, after IV fluid came up to 105/58.,CHEST:  Shows bilateral air entry present, clear to auscultate.,HEART:  S1 and S2 regular.,ABDOMEN:  Soft, nondistended, and nontender.,EXTREMITIES:  Shows the patient's straight leg raising to be only up to 30% causing the patient severe back pain.,IMAGING: , The patient's x-ray of the lumbosacral spine done shows there is a L1 compression fracture with some osteophyte formation in the lumbar spine suggestive of degenerative joint disease.,LABORATORY DATA: , The patient's lab test is not done currently, but previous lab test done in 3/2009 seems to be in acceptable range.,IMPRESSION: , The patient, because of near syncopal episode and polypharmacy, almost passed out for about 3 to 4 minutes in front of me with a low blood pressure.,1.  Vasovagal syncope versus polypharmacy because of 3 to 4 medications and muscle relaxants.,2.  Osteoporosis of the spine with L1 compression fracture causing the patient severe pain.,3.  Hypertension, now hypotension.,4.  Incontinence of the bladder.,5.  Dementia, most likely Alzheimer type.,PLAN AND SUGGESTION: , Initial plan was to send the patient to the nursing home, but because of the patient's low blood pressure and heart rate low, we will admit the patient to DOU for 23-hour observation, start the patient on IV fluid, normal saline, 20 mEq KCl, and Protonix 40 mg, and we will also continue the patient's Namenda and Aricept.  I will hold the patient's hydrocodone.  I will hold the Flexeril and I will also hold gabapentin at this moment.  We will give the patient's pain control with Percocet and very minimal morphine sulfate as needed.  Also give the patient calcium with vitamin D and physical therapy.  We will also order a blood test and further management will be based on the patient's all test results.  I also explained to the husband that tomorrow if the patient is better and more alert and awake, then we will send her to the nursing care versus home, it depends on the pain control.",
 Sepsis.  The patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter., General Medicine, Sepsis - Consult ,"REASON FOR ADMISSION: , Sepsis.,HISTORY OF PRESENT ILLNESS:  ,The patient is a pleasant but demented 80-year-old male, who lives in board and care, who presented with acute onset of abdominal pain.  In the emergency room, the patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter.  The patient is unable to provide further history.  The patient's son is at the bedside and confirmed his history.  The patient was given IV antibiotics in the emergency room.  He was also given some hydration.,PAST MEDICAL HISTORY:,1.  History of CAD.,2.  History of dementia.,3.  History of CVA.,4.  History of nephrolithiasis.,ALLERGIES: , NONE.,MEDICATIONS:,1.  Ambien.,2.  Milk of magnesia.,3.  Tylenol.,4.  Tramadol.,5.  Soma.,6.  Coumadin.,7.  Zoloft.,8.  Allopurinol.,9.  Digoxin.,10.  Namenda.,11.  Zocor.,12.  BuSpar.,13.  Detrol.,14.  Coreg.,15.  Colace.,16.  Calcium.,17.  Zantac.,18.  Lasix.,19.  Seroquel.,20.  Aldactone.,21.  Amoxicillin.,FAMILY HISTORY:  ,Noncontributory.,SOCIAL HISTORY: , The patient lives in a board and care.  No tobacco, alcohol or IV drug use.,REVIEW OF SYSTEMS: , As per the history of present illness, otherwise unremarkable.,PHYSICAL EXAMINATION:,VITAL SIGNS:  The patient is currently afebrile.  Pulse 52, respirations 20, blood pressure 104/41, and saturating 98% on room air.,GENERAL:  The patient is awake.  Not oriented x3, in no acute distress.,HEENT:  Pupils are equal, round, and reactive to light and accommodation.  Extraocular movements are intact.  Mucous membranes are dry.,NECK:  Supple.  No thyromegaly.  No jugular venous distention.,HEART:  Irregularly irregular, brady.,LUNGS:  Clear to auscultation bilaterally anteriorly.,ABDOMEN:  Positive normoactive bowel sounds.  Soft.  Tenderness in the suprapubic region without rebound.,EXTREMITIES:  No clubbing, cyanosis or edema in upper and lower extremities.",
 The patient was admitted approximately 3 days ago with increasing shortness of breath secondary to pneumonia.  Pulmonary Medicine Associates have been contacted to consult in light of the ICU admission. , General Medicine, Shortness Of Breath - Progress Note ,"She was evaluated this a.m. and was without any significant clinical change.  Her white count has been improving and down to 12,000.  A chest x-ray obtained today showed some bilateral infiltrates, but no acute cardiopulmonary change.  There was a suggestion of a bilateral lower lobe pneumonitis or pneumonia.,She has been on Zosyn for the infection.,Throughout her hospitalization, we have been trying to adjust her pain medications.  She states that the methadone did not work for her.  She was ""immune"" to oxycodone.  She had been on tramadol before and was placed back on that.  There was some question that this may have been causing some dizziness.  She also was on clonazepam and alprazolam for the underlying bipolar disorder.,Apparently, her husband was in this afternoon.  He had a box of her pain medications.  It is unclear whether she took a bunch of these or precisely what happened.  I was contacted that she was less responsive.  She periodically has some difficulty to arouse due to pain medications, which she has been requesting repeatedly, though at times does not appear to have objective signs of ongoing pain.  The nurse found her and was unable to arouse her at this point.  There was a concern that she had taken some medications from home.  She was given Narcan and appeared to come around some.  Breathing remained somewhat labored and she had some diffuse scattered rhonchi, which certainly changed from this a.m.  Additional Narcan was given as well as some medications to reverse a possible benzodiazepine toxicity.  With O2 via mask, oxygenation was stable at 90% to 95% after initial hypoxia was noted.  A chest x-ray was obtained at this time.  An ECG was obtained, which shows a sinus tachycardia, noted to have ischemic abnormalities.,In light of the acute decompensation, she was then transferred to the ICU.  We will continue the IV Zosyn.  Respiratory protocol with respiratory management.  Continue alprazolam p.r.n., but avoid if she appears sedated.  We will attempt to avoid additional pain medications, but we will continue with the Dilaudid for time being.  I suspect she will need something to control her bipolar disorder.,Pulmonary Medicine Associates have been contacted to consult in light of the ICU admission.  At this juncture, she does not appear to need an intubation.  Pending chest x-ray, she may require additional IV furosemide.","general medicine, shortness of breath, pulmonary medicine, bipolar disorder, icuNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Chronic snoring in children, General Medicine, Snoring ,"CHRONIC SNORING,Chronic snoring in children can be associated with obstructive sleep apnea or upper airway resistant syndrome.  Both conditions may lead to sleep fragmentation and/or intermittent oxygen desaturation, both of which have significant health implications including poor sleep quality and stress on the cardiovascular system.  Symptoms like daytime somnolence, fatigue, hyperactivity, behavior difficulty (i.e., ADHD) and decreased school performance have been reported with these conditions.  In addition, the most severe cases may be associated with right ventricular hypertrophy, pulmonary and/or systemic hypertension and even cor pulmonale.,In this patient, the risks for a sleep-disordered breathing include obesity and the tonsillar hypertrophy.  It is therefore indicated and medically necessary to perform a polysomnogram for further evaluation.  A two week sleep diary will be given to the parents to fill out daily before the polysomnogram is performed.","general medicine, snoring, chronic snoring, behavior difficulty, fatigue, hyperactivity, obstructive sleep apnea, oxygen, oxygen desaturation, polysomnogram, poor sleep quality, right ventricular hypertrophy, school performance, sleep fragmentation, somnolence, systemic hypertension, upper airway, upper airway resistant syndrome, snoring chronic, hypertrophy, sleepNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" He got addicted to drugs.  He decided it would be a good idea to get away from the ""bad crowd"" and come up and live with his mom.", General Medicine, SOAP - Substance Abuse ,"SUBJECTIVE: , This patient presents to the office today with his mom for checkup.  He used to live in the city.  He used to go to college down in the city.  He got addicted to drugs.  He decided it would be a good idea to get away from the ""bad crowd"" and come up and live with his mom.  He has a history of doing heroin.  He was injecting into his vein.  He was seeing a physician in the city.  They were prescribing methadone for some time.  He says that did help.  He was on 10 mg of methadone.  He was on it for three to four months.  He tried to wean down on the methadone a couple of different times, but failed.  He has been intermittently using heroin.  He says one of the big problems is that he lives in a household full of drug users and he could not get away from it.  All that changed now that he is living with his mom.  The last time he did heroin was about seven to eight days ago.  He has not had any methadone in about a week either.  He is coming in today specifically requesting methadone.  He also admits to being depressed.  He is sad a lot and down.  He does not have much energy.  He does not have the enthusiasm.  He denies any suicidal or homicidal ideations at the present time.  I questioned him on the symptoms of bipolar disorder and he does not seem to have those symptoms.  His past medical history is significant for no medical problems.  Surgical history, he voluntarily donated his left kidney.  Family and social history were reviewed per the nursing notes.  His allergies are no known drug allergies.  Medications, he takes no medications regularly.,OBJECTIVE: , His weight is 164 pounds, blood pressure 108/60, pulse 88, respirations 16, and temperature was not taken.  General:  He is nontoxic and in no acute distress.  Psychiatric:  Alert and oriented times 3.  Skin:  I examined his upper extremities.  He showed me his injection sites.  I can see marks, but they seem to be healing up nicely.  I do not see any evidence of cellulitis.  There is no evidence of necrotizing fasciitis.,ASSESSMENT: , Substance abuse.,PLAN: , I had a long talk with the patient and his mom.  I am not prescribing him any narcotics or controlled substances.  I am not in the practice of trading one addiction for another.  It has been one week without any sort of drugs at all.  I do not think he needs weaning.  I think right now it is mostly psychological, although there still could be some residual physical addiction.  However, once again I do not believe it to be necessary to prescribe him any sort of controlled substance at the present time.  I do believe that his depression needs to be treated.  I gave him fluoxetine 20 mg one tablet daily.  I discussed the side effects in detail.  I did also warn him that all antidepressant medications carry an increased risk of suicide.  If he should start to feel any of these symptoms, he should call #911 or go to the emergency room immediately.  If he has any problems or side effects, he was also directed to call me here at the office.  After-hours, he can go to the emergency room or call #911.  I am going to see him back in three weeks for the depression.  I gave him the name and phone number of Behavioral Health and I told him to call so that he can get into rehabilitation program or at least a support group.  We are unable to make a referral for him to do that.  He has to call on his own.  He has no insurance.  However, I think fluoxetine is very affordable.  He can get it for $4 per month at Wal-Mart.  His mom is going to keep an eye on him as well.  He is going to be staying there.  It sounds like he is looking for a job.","general medicine, addicted to drugs, substance abuse, abuse, heroin, methadone"
 Followup of moderate-to-severe sleep apnea.  The patient returns today to review his response to CPAP.  Recommended a fiberoptic ENT exam to exclude adenoidal tissue that may be contributing to obstruction. , General Medicine, Sleep Apnea ,"REASON FOR VISIT: , Mr. ABC is a 30-year-old man who returns in followup of his still moderate-to-severe sleep apnea.  He returns today to review his response to CPAP.,HISTORY OF PRESENT ILLNESS: , The patient initially presented with loud obnoxious snoring that disrupted the sleep of his bed partner.  He was found to have moderate-to-severe sleep apnea (predominantly hypopnea), was treated with nasal CPAP at 10 cm H2O nasal pressure.  He has been on CPAP now for several months, and returns for followup to review his response to treatment.,The patient reports that the CPAP has limited his snoring at night.  Occasionally, his bed partner wakes him in the middle of the night, when the mask comes off, and reminds him to replace the mask.  The patient estimates that he uses the CPAP approximately 5 to 7 nights per week, and on occasion takes it off and does not replace the mask when he awakens spontaneously in the middle of the night.,The patient's sleep pattern consists of going to bed between 11:00 and 11:30 at night and awakening between 6 to 7 a.m. on weekdays.  On weekends, he might sleep until 8 to 9 a.m.  On Saturday night, he might go to bed approximately mid night.,As noted, the patient is not snoring on CPAP.  He denies much tossing and turning and does not awaken with the sheets in disarray.  He awakens feeling relatively refreshed.,In the past few months, the patient has lost between 15 and 18 pounds in combination of dietary and exercise measures.,He continues to work at Smith Barney in downtown Baltimore.  He generally works from 8 to 8:30 a.m. until approximately 5 to 5:30 p.m.  He is involved in training purpose to how to sell managed funds and accounts.,The patient reports no change in daytime stamina.  He has no difficulty staying awake during the daytime or evening hours.,The past medical history is notable for allergic rhinitis.,MEDICATIONS: , He is maintained on Flonase and denies much in the way of nasal symptoms.,ALLERGIES: , Molds.,FINDINGS:  ,Vital signs:  Blood pressure 126/75, pulse 67, respiratory rate 16, weight 172 pounds, height 5 feet 9 inches, temperature 98.4 degrees and SaO2 is 99% on room air at rest.,The patient has adenoidal facies as noted previously.,Laboratories:  The patient forgot to bring his smart card in for downloading today.,ASSESSMENT: , Moderate-to-severe sleep apnea.  I have recommended the patient continue CPAP indefinitely.  He will be sending me his smart card for downloading to determine his CPAP usage pattern.  In addition, he will continue efforts to maintain his weight at current levels or below.  Should he succeed in reducing further, we might consider re-running a sleep study to determine whether he still requires a CPAP.,PLANS: , In the meantime, if it is also that the possible nasal obstruction is contributing to snoring and obstructive hypopnea.  I have recommended that a fiberoptic ENT exam be performed to exclude adenoidal tissue that may be contributing to obstruction.  He will be returning for routine followup in 6 months.","general medicine, daytime stamina, fiberoptic ent exam, moderate to severe, smart card, sleep apnea, cpap, apnea, sleep, "
" Right hand laceration x3, repaired.", General Medicine, Right Hand Laceration ,"HISTORY: , The patient is a 19-year-old male who was involved in a fight approximately an hour prior to his ED presentation.  He punched a guy few times on the face, might be the mouth and then punched a drinking glass, breaking it and lacerating his right hand.  He has three lacerations on his right hand.  His wound was cleaned out thoroughly with tap water, and one of the navy corpsman tried to use Superglue and gauze to repair it.  However, it continues to bleed and he is here for evaluation.,PAST MEDICATION HISTORY:,  Significant for asthma and acne.,CURRENT MEDICATIONS: , Accutane and takes no other medications.,TETANUS STATUS: , Up-to-date.,SOCIAL HISTORY: , He is a nonsmoker.  He has been drinking alcohol today, but has no history of alcohol or drug abuse.,REVIEW OF SYSTEMS: , Otherwise well.  No febrile illness.  No motor or sensory complaints of any sort or paresthesias in the hand.,PHYSICAL EXAM:  ,GENERAL:  He is in no apparent distress.  He is alert and oriented x3.  Mental status is clear and appropriate.  VITALS SIGNS:  Temperature is 98.3, heart rate 100, respirations 18, blood pressure 161/98, oxygen saturation 99% on room air by pulse oximetry, which is normal.  EXTREMITIES:  Right hand, he has three lacerations all over the MCP joint of his right hand, irregular shaped over the fifth MCP and then over the fourth and third half wound, similarly the lacerations.  All total approximately 4 cm in length.  I see no foreign bodies, just capillary refills less than 2 seconds.  Radial pulses intact.  There is full range of motion with no gross deformities.  No significant amount of edema associated with these in the dorsum of the hand.,STUDIES: , X-rays shows no open fracture or bony abnormality.,EMERGENCY DEPARTMENT COURSE:  ,The patient was anesthetized with 1% Xylocaine.  Wounds were thoroughly irrigated with tap water with at least 2 liters.  They were repaired with simple sutures of 4-0 Ethilon, total of 17 sutures, 16 of which were simple, one is a horizontal mattress.  The patient was given Augmentin 875 mg p.o. due to the possibility of human bite wound.,ASSESSMENT: , RIGHT HAND LACERATIONS, SIMPLE X3, REPAIRED AS DESCRIBED.  NO SIGNS OF BONY ABNORMALITY OR FOREIGN BODY.,PLAN:  ,The patient will be given Augmentin 875 mg 1 p.o. b.i.d. for 7 days.  He will be given a prescription of Vicoprofen as he is unable to tolerate the Tylenol due to his Accutane.  He will take 1 p.o. every 6 hours or as needed, #12.  He will follow up for suture removal in 8 days.  Should he develop any signs of infection, he will come immediately here for reevaluation.  He is discharged in stable condition.,","general medicine, accutane, hand laceration, laceration, hand, "
 Consultation for evaluation of thrombocytopenia., General Medicine, Thrombocytopenia - Consult ,"REASON FOR CONSULTATION:,  Thrombocytopenia.,HISTORY OF PRESENT ILLNESS:,  Mrs. XXX is a 17-year-old lady who is going to be 18 in about 3 weeks.  She has been referred for the further evaluation of her thrombocytopenia.  This thrombocytopenia was detected on a routine blood test performed on the 10th of June 2006.  Her hemoglobin was 13.3 with white count of 11.8 at that time.  Her lymphocyte count was 6.7.  The patient, subsequently, had a CBC repeated on the 10th at Hospital where her hemoglobin was 12.4 with a platelet count of 26,000.  She had a repeat of her CBC again on the 12th of June 2006 with hemoglobin of 14, white count of 11.6 with an increase in the number of lymphocytes.  Platelet count was 38.  Her rapid strep screen was negative but the infectious mononucleosis screen is positive.  The patient had a normal platelet count prior too and she is being evaluated for this low platelet count.,The patient gives a history of feeling generally unwell for a couple of days towards the end of May.  She was fine for a few days after that but then she had sore throat and fever 2-3 days subsequent to that.  The patient continues to have sore throat.,She denies any history of epistaxis.  Denies any history of gum bleeding.  The patient denies any history of petechiae.  She denies any history of abnormal bleeding.  Denies any history of nausea, vomiting, neck pain, or any headaches at the present time.,The patient was accompanied by her parents.,PAST MEDICAL HISTORY: , Asthma.,CURRENT MEDICATIONS: , Birth control pills, Albuterol, QVAR and Rhinocort.,DRUG ALLERGIES: , None.,PERSONAL HISTORY: , She lives with her parents.,SOCIAL HISTORY:,  Denies the use of alcohol or tobacco.,FAMILY HISTORY: , Noncontributory.,OCCUPATION: , The patient is currently in school.,REVIEW OF SYSTEMS:,Constitutional:  The history of fever about 2 weeks ago.,HEENT:  Complains of some difficulty in swallowing.,Cardiovascular:  Negative.,Respiratory:  Negative.,Gastrointestinal:  No nausea, vomiting, or abdominal pain.,Genitourinary:  No dysuria or hematuria.,Musculoskeletal:  Complains of generalized body aches.,Psychiatric:  No anxiety or depression.,Neurologic:  Complains of episode of headaches about 2-3 weeks ago.,PHYSICAL EXAMINATION:  ,She was not in any distress.  She appears her stated age.  Temperature 97.9.  Pulse 84.  Blood pressure was 110/60.  Weighs 162 pounds.  Height of 61 inches.  Lungs - Normal effort.  Clear.  No wheezing.  Heart - Rate and rhythm regular.  No S3, no S4.  Abdomen - Soft.  Bowel sounds are present.  No palpable hepatosplenomegaly.  Extremities - Without any edema, pallor, or cyanosis.  Neurological:  Alert and oriented x 3.  No focal deficit.  Lymph Nodes - No palpable lymphadenopathy in the neck or the axilla.  Skin examination reveals few petechiae along the lateral aspect of the left thigh but otherwise there were no ecchymotic patches.,DIAGNOSTIC DATA: , The patient's CBC results from before were reviewed.  Her CBC performed in the office today showed hemoglobin of 13.7, white count of 13.3, lymphocyte count of 7.6, and platelet count of 26,000.,IMPRESSION: , ITP, the patient has a normal platelet count.,PLAN:,1.  I had a long discussion with family regarding the treatment of ITP.  In view of the fact that the patient's platelet count is 26,000 and she is asymptomatic, we will continue to monitor the counts.,2.  An ultrasound of the abdomen will be performed tomorrow.,3.  I have given her a requisition to obtain some blood work tomorrow.",
 Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia.  This patient presents with history of sleep disruption and daytime sleepiness with fatigue.  Her symptoms are multifactorial., General Medicine, Sleep Study Followup ,"REASON FOR VISIT:,  This 48-year-old woman returns in followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia.,HISTORY OF PRESENT ILLNESS: , The patient presented initially to the Pulmonary Clinic with dyspnea on minimal exertion.  At that time, she was evaluated and found to have evidence for sleep disruption and daytime fatigue.  She also complained of nocturnal choking episodes that have since abated over the past several months.  In the meantime, she had been scheduled for an overnight sleep study performed to evaluate her for sleep apnea, returns today to review her study results.,The patient's sleep patterns consist of going to bed between 9.00 and 10.00 p.m. and awakening in the morning between 5.00 and 6.00 a.m.  She reports difficulty in initiating sleep and then recurrent awakenings every 1 to 2 hours throughout the night.  She reports tossing and turning throughout the night and awakening with the sheets in disarray.  She reports that her sleep was much better quality in the sleep laboratory as compared to home.  When she awakens, she might have a dull headache and feels tired in the morning.  Her daughter reports that she has heard the patient talking during sleep and snoring.  There are no apneic episodes.  The patient reports that she used to cough a lot in the middle of the night, but has no longer been doing so in recent weeks.,During the daytime, the patient reports spending a lot of sedentary time reading and watching TV.  She routinely dozes off during these sedentary activities.  She also might nap between 2.00 and 3.00 p.m., and nods off in the evening hours.,The patient smokes perhaps one to two packs of cigarettes per day, particularly after dinner.,She reports that her weight has fluctuated and peaked at 260 pounds approximately 1 year ago.  Since that time, her weight is down by approximately 30 pounds.,The patient is managed in Outpatient Psychiatry and at her Maintenance Clinic.  She takes methadone, trazodone, and Seroquel.,PAST MEDICAL HISTORY:,1.  Depression.,2.  Hepatitis C.,3.  Hypertension.,4.  Inhaled and intravenous drug abuse history.,The patient has a history of smoking two packs per day of cigarettes for approximately 25 pounds.  She also has a history of recurrent atypical chest pain for which she has been evaluated.,FAMILY HISTORY: , As previously documented.,SOCIAL HISTORY:  ,The patient has a history of inhalation on intravenous drug abuse.  She is currently on methadone maintenance.  She is being followed in Psychiatry for depression and substance abuse issues.  She lives with a room-mate.,REVIEW OF SYSTEMS:,  Not contributory.,MEDICATIONS: , Current medications include the following:,1.  Methadone 110 mg by mouth every day.,2.  Paxil 60 mg by mouth every day.,3.  Trazodone 30 mg by mouth nightly.,4.  Seroquel 20 mg by mouth nightly.,5.  Avalide (irbesartan) and hydrochlorothiazide.,6.  Albuterol and Flovent inhalers two puffs by mouth twice a day.,7.  Atrovent as needed.,FINDINGS: , Vital Signs:  Blood pressure 126/84, pulse 67, respiratory rate 18, weight 232 pounds, height 5 feet 8 inches, temperature 97.4 degrees, SaO2 is 99 percent on room air at rest.  HEENT:  Sclerae anicteric.  Conjunctivae pink.  Extraocular movements are intact.  Pupils are equal, round, and reactive to light.  The nasal passages show deviation in the nasal septum to the right.  There is a slight bloody exudate at the right naris.  Some nasal mucosal edema was noted with serous exudate bilaterally.  The jaw is not foreshortened.  The tongue is not large.  Mallampati airway score was 3.  The oropharynx was not shallow.  There is no pharyngeal mucosa hypertrophy.  No tonsillar tissue noted.  The tongue is not large.  Neck is supple.  Thyroid without nodules or masses.  Carotid upstrokes normal.  No bruits.  No jugular venous distention.  Chest is clear to auscultation and percussion.  No wheezing, rales, rhonchi or adventitious sounds.  No prolongation of the expiratory phase.  Cardiac:  PMI not palpable.  Regular rate and rhythm.  S1 and S2 normal.  No murmurs or gallops.  Abdomen:  Nontender.  Bowel sounds normal.  No liver or spleen palpable.  Extremities:  No clubbing or cyanosis.  There is 1+ pretibial edema.  Pulses are 2+ in upper and lower extremities.  Neurologic:  Grossly nonfocal.,LABORATORIES:,  Pulmonary function studies reportedly show a mild restrictive ventilatory defect without obstruction.  Diffusing capacity is well preserved.,An overnight sleep study was performed on this patient at the end of 02/07.  At that time, she reported that her sleep was better in the laboratories compared to home.  She slept for a total sleep time of 398 minutes out of 432 minutes in bed (sleep proficiency 92 percent).  She fell asleep in the middle of latency of less than 1 minute.  She woke up after sleep onset of 34 minutes.  She had stage I sleep that was some elevated at 28 percent of total sleep time, and stage I sleep is predominantly evident in the lateral portion of the night.  The remainders were stage II at 69 percent, stage III and IV at 3 percent of total sleep time.,The patient had no REM sleep.,The patient had no periodic limb movements during sleep.,The patient had no significant sleep-disordered breathing during non-REM sleep with less than one episode per hour.  Oxyhemoglobin saturation remained in the low to mid 90s throughout the night.,Intermittent inspiratory flow limitation compatible with snoring was observed during non-REM sleep.,ASSESSMENT AND PLAN: , This patient presents with history of sleep disruption and daytime sleepiness with fatigue.  Her symptoms are multifactorial.,Regarding the etiology of difficulty in initiating and maintaining sleep, the patient has a component of psychophysiologic insomnia, based on reports of better sleep in the laboratory as compared to home.  In addition, nontrivial smoking in the home setting may be contributing significantly to sleep disruption.,Regarding her daytime sleepiness, the patient is taking a number of long-acting central nervous system acting medications to sedate her and can produce a lasting sedation throughout the daytime.  These include trazodone, Seroquel, and methadone.  Of these medications, the methadone is clearly indicative, given the history of substance abuse.  It would be desirable to reduce or discontinue trazodone and then perhaps consider doing the same with Seroquel.  I brought this possibility up with the patient, and I asked her to discuss this further with her psychiatrist.,Finally, to help mitigate sleep disruption at night, I have provided her with tips for sleep hygiene.  These include bedtime rituals, stimulus control therapy, and sleep restriction as well as avoidance of nicotine in the evening hours.",
" Request for consultation to evaluate stomatitis, possibly methotrexate related.", General Medicine, Request For Consultation ,"REASON FOR CONSULTATION:, Please evaluate stomatitis, possibly methotrexate related.,HISTORY OF PRESENT ILLNESS:, The patient is a very pleasant 57-year old white female, a native of Cuba, being seen for evaluation and treatment of sores in her mouth that she has had for the last 10-12 days.  The patient has a long history of severe and debilitating rheumatoid arthritis for which she has had numerous treatments, but over the past ten years she has been treated with methotrexate quite successfully.  Her dosage has varied somewhere between 20 and 25 mg per week.  About the beginning of this year, her dosage was decreased from 25 mg to 20 mg, but because of the flare of the rheumatoid arthritis, it was increased to 22.5 mg per week.  She has had no problems with methotrexate as far as she knows.  She also took an NSAID about a month ago that was recently continued because of the ulcerations in her mouth.  About two weeks ago, just about the time the stomatitis began she was placed on an antibiotic for suspected upper respiratory infection.  She does not remember the name of the antibiotic.  Although she claims she remembers taking this type of medication in the past without any problems.  She was on that medication three pills a day for three to four days.  She notes no other problems with her skin.  She remembers no allergic reactions to medication.  She has no previous history of fever blisters.  ,PHYSICAL EXAMINATION:, Reveals superficial erosions along the lips particularly the lower lips.  The posterior buccal mucosa along the sides of the tongue and also some superficial erosions along the upper and lower gingiva.  Her posterior pharynx was difficult to visualize, but I saw no erosions on the areas today.  There did however appear to be one small erosion on the soft palate.  Examination of the rest of her skin revealed no areas of dermatitis or blistering.  There were some macular hyperpigmentation on the right arm where she has had a previous burn, plus the deformities from her rheumatoid arthritis on her hands and feet as well as scars on her knees from total joint replacement surgeries.  ,IMPRESSION: , Erosive stomatitis probably secondary to methotrexate even though the medication has been used for ten years without any problems.  Methotrexate may produce an erosive stomatitis and enteritis after such a use. The patient also may have an enteritis that at this point may have become more quiescent as she notes that she did have some diarrhea about the time her mouth problem developed. She has had no diarrhea today, however. She has noted no blood in her stools and has had no episodes of nausea or vomiting.  ,I am not as familiar with the NSAID causing an erosive stomatitis.  I understand that it can cause gastrointestinal upset, but given the choice between the two, I would think the methotrexate is the most likely etiology for the stomatitis.  ,RECOMMENDED THERAPY: ,I agree with your therapeutic regimen regarding this condition with the use of prednisone and folic acid.  I also agree that the methotrexate must be discontinued in order to produce a resolution of this patients’ skin problem. However, in my experience, this stomatitis may take a number of weeks to go away completely if a patient been on methotrexate, for an extended period of time, because the medication is stored within the liver and in fatty tissue.  Topically I have prescribed Lidex gel, which I find works extremely well in stomatitis conditions.  It can be applied t.i.d.  ,Thank you very much for allowing me to share in the care of this pleasant patient.  I will follow her with you as needed.","general medicine, stomatitis, nsaid, blistering, blisters, buccal mucosa, dermatitis, erosive stomatitis, gastrointestinal, methotrexate, mouth, rheumatoid arthritis, stomatitis conditions, superficial erosions, upper respiratory infection, illness, medication"
" A 40-year-old male seen today for a 90-day revocation admission.  Noncompliant with medications, refusing oral or IM medications, became agitated.  History of hyperlipidemia with elevated triglycerides.", General Medicine, Revocation Admission ,"IDENTIFYING DATA:,  This is a 40-year-old male seen today for a 90-day revocation admission.  He had been reported by his case manager as being noncompliant with medications, refusing oral or IM medications, became agitated, had to be taken to ABCD for evaluation, admitted at that time to auditory hallucinations and confusion and was committed for admission at this time.  He has a psychiatric history of schizophrenia, was previously admitted here at XYZ on 12/19/2009, had another voluntary admission in ABCD in 1998.,MEDICATIONS: , Listed as Invega and Risperdal.,ALLERGIES: , None known to medications.,PAST MEDICAL HISTORY:  ,The only identified problem in his chart is that he is being treated for hyperlipidemia with gemfibrozil.  The patient is unaware and cannot remember what medications he had been taking or whether he had been taking them at all as an outpatient.,FAMILY HISTORY: , Listed as unknown in the chart as far as other psychiatric illnesses.  The patient himself states that his parents are deceased and that he raised himself in the Philippines.,SOCIAL HISTORY:,  He immigrated to this country in 1984, although he lists himself as having a green card still at this time.  He states he lives on his own.  He is a single male with no history of marriage or children and that he had high school education.  His recreational drug use in the chart indicates that he has had a history of methamphetamines.  The patient denies this at this time.  He also denies current alcohol use.  He does smoke.  He is unable to tell me of any PCP.  He is in counseling service with his case manager being XYZ.,LEGAL HISTORY:  ,  He had an assault in December 2009, which led to his previous detention.  It is unknown whether he is under legal constraints at this time.,OBJECTIVE FINDINGS:  ,VITAL SIGNS: , Blood pressure is 125/75.  His weight is 197 with height 5 feet 4 inches.,GENERAL:,  He is cooperative, although disorganized and focusing entirely and telling me that he is here because there was some confusion in how he took his medications.  He does not endorse any voices at this time.,HEENT: , His head exam is normal with normal scalp.  HEENT is unremarkable.  Pupils equal and reactive to light and accommodation.  TMs are normal.,NECK:,  Unremarkable with no masses or tenderness.,CARDIOVASCULAR:,  Normal S1 and S2.  No murmurs.,LUNGS:,  Clear.,ABDOMEN:  ,Negative with no scars.,GU:  ,Not done.,RECTAL:,  Not done.,DERM:,  He does have a scarring of acne lesions, both face and back.,EXTREMITIES:,  Otherwise negative.,NEUROLOGIC: , Cranial nerves II through X normal.  Reflexes are normal and gait is unremarkable.,LABORATORY DATA: , His labs done at ABCD showed his CMP to be normal with an elevated white count of 17.2.  Chest x-ray was indicated as being done and normal as was a UA and he did apparently receive hydration in the hospital with IV fluids.,ASSESSMENT: , History of hyperlipidemia with elevated triglycerides.  We will maintain his gemfibrozil 600 b.i.d. and for health maintenance issues, we will also maintain just a vitamin daily and we will obtain recheck on his labs and lipid levels in one week after treatment is initiated.",
" Recurrent abscesses in the thigh, as well as the pubic area for at least about 2 years.   In the past, Accutane has been used.", General Medicine, Recurrent Abscesses - Consult ,"REASON FOR CONSULTATION: , Recurrent abscesses in the thigh, as well as the pubic area for at least about 2 years.,HISTORY OF PRESENT ILLNESS:,  A 23-year-old female who is approximately 5 months' pregnant, who has had recurrent abscesses in the above-mentioned areas.  She would usually have pustular type of lesion that would eventually break and would be quite painful.  The drainage would be malodorous.  It would initially not be infected as far as she knows, but then could eventually become infected.  She stated that this first started after she had her first born about 2 years ago.  She had recurrences of these abscesses and had pain, actually hospitalized at Hospital approximately a year and a half ago for about 1-1/2 months.  She was treated with multiple courses of antibiotics.  She had biopsies done.  She was seen by Dr. X.  Reportedly, she had a HIV test done that was negative.  She had been seen by a dermatologist who said that she had a problem with her sweat glands.  She has been on multiple courses of antibiotics.  She never had any fevers.  She has pain, drainage, and reportedly there was some bleeding in the area of the perineum/vaginal area.,PAST MEDICAL HISTORY:,1.  History of recurrent abscesses in the perineum, upper medial thigh, and the vulva area for about 2 years.  Per her report, a dermatologist had told her that she had an overactive sweat gland, and I believe she probably has hidradenitis suppurativa.  Probably, she has had Staphylococcus infection associated with it as well.,2.  Reported history of asthma.,GYNECOLOGIC HISTORY: , G3, P1.  She is currently 5 months' pregnant.,ALLERGIES: , None.,MEDICATIONS: , Her medication had been Augmentin.,SOCIAL HISTORY: , She is followed by a gynecologist in Bartow.  She is not an alcohol or tobacco user.  She is not married.  She has a 2-year-old child.,FAMILY HISTORY:  ,Noncontributory.,REVIEW OF SYSTEMS: , The patient has been complaining of diarrhea about 5 or 6 times a day for several weeks now.,PHYSICAL EXAMINATION,GENERAL:",
" Patient with a history of coronary artery disease, congestive heart failure, COPD, hypertension, and renal insufficiency.", General Medicine, Renal Insufficiency - Consult ,"REASON FOR CONSULT:, Renal insufficiency.,HISTORY OF PRESENT ILLNESS:, A 48-year-old African-American male with a history of coronary artery disease, COPD, congestive heart failure with EF of 20%-25%, hypertension, renal insufficiency, and recurrent episodes of hypertensive emergency, admitted secondary to shortness of breath and productive cough. The patient denies any chest pain, palpitations, syncope, or fever. Denied any urinary disturbances, difficulty, burning micturition, hematuria, or back pain. Nephrology is consulted regarding renal insufficiency.,REVIEW OF SYSTEMS:, Reviewed entirely and negative except for HPI.,PAST MEDICAL HISTORY:, Hypertension, congestive heart failure with ejection fraction of 20%-25% in December 2005, COPD, mild diffuse coronary artery disease, and renal insufficiency.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,MEDICATIONS:, Clonidine 0.3 p.o. q.8, aspirin 325 daily, hydralazine 100 q.8, Lipitor 20 at bedtime, Toprol XL 100 daily.,FAMILY HISTORY:, Noncontributory.,SOCIAL HISTORY:, The patient denies any alcohol, IV drug abuse, tobacco, or any recreational drugs.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 180/110. Temperature 98.1. Pulse rate 60. Respiratory rate 23. O2 sat 95% on room air.,GENERAL: A 48-year-old African-American male in no acute distress.,HEENT: Pupils equal, round, and reactive to light and accommodation. No pallor or icterus.,NECK: No JVD, bruit, or lymphadenopathy.,HEART: S1 and S2, regular rate and rhythm, no murmurs, rubs, or gallops.,LUNGS: Clear. No wheezes or crackles.,ABDOMEN: Soft, nontender, nondistended, no organomegaly, bowel sounds present.,EXTREMITIES: No cyanosis, clubbing, or edema.,CNS: Exam is nonfocal.,LABS:, WBC 7, H and H 13 and 40, platelets 330, PT 12, PTT 26, CO2 20, BUN 27, creatinine 3.1, cholesterol 174, BNP 973, troponin 0.18. Previous creatinine levels were 2.7 in December. Urine drug screen positive for cocaine.,ASSESSMENT:, A 48-year-old African-American male with a history of coronary artery disease, congestive heart failure, COPD, hypertension, and renal insufficiency with:,1. Hypertensive emergency.,2. Acute on chronic renal failure.,3. Urine drug screen positive.,4. Question CHF versus COPD exacerbation.,PLAN:,1. Most likely, renal insufficiency is a chronic problem. Hypertensive etiology worsened by the patient's chronic cocaine abuse.,2. Control blood pressure with medications as indicated. Hypertensive emergency most likely related to cocaine drug abuse.,Thank you for this consult. We will continue to follow the patient with you.",
  Symptomatic thyroid goiter.  Total thyroidectomy., General Medicine, Post Thyroidectomy - Discharge Summary ,"ADMISSION DIAGNOSIS: , Symptomatic thyroid goiter.,DISCHARGE DIAGNOSIS:  ,Symptomatic thyroid goiter.,PROCEDURE PERFORMED DURING THIS HOSPITALIZATION: , Total thyroidectomy.,INDICATIONS FOR THE SURGERY:  ,Briefly, the patient is a 71-year-old female referred with increasingly symptomatic large nodular thyroid goiter.  She presented now after informed consent for the above procedure, understanding the inherent risks and complications and risk-benefit ratio.,HOSPITAL COURSE:  ,The patient underwent total thyroidectomy on 09/22/08, which she tolerated very well and remained stable in the postoperative period.  On postoperative day #1, she was tolerating her diet, began on thyroid hormone replacement, and remained afebrile with stable vital signs.  She required intravenous narcotics for pain control.  She was judged stable for discharge home on 09/25/08, tolerating a diet well, having no fever, stable vital signs, and good pain control.  The wound was clean and dry.  The drain was removed.  She was instructed to follow up in the surgical office within one week after discharge.  She was given prescription for Vicodin for pain and Synthroid thyroid hormone, and otherwise the appropriate wound care instructions per my routine wound care sheet.","general medicine, nodular, symptomatic thyroid goiter, thyroidectomy, goiter, "
 Patient with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung. , General Medicine, Pneumoconiosis ,"HISTORY OF PRESENT ILLNESS: , This is a 91-year-old male with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung.  The patient also has a positive history of smoking in the past.  At the present time, he is admitted for continued,management of respiratory depression with other medical complications.  The patient was treated for multiple problems at Jefferson Hospital prior to coming here including abdominal discomfort due to a ureteral stone with resultant hydronephrosis and hydroureter.  In addition, he also developed cardiac complications including atrial fibrillation.  The patient was evaluated by the cardiologist as well as the pulmonary service and Urology.  He had a cystoscopy performed and a left ureteral stone was removed as well as insertion of a left ureteral stent on 07/23/2008.  He subsequently underwent cardiac arrest and he was resuscitated at that time.  He was intubated and placed on mechanical ventilatory support.  Subsequent weaning was unsuccessful.  He then had a tracheostomy placed.,CURRENT MEDICATIONS:,1.  Albuterol.,2.  Pacerone.,3.  Theophylline,4.  Lovenox.,5.  Atrovent.,6.  Insulin.,7.  Lantus.,8.  Zestril.,9.  Magnesium oxide.,10.  Lopressor.,11.  Zegerid.,12.  Tylenol as needed.,ALLERGIES:,  PENICILLIN.,PAST MEDICAL HISTORY:,1.  History of coal miner's disease.,2.  History of COPD.,3.  History of atrial fibrillation.,4.  History of coronary artery disease.,5.  History of coronary artery stent placement.,6.  History of gastric obstruction.,7.  History of prostate cancer.,8.  History of chronic diarrhea.,9.  History of pernicious anemia.,10.  History of radiation proctitis.,11.  History of anxiety.,12.  History of ureteral stone.,13.  History of hydronephrosis.,SOCIAL HISTORY: , The patient had been previously a smoker.  No other could be obtained because of tracheostomy presently.,FAMILY HISTORY: , Noncontributory to the present condition and review of his previous charts.,SYSTEMS REVIEW: , The patient currently is agitated.  Rapidly moving his upper extremities.  No other history regarding his systems could be elicited from the patient.,PHYSICAL EXAM:,General:  The patient is currently agitated with some level of distress.  He has rapid respiratory rate.  He is responsive to verbal commands by looking at the eyes.,Vital Signs:  As per the monitors are stable.,Extremities:  Inspection of the upper extremities reveals extreme xerosis of the skin with multiple areas of ecchymosis and skin tears some of them to the level of stage II especially over the dorsum of the hands and forearm areas.  There is also edema of the forearm extending up to the mid upper arm area.  Palpation of the upper extremities reveals fibrosis more prominent on the right forearm area with the maximum edema in the elbow area on the ulnar aspect.  There is also scabbing of some of the possibly from earlier skin tears in the upper side forearm area.,IMPRESSION:,1.  Ulceration of bilateral upper extremities.,2.  Cellulitis of upper extremities.,3.  Lymphedema of upper extremities.,4.  Other noninfectious disorders of lymphatic channels.,5.  Ventilatory-dependent respiratory failure.",
" Refractory hypertension, much improved, history of cardiac arrhythmia and history of pacemaker secondary to AV block, history of GI bleed, and history of depression.", General Medicine, Refractory Hypertension - Followup ,"PROBLEM LIST:,1.  Refractory hypertension, much improved.,2.  History of cardiac arrhythmia and history of pacemaker secondary to AV block.,3.  History of GI bleed in 1995.,4.  History of depression.,HISTORY OF PRESENT ILLNESS:,  This is a return visit to the renal clinic for this patient.  She is an 85-year-old woman with history as noted above.  Her last visit was approximately four months ago.  Since that time, the patient has been considerably more compliant with her antihypertensive medications and actually had a better blood pressure reading today than she had had for many visits previously.  She is not reporting any untoward side effect.  She is not having weakness, dizziness, lightheadedness, nausea, vomiting, constipation, diarrhea, abdominal pain, chest pain, shortness of breath or difficulty breathing.  She has no orthopnea.  Her exercise capacity is about the same.  The only problem she has is musculoskeletal and that pain in the right buttock, she thinks originating from her spine.  No history of extremity pain.,CURRENT MEDICATIONS:,1.  Triamterene/hydrochlorothiazide 37.5/25 mg.,2.  Norvasc 10 mg daily.,3.  Atenolol 50 mg a day.,4.  Atacand 32 mg a day.,5.  Cardura 4 mg a day.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 36.2, pulse 47, respirations 16, and blood pressure 157/56.  THORAX:  Revealed lungs that are clear, PA and lateral without adventitious sounds.  CARDIOVASCULAR:  Demonstrated regular rate and rhythm.  S1 and S2 without murmur.  No S3.  I could not hear murmur today.  ABDOMEN:  Above plane, but nontender.  EXTREMITIES:  Revealed no edema.,ASSESSMENT:,  This is a return visit for this patient who has refractory hypertension.  This seems to be doing very well given her current blood pressure reading, at least much improved from what she had been previously.  We had discussed with her in the past beginning to see an internist at the senior center.  She apparently had an appointment scheduled and it was missed.  We are going to reschedule that today given her overall state of well-being and the fact that she has no evidence of GFR that is greater than 60%.,PLAN: , The plan will be for her to follow up at the senior center for her routine health care, and should the need arise for further management of blood pressure, a referral back to us.  In the meantime, we will discharge her from our practice.  Should there be confusion or difficulty getting in the senior center, we can always see her back in followup","general medicine, cardiac arrhythmia, av block, refractory hypertension, blood pressure, pacemaker, atenolol, arrhythmia"
" Before surgery, the patient's blood pressure was 181/107.  The patient received IV labetalol.  Blood pressure improved, but postsurgery, the patient's blood pressure went up again to 180/100. ", General Medicine, Perioperative Elevated Blood Pressure ,"REASON FOR CONSULTATION:,  Perioperative elevated blood pressure.,PAST MEDICAL HISTORY:,1.  Graves disease.,2.  Paroxysmal atrial fibrillation, has been in normal sinus rhythm for several months, off medication.,3.  Diverticulosis.,4.  GERD.,5.  High blood pressure.,6.  Prostatic hypertrophy, status post transurethral resection of the prostate.,PAST SURGICAL HISTORY: , Bilateral inguinal hernia repair, right shoulder surgery with reconstruction, both shoulders rotator cuff repair, left knee arthroplasty, and transurethral resection of prostate.,HISTORY OF PRESENTING COMPLAINT:  ,This 71-year-old gentleman with the above history, underwent laser surgery for the prostate earlier today.  Before surgery, the patient's blood pressure was 181/107.  The patient received IV labetalol.  Blood pressure improved, but postsurgery, the patient's blood pressure went up again to 180/100.  Currently, blood pressure is 158/100, goes up to 155 systolic when he is talking.  On further questioning, the patient denies shortness of breath, chest pain, palpitations, or dizziness.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No recent fever or general malaise.,ENT:  Unremarkable.,RESPIRATORY:  No cough or shortness of breath.,CARDIOVASCULAR:  No chest pain.,GASTROINTESTINAL:  No nausea or vomiting.,GENITOURINARY:  The patient has prostatic hypertrophy, had laser surgery earlier today.,ENDOCRINE:  Negative for diabetes, but positive for Graves disease.,MEDICATIONS:  ,The patient takes Synthroid and aspirin.  Aspirin had been discontinued about 1 week ago.  He used to be on atenolol, lisinopril, and terazosin, both of which have been discontinued by his cardiologist, Dr. X several months ago.,PHYSICAL EXAMINATION:,GENERAL:  A 71-year-old gentleman, not in acute distress.,CHEST:  Clear to auscultation.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmur was appreciated.,ABDOMEN:  Benign.,EXTREMITIES:  There is no swelling.,NEUROLOGICAL:  The patient is alert and oriented x3.  Examination is nonfocal.,ASSESSMENT AND PLAN:,1.  Perioperative hypertension.  We will restart lisinopril at half the previous dose.  He will be on 20 mg p.o. daily.  If blood pressure remains above systolic of 150 within 3 days, the patient should increase lisinopril to 40 mg p.o. daily.  The patient should see his primary physician, Dr. Y in 2 weeks' time.  If blood pressure, however, remains above 150 systolic despite 40 mg of lisinopril, the patient should make an appointment to see his primary physician in a week's time.,2.  Prostatic hypertrophy, status post laser surgery.  The patient tolerated the procedure well.,3.  History of Graves disease.,4.  History of atrial fibrillation.  The patient is in normal sinus rhythm.,DISPOSITION:  ,The patient is stable to be discharged to home.  Nurse should observe for 1 hour after lisinopril to make sure the blood pressure does not go too low.",
" Pressure decubitus, right hip", General Medicine, Pressure decubitus ,"CHIEF COMPLAINT:, Pressure decubitus, right hip.,HISTORY OF PRESENT ILLNESS:, This is a 30-year-old female patient presenting with the above chief complaint. She has a history of having had a similar problem last year which resolved in about three treatments. She appears to have residual from spina bifida, thus spending most of her time in a wheelchair. She relates recently she has been spending up to 16 hours a day in a wheelchair. She has developed a pressure decubitus on her right trochanter ischial area of several weeks' duration. She is now presenting for evaluation and management of same. Denies any chills or fever, any other symptoms.,PAST MEDICAL HISTORY:, Back closure for spina bifida, hysterectomy, breast reduction, and a shunt.,SOCIAL HISTORY:, She denies the use of alcohol, illicits, or tobacco.,MEDICATIONS:, Pravachol, Dilantin, Toprol, and Macrobid.,ALLERGIES:, SULFA AND LATEX.,REVIEW OF SYSTEMS:, Other than the above aforementioned, the remaining ROS is unremarkable.,PHYSICAL EXAMINATION:,GENERAL: A pleasant female with deformity of back.,HEENT: Head is normocephalic. Oral mucosa and dentition appear to be normal.,CHEST: Breath sounds equal and present bilateral.,CVS: Sinus.,GI: Obese, nontender, no hepatosplenomegaly.,EXTREMITIES: Deformity of lower extremities secondary to spina bifida.,SKIN: She has a full-thickness pressure decubitus involving the right hip which is 2 x 6.4 x 0.3, moderate amount of serous material, appears to have good granulation tissue.,PLAN:, Daily applications of Acticoat, pressure relief, at least getting out of the chair for half of the time, at least eight hours out of the chair, and we will see her in one week.,DIAGNOSIS:, Sequelae of spina bifida; pressure decubitus of right hip area.","general medicine, pressure decubitus, acticoat, sequelae, breast reduction, decubitus, hysterectomy, ischial area, pressure, spina bifida, trochanter, wheelchair, bifida, "
" Atypical pneumonia, hypoxia, rheumatoid arthritis, and suspected mild stress-induced adrenal insufficiency.  This very independent 79-year old had struggled with cough, fevers, weakness, and chills for the week prior to admission.", General Medicine, Pneumonia - Discharge Summary ,"ADMISSION DIAGNOSES:,1.  Pneumonia, failed outpatient treatment.,2.  Hypoxia.,3.  Rheumatoid arthritis.,DISCHARGE DIAGNOSES:,1.  Atypical pneumonia, suspected viral.,2.  Hypoxia.,3.  Rheumatoid arthritis.,4.  Suspected mild stress-induced adrenal insufficiency.,HOSPITAL COURSE: , This very independent 79-year old had struggled with cough, fevers, weakness, and chills for the week prior to admission.  She was seen on multiple occasions at Urgent Care and in her physician's office.  Initial x-ray showed some mild diffuse patchy infiltrates.  She was first started on Avelox, but had a reaction, switched to Augmentin, which caused loose stools, and then three days prior to admission was given daily 1 g Rocephin and started on azithromycin.  Her O2 saturations drifted downward.  They were less than 88% when active; at rest, varied between 88% and 92%.  Decision was made because of failed outpatient treatment of pneumonia.  Her medical history is significant for rheumatoid arthritis.  She is on 20 mg of methotrexate every week as well as Remicade every eight weeks.  Her last dose of Remicade was in the month of June.  Hospital course was relatively unremarkable.  CT scan was performed and no specific focal pathology was seen.  Dr. X, pulmonologist was consulted.  He also was uncertain as to the exact etiology, but viral etiology was most highly suspected.  Because of her loose stools, C. difficile toxin was ordered, although that is pending at the time of discharge.  She was continued on Rocephin IV and azithromycin.  Her fever broke 18 hours prior to discharge, and O2 saturations improved, as did her overall strength and clinical status.  She was instructed to finish azithromycin.  She has two pills left at home.  She is to follow up with Dr. X in two to three days.  Because she is on chronic prednisone therapy, it was suspected that she was mildly adrenal insufficient from the stress of her pneumonia.  She is to continue the increased dose of prednisone at 20 mg (up from 5 mg per day).  We will consult her rheumatologist as to whether to continue her methotrexate, which we held this past Friday.  Methotrexate is known on some occasions to cause pneumonitis.","general medicine, adrenal insufficiency, hypoxia, cough, fevers, weakness, chills, atypical pneumonia, loose stools, rheumatoid arthritis, azithromycin, arthritis, pneumonia, "
" Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit, hypertension, mild renal insufficiency, and anemia, which has been present chronically over the past year.", General Medicine, Pyelonephritis - Discharge Summary ,"ADMISSION DIAGNOSES:,1.  Pyelonephritis.,2.  History of uterine cancer and ileal conduit urinary diversion.,3.  Hypertension.,4.  Renal insufficiency.,5.  Anemia.,DISCHARGE DIAGNOSES:,1.  Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit.,2.  Hypertension.,3.  Mild renal insufficiency.,4.  Anemia, which has been present chronically over the past year.,HOSPITAL COURSE:,  The patient was admitted with suspected pyelonephritis.  Renal was consulted.  It was thought that there was a thick mucous plug in the Foley in the ileal conduit that was irrigated by Dr. X.  Her symptoms responded to IV antibiotics and she remained clinically stable.  Klebsiella was isolated in this urine, which was sensitive to Bactrim and she was discharged on p.o.  Bactrim.  She was scheduled on 08/07/2007 for further surgery.  She is to follow up with Dr. Y in 7-10 days.  She also complained of right knee pain and the right knee showed no sign of effusion.  She was exquisitely tender to touch of the patellar tendon.  It was thought that this did not represent intraarticular process.  She was advised to use ibuprofen over-the-counter two to three tabs t.i.d.","general medicine, uterine cancer, renal insufficiency, pyelonephritis, mucous plugging, ileal conduit "
 Patient in emergency room due to high potassium value., General Medicine, Patient with High Potassium ,"CHIEF COMPLAINT:, ""My potassium is high"",HISTORY OF PRESENT ILLNESS:, A 47-year-old Latin American man presented to the emergency room after being told to come in for a high potassium value drawn the previous day. He had gone to an outside clinic the day prior to presentation complaining of weakness and fatigue. Labs drawn there revealed a potassium of 7.0 and he was told to come here for further evaluation. At time of his assessment in the emergency room, he noted general malaise and fatigue for eight months. Over this same time period he had subjective fevers and chills, night sweats, and a twenty-pound weight loss. He described anorexia with occasional nausea and vomiting of non-bilious material along with a feeling of light-headedness that occurred shortly after standing from a sitting or lying position. He denied a productive cough but did note chronic left sided upper back pain located in the ribs that was worse with cough and better with massage. He denied orthopnea or paroxysmal nocturnal dyspnea but did become dyspneic after walking 2-3 blocks where before he had been able to jog 2-3 miles. He also noted that over the past year his left testicle had been getting progressively more swollen and painful. He had been seen for this at the onset of symptoms and given a course of antibiotics without improvement. Over the last several months there had been chronic drainage of yellowish material from this testicle. He denied trauma to this area. He denied diarrhea or constipation, changes in his urinary habits, rashes or skin changes, arthritis, arthralgias, abdominal pain, headache or visual changes.,PAST MEDICAL HISTORY:, None.,PAST SURGICAL HISTORY:, Mone.,MEDICATIONS:, Occasional acetaminophen.,ALLERGIES:, NKDA.,SOCIAL HISTORY:, He drank a 6 pack of beer per day for the past 30 years. He smoked a pack and a half of cigarettes per day for the past 35 years. He was currently unemployed but had worked as a mechanic and as a carpet layer in the past. He had been briefly incarcerated 5 years prior to admission. He denied intravenous drug use or unprotected sexual exposures.,FAMILY HISTORY:, There was a history of coronary artery disease and diabetes mellitus in the family.,PHYSICAL EXAM:,VITAL SIGNS - Temp 98.6° F, Respirations 16/minute Lying down - Blood pressure 109/70, pulse 70/minute Sitting - Blood pressure 78/65, pulse 79/minute Standing - Blood pressure 83/70, pulse 95/minute GENERAL: well developed, well nourished, no acute distress HEENT: Normocephalic, atraumatic. Sclerae anicteric. Oropharynx with hyperpigmented patches on the mucosa of the palate. No oral thrush. No lymphadenopathy. No jugular venous distension. No thyromegaly. Neck supple. LUNGS: Decreased intensity of breath sounds throughout without adventitious sounds. No dullness to percussion or changes in fremitus. CARDIOVASCULAR: Regular rate and rhythm. No murmurs, gallops, or rubs. Normal intensity of heart sounds. Normal peripheral pulses. ABDOMEN: Soft, non-tender, non-distended. Positive bowel sounds. No organomegaly. RECTAL: Normal sphincter tone. No masses. Normal prostate. Guaiac negative stool. GENITOURINARY: Left testicle indurated and painful to palpation with slight amount of pustular drainage expressible on anterior aspect. Right testicle normal. EXTREMITIES: Marked clubbing noted in fingers and toes. No cyanosis or edema. No rash or arthritis. LYMPHATICS: 1 x 1 cm mobile, firm, non-tender lymph node noted in left inguinal region. Otherwise no other palpable lymphadenopathy.,CHEST X-RAY:, Ill-defined reticular densities in both apices. No pleural effusions. Cardiomediastinal silhouette within normal range.,CHEST CT SCAN:, Multiple bilateral apical nodules/masses. Largest 3.2 x 1.6 cm in left apex. Several of these masses demonstrate spiculation. There is an associated 1 cm lymph node in the prevascular space as well as subcentimeter nodes in the pretracheal and subcarinal regions. There is a subcarinal node that demonstrates calcifications.,ABDOMINAL CT SCAN: ,Multiple hypodense lesions are noted throughout the liver. The right adrenal gland is full, measuring 1.0 x 2.3 cm. Otherwise the spleen, pancreas, left adrenal, and kidneys are free of gross mass. No significant lymphadenopathy or abnormal fluid collections are seen.,TESTICULAR ULTRASOUND: ,There is an enlarged irregular inhomogenous left epididymis with increased vascularity throughout the left epididymis and testis. There is a large septated hydrocele on the left. The right epididymis and testis is normal.,HOSPITAL COURSE:, The above-mentioned studies were obtained. Further laboratory tests and a diagnostic procedure were performed.","general medicine, potassium is high, chest x-ray, chest ct scan, abdominal ct scan, testicular ultrasound, lymph node, ct scan, blood pressure, abdominal, multiple, subcarinal, epididymis, potassium, lymphadenopathy, "
" Obesity hypoventilation syndrome.  A 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study.", General Medicine, Obesity Hypoventilation Syndrome ,"HISTORY OF PRESENT ILLNESS: , This is a 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study, on CPAP and oxygen to evaluate her for difficulty in initiating and maintaining sleep.  She returns today to review results of an inpatient study performed approximately two weeks ago.,In the meantime, the patient reports she continues on substantial doses of opiate medication to control leg pain from mononeuritis multiplex.,She also takes Lasix for lower extremity edema.,The patient reports that she generally initiates sleep on CPAP, but rips her mask off, tosses and turns throughout the night and has ""terrible quality sleep."",MEDICATIONS: , Current medications are as previously noted.  Changes include reduction in prednisone from 9 to 6 mg by mouth every morning.  She continues to take Ativan 1 mg every six hours as needed.  She takes imipramine 425 mg at bedtime.,Her MS Contin dose is 150 mg every 8 to 12 hours and an immediate release morphine preparation, 45 to 75 mg by mouth every 8 hours as needed.,FINDINGS: , Vital signs:  Blood pressure 153/81, pulse 90, respiratory rate 20, weight 311.8 pounds (up 10 pounds from earlier this month), height 5 feet 6 inches, temperature 98.4 degrees, SaO2 is 88% on room air at rest.  Chest is clear.  Extremities show lower extremity pretibial edema with erythema.,LABORATORIES: , An arterial blood gas on room air showed a pH of 7.38, PCO2 of 52, and PO2 of 57.,CPAP compliance monitoring over the past two to three weeks showed average use of 3 hours 26 minutes on nights used.  She used it for greater than 4 hours per night on 67% of night surveyed.  Her estimated apnea/hypopnea index was 3 per hour.  Her average leak flow was 67 liters per minute.,The patient's overnight sleep study was performed as an inpatient sleep study during a routine hospitalization for intravenous gamma globulin therapy.  She slept for a total sleep time of 257 minutes out of 272 minutes in bed (sleep efficiency approximately 90%).  Sleep stage distribution was relatively normal with 2% stage I, 72% stage II, 24% stage III, IV, and 2% stage REM sleep.,There were no periodic limb movements during sleep.,There was evidence of a severe predominantly central sleep apnea during non-REM sleep at 173 episodes per hour and during REM sleep at 77 episodes per hour.  Oxyhemoglobin saturations during non-REM sleep fluctuated from the baseline of 92% to an average low of 82%.  During REM sleep, the baseline oxyhemoglobin saturation was 87% , decreased to 81% with sleep-disordered breathing episodes.,Of note, the sleep study was performed on CPAP at 10.5 cm of H2O with oxygen at 8 liters per minute.,ASSESSMENT:,1.  Obesity hypoventilation syndrome.  The patient has evidence of a well-compensated respiratory acidosis, which is probably primarily related to severe obesity.  In addition, there may be contribution from large doses of opiates and standing doses of gabapentin.,2.  Severe central sleep apnea, on CPAP at 10 cmH2O and supplemental oxygen at 8 liters per minute.  The breathing pattern is that of cluster or Biot's breathing throughout sleep.  The primary etiology is probably opiate use, with contribution with further exacerbation by severe obesity which acts to lower the baseline oxyhemoglobin saturation, and worsen desaturations during apneic episodes.,3.  Mononeuritis multiplex with pain requiring significant substantial doses of analgesia.,4.  Hypoxemia primarily due to obesity, hypoventilation, and presumably basilar atelectasis and a combination of V/Q mismatch and shunt on that basis.,PLANS: , My overall impression is that we should treat this patient's sleep disruption with measures to decrease central sleep apnea during sleep.  These will include, (1).  Decrease in evening doses of MS Contin, (2).  Modest weight loss of approximately 10 to 20 pounds, and (3).  Instituting Automated Servo Ventilation via nasal mask.  With regard to latter, the patient will be returning for a trial of ASV to examine its effect on sleep-disordered breathing patterns.,In addition, the patient will benefit from modest diuresis, with improvement of oxygenation, as well as nocturnal desaturation and oxygen requirements.  I have encouraged the patient to increase her dose of Lasix from 100 to 120 mg by mouth every morning as previously prescribed.  I have also asked her to add Lasix in additional late afternoon to evening dose of Lasix at 40 mg by mouth at that time.  She was instructed to take between one and two K-Tab with her evening dose of Lasix (10 to 20 mEq).,In addition, we will obtain a complete set of pulmonary function studies to evaluate this patient for underlying causes of parenchymal lung disease that may interfere with oxygenation.  Further workup for hypoxemia may include high-resolution CT scanning if evidence for significant pulmonary restriction and/or reductions in diffusion capacity is evident on pulmonary function testing.","general medicine, polyarteritis nodosa, obesity hypoventilation syndrome, pulmonary function, obesity hypoventilation, mononeuritis multiplex, sleep apnea, sleep study, rem sleep, ativan, sleep, hypoventilation, obesity, "
 A 47-year-old white female presents with concern about possible spider bite to the left side of her neck., General Medicine, Possible Spider Bite ,"SUBJECTIVE:,  This 47-year-old white female presents with concern about possible spider bite to the left side of her neck.  She is not aware of any specific injury.  She noticed a little tenderness and redness on her left posterior shoulder about two days ago.  It seems to be getting a little bit larger in size, and she saw some red streaks extending up her neck.  She has had no fever.  The area is very minimally tender, but not particularly so.,CURRENT MEDICATIONS:,  Generic Maxzide, Climara patch, multivitamin, Tums, Claritin, and vitamin C.,ALLERGIES:,  No known medicine allergies.,OBJECTIVE:,Vital Signs:  Weight is 150 pounds.  Blood pressure 122/82.,Extremities:  Examination of the left posterior shoulder near the neckline is an area of faint erythema which is 6 cm in diameter.  In the center is a tiny mark which could certainly be an insect or spider bite.  There is no eschar there, but just a tiny marking.  There are a couple of erythematous streaks extending towards the neck.,ASSESSMENT:,  Possible insect bite with lymphangitis.,PLAN:,1.  Duricef 1 g daily for seven days.,2.  Cold packs to the area.,3.  Discussed symptoms that were suggestive of the worsening, in which case she would need to call me.,4.  Incidentally, she has noticed a little bit of dryness and redness on her eyelids, particularly the upper ones’ and the lower lateral areas.  I suspect she has a mild contact dermatitis and suggested hydrocortisone 1% cream to be applied sparingly at bedtime only.","general medicine, spider bite, injury, tenderness, redness, insect bite, lymphangitis, streaks, spider, neck, bite,"
" This is a 53-year-old man, who presented to emergency room with multiple complaints including pain from his hernia, some question of blood in his stool, nausea, and vomiting, and also left lower extremity pain. ", General Medicine, Pain from Hernia - ER Consult ,"HISTORY OF PRESENT ILLNESS:  ,This is a 53-year-old man, who presented to emergency room with multiple complaints including pain from his hernia, some question of blood in his stool, nausea, and vomiting, and also left lower extremity pain.  At the time of my exam, he states that his left lower extremity pain has improved considerably.  He apparently had more significant paresthesias in the past and now he feels that the paresthesias have improved considerably.  He does have a history of multiple medical problems including atrial fibrillation, he is on Coumadin, which is currently subtherapeutic, multiple CVAs in the past, peripheral vascular disease, and congestive heart failure.  He has multiple chronic history of previous ischemia of his large bowel in the past.,PHYSICAL EXAM,VITAL SIGNS:  Currently his temperature is 98.2, pulse is 95, and blood pressure is 138/98.,HEENT:  Unremarkable.,LUNGS:  Clear.,CARDIOVASCULAR:  An irregular rhythm.,ABDOMEN:  Soft.,EXTREMITIES:  His upper extremities are well perfused.  He has palpable radial and femoral pulses.  He does not have any palpable pedal pulses in either right or left lower extremity.  He does have reasonable capillary refill in both feet.  He has about one second capillary refill on both the right hand and left lower extremities and his left foot is perhaps little cool, but it is relatively warm.  Apparently, this was lot worst few hours ago.  He describes significant pain and pallor, which he feels has improved and certainly clinically at this point does not appear to be as significant.,IMPRESSION AND PLAN: , This gentleman with a history of multiple comorbidities as detailed above had what sounds clinically like acute exacerbation of chronic peripheral vascular disease, essentially related to spasm versus a small clot, which may have been lysed to some extent.  He currently has a viable extremity and viable foot, but certainly has significant making compromised flow.  It is unclear to me whether this is chronic or acute, and whether he is a candidate for any type of intervention.  He certainly would benefit from an angiogram to better to define his anatomy and anticoagulation in the meantime.  Given his potential history of recent lower GI bleeding, he has been evaluated by GI to see whether or not he is a candidate for heparinization.  We will order an angiogram for the next few hours and followup on those results to better define his anatomy and to determine whether or not if any interventions are appropriate.  Again, at this point, he has no pain, relatively rapid capillary refill, and relatively normal motor function suggesting a viable extremity.  We will follow him along closely.","general medicine, blood in stool, nausea, capillary refill, angiogram, hernia, extremity, "
 A 93-year-old female called up her next-door neighbor to say that she was not feeling well.  The patient was given discharge instructions on dementia and congestive heart failure and asked to return to the emergency room should she have any new problems or symptoms of concern., General Medicine, Not Feeling Well - ER Visit ,"CHIEF COMPLAINT:  ,The patient does not have any chief complaint.,HISTORY OF PRESENT ILLNESS:,  This is a 93-year-old female who called up her next-door neighbor to say that she was not feeling well.  The next-door neighbor came over and decided that she should go to the emergency room to be check out for her generalized complaint of not feeling well.  The neighbor suspects that this may have been due to the patient taking too many of her Tylenol PM, which the patient has been known to do.  The patient was a little somnolent early this morning and was found only to be oriented x1 with EMS upon their arrival to the patient's house.  The patient states that she just simply felt funny and does not give any more specific details than this.  The patient denies any pain at any time.  She did not have any shortness of breath.  No nausea or vomiting.  No generalized weakness.  The patient states that all that has gone away since arrival here in the hospital, that she feels at her usual self, is not sure why she is here in the hospital, and thinks she should go.  The patient's primary care physician, Dr. X reports that the patient spoke with him yesterday and had complained of shortness of breath, nausea, dizziness, as well as generalized weakness, but the patient states that all this has resolved.  The patient was actually seen here two days ago for those same symptoms and was found to have exacerbation of her COPD and CHF.  The patient was discharged home after evaluation in the emergency room.  The patient does use home O2.,REVIEW OF SYSTEMS: , CONSTITUTIONAL:  The patient had complained of generalized fatigue and weakness two days ago in the emergency room and yesterday to her primary care physician.  The patient denies having any other symptoms today.  The patient denies any fever or chills.  Has not had any recent weight change.  HEENT:  The patient denies any headache.  No neck pain.  No rhinorrhea.  No sinus congestion.  No sore throat.  No any vision or hearing change.  No eye or ear pain.  CARDIOVASCULAR:  The patient denies any chest pain.  RESPIRATIONS:  No shortness of breath.  No cough.  No wheeze.  The patient did report having shortness of breath and wheeze with her presentation to the emergency room two days ago and shortness of breath to her primary care physician yesterday, but the patient states that all this has resolved.  GASTROINTESTINAL:  No abdominal pain.  No nausea or vomiting.  No change in the bowel movements.  There has not been any diarrhea or constipation.  No melena or hematochezia.  GENITOURINARY:  No dysuria, hematuria, urgency, or frequency.  MUSCULOSKELETAL:  No back pain.  No muscle or joint aches.  No pain or abnormalities to any portion of the body.  SKIN:  No rashes or lesions.  NEUROLOGIC:  The patient reported dizziness to her primary care physician yesterday over the phone, but the patient denies having any problems with dizziness over the past few days.  The patient denies any dizziness at this time.  No syncope or no near-syncope.  The patient denies any focal weakness or numbness.  No speech change.  No difficulty with ambulation.  The patient has not had any vision or hearing change.  PSYCHIATRIC:  The patient denies any depression.  ENDOCRINE:  No heat or cold intolerance.,PAST MEDICAL HISTORY:,  COPD, CHF, hypertension, migraines, previous history of depression, anxiety, diverticulitis, and atrial fibrillation.,PAST SURGICAL HISTORY:,  Placement of pacemaker and hysterectomy.,CURRENT MEDICATIONS: , The patient takes Tylenol PM for insomnia, Lasix, Coumadin, Norvasc, Lanoxin, Diovan, atenolol, and folic acid.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient used to smoke, but quit approximately 30 years ago.  The patient denies any alcohol or drug use although her son reports that she has had a long history of this in the past and the patient has abused prescription medication in the past as well according to her son.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Temperature 99.1 oral, blood pressure 139/65, pulse is 72, respirations 18, and oxygen saturation is 92% on room air and interpreted as low normal.  CONSTITUTIONAL:  The patient is well nourished and well developed.  The patient appears to be healthy.  The patient is calm, comfortable, in no acute distress, and looks well.  The patient is pleasant and cooperative.  HEENT:  Head is atraumatic, normocephalic, and nontender.  Eyes are normal with clear sclerae and cornea bilaterally.  Nose is normal without rhinorrhea or audible congestion.  Mouth and oropharynx are normal without any sign of infection.  Mucous membranes are moist.  NECK:  Supple and nontender.  Full range of motion.  There is no JVD.  No cervical lymphadenopathy.  No carotid artery or vertebral artery bruits.  CARDIOVASCULAR:  Heart is regular rate and rhythm without murmur, rub or gallop.  Peripheral pulses are +2.  The patient does have +1 bilateral lower extremity edema.  RESPIRATIONS:  The patient has coarse breath sounds bilaterally, but no dyspnea.  Good air movement.  No wheeze.  No crackles.  The patient speaks in full sentences without any difficulty.  The patient does not exhibit any retractions, accessory muscle use or abdominal breathing.  GASTROINTESTINAL:  Abdomen is soft, nontender, and nondistended.  No rebound or guarding.  No hepatosplenomegaly.  Normal bowel sounds.  No bruits, no mass, no pulsatile mass, and no inguinal lymphadenopathy.  MUSCULOSKELETAL:  No abnormalities noted to the back, arms or legs.  SKIN:  No rashes or lesions.  NEUROLOGICAL:  Cranial nerves II through XII are intact.  Motor is 5/5 and equal to bilateral arms and legs.  Sensory is intact to light touch.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is awake, alert, and oriented x3 although the patient first stated that the year was 1908, but did manage to correct herself up on addressing this with her.  The patient has normal mood and affect.  HEMATOLOGIC AND LYMPHATIC:  There is no evidence of lymphadenopathy.,EMERGENCY DEPARTMENT TESTING: , EKG is a rate of 72 with evidence of a pacemaker that has good capture.  There is no evidence of acute cardiac disease on the EKG and there is no apparent change in the EKG from 03/17/08.  CBC has no specific abnormalities of issue.  Chemistry has a BUN of 46 and creatinine of 2.25, glucose is 135, and an estimated GFR is 20.  The rest of the values are normal and unremarkable.  LFTs are all within normal limits.  Cardiac enzymes are all within normal limits.  Digoxin level is therapeutic at 1.6.  Chest x-ray noted cardiomegaly and evidence of congestive heart failure, but no acute change from her chest x-ray done two days ago.  CAT scan of the head did not identify any acute abnormalities.  I spoke with the patient's primary care physician, Dr. X who stated that he would be able to follow up with the patient within the next day.  I spoke with the patient's neighbor who contacted the ambulance service who stated that the patient just reported not feeling well and appeared to be a little somnolent and confused at the time, but suspected that she may have taken too many of her Tylenol PM as she often has done in the past.  The neighbor is XYZ and he says that he checks on her three times a day every day.  ABC is the patient's son and although he lives out of town he calls and checks on her every day as well.  He states that he spoke to her yesterday.  She sounded fine, did not express any other problems that she had apparently been in contact with her primary care physician.  She sounded her usual self to him.  Mr. ABC also spoke to the patient while she was here in the emergency room and she appears to be her usual self and has her normal baseline mental status to him.  He states that he will be able to check on her tomorrow as well.  Although it is of some concern that there may be problems with development of some early dementia, the patient is adamant about not going to a nursing home and has been placed in a Nursing Home in the past, but Dr. Y states that she has managed to be discharged after two previous nursing home placements.  The patient does have Home Health that checks on her as well as housing care in between the two services they share visits every single day  by them as well as the neighbor who checks on her three times a day and her son who calls her each day as well.  The patient although she lives alone, does appear to have good followup and the patient is adamant that she wishes to return home.,DIAGNOSES,1.  EARLY DEMENTIA.,2.",
" Normal review of systems template.  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.", General Medicine, Normal ROS Template - 5 ,"REVIEW OF SYSTEMS,GENERAL:  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.,INTEGUMENTARY:  Negative rash, negative jaundice.,HEMATOPOIETIC:  Negative bleeding, negative lymph node enlargement, negative bruisability.,NEUROLOGIC:  Negative headaches, negative syncope, negative seizures, negative weakness, negative tremor.  No history of strokes, no history of other neurologic conditions.,EYES:  Negative visual changes, negative diplopia, negative scotomata, negative impaired vision.,EARS:  Negative tinnitus, negative vertigo, negative hearing impairment.,NOSE AND THROAT:  Negative postnasal drip, negative sore throat.,CARDIOVASCULAR:  Negative chest pain, negative dyspnea on exertion, negative palpations, negative edema.  No history of heart attack, no history of arrhythmias, no history of hypertension.,RESPIRATORY:  No history of shortness of breath, no history of asthma, no history of chronic obstructive pulmonary disease, no history of obstructive sleep apnea.,GASTROINTESTINAL:  Negative dysphagia, negative nausea, negative vomiting, negative hematemesis, negative abdominal pain.,GENITOURINARY:  Negative frequency, negative urgency, negative dysuria, negative incontinence.  No history of STDs.  **No history of OB/GYN problems.,MUSCULOSKELETAL:  Negative myalgia, negative joint pain, negative stiffness, negative weakness, negative back pain.,PSYCHIATRIC:  See psychiatric evaluation.,ENDOCRINE:  No history of diabetes mellitus, no history of thyroid problems, no history of endocrinologic abnormalities.","general medicine, respiratory, gastrointestinal, integumentary, hematopoietic, night sweats, negative allergies, negative weakness, neurologic, throat, weakness"
" Negative for any nausea, vomiting, fevers, chills, or weight loss.", General Medicine, Normal ROS Template - 4 ,"GENERAL:  Negative for any nausea, vomiting, fevers, chills, or weight loss.,NEUROLOGIC:  Negative for any blurry vision, blind spots, double vision, facial asymmetry, dysphagia, dysarthria, hemiparesis, hemisensory deficits, vertigo, ataxia.,HEENT:  Negative for any head trauma, neck trauma, neck stiffness, photophobia, phonophobia, sinusitis, rhinitis.,CARDIAC:  Negative for any chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, peripheral edema.,PULMONARY:  Negative for any shortness of breath, wheezing, COPD, or TB exposure.,GASTROINTESTINAL:  Negative for any abdominal pain, nausea, vomiting, bright red blood per rectum, melena.,GENITOURINARY:  Negative for any dysuria, hematuria, incontinence.,INTEGUMENTARY:  Negative for any rashes, cuts, insect bites.,RHEUMATOLOGIC:  Negative for any joint pains, photosensitive rashes, history of vasculitis or kidney problems.,HEMATOLOGIC:  Negative for any abnormal bruising, frequent infections or bleeding.","general medicine, review of systems, trauma, neck, dyspnea, rashes, nausea, vomiting, "
" Normal physical exam template.  Normal appearance for chronological age, does not appear chronically ill.", General Medicine, Normal Physical Exam Template - 6 ,"VITAL SIGNS:,  Reveal a blood pressure of *, temperature of *, respirations *, and pulse of *.,CONSTITUTIONAL: , Normal appearance for chronological age, does not appear chronically ill.,HEENT: , The pupils are equal and reactive.  Funduscopic examination is normal.  Posterior pharynx is normal.  Tympanic membranes are clear.,NECK:  ,Trachea is midline.  Thyroid is normal.  The neck is supple.  Negative nodes.,RESPIRATORY:,  Lungs are clear to auscultation bilaterally.  The patient has a normal respiratory rate, no signs of consolidation and no egophony.  There are no retractions or secondary muscle use.  Good bilateral breath sounds are noted.,CARDIOVASCULAR: , No jugular venous distention or carotid bruits.  No increase in heart size to percussion.  There is no murmur.  Normal S1 and S2 sounds are noted without gallop.,ABDOMEN: , Soft to palpation in all four quadrants.  There is no organomegaly and no rebound tenderness.  Bowel sounds are normal.  Obturator and psoas signs are negative.,GENITOURINARY: , No bladder tenderness, negative flank pain.,MUSCULOSKELETAL:,  Extremities are normal with good motor tone and strength, normal reflexes, and normal joint strength and sensation.,NEUROLOGIC: , Normal Glasgow Coma Scale.  Cranial nerves II through XII appear grossly intact.  Normal motor and cerebellar tests.  Reflexes are normal.,HEME/LYMPH:  ,No abnormal lymph nodes, no signs of bleeding, skin purpura, petechiae or hemorrhage.,PSYCHIATRIC: , Normal with no overt depression or suicidal ideations.","general medicine, jugular venous distention, flank, bladder, normal physical exam, neck, nodes, respiratory, tenderness, motor, strength, reflexes, sounds, "
" Normal review of systems template.  No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter.", General Medicine, Normal ROS Template - 3 ,"HEENT:,  No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter.,RESPIRATORY: , No shortness of breath, wheezing, dyspnea, pulmonary disease, tuberculosis or past pneumonias.,CARDIOVASCULAR: , No history of palpitations, irregular rhythm, chest pain, hypertension, hyperlipidemia, diaphoresis, congestive heart failure, heart catheterization, stress test or recent cardiac tests.,GASTROINTESTINAL:,  No history of rectal bleeding, appetite change, abdominal pain, hiatal hernia, ulcer, jaundice, change in bowel habits or liver problems, and no history of inflammatory bowel problems.,GENITOURINARY: , No dysuria, hematuria, frequency, incontinence or colic.,NERVOUS SYSTEM: , No gait problems, strokes, numbness or muscle weakness.,PSYCHIATRIC: , No history of emotional lability, depression or sleep disturbances.,ONCOLOGIC:,  No history of any cancer, change in moles or rashes.  No history of weight loss.  The patient has a good energy level.,ALLERGIC/LYMPH: , No history of systemic allergy, abnormal lymph nodes or swelling.,MUSCULOSKELETAL: , No fractures, motor weakness, arthritis or other joint pains.","general medicine, review of systems, tinnitus, sinusitis, sore, mouth, hoarseness, goiter, heart, appetite, bowel, weakness, loss, swelling,"
 Most commonly used phrases in physical exam., General Medicine, Normal Physical Exam Template - 7 ,"EYES: , The conjunctivae are clear.  The lids are normal appearing without evidence of chalazion or hordeolum.  The pupils are round and reactive.  The irides are without any obvious lesions noted.  Funduscopic examination shows sharp disk margins.  There are no exudates or hemorrhages noted.  The vessels are normal appearing.,EARS, NOSE, MOUTH AND THROAT:,  The nose is without any evidence of any deformity.  The ears are with normal-appearing pinna.  Examination of the canals is normal appearing bilaterally.  There is no drainage or erythema noted.  The tympanic membranes are normal appearing with pearly color, normal-appearing landmarks and normal light reflex.  Hearing is grossly intact to finger rubbing and whisper.  The nasal mucosa is moist.  The septum is midline.  There is no evidence of septal hematoma.  The turbinates are without abnormality.  No obvious abnormalities to the lips.  The teeth are unremarkable.  The gingivae are without any obvious evidence of infection.  The oral mucosa is moist and pink.  There are no obvious masses to the hard or soft palate.  The uvula is midline.  The salivary glands appear unremarkable.  The tongue is midline.  The posterior pharynx is without erythema or exudate.  The tonsils are normal appearing.,NECK:,  The neck is nontender and supple.  The trachea is midline.  The thyroid is without any evidence of thyromegaly.  No obvious adenopathy is noted to the neck.,RESPIRATORY: , The patient has normal respiratory effort.  There is normal lung excursion.  Percussion of the chest is without any obvious dullness.  There is no tactile fremitus or egophony noted.  There is no tenderness to the chest wall or ribs.  There are no obvious abnormalities.  The lungs are clear to auscultation.  There are no wheezes, rales or rhonchi heard.  There are no obvious rubs noted.,CARDIOVASCULAR: , There is a normal PMI on palpation.  I do not hear any obvious abnormal sounds.  There are no obvious murmurs.  There are no rubs or gallops noted.  The carotid arteries are without bruit.  No obvious thrill is palpated. There is no evidence of enlarged abdominal aorta to palpation.  There is no abdominal mass to suggest enlargement of the aorta.  Good strong femoral pulses are palpated.  The pedal pulses are intact.  There is no obvious edema noted to the extremities.  There is no evidence of any varicosities or phlebitis noted.,GASTROINTESTINAL: , The abdomen is soft.  Bowel sounds are present in all quadrants.  There are no obvious masses.  There is no organomegaly, and no liver or spleen is palpable.  No obvious hernia is noted.  The perineum and anus are normal in appearance.  There is good sphincter tone and no obvious hemorrhoids are noted.  There are no masses.  On digital examination, there is no evidence of any tenderness to the rectal vault; no lesions are noted.  Stool is brown and guaiac negative.,GENITOURINARY (FEMALE): , The external genitalia is normal appearing with no obvious lesions, no evidence of any unusual rash.  The vagina is normal in appearance with normal-appearing mucosa.  The urethra is without any obvious lesions or discharge.  The cervix is normal in color with no obvious cervical discharge.  There are no obvious cervical lesions noted.  The uterus is nontender and small, and there is no evidence of any adnexal masses or tenderness.  The bladder is nontender to palpation.  It is not enlarged.,GENITOURINARY (MALE): , Normal scrotal contents are noted.  The testes are descended and nontender.  There are no masses and no swelling to the epididymis noted.  The penis is without any lesions.  There is no urethral discharge.  Digital examination of the prostate reveals a nontender, non-nodular prostate.,BREASTS:,  The breasts are normal in appearance.  There is no puckering noted.  There is no evidence of any nipple discharge.  There are no obvious masses palpable.  There is no axillary adenopathy.  The skin is normal appearing over the breasts.,LYMPHATICS: , There is no evidence of any adenopathy to the anterior cervical chain.  There is no evidence of submandibular nodes noted.  There are no supraclavicular nodes palpable.  The axillae are without any abnormal nodes.  No inguinal adenopathy is palpable.  No obvious epitrochlear nodes are noted.,MUSCULOSKELETAL/EXTREMITIES: , The patient has normal gait and station.  The patient has normal muscle strength and tone to all extremities.  There is no obvious evidence of any muscle atrophy.  The joints are all stable.  There is no evidence of any subluxation or laxity to any of the joints.  There is no evidence of any dislocation.  There is good range of motion of all extremities without any pain or tenderness to the joints or extremities.  There is no evidence of any contractures or crepitus.  There is no evidence of any joint effusions.  No obvious evidence of erythema overlying any of the joints is noted.  There is good range of motion at all joints.  There are normal-appearing digits.  There are no obvious lesions to any of the nails or nail beds.,SKIN:,  There is no obvious evidence of any rash.  There are no petechiae, pallor or cyanosis noted.  There are no unusual nodules or masses palpable.,NEUROLOGIC: , The cranial nerves II XII are tested and are intact.  Deep tendon reflexes are symmetrical bilaterally.  The toes are downgoing with normal Babinskis.  Sensation to light touch is intact and symmetrical.  Cerebellar testing reveals normal finger nose, heel shin.  Normal gait.  No ataxia.,PSYCHIATRIC:  ,The patient is oriented to person, place and time.  The patient is also oriented to situation.  Mood and affect are appropriate for the present situation.  The patient can remember 3 objects after 3 minutes without any difficulties.  Remote memory appears to be intact.  The patient seems to have normal judgment and insight into the situation.","general medicine, ears, nose, mouth, neck, respiratory, cardiovascular, eyes, gastrointestinal, genitourinary, breasts, lymphatics, musculoskeletal, extremities, skin, neurologic, psychiatric, normal appearing, physical exam, examination, "
" Normal review of systems template.  The patient denies fever, fatigue, weakness, weight gain or weight loss.", General Medicine, Normal ROS Template ,"REVIEW OF SYSTEMS,GENERAL/CONSTITUTIONAL: , The patient denies fever, fatigue, weakness, weight gain or weight loss.,HEAD, EYES, EARS, NOSE AND THROAT:,  Eyes - The patient denies pain, redness, loss of vision, double or blurred vision, flashing lights or spots, dryness, the feeling that something is in the eye and denies wearing glasses.  Ears, nose, mouth and throat.  The patient denies ringing in the ears, loss of hearing, nosebleeds, loss of sense of smell, dry sinuses, sinusitis, post nasal drip, sore tongue, bleeding gums, sores in the mouth, loss of sense of taste, dry mouth, dentures or removable dental work, frequent sore throats, hoarseness or constant feeling of a need to clear the throat when nothing is there, waking up with acid or bitter fluid in the mouth or throat, food sticking in throat when swallows or painful swallowing.,CARDIOVASCULAR: , The patient denies chest pain, irregular heartbeats, sudden changes in heartbeat or palpitation, shortness of breath, difficulty breathing at night, swollen legs or feet, heart murmurs, high blood pressure, cramps in his legs with walking, pain in his feet or toes at night or varicose veins.,RESPIRATORY: , The patient denies chronic dry cough, coughing up blood, coughing  up mucus, waking at night coughing or choking, repeated pneumonias, wheezing or night sweats.,GASTROINTESTINAL: , The patient denies decreased appetite, nausea, vomiting, vomiting blood or coffee ground material, heartburn, regurgitation, frequent belching, stomach pain relieved by food, yellow jaundice, diarrhea, constipation, gas, blood in the stools, black tarry stools or hemorrhoids.,GENITOURINARY:  ,The patient denies difficult urination, pain or burning with urination, blood in the urine, cloudy or smoky urine, frequent need to urinate, urgency, needing to urinate frequently at night, inability to hold the urine, discharge from the penis, kidney stones, rash or ulcers, sexual difficulties, impotence or prostate trouble, no sexually transmitted diseases.,MUSCULOSKELETAL: , The patient denies arm, buttock, thigh or calf cramps.  No joint or muscle pain.  No muscle weakness or tenderness.  No joint swelling, neck pain, back pain or major orthopedic injuries.,SKIN AND BREASTS:  ,The patient denies easy bruising, skin redness, skin rash,  hives, sensitivity to sun exposure, tightness, nodules or bumps, hair loss, color changes in the hands or feet with cold, breast lump, breast pain or nipple discharge.,NEUROLOGIC: , The patient denies headache, dizziness, fainting, muscle spasm, loss of consciousness, sensitivity or pain in the hands and feet or memory loss.,PSYCHIATRIC:  ,The patient denies depression with thoughts of suicide, voices in ?? head telling ?? to do things and has not been seen for psychiatric counseling or treatment.,ENDOCRINE: , The patient denies intolerance to hot or cold temperature, flushing, fingernail changes, increased thirst, increased salt intake or decreased sexual desire.,HEMATOLOGIC/LYMPHATIC:  ,The patient denies anemia, bleeding tendency or clotting tendency.,ALLERGIC/IMMUNOLOGIC: , The patient denies rhinitis, asthma, skin sensitivity, latex allergies or sensitivity.","general medicine, cardiovascular, ears, eyes, gastrointestinal, head, nose, respiratory, review of systems, denies fever, blood, tongue, loss, "
" Normal physical exam template.  Normocephalic.  Negative lesions, negative masses.", General Medicine, Normal Physical Exam Template - 4 ,"GENERAL:  ,XXX,VITAL SIGNS: , Blood pressure XXX, pulse XXX, temperature XXX, respirations XXX.  Height XXX, weight XXX.,HEAD: , Normocephalic.  Negative lesions, negative masses.,EYES: , PERLA, EOMI.  Sclerae clear.  Negative icterus, negative conjunctivitis.,ENT:,  Negative nasal hemorrhages, negative nasal obstructions, negative nasal exudates.  Negative ear obstructions, negative exudates.  Negative inflammation in external auditory canals.  Negative throat inflammation or masses.,SKIN: , Negative rashes, negative masses, negative ulcers.  No tattoos.,NECK:,  Negative palpable lymphadenopathy, negative palpable thyromegaly, negative bruits.,HEART:,  Regular rate and rhythm.  Negative rubs, negative gallops, negative murmurs.,LUNGS:,  Clear to auscultation.  Negative rales, negative rhonchi, negative wheezing.,ABDOMEN: , Soft, nontender, adequate bowel sounds.  Negative palpable masses, negative hepatosplenomegaly, negative abdominal bruits.,EXTREMITIES: , Negative inflammation, negative tenderness, negative swelling, negative edema, negative cyanosis, negative clubbing.  Pulses adequate bilaterally.,MUSCULOSKELETAL:,  Negative muscle atrophy, negative masses.  Strength adequate bilaterally.  Negative movement restriction, negative joint crepitus, negative deformity.,NEUROLOGIC: , Cranial nerves I through XII intact.  Negative gait disturbance.  Balance and coordination intact.  Negative Romberg, negative Babinski.  DTRs equal bilaterally.,GENITOURINARY:  ,Deferred.,", 
" Normal physical exam template.  Well developed, well nourished, in no acute distress.", General Medicine, Normal Physical Exam Template - 3 ,"PHYSICAL EXAMINATION,GENERAL APPEARANCE: , Well developed, well nourished, in no acute distress.,VITAL SIGNS:,  ***,SKIN:  ,Inspection of the skin reveals no rashes, ulcerations or petechiae.,HEENT:,  The sclerae were anicteric and conjunctivae were pink and moist.  Extraocular movements were intact and pupils were equal, round, and reactive to light with normal accommodation.  External inspection of the ears and nose showed no scars, lesions, or masses.  Lips, teeth, and gums showed normal mucosa.  The oral mucosa, hard and soft palate, tongue and posterior pharynx were normal.,NECK:  ,Supple and symmetric.  There was no thyroid enlargement, and no tenderness, or masses were felt.,CHEST: , Normal AP diameter and normal contour without any kyphoscoliosis.,LUNGS: , Auscultation of the lungs revealed normal breath sounds without any other adventitious sounds or rubs.,CARDIOVASCULAR:  ,There was a regular rate and rhythm without any murmurs, gallops, rubs.  The carotid pulses were normal and 2+ bilaterally without bruits.  Peripheral pulses were 2+ and symmetric.,ABDOMEN:  ,Soft and nontender with normal bowel sounds.  The liver span was approximately 5-6 cm in the right midclavicular line by percussion.  The liver edge was nontender.  The spleen was not palpable.  There were no inguinal or umbilical hernias noted.  No ascites was noted.,RECTAL:  ,Normal perineal exam.  Sphincter tone was normal.  There was no external hemorrhoids or rectal masses.  Stool Hemoccult was negative.  The prostate was normal size without any nodules appreciated (men only).,LYMPH NODES: , No lymphadenopathy was appreciated in the neck, axillae or groin.,MUSCULOSKELETAL: , Gait was normal.  There was no tenderness or effusions noted.  Muscle strength and tone were normal.,EXTREMITIES: , No cyanosis, clubbing or edema.,NEUROLOGIC:  ,Alert and oriented x 3.  Normal affect.  Gait was normal.  Normal deep tendon reflexes with no pathological reflexes.  Sensation to touch was normal.", 
" There was no weight loss, fevers, chills, sweats.  There is no blurring of the vision, itching, throat or neck pain, or neck fullness.  There is no vertigo or hoarseness or painful swallowing. ", General Medicine, Normal ROS Template - 1 ,"REVIEW OF SYSTEMS,There was no weight loss, fevers, chills, sweats.  There is no blurring of the vision, itching, throat or neck pain, or neck fullness.  There is no vertigo or hoarseness or painful swallowing.  There is no chest pain, shortness of breath, paroxysmal nocturnal dyspnea, or chest pain with exertion.  There is no shortness of breath and no cough or hemoptysis.  No melena, nausea, vomiting, dysphagia, abdominal pain, diarrhea, constipation or blood in the stools.  No dysuria, hematuria or excessive urination.  No muscle weakness or tenderness.  No new numbness or tingling.  No arthralgias or arthritis.  There are no rashes.  No excessive fatigability, loss of motor skills or sensation.  No changes in hair texture, change in skin color, excessive or decreased appetite.  No swollen lymph nodes or night sweats.  No headaches.  The rest of the review of systems is negative.","general medicine, weight loss, fevers, chills, sweats, melena, nausea, vomiting, dysphagia, abdominal pain, diarrhea, constipation, itching throat, neck fullness, painful swallowing, breath, loss, neckNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Normal review of systems template.  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.", General Medicine, Normal ROS Template - 2 ,"GENERAL:,  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.,INTEGUMENTARY: , Negative rash, negative jaundice.,HEMATOPOIETIC: , Negative bleeding, negative lymph node enlargement, negative bruisability.,NEUROLOGIC: , Negative headaches, negative syncope, negative seizures, negative weakness, negative tremor.  No history of strokes, no history of other neurologic conditions.,EYES:,  Negative visual changes, negative diplopia, negative scotomata, negative impaired vision.,EARS: , Negative tinnitus, negative vertigo, negative hearing impairment.,NOSE AND THROAT:  ,Negative postnasal drip, negative sore throat.,CARDIOVASCULAR: , Negative chest pain, negative dyspnea on exertion, negative palpations, negative edema.  No history of heart attack, no history of arrhythmias, no history of hypertension.,RESPIRATORY:,  No history of shortness of breath, no history of asthma, no history of chronic obstructive pulmonary disease, no history of obstructive sleep apnea.,GASTROINTESTINAL: , Negative dysphagia, negative nausea, negative vomiting, negative hematemesis, negative abdominal pain.,GENITOURINARY: , Negative frequency, negative urgency, negative dysuria, negative incontinence.  No history of STDs.,MUSCULOSKELETAL:,  Negative myalgia, negative joint pain, negative stiffness, negative weakness, negative back pain.,PSYCHIATRIC: , See psychiatric evaluation.,ENDOCRINE: , No history of diabetes mellitus, no history of thyroid problems, no history of endocrinologic abnormalities.","general medicine, nose and throat, cardiovascular, integumentary, negative weakness, neurologic, throat, psychiatric, weakness, "
 Normal newborn infant physical exam.  A well-developed infant in no acute respiratory distress., General Medicine, Normal Newborn Infant Physical Exam ,"GENERAL: , A well-developed infant in no acute respiratory distress.,VITAL SIGNS:  ,Initial temperature was XX, pulse XX, respirations XX.  Weight XX grams, length XX cm, head circumference XX cm.,HEENT:  ,Head is normocephalic with anterior fontanelle open, soft, and non-bulging.  Eyes:  Red reflex elicited bilaterally.  TMs occluded with vernix and not well visualized.  Nose and throat are patent without palatal defect.,NECK: , Supple without clavicular fracture.,LUNGS:,  Clear to auscultation.,HEART:,  Regular rate without murmur, click, or gallop present.  Pulses are 2/4 for brachial and femoral.,ABDOMEN:,  Soft with bowel sounds present.  No masses or organomegaly.,GENITALIA: , Normal.,EXTREMITIES: , Without evidence of hip defects.,NEUROLOGIC:  ,The infant has good Moro, grasp, and suck reflexes.,SKIN: , Warm and dry without evidence of rash.","general medicine, fontanelle, normocephalic, newborn infant, physical exam, acute respiratory, newborn, respiratory, distress, head, infant,"
 An example normal physical exam, General Medicine, Normal Physical Exam Template - 1 ,"GENERAL: , Vital signs and temperature as documented in nursing notes.  The patient appears stated age and is adequately developed.,EYES:,  Pupils are equal, round, reactive to light and accommodation.  Lids and conjunctivae reveal no gross abnormality.,ENT:  ,Hearing appears adequate.  No obvious asymmetry or deformity of the ears and nose.,NECK: , Trachea midline.  Symmetric with no obvious deformity or mass; no thyromegaly evident.,RESPIRATORY:,  The patient has normal and symmetric respiratory effort.  Lungs are clear to auscultation.,CARDIOVASCULAR: , S1, S2 without significant murmur.,ABDOMEN: , Abdomen is flat, soft, nontender.  Bowel sounds are active.  No masses or pulsations present.,EXTREMITIES: , Extremities reveal no remarkable dependent edema or varicosities.,MUSCULOSKELETAL:  ,The patient is ambulatory with normal and symmetric gait.  There is adequate range of motion without significant pain or deformity.,SKIN: , Essentially clear with no significant rash or lesions.  Adequate skin turgor.,NEUROLOGICAL: , No acute focal neurologic changes.,PSYCHIATRIC:,  Mental status, judgment and affect are grossly intact and normal for age.","general medicine, vital signs, equal, round, reactive, normal physical exam, physical exam, "
 An example of a physical exam, General Medicine, Normal Physical Exam Template ,"GENERAL: , Alert, well developed, in no acute distress.,MENTAL STATUS: , Judgment and insight appropriate for age.  Oriented to time, place and person.  No recent loss of memory.  Affect appropriate for age.,EYES:  ,Pupils are equal and reactive to light.  No hemorrhages or exudates.  Extraocular muscles intact.,EAR, NOSE AND THROAT: , Oropharynx clean, mucous membranes moist.  Ears and nose without masses, lesions or deformities.  Tympanic membranes clear bilaterally.  Trachea midline.  No lymph node swelling or tenderness.,RESPIRATORY:  ,Clear to auscultation and percussion.  No wheezing, rales or rhonchi.,CARDIOVASCULAR: , Heart sounds normal.  No thrills.  Regular rate and rhythm, no murmurs, rubs or gallops.,GASTROINTESTINAL: , Abdomen soft, nondistended.  No pulsatile mass, no flank tenderness or suprapubic tenderness.  No hepatosplenomegaly.,NEUROLOGIC: , Cranial nerves II-XII grossly intact.  No focal neurological deficits.  Deep tendon reflexes +2 bilaterally.  Babinski negative.  Moves all extremities spontaneously.  Sensation intact bilaterally.,SKIN: , No rashes or lesions.  No petechia.  No purpura.  Good turgor.  No edema.,MUSCULOSKELETAL: , No cyanosis or clubbing.  No gross deformities.  Capable of free range of motion without pain or crepitation.  No laxity, instability or dislocation.,BONE: , No misalignment, asymmetry, defect, tenderness or effusion.  Capable of from of joint above and below bone.,MUSCLE:  ,No crepitation, defect, tenderness, masses or swellings.  No loss of muscle tone or strength.,LYMPHATIC:,  Palpation of neck reveals no swelling or tenderness of neck nodes.  Palpation of groin reveals no swelling or tenderness of groin nodes.","general medicine, mental status, ear, nose and throat, abdomen soft, nondistended, cranial nerves ii-xii grossly intact, physical exam, "
" Normal Physical Exam Template.  Well developed, well nourished, alert, in no acute distress. ", General Medicine, Normal Physical Exam Template - 5 ,"GENERAL: , Well developed, well nourished, alert, in no acute distress.  GCS 50, nontoxic.,VITAL SIGNS: , Blood pressure *, pulse *, respirations *, temperature * degrees F.  Pulse oximetry *%.,HEENT: , Eyes: Lids and conjunctiva.  No lesions.  Pupils equal, round, reactive to light and accommodation.  Irises symmetrical, undilated.  Funduscopic exam reveals no hemorrhages or discopathy.  Ears, Nose, Mouth, and throat:  External ears without lesions.  Nares patent.  Septum midline.  Tympanic membranes without erythema, bulging or retraction.  Canals without lesion.  Hearing is grossly intact.  Lips, teeth, gums, palate without lesion.  Posterior oropharynx:  No erythema.  No tonsillar enlargement, crypt formation or abscess.,NECK:  ,Supple and symmetric.  No masses. Thyroid midline, non enlarged.  No JVD.  Neck is nontender.  Full range of motion without pain.,RESPIRATORY: , Good respiratory effort.  Clear to auscultation.  Clear to percussion.  Chest:  Symmetrical rise and fall.  Symmetrical expansion.  No egophony or tactile fremitus.,CARDIOVASCULAR:,  Regular rate and rhythm.  No murmur, gallops, clicks, heaves or rub.  Cardiac palpation within normal limits.  Pulses equal at carotid.  Femoral and pedal pulses:  No peripheral edema.,GASTROINTESTINAL:  ,No tenderness or mass.  No hepatosplenomegaly.  No hernia.  Bowel sounds equal times four quadrants.  Abdomen is nondistended.  No rebound, guarding, rigidity or ecchymosis.,MUSCULOSKELETAL: , Normal gait and station.  No pathology to digits or nails.  Extremities move times four.  No tenderness or effusion.  Range of motion adequate.  Strength and tone equal bilaterally, stable.,BACK: , Nontender on midline.  Full range of motion with flexion, extension and sidebending.,SKIN:,  Inspection within normal limits.  Well hydrated.  No diaphoresis.  No obvious wound.,LYMPH:,  Cervical lymph nodes.  No lymphadenopathy.,NEUROLOGICAL:  ,Cranial nerves II-XII grossly intact.  DTRs symmetric 2 out of 4 bilateral upper and lower extremity, elbow, patella and ankle.  Motor strength 4/4 bilateral upper and lower extremity.  Straight leg raise is negative bilaterally.,PSYCHIATRIC: , Judgment and insight adequate.  Alert and oriented times three.  Memory and mood within normal limits.  No delusions, hallucinations.  No suicidal or homicidal ideation.","general medicine, respiratory, abdomen, normal physical exam, pulses, tenderness, strength, lymph, extremity, midline, range, motion, lesions, symmetrical, "
" Normal physical exam template.  This is a well-developed and well-nourished.  The pupils were equal, round and reactive to light.  Extraocular movements are intact.", General Medicine, Normal Physical Exam Template - 2 ,"GENERAL APPEARANCE: , This is a well-developed and well-nourished, ??,VITAL SIGNS: , Blood pressure ??, heart rate ?? and regular, respiratory rate ??, temperature is ?? degrees Fahrenheit.  Height is ?? feet ?? inches.  Weight is ?? pounds.  This yields a body mass index of ??.,HEAD, EYES, EARS, NOSE AND THROAT:,  The pupils were equal, round and reactive to light.  Extraocular movements are intact.  Sclera are nonicteric.  Ears, nose, mouth and throat - Externally the ears and nose are normal.  The mucous membranes are moist and midline.,NECK:  ,The neck is supple without masses.  No thyromegaly, no carotid bruits, no adenopathy.,LUNGS:  ,There is a normal respiratory effort.  Bilateral breath sounds are clear.  No wheezes or rales or rhonchi.,CARDIAC: , Normal cardiac impulse location.  S1 and S2 are normal.  No rubs, murmurs or gallops.  A regular rate and rhythm.  There are no abdominal aortic bruits.  The carotid, brachial, radial, femoral, popliteal and dorsalis pedis pulses are 2+ and equal bilaterally.,EXTREMITIES: , The extremities are without clubbing, cyanosis, or edema.,CHEST: , The chest examination is unremarkable.,BREASTS:  ,The breasts show no masses or tenderness.  No axillary adenopathy.,ABDOMEN:,  The abdomen is flat, soft, nontender, no organomegaly, no masses, normal bowel sounds are present.,RECTAL: , Examination was deferred.,LYMPHATIC: , No neck, axillary or groin adenopathy was noted.,SKIN EXAMINATION:,  Unremarkable.,MUSCULOSKELETAL EXAMINATION: , Grossly normal.,NEUROLOGIC: , The cranial nerves two through twelve are grossly intact.  Patellar and biceps reflexes are normal.,PSYCHIATRIC: , The patient is awake, alert and oriented times three.  Judgment and insight are good.  Affect is appropriate.",
 Template for History and Physical for a newborn., General Medicine, Normal Newborn H&P Template ,"HISTORY OF PRESENT ILLNESS: , This is a ** week gestational age ** delivered by ** at ** on **.  Gestational age was determined by last menstrual period and consistent with ** trimester ultrasound.  ** rupture of membranes occurred ** prior to delivery and amniotic fluid was clear.  The baby was vertex presentation.  The baby was dried, stimulated, and bulb suctioned.  Apgar scores of ** at one minute and ** at five minutes.,PAST MEDICAL HISTORY,MATERNAL HISTORY:,  The mother is a **-year-old, G**, P** female with blood type **.  She is rubella immune, hepatitis surface antigen negative, RPR nonreactive, HIV negative.  Mother was group B strep **.  Mother's past medical history is **.,PRENATAL CARE: , Mother began prenatal care in the ** trimester and had at least ** documented prenatal visits.  She did not smoke, drink alcohol, or use illicit drugs during pregnancy.,SURGICAL HISTORY: , **,MEDICATIONS:,  Medications taken during this pregnancy were **.,ALLERGIES: , **,FAMILY HISTORY: , **,SOCIAL HISTORY: , **,PHYSICAL EXAMINATION,VITAL SIGNS:  Temperature **, heart rate **, respiratory rate **.  Dextrose stick **.  Ballard score by the RN is ** weeks.  Birth weight is ** grams, which is the ** percentile for gestational age.  Length is ** centimeters which is ** percentile for gestational age.  Head circumference is ** centimeters which is ** percentile for gestational age.,GENERAL:  **Alert, active, nondysmorphic-appearing infant in no acute distress.,HEENT:  Anterior fontanelle open and flat.  Positive bilateral red reflexes.,Ears have normal shape and position with no pits or tags.  Nares patent.  Palate intact.  Mucous membranes moist.,NECK:  Full range of motion.,CARDIOVASCULAR:  Normal precordium, regular rate and rhythm.  No murmurs.  Normal femoral pulses.,RESPIRATORY;  Clear to auscultation bilaterally.  No retractions.,ABDOMEN:  Soft, nondistended.  Normal bowel sounds.  No hepatosplenomegaly.  Umbilical stump is clean, dry, and intact.,GENITOURINARY:  Normal tanner I **.  Anus patent.,MUSCULOSKELETAL:  Negative Barlow and Ortolani.  Clavicles intact.  Spine straight.  No sacral dimple or hair tuft.  Leg lengths grossly symmetric.  Five fingers on each hand and five toes on each foot.,SKIN:  Warm and pink with brisk capillary refill.  No jaundice.,NEUROLOGICAL:  Normal tone.  Normal root, suck, grasp, and Moro reflexes.  Moves all extremities equally.,DIAGNOSTIC STUDIES,LABORATORY DATA:,  **,ASSESSMENT: , Full term, appropriate for gestational age **.,PLAN:,1.  Routine newborn care.,2.  Anticipatory guidance.,3.  Hepatitis B immunization prior to discharge.,",
 An example/template for a routine normal male physical exam., General Medicine, Normal Male Exam Template - 3 ,"PHYSICAL EXAMINATION,GENERAL: , The patient is awake and alert, in no apparent distress, appropriate, pleasant and cooperative.  No dysarthria is noted.  No discomfort on presentation is noted.  ,HEAD: , Atraumatic, normocephalic. Pupils are equal, round and reactive to light.  Extraocular muscles are intact.  Sclerae are white without injection or icterus.  Fundi are without papilledema, hemorrhages or exudates with normal vessels.  ,EARS: , The ear canals are patent without edema, exudate or drainage.  Tympanic membranes are intact with a normal cone of light.  No bulging or erythema to indicate infection is present.  There is no hemotympanum.  Hearing is grossly intact.  ,NOSE:,  Without deformity, bleeding or discharge.  No septal hematoma is noted.  ,ORAL CAVITY:,  No swelling or abnormality to the lip or teeth.  Oral mucosa is pink and moist.  No swelling to the palate or pharynx.  Uvula is midline.  The pharynx is without exudate or erythema.  No edema is seen of the tonsils.  The airway is completely patent.  The voice is normal.  No stridor is heard.  ,NECK: , No signs of meningismus.  No Brudzinski or Kernig sign is present.  No adenopathy is noted.  No JVD is seen.  No bruits are auscultated.  Trachea is midline.  ,CHEST: , Symmetrical with equal breath sounds.  Equal excursion.  No hyperresonance or dullness to percussion is noted.  There is no tenderness on palpation of the chest.  ,LUNGS:  ,Clear to auscultation bilaterally.  No rales, rhonchi or wheezes are appreciated.  Good air movement is auscultated in all 4 lung fields.  ,HEART:,  Regular rate and rhythm.  No murmur.  No S3, S4 or rub is auscultated.  Point of maximal impulse is strong and in normal position.  Abdominal aorta is not palpable.  The carotid upstroke is normal.  ,ABDOMEN:  ,Soft, nontender and nondistended.  Normal bowel sounds are auscultated.  No organomegaly is appreciated.  No masses are palpated.  No tympany is noted on percussion.  No guarding, rigidity or rebound tenderness is seen on exam.  Murphy and McBurney sign is negative.  There is no Rovsing, obturator or psoas sign present.  No hepatosplenomegaly and no hernias are noted.  ,RECTAL:,  Normal tone.  No masses.  Soft, brown stool in the vault.  Guaiac negative.  ,GENITOURINARY:,  Penis is normal without lesion or urethral discharge.  Scrotum is without edema.  The testes are descended bilaterally.  No masses are palpated.  There is no tenderness.  ,EXTREMITIES: , No clubbing, cyanosis or edema.  Pulses are strong and equal in the femoral and dorsalis pedis arteries, bounding and equal.  No deformity or signs of trauma.  All joints are stable without laxity.  There is good range of motion of all joints without tenderness or discomfort.  Homan sign is negative.  No atrophy or contractures are noted.  ,SKIN: , No rashes.  No jaundice.  Pink and warm with good turgor.  Good color.  No erythema or nodules noted.  No petechia, bulla or ecchymosis.  ,NEUROLOGIC: , Cranial nerves II through XII are grossly intact.  Muscle strength is graded 5/5 in the upper and lower extremities bilaterally.  Deep tendon reflexes are symmetrical in the upper and lower extremities bilaterally. Babinski is downgoing bilaterally.  Sensation is intact to light touch and vibration.  Gait is normal.  Romberg, finger-to-nose, rapid alternating movements and heel-to-shin are all normal.  There is no ataxia seen on gait testing.  Tone is normal.  No pronator drift is seen.  ,PSYCHIATRIC:  ,The patient is oriented x4.  Mood and affect are appropriate.  Memory is intact with good short- and long-term memory recall.  No dysarthria is noted.  Remote memory is intact.  Judgment and insight appear normal.,",
 An example/template for a routine normal male ROS., General Medicine, Normal Male ROS Template - 1 ,"REVIEW OF SYSTEMS:,CONSTITUTIONAL:  Patient denies fevers, chills, sweats and weight changes.,EYES:  Patient denies any visual symptoms.,EARS, NOSE, AND THROAT:  No difficulties with hearing.  No symptoms of rhinitis or sore throat.,CARDIOVASCULAR:  Patient denies chest pains, palpitations, orthopnea and paroxysmal nocturnal dyspnea.,RESPIRATORY:  No dyspnea on exertion, no wheezing or cough.,GI:  No nausea, vomiting, diarrhea, constipation, abdominal pain, hematochezia or melena.,GU:  No urinary hesitancy or dribbling.  No nocturia or urinary frequency.  No abnormal urethral discharge.,MUSCULOSKELETAL:  No myalgias or arthralgias.,NEUROLOGIC:  No chronic headaches, no seizures.  Patient denies numbness, tingling or weakness.,PSYCHIATRIC:  Patient denies problems with mood disturbance.  No problems with anxiety.,ENDOCRINE:  No excessive urination or excessive thirst.,DERMATOLOGIC:  Patient denies any rashes or skin changes.","general medicine, review of systems, normal male ros, normal male, male ros, male, ros, throat, urinary "
 An example/template for a routine normal male physical exam., General Medicine, Normal Male Exam Template - 1 ,"MALE PHYSICAL EXAMINATION,HEENT:  Pupils equal, round and reactive to light and accommodation.  Extraocular movements are intact.  Sclerae are anicteric.  TMs are clear bilaterally.  Oropharynx is clear without erythema or exudate.,NECK:  Supple without lymphadenopathy or thyromegaly.  Carotids are silent.  There is no jugular venous distention.,CHEST:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  Regular rate and rhythm without S3, S4.  No murmurs or rubs are appreciated.,ABDOMEN:  Soft, nontender, nondistended with positive bowel sounds.  No masses, hepatomegaly or splenomegaly are appreciated.,GU:  Normal **circumcised male.  No discharge or hernias.  No testicular masses.,RECTAL EXAM:  Normal rectal tone.  Prostate is smooth and not enlarged.  Stool is Hemoccult negative.,EXTREMITIES:  Reveal no clubbing, cyanosis, or edema.  Peripheral pulses are +2 and equal bilaterally in all four extremities.,JOINT EXAM:  Reveals no tenosynovitis.,NEUROLOGIC:  Cranial nerves II through XII are grossly intact.  Motor strength is 5/5 and equal in all four extremities.  Deep tendon reflexes are +2/4 and equal bilaterally.  Patient is alert and oriented times 3.,PSYCHIATRIC:  Grossly normal.,DERMATOLOGIC:  No lesions or rashes.","general medicine, male exam, physical exam, normal, normal male, physical, male, sclerae, extremities, intact, oropharynx "
 An example/template for a routine normal male physical exam., General Medicine, Normal Male Exam Template - 2 ,"MALE PHYSICAL EXAMINATION,Eye:  Eyelids normal color, no edema.  Conjunctivae with no erythema, foreign body, or lacerations.  Sclerae normal white color, no jaundice.  Cornea clear without lesions.  Pupils equally responsive to light.  Iris normal color, no lesions.  Anterior chamber clear.  Lacrimal ducts normal.  Fundi clear.,Ear:  External ear has no erythema, edema, or lesions.  Ear canal unobstructed without edema, discharge, or lesions.  Tympanic membranes clear with normal light reflex.  No middle ear effusions.,Nose:  External nose symmetrical.  No skin lesions.  Nares open and free of lesions.  Turbinates normal color, size and shape.  Mucus clear.  No internal lesions.,Throat:  No erythema or exudates.  Buccal mucosa clear.  Lips normal color without lesions.  Tongue normal shape and color without lesion.  Hard and soft palate normal color without lesions.  Teeth show no remarkable features.  No adenopathy.  Tonsils normal shape and size.  Uvula normal shape and color.,Neck:  Skin has no lesions.  Neck symmetrical.  No adenopathy, thyromegaly, or masses.  Normal range of motion, nontender.  Trachea midline.,Chest:  Symmetrical.  Clear to auscultation bilaterally.  No wheezing, rales or rhonchi.  Chest nontender.  Normal lung excursion.  No accessory muscle use.,Cardiovascular:  Heart has regular rate and rhythm with no S3 or S4.  Heart rate is normal.,Abdominal:  Soft, nontender, nondistended, bowel sounds present.  No hepatomegaly, splenomegaly, masses, or bruits.,Genital:  Penis normal shape without lesions.  Testicles normal shape and contour without tenderness.  Epididymides normal shape and contour without tenderness.  Rectum normal tone to sphincter.  Prostate normal shape and contour without nodules.  Stool hemoccult negative.  No external hemorrhoids.  No skin lesions.,Musculoskeletal:  Normal strength all muscle groups.  Normal range of motion all joints.  No joint effusions.  Joints normal shape and contour.  No muscle masses.,Foot:  No erythema.  No edema.  Normal range of motion all joints in the foot.  Nontender.  No pain with inversion, eversion, plantar or dorsiflexion.,Ankle:  Anterior and posterior drawer test negative.  No pain with inversion, eversion, dorsiflexion, or plantar flexion.  Collateral ligaments intact.  No joint effusion, erythema, edema, crepitus, ecchymosis, or tenderness.,Knee:  Normal range of motion.  No joint effusion, erythema, nontender.  Anterior and posterior drawer tests negative.  Lachman's test negative.  Collateral ligaments intact.  Bursas nontender without edema.,Wrist:  Normal range of motion.  No edema or effusion, nontender.  Negative Tinel and Phalen tests.  Normal strength all muscle groups.,Elbow:  Normal range of motion.  No joint effusion or erythema.  Normal strength all muscle groups.  Nontender.  Olecranon bursa flat and nontender, no edema.  Normal supination and pronation of forearm.  No crepitus.,Hip:  Negative swinging test.  Trochanteric bursa nontender.  Normal range of motion.  Normal strength all muscle groups.  No pain with eversion and inversion.  No crepitus.  Normal gait.,Psychiatric:  Alert and oriented times four.  No delusions or hallucinations, no loose associations, no flight of ideas, no tangentiality.  Affect is appropriate.  No psychomotor slowing or agitation.  Eye contact is appropriate.","general medicine, male exam, normal, physical exam, normal range of motion, male physical, nontender, lesions, dorsiflexion, sclerae, contour, muscle, erythema, joints, edema, shape,"
 An example/template for a routine normal male physical exam., General Medicine, Normal Male Exam Template - 4 ,"VITAL SIGNS:,  Blood pressure *, pulse *, respirations *, temperature *.,GENERAL APPEARANCE: , Alert and in no apparent distress, calm, cooperative, and communicative.,HEENT:,  Eyes:  EOMI.  PERRLA.  Sclerae nonicteric.  No lesions lids, lashes, brows, or conjunctivae noted.  Funduscopic examination unremarkable.  No papilledema, glaucoma, or cataracts.  Ears:  Normal set and shape with normal hearing and normal TMs. Nose and Sinus:  Unremarkable.  Mouth, Tongue, Teeth, and Throat:  Negative except for dental work.,NECK: , Supple and pain free without carotid bruit, JVD, or significant cervical adenopathy.  Trachea is midline without stridor, shift, or subcutaneous emphysema.  Thyroid is palpable, nontender, not enlarged, and free of nodularity.,CHEST: , Lungs bilaterally clear to auscultation and percussion.,HEART: , S1 and S2.  Regular rate and rhythm without murmur, heave, click, lift, thrill, rub, or gallop.  PMI is nondisplaced.  Chest wall is unremarkable to inspection and palpation.  No axillary or supraclavicular adenopathy detected.,BREASTS: , Normal male breast tissue.,ABDOMEN:,  No hepatosplenomegaly, mass, tenderness, rebound, rigidity, or guarding.  No widening of the aortic impulse and intraabdominal bruit on auscultation.,EXTERNAL GENITALIA: , Normal for age.  Normal penis with bilaterally descended testes that are normal in size, shape, and contour, and without evidence of hernia or hydrocele.,RECTAL:,  Negative to 7 cm by gloved digital palpation with Hemoccult-negative stool and normal-sized prostate that is free of nodularity or tenderness.  No rectal masses palpated.,EXTREMITIES: , Good distal pulse and perfusion without evidence of edema, cyanosis, clubbing, or deep venous thrombosis.  Nails of the hands and feet, and creases of the palms and soles are unremarkable.  Good active and passive range of motion of all major joints.,BACK: , Normal to inspection and percussion.  Negative for spinous process tenderness or CVA tenderness.  Negative straight-leg raising, Kernig, and Brudzinski signs.,NEUROLOGIC: , Nonfocal for cranial and peripheral nervous systems, strength, sensation, and cerebellar function.  Affect is normal.  Speech is clear and fluent.  Thought process is lucid and rational.  Gait and station are unremarkable.,SKIN:  ,Unremarkable for any premalignant or malignant condition with normal changes for age.","general medicine, digital palpation, hemoccult-negative, heent, palpation, breasts, male, tenderness, tongue, "
 Sample/template for a normal male multisystem exam., General Medicine, Normal Male Exam Template ,"MULTISYSTEM EXAM,CONSTITUTIONAL:  ,The vital signs showed that the patient was afebrile; blood pressure and heart rate were within normal limits.  The patient appeared alert.,EYES:  ,The conjunctiva was clear.  The pupil was equal and reactive.  There was no ptosis.  The irides appeared normal.,EARS, NOSE AND THROAT:  ,The ears and the nose appeared normal in appearance.  Hearing was grossly intact.  The oropharynx showed that the mucosa was moist.  There was no lesion that I could see in the palate, tongue. tonsil or posterior pharynx.,NECK:  ,The neck was supple.  The thyroid gland was not enlarged by palpation.,RESPIRATORY:  ,The patient's respiratory effort was normal.  Auscultation of the lung showed it to be clear with good air movement.,CARDIOVASCULAR:  ,Auscultation of the heart revealed S1 and S2 with regular rate with no murmur noted.  The extremities showed no edema.,GASTROINTESTINAL: , The abdomen was soft, nontender with no rebound, no guarding, no enlarged liver or spleen.  Bowel sounds were present.,GU: , The scrotal elements were normal.  The testes were without discrete mass.  The penis showed no lesion, no discharge.,LYMPHATIC:  ,There was no appreciated node that I could feel in the groin or neck area.,MUSCULOSKELETAL:  ,The head and neck by inspection showed no obvious deformity.  Again, the extremities showed no obvious deformity.  Range of motion appeared to be normal for the upper and lower extremities.,SKIN: , Inspection of the skin and subcutaneous tissues appeared to be normal.  The skin was pink, warm and dry to touch.,NEUROLOGIC:  ,Deep tendon reflexes were symmetrical at the patellar area.  Sensation was grossly intact by touch.,PSYCHIATRIC: , The patient was oriented to time, place and person.  The patient's judgment and insight appeared to be normal.","general medicine, within normal limits, conjunctiva, eyes, ears, nose, throat, male, multisystem, heart, respiratory, auscultation, extremities, oropharynx, neck, tongue, "
 Normal child physical exam template., General Medicine, Normal Child Exam Template ,"CHILD PHYSICAL EXAMINATION,VITAL SIGNS:  Birth weight is ** grams, length **, occipitofrontal circumference **.  Character of cry was lusty.,GENERAL APPEARANCE:  Well.,BREATHING:  Unlabored.,SKIN:  Clear.  No cyanosis, pallor, or icterus.  Subcutaneous tissue is ample.,HEAD:  Normal.  Fontanelles are soft and flat.  Sutures are opposed.,EYES:  Normal with red reflex x2.,EARS:  Patent.  Normal pinnae, canals, TMs.,NOSE:  Patent nares.,MOUTH:  No cleft.,THROAT:  Clear.,NECK:  No masses.,CHEST:  Normal clavicles.,LUNGS:  Clear bilaterally.,HEART:  Regular rate and rhythm without murmur.,ABDOMEN:  Soft, flat.  No hepatosplenomegaly.  The cord is three vessel.,GENITALIA:  Normal ** genitalia **with testes descended bilaterally.,ANUS:  Patent.,SPINE:  Straight and without deformity.,EXTREMITIES:  Equal movements.,MUSCLE TONE:  Good.,REFLEXES:  Moro, grasp, and suck are normal.,HIPS:  No click or clunk.","general medicine, child physical examination, physical, genitalia, child, "
 Sample/template for a normal female multisystem exam, General Medicine, Normal Female Exam Template ,"MULTISYSTEM EXAM,CONSTITUTIONAL: , The vital signs showed that the patient was afebrile; blood pressure and heart rate were within normal limits.  The patient appeared alert.,EYES: , The conjunctiva was clear.  The pupil was equal and reactive.  There was no ptosis.  The irides appeared normal.,EARS, NOSE AND THROAT: , The ears and the nose appeared normal in appearance.  Hearing was grossly intact.  The oropharynx showed that the mucosa was moist.  There was no lesion that I could see in the palate, tongue. tonsil or posterior pharynx.,NECK: , The neck was supple.  The thyroid gland was not enlarged by palpation.,RESPIRATORY:  ,The patient's respiratory effort was normal.  Auscultation of the lung showed it to be clear with good air movement.,CARDIOVASCULAR: , Auscultation of the heart revealed S1 and S2 with regular rate with no murmur noted.  The extremities showed no edema.,BREASTS:  ,Breast inspection showed them to be symmetrical with no nipple discharge.  Palpation of the breasts and axilla revealed no obvious mass that I could appreciate.,GASTROINTESTINAL:  ,The abdomen was soft, nontender with no rebound, no guarding, no enlarged liver or spleen.  Bowel sounds were present.,GU:  ,The external genitalia appeared to be normal.  The pelvic exam revealed no adnexal masses.  The uterus appeared to be normal in size and there was no cervical motion tenderness.,LYMPHATIC:  ,There was no appreciated node that I could feel in the groin or neck area.,MUSCULOSKELETAL:  ,The head and neck by inspection showed no obvious deformity.  Again, the extremities showed no obvious deformity.  Range of motion appeared to be normal for the upper and lower extremities.,SKIN:,  Inspection of the skin and subcutaneous tissues appeared to be normal.  The skin was pink, warm and dry to touch.,NEUROLOGIC: , Deep tendon reflexes were symmetrical at the patellar area.  Sensation was grossly intact by touch.,PSYCHIATRIC:  ,The patient was oriented to time, place and person.  The patient's judgment and insight appeared to be normal.", 
" Sample normal ear, nose, mouth, and throat exam.", General Medicine, Normal ENT Exam - 1 ,"EARS, NOSE, MOUTH AND THROAT,EARS/NOSE: , The auricles are normal to palpation and inspection without any surrounding lymphadenitis.  There are no signs of acute trauma.  The nose is normal to palpation and inspection externally without evidence of acute trauma.  Otoscopic examination of the auditory canals and tympanic membranes reveals the auditory canals without signs of mass lesion, inflammation or swelling.  The tympanic membranes are without disruption or infection.  Hearing intact bilaterally to normal level speech.  Nasal mucosa, septum and turbinate examination reveals normal mucous membranes without disruption or inflammation.  The septum is without acute traumatic lesions or disruption.  The turbinates are without abnormal swelling.  There is no unusual rhinorrhea or bleeding.  ,LIPS/TEETH/GUMS:  ,The lips are without infection, mass lesion or traumatic lesions.  The teeth are intact without obvious signs of infection.  The gingivae are normal to palpation and inspection.  ,OROPHARYNX:  ,The oral mucosa is normal.  The salivary glands are without swelling.  The hard and soft palates are intact.  The tongue is without masses or swelling with normal movement.  The tonsils are without inflammation.  The posterior pharynx is without mass lesion with good patent oropharyngeal airway.","general medicine, oral mucosa, lips, hearing, auditory canals, tympanic membranes, traumatic lesions, mouth, throat, trauma, nose, membranes, inflammation, infection, swelling,"
 She is a 28-year-old G1 at approximately 8 plus weeks presented after intractable nausea and vomiting with blood-tinged vomit starting approximately worse over the past couple of days.  This is patient's fourth trip to the emergency room and second trip for admission., General Medicine, Nausea & Vomiting - ER Visit ,"HISTORY OF PRESENT ILLNESS: , She is a 28-year-old G1 at approximately 8 plus weeks presented after intractable nausea and vomiting with blood-tinged vomit starting approximately worse over the past couple of days.  This is patient's fourth trip to the emergency room and second trip for admission.,PAST MEDICAL HISTORY: , Nonsignificant.,PAST SURGICAL HISTORY: , None.,SOCIAL HISTORY: , No alcohol, drugs, or tobacco.,PAST OBSTETRICAL HISTORY:  ,This is her first pregnancy.,PAST GYNECOLOGICAL HISTORY: , Not pertinent.,While in the emergency room, the patient was found to have slight low sodium, potassium slightly elevated and her ALT of 93, AST of 35, total bilirubin is 1.2.  Her urine was 3+ ketones, 2+ protein, and 1+ esterase, and rbc too numerous to count with moderate amount of bacteria.  H and H stable at 14.1 and 48.7.  She was then admitted after giving some Phenergan and Zofran IV.  As started on IV, given hydration as well as given a dose of Rocephin to treat bladder infection.  She was admitted overnight, nausea and vomiting resolved to only one episode of vomiting after receiving Maalox, tolerated fluids as well as p.o. food.  Followup chemistry was obtained for AST, ALT and we will plan for discharge if lab variables resolve.,ASSESSMENT AND PLAN:,1.  This is a 28-year-old G1 at approximately 8 to 9 weeks gestation with one hyperemesis gravidarum admit for IV hydration and followup.,2.  Slightly elevated ALT, questionable, likely due to the nausea and vomiting.  We will recheck for followup.","general medicine, iv hydration, elevated alt, emergency, nausea, vomiting,"
 An example/template for a routine normal female physical exam., General Medicine, Normal Female Exam Template - 1 ,"PHYSICAL EXAMINATION,GENERAL:  ,The patient is awake and alert, in no apparent distress, appropriate, pleasant and cooperative.  No dysarthria is noted.  No discomfort on presentation is noted.,HEAD: , Atraumatic, normocephalic.  Pupils are equal, round and reactive to light.  Extraocular muscles are intact.  Sclerae are white without injection or icterus.  Fundi are without papilledema, hemorrhages or exudates with normal vessels.,EARS:  ,The ear canals are patent without edema, exudate or drainage.  Tympanic membranes are intact with a normal cone of light.  No bulging or erythema to indicate infection is present.  There is no hemotympanum.  Hearing is grossly intact.,NOSE: , Without deformity, bleeding or discharge.  No septal hematoma is noted.,ORAL CAVITY: , No swelling or abnormality to the lip or teeth.  Oral mucosa is pink and moist.  No swelling to the palate or pharynx.  Uvula is midline.  The pharynx is without exudate or erythema.  No edema is seen of the tonsils.  The airway is completely patent.  The voice is normal.  No stridor is heard.,NECK: , No signs of meningismus.  No Brudzinski or Kernig sign is present.  No adenopathy is noted.  No JVD is seen.  No bruits are auscultated.  Trachea is midline.,CHEST: , Symmetrical with equal breath sounds.  Equal excursion.  No hyperresonance or dullness to percussion is noted.  There is no tenderness on palpation of the chest.,LUNGS: , Clear to auscultation bilaterally.  No rales, rhonchi or wheezes are appreciated.  Good air movement is auscultated in all 4 lung fields.,HEART: , Regular rate and rhythm.  No murmur.  No S3, S4 or rub is auscultated.  Point of maximal impulse is strong and in normal position.  Abdominal aorta is not palpable.  The carotid upstroke is normal.,ABDOMEN: , Soft, nontender and nondistended.  Normal bowel sounds are auscultated.  No organomegaly is appreciated.  No masses are palpated.  No tympany is noted on percussion.  No guarding, rigidity or rebound tenderness is seen on exam.  Murphy and McBurney sign is negative.  There is no Rovsing, obturator or psoas sign present.  No hepatosplenomegaly and no hernias are noted.,RECTAL: , Normal tone.  No masses.  Soft, brown stool in the vault.  Guaiac negative.,GENITOURINARY: , External genitalia without erythema, exudate or discharge.  Vaginal vault is without discharge.  Cervix is of normal color without lesion.  The os is closed.  There is no bleeding noted.  Uterus is noted to be of normal size and nontender.  No cervical motion tenderness is seen.  No masses are palpated.  The adnexa are without masses or tenderness.,EXTREMITIES: , No clubbing, cyanosis or edema.  Pulses are strong and equal in the femoral and dorsalis pedis arteries, bounding and equal.  No deformity or signs of trauma.  All joints are stable without laxity.  There is good range of motion of all joints without tenderness or discomfort.  Homan sign is negative.  No atrophy or contractures are noted.,SKIN: , No rashes.  No jaundice.  Pink and warm with good turgor.  Good color.  No erythema or nodules noted.  No petechia, bulla or ecchymosis.,NEUROLOGIC: , Cranial nerves II through XII are grossly intact.  Muscle strength is graded 5/5 in the upper and lower extremities bilaterally.  Deep tendon reflexes are symmetrical in the upper and lower extremities bilaterally.  Babinski is downgoing bilaterally.  Sensation is intact to light touch and vibration.  Gait is normal.  Romberg, finger-to-nose, rapid alternating movements and heel-to-shin are all normal.  There is no ataxia seen on gait testing.  Tone is normal.  No pronator drift is seen.,PSYCHIATRIC:  ,The patient is oriented x4.  Mood and affect are appropriate.  Memory is intact with good short- and long-term memory recall.  No dysarthria is noted.  Remote memory is intact.  Judgment and insight appear normal.",
" Normal female review of systems template.  Negative for fever, weight change, fatigue, or aching.", General Medicine, Normal Female ROS Template ,"CONSTITUTIONAL:,  Normal; negative for fever, weight change, fatigue, or aching.,HEENT:,  Eyes normal; Negative for glasses, cataracts, glaucoma, retinopathy, irritation, or visual field defects.  Ears normal; Negative for hearing or balance problems.  Nose normal; Negative for runny nose, sinus problems, or nosebleeds.  Mouth normal; Negative for dental problems, dentures, or bleeding gums.  Throat normal; Negative for hoarseness, difficulty swallowing, or sore throat.,CARDIOVASCULAR:,  Normal; Negative for angina, previous MI, irregular heartbeat, heart murmurs, bad heart valves, palpitations, swelling of feet, high blood pressure, orthopnea, paroxysmal nocturnal dyspnea, or history of stress test, arteriogram, or pacemaker implantation.,PULMONARY: , Normal; Negative for cough, sputum, shortness of breath, wheezing, asthma, or emphysema.,GASTROINTESTINAL: , Normal; Negative for pain, vomiting, heartburn, peptic ulcer disease, change in stool, rectal pain, hernia, hepatitis, gallbladder disease, hemorrhoids, or bleeding.,GENITOURINARY:, Normal female OR male; Negative for incontinence, UTI, dysuria, hematuria, vaginal discharge, abnormal bleeding, breast lumps, nipple discharge, skin or nipple changes, sexually transmitted diseases, incontinence, yeast infections, or itching.,SKIN: , Normal; Negative for rashes, keratoses, skin cancers, or acne.,MUSCULOSKELETAL: , Normal; Negative for back pain, joint pain, joint swelling, arthritis, joint deformity, problems with ambulation, stiffness, osteoporosis, or injuries.,NEUROLOGIC: , Normal; Negative for blackouts, headaches, seizures, stroke, or dizziness.,PSYCHIATRIC: , Normal; Negative for anxiety, depression, or phobias.,ENDOCRINE:,  Normal; Negative for diabetes, thyroid, or problems with cholesterol or hormones.,HEMATOLOGIC/LYMPHATIC: , Normal; Negative for anemia, swollen glands, or blood disorders.,IMMUNOLOGIC: , Negative; Negative for steroids, chemotherapy, or cancer.,VASCULAR:,  Normal; Negative for varicose veins, blood clots, atherosclerosis, or leg ulcers.","general medicine, cough, sputum, shortness of breath, fever, weight, fatigue, aching, nose, throat, swelling, disease, incontinence, bleeding, heartbeat, blood, joint, "
" Sample normal ear, nose, mouth, and throat exam.", General Medicine, Normal ENT Exam ,"EARS, NOSE, MOUTH AND THROAT: , The nose is without any evidence of any deformity.  The ears are with normal-appearing pinna.  Examination of the canals is normal appearing bilaterally.  There is no drainage or erythema noted.  The tympanic membranes are normal appearing with pearly color, normal-appearing landmarks and normal light reflex.  Hearing is grossly intact to finger rubbing and whisper.  The nasal mucosa is moist.  The septum is midline.  There is no evidence of septal hematoma.  The turbinates are without abnormality.  No obvious abnormalities to the lips.  The teeth are unremarkable.  The gingivae are without any obvious evidence of infection.  The oral mucosa is moist and pink.  There are no obvious masses to the hard or soft palate.  The uvula is midline.  The salivary glands appear unremarkable.  The tongue is midline.  The posterior pharynx is without erythema or exudate.  The tonsils are normal appearing.","general medicine, erythema, tympanic, mouth, throat, ears, mucosa, noseNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 An example/template for a routine normal female physical exam., General Medicine, Normal Female Exam Template - 2 ,"VITAL SIGNS: , Blood pressure *, pulse *, respirations *, temperature *.,GENERAL APPEARANCE:,  Alert and in no apparent distress, calm, cooperative, and communicative.,HEENT: , Eyes:  EOMI.  PERRLA.  Sclerae nonicteric.  No lesions of lids, lashes, brows, or conjunctivae noted.  Funduscopic examination unremarkable.  Ears:  Normal set, shape, TMs, canals and hearing.  Nose and Sinuses:  Negative.  Mouth, Tongue, Teeth, and Throat:  Negative except for dental work.,NECK: , Supple and pain free without bruit, JVD, adenopathy or thyroid abnormality.,CHEST:,  Lungs are bilaterally clear to auscultation and percussion.,HEART: , S1 and S2.  Regular rate and rhythm without murmur, heave, click, lift, thrill, rub, or gallop.  PMI nondisplaced.  Chest wall unremarkable to inspection and palpation.  No axillary or supraclavicular adenopathy detected.,BREASTS:,  In the seated and supine position unremarkable.,ABDOMEN: , No hepatosplenomegaly, mass, tenderness, rebound, rigidity, or guarding.  No widening of the aortic impulse and no intraabdominal bruit auscultated.,EXTERNAL GENITALIA: , Normal for age.,RECTAL: , Negative to 7 cm by gloved digital palpation with Hemoccult-negative stool.,EXTREMITIES: , Good distal pulse and perfusion without evidence of edema, cyanosis, clubbing, or deep venous thrombosis.  Nails of the hands and feet, and creases of the palms and soles are unremarkable.  Good active and passive range of motion of all major joints.,BACK:,  Normal to inspection and percussion.  Negative for spinous process tenderness or CVA tenderness.  Negative straight-leg raising, Kernig, and Brudzinski signs.,NEUROLOGIC:,  Nonfocal for cranial and peripheral nervous systems, strength, sensation, and cerebellar function.  Affect is normal.  Speech is clear and fluent.  Thought process is lucid and rational.  Gait and station are unremarkable.,SKIN: , Unremarkable for any premalignant or malignant condition with normal changes for age.","general medicine, heent, general appearance, hepatosplenomegaly, mass, tenderness, rebound, rigidity, pulse, bruit, adenopathy, chest, percussion, inspection, palpation, signs, tongue, "
" MRI Brain, Carbon Monoxide poisoning.", General Medicine, MRI Brain - CO poisoning ,"CC:, Found down.,HX:, 54y/o RHF went to bed at 10 PM at her boyfriend's home on 1/16/96. She was found lethargic by her son the next morning. Three other individuals in the house were lethargic and complained of HA that same morning. Her last memory was talking to her granddaughter at 5:00PM on 1/16/96. She next remembered riding in the ambulance from a Hospital. Initial Carboxyhemoglobin level was 24% (normal < 1.5%) and ABG 7.41/30/370 with O2Sat 75% on 100%FiO2.,MEDS:, unknown anxiolytic, estrogen.,PMH:, PUD, ?stroke and memory difficulty in the past 1-2 years.,FHX:, unknown.,SHX:, divorced. unknown history of tobacco/ETOH/illicit drug use.,EXAM: ,BP126/91, HR86, RR 30, 37.1C.,MS:, Oriented to name only. Speech without dysarthria. 2/3 recall at 5minutes.,CN:, unremarkable.,MOTOR: ,full strength throughout with normal muscle tone and bulk.,SENSORY: ,unremarkable.,COORD/STATION:, unremarkable.,GAIT:, not tested on admission.,GEN EXAM:, notable for erythema of the face and chest.,COURSE:, She underwent a total of four dives under Hyperbaric Oxygen ( 2 dives on 1/17 and 2 dives on 1/18). Neuropsychologic assessment on 1/18/96 revealed marked cognitive impairments with defects in anterograde memory, praxis, associative fluency, attention, and speed of information processing. She was discharged home on 1/19/96 and returned on 2/11/96 after neurologic deterioration. She progressively developed more illogical behavior, anhedonia, anorexia and changes in sleep pattern. She became completely dependent and could not undergo repeat neuropsychologic assessment in 2/96. She was later transferred to another care facility against medical advice. The etiology for these changes became complicated by a newly discovered history of possible ETOH abuse and usual ""anxiety"" disorder.,MRI brain, 2/14/96, revealed increased T2 signal within the periventricular white matter, bilaterally. EEG showed diffuse slowing without epileptiform activity.",
" Seizure, hypoglycemia, anemia, dyspnea, edema. colon cancer status post right hemicolectomy, hospital-acquired pneumonia, 
and congestive heart failure.", General Medicine, Multiple Medical Problems - Discharge Summary ,"ADMISSION DIAGNOSES:,1.  Seizure.,2.  Hypoglycemia.,3.  Anemia.,4.  Hypotension.,5.  Dyspnea.,6.  Edema.,DISCHARGE DIAGNOSES:,1.  Colon cancer, status post right hemicolectomy.,2.  Anemia.,3.  Hospital-acquired pneumonia.,4.  Hypertension.,5.  Congestive heart failure.,6.  Seizure disorder.,PROCEDURES PERFORMED:,1.  Colonoscopy.,2.  Right hemicolectomy.,HOSPITAL COURSE: , The patient is a 59-year-old female with multiple medical problems including diabetes mellitus requiring insulin for 26 years, previous MI and coronary artery disease, history of seizure disorder, GERD, bipolar disorder, and anemia.  She was admitted due to a seizure and myoclonic jerks as well as hypoglycemia and anemia.  Regarding the seizure disorder, Neurology was consulted.  Noncontrast CT of the head was negative.  Neurology felt that the only necessary intervention at that time would be to increase her Lamictal to 150 mg in the morning and 100 mg in the evening with gradual increase of the dosage until she was on 200 mg b.i.d.  Regarding the hypoglycemia, the patient has diabetic gastroparesis and was being fed on J-tube intermittent feedings throughout the night at the rate of 120 an hour.  Her insulin pump had a basal rate of roughly three at night during the feedings.  While in the hospital, the insulin pump rate was turned down to 1.5 and then subsequently decreased a few other times.  She seemed to tolerate the insulin pump rate well throughout her hospital course.  There were a few episodes of hypoglycemia as well as hyperglycemia, but the episode seem to be related to the patient's n.p.o. status and the changing rates of tube feedings throughout her hospital course.,At discharge, her endocrinologist was contacted.  It was decided to change her insulin pump rate to 3 units per hour from midnight till 6 a.m., from 0.8 units per hour from 6 a.m. until 8 a.m., and then at 0.2 units per hour from 8 a.m. until 6 p.m.  The insulin was to be NovoLog.  Regarding the anemia, the gastroenterologists were consulted regarding her positive Hemoccult stools.  A colonoscopy was performed, which found a mass at the right hepatic flexure.  General Surgery was then consulted and a right hemicolectomy was performed on the patient.  The patient tolerated the procedure well and tube feeds were slowly restarted following the procedure, and prior to discharge were back at her predischarge rates of 120 per hour.  Regarding the cancer itself, it was found that 1 out of 53 nodes were positive for cancer.  CT of the abdomen and pelvis revealed no metastasis, a CT of the chest revealed possible lung metastasis.  Later in hospital course, the patient developed a septic-like picture likely secondary to hospital-acquired pneumonia.  She was treated with Zosyn, Levaquin, and vancomycin, and tolerated the medications well.  Her symptoms decreased and serial chest x-rays were followed, which showed some resolution of the illness.  The patient was seen by the Infectious Disease specialist.  The Infectious Disease specialist recommended vancomycin to cover MRSA bacteria, which was found at the J-tube site.  At discharge, the patient was given three additional days of p.o. Levaquin 750 mg as well as three additional days of Bactrim DS every 12 hours.  The Bactrim was used to cover the MRSA at the J-tube site.  It was found that MRSA was sensitive to Bactrim.  Throughout her hospital course, the patient continued to receive Coreg 12.5 mg daily and Lasix 40 mg twice a day for her congestive heart failure, which remains stable.  She also received Lipitor for her high cholesterol.  Her seizure disorder remained stable and she was discharged on a dose of 100 mg in the morning and 150 mg at night.  The dosage increases can begin on an outpatient basis.,DISCHARGE INSTRUCTIONS/MEDICATIONS: , The patient was discharged to home.  She was told to shy away from strenuous activity.  Her discharge diet was to be her usual diet of isotonic fiber feeding through the J-tube at a rate of 120 per hour throughout the night.  The discharge medications were as follows:,1.  Coreg 12.5 mg p.o. b.i.d.,2.  Lipitor 10 mg p.o. at bedtime.,3.  Nitro-Dur patch 0.3 mg per hour one patch daily.,4.  Phenergan syrup 6.25 mg p.o. q.4h. p.r.n.,5.  Synthroid 0.175 mg p.o. daily.,6.  Zyrtec 10 mg p.o. daily.,7.  Lamictal 100 mg p.o. daily.,8.  Lamictal 150 mg p.o. at bedtime.,9.  Ferrous sulfate drops 325 mg, PEG tube b.i.d.,10.  Nexium 40 mg p.o. at breakfast.,11.  Neurontin 400 mg p.o. t.i.d.,12.  Lasix 40 mg p.o. b.i.d.,13.  Fentanyl 50 mcg patch transdermal q.72h.,14.  Calcium and vitamin D combination, calcium carbonate 500 mg/vitamin D 200 units one tab p.o. t.i.d.,15.  Bactrim DS 800mg/160 mg tablet one tablet q.12h. x3 days.,16.  Levaquin 750 mg one tablet p.o. x3 days.,The medications listed above, one listed as p.o. are to be administered via the J-tube.,FOLLOWUP:  ,The patient was instructed to see Dr. X in approximately five to seven days.  She was given a lab sheet to have a CBC with diff as well as a CMP to be drawn prior to her appointment with Dr. X.  She is instructed to follow up with Dr. Y if her condition changes regarding her colon cancer.  She was instructed to follow up with Dr. Z, her oncologist, regarding the positive lymph nodes.  We were unable to contact Dr. Z, but his telephone number was given to the patient and she was instructed to make a followup appointment.  She was also instructed to follow up with her endocrinologist, Dr. A, regarding any insulin pump adjustments, which were necessary and she was also instructed to follow up with Dr. B, her gastroenterologist, regarding any issues with her J-tube.,CONDITION ON DISCHARGE: , Stable.",
" Multiple contusions and abdominal pain, status post motor vehicle collision. ", General Medicine, Motor Vehicle Accident ,"CHIEF COMPLAINT: , Motor vehicle accident.,HISTORY OF PRESENT ILLNESS: , This is a 32-year-old Hispanic female who presents to the emergency department today via ambulance.  The patient was brought by ambulance following a motor vehicle collision approximately 45 minutes ago.  The patient states that she was driving her vehicle at approximately 40 miles per hour.  The patient was driving a minivan.  The patient states that the car in front of her stopped too quickly and she rear-ended the vehicle ahead of her.  The patient states that she was wearing her seatbelt.  She was driving.  There were no other passengers in the van.  The patient states that she was restrained by the seatbelt and that her airbag deployed.  The patient denies hitting her head.  She states that she does have some mild pain on the left aspect of her neck.  The patient states that she believes she may have passed out shortly after the accident.  The patient states that she also has some pain low in her abdomen that she believes is likely due to the steering wheel or deployment on the airbag.  The patient denies any pain in her knees, ankles, or feet.  She denies any pain in her shoulders, elbows, and wrists.  The patient does state that she is somewhat painful throughout the bones of her pelvis as well.  The patient did not walk after this accident.  She was removed from her car and placed on a backboard and immobilized.  The patient denies any chest pain or difficulty breathing.  She denies any open lacerations or abrasions.  The patient has not had any headache, nausea or vomiting.  She has not felt feverish or chilled.  The patient does states that there is significant deformity to the front of the vehicle that she was driving, which again was a minivan.  There were no oblique vectors or force placed on this accident.  The patient had straight rear-ending of the vehicle in front of her.  The pain in her abdomen is most significant pain currently and she ranks it at 5 out of 10.  The patient states that her last menstrual cycle was at the end of May.  She does not believe that she could be pregnant.  She is taking oral birth control medications and also has an intrauterine device to prevent pregnancy as the patient is on Accutane.,PAST MEDICAL HISTORY:,  No significant medical history other than acne.,PAST SURGICAL HISTORY:,  None.,SOCIAL HABITS: ,  The patient denies tobacco, alcohol or illicit drug usage.,MEDICATIONS:,  Accutane.,ALLERGIES: , No known medical allergies.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL:  This is a Hispanic female who appears her stated age of 32 years.  She is well-nourished, well-developed, in no acute distress.  The patient is pleasant.  She is immobilized on a backboard and also her cervical spine is immobilized as well on a collar.  The patient is without capsular retractions, labored respirations or accessory muscle usage.  She responds well and spontaneously.,VITAL SIGNS:  Temperature 98.2 degrees Fahrenheit, blood pressure 129/84, pulse 75, respiratory rate 16, and pulse oximetry 97% on room air.,HEENT:  Head is normocephalic.  There is no crepitus.  No bony step-offs.  There are no lacerations on the scalp.  Sclerae are anicteric and noninjected.  Fundoscopic exam appears normal without papilledema.  External ocular movements are intact bilaterally without nystagmus or entrapment.  Nares are patent and free of mucoid discharge.  Mucous membranes are moist and free of exudate or lesions.,NECK:  Supple.  No thyromegaly.  No JVD.  No carotid bruits.  Trachea is midline.  There is no stridor.,HEART:  Regular rate and rhythm.  Clear S1 and S2.  No murmur, rub or gallop is appreciated.,LUNGS:  Clear to auscultation bilaterally.  No wheezes, rales, or rhonchi.,ABDOMEN:  Soft, nontender with the exception of mild-to-moderate tenderness in the bilateral lower pelvic quadrants.  There is no organomegaly here.  Positive bowel sounds are auscultated throughout.  There is no rigidity or guarding.  Negative CVA tenderness bilaterally.,EXTREMITIES:  No edema.  There are no bony abnormalities or deformities.,PERIPHERAL VASCULAR:  Capillary refill is less than two seconds in all extremities.  The patient does have intact dorsalis pedis and radial pulses bilaterally.,PSYCHIATRIC:  Alert and oriented to person, place, and time.  The patient recalls all events regarding the accident today.,NEUROLOGIC:  Cranial nerves II through XII are intact bilaterally.  No focal deficits are appreciated.  The patient has equal and strong distal and proximal muscle group strength in all four extremities.  The patient has negative Romberg and negative pronator drift.,LYMPHATICS:  No appreciable adenopathy.,MUSCULOSKELETAL:  The patient does have pain free range of motion at the bilateral ankles, bilateral knees, bilateral hips, bilateral shoulders, bilateral elbows, and bilateral wrists.  There are no bony abnormalities identified.  The patient does have some mild tenderness over palpation of the bilateral iliac crests.,SKIN:  Warm, dry, and intact.  No lacerations.  There are no abrasions other than a small abrasion on the patient's abdomen just inferior to the umbilicus.  No lacerations and no sites of trauma or bleeding are identified.,DIAGNOSTIC STUDIES: , The patient does have multiple x-rays done.  There is an x-ray of the pelvis, which shows normal pelvis and right hip.  There is also a CT scan of the cervical spine that shows no evidence of acute traumatic bony injury of the cervical spine.  There is some prevertibral soft tissue swelling from C5 through C7.  This is nonspecific and could be due to prominence of upper esophageal sphincter.  The CT scan of the brain without contrast shows no evidence of acute intracranial injury.  There is some mucus in the left sphenoid sinus.  The patient also has emergent CT scan without contrast of the abdomen.  The initial studies show some dependent atelectasis in both lungs.  There is also some low density in the liver, which could be from artifact or overlying ribs; however, a CT scan with contrast is indicated.  A CT scan with contrast is obtained and this is found to be normal without bleeding or intraabdominal or pelvic abnormalities.  The patient has laboratory studies done as well.  CBC is within normal limits without anemia, thrombocytopenia or leukocytosis.  The patient has a urine pregnancy test, which is negative and urinalysis shows no blood and is normal.,EMERGENCY DEPARTMENT COURSE: , The patient was removed from the backboard within the first half hour of her emergency department stay.  The patient has no significant bony deformities or abnormalities.  The patient is given a dose of Tylenol here in the emergency department for treatment of her pain.  Her pain is controlled with medication and she is feeling more comfortable and removed from the backboard.  The patient's CT scans of the abdomen appeared normal.  She has no signs of bleeding.  I believe, she has just a contusion and abrasion to her abdomen from the seatbelt and likely from the airbag as well.  The patient is able to stand and walk through the emergency department without difficulty.  She has no abrasions or lacerations.,ASSESSMENT AND PLAN:,  Multiple contusions and abdominal pain, status post motor vehicle collision.  Plan is the patient does not appear to have any intraabdominal or pelvic abnormities following her CT scans.  She has normal scans of the brain and her C-spine as well.  The patient is in stable condition.  She will be discharged with instructions to return to the emergency department if her pain increases or if she has increasing abdominal pain, nausea or vomiting.  The patient is given a prescription for Vicodin and Flexeril to use it at home for her muscular pain.",
 Nausea and feeling faint.  She complains of some nausea.  She feels weak.  The patient is advised to put salt on her food for the next week.  , General Medicine, Nausea - ER Visit ,"CHIEF COMPLAINT: , Nausea and feeling faint.,HPI:  ,The patient is a 74-year-old white female brought in by husband.  The patient is a vague historian at times.  She reports her appetite has been fair over the last several days.  Today, she complains of some nausea.  She feels weak.  No other specific complaints.,REVIEW OF SYSTEMS:  ,The patient denies fever, chills, sweats, ear pain, URI symptoms, cough, dyspnea, chest pain, vomiting, diarrhea, abdominal pain, melena, hematochezia, urinary symptoms, headache, neck pain, back pain, weakness or paresthesias in extremities.,CURRENT MEDICATIONS:  ,Diovan, estradiol, Norvasc, Wellbutrin SR inhaler, and home O2.,ALLERGIES: , MORPHINE CAUSES VOMITING.,PAST MEDICAL HISTORY:  ,COPD and hypertension.,HABITS:  ,Tobacco use, averages two cigarettes per day.  Alcohol use, denies.,LAST TETANUS IMMUNIZATION: , Not sure.,LAST MENSTRUAL PERIOD: , Status post hysterectomy.,SOCIAL HISTORY:  ,The patient is married and retired.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Temperature 98.2, pulse is 105, respirations 20, and BP 137/80.  GENERAL:  A well developed, well nourished, alert, cooperative, nontoxic, and appears hydrated.  SKIN:  Warm, dry, and good color.  EYES:  EOMI.  PERRL.  MOUTH:  Clear.  Mucous membranes moist.  NECK:  Supple.  No JVD.  LUNGS:  Reveal faint expiratory wheeze heard in the posterior lung fields.  HEART:  Slightly tachycardic without murmur.  ABDOMEN:  Soft, positive bowel sounds, and nontender.  No rebound or guarding is appreciated.  BACK:  No CVA tenderness.  EXTREMITIES:  Moves all four extremities.  No pretibial edema.  NEURO:  Cranial nerves II to XII, motor, and cerebellar are grossly intact and nonfocal.,LABORATORY STUDIES: , WBC 9200, differential with 82 neutrophils, 8 lymphocytes, 6 monocytes, and 4 eosinophils.  Hemoglobin 10.7 and hematocrit 31.2 both are decreased.  Comprehensive medical profile normal except for decreased sodium of 129, decreased chloride of 92, calcium decreased 8.4, total protein decreased 6.1, and albumin decreased 3.2.  Amylase and lipase both normal.  Clean catch urinalysis is unremarkable.  Review of EMR indicates on 05/09/06 hemoglobin was 12.1, on 05/10/07 hemoglobin was 9.9, and today hemoglobin is 10.7.  It seems to indicate that the patient had previous problems with anemia.,RADIOLOGY STUDIES: , Chest x-ray indicates chronic changes, reviewed by me, official report is pending.,ED STUDIES: , O2 sat on room air is 92%, which is satisfactory for this patient with COPD.  Monitor indicates sinus tachycardia at rate 103.  No ectopy.,ED COURSE:  ,The patient was assessed for orthostatic vital sign changes and none were detected by the nurse.  The patient was given albuterol unit dose small volume nebulizer treatment.  Repeat lung exam reveals resolution of expiratory wheezing.  The patient later had normal saline lock started by the nurse.  She was given IV fluids of normal saline 1L wide open over approximately one hour.  She was able to void urine indicating that she is well hydrated.  Rectal examination was performed with female nurse in attendance.  Good sphincter tone.  No masses.  The rectal secretions were heme negative.  The patient was reassessed.  She feels slightly better.  Monitor now shows normal sinus rhythm, rate 81, no ectopy.  Blood pressure is 136/66.  The patient is stable and will be discharged.,MEDICAL DECISION MAKING: , This patient presents with the above history.  Laboratory evaluation today indicates the following problems, anemia and hyponatremia.  This could contribute the patient's feelings of tiredness and not feeling well.  There is no evidence of rectal bleeding at this time.  The patient was advised that she needs to follow up with Dr. X to further investigate these problems.  The patient is hemodynamically stable and will be discharged.,ASSESSMENT:,1.  Acute tiredness.,2.  Anemia of unknown etiology.,3.  Acute hyponatremia.,PLAN:  ,The patient is advised to put salt on her food for the next week.  Should be given discharge instruction sheet for anemia.  Recommend follow up with personal physician, Dr. X in two to three days for recheck.  Return to ED sooner if condition changes or worsen anyway.  Discharged in stable condition.",
" Patient started out having toothache, now radiating into his jaw and towards his left ear.  Ellis type II dental fracture.", General Medicine, Jaw Pain - ER Visit ,"CHIEF COMPLAINT: , Jaw pain.,HISTORY OF PRESENT ILLNESS:  ,This is a 58-year-old male who started out having toothache in the left lower side of the mouth that is now radiating into his jaw and towards his left ear.  Triage nurse reported that he does not believe it is his tooth because he has regular dental appointments, but has not seen a dentist since this new toothache began.  The patient denies any facial swelling.  No headache.  No swelling to the throat.  No sore throat.  No difficulty swallowing liquids or solids.  No neck pain.  No lymph node swelling.  The patient denies any fever or chills.  Denies any other problems or complaints.,REVIEW OF SYSTEMS:,  CONSTITUTIONAL:  No fever or chills.  No fatigue or weakness.  HEENT:  No headache.  No neck pain.  No eye pain or vision change.  No rhinorrhea.  No sinus congestion, pressure, or pain.  No sore throat.  No throat swelling.  The patient does have the toothache on the left lower side that radiates towards his left ear as previously described.  The patient does not have ear pain or hearing change.  No pressure in the ear.  CARDIOVASCULAR:  No chest pain.  RESPIRATIONS:  No shortness of breath.  GASTROINTESTINAL:  No nausea or vomiting.  No abdominal pain.  MUSCULOSKELETAL:  No back pain.  SKIN:  No rashes or lesions.  NEUROLOGIC:  No vision or hearing change.  No speech change.  HEMATOLOGIC/LYMPHATIC:  No lymph node swelling.,PAST MEDICAL HISTORY: , None.,PAST SURGICAL HISTORY:,  None.,CURRENT MEDICATIONS: , None.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient smokes marijuana.  The patient does not smoke cigarettes.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Temperature 98.2 oral, blood pressure is 168/84, pulse is 87, respirations 16, and oxygen saturation is 100% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished, well developed.  The patient appears to be healthy.  The patient is calm, comfortable in no acute distress, looks well.  The patient is pleasant and cooperative.  HEENT:  Head is atraumatic, normocephalic, and nontender.  Eyes are normal with clear cornea and conjunctivae bilaterally.  Nose, normal without rhinorrhea or audible congestion.  There is no tenderness over the sinuses.  Ears are normal without any sign of infection.  No erythema or swelling of the canals.  Tympanic membranes are intact and normal without any erythema, bulging, air fluid levels, or bubbles behind it.  MOUTH:  The patient has a dental fracture at tooth #18.  The patient states that the fracture is a couple of months old.  The patient does not have any obvious dental caries.  The gums are normal without any erythema, swelling, or evidence of infection.  There is no fluctuance or suggestion of abscess.  There is slight tenderness of the tooth #18.  The oropharynx is normal without any sign of infection.  There is no erythema, exudate, lesion, or swelling.  Mucous membranes are moist.  Floor of the mouth is normal without any tenderness or swelling.  No suggestion of abscess.  There is no pre or post auricular lymphadenopathy either.  NECK:  Supple.  Nontender.  Full range of motion.  No meningismus.  No cervical lymphadenopathy.  No JVD.  No carotid artery or vertebral artery bruits.  CARDIOVASCULAR:  Heart is regular rate and rhythm without murmur, rub, or gallop.  RESPIRATIONS:  Clear to auscultation bilaterally.  No shortness of breath.  GASTROINTESTINAL:  Abdomen is normal and nontender.  MUSCULOSKELETAL:  No abnormalities are noted to the back, arms, or legs.  The patient has normal use of the extremities.  SKIN:  No rashes or lesions.  NEUROLOGIC:  Cranial nerves II through XII are intact.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is alert and oriented x4.  Normal mood and affect.  No evidence of clinical intoxification.  HEMATOLOGIC/LYMPHATIC:  No lymphadenitis is palpated.,DIAGNOSES:,1.  ACUTE LEFT JAW PAIN.,2.  #18 DENTAL FRACTURE, WHICH IS AN ELLIS TYPE II FRACTURE.,3.  ELEVATED BLOOD PRESSURE.,CONDITION UPON DISPOSITION: , Stable.,DISPOSITION:,  Home.,PLAN: , We will have the patient follow up with his dentist Dr. X in three to five days for reevaluation.  The patient was encouraged to take Motrin 400 mg q.6h. as needed for pain.  The patient was given prescription for Vicodin for any breakthrough or uncontrolled pain.  He was given precautions for drowsiness and driving with the use of this medication.  The patient was also given a prescription for pen V.  The patient was given discharge instructions on toothache and asked to return to emergency room should he have any worsening of his condition, develop any other problems or symptoms of concern.","general medicine, jaw pain, dental appointment, ellis type ii fracture, ellis type, dental fracture, toothache, tenderness, pressure, erythema, "
" Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath. ", General Medicine, Melena - ICU Followup ,"HISTORY:,  Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath.  Please see dictated ICU transfer note yesterday detailing the need for emergent transfer transfusion and EGD in this patient.  Over the last 24 hours, the patient has received 2 units of packed red blood cells and his hematocrit and hemoglobin have returned to their baseline of approximately 11 appropriate for hemoglobin value.  He also underwent EGD earlier today with Dr. X.  I have discussed the case with him at length earlier this afternoon and the patient had symptoms of ulcerative esophagitis with no active bleeding.  Dr. X recommended to increase the doses of his proton pump inhibitor and to avoid NSAIDs in the future.  The patient today complains that he is still having issues with shortness of breath and wheezing and productive cough, now producing yellow-brown sputum with increasing frequency, but he has had no further episodes of melena since transfer to the ICU.  He is also complaining of some laryngitis and some pharyngitis, but is denying any abdominal complaints, nausea, or diarrhea.,PHYSICAL EXAMINATION,VITAL SIGNS:  Blood pressure is 100/54, heart rate 80 and temperature 98.8.  Is and Os negative fluid balance of 1.4 liters in the last 24 hours.,GENERAL:  This is a somnolent 68-year-old male, who arouses to voice, wakes up, seems to have good appetite, has continuing cough.  Pallor is improved.,EYES:  Conjunctivae are now pink.,ENT:  Oropharynx is clear.,CARDIOVASCULAR:  Reveals distant heart tones with regular rate and rhythm.,LUNGS:  Have coarse breath sounds with wheezes, rhonchi, and soft crackles in the bases.,ABDOMEN:  Soft and nontender with no organomegaly appreciated.,EXTREMITIES:  Showed no clubbing, cyanosis or edema.  Capillary refill time is now normal in the fingertips.,NEUROLOGICAL:  Cranial nerves II through XII are grossly intact with no focal neurological deficits.,LABORATORY DATA:,  Laboratories drawn at 1449 today, WBC 10, hemoglobin and hematocrit 11.5 and 33.1, and platelets 288,000.  This is up from 8.6 and 24.7.  Platelets are stable.  Sodium is 134, potassium 4.0, chloride 101, bicarb 26, BUN 19, creatinine 1.0, glucose 73, calcium 8.4, INR 0.96, iron 13%, saturations 4%, TIBC 312, TSH 0.74, CEA elevated at 8.6, ferritin 27.5 and occult blood positive.  EGD, final results pending per Dr. X's note and conversation with me earlier, ulcerative esophagitis without signs of active bleeding at this time.,IMPRESSION/PLAN,1.  Melena secondary to ulcerative esophagitis.  We will continue to monitor the patient overnight to ensure there is no further bleeding.  If there are no further episodes of melena and hemoglobin is stable or unchanged in the morning, the patient will be transferred back to medical floor for continuing treatment of his chronic obstructive pulmonary disease exacerbation.,2.  Chronic obstructive pulmonary disease exacerbation.  The patient is doing well, taking PO.  We will continue him on his oral Omnicef and azithromycin and continuing breathing treatments.  We will add guaifenesin and N-acetyl-cysteine in a hope to mobilize some of his secretions.  This does appear to be improving.  His white count is normalized and I am hopeful we can discharge him on oral antibiotics within the next 24 to 48 hours if there are no further complications.,3.  Elevated CEA.  The patient will need colonoscopy on an outpatient basis.  He has refused this today.  We would like to encourage him to do so.  Of note, the patient when he came in was on bloodless protocol, but with urging did accept the transfusion.  Similarly, I am hoping that with proper counseling, the patient will consent to further examination with colonoscopy given his guaiac-positive status, elevated CEA and risk factors.,4.  Anemia, normochromic normocytic with low total iron binding capacity.  This appears to be anemia of chronic disease.  However, this is likely some iron deficiency superimposed on top of this given his recent bleeding, with consider iron, vitamin C, folate and B12 supplementation and discharge given his history of alcoholic malnutrition and recent gastrointestinal bleeding.  Total critical care time spent today discussing the case with Dr. X, examining the patient, reviewing laboratory trends, adjusting medications and counseling the patient in excess is 35 minutes.","general medicine, anemia, gi bleeding, hemoglobin, ulcerative, esophagitis, obstructive pulmonary disease, icu followup, infection, obstructive, pulmonary, egd, melena, bleeding"
" A 10-day-old Caucasian female with bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then.", General Medicine, Infantile Spasms ,"CHIEF COMPLAINT:,  Arm and leg jerking.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 10-day-old Caucasian female here for approximately 1 minute bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then.  Mom denies any apnea, perioral cyanosis, or color changes.  These movements are without any back arching.  They mainly occur during sleep, so mom is unaware of any eye rolling.  Mom is able to wake the patient up during this periods and stop the patient's extremity movements.,Otherwise, this patient has been active, breast-feeding well, although she falls asleep at the breast.  She is currently taking in 15 to 20 minutes of breast milk every 2 to 3 hours.  She is having increased diapers up to 8 wet and 6 to 7 dirty-yellow stools per day.,REVIEW OF SYSTEMS:,  Negative fever, negative fussiness, tracks with her eyes, some sneezing and hiccups.  This patient has developed some upper airway congestion in the past day.  She has not had any vomiting or diarrhea.  Per mom, she does not spit up, and mom is also unable to notice any relationship between these movements and feeds.  This patient has not had any rashes.  Mom was notified by the nurses at birth that her temperature may be low of approximately 97.5 degrees Fahrenheit.  Otherwise, the above history of present illness and other review of systems negative.,BIRTH/PAST MEDICAL HISTORY: , The patient was an 8 pound 11 ounce baby, ex-41-weeker born via vaginal delivery without vacuum assist or forceps.  There were no complications during pregnancy such as diabetes or hypertension.  Prenatal care started at approximately 3 weeks, and mom maintained all visits.  She also denies any smoking, alcohol, or drug use during the pregnancy.  Mom was GBS status positive, but denies any other infections such as urinary tract infections.  She did not have any fever during labor and received inadequate intrapartum antibiotics prophylaxis.  After delivery, this patient did not receive antibiotics secondary to ""borderline labs.""  She was jaundiced after birth and received photo treatments.  Her discharge bilirubin level was approximately 11.  Mom and child stayed in the hospital for approximately 3-1/2 days.,Mom denies any history of sexually transmitted disease in her or dad.  She specifically denies any blistering, herpetic genital lesions.  She does have a history though of human papillomavirus warts (vaginal), removed 20 years ago.,PAST SURGICAL HISTORY:,  Negative.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , None.,SOCIAL HISTORY: , At home live mom, dad, and 18-, 16-, 14-, 12-year-old brothers, and a 3-year-old sister.  All the residents at home are sick currently with cold, cough, runny nose, except for mom.  At home also live 2 dogs and 2 outside cats.  Mom denies any recent travel history, especially during the recent holidays and no smoke exposures.,FAMILY HISTORY:,  Dad is with a stepdaughter with seizures starting at 14 years old, on medications currently.  The patient's 16-year-old brother has incessant nonsustained ventricular tachycardia.  The maternal grandmother is notable for hypertension and diabetes.  There are no other children in the family who see a specialist or no child death less than 1 year of age.,PHYSICAL EXAMINATION:",
" Local reaction secondary to insect sting.  Patient was stung by a bee on his right hand, left hand, and right knee at approximately noon today. ", General Medicine, Insect Sting ,"HISTORY OF PRESENT ILLNESS:,  Patient is a 76-year-old white male who presents with his wife stating that he was stung by a bee on his right hand, left hand, and right knee at approximately noon today.  He did not note any immediate reaction.  Since that time, he has noted some increasing redness and swelling to his left hand, but he denies any generalized symptoms such as itching, hives, or shortness of breath.  He denies any sensation of tongue swelling or difficulty swallowing.,The patient states he was stung approximately one month ago without any serious reaction.  He did windup taking Benadryl at that time.  He has not taken anything today for his symptoms, but he is on hydrochlorothiazide and metoprolol for hypertension as well as a baby aspirin each day.,ALLERGIES: , HE DOES HAVE MEDICATION INTOLERANCES TO SULFA DRUGS (HEADACHE), MORPHINE (NAUSEA AND VOMITING), AND TORADOL (ULCER).,SOCIAL HISTORY: , Patient is married and is a nonsmoker and lives with his wife, who is here with him.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS:  Temp and vital signs are all within normal limits.,GENERAL:  In general, the patient is an elderly white male who is sitting on the stretcher in no acute distress.,HEENT:  Head is normocephalic and atraumatic.  The face shows no edema.  The tongue is not swollen and the airway is widely patent.,NECK:  No stridor.,HEART:  Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS:  Clear without rales, rhonchi, or wheezes.,EXTREMITIES:  Upper extremities, there is some edema and erythema to the dorsum of the left hand in the region of the distal third to fifth metacarpals.  There was some slight edema of the fourth digit, on which he still is wearing his wedding band.  The right hand shows no reaction.  The right knee is not swollen either.,The left fourth digit was wrapped in a rubber tourniquet to express the edema and using some Surgilube, I was able to remove his wedding band without any difficulty.  Patient was given Claritin 10 mg orally for what appears to be a simple local reaction to an insect sting.  I did explain to him that his swelling and redness may progress over the next few days.,ASSESSMENT: , Local reaction secondary to insect sting.,PLAN: , The patient was reassured that this is not a serious reaction to an insect sting and he should not progress to such a reaction.  I did urge him to use Claritin 10 mg once daily until the redness and swelling has gone.  I did explain that the swelling may worsen over the next two to three days, it may produce a large local reaction, but that anti-histamines were still the mainstay of therapy for such a reaction.  If he is not improved in the next four days, follow up with his PCP for a re-exam.","general medicine, stung by a bee, local reaction, insect sting, reaction, insect, bee, knee, edema, sting, swelling, hand"
" Pancreatic and left adrenal lesions.  The adrenal lesion is a small lesion, appears as if probable benign adenoma, where as the pancreatic lesion is the cystic lesion, and neoplasm could not be excluded. ", General Medicine, Lesions - Adrenal and Pancreatic ,"CHIEF COMPLAINT: , Both pancreatic and left adrenal lesions.,HISTORY OF PRESENT ILLNESS:,  This 60-year-old white male is referred to us by his medical physician with a complaint of recent finding of a both pancreatic lesion and lesions with left adrenal gland.  The patient's history dates back to at the end of the January of this past year when he began experiencing symptoms consistent with difficulty almost like a suffocating feeling whenever he would lie flat on his back.  He noticed whenever he would recline backwards, he would begin this feeling and it is so bad now that he can barely recline, very little before he has this feeling.  He is now sleeping in an upright position.  He was sent for CAT scan originally of his chest.  The CAT scan of the chest reveals a pneumonitis, but also saw a left adrenal nodule and a small pancreatic lesion.  He was subsequently was sent for a dedicated abdominal CAT scan and MRI.  The CAT scan revealed 1.8-cm lesion of his left adrenal gland, suspected to be a benign adenoma.  The pancreas showed pancreatic lesion towards the mid body tail aspect of the pancreas, approximately 1 cm, most likely of cystic nature.  Neoplasm could not be excluded.  He was referred to us for further assessment.  He denies any significant abdominal pain, any nausea or vomiting.  His appetite is fine.  He has had no significant changes in his bowel habits or any rectal bleeding or melena.  He has undergone a colonoscopy in September of last year and was found to have three adenomatous polyps.  He does have a history of frequent urination.  Has been followed by urologist for this.  There is no family history of pancreatic cancer.  There is a history of gallstone pancreatitis in the patient's sister.,PAST MEDICAL HISTORY:,  Significant for hypertension, type 2 diabetes mellitus, asthma, and high cholesterol.,ALLERGIES: , ENVIRONMENTAL.,MEDICATIONS:,  Include glipizide 5 mg b.i.d., metformin 500 mg b.i.d., Atacand 16 mg daily, metoprolol 25 mg b.i.d., Lipitor 10 mg daily, pantoprazole 40 mg daily, Flomax 0.4 mg daily, Detrol 4 mg daily, Zyrtec 10 mg daily, Advair Diskus 100/50 mcg one puff b.i.d., and fluticasone spray 50 mcg two sprays daily.,PAST SURGICAL HISTORY:,  He has not had any previous surgery.,FAMILY HISTORY: , His brothers had prostate cancer.  Father had brain cancer.  Heart disease in both sides of the family.  Has diabetes in his brother and sister.,SOCIAL HISTORY:,  He is a non-cigarette smoker and non-ETOH user.  He is single and he has no children.  He works as a payroll representative and previously did lot of work in jewelry business, working he states with chemical.,REVIEW OF SYSTEMS: , He denies any chest pain.  He admits to exertional shortness of breath.  He denies any GI problems as noted.  Has frequent urination as noted.  He denies any bleeding disorders or bleeding history.,PHYSICAL EXAMINATION:,GENERAL:  Presents as an obese 60-year-old white male, who appears to be in no apparent distress.,HEENT:  Unremarkable.,NECK:  Supple.  There is no mass, adenopathy or bruit.,CHEST:  Normal excursion.,LUNGS:  Clear to auscultation and percussion.,COR:  Regular.  There is no S3 or S4 gallop.  There is no obvious murmur.,HEART:  There is distant heart sounds.,ABDOMEN:  Obese.  It is soft.  It is nontender.  Examination was done as relatively sitting up as the patient was unable to recline.  Bowel sounds are present.  There is no obvious mass or organomegaly.,GENITALIA:  Deferred.,RECTAL:  Deferred.,EXTREMITIES:  Revealed about 1+ pitting edema.  Bilateral peripheral pulses are intact.,NEUROLOGIC:  Without focal deficits.  The patient is alert and oriented.,IMPRESSION:,  Both left adrenal and pancreatic lesions.  The adrenal lesion is a small lesion, appears as if probable benign adenoma, where as the pancreatic lesion is the cystic lesion, and neoplasm could not be excluded.  Given the location of these pancreatic lesions in the mid body towards the tail and size of 1 cm, the likelihood is an ERCP will be of no value and the likelihood is that it is too small to biopsy.  We are going to review x-rays with Radiology prior with the patient probably at some point will present for operative intervention.  Prior to that the patient will undergo an esophagogastroduodenoscopy.",
" Patient with Hypertension, atrial fibrillation, large cardioembolic stroke initially to the right brain requesting medical management", General Medicine, Medical Management Consult Request ,"CONSULT REQUEST FOR:, Medical management.,The patient has been in special procedures now for over 2 hours and I am unable to examine.,HISTORY OF PRESENT ILLNESS:, Obtained from Dr. A on an 81-year-old white female, who is right handed, who by history, had a large stroke to the right brain, causing left body findings, last night. She was unfortunately outside of the window for emergent treatment and had a negative CT scan of the head. Was started on protocol medication and that is similar to TPA, which is an investigational study.,During the evaluation she was found to be in atrial fibrillation on admission with hypertension that was treated with labetalol en route. Her heart rate was 130. She was brought down with Cardizem. She received the study drug in the night and about an hour later thought to have another large stroke effecting the opposite side of the brain, that the doctors and company think is probably cardioembolic and not related to the study drug, as TPA has no obvious known association with this.,At that time the patient became comatose and required emergent intubation and paralyzation. Her diastolic at that time rose up to 190, likely the result of the acute second stroke. She is currently in arteriogram and a clot has been extracted from the proximal left carotid, but there is still distal clot that they are working on. Dr. A has updated the family to her extremely guarded and critical prognosis.,At present, it is not known yet, we do not have the STAT echocardiogram, if she has a large clot in the heart or if she could have a patent foramen ovale clot in the legs that has been passed to the heart. Echo that is pending, and cannot be done till the patient is out of arteriogram, which is her lifesaving procedure right now.,REVIEW OF SYSTEMS:, Complete review of systems is unobtainable at present. From what I can tell, is that she is scheduled for an upcoming bladder distension surgery and I do not know if this is why she is off Coumadin for chronic AFib or what, at this point. Tremor for 3-4 years, diagnosed as early Parkinson's.,PAST MEDICAL HISTORY:, GERD, hypertension times 20 years, arthritis, Parkinson's, TIA, chronic atrial fibrillation, on Coumadin three years.,PAST SURGICAL HISTORY:, Cholecystectomy, TAH 33, gallstones, back surgery 1998, thoracotomy for unknown reason at present.,ALLERGIES:, MORPHINE, SULFAS (RASH), PROZAC.,MEDICATIONS AT HOME: Lanoxin 0.25 daily; Inderal LA 80 daily; MOBIC 7.5 daily; Robaxin 750 q.8; aspirin 80 one daily; acyclovir dose unknown daily; potassium, dose unknown; oxazepam 15 mg daily; aspirin 80 one daily; ibuprofen PRN; Darvocet-N 100 PRN.,SOCIAL HISTORY:, She does not drink or smoke. Lives in Fayetteville, Tennessee.,FAMILY HISTORY:, Mother died of cancer, unknown type. Dad died of an MI.,VACCINATION STATUS: Unknown.,PHYSICAL EXAMINATION:,VITAL SIGNS: On arrival were temperature 97.1, blood pressure 174/100, heart rate 100, 97%, respirations 15.,GENERAL: She was apparently alert and able to give history on arrival. Currently do not have any available vital signs or physical exam, as I cannot get to the patient.,LABORATORY: ,Reviewed and are remarkable for white count of 13 with 76 neutrophils. BMP is normal, except for a blood sugar of 157, hemoglobin A1c is pending. TSH 2.1, cholesterol 165, Digoxin 1.24, CPK 57. ABG 7.47/32/459 on 100%. Magnesium 1.5. ESR 9, coags normal.,EKG is pending my review.,Chest x-ray is read as mild cardiomegaly and atherosclerotic aorta.,Chest x-ray, shoulder films and CT scan of the head: I have reviewed. Chest x-ray has good ET tube placement. She has mild cardiomegaly. Some mild interstitial opacities consistent with OGD and minimal amount of atherosclerosis of the aorta.,CT scan of the head: I do not see any active bleeding.,X-rays of the shoulders appear intact to me and we are awaiting radiologies final approval on those.,ASSESSMENT/PLAN/PROBLEMS:,1. Large cardioembolic stroke initially to the right brain, with devastating effects, and now stroke into the left brain as well, with fluctuating mental status. Obviously she is in critical condition and stable with multiple strokes. One must also wonder if she could have a large clot burden below the heart and patent foramen ovale, etc. We need STAT records from her prior cardiologist and prior echocardiogram report to see exactly what are the details. I have ordered a STAT echo and to have the group that sees her read it, that if he has a large clot burdened in the heart or has distal clot with a PFO we may be able to better prognosticate at this point. Obviously, she cannot have any anticoagulants, except for the study drug, at present, which is her only chance and hopefully they will be able to retrieve most of the clot with emergency retrieval device as activated heroically, by Dr. A and interventional radiology.,2. Hypertension/atrial fibrillation: This will be a difficult management and the fact that she has been on a beta-blocker for Parkinson's, she may have withdrawal to the beta-blockers as we remove this. Given her atrial fibrillation, I do agree the safest agent right now is to use a Cardizem drip as needed and would use it for systolic greater than 160 to 180, or diastolics greater than 90 to 100. Also, would use it to control the atrial fibrillation. We would, however, be very cautious not to put her in heart block with the Digoxin and the beta-blocker on board. Weighing all risks and benefits, I think that given the fact that she has a beta-blocker on board and Digoxin, we would like to avoid the beta-blocker for vasospasm protection and will favor using calcium channel blocker for now. If, however, we run into trouble with this, I would prefer to switch her to Brevibloc or an Esmolol drip and see how she does, as she may withdraw from the beta-blocker. I will be watching this closely and managing the hypertension as I see fit at the moment, based on all factors. Will also ask cardiology if she has one that sees her here, to help guide this. Her Digoxin level is appropriate, as well as a TSH. I do not feel that we need to work this up further, other than the STAT echo and ultrasound of the leg.,3. Respiratory failure requiring ventilator: I have discussed this with Dr. Devlin, we do not feel the need to hyperventilate her at present. We will keep her comfortable on the breathing machine and try to keep her pH in a normal range, around 7.4, and her CO2 in the 30 to 40 range. If she has brain swelling, we will need to hyperventilate her to a pCO2 of 30 and a pH of 7.5, to optimize the cardiac arrhythmia potential of alkalosis weighed with the control of brain swelling.,4. Optimize electrolytes as you can.,5. Deep vein thrombosis prophylaxis for now, with thigh-high TED hose, possibly SCDs, although I do not have experience with the vampire/venom to know if we need to worry about DIC which the SCDs may worsen. Will follow daily CBCs for that.,6. Nutrition: Will go ahead and start a low dose of tube feeds and hope that she does survive.,I will defer all updates to the family for the next 24 to 48 hours to Dr. Devlin's expertise, given her unknown and fluctuating neurologic prognosis.,Thank you so much for allowing us to participate in her care. We will be happy to do all medication treatment until the point that I feel that I would need any help from critical care. I believe that we will be able to manage her fully at this point, for simplicity sake.",
 This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms., General Medicine, Itchy Rash - ER Visit ,"CHIEF COMPLAINT:,  Itchy rash.,HISTORY OF PRESENT ILLNESS: , This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms.  No facial swelling.  No tongue or lip swelling.  No shortness of breath, wheezing, or other associated symptoms.  He cannot think of anything that could have triggered this off.  There have been no changes in his foods, medications, or other exposures as far as he knows.  He states a couple of days ago he did work and was removing some insulation but does not remember feeling itchy that day.,PAST MEDICAL HISTORY: , Negative for chronic medical problems.  No local physician.  Has had previous back surgery and appendectomy, otherwise generally healthy.,REVIEW OF SYSTEMS: , As mentioned denies any oropharyngeal swelling.  No lip or tongue swelling.  No wheezing or shortness of breath.  No headache.  No nausea.  Notes itchy rash, especially on his torso and upper arms.,SOCIAL HISTORY: , The patient is accompanied with his wife.,FAMILY HISTORY: , Negative.,MEDICATIONS: , None.,ALLERGIES: , TORADOL, MORPHINE, PENICILLIN, AND AMPICILLIN.,PHYSICAL EXAMINATION: , VITAL SIGNS:  The patient was afebrile.  He is slightly tachycardic, 105, but stable blood pressure and respiratory rate.  GENERAL:  The patient is in no distress.  Sitting quietly on the gurney.  HEENT:  Unremarkable.  His oral mucosa is moist and well hydrated.  Lips and tongue look normal.  Posterior pharynx is clear.  NECK:  Supple.  His trachea is midline.  There is no stridor.  LUNGS:  Very clear with good breath sounds in all fields.  There is no wheezing.  Good air movement in all lung fields.  CARDIAC:  Without murmur.  Slight tachycardia.  ABDOMEN:  Soft, nontender.  SKIN:  Notable for a confluence erythematous, blanching rash on the torso as well as more of a blotchy papular, macular rash on the upper arms.  He noted some on his buttocks as well.  Remaining of the exam is unremarkable.,ED COURSE: , The patient was treated with epinephrine 1:1000, 0.3 mL subcutaneously along with 50 mg of Benadryl intramuscularly.  After about 15-20 minutes he states that itching started to feel better.  The rash has started to fade a little bit and feeling a lot more comfortable.,IMPRESSION:,  ACUTE ALLERGIC REACTION WITH URTICARIA AND PRURITUS.,ASSESSMENT AND PLAN: , The patient has what looks to be some type of allergic reaction, although the underlying cause is difficult to assess.  He will make sure he goes home to look around to see if there is in fact anything that changed recently that could have triggered this off.  In the meantime, I think he can be managed with some antihistamine over-the-counter.  He is responding already to Benadryl and the epinephrine that we gave him here.  He is told that if he develops any respiratory complaints, shortness of breath, wheezing, or tongue or lip swelling he will return immediately for evaluation.  He is discharged in stable condition.","general medicine, urticaria, pruritus, lip swelling, allergic reaction, itchy rash, torso, swelling, itchy, rash, "
" Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, and pharmacologic thrombolysis following placement of a vena caval filter.", General Medicine, Lymphoblastic Leukemia - Consult ,"CHIEF COMPLAINT: , Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, right iliac vein and inferior vena cava (IVC), status post balloon angioplasty, and mechanical and pharmacologic thrombolysis following placement of a vena caval filter.,HISTORY OF PRESENT ILLNESS: , The patient was transferred here the evening of 02/23/2007 from Hospital with a new diagnosis of high-risk acute lymphoblastic leukemia based on confirmation by flow cytometry of peripheral blood lymphoblasts that afternoon.  History related to this illness probably dates back to October of 2006 when he had onset of swelling and discomfort in the left testicle with what he described as a residual ""lump"" posteriorly.  The left testicle has continued to be painful off and on since.  In early November, he developed pain in the posterior part of his upper right leg, which he initially thought was related to skateboarding and muscle strain.  Physical therapy was prescribed and the discomfort temporarily improved.  In December, he noted onset of increasing fatigue.  He used to work out regularly, lifting lifts, doing abdominal exercises, and playing basketball and found he did not have energy to pursue these activities.  He has lost 10 pounds since December and feels his appetite has decreased.  Night sweats and cough began in December, for which he was treated with a course of Augmentin.  However, both of these problems have continued.  He also began taking Accutane for persistent acne in December (this agent was stopped on 02/19/2007).  Despite increasing fatigue and lethargy, he continues his studies at University of Denver, has a biology major (he aspires to be an ophthalmologist).,The morning of 02/19/2007, he awakened with severe right inguinal and right lower quadrant pain.  He was seen in Emergency Room where it was noted that he had an elevated WBC of 18,000.  CT scan of the abdomen was obtained to rule out possible appendicitis and on that CT, a large clot in the inferior vena cava extending to the right iliac and femoral veins was found.  He promptly underwent appropriate treatment in interventional radiology with the above-noted angioplasty and placement of a vena caval filter followed by mechanical and pharmacologic thrombolysis.  Repeat ultrasound there on 02/20/2007 showed no evidence of deep venous thrombosis (DVT).  Continuous intravenous unfractionated heparin infusion was continued.  Because there was no obvious cause of this extensive thrombosis, occult malignancy was suspected.  Appropriate blood studies were obtained and he underwent a PET/CT scan as part of his diagnostic evaluation.  This study showed moderately increased diffuse bone marrow metabolic activity.  Because the WBC continued to rise and showed a preponderance of lymphocytes, the smear was reviewed by pathologist, Sheryl Asplund, M.D., and flow cytometry was performed on the peripheral blood.  These studies became available the afternoon of 02/23/2007, and confirmed the diagnosis of precursor-B acute lymphoblastic leukemia.  The patient was transferred here after stopping of the continuous infusion heparin and receiving a dose of Lovenox 60 mg subcutaneously for further diagnostic evaluation and management of the acute lymphoblastic leukemia (ALL).,ALLERGIES: , NO KNOWN DRUG ALLERGIES.  HE DOES SEEM TO REACT TO CERTAIN ADHESIVES.,CURRENT MEDICATIONS:  ,1.  Lovenox 60 mg subcutaneously q.12h. initiated.,2.  Coumadin 5 mg p.o., was administered on 02/19/2007 and 02/22/2007.,3.  Protonix 40 mg intravenous (IV) daily.,4.  Vicodin p.r.n.,5.  Levaquin 750 mg IV on 02/23/2007.,IMMUNIZATIONS: , Up-to-date.,PAST SURGICAL HISTORY:  ,The treatment of the thrombosis as noted above on 02/19/2007 and 02/20/2007.,FAMILY HISTORY:  ,Two half-brothers, ages 26 and 28, both in good health.  Parents are in good health.  A maternal great-grandmother had a deep venous thrombosis (DVT) of leg in her 40s.  A maternal great-uncle developed leukemia around age 50.  A maternal great-grandfather had bone cancer around age 80.  His paternal grandfather died of colon cancer at age 73, which he had had since age 68.  Adult-onset diabetes is present in distant relatives on both sides.,SOCIAL HISTORY:  ,The patient is a student at the University majoring in biology.  He lives in a dorm there.  His parents live in Breckenridge.  He admits to having smoked marijuana off and on with friends and drinking beer off and on as well.,REVIEW OF SYSTEMS: , He has had emesis off and on related to Vicodin and constipation since 02/19/2007, also related to pain medication.  He has had acne for about two years, which he describes as mild to moderate.  He denied shortness of breath, chest pain, hemoptysis, dyspnea, headaches, joint pains, rashes, except where he has had dressings applied, and extremity pain except for the right leg pain noted above.,PHYSICAL EXAMINATION:  ,GENERAL:  Alert, cooperative, moderately ill-appearing young man.,VITAL SIGNS:  At the time of admission, pulse was 94, respirations 20, blood pressure 120/62, temperature 98.7, height 171.5 cm, weight 63.04 kg, and pulse oximetry on room air 95%.,HAIR AND SKIN:  Mild facial acne.,HEENT:  Extraocular muscles (EOMs) intact.  Pupils equal, round, and reactive to light and accommodation (PERRLA), fundi normal.,CARDIOVASCULAR:  A 2/6 systolic ejection murmur (SEM), regular sinus rhythm (RSR).,LUNGS:  Clear to auscultation with an occasional productive cough.,ABDOMEN:  Soft with mild lower quadrant tenderness, right more so than left; liver and spleen each decreased 4 cm below their respective costal margins.,MUSCULOSKELETAL:  Mild swelling of the dorsal aspect of the right foot and distal right leg.  Mild tenderness over the prior catheter entrance site in the right popliteal fossa and mild tenderness over the right medial upper thigh.,GENITOURINARY:  Testicle exam disclosed no firm swelling with mild nondiscrete fullness in the posterior left testicle.,NEUROLOGIC:  Exam showed him to be oriented x4.  Normal fundi, intact cranial nerves II through XII with downgoing toes, symmetric muscle strength, and decreased patellar deep tendon reflexes (DTRs).,LABORATORY DATA:  ,White count 25,500 (26 neutrophils, 1 band, 7 lymphocytes, 1 monocyte, 1 myelocyte, 64 blasts), hemoglobin 13.3, hematocrit 38.8, and 312,000 platelets.  Electrolytes, BUN, creatinine, phosphorus, uric acid, AST, ALT, alkaline phosphatase, and magnesium were all normal.  LDH was elevated to 1925 units/L (upper normal 670), and total protein and albumin were both low at 6.2 and 3.4 g/dL respectively.  Calcium was also slightly low at 8.8 mg/dL.  Low molecular weight heparin test was low at 0.27 units/mL.  PT was 11.8, INR 1.2, and fibrinogen 374.  Urinalysis was normal.,ASSESSMENT: , 1.  Newly diagnosed high-risk acute lymphoblastic leukemia.,2.  Deep vein thrombosis of the distal iliac and common femoral/right femoral and iliac veins, status post vena caval filter placement and mechanical and thrombolytic therapy, on continued anticoagulation.,3.  Probable chronic left epididymitis.,PLAN: , 1.  Proceed with diagnostic bone marrow aspirate/biopsy and lumbar puncture (using a #27-gauge pencil-tip needle for minimal trauma) as soon as these procedures can be safely done with regard to the anticoagulation status.,2.  Prompt reassessment of the status of the deep venous thrombosis with Doppler studies.,3.  Ultrasound/Doppler of the testicles.,4.  Maintain therapeutic anticoagulation as soon as the diagnostic procedures for ALL can be completed.,",
" Hypothermia.  Rule out sepsis, was negative as blood cultures, sputum cultures, and urine cultures were negative.  Organic brain syndrome.  Seizure disorder.  Adrenal insufficiency.  Hypothyroidism.  Anemia of chronic disease.", General Medicine, Hypothermia - Discharge Summary  ,"DIAGNOSIS AT ADMISSION: , Hypothermia.,DIAGNOSES ON DISCHARGE,1. Hypothermia.,2. Rule out sepsis, was negative as blood cultures, sputum cultures, and urine cultures were negative.,3. Organic brain syndrome.,4. Seizure disorder.,5. Adrenal insufficiency.,6. Hypothyroidism.,7. Anemia of chronic disease.,HOSPITAL COURSE:  ,The patient was admitted through the emergency room.  He was admitted to the Intensive Care Unit.  He was rewarmed and had blood, sputum, and urine cultures done.  He was placed on IV Rocephin.  His usual medications of Dilantin and Depakene were given.  The patient's hypertension was treated with fluid boluses.  The patient was empirically placed on Synthroid and hydrocortisone by Dr. X.  Blood work consisted of a chemistry panel that was unremarkable, except for decreased proteins.  H&H was stable at 33.3/10.9 and platelets of 80,000.  White blood cell counts were normal, differential was normal.  TSH was 3.41.  Free T4 was 0.9.  Dr. X felt this was consistent with secondary hypothyroidism and recommended Synthroid replacement.  A cortisol level was obtained prior to administration of hydrocortisone.  This was 10.9 and that was not a fasting level.  Dr. X felt because of his hypothyroidism and his hypothermia that he had secondary adrenal insufficiency and recommended hydrocortisone and Florinef.  The patient was eventually changed to prednisone 2.5 mg b.i.d. in addition to his Florinef 0.1 mg on Monday, Wednesday, and Friday.  The patient was started back on his tube feeds.  He tolerated these poorly with residuals.  Reglan was increased to 10 mg q.6 h. and erythromycin is being added.  The patient's temperature has been stable in the 94 to 95 range.  Other vital signs have been stable.  His urine output has been diminished.  An external jugular line was placed in the Intensive Care Unit.  The patient's legal guardian, Janet Sanchez in Albuquerque has requested he be transported there.  As per several physicians in Albuquerque and Dr. Y, an internist, we will accept him once we have a nursing home available to him.  He is being transported back to the nursing home today and discharge planners are working on getting him a nursing home in Albuquerque.  His prognosis is poor.","general medicine, sepsis, organic brain syndrome, seizure disorder, anemia of chronic disease, adrenal insufficiency, blood, cultures"
 Sample male exam and review of systems., General Medicine, Male Exam & ROS ,"GENERAL REVIEW OF SYSTEMS,General:  No fevers, chills, or sweats.  No weight loss or weight gain.,Cardiovascular:  No exertional chest pain, orthopnea, PND, or pedal edema.  No palpitations.,Neurologic:  No paresis, paresthesias, or syncope.,Eyes:  No double vision or blurred vision.,Ears:  No tinnitus or decreased auditory acuity.,ENT:  No allergy symptoms, such as rhinorrhea or sneezing.,GI:  No indigestion, heartburn, or diarrhea.  No blood in the stools or black stools.  No change in bowel habits.,GU:  No dysuria, hematuria, or pyuria.  No polyuria or nocturia.  Denies slow urinary stream.,Psych:  No symptoms of depression or anxiety.,Pulmonary:  No wheezing, cough, or sputum production.,Skin:  No skin lesions or nonhealing lesions.,Musculoskeletal:  No joint pain, bone pain, or back pain.  No erythema at the joints.,Endocrine:  No heat or cold intolerance.  No polydipsia.,Hematologic:  No easy bruising or easy bleeding.  No swollen lymph nodes.,PHYSICAL EXAM,Vital: Blood pressure today was *, heart rate *, respiratory rate *.,Ears:  TMs intact bilaterally.  Throat is clear without hyperemia.,Mouth:  Mucous membranes normal.  Tongue normal.,Neck:  Supple; carotids 2+ bilaterally without bruits; no lymphadenopathy or thyromegaly.,Chest:  Clear to auscultation; no dullness to percussion.,Heart:  Revealed a regular rhythm, normal S1 and S2.  No murmurs, clicks or gallops.,Abdomen:  Soft to palpation without guarding or rebound.  No masses or hepatosplenomegaly palpable.  Bowel sounds are normoactive.,Extremities:  bilaterally symmetrical.  Peripheral pulses 2+ in all extremities.  No pedal edema.,Neurologic examination:  Essentially intact including cranial nerves II through XII intact bilaterally.  Deep tendon reflexes 2+ and symmetrical.,Genitalia:  Bilaterally descended testes without tenderness or masses.  No hernias palpable.  Rectal examination revealed normal sphincter tone, no rectal mass.  Prostate was *.  Stool was Hemoccult negative.","general medicine, male exam, cardiovascular, ent, ears, endocrine, extremities, genitalia, hemoccult, musculoskeletal, pulmonary, auditory acuity, blurred vision, heart rate, nocturia, pedal edema, percussion, polydipsia, rectal mass, regular rhythm, respiratory rate, review of systems, swollen lymph nodes, tinnitus, intact bilaterally, masses, "
" Chief complaint of chest pain, previously diagnosed with hyperthyroidism.", General Medicine, Hyperthyroidism Following Pregnancy ,"HISTORY: , Patient is a 21-year-old white woman who presented with a chief complaint of chest pain.  She had been previously diagnosed with hyperthyroidism.  Upon admission, she had complaints of constant left sided chest pain that radiated to her left arm.  She had been experiencing palpitations and tachycardia.  She had no diaphoresis, no nausea, vomiting, or dyspnea.,She had a significant TSH of 0.004 and a free T4 of 19.3.  Normal ranges for TSH and free T4 are 0.5-4.7 µIU/mL and 0.8-1.8 ng/dL, respectively.  Her symptoms started four months into her pregnancy as tremors, hot flashes, agitation, and emotional inconsistency.  She gained 16 pounds during her pregnancy and has lost 80 pounds afterwards.  She complained of sweating, but has experienced no diarrhea and no change in appetite.  She was given isosorbide mononitrate and IV steroids in the ER.,FAMILY HISTORY:,  Diabetes, Hypertension, Father had a Coronary Artery Bypass Graph (CABG) at age 34.,SOCIAL HISTORY:,  She had a baby five months ago.  She smokes a half pack a day.  She denies alcohol and drug use.,MEDICATIONS:,  Citalopram 10mg once daily for depression; low dose tramadol PRN pain.,PHYSICAL EXAMINATION: , Temperature 98.4; Pulse 123; Respiratory Rate 16; Blood Pressure 143/74.,HEENT:  She has exophthalmos and could not close her lids completely.,Cardiovascular:  tachycardia.,Neurologic:  She had mild hyperreflexiveness.,LAB:,  All labs within normal limits with the exception of Sodium 133, Creatinine 0.2, TSH 0.004, Free T4 19.3 EKG showed sinus tachycardia with a rate of 122.  Urine pregnancy test was negative.,HOSPITAL COURSE: , After admission, she was given propranolol at 40mg daily and continued on telemetry.  On the 2nd day of treatment, the patient still complained of chest pain.  EKG again showed tachycardia.  Propranolol was increased from 40mg daily to 60mg twice daily., A I-123 thyroid uptake scan demonstrated an increased thyroid uptake of 90% at 4 hours and 94% at 24 hours.  The normal range for 4-hour uptake is 5-15% and 15-25% for 24-hour uptake.  Endocrine consult recommended radioactive I-131 for treatment of Graves disease.,Two days later she received 15.5mCi of I-131.  She was to return home after the iodine treatment.  She was instructed to avoid contact with her baby for the next week and to cease breast feeding.,ASSESSMENT / PLAN:,1. Treatment of hyperthyroidism.  Patient underwent radioactive iodine 131 ablation therapy.,2. Management of cardiac symptoms stemming from hyperthyroidism.  Patient was discharged on propranolol 60mg, one tablet twice daily.,3. Monitor patient for complications of I-131 therapy such as hypothyroidism.  She should return to Endocrine Clinic in six weeks to have thyroid function tests performed.  Long-term follow-up includes thyroid function tests at 6-12 month intervals.,4. Prevention of pregnancy for one year post I-131 therapy.  Patient was instructed to use 2 forms of birth control and was discharged an oral contraceptive, taken one tablet daily.,5. Monitor ocular health.  Patient was given methylcellulose ophthalmic, one drop in each eye daily.  She should follow up in 6 weeks with the Ophthalmology clinic.,6. Management of depression.  Patient will be continued on citalopram 10 mg.","general medicine, hyperthyroidism, diabetes, hypertension, hospital course, thyroid function, tachycardia, pregnancy, "
" Human immunodeficiency virus disease with stable control on Atripla.  Resolving left gluteal abscess, completing Flagyl.  Diabetes mellitus, currently on oral therapy.  Hypertension, depression, and chronic musculoskeletal pain of unclear etiology.", General Medicine, HIV Followup ,"HISTORY OF PRESENT ILLNESS: , The patient is a 41-year-old white male with a history of HIV disease.  His last CD4 count was 425, viral load was less than 50 in 08/07.  He was recently hospitalized for left gluteal abscess, for which he underwent I&D and he has newly diagnosed diabetes mellitus.  He also has a history of hypertension and hypertriglyceridemia.  He had been having increased urination and thirst.  He was seen in the hospital by the endocrinology staff and treated with insulin while hospitalized and getting treatment for his perirectal abscess.  The endocrine team apparently felt that insulin might be best for this patient, but because of financial issues, elected to place him on Glucophage and glyburide.  The patient reports that he has been taking the medication.  He is in general feeling better.  He says that his gluteal abscess is improving and he will be following up with Surgery today.,CURRENT MEDICATIONS:,1.  Gabapentin 600 mg at night.,2.  Metformin 1000 mg twice a day.,3.  Glipizide 5 mg a day.,4.  Flagyl 500 mg four times a day.,5.  Flexeril 10 mg twice a day.,6.  Paroxetine 20 mg a day.,7.  Atripla one at night.,8.  Clonazepam 1 mg twice a day.,9.  Blood pressure medicine, name unknown.,REVIEW OF SYSTEMS:,  He otherwise has a negative review of systems.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 36.6, blood pressure 145/90, pulse 123, respirations 20, and weight is 89.9 kg (198 pounds.)  HEENT:  Unremarkable except for some submandibular lymph nodes.  His fundi are benign.  NECK:  Supple.  LUNGS:  Clear to auscultation and percussion.  CARDIAC:  Reveals regular rate and rhythm without murmur, rub or gallop.  ABDOMEN:  Soft and nontender without organomegaly or mass.  EXTREMITIES:  Show no cyanosis, clubbing or edema.  GU:  Examination of the perineum revealed an open left gluteal wound that appears clear with no secretions.,IMPRESSION:,1.  Human immunodeficiency virus disease with stable control on Atripla.,2.  Resolving left gluteal abscess, completing Flagyl.,3.  Diabetes mellitus, currently on oral therapy.,4.  Hypertension.,5.  Depression.,6.  Chronic musculoskeletal pain of unclear etiology.,PLAN: , The patient will continue his current medications.  He will have laboratory studies done in 3 to 4 weeks, and we will see him a few weeks thereafter.  He has been encouraged to keep his appointment with his psychologist.","general medicine, human immunodeficiency virus disease, diabetes mellitus, atripla, hiv, depression, musculoskeletal, diabetes, hypertension, "
" Nonischemic cardiomyopathy, branch vessel coronary artery disease, congestive heart failure - NYHA Class III, history of nonsustained ventricular tachycardia, hypertension, and hepatitis C.", General Medicine, Hypertension & Cardiomyopathy ,"PROBLEMS LIST:,1.  Nonischemic cardiomyopathy.,2.  Branch vessel coronary artery disease.,3.  Congestive heart failure, NYHA Class III.,4.  History of nonsustained ventricular tachycardia.,5.  Hypertension.,6.  Hepatitis C.,INTERVAL HISTORY: , The patient was recently hospitalized for CHF exacerbation and was discharged with increased medications.  However, he did not fill his prescriptions and came back with persistent shortness of breath on exertion and on rest.  He has history of orthopnea and PND.  He has gained a few pounds of weight but denied to have any palpitation, presyncope, or syncope.,REVIEW OF SYSTEMS: , Positive for right upper quadrant pain.  He has occasional nausea, but no vomiting.  His appetite has decreased.  No joint pain, TIA, seizure or syncope.  Other review of systems is unremarkable.,I reviewed his past medical history, past surgical history, and family history.,SOCIAL HISTORY: , He has quit smoking, but unfortunately was positive for cocaine during last hospital stay in 01/08.,ALLERGIES: , He has no known drug allergies.,MEDICATIONS:,  I reviewed his medication list in the chart.  He states he is compliant, but he was not taking the revised dose of medications as per discharge orders and prescription.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse 91 per minute and regular, blood pressure 151/102 in the right arm and 152/104 in the left arm, weight 172 pounds, which is about 6 pounds more than last visit in 11/07.  HEENT:  Atraumatic and normocephalic.  No pallor, icterus or cyanosis.  NECK:  Supple.  Jugular venous distention 5 cm above the clavicle present.  No thyromegaly.  LUNGS:  Clear to auscultation.  No rales or rhonchi.  Pulse ox was 98% on room air.  CVS:  S1 and S2 present.  S3 and S4 present.  ABDOMEN:  Soft and nontender.  Liver is palpable 5 cm below the right subcostal margin.  EXTREMITIES:  No clubbing or cyanosis.  A 1+ edema present.,ASSESSMENT AND PLAN:,  The patient has hypertension, nonischemic cardiomyopathy, and branch vessel coronary artery disease.  Clinically, he is in NYHA Class III.  He has some volume overload and was not unfortunately taking Lasix as prescribed.  I have advised him to take Lasix 40 mg p.o. b.i.d.  I also increased the dose of hydralazine from 75 mg t.i.d. to 100 mg t.i.d.  I advised him to continue to take Toprol and lisinopril.  I have also added Aldactone 25 mg p.o. daily for survival advantage.  I reinforced the idea of not using cocaine.  He states that it was a mistake, may be somebody mixed in his drink, but he has not intentionally taken any cocaine.  I encouraged him to find a primary care provider.  He will come for a BMP check in one week.  I asked him to check his blood pressure and weight.  I discussed medication changes and gave him an updated list.  I have asked him to see a gastroenterologist for hepatitis C.  At this point, his Medicaid is pending.  He has no insurance and finds hard to find a primary care provider.  I will see him in one month.  He will have his fasting lipid profile, AST, and ALT checked in one week.","general medicine, congestive heart failure, hypertension, cardiomyopathy, coronary artery disease, ventricular tachycardia, nonischemic cardiomyopathy, branch vessel, nyha class, nonischemic, tachycardia, orthopnea,"
 Probable Coumadin hypersensitivity., General Medicine, Hypersensitivity to Coumadin ,"PROBLEM:,  Probable Coumadin hypersensitivity.,HISTORY OF PRESENT ILLNESS:,  The patient is an 82-year-old Caucasian female admitted to the Hospital for elective total left knee arthroplasty.  At the time of admission, the patient has a normal prothrombin time and INR of 13.4 seconds and 1.09 respectively and postoperatively, she was placed on Coumadin which is the usual orthopedic surgery procedure for reducing the risk of postoperative thromboembolic activity.  However, the patient's prothrombin time and INR rapidly rose to supratherapeutic levels.  Even though Coumadin was discontinued on 01/21/09, the patient's prothrombin time and INR has continued to rise.  Her prothrombin time is now 83.3 seconds with an INR of 6.52.  Hematology/Oncology consult was requested for recommendation regarding further evaluation and management.,SOCIAL HISTORY: , The patient is originally from Maine.  She has lived in Arizona for 4 years.  She has had 2 children; however, only one is living.  She had one child died from complications of ulcerative colitis.  She has been predominantly a homemaker during her life, but has done some domestic cleaning work in the past.,CHILDHOOD HISTORY: , Negative for rheumatic fever.  The patient has usual childhood illnesses.,ALLERGIES:  ,No known drug allergies.,FAMILY HISTORY: , The patient's mother died from gastric cancer.  She had a brother who died from mesothelioma.  He did have a positive asbestos exposure working in the shipyards.  The patient's father died from motor vehicle accident.  She had a sister who succumbed to pneumonia as a complication to Alzheimer disease.,HABITS: , No use of ethanol, tobacco, illicit, or recreational substances.,ADULT MEDICAL PROBLEMS: , The patient has a history of diabetes mellitus, hypertension, and hypercholesterolemia, which is all consistent with the metabolic syndrome X.  In addition, the patient's husband, who is present, knows that she has early dementia and has problems with memory and difficulty in processing new information.,SURGERIES: , The patient's only surgery is the aforementioned left knee arthroplasty and bilateral cataract surgery, otherwise negative.,MEDICATIONS: , The patient's medications on admission include:,1.  Fosamax.,2.  TriCor.,3.  Gabapentin.,4.  Hydrochlorothiazide.,5.  Labetalol.,6.  Benicar.,7.  Crestor.,8.  Detrol.,REVIEW OF SYSTEMS: , Unable to obtain review of systems as the patient was given a dose of morphine for postoperative pain and she is a bit obtunded at this time.  She is arousable, but not particularly conversant.,OBSERVATIONS:,GENERAL:  The patient is a drowsy, but arousable, nonconversant, elderly Caucasian female.,HEENT:  Pupils were equal, round, and reactive to light and accommodation.  Extraocular muscles are grossly intact.  Oropharynx benign.,NECK:  Supple.  Full range of motion without bruits or thyromegaly.,LUNGS:  Clear to auscultation and percussion.,BACK:  Without spine or CVA tenderness.,HEART:  Regular rate and rhythm without murmurs, rubs, thrills, or heaves.,ABDOMEN:  Soft and nontender.  Positive bowel sounds without mass or visceromegaly.,LYMPHATIC:  No appreciable adenopathy.,EXTREMITIES:  The patient has some postoperative fullness involving her left knee.  She has a dressing over the left knee.,SKIN:  Without lesions.,NEURO:  Unable to assess in light of post morphine obtunded state.,ASSESSMENT: , Hypersensitivity to Coumadin.,PLAN: , Gave the patient vitamin K at this time.  Literature suggested oral vitamin K is actually more efficacious than parenteral.  However, in light of the fact that the patient is obtunded and is not taking anything right now in the way of oral food or fluids, we will give this to her in an IM fashion.  Repeat prothrombin time and INR in a.m.  Once she has come down to a more therapeutic range, I would initiate low-molecular weight heparin in the form of Fragmin one time a day or Lovenox on a b.i.d. schedule for 4 to 6 weeks postoperatively.",
" Human immunodeficiency virus, stable on Trizivir.  Hepatitis C with stable transaminases.  History of depression, stable off meds.   Hypertension, moderately controlled on meds.", General Medicine, HIV Followup - 1 ,"PROBLEM LIST:,1.  HIV stable.,2.  Hepatitis C chronic.,3.  History of depression, stable off meds.,4.  Hypertension, moderately controlled.,CHIEF COMPLAINT: , The patient comes for a routine followup appointment.,HISTORY OF PRESENTING ILLNESS: , This is a 34-year-old African American female who comes today for routine followup.  She has no acute complaints.  She reports that she has a muscle sprain on her upper back from lifting.  The patient is a housekeeper by profession.  It does not impede her work in anyway.  She just reports that it gives her some trouble sleeping at night, pain on 1 to 10 scale was about 2 and at worse it is 3 to 4 but relieved with over-the-counter medication.  No other associated complaints.  No neurological deficits or other specific problems.  The patient denies any symptoms associated with opportunistic infection.,PAST MEDICAL HISTORY:,1.  Significant for HIV.,2.  Hepatitis.,3.  Depression.,4.  Hypertension.,CURRENT MEDICATIONS:,1.  She is on Trizivir 1 tablet p.o. b.i.d.,2.  Ibuprofen over-the-counter p.r.n.,MEDICATION COMPLIANCE: , The patient is 100% compliant with her meds.  She reports she does not miss any doses.,ALLERGIES: , She has no known drug allergies.,DRUG INTOLERANCE:  ,There is no known drug intolerance in the past.,NUTRITIONAL STATUS: , The patient eats regular diet and eats 3 meals a day.,REVIEW OF SYSTEMS: , Noncontributory except as mentioned in the HPI.,LABORATORY DATA: , Most recent labs from 11/07.,RADIOLOGICAL DATA:,  She has had no recent radiological procedures.,IMMUNIZATIONS: , Up-to-date.,SEXUAL HISTORY: , She has had no recent STDs and she is not currently sexually active.  PPD status was negative in the past.  PPD will be placed again today.,Treatment adherence counseling was performed by both nursing staff and myself.  Again, the patient is a 100% compliant with her meds.  Last dental exam was in 11/07, where she had 2 teeth extracted.  Last Pap smear was 1 year ago was negative.  The patient has not had mammogram yet, as she is not of the age where she would start screening mammogram.  She has no family history of breast cancer.,MENTAL HEALTH AND SUBSTANCE ABUSE: , The patient has a history of depression.  No history of substance abuse.,ADVANCED DIRECTIVE: , Unknown.,PHYSICAL EXAMINATION:,GENERAL:  This is a thinly built female, not in acute distress.  VITAL SIGNS:  Temperature 36.5, blood pressure 132/89, pulse of 82, and weight of 104 pounds.  HEAD AND NECK:  Reveals bilaterally reactive pupils.  Supple neck.  No thrush.  No adenopathy.  HEART:  Heart sounds S1 and S2 regular.  No murmur.  LUNGS:  Clear bilaterally to auscultation.  ABDOMEN:  Soft and nontender with good bowel sounds.  NEUROLOGIC:  She is alert and oriented x3 with no focal neurological deficit.  EXTREMITIES:  Peripheral pulses are felt bilaterally.  She has no pitting pedal edema, clubbing or cyanosis.  GU:  Examination of external genitalia is unremarkable.  There are no lesions.,LABORATORY DATA: , From 11/07 shows hemoglobin and hematocrit of 16 and 46.  Creatinine of 0.6.  LFTs within normal limits.  Viral load of less than 48 and CD4 count of 918.,ASSESSMENT:,1.  Human immunodeficiency virus, stable on Trizivir.,2.  Hepatitis C with stable transaminases.,3.  History of depression, stable off meds.",
 Non-healing surgical wound to the left posterior thigh. Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg., General Medicine, Hypergranulation - Consult ,"CHIEF COMPLAINT:,  Non-healing surgical wound to the left posterior thigh.,HISTORY OF PRESENT ILLNESS: , This is a 49-year-old white male who sustained a traumatic injury to his left posterior thighthis past year while in ABCD.  He sustained an injury from the patellar from a boat while in the water.  He was air lifted actually up to XYZ Hospital and underwent extensive surgery.  He still has an external fixation on it for the healing fractures in the leg and has undergone grafting and full thickness skin grafting closure to a large defect in his left posterior thigh, which is nearly healed right in the gluteal fold on that left area.  In several areas right along the graft site and low in the leg, the patient has several areas of hypergranulation tissue.  He has some drainage from these areas.  There are no signs and symptoms of infection.  He is referred to us to help him get those areas under control.,PAST MEDICAL HISTORY:,  Essentially negative other than he has had C. difficile in the recent past.,ALLERGIES:,  None.,MEDICATIONS: , Include Cipro and Flagyl.,PAST SURGICAL HISTORY: , Significant for his trauma surgery noted above.,FAMILY HISTORY: , His maternal grandmother had pancreatic cancer.  Father had prostate cancer.  There is heart disease in the father and diabetes in the father.,SOCIAL HISTORY:,  He is a non-cigarette smoker and non-ETOH user.  He is divorced.  He has three children.  He has an attorney.,REVIEW OF SYSTEMS:,CARDIAC:  He denies any chest pain or shortness of breath.,GI:  As noted above.,GU:  As noted above.,ENDOCRINE:  He denies any bleeding disorders.,PHYSICAL EXAMINATION:,GENERAL:  He presents as a well-developed, well-nourished 49-year-old white male who appears to be in no significant distress.,HEENT:  Unremarkable.,NECK:  Supple.  There is no mass, adenopathy, or bruit.,CHEST:  Normal excursion.,LUNGS:  Clear to auscultation and percussion.,COR:  Regular.  There is no S3, S4, or gallop.  There is no murmur.,ABDOMEN:  Soft.  It is nontender.  There is no mass or organomegaly.,GU:  Unremarkable.,RECTAL:  Deferred.,EXTREMITIES:  His right lower extremity is unremarkable.  Peripheral pulse is good.  His left lower extremity is significant for the split thickness skin graft closure of a large defect in the posterior thigh, which is nearly healed.  The open areas that are noted above __________ hypergranulation tissue both on his gluteal folds on the left side.  There is one small area right essentially within the graft site, and there is one small area down lower on the calf area.  The patient has an external fixation on that comes out laterally on his left thigh.  Those pin sites look clean.,NEUROLOGIC:  Without focal deficits.  The patient is alert and oriented.,IMPRESSION: , Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg.,PLAN:,  Plan would be for chemical cauterization of these areas.  Series of treatment with chemical cauterization till these are closed.",
" The patient ingested tiki oil (kerosene, liquid paraffin, citronella oil) approximately two days prior to admission.  He subsequently developed progressive symptoms of dyspnea, pleuritic chest pain, hemoptysis with nausea and vomiting. ", General Medicine, Hydrocarbon Aspiration - ER Visit ,"SUBJECTIVE: , The patient is a 20-year-old Caucasian male admitted via ABCD Hospital Emergency Department for evaluation of hydrocarbon aspiration.  The patient ingested ""tiki oil"" (kerosene, liquid paraffin, citronella oil) approximately two days prior to admission.  He subsequently developed progressive symptoms of dyspnea, pleuritic chest pain, hemoptysis with nausea and vomiting.  He was seen in the ABCD Hospital Emergency Department, toxic appearing with an abnormal chest x-ray demonstrating bilateral lower lobe infiltrates, greater on the right.  He had a temperature of 38.3 with tachycardia approximating 130.  White count was 59,300 with a marked left shift.  Arterial blood gases showed pH 7.48, pO2 79, and pCO2 35.  He was admitted for further medical management.,PAST MEDICAL HISTORY:,  Aplastic crisis during childhood requiring splenectomy and a cholecystectomy at age 9.,DRUG ALLERGIES: , NONE KNOWN.,CURRENT MEDICATIONS: , None.,FAMILY HISTORY:  ,Noncontributory.,SOCIAL HISTORY:  ,The patient works at a local Christmas tree farm.  He smokes cigarettes approximately one pack per day.,REVIEW OF SYSTEMS:,  Ten-system review significant for nausea, vomiting, fever, hemoptysis, and pleuritic chest pain.,PHYSICAL EXAMINATION,GENERAL:  A toxic-appearing 20-year-old Caucasian male, in mild respiratory distress.,VITAL SIGNS:  Blood pressure 122/74, pulse 130 and regular, respirations 24, temperature 38.3, and oxygen saturation 93%.,SKIN:  No rashes, petechiae or ecchymoses.,HEENT:  Within normal limits.  Pupils are equally round and reactive to light and accommodation.  Ears clean.  Throat clean.,NECK:  Supple without thyromegaly.  Lymph nodes are nonpalpable.,CHEST:  Decreased breath sounds bilaterally, greater on the right, at the right base.,CARDIAC:  No murmur or gallop rhythm.,ABDOMEN:  Mild direct diffuse tenderness without rebound.  No detectable masses, pulsations or organomegaly.,EXTREMITIES:  No edema.  Pulses are equal and full bilaterally.,NEUROLOGIC:  Nonfocal.,DATABASE: , Chest x-ray, bilateral lower lobe pneumonia, greater on the right.  EKG, sinus tachycardia, rate of 130, normal intervals, no ST changes.  Arterial blood gases on 2 L of oxygen, pH 7.48, pO2 79, and pCO2 35.,BLOOD STUDIES: , Hematocrit is 43, WBC 59,300 with a left shift, and platelet count 394,000.  Sodium is 130, potassium 3.8, chloride 97, bicarbonate 24, BUN 14, creatinine 0.8, random blood sugar 147, and calcium 9.4.,IMPRESSION,1.  Hydrocarbon aspiration.,2.  Bilateral pneumonia with pneumonitis secondary to aspiration.,3.  Asplenic patient.,PLAN,1.  ICU monitoring.,2.  O2 protocol.,3.  Hydration.,4.  Antiemetic therapy.,5.  Parenteral antibiotics.,6.  Prophylactic proton pump inhibitors.,The patient will need ICU monitoring and Pulmonary Medicine evaluation pending clinical course.,",
" An 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation.", General Medicine, Hypertension - Consult ,"HISTORY OF PRESENT ILLNESS: , The patient is an 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation although not seen recently and I was asked to perform cardiology consultation for her because there was concern for atrial fibrillation after a fall.  Basically the patient states that yesterday she fell and she is not certain about the circumstances, on her driveway, and on her left side hit a rock.  When she came to the emergency room, she was found to have a rapid atrial tachyarrhythmia, and was put on Cardizem with reportedly heart rate in the 50s, so that was stopped.  Review of EKGs from that time shows what appears to be multifocal atrial tachycardia with followup EKG showing wandering atrial pacemaker.  An ECG this morning showing normal sinus rhythm with frequent APCs.  Her potassium at that time was 3.1.  She does recall having palpitations because of the pain after the fall, but she states she is not having them since and has not had them prior.  She denies any chest pain nor shortness of breath prior to or since the fall.  She states clearly she can walk and she would be able to climb 2 flights of stairs without problems.,PAST CARDIAC HISTORY: , She is followed by Dr. X in our office and has a history of severe tricuspid regurgitation with mild elevation and PA pressure.  On 05/12/08, preserved left and right ventricular systolic function, aortic sclerosis with apparent mild aortic stenosis, and bi-atrial enlargement.  She has previously had a Persantine Myoview nuclear rest-stress test scan completed at ABCD Medical Center in 07/06 that was negative.  She has had significant mitral valve regurgitation in the past being moderate, but on the most recent echocardiogram on 05/12/08, that was not felt to be significant.  She has a history of hypertension and EKGs in our office show normal sinus rhythm with frequent APCs versus wandering atrial pacemaker.  She does have a history of significant hypertension in the past.  She has had dizzy spells and denies clearly any true syncope.  She has had bradycardia in the past from beta-blocker therapy.,MEDICATIONS ON ADMISSION:,1.  Multivitamin p.o. daily.,2.  Aspirin 325 mg once a day.,3.  Lisinopril 40 mg once a day.,4.  Felodipine 10 mg once a day.,5.  Klor-Con 20 mEq p.o. b.i.d.,6.  Omeprazole 20 mg p.o. daily presumably for GERD.,7.  MiraLax 17 g p.o. daily.,8.  Lasix 20 mg p.o. daily.,ALLERGIES: , PENICILLIN.  IT IS LISTED THAT TOPROL HAS CAUSED SHORTNESS OF BREATH IN HER OFFICE CHART AND I BELIEVE SHE HAS HAD SIGNIFICANT BRADYCARDIA WITH THAT IN THE PAST.,FAMILY HISTORY:,  She states her brother died of an MI suddenly in his 50s.,SOCIAL HISTORY: , She does not smoke cigarettes, abuse alcohol, nor use any illicit drugs.  She is retired from Morse Chain and delivering newspapers.  She is widowed.  She lives alone but has family members who live either on her property or adjacent to it.,REVIEW OF SYSTEMS: , She denies a history of stroke, cancer, vomiting of blood, coughing up blood, bright red blood per rectum, bleeding, stomach ulcers.  She does not recall renal calculi, nor cholelithiasis, denies asthma, emphysema, pneumonia, tuberculosis, sleep apnea, home oxygen use.  She does note occasional peripheral edema.  She is not aware of prior history of MI.  She denies diabetes.  She does have a history of GERD.  She notes feeling depressed at times because of living alone.  She denies rheumatologic conditions including psoriasis or lupus.  Remainder of review of systems is negative times 15 except as described above.,PHYSICAL EXAM:  ,Height 5 feet 0 inches, weight 123 pounds, temperature 99.2 degrees Fahrenheit, blood pressure has ranged from 160/87 with pulses recorded at being 144, and currently ranges 101/53 to 147/71, pulse 64, respiratory rate 20, O2 saturation 97%.  On general exam, she is a pleasant elderly woman who is hard of hearing, but is alert and interactive.  HEENT:  Shows cranium is  normocephalic and atraumatic.  She has moist mucosal membranes.  Neck veins were not distended.  There are no carotid bruits.  Lungs:  Clear to auscultation anteriorly without wheezes.  She is relatively immobile because of her left hip fracture.  Cardiac Exam:  S1, S2, regular rate, frequent ectopic beats, 2/6 systolic ejection murmur, preserved aortic component of the second heart sound.  There is also a soft holosystolic murmur heard.  There is no rub or gallop.  PMI is nondisplaced.  Abdomen is soft and nondistended.  Bowel sounds present.  Extremities without significant clubbing, cyanosis, and there is trivial to 1+ peripheral edema.  Pulses appear grossly intact.  Affect is appropriate.  Visible skin warm and perfused.  She is not able to move because of left hip fracture easily in bed.,DIAGNOSTIC STUDIES/LAB DATA: , Pertinent labs include chest x-ray with radiology report pending but shows only a calcified aortic knob.  No clear pulmonary vascular congestion.  Sodium 140, potassium 3.7, it was 3.1 on admission, chloride 106, bicarbonate 27, BUN 17, creatinine 0.9, glucose 150, magnesium was 2 on 07/13/06.  Troponin was 0.03 followed by 0.18.  INR is 0.93, white blood cell count 10.2, hematocrit 36, platelet count 115,000.,EKGs are reviewed.  Initial EKG done on 08/19/08 at 1832 shows MAT, heart rate of 104 beats per minute, no ischemic changes.  She had a followup EKG done at 20:37 on 08/19/08, which shows wandering atrial pacemaker and some lateral T-wave changes, not significantly changed from prior.  Followup EKG done this morning shows normal sinus rhythm with frequent APCs.,IMPRESSION:  ,She is an 84-year-old female with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension and mild aortic stenosis admitted after a fall with left hip fracture and she will require surgery.  Telemetry now reviewed, shows predominantly normal sinus rhythm with frequent APCs _____ earlier yesterday evening showed burst of multifocal atrial tachycardia and I suspect that was exacerbated by prior hypokalemia, which has been corrected.  There has been no atrial fibrillation documented.  I do not feel these troponins are significant given the stress or fall in prior multifocal atrial tachycardia with increased rate especially in the absence of chest pain or shortness of breath.  She actually describes feeling good exercise capacity prior to this fall.  Given favorable risk to benefit ratio for needed left hip surgery, I feel she may proceed with needed left hip surgery from a cardiac standpoint with continued verapamil, which has been started, which should help control the multifocal atrial tachycardia, which she had and would watch for heart rate with that.  Continued optimization of electrolytes.  The patient cannot take beta-blockers as previously Toprol reportedly caused shortness of breath, although, there was some report that it caused bradycardia so we would watch her heart rate on the verapamil.  The patient is aware of the cardiac risks, certainly it is moderate, and wishes to proceed with needed surgery.  I do not feel any further cardiac evaluation is needed at this time and the patient may followup with Dr. X after discharge.  Regarding her mild thrombocytopenia, I would defer that to hospitalist and continue proton pump inhibitors for history of gastroesophageal reflux disease, management of left hip fracture as per orthopedist.","general medicine, hypokalemia, shortness of breath, atrial tachycardia, sinus rhythm, hip fracture, atrial, tachycardia, rhythm, apcs, cardiac, regurgitation, aortic, hypertension, pulmonary, "
 The patient with continued problems with her headaches. , General Medicine, Headache - Office Visit ,"She also had EMG/nerve conduction studies since she was last seen in our office that showed severe left ulnar neuropathy, moderate right ulnar neuropathy, bilateral mild-to-moderate carpal tunnel and diabetic neuropathy.  She was referred to Dr. XYZ and will be seeing him on August 8, 2006.,She was also never referred to the endocrine clinic to deal with her poor diabetes control.  Her last hemoglobin A1c was 10.,PAST MEDICAL HISTORY:,  Diabetes, hypertension, elevated lipids, status post CVA, and diabetic retinopathy.,MEDICATIONS: , Glyburide, Avandia, metformin, lisinopril, Lipitor, aspirin, metoprolol and Zonegran.,PHYSICAL EXAMINATION:,  Blood pressure was 140/70, heart rate was 76, respiratory rate was 18, and weight was 226 pounds.  On general exam she has an area of tenderness on palpation in the left parietal region of her scalp.  Neurological exam is detailed on our H&P form.  Her neurological exam is within normal limits.,IMPRESSION AND PLAN:,  For her headaches we are going to titrate Zonegran up to 200 mg q.h.s. to try to maximize the Zonegran therapy.  If this is not effective, when she comes back on August 7, 2006 we will then consider other anticonvulsants such as Neurontin or Lyrica.  We also discussed with Ms. Hawkins the possibility of nerve block injection; however, at this point she is not interested.,She will be seeing Dr. XYZ for her neuropathies.,We made an appointment in endocrine clinic today for a counseling in terms of better diabetes control and she is responsible for trying to get her referral from her primary care physician to go for this consult.","general medicine, nerve conduction studies, emg, zonegran therapy, ulnar neuropathy, endocrine clinic, diabetes control, neurological exam, headache, zonegran"
" History of diabetes, osteoarthritis, atrial fibrillation, hypertension, asthma, obstructive sleep apnea on CPAP, diabetic foot ulcer, anemia, and left lower extremity cellulitis.", General Medicine, H&P - Gen Med - 2 ,"HISTORY OF PRESENT ILLNESS:, The patient is a 71-year-old Caucasian female with a history of diabetes, osteoarthritis, atrial fibrillation, hypertension, asthma, obstructive sleep apnea on CPAP, diabetic foot ulcer, anemia and left lower extremity cellulitis. She was brought in by the EMS service to Erlanger emergency department with pulseless electrical activity. Her husband states that he was at home with his wife, when she presented to him complaining of fever and chills. She became acutely unresponsive. She was noted to have worsening of her breathing. She took several of her MDIs and then was placed on her CPAP. He went to notify EMS and when he returned, she was found to not be breathing. He stated that she was noted to have no breathing in excess of 10 minutes. He states that the EMS system arrived at the home and she was found not breathing. The patient was intubated at the scene and upon arrival to Erlanger Medical Center, she was found to have pupils fixed and dilated. She was seen by me in the emergency department and was on Neo-Synephrine, dopamine with a blood pressure of 97/22 with a rapid heart rate and again, in an unresponsive state.,REVIEW OF SYSTEMS:, Review of systems was not obtainable.,PAST MEDICAL HISTORY:, Diabetes, osteoarthritis, hypertension, asthma, atrial fibrillation, diabetic foot ulcer and anemia.,PAST SURGICAL HISTORY:, Noncontributory to above.,FAMILY HISTORY:, Mother with history of coronary artery disease.,SOCIAL HISTORY:, The patient is married. She uses no ethanol, no tobacco and no illicits. She has a very support family unit.,MEDICATIONS:, Augmentin; Detrol LA; lisinopril.,IMMUNIZATIONS:, Immunizations were up to date for influenza, negative for Pneumovax.,ALLERGIES:, PENICILLIN.,LABORATORY AT PRESENTATION:, White blood cell count 11, hemoglobin 10.5, hematocrit 32.2, platelets 175,000. Sodium 148, potassium 5.2, BUN 30, creatinine 2.2 and glucose 216. PT was 22.4.,RADIOLOGIC DATA:, Chest x-ray revealed a diffuse pulmonary edema.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 97/52, pulse of 79, respirations 16, O2 sat 100%.,HEENT: The patient's pupils were again, fixed and dilated and intubated on the monitor.,CHEST: Poor air movement bilateral with bilateral rales.,CARDIOVASCULAR: Regular rate and rhythm.,ABDOMEN: The abdomen was obese, nondistended and nontender.,EXTREMITIES: Left diabetic foot had oozing pus drainage from the foot.,GU: Foley catheter was in place.,IMPRESSION AND PLAN:,1. Acute cardiac arrest with pulseless electrical activity with hypotensive shock and respiratory failure: Will continue ventilator support. Will rule out pulmonary embolus, rule out myocardial infarction. Continue pressors. The patient is currently on dopamine, Neo-Synephrine and Levophed.,2. Acute respiratory distress syndrome: Will continue ventilatory support.,3. Questionable sepsis: Will obtain blood cultures, intravenous vancomycin and Rocephin given.,4. Hypotensive shock: Will continue pressors. Will check random cortisol. Hydrocortisone was added.,Further inpatient management for this patient will be provided by Dr. R. The patient's status was discussed with her daughter and her husband. The husband states that his wife has been very ill in the past with multiple admissions, but he had never seen her as severely ill as with this event. He states that she completely was not breathing at all and he is aware of the severity of her illness and the gravity of her current prognosis. Will obtain the assistance with cardiology with this admission and will continue pressors and supportive therapy. The family will make an assessment and final decision concerning her long-term management after a 24 hour period.",
" Upper respiratory tract infection, persistent.  Tinea pedis.  Wart on the finger.  Hyperlipidemia.  Tobacco abuse.", General Medicine, Gen Med SOAP - 9 ,"SUBJECTIVE:  ,This patient presents to the office today for a checkup.  He has several things to go over and discuss.  First he is sick.  He has been sick for a month intermittently, but over the last couple of weeks it is worse.  He is having a lot of yellow phlegm when he coughs.  It feels likes it is in his chest.  He has been taking Allegra-D intermittently, but he is almost out and he needs a refill.  The second problem, his foot continues to breakout.  It seems like it was getting a lot better and now it is bad again.  He was diagnosed with tinea pedis previously, but he is about out of the Nizoral cream.  I see that he is starting to breakout again now that the weather is warmer and I think that is probably not a coincidence.  He works in the flint and it is really hot where he works and it has been quite humid lately.  The third problem is that he has a wart or a spot that he thinks is a wart on the right middle finger.  He is interested in getting that frozen today.  Apparently, he tells me I froze a previous wart on him in the past and it went away.  Next, he is interested in getting some blood test done.  He specifically mentions the blood test for his prostate, which I informed him is called the PSA.  He is 50 years old now.  He will also be getting his cholesterol checked again because he has a history of high cholesterol.  He made a big difference in his cholesterol by quitting smoking, but unfortunately after taking his social history today he tells me that he is back to smoking.  He says it is difficult to quit.  He tells me he did quit chewing tobacco.  I told him to keep trying to quit smoking.  ,REVIEW OF SYSTEMS:,  General:  With this illness he has had no problems with fever.  HEENT:  Some runny nose, more runny nose than congestion.  Respiratory:  Denies shortness of breath.  Skin:  He has a peeling skin on the bottom of his feet, mostly the right foot that he is talking about today.  At times it is itchy.,OBJECTIVE: , His weight is 238.4 pounds, blood pressure 128/74, temperature 97.8, pulse 80, and respirations 16.  General exam:  The patient is nontoxic and in no acute distress.  Ears:  Tympanic membranes pearly gray bilaterally.  Mouth:  No erythema, ulcers, vesicles, or exudate noted.  Neck is supple.  No lymphadenopathy.  Lungs:  Clear to auscultation.  No rales, rhonchi, or wheezing.  Cardiac:  Regular rate and rhythm without murmur.  Extremities:  No edema, cyanosis, or clubbing.  Skin exam:  I checked out the bottom of his right foot.  He has peeling skin visible consistent with tinea pedis.  On the anterior aspect of the right third finger there is a small little raised up area that I believe represents a wart.  The size of this wart is approximately 3 mm in diameter.,ASSESSMENT:  ,1.  Upper respiratory tract infection, persistent.,2.  Tinea pedis.,3.  Wart on the finger.,4.  Hyperlipidemia.,5.  Tobacco abuse.,PLAN: , The patient is getting a refill on Allegra-D.  I am giving him a refill on the Nizoral 2% cream that he should use to the foot area twice a day.  I gave him instructions on how to keep the foot clean and dry because I think the reason we are dealing with this persistent problem is the fact that his feet are hot and sweaty a lot because of his work.  His wart has been present for some time now and he would like to get it frozen.  I offered him the liquid nitrogen treatment and he did agree to it.  I used liquid nitrogen after a verbal consent was obtained from the patient to freeze the wart.  He tolerated the procedure very well.  I froze it once and I allowed for a 3 mm freeze zone.  I gave him verbal wound care instructions after the procedure.  Lastly, when he is fasting I am going to send him to the lab with a slip, which I gave him today for a basic metabolic profile, CBC, fasting lipid profile, and a screening PSA test.  Lastly, for the upper respiratory tract infection, I am giving him amoxicillin 500 mg three times a day for 10 days.","general medicine, hyperlipidemia, allegra-d, upper respiratory tract infection, tinea pedis wart, tobacco abuse, blood test, runny nose, peeling skin, tinea pedis, abuse, infection, wart,"
 Muscle tension cephalgia.  Right trapezius and rhomboid muscle spasm., General Medicine, Headache - Emergency Visit ,"CHIEF COMPLAINT: , Headache.,HISTORY OF PRESENT ILLNESS:,  This is a 16-year-old white female who presents here to the emergency department in a private auto with her mother for evaluation of headache.  She indicates intense constant right frontal headache, persistent since onset early on Monday, now more than 48 hours ago.  Indicates pressure type of discomfort with throbbing component.  It is as high as a 9 on a 0 to 10 scale of intensity.  She denies having had similar discomfort in the past.  Denies any trauma.,Review of systems:  No fever or chills.  No sinus congestion or nasal drainage.  No cough or cold symptoms.  No head trauma.  Mild nausea.  No vomiting or diarrhea.  Other systems reviewed and are negative.,PMH: , Acne.  Psychiatric history is unremarkable.,PSH: , Right knee surgery.,SH: , The patient is single.  Living at home.  No smoking or alcohol.,FH: , Noncontributory.,ALLERGIES:  ,No drug allergies.,MEDICATIONS: , Accutane and Ovcon.,PHYSICAL EXAMINATION:,VITALS:  Temperature of 97.8 degrees F., pulse of 80, respiratory rate of 16, and blood pressure is 131/96.,GENERAL:  This is a 16-year-old white female.  She is awake, alert, and oriented x3.  She does appear bit uncomfortable.,HEAD:  Normocephalic and atraumatic.,EYES:  The pupils were equal and reactive to light.  Extraocular movements are intact.,ENT:  TMs are clear.  Nose and throat are unremarkable.,NECK:  There is no evidence of nuchal rigidity.  She does, however, have notable tenderness and spasm of the right trapezius and rhomboid muscles when she extends up to the right paracervical muscles.  Palpation clearly causes having exacerbation of her discomfort.,CHEST:  Thorax is unremarkable.,GI:  Abdomen is nontender.,MUSCLES:  Extremities are unremarkable.,NEURO:  Cranial nerves II through XII are grossly intact.  Motor and sensory are grossly intact.  ,SKIN:  Skin is warm and dry.,ED COURSE:,  The patient was given IV Norflex 60 mg, Zofran 4 mg, and morphine sulfate 4 mg and with that has significant improvement in her discomfort.,DIAGNOSES:,1.  Muscle tension cephalgia.,2.  Right trapezius and rhomboid muscle spasm.,PLAN: , Scripts were given for Darvocet-N 100 one every 4 to 6 hours #15, Soma one 4 times a day #20.  She was instructed to apply warm compresses and perform gentle massage.  Follow up with regular provider as needed.  Return if any problems.",
" An 85-year-old female with diarrhea, vomiting, and abdominal pain.", General Medicine, H&P - Gen Med - 1  ,"CHIEF COMPLAINT:, Diarrhea, vomiting, and abdominal pain.,HISTORY OF PRESENT ILLNESS:, The patient is an 85-year-old female who presents with a chief complaint as described above. The patient is a very poor historian and is extremely hard of hearing, and therefore, very little history is available. She was found by EMS sitting on the toilet having diarrhea, and apparently had also just vomited. Upon my questioning of the patient, she can confirm that she has been sick to her stomach and has vomited. She cannot tell me how many times. She is also unable to describe the vomitus. She also tells me that her belly has been hurting. I am unable to get any further history from the patient because, again, she is an extremely poor historian and very hard of hearing.,PAST MEDICAL HISTORY:, Per the ER documentation is hypertension, diverticulosis, blindness, and sciatica.,MEDICATIONS:, Lorazepam 0.5 mg, dosing interval is not noted; Tylenol PM; Klor-Con 10 mEq; Lexapro; calcium with vitamin D.,ALLERGIES:, SHE IS ALLERGIC TO PENICILLIN.,FAMILY HISTORY:, Unknown.,SOCIAL HISTORY:, Also unknown.,REVIEW OF SYSTEMS:, Unobtainable secondary to the patient's condition.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse 80. Respiratory rate 18. Blood pressure 130/80. Temperature 97.6.,GENERAL: Elderly black female who is initially sleeping upon my evaluation, but is easily arousable.,NECK: No JVD. No thyromegaly.,EARS, NOSE, AND THROAT: Her oropharynx is dry. Her hearing is very diminished.,CARDIOVASCULAR: Regular rhythm. No lower extremity edema.,GI: Mild epigastric tenderness to palpation without guarding or rebound. Bowel sounds are normoactive.,RESPIRATORY: Clear to auscultation bilaterally with a normal effort.,SKIN: Warm, dry, no erythema.,NEUROLOGICAL: The patient attempts to answer questions when asked, but is very hard of hearing. She is seen to move all extremities spontaneously.,DIAGNOSTIC DATA:, White count 9.6, hemoglobin 15.9, hematocrit 48.2, platelet count 345, PTT 24, PT 13.3, INR 0.99, sodium 135, potassium 3.3, chloride 95, bicarb 20, BUN 54, creatinine 2.2, glucose 165, calcium 10.3, magnesium 2.5, total protein 8.2, albumin 3.8, AST 33, ALT 26, alkaline phosphatase 92. Cardiac isoenzymes negative x1. EKG shows sinus rhythm with a rate of 96 and a prolonged QT interval.,ASSESSMENT AND PLAN:,1. Pancreatitis. Will treat symptomatically with morphine and Zofran, and also IV fluids. Will keep NPO.,2. Diarrhea. Will check stool studies.,3. Volume depletion. IV fluids.,4. Hyperglycemia. It is unknown whether the patient is diabetic. I will treat her with sliding scale insulin.,5. Hypertension. If the patient takes blood pressure medications, it is not listed on the only medication listing that is available. I will prescribe clonidine as needed.,6. Renal failure. Her baseline is unknown. This is at least partly prerenal. Will replace volume with IV fluids and monitor her renal function.,7. Hypokalemia. Will replace per protocol.,8. Hypercalcemia. This is actually rather severe when adjusted for the patient's low albumin. Her true calcium level comes out to somewhere around 12. For now, I will just treat her with IV fluids and Lasix, and monitor her calcium level.,9. Protein gap. This, in combination with the calcium, may be suggestive of multiple myeloma. It is my understanding that the family is seeking hospice placement for the patient right now. I would have to discuss with the family before undertaking any workup for multiple myeloma or other malignancy.",
" Patient with right-sided arm weakness with speech difficulties, urinary tract infection, dehydration, and diabetes mellitus type 2", General Medicine, H&P - Weakness ,"CHIEF COMPLAINT:, Right-sided weakness.,HISTORY OF PRESENT ILLNESS:, The patient was doing well until this morning when she was noted to have right-sided arm weakness with speech difficulties. She was subsequently sent to ABC Medical Center for evaluation and treatment. At ABC, the patient was seen by Dr. H including labs and a head CT which is currently pending. The patient has continued to have right-sided arm and hand weakness, and has difficulty expressing herself. She does seem to comprehend words. The daughter states the patient is in the Life Care Center, and she believes this started this morning. The patient denies headache, visual changes, chest pain and shortness of breath. These changes have been constant since onset this morning, have not improved or worsened, and the patient notes no modifying factors.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,MEDICATIONS:, Medications are taken from the paperwork from Life Care Center and include: Lortab 3-4 times a day for pain, Ativan 0.25 mg by mouth every 12 hours p.r.n. pain, Depakote ER 250 mg p.o. q nightly, Actos 15 mg p.o. t.i.d., Lantus 35 units subcu q nightly, Glipizide 10 mg p.o. q day, Lanoxin 0.125 mg p.o. q day, Lasix 40 mg p.o. q day, Lopressor 50 mg p.o. b.i.d., insulin sliding scale, Lunesta 1 mg p.o. q nightly, Sorbitol 15 mg p.o. q day, Zoloft 50 mg p.o. q nightly, Dulcolax as needed for constipation.,PAST MEDICAL HISTORY:, Significant for moderate to severe aortic stenosis, urinary tract infection, hypertension, chronic kidney disease (although her creatinine is near normal).,SOCIAL HISTORY:, The patient lives at Life Care Center. She does not smoke, drink or use intravenous drugs.,FAMILY HISTORY:, Negative for cerebrovascular accident or cardiac disease.,REVIEW OF SYSTEMS:, As in HPI. Patient and daughter also deny weight loss, fevers, chills, sweats, nausea, vomiting, abdominal pain. She has had some difficulty expressing herself, but seems to comprehend speech as above. The patient has had a history of chronic urinary tract infections and her drainage is similar to past episodes when she has had such infection.,PHYSICAL EXAMINATION:,VITAL SIGNS: The patient is currently with a temperature of 99.1, blood pressure 138/59, pulse 69, respirations 15. She is 95% on room air.,GENERAL: This is a pleasant elderly female who appears stated age, in mild distress.,HEENT: Oropharynx is dry.,NECK: Supple with no jugular venous distention or thyromegaly.,RESPIRATORY: Clear to auscultation. No wheezes, rubs or crackles.,CARDIOVASCULAR: A 4/6 systolic ejection murmur best heard at the 2nd right intercostal space with radiation to the carotids.,ABDOMEN: Soft. Normal bowel sounds.,EXTREMITIES: No clubbing, cyanosis or edema. She does have bilateral above knee amputations.,NEUROLOGIC: Strength 2/5 in her right hand, 4/5 in her left hand. She does have mild right facial droop and an expressive aphasia.,VASCULAR: The patient has good capillary refill in her fingertips.,LABORATORY DATA:, BUN 52, creatinine 1.3. Normal coags. Glucose 220. White blood cell count 10,800. Urinalysis has 608 white cells, 625 RBCs. Head CT is currently pending. EKG shows normal sinus rhythm with mild ST-depression and biphasic T-waves diffusely.,ASSESSMENT AND PLAN:,1. Right-sided weakness with an expressive aphasia, at this time concerning for a left-sided middle cerebral artery cerebrovascular accident/transient ischemic attach given the patient's serious vascular disease. At this point we will hydrate, treat her urinary tract infection, check an MRI, ultrasound of her carotids, and echocardiogram to reevaluate valvular and left ventricular function. Start antiplatelet therapy and ask Neuro to see the patient.,2. Urinary tract infection. Will treat with ceftriaxone, check urine culture data and adjust as needed.,3. Dehydration. Will hydrate with IV fluids and follow p.o. intake while holding diuretics.,4. Diabetes mellitus type 2 uncontrolled. Her sugar is 249. We will continue Lantus insulin and sliding scale coverage, and check hemoglobin A1c to gauge prior control.,5. Prophylaxis. Will institute low molecular weight heparin and follow activity levels.",
 Intractable nausea and vomiting/history of diabetic gastroparesis/multiple endoscopies revealing gastritis and esophagitis. , General Medicine, H&P - Nausea & Vomiting ,"CHIEF COMPLAINT:, Intractable nausea and vomiting.,HISTORY OF PRESENT ILLNESS:, This is a 43-year-old black female who was recently admitted and discharged yesterday for the same complaint. She has a long history of gastroparesis dating back to 2000, diagnosed by gastroscopy. She also has had multiple endoscopies revealing gastritis and esophagitis. She has been noted in the past multiple times to be medically noncompliant with her medication regimen. She also has very poorly controlled hypertension, diabetes mellitus and she also underwent a laparoscopic right adrenalectomy due to an adrenal adenoma in January, 2006. She presents to the emergency room today with elevated blood pressure and extreme nausea and vomiting. She was discharged on Reglan and high-dose PPI yesterday, and was instructed to take all of her medications as prescribed. She states that she has been compliant, but her symptoms have not been controlled. It should be noted that on her hospital admission she would have times where she would feel extremely sick to her stomach, and then soon after she would be witnessed going outside to smoke.,PAST MEDICAL HISTORY:,1. Diabetes mellitus (poorly controlled).,2. Hypertension (poorly controlled).,3. Chronic renal insufficiency.,4. Adrenal mass.,5. Obstructive sleep apnea.,6. Arthritis.,7. Hyperlipidemia.,PAST SURGICAL HISTORY:,1. Removal of ovarian cyst.,2. Hysterectomy.,3. Multiple EGDs with biopsies over the last six years. Her last EGD was in June, 2005, which showed esophagitis and gastritis.,4. Colonoscopy in June, 2005, showing diverticular disease.,5. Cardiac catheterization in February, 2002, showing normal coronary arteries and no evidence of renal artery stenosis.,6. Laparoscopic adrenalectomy in January, 2006.,MEDICATIONS:,1. Reglan 10 mg orally every 6 hours.,2. Nexium 20 mg orally twice a day.,3. Labetalol.,4. Hydralazine.,5. Clonidine.,6. Lantus 20 units at bedtime.,7. Humalog 30 units before meals.,8. Prozac 40 mg orally daily.,SOCIAL HISTORY:, She has a 27 pack year smoking history. She denies any alcohol use. She does have a history of chronic marijuana use.,FAMILY HISTORY:, Significant for diabetes and hypertension.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,REVIEW OF SYSTEMS:,HEENT: See has had headaches, and some dizziness. She denies any vision changes.,CARDIAC: She denies any chest pain or palpitations.,RESPIRATORY: She denies any shortness of breath.,GI: She has had persistent nausea and vomiting. She denies diarrhea, melena or hematemesis.,NEUROLOGICAL: She denies any neurological deficits.,All other systems were reviewed and were negative unless otherwise mentioned in HPI.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure: 220/130. Heart rate: 113. Respiratory rate: 18. Temperature: 98.,GENERAL: This is a 43-year-old obese African-American female who appears in no acute distress. She has a depressed mood and flat affect, and does not answer questions elaborately. She will simply state that she does not feel well.,HEENT: Normocephalic, atraumatic, anicteric. PERRLA. EOMI. Mucous membranes moist. Oropharynx is clear.,NECK: Supple. No JVD. No lymphadenopathy.,LUNGS: Clear to auscultation bilaterally, nonlabored.,HEART: Regular rate and rhythm. S1 and S2. No murmurs, rubs, or gallops.",
 Migraine headache - The patient was seen in the urgent care., General Medicine, Headache - Urgent Care Visit ,"CC: , Headache.,HPI: , This is a 15-year-old girl presenting with occipital headache for the last six hours.  She denies trauma.  She has been intermittently nauseated but has not vomited and has some photophobia.  Denies fever or change in vision.  She has no past history of headaches.  ,PMH: , None. ,MEDICATIONS:  ,Tylenol for pain.,ALLERGIES:,  None.,FAMILY HISTORY: , Grandmother died of cerebral aneurysm.  ,ROS:,  Negative.,PHYSICAL EXAM:  ,Vital Signs:  BP 102/60 P 70 RR 20 T 98.2 ,HEENT:  Throat is clear, nasopharynx clear, TMs clear, there is no lymphadenopathy, no tenderness to palpations, sinuses nontender. ,Neck:  Supple without meningismus. ,Chest:  Lungs clear; heart regular without murmur.,COURSE IN THE ED: , The patient was seen in the urgent care and examined.  At this time, her photophobia and nausea make migraine highly likely.  She is well appearing and we'll try Tylenol with codeine for her pain.  One day off school and follow up with her primary doctor.  ,IMPRESSION: , Migraine headache.  ,PLAN: , See above.","general medicine, photophobia, nausea, migraine headache, tylenol, migraine, headache, "
" One-month followup for unintentional weight loss, depression, paranoia, dementia, and osteoarthritis of knees.  Doing well.", General Medicine, Gen Med SOAP - 7 ,"CHIEF COMPLAINT:,  One-month followup.,HISTORY OF PRESENT ILLNESS:,  The patient is an 88-year-old Caucasian female.  She comes here today with a friend.  The patient has no complaints.  She states she has been feeling well.  Her knees are not hurting her at all anymore and she is not needing Bextra any longer.  I think the last steroid injection that she had with Dr. XYZ really did help.  The patient denies any shortness of breath or cough.  Has no nausea, vomiting, abdominal pain.  No diarrhea or constipation.  She states her appetite is good.  She clears her plate at noon.  She has had no fevers, chills, or sweats.  The friend with her states she is doing very well.  Seems to eat excellently at noontime, despite this, the patient continues to lose weight.  When I asked her what she eats for breakfast and for supper, she states she really does not eat anything.  Her only meal that she eats at the nursing home is the noon meal and then I just do not think she is eating much the rest of the time.  She states she is really not hungry the rest of the time except at lunchtime.  She denies any fevers, chills, or sweats.  We did do some lab work at the last office visit and CBC was essentially normal.  Comprehensive metabolic was essentially normal as was of the BUN of 32 and creatinine of 1.3.  This is fairly stable for her.  Liver enzymes were normal.  TSH was normal.  Free albumin was normal at 23.  She is on different antidepressants and that may be causing some difficulties with unintentional weight loss.,MEDICATIONS:  ,Currently are Aricept 10 mg a day, Prevacid 30 mg a day, Lexapro 10 mg a day, Norvasc 2.5 mg a day, Milk of Magnesia 30 cc daily, and Amanda 10 mg b.i.d.,ALLERGIES:,  No known drug allergies.,PAST MEDICAL HISTORY:,  Reviewed from 05/10/2004 and unchanged other than the addition of paranoia, which is much improved on her current medications.,SOCIAL HISTORY:,  The patient is widow.  She is a nonsmoker, nondrinker.  She lives at Kansas Christian Home independently, but actually does get a lot of help with medications, having a driver to bring her here, and going to the noon meal.,REVIEW OF SYSTEMS:,  As above in HPI.,PHYSICAL EXAM:,General:  This is a well-developed, pleasant Caucasian female, who appears thinner especially in her face.  States are clothes are fitting more loosely.,Vital Signs:  Weight:  123, down 5 pounds from last month and down 11 pounds from May 2004.  Blood pressure:  128/62.  Pulse:  60.  Respirations:  20.  Temperature:  96.8.,Neck:  Supple.  Carotids are silent.,Chest:  Clear to auscultation.,Cardiovascular:  Regular rate and rhythm.,Abdomen:  Soft and nontender, nondistended with positive bowel sounds.  No organomegaly or masses are appreciated.,Extremities:  Free of edema.,ASSESSMENT:,1.  Unintentional weight loss.  I think this is more a problem of just not getting in any calories though does not appear to be a medical problem go on, although her dementia may make it difficult for her to remember to eat, and with her antidepressant medication she is on, she just may not have much of an appetite to eat unless food is prepared for her.,2.  Depression, doing well.,3.  Paranoia, doing well.,4.  Dementia, stable.,5.  Osteoarthritis of the knees, pain is much improved.,PLAN:,1.  Continue on current medications.,2.  I did call and talk with doctor at hospital.  We discussed different options.  We have decided to have the patient eat the evening meal at the nursing home also and have her take a supplement drink such as Ensure at breakfast time.  Connie will weigh the patient once a week and I will go ahead and see the patient in one month.  We can see how she is doing at that time.  If she continues to lose weight despite eating better, then I think we will need to do further evaluation.",
" General Medicine SOAP note.  Patient with shoulder bursitis, pharyngitis, attention deficit disorder, ", General Medicine, Gen Med SOAP - 5 ,"S:,  The patient is here today with his mom for several complaints.  Number one, he has been having issues with his right shoulder.  Approximately 10 days ago he fell, slipping on ice, did not hit his head but fell straight on his shoulder.  He has been having issues ever since.  He is having difficulties raising his arm over his head.  He does have some intermittent numbness in his fingers at night.  He is not taking any anti-inflammatories or pain relievers.  He is also complaining of a sore throat.  He did have some exposure to Strep and he has a long history of strep throat.  Denies any fevers, rashes, nausea, vomiting, diarrhea, and constipation.  He is also being seen for ADHD by Dr. B.  Adderall and Zoloft.  He takes these once a day.  He does notice when he does not take his medication.  He is doing well in school.  He is socializing well.  He is maintaining his weight and tolerating the medications.  However, he is having issues with anger control.  He realizes when he has anger outbursts that it is a problem.  His mom is concerned.  He actually was willing to go to counseling and was wondering if there was anything available for him at this time.,PAST MEDICAL/SURGICAL/SOCIAL HISTORY:,  Reviewed and unchanged.,O:,  VSS.  In general, patient is A&Ox3.  NAD.  Heart:  RRR.  Lungs:  CTA.  HEENT:  Unremarkable.  He does have 2+ tonsils, no erythema or exudate noted except for some postnasal drip.  Musculoskeletal:  Limited in range of motion, active on the right.  He stops at about 95 degrees.  No muscle weakness.  Neurovascularly intact.  Negative biceps tenderness.  Psych:  No suicidal, homicidal ideations.  Answering questions appropriately.  No hallucinations.","general medicine, adhd, attention deficit disorde, pharyngitis, anger control, anti-inflammatories, bursitis, diarrhea, fevers, nausea, numbness, rashes, shoulder, strep throat, vomiting, attention deficit, deficit disorder, anti inflammatories, soap, anger, intermittent"
 Patient today with multiple issues.  , General Medicine, Gen Med SOAP - 8 ,"SUBJECTIVE: , I am following the patient today for multiple issues.  He once again developed gross hematuria, which was unprovoked.  His Coumadin has been held.  The patient has known BPH and is on Flomax.  He is being treated with Coumadin because of atrial fibrillation and stroke.  This is the second time he has had significant gross hematuria this month.  He also fell about a week ago and is complaining of buttock pain and leg pain.  We did get x-rays of hips, knees, and ankles.  Clearly, he has significant degenerative disease in all these areas.  No fractures noted however.  He felt that the pain is pretty severe and particularly worse in the morning.  His sinuses are bothering him.  He wonders about getting some nasal saline spray.  We talked about Coumadin, stroke risk, etc. in the setting of atrial fibrillation.,PHYSICAL EXAMINATION: , Vitals:  As in chart.  The patient is alert, pleasant, and cooperative.  He is not in any apparent distress.  He is comfortable in a seated position.  I did not examine him further today.,ASSESSMENT AND PLAN:,1.  Hematuria.  Coumadin needs to be stopped, so we will evaluate what is going on, which is probably just some BPH.  We will also obtain a repeat UA as he did describe to me some dysuria.  However, I do not think this would account for the gross hematuria.  He will be started on an aspirin 81 mg p.o. daily.,2.  For the pain we will try him on Lortab.  He will get a Lortab everyday in the morning 5/500 prior to getting out of bed, and then he will have the option of having a few more throughout the day if he requires it.,3.  We will see about getting him set up with massage therapy and/or physical therapy as well for his back pain.,4.  For his sinuses, we will arrange for him to have saline nasal spray at the bedside for p.r.n. use.","general medicine, multiple issues, atrial fibrillation, gross hematuria, multiple, bph, fibrillation, hematuria,"
" Patient with several medical problems - mouth being sore, cough, right shoulder pain, and neck pain", General Medicine, Gen Med SOAP - 6 ,"SUBJECTIVE:,  The patient is in with several medical problems.  He complains his mouth being sore since last week and also some ""trouble with my eyes.""  He states that they feel ""funny"" but he is seeing okay.  He denies any more diarrhea or abdominal pain.  Bowels are working okay.  He denies nausea or diarrhea.  Eating is okay.  He is emptying his bladder okay.  He denies dysuria.  His back is hurting worse.  He complains of right shoulder pain and neck pain over the last week but denies any injury.  He reports that his cough is about the same.,CURRENT MEDICATIONS:,  Metronidazole 250 mg q.i.d., Lortab 5/500 b.i.d., Allegra 180 mg daily, Levothroid 100 mcg daily, Lasix 20 mg daily, Flomax 0.4 mg at h.s., aspirin 81 mg daily, Celexa 40 mg daily, verapamil SR 180 mg one and a half tablet daily, Zetia 10 mg daily, Feosol b.i.d.,ALLERGIES: , Lamisil, Equagesic, Bactrim, Dilatrate, cyclobenzaprine.,OBJECTIVE:,General:  He is a well-developed, well-nourished, elderly male in no acute distress.,Vital Signs:  His age is 66.  Temperature:  97.7.  Blood pressure:  134/80.  Pulse:  88.  Weight:  201 pounds.,HEENT:  Head was normocephalic.  Examination of the throat reveals it to be clear.  He does have a few slight red patches on his upper inner lip consistent with yeast dermatitis.,Neck:  Supple without adenopathy or thyromegaly.,Lungs:  Clear.,Heart:  Regular rate and rhythm.,Extremities:  He has full range of motion of his shoulders but some tenderness to the trapezius over the right shoulder.  Back has limited range of motion.  He is nontender to his back.  Deep tendon reflexes are 2+ bilaterally in lower extremities.  Straight leg raising is positive for back pain on the right side at 90 degrees.,Abdomen:  Soft, nontender without hepatosplenomegaly or mass.  He has normal bowel sounds.,ASSESSMENT:,1.  Clostridium difficile enteritis, improved.,2.  Right shoulder pain.,3.  Chronic low back pain.,4.  Yeast thrush.,5.  Coronary artery disease.,6.  Urinary retention, which is doing better.,PLAN:,  I put him on Diflucan 200 mg daily for seven days.  We will have him stop his metronidazole little earlier at his request.  He can drop it down to t.i.d. until Friday of this week and then finish Friday’s dose and then stop the metronidazole and that will be more than a 10-day course.  I ordered physical therapy to evaluate and treat his right shoulder and neck as indicated x 6 visits and he may see Dr. XYZ p.r.n. for his eye discomfort and his left eye pterygium which is noted on exam (minimal redness is noted to the conjunctiva on the left side but no mattering was seen.)  Recheck with me in two to three weeks.","general medicine, clostridium difficile enteritis, coronary artery disease, urinary retention, yeast thrush, cough, neck pain, several medical problems, shoulder pain, range of motion, soap, metronidazole, shoulder, neck, "
 General Medicine SOAP note., General Medicine, Gen Med SOAP - 3 ,"S:,  XYZ is in today not feeling well for the last three days.  She is a bit sick with bodyaches.  She is coughing.  She has a sore throat, especially when she coughs.  Her cough is productive of green colored sputum.  She has had some chills.  No vomiting.  No diarrhea.  She is sleeping okay.  She does not feel like she needs anything for the cough.  She did call in yesterday, and got a refill of her Keflex.  She took two Keflex this morning and she is feeling a little bit better now.  She is tearful, just tired of feeling ran down.,O:,  Vital signs as per chart.  Respirations 15.  Exam:  Nontoxic.  No acute distress.  Alert and oriented.  HEENT:  TMs are clear bilaterally without erythema or bulging.  Clear external canals.  Clear tympanic.  Conjunctivae are clear.  Clear nasal mucosa.  Clear oropharynx with moist mucous membranes.  NECK is soft and supple without lymphadenopathy.  LUNGS are coarse with no severe rhonchi or wheezes.  HEART is regular rate and rhythm without murmur.  ABDOMEN is soft and nontender.,Chest x-ray reveals no obvious consolidation or infiltrates.  We will send the x-ray for over-read.,Influenza test is negative.  Rapid strep screen is negative.,A:,  Bronchitis/URI.,P: , ,1.  Motrin as needed for fever and discomfort.,2.  Push fluids.,3.  Continue on the Keflex.,4.  Follow up with Dr. ABC if symptoms persist or worsen, otherwise as needed.","general medicine, bodyaches, alert and oriented, no acute distress, soap, diarrhea, lymphadenopathy, regular rate and rhythm, rhonchi, soft and nontender, supple, vomiting, wheezes, coughing, keflex, oriented,"
 General Medicine SOAP note., General Medicine, Gen Med SOAP - 4 ,"S:,  ABC is in today for a followup of her atrial fibrillation.  They have misplaced the Cardizem.  She is not on this and her heart rate is up just a little bit today.  She does complain of feeling dizziness, some vertigo, some lightheadedness, and has attributed this to the Coumadin therapy.  She is very adamant that she wants to stop the Coumadin.  She is tired of blood draws.  We have had a difficult time getting her regulated.  No chest pains.  No shortness of breath.  She is moving around a little bit better.  Her arm does not hurt her.  Her back pain is improving as well.,O:,  Vital signs as per chart.  Respirations 15.  Exam:  Nontoxic.  No acute distress.  Alert and oriented.  HEENT:  TMs are clear bilaterally without erythema or bulging.  Clear external canals.  Clear tympanic.  Conjunctivae are clear.  Clear nasal mucosa.  Clear oropharynx with moist mucous membranes.  NECK is soft and supple.  LUNGS are clear to auscultation.  HEART is irregularly irregular, mildly tachycardic.  ABDOMEN is soft and nontender.  EXTREMITIES:  No cyanosis, no clubbing, no edema.,EKG shows atrial fibrillation with a heart rate of 104.,A:,1.","general medicine, soap, alert and oriented, no acute distress, no cyanosis, atrial fibrillation, blood draw, dizziness, irregularly irregular, lightheadedness, no clubbing, no edema, shortness of breath, soft and nontender, vertigo, heart, fibrillation, coumadin, atrial, "
 The patient has recently had an admission for pneumonia with positive blood count.  She returned after vomiting and a probable seizure., General Medicine, Gen Med SOAP - 11 ,"SUBJECTIVE:,  The patient has recently had an admission for pneumonia with positive blood count.  She was treated with IV antibiotics and p.o. antibiotics; she improved on that.  She was at home and doing quite well for approximately 10 to 12 days when she came to the ER with a temperature of 102.  She was found to have strep.  She was treated with penicillin and sent home.  She returned about 8 o'clock after vomiting and a probable seizure.  Temperature was 104.5; she was lethargic after that.  She had an LP, which was unremarkable.  She had blood cultures, which have not grown anything.  The CSF has not grown anything at this point.,PHYSICAL EXAMINATION:,  She is alert, recovering from anesthesia.  Head, eyes, ears, nose and throat are unremarkable.  Chest is clear to auscultation and percussion.  Abdomen is soft.  Extremities are unremarkable.,LAB STUDIES: , White count in the emergency room was 9.8 with a slight shift.  CSF glucose was 68, protein was 16, and there were no cells.  The Gram-stain was unremarkable.,ASSESSMENT: , I feel that this patient has a febrile seizure.,PLAN: , My plan is to readmit the patient to control her temperature and assess her white count.  I am going to observe her overnight.","general medicine, antibiotics, febrile seizure, temperature, blood count, white count, pneumonia, seizure, "
" Patient with NIDDM, hypertension, CAD status post CABG, hyperlipidemia, etc.", General Medicine, Gen Med SOAP - 2 ,"SUBJECTIVE:,  Overall, she has been doing well.  Her blood sugars have usually been less than or equal to 135 by home glucose monitoring.  Her fasting blood sugar today is 120 by our Accu-Chek.  She is exercising three times per week.  Review of systems is otherwise unremarkable. ,OBJECTIVE:,  Her blood pressure is 110/60.  Other vitals are stable.  HEENT:  Unremarkable.  Neck:  Unremarkable.  Lungs:  Clear.  Heart:  Regular.  Abdomen:  Unchanged.  Extremities:  Unchanged.  Neurologic:  Unchanged. ,ASSESSMENT:,  ,1.  NIDDM with improved control. ,2.  Hypertension. ,3.  Coronary artery disease status post coronary artery bypass graft. ,4.  Degenerative arthritis. ,5.  Hyperlipidemia. ,6.  Hyperuricemia. ,7.  Renal azotemia. ,8.  Anemia. ,9.  Fibroglandular breasts. ,PLAN:,  We will get follow-up labs today.  We will continue with current medications and treatment.  We will arrange for a follow-up mammogram as recommended by the radiologist in six months, which will be approximately Month DD, YYYY.  The patient is advised to proceed with previous recommendations.  She is to follow-up with Ophthalmology and Podiatry for diabetic evaluation and to return for follow-up as directed.","general medicine, accu-chek, heent: unremarkable, hyperlipidemia, hypertension, lungs: clear, niddm, neck: unremarkable, progress note, soap, coronary artery bypass graft, follow-up labs, glucose monitoring, coronary artery"
" Multiple problems including left leg swelling, history of leukocytosis, joint pain left shoulder, low back pain, obesity, frequency with urination, and tobacco abuse.", General Medicine, Gen Med Progress Note - 9 ,"SUBJECTIVE:,  The patient is a 44-year-old white female who is here today with multiple problems.  The biggest concern she has today is her that left leg has been swollen.  It is swollen for three years to some extent, but worse for the past two to three months.  It gets better in the morning when she is up, but then through the day it begins to swell again.  Lately it is staying bigger and she somewhat uncomfortable with it being so large.  The right leg also swells, but not nearly like the left leg.  The other problem she had was she has had pain in her shoulder and back.  These occurred about a year ago, but the pain in her left shoulder is of most concern to her.  She feels like the low back pain is just a result of a poor mattress.  She does not remember hurting her shoulder, but she said gradually she has lost some mobility.  It is hard time to get her hands behind her back or behind her head.  She has lost strength in the left shoulder.  As far as the blood count goes, she had an elevated white count.  In April of 2005, Dr. XYZ had asked Dr. XYZ to see her because of the persistent leukocytosis; however, Dr. XYZ felt that this was not a problem for the patient and asked her to just return here for follow up.  She also complains of a lot of frequency with urination and nocturia times two to three.  She has gained weight; she thinks about 12 pounds since March.  She now weighs 284.  Fortunately, her blood pressure is staying stable.  She takes atenolol 12.5 mg per day and takes Lasix on a p.r.n. basis, but does not like to take it because it causes her to urinate so much.  She denies chest pain, but she does feel like she is becoming gradually more short of breath.  She works for the city of Wichita as bus dispatcher, so she does sit a lot, and just really does not move around much.  Towards the end of the day her leg was really swollen.  I reviewed her lab work.  Other than the blood count her lab work has been pretty normal, but she does need to have a cholesterol check.,OBJECTIVE:,General:  The patient is a very pleasant 44-year-old white female quite obese.,Vital Signs:  Blood pressure:  122/70.  Temperature:  98.6.,HEENT:  Head:  Normocephalic.  Ears:  TMs intact.  Eyes:  Pupils round, and equal.  Nose:  Mucosa normal.  Throat:  Mucosa normal.,Lungs:  Clear.,Heart:  Regular rate and rhythm.,Abdomen:  Soft and obese.,Extremities:  A lot of fluid in both legs, but especially the left leg is really swollen.  At least 2+ pedal edema.  The right leg just has a trace of edema.  She has pain in her low back with range of motion.  She has a lot of pain in her left shoulder with range of motion.  It is hard for her to get her hand behind her back.  She cannot get it up behind her head.  She has pain in the anterior left shoulder in that area.,ASSESSMENT:,1.  Multiple problems including left leg swelling.,2.  History of leukocytosis.,3.  Joint pain involving the left shoulder, probably impingement syndrome.,4.  Low back pain, chronic with obesity.,5.  Obesity.,6.  Frequency with urination.,7.  Tobacco abuse.,PLAN:,1.  I will schedule for a venous Doppler of the left leg and will have her come back in the morning for a CBC and a metabolic panel.  We will start her on Detrol 0.4 mg one daily and also started on Mobic 15 mg per day.,2.  Elevate her leg as much as possible and wear support hose if possible.  Keep her foot up during the day.  We will see her back in two weeks.  We will have the results of the Doppler, the lab work and see how she is doing with the Detrol and the joint pain.  If her shoulder pain is not any better, we probably should refer her on over to orthopedist.  We did do x-rays of her shoulder today that did not show anything remarkable.  See her in two weeks or p.r.n.","general medicine, leg swelling, leukocytosis, joint pain, left shoulder, low back pain, obesity, frequency with urination, tobacco abuse, multiple problems, blood count, blood pressure, leg, shoulder, tobacco, swelling, weight"
 The patient has NG tube in place for decompression., General Medicine, Gen Med SOAP - 10 ,"SUBJECTIVE: , The patient has NG tube in place for decompression.  She says she is feeling a bit better.,PHYSICAL EXAMINATION:,VITAL SIGNS:  She is afebrile.  Pulse is 58 and blood pressure is 110/56.,SKIN:  There is good skin turgor.,GENERAL:  She is not in acute distress.,CHEST:  Clear to auscultation.  There is good air movement bilaterally.,CARDIOVASCULAR:  First and second sounds are heard.  No murmurs appreciated.,ABDOMEN:  Less distended.  Bowel sounds are absent.,EXTREMITIES:  She has 3+ pedal swelling.,NEUROLOGICAL:  The patient is alert and oriented x3.  Examination is nonfocal.,LABORATORY DATA:,  White count is down from 20,000 to 12.5, hemoglobin is 12, hematocrit 37, and platelets 199,000.  Glucose is 157, BUN 14, creatinine 0.6, sodium is 131, potassium is 4.0, and CO2 is 31.,ASSESSMENT AND PLAN:,1.  Small bowel obstruction/paralytic ileus, rule out obstipation.  Continue with less aggressive decompression.  Follow surgeon's recommendation.,2.  Pulmonary fibrosis, status post biopsy.  Manage as per pulmonologist.,3.  Leukocytosis, improving.  Continue current antibiotics.,4.  Bilateral pedal swelling.  Ultrasound of the lower extremity negative for DVT.,5.  Hyponatremia, improving.,6.  DVT prophylaxis.,7.  GI prophylaxis.","general medicine, small bowel obstruction, paralytic ileus, decompression, ng tube, pedal swelling, prophylaxis"
" Short-term followup - Hypertension, depression, osteoporosis, and osteoarthritis.", General Medicine, Gen Med Progress Note - 8 ,"SUBJECTIVE:,  The patient is an 89-year-old lady.  She actually turns 90 later this month, seen today for a short-term followup.  Actually, the main reasons we are seeing her back so soon which are elevated blood pressure and her right arm symptoms are basically resolved.  Blood pressure is better even though she is not currently on the higher dose Mavik likely recommended.  She apparently did not feel well with the higher dose, so she just went back to her previous dose of 1 mg daily.  She thinks, she also has an element of office hypertension.  Also, since she is on Mavik plus verapamil, she could switch over to the combined drug Tarka.  However, when we gave her samples of that she thought they were too big for her to swallow.  Basically, she is just back on her previous blood pressure regimen.  However, her blood pressure seems to be better today.  Her daughter says that they do check it periodically and it is similar to today’s reading.  Her right arm symptoms are basically resolved and she attributed that to her muscle problem back in the right shoulder blade.  We did do a C-spine and right shoulder x-ray and those just mainly showed some degenerative changes and possibly some rotator cuff injury with the humeral head quite high up in the glenoid in the right shoulder, but this does not seem to cause her any problems.  She has some vague “stomach problems”, although apparently it is improved when she stopped Aleve and she does not have any more aches or pains off Aleve.  She takes Tylenol p.r.n., which seems to be enough for her.  She does not think she has any acid reflux symptoms or heartburn.  She does take Tums t.i.d. and also Mylanta at night.  She has had dentures for many, many years and just recently I guess in the last few months, although she was somewhat vague on this, she has had some sores in her mouth.  They do heal up, but then she will get another one.  She also thinks since she has been on the Lexapro, she has somewhat of a tremor of her basically whole body at least upper body including the torso and arms and had all of the daughters who I not noticed to speak of and it is certainly difficult to tell her today that she has much tremor.  They do think the Lexapro has helped to some extent.,ALLERGIES: , None.,MEDICATION: , Verapamil 240 mg a day, Mavik 1 mg a day, Lipitor 10 mg one and half daily, vitamins daily, Ocuvite daily, Tums t.i.d., Tylenol 2-3 daily p.r.n., and Mylanta at night.,REVIEW OF SYSTEMS:,  Mostly otherwise as above.,OBJECTIVE:,General:  She is a pleasant elderly lady.  She is in no acute distress, accompanied by daughter.,Vital signs:  Blood pressure:  128/82.  Pulse:  68.  Weight:  143 pounds.,HEENT:  No acute changes.  Atraumatic, normocephalic.  On mouth exam, she does have dentures.  She removed her upper denture.  I really do not see any sores at all.  Her mouth exam was unremarkable.,Neck:  No adenopathy, tenderness, JVD, bruits, or mass.,Lungs:  Clear.,Heart:  Regular rate and rhythm.,Extremities:  No significant edema.  Reasonable pulses.  No clubbing or cyanosis, may be just a minimal tremor in head and hands, but it is very subtle and hardly noticeable.  No other focal or neurological deficits grossly.,IMPRESSION:,1.  Hypertension, better reading today.,2.  Right arm symptoms, resolved.,3.  Depression probably somewhat improved with Lexapro and she will just continue that.  She only got up to the full dose 10 mg pill about a week ago and apparently some days does not need to take it.,4.  Perhaps a very subtle tremor.  I will just watch that.,5.  Osteoporosis.,6.  Osteoarthritis.,PLAN:,  I think I will just watch everything for now.  I would continue the Lexapro, we gave her more samples plus a prescription for the 20 mg that she can cut in half.  I offered to see her for again short-term followup.  However, they both preferred just to wait until the annual check up already set up for next April and they know they can call sooner.  She might get a flu shot here in the next few weeks.  Daughter mentioned here today that she thinks her mom is doing pretty well, especially given that she is turning 90 here later this month and I would tend to agree with that.","general medicine, osteoporosis, osteoarthritis, hypertension, depression, short term followup, blood pressure, progress, blood, pressure, dose, "
" Palpitations, possibly related to anxiety. Fatigue. Loose stools with some green color and also some nausea.", General Medicine, Gen Med SOAP ,"SUBJECTIVE: , This patient presents to the office today because he has not been feeling well.  He was in for a complete physical on 05/02/2008.  According to the chart, the patient gives a history of feeling bad for about two weeks.  At first he thought it was stress and anxiety and then he became worried it was something else.  He says he is having a lot of palpitations.  He gets a fluttering feeling in his chest.  He has been very tired over two weeks as well.  His job has been really getting to him.  He has been feeling nervous and anxious.  It seems like when he is feeling stressed he has more palpitations, sometimes they cause chest pain.  These symptoms are not triggered by exertion.  He had similar symptoms about 9 or 10 years ago.  At that time he went through a full workup.  Everything ended up being negative and they gave him something that he took for his nerves and he says that helped.  Unfortunately, he does not remember what it was.  Also over the last three days he has had some intestinal problems.  He has had some intermittent nausea and his stools have been loose.  He has been having some really funny green color to his bowel movements.  There has been no blood in the stool.  He is not having any abdominal pain, just some nausea.  He does not have much of an appetite.  He is a nonsmoker.,OBJECTIVE: , His weight today is 168.4 pounds, blood pressure 142/76, temperature 97.7, pulse 68, and respirations 16.  General exam:  The patient is nontoxic and in no acute distress.  There is no labored breathing.  Psychiatric:  He is alert and oriented times 3.  Ears:  Tympanic membranes pearly gray bilaterally.  Mouth:  No erythema, ulcers, vesicles, or exudate noted.  Eyes:  Pupils equal, round, and reactive to light bilaterally.  Neck is supple.  No lymphadenopathy.  Lungs:  Clear to auscultation.  No rales, rhonchi, or wheezing.  Cardiac:  Regular rate and rhythm without murmur.  Extremities:  No edema, cyanosis, or clubbing.,ASSESSMENT:  ,1.  Palpitations, possibly related to anxiety.,2.  Fatigue.,3.  Loose stools with some green color and also some nausea.  There has been no vomiting, possibly a touch of gastroenteritis going on here.,PLAN: , The patient admits he has been putting this off now for about two weeks.  He says his work is definitely contributing to some of his symptoms and he feels stressed.  He is leaving for a vacation very soon.  Unfortunately, he is actually leaving Wednesday for XYZ, which puts us into a bit of a bind in terms of doing testing on him.  My overall opinion is he has some anxiety related issues and he may also have a touch of gastroenteritis.  A 12-lead EKG was performed on him in the office today.  This EKG was compared with the previous EKG contained in the chart from 2006 and I see that these EKGs look very similar with no significant changes noted, which is definitely a good news.  I am going to send him to the lab from our office to get the following tests done:  Comprehensive metabolic profile, CBC, urinalysis with reflex to culture and we will also get a chest X-ray.  Tomorrow morning I will manage to schedule him for an exercise stress test at Bad Axe Hospital.  We were able to squeeze him in.  His appointment is at 8:15 in the morning.  He is going to have the stress test done in the morning and he will come back to the office in the afternoon for recheck.  I am not going to be here so he is going to see Dr. X.  Dr. X should hopefully be able to call over and speak with the physician who attended the stress test and get a preliminary result before he leaves for XYZ.  Certainly, if something comes up we may need to postpone his trip.  We petitioned his medical records from his former physician and with luck we will be able to find out what medication he was on about nine or ten years ago.  In the meantime I have given him Ativan 0.5 mg one tablet two to three times a day as needed for anxiety.  I talked about Ativan, how it works.  I talked about the side effects.  I told him to use it only as needed and we can see how he is doing tomorrow when he comes back for his recheck.  I took him off of work today and tomorrow so he could rest.","general medicine, palpitations, nausea, loose stools, fatigue, related to anxiety, stress test, anxiety, "
 Sample progress note - Gen Med., General Medicine, Gen Med SOAP - 1 ,"SUBJECTIVE:,","general medicine, progress note, clear to auscultation, s1, s2, s3, s4, blood pressure, clubbing, cyanosis, peripheral edema, rubs, tenderness, abdomen, pressure, soap, blood"
 A 62-year-old white female with multiple chronic problems including hypertension and a lipometabolism disorder., General Medicine, Gen Med Progress Note - 5 ,"SUBJECTIVE:,  The patient is a 62-year-old white female with multiple chronic problems including hypertension and a lipometabolism disorder.  She follows with Dr. XYZ on her hypertension, as well as myself.  She continues to gain weight.  Diabetes is therefore a major concern.  In fact, her dad had diabetes and she has a brother who has diabetes.  The patient also has several additional concerns she brings up today.  One is that her left knee continues to bother her and it hurts.  She cannot really isolate where the pain is, it just seems to hurt through her knee.  She has had this for some time now and in fact as we reviewed her records, her left knee has been x-rayed in 1999.  There was some minimal narrowing of the weightbearing joint with some minor hypertrophic spurring medially.  She would like to have this x-rayed again today.  She is certainly not interested in any surgery.  She has noted that it particularly hurts to kneel.  In addition, she complains of her stools being a baby-yellow.  She has rectal bleeding off and on.  It is bright red.  She had a colonoscopy done in 1999.  She does have a family history of colon cancer questionable in her mother, who is deceased.  She complains of some diffuse abdominal pain off and on.  She has given up fast foods and her pop and this has not seemed to help.  She does admit however, that she is not eating right.  Sometimes her stools are hard.  Sometimes they are runny.  The blood does not really seem to be related to necessarily a hard stool.  It is always bright red and will sometimes drip into the toilet.  Over the last couple of days, she had also been sneezing and has had an itchy throat.  She tried some Claritin and this did not help.  She has had some body aches.  She is finally feeling better today with this.  She also is questioning whether she has some sleep apnea.  She will awaken suddenly in the middle of the night.  She was told that she does snore.  She does not smoke.  As stated, she has gained significant weight.,GYNECOLOGICAL HISTORY: , She does not bleed.  She has both ovaries, as well as her uterus and cervix.  She is on no hormonal therapy.,PREVENTATIVE HISTORY:,  She is not exercising.  She does not do self breast examinations.  She has recently had her mammogram and it was unremarkable.  She does take her low-dose aspirin daily as well as her multivitamin.  She does wear her seatbelt.  As previously noted, she does not smoke or drink alcohol.,PAST MEDICAL, FAMILY AND SOCIAL HISTORY:,  Per health summary sheet, unchanged.,REVIEW OF SYSTEMS:,  Unremarkable with the exception of that above. ,ALLERGIES: , No known drug allergies.,CURRENT MEDICATIONS:,  Benicar 20 mg daily; multivitamin; glucosamine; vitamin B complex; vitamin E and a low-dose aspirin.,OBJECTIVE:,General:  Well-nourished, well-developed, a very pleasant 61-year-old in no acute distress.,Vitals:  Her weight today is 246 pounds.  In March of 2002 she weighed 231 pounds.  In March 2001 she weighed 203 pounds.  Her blood pressure is 160/78.  Pulse is 84.  Respiratory rate of 20.  She is afebrile.,HEENT:  Head is of normocephalic, atraumatic.  PERLA.  Conjunctivae clear.  TMs are unremarkable and canals are patent.  Nasal mucosa is slightly reddened.  Nares are patent.  Throat shows some clear posterior pharyngeal drainage.  Throat is slightly reddened.  Non-exudative.  No oral lesions or dental caries noted.,Neck:  Supple, No adenopathy.  Thyroid without any nodules or enlargements, no JVD or carotid bruits.,Heart:  Regular rate and rhythm without murmurs, clicks or rubs.  PMI is nondisplaced.,Lungs:  Clear to A&P.  No CVA tenderness.,Breast exam:  Negative for any axillary nodes, skin changes, discrete nodules or nipple discharge.  Breasts were examined both lying and sitting.,Abdomen:  Soft, nondistended, normoactive bowel sounds, no hepatosplenomegaly or masses.  Non tender.,Pelvic exam:  BUS unremarkable.  Speculum exam shows normal physiologic discharge.  There are some atrophic vaginal changes.  Cervix visualized, no gross abnormalities.  Pap smear obtained.  Bimanual is negative for any adnexal masses or tenderness.  Rectal exam is negative for any adnexal masses or tenderness.  No rectal masses.  She does have some external hemorrhoids, none of which are inflamed at this time.  No palpable rectal masses.,Neuromusculoskeletal exam:  Cranial nerves II-XII are grossly intact.  No cerebellar signs are noted.  No evidence of a gait disturbance.  DTRs are 1+/4+ and equal throughout.  Good uptoeing.  Skin:  Inspection of her skin, subcuticular tissues negative for any concerning skin lesions, rashes or subcuticular masses.,ASSESSMENT:,1.  Weight-gain.,2.  Hypertension.,3.  Lipometabolism disorder.,4.  Rectal bleeding.,5.  Left knee pain.,6.  Question of sleep apnea.,7.  Upper respiratory infection, improving.,8.  Gynecological examination is unremarkable for her age.,PLAN:,  We discussed at length, the issue of sleep apnea and its negative sequela.  I have recommended that she be referred for a sleep study.  She is certainly at risk for sleep apnea.  She refuses this.  I do not think that her upper respiratory tract infection needs any further treatment at this time since she is feeling better.  I did x-ray her knee and with the exception of some degenerative changes, it was unremarkable.  I reviewed this with her.  I do think that since she is having rectal bleeding, while this is not real unusual for her, with her family history of colon cancer, I am going to have her discuss this further with Dr. XYZ and leave further studies up to them.  I will dictate Dr. XYZ a note.  I am not going to order any further studies at this time in terms of her yellow stools and right upper quadrant discomfort.  She has had a gallbladder sonogram done in the past, this has been unremarkable and these symptoms really have not changed for her.  This however, has been some time ago.  I suspect she has an element of irritable bowel syndrome.  I have strongly encouraged weight reduction, both through diet and exercise.  I would like to see her back in the office in six months.  I did retake her blood pressure today and it was 130/70.  She is fasting this morning, so we will get a fasting blood sugar, chem-12, lipid profile, and CPK.  I will her mail the results.  I have strongly encouraged medication management if her lipids are elevated.  I think she is amenable to this.  Her DEXA scan is up to date having been done on 04/09/03.  I do not recommend one this year.",
 Patient with a three-day history of emesis and a four-day history of diarrhea, General Medicine, Gen Med Progress Note - 7 ,"SUBJECTIVE:,  The patient is a 7-year-old male who comes in today with a three-day history of emesis and a four-day history of diarrhea.  Apparently, his brother had similar symptoms.  They had eaten some chicken and then ate some more of it the next day, and I could not quite understand what the problem was because there is a little bit of language barrier, although dad was trying very hard to explain to me what had happened.  But any way, after he and his brother got done eating with chicken, they both felt bad and have continued to feel bad.  The patient has had diarrhea five to six times a day for the last four days and then he had emesis pretty frequently three days ago and then has just had a couple of it each day in the last two days.  He has not had any emesis today.  He has urinated this morning.  His parents are both concerned because he had a fever of 103 last night.  Also, he ate half of a hamburger yesterday and he tried drinking some milk and that is when he had an emesis.  He has been drinking Pedialyte, Gatorade, white grape juice, and 7Up, otherwise he has not been eating anything.,MEDICATIONS:  ,None.,ALLERGIES:  ,He has no known drug allergies.,REVIEW OF SYSTEMS:,  Negative as far as sore throat, earache, or cough.,PHYSICAL EXAMINATION:,General:  He is awake and alert, no acute distress.,Vital Signs:  Blood pressure:  106/75.  Temperature:  99.  Pulse:  112.  Weight is 54 pounds.,HEENT:  His TMs are normal bilaterally.  Posterior pharynx is unremarkable.,Neck:  Without adenopathy or thyromegaly.,Lungs:  Clear to auscultation.,Heart:  Regular rate and rhythm without murmur.,Abdomen:  Benign.,Skin:  Turgor is intact.  His capillary refill is less than 3 seconds.,LABORATORY: , White blood cell count is 5.3 with 69 segs, 15 lymphs, and 13 monos.  His platelet count on his CBC is 215.,ASSESSMENT:,  Viral gastroenteritis.,PLAN:,  The parents did point out to me a rash that he had on his buttock.  There were some small almost pinpoint erythematous patches of papules that have a scab on them.  I did not see any evidence of petechiae.  Therefore, I just reassured them that this is a viral gastroenteritis.  I recommended that they stop giving him juice and just go with the Gatorade and water.  He is to stay away from milk products until his diarrhea and stomach upset have calmed down.  We talked about BRAT diet and slowly advancing his diet as he tolerates.  They have used some Kaopectate, which did not really help with the diarrhea.  Otherwise follow up as needed.","general medicine, diarrhea, emesis, history of, gastroenteritis, viral, brat diet, progress note, "
" A 3-year-old male brought in by his mother with concerns about his eating - a very particular eater, not eating very much in general.", General Medicine, Gen Med Progress Note - 6 ,"SUBJECTIVE:,  This 3-year-old male is brought by his mother with concerns about his eating.  He has become a very particular eater, and not eating very much in general.  However, her primary concern was he was vomiting sometimes after particular foods.  They had noted that when he would eat raw carrots, within 5 to 10 minutes he would complain that his stomach hurt and then vomit.  After this occurred several times, they stopped giving him carrots.  Last week, he ate some celery and the same thing happened.  They had not given him any of that since.  He eats other foods without any apparent pain or vomiting.  Bowel movements are normal.  He does have a history of reactive airway disease, intermittently.  He is not diagnosed with intrinsic asthma at this time and takes no medication regularly.,CURRENT MEDICATIONS:,  He is on no medications.,ALLERGIES: , He has no known medicine allergies.,OBJECTIVE:,Vital Signs:  Weight:  31.5 pounds, which is an increase of 2.5 pounds since May.  Temperature is 97.1.  He certainly appears in no distress.  He is quite interested in looking at his books.,Neck:  Supple without adenopathy.,Lungs:  Clear.,Cardiac:  Regular rate and rhythm without murmurs.,Abdomen:  Soft without organomegaly, masses, or tenderness.,ASSESSMENT:,  Report of vomiting and abdominal pain after eating raw carrots and celery.  Etiology of this is unknown.,PLAN:,  I talked with mother about this.  Certainly, it does not suggest any kind of an allergic reaction, nor obstruction.  At this time, they will simply avoid those foods.  In the future, they may certainly try those again and see how he tolerates those.  I did encourage a wide variety of fruits and vegetables in his diet as a general principle.  If worsening symptoms, she is welcome to contact me again for reevaluation.","general medicine, eating, foods, vomiting, reactive airway disease, raw carrots, carrots,"
 The patient is in complaining of headaches and dizzy spells., General Medicine, Gen Med Progress Note - 4 ,"SUBJECTIVE:,  The patient is in complaining of headaches and dizzy spells, as well as a new little rash on the medial right calf.  She describes her dizziness as both vertigo and lightheadedness.  She does not have a headache at present but has some intermittent headaches, neck pains, and generalized myalgias.  She has noticed a few more bruises on her legs.  No fever or chills with slight cough.  She has had more chest pains but not at present.  She does have a little bit of nausea but no vomiting or diarrhea.  She complains of some left shoulder tenderness and discomfort.  She reports her blood sugar today after lunch was 155.,CURRENT MEDICATIONS:,  She is currently on her nystatin ointment to her lips q.i.d. p.r.n.  She is still using a triamcinolone 0.1% cream t.i.d. to her left wrist rash and her Bactroban ointment t.i.d. p.r.n. to her bug bites on her legs.  Her other meds remain as per the dictation of 07/30/2004 with the exception of her Klonopin dose being 4 mg in a.m. and 6 mg at h.s. instead of what the psychiatrist had recommended which should be 6 mg and 8 mg.,ALLERGIES: , Sulfa, erythromycin, Macrodantin, and tramadol.,OBJECTIVE:,General:  She is a well-developed, well-nourished, obese female in no acute distress.,Vital Signs:  Her age is 55.  Temperature:  98.2.  Blood pressure:  110/70.  Pulse:  72.  Weight:  174 pounds.,HEENT:  Head was normocephalic.  Throat:  Clear.  TMs clear.,Neck:  Supple without adenopathy.,Lungs:  Clear.,Heart:  Regular rate and rhythm without murmur.,Abdomen:  Soft, nontender without hepatosplenomegaly or mass.,Extremities:  Trace of ankle edema but no calf tenderness x 2 in lower extremities is noted.  Her shoulders have full range of motion.  She has minimal tenderness to the left shoulder anteriorly.,Skin:  There is bit of an erythematous rash to the left wrist which seems to be clearing with triamcinolone and her rash around her lips seems to be clearing nicely with her nystatin.,ASSESSMENT:,1.  Headaches.,2.  Dizziness.,3.  Atypical chest pains.,4.  Chronic renal failure.,5.  Type II diabetes.,6.  Myalgias.,7.  Severe anxiety (affect is still quite anxious.),PLAN:,  I strongly encouraged her to increase her Klonopin to what the psychiatrist recommended, which should be 6 mg in the a.m. and 8 mg in the p.m.  I sent her to lab for CPK due to her myalgias and pro-time for monitoring her Coumadin.  Recheck in one week.  I think her dizziness is multifactorial and due to enlarged part of her anxiety.  I do note that she does have a few new bruises on her extremities, which is likely due to her Coumadin.","general medicine, headaches and dizzy spells, chest pains, shoulder, progress, headaches, "
" Patient comes in for two-month followup - Hypertension, family history of CVA, Compression fracture of L1, and osteoarthritis of knee.", General Medicine, Gen Med Progress Note - 10 ,"CHIEF COMPLAINT:,  The patient is here for two-month followup.,HISTORY OF PRESENT ILLNESS:,  The patient is a 55-year-old Caucasian female.  She has hypertension.  She has had no difficulties with chest pain.  She has some shortness of breath only at walking up the stairs.  She has occasional lightheadedness only if she bends over then stands up quickly.  She has had no nausea, vomiting, or diarrhea.  She does have severe osteoarthritis of the left knee and is likely going to undergo total knee replacement with Dr. XYZ in January of this coming year.  The patient is wanting to lose weight before her surgery.  She is concerned about possible coronary disease or stroke risk.  She has not had any symptoms of cardiac disease other than some shortness of breath with exertion, which she states has been fairly stable.  She has had fairly normal lipid panel, last being checked on 11/26/2003.  Cholesterol was 194, triglycerides 118, HDL 41, and LDL 129.  The patient is a nonsmoker.  Her fasting glucose in November 2003 was within normal limits at 94.  Her fasting insulin level was normal.  Repeat nonfasting glucose was 109 on 06/22/2004.  She does not have history of diabetes.  She does not exercise regularly and is not able to because of knee pain.  She also has had difficulties with low back pain.  X-ray of the low back did show a mild compression fracture of L1.  She has had no falls that would contribute to a compression fracture.  She has had a normal DEXA scan on 11/07/2003 that does not really correlate with having a compression fracture of the lumbar spine; however, it is possible that arthritis could contribute to falsely high bone density reading on DEXA scan.  She is wanting to consider treatment for prevention of further compression fractures and possible osteoporosis.,CURRENT MEDICATIONS:,  Hydrochlorothiazide 12.5 mg a day, Prozac 20 mg a day, Vioxx 25 mg a day, vitamin C 250 mg daily, vitamin E three to four tablets daily, calcium with D 1500 mg daily, multivitamin daily, aspirin 81 mg daily, Monopril 40 mg daily, Celexa p.r.n.,ALLERGIES:  ,Bactrim, which causes nausea and vomiting, and adhesive tape.,PAST MEDICAL HISTORY:,1.  Hypertension.,2.  Depression.,3.  Myofascitis of the feet.,4.  Severe osteoarthritis of the knee.,5.  Removal of the melanoma from the right thigh in 1984.,6.  Breast biopsy in January of 1997, which was benign.,7.  History of Holter monitor showing ectopic beat.  Echocardiogram was normal.  These were in 1998.,8.  Compression fracture of L1, unknown cause.  She had had no injury.  Interestingly, DEXA scan was normal 11/07/2003, which is somewhat conflicting.,SOCIAL HISTORY:,  The patient is married.  She is a nonsmoker and nondrinker.,REVIEW OF SYSTEMS:,  As per the HPI.,PHYSICAL EXAMINATION:,General:  This is a well-developed, well-nourished, pleasant Caucasian female, who is overweight.,Vital signs:  Weight:  Refused.  Blood pressure:  148/82, on recheck by myself with a large cuff, it was 125/60.  Pulse:  64.  Respirations:  20.  Temperature:  96.3.,Neck:  Supple.  Carotids are silent.,Chest:  Clear to auscultation.,Cardiovascular:  Revealed a regular rate and rhythm without murmur, S3, or S4.,Extremities:  Revealed no edema.,Neurologic:  Grossly intact.,RADIOLOGY:  EKG revealed normal sinus rhythm, rate 61, borderline first degree AV block, and poor R-wave progression in the anterior leads.,ASSESSMENT:,1.  Hypertension, well controlled.,2.  Family history of cerebrovascular accident.,3.  Compression fracture of L1, mild.,4.  Osteoarthritis of the knee.,5.  Mildly abnormal chest x-ray.,PLAN:,1.  We will get a C-reactive protein cardiac.,2.  We discussed weight loss options.  I would recommend Weight Watchers or possibly having her see a dietician.  She will think about these options.  She is not able to exercise regularly right now because of knee pain.,3.  We would recommend a screening colonoscopy.  She states that we discussed this in the past and she canceled her appointment to have that done.  She will go ahead and make an appointment to see Dr. XYZ for screening colonoscopy.,4.  We will start Fosamax 70 mg once weekly.  She is to take this in the morning on an empty stomach with full glass of water.  She is not to eat, lie down, or take other medications for at least 30 minutes after taking Fosamax.,5.  I would like to see her back in one to two months.  At that time, we can do preoperative evaluation and we will probably send her to a cardiologist because of mildly abnormal EKG for preoperative cardiac testing.  One would also consider preoperative beta-blocker for cardiac protection.",
" Rhabdomyolysis, acute on chronic renal failure, anemia, leukocytosis, elevated liver enzyme, hypertension, elevated cardiac enzyme, obesity.", General Medicine, Gen Med Progress Note - 12 ,"SUBJECTIVE: , The patient was seen and examined.  He feels much better today, improved weakness and decreased muscular pain.  No other complaints.,PHYSICAL EXAMINATION:,GENERAL:  Not in acute distress, awake, alert and oriented x3.,VITAL SIGNS:  Blood pressure 147/68, heart rate 82, respiratory rate 20, temperature 97.7, O2 saturation 99% on 3 L.,HEENT:  NC/T, PERRLA, EOMI.,NECK:  Supple.,HEART: Regular rate and rhythm.,RESPIRATORY:  Clear bilateral.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema.  Pulses present bilateral.,LABORATORY DATA: , Total CK coming down 70,142 from 25,573, total CK is 200, troponin is 2.3 from 1.9 yesterday.,BNP, blood sugar 93, BUN of 55.7, creatinine 2.7, sodium 137, potassium 3.9, chloride 108, and CO2 of 22.,Liver function test, AST 704, ALT 298, alkaline phosphatase 67, total bilirubin 0.3.  CBC, WBC count 9.1, hemoglobin 9.9, hematocrit 29.2, and platelet count 204.  Blood cultures are still pending.,Ultrasound of abdomen, negative abdomen, both kidneys were echogenic, cortices suggesting chronic medical renal disease.  Doppler of lower extremities negative for DVT., ,ASSESSMENT AND PLAN:,1.  Rhabdomyolysis, most likely secondary to statins, gemfibrozil, discontinue it on admission.  Continue IV fluids.  We will monitor.,2.  Acute on chronic renal failure.  We will follow up with Nephrology recommendation.,3.  Anemia, drop in hemoglobin most likely hemodilutional.  Repeat CBC in a.m.,4.  Leukocytosis, improving.,5.  Elevated liver enzyme, most likely secondary to rhabdomyolysis.  The patient denies any abdominal pain and ultrasound is unremarkable.,6.  Hypertension.  Blood pressure controlled.,7.  Elevated cardiac enzyme, follow up with Cardiology recommendation.,8.  Obesity.,9.  Deep venous thrombosis prophylaxis.  Continue Lovenox 40 mg subcu daily.","general medicine, rhabdomyolysis, acute on chronic renal failure, anemia, leukocytosis, elevated liver enzyme, hypertension, elevated cardiac enzyme, obesity, cardiac enzyme, blood pressure, "
" 5-month recheck on type II diabetes mellitus, as well as hypertension.", General Medicine, Gen Med Progress Note - 11 ,"SUBJECTIVE:,  The patient is a 66-year-old female who presents to the clinic today for a five-month recheck on her type II diabetes mellitus, as well as hypertension.  While here she had a couple of other issues as well.  She stated that she has been having some right shoulder pain.  She denies any injury but certain range of motion does cause it to hurt.  No weakness, numbness or tingling.  As far as her diabetes she states that she only checks her blood sugars in the morning and those have all been ranging less than 100.  She has not been checking any two hours after meals.  Her blood pressures when she does check them have been running normal as well but she does not have any record of these present with her.  No other issues or concerns.  Upon review of her chart it did show that she had a benign breast biopsy done back on 06/11/04 and was told to have a repeat mammogram in six months but she has never had that done so she is needing to have this done as well.,ALLERGIES: , None.,MEDICATIONS:,  She is on Hyzaar 50/12.5 one-half p.o. daily, coated aspirin daily, lovastatin 40 mg one-half tab p.o. daily, multivitamin daily, metformin 500 mg one tab p.o. b.i.d.; however, she has been skipping her second dose during the day.,SOCIAL HISTORY:,  She is a nonsmoker.,REVIEW OF SYSTEMS:,  As noted above.,OBJECTIVE:,Vital Signs:  Temperature:  98.2.  Pulse:  64.  Respirations:  16.  Blood pressure:  110/56.  Weight:  169.,General:  Alert and oriented x 3.  No acute distress noted.,Neck:  No lymphadenopathy, thyromegaly, JVD or bruits.,Lungs:  Clear to auscultation.,Heart:  Regular rate and rhythm without murmur or gallops present.,Breasts:  Exam performed with a female nurse present.  The breasts do have some scars present underneath them bilaterally from prior breast reduction surgery.  There is no axillary adenopathy or tenderness.  Breasts appear to be symmetric.  There was no nipple discharge or retraction.  No breast tissue retraction noted in either the sitting or the supine position.  Upon palpation there were no palpable lumps or bumps and no palpable discharge.,Musculoskeletal:  She did have full range of motion of her shoulders.  She did have tenderness upon palpation over the right bicipital tendon.  There is no swelling, crepitus or discoloration noted.,MEDICAL DECISION MAKING:  Most recent hemoglobin A1c was 5.6% back in October 2004.  Most recent lipid checks were obtained back in July 2004.  We have not had this checked since that time.,ASSESSMENT:,1.  Type II diabetes mellitus.,2.  Hypertension.,3.  Right shoulder pain.,4.  Hyperlipidemia.,PLAN:,1.  She is going to go to lab to obtain a hemoglobin A1c, BMP, lipids, CPK, liver enzymes and quantitative microalbumin.,2.  We are going to set her up for a diagnostic bilateral mammogram due to a history of abnormal mammogram in the past which subsequently showed a benign breast cyst.,3.  I told her for her shoulder to take ibuprofen 600 mg three times daily with her meals for a minimum of the next one week.,4.  She is going to follow up in the clinic in three months for a complete comprehensive examination.  If any questions, concerns or problems arise between now and then she should let us know.", 
 Patient has a past history of known hyperthyroidism and a recent history of atrial fibrillation and congestive cardiac failure with an ejection fraction of 20%-25%., General Medicine, Gen Med Office Note - 1 ,"HISTORY OF PRESENT ILLNESS:, The patient is a 43-year-old male who was recently discharged from our care on the 1/13/06 when he presented for shortness of breath. He has a past history of known hyperthyroidism since 1992 and a more recent history of atrial fibrillation and congestive cardiac failure with an ejection fraction of 20%-25%. The main cause for his shortness of breath was believed to be due to atrial fibrillation secondary to hyperthyroidism in a setting with congestive cardiac failure. During his hospital stay, he was commenced on metoprolol for rate control, and given that he had atrial fibrillation, he was also started on warfarin, which his INR has been followed up by the Homeless Clinic. For his congestive cardiac failure, he was restarted on Digoxin and lisinopril. For his hyperthyroidism, we restarted him on PTU and the endocrinologists were happy to review him when he was euthymic to discuss further radioiodine or radiotherapy. He was restarted on PTU and discharged from the hospital on this medication. While in the hospital, it was also noted that he abused cigarettes and cocaine, and we advised strongly against this given the condition of his heart. It was also noted that he had elevated liver function tests, which an ultrasound was normal, but his hepatitis panel was pending. Since his discharge, his hepatitis panel has come back normal for hepatitis A, B, and C. Since discharge, the patient has complained of shortness of breath, mainly at night when lying flat, but otherwise he states he has been well and compliant with his medication.,MEDICATIONS:, Digoxin 250 mcg daily, lisinopril 5 mg daily, metoprolol 50 mg twice daily, PTU (propylthiouracil) 300 mg orally four times a day, warfarin variable dose based on INR.,PHYSICAL EXAMINATION:,VITAL SIGNS: He was afebrile today. Blood pressure 114/98. Pulse 92 but irregular. Respiratory rate 25.,HEENT: Obvious exophthalmus, but no obvious lid lag today.,NECK: There was no thyroid mass palpable.,CHEST: Clear except for occasional bibasilar crackles.,CARDIOVASCULAR: Heart sounds were dual, but irregular, with no additional sounds.,ABDOMEN: Soft, nontender, nondistended.,EXTREMITIES: Mild +1 peripheral edema in both legs.,PLAN:, The patient has also been attending the Homeless Clinic since discharge from the hospital, where he has been receiving quality care and they have been looking after every aspect of his health, including his hyperthyroidism. It is our recommendation that a TSH and T4 be continually checked until the patient is euthymic, at which time he should attend endocrine review with Dr. Huffman for further treatment of his hyperthyroidism. Regarding his atrial fibrillation, he is moderately rate controlled with metoprolol 50 mg b.i.d. His rate in clinic today was 92. He could benefit from increasing his metoprolol dose, however, in the hospital it was noted that he was bradycardic in the morning with a pulse rate down to the 50s, and we were concerned with making this patient bradycardic in the setting of congestive cardiac failure. Regarding his congestive cardiac failure, he currently appears stable, with some variation in his weight. He states he has been taking his wife's Lasix tablets for diuretic benefit when he feels weight gain coming on and increased edema. We should consider adding him on a low-dose furosemide tablet to be taken either daily or when his weight is above his target range. A Digoxin level has not been repeated since discharge, and we feel that this should be followed up. We have also increased his lisinopril to 5 mg daily, but the patient did not receive his script upon departing our clinic. Regarding his elevated liver function tests, we feel that these are very likely secondary to hepatic congestion secondary to congestive cardiac failure with a normal ultrasound and normal hepatitis panel, but yet the liver function tests should be followed up.","general medicine, congestive cardiac failure, ejection fraction, atrial fibrillation, congestive cardiac, cardiac failure, office, lisinopril, metoprolol, hepatitis, fibrillation, hyperthyroidism, atrial, cardiac, congestive,"
 Sample progress note - Gen Med., General Medicine, Gen Med Progress Note - 2 ,"CHIEF COMPLAINT:,  Followup on hypertension and hypercholesterolemia.,SUBJECTIVE:,  This is a 78-year-old male who recently had his right knee replaced and also back surgery about a year and a half ago.  He has done well with that.  He does most of the things that he wants to do.  He travels at every chance he has, and he just got back from a cruise.  He denies any type of chest pain, heaviness, tightness, pressure, shortness of breath with stairs only, cough or palpitations.  He sees Dr. Ferguson.  He is known to have Crohn's and he takes care of that for him.  He sees Dr. Roszhart for his prostate check.  He is a nonsmoker and denies swelling in his ankles.,MEDICATIONS:, Refer to chart.,ALLERGIES:, Refer to chart.,PHYSICAL EXAMINATION:, ,Vitals:  Wt; 172 lbs, up 2 lbs,  B/P; 150/60, T; 96.4, P; 72 and regular.  ,General:  A 78-year-old male who does not appear to be in any acute distress.  Glasses.  Good dentition.,CV: Distant S1, S2 without murmur or gallop. No carotid bruits. P: 2+ all around.,Lungs: Diminished with increased AP diameter. ,Abdomen:  Soft, bowel sounds active x 4 quadrants. No tenderness, no distention, no masses or organomegaly noted.,Extremities:  Well-healed surgical scar on the right knee.  No edema.  Hand grasps are strong and equal.,Back:  Surgical scar on the lower back.,Neuro: Intact.  A&O. Moves all four with no focal motor or sensory deficits.,IMPRESSION:,1.  Hypertension.,2.  Hypercholesterolemia.,3.  Osteoarthritis.,4.  Fatigue.,PLAN:,  We will check a BMP, lipid, liver profile, CPK, and CBC.  Refill his medications x 3 months.  I gave him a copy of Partners in Prevention.  Increase his Altace to 5 mg day for better blood pressure control.  Diet, exercise, and weight loss, and we will see him back in three months and p.r.n.","general medicine, progress note, fatigue, osteoarthritis, back surgery, chest pain, cough, heaviness, hypercholesterolemia, hypertension, palpitations, pressure, shortness of breath, tightness, surgical scar, progress, "
 The patient states that he feels sick and weak., General Medicine, Gen Med Progress Note ,"SUBJECTIVE:,  The patient states that he feels sick and weak.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Highest temperature recorded over the past 24 hours was 101.1, and current temperature is 99.2.,GENERAL:  The patient looks tired.,HEENT:  Oral mucosa is dry.,CHEST:  Clear to auscultation.  He states that he has a mild cough, not productive.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmur was appreciated.,ABDOMEN:  Soft and nontender.  Bowel sounds are positive. Murphy's sign is negative.,EXTREMITIES:  There is no swelling.,NEURO:  The patient is alert and oriented x 3.  Examination is nonfocal.,LABORATORY DATA: , White count is normal at 6.8, hemoglobin is 15.8, and platelets 257,000.  Glucose is in the low 100s.  Comprehensive metabolic panel is unremarkable.  UA is negative for infection.,ASSESSMENT AND PLAN:,1.  Fever of undetermined origin, probably viral since white count is normal.  Would continue current antibiotics empirically.,2.  Dehydration.  Hydrate the patient.,3.  Prostatic hypertrophy.  Urologist, Dr. X.,4.  DVT prophylaxis with subcutaneous heparin.","general medicine, fever, dehydration, prophylaxis, white count is normal, white count, sick, weak, temperature,"
 Sample progress note - Gen Med., General Medicine, Gen Med Progress Note - 1 ,"CHIEF COMPLAINT:,  Followup on diabetes mellitus, status post cerebrovascular accident.,SUBJECTIVE:,  This is a 70-year-old male who has no particular complaints other than he has just discomfort on his right side.  We have done EMG studies.  He has noticed it since his stroke about five years ago.  He has been to see a neurologist.  We have tried different medications and it just does not seem to help.  He checks his blood sugars at home two to three times a day.  He kind of adjusts his own insulin himself.  Re-evaluation of symptoms is essentially negative.  He has a past history of heavy tobacco and alcohol usage.,MEDICATIONS:, Refer to chart.,ALLERGIES:, Refer to chart.,PHYSICAL EXAMINATION: ,Vitals: Wt; 118 lbs, B/P; 108/72, T; 96.5, P; 80 and regular.  ,General:  A 70-year-old male who does not appear to be in acute distress but does look older than his stated age.  He has some missing dentition.,Skin:  Dry and flaky. ,CV:  Heart tones are okay, adequate carotid pulsations.  He has 2+ pedal pulse on the left and 1+ on the right.,Lungs: Diminished but clear.,Abdomen:  Scaphoid.,Rectal:  His prostate check was normal per Dr. Gill.,Neuro:  Sensation with monofilament testing is better on the left than it is on the right.,IMPRESSION:,1.  Diabetes mellitus.,2.  Neuropathy.,3.  Status post cerebrovascular accident.,PLAN:,  Refill his medications x 3 months.  We will check an A1c and BMP.  I have talked to him several times about a colonoscopy, which he has refused, and so we have been doing stools for occult blood.  We will check a PSA.  Continue with yearly eye exams, foot exams, Accu-Cheks, and we will see him in three months and p.r.n.","general medicine, diabetes mellitus, neuropathy, genernal medicine, post cerebrovascular accident, progerss note, post cerebrovascular, cerebrovascular accident, accident, cerebrovascular, neurologist, insulin, "
 Sample progress note - Gen Med., General Medicine, Gen Med Progress Note - 3 ,"CHIEF COMPLAINT:, Followup on diabetes mellitus, hypercholesterolemia, and sinusitis. ,SUBJECTIVE:,  A 70-year-old female who was diagnosed with diabetes mellitus last fall.  She has been checking her Accu-Cheks generally once a day, and they range from 82 to a high of 132.  She feels well.  She walks 1-2 miles most days.  If the weather is bad, they go to a local mall.  Otherwise they walk outside.  She does complain of some sinus congestion and drainage for the last several days.  She is up-to-date on her mammogram that she had at the Baylis Building.  She sees Dr. Cheng for her gynecological care.  She is a nonsmoker.  Denies abdominal pain, nausea, vomiting, diarrhea, constipation, blood in her urine, blood in her stools.  She has nocturia x 1.  Denies swelling in her ankles.  She checks her feet regularly., ,PAST MEDICAL HISTORY:,  Refer to chart.,MEDICATIONS:, Refer to chart.,ALLERGIES:, Refer to chart.,PHYSICAL EXAMINATION: ,Vitals: Wt:  185 B/P: 142/70.  When she checks it at the mall and other places, it is usually about 120/56. T: 96.5 P:  84 and regular.,General: A 70-year-old female who does not appear to be in acute distress.  ,HEENT: She has frontal and maxillary sinus tenderness on the right to palpation.  The right TM is slightly dull.",
" Weakness, malaise dyspnea on exertion, 15-pound weight loss - Bilateral pneumonia, hepatitis, renal insufficiency, ", General Medicine, Gen Med H&P - 2 ,"HISTORY OF PRESENT ILLNESS: , This is a 43-year-old black man with no apparent past medical history who presented to the emergency room with the chief complaint of weakness, malaise and dyspnea on exertion for approximately one month.  The patient also reports a 15-pound weight loss.  He denies fever, chills and sweats.  He denies cough and diarrhea.  He has mild anorexia.,PAST MEDICAL HISTORY:,  Essentially unremarkable except for chest wall cysts which apparently have been biopsied by a dermatologist in the past, and he was given a benign diagnosis.  He had a recent PPD which was negative in August 1994.,MEDICATIONS: , None.,ALLERGIES: , No known drug allergies.,SOCIAL HISTORY: , He occasionally drinks and is a nonsmoker.  The patient participated in homosexual activity in Haiti during 1982 which he described as ""very active."" Denies intravenous drug use.  The patient is currently employed.,FAMILY HISTORY:,  Unremarkable.,PHYSICAL EXAMINATION:,GENERAL:  This is a thin, black cachectic man speaking in full sentences with oxygen.,VITAL SIGNS:  Blood pressure 96/56, heart rate 120.  No change with orthostatics.  Temperature 101.6 degrees Fahrenheit.  Respirations 30.,HEENT:  Funduscopic examination normal.  He has oral thrush.,LYMPH:  He has marked adenopathy including right bilateral epitrochlear and posterior cervical nodes.,NECK:  No goiter, no jugular venous distention.,CHEST:  Bilateral basilar crackles, and egophony at the right and left middle lung fields.,HEART:  Regular rate and rhythm, no murmur, rub or gallop.,ABDOMEN:  Soft and nontender.,GENITOURINARY:  Normal.,RECTAL:  Unremarkable.,SKIN:  The patient has multiple, subcutaneous mobile nodules on the chest wall that are nontender.  He has very pale palms., ,LABORATORY AND X-RAY DATA: , Sodium 133, potassium 5.3, BUN 29, creatinine 1.8.  Hemoglobin 14, white count 7100, platelet count 515.  Total protein 10, albumin 3.1, AST 131, ALT 31.  Urinalysis shows 1+ protein, trace blood.  Total bilirubin 2.4, direct bilirubin 0.1.  Arterial blood gases:  pH 7.46, pC02 32, p02 46 on room air.  Electrocardiogram shows normal sinus rhythm.  Chest x-ray shows bilateral alveolar and interstitial infiltrates.,IMPRESSION:,1.  Bilateral pneumonia; suspect atypical pneumonia, rule out Pneumocystis carinii pneumonia and tuberculosis.,2.  Thrush.,3.  Elevated unconjugated bilirubins.,4.  Hepatitis.,5.  Elevated globulin fraction.,6.  Renal insufficiency.,7.  Subcutaneous nodules.,8.  Risky sexual behavior in 1982 in Haiti.,PLAN:,1.  Induced sputum, rule out Pneumocystis carinii pneumonia and tuberculosis.,2.  Begin intravenous Bactrim and erythromycin.,3.  Begin prednisone.,4.  Oxygen.,5.  Nystatin swish and swallow.,6.  Dermatologic biopsy of lesions.,7.  Check HIV and RPR.,8.  Administer Pneumovax, tetanus shot and Heptavax if indicated.",
 Sepsis due to urinary tract infection., General Medicine, Gen Med Progress Note - 13 ,"SUBJECTIVE: , The patient states she is feeling a bit better.,OBJECTIVE:,VITAL SIGNS:  Temperature is 95.4.  Highest temperature recorded over the past 24 hours is 102.1.,CHEST:  Examination of the chest is clear to auscultation.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmurs appreciated.,ABDOMEN:  Benign.  Right renal angle is tender.  Bowel sounds are positive.,EXTREMITIES:  There is no swelling.,NEUROLOGIC:  The patient is alert and oriented x3.  Examination is nonfocal.,LABORATORY DATA: , White count is down from 35,000 to 15.5.  Hemoglobin is 9.5, hematocrit is 30, and platelets are 269,000.  BUN is down to 22, creatinine is within normal limits.,ASSESSMENT AND PLAN:,1.  Sepsis due to urinary tract infection.  Urine culture shows Escherichia coli, resistant to Levaquin.  We changed to doripenem.,2.  Urinary tract infection, we will treat with doripenem, change Foley catheter,3.  Hypotension.  Resolved, continue intravenous fluids.,4.  Ischemic cardiomyopathy.  No evidence of decompensation, we with monitor.,5.  Diabetes type 2.  Uncontrolled.  Continue insulin sliding scale.,6.  Recent pulmonary embolism, INR is above therapeutic range, Coumadin is on hold, we will monitor.,7.  History of coronary artery disease.  Troponin indeterminate.  Cardiologist intends no further workup.  Continue medical treatment.  Most likely troponin is secondary to impaired clearance.","general medicine, sepsis, escherichia coli, urinary tract infection, doripenem, troponin, urinary, infection"
 Right-sided facial droop and right-sided weakness.  Recent cerebrovascular accident.  he CT scan of the head did not show any acute events with the impression of a new-onset cerebrovascular accident., General Medicine, Gen Med Consult - 7 ,"CHIEF COMPLAINT:,  Right-sided facial droop and right-sided weakness.,HISTORY OF PRESENT ILLNESS: , The patient is an 83-year-old lady, a resident of a skilled nursing facility, with past medical history of a stroke and dementia with expressive aphasia, was found today with a right-sided facial droop, and was transferred to the emergency room for further evaluation.  While in the emergency room, she was found to having the right-sided upper extremity weakness and right-sided facial droop.  The CT scan of the head did not show any acute events with the impression of a new-onset cerebrovascular accident, will be admitted to monitor bed for observation and treatment and also she was recently diagnosed with urinary tract infection, which was resistant to all oral medications.,ALLERGIES: , SHE IS ALLERGIC TO PENICILLIN.,SOCIAL HISTORY: , She is a nondrinker and nonsmoker and currently lives at the skilled nursing facility.,FAMILY HISTORY: , Noncontributory.,PAST MEDICAL HISTORY:,1.  Cerebrovascular accident with expressive aphasia and lower extremity weakness.,2.  Abnormality of gait and wheelchair bound secondary to #1.,3.  Hypertension.,4.  Chronic obstructive pulmonary disease, on nasal oxygen.,5.  Anxiety disorder.,6.  Dementia.,PAST SURGICAL HISTORY: , Status post left mastectomy secondary to breast cancer and status post right knee replacement secondary to osteoarthritis.,REVIEW OF SYSTEMS: , Because of the patient's inability to communicate, is not obtainable, but apparently, she has urine incontinence and also stool incontinence, and is wheelchair bound.,PHYSICAL EXAMINATION:,GENERAL:  She is an 83-year-old patient, awake, and non-communicable lady, currently in bed, follows commands by closing and opening her eyes.,VITAL SIGNS:  Temperature is 99.6, pulse is 101, respirations 18, and blood pressure is in the 218/97.,HEENT:  Pupils are equal, round, and reactive to light.  External ocular muscles are intact.  Conjunctivae anicteric.  There is a slight right-sided facial droop.  Oropharynx is clear with the missing teeth on the upper and the lower part.  Tympanic membranes are clear.,NECK:  Supple.  There is no carotid bruit.  No cervical adenopathy.,CARDIAC:  Regular rate and rhythm with 2/6 systolic murmur, more at the apex.,LUNGS:  Clear to auscultation.,ABDOMEN:  Soft and no tenderness.  Bowel sound is present.,EXTREMITIES:  There is no pedal edema.  Both knees are passively extendable with about 10-15 degrees of fixed flexion deformity on both sides.,NEUROLOGIC:  There is right-sided slight facial droop.  She moves both upper extremities equally.  She has withdrawal of both lower extremities by touching her sole of the feet.,SKIN:  There is about 2 cm first turning to second-degree pressure ulcer on the right buttocks.,LABORATORY DATA: , The CT scan of the head shows brain atrophy with no acute events.  Sodium is 137, potassium 3.7, chloride 102, bicarbonate 24, BUN of 22, creatinine 0.5, and glucose of 92.  Total white blood cell count is 8.9000, hemoglobin 14.4, hematocrit 42.7, and the platelet count of 184,000.  The urinalysis was more than 100 white blood cells and 10-25 red blood cells.  Recent culture showed more than 100,000 colonies of E. coli, resistant to most of the tested medications except amikacin, nitrofurantoin, imipenem, and meropenem.,ASSESSMENT:,1.  Recent cerebrovascular accident with right-sided weakness.,2.  Hypertension.,3.  Dementia.,4.  Anxiety.,5.  Urinary tract infection.,6.  Abnormality of gait secondary to lower extremity weakness.,PLAN: , We will keep the patient NPO until a swallowing evaluation was done.  We will start her on IV Vasotec every 4 hours p.r.n. systolic blood pressure more than 170.  Neuro check every 4 hours for 24 hours.  We will start her on amikacin IV per pharmacy.  We will start her on Lovenox subcutaneously 40 mg every day and we will continue with the Ecotrin as swallowing evaluation was done.  Resume home medications, which basically include Aricept 10 mg p.o. daily, Diovan 160 mg p.o. daily, multivitamin, calcium with vitamin D, Ecotrin, and Tylenol p.r.n.  I will continue with the IV fluids at 75 mL an hour with a D5 normal saline at the range of 75 mL an hour and adding potassium 10 mEq per 1000 mL and I would follow the patient on daily basis.",
" Comprehensive Evaluation - Generalized anxiety and hypertension, both under fair control.", General Medicine, Gen Med Consult - 8 ,"SUBJECTIVE:,  The patient comes in today for a comprehensive evaluation.  She is well-known to me.  I have seen her in the past multiple times.,PAST MEDICAL HISTORY/SOCIAL HISTORY/FAMILY HISTORY: , Noted and reviewed today.  They are on the health care flow sheet.  She has significant anxiety which has been under fair control recently.  She has a lot of stress associated with a son that has some challenges.  There is a family history of hypertension and strokes.,CURRENT MEDICATIONS:,  Currently taking Toprol and Avalide for hypertension and anxiety as I mentioned.,REVIEW OF SYSTEMS:,  Significant for occasional tiredness.  This is intermittent and currently not severe.  She is concerned about the possibly of glucose abnormalities such diabetes.  We will check a glucose, lipid profile and a Hemoccult test also and a mammogram.  Her review of systems is otherwise negative.,PHYSICAL EXAMINATION:,VITAL SIGNS:  As above.,GENERAL:  The patient is alert, oriented, in no acute distress.,HEENT:  PERRLA.  EOMI.  TMs clear bilaterally.  Nose and throat clear.,NECK:  Supple without adenopathy or thyromegaly.  Carotid pulses palpably normal without bruit.,CHEST:  No chest wall tenderness.,BREAST EXAM:  No asymmetry, skin changes, dominant masses, nipple discharge, or axillary adenopathy.,HEART:  Regular rate and rhythm without murmur, clicks, or rubs.,LUNGS:  Clear to auscultation and percussion.,ABDOMEN:  Soft, nontender, bowel sounds normoactive.  No masses or organomegaly.,GU:  External genitalia without lesions.  BUS normal.  Vulva and vagina show just mild atrophy without any lesions.  Her cervix and uterus are within normal limits.  Ovaries are not really palpable.  No pelvic masses are appreciated.,RECTAL:  Negative.,BREASTS:  No significant abnormalities.,EXTREMITIES:  Without clubbing, cyanosis, or edema.  Pulses within normal limits.,NEUROLOGIC:  Cranial nerves II-XII intact.  Strength, sensation, coordination, and reflexes all within normal limits.,SKIN:  Noted to be normal.  No subcutaneous masses noted.,LYMPH SYSTEM:  No lymphadenopathy.,ASSESSMENT:,  Generalized anxiety and hypertension, both under fair control.,PLAN:,  We will not make any changes in her medications.  I will have her check a lipid profile as mentioned, and I will call her with that.  Screening mammogram will be undertaken.  She declined a sigmoidoscopy at this time.  I look forward to seeing her back in a year and as needed.", 
" Comprehensive Evaluation - Diabetes, hypertension, irritable bowel syndrome, and insomnia.", General Medicine, Gen Med Consult - 9 ,"SUBJECTIVE:,  The patient is well-known to me.  He comes in today for a comprehensive evaluation.  Really, again he borders on health crises with high blood pressure, diabetes, and obesity.  He states that he has reached a critical decision in the last week that he understands that he cannot continue with his health decisions as they have been made, specifically the lack of exercise, the obesity, the poor eating habits, etc.  He knows better and has been through some diabetes training.  In fact, interestingly enough, with his current medications which include the Lantus at 30 units along with Actos, glyburide, and metformin, he achieved ideal blood sugar control back in August 2004.  Since that time he has gone off of his regimen of appropriate eating, and has had sugars that are running on average too high at about 178 over the last 14 days.  He has had elevated blood pressure.  His other concerns include allergic symptoms.  He has had irritable bowel syndrome with some cramping.  He has had some rectal bleeding in recent days.  Also once he wakes up he has significant difficulty in getting back to sleep.  He has had no rectal pain, just the bleeding associated with that.,MEDICATIONS/ALLERGIES:,  As above.,PAST MEDICAL/SURGICAL HISTORY: , Reviewed and updated - see Health Summary Form for details.,FAMILY AND SOCIAL HISTORY:,  Reviewed and updated - see Health Summary Form for details.,REVIEW OF SYSTEMS:,  Constitutional, Eyes, ENT/Mouth, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin/Breasts, Neurologic, Psychiatric, Endocrine, Heme/Lymph, Allergies/Immune all negative with the following exceptions:  None.,PHYSICAL EXAMINATION:,VITAL SIGNS:  As above.,GENERAL:  The patient is alert, oriented, well-developed, obese male who is in no acute distress.,HEENT:  PERRLA.  EOMI.  TMs clear bilaterally.  Nose and throat clear.,NECK:  Supple without adenopathy or thyromegaly.  Carotid pulses palpably normal without bruit.,CHEST:  No chest wall tenderness or breast enlargement.,HEART:  Regular rate and rhythm without murmur, clicks, or rubs.,LUNGS:  Clear to auscultation and percussion.,ABDOMEN:  Significantly obese without any discernible organomegaly.  GU:  Normal male genitalia without testicular abnormalities, inguinal adenopathy, or hernia.,RECTAL:  Smooth, nonenlarged prostate with just some irritation around the rectum itself.  No hemorrhoids are noted.,EXTREMITIES:  Some slow healing over the tibia.  Without clubbing, cyanosis, or edema.  Peripheral pulses within normal limits.,NEUROLOGIC:  Cranial nerves II-XII intact.  Strength, sensation, coordination, and reflexes all within normal limits.,SKIN:  Noted to be normal.  No subcutaneous masses noted.,LYMPH SYSTEM:  No lymphadenopathy noted.,BACK:  He has pain in his back in general.,ASSESSMENT/PLAN:,1.  Diabetes and hypertension, both under less than appropriate control.  In fact, we discussed increasing the Lantus.  He appears genuine in his desire to embark on a substantial weight-lowering regime, and is going to do that through dietary control.  He knows what needs to be done with the absence of carbohydrates, and especially simple sugar.  He will also check a hemoglobin A1c, lipid profile, urine for microalbuminuria and a chem profile.  I will need to recheck him in a month to verify that his sugars and blood pressure have come into the ideal range.  He has allergic rhinitis for which Zyrtec can be used.,2.  He has irritable bowel syndrome.  We will use Metamucil for that which also should help stabilize the stools so that the irritation of the rectum is lessened.  For the bleeding I would like to obtain a sigmoidoscopy.  It is bright red blood.,3.  For his insomnia, I found there is very little in the way of medications that are going to fix that, however I have encouraged him in good sleep hygiene.  I will look forward to seeing him back in a month.  I will call him with the results of his lab.  His medications were made out.  We will use some Elocon cream for his seborrheic dermatitis of the face.  Zyrtec and Flonase for his allergic rhinitis.", 
" Patient with several medical problems - numbness, tingling, and a pain in the toes.", General Medicine, Gen Med Consult - 6 ,"SUBJECTIVE:,  The patient is in with several medical problems.  She complains of numbness, tingling, and a pain in the toes primarily of her right foot described as a moderate pain.  She initially describes it as a sharp quality pain, but is unable to characterize it more fully.  She has had it for about a year, but seems to be worsening.  She has little bit of paraesthesias in the left toe as well and seem to involve all the toes of the right foot.  They are not worse with walking.  It seems to be worse when she is in bed.  There is some radiation of the pain up her leg.  She also continues to have bilateral shoulder pains without sinus allergies.  She has hypothyroidism.  She has thrombocythemia, insomnia, and hypertension.,PAST MEDICAL HISTORY:,  Surgeries include appendectomy in 1933, bladder obstruction surgery in 1946, gallbladder surgery in 1949, another gallbladder surgery in 1954, C-section in 1951, varicose vein surgery in 1951 and again in 1991, thyroid gland surgery in 1964, hernia surgery in 1967, bilateral mastectomies in 1968 for benign disease, hysterectomy leaving her ovaries behind in 1970, right shoulder surgery x 4 and left shoulder surgery x 2 between 1976 and 1991, and laparoscopic bowel adhesion removal in October 2002.  She had a Port-A-Cath placed in June 2003, left total knee arthroplasty in June 2003, and left hip pinning due to fracture in October 2003, with pins removed in May 2004.  She has had a number of colonoscopies; next one is being scheduled at the end of this month.  She also had a right total knee arthroplasty in 1993.  She was hospitalized for synovitis of the left knee in April 2004, for zoster and infection of the left knee in May 2003, and for labyrinthitis in June 2004.,ALLERGIES: , Sulfa, aspirin, Darvon, codeine, NSAID, amoxicillin, and quinine.,CURRENT MEDICATIONS:,  Hydroxyurea 500 mg daily, Metamucil three teaspoons daily, amitriptyline 50 mg at h.s., Synthroid 0.1 mg daily, Ambien 5 mg at h.s., triamterene/hydrochlorothiazide 75/50 daily, and Lortab 5/500 at h.s. p.r.n.,SOCIAL HISTORY:,  She is a nonsmoker and nondrinker.  She has been widowed for 18 years.  She lives alone at home.  She is retired from running a restaurant.,FAMILY HISTORY:,  Mother died at age 79 of a stroke.  Father died at age 91 of old age.  Her brother had prostate cancer.  She has one brother living.  No family history of heart disease or diabetes.,REVIEW OF SYSTEMS:,General:  Negative.,HEENT:  She does complain of some allergies, sneezing, and sore throat.  She wears glasses.,Pulmonary history:  She has bit of a cough with her allergies.,Cardiovascular history:  Negative for chest pain or palpitations.  She does have hypertension.,GI history:  Negative for abdominal pain or blood in the stool.,GU history:  Negative for dysuria or frequency.  She empties okay.,Neurologic history:  Positive for paresthesias to the toes of both feet, worse on the right.,Musculoskeletal history:  Positive for shoulder pain.,Psychiatric history:  Positive for insomnia.,Dermatologic history:  Positive for a spot on her right cheek, which she was afraid was a precancerous condition.,Metabolic history:  She has hypothyroidism.,Hematologic history:  Positive for essential thrombocythemia and anemia.,OBJECTIVE:,General:  She is a well-developed, well-nourished, elderly female in no acute distress.,Vital Signs:  Her age is 81.  Temperature:  98.0.  Blood pressure:  140/70.  Pulse:  72.  Weight:  127.,HEENT:  Head was normocephalic.  Pupils equal, round, and reactive to light.  Extraocular movements are intact.  Fundi are benign.  TMs, nares, and throat were clear.,Neck:  Supple without adenopathy or thyromegaly.,Lungs:  Clear.,Heart:  Regular rate and rhythm without murmur, click, or rub.  No carotid bruits are heard.,Abdomen:  Normal bowel sounds.  It is soft and nontender without hepatosplenomegaly or mass.,Breasts:  Surgically absent.  No chest wall mass was noted, except for the Port-A-Cath in the left chest.  No axillary adenopathy is noted.,Extremities:  Examination of the extremities reveals no ankle edema or calf tenderness x 2 in lower extremities.  There is a cyst on the anterior portion of the right ankle.  Pedal pulses were present.,Neurologic:  Cranial nerves II-XII grossly intact and symmetric.  Deep tendon reflexes were 1 to 2+ bilaterally at the knees.  No focal neurologic deficits were observed.,Pelvic:  BUS and external genitalia were atrophic.  Vaginal rugae were atrophic.  Cervix was surgically absent.  Bimanual exam confirmed the absence of uterus and cervix and I could not palpate any ovaries.,Rectal:  Exam confirmed there is brown stool present in the rectal vault.,Skin:  Clear other than actinic keratosis on the right cheek.,Psychiatric:  Affect is normal.,ASSESSMENT:,1.  Peripheral neuropathy primarily of the right foot.,2.  Hypertension.,3.  Hypothyroidism.,4.  Essential thrombocythemia.,5.  Allergic rhinitis.,6.  Insomnia.,PLAN:",
"  The patient is a 35-year-old lady who was admitted with chief complaints of chest pain, left-sided with severe chest tightness after having an emotional argument with her boyfriend.   The patient has a long history of psychological disorders.", General Medicine, Gen Med Consult - 54 ,"HISTORY OF PRESENT ILLNESS: , The patient is a 35-year-old lady who was admitted with chief complaints of chest pain, left-sided with severe chest tightness after having an emotional argument with her boyfriend.  The patient has a long history of psychological disorders.  As per the patient, she also has a history of supraventricular tachycardia and coronary artery disease, for which the patient has had workup done in ABC Medical Center.  The patient was evaluated in the emergency room.  The initial cardiac workup was negative.  The patient was admitted to telemetry unit for further evaluation.  In the emergency room, the patient was also noted to have a strongly positive drug screen including methadone and morphine.  The patient's EKG in the emergency room was normal and the patient had some relief from her chest pain after she got some nitroglycerin.,PAST MEDICAL HISTORY: , As mentioned above is significant for history of seizure disorder, migraine headaches, coronary artery disease, CHF, apparently coronary stenting done, mitral valve prolapse, supraventricular tachycardia, pacemaker placement, colon cancer, and breast cancer.  None of the details of these are available.,PAST SURGICAL HISTORY: , Significant for history of lumpectomy on the left breast, breast augmentation surgery, cholecystectomy, cardiac ablation x3, left knee surgery as well as removal of half the pancreas.,CURRENT MEDICATIONS AT HOME: , Included Dilantin 400 mg daily, Klonopin 2 mg 3 times a day, Elavil 300 mg at night, nitroglycerin sublingual p.r.n., Thorazine 300 mg 3 times a day, Neurontin 800 mg 4 times a day, and Phenergan 25 mg as tolerated.,OB HISTORY: , Her last menstrual period was 6/3/2009.  The patient is admitting to having a recent abortion done.  She is not too sure whether the abortion was completed or not, has not had a followup with her OB/GYN.,FAMILY HISTORY:  ,Noncontributory.,SOCIAL HISTORY:  ,She lives with her boyfriend.  The patient has history of tobacco abuse as well as multiple illicit drug abuse.,REVIEW OF SYSTEMS:  As mentioned above.,PHYSICAL EXAMINATION:,GENERAL:  She is alert, awake, and oriented.,VITAL SIGNS:  Her blood pressure is about 132/72, heart rate of about 87 per minute, respiratory rate of 16.,HEENT:  Shows head is atraumatic.  Pupils are round and reactive to light.  Extraocular muscles are intact.  No oropharyngeal lesions noted.,NECK:  Supple, no JV distention, no carotid bruits, and no lymphadenopathy.,LUNGS:  Clear to auscultation bilaterally.,CARDIAC:  Reveals regular rate and rhythm.,ABDOMEN:  Soft, nontender, nondistended.  Bowel sounds are normally present.,LOWER EXTREMITIES:  Shows no edema.  Distal pulses are 2+.,NEUROLOGICAL:  Grossly nonfocal.,LABORATORY DATA: , The database that is available at this point of time, WBC count is normal, hemoglobin and hematocrit are normal.  Sodium, potassium, chloride, glucose, bicarbonate, BUN and creatinine, and liver function tests are normal.  The patient's 3 sets of cardiac enzymes including troponin-I, CPK-MB, and myoglobulin have been normal.  EKG is normal, sinus rhythm without any acute ST-T wave changes.  As mentioned before, the patient's toxicology screen was positive for morphine, methadone, and marijuana.  The patient also had a head CT done in the emergency room, which was fairly unremarkable.  The patient's beta-hCG level was marginally elevated at about 48.,ASSESSMENT AND EVALUATION:,1.  Chest pains, appear to be completely noncardiac.  The patient does seem to have a psychosomatic component to her chest pain.  There is no evidence of acute coronary syndrome or unstable angina at this point of time.,2.  Possible early pregnancy.  The patient's case was discussed with OB/GYN on-call over the phone.  Some of the medications have to be held secondary to potential danger.  The patient will follow up on an outpatient basis with her primary OB/GYN as well as PCP for the workup of her pregnancy as well as continuation of the pregnancy and prenatal visits.,3.  Migraine headaches for which the patient has been using her routine medications and the headaches seem to be under control.  Again, this is an outpatient diagnosis.  The patient will follow up with her PCP for control of migraine headache.,Overall prognosis is too soon to predict.,The plan is to discharge the patient home secondary to no evidence of acute coronary syndrome.",
" The patient is a 61-year-old lady who was found down at home and was admitted for respiratory failure, septic shock, acute renal failure as well as metabolic acidosis.", General Medicine, Gen Med Consult - 53 ,"HISTORY OF PRESENT ILLNESS: , Goes back to yesterday, the patient went out for dinner with her boyfriend.  The patient after coming home all the family members had some episodes of diarrhea; it is unclear how many times the patient had diarrhea last night.  She was found down on the floor this morning, soiled her bowel movements.  Paramedics were called and the patient was brought to the emergency room.  The patient was in the emergency room noted to be in respiratory failure, was intubated.  The patient was in septic shock with metabolic acidosis and no blood pressure and very rapid heart rate with acute renal failure.  The patient was started on vasopressors.  The patient was started on IV fluids as well as IV antibiotic.  The CT of the abdomen showed ileus versus bowel distention without any actual bowel obstruction or perforation.  A General Surgery consultation was called who did not think the patient was a surgical candidate and needed an acute surgical procedure.  The patient underwent an ultrasound of the abdomen, which did not show any evidence of cholecystitis or cholelithiasis.  The patient was also noted to have acute rhabdomyolysis on the workup in the emergency room.,PAST MEDICAL HISTORY:  ,Significant for history of osteoporosis, hypertension, tobacco dependency, anxiety, neurosis, depression, peripheral arterial disease, peripheral neuropathy, and history of uterine cancer.,PAST SURGICAL HISTORY:  ,Significant for hysterectomy, bilateral femoropopliteal bypass surgeries as well as left eye cataract surgery and appendicectomy.,SOCIAL HISTORY: , She lives with her boyfriend.  The patient has a history of heavy tobacco and alcohol abuse for many years.,FAMILY HISTORY: , Not available at this current time.,REVIEW OF SYSTEMS: , As mentioned above.,PHYSICAL EXAMINATION:,GENERAL:  She is intubated, obtunded, gangrenous ears with gangrenous fingertips.,VITAL SIGNS:  Blood pressure is absent, heart rate of 138 per minute, and the patient is on the ventilator.,HEENT:  Examination shows head is atraumatic, pupils are dilated and very, very sluggishly reacting to light.  No oropharyngeal lesions noted.,NECK:  Supple.  No JVD, distention or carotid bruit.  No lymphadenopathy.,LUNGS:  Bilateral crackles and bruits.,ABDOMEN:  Distended, unable to evaluate if this is tender.  No hepatosplenomegaly.  Bowel sounds are very hyperactive.,LOWER EXTREMITIES:  Show no edema.  Distal pulses are decreased.,OVERALL NEUROLOGICAL:  Examination cannot be assessed.,LABORATORY DATA: , The database was available at this point of time.  WBC count is elevated at 19,000 with the left shift, hemoglobin of 17.7, and hematocrit of 55.8 consistent with severe dehydration.  PT INR is prolonged at 1.7 and aPTT is prolonged at 60.  Sodium was 143, BUN of 36, and creatinine of 2.5.  The patient's blood gas shows pH of 7.05, pO2 of 99.6, and pCO2 of 99.6.  Bicarb is 16.5.,ASSESSMENT AND EVALUATION:,1.  Septicemia with septic shock.,2.  Metabolic acidosis.,3.  Respiratory failure.,4.  Anuria.,5.  Acute renal failure.,The patient has no blood pressure at this point in time.  The patient is on IV fluids.  The patient is on vasopressors due to ventilator support, bronchodilators as well as IV antibiotics.  Her overall prognosis is extremely poor.  This was discussed with the patient's niece who is at bedside and will become indicated with her daughter when she arrives who is on the plane right now from Iowa.  The patient will be maintained on these supports at this point in time, but prognosis is poor.",
" Abdominal pain, nausea and vomiting, rule out recurrent small bowel obstruction.  The patient is an 89-year-old white male who developed lower abdominal pain, which was constant, onset approximately half an hour after dinner on the evening prior to admission.", General Medicine, Gen Med Consult - 51 ,"CHIEF COMPLAINT: , Abdominal pain.,HISTORY OF PRESENT ILLNESS:  ,The patient is an 89-year-old white male who developed lower abdominal pain, which was constant, onset approximately half an hour after dinner on the evening prior to admission.  He described the pain as 8/10 in severity and the intensity varied.  The symptoms persisted and he subsequently developed nausea and vomiting at 3 a.m. in the morning of admission.  The patient vomited twice and he states that he did note a temporary decrease in pain following his vomiting.  The patient was brought to the emergency room approximately 4 a.m. and evaluation including the CT scan, which revealed dilated loops of bowel without obvious obstruction.  The patient was subsequently admitted for possible obstruction.  The patient does have a history of previous small bowel obstruction approximately 20 times all but 2 required hospitalization, but all resolved with conservative measures (IV fluid, NG tube decompression, bowel rest.)  He has had previous abdominal surgeries including colon resection for colon CA and cholecystectomy as well as appendectomy.,PAST HISTORY: , Hypertension treated with Cozaar 100 mg daily and Norvasc 10 mg daily.  Esophageal reflux treated with Nexium 40 mg daily.  Allergic rhinitis treated with Allegra 180 mg daily.  Sleep disturbances, depression and anxiety treated with Paxil 25 mg daily, Advair 10 mg nightly and Ativan 1 mg nightly.  Glaucoma treated with Xalatan drops.  History of chronic bronchitis with no smoking history for which he uses p.r.n. Flovent and Serevent.,PREVIOUS SURGERIES:  ,Partial colon resection of colon carcinoma in 1961 with no recurrence, cholecystectomy 10 years ago, appendectomy, and glaucoma surgery.,FAMILY HISTORY: , Father died at age 85 of ""old age,"" mother died at age 89 of ""old age.""  Brother died at age 92 of old age, 2 brothers died in their 70s of Parkinson disease.  Son is at age 58 and has a history of hypertension, hypercholesterolemia, rheumatoid arthritis, and glaucoma.,SOCIAL HISTORY:  ,The patient is widowed and a retired engineer.  He denies cigarettes smoking or alcohol intake.,REVIEW OF SYSTEMS: , Denies fevers or weight loss.  HEENT:  Denies headaches, visual abnormality, decreased hearing, tinnitus, rhinorrhea, epistaxis or sore throat.  Neck:  Denies neck stiffness, no pain or masses in the neck.  Respiratory:  Denies cough, sputum production, hemoptysis, wheezing or shortness of breath.  Cardiovascular:  Denies chest pain, angina pectoris, DOE, PND, orthopnea, edema or palpitation.  Gastrointestinal:  See history of the present illness.  Urinary:  Denies dysuria, frequency, urgency or hematuria.  Neuro:  Denies seizure, syncope, incoordination, hemiparesis or paresthesias.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a well-developed, well-nourished elderly white male who is currently in no acute distress after receiving analgesics.,HEENT:  Atraumatic, normocephalic.  Eyes, EOMs full, PERRLA.  Fundi benign.  TMs normal.  Nose clear.  Throat benign.,NECK:  Supple with no adenopathy.  Carotid upstrokes normal with no bruits.  Thyroid is not enlarged.,LUNGS:  Clear to percussion and auscultation.,HEART:  Regular rate, normal S1 and S2 with no murmurs or gallops.  PMI is nondisplaced.,ABDOMEN:  Mildly distended with mild diffuse tenderness.  There is no rebound or guarding.  Bowel sounds are hypoactive.,EXTREMITIES:  No cyanosis, clubbing or edema.  Pulses are strong and intact throughout.,GENITALIA:  Atrophic male, no scrotal masses or tenderness.  Testicles are atrophic.  No hernia is noted.,RECTAL:  Unremarkable, prostate was not enlarged and there were no nodules or tenderness.,LAB DATA:,  WBC 12.1, hemoglobin and hematocrit 16.9/52.1, platelets 277,000.  Sodium 137, potassium 3.9, chloride 100, bicarbonate 26, BUN 27, creatinine 1.4, glucose 157, amylase 103, lipase 44.  Alkaline phosphatase, AST and ALT are all normal.  UA is negative.,Abdomen and pelvic CT showed mild stomach distention with multiple fluid-filled loops of bowel, no obvious obstruction noted.,IMPRESSION:,1.  Abdominal pain, nausea and vomiting, rule out recurrent small bowel obstruction.,2.  Hypertension.,3.  Esophageal reflux.,4.  Allergic rhinitis.,5.  Glaucoma.,PLAN: , The patient is admitted to the medical floor.  He has been kept NPO and will be given IV fluids.  He will also be given antiemetic medications with Zofran and an analgesic as necessary.  General surgery consultation was obtained.  Abdominal series x-ray will be done.",
" An 86-year-old female with persistent abdominal pain, nausea and vomiting, during evaluation in the emergency room, was found to have a high amylase, as well as lipase count and she is being admitted for management of acute pancreatitis.", General Medicine, Gen Med Consult - 50 ,"CHIEF COMPLAINT: , Abdominal pain.,HISTORY OF PRESENT ILLNESS: , This is an 86-year-old female who is a patient of Dr. X, who was transferred from ABCD Home due to persistent abdominal pain, nausea and vomiting, which started around 11:00 a.m. yesterday.  During evaluation in the emergency room, the patient was found to have a high amylase as well as lipase count and she is being admitted for management of acute pancreatitis.,PAST MEDICAL HISTORY:,  Significant for dementia of Alzheimer type, anxiety, osteoarthritis, and hypertension.,ALLERGIES: , THE PATIENT IS ALLERGIC TO POLLENS.,MEDICATIONS: , Include alprazolam 0.5 mg b.i.d. p.r.n., mirtazapine 30 mg p.o. daily, Aricept 10 mg p.o. nightly, Namenda 10 mg p.o. b.i.d., Benicar 40 mg p.o. daily, and Claritin 10 mg daily p.r.n.,FAMILY HISTORY: , Not available.,PERSONAL HISTORY:  ,Not available.,SOCIAL HISTORY:  ,Not available.  The patient lives at a skilled nursing facility.,REVIEW OF SYSTEMS:  ,She has moderate-to-severe dementia and is unable to give any information about history or review of systems.,PHYSICAL EXAMINATION:,GENERAL:  She is awake and alert, able to follow few simple commands, resting comfortably, does not appear to be in any acute distress.,VITAL SIGNS:  Temperature of 99.5, pulse 82, respirations 18, blood pressure of 150/68, and pulse ox is 90% on room air.,HEENT:  Atraumatic.  Pupils are equal and reactive to light.  Sclerae and conjunctivae are normal.  Throat without any pharyngeal inflammation or exudate.  Oral mucosa is normal.,NECK:  No jugular venous distention.  Carotids are felt normally.  No bruit appreciated.  Thyroid gland is not palpable.  There are no palpable lymph nodes in the neck or the supraclavicular region.,HEART:  S1 and S2 are heard normally.  No murmur appreciated.,LUNGS:  Clear to auscultation.,ABDOMEN:  Soft, diffusely tender.  No rebound or rigidity.  Bowel sounds are heard.  Most of the tenderness is located in the epigastric region.,EXTREMITIES:  Without any pedal edema, normal dorsalis pedis pulsations bilaterally.,BREASTS:  Normal.,BACK:  The patient does not have any decubitus or skin changes on her back.,LABS DONE AT THE TIME OF ADMISSION: , WBC of 24.3, hemoglobin and hematocrit 15.3 and 46.5, MCV 89.3, and platelet count of 236,000.  PT 10.9, INR 1.1, PTT of 22.  Urinalysis with positive nitrite, 5 to 10 wbc's, and 2+ bacteria.  Sodium 134, potassium 3.6, chloride 97, bicarbonate 27, calcium 8.8, BUN 25, creatinine 0.9, albumin of 3.4, alkaline phosphatase 109, ALT 121, AST 166, amylase 1797, and lipase over 3000.  X-ray of abdomen shows essentially normal abdomen with possible splenic granulomas and degenerative spine changes.  CT of the abdomen revealed acute pancreatitis, cardiomegaly, and right lung base atelectasis.  Ultrasound of the abdomen revealed echogenic liver with fatty infiltration.  Repeat CBC from today showed white count to be 21.6, hemoglobin and hematocrit 13.9 and 41.1, platelet count is normal, 89% segments and 2% bands.  Sodium 132, potassium 4.0, chloride 98, bicarbonate 22, glucose 184, ALT 314, AST 382, amylase 918, and lipase 1331.  The cultures are pending at this time.  EKG shows sinus rhythm, rate about 90 per minute, multiple ventricular premature complexes are noted.  Troponin 0.004 and myoglobin is 39.6.,ASSESSMENT:,1.  Acute pancreatitis.,2.  Leukocytosis.,3.  Urinary tract infection.,4.  Hyponatremia.,5.  Dementia.,6.  Anxiety.,7.  History of hypertension.,8.  Abnormal electrocardiogram.,9.  Osteoarthrosis.,PLAN:,  Admit the patient to medical floor, NPO, IV antibiotics, IV fluids, hold p.o. medications, GI consult, pain control, Zofran IV p.r.n., bedrest, DVT prophylaxis, check blood and urine cultures.  I have left a message for the patient's son to call me back.",
" History and Physical - A history of stage IIIC papillary serous adenocarcinoma of the ovary, presented to the office today left leg pain (left leg DVT).", General Medicine, Gen Med H&P - 1 ,"CHIEF COMPLAINT:, Left leg pain.,HISTORY OF PRESENT ILLNESS:, The patient is a 59-year-old gravida 1, para 0-0-1-0, with a history of stage IIIC papillary serous adenocarcinoma of the ovary who presented to the office today with left leg pain that started on Saturday. The patient noticed the pain in her left groin and left thigh and also noticed swelling in that leg. A Doppler ultrasound of her leg that was performed today noted a DVT. She is currently on course one, day 14 of 21 of Taxol and carboplatin. She is scheduled for intraperitoneal port placement for intraperitoneal chemotherapy to begin next week. She denies any chest pain or shortness of breath, nausea, vomiting, or dysuria. She has a positive appetite and ambulates without difficulty.,PAST MEDICAL HISTORY:,1. Gastroesophageal reflux disease.,2. Mitral valve prolapse.,3. Stage IIIC papillary serous adenocarcinoma of the ovaries.,PAST SURGICAL HISTORY:,1. A D and C.,2. Bone fragment removed from her right arm.,3. Ovarian cancer staging.,OBSTETRICAL HISTORY:, Spontaneous miscarriage at 3 months approximately 30 years ago.,GYNECOLOGICAL HISTORY: ,The patient started menses at age 12; she states that they were regular and occurred every month. She finished menopause at age 58. She denies any history of STDs or abnormal Pap smears. Her last mammogram was in April 2005 and was within normal limits.,FAMILY HISTORY:,1. A sister with breast carcinoma who was diagnosed in her 50s.,2. A father with gastric carcinoma diagnosed in his 70s.,3. The patient denies any history of ovarian, uterine, or colon cancer in her family.,SOCIAL HISTORY:, No tobacco, alcohol, or drug abuse.,MEDICATIONS:,1. Prilosec.,2. Tramadol p.r.n.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 97.3, pulse 91, respiratory rate 18, blood pressure 142/46, O2 saturation 99% on room air.,GENERAL: Alert, awake, and oriented times three, no apparent distress, a well-developed, well-nourished white female.,HEENT: Normocephalic and atraumatic. The oropharynx is clear. The pupils are equal, round, and reactive to light.,NECK: Good range of motion, nontender, no thyromegaly.,CHEST: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi.,CARDIOVASCULAR: Regular rate and rhythm with a 2/6 systolic ejection murmur on her left side.,ABDOMEN: Positive bowel sounds, soft, nontender, nondistended, no hepatosplenomegaly, a well-healing midline incision.,EXTREMITIES: 2+ pulses bilaterally, right leg without swelling, nontender, no erythema, negative Homans' sign bilaterally, left thigh swollen, erythematous, and warm to the touch compared to the right. Her left groin is slightly tender to palpation.,LYMPHATICS: No axillary, groin, clavicular, or mandibular nodes palpated.,LABORATORY DATA:, White blood cell count 15.5, hemoglobin 11.4, hematocrit 34.5, platelets 159, percent neutrophils 88%, absolute neutrophil count 14,520. Sodium 142, potassium 3.3, chloride 103, CO2 26, BUN 15, creatinine 0.9, glucose 152, calcium 8.7. PT 13.1, PTT 28, INR 0.97.,ASSESSMENT AND PLAN:, Miss Bolen is a 59-year-old gravida 1, para 0-0-1-0 with stage IIIC papillary serous adenocarcinoma of the ovary. She is postop day 21 of an exploratory laparotomy with ovarian cancer staging. She is currently with a left leg DVT.,1. The patient is doing well and is currently without any complaints. We will start Lovenox 1 mg per kg subcu daily and Coumadin 5 mg p.o. daily. The patient will receive INR in the morning; the goal was obtain an INR between 2.5 and 3.0 before the Lovenox is instilled. The patient is scheduled for port placement for intraperitoneal chemotherapy and this possibly may be delayed.,2. Aranesp 200 mcg subcu was given today. The patient's absolute neutrophil count is 14,520.",
 The patient had temperature of 104 degrees F.  It has been spiking ever since and she has had left sacroiliac type hip pain.  She does have degenerative disk disease of her lumbar spine but no hip pathology.  She has swollen inguinal nodes bilaterally., General Medicine, Gen Med Consult - 47 ,"HISTORY OF PRESENT ILLNESS: , This is a 76-year-old female that was admitted with fever, chills, and left pelvic pain.  The patient was well visiting in ABC, with her daughter that evening.  She had pain in her left posterior pelvic and low back region.  They came back to XYZ the following day.  By the time they got here, she was in severe pain and had fever.  They came straight to the emergency room.  She was admitted.  She had temperature of 104 degrees F.  It has been spiking ever since and she has had left sacroiliac type hip pain.  Multiple blood studies have been done including cultures, febrile agglutinins, etc.  She has had run a higher blood glucose to the normal and she has been on sliding scale insulin.  She was not known previously to be a diabetic.  All x-rays have not been helpful as far as to determine the etiology of her discomfort.  MRIs of the lumbar spine and the pelvis and both thighs have been unremarkable for any inflammatory process.  She does have degenerative disk disease of her lumbar spine but no hip pathology.  She has swollen inguinal nodes bilaterally.,PAST MEDICAL HISTORY AND REVIEW OF SYSTEMS: , She was not known to be a diabetic until this admission.  She had been hypertensive.  She has been on medications and has been controlled.  She has not had hyperlipidemia.  She has had no thyroid problems.  There has been no asthma, bronchitis, TB, emphysema or pneumonia.  No tuberculosis.  She has had no breast tumors.  She has had no chest pain or cardiac problems.  She has had gallbladder surgery.  She has not had any gastritis or ulcers.  She has had no kidney disease.  She has had a hysterectomy.  She has had 9 pregnancies and 8 living children.  She had A&P repair.  She had a sacral abscess after a spinal.  It sounds to me like she had a pilonidal cyst, which took about 3 operations to heal.  There have been fractures and no significant arthritis.  She has been quite active at her ranch in Mexico.  She raises goats and cattle.  She drives a tractor and in short, has been very active.,PHYSICAL EXAMINATION:,  She is a short female, alert.  She is shivering.  She has ice in her axilla and behind her neck.  She is febrile to 101 degrees F. She is alert.  Her complaint is that of hip pain in the posterior sacroiliac joint area.  She moves both her upper extremities well.  She can move her right leg well.  She actually can move her left hip and knee without much discomfort but the pain radiates from her sacroiliac joint.  She cannot stand, sit or turn without severe pain.  She has normal knee reflexes.  No ankle reflexes.  She has bounding tibial pulses.  No sensory deficit.  She says she knows when she has to void.  She has a healed scar in the upper sacral region.  There is some bruising around the buttocks but the daughter says that is from her being in bed lying on her back.,PLAN: , My plan is to do a triple-phase bone scan.  I am suspecting an infection possibly in the left sacroiliac joint.  It is probably some type of bacterium, the etiology of which is undetermined.  She has had a normal white count despite her fever.  There has been a history of brucellosis in the past, but her titers at this time are negative.  Continue medication which included antibiotics and also the Motrin and Darvocet.,","general medicine, inflammatory, degenerative, fever, lumbar spine, sacroiliac joint, inguinal, sacroiliac, hip,"
" Anxiety, alcohol abuse, and chest pain.   This is a 40-year-old male with digoxin toxicity secondary to likely intentional digoxin overuse.  Now, he has had significant block with EKG changes as stated. ", General Medicine, Gen Med Consult - 52 ,"CHIEF COMPLAINT: , Anxiety, alcohol abuse, and chest pain.,HISTORY OF PRESENT ILLNESS:,  This is a pleasant 40-year-old male with multiple medical problems, basically came to the hospital yesterday complaining of chest pain.  The patient states that he complained of this chest pain, which is reproducible, pleuritic in both chest radiating to the left back and the jaw, complaining of some cough, nausea, questionable shortness of breath.  The patient describes the pain as aching, sharp and alleviated with pain medications, not alleviated with any nitrates.  Aggravated by breathing, coughing, and palpation over the area.  The pain was 9/10 in the emergency room and he was given some pain medications in the ER and was basically admitted.  Labs were drawn, which were essentially, potassium was about 5.7 and digoxin level was drawn, which was about greater than 5.  The patient said that he missed 3 doses of digoxin in the last 3 days after being discharged from Anaheim Memorial and then took 3 tablets together.  The patient has a history prior digoxin overdose of the same nature.,MEDICATIONS:,  Digoxin 0.25 mg, metoprolol 50 mg, Naprosyn 500 mg, metformin 500 mg, lovastatin 40 mg, Klor-Con 20 mEq, Advair Diskus, questionable Coreg.,PAST MEDICAL HISTORY: , MI in the past and atrial fibrillation, he said that he has had one stent put in, but he is not sure.  The last cardiologist he saw was Dr. X and his primary doctor is Dr. Y.,SOCIAL HISTORY:,  History of alcohol use in the past.,He is basically requesting for more and more pain medications.  He states that he likes Dilaudid and would like to get the morphine changed to Dilaudid.  His pain is tolerable.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Stable.,GENERAL:  Alert and oriented x3, no apparent distress.,HEENT:  Extraocular muscles are intact.,CVS:  S1, S2 heard.,CHEST:  Clear to auscultation bilaterally.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema or clubbing.,NEURO:  Grossly intact.  Tender to palpate over the left chest, no obvious erythema or redness, or abnormal exam is found.,EKG basically shows atrial fibrillation, rate controlled, nonspecific ST changes.,ASSESSMENT AND PLAN:,1.  This is a 40-year-old male with digoxin toxicity secondary to likely intentional digoxin overuse.  Now, he has had significant block with EKG changes as stated.  Continue to follow the patient clinically at this time.  The patient has been admitted to ICU and will be changed to DOU.,2.  Chronic chest pain with a history of myocardial infarction in the past, has been ruled out with negative cardiac enzymes.  The patient likely has opioid dependence and requesting more and more pain medications.  He is also bargaining for pain medications with me.  The patient was advised that he will develop more opioid dependence and I will stop the pain medications for now and give him only oral pain medications in the anticipation of the discharge in the next 1 or 2 days.  The patient was likely advised to also be seen by a pain specialist as an outpatient after being referred.  We will try to verify his pain medications from his primary doctor and his pharmacy.  The patient said that he has been on Dilaudid and Vicodin ES and Norco and all these medications in the past.","general medicine, anxiety, alcohol abuse, chest pain, digoxin toxicity, digoxin overuse, atrial fibrillation, opioid dependence, toxicity, dilaudid, "
" Pneumonia in the face of fairly severe Crohn disease with protein-losing enteropathy and severe malnutrition with anasarca.  He also has anemia and leukocytosis, which may be related to his Crohn disease as well as his underlying pneumonia.", General Medicine, Gen Med Consult - 46 ,"DIAGNOSES:,1.  Pneumonia.,2.  Crohn disease.,3.  Anasarca.,4.  Anemia.,CHIEF COMPLAINT: , I have a lot of swelling in my legs.,HISTORY:  ,The patient is a 41-year-old gentleman with a long history of Crohn disease.  He has been followed by Dr. ABC, his primary care doctor, but he states that he has had multiple gastroenterology doctors and has not seen one in the past year to 18 months.  He has been treated with multiple different medications for his Crohn disease and most recently has been taking pulses of steroids off and on when he felt like he was having symptoms consistent with crampy abdominal pain, increased diarrhea, and low-grade fevers.  This has helped in the past, but now he developed symptoms consistent with pneumonia and was admitted to the hospital.  He has been treated with IV antibiotics and is growing Streptococcus.  At this time, he seems relatively stable although slightly dyspneic.  Other symptoms include lower extremity edema, pain in his ankles and knees, and actually symptoms of edema in his entire body including his face and upper extremities.  At this time, he continues to have symptoms consistent with diarrhea and malabsorption.  He also has some episodes of nausea and vomiting at times.  He currently has a cough and symptoms of dyspnea.  Further review of systems was not otherwise contributory.,MEDICATIONS:,1.  Prednisone.,2.  Effexor.,3.  Folic acid.,4.  Norco for pain.,PAST MEDICAL HISTORY: , As mentioned above, but he also has anxiety and depression.,PAST SURGICAL HISTORY:,1.  Small bowel resections.,2.  Appendectomy.,3.  A vasectomy.,ALLERGIES:  ,He has no known drug allergies.,SOCIAL HISTORY:  ,He does smoke two packs of cigarettes per day.  He has no alcohol or drug use.  He is a painter.,FAMILY HISTORY:  ,Significant for his father who died of IPF and irritable bowel syndrome.,REVIEW OF SYSTEMS: , As mentioned in the history of present illness and further review of systems is not otherwise contributory.,PHYSICAL EXAMINATION:,GENERAL:  He is a thin appearing man in very mild respiratory distress when his oxygen is off.,VITAL SIGNS:  His respiratory rate is approximately 18 to 20, his blood pressure is 100/70, his pulse is 90 and regular, he is afebrile currently at 96, and weight is approximately 163 pounds.,HEENT:  Sclerae anicteric.  Conjunctivae normal.  Nasal and oropharynx are clear.,NECK:  Supple.  No jugular venous pressure distention is noted.  There is no adenopathy in the cervical, supraclavicular or axillary areas.,CHEST:  Reveals some crackles in the right chest, in the base, and in the upper lung fields.  His left is relatively clear with decreased breath sounds.,HEART:  Regular rate and rhythm.,ABDOMEN:  Slightly protuberant.  Bowel sounds are present.  He is slightly tender and it is diffuse.  There is no organomegaly and no ascites appreciable.,EXTREMITIES:  There is a mild scrotal edema and in his lower extremities he has 2 to 3+ edema at pretibial and lateral feet.,DERMATOLOGIC:  Shows thin skin.  No ecchymosis or petechiae.,LABORATORY STUDIES: , Laboratory studies are pertinent for a total protein of 3 and albumin of 1.3.  There is no M-spike observed.  His B12 is 500 with a folic acid of 11.  His white count is 21 with a hemoglobin of 10, and a platelet count 204,000.,IMPRESSION AT THIS TIME:,1.  Pneumonia in the face of fairly severe Crohn disease with protein-losing enteropathy and severe malnutrition with anasarca.,2.  He also has anemia and leukocytosis, which may be related to his Crohn disease as well as his underlying pneumonia.,ASSESSMENT AND PLAN: , At this time, I believe evaluation of protein intake and dietary supplement will be most appropriate.  I believe that he needs a calorie count.  We will check on a sedimentation rate, C-reactive protein, LDH, prealbumin, thyroid, and iron studies in the morning with his laboratory studies that are already ordered.  I have recommended strongly to him that when he is out of the hospital, he return to the care of his gastroenterologist.  I will help in anyway that I can to improve the patient's laboratory abnormalities.  However, his lower extremity edema is primarily due to his marked hypoalbuminemia and I do not believe that diuretics will help him at this time.  I have explained this in detail to the patient and his family.  Everybody expresses understanding and all questions were answered.  At this time, follow him up during his hospital stay and plan to see him in the office as well.",
" The patient presents to the office today with complaints of extreme fatigue, discomfort in the chest and the back that is not related to any specific activity.  Stomach gets upset with pain. ", General Medicine, Gen Med Consult - 48 ,"HISTORY:,  The patient presents today for medical management.  The patient presents to the office today with complaints of extreme fatigue, discomfort in the chest and the back that is not related to any specific activity.  Stomach gets upset with pain.  She has been off her supplements for four weeks with some improvement.  She has loose bowel movements.  She complains of no bladder control.  She has pain in her hips.  The peripheral neuropathy is in both legs, her swelling has increased and headaches in the back of her head.,DIAGNOSES:,1.  Type II diabetes mellitus.,2.  Generalized fatigue and weakness.,3.  Hypertension.,4.  Peripheral neuropathy with atypical symptoms.,5.  Hypothyroidism.,6.  Depression.,7.  Long-term use of high-risk medications.,8.  Postmenopausal age-related symptoms.,9.  Abdominal pain with nonspecific irritable bowel type symptoms, intermittent diarrhea.,CURRENT MEDICATIONS: , Her list of medicines is as noted on 04/22/03.  There is a morning and evening lift.,PAST SURGICAL HISTORY:,  As listed on 04/22/04 along with allergies 04/22/04.,FAMILY HISTORY: , Basically unchanged.  Her father died of an MI at 65, mother died of a stroke at 70.  She has a brother, healthy.,SOCIAL HISTORY:  ,She has two sons and an adopted daughter.  She is married long term, retired from Avon.  She is a nonsmoker, nondrinker.,REVIEW OF SYSTEMS:,GENERAL:  Certainly at the present time on general exam no fever, sweats or chills and no significant weight change.  She is 189 pounds currently and she was 188 pounds in January.,HEENT:  HEENT, there is no marked decrease in visual or auditory function.  ENT, there is no change in hearing or epistaxis, sore throat or hoarseness.,RESPIRATORY:  Chest, there is no history of palpitations, PND or orthopnea.  The chest pains are nonspecific, tenderness to palpation has been reported.  There is no wheezing or cough reported.,CARDIOVASCULAR:  No PND or orthopnea.  Thromboembolic disease history.,GASTROINTESTINAL:  Intermittent symptoms of stomach pain, they are nonspecific.  No nausea or vomiting noted.  Diarrhea is episodic and more related to nerves.,GENITOURINARY:  She reports there is generally poor bladder control, no marked dysuria, hematuria or history of stones.,MUSCULOSKELETAL:  Peripheral neuropathy and generalized muscle pain, joint pain that are sporadic.,NEUROLOGICAL:  No marked paralysis, paresis or paresthesias.,SKIN:  No rashes, itching or changes in the nails.,BREASTS:  No report of any lumps or masses.,HEMATOLOGY AND IMMUNE:  No bruising or bleeding-type symptoms.,PHYSICAL EXAMINATION:,WEIGHT:  189 pounds.  BP:  140/80.  PULSE:  76.  RESPIRATIONS:  20.  GENERAL APPEARANCE:  Well developed, well nourished.  No acute distress.,HEENT:  Head is normocephalic.  Ears, nose, and throat, normal conjunctivae.  Pupils are reactive.  Ear canals are patent.  TMs are normal.  Nose, nares patent.  Septum midline.  Oral mucosa is normal in appearance.  No tonsillar lesions, exudate or asymmetry.  Neck, adequate range of motion.  No thyromegaly or adenopathy.,CHEST:  Symmetric with clear lungs clear to auscultation and percussion.,HEART:  Rate and rhythm is regular.  S1 and S2 audible.  No appreciable murmur or gallop.,ABDOMEN:  Soft.  No masses, guarding, rigidity, tenderness or flank pain.,GU:  No examined.,EXTREMITIES:  No cyanosis, clubbing or edema currently.,SKIN AND INTEGUMENTS:  Intact.  No lesions or rashes.,NEUROLOGIC:  Nonfocal to cranial nerve testing II through XII, motor, sensory, gait and random motion.,Additional information, the patient has been off metformin for few months and this is not part of her medication list.,IMPRESSION:,",
" For evaluation of left-sided chest pain, 5 days post abdominal surgery.", General Medicine, Gen Med Consult - 45 ,"REASON FOR CONSULT: , For evaluation of left-sided chest pain, 5 days post abdominal surgery.,PAST MEDICAL HISTORY:, None.,HISTORY OF PRESENT COMPLAINT: , This 87-year-old patient has been admitted in this hospital on 12/03/08.  The patient underwent laparoscopic appendicectomy by Dr. X.  The patient had postoperative paralytic ileus, which has resolved.  The patient had developed left-sided chest pain yesterday.  In the postoperative period, the patient has had fluid retention, had gain about 25 pounds, and he had swelling of the lower extremities.,REVIEW OF SYSTEMS:,CONSTITUTIONAL SYMPTOMS:  No recent fever.,ENT:  Unremarkable.,RESPIRATORY:  He denies cough but develop this left-sided chest pain, which does not increase with inspiration, pain is located on the left posterior axillary line and over the fourth and fifth rib.,CARDIOVASCULAR:  No known heart problems.,GASTROINTESTINAL:  The patient denies nausea or vomiting.  He is status post laparoscopic appendicectomy, and he is tolerating oral diet.,GENITOURINARY:  No dysuria, no hematuria.,ENDOCRINE:  Negative for diabetes or thyroid problems.,NEUROLOGIC:  No history of CVA or TIA.,Rest of review of systems unremarkable.,SOCIAL HISTORY:  ,The patient is a nonsmoker.  He denies use of alcohol.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL:  An 87-year-old gentleman, not toxic looking.,HEAD AND NECK:  Oral mucosa is moist.,CHEST:  Clear to auscultation.  No wheezing.  No crepitations.  There is reproducible tenderness over the left posterior-lateral axis.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmurs appreciated.,ABDOMEN:  Slightly distended.  Bowel sounds are positive.,EXTREMITIES:  He has 2+ to 3+ pedal swelling.,NEUROLOGIC:  The patient is alert and oriented x3.  Examination is nonfocal.,LABORATORY DATA: , White count is 12,500, hemoglobin is 13, hematocrit is 39, and platelets 398,000.  Glucose is 123, total protein is 6, and albumin is 2.9.,ASSESSMENT AND PLAN:,1.  Ruptured appendicitis.  The patient is 6 days post surgery.  He is tolerating oral fluids and moving bowels.,2.  Left-sided chest pain, need to rule out PE by distance of pretty low probability.  The patient, however, has low-oxygen saturation.  We will do ultrasound of the lower extremity and if this is positive we would proceed with the CT angiogram.,3.  Fluid retention, manage as per surgeon.,4.  Paralytic ileus, resolving.,5.  Leukocytosis, we will monitor.",
 Patient with swelling of lips and dysphagia and Arthritis., General Medicine, Gen Med Consult - 5 ,"CHIEF COMPLAINT: , Swelling of lips causing difficulty swallowing.,HISTORY OF PRESENT ILLNESS:, This patient is a 57-year old white Cuban woman with a long history of rheumatoid arthritis.  She has received methotrexate on a weekly basis as an outpatient for many years.  Approximately two weeks ago, she developed a respiratory infection for which she received antibiotics.  She developed some ulcerations of the mouth and was instructed to discontinue the methotrexate approximately ten days ago.  She showed some initial improvement, but over the last 3-5 days has had malaise, a low-grade fever, and severe oral ulcerations with difficulty in swallowing although she can drink liquids with less difficulty.  ,The patient denies any other problems at this point except for a flare of arthritis since discontinuing the methotrexate.  She has rather diffuse pain involving both large and small joints.  ,MEDICATIONS:, Prednisone 7.5 mg p.o. q.d., Premarin 0.125 mg p.o. q.d., and Dolobid 1000 mg p.o. q.d., recently discontinued because of questionable allergic reaction.  HCTZ 25 mg p.o. q.o.d., Oral calcium supplements.  In the past she has been on penicillin, azathioprine, and hydroxychloroquine, but she has not had Azulfidine, cyclophosphamide, or chlorambucil. ,ALLERGIES: ,None by history.  ,FAMILY/SOCIAL HISTORY:, Noncontributory.,PHYSICAL EXAMINATION:, This is a chronically ill appearing female, alert, oriented, and cooperative.  She moves with great difficulty because of fatigue and malaise.  Vital signs: Blood pressure 107/80, heart rate: 100 and regular, respirations 22.  HEENT: Normocephalic. No scalp lesions.  Dry eyes with conjuctival injections.  Mild exophthalmos.  Dry nasal mucosa.  Marked cracking and bleeding of her lips with erosion of the mucosa.  She has a large ulceration of the mucosa at the bite margin on the left.  She has some scattered ulcerations on her hard and soft palette.  Tonsils not enlarged.  No visible exudate.  She has difficulty opening her mouth because of pain.  SKIN: She has some mild ecchymoses on her skin and some erythema; she has patches but no obvious skin breakdown.  She has some fissuring in the buttocks crease.  PULMONARY: Clear to percussion in auscultation.  CARDIOVASCULAR: No murmurs or gallops noted.  ABDOMEN: Protuberant no organomegaly and positive bowel sounds.  NEUROLOGIC EXAM: Cranial nerves II through XII are grossly intact. Diffuse hyporeflexia.  MUSCULOSKELATAL: Erosive, destructive changes in the elbows, wrist and hands consistent with rheumatoid arthritis.  She also has bilateral total knee replacements with stovepipe legs and parimalleolar pitting adema 1+.  I feel no pulse distally in either leg.  ,PROBLEMS: ,1.  Swelling of lips and dysphagia with questionable early Stevens-Johnson syndrome.,2.  Rheumatoid Arthritis class 3, stage 4.,3.  Flare of arthritis after discontinuing methotrexate.,4.  Osteoporosis with compression fracture.,5.  Mild dehydration.,6.  Nephrolithiasis.,PLAN:, Patient is admitted for IV hydration and treatment of oral ulcerations.  We will obtain a dermatology consult.  IV leucovorin will be started, and the patient will be put on high-dose corticosteroids.","general medicine, swelling, iv hydration, osteoporosis, swelling of lips, allergic reaction, arthritis, difficulty swallowing, leucovorin, low-grade fever, methotrexate, respiratory infection, rheumatoid arthritis, flare of arthritis, rheumatoid, mucosa, dysphagia,"
" A female with a past medical history of chronic kidney disease, stage 4; history of diabetes mellitus; diabetic nephropathy; peripheral vascular disease, status post recent PTA of right leg, admitted to the hospital because of swelling of the right hand and left foot.", General Medicine, Gen Med Consult - 49 ,"HISTORY OF PRESENT ILLNESS: , This is a 70-year-old female with a past medical history of chronic kidney disease, stage 4; history of diabetes mellitus; diabetic nephropathy; peripheral vascular disease, status post recent PTA of right leg, admitted to the hospital because of swelling of the right hand and left foot.  The patient says that the right hand was very swollen, very painful, could not move the fingers, and also, the left foot was very swollen and very painful, and again could not move the toes, came to emergency room, diagnosed with gout and gouty attacks.  I was asked to see the patient regarding chronic kidney disease.,PAST MEDICAL HISTORY:,1.  Diabetes mellitus type 2.,2.  Diabetic nephropathy.,3.  Chronic kidney disease, stage 4.,4.  Hypertension.,5.  Hypercholesterolemia and hyperlipidemia.,6.  Peripheral vascular disease, status post recent, last week PTA of right lower extremity.,SOCIAL HISTORY:,  Negative for smoking and drinking.,CURRENT HOME MEDICATIONS:,  NovoLog 20 units with each meal, Lantus 30 units at bedtime, Crestor 10 mg daily, Micardis 80 mg daily, Imdur 30 mg daily, Amlodipine 10 mg daily, Coreg 12.5 mg b.i.d., Lasix 20 mg daily, Ecotrin 325 mg daily, and calcitriol 0.5 mcg daily.,REVIEW OF SYSTEMS: , The patient denies any complaints, states that the right hand and left foot was very swollen and very painful, and came to emergency room.  Also, she could not urinate and states as soon as they put Foley in, 500 mL of urine came out.  Also they started her on steroids and colchicine, and the pain is improving and the swelling is getting better.  Denies any fever and chills.  Denies any dysuria, frequency or hematuria.  States that the urine output was decreased considerably, and she could not urinate.  Denies any cough, hemoptysis or sputum production.  Denies any chest pain, orthopnea or paroxysmal nocturnal dyspnea.,PHYSICAL EXAMINATION:,General:  The patient is alert and oriented, in no acute distress.,Vital Signs:  Blood pressure 126/67, temperature 97.9, pulse 71, and respirations 20.  The patient's weight is 105.6 kg.,Head:  Normocephalic.,Neck:  Supple.  No JVD.  No adenopathy.,Chest:  Symmetric.  No retractions.,Lungs:  Clear.,Heart:  RRR with no murmur.,Abdomen:  Obese, soft, and nontender.  No rebound.  No guarding.,Extremity:  She has 2+ pretibial edema bilaterally at the lower extremity, but also the left foot, in dorsum of left foot and also right hand is swollen and very tender to move the toes and also fingers in those extremities.,LAB TESTS: , Showed that urine culture is negative up to date.  The patient's white cell is 12.7, hematocrit 26.1.  The patient has 90% segs and 0% bands.  Serum sodium 133, potassium 5.9, chloride 100, bicarb 21, glucose 348, BUN 57, creatinine is 2.39, calcium 8.9, and uric acid yesterday was 10.9.  Sed rate was 121.  BNP was 851.  Urinalysis showed 15 to 20 white cells, 3+ protein, 3+ blood with 25 to 30 red blood cells also.,IMPRESSION:,1.  Urinary tract infection.,2.  Acute gouty attack.,3.  Diabetes mellitus with diabetic nephropathy.,4.  Hypertension.,5.  Hypercholesterolemia.,6.  Peripheral vascular disease, status post recent PTA in the right side.,7.  Chronic kidney disease, stage 4.,PLAN: , At this time is I agree with treatment.  We will add allopurinol 50 mg daily.  This is secondary to the patient is already on colchicine, and also we will discontinue Micardis, we will increase Lasix to 40 b.i.d., and we will follow with the lab results.",
 An 80-year-old female with recent complications of sepsis and respiratory failure who is now receiving tube feeds., General Medicine, Gen Med Consult - 44 ,"PAST MEDICAL HISTORY:  Include:,1.  Type II diabetes mellitus.,2.  Hypertension.,3.  Hyperlipidemia.,4.  Gastroesophageal reflux disease.,5.  Renal insufficiency.,6.  Degenerative joint disease, status post bilateral hip and bilateral knee replacements.,7.  Enterocutaneous fistula.,8.  Respiratory failure.,9.  History of atrial fibrillation.,10.  Obstructive sleep apnea.,11.  History of uterine cancer, status post total hysterectomy.,12.  History of ventral hernia repair for incarcerated hernia.,SOCIAL HISTORY:  The patient has been admitted to multiple hospitals over the last several months.,FAMILY HISTORY:  Positive for diabetes mellitus type 2 in both mother and her sister.,MEDICATIONS:  Currently include,,1.  Albuterol inhaler q.4 h.,2.  Paradox swish and spit mouthwash twice a day.,3.  Digoxin 0.125 mg daily.,4.  Theophylline 50 mg q.6 h.,5.  Prozac 20 mg daily.,6.  Lasix 40 mg daily.,7.  Humulin regular high dose sliding scale insulin subcu. q.6 h.,8.  Atrovent q.4 h.,9.  Lantus 12 units subcu. q.12 h.,10.  Lisinopril 10 mg daily.,11.  Magnesium oxide 400 mg three times a day.,12.  Metoprolol 25 mg twice daily.,13.  Nitroglycerin topical q.6 h.,14.  Zegerid 40 mg daily.,15.  Simvastatin 10 mg daily.,ALLERGIES:  Percocet, Percodan, oxycodone, and Duragesic.,REVIEW OF SYSTEMS:  The patient currently denies any pain, denies any headache or blurred vision.  Denies chest pain or shortness of breath.  She denies any nausea or vomiting.  Otherwise, systems are negative.,PHYSICAL EXAM:,General:  The patient is awake, alert, and oriented.  She is in no apparent respiratory distress.,Vital Signs:  Temperature 97.6, blood pressure is 139/53, pulse 100, respirations 24.  The patient has a tracheostomy in place.  She will also have an esophageal gastric tube in place.,Cardiac:  Regular rate and rhythm without audible murmurs, rubs or gallops.  Lungs are clear to auscultation bilaterally with slightly diminished breath sounds on the bases.  No adventitious sounds are noted.,Abdomen:  Obese.  There is an open wound on the ventral abdomen overlying the midline abdominal incision from previous surgery.  The area is covered with bandage with serosanguineous fluid.  Abdomen is nontender to palpation.  Bowel sounds are heard in all 4 quadrants.,Extremities:  Bilateral lower extremities are edematous and very cool to touch.,LABORATORY DATA:  Pending.  Capillary blood sugars thus far have been 132 and 135.,ASSESSMENT:  This is an 80-year-old female with an unfortunate past medical history with recent complications of sepsis and respiratory failure who is now receiving tube feeds.,PLAN:  For her diabetes mellitus, we will continue the patient on her current regimen of Lantus 12 units subcu. q.12 h. and Regular Insulin at a high dose sliding scale every 6 hours.  The patient had been previously controlled on this.  We will continue to check her sugars every 6 hours and adjust insulin as necessary.",
" A 69-year-old female with past history of type II diabetes, atherosclerotic heart disease, hypertension, carotid stenosis. ", General Medicine, Gen Med Consult - 43 ,"HISTORY:,  A 69-year-old female with past history of type II diabetes, atherosclerotic heart disease, hypertension, carotid stenosis.  The patient was status post coronary artery bypass surgery aortic valve repair at Shadyside Hospital.  The patient subsequently developed CVA.  She also developed thrombosis of the right arm, which ultimately required right hand amputation.  She was stabilized and eventually transferred to HealthSouth for further management.,PHYSICAL EXAMINATION:,Vital Signs:  Pulse of 90 and blood pressure 150/70.,Heart:  Sounds were heard, grade 2/6 systolic murmur at the precordium.,Chest:  Clinically clear.,Abdomen:  Some suprapubic tenderness.  Evidence of right lower arm amputation.,The patient was started on Prevacid 30 mg daily, levothyroxine 75 mcg a day, Toprol 25 mg twice a day, Zofran 4 mg q.6 h, Coumadin dose at 5 mg and was adjusted.  She was given a pain control using Vicodin and Percocet, amiodarone 200 mg a day, Lexapro 20 mg a day, Plavix 75 mg a day, fenofibrate 145 mg, Lasix 20 mg IV twice a day, Lantus 50 units at bedtime and Humalog 10 units a.c. and sliding scale insulin coverage.  Wound care to the right heel was supervised by Dr. X.  The patient initially was fed through NG tube, which was eventually discontinued.  Physical therapy was ordered.  The patient continued to do well.  She was progressively ambulated.  Her meds were continuously adjusted.  The patient's insulin was eventually changed from Lantus to Levemir 25 units twice a day.  Dr. Y also followed the patient closely for left heel ulcer.,LABORATORY DATA: , The latest cultures from left heel are pending.  Her electrolytes revealed sodium of 135 and potassium of 3.2.  Her potassium was switched to K-Dur 40 mEq twice a day.  Her blood chemistries are otherwise closely monitored.  INRs were obtained and were therapeutic.  Throughout her hospitalization, multiple cultures were also obtained.  Urine cultures grew Klebsiella.  She was treated with appropriate antibiotics.  Her detailed blood work is as in the chart.  Detailed radiological studies are as in the chart.  The patient made a steady progress and eventually plans were made to transfer the patient to ABC furthermore aggressive rehabilitation.,FINAL DIAGNOSES:,1.  Atherosclerotic heart disease, status post coronary artery bypass graft.,2.  Valvular heart disease, status post aortic valve replacement.,3.  Right arm arterial thrombosis, status post amputation right lower arm.,4.  Hypothyroidism.,5.  Uncontrolled diabetes mellitus, type 2.,6.  Urinary tract infection.,7.  Hypokalemia.,8.  Heparin-induced thrombocytopenia.,9.  Peripheral vascular occlusive disease.,10.  Paroxysmal atrial fibrillation.,11.  Hyperlipidemia.,12.  Depression.,13.  Carotid stenosis.","general medicine, arterial thrombosis, valvular heart disease, atherosclerotic heart disease, type ii diabetes, hypertension, carotid stenosis, heart disease, diabetes, carotid, stenosis, bypass, amputation, heart, atherosclerotic, "
" Patient with one-week history of increased progressive shortness of breath, orthopnea for the past few nights, mild increase in peripheral edema, and active wheezing with dyspnea.  Medifast does fatigue", General Medicine, Gen Med Consult - 42 ,"HISTORY AND CLINICAL DATA:  ,The patient is an 88-year-old gentleman followed by Dr. X, his primary care physician, Dr. Y for the indication of CLL and Dr. Z for his cardiovascular issues.  He presents to the Care Center earlier today with approximately a one-week history of increased progressive shortness of breath, orthopnea over the course of the past few nights, mild increase in peripheral edema, and active wheezing with dyspnea presenting this morning.,He reports no clear-cut chest discomfort or difficulty with angina.  He has had no dizziness, lightheadedness, no near or true syncope, nothing supportive of CVA, TIA, nor peripheral vascular claudication.,REVIEW OF SYSTEMS:,  General review of system is significant for difficulty with intermittent constipation, which has been problematic recently.  He reports no fever, shaking chills, nothing supportive of GI or GU blood loss, no productive or nonproductive cough.,PAST MEDICAL HISTORY:,  Remarkable for hypertension, diabetes, prostate cancer, status post radium seed implant, COPD, single vessel coronary disease, esophageal reflux, CLL, osteopenia, significant hearing loss, anxiety, and degenerative joint disease.,SOCIAL HISTORY: , Remarkable for being married, retired, quit smoking in 1997, rare use of alcohol, lives locally with his wife.,MEDICATIONS AT HOME:,  Include, Lortab 7.5 mg up to three times daily for chronic arthritic discomfort, Miacalcin nasal spray once daily, omeprazole 20 mg daily, Diovan 320 mg daily, Combivent two puffs t.i.d., folate, one adult aspirin daily, glyburide 5 mg daily, atenolol 50 mg daily, furosemide 40 mg daily, amlodipine 5 mg daily, hydralazine 50 mg p.o. t.i.d., in addition to Tekturna 150 mg daily, Zoloft 25 mg daily.,ALLERGIES:  ,He has known history of allergy to clonidine, Medifast does fatigue.,DIAGNOSTIC AND LABORATORY DATA: , Chest x-ray upon presentation to the Ellis Emergency Room this evening demonstrate significant congestive heart failure with moderate-sized bilateral pleural effusions.,A 12-lead EKG, sinus rhythm at a rate of 68 per minute, right bundle-branch block type IVCV with moderate nonspecific ST changes.  Low voltage in the limb leads.,WBC 29,000, hemoglobin 10.9, hematocrit 31, platelets 187,000.  Low serum sodium at 132, potassium 4, BUN 28, creatinine 1.2, random glucose 179.  Low total protein 5.7.  Magnesium level 2.3, troponin 0.404 with the B-natriuretic peptide of 8200.,PHYSICAL EXAMINATION:  ,He is an elderly gentleman, who appears to be in no acute distress, lying comfortably flat at 30 degrees, measured pressure of 150/80 with a pulse of 68 and regular.  JVD difficult to assess.  Normal carotids with obvious bruits.  Conjunctivae pink.  Oropharynx clear.  Mild kyphosis.  Diffusely depressed breath sounds halfway up both posterior lung fields.  No active wheezing.  Cardiac Exam:  Regular, soft, 1-2/6 early systolic ejection murmur best heard at the base.  Abdomen:  Soft, nontender, protuberant, benign.  Extremities:  2+ bilateral pitting edema to the level of the knees.  Neuro Exam:  Appears alert, oriented x3.  Appropriate manner and affect, exceedingly hard of hearing.,OVERALL IMPRESSION:,  An 88-year-old white male with the following major medical issues:,1.  Presentation consists with subclinical congestive heart failure possibly systolic, no recent echocardiogram available for review.,2.  Hypertension with suboptimal controlled currently.,3.  Diabetes.,4.  Prostate CA, status post radium seed implant.,5.  COPD, on metered-dose inhaler.,6.  CLL followed by Dr. Y.,7.  Single-vessel coronary disease, no recent anginal quality chest pain, no changes in ECG suggestive of acute ischemia; however, initial troponin 0.4 - to be followed with serial enzyme determinations and telemetry.,8.  Hearing loss, anxiety.,9.  Significant degenerative joint disease.,PLAN:,1.  Admit to A4 with telemetry, congestive heart failure pathway, intravenous diuretic therapy.,2.  Strict I&O, Foley catheter has already been placed.,3.  Daily BMP.,4.  Two-dimensional echocardiogram to assess left ventricular systolic function.  Serum iron determination to exclude the possibility of a subclinical ischemic cardiac event.  Further recommendations will be forthcoming pending his clinical course and hospital.",
" Patient admitted with abdominal pain, nausea and vomiting.", General Medicine, Gen Med Consult - 38 ,"Chief Complaint:, Abdominal pain, nausea and vomiting.,History of Present Illness:, A 50-year-old Asian female comes to The Methodist Hospital on January 2, 2001, complaining of a 3-day history of abdominal pain. The pain is described as crampy in the central part of her abdomen, and is associated with nausea and vomiting during the previous 24 hours. The patient denied passing any stool or gas per rectum for the previous 24 hours. She had been admitted recently to the hospital from December 19 to December 23, 2000, with a three-week history of fevers to 101.8, diaphoresis, anorexia, malaise and skin ""lumps"". She described a total of three ""lumps"". The first one started as a pin-sized lesion that grew up and then disappeared, the other two didn't resolve. They were described as ""erythematous nodular lesions on the extensor surface of the left arm."" A punch biopsy was obtained from these skin lesions, showing deep dermis and subcutaneous adipose tissue that contained ""multiple granulomas composed of histiocytes and multinucleated giant cells without caseating necrosis"". However, one granuloma in the deep dermis, showed a hint of central necrosis. Special stains for acid - fast bacilli and fungi were reported as negative. No atypia or malignancy was noted. A CT scan of the chest was obtained on December 19, 2000 and showed numerous masses with spiculated borders bilaterally, predominately in the upper lobes and superior segments of the lower lobes. No cavitary lesions, mediastinal masses or definite hilar adenopathy were reported. The patient underwent bronchoscopy and transbronchial biopsy which showed fragments of bronchial mucosa and wall with underlying lung parenchyma. Minimal to mild interstitial lymphocytes with a few microfoci of neutrophils were seen. They were also able to appreciate intra-alveolar fibrinous exudates. One of the blood cultures drawn on December 19, 2000 grew Streptococcus mitis.,The patient was discharged on ethambutol 1200 mg po qd, clarithromycin 500 mg po bid, ampicillin 500 mg po q 6h and fluconazole 200 mg po qd.,Past Medical History:,1. Post-streptococcal glomerulonephritis at age 10.,2. End stage renal disease diagnosed in 1994, on peritoneal dialysis until 1996.,3. Cadaveric transplant in October 1996,4. Steroid induced diabetes mellitus,5. Hypertension,Past Surgical History:,1. Total abdominal hysterectomy in January 1996,2. Cesarean section X2 in 1996 and 1997,3. Appendectomy in 1971,4. Insertion of peritoneal dialysis catheter in 1994,5. Cadaveric transplant in October 1996,Social History:,The patient denies a history of smoking, drinking or intravenous drug use. She came to the United States in 1973. She works as a nurse in a newborn nursery. Her hobby is gardening. She traveled to Las Vegas on May 2000 and stayed for 6 months. She denied ill contacts or pets.,Allergies:, Ciprofloxacin and Enteric coated aspirin,Medications:, prednisone 20 mg po qd, enalapril 2.5 mg po qd, clonidine patch TTS 3 1/week, Prograf 5 mg po bid, ranitidine 150 mg po bid, furosemide 40 mg po bid, atorvastatin 10 mg po qd, multivitamins 1 tab po qd, estrogen patch, fluconazole 200 mg po qd, metformin 500 mg po bid, glyburide 10 mg po qd, clarithromycin 500 mg po bid, ethambutol 1200 mg po qd, ampicillin 500 mg po q 6h.,Family History:, She described a family history of hypertension. Her mother died after a myocardial infarction at age 59. Her father was diagnosed with congestive heart failure and had a pacemaker placed.,Review of systems:, Non-contributory. The patient denied fever, chills, ulcers, liver disease or history of gallstones.,Vaccines: The patient was vaccinated with BCG before starting elementary school in the Philippines.,Physical Examination:, At the time of the examination the patient was alert and oriented times three and in no acute distress. She was well nourished.,BP 106/60 lying down; HR 86; RR 12; T 96.1° F; Hgt. =5' 2""; Wgt. =121 lbs.,SKIN: There was no rash or skin lesions.,HEENT: She had no oral lesions and moist mucous membranes. No icterus was noted.,NECK: Her neck was supple without lymphadenopathy or thyromegaly.,LUNGS: Crackles at the right lower base with normal respiratory excursion and no dullness to percussion.,HEART: IV/VI crescendo - decrescendo systolic murmur was heard at the second intercostal space with radiation to the neck.,ABDOMEN: The abdomen was distended. Bowel sounds were normal. No hepatosplenomegaly, tenderness or rebound tenderness could be detected during the examination.,EXTREMITIES: No cyanosis, clubbing or edema was noted.,RECTAL: Normal rectal exam. Guaiac negative.,NEUROLOGIC: Normal and non-focal.,Hospital Course:,  The patient was admitted and a nasogastric tube was placed. IV fluids were started. A KUB was obtained showing an abnormal bowel gas pattern. Multiple loops of distended bowel were noted in the mid abdomen. Air and feces were noted within the colon in the right side. An Abdominal CT scan was obtained. There was a small amount of perihepatic fluid noted. The liver and spleen were normal. The kidneys were atrophic. The gallbladder was moderately distended. There was marked dilatation of the small bowel proximally and distally. There was gas and contrast material in the colon. A diagnostic procedure was performed.",
" Backache, stomachache, and dysuria for the last two days - Urinary dysuria, left flank pain, pharyngitis.", General Medicine, Gen Med Consult - 41 ,"SUBJECTIVE:,  The patient complains of backache, stomachache, and dysuria for the last two days.  Fever just started today and cough.  She has history of kidney stones less than a year ago and had a urinary tract infection at that time.  Her back started hurting last night.,PAST MEDICAL HISTORY:,  She denies sexual activities since two years ago.  Her last menstrual period was 06/01/2004.  Her periods have been irregular.  She started menarche at 10 years of age and she is still irregular and it runs in Mom’s side of the family.  Mom and maternal aunt have had total hysterectomies.  She also is diagnosed with abnormal valve has to be on SBE prophylaxis, sees Dr. XYZ Allen.  She avoids decongestants.  She is limited on her activity secondary to her heart condition.,MEDICATION:,  Cylert.,ALLERGIES: , No known drug allergies.,OBJECTIVE:,Vital Signs:  Blood pressure is 124/72.  Temperature 99.2.  Respirations 20 unlabored.  Weight:  137 pounds.,HEENT:  Normocephalic.  Conjunctivae noninjected.  No mattering noted.  Her TMs are bilaterally clear, nonerythematous.  Throat clear, good mucous membrane moisture, but she did have erythema and edema at her posterior soft palate.,Neck:  Supple.  Increased lymphadenopathy noted in the submandibular nodes, but no axillary nodes and no hepatosplenomegaly.,Respiratory:  Clear.  No wheezes, no crackles, no tachypnea, and no retractions.,Cardiovascular:  Regular rate and rhythm.  S1 and S2 normal, no murmur.,Abdomen:  Soft.  No organomegaly.  She did have exquisite tenderness to palpation of the left upper quadrant and flank area, but the spleen was not palpable.  She has no suprapubic tenderness.,Extremities:  She has good range of motion of upper and lower extremities.  Good ambulation.,Her UA was positive for 2+ leukocyte esterase, positive nitrites, 1+ protein, 2+ ketones, 4+ blood, greater than 50 white blood cells, 10-20 rbc’s, and 1+ bacteria.  Culture and sensitivity is pending.  Her Strep test is negative.  Culture is pending.,ASSESSMENT:,1.  Urinary dysuria.,2.  Left flank pain.,3.  Pharyngitis.,PLAN:,  A 1 g of Rocephin IM was given.  Call Dr. B's office tomorrow morning incase a second IM dose is needed.  If not then she will fill a prescription for Omnicef 300 mg capsule 1 p.o. b.i.d. for 10 days total and then we will await the culture and sensitivity results to see if this is appropriate drug.  Push fluids.  Await strep culture report.  Follow up with Dr. XYZ if no better or symptoms worsen.","general medicine, backache, stomachache, dysuria, cylert, urinary dysuria, pharyngitis, culture and sensitivity, tenderness, urinary, infection, "
 Patient with a diagnosis of stroke., General Medicine, Gen Med Consult - 40 ,"CHIEF COMPLAINT:, Altered mental status.,HISTORY OF PRESENT ILLNESS:, The patient is a 69-year-old male transferred from an outlying facility with diagnosis of a stroke. History is taken mostly from the emergency room record. The patient is unable to give any history and no family member is present for questioning. When asked why he came to the emergency room, the patient replies that it started about 2 PM yesterday. However, he is unable to tell me exactly what started at 2 PM yesterday. The patient's speech is clear, but he speaks nonsensically using words in combinations that don't make any sense. No other history of present illness is available.,PAST MEDICAL HISTORY:, Per the emergency room record, significant for atrial fibrillation, hypertension, and hyperlipidemia.,PAST SURGICAL HISTORY:, Unknown.,FAMILY HISTORY:, Unknown.,SOCIAL HISTORY:, The patient denies smoking and drinking.,MEDICATIONS:, Per the emergency room record, medications are Lotensin 20 mg daily, Toprol 50 mg daily, Plavix 75 mg daily and aspirin 81 mg daily.,ALLERGIES:, UNKNOWN.,REVIEW OF SYSTEMS:, Unobtainable secondary to the patient's condition.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature: 97.9. Pulse: 79. Respiratory rate: 20. Blood pressure: 117/84.,GENERAL: Well-developed, well-nourished male in no acute distress.,HEENT: Eyes: Pupils are equal, round and reactive. There is no scleral icterus. Ears, nose and throat: His oropharynx is moist. His hearing is normal.,NECK: No JVD. No thyromegaly.,CARDIOVASCULAR: Irregular rhythm. No lower extremity edema.,RESPIRATORY: Clear to auscultation bilaterally with normal effort.,ABDOMEN: Nontender. Nondistended. Bowel sounds are positive.,MUSCULOSKELETAL: There is no clubbing of the digits. The patient's strength is 5/5 throughout.,NEUROLOGICAL: Babinski's are downgoing bilaterally. Deep tendon reflexes are 2+ throughout.,LABORATORY DATA:, By report, head CT from the outlying facility was negative. An EKG showed atrial fibrillation with a rate of 75. There is no indication of any acute cardiac ischemia. A chest x-ray shows no acute pulmonary process, but does show cardiomegaly.,Labs are as follows: White count 9.4, hemoglobin 17.2, hematocrit 52.5, platelet count 219. PTT 24, PT 13, INR 0.96. Sodium 135, potassium 3.6, chloride 99, bicarb 27, BUN 13, creatinine 1.4, glucose 161, calcium 9, magnesium 1.9, total protein 7, albumin 3.7, AST 22, ALT 41, alkaline phosphatase 85, total bilirubin 0.7, total cholesterol 193. Cardiac isoenzymes are negative times one with a troponin of 0.09.,ASSESSMENT AND PLAN:,1. Probable stroke. The patient has an expressive aphasia. He does not have dysarthria, however. Also, his strength is not affected. I suspect that the patient has had strokes or TIAs in the past because he was taking aspirin and Plavix at home. Head CT is reportedly negative. I will ask our radiologist to re-read the head CT. I will also order MRI and MRA, carotid Doppler ultrasound and echocardiogram in addition to a fasting lipid profile. I will consult neurology to evaluate and continue his aspirin and Plavix.,2. Atrial fibrillation. The patient's rate is controlled currently. I will continue him on his amiodarone 200 mg twice daily and consult CHI to evaluate him.,3. Hypertension. I will continue his home medications and add clonidine as needed.,4. Hyperlipidemia. The patient takes no medications for this currently. I will check a fasting lipid profile.,5. Hyperglycemia. It is unknown whether the patient has a history of diabetes. His glucose is currently 171. I will start him on sliding scale insulin for now and monitor closely.,6. Renal insufficiency. It is also unknown whether the patient has a history of this and what his baseline creatinine might be. Currently he has only mild renal insufficiency. This does not appear to be prerenal. Will monitor for now.",
 Patient with confusion and hallucinations., General Medicine, Gen Med Consult - 35 ,"Chief Complaint:, Confusion and hallucinations.,History of Present Illness:, The patient was a 27-year-old Hispanic man who presented to St. Luke's Episcopal Hospital with a five day history of confusion and hallucinations. The patient was doing well until three months prior to admission when he developed wheezing and shortness of breath upon exertion. He was seen by his primary care physician and was prescribed Salmeterol and Fluticasone nasal inhaler for presumed asthma. His wheezing improved with treatment.,Over the five days prior to admission, his family noticed the patient's increasing confusion and bizarre behavior. The patient was intermittently unable to recognize his family members or surroundings. He was restless and anxious, paced the floor at night, and complained of insomnia. He stated he was unable to sleep because he feared his family was trying to hurt him. When he did sleep, he described night terrors. He also complained of both auditory and visual hallucinations. He stated the voices ""told him to do good things"". He denied any previous history of depression or manic episodes. The patient denied suicidal or homicidal ideation. He admitted he had recently lost weight although he was unable to quantify how much. He stated his appetite was good, but he had not been eating for fear of being poisoned.,The patient denied having headaches or a history of trauma. He denied fevers or chills but he complained of recent night sweats. He denied nausea, vomiting, diarrhea, or dysuria. He denied chest pain, palpitations, or episodic flushing; but he complained of lightheadedness. He denied orthopnea or paroxysmal nocturnal dyspnea. The shortness of breath symptoms had resolved.,Past Medical History:, None. No history of hypertension or of cardiac, renal, lung, or liver disease.,Past Surgical History:, None,Past Psychological History: None,Social History:, The patient was from Brazil. He moved to the United States one year ago. He denied any history of tobacco, alcohol, or illicit drug use. He was married and monogamous. He worked as an engineer/manager, and stated that his job was ""very stressful"". He had recently been admitted to an MBA program. The patient denied recent travel or exposures of any kind.,Family History:, The patient had a second-degree relative with a history of depression and ""nervous breakdown"".,Allergies:, There were no known drug allergies.,Medications:, Prescribed medications were Salmeterol inhaler, prn; and Fluticasone nasal inhaler. The patient was taking no over the counter or alternative medicines.,Physical Examination:, The patient was a 27-year-old Hispanic man who presented with symptoms of confusion and hallucinations. He was a thin man but appeared to be well developed and well nourished. The patient paced the room during the examination. He appeared anxious and distracted. He was coherent, yet he had poor concentration and was unable to cooperate fully with the examination. The patient had a pulse rate of 110 beats per minute and blood pressure of 186/101 mm Hg when reclining; and a pulse rate of 122 beats per minute and blood pressure of 166/92 mm Hg when standing. His oral temperature was 100.8 degrees Fahrenheit, and his respiratory rate was 12 breaths per minute.,HEENT: Conjunctivae were pink; sclerae anicteric; mucous membranes moist and pink without lesions.,NECK: The neck was supple, normal jugular venous pressure, no carotid bruits, no thyromegaly.,LUNGS: The lungs were clear to auscultation bilaterally; no wheezes, rales or rhonchi.,HEART: The heart had a regular rhythm, tachycardic, II/VI systolic ejection murmur LUSB, no rubs or gallops, PMI nondisplaced, hyperdynamic precordium.,ABDOMEN: The abdomen was soft, nontender and nondistended; normoactive bowel sounds, no hepatosplenomegaly, no masses; positive bruit heard throughout mid-abdomen, positive bilateral femoral bruits.,EXTREMITIES: No clubbing, cyanosis, or edema; 2+ pulses.,GENITOURINARY: Normal male phallus, no testicular masses.,RECTAL: Guaiac negative, no masses.,LYMPH NODES: Negative in the anterior and posterior clavicular, supraclavicular, axillary, and inguinal regions.,SKIN: Acneiform eruption over back and trunk, no papules or vesicles.,NEUROLOGICAL EXAMINATION: The patient was alert and oriented to self and year, but not to month or place. He had difficulty with mathematics and following commands (when asked to stand on his heels, the patient stood on his toes and turned on the television). Cranial nerves II-XII intact, motor 5/5 throughout all extremities; reflexes 2+ and symmetrical throughout. Sensory: Intact to light touch, vibration, proprioception, and temperature. Cerebellar: intact finger to nose, no ataxia. Romberg negative.,PSYCHOLOGICAL EXAMINATION: The patient's mood was elevated and euphoric; affect was appropriate; his speech was normal in rate, volume, and tone.,Hospital Course:, The patient was admitted to St. Luke's Episcopal Hospital and a workup for his altered mental status was begun. The following studies were performed:,Twelve-lead EKG: sinus tachycardia.,CXR (PA/lat): normal cardiac silhouette and normal lung fields.,CT scan of head without contrast: ventricles were normal in size and position. There was no evidence of mass or hemorrhage.,Lumbar puncture: clear, colorless; WBC--0; RBC--56; protein--45; glucose--126; VDRL--negative; cryptococcal Ag--negative; cultures--negative.,MRI with gadolinium: no discrete areas of abnormal signal intensity.,EEG: no focal or epileptiform activity.,The patient was treated with haldol and risperidone for his agitation, and further diagnostic testing was performed.",
" Patient with abdominal pain, nausea, vomiting, fever, altered mental status.", General Medicine, Gen Med Consult - 39 ,"Chief Complaint:, Abdominal pain, nausea, vomiting, fever, altered mental status.,History of Present Illness:, 55 yo WM with reactive airways disease, allergic rhinitis who was in his usual state of health until he underwent a dental extraction with administration of cephalexin 1 week prior to admission. Approximately one day after the dental procedure, he began having nausea, and abdominal pain along with fatigue. The abdominal pain was described as pressure-like and was located in the epigastrium and periumbilical regions. He initially attributed the symptoms to a side effect of the antibiotic he was taking. However, with worsening of his symptoms, he presented to the ER 5 days after dental extraction.,At that time his vitals were T 99.9 ° HR 115 RR 18 BP 182/101. His exam was notable for mild tenderness in the central abdomen. Laboratory evaluation was notable for WBC 15.6, Hgb 13.1, Plt 189, 16% bands, 68% PMNs. Na 127, K4.7, Cl 88, CO2 29, BUN 19, Cr 1.5, Glucose 155, Ca 9.6, alk phos 125, t bili 0.7, ALT 29, nl amylase and lipase. UA with 100 protein, lg blood, 53 RBC, 2 WBC. Plain films done at that time revealed dilation of small bowel loops in mid-abdomen up to 3.5cm in diameter, thought to be most consistent with a paralytic ileus. The patient was discharged home with diagnosis of medication-induced gastroenteritis vs. UTI. He was instructed to stop his current antibiotic but start Levaquin, and he was given Vicodin, and phenergan for symptomatic relief.,Over the next 2 days, the patient began having fevers, non-bloody emesis, diarrhea, and confusion in addition to his persistent nausea, and abdominal pain. On the night of presentation, the patient was found by a cousin in his bathroom lethargic and disoriented. EMS was called and patient was taken to the ER. In the ER, the pt was diaphoretic, unable to answer questions appropriately, hypotensive, and febrile, with some response of bp to multiple IVF boluses (4L). He received acetaminophen, and ceftriaxone 2g IV after blood cultures were obtained and an LP was performed in the ER. He was then admitted to the ICU for further evaluation and management.,Past Medical History:,Asthma,Allergic Rhinitis,Medications:,loratadine,beclomethasone nasal,fluticasone/salmeterol inhaled,Montelukast,cephalexin,hydrocodone,Allergies:, PCN, but has tolerated cephalosporins in the past.,Social History:, No tobacco use, occasional EtOH, no known drug use, works as a real estate agent.,Family History:, HTN, father with SLE, uncle with Addison’s Disease.,Physical Exam:,T 102.9 ° HR 145 RR 22 BP 99/50 98% on room air, (orthostatics were not performed due to patient’s mental status),I/O: minimal urine output after Foley insertion,Gen: lethargic, mild tachypnea,HEENT: no evidence of trauma, sclerae anicteric, pupils are equal round and reactive to light, oropharynx clear, MM dry.,Neck: supple, without increased JVP, lymphadenopathy or bruits. No thyromegaly,Chest: coarse rhonchi bilaterally,CV: tachycardia, regular, no murmurs, gallops, rubs,Abd: hypoactive bowel sounds, soft, slightly distended, mild tenderness throughout. No rebound, no masses or hepatosplenomegaly.,Ext: no cyanosis, clubbing, or edema. 2+ pulses bilateral distal extremities, no petechiae or splinter hemorrhages.,Neuro: lethargic, but arousable, oriented to person, but not to place, or time. He was not able to answer questions appropriately. Moved all extremities equally but was uncooperative with exam. 2+ DTRs bilaterally, no Babinski reflex.,Skin: no rash, ecchymosis, or petechiae,STUDIES:,EKG: sinus tachycardia, normal axis, isolated Q in III, no TWI or ST elevations or depressions,CXR: Heart normal in size, pulmonary vasculature unremarkable, subsegmental atelectasis in the lower lobes. Acromioclavicular osteoarthritis bilaterally. Lucent lesion in the subchondral bone of the R humeral head, likely a degenerative subchondral cyst.,AXR: Minimal dilation of the small bowel loops in the mid abdomen measuring up to 3cm, no mass lesion or free air visible.,MRI brain pre and post gadolinium: No evidence of hemorrhage, abnormal enhancement, mass lesions, mass effect or edema. The ventricles, sulci, and cisterns are age appropriate in size and configuration. There is no evidence for restricted diffusion. There is mucosal thickening lining the walls of the left maxillary sinus, also containing an air fluid level with two different levels within it, most likely from proteinaceous differences. There is mucosal thickening along the posterior wall of the right maxillary sinus. Mucosal thickening is identified along the walls of the sphenoid sinus, ethmoid sinuses and frontal sinus. Sinusitis with chronic and acute features.,Echo: EF 50%, mild LV concentric hypertrophy, otherwise normal chamber sizes and function,TEE: Normal valves, no thrombi, PFO with R to L shunt, trivial MR, trivial TR,RLE Ultrasound with Dopplers – total deep venous obstruction in distal external iliac, common femoral, profunda femoral, and femoral vein, partial DVT in popliteal and posterior tibial veins, and total DVT greater saphenous vein. No venous obstruction on the L LE. R calf 34cm, R thigh 42 cm, L calf 31cm, L thigh 39cm.,CT Abdomen (initial ER visit): Trace bilateral pleural fluid, findings in liver compatible with diffuse fatty infiltration, 3.5cm non calcified R adrenal mass was noted, along with an edematous L adrenal with no discrete mass. There was retroperitoneal edema around the lower abdominal aorta with perinephric stranding, no stone or obstruction. Moderate fullness of small bowel loops was noted, most consistent with a paralytic ileus.,Hospital Course:, The patient developed right lower extremity swelling and was diagnosed with deep venous thrombosis. Diagnostic studies were performed.",
 A male patient presented for evaluation of chronic abdominal pain., General Medicine, Gen Med Consult - 34 ,"Chief Complaint:, Chronic abdominal pain.,History of Present Illness:, 23-year-old Hispanic male who presented for evaluation of chronic abdominal pain. Patient described the pain as dull, achy, constant and located at the epigastric area with some radiation to the back. There are also occasional episodes of stabbing epigastric pain unrelated to meals lasting only minutes. Patient noted that the pain started approximately six months prior to this presentation. He self medicated ""with over the counter"" antacids and obtained some relief so he did not seek medical attention at that time.,Two months prior to current presentation, he had worsening of his pain as well as occasional nausea and vomiting. At this time the patient was found to be H. pylori positive by serology and was treated with triple therapy for two weeks and continued on omeprazole without relief of his pain.,The patient felt he had experienced a twenty-pound weight loss since his symptoms began but he also admitted to poor appetite. He stated that he had two to three loose bowel movements a day but denied melena or bright red blood per rectum. Patient denied NSAID use, ethanol abuse or hematemesis. Position did not affect the quality of the pain. Patient denied fever or flushing. He stated he was a very active and healthy individual prior to these recent problems.,Past Medical History:, No significant past medical history.,Past Surgical History:, No prior surgeries.,Allergies:, No known drug allergies.,Medications:, Omeprazole 40 mg once a day. Denies herbal medications.,Family History:, Mother, father and siblings were alive and well.,Social History:, He is employed as a United States Marine officer, artillery repair specialist. He was a social drinker in the past but quit altogether two years ago. He never used tobacco products or illicit/intravenous drugs.,Physical Examination:, The patient was a thin male in no apparent distress. His oral temperature was 98.2 Fahrenheit, blood pressure was 114/67 mmHg, pulse rate of 91 beats per minute and regular, respiratory rate was 14 and his pulse oximetry on room air was 98%. Patient was 52 kg in weight and 173 cm height.,SKIN: No skin rashes, lesions or jaundice. He had one tattoo on each upper arm.,HEENT: Head was normocephalic and atraumatic. Pupils were equal, round and reactive. Anicteric sclerae. Tympanic membranes had a normal appearance. Normal funduscopic examination. Oral mucosa was moist and pink. Oral/pharynx was clear.,NECK: No lymphadenopathy. No carotid bruits. Trachea midline. Thyroid non-palpable. No jugular venous distension.,CHEST: Lungs were clear bilaterally with good air movement.,HEART: Regular rate and rhythm. Normal S1 and S2 with no murmurs, gallops or rubs. PMI was non-displaced.,ABDOMEN: Abdomen was flat. Normal active bowel sounds. Liver span percussed sixteen centimeters, six centimeters below R costal margin with irregular border that was mildly tender to palpation. Slightly tender to palpation in epigastric area. There was no splenomegaly. No abdominal masses were appreciated. No CVA tenderness was noted.,RECTAL: No perirectal lesions were found. Normal sphincter tone and no rectal masses. Prostate size was normal without nodules. Guaiac positive.,GENITALIA: Testes descended bilaterally, no penile lesions or discharge.,EXTREMITIES: No clubbing, cyanosis, or edema. No peripheral lymphadenopathy was noted.,NEUROLOGIC: Alert and oriented times three. Cranial nerves II to XII appeared intact. No muscle weakness or sensory deficits. DTRs equal and normal.,Radiology/Studies: 2 view CXR: Mild elevation right diaphragm.,CT of abdomen and pelvis: Too numerous to count bilobar liver masses up to about 8 cm. Extensive mass in the pancreatic body and tail, peripancreatic region and invading the anterior aspect of the left kidney. Question of vague splenic masses. No definite abnormality of the moderately distended gallbladder, bile ducts, right kidney, poorly seen adrenals, bowel or bladder. Evaluation of the retroperitoneum limited by paucity of fat.,Patient underwent several diagnostic procedures and soon after he was transferred to Houston Veterans Administration Medical Center to be near family and to continue work-up and treatment. At the HVAMC these diagnostic procedures were reviewed.",
 Patient with complaint of dark urine and generalized weakness., General Medicine, Gen Med Consult - 37 ,"Chief Complaint:, Dark urine and generalized weakness.,History of Present Illness:,40 year old Hispanic male presented to the emergency room complaining of generalized weakness, fatigue and dark urine for one week. In addition, he stated that his family had noticed yellowing of his skin and eyes, though he himself had not noticed.,He did complain of subjective fever and chills along with occasional night sweats during the prior week or so and he noted anorexia for 3-4 weeks leading to 26 pound weight loss (213 lbs. to 187 lbs.). He was nauseated but denied vomiting. He did admit to intermittent abdominal discomfort which he could not localize. In addition, he denied any history of liver disease, but had undergone cholecystectomy many years previous.,Past Medical History:, DM II-HbA1c unknown,Past Surgical History:, Cholecystectomy without complication,Family History:, Mother with diabetes and hypertension. Father with diabetes. Brother with cirrhosis (etiology not documented).,Social History:, He was unemployed and denied any alcohol or drug use. He was a prior “mild” smoker, but quit 10 years previous.,Medications:, Insulin (unknown dosage),Allergies:, No known drug allergies.,Physical Exam:,Temperature: 98.2,Blood pressure:118/80,Heart rate: 95,Respiratory rate: 18,GEN: Middle age Latin-American Male, jaundice, alert and oriented to person/place/time.,HEENT: Normocephalic, atraumatic. Icteric sclerae, pupils equal, round and reactive to light. Clear oropharynx.,NECK: Supple, without jugular venous distension, lymphadenopathy, thyromegaly or carotid bruits.,CV: Regular rate and rhythm, normal S1 and S2. No murmurs, gallops or rubs,PULM: Clear to auscultation bilaterally without rhonchi, rales or wheezes,ABD: Soft with mild RUQ tenderness to deep palpation, Murphy’s sign absent. Bowel sounds present. Hepatomegaly with liver edge 3 cm below costal margin. Splenic tip palpable.,RECTAL: Guaiac negative,EXT: Shotty inguinal lymphadenopathy bilaterally, largest node 2cm,NEURO: Strength 5/5 throughout, sensation intact, reflexes symmetric. No focal abnormality identified. No asterixis,SKIN: Jaundice, no rash. No petechiae, gynecomastia or spider angiomata.,Hospital Course:,The patient was admitted to the hospital to begin workup of liver failure. Initial labs were considered to be consistent with an obstructive pattern, so further imaging was obtained. A CT scan of the abdomen and pelvis revealed lymphadenopathy and a markedly enlarged liver. His abdominal pain was controlled with mild narcotics and he was noted to have decreasing jaundice by hospital day 4. An US guided liver biopsy revealed only acute granulomatous inflammation and fibrosis. The overall architecture of the liver was noted to be well preserved.,Gastroenterology was consulted for EGD and ERCP. The EGD was normal and the ERCP showed normal biliary anatomy without evidence of obstruction. In addition, they performed an endoscopic ultrasound-guided fine needle aspiration of two lymph-nodes, one in the subcarinal region and one near the celiac plexus. Again, pathologic results were insufficient to make a tissue diagnosis.,By the second week of hospitalization, the patient was having intermittent low-grade fevers and again experiencing night-sweats. He remained jaundice. Given the previous negative biopsies, surgery was consulted to perform an excisional biopsy of the right groin lymph node, which revealed no evidence of carcinoma, negative AFB and GMS stains and a single noncaseating granuloma.,By his fourth week of hospitalization, he remained ill with evidence of ongoing liver failure. Surgery performed an open liver biopsy and lymph node resection.,STUDIES (HISTORICAL):,CT abdomen: Multiple enlarged lymph nodes near the porta hepatis and peri-pancreatic regions. The largest node measures 3.5 x 3.0 cm. The liver is markedly enlarged (23cm) with a heterogenous pattern of enhancement. The spleen size is at the upper limit of normal. Pancreas, adrenal glands and kidneys are within normal limits. Visualized portions of the lung parenchyma are grossly normal.,CT neck: No abnormalities noted,CT head: No intracranial abnormalities,RUQ US (for biopsy): Heterogenous liver with lymphadenopathy.,ERCP: No filling defect noted; normal pancreatic duct visualized. Normal visualization of the biliary tree, no strictures. Normal exam.",
 Patient coughing up blood and with severe joint pain., General Medicine, Gen Med Consult - 36 ,"Chief Complaint:, coughing up blood and severe joint pain.,History of Present Illness:,  The patient is a 37 year old African American woman with history of chronic allergic rhinitis who presents to an outpatient clinic with severe pain in multiple joints and hemoptysis for 1 day. The patient was at her baseline state of health until 2 months prior to admission when her usual symptoms of allergic rhinitis worsened. In addition to increased nasal congestion and drainage, she also began having generalized fatigue, malaise, and migratory arthralgias involving bilateral wrists, shoulders, elbows, knees, ankles, and finger joints. She also had intermittent episodes of swollen fingers that prevented her from making a fist. Patient denied recent flu-like illness, fever, chills, myalgias, or night sweats. Four weeks after the onset of arthralgias patient developed severe bilateral eye dryness and redness without any discharge. She was evaluated by an ophthalmologist and diagnosed with conjunctivitis. She was given eye drops that did not relieve her eye symptoms. Two weeks prior to admission patient noted the onset of rust colored urine. No bright red blood or clots in the urine. She denied having dysuria, decreased urine output, abdominal pain, flank pain, or nausea/vomiting. Patient went to a community ER, and had a CT Scan of the abdomen that was negative for kidney stones. She was discharged from the ER with Bactrim for possible UTI. During the next week patient had progressively worsening arthralgias to the point where she could hardly walk. On the day of admission, she developed a cough productive of bright red blood associated with shortness of breath and nausea, but no chest pain or dizziness. This prompted the patient to go see her primary care physician. After being seen in clinic, she was transferred to St. Luke’s Episcopal Hospital for further evaluation.,Past Medical History:, Allergic rhinitis, which she has had for many years and treated with numerous medications. No history of diabetes, hypertension, or renal disease. No history tuberculosis, asthma, or upper airway disease.,Past Surgical History:, Appendectomy at age 21. C-Section 8 years ago.,Ob/Gyn: G2P2; last menstrual period 3 weeks ago. Heavy menses due to fibroids.,Social History:, Patient is married and lives with her husband and 2 children. Works in a business office. Denies any tobacco, alcohol, or illicit drug use of any kind. No history of sexually transmitted diseases. Denies exposures to asbestos, chemicals, or industrial gases. No recent travel. No recent sick contacts.,Family History:, Mother and 2 maternal aunts with asthma. No history of renal or rheumatologic diseases.,Medications:, Allegra 180mg po qd, Zyrtec 10mg po qd, Claritin 10mg po qd,No herbal medication use.,Allergies:, No known drug allergies.,Review of systems:, No rashes, headache, photophobia, diplopia, or oral ulcers. No palpitations, orthopnea or PND. No diarrhea, constipation, melena, bright red blood per rectum, or pale stool. No jaundice. Decreased appetite, but no weight loss.,Physical Examination:,VS: T 100.2F BP 132/85 P 111 RR 20 O2 Sat 95% on room air,GEN: Well-developed woman in no apparent distress.,SKIN: No rashes, nodules, ecchymoses, or petechiae.,LYMPH NODES: No cervical, axillary, or inguinal lymphadenopathy.,HEENT: Pupils equally round and reactive to light. Extra-ocular movements intact. Anicteric sclerae. Erythematous sclerae and pale conjunctivae. Dry mucous membranes. No oropharyngeal lesions. Bilateral tympanic membranes clear. No nasal deformities.,NECK: Supple. No increased jugular venous pressure. No thyromegaly.,CHEST: Decreased breath sounds throughout bilateral lung fields with occasional diffuse crackles. No wheezes or rales.,CV: Tachycardic. Regular rhythm. No murmurs, gallops, or rubs.,ABDOMEN: Soft with normal active bowel sounds. Non-distended and non-tender. No masses palpated. No hepatosplenomegaly.,RECTAL: Brown stool. Guaiac negative.,EXT: No clubbing, cyanosis, or edema. 2+ pulses bilaterally. Tenderness and mild swelling of bilateral wrists, MCPs and PIPs with decreased range of motion and grip function. Bilateral wrists warm without erythema. Bilateral elbows, knees, and ankles tender to palpation with decreased range of motion, but no erythema, warmth, or swelling of these joints.,NEURO: Cranial nerves intact. 2+ DTRs bilaterally and symmetrically. Motor strength and sensation are within normal limits.,STUDIES:,Chest X-ray (10/03):,Suboptimal inspiratory effort. No evidence of pneumonic consolidation, pleural effusion, pneumothorax, or pulmonary edema. Cardiomediastinal silhouette is unremarkable.,CT Scan of Chest (10/03):,Prominence of the bronchovascular markings bilaterally with a nodular configuration. There are mixed ground glass interstitial pulmonary infiltrates throughout both lungs with a perihilar predominance. Aortic arch is of normal caliber. The pulmonary arteries are of normal caliber. There is right paratracheal lymphadenopathy. There is probable bilateral hilar lymphadenopathy. Trachea and main stem bronchi are normal. The heart is of normal size.,Renal Biopsy:,Microscopic Description : Ten glomeruli are present. There are crescents in eight of the glomeruli. Some of the glomeruli show focal areas of apparent necrosis with fibrin formation. The interstitium consists of a fairly dense infiltrate of lymphocytes, plasma cells with admixed eosinophils. The tubules for the most part are unremarkable. No vasculitis is identified.,Immunofluorescence Description : There are no staining for IgG, IgA, IgM, C3, Kappa, Lambda, C1q, or albumin.,Electron Microscopic Description : Mild to moderate glomerular, tubular, and interstitial changes. Mesangium has multifocal areas with increased matrix and cells. There is focal mesangial interpositioning with the filtration membrane. Interstitium has multifocal areas with increased collagen. There are focal areas with interstitial aggregate of fibrin. Within the collagen substrate are infiltrates of lymphocytes, plasma cells, eosinophils, and macrophages. The glomerular sections evaluated show no electron-dense deposits in the filtration membrane or mesangium.,Microscopic Diagnosis: Pauci-immune crescentic glomerulonephritis with eosinophilic interstitial infiltrate.",
 Patient was found to have decrease in mental alertness, General Medicine, Gen Med Consult - 30 ,"CHIEF COMPLAINT: , Mental changes today.,HISTORY OF PRESENT ILLNESS: , This patient is a resident from Mazatlan, Mexico, visiting her son here in Utah, with a history of diabetes.  She usually does not take her meal on time, and also not having her regular meals lately.  The patient usually still takes her diabetic medication.  Today, the patient was found to have decrease in mental alertness, but no other GI symptoms.  Some sweating and agitation, but no fever or chills.  No other rash.  Because of the above symptoms, the patient was treated in the emergency department here.  She was found to glucose in 30 range, and hypertension.  There was some question whether she also take her blood pressure medication or not.  Because of the above symptoms, the patient was admitted to the hospital for further care.  The patient was given labetalol IV and also Norvasc blood pressure, and also some glucose supplement.  At this time, the patient's glucose was in the 175 range.,PAST MEDICAL HISTORY: , Diabetes, hypertension.,PAST SURGICAL HISTORY:,  None.,FAMILY HISTORY: , Unremarkable.,ALLERGIES: , No known drug allergies.,MEDICATIONS:,  In Spanish label.  They are the diabetic medication, and also blood pressure medication.  She also takes aspirin a day.,SOCIAL HISTORY:  ,The patient is a Mazatlan, Mexico resident, visiting her son here.,PHYSICAL EXAMINATION:,GENERAL:  The patient appears to be no acute distress, resting comfortably in bed, alert, oriented x3, and coherent through interpreter.,HEENT:  Clear, atraumatic, normocephalic.  No sinus tenderness.  No obvious head injury or any laceration.  Extraocular movements are intact.  Dry mucosal linings.,HEART:  Regular rate and rhythm, without murmur.  Normal S1, S2.,LUNGS:  Clear.  No rales.  No wheeze.  Good excursion.,ABDOMEN:  Soft, active bowel sounds in 4 quarters, nontender, no organomegaly.,EXTREMITIES:  No edema, clubbing, or cyanosis.  No rash.,LABORATORY FINDINGS: , On Admission:  CPK, troponin are negative.  CMP is remarkable for glucose of 33.  BMP is remarkable for BUN of 60, creatinine is 4.3, potassium 4.7.  Urinalysis shows specific gravity of 10.30.  CT of the brain showed no hemorrhage.  Chest x-ray showed no acute cardiomegaly or any infiltrates.,IMPRESSION:,1.  Hypoglycemia due to not eating her meals on a regular basis.,2.  Hypertension.,3.  Renal insufficiency, may be dehydration, or diabetic nephropathy.,PLAN: , Admit the patient to the medical ward, IV fluid, glucometer checks, and adjust the blood pressure medication and also diabetic medication.",
 Consultation for jaw pain., General Medicine, Gen Med Consult - 4 ,"CHIEF COMPLAINT:,  Jaw pain this morning.,BRIEF HISTORY OF PRESENT ILLNESS:,  This is a very nice 53-year-old white male with no previous history of heart disease, was admitted to rule out MI and coronary artery disease.  The patient has history of hypercholesterolemia, presently on Lipitor 20 mg a day and hyperthyroidism, on Synthroid 0.088 mg per day.  Also, history of chronic diverticulitis with recent bouts.  The patient has been doing well, seen in my office at the end of December for complete physical examination.  I had ordered a stress test for him, then delayed due to a family illness.  However, denies any chest pain or chest tightness with exertion.  The patient was doing well.  He was watching television yesterday afternoon or p.m. and fell asleep holding his head in his left hand.  He awoke and noticed pain in the jaw and neck area, on both sides, but no shortness of breath, diaphoresis, nausea, or chest pain.  He is able to go to sleep, woke up this morning with same discomfort, decided to call our office, talked to our triage nurse, who instructed to come to the emergency room for possibility of just having a cardiac event.  The patient's pain resolved.  He was given nitroglycerin in the emergency room drawing his blood pressure 67/32.  Blood pressure quickly came back to normal with the patient's reverse Trendelenburg.,FAMILY HISTORY: , Strongly positive for heart disease in his father.  He had a bypass at age 60.  Both parents are alive.  Both have dementia.  His father has history of coronary artery disease and multiple vascular strokes.  He is in his 80s.  His mother is 80, also with dementia.  The patient does not smoke or drink.,PAST MEDICAL HISTORY:,  Remarkable for tonsillectomies.,MEDICATIONS:,  Synthroid and Lipitor.,ALLERGIES:,  PENICILLIN AND BIAXIN.,REVIEW OF SYSTEMS:,  Noncontributory.,PHYSICAL EXAMINATION:,VITAL SIGNS:  The patient's blood pressure is 113/74, pulse rate is 72, respiratory rate is 18.  He is afebrile.,GENERAL:  He is well-developed, well-nourished white male, in no acute distress.,HEENT:  Pupils equal, round, and reactive to light and accommodation.  Extraocular movements were intact.  Throat was clear.,NECK:  Supple.  There is no organomegaly or thyromegaly.  Carotids are +2 without bruits.,CHEST:  Lungs are clear to auscultation and percussion.,CV:  Without any murmurs or gallops.,ABDOMEN:  Soft.  There is no hepatosplenomegaly.  Bowel sounds are active.  No tenderness.,EXTREMITIES:  No cyanosis, clubbing, or edema.  Peripheral pulses 2+.,NEUROLOGICAL:  Intact.  Motor exam is 5/5.,LABORATORY STUDIES:,  EKG is within normal limits, good sinus rhythm.  His axis is somewhat leftward.  CBC and BMP were normal and cardiac enzymes were negative x1.,IMPRESSION:,1.  Jaw pain, sounds musculoskeletal.  We will rule out angina equivalent.,2.  Hypercholesterolemia.,3.  Hypothyroidism.,PLAN: , Lipitor and thyroid have been ordered.  His chest pain unit protocol for the stress thallium that will be done in the morning.  If test is negative, we will discharge home.  If positive, we will consult Cardiology.  The patient requests Dr. ABC.",
" Patient was confused, had garbled speech, significantly worse from her baseline, and had decreased level of consciousness.", General Medicine, Gen Med Consult - 31 ,"CHIEF COMPLAINT:,  A 74-year-old female patient admitted here with altered mental status.,HISTORY OF PRESENT ILLNESS:,  The patient started the last 3-4 days to do poorly.  She was more confused, had garbled speech, significantly worse from her baseline.  She has also had decreased level of consciousness since yesterday.  She has had aphasia which is baseline but her aphasia has gotten significantly worse.  She eventually became unresponsive and paramedics were called.  Her blood sugar was found to be 40 because of poor p.o. intake.  She was given some D50 but that did not improve her mental status, and she was brought to the emergency department.  By the time she came to the emergency department, she started having some garbled speech.  She was able to express her husband's name and also recognize some family members, but she continued to be more somnolent when she was in the emergency department.  When seen on the floor, she is more awake, alert.,PAST MEDICAL HISTORY: , Significant for recurrent UTIs as she was recently to the hospital about 3 weeks ago for urinary tract infection.  She has chronic incontinence and bladder atony, for which eventually it was decided for the care of the patient to put a Foley catheter and leave it in place.  She has had right-sided CVA.  She has had atrial fibrillation status post pacemaker.  She is a type 2 diabetic with significant neuropathy.  She has also had significant pain on the right side from her stroke.  She has a history of hypothyroidism.  Past surgical history is significant for cholecystectomy, colon cancer surgery in 1998.  She has had a pacemaker placement.  ,REVIEW OF SYSTEMS:,GENERAL:  No recent fever, chills.  No recent weight loss.,PULMONARY:  No cough, chest congestion.,CARDIAC:  No chest pain, shortness of breath.,GI:  No abdominal pain, nausea, vomiting.  No constipation.  No bleeding per rectum or melena.,GENITOURINARY:  She has had frequent urinary tract infection but does not have any symptoms with it.  ENDOCRINE:  Unable to assess because of patient's bed-bound status.,MEDICATIONS:  ,Percocet 2 tablets 4 times a day, Neurontin 1 tablet b.i.d.  600 mg, Cipro recently started 500 b.i.d., Humulin N 30 units twice a day.  The patient had recently reduced that to 24 units.  MiraLax 1 scoop nightly, Avandia 4 mg b.i.d., Flexeril 1 tablet t.i.d., Synthroid 125 mcg daily, Coumadin 5 mg.  On the medical records, it shows she is also on ibuprofen, Lasix 40 mg b.i.d., Lipitor 20 mg nightly, Reglan t.i.d.  5 mg, Nystatin powder.  She is on oxygen chronically.,SOCIAL/FAMILY HISTORY: , She is married, lives with her husband, has 2 children that passed away and 4 surviving children.  No history of tobacco use.  No history of alcohol use.  Family history is noncontributory.,PHYSICAL EXAMINATION:,GENERAL:  She is awake, alert, appears to be comfortable.,VITAL SIGNS:  Blood pressure 111/43, pulse 60 per minute, temperature 37.2.  Weight is 98 kg.  Urine output is so far 1000 mL.  Her intake has been fairly similar.  Blood sugars are 99 fasting this morning.  ,HEENT:  Moist mucous membranes.  No pallor,NECK:  Supple.  She has a rash on her neck.  ,HEART:  Regular rhythm, pacemaker could be palpated.,CHEST:  Clear to auscultation.,ABDOMEN:  Soft, obese, nontender.,EXTREMITIES:  Bilateral lower extremities edema present.  She is able to move the left side more efficiently than the right.  The power is about 5 x 5 on the left and about 3-4 x 5 on the right.  She has some mild aphasia.,DIAGNOSTIC STUDIES: , BUN 48, creatinine 2.8.  LFTs normal.  She is anemic with a hemoglobin of 9.6, hematocrit 29.  INR 1.1, pro time 14.  Urine done in the emergency department showed 20 white cells.  It was initially cloudy but on the floor it has cleared up.  Cultures from the one done today are pending.  The last culture done on August 20 showed guaiac negative status and prior to that she has had mixed cultures.  There is a question of her being allergic to Septra that was used for her last UTI.,IMPRESSION/PLAN:,1.  Cerebrovascular accident as evidenced by change in mental status and speech.  She seems to have recovered at this point.  We will continue Coumadin.  The patient's family is reluctant in discontinuing Coumadin but they do express the patient since has overall poor quality of life and had progressively declined over the last 6 years, the family has expressed the need for her to be on hospice and just continue comfort care at home.,2.  Recurrent urinary tract infection.  Will await culture at this time, continue Cipro.,3.  Diabetes with episode of hypoglycemia.  Monitor blood sugar closely, decrease the dose of Humulin N to 15 units twice a day since intake is poor.  At this point, there is no clear evidence of any benefit from Avandia but will continue that for now.,4.  Neuropathy, continue Neurontin 600 mg b.i.d., for pain continue the Percocet that she has been on.,5.  Hypothyroidism, continue Synthroid.,6.  Hyperlipidemia, continue Lipitor.,7.  The patient is not to be resuscitated.  Further management based on the hospital course.",
" Patient with osteoarthritis and osteoporosis with very limited mobility, depression, hypertension, hyperthyroidism, right breast mass, and chronic renal insufficiency", General Medicine, Gen Med Consult - 32 ,"PROBLEM LIST:,1.  Generalized osteoarthritis and osteoporosis with very limited mobility.,2.  Adult failure to thrive with history of multiple falls, none recent.,3.  Degenerative arthritis of the knees with chronic bilateral knee pain.,4.  Chronic depression.,5.  Hypertension.,6.  Hyperthyroidism.,7.  Aortic stenosis with history of CHF and bilateral pleural effusions.,8.  Right breast mass, slowly enlarging.  Patient refusing workup.,9.  Status post ORIF of the right wrist, now healed.,10.  Anemia of chronic disease.,11.  Hypoalbuminemia.,12.  Chronic renal insufficiency.,CURRENT MEDICATIONS:,  Acetaminophen 325 mg 2 tablets twice daily, Coreg 6.25 mg twice daily, Docusate sodium 100 mg 1 cap twice daily, ibuprofen 600 mg twice daily with food, Lidoderm patch 5% to apply 1 patch to both knees every morning and off in the evening, one vitamin daily, ferrous sulfate 325 mg daily, furosemide 20 mg q.a.m., Tapazole 5 mg daily, potassium chloride 10 mEq daily, Zoloft 50 mg daily, Ensure t.i.d., and p.r.n. medications.,ALLERGIES:,  NKDA.,CODE STATUS:,  DNR, healthcare proxy, durable power of attorney.,DIET:,  Regular with regular consistency with thin liquids and ground meat.,RESTRAINTS: , None.  She does have a palm protector in her right hand.,INTERVAL HISTORY:,  No significant change over the past month has occurred.  The patient mainly complains about pain in her back.  On a scale from 1 to 10, it is 8 to 10, worse at night before she goes to bed.  She is requesting something more for the pain.  Other than that, she complains about her generalized pain.  There has been no significant change in her weight.  No fever or chills.  No complaint of headaches or visual changes, chest pain, shortness of breath, dyspnea on exertion, orthopnea, or PND.  No hemoptysis or night sweats.  No change in her bowels, abdominal pain, bright red rectal bleeding, or melena.  No nausea or vomiting.  Her appetite is fair.  She is a picky eater but definitely likes her candy.  There has been no change in her depression.  It seems to be stable on the Zoloft 50 mg daily, which she has been on since October 17, 2006.  She denies feeling depressed to me but complains of being bored, stating she just sits and watches TV or sometimes may go to activities but not very seldom due to her back pain.  No history of seizures.  She denies any tremors.  She is hyperthyroid and is on replacement.,PHYSICAL EXAMINATION: , An elderly female, sitting in a wheelchair, in no acute distress, very kyphotic.  She is very pleasant and alert.  Vital signs per chart.  Skin is normal in texture and turgor for her age.  She does have dry lips, which she picks at and was picking at her lips while I was talking with her.  HEENT:  Normocephalic, atraumatic.  She has nevi above her left eye, which she states she has had since birth and has not changed.  Pupils are equal, round and reactive to light and accommodation.  No exophthalmos or lid lag.  Anicteric sclerae.  Conjunctivae pink, nasal passages clear.  She is edentulous but does have her upper dentures in.  No mucosal ulcerations.  External ears normal.  Neck is supple.  No increased JVD, cervical or supraclavicular adenopathy.  No thyromegaly or masses.  Trachea is midline.  Her chest is very kyphotic, clear to A&P.  Heart:  Regular rate and rhythm with a 2-3/6 systolic murmur heard best at the left sternal border.  Abdomen:  Soft.  Good bowel sounds.  Nontender.  Unable to appreciate any organomegaly or masses as she is sitting in a wheelchair.  Extremities are without edema, cyanosis, clubbing, or tremor.  She does have Lidoderm patches over both of her knees and is wearing a brace in her right hand.,LABORATORY TESTS: , Albumin was 3.2 on 12/06/06.  Dietary is aware.  Electrolytes done 11/28/06, her sodium was 144, potassium 4.4, chloride 109, bicarbonate 26, anion gap 9, BUN 28, creatinine 1.2, GFR 44.  Digoxin was done and was less than 0.9, but she is not on digoxin.  CBC showed a white count of 7400, hemoglobin 11.1, hematocrit 35.9, MCV of 95.2, and platelet count of 252,000.  Her TSH was 1.52.  No changes were made in her Tapazole.,ASSESSMENT AND PLAN:,  We will continue present therapy except we will add Tylenol No.  3 to take 1 tablet before bed as needed for her back pain.  If she does develop drowsiness from this, then the CNS side effects will help her sleep.  During the day, her daughter likes the patient to remain alert and will use the ibuprofen at that time as long as she does not develop any GI symptoms.  We will make sure that she is taking the ibuprofen with food.  No further laboratory tests will be done at this time.",
 Patient with intermittent episodes of severe nausea and abdominal pain., General Medicine, Gen Med Consult - 29 ,"CHIEF COMPLAINT: , This is a previously healthy 45-year-old gentleman.  For the past 3 years, he has had some intermittent episodes of severe nausea and abdominal pain.  On the morning of this admission, he had the onset of severe pain with nausea and vomiting and was seen in the emergency department, where Dr. XYZ noted an incarcerated umbilical hernia.  He was able to reduce this, with relief of pain.  He is now being admitted for definitive repair.,PAST MEDICAL HISTORY: , Significant only for hemorrhoidectomy.  He does have a history of depression and hypertension.,MEDICATIONS: , His only medications are Ziac and Remeron.,ALLERGIES:,  No allergies.,FAMILY HISTORY: , Negative for cancer.,SOCIAL HISTORY:,  He is single.  He has 2 children.  He drinks 4-8 beers per night and smokes half a pack per day for 30 years.  He was born in Salt Lake City.  He works in an electronic assembly for Harmony Music.  He has no history of hepatitis or blood transfusions.,PHYSICAL EXAMINATION:,GENERAL:  Examination shows a moderate to markedly obese gentleman in mild distress since his initial presentation to the emergency department.,HEENT:  No scleral icterus.,NECK:  No cervical, supraclavicular, or axillary adenopathy.,LUNGS:  Clear.,HEART:  Regular.  No murmurs or gallops.,ABDOMEN:  As noted, obese with mildly visible bulging in the umbilicus at the superior position.  With gentle traction, we were able to feel both herniated contents, which when reduced, reveals an approximately 2-cm palpable defect in the umbilicus.,DIAGNOSTIC STUDIES:  ,Normal sinus rhythm on EKG, prolonged QT.  Chest x-ray was negative.  The abdominal x-rays were read as being negative.  His electrolytes were normal.  Creatinine was 0.9.  White count was 6.5, hematocrit was 48, and platelet count was 307.,ASSESSMENT AND PLAN:,  Otherwise previously healthy gentleman, who presents with an incarcerated umbilical hernia, now for repair with mesh.","general medicine, sinus rhythm, ekg, prolonged qt, platelet count, hematocrit, umbilical hernia, emergency department, healthy, incarcerated, intermittent, "
" Patient with hypertension, dementia, and depression.", General Medicine, Gen Med Consult - 33 ,"MEDICAL PROBLEM LIST:,1.  Status post multiple cerebrovascular accidents and significant left-sided upper extremity paresis in 2006.,2.  Dementia and depression.,3.  Hypertension.,4.  History of atrial fibrillation.  The patient has been in sinus rhythm as of late.  The patient is not anticoagulated due to fall risk.,5.  Glaucoma.,6.  Degenerative arthritis of her spine.,7.  GERD.,8.  Hypothyroidism.,9.  Chronic rhinitis (the patient declines nasal steroids).,10.  Urinary urge incontinence.,11.  Chronic constipation.,12.  Diabetes type II, 2006.,13.  Painful bunions on feet bilaterally.,CURRENT MEDICINES: , Aspirin 81 mg p.o. daily, Cymbalta 60 mg p.o. daily, Diovan 80 mg p.o. daily, felodipine 5 mg p.o. daily, omeprazole 20 mg daily, Toprol-XL 100 mg daily, Levoxyl 50 mcg daily, Lantus insulin 12 units subcutaneously h.s., simvastatin 10 mg p.o. daily, AyrGel to both nostrils twice daily, Senna S 2 tablets twice daily, Timoptic 1 drop both eyes twice daily, Tylenol 1000 mg 3 times daily, Xalatan 0.005% drops 1 drop both eyes at bedtime, and Tucks to rectum post BMs.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.  ACE INHIBITOR MAY HAVE CAUSED A COUGH.,CODE STATUS:,  Do not resuscitate, healthcare proxy, palliative care orders in place.,DIET:,  No added salt, no concentrated sweets, thin liquids.,RESTRAINTS:,  None.  The patient has declined use of chair check and bed check.,INTERVAL HISTORY: , Overall, the patient has been doing reasonably well.  She is being treated for some hemorrhoids, which are not painful for her.  There has been a note that she is constipated.,Her blood glucoses have been running reasonably well in the morning, perhaps a bit on the high side with the highest of 188.  I see a couple in the 150s.  However, I also see one that is in the one teens and a couple in the 120s range.,She is not bothered by cough or rib pain.  These are complaints, which I often hear about.,Today, I reviewed Dr. Hudyncia's note from psychiatry.  Depression responded very well to Cymbalta, and the plan is to continue it probably for a minimum of 1 year.,She is not having problems with breathing.  No neurologic complaints or troubles.  Pain is generally well managed just with Tylenol.,PHYSICAL EXAMINATION: , Vitals:  As in chart.  The patient is pleasant and cooperative.  She is in no apparent distress.  Her lungs are clear to auscultation and percussion.  Heart sounds regular to me.  Abdomen:  Soft.  Extremities without any edema.  At the rectum, she has a couple of large hemorrhoids, which are not thrombosed and are not tender.,ASSESSMENT AND PLAN:,1.  Hypertension, good control, continue current.,2.  Depression, well treated on Cymbalta.  Continue.,3.  Other issues seem to be doing pretty well.  These include blood pressure, which is well controlled.  We will continue the medicines.  She is clinically euthyroid.  We check that occasionally.  Continue Tylenol.,4.  For the bowels, I will increase the intensity of regimen there.  I have a feeling she would not tolerate either the FiberCon tablets or Metamucil powder in a drink.  I will try her on annulose and see how she does with that.",
 Examination due to blood-borne pathogen exposure., General Medicine, Gen Med Consult - 3 ,"CHIEF COMPLAINT:, Blood-borne pathogen exposure., ,HISTORY OF PRESENT ILLNESS: ,The patient is a 54-year-old right-handed male who works as a phlebotomist and respiratory therapist at Hospital. The patient states that he was attempting to do a blood gas. He had his finger of the left hand over the pulse and was inserting a needle using the right hand. He did have a protective clothing including use of gloves at the time of the incident. As he advanced the needle, the patient jerked away, this caused him to pull out of the arm and inadvertently pricked the tip of his index finger. The patient was seen and evaluated at the emergency department at the time of incident and had baseline studies drawn, and has been followed by employee health for his injury. The source patient was tested for signs of disease and was found to be negative for HIV, but was found to be a carrier for hepatitis C. The patient has had periodic screening including a blood tests and returns now for his final exam., ,REVIEW OF SYSTEMS: ,The patient prior to today has been very well without any signs or symptoms of viral illness, but yesterday he began to experience symptoms of nausea, had an episode of vomiting last night. Has low appetite. There were no fevers, chills, or malaise. No headache. No congestion or cold. No coughing. He had no sore throat. There was no chest pain or troubled breathing. He did have abdominal symptoms as described above but no abdominal pain. There were no urinary symptoms. No darkening of the skin or eyes. He had no yellowing or darkening of the urine. He had no rash to the skin. There was no local infection at the side of the fingerstick. All other systems were negative., ,PAST MEDICAL HISTORY: ,Significant for degenerative disc disease in the back., ,MEDICATIONS: ,Nexium., ,ALLERGIES:, IV contrast., ,CURRENT WORK STATUS:, He continues on full duty work., ,PHYSICAL EXAMINATION:, The patient was awake and alert. He was seated upright. He did not appear ill or toxic, and was well hydrated. His temperature was 97.2 degrees, pulse was 84, respirations 14 and unlabored, and blood pressure 102/70. HEENT exam, the sclerae were clear. Ocular movements were full and intact. His oropharynx was clear. There was no pharyngeal erythema. No tonsillar enlargement. His neck was supple and nontender. He had no masses. There was no adenopathy in his cervical or axillary chain. Breath sounds were clear and equal without wheeze or rales. Heart tones were regular without murmur or gallop. His abdomen was soft, flat, and nontender. There was no enlargement of the liver or spleen. His extremities were without rash or edema. He had normal gait and balance without ataxia., ,ASSESSMENT: ,The patient presents for evaluation after a contaminated needlestick to the index finger. The source patient was tested and found to be negative for HIV. However, he did test positive for hepatitis C. He was described as a carrier without active disease. The patient has been followed with periodic evaluation including blood testing. He has completed a 3 shot series for hepatitis B and had titers drawn that showed protected antibodies. He also was up-to-date on his immunization including tetanus. The patient has been well during this time except for the onset of a intestinal illness being investigated with some squeakiness and vomiting. He had no other symptoms that were suggestive of acute hepatitis. His abdominal exam was normal. He had no generalized lymphadenopathy and no fever. Blood tests were drawn on 02/07/2005. The results of which were reviewed with the patient. His liver function test was normal at 18. His hepatitis C and HIV, both of which were negative. He had no local signs of infection, and otherwise has been doing well except for his acute intestinal illness as described above., ,IMPRESSION:, Blood-borne pathogen exposure secondary to contaminated needlestick., ,PLAN: ,The patient is now six months out from his injury. He had negative lab studies. There were no physical findings that were suggestive of disease transmission. He was counseled on ways to prevent exposure in the future including use of protective gear including gloves, which he states that he always does. He was counseled that ways to prevent transmission or exposure to intimate contacts., ,WORK STATUS:, He was released to regular work., ,CONDITION: ,He was reassured that no signs of disease transmission had occurred as result of his injury. He therefore was found to be medically stationary without signs of impairment of today's date.",
 Patient presents complaining of abdominal pain and discomfort for 3 weeks., General Medicine, Gen Med Consult - 26 ,"CHIEF COMPLAINT:, Abdominal pain and discomfort for 3 weeks.,HISTORY OF PRESENT ILLNESS:, ,The patient is a 38 year old white female with no known medical problems who presents complaining of abdominal pain and discomfort for 3 weeks. She had been in her normal state of health when she started having this diffuse abdominal pain and discomfort which is mostly located in the epigastrium and right upper quadrant. She also complains of indigestion and right scapular pain during this same period. None of these complaints are alleviated or aggravated by food. She denies any NSAIDs use. The patient went to an outside hospital where a right upper quadrant ultrasound showed no gallbladder disease, but was suspicious for a liver mass. A CT and MRI of the abdomen and pelvis showed a 12.5 X 10.9 X 11.1 cm right suprarenal mass and a 7.1 X 5.4 X 6.5 cm intrahepatic mass in the region of the dome of the liver. CT of the chest revealed multiple small (<5 mm) bilateral lung nodules. Total body bone scan had no abnormal uptake. She was transferred to Methodist for further care.,The patient reports having a good appetite and denies any weight loss. She denies having any fever or chills. She has noticed increasing dyspnea with moderate exercise, but not at rest. She denies having palpitations. She occasionally has nausea, but no vomiting, constipation, or diarrhea. Over the last 2 months, she has noticed increasing facial hair and a mustache.,There is an extensive family history of colon and other cancers in her family. She was told there is a genetic defect in her family but cannot recall the name of the syndrome. She had a colonoscopy and a polyp removed at the age of 14 years old. Her last colonoscopy was 2 months ago and was unremarkable.,PAST MEDICAL HISTORY :, None.  No history of hypertension, diabetes, heart disease, liver disease or cancer.,PAST SURGICAL HISTORY:, Bilateral tubal ligation in 2001, colon polyp removed at 14 years old.,GYN HISTORY:, Gravida 2, Para 2, Ab 0. Menstrual periods have been regular, last menstrual period almost 1 month ago. No menorrhagia. Never had a mammogram. Has yearly Pap smears which have all been normal.,FAMILY HISTORY:, Mother is 61 years old and brother is 39 years old, both alive and well. Father died at 48 of colon cancer and questionable pancreatic cancer. One paternal uncle died at 32 of colon cancer and bile duct cancer. One paternal uncle had colon cancer in his 40s. Thirty cancers are noted on the father’s side of the family, many are colon; two women had breast cancer. The family was told that there is a genetic syndrome in the family, but no one remembers the name of the syndrome.,SOCIAL HISTORY:, No tobacco, alcohol or illicit drug use. Patient is born and raised in Oklahoma . No known exposures. Married with 2 children.,MEDICATION:,  None.,REVIEW OF SYSTEMS:,  No headaches. No visual, hearing, or swallowing difficulties. No cough or hemoptysis. No chest pain, PND, orthopnea. No changes in bowel or urinary habits. Otherwise, as stated in HPI.,PHYSICAL EXAM:,VS: T 97.6 BP 121/85 P 84 R 18 O2 Sat 100% on room air,GEN: Pleasant, thin woman in mild distress secondary to abdominal pain and discomfort.,HEENT: Pupils equally round and reactive to light. Extra-ocular movements intact. Anicteric. Sclerae clear. Pink conjunctiva. Moist mucous membranes. No oropharyngeal lesions.,NECK: Supple, no masses, jugular venous distention or bruits.,LUNGS: Clear to auscultation bilaterally.,HEART: Regular rate and rhythm. No murmurs, gallops, rubs.,BREASTS: Symmetric, no skin changes, no discharge, no masses,ABDOMEN: Soft with active bowel sounds. There is minimal diffuse tenderness on examination. No masses palpated. There is fullness in the right upper quadrant with negative Murphy’s sign. No rebound or guarding. The liver span is 12 cm by percussion, but not palpable below the costal margin. No splenomegaly.,PELVIC: not done,EXT: No clubbing, cyanosis, or edema. 2+ pulses bilaterally.,NEURO: Cranial nerves intact. 2+ DTRs bilaterally and symmetrically. Motor strength and sensation within the normal limits.,LYMPH: No cervical, axillary, or inguinal lymph nodes palpated,SKIN: warm, no rashes, no lesions; no tattoos,STUDIES:,CT Chest:  Multiple bilateral small (<5 mm) pulmonary nodules, no mediastinal mass or hilar adenopathy.,MRI Abdomen: 12.5 x 10.9 x 11.1 cm suprarenal mass, 7.1 x 5.4 x 6.5 cm intrahepatic lesion in the region of the dome of the liver, abnormal signal intensity within the inferior vena cava at the level of porta hepatic worrisome for thrombus.,Total Body Bone Scan: No abnormal uptake.,HOSPITAL COURSE:, ,The patient was transferred from an outside hospital for further workup and management. She was taken to the Operating Room for abdominal exploration. A liver biopsy was done.",
" Nausea, vomiting, diarrhea, and fever.", General Medicine, Gen Med Consult - 27 ,"CHIEF COMPLAINT: , Nausea, vomiting, diarrhea, and fever.,HISTORY OF PRESENT ILLNESS: , This patient is a 76-year-old woman who was treated with intravenous ceftriaxone and intravenous clindamycin at a care facility for pneumonia.  She has developed worsening confusion, fever, and intractable diarrhea.  She was brought to the emergency department for evaluation.  Diagnostic studies in the emergency department included a CBC, which revealed a white blood cell count of 23,500, and a low potassium level of 2.6.  She was admitted to the hospital for treatment of profound hypokalemia, dehydration, intractable diarrhea, and febrile illness.,PAST MEDICAL HISTORY: , Recent history of pneumonia, urosepsis, dementia, amputation, osteoporosis, and hypothyroidism.,MEDICATIONS:  ,Synthroid, clindamycin, ceftriaxone, Remeron, Actonel, Zanaflex, and hydrocodone.,SOCIAL HISTORY: , The patient has been residing at South Valley Care Center.,REVIEW OF SYSTEMS: , The patient is unable answer review of systems.,PHYSICAL EXAMINATION:,GENERAL:  This is a very elderly, cachectic woman lying in bed in no acute distress.,HEENT:  Examination is normocephalic and atraumatic.  The pupils are equal, round and reactive to light and accommodation.  The extraocular movements are full.,NECK:  Supple with full range of motion and no masses.,LUNGS:  There are decreased breath sounds at the bases bilaterally.,CARDIOVASCULAR:  Regular rate and rhythm with normal S1 and S2, and no S3 or S4.,ABDOMEN:  Soft and nontender with no hepatosplenomegaly.,EXTREMITIES:  No clubbing, cyanosis or edema.,NEUROLOGIC:  The patient moves all extremities but does not communicate.,DIAGNOSTIC STUDIES: , The CBC shows a white blood cell count of 23,500, hemoglobin 13.0, hematocrit 36.3, and platelets 287,000.  The basic chemistry panel is remarkable for potassium 2.6, calcium 7.5, and albumin 2.3.,IMPRESSION/PLAN:,1.  Elevated white count.  This patient is admitted to the hospital for treatment of a febrile illness.  There is concern that she has a progression of pneumonia.  She may have aspirated.  She has been treated with ceftriaxone and clindamycin.  I will follow her oxygen saturation and chest x-ray closely.  She is allergic to penicillin.  Therefore, clindamycin is the appropriate antibiotic for possible aspiration.,2.  Intractable diarrhea.  The patient has been experiencing intractable diarrhea.  I am concerned about Clostridium difficile infection with possible pseudomembranous colitis.  I will send her stool for Clostridium difficile toxin assay.  I will consider treating with metronidazole.,3.  Hypokalemia.  The patient's profound hypokalemia is likely secondary to her diarrhea.  I will treat her with supplemental potassium.,4.  DNR status:  I have ad a discussion with the patient's daughter, who requests the patient not receive CPR or intubation if her clinical condition or of the patient does not respond to the above therapy.  ,", 
" Patient complaining of headaches, neck pain, and lower back pain over the last 2-3 weeks.", General Medicine, Gen Med Consult - 24 ,"CHIEF COMPLAINT:, Headache and pain in the neck and lower back.,HISTORY OF PRESENT ILLNESS:, The patient is a 34 year old white man with AIDS (CD4 -67, VL -341K) and Castleman’s Disease who presents to the VA Hospital complaining of headaches, neck pain, and lower back pain over the last 2-3 weeks. He was hospitalized 3 months prior to his current presentation with abdominal pain and diffuse lymphadenopathy. Excisional lymph node biopsy during that admission showed multicentric Castleman’s Disease. He was started on cyclophosphamide and prednisone and his lymphadenopathy dramatically improved. His hospitalization was complicated by the development of acute renal failure from tumor lysis syndrome and he required hemodialysis for only a few sessions. The patient was discharged on HAART and later returned for 2 cycles of modified CHOP chemotherapy.,Approximately five weeks prior to his current presentation, the patient was involved in a motor vehicle accident at 40 mph. He said he was not wearing his seatbelt and had hit his head on the roof of the car. He did not lose consciousness. The patient went to the VA ER but left against medical advice prior to being fully evaluated. Records showed that the patient had complained of some neck soreness but he was able to move his neck without any difficulty.,Two weeks later, the patient started having headaches, neck and lower back pain during a road trip with his family to Mexico . He returned to Houston and approximately one week prior to admission, the patient presented to the VA ER for further evaluation. Spinal films were unremarkable and the patient was sent home on pain medications with a diagnosis of muscle strain. The patient followed up with his primary care physician and was admitted for further workup.,On the day of admission, the patient complains of severe pain that is worse in the lower back than in the neck. The pain is 7-8 out of 10 and does not radiate. He also complains of diffuse headaches and intermittent blurriness of his vision. He complains of having a very stiff neck that hurts when he bends it. He denies any fevers, chills, or night sweats. He denies any numbness or tingling of his extremities and he denies any bowel or bladder incontinence. None of the medications that he takes provides adequate relief of his pain.,Regarding his AIDS and Castleman’s Disease, his lymphadenopathy have completely resolved by physical exam. He no longer has any of the symptoms from his previous hospitalization. He is scheduled to have his next cycle of chemotherapy during the week of his current admission. He has been noncompliant with his HAART and has been off the medications for >3 weeks.,Past Medical History:, HIV diagnosed 11 years ago. No history of opportunistic infections. Recently diagnosed with Castleman’s Disease (9/03) from excisional lymph node biopsy s/p cyclophosphamide/prednisone ( 9/25/03 ) and modified CHOP ( 10/15/03 , 11/10/03 ). Last CD4 count is 67 and viral load is 341K (9/03). Currently is off HAART x 3 weeks because of noncompliance.,PAST SURGICAL HISTORY:, Excisional lymph node biopsy (9/03).,FAMILY HISTORY:, There was no history of hypertension, coronary artery disease, stroke, cancer or diabetes.,SOCIAL HISTORY:, Patient is single and he lives alone. He is heterosexual and has a history of sexual encounter with prostitutes in Japan. He works as a plumber over the last 5 years. He smokes and drinks occasionally and denies any history of IV drug use. No blood transfusion. No history of incarceration. Recently traveled to Mexico .,MEDICATION:, Tylenol #3 q6h prn, ibuprofen 800 mg q8h prn, methocarbamol 750 mg qid.,ALLERGIES:, ,  Sulfa (rash).,REVIEW OF SYSTEMS:, The patient complains of feeling weak and fatigued. He has no appetite over the past week and has lost 8 pounds during this period. No chest pain, palpitations, shortness of breath or coughing. He denies any nausea, vomiting, or abdominal pain. No focal neuro deficits. Otherwise, as stated in HPI.,PHYSICAL EXAM:,VS: T 98 BP 121/89 P 80 R 20 O2 Sat 100% on room air.,Ht: 5'9"" Wt: 159 lbs.,GEN: Well developed man in no apparent distress. Alert and Oriented X 3.,HEENT: Pupils equally round and reactive to light. Extra-ocular movements intact. Anicteric. Papilledema present bilaterally. Moist mucous membranes. No oropharyngeal lesions.,NECK: Stiff, difficulty with neck flexion; no lymphadenopathy,LUNGS: Clear to auscultation bilaterally.,CV: Regular rate and rhythm. No murmurs, gallops, rubs.,ABD: Soft with active bowel sounds. Nontender/Nondistended. No rebound or guarding. No hepatosplenomegaly.,EXT: No clubbing, cyanosis, or edema. 2+ pulses bilaterally.,BACK: No point tenderness to spine,NEURO: Cranial nerves intact. 2+ DTRs bilaterally and symmetrically. Motor strength and sensation within the normal limits.,LYMPH: No cervical, axillary, or inguinal lymph nodes palpated,SKIN: warm, no rashes, no lesions,STUDIES:,C-spine/lumbosacral spine (11/30):  Within normal limits.,CXR (12/8):  Normal heart size, no infiltrate. Hila and mediastinum are not enlarged.,CT Head with and without contrast (12/8): Ventriculomegaly and potentially minor hydrocephalus. Otherwise normal CT scan of the brain. No evidence of abnormal enhancement of the brain or mass lesions within the brain or dura.,HOSPITAL COURSE:,  The patient was admitted to the medicine floor and a lumbar puncture was performed. The opening pressure was greater than 55. The CSF results are shown in the table. A diagnostic study was sent.",
" A 2-year-old little girl with stuffiness, congestion, and nasal drainage. - Allergic rhinitis", General Medicine, Gen Med Consult - 21 ,"SUBJECTIVE:,  The patient is a 2-year-old little girl who comes in with concerns about stuffiness, congestion and nasal drainage.  She does take Zyrtec on a fairly regular basis.  Mom is having some allergy trouble herself right now.  She does not know her colors.  She knows some of her shapes.  She speaks in sentences.  She is not showing much interest in the potty.  She is in the 80th percentile for height and weight, and still over 95th percentile for head circumference.  Mom has no other concerns.,ALLERGIES:,  Eggs and peanuts.,OBJECTIVE:,General:  Alert, very talkative little girl.,HEENT:  TMs clear and mobile.  Eyes:  PERRL.  Fundi benign.  Pharynx clear.  Mouth moist.  Nasal mucosa is pale with clear discharge.,Neck:  Supple without adenopathy.,Heart:  Regular rate and rhythm without murmur.,Lungs:  Clear.  No tachypnea, wheezing, rales or retractions.,Abdomen:  Soft and nontender without mass or organomegaly.,GU:  Normal female genitalia.  Tanner stage I.,Extremities:  No clubbing, cyanosis or edema.  Pulses 2+ and equal.,Hips:  Intact.,Neurological:  Normal.  DTRs are 2+.  Gait was normal.,Skin:  Warm and dry.  No rashes noted.,ASSESSMENT:,  Allergic rhinitis.  Otherwise healthy 2-year-old young lady.,PLAN:,  In addition to her Zyrtec, I put her on Nasonex spray one spray each nostril daily.  If this works for her, certainly she can do it through the ragweed season.  Otherwise she is doing well.  I talked about ways to improve her potty training.  She is a very good eater.  I will see her yearly or p.r.n.  Unfortunately she is not able to get the flu shot due to her egg allergy.","general medicine, allergic rhinitis, nasal drainage, stuffiness, congestion, drainage,"
 The patient brought in by EMS with a complaint of a decreased level of consciousness., General Medicine, Gen Med Consult - 28 ,"HISTORY OF PRESENT ILLNESS: , The patient is an 85-year-old male who was brought in by EMS with a complaint of a decreased level of consciousness.  The patient apparently lives with his wife and was found to have a decreased status since the last one day.  The patient actually was seen in the emergency room the night before for injuries of the face and for possible elderly abuse.  When the Adult Protective Services actually went to the patient's house, he was found to be having decreased consciousness for a whole day by his wife.  Actually the night before, he fell off his wheelchair and had lacerations on the face.  As per his wife, she states that the patient was given an entire mg of Xanax rather than 0.125 mg of Xanax, and that is why he has had decreased mental status since then.  The patient's wife is not able to give a history.  The patient has not been getting Sinemet and his other home medications in the last 2 days.  ,PAST MEDICAL HISTORY:  ,Parkinson disease.,MEDICATIONS:,  Requip, Neurontin, Sinemet, Ambien, and Xanax.,ALLERGIES: , No known drug allergies.,SOCIAL HISTORY: , The patient lives with his wife.,PHYSICAL EXAMINATION:,GENERAL:","general medicine, level of consciousness, parkinson disease, altered mental status, dehydration, elderly abuse, decreased level of consciousness, ems, parkinson, consciousness, xanax, sinemet, decreased, "
 Patient with a past medical history of atrial fibrillation and arthritis complaining of progressively worsening shortness of breath., General Medicine, Gen Med Consult - 25 ,"CHIEF COMPLAINT:, ""I can’t walk as far as I used to."",HISTORY OF PRESENT ILLNESS:, The patient is a 66-year-old African American gentleman with a past medical history of atrial fibrillation and arthritis who presented c/o progressively worsening shortness of breath. The patient stated that he had been in his usual state of health six years ago at which time he had been able to walk more than five blocks without difficulty. Approximately five years prior to admission, he began to note a decreased tolerance to exercise. This progressed with a gradual worsening in his functional capacity such that he is presently unable to walk for more than 25 feet. Over the two years prior to admission, he has been having a gradually worsening non-productive cough associated with shortness of breath. His shortness of breath is worse when he lies flat, and he periodically wakes at night gasping for air. He sleeps with three pillows. He has also noted swelling of his legs and states that he has had two episodes of syncope at home for which he has not sought medical attention. Approximately one month prior to admission he was seen in an outside clinic where he states that he was started on medications for heart failure. He stated that he had had a brother who died of heart failure at age 72.,He did report that he had had an episode of hemoptysis approximately 2 years prior to admission for which he did not seek medical attention. He denied any history of chest pain and did not report any history of myocardial infarction. He denied fever, chills, and night sweats. He denied diarrhea, dysuria, hematuria, urgency and frequency. He denied any history of rash. He had been diagnosed with osteoarthritis of the knees and had undergone arthroscopy years prior to admission.,PAST MEDICAL HISTORY :,  Atrial fibrillation on anticoagulation, osteoarthritis of the knees bilaterally, h/o retinal tear.,PAST SURGICAL HISTORY :,  Hernia repair, bilateral arthroscopic evaluation, h/o surgical correction of retinal tear.,FAMILY HISTORY:, The Father of the patient died at age 69 with a CVA. The Mother of the patient died at age 79 when her ""heart stopped"". There were 12 siblings. Four siblings have died, two due to diabetes, one cause unknown, and one brother died at age 72 with heart failure. The patient has four children with no known medical problems.,SOCIAL HISTORY:, The patient retired one year PTA due to his disability. He was formerly employed as an electronic technician for the US postal service. The patient lives with his wife and daughter in an apartment. He denied any smoking history. He used to drink alcohol rarely but stopped entirely with the onset of his symptoms. He denied any h/o drug abuse. He denied any recent travel history.,MEDICATIONS:,1.  Spironolactone 25 mg po qd.,2.  Digoxin 0.125 mg po qod.,3.  Coumadin 3 mg Monday and Tuesday and 4.5 mg Saturday and Sunday.,4.  Metolazone 10 mg po qd.,5.  Captopril 25 mg po tid.,6.  Torsemide 40 mg po qam and 20 mg po qpm.,7.  Carvedilol 3.125 mg po bid.,ALLERGIES:, No known drug allergies.,REVIEW OF SYSTEMS:, No headaches. No visual, hearing, or swallowing difficulties. No changes in bowel or urinary habits.,PHYSICAL EXAM:,Temperature: 98.4 degrees Fahrenheit.,Blood pressure: 134/84.,Heart rate: 98 beats per minute.,Respiratory rate: 18 breaths per minute.,Pulse oximetry: 92% on 2L O 2 via nasal canula.,GEN: Elderly gentleman lying in bed in mild respiratory distress, thin, tired appearing, wife and daughter present at bedside, articulate.,HEENT: The right eye was opacified. The left pupil was reactive to light. There was mild bitemporal wasting. The tongue was moist. There was no lymphadenopathy. The sclerae were anicteric. The oropharynx was clear. The conjunctivae were pink.,NECK: The neck was supple with 15 cm of jugular venous distension.,HEART: Irregularly irregular. No murmurs, gallops, rubs. No displaced PMI.,LUNGS: Breath sounds were absent over two thirds of the right lower lung field. There were trace crackles at the left base.,ABDOMEN: Soft, nontender, nondistended, bowel sounds were present. There was no hepatosplenomegaly. No rebound or guarding.,EXT: Bilateral pitting edema to the thighs with diminished peripheral pulses bilaterally.,NEURO: The patient was alert and oriented x three. Cranial nerves were intact. The DTRs were 2+ bilaterally and symmetrically. Motor strength and sensation were within normal limits.,LYMPH: No cervical, axillary, or inguinal lymph nodes were present.,SKIN: Warm, no rashes, no lesions; no tattoos.,MUSCULOSKELETAL: No synovitis. There were no joint deformities. Full range of motion b/l throughout.,STUDIES:,CXR: Large right sided pleural effusion. A small pleural effusion with atelectatic changes are seen on the left. The heart size is borderline.,ECHO: LV size is normal. There is severe concentric LV hypertrophy. Global hypokinesis. LV function is severely depressed. Estimate EF is 20-24%. There is RV hypertrophy. RV size is mildly enlarged. RV function is severely depressed. RV wall motion is severely hypokinetic. LA size is moderately enlarged. RA size is mildly enlarged. Trace aortic regurgitation. Moderate tricuspid regurgitation. Estimated PA systolic pressure is 46-51 mmHg, assuming a mean RAP of 15-20mmHg. Small anterior and posterior pericardial effusion.,HOSPITAL COURSE:, The patient was admitted to the hospital for workup and management. A diagnostic procedure was performed.",
 A 12-year-old young man with sinus congestion., General Medicine, Gen Med Consult - 22 ,"SUBJECTIVE:,  This is a 12-year-old young man who comes in with about 10 days worth of sinus congestion.  He does have significant allergies including ragweed.  The drainage has been clear.  He had a little bit of a headache yesterday.  He has had no fever.  No one else is ill at home currently.,CURRENT MEDICATIONS:,  Advair and Allegra.  He has been taking these regularly.  He is not sure the Allegra is working for him anymore.  He does think though better than Claritin.,PHYSICAL EXAM:,General:  Alert young man in no distress.,HEENT:  TMs clear and mobile.  Pharynx clear.  Mouth moist.  Nasal mucosa pale with clear discharge.,Neck:  Supple without adenopathy.,Heart:  Regular rate and rhythm without murmur.,Lungs:  Lungs clear, no tachypnea, wheezing, rales or retractions.,Abdomen:  Soft, nontender, without masses or splenomegaly.,ASSESSMENT:,  I think this is still his allergic rhinitis rather than a sinus infection.,PLAN:,  Change to Zyrtec 10 mg samples were given.  He is not using nasal spray, but he has some at home.  He should restart this.  Continue to watch his peak flows to make sure his asthma does not come under poor control.  Call if any further problems.","general medicine, allergic rhinitis, sinus infection, sinus congestion, congestion, sinus"
 Patient in with mom for possible ear infection., General Medicine, Gen Med Consult - 23 ,"SUBJECTIVE:,  Mom brings the patient in today for possible ear infection.  He is complaining of left ear pain today.  He was treated on 04/14/2004, with amoxicillin for left otitis and Mom said he did seem to get better but just started complaining of the left ear pain today.  He has not had any fever but the congestion has continued to be very thick and purulent.  It has never really resolved.  He has a loose, productive-sounding cough but not consistently and not keeping him up at night.  No wheezing or shortness of breath.,PAST MEDICAL HISTORY:,  He has had some wheezing in the past but nothing recently.,FAMILY HISTORY: , All siblings are on antibiotics for ear infections and URIs.,OBJECTIVE:,General:  The patient is a 5-year-old male.  Alert and cooperative.  No acute distress.,Neck:  Supple without adenopathy.,HEENT:  Ear canals clear.  TMs, bilaterally, have distorted light reflexes but no erythema.  Gray in color.  Oropharynx pink and moist with a lot of postnasal discharge.  Nares are swollen and red.  Thick, purulent drainage.  Eyes are a little puffy.,Chest:  Respirations regular, nonlabored.,Lungs:  Clear to auscultation throughout.,Heart:  Regular rhythm without murmur.,Skin:  Warm, dry, pink.  Moist mucus membranes.  No rash.,ASSESSMENT:,  Ongoing purulent rhinitis.  Probable sinusitis and serous otitis.,PLAN:,  Change to Omnicef two teaspoons daily for 10 days.  Frequent saline in the nose.  Also, there was some redness around the nares with a little bit of yellow crusting.  It appeared to be the start of impetigo, so hold off on the Rhinocort for a few days and then restart.  Use a little Neosporin for now.","general medicine, ear infection, productive-sounding cough, purulent rhinitis, serous otitis, sinusitis, wheezing, ear, amoxicillin,"
 Initial clinic visit for foreign body in left eye., General Medicine, Gen Med Consult - 2 ,"HISTORY OF PRESENT ILLNESS:, This is the initial clinic visit for a 41-year-old worker who is seen for a foreign body to his left eye.  He states that he was doing his normal job when he felt a foreign body sensation.  He attempted to flush this at work, but has had persistent pain which has progressively worsened throughout the course of the day.  He has no significant blurriness of vision or photophobia.",
" An 18-month-old white male here with his mother for complaint of intermittent fever for the past five days. - Allergic rhinitis, fever history, sinusitis resolved, and teething.", General Medicine, Gen Med Consult - 17 ,"CHIEF COMPLAINT:,  Fever.,HISTORY OF PRESENT ILLNESS:,  This is an 18-month-old white male here with his mother for complaint of intermittent fever for the past five days.  Mother states he just completed Amoxil several days ago for a sinus infection.  Patient does have a past history compatible with allergic rhinitis and he has been taking Zyrtec serum.  Mother states that his temperature usually elevates at night.  Two days his temperature was 102.6.  Mother has not taken it since, and in fact she states today he seems much better.  He is cutting an eye tooth that causes him to be drooling and sometimes fussy.  He has had no vomiting or diarrhea.  There has been no coughing.  Nose secretions are usually discolored in the morning, but clear throughout the rest of the day.  Appetite is fine.,PHYSICAL EXAMINATION:,General:  He is alert in no distress.,Vital Signs:  Afebrile.,HEENT:  Normocephalic, atraumatic.  Pupils equal, round and react to light.  TMs are clear bilaterally.  Nares patent.  Clear secretions present.  Oropharynx is clear.,Neck:  Supple.,Lungs:  Clear to auscultation.,Heart:  Regular, no murmur.,Abdomen:  Soft.  Positive bowel sounds.  No masses.  No hepatosplenomegaly.,Skin:  Normal turgor.,ASSESSMENT:,1.  Allergic rhinitis.,2.  Fever history.,3.  Sinusitis resolved.,4.  Teething.,PLAN:,  Mother has been advised to continue Zyrtec as directed daily.  Supportive care as needed.  Reassurance given and he is to return to the office as scheduled.","general medicine, sinusitis, fever, intermittent fever, allergic rhinitis, fever history, teething,"
" 2-year-old female who comes in for just rechecking her weight, her breathing status, and her diet.", General Medicine, Gen Med Consult - 19 ,"SUBJECTIVE:,  This is a 2-year-old female who comes in for just rechecking her weight, her breathing status, and her diet.  The patient is in foster care, has a long history of the prematurity, born at 22 weeks.  She has chronic lung disease, is on ventilator, but doing sprints, has been doing very well, is up to 4-1/2 hours sprints twice daily and may go up 15 minutes every three days or so; which she has been tolerating fairly well as long as they kind of get her distracted towards the end, otherwise, she does get sort of tachypneic.  She is on 2-1/2 liters of oxygen and does require that.  Her diet has been fluctuating.  They have been trying to figure out what works best with her.  She has been on some Pediasure for the increased calories but that really makes her distended in the abdomen and constipates her.  They have been doing more pureed foods and that seems to loosen her up, so they have been doing more Isomil 24 cal and baby foods and not so much Pediasure.  She was hospitalized a couple of weeks back for the distension she had in the abdomen.  Dr. XYZ has been working with her G-tube, increasing her Mic-key button size, but also doing some silver nitrate applications, and he is going to evaluate her again next week, but they are happy with the way her G-tube site is looking.  She also has been seen Dr. Eisenbaum, just got of new pair of glasses this week and sees him in another couple of weeks for reevaluation.,CURRENT MEDICATIONS:,  Flagyl, vitamins, Zyrtec, albuterol, and some Colace.,ALLERGIES TO MEDICINES: , None.,FAMILY SOCIAL HISTORY:,  As mentioned, she is in foster care.  Foster mom is actually going to be out of town for a week the 19th through the 23rd, so she will probably be hospitalized in respite care because there are no other foster care situations that can handle the patient.  Biological Mom and Grandma do visit on Thursdays for about an hour.,REVIEW OF SYSTEMS:,  The patient has been eating fairly well, sleeping well, doing well with her sprints.  A little difficulty with her stools hard versus soft as mentioned with the diet situation up in HPI.,PHYSICAL EXAMINATION:,Vital Signs:  She is 28 pounds 8 ounces today, 33-1/2 inches tall.  She is on 2-1/2 liters, but she is not the vent currently, she is doing her sprints, and her respiratory rate is around 40.,HEENT:  Sclerae and conjunctivae are clear.  TMs are clear.  Nares are patent.  Oropharynx is clear.  Trach site is clear of any signs of infection.,Chest:  Coarse.  She has got little bit of wheezing going on, but she is moving air fairly well.,Abdomen:  Positive bowel sounds and soft.  The G-tube site looks fairly clean today and healthy.  No signs of infection.  Her tone is good.  Capillary refill is less than three seconds.,ASSESSMENT:,  A 2-year-old with chronic lung disease, doing the sprints, some bowel difficulties, also just weight gain issues because of the high-energy expenditure with the sprints that she is doing.,PLAN:,  At this point is to continue with the Isomil and pureed baby foods, a little bit of Pediasure.  They are going to see Dr. XYZ towards the end of this month and follow up with Dr. Eisenbaum.  I would like to see her in approximately six weeks again, but we do need to keep a close check on her weight and call if there are problems beforehand.  She is just doing wonderful progression on her development.  Each time I see her, I am very impressed, that relayed to foster mom.  Approximately 25 minutes spent with the patient, most of it counseling.","general medicine, chronic lung disease, signs of infection, breathing status, foster mom, foster care, pediasure"
" 11-year-old female.  History of congestion, possibly enlarged adenoids.  ", General Medicine, Gen Med Consult - 20 ,"SUBJECTIVE:,  This is an 11-year-old female who comes in for two different things.  1.  She was seen by the allergist.  No allergies present, so she stopped her Allegra, but she is still real congested and does a lot of snorting.  They do not notice a lot of snoring at night though, but she seems to be always like that.  2.  On her right great toe, she has got some redness and erythema.  Her skin is kind of peeling a little bit, but it has been like that for about a week and a half now.,PAST MEDICAL HISTORY:,  Otherwise reviewed and noted.,CURRENT MEDICATIONS:,  None.,ALLERGIES TO MEDICINES:,  None.,FAMILY SOCIAL HISTORY:,  Everyone else is healthy at home.,REVIEW OF SYSTEMS:,  She has been having the redness of her right great toe, but also just a chronic nasal congestion and fullness.  Review of systems is otherwise negative.,PHYSICAL EXAMINATION:,General:  Well-developed female, in no acute distress, afebrile.,HEENT:  Sclerae and conjunctivae clear.  Extraocular muscles intact.  TMs clear.  Nares patent.  A little bit of swelling of the turbinates on the left.  Oropharynx is essentially clear.  Mucous membranes are moist.,Neck:  No lymphadenopathy.,Chest:  Clear.,Abdomen:  Positive bowel sounds and soft.,Dermatologic:  She has got redness along the lateral portion of her right great toe, but no bleeding or oozing.  Some dryness of her skin.  Her toenails themselves are very short and even on her left foot and her left great toe the toenails are very short.,ASSESSMENT:,1.  History of congestion, possibly enlarged adenoids, or just her anatomy.,2.  Ingrown toenail, but slowly resolving on its own.,PLAN:,1.  For the congestion, we will have ENT evaluate.  Appointment has been made with Dr. XYZ for in a couple of days.,2.  I told her just Neosporin for her toe, letting the toenail grow out longer.  Call if there are problems.","general medicine, enlarged adenoids, adenoids, oropharynx, congestion, toenails, toe, "
 Short-term memory loss (probable situational) and anxiety stress issues., General Medicine, Gen Med Consult - 16 ,"CHIEF COMPLAINT:,  Here with a concern of possibly issues of short-term memory loss.  She is under exceeding amount of stress over the last 5 to 10 years.  She has been a widow over the last 11 years.  Her husband died in an MVA from a drunk driver accident.  She had previously worked at the bank in Conway Springs in Norwich and had several other jobs related to accounting or management services.  She does have an MBA in business.  Currently, she works at T-Mobile Customer Service, and there is quite a bit of technical knowledge, deadlines, and stress related to that job as well.  She feels she has trouble at times absorbing all that she needs to learn as far as the computer skills, protocols, customer service issues, etc.  She describes the job is very demanding and high stress.  She denies any history of weakness, lethargy, or dizziness.  No history of stroke.,CURRENT MEDICATIONS:,  Vioxx 25 mg daily, HCTZ 25 mg one-half tablet daily, Zoloft 100 mg daily, Zyrtec 10 mg daily.,ALLERGIES TO MEDICATIONS: , Naprosyn.,SOCIAL HISTORY, FAMILY HISTORY, PAST MEDICAL HISTORY AND SURGICAL HISTORY: , She has had hypertension very well controlled and history of elevated triglycerides.  She has otherwise been generally healthy.  Nonsmoker.  Please see notes dated 06/28/2004.,REVIEW OF SYSTEMS:,  Review of systems is otherwise negative.,PHYSICAL EXAMINATION:,Vital Signs:  Age:  60.  Weight:  192 pounds.  Blood pressure:  134/80.  Temperature:  97.8 degrees.,General:  A very pleasant 60-year-old white female in no acute distress.  Alert, ambulatory and nonlethargic.,HEENT:  PERRLA.  EOMs are intact.  TMs are clear bilaterally.  Throat is clear.,Neck:  Supple.  No cervical adenopathy.,Lungs:  Clear without wheezes or rales.,Heart:  Regular rate and rhythm.,Abdomen:  Soft nontender to palpation.,Extremities:  Moving all extremities well.,IMPRESSION:,1.  Short-term memory loss, probable situational.,2.  Anxiety stress issues.,PLAN:,  Thirty-minute face-to-face appointment in counseling with the patient.  At length discussion on her numerous stress issues which can certainly cause a loss of concentration and inability to learn.  The current job she is at does sound extremely stressful and demanding.  I think her stress reactions to these as far as feeling frustrated are within normal limits.  We did complete a mini mental state exam including clock drawing, sentence writing, signature, etc.  She does score a maximum score of 30/30 and all other tasks were completed without difficulty or any hesitation.  I did spend quite a bit of time reassuring her as well.  She is currently on Zoloft 100 mg which I think is an appropriate dose.  We will have her continue on that.  She did verbalize understanding and that she actually felt better after our discussion concerning these issues.  At some point in time; however, I would possibly recommend job change if this one would persist as far as the stress levels.  She is going to think about that.","general medicine, short-term memory loss, anxiety, short term memory loss, memory loss, stress issues, situational, memory, stress, "
 Complaint of left otalgia (serous otitis) and headache.  History of atopic dermatitis., General Medicine, Gen Med Consult - 14 ,"HISTORY OF PRESENT ILLNESS:,  A 49-year-old female with history of atopic dermatitis comes to the clinic with complaint of left otalgia and headache.  Symptoms started approximately three weeks ago and she was having difficulty hearing, although that has greatly improved.  She is having some left-sided sinus pressure and actually went to the dentist because her teeth were hurting; however, the teeth were okay.  She continues to have some left-sided jaw pain.  Denies any headache, fever, cough, or sore throat.  She had used Cutivate cream in the past for the atopic dermatitis with good results and is needing a refill of that.  She has also had problems with sinusitis in the past and chronic left-sided headache.,FAMILY HISTORY:,  Reviewed and unchanged.,ALLERGIES: , To cephalexin.,CURRENT MEDICATIONS:,  Ibuprofen.,SOCIAL HISTORY:,  She is a nonsmoker.,REVIEW OF SYSTEMS:,  As above.  No nausea, vomiting, or diarrhea.,PHYSICAL EXAMINATION:,General:  A well-developed and well-nourished female, conscious, alert, and in no acute distress.,Vital Signs:  Weight:  121 pounds.  Temperature:  97.9 degrees.,Skin:  Reveals scattered erythematous plaques with some mild lichenification on the nuchal region and behind the knees.,Eyes:  PERRLA.  Conjunctivae are clear.,Ears:  Left TM with some effusion.  Right TM is clear.  Canals are clear.  External auricles are nontender to manipulation.,Nose:  Nasal mucosa is pink and moist without discharge.,Throat:  Nonerythematous.  No tonsillar hypertrophy or exudate.,Neck:  Supple without adenopathy or thyromegaly.,Lungs:  Clear.  Respirations are regular and unlabored.,Heart:  Regular rate and rhythm at rate of 100 beats per minute.,ASSESSMENT:,1.  Serous otitis.,2.  Atopic dermatitis.,PLAN:,1.  Nasacort AQ two sprays each nostril daily.,2.  Duraphen II one b.i.d.,3.  Refills Cutivate cream 0.05% to apply to affected areas b.i.d.  Recheck p.r.n.",
 1-year-old male who comes in with a cough and congestion.  Clinical sinusitis and secondary cough., General Medicine, Gen Med Consult - 18 ,"SUBJECTIVE:,  This is a 1-year-old male who comes in with a cough and congestion for the past two to three weeks.  Started off as a congestion but then he started coughing about a week ago.  Cough has gotten worsen.  Mother was also worried.  He had Pop Can just three days ago and she never found the top of that and was wondering if he had swallowed that, but his breathing has not gotten worse since that happened.  He is not running any fevers.,PAST MEDICAL HISTORY:,  Otherwise, reviewed.  Fairly healthy.,CURRENT MEDICATIONS:,  None.,ALLERGIES TO MEDICINES:,  None.,FAMILY SOCIAL HISTORY:,  The sister is in today with clinical sinusitis.  Mother and father have been healthy.,REVIEW OF SYSTEMS:,  He has been congested for about three weeks ago.  Coughing now but no fevers.  No vomiting.  Review of systems is otherwise negative.,PHYSICAL EXAMINATION:,General:  Well-developed male in no acute distress, afebrile.,Vital Signs:  Weight:  22 pounds 6 ounces.,HEENT:  Sclerae and conjunctivae are clear.  Extraocular muscles are intact.  TMs are clear.  Nares are very congested.  Oropharynx has drainage in the back of the throat.  Mucous membranes are moist.  Mild erythema though.,Neck:  Some shotty lymphadenopathy.  Full range of motion.  Supple.,Chest:  Clear.  No crackles.  No wheezes.,Cardiovascular:  Regular rate and rhythm.  Normal S1, S2.,Abdomen:  Positive bowel sounds and soft.,Dermatologic:  Clear.  Tone is good.  Capillary refill less than 3 seconds.,RADIOLOGY:,  Chest x-ray:  No foreign body noted as well.  No signs of pneumonia.,ASSESSMENT:,  Clinical sinusitis and secondary cough.,PLAN:,  Amoxicillin a teaspoon twice daily for 10 days.  Plenty of fluids.  Tylenol and Motrin p.r.n., as well as oral decongestant and if coughing is not improving.","general medicine, congestion, cough, sinusitis and secondary cough, cough and congestion, secondary cough, clinical sinusitis, male, sinusitis, "
 Checkup - Joints hurting all over - Arthralgias that are suspicious for inflammatory arthritis., General Medicine, Gen Med Consult - 10 ,"CHIEF COMPLAINT:,  Joints are hurting all over and checkup.,HISTORY OF PRESENT ILLNESS:,  A 77-year-old white female who is having more problems with joint pain.  It seems to be all over decreasing her mobility, hands and wrists.  No real swelling but maybe just a little more uncomfortable than they have been.  The Daypro generic does not seem to be helping at all.  No fever or chills.  No erythema.,She actually is doing better.  Her diarrhea now has settled down and she is having less urinary incontinence, less pedal edema.  Blood sugars seem to be little better as well.,The patient also has gotten back on her Zoloft because she thinks she may be depressed, sleeping all the time, just not herself and really is disturbed that she cannot be more mobile in things.  She has had no polyuria, polydipsia, or other problems.  No recent blood pressure checks.,PAST MEDICAL HISTORY:,  Little over a year ago, the patient was found to have lumbar discitis and was treated with antibiotics and ended up having debridement and instrumentation with Dr. XYZ and is doing really quite well.  She had a pulmonary embolus with that hospitalization.,PAST SURGICAL HISTORY:,  She has also had a hysterectomy, salpingoophorectomy, appendectomy, tonsillectomy, two carpal tunnel releases.  She also has had a parathyroidectomy but still has had some borderline elevated calcium.  Also, hypertension, hyperlipidemia, as well as diabetes.  She also has osteoporosis.,SOCIAL HISTORY:,  The patient still smokes about a third of a pack a day, also drinks only occasional alcoholic drinks.  The patient is married.  She has three grown sons, all of which are very successful in professional positions.  One son is a gastroenterologist in San Diego, California.,MEDICATIONS:,  Nifedipine-XR 90 mg daily, furosemide 20 mg half tablet b.i.d., lisinopril 20 mg daily, gemfibrozil 600 mg b.i.d., Synthroid 0.1 mg daily, Miacalcin one spray in alternate nostrils daily, Ogen 0.625 mg daily, Daypro 600 mg t.i.d., also Lortab 7.5 two or three a day, also Flexeril occasionally, also other vitamin.,ALLERGIES: , She had some adverse reactions to penicillin, sulfa, perhaps contrast medium, and some mycins.,FAMILY HISTORY:,  As far as heart disease there is none in the family.  As far as cancer two cousins had breast cancer.  As far as diabetes father and grandfather had type II diabetes.  Son has type I diabetes and is struggling with that at the moment.,REVIEW OF SYSTEMS:,General:  No fever, chills, or night sweats.  Weight stable.,HEENT:  No sudden blindness, diplopia, loss of vision, i.e., in one eye or other visual changes.  No hearing changes or ear problems.  No swallowing problems or mouth lesions.,Endocrine:  Hypothyroidism but no polyuria or polydipsia.  She watches her blood sugars.  They have been doing quite well.,Respiratory:  No shortness of breath, cough, sputum production, hemoptysis or breathing problems.,Cardiovascular:  No chest pain or chest discomfort.  No paroxysmal nocturnal dyspnea, orthopnea, palpitations, or heart attacks.,GI:  As mentioned, has had diarrhea though thought to be possibly due to Clostridium difficile colitis that now has gotten better.  She has had some irritable bowel syndrome and bowel abnormalities for years.,GU:  No urinary problems, dysuria, polyuria or polydipsia, kidney stones, or recent infections.  No vaginal bleeding or discharge.,Musculoskeletal:  As above.,Hematological:  She has had some anemia in the past.,Neurological:  No blackouts, convulsions, seizures, paralysis, strokes, or headaches.,PHYSICAL EXAMINATION:,Vital Signs:  Weight is 164 pounds.  Blood pressure:  140/64.  Pulse:  72.  Blood pressure repeated by me with the patient sitting taken on the right arm is 148/60, left arm 136/58; these are while sitting on the exam table.,General:  A well-developed pleasant female who is comfortable in no acute distress otherwise but she does move slowly.,HEENT:  Skull is normocephalic.  TMs intact and shiny with good auditory acuity to finger rub.  Pupils equal, round, reactive to light and accommodation with extraocular movements intact.  Fundi benign.  Sclerae and conjunctivae were normal.,Neck:  No thyromegaly or cervical lymphadenopathy.  Carotids are 2+ and equal bilaterally and no bruits present.,Lungs:  Clear to auscultation and percussion with good respiratory movement.  No bronchial breath sounds, egophony, or rales are present.,Heart:  Regular rhythm and rate with no murmurs, gallops, rubs, or enlargement.  PMI normal position.  All pulses are 2+ and equal bilaterally.,Abdomen:  Obese, soft with no hepatosplenomegaly or masses.,Breasts:  No predominant masses, discharge, or asymmetry.,Pelvic Exam:  Normal external genitalia, vagina and cervix.  Pap smear done.  Bimanual exam shows no uterine enlargement and is anteroflexed.  No adnexal masses or tenderness.  Rectal exam is normal with soft brown stool Hemoccult negative.,Extremities:  The patient does appear to have some doughiness of all of the MCP joints of the hands and the wrists as well.  No real erythema.  There is no real swelling of the knees.  No new pedal edema.,Lymph nodes:  No cervical, axillary, or inguinal adenopathy.,Neurological:  Cranial nerves II-XII are grossly intact.  Deep tendon reflexes are 2+ and equal bilaterally.  Cerebellar and motor function intact in all extremities.  Good vibratory and positional sense in all extremities and dermatomes.  Plantar reflexes are downgoing bilaterally.,LABORATORY:  ,CBC shows a hemoglobin of 10.5, hematocrit 35.4, otherwise normal.  Urinalysis is within normal limits.  Chem profile showed a BUN of 54, creatinine 1.4, glucose 116, calcium was 10.8, cholesterol 198, triglycerides 171, HDL 43, LDL 121, TSH is normal, hemoglobin A1C is 5.3.,ASSESSMENT:,1.  Arthralgias that are suspicious for inflammatory arthritis, but certainly seems to be more active and bothersome.  I think we need to look at this more closely.,2.  Diarrhea that seems to have resolved.  Whether this is related to the above is unclear.,3.  Diabetes mellitus type II, really fairly well controlled.",
 Feeling weak and shaky - Dyspnea on exertion and history of diabetes, General Medicine, Gen Med Consult - 12 ,"CHIEF COMPLAINT:,  Weak and shaky.,HISTORY OF PRESENT ILLNESS:,  The patient is a 75-year-old, Caucasian female who comes in today with complaint of feeling weak and shaky.  When questioned further, she described shortness of breath primarily with ambulation.  She denies chest pain.  She denies cough, hemoptysis, dyspnea, and wheeze.  She denies syncope, presyncope, or palpitations.  Her symptoms are fairly longstanding but have been worsening as of late.,PAST MEDICAL HISTORY:,  She has had a fairly extensive past medical history but is a somewhat poor historian and is unable to provide details about her history.  She states that she has underlying history of heart disease but is not able to elaborate to any significant extent.  She also has a history of hypertension and type II diabetes but is not currently taking any medication.  She has also had a history of pulmonary embolism approximately four years ago, hyperlipidemia, peptic ulcer disease, and recurrent urinary tract infections.  Surgeries include an appendectomy, cesarean section, cataracts, and hernia repair.,CURRENT MEDICATIONS:,  She is on two different medications, neither of which she can remember the name and why she is taking it.,ALLERGIES: , She has no known medical allergies.,FAMILY HISTORY:,  Remarkable for coronary artery disease, stroke, and congestive heart failure.,SOCIAL HISTORY:,  She is a widow, lives alone.  Denies any tobacco or alcohol use.,REVIEW OF SYSTEMS:,  Dyspnea on exertion.  No chest pain or tightness, fever, chills, sweats, cough, hemoptysis, or wheeze, or lower extremity swelling.,PHYSICAL EXAMINATION:,General:  She is alert but seems somewhat confused and is not able to provide specific details about her past history.,Vital Signs:  Blood pressure:  146/80.  Pulse:  68.  Weight:  147 pounds.,HEENT:  Unremarkable.,Neck:  Supple without JVD, adenopathy, or bruit.,Chest:  Clear to auscultation.,Cardiovascular:  Regular rate and rhythm.,Abdomen:  Soft.,Extremities:  No edema.,LABORATORY:,  O2 sat 100% at rest and with exertion.  Electrocardiogram was normal sinus rhythm.  Nonspecific S-T segment changes.  Chest x-ray pending.,ASSESSMENT/PLAN:,1.  Dyspnea on exertion, uncertain etiology.  Mother would be concerned about the possibility of coronary artery disease given the patient’s underlying risk factors.  We will have the patient sign a release of records so that we can review her previous history.  Consider setting up for a stress test.,2.  Hypertension, blood pressure is acceptable today.  I am not certain as to what, if the patient’s is on any antihypertensive agents.  We will need to have her call us what the names of her medications, so we can see exactly what she is taking.,3.  History of diabetes.  Again, not certain as to whether the patient is taking anything for this particular problem when she last had a hemoglobin A1C.  I have to obtain some further history and review records before proceeding with treatment recommendations.",
 Return to work & Fit for duty evaluation., General Medicine, Gen Med Consult - 1 ,"HISTORY OF PRESENT ILLNESS: ,This is the initial clinic visit for a 29-year-old man who is seen for new onset of right shoulder pain.  He states that this began approximately one week ago when he was lifting stacks of cardboard.  The motion that he describes is essentially picking up a stack of cardboard at his waist level, twisting to the right and delivering it at approximately waist level.  Sometimes he has to throw the stacks a little bit as well.  He states he felt a popping sensation on 06/30/04.  Since that time, he has had persistent shoulder pain with lifting activities.  He localizes the pain to the posterior and to a lesser extent the lateral aspect of the shoulder.  He has no upper extremity .  , ,REVIEW OF SYSTEMS: ,Focal lateral and posterior shoulder pain without a suggestion of any cervical radiculopathies.  He denies any chronic cardiac, pulmonary, GI, GU, neurologic, musculoskeletal, endocrine abnormalities.  , ,MEDICATIONS: , Claritin for allergic rhinitis.  , ,ALLERGIES: , None.  , ,PHYSICAL EXAMINATION:, Blood pressure 120/90, respirations 10, pulse 72, temperature 97.2.  He is sitting upright, alert and oriented, and in no acute distress.  Skin is warm and dry. Gross neurologic examination is normal.  ENT examination reveals normal oropharynx, nasopharynx, and tympanic membranes.  Neck: Full range of motion with no adenopathy or thyromegaly.  Cardiovascular:  Regular rate and rhythm.  Lungs:  Clear.  Abdomen: Soft.","general medicine, return to work, consult, fit for duty, cleared for work, muscular, paresthesias, shoulder, shoulder pain, strain, waist, x-rays, waist level, neurologic, abnormalities, impingement, examination, "
" Foreign body of the left fifth fingernail (wooden splinter).  He attempted to remove it with tweezers at home, but was unsuccessful.  He is requesting we attempt to remove this for him.", General Medicine, Foreign Body - Fingernail ,"HISTORY OF PRESENT ILLNESS:,  Patient is a 72-year-old white male complaining of a wooden splinter lodged beneath his left fifth fingernail, sustained at 4 p.m. yesterday.  He attempted to remove it with tweezers at home, but was unsuccessful.  He is requesting we attempt to remove this for him.,The patient believes it has been over 10 years since his last tetanus shot, but states he has been allergic to previous immunizations primarily with ""horse serum.""  Consequently, he has declined to update his tetanus immunization.,MEDICATIONS: , He is currently on several medications, a list of which is attached to the chart, and was reviewed.  He is not on any blood thinners.,ALLERGIES: , HE IS ALLERGIC ONLY TO TETANUS SERUM.,SOCIAL HISTORY: , Patient is married and is a nonsmoker and lives with his wife.  ,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS:  Temp and vital signs are all within normal limits.,GENERAL:  The patient is a pleasant elderly white male who is sitting on the stretcher in no acute distress.,EXTREMITIES:  Exam of the left fifth finger shows a 5- to 6-mm splinter lodged beneath the medial aspect of the nail plate.  It does not protrude beyond the end of the nail plate.  There is no active bleeding.  There is no edema or erythema of the digit tip.  Flexion and extension of the DIP joint is intact.  The remainder of the hand is unremarkable.,TREATMENT: , I did attempt to grasp the end of the splinter with splinter forceps, but it is brittle and continues to break off.  In order to better grasp the splinter, will require penetration beneath the nail plate, which the patient cannot tolerate due to pain.  Consequently, the base of the digit tip was prepped with Betadine, and just distal to the DIP joint, a digital block was applied with 1% lidocaine with complete analgesia of the digit tip.  I was able to grasp the splinter and remove this.  No further foreign body was seen beneath the nail plate and the area was cleansed and dressed with bacitracin and bandage.,ASSESSMENT: , Foreign body of the left fifth fingernail (wooden splinter).,PLAN: , Patient was urged to clean the area b.i.d. with soap and water and to dress with bacitracin and a Band-Aid.  If he notes increasing redness, pain, or swelling, he was urged to return for re-evaluation.","general medicine, horse serum, wooden splinter, foreign body, nail plate, grasp, fingernail, splinter,"
" Questionable foreign body, right nose.  Belly and back pain.   Mild constipation.", General Medicine, Foreign Body - Right Nose ,"CHIEF COMPLAINT:,  Questionable foreign body, right nose.  Belly and back pain.  ,SUBJECTIVE: , Mr. ABC is a 2-year-old boy, who is brought in by parents, stating that the child keeps complaining of belly and back pain.  This does not seem to be slowing him down.  They have not noticed any change in his urine or bowels.  They have not noted him to have any fevers or chills or any other illness.  They state he is otherwise acting normally.  He is eating and drinking well.  He has not had any other acute complaints, although they have noted a foul odor coming from his nose.  Apparently, he was seen here a few weeks ago for a foreign body in the right nose, which was apparently a piece of cotton; this was removed and placed on antibiotics.  His nose got better and then started to become malodorous again.  Mother restarted him on the remainder of the antibiotics and they are also stating that they think there is something still in there.  Otherwise, he has not had any runny nose, earache, no sore throat.  He has not had any cough, congestion.  He has been acting normally.  Eating and drinking okay.  No other significant complaints.  He has not had any pain with bowel movement or urination, nor have they noted him to be more frequently urinating, then again he is still on a diaper.,PAST MEDICAL HISTORY: , Otherwise negative.,ALLERGIES: , No allergies.,MEDICATIONS: , No medications other than recent amoxicillin.,SOCIAL HISTORY: , Parents do smoke around the house.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Stable.  He is afebrile.,GENERAL:  This is a well-nourished, well-developed 2-year-old little boy, who is appearing very healthy, normal for his stated age, pleasant, cooperative, in no acute distress, looks very healthy, afebrile and nontoxic in appearance.,HEENT:  TMs, canals are normal.  Left naris normal.  Right naris, there is some foul odor as well as questionable purulent drainage.  Examination of the nose, there was a foreign body noted, which was the appearance of a cotton ball in the right nose, that was obviously infected and malodorous.  This was removed and reexamination of the nose was done and there was absolutely no foreign body left behind or residual.  There was some erythema.  No other purulent drainage noted.  There was some bloody drainage.  This was suctioned and all mucous membranes were visualized and are negative.,NECK:  Without lymphadenopathy.  No other findings.,HEART:  Regular rate and rhythm.,LUNGS:  Clear to auscultation.,ABDOMEN:  His abdomen is entirely benign, soft, nontender, nondistended.  Bowel sounds active.  No organomegaly or mass noted.,BACK:  Without any findings.  Diaper area normal.,GU:  No rash or infections.  Skin is intact.,ED COURSE: , He also had a P-Bag placed, but did not have any urine.  Therefore, a straight catheter was done, which was done with ease without complication and there was no leukocytes noted within the urine.  There was a little bit of blood from catheterization but otherwise normal urine.  X-ray noted some stool within the vault.  Child is acting normally.  He is jumping up and down on the bed without any significant findings.,ASSESSMENT:,1.  Infected foreign body, right naris.,2.  Mild constipation.,PLAN:,  As far as the abdominal pain is concerned, they are to observe for any changes.  Return if worse, follow up with the primary care physician.  The right nose, I will place the child on amoxicillin 125 per 5 mL, 1 teaspoon t.i.d.  Return as needed and observe for more foreign bodies.  I suspect, the child had placed this cotton ball in his nose again after the first episode.", 
 Complaint of mood swings and tearfulness., General Medicine, Gen Med Consult - 15 ,"HISTORY OF PRESENT ILLNESS:,  A 50-year-old female comes to the clinic with complaint of mood swings and tearfulness.  This has been problematic over the last several months and is just worsening to the point where it is impairing her work.  Her boss asks her if she was actually on drugs in which she said no.  She stated may be she needed to be, meaning taking some medications.  The patient had been prescribed Wellbutrin in the past and responded well to it; however, at that time it was prescribed for obsessive-compulsive type disorder relating to overeating and therefore her insurance would not cover the medication.  She has not been on any other antidepressants in the past.  She is not having any suicidal ideation but is having difficulty concentrating, rapid mood swings with tearfulness, and insomnia.  She denies any hot flashes or night sweats.  She underwent TAH with BSO in December of 2003.,FAMILY HISTORY: , Benign breast lump in her mother; however, her paternal grandmother had breast cancer.  The patient denies any palpitations, urinary incontinence, hair loss, or other concerns.  She was recently treated for sinusitis.,ALLERGIES:,  She is allergic to Sulfa.,CURRENT MEDICATIONS:,  Recently finished Minocin and Duraphen II DM.,PHYSICAL EXAMINATION:,General:  A well-developed and well-nourished female, conscious, alert, oriented times three in no acute distress.  Mood is dysthymic.  Affect is tearful.,Skin:  Without rash.,Eyes:  PERRLA.  Conjunctivae are clear.,Neck:  Supple with adenopathy or thyromegaly.,Lungs:  Clear.,Heart:  Regular rate and rhythm without murmur.,ASSESSMENT:,1.  Postsurgical menopause.,2.  Mood swings.,PLAN:,  I spent about 30 minutes with the patient discussing treatment options.  I do believe that her moods would greatly benefit from hormone replacement therapy; however, she is reluctant to do this because of family history of breast cancer.  We will try starting her back on Wellbutrin XL 150 mg daily.  She may increase to 300 mg daily after three to seven days.  Samples provided initially.  If she is not obtaining adequate relief from medication alone, we will then suggest that we explore the use of hormone replacement therapy.  I also recommended increasing her exercise.  We will also obtain some screening lab work including CBC, UA, TSH, chemistry panel, and lipid profile.  Follow up here in two weeks or sooner if any other problems.  She is needing her annual breast exam as well.","general medicine, tearfulness, mood swings, menopause, postsurgical menopause, mood swings and tearfulness, hormone replacement therapy, breast cancer, wellbutrin,"
 A female for a complete physical and follow up on asthma with allergic rhinitis., General Medicine, Followup on Asthma ,"SUBJECTIVE: , This is a 42-year-old white female who comes in today for a complete physical and follow up on asthma.  She says her asthma has been worse over the last three months.  She has been using her inhaler daily.  Her allergies seem to be a little bit worse as well.  Her husband has been hauling corn and this seems to aggravate things.  She has not been taking Allegra daily but when she does take it, it seems to help somewhat.  She has not been taking her Flonase which has helped her in the past.  She also notes that in the past she was on Advair but she got some vaginal irritation with that.,She had been noticing increasing symptoms of irritability and PMS around her menstrual cycle.  She has been more impatient around that time.  Says otherwise her mood is normal during the rest of the month.  It usually is worse the week before her cycle and improves the day her menstrual cycle starts.  Menses have been regular but somewhat shorter than in the past.  Occasionally she will get some spotting after her cycles.  She denies any hot flashes or night sweats with this.  In reviewing the chart it is noted that she did have 3+ blood with what appeared to be a urinary tract infection previously.  Her urine has not been rechecked.  She recently had lab work and cholesterol drawn for a life insurance application and is going to send me those results when available.,REVIEW OF SYSTEMS: , As above.  No fevers, no headaches, no shortness of breath currently.  No chest pain or tightness.  No abdominal pain, no heartburn, no constipation, diarrhea or dysuria.  Occasional stress incontinence.  No muscle or joint pain.  No concerns about her skin.  No polyphagia, polydipsia or polyuria.,PAST MEDICAL HISTORY: , Significant for asthma, allergic rhinitis and cervical dysplasia.,SOCIAL HISTORY: , She is married.  She is a nonsmoker.,MEDICATIONS: , Proventil and Allegra.,ALLERGIES: , Sulfa.,OBJECTIVE:,Vital signs:  Her weight is 151 pounds.  Blood pressure is 110/60.  Pulse is 72.  Temperature is 97.1 degrees.  Respirations are 20.,General:  This is a well-developed, well-nourished 42-year-old white female, alert and oriented in no acute distress.  Affect is appropriate and is pleasant.,HEENT:  Normocephalic, atraumatic.  Tympanic membranes are clear.  Conjunctivae are clear.  Pupils are equal, round and reactive to light.  Nares without turbinate edema.  Oropharynx is nonerythematous.,Neck:  Supple without lymphadenopathy, thyromegaly, carotid bruit or JVD.,Chest:  Clear to auscultation bilaterally.,Cardiovascular:  Regular rate and rhythm without murmur.,Abdomen:  Soft, nontender, nondistended.  Normoactive bowel sounds.  No masses or organomegaly to palpation.,Extremities:  Without cyanosis or edema.,Skin:  Without abnormalities.,Breasts:  Normal symmetrical breasts without dimpling or retraction.  No nipple discharge.  No masses or lesions to palpation.  No axillary masses or lymphadenopathy.,Genitourinary:  Normal external genitalia.  The walls of the vaginal vault are visualized with normal pink rugae with no lesions noted.  Cervix is visualized without lesion.  She has a moderate amount of thick white/yellow vaginal discharge in the vaginal vault.  No cervical motion tenderness.  No adnexal tenderness or fullness.,ASSESSMENT/PLAN:,1.  Asthma.  Seems to be worse than in the past.  She is just using her Proventil inhaler but is using it daily.  We will add Flovent 44 mcg two puffs p.o. b.i.d.  May need to increase the dose.  She did get some vaginal irritation with Advair in the past but she is willing to retry that if it is necessary.  May also need to consider Singulair.  She is to call me if she is not improving.  If her shortness of breath worsens she is to call me or go into the emergency department.  We will plan on following up for reevaluation in one month.,2.  Allergic rhinitis.  We will plan on restarting Allegra and Flonase daily for the time being.,3.  Premenstrual dysphoric disorder.  She may have some perimenopausal symptoms.  We will start her on fluoxetine 20 mg one tablet p.o. q.d.,4.  Hematuria.  Likely this is secondary to urinary tract infection but we will repeat a UA to document clearing.  She does have some frequent dysuria but is not having it currently.,5.  Cervical dysplasia.  Pap smear is taken.  We will notify the patient of results.  If normal we will go back to yearly Pap smear.  She is scheduled for screening mammogram and instructed on monthly self-breast exam techniques.  Recommend she get 1200 mg of calcium and 400 U of vitamin D a day.",
" Left flank pain, ureteral stone.", General Medicine, Flank Pain - Consult - 1 ,"REASON FOR CONSULTATION: , Left flank pain, ureteral stone.,BRIEF HISTORY: , The patient is a 76-year-old female who was referred to us from Dr. X for left flank pain.  The patient was found to have a left ureteral stone measuring about 1.3 cm in size per the patient's history.  The patient has had pain in the abdomen and across the back for the last four to five days.  The patient has some nausea and vomiting.  The patient wants something done for the stone.  The patient denies any hematuria, dysuria, burning or pain.  The patient denies any fevers.,PAST MEDICAL HISTORY: , Negative.,PAST SURGICAL HISTORY:  ,Years ago she had surgery that she does not recall.,MEDICATIONS: , None.,ALLERGIES: , None.,REVIEW OF SYSTEMS: , Denies any seizure disorder, chest pain, denies any shortness of breath, denies any dysuria, burning or pain, denies any nausea or vomiting at this time.  The patient does have a history of nausea and vomiting, but is doing better.,PHYSICAL EXAMINATION:,VITAL SIGNS:  The patient is afebrile.  Vitals are stable.,HEART:  Regular rate and rhythm.,ABDOMEN:  Soft, left-sided flank pain and left lower abdominal pain.,The rest of the exam is benign.,LABORATORY DATA: , White count of 7.8, hemoglobin 13.8, and platelets 234,000.  The patient's creatinine is 0.92.,ASSESSMENT:,1.  Left flank pain.,2.  Left ureteral stone.,3.  Nausea and vomiting.,PLAN: , Plan for laser lithotripsy tomorrow.  Options such as watchful waiting, laser lithotripsy, and shockwave lithotripsy were discussed.  The patient has a pretty enlarged stone.  Failure of the procedure if the stone is significantly impacted into the ureteral wall was discussed.  The patient understood that the success of the surgery may be or may not be 100%, that she may require shockwave lithotripsy if we are unable to get the entire stone out in one sitting.  The patient understood all the risk, benefits of the procedure and wanted to proceed.  Need for stent was also discussed with the patient.  The patient will be scheduled for surgery tomorrow.  Plan for continuation of the antibiotics, obtain urinalysis and culture, and plan for KUB to evaluate for the exact location of the stone prior to surgery tomorrow.","general medicine, flank pain, ureteral stone, shockwave lithotripsy, shockwave, nausea, vomiting, lithotripsy, ureteral, stone, "
 Left flank pain and unable to urinate., General Medicine, Flank Pain - Consult ,"CHIEF COMPLAINT: , Left flank pain and unable to urinate.,HISTORY: , The patient is a 46-year-old female who presented to the emergency room with left flank pain and difficulty urinating.  Details are in the history and physical.  She does have a vague history of a bruised left kidney in a motor vehicle accident.  She feels much better today.  I was consulted by Dr. X.,MEDICATIONS:,  Ritalin 50 a day.,ALLERGIES: , To penicillin.,PAST MEDICAL HISTORY: , ADHD.,SOCIAL HISTORY:,  No smoking, alcohol, or drug abuse.,PHYSICAL EXAMINATION: , She is awake, alert, and quite comfortable.  Abdomen is benign.  She points to her left flank, where she was feeling the pain.,DIAGNOSTIC DATA: , Her CAT scan showed a focal ileus in left upper quadrant, but no thickening, no obstruction, no free air, normal appendix, and no kidney stones.,LABORATORY WORK: , Showed white count 6200, hematocrit 44.7.  Liver function tests and amylase were normal.  Urinalysis 3+ bacteria.,IMPRESSION:,1.  Left flank pain, question etiology.,2.  No evidence of surgical pathology.,3.  Rule out urinary tract infection.,PLAN:,1.  No further intervention from my point of view.,2.  Agree with discharge and followup as an outpatient.  Further intervention will depend on how she does clinically.  She fully understood and agreed.","general medicine, flank pain, unable to urinate, urinary tract infection, flank, "
 Sample female review of systems., General Medicine, Female ROS ,"FEMALE REVIEW OF SYSTEMS:,Constitutional:  Patient denies fevers, chills, sweats and weight changes.,Eyes:  Patient denies any visual symptoms.,Ears, Nose, and Throat:  No difficulties with hearing.  No symptoms of rhinitis or sore throat.,Cardiovascular:  Patient denies chest pains, palpitations, orthopnea and paroxysmal nocturnal dyspnea.,Respiratory:  No dyspnea on exertion, no wheezing or cough.,GI:  No nausea, vomiting, diarrhea, constipation, abdominal pain, hematochezia or melena.,GU:  No dysuria, frequency or incontinence.  No difficulties with vaginal discharge.,Musculoskeletal:  No myalgias or arthralgias.,Breasts:  Patient performs self-breast examinations and has noticed no abnormalities or nipple discharge.,Neurologic:  No chronic headaches, no seizures.  Patient denies numbness, tingling or weakness.,Psychiatric:  Patient denies problems with mood disturbance.  No problems with anxiety.,Endocrine:  No excessive urination or excessive thirst.,Dermatologic:  Patient denies any rashes or skin changes.","general medicine, constitutional, breasts, cardiovascular, dermatologic, endocrine, female review of systems, musculoskeletal, neurologic, psychiatric, review of systems, respiratory, abdominal pain, chest pains, constipation, diarrhea, hematochezia, melena, nausea, nipple discharge, numbness, orthopnea, palpitations, paroxysmal nocturnal dyspnea, rashes, tingling, vomiting, weakness, wheezing, nose, systems,"
" Infection (folliculitis), pelvic pain, mood swings, and painful sex (dyspareunia).", General Medicine, Gen Med Consult - 11 ,"CHIEF COMPLAINT:,1.  Infection.,2.  Pelvic pain.,3.  Mood swings.,4.  Painful sex.,HISTORY OF PRESENT ILLNESS:,  The patient is a 29-year-old female who is here today with the above-noted complaints.  She states that she has been having a lot of swelling and infection in her inner thigh area with the folliculitis she has had in the past.  She is requesting antibiotics.  She has been squeezing them and some of them are very bruised and irritated.  She also states that she is having significant pelvic pain and would like to go back and see Dr. XYZ again.  She also states that she took herself off of lithium, but she has been having significant mood swings, anger outbursts and not dealing with the situation well at all.  She also has had some psychiatric evaluation, but she states that she did not feel like herself on the medication, so she took herself off.  She states she does not wish to be on any medication at the current time.  She otherwise states that sex is so painful that she is unable to have sex with her husband, even though she ""wants to."",PAST MEDICAL HISTORY:,  Significant for cleft palate.,ALLERGIES:,  She is allergic to Lortab.,CURRENT MEDICATIONS:,  None.,REVIEW OF SYSTEMS:,  Please see history of present illness.,Psychiatric:  She has had some suicidal thoughts, but no plans.  She denies being suicidal at the current time.,Cardiopulmonary:  She has not had any chest pain or shortness of breath.,GI:  Denies any nausea or vomiting.,Neurological:  No numbness, weakness or tingling.,PHYSICAL EXAMINATION:,General:  The patient is a well-developed, well-nourished, 29-year-old female who is in no acute distress.,Vital signs:  Weight:  160 pounds.  Blood pressure:  100/60.  Pulse:  62.,Psychiatric:  I did spend over 25 minutes face-to-face with the patient talking about the situation she was in and the medication and her discontinuing use of that.,Extremities:  Her inner thighs are covered with multiple areas of folliculitis and mild abscesses.  They are bruised from her squeezing them.  We talked about that in detail.,ASSESSMENT:,1.  Folliculitis.,2.  Pelvic pain.,3.  Mood swings.,4.  Dyspareunia.,PLAN:,1.  I would like her to go to the lab and get a CBC, chem-12, TSH and UA.,2.  We will put her on cephalexin 500 mg three times a day.,3.  We will send her back to see Dr. XYZ regarding the pelvic pain per her request.,4.  We will get her an appointment with a psychiatrist for evaluation and treatment.,5.  She is to call if she has any further problems or concerns.  Otherwise I will see her back for her routine care or sooner if there are any further issues.",
" Consult for hypertension and a med check.  History of osteoarthritis, osteoporosis, hypothyroidism, allergic rhinitis and kidney stones.", General Medicine, Gen Med Consult - 13 ,"SUBJECTIVE:,  The patient is a 76-year-old white female who presents to the clinic today originally for hypertension and a med check.  She has a history of hypertension, osteoarthritis, osteoporosis, hypothyroidism, allergic rhinitis and kidney stones.  Since her last visit she has been followed by Dr. Kumar.  Those issues are stable.  She has had no fever or chills, cough, congestion, nausea, vomiting, chest pain, chest pressure.,PAST MEDICAL HISTORY:,  She has an intolerance to Prevacid.,CURRENT MEDICATIONS:,  Evista 60 daily, Levothroid 0.05 mg daily, Claritin 10 daily, Celebrex 200 daily, HCTZ 25 daily and amitriptyline p.r.n.,PAST SURGICAL HISTORY:,  Bilateral mastectomies, tonsillectomy, EGD, flex sig in 2001 and a heart cath.,FAMILY HISTORY: , Father passed away at 81; mother of multiple myeloma at 83.,SOCIAL HISTORY:,  She is married.  A 76-year-old who used to smoke a pack a day and quit in 1985.  She is retired.,REVIEW OF SYSTEMS:,  Essentially negative in HEENT, chest, cardiovascular, GI, GU, musculoskeletal, or neurologic.,OBJECTIVE:,  Temperature is 97.5 degrees.  Blood pressure is 168/70.  Pulse is 88.  Weight is 129 pounds.,GENERAL:  She is an elderly 76-year-old in no acute distress.,HEENT:  Atraumatic.  Extraocular muscles were intact.  Pupils equal, round and reactive to light and accommodation.  Tympanic membranes are clear, dry and intact.  Sinuses and throat are clear.  Neck is soft, supple.  No meningeal signs are present.  No thyromegaly is present.,CHEST:  Clear to auscultation.,CARDIOVASCULAR:  Regular rate and rhythm without murmur.,ABDOMEN:  Soft, nontender.  Bowel sounds are positive.  No organomegaly or peritoneal signs are present.,EXTREMITIES:  Moving all extremities.  Peripheral pulses are normal.  No edema is present.,NEUROLOGIC:  Alert and oriented.  Cranial nerves II-XII grossly intact.  Strength 5+/5 globally.  Reflexes 2+/IV globally.  Romberg is negative.  There is no numbness, tingling, weakness or other neurologic deficit present.,BREASTS:  Surgically absent but there are no lumps, lesions, masses, discharge or adenopathy present.,BACK:  Straight.,SKIN:  Clear.,GENITALIA:  Deferred as she has been followed by Dr. XYZ many times this year.  She does have a history of some elevated cholesterol.,ASSESSMENT:,1.  Hypertension, suboptimal control.,2.  Hypothyroidism.,3.  Arthritis.,4.  Allergic rhinitis.,5.  History of kidney stones.,6.  Osteoporosis.,PLAN:,1.  CBC, complete metabolic profile, UA for hypertension.,2.  Chest x-ray for history of breast cancer.,3.  DEXA scan, full body for osteoporosis.,4.  Flex is up to date.,5.  Pneumovax has been given in the last five years.,6.  Lipid profile for elevated cholesterol.,7.  Refill meds.,8.  Follow up every three to six months for blood pressure check or sooner p.r.n. problems.",
 Sample female physical exam, General Medicine, Female Physical Exam - 1 ,"FEMALE PHYSICAL EXAMINATION,Eye:  Eyelids normal color, no edema.  Conjunctivae with no erythema, foreign body, or lacerations.  Sclerae normal white color, no jaundice.  Cornea clear without lesions.  Pupils equally responsive to light.  Iris normal color, no lesions.  Anterior chamber clear.  Lacrimal ducts normal.  Fundi clear.,Ear:  External ear has no erythema, edema, or lesions.  Ear canal unobstructed without edema, discharge, or lesions.  Tympanic membranes clear with normal light reflex.  No middle ear effusions.,Nose:  External nose symmetrical.  No skin lesions.  Nares open and free of lesions.  Turbinates normal color, size and shape.  Mucus clear.  No internal lesions.,Throat:  No erythema or exudates.  Buccal mucosa clear.  Lips normal color without lesions.  Tongue normal shape and color without lesion.  Hard and soft palate normal color without lesions.  Teeth show no remarkable features.  No adenopathy.  Tonsils normal shape and size.  Uvula normal shape and color.,Neck:  Skin has no lesions.  Neck symmetrical.  No adenopathy, thyromegaly, or masses.  Normal range of motion, nontender.  Trachea midline.,Chest:  Symmetrical.  Clear to auscultation bilaterally.  No wheezing, rales or rhonchi.  Chest nontender.  Normal lung excursion.  No accessory muscle use.,Cardiovascular:  Heart has regular rate and rhythm with no S3 or S4.  Heart rate is normal.,Abdominal:  Soft, nontender, nondistended, bowel sounds present.  No hepatomegaly, splenomegaly, masses, or bruits.,Genital:  Labia majora normal shape without erythema or lesions.  Labia minora normal shape without erythema or lesions.  Clitoris normal shape and contour.  Vaginal mucosa normal color without lesions.  No significant discharge.  Cervix normal shape and parity without lesions.  Ovaries normal shape and contour.  No pelvic masses.  Uterus normal shape and contour.  No external hemorrhoids.,Musculoskeletal:  Normal strength all muscle groups.  Normal range of motion all joints.  No joint effusions.  Joints normal shape and contour.  No muscle masses.,Foot:  No erythema.  No edema.  Normal range of motion all joints in the foot.  Nontender.  No pain with inversion, eversion, plantar or dorsiflexion.,Ankle:  Anterior and posterior drawer test negative.  No pain with inversion, eversion, dorsiflexion, or plantar flexion.  Collateral ligaments intact.  No joint effusion, erythema, edema, crepitus, ecchymosis, or tenderness.,Knee:  Normal range of motion.  No joint effusion, erythema, nontender.  Anterior and posterior drawer tests negative.  Lachman's test negative.  Collateral ligaments intact.  Bursas nontender without edema.,Wrist:  Normal range of motion.  No edema or effusion, nontender.  Negative Tinel and Phalen tests.  Normal strength all muscle groups.,Elbow:  Normal range of motion.  No joint effusion or erythema.  Normal strength all muscle groups.  Nontender.  Olecranon bursa flat and nontender, no edema.  Normal supination and pronation of forearm.  No crepitus.,Hip:  Negative swinging test.  Trochanteric bursa nontender.  Normal range of motion.  Normal strength all muscle groups.  No pain with eversion and inversion.  No crepitus.  Normal gait.,Psychiatric:  Alert and oriented times four.  No delusions or hallucinations, no loose associations, no flight of ideas, no tangentiality.  Affect is appropriate.  No psychomotor slowing or agitation.  Eye contact is appropriate.","general medicine, physical examination, abdominal, anterior chamber, cardiovascular, chest, ear, ear canal, eye, eyelids, female, female physical examination, labia majora, labia minora, nares, neck symmetrical, vaginal mucosa, crepitus, ecchymosis, edema, erythema, joint effusion, normal range of motion, shape and contour, normal strength, joint effusions, normal color, nontender, lesions, effusions, muscle, joints,"
 A 66-year-old patient who came to the emergency room because she was feeling dizzy and was found to be tachycardic and hypertensive., General Medicine, Feeling Dizzy - ER Visit  ,"REASON FOR CONSULTATION:,  This is a 66-year-old patient who came to the emergency room because she was feeling dizzy and was found to be tachycardic and hypertensive.,PAST MEDICAL HISTORY: , Hypertension.  The patient noncompliant,HISTORY OF PRESENT COMPLAINT: , This 66-year-old patient has history of hypertension and has not taken medication for several months.  She is a smoker and she drinks alcohol regularly.  She drinks about 5 glasses of wine every day.  Last drink was yesterday evening.  This afternoon, the patient felt palpitations and generalized weakness and came to the emergency room.  On arrival in the emergency room, the patient's heart rate was 121 and blood pressure was 195/83.  The patient received 5 mg of metoprolol IV, after which heart rate was reduced to the 70 and blood pressure was well controlled.  On direct questioning, the patient said she had been drinking a lot.  She had not had any withdrawal before.  Today is the first time she has been close to withdrawal.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No fever.,ENT:  Not remarkable.,RESPIRATORY:  No cough or shortness of breath.,CARDIOVASCULAR:  The patient denies chest pain.,GASTROINTESTINAL:  No nausea.  No vomiting.  No history of GI bleed.,GENITOURINARY:  No dysuria.  No hematuria.,ENDOCRINE:  Negative for diabetes or thyroid problems.,NEUROLOGIC:  No history of CVA or TIA.,Rest of review of systems is not remarkable.,SOCIAL HISTORY:  ,The patient is a smoker and drinks alcohol daily in considerable amounts.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL:  This is a 66-year-old lady with telangiectasia of the face.  She is not anxious at this moment and had no tremors.,CHEST:  Clear to auscultation.  No wheezing.  No crepitations.  Chest is tympanitic to percussion.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmur was appreciated.,ABDOMEN:  Soft and nontender.  Bowel sounds are positive.,EXTREMITIES:  There is no swelling.  No clubbing.  No cyanosis.,NEUROLOGIC:  The patient is alert and oriented x3.  Examination is nonfocal.,DIAGNOSTIC DATA: , EKG shows sinus tachycardia, no acute ST changes.,LABORATORY DATA: , White count is 6.3, hemoglobin is 12.4, hematocrit 38, and platelets 488,000.  Glucose is 124, BUN is 18, creatinine is 1.07, sodium is 146, and potassium is 3.4.  Liver enzymes are within normal limits.  TSH is normal.,ASSESSMENT AND PLAN:,1.  Uncontrolled hypertension.  We will start the patient on beta-blockers.  The patient is to see her primary physician within 1 week's time.,2.  Tachycardia, probable mild withdrawal to alcohol.  The patient is stable now.  We will discharge home with diazepam p.r.n.  The patient had been advised that she should not take alcohol if she takes the diazepam.,3.  Tobacco smoking disorder.  The patient has been counseled.  She is not contemplating quitting at this time.,DISPOSITION: , The patient is discharged home.,DISCHARGE MEDICATIONS:,1.  Atenolol 50 mg p.o. b.i.d.,2.  Diazepam 5 mg tablet 1 p.o. q.8h. p.r.n., total of 5 tablets.,3.  Thiamine 100 mg p.o. daily.",
 Sample female exam and review of systems., General Medicine, Female Exam & ROS ,"GENERAL REVIEW OF SYSTEMS,General:  No fevers, chills, or sweats.  No weight loss or weight gain.,Cardiovascular:  No exertional chest pain, orthopnea, PND, or pedal edema.  No palpitations.,Neurologic:  No paresis, paresthesias, or syncope.,Eyes:  No double vision or blurred vision.,Ears:  No tinnitus or decreased auditory acuity.,ENT:  No allergy symptoms, such as rhinorrhea or sneezing.,GI:  No indigestion, heartburn, or diarrhea.  No blood in the stools or black stools.  No change in bowel habits.,GU:  No dysuria, hematuria, or pyuria.  No polyuria or nocturia.  Denies slow urinary stream.,Psych:  No symptoms of depression or anxiety.,Pulmonary:  No wheezing, cough, or sputum production.,Skin:  No skin lesions or nonhealing lesions.,Musculoskeletal:  No joint pain, bone pain, or back pain.  No erythema at the joints.,Endocrine:  No heat or cold intolerance.  No polydipsia.,Hematologic:  No easy bruising or easy bleeding.  No swollen lymph nodes.,PHYSICAL EXAM,Vitals:  Blood pressure today was *, heart rate *, respiratory rate *.,Ears:  TMs intact bilaterally.  Throat is clear without hyperemia.,Mouth:  Mucous membranes normal.  Tongue normal.,Neck:  Supple; carotids 2+ bilaterally without bruits; no lymphadenopathy or thyromegaly.,Chest:  Clear to auscultation; no dullness to percussion.,Heart:  Revealed a regular rhythm, normal S1 and S2.  No murmurs, clicks or gallops.,Abdomen:  Soft to palpation without guarding or rebound.  No masses or hepatosplenomegaly palpable.  Bowel sounds are normoactive.,Extremities:  Bilaterally symmetrical.  Peripheral pulses 2+ in all extremities.  No pedal edema.,Neurologic examination:  Essentially intact including cranial nerves II through XII intact bilaterally.  Deep tendon reflexes 2+ and symmetrical.,Breasts:  Bilaterally symmetrical without tenderness, masses.  No axillary tenderness or masses.,Pelvic examination:  Revealed normal external genitalia.  Pap smear obtained without difficulty.  Bimanual examination revealed no pelvic tenderness or masses.  No uterine enlargement.  Rectal examination revealed normal sphincter tone, no rectal masses.  Stool is Hemoccult negative.","general medicine, female exam, extremities, hemoccult, musculoskeletal, neurologic examination, pelvic examination, back pain, bone pain, chills, cough, cranial nerves ii through xii, fevers, heart rate, joint pain, paresis, paresthesias, polydipsia, regular rhythm, weight gain, wheezing, examination revealed, pelvic, rectal, heartburn, symmetrical, tenderness, indigestion, masses, "
 Sample female physical exam., General Medicine, Female Physical Exam - 2 ,"FEMALE PHYSICAL EXAMINATION,HEENT:  Pupils equal, round and reactive to light and accommodation.  Extraocular movements are intact.  Sclerae are anicteric.  TMs are clear bilaterally.  Oropharynx is clear without erythema or exudate.,Neck:  Supple without lymphadenopathy or thyromegaly.  Carotids are silent.  There is no jugular venous distention.,Chest:  Clear to auscultation bilaterally.,Cardiovascular:  Regular rate and rhythm without S3, S4.  No murmurs or rubs are appreciated.  Peripheral pulses are +2 and equal bilaterally in all four extremities.,Abdomen:  Soft, nontender, nondistended with positive bowel sounds.  No masses, hepatomegaly or splenomegaly are appreciated.,GU:  Reveals normal female external genitalia.  Speculum exam reveals vaginal mucosa to be pink and rugous.  Cervix appears normal.  Bimanual exam reveals uterus to be within normal limits.  Adnexa are normal without masses appreciated.  There is no cervical motion tenderness.,Rectal Exam:  Normal rectal tone.  No masses are appreciated.  Hemoccult is negative.,Extremities:  Reveal no clubbing, cyanosis, or edema.,Joint Exam:  Reveals no tenosynovitis.,Integumentary:  Normal breast tissue without lumps or masses.  There are no skin changes over the breasts.  Axillae are free of masses.,Neurologic:  Cranial nerves II through XII are grossly intact.  Motor strength is 5/5 and equal in all four extremities.  Deep tendon reflexes are +2/4 and equal bilaterally.  Patient is alert and oriented times 3.,Psychiatric:  Grossly normal.,Dermatologic:  No lesions or rashes.","general medicine, female physical examination, bimanual exam, heent, hemoccult, ii through xii, breast tissue, cardiovascular, dermatologic, external genitalia, integumentary, joint exam, lymphadenopathy, neck, neurologic, physical examination, rectal exam, skin changes, speculum exam, female physical, extremities, masses, oropharynx,"
 Fifth disease with sinusitis, General Medicine, Fifth Disease - SOAP ,"SUBJECTIVE:,  Grandfather brings the patient in today because of headaches, mostly in her face.  She is feeling pressure there with a lot of sniffles.  Last night, she complained of sore throat and a loose cough.  Over the last three days, she has had a rash on her face, back and arms.  A lot of fifth disease at school.  She says it itches and they have been doing some Benadryl for this.  She has not had any wheezing lately and is not taking any ongoing medications for her asthma.,PAST MEDICAL HISTORY:,  Asthma and allergies.,FAMILY HISTORY:  ,Sister is dizzy but no other acute illnesses.,OBJECTIVE:,General:  The patient is an 11-year-old female.  Alert and cooperative.  No acute distress.,Neck:  Supple without adenopathy.,HEENT:  Ear canals clear.  TMs, bilaterally, gray in color and good light reflex.  Oropharynx is pink and moist.  No erythema or exudates.  She has postnasal discharge.  Nares are swollen and red.  Purulent discharge in the posterior turbinates.  Both maxillary sinuses are tender.  She has some mild tenderness in the left frontal sinus.  Eyes are puffy and she has dark circles.,Chest:  Respirations are regular and nonlabored.,Lungs:  Clear to auscultation throughout.,Heart:  Regular rhythm without murmur.,Skin:  Warm, dry and pink.  Moist mucous membranes.  Red, lacey rash from the wrists to the elbows, both sides.  It is very faint on the lower back and she has reddened cheeks, as well.,ASSESSMENT:,  Fifth disease with sinusitis.,PLAN:,  Omnicef 300 mg daily for 10 days.  May use some Zyrtec for the itching.  Samples are given.","general medicine, fifth disease, soap, asthma, headaches, sinusitis, sore throat, oropharynx,"
" A 46-year-old white male with Down’s syndrome presents for followup of hypothyroidism, as well as onychomycosis.", General Medicine, Down's syndrome ,"SUBJECTIVE:,  This 46-year-old white male with Down’s syndrome presents with his mother for followup of hypothyroidism, as well as onychomycosis.  He has finished six weeks of Lamisil without any problems.  He is due to have an ALT check today.  At his appointment in April, I also found that he was hypothyroid with elevated TSH.  He was started on Levothroid 0.1 mg and has been taking that daily.  We will recheck a TSH today as well.  His mother notes that although he does not like to take the medications, he is taking it with encouragement.  His only other medications are some eyedrops for his cornea.,OBJECTIVE:,  Weight was 149 pounds, which is up 2 pounds.  Blood pressure was 120/80.  Pulse is 80 and regular.,Neck:  Supple without adenopathy.  No thyromegaly or nodules were palpable.,Cardiac:  Regular rate and rhythm without murmurs.,Skin:  Examination of the toenails showed really no change yet.  They are still quite thickened and yellowed.,ASSESSMENT:,1.  Down’s syndrome.,2.  Onychomycosis.,3.  Hypothyroidism.,PLAN:,1.  Recheck ALT and TSH today and call results.,2.  Lamisil 250 mg #30 one p.o. daily with one refill.  They will complete the next eight weeks of therapy as long as the ALT is normal.  I again reviewed the symptoms of liver dysfunction.,3.  Continue Levothroid 0.1 mg daily unless dosage need to be adjusted based on the TSH.","general medicine, down’s syndrome, hypothyroidism, onychomycosis, hypothyroid, tsh, down’s"
" Patient went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight, the patient ended up taking a total of six Ecstasy tablets.", General Medicine, Ecstasy Ingestion - ER Visit ,"CHIEF COMPLAINT:,  ""I took Ecstasy."",HISTORY OF PRESENT ILLNESS: , This is a 17-year-old female who went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight, the patient ended up taking a total of six Ecstasy tablets.  The patient upon returning to home was energetic and agitated and shaking and had one episode of nonbloody, nonbilious emesis.  Mother called the EMS service when the patient vomited.  On arrival here, the patient states that she no longer has any nausea and that she feels just fine.  The patient states she feels wired but has no other problems or complaints.  The patient denies any pain.  The patient does not have any auditory of visual hallucinations.  The patient denies any depression or suicidal ideation.  The patient states that the alcohol and the Ecstasy was done purely as a recreational thing and not as an attempt to harm herself.  The patient denies any homicidal ideation.  The patient denies any recent illness or recent injuries.  The mother states that the daughter appears to be back to her usual self now.,REVIEW OF SYSTEMS: , CONSTITUTIONAL:  No recent illness.  No fever or chills.  HEENT:  No headache.  No neck pain.  No vision change or hearing change.  No eye or ear pain.  No rhinorrhea.  No sore throat.  CARDIOVASCULAR:  No chest pain.  No palpitations or racing heart.  RESPIRATIONS:  No shortness of breath.  No cough.  GASTROINTESTINAL: One episode of nonbloody, nonbilious emesis this morning without any nausea since then.  The patient denies any abdominal pain.  No change in bowel movements.  GENITOURINARY:  No dysuria.  MUSCULOSKELETAL:  No back pain.  No muscle or joint aches.  SKIN:  No rashes or lesions.  NEUROLOGIC:  No dizziness, syncope, or near syncope.  PSYCHIATRIC:  The patient denies any depression, suicidal ideation, homicidal ideation, auditory hallucinations or visual hallucinations.  ENDOCRINE:  No heat or cold intolerance.,PAST MEDICAL HISTORY:,  None.,PAST SURGICAL HISTORY: , Appendectomy when she was 9 years old.,CURRENT MEDICATIONS: , Birth control pills.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient denies smoking cigarettes.  The patient does drink alcohol and also uses illicit drugs.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Temperature is 98.8 oral, blood pressure 140/86, pulse is 79, respirations 16, oxygen saturation 100% on room air and is interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished, and well developed, appears to be healthy.  The patient is calm and comfortable, in no acute distress and looks well.  The patient is pleasant and cooperative.  HEENT:  Head is atraumatic, normocephalic, and nontender.  Eyes are normal with clear cornea and conjunctiva bilaterally.  The patient does have dilated pupils of approximately 8 mm each and are equally round and reactive to light bilaterally.  No evidence of light sensitivity or photophobia.  Extraocular motions are intact bilaterally.  Nose is normal without rhinorrhea or audible congestion.  Ears are normal without any sign of infection.  Mouth and oropharynx are normal without any signs of infection.  Mucous membranes are moist.  NECK:  Supple and nontender.  Full range of motion.  There is no JVD.  CARDIOVASCULAR:  Heart is regular rate and rhythm without murmur, rub or gallop.  Peripheral pulses are +3 and bounding.  RESPIRATIONS:  Clear to auscultation bilaterally.  No shortness of breath.  No wheezes, rales or rhonchi.  Good air movement bilaterally.  GASTROINTESTINAL:  Abdomen is soft, nontender, normal and benign.  MUSCULOSKELETAL:  No abnormalities noted in back, arms, or legs.  The patient is normal use of her extremities.  SKIN:  No rashes or lesions.  NEUROLOGIC:  Cranial nerves II through XII are intact.  Motor and sensory are intact in all extremities.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is alert and oriented x4.  The patient does not have any smell of alcohol and does not exhibit any clinical intoxication.  The patient is quite pleasant, fully cooperative.  HEMATOLOGIC/LYMPHATIC: NO lymphadenitis is noted.  No bruising is noted.,DIAGNOSES:,1.  ECSTASY INGESTION.,2.  ALCOHOL INGESTION.,3.  VOMITING SECONDARY TO STIMULANT ABUSE.,CONDITION UPON DISPOSITION: , Stable disposition to home with her mother.,PLAN:,  I will have the patient followup with her physician at the ABC Clinic in two days for reevaluation.  The patient was advised to stop drinking alcohol, and taking Ecstasy as this is not only in the interest of her health, but was also illegal.  The patient is asked to return to the emergency room should she have any worsening of her condition, develop any other problems or symptoms of concern.","general medicine, nonbilious emesis, hallucinations, visual, auditory, ecstasy ingestion, suicidal ideation, homicidal ideation, ingestion, infection, alcohol, ecstasy, "
" Patient running to catch a taxi and stumbled, fell and struck his face on the sidewalk.", General Medicine, Fall & Laceration ,"CC:,  Fall and laceration.,HPI: , Mr. B is a 42-year-old man who was running to catch a taxi when he stumbled, fell and struck his face on the sidewalk.  He denies loss of consciousness but says he was dazed for a while after it happened.  He complains of pain over the chin and right forehead where he has abrasions.  He denies neck pain, back pain, extremity pain or pain in the abdomen.,PMH: , Hypertension.,MEDS:,  None.,ROS: , As above.  Otherwise negative.,PHYSICAL EXAM: , This is a gentleman in full C-spine precautions on a backboard brought by EMS.  He is in no apparent distress.  ,Vital Signs:  BP 165/95 HR 80 RR 12 Temp 98.4 SpO2 95% ,HEENT:  No palpable step offs, there is blood over the right fronto-parietal area where there is a small 1cm laceration and surrounding abrasion.  Also, 2 cm laceration over the base of the chin without communication to the oro-pharynx.  No other trauma noted.  No septal hematoma.  No other facial bony tenderness.  ,Neck:  Nontender ,Chest:  Breathing comfortably; equal breath sounds.  ,Heart:  Regular rhythm.,Abd:  Benign.,Ext:  No tenderness or deformity; pulses are equal throughout; good cap refill ,Neuro:  Awake and alert; slight slurring of speech and cognitive slowing consistent with alcohol; moves all extremities; cranial nerves normal.  ,COURSE IN THE ED:,  Patient arrived and was placed on monitors.  An IV had been placed in the field and labs were drawn.  X-rays of the C spine show no fracture and I've removed the C-collar.  The lacerations were explored and no foreign body found.  They were irrigated and closed with simple interrupted sutures.  Labs showed normal CBC, Chem-7, and U/A except there was moderate protein in the urine.  The blood alcohol returned at 0.146.  A banana bag is ordered and his care will be turned over to Dr. G for further evaluation and care.","general medicine, loss of consciousness, laceration, fall, course in the ed, placed on monitors, fell and struck, abrasions,"
" A 50-year-old white male with dog bite to his right leg with a history of pulmonary fibrosis, status post bilateral lung transplant several years ago.", General Medicine, Dog Bite ,"CHIEF COMPLAINT:,  Dog bite to his right lower leg.,HISTORY OF PRESENT ILLNESS:,  This 50-year-old white male earlier this afternoon was attempting to adjust a cable that a dog was tied to.  Dog was a German shepherd, it belonged to his brother, and the dog spontaneously attacked him.  He sustained a bite to his right lower leg.  Apparently, according to the patient, the dog is well known and is up-to-date on his shots and they wanted to confirm that.  The dog has given no prior history of any reason to believe he is not a healthy dog.  The patient himself developed a puncture wound with a flap injury.  The patient has a flap wound also below the puncture wound, a V-shaped flap, which is pointing towards the foot.  It appears to be viable.  The wound is open about may be roughly a centimeter in the inside of the flap.  He was seen by his medical primary care physician and was given a tetanus shot and the wound was cleaned and wrapped, and then he was referred to us for further assessment.,PAST MEDICAL HISTORY:  ,Significant for history of pulmonary fibrosis and atrial fibrillation.  He is status post bilateral lung transplant back in 2004 because of the pulmonary fibrosis.,ALLERGIES:  ,There are no known allergies.,MEDICATIONS:,  Include multiple medications that are significant for his lung transplant including Prograf, CellCept, prednisone, omeprazole, Bactrim which he is on chronically, folic acid, vitamin D, Mag-Ox, Toprol-XL, calcium 500 mg, vitamin B1, Centrum Silver, verapamil, and digoxin.,FAMILY HISTORY: , Consistent with a sister of his has ovarian cancer and his father had liver cancer.  Heart disease in the patient's mother and father, and father also has diabetes.,SOCIAL HISTORY:,  He is a non-cigarette smoker.  He has occasional glass of wine.  He is married.  He has one biological child and three stepchildren.  He works for ABCD.,REVIEW OF SYSTEMS:,  He denies any chest pain.  He does admit to exertional shortness of breath.  He denies any GI or GU problems.  He denies any bleeding disorders.,PHYSICAL EXAMINATION,GENERAL:  Presents as a well-developed, well-nourished 50-year-old white male who appears to be in mild distress.,HEENT:  Unremarkable.,NECK:  Supple.  There is no mass, adenopathy or bruit.,CHEST:  Normal excursion.,LUNGS:  Clear to auscultation and percussion.,COR:  Regular.  There is no S3 or S4 gallop.  There is no obvious murmur.,ABDOMEN:  Soft.  It is nontender.  Bowel sounds are present.  There is no tenderness.,SKIN:  He does have like a Chevron incisional scar across his lower chest and upper abdomen.  It appears to be well healed and unremarkable.,GENITALIA:  Deferred.,RECTAL:  Deferred.,EXTREMITIES:  He has about 1+ pitting edema to both legs and they have been present since the surgery.  In the right leg, he has an about midway between the right knee and right ankle on the anterior pretibial area, he has a puncture wound that measures about may be centimeter around that appears to be relatively clean, and just below that about may be 3 cm below, he has a flap traumatic injury that measures about may be 4 cm to the point of the flap.  The wound is spread apart about may be a centimeter all along that area and it is relatively clean.  There was some bleeding when I removed the dressing and we were able to pretty much control that with pressure and some silver nitrate.  There were exposed subcutaneous tissues, but there was no exposed tendons that we could see, etc.  The flap appeared to be viable.,NEUROLOGIC:  Without focal deficits.  The patient is alert and oriented.,IMPRESSION:,  A 50-year-old white male with dog bite to his right leg with a history of pulmonary fibrosis, status post bilateral lung transplant several years ago.  He is on multiple medications and he is on chronic Bactrim.  We are going to also add some fluoroquinolone right now to protect the skin and probably going to obtain an Infectious Disease consult.  We will see him back in the office early next week to reassess his wound.  He is to keep the wound clean with the moist dressing right now.  He may shower several times a day.",
 A 48-year-old white married female presents in the emergency room after two days of increasing fever with recent diagnosis of urinary tract infection on outpatient treatment with nitrofurantoin., General Medicine, ER Report - Chest Pain & Fever ,"CHIEF COMPLAINT: , Chest pain and fever.,HISTORY OF PRESENT ILLNESS: , This 48-year-old white married female presents in the emergency room after two days of increasing fever with recent diagnosis of urinary tract infection on outpatient treatment with nitrofurantoin.  The patient noted since she began to feel poorly earlier on the day of admission, had an episode of substernal chest discomfort that was associated with nausea, dizziness, and sweating.  The patient does have a past medical history of diabetes and hypertension.  In addition, the patient complained of some neck and head discomfort for which she underwent a lumbar puncture in the emergency room; this was normal, causes turned out to be normal as well.  The patient denies nosebleed, visual changes, nausea, vomiting, diarrhea or changes in bowel habits.  She has not had any musculoskeletal or neurological deficits.  She denies any rashes or skin lesions.,PAST MEDICAL HISTORY:  ,Hypertension, diabetes, hyperlipidemia, particularly elevated triglycerides with a slightly elevated LDL at 81 with an new standard LDL of 74, diabetics with a bad family history for cardiovascular disease such as this patient does have, and postmenopausal hot flashes.,PAST SURGICAL HISTORY:  ,Cholecystectomy, appendectomy, oophorectomy.,FAMILY HISTORY: , Positive for coronary artery disease in her father and brother in their 40s.,SOCIAL HISTORY: , She is married and does not smoke or drink nor did she ever.,PHYSICAL EXAMINATION: , On admission, temperature 99.4 degrees F., blood pressure 137/60, pulse 90 and regular without ectopy, respiratory rate 20 without unusual respiratory effort.  In general, she is well developed, well nourished, oriented, and alert and in no apparent distress.  Head, ears, eyes, nose, and throat are unremarkable.  Neck is supple.  No neck vein distention is noted.  No bruits are heard.  Chest is clear to percussion and auscultation.  Heart has a regular rhythm and rate without murmurs or rubs or gallops.  Abdomen is soft, obese, and nontender.  Musculoskeletal is intact without deformity.  However, the patient did develop severe cramp behind her left knee during her treadmill testing.  Neurologic:  Cranial nerves are intact and she is nonfocal.  Skin is warm and dry without rash or lesions noted.,LABORATORY FINDINGS: , Glucose 162, BUN 14, creatinine 1.0, sodium 137, potassium 3.6, chloride 103, bicarbonate 23, protein 4.2.  Liver function panel is normal.  CK was 82.  MB fraction was 1.0.  Troponin was less than 0.1 on three occasions.  White count was 12,200 with a normal differential, hemoglobin was 12.1, platelet count 230,000.  Urinalysis showed positive nitrites, positive leukocyte esterase, 5 to 10 white cells per high power field, and 1+ bacteria rods.  Spinal fluid was clear with 11 red cells, glucose 75, protein 67, white count 0.  EKG was normal.,DIAGNOSES ON ADMISSION:,1.  Urinary tract infection.,2.  Chest pain of unclear etiology, rule out myocardial infarction.,3.  Neck and back pain of unclear etiology with a negative spinal tap.,4.  Hypertension.,5.  Diabetes type II, not treated with insulin.,6.  Hyperlipidemia treated with TriCor but not statins.,7.  Arthritis.,ADDITIONAL LABORATORY STUDIES:,  B-natriuretic peptide was 26.  Urine smear and culture negative on 24 and 48 hours.  Chest x-ray was negative.  Lipid panel - triglycerides 249, VLDL 49, HDL 33, LDL 81.,COURSE IN THE HOSPITAL: , The patient was placed on home medications.  This will be listed at the end of the discharge summary.  She was put on rule out acute myocardial infarction routine, and she did in fact rule out.  She had a stress test completed on the day of discharge which was normal, and she was discharged with a diagnoses of chest pain, acute myocardial infarction ruled out, urinary tract infection, fever secondary to UTI, diabetes mellitus type 2 non-insulin treated, hyperlipidemia with elevated triglycerides and an LDL elevated to 81 with new normal being less than 70.  She has a strong family history of early myocardial disease in the men in their 40s.,DISCHARGE MEDICATIONS:,1.  Enteric-coated aspirin 81 mg one daily.  This is new, as the patient was not taking aspirin at home.,2.  TriCor 48 mg one daily.,3.  Zantac 40 mg one daily.,4.  Lisinopril 20 mg one daily.,5.  Mobic 75 mg one daily for arthritis.,6.  Metformin 500 mg one daily.,7.  Macrodantin one two times a day for several more days.,8.  Zocor 20 mg one daily, which is a new addition.,9.  Effexor XR 37.5 mg one daily.,DIET: , ADA 1800-calorie diet.,ACTIVITY:,  As tolerated.  Continue water exercise five days a week.,DISPOSITION: , Recheck at Hospital with a regular physician there in 1 week.  Consider Byetta as an adjunct to her diabetic treatment and efforts to weight control.",
" The patient is an 88-year-old white female, household ambulator with a walker, who presents to the emergency department this morning after incidental fall at home.", General Medicine, Fall - ER Visit ,"HISTORY OF PRESENT ILLNESS:,  The patient is an 88-year-old white female, household ambulator with a walker, who presents to the emergency department this morning after incidental fall at home.  The patient states that she was on the ladder on Saturday and she stepped down after the ladder.  Felt some pain in her left hip.  Subsequently fell injuring her left shoulder.  It's unclear how long she was on the floor.  She was taken by EMS to Hospital where she was noted radiographically to have a left proximal humerus fracture and a nondisplaced left hip fracture.  Orthopedics was consulted.  Given the nature of the injury and the unclear events, an extensive workup was performed including a head CT and CT of the abdomen, which identified no evidence of intracranial injury and renal calculi only.  She presently is complaining of pain to the left shoulder.  She states she also has pain to the hip with motion of the leg.  She denies any numbness or paresthesias.  She states prior to this, she was relatively active within her home.  She does care for her daughter who has a mess.  The patient denies any other injuries.  Denies back pain.,PREVIOUS MEDICAL HISTORY:,  Extensive including coronary artery disease, peripheral vascular disease, status post MI, history of COPD, diverticular disease, irritable bowel syndrome, GERD, PMR, depressive disorder, and hypertension.,PREVIOUS SURGICAL HISTORY:,  Includes a repair of a right intertrochanteric femur fracture.,ALLERGIES,1.  PENICILLIN.,2.  SULFA.,3.  ACE INHIBITOR.,PRESENT MEDICATIONS,1.  Lipitor 20 mg q.d.,2.  Metoprolol 25 mg b.i.d.,3.  Plavix 75 mg once a day.,4.  Aspirin 325 mg.,5.  Combivent Aerosol two puffs twice a day.,6.  Protonix 40 mg q.d.,7.  Fosamax 70 mg weekly.,8.  Multivitamins including calcium and vitamin D.,9.  Hydrocortisone.,10.  Nitroglycerin.,11.  Citalopram 20 mg q.d.,SOCIAL HISTORY:,  She denies alcohol or tobacco use.  She is the caretaker for her daughter, who is widowed and lives at home.,FAMILY HISTORY:,  Not obtainable.,REVIEW OF SYSTEMS: , Patient is hard of hearing.  She also has vision problems.  Denies headache syndrome.  Presently, denies chest pain or shortness of breath.  She denies abdominal pain.  Presently, she has left hip pain and left shoulder pain.  No urinary frequency or dysuria.  No skin lesions.  She does have swelling to both lower extremities for the last several weeks.  She denies endocrinopathies.  Psychiatric issues include chronic depression.,PHYSICAL EXAMINATION,GENERAL:  The patient is alert and responsive.,EXTREMITIES:  The left upper extremity, there is moderate swelling and ecchymosis to the brachial compartment.  She is diffusely tender over the proximal humerus.  She is unable to actively elevate her arm due to pain.  The neurovascular exam to the left upper extremity is otherwise intact with a 1+ radial pulse.  She does have chronic degenerative change to the MP and IP joints of both hands.  The left lower extremity, the thigh compartment is supple.  She has pain with log rolling tenderness over the greater trochanter.  The patient has pain with any attempt at hip flexion passively or actively.  The knee range of motion between 5 and 60 degrees with no point specific tenderness, no joint effusion, and an intact extensive mechanism.  She has 2 to 3+ bilateral pitting edema pretibially and pedally.  The patient has a weak motor response to the left lower extremity.  She has a 1+ dorsalis pedis pulse.  Her sensory examination is intact plantarly and dorsally on the foot.,RADIOGRAPHS:,  Left shoulder series was performed which identifies a three-part valgus-impacted left proximal humerus fracture with displacement of the greater tuberosity fragment approximately 1 cm.  There is no evidence of dislocation.  There was an AP pelvis as well as left hip series, which identify a nondisplaced valgus-impacted type 1 femoral neck fracture.  There is also evidence of severe degenerative disk disease with degenerative scoliosis of the LS spine.  There is evidence of previous surgical repair of the right proximal femur with an intact intramedullary nail.,LABORATORY STUDIES: , Patient's H&H is 13 and 38.7, white blood cell count is 6.9, and there are 198,000 platelets.  Electrolytes, sodium 137, potassium 4.1, chloride 102, CO2 is 27, BUN is 20, and creatinine 0.62.  Urinalysis, the urine is clear yellow, 0 to 2 white cells, and no bacteria.,ASSESSMENT,1.  This is an 88-year-old household ambulator with a walker, status post fall with injuries to left shoulder and left hip.  The left shoulder fracture is a valgus-impacted proximal humerus fracture and the left hip is a nondisplaced type 1 femoral neck fracture.,2.  Extensive medical history including coronary artery disease, peripheral vascular disease, and chronic obstructive pulmonary disease on Plavix.,PLAN:,  I have discussed this case with the emergency room physician as well as the patient.  Patient should be admitted to medical service for medical clearance for surgery of her left hip, which will include a percutaneous screw fixation.  Since the patient is on Plavix, I recommend that the Plavix be discontinued and should be placed on Lovenox 30 mg subcu q.d. which may be stopped 24 hours before the procedure.  She will need cardiology clearance, which would include an echo in advance of the procedure.  I have explained the nature of the injuries to the patient, the recommended surgical procedures, and the postop course and rehabilitation required thereafter.  She presently understands and agrees with the plan.",
 Patient in ER with upper respiratory infection, General Medicine, ER Report - URI ,"HISTORY OF PRESENT ILLNESS:,  The patient is a two-and-a-half-month-old male who has been sick for the past three to four days.  His mother has described congested sounds with cough and decreased appetite.  He has had no fever.  He has had no rhinorrhea.  Nobody else at home is currently ill.  He has no cigarette smoke exposure.  She brought him to the emergency room this morning after a bad coughing spell.  He did not have any apnea during this episode.,PAST MEDICAL HISTORY:,  Unremarkable.  He has had his two-month immunizations.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 99.1, oxygen saturations 98%, respirations by the nurse at 64, however, at my examination was much slower and regular in the 40s.,GENERAL:  Sleeping, easily aroused, smiling, and in no distress.,HEENT:  Soft anterior fontanelle.  TMs are normal.  Moist mucous membranes.,LUNGS:  Equal and clear.,CHEST:  Without retraction.,HEART:  Regular in rate and rhythm without murmur.,ABDOMEN:  Benign.,DIAGNOSTIC STUDIES:,  Chest x-ray ordered by ER physician is unremarkable, but to me also.,ASSESSMENT:,  Upper respiratory infection.,TREATMENT: , Use the bulb syringe and saline nose drops if there is any mucus in the anterior nares.  Smaller but more frequent feeds.  Discuss proper sleeping position.  Recheck if there is any fever or if he is no better in the next three days.","general medicine, er, uri, emergency room, upper respiratory infection, respiratory, sick, fever, chest,"
" Left elbow pain.  Fracture of the humerus, spiral.  Possible nerve injuries to the radial and median nerve, possibly neurapraxia.", General Medicine, Elbow Pain - Consult ,"CHIEF COMPLAINT: , Left elbow pain.,HISTORY OF PRESENT ILLNESS:  ,This 17-year-old male was fighting with some other kids in Juvenile Hall when he felt some pain in his left elbow, causing sudden pain.  He also has pain in his left ankle, but he is able to walk normally.  He has had previous pain in his left knee.  He denies any passing out, any neck pain at this time even though he did get hit in the head.  He has no chest or abdominal pain.  Apparently, no knives or guns were involved.,PAST MEDICAL HISTORY: , He has had toe problems and left knee pain in the past.,REVIEW OF SYSTEMS: , No coughing, sputum production, dyspnea or chest pain.  No vomiting or abdominal pain.  No visual changes.  No neurologic deficits other than some numbness in his left hand.,SOCIAL HISTORY: , He is in Juvenile Hall for about 25 more days.  He is a nonsmoker.,ALLERGIES: , MORPHINE.,CURRENT MEDICATIONS:  ,Abilify.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Stable.  HEENT:  PERRLA.  EOMI.  Conjunctivae anicteric.  Skull is normocephalic.  He is not complaining of bruising.  HEENT:  TMs and canals are normal.  There is no Battle sign.  NECK:  Supple.  He has good range of motion.  Spinal processes are normal to palpation.  LUNGS:  Clear.  CARDIAC:  Regular rate.  No murmurs or rubs.  EXTREMITIES:  Left elbow is tender.  He does not wish to move it at all.  Shoulder and clavicle are within normal limits.  Wrist is normal to inspection.  He does have some pain to palpation.  Hand has good capillary refill.  He seems to have decreased sensation in all three dermatomes.  He has moderately good abduction of all fingers.  He has moderate opponens strength with his thumb.  He has very good extension of all of his fingers with good strength.,We did an x-ray of his elbow.  He has a spiral fracture of the distal one-third of the humerus, about 13 cm in length.  The proximal part looks like it is in good position.  The distal part has about 6 mm of displacement.  There is no significant angulation.  The joint itself appears to be intact.  The fracture line ends where it appears above the joint.  I do not see any extra blood in the joint.  I do not see any anterior or posterior Siegert sign.,I spoke with Dr. X.  He suggests we go ahead and splint him up and he will follow the patient up.  At this point, it does not seem like there needs to be any surgical revision.  The chance of a compartment syndrome seems very low at this time.,Using 4-inch Ortho-Glass and two assistants, we applied a posterior splint to immobilize his fingers, hand, and wrist all the way up to his elbow to well above the elbow.,He had much better comfort once this was applied.  There was good color to his fingers and again, much better comfort.,Once that was on, I took some 5-inch Ortho-Glass and put in extra reinforcement around the elbow so he would not be moving it, straightening it or breaking the fiberglass.,We then gave him a sling.,We gave him #2 Vicodin p.o. and #4 to go.  Gave him a prescription for #15 more and warned him to take it only at nighttime and use Tylenol or Motrin, and ice in the daytime.,I gave him the name and telephone number of Dr. X whom they can follow up with.  They were warned to come back here if he has increasing neurologic deficits in his hands or any new problems.,DIAGNOSES:,1.  Fracture of the humerus, spiral.,2.  Possible nerve injuries to the radial and median nerve, possibly neurapraxia.,3.  Psychiatric disorder, unspecified.,DISPOSITION:  The patient will follow up as mentioned above.  They can return here anytime as needed.", 
 Aftercare of multiple trauma from an motor vehicle accident., General Medicine, Discharge Summary - Multiple Trauma ,"ADMITTING DIAGNOSIS:,  Aftercare of multiple trauma from an motor vehicle accident.,DISCHARGE DIAGNOSES:,1.  Aftercare following surgery for injury and trauma.,2.  Decubitus ulcer, lower back.,3.  Alcohol induced persisting dementia.,4.  Anemia.,5.  Hypokalemia.,6.  Aftercare healing traumatic fracture of the lower arm.,7.  Alcohol abuse, not otherwise specified.,8.  Aftercare healing traumatic lower leg fracture.,9.  Open wound of the scalp.,10.  Cervical disk displacement with myelopathy.,11.  Episodic mood disorder.,12.  Anxiety disorder.,13.  Nervousness.,14.  Psychosis.,15.  Generalized pain.,16.  Insomnia.,17.  Pain in joint pelvic region/thigh.,18.  Motor vehicle traffic accident, not otherwise specified.,PRINCIPAL PROCEDURES:,  None.,HISTORY OF PRESENT ILLNESS: , As per Dr. X without any changes or corrections.,HOSPITAL COURSE:  ,This is a 50-year-old male, who is initially transferred from Medical Center after treatment for multiple fractures after a motor vehicle accident.  He had a left tibial plateau fracture, right forearm fracture with ORIF, head laceration, and initially some symptoms of head injury.  When he was initially transferred to HealthSouth, he was status post ORIF for his right forearm.  He had a brace placed in the left leg for his left tibial plateau fracture.  He was confused initially and initially started on rehab.  He was diagnosed with some acute psychosis and thought problems likely related to his alcohol abuse history.  He did well from orthopedic standpoint.  He did have a small sacral decubitus ulcer, which was well controlled with the wound care team and healed quite nicely.  He did have some anemia initially and he had dropped down in to the low 9, but he was 9.2 with his lowest on 06/11/2008, which had responded well to iron treatment and by the time of discharge, he was lower at 11.0.  He made slow progress from therapy.  His confusion gradually cleared.  He did have some problems with insomnia and was placed on Seroquel to help with both of his moods and other issues and he did quite well with this.  He did require some Ativan for agitation.  He was on chronic pain medications as an outpatient.  His medications were adjusted here and he did well with this as well.  The patient was followed throughout his entire stay with case management and discussions were made with them and the psychologist concerning the placement upon discharge to an acute alcohol rehab facility; however, the patient refused throughout this entire stay.  We did have orthopedic followup.  He was taken out of his right leg brace the week of 06/16/2008.  He did well with therapy.  Overall, he was doing much and much better.  He had progressed with the therapy to the point where that he was comfortable to go home and receive outpatient therapy and follow up with his primary care physician.  On 06/20/2008, with all parties in agreement, the patient was discharged to home in stable condition.,At the time of discharge, the patient's ambulatory status was much better.  He was using a wheeled walker.  He was able to bear weight on his left leg.  His pain level had been well controlled and his moods had improved dramatically.  He was no longer having any signs of agitation or confusion and he seemed to be at a stable baseline.  His anemia had resolved almost completely and he was doing quite well. ,MEDICATIONS: , On discharge included:,1.  Calcium with vitamin D 1 tablet twice a day.,2.  Ferrous sulfate 325 mg t.i.d.,3.  Multivitamin 1 daily.,4.  He was on nicotine patch 21 mg per 24 hour.,5.  He was on Seroquel 25 mg at bedtime.,6.  He was on Xenaderm for his sacral pressure ulcer.,7.  He was on Vicodin p.r.n. for pain.,8.  Ativan 1 mg b.i.d. for anxiety and otherwise he is doing quite well.,The patient was told to follow up with his orthopedist Dr. Y and also with his primary care physician upon discharge.",
" A white male veteran with multiple comorbidities, who has a history of bladder cancer diagnosed approximately two years ago by the VA Hospital. ", General Medicine, Discharge Summary - 6 ,"DISCHARGE DATE:  MM/DD/YYYY,HISTORY OF PRESENT ILLNESS:  Mr. ABC is a 60-year-old white male veteran with multiple comorbidities, who has a history of bladder cancer diagnosed approximately two years ago by the VA Hospital.  He underwent a resection there.  He was to be admitted to the Day Hospital for cystectomy.  He was seen in Urology Clinic and Radiology Clinic on MM/DD/YYYY.,HOSPITAL COURSE:  Mr. ABC presented to the Day Hospital in anticipation for Urology surgery.  On evaluation, EKG, echocardiogram was abnormal, a Cardiology consult was obtained.  A cardiac adenosine stress MRI was then proceeded, same was positive for inducible ischemia, mild-to-moderate inferolateral subendocardial infarction with peri-infarct ischemia.  In addition, inducible ischemia seen in the inferior lateral septum.  Mr. ABC underwent a left heart catheterization, which revealed two vessel coronary artery disease.  The RCA, proximal was 95% stenosed and the distal 80% stenosed.  The mid LAD was 85% stenosed and the distal LAD was 85% stenosed.  There was four Multi-Link Vision bare metal stents placed to decrease all four lesions to 0%.  Following intervention, Mr. ABC was admitted to 7 Ardmore Tower under Cardiology Service under the direction of Dr. XYZ.  Mr. ABC had a noncomplicated post-intervention hospital course.  He was stable for discharge home on MM/DD/YYYY with instructions to take Plavix daily for one month and Urology is aware of the same.,DISCHARGE EXAM:,VITAL SIGNS:  Temperature 97.4, heart rate 68, respirations 18, blood pressure 133/70.,HEART:  Regular rate and rhythm.,LUNGS:  Clear to auscultation.,ABDOMEN:  Obese, soft, nontender.  Lower abdomen tender when touched due to bladder cancer.,RIGHT GROIN:  Dry and intact, no bruit, no ecchymosis, no hematoma.  Distal pulses are intact.,DISCHARGE LABS:  CBC:  White count 5.4, hemoglobin 10.3, hematocrit 30, platelet count 132, hemoglobin A1c 9.1.  BMP:  Sodium 142, potassium 4.4, BUN 13, creatinine 1.1, glucose 211.  Lipid profile:  Cholesterol 157, triglycerides 146, HDL 22, LDL 106.,PROCEDURES:,1.  On MM/DD/YYYY, cardiac MRI adenosine stress.,2.  On MM/DD/YYYY, left heart catheterization, coronary angiogram, left ventriculogram, coronary angioplasty with four Multi-Link Vision bare metal stents, two placed to the LAD in two placed to the RCA.,DISCHARGE INSTRUCTIONS:  Mr. ABC is discharged home.  He should follow a low-fat, low-salt, low-cholesterol, and heart healthy diabetic diet.  He should follow post-coronary artery intervention restrictions.  He should not lift greater than 10 pounds for seven days.  He should not drive for two days.  He should not immerse in water for two weeks.  Groin site care reviewed with patient prior to being discharged home.  He should check groin for bleeding, edema, and signs of infection.  Mr. ABC is to see his primary care physician within one to two weeks, return to Dr. XYZ's clinic in four to six weeks, appointment card to be mailed him.  He is to follow up with Urology in their clinic on MM/DD/YYYY at 10 o'clock and then to scheduled CT scan at that time.,DISCHARGE DIAGNOSES:,1.  Coronary artery disease status post percutaneous coronary artery intervention to the right coronary artery and to the LAD.,2.  Bladder cancer.,3.  Diabetes.,4.  Dyslipidemia.,5.  Hypertension.,6.  Carotid artery stenosis, status post right carotid endarterectomy in 2004.,7.  Multiple resections of the bladder tumor.,8.  Distant history of appendectomy.,9.  Distant history of ankle surgery.","general medicine, coronary artery disease, heart catheterization, artery disease, bare metal, metal stents, artery intervention, bladder cancer, coronary artery, veteran, surgery, cardiac, inducible, catheterization, ischemia, cancer, urology, stenosed, bladder, heart, artery, coronary, "
" A female with the past medical history of Ewing sarcoma, iron deficiency anemia, hypertension, and obesity.", General Medicine, Discharge Summary - 5 ,"DATE OF ADMISSION:,  MM/DD/YYYY.,DATE OF DISCHARGE: , MM/DD/YYYY.,REFERRING PHYSICIAN: , AB CD, M.D.,ATTENDING PHYSICIAN AT DISCHARGE:,  X Y, M.D.,ADMITTING DIAGNOSES:,1.  Ewing sarcoma.,2.  Anemia.,3.  Hypertension.,4.  Hyperkalemia.,PROCEDURES DURING HOSPITALIZATION:  ,Cycle seven Ifosfamide, mesna, and VP-16 chemotherapy.,HISTORY OF PRESENT ILLNESS: , Ms. XXX is a pleasant 37-year-old African-American female with the past medical history of Ewing sarcoma, iron deficiency anemia, hypertension, and obesity.  She presented initially with a left frontal orbital swelling to Dr. XYZ on MM/DD/YYYY.  A biopsy revealed small round cells and repeat biopsy on MM/DD/YYYY also showed round cells consistent with Ewing sarcoma, genetic analysis indicated a T1122 translocation.  MRI on MM/DD/YYYY showed a 4 cm soft tissue mass without bony destruction.  CT showed similar result.  The patient received her first cycle of chemotherapy on MM/DD/YYYY.  On MM/DD/YYYY, she was admitted to the ED with nausea and vomitting and was admitted to the Hematology and Oncology A Service following her first course of chemotherapy.  She had her last course of chemotherapy on MM/DD/YYYY followed by radiation treatment to the ethmoid sinuses on MM/DD/YYYY.,HOSPITAL COURSE: ,1.  Ewing sarcoma, she presented for cycle seven of VP-16, ifosfamide, and mesna infusions, which she tolerated well throughout the admission.,2.  She was followed for hemorrhagic cystitis with urine dipsticks and only showed trace amounts of blood in the urine throughout the admission.","general medicine, iron deficiency anemia, hypertension and obesity, iron deficiency, urine, anemia, hypertension, chemotherapy, discharge, ewing, sarcoma,"
 Patient admitted after an extensive workup for peritoneal carcinomatosis from appendiceal primary., General Medicine, Discharge Summary - 4 ,"DATE OF ADMISSION: , MM/DD/YYYY.,DATE OF DISCHARGE: , MM/DD/YYYY.,ADMITTING DIAGNOSIS:, Peritoneal carcinomatosis from appendiceal primary.,DISCHARGE DIAGNOSIS:  , Peritoneal carcinomatosis from appendiceal primary.,SECONDARY DIAGNOSIS: , Diarrhea.,ATTENDING PHYSICIAN: , AB CD, M.D.,SERVICE: , General surgery C, Surgery Oncology.,CONSULTING SERVICES:,  Urology.,PROCEDURES DURING THIS HOSPITALIZATION:,  On MM/DD/YYYY, ,1.  Cystoscopy, bilaterally retrograde pyelograms, insertion of bilateral externalized ureteral stents.,2.  Exploratory laparotomy, right hemicolectomy, cholecystectomy, splenectomy, omentectomy, IPHC with mitomycin-C.,HOSPITAL COURSE: , The patient is a pleasant 56-year-old gentleman with no significant past medical history who after an extensive workup for peritoneal carcinomatosis from appendiceal primary was admitted on MM/DD/YYYY.  He was admitted to General Surgery C Service for a routine preoperative evaluation including baseline labs, bowel prep, urology consult for ureteral stent placement.  The patient was taken to the operative suite on MM/DD/YYYY and was first seen by Urology for a cystoscopy with bilateral ureteral stent placement.  Dr. XYZ performed an exploratory laparotomy, right hemicolectomy, cholecystectomy, splenectomy, omentectomy, and IPHC with mitomycin-C.  The procedure was without complications.  The patient was observed closely in the ICU for one day postoperatively for persistent tachycardia after extubation.  He was then transferred to the floor where he has done exceptionally well.,On postoperative day #2, the patient passed flatus and we were able to start a clear liquid diet.  We advanced him as tolerated to a regular health select diet by postoperative day #4.  His pain was well controlled throughout this hospitalization, initially with a PCA pump, which he very seldomly used.  He was then switched over to p.o. pain medicines and has required very little for adequate pain control.  By postoperative date #2, the patient had been out of bed and ambulating in the hallways.  The patient's only problem was with some mild diarrhea on postoperative days #3 and 4.  This was thought to be a result of his right hemicolectomy.  A C. diff toxin was sent and came back negative and he was started on Imodium to manage his diarrhea.  His post-splenectomy vaccines including pneumococcal, HiB, and meningococcal vaccines were administered during his hospitalization.,On the day of discharge, the patient was resting comfortably in the bed without complaints.  He had been afebrile throughout his hospitalization and his vital signs were stable.  Pertinent physical exam findings include that his abdomen was soft, nondistended and nontender with bowel sounds present throughout.  His midline incision is clean, dry, and intact and staples are in place.  He is just six days postop, he will go home with his staples in place and they will be removed on his follow-up appointment.,CONDITION AT DISCHARGE:  ,The patient was discharged in good and stable condition.,DISCHARGE MEDICATIONS:,1.  Multivitamins daily.,2.  Lovenox 40 mg in 0.4 mL solution inject subcutaneously once daily for 14 days.,3.  Vicodin 5/500 mg and take one tablet by mouth every four hours as needed for pain.,4.  Phenergan 12.5 mg tablets, take one tablet by mouth every six hours p.r.n. for nausea.,5.  Imodium A-D tablets take one tablet by mouth b.i.d. as needed for diarrhea.,DISCHARGE INSTRUCTIONS:,  The patient was instructed to contact us with any questions or concerns that may arise.  In addition, he was instructed to contact us, if he would have fevers greater than 101.4, chills, nausea or vomitting, continuing diarrhea, redness, drainage, or warmth around his incision site.  He will be seen in about one week's time in Dr. XYZ's clinic and his staples will be removed at that time.,FOLLOW-UP APPOINTMENT: , The patient will be seen by Dr. XYZ in clinic in one week's time.",
 Disseminated intravascular coagulation and Streptococcal pneumonia with sepsis.  Patient presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation., General Medicine, Disseminated Intravascular Coagulation ,"DIAGNOSES:,1.  Disseminated intravascular coagulation.,2.  Streptococcal pneumonia with sepsis.,CHIEF COMPLAINT: , Unobtainable as the patient is intubated for respiratory failure.,CURRENT HISTORY OF PRESENT ILLNESS: , This is a 20-year-old female who presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation.  At this time, she is being treated aggressively with mechanical ventilation and other supportive measures and has developed disseminated intravascular coagulation with prolonged partial thromboplastin time, prothrombin time, low fibrinogen, and elevated D-dimer.  At this time, I am being consulted for further evaluation and recommendations for treatment.  The nurses report that she has actually improved clinically over the last 24 hours.  Bleeding has been a problem; however, it seems to have been abrogated at this time with factor replacement as well as platelet infusion.  There is no prior history of coagulopathy.,PAST MEDICAL HISTORY:  ,Otherwise nondescript as is the past surgical history.,SOCIAL HISTORY:  ,There were possible illicit drugs.  Her family is present, and I have discussed her case with her mother and sister.,FAMILY HISTORY:  ,Otherwise noncontributory.,REVIEW OF SYSTEMS: , Not otherwise pertinent.,PHYSICAL EXAMINATION:,GENERAL:  She is a sedated, young black female in no acute distress, lying in bed intubated.,VITAL SIGNS:  She has a rate of 67, blood pressure of 100/60, and the respiratory rate per the ventilator approximately 14 to 16.,HEENT:  Her sclerae showed conjunctival hemorrhage.  There are no petechiae.  Her nasal vestibules are clear.  Oropharynx has ET tube in place.,NECK:  No jugular venous pressure distention.,CHEST:  Coarse breath sounds bilaterally.,HEART:  Regular rate and rhythm.,ABDOMEN:  Soft and nontender with good bowel sounds.  There was some oozing around the site of her central line.,EXTREMITIES:  No clubbing, cyanosis, or edema.  There is no evidence of compromise arterial blood flow at the digits or of her hands or feet.,LABORATORY STUDIES:  ,The DIC parameters with a platelet count of approximately 50,000, INR of 2.4, normal PTT at this time, fibrinogen of 200, and a D-dimer of 13.,IMPRESSION/PLAN:  ,At this time is disseminated intravascular coagulation from sepsis from pneumococcal disease.  My recommendation for the patient is to continue factor replacement as you are.  It seems that her clinical course is reversing and simple factor replacement is probably is the best measure at this time.  There is no indication at this point for Xigris.  However, if her coagulopathy does not resolve within the next 24 hours and continue to improve with an elevated fibrinogen, normalization of her coagulation times, I would consider low-dose continuous infusion heparin for abrogation of consumption of coagulation routines and continued supportive infusions.  I will repeat her laboratory studies in the morning and give more recommendations at that time.","general medicine, intravascular, coagulation, pneumonia, thromboplastin time, prothrombin time, disseminated intravascular coagulation, streptococcal pneumonia, intravascular coagulation, infusion, coagulopathy, fibrinogen, respiratory, oropharynx, sepsis, disseminated, "
" A woman presented to the ER with complaints of nausea, vomiting, and epigastric discomfort, ongoing for about 4 to 5 months. ", General Medicine, Discharge Summary - 9 ,"DISCHARGE DIAGNOSIS:,1.  Epigastric pain.  Questionable gastritis, questionable underlying myocardial ischemia.,2.  Congestive heart failure exacerbation.,3.  Small pericardial effusion with no tamponade.,4.  Hypothyroidism.,5.  Questionable subacute infarct versus neoplasm in the pons.,6.  History of coronary artery disease, status post angioplasty and stent.,7.  Hypokalemia.,CLINICAL RESUME: , This 83 year-old woman who presented to the ER with complaints of nausea, vomiting, and epigastric discomfort, ongoing for about 4 to 5 months.  She has had extensive work up and had her gallbladder removed on April 22, 2007, and had an endoscopy, which had demonstrative gastric ulcer disease apparently about a year ago.  She has had abdominal CAT scan and gastric emptying studies which was normal.,A CT scan of the abdomen done on her May 9, 2007, which showed bilateral peripelvic renal cysts and a redundant sigmoid colon.  Otherwise unremarkable.  The patient follows with Dr. XYZ as an outpatient.  The patient had some worsening of her symptoms over the last few days and then came to the ER.  She was admitted.  Please refer to Dr. XYZ initial H&P for complete details.,HOSPITAL COURSE:,1.  Epigastric pain, nausea, and vomiting.  The patient was restituted with antiemetics and her symptoms improved.  It was not clear whether her nausea and abdominal pain were due to gastritis, peptic ulcer disease/gastric ischemia, or cardiac origin.  A brain MRI was also done which basically showed a tiny focus of abnormal enhancement in the pons, which could be subacute like infarct.  However, brain neoplasm could not be excluded.  Other workup including a CT angio did not show any evidence of acute pulmonary emboli.  It showed some moderate cardiomegaly with bilateral pleural effusions, and a small pericardial effusion.  The patient underwent Cardiolite stress test but finished only the resting studies, which was inconclusive.  She refused to complete the stress test.  She was seen by Dr. XYZ in consultation who recommended that the patient should have a small bowel follow through and eventually angiogram as an outpatient.,2.  Congestive heart failure exacerbation.  The patient was treated with ACE inhibitors, diuretics, Aldactone, and Lasix, and improved.  An echocardiogram done showed an ejection fraction of about 30% to 35%, mild water decrease in LV systolic function, with multiple segmental wall motion abnormalities, a small anterior pericardial effusion, but no electrocardiographic signs of cardiac tamponade.  There was some pseudo normal pattern of filling, mild MR and global hypokinesis of the LV.,3.  Small pericardial effusion.  The patient did not have any clinical or echocardiographic evidence of tamponade.,4.  Hypothyroidism.  TSH was quite elevated at 19.,5.  Questionable subacute infarct versus neoplasm in the pons on an MRI of the head.,6.  History of coronary artery disease/angioplasty and stents.,7.  Hyperkalemia.,8.  Patient was doing well.  She was back to her baseline and was refusing further workup and the patient was stable and it was felt she could be safely discharged home to have further testing done as an outpatient.,MEDICATIONS AND ADVICE ON DISCHARGE:,1.  She is to continue taking Coreg 12.5 mg p.o. b.i.d.,2.  Cozaar 50 mg p.o. daily.,3.  Aldactone 25 mg p.o. daily.,4.  Synthroid 0.075 mg p.o. daily.,5.  Carafate 1 gram p.o.  4 times a day.,6.  Claritin 10 mg p.o. daily.,7.  Lasix 20 mg p.o. daily.,8.  K-Dur 20 mEq p.o. daily.,9.  Prilosec 40 mg p.o. daily.,10.  Zofran 4 mg p.o. q.4-6 hourly p.r.n.,She is to follow up with her primary care physician, Dr. XYZ in 2 to 3 days' time.  She is to follow up with Dr. XYZ her cardiologist in 1 to 2 days' time.  She is to follow up with Dr. XYZ from GI as scheduled.  The patient was advised that she will need a small bowel follow through with angiogram which can be arranged by her gastroenterologist as an outpatient.  She was also advised that she would need a repeat MRI of her head in 2 to 3 months' time.  She will also need repeat echocardiogram done in one month for a pericardial effusion.  This can be arranged by her primary care physician.  Repeat TSH to be done in 6 weeks' time.,Over 35 minutes were spent in the patient discharged.",
 Patient with complaints of shortness of breath and was found to have acute COPD exacerbation., General Medicine, Discharge Summary - 2 ,"ADMISSION DIAGNOSIS (ES):,1. Chronic obstructive pulmonary disease.,2. Pneumonia.,3. Congestive heart failure.,4. Diabetes mellitus.,5. Neuropathy.,6. Anxiety.,7. Hypothyroidism.,8. Depression.,9. Hypertension.,DISCHARGE DIAGNOSIS (ES):,1. Severe chronic obstructive pulmonary disease.,2. Diabetes mellitus.,3. Hypothyroidism.,4. Altered mental status, less somnolent, likely secondary to medications, resolved.,5. Lower gastrointestinal bleed.,6. Status post episode of atrial fibrillation.,7. Status post diverticular bleed.,DISCHARGE MEDICATIONS:,1. Albuterol inhaler q.i.d.,2. Xanax 1 mg t.i.d.,3. Cardizem CD 120 mg daily.,4. Colace 100 mg b.i.d.,5. Iron sulfate 325 mg b.i.d.,6. NPH 10 units subcutaneous b.i.d.,7. Atrovent inhaler q.i.d.,8. Statin oral suspension p.o. q.i.d., swish and spit.,9. Paxil 10 mg daily.,10. Prednisone 20 mg daily.,11. Darvocet Darvocet-N 100, one q.4h PRN pain.,12. Metamucil one pack b.i.d.,13. Synthroid 50 mcg daily.,14. Nexium 40 mg daily.,HOSPITAL COURSE:, The patient was a 66-year-old who presented with complaints of shortness of breath and was found to have acute COPD exacerbation. She had previously been at outlying hospital and had left AMA after 10 sets of BiPAP use. Here she was able to be kept off BiPAP later and slowly improved her exacerbation of COPD with the assistance of pulmonary. She was thought to have bronchitis as well and was treated with antibiotics. During hospitalization she developed acute lower GI bleed and was transferred to intensive care unit and transfused packed red blood cells. GI was consulted, performed endoscopy, revealing diverticular disease of the sigmoid colon, with this being the suspected cause of hemorrhage. Plavix is being held for at least 10 days. Lovenox held as well. No further signs of bleeding. The patient's respiratory status did slowly improve to baseline. She is discharged and given the above noted medications. Followup with Dr. Pesce, of diagnostic pulmonary, in the outpatient setting. She will also followup with Dr. Pesce, in the outpatient setting.",
 Patient with fever of unknown origin., General Medicine, Discharge Summary - 7 ,"REASON FOR ADMISSION: , Fever of unknown origin.,HISTORY OF PRESENT ILLNESS: , The patient is a 39-year-old woman with polymyositis/dermatomyositis on methotrexate once a week.  The patient has also been on high-dose prednisone for an urticarial rash.  The patient was admitted because of persistent high fevers without a clear-cut source of infection.  She had been having temperatures of up to 103 for 8-10 days.  She had been seen at Alta View Emergency Department a week prior to admission.  A workup there including chest x-ray, blood cultures, and a transthoracic echocardiogram had all remained nondiagnostic, and were normal.  Her chest x-ray on that occasion was normal.  After the patient was seen in the office on August 10, she persisted with high fevers and was admitted on August 11 to Cottonwood Hospital.  Studies done at Cottonwood:  CT scan of the chest, abdomen, and pelvis.  Results:  CT chest showed mild bibasilar pleural-based interstitial changes.  These were localized to mid and lower lung zones.  The process was not diffuse.  There was no ground glass change.  CT abdomen and pelvis was normal.  Infectious disease consultation was obtained.  Dr. XYZ saw the patient.  He ordered serologies for CMV including a CMV blood PCR.  Next serologies for EBV, Legionella, Chlamydia, Mycoplasma, Coccidioides, and cryptococcal antigen, and a PPD.  The CMV serology came back positive for IgM.  The IgG was negative.  The CMV blood PCR was positive, as well.  Other serologies and her PPD stayed negative.  Blood cultures stayed negative.,In view of the positive CMV, PCR, and the changes in her CAT scan, the patient was taken for a bronchoscopy.  BAL and transbronchial biopsies were performed.  The transbronchial biopsies did not show any evidence of pneumocystis, fungal infection, AFB.  There was some nonspecific interstitial fibrosis, which was minimal.  I spoke with the pathologist, Dr. XYZ and immunopathology was done to look for CMV.  The patient had 3 nucleoli on the biopsy specimens that stained positive and were consistent with CMV infection.  The patient was started on ganciclovir once her CMV serologies had come back positive.  No other antibiotic therapy was prescribed.  Next, the patient's methotrexate was held.,A chest x-ray prior to discharge showed some bibasilar disease, showing interstitial infiltrates.  The patient was given ibuprofen and acetaminophen during her hospitalization, and her fever resolved with these measures.,On the BAL fluid cell count, the patient only had 5 WBCs and 5 RBCs on the differential.  It showed 43% neutrophils, 45% lymphocytes.,Discussions were held with Dr. XYZ, Dr. XYZ, her rheumatologist, and with pathology.,DISCHARGE DIAGNOSES:,1.  Disseminated CMV infection with possible CMV pneumonitis.,2.  Polymyositis on immunosuppressive therapy (methotrexate and prednisone).,DISCHARGE MEDICATIONS:,1.  The patient is going to go on ganciclovir 275 mg IV q.12 h. for approximately 3 weeks.,2.  Advair 100/50, 1 puff b.i.d.,3.  Ibuprofen p.r.n. and Tylenol p.r.n. for fever, and will continue her folic acid.,4.  The patient will not restart for methotrexate for now.,She is supposed to follow up with me on August 22, 2007 at 1:45 p.m.  She is also supposed to see Dr. XYZ in 2 weeks, and Dr. XYZ in 2-3 weeks.  She also has an appointment to see an ophthalmologist in about 10 days' time.  This was a prolonged discharge, more than 30 minutes were spent on discharging this patient.","general medicine, fever of unknown origin, blood cultures, transbronchial biopsies, infection, cmv, admission, illness, interstitial, fever, serologies, chest, nondiagnostic, methotrexate"
 Patient with increased shortness of breath of one day duration., General Medicine, Discharge Summary - 3 ,"DISCHARGE DIAGNOSES:,1. Chronic obstructive pulmonary disease with acute hypercapnic respiratory failure.,2. Chronic atrial fibrillation with prior ablation done on Coumadin treatment.,3. Mitral stenosis.,4. Remote history of lung cancer with prior resection of the left upper lobe.,5. Anxiety and depression.,HISTORY OF PRESENT ILLNESS:, Details are present in the dictated report.,BRIEF HOSPITAL COURSE:, The patient is a 71-year-old lady who came in with increased shortness of breath of one day duration. She denied history of chest pain or fevers or cough with purulent sputum at that time. She was empirically treated with a course of antibiotics of Avelox for ten days. She also received steroids, prednisolone 60 mg, and breathing treatments with albuterol, Ipratropium and her bronchodilator therapy was also optimized with theophylline. She continued to receive Coumadin for her chronic atrial fibrillation. Her heart rate was controlled and was maintained in the 60s-70s. On the third day of admission she developed worsening respiratory failure with fatigue, and hence was required to be intubated and ventilated. She was put on mechanical ventilation from 1/29 to 2/6/06. She was extubated on 2/6 and put on BI-PAP. The pressures were gradually increased from 10 and 5 to 15 of BI-PAP and 5 of E-PAP with FIO2 of 35% at the time of transfer to Kindred. Her bronchospasm also responded to the aggressive bronchodilation and steroid therapy.,DISCHARGE MEDICATIONS:, Prednisolone 60 mg orally once daily, albuterol 2.5 mg nebulized every 4 hours, Atrovent Respules to be nebulized every 6 hours, Pulmicort 500 micrograms nebulized twice every 8 hours, Coumadin 5 mg orally once daily, magnesium oxide 200 mg orally once daily.,TRANSFER INSTRUCTIONS:, The patient is to be strictly kept on bi-level PAP of 15 I-PAP/E-PAP of 5 cm and FIO2 of 35% for most of the times during the day. She may be put on nasal cannula 2 to 3 liters per minute with an O2 saturation of 90-92% at meal times only, and that is to be limited to 1-2 hours every meal. On admission her potassium had risen slightly to 5.5, and hence her ACE inhibitor had to be discontinued. We may restart it again at a later date once her blood pressure control is better if required.","general medicine, chronic obstructive pulmonary disease, hypercapnic respiratory failure, atrial fibrillation, chronic atrial fibrillation, increased shortness of breath, shortness of breath, increased shortness, coumadin, atrial,"
 A white female with a history of fevers., General Medicine, Discharge Summary - 8 ,"DISCHARGE DIAGNOSES:,1.  Gram-negative rod bacteremia, final identification and susceptibilities still pending.,2.  History of congenital genitourinary abnormalities with multiple surgeries before the 5th grade.,3.  History of urinary tract infections of pyelonephritis.,OPERATIONS PERFORMED: , Chest x-ray July 24, 2007, that was normal.  Transesophageal echocardiogram July 27, 2007, that was normal.  No evidence of vegetations.  CT scan of the abdomen and pelvis July 27, 2007, that revealed multiple small cysts in the liver, the largest measuring 9 mm.  There were 2-3 additional tiny cysts in the right lobe.  The remainder of the CT scan was normal.,HISTORY OF PRESENT ILLNESS: , Briefly, the patient is a 26-year-old white female with a history of fevers.  For further details of the admission, please see the previously dictated history and physical.  ,HOSPITAL COURSE:,  Gram-negative rod bacteremia.  The patient was admitted to the hospital with suspicion of endocarditis given the fact that she had fever, septicemia, and Osler nodes on her fingers.  The patient had a transthoracic echocardiogram as an outpatient, which was equivocal, but a transesophageal echocardiogram here in the hospital was normal with no evidence of vegetations.  The microbiology laboratory stated that the Gram-negative rod appeared to be anaerobic, thus raising the possibility of organisms like bacteroides.  The patient does have a history of congenital genitourinary abnormalities which were surgically corrected before the fifth grade.  We did a CT scan of the abdomen and pelvis, which only showed some benign appearing cysts in the liver.  There was nothing remarkable as far as her kidneys, ureters, or bladder were concerned.  I spoke with Dr. XYZ of infectious diseases, and Dr. XYZ asked me to talk to the patient about any contact with animals, given the fact that we have had a recent outbreak of tularemia here in Utah.  Much to my surprise, the patient told me that she had multiple pet rats at home, which she was constantly in contact with.  I ordered tularemia and leptospirosis serologies on the advice of Dr. XYZ, and as of the day after discharge, the results of the microbiology still are not back yet.  The patient, however, appeared to be responding well to levofloxacin.  I gave her a 2-week course of 750 mg a day of levofloxacin, and I have instructed her to follow up with Dr. XYZ in the meantime.  Hopefully by then we will have a final identification and susceptibility on the organism and the tularemia and leptospirosis serologies will return.  A thought of ours was to add doxycycline, but again the patient clinically appeared to be responding to the levofloxacin.  In addition, I told the patient that it would be my recommendation to get rid of the rats.  I told her that if indeed the rats were carriers of infection and she received a zoonotic infection from exposure to the rats, that she could be in ongoing continuing danger and her children could also potentially be exposed to a potentially lethal infection.  I told her very clearly that she should, indeed, get rid of the animals.  The patient seemed reluctant to do so at first, but I believe with some coercion from her family, that she finally came to the realization that this was a recommendation worth following.,  ,DISPOSITION,DISCHARGE INSTRUCTIONS: , Activity is as tolerated.  Diet is as tolerated.,MEDICATIONS: , Levaquin 750 mg daily x14 days.,Followup is with Dr. XYZ of infectious diseases.  I gave the patient the phone number to call on Monday for an appointment.  Additional followup is also with Dr. XYZ, her primary care physician.  Please note that 40 minutes was spent in the discharge.","general medicine, abdomen and pelvis, gram negative rod, congenital genitourinary, genitourinary abnormalities, transesophageal echocardiogram, infectious diseases, leptospirosis serologies, gram negative, ct scan, identification, infections, levofloxacin, additional, discharge"
" Intractable migraine with aura.  The patient is discharged home.  Secondary diagnoses are Bipolar disorder, iron deficiency anemia, anxiety disorder, and history of tubal ligation.", General Medicine, Discharge Summary - Migraine ,"ADMITTING DIAGNOSIS: , Intractable migraine with aura.,DISCHARGE DIAGNOSIS:,  Migraine with aura.,SECONDARY DIAGNOSES:,1.  Bipolar disorder.,2.  Iron deficiency anemia.,3.  Anxiety disorder.,4.  History of tubal ligation.,PROCEDURES DURING THIS HOSPITALIZATION:,1.  CT of the head with and without contrast, which was negative.,2.  An MRA of the head and neck with and without contrast also negative.,3.  The CTA of the neck also read as negative.,4.  The patient also underwent a lumbar puncture in the Emergency Department, which was grossly unremarkable though an opening pressure was not obtained.,HOME MEDICATIONS:,1.  Vicodin 5/500 p.r.n.,2.  Celexa 40 mg daily.,3.  Phenergan 25 mg p.o. p.r.n.,4.  Abilify 10 mg p.o. daily.,5.  Klonopin 0.5 mg p.o. b.i.d.,6.  Tramadol 30 mg p.r.n.,7.  Ranitidine 150 mg p.o. b.i.d.,ALLERGIES:,  SULFA drugs.,HISTORY OF PRESENT ILLNESS: , The patient is a 25-year-old right-handed Caucasian female who presented to the emergency department with sudden onset of headache occurring at approximately 11 a.m. on the morning of the July 31, 2008.  She described the headache as worse in her life and it was also accompanied by blurry vision and scotoma.  The patient also perceived some swelling in her face.  Once in the Emergency Department, the patient underwent a very thorough evaluation and examination.  She was given the migraine cocktail.  Also was given morphine a total of 8 mg while in the Emergency Department.  For full details on the history of present illness, please see the previous history and physical.,BRIEF SUMMARY OF HOSPITAL COURSE:  ,The patient was admitted to the neurological service after her headache felt to be removed with the headache cocktail.  The patient was brought up to 4 or more early in the a.m. on the August 1, 2008 and was given the dihydroergotamine IV, which did allow some minimal resolution in her headache immediately.  At the time of examination this morning, the patient was feeling better and desired going home.  She states the headache had for the most part resolved though she continues to have some diffuse trigger point pain.,PHYSICAL EXAMINATION AT THE TIME OF DISCHARGE: , General physical exam was unremarkable.  HEENT:  Pupils were equal and respond to light and accommodation bilaterally.  Extraocular movements were intact.  Visual fields were intact to confrontation.  Funduscopic exam revealed no disc pallor or edema.  Retinal vasculature appeared normal.  Face is symmetric.  Facial sensation and strength are intact.  Auditory acuities were grossly normal.  Palate and uvula elevated symmetrically.  Sternocleidomastoid and trapezius muscles are full strength bilaterally.  Tongue protrudes in midline.  Mental status exam: revealed the patient alert and oriented x 4.  Speech was clear and language is normal.  Fund of knowledge, memory, and attention are grossly intact.  Neurologic exam:  Vasomotor system revealed full power throughout.  Normal muscle tone and bulk.  No pronator drift was appreciated.  Coordination was intact to finger-to-nose, heel-to-shin and rapid alternating movement.  No tremor or dysmetria.  Excellent sensory.  Sensation is intact in all modalities throughout. The patient does have notable trigger points diffusely including the occiput, trapezius bilaterally, lumbar, back, and sacrum.  Gait was assessed, the patient's routine and tandem gait were normal.  The patient is able to balance on heels and toes.  Romberg is negative.  Reflexes are 2+ and symmetric throughout.  Babinski reflexes are plantar.,DISPOSITION:,  The patient is discharged home.,INSTRUCTIONS FOR FOLLOWUP:  ,The patient is to followup with her primary care physician as needed.",
" The patient is a 93-year-old Caucasian female with a past medical history of chronic right hip pain, osteoporosis, hypertension, depression, and chronic atrial fibrillation admitted for evaluation and management of severe nausea and vomiting and urinary tract infection.", General Medicine, Discharge Summary - 19 ,"PRIMARY DISCHARGE DIAGNOSES:,1.  Urinary tract infection.,2.  Gastroenteritis with nausea and vomiting.,3.  Upper gastrointestinal bleed likely secondary to gastritis.,4.  Right hip osteoarthritic pain.,SECONDARY DISCHARGE DIAGNOSES:,1.  Hypertension.,2.  Gastroesophageal reflux disease.,3.  Chronic atrial fibrillation.,4.  Osteoporosis.,5.  Valvular heart disease.,HOSPITAL COURSE SUMMARY: , The patient is 93-year-old Caucasian female with a past medical history of hypertension, chronic atrial fibrillation, gastroesophageal reflux disease, osteoporosis and chronic right hip pain after total hip arthroplasty was admitted to our hospital for complaints of nausea and vomiting and urinary tract infection.  Over the course of her hospitalization, the patient was started on antibiotic regimen and proton pump inhibitors for an episode of coffee-ground emesis.  The patient was managed conservatively and was also provided with physical therapy for chronic right hip pain.,At the time of discharge, the patient continues to complain of right hip pain impairing ability to walk.  The patient denies any chest pain, nausea, vomiting, fever, chills, shortness of breath, abdominal pain or any urine or bowel problems.,PAST MEDICAL HISTORY: , Can be referred to the H&P dictated in the chart.,PAST SURGICAL HISTORY: , Can be referred to the H&P dictated in the chart.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  At the time of discharge temperature 36.6 degree Celsius, pulse rate of 77 per minute, respiratory rate 20 per minute, blood pressure 115/63, and oxygen saturation of 94% on room air.,GENERAL:  The patient is a thin built Caucasian female with no pallor, cyanosis or icterus.  She is alert and oriented x3.,HEENT:  No carotid bruits, JVD, lymphadenopathy or thyromegaly.  Pupils are equally reactive to light and accommodation.,BACK AND EXTREMITY:  Bilateral pitting edema and peripheral pulses are palpable.  The patient has right hip brace/immobilizer.,HEART:  Irregularly irregular heart rhythm, grade 2-3/6 systolic ejection murmur best heard over the aortic area and normal S1 and S2.,CHEST:  Auscultation revealed bibasilar crackles.,ABDOMEN:  Soft, nontender, no organomegaly and bowel sounds are present.,CNS:  Nonfocal.,LABORATORY STUDIES: , WBC 6.5, hemoglobin 12.5, hematocrit 38.9, platelet count 177,000, INR 1.2, sodium 141, potassium 3.6 and serum creatinine of 0.8.  Liver function tests were normal.  The patient's troponin was elevated at 0.05 at the time or presentation, but it trended down to 0.04 on the third set.  Urinalysis revealed trace protein, trace blood, and 10-20 WBCs.  Blood culture showed no growth till date.  Urine culture grew 50-100,000 colonies of Enterococcus susceptible to ampicillin and nitrofurantoin.,Chest x-ray showed enlarged heart with large intrathoracic hiatal hernia.  Lung parenchyma was otherwise clear.,Right hip x-ray showed that the prosthesis was in satisfactory position.  There was small gap between the cancellous bone and the long stem femoral component of the prosthesis, which is within normal limits.,DISCHARGE MEDICATIONS:,1.  Aspirin 81 mg orally once daily.,2.  Calcium with vitamin D two tablets orally once daily.,3.  Nexium 40 mg orally once daily.,4.  Multivitamins with minerals one capsule once daily.,5.  Zoloft 25 mg orally once daily.,6.  Norco 325/10 mg every 6-8 hours as needed for pain.,7.  Systane ophthalmic solution two drops in both eyes every two hours as needed.,8.  Herbal __________ by mouth everyday.,9.  Macrodantin 100 mg orally every six hours for seven days.,ALLERGIES:,  Penicillin.,PROGNOSIS: , Improved.,ASSESSMENT AND DISCHARGE PLAN:  ,The patient is a 93-year-old Caucasian female with a past medical history of chronic right hip pain, osteoporosis, hypertension, depression, and chronic atrial fibrillation admitted for evaluation and management of severe nausea and vomiting and urinary tract infection.,PROBLEM #1: ",
" The patient is a 53-year-old woman with history of hypertension, diabetes, and depression.  Serotonin syndrome secondary to high doses of Prozac and atypical chest pain with myocardial infarction ruled out.", General Medicine, Discharge Summary - 18 ,"ADMISSION DIAGNOSES:,1.  Atypical chest pain.,2.  Nausea.,3.  Vomiting.,4.  Diabetes.,5.  Hypokalemia.,6.  Diarrhea.,7.  Panic and depression.,8.  Hypertension.,DISCHARGE DIAGNOSES:,1.  Serotonin syndrome secondary to high doses of Prozac.,2.  Atypical chest pain with myocardial infarction ruled out.,3.  Diabetes mellitus.,4.  Hypertension.,5.  Diarrhea resolved.,ADMISSION SUMMARY: , The patient is a 53-year-old woman with history of hypertension, diabetes, and depression.  Unfortunately her husband left her 10 days prior to admission and she developed severe anxiety and depression.  She was having chest pains along with significant vomiting and diarrhea.  Of note, she had a nuclear stress test performed in February of this year, which was normal.  She was readmitted to the hospital to rule out myocardial infarction and for further evaluation.,ADMISSION PHYSICAL: , Significant for her being afebrile.  Apparently there was one temperature registered mildly high at 100.  Her blood pressure was 140/82, heart rate 83, oxygen saturation was 100%.  She was tearful.  HEART:  Heart sounds were regular.  LUNGS:  Clear.  ABDOMEN:  Soft.  Apparently there were some level of restlessness and acathexia.  She was also pacing.,ADMISSION LABS:  ,Showed CBC with a white count of 16.9, hematocrit of 46.9, platelets 318,000.  She had 80% neutrophils, no bands.  UA on 05/02 came out negative.  Chemistry panel shows sodium 138, potassium 3.5, creatinine 0.6, calcium 8.3, lactate 0.9, ALT was 39, AST 38, total bilirubin 0.6.  Her initial CK came out at 922.  CK-MB was low.  Troponin was 0.04.  She had a normal amylase and lipase.  Previous TSH few days prior was normal.  Chest x-ray was negative.,HOSPITAL COURSE:,1.  Serotonin syndrome.  After reevaluation of the patient including evaluation of the lab abnormalities it was felt that she likely had serotonin syndrome with obvious restlessness, increased bowel activity, agitation, and elevated white count and CPK.  She did not have fever, tremor or hyperreflexia.  Her CPK improved with IV fluids.  She dramatically improved with this discontinuation of her Prozac.  Her white count came back down towards normal.  At time of discharge, she was really feeling back to normal.,2.  Depression and anxiety with history of panic attacks exacerbated by her husband leaving her 2 weeks ago.  We discussed this.  Also, discussed the situation with a psychiatrist who is available on Friday and I discussed the situation with the patient.  In regards to her medications, we are discontinuing the Prozac and she is being reevaluated by Dr. X on Monday or Tuesday.  Cymbalta has been recommended as a good alternative medication for her.  The patient does have a counselor.  It is going to be difficult for her to go home alone.  I discussed the resources with her.  She has a daughter who will be coming to town in a couple of weeks, but she does have a friend that she can call and stay the next few days with.,3.  Hypertension.  She will continue on her usual medications.,4.  Diabetes mellitus.  She will continue on her usual medications.,5.  Diarrhea resolved.  Her electrolyte abnormalities resolved.  She had received fluid rehydration.,DISPOSITION:,  She is being discharged to home.  She will stay with a friend for a couple of days.  She will be following up with Dr. X on Monday or Tuesday.  Apparently Dr. Y has already discussed the situation and the plan with her.  She will continue on her usual medications except for discontinuing the Prozac.,DISCHARGE MEDICATIONS: , Include,1.  Omeprazole 20 mg daily.,2.  Temazepam 15 mg at night.,3.  Ativan 1 mg one-half to one three times a day as needed.,4.  Cozaar 50 daily.,5.  Prandin 1 mg before meals.,6.  Aspirin 81 mg.,7.  Multivitamin daily.,8.  Lantus 60 units at bedtime.,9.  Percocet 10/325 one to two at night for chronic pain.  She is running out of that, so we are calling a prescription for #10 of those.",
" Bradycardia, dizziness, diabetes, hypertension, abdominal pain, and sick sinus syndrome.", General Medicine, Discharge Summary - 13 ,"ADMITTING DIAGNOSES:,1.  Bradycardia.,2.  Dizziness.,3.  Diabetes.,4.  Hypertension.,5.  Abdominal pain.,DISCHARGE DIAGNOSIS:,  Sick sinus syndrome.  The rest of her past medical history remained the same.,PROCEDURES DONE: , Permanent pacemaker placement after temporary internal pacemaker.,HOSPITAL COURSE: , The patient was admitted to the intensive care unit.  Dr. X was consulted.  A temporary intracardiac pacemaker was placed.  Consultation was requested to Dr. Y. He considered the need to have a permanent pacemaker after reviewing electrocardiograms and telemetry readings.  The patient remained in sinus rhythm with severe bradycardias, but all of them one to one transmission.  This was considered to be a sick sinus syndrome.  Permanent pacemaker was placed on 09/05/2007 with right atrium appendage and right ventricular apex electrode placement.  This is a Medtronic pacemaker.  After this, the patient remained with pain in the left side of the chest in the upper area as expected, but well controlled.  Right femoral artery catheter was removed.  The patient remained with good pulses in the right lower extremity with no hematoma.  Other problem was the patient's blood pressure, which on 09/05/2007 was found at 180/90.  Medication was adjusted to benazepril 20 mg a day.  Norvasc 5 mg was added as well.  Her blood pressure has remained better, being today 144/74 and 129/76.,FINAL DIAGNOSES:  ,Sick sinus syndrome.  The rest of her past medical history remained without change, which are:,1.  Diabetes mellitus.,2.  History of peptic ulcer disease.,3.  Hypertension.,4.  Insomnia.,5.  Osteoarthritis.,PLAN: , The patient is discharged home to continue her previous home medications, which are:,1.  Actos 45 mg a day.,2.  Bisacodyl 10 mg p.o. daily p.r.n. constipation.,3.  Cosopt eye drops, 1 drop in each eye 2 times a day.,4.  Famotidine 20 mg 1 tablet p.o. b.i.d.,5.  Lotemax 0.5% eye drops, 1 drop in each eye 4 times a day.,6.  Lotensin (benazepril) increased to 20 mg a day.,7.  Triazolam 0.125 mg p.o. at bedtime.,8.  Milk of Magnesia suspension 30 mL daily for constipation.,9.  Tylenol No.  3, one to two tablets every 6 hours p.r.n. pain.,10.  Promethazine 25 mg IM every 6 hours p.r.n. nausea or vomiting.,11.  Tylenol 325 mg tablets every 4 to 6 hours as needed for pain.,12.  The patient will finish cefazolin 1 g IV every 6 hours, total 5 dosages after pacemaker placement.,DISCHARGE INSTRUCTIONS: , Follow up in the office in 10 days for staple removal.  Resume home activities as tolerated with no starch, sugar-free diet.",
" The patient underwent a scalp skin biopsy with pathology specimen obtained.   At the time of discharge, the patient had improved.", General Medicine, Discharge Summary - 17 ,"FINAL DIAGNOSIS/REASON FOR ADMISSION:,1.  Acute right lobar pneumonia.,2.  Hypoxemia and hypotension secondary to acute right lobar pneumonia.,3.  Electrolyte abnormality with hyponatremia and hypokalemia - corrected.,4.  Elevated liver function tests, etiology undetermined.,5.  The patient has a history of moderate-to-severe dementia, Alzheimer's type.,6.  Anemia secondary to current illness and possible iron deficiency.,7.  Darkened mole on the scalp, status post skin biopsy, pending pathology report.,OPERATION AND PROCEDURE: , The patient underwent a scalp skin biopsy with pathology specimen obtained on 6/11/2009.  Dr. X performed the procedure, thoracentesis on 6/12/2009 both diagnostic and therapeutic.  Dr. Y's results pending.,DISPOSITION: , The patient discharged to long-term acute facility under the care of Dr. Z.,CONDITION ON DISCHARGE: , Clinically improved, however, requiring acute care.,CURRENT MEDICATIONS:  ,Include those on admission combined with IV Flagyl 500 mg every 8 hours and Levaquin 500 mg daily.,HOSPITAL SUMMARY: , This is one of several admissions for this 68-year-old female who over the initial 48 hours preceding admission had a complaint of low-grade fever, confusion, dizziness, and a nonproductive cough.  Her symptoms progressed and she presented to the emergency room at Brighton Gardens where a chest x-ray revealed evolving right lobar infiltrate.  She was started on antibiotics.  Infectious Disease was consulted.  She was initially begun on vancomycin.  Blood, sputum, and urine cultures were obtained; the results of which were negative for infection.  She was switched to IV Levaquin and received IV Flagyl for possible C. diff colitis as well as possible cholecystitis.  During her hospital stay, she initially was extremely relatively hypotensive with mild symptoms and she became dizzy with upright positioning.  Her systolic blood pressure was 60-70 mmHg despite rather aggressive IV fluid management up to 250 mL an hour.  She was seen in consultation by Dr. Y who monitored her fluid and pulmonary treatment.  Due to some elevated liver function tests, she was seen in consultation by Dr. X.  An ultrasound was negative; however, she did undergo CT scan of the chest and abdomen and there was a suspicion of fluid circling the gallbladder.  A HIDA scan was performed and revealed no evidence of gallbladder dysfunction.  Liver functions were monitored throughout her stay and while elevated, did reduce to approximately 1.5 times normal value.  She also was seen in consultation by Infectious Disease who followed her for several days and agreed with current management of antibiotics.  Over her week-stay, the patient was moderately hypoxemic with room air pulse oximetry of 90%.  She was placed on incentive spirometry and over the succeeding days, she did have improved pulmonary function.,LABORATORY TESTS: , Initially revealed a white count of 13,000, however, approximately 24 hours following admission her white count stabilized and in fact remained normal throughout her stay.  Blood cultures were negative at 5 days.  Sputum culture was negative.  Urine culture was negative and thoracentesis culture negative at 24 hours.  The patient did receive 2 units of packed red cells with the hemoglobin drop to 9 for cardiovascular support, as no evidence of GI bleeding was obtained.  Her most recent blood work on 6/14/2009 revealed a white count of 7000 and hemoglobin of 12.1 with a hematocrit of 36.8.  Her PT and PTT were normal.  Occult blood studies were negative for occult blood.  Hepatitis B antigen was negative.  Hepatitis A antibody IgM was negative.  Hepatitis B core IgM negative, and hepatitis C core antibody was negative.  At the time of discharge on 6/14/2009, sodium was 135, potassium was 3.7, calcium was 8.0, her ALT was 109, AST was 70, direct bilirubin was 0.2, LDH was 219, serum iron was 7, total iron unbound 183, and ferritin level was 267.,At the time of discharge, the patient had improved.  She complained of some back discomfort and lumbosacral back x-ray did reveal some evidence of mild degenerative disk disease with no obvious compression fracture acute noted and she will be followed by Dr. Z.","general medicine, pneumonia, hypoxemia, hypotension, electrolyte abnormality, anemia, scalp skin biopsy, liver function tests, lobar pneumonia, infectious disease, skin biopsy, white count, cultures"
" Upper respiratory illness with apnea, possible pertussis.  a one plus-month-old female with respiratory symptoms for approximately a week prior to admission.  This involved cough, post-tussive emesis, and questionable fever.", General Medicine, Discharge Summary - 16 ,"ADMISSION DIAGNOSIS: , Upper respiratory illness with apnea, possible pertussis.,DISCHARGE DIAGNOSIS: , Upper respiratory illness with apnea, possible pertussis.,COMPLICATIONS: , None.,OPERATIONS: , None,BRIEF HISTORY AND PHYSICAL: , This is a one plus-month-old female with respiratory symptoms for approximately a week prior to admission.  This involved cough, post-tussive emesis, questionable fever, but only 99.7.  Their usual doctor prescribed amoxicillin over the phone.  The coughing persisted and worsened.  She went to the ER, where sats were normal at baseline, but dropped into the 80s with coughing spells.  They did witness some apnea.  They gave some Rocephin, did some labs, and the patient was transferred to hospital.,PHYSICAL EXAMINATION: , On admission, GENERAL:  Well-developed, well-nourished baby in no apparent distress. HEENT:  There was some nasal discharge.  Remainder of the HEENT was normal.  LUNG:  Had few rhonchi.  No retractions.  No significant coughing or apnea during the admission physical.  ABDOMEN:  Benign.  EXTREMITIES:  Were without any cyanosis.,SIGNIFICANT LABS AND X-RAYS:  ,She had a CBC done Garberville, which showed a white count of 12.4, with a differential of 10 segs, 82 lymphs, 8 monos, hemoglobin of 15, hematocrit 42, platelets 296,000, and a normal BMP.  An x-ray was done and I do not have an official interpretation, but to the admitting physician, Dr. X it showed no significant infiltrate.  Well at hospital, she had a rapid influenza swab done, which was negative.  She had a rapid RSV done, which is still not in the chart, but I believe I was told that it was negative.  She also had a pertussis PCR swab done and a pertussis culture done, neither of which has result in the chart.  I do know that the pertussis culture proved to be negative.,CONSULTATION: , Public Health Department was notified of a case of suspected pertussis.,HOSPITAL COURSE: , The baby was afebrile.  Required no oxygen in the hospital.  Actually fed reasonably well.  Did have one episode of coughing with slight emesis.  Appeared basically quite well between episodes.  Had no apnea witnessed and after overnight observation, the parents were anxious to go home.  The patient was started on Zithromax in the hospital.,CONDITION AND TREATMENT: , The patient was in stable condition and good condition on exam at the time and was discharged home on Zithromax to be followed up in the office within a week.,INSTRUCTIONS TO PATIENT:,  Include usual diet and to follow up within a week, but certainly sooner if the coughing is worse and there is cyanosis or apnea again.","general medicine, emesis, cough, upper respiratory illness, respiratory illness, apnea, pertussis,"
 Gastroenteritis and autism.  She developed constipation one week prior to admission and mother gave her MiraLax and her constipation improved. , General Medicine, Discharge Summary - 15 ,"FINAL DIAGNOSES:,1.  Gastroenteritis.,2.  Autism.,DIET ON DISCHARGE:,  Regular for age.,MEDICATIONS ON DISCHARGE: , Adderall and clonidine for attention deficit hyperactivity disorder.,ACTIVITY ON DISCHARGE: , As tolerated.,DISPOSITION ON DISCHARGE: , Follow up with Dr. X in ABC Office in 1 to 2 weeks.,HISTORY OF PRESENT ILLNESS: , This 10-and-4/12-year-old Caucasian female has autism and is enrolled at ABC School, and she takes Adderall and clonidine for her hyperactivity.  She developed constipation one week prior to admission and mother gave her MiraLax and her constipation improved.  She developed vomiting 3 days prior to admission, but did not have diarrhea.  She voided on the day of admission.  When she presented to the office, her weight was 124 pounds, which was approximately 10 pounds below previous weights and even had a weight of 151.5 pounds, 05/30/2007 and weight of 137.5 pounds, 09/11/2007 with mother giving no good explanation as to why she had lost all this weight.  She was admitted because of the persistent vomiting, but there was concern about the weight loss.,Physical examination on admission was unremarkable except for the obvious signs autistic spectrum disorder.,LABORATORY DATA:  ,Laboratory data included sedimentation rate of 12, magnesium level of 2.2, TSH of 2.63 with normal being 0.34 to 5.60, free T4 of 1.68 with normal being 0.58 to 1.64.  Chest x-ray and abdominal films were unremarkable.  Hemoglobin 14.5, hematocrit 43.5, platelet count 400,000, white blood count 11,800.  Urinalysis was negative for ketones.  Specific gravity 1.023, and negative for protein.  Sodium 137, potassium 3.4, chloride 103, CO2 20, BUN 21, creatinine 0.9, and anion gap 14, glucose 90, total protein 8.1, albumin 4.5, calcium 8.8, bilirubin 1.5, AST 26, ALT 16, alkaline phosphatase 118.  Thyroid peroxidase antibody studies are pending.,HOSPITAL COURSE:  ,The child was observed on IV fluids and advanced to clear liquids and then regular diet as tolerated.  On the second hospital day, mother was comfortable taking her to home.  Mother did not have a good explanation for the weight loss.  In the hospital, her weight was 124 pounds, her height 58 inches, temperature 98.0 degree F., pulse 123, respirations 18, blood pressure 148/94.  Follow up blood pressure were some of them were in the 125 to 70 range making us think her hypertension as labile and perhaps related to the excitement of the admission.,She seem quite happy and in no distress at the time of discharge.  We will follow up in the office and try to further evaluate her for the unexplained weight loss.  She has been taking the Adderall for at least a year, and the mother does not think the Adderall is the cause of the weight loss.  The free T4 is borderline high and probably bears repeating along with further studies for Graves disease as an outpatient.","general medicine, gastroenteritis, autism, constipation, hyperactivity, blood pressure, weight loss, adderall"
" Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, hypertension, and cholecystitis.", General Medicine, Discharge Summary - 11 ,"ADMISSION DIAGNOSES: , Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, and hypertension.,DISCHARGE DIAGNOSES: , Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, hypertension, and cholecystitis.,PROCEDURE: , Laparoscopic cholecystectomy.,SERVICE: , Surgery.,HISTORY OF PRESENT ILLNESS:,  Ms. ABC is a 57-year-old woman.  She suffers from morbid obesity.  She also has diabetes and obstructive sleep apnea.  She was evaluated in the Bariatric Surgical Center for placement of a band.  During her workup, she was noted to have evidence of cholelithiasis.  It was felt that the patient would benefit from removal of her gallbladder prior to having band placement secondary to her diabetes and the risk of infection of the band.  The patient was scheduled to undergo her procedure on 12/31/09; however, at blood glucose check, the patient was noted to be hyperglycemic, her sugar was 438.  She was admitted to the hospital for treatment of her hyperglycemia.,HOSPITAL COURSE: , Ms. ABC was admitted to the hospital.  She was seen by Dr. A.  He put her on an insulin drip.  Her sugars slowly did come down to normal down to between 115 and 134.  On the next day, she was then taken to the operating room, where she underwent her laparoscopic cholecystectomy.  She was noted to be a difficult intubation for the procedure.  There were some indications of chronic cholecystitis, a little bit of edema, mild edema and adhesions of omentum around the gallbladder.  She underwent the procedure.  She tolerated without difficulty.  She was recovered in the Postoperative Care Unit and then returned to the floor.  Her blood sugar postprocedure was noted to be 233.  She was started back on a sliding scale insulin.  She continued to do well and was felt to be stable for discharge following the procedure.,DISCHARGE INSTRUCTIONS:  ,To return to the Medifast diet.  To continue with her blood glucose.  She needs to follow up with Dr. B, and she will see me next week on Friday.  We will determine if we will proceed with her lap band at that time.  She may shower.  She needs to keep her wounds clean and dry.  No heavy lifting.  No driving on narcotic pain medicines.  She needs to continue with her CPAP machine and continue to monitor her sugars.","general medicine, medifast, hyperglycemia, laparoscopic cholecystectomy, medifast diet, cholecystitis, cholelithiasis, diabetes mellitus, hypertension, morbid obesity, obstructive sleep apnea, sleep apnea, diabetes,"
" Acute cerebrovascular accident/left basal ganglia and deep white matter of the left parietal lobe, hypertension, urinary tract infection, and hypercholesterolemia.", General Medicine, Discharge Summary - 1 ,"DISCHARGE DIAGNOSES:,1. Acute cerebrovascular accident/left basal ganglia and deep white matter of the left parietal lobe.,2. Hypertension.,3. Urinary tract infection.,4. Hypercholesterolemia.,PROCEDURES:,1. On 3/26/2006, portable chest, single view. Impression: atherosclerotic change in the aortic knob.,2. On 3/26/2006, chest, portable, single view. Impression: Mild tortuosity of the thoracic aorta, maybe secondary to hypertension; right lateral costophrenic angle is not evaluated due to positioning of the patient.,3. On March 27, 2006, swallowing study: Normal swallowing study with minimal penetration with thin liquids.,4. On March 26, 2006, head CT without contrast: 1) Air-fluid level in the right maxillary sinus suggestive of acute sinusitis; 2) A 1.8-cm oval, low density mass in the dependent portion of the left maxillary sinus is consistent with a retention cyst; 3) Mucoparietal cell thickening in the right maxillary sinus and ethmoid sinuses.,4. IV contrast CT scan of the head is unremarkable.,5. On 3/26/2006, MRI/MRA of the neck and brain, with and without contrast: 1) Changes consistent with an infarct involving the right basal ganglia and deep white matter of the left parietal lobe, as described above; 2) Diffuse smooth narrowing of the left middle cerebral artery that may be a congenital abnormality. Clinical correlation is necessary.,6. On March 27th, echocardiogram with bubble study. Impression: Normal left ventricular systolic function with estimated left ventricular ejection fraction of 55%. There is mild concentric left ventricular hypertrophy. The left atrial size is normal with a negative bubble study.,7. On March 27, 2006, carotid duplex ultrasound showed: 1) Grade 1 carotid stenosis on the right; 2) No evidence of carotid stenosis on the left.,HISTORY AND PHYSICAL: ,This is a 56-year-old white male with a history of hypertension for 15 years, untreated. The patient woke up at 7: 15 a.m. on March 26 with the sudden onset of right-sided weakness of his arm, hand, leg and foot and also with a right facial droop, right hand numbness on the dorsal side, left face numbness and slurred speech. The patient was brought by EMS to emergency room. The patient was normal before he went to bed the prior night. He was given aspirin in the ER. The CT of the brain without contrast did not show any changes. He could not have a CT with contrast because the machine was broken. He went ahead and had the MRI/MRA of the brain and neck, which showed infarct involving the right basal ganglia and deep white matter of the left parietal lobe. Also, there is diffuse smooth narrowing of the left middle cerebral artery.,The patient was admitted to the MICU.,HOSPITAL COURSE PER PROBLEM LIST:,1. Acute cerebrovascular accident: The patient was not a candidate for tissue plasminogen activator. A neurology consult was obtained from Dr. S. She agrees with our treatment for this patient. The patient was on aspirin 325 mg and also on Zocor 20 mg once a day. We also ordered fasting blood lipids, which showed cholesterol of 165, triglycerides 180, HDL cholesterol 22, LDL cholesterol 107. Dr. Farber agreed to treat the risk factors, to not treat blood pressure for the first two weeks of the stroke. We put the patient on p.r.n. labetalol only for systolic blood pressure greater than 200, diastolic blood pressure greater than 120. The patient's blood pressure has been stable and he did not need any blood pressure medications. His right leg kept improving with increased muscle strength and it was 4-5/5, however, his right upper extremity did not improve much and was 0-1/5. His slurred speech has been improved a little bit. The patient started PT, OT and speech therapy on the second day of hospitalization. The patient was transferred out to a regular floor on the same day of admission based on his stable neurologic exam. Also, we added Aggrenox for secondary stroke prevention, suggested by Dr. F. Echocardiogram was ordered and showed normal left ventricular function with bubble study that was negative. Carotid ultrasound only showed mild stenosis on the right side. EKG did not show any changes, so the patient will be transferred to Siskin Rehabilitation Hospital today on Aggrenox for secondary stroke prevention. He will not need blood pressure treatment unless systolic is greater than 220, diastolic greater than 120, for the first week of his stroke. On discharge, on his neurologic exam, he has a right facial palsy from the eye below, he has right upper extremity weakness with 0-1/5 muscle strength, right leg is 4-5/5, improved slurred speech.,2. Hypertension: As I mentioned in item #1, see above, his blood pressure has been stable. This did not need any treatment.,3. Urinary tract infection: The patient had urinalysis on March 26th, which showed a large amount of leukocyte esterase, small amount of blood with red blood cells 34, white blood cells 41, moderate amount of bacteria. The patient was started on Cipro 250 mg p.o. b.i.d. on March 26th. He needs to finish seven days of antibiotic treatment for his UTI. Urine culture and sensitivity were negative.,4. Hypercholesterolemia: The patient was put on Zocor 20 mg p.o. daily. The goal LDL for this patient will be less than 70. His LDL currently is 107, HDL is 22, triglycerides 180, cholesterol is 165.,CONDITION ON DISCHARGE:, Stable.,ACTIVITY: ,As tolerated.,DIET:, Low-fat, low-salt, cardiac diet.,DISCHARGE INSTRUCTIONS:,1. Take medications regularly.,2. PT, OT, speech therapist to evaluate and treat at Siskin Rehab Hospital.,3. Continue Cipro for an additional two days for his UTI.,DISCHARGE MEDICATIONS:,1. Cipro 250 mg, one tablet p.o. b.i.d. for an additional two days.,2. Aggrenox, one tablet p.o. b.i.d.,3. Docusate sodium 100 mg, one cap p.o. b.i.d.,4. Zocor 20 mg, one tablet p.o. at bedtime.,5. Prevacid 30 mg p.o. once a day.,FOLLOW UP:,1. The patient needs to follow up with Rehabilitation Hospital after he is discharged from there.,2. The patient can call the Clinic if he needs a follow up appointment with us, or the patient can find a primary care physician since he has insurance.",
" The patient is a 60-year-old female patient who off and on for the past 10 to 12 months has had almost daily diarrhea, nausea, inability to eat. ", General Medicine, Discharge Summary - 14 ,"HISTORY OF PRESENT ILLNESS: , The patient is a 60-year-old female patient who off and on for the past 10 to 12 months has had almost daily diarrhea, nausea, inability to eat.  She had an EGD and colonoscopy with Dr. ABC a few days prior to this admission.  Colonoscopy did reveal diverticulosis and EGD showed retained bile and possible gastritis.  Biopsies were done.  The patient presented to our emergency room for worsening abdominal pain as well as swelling of the right lower leg.,PAST MEDICAL HISTORY: , Extensive and well documented in prior charts.,PHYSICAL EXAMINATION: , Abdomen was diffusely tender.  Lungs clear.  Blood pressure 129/69 on admission.  At the time of admission, she had just a trace of bilateral lower edema.,LABORATORY STUDIES: , White count 6.7, hemoglobin 13, hematocrit 39.3.  Potassium of 3.2 on 08/15/2007.,HOSPITAL COURSE: , Dr. ABC apparently could not advance the scope into the cecum and therefore warranted a barium enema.  This was done and did not really show what the cecum on the barium enema.  There was some retained stool in that area and the patient had a somewhat prolonged hospital course on the remaining barium from the colon.  She did have some enemas.  She had persistent nausea, headache, neck pain throughout this hospitalization.  Finally, she did improve enough to the point where she could be discharged home.,DISCHARGE DIAGNOSIS: , Nausea and abdominal pain of uncertain etiology.,SECONDARY DIAGNOSIS:  ,Migraine headache.,COMPLICATIONS:  ,None.,DISCHARGE CONDITION: , Guarded.,DISCHARGE PLAN:  ,Follow up with me in the office in 5 to 7 days to resume all pre-admission medications.  Diet and activity as tolerated.","general medicine, diarrhea, nausea, inability to eat, egd, colonoscopy, biopsies, barium enema, cecum, barium, admission,"
 Patient today with ongoing issues with diabetic control., General Medicine, Diabetes Mellitus - SOAP Note - 2 ,"SUBJECTIVE:,  I am asked to see the patient today with ongoing issues around her diabetic control.  We have been fairly aggressively, downwardly adjusting her insulins, both the Lantus insulin, which we had been giving at night as well as her sliding scale Humalog insulin prior to meals.  Despite frequent decreases in her insulin regimen, she continues to have somewhat low blood glucoses, most notably in the morning when the glucoses have been in the 70s despite decreasing her Lantus insulin from around 84 units down to 60 units, which is a considerable change.  What I cannot explain is why her glucoses have not really climbed at all despite the decrease in insulin.  The staff reports to me that her appetite is good and that she is eating as well as ever.  I talked to Anna today.  She feels a little fatigued.  Otherwise, she is doing well.,PHYSICAL EXAMINATION:  ,Vitals as in the chart.  The patient is a pleasant and cooperative.  She is in no apparent distress.,ASSESSMENT AND PLAN: , Diabetes, still with some problematic low blood glucoses, most notably in the morning.  To address this situation, I am going to hold her Lantus insulin tonight and decrease and then change the administration time to in the morning.  She will get 55 units in the morning.  I am also decreasing once again her Humalog sliding scale insulin prior to meals.  I will review the blood glucoses again next week.,","general medicine, diabetic control, insulin prior to meals, low blood glucoses, sliding scale, lantus insulin, diabetes, mellitus, lantus, glucoses,"
" Consult for generalized body aches, cough, nausea, and right-sided abdominal pain for two days - Bronchitis.", General Medicine, Cough & Abdominal Pain ,"CHIEF COMPLAINT: , Cough and abdominal pain for two days.,HISTORY OF PRESENT ILLNESS: , This is a 76-year-old female who has a history of previous pneumonia, also hypertension and macular degeneration, who presents with generalized body aches, cough, nausea, and right-sided abdominal pain for two days.  The patient stated that the abdominal pain was only associated with coughing.  The patient reported that the cough is dry in nature and the patient had subjective fevers and chills at home.,PAST MEDICAL HISTORY:  ,Significant for pneumonia in the past, pleurisy, macular degeneration, hypertension, and phlebitis.,PAST SURGICAL HISTORY:  ,The patient had bilateral cataract extractions in 2007, appendectomy as a child, and three D&Cs in the past secondary to miscarriages.,MEDICATIONS: , On presentation included hydrochlorothiazide 12.5 mg p.o. daily, aspirin 81 mg p.o. daily, and propranolol 40 mg p.o. daily.  The patient also takes multivitamin and Lutein over-the-counter for macular degeneration.,ALLERGIES: , THE PATIENT HAS NO KNOWN DRUG ALLERGIES.,FAMILY HISTORY:,  Mother died at the age of 59 due to stomach cancer and father died at the age of 91 years old.,SOCIAL HISTORY:,  The patient quit smoking 17 years ago; prior to that had smoked one pack per day for 44 years.  Denies any alcohol use.  Denies any IV drug use.,PHYSICAL EXAMINATION:  ,GENERAL:  This is a 76-year-old female, well nourished.  VITAL SIGNS:  On presentation included a temperature of 100.1, pulse of 144 with a blood pressure of 126/77, the patient is saturating at 95% on room air, and has respiratory rate of 20.  HEENT:  Anicteric sclerae.  Conjunctivae pink.  Throat was clear.  Mucosal membranes were dry.  CHEST:  Coarse breath sounds bilaterally at the bases.  CARDIAC:  S1 and S2.  No murmurs, rubs or gallops.  No evidence of carotid bruits.  ABDOMEN:  Positive bowel sounds, presence of soreness on examination in the abdomen on palpation.  There is no rebound or guarding.  EXTREMITIES:  No clubbing, cyanosis or edema.,HOSPITAL COURSE: , The patient had a chest x-ray, which showed increased markings present bilaterally likely consistent with chronic lung changes.  There is no evidence of effusion or consolidation.  Degenerative changes were seen in the shoulder.  The patient also had an abdominal x-ray, which showed nonspecific bowel gas pattern.  Urinalysis showed no evidence of infection as well as her influenza A&B were negative.  Preliminary blood cultures have been with no growth to date status post 48 hours.  The patient was started on cefepime 1 g IV q.12h. and given IV hydration.  She has also been on Xopenex nebs q.8h. round the clock and in regards to her hypertension, she was continued on her hydrochlorothiazide and propranolol.  In terms of prophylactic measures, she received Lovenox subcutaneously for DVT prophylaxis.  Currently today, she feels much improved with still only a mild cough.  The patient has been afebrile for two days, saturating at 97% on room air with a respiratory rate of 18.  Her white count on presentation was 13.6 and yesterday's white count was 10.3.,FINAL DIAGNOSIS:,  Bronchitis.,DISPOSITION: , The patient will be going home.,MEDICATIONS: , Hydrochlorothiazide 12.5 mg p.o. daily, propranolol 40 mg p.o. daily.  Also, Avelox 400 mg p.o. daily x10 days, guaifenesin 10 cc p.o. q.6h. p.r.n. for cough, and aspirin 81 mg p.o. daily.,DIET:,  To follow a low-salt diet.,ACTIVITY:,  As tolerated.,FOLLOWUP:  ,To follow up with Dr. ABC in two weeks.",
" A gentleman with a long history of heroin abuse, trying to get off the heroin, last use shortly prior to arrival including cocaine.  The patient does have a history of alcohol abuse, but mostly he is concerned about the heroin abuse.", General Medicine, Detox from Heroin ,"CHIEF COMPLAINT:,  Detox from heroin.,HISTORY OF PRESENT ILLNESS: , This is a 52-year-old gentleman with a long history of heroin abuse, who keeps relapsing, presents once again, trying to get off the heroin, last use shortly prior to arrival including cocaine.  The patient does have a history of alcohol abuse, but mostly he is concerned about the heroin abuse.,PAST MEDICAL HISTORY: , Remarkable for chronic pain.  He has had multiple stab wounds, gunshot wounds, and a variety of other injuries that resulted him having chronic pain and he states that is what triggers of him getting on heroin to try to get out of pain.  He has previously been followed by ABC but has not seen him for several years.,REVIEW OF SYSTEMS:  ,The patient states that he did use heroin as well as cocaine earlier today and feels under the influence.  Denies any headache or visual complaints.  No hallucinations.  No chest pain, shortness of breath, abdominal pain or back pain.  Denies any abscesses.,SOCIAL HISTORY: , The patient is a smoker.  Admits to heroin use, alcohol abuse as well.  Also admits today using cocaine.,FAMILY HISTORY:,  Noncontributory.,MEDICATIONS: , He has previously been on analgesics and pain medications chronically.  Apparently, he just recently got out of prison.  He has previously also been on Klonopin and lithium.  He was previously on codeine for this pain.,ALLERGIES: , NONE.,PHYSICAL EXAMINATION: , VITAL SIGNS:  The patient is afebrile.  He is markedly hypertensive, 175/104 and pulse 117 probably due to the cocaine onboard.  His respiratory rate is normal at 18.  GENERAL:  The patient is a little jittery but lucid, alert, and oriented to person, place, time, and situation.  HEENT:  Unremarkable.  Pupils are actually moderately dilated about 4 to 5 mm, but reactive.  Extraoculars are intact.  His oropharynx is clear.  NECK:  Supple.  His trachea is midline.  LUNGS:  Clear.  He has good breath sounds and no wheezing.  No rales or rhonchi.  Good air movement and no cough.  CARDIAC:  Without murmur.  ABDOMEN:  Soft and nontender.  He has multiple track marks, multiple tattoos, but no abscesses.  NEUROLOGIC:  Nonfocal.,IMPRESSION: , MEDICAL EXAMINATION FOR THE PATIENT WHO WILL BE DETOXING FROM HEROIN.,ASSESSMENT AND PLAN:  ,At this time, I think the patient can be followed up at XYZ.  I have written a prescription of clonidine and Phenergan for symptomatic relief and this has been faxed to the pharmacy.  I do not think he needs any further workup at this time.  He is discharged otherwise in stable condition.","general medicine, phenergan, detox from heroin, alcohol abuse, heroin abuse, detox, heroin, alcohol, cocaine, abuse,"
" Patient had a piece of glass fall on to his right foot.  A 4-mm laceration.  Acute foot pain, now resolved.   The patient was given discharge instructions on wound care.", General Medicine, Cut on Foot - ER Visit ,"CHIEF COMPLAINT:,  Cut on foot.,HISTORY OF PRESENT ILLNESS:,  This is a 32-year-old male who had a piece of glass fall on to his right foot today.  The patient was concerned because of the amount of bleeding that occurred with it.  The bleeding has been stopped and the patient does not have any pain.  The patient has normal use of his foot, there is no numbness or weakness, the patient is able to ambulate well without any discomfort.  The patient denies any injuries to any other portion of his body.  He has not had any recent illness.  The patient has no other problems or complaints.,PAST MEDICAL HISTORY:,  Asthma.,CURRENT MEDICATION: , Albuterol.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient is a smoker.,PHYSICAL EXAMINATION:,  VITAL SIGNS:  Temperature 98.8 oral, blood pressure 132/86, pulse is 76, and respirations 16.  Oxygen saturation is 100% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well-nourished, well-developed, the patient appears to be healthy.  The patient is calm and comfortable in no acute distress and looks well.  The patient is pleasant and cooperative.  HEENT:  Head is atraumatic, normocephalic, and nontender.  Eyes are normal with clear conjunctiva and cornea bilaterally.  NECK:  Supple with full range of motion.  CARDIOVASCULAR:  Peripheral pulse is +2 to the right foot.  Capillary refills less than two seconds to all the digits of the right foot.  RESPIRATIONS:  No shortness of breath.  MUSCULOSKELETAL:  The patient has a 4-mm partial thickness laceration to the top of the right foot and about the area of the mid foot.  There is no palpable foreign body, no foreign body is visualized.  There is no active bleeding, there is no exposed deeper tissues and certainly no exposed tendons, bone, muscle, nerves, or vessels.  It appears that the laceration may have nicked a small varicose vein, which would have accounted for the heavier than usual bleeding that currently occurred at home.  The patient does not have any tenderness to the foot.  The patient has full range of motion to all the joints, all the toes, as well as the ankles.  The patient ambulates well without any difficulty or discomfort.  There are no other injuries noted to the rest of the body.  SKIN:  The 4-mm partial thickness laceration to the right foot as previously described.  No other injuries are noted.  NEUROLOGIC:  Motor is 5/5 to all the muscle groups of the right lower extremity.  Sensory is intact to light touch to all the dermatomes of the right foot.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is alert and oriented x4.  Normal mood and affect.  HEMATOLOGIC/LYMPHATIC:  No active bleeding is occurring at this time.  No evidence of bruising is noted to the body.,EMERGENCY DEPARTMENT COURSE:,  The patient had antibiotic ointment and a bandage applied to his foot.,DIAGNOSES:,1.  A 4-MM LACERATION TO THE RIGHT FOOT.,2.  ACUTE RIGHT FOOT PAIN, NOW RESOLVED.,CONDITION UPON DISPOSITION: , Stable.,DISPOSITION:,  To home.  The patient was given discharge instructions on wound care and asked to return to emergency room should he have any evidence or signs and symptoms of infection.  The patient was precautioned that there may still be a small piece of glass retained in the foot and that there is a possibility of infection or that the piece of glass may be extruded later on.","general medicine, foot pain, cut on foot, piece of glass, foreign body, active bleeding, foot, injuries, atraumatic, laceration, bleeding, body, "
 A 94-year-old female from the nursing home with several days of lethargy and anorexia.  She was found to have evidence of UTI and also has renal insufficiency and digitalis toxicity., General Medicine, Discharge Summary - 12 ,"CURRENT HISTORY:,  A 94-year-old female from the nursing home with several days of lethargy and anorexia.  She was found to have evidence of UTI.  She also has renal insufficiency and digitalis toxicity.  She is admitted for further treatment.,Past medical history, social history, family history, physical examination can be seen on the admission H&P.,LABORATORIES ON ADMISSION: , White count 11,700, hemoglobin 12.8, hematocrit 37.2, BUN 91, creatinine 2.2, sodium 131, potassium 5.1.  Digoxin level of 4.1.,HOSPITAL COURSE: , The patient was admitted and intravenous fluids and antibiotics were administered.  Blood cultures were negative.  Urine cultures were nondiagnostic.  Renal function improved with creatinine down to 1 at the time of discharge.  Digoxin was restarted at a lower dose.  Her condition improved and she is stabilized and transferred back to assisted living in good condition.,PRIMARY DIAGNOSES:,1.  Urinary tract infection.,2.  Volume depletion.,3.  Renal insufficiency.,4.  Digitalis toxicity.,SECONDARY DIAGNOSES:,1.  Aortic valve stenosis.,2.  Congestive heart failure.,3.  Hypertension.,4.  Chronic anemia.,5.  Degenerative joint disease.,6.  Gastroesophageal reflux disease.,PROCEDURES:,  None.,COMPLICATIONS: , None.,DISCHARGE CONDITION: , Improved and stable.,DISCHARGE PLAN:  ,Physical activity:  With assistance.  ,Diet:  No restriction.  ,Medications:  Lasix 40 mg daily, lisinopril 5 mg daily, digoxin 0.125 mg daily, Augmentin 875 mg 1 tablet twice a day for 1 week, Nexium 40 mg daily, Elavil 10 mg at bedtime, Detrol 2 mg twice a day, potassium 10 mEq daily and diclofenac 50 mg twice a day.  ,Follow up:  She will see Dr. X in the office as scheduled.",
 Patient with a past medical history of hypertension for 15 years., General Medicine, Consult - Hypertension ,"HISTORY OF PRESENT ILLNESS:,  The patient is a 74-year-old white woman who has a past medical history of hypertension for 15 years, history of CVA with no residual hemiparesis and uterine cancer with pulmonary metastases, who presented for evaluation of recent worsening of the hypertension.  According to the patient, she had stable blood pressure for the past 12-15 years on 10 mg of lisinopril.  In August of 2007, she was treated with doxorubicin and, as well as Procrit and her blood pressure started to go up to over 200s.  Her lisinopril was increased to 40 mg daily.  She was also given metoprolol and HCTZ two weeks ago, after she visited the emergency room with increased systolic blood pressure.  Denies any physical complaints at the present time.  Denies having any renal problems in the past.,PAST MEDICAL HISTORY:,  As above plus history of anemia treated with Procrit.  No smoking or alcohol use and lives alone.,FAMILY HISTORY:,  Unremarkable.,PRESENT MEDICATIONS: , As above.,REVIEW OF SYSTEMS: , Cardiovascular:  No chest pain.  No palpitations.  Pulmonary:  No shortness of breath, cough, or wheezing.  Gastrointestinal:  No nausea, vomiting, or diarrhea.  GU:  No nocturia.  Denies having gross hematuria.  Salt intake is minimal.  Neurological:  Unremarkable, except for history of old CVA.,PHYSICAL EXAMINATION: , Blood pressure today is 182/78.  Examination of the head is unremarkable.  Neck is supple with no JVD.  Lungs are clear.  There is no abdominal bruit.  Extremities 1+ edema bilaterally.,LABORATORY DATA:,  Urinalysis done in the office shows 1+ proteinuria; same is shown by urinalysis done at Hospital.  The creatinine is 0.8.  Renal ultrasound showed possible renal artery stenosis and a 2 cm cyst in the left kidney.  MRA of the renal arteries was essentially unremarkable with no suspicion for renal artery stenosis.,IMPRESSION AND PLAN:,  Accelerated hypertension.  No clear-cut etiology for recent worsening since renal artery stenosis was ruled out by negative MRA.  I could only blame Procrit initiation, as well as possible fluid retention as a cause of the patient's accelerated hypertension.  She was started on hydrochlorothiazide less than two weeks ago with some improvement in her hypertension.  At this point, I would not pursue a diagnosis of renal artery stenosis.  Since she is maxed out on lisinopril and her pulse is 60, I would not increase beta-blocker or ACE inhibitor.  I will continue HCTZ at 24 mg daily.  The patient was also given a sample of Tekturna, which would hopefully improve her systolic blood pressure.  The patient was told to be stick with her salt intake.  She will report to me in 10 days with the result of her blood pressure.  She will also repeat an SMA7 to rule out possible hyperkalemia due to Tekturna.","general medicine, hypertension, ace inhibitor, accelerated hypertension, hctz, mra of the renal arteries, procrit, sma7, anemia, beta-blocker, doxorubicin, hemiparesis, history of cva, hyperkalemia, no abdominal bruit, uterine cancer, renal artery stenosis, artery stenosis, blood pressure, blood, pressure, renal,"
" Sepsis, possible SBP.  A 53-year-old Hispanic man with diabetes, morbid obesity, hepatitis C, cirrhosis, history of alcohol and cocaine abuse presented in the emergency room for ground-level fall secondary to weak knees.  He complained of bilateral knee pain, but also had other symptoms including hematuria and epigastric pain for at least a month. ", General Medicine, Consult - Sepsis ,"REASON FOR THE CONSULT: , Sepsis, possible SBP.,HISTORY OF PRESENT ILLNESS: , This is a 53-year-old Hispanic man with diabetes, morbid obesity, hepatitis C, cirrhosis, history of alcohol and cocaine abuse, who presented in the emergency room on 01/07/09 for ground-level fall secondary to weak knees.  He complained of bilateral knee pain, but also had other symptoms including hematuria and epigastric pain for at least a month.  He ran out of prescription medications 1 month ago.  In the ER he was initially afebrile, but then spiked up to 101.3 with heart rate of 130, respiratory rate of 24.  White blood cell count was slightly low at 4 and platelet count was only 22,000.  Abdominal ultrasound showed mild-to-moderate ascites.  He was given 1 dose of Zosyn and then started on levofloxacin and Flagyl last night.  Dr. X was called early this morning due to hypotension, SBP in the 70s.  He then changed antibiotic regiment to vancomycin and doripenem.,PAST MEDICAL HISTORY: , Hepatitis C, cirrhosis, coronary artery disease, hyperlipidemia, chronic venous stasis, gastroesophageal reflux disease, history of exploratory laparotomy for stab wounds, chronic recurrent leg wounds, and hepatic encephalopathy.,SOCIAL HISTORY: , The patient is a former smoker, reportedly quit in 2007.  He used cocaine in the past, reportedly quit in 2005.  He also has a history of alcohol abuse, but apparently quit more than 10 years ago.,ALLERGIES:,  None known.,CURRENT MEDICATIONS: , Vancomycin, doripenem, thiamine, Protonix, potassium chloride p.r.n., magnesium p.r.n., Zofran. p.r.n., norepinephrine drip, and vitamin K.,REVIEW OF SYSTEMS: , Not obtainable as the patient is drowsy and confused.,PHYSICAL EXAMINATION:,CONSTITUTIONAL/VITAL SIGNS:  Heart rate 101, respiratory rate 17, blood pressure 92/48, temperature 97.5, and oxygen saturation 98% on 2 L nasal cannula.,GENERAL APPEARANCE:  The patient is drowsy.  Morbidly obese.  Height 5 feet 8 inches, body weight 182 kilos.,EYES:  Slightly pale conjunctivae, icteric sclerae.  Pupils equal, brisk reaction to light.,EARS, NOSE, MOUTH AND THROAT:  Intact gross hearing.  Moist oral mucosa.  No oral lesions.,NECK:  No palpable neck masses.  Thyroid is not enlarged on inspection.,RESPIRATORY:  Regular inspiratory effort.  No crackles or wheezes.,CARDIOVASCULAR:  Regular cardiac rhythm.  No rales or rubs.  Positive bipedal edema, 2+, right worse than left.,GASTROINTESTINAL:  Globular abdomen.  Soft.  No guarding, no rigidity.  Tender on palpation of n right upper quadrant and epigastric area.  Mildly tender on palpation of right upper quadrant and epigastric area.,LYMPHATIC:  No cervical lymphadenopathy.,SKIN:  Positive diffuse jaundice.  No palpable subcutaneous nodules.,PSYCHIATRIC:  Poor judgment and insight.,LABORATORY DATA: , White blood cell count from 01/08/09 is 9 with 68% neutrophils, 20% bands, H&H 9.7/28.2, platelet count 24,000.  INR 3.84, PTT more than 240.  BUN and creatinine 26.8/1.2.  AST 76, ALT 27, alkaline phosphatase 48, total bilirubin 17.85.  Total CK 1198.6, LDH 873.2.  Troponin 0.09, myoglobin 2792.  Urinalysis from 01/07/09 shows small leucocyte esterase, positive nitrites, 1 to 3 wbc's, 0 to 1 rbc's, 2+ bacteria.  Two sets of blood cultures from 01/07/09 still pending.,RADIOLOGY:,  Chest x-ray from 01/07/09 did not show any pathologic abnormalities of the heart, mediastinum, lung fields, bony or soft tissue structures.  Left knee x-rays on 01/07/09 showed advanced osteoarthritis.  Abdominal ultrasound on 01/07/09 showed mild-to-moderate ascites, mild prominence of the gallbladder with thickened ball and pericholecystic fluid.  Preliminary report of CAT scan of the abdomen showed changes consistent to liver cirrhosis and portal hypertension with mild ascites, splenomegaly, and dilated portal/splenic and superior mesenteric vein.  Appendix was not clearly seen, but there was no evidence of pericecal inflammation.,IMPRESSION:,1.  Septic shock.,2.  Possible urinary tract infection.,3.  Ascites, rule out spontaneous bacterial peritenonitis.,4.  Hyperbilirubinemia, consider cholangitis.,5.  Alcoholic liver disease.,6.  Thrombocytopenia.,7.  Hepatitis C.,8.  Cryoglobulinemia.,RECOMMENDATIONS:,1.  Continue with vancomycin and doripenem at this point.,2.  Agree with paracentesis.,3.  Send ascitic fluid for cell count, differential and cultures.,4.  Follow up with result of blood cultures.,5.  We will get urine culture from the specimen on admission.,6.  The patient needs hepatitis A vaccination.,Additional ID recommendations as appropriate upon followup.",
 The patient needs refills on her Xanax, General Medicine, Consult - Smoking Cessation  ,"CHIEF COMPLAINT: , I need refills.,HISTORY OF PRESENT ILLNESS:,  The patient presents today stating that she needs refills on her Xanax, and she would also like to get something to help her quit smoking.  She is a new patient today.  She states that she has mesothelioma in the lining of her stomach and that it does cause her some problems with eating and it causes some chronic pain.  She states that she is under the care of a cancer specialist; however, she just recently moved back to this area and is trying to find a doctor a little closer than his office.  She states that she has tried several different things to help her quit smoking and she has failed everything and had heard good results about Chantix and wanted to give it a try.,OBJECTIVE:  ,Well developed and well nourished.  She does not appear to be in any acute distress.  Cardiovascular:  Regular rhythm.  No murmurs, gallops, or rubs.  Capillary refill less than 3 seconds.  Peripheral pulses are 2+ bilaterally.  Respiratory:  Her lungs are clear to auscultation bilaterally with good effort.  No tenderness to palpation over chest wall.  Musculoskeletal:  She has full range of motion of all four extremities.  No tenderness to palpation over long bones.  Skin:  Warm and dry.  No rashes or lesions.  Neuro:  Alert and oriented x3.  Cranial nerves II-XII are grossly intact.  No focal deficits.,PLAN: , I did refill her medications.  I have requested that she have her primary doctor forward her records to me.  I have discussed Chantix and its use and success rate.  She was given a prescription, as well as a coupon.  She is to watch for any worsening signs or symptoms.  She verbalized understanding of discharge instructions and prescriptions.  I would like to see her back to proceed with her preventive health measures.","general medicine, quit smoking, chantix, mesothelioma, smoking, xanax, refills"
" Followup diabetes mellitus, type 1.", General Medicine, Diabetes Mellitus - SOAP Note - 1 ,"CHIEF COMPLAINT:  ,Followup diabetes mellitus, type 1., ,SUBJECTIVE:,  Patient is a 34-year-old male with significant diabetic neuropathy.  He has been off on insurance for over a year.  Has been using NPH and Regular insulin to maintain his blood sugars.  States that he is deathly afraid of having a low blood sugar due to motor vehicle accident he was in several years ago.  Reports that his blood sugar dropped too low which caused the accident.  Since this point in time, he has been unwilling to let his blood sugars fall within a normal range, for fear of hypoglycemia. Also reports that he regulates his blood sugars with how he feels, rarely checking his blood sugar with a glucometer., ,Reports that he has been worked up extensively at hospital and was seeing an Endocrinologist at one time.  Reports that he had some indications of kidney damage when first diagnosed.  His urine microalbumin today is 100.  His last hemoglobin A1C drawn at the end of December is 11.9.  Reports that at one point, he was on Lantus which worked well and he did not worry about his blood sugars dropping too low. While using Lantus, he was able to get his hemoglobin A1C down to 7.  His last CMP shows an elevated alkaline phosphatase level of 168. He denies alcohol or drug use and is a non smoker.  Reports he quit drinking 3 years ago. I have discussed with patient that it would be appropriate to do an SGGT and hepatic panel today.  Patient also has a history of gastroparesis and impotence.  Patient requests Nexium and Viagra, neither of which are covered under the Health Plan.  , ,Patient reports that he was in a scooter accident one week ago, fell off his scooter, hit his head.  Was not wearing a helmet.  Reports that he did not go to the emergency room and had a headache for several days after this incident.  Reports that an ambulance arrived at the scene and he was told he had a scalp laceration and to go into the emergency room.  Patient did not comply.  Reports that the headache has resolved.  Denies any dizziness, nausea, vomiting, or other neurological abnormalities., ,PHYSICAL EXAMINATION: , WD, WN.  Slender, 34-year-old white male.  VITAL SIGNS:  Blood sugar 145, blood pressure 120/88, heart rate 104, respirations 16.  Microalbumin 100. SKIN:  There appears to be 2 skin lacerations on the left parietal region of the scalp, each approximately 1 inch long.  No signs of infection.  Wound is closed with new granulation tissue.  Appears to be healing well.  HEENT:  Normocephalic.  PERRLA.  EOMI.  TMs pearly gray with landmarks present.  Nares patent.  Throat with no redness or swelling.  Nontender sinuses.  NECK:  Supple.  Full ROM.  No LAD. CARDIAC:","general medicine, diabetes mellitus, nph, regular insulin, sggt, diabetic neuropathy, dizziness, followup, glucometer, hypoglycemia, microalbumin, nausea, neurological, vomiting, mellitus type, blood sugars, blood, diabetes, mellitus, sugars"
" Coronary artery disease, prior bypass surgery.  The patient has history of elevated PSA and BPH.  He had a prior prostate biopsy and he recently had some procedure done, subsequently developed urinary tract infection, and presently on antibiotic.  From cardiac standpoint, the patient denies any significant symptom except for fatigue and tiredness.", General Medicine, Consult - Coronary Artery Disease ,"REASON FOR CONSULTATION:,  Coronary artery disease (CAD), prior bypass surgery.,HISTORY OF PRESENT ILLNESS: , The patient is a 70-year-old gentleman who was admitted for management of fever.  The patient has history of elevated PSA and BPH.  He had a prior prostate biopsy and he recently had some procedure done, subsequently developed urinary tract infection, and presently on antibiotic.  From cardiac standpoint, the patient denies any significant symptom except for fatigue and tiredness.  No symptoms of chest pain or shortness of breath.,His history from cardiac standpoint as mentioned below.,CORONARY RISK FACTORS: , History of hypertension, history of diabetes mellitus, nonsmoker.  Cholesterol elevated.  History of established coronary artery disease in the family and family history positive.,FAMILY HISTORY: , Positive for coronary artery disease.,SURGICAL HISTORY: , Coronary artery bypass surgery and a prior angioplasty and prostate biopsies.,MEDICATIONS:,1.  Metformin.,2.  Prilosec.,3.  Folic acid.,4.  Flomax.,5.  Metoprolol.,6.  Crestor.,7.  Claritin.,ALLERGIES:,  DEMEROL, SULFA.,PERSONAL HISTORY: , He is married, nonsmoker, does not consume alcohol, and no history of recreational drug use.,PAST MEDICAL HISTORY:,  Significant for multiple knee surgeries, back surgery, and coronary artery bypass surgery with angioplasty, hypertension, hyperlipidemia, elevated PSA level, BPH with questionable cancer.  Symptoms of shortness of breath, fatigue, and tiredness.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No history of fever, rigors, or chills except for recent fever and rigors.,HEENT:  No history of cataract or glaucoma.,CARDIOVASCULAR:  As above.,RESPIRATORY:  Shortness of breath.  No pneumonia or valley fever.,GASTROINTESTINAL:  Nausea and vomiting.  No hematemesis or melena.,UROLOGICAL:  Frequency, urgency.,MUSCULOSKELETAL:  No muscle weakness.,SKIN:  None significant.,NEUROLOGICAL:  No TIA or CVA.  No seizure disorder.,PSYCHOLOGICAL:  No anxiety or depression.,ENDOCRINE:  As above.,HEMATOLOGICAL:  None significant.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 75, blood pressure 130/68, afebrile, and respiratory rate 16 per minute.,HEENT:  Atraumatic, normocephalic.,NECK:  Veins flat.  No significant carotid bruits.,LUNGS:  Air entry bilaterally fair.,HEART:  PMI displaced.  S1 and S2 regular.,ABDOMEN:  Soft, nontender.  Bowel sounds present.,EXTREMITIES:  No edema.  Pulses are palpable.  No clubbing or cyanosis.,CNS:  Benign.,EKG: ",
" Nonhealing right ankle stasis ulcer.  A 52-year-old native American-Indian man with hypertension, chronic intermittent bipedal edema, and recurrent leg venous ulcers was admitted for scheduled vascular surgery. ", General Medicine, Consult - Stasis Ulcer ,"REASON FOR THE CONSULT:,  Nonhealing right ankle stasis ulcer.,HISTORY OF PRESENT ILLNESS: , This is a 52-year-old native American-Indian man with hypertension, chronic intermittent bipedal edema, and recurrent leg venous ulcers, who was admitted on 01/27/09 for scheduled vascular surgery per Dr. X. I was consulted for nonhealing right ankle stasis ulcer.  There is a concern that the patient had a low-grade fever of 100.2 early this morning.  The patient otherwise feels well.  He was not even aware of the fever.  He does have some ankle pain, worse on the right than the left.  Old medical records were reviewed.  He has multiple hospitalizations for leg cellulitis.  Multiple wound cultures have repeatedly grown Pseudomonas, Enterococcus, and Stenotrophomonas in the past.  Klebsiella and Enterobacter have also grown in the few wound cultures at some point.  The patient has been following up at the wound center as an outpatient and was referred to Dr. X for definitive surgical management.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No malaise.  Positive recent low-grade fevers.  No chills.,HEENT:  No acute change in visual acuity, no diplopia, no acute hearing disturbances, and no sinus congestion.  No sore throat.,CARDIAC:  No chest pain or cough.,GASTROINTESTINAL:  No nausea, vomiting or diarrhea.,All other systems were reviewed and were negative.,PAST MEDICAL HISTORY:  ,Hypertension, exploratory laparotomy in 2004 for abdominal obstruction, cholecystectomy in 2005, chronic intermittent bipedal edema, venous insufficiency, chronic recurrent stasis ulcers.,SOCIAL HISTORY: , The patient admits to heavy alcohol drinking in the past, quit several years ago.  He is also a former cigarette smoker, quit several years ago.,ALLERGIES:,  None known.,CURRENT MEDICATIONS:,  Primaxin, daptomycin, clonidine, furosemide, potassium chloride, lisinopril, metoprolol, ranitidine, Colace, amlodipine, zinc sulfate, Lortab p.r.n., multivitamins with minerals.,PHYSICAL EXAMINATION:,CONSTITUTIONAL/VITAL SIGNS:  Heart rate 73, respiratory rate 20, blood pressure 104/67, temperature 98.3, and oxygen saturation 92% on room air.,GENERAL APPEARANCE:  The patient is awake, alert, and not in cardiorespiratory distress.  Height 6 feet 1.5 inches, body weight 125.26 kilos.,EYES:  Pink conjunctivae, anicteric sclerae.  Pupils equal, brisk reaction to light.,EARS, NOSE, MOUTH AND THROAT:  Intact gross hearing.  Moist oral mucosa.  No oral lesions.,NECK:  No palpable neck masses.  Thyroid is not enlarged on inspection.,RESPIRATORY:  Regular inspiratory effort.  No crackles or wheezes.,CARDIOVASCULAR:  Regular cardiac rhythm.  No thrills or rubs.,GASTROINTESTINAL:  Normoactive bowel sounds.  Soft.  No guarding or rigidity.,LYMPHATIC:  No cervical lymphadenopathy.,MUSCULOSKELETAL:  Good range of motion of upper and lower extremities.,SKIN:  There is hyperpigmentation involving the distal calf of both legs.  There is an open wound on the right medial,malleolar area measuring 9 x 5cm with minimal serous drainage.  Periwound is hyperpigmented with a hint of erythema extending proximally to the medial aspect, distal third of the right lower leg.  There is warmth, but minimal tenderness on palpation of this area.  There is also a wound on the right lateral malleolar area measuring 4 x 3 cm, another open wound on the left medial malleolar area measuring 7 x 4 cm.  Wound edges are poorly defined.,PSYCHIATRIC:  Appropriate mood and affect, oriented x3.  Fair judgment and insight.,LABORATORY RESULTS: , White blood cell count from 01/28/09 is 5.8 with 64% neutrophils, H&H 11.3/33.8, and platelet count 176,000.  BUN and creatinine 9.2/0.52.  Albumin 3.6, AST 25, ALT 9, alk phos 87, and total bilirubin 0.6.  One wound culture from right leg wound culture from 01/27/09 noted with young growth.  Left leg wound culture from 01/27/09 also with young growth.,RADIOLOGY:,  Chest x-ray done on 01/28/09 showed chronic bibasilar subsegmental atelectasis likely related to elevated hemidiaphragm secondary to chronic ileus.  No absolute findings.,IMPRESSION:,1.  Fevers.,2.  Right leg/ankle cellulitis.,3.  Chronic recurrent bilateral ankle venous ulcers.,4.  Multiple previous wound cultures positive for Pseudomonas, Enterococcus, and Stenotrophomonas.,5.  Hypertension.,RECOMMENDATIONS:,1.  We have ordered 2 sets of blood cultures.,2.  Agree with daptomycin and Primaxin IV.,3.  Follow up result of wound cultures.,4.  I will order an MRI of the right ankle to check for underlying osteomyelitis.,Additional ID recommendations as appropriate upon followup.",
 The patient is a 63-year-old white male who was admitted to the hospital with CHF and lymphedema., General Medicine, Consult - CHF & Lymphedema ,"HISTORY OF PRESENT ILLNESS:,  The patient is a 63-year-old white male who was admitted to the hospital with CHF and lymphedema.  He also has a history of obesity, hypertension, sleep apnea, chronic low back pain, cataracts, and past history of CA of the lung.  This consultation was made for better control of his blood sugars.  On questioning, the patient says that he does not have diabetes.  He says that he has never been told about diabetes except during his last admission at Jefferson Hospital.  Apparently, he was started on glipizide at that time.  His blood sugars since then have been good and he says when he went back to Jefferson three weeks later, he was told that he does not have a sugar problem.  He is not sure.  He is not following any specific diet.  He says ""my doctor wants me to lose 30-40 pounds in weight"" and he would not mind going on a diet.  He has a long history of numbness of his toes.  He denies any visual problems.,PAST MEDICAL HISTORY: , As above that includes CA of the lung, COPD, bilateral cataracts.  He has had chronic back pain.  There is also a history of bilateral hip surgeries, penile implant and removal, umbilical hernia repair, and back pain with two surgeries with details of which are unknown.,SOCIAL HISTORY: , The patient has been a smoker since the age of 10.  So, he was smoking 2-3 packs per day.  Since being started on Chantix, he says he has cut it down to half a pack per day.  He does not abuse alcohol.,MEDICATIONS: ,1.  Glipizide 5 mg p.o. daily.,2.  Theophylline.,3.  Z-Pak.,4.  Chantix.,5.  Januvia 100 mg daily.,6.  K-Lor.,7.  OxyContin.,8.  Flomax.,9.  Lasix.,10.  Advair.,11.  Avapro.,12.  Albuterol sulfate.,13.  Vitamin B tablet.,14.  OxyContin and oxycodone for pain.,FAMILY HISTORY: , Positive for diabetes mellitus in the maternal grandmother.,REVIEW OF SYSTEMS: , As above.  He says he has had numbness of toes for a long time.  He denies any visual problems.  His legs have been swelling up from time to time for a long time.  He also has history of COPD and gets short of breath with minimal activity.  He is also not able to walk due to his weight.  He has had ulcers on his legs, which he gets discharge from.  He has chronic back pain and takes OxyContin.  He denies any constipation, diarrhea, abdominal pain, nausea or vomiting.  There is no chest pain.  He does get short of breath on walking.,PHYSICAL EXAMINATION:,The patient is a well-built, obese, white male in no acute distress.,Vital signs:  Pulse rate of 89 per minute and regular.  Blood pressure of 113/69, temperature is 98.4 degrees Fahrenheit, and respirations are 18.,HEENT:  Head is normocephalic and atraumatic.  Eyes, PERRLA.  EOMs intact.  Fundi were not examined.,Neck:  Supple.  JVP is low.  Trachea central.  Thyroid small in size.  No carotid bruits.,Heart:  Shows normal sinus rhythm with S1 and S2.,Lungs:  Show bilateral wheezes with decreased breath sounds at the bases.,Abdomen:  Soft and obese.  No masses.  Bowel sounds are present.,Extremities:  Show bilateral edema with changes of chronic venostasis.  He does have some open weeping sores.  Pulses could not be palpated due to leg swelling.,IMPRESSION/PLAN:,1.  Diabetes mellitus, type 2, new onset.  At this time, the patient is on Januvia as well as glipizide.  His blood sugar right after eating his supper was 101.  So, I am going to discontinue glipizide, continue on Januvia, and add no-concentrated sweets to the diet.  We will continue to follow his blood sugars closely and make adjustments as needed.,2.  Neuropathy, peripheral, query etiology.  We will check TSH and B12 levels.,3.  Lymphedema.,4.  Recurrent cellulitis.,5.  Obesity, morbid.,6.  Tobacco abuse.  He was encouraged to cut his cigarettes down to 5 cigarettes a day.  He says he feels like smoking after meals.  So, we will let him have it after meals first thing in the morning and last thing at night.,7.  Chronic venostasis.,8.  Lymphedema.  We would check his lipid profile also.,9.  Hypertension.,10.  Backbone pain, status post back surgery.,11.  Status post hernia repair.,12.  Status post penile implant and removal.,13.  Umbilical hernia repair.",
" Acute on chronic COPD exacerbation and community acquired pneumonia both resolving.  However, she may need home O2 for a short period of time.", General Medicine, COPD & Pneumonia - SOAP ,"SUBJECTIVE: , Review of the medical record shows that the patient is a 97-year-old female patient who has been admitted and has been treated for community acquired pneumonia along with COPD exacerbation.  The patient does have a longstanding history of COPD.  However, she does not use oxygen at her independent assisted living home.  Yesterday, she had made improvement since being here at the hospital.  She needed oxygen.  She was tested for home O2 and qualified for it yesterday also.  Her lungs were very tight.  She did have wheezes bilaterally and rhonchi on the right side mostly.  She appeared to be a bit weak and although she was requesting to be discharged home, she did not appear to be fit for it.,Overnight, the patient needed to use the rest room.  She stated that she needed to urinate.  She awoke, decided not to call for assistance.  She stated that she did have her nurse call light button next to her and she was unable to gain access to her walker.  She attempted to walk to the rest room on her own.  She sustained a fall.  She stated that she just felt weak.  She bumped her knee and her elbow.  She had femur x-rays, knee x-rays also.  There was possibility of subchondral fracture and some swelling of her suprapatellar bursa on the right side.  This morning, she denied any headache, back pain or neck pain.  She complained mostly of right anterior knee pain for which she had some bruising and swelling.,OBJECTIVE:,VITAL SIGNS:  The patient's max temperature over the past 24 hours was 36.5; her blood pressure is 148/77, her pulse is 87 to 106.  She is 95% on 2 L via nasal cannula.,HEART:  Regular rate and rhythm without murmur, gallop or rub.,LUNGS:  Reveal no expiratory wheezing throughout.  She does have some rhonchi on the right mid base.  She did have a productive cough this morning and she is coughing green purulent sputum finally.,ABDOMEN:  Soft and nontender.  Her bowel sounds x4 are normoactive.,NEUROLOGIC:  She is alert and oriented x3.  Her pupils are equal and reactive.  She has got a good head and facial muscle strength.  Her tongue is midline.  She has got clear speech.  Her extraocular motions are intact.  Her spine is nontender on palpation from neck to lumbar spine.  She has good range of motion with regard to her shoulders, elbows, wrists and fingers.  Her grip strengths are equal bilaterally.  Both elbows are strong from extension to flexion.  Her hip flexors and extenders are also strong and equal bilaterally.  Extension and flexion of the knee bilaterally and ankles also are strong.  Palpation of her right knee reveals no crepitus.  She does have suprapatellar inflammation with some ecchymosis and swelling.  She has got good joint range of motion however.,SKIN:  She did have a skin tear involving her right forearm lateral, which is approximately 2 to 2.5 inches in length and is at this time currently Steri-Stripped and wrapped with Coban and is not actively bleeding.,ASSESSMENT:,1.  Acute on chronic COPD exacerbation.,2.  Community acquired pneumonia both resolving.  However, she may need home O2 for a short period of time.,3.  Generalized weakness and deconditioning secondary to the above.  Also sustained a fall secondary to instability and not using her walker or calling for assistance.  The patient stated that she knew better and she should have called for assistance and she had been told repeatedly from her family members and staff to call for assistance if she needed to get out of bed.,PLAN:,1.  I will have PT and OT evaluate the patient and give recommendation to safety and appliance use at home i.e. walker.  Myself and one of her daughter's spoke today about the fact that she generally lives independently at the Brooke and she may need assisted living along with physical therapy and oxygen for a period of time rather than going back to independent living.,2.  We will obtain an orthopedic consult secondary to her fall to evaluate her x-rays and function.","general medicine, community acquired pneumonia, copd exacerbation, home o2, acute on chronic, pneumonia, exacerbation, copd"
" A 52-year-old female who said she has had 1 week of nausea and vomiting, which is moderate-to-severe.", General Medicine, Consult - Vomiting & Nausea ,"CHIEF COMPLAINT:,  Vomiting and nausea.,HPI: , The patient is a 52-year-old female who said she has had 1 week of nausea and vomiting, which is moderate-to-severe.  She states she has it at least once a day.  It can be any time, but can also be postprandial.  She states she will vomit up some dark brown-to-green fluid.  There has been no hematemesis.  She states because of the nausea and vomiting, she has not been able to take much in the way of PO intake over the past week.  She states her appetite is poor.  The patient has lost 40 pounds of weight over the past 16 months.  She states for the past few days, she has been getting severe heartburn.  She used Tums over-the-counter and that did not help.  She denies having any dysphagia or odynophagia.  She is not having any abdominal pain.  She has no diarrhea, rectal bleeding, or melena.  She has had in the past, which was remote.  She did have some small amounts of rectal bleeding on the toilet tissue only if she passed a harder stool.  She has a history of chronic constipation for most of her life but she definitely has a bowel movement every 3 to 4 days and this is unchanged.  The patient states she has never had any endoscopy or barium studies of the GI tract.,The patient is anemic and her hemoglobin is 5.7 and she is thrombocytopenic with the platelet count of 34.  She states she has had these abnormalities since she has been diagnosed with breast cancer.  She states that she has metastatic breast cancer and that is in her rib cage and spine and she is getting hormonal chemotherapy for this and she is currently under the care of an oncologist.  The patient also has acute renal failure at this point.  The patient said she had a PET scan done about a week ago.,PAST MEDICAL HISTORY:,  Metastatic breast cancer to her rib cage and spine, hypothyroidism, anemia, thrombocytopenia, hypertension, Bells palsy, depression, uterine fibroids, hysterectomy, cholecystectomy, breast lumpectomy, and thyroidectomy.,ALLERGIES: , No known drug allergies.,MEDICINES:,  She is on Zofran, Protonix, fentanyl patch, Synthroid, Ativan, and Ambien.,SOCIAL HISTORY:  ,The patient is divorced and is a homemaker.  No smoking or alcohol.,FAMILY HISTORY:,  Negative for any colon cancer or polyps.  Her father died of mesothelioma, mother died of Hodgkin lymphoma.,SYSTEMS REVIEW: , No fevers, chills or sweats.  She has no chest pain, palpitations, coughing or wheezing.  She does get shortness of breath, no hematuria, dysuria, arthralgias, myalgias, rashes, jaundice, bleeding or clotting disorders.  The rest of the system review is negative as per the HPI.,PHYSICAL EXAM: , Temperature 98.4, blood pressure 95/63, heart rate 84, respiratory rate of 18, and weight is 108 kg.  GENERAL APPEARANCE:  The patient was comfortable in bed.  Skin exam is negative for any rashes or jaundice.  LYMPHATICS:  There is no palpable lymphadenopathy of the cervical or the supraclavicular area.  HEENT:  She has some mild ptosis of the right eye.  There is no icterus.  The patient's conjunctivae and sclerae are normal.  Pupils are equal, round, and reactive to light and accommodation.  No lesions of the oral mucosa or mucosa of the pharynx.  NECK:  Supple.  Carotids are 2+.  No thyromegaly, masses or adenopathy.  HEART:  Has regular rhythm.  Normal S1 and S2.  She has a 2/6 systolic ejection murmur.  No rubs or gallops.  Lungs are clear to percussion and auscultation.  Abdomen is obese, it may be mildly distended.  There is no increased tympany.  The patient does have hepatosplenomegaly.  There is no obvious evidence of ascites.  The abdomen is nontender, bowel sounds are present.  The extremities show some swelling and edema of the ankle regions bilaterally.  Legs are in SCDs.  No cyanosis or clubbing.  For the rectal exam, it shows brown stool that is very trace heme positive at most.  For the neuro exam, she is awake, alert, and oriented x3.  Memory intact.  No focal deficits.  Insight and judgment are intact.,X-RAY AND LABORATORY DATA:  ,She came in, white count 9.2, hemoglobin 7.2, hematocrit 22.2, MCV of 87, platelet count is 47,000.  Calcium is 8.1, sodium 134, potassium 5.3, chloride 102, bicarbonate 17, BUN of 69, creatinine of 5.2, albumin 2.2, ALT 28, bilirubin is 2.2, alkaline phosphatase is 359, AST is 96, and lipase is 30.  Today, her hemoglobin is 5.7, TSH is 1.1, platelet count is 34,000, alkaline phosphatase is 303, and bilirubin of 1.7.,IMPRESSION,1.  The patient has one week of nausea and vomiting with decreased p.o. intake as well as dehydration.  This could be on the basis of her renal failure.  She may have a viral gastritis.  The patient does have a lot of gastroesophageal reflux disease symptoms recently.  She could have peptic mucosal inflammation or peptic ulcer disease.,2.  The patient does have hepatosplenomegaly.  There is a possibility she could have liver metastasis from the breast cancer.,3.  She has anemia as well as thrombocytopenia.  The patient states this is chronic.,4.  A 40-pound weight loss.,5.  Metastatic breast cancer.,6.  Increased liver function tests.  Given her bone metastasis, the elevated alkaline phosphatase may be from this as opposed to underlying liver disease.,7.  Chronic constipation.,8.  Acute renal failure.,PLAN:  ,The patient will be on a clear liquid diet.  She will continue on the Zofran.  She will be on IV Protonix.  The patient is going to be transfused packed red blood cells and her hemoglobin and hematocrit will be monitored.  I obtained the result of the abdominal x-rays she had done through the ER.  The patient has a consult pending with the oncologist to see what her PET scan show.  There is a renal consult pending.  I am going to have her get a total abdominal ultrasound to see if there is any evidence of liver metastasis and also to assess her kidneys.  Her laboratory studies will be followed.  Based upon the patient's medical condition and including her laboratory studies including a platelet count, we talked about EGD versus upper GI workup per upper GI symptoms.  I discussed informed consent for EGD.  I discussed the indications, risks, benefits, and alternatives.  The risks reviewed included, but were not limited to an allergic reaction or side effect to medicines, cardiopulmonary complications, bleeding, infection, perforation, and needing to get admitted for antibiotics or blood transfusion or surgery.  The patient voices her understanding of the above.  She wants to think about what she wants to do.  Overall, this is a very ill patient with multiorgan involvement.",
" Patient was brought in the Emergency Room following an episode of syncope.  The patient relates that he may have had a seizure activity prior to that.  Prior to the episode, he denies having any symptoms of chest pain or shortness of breath. ", General Medicine, Consult - Syncope ,"REASON FOR CONSULTATION: , Syncope.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 69-year-old gentleman, a good historian, who relates that he was brought in the Emergency Room following an episode of syncope.  The patient relates that he may have had a seizure activity prior to that.  Prior to the episode, he denies having any symptoms of chest pain or shortness of breath.  No palpitation.  Presently, he is comfortable, lying in the bed.  As per the patient, no prior cardiac history.,CORONARY RISK FACTORS: , History of hypertension.  No history of diabetes mellitus.  Nonsmoker.  Cholesterol status is borderline elevated.  No history of established coronary artery disease.  Family history noncontributory.,PAST MEDICAL HISTORY:  ,Hypertension, hyperlipidemia, recently diagnosed with Parkinson's, as a Parkinson's tremor, admitted for syncopal evaluation.,PAST SURGICAL HISTORY: ,Back surgery, shoulder surgery, and appendicectomy.,FAMILY HISTORY: , Nonsignificant.,MEDICATIONS:,1.  Pain medications.,2.  Thyroid supplementation.,3.  Lovastatin 20 mg daily.,4.  Propranolol 20 b.i.d.,5.  Protonix.,6.  Flomax.,ALLERGIES:,  None.,PERSONAL HISTORY:,  He is married.  Nonsmoker.  Does not consume alcohol.  No history of recreational drug use.,REVIEW OF SYSTEMS,CONSTITUTIONAL:  No weakness, fatigue, or tiredness.,HEENT:  No history of cataract or glaucoma.,CARDIOVASCULAR:  No congestive heart failure.  No arrhythmias.,RESPIRATORY:  No history of pneumonia or valley fever.,GASTROINTESTINAL:  No nausea, vomiting, hematemesis, or melena.,UROLOGICAL:  No frequency or urgency.,MUSCULOSKELETAL:  Arthritis and muscle weakness.,SKIN:  Nonsignificant.,NEUROLOGIC:  No TIA or CVA.  No seizure disorder.,ENDOCRINE/HEMATOLOGIC:  Nonsignificant.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse of 93, blood pressure of 158/93, afebrile, and respiratory rate 16 per minute.,HEENT:  Atraumatic and normocephalic.,NECK:  Neck veins are flat.  No significant carotid bruits.,LUNGS:  Air entry is bilaterally decreased.,HEART:  PMI is displaced.  S1 and S2 are regular.,ABDOMEN:  Soft and nontender.  Bowel sounds are present.,EXTREMITIES:  No edema.  Pulses are palpable.  No clubbing or cyanosis.  The patient is moving all extremities; however, the patient has tremors.,RADIOLOGICAL DATA: , EKG reveals normal sinus rhythm with underlying nonspecific ST-T changes secondary to tremors.,LABORATORY DATA: , H&H stable.  White count of 14.  BUN and creatinine are within normal limits.  Cardiac enzyme profile is negative.  Ammonia level is elevated at 69.  CT angiogram of the chest, no evidence of pulmonary embolism.  Chest x-ray is negative for acute changes.  CT of the head, unremarkable, chronic skin changes.  Liver enzymes are within normal limits.,IMPRESSION:,1.  The patient is a 69-year-old gentleman, admitted with syncopal episode and possible seizure disorder.",
" A 37-year-old admitted through emergency, presented with symptoms of chest pain, described as a pressure-type dull ache and discomfort in the precordial region.  Also, shortness of breath is noted without any diaphoresis.  Symptoms on and off for the last 3 to 4 days especially when he is under stress.  No relation to exertional activity.  No aggravating or relieving factors. ", General Medicine, Consult - Chest Pain - 1 ,"REASON FOR CONSULTATION:,  Chest pain.,HISTORY OF PRESENT ILLNESS: , The patient is a 37-year-old gentleman admitted through emergency room.  He presented with symptoms of chest pain, described as a pressure-type dull ache and discomfort in the precordial region.  Also, shortness of breath is noted without any diaphoresis.  Symptoms on and off for the last 3 to 4 days especially when he is under stress.  No relation to exertional activity.  No aggravating or relieving factors.  His history is significant as mentioned below.  His workup so far has been negative.,CORONARY RISK FACTORS:,  No history of hypertension or diabetes mellitus.  Active smoker.  Cholesterol status, borderline elevated.  No history of established coronary artery disease.  Family history positive.,FAMILY HISTORY: , His father died of coronary artery disease.,SURGICAL HISTORY: , No major surgery except for prior cardiac catheterization.,MEDICATIONS AT HOME:,  Includes pravastatin, Paxil, and BuSpar.,ALLERGIES:,  None.,SOCIAL HISTORY: , Active smoker.  Does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY: , Hyperlipidemia, smoking history, and chest pain.  He has been, in October of last year, hospitalized.  Subsequently underwent cardiac catheterization.  The left system was normal.  There was a question of a right coronary artery lesion, which was thought to be spasm.  Subsequently, the patient did undergo nuclear and myocardial perfusion scan, which was normal.  The patient continues to smoke actively since in last 3 to 4 days especially when he is stressed.  No relation to exertional activity.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No history of fever, rigors, or chills.,HEENT:  No history of cataract, blurring vision, or glaucoma.,CARDIOVASCULAR:  As above.,RESPIRATORY:  Shortness of breath.  No pneumonia or valley fever.,GASTROINTESTINAL:  No epigastric discomfort, hematemesis, or melena.,UROLOGICAL:  No frequency or urgency.,MUSCULOSKELETAL:  No arthritis or muscle weakness.,CNS:  No TIA.  No CVA.  No seizure disorder.,ENDOCRINE:  Nonsignificant.,HEMATOLOGICAL:  Nonsignificant.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 75, blood pressure of 112/62, afebrile, and respiratory rate 16 per minute.,HEENT:  Head is atraumatic and normocephalic.  Neck veins flat.,LUNGS:  Clear.,HEART:  S1 and S2, regular.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema.  Pulses palpable.  No clubbing or cyanosis.,CNS:  Benign.,PSYCHOLOGICAL:  Normal.,MUSCULOSKELETAL:  Within normal limits.,DIAGNOSTIC DATA: , EKG, normal sinus rhythm.  Chest x-ray unremarkable.,LABORATORY DATA: , First set of cardiac enzyme profile negative.  H&H stable.  BUN and creatinine within normal limits.,IMPRESSION:,1.  Chest pain in a 37-year-old gentleman with negative cardiac workup as mentioned above, questionably right coronary spasm.,2.  Hyperlipidemia.,3.  Negative EKG and cardiac enzyme profile.,RECOMMENDATIONS:",
" Followup evaluation and management of chronic medical conditions.  Congestive heart failure, stable on current regimen.  Diabetes type II, A1c improved with increased doses of NPH insulin.  Hyperlipidemia, chronic renal insufficiency, and arthritis.", General Medicine, Chronic Medical Conditions - Followup ,"REASON FOR VISIT: , Followup evaluation and management of chronic medical conditions.,HISTORY OF PRESENT ILLNESS:,  The patient has been doing quite well since he was last seen.  He comes in today with his daughter.  He has had no symptoms of CAD or CHF.  He had followup with Dr. X and she thought he was doing quite well as well.  He has had no symptoms of hyperglycemia or hypoglycemia.  He has had no falls.  His right knee does pain him at times and he is using occasional doses of Tylenol for that.  He wonders whether he could use a knee brace to help him with that issue as well.  His spirits are good.  He has had no incontinence.  His memory is clear, as is his thinking.,MEDICATIONS:,1.  Bumex - 2 mg daily.,2.  Aspirin - 81 mg daily.,3.  Lisinopril - 40 mg daily.,4.  NPH insulin - 65 units in the morning and 25 units in the evening.,5.  Zocor - 80 mg daily.,6.  Toprol-XL - 200 mg daily.,7.  Protonix - 40 mg daily.,8.  Chondroitin/glucosamine - no longer using.,MAJOR FINDINGS:,  Weight 240, blood pressure by nurse 160/80, by me 140/78, pulse 91 and regular, and O2 saturation 94%.  He is afebrile.  JVP is normal without HJR.  CTAP.  RRR.  S1 and S2.  Aortic murmur unchanged.  Abdomen:  Soft, NT without HSM, normal BS.  Extremities:  No edema on today's examination.  Awake, alert, attentive, able to get up on to the examination table under his own power.  Able to get up out of a chair with normal get up and go.  Bilateral OA changes of the knee.,Creatinine 1.7, which was down from 2.3.  A1c 7.6 down from 8.5.  Total cholesterol 192, HDL 37, and triglycerides 487.,ASSESSMENTS:,1.  Congestive heart failure, stable on current regimen.  Continue.,2.  Diabetes type II, A1c improved with increased doses of NPH insulin.  Doing self-blood glucose monitoring with values in the morning between 100 and 130.  Continue current regimen.  Recheck A1c on return.,3.  Hyperlipidemia, at last visit, he had 3+ protein in his urine.  TSH was normal.  We will get a 24-hour urine to rule out nephrosis as the cause of his hypertriglyceridemia.  In the interim, both Dr. X and I have been considering together as to whether the patient should have an agent added to treat his hypertriglyceridemia.  Specifically we were considering TriCor (fenofibrate).  Given his problems with high CPK values in the past for now, we have decided not to engage in that strategy.  We will leave open for the future.  Check fasting lipid panel today.,4.  Chronic renal insufficiency, improved with reduction in dose of Bumex over time.,5.  Arthritis, stable.  I told the patient he could use Extra Strength Tylenol up to 4 grams a day, but I suggest that he start with a regular dose of 1 to 2 to 3 grams per day.  He states he will inch that up slowly.  With regard to a brace, he stated he used one in the past and that did not help very much.  I worry a little bit about the tourniquet type effect of a brace that could increase his edema or put him at risk for venous thromboembolic disease.  For now he will continue with his cane and walker.,6.  Health maintenance, flu vaccination today.,PLANS: , Followup in 3 months, by phone sooner as needed.","general medicine, congestive heart failure, diabetes, hyperlipidemia, chronic renal insufficiency, arthritis, chronic medical conditions, heart, "
 A 2-month-old female with 1-week history of congestion and fever x2 days., General Medicine, Congestion & Fever - 2-month-old ,"CHIEF COMPLAINT:,  A 2-month-old female with 1-week history of congestion and fever x2 days.,HISTORY OF PRESENT ILLNESS:,  The patient is a previously healthy 2-month-old female, who has had a cough and congestion for the past week.  The mother has also reported irregular breathing, which she describes as being rapid breathing associated with retractions.  The mother states that the cough is at times paroxysmal and associated with posttussive emesis.  The patient has had short respiratory pauses following the coughing events.  The patient's temperature has ranged between 102 and 104.  She has had a decreased oral intake and decreased wet diapers.  The brother is also sick with URI symptoms, and the patient has had no diarrhea.  The mother reports that she has begun to regurgitate after her feedings.  She did not do this previously.,MEDICATIONS: , None.,SMOKING EXPOSURE: , None.,IMMUNIZATIONS: , None.,DIET:  ,Similac 4 ounces every 2 to 3 hours.,ALLERGIES:,  No known drug allergies.,PAST MEDICAL HISTORY:  ,The patient delivered at term.  Birth weight was 6 pounds 1 ounce.  Postnatal complications:  Neonatal Jaundice.  The patient remained in the hospital for 3 days.  The in utero ultrasounds were reported to be normal.,PRIOR HOSPITALIZATIONS: , None.,FAMILY/SOCIAL HISTORY: , Family history is positive for asthma and diabetes.  There is also positive family history of renal disease on the father's side of the family.,DEVELOPMENT: , Normal.  The patient tests normal on the newborn hearing screen.,REVIEW OF SYSTEMS:  GENERAL: , The patient has had fever, there have been no chills.  SKIN:  No rashes.  HEENT:  Mild congestion x1 week.  Cough, at times paroxysmal, no cyanosis.  The patient turns red in the face during coughing episodes, posttussive emesis.  CARDIOVASCULAR:  No cyanosis.  GI:  Posttussive emesis, decreased oral intake.  GU:  Decreased urinary output.  ORTHO:  No current issues.  NEUROLOGIC:  No change in mental status.  ENDOCRINE:  There is no history of weight loss.  DEVELOPMENT:  No loss of developmental milestones.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Weight is 4.8 kg, temperature 100.4, heart rate is 140, respiratory rate 30, and saturations 100%.,GENERAL:  This is a well-appearing infant in no acute distress.,HEENT:  Shows anterior fontanelle to be open and flat.  Pupils are equal and reactive to light with red reflex.  Nares are patent.  Oral mucosa is moist.  Posterior pharynx is clear.  Hard palate is intact.  Normal gingiva.,HEART:  Regular rate and rhythm without murmur.,LUNGS:  A few faint rales.  No retractions.  No stridor.  No wheezing on examination.  Mild tachypnea.,EXTREMITIES:  Warm, good perfusion.  No hip clicks.,NEUROLOGIC:  The patient is alert.  Normal tone throughout.  Deep tendon reflexes are 2+/4.  No clonus.,SKIN:  Normal.,LABORATORY DATA:,  CBC shows a white count of 12.4, hemoglobin 10.1, platelet count 611,000; 38 segs 3 bands, 42 lymphocytes, and 10 monocytes.  Electrolytes were within normal limits.  C-reactive protein 0.3.  Chest x-ray shows no acute disease with the exception of a small density located in the retrocardiac area on the posterior view.  UA shows 10 to 25 bacteria.,ASSESSMENT/PLAN:  ,This is a 2-month-old, who presents with fever, paroxysmal cough and episodes of respiratory distress.  The patient is currently stable in the emergency room.  We will admit the patient to the pediatric floor.  We will send out pertussis PCR.  We will also follow results of urine culture and that the urine dip shows 10 to 25 bacteria.  The patient will be followed up for signs of sepsis, apnea, urinary tract infection, and pneumonia.  We will wait for a radiology reading on the chest x-ray to determine if the density seen on the lateral film is a normal variant or represents pathology.",
" Patient with multiple problems, main one is chest pain at night.", General Medicine, Consult - Chest Pain ,"CHIEF COMPLAINT:,  Multiple problems, main one is chest pain at night.,HISTORY OF PRESENT ILLNESS:,  This is a 60-year-old female with multiple problems as numbered below:,1.  She reports that she has chest pain at night.  This happened last year exactly the same.  She went to see Dr. Murphy, and he did a treadmill and an echocardiogram, no concerns for cardiovascular disease, and her symptoms resolved now over the last month.  She wakes in the middle of the night and reports that she has a pressure.  It is mild-to-moderate in the middle of her chest and will stay there as long she lies down.  If she gets up, it goes away within 15 minutes.  It is currently been gone on for the last week.  She denies any fast heartbeats or irregular heartbeats at this time.,2.  She has been having stomach pains that started about a month ago.  This occurs during the daytime.  It has no relationship to foods.  It is mild in nature, located in the mid epigastric area.  It has been better for one week as well.,3.  She continues to have reflux, has noticed that if she stops taking Aciphex, then she has symptoms.  If she takes her Aciphex, she seems that she has the reflux belching, burping, and heartburn under control.,4.  She has right flank pain when she lies down.  She has had this off and on for four months.  It is a dull achy pain.  It is mild in nature.,5.  She has some spots on her shoulder that have been present for a long time, but over the last month have been getting bigger in size and is elevated whereas they had not been elevated in the past.  It is not painful.,6.  She has had spots in her armpits initially on the right side and then going to the left side.  They are not itchy.,7.  She is having problems with urgency of urine.  When she has her bladder full, she suddenly has an urge to use the restroom, and sometimes does not make it before she begins leaking.  She is wearing a pad now.,8.  She is requesting a colonoscopy for screening as well.  She is wanting routine labs for following her chronic leukopenia, also is desiring a hepatitis titer.,9.  She has had pain in her thumbs when she is trying to do fine motor skills, has noticed this for the last several months.  There has been no swelling or redness or trauma to these areas.,REVIEW OF SYSTEMS:,  She has recently been to the eye doctor.  She has noticed some hearing loss gradually.  She denies any problems with swallowing.  She denies episodes of shortness of breath, although she has had a little bit of chronic cough.  She has had normal bowel movements.  Denies any black or bloody stools, diarrhea, or constipation.  Denies seeing blood in her urine and has had no urinary problems other than what is stated above.  She has had no problems with edema or lower extremity numbness or tingling.,SOCIAL HISTORY:,  She works at nursing home.  She is a nonsmoker.  She is currently trying to lose weight.  She is on the diet and has lost several pounds in the last several months.  She quit smoking in 1972.,FAMILY HISTORY: , Her father has type I diabetes and heart disease.  She has a brother who had heart attack at the age of 52.  He is a smoker.,PAST MEDICAL HISTORY:,  Episodic leukopenia and mild irritable bowel syndrome.,CURRENT MEDICATIONS:,  Aciphex 20 mg q.d. and aspirin 81 mg q.d.,ALLERGIES:,  No known medical allergies.,OBJECTIVE:,Vital Signs:  Weight:  142 pounds.  Blood pressure:  132/78.  Pulse:  72.,General:  This is a well-developed adult female who is awake, alert, and in no acute distress.,HEENT:  Her pupils are equally round and reactive to light.  Conjunctivae are white.  TMs look normal bilaterally.  Oropharynx appears to be normal.  Dentition is excellent.,Neck:  Supple without lymphadenopathy or thyromegaly.,Lungs:  Clear with normal respiratory effort.,Heart:  Regular rhythm and rate without murmur.  Radial pulses are normal bilaterally.,Abdomen:  Soft, nontender, and nondistended without organomegaly.,Extremities:  Examination of the hands reveals some tenderness at the base of her thumbs bilaterally as well as at the PIP joint and DIP joint.  Her armpits are examined.  She has what appears to be a tinea versicolor rash present in the armpits bilaterally.  She has a lesion on her left shoulder, which is 6 mm in diameter.  It has diffuse borders and is slightly red.  It has two brown spots in it.  In her lower extremities, there is no cyanosis or edema.  Pulses at the radial and posterior tibial pulses are normal bilaterally.  Her gait is normal.,Psychiatric:  Her affect is pleasant and positive.,Neurological:  She is grossly intact.  Her speech seems to be clear.  Her coordination of upper and lower extremities is normal.,ASSESSMENT/PLAN:,1.  Chest pain.  At this point, because of Dr. Murphy’s evaluation last year and the symptoms exactly the same, I think this is noncardiac.  My intonation is that this is reflux.  I am going have her double her Aciphex or increase it to b.i.d., and I am going to have her see Dr. XYZ for possible EGD if he thinks that would be appropriate.  She is to let me know if her symptoms are getting worse or if she is having any severe episodes.,2.  Stomach pain, uncertain at this point, but I feel like this is probably related as well to chest pain.,3.  Suspicious lesions on the left shoulder.  We will do a punch biopsy and set her up for an appointment for that.,4.  Tinea versicolor in the axillary area.  I have prescribed selenium sulfide lotion to apply 10 minutes a day for seven days.,5.  Cystocele.  We will have her see Dr. XYZ for further discussion of repair due to her urinary incontinence.,6.  History of leukopenia.  We will check a CBC.,7.  Pain in the thumbs, probably arthritic in nature, observe for now.,8.  Screening.  We will have her see Dr. XYZ for discussion of colon cancer screening.,9.  Gastroesophageal reflux disease.  I have increased Aciphex to b.i.d. for now.",
" A 5-month-old infant with cold, cough, and runny nose for 2 days.  Mom states she had no fever.  Her appetite was good but she was spitting up a lot.", General Medicine, Congestion & Cough - 5-month-Old ,"CHIEF COMPLAINT: , Congestion and cough.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 5-month-old infant who presented initially on Monday with a cold, cough, and runny nose for 2 days.  Mom states she had no fever.  Her appetite was good but she was spitting up a lot.  She had no difficulty breathing and her cough was described as dry and hacky.  At that time, physical exam showed a right TM, which was red.  Left TM was okay.  She was fairly congested but looked happy and playful.  She was started on Amoxil and Aldex and we told to recheck in 2 weeks to recheck her ear.  Mom returned to clinic again today because she got much worse overnight.  She was having difficulty breathing.  She was much more congested and her appetite had decreased significantly today.  She also spiked a temperature yesterday of 102.6 and always having trouble sleeping secondary to congestion.,ALLERGIES: , She has no known drug allergies.,MEDICATIONS:  ,None except the Amoxil and Aldex started on Monday.,PAST MEDICAL HISTORY:  ,Negative.,SOCIAL HISTORY: , She lives with mom, sister, and her grandparent.,BIRTH HISTORY: , She was born, normal spontaneous vaginal delivery at Woman's weighing 7 pounds 3 ounces.  No complications.  Prevented, she passed her hearing screen at birth.,IMMUNIZATIONS: , Also up-to-date.,PAST SURGICAL HISTORY: , Negative.,FAMILY HISTORY:  ,Noncontributory.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Her respiratory rate was approximately 60 to 65.,GENERAL:  She was very congested and she looked miserable.  She had no retractions at this time.,HEENT:  Her right TM was still red and irritated with no light reflex.  Her nasal discharge was thick and whitish yellow.  Her throat was clear.  Her extraocular muscles were intact.,NECK:  Supple.  Full range of motion.,CARDIOVASCULAR EXAM:  She was tachycardic without murmur.,LUNGS:  Revealed diffuse expiratory wheezing.,ABDOMEN:  Soft, nontender, and nondistended.,EXTREMITIES:  Showed no clubbing, cyanosis or edema.,LABORATORY DATA:  ,Her chem panel was normal.  RSV screen is positive.  Chest x-ray and CBC are currently pending.,IMPRESSION AND PLAN:  ,RSV bronchiolitis with otitis media.  Admit for oral Orapred, IV Rocephin, nebulizer treatments and oxygen as needed.",
" Congestion, tactile temperature.", General Medicine, Congestion - 21-day-old ,"CHIEF COMPLAINT:,  Congestion, tactile temperature.,HISTORY OF PRESENT ILLNESS: , The patient is a 21-day-old Caucasian male here for 2 days of congestion - mom has been suctioning yellow discharge from the patient's nares, plus she has noticed some mild problems with his breathing while feeding (but negative for any perioral cyanosis or retractions).  One day ago, mom also noticed a tactile temperature and gave the patient Tylenol.,Baby also has had some decreased p.o. intake.  His normal breast-feeding is down from 20 minutes q.2h. to 5 to 10 minutes secondary to his respiratory congestion.  He sleeps well, but has been more tired and has been fussy over the past 2 days.  The parents noticed no improvement with albuterol treatments given in the ER.  His urine output has also decreased; normally he has 8 to 10 wet and 5 dirty diapers per 24 hours, now he has down to 4 wet diapers per 24 hours.  Mom denies any diarrhea.  His bowel movements are yellow colored and soft in nature.,The parents also noticed no rashes, just his normal neonatal acne.  The parents also deny any vomiting, apnea.,EMERGENCY ROOM COURSE: , In the ER, the patient received a lumbar puncture with CSF fluid sent off for culture and cell count.  This tap was reported as clear, then turning bloody in nature.  The patient also received labs including a urinalysis and urine culture, BMP, CBC, CRP, blood culture.  This patient also received as previously noted, 1 albuterol treatment, which did not help his respiratory status.  Finally, the patient received 1 dose of ampicillin and cefotaxime respectively each.,REVIEW OF SYSTEMS: , See above history of present illness.  Mom's nipples are currently cracked and bleeding.  Mom has also noticed some mild umbilical discharge as well as some mild discharge from the penile area.  He is status post a circumcision.  Otherwise, review of systems is negative.,BIRTH/PAST MEDICAL HISTORY: , The patient was an 8 pounds 13 ounces' term baby born 1 week early via a planned repeat C-section.  Mom denies any infections during pregnancy, except for thumb and toenail infections, treated with rubbing alcohol (mom denies any history of boils in the family).  GBS status was negative.  Mom smoked up to the last 5 months of the pregnancy.  Mom and dad both deny any sexually transmitted diseases or genital herpetic lesions.  Mom and baby were both discharged out of the hospital last 48 hours.  This patient has received no hospitalizations so far.,PAST SURGICAL HISTORY:,  Circumcision.,ALLERGIES: , No known drug allergies.,MEDICATIONS:,  Tylenol.,IMMUNIZATIONS:,  None of the family members this year have received a flu vaccine.,SOCIAL HISTORY:,  At home lives mom, dad, a 2-1/2-year-old brother, and a 5-1/2-year-old maternal stepbrother.  Both brothers at home are sick with cold symptoms including diarrhea and vomiting.  The brother (2-1/2-year-old) was seen in the ER tonight with this patient and discharged home with an albuterol prescription.  A nephew of the mom with an ear infection.  Mom also states that she herself was sick with the flu soon after delivery.  There has been recent travel exposure to dad's family over the Christmas holidays.  At this time, there is also exposure to indoor cats and dogs.  This patient also has positive smoking exposure coming from mom.,FAMILY HISTORY: , Paternal grandmother has diabetes and hypertension, paternal grandfather has emphysema and was a smoker.  There are no children needing the use of a pediatric subspecialist or any childhood deaths less than 1 year of age.,PHYSICAL EXAMINATION:  ,VITALS:  Temperature max is 99, heart rate was 133 to 177, blood pressure is 114/43 (while moving), respiratory rate was 28 to 56 with O2 saturations 97 to 100% on room air.  Weight was 4.1 kg.,GENERAL:  Not in acute distress, sneezing, positive congestion with breaths taken.,HEENT:  Normocephalic, atraumatic head.  Anterior fontanelle was soft, open, and flat.  Bilateral red reflexes were positive.  Oropharynx is clear with palate intact, negative rhinorrhea.,CARDIOVASCULAR:  Heart was regular rate and rhythm with a 2/6 systolic ejection murmur heard best at the upper left sternal border, vibratory in nature.  Capillary refill was less than 3 seconds.,LUNGS:  Positive upper airway congestion, transmitted sounds; negative retractions, nasal flaring, or wheezes.,ABDOMEN:  Bowel sounds are positive, nontender, soft, negative hepatosplenomegaly.  Umbilical site was with scant dried yellow discharge.,GU:  Tanner stage 1 male, circumcised.  There was mild hyperemia to the penis with some mild yellow dried discharge.,HIPS:  Negative Barlow or Ortolani maneuvers.,SKIN:  Positive facial erythema toxicum.,LABORATORY DATA: , CBC drawn showed a white blood cell count of 14.5 with a differential of 25 segmental cells, 5% bands, 54% lymphocytes.  The hemoglobin was 14.4, hematocrit was 40.  The platelet count was elevated at 698,000.  A CRP was less than 0.3.,A hemolyzed BMP sample showed a sodium of 139, potassium of 5.6, chloride 105, bicarb of 21, and BUN of 4, creatinine 0.4, and a glucose of 66.,A cath urinalysis was negative.,A CSF sample showed 0 white blood cells, 3200 red blood cells (again this was a bloody tap per ER personnel), CSF glucose was 41, CSF protein was 89.  A Gram stain showed rare white blood cells, many red blood cells, no organisms.,ASSESSMENT: , A 21-day-old with:,1.  Rule out sepsis.,2.  Possible upper respiratory infection.,Given the patient's multiple sick contacts, he is possibly with a viral upper respiratory infection causing his upper airway congestion plus probable fever.  The bacterial considerations although to consider in this child include group B streptococcus, E. coli, and Listeria.  We should also consider herpes simplex virus, although these 3200 red blood cells from his CSF could be due to his bloody tap in the ER.  Also, there is not a predominant lymphocytosis of his CSF sample (there is 0 white blood cell count in the cell count).,Also to consider in this child is RSV.  The patient though has more congested, nasal breathing more than respiratory distress, for example retractions, desaturations, or accessory muscle use.  Also, there is negative apnea in this patient.,PLAN:  ,1.  We will place this patient on the rule out sepsis pathway including IV antibiotics, ampicillin and gentamicin for at least 48 hours.,2.  We will follow up with his blood, urine, and CSF cultures.",
" Multiple extensive subcutaneous abscesses, right thigh.  Massive open wound, right thigh, status post right excision of multiple subcutaneous abscesses, right thigh.", General Medicine, Chronic Abscesses - Discharge Summary ,"DISCHARGE DIAGNOSES,1.  Multiple extensive subcutaneous abscesses, right thigh.,2.  Massive open wound, right thigh, status post right excision of multiple subcutaneous abscesses, right thigh.,PROCEDURES PERFORMED,1.  On 03/05/08, by Dr. X, was massive debridement of soft tissue, right lateral thigh and hip.,2.  Soft tissue debridement on 03/16/08 of right thigh and hip by Dr. X.,3.  Split thickness skin graft to right thigh and right hip massive open wound on 04/01/08 by Dr. Y.,REASON FOR ADMISSION: , The patient is a 62-year-old male with a history of drug use.  He had a history of injection of heroin into his bilateral thighs.  Unfortunately, he developed chronic abscesses, open wounds on his bilateral thighs, much worse on his right than his left.  Decision was made to do a radical excision and then it is followed by reconstruction.,HOSPITAL COURSE:  ,The patient was admitted on 03/05/08 by Dr. X.  He was taken to the operating room.  He underwent a massive resection of multiple subcutaneous abscesses, heroin remnants, which left massive huge open wounds to his right thigh and hip.  This led to a prolonged hospital course.  The patient initially was treated with local wound care.  He was treated with broad spectrum antibiotics.  He ended up growing out different species of Clostridium.  Infectious Disease consult was obtained from Dr. Z.  He assisted in further antibiotic coverage throughout the rest of his hospitalization.  The patient also had significant hypoalbuminemia, decreased nutrition.  Given his large wounds, he did end up getting a feeding tube placement, and prior to grafting, he received significant feeding tube supplementation to help achieve adequate nutrition for healing.  The patient had this superior area what appeared to be further necrotic, infected soft tissue.  He went back to the OR on 03/16/08 and further resection done by Dr. X.  After this, his wound appeared to be free of infection.  He is treated with a wound VAC.  He slowly, but progressively had significant progress in his wound.  I went from a very poor-looking wound to a red granulated wound throughout its majority.  He was thought ready for skin grafting.  Note that the patient had serial ultrasounds given his high risk of DVT from this massive wound and need for decreased activity.  These were negative.  He was treated with SCDs to help decrease his risk.  On 04/01/08, the patient was taken to the operating room, was thought to have an adequate ________ grafting.  He underwent skin grafting to his right thigh and hip massive open wound.  Donor sites were truncated.  Postoperatively, the patient ended up with a vast majority of skin graft taking.  To unable to take, he was kept on IV antibiotics, strict bed rest, and limited range of motion of his hip.  He is continued on VAC dressing.  Graft progressively improved with this therapy.  Had another ultrasound, which was negative for DVT.  The patient was mobilized up out of his bed.  Infectious Disease recommendations were obtained.  Plan was to complete additional 10 days of antibiotics at discharge.  This will be oral antibiotics.  I would monitor his left side, which has significantly decreased inflammation and irritation or infection given the antibiotic coverage.  So, decision was not made to excise this, but instead monitor.  By 04/11/08, his graft looked good.  It was pink and filling in.  He looked stable for discharge.  The patient was discharged to home.,DISCHARGE INSTRUCTIONS: , Discharge to home.,CONDITION: , Stable.,Antibiotic Augmentin XR script was written.  He is okay to shower.  Donor site and graft site dressing instruction orders were given for Home Health and the patient.  His followup was arranged with Dr. X and myself.","general medicine, multiple extensive subcutaneous abscesses, open wound, subcutaneous abscesses, multiple subcutaneous abscesses, skin grafting, thigh, wound, abscesses, wounds, subcutaneous, antibiotics,"
" Lump in the chest wall.   Probably an old fracture of the area with callus formation, need to rule out the possibility of a tumor. ", General Medicine, Chest Wall Lump - Consult ,"CHIEF COMPLAINT:,  Lump in the chest wall.,HISTORY OF PRESENT ILLNESS: , This is a 56-year-old white male who has been complaining of having had a lump in the chest for the past year or so and it has been getting larger and tender according to the patient.  It is tender on palpation and also he feels like, when he takes a deep breath also, it hurts.,CHRONIC/INACTIVE CONDITIONS,1.  Hypertension.,2.  Hyperlipidemia.,3.  Glucose intolerance.,4.  Chronic obstructive pulmonary disease?,5.  Tobacco abuse.,6.  History of anal fistula.,ILLNESSES:,  See above.,PREVIOUS OPERATIONS: , Anal fistulectomy, incision and drainage of perirectal abscess, hand surgery, colonoscopy, arm nerve surgery, and back surgery.,PREVIOUS INJURIES: , He had a broken ankle in the past.  They questioned the patient who is a truck driver whether he has had an auto accident in the past, he said that he has not had anything major.  He said he bumped his head once, but not his chest, although he told the nurse that a car fell on his chest that is six years ago.  He told me that he hit a moose once, but he does not remember hitting his chest.,ALLERGIES: , TO BACTRIM, SIMVASTATIN, AND CIPRO.,CURRENT MEDICATIONS,1.  Lisinopril.,2.  Metoprolol.,3.  Vitamin B12.,4.  Baby aspirin.,5.  Gemfibrozil.,6.  Felodipine.,7.  Levitra.,8.  Pravastatin.,FAMILY HISTORY: , Positive for hypertension, diabetes, and cancer.  Negative for heart disease, obesity or stroke.,SOCIAL HISTORY:  ,The patient is married.  He works as a truck driver and he drives in town.  He smokes two packs a day and he has two beers a day he says, but not consuming illegal drugs.,REVIEW OF SYSTEMS,CONSTITUTIONAL:  Denies weight loss/gain, fever or chills.,ENMT:  Denies headaches, nosebleeds, voice changes, blurry vision or changes in/loss of vision.,CV:  See history of present illness.  Denies chest pain, SOB supine, palpitations, edema, varicose veins or leg pains.,RESPIRATORY:  He has a chronic cough.  Denies shortness of breath, wheezing, sputum production or bloody sputum.,GI:  Denies heartburn, blood in stools, loss of appetite, abdominal pain or constipation.,GU:  Denies painful/burning urination, cloudy/dark urine, flank pain or groin pain.,MS:  Denies joint pain/stiffness, backaches, tendon/ligaments/muscle pains/strains, bone aches/pains or muscle weakness.,NEURO:  Denies blackouts, seizures, loss of memory, hallucinations, weakness, numbness, tremors or paralysis.,PSYCH:  Denies anxiety, irritability, apathy, depression, sleep disturbances, appetite disturbances or suicidal thoughts.,INTEGUMENTARY:  Denies unusual hair loss/breakage, skin lesions/discoloration or unusual nail breakage/discoloration.,PHYSICAL EXAMINATION,CONSTITUTIONAL:  Blood pressure 140/84, pulse rate 100, respiratory rate 20, temperature 97.2, height 5 feet 10 inches, and weight 218 pounds.  The patient is well developed, well nourished, and with fair attention to grooming.  The patient is moderately overweight.,NECK:  The neck is symmetric, the trachea is in the midline, and there are no masses.  No crepitus is palpated.  The thyroid is palpable, not enlarged, smooth, moves with swallowing, and has no palpable masses.,RESPIRATION:  Normal respiratory effort.  There is no intercostal retraction or action by the accessory muscles.  Normal breath sounds bilaterally with no rhonchi, wheezing or rubs.  There is a localized 2-cm diameter hard mass in relationship to the costosternal cartilages in the lower most position in the left side, just adjacent to the sternum.,CARDIOVASCULAR:  The PMI is palpable at the 5ICS in the MCL.  No thrills on palpation.  S1 and S2 are easily audible.  No audible S3, S4, murmur, click, or rub.  Carotid pulses 2+ without bruits.  Abdominal aorta is not palpable.  No audible abdominal bruits.  Femoral pulses are 2+ bilaterally, without audible bruits.  Extremities show no edema or varicosities.",
" The patient is a very pleasant 72-year-old female with previous history of hypertension and also recent diagnosis of C. diff,  presents to the hospital with abdominal pain, cramping, and persistent diarrhea.", General Medicine, C. Diff Colitis Consult ,"REASON FOR CONSULT:  ,I was asked to see the patient for C. diff colitis.,HISTORY OF PRESENTING ILLNESS: , Briefly, the patient is a very pleasant 72-year-old female with previous history of hypertension and also recent diagnosis of C. diff for which she was admitted here in 5/2009, who presents to the hospital on 6/18/2009 with abdominal pain, cramping, and persistent diarrhea.  After admission, she had a CT of the abdomen done, which showed evidence of diffuse colitis and she was started on IV Flagyl and also on IV Levaquin.  She was also placed on IV Reglan because of nausea and vomiting.  In spite of the above, her white count still continues to be elevated today.  On questioning the patient, she states the nausea and vomiting has resolved, but the diarrhea still present, but otherwise denies any other specific complaints except for some weakness.,PAST MEDICAL HISTORY: , Hypertension, hyperlipidemia, recent C. diff colitis, which had resolved based on speaking to Dr. X.  Two weeks ago, he had seen the patient and she was clinically well.,PAST SURGICAL HISTORY:  ,Noncontributory.,SOCIAL HISTORY:  ,No history of smoking, alcohol, or drug use.  She lives at home.,HOME MEDICATIONS:  ,She is on atenolol and Mevacor.,ALLERGIES:  NO KNOWN DRUG ALLERGIES.,REVIEW OF SYSTEMS:  ,Positive for diarrhea and abdominal pain, otherwise main other complaints are weakness.  She denies any cough, sputum production, or dysuria at this time.  Otherwise, a 10-system review is essentially negative.,PHYSICAL EXAM:,GENERAL:  She is awake and alert, currently in no apparent distress.,VITAL SIGNS:  She has been afebrile since admission, temperature today 96.5, heart rate 80, respirations 18, blood pressure 125/60, and O2 sat is 98% on 2 L.,HEENT:  Pupils are round and reactive to light and accommodation.,CHEST:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  S1 and S2 are present.  No rales appreciated.,ABDOMEN:  She does have tenderness to palpation all over with some mild rebound tenderness also.  No guarding noted.  Bowel sounds present.,EXTREMITIES:  No clubbing, cyanosis, or edema.,CT of the abdomen and pelvis is also reviewed on the computer, which showed evidence of diffuse colitis.,LABORATORY: , White blood cell count today 21.5, hemoglobin 12.4, platelet count 284,000, and neutrophils 89.  UA on 6/18/2009 showed no evidence of UTI.  Sodium today 130, potassium 2.7, and creatinine 0.4.  AST and ALT on 6/20/2009 were normal.  Blood cultures from admission were negative.  Urine culture on admission was negative.  C. diff was positive.  Stool culture was negative.,ASSESSMENT:,1.  A 72-year-old female with Clostridium difficile colitis.,2.  Diarrhea secondary to above and also could be related Reglan, which was discontinued today.,3.  Leukocytosis secondary to above, mild improvement today though.,4.  Bilateral pleural effusion by CT of the chest, although could represent thickening.,5.  New requirement for oxygen, rule out pneumonia.,6.  Hypertension.,PLAN:,1.  Treat the C. diff aggressively especially given CT appearance and her continued leukocytosis and because of the Levaquin, which could have added additional antibiotic pressure, so I will restart the IV Flagyl.,2.  Continue p.o. vancomycin.  Add Florastor to help replenish the gut flora.,3.  Monitor WBCs closely and follow clinically and if there is any deterioration in her clinical status, I would recommend getting surgical evaluation immediately for surgery if needed.,4.  We will check a chest x-ray especially given her new requirement for oxygen.",
" Suspicious calcifications upper outer quadrant, left breast.  Left breast excisional biopsy with preoperative guidewire localization and intraoperative specimen radiography.", General Medicine, Breast Calcifications - Preop Consult  ,"REASON FOR HOSPITALIZATION:  ,Suspicious calcifications upper outer quadrant, left breast.,HISTORY OF PRESENT ILLNESS: , The patient is a 78-year-old woman who had undergone routine screening mammography on 06/04/08.  That study disclosed the presence of punctate calcifications that were felt to be in a cluster distribution in the left breast mound at the 2 o'clock position.  Additional imaging studies confirmed the suspicious nature of these calcifications.  The patient underwent a stereotactic core needle biopsy of the left breast 2 o'clock position on 06/17/08.  The final histologic diagnosis of the tissue removed during that procedure revealed focal fibrosis.  No calcifications could be identified in examination of the biopsy material including radiograph taken of the preserved tissue.,Two days post stereotactic core needle biopsy, however, the patient returned to the breast center with severe swelling and pain and mass in the left breast.  She underwent sonographic evaluation and was found to have a development of false aneurysm formation at the site of stereotactic core needle biopsy.  I was called to see the patient in the emergency consultation in the breast center.  At the same time, Dr. Y was consulted in Interventional Radiology.  Dr. Z and Dr. Y were able to identify the neck of the false aneurysm in the left breast mound and this was injected with ultrasound guidance with thrombin material.  This resulted in immediate occlusion of the false aneurysm.  The patient was seen in my office for followup appointment on 06/24/08.  At that time, the patient continued to have signs of a large hematoma and extensive ecchymosis, which resulted from the stereotactic core needle biopsy.  There was, however, no evidence of reforming of the false aneurysm.  There was no evidence of any pulsatile mass in the left breast mound or on the left chest wall.,I discussed the issues with the patient and her husband.  The underlying problem is that the suspicious calcifications, which had been identified on mammography had not been adequately sampled with the stereotactic core needle biopsy; therefore, the histologic diagnosis is not explanatory of the imaging findings.  For this reason, the patient was advised to have an excisional biopsy of this area with guidewire localization.  Since the breast mound was significantly disturbed from the stereotactic core needle biopsy, the decision was to postpone any surgical intervention for at least three to four months.  The patient now returns to undergo the excision of the left breast tissue with preoperative guidewire localization to identify the location of suspicious calcifications.,The patient has a history of prior stereotactic core needle biopsy of the left breast, which was performed on 01/27/04.  This revealed benign histologic findings.  The family history is positive involving a daughter who was diagnosed with breast cancer at the age of 40.  Other than her age, the patient has no other risk factors for development of breast cancer.  She is not receiving any hormone replacement therapy.  She has had five children with the first pregnancy occurring at the age of 24.  Other than her daughter, there are no other family members with breast cancer.  There are no family members with a history of ovarian cancer.,PAST MEDICAL HISTORY: , Other hospitalizations have occurred for issues with asthma and pneumonia.,PAST SURGICAL HISTORY: , Colon resection in 1990 and sinus surgeries in 1987, 1990 and 2005.,CURRENT MEDICATIONS:,1.  Plavix.,2.  Arava.,3.  Nexium.,4.  Fosamax.,5.  Advair.,6.  Singulair.,7.  Spiriva.,8.  Lexapro.,DRUG ALLERGIES:,  ASPIRIN, PENICILLIN, IODINE AND CODEINE.,FAMILY HISTORY:, Positive for heart disease, hypertension and cerebrovascular accidents.  Family history is positive for colon cancer affecting her father and a brother.  The patient has a daughter who was diagnosed with breast cancer at age 40.,SOCIAL HISTORY: , The patient does not smoke.  She does have an occasional alcoholic beverage.,REVIEW OF SYSTEMS:  ,The patient has multiple medical problems, for which she is under the care of Dr. X.  She has a history of chronic obstructive lung disease and a history of gastroesophageal reflux disease.  There is a history of anemia and there is a history of sciatica, which has been caused by arthritis.  The patient has had skin cancers, which have been treated with local excision.,PHYSICAL EXAMINATION:,GENERAL:  The patient is an elderly aged female who is alert and in no distress.,HEENT:  Head, normocephalic.  Eyes, PERRL.  Sclerae are clear.  Mouth, no oral lesions.,NECK:  Supple without adenopathy.,HEART:  Regular sinus rhythm.,CHEST:  Fair air entry bilaterally.  No wheezes are noted on examination.,BREASTS:  Normal topography bilaterally.  There are no palpable abnormalities in either breast mound.  Nipple areolar complexes are normal.  Specifically, the left breast upper outer quadrant near the 2 o'clock position has no palpable masses.  The previous tissue changes from the stereotactic core needle biopsy have resolved.  Axillary examination normal bilaterally without suspicious lymphadenopathy or masses.,ABDOMEN:  Obese.  No masses.  Normal bowel sounds are present.,BACK:  No CVA tenderness.,EXTREMITIES:  No clubbing, cyanosis or edema.,ASSESSMENT:,1.  Left breast mound clustered calcifications, suspicious by imaging located in the upper outer quadrant at the 2 o'clock position.,2.  Prior stereotactic core needle biopsy of the left breast did not resolve the nature of the calcifications, this now requires excision of the tissue with preoperative guidewire localization.,3.  History of chronic obstructive lung disease and asthma, controlled with medications.,4.  History of gastroesophageal reflux disease, controlled with medications.,5.  History of transient ischemic attack managed with medications.,6.  History of osteopenia and osteoporosis, controlled with medications.,7.  History of anxiety controlled with medications.,PLAN: , Left breast excisional biopsy with preoperative guidewire localization and intraoperative specimen radiography.  This will be performed on an outpatient basis.",
 Complex open wound right lower extremity complicated by a methicillin-resistant staphylococcus aureus cellulitis.  The patient is a 52-year-old male who has had a very complex course secondary to a right lower extremity complex open wound. , General Medicine, Cellulitis - Discharge Summary ,"DISCHARGE DIAGNOSIS:  ,Complex open wound right lower extremity complicated by a methicillin-resistant staphylococcus aureus cellulitis.,ADDITIONAL DISCHARGE DIAGNOSES:,1.  Chronic pain.,2.  Tobacco use.,3.  History of hepatitis C.,REASON FOR ADMISSION:,  The patient is a 52-year-old male who has had a very complex course secondary to a right lower extremity complex open wound.  He has had prolonged hospitalizations because of this problem.  He was recently discharged when he was noted to develop as an outpatient swollen, red tender leg.  Examination in the emergency room revealed significant concern for significant cellulitis.  Decision was made to admit him to the hospital.,HOSPITAL COURSE:,  The patient was admitted on 03/26/08 and was started on IV antibiotics elevation, was also counseled to minimizing the cigarette smoking.  The patient had edema of his bilateral lower extremities.  The hospital consult was also obtained to address edema issue question was related to his liver hepatitis C.  Hospital consult was obtained.  This included an ultrasound of his abdomen, which showed just mild cirrhosis.  His leg swelling was thought to be secondary to chronic venostasis and with likely some contribution from his liver as well.  The patient eventually grew MRSA in a moderate amount.  He was treated with IV vancomycin.  Local wound care and elevation.  The patient had slow progress.  He was started on compression, and by 04/03/08 his leg got much improved, minimal redness and swelling was down with compression.  The patient was thought safe to discharge home.,DISCHARGE INSTRUCTIONS: , The patient was discharged on doxycycline 100 mg p.o. b.i.d. x10 days.  He was also given prescription for Percocet and OxyContin, picked up at my office.  He is instructed to do daily wound care and also wrap his leg with an Ace wrap.  Followup was arranged in a couple of weeks.,DISCHARGE CONDITION: , Stable.","general medicine, chronic pain, methicillin-resistant staphylococcus aureus cellulitis, complex open wound, staphylococcus aureus, wound care, cellulitis, wound, hepatitis,"
" First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.", General Medicine, Burn - Consult ,"CHIEF COMPLAINT: , Burn, right arm.,HISTORY OF PRESENT ILLNESS: , This is a Workers' Compensation injury.  This patient, a 41 year-old male, was at a coffee shop, where he works as a cook, and hot oil splashed onto his arm, burning from the elbow to the wrist on the medial aspect.  He has had it cooled, and presents with his friend to the Emergency Department for care.,PAST MEDICAL HISTORY:  ,Noncontributory.,MEDICATIONS:  ,None.,ALLERGIES:  ,None.,PHYSICAL EXAMINATION: , GENERAL:  Well-developed, well-nourished 21-year-old male adult who is appropriate and cooperative.  His only injury is to the right upper extremity.  There are first and second degree burns on the right forearm, ranging from the elbow to the wrist.  Second degree areas with blistering are scattered through the medial aspect of the forearm.  There is no circumferential burn, and I see no areas of deeper burn.  The patient moves his hands well.  Pulses are good.  Circulation to the hand is fine.,FINAL DIAGNOSIS:,1.  First-degree and second-degree burns, right arm secondary to hot oil spill.,2.  Workers' Compensation industrial injury.,TREATMENT: , The wound is cooled and cleansed with soaking in antiseptic solution.  The patient was ordered Demerol 50 mg IM for pain, but he refused and did not want pain medication.  A burn dressing is applied with Neosporin ointment.  The patient is given Tylenol No. 3, tabs #4, to take home with him and take one or two every four hours p.r.n. for pain.  He is to return tomorrow for a dressing change.  Tetanus immunization is up to date.  Preprinted instructions are given.  Workers' Compensation first report and work status report are completed.,DISPOSITION: , Home.","general medicine, burn, workers' compensation industrial injury, workers' compensation, degree"
" Left buttock abscess, status post incision and drainage.   Recommended some local wound care", General Medicine, Buttock Abscess ,"CHIEF COMPLAINT: , Buttock abscess.,HISTORY OF PRESENT ILLNESS: , This patient is a 24-year-old African-American female who presented to the hospital with buttock pain.  She started off with a little pimple on the buttock.  She was soaking it at home without any improvement.  She came to the hospital on the first.  The patient underwent incision and drainage in the emergency department.  She was admitted to the hospitalist service with elevated blood sugars.  She has had positive blood cultures.  Surgery is consulted today for evaluation.,PAST MEDICAL HISTORY:  ,Diabetes type II, poorly controlled, high cholesterol.,PAST SURGICAL HISTORY: , C-section and D&C.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,MEDICATIONS: , Insulin, metformin, Glucotrol, and Lipitor.,FAMILY HISTORY: , Diabetes, hypertension, stroke, Parkinson disease, and heart disease.,REVIEW OF SYSTEMS: , Significant for pain in the buttock.  Otherwise negative.,PHYSICAL EXAMINATION:,GENERAL:  This is an overweight African-American female not in any distress.,VITAL SIGNS:  She has been afebrile since admission.  Vital signs have been stable.  Blood sugars have been in the 200 range.,HEENT:  Normal to inspection.,NECK:  No bruits or adenopathy.,LUNGS:  Clear to auscultation.,CV:  Regular rate and rhythm.,ABDOMEN:  Protuberant, soft, and nontender.,EXTREMITIES:  No clubbing, cyanosis or edema.,RECTAL EXAM:  The patient has a drained abscess on the buttock cheek.  There is some serosanguineous drainage.  There is no longer any purulent drainage.  The wound appears relatively clean.  I do not see a lot of erythema.,ASSESSMENT AND PLAN: , Left buttock abscess, status post incision and drainage.  I do not believe surgical intervention is warranted.  I have recommended some local wound care.  Please see orders for details.","general medicine, buttock pain, pimple, incision and drainage, local wound care, blood sugars, diabetes, buttock, abscess, "
 Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a patient with code last night with CPR and advanced cardiac life support., General Medicine, Care Conference With Family ,"REASON FOR FOLLOWUP:,  Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a patient with code last night with CPR and advanced cardiac life support.,HISTORY OF PRESENT ILLNESS: , This is a 65-year-old patient originally admitted by me several weeks ago with profound hyponatremia and mental status changes.  Her history is also significant for likely recurrent aspiration pneumonia and intubation earlier on this admission as well.  Previously while treating this patient I had met with the family and discussed how aggressive the patient would wish her level of care to be given that there was evidence of possible ovarian malignancy with elevated CA-125 and a complex mass located in the ovary.  As the patient was showing signs of improvement with some speech and ability to follow commands, decision was made to continue to pursue an aggressive level of care, treat her dysphagia, hypertension, debilitation and this was being done.  However, last night the patient had apparently catastrophic event around 2:40 in the morning.  Rapid response was called and the patient was intubated, started on pressure support, and given CPR.  This morning I was called to the bedside by nursing stating the family had wished at this point not to continue this aggressive level of care.  The patient was seen and examined, she was intubated and sedated.  Limbs were cool.  Cardiovascular exam revealed tachycardia.  Lungs had coarse breath sounds.  Abdomen was soft.  Extremities were cool to the touch.  Pupils were 6 to 2 mm, doll's eyes were not intact.  They were not responsive to light.  Based on discussion with all family members involved including both sons, daughter and daughter-in-law, a decision was made to proceed with terminal wean and comfort care measures.  All pressure support was discontinued.  The patient was started on intravenous morphine and respiratory was requested to remove the ET tube.  Monitors were turned off and the patient was made as comfortable as possible.  Family is at the bedside at this time.  The patient appears comfortable and the family is in agreement that this would be her wishes per my understanding of the family and the patient dynamics over the past month, this is a very reasonable and appropriate approach given the patient's failure to turn around after over a month of aggressive treatment with likely terminal illness from ovarian cancer and associated comorbidities.,Total time spent at the bedside today in critical care services, medical decision making and explaining options to the family and proceeding with terminal weaning was excess of 37 minutes.","general medicine, full code status, terminal wean, comfort care, cpr, advanced cardiac life support, care conference, family, bedsideNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" Atrial fibrillation with rapid ventricular response, Wolff-Parkinson White Syndrome, recent aortic valve replacement with bioprosthetic Medtronic valve, and hyperlipidemia.", General Medicine, Atrial Fibrillation - SOAP ,"SUBJECTIVE: , The patient states that she feels better.  She is on IV amiodarone, the dosage pattern is appropriate for ventricular tachycardia.  Researching the available records, I find only an EMS verbal statement that tachycardia of wide complex was seen.  There is no strip for me to review all available EKG tracings show a narrow complex atrial fibrillation pattern that is now converted to sinus rhythm.,The patient states that for a week, she has been home postoperative from aortic valve replacement on 12/01/08 at ABC Medical Center.  The aortic stenosis was secondary to a congenital bicuspid valve, by her description.  She states that her shortness of breath with exertion has been stable, but has yet to improve from its preoperative condition.  She has not had any decline in her postoperative period of her tolerance to exertion.,The patient had noted intermittent bursts of fast heart rate at home that had been increasing over the last several days.  Last night, she had a prolonged episode for which she contacted EMS.  Her medications at home had been uninterrupted and without change from those listed, being Toprol-XL 100 mg q.a.m., Dyazide 25/37.5 mg, Nexium 40 mg, all taken once a day.  She has been maintaining her Crestor and Zetia at 20 and 10 mg respectively.  She states that she has been taking her aspirin at 325 mg q.a.m.  She remains on Zyrtec 10 mg q.a.m.  Her only allergy is listed to latex.,OBJECTIVE:,VITAL SIGNS:  Temperature 36.1, heart rate 60, respirations 14, room air saturation 98%, and blood pressure 108/60.  The patient shows a normal sinus rhythm on the telemetry monitor with an occasional PAC.,GENERAL:  She is alert and in no apparent distress.,HEENT:  Eyes:  EOMI.  PERRLA.  Sclerae nonicteric.  No lesions of lids, lashes, brows, or conjunctivae noted.  Funduscopic examination unremarkable.  Ears:  Normal set, shape, TMs, canals and hearing.  Nose and Sinuses:  Negative.  Mouth, Tongue, Teeth, and Throat:  Negative except for dental work.,NECK:  Supple and pain free without bruit, JVD, adenopathy or thyroid abnormality.,CHEST:  Lungs are clear bilaterally to auscultation.  The incision is well healed and without evidence of significant cellulitis.,HEART:  Shows a regular rate and rhythm without murmur, gallop, heave, click, thrill or rub.  There is an occasional extra beat noted, which corresponds to a premature atrial contraction on the monitor.,ABDOMEN:  Soft and benign without hepatosplenomegaly, rebound, rigidity or guarding.,EXTREMITIES:  Show no evidence of DVT, acute arthritis, cellulitis or pedal edema.,NEUROLOGIC:  Nonfocal without lateralizing findings for cranial or peripheral nervous systems, strength, sensation, and cerebellar function.  Gait and station were not tested.,MENTAL STATUS:  Shows the patient to be alert, coherent with full capacity for decision making.,BACK:  Negative to inspection or percussion.,LABORATORY DATA: , Shows from 12/15/08 2100, hemoglobin 11.6, white count 12.9, and platelets 126,000.  INR 1.0.  Electrolytes are normal with exception potassium 3.3.  GFR is decreased at 50 with creatinine of 1.1.  Glucose was 119.  Magnesium was 2.3.  Phosphorus 3.8.  Calcium was slightly low at 7.8.  The patient has had ionized calcium checked at Munson that was normal at 4.5 prior to her discharge.  Troponin is negative x2 from 2100 and repeat at 07:32.  This morning, her BNP was 163 at admission.  Her admission chest x-ray was unremarkable and did not show evidence of cardiomegaly to suggest pericardial effusion.  Her current EKG tracing from 05:42 shows a sinus bradycardia with Wolff-Parkinson White Pattern, a rate of 58 beats per minute, and a corrected QT interval of 557 milliseconds.  Her PR interval was 0.12.,We received a call from Munson Medical Center that a bed had been arranged for the patient.  I contacted Dr. Varner and we reviewed the patient's managed to this point.  All combined impression is that the patient was likely to not have had actual ventricular tachycardia.  This is based on her EP study from October showing her to be non-inducible.  In addition, she had a cardiac catheterization that showed no evidence of coronary artery disease.  What is most likely that the patient has postoperative atrial fibrillation.  Her WPW may have degenerated into a ventricular tachycardia, but this is unlikely.  At this point, we will convert the patient from IV amiodarone to oral amiodarone and obtain an echocardiogram to verify that she does not have evidence of pericardial effusion in the postoperative period.  I will recheck her potassium, magnesium, calcium, and phosphorus at this point and make adjustments if indicated.  Dr. Varner will be making arrangements for an outpatient Holter monitor and further followup post-discharge.,IMPRESSION:,1.  Atrial fibrillation with rapid ventricular response.,2.  Wolff-Parkinson White Syndrome.,3.  Recent aortic valve replacement with bioprosthetic Medtronic valve.,4.  Hyperlipidemia.","general medicine, ventricular tachycardia, wolff-parkinson white syndrome., ventricular response, medtronic valve, wolff parkinson white syndrome, aortic valve replacement, atrial fibrillation, atrial, aortic, tachycardia, fibrillation, ventricular, valve, medtronic, "
 A lady was admitted to the hospital with chest pain and respiratory insufficiency.  She has chronic lung disease with bronchospastic angina., General Medicine, Chest Pain & Respiratory Insufficiency ,"We discovered new T-wave abnormalities on her EKG.  There was of course a four-vessel bypass surgery in 2001.  We did a coronary angiogram.  This demonstrated patent vein grafts and patent internal mammary vessel and so there was no obvious new disease.,She may continue in the future to have angina and she will have nitroglycerin available for that if needed.,Her blood pressure has been elevated and so instead of metoprolol, we have started her on Coreg 6.25 mg b.i.d.  This should be increased up to 25 mg b.i.d. as preferred antihypertensive in this lady's case.  She also is on an ACE inhibitor.,So her discharge meds are as follows:,1.  Coreg 6.25 mg b.i.d.,2.  Simvastatin 40 mg nightly.,3.  Lisinopril 5 mg b.i.d.,4.  Protonix 40 mg a.m.,5.  Aspirin 160 mg a day.,6.  Lasix 20 mg b.i.d.,7.  Spiriva puff daily.,8.  Albuterol p.r.n. q.i.d.,9.  Advair 500/50 puff b.i.d.,10.  Xopenex q.i.d. and p.r.n.,I will see her in a month to six weeks.  She is to follow up with Dr. X before that.","general medicine, chest pain, respiratory insufficiency, chronic lung disease, bronchospastic angina, insufficiency, chest, angina, respiratory, bronchospastic"
 Patient has prostate cancer with metastatic disease to his bladder.  The patient has had problems with hematuria in the past.  The patient was encouraged to drink extra water and was given discharge instructions on hematuria., General Medicine, Blood in Urine - ER Visit ,"CHIEF COMPLAINT: , Blood in urine.,HISTORY OF PRESENT ILLNESS:  ,This is a 78-year-old male who has prostate cancer with metastatic disease to his bladder and in several locations throughout the skeletal system including the spine and shoulder.  The patient has had problems with hematuria in the past, but the patient noted that this episode began yesterday, and today he has been passing principally blood with very little urine.  The patient states that there is no change in his chronic lower back pain and denies any incontinence of urine or stool.  The patient has not had any fever.  There is no abdominal pain and the patient is still able to pass urine.  The patient has not had any melena or hematochezia.  There is no nausea or vomiting.  The patient has already completed chemotherapy and is beyond treatment for his cancer at this time.  The patient is receiving radiation therapy, but it is targeted to the bones and intended to give symptomatic relief of his skeletal pain and not intended to treat and cure the cancer.  The patient is not enlisted in hospice, but the principle around the patient's current treatment management is focusing on comfort care measures.,REVIEW OF SYSTEMS: , CONSTITUTIONAL:  No fever or chills.  The patient does report generalized fatigue and weakness over the past several days.  HEENT:  No headache, no neck pain, no rhinorrhea, no sore throat.  CARDIOVASCULAR:  No chest pain.  RESPIRATIONS:  No shortness of breath or cough, although the patient does get easily winded with exertion over these past few days.  GASTROINTESTINAL:  The patient denies any abdominal pain.  No nausea or vomiting.  No changes in the bowel movement.  No melena or hematochezia.  GENITOURINARY:  A gross hematuria since yesterday as previously described.  The patient is still able to pass urine without difficulty.  The patient denies any groin pain.  The patient denies any other changes to the genital region.  MUSCULOSKELETAL:  The chronic lower back pain which has not changed over these past few days.  The patient does have multiple other joints, which cause him discomfort, but there have been no recent changes in these either.  SKIN:  No rashes or lesions.  No easy bruising.  NEUROLOGIC:  No focal weakness or numbness.  No incontinence of urine or stool.  No saddle paresthesia.  No dizziness, syncope or near-syncope.  ENDOCRINE:  No polyuria or polydipsia.  No heat or cold intolerance.  HEMATOLOGIC/LYMPHATIC:  The patient does not have a history of easy bruising or bleeding, but the patient has had previous episodes of hematuria.,PAST MEDICAL HISTORY: , Prostate cancer with metastatic disease as previously described.,PAST SURGICAL HISTORY: , TURP.,CURRENT MEDICATIONS:,  Morphine, Darvocet, Flomax, Avodart and ibuprofen.,ALLERGIES: , VICODIN.,SOCIAL HISTORY: , The patient is a nonsmoker.  Denies any alcohol or illicit drug use.  The patient does live with his family.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Temperature is 98.8 oral, blood pressure is 108/65, pulse is 109, respirations 16, oxygen saturation is 97% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished, well developed.  The patient appears to be pale, but otherwise looks well.  The patient is calm, comfortable.  The patient is pleasant and cooperative.  HEENT:  Eyes normal with clear conjunctivae and corneas.  Nose is normal without rhinorrhea or audible congestion.  Mouth and oropharynx normal without any sign of infection.  Mucous membranes are moist.  NECK:  Supple.  Full range of motion.  No JVD.  CARDIOVASCULAR:  Heart is mildly tachycardic with regular rhythm without murmur, rub or gallop.  Peripheral pulses are +2.  RESPIRATIONS:  Clear to auscultation bilaterally.  No shortness of breath.  No wheezes, rales or rhonchi.  Good air movement bilaterally.  GASTROINTESTINAL:  Abdomen is soft, nontender, nondistended.  No rebound or guarding.  No hepatosplenomegaly.  Normal bowel sounds.  No bruit.  No masses or pulsatile masses.  GENITOURINARY:  The patient has normal male genitalia, uncircumcised.  There is no active bleeding from the penis at this time.  There is no swelling of the testicles.  There are no masses palpated to the testicles, scrotum or the penis.  There are no lesions or rashes noted.  There is no inguinal lymphadenopathy.  Normal male exam.  MUSCULOSKELETAL:  Back is normal and nontender.  There are no abnormalities noted to the arms or legs.  The patient has normal use of the extremities.  SKIN:  The patient appears to be pale, but otherwise the skin is normal.  There are no rashes or lesions.  NEUROLOGIC:  Motor and sensory are intact to the extremities.  The patient has normal speech.  PSYCHIATRIC:  The patient is alert and oriented x4.  Normal mood and affect.  HEMATOLOGIC/LYMPHATIC:  There is no evidence of bruising noted to the body.  No lymphadenitis is palpated.,EMERGENCY DEPARTMENT TESTING:,  CBC was done, which had a hemoglobin of 7.7 and hematocrit of 22.6.  Neutrophils were 81%.  The RDW was 18.5, and the rest of the values were all within normal limits and unremarkable.  Chemistry had a sodium of 134, a glucose of 132, calcium is 8.2, and rest of the values are unremarkable.  Alkaline phosphatase was 770 and albumin was 2.4.  Rest of the values all are within normal limits of the LFTs.  Urinalysis was grossly bloody with a large amount of blood and greater than 50 rbc's.  The patient also had greater than 300 of the protein reading, moderate leukocytes, 30-50 white blood cells, but no bacteria were seen.  Coagulation profile study had a PT of 15.9, PTT of 43 and INR of 1.3.,EMERGENCY DEPARTMENT COURSE: , The patient was given normal saline 2 liters over 1 hour without any adverse effect.  The patient was given multiple doses of morphine to maintain his comfort while here in the emergency room without any adverse effect.  The patient was given Levaquin 500 mg by mouth as well as 2 doses of Phenergan over the course of his stay here in the emergency department.  The patient did not have an adverse reaction to these medicines either.  Phenergan resolved his nausea and morphine did relieve his pain and make him pain free.  I spoke with Dr. X, the patient's urologist, about most appropriate step for the patient, and Dr. X said he would be happy to care for the patient in the hospital and do urologic scopes if necessary and surgery if necessary and blood transfusion.  It was all a matter of what the patient wished to do given the advanced stage of his cancer.  Dr. X was willing to assist in any way the patient wished him to.  I spoke with the patient and his son about what he would like to do and what the options were from doing nothing from keeping him comfortable with pain medicines to admitting him to the hospital with the possibility of scopes and even surgery being done as well as the blood transfusion.  The patient decided to choose a middle ground in which he would be transfused with 2 units of blood here in the emergency room and go home tonight.  The patient's son felt comfortable with his father's choice.  This was done.  The patient was transfused 2 units of packed red blood cells after appropriately typed and match.  The patient did not have any adverse reaction at any point with his transfusion.  There was no fever, no shortness of breath, and at the time of disposition, the patient stated he felt a little better and felt like he had a little more strength.  Over the course of the patient's several-hour stay in the emergency room, the patient did end up developing enough problems with clotted blood in his bladder that he had a urinary obstruction.  Foley catheter was placed, which produced bloody urine and relieved the developing discomfort of a full bladder.  The patient was given a leg bag and the Foley catheter was left in place.,DIAGNOSES,1.  HEMATURIA.,2.  PROSTATE CANCER WITH BONE AND BLADDER METASTATIC DISEASE.,3.  SIGNIFICANT ANEMIA.,4.  URINARY OBSTRUCTION.,CONDITION ON DISPOSITION:  ,Fair, but improved.,DISPOSITION: , To home with his son.,PLAN: , We will have the patient follow up with Dr. X in his office in 2 days for reevaluation.  The patient was given a prescription for Levaquin and Phenergan tablets to take home with him tonight.  The patient was encouraged to drink extra water.  The patient was given discharge instructions on hematuria and asked to return to the emergency room should he have any worsening of his condition or develop any other problems or symptoms of concern.",
 Patient complaining of cough and blood mixed with sputum production with a past medical history significant for asbestos exposure., General Medicine, Asbestos Exposure - Hemoptysis ,"REASON FOR CONSULTATION: , Hemoptysis.,HISTORY OF PRESENT ILLNESS: , The patient is an 80-year-old African-American male, very well known to my service, with a past medical history significant for asbestos exposure.  The patient also has a very extensive cardiac history that would be outlined below.  He is being admitted with worsening shortness of breath and constipation.  He is also complaining of cough and blood mixed with sputum production, but there is no fever.,PAST MEDICAL HISTORY,1.  Benign prostatic hypertrophy.,2.  Peptic ulcer disease.,3.  Atrial fibrillation.,4.  Coronary artery disease.,5.  Aortic valve replacement in 1991, St. Jude mechanical valve #23.,6.  ICD implantation.,7.  Peripheral vascular disease.,8.  CABG in 1991 and 1998.,9.  Congestive heart failure, EF 40%.,10.  Asbestos exposure.,MEDICATIONS,1.  Coumadin 6 mg alternating with 9 mg.,2.  Prevacid 30 mg once a day.,3.  Diovan 160 mg every day.,4.  Flomax 0.4 mg every day.,5.  Coreg 25 mg in the morning and 12.5 mg at night.,6.  Aldactone 25 mg a day.,7.  Lasix 20 mg a day.,8.  Zocor 40 mg every day.,ALLERGIES,1. DARVOCET.,2. CLONIDINE.,PHYSICAL EXAMINATION,GENERAL:  The patient is an elderly male; awake, alert, and oriented, in no acute distress.,VITAL SIGNS:  Blood pressure is 136/80, pulse is 70, respiratory rate is 20, temperature 99.3, pulse oximetry 96% on 2 L nasal cannula.,HEENT:  Significant for peripheral cyanosis.,NECK:  Supple.,LUNGS:  Bibasilar crackles with decreased breath sounds in the left base.,CARDIOVASCULAR:  Regular rate and rhythm with murmur and metallic click.,ABDOMEN:  Soft and benign.,EXTREMITIES:  1+ cyanosis.  No clubbing.  No edema.,LABORATORY DATA:,  Shows a white count of 6.9, hemoglobin 10.6, hematocrit 31.2, and platelet count 160,000.  CK 266, PTT 37, PT 34, and INR 3.7.  Sodium 141, potassium 4.2, chloride 111, CO2 23, BUN 18, creatinine 1.7, glucose 91, calcium 8.6, total protein 6.1, albumin 3.3, total bilirubin 1.4, alkaline phosphatase 56, and troponin I 0.085 and 0.074.,DIAGNOSTIC STUDIES: , Chest x-ray shows previous sternotomy with ICD implantation and aortic valve mechanical implant with left-sided opacification of the diaphragm worrisome for pleural effusion.,ASSESSMENT,1.  Hemoptysis.,2.  Acute bronchitis.,3.  Coagulopathy.,4.  Asbestos exposure.,5.  Left pleural effusion.,RECOMMENDATIONS,1.  Antibiotics.",
  Antibiotic management for a right foot ulcer and possible osteomyelitis., General Medicine, Antibiotic Management Consult ,"REASON FOR CONSULTATION: , Antibiotic management for a right foot ulcer and possible osteomyelitis.,HISTORY OF PRESENT ILLNESS:,  The patient is a 68-year-old Caucasian male with past medical history of diabetes mellitus.  He was doing fairly well until last week while mowing the lawn, he injured his right foot.  He presented to the Hospital Emergency Room.  Cultures taken from the wound on 06/25/2008, were reported positive for methicillin-sensitive Staphylococcus aureus (MSSA).  The patient was started on intravenous antibiotic therapy with Levaquin and later on that was changed to oral formulation.  The patient underwent debridement of the wound on 07/29/2008.  Apparently, MRI and a bone scan was performed at that facility, which was reported negative for osteomyelitis.  The patient was then referred to the wound care center at General Hospital.  From there, he has been admitted to Long-Term Acute Care Facility for wound care with wound VAC placement.  On exam, he has a lacerated wound on the plantar aspect of the right foot, which extends from the second metatarsal area to the fifth metatarsal area, closed with the area of the head of these bones.  The wound itself is deep and stage IV and with exam of her gloved finger in my opinion, the third metatarsal bone is palpable, which leads to the clinical diagnosis of osteomyelitis.  The patient has serosanguineous drainage in this wound and it tracks under the skin in all directions except distal.,PAST MEDICAL HISTORY: , Positive for:,1.  Diabetes mellitus.,2.  Osteomyelitis of the right fifth toe, which was treated with intravenous antibiotic therapy for 6 weeks about 5 years back.,FAMILY HISTORY: , Positive for mother passing away in her late 60s from heart attack, father had liver cancer, and passed away from that.  One of his children suffers from hypothyroidism, 2 grandchildren has cerebral palsy secondary to being prematurely born.,ALLERGIES: , No known drug allergies.,REVIEW OF SYSTEMS: , Positive findings of the foot that have been mentioned above.  All other systems reviewed were negative.,PHYSICAL EXAMINATION:,General:  A 68-year-old Caucasian male who was not in any acute hemodynamic distress at present.,Vital Signs:  Show a maximum recorded temperature of 98, pulse is rating between 67 to 80 per minute, respiratory rate is 20 per minute, blood pressure is varying between 137/63 to 169/75.,HEENT:  Pupils equal, round, reactive to light.  Extraocular movements intact.  Head is normocephalic.  External ear exam is normal.,Neck:  Supple.  There is no palpable lymphadenopathy.,Cardiovascular:  Regular rate and rhythm of the heart without any appreciable murmur, rub or gallop.,Lungs:  Clear to auscultation and percussion bilaterally.,Abdomen:  Soft, nontender, and nondistended without any organomegaly and bowel sounds are positive.  There is no palpable lymphadenopathy in the inguinal and femoral area.,Extremities:  There is no cyanosis, clubbing or edema.  There is no peripheral stigmata of endocarditis.  On the plantar aspect of the distal part of the right foot, the patient has a lacerated wound, which extends from the second metatarsal area to the fifth metatarsal area.  Tracking under the skin is palpable with a gloved finger in all direction except the distal one.  On the proximal tracking, the area of the wound, the third metatarsal bone is palpable.  Therefore, clinically, the patient has diagnoses of osteomyelitis.,Central nervous system:  The patient is alert, oriented x3.  Cranial nerves II through XII are intact.  There is no focal deficit appreciated.,LABORATORY DATA:,  No laboratory or radiological data is available at present in the chart.,IMPRESSION/PLAN: , A 68-year-old Caucasian male with history of diabetes mellitus who had an accidental lawn mower-associated injury on the right foot.  He has undergone debridement on 07/29/2008.  Culture results from the debridement procedure are not available.  Wound cultures from 07/25/2008 showed methicillin-sensitive Staphylococcus aureus.,From the Infectious Disease point of view, the patient has the following problems, and I would recommend following treatments strategy.,1.  Right foot infected ulcer with clinical evidence of osteomyelitis.  Even if the MRI and bone scan are negative, the treatment should be guided with diagnosis on clinical counts in my opinion.  Cultures have been reported positive for methicillin-sensitive Staphylococcus aureus.  Therefore, I would discontinue the current antibiotic regimen of oral Levaquin, Zyvox, and intravenous Zosyn, and start the patient on intravenous Ancef 2 g q.8 h.  We will need to continue this treatment for 6 weeks for treatment of osteomyelitis and deep wound infection.  I would also recommend continuation of wound care and wound VAC placement that would start tomorrow.  We will get a PICC line placed to complete the 6-week course of intravenous antibiotic therapy.,2.  We would check labs including CBC with differential, chemistry 7 panel, LFTs, ESR, and C-reactive protein levels every Monday and chemistry 7 panel and CBC every Thursday for the duration of antibiotic therapy.,3.  I will continue to monitor wound healing 2 to 3 times a week.  Wound care will be managed by the wound care team at the Long-Term Acute Care Facility.,4.  The treatment plan was discussed in detail with the patient and his daughter who was visiting him when I saw him.,5.  Other medical problems will continue to be followed and treated by Dr. X's group during this hospitalization.,6.  I appreciate the opportunity of participating in this patient's care.  If you have any questions please feel free to call me at any time.  I will continue to follow the patient along with you for the next few days during this hospitalization.  We would also try to get the results of the deep wound cultures from 07/29/2008, MRI, and bone scan from Hospital.",
 Questionable need for antibiotic therapy for possible lower extremity cellulitis., General Medicine, Antibiotic Therapy Consult ,"REASON FOR CONSULTATION: , Questionable need for antibiotic therapy for possible lower extremity cellulitis.,HISTORY OF PRESENT ILLNESS: , The patient is a 51-year-old Caucasian female with past medical history of morbid obesity and chronic lower extremity lymphedema.  She follows up at the wound care center at Hospital.  Her lower extremity edema is being managed there.  She has had multiple episodes of cellulitis of the lower extremities for which she has received treatment with oral Bactrim and ciprofloxacin in the past according to her.  As her lymphedema was not improving on therapy at that facility, she was referred for admission to Long-Term Acute Care Facility for lymphedema management.  She at present has a stage II ulcer on the lower part of the medial aspect of left leg without any drainage and has slight erythema of bilateral lower calf and shin areas.  Her measurements for lymphedema wraps have been taken and in my opinion, it is going to be started in a day or two.,I have been consulted to rule out the possibility of lower extremity cellulitis that may require antibiotic therapy.,PAST MEDICAL HISTORY:,  Positive for morbid obesity, chronic lymphedema of the lower extremities, at least for the last three years, spastic colon, knee arthritis, recurrent cellulitis of the lower extremities.  She has had a hysterectomy and a cholecystectomy in the remote past.,SOCIAL HISTORY: , The patient lives by herself and has three pet cats.  She is an ex-smoker, quit smoking about five years ago.  She occasionally drinks a glass of wine.  She denies any other recreational drugs use.  She recently retired from State of Pennsylvania as a psychiatric aide after 32 years of service.,FAMILY HISTORY: , Positive for mother passing away at the age of 38 from heart problems and alcoholism, dad passed away at the age of 75 from leukemia.  One of her uncles was diagnosed with leukemia.,ALLERGIES: , ADHESIVE TAPE ALLERGIES.,REVIEW OF SYSTEMS:,  At present, the patient is admitted with a nonresolving bilateral lower extremity lymphedema, which is a little bit more marked on the right lower extremity compared to the left.  She denies any nausea, vomiting or diarrhea.  She denies any pain, tenderness, increased warmth or drainage from the lower extremities.  Denies chest pain, cough or phlegm production.  All other systems reviewed were negative.,PHYSICAL EXAMINATION:,General:  A 51-year-old morbidly obese Caucasian female who is not in any acute hemodynamic distress at present.,Vital signs:  Her maximum recorded temperature since admission today is 96.8, pulse is 65 per minute, respiratory rate is 18 to 20 per minute, blood pressure is 150/54, I do not see a recorded weight at present.,HEENT:  Pupils are equal, round, and reactive to light.  Extraocular movements intact.  Head is normocephalic and external ear exam is normal.,Neck:  Supple.  There is no palpable lymphadenopathy.,Cardiovascular system:  Regular rate and rhythm of the heart without any appreciable murmur, rub or gallop.  Heart sounds are little distant secondary to thick chest wall.,Lungs:  Clear to auscultation and percussion bilaterally.,Abdomen:  Morbidly obese, soft, nontender, nondistended, there is no percussible organomegaly, there is no evidence of lymphedema on the abdominal pannus.  There is no evidence of cutaneous candidiasis in the inguinal folds.  There is no palpable lymphadenopathy in the inguinal and femoral areas.,Extremities:  Bilateral lower extremities with evidence of extensive lymphedema, there is slight pinkish discoloration of the lower part of calf and shin areas, most likely secondary to stasis dermatosis.  There is no increased warmth or tenderness, there is no skin breakdown except a stage II chronic ulcer on the lower medial aspect of the right calf area.  It has minimal serosanguineous drainage and there is no surrounding erythema.  Therefore, in my opinion, there is no current evidence of cellulitis or wound infection.  There is no cyanosis or clubbing.  There is no peripheral stigmata of endocarditis.,Central nervous system:  The patient is alert and oriented x3, cranial nerves II through XII are intact, and there is no focal deficit appreciated.,LABORATORY DATA: , White cell count is 7.4, hemoglobin 12.9, hematocrit 39, platelet count of 313,000, differential is normal with 51% neutrophils, 37% lymphocytes, 9% monocytes and 3% eosinophils.  The basic electrolyte panel is within normal limits and the renal function is normal with BUN of 17 and creatinine of 0.5.  Liver function tests are also within normal limits.,The nasal screen for MRSA is negative.  Urine culture is negative so far from admission.  Urinalysis was negative for pyuria, leucocyte esterase, and nitrites.,IMPRESSION AND PLAN:,  A 51-year-old Caucasian female with multiple medical problems mentioned above including history of morbid obesity and chronic lower extremity lymphedema.  Admitted for inpatient management of bilateral lower extremity lymphedema.  I have been consulted to rule out possibility of active cellulitis and wound infection.,At present, I do not find evidence of active cellulitis that needs antibiotic therapy.  In my opinion, lymphedema wraps could be initiated.  We will continue to monitor her legs with lymphedema wraps changes 2 to 3 times a week.  If she develops any cellulitis, then appropriate antibiotic therapy will be initiated. ,Her stage II ulcer on the right leg does not look infected.  I would recommend continuation of wound care along with lymphedema wraps.,Other medical problems will continue to be followed and treated by Dr. X's group during this hospitalization.  Dr. Y from Plastic Surgery and Lymphedema Management Clinic is following.,I appreciate the opportunity of participating in this patient's care.  If you have any questions, please feel free to call me at any time.  I will continue to follow the patient along with you 2-3 times per week during this hospitalization at the Long-Term Acute Care Facility.",
" Refractory anemia that is transfusion dependent.  At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion.", General Medicine, Anemia - Consult ,"DIAGNOSIS:,  Refractory anemia that is transfusion dependent.,CHIEF COMPLAINT: , I needed a blood transfusion.,HISTORY: , The patient is a 78-year-old gentleman with no substantial past medical history except for diabetes.  He denies any comorbid complications of the diabetes including kidney disease, heart disease, stroke, vision loss, or neuropathy.  At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion.  He reports that he has no signs or symptom of bleeding and had a blood transfusion approximately two months ago and actually several weeks before that blood transfusion, he had a transfusion for anemia.  He has been placed on B12, oral iron, and Procrit.  At this time, we are asked to evaluate him for further causes and treatment for his anemia.  He denies any constitutional complaints except for fatigue, malaise, and some dyspnea.  He has no adenopathy that he reports.  No fevers, night sweats, bone pain, rash, arthralgias, or myalgias.,PAST MEDICAL HISTORY:  ,Diabetes.,PAST SURGICAL HISTORY:,  Hernia repair.,ALLERGIES: , He has no allergies.,MEDICATIONS: , Listed in the chart and include Coumadin, Lasix, metformin, folic acid, diltiazem, B12, Prevacid, and Feosol.,SOCIAL HISTORY: , He is a tobacco user.  He does not drink.  He lives alone, but has family and social support to look on him.,FAMILY HISTORY:,  Negative for blood or cancer disorders according to the patient.,PHYSICAL EXAMINATION:,GENERAL:  He is an elderly gentleman in no acute distress.  He is sitting up in bed eating his breakfast.  He is alert and oriented and answering questions appropriately.,VITAL SIGNS:  Blood pressure of 110/60, pulse of 99, respiratory rate of 14, and temperature of 97.4.  He is 69 inches tall and weighs 174 pounds.,HEENT:  Sclerae show mild arcus senilis in the right.  Left is clear.  Pupils are equally round and reactive to light.  Extraocular movements are intact.  Oropharynx is clear.,NECK:  Supple.  Trachea is midline.  No jugular venous pressure distention is noted.  No adenopathy in the cervical, supraclavicular, or axillary areas.,CHEST:  Clear.,HEART:  Regular rate and rhythm.,ABDOMEN:  Soft and nontender.  There may be some fullness in the left upper quadrant, although I do not appreciate a true spleen with inspiration.,EXTREMITIES:  No clubbing, but there is some edema, but no cyanosis.,NEUROLOGIC:  Noncontributory.,DERMATOLOGIC:  Noncontributory.,CARDIOVASCULAR:  Noncontributory.,IMPRESSION: , At this time is refractory anemia, which is transfusion dependent.  He is on B12, iron, folic acid, and Procrit.  There are no sign or symptom of blood loss and a recent esophagogastroduodenoscopy, which was negative.  His creatinine was 1.  My impression at this time is that he probably has an underlying myelodysplastic syndrome or bone marrow failure.  His creatinine on this hospitalization was up slightly to 1.6 and this may contribute to his anemia.,RECOMMENDATIONS:  ,At this time, my recommendation for the patient is that he undergoes further serologic evaluation with reticulocyte count, serum protein, and electrophoresis, LDH, B12, folate, erythropoietin level, and he should undergo a bone marrow aspiration and biopsy.  I have discussed the procedure in detail which the patient.  I have discussed the risks, benefits, and successes of that treatment and usefulness of the bone marrow and predicting his cause of refractory anemia and further therapeutic interventions, which might be beneficial to him.  He is willing to proceed with the studies I have described to him.  We will order an ultrasound of his abdomen because of the possible fullness of the spleen, and I will probably see him in follow up after this hospitalization.,As always, we greatly appreciate being able to participate in the care of your patient.  We appreciate the consultation of the patient.",
" Blood in toilet.  Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed.", General Medicine, Blood In Toilet ,"CHIEF COMPLAINT:  ,Blood in toilet.,HISTORY: , Ms. ABC is a 77-year-old female who is brought down by way of ambulance from XYZ Nursing Home after nursing staff had noted there to be blood in the toilet after she had been sitting on the toilet.  They did not note any urine or stool in the toilet and the patient had no acute complaints.  The patient is unfortunately a poor historian in that she has dementia and does not recall any of the events.  The patient herself has absolutely no complaints, such as abdominal pain or back pain, urinary and GI complaints.  There is no other history provided by the nursing staff from XYZ.  There apparently were no clots noted within there.  She does not have a history of being on anticoagulants.,PAST MEDICAL HISTORY: , Actually quite limited, includes that of dementia, asthma, anemia which is chronic, hypothyroidism, schizophrenia, positive PPD in the past.,PAST SURGICAL HISTORY:  ,Unknown.,SOCIAL HISTORY: , No tobacco or alcohol.,MEDICATIONS: , Listed in the medical records.,ALLERGIES:,  No known drug allergies.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Stable.,GENERAL:  This is a well-nourished, well-developed female who is alert, oriented in all spheres, pleasant, cooperative, resting comfortably, appearing otherwise healthy and well in no acute distress.,HEENT:  Visually normal.  Pupils are reactive.  TMs, canals, nasal mucosa, and oropharynx are intact.,NECK:  No lymphadenopathy or JVD.,HEART:  Regular rate and rhythm.  S1, S2.  No murmurs, gallops, or rubs.,LUNGS:  Clear to auscultation.  No wheeze, rales, or rhonchi.,ABDOMEN:  Benign, flat, soft, nontender, and nondistended.  Bowel sounds active.  No organomegaly or mass noted.,GU/RECTAL:  External rectum was normal.  No obvious blood internally.  There is no stool noted within the vault.  There is no gross amount of blood noted within the vault.  Guaiac was done and was trace positive.  Visual examination anteriorly during the rectal examination noted no blood within the vaginal region.,EXTREMITIES:  No significant abnormalities.,WORKUP: , CT abdomen and pelvis was negative.  CBC was entirely within normal limits without any signs of anemia with an H and H of 14 and 42%.  CMP also within normal limits.  PTT, PT, and INR were normal.  Attempts at getting the patient to give A urine were unsuccessful and the patient was very noncompliant, would not allow us to do any kind of Foley catheterization.,ER COURSE:,  Uneventful.  I have discussed the patient in full with Dr. X who agrees that she does not require any further workup or evaluation as an inpatient.  We have decided to send the patient back to XYZ with observation by the staff there.  She will have a CBC done daily for the next 3 days with results to Dr. X.  They are to call him if there is any recurrences of blood or worsening of symptoms and they are to do a urinalysis at XYZ for blood.,ASSESSMENT: , Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed.",
" Patient status post gastric bypass surgery, developed nausea and right upper quadrant pain.", General Medicine, Admission History & Physical - Nausea ,"CHIEF COMPLAINT: , Nausea.,PRESENT ILLNESS: , The patient is a 28-year-old, who is status post gastric bypass surgery nearly one year ago.  He has lost about 200 pounds and was otherwise doing well until yesterday evening around 7:00-8:00 when he developed nausea and right upper quadrant pain, which apparently wrapped around toward his right side and back.  He feels like he was on it but has not done so.  He has overall malaise and a low-grade temperature of 100.3.  He denies any prior similar or lesser symptoms.  His last normal bowel movement was yesterday.  He denies any outright chills or blood per rectum.,PAST MEDICAL HISTORY: , Significant for hypertension and morbid obesity, now resolved.,PAST SURGICAL HISTORY: , Gastric bypass surgery in December 2007.,MEDICATIONS:  ,Multivitamins and calcium.,ALLERGIES: , None known.,FAMILY HISTORY:  ,Positive for diabetes mellitus in his father, who is now deceased.,SOCIAL HISTORY: , He denies tobacco or alcohol.  He has what sounds like a data entry computer job.,REVIEW OF SYSTEMS:  ,Otherwise negative.,PHYSICAL EXAMINATION:,  His temperature is 100.3, blood pressure 129/59, respirations 16, heart rate 84.  He is drowsy, but easily arousable and appropriate with conversation.  He is oriented to person, place, and situation.  He is normocephalic, atraumatic.  His sclerae are anicteric.  His mucous membranes are somewhat tacky.  His neck is supple and symmetric.  His respirations are unlabored and clear.  He has a regular rate and rhythm.  His abdomen is soft.  He has diffuse right upper quadrant tenderness, worse focally, but no rebound or guarding.  He otherwise has no organomegaly, masses, or abdominal hernias evident.  His extremities are symmetrical with no edema.  His posterior tibial pulses are palpable and symmetric.  He is grossly nonfocal neurologically.,STUDIES:,  His white blood cell count is 8.4 with 79 segs.  His hematocrit is 41.  His electrolytes are normal.  His bilirubin is 2.8.  His AST 349, ALT 186, alk-phos 138 and lipase is normal at 239.,ASSESSMENT: , Choledocholithiasis, ? cholecystitis.,PLAN: , He will be admitted and placed on IV antibiotics.  We will get an ultrasound this morning.  He will need his gallbladder out, probably with intraoperative cholangiogram.  Hopefully, the stone will pass this way.  Due to his anatomy, an ERCP would prove quite difficult if not impossible unless laparoscopic assisted.  Dr. X will see him later this morning and discuss the plan further.  The patient understands.","general medicine, gastric bypass surgery, nausea, choledocholithiasis, cholecystitis, ercp, gastric bypass, bypass surgery, "
" Comprehensive annual health maintenance examination, dyslipidemia, tinnitus in left ear, and hemorrhoids.", General Medicine, Annual Health Maintenance Exam ,"HISTORY OF PRESENT ILLNESS:  ,This 59-year-old white male is seen for comprehensive annual health maintenance examination on 02/19/08, although this patient is in excellent overall health.  Medical problems include chronic tinnitus in the left ear with moderate hearing loss for many years without any recent change, dyslipidemia well controlled with niacin, history of hemorrhoids with occasional external bleeding, although no problems in the last 6 months, and also history of concha bullosa of the left nostril, followed by ENT associated with slight septal deviation.  There are no other medical problems.  He has no symptoms at this time and remains in excellent health.,PAST MEDICAL HISTORY: , Otherwise noncontributory.  There is no operation, serious illness or injury other than as noted above.,ALLERGIES: , There are no known allergies.,FAMILY HISTORY: , Father died of an MI at age 67 with COPD and was a heavy smoker.  His mother is 88, living and well, status post lung cancer resection.  Two brothers, living and well.  One sister died at age 20 months of pneumonia.,SOCIAL HISTORY:,  The patient is married.  Wife is living and well.  He jogs or does Cross Country track 5 times a week, and weight training twice weekly.  No smoking or significant alcohol intake.  He is a physician in allergy/immunology.,REVIEW OF SYSTEMS:,  Otherwise noncontributory.  He has no gastrointestinal, cardiopulmonary, genitourinary or musculoskeletal symptomatology.  No symptoms other than as described above.,PHYSICAL EXAMINATION:,GENERAL:  He appears alert, oriented, and in no acute distress with excellent cognitive function.  VITAL SIGNS:  His height is 6 feet 2 inches, weight is 181.2, blood pressure is 126/80 in the right arm, 122/78 in the left arm, pulse rate is 68 and regular, and respirations are 16.  SKIN:  Warm and dry.  There is no pallor, cyanosis or icterus.  HEENT:  Tympanic membranes benign.  The pharynx is benign.  Nasal mucosa is intact.  Pupils are round, regular, and equal, reacting equally to light and accommodation.  EOM intact.  Fundi reveal flat discs with clear margins.  Normal vasculature.  No hemorrhages, exudates or microaneurysms.  No thyroid enlargement.  There is no lymphadenopathy.  LUNGS:  Clear to percussion and auscultation.  Normal sinus rhythm.  No premature beat, murmur, S3 or S4.  Heart sounds are of good quality and intensity.  The carotids, femorals, dorsalis pedis, and posterior tibial pulsations are brisk, equal, and active bilaterally.  ABDOMEN:  Benign without guarding, rigidity, tenderness, mass or organomegaly.  NEUROLOGIC:  Grossly intact.  EXTREMITIES:  Normal.  GU:  Genitalia normal.  There are no inguinal hernias.  There are mild hemorrhoids in the anal canal.  The prostate is small, if any normal to mildly enlarged with discrete margins, symmetrical without significant palpable abnormality.  There is no rectal mass.  The stool is Hemoccult negative.,IMPRESSION:,1.  Comprehensive annual health maintenance examination.,2.  Dyslipidemia.,3.  Tinnitus, left ear.,4.  Hemorrhoids.,PLAN:,  At this time, continue niacin 1000 mg in the morning, 500 mg at noon, and 1000 mg in the evening; aspirin 81 mg daily; multivitamins; vitamin E 400 units daily; and vitamin C 500 mg daily.  Consider adding lycopene, selenium, and flaxseed to his regimen.  All appropriate labs will be obtained today.  Followup fasting lipid profile and ALT in 6 months.","general medicine, tinnitus, dyslipidemia, annual health maintenance, health, hemorrhoids, benign"
" Possible exposure to ant bait.  She is not exhibiting any symptoms and parents were explained that if she develops any vomiting, she should be brought back for reevaluation.", General Medicine, Ant Bait Exposure - ER Visit ,"CHIEF COMPLAINT: , Possible exposure to ant bait.,HISTORY OF PRESENT ILLNESS:,  This is a 14-month-old child who apparently was near the sink, got into the childproof cabinet and pulled out ant bait that had Borax in it.  It had 11 mL of this fluid in it.  She spilled it on her, had it on her hands.  Parents were not sure whether she ingested any of it.  So, they brought her in for evaluation.  They did not note any symptoms of any type.,PAST MEDICAL HISTORY: , Negative.  Generally very healthy.,REVIEW OF SYSTEMS: , The child has not been having any coughing, gagging, vomiting, or other symptoms.  Acting perfectly normal.  Family mostly noted that she had spilled it on the ground around her, had it on her hands, and on her clothes.  They did not witness that she ingested any, but did not see anything her mouth.,MEDICATIONS: , None.,ALLERGIES: , NONE.,PHYSICAL EXAMINATION: , VITAL SIGNS:  The patient was afebrile.  Stable vital signs and normal pulse oximetry.  GENERAL:  The child is very active, cheerful youngster, in no distress whatsoever.  HEENT:  Unremarkable.  Oral mucosa is clear, moist, and well hydrated.  I do not see any evidence of any sort of liquid on the face.  Her clothing did have the substance on the clothes, but I did not see any evidence of anything on her torso.  Apparently, she had some on her hands that has been wiped off.,EMERGENCY DEPARTMENT COURSE:,  I discussed the case with Poison Control and apparently this is actually relatively small quantity and it is likely to be a nontoxic ingestion if she even ingested, which should does not appear likely to be the case.,IMPRESSION: , Exposure to ant bait.,PLAN: , At this point, it is fairly unlikely that this child ingested any significant amount, if at all, which seems unlikely.  She is not exhibiting any symptoms and I explained to the parents that if she develops any vomiting, she should be brought back for reevaluation.  So, the patient is discharged in stable condition.","general medicine, borax, vomiting, exposure to ant bait, ant bait, exposure, symptoms,"
" This is a pleasant 50-year-old female who has undergone an APR secondary to refractory ulcerative colitis.  Overall, her quality of life has significantly improved since she had her APR.  She is functioning well with her ileostomy. ", Gastroenterology, Wound Check - Status Post APR ,"HISTORY OF PRESENT ILLNESS:,  Ms. Connor is a 50-year-old female who returns to clinic for a wound check.  The patient underwent an APR secondary to refractory ulcerative colitis.  Subsequently, she developed a wound infection, which has since healed.  On our most recent visit to our clinic, she has her perineal stitches removed and presents today for followup of her perineal wound.  She describes no drainage or erythema from her bottom.  She is having good ostomy output.  She does not describe any fevers, chills, nausea, or vomiting.  The patient does describe some intermittent pain beneath the upper portion of the incision as well as in the right lower quadrant below her ostomy.  She has been taking Percocet for this pain and it does work.  She has since run out has been trying extra strength Tylenol, which will occasionally help this intermittent pain.  She is requesting additional pain medications for this occasional abdominal pain, which she still experiences.,PHYSICAL EXAMINATION: , Temperature 95.8, pulse 68, blood pressure 132/73, and weight 159 pounds.  This is a pleasant female in no acute distress.  The patient's abdomen is soft, nontender, nondistended with a well-healed midline scar.  There is an ileostomy in the right hemiabdomen, which is pink, patent, productive, and protuberant.  There are no signs of masses or hernias over the patient's abdomen.,ASSESSMENT AND PLAN: , This is a pleasant 50-year-old female who has undergone an APR secondary to refractory ulcerative colitis.  Overall, her quality of life has significantly improved since she had her APR.  She is functioning well with her ileostomy.  She did have concerns or questions about her diet and we discussed the BRAT diet, which consisted of foods that would slow down the digestive tract such as bananas, rice, toast, cheese, and peanut butter.  I discussed the need to monitor her ileostomy output and preferential amount of daily output is 2 liters or less.  I have counseled her on refraining from soft drinks and fruit drinks.  I have also discussed with her that this diet is moreover a trial and error and that she may try certain foods that did not agree with her ileostomy, however others may and that this is something she will just have to perform trials with over the next several months until she finds what foods that she can and cannot eat with her ileostomy.  She also had questions about her occasional abdominal pain.  I told her that this was probably continue to improve as months went by and I gave her a refill of her Percocet for the continued occasional pain.  I told her that this would the last time I would refill the Percocet and if she has continued pain after she finishes this bottle then she would need to start ibuprofen or Tylenol if she had continued pain.  The patient then brought up some right hand and arm numbness, which has been there postsurgically and was thought to be from positioning during surgery.  This is all primarily gone away except for a little bit of numbness at the tip of the third digit as well as some occasional forearm muscle cramping.  I told her that I felt that this would continue to improve as it has done over the past two months since her surgery.  I told her to continue doing hand exercises as she has been doing and this seems to be working for her.  Overall, I think she has healed from her surgery and is doing very well.  Again, her quality of life is significantly improved.  She is happy with her performance.  We will see her back in six months just for a general routine checkup and see how she is doing at that time.","gastroenterology, perineal wound, wound infection, wound, wound check, ulcerative colitis, apr, ileostomyNOTE"
 Upper endoscopy with foreign body removal (Penny in proximal esophagus)., Gastroenterology, Upper Endoscopy - Foreign Body Removal ,"PROCEDURE:, Upper endoscopy with foreign body removal.,PREOPERATIVE DIAGNOSIS (ES):, Esophageal foreign body.,POSTOPERATIVE DIAGNOSIS (ES):, Penny in proximal esophagus.,ESTIMATED BLOOD LOSS:, None.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: ,After informed consent was obtained, the patient was taken to the pediatric endoscopy suite. After appropriate sedation by the anesthesia staff and intubation, an upper endoscope was inserted into the mouth, over the tongue, into the esophagus, at which time the foreign body was encountered. It was grasped with a coin removal forcep and removed with an endoscope. At that time, the endoscope was reinserted, advanced to the level of the stomach and stomach was evaluated and was normal. The esophagus was normal with the exception of some mild erythema, where the coin had been sitting. There were no erosions. The stomach was decompressed of air and fluid. The scope was removed without difficulty.,SUMMARY:, The patient underwent endoscopic removal of esophageal foreign body.,PLAN:, To discharge home, follow up as needed.","gastroenterology, upper endoscopy, endoscopy, endoscopy suite, esophagus, foreign body, foreign body removal, esophageal foreign body, stomach,"
 Possible free air under the diaphragm.  On a chest x-ray for what appeared to be shortness of breath she was found to have what was thought to be free air under the right diaphragm.  No intra-abdominal pathology., General Medicine, Air Under Diaphragm - Consult ,"REASON FOR CONSULTATION: , Possible free air under the diaphragm.,HISTORY OF PRESENT ILLNESS: , The patient is a 77-year-old female who is unable to give any information.  She has been sedated with Ativan and came into the emergency room obtunded and unable to give any history.  On a chest x-ray for what appeared to be shortness of breath she was found to have what was thought to be free air under the right diaphragm.,PAST MEDICAL HISTORY: , Significant for alcohol abuse.  Unable to really gather any other information because she is so obtunded.,PAST SURGICAL HISTORY:  ,Looking at the medical chart, she had an appendectomy, right hip fracture from a fall in 2005, and TAH/BSO.,MEDICATIONS:,  Unable to evaluate.,ALLERGIES: , UNABLE TO EVALUATE.,SOCIAL HISTORY:  ,Significant history of alcohol abuse, according to the emergency room physician, who sees her on a regular basis.,REVIEW OF SYSTEMS: , Unable to obtain.,PHYSICAL EXAM,VITAL SIGNS:  Temp 98.3, heart rate 82, respiratory rate 24, and blood pressure 141/70.,GENERAL:  She is a very obtunded female who upon arousal is not able to provide any information of any use.,HEENT:  Atraumatic.,NECK:  Soft and supple.,LUNGS:  Bilaterally diminished.,HEART:  Regular.,ABDOMEN:  Soft, and with deep palpation I am unable to arouse the patient, unable to elicit any tenderness.,LABORATORY STUDIES: , Show a normal white blood cell count with no shift.  Elevated AST at 138, with a normal ALT at 38.  Alkaline phosphatase of 96, bilirubin 0.8.  Sodium is 107, with 68 chloride and potassium of 2.8.,X-ray of the chest shows the possibility of free air; therefore, a CT scan was obtained because of the patient's physical examination, which shows no evidence of intra-abdominal pathology.  The etiology of the air under the diaphragm is actually a colonic air that is anterior superior to the dome of the diaphragm, near the dome of the liver.,ASSESSMENT: , No intra-abdominal pathology.,PLAN:,  Have her admitted to the medical service for treatment of her hyponatremia.",
" Umbilical hernia repair. A standard curvilinear umbilical incision was made, and dissection was carried down to the hernia sac using a combination of Metzenbaum scissors and Bovie electrocautery.  ", Gastroenterology, Umbilical Hernia Repair - 1 ,"PROCEDURE PERFORMED: , Umbilical hernia repair.,PROCEDURE:,  After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table.  The patient was sedated, and an adequate local anesthetic was administered using 1% lidocaine without epinephrine.  The patient was prepped and draped in the usual sterile manner.,A standard curvilinear umbilical incision was made, and dissection was carried down to the hernia sac using a combination of Metzenbaum scissors and Bovie electrocautery.  The sac was cleared of overlying adherent tissue, and the fascial defect was delineated.  The fascia was cleared of any adherent tissue for a distance of 1.5 cm from the defect.  The sac was then placed into the abdominal cavity and the defect was closed primarily using simple interrupted 0 Vicryl sutures.  The umbilicus was then re-formed using 4-0 Vicryl to tack the umbilical skin to the fascia.,The wound was then irrigated using sterile saline, and hemostasis was obtained using Bovie electrocautery.  The skin was approximated with 4-0 Vicryl in a subcuticular fashion.  The skin was prepped with benzoin, and Steri-Strips were applied.  A dressing was then applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.","gastroenterology, fascial defect, umbilical hernia repair, curvilinear umbilical, hernia sac, metzenbaum scissors, umbilical hernia, bovie electrocautery, electrocautery, hernia, incision, umbilical,"
" The patient complaining of abdominal pain, has a long-standing history of diabetes treated with Micronase daily.", General Medicine, Acute Cystitis & Diabetes Type II ,"HISTORY OF PRESENT ILLNESS: , The patient is a 45-year-old male complaining of abdominal pain.  The patient also has a long-standing history of diabetes which is treated with Micronase daily.,PAST MEDICAL HISTORY: , There is no significant past medical history noted today.,PHYSICAL EXAMINATION:,HEENT:  Patient denies ear abnormalities, nose abnormalities and throat abnormalities.,Cardio:  Patient has history of elevated cholesterol, but does not have ASHD, hypertension and PVD.,Resp:  Patient denies asthma, lung infections and lung lesions.,GI:  Patient denies colon abnormalities, gall bladder problems, liver abnormalities and peptic ulcer disease.,GU:  Patient has history of Urinary tract disorder, but does not have Bladder disorder and Kidney disorder.,Endocrine:  Patient has history of diabetes, but does not have hormonal irregularities and thyroid abnormalities.,Dermatology:  Patient denies allergic reactions, rashes and skin lesions.,MEDS:,  Micronase 2.5 mg Tab PO QAM #30.  Bactrim 400/80 Tab PO BID #30.,SOCIAL HISTORY:,  No known history of drug or alcohol abuse.  Work, diet, and exercise patterns are within normal limits.,FAMILY HISTORY:,  No significant family history.,REVIEW OF SYSTEMS:,  Non-contributory.,Vital Signs:  Height = 72 in.  Weight =184 lbs.  Upright BP = 120/80 mmHg.  Pulse = 80 bpm.  Resp =12 pm.  Patient is afebrile.,Neck:  The neck is supple.  There is no jugular venous distension.  The thyroid is nontender, or normal size and conto.,Lungs:  Lung expansion and excursions are symmetric.  The lungs are clear to auscultation and percussion.,Cardio:  There is a regular rhythm.  SI and S2 are normal.  No abnormal heart sounds are detected.  Blood pressure is equal bilaterally.,Abdomen:  Normal bowel sounds are present.  The abdomen is soft; The abdomen is nontender; without organomegaly; There is no CVA tenderness.  No hernias are noted.,Extremities:  There is no clubbing, cyanosis, or edema.,ASSESSMENT: , Diabetes type II uncontrolled.  Acute cystitis.,PLAN: , Endocrinology Consult, complete CBC.  ,RX: , Micronase 2.5 mg Tab PO QAM #30, Bactrim 400/80 Tab PO BID #30.",
 Patient is a three years old male who about 45 minutes prior admission to the emergency room ingested about two to three tablets of Celesta 40 mg per tablets., General Medicine, Accidental Celesta Ingestion - ER Visit ,"HISTORY OF PRESENT ILLNESS:,  Patient is a three years old male who about 45 minutes prior admission to the emergency room ingested about two to three tablets of Celesta 40 mg per tablets.  Mom called to the poison control center and the recommendation was to take the patient to the emergency room and be evaluated.  The patient was alert and did not vomit during the transport to the emergency room.  Mom left the patient and his little one-year-old brother in the room by themselves and she went outside of the house for a couple of minutes, and when came back, she saw the patient having the Celesta foils in his hands and half of tablet was moist and on the floor.  The patient said that the pills ""didn't taste good,"" so it is presumed that the patient actually ingested at least two-and-a-half tablets of Celesta, 40 mg per tablet.,PAST MEDICAL HISTORY:,  Baby was born premature and he required hospitalization, but was not on mechanical ventilation.  He doesn't have any hospitalizations after the new born.  No surgeries.,IMMUNIZATIONS: , Up-to-date.,ALLERGIES: , NOT KNOWN DRUG ALLERGIES.,PHYSICAL EXAMINATION,VITAL SIGNS:  Temperature 36.2 Celsius, pulse 112, respirations 24, blood pressure 104/67, weight 15 kilograms.,GENERAL:  Alert, in no acute distress.,SKIN:  No rashes.,HEENT:  Head:  Normocephalic, atraumatic.  Eyes:  EOMI, PERRL.  Nasal mucosa clear.  Throat and tonsils, normal.  No erythema, no exudates.,NECK:  Supple, no lymphadenopathy, no masses.,LUNGS:  Clear to auscultation bilateral.,HEART:  Regular rhythm and rate without murmur.  Normal S1, S2.,ABDOMEN:  Soft, nondistended, nontender, present bowel sounds, no hepatosplenomegaly, no masses.,EXTREMITIES:  Warm.  Capillary refill brisk.  Deep tendon reflexes present bilaterally.,NEUROLOGICAL:  Alert.  Cranial nerves II through XII intact.  No focal exam.  Normal gait.,RADIOGRAPHIC DATA: , Patient has had an EKG done at the admission and it was within normal limits for the age.,EMERGENCY ROOM COURSE: , Patient was under observation for 6 hours in the emergency room.  He had two more EKGs during observation in the emergency room and they were all normal.  His vital signs were monitored every hour and were within normal limits.  There was no vomiting, no diarrhea during observation.  Patient did not receive any medication or has had any other lab work besides the EKG.,ASSESSMENT AND PLAN: , Three years old male with accidental ingestion of Celesta.  Discharged home with parents, with a followup in the morning with his primary care physician.","general medicine, accidental ingestion of celesta, celesta, tablets, ingestion, "
 The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent., General Medicine, Abdominal Pain - Consult ,"CHIEF COMPLAINT:,  Abdominal pain.,HISTORY OF PRESENT ILLNESS:,  The patient is a 71-year-old female patient of Dr. X. The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent.  She was seen 3 to 4 days ago at ABC ER and underwent evaluation and discharged and had a CT scan at that time and she was told it was ""normal.""  She was given oral antibiotics of Cipro and Flagyl.  She has had no nausea and vomiting, but has had persistent associated anorexia.  She is passing flatus, but had some obstipation symptoms with the last bowel movement two days ago.  She denies any bright red blood per rectum and no history of recent melena.  Her last colonoscopy was approximately 5 years ago with Dr. Y. She has had no definite fevers or chills and no history of jaundice.  The patient denies any significant recent weight loss.,PAST MEDICAL HISTORY:  ,Significant for history of atrial fibrillation, under good control and now in normal sinus rhythm and on metoprolol and also on Premarin hormone replacement.,PAST SURGICAL HISTORY: , Significant for cholecystectomy, appendectomy, and hysterectomy.  She has a long history of known grade 4 bladder prolapse and she has been seen in the past by Dr. Chip Winkel, I believe that he has not been re-consulted.,ALLERGIES: , SHE IS ALLERGIC OR SENSITIVE TO MACRODANTIN.,SOCIAL HISTORY: , She does not drink or smoke.,REVIEW OF SYSTEMS: , Otherwise negative for any recent febrile illnesses, chest pains or shortness of breath.,PHYSICAL EXAMINATION:,GENERAL:  The patient is an elderly thin white female, very pleasant, in no acute distress.,VITAL SIGNS:  Her temperature is 98.8 and vital signs are all stable, within normal limits.,HEENT:  Head is grossly atraumatic and normocephalic.  Sclerae are anicteric.  The conjunctivae are non-injected.,NECK:  Supple.,CHEST:  Clear.,HEART:  Regular rate and rhythm.,ABDOMEN:  Generally nondistended and soft.  She is focally tender in the left lower quadrant to deep palpation with a palpable fullness or mass and focally tender, but no rebound tenderness.  There is no CVA or flank tenderness, although some very minimal left flank tenderness.,PELVIC:  Currently deferred, but has history of grade 4 urinary bladder prolapse.,EXTREMITIES:  Grossly and neurovascularly intact.,LABORATORY VALUES:  ,White blood cell count is 5.3, hemoglobin 12.8, and platelet count normal.  Alkaline phosphatase elevated at 184.  Liver function tests otherwise normal.  Electrolytes normal.  Glucose 134, BUN 4, and creatinine 0.7.,DIAGNOSTIC STUDIES:,  EKG shows normal sinus rhythm.,IMPRESSION AND PLAN: , A 71-year-old female with greater than one-week history of abdominal pain now more localized to the left lower quadrant.  Currently is a nonacute abdomen.  The working diagnosis would be sigmoid diverticulitis.  She does have a history in the distant past of sigmoid diverticulitis.  I would recommend a repeat stat CT scan of the abdomen and pelvis and keep the patient nothing by mouth.  The patient was seen 5 years ago by Dr. Y in Colorectal Surgery.  We will consult her also for evaluation.  The patient will need repeat colonoscopy in the near future and be kept nothing by mouth now empirically.  The case was discussed with the patient's primary care physician, Dr. X. Again, currently there is no indication for acute surgical intervention on today's date, although the patient will need close observation and further diagnostic workup.",
 Viral gastroenteritis.  Patient complaining of the onset of nausea and vomiting after she drank lots of red wine.  She denies any sore throat or cough.  She states no one else at home has been ill., Gastroenterology, Viral Gastroenteritis ,"HISTORY OF PRESENT ILLNESS: , Patient is a 40-year-old white female visiting with her husband complaining of the onset of nausea and vomiting approximately at 11 p.m. last night, after she states she drank ""lots of red wine.""  She states after vomiting, she felt ""fine through the night,"" but woke with more nausea and vomiting and diaphoresis.  She states she has vomited approximately 20 times today and has also had some slight diarrhea.  She denies any sore throat or cough.  She states no one else at home has been ill.  She has not taken anything for her symptoms.,MEDICATIONS: , Currently the patient is on fluoxetine for depression and Zyrtec for environmental allergies.,ALLERGIES: , SHE HAS NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY:,  The patient is married and is a nonsmoker, and lives with her husband, who is here with her.,REVIEW OF SYSTEMS,Patient denies any fever or cough.  She notes no blood in her vomitus or stool.  The remainder of her review of systems is discussed and all are negative.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS:  Temp is 37.6.  Other vital signs are all within normal limits.,GENERAL:  Patient is a healthy-appearing, middle-aged white female who is lying on the stretcher and appears only mildly ill.,HEENT:  Head is normocephalic and atraumatic.  Pharynx shows no erythema, tonsillar edema, or exudate.  NECK:  No enlarged anterior or posterior cervical lymph nodes.  There is no meningismus.,HEART:  Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS:  Clear without rales, rhonchi, or wheezes.,ABDOMEN:  Active bowel sounds.  Soft without any focal tenderness on palpation.  There are no masses, guarding, or rebound noted.,SKIN:  No rash.,EXTREMITIES:  No cyanosis, clubbing, or edema.,LABORATORY DATA: , CBC shows a white count of 12.9 with an elevation in the neutrophil count on differential.  Hematocrit is 33.8, but the indices are normochromic and normocytic.  BMP is remarkable for a random glucose of 147.  All other values are unremarkable.  LFTs are normal.  Serum alcohol is less than 5.,TREATMENT: , Patient was given 2 L of normal saline wide open as well as Compazine 5 mg IV x2 doses with resolution of her nausea.  She was given two capsules of Imodium with some apple juice, which she was able to keep down.  The patient did feel well enough to be discharged home.,ASSESSMENT:,  Viral gastroenteritis.,PLAN: , Rx for Compazine 10 mg tabs, dispense five, sig. one p.o. q.8h. p.r.n. for any recurrent nausea.  She was urged to use liquids only until the nausea has gone for 12 to 24 hours with slow advancement of her diet.  Imodium for any diarrhea, but no dairy products until the diarrhea has gone for at least 24 hours.  If she is unimproved in the next two days, she was urged to follow up with her PCP back home.","gastroenterology, nausea, vomiting, viral gastroenteritis, wine, gastroenteritis, ill, "
 Upper endoscopy with removal of food impaction., Gastroenterology, Upper Endoscopy  ,"PROCEDURE:,  Upper endoscopy with removal of food impaction.,HISTORY OF PRESENT ILLNESS: , A 92-year-old lady with history of dysphagia on and off for two years.  She comes in this morning with complaints of inability to swallow anything including her saliva.  This started almost a day earlier.  She was eating lunch and had beef stew and suddenly noticed inability to finish her meal and since then has not been able to eat anything.  She is on Coumadin and her INR is 2.5.,OPERATIVE NOTE: , Informed consent was obtained from patient.  The risks of aspiration, bleeding, perforation, infection, and serious risk including need for surgery and ICU stay particularly in view of food impaction for almost a day was discussed.  Daughter was also informed about the procedure and risks.  Conscious sedation initially was administered with Versed 2 mg and fentanyl 50 mcg.  The scope was advanced into the esophagus and showed liquid and solid particles from mid esophagus all the way to the distal esophagus.  There was a meat bolus in the distal esophagus.  This was visualized after clearing the liquid material and small particles of what appeared to be carrots.  The patient, however, was not tolerating the conscious sedation.  Hence, Dr. X was consulted and we continued the procedure with propofol sedation.,The scope was reintroduced into the esophagus after propofol sedation.  Initially a Roth net was used and some small amounts of soft food in the distal esophagus was removed with the Roth net.  Then, a snare was used to cut the meat bolus into pieces, as it was very soft.  Small pieces were grabbed with the snare and pulled out.  Thereafter, the residual soft meat bolus was passed into the stomach along with the scope, which was passed between the bolus and the esophageal wall carefully.  The patient had severe bruising and submucosal hemorrhage in the esophagus possibly due to longstanding bolus impaction and Coumadin therapy.  No active bleeding was seen.  There was a distal esophageal stricture, which caused slight resistance to the passage of the scope into the stomach.  As this area was extremely inflamed, a dilatation was not attempted.,IMPRESSION: , Distal esophageal stricture with food impaction.  Treated as described above.,RECOMMENDATIONS:,  IV Protonix 40 mg q.12h.  Clear liquid diet for 24 hours.  If the patient is stable, thereafter she may take soft pureed diet only until next endoscopy, which will be scheduled in three to four weeks.  She should take Prevacid SoluTab 30 mg b.i.d. on discharge.","gastroenterology, dysphagia, removal of food impaction, distal esophagus, stomach, distal esophageal, esophageal stricture, upper endoscopy, food impaction, endoscopy, aspiration, sedation, bolus, impaction, esophagus, "
" Insertion of a triple-lumen central line through the right subclavian vein by the percutaneous technique.  This lady has a bowel obstruction.  She was being fed through a central line, which as per the patient was just put yesterday and this slipped out. ", Gastroenterology, Ttriple-Lumen Central Line ,"PREOPERATIVE DIAGNOSES,1.  Bowel obstruction.,2.  Central line fell off.,POSTOPERATIVE DIAGNOSES,1.  Bowel obstruction.,2.  Central line fell off.,PROCEDURE: , Insertion of a triple-lumen central line through the right subclavian vein by the percutaneous technique.,PROCEDURE DETAIL: , This lady has a bowel obstruction.  She was being fed through a central line, which as per the patient was just put yesterday and this slipped out.  At the patient's bedside after obtaining an informed consent, the patient's right deltopectoral area was prepped and draped in the usual fashion.  Xylocaine 1% was infiltrated and with the patient in Trendelenburg position, she had her right subclavian vein percutaneously cannulated without any difficulty.  A Seldinger technique was used and a triple-lumen catheter was inserted.  There was a good flow through all three ports, which were irrigated with saline prior to connection to the IV solutions.,The catheter was affixed to the skin with sutures and then a dressing was applied.,The postprocedure chest x-ray revealed that there were no complications to the procedure and that the catheter was in good place.","gastroenterology, central line, triple lumen central line, subclavian vein, bowel obstruction, lumen, percutaneous, bowel, obstruction"
 Ultrasound Abdomen - elevated liver function tests., Gastroenterology, Ultrasound - Abdomen - 1 ,"EXAM: , Ultrasound Abdomen., ,REASON FOR EXAM: , Elevated liver function tests., ,INTERPRETATION: , The liver demonstrates heterogeneously increased echotexture with significant fatty infiltration.  The gallbladder is surgically absent. There is no fluid collection in the cholecystectomy bed.  There is dilatation of the common bile duct up to 1 cm.  There is also dilatation of the pancreatic duct that measures up to 3 mm.  There is caliectasis in the right kidney.  The bladder is significantly distended measuring 937 cc in volume.  The caliectasis in the right kidney may be secondary to back pressure from the distended bladder.  The aorta is normal in caliber., ,IMPRESSION:,1.  Dilated common duct as well as pancreatic duct as described.  Given the dilatation of these two ducts, ERCP versus MRCP is recommended to exclude obstructing mass.  The findings could reflect changes of cholecystectomy.  ,2.  Significantly distended bladder with probably resultant caliectasis in the right kidney.  Clinical correlation recommended.","gastroenterology, aorta, dilated common duct, mrcp, ercp, elevated liver function tests, pancreatic duct, distended bladder, ultrasound abdomen, cholecystectomy, ultrasound, abdomen, liver, dilatation, caliectasis, kidney, bladder, duct"
" Ultrasound abdomen, complete", Gastroenterology, Ultrasound - Abdomen ,"EXAM: , Ultrasound abdomen, complete.,HISTORY: , 38-year-old male admitted from the emergency room 04/18/2009, decreased mental status and right upper lobe pneumonia.  The patient has diffuse abdominal pain.  There is a history of AIDS.,TECHNIQUE:,  An ultrasound examination of the abdomen was performed.,FINDINGS:,  The liver has normal echogenicity.  The liver is normal sized.  The gallbladder has a normal appearance without gallstones or sludge.  There is no gallbladder wall thickening or pericholecystic fluid.  The common bile duct has a normal caliber at 4.6 mm.  The pancreas is mostly obscured by gas.  A small portion of the head of pancreas is visualized which has a normal appearance.  The aorta has a normal caliber.  The aorta is smooth walled.  No abnormalities are seen of the inferior vena cava.  The right kidney measures 10.8 cm in length and the left kidney 10.5 cm.  No masses, cysts, calculi, or hydronephrosis is seen.  There is normal renal cortical echogenicity.  The spleen is somewhat prominent with a maximum diameter of 11.2 cm.  There is no ascites.  The urinary bladder is distended with urine and shows normal wall thickness without masses.  The prostate is normal sized with normal echogenicity.,IMPRESSION:  ,1.  Spleen size at the upper limits of normal.,2.  Except for small portions of pancreatic head, the pancreas could not be visualized because of bowel gas.  The visualized portion of the head had a normal appearance.,3.  The gallbladder has a normal appearance without gallstones.  There are no renal calculi.","gastroenterology, echogenicity, gallbladder, ultrasound abdomen complete, ultrasound abdomen, abdomen, liver, gallstones, kidney, calculi, renal, spleen, pancreas, ultrasound"
" Left thoracotomy with drainage of pleural fluid collection, esophageal exploration and repair of esophageal perforation, diagnostic laparoscopy and gastrostomy, and radiographic gastrostomy tube study with gastric contrast, interpretation.", Gastroenterology, Thoracotomy & Esophageal Exploration ,"PREOPERATIVE DIAGNOSIS:  ,Esophageal rupture.,POSTOPERATIVE DIAGNOSIS:,  Esophageal rupture.,OPERATION PERFORMED,1.  Left thoracotomy with drainage of pleural fluid collection.,2.  Esophageal exploration and repair of esophageal perforation.,3.  Diagnostic laparoscopy and gastrostomy.,4.  Radiographic gastrostomy tube study with gastric contrast, interpretation.,ANESTHESIA: , General anesthesia.,INDICATIONS OF THE PROCEDURE: , The patient is a 47-year-old male with a history of chronic esophageal stricture who is admitted with food sticking and retching.  He has esophageal rupture on CT scan and comes now for a thoracotomy and gastrostomy.,DETAILS OF THE PROCEDURE: , After an extensive informed consent discussion process, the patient was brought to the operating room.  He was placed in a supine position on the operating table.  After induction of general anesthesia and placement of a double lumen endotracheal tube, he was turned and placed in a right lateral decubitus position on a beanbag with appropriate padding and axillary roll.  Left chest was prepped and draped in a usual sterile fashion.  After administration of intravenous antibiotics, a left thoracotomy incision was made, dissection was carried down to the subcutaneous tissues, muscle layers down to the fifth interspace.  The left lung was deflated and the pleural cavity entered.  The Finochietto retractor was used to help provide exposure.  The sixth rib was shingled in the posterior position and a careful expiration of the left pleural cavity was performed.,Immediately encountered was left pleural fluid including some purulent fluid.  Cultures of this were sampled and sent for microbiology analysis.  The left pleural space was then copiously irrigated.  A careful expiration demonstrated that the rupture appeared to be sealed.  There was crepitus within the mediastinal cavity.  The mediastinum was opened and explored and the esophagus was explored.  The tissues of the esophagus appeared to show some friability and an area of the rupture in the distal esophagus.  It was not possible to place any stitches in this tissue and instead a small intercostal flap was developed and placed to cover the area.  The area was copiously irrigated, this provided nice coverage and repair.  After final irrigation and inspection, two chest tubes were placed including a #36 French right angled tube at the diaphragm and a posterior straight #36 French.  These were secured at the left axillary line region at the skin level with #0-silk.,The intercostal sutures were used to close the chest wall with a #2 Vicryl sutures.  Muscle layers were closed with running #1 Vicryl sutures.  The wound was irrigated and the skin was closed with skin staples.,The patient was then turned and placed in a supine position.  A laparoscopic gastrostomy was performed and then a diagnostic laparoscopy performed.  A Veress needle was carefully inserted into the abdomen, pneumoperitoneum was established in the usual fashion, a bladeless 5-mm separator trocar was introduced.  The laparoscope was introduced.  A single additional left-sided separator trocar was introduced.  It was not possible to safely pass a nasogastric or orogastric tube, pass the stricture and perforation and so the nasogastric tube was left right at the level where there was some stricture or narrowing or resistance.  The stomach however did have some air insufflation and we were able to place our T-fasteners through the anterior abdominal wall and through the anterior gastric wall safely.  The skin incision was made and the gastric lumen was then accessed with the Seldinger technique.  Guide wire was introduced into the stomach lumen and series of dilators was then passed over the guide wire.  #18 French Gastrostomy was then passed into the stomach lumen and the balloon was inflated.  We confirmed that we were in the gastric lumen and the balloon was pulled up, creating apposition of the gastric wall and the anterior abdominal wall.  The T-fasteners were all crimped and secured into position.  As was in the plan, the gastrostomy was secured to the skin and into the tube.  Sterile dressing was applied.  Aspiration demonstrated gastric content.,Gastrostomy tube study, with interpretation.  Radiographic gastrostomy tube study with gastric contrast, with","gastroenterology, esophageal rupture, thoracotomy, drainage of pleural fluid, esophageal perforation, esophageal exploration, laparoscopy, gastrostomy, pleural fluid, diagnostic laparoscopy, radiographic gastrostomy, gastric lumen, gastrostomy tube, gastric contrast, gastric, interpretation, abdominal, pleural, lumen, esophageal, tube, "
" Umbilical hernia repair template.  The umbilical hernia carefully reduced back into the cavity, and the fascia was closed with interrupted vertical mattress sutures to approximate the fascia.", Gastroenterology, Umbilical Hernia Repair ,"PREOPERATIVE DIAGNOSIS: , Umbilical hernia.,POSTOPERATIVE DIAGNOSIS: , Umbilical hernia.,PROCEDURE PERFORMED: , Repair of umbilical hernia.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,PROCEDURE IN DETAIL:  ,The patient was prepped and draped in the sterile fashion.  An infraumbilical incision was formed and taken down to the fascia.  The umbilical hernia carefully reduced back into the cavity, and the fascia was closed with interrupted vertical mattress sutures to approximate the fascia, and then the wounds were infiltrated with 0.25% Marcaine.  The skin was reattached to the fascia with 2-0 Vicryls.  The skin was approximated with 2-0 Vicryl subcutaneous and then 4-0 Monocryl subcuticular stitches, dressed with Steri-Strips and 4 x 4's.  Patient was extubated and taken to the recovery area in stable condition.","gastroenterology, marcaine, steri-strips, mattress sutures, umbilical hernia, repair, umbilical, hernia,"
 Closure of gastrostomy placed due to feeding difficulties. , Gastroenterology, Surgical Closure of Gastrostomy ,"PREOPERATIVE DIAGNOSIS: , Gastrostomy (gastrocutaneous fistula).,POSTOPERATIVE DIAGNOSIS: , Gastrostomy (gastrocutaneous fistula).,OPERATION PERFORMED: , Surgical closure of gastrostomy.,ANESTHESIA: , General.,INDICATIONS: , This 1-year-old child had a gastrostomy placed due to feeding difficulties.  Since then, he has reached a point where he is now eating completely by mouth and no longer needed the gastrostomy.  The tube was, therefore, removed, but the tract has not shown signs of spontaneous closure.  He, therefore, comes to the operating room today for surgical closure of his gastrostomy.,OPERATIVE PROCEDURE: , After the induction of general anesthetic, the abdomen was prepped and draped in the usual manner.  An elliptical incision was made around the gastrostomy site and carried down through skin and subcutaneous tissue with sharp dissection.  The tract and the stomach were freed.  Stay sutures were then placed on either side of the tract.  The tract was amputated.  The intervening stomach was then closed with interrupted #4-0 Lembert, Nurolon sutures.  The fascia was then closed over the stomach using #3-0 Vicryl sutures.  The skin was closed with #5-0 subcuticular Monocryl.  A dressing was applied, and the child was awakened and taken to the recovery room in satisfactory condition.","gastroenterology, gastrocutaneous fistula, nurolon, closure of gastrostomy, feeding difficulties, surgical closure, gastrostomy"
" Open Stamm gastrotomy tube, lysis of adhesions, and closure of incidental colotomy", Gastroenterology, Stamm Gastrostomy Tube Placement ,"PREOPERATIVE DIAGNOSES:,1. Squamous cell carcinoma of the head and neck.,2. Ethanol and alcohol abuse.,POSTOPERATIVE DIAGNOSES:,1. Squamous cell carcinoma of the head and neck.,2. Ethanol and alcohol abuse.,PROCEDURE:,1. Failed percutaneous endoscopic gastrostomy tube placement.,2. Open Stamm gastrotomy tube.,3. Lysis of adhesions.,4. Closure of incidental colotomy.,ANESTHESIA:, General endotracheal anesthesia.,IV FLUIDS:, Crystalloid 1400 ml.,ESTIMATED BLOOD LOSS:, Thirty ml.,DRAINS:, Gastrostomy tube was placed to Foley.,SPECIMENS:, None.,FINDINGS:, Stomach located high in the peritoneal cavity. Multiple adhesions around the stomach to the diaphragm and liver.,HISTORY: ,The patient is a 59-year-old black male who is indigent, an ethanol and tobacco abuse. He presented initially to the emergency room with throat and bleeding. Following evaluation by ENT and biopsy, it was determined to be squamous cell carcinoma of the right tonsil and soft palate, The patient is to undergo radiation therapy and possibly chemotherapy and will need prolonged enteral feeding with a bypass route from the mouth. The malignancy was not obstructing. Following obtaining informed consent for percutaneous endoscopic gastrostomy tube with possible conversion to open procedure, we elected to proceed following diagnosis of squamous cell carcinoma and election for radiation therapy.,DESCRIPTION OF PROCEDURE:, The patient was placed in the supine position and general endotracheal anesthesia was induced. Preoperatively, 1 gram of Ancef was given. The abdomen was prepped and draped in the usual sterile fashion. After anesthesia was achieved, an endoscope was placed down into the stomach, and no abnormalities were noted. The stomach was insufflated with air and the endoscope was positioned in the midportion and directed towards the anterior abdominal wall. With the room darkened and intensity turned up on the endoscope, a light reflex was noted on the skin of the abdominal wall in the left upper quadrant at approximately 2 fingerbreadths inferior from the most inferior rib. Finger pressure was applied to the light reflex with adequate indentation on the stomach wall on endoscopy. A 21-gauge 1-1/2 inch needle was initially placed at the margin of the light reflex, and this was done twice. Both times it was not visualized on the endoscopy. At this point, repositioning was made and, again, what was felt to be adequate light reflex was obtained, and the 14-gauge angio catheter was placed. Again, after two attempts, we were unable to visualize the needle in the stomach endoscopically. At this point, decision was made to convert the procedure to an open Stamm gastrostomy.,OPEN STAMM GASTROSTOMY: ,A short upper midline incision was made and deepened through the subcutaneous tissues. Hemostasis was achieved with electrocautery. The linea alba was identified and incised, and the peritoneal cavity was entered. The abdomen was explored. Adhesions were lysed with electrocautery under direct vision. The stomach was identified, and a location on the anterior wall near the greater curvature was selected. After lysis of adhesions was confirmed, we sufficiently moved the original chosen site without tension. A pursestring suture of #3-0 silk was placed on the interior surface of the stomach, and a second #3-0 pursestring silk stitch was placed exterior to that pursestring suture. An incision was then made at the location of the anterior wall which was near the greater curvature and was dissected down to the anterior abdominal wall. A Vanderbilt was used to pass through the abdominal wall in through the skin and then returned to the level of the skin and pulled the Bard feeding tube through the anterior wall into the field. An incision in the center of the pursestring suture on the anterior surface of the stomach was then made with electrocautery. The interior pursestring suture was sutured into place in such a manner as to inkwell the stomach around the catheter. The second outer concentric pursestring suture was then secured as well and tied to further inkwell the stomach. The stomach was then tacked to the anterior abdominal wall at the catheter entrance site with four #2-0 silk sutures in such a manner as to prevent leakage or torsion. The catheter was then secured to the skin with two #2-0 silk sutures. Hemostasis was checked and the peritoneal cavity was washed out and brought to the surgical field. Prior to the initiation of the gastrotomy, the bowel was run and at that time there was noted to be one incidental colotomy. This was oversewn with three #4-0 silk Lembert sutures. At the completion of the operation, the fascia was closed with #1 interrupted Vicryl suture, and the skin was closed with staples. The patient tolerated the procedure well and was taken to the postanesthesia care unit in stable condition.", 
" She is a 79-year-old female who came in with acute cholecystitis and underwent attempted laparoscopic cholecystectomy 8 days ago.  The patient has required conversion to an open procedure due to difficult anatomy.  Her postoperative course has been lengthened due to a prolonged ileus, which resolved with tetracycline and Reglan.  The patient is starting to improve, gain more strength.  She is tolerating her regular diet.", Gastroenterology, SOAP - Cholecystitis ,"SUBJECTIVE: , She is a 79-year-old female who came in with acute cholecystitis and underwent attempted laparoscopic cholecystectomy 8 days ago.  The patient has required conversion to an open procedure due to difficult anatomy.  Her postoperative course has been lengthened due to a prolonged ileus, which resolved with tetracycline and Reglan.  The patient is starting to improve, gain more strength.  She is tolerating her regular diet.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Today, her temperature is 98.4, heart rate 84, respirations 20, and BP is 140/72.,LUNGS:  Clear to auscultation.  No wheezes, rales, or rhonchi.,HEART:  Regular rhythm and rate.,ABDOMEN:  Soft, less tender.,LABORATORY DATA:,  Her white count continues to come down.  Today, it is 11.6, H&H of 8.8 and 26.4, platelets 359,000.  We have ordered type and cross for 2 units of packed red blood cells.  If it drops below 25, she will receive a transfusion.  Her electrolytes today show a glucose of 107, sodium 137, potassium 4.0, chloride 103.2, bicarbonate 29.7.  Her AST is 43, ALT is 223, her alkaline phosphatase is 214, and her bilirubin is less than 0.10.,ASSESSMENT AND PLAN:,  She had a bowel movement today and is continuing to improve.,I anticipate another 3 days in the hospital for strengthening and continued TPN and resolution of elevated white count.","gastroenterology, laparoscopic cholecystectomy, anatomy, acute cholecystitis, prolonged ileus, white count, cholecystitis"
 Pediatric Gastroenterology - Rectal Bleeding Consult., Gastroenterology, Rectal Bleeding - 1-year-old ,"HISTORY OF PRESENT ILLNESS:,  This is a 1-year-old male patient who was admitted on 12/23/2007 with a history of rectal bleeding.  He was doing well until about 2 days prior to admission and when he passes hard stools, there was bright red blood in the stool.  He had one more episode that day of stool; the stool was hard with blood in it.  Then, he had one episode of rectal bleeding yesterday and again one stool today, which was soft and consistent with dark red blood in it.  No history of fever, no diarrhea, no history of easy bruising.  Excessive bleeding from minor cut.  He has been slightly fussy.,PAST MEDICAL HISTORY:  ,Nothing significant.,PREGNANCY DELIVERY AND NURSERY COURSE: , He was born full term without complications.,PAST SURGICAL HISTORY: , None.,SIGNIFICANT ILLNESS AND REVIEW OF SYSTEMS: , Negative for heart disease, lung disease, history of cancer, blood pressure problems, or bleeding problems.,DIET:,  Regular table food, 24 ounces of regular milk.  He is n.p.o. now.,TRAVEL HISTORY: , Negative.,IMMUNIZATION: , Up-to-date.,ALLERGIES: , None.,MEDICATIONS: , None, but he is on IV Zantac now.,SOCIAL HISTORY: , He lives with parents and siblings.,FAMILY HISTORY:,  Nothing significant.,LABORATORY EVALUATION: , On 12/24/2007, WBC 8.4, hemoglobin 7.6, hematocrit 23.2 and platelets 314,000.  Sodium 135, potassium 4.7, chloride 110, CO2 20, BUN 6 and creatinine 0.3.  Albumin 3.3.  AST 56 and ALT 26.  CRP less than 0.3.  Stool rate is still negative.,DIAGNOSTIC DATA: , CT scan of the abdomen was read as normal.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Temperature 99.5 degrees Fahrenheit, pulse 142 per minute and respirations 28 per minute.  Weight 9.6 kilogram.,GENERAL:  He is alert and active child in no apparent distress.,HEENT:  Atraumatic and normocephalic.  Pupils are equal, round and reactive to light.  Extraocular movements, conjunctivae and sclerae fair.  Nasal mucosa pink and moist.  Pharynx is clear.,NECK:  Supple without thyromegaly or masses.,LUNGS:  Good air entry bilaterally.  No rales or wheezing.,ABDOMEN:  Soft and nondistended.  Bowel sounds positive.  No mass palpable.,GENITALIA:  Normal male.,RECTAL:  Deferred, but there was no perianal lesion.,MUSCULOSKELETAL:  Full range of movement.  No edema.  No cyanosis.,CNS:  Alert, active and playful.,IMPRESSION: , A 1-year-old male patient with history of rectal bleeding.  Possibilities include Meckel's diverticulum, polyp, infection and vascular malformation.,PLAN:,  To proceed with Meckel scan today.  If Meckel scan is negative, we will consider upper endoscopy and colonoscopy.  We will start colon clean out if Meckel scan is negative.  We will send his stool for C. diff toxin, culture, blood for RAST test for cow milk, soy, wheat and egg.  Monitor hemoglobin.",
 A 10-year-old with a history of biliary atresia and status post orthotopic liver transplantation., Gastroenterology, Status Post Liver Transplant ,"HISTORY OF PRESENT ILLNESS:,  This is a 10-year-old who was found with biliary atresia and underwent a Kasai procedure and did not really well because she ended up having a liver transplant.  The patient did well after the liver transplant and the only problems started:,1.  History of food allergies.,2.  History of dental cavities.,At this time, the patient came for a followup and is complaining of a left upper molar pain.  There are no other complaints.,DIET: , Lactose-limited diet.,MEDICATIONS: , Please see the MRC form.,ALLERGIES: , There are no allergies.,SOCIAL HISTORY:,  The patient lives with the parents in Lindsay, California and has a good environment.,FAMILY HISTORY: , Negative for gastrointestinal illness except that a sibling has ulcerative colitis.,REVIEW OF SYSTEMS: , The system review was only positive for molar pain, but rest of the 13 review of systems were negative to date.,PHYSICAL EXAMINATION:  ,MEASUREMENTS:  Height 135 cm and weight 28.1 kg.,VITAL SIGNS:  Temperature 98.9 and blood pressure 105/57.,GENERAL:  A well-developed, well-nourished child in no acute distress.,HEENT:  Atraumatic and normocephalic.  The pupils are equal, round, and reactive to light.  Full EOMs.  The conjunctivae and sclerae are clear.  The TMs show normal landmarks.  The nasal mucosa is pink and moist.  The teeth and gums are in good condition.  The pharynx is clear.,NECK:  Supple, without thyromegaly and without masses.,LYMPHATIC:  No adenopathy.,LUNGS:  Clear to auscultation, with no retractions.,CORONARY:  Regular rhythm without murmur.  S1 and S2 are normal.  The pulses are full and symmetrical bilaterally.,ABDOMEN:  Normal bowel sounds.  No hepatosplenomegaly, no masses, and no tenderness.,GENITALIA:  Normal female by inspection.,SKIN:  No unusual lesions.,BACK:  No scoliosis, hairy patch, lipoma, or sacral dimple.,EXTREMITIES:  No cyanosis, clubbing, or edema.,CENTRAL NERVOUS SYSTEM:  Developmentally appropriate for age.  DTRs are 2+ and symmetrical.  The toes are downgoing bilaterally.  Motor and sensory without asymmetry.  Cranial nerves II through XII are grossly intact.,LABORATORY DATA:,  Laboratory data from 12/30/2007 tacrolimus 3.1 and negative Epstein-Barr, CMV was not detected.,FINAL IMPRESSION:,  This is a 10-year-old with history of:,1.  Biliary atresia.,2.  Status post orthotopic liver transplantation.,3.  Dental cavities.,4.  Food allergies.,5.  History of urinary tract infections.,PLAN: , Our plan would be to continue with the medications as follows:,1.  Prograf 0.5 mg p.o. b.i.d.,2.  Valganciclovir 420 mg p.o. b.i.d.,3.  Labs every 2 to 3 months.,4.  To return to clinic in 4 months.,5.  To refer this patient to a pediatric dentist for assessment of the dental cavities.",
" History of abdominal pain, obstipation, and distention with nausea and vomiting - paralytic ileus and mechanical obstruction.", Gastroenterology, Small Bowel Obstruction ,"CHIEF COMPLAINT:,  Patient AF is a 50-year-old hepatitis C positive African-American man presenting with a 2-day history of abdominal pain and distention with nausea and vomiting.,HISTORY OF PRESENT ILLNESS: , AF's symptoms began 2 days ago, and he has not passed gas or had any bowel movements.  He has not eaten anything, and has vomited 8 times.  AF reports 10/10 pain in the LLQ.,PAST MEDICAL HISTORY:,  AF's past medical history is significant for an abdominal injury during the Vietnam War which required surgery, and multiple episodes of small bowel obstruction and abdominal pain.  Other elements of his history include alcoholism, cocaine abuse, alcoholic hepatitis, hepatitis C positive, acute pancreatitis, chronic pancreatitis, appendicitis, liver hematoma/contusion, Hodgkin's Disease, constipation, diarrhea, paralytic ileus, anemia, multiple blood transfusions, chorioretinitis, pneumonia, and ""crack chest pain"" ,PAST SURGICAL HISTORY: , AF has had multiple abdominal surgeries, including Bill Roth Procedure Type 1 (partial gastrectomy) during Vietnam War, at least 2 exploratory laparotomies and enterolysis procedures (1993; 2000), and appendectomy,MEDICATIONS:,  None.,ALLERGIES:,  Iodine, IV contrast (anaphylaxis), and seafood/shellfish.,FAMILY HISTORY:,  Noncontributory.,SOCIAL HISTORY:,  AF was born and raised in San Francisco.  His father was an alcoholic.  He currently lives with his sister, and does not work; he collects a pension.,HEALTH-RELATED BEHAVIORS:,  AF reports that he smokes 1 to 2 cigarettes per day, and drinks 40 ounces of beer per day.,REVIEW OF SYSTEMS: , Noncontributory, except that patient reports a 6 pound weight loss since his symptoms began, and reports multiple transfusions for anemia.,PHYSICAL EXAM:,Vital Signs:  T:  37.1",
" A 68-year-old male with history of bilateral hernia repair, who presents with 3 weeks of diarrhea and 1 week of rectal bleeding.  He states that he had some stomach discomfort in the last 4 weeks.  ", Gastroenterology, Rectal Bleeding - Consult ,"REASON FOR ADMISSION: , Rectal bleeding.,HISTORY OF PRESENT ILLNESS:  ,The patient is a very pleasant 68-year-old male with history of bilateral hernia repair, who presents with 3 weeks of diarrhea and 1 week of rectal bleeding.  He states that he had some stomach discomfort in the last 4 weeks.  He has had some physical therapy for his lower back secondary to pain after hernia repair.  He states that the pain worsened after this.  He has had previous history of rectal bleeding and a colonoscopy approximately 8 years ago that was normal.  He denies any dysuria.  He denies any hematemesis.  He denies any pleuritic chest pain.  He denies any hemoptysis.,PAST MEDICAL HISTORY:,1.  History of bilateral hernia repair by Dr. X in 8/2008.,2.  History of rectal bleeding.,ALLERGIES: , NONE.,MEDICATIONS:,1.  Cipro.,2.  Lomotil.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: , No tobacco, alcohol or IV drug use.,REVIEW OF SYSTEMS: , As per the history of present illness otherwise unremarkable.,PHYSICAL EXAMINATION:,VITAL SIGNS:  The patient is afebrile.  Pulse 117, respirations 18, and blood pressure 117/55.  Saturating 98% on room air.,GENERAL:  The patient is alert and oriented x3.,HEENT:  Pupils are equal, round, and reactive to light and accommodation.  Extraocular movements are intact.  Oropharynx is clear without exudates.,NECK:  Supple.  No thyromegaly.  No jugular venous distention.,HEART:  Tachycardic.  Regular rhythm without murmurs, rubs or gallops.,LUNGS:  Clear to auscultation bilaterally both anteriorly and posteriorly.,ABDOMEN:  Positive bowel sounds.  Soft and nontender with no guarding.,EXTREMITIES:  No clubbing, cyanosis or edema in the upper or lower extremities.,NEUROLOGIC:  Nonfocal.,LABORATORY STUDIES:,  Sodium 131, potassium 3.9, chloride 94, CO2 25, BUN 15, creatinine 0.9, glucose 124, INR 1.2, troponin less than 0.04, white count 17.5, hemoglobin 12.3, and platelet count 278 with 91% neutrophils.  EKG shows sinus tachycardia.,PROBLEM LIST:,1.  Colitis.,2.  Sepsis.,3.  Rectal bleeding.,RECOMMENDATIONS:,1.  GI consult with Dr. Y's group.,2.  Continue Levaquin and Flagyl.,3.  IV fluids.,4.  Send for fecal WBCs, O&P, and C. diff.,5.  CT of the abdomen and pelvis to rule out abdominal pathology.,6.  PPI for PUD prophylaxis.",
" Sigmoidoscopy performed for evaluation of anemia, gastrointestinal Bleeding.", Gastroenterology, Sigmoidoscopy - 1 ,"PROCEDURE: , Sigmoidoscopy.,INDICATIONS:,  Performed for evaluation of anemia, gastrointestinal Bleeding.,MEDICATIONS: , Fentanyl (Sublazine) 0.1 mg IV Versed (midazolam) 1 mg IV,BIOPSIES: , No BRUSHINGS:,PROCEDURE:,  A history and physical examination were performed.  The procedure, indications, potential complications (bleeding, perforation, infection, adverse medication reaction), and alternative available were explained to the patient who appeared to understand and indicated this.  Opportunity for questions was provided and informed consent obtained.  After placing the patient in the left lateral decubitus position, the sigmoidoscope was inserted into the rectum and under direct visualization advanced to 25 cm.  Careful inspection was made as the sigmoidoscope was withdrawn.  The quality of the prep was good.  The procedure was stopped due to patient discomfort.  The patient otherwise tolerated the procedure well.  There were no complications.,FINDINGS: , Was unable to pass scope beyond 25 cm because of stricture vs very short bends secondary to multiple previous surgeries.  Retroflexed examination of the rectum revealed small hemorrhoids.  External hemorrhoids were found.  Other than the findings noted above, the visualized colonic segments were normal.,IMPRESSION: , Internal hemorrhoids  External hemorrhoids  Unable to pass scope beyond 25 cm due either to stricture or very sharp bend secondary to multiple surgeries.  Unsuccessful Sigmoidoscopy.  Otherwise Normal Sigmoidoscopy to 25 cm.  External hemorrhoids were found.","gastroenterology, gastrointestinal bleeding, gastrointestinal, sigmoidoscope, rectum, anemia, bleeding, sigmoidoscopy, hemorrhoids,"
 Ultrasound-Guided Paracentesis for Ascites, Gastroenterology, Paracentesis - Ultrasound-Guided ,"EXAM:,  Ultrasound-guided paracentesis,HISTORY: , Ascites.,TECHNIQUE AND FINDINGS:  ,Informed consent was obtained from the patient after the risks and benefits of the procedure were thoroughly explained.  Ultrasound demonstrates free fluid in the abdomen.  The area of interest was localized with ultrasonography.  The region was sterilely prepped and draped in the usual manner.  Local anesthetic was administered.  A 5-French Yueh catheter needle combination was taken.  Upon crossing into the peritoneal space and aspiration of fluid, the catheter was advanced out over the needle.  A total of approximately 5500 mL of serous fluid was obtained.  The catheter was then removed.  The patient tolerated the procedure well with no immediate postprocedure complications.,IMPRESSION: , Ultrasound-guided paracentesis as above.","gastroenterology, yueh catheter, aspiration of fluid, ultrasound guided paracentesis, ultrasound guided, needle, catheter, paracentesis, ultrasound, ascites"
 Bleeding after transanal excision five days ago.  Exam under anesthesia with control of bleeding via cautery.  The patient is a 42-year-old gentleman who is five days out from transanal excision of a benign anterior base lesion.  He presents today with diarrhea and bleeding., Gastroenterology, Postop Transanal Excision ,"PREOPERATIVE DIAGNOSIS: , Bleeding after transanal excision five days ago.,POSTOPERATIVE DIAGNOSIS: , Bleeding after transanal excision five days ago.,PROCEDURE:,  Exam under anesthesia with control of bleeding via cautery.,ANESTHESIA:,  General endotracheal.,INDICATION: , The patient is a 42-year-old gentleman who is five days out from transanal excision of a benign anterior base lesion.  He presents today with diarrhea and bleeding.  Digital exam reveals bright red blood on the finger.  He is for exam under anesthesia and control of hemorrhage at this time.,FINDINGS: , There was an ulcer where most of the polypoid lesion had been excised before.  In a near total fashion the wound had opened and again there was a raw ulcer surface in between the edges of the mucosa.  There were a few discrete sites of mild oozing, which were treated with cautery and #1 suture.  No other obvious bleeding was seen.,TECHNIQUE: , The patient was taken to the operating room and placed on the operative table in supine position.  After adequate general anesthesia was induced, the patient was then placed in modified prone position.  His buttocks were taped, prepped and draped in a sterile fashion.  The anterior rectal wall was exposed using a Parks anal retractor.  The entire wound was visualized with a few rotations of the retractor and a few sites along the edges were seen to be oozing and were touched up with cautery.  There was one spot in the corner that was oozing and this may have been from simply opening the retractor enough to see well.  This was controlled with a 3-0 Monocryl figure-of-eight suture.  At the completion, there was no bleeding, no oozing, it was completely dry, and we removed our retractor, and the patient was then turned and extubated and taken to the recovery room in stable condition.","gastroenterology, diarrhea, anterior base lesion, polypoid lesion, transanal excision, transanal, anesthesia, bleeding,"
" Percutaneous endoscopic gastrostomy tube.  Protein-calorie malnutrition.  The patient was unable to sustain enough caloric intake and had markedly decreased albumin stores.  After discussion with the patient and the son, they agreed to place a PEG tube for nutritional supplementation.", Gastroenterology, PEG Tube ,"PREOPERATIVE DIAGNOSIS:,  Protein-calorie malnutrition.,POSTOPERATIVE DIAGNOSIS: , Protein-calorie malnutrition.,PROCEDURE PERFORMED:, Percutaneous endoscopic gastrostomy (PEG) tube.,ANESTHESIA: , Conscious sedation per Anesthesia.,SPECIMEN: , None.,COMPLICATIONS: , None.,HISTORY:  ,The patient is a 73-year-old male who was admitted to the hospital with some mentation changes.  He was unable to sustain enough caloric intake and had markedly decreased albumin stores.  After discussion with the patient and the son, they agreed to place a PEG tube for nutritional supplementation.,PROCEDURE: , After informed consent was obtained, the patient was brought to the endoscopy suite.  He was placed in the supine position and was given IV sedation by the Anesthesia Department.  An EGD was performed from above by Dr. X.  The stomach was transilluminated and an optimal position for the PEG tube was identified using the single poke method.  The skin was infiltrated with local and the needle and sheath were inserted through the abdomen into the stomach under direct visualization.  The needle was removed and a guidewire was inserted through the sheath.  The guidewire was grasped from above with a snare by the endoscopist.  It was removed completely and the Ponsky PEG tube was secured to the guidewire.,The guidewire and PEG tube were then pulled through the mouth and esophagus and snug to the abdominal wall.  There was no evidence of bleeding.  Photos were taken.  The Bolster was placed on the PEG site.  A complete dictation for the EGD will be done separately by Dr. X.  The patient tolerated the procedure well and was transferred to recovery room in stable condition.  He will be started on tube feedings in 6 hours with aspiration precautions and dietary to determine his nutritional goal.","gastroenterology, percutaneous endoscopic gastrostomy tube, protein calorie malnutrition, peg tube, malnutrition, nutritional"
" Paracentesis.  A large abdominal mass, which was cystic in nature and the radiologist inserted a pigtail catheter in the emergency room. ", Gastroenterology, Paracentesis ,"PREOPERATIVE DIAGNOSIS: , Abdominal mass.,POSTOPERATIVE DIAGNOSIS: , Abdominal mass.,PROCEDURE:,  Paracentesis.,DESCRIPTION OF PROCEDURE:  ,This 64-year-old female has stage II endometrial carcinoma, which had been resected before and treated with chemotherapy and radiation.  At the present time, the patient is under radiation treatment.  Two weeks ago or so, she developed a large abdominal mass, which was cystic in nature and the radiologist inserted a pigtail catheter in the emergency room.  We proceeded to admit the patient and drained a significant amount of clear fluid in the subsequent days.  The cytology of the fluid was negative and the culture was also negative.  Eventually, the patient was sent home with the pigtail shut off and the patient a week later underwent a repeat CAT scan of the abdomen and pelvis.,The CAT scan showed accumulation of the fluid and the mass almost achieving 80% of the previous size.  Therefore, I called the patient home and she came to the emergency department where the service was provided.  At that time, I proceeded to work on the pigtail catheter after obtaining an informed consent and preparing and draping the area in the usual fashion.  Unfortunately, the catheter was open.  I did not have a drainage system at that time.  So, I withdrew directly with a syringe 700 mL of clear fluid.  The system was connected to the draining bag, and the patient was instructed to keep a log and how to use equipment.  She was given an appointment to see me in the office next Monday, which is three days from now.","gastroenterology, abdominal mass, clear fluid, cat scan, pigtail catheter, paracentesis,"
 Acute acalculous cholecystitis.  Open cholecystectomy.  The patient's gallbladder had some patchy and necrosis areas.  There were particular changes on the serosal surface as well as on the mucosal surface with multiple clots within the gallbladder., Gastroenterology, Open Cholecystectomy ,"PREOPERATIVE DIAGNOSIS: , Acute acalculous cholecystitis.,POSTOPERATIVE DIAGNOSIS:,  Acute hemorrhagic cholecystitis.,PROCEDURE PERFORMED: , Open cholecystectomy.,ANESTHESIA: , Epidural with local.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well and was transferred to recovery in stable condition.,SPECIMEN:  ,Gallbladder.,BRIEF HISTORY:  ,The patient is a 73-year-old female who presented to ABCD General Hospital on 07/23/2003 secondary to a fall at home from which the patient suffered a right shoulder as well as hip fracture.  The patient subsequently went to the operating room on 07/25/2003 for a right hip hemiarthroplasty per the Orthopedics Department.  Subsequently, the patient was doing well postoperatively, however, the patient does have severe O2 and steroid-dependent COPD and at an extreme risk for any procedure.  The patient began developing abdominal pain over the course of the next several days and a consultation was requested on 08/07/2003 for surgical evaluation for upper abdominal pain.  During the evaluation, the patient was found to have an acute acalculous cholecystitis in which nonoperative management was opted for and on 08/08/03, the patient underwent a percutaneous cholecystostomy tube placement to drain the gallbladder.  The patient did well postdrainage.  The patient's laboratory values and biliary values returned to normal and the patient was planned for a removal of the tube with 48 hours of the tubing clamp.  However, once the tube was removed, the patient re-obstructed with recurrent symptoms and a second tube was needed to be placed; this was done on 08/16/2003.  A HIDA scan had been performed, which showed no cystic duct obstruction.  A tube cholecystogram was performed, which showed no cystic or common duct obstruction.  There was abnormal appearance of the gallbladder, however, the pathway was patent.  Thus after failure of two nonoperative management therapies, extensive discussions were made with the family and the patient's only option was to undergo a cholecystectomy.  Initial thoughts were to do a laparoscopic cholecystectomy, however, with the patient's severe COPD and risk for ventilator management, the options were an epidural and an open cholecystectomy under local was made and to be performed.,INTRAOPERATIVE FINDINGS:  ,The patient's gallbladder had some patchy and necrosis areas.  There were particular changes on the serosal surface as well as on the mucosal surface with multiple clots within the gallbladder.  The patient also had no plane between the gallbladder and the liver bed.,OPERATIVE PROCEDURE: , After informed written consent, risks and benefits of the procedure were explained to the patient and discussed with the patient's family.  The patient was brought to the operating room after an epidural was performed per anesthesia.  Local anesthesia was given with 1% lidocaine.  A paramedian incision was made approximately 5 cm in length with a #15 blade scalpel.  Next, hemostasis was obtained using electro Bovie cautery.  Dissection was carried down transrectus in the midline to the posterior rectus fascia, which was grasped with hemostats and entered with a #10 blade scalpel.  Next, Metzenbaum scissors were used to extend the incision and the abdomen was entered .  The gallbladder was immediately visualized and brought up into view, grasped with two ring clamps elevating the biliary tree into view.  Dissection with a ______ was made to identify the cystic artery and cystic duct, which were both easily identified.  The cystic artery was clipped, two distal and one proximal to the gallbladder cutting between with Metzenbaum scissors.  The cystic duct was identified.  A silk tie #3-0 silk was placed one distal and one proximal with #3-0 silk and then cutting in between with a Metzenbaum scissors.  The gallbladder was then removed from the liver bed using electro Bovie cautery.  A plane was created.  The hemostasis was obtained using the electro Bovie cautery as well as some Surgicel.  The gallbladder was then removed as specimen, sent to pathology for frozen sections for diagnosis, of which the hemorrhagic cholecystitis was diagnosed on frozen sections.  Permanent sections are still pending.  The remainder of the fossa was hemostatic with the Surgicel and attention was next made to closing the abdomen.  The peritoneum as well as posterior rectus fascia was approximated with a running #0 Vicryl suture and then the anterior rectus fascia was closed in interrupted figure-of-eight #0 Vicryl sutures.  Skin staples were used on the skin and sterile dressings were applied and the patient was transferred to recovery in stable condition.","gastroenterology, open cholecystectomy, hemorrhagic, gallbladder, serosal, liver bed, acute acalculous, acalculous cholecystitis, cystic duct, bovie cautery, rectus fascia, metzenbaum scissors, fascia, cholecystitis, cholecystectomy, cystic,"
 Nissen fundoplication.   A 2 cm midline incision was made at the junction of the upper two-thirds and lower one-third between the umbilicus and the xiphoid process. , Gastroenterology, Nissen Fundoplication ,"PROCEDURE PERFORMED: , Nissen fundoplication.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained detailing the risks of infection, bleeding, esophageal perforation and death, the patient was brought to the operative suite and placed supine on the operating room table.  General endotracheal anesthesia was induced without incident.  The patient was then placed in a modified lithotomy position taking great care to pad all extremities.  TEDs and Venodynes were placed as prophylaxis against deep venous thrombosis.  Antibiotics were given for prophylaxis against surgical infection.,A 52-French bougie was placed in the proximal esophagus by Anesthesia, above the cardioesophageal junction.  A 2 cm midline incision was made at the junction of the upper two-thirds and lower one-third between the umbilicus and the xiphoid process.  The fascia was then cleared of subcutaneous tissue using a tonsil clamp.  A 1-2 cm incision was then made in the fascia gaining entry into the abdominal cavity without incident.  Two sutures of 0 Vicryl were then placed superiorly and inferiorly in the fascia, and then tied to the special 12 mm Hasson trocar fitted with a funnel-shaped adaptor in order to occlude the fascial opening.  Pneumoperitoneum was then established using carbon dioxide insufflation to a steady state of pressure of 16 mmHg.  A 30-degree laparoscope was inserted through this port and used to guide the remaining trocars.,The remaining trocars were then placed into the abdomen taking care to make the incisions along Langer's line, spreading the subcutaneous tissue with a tonsil clamp, and confirming the entry site by depressing the abdominal wall prior to insertion of the trocar.  A total of 4 other 10/11 mm trocars were placed.  Under direct vision 1 was inserted in the right upper quadrant at the midclavicular line, at a right supraumbilical position; another at the left upper quadrant at the midclavicular line, at a left supraumbilical position; 1 under the right costal margin in the anterior axillary line; and another laterally under the left costal margin on the anterior axillary line.  All of the trocars were placed without difficulty.  The patient was then placed in reverse Trendelenburg position.,The triangular ligament was taken down sharply, and the left lobe of the liver was retracted superolaterally using a fan retractor placed through the right lateral cannula.  The gastrohepatic ligament was then identified and incised in an avascular plane.  The dissection was carried anteromedially onto the phrenoesophageal membrane.  The phrenoesophageal membrane was divided on the anterior aspect of the hiatal orifice.  This incision was extended to the right to allow identification of the right crus.  Then along the inner side of the crus, the right esophageal wall was freed by dissecting the cleavage plane.,The liberation of the posterior aspect of the esophagus was started by extending the dissection the length of the right diaphragmatic crus.  The pars flaccida of the lesser omentum was opened, preserving the hepatic branches of the vagus nerve.  This allowed free access to the crura, left and right, and the right posterior aspect of the esophagus, and the posterior vagus nerve.,Attention was next turned to the left anterolateral aspect of the esophagus.  At its left border, the left crus was identified.  The dissection plane between it and the left aspect of the esophagus was freed.  The gastrophrenic ligament was incised, beginning the mobilization of the gastric pouch.  By dissecting the intramediastinal portion of the esophagus, we elongated the intra-abdominal segment of the esophagus and reduced the hiatal hernia.,The next step consisted of mobilization of the gastric pouch.  This required ligation and division of the gastrosplenic ligament and several short gastric vessels using the harmonic scalpel.  This dissection started on the stomach at the point where the vessels of the greater curvature turned towards the spleen, away from the gastroepiploic arcade.  The esophagus was lifted by a Babcock inserted through the left upper quadrant port.  Careful dissection of the mesoesophagus and the left crus revealed a cleavage plane between the crus and the posterior gastric wall.  Confirmation of having opened the correct plane was obtained by visualizing the spleen behind the esophagus.  A one-half inch Penrose drain was inserted around the esophagus and sewn to itself in order to facilitate retraction of the distal esophagus.  The retroesophageal channel was enlarged to allow easy passage of the antireflux valve.,The 52-French bougie was then carefully lowered into the proximal stomach, and the hiatal orifice was repaired.  Two interrupted 0 silk sutures were placed in the diaphragmatic crura to close the orifice.,The last part of the operation consisted of the passage and fixation of the antireflux valve.  With anterior retraction on the esophagus using the Penrose drain, a Babcock was passed behind the esophagus, from right to left.  It was used to grab the gastric pouch to the left of the esophagus and to pull it behind, forming the wrap.  The,52-French bougie was used to calibrate the external ring.  Marcaine 0.5% was injected 1 fingerbreadth anterior to the anterior superior iliac spine and around the wound for postanesthetic pain control.  The skin incision was approximated with skin staples.  A dressing was then applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.","gastroenterology, umbilicus, insufflation, phrenoesophageal membrane, nissen fundoplication, gastric pouch, esophagus, penrose, antireflux, nissen, fundoplication, trocars, ligament,"
 Patient presents to the emergency department (ED) with rectal bleeding and pain on defecation., Gastroenterology, Proctitis & Proctocolitis ,"PRESENTATION: , A 16-year-old male presents to the emergency department (ED) with rectal bleeding and pain on defecation.,HISTORY:,  A 16-year-old African American male presents to the ED with a chief complaint of rectal bleeding and pain on defecation.  The patient states that he was well until about three days prior to presentation when he first started to experience some pain when defecating.  The following day he noted increasing pain and first noted blood on the surface of his stool.  The pain worsened on the subsequent day with increasing bleeding as well as some mucopurulent anal discharge.  The patient denies any previous history of rectal bleeding or pain.  He also denies any previous sexually transmitted diseases (STDs) and states that he was screened for HIV infection eight months ago and was negative.  The patient does state that he has not felt well for the past week.  He states that he had felt ""feverish"" on several occasions but has not taken his temperature.  He has also complained of some abdominal discomfort with nausea and diarrhea as well as generalized myalgias and fatigue.  He thinks he has lost a few pounds but has not been weighing himself to determine the exact amount of weight loss.,The patient states that he has been sexually active since age 13.  He admits to eight previous partners and states that he ""usually"" uses a condom.  On further questioning, the patient states that of his eight partners, three were female and five were male.  His most recent sexual partner was a 38-year-old man whom he has been with for the past six months.  He states that he has been tested for STDs in the past but states that he only gave urine and blood for the testing.  He is unaware of the HIV status of his partner but assumes that the partner is uninfected because he looks healthy.  The patient also admits to one episode of sexual abuse at the age of 8 by a friend of the family.  As the man was a member of the family's church, the patient never felt comfortable disclosing this to any of the adults in his life.  He is very concerned about disclosure of his sexual behavior to his family, as they have expressed very negative comments concerning men who have sex with men.  He is accessing care in the ED unaccompanied by an adult.,PHYSICAL EXAM: , Thin but non-toxic young man with clear discomfort.,Pulse = 105,RR = 23,BP = 120/62,HEENT:  Several areas of white plaque-like material on the buccal mucosa.,Neck:  Multiple anterior/posterior cervical nodes in both anterior and posterior chains- 1-2 cm in diameter.,Lungs:  Clear to auscultation.,Cardiac:  Quiet precordium.,Nl S1/S2 with a II/VI systolic murmur. ,Abdomen:  Soft without hepatosplenomegaly.,GU:  Tanner V male with no external penile lesions.,Lymph:  2-3 cm axillary nodes bilaterally.,1-2 cm epitrochlear nodes.,Multiple 1-2 cm inguinal nodes.,Rectal:  Extremely painful digital exam.,+ gross blood and mucous.,LABORATORY EVALUATION:,Hbg = 12.  5 gm/dL,Hct = 32%,WBC = 3.9 thou/µL,Platelets = 120,000 thou/µL,76% neutrophils,19% lymphocytes,1% eosinophils,4% monocytes,ALT = 82 U/L,AST= 90 U/L,Erythrocyte sedimentation rate = 90,Electrolytes = normal,Gram stain of anal swab:  numerous WBCs,DIFFERENTIAL DIAGNOSIS: , This patient is presenting with acute rectal pain with bleeding and anal discharge.  The patient also presents with some constitutional symptoms including fever, fatigue, abdominal discomfort, and adenopathy on physical examination.  The following are in the differential diagnosis:  Acute Proctitis and  Proctocolitis.,ACUTE HIV SEROCONVERSION: , This subject is sexually active and reports inconsistent condom use.  Gastrointestinal symptoms have recently been reported commonly in patients with a history of HIV seroconversion.  The rectal symptoms of bleeding and pain are not common with HIV, and an alternative diagnosis would be required.,PERIRECTAL ABSCESS: , A patient with a history of receptive anal intercourse is at risk for developing a perirectal abscess either from trauma or a concurrent STD.  The patient could experience more systemic symptoms with fever and malaise, as found with this patient.  However, the physical examination did not reveal the typical localized area of pain and edema.,DIAGNOSIS:  ,The subject had rectal cultures obtained, which were positive for Neisseria gonorrhoeae.  An HIV ELISA was positive, as was the RNA PCR.,DISCUSSION: , This patient demonstrates a number of key issues to consider when caring for an adolescent or young adult.  First, the patient utilized the emergency department for care as opposed to identifying a primary care provider.  Although not ideal in many circumstances, testing for HIV infection is crucial when there is suspicion, since many newly diagnosed patients identify earlier contacts with health care providers when HIV counseling and testing were not performed.  Second, this young man has had both male and female sexual partners.  As young people explore their sexuality, asking about partners in an open, nonjudgmental manner without applying labels is integral to helping the young person discuss their sexual behaviors.  Assuming heterosexuality is a major barrier to disclosure for many young people who have same-sex attractions.  Third, screening for STDs must take into account sexual behaviors.  Although urine-based screening has expanded testing of young people, it misses anal and pharyngeal infections.  If a young person is only having receptive oral or anal intercourse, urine screening is insufficient to rule out STDs.  Fourth, this young man had both localized and systemic symptoms.  As his anal symptoms were most suggestive of a current STD, performing an HIV test should be part of the standard evaluation.  In addition, as acute infection is on the differential diagnosis, PCR testing should also be considered.  The care provided to this young man included the following.  He was treated presumptively for proctitis with both IM ceftriaxone as well as oral doxycycline to treat N gonorrhoeae and C trachomatis.  Ceftriaxone was chosen due to the recent reports of resistant N gonorrhoeae.  At the time of the diagnosis, the young man was given the opportunity to meet with the case manager from the adolescent-specific HIV program.  The case manager linked this young man directly to care after providing brief counseling and support.  The case manager maintained contact with the young man until his first clinical visit four days later.  Over the subsequent three months, the young man had two sets of laboratory testing to stage his HIV infection.,Set #1 CD4 T-lymphocyte count = 225 cells/mm3, 15% ,Quantitative RNA PCR = 75,000 copies/mL",
" The patient has had abdominal pain associated with a 30-pound weight loss and then developed jaundice.  He had epigastric pain and was admitted to the hospital.  A thin-slice CT scan was performed, which revealed a pancreatic mass with involved lymph nodes and ring enhancing lesions consistent with liver metastases. ", Gastroenterology, Pancreatic Mass - Discharge Summary ,"HISTORY OF PRESENT ILLNESS: ,  The patient is a 48-year-old man who has had abdominal pain since October of last year associated with a 30-pound weight loss and then developed jaundice.  He had epigastric pain and was admitted to the hospital.  A thin-slice CT scan was performed, which revealed a 4 x 3 x 2 cm pancreatic mass with involved lymph nodes and ring enhancing lesions consistent with liver metastases.  The patient, additionally, had a questionable pseudocyst in the tail of the pancreas.  The patient underwent ERCP on 04/04/2007 with placement of a stent.  This revealed a strictured pancreatic duct, as well as strictured bile duct.  A 10-french x 9 cm stent was placed with good drainage.  The next morning, the patient felt quite a bit more comfortable.  He additionally had a modest drop in his bilirubin and other liver tests.  Of note, the patient has been having quite a bit of nausea during his admission.  This responded to Zofran.  It did not, initially, respond well to Phenergan, though after stent placement, he was significantly more comfortable and had less nausea, and in fact, had better response to the Phenergan itself.  At the time of discharge, the patient's white count was 9.4, hemoglobin 10.8, hematocrit 32 with a MCV of 79, platelet count of 585,000.  His sodium was 132, potassium 4.1, chloride 95, CO2 27, BUN of 8 with a creatinine of 0.3.  His bilirubin was 17.1, alk phos 273, AST 104, ALT 136, total protein 7.8 and albumin of 3.8.  He was tolerating a regular diet.  The patient had been on oral hypoglycemics as an outpatient, but in hospital, he was simply managed with an insulin sliding scale.  The patient will be transferred back to Pelican Bay, under the care of Dr. X at the infirmary.  He will be further managed for his diabetes there.  The patient will additionally undergo potential end of life meetings.  I discussed the potentials of chemotherapy with patient.  Certainly, there are modest benefits, which can be obtained with chemotherapy in metastatic pancreatic cancer, though at some cost with morbidity.  The patient will consider this and will discuss this further with Dr. X.  ,DISCHARGE MEDICATIONS:,1.  Phenergan 25 mg q.6. p.r.n.,2.  Duragesic patch 100 mcg q.3.d.,3.  Benadryl 25-50 mg p.o. q.i.d. for pruritus.,4.  Sliding scale will be discontinued at the time of discharge and will be reinstituted on arrival at Pelican Bay Infirmary.,5.  The patient had initially been on enalapril here.  His hypertension will be managed by Dr. X as well.  ,PLAN: , The patient should return for repeat ERCP if there are signs of stent occlusion such as fever, increased bilirubin, worsening pain.  In the meantime, he will be kept on a regular diet and activity per Dr. X.","gastroenterology, abdominal pain, lymph nodes, weight loss, pancreatic mass, chemotherapy, abdominal, bilirubin, phenergan, stent, drainage, "
" Patient seen initially with epigastric and right upper quadrant abdominal pain, nausea, dizziness, and bloating.", Gastroenterology, Progress Note - Liver Cirrhosis ,"HISTORY OF PRESENT ILLNESS: , The patient is a 55-year-old Hispanic male who was seen initially in the office February 15, 2006, with epigastric and right upper quadrant abdominal pain, nausea, dizziness, and bloating.  The patient at that time stated that he had established diagnosis of liver cirrhosis.  Since the last visit the patient was asked to sign a lease of information form and we sent request for information from the doctor the patient saw before, Dr. X in Las Cruces and his primary care physician in Silver City, and unfortunately we did not get any information from anybody.  Also the patient had admission in Gila Medical Center with epigastric pain, diarrhea, and confusion.  He spent 3 days in the hospital.  He was followed by Dr. X and unfortunately we also do not have the information of what was wrong with the patient.  From the patient's report he was diagnosed with some kind of viral infection.  At the time of admission he had a lot of epigastric pain, nausea, vomiting, fever, and chills.,PHYSICAL EXAMINATION,VITAL SIGNS:  Weight 107, height 6 feet 1 inch, blood pressure 128/67, heart rate 74, saturation 98%; pain is 3/10 with localization of the pain in the epigastric area.,HEENT:  PERRLA.  EOM intact.  Oropharynx is clear of lesions.,NECK:  Supple.  No lymphadenopathy.  No thyromegaly.,LUNGS:  Clear to auscultation and percussion bilateral.,CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs, rubs, or gallops.,ABDOMEN:  Not tender, not distended.  Splenomegaly about 4 cm under the costal margin.  No hepatomegaly.  Bowel sounds present.,MUSCULOSKELETAL:  No cyanosis, no clubbing, no pitting edema.,NEUROLOGIC:  Nonfocal.  No asterixis.  No costovertebral tenderness.,PSYCHE:  The patient is oriented x4, alert and cooperative.,LABORATORY DATA: , We were able to collect lab results from Medical Center; we got only CMP from the hospital which showed glucose level 79, BUN 9, creatinine 0.6, sodium 136, potassium 3.5, chloride 104, CO2 23.7, calcium 7.3, total protein 5.9, albumin 2.5, total bilirubin 5.63.  His AST 56, ALT 37, alkaline phosphatase 165, and his ammonia level was 53.  We do not have any other results back.  No hepatitis panels.  No alpha-fetoprotein level.  The patient told me today that he also got an ultrasound of the abdomen and the result was not impressive, but we do not have this result despite calling medical records in the hospital to release this information.,ASSESSMENT AND PLAN:,  The patient is a 55-year-old with established diagnosis of liver cirrhosis, unknown cause.,1.  Epigastric pain.  The patient had chronic pain syndrome, he had multiple back surgeries, and he has taken opiate for a prolonged period of time.  In the office twice the patient did not have any abdominal pain on physical exam.  His pain does not sound like obstruction of common bile duct and he had these episodes of abdominal pain almost continuously.  He probably requires increased level of pain control with increased dose of opiates, which should be addressed with his primary care physician.,2.  End-stage liver disease.  Of course, we need to find out the cause of the liver cirrhosis.  We do not have hepatitis panel yet and we do not have information about the liver biopsy which was performed before.  We do not have any information of any type of investigation in the past.  Again, patient was seen by gastroenterologist already in Las Cruces, Dr. X.  The patient was advised to contact Dr. X by himself to convince him to send available information because we already send release information form signed by the patient without any result.  It will be not reasonable to repeat unnecessary tests in that point in time.,We are waiting for the hepatitis panel and alpha-fetoprotein level.  We will also need to get information about ultrasound which was done in Gila Medical Center, but obviously no tumor was found on this exam of the liver.  We have to figure out hepatitis status for another reason if he needs vaccination against hepatitis A and B.  Until now we do not know exactly what the cause of the patient's end-stage liver disease is and my differential diagnosis probably is hepatitis C.  The patient denied any excessive alcohol intake, but I could not preclude alcohol-related liver cirrhosis also.  We will need to look for nuclear antibody if it is not done before.  PSC is extremely unlikely but possible.  Wilson disease also possible diagnosis but again, we first have to figure out if these tests were done for the patient or not.  Alpha1-antitrypsin deficiency will be extremely unlikely because the patient has no lung problem.  On his end-stage liver disease we already know that he had low platelet count splenomegaly.  We know that his bilirubin is elevated and albumin is very low.  I suspect that at the time of admission to the hospital the patient presented with encephalopathy.  We do not know if INR was checked to look for coagulopathy.  The patient had an EGD in 2005 as well as colonoscopy in Silver City.  We have to have this result to evaluate if the patient had any varices and if he needs any intervention for that.,At this point in time, I recommended the patient to continue to take lactulose 50 mL 3 times daily.  The patient tolerated it well; no diarrhea at this point in time.  I also recommended for him to contact his primary care physician for increased dose of opiates for him.  As a primary prophylaxis of GI bleeding in patient with end-stage liver disease we will try to use Inderal.  The patient got a prescription for 10 mg pills.  He will take 10 mg twice daily and we will gradually increase his dose until his heart rate will drop to 25% from 75% to probably 60-58.  The patient was educated how to use Inderal and he was explained why we decided to use this medication.  The patient will hold this medication if he is orthostatic or bradycardic.,Again, the patient and his wife were advised to contact all offices they have seen before to get information about what tests were already done and if on the next visit in 2 weeks we still do not have any information we will need to repeat all these tests I mentioned above.,We also discussed nutrition issues.  The patient was provided information that his protein intake is supposed to be about 25 g per day.  He was advised not to over-eat protein and advised not to starve.  He also was advised to stay away from alcohol.  His next visit is in 2 weeks with all results available.","gastroenterology, abdominal pain, nausea, dizziness, liver disease, epigastric pain, liver cirrhosis, liver, abdominal, cirrhosis, epigastric, hepatitis,"
" Seizure, hypoglycemia, anemia, dyspnea, edema. colon cancer status post right hemicolectomy, hospital-acquired pneumonia, 
and congestive heart failure.", Gastroenterology, Multiple Medical Problems - Discharge Summary ,"ADMISSION DIAGNOSES:,1.  Seizure.,2.  Hypoglycemia.,3.  Anemia.,4.  Hypotension.,5.  Dyspnea.,6.  Edema.,DISCHARGE DIAGNOSES:,1.  Colon cancer, status post right hemicolectomy.,2.  Anemia.,3.  Hospital-acquired pneumonia.,4.  Hypertension.,5.  Congestive heart failure.,6.  Seizure disorder.,PROCEDURES PERFORMED:,1.  Colonoscopy.,2.  Right hemicolectomy.,HOSPITAL COURSE: , The patient is a 59-year-old female with multiple medical problems including diabetes mellitus requiring insulin for 26 years, previous MI and coronary artery disease, history of seizure disorder, GERD, bipolar disorder, and anemia.  She was admitted due to a seizure and myoclonic jerks as well as hypoglycemia and anemia.  Regarding the seizure disorder, Neurology was consulted.  Noncontrast CT of the head was negative.  Neurology felt that the only necessary intervention at that time would be to increase her Lamictal to 150 mg in the morning and 100 mg in the evening with gradual increase of the dosage until she was on 200 mg b.i.d.  Regarding the hypoglycemia, the patient has diabetic gastroparesis and was being fed on J-tube intermittent feedings throughout the night at the rate of 120 an hour.  Her insulin pump had a basal rate of roughly three at night during the feedings.  While in the hospital, the insulin pump rate was turned down to 1.5 and then subsequently decreased a few other times.  She seemed to tolerate the insulin pump rate well throughout her hospital course.  There were a few episodes of hypoglycemia as well as hyperglycemia, but the episode seem to be related to the patient's n.p.o. status and the changing rates of tube feedings throughout her hospital course.,At discharge, her endocrinologist was contacted.  It was decided to change her insulin pump rate to 3 units per hour from midnight till 6 a.m., from 0.8 units per hour from 6 a.m. until 8 a.m., and then at 0.2 units per hour from 8 a.m. until 6 p.m.  The insulin was to be NovoLog.  Regarding the anemia, the gastroenterologists were consulted regarding her positive Hemoccult stools.  A colonoscopy was performed, which found a mass at the right hepatic flexure.  General Surgery was then consulted and a right hemicolectomy was performed on the patient.  The patient tolerated the procedure well and tube feeds were slowly restarted following the procedure, and prior to discharge were back at her predischarge rates of 120 per hour.  Regarding the cancer itself, it was found that 1 out of 53 nodes were positive for cancer.  CT of the abdomen and pelvis revealed no metastasis, a CT of the chest revealed possible lung metastasis.  Later in hospital course, the patient developed a septic-like picture likely secondary to hospital-acquired pneumonia.  She was treated with Zosyn, Levaquin, and vancomycin, and tolerated the medications well.  Her symptoms decreased and serial chest x-rays were followed, which showed some resolution of the illness.  The patient was seen by the Infectious Disease specialist.  The Infectious Disease specialist recommended vancomycin to cover MRSA bacteria, which was found at the J-tube site.  At discharge, the patient was given three additional days of p.o. Levaquin 750 mg as well as three additional days of Bactrim DS every 12 hours.  The Bactrim was used to cover the MRSA at the J-tube site.  It was found that MRSA was sensitive to Bactrim.  Throughout her hospital course, the patient continued to receive Coreg 12.5 mg daily and Lasix 40 mg twice a day for her congestive heart failure, which remains stable.  She also received Lipitor for her high cholesterol.  Her seizure disorder remained stable and she was discharged on a dose of 100 mg in the morning and 150 mg at night.  The dosage increases can begin on an outpatient basis.,DISCHARGE INSTRUCTIONS/MEDICATIONS: , The patient was discharged to home.  She was told to shy away from strenuous activity.  Her discharge diet was to be her usual diet of isotonic fiber feeding through the J-tube at a rate of 120 per hour throughout the night.  The discharge medications were as follows:,1.  Coreg 12.5 mg p.o. b.i.d.,2.  Lipitor 10 mg p.o. at bedtime.,3.  Nitro-Dur patch 0.3 mg per hour one patch daily.,4.  Phenergan syrup 6.25 mg p.o. q.4h. p.r.n.,5.  Synthroid 0.175 mg p.o. daily.,6.  Zyrtec 10 mg p.o. daily.,7.  Lamictal 100 mg p.o. daily.,8.  Lamictal 150 mg p.o. at bedtime.,9.  Ferrous sulfate drops 325 mg, PEG tube b.i.d.,10.  Nexium 40 mg p.o. at breakfast.,11.  Neurontin 400 mg p.o. t.i.d.,12.  Lasix 40 mg p.o. b.i.d.,13.  Fentanyl 50 mcg patch transdermal q.72h.,14.  Calcium and vitamin D combination, calcium carbonate 500 mg/vitamin D 200 units one tab p.o. t.i.d.,15.  Bactrim DS 800mg/160 mg tablet one tablet q.12h. x3 days.,16.  Levaquin 750 mg one tablet p.o. x3 days.,The medications listed above, one listed as p.o. are to be administered via the J-tube.,FOLLOWUP:  ,The patient was instructed to see Dr. X in approximately five to seven days.  She was given a lab sheet to have a CBC with diff as well as a CMP to be drawn prior to her appointment with Dr. X.  She is instructed to follow up with Dr. Y if her condition changes regarding her colon cancer.  She was instructed to follow up with Dr. Z, her oncologist, regarding the positive lymph nodes.  We were unable to contact Dr. Z, but his telephone number was given to the patient and she was instructed to make a followup appointment.  She was also instructed to follow up with her endocrinologist, Dr. A, regarding any insulin pump adjustments, which were necessary and she was also instructed to follow up with Dr. B, her gastroenterologist, regarding any issues with her J-tube.,CONDITION ON DISCHARGE: , Stable.",
" Percutaneous liver biopsy.   With the patient lying in the supine position and the right hand underneath the head, an area of maximal dullness was identified in the mid-axillary location by percussion.", Gastroenterology, Liver Biopsy ,"TITLE OF PROCEDURE: , Percutaneous liver biopsy.,ANALGESIA: , 2% Lidocaine.,ALLERGIES: , The patient denied any allergy to iodine, lidocaine or codeine.,PROCEDURE IN DETAIL:  ,The procedure was described in detail to the patient at a previous clinic visit and by the medical staff today.  The patient was told of complications which might occur consisting of bleeding, bile peritonitis, bowel perforation, pneumothorax, or death.  The risks and benefits of the procedure were understood, and the patient signed the consent form freely.,With the patient lying in the supine position and the right hand underneath the head, an area of maximal dullness was identified in the mid-axillary location by percussion.  The area was prepped and cleaned with povidone iodine following which the skin, subcutaneous tissue, and serosal surfaces were infiltrated with 2% lidocaine down to the capsule of the liver.  Next, a small incision was made with a Bard-Parker #11 scalpel.  A 16-gauge modified Klatskin needle was inserted through the incision and into the liver on one occasion with the patient in deep expiration.  Liver cores measuring *** cm were obtained and will be sent to Pathology for routine histologic study.,POST-PROCEDURE COURSE AND DISPOSITION: , The patient will remain under close observation in the medical treatment room for four to six hours and then be discharged home without medication.  Normal activities can be resumed tomorrow.  The patient is to contact me if severe abdominal or chest pain, fever, melena, light-headedness or any unusual symptoms develop.  An appointment will be made for the patient to see me in the clinic in the next few weeks to discuss the results of the liver biopsy so that management decisions can be made.,COMPLICATIONS:,  None.,RECOMMENDATIONS: , Prior to discharge, hepatitis A and B vaccines will be recommended.  Risks and benefits for vaccination have been addressed and the patient will consider this option.","gastroenterology, bile peritonitis, bowel perforation, pneumothorax, klatskin needle, mid axillary, liver biopsy, percutaneous, lidocaine, biopsy, liver"
" Abdominal pain right lower quadrant, radiating around her side to her right flank.  Etiology is unclear.  ", Gastroenterology, Lower Quadrant Pain ,"REASON:,  Right lower quadrant pain.,HISTORY OF PRESENT ILLNESS:  ,The patient is a pleasant 48-year-old female with an approximately 24-hour history of right lower quadrant pain, which she describes as being stabbed with a knife, radiating around her side to her right flank.  She states that is particularly bad when up and walking around, goes away when she is lying down.  She has no nausea or vomiting, no dysuria, no fever or chills, though she said she did feel warm.  She states that she feels a bit like she did when she had her gallbladder removed nine years ago.  Additionally, I should note that the patient is currently premenopausal with irregular menses, going anywhere from one to two months between cycles.  She has no abnormal vaginal discharge, and she is sexually active.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,MEDICATIONS,1.  Hydrochlorothiazide 25 mg p.o. daily.,2.  Lisinopril 10 mg p.o. daily.,3.  Albuterol p.r.n.,PAST MEDICAL HISTORY:  ,Hypertension and seasonal asthma.,PAST SURGICAL HISTORY: , Left bilateral breast biopsy for benign disease.  Cholecystitis/cholecystectomy following tubal pregnancy 22 years ago.,FAMILY HISTORY: , Mother is alive and well.  Father with coronary artery disease.  She has siblings who have increased cholesterol.,SOCIAL HISTORY:  ,The patient does not smoke.  She quit 25 years ago.  She drinks one beer a day.  She works as a medical transcriptionist.,REVIEW OF SYSTEMS: , Positive for an umbilical hernia, but otherwise negative with the exception of what is noted above.,PHYSICAL EXAMINATION,GENERAL:  Reveals a morbidly obese female who is alert and oriented x3, pleasant and well groomed, and in mild discomfort.,VITAL SIGNS:  Her temperature is 38.7, pulse 113, respirations 18, and blood pressure 144/85.,HEENT:  Normocephalic and atraumatic.  Sclerae are without icterus.  Conjunctivae are not injected.,NECK:  Neck is supple.  Carotids 2+.  Trachea is midline.  Carotids are without bruits.,LYMPH NODES:  There is no cervical, supraclavicular, or occipital adenopathy.,LUNGS:  Clear to auscultation.,CARDIAC:  Regular rate and rhythm.,ABDOMEN:  Soft.  No hepatosplenomegaly.  She has a positive Rovsing sign and a positive obturator sign.  She is tender in the right lower quadrant with mild rebound and no guarding.,EXTREMITIES:  Reveal 2+ femoral, popliteal, dorsalis pedis, and posterior tibial pulses.  She has only trace edema with varicosities around the bilateral ankles.,CNS:  Without gross neurologic deficits.,INTEGUMENTARY:  Skin integrity is excellent.,DIAGNOSTICS: , Urine, specific gravity is 1.010, blood is 50, leukocytes 1+, white blood cells 10 to 25, rbc's 2 to 5, and 2 to 5 squamous epithelial cells.  White blood cell count is 20,000 with 75 polys and 16 lymphs.  H&H is 13.7 and 39.7.  Total bilirubin 1.3, direct bilirubin 0.2, and alk phos 98.  Sodium 138, potassium 3.1, chloride 101, CO2 26, calcium 9.5, glucose 103, BUN 16, and creatinine 0.91.  Lipase is 19.  CAT scan is negative for acute appendicitis.  In fact, it mentions that the appendix is not discretely identified.  There are no focal inflammatory masses, abscess, ascites, or pneumoperitoneum.,IMPRESSION: , Abdominal pain right lower quadrant, etiology is unclear.,PLAN:,  Plan is to admit the patient.  Recheck the white blood cell count in the morning.  Re-examine her and further plan is pending, the results of that evaluation.",
" Diagnostic laparoscopy and laparoscopic appendectomy.  Right lower quadrant abdominal pain, rule out acute appendicitis.", Gastroenterology, Laparoscopy & Laparoscopic Appendectomy ,"PREOPERATIVE DIAGNOSIS: , Right lower quadrant abdominal pain, rule out acute appendicitis.,POSTOPERATIVE DIAGNOSIS:,  Acute suppurative appendicitis.,PROCEDURE PERFORMED:,1.  Diagnostic laparoscopy.,2.  Laparoscopic appendectomy.,ANESTHESIA: , General endotracheal and injectable 1% lidocaine and 0.25% Marcaine.,ESTIMATED BLOOD LOSS: , Minimal.,SPECIMEN: , Appendix.,COMPLICATIONS: , None.,BRIEF HISTORY: , This is a 37-year-old Caucasian female presented to ABCD General Hospital with progressively worsening suprapubic and right lower quadrant abdominal pain, which progressed throughout its course starting approximately 12 hours prior to presentation.  She admits to some nausea associated with it.  There have been no fevers, chills, and/or genitourinary symptoms.  The patient had right lower quadrant tenderness with rebound and percussion tenderness in the right lower quadrant.  She had a leukocytosis of 12.8.  She did undergo a CT of the abdomen and pelvis, which was non diagnostic for an acute appendicitis.  Given the severity of her abdominal examination and her persistence of her symptoms, we recommend the patient undergo diagnostic laparoscopy with probable need for laparoscopic appendectomy and possible open appendectomy.  The risks, benefits, complications of the procedure, she gave us informed consent to proceed.,OPERATIVE FINDINGS:  ,Exploration of the abdomen via laparoscopy revealed an appendix with suppurative fluid surrounding it, it was slightly enlarged.  The left ovary revealed some follicular cysts.  There was no evidence of adnexal masses and/or torsion of the fallopian tubes.  The uterus revealed no evidence of mass and/or fibroid tumors.  The remainder of the abdomen was unremarkable.,OPERATIVE PROCEDURE: , The patient was brought to the operative suite, placed in the supine position.  The abdomen was prepped and draped in the normal sterile fashion with Betadine solution.  The patient underwent general endotracheal anesthesia.  The patient also received a preoperative dose of Ancef 1 gram IV.  After adequate sedation was achieved, a #10 blade scalpel was used to make an infraumbilical transverse incision utilizing a Veress needle.  Veress needle was inserted into the abdomen and the abdomen was insufflated approximately 15 mmHg.  Once the abdomen was sufficiently insufflated, a 10 mm bladed trocar was inserted into the abdomen without difficulty.  A video laparoscope was inserted into the infraumbilical trocar site and the abdomen was explored.  Next, a 5 mm port was inserted in the midclavicular line of the right upper quadrant region.  This was inserted under direct visualization.  Finally, a suprapubic 12 mm portal was created.  This was performed with #10 blade scalpel to create a transverse incision.  A bladed trocar was inserted into the suprapubic region.  This was done again under direct visualization.  Maryland dissector was inserted into the suprapubic region and a window was created between the appendix and mesoappendix at the base of the cecum.  This was done while the 5 mm trocar was used to grasp the middle portion of the appendix and retracted anteriorly.  Utilizing a endovascular stapling device, the appendix was transected and doubly stapled with this device.  Next, the mesoappendix was doubly stapled and transected with the endovascular stapling device.  The staple line was visualized and there was no evidence of bleeding.  The abdomen was fully irrigated with copious amounts of normal saline.  The abdomen was then aspirated.  There was no evidence of bleeding.  All ports were removed under direct visualization.  No evidence of bleeding from the port sites.  The infraumbilical and suprapubic ports were then closed.  The fascias were then closed with #0-Vicryl suture on a UR6 needle.  Once the fascias were closed, all incisions were closed with #4-0 undyed Vicryl.  The areas were cleaned, Steri-Strips were placed across the wound.  Sterile dressing was applied.,The patient tolerated the procedure well.  She was extubated following the procedure, returned to Postanesthesia Care Unit in stable condition.  She will be admitted to General Medical Floor and she will be followed closely in the early postoperative course.","gastroenterology, lower quadrant, diagnostic laparoscopy, acute appendicitis, laparoscopic appendectomy, abdomen, appendectomy, laparoscopy, appendix, suprapubic,"
" Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath. ", Gastroenterology, Melena - ICU Followup ,"HISTORY:,  Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath.  Please see dictated ICU transfer note yesterday detailing the need for emergent transfer transfusion and EGD in this patient.  Over the last 24 hours, the patient has received 2 units of packed red blood cells and his hematocrit and hemoglobin have returned to their baseline of approximately 11 appropriate for hemoglobin value.  He also underwent EGD earlier today with Dr. X.  I have discussed the case with him at length earlier this afternoon and the patient had symptoms of ulcerative esophagitis with no active bleeding.  Dr. X recommended to increase the doses of his proton pump inhibitor and to avoid NSAIDs in the future.  The patient today complains that he is still having issues with shortness of breath and wheezing and productive cough, now producing yellow-brown sputum with increasing frequency, but he has had no further episodes of melena since transfer to the ICU.  He is also complaining of some laryngitis and some pharyngitis, but is denying any abdominal complaints, nausea, or diarrhea.,PHYSICAL EXAMINATION,VITAL SIGNS:  Blood pressure is 100/54, heart rate 80 and temperature 98.8.  Is and Os negative fluid balance of 1.4 liters in the last 24 hours.,GENERAL:  This is a somnolent 68-year-old male, who arouses to voice, wakes up, seems to have good appetite, has continuing cough.  Pallor is improved.,EYES:  Conjunctivae are now pink.,ENT:  Oropharynx is clear.,CARDIOVASCULAR:  Reveals distant heart tones with regular rate and rhythm.,LUNGS:  Have coarse breath sounds with wheezes, rhonchi, and soft crackles in the bases.,ABDOMEN:  Soft and nontender with no organomegaly appreciated.,EXTREMITIES:  Showed no clubbing, cyanosis or edema.  Capillary refill time is now normal in the fingertips.,NEUROLOGICAL:  Cranial nerves II through XII are grossly intact with no focal neurological deficits.,LABORATORY DATA:,  Laboratories drawn at 1449 today, WBC 10, hemoglobin and hematocrit 11.5 and 33.1, and platelets 288,000.  This is up from 8.6 and 24.7.  Platelets are stable.  Sodium is 134, potassium 4.0, chloride 101, bicarb 26, BUN 19, creatinine 1.0, glucose 73, calcium 8.4, INR 0.96, iron 13%, saturations 4%, TIBC 312, TSH 0.74, CEA elevated at 8.6, ferritin 27.5 and occult blood positive.  EGD, final results pending per Dr. X's note and conversation with me earlier, ulcerative esophagitis without signs of active bleeding at this time.,IMPRESSION/PLAN,1.  Melena secondary to ulcerative esophagitis.  We will continue to monitor the patient overnight to ensure there is no further bleeding.  If there are no further episodes of melena and hemoglobin is stable or unchanged in the morning, the patient will be transferred back to medical floor for continuing treatment of his chronic obstructive pulmonary disease exacerbation.,2.  Chronic obstructive pulmonary disease exacerbation.  The patient is doing well, taking PO.  We will continue him on his oral Omnicef and azithromycin and continuing breathing treatments.  We will add guaifenesin and N-acetyl-cysteine in a hope to mobilize some of his secretions.  This does appear to be improving.  His white count is normalized and I am hopeful we can discharge him on oral antibiotics within the next 24 to 48 hours if there are no further complications.,3.  Elevated CEA.  The patient will need colonoscopy on an outpatient basis.  He has refused this today.  We would like to encourage him to do so.  Of note, the patient when he came in was on bloodless protocol, but with urging did accept the transfusion.  Similarly, I am hoping that with proper counseling, the patient will consent to further examination with colonoscopy given his guaiac-positive status, elevated CEA and risk factors.,4.  Anemia, normochromic normocytic with low total iron binding capacity.  This appears to be anemia of chronic disease.  However, this is likely some iron deficiency superimposed on top of this given his recent bleeding, with consider iron, vitamin C, folate and B12 supplementation and discharge given his history of alcoholic malnutrition and recent gastrointestinal bleeding.  Total critical care time spent today discussing the case with Dr. X, examining the patient, reviewing laboratory trends, adjusting medications and counseling the patient in excess is 35 minutes.","gastroenterology, anemia, gi bleeding, hemoglobin, ulcerative, esophagitis, obstructive pulmonary disease, icu followup, infection, obstructive, pulmonary, egd, melena, bleeding"
" Morbid obesity.  Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy.", Gastroenterology, Laparoscopic Gastric Bypass - 1 ,"PREOPERATIVE DIAGNOSIS: , Morbid obesity. ,POSTOPERATIVE DIAGNOSIS: , Morbid obesity. ,PROCEDURE:,  Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy. ,ANESTHESIA: , General with endotracheal intubation. ,INDICATIONS FOR PROCEDURE: , This is a 50-year-old male who has been overweight for many years and has tried multiple different weight loss diets and programs.  The patient has now begun to have comorbidities related to the obesity.  The patient has attended our bariatric seminar and met with our dietician and psychologist.  The patient has read through our comprehensive handout and understands the risks and benefits of bypass surgery as evidenced by the signing of our consent form.,PROCEDURE IN DETAIL: , The risks and benefits were explained to the patient.  Consent was obtained.  The patient was taken to the operating room and placed supine on the operating room table.  General anesthesia was administered with endotracheal intubation.  A Foley catheter was placed for bladder decompression.  All pressure points were carefully padded, and sequential compression devices were placed on the legs.  The abdomen was prepped and draped in standard, sterile, surgical fashion.  Marcaine was injected into the umbilicus.","gastroenterology, morbid obesity, roux-en-y, gastric bypass, antecolic, antegastric, anastamosis, esophagogastroduodenoscopy, eea, surgidac sutures, roux limb, port, stapler, laparoscopic, intubation"
" Diagnostic laparoscopy and rigid sigmoidoscopy.  Acute pain, fever postoperatively, hemostatic uterine perforation, no bowel or vascular trauma.", Gastroenterology, Laparoscopy & Sigmoidoscopy ,"PREOPERATIVE DIAGNOSES:,1.  Acute pain.,2.  Fever postoperatively.,POSTOPERATIVE DIAGNOSIS:,1.  Acute pain.,2.  Fever postoperatively.,3.  Hemostatic uterine perforation.,4.  No bowel or vascular trauma.,PROCEDURE PERFORMED:,1.  Diagnostic laparoscopy.,2.  Rigid sigmoidoscopy by Dr. X.,ANESTHESIA: , General endotracheal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Scant.,SPECIMEN:,  None.,INDICATIONS:  ,This is a 17-year-old African-American female, gravida-1, para-1, and had a hysteroscopy and dilation curettage on 09/05/03.  The patient presented later that evening after having increasing abdominal pain, fever and chills at home with a temperature up to 101.2.  The patient denied any nausea, vomiting or diarrhea.  She does complain of some frequent urination.  Her vaginal bleeding is minimal.,FINDINGS: , On bimanual exam, the uterus is approximately 6-week size, anteverted, and freely mobile with no adnexal masses appreciated.  On laparoscopic exam, there is a small hemostatic perforation noted on the left posterior aspect of the uterus.  There is approximately 40 cc of serosanguineous fluid in the posterior cul-de-sac.  The bilateral tubes and ovaries appeared normal.  There is no evidence of endometriosis in the posterior cul-de-sac or along the bladder flap.  There is no evidence of injury to the bowel or pelvic sidewall.  The liver margin, gallbladder and remainder of the bowel including the appendix appeared normal.,PROCEDURE: , After consent was obtained, the patient was taken to the Operating Room where general anesthetic was administered.  The patient was placed in the dorsal lithotomy position and prepped and draped in the normal sterile fashion.  A sterile speculum was placed in the patient's vagina and the anterior lip of the cervix was grasped with a vulsellum tenaculum.  The uterine manipulator was then placed into the patient's cervix and the vulsellum tenaculum and sterile speculum were removed.  Gloves were changed and attention was then turned to the abdomen where approximately 10 mm transverse infraumbilical incision was made.  Veress needle was placed through this incision and the gas turned on.  When good flow and low abdominal pressures were noted, the gas was turned up and the abdomen was allowed to insufflate.  A 11 mm trocar was then placed through this incision.  The camera was placed with the above findings noted.  A 5 mm step trocar was placed 2 cm superior to the pubic bone and along the midline.  A blunt probe was placed through this trocar to help for visualization of the pelvic and abdominal organs.  The serosanguineous fluid of the cul-de-sac was aspirated and the pelvis was copiously irrigated with sterile saline.  At this point, Dr. X was consulted.  He performed a rigid sigmoidoscopy, please see his dictation for further details.  There does not appear to be any evidence of colonic injury.  The saline in the pelvis was then suctioned out using Nezhat-Dorsey.  All instruments were removed.  The 5 mm trocar was removed under direct visualization with excellent hemostasis noted.  The camera was removed and the abdomen was allowed to desufflate.  The 11 mm trocar introducer was replaced and the trocar removed.  The skin was then closed with #4-0 undyed Vicryl in a subcuticular fashion.  Approximately 10 cc of 0.25% Marcaine was injected into the incision sites for postoperative pain relief.  Steri-Strips were then placed across the incision.  The uterine manipulator was then removed from the patient's cervix with excellent hemostasis noted.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct at the end of the procedure.  The patient was taken to the recovery room in satisfactory condition.,She will be followed immediately postoperatively within the hospital and started on IV antibiotics.","gastroenterology, uterine perforation, vascular, bowel, diagnostic laparoscopy, vulsellum tenaculum, uterine manipulator, excellent hemostasis, rigid sigmoidoscopy, laparoscopy, sigmoidoscopy, postoperatively, trocar, "
" Laparoscopy, laparotomy, cholecystectomy with operative cholangiogram, choledocholithotomy with operative choledochoscopy and T-tube drainage of the common bile duct.", Gastroenterology," Laparoscopy, Laparotomy, & Cholecystectomy  ","PREOPERATIVE DIAGNOSES: , Cholelithiasis, cholecystitis, and recurrent biliary colic.,POSTOPERATIVE DIAGNOSES: , Severe cholecystitis, cholelithiasis, choledocholithiasis, and morbid obesity.,PROCEDURES PERFORMED: , Laparoscopy, laparotomy, cholecystectomy with operative cholangiogram, choledocholithotomy with operative choledochoscopy and T-tube drainage of the common bile duct.,ANESTHESIA: , General.,INDICATIONS: , This is a 63-year-old white male patient with multiple medical problems including hypertension, diabetes, end-stage renal disease, coronary artery disease, and the patient is on hemodialysis, who has had recurrent episodes of epigastric right upper quadrant pain.  The patient was found to have cholelithiasis on last admission.  He was being worked up for this including cardiac clearance.  However, in the interim, he returned again with another episode of same pain.  The patient had a HIDA scan done yesterday, which shows nonvisualization of the gallbladder consistent with cystic duct obstruction.  Because of these, laparoscopic cholecystectomy was advised with cholangiogram.  Possibility of open laparotomy and open procedure was also explained to the patient.  The procedure, indications, risks, and alternatives were discussed with the patient in detail and informed consent was obtained.,DESCRIPTION OF PROCEDURE: , The patient was put in supine position on the operating table under satisfactory general anesthesia.  The entire abdomen was prepped and draped.  A small transverse incision was made about 2-1/2 inches above the umbilicus in the midline under local anesthesia.  The patient has a rather long torso.  Fascia was opened vertically and stay sutures were placed in the fascia.  Peritoneal cavity was carefully entered.  Hasson cannula was inserted into the peritoneal cavity and it was insufflated with CO2.  Laparoscopic camera was inserted and examination at this time showed difficult visualization with a part of omentum and hepatic flexure of the colon stuck in the subhepatic area.  The patient was placed in reverse Trendelenburg and rotated to the left.  An 11-mm trocar was placed in the subxiphoid space and two 5-mm in the right subcostal region.  Slowly, the dissection was carried out in the right subhepatic area.  Initially, I was able to dissect some of the omentum and hepatic flexure off the undersurface of the liver.  Then, some inflammatory changes were noted with some fatty necrosis type of changes and it was not quite clear whether this was part of the gallbladder or it was just pericholecystic infection/inflammation.  The visualization was extremely difficult because of the patient's obesity and a lot of fat intra-abdominally, although his abdominal wall is not that thick.  After evaluating this for a little while, we decided that there was no way that this could be done laparoscopically and proceeded with formal laparotomy.  The trocars were removed.,A right subcostal incision was made and peritoneal cavity was entered.  A Bookwalter retractor was put in place.  The dissection was then carried out on the undersurface of the liver.  Eventually, the gallbladder was identified, which was markedly scarred down and shrunk and appeared to have palpable stone in it.  Dissection was further carried down to what was felt to be the common bile duct, which appeared to be somewhat larger than normal about a centimeter in size.  The duodenum was kocherized.  The gallbladder was partly intrahepatic.  Because of this, I decided not to dig it out of the liver bed causing further bleeding and problem.  The inferior wall of the gallbladder was opened and two large stones, one was about 3 cm long and another one about 1.5 x 2 cm long, were taken out of the gallbladder.,It was difficult to tell where the cystic duct was.  Eventually after probing near the neck of the gallbladder, I did find the cystic duct, which was relatively very short.  Intraoperative cystic duct cholangiogram was done using C-arm fluoroscopy.  This showed a rounded density at the lower end of the bile duct consistent with the stone.  At this time, a decision was made to proceed with common duct exploration.  The common duct was opened between stay sutures of 4-0 Vicryl and immediately essentially clear bile came out.  After some pressing over the head of the pancreas through a kocherized maneuver, the stone did fall into the opening in the common bile duct.  So, it was about a 1-cm size stone, which was removed.  Following this, a 10-French red rubber catheter was passed into the common bile duct both proximally and distally and irrigated generously.  No further stones were obtained.  The catheter went easily into the duodenum through the ampulla of Vater.  At this point, a choledochoscope was inserted and proximally, I did not see any evidence of any common duct stones or proximally into the biliary tree.  However, a stone was found distally still floating around.  This was removed with stone forceps.  The bile ducts were irrigated again.  No further stones were removed.  A 16-French T-tube was then placed into the bile duct and the bile duct was repaired around the T-tube using 4-0 Vicryl interrupted sutures obtaining watertight closure.  A completion T-tube cholangiogram was done at this time, which showed slight narrowing and possibly a filling defect proximally below the confluence of the right and left hepatic duct, although externally, I was unable to see anything or palpate anything in this area.  Because of this, the T-tube was removed, and I passed the choledochoscope proximally again, and I was unable to see any evidence of any lesion or any stone in this area.  I felt at this time this was most likely an impression from the outside, which was still left over a gallbladder where the stone was stuck and it was impressing on the bile duct.  The bile duct lumen was widely open.  T-tube was again replaced into the bile duct and closed again and a completion T-tube cholangiogram appeared to be more satisfactory at this time.  The cystic duct opening through which I had done earlier a cystic duct cholangiogram, this was closed with a figure-of-eight suture of 2-0 Vicryl, and this was actually done earlier and completion cholangiogram did not show any leak from this area.,The remaining gallbladder bed, which was left in situ, was cauterized both for hemostasis and to burn off the mucosal lining.  Subhepatic and subdiaphragmatic spaces were irrigated with sterile saline solution.  Hemostasis was good.  A 10-mm Jackson-Pratt drain was left in the foramen of Winslow and brought out through the lateral 5-mm port site.  The T-tube was brought out through the middle 5-mm port site, which was just above the incision.  Abdominal incision was then closed in layers using 0 Vicryl running suture for the peritoneal layer and #1 Novafil running suture for the fascia.  Subcutaneous tissue was closed with 3-0 Vicryl running sutures in two layers.  Subfascial and subcutaneous tissues were injected with a total of 20 mL of 0.25% Marcaine with epinephrine for postoperative pain control.  The umbilical incision was closed with 0 Vicryl figure-of-eight sutures for the fascia, 2-0 Vicryl for the subcutaneous tissues, and staples for the skin.  Sterile dressing was applied, and the patient transferred to recovery room in stable condition.","gastroenterology, cholelithiasis, cholecystitis, biliary colic, choledocholithiasis, laparoscopy, laparotomy, cholecystectomy, cholangiogram, choledocholithotomy, choledochoscopy, t-tube drainage, cystic duct cholangiogram, common bile duct, peritoneal cavity, gallbladder"
 Laparoscopic cholecystectomy with cholangiogram.  Acute gangrenous cholecystitis with cholelithiasis.  The patient had essentially a dead gallbladder with stones and positive wide bile/pus coming from the gallbladder., Gastroenterology, Laparoscopic Cholecystectomy & Cholangiogram ,"PREOPERATIVE DIAGNOSIS:,  Acute cholecystitis.,POSTOPERATIVE DIAGNOSIS:,  Acute gangrenous cholecystitis with cholelithiasis.,OPERATION PERFORMED: , Laparoscopic cholecystectomy with cholangiogram.,FINDINGS:  ,The patient had essentially a dead gallbladder with stones and positive wide bile/pus coming from the gallbladder.,COMPLICATIONS:  ,None.,EBL: , Scant.,SPECIMEN REMOVED: , Gallbladder with stones.,DESCRIPTION OF PROCEDURE:  ,The patient was prepped and draped in the usual sterile fashion under general anesthesia.  A curvilinear incision was made below the umbilicus.  Through this incision, the camera port was able to be placed into the peritoneal cavity under direct visualization.  Once this complete, insufflation was begun.  Once insufflation was adequate, additional ports were placed in the epigastrium as well as right upper quadrant.  Once all four ports were placed, the right upper quadrant was then explored.  The patient had significant adhesions of omentum and colon to the liver, the gallbladder constituting definitely an acute cholecystitis.  This was taken down using Bovie cautery to free up visualization of the gallbladder.  The gallbladder was very thick and edematous and had frank necrosis of most of the anterior gallbladder wall.  Adhesions were further taken down between the omentum, the colon, and the gallbladder slowly starting superiorly and working inferiorly towards the cystic duct area.  Once the adhesions were fully removed, the cholangiogram was done which did not show any evidence of any common bile duct dilatation or obstruction.  At this point, due to the patient's gallbladder being very necrotic, it was deemed that the patient should have a drain placed.  The cystic duct and cystic artery were serially clipped and transected.  The gallbladder was removed from the gallbladder fossa removing the entire gallbladder.  Adequate hemostasis with Bovie cautery was achieved.  The gallbladder was then placed into a bag and removed from the peritoneal cavity through the camera port.  A JP drain was then run through the anterior port and out of one of the trochar sites and secured to the skin using 3-0 nylon suture.  Next, the right upper quadrant was copiously irrigated out using the suction irrigator.  Once this was complete, the additional ports were able to be removed.  The fascial opening at the umbilicus was reinforced by closing it using a 0 Vicryl suture in a figure-of-8 fashion.  All skin incisions were injected using Marcaine 1/4 percent plain.  The skin was reapproximated further using 4-0 Monocryl sutures in a subcuticular technique.  The patient tolerated the procedure well and was able to be transferred to the recovery room in stable condition.","gastroenterology, acute cholecystitis, cholangiogram, cholelithiasis, cholecystitis, gallbladder, gangrenous cholecystitis, bovie cautery, cystic duct, laparoscopic cholecystectomy, laparoscopic, cholecystectomy, cystic, duct,"
 Laparoscopic cholecystectomy with attempted intraoperative cholangiogram.  A 2 cm infraumbilical midline incision was made.  The fascia was then cleared of subcutaneous tissue using a tonsil clamp., Gastroenterology, Laparoscopic Cholecystectomy & Cholangiogram - 1 ,"PROCEDURE PERFORMED:,  Laparoscopic cholecystectomy with attempted intraoperative cholangiogram.,PROCEDURE: , After informed consent was obtained, the patient was brought to the operating room and placed supine on the operating room table.  General endotracheal anesthesia was induced without incident.  The patient was prepped and draped in the usual sterile manner.,A 2 cm infraumbilical midline incision was made.  The fascia was then cleared of subcutaneous tissue using a tonsil clamp.  A 1-2 cm incision was then made in the fascia, gaining entry into the abdominal cavity without incident.  Two sutures of 0 Vicryl were then placed superiorly and inferiorly in the fascia, and then tied to the special 12 mm Hasson trocar fitted with a funnel-shaped adapter in order to occlude the fascial opening.  Pneumoperitoneum was then established using carbon dioxide insufflation to a steady pressure of 16 mmHg.,The remaining trocars were then placed into the abdomen under direct vision of the 30 degree laparoscope taking care to make the incisions along Langer's lines, spreading the subcutaneous tissues with a tonsil clamp, and confirming the entry site by depressing the abdominal wall prior to insertion of the trocar.  A total of 3 other trocars were placed.  The first was a 10/11 mm trocar in the upper midline position.  The second was a 5 mm trocar placed in the anterior axillary line approximately 3 cm above the anterior superior iliac spine.  The third was a 5 mm trocar placed to bisect the distance between the second and upper midline trocars.  All of the trocars were placed without difficulty.,The patient was then placed in reverse Trendelenburg position and was rotated slightly to the left.  The gallbladder was then grasped through the second and third trocars and retracted cephalad toward the right shoulder.  A laparoscopic dissector was then placed through the upper midline cannula, fitted with a reducer, and the structures within the triangle of Calot were meticulously dissected free.,A laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic duct close to the gallbladder.  The gallbladder was then grasped through the upper midline cannula and a fine-tipped scissors introduced through the third cannula and used to make a small ductotomy in the cystic duct near the clips.  Several attempts at passing the cholangiocatheter into the ductotomy were made.  Despite numerous attempts at several angles, the cholangiocatheter could not be inserted into the cystic duct.  After several such attempts, and due to the fact that the anatomy was clear, we aborted any further attempts at cholangiography.  The distal cystic duct was doubly clipped.  The duct was divided between the clips.  The clips were carefully placed to avoid occluding the juncture with the common bile duct.  The port sites were injected with 0.5% Marcaine.,The cystic artery was found medially and slightly posteriorly to the cystic duct.  It was carefully dissected free from its surrounding tissues.  A laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic artery proximally and distally.  The artery was divided between the clips.  The port sites were injected with 0.5% Marcaine.,After the cystic duct and artery were transected, the gallbladder was dissected from the liver bed using Bovie electrocautery.  Prior to complete dissection of the gallbladder from the liver, the peritoneal cavity was copiously irrigated with saline and the operative field was examined for persistent blood or bile leaks of which there were none.,After the complete detachment of the gallbladder from the liver, the video laparoscope was removed and placed through the upper 10/11 mm cannula.  The neck of the gallbladder was grasped with a large penetrating forceps placed through the umbilical 12 mm Hasson cannula.  As the gallbladder was pulled through the umbilical fascial defect, the entire sheath and forceps were removed from the abdomen.  The neck of the gallbladder was then secured with a Kocher clamp, and the gallbladder was removed from the abdomen.,Following gallbladder removal, the remaining carbon dioxide was expelled from the abdomen.,Both midline fascial defects were then approximated using 0 Vicryl suture.  All skin incisions were approximated with 4-0 Vicryl in a subcuticular fashion.  The skin was prepped with benzoin, and Steri-Strips were applied.  Dressings were applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition.","gastroenterology, intraoperative cholangiogram, cystic artery, laparoscopic cholecystectomy, cystic duct, gallbladder, tonsil, cholecystectomy, cholangiogram, abdomen, laparoscopic, cannula,"
" Morbid obesity.  Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis.  This is a 30-year-old female, who has been overweight for many years.  She has tried many different diets, but is unsuccessful. ", Gastroenterology, Laparoscopic Gastric Bypass ,"PREOPERATIVE DIAGNOSIS: , Morbid obesity.,POSTOPERATIVE DIAGNOSIS:  ,Morbid obesity.,PROCEDURE: , Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis.,ANESTHESIA: , General with endotracheal intubation.,INDICATION FOR PROCEDURE: , This is a 30-year-old female, who has been overweight for many years.  She has tried many different diets, but is unsuccessful.  She has been to our Bariatric Surgery Seminar, received some handouts, and signed the consent.  The risks and benefits of the procedure have been explained to the patient.,PROCEDURE IN DETAIL:  ,The patient was taken to the operating room and placed supine on the operating room table.  All pressure points were carefully padded.  She was given general anesthesia with endotracheal intubation.  SCD stockings were placed on both legs.  Foley catheter was placed for bladder decompression.  The abdomen was then prepped and draped in standard sterile surgical fashion.  Marcaine was then injected through umbilicus.  A small incision was made.  A Veress needle was introduced into the abdomen.  CO2 insufflation was done to a maximum pressure of 15 mmHg.  A 12-mm VersaStep port was placed through the umbilicus.  I then placed a 5-mm port just anterior to the midaxillary line and just subcostal on the right side.  I placed another 5-mm port in the midclavicular line just subcostal on the right side, a few centimeters below and medial to that, I placed a 12-mm VersaStep port.  On the left side, just anterior to the midaxillary line and just subcostal, I placed a 5-mm port.  A few centimeters below and medial to that, I placed a 15-mm port.  I began by lifting up the omentum and identifying the transverse colon and lifting that up and thereby identifying my ligament of Treitz.  I ran the small bowel down approximately 40 cm and divided the small bowel with a white load GIA stapler.  I then divided the mesentery all the way down to the base of the mesentery with a LigaSure device.  I then ran the distal bowel down, approximately 100 cm, and at 100 cm, I made a hole at the antimesenteric portion of the Roux limb and a hole in the antimesenteric portion of the duodenogastric limb, and I passed a 45 white load stapler and fired a stapler creating a side-to-side anastomosis.  I reapproximated the edges of the defect.  I lifted it up and stapled across it with another white load stapler.  I then closed the mesenteric defect with interrupted Surgidac sutures.  I divided the omentum all the way down to the colon in order to create a passageway for my small bowel to go antecolic.  I then put the patient in reverse Trendelenburg.  I placed a liver retractor, identified, and dissected the angle of His.  I then dissected on the lesser curve, approximately 2.5 cm below the gastroesophageal junction, and got into a lesser space.  I fired transversely across the stomach with a 45 blue load stapler.  I then used two fires of the 60 blue load with SeamGuard to go up into my angle of His, thereby creating my gastric pouch.  I then made a hole at the base of the gastric pouch and had Anesthesia remove the bougie and place the OG tube connected to the anvil.  I pulled the anvil into place, and I then opened up my 15-mm port site and passed my EEA stapler.  I passed that in the end of my Roux limb and had the spike come out antimesenteric.  I joined the spike with the anvil and fired a stapler creating an end-to-side anastomosis, then divided across the redundant portion of my Roux limb with a white load GI stapler, and removed it with an Endocatch bag.  I put some additional 2-0 Vicryl sutures in the anastomosis for further security.  I then placed a bowel clamp across the bowel.  I went above and passed an EGD scope into the mouth down to the esophagus and into the gastric pouch.  I distended gastric pouch with air.  There was no air leak seen.  I could pass the scope easily through the anastomosis.  There was no bleeding seen through the scope.  We closed the 15-mm port site with interrupted 0 Vicryl suture utilizing Carter-Thomason.  I copiously irrigated out that incision with about 2 L of saline.  I then closed the skin of all incisions with running Monocryl.  Sponge, instrument, and needle counts were correct at the end of the case.  The patient tolerated the procedure well without any complications.","gastroenterology, gastric bypass, eea anastomosis, roux-en-y, antegastric, antecolic, morbid obesity, roux limb, gastric pouch, intubation, laparoscopic, bypass, roux, endotracheal, anastomosis, gastric"
 Laparoscopic cholecystectomy.  A 2 cm infraumbilical midline incision was made.  The fascia was then cleared of subcutaneous tissue using a tonsil clamp., Gastroenterology, Laparoscopic Cholecystectomy - 9 ,"PROCEDURE PERFORMED: , Laparoscopic cholecystectomy.,PROCEDURE:  ,After informed consent was obtained, the patient was brought to the operating room and placed supine on the operating room table.  General endotracheal anesthesia was induced without incident.  The patient was prepped and draped in the usual sterile manner.,A 2 cm infraumbilical midline incision was made.  The fascia was then cleared of subcutaneous tissue using a tonsil clamp.  A 1-2 cm incision was then made in the fascia, gaining entry into the abdominal cavity without incident.  Two sutures of 0 Vicryl were then placed superiorly and inferiorly in the fascia, and then tied to the special 12 mm Hasson trocar fitted with a funnel-shaped adapter in order to occlude the fascial opening.  Pneumoperitoneum was then established using carbon dioxide insufflation to a steady pressure of 16 mmHg.,The remaining trocars were then placed into the abdomen under direct vision of the 30 degree laparoscope taking care to make the incisions along Langer's lines, spreading the subcutaneous tissues with a tonsil clamp, and confirming the entry site by depressing the abdominal wall prior to insertion of the trocar.  A total of 3 other trocars were placed.  The first was a 10/11 mm trocar in the upper midline position.  The second was a 5 mm trocar placed in the anterior iliac spine.  The third was a 5 mm trocar placed to bisect the distance between the second and upper midline trocars.  All of the trocars were placed without difficulty.,The patient was then placed in reverse Trendelenburg position and was rotated slightly to the left.  The gallbladder was then grasped through the second and third trocars and retracted cephalad toward the right shoulder.  A laparoscopic dissector was then placed through the upper midline cannula, fitted with a reducer, and the structures within the triangle of Calot were meticulously dissected free.,A laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic duct proximally and distally.  The duct was divided between the clips.  The clips were carefully placed to avoid occluding the juncture with the common bile duct.  The cystic artery was found medially and slightly posterior to the cystic duct.  It was carefully dissected free from its surrounding tissues.  A laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic artery proximally and distally.  The artery was divided between the clips.  The 2 midline port sites were injected with 5% Marcaine.,After the complete detachment of the gallbladder from the liver, the video laparoscope was removed and placed through the upper 10/11 mm cannula.  The neck of the gallbladder was grasped with a large penetrating forceps placed through the umbilical 12 mm Hasson cannula.  As the gallbladder was pulled through the umbilical fascial defect, the entire sheath and forceps were removed from the abdomen.  The neck of the gallbladder was removed from the abdomen.  Following gallbladder removal, the remaining carbon dioxide was expelled from the abdomen.,Both midline fascial defects were then approximated using 0 Vicryl suture.  All skin incisions were approximated with 4-0 Vicryl in a subcuticular fashion.  The skin was prepped with benzoin, and Steri-Strips were applied.  Dressings were applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition.","gastroenterology, langer's lines, laparoscope, cystic duct, cystic artery, laparoscopic cholecystectomy, midline cannula, infraumbilical, tonsil, cholecystectomy, fascia, abdomen, trocars, cannula, laparoscopic, gallbladder, "
" Symptomatic cholelithiasis.  Laparoscopic cholecystectomy and appendectomy (CPT 47563, 44970).  The patient requested appendectomy because of the concern of future diagnostic dilemma with pain crisis.  Laparoscopic cholecystectomy and appendectomy were recommended to her. ", Gastroenterology, Laparoscopic Cholecystectomy & Appendectomy ,"PREOPERATIVE DIAGNOSIS: , Symptomatic cholelithiasis.,POSTOPERATIVE DIAGNOSIS: , Symptomatic cholelithiasis.,PROCEDURE: , Laparoscopic cholecystectomy and appendectomy (CPT 47563, 44970).,ANESTHESIA: , General endotracheal.,INDICATIONS:  ,This is an 18-year-old girl with sickle cell anemia who has had symptomatic cholelithiasis.  She requested appendectomy because of the concern of future diagnostic dilemma with pain crisis.  Laparoscopic cholecystectomy and appendectomy were recommended to her.  The procedure was explained in detail including the risks of bleeding, infection, biliary injury, retained common duct stones.  After answering her questions, she wished to proceed and gave informed consent.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine on the operating table.  She was positively identified and the correct surgical site and procedure reviewed.  After successful administration of general endotracheal anesthesia, the skin of the abdomen was prepped with chlorhexidine solution and sterilely draped.,The infraumbilical skin was infiltrated with 0.25% bupivacaine with epinephrine and horizontal incision created.  The linea alba was grasped with a hemostat and Veress needle was placed into the peritoneal cavity and used to insufflate carbon dioxide gas to a pressure of 15 mmHg.  A 12-mm expandable disposable trocar was placed and through this a 30 degree laparoscope was used to inspect the peritoneal cavity.  Upper abdominal anatomy was normal.  Pelvic laparoscopy revealed bilaterally closed internal inguinal rings.  Additional trocars were placed under direct vision including a 5-mm reusable in the right lateral _____.  There was a 12-mm expandable disposable in the right upper quadrant and a 5-mm reusable in the subxiphoid region.  Using these, the gallbladder was grasped and retraced cephalad.  Adhesions were taken down over the cystic duct and the duct was circumferentially dissected and clipped at the gallbladder cystic duct junction.  A small ductotomy was created.  Reddick cholangiogram catheter was then placed within the duct and the balloon inflated.  Continuous fluoroscopy was used to instill contrast material.  This showed normal common bile duct which entered the duodenum without obstruction.  There was no evidence of common bile duct stones.  The cholangiogram catheter was removed.  The duct was doubly clipped and divided.  The artery was divided and cauterized.  The gallbladder was taken out of the gallbladder fossa.  It was then placed in Endocatch bag and left in the abdomen.  Attention was then paid to the appendix.  The appendix was identified and window was made in the mesoappendix at the base.  This was amputated with an Endo-GIA stapler.  The mesoappendix was divided with an Endo-GIA vascular stapler.  This was placed in another Endocatch bag.  The abdomen was then irrigated.  Hemostasis was satisfactory.  Both the appendix and gallbladder were removed and sent for pathology.  All trocars were removed.  The 12-mm port sites were closed with 2-0 PDS figure-of-eight fascial sutures.  The umbilical skin was reapproximated with interrupted 5-0 Vicryl Rapide.  The remaining skin incisions were closed with 5-0 Monocryl subcuticular suture.  The skin was cleaned.  Mastisol, Steri-Strips and band-aids were applied.  The patient was awakened, extubated in the operating room, transferred to the recovery room in stable condition.","gastroenterology, endo-gia, endocatch bag, symptomatic cholelithiasis, laparoscopic cholecystectomy, appendectomy, cholangiogram, mesoappendix, abdomen, appendix, cholelithiasis, endotracheal, laparoscopic, cholecystectomy, gallbladder, duct "
" Chronic cholecystitis, cholelithiasis, and liver cyst.  Laparoscopic cholecystectomy and excision of liver cyst.  Exploration of the abdomen revealed multiple adhesions of omentum overlying the posterior aspect of the gallbladder. ", Gastroenterology, Laparoscopic Cholecystectomy & Liver Cyst Excision ,"PREOPERATIVE DIAGNOSES:,1.  Chronic cholecystitis.,2.  Cholelithiasis.,POSTOPERATIVE DIAGNOSES:,1.  Chronic cholecystitis.,2.  Cholelithiasis.,3.  Liver cyst.,PROCEDURES PERFORMED:,1.  Laparoscopic cholecystectomy.,2.  Excision of liver cyst.,ANESTHESIA:  ,General endotracheal and injectable 0.25% Marcaine with 1% lidocaine.,SPECIMENS: , Include,1.  Gallbladder.,2.  Liver cyst.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,OPERATIVE FINDINGS:,  Exploration of the abdomen revealed multiple adhesions of omentum overlying the posterior aspect of the gallbladder.  Additionally, there was a notable liver cyst.  The remainder of the abdomen remained free of any adhesions.,BRIEF HISTORY: , This is a 66-year-old Caucasian female who presented to ABCD General Hospital for an elective cholecystectomy.  The patient complained of intractable nausea, vomiting, and abdominal bloating after eating fatty foods.  She had had multiple attacks in the past of these complaints.  She was discovered to have had right upper quadrant pain on examination.  Additionally, she had an ultrasound performed on 08/04/2003, which revealed cholelithiasis.  The patient was recommended to undergo laparoscopic cholecystectomy for her recurrent symptoms.  She was explained the risks, benefits, and complications of the procedure and she gave informed consent to proceed.,OPERATIVE PROCEDURE:  ,The patient was brought to the operative suite and placed in the supine position.  The patient received preoperative antibiotics with Kefzol.  The abdomen was prepped and draped in the normal sterile fashion with Betadine solution.  The patient did undergo general endotracheal anesthesia.  Once the adequate sedation was achieved, a supraumbilical transverse incision was created with a #10 blade scalpel.  Utilizing a Veress needle, the Veress needle was inserted intra-abdominally and was hooked to the CO2 insufflation.  The abdomen was insufflated to 15 mmHg.  After adequate insufflation was achieved, the laparoscopic camera was inserted into the abdomen and to visualize a distended gallbladder as well as omental adhesion adjacent to the gallbladder.  Decision to proceed with laparoscopic cystectomy was decided.  A subxiphoid transverse incision was created with a #10 blade scalpel and utilizing a bladed 12 mm trocar, the trocar was inserted under direct visualization into the abdomen.  Two 5 mm ports were placed, one at the midclavicular line 2 cm below the costal margin and a second at the axillary line, one hand length approximately below the costal margin.  All ports were inserted with bladed 5 mm trocar then under direct visualization.  After all trocars were inserted, the gallbladder was grasped at the fundus and retracted superiorly and towards the left shoulder.  Adhesions adjacent were taken down with a Maryland dissector.  Once this was performed, the infundibulum of the gallbladder was grasped and retracted laterally and anteriorly.  This helped to better delineate the cystic duct as well as the cystic artery.  Utilizing Maryland dissector, careful dissection of the cystic duct and cystic artery were created posteriorly behind each one.  Utilizing Endoclips, clips were placed on the cystic duct and cystic artery, one proximal to the gallbladder and two distally.  Utilizing endoscissors, the cystic duct and cystic artery were ligated.  Next, utilizing electrocautery, the gallbladder was carefully dissected off the liver bed.  Electrocautery was used to stop any bleeding encountered along the way.  The gallbladder was punctured during dissection and cleared, biliary contents did drained into the abdomen.  No evidence of stones were visualized.  Once the gallbladder was completely excised from the liver bed, an EndoCatch was placed and the gallbladder was inserted into EndoCatch and removed from the subxiphoid port.  This was sent off as an specimen, a gallstone was identified within the gallbladder.  Next, utilizing copious amounts of irrigation, the abdomen was irrigated.  A small liver cyst that have been identified upon initial aspiration was grasped with a grasper and utilizing electrocautery was completely excised off the left lobe of the liver.  This was also taken and sent off as specimen.  The abdomen was then copiously irrigated until clear irrigation was identified.  All laparoscopic ports were removed under direct visualization.  The abdomen was de-insufflated.  Utilizing #0 Vicryl suture, the abdominal fascia was approximated with a figure-of-eight suture in the supraumbilical and subxiphoid region.  All incisions were then closed with #4-0 undyed Vicryl.  Two midline incisions were closed with a running subcuticular stitch and the lateral ports were closed with interrupted sutures.  The areas were cleaned and dried.  Steri-Strips were placed.  On the incisions, sterile dressing was applied.  The patient tolerated the procedure well.  She was extubated following procedure.  She is seen to tolerate the procedure well and she will follow up with Dr. X within one week for a follow-up evaluation.","gastroenterology, excision of liver cyst, gallbladder, omentum, cystic artery, gallstone, laparoscopic cholecystectomy, cystic duct, liver cyst, liver, abdomen, electrocautery, cholelithiasis, cholecystectomy, adhesions, laparoscopic, cyst, cystic, "
" Biliary colic.   Laparoscopic cholecystectomy.  Laparoscopic examination showed no injury from entry.  Marcaine was then injected just subxiphoid, and a 5-mm port was placed under direct visualization for the laparoscope. ", Gastroenterology, Laparoscopic Cholecystectomy - 5 ,"PREOPERATIVE DIAGNOSIS: , Biliary colic.","gastroenterology, veress needle, gallbladder, laparoscope, laparoscopic examination, endotracheal intubation, laparoscopic cholecystectomy, biliary colic, abdomen, cholecystectomy, endotracheal, umbilicus, laparoscopic, "
 Acute cholecystitis.  Laparoscopic cholecystectomy.  The abdominal area was prepped and draped in the usual sterile fashion.  A small skin incision was made below the umbilicus.  It was carried down in the transverse direction on the side of her old incision.  It was carried down to the fascia., Gastroenterology, Laparoscopic Cholecystectomy - 4 ,"PREOPERATIVE DIAGNOSIS: , Acute cholecystitis.,POSTOPERATIVE DIAGNOSIS:,  Acute cholecystitis.,PROCEDURE PERFORMED:,  Laparoscopic cholecystectomy.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS:,  Zero.,COMPLICATIONS: , None.,PROCEDURE:  ,The patient was taken to the operating room, and after obtaining adequate general anesthesia, the patient was placed in the supine position.  The abdominal area was prepped and draped in the usual sterile fashion.  A small skin incision was made below the umbilicus.  It was carried down in the transverse direction on the side of her old incision.  It was carried down to the fascia.  An open pneumoperitoneum was created with Hasson technique.  Three additional ports were placed in the usual fashion.  The gallbladder was found to be acutely inflamed, distended, and with some necrotic areas.  It was carefully retracted from the isthmus, and the cystic structure was then carefully identified, dissected, and divided between double clips.  The gallbladder was then taken down from the gallbladder fossa with electrocautery.  There was some bleeding from the gallbladder fossa that was meticulously controlled with a Bovie.  The gallbladder was then finally removed via the umbilical port with some difficulty because of the size of the gallbladder and size of the stones.  The fascia had to be opened.  The gallbladder had to be opened, and the stones had to be extracted carefully.  When it was completed, I went back to the abdomen and achieved complete hemostasis.  The ports were then removed under direct vision with the scope.  The fascia of the umbilical wound was closed with a figure-of-eight 0 Vicryl.  All the incisions were injected with 0.25% Marcaine, closed with 4-0 Monocryl, Steri-Strips, and sterile dressing.,The patient tolerated the procedure satisfactorily and was transferred to the recovery room in stable condition.","gastroenterology, laparoscopic, cholecystectomy, cholecystitis, gallbladder fossa, laparoscopic cholecystectomy, acute cholecystitis, gallbladder"
" Chronic cholecystitis.   Laparoscopic cholecystectomy.  Patient with increasingly severe more frequent right upper quadrant abdominal pain, more after meals, had a positive ultrasound for significant biliary sludge.", Gastroenterology, Laparoscopic Cholecystectomy - 8 ,"PREOPERATIVE DIAGNOSIS: , Chronic cholecystitis.,POSTOPERATIVE DIAGNOSIS:  ,Chronic cholecystitis.,PROCEDURE PERFORMED:  ,Laparoscopic cholecystectomy.,BLOOD LOSS: , Minimal.,ANESTHESIA: , General endotracheal anesthesia.,COMPLICATIONS: , None.,CONDITION: , Stable.,DRAINS: , None.,DISPOSITION:  ,To recovery room and to home.,FLUIDS:  ,Crystalloid.,FINDINGS: , Consistent with chronic cholecystitis.  Final pathology is pending.,INDICATIONS FOR THE PROCEDURE:  ,Briefly, the patient is a 38-year-old male referred with increasingly severe more frequent right upper quadrant abdominal pain, more after meals, had a positive ultrasound for significant biliary sludge.  He presented now after informed consent for the above procedure.,PROCEDURE IN DETAIL:  ,The patient was identified in the preanesthesia area, then taken to the operating room, placed in the supine position on the operating table, and induced under general endotracheal anesthesia.  The patient was correctly positioned, padded at all pressure points, had antiembolic TED hose and Flowtrons in the lower extremities.  The anterior abdomen was then prepared and draped in a sterile fashion.  Preemptive local anesthetic was infiltrated with 1% lidocaine and 0.5% ropivacaine.  The initial incision was made sharply at the umbilicus with a #15-scalpel blade and carried down through deeper tissues with Bovie cautery, down to the midline fascia with a #15 scalpel blade.  The blunt-tipped Hasson introducer cannula was placed into the abdominal cavity under direct vision where it was insufflated using carbon dioxide gas to a pressure of 15 mmHg.  The epigastric and right subcostal trocars were placed under direct vision.  The right upper quadrant was well visualized.  The gallbladder was noted to be significantly distended with surrounding dense adhesions.  The fundus of the gallbladder was grasped and retracted anteriorly and superiorly, and the surrounding adhesions were then taken down off the gallbladder using a combination of the bullet-nose Bovie dissector and the blunt Kittner peanut dissector.  Further dissection allowed identification of the infundibulum and cystic duct junction where the cystic duct was identified and dissected out further using a right-angle clamp.  The cystic duct was clipped x3 and then divided.  The cystic artery was dissected out in like fashion, clipped x3, and then divided.  The gallbladder was then taken off the liver bed in a retrograde fashion using the hook-tip Bovie cautery with good hemostasis.  Prior to removal of the gallbladder, all irrigation fluid was clear.  No active bleeding or oozing was seen.  All clips were noted to be secured and intact and in place.  The gallbladder was placed in a specimen pouch after placing the camera in the epigastric port.  The gallbladder was retrieved through the umbilical fascial defect and submitted to Pathology.  The camera was placed back once again into the abdominal cavity through the umbilical port, and all areas remained clean and dry and the trocar was removed under direct visualization.  The insufflation was allowed to escape.  The umbilical fascia was closed using interrupted #1 Vicryl sutures.  Finally, the skin was closed in a layered subcuticular fashion with interrupted 3-0 and 4-0 Monocryl.  Sterile dressings were applied.  The patient tolerated the procedure well.,","gastroenterology, abdomen, bovie cautery, endotracheal anesthesia, laparoscopic cholecystectomy, cystic duct, chronic cholecystitis, abdominal, laparoscopic, cholecystectomy, cholecystitis, gallbladder, "
 Cholecystitis and cholelithiasis.  Laparoscopic cholecystectomy and intraoperative cholangiogram.  The patient received 1 gm of IV Ancef intravenously piggyback.  The abdomen was prepared and draped in routine sterile fashion., Gastroenterology, Laparoscopic Cholecystectomy - 7 ,"PREOPERATIVE DIAGNOSIS: , Cholecystitis and cholelithiasis.,POSTOPERATIVE DIAGNOSIS:  ,Cholecystitis and cholelithiasis.,TITLE OF PROCEDURE,1.  Laparoscopic cholecystectomy.,2.  Intraoperative cholangiogram.,ANESTHESIA:  ,General.,PROCEDURE IN DETAIL:  ,The patient was taken to the operative suite and placed in the supine position under general endotracheal anesthetic.  The patient received 1 gm of IV Ancef intravenously piggyback.  The abdomen was prepared and draped in routine sterile fashion.,A 1-cm incision was made at the umbilicus and a Veress needle was inserted.  Saline test was performed.  Satisfactory pneumoperitoneum was achieved by insufflation of CO2 to a pressure of 14 mmHg.  The Veress needle was removed.  A 10- to 11-mm cannula was inserted.  Inspection of the peritoneal cavity revealed a gallbladder that was soft and without adhesions to it.  It was largely mobile.  The liver had a normal appearance as did the peritoneal cavity.  A 5-mm cannula was inserted in the right upper quadrant anterior axillary line.  A second 5-mm cannula was inserted in the subcostal space.  A 10- to 11-mm cannula was inserted into the upper midline.,The gallbladder was reflected in a cephalad direction.  The gallbladder was punctured with the aspirating needle, and under C-arm fluoroscopy was filled with contrast, filling the intra- and extrahepatic biliary trees, which appeared normal.  Extra contrast was aspirated and the aspirating needle was removed.  The ampulla was grasped with a second grasper, opening the triangle of Calot.  The cystic duct was dissected and exposed at its junction with the ampulla, was controlled with a hemoclip, digitally controlled with two clips and divided.  This was done while the common duct was in full visualization.  The cystic artery was similarly controlled and divided.  The gallbladder was dissected from its bed and separated from the liver, brought to the outside through the upper midline cannula and removed.,The subhepatic and subphrenic spaces were irrigated thoroughly with saline solution.  There was oozing and bleeding from the lateral 5-mm cannula site, but this stopped spontaneously with removal of the cannula.  The subphrenic and subhepatic spaces were again irrigated thoroughly with saline until clear.  Hemostasis was excellent.  CO2 was evacuated and the camera removed.  The umbilical fascia was closed with 2-0 Vicryl, the subcu with 3-0 Vicryl, and the skin was closed with 4-0 nylon.  Sterile dressings were applied.  Sponge and needle counts were correct.","gastroenterology, cholangiogram, cholecystitis, cholelithiasis, ancef, endotracheal, umbilicus, veress needle, c-arm fluoroscopy, intraoperative cholangiogram, laparoscopic cholecystectomy, laparoscopic, cholecystectomy, gallbladder, cannula,"
" Cholelithiasis; possible choledocholithiasis.  Laparoscopic cholecystectomy and intraoperative cholangiogram.  A small incision was made in the umbilicus, and a Veress needle was introduced into the abdomen.  CO2 insufflation was done to a maximum pressure of 15 mmHg, and a 12-mm VersaStep port was placed into the umbilicus.", Gastroenterology, Laparoscopic Cholecystectomy - 6 ,"PREOPERATIVE DIAGNOSIS:,  Cholelithiasis; possible choledocholithiasis.","gastroenterology, choledocholithiasis, cholangiogram, co2 insufflation, umbilicus, common bile duct, bile duct, laparoscopic cholecystectomy, cystic duct, intraoperative, laparoscopic, cholecystectomy, cholelithiasis, endotracheal, gallbladder, cystic, duct, "
" Laparoscopic cholecystectomy.  Biliary colic and biliary dyskinesia.  The patient had a workup for her gallbladder, which showed evidence of biliary dyskinesia.", Gastroenterology, Laparoscopic Cholecystectomy - 10 ,"PREOPERATIVE DIAGNOSIS: , Biliary colic and biliary dyskinesia.,POSTOPERATIVE DIAGNOSIS:,  Biliary colic and biliary dyskinesia.,PROCEDURE PERFORMED:,  Laparoscopic cholecystectomy.,ANESTHESIA: , General endotracheal.,COMPLICATIONS:,  None.,DISPOSITION:  ,The patient tolerated the procedure well and was transferred to recovery in stable condition.,BRIEF HISTORY:  ,This patient is a 42-year-old female who presented to Dr. X's office with complaints of upper abdominal and back pain, which was sudden onset for couple of weeks.  The patient is also diabetic.  The patient had a workup for her gallbladder, which showed evidence of biliary dyskinesia.  The patient was then scheduled for laparoscopic cholecystectomy for biliary colic and biliary dyskinesia.,INTRAOPERATIVE FINDINGS: , The patient's abdomen was explored.  There was no evidence of any peritoneal studding or masses.  The abdomen was otherwise within normal limits.  The gallbladder was easily visualized.  There was an intrahepatic gallbladder.  There was no evidence of any inflammatory change.,PROCEDURE:,  After informed written consent, the risks and benefits of the procedure were explained to the patient.  The patient was brought into the operating suite.,After general endotracheal intubation, the patient was prepped and draped in normal sterile fashion.  Next, an infraumbilical incision was made with a #10 scalpel.  The skin was elevated with towel clips and a Veress needle was inserted.  The abdomen was then insufflated to 15 mmHg of pressure.  The Veress needle was removed and a #10 blade trocar was inserted without difficulty.  The laparoscope was then inserted through this #10 port and the abdomen was explored.  There was no evidence of any peritoneal studding.  The peritoneum was smooth.  The gallbladder was intrahepatic somewhat.  No evidence of any inflammatory change.  There were no other abnormalities noted in the abdomen.  Next, attention was made to placing the epigastric #10 port, which again was placed under direct visualization without difficulty.  The two #5 ports were placed, one in the midclavicular and one in the anterior axillary line again in similar fashion under direct visualization.  The gallbladder was then grasped out at its fundus, elevated to patient's left shoulder.  Using a curved dissector, the cystic duct was identified and freed up circumferentially.  Next, an Endoclip was used to distal and proximal to the gallbladder, Endoshears were used in between to transect the cystic duct.  The cystic artery was transected in similar fashion.  Attention was next made in removing the gallbladder from the liver bed using electrobovie cautery and spatulated tip.  It was done without difficulty.  The gallbladder was then grasped via the epigastric port and removed without difficulty and sent to pathology.  Hemostasis was maintained using electrobovie cautery.  The liver bed was then copiously irrigated and aspirated.  All the fluid and air was then aspirated and then all ports were removed under direct visualization.  The two #10 ports were then closed in the fascia with #0 Vicryl and a UR6 needle.  The skin was closed with a running subcuticular #4-0 undyed Vicryl.  0.25% Marcaine was injected and Steri-Strips and sterile dressings were applied.  The patient tolerated the procedure well and was transferred to Recovery in stable condition.","gastroenterology, electrobovie cautery, laparoscopic cholecystectomy, biliary colic, biliary dyskinesia, biliary, laparoscopic, cholecystectomy, colic, abdomen, dyskinesia, gallbladder"
 Laparoscopic cholecystectomy., Gastroenterology, Laparoscopic Cholecystectomy - 1 ,"PROCEDURE:,:  After informed consent was obtained, the patient was brought to the operating room and placed supine on the operating room table.  General endotracheal anesthesia was induced.  The patient was then prepped and draped in the usual sterile fashion.  An #11 blade scalpel was used to make a small infraumbilical skin incision in the midline.  The fascia was elevated between two Ochsner clamps and then incised.  A figure-of-eight stitch of 2-0 Vicryl was placed through the fascial edges.  The 11-mm port without the trocar engaged was then placed into the abdomen.  A pneumoperitoneum was established.  After an adequate pneumoperitoneum had been established, the laparoscope was inserted.  Three additional ports were placed all under direct vision.  An 11-mm port was placed in the epigastric area.  Two 5-mm ports were placed in the right upper quadrant.  The patient was placed in reverse Trendelenburg position and slightly rotated to the left.  The fundus of the gallbladder was retracted superiorly and laterally.  The infundibulum was retracted inferiorly and laterally.  Electrocautery was used to carefully begin dissection of the peritoneum down around the base of the gallbladder.  The triangle of Calot was carefully opened up.  The cystic duct was identified heading up into the base of the gallbladder.  The cystic artery was also identified within the triangle of Calot.  After the triangle of Calot had been carefully dissected, a clip was then placed high up on the cystic duct near its junction with the gallbladder.  The cystic artery was clipped twice proximally and once distally.  Scissors were then introduced and used to make a small ductotomy in the cystic duct, and the cystic artery was divided.  An intraoperative cholangiogram was obtained.  This revealed good flow through the cystic duct and into the common bile duct.  There was good flow into the duodenum without any filling defects.  The hepatic radicals were clearly visualized.  The cholangiocatheter was removed, and two clips were then placed distal to the ductotomy on the cystic duct.  The cystic duct was then divided using scissors.  The gallbladder was then removed up away from the liver bed using electrocautery.  The gallbladder was easily removed through the epigastric port site.  The liver bed was then irrigated and suctioned.  All dissection areas were inspected.  They were hemostatic.  There was not any bile leakage.  All clips were in place.  The right gutter up over the edge of the liver was likewise irrigated and suctioned until dry.  All ports were then removed under direct vision.  The abdominal cavity was allowed to deflate.  The fascia at the epigastric port site was closed with a stitch of 2-0 Vicryl.  The fascia at the umbilical port was closed by tying the previously placed stitch.  All skin incisions were then closed with subcuticular sutures of 4-0 Monocryl and 0.25% Marcaine with epinephrine was infiltrated into all port sites.  The patient tolerated the procedure well.  The patient is currently being aroused from general endotracheal anesthesia.  I was present during the entire case.","gastroenterology, laparoscopic, calot, ochsner clamps, additional ports, cholangiogram, cholecystectomy, cystic duct, duodenum, epigastric, fascia, gallbladder, infraumbilical skin incision, infundibulum, pneumoperitoneum, triangle of calot, laparoscopic cholecystectomy, liver bed, epigastric port, port site, cystic artery, triangle, port, duct, cysticNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Appendicitis.  Laparoscopic appendectomy.   CO2 insufflation was done to a maximum pressure of 15 mmHg and a 12-mm VersaStep port was placed through his umbilicus., Gastroenterology, Laparoscopic Appendectomy - 3 ,"PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS:,  Appendicitis. ,PROCEDURE: , Laparoscopic appendectomy. ,ANESTHESIA: , General with endotracheal intubation. ,PROCEDURE IN DETAIL:  ,The patient was taken to the operating room and placed supine on the operating room table.  General anesthesia was administered with endotracheal intubation.  His abdomen was prepped and draped in a standard, sterile surgical fashion.  A Foley catheter was placed for bladder decompression.  Marcaine was injected into his umbilicus.  A small incision was made.  A Veress needle was introduced in his abdomen.  CO2 insufflation was done to a maximum pressure of 15 mmHg and a 12-mm VersaStep port was placed through his umbilicus.  A 5-mm port was then placed just to the right side of the umbilicus.  Another 5-mm port was placed just suprapubic in the midline.  Upon inspection of the cecum, I was able find an inflamed and indurated appendix.  I was able to clear the mesentery at the base of the appendix between the appendix and the cecum.  I fired a white load stapler across the appendix at its base and fired a grey load stapler across the mesentery, and thereby divided the mesentery and freed the appendix.  I put the appendix in an Endocatch bag and removed it through the umbilicus.  I irrigated out the abdomen.  I then closed the fascia of the umbilicus with interrupted 0 Vicryl suture utilizing Carter-Thomason and closed the skin of all incisions with a running Monocryl.  Sponge, instrument, and needle counts were correct at the end of the case.  The patient tolerated the procedure well without any complications.","gastroenterology, foley catheter, co2 insufflation, endotracheal intubation, laparoscopic appendectomy, appendectomy, intubation, cecum, laparoscopic, appendicitis, endotracheal, abdomen, mesentery, umbilicus, appendix, "
 Laparoscopic cholecystectomy due to chronic cholecystitis and cholelithiasis., Gastroenterology, Laparoscopic Cholecystectomy - 2 ,"PREOPERATIVE DIAGNOSIS:,1.  Cholelithiasis.,2.  Chronic cholecystitis.,POSTOPERATIVE DIAGNOSIS:,1.  Cholelithiasis.,2.  Chronic cholecystitis.,NAME OF OPERATION: , Laparoscopic cholecystectomy.,ANESTHESIA:,  General.,FINDINGS:,  The gallbladder was thickened and showed evidence of chronic cholecystitis.  There was a great deal of inflammatory reaction around the cystic duct.  The cystic duct was slightly larger.  There was a stone impacted in the cystic duct with the gallbladder.  The gallbladder contained numerous stones which were small.  With the stone impacted in the cystic duct, it was felt that probably none were within the common duct.  Other than rather marked obesity, no other significant findings were noted on limited exploration of the abdomen.,PROCEDURE:,  Under general anesthesia after routine prepping and draping, the abdomen was insufflated with the Veress needle, and the standard four trocars were inserted uneventfully.  Inspection was made for any entry problems, and none were encountered.,After limited exploration, the gallbladder was then retracted superiorly and laterally, and the cystic duct was dissected out.  This was done with some difficulty due to the fibrosis around the cystic duct, but care was taken to avoid injury to the duct and to the common duct.  In this manner, the cystic duct and cystic artery were dissected out.  Care was taken to be sure that the duct that was identified went into the gallbladder and was the cystic duct.  The cystic duct and cystic artery were then doubly clipped and divided, taking care to avoid injury to the common duct.  The gallbladder was then dissected free from the gallbladder bed.  Again, the gallbladder was somewhat adherent to the gallbladder bed due to previous inflammatory reaction.  The gallbladder was dissected free from the gallbladder bed utilizing the endo shears and the cautery to control bleeding.  The gallbladder was extracted through the operating trocar site, and the trocar was reinserted.  Inspection was made of the gallbladder bed.  One or two bleeding areas were fulgurated, and bleeding was well controlled.","gastroenterology, cholelithiasis chronic, inflammatory reaction, cystic artery, laparoscopic cholecystectomy, common duct, chronic cholecystitis, gallbladder bed, cystic duct, cystic, gallbladder, duct, inflammatory"
 Standard Laparoscopic Cholecystectomy Operative Note., Gastroenterology, Laparoscopic Cholecystectomy ,"The patient's abdomen was prepped and draped in the usual sterile fashion.  A subumbilical skin incision was made.  The Veress needle was inserted, and the patient's abdominal cavity was insufflated with moderate pressure all times.  A subumbilical trocar was inserted.  The camera was inserted in the panoramic view.  The abdomen demonstrated some inflammation around the gallbladder.  A 10-mm midepigastric trocar was inserted.  A. 2 mm and 5 mm trocars were inserted.  The most lateral trocar grasping forceps was inserted and grasped the fundus of the gallbladder and placed in tension at liver edge.,Using the dissector, the cystic duct was identified and double Hemoclips were invited well away from the cystic-common duct junction.  The cystic artery was identified and double Hemoclips applied.  The gallbladder was taken down from the liver bed using Endoshears and electrocautery.  Hemostasis was obtained.  The gallbladder was removed from the midepigastric trocar site without difficulty.  The trocars were removed and the skin incisions were reapproximated using 4-0 Monocryl.  Steri-Strips and sterile dressing were placed.  The patient tolerated the procedure well and was taken to the recovery room in stable condition.","gastroenterology, gallbladder, laparoscopic cholecystectomy, midepigastric trocar, double hemoclips, laparoscopic, cholecystectomy, midepigastric, trocars, hemoclips, trocarNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Acute appendicitis with perforation.  Laparoscopic appendectomy.   A CT scan of abdomen showed evidence of appendicitis with perforation. , Gastroenterology, Laparoscopic Appendectomy - 4 ,"PREOPERATIVE DIAGNOSIS:,  Acute appendicitis with perforation.,POSTOPERATIVE DIAGNOSIS:  ,Acute appendicitis with perforation.,ANESTHESIA:,  General.,PROCEDURE: , Laparoscopic appendectomy.,INDICATIONS FOR PROCEDURE: , The patient is a 4-year-old little boy, who has been sick for several days and was seen in our Emergency Department yesterday where a diagnosis of possible constipation was made, but he was sent home with a prescription for polyethylene glycol but became more acutely ill and returned today with tachycardia, high fever and signs of peritonitis.  A CT scan of his abdomen showed evidence of appendicitis with perforation.  He was evaluated in the Emergency Department and placed on the appendicitis critical pathway for this acute appendicitis process.  He required several boluses of fluid for tachycardia and evidence of dehydration.,I met with Carlos' parents and talked to them about the diagnosis of appendicis and surgical risks, benefits, and alternative treatment options.  All their questions have been answered and they agree with the surgical plan.,OPERATIVE FINDINGS: , The patient had acute perforated appendicitis with diffuse suppurative peritonitis including multiple intraloop abscesses and purulent debris in all quadrants of the abdomen including the perihepatic and subphrenic recesses as well.,DESCRIPTION OF PROCEDURE: , The patient came to the operating room and had an uneventful induction of general anesthesia.  A Foley catheter was placed for decompression, and his abdomen was prepared and draped in a standard fashion.  A 0.25% Marcaine was infiltrated in the soft tissues around his umbilicus and in the suprapubic and left lower quadrant locations chosen for trocar insertion.  We conducted our surgical timeout and reiterated all of Carlos' unique and important identifying information and confirmed the diagnosis of appendicitis and planned laparoscopic appendectomy as the procedure.  A 1-cm vertical infraumbilical incision was made and an open technique was used to place a 12-mm Step trocar through the umbilical fascia.  CO2 was insufflated to a pressure of 15 mmHg and then two additional 5-mm working ports were placed in areas that had been previously anesthetized.,There was a lot of diffuse purulent debris and adhesions between the omentum and adjacent surfaces of the bowel and the parietal peritoneum.  After these were gently separated, we began to identify the appendix.  In the __________ due to the large amount of small bowel dilatation and distension, I used the hook cautery with the lowest intraperitoneal __________ profile to coagulate the mesoappendix.  The base of the appendix was then ligated with 2-0 PDS Endoloops, and the appendix was amputated and withdrawn through the umbilical port.  I spent the next 10 minutes irrigating purulent fluid and debris from the peritoneal cavity using 2 L of sterile crystalloid solution and a suction power irrigation system.  When this was complete, the CO2 was released one final time and as much of the fluid was drained from the peritoneal cavity as possible.  The umbilical fascia was closed with figure-of-eight suture of 0 Monocryl and the skin incisions were closed with subcuticular 5-0 Monocryl and Steri-Strips.  The patient tolerated the operation well.  He was awakened and taken to the recovery room in satisfactory condition.  His blood loss was less than 10 mL, and he received only crystalloid fluid during the procedure.","gastroenterology, adhesions, peritoneum, purulent debris, umbilical fascia, peritoneal cavity, laparoscopic appendectomy, appendectomy, constipation, purulent, debris, umbilical, appendix, abdomen, laparoscopic, perforation, appendicitis,"
 Chronic cholecystitis without cholelithiasis., Gastroenterology, Laparoscopic Cholecystectomy - 3 ,"PREOPERATIVE DIAGNOSIS: , Chronic cholecystitis without cholelithiasis.,POSTOPERATIVE DIAGNOSIS:  ,Chronic cholecystitis without cholelithiasis.,PROCEDURE: , Laparoscopic cholecystectomy.,BRIEF DESCRIPTION: , The patient was brought to the operating room and anesthesia was induced.  The abdomen was prepped and draped and ports were placed.  The gallbladder was grasped and retracted.  The cystic duct and cystic artery were circumferentially dissected and a critical view was obtained.  The cystic duct and cystic artery were then doubly clipped and divided and the gallbladder was dissected off the liver bed with electrocautery and placed in an endo catch bag.  The gallbladder fossa and clips were examined and looked good with no evidence of bleeding or bile leak.  The ports were removed under direct vision with good hemostasis.  The Hasson was removed.  The abdomen was desufflated.  The gallbladder in its endo catch bag was removed.  The ports were closed.  The patient tolerated the procedure well.  Please see full hospital dictation.","gastroenterology, chronic cholecystitis without cholelithiasis, laparoscopic cholecystectomy, cystic duct, cystic artery, endo catch, chronic cholecystitis, laparoscopic, cholecystectomy, abdomen, cholecystitis, cholelithiasis, gallbladder, cystic"
 Laparoscopic appendectomy.  The patient is a 42-year-old female who presented with right lower quadrant pain.  She was evaluated and found to have a CT evidence of appendicitis., Gastroenterology, Laparoscopic Appendectomy - 5 ,"PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS: , Appendicitis.,PROCEDURE PERFORMED: , Laparoscopic appendectomy.,ANESTHESIA: , General endotracheal.,INDICATION FOR OPERATION: , The patient is a 42-year-old female who presented with right lower quadrant pain.  She was evaluated and found to have a CT evidence of appendicitis.  She was subsequently consented for a laparoscopic appendectomy.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained, the patient was brought to the operating room, placed supine on the table.  The abdomen was prepared and draped in usual sterile fashion.  After the induction of satisfactory general endotracheal anesthesia, supraumbilical incision was made.  A Veress needle was inserted.  Abdomen was insufflated to 15 mmHg.  A 5-mm port and camera placed.  The abdomen was visually explored.  There were no obvious abnormalities.  A 15-mm port was placed in the suprapubic position in addition of 5 mm was placed in between the 1st two.  Blunt dissection was used to isolate the appendix.  Appendix was separated from surrounding structures.  A window was created between the appendix and the mesoappendix.  GIA stapler was tossed across it and fired.  Mesoappendix was then taken with 2 fires of the vascular load on the GIA stapler.  Appendix was placed in an Endobag and removed from the patient.  Right lower quadrant was copiously irrigated.  All irrigation fluids were removed.  Hemostasis was verified.  The 15-mm port was removed and the port site closed with 0-Vicryl in the Endoclose device.  All other ports were irrigated, infiltrated with 0.25% Marcaine and closed with 4-0 Vicryl subcuticular sutures.  Steri-Strips and sterile dressings were applied.  Overall, the patient tolerated this well, was awakened and returned to recovery in good condition.","gastroenterology, gia stapler, laparoscopic appendectomy, appendectomy, endotracheal, mesoappendix, laparoscopic, appendicitis, appendix"
" Laparoscopic cholecystectomy.  Acute cholecystitis, status post laparoscopic cholecystectomy, end-stage renal disease on hemodialysis, hyperlipidemia, hypertension, congestive heart failure, skin lymphoma 5 years ago, and hypothyroidism.", Gastroenterology, Lap Chole - Discharge Summary ,"PROCEDURE:,  Laparoscopic cholecystectomy.,DISCHARGE DIAGNOSES:,1.  Acute cholecystitis.,2.  Status post laparoscopic cholecystectomy.,3.  End-stage renal disease on hemodialysis.,4.  Hyperlipidemia.,5.  Hypertension.,6.  Congestive heart failure.,7.  Skin lymphoma 5 years ago.,8.  Hypothyroidism.,HOSPITAL COURSE: , This is a 78-year-old female with past medical condition includes hypertension, end-stage renal disease, hyperlipidemia, hypothyroidism, and skin lymphoma who had a left AV fistula done about 3 days ago by Dr. X and the patient went later on home, but started having epigastric pain and right upper quadrant pain and mid abdominal pain, some nauseated feeling, and then she could not handle the pain, so came to the emergency room, brought by the family.  The patient's initial assessment, the patient's vital signs were stable, showed temperature 97.9, pulse was 106, and blood pressure was 156/85.  EKG was not available and ultrasound of the abdomen showed there is a renal cyst about 2 cm.  There is sludge in the gallbladder wall versus a stone in the gallbladder wall.  Thickening of the gallbladder wall with positive Murphy sign.  She has a history of cholecystitis.  Urine shows positive glucose, but negative for nitrite and creatinine was 7.1, sodium 131, potassium was 5.2, and lipase and amylase were normal.  So, the patient admitted to the Med/Surg floor initially and the patient was started on IV fluid as well as low-dose IV antibiotic and 2-D echocardiogram and EKG also was ordered.  The patient also had history of CHF in the past and recently had some workup done.  The patient does not remember initially.  Surgical consult also requested and blood culture and urine culture also ordered.  The same day, the patient was seen by Dr. Y and the patient should need cholecystectomy, but the patient also needs dialysis and also needs to be cleared by the cardiologist, so the patient later on seen by Dr. Z and cleared the patient for the surgery with moderate risk and the patient underwent laparoscopic cholecystectomy.  The patient also seen by nephrologist and underwent dialysis.  The patient's white count went down 6.1, afebrile.  On postop day #1, the patient started eating and also walking.  The patient also had chronic bronchitis.  The patient was later on feeling fine, discussed with surgery.  The patient was then able to discharge to home and follow with the surgeon in about 3-5 days.  Discharged home with Synthroid 0.5 mg 1 tablet p.o. daily, Plavix 75 mg p.o. daily, folic acid 1 mg p.o. daily, Diovan 80 mg p.o. daily, Renagel 2 tablets 800 mg p.o. twice a day, Lasix 40 mg p.o.  2 tablets twice a day, lovastatin 20 mg p.o. daily, Coreg 3.125 mg p.o. twice a day, nebulizer therapy every 3 hours as needed, also Phenergan 25 mg p.o. q.8 hours for nausea and vomiting, Pepcid 20 mg p.o. daily, Vicodin 1 tablet p.o. q.6 hours p.r.n. as needed, and Levaquin 250 mg p.o. every other day for the next 5 days.  The patient also had Premarin that she was taking, advised to discontinue because of increased risk of heart disease and stroke explained to the patient.  Discharged home.","gastroenterology, end-stage renal disease, lymphoma, cholecystitis, congestive heart failure, skin lymphoma, gallbladder wall, laparoscopic cholecystectomy "
 Ruptured appendicitis., Gastroenterology, Laparoscopic Appendectomy - 1 ,"PREOPERATIVE DIAGNOSIS:,  Acute appendicitis.,POSTOPERATIVE DIAGNOSIS:,  Ruptured appendicitis.,PROCEDURE:,  Laparoscopic appendectomy.,INDICATIONS FOR PROCEDURE:,  This patient is a 4-year-old boy with less than 24-hour history of apparent right lower quadrant abdominal pain associated with vomiting and fevers.  The patient has elevated white count on exam and CT scan consistent with acute appendicitis.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine, put under general endotracheal anesthesia.  The patient's abdomen was prepped and draped in usual sterile fashion.  A periumbilical incision was made.  The fascia was incised.  Peritoneal cavity entered bluntly.  A 10-mm trocar and scope was passed.  Peritoneal cavity was insufflated.  Five-mm ports placed in left lower and hypogastric areas.  On visualization of the right lower quadrant, appendix was visualized stuck against the right anterior abdominal wall, there is obvious site of perforation and leakage of content and pus.  We proceeded to take the mesoappendix down to the base, and once the base was free, we placed GIA stapler across the base, fired the stapler, removed the appendix through the periumbilical port site.  We irrigated and suctioned out the right lower and pelvic areas.  We then removed the ports under direct visualization, closed the periumbilical port site fascia with 0 Vicryl, all skin incisions with 5-0 Monocryl, and dressed with Steri-Strips.  The patient was extubated in the operating table and taken back to recovery room.  The patient tolerated the procedure well.","gastroenterology, ruptured appendicitis, acute appendicitis, laparoscopic appendectomy, laparoscopic, ruptured, abdominal, peritoneal, periumbilical, appendicitis, appendectomy, "
 Repair of juxtarenal abdominal aortic aneurysm with 14 mm Hemashield tube graft., Gastroenterology, Juxtarenal Abdominal Aortic Aneurysm Repair ,"PREOPERATIVE DIAGNOSIS:  Large juxtarenal abdominal aortic aneurysm.,POSTOPERATIVE DIAGNOSIS:  Large juxtarenal abdominal aortic aneurysm.,ANESTHESIA:  General endotracheal anesthesia.,OPERATIVE TIME:  Three hours.,ANESTHESIA TIME:  Four hours.,DESCRIPTION OF PROCEDURE:  After thorough preoperative evaluation, the patient was brought to the operating room and placed on the operating table in supine position and after placement of upper extremity IV access and radial A-line, general endotracheal anesthesia was induced.  A Foley catheter was placed and a right internal jugular central line was placed.  The chest, abdomen, both groin, and perineum were prepped widely with Betadine and draped as a sterile field with an Ioban drape.  A long midline incision from xiphoid to pubis was created with a scalpel and the abdomen was carefully entered.  A sterile Omni-Tract was introduced into the field to retract the abdominal wall and gentle exploration of the abdomen was performed.  With the exception of the vascular findings to be described, there were no apparent intra-abdominal abnormalities.,The transverse colon retracted superiorly.  The small bowel was wrapped in moist green towel and retracted in the right upper quadrant.  The posterior peritoneum overlying the aneurysm was scribed mobilizing the ligament of Treitz thoroughly ligating and dividing the inferior mesenteric vein.  Dissection continued superiorly to identify the left renal vein and the right and left inferior renal arteries.  The mid left renal artery was likewise identified.  The perirenal aorta was prepared for clamp superior to the inferior left renal artery.  During this portion of the dissection, the patient was given multiple small doses of intravenous mannitol to establish an osmotic diuresis.  The distal dissection was then completed exposing each common iliac artery.  The arteries were suitable for control.,The patient was then given 8000 units of intravenous sodium heparin and systemic anticoagulation verified by activated clotting time.  The aneurysm was repaired.,First, the common carotid arteries were controlled with atraumatic clamps.  The inferior left renal artery was controlled with a microvascular clamp and a straight aortic clamp was used to control the aorta superior to this renal artery.  The aneurysm was opened on the right anterior lateral aspect and an endarterectomy of the aneurysm sac was performed.  There was a high-grade stenosis at the origin of the inferior mesenteric artery and an eversion endarterectomy was performed at this site.  The vessel was controlled with a microvascular clamp.  Two pairs of lumbar arteries were oversewn with 2-0 silk.  A 14 mm Hemashield tube graft was selected and sewn end-to-end fashion to the proximal aorta using a semi continuous 3-0 Prolene suture.  At the completion of anastomosis three patch stitches of 3-0 Prolene were required for hemostasis.  The graft was cut to appropriate length and sewn end-to-end at the iliac bifurcation using semi-continuous 3-0 Prolene suture.  Prior to completion of this anastomosis, the graft was flushed of air and debris and blood flow was reestablished slowly to the distal native circulation first to the pelvis with external compression on the femoral vessels and finally to the distal native circulation.  The distal anastomosis was competent without leak.,The patient was then given 70 mg of intravenous protamine and final hemostasis obtained using electrocoagulation.  The back bleeding from the inferior mesenteric artery was assessed and was pulsatile and vigorous.  The colon was normal in appearance and this vessel was oversewn using 2-0 silk.  The aneurysm sac was then closed about the grafts snuggly using 3-0 PDS in a vest-over-pants fashion.  The posterior peritoneum was reapproximated using running 3-0 PDS.  The entire large and small bowel were inspected and these structures were well perfused with a strong pulse within the SMA normal appearance of the entire viscera.  The NG tube was positioned in the fundus of the stomach and the viscera returned to their anatomic location.  The midline fascia was then reapproximated using running #1 PDS suture.  The subcutaneous tissues were irrigated with bacitracin and kanamycin solution.  The skin edges coapted using surgical staples.,At the conclusion of the case, sponge and needle counts were correct and a sterile occlusive compressive dressing was applied.","gastroenterology, inferior left renal artery, semi continuous prolene suture, juxtarenal abdominal aortic aneurysm, inferior mesenteric artery, continuous prolene suture, abdominal aortic aneurysm, hemashield tube, inferior mesenteric, renal artery, aortic aneurysm, aneurysm, iliac, endarterectomy, viscera, hemashield, abdomen, prolene, arteries, juxtarenal, graft, aortic, endotracheal, renal, artery, "
 Appendicitis.  Laparoscopic appendectomy. Infraumbilical incision was performed and taken down to the fascia.  The fascia was incised.  The peritoneal cavity was carefully entered.  Two other ports were placed in the right and left lower quadrants., Gastroenterology, Laparoscopic Appendectomy - 2 ,"PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS:,  Appendicitis.,PROCEDURE PERFORMED: , Laparoscopic appendectomy.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  Minimal.,PROCEDURE IN DETAIL: , The patient was prepped and draped in sterile fashion.  Infraumbilical incision was performed and taken down to the fascia.  The fascia was incised.  The peritoneal cavity was carefully entered.  Two other ports were placed in the right and left lower quadrants.  The appendix was readily identified, and the base of the appendix as well as the mesoappendix was divided with the Endo GIA stapler and brought out through the umbilical wound with the Endocatch bag.,All hemostasis was further reconfirmed.  No leakage of enteral contents was noted.  All trocars were removed under direct visualization.  The umbilical fascia was closed with interrupted 0 Vicryl sutures.  The skin was closed with 4-0 Monocryl subcuticular stitch and dressed with Steri-Strips and 4 x 4's.  The patient was extubated and taken to the recovery area in stable condition.  The patient tolerated the procedure well.","gastroenterology, mesoappendix, endocatch, laparoscopic appendectomy, appendix, umbilical, laparoscopic, appendectomy, appendicitis, fascia, infraumbilical"
 Laparoscopic appendectomy.  Acute appendicitis., Gastroenterology, Laparoscopic Appendectomy ,"PREOPERATIVE DIAGNOSIS: , Acute appendicitis.,POSTOPERATIVE DIAGNOSIS: , Acute appendicitis.,OPERATIVE PROCEDURE:,  Laparoscopic appendectomy.,INTRAOPERATIVE FINDINGS: , Include inflamed, non-perforated appendix.,OPERATIVE NOTE:  ,The patient was seen by me in the preoperative holding area.  The risks of the procedure were explained.  She was taken to the operating room and given perioperative antibiotics prior to coming to the surgery.  General anesthesia was carried out without difficulty and a Foley catheter was inserted.  The left arm was tucked and the abdomen was prepped with Betadine and draped in sterile fashion.  A 5-mm blunt port was inserted infra-umbilically at the level of the umbilicus under direct vision of a 5-mm 0-degree laparoscope.  Once we were inside the abdominal cavity, CO2 was instilled to attain an adequate pneumoperitoneum.  A left lower quadrant 5-mm port was placed under direct vision and a 12-mm port in the suprapubic region.  The 5-mm scope was introduced at the umbilical port and the appendix was easily visualized.  The base of the cecum was acutely inflamed but not perforated.  I then was easily able to grasp the mesoappendix and create a window between the base of the mesoappendix and the base of the appendix.  The window is big enough to get an Endo GIA blue cartridge through it and fired across the base of the mesoappendix without difficulty.  I reloaded with a red vascular cartridge, came across the mesoappendix without difficulty.  I then placed the appendix in an Endobag and brought out through the suprapubic port without difficulty.  I reinserted the suprapubic port and irrigated out the right lower quadrant until dry.  One final inspection revealed no bleeding from the staple line.  We then removed all ports under direct vision, and there was no bleeding from the abdominal trocar sites.  The pneumoperitoneum was then deflated and the suprapubic fascial defect was closed with 0-Vicryl suture.  The skin incision was injected with 0.25% Marcaine and closed with 4-0 Monocryl suture.  Steri-strips and sterile dressings were applied.  No complications.  Minimal blood loss.  Specimen is the appendix.  Brought to the recovery room in stable condition.","gastroenterology, appendix, endobag, laparoscopic appendectomy, acute appendicitis, appendectomy, umbilically, abdominal, pneumoperitoneum, laparoscopic, appendicitis, suprapubic, mesoappendix, "
" Pneumatosis coli in the cecum.  Possible ischemic cecum with possible metastatic disease, bilateral hydronephrosis on atrial fibrillation, aspiration pneumonia, chronic alcohol abuse, acute renal failure, COPD, anemia with gastric ulcer.", Gastroenterology, Ischemic Cecum - Consult ,"REASON FOR CONSULTATION: , Pneumatosis coli in the cecum.,HISTORY OF PRESENT ILLNESS:  ,The patient is an 87-year-old gentleman who was admitted on 10/27/07 with weakness and tiredness with aspiration pneumonia.  The patient is very difficult to obtain information from; however, he appears to be having frequent nausea and vomiting with an aspiration pneumonia and abdominal discomfort.  In addition, this hospitalization, he has undergone an upper endoscopy, which found a small ulcer after dropping his hematocrit and becoming anemic.  He had a CT scan on Friday, 11/02/07, which apparently showed pneumatosis and his cecum worrisome for ischemic colitis as well as bilateral hydronephrosis and multiple liver lesions, which could be metastatic disease versus cysts.  In discussions with the patient, he had multiple bowel movements yesterday and is currently passing flatus and has epigastric pain.,PAST MEDICAL HISTORY:  ,Obtained from the medical chart.  Chronic obstructive pulmonary disease, history of pneumonia, and aspiration pneumonia, osteoporosis, alcoholism, microcytic anemia.,MEDICATIONS: , Per his current medical chart.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient had a long history of smoking but quit many years ago.  He does have chronic alcohol use.,PHYSICAL EXAMINATION:,GENERAL:  A very thin white male who is dyspneic and having difficulty breathing at the moment.,VITAL SIGNS:  Afebrile.  Heart rate in the 100s to 120s at times with atrial fibrillation.  Respiratory rate is 17-20.  Blood pressure 130s-150s/60s-70s.,NECK:  Soft and supple, full range of motion.,HEART:  Regular.,ABDOMEN:  Distended with tenderness mainly in the upper abdomen but very difficult to localize due to his difficulty providing information.  He does appear to have tenderness but does not have rebound and does not have peritoneal signs.,DIAGNOSTICS: , A CT scan done on 11/02/07 shows pneumatosis in the cecum with an enlarged cecum filled with stool and air fluid levels with chronically dilated small bowel.,ASSESSMENT: , Possible ischemic cecum with possible metastatic disease, bilateral hydronephrosis on atrial fibrillation, aspiration pneumonia, chronic alcohol abuse, acute renal failure, COPD, anemia with gastric ulcer.,PLAN: , The patient appears to have pneumatosis from a CT scan 2 days ago.  Nothing was done about it at that time as the patient appeared to not be symptomatic, but he continues to have nausea and vomiting with abdominal pain, but the fact that pneumatosis was found 2 days ago and the patient has survived this long indicates this may be a benign process at the moment, and I would recommend getting a repeat CT scan to assess it further to see if there is worsening of pneumatosis versus resolution to further evaluate the liver lesions and make decisions regarding planning at that time.  The patient has frequent desaturations secondary to his aspiration pneumonia, and any surgical procedure or any surgical intervention would certainly require intubation, which would then necessitate long-term ventilator care as he is not someone who would be able to come off of a ventilator very well in his current state.  So we will look at the CT scan and make decisions based on the findings as far as that is concerned.","gastroenterology, ischemic cecum, metastatic disease, bilateral hydronephrosis, chronic alcohol abuse, acute renal failure, copd, anemia, gastric ulcer, pneumatosis coli, cecum, aspiration pneumonia, aspiration, ischemic, atrial, metastatic, hydronephrosis, fibrillation, pneumatosis, pneumonia, "
 Debridement left ischial ulcer., Gastroenterology, Ischial Ulcer Debridement ,"PREOPERATIVE DIAGNOSES: , Nonhealing decubitus ulcer, left ischial region? Osteomyelitis, paraplegia, and history of spina bifida.,POSTOPERATIVE DIAGNOSES: , Nonhealing decubitus ulcer, left ischial region? Osteomyelitis, paraplegia, and history of spina bifida.,PROCEDURE PERFORMED:  ,Debridement left ischial ulcer.,ANESTHESIA: ,Local MAC.,INDICATIONS:,  This is a 27-year-old white male patient, with a history of spina bifida who underwent spinal surgery about two years ago and subsequently he has been paraplegic.  The patient has a nonhealing decubitus ulcer in the left ischial region, which is quite deep.  It appears to be right down to the bone.  MRI shows findings suggestive of osteomyelitis.  The patient is being brought to operating room for debridement of this ulcer.  Procedure, indication, and risks were explained to the patient.  Consent obtained.,PROCEDURE IN DETAIL: ,The patient was put in right lateral position and left buttock and ischial region was prepped and draped.  Examination at this time showed fair amount of chronic granulation tissue and scarred tissue circumferentially as well as the base of this decubitus ulcer.  This was sharply excised until bleeding and healthy tissue was obtained circumferentially as well as the base.  The ulcer does not appear to be going into the bone itself as there was a covering on the bone, which appears to be quite healthy, normal and bone itself appeared solid.,I did not rongeur the bone.  The deeper portion of the excised tissue was also sent for tissue cultures.  Hemostasis was achieved with cautery and the wound was irrigated with sterile saline solution and then packed with medicated Kerlix.  Sterile dressing was applied.  The patient transferred to recovery room in stable condition.","gastroenterology, debridement, ischial ulcer, ischial region, osteomyelitis, paraplegia, spina bifida, decubitus ulcer "
" Exploratory laparotomy, lysis of adhesions, and right hemicolectomy.  Right colon cancer, ascites, and adhesions.", Gastroenterology, Hemicolectomy ,"PREOPERATIVE DIAGNOSIS: , Right colon tumor.,POSTOPERATIVE DIAGNOSES:,1.  Right colon cancer.,2.  Ascites.,3.  Adhesions.,PROCEDURE PERFORMED:,1.  Exploratory laparotomy.,2.  Lysis of adhesions.,3.  Right hemicolectomy.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Less than 200 cc.,URINE OUTPUT: , 200 cc.,CRYSTALLOIDS GIVEN: , 2700 cc.,INDICATIONS FOR THIS PROCEDURE:  ,The patient is a 53-year-old African-American female who presented with near obstructing lesion at the hepatic flexure.  The patient underwent a colonoscopy which found this lesion and biopsies were taken proving invasive adenocarcinoma.  The patient was NG decompressed preoperatively and was prepared for surgery.  The need for removal of the colon cancer was explained at length.  The patient was agreeable to proceed with the surgery and signed preoperatively informed consent.,PROCEDURE: , The patient was taken to the Operative Suite and placed in the supine position under general anesthesia per Anesthesia Department and NG and Foley catheters were placed preoperatively.  She was given triple antibiotics IV.  Due to her near obstructive symptoms, a formal ________ was not performed.,The abdomen was prepped and draped in the usual sterile fashion.  A midline laparotomy incision was made with a #10 blade scalpel and subcutaneous tissues were separated with electrocautery down to the anterior abdominal fascia.  Once divided, the intraabdominal cavity was accessed and bowel was protected as the rest of the abdominal wall was opened in the midline.  Extensive fluid was seen upon entering the abdomen, ascites fluid, which was clear straw-colored and this was sampled for cytology.  Next, the small bowel was retracted with digital exploration and there was a evidence of hepatic flexure, colonic mass, which was adherent to the surrounding tissues.  With mobilization of the colon along the line of Toldt down to the right gutter, the entire ileocecal region up to the transverse colon was mobilized into the field.  Next, a window was made 5 inches from the ileocecal valve and a GIA-75 was fired across the ileum.  Next, a second GIA device was fired across the proximal transverse colon, just sparring the middle colic artery.  The dissection was then carried down along the mesentry, down to the root of the mesentry.  Several lymph nodes were sampled carefully, and small radiopaque clips were applied along the base of the mesentry.  The mesentry vessels are hemostated and tied with #0-Vicryl suture sequentially, ligated in between.  Once this specimen was submitted to pathology, the wound was inspected.  There was no evidence of bleeding from any of the suture sites.  Next, a side-by-side anastomosis was performed between the transverse colon and the terminal ileum.  A third GIA-75 was fired side-by-side and GIA-55 was used to close the anastomosis.  A patent anastomosis was palpated.  The anastomosis was then protected with a #2-0 Vicryl #0-muscular suture.  Next, the mesenteric root was closed with a running #0-Vicryl suture to prevent any chance of internal hernia.  The suture sites were inspected and there was no evidence of leakage.  Next, the intraabdominal cavity was thoroughly irrigated with sterile saline and the anastomosis was carried into the right lower gutter.  Omentum was used to cover the intestines which appeared dilated and indurated from the near obstruction.  Next, the abdominal wall was reapproximated and the fascial layer using a two running loop PDS sutures meeting in the middle with good approximation of both the abdominal fascia.  Additional sterile saline was used to irrigate the subcutaneous fat and then the skin was closed with sequential sterile staples.,Sterile dressing was applied and the skin was cleansed and the patient was awakened from anesthesia without difficulty and extubated in the Operating Room and she was transferred to Recovery Room in stable condition and will be continued to be monitored on the Telemetry Floor with triple antibiotics and NG decompression.,","gastroenterology, colon tumor, ascites, adhesions, lysis of adhesions, exploratory laparotomy, colon cancer, transverse colon, hemicolectomy, laparotomy, "
 Nausea and abdominal pain after eating - Gall bladder disease - Laparoscopic cholecystectomy scheduled., Gastroenterology, GI Consultation - 4 ,"CHIEF COMPLAINT:, Nausea and abdominal pain after eating.,GALL BLADDER HISTORY:, The patient is a 36 year old white female.  Patient's complaints are fatty food intolerance, dark colored urine, subjective chills, subjective low-grade fever, nausea and sharp stabbing pain. The patient's symptoms have been present for 3 months. Complaints are relieved with lying on right side and antacids. Prior workup by referring physicians have included abdominal ultrasound positive for cholelithiasis without CBD obstruction. Laboratory studies that are elevated include total bilirubin and elevated WBC.,PAST MEDICAL HISTORY:, No significant past medical problems.,PAST SURGICAL HISTORY:, Diagnostic laparoscopic exam for pelvic pain/adhesions.,ALLERGIES:, No known drug allergies.,CURRENT MEDICATIONS:, No current medications.,OCCUPATIONAL /SOCIAL HISTORY:, Marital status: married. Patient states smoking history of 1 pack per day. Patient quit smoking 1 year ago. Admits to no history of using alcohol. States use of no illicit drugs.,FAMILY MEDICAL HISTORY:, There is no significant, contributory family medical history.,OB GYN HISTORY:, LMP: 5/15/1999. Gravida: 1. Para: 1.  Date of last pap smear: 1/15/1998.,REVIEW OF SYSTEMS:,Cardiovascular: Denies angina, MI history, dysrhythmias, palpitations, murmur, pedal edema, PND, orthopnea, TIA's, stroke, amaurosis fugax.,Pulmonary: Denies cough, hemoptysis, wheezing, dyspnea, bronchitis, emphysema, TB exposure or treatment.,Neurological: Patient admits to symptoms of seizures and ataxia.,Skin: Denies scaling, rashes, blisters, photosensitivity.,PHYSICAL EXAMINATION:,Appearance: Healthy appearing. Moderately overweight.,HEENT: Normocephalic. EOM's intact. PERRLA. Oral pharynx without lesions.,Neck: Neck mobile. Trachea is midline.,Lymphatic: No apparent cervical, supraclavicular, axillary or inguinal adenopathy.,Breast: Normal appearing breasts bilaterally, nipples everted.  No nipple discharge, skin changes.,Chest: Normal breath sounds heard bilaterally without rales or rhonchi.  No pleural rubs. No scars.,Cardiovascular: Regular heart rate and rhythm without murmur or gallop.,Abdominal: Bowel sounds are high pitched.,Extremities: Lower extremities are normal in color, touch and temperature. No ischemic changes are noted. Range of motion is normal.,Skin: Normal color, temperature, turgor and elasticity; no significant skin lesions.,IMPRESSION DIAGNOSIS:  ,  Gall Bladder Disease. Abdominal Pain.,DISCUSSION:, Laparoscopic Cholecystectomy handout was given to the patient, reviewed with them and questions answered. The patient has given both verbal and written consent for the procedure.,PLAN:, We will proceed with Laparoscopic Cholecystectomy with intraoperative cholangiogram.,MEDICATIONS PRESCRIBED:,",
 A male with known alcohol cirrhosis who presented to the emergency room after an accidental fall in the bathroom., Gastroenterology, Hepatic Encephalopathy ,"REASON FOR ADMISSION: , Hepatic encephalopathy.,HISTORY OF PRESENT ILLNESS: , The patient is a 51-year-old Native American male with known alcohol cirrhosis who presented to the emergency room after an accidental fall in the bathroom.  He said that he was doing fine prior to that and denied having any complaints.  He was sitting watching TV and he felt sleepy.  So, he went to the bathroom to urinate before going to bed and while he was trying to lift the seat, he tripped and fell and hit his head on the back.  His head hit the toilet seat.  Then, he started having bleeding and had pain in the area with headache.  He did not lose consciousness as far as he can tell.  He went and woke up his sister.  This happened somewhere between 10:30 and 11 p.m.  His sister brought a towel and covered the laceration on the back of his head and called EMS, who came to his house and brought him to the emergency room, where he was found to have a laceration on the back of his head, which was stapled and a CT of the head was obtained and ruled out any acute intracranial pathology.  On his lab work, his ammonia was found to be markedly elevated at 106.  So, he is being admitted for management of this.  He denied having any abdominal pain, change in bowel habits, GI bleed, hematemesis, melena, or hematochezia.  He said he has been taking his medicines, but he could not recall those.  He denied having any symptoms prior to this fall.  He said earlier today he also fell.  He also said that this was an accidental fall caused by problem with his walker.  He landed on his back at that time, but did not have any back pain afterwards.,PAST MEDICAL HISTORY:,1.  Liver cirrhosis caused by alcohol.  This is per the patient.,2.  He thinks he is diabetic.,3.  History of intracranial hemorrhage.  He said it was subdural hematoma.  This was traumatic and happened seven years ago leaving him with the right-sided hemiparesis.,4.  He said he had a seizure back then, but he does not have seizures now.,PAST SURGICAL HISTORY:,1.  He has a surgery on his stomach as a child.  He does not know the type.,2.  Surgery for a leg fracture.,3.  Craniotomy seven years ago for an intracranial hemorrhage/subdural hematoma.,MEDICATIONS: , He does not remember his medications except for the lactulose and multivitamins.,ALLERGIES: , Dilantin.,SOCIAL HISTORY: , He lives in Sacaton with his sister.  He is separated from his wife who lives in Coolidge.  He smokes one or two cigarettes a day.  Denies drug abuse.  He used to be a heavy drinker, quit alcohol one year ago and does not work currently.,FAMILY HISTORY:,  Negative for any liver disease.,REVIEW OF SYSTEMS:,GENERAL:  Denies fever or chills.  He said he was in Gilbert about couple of weeks ago for fever and was admitted there for two days.  He does not know the details.,ENT:  No visual changes.  No runny nose.  No sore throat.,CARDIOVASCULAR:  No syncope, chest pain, or palpitations.,RESPIRATORY:  No cough or hemoptysis.  No dyspnea.,GI:  No abdominal pain.  No nausea or vomiting.  No GI bleed.  History of alcoholic liver disease.,GU:  No dysuria, hematuria, frequency, or urgency.,MUSCULOSKELETAL:  Denies any acute joint pain or swelling.,SKIN:  No new skin rashes or itching.,CNS:  Had a seizure many years ago with no recurrences.  Left-sided hemiparesis after subdural hematoma from a fight/trauma.,ENDOCRINE:  He thinks he has diabetes but does not know if he is on any diabetic treatment.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 97.7, heart rate 83, respiratory rate 18, blood pressure 125/72, and saturation 98% on room air.,GENERAL:  The patient is lying in bed, appears comfortable, very pleasant Native American male in no apparent distress.,HEENT:  His skull has a scar on the left side from previous surgery.  On the back of his head, there is a laceration, which has two staples on.  It is still oozing minimally.  It is tender.  No other traumatic injury is noted.  Eyes, pupils react to light.  Sclerae anicteric.  Nostrils are normal.  Oral cavity is clear with no thrush or exudate.,NECK:  Supple.  Trachea midline.  No JVD.  No thyromegaly.,LYMPHATICS:  No cervical or supraclavicular lymphadenopathy.,LUNGS:  Clear to auscultation bilaterally.,HEART:  Normal S1 and S2.  No murmurs or gallops.  Regular rate and rhythm.,ABDOMEN:  Soft, distended, nontender.  No organomegaly or masses.,LOWER EXTREMITIES:  +1 edema bilaterally.  Pulses strong bilaterally.  No skin ulcerations noted.  No erythema.,SKIN:  Several spider angiomas noted on his torso and upper extremities consistent with liver cirrhosis.,BACK:  No tenderness by exam.,RECTAL:  No masses.  No abscess.  No rectal fissures.  Guaiac was performed by me and it was negative.,NEUROLOGIC:  He is alert and oriented x2.  He is slow to some extent in his response.  No asterixis.  Right-sided spastic hemiparesis with increased tone, increased reflexes, and weakness.  Increased tone noted in upper and lower extremities on the right compared to the left.  Deep tendon reflexes are +3 on the right and +2 on the left.  Muscle strength is decreased on the right, more pronounced in the lower extremity compared to the upper extremity.  The upper extremity is +4/5.  Lower extremity is 3/5.  The left side has a normal strength.  Sensation appears to be intact.  Babinski is upward on the right, equivocal on the left.,PSYCHIATRIC:  Flat affect.  Mood appeared to be appropriate.  No active hallucinations or psychotic symptoms.,LABORATORY DATA: ",
 Right upper quadrant pain.  Nuclear medicine hepatobiliary scan.  Radiopharmaceutical 6.9 mCi of Technetium-99m Choletec., Gastroenterology, Hepatobiliary Scan ,"NUCLEAR MEDICINE HEPATOBILIARY SCAN,REASON FOR EXAM: , Right upper quadrant pain.,COMPARISONS:  ,CT of the abdomen dated 02/13/09 and ultrasound of the abdomen dated 02/13/09.,Radiopharmaceutical 6.9 mCi of Technetium-99m Choletec.,FINDINGS:,  Imaging obtained up to 30 minutes after the injection of radiopharmaceutical shows a normal hepatobiliary transfer time.  There is normal accumulation within the gallbladder.,After the injection of 2.1 mcg of intravenous cholecystic _______, the gallbladder ejection fraction at 30 minutes was calculated to be 32% (normal is greater than 35%).  The patient experienced 2/10 pain at 5 minutes after the injection of the radiopharmaceutical and the patient also complained of nausea.,IMPRESSION:,1.  Negative for acute cholecystitis or cystic duct obstruction.,2.  Gallbladder ejection fraction just under the lower limits of normal at 32% that can be seen with very mild chronic cholecystitis.","gastroenterology, radiopharmaceutical, gallbladder ejection fraction, nuclear medicine hepatobiliary, hepatobiliary scan, quadrant, nuclear, technetium, choletec, ejection, fraction, cholecystitis, scan, abdomen, injection, gallbladder, hepatobiliary, medicine"
" Gastrostomy, a 6-week-old with feeding disorder and Down syndrome.", Gastroenterology, Gastrostomy ,"PREOPERATIVE DIAGNOSES:,1.  Feeding disorder.,2.  Down syndrome.,3.  Congenital heart disease.,POSTOPERATIVE DIAGNOSES:,1.  Feeding disorder.,2.  Down syndrome.,3.  Congenital heart disease.,OPERATION PERFORMED: , Gastrostomy.,ANESTHESIA: , General.,INDICATIONS:  ,This 6-week-old female infant had been transferred to Children's Hospital because of Down syndrome and congenital heart disease.  She has not been able to feed well and in fact has to now be NG tube fed.  Her swallowing mechanism does not appear to be very functional, and therefore, it was felt that in order to aid in her home care that she would be better served with a gastrostomy.,OPERATIVE PROCEDURE:  ,After the induction of general anesthetic, the abdomen was prepped and draped in usual manner.  Transverse left upper quadrant incision was made and carried down through skin and subcutaneous tissue with sharp dissection.  The muscle was divided and the peritoneal cavity entered.  The greater curvature of the stomach was grasped with a Babcock clamp and brought into the operative field.  The site for gastrostomy was selected and a pursestring suture of #4-0 Nurolon placed in the gastric wall.  A 14-French 0.8 cm Mic-Key tubeless gastrostomy button was then placed into the stomach and the pursestring secured about the tube.  Following this, the stomach was returned to the abdominal cavity and the posterior fascia was closed using a #4-0 Nurolon affixing the stomach to the posterior fascia.  The anterior fascia was then closed with #3-0 Vicryl, subcutaneous tissue with the same, and the skin closed with #5-0 subcuticular Monocryl.  The balloon was inflated to the full 5 mL.  A sterile dressing was then applied and the child awakened and taken to the recovery room in satisfactory condition.,","gastroenterology, feeding disorder, down syndrome, congenital heart disease, mic-key tubeless, nurolon, subcutaneous tissue, fascia, syndrome, stomach, gastrostomy"
 GI Consultation for Chrohn's disease., Gastroenterology, GI Consultation - 3 ,"PROBLEM:  ,Prescription evaluation for Crohn's disease., ,HISTORY: , This is a 46-year-old male who is here for a refill of Imuran.  He is taking it at a dose of 100 mg per day.  He is status post resection of the terminal ileum and has experienced intermittent obstructive symptoms for the past several years.  In fact, he had an episode three weeks ago in which he was seen at the emergency room after experiencing sudden onset of abdominal pain and vomiting. An x-ray was performed, which showed no signs of obstruction per his report.  He thinks that the inciting factor of this incident was too many grapes eaten the day before.  He has had similar symptoms suggestive of obstruction when eating oranges or other high-residue fruits in the past.  The patient's normal bowel pattern is loose stools and this is unchanged recently.  He has not had any rectal bleeding. He asks today about a rope-like vein on his anterior right arm that has been a little tender and enlarged after he was in the emergency room and they had difficulty with IV insertion.  He has not had any fever, red streaking up the arm, or enlargement of lymph nodes.  The tenderness has now completely resolved.  , ,He had a colonoscopy performed in August of 2003, by Dr. S.  An anastomotic stricture was found at the terminal ileum/cecum junction.  Dr. S recommended that if the patient experienced crampy abdominal pain or other symptoms of obstruction, that he may consider balloon dilation.  No active Crohn's disease was found during the colonoscopy.  , ,Earlier this year, he experienced a non-specific hepatitis with elevation of his liver function tests.  At that time he was taking a lot of Tylenol for migraine-type headaches.  Under Dr. S's recommendation, he stopped the Imuran for one month and reduced his dose of Tylenol.  Since that time his liver enzymes have normalized and he has restarted the Imuran with no problems.  , ,He also reports heartburn that is occurring on a slightly more frequent basis than it has in the past.  It used to occur once a week only, but has now increased in frequency to twice a week.  He takes over-the-counter H2 blockers as needed, as well as Tums.  He associates the onset of his symptoms with eating spicy Mexican food., ,PAST MEDICAL HISTORY: , Reviewed and unchanged.,ALLERGIES: , No known allergies to medications.,OPERATIONS: , Unchanged.,ILLNESSES: , Crohn's disease, vitamin B12 deficiency.,MEDICATIONS:,  Imuran, Nascobal, Vicodin p.r.n., ,REVIEW OF SYSTEMS: , Dated 08/04/04 is reviewed and noted.  Please see pertinent GI issues as discussed above.  Otherwise unremarkable., ,PHYSICAL EXAMINATION:  , GENERAL:  Pleasant male in no acute distress.  Well nourished and well developed. SKIN: indurated, cord-like superficial vein on the right anterior forearm, approx. 3 cm in length.  Non-tender to palpation. No erythema or red streaking.  No edema. LYMPH:  No epitrochlear or axillary lymph node enlargement or tenderness on the right side. , ,DATA REVIEWED: Labs from June 8th and July 19th reviewed.  Liver function tests normal with AST 14 and ALT 44.  WBCs were slightly low at 4.8.  Hemoglobin dropped slightly from 14.1 on 6/8 to 12.9 on 7/19. Hematocrit dropped slightly as well from 43.2 on 6/804 to 40.0 on 7/19/04.  These results were reviewed by Dr. S and lab results letter sent., ,IMPRESSION:  ,1. Crohn's disease, status post terminal ileum resection, on Imuran.  Intermittent symptoms of bowel obstruction.  Last episode three weeks ago.,2.  History of non-specific hepatitis while taking high doses of Tylenol.  Now resolved. ,2.  Increased frequency of reflux symptoms.,3.  Superficial thrombophlebitis, resolving. ,4.  Slightly low H&H., ,PLAN:  ,1.  We discussed Dr. S's recommendation that the patient undergo balloon dilation for recurrent bowel obstruction type symptoms.  The patient emphatically states that he does not want to consider dilation at this time.  The patient is strongly encouraged to call us when he does experience any obstructive symptoms, including abdominal pain, nausea, vomiting, or change in bowel habits.  He states understanding of this. Advised to maintain low residue diet to avoid obstructions. ,2.  Continue with liver panel and ABC every month per Dr. S's instructions.,3.  Continue Imuran 100 mg per day.,4.  Continue to minimize Tylenol use.  The patient is wondering if he can take another type of medication for migraines that is not Tylenol or antiinflammatories or aspirin.  Dr. S is consulted and agrees that Imitrex is an acceptable alternative for migraine headaches since he does not have advanced liver disease. The patient will make an appointment with his primary care provider to discuss this further. ,5.  Reviewed the importance of prophylactic treatment of reflux-type symptoms.  Encouraged the patient to take over-the-counter H2 blockers on a daily basis to prevent symptoms from occurring.  The patient will try this and if he remains symptomatic, then he will call our office and a prescription for Zantac 150 mg per day will be provided.  Reviewed the potential need for upper endoscopy should his symptoms continue or become more frequent.  He does not want to undergo any type of procedure such as that at this time.,6.",
" GI Consultation for chronic abdominal pain, nausea, vomiting, abnormal liver function tests.", Gastroenterology, GI Consultation - 2 ,"PROBLEM:  ,Chronic abdominal pain, nausea, vomiting, abnormal liver function tests., ,HISTORY: , The patient is a 23-year-old female referred for evaluation due to a chronic history of abdominal pain and extensive work-up for abnormal liver function tests and this chronic nausea and vomiting referred here for further evaluation due to the patient's recent move from Eugene to Portland.  The patient is not a great historian.  Most of the history is obtained through the old history and chart that the patient has with her.  According to what we can make out, she began experiencing nausea, vomiting, recurrent epigastric and right upper quadrant pain in 2001.  She was initially seen by Dr. A back in September 2001 for abdominal pain, nausea and vomiting.  During those times, it was suspected that part of her symptoms may be secondary to biliary disease and underwent a cholecystectomy performed in Oregon by Dr.  A in August 2001.  It was assumed that this was caused by biliary dyskinesia.  Previous to that, an upper endoscopy was performed by Dr. B in July 2001 that showed to be mild gastritis secondary to anti-inflammatory use.  Postoperatively she continued to have nausea and vomiting, right upper quadrant abdominal pain and epigastric pain similar to her gallbladder pain in the past.",
" GI Consultation due to rectal bleeding, positive celiac sprue panel", Gastroenterology, GI Consultation - 1 ,"PROBLEM:  ,Rectal bleeding, positive celiac sprue panel.,HISTORY:  ,The patient is a 19-year-old Irish-Greek female who ever since elementary school has noted diarrhea, constipation, cramping, nausea, vomiting, bloating, belching, abdominal discomfort, change in bowel habits.  She noted that her symptoms were getting increasingly worse and so she went for evaluation and was finally tested for celiac sprue and found to have a positive tissue transglutaminase as well as antiendomysial antibody.  She has been on a gluten-free diet for approximately one week now and her symptoms are remarkably improved.  She actually has none of these symptoms since starting her gluten-free diet.  She has noted intermittent rectal bleeding with constipation, on the toilet tissue.  She feels remarkably better after starting a gluten-free diet.,ALLERGIES: , No known drug allergies.,OPERATIONS: , She is status post a tonsillectomy as well as ear tubes.,ILLNESSES: , Questionable kidney stone.,MEDICATIONS: , None.,HABITS: , No tobacco.  No ethanol.,SOCIAL HISTORY: , She lives by herself.  She currently works in a dental office.,FAMILY HISTORY: , Notable for a mother who is in good health, a father who has joint problems and questionable celiac disease as well.  She has two sisters and one brother.  One sister interestingly has inflammatory arthritis.,REVIEW OF SYSTEMS:  ,Notable for fever, fatigue, blurred vision, rash and itching; her GI symptoms that were discussed in the HPI are actually resolved in that she started the gluten-free diet.  She also notes headaches, anxiety, heat and cold intolerance, excessive thirst and urination.  Please see symptoms summary sheet dated April 18, 2005.,PHYSICAL EXAMINATION:  , GENERAL:  She is a well-developed pleasant 19 female.  She has a blood pressure of 120/80, a pulse of 70, she weighs 170 pounds.  She has anicteric sclerae.  Pink conjunctivae.  PERRLA.  ENT:  MMM.  NECK:  Supple.  LUNGS: Clear to auscultation.","gastroenterology, bleeding, abdominal discomfort, belching, bloating, bowel, celiac sprue, change in bowel habits, constipation, cramping, diarrhea, gluten-free, nausea, rectal, vomiting, inflammatory arthritis, rectal bleeding, gi, inflammatory, sprue, celiac, gluten, diet, "
 GI bleed.   Upper gastrointestinal bleed.  CBC revealed microcytic anemia., Gastroenterology, GI Bleed - Discharge Summary ,"CHIEF COMPLAINT:,  GI bleed.,HISTORY OF PRESENT ILLNESS:,  The patient is an 80-year-old white female with history of atrial fibrillation, on Coumadin, who presented as outpatient, complaining of increasing fatigue.  CBC revealed microcytic anemia with hemoglobin of 8.9.  Stool dark brown, strongly OB positive.  The patient denied any shortness of breath.  No chest pain.  No GI complaints.  The patient was admitted to ABCD for further evaluation.,PAST MEDICAL HISTORY:  ,Significant for atrial fibrillation, hypertension, osteoarthritis of the knees, hypercholesterolemia, non-insulin-dependent diabetes mellitus, asthma, and hypothyroidism.,PHYSICAL EXAMINATION:,GENERAL:  The patient is in no acute distress.,VITAL SIGNS:  Stable.,HEENT:  Benign.,NECK:  Supple.  No adenopathy.,LUNGS:  Clear with good air movement.,HEART:  Irregularly regular.  No gallops.,ABDOMEN:  Positive bowel sounds, soft, and nontender.  No masses or organomegaly.,EXTREMITIES:  1+ lower extremity edema bilaterally.,HOSPITAL COURSE: , The patient underwent upper endoscopy performed by Dr. A, which revealed erosive gastritis.  Colonoscopy did reveal diverticulosis as well as polyp, which was resected.  The patient tolerated the procedure well.  She was transfused, and prior to discharge hemoglobin was stable at 10.7.  The patient was without further GI complaints.  Coumadin was held during hospital stay and recommendations were given by GI to hold Coumadin for an additional three days after discharge then resume.  The patient was discharged with outpatient PMD, GI, and Cardiology followup.,DISCHARGE DIAGNOSES:,1.  Upper gastrointestinal bleed.,2.  Anemia.,3.  Atrial fibrillation.,4.  Non-insulin-dependent diabetes mellitus.,5.  Hypertension.,6.  Hypothyroidism.,7.  Asthma.,CONDITION UPON DISCHARGE: , Stable.,MEDICATIONS: , Feosol 325 mg daily, multivitamins one daily, Protonix 40 mg b.i.d., KCl 20 mEq daily, Lasix 40 mg b.i.d., atenolol 50 mg daily, Synthroid 80 mcg daily, Actos 30 mg daily, Mevacor 40 mg daily, and lisinopril 20 mg daily.,ALLERGIES:,  None.,DIET: , 1800-calorie ADA.,ACTIVITY: , As tolerated.,FOLLOWUP: , The patient to hold Coumadin through weekend.  Followup CBC and INR were ordered.  Outpatient followup as arranged.",
 Gastroscopy.  Dysphagia and globus.  No evidence of inflammation or narrowing to explain her symptoms., Gastroenterology, Gastroscopy - 2 ,"PROCEDURE:,  Gastroscopy.,PREOPERATIVE DIAGNOSIS:,  Dysphagia and globus.,POSTOPERATIVE DIAGNOSIS: , Normal.,MEDICATIONS:,  MAC.,DESCRIPTION OF PROCEDURE: , The Olympus gastroscope was introduced through the oropharynx and passed carefully through the esophagus and stomach, and then through the gastrojejunal anastomosis into the efferent jejunal loop.  The preparation was good and all surfaces were well seen.  The hypopharynx was normal with no evidence of inflammation.  The esophagus had a normal contour and normal mucosa throughout with no sign of stricturing or inflammation or exudate.  The GE junction was located at 39 cm from the incisors and appeared normal with no evidence of reflux, damage, or Barrett's.  Below this there was a small gastric pouch measuring 6 cm with intact mucosa and no retained food.  The gastrojejunal anastomosis was patent measuring about 12 mm, with no inflammation or ulceration.  Beyond this there was a side-to-side gastrojejunal anastomosis with a short afferent blind end and a normal efferent end with no sign of obstruction or inflammation.  The scope was withdrawn and the patient was sent to recovery room.  She tolerated the procedure well.,FINAL DIAGNOSES:,1.  Normal post-gastric bypass anatomy.,2.  No evidence of inflammation or narrowing to explain her symptoms.","gastroenterology, olympus gastroscope, gastric pouch, gastrojejunal anastomosis, dysphagia, globus, esophagus, mucosa, gastric, gastroscopy, gastrojejunal, inflammation "
" Dysphagia, possible stricture.  Retained gastric contents forming a partial bezoar, suggestive of gastroparesis.", Gastroenterology, Gastroscopy - 1 ,"PROCEDURE: , Gastroscopy.,PREOPERATIVE DIAGNOSES: , Dysphagia, possible stricture.,POSTOPERATIVE DIAGNOSIS: , Gastroparesis.,MEDICATION: , MAC.,DESCRIPTION OF PROCEDURE: , The Olympus gastroscope was introduced into the hypopharynx and passed carefully through the esophagus, stomach, and duodenum.  The hypopharynx was normal.  The esophagus had a normal upper esophageal sphincter, normal contour throughout, and a normal gastroesophageal junction viewed at 39 cm from the incisors.  There was no evidence of stricturing or extrinsic narrowing from her previous hiatal hernia repair.  There was no sign of reflux esophagitis.  On entering the gastric lumen, a large bezoar of undigested food was seen occupying much of the gastric fundus and body.  It had 2 to 3 mm diameter.  This was broken up using a scope into smaller pieces.  There was no retained gastric liquid.  The antrum appeared normal and the pylorus was patent.  The scope passed easily into the duodenum, which was normal through the second portion.  On withdrawal of the scope, additional views of the cardia were obtained, and there was no evidence of any tumor or narrowing.  The scope was withdrawn.  The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1.  Normal postoperative hernia repair.,2.  Retained gastric contents forming a partial bezoar, suggestive of gastroparesis.,3.  Otherwise normal upper endoscopy to the descending duodenum.,RECOMMENDATIONS:,1.  Continue proton pump inhibitors.,2.  Use Reglan 10 mg three to four times a day.",gastroenterology
" Gastroscopy.  A short-segment Barrett esophagus, hiatal hernia, and incidental fundic gland polyps in the gastric body; otherwise, normal upper endoscopy to the transverse duodenum.", Gastroenterology, Gastroscopy - 3 ,"PROCEDURE: , Gastroscopy.,PREOPERATIVE DIAGNOSIS: , Gastroesophageal reflux disease.,POSTOPERATIVE DIAGNOSIS:,  Barrett esophagus.,MEDICATIONS: , MAC.,PROCEDURE: , The Olympus gastroscope was introduced into the oropharynx and passed carefully through the esophagus, stomach, and duodenum to the transverse duodenum.  The preparation was excellent and all surfaces were well seen.  The hypopharynx appeared normal.  The esophagus had a normal contour and normal mucosa throughout its distance, but at the distal end, there was a moderate-sized hiatal hernia noted.  The GE junction was seen at 40 cm and the hiatus was noted at 44 cm from the incisors.  Above the GE junction, there were three fingers of columnar epithelium extending cephalad, to a distance of about 2 cm.  This appears to be consistent with Barrett esophagus.  Multiple biopsies were taken from numerous areas in this region.  There was no active ulceration or inflammation and no stricture.  The hiatal hernia sac had normal mucosa except for one small erosion at the hiatus.  The gastric body had normal mucosa throughout.  Numerous small fundic gland polyps were noted, measuring 3 to 5 mm in size with an entirely benign appearance.  Biopsies were taken from the antrum to rule out Helicobacter pylori.  A retroflex view of the cardia and fundus confirmed the small hiatal hernia and demonstrated no additional lesions.  The scope was passed through the pylorus, which was patent and normal.  The mucosa throughout the duodenum in the first, second, and third portions was entirely normal.  The scope was withdrawn and the patient was sent to the recovery room.  He tolerated the procedure well.,FINAL DIAGNOSES:,1.  A short-segment Barrett esophagus.,2.  Hiatal hernia.,3.  Incidental fundic gland polyps in the gastric body.,4.  Otherwise, normal upper endoscopy to the transverse duodenum.,RECOMMENDATIONS:,1.  Follow up biopsy report.,2.  Continue PPI therapy.,3.  Follow up with Dr. X as needed.,4.  Surveillance endoscopy for Barrett in 3 years (if pathology confirms this diagnosis).","gastroenterology, olympus, gastroscope, barrett, gastroesophageal reflux disease, transverse duodenum, barrett esophagus, hiatal hernia, gastroscopy, endoscopy, hiatal, duodenum, esophagus, hernia,"
 Gastrointestinal Bleed.  An 81-year-old presented to the emergency room after having multiple black tarry stools and a weak spell.  She woke yesterday morning had a very dark and smelly bowel movement. , Gastroenterology, Gastrointestinal Bleed - ER Visit ,"ADMITTING DIAGNOSIS: , Gastrointestinal bleed.,HISTORY OF PRESENT ILLNESS:  ,Ms. XYZ is an 81-year-old who presented to the emergency room after having multiple black tarry stools and a weak spell.  She states that she woke yesterday morning and at approximately 10:30 had a bowel movement.  She noticed it was very dark and smelly.  She said she felt okay.  She got up.  She proceeded to clean her house without any difficulty or problems and then at approximately 2 o'clock in the afternoon she went back to the bathroom at which point she had another large stool and had weak spell felt like she was going to pass out.  She is able to get to her phone, called EMS and when the EMS arrived they found her with some blood and some very dark stools.  She states that she was perfectly fine up until Monday when she had an incident where at the Southern University where she works where there was an altercation between a dorm resistant and a young male, which ensued.  She came to place her call, etc.  She said she noticed her stomach was hurting after that, continued to hurt and she took the day off on Tuesday and this happened yesterday.  She denies any nausea except for when she got weak.  She denies any vomiting or any other symptoms.,ALLERGIES:  ,She has no known drug allergies.,CURRENT MEDICATIONS:,1.  Lipitor, dose unknown.,2.  Paxil, dose unknown.,3.  Lasix, dose unknown.,4.  Toprol, dose unknown.,5.  Diphenhydramine p.r.n.,6.  Ibuprofen p.r.n.,7.  Daypro p.r.n.,PAST MEDICAL HISTORY:,1.  Non-insulin diabetes mellitus.,2.  History of congestive heart failure.,3.  History of hypertension.,4.  Depression.,5.  Arthritis.  She states she has not needed any medications and not taken ibuprofen or Daypro recently.,6.  Hyperlipidemia.,7.  Peptic ulcer disease diagnosed in 2005.,PAST SURGICAL HISTORY: , C-section and tonsillectomy.,FAMILY HISTORY: , Her mother had high blood pressure and coronary artery disease.,SOCIAL HISTORY:,  She is a nonsmoker.  She occasionally has a drink every few weeks.  She is divorced.  She has 2 sons.  She is houseparent at Southern University.,REVIEW OF SYSTEMS:  ,Negative for the last 24 to 48 hours as mentioned in her HPI.,PREVENTIVE CARE:  ,She had an EGD done in 09/05 at which point she was diagnosed with peptic ulcer disease and she also had a colonoscopy at that time which revealed two polyps in the transverse colon.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Currently was stable.  She is afebrile.,GENERAL:  She is alert, pleasant in no acute distress.  She does complain of some dizziness when she stands up.,HEENT:  Pupils equal, round and reactive to light.  Extraocular muscles intact.  Sclerae clear.  Oropharynx is clear.,NECK:  Supple.  Full range of motion.,CARDIOVASCULAR:  She is slightly tachycardic but otherwise normal.,LUNGS:  Clear bilaterally.,ABDOMEN:  Soft, nontender, and nondistended.  She has no hepatomegaly.,EXTREMITIES:  No clubbing, cyanosis, only trace edema.,LABORATORY DATA UPON ADMISSION:,  Her initial chem panel was within normal limits.  Her PT and PTT were normal.  Her initial hematocrit was 31.2 subsequently dropped to 26.9 and 25.6.  She is currently administered transfusion.  Platelet count was 125.  Her chem panel actually showed an elevated BUN of 16, creatinine of 1.7.  PT and PTT were normal.  Cardiac enzymes were negative and initial hemoglobin was 10.6 with hematocrit of 31.2 that subsequently fell to 25.6 and she is currently receiving blood.,IMPRESSION AND PLAN:,1.  Gastrointestinal bleed.",
 Followup of laparoscopic fundoplication and gastrostomy.  Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access., Gastroenterology, Fundoplication & Gastrostomy Followup ,"REASON FOR VISIT: , Followup of laparoscopic fundoplication and gastrostomy.,HISTORY OF PRESENT ILLNESS: , The patient is a delightful baby girl, who is now nearly 8 months of age and had a tracheostomy for subglottic stenosis.  Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access and to protect her airway at a time when it is either going to heal enough to improve and allow decannulation or eventually prove that she will need laryngotracheoplasty.  Dr. X is following The patient for this and currently plans are to perform a repeat endoscopic exam every couple of months to assist the status of her airway caliber.,The patient had a laparoscopic fundoplication and gastrostomy on 10/05/2007.  She has done well since that time.  She has had some episodes of retching intermittently and these seemed to be unpredictable.  She also had some diarrhea and poor feeding tolerance about a week ago but that has also resolved.  The patient currently takes about 1 ounce to 1.5 ounce of her feedings by mouth and the rest is given by G-tube.  She seems otherwise happy and is not having an excessive amount of stools.  Her parents have not noted any significant problems with the gastrostomy site.,The patient's exam today is excellent.  Her belly is soft and nontender.  All of her laparoscopic trocar sites are healing with a normal amount of induration, but there is no evidence of hernia or infection.  We removed The patient's gastrostomy button today and showed her parents how to reinsert one without difficulty.  The site of the gastrostomy is excellent.  There is not even a hint of granulation tissue or erythema, and I am very happy with the overall appearance.,IMPRESSION: , The patient is doing exceptionally well status post laparoscope fundoplication and gastrostomy.  Hopefully, the exquisite control of acid reflux by fundoplication will help her airway heal, and if she does well, allow decannulation in the future.  If she does require laryngotracheoplasty, the protection from acid reflux will be important to healing of that procedure as well.,PLAN:  ,The patient will follow up as needed for problems related to gastrostomy.  We will see her when she comes in the hospital for endoscopic exams and possibly laryngotracheoplasty in the future.","gastroenterology, decannulation, enteral feeding, feeding access, laparoscopic fundoplication, gastrostomy, airway, laryngotracheoplasty, laparoscopic, fundoplication, "
" Acute gastroenteritis, resolved.  Gastrointestinal bleed and chronic inflammation of the mesentery of unknown etiology.", Gastroenterology, Gastroenteritis - Discharge Summary ,"ADMITTING DIAGNOSES,1.  Acute gastroenteritis.,2.  Nausea.,3.  Vomiting.,4.  Diarrhea.,5.  Gastrointestinal bleed.,6.  Dehydration.,DISCHARGE DIAGNOSES,1.  Acute gastroenteritis, resolved.,2.  Gastrointestinal bleed and chronic inflammation of the mesentery of unknown etiology.,BRIEF H&P AND HOSPITAL COURSE: , This patient is a 56-year-old male, a patient of Dr. X with 25-pack-year history, also a history of diabetes type 2, dyslipidemia, hypertension, hemorrhoids, chronic obstructive pulmonary disease, and a left lower lobe calcified granuloma that apparently is stable at this time.  This patient presented with periumbilical abdominal pain with nausea, vomiting, and diarrhea for the past 3 days and four to five watery bowel movements a day with symptoms progressively getting worse.  The patient was admitted into the ER and had trop x1 done, which was negative and ECG showed to be of normal sinus rhythm.,Lab findings initially presented with a hemoglobin of 13.1, hematocrit of 38.6 with no elevation of white count.  Upon discharge, his hemoglobin and hematocrit stayed at 10.9 and 31.3 and he was still having stool guaiac positive blood, and a stool study was done which showed few white blood cells, negative for Clostridium difficile and moderate amount of occult blood and moderate amount of RBCs.  The patient's nausea, vomiting, and diarrhea did resolve during his hospital course.  Was placed on IV fluids initially and on hospital day #2 fluids were discontinued and was started on clear liquid diet and diet was advanced slowly, and the patient was able to tolerate p.o. well.  The patient also denied any abdominal pain upon day of discharge.  The patient was also started on prednisone as per GI recommendations.  He was started on 60 mg p.o.  Amylase and lipase were also done which were normal and LDH and CRP was also done which are also normal and LFTs were done which were also normal as well.,PLAN: , The plan is to discharge the patient home.  He can resume his home medications of Prandin, Actos, Lipitor, Glucophage, Benicar, and Advair.  We will also start him on a tapered dose of prednisone for 4 weeks.  We will start him on 15 mg p.o. for seven days.  Then, week #2, we will start him on 40 mg for 1 week.  Then, week #3, we will start him on 30 mg for 1 week, and then, 20 mg for 1 week, and then finally we will stop.  He was instructed to take tapered dose of prednisone for 4 weeks as per the GI recommendations.","gastroenterology, nausea, vomiting, diarrhea, gastrointestinal bleed, mesentery, hemoglobin, hematocrit, gastrointestinal, periumbilical, gastroenteritis, hemorrhoids"
 Pediatric Gastroenterology - History of gagging., Gastroenterology, Gagging - 3-year-old ,"HISTORY OF PRESENT ILLNESS: , This is a 3-year-old female patient, who was admitted today with a history of gagging.  She was doing well until about 2 days ago, when she developed gagging.  No vomiting.  No fever.  She has history of constipation.  She normally passes stool every two days after giving an enema.  No rectal bleeding.  She was brought to the Hospital with some loose stool.  She was found to be dehydrated.  She was given IV fluid bolus, but then she started bleeding from G-tube site.  There was some fresh blood coming out of the G-tube site.  She was transferred to PICU.  She is hypertensive.  Intensivist Dr. X requested me to come and look at her, and do upper endoscopy to find the site of bleeding.,PAST MEDICAL HISTORY: , PEHO syndrome, infantile spasm, right above knee amputation, developmental delay, G-tube fundoplication.,PAST SURGICAL HISTORY: , G-tube fundoplication on 05/25/2007.  Right above knee amputation.,ALLERGIES:,  None.,DIET: , She is NPO now, but at home she is on PediaSure 4 ounces 3 times a day through G-tube, 12 ounces of water per day.,MEDICATIONS: , Albuterol, Pulmicort, MiraLax 17 g once a week, carnitine, phenobarbital, Depakene and Reglan.,FAMILY HISTORY:,  Positive for cancer.,PAST LABORATORY EVALUATION: , On 12/27/2007; WBC 9.3, hemoglobin 7.6, hematocrit 22.1, platelet 132,000.  KUB showed large stool with dilated small and large bowel loops.  Sodium 140, potassium 4.4, chloride 89, CO2 21, BUN 61, creatinine 2, AST 92 increased, ALT 62 increased, albumin 5.3, total bilirubin 0.1.  Earlier this morning, she had hemoglobin of 14.5, hematocrit 41.3, platelets 491,000.  PT 58 increased, INR 6.6 increased, PTT 75.9 increased.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Temperature 99 degrees Fahrenheit, pulse 142 per minute, respirations 34 per minute, weight 8.6 kg.,GENERAL:  She is intubated.,HEENT:  Atraumatic.  She is intubated.,LUNGS:  Good air entry bilaterally.  No rales or wheezing.,ABDOMEN:  Distended.  Decreased bowel sounds.,GENITALIA:  Grossly normal female.,CNS:  She is sedated.,IMPRESSION: , A 3-year-old female patient with history of passage of blood through G-tube site with coagulopathy.  She has a history of G-tube fundoplication, developmental delay, PEHO syndrome, which is progressive encephalopathy optic atrophy.,PLAN:  ,Plan is to give vitamin K, FFP, blood transfusion.  Consider upper endoscopy.  Procedure and informed consent discussed with the family.","gastroenterology, g-tube, peho syndrome, tube site, gagging, constipation, endoscopy, peho, hemoglobin, hematocrit, intubated, bleeding, blood, fundoplication, tube, "
 Foul-smelling urine and stomach pain after meals., Gastroenterology, Foul-Smelling Urine ,"CHIEF COMPLAINT:,  Foul-smelling urine and stomach pain after meals.,HISTORY OF PRESENT ILLNESS:,  Stomach pain with most meals x one and a half years and urinary symptoms for same amount of time.  She was prescribed Reglan, Prilosec, Pepcid, and Carafate at ED for her GI symptoms and Bactrim for UTI.  This visit was in July 2010.,REVIEW OF SYSTEMS:,  HEENT:  No headaches.  No visual disturbances, no eye irritation.  No nose drainage or allergic symptoms.  No sore throat or masses.  Respiratory:  No shortness of breath.  No cough or wheeze.  No pain.  Cardiac:  No palpitations or pain.  Gastrointestinal:  Pain and cramping.  Denies nausea, vomiting, or diarrhea.  Has some regurgitation with gas after meals.  Genitourinary:  ""Smelly"" urine.  Musculoskeletal:  No swelling, pain, or numbness.,MEDICATION ALLERGIES:,  No known drug allergies.,PHYSICAL EXAMINATION:,General:  Unremarkable.,HEENT:  PERRLA.  Gaze conjugate.,Neck:  No nodes.  No thyromegaly.  No masses.,Lungs:  Clear.,Heart:  Regular rate without murmur.,Abdomen:  Soft, without organomegaly, without guarding or tenderness.,Back:  Straight.  No paraspinal spasm.,Extremities:  Full range of motion.  No edema.,Neurologic:  Cranial nerves II-XII intact.  Deep tendon reflexes 2+ bilaterally.,Skin:  Unremarkable.,LABORATORY STUDIES:,  Urinalysis was done, which showed blood due to her period and moderate leukocytes.,ASSESSMENT:,1.  UTI.,2.  GERD.,3.  Dysphagia.,4.  Contraception consult.,PLAN:,1.  Cipro 500 mg b.i.d. x five days.  Ordered BMP, CBC, and urinalysis with microscopy.,2.  Omeprazole 20 mg daily and famotidine 20 mg b.i.d.,3.  Prescriptions same as #2.  Also referred her for a barium swallow series to rule out a stricture.,4.  Ortho Tri-Cyclen Lo.,",
 Flexible sigmoidoscopy due to rectal bleeding., Gastroenterology, Flex Sig - 1 ,"INDICATION:  , Rectal bleeding.,PREMEDICATION:, See procedure nurse NCS form.,PROCEDURE:  ,","gastroenterology, rectal bleeding, digital rectal exam, pentax video, anal verge, angiodysplasia, colonic mucosa, diverticula, endoscope, flexible, flexible sigmoidoscopy, hemorrhoids, masses, polyps, rectum, sigmoidoscopy, sphincter tone, internal hemorrhoids, bleeding, rectal "
 Flexible sigmoidoscopy.  The Olympus video colonoscope then introduced into the rectum and passed by directed vision to the distal descending colon., Gastroenterology, Flex Sig - 2 ,"PROCEDURE IN DETAIL: , Following a barium enema prep and lidocaine ointment to the rectal vault, perirectal inspection and rectal exam were normal.  The Olympus video colonoscope then introduced into the rectum and passed by directed vision to the distal descending colon.  Withdrawal notes an otherwise normal descending, rectosigmoid and rectum.  Retroflexion noted no abnormality of the internal ring.  No hemorrhoids were noted.  Withdrawal from the patient terminated the procedure.","gastroenterology, flexible sigmoidoscopy, flex sig, colonoscope, olympus video colonoscope, rectumNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Gastrointestinal bleed, source undetermined, but possibly due to internal hemorrhoids.  Poor prep with friable internal hemorrhoids, but no gross lesions, no source of bleed.", Gastroenterology, Gastrointestinal Bleed - Discharge Summary ,"DIAGNOSIS ON ADMISSION: , Gastrointestinal bleed.,DIAGNOSES ON DISCHARGE,1. Gastrointestinal bleed, source undetermined, but possibly due to internal hemorrhoids.,2. Atherosclerotic cardiovascular disease.,3. Hypothyroidism.,PROCEDURE:,  Colonoscopy.,FINDINGS:,  Poor prep with friable internal hemorrhoids, but no gross lesions, no source of bleed.,HOSPITAL COURSE:  ,The patient was admitted to the emergency room by Dr. X. He apparently had an NG tube placed in the emergency room with gastric aspirate revealing no blood.  Dr. Y Miller saw him in consultation and recommended a colonoscopy.  A bowel prep was done.  H&Hs were stable.  His most recent H&H was 38.6/13.2 that was this morning.  His H&H at admission was 41/14.3.  The patient had the bowel prep that revealed no significant bleeding.  His vital signs are stable.  He is continuing on his usual medications of Imdur, metoprolol, and Synthroid.  His Plavix is discontinued.  He is given IV Protonix.  I am hesitant to use Prilosec or Protonix because of his history of pancreatitis associated with Prilosec.,The patient's PT/INR was 1.03, PTT 25.8.  Chemistry panel was unremarkable.  The patient was given a regular diet after his colonoscopy today.  He tolerated it well and is being discharged home.  He will be followed closely as an outpatient.  He will continue his Pepcid 40 mg at night, Imdur, Synthroid, and metoprolol as prior to admission.  He will hold his Plavix for now.  They will call me for further dark stools and will avoid Pepto-Bismol.  They will follow up in the office on Thursday.","gastroenterology, atherosclerotic cardiovascular disease, colonoscopy, gross lesions, bowel prep, gastrointestinal bleed, internal hemorrhoids, hemorrhoids, gastrointestinal, prep "
" Esophagitis, minor stricture at the gastroesophageal junction, hiatal hernia.  Otherwise normal upper endoscopy to the transverse duodenum.", Gastroenterology, Gastroscopy ,"PREOPERATIVE DIAGNOSES: , Dysphagia and esophageal spasm.,POSTOPERATIVE DIAGNOSES: , Esophagitis and esophageal stricture.,PROCEDURE:,  Gastroscopy.,MEDICATIONS:,  MAC.,DESCRIPTION OF PROCEDURE: , The Olympus gastroscope was introduced into the oropharynx and passed carefully through the esophagus, stomach, and duodenum, to the third portion of the duodenum.  The hypopharynx was normal and the upper esophageal sphincter was unremarkable.  The esophageal contour was normal, with the gastroesophageal junction located at 38 cm from the incisors.  At this point, there were several linear erosions and a sense of stricturing at 38 cm.  Below this, there was a small hiatal hernia with the hiatus noted at 42 cm from the incisors.  The mucosa within the hernia was normal.  The gastric lumen was normal with normal mucosa throughout.  The pylorus was patent permitting passage of the scope into the duodenum, which was normal through the third portion.  During withdrawal of the scope, additional views were obtained of the cardia, confirming the presence of a small hiatal hernia.  It was decided to attempt dilation of the strictured area, so an 18-mm TTS balloon was placed across the stricture and inflated to the recommended diameter.  When the balloon was fully inflated, the lumen appeared to be larger than 18 mm diameter, suggesting that the stricture was in fact not a significant one.  No stretching of the mucosa took place.  The balloon was deflated and the scope was withdrawn.  The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1.  Esophagitis.,2.  Minor stricture at the gastroesophageal junction.,3.  Hiatal hernia.,4.  Otherwise normal upper endoscopy to the transverse duodenum.,RECOMMENDATIONS:  ,Continue proton pump inhibitor therapy.","gastroenterology, duodenum, esophagus, gastroscope, stomach, upper endoscopy, transverse duodenum, gastroesophageal junction, hiatal hernia, gastroscopy, endoscopy, esophagitis, gastroesophageal, hiatal, esophageal, hernia"
" Female with intermittent rectal bleeding, not associated with any weight loss.  The patient is chronically constipated.", Gastroenterology, Gastroenterology - Letter ,"Sample Address,Re:  Mrs. Sample Patient,Dear Sample Doctor:,I had the pleasure of seeing your patient, Mrs. Sample Patient , in my office today.  Mrs. Sample Patient is a 48-year-old, African-American female with a past medical history of hypertension and glaucoma, who was referred to me to be evaluated for intermittent rectal bleeding.  The patient denies any weight loss, does have a good appetite, no nausea and no vomiting.,PAST MEDICAL HISTORY:,  Significant for hypertension and diabetes.,PAST SURGICAL HISTORY:,  The patient denies any past surgical history.,MEDICATIONS:,  The patient takes Cardizem CD 240-mg.  The patient also takes eye drops.,ALLERGIES:,  The patient denies any allergies.,SOCIAL HISTORY:,  The patient smokes about a pack a day for more than 25 years.  The patient drinks alcohol socially.,FAMILY HISTORY:,  Significant for hypertension and strokes.,REVIEW OF SYSTEMS:,  The patient does have a good appetite and no weight loss.  She does have intermittent rectal bleeding associated with irritation in the rectal area.  The patient denies any nausea, any vomiting, any night sweats, any fevers or any chills.,The patient denies any shortness of breath, any chest pain, any irregular heartbeat or chronic cough.,The patient is chronically constipated.,PHYSICAL EXAMINATION:,  This is a 48 year-old lady who is awake, alert and oriented x 3.  She does not seem to be in any acute distress.  Her vital signs are blood pressure is 130/70 with a heart rate of 75 and respirations of 16.  HEENT is normocephalic, atraumatic.  Sclerae are non-icteric.  Her neck is supple, no bruits, no lymph nodes.  Lungs are clear to auscultation bilaterally, no crackles, no rales and no wheezes.  The cardiovascular system has a regular rate and rhythm, no murmurs.  The abdomen is soft and non-tender.  Bowel sounds are positive and no organomegaly.  Extremities have no edema.,IMPRESSION:,  This is a 48-year-old female presenting with painless rectal bleeding not associated with any weight loss.  The patient is chronically constipated.,1.  Rule out colon cancer.,2.  Rule out colon polyps. ,3.  Rule out hemorrhoids, which is the most likely diagnosis.,RECOMMENDATIONS:,  Because of the patient's age, the patient will need to have a complete colonoscopy exam.,The patient will also need to have a CBC check and monitor.,The patient will be scheduled for the colonoscopy at Sample Hospital and the full report will be forwarded to your office.,Thank you very much for allowing me to participate in the care of your patient.,Sincerely yours,,Sample Doctor, MD",
" Flexible sigmoidoscopy.  Sigmoid and left colon diverticulosis; otherwise, normal flexible sigmoidoscopy to the proximal descending colon.", Gastroenterology, Flex Sig - 3 ,"PROCEDURE: , Flexible sigmoidoscopy.,PREOPERATIVE DIAGNOSIS:,  Rectal bleeding.,POSTOPERATIVE DIAGNOSIS:  ,Diverticulosis.,MEDICATIONS: , None.,DESCRIPTION OF PROCEDURE:  ,The Olympus gastroscope was introduced through the rectum and advanced carefully through the colon for a distance of 90 cm, reaching the proximal descending colon.  At this point, stool occupied the lumen, preventing further passage.  The colon distal to this was well cleaned out and easily visualized.  The mucosa was normal throughout the regions examined.  Numerous diverticula were seen.  There was no blood or old blood or active bleeding.  A retroflexed view of the anorectal junction showed no hemorrhoids.  He tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1.  Sigmoid and left colon diverticulosis.,2.  Otherwise normal flexible sigmoidoscopy to the proximal descending colon.,3.  The bleeding was most likely from a diverticulum, given the self limited but moderately severe quantity that he described.,RECOMMENDATIONS:,1.  Follow up with Dr. X as needed.,2.  If there is further bleeding, a full colonoscopy is recommended.","gastroenterology, olympus, gastroscope, rectal bleeding, flexible sigmoidoscopy, colon diverticulosis, descending colon, diverticulosis, hemorrhoids, flexible, sigmoidoscopy, colon"
" Exploratory laparotomy, release of small bowel obstruction, and repair of periumbilical hernia.  Acute small bowel obstruction and incarcerated umbilical Hernia.", Gastroenterology, Exploratory Laparotomy & Hernia Repair ,"PREOPERATIVE DIAGNOSIS:,1.  Acute bowel obstruction.,2.  Umbilical hernia.,POSTOPERATIVE DIAGNOSIS:,1.  Acute small bowel obstruction.,2.  Incarcerated umbilical Hernia.,PROCEDURE PERFORMED:,1.  Exploratory laparotomy.,2.  Release of small bowel obstruction.,3.  Repair of periumbilical hernia.,ANESTHESIA: , General with endotracheal intubation.,COMPLICATIONS:,  None.,DISPOSITION: , The patient tolerated the procedure well and was transferred to recovery in stable condition.,SPECIMEN: , Hernia sac.,HISTORY:  ,The patient is a 98-year-old female who presents from nursing home extended care facility with an incarcerated umbilical hernia, intractable nausea and vomiting and a bowel obstruction.  Upon seeing the patient and discussing in extent with the family, it was decided the patient needed to go to the operating room for this nonreducible umbilical hernia and bowel obstruction and the family agreed with surgery.,INTRAOPERATIVE FINDINGS: , The patient was found to have an incarcerated umbilical hernia.  There was a loop of small bowel incarcerated within the hernia sac.  It showed signs of ecchymosis, however no signs of any ischemia or necrosis.  It was easily reduced once opening the abdomen and the rest of the small bowel was ran without any other defects or abnormalities.,PROCEDURE: , After informed written consent, risks and benefits of the procedure were explained to the patient and the patient's family.  The patient was brought to the operating suite.  After general endotracheal intubation, prepped and draped in normal sterile fashion.  A midline incision was made around the umbilical hernia defect with a #10 blade scalpel.  Dissection was then carried down to the fascia.  Using a sharp dissection, an incision was made above the defect superior to the defect entering the fascia.  The abdomen was entered under direct visualization.  The small bowel that was entrapped within the hernia sac was easily reduced and observed and appeared to be ecchymotic, however, no signs of ischemia were noted or necrosis.  The remaining of the fascia was then extended using Metzenbaum scissors.  The hernia sac was removed using Mayo scissors and sent off as specimen.  Next, the bowel was run from the ligament of Treitz to the ileocecal valve with no evidence of any other abnormalities.  The small bowel was then milked down removing all the fluid.  The bowel was decompressed distal to the obstruction.  Once returning the abdominal contents to the abdomen, attention was next made in closing the abdomen and using #1 Vicryl suture in the figure-of-eight fashion the fascia was closed.  The umbilicus was then reapproximated to its anatomical position with a #1 Vicryl suture.  A #3-0 Vicryl suture was then used to reapproximate the deep dermal layers and skin staples were used on the skin.  Sterile dressings were applied.  The patient tolerated the procedure well and was transferred to recovery in stable condition.","gastroenterology, endotracheal intubation, acute bowel obstruction, umbilical hernia, exploratory laparotomy, release of small bowel obstruction, repair of periumbilical hernia, incarcerated umbilical hernia, incarcerated, bowel, hernia, exploratory, laparotomy, abdomen, umbilical, obstruction, "
 Flexible Sigmoidoscopy., Gastroenterology, Flex Sig ,"MEDICATIONS:,  None.,DESCRIPTION OF THE PROCEDURE:,  After informed consent was obtained, the patient was placed in the left lateral decubitus position and the Olympus video colonoscope was inserted through the anus and advanced in retrograde fashion for a distance of *** cm to the proximal descending colon and then slowly withdrawn.  The mucosa appeared normal.  Retroflex examination of the rectum was normal.","gastroenterology, flexible sigmoidoscopy, flex sig, olympus video colonoscope, colonoscopeNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Exploratory laparotomy, low anterior colon resection, flexible colonoscopy, and transverse loop colostomy and JP placement.  Colovesical fistula and intraperitoneal abscess.", Gastroenterology, Exploratory Laparotomy & Colon Resection ,"PREOPERATIVE DIAGNOSIS: , Colovesical fistula.,POSTOPERATIVE DIAGNOSES:,1.  Colovesical fistula.,2.  Intraperitoneal abscess.,PROCEDURE PERFORMED:,1.  Exploratory laparotomy.,2.  Low anterior colon resection.,3.  Flexible colonoscopy.,4.  Transverse loop colostomy and JP placement.,ANESTHESIA: , General.,HISTORY:  ,This 74-year-old female who had a recent hip fracture and the patient was in rehab when she started having some stool coming out of the urethra.  The patient had retrograde cystogram, which revealed colovesical fistula.  Recommendation for a surgery was made.  The patient was explained the risks and benefits as well as the two sons and the daughter.  They understood that the patient can even die from this procedure.  All the three procedures were explained, without a colostomy, with Hartmann's colostomy, and with a transverse loop colostomy, and out of the three procedures, the patient's requested to have the loop colostomy and stated that the Hartmann's colostomy leaving the anastomosis with the risk of leaking.,PROCEDURE DETAILS: , The patient was taken to the operating room, prepped and draped in the sterile fashion and was given general anesthetic.  An incision was performed in the midline below the umbilicus to the pubis with a #10 blade Bard Parker.  Electrocautery was used for hemostasis down to the fascia.  The fascia was grasped with Ochsner's and then immediately the peritoneum was entered and the incision was carried cephalad and caudad with electrocautery.,Once within the peritoneum, adhesiolysis was performed to separate the small bowel from the attachment of the anterior abdominal wall.  At this point, immediately a small bowel was retracted cephalad.  The patient was taken to a slightly Trendelenburg position and the descending colon was seen.  The white line of Toldt was opened all the way down to the area of inflammation.  At this point, meticulous dissection was carried to separate the small bowel from the attachment to the abscess.  When the small bowel was completely freed of  abscess, bulk of the bladder was seen anteriorly to the uterus.  The abscess was cultured and sent it back to Bacteriology Department and immediately the opening into the bladder was visualized.  At this point, the entire sigmoid colon was separated posteriorly as well as laterally and it was all the way down to sigmoid down to the rectum.  At this point, decision to place a moist towel and retract old intestine superiorly as well as to place first self-retaining retractor in the abdominal cavity with a bladder blade was placed.  Immediately, a GIA was fired right across the descending colon and sigmoid colon junction and then with peons within the mesentery were placed all the way down to the rectosigmoid junction where a TA-55 balloon Roticulator was fired.  The specimen was cut with #10 blade Bard-Parker and sent it to Pathology.  Immediately copious amount of irrigation was used and the staple line in the descending colon was brought with Allis.  A pursestring device was fired.  The staple line was cut.  The dilators were used using #25 and #29, then _________ #29 EEA was placed and the suture was tied.  At this point, attention was directed down to the rectal stump where dilators #25 and #29 were passed from the anus into the rectum and then the #29 Ethicon GIA was introduced.  The spike came posteriorly through the staple line to avoid the inflammatory process anteriorly that was present in the area of the cul-de-sac as well as the uterine was present in this patient.  ,Immediately, the EEA was connected with a mushroom.  It was tied, fired, and a Doyen was placed above the anastomosis approximately four inches.  Fluid was placed within the _________ and immediately a colonoscope was introduced from the patient's anus insufflating air.  No air was seen evolving from the staple line.  All fluid was removed and pictures of the staple line were taken.  The scope was removed at this point.  The case was passed to Dr. X for repair of the vesicle fistula.  Dr. X did repair down the perforation of the bladder that was communicating with an abscess secondary to the perforated diverticulitis and the colon.  After this was performed, copious amount of irrigation was used again.  More lysis of adhesions were performed and decision to make a loop transverse colostomy was made to protect the anastomosis in a phase of a severe inflammatory process in the pelvis in the infected area.  The incision was performed in the right upper quadrant.,This incision was performed with cutting in the cautery, down into the fascia splitting the muscle and then the Penrose was passed under transverse colon, and was grasped on pulling the transverse colon at the level of the skin.  The wire was passed under the transverse colon.  It was left in place.  Moderate irrigation was used in the peritoneal cavity and in the right lower quadrant, a JP was placed in the pelvis posteriorly to the abscess cavity that was down on the pelvis.  At this point, immediately, yellow fluid was removed from the peritoneal cavity and the abdomen was closed with cephalad to caudad and caudad to cephalad with a loop PDS suture and then tied.  Electrocautery for hemostasis and the subcutaneous tissue.  Copious amount of irrigation was used.  The skin was approximated with staples.  At this point, immediately, the wound was covered with a moist towel and decision to mature the loop colostomy was made.  The colostomy was opened longitudinally and then matured with interrupted #3-0 Vicryl suture through the skin edge.  One it was completely matured, immediately the index finger was probed proximally and distally and both loops were completely opened.  As previously mentioned, the Penrose was removed and the Bard was secured with a #3-0 nylon suture.  The JP was secured with #3-0 nylon suture as well.  At this point, dressings were applied.  The patient tolerated the procedure well.  The stent from the left ureter was removed and the Foley was left in place.  The patient did tolerate the procedure well and will be followed up during the hospitalization.","gastroenterology, intraperitoneal abscess, colovesical fistula, low anterior colon resection, flexible colonoscopy, transverse loop colostomy, jp placement, exploratory laparotomy, colon resection, descending colon, transverse colon, colostomy, colon, laparotomy, aparotomy, fistula"
 Leaking anastomosis from esophagogastrectomy.   Exploratory laparotomy and drainage of intra-abdominal abscesses with control of leakage. , Gastroenterology, Exploratory Laparotomy ,"PREOPERATIVE DIAGNOSIS: , Leaking anastomosis from esophagogastrectomy. ,POSTOPERATIVE DIAGNOSIS: ,  Leaking anastomosis from esophagogastrectomy. ,PROCEDURE: ,  Exploratory laparotomy and drainage of intra-abdominal abscesses with control of leakage. ,COMPLICATIONS:,  None. ,ANESTHESIA: , General oroendotracheal intubation. ,PROCEDURE:  , After adequate general anesthesia was administered, the patient's abdomen was prepped and draped aseptically. Sutures and staples were removed. The abdomen was opened. The were some very early stage adhesions that were easy to separate. Dissection was carried up toward the upper abdomen where the patient was found to have a stool filled descended colon. This was retracted caudally to expose the stomach. There were a number of adhesions to the stomach. These were carefully dissected to expose initially the closure over the gastrotomy site. Initially this looked like this was leaking but it was actually found to be intact.  The pyloroplasty was identified and also found to be intact with no evidence of leakage. Further dissection up toward the hiatus revealed an abscess collection. This was sent for culture and sensitivity and was aspirated and lavaged. Cavity tracked up toward the hiatus. Stomach itself appeared viable, there was no necrotic sections. Upper apex of the stomach was felt to be viable also. I did not pull the stomach and esophagus down into the abdomen from the mediastinum, but placed a sucker up into the mediastinum where additional turbid fluid was identified. Carefully placed a 10 mm flat Jackson-Pratt drain into the mediastinum through the hiatus to control this area of leakage. Two additional Jackson-Pratt drains were placed essentially through the gastrohepatic omentum. This was the area that most of the drainage had collected in. As I had previously discussed with Dr. Sageman I did not feel that mobilizing the stomach to redo the anastomosis in the chest would be a recoverable situation for the patient. I therefore did not push to visualize any focal areas of the anastomosis with the intent of repair. Once the drains were secured, they were brought out through the anterior abdominal wall and secured with 3-0 silk sutures and secured to bulb suction. The midline fascia was then closed using running #2 Prolene sutures bolstered with retention sutures. Subcutaneous tissue was copiously lavaged and then the skin was closed with loosely approximated staples. Dry gauze dressing was placed. The patient tolerated the procedure well, there were no complications.","gastroenterology, drainage, oroendotracheal, intubation, intra abdominal, abdominal abscesses, jackson pratt, exploratory laparotomy, anastomosis, esophagogastrectomy, mediastinum, abdomen, stomach"
" Esophageal foreign body, US penny.  Esophagoscopy with foreign body removal.  The patient had a penny lodged in the proximal esophagus in the typical location. ", Gastroenterology, Esophagoscopy & Foreign Body Removal ,"PREOPERATIVE DIAGNOSIS: , Esophageal foreign body.,POSTOPERATIVE DIAGNOSIS:,  Esophageal foreign body, US penny.,PROCEDURE: , Esophagoscopy with foreign body removal.,ANESTHESIA: , General.,INDICATIONS: , The patient is a 17-month-old baby girl with biliary atresia, who had a delayed diagnosis and a late attempted Kasai portoenterostomy, which failed.  The patient has progressive cholestatic jaundice and is on the liver transplant list at ABCD.  The patient is fed by mouth and also with nasogastric enteral feeding supplements.  She has had an __________ cough and relatively disinterested in oral intake for the past month.  She was recently in the GI Clinic and an x-ray was ordered to check her tube placement and an incidental finding of a coin in the proximal esophagus was noted.  Based on the history, it is quite possible this coin has been there close to a month.  She is brought to the operating room now for attempted removal.  I met with the parents and talked to them at length about the procedure and the increased risk in a child with a coin that has been in for a prolonged period of time.  Hopefully, there will be no coin migration or significant irrigation that would require prolonged hospitalization.,OPERATIVE FINDINGS: , The patient had a penny lodged in the proximal esophagus in the typical location.  There was no evidence of external migration and surrounding irritation was noted, but did not appear to be excessive.  The coin actually came out with relative ease after which endoscopically identified.,DESCRIPTION OF OPERATION: , The patient came to the operating room and had induction of general anesthesia.  She was slow to respond to the usual propofol and other inducing agents and may be has some difficulty with tolerance or __________ tolerance to these medications.  After her endotracheal tube was placed and securely taped to the left side of her mouth, I positioned the patient with a prominent shoulder roll and neck hyperextension and then used the laryngoscope to elevate the tiny glottic mechanism.  A rigid esophagoscope was then inserted into the proximal esophagus, and the scope was gradually advanced with the lumen directly in frontal view.  This was facilitated by the nasoenteric feeding tube that was in place, which I followed carefully until the edge of the coin could be seen.  At this location, there was quite a bit of surrounding mucosal inflammation, but the coin edge could be clearly seen and was secured with the coin grasping forceps.  I then withdrew the scope, forceps, and the coin as one unit, and it was easily retrieved.  The patient tolerated the procedure well.  There were no intraoperative complications.  There was only one single coin noted, and she was awakened and taken to the recovery room in good condition.","gastroenterology, portoenterostomy, foreign body removal, proximal esophagus, coin, esophagoscopy, esophageal, esophagus,"
" Esophagoscopy with removal of foreign body.   Esophageal foreign body, no associated comorbidities are noted.", Gastroenterology, Esophagoscopy & Foreign Body Removal - 1 ,"PRIMARY DIAGNOSIS:,  Esophageal foreign body, no associated comorbidities are noted.,PROCEDURE:,  Esophagoscopy with removal of foreign body.,CPT CODE: , 43215.,PRINCIPAL DIAGNOSIS:,  Esophageal foreign body, ICD-9 code 935.1.,DESCRIPTION OF PROCEDURE: , Under general anesthesia, flexible EGD was performed.  Esophagus was visualized.  The quarter was visualized at the aortic knob, was removed with grasper.  Estimated blood loss 0.  Intravenous fluids during time of procedure 100 mL.  No tissues.  No complications.  The patient tolerated the procedure well.  Dr. X Pipkin attending pediatric surgeon was present throughout the entire procedure.  The patient was transferred from OR to PACU in stable condition.","gastroenterology, esophagus, foreign body, esophagoscopy, esophageal, "
" Exploratory laparotomy, lysis of adhesions and removal, reversal of Hartmann's colostomy, flexible sigmoidoscopy, and cystoscopy with left ureteral stent.", Gastroenterology, Exploratory Laparotomy - 1 ,"PREOPERATIVE DIAGNOSIS:,  History of perforated sigmoid diverticuli with Hartmann's procedure.,POSTOPERATIVE DIAGNOSES:  ,1.  History of perforated sigmoid diverticuli with Hartmann's procedure.,2.  Massive adhesions.,PROCEDURE PERFORMED:,1.  Exploratory laparotomy.,2.  Lysis of adhesions and removal.,3.  Reversal of Hartmann's colostomy.,4.  Flexible sigmoidoscopy.,5.  Cystoscopy with left ureteral stent.,ANESTHESIA: , General.,HISTORY: , This is a 55-year-old gentleman who had a previous perforated diverticula.  Recommendation for reversal of the colostomy was made after more than six months from the previous surgery for a sigmoid colon resection and Hartmann's colostomy.,PROCEDURE:  ,The patient was taken to the operating room placed into lithotomy position after being prepped and draped in the usual sterile fashion.  A cystoscope was introduced into the patient's urethra and to the bladder.  Immediately, no evidence of cystitis was seen and the scope was introduced superiorly, measuring the bladder and immediately a #5 French ____ was introduced within the left urethra.  The cystoscope was removed, a Foley was placed, and wide connection was placed attaching the left ureteral stent and Foley.  At this point, immediately the patient was re-prepped and draped and immediately after the ostomy was closed with a #2-0 Vicryl suture, immediately at this point, the abdominal wall was opened with a #10 blade Bard-Parker down with electrocautery for complete hemostasis through the midline.,The incision scar was cephalad due to the severe adhesions in the midline.  Once the abdomen was entered in the epigastric area, then massive lysis of adhesions was performed to separate the small bowel from the anterior abdominal wall.  Once the small bowel was completely free from the anterior abdominal wall, at this point, the ostomy was taken down with an elliptical incision with cautery and then meticulous dissection with Metzenbaum scissors and electrocautery down to the anterior abdominal wall, where a meticulous dissection was carried with Metzenbaum scissors to separate the entire ostomy from the abdominal wall.  Immediately at this point, the bowel was dropped within the abdominal cavity, and more lysis of adhesions was performed cleaning the left gutter area to mobilize the colon further down to have no tension in the anastomosis.  At this point, the rectal stump, where two previous sutures with Prolene were seen, were brought with hemostats.  The rectal stump was free in a 360 degree fashion and immediately at this point, a decision to perform the anastomosis was made.  First, a self-retaining retractor was introduced in the abdominal cavity and a bladder blade was introduced as well.  Blue towel was placed above the small bowel retracting the bowel to cephalad and at this point, immediately the rectal stump was well visualized, no evidence of bleeding was seen, and the towels were placed along the edges of the abdominal wound.  Immediately, the pursestring device was fired approximately 1 inch from the skin and on the descending colon, this was fired.  The remainder of the excess tissue was closed with Metzenbaum scissors and immediately after dilating #25 and #29 mushroom tip from the T8 Ethicon was placed within the colon and then #9-0 suture was tied.  Immediately from the anus, the dilator #25 and #29 was introduced dilating the rectum.  The #29 EEA was introduced all the way anteriorly to the staple line and this spike from the EEA was used to perforate the rectum and then the mushroom from the descending colon was attached to it.  The EEA was then fired.  Once it was fired and was removed, the pelvis was filled with fluid.  Immediately both doughnuts were ____ from the anastomosis.  A Doyen was placed in both the anastomosis.  Colonoscope was introduced.  No bubble or air was seen coming from the anastomosis.  There was no evidence of bleeding.  Pictures of the anastomosis were taken.  The scope then was removed from the patient's rectum.  Copious amount of irrigation was used within the peritoneal cavity.  Immediately at this point, all complete sponge and instrument count was performed.  First, the ostomy site was closed with interrupted figure-of-eight #0 Vicryl suture.  The peritoneum was closed with running #2-0 Vicryl suture.  Then, the midline incision was closed with a loop PDS in cephalad to caudad and caudad to cephalad tight in the middle.  Subq tissue was copiously irrigated and the staples on the skin.,The iodoform packing was placed within the old ostomy site and then the staples on the skin as well.  The patient did tolerate the procedure well and will be followed during the hospitalization.  The left ureteral stent was removed at the end of the procedure.  _____ were performed.  Lysis of adhesions were performed.  Reversal of colostomy and EEA anastomosis #29 Ethicon.","gastroenterology, reversal of hartmann's colostomy, flexible sigmoidoscopy, cystoscopy, ureteral stent, lysis of adhesions, exploratory laparotomy, hartmann's colostomy, abdominal wall, immediately, adhesions, colostomy, sigmoidoscopy, bowel, anastomosis, abdominal"
" Esophagogastroduodenoscopy with biopsies.  Gastroesophageal reflux disease, chronic dyspepsia, alkaline reflux gastritis, gastroparesis, probable Billroth II anastomosis, and status post Whipple's pancreaticoduodenectomy.", Gastroenterology, Esophagogastroduodenoscopy with Biopsies ,"PREOPERATIVE DIAGNOSES:,1.  Gastroesophageal reflux disease.,2.  Chronic dyspepsia.,POSTOPERATIVE DIAGNOSES:,1.  Gastroesophageal reflux disease.,2.  Chronic dyspepsia.,3.  Alkaline reflux gastritis.,4.  Gastroparesis.,5.  Probable Billroth II anastomosis.,6.  Status post Whipple's pancreaticoduodenectomy.,PROCEDURE PERFORMED:,  Esophagogastroduodenoscopy with biopsies.,INDICATIONS FOR PROCEDURE: , This is a 55-year-old African-American female who had undergone Whipple's procedure approximately five to six years ago for a benign pancreatic mass.  The patient has pancreatic insufficiency and is already on replacement.  She is currently using Nexium.  She has continued postprandial dyspepsia and reflux symptoms.  To evaluate this, the patient was boarded for EGD.  The patient gave informed consent for the procedure.,GROSS FINDINGS: , At the time of EGD, the patient was found to have alkaline reflux gastritis.  There was no evidence of distal esophagitis.  Gastroparesis was seen as there was retained fluid in the small intestine.  The patient had no evidence of anastomotic obstruction and appeared to have a Billroth II reconstruction by gastric jejunostomy.  Biopsies were taken and further recommendations will follow.,PROCEDURE:  ,The patient was taken to the Endoscopy Suite.  The heart and lungs examination were unremarkable.  The vital signs were monitored and found to be stable throughout the procedure.  The patient's oropharynx was anesthetized with Cetacaine spray.  She was placed in left lateral position.  The patient had the video Olympus GIF gastroscope model inserted per os and was advanced without difficulty through the hypopharynx.  GE junction was in normal position.  There was no evidence of any hiatal hernia.  There was no evidence of distal esophagitis.  The gastric remnant was entered.  It was noted to be inflamed with alkaline reflux gastritis.  The anastomosis was open and patent.  The small intestine was entered.  There was retained fluid material in the stomach and small intestine and _______ gastroparesis.  Biopsies were performed.  Insufflated air was removed with withdrawal of the scope.  The patient's diet will be adjusted to postgastrectomy-type diet.  Biopsies performed.  Diet will be reviewed.  The patient will have an upper GI series performed to rule out more distal type obstruction explaining the retained fluid versus gastroparesis.  Reglan will also be added.  Further recommendations will follow.","gastroenterology, gastroesophageal reflux disease, chronic dyspepsia, alkaline reflux gastritis, gastroparesis, whipple's pancreaticoduodenectomy, billroth ii anastomosis, gastroesophageal reflux, alkaline reflux, reflux gastritis, gif, esophagogastroduodenoscopy, dyspepsia, gastritis, anastomosis, pancreaticoduodenectomy, biopsies, alkaline, reflux,"
 Esophagogastroduodenoscopy with photo.  Insertion of a percutaneous endoscopic gastrostomy tube.  Neuromuscular dysphagia.  Protein-calorie malnutrition., Gastroenterology, Esophagogastroduodenoscopy & Gastrostomy Tube Insertion ,"PREOPERATIVE DIAGNOSES:,1.  Neuromuscular dysphagia.,2.  Protein-calorie malnutrition.,POSTOPERATIVE DIAGNOSES:,1.  Neuromuscular dysphagia.,2.  Protein-calorie malnutrition.,PROCEDURES PERFORMED:,1.  Esophagogastroduodenoscopy with photo.,2.  Insertion of a percutaneous endoscopic gastrostomy tube.,ANESTHESIA:,  IV sedation and local.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well without difficulty.,BRIEF HISTORY:  ,The patient is a 50-year-old African-American male who presented to ABCD General Hospital on 08/18/2003 secondary to right hemiparesis from a CVA.  The patient deteriorated with several CVAs and had became encephalopathic requiring a ventilator-dependency with respiratory failure.  The patient also had neuromuscular dysfunction.  After extended period of time, per the patient's family request and requested by the ICU staff, decision to place a feeding tube was decided and scheduled for today.,INTRAOPERATIVE FINDINGS: , The patient was found to have esophagitis as well as gastritis via EGD and was placed on Prevacid granules.,PROCEDURE: , After informed written consent, the risks and benefits of the procedure were explained to the patient and the patient's family.  First, the EGD was to be performed.,The Olympus endoscope was inserted through the mouth, oropharynx and into the esophagus.  Esophagitis was noted.  The scope was then passed through the esophagus into the stomach.  The cardia, fundus, body, and antrum of the stomach were visualized.  There was evidence of gastritis.  The scope was passed into the duodenal bulb and sweep via the pylorus and then removed from the duodenum retroflexing on itself in the stomach looking at the hiatus.  Next, attention was made to transilluminating the anterior abdominal wall for the PEG placement.  The skin was then anesthetized with 1% lidocaine.  The finder needle was then inserted under direct visualization.  The catheter was then grasped via the endoscope and the wire was pulled back up through the patient's mouth.  The Ponsky PEG tube was attached to the wire.  A skin nick was made with a #11 blade scalpel.  The wire was pulled back up through the abdominal wall point and Ponsky PEG back up through the abdominal wall and inserted into position.  The endoscope was then replaced confirming position.  Photograph was taken.  The Ponsky PEG tube was trimmed and the desired attachments were placed and the patient did tolerate the procedure well.  We will begin tube feeds later this afternoon.","gastroenterology, neuromuscular dysphagia, protein-calorie malnutrition, esophagogastroduodenoscopy, endoscopic, gastrostomy, percutaneous, gastrostomy tube, percutaneous endoscopic gastrostomy tube, protein calorie malnutrition, abdominal wall, dysphagia, stomach, abdominal, neuromuscular, tube,"
 Esophagogastroduodenoscopy with pseudo and esophageal biopsy.  Hiatal hernia and reflux esophagitis. The patient is a 52-year-old female morbidly obese black female who has a long history of reflux and GERD type symptoms including complications such as hoarseness and chronic cough., Gastroenterology, Esophagogastroduodenoscopy with Biopsies -2 ,"PREOPERATIVE DIAGNOSIS: , Refractory dyspepsia.,POSTOPERATIVE DIAGNOSIS:,1.  Hiatal hernia.,2.  Reflux esophagitis.,PROCEDURE PERFORMED:,  Esophagogastroduodenoscopy with pseudo and esophageal biopsy.,ANESTHESIA:,  Conscious sedation with Demerol and Versed.,SPECIMEN: , Esophageal biopsy.,COMPLICATIONS: , None.,HISTORY:,  The patient is a 52-year-old female morbidly obese black female who has a long history of reflux and GERD type symptoms including complications such as hoarseness and chronic cough.  She has been on multiple medical regimens and continues with dyspeptic symptoms.,PROCEDURE: , After proper informed consent was obtained, the patient was brought to the endoscopy suite.  She was placed in the left lateral position and was given IV Demerol and Versed for sedation.  When adequate level of sedation achieved, the gastroscope was inserted into the hypopharynx and the esophagus was easily intubated.  At the GE junction, a hiatal hernia was present.  There were mild inflammatory changes consistent with reflux esophagitis.  The scope was then passed into the stomach.  It was insufflated and the scope was coursed along the greater curvature to the antrum.  The pylorus was patent.  There was evidence of bile reflux in the antrum.  The duodenal bulb and sweep were examined and were without evidence of mass, ulceration, or inflammation.  The scope was then brought back into the antrum.,A retroflexion was attempted multiple times, however, the patient was having difficulty holding the air and adequate retroflexion view was not visualized.  The gastroscope was then slowly withdrawn.  There were no other abnormalities noted in the fundus or body.  Once again at the GE junction, esophageal biopsy was taken.  The scope was then completely withdrawn.  The patient tolerated the procedure and was transferred to the recovery room in stable condition.  She will return to the General Medical Floor.  We will continue b.i.d proton-pump inhibitor therapy as well as dietary restrictions.  She should also attempt significant weight loss.","gastroenterology, refractory dyspepsia, hiatal hernia, reflux esophagitis, esophagogastroduodenoscopy, esophageal, pseudo, esophageal biopsy, ge junction, hiatal, hernia, esophagitis, antrum, gerd,"
 Esophagogastroduodenoscopy with biopsy of one of the polyps and percutaneous endoscopic gastrostomy tube placement.  Malnutrition and dysphagia with two antral polyps and large hiatal hernia., Gastroenterology, Esophagogastroduodenoscopy - 9 ,"PREOPERATIVE DIAGNOSES: , Malnutrition and dysphagia.,POSTOPERATIVE DIAGNOSES: , Malnutrition and dysphagia with two antral polyps and large hiatal hernia.,PROCEDURES: , Esophagogastroduodenoscopy with biopsy of one of the polyps and percutaneous endoscopic gastrostomy tube placement.,ANESTHESIA: , IV sedation, 1% Xylocaine locally.,CONDITION:,  Stable.,OPERATIVE NOTE IN DETAIL: , After risk of operation was explained to this patient's family, consent was obtained for surgery.  The patient was brought to the GI lab.  There, she was placed in partial left lateral decubitus position.  She was given IV sedation by Anesthesia.  Her abdomen was prepped with alcohol and then Betadine.  Flexible gastroscope was passed down the esophagus, through the stomach into the duodenum.  No lesions were noted in the duodenum.  There appeared to be a few polyps in the antral area, two in the antrum.  Actually, one appeared to be almost covering the pylorus.  The scope was withdrawn back into the antrum.  On retroflexion, we could see a large hiatal hernia.  No other lesions were noted.  Biopsy was taken of one of the polyps.  The scope was left in position.  Anterior abdominal wall was prepped with Betadine, 1% Xylocaine was injected in the left epigastric area.  A small stab incision was made and a large bore Angiocath was placed directly into the anterior abdominal wall, into the stomach, followed by a thread, was grasped with a snare using the gastroscope, brought out through the patient's mouth.  Tied to the gastrostomy tube, which was then pulled down and up through the anterior abdominal wall.  It was held in position with a dressing and a stent.  A connector was applied to the cut gastrostomy tube, held in place with a 2-0 silk ligature.  The patient tolerated the procedure well.  She was returned to the floor in stable condition.","gastroenterology, antral, polyps, gastrostomy, endoscopic gastrostomy, hiatal hernia, abdominal wall, gastrostomy tube, esophagogastroduodenoscopy, malnutrition, dysphagia, abdominal"
" Esophagogastroduodenoscopy with gastric biopsies.  Antral erythema; 2 cm polypoid pyloric channel tissue, questionable inflammatory polyp which was biopsied; duodenal erythema and erosion.", Gastroenterology, Esophagogastroduodenoscopy with Biopsies - 1 ,"PROCEDURE: , Esophagogastroduodenoscopy with gastric biopsies.,INDICATION:,  Abdominal pain.,FINDINGS:,  Antral erythema; 2 cm polypoid pyloric channel tissue, questionable inflammatory polyp which was biopsied; duodenal erythema and erosion.,MEDICATIONS: , Fentanyl 200 mcg and versed 6 mg.,SCOPE: , GIF-Q180.,PROCEDURE DETAIL: , Following the preprocedure patient assessment the procedure, goals, risks including bleeding, perforation and side effects of medications and alternatives were reviewed.  Questions were answered.  Pause preprocedure was performed.,Following titrated intravenous sedation the flexible video endoscope was introduced into the esophagus and advanced to the second portion of the duodenum without difficulty.  The esophagus appeared to have normal motility and mucosa.  Regular Z line was located at 44 cm from incisors.  No erosion or ulceration.  No esophagitis.,Upon entering the stomach gastric mucosa was examined in detail including retroflexed views of cardia and fundus.  There was pyloric channel and antral erythema, but no visible erosion or ulceration.  There was a 2 cm polypoid pyloric channel tissue which was suspicious for inflammatory polyp.  This was biopsied and was placed separately in bottle #2.  Random gastric biopsies from antrum, incisura and body were obtained and placed in separate jar, bottle #1.  No active ulceration was found.,Upon entering the duodenal bulb there was extensive erythema and mild erosions, less than 3 mm in length, in first portion of duodenum, duodenal bulb and junction of first and second part of the duodenum.  Postbulbar duodenum looked normal.,The patient was assessed upon completion of the procedure.  Okay to discharge once criteria met.,Follow up with primary care physician.,I met with patient afterward and discussed with him avoiding any nonsteroidal anti-inflammatory medication.  Await biopsy results.","gastroenterology, gastric biopsies, duodenal erythema, inflammatory polyp, pyloric channel tissue, pyloric channel, esophagogastroduodenoscopy, pyloric, duodenal, duodenum, polypoid,"
" Positive peptic ulcer disease.  Gastritis.  Esophagogastroduodenoscopy with photography and biopsy.   The patient had a history of peptic ulcer disease, epigastric abdominal pain x2 months, being evaluated at this time for ulcer disease.", Gastroenterology, Esophagogastroduodenoscopy - 7 ,"PREOPERATIVE DIAGNOSIS:,  Positive peptic ulcer disease.,POSTOPERATIVE DIAGNOSIS:,  Gastritis.,PROCEDURE PERFORMED: , Esophagogastroduodenoscopy with photography and biopsy.,GROSS FINDINGS:,  The patient had a history of peptic ulcer disease, epigastric abdominal pain x2 months, being evaluated at this time for ulcer disease.,Upon endoscopy, gastroesophageal junction was at 40 cm, no esophageal tumor, varices, strictures, masses, or no reflux esophagitis was noted.  Examination of the stomach reveals mild inflammation of the antrum of the stomach, no ulcers, erosions, tumors, or masses.  The profundus and the cardia of the stomach were unremarkable.  The pylorus was concentric.  The duodenal bulb and sweep with no inflammation, tumors, or masses.,OPERATIVE PROCEDURE: , The patient taken to the Endoscopy Suite, prepped and draped in the left lateral decubitus position.  She was given IV sedation using Demerol and Versed.  Olympus videoscope was inserted in the hypopharynx, upon deglutition passed into the esophagus.  Using air insufflation, the scope was advanced down through the esophagus into the stomach along the greater curvature of the stomach to the pylorus to the duodenal bulb and sweep.  The above gross findings noted.  The panendoscope was withdrawn back from the stomach, deflected upon itself.  The lesser curve fundus and cardiac were well visualized.  Upon examination of these areas, panendoscope was returned to midline.  Photographs and biopsies were obtained of the antrum of the stomach.  Air was aspirated from the stomach and panendoscope was slowly withdrawn carefully examining the lumen of the bowel.,Photographs and biopsies were obtained as appropriate.  The patient is sent to recovery room in stable condition.","gastroenterology, antrum, esophageal tumor, varices, strictures, masses, duodenal bulb, peptic ulcer, duodenal, esophagus, esophagogastroduodenoscopy, panendoscope, peptic, inflammation, ulcer, disease, stomach"
 Esophagogastroduodenoscopy with biopsy and colonoscopy with biopsy., Gastroenterology, Esophagogastroduodenoscopy - 4 ,"PROCEDURE: , Esophagogastroduodenoscopy with biopsy and colonoscopy with biopsy.,INDICATIONS FOR PROCEDURE: , A 17-year-old with history of 40-pound weight loss, abdominal pain, status post appendectomy with recurrent abscess formation and drainage.  Currently, he has a fistula from his anterior abdominal wall out.  It does not appear to connect to the gastrointestinal tract, but merely connect from the ventral surface of the rectus muscles out the abdominal wall.  CT scans show thickened terminal ileum, which suggest that we are dealing with Crohn's disease.  Endoscopy is being done to evaluate for Crohn's disease.,MEDICATIONS:  ,General anesthesia.,INSTRUMENT:,  Olympus GIF-160 and PCF-160.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  Less than 5 mL.,FINDINGS: , With the patient in the supine position, intubated under general anesthesia.  The endoscope was inserted without difficulty into the hypopharynx.  The scope was advanced down the esophagus, which had normal mucosal coloration and vascular pattern.  Lower esophageal sphincter was located at 40 cm from the central incisors.  It appeared normal and appeared to function normally.  The endoscope was advanced into the stomach, which was distended with excess air.  Rugal folds were flattened completely.  There were multiple superficial erosions scattered throughout the fundus, body, and antral portions consistent with Crohn's involvement of the stomach.  The endoscope was advanced through normal-appearing pyloric valve into the first, second, and third portion of the duodenum, which had normal mucosal coloration and fold pattern.  Biopsies were obtained x2 in the second portion of the duodenum, antrum, body, and distal esophagus at 37 cm from the central incisors for histology.  Two additional biopsies were obtained in the antrum for CLO testing.  Excess air was evacuated from the stomach.  The scope was removed from the patient who tolerated that part of the procedure well.,The patient was turned and scope was changed for colonoscopy.  Prior to colonoscopy, it was noted that there was a perianal fistula at 7 o'clock.  The colonoscope was then inserted into the anal verge.  The colonic clean out was excellent.  The scope was advanced without difficulty to the cecum.  The cecal area had multiple ulcers with exudate.  The ileocecal valve was markedly distorted.  Biopsies were obtained x2 in the cecal area and then the scope was withdrawn through the ascending, transverse, descending, sigmoid, and rectum.  The colonic mucosa in these areas was well seen and there were a few scattered aphthous ulcers in the ascending and descending colon.  Biopsies were obtained in the cecum at 65 cm, transverse colon 50 cm, rectosigmoid 20 cm, and rectum at 5 cm.  No fistulas were noted in the colon.  Excess air was evacuated from the colon.  The scope was removed.  The patient tolerated the procedure well and was taken to recovery in satisfactory condition.,IMPRESSION: , Normal esophagus and duodenum.  There were multiple superficial erosions or aphthous ulcers in the stomach along with a very few scattered aphthous ulcers in the colon with marked cecal involvement with large ulcers and a very irregular ileocecal valve.  All these findings are consistent with Crohn's disease.,PLAN:  ,Begin prednisone 30 mg p.o. daily.  Await PPD results and chest x-ray results, as well as cocci serology results.  If these are normal, then we would recommend Remicade 5 mg/kg IV infusion.  We would start Modulon 50 mL/h for 20 hours to reverse the malnutrition state of this boy.  Check CMP and phosphate every Monday, Wednesday, and Friday for receding syndrome noted by following potassium and phosphate.  We will discuss with Dr. X possibly repeating the CT fistulogram if the findings on the previous ones are inconclusive as far as the noting whether we can rule in or out an enterocutaneous fistula.  He will need an upper GI to rule out small intestinal strictures and involvement of the small intestine that cannot be seen with upper and lower endoscopy.  If he has no stricture formation in the small bowel, we would then recommend a video endoscopy capsule to further evaluate any mucosal lesions consistent with Crohn's in the small intestine that we cannot visualize with endoscopy.","gastroenterology, olympus gif-160, pcf-160, endoscopy, crohn's disease, aphthous ulcers, esophagogastroduodenoscopy, endoscope, esophagus, duodenum, mucosal, stomach, biopsies, colonoscopy"
 Esophagogastroduodenoscopy.   The Olympus video gastroscope was then introduced into the upper esophagus and passed by direct vision to the descending duodenum., Gastroenterology, Esophagogastroduodenoscopy - 6 ,"PROCEDURE IN DETAIL: , Following premedication with Vistaril 50 mg and Atropine 0.4 mg IM, the patient received Versed 5.0 mg intravenously after Cetacaine spray to the posterior palate.  The Olympus video gastroscope was then introduced into the upper esophagus and passed by direct vision to the descending duodenum.  The upper, mid and lower portions of the esophagus; the lesser and greater curves of the stomach; anterior and posterior walls; body and antrum; pylorus; duodenal bulb; and duodenum were all normal.  No evidence of friability, ulceration or tumor mass was encountered.  The instrument was withdrawn to the antrum, and biopsies taken for CLO testing, and then the instrument removed.","gastroenterology, cetacaine, pylorus, antrum, duodenum, upper esophagus, esophagogastroduodenoscopy, descending, esophagusNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Esophagogastroduodenoscopy and colonoscopy with biopsy and polypectomy., Gastroenterology, Esophagogastroduodenoscopy - 3 ,"PROCEDURES:,  Esophagogastroduodenoscopy and colonoscopy with biopsy and polypectomy.,REASON FOR PROCEDURE: , Child with abdominal pain and rectal bleeding.  Rule out inflammatory bowel disease, allergic enterocolitis, rectal polyps, and rectal vascular malformations.,CONSENT:,  History and physical examination was performed.  The procedure, indications, alternatives available, and complications, i.e. bleeding, perforation, infection, adverse medication reaction, the possible need for blood transfusion, and surgery should a complication occur were discussed with the parents who understood and indicated this.  Opportunity for questions was provided and informed consent was obtained.,MEDICATION:  ,General anesthesia.,INSTRUMENT: , Olympus GIF-160.,COMPLICATIONS:,  None.,FINDINGS: , With the patient in the supine position and intubated, the endoscope was inserted without difficulty into the hypopharynx.  The esophageal mucosa and vascular pattern appeared normal.  The lower esophageal sphincter was located at 25 cm from the central incisors.  It appeared normal.  A Z-line was identified within the lower esophageal sphincter.  The endoscope was advanced into the stomach, which distended with excess air.  Rugal folds flattened completely.  Gastric mucosa appeared normal throughout.  No hiatal hernia was noted.  Pyloric valve appeared normal.  The endoscope was advanced into the first, second, and third portions of duodenum, which had normal mucosa, coloration, and fold pattern.  Biopsies were obtained x2 in the second portion of duodenum, antrum, and distal esophagus at 22 cm from the central incisors for histology.  Additional 2 biopsies were obtained for CLO testing in the antrum.  Excess air was evacuated from the stomach.  The scope was removed from the patient who tolerated that part of procedure well.  The patient was turned and the scope was advanced with some difficulty to the terminal ileum.  The terminal ileum mucosa and the colonic mucosa throughout was normal except at approximately 10 cm where a 1 x 1 cm pedunculated juvenile-appearing polyp was noted.  Biopsies were obtained x2 in the terminal ileum, cecum, ascending colon, transverse colon, descending colon, sigmoid, and rectum.  Then, the polyp was snared right at the base of the polyp on the stalk and 20 watts of pure coag was applied in 2-second bursts x3.  The polyp was severed.  There was no bleeding at the stalk after removal of the polyp head.  The polyp head was removed by suction.  Excess air was evacuated from the colon.  The patient tolerated that part of the procedure well and was taken to recovery in satisfactory condition.  Estimated blood loss approximately 5 mL.,IMPRESSION: , Normal esophagus, stomach, duodenum, and colon as well as terminal ileum except for a 1 x 1-cm rectal polyp, which was removed successfully by polypectomy snare.,PLAN:  ,Histologic evaluation and CLO testing.  I will contact the parents next week with biopsy results and further management plans will be discussed at that time.","gastroenterology, esophagus, stomach, duodenum, rectal polyp, polypectomy snare, olympus gif-160, endoscope was advanced, clo testing, polyp head, terminal ileum, polypectomy, biopsies, esophagogastroduodenoscopy, ileum, mucosa, colonoscopy,"
" Chronic abdominal pain and heme positive stool, antral gastritis, and duodenal polyp.  Esophagogastroduodenoscopy with photos and antral biopsy.", Gastroenterology, Esophagogastroduodenoscopy - 8 ,"PREOPERATIVE DIAGNOSIS:, Chronic abdominal pain and heme positive stool.,POSTOPERATIVE DIAGNOSES:,1.  Antral gastritis.,2.  Duodenal polyp.,PROCEDURE PERFORMED:,  Esophagogastroduodenoscopy with photos and antral biopsy.,ANESTHESIA: , Demerol and Versed.,DESCRIPTION OF PROCEDURE: , Consent was obtained after all risks and benefits were described.  The patient was brought back into the Endoscopy Suite.  The aforementioned anesthesia was given.  Once the patient was properly anesthetized, bite block was placed in the patient's mouth.  Then, the patient was given the aforementioned anesthesia.  Once he was properly anesthetized, the endoscope was placed in the patient's mouth that was brought down to the cricopharyngeus muscle into the esophagus and from the esophagus to his stomach.  The air was insufflated down.  The scope was passed down to the level of the antrum where there was some evidence of gastritis seen.  The scope was passed into the duodenum and then duodenal sweep where there was a polyp seen.  The scope was pulled back into the stomach in order to flex upon itself and straightened out.  Biopsies were taken for CLO and histology of the antrum.  The scope was pulled back.  The junction was visualized.  No other masses or lesions were seen.  The scope was removed.  The patient tolerated the procedure well.  We will recommend the patient be on some type of a H2 blocker.  Further recommendations to follow.","gastroenterology, endoscopy, gastritis, clo, histology, antrum, heme positive stool, esophagogastroduodenoscopy, duodenal, polyp, antral, "
 Esophagogastroduodenoscopy.  The Olympus video panendoscope was advanced under direct vision into the esophagus.  The esophagus was normal in appearance and configuration.  The gastroesophageal junction was normal. , Gastroenterology, Esophagogastroduodenoscopy - 5 ,"MEDICATIONS:,1.  Versed intravenously.,2.  Demerol intravenously.,DESCRIPTION OF THE PROCEDURE: , After informed consent, the patient was placed in the left lateral decubitus position and Cetacaine spray was applied to the posterior pharynx.  The patient was sedated with the above medications.  The Olympus video panendoscope was advanced under direct vision into the esophagus.  The esophagus was normal in appearance and configuration.  The gastroesophageal junction was normal.  The scope was advanced into the stomach, where the fundic pool was aspirated and the stomach was insufflated with air.  The gastric mucosa appeared normal.  The pylorus was normal.  The scope was advanced through the pylorus into the duodenal bulb, which was normal, then into the second part of the duodenum, which was normal as well.  The scope was pulled back into the stomach.  Retroflexed view showed a normal incisura, lesser curvature, cardia and fundus.  The scope was straightened out, the air removed and the scope withdrawn.  The patient tolerated the procedure well.  There were no apparent complications.,","gastroenterology, duodenal bulb, gastric mucosa, olympus video, video panendoscope, gastroesophageal junction, esophagogastroduodenoscopy, gastroesophageal, pylorus, stomach, esophagus, scopeNOTE"
" Esophagogastroduodenoscopy, photography, and biopsy.  Gastroesophageal reflux disease, hiatal hernia, and enterogastritis.", Gastroenterology, Esophagogastroduodenoscopy - 12 ,"PREOPERATIVE DIAGNOSES:,1.  Gastroesophageal reflux disease.,2.  Hiatal hernia.,POSTOPERATIVE DIAGNOSES:,1.  Gastroesophageal reflux disease.,2.  Hiatal hernia.,3.  Enterogastritis.,PROCEDURE PERFORMED:  ,Esophagogastroduodenoscopy, photography, and biopsy.,GROSS FINDINGS: , The patient has a history of epigastric abdominal pain, persistent in nature.  She has a history of severe gastroesophageal reflux disease, takes Pepcid frequently.  She has had a history of hiatal hernia.  She is being evaluated at this time for disease process.  She does not have much response from Protonix.,Upon endoscopy, the gastroesophageal junction is approximately 40 cm.  There appeared to be some inflammation at the gastroesophageal junction and a small 1 cm to 2 cm hiatal hernia.  There is no advancement of the gastric mucosa up into the lower one-third of the esophagus.  However there appeared to be inflammation as stated previously in the gastroesophageal junction.  There was some mild inflammation at the antrum of the stomach.  The fundus of the stomach was within normal limits.  The cardia showed some laxity to the lower esophageal sphincter.  The pylorus is concentric.  The duodenal bulb and sweep are within normal limits.  No ulcers or erosions.,OPERATIVE PROCEDURE: , The patient is taken to the Endoscopy Suite, prepped and draped in the left lateral decubitus position.  The patient was given IV sedation using Demerol and Versed.  Olympus videoscope was inserted into the hypopharynx and upon deglutition passed into the esophagus.  Using air insufflation, panendoscope was advanced down the esophagus into the stomach along the greater curvature of the stomach through the pylorus into the duodenal bulb and sweep and the above gross findings were noted.  Panendoscope was slowly withdrawn carefully examining the lumen of the bowel.  Photographs were taken with the pathology present.  Biopsy was obtained of the antrum of the stomach and also CLO test.  The biopsy is also obtained of the gastroesophageal junction at 12, 3, 6 and 9 o' clock positions to rule out occult Barrett's esophagitis.  Air was aspirated from the stomach and the panendoscope was removed.  The patient sent to recovery room in stable condition.","gastroenterology, biopsy, gastroesophageal reflux, gastroesophageal reflux disease, duodenal bulb, gastroesophageal junction, hiatal hernia, enterogastritis, endoscopy, esophagogastroduodenoscopy, gastroesophageal,"
 Esophagogastroduodenoscopy with biopsy., Gastroenterology, Esophagogastroduodenoscopy - 2 ,"PROCEDURE:,  Esophagogastroduodenoscopy with biopsy.,REASON FOR PROCEDURE:,  The child with history of irritability and diarrhea with gastroesophageal reflux.  Rule out reflux esophagitis, allergic enteritis, and ulcer disease, as well as celiac disease.  He has been on Prevacid 7.5 mg p.o. b.i.d. with suboptimal control of this irritability.,Consent history and physical examinations were performed.  The procedure, indications, alternatives available, and complications i.e. bleeding, perforation, infection, adverse medication reactions, possible need for blood transfusion, and surgery associated complication occur were discussed with the mother who understood and indicated this.  Opportunity for questions was provided and informed consent was obtained.,MEDICATIONS:  ,General anesthesia.,INSTRUMENT: , Olympus GIF-XQ 160.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  Less than 5 mL.,FINDINGS: , With the patient in the supine position intubated under general anesthesia, the endoscope was inserted without difficulty into the hypopharynx.  The proximal, mid, and distal esophagus had normal mucosal coloration and vascular pattern.  Lower esophageal sphincter appeared normal and was located at 25 cm from the central incisors.  A Z-line was identified within the lower esophageal sphincter.  The endoscope was advanced into the stomach, which was distended with excess air.  The rugal folds flattened completely.  The gastric mucosa was entirely normal.  No hiatal hernia was seen and the pyloric valve appeared normal.  The endoscope was advanced into first, second, and third portion of the duodenum, which had normal mucosal coloration and fold pattern.  Ampule of Vater was identified and found to be normal.  Biopsies were obtained x2 in the second portion of duodenum, antrum, and distal esophagus at 22 cm from the central incisors for histology.  Additional two antral biopsies were obtained for CLO testing.  Excess air was evacuated from the stomach.  The scope was removed from the patient who tolerated the procedure well.  The patient was taken to recovery room in satisfactory condition.,IMPRESSION:,  Normal esophagus, stomach, and duodenum.,PLAN:,  Histologic evaluation and CLO testing.  Continue Prevacid 7.5 mg p.o. b.i.d.  I will contact the parents next week with biopsy results and further management plans will be discussed at that time.","gastroenterology, olympus gif-xq 160, diarrhea, gastroesophageal, esophagitis, reflux, clo testing, esophagogastroduodenoscopy with biopsy, endoscope, esophagus, stomach, duodenum, esophagogastroduodenoscopy"
 Esophagogastroduodenoscopy performed in the emergency department., Gastroenterology, Esophagogastroduodenoscopy - 13 ,"PROCEDURE PERFORMED: , Esophagogastroduodenoscopy performed in the emergency department.,INDICATION: , Melena, acute upper GI bleed, anemia, and history of cirrhosis and varices.,FINAL IMPRESSION,1.  Scope passage massive liquid in stomach with some fresh blood near the fundus, unable to identify source due to gastric contents.,2.  Endoscopy following erythromycin demonstrated grade I esophageal varices.  No stigmata of active bleeding.  Small amount of fresh blood within the hiatal hernia.  No definite source of bleeding seen.,PLAN,1.  Repeat EGD tomorrow morning following aggressive resuscitation and transfusion.,2.  Proton-pump inhibitor drip.,3.  Octreotide drip.,4.  ICU bed.,PROCEDURE DETAILS:  ,Prior to the procedure, physical exam was stable.  During the procedure, vital signs remained within normal limits.  Prior to sedation, informed consent was obtained.  Risks, benefits, and alternatives including, but not limited to risk of bleeding, infection, perforation, adverse reaction to medication, failure to identify pathology, pancreatitis, and death explained to the patient and his wife, who accepted all risks.  The patient was prepped in the left lateral position.  IV sedation was given to a total of fentanyl 100 mcg and midazolam 4 mg for the initial EGD.  An additional 50 mcg of fentanyl and 2 mg of midazolam were given following erythromycin.  Scope tip of the Olympus gastroscope was passed into the esophagus.  Proximal, middle, and distal thirds of the esophagus were well visualized.  There was fresh blood in the esophagus, which was washed thoroughly, but no source was seen.  No evidence of varices was seen.  The stomach was entered.  The stomach was filled with very large clot and fresh blood and liquid, which could not be suctioned due to the clot burden.  There was a small amount of bright red blood near the fundus, but a source could not be identified due to the clot burden.  Because of this, the gastroscope was withdrawn.  The patient was given 250 mg of erythromycin in the Emergency Department and 30 minutes later, the scope was repassed.  On the second look, the esophagus was cleared.  The liquid gastric contents were cleared.  There was still a moderate amount of clot burden in the stomach, but no active bleeding was seen.  There was a small grade I esophageal varices, but no stigmata of bleed.  There was also a small amount of fresh blood within the hiatal hernia, but no source of bleeding was identified.  The patient was hemodynamically stable; therefore, a decision was made for a second look in the morning.  The scope was withdrawn and air was suctioned.  The patient tolerated the procedure well and was sent to recovery without immediate complications.","gastroenterology, gi bleed, anemia, cirrhosis, stomach, fundus, hiatal hernia, esophagogastroduodenoscopy, erythromycin, varices, esophagus,"
 Esophagogastroduodenoscopy with bile aspirate.  Recurrent right upper quadrant pain with failure of antacid medical therapy.  Normal esophageal gastroduodenoscopy., Gastroenterology, Esophagogastroduodenoscopy - 11 ,"PREOPERATIVE DIAGNOSIS:,  Recurrent right upper quadrant pain with failure of antacid medical therapy.,POSTOPERATIVE DIAGNOSIS: , Normal esophageal gastroduodenoscopy.,PROCEDURE PERFORMED:,  Esophagogastroduodenoscopy with bile aspirate.,ANESTHESIA: , IV Demerol and Versed in titrated fashion.,INDICATIONS: , This 41-year-old female presents to surgical office with history of recurrent right upper quadrant abdominal pain.  Despite antacid therapy, the patient's pain has continued.  Additional findings were concerning with possibility of a biliary etiology.  The patient was explained the risks and benefits of an EGD as well as a Meltzer-Lyon test where upon bile aspiration was performed.  The patient agreed to the procedure and informed consent was obtained.,GROSS FINDINGS: , No evidence of neoplasia, mucosal change, or ulcer on examination.  Aspiration of the bile was done after the administration of 3 mcg of Kinevac.,PROCEDURE DETAILS: , The patient was placed in the supine position.  After appropriate anesthesia was obtained, an Olympus gastroscope inserted from the oropharynx through the second portion of duodenum.  Prior to this, 3 mcg of IV Kinevac was given to the patient to aid with the stimulation of bile.  At this time, the patient as well complained of epigastric discomfort and nausea.  This pain was similar to her previous pain.,Bile was aspirated with a trap to enable the collection of the fluid.  This fluid was then sent to lab for evaluation for crystals.  Next, photodocumentation obtained and retraction of the gastroscope through the antrum revealed no other evidence of disease, retroflexion revealed no evidence of hiatal hernia or other mass and after straightening the scope and aspiration ________, gastroscope was retracted.  The gastroesophageal junction was noted at 20 cm.  No other evidence of disease was appreciated here.  Retraction of the gastroscope backed through the esophagus, off the oropharynx, removed from the patient.  The patient tolerated the procedure well.  We will await evaluation of bile aspirate.","gastroenterology, bile aspirate, esophageal, gastroduodenoscopy, kinevac, oropharynx, esophagogastroduodenoscopy, gastroscope"
 Patient presents to the emergency room with complaints of mid-epigastric and right upper quadrant abdominal pain for the last 14 days., Gastroenterology, ER Report - Stomach Pain ,"CHIEF COMPLAINT:, Stomach pain for 2 weeks.,HISTORY OF PRESENT ILLNESS:, The patient is a 45yo Mexican man without significant past medical history who presents to the emergency room with complaints of mid-epigastric and right upper quadrant abdominal pain for the last 14 days. The pain was initially crampy and burning in character and was relieved with food intake. He also reports that it initially was associated with a sour taste in his mouth. He went to his primary care physician who prescribed cimetidine 400mg qhs x 5 days; however, this did not relieve his symptoms. In fact, the pain has worsened such that the pain now radiates to the back but is waxing and waning in duration. It is relieved with standing and ambulation and exacerbated when lying in a supine position. He reports a decrease in appetite associated with a 4 lb. wt loss over the last 2 wks. He does have nausea with only one episode of non-bilious, non-bloody emesis on day of admission. He reports a 2 wk history of subjective fever and diaphoresis. He denies any diarrhea, constipation, dysuria, melena, or hematochezia. His last bowel movement was during the morning of admission and was normal. He denies any travel in the last 9 years and sick contacts.,PAST MEDICAL HISTORY:, Right inguinal groin cyst removal 15 years ago. Unknown etiology. No recurrence.,PAST SURGICAL HISTORY:, Left femoral neck fracture with prosthesis secondary to a fall 4 years ago.,FAMILY HISTORY:, Mother with diabetes. No history of liver disease. No malignancies.,SOCIAL HISTORY:, The patient was born in central Mexico but moved to the United States 9 years ago. He is on disability due to his prior femoral fracture. He denies any tobacco or illicit drug use. He only drinks alcohol socially, no more than 1 drink every few weeks. He is married and has 3 healthy children. He denies any tattoos or risky sexual behavior.,ALLERGIES:, NKDA.,MEDICATIONS:, Tylenol prn (1-2 tabs every other day for the last 2 wks), Cimetidine 400mg po qhs x 5 days.,REVIEW OF SYSTEMS:,  No headache, vision changes. No shortness of breath. No chest pain or palpitations.,PHYSICAL EXAMINATION:,Vitals: T 100.9-102.7 BP 136/86 Pulse 117 RR 12 98% sat on room air,Gen: Well-developed, well-nourished, no apparent distress.,HEENT: Pupils equal, round and reactive to light. Anicteric. Oropharynx clear and moist.,Neck: Supple. No lymphadenopathy or carotid bruits. No thyromegaly or masses.,CHEST: Clear to auscultation bilaterally.,CV: Tachycardic but regular rhythm, normal S1/S2, no murmurs/rubs/gallops.,Abd: Soft, active bowel sounds. Tender in the epigastrium and right upper quadrant with palpation associated with slight guarding. No rebound tenderness. No hepatomegaly. No splenomegaly.,Rectal: Stool was brown and guaiac negative.,Ext: No cyanosis/clubbing/edema.,Neurological: He was alert and oriented x3. CN II-XII intact. Normal 2+ DTRs. No focal neurological deficit.,Skin: No jaundice. No skin rashes or lesions.,IMAGING DATA:,CT Abdomen with contrast ( 11/29/03 ):  There is a 6x6 cm multilobular hypodense mass seen at the level of the hepatic hilum and caudate lobe which is resulting in mass effect with dilatation of the intrahepatic radicals of the left lobe of the liver. The rest of the liver parenchyma is homogeneous. The gallbladder, pancreas, spleen, adrenal glands and kidneys are within normal limits. The retroperitoneal vascular structures are within normal limits. There is no evidence of lymphadenopathy, free fluid or fluid collections.,HOSPITAL COURSE:,  The patient was admitted to the hospital for further evaluation. A diagnostic procedure was performed.",
" Ivor-Lewis esophagogastrectomy, feeding jejunostomy, placement of two right-sided 28 French chest tubes, and right thoracotomy.", Gastroenterology," Esophagogastrectomy, Jejunostomy, & Chest Tubes ","OPERATION,1.  Ivor-Lewis esophagogastrectomy.,2.  Feeding jejunostomy.,3.  Placement of two right-sided #28-French chest tubes.,4.  Right thoracotomy.,ANESTHESIA:  ,General endotracheal anesthesia with a dual-lumen tube.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered.  Prior to administration of general anesthesia, the patient had an epidural anesthesia placed.  In addition, he had a dual-lumen endotracheal tube placed.  The patient was placed in the supine position to begin the procedure.  His abdomen and chest were prepped and draped in the standard surgical fashion.  After applying sterile dressings, a #10-blade scalpel was used to make an upper midline incision from the level of the xiphoid to just below the umbilicus.  Dissection was carried down through the linea using Bovie electrocautery.  The abdomen was opened.  Next, a Balfour retractor was positioned as well as a mechanical retractor.  Next, our attention was turned to freeing up the stomach.  In an attempt to do so, we identified the right gastroepiploic artery and arcade.  We incised the omentum and retracted it off the stomach and gastroepiploic arcade.  The omentum was divided using suture ligature with 2-0 silk.  We did this along the greater curvature and then moved to the lesser curvature where the short gastric arteries were taken down with ligation using 2-0 silk.  Next, we turned our attention to performing a Kocher maneuver.  This was done and the stomach was freed up.  We took down the falciform ligament as well as the caudate attachment to the diaphragm.  We enlarged the diaphragmatic hiatus so as to be able to place approximately 3 fingers into the chest.  We also did a portion of the esophageal dissection from the abdomen into the chest area.  The esophagus and the esophageal hiatus were identified in the abdomen.  We next turned our attention to the left gastric artery.  The left gastric artery was identified at the base of the stomach.  We first took the left gastric vein by ligating and dividing it using 0 silk ties.  The left gastric artery was next taken using suture ligature with silk ties followed by 2-0 stick tie reinforcement.  At this point the stomach was freely mobile.  We then turned our attention to performing our jejunostomy feeding tube.  A 2-0 Vicryl pursestring was placed in the jejunum approximately 20 cm distal to the ligament of Treitz.  We then used Bovie electrocautery to open the jejunum at this site.  We placed a 16-French red rubber catheter through this site.  We tied down in place.  We then used 3-0 silk sutures to perform a Witzel.  Next, the loop of jejunum was tacked up to the abdominal wall using 2-0 silk ties.  After doing so and pulling the feeding jejunostomy out through the skin and securing it appropriately, we turned our attention to closing the abdomen.  This was done with #1 Prolene.  We put in a 2nd layer of 2-0 Vicryl.  The skin was closed with 4-0 Monocryl.,Next, we turned our attention to performing the thoracic portion of the procedure.  The patient was placed in the left lateral decubitus position.  The right chest was prepped and draped appropriately.  We then used a #10 blade scalpel to make an incision in a posterolateral, non-muscle-sparing fashion.  Dissection was carried down to the level of the ribs with Bovie electrocautery.  Next, the ribs were counted and the 5th interspace was entered.  The lung was deflated.  We placed standard chest retractors.  Next, we incised the peritoneum over the esophagus.  We dissected the esophagus to just above the azygos vein.  The azygos vein, in fact, was taken with 0 silk ligatures and reinforced with 2-0 stick ties.  As mentioned, we dissected the esophagus both proximally and distally down to the level of the hiatus.  After doing this, we backed our NG tube out to above the level where we planned to perform our pursestring.  We used an automatic pursestring and applied.  We then transected the proximal portion of the stomach with Metzenbaum scissors.  We secured our pursestring and then placed a 28 anvil in the divided proximal portion of the esophagus.  The pursestring was then tied down without difficulty.  Next, we tabularized our stomach using a #80 GIA stapler.  After doing so, we chose a portion of the stomach more distally and opened it using Bovie electrocautery.  We placed our EEA stapler through it and then punched out through the gastric wall.  We connected our anvil to the EEA stapler.  This was then secured appropriately.  We checked to make sure that there was appropriate muscle apposition.  We then fired the stapler.  We obtained 2 complete rings, 1 of the esophagus and 1 of the stomach, which were sent for pathology.  We also sent the gastroesophageal specimen for pathology.  Of note was the fact that the frozen section showed no evidence of tumor and in the proximal distal margins.  We then turned our attention to closing the gastrostomy opening.  This was closed with 2-0 Vicryl in a running fashion.  We then buttressed this with serosal 3-0 Vicryl interrupted sutures.  We returned the newly constructed gastroesophageal anastomosis into the chest and covered it by covering the pleura over it.  Next, we placed two #28-French chest tubes, 1 anteriorly and 1 posteriorly, taking care not to place it near the anastomosis.  We then closed the chest with #2 Vicryl in an interrupted figure-of-eight fashion.  The lung was brought up.  We closed the muscle layers with #0 Vicryl followed by #0 Vicryl; then we closed the subcutaneous layer with 2-0 Vicryl and the skin with 4-0 Monocryl.  Sterile dressing was applied.  The instrument and sponge count was correct at the end of the case.  The patient tolerated the procedure well and was extubated in the operating room and transferred to the ICU in good condition.","gastroenterology, ivor-lewis, esophagogastrectomy, jejunostomy, thoracotomy, dual-lumen tube, chest tubes, bovie electrocautery, chest, endotracheal, electrocautery, abdomen, gastric, esophagus, tubes, vicryl, stomach, "
 Endoscopic retrograde cholangiopancreatography (ERCP) with brush cytology and biopsy., Gastroenterology, ERCP ,"PROCEDURE:, Endoscopic retrograde cholangiopancreatography with brush cytology and biopsy.,INDICATION FOR THE PROCEDURE:, Patient with a history of chronic abdominal pain and CT showing evidence of chronic pancreatitis, with a recent upper endoscopy showing an abnormal-appearing ampulla.,MEDICATIONS:, General anesthesia.,The risks of the procedure were made aware to the patient and consisted of medication reaction, bleeding, perforation, aspiration, and post ERCP pancreatitis.,DESCRIPTION OF PROCEDURE: ,After informed consent and appropriate sedation, the duodenoscope was inserted into the oropharynx, down the esophagus, and into the stomach. The scope was then advanced through the pylorus to the ampulla. The ampulla had a markedly abnormal appearance, as it was enlarged and very prominent. It extended outward with an almost polypoid shape. It had what appeared to be adenomatous-appearing mucosa on the tip. There also was ulceration noted on the tip of this ampulla. The biliary and pancreatic orifices were identified. This was located not at the tip of the ampulla, but rather more towards the base. Cannulation was performed with a Wilson-Cooke TriTome sphincterotome with easy cannulation of the biliary tree. The common bile duct was mildly dilated, measuring approximately 12 mm. The intrahepatic ducts were minimally dilated. There were no filling defects identified. There was felt to be a possible stricture within the distal common bile duct, but this likely represented an anatomic variant given the abnormal shape of the ampulla. The patient has no evidence of obstruction based on lab work and clinically. Nevertheless, it was decided to proceed with brush cytology of this segment. This was done without any complications. There was adequate drainage of the biliary tree noted throughout the procedure. Multiple efforts were made to access the pancreatic ductal anatomy; however, because of the shape of the ampulla, this was unsuccessful. Efforts were made to proceed in a long scope position, but still were unsuccessful. Next, biopsies were obtained of the ampulla away from the biliary orifice. Four biopsies were taken. There was some minor oozing which had ceased by the end of the procedure. The stomach was then decompressed and the endoscope was withdrawn.,FINDINGS:,1. Abnormal papilla with bulging, polypoid appearance, and looks adenomatous with ulceration on the tip; biopsies taken.,2. Cholangiogram reveals mildly dilated common bile duct measuring 12 mm and possible distal CBD stricture, although I think this is likely an anatomic variant; brush cytology obtained.,3. Unable to access the pancreatic duct.,RECOMMENDATIONS:,1. NPO except ice chips today.,2. Will proceed with MRCP to better delineate pancreatic ductal anatomy.,3. Follow up biopsies and cytology.","gastroenterology, endoscopic retrograde cholangiopancreatography, biopsy, brush cytology, cholangiopancreatography, pancreatitis, endoscopy, duodenoscope, wilson-cooke tritome, ampulla, common bile duct, ercp, endoscopic, biliary, pancreatic, duct, biopsies, cytology"
" Esophagogastroduodenoscopy with biopsy, a 1-year-10-month-old with a history of dysphagia to solids.", Gastroenterology, Esophagogastroduodenoscopy - 1 ,"PROCEDURE: , Esophagogastroduodenoscopy with biopsy.,PREOPERATIVE DIAGNOSIS: , A 1-year-10-month-old with a history of dysphagia to solids.  The procedure was done to rule out organic disease.,POSTOPERATIVE DIAGNOSES: , Loose lower esophageal sphincter and duodenal ulcers.,CONSENT: , The consent is signed.,MEDICATIONS:  ,The procedure was done under general anesthesia given by Dr. Marino Fernandez.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL:,  A history and physical examination were performed, and the procedure, indications, potential complications including bleeding, perforation, the need for surgery, infection, adverse medical reaction, risks, benefits, and alternatives available were explained to the parents, who stated good understanding and consented to go ahead with the procedure.  The opportunity for questions was provided, and informed consent was obtained.  Once the consent was obtained, the patient was sedated with IV medications and intubated by Dr. Fernandez and placed in the supine position.  Then, the tip of the XP-160 videoscope was introduced into the oropharynx, and under direct visualization, we could advance the endoscope into the upper, mid, and lower esophagus.  We did not find any strictures in the upper esophagus, but the patient had the lower esophageal sphincter totally loose.  Then the tip of the endoscope was advanced down into the stomach and guided into the pylorus, and then into the first portion of the duodenum.  We noticed that the patient had several ulcers in the first portion of the duodenum.  Then the tip of the endoscope was advanced down into the second portion of the duodenum, one biopsy was taken there, and then, the tip of the endoscope was brought back to the first portion, and two biopsies were taken there.  Then, the tip of the endoscope was brought back to the antrum, where two biopsies were taken, and one biopsy for CLOtest.  By retroflexed view, at the level of the body of the stomach, I could see that the patient had the lower esophageal sphincter loose.  Finally, the endoscope was unflexed and was brought back to the lower esophagus, where two biopsies were taken.  At the end, air was suctioned from the stomach, and the endoscope was removed out of the patient's mouth.  The patient tolerated the procedure well with no complications.,FINAL IMPRESSION:  ,1.  Duodenal ulcers.,2.  Loose lower esophageal sphincter.,PLAN:,1.  To start omeprazole 20 mg a day.,2.  To review the biopsies.,3.  To return the patient back to clinic in 1 to 2 weeks.","gastroenterology, esophagogastroduodenoscopy, esophageal, biopsies, endoscope"
 The patient was brought to the OR with the known 4 cm abdominal aortic aneurysm + 2.5 cm right common iliac artery aneurysm., Gastroenterology, Endovascular Abdominal Aortic Aneurysm Repair ,"PREOPERATIVE DIAGNOSIS: , Abdominal aortic aneurysm.,POSTOPERATIVE DIAGNOSIS: , Abdominal aortic aneurysm.,OPERATION PERFORMED:,  Endovascular abdominal aortic aneurysm repair.,FINDINGS: , The patient was brought to the OR with the known 4 cm abdominal aortic aneurysm + 2.5 cm right common iliac artery aneurysm.  A Gore exclusive device was used 3 pieces were used to effect the repair.  We had to place an iliac extender down in to right external iliac artery to manage the right common iliac artery aneurysm.  The right hypogastric artery had been previously coiled off.  Left common femoral artery was used for the _____ side.  We had small type 2 leak right underneath the take off the renal arteries, this was not felt to be type I leak and this was very delayed filling and it was felt that this was highly indicative of type 2 leak from a lumbar artery, which commonly come off in this area.  It was felt that this would seal after reversal of the anticoagulation given sufficient time.,PROCEDURE: , With the patient supine position under general anesthesia, the abdomen and lower extremities were prepped and draped in a sterile fashion.,Bilateral groin incisions were made, and the common femoral arteries were dissected out bilaterally.  The patient was then heparinized.,The 7-French sheaths were then placed retrograde bilaterally.,A stiff Amplatz wires were then placed up the right femoral artery and a stiff Amplatz were placed left side a calibrated catheter was placed up the right side.  The calibrated aortogram was the done.  We marked the renal arteries aortic bifurcation and bifurcation, common iliac arteries.  We then preceded placement of the main trunk, by replacing the 7 French sheath in the left groin area with 18-french sheath and then deployed the trunk body just below the take off renal arteries.,Once the main trunk has been deployed within wired _____ then deployed an iliac limb down in to the right common iliac artery.  As noted above, we then had to place an iliac extension, down in the external iliac artery to exclude the right common iliac artery and resume completely.,Following completion of the above all arteries were ballooned appropriately.  A completion angiogram was done which showed late small type 2 leak just under the take off renal arteries.  The area was ballooned aggressively.  It was felt that this would dissolve as discussed above.,Following completion of the above all wire sheaths etc., were removed from both groin areas.  Both femoral arteries were repaired by primary suture technique.  Flow was then reestablished to the lower extremities, and protamine was given to reverse the heparin.,Both surgical sites were then irrigated thoroughly.  Meticulous hemostasis was achieved.  Both wounds were then closed in a routine layered fashion.,Sterile antibiotic dressings were applied.  Sponge and needle counts were reported as correct.  The patient tolerated the procedure well the patient was taken to the recovery room in satisfactory condition.","gastroenterology, gore, common iliac artery aneurysm, abdominal aortic aneurysm repair, abdominal aortic aneurysm, common iliac, aortic aneurysm, iliac artery, artery, aneurysm, iliac, abdominal, aortic, arteries,"
 Esophagogastroduodenoscopy with biopsy and snare polypectomy - Iron-deficiency anemia, Gastroenterology, Esophagogastroduodenoscopy ,"PROCEDURE:, Esophagogastroduodenoscopy with biopsy and snare polypectomy.,INDICATION FOR THE PROCEDURE:, Iron-deficiency anemia.,MEDICATIONS:, MAC.,The risks of the procedure were made aware to the patient and consisted of medication reaction, bleeding, perforation, and aspiration.,PROCEDURE:, After informed consent and appropriate sedation, the upper endoscope was inserted into the oropharynx down into the stomach and beyond the pylorus and the second portion of the duodenum. The duodenal mucosa was completely normal. The pylorus was normal. In the stomach, there was evidence of diffuse atrophic-appearing nodular gastritis. Multiple biopsies were obtained. There also was a 1.5-cm adenomatous appearing polyp along the greater curvature at the junction of the body and antrum. There was mild ulceration on the tip of this polyp. It was decided to remove the polyp via snare polypectomy. Retroflexion was performed, and this revealed a small hiatal hernia in the distal esophagus. The Z-line was identified and was unremarkable. The esophageal mucosa was normal.,FINDINGS:,1. Hiatal hernia.,2. Diffuse nodular and atrophic appearing gastritis, biopsies taken.,3. A 1.5-cm polyp with ulceration along the greater curvature, removed.,RECOMMENDATIONS:,1. Follow up biopsies.,2. Continue PPI.,3. Hold Lovenox for 5 days.,4. Place SCDs.","gastroenterology, esophagogastroduodenoscopy, iron-deficiency, iron-deficiency anemia, anemia, biopsy, endoscope, esophageal mucosa, esophagus, hiatal hernia, polypectomy, snare polypectomy, esophagogastroduodenoscopy with biopsy, iron deficiency anemia,"
 Esophagogastroduodenoscopy with antral biopsies for H. pylori x2 with biopsy forceps.  Nausea and vomiting and upper abdominal pain., Gastroenterology, Esophagogastroduodenoscopy - 10 ,"PREOPERATIVE DIAGNOSIS: , Nausea and vomiting and upper abdominal pain.,POST PROCEDURE DIAGNOSIS:  ,Normal upper endoscopy.,OPERATION: , Esophagogastroduodenoscopy with antral biopsies for H. pylori x2 with biopsy forceps.,ANESTHESIA:,  IV sedation 50 mg Demerol, 8 mg of Versed.,PROCEDURE: , The patient was taken to the endoscopy suite.  After adequate IV sedation with the above medications, hurricane was sprayed in the mouth as well as in the esophagus.  A bite block was placed and the gastroscope placed into the mouth and was passed into the esophagus and negotiated through the esophagus, stomach, and pylorus.  The first, second, and third portions of the duodenum were normal.  The scope was withdrawn into the antrum which was normal and two bites with the biopsy forceps were taken in separate spots for H. pylori.  The scope was retroflexed which showed a normal GE junction from the inside of the stomach and no evidence of pathology or paraesophageal hernia.  The scope was withdrawn at the GE junction which was in a normal position with a normal transition zone.  The scope was then removed throughout the esophagus which was normal.  The patient tolerated the procedure well.,The plan is to obtain a HIDA scan as the right upper quadrant ultrasound appeared to be normal, although previous ultrasounds several years ago showed a gallstone.","gastroenterology, h. pylori, forceps, antral biopsies, ge junction, esophagogastroduodenoscopy, pylori, esophagus, antral, "
" Upper endoscopy with biopsy.   The patient admitted for coffee-ground emesis, which has been going on for the past several days.  An endoscopy is being done to evaluate for source of upper GI bleeding.", Gastroenterology, Endoscopy With Biopsy ,"PROCEDURE:,  Upper endoscopy with biopsy.,PROCEDURE INDICATION: , This is a 44-year-old man who was admitted for coffee-ground emesis, which has been going on for the past several days.  An endoscopy is being done to evaluate for source of upper GI bleeding.,Informed consent was obtained.  Outlining the risks, benefits and alternatives of the procedure included, but not to risks of bleeding, infection, perforation, the patient agreed for the procedure.,MEDICATIONS: , Versed 4 mg IV push and fentanyl 75 mcg IV push given throughout the procedure in incremental fashion with careful monitoring of patient's pressures and vital signs.,PROCEDURE IN DETAIL:  ,The patient was placed in the left lateral decubitus position.  Medications were given.  After adequate sedation was achieved, the Olympus video endoscope was inserted into the mouth and advanced towards the duodenum.","gastroenterology, coffee-ground emesis, gi bleeding, upper endoscopy, iv push, esophagus, duodenum, mucosa, stomach, endoscopy, biopsy,"
 Intermittent rectal bleeding with abdominal pain., Gastroenterology, Endoscopy - 4 ,"PROCEDURE: , Endoscopy.,CLINICAL INDICATIONS: , Intermittent rectal bleeding with abdominal pain.,ANESTHESIA: , Fentanyl 100 mcg and 5 mg of IV Versed.,PROCEDURE:,  The patient was taken to the GI lab and placed in the left lateral supine position.  Continuous pulse oximetry and blood pressure monitoring were in place.  After informed consent was obtained, the video endoscope was inserted over the dorsum of the tongue without difficulty.  With swallowing, the scope was advanced down the esophagus into the body of the stomach.  The scope was further advanced down to the antrum and through the pylorus into the duodenum, which was visualized into its second portion.  It appeared free of stricture, neoplasm, or ulceration.  Samples were obtained from the antrum and prepyloric area to check for Helicobacter, rapid urease, and additional samples were sent to pathology.  Retroflexion view of the fundus of the stomach was normal without evidence of a hiatal hernia.  The scope was then slowly removed.  The distal esophagus appeared benign with a normal-appearing gastroesophageal sphincter and no esophagitis.  The remaining portion of the esophagus was normal.,IMPRESSION:,  Abdominal pain.  Symptoms most consistent with gastroesophageal reflux disease without endoscopic evidence of hiatal hernia.,RECOMMENDATIONS:,  Await results of CLO testing and biopsies.  Return to clinic with Dr. Spencer in 2 weeks for further discussion.","gastroenterology, duodenum, stomach, hiatal hernia, endoscopy, antrum, hiatal, hernia, gastroesophageal, scope, esophagus, abdominal"
 Epigastric herniorrhaphy.  Epigastric hernia., Gastroenterology, Epigastric Herniorrhaphy ,"PREOPERATIVE DIAGNOSIS: , Epigastric hernia.,POSTOPERATIVE DIAGNOSIS: , Epigastric hernia.,OPERATIONS:,  Epigastric herniorrhaphy.,ANESTHESIA: , General inhalation.,PROCEDURE: , Following attainment of satisfactory anesthesia, the patient's abdomen was prepped with Hibiclens and draped sterilely.  The hernia mass had been marked preoperatively.  This area was anesthetized with a mixture of Marcaine and Xylocaine.  A transverse incision was made over the hernia and dissection carried down to the entrapped fat.  Sharp dissection was carried around the fat down to the fascial edge.  The preperitoneal fat could not be reduced; therefore, it is trimmed away and the small fascial defect then closed with interrupted 0-Ethibond sutures.  The fascial edges were injected with the local anesthetic mixture.  Subcutaneous tissues were then closed with interrupted 4-0 Vicryl and skin edges closed with running subcuticular 4-0 Vicryl.  Steri-Strips and a sterile dressing were applied to complete the closure.  The patient was then awakened and taken to the PACU in satisfactory condition.,ESTIMATED BLOOD LOSS: , 10 mL.,SPONGE AND NEEDLE COUNT: , Reported as correct.,COMPLICATIONS: , None.","gastroenterology, hibiclens, epigastric herniorrhaphy, epigastric hernia, herniorrhaphy,"
 Normal upper GI endoscopy., Gastroenterology, Endoscopy Template ,"INDICATIONS:,  Dysphagia.,PREMEDICATION:,  Topical Cetacaine spray and Versed IV.,PROCEDURE:,:  The scope was passed into the esophagus under direct vision.  The esophageal mucosa was all unremarkable.  There was no evidence of any narrowing present anywhere throughout the esophagus and no evidence of esophagitis.  The scope was passed on down into the stomach.  The gastric mucosa was all examined including a retroflexed view of the fundus and there were no abnormalities seen.  The scope was then passed into the duodenum and the duodenal bulb and second and third portions of the duodenum were unremarkable.  The scope was again slowly withdrawn through the esophagus and no evidence of narrowing was present.  The scope was then withdrawn.,IMPRESSION:,  Normal upper GI endoscopy without any evidence of anatomical narrowing.","gastroenterology, dysphagia, cetacaine spray, esophagus, esophageal mucosa, duodenum, scope was passed, upper gi, gi endoscopy, gi, endoscopy, scope"
 Patient with dysphagia., Gastroenterology, Endoscopy - 3 ,"PROCEDURES PERFORMED: , Endoscopy.,INDICATIONS: , Dysphagia.,POSTOPERATIVE DIAGNOSIS:,  Esophageal ring and active reflux esophagitis.,PROCEDURE: , Informed consent was obtained prior to the procedure from the parents and patient.  The oral cavity is sprayed with lidocaine spray.  A bite block is placed.  Versed IV 5 mg and 100 mcg of IV fentanyl was given in cautious increments.  The GIF-160 diagnostic gastroscope used.  The patient was alert during the procedure.  The esophagus was intubated under direct visualization.  The scope was advanced toward the GE junction with active reflux esophagitis involving the distal one-third of the esophagus noted.  The stomach was unremarkable.  Retroflexed exam unremarkable.  Duodenum not intubated in order to minimize the time spent during the procedure.  The patient was alert although not combative.  A balloon was then inserted across the GE junction, 15 mm to 18 mm, and inflated to 3, 4.7, and 7 ATM, and left inflated at 18 mm for 45 seconds.  The balloon was then deflated.  The patient became uncomfortable and a good-size adequate distal esophageal tear was noted.  The scope and balloon were then withdrawn.  The patient left in good condition.,IMPRESSION: , Successful dilation of distal esophageal fracture in the setting of active reflux esophagitis albeit mild.,PLAN: , I will recommend that the patient be on lifelong proton pump inhibition and have repeat endoscopy performed as needed.  This has been discussed with the parents.  He was sent home with a prescription for omeprazole.","gastroenterology, active reflux esophagitis, ge junction, distal esophageal, active reflux, reflux esophagitis, dysphagia, esophagus, scope, ge, junction, endoscopy, esophageal, reflux, esophagitis, distal, balloon"
" EGD with photos and biopsies.  This is a 75-year-old female who presents with difficulty swallowing, occasional choking, and odynophagia.  She has a previous history of hiatal hernia.  She was on Prevacid currently. ", Gastroenterology, EGD With Photos & Biopsies. ,"1.  Odynophagia.,2.  Dysphagia.,3.  Gastroesophageal reflux disease rule out stricture.,POSTOPERATIVE DIAGNOSES:,1.  Antral gastritis.,2.  Hiatal hernia.,PROCEDURE PERFORMED:  EGD with photos and biopsies.,GROSS FINDINGS:  This is a 75-year-old female who presents with difficulty swallowing, occasional choking, and odynophagia.  She has a previous history of hiatal hernia.  She was on Prevacid currently.  At this time, an EGD was performed to rule out stricture.  At the time of EGD, there was noted some antral gastritis and hiatal hernia.  There are no strictures, tumors, masses, or varices present.,OPERATIVE PROCEDURE:  The patient was taken to the Endoscopy Suite in the lateral decubitus position.  She was given sedation by the Department Of Anesthesia.  Once adequate sedation was reached, the Olympus gastroscope was inserted into oropharynx.  With air insufflation entered through the proximal esophagus to the GE junction.  The esophagus was without evidence of tumors, masses, ulcerations, esophagitis, strictures, or varices.  There was a hiatal hernia present.  The scope was passed through the hiatal hernia into the body of the stomach.  In the distal antrum, there was some erythema with patchy erythematous changes with small superficial erosions.  Multiple biopsies were obtained.  The scope was passed through the pylorus into the duodenal bulb and duodenal suite, they appeared within normal limits.  The scope was pulled back from the stomach, retroflexed upon itself, _____ fundus and GE junction.  As stated, multiple biopsies were obtained.,The scope was then slowly withdrawn.  The patient tolerated the procedure well and sent to recovery room in satisfactory condition.","gastroenterology, odynophagia, dysphagia, gastroesophageal reflux disease, antral gastritis, hiatal hernia, difficulty swallowing, esophagus, stomach, duodenal, egd, biopsies, hiatal, hernia, "
 Upper gastrointestinal endoscopy., Gastroenterology, Endoscopy ,"PREOPERATIVE DIAGNOSIS: , Anemia.,PROCEDURE:,  Upper gastrointestinal endoscopy.,POSTOPERATIVE DIAGNOSES:,1.  Severe duodenitis.,2.  Gastroesophageal junction small ulceration seen.,3.  No major bleeding seen in the stomach.,PROCEDURE IN DETAIL: , The patient was put in left lateral position.  Olympus scope was inserted from the mouth, under direct visualization advanced to the upper part of the stomach, upper part of esophagus, middle of esophagus, GE junction, and some intermittent bleeding was seen at the GE junction.  Advanced into the upper part of the stomach into the antrum.  The duodenum showed extreme duodenitis and the scope was then brought back.  Retroflexion was performed, which was normal.  Scope was then brought back slowly.  Duodenitis was seen and a little bit of ulceration seen at GE junction.,FINDING: , Severe duodenitis, may be some source of bleeding from there, but no active bleeding at this time.","gastroenterology, upper gastrointestinal endoscopy, ge junction, gastrointestinal, esophagus, endoscopy, stomach, duodenitis, bleeding"
 EGD with dilation for dysphagia., Gastroenterology, EGD with Dilation ,"INDICATION:  ,","gastroenterology, egd, hurricaine spray, olympus endoscope, savary wire, cricopharyngeus, decubitus, dilator, duodenum, dysphagia, esophagus, hiatal hernia, peptic, pylorus, stomach, tortuosity, egd with dilation, tortuous, scope, hiatal, hernia,"
" Patient admitted because of recurrent nausea and vomiting, with displacement of the GEJ feeding tube.", Gastroenterology, EGD with Biopsy - 1 ,"PROCEDURE PERFORMED: , EGD with biopsy.,INDICATION: , Mrs. ABC is a pleasant 45-year-old female with a history of severe diabetic gastroparesis, who had a gastrojejunal feeding tube placed radiologically approximately 2 months ago.  She was admitted because of recurrent nausea and vomiting, with displacement of the GEJ feeding tube.  A CT scan done yesterday revealed evidence of feeding tube remnant still seen within the stomach.  The endoscopy is done to confirm this and remove it, as well as determine if there are any other causes to account for her symptoms.  Physical examination done prior to the procedure was unremarkable, apart from upper abdominal tenderness.,MEDICATIONS: , Fentanyl 25 mcg, Versed 2 mg, 2% lidocaine spray to the pharynx.,INSTRUMENT: , GIF 160.,PROCEDURE REPORT:,  Informed consent was obtained from Mrs. ABC's sister, after the risks and benefits of the procedure were carefully explained, which included but were not limited to bleeding, infection, perforation, and allergic reaction to the medications.  Consent was not obtained from Mrs. Morales due to her recent narcotic administration.  Conscious sedation was achieved with the patient lying in the left lateral decubitus position.  The endoscope was then passed through the mouth, into the esophagus, the stomach, where retroflexion was performed, and it was advanced into the second portion of the duodenum.,FINDINGS:,1.  ESOPHAGUS:  There was evidence of grade C esophagitis, with multiple white-based ulcers seen from the distal to the proximal esophagus, at 12 cm in length.  Multiple biopsies were obtained from this region and placed in jar #1.,2.  STOMACH:  Small hiatal hernia was noted within the cardia of the stomach.  There was an indentation/scar from the placement of the previous PEG tube and there was suture material noted within the body and antrum of the stomach.  The remainder of the stomach examination was normal.  There was no feeding tube remnant seen within the stomach.,3.  DUODENUM:  This was normal.,COMPLICATIONS:,  None.,ASSESSMENT:,1.  Grade C esophagitis seen within the distal, mid, and proximal esophagus.,2.  Small hiatal hernia.,3.  Evidence of scarring at the site of the previous feeding tube, as well as suture line material seen in the body and antrum of the stomach.,PLAN: , Followup results of the biopsies and will have radiology replace her gastrojejunal feeding tube.","gastroenterology, recurrent nausea and vomiting, egd with biopsy, nausea and vomiting, gastrojejunal feeding tube, feeding tube remnant, recurrent nausea, gej feeding, gastrojejunal feeding, proximal esophagus, hiatal hernia, feeding tube, egd, biopsy, nausea, vomiting, gej, gastrojejunal, duodenum, esophagitis, multiple, distal, biopsies, hiatal, hernia, antrum, esophagus, feeding, tube, stomach,"
" Melena and solitary erosion over a fold at the GE junction, gastric side.", Gastroenterology, Endoscopy - 2 ,"PREOPERATIVE DIAGNOSIS:,  Melena.,POSTOPERATIVE DIAGNOSIS:,  Solitary erosion over a fold at the GE junction, gastric side.,PREMEDICATIONS: , Versed 5 mg IV.,REPORTED PROCEDURE:,  The Olympus gastroscope was used.  The scope was placed in the upper esophagus under direct visit.  The esophageal mucosa was entirely normal.  There was no evidence of erosions or ulceration.  There was no evidence of varices.  The body and antrum of the stomach were normal.  They pylorus duodenum bulb and descending duodenum are normal.  There was no blood present within the stomach.,The scope was then brought back into the stomach and retroflexed in order to inspect the upper portion of the body of the stomach.  When this was done, a prominent fold was seen lying along side the GE junction along with gastric side and there was a solitary erosion over this fold.  The lesion was not bleeding.  If this fold were in any other location of the stomach, I would consider the fold, but at this location, one would have to consider that this would be an isolated gastric varix.  As such, the erosion may be more significant.  There was no bleeding.  Obviously, no manipulation of the lesion was undertaken.  The scope was then straightened, withdrawn, and the procedure terminated.,ENDOSCOPIC IMPRESSION:,1.  Solitary erosion overlying a prominent fold at the gastroesophageal junction, gastric side – may simply be an erosion or may be an erosion over a varix.,2.  Otherwise unremarkable endoscopy - no evidence of a bleeding lesion of the stomach.,PLAN:,1.  Liver profile today.,2.  Being Nexium 40 mg a day.,3.  Scheduled colonoscopy for next week.","gastroenterology, ge junction, melena, olympus gastroscope, solitary erosion, descending duodenum, esophageal mucosa, esophagus, gastric side, pylorus duodenum bulb, stomach, liver profile, colonoscopy, ge junction gastric, junction gastric, endoscopy, duodenum, scope, solitary, junction, gastric, erosion,"
 Common description of EGD, Gastroenterology, EGD Template - 4 ,,"gastroenterology, lateral supine position, stomach, duodenum, stricture, egd, advanced, scopeNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Common description of EGD., Gastroenterology, EGD Template - 3 ,"without difficulty, into the upper GI tract.  The anatomy and mucosa of the esophagus, gastroesophageal junction, stomach, pylorus, and small bowel were all carefully inspected.  All structures were visually normal in appearance.  Biopsies of the distal duodenum, gastric antrum, and distal esophagus were taken and sent for pathological evaluation.  The endoscope and insufflated air were slowly removed from the upper GI tract.  A repeat look at the structures involved again showed no visible abnormalities, except for the biopsy sites.,The patient tolerated the procedure with excellent comfort and stable vital signs.  After a recovery period in the Endoscopy Suite, the patient is discharged to continue recovering in the family's care at home.  The family knows to follow up with me today if there are concerns about the patient's recovery,from the procedure.  They will follow up with me later this week for biopsy and CLO test results so that appropriate further diagnostic and therapeutic plans can be made.,","gastroenterology, gastric antrum, distal duodenum, distal esophagus, esophagus, duodenum, clo test, upper gi tract, upper gi, gi tract, egd, endoscope, gi, tract, structures, distal, biopsyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Esophagogastroduodenoscopy with biopsy.  Patient has had biliary colic-type symptoms for the past 3-1/2 weeks, characterized by severe pain, and brought on by eating greasy foods.", Gastroenterology, EGD with Biopsy - 2 ,"TYPE OF PROCEDURE: , Esophagogastroduodenoscopy with biopsy.,PREOPERATIVE DIAGNOSIS:,  Abdominal pain.,POSTOPERATIVE DIAGNOSIS:,  Normal endoscopy.,PREMEDICATION: , Fentanyl 125 mcg IV, Versed 8 mg IV.,INDICATIONS:  ,This healthy 28-year-old woman has had biliary colic-type symptoms for the past 3-1/2 weeks, characterized by severe pain, and brought on by eating greasy foods.  She has had similar episodes couple of years ago and was told, at one point, that she had gallstones, but after her pregnancy, a repeat ultrasound was done, and apparently was normal, and nothing was done at that time.  She was evaluated in the emergency department recently, when she developed this recurrent pain, and laboratory studies were unrevealing.  Ultrasound was normal and a HIDA scan was done, which showed a low normal ejection fraction of 40%, and moderate reproduction of her pain.  Endoscopy was requested to make sure there is not upper GI source of her pain before considering cholecystectomy.,PROCEDURE: , The patient was premedicated and the Olympus GIF 160 video endoscope advanced to the distal duodenum.  Gastric biopsies were taken to rule out Helicobacter and the procedure was completed without complication.,IMPRESSION:  ,Normal endoscopy.,PLAN: , Refer to a general surgeon for consideration of cholecystectomy.","gastroenterology, hida scan, endoscopy, gallstones, olympus, esophagogastroduodenoscopy with biopsy, biliary colic, colic type, greasy foods, normal endoscopy, esophagogastroduodenoscopy, biliary, colic, greasy, foods, cholecystectomy, biopsy,"
" EGD with PEG tube placement using Russell technique.  Protein-calorie malnutrition, intractable nausea, vomiting, and dysphagia, and enterogastritis.", Gastroenterology, EGD & PEG Tube Placement ,"PREOPERATIVE DIAGNOSES:,1.  protein-calorie malnutrition.,2.  Intractable nausea, vomiting, and dysphagia.,POSTOPERATIVE DIAGNOSES:,1.  Protein-calorie malnutrition.,2.  Intractable nausea, vomiting, and dysphagia.,3.  Enterogastritis.,PROCEDURE PERFORMED: , EGD with PEG tube placement using Russell technique.,ANESTHESIA: , IV sedation with 1% lidocaine for local.,ESTIMATED BLOOD LOSS:  ,None.,COMPLICATIONS:  ,None.,BRIEF HISTORY: , This is a 44-year-old African-American female who is well known to this service.  She has been hospitalized multiple times for intractable nausea and vomiting and dehydration.  She states that her decreased p.o. intake has been progressively worsening.  She was admitted to the service of Dr. Lang and was evaluated by Dr. Wickless as well all of whom agreed that the best option for supplemental nutrition for this patient was placement of a PEG tube.,PROCEDURE: , After risks, complications, and benefits were explained to the patient and informed consent was obtained, the patient was taken to the operating room.  She was placed in the supine position.  The area was prepped and draped in the sterile fashion.  After adequate IV sedation was obtained by anesthesia, esophagogastroduodenoscopy was performed.  The esophagus, stomach, and duodenum were visualized without difficulty.  There was no gross evidence of any malignancy.  There was some enterogastritis which was noted upon exam.  The appropriate location was noted on the anterior wall of the stomach.  This area was localized externally with 1% lidocaine.  Large gauge needle was used to enter the lumen of the stomach under visualization.  A guide wire was then passed again under visualization and the needle was subsequently removed.  A scalpel was used to make a small incision, next to the guidewire and ensuring that the underlying fascia was nicked as well.  A dilator with break-away sheath was then inserted over the guidewire and under direct visualization was seen to enter the lumen of the stomach without difficulty.  The guidewire and dilator were then removed again under visualization and the PEG tube was placed through the break-away sheath and visualized within the lumen of the stomach.  The balloon was then insufflated and the break-away sheath was then pulled away.  Proper placement of the tube was ensured through visualization with a scope.  The tube was then sutured into place using nylon suture.  Appropriate sterile dressing was applied.,DISPOSITION:  ,The patient was transferred to the recovery in a stable condition.  She was subsequently returned to her room on the General Medical Floor.  Previous orders will be resumed.  We will instruct the Nursing that the PEG tube can be used at 5 p.m. this evening for medications if necessary and bolus feedings.","gastroenterology, protein-calorie malnutrition, nausea, vomiting, peg tube placement, russell technique, peg tube, egd, protein, dysphagia, malnutrition, enterogastritis"
 Common description of EGD., Gastroenterology, EGD Template - 2 ,"The patient was placed in the left lateral decubitus position, medicated with the above medications to achieve and maintain a conscious sedation.  Vital signs were monitored throughout the procedure without evidence of hemodynamic compromise or desaturation.,The Olympus single-channel endoscope was passed under direct visualization through the oral cavity and advanced to the second portion of the duodenum.,FINDINGS:,ESOPHAGUS:  Proximal and mid esophagus were without abnormalities.,STOMACH:  Insufflated and retroflexed visualization of the gastric cavity revealed,DUODENUM:  Normal.","gastroenterology, gastric cavity, lateral decubitus position, endoscope, olympus, egd, visualization, cavity, duodenum, esophagusNOTE"
" Upper endoscopy, patient with dysphagia.", Gastroenterology, Endoscopy - 1 ,"PROCEDURE:,  Upper endoscopy.,PREOPERATIVE DIAGNOSIS: , Dysphagia.,POSTOPERATIVE DIAGNOSIS:,1.  GERD, biopsied.,2.  Distal esophageal reflux-induced stricture, dilated to 18 mm.,3.  Otherwise normal upper endoscopy.,MEDICATIONS: , Fentanyl 125 mcg and Versed 7 mg slow IV push.,INDICATIONS: , This is a 50-year-old white male with dysphagia, which has improved recently with Aciphex.,FINDINGS: , The patient was placed in the left lateral decubitus position and the above medications were administered.  The oropharynx was sprayed with Cetacaine.  The endoscope was passed, under direct visualization, into the esophagus.  The squamocolumnar junction was irregular and edematous.  Biopsies were obtained for histology.  There was a mild ring at the LES, which was dilated with a 15 to 18 mm balloon, with no resultant mucosal trauma.  The entire gastric mucosa was normal, including a retroflexed view of the fundus.  The entire duodenal mucosa was normal to the second portion.  The patient tolerated the procedure well without complication.,IMPRESSION:,1.  Gastroesophageal reflux disease, biopsied.,2.  Distal esophageal reflux-induced stricture, dilated to 18 mm.,3.  Otherwise normal upper endoscopy.,PLAN:,I will await the results of the biopsies.  The patient was told to continue maintenance Aciphex and anti-reflux precautions.  He will follow up with me on a p.r.n. basis.","gastroenterology, lateral decubitus position, gastroesophageal reflux disease, gerd, normal upper endoscopy, mucosa was normal, esophageal reflux, stricture dilated, upper endoscopy, distal, esophageal, aciphex, biopsies, dysphagia, endoscopy, reflux,"
 Common description of EGD., Gastroenterology, EGD Template - 1 ,,"gastroenterology, duodenal mucosa, duodenal, esophageal mucosa, fundus, egd, entire, mucosaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Esophagogastroduodenoscopy, patient with dysphagia.", Gastroenterology, EGD - 2 ,"PROCEDURES PERFORMED: , Esophagogastroduodenoscopy.,PREPROCEDURE DIAGNOSIS: , Dysphagia.,POSTPROCEDURE DIAGNOSIS: , Active reflux esophagitis, distal esophageal stricture, ring due to reflux esophagitis, dilated with balloon to 18 mm.,PROCEDURE: , Informed consent was obtained prior to the procedure with special attention to benefits, risks, alternatives.  Risks explained as bleeding, infection, bowel perforation, aspiration pneumonia, or reaction to the medications.  Vital signs were monitored by blood pressure, heart rate, and oxygen saturation.  Supplemental O2 given.  Specifics of the procedure discussed.  The procedure was discussed with father and mother as the patient is mentally challenged.  He has no complaints of dysphagia usually for solids, better with liquids, worsening over the last 6 months, although there is an emergency department report from last year.  He went to the emergency department yesterday with beef jerky.,All of this reviewed.  The patient is currently on Cortef, Synthroid, Tegretol, Norvasc, lisinopril, DDAVP.  He is being managed for extensive past history due to an astrocytoma, brain surgery, hypothyroidism, endocrine insufficiency.  He has not yet undergone significant workup.  He has not yet had an endoscopy or barium study performed.  He is developmentally delayed due to the surgery, panhypopituitarism.,His family history is significant for his father being of mine, also having reflux issues, without true heartburn, but distal esophageal stricture.  The patient does not smoke, does not drink.  He is living with his parents.  Since his emergency department visitation yesterday, no significant complaints.,Large male, no acute distress.  Vital signs monitored in the endoscopy suite.  Lungs clear.  Cardiac exam showed regular rhythm.  Abdomen obese but soft.  Extremity exam showed large hands.  He was a Mallampati score A, ASA classification type 2.,The procedure discussed with the patient, the patient's mother.  Risks, benefits, and alternatives discussed.  Potential alternatives for dysphagia, such as motility disorder, given his brain surgery, given the possibility of achalasia and similar discussed.  The potential need for a barium swallow, modified barium swallow, and similar discussed.  All questions answered.  At this point, the patient will undergo endoscopy for evaluation of dysphagia, with potential benefit of the possibility to dilate him should there be a stricture.  He may have reflux symptoms, without complaining of heartburn.  He may benefit from a trial of PPI.  All of this reviewed.  All questions answered.,","gastroenterology, distal esophageal stricture, reflux esophagitis, distal esophageal, esophageal stricture, barium swallow, esophagogastroduodenoscopy, esophagitis, esophageal, heartburn, stricture, endoscopy, reflux, dysphagia "
" EGD and colonoscopy.  Blood loss anemia, normal colon with no evidence of bleeding, hiatal hernia, fundal gastritis with polyps, and antral mass.", Gastroenterology, EGD & Colonoscopy ,"PREOPERATIVE DIAGNOSIS: , Blood loss anemia.,POSTOPERATIVE DIAGNOSES:,1.  Normal colon with no evidence of bleeding.,2.  Hiatal hernia.,3.  Fundal gastritis with polyps.,4.  Antral mass.,ANESTHESIA: , Conscious sedation with Demerol and Versed.,SPECIMEN:  ,Antrum and fundal polyps.,HISTORY: , The patient is a 66-year-old African-American female who presented to ABCD Hospital with mental status changes.  She has been anemic as well with no gross evidence of blood loss.  She has had a decreased appetite with weight loss greater than 20 lb over the past few months.  After discussion with the patient and her daughter, she was scheduled for EGD and colonoscopy for evaluation.,PROCEDURE: , After informed consent was obtained, the patient was brought to the endoscopy suite.  She was placed in the left lateral position and was given IV Demerol and Versed for sedation.  When adequate level of sedation was achieved, a digital rectal exam was performed, which demonstrated no masses and no hemorrhoids.  The colonoscope was inserted into the rectum and air was insufflated.  The scope was coursed through the rectum and sigmoid colon, descending colon, transverse colon, ascending colon to the level of the cecum.  There were no polyps, masses, diverticuli, or areas of inflammation.  The scope was then slowly withdrawn carefully examining all walls.  Air was aspirated.  Once in the rectum, the scope was retroflexed.  There was no evidence of perianal disease.  No source of the anemia was identified.,Attention was then taken for performing an EGD.  The gastroscope was inserted into the hypopharynx and was entered into the hypopharynx.  The esophagus was easily intubated and traversed.  There were no abnormalities of the esophagus.  The stomach was entered and was insufflated.  The scope was coursed along the greater curvature towards the antrum.  Adjacent to the pylorus, towards the anterior surface, was a mass like lesion with a central _______.  It was not clear if this represents a healing ulcer or neoplasm.  Several biopsies were taken.  The mass was soft.  The pylorus was then entered.  The duodenal bulb and sweep were examined.  There was no evidence of mass, ulceration, or bleeding.  The scope was then brought back into the antrum and was retroflexed.  In the fundus and body, there was evidence of streaking and inflammation.  There were also several small sessile polyps, which were removed with biopsy forceps.  Biopsy was also taken for CLO.  A hiatal hernia was present as well.  Air was aspirated.  The scope was slowly withdrawn.  The GE junction was unremarkable.  The scope was fully withdrawn.  The patient tolerated the procedure well and was transferred to recovery room in stable condition.  She will undergo a CAT scan of her abdomen and pelvis to further assess any possible adenopathy or gastric obstructional changes.  We will await the biopsy reports and further recommendations will follow.","gastroenterology, esophagus, gastroscope, hypopharynx, rectum, fundal gastritis, antral mass, hiatal hernia, egd, hernia, polyps, colonoscopy,"
 Problems with dysphagia to solids and had food impacted in the lower esophagus.  Upper endoscopy to evaluate the esophagus., Gastroenterology, EGD - 1 ,"HISTORY OF PRESENT ILLNESS:,  Briefly, this is a 17-year-old male, who has had problems with dysphagia to solids and recently had food impacted in the lower esophagus.  He is now having upper endoscopy to evaluate the esophagus after edema and inflammation from the food impaction has resolved, to look for any stricture that may need to be dilated, or any other mucosal abnormality.,PROCEDURE PERFORMED: , EGD.,PREP: , Cetacaine spray, 100 mcg of fentanyl IV, and 5 mg of Versed IV.,FINDINGS:,  The tip of the endoscope was introduced into the esophagus, and the entire length of the esophagus was dotted with numerous, white, punctate lesions, suggestive of eosinophilic esophagitis.  There were come concentric rings present.  There was no erosion or flame hemorrhage, but there was some friability in the distal esophagus.  Biopsies throughout the entire length of the esophagus from 25-40 cm were obtained to look for eosinophilic esophagitis.  There was no stricture or Barrett mucosa.  The bony and the antrum of the stomach are normal without any acute peptic lesions.  Retroflexion of the tip of the endoscope in the body of the stomach revealed a normal cardia.  There were no acute lesions and no evidence of ulcer, tumor, or polyp.  The pylorus was easily entered, and the first, second, and third portions of the duodenum are normal.  Adverse reactions:  None.,FINAL IMPRESSION:  ,Esophageal changes suggestive of eosinophilic esophagitis.  Biopsies throughout the length of the esophagus were obtained for microscopic analysis.  There was no evidence of stricture, Barrett, or other abnormalities in the upper GI tract.","gastroenterology, length of the esophagus, food impacted, lower esophagus, upper endoscopy, entire length, eosinophilic esophagitis, egd, dysphagia, solids, impacted, endoscopy, mucosal, endoscope, biopsies, barrett, stomach, stricture, eosinophilic, esophagitis, esophagus, "
" Diagnostic laparotomy, exploratory laparotomy, Meckel's diverticulectomy, open incidental appendectomy, and peritoneal toilet.", Gastroenterology, Diverticulectomy & Laparotomy ,"PREOPERATIVE DIAGNOSIS: , Acute appendicitis.,POSTOPERATIVE DIAGNOSIS: , Perforated Meckel's diverticulum.,PROCEDURES PERFORMED:,1.  Diagnostic laparotomy.,2.  Exploratory laparotomy.,3.  Meckel's diverticulectomy.,4.  Open incidental appendectomy.,5.  Peritoneal toilet.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:  ,300 ml.,URINE OUTPUT: , 200 ml.,TOTAL FLUID:,  1600 mL.,DRAIN:,  JP x1 right lower quadrant and anterior to the rectum.,TUBES:,  Include an NG and a Foley catheter.,SPECIMENS: , Include Meckel's diverticulum and appendix.,COMPLICATIONS: , Ventilator-dependent respiratory failure with hypoxemia following closure.,BRIEF HISTORY: , This is a 45-year-old Caucasian gentleman presented to ABCD General Hospital with acute onset of right lower quadrant pain that began 24 hours prior to this evaluation.,The pain was very vague and progressed in intensity.  The patient has had anorexia with decrease in appetite.  His physical examination revealed the patient to be febrile with the temperature of 102.4.  He had right lower quadrant and suprapubic tenderness with palpation with Rovsing sign and rebound consistent with acute surgical abdomen.  The patient was presumed acute appendicitis and was placed on IV antibiotics and recommended that he undergo diagnostic laparoscopy with possible open exploratory laparotomy.  He was explained the risks, benefits, and complications of the procedure and gave informed consent to proceed.,OPERATIVE FINDINGS: , Diagnostic laparoscopy revealed purulent drainage within the region of the right lower quadrant adjacent to the cecum and terminal ileum.  There was large amounts of purulent drainage.  The appendix was visualized, however, it was difficult to be visualized secondary to the acute inflammatory process, purulent drainage, and edema.  It was decided given the signs of perforation and purulent drainage within the abdomen that we would convert to an open exploratory laparotomy.  Upon exploration of the ileum, there was noted to be a ruptured Meckel's diverticulum, this was resected.  Additionally, the appendix appeared normal without evidence of perforation and/or edema and a decision to proceed with incidental appendectomy was performed.  The patient was irrigated with copious amounts of warmth normal saline approximately 2 to 3 liters.  The patient was closed and did develop some hypoxemia after closure.  He remained ventilated and was placed on a large amount of ________.  His hypoxia did resolve and he remained intubated and proceed to the Critical Care Complex or postop surgical care.,OPERATIVE PROCEDURE:,  The patient was brought to the operative suite and placed in the supine position.  He did receive preoperative IV antibiotics, sequential compression devices, NG tube placement with Foley catheter, and heparin subcutaneously.  The patient was intubated by the Anesthesia Department.  After adequate anesthesia was obtained, the abdomen was prepped and draped in the normal sterile fashion with Betadine solution.  Utilizing a #10 blade scalpel, an infraumbilical incision was created.  The Veress needle was inserted into the abdomen.  The abdomen was insufflated to approximately 15 mmHg.  A #10 mm ablated trocar was inserted into the abdomen and a video laparoscope was inserted and the abdomen was explored and the above findings were noted.  A right upper quadrant 5 mm port was inserted to help with manipulation of bowel and to visualize the appendix.  Decision was then made to convert to exploratory laparotomy given the signs of acute perforation.  The instruments were then removed.  The abdomen was then deflated.  Utilizing ________ #10 blade scalpel, a midline incision was created from the xiphoid down to level of the pubic symphysis.,The incision was carried down with a #10 blade scalpel and the bleeding was controlled along the way with electrocautery.  The posterior layer of the rectus fascia and peritoneum was opened carefully with the scissors as the peritoneum had already been penetrated during laparoscopy.  Incision was carried down to the midline within the linea alba.  Once the abdomen was opened, there was noted to be gross purulent drainage.  The ileum was explored and there was noted to be a perforated Meckel's diverticulum.  Decision to resect the diverticulum was performed.,The blood supply to the Meckel's diverticulum was carefully dissected free and a #3-0 Vicryl was used to tie off the blood supply to the Meckel's diverticulum.  Clamps were placed to the proximal supply to the Meckel's diverticulum was tied off with #3-0 Vicryl sutures.  The Meckel's diverticulum was noted to be completely free and was grasped anteriorly and utilizing a GIA stapling device, the diverticulum was transected.  There was noted to be a hemostatic region within the transection and staple line looked intact without evidence of perforation and/or leakage.  Next, decision was decided to go ahead and perform an appendectomy.  Mesoappendix was doubly clamped with hemostats and cut with Metzenbaum scissors.  The appendiceal artery was identified and was clamped between two hemostats and transected as well.  Once the appendix was completely freed of the surrounding inflammation and adhesion.  A plain gut was placed at the base of the appendix and tied down.  The appendix was milked distally with a straight stat and clamped approximately halfway.  A second piece of plain gut suture was used to ligate above and then was transected with a #10 blade scalpel.  The appendiceal stump was then inverted with a pursestring suture of #2-0 Vicryl suture.  Once the ________ was completed, decision to place a JP drain within the right lower quadrant was performed.  The drain was positioned within the right lower quadrant and anterior to the rectum and brought out through a separate site in the anterior abdominal wall.  It was sewn in place with a #3-0 nylon suture.  The abdomen was then irrigated with copious amounts of warmed normal saline.  The remainder of the abdomen was unremarkable for pathology.  The omentum was replaced over the bowel contents and utilizing #1-0 PDS suture, the abdominal wall, anterior and posterior rectus fascias were closed with a running suture.  Once the abdomen was completely closed, the subcutaneous tissue was irrigated with copious amounts of saline and the incision was closed with staples.  The previous laparoscopic sites were also closed with staples.  Sterile dressings were placed over the wound with Adaptic and 4x4s and covered with ABDs.  JPs replaced with bulb suction.  NG tube and Foley catheter were left in place.  The patient tolerated this procedure well with exception of hypoxemia which resolved by the conclusion of the case.,The patient will proceed to the Critical Care Complex where he will be closely evaluated and followed in his postoperative course.  To remain on IV antibiotics and we will manage ventilatory-dependency of the patient.",
 Esophagogastroduodenoscopy and colonoscopy with polypectomy, Gastroenterology, EGD - Colonoscopy - Polypectomy ,"PROCEDURES:,1.  Esophagogastroduodenoscopy.,2.  Colonoscopy with polypectomy.,PREOPERATIVE DIAGNOSES:,1.  History of esophageal cancer.,2.  History of colonic polyps.,POSTOPERATIVE FINDINGS:,1.  Intact surgical intervention for a history of esophageal cancer.,2.  Melanosis coli.,3.  Transverse colon polyps in the setting of surgical changes related to partial and transverse colectomy.,MEDICATIONS:,  Fentanyl 250 mcg and 9 mg of Versed.,INDICATIONS:,  The patient is a 55-year-old dentist presenting for surveillance upper endoscopy in the setting of a history of esophageal cancer with staging at T2N0M0.,He also has a history of adenomatous polyps and presents for surveillance of this process.,Informed consent was obtained after explanation of the procedures, as well as risk factors of bleeding, perforation, and adverse medication reaction.,ESOPHAGOGASTRODUODENOSCOPY:,  The patient was placed in the left lateral decubitus position and medicated with the above medications to achieve and maintain a conscious sedation.  Vital signs were monitored throughout the procedure without evidence of hemodynamic compromise or desaturation.  The Olympus single-channel endoscope was passed under direct visualization, through the oral cavity, and advanced to the second portion of the duodenum.,FINDINGS:,1.  ESOPHAGUS:  Anatomy consistent with esophagectomy with colonic transposition.,2.  STOMACH:  Revealed colonic transposition with normal mucosa.,3.  DUODENUM:  Normal.,IMPRESSION: , Intact surgical intervention with esophagectomy colonic transposition.,COLONOSCOPY: , The patient was then turned and a colonic 140-series colonoscope was passed under direct visualization through the anal verge and advanced to the cecum as identified by the appendiceal orifice.  Circumferential visualization the colonic mucosa revealed the following:,1.  Cecum revealed melanosis coli.,2.  Ascending, melanosis coli.,3.  Transverse revealed two diminutive sessile polyps, excised by cold forceps technique and submitted to histology as specimen #1 with surgical changes consistent with partial colectomy related to the colonic transposition.,4.  Descending, melanosis coli.,5.  Sigmoid, melanosis coli.,6.  Rectum, melanosis coli.,IMPRESSION: , Diffuse melanosis coli with incidental finding of transverse colon polyps.,RECOMMENDATION: , Follow-up histology.  Continue fiber with avoidance of stimulant laxatives.",
 Patient with complaint of symptomatic cholelithiasis., Gastroenterology, Discharge Summary - Cholelithiasis ,"ADMISSION DIAGNOSIS: , Symptomatic cholelithiasis.,DISCHARGE DIAGNOSIS:,  Symptomatic cholelithiasis.,SERVICE: , Surgery.,CONSULTS:,  None.,HISTORY OF PRESENT ILLNESS: , Ms. ABC is a 27-year-old woman who apparently presented with complaint of symptomatic cholelithiasis.  She was afebrile.  She was taken by Dr. X to the operating room.,HOSPITAL COURSE: , The patient underwent a procedure.  She tolerated without difficulty.  She had her pain controlled with p.o. pain medicine.  She was afebrile.  She is tolerating liquid diet.  It was felt that the patient is stable for discharge.  She did complain of bladder spasms when she urinated and she did say that she has a history of chronic UTIs.  We will check a UA and urine culture prior to discharge.  I will give her prescription for ciprofloxacin that she can take for 3 days presumptively and I have discharged her home with omeprazole and Colace to take over-the-counter for constipation and we will send her home with Percocet for pain.  Her labs were within normal limits.  She did have an elevated white blood cell count, but I believe this is just leukemoid reaction, but she is afebrile, and if she does have UTI, may also be related.  Her labs in terms of her bilirubin were within normal limits.  Her LFTs were slightly elevated, I do believe this is related to the cautery used on the liver bed.  They were 51 and 83 for the AST and ALT respectively.  I feel that she looks good for discharge.,DISCHARGE INSTRUCTIONS: , Clear liquid diet x48 hours and she can return to her Medifast, she may shower.  She needs to keep her wound clean and dry.  She is not to engage in any heavy lifting greater than 10 pounds x2 weeks.  No driving for 1 to 2 weeks.  She must be able to stop in an emergency and be off narcotic meds, no strenuous activity, but she needs to maintain mobility.  She can resume her medications per med rec sheets.,DISCHARGE MEDICATIONS: , As previously mentioned.,FOLLOWUP:,  We will follow up on both urinalysis and cultures.  She is instructed to follow up with Dr. X in 2 weeks.  She needs to call for any shortness of breath, temperature greater than 101.5, chest pain, intractable nausea, vomiting, and abdominal pain, any redness, swelling or foul smelling drainage from her wounds.","gastroenterology, medifast, liquid diet, symptomatic cholelithiasis, symptomatic, cholelithiasis, discharge,"
 Dysphagia and hematemesis while vomiting.  Diffuse esophageal dilatation/hematemesis, Gastroenterology, Dysphagia & Hematemesis ,"CHIEF COMPLAINT: , Dysphagia and hematemesis while vomiting.,HISTORY OF PRESENT ILLNESS: , This is a 53-year-old African American female with 15 years known history of HIV and hepatitis B, and known history of compensated heart failure, COPD, who presented today with complaint of stuck food in her esophagus, bloody cough, and bloody vomiting since 4 o'clock this vomiting, when she ate eggplant parmigiana meal.  The back and chest pain is 8/10, no radiation and is constant.  She denied fever, abdominal pain, or dysphagia before current event eating bones or fish.  This is the first episode of hematemesis and feeling of globus pallidus.  In the emergency room, the patient was treated with nitropaste, morphine, and Lopressor with positive results for chest pain.  CAT scan of the chest showed diffuse esophageal dilatation with residual food in it, no mediastinal air was identified.,REVIEW OF SYSTEMS: , The patient denied diarrhea, abdominal pain, fever, weight loss, dysphagia before this event.  Denied any exertional chest pain or shortness of breath.  No headache, limb weakness.  No joint pain or muscle ache.  No dysuria.,PAST MEDICAL HISTORY:  ,Remarkable for:,1.  Asthma.,2.  Hepatitis C - 1995.,3.  HIV, known since 1995 and followed up by Dr. X, ABCD Medical Center, the last visit was 08/09.  The patient does not take HIV medications against medical advice.,4.  Hypertension, known since 2008.,5.  Negative PPD test, 10/08.,PAST SURGICAL HISTORY: , Remarkable for hysterectomy in 2001, pilonidal cyst surgery in 2005.,FAMILY HISTORY: , Mother deceased at age 68 of cirrhosis.  She had history of alcohol abuse.  Father deceased at age 45, also has a history of alcohol abuse, cardiac disease, and hypertension.,ALLERGIES: , Not known allergies.,MEDICATIONS AT HOME: , Lisinopril 5 mg daily; metoprolol 25 mg twice daily; furosemide 40 mg once daily; Isentress 400 mg once daily, the patient does not take this medication for the last 3 months; Norvir 100 mg once daily; Prezista 400 mg once daily.  The patient does not take her HIV medications for the last 2 to 3 months.  Occasionally, she takes inhalation of albuterol and Ambien 10 mg once daily.,SOCIAL HISTORY: , She is single, lives with her 21-year-old daughter, works as CNA, smokes one pack per day for the last 8 years.  She had periods when she quit smoking and started again 2-1/2 years ago.  She denied alcohol abuse and she was using cocaine in the past, last time she used cocaine 10 years ago.,PHYSICAL EXAMINATION: , Temperature 99.8, pulse 106, respiratory rate 18, blood pressure 162/97, saturation 99 on room air.  African American female, not in acute respiratory distress, but uncomfortable, and showing some signs of back discomfort.  Oriented x3, mildly drowsy, calm and cooperative.  Eyes, EOMI, PERRLA.  Tympanic membranes normal appearance bilaterally.  External canal, no erythema or discharge.  Nose, no erythema or discharge.  Throat, dry mucous, no exudates.  No ulcers in oral area.  Full upper denture and extensive decayed lower teeth.  No cervical lymphadenopathy, no carotid bruits bilaterally.  Heart:  RRR, S1 and S2 appreciated.  No additional sounds or murmurs were auscultated.  Lung:  Good air entrance bilaterally.  No rales or rhonchi.  Abdomen:  Soft, nontender, nondistended.  No masses or organomegaly were palpated.  Legs:  No signs of DVT, peripheral pulses full, posterior dorsalis pedis 2+.  Skin:  No rashes or other lesions, warm and well perfused.  Nails:  No clubbing.  No other signs of skin infection.  Neurological exam:  Cranial nerves II through XII grossly intact.  No motor or sensory deficit was found.,CAT scan of the chest, which was done at 8 o'clock in the morning on 01/12/10.  Impression:  Cardiomegaly, normal aorta, large distention of esophagus containing food.  Chest x-ray:  Cardiomegaly, no evidence of CHF or pneumonia.  EKG:  Normal sinus rhythm, no signs of ischemia.,LABORATORY DATA: , Hemoglobin 10.4, hematocrit 30.6, white blood cells 7.3, neutrophils 75, platelets 197.  Sodium 140, potassium 3.1, chloride 104, bicarb 25, glucose 113, BUN 19, creatinine 1.1, GFR 55, calcium 8.8, total protein 8.1, albumin 3.1, globulin 5.0, bilirubin 0.3, alk phos 63, GOT 23, GPT 22, lipase 104, amylase 85, protime 10.2, INR 1, PTT 25.8.  Urine:  Negative for ketones, protein, glucose, blood, and nitrite, bacteria 2+.  Troponin 0.040.  BNP 1328.,PLAN:,1.  Diffuse esophageal dilatation/hematemesis.  We will put her n.p.o., we will give IV fluid, half normal saline D5 100 mL per hour.  I discussed the case with Dr. Y, gastroenterologist.  The patient planned for EGD starting today.  Differential diagnosis may include foreign body, achalasia, Candida infection, or CMV esophagitis.  We will treat according to the EGD findings.  We will give IV Nexium 40 mg daily for GI prophylaxis.  We will hold all p.o. medication.,2.  CHF.  Cardiomegaly on x-ray.  She is clinically stable.  Lungs are clear.  No radiological sign of CHF exacerbation.  We will restart lisinopril and metoprolol after EGD study will be completed.,3.  HIV - follow up by Dr. X, (ABCD Medical Center).  The last visit was on 08/08.  The patient was not taking her HIV medications for the last 3 months and does not know her CD4 number or viral load.  We will check CD4 number and viral load.  We will contact Dr. X (ID specialist in ABCD Med).,4.  Hypertension.  We will control blood pressor with Lopressor 5 mg IV p.r.n.  If blood pressure more than 160/90, we will hold metoprolol and lisinopril.,5.  Hepatitis C, known since 1995.  The patient does not take any treatment.,6.  Tobacco abuse.  The patient refused nicotine patch.,7.  GI prophylaxis as stated above; and DVT prophylaxis, compression socks.  We will restrain from using heparin or Lovenox.,ADDENDUM: , The patient was examined by Dr. Y, gastroenterologist, who ordered a CAT scan with oral contrast, which showed persistent distention of the esophagus with elementary debris within the lumen of the esophagus.  There is no evidence of leakage of the oral contrast.  There is decrease in size of periaortic soft tissue density around the descending aorta, this is associated with increase in very small left pleural effusion in the intervening time.  There is no evidence of pneumomediastinum or pneumothorax, lungs are clear, contrast is present in stomach.  After procedure, the patient had profuse vomiting with bloody content and spiked fever 102.  The patient felt relieved after vomiting.  The patient was started on aztreonam 1 g IV every 8 hours, Flagyl 500 mg IV every 8 hours.  ID consult was called and thoracic surgeon consult was ordered.",
 Patient with a history of a Nissen fundoplication performed six years ago for gastric reflux. , Gastroenterology, Discharge Summary - 10 ,"ADMITTING DIAGNOSES:,  Hiatal hernia, gastroesophageal reflux disease reflux.,DISCHARGE DIAGNOSES:,  Hiatal hernia, gastroesophageal reflux disease reflux.,SECONDARY DIAGNOSIS: , Postoperative ileus.,PROCEDURES DONE: , Hiatal hernia repair and Nissen fundoplication revision.,BRIEF HISTORY: , The patient is an 18-year-old male who has had a history of a Nissen fundoplication performed six years ago for gastric reflux.  Approximately one year ago, he was involved in a motor vehicle accident and CT scan at that time showed that he had a hiatal hernia.  Over the past year, this has caused him an increasing number of problems, including chest pain when he eats, and shortness of breath after large meals.  He is also having reflux symptoms again.  He presents to us for repair of the hiatal hernia and revision of the Nissen fundoplication.,HOSPITAL COURSE: , Mr. A was admitted to the adolescent floor by Brenner Children's Hospital after his procedure.  He was stable at that time.  He did complain of some nausea.  However, he did not have any vomiting at that time.  He had an NG tube in and was n.p.o.  He also had a PCA for pain management as well as Toradol.  On postoperative day #1, he complained of not being able to urinate, so a Foley catheter was placed.  Over the next several days, his hospital course proceeded as follows.  He continued to complain of some nausea; however, he did not ever have any vomiting.  Eventually, the Foley catheter was discontinued and he had excellent urine output without any complications.  He ambulated frequently.  He remained n.p.o. for three days.  He also had the NG tube in during that time.  On postoperative day #4, he began to have some flatus, and the NG tube was discontinued.  He was advanced to a liquid diet and tolerated this without any complications.  At this time, he was still using the PCA for pain control.  However, he was using it much less frequently than on days #1 and #2 postoperatively.  After tolerating the full liquid diet without any complications, he was advanced to a soft diet and his pain medications were transitioned to p.o. medications rather than the PCA.  The PCA was discontinued.  He tolerated the soft diet without any complications and continued to have flatus frequently.  On postoperative day #6, it was determined that he was stable for discharge to home as he was taking p.o. without any complications.  His pain was well controlled with p.o. pain medications.  He was passing gas frequently, had excellent urine output, and was ambulating frequently without any issues.,DISCHARGE CONDITION:,  Stable.,DISPOSITION: , Discharged to home.,DISCHARGE INSTRUCTIONS: , The patient was discharged to home with instructions for maintaining a soft diet.  It was also recommended that he does not drink any soda postoperatively.  He is instructed to keep his incision site clean and dry and it was also recommended that he avoid any heavy lifting.  He will be able to attend school when it starts in a few weeks.  However, he is not going to be able to play football in the near future.  He was given prescription for pain medication upon discharge.  He is instructed to contact Pediatric Surgery if he has any fevers, any nausea and vomiting, any chest pain, any constipation, or any other concerns.","gastroenterology,"
 Modified Barium swallow (Deglutition Study) for Dysphagia with possible aspiration., Gastroenterology, Deglutition Study - Modified Barium swallow ,"EXAM: , Modified barium swallow.,SYMPTOM:,  Dysphagia with possible aspiration.,FINDINGS:,  A cookie deglutition study was performed.  The patient was examined in the direct lateral position.,Patient was challenged with thin liquids, thick liquid, semisolids and solids.,Persistently demonstrable is the presence of penetration with thin liquids.  This is not evident with thick liquids, semisolids or solids.,There is weakness in the oral phase of deglutition.  Subglottic region appears normal.  There is no evidence of aspiration demonstrated.,IMPRESSION: , Penetration demonstrated with thin liquids with weakness of the oral phase of deglutition.","gastroenterology, aspiration, deglutition study, thin liquids, thick liquid, semisolids, solids, modified barium swallow, barium swallow, dysphagia, deglutition, "
 CT scan of the abdomen and pelvis with contrast to evaluate abdominal pan., Gastroenterology, CT Scan of Abdomen & Pelvis with Contrast ,"EXAM: , CT scan of the abdomen and pelvis with contrast.,REASON FOR EXAM: , Abdominal pain.,COMPARISON EXAM: , None.,TECHNIQUE: , Multiple axial images of the abdomen and pelvis were obtained.  5-mm slices were acquired after injection of 125 cc of Omnipaque IV.  In addition, oral ReadiCAT was given.  Reformatted sagittal and coronal images were obtained.,DISCUSSION:,  There are numerous subcentimeter nodules seen within the lung bases.  The largest measures up to 6 mm.  No hiatal hernia is identified.  Consider chest CT for further evaluation of the pulmonary nodules.  The liver, gallbladder, pancreas, spleen, adrenal glands, and kidneys are within normal limits.  No dilated loops of bowel.  There are punctate foci of air seen within the nondependent portions of the peritoneal cavity as well as the anterior subcutaneous fat.  In addition, there is soft tissue stranding seen of the lower pelvis.  In addition, the uterus is not identified.  Correlate with history of recent surgery.  There is no free fluid or lymphadenopathy seen within the abdomen or pelvis.  The bladder is within normal limits for technique.,No acute bony abnormalities appreciated.  No suspicious osteoblastic or osteolytic lesions.,IMPRESSION:,1.  Postoperative changes seen within the pelvis without appreciable evidence for free fluid.,2.  Numerous subcentimeter nodules seen within the lung bases.  Consider chest CT for further characterization.","gastroenterology, ct scan, abdominal pain, multiple axial images, abdomen and pelvis, adrenal glands, chest ct, coronal, gallbladder, kidneys, liver, lymphadenopathy, nodules, osteoblastic, osteolytic, pancreas, sagittal, spleen, with contrast, free fluid, ct, abdomen, pelvis,"
" Generalized abdominal pain, nausea, diarrhea, and recent colonic resection.  CT abdomen with and without contrast and CT pelvis with contrast.  Axial CT images of the abdomen were obtained without contrast.  Axial CT images of the abdomen and pelvis were then obtained utilizing 100 mL of Isovue-300.", Gastroenterology, CT Abdomen & Pelvis - 8 ,"CT ABDOMEN WITH AND WITHOUT CONTRAST AND CT PELVIS WITH CONTRAST,REASON FOR EXAM: , Generalized abdominal pain, nausea, diarrhea, and recent colonic resection in 11/08.,TECHNIQUE:,  Axial CT images of the abdomen were obtained without contrast.  Axial CT images of the abdomen and pelvis were then obtained utilizing 100 mL of Isovue-300.,FINDINGS: , The liver is normal in size and attenuation.,The gallbladder is normal.,The spleen is normal in size and attenuation.,The adrenal glands and pancreas are unremarkable.,The kidneys are normal in size and attenuation.,No hydronephrosis is detected.  Free fluid is seen within the right upper quadrant within the lower pelvis.  A markedly thickened loop of distal small bowel is seen.  This segment measures at least 10-cm long.  No definite pneumatosis is appreciated.  No free air is apparent at this time.  Inflammatory changes around this loop of bowel.  Mild distention of adjacent small bowel loops measuring up to 3.5 cm is evident.  No complete obstruction is suspected, as there is contrast material within the colon.  Postsurgical changes compatible with the partial colectomy are noted.  Postsurgical changes of the anterior abdominal wall are seen.  Mild thickening of the urinary bladder wall is seen.,IMPRESSION:,1.  Marked thickening of a segment of distal small bowel is seen with free fluid within the abdomen and pelvis.  An inflammatory process such as infection or ischemia must be considered.  Close interval followup is necessary.,2.  Thickening of the urinary bladder wall is nonspecific and may be due to under distention.  However, evaluation for cystitis is advised.","gastroenterology, abdominal pain, nausea, diarrhea, colonic resection, axial ct images, ct abdomen, isovue, inflammatory, urinary, bladder, abdominal, colonic, wall, thickening, axial, bowel, contrast, attenuation, pelvis, ct, abdomen"
 Generalized abdominal pain with swelling at the site of the ileostomy.  CT abdomen with contrast and CT pelvis with contrast.  Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300., Gastroenterology, CT Abdomen & Pelvis - 9 ,"CT ABDOMEN WITH CONTRAST AND CT PELVIS WITH CONTRAST,REASON FOR EXAM: , Generalized abdominal pain with swelling at the site of the ileostomy.,TECHNIQUE:,  Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.,CT ABDOMEN:  ,The liver, spleen, pancreas, adrenal glands, and kidneys are unremarkable.  Punctate calcifications in the gallbladder lumen likely represent a gallstone.,CT PELVIS:  ,Postsurgical changes of a left lower quadrant ileostomy are again seen.  There is no evidence for an obstruction.  A partial colectomy and diverting ileostomy is seen within the right lower quadrant.  The previously seen 3.4 cm subcutaneous fluid collection has resolved.  Within the left lower quadrant, a 3.4 cm x 2.5 cm loculated fluid collection has not significantly changed.  This is adjacent to the anastomosis site and a pelvic abscess cannot be excluded.  No obstruction is seen.  The appendix is not clearly visualized.  The urinary bladder is unremarkable.,IMPRESSION:,1.  Resolution of the previously seen subcutaneous fluid collection.,2.  Left pelvic 3.4 cm fluid collection has not significantly changed in size or appearance.  These findings may be due to a pelvic abscess.,3.  Right lower quadrant ileostomy has not significantly changed.,4.  Cholelithiasis.","gastroenterology, axial ct images, isovue-300, ct pelvis, ct abdomen, fluid collection, abdomen, obstruction, subcutaneous, abscess, pelvic, fluid, collection, pelvis, ileostomy, ct, isovue,"
 Abdominal pain.  CT examination of the abdomen and pelvis with intravenous contrast., Gastroenterology, CT Abdomen & Pelvis - OB-GYN ,"EXAM:,  CT examination of the abdomen and pelvis with intravenous contrast.,INDICATIONS:,  Abdominal pain.,TECHNIQUE:  ,CT examination of the abdomen and pelvis was performed after 100 mL of intravenous Isovue-300 contrast administration.  Oral contrast was not administered.  There was no comparison of studies.,FINDINGS,CT PELVIS:,Within the pelvis, the uterus demonstrates a thickened-appearing endometrium.  There is also a 4.4 x 2.5 x 3.4 cm hypodense mass in the cervix and lower uterine segment of uncertain etiology.  There is also a 2.5 cm intramural hypodense mass involving the dorsal uterine fundus likely representing a fibroid.  Several smaller fibroids were also suspected.,The ovaries are unremarkable in appearance.  There is no free pelvic fluid or adenopathy.,CT ABDOMEN:,The appendix has normal appearance in the right lower quadrant.  There are few scattered diverticula in the sigmoid colon without evidence of diverticulitis.  The small and large bowels are otherwise unremarkable.  The stomach is grossly unremarkable.  There is no abdominal or retroperitoneal adenopathy.  There are no adrenal masses.  The kidneys, liver, gallbladder, and pancreas are in unremarkable appearance.  The spleen contains several small calcified granulomas, but no evidence of masses.  It is normal in size.  The lung bases are clear bilaterally.  The osseous structures are unremarkable other than mild facet degenerative changes at L4-L5 and L5-S1.,IMPRESSION:,1.  Hypoattenuating mass in the lower uterine segment and cervix of uncertain etiology measuring approximately 4.4 x 2.5 x 3.4 cm.,2.  Multiple uterine fibroids.,3.  Prominent endometrium.,4.  Followup pelvic ultrasound is recommended.","gastroenterology, ovaries, pelvic fluid, adenopathy, uterine segment, cervix, hypodense mass, ct examination, fibroids, pelvic, ct, pelvis, isovue, abdomen"
" Lower quadrant pain with nausea, vomiting, and diarrhea.  CT abdomen without contrast and CT pelvis without contrast.  Noncontrast axial CT images of the abdomen and pelvis are obtained.", Gastroenterology, CT Abdomen & Pelvis - 7 ,"REASON FOR EXAM: , Lower quadrant pain with nausea, vomiting, and diarrhea.,TECHNIQUE: , Noncontrast axial CT images of the abdomen and pelvis are obtained.,FINDINGS: , Please note evaluation of the abdominal organs is secondary to the lack of intravenous contrast material.,Gallstones are seen within the gallbladder lumen.  No abnormal pericholecystic fluid is seen.,The liver is normal in size and attenuation.,The spleen is normal in size and attenuation.,A 2.2 x 1.8 cm low attenuation cystic lesion appears to be originating off of the tail of the pancreas.  No pancreatic ductal dilatation is seen.  There is no abnormal adjacent stranding.  No suspected pancreatitis is seen.,The kidneys show no stone formation or hydronephrosis.,The large and small bowels are normal in course and caliber.  There is no evidence for obstruction.  The appendix appears within normal limits.,In the pelvis, the urinary bladder is unremarkable.  There is a 4.2 cm cystic lesion of the right adnexal region.  No free fluid, free air, or lymphadenopathy is detected.,There is left basilar atelectasis.,IMPRESSION:,1.  A 2.2 cm low attenuation lesion is seen at the pancreatic tail.  This is felt to be originating from the pancreas, a cystic pancreatic neoplasm must be considered and close interval followup versus biopsy is advised.  Additionally, when the patient's creatinine improves, a contrast-enhanced study utilizing pancreatic protocol is needed.  Alternatively, an MRI may be obtained.,2.  Cholelithiasis.,3.  Left basilar atelectasis.,4.  A 4.2 cm cystic lesion of the right adnexa, correlation with pelvic ultrasound is advised.","gastroenterology, ct abdomen, ct pelvis, neoplasm, lesion, attenuation, hydronephrosis, stone formation, ct images, cystic lesion, abdomen, cystic, pancreatic, ct, pelvis, intravenous, noncontrast"
 Right-sided abdominal pain with nausea and fever.  CT abdomen with contrast and CT pelvis with contrast.  Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300., Gastroenterology, CT Abdomen & Pelvis - 6 ,"REASON FOR EXAM: , Right-sided abdominal pain with nausea and fever.,TECHNIQUE: , Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.,CT ABDOMEN:  ,The liver, spleen, pancreas, gallbladder, adrenal glands, and kidney are unremarkable.,CT PELVIS: , Within the right lower quadrant, the appendix measures 16 mm and there are adjacent inflammatory changes with fluid in the right lower quadrant.  Findings are compatible with acute appendicitis.,The large and small bowels are normal in course and caliber without obstruction.  The urinary bladder is normal.  The uterus appears unremarkable.  Mild free fluid is seen in the lower pelvis.,No destructive osseous lesions are seen.  The visualized lung bases are clear.,IMPRESSION: , Acute appendicitis.","gastroenterology, adrenal glands, appendicitis, gallbladder, kidney, liver, pancreas, spleen, acute appendicitis, ct pelvis, ct abdomen, abdominal, contrast, fluid, abdomen, inflammatory, pelvis, ct"
"  CT abdomen without contrast and pelvis without contrast, reconstruction.", Gastroenterology, CT Abdomen & Pelvis - 5 ,"EXAM: , CT abdomen without contrast and pelvis without contrast, reconstruction.,REASON FOR EXAM: , Right lower quadrant pain, rule out appendicitis.,TECHNIQUE:  ,Noncontrast CT abdomen and pelvis.  An intravenous line could not be obtained for the use of intravenous contrast material.,FINDINGS: , The appendix is normal.  There is a moderate amount of stool throughout the colon.  There is no evidence of a small bowel obstruction or evidence of pericolonic inflammatory process.  Examination of the extreme lung bases appear clear, no pleural effusions.  The visualized portions of the liver, spleen, adrenal glands, and pancreas appear normal given the lack of contrast.  There is a small hiatal hernia.  There is no intrarenal stone or evidence of obstruction bilaterally.  There is a questionable vague region of low density in the left anterior mid pole region, this may indicate a tiny cyst, but it is not well seen given the lack of contrast.  This can be correlated with a followup ultrasound if necessary.  The gallbladder has been resected.  There is no abdominal free fluid or pathologic adenopathy.  There is abdominal atherosclerosis without evidence of an aneurysm.,Dedicated scans of the pelvis disclosed phleboliths, but no free fluid or adenopathy.  There are surgical clips present.  There is a tiny airdrop within the bladder.  If this patient has not had a recent catheterization, correlate for signs and symptoms of urinary tract infection.,IMPRESSION:,1.Normal appendix.,2.Moderate stool throughout the colon.,3.No intrarenal stones.,4.Tiny airdrop within the bladder.  If this patient has not had a recent catheterization, correlate for signs and symptoms of urinary tract infection.  The report was faxed upon dictation.","gastroenterology, reconstruction, appendicitis, urinary tract infection, ct abdomen, abdomen, ct, pelvis, contrast, noncontrast,"
" CT abdomen and pelvis without contrast, stone protocol, reconstruction.", Gastroenterology, CT Abdomen & Pelvis - 4 ,"EXAM: , CT abdomen and pelvis without contrast, stone protocol, reconstruction.,REASON FOR EXAM: , Flank pain.,TECHNIQUE: , Noncontrast CT abdomen and pelvis with coronal reconstructions.,FINDINGS: , There is no intrarenal stone bilaterally.  However, there is very mild left renal pelvis and proximal ureteral dilatation with a small amount of left perinephric stranding asymmetric to the right.  The right renal pelvis is not dilated.  There is no stone along the course of the ureter.  I cannot exclude the possibility of recent stone passage, although the findings are ultimately technically indeterminate and clinical correlation is advised.  There is no obvious solid-appearing mass given the lack of contrast.,Scans of the pelvis disclose no evidence of stone within the decompressed bladder.  No pelvic free fluid or adenopathy.,There are few scattered diverticula.  There is a moderate amount of stool throughout the colon.  There are scattered diverticula, but no CT evidence of acute diverticulitis.  The appendix is normal.,There are mild bibasilar atelectatic changes.,Given the lack of contrast, visualized portions of the liver, spleen, adrenal glands, and the pancreas are grossly unremarkable.  The gallbladder is present.  There is no abdominal free fluid or pathologic adenopathy.,There are degenerative changes of the lumbar spine.,IMPRESSION:,1.Very mild left renal pelvic dilatation and proximal ureteral dilatation with mild left perinephric stranding.  There is no stone identified along the course of the left ureter or in the bladder.  Could this patient be status post recent stone passage?  Clinical correlation is advised.,2.Diverticulosis.,3.Moderate amount of stool throughout the colon.,4.Normal appendix.","gastroenterology, coronal reconstructions, stone protocol, renal pelvic dilatation, proximal ureteral dilatation, ct abdomen and pelvis, stone protocol reconstruction, abdomen and pelvis, perinephric stranding, free fluid, scattered diverticula, renal, dilatation, contrast, ureteral, ct, abdomen, pelvis, stone, noncontrast,"
 CT of the abdomen and pelvis without contrast., Gastroenterology, CT Abdomen & Pelvis - 3 ,"EXAM: , CT of the abdomen and pelvis without contrast.,HISTORY: , Lower abdominal pain.,FINDINGS:,  Limited views of the lung bases demonstrate linear density most likely representing dependent atelectasis.  There is a 1.6 cm nodular density at the left posterior sulcus.,Noncontrast technique limits evaluation of the solid abdominal organs.  Cardiomegaly and atherosclerotic calcifications are seen.,Hepatomegaly is observed.  There is calcification within the right lobe of the liver likely related to granulomatous changes.  Subtle irregularity of the liver contour is noted, suggestive of cirrhosis.  There is splenomegaly seen.  There are two low-attenuation lesions seen in the posterior aspect of the spleen, which are incompletely characterized that may represent splenic cyst.  The pancreas appears atrophic.  There is a left renal nodule seen, which measures 1.9 cm with a Hounsfield unit density of approximately 29, which is indeterminate.,There is mild bilateral perinephric stranding.  There is an 8-mm fat density lesion in the anterior inner polar region of the left kidney, compatible in appearance with angiomyolipoma.  There is a 1-cm low-attenuation lesion in the upper pole of the right kidney, likely representing a cyst, but incompletely characterized on this examination.  Bilateral ureters appear normal in caliber along their visualized course.  The bladder is partially distended with urine, but otherwise unremarkable.,Postsurgical changes of hysterectomy are noted.  There are pelvic phlebolith seen.  There is a calcified soft tissue density lesion in the right pelvis, which may represent an ovary with calcification, as it appears continuous with the right gonadal vein.,Scattered colonic diverticula are observed.  The appendix is within normal limits.  The small bowel is unremarkable.  There is an anterior abdominal wall hernia noted containing herniated mesenteric fat.  The hernia neck measures approximately 2.7 cm.  There is stranding of the fat within the hernia sac.,There are extensive degenerative changes of the right hip noted with changes suggestive of avascular necrosis.  Degenerative changes of the spine are observed.,IMPRESSION:,1.  Anterior abdominal wall hernia with mesenteric fat-containing stranding, suggestive of incarcerated fat.,2.  Nodule in the left lower lobe, recommend follow up in 3 months.,3.  Indeterminate left adrenal nodule, could be further assessed with dedicated adrenal protocol CT or MRI.,4.  Hepatomegaly with changes suggestive of cirrhosis.  There is also splenomegaly observed.,5.  Low-attenuation lesions in the spleen may represent cyst, that are incompletely characterized on this examination.,6.  Fat density lesion in the left kidney, likely represents angiomyolipoma.,7.  Fat density soft tissue lesion in the region of the right adnexa, this contains calcifications and may represent an ovary or possibly dermoid cyst.","gastroenterology, abdominal pain, cardiomegaly, atherosclerotic calcifications, hepatomegaly, perinephric stranding, low attenuation lesions, abdominal, calcifications, lesions, abdomen,"
 Patient presents for a colostomy reversal as well as repair of an incisional hernia. , Gastroenterology, Consult for Colostomy Reversal ,"CHIEF COMPLAINT: , ""I want my colostomy reversed."",HISTORY OF PRESENT ILLNESS: , Mr. A is a pleasant 43-year-old African-American male who presents to our clinic for a colostomy reversal as well as repair of an incisional hernia.  The patient states that in November 2007, he presented to High Point Regional Hospital with sharp left lower quadrant pain and was emergently taken to Surgery where he woke up with a ""bag.""  According to some notes that were faxed to our office from the surgeon in High Point who performed his initial surgery, Dr. X, the patient had diverticulitis with perforated sigmoid colon, and underwent a sigmoid colectomy with end colostomy and Hartmann's pouch.  The patient was unaware of his diagnosis; therefore, we discussed that with him today in clinic.  The patient also complains of the development of an incisional hernia since his surgery in November.  He was seen back by Dr. X in April 2008 and hopes that Dr. X may reverse his colostomy and repair his hernia since he did his initial surgery, but because the patient has lost his job and has no insurance, he was referred to our clinic by Dr. X.  Currently, the patient does state that his hernia bothers him more so than his colostomy, and if it were not for the hernia then he may just refrain from having his colostomy reversed; however, the hernia has grown in size and causing him significant discomfort.  He feels that he always has to hold his hand over the hernia to prevent it from prolapsing and causing him even more discomfort.,PAST MEDICAL AND SURGICAL HISTORY:,1.  Gastroesophageal reflux disease.,2.  Question of hypertension.,3.  Status post sigmoid colectomy with end colostomy and Hartmann's pouch in November 2007 at High Point Regional.,4.  Status post cholecystectomy.,7.  Status post unknown foot surgery.,MEDICATIONS:,  None.,ALLERGIES: , No known drug allergies.,SOCIAL HISTORY: , The patient lives in Greensboro.  He smokes one pack of cigarettes a day and has done so for 15 years.  He denies any IV drug use and has an occasional alcohol.,FAMILY HISTORY:  ,Positive for diabetes, hypertension, and coronary artery disease.,REVIEW OF SYSTEMS: , Please see history of present illness; otherwise, the review of systems is negative.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 95.9, pulse 67, blood pressure 135/79, and weight 208 pounds.,GENERAL:  This is a pleasant African-American male appearing his stated age in no acute distress.,HEENT:  Normocephalic, atraumatic.  Pupils are equal, round, and reactive to light and accommodation.  Moist mucous membranes.  Extraocular movements intact.,NECK:  Supple, no JVD, and no lymphadenopathy.,CARDIOVASCULAR:  Regular rate and rhythm.,LUNGS:  Clear to auscultation bilaterally.,ABDOMEN:  Soft, nontender, and nondistended with a left lower quadrant stoma.  The stoma is pink, protuberant, and productive.  The patient also has a midline incisional hernia approximately 6 cm in diameter.  It is reducible.  Otherwise, there are no further hernias or masses noted.,EXTREMITIES:  No clubbing, cyanosis or edema.,ASSESSMENT AND PLAN:  ,This is a 43-year-old gentleman who underwent what sounds like a sigmoid colectomy with end colostomy and Hartmann's pouch in November of 2007 secondary to perforated colon from diverticulitis.  The patient presents for reversal of his colostomy as well as repair of his incisional hernia.  I have asked the patient to return to High Point Regional and get his medical records including the operative note and pathology results from his initial surgery so that I would have a better idea of what was done during his initial surgery.  He stated that he would try and do this and bring the records to our clinic on his next appointment.  I have also set him up for a barium enema to study the rectal stump.  He will return to us in two weeks at which time we will review his radiological studies and his medical records from the outside hospital and determine the best course of action from that point.  This was discussed with the patient as well as his sister and significant other in the clinic today.  They were in agreement with this plan.  We also called the social worker to come and help the patient get more ostomy appliances, as he stated that he had no more and he was having to reuse the existing ostomy bag.  To my understanding, his social worker, as well as the ostomy nurses were able to get him some assistance with this.,",
 CT Abdomen & Pelvis W&WO Contrast, Gastroenterology, CT Abdomen & Pelvis ,"EXAM:,  CT Abdomen & Pelvis W&WO Contrast, ,REASON FOR EXAM: , Status post aortobiiliac graft repair. , ,TECHNIQUE: , 5 mm spiral thick spiral CT scanning was performed through the entire abdomen and pelvis utilizing intravenous dynamic bolus contrast enhancement.  No oral or rectal contrast was utilized.  Comparison is made with the prior CT abdomen and pelvis dated 10/20/05.  There has been no significant change in size of the abdominal aortic aneurysm centered roughly at the renal artery origin level which has dimensions of 3.7 cm transversely x 3.4 AP.  Just below this level is the top of the endoluminal graft repair with numerous surrounding surgical clips.  The size of the native aneurysm component at this level is stable at 5.5 cm in diameter with mural thrombus surrounding the enhancing endolumen.  There is no abnormal entrance of contrast agent into the mural thrombus to indicate an endoluminal leak.  Further distally, there is extension of the graft into both proximal common iliac arteries without evidence for endoluminal leak at this level either.  No exoluminal leakage is identified at any level.  There is no retroperitoneal hematoma present.  The findings are unchanged from the prior exam.  ,The liver, spleen, pancreas, adrenals and right kidney are unremarkable with moderate diffuse atrophy of the pancreas present.  There is advanced atrophy of the left kidney.  No hydronephrosis is present.  No acute findings are identified elsewhere in the abdomen. ,The lung bases are clear. ,Concerning the remainder of the pelvis, no acute pathology is identified.  There is prominent streak artifact from the left total hip replacement.  There is diffuse moderate sigmoid diverticulosis without evidence for diverticulitis.  The bladder grossly appears normal.  A hysterectomy has been performed.  ,IMPRESSION:,1.  No complications identified regarding endoluminal aortoiliac graft repair as described.  The findings are stable compared to the study of 10/20/04.  ,2.  Stable mild aneurysm of aortic aneurysm, centered roughly at renal artery level.  ,3.  No other acute findings noted. ,4.  Advanced left renal atrophy.","gastroenterology, aortobiiliac graft repair, renal atrophy, ct abdomen & pelvis, w&wo contrast, aortic aneurysm, renal artery, mural thrombus, endoluminal leak, ct abdomen, ct, contrast, pelvis, abdomen,"
 Patient with family history of colon cancer and has rectal bleeding on a weekly basis and also heartburn once every 1 or 2 weeks. , Gastroenterology, Consult - Rectal Bleeding ,"PRESENT ILLNESS: , The patient is a very pleasant 69-year-old Caucasian male whom we are asked to see primarily because of a family history of colon cancer, but the patient also has rectal bleeding on a weekly basis and also heartburn once every 1 or 2 weeks.  The patient states that he had his first colonoscopy 6 years ago and it was negative.  His mother was diagnosed with colon cancer probably in her 50s, but she died of cancer of the esophagus at age 86.  The patient does have hemorrhoidal bleed about once a week.  Otherwise, he denies any change in bowel habits, abdominal pain, or weight loss.  He gets heartburn mainly with certain food such as raw onions and he has had it for years.  It will typically occur every couple of weeks.  He has had no dysphagia.  He has never had an upper endoscopy.,MEDICAL HISTORY: , Remarkable for hypertension, adult-onset diabetes mellitus, hyperlipidemia, and restless legs syndrome.,SURGICAL HISTORY: , Appendectomy as a child and cholecystectomy in 2003.,MEDICATIONS:  ,His medications are lisinopril 40 mg daily, hydrochlorothiazide 25 mg daily, metformin 1000 mg twice a day, Januvia 100 mg daily, clonazepam 10 mg at bedtime for restless legs syndrome, Crestor 10 mg nightly, and Flomax 0.4 mg daily.,ALLERGIES: , No known drug allergies.,SOCIAL HISTORY: , The patient is retired.  He is married.  He had 4 children.  He quite smoking 25 years ago after a 35-year history of smoking.  He does not drink alcohol.,FAMILY HISTORY: , Mother had colon cancer in her 50s, esophageal cancer in her 80s.  Her mother smoked and drank.  Father got a mesothelioma at age 65.  There is a brother of 65 with hypertension.,REVIEW OF SYSTEMS: , He has had prostatitis with benign prostatic hypertrophy.  He has some increased urinary frequency from a history of prostatitis.  He has the heartburn, which is diet dependent and the frequent rectal bleeding.  He also has restless legs syndrome at night.  No cardio or pulmonary complaints.  No weight loss.,PHYSICAL EXAMINATION: , Reveals a well-developed, well-nourished man in no acute distress.  BP 112/70.  Pulse 80 and regular.  Respirations non-labored.  Height 5 feet 7-1/2 inches.  Weight 209 pounds.  HEENT exam:  Sclerae are anicteric.  Pupils equal, conjunctivae clear.  No gross oropharyngeal lesions.  Neck is supple without lymphadenopathy, thyromegaly, or JVD.  Lungs are clear to percussion and auscultation.  Heart sounds are regular without murmur, gallop, or rub.  The abdomen is soft and nontender.  There are no masses.  There is no hepatosplenomegaly.  The bowel sounds are normal.  Rectal examination:  Deferred.  Extremities have no clubbing, cyanosis or edema.  Skin is warm and dry.  The patient is alert and oriented with a pleasant affect and no gross motor deficits.,IMPRESSION:,1.  Family history of colon cancer.,2.  Rectal bleeding.,3.  Heartburn and a family history of esophageal cancer.,PLAN:,  I agree with the indications for repeat colonoscopy, which should be done at least every 5 years.  Also, discussed IRC to treat bleeding and internal hemorrhoids if he is deemed to be an appropriate candidate at the time of his colonoscopy and the patient was agreeable.  I am also a little concerned about his family history of esophageal cancer and his personal history of heartburn and suggested that we check him once for Barrett's esophagus.  If he does not have it now then it should not be a significant risk in the future.  The indications and benefits of EGD, colonoscopy, and IRC were discussed.  The risks including sedation, bleeding, infection, and perforation were discussed.  The importance of a good bowel prep so as to minimize missing any lesions was discussed.  His questions were answered and informed consent obtained.  It was a pleasure to care for this nice patient.","gastroenterology, heartburn, family history of esophageal cancer, repeat colonoscopy, colonoscopy, egd, irc, barrett's esophagus, restless legs syndrome, esophageal cancer, rectal bleeding, colon cancer, rectal, bleeding, cancer, "
 Patient comes for discussion of a screening colonoscopy. , Gastroenterology, Consult - Screening Colonoscopy ,"HISTORY:,  A is a 55-year-old who I know well because I have been taking care of her husband.  She comes for discussion of a screening colonoscopy.  Her last colonoscopy was in 2002, and at that time she was told it was essentially normal.  Nonetheless, she has a strong family history of colon cancer, and it has been almost four to five years so she wants to have a repeat colonoscopy.  I told her that the interval was appropriate and that it made sense to do so.  She denies any significant weight change that she cannot explain.  She has had no hematochezia.  She denies any melena.  She says she has had no real change in her bowel habit but occasionally does have thin stools.,PAST MEDICAL HISTORY:,  On today's visit we reviewed her entire health history.  Surgically she has had a stomach operation for ulcer disease back in 1974, she says.  She does not know exactly what was done.  It was done at a hospital in California which she says no longer exists.  This makes it difficult to find out exactly what she had done.  She also had her gallbladder and appendix taken out in the 1970s at the same hospital.  Medically she has no significant problems and no true medical illnesses.  She does suffer from some mild gastroparesis, she says.,MEDICATIONS: , Reglan 10 mg once a day.,ALLERGIES: , She denies any allergies to medications but is sensitive to medications that cause her to have ulcers, she says.,SOCIAL HISTORY: , She still smokes one pack of cigarettes a day.  She was counseled to quit.  She occasionally uses alcohol.  She has never used illicit drugs.  She is married, is a housewife, and has four children.,FAMILY HISTORY: , Positive for diabetes and cancer.,REVIEW OF SYSTEMS: , Essentially as mentioned above.,PHYSICAL EXAMINATION:,GENERAL:  A is a healthy appearing female in no apparent distress.,VITAL SIGNS:  Her vital signs reveal a weight of 164 pounds, blood pressure 140/90, temperature of 97.6 degrees F.,HEENT:  No cervical bruits, thyromegaly, or masses.  She has no lymphadenopathy in the head and neck, supraclavicular, or axillary spaces bilaterally.,LUNGS:  Clear to auscultation bilaterally with no wheezes, rubs, or rhonchi.,HEART:  Regular rate and rhythm without murmur, rub, or gallop.,ABDOMEN:  Soft, nontender, nondistended.,EXTREMITIES:  No cyanosis, clubbing, or edema, with good pulses in the radial arteries bilaterally.,NEURO:  No focal deficits, is intact to soft touch in all four.,ASSESSMENT AND RECOMMENDATIONS: , In light of her history and physical, clearly the patient would be well served with an upper and lower endoscopy.  We do not know what the anatomy is, and if she did have an antrectomy, she needs to be checked for marginal ulcers.  She also complains of significant reflux and has not had an upper endoscopy in over five to six years as well.  I discussed the risks, benefits, and alternatives to upper and lower endoscopy, and these include over sedation, perforation, and dehydration, and she wants to proceed.,We will schedule her for an upper and lower endoscopy at her convenience.","gastroenterology, screening colonoscopy, colonoscopy, hematochezia, screening, endoscopy, "
 Abnormal liver enzymes and diarrhea.  CT pelvis with contrast and ct abdomen with and without contrast., Gastroenterology, CT Abdomen & Pelvis - 11 ,"EXAM: , CT pelvis with contrast and ct abdomen with and without contrast.,INDICATIONS:  ,Abnormal liver enzymes and diarrhea.,TECHNIQUE: , CT examination of the abdomen and pelvis was performed after 100 mL of intravenous contrast administration and oral contrast administration.  Pre-contrast images through the abdomen were also obtained.,COMPARISON:  ,There were no comparison studies.,FINDINGS:  ,The lung bases are clear.,The liver demonstrates mild intrahepatic biliary ductal dilatation.  These findings may be secondary to the patient's post cholecystectomy state.  The pancreas, spleen, adrenal glands, and kidneys are unremarkable.,There is a 13 mm peripheral-enhancing fluid collection in the anterior pararenal space of uncertain etiology.  There are numerous nonspecific retroperitoneal and mesenteric lymph nodes.  These may be reactive; however, an early neoplastic process would be difficult to totally exclude.,There is a right inguinal hernia containing a loop of small bowel.  This may produce a partial obstruction as there is mild fluid distention of several small bowel loops, particularly in the right lower quadrant.  The large bowel demonstrates significant diverticulosis coli of the sigmoid and distal descending colon without evidence of diverticulitis.,There is diffuse osteopenia along with significant degenerative changes in the lower lumbar spine.,The urinary bladder is unremarkable.  The uterus is not visualized.,IMPRESSION:,1.  Right inguinal hernia containing small bowel.  Partial obstruction is suspected.,2.  Nonspecific retroperitoneal and mesenteric lymph nodes.,3.  Thirteen millimeter of circumscribed fluid collection in the anterior pararenal space of uncertain etiology.,4.  Diverticulosis without evidence of diverticulitis.,5.  Status post cholecystectomy with mild intrahepatic biliary ductal dilatation.,6.  Osteopenia and degenerative changes of the spine and pelvis.","gastroenterology, pre-contrast images, contrast, biliary ductal dilatation, pancreas, spleen, adrenal glands, kidneys, mesenteric lymph nodes, fluid collection, inguinal hernia, ct abdomen, hernia, diverticulosis, diverticulitis, osteopenia, degenerative, spine, bowel, pelvis, ct, abdomen,"
" A 50-year-old female whose 51-year-old sister has a history of multiple colon polyps, which may slightly increase her risk for colon cancer in the future.", Gastroenterology, Consult - Multiple Colon Polyps ,"HISTORY OF PRESENT ILLNESS: , See chart attached.,MEDICATIONS: , Tramadol 50 mg every 4 to 6 hours p.r.n., hydrocodone 7.5 mg/500 mg every 6 hours p.r.n., zolpidem 10 mg at bedtime, triamterene 37.5 mg, atenolol 50 mg, vitamin D, TriCor 145 mg, simvastatin 20 mg, ibuprofen 600 mg t.i.d., and Lyrica 75 mg.,FAMILY HISTORY: , Mother is age 78 with history of mesothelioma.  Father is alive, but unknown medical history as they have been estranged.  She has a 51-year-old sister with history of multiple colon polyps.  She has 2 brothers, 1 of whom has schizophrenia, but she knows very little about their medical history.  To the best of her knowledge, there are no family members with stomach cancer or colon cancer.,SOCIAL HISTORY: , She was born in Houston, Texas and moved to Florida about 3 years ago.  She is divorced.  She has worked as a travel agent.  She has 2 sons ages 24 and 26, both of whom are alive and well.  She smokes a half a pack of cigarettes per day for more than 35 years.  She does not consume alcohol.,REVIEW OF SYSTEMS: , As per the form filled out in our office today is positive for hypertension, weakness in arms and legs, arthritis, pneumonia, ankle swelling, getting full quickly after eating, loss of appetite, weight loss, which is stated as fluctuating up and down 4 pounds, trouble swallowing, heartburn, indigestion, belching, nausea, diarrhea, constipation, change in bowel habits, change in consistency, rectal bleeding, hemorrhoids, abdominal discomfort and cramping associated with constipation, hepatitis A or infectious hepatitis in the past, and smoking and alcohol as previously stated.  Otherwise, review of systems is negative for strokes, paralysis, gout, cataracts, glaucoma, respiratory difficulties, tuberculosis, chest pain, heart disease, kidney stones, hematuria, rheumatic fever, scarlet fever, cancer, diabetes, thyroid disease, seizure disorder, blood transfusions, anemia, jaundice, or pruritus.,PHYSICAL EXAMINATION:  ,Weight 152 pounds.  Height is 5 feet 3 inches.  Blood pressure 136/80.  Pulse 68.  In general:  She is a well-developed and well-nourished female who ambulates with the assistance of a cane.  Neurologically nonfocal.  Awake, alert, and oriented x 3.  HEENT:  Head normocephalic, atraumatic.  Sclerae anicteric.  Conjunctivae are pink.  Mouth is moist without any obvious oral lesions.  Neck is supple.  There is no submandibular, submaxillary, axillary, supraclavicular, or epitrochlear adenopathy appreciable.  Lungs are clear to auscultation bilaterally.  Heart:  Regular rate and rhythm without obvious gallops or murmurs.  Abdomen is soft, nontender with good bowel sounds.  No organomegaly or masses are appreciable.  Extremities are without clubbing, cyanosis, and/or edema.  Skin is warm and dry.  Rectal was deferred and will be done at the time of the colonoscopy.,IMPRESSION:,1.  A 50-year-old female whose 51-year-old sister has a history of multiple colon polyps, which may slightly increase her risk for colon cancer in the future.,2.  Reports of recurrent bright red blood per rectum, mostly on the toilet paper over the past year.  Bleeding most likely consistent with internal hemorrhoids; however, she needs further evaluation for colon polyps or colon cancer.,3.  Alternations between constipation and diarrhea for the past several years with some lower abdominal cramping and discomfort particularly associated with constipation.  She is on multiple medications including narcotics and may have developed narcotic bowel syndrome.,4.  A long history of pyrosis, dyspepsia, nausea, and belching for many years relieved by antacids.  She may likely have underlying gastroesophageal reflux disease.,5.  A 1-year history of some early satiety and fluctuations in her weight up and down 4 pounds.  She may also have some GI dysmotility including gastroparesis.,6.  Report of dysphagia to solids over the past several years with a history of a bone spur in her cervical spine.  If this bone spur is pressing anteriorly, it could certainly cause recurrent symptoms of dysphagia.  Differential also includes peptic stricture or Schatzki's ring, and even remotely, the possibility of an esophageal malignancy.,7.  A history of infectious hepatitis in the past with some recent mild elevations in AST and ALT levels without clear etiology.  She may have some reaction to her multiple medications including her statin drugs, which can cause mild elevations in transaminases.  She may have some underlying fatty liver disease and differential could include some form of viral hepatitis such as hepatitis B or even C.,PLAN:,1.  We have asked her to follow up with her primary care physician with regard to this recent elevation in her transaminases.  She will likely have the lab tests repeated in the future, and if they remain persistently elevated, we will be happy to see her in the future for further evaluation if her primary care physician would like.,2.  Discussed reflux precautions and gave literature for further review.,3.  Schedule an upper endoscopy with possible esophageal dilatation, as well as colonoscopy with possible infrared coagulation of suspected internal hemorrhoids.  Both procedures were explained in detail including risks and complications such as adverse reaction to medication, as well as respiratory embarrassment, infection, bleeding, perforation, and possibility of missing a small polyp or tumor.,4.  Alternatives including upper GI series, flexible sigmoidoscopy, barium enema, and CT colonography were discussed; however, the patient agrees to proceed with the plan as outlined above.,5.  Due to her sister's history of colon polyps, she will likely be advised to have a repeat colonoscopy in 5 years or perhaps sooner pending the results of her baseline examination.,","gastroenterology, mesothelioma, risk for colon cancer, constipation, diarrhea, multiple colon polyps, colon cancer, colon polyps, colon, cancer, polyps, "
" Evaluate for retroperitoneal hematoma, the patient has been following, is currently on Coumadin.  CT abdomen without contrast and CT pelvis without contrast.", Gastroenterology, CT Abdomen & Pelvis - 10 ,"CT ABDOMEN WITHOUT CONTRAST AND CT PELVIS WITHOUT CONTRAST,REASON FOR EXAM: , Evaluate for retroperitoneal hematoma, the patient has been following, is currently on Coumadin.,CT ABDOMEN: , There is no evidence for a retroperitoneal hematoma.,The liver, spleen, adrenal glands, and pancreas are unremarkable.  Within the superior pole of the left kidney, there is a 3.9 cm cystic lesion.  A 3.3 cm cystic lesion is also seen within the inferior pole of the left kidney.  No calcifications are noted.  The kidneys are small bilaterally.,CT PELVIS: , Evaluation of the bladder is limited due to the presence of a Foley catheter, the bladder is nondistended.  The large and small bowels are normal in course and caliber.  There is no obstruction.,Bibasilar pleural effusions are noted.,IMPRESSION:,1. No evidence for retroperitoneal bleed.,2. There are two left-sided cystic lesions within the kidney, correlation with a postcontrast study versus further characterization with an ultrasound is advised as the cystic lesions appear slightly larger as compared to the prior exam.,3. The kidneys are small in size bilaterally.,4. Bibasilar pleural effusions.","gastroenterology, cystic lesion, superior pole, kidney, ct pelvis, ct abdomen, retroperitoneal hematoma, lesion, kidneys, bladder, bibasilar, pleural, effusions, lesions, pelvis, hematoma, retroperitoneal, cystic, ct, abdomen,"
 CT scan of the abdomen and pelvis without and with intravenous contrast., Gastroenterology, CT Abdomen & Pelvis - 2 ,"EXAM: , CT scan of the abdomen and pelvis without and with intravenous contrast.,CLINICAL INDICATION: , Left lower quadrant abdominal pain.,COMPARISON: , None.,FINDINGS: , CT scan of the abdomen and pelvis was performed without and with intravenous contrast.  Total of 100 mL of Isovue was administered intravenously.  Oral contrast was also administered.,The lung bases are clear.  The liver is enlarged and decreased in attenuation.  There are no focal liver masses.,There is no intra or extrahepatic ductal dilatation.,The gallbladder is slightly distended.,The adrenal glands, pancreas, spleen, and left kidney are normal.,A 12-mm simple cyst is present in the inferior pole of the right kidney.  There is no hydronephrosis or hydroureter.,The appendix is normal.,There are multiple diverticula in the rectosigmoid.  There is evidence of focal wall thickening in the sigmoid colon (image #69) with adjacent fat stranding in association with a diverticulum.  These findings are consistent with diverticulitis.  No pneumoperitoneum is identified.  There is no ascites or focal fluid collection.,The aorta is normal in contour and caliber.,There is no adenopathy.,Degenerative changes are present in the lumbar spine.,IMPRESSION: , Findings consistent with diverticulitis.  Please see report above.","gastroenterology, extrahepatic ductal dilatation, gallbladder, glands, pancreas, spleen, kidney, adrenal, abdomen and pelvis, ct scan, intravenous, abdomen,"
 CT Abdomen and Pelvis with contrast , Gastroenterology, CT Abdomen & Pelvis - 1 ,"EXAM: , CT Abdomen and Pelvis with contrast ,REASON FOR EXAM:, Nausea, vomiting, diarrhea for one day.  Fever.  Right upper quadrant pain for one day.  ,COMPARISON: , None. ,TECHNIQUE:,  CT of the abdomen and pelvis performed without and with approximately 54 ml Isovue 300 contrast enhancement.  ,CT ABDOMEN: , Lung bases are clear.  The liver, gallbladder, spleen, pancreas, and bilateral adrenal/kidneys are unremarkable.  The aorta is normal in caliber.  There is no retroperitoneal lymphadenopathy.  ,CT PELVIS: , The appendix is visualized along its length and is diffusely unremarkable with no surrounding inflammatory change.  Per CT, the colon and small bowel are unremarkable.  The bladder is distended.  No free fluid/air.  Visualized osseous structures demonstrate no definite evidence for acute fracture, malalignment, or dislocation.,IMPRESSION:,1.  Unremarkable exam; specifically no evidence for acute appendicitis. ,2.  No acute nephro-/ureterolithiasis. ,3.  No secondary evidence for acute cholecystitis.,Results were communicated to the ER at the time of dictation.","gastroenterology, liver, gallbladder, spleen, pancreas, adrenal, kidneys, lymphadenopathy, abdomen and pelvis, contrast, ct"
 Patient in ER due to colostomy failure - bowel obstruction., Gastroenterology, Colostomy Failure ,"CHIEF COMPLAINT:, Colostomy failure. ,HISTORY OF PRESENT ILLNESS:, This patient had a colostomy placed 9 days ago after resection of colonic carcinoma. Earlier today, he felt nauseated and stated that his colostomy stopped filling. He also had a sensation of ""heartburn."" He denies vomiting but has been nauseated. He denies diarrhea. He denies hematochezia, hematemesis, or melena. He denies frank abdominal pain or fever. ,PAST MEDICAL HISTORY:, As above. Also, hypertension. ,ALLERGIES:, ""Fleet enema."" ,MEDICATIONS:, Accupril and vitamins. ,REVIEW OF SYSTEMS:,SYSTEMIC: The patient denies fever or chills.,HEENT: The patient denies blurred vision, headache, or change in hearing.,NECK: The patient denies dysphagia, dysphonia, or neck pain.,RESPIRATORY: The patient denies shortness of breath, cough, or hemoptysis.,CARDIAC: The patient denies history of arrhythmia, swelling of the extremities, palpitations, or chest pain.,GASTROINTESTINAL: See above.,MUSCULOSKELETAL: The patient denies arthritis, arthralgias, or joint swelling.,NEUROLOGIC: The patient denies difficulty with balance, numbness, or paralysis.,GENITOURINARY: The patient denies dysuria, flank pain, or hematuria.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Blood pressure 183/108, pulse 76, respirations 16, temperature 98.7. ,HEENT: Cranial nerves are grossly intact. There is no scleral icterus. ,NECK: No jugular venous distention. ,CHEST: Clear to auscultation bilaterally. ,CARDIAC: Regular rate and rhythm. No murmurs. ,ABDOMEN: Soft, nontender, nondistended. Bowel sounds are decreased and high-pitched. There is a large midline laparotomy scar with staples still in place. There is no evidence of wound infection. Examination of the colostomy port reveals no obvious fecal impaction or site of obstruction. There is no evidence of infection. The mucosa appears normal. There is a small amount of nonbloody stool in the colostomy bag. There are no masses or bruits noted. ,EXTREMITIES: There is no cyanosis, clubbing, or edema. Pulses are 2+ and equal bilaterally. ,NEUROLOGIC: The patient is alert and awake with no focal motor or sensory deficit noted. ,MEDICAL DECISION MAKING:, Failure of colostomy to function may repre- sent an impaction; however, I did not appreciate this on physical examination. There may also be an adhesion or proximal impaction which I cannot reach, which may cause a bowel obstruction, failure of the shunt, nausea, and ultimately vomiting. ,An abdominal series was obtained, which confirmed this possibility by demonstrating air-fluid levels and dilated bowel. ,The CBC showed WBC of 9.4 with normal differential. Hematocrit is 42.6. I interpret this as normal. Amylase is currently pending. ,I have discussed this case with Dr. S, the patient's surgeon, who agrees that there is a possibility of bowel obstruction and the patient should be admitted to observation. Because of the patient's insurance status, the patient will actually be admitted to Dr. D on observation. I have discussed the case with Dr. P, who is the doctor on call for Dr. D. Both Dr. S and Dr. P have been informed of the patient's condition and are aware of his situation. ,FINAL IMPRESSION:, Bowel obstruction, status post colostomy. ,DISPOSITION:, Admission to observation. The patient's condition is good. He is hemodynamically stable.",
 Patient with mid-epigastric abdominal pain.  Sonogram revealed gallstones., Gastroenterology, Consult - Laparoscopic Cholecystectomy  ,"PAST MEDICAL HISTORY: , Significant for arthritis in her knee, anxiety, depression, high insulin levels, gallstone attacks, and PCOS.,PAST SURGICAL HISTORY: , None.,SOCIAL HISTORY: , Currently employed.  She is married.  She is in sales.  She does not smoke.  She drinks wine a few drinks a month.,CURRENT MEDICATIONS: , She is on Carafate and Prilosec.  She was on metformin, but she stopped it because of her abdominal pains.,ALLERGIES: , She is allergic to PENICILLIN.,REVIEW OF SYSTEMS:,  Negative for heart, lungs, GI, GU, cardiac, or neurologic.  Denies specifically asthma, allergies, high blood pressure, high cholesterol, diabetes, chronic lung disease, ulcers, headache, seizures, epilepsy, strokes, thyroid disorder, tuberculosis, bleeding, clotting disorder, gallbladder disease, positive liver disease, kidney disease, cancer, heart disease, and heart attack.,PHYSICAL EXAMINATION: , She is afebrile.  Vital Signs are stable.  HEENT:  EOMI.  PERRLA.  Neck is soft and supple.  Lungs clear to auscultation.  She is mildly tender in the abdomen in the right upper quadrant.  No rebound.  Abdomen is otherwise soft.  Positive bowel sounds.  Extremities are nonedematous.  Ultrasound reveals gallstones, no inflammation, common bile duct in 4 mm.,IMPRESSION/PLAN: , I have explained the risks and potential complications of laparoscopic cholecystectomy in detail including bleeding, infection, deep venous thrombosis, pulmonary embolism, cystic leak, duct leak, possible need for ERCP, and possible need for further surgery among other potential complications.  She understands and we will proceed with the surgery in the near future.,","gastroenterology, laparoscopic cholecystectomy, mid epigastric, epigastric abdominal, potential complications, laparoscopic, cholecystectomy, epigastric, abdomen, surgery, gallstones, disease, abdominal"
 Patient complains of constipation.  Has not had BM for two days., Gastroenterology, Constipation - 1 ,"Patient was informed by Dr. ABC that he does not need sleep study as per patient.,PHYSICAL EXAMINATION:,General:  Pleasant, brighter.,Vital signs:  117/78, 12, 56.,Abdomen:  Soft, nontender.  Bowel sounds normal.,ASSESSMENT AND PLAN:,1.  Constipation.  Milk of Magnesia 30 mL daily p.r.n., Dulcolax suppository twice a week p.r.n.,2.  CAD/angina.  See cardiologist this afternoon.,Call me if constipation not resolved by a.m., consider a Fleet enema then as discussed.,","gastroenterology, constipation, bm, milk of magnesia, suppository, dulcolax, fleet enema, "
" Colonoscopy with photos.  The patient is an 85-year-old female who was admitted to the hospital with a markedly decreased hemoglobin and blood loss anemia.  She underwent an EGD and attempted colonoscopy; however, due to a very poor prep, only a flexible sigmoidoscopy was performed at that time.  A coloscopy is now being performed for completion.", Gastroenterology, Colonoscopy With Photos ,"PREOPERATIVE DIAGNOSIS: , Blood loss anemia.,POSTOPERATIVE DIAGNOSES:,1.  Diverticulosis coli.,2.  Internal hemorrhoids.,3.  Poor prep.,PROCEDURE PERFORMED:,  Colonoscopy with photos.,ANESTHESIA: , Conscious sedation per Anesthesia.,SPECIMENS:,  None.,HISTORY:,  The patient is an 85-year-old female who was admitted to the hospital with a markedly decreased hemoglobin and blood loss anemia.  She underwent an EGD and attempted colonoscopy; however, due to a very poor prep, only a flexible sigmoidoscopy was performed at that time.  A coloscopy is now being performed for completion.,PROCEDURE:,  After proper informed consent was obtained, the patient was brought to the Endoscopy Suite.  She was placed in the left lateral position and was given sedation by the Anesthesia Department.  A digital rectal exam was performed and there was no evidence of mass.  The colonoscope was then inserted into the rectum.  There was some solid stool encountered.  The scope was maneuvered around this.  There was relatively poor prep as the scope was advanced through the sigmoid colon and portions of the descending colon.  The scope was then passed through the transverse colon and ascending colon to the cecum.  No masses or polyps were noted.  Visualization of the portions of the colon was however somewhat limited.  There were scattered diverticuli noted in the sigmoid.,The scope was slowly withdrawn carefully examining all walls.  Once in the rectum, the scope was retroflexed and nonsurgical internal hemorrhoids were noted.  The scope was then completely withdrawn.  The patient tolerated the procedure well and was transferred to recovery room in stable condition.  She will be placed on a high-fiber diet and Colace and we will continue to monitor her hemoglobin.","gastroenterology, blood loss anemia, diverticulosis coli, internal hemorrhoids, poor prep, colonoscopy, sigmoidoscopy, hemoglobin, coloscopy, colonoscopy with photos, attempted colonoscopy, flexible sigmoidoscopy, photos, anemia, scope"
 Colonoscopy with random biopsies and culture., Gastroenterology, Colonoscopy with Biopsy - 4 ,"PREOPERATIVE DIAGNOSIS: , Antibiotic-associated diarrhea.  ,POSTOPERATIVE DIAGNOSIS:  ,Antibiotic-associated diarrhea.  ,OPERATION PERFORMED: , Colonoscopy with random biopsies and culture.,INDICATIONS: , The patient is a 50-year-old woman who underwent hemorrhoidectomy approximately one year ago.  She has been having difficulty since that time with intermittent diarrhea and abdominal pain.  She states this happens quite frequently and can even happen when she uses topical prednisone for her ears or for her eyes.  She presents today for screening colonoscopy, based on the same.,OPERATIVE COURSE:  , The risks and benefits of colonoscopy were explained to the patient in detail.  She provided her consent.  The morning of the operation, the patient was transported from the preoperative holding area to the endoscopy suite.  She was placed in the left lateral decubitus position.  In divided doses, she was given 7 mg of Versed and 125 mcg of fentanyl.  A digital rectal examination was performed, after which time the scope was intubated from the anus to the level of the hepatic flexure.  This was intubated fairly easily; however, the patient was clearly in some discomfort and was shouting out, despite the amount of anesthesia she was provided.  In truth, the pain she was experiencing was out of proportion to any maneuver or difficulty with the procedure.  While more medication could have been given, the patient is actually a fairly thin woman and diminutive and I was concerned that giving her any more sedation may lead to respiratory or cardiovascular collapse.  In addition, she was really having quite some difficulty staying still throughout the procedure and was putting us all at some risk.  For this reason, the procedure was aborted at the level of the hepatic flexure.  She was noted to have some pools of stool.  This was suctioned and sent to pathology for C difficile, ova and parasites, and fecal leukocytes.  Additionally, random biopsies were performed of the colon itself.  It is unfortunate we were unable to complete this procedure, as I would have liked to have taken biopsies of the terminal ileum.  However, given the degree of discomfort she had, again, coupled with the relative ease of the procedure itself, I am very suspicious of irritable bowel syndrome.  The patient tolerated the remainder of the procedure fairly well and was sent to the recovery room in stable condition, where it is anticipated she will be discharged to home.,PLAN:,  She needs to follow up with me in approximately 2 weeks' time, both to follow up with her biopsies and cultures.  She has been given a prescription for VSL3, a probiotic, to assist with reculturing the rectum.  She may also benefit from an antispasmodic and/or anxiolytic.  Lastly, it should be noted that when she next undergoes endoscopic procedure, propofol would be indicated.","gastroenterology, colonoscopy with random biopsies, hepatic flexure, topical, culture, antibiotic, hepatic, flexure, diarrhea, biopsies, colonoscopy"
 Common description of colonoscopy, Gastroenterology, Colonoscopy Template - 2 ,,"gastroenterology, cecum, retroflexion, colon, tumor, polyp, mass, ulceration, tip, endoscope, inserted, colonoscopyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 The patient with a recent change in bowel function and hematochezia., Gastroenterology, Colonoscopy with Biopsy - 1 ,"PREPROCEDURE DIAGNOSIS:,  Change in bowel function.,POSTPROCEDURE DIAGNOSIS:,  Proctosigmoiditis.,PROCEDURE PERFORMED:,  Colonoscopy with biopsy.,ANESTHESIA: , IV sedation.,POSTPROCEDURE CONDITION: , Stable.  ,INDICATIONS:,  The patient is a 33-year-old with a recent change in bowel function and hematochezia.  He is here for colonoscopy.  He understands the risks and wishes to proceed.  ,PROCEDURE: , The patient was brought to the endoscopy suite where he was placed in left lateral Sims position, underwent IV sedation.  Digital rectal examination was performed, which showed no masses, and a boggy prostate.  The colonoscope was placed in the rectum and advanced, under direct vision, to the cecum.  In the rectum and sigmoid, there were ulcerations, edema, mucosal abnormalities, and loss of vascular pattern consistent with proctosigmoiditis.  Multiple random biopsies were taken of the left and right colon to see if this was in fact pan colitis.,RECOMMENDATIONS: , Follow up with me in 2 weeks and we will begin Canasa suppositories.","gastroenterology, change in bowel function, iv sedation, bowel function, proctosigmoiditis, sedation, rectum, bowel, function, colonoscopy, hematochezia,"
" Colonoscopy with multiple biopsies, including terminal ileum, cecum, hepatic flexure, and sigmoid colon.", Gastroenterology, Colonoscopy with Biopsy - 3 ,"PREPROCEDURE DIAGNOSIS: , Abdominal pain, diarrhea, and fever.,POSTPROCEDURE DIAGNOSIS: , Pending pathology.,PROCEDURES PERFORMED: , Colonoscopy with multiple biopsies, including terminal ileum, cecum, hepatic flexure, and sigmoid colon.","gastroenterology, colonoscopy with multiple biopsies, length of the colon, diarrhea and fever, terminal ileum cecum, multiple biopsies, ileum cecum, cecum hepatic, hepatic flexure, terminal ileum, sigmoid colon, colonoscopy, diarrhea, cecum, hepatic, flexure, inflammation, biopsies, terminal, ileum, sigmoid, scope, "
 Common description of colonoscopy, Gastroenterology, Colonoscopy Template - 4 ,"A colonoscope was then passed through the rectum, all the way toward the cecum, which was identified by the presence of the appendiceal orifice and ileocecal valve.  This was done without difficulty and the bowel preparation was good.  The ileocecal valve was intubated and the distal 2 to 3 cm of terminal ileum was inspected and was normal.  The colonoscope was then slowly withdrawn and a careful examination of the mucosa was performed.,COMPLICATIONS: , None.","gastroenterology, cecum, colonoscope, bleeding, infection, perforation, allergic reaction, ileocecal valve, informed, allergic, ileocecal, valve, colonoscopyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Small internal hemorrhoids and Ileal colonic anastomosis., Gastroenterology, Colonoscopy with Biopsy - 2 ,"PROCEDURE PERFORMED: , Colonoscopy and biopsy.,INDICATIONS:,  The patient is a 50-year-old female who has had a history of a nonspecific colitis, who was admitted 3 months ago at Hospital because of severe right-sided abdominal pains, was found to have multiple ulcers within the right colon, and was then readmitted approximately 2 weeks later because of a cecal volvulus, and had a right hemicolectomy.  Since then, she has had persistent right abdominal pains, as well as diarrhea, with up to 2-4 bowel movements per day.  She has had problems with recurrent seizures and has been seen by Dr. XYZ, who started her recently on methadone.,MEDICATIONS: , Fentanyl 200 mcg, Versed 10 mg, Phenergan 25 mg intravenously given throughout the procedure.,INSTRUMENT: , PCF-160L.,PROCEDURE REPORT: , Informed consent was obtained from the patient, after the risks and benefits of the procedure were carefully explained, which included but were not limited to bleeding, infection, perforation, and allergic reaction to the medications, as well as the possibility of missing polyps within the colon.,A colonoscope was then passed through the rectum, all the way toward the ileal colonic anastomosis, seen within the proximal transverse colon.  The distal ileum was examined, which was normal in appearance.  Random biopsies were obtained from the ileum and placed in jar #1.  Random biopsies were obtained from the normal-appearing colon and placed in jar #2.  Small internal hemorrhoids were noted within the rectum on retroflexion.,COMPLICATIONS: , None.,ASSESSMENT:,1.  Small internal hemorrhoids.,2.  Ileal colonic anastomosis seen in the proximal transverse colon.,3.  Otherwise normal colonoscopy and ileum examination.,PLAN:, Followup results of biopsies.  If the biopsies are unremarkable, the patient may benefit from a trial of tricyclic antidepressants, if it's okay with Dr. XYZ, for treatment of her chronic abdominal pains.","gastroenterology, proximal transverse, transverse colon, internal hemorrhoids, colonic anastomosis, biopsy, rectum, transverse, hemorrhoids, colonic, anastomosis, abdominal, ileum, biopsies, colonoscopy"
 Common description of colonoscopy, Gastroenterology, Colonoscopy Template - 3 ,,"gastroenterology, left lateral sims position, cecum, mass, lesions, mucosal abnormalities, friability, polyps, endoscopy suite, endoscopyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" A woman referred for colonoscopy secondary to heme-positive stools.  Procedure done to rule out generalized diverticular change, colitis, and neoplasia.", Gastroenterology, Colonoscopy with Biopsy ,"INDICATIONS FOR PROCEDURE: , A 79-year-old Filipino woman referred for colonoscopy secondary to heme-positive stools.  Procedure done to rule out generalized diverticular change, colitis, and neoplasia.,DESCRIPTION OF PROCEDURE: , The patient was explained the procedure in detail, possible complications including infection, perforation, adverse reaction of medication, and bleeding.  Informed consent was signed by the patient.,With the patient in left decubitus position, had received a cumulative dose of 4 mg of Versed and 75 mg of Demerol, using Olympus video colonoscope under direct visualization was advanced to the cecum.  Photodocumentation of appendiceal orifice and the ileocecal valve obtained.  Cecum was slightly obscured with stool but the colon itself was adequately prepped.  There was no evidence of overt colitis, telangiectasia, or overt neoplasia.  There was moderately severe diverticular change, which was present throughout the colon and photodocumented.  The rectal mucosa was normal and retroflexed with mild internal hemorrhoids.  The patient tolerated the procedure well without any complications.,IMPRESSION:,1.  Colonoscopy to the cecum with adequate preparation.,2.  Long tortuous spastic colon.,3.  Moderately severe diverticular changes present throughout.,4.  Mild internal hemorrhoids.,RECOMMENDATIONS:,1.  Clear liquid diet today.,2.  Follow up with primary care physician as scheduled from time to time.,3.  Increase fiber in diet, strongly consider fiber supplementation.","gastroenterology, olympus video colonoscope, advanced to the cecum, heme-positive stools, diverticular change, colitis, colonoscopy to the cecum, spastic colon, colonoscopy with biopsy, liver disease, biopsy, hepatitis, chronic, liver, disease, mucosa, polyp, rectal, colonoscopy,"
" Colonoscopy, conscious sedation, and snare polypectomy.", Gastroenterology, Colonoscopy & Polypectomy - 2 ,"PREPROCEDURE DIAGNOSIS: , Colon cancer screening.,POSTPROCEDURE DIAGNOSIS:  ,Colon polyps, diverticulosis, hemorrhoids.,PROCEDURE PERFORMED: , Colonoscopy, conscious sedation, and snare polypectomy.  ,INDICATIONS:  ,The patient is a 63-year-old male who has myelodysplastic syndrome, who was referred for colonoscopy.  He has had previous colonoscopy.  There is no family history of bleeding, no current problems with his bowels.  On examination, he has internal hemorrhoids.  His prostate is enlarged and increased somewhat in firmness.  He has scattered diverticular disease of a moderate degree and he has two polyps, one 1 cm in the mid ascending colon, and one in the left transverse colon, which is also 1 cm.  These were removed with snare polypectomy technique.  I would recommend that the patient have an increased fiber diet and repeat colonoscopy in 5 years or sooner if he develops bowel habit change or bleeding.,PROCEDURE: , After explaining the operative procedure, the risks and potential complications of bleeding and perforation, the patient was given 175 mcg fentanyl, and 8 mg Versed intravenously for conscious sedation.  Blood pressure 115/60, pulse 98, respiration 18, and saturation 92%.  A rectal examination was done and then the colonoscope was inserted through the anorectum, rectosigmoid, descending, transverse, and ascending colon, to the ileocecal valve.  The scope was withdrawn to the mid ascending colon, where the polyp was encircled with a snare and removed with a mixture of cutting and coagulating current, then retrieved through the suction port.  The scope was withdrawn into the left transverse colon, where the second polyp was identified.  It was encircled with a snare and removed with a mixture of cutting and coagulating current, and then removed through the suction port as well.  The scope was then gradually withdrawn the remaining distance and removed.  The patient tolerated the procedure well.","gastroenterology, colon polyps, diverticulosis, hemorrhoids, cutting and coagulating, transverse colon, snare polypectomy, ascending colon, colonoscopy, polyps, bowels, coagulating, sedation, scope, ascending, snare, polypectomy, "
 Common description of colonoscopy, Gastroenterology, Colonoscopy Template - 5 ,,"gastroenterology, cecum, colonoscope, digital rectal examination, colonoscopyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Total colonoscopy and polypectomy, Gastroenterology, Colonoscopy & Polypectomy - 1 ,"PREOPERATIVE DIAGNOSIS:,  History of colitis.,POSTOPERATIVE DIAGNOSIS: , Small left colon polyp.,PROCEDURE PERFORMED: , Total colonoscopy and polypectomy.,ANESTHESIA:,  IV Versed 8 mg and 175 mcg of IV fentanyl.,CLINICAL HISTORY: , This patient had a tough time with colitis 10 years ago and has intermittent problems with bleeding.  He has been admitted to the hospital now for colonoscopy and polyp surveillance.,PROCEDURE:  ,The patient was prepped and draped in a left lateral decubitus position.  The flexible 165 cm CF video Olympus colonoscope was inserted through the anus and passed under TV-directed monitor through the area of the rectum, sigmoid colon, left colon, transverse colon, right colon, and cecum.  He had an excellent prep.  He had a 2-3 mm polyp in the left colon that was removed with a jumbo biopsy forceps.  He tolerated the procedure well.  There was no other evidence of any cancer, growth, tumor, colitis, or problems throughout the entire colon.  His exam that he had in 1997 showed a small amount of colitis at that time and he has had some intermittent symptoms since.  Representative pictures were taken throughout the entire exam.  There was no other evidence any problems.  On withdrawal of the scope, the same findings were noted.,FINAL IMPRESSION: , Small, left colon polyp in a patient with intermittent colitis-like symptoms and bleeding.","gastroenterology, anus, lateral decubitus position, colon, colonoscopy and polypectomy, total colonoscopy, colon polyp, colonoscopy, bleeding, colitis, polypectomy, intermittent,"
 Total colonoscopy with biopsy and snare polypectomy., Gastroenterology, Colonoscopy & Polypectomy - 3 ,"PREOPERATIVE DIAGNOSIS:,  Alternating hard and soft stools.,POSTOPERATIVE DIAGNOSIS:,Sigmoid diverticulosis.,Sessile polyp of the sigmoid colon.,Pedunculated polyp of the sigmoid colon.,PROCEDURE: , Total colonoscopy with biopsy and snare polypectomy.,PREP:,  4/4.,DIFFICULTY:,  1/4.,PREMEDICATION AND SEDATION: , Fentanyl 100, midazolam 5.,INDICATION FOR PROCEDURE:,  A 64-year-old male who has developed alternating hard and soft stools.  He has one bowel movement a day.,FINDINGS: , There is extensive sigmoid diverticulosis, without evidence of inflammation or bleeding.  There was a small, sessile polyp in the sigmoid colon, and a larger pedunculated polyp in the sigmoid colon, both appeared adenomatous.,DESCRIPTION OF PROCEDURE: , Preoperative counseling, including an explicit discussion of the risk and treatment of perforation was provided.  Preoperative physical examination was performed.  Informed consent was obtained.  The patient was placed in the left lateral decubitus position.  Premedications were given slowly by intravenous push.  Rectal examination was performed, which was normal.  The scope was introduced and passed with minimal difficulty to the cecum.  This was verified anatomically and video photographs were taken of the ileocecal valve and appendiceal orifice.  The scope was slowly withdrawn, the mucosa carefully visualized.  It was normal in its entirety until reaching the sigmoid colon.  Sigmoid colon had extensive diverticular disease, small-mouth, without inflammation or bleeding.  In addition, there was a small sessile polyp, which was cold biopsied and recovered, and approximately an 8 mm pedunculated polyp.  A snare was placed on the stalk of the polyp and divided with electrocautery.  The polyp was recovered and sent for pathologic examination.  Examination of the stalk showed good hemostasis.  The scope was slowly withdrawn and the remainder of the examination was normal.,ASSESSMENT: , Diverticular disease.  A diverticular disease handout was given to the patient's wife and a high fiber diet was recommended.  In addition, 2 polyps, one of which is assuredly an adenoma.  Patient needs a repeat colonoscopy in 3 years.","gastroenterology, total colonoscopy with biopsy, colonoscopy with biopsy, total colonoscopy, snare polypectomy, sigmoid diverticulosis, sessile polyp, pedunculated polyp, diverticular disease, sigmoid colon, colonoscopy, polypectomy, biopsy, diverticulosis, inflammation, adenomatous, sessile, sigmoid,"
 Common description of colonoscopy, Gastroenterology, Colonoscopy Template - 1 ,,"gastroenterology, decubitus position, cecum, colonic mucosa, ileocecal, rectum, colonoscopy, colonoscopeNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Patient with active flare of Inflammatory Bowel Disease, not responsive to conventional therapy including sulfasalazine, cortisone, local therapy.", Gastroenterology, Colonoscopy - 8 ,"PROCEDURES PERFORMED:,  Colonoscopy.,INDICATIONS:,  Renewed symptoms likely consistent with active flare of Inflammatory Bowel Disease, not responsive to conventional therapy including sulfasalazine, cortisone, local therapy.,PROCEDURE: , Informed consent was obtained prior to the procedure with special attention to benefits, risks, alternatives.  Risks explained as bleeding, infection, bowel perforation, aspiration pneumonia, or reaction to the medications.  Vital signs were monitored by blood pressure, heart rate, and oxygen saturation.  Supplemental O2 given.  Specifics discussed.  Preprocedure physical exam performed.  Stable vital signs.  Lungs clear.  Cardiac exam showed regular rhythm.  Abdomen soft.  Her past history, her past workup, her past visitation with me for Inflammatory Bowel Disease, well responsive to sulfasalazine reviewed.  She currently has a flare and is not responding, therefore, likely may require steroid taper.  At the same token, her symptoms are mild.  She has rectal bleeding, essentially only some rusty stools.  There is not significant diarrhea, just some lower stools.  No significant pain.  Therefore, it is possible that we are just dealing with a hemorrhoidal bleed, therefore, colonoscopy now needed.  Past history reviewed.  Specifics of workup, need for followup, and similar discussed.  All questions answered.,A normal digital rectal examination was performed.  The PCF-160 AL was inserted into the anus and advanced to the cecum without difficulty, as identified by the ileocecal valve, cecal stump, and appendical orifice.  All mucosal aspects thoroughly inspected, including a retroflexed examination.  Withdrawal time was greater than six minutes.  Unfortunately, the terminal ileum could not be intubated despite multiple attempts.,Findings were those of a normal cecum, right colon, transverse colon, descending colon.  A small cecal polyp was noted, this was biopsy-removed, placed in bottle #1.  Random biopsies from the cecum obtained, bottle #2; random biopsies from the transverse colon obtained, as well as descending colon obtained, bottle #3.  There was an area of inflammation in the proximal sigmoid colon, which was biopsied, placed in bottle #4.  There was an area of relative sparing, with normal sigmoid lining, placed in bottle #5, randomly biopsied, and then inflammation again in the distal sigmoid colon and rectum biopsied, bottle #6, suggesting that we may be dealing with Crohn disease, given the relative sparing of the sigmoid colon and junk lesion.  Retroflexed showed hemorrhoidal disease.  Scope was then withdrawn, patient left in good condition.  ,IMPRESSION:,  Active flare of Inflammatory Bowel Disease, question of Crohn disease.,PLAN: , I will have the patient follow up with me, will follow up on histology, follow up on the polyps.  She will be put on a steroid taper and make an appointment and hopefully steroids alone will do the job.  If not, she may be started on immune suppressive medication, such as azathioprine, or similar.  All of this has been reviewed with the patient.  All questions answered.","gastroenterology, sulfasalazine cortisone local therapy, inflammatory bowel disease, cortisone local, local therapy, crohn disease, sigmoid colon, bowel disease, colonoscopy, inflammatory, rectal, sulfasalazine, cecum, sigmoid, bowel, disease"
" Colonoscopy - Diarrhea, suspected irritable bowel", Gastroenterology, Colonoscopy - 4 ,"PREOPERATIVE DIAGNOSIS:,  Diarrhea, suspected irritable bowel.,POSTOPERATIVE DIAGNOSIS:,  Normal colonoscopy., PREMEDICATIONS: , Versed 5 mg, Demerol 75 mg IV.,REPORTED PROCEDURE:,  The rectal exam revealed no external lesions.  The prostate was normal in size and consistency.,The colonoscope was inserted into the cecum with ease.  The cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, sigmoid colon, and rectum were normal.  The scope was retroflexed in the rectum and no abnormality was seen, so the scope was straightened, withdrawn, and the procedure terminated.,ENDOSCOPIC IMPRESSION:,  Normal colonoscopy - no evidence of inflammatory disease, polyp, or other neoplasm.  These findings are certainly consistent with irritable bowel syndrome.","gastroenterology, diarrhea, ascending colon, cecum, colonoscope, colonoscopy, descending colon, hepatic flexure, inflammatory disease, irritable bowel syndrome, irritable bowel., polyp, rectal exam, rectum, sigmoid colon, splenic flexure, transverse colon, normal colonoscopy, irritable bowel, flexure, irritable, bowel, "
" Colonoscopy to cecum with snare polypectomy and esophagogastroduodenoscopy with biopsies.  Hematochezia, refractory dyspepsia, colonic polyps at 35 cm and 15 cm, diverticulosis coli, and acute and chronic gastritis.
", Gastroenterology, Colonoscopy & Esophagogastroduodenoscopy ,"PREOPERATIVE DIAGNOSES:,1.  Hematochezia.,2.  Refractory dyspepsia.,POSTOPERATIVE DIAGNOSES:,1.  Colonic polyps at 35 cm and 15 cm.,2.  Diverticulosis coli.,2.  Acute and chronic gastritis.,PROCEDURE PERFORMED:,1.  Colonoscopy to cecum with snare polypectomy.,2.  Esophagogastroduodenoscopy with biopsies.,INDICATIONS FOR PROCEDURES:  ,This is a 43-year-old white male who presents as an outpatient to the General Surgery Service with hematochezia with no explainable source at the anal verge.  He also had refractory dyspepsia despite b.i.d., Nexium therapy.  The patient does use alcohol and tobacco.  The patient gave informed consent for the procedure.,GROSS FINDINGS: , At the time of colonoscopy, the entire length of colon was visualized.  The patient was found to have a sigmoid diverticulosis.  He also was found to have some colonic polyps at 35 cm and 15 cm.  The polyps were large enough to be treated with snare cautery technique.  The polyps were achieved and submitted to pathology.  EGD did confirm acute and chronic gastritis.  The biopsies were performed for H&E and CLO testing.  The patient had no evidence of distal esophagitis or ulcers.  No mass lesions were seen.,PROCEDURE:  ,The patient was taken to the Endoscopy Suite with the heart and lungs examination unremarkable.  The vital signs were monitored and found to be stable throughout the procedure.  The patient was placed in the left lateral position where intravenous Demerol and Versed were given in a titrated fashion.,The video Olympus colonoscope was advanced per anus and without difficulty to the level of cecum.  Photographic documentation of the diverticulosis and polyps were obtained.  The patient's polyps were removed in a similar fashion, each removed with snare cautery.  The polyps were encircled at their stalk.  Increasing the tension and cautery was applied as coagulation and cutting blunt mode, 15/15 was utilized.  Good blanching was seen.  The polyp was retrieved with the suction port of the scope.  The patient was re-scoped to the polyp levels to confirm that there was no evidence of perforation or bleeding at the polypectomy site.  Diverticulosis coli was also noted.  With colonoscopy completed, the patient was then turned for EGD.  The oropharynx was previously anesthetized with Cetacaine spray and a biteblock was placed.  Video Olympus GIF gastroscope model was inserted per os and advanced without difficulty through the hypopharynx.  The esophagus revealed a GE junction at 39 cm.  The GE junction was grossly within normal limits.  The stomach was entered and distended with air.  Acute and chronic gastritis features as stated were appreciated.  The pylorus was traversed with normal duodenum.  The stomach was again reentered.  Retroflex maneuver of the scope confirmed that there was no evidence of hiatal hernia.  There were no ulcers or mass lesions seen.  The patient had biopsy performed of the antrum for H&E and CLO testing.  There was no evidence of untoward bleeding at biopsy sites.  Insufflated air was removed with withdrawal of the scope.  The patient will be placed on a reflux diet, given instruction and information on Nexium usage.  Additional recommendations will follow pending biopsy results.  He is to also abstain from alcohol and tobacco.  He will require follow-up colonoscopy again in three years for polyp disease.","gastroenterology, endoscopy, olympus colonoscope, snare polypectomy, ge junction, refractory dyspepsia, colonic polyps, diverticulosis coli, chronic gastritis, esophagogastroduodenoscopy, snare, biopsies, dyspepsia, gastritis, diverticulosis, polypectomy, colonoscopy, hematochezia, polyps"
 Colonoscopy due to hematochezia and personal history of colonic polyps., Gastroenterology, Colonoscopy - 5 ,"PROCEDURE: , Colonoscopy.,INDICATIONS: , Hematochezia, Personal history of colonic polyps.,MEDICATIONS:,  Midazolam 2 mg IV, Fentanyl 100 mcg IV,PROCEDURE:,  A History and Physical has been performed, and patient medication allergies have been reviewed.  The patient's tolerance of previous anesthesia has been reviewed.  The risks and benefits of the procedure and the sedation options and risks were discussed with the patient.  All questions were answered and informed consent was obtained.  Mental Status Examination:  alert and oriented.  Airway Examination:  normal oropharyngeal airway and neck mobility.  Respiratory Examination:  clear to auscultation.  CV Examination:  RRR, no murmurs, no S3 or S4.  ASA Grade Assessment:  P1 A normal healthy patient.  After reviewing the risks and benefits, the patient was deemed in satisfactory condition to undergo the procedure.  The anesthesia plan was to use conscious sedation.  Immediately prior to administration of medications, the patient was re-assessed for adequacy to receive sedatives.  The heart rate, respiratory rate, oxygen saturations, blood pressure, adequacy of pulmonary ventilation, and response to care were monitored throughout the procedure.  The physical status of the patient was re-assessed after the procedure.  After I obtained informed consent, the scope was passed under direct vision.  Throughout the procedure, the patient's blood pressure, pulse, and oxygen saturations were monitored continuously.  The colonoscope was introduced through the anus and advanced to the cecum, identified by appendiceal orifice & IC valve.  The quality of the prep was good.  The patient tolerated the procedure well.,FINDINGS:,1.  A sessile, non-bleeding polyp was found in the rectum.  The polyp was 5 mm in size.  Polypectomy was performed with a saline injection-lift technique using the snare.  Resection and retrieval were complete.  Estimated blood loss was minimal.,2.  One pedunculated, non-bleeding polyp was found in the sigmoid colon.  The polyp was 7 mm in size.  Polypectomy was performed with a hot forceps.  Resection and retrieval were complete.  Estimated blood loss was minimal.,3.  Multiple large-mouthed diverticula were found in the descending colon.,4.  Internal, non-bleeding, prolapsed with spontaneous reduction (grade II) hemorrhoids were found on retroflexion.,IMPRESSION:,1.  One 5 mm benign appearing polyp in the rectum.  Resected and retrieved.,2.  One 7 mm polyp in the sigmoid colon.  Resected and retrieved.,3.  Diverticulosis.,4.  Internal hemorrhoids were found.,RECOMMENDATION:,1.  High fiber diet.,2.  Await pathology results.,3.  Repeat colonoscopy for surveillance in 3 years.,4.  The findings and recommendations were discussed with the patient.,CPT CODE(S):,45385, Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare,technique.,45384, 59, Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot,biopsy forceps or bipolar cautery.,45381, 59, Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance.,ICD9 CODE(S):,211.4, Benign neoplasm of rectum and anal canal.,211.3, Benign neoplasm of colon.,562.10, Diverticulosis of colon (without mention of hemorrhage).,455.2, Internal hemorrhoids with other complication,578.1, Blood in stool.,v12.72, Personal history of colonic polyps.",
 Patient with history of polyps., Gastroenterology, Colonoscopy - 9 ,"PREOPERATIVE DIAGNOSIS:,  Prior history of polyps.,POSTOPERATIVE DIAGNOSIS:,  Small polyps, no evidence of residual or recurrent polyp in the cecum.,PREMEDICATIONS: , Versed 5 mg, Demerol 100 mg IV.,REPORTED PROCEDURE:,  The rectal chamber revealed no external lesions.  Prostate was normal in size and consistency.,The colonoscope was inserted into the rectal ampulla and advanced under direct vision at all times until the tip of the scope was placed in the cecum.  The position of the scope within the cecum was verified by identification of the ileocecal valve.  Navigation was difficult because it seemed that the cecum took an upward turn at its final turn, but the examination was completed.,The cecum was extensively studied and no lesion was seen.  There was not even a scar representing the prior polyp.  I was able to see the area across from the ileocecal valve exactly where the polyp was two years ago, and I saw no lesion at all.  The scope was then slowly withdrawn.  In the mid transverse colon, was a small submucosal lesion, which appeared to be a lipoma.  It was freely mobile and very small with normal overlying mucosa.  There was a similar lesion in the descending colon.  Both of these appeared to be lipomatous, so no attempt was made to remove them.  There were diverticula present in the sigmoid colon.  In addition, there were two polyps in the sigmoid colon both of which were resected using electrocautery.  There was no bleeding.  The scope was then withdrawn.  The rectum was normal.  When the scope was retroflexed in the rectum, two very small polyps were noted just at the anorectal margin, and so these were obliterated using the electrocautery snare.  There was no specimen and there was no bleeding.  The scope was then straightened, withdrawn, and the procedure terminated.,ENDOSCOPIC IMPRESSION:,1.  Small polyps, sigmoid colon, resected them.,2.  Diverticulosis, sigmoid colon.,3.  Small rectal polyps, obliterated them.,4.  Submucosal lesions, consistent with lipomata as described.,5.  No evidence of residual or recurrent neoplasm in the cecum.","gastroenterology, ileocecal valve, sigmoid colon, polyps, ileocecal, submucosal, electrocautery, bleeding, rectum, rectal, sigmoid, cecum, scope, colonoscopy,"
 Patient with history of adenomas and irregular bowel habits., Gastroenterology, Colonoscopy - 7 ,"PROCEDURE:,  Colonoscopy.,PREOPERATIVE DIAGNOSIS: , Follow up adenomas.,POSTOPERATIVE DIAGNOSES:,1.  Two colon polyps, removed.,2.  Small internal hemorrhoids.,3.  Otherwise normal examination of cecum.,MEDICATIONS: , Fentanyl 150 mcg and Versed 7 mg slow IV push.,INDICATIONS: , This is a 60-year-old white female with a history of adenomas.  She does have irregular bowel habits.,FINDINGS: , The patient was placed in the left lateral decubitus position and the above medications were administered.  The colonoscope was advanced to the cecum as identified by the ileocecal valve, appendiceal orifice, and blind pouch.  The colonoscope was slowly withdrawn and a careful examination of the colonic mucosa was made, including a retroflexed view of the rectum.  There was a 4 mm descending colon polyp, which was removed with jumbo forceps, and sent for histology in bottle one.  There was a 10 mm pale, flat polyp in the distal rectum, which was removed with jumbo forceps, and sent for histology in bottle 2.  There were small internal hemorrhoids.  The remainder of the examination was normal to the cecum.  The patient tolerated the procedure well without complication.,IMPRESSION:,1.  Two colon polyps, removed.,2.  Small internal hemorrhoids.,3.  Otherwise normal examination to cecum.,PLAN: , I will await the results of the colon polyp histology.  The patient was told the importance of daily fiber.","gastroenterology, colon polyps, internal hemorrhoids, rectum, irregular bowel habits, colon polyps removed, irregular bowel, bowel habits, polyps removed, bowel, habits, colonoscope, hemorrhoids, cecum, forceps, polyps, colonoscopy, adenomas,"
 Colonoscopy to evaluate prior history of neoplastic polyps., Gastroenterology, Colonoscopy - 3 ,"PREOPERATIVE DIAGNOSIS:,  Prior history of neoplastic polyps.,POSTOPERATIVE DIAGNOSIS:,  Small rectal polyps/removed and fulgurated.,PREMEDICATIONS:,  Prior to the colonoscopy, the patient complained of a sever headache and she was concerned that she might become ill.  I asked the nurse to give her 25 mg of Demerol IV.,Following the IV Demerol, she had a nausea reaction.  She was then given 25 mg of Phenergan IV.  Following this, her headache and nausea completely resolved.  She was then given a total of 7.5 mg of Versed with adequate sedation.  Rectal exam revealed no external lesions.  Digital exam revealed no mass.,REPORTED PROCEDURE:,  The P160 colonoscope was used.  The scope was placed in the rectal ampulla and advanced to the cecum.  Navigation through the sigmoid colon was difficult.  Beginning at 30 cm was a very tight bend.  With gentle maneuvering, the scope passed through and then entered the cecum.  The cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, and descending colon were normal.  The sigmoid colon was likewise normal.  There were five very small (punctate) polyps in the rectum.  One was resected using the electrocautery snare and the other four were ablated using the snare and cautery.  There was no specimen because the polyps were so small.  The scope was retroflexed in the rectum and no further abnormality was seen, so the scope was straightened, withdrawn, and the procedure terminated.,ENDOSCOPIC IMPRESSION:,1.  Five small polyps as described, all fulgurated.,2.  Otherwise unremarkable colonoscopy.","gastroenterology, colonoscopy, demerol, phenergan, rectal exam, versed, ascending colon, cecum, colonoscope, descending colon, fulgurated, hepatic flexure, neoplastic, polyps, punctate, rectal ampulla, splenic flexure, transverse colon, scope"
 Colonoscopy to screen for colon cancer, Gastroenterology, Colonoscopy - 6 ,"INDICATIONS: , This is a 55-year-old female who is having a colonoscopy to screen for colon cancer.  There is no family history of colon cancer and there has been no blood in the stool.,PROCEDURE PERFORMED:  ,Colonoscopy.,PREP: , Fentanyl 100 mcg IV and 3 mg Versed IV.,PROCEDURE:,  The tip of the endoscope was introduced into the rectum.  Retroflexion of the tip of the endoscope failed to reveal any distal rectal lesions.  The rest of the colon through to the cecum was well visualized.  The cecal strap, ileocecal valve, and light reflex in the right lower quadrant were all identified.  There was no evidence of tumor, polyp, mass, ulceration, or other focus of inflammation.  Adverse reactions none.,IMPRESSION:,  Normal colonic mucosa through to the cecum.  There was no evidence of tumor or polyp.","gastroenterology, versed iv, colon, tumor, polyp, mass, ulceration, focus of inflammation, tip of the endoscope, evidence of tumor, colon cancer, endoscope, cecum, cancer, colonoscopy, "
" Screening colonoscopy.  Tiny polyps.   If adenomatous, repeat exam in five years.  ", Gastroenterology, Colonoscopy - 20 ,"PREOPERATIVE DIAGNOSIS: , Screening. ,POSTOPERATIVE DIAGNOSIS:,  Tiny Polyps.,PROCEDURE PERFORMED:  , Colonoscopy.,PROCEDURE:  , The procedure, indications, and risks were explained to the patient, who understood and agreed.  He was sedated with Versed 3 mg, Demerol 25 mg during the examination.  ,A digital rectal exam was performed and the Pentax Video Colonoscope was advanced over the examiner's finger into the rectum.  It was passed to the level of the cecum.  The ileocecal valve was identified, as was the appendiceal orifice.  ,Slowly withdrawal through the colon revealed a small polyp in the transverse colon.  This was approximately 3 mm in size and was completely removed using multiple bites with cold biopsy forceps.  In addition, there was a 2 mm polyp versus lymphoid aggregate in the descending colon.  This was also removed using the cold biopsy forceps.  Further detail failed to reveal any other lesions with the exception of small hemorrhoids.  ,IMPRESSION:  , Tiny polyps.  ,PLAN:  , If adenomatous, repeat exam in five years.  Otherwise, repeat exam in 10 years.,","gastroenterology, pentax video colonoscope, biopsy forceps, tiny polyps, polyps, adenomatous, colonoscopy"
" Colonoscopy and biopsies, epinephrine sclerotherapy, hot biopsy cautery, and snare polypectomy.  Colon cancer screening.  Family history of colon polyps.", Gastroenterology, Colonoscopy - 21 ,"OPERATIVE PROCEDURES: , Colonoscopy and biopsies, epinephrine sclerotherapy, hot biopsy cautery, and snare polypectomy.,PREOPERATIVE DIAGNOSES:,1.  Colon cancer screening.,2.  Family history of colon polyps.,POSTOPERATIVE DIAGNOSES:,1.  Multiple colon polyps (5).,2.  Diverticulosis, sigmoid colon.,3.  Internal hemorrhoids.,ENDOSCOPE USED: , EC3870LK.,BIOPSIES:  ,Biopsies taken from all polyps.  Hot biopsy got applied to one.  Epinephrine sclerotherapy and snare polypectomy applied to four polyps.,ANESTHESIA: , Fentanyl 75 mcg, Versed 6 mg, and glucagon 1.5 units IV push in divided doses.  Also given epinephrine 1:20,000 total of 3 mL.,The patient tolerated the procedure well.,PROCEDURE:  ,The patient was placed in left lateral decubitus after appropriate sedation.  Digital rectal examination was done, which was normal.  Endoscope was introduced and passed through a rather spastic tortuous sigmoid colon with multiple diverticula seen all the way through transverse colon where about 1 cm x 1 cm sessile polyp was seen.  It was biopsied and then in piecemeal fashion removed using snare polypectomy after base was infiltrated with epinephrine.  Pedunculated polyp next to it was hard to see and there was a lot of peristalsis.  The scope then was advanced through rest of the transverse colon to ascending colon and cecum.  Terminal ileum was briefly reviewed, appeared normal and so did cecum after copious amount of fecal material was irrigated out.  Ascending colon was unremarkable.  At hepatic flexure may be proximal transverse colon, there was a sessile polyp about 1.2 cm x 1 cm that was removed in the same manner with a biopsy taken, base infiltrated with epinephrine and at least two passes of snare polypectomy and subsequent hot biopsy cautery removed to hold polypoid tissue, which could be seen.  In transverse colon on withdrawal and relaxation with epinephrine, an additional 1 mm to 2 mm sessile polyp was removed by hot biopsy.  Then in the transverse colon, additional larger polyp about 1.3 cm x 1.2 cm was removed in piecemeal fashion again with epinephrine, sclerotherapy, and snare polypectomy.  Subsequently pedunculated polyp in distal transverse colon near splenic flexure was removed with snare polypectomy.  The rest of the splenic flexure and descending colon were unremarkable.  Diverticulosis was again seen with almost constant spasm despite of glucagon.  Sigmoid colon did somewhat hinder the inspection of that area.  Rectum, retroflexion posterior anal canal showed internal hemorrhoids moderate to large.  Excess of air insufflated was removed.  The endoscope was withdrawn.,PLAN: , Await biopsy report.  Pending biopsy report, recommendation will be made when the next colonoscopy should be done at least three years perhaps sooner besides and due to multitude of the patient's polyps.","gastroenterology, colon cancer, colon polyps, snare polypectomy, cautery, epinephrine sclerotherapy, transverse colon, polypectomy, colonoscopy, sigmoid, endoscope, sclerotherapy, epinephrine, biopsy,"
 Mild-to-moderate diverticulosis.  She was referred for a screening colonoscopy.  There is no family history of colon cancer.  No evidence of polyps or malignancy., Gastroenterology, Colonoscopy - 22 ,"PROCEDURE: , Colonoscopy.,PREOPERATIVE DIAGNOSES:,  The patient is a 56-year-old female.  She was referred for a screening colonoscopy.  The patient has bowel movements every other day.  There is no blood in the stool, no abdominal pain.  She has hypertension, dyslipidemia, and gastroesophageal reflux disease.  She has had cesarean section twice in the past.  Physical examination is unremarkable.  There is no family history of colon cancer.,POSTOPERATIVE DIAGNOSIS: , Diverticulosis.,PROCEDURE IN DETAIL: , Procedure and possible complications were explained to the patient.  Ample opportunity was provided to her to ask questions.  Informed consent was obtained.  She was placed in left lateral position.  Inspection of perianal area was normal.  Digital exam of the rectum was normal.,Video Olympus colonoscope was introduced into the rectum.  The sigmoid colon is very tortuous.  The instrument was advanced to the cecum after placing the patient in a supine position.  The patient was well prepared and a good examination was possible.  The cecum was identified by the ileocecal valve and the appendiceal orifice.  Images were taken.  The instrument was then gradually withdrawn while examining the colon again in a circumferential manner.  Few diverticula were encountered in the sigmoid and descending colon.  Retroflex view of the rectum was unremarkable.  No polyps or malignancy was identified.,After obtaining images, the air was suctioned.  Instrument was withdrawn from the patient.  The patient tolerated the procedure well.  There were no complications.,SUMMARY OF FINDINGS:  ,Colonoscopy was performed to cecum and demonstrates the following:,1.  Mild-to-moderate diverticulosis.,2.  ,RECOMMENDATION:,1.  The patient was provided information on diverticulosis including dietary advice.,2.  She was advised repeat colonoscopy after 10 years.","gastroenterology, screening colonoscopy, colon cancer, colonoscopy, polyps, malignancy, sigmoid, rectum, cecum, diverticulosis"
 Colonoscopy with terminal ileum examination.   Iron deficiency anemia.  Following titrated intravenous sedation the flexible video endoscope was introduced into the rectum and advanced to the cecum without difficulty. , Gastroenterology, Colonoscopy - 19 ,"INDICATION: , Iron deficiency anemia.,PROCEDURE:  ,Colonoscopy with terminal ileum examination.,POSTOPERATIVE DIAGNOSIS:,  Normal examination.,WITHDRAWAL TIME: , 15 minutes.,SCOPE: , CF-H180AL.,MEDICATIONS: , Fentanyl 100 mcg and versed 10 mg.,PROCEDURE DETAIL:  ,Following the preprocedure patient assessment the procedure, goals, risks including bleeding, perforation, missed polyp rate as well as side effects of medications and alternatives were reviewed.  Questions were answered.  Pause preprocedure was performed.,Following titrated intravenous sedation the flexible video endoscope was introduced into the rectum and advanced to the cecum without difficulty.  The ileocecal valve looked normal.  Preparation was fair allowing examination of 85% of mucosa after washing and cleaning with tap water through the scope.  The terminal ileum was intubated through the ileocecal valve for a 5 cm extent.  Terminal ileum mucosa looked normal.,Then the scope was withdrawn while examining the mucosa carefully including the retroflexed views of the rectum.  No polyp, no diverticulum and no bleeding source was identified.,The patient was assessed upon completion of the procedure.  Okay to discharge once criteria met.  ,RECOMMENDATIONS:,  Follow up with primary care physician.","gastroenterology, polyp, endoscope, mucosa, iron deficiency anemia, ileocecal valve, terminal ileum, colonoscopy, anemia, rectum, ileum"
 Universal diverticulosis and nonsurgical internal hemorrhoids. Total colonoscopy with photos.  The patient is a 62-year-old white male who presents to the office with a history of colon polyps and need for recheck., Gastroenterology, Colonoscopy - 17 ,"PREOPERATIVE DIAGNOSIS: , Colon polyps.,POSTOPERATIVE DIAGNOSES:,1.  Universal diverticulosis.,2.  Nonsurgical internal hemorrhoids.,PROCEDURE PERFORMED:, Total colonoscopy with photos.,ANESTHESIA:,  Demerol 100 mg IV with Versed 3 mg IV.,SPECIMENS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,INDICATIONS FOR PROCEDURE:  ,The patient is a 62-year-old white male who presents to the office with a history of colon polyps and need for recheck.,PROCEDURE:,  Informed consent was obtained.  All risks and benefits of the procedure were explained and all questions were answered.  The patient was brought back to the Endoscopy Suite where he was connected to cardiopulmonary monitoring.  Demerol 100 mg IV and Versed 3 mg IV was given in a titrated fashion until appropriate anesthesia was obtained.  Upon appropriate anesthesia, a digital rectal exam was performed, which showed no masses.  The colonoscope was then placed into the anus and the air was insufflated.  The scope was then advanced under direct vision into the rectum, rectosigmoid colon, descending colon, transverse colon, ascending colon until it reached the cecum.  Upon entering the sigmoid colon and throughout the rest of the colon, there was noted diverticulosis.  After reaching the cecum, the scope was fully withdrawn visualizing all walls again noting universal diverticulosis.,Upon reaching the rectum, the scope was then retroflexed upon itself and there was noted to be nonsurgical internal hemorrhoids.  The scope was then subsequently removed.  The patient tolerated the procedure well and there were no complications.","gastroenterology, endoscopy, rectum, rectosigmoid colon, descending colon, transverse colon, ascending colon, total colonoscopy, colon polyps, colonoscopy, cecum, polyps, diverticulosis, hemorrhoids,"
 Possible inflammatory bowel disease.  Polyp of the sigmoid colon..  Total colonoscopy with photography and polypectomy., Gastroenterology, Colonoscopy - 18 ,"PREOPERATIVE DIAGNOSIS: , Possible inflammatory bowel disease.,POSTOPERATIVE DIAGNOSIS: , Polyp of the sigmoid colon.,PROCEDURE PERFORMED:  ,Total colonoscopy with photography and polypectomy.,GROSS FINDINGS: , The patient had a history of ischiorectal abscess.  He has been evaluated now for inflammatory bowel disease.  Upon endoscopy, the colon prep was good.  We were able to reach the cecum without difficulty.  There are no diverticluli, inflammatory bowel disease, strictures, or obstructing lesions.  There was a pedunculated polyp approximately 4.5 cm in size located in the sigmoid colon at approximately 35 cm.  This large polyp was removed using the snare technique.,OPERATIVE PROCEDURE:  ,The patient was taken to the endoscopy suite, prepped and draped in left lateral decubitus position.  IV sedation was given by Anesthesia Department.  The Olympus videoscope was inserted into anus.  Using air insufflation, the colonoscope was advanced through the anus to the rectum, sigmoid colon, descending colon, transverse colon, ascending colon and cecum, the above gross findings were noted.  The colonoscope was slowly withdrawn and carefully examined the lumen of the bowel.  When the polyp again was visualized, the snare was passed around the polyp.  It required at least two to three passes of the snare to remove the polyp in its totality.  There was a large stalk on the polyp.  ________ the polyp had been removed down to the junction of the polyp in the stalk, which appeared to be cauterized and no residual adenomatous tissue was present.  No bleeding was identified.  The colonoscope was then removed and patient was sent to recovery room in stable condition.","gastroenterology, polypectomy, inflammatory bowel disease, sigmoid colon, rectum, descending colon, transverse colon, ascending colon, cecum, total colonoscopy, bowel disease, inflammatory, polyp, colonoscopy, colonoscope, bowel, "
" Colonoscopy. History of colon polyps and partial colon resection, right colon.  Mild diverticulosis of the sigmoid colon.  Hemorrhoids.", Gastroenterology, Colonoscopy - 14 ,"PREPROCEDURE DIAGNOSIS: , History of colon polyps and partial colon resection, right colon.,POSTPROCEDURE DIAGNOSES:  ,1. Normal operative site.  ,2. Mild diverticulosis of the sigmoid colon.  ,3. Hemorrhoids.,PROCEDURE:  ,Total colonoscopy.,PROCEDURE IN DETAIL:  ,The patient is a 60-year-old of Dr. ABC's being evaluated for the above.  The patient also apparently had an x-ray done at the Hospital and it showed a dark spot, and because of this, a colonoscopy was felt to be needed.  She was prepped the night before and on the morning of the test with oral Fleet's, brought to the second floor and sedated with a total of 50 mg of Demerol and 3.75 mg of Versed IV push.  Digital rectal exam was done, unremarkable.  At that point, the Pentax video colonoscope was inserted.  The rectal vault appeared normal.  The sigmoid showed diverticula throughout, mild to moderate in nature.  The scope was then passed through the descending and transverse colon over to the hepatic flexure area and then the anastomosis site was visualized.  The scope was passed a short distance up the ileum, which appeared normal.  The scope was then withdrawn through the transverse, descending, sigmoid, and rectal vault area.  The scope was then retroflexed, and anal verge visualized showed some hemorrhoids.  The scope was then removed.  The patient tolerated the procedure well.,RECOMMENDATIONS:  ,Repeat colonoscopy in three years.","gastroenterology, partial colon resection, diverticulosis, colon polyps, rectal vault, colonoscopy, polyps, hemorrhoids, sigmoid"
 Colonoscopy in a patient with prior history of anemia and abdominal bloating., Gastroenterology, Colonoscopy - 2 ,"PREOPERATIVE DIAGNOSES:,  Prior history of anemia, abdominal bloating.,POSTOPERATIVE DIAGNOSIS:,  External hemorrhoids, otherwise unremarkable colonoscopy.,PREMEDICATIONS:,  Versed 5 mg, Demerol 50 mg IV.,REPORT OF PROCEDURE:,  Digital rectal exam revealed external hemorrhoids.  The colonoscope was inserted into the rectal ampulla and advanced to the cecum.  The position of the scope within the cecum was verified by identification of the appendiceal orifice.  The cecum, the ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, and rectum were normal.  The scope was retroflexed in the rectum and no abnormality was seen.  So the scope was straightened, withdrawn, and the procedure terminated.,ENDOSCOPIC IMPRESSION:,1.  Normal colonoscopy.,2.  External hemorrhoids.","gastroenterology, colonoscopy, digital rectal exam, abdominal, anemia, ascending colon, bloating, cecum, colonoscope, descending colon, hemorrhoids, hepatic flexure, rectal ampulla, rectum, splenic flexure, transverse colon, external hemorrhoids, scope, "
" Colonoscopy.   Rectal bleeding and perirectal abscess.  Normal colonoscopy to the terminal ileum.  Opening in the skin at the external anal verge, consistent with drainage from a perianal abscess, with no palpable abscess at this time, and with no evidence of fistulous connection to the bowel lumen.", Gastroenterology, Colonoscopy - 16 ,"PROCEDURE: , Colonoscopy.,PREOPERATIVE DIAGNOSES: , Rectal bleeding and perirectal abscess.,POSTOPERATIVE DIAGNOSIS: , Perianal abscess.,MEDICATIONS:,  MAC.,DESCRIPTION OF PROCEDURE:  ,The Olympus pediatric variable colonoscope was introduced through the rectum and advanced carefully through the colon into the cecum and then through the ileocecal valve into the terminal ileum.  The preparation was excellent and all surfaces were well seen.  The mucosa throughout the colon and in the terminal ileum was normal, with no evidence of colitis.  Special attention was paid to the rectum, including retroflexed views of the distal rectum and the anorectal junction.  There was no evidence of either inflammation or a fistulous opening.  The scope was withdrawn.  A careful exam of the anal canal and perianal area demonstrated a jagged 8-mm opening at the anorectal junction posteriorly (12 o'clock position).  Some purulent material could be expressed through the opening.  There was no suggestion of significant perianal reservoir of inflamed tissue or undrained material.  Specifically, the posterior wall of the distal rectum and anal canal were soft and unremarkable.  In addition, scars were noted in the perianal area.  The first was a small dimpled scar, 1 cm from the anal verge in the 11 o'clock position.  The second was a dimpled scar about 5 cm from the anal verge on the left buttock's cheek.  There were no other abnormalities noted.  The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1.  Normal colonoscopy to the terminal ileum.,2.  Opening in the skin at the external anal verge, consistent with drainage from a perianal abscess, with no palpable abscess at this time, and with no evidence of fistulous connection to the bowel lumen.,RECOMMENDATIONS:,1.  Continue antibiotics.,2.  Followup with Dr. X.,3.  If drainage persists, consider surgical drainage.","gastroenterology, olympus, colonoscope, rectal bleeding, perianal abscess, terminal ileum, anal verge, anorectal, fistulous, ileum, verge, rectum, anal, perianal, colonoscopy, abscess"
" History of polyps.  Total colonoscopy and photography.  Normal colonoscopy, left colonic diverticular disease.  3+ benign prostatic hypertrophy.", Gastroenterology, Colonoscopy - 13 ,"PREOPERATIVE DIAGNOSIS: , History of polyps.,POSTOPERATIVE DIAGNOSES:,1.  Normal colonoscopy, left colonic diverticular disease.,2.  3+ benign prostatic hypertrophy.,PROCEDURE PERFORMED: , Total colonoscopy and photography.,GROSS FINDINGS: , This is a 74-year-old white male here for recheck colonoscopy for a history of polyps.  After signed informed consent, blood pressure monitoring, EKG monitoring, and pulse oximetry monitoring, he was brought to the Endoscopic Suite.  He was given 100 mg of Demerol, 3 mg of Versed IV push slowly.  Digital examination revealed a large prostate for which he is following up with his urologist.  No nodules.  3+ BPH.  Anorectal canal was within normal limits.  No stricture tumor or ulcer.  The Olympus CF 20L video endoscope was inserted per anus.  The anorectal canal was visualized, was normal.  The sigmoid, descending, splenic, and transverse showed scattered diverticula.  The hepatic, ascending, cecum, and ileocecal valve was visualized and was normal.  The colonoscope was removed.  The air was aspirated.  The patient was discharged with high-fiber, diverticular diet.  Recheck colonoscopy three years.","gastroenterology, digital examination, benign prostatic hypertrophy, anorectal canal, diverticular disease, photography, anorectal, colonoscopy,"
 Colonoscopy.  Change in bowel habits and rectal prolapse.  Normal colonic mucosa to the cecum.  , Gastroenterology, Colonoscopy - 15 ,"PROCEDURE:,  Colonoscopy.,PREOPERATIVE DIAGNOSES: , Change in bowel habits and rectal prolapse.,POSTOPERATIVE DIAGNOSIS: , Normal colonoscopy.,PROCEDURE:  ,The Olympus pediatric variable colonoscope was introduced through the rectum and advanced carefully through the colon to the cecum identified by the ileocecal valve and the appendiceal orifice.  The preparation was poor, but mucosa was visible after lavage and suction.  Small lesions might have been missed in certain places, but no large lesions are likely to have been missed.  The mucosa was normal, was visualized.  In particular, there was no mucosal abnormality in the rectum and distal sigmoid, which is reported to be prolapsing.  Biopsies were taken from the rectal wall to look for microscopic changes.  The anal sphincter was considerably relaxed, with no tone and a gaping opening.  The patient tolerated the procedure well and was sent to recovery room.,FINAL DIAGNOSIS: , Normal colonic mucosa to the cecum.  No contraindications to consideration of a repair of the prolapse.","gastroenterology, olympus, colonoscope, bowel habits, colonic mucosa, colonic, rectum, rectal, cecum, mucosa, colonoscopy, "
 Routine colorectal cancer screening.  He occasionally gets some loose stools.  , Gastroenterology, Colon Cancer Screening ,"HISTORY AND REASON FOR CONSULTATION:, For evaluation of this patient for colon cancer screening.,HISTORY OF PRESENT ILLNESS:, Mr. A is a 53-year-old gentleman who was referred for colon cancer screening.  The patient said that he occasionally gets some loose stools.  Other than that, there are no other medical problems. ,PAST MEDICAL HISTORY:, The patient does not have any serious medical problems at all.  He denies any hypertension, diabetes, or any other problems.  He does not take any medications.,PAST SURGICAL HISTORY: ,Surgery for deviated nasal septum in 1996.,ALLERGIES:, No known drug allergies.,SOCIAL HISTORY: ,Does not smoke, but drinks occasionally for the last five years.,FAMILY HISTORY:, There is no history of any colon cancer in the family.,REVIEW OF SYSTEMS:, Denies any significant diarrhea.  Sometimes he gets some loose stools.  Occasionally there is some constipation.  Stools caliber has not changed.  There is no blood in stool or mucus in stool.  No weight loss.  Appetite is good.  No nausea, vomiting, or difficulty in swallowing.  Has occasional heartburn.,PHYSICAL EXAMINATION:, The patient is alert and oriented x3.  Vital signs: Weight is 214 pounds.  Blood pressure is 111/70.  Pulse is 69 per minute.  Respiratory rate is 18.  HEENT: Negative.  Neck: Supple.  There is no thyromegaly.  Cardiovascular: Both heart sounds are heard.  Rhythm is regular.  No murmur.  Lungs: Clear to percussion and auscultation.  Abdomen: Soft and nontender.  No masses felt.  Bowel sounds are heard.  Extremities: Free of any edema.,IMPRESSION: ,Routine colorectal cancer screening.,RECOMMENDATIONS:, Colonoscopy.  I have explained the procedure of colonoscopy with benefits and risks, in particular the risk of perforation, hemorrhage, and infection.  The patient agreed for it.  We will proceed with it.  I also explained to the patient about conscious sedation.  He agreed for conscious sedation.","gastroenterology, colon cancer screening, loose stools, colorectal, colonoscopy,"
 Colon cancer screening and family history of polyps.  Sigmoid diverticulosis and internal hemorrhoids., Gastroenterology, Colonoscopy - 10 ,"PREOPERATIVE DIAGNOSES: , Colon cancer screening and family history of polyps.,POSTOPERATIVE DIAGNOSIS:,  Colonic polyps.,PROCEDURE:,  Colonoscopy.,ANESTHESIA:,  MAC,DESCRIPTION OF PROCEDURE:  ,The Olympus pediatric variable colonoscope was introduced into the rectum and advanced carefully through the colon into the cecum and then through the ileocecal valve into the terminal ileum.  The preparation was excellent and all surfaces were well seen.  The mucosa was normal throughout the colon and in the terminal ileum.  Two polyps were identified and were removed.  The first was a 7-mm sessile lesion in the mid transverse colon at 110 cm, removed with the snare without cautery and retrieved.  The second was a small 4-mm sessile lesion in the sigmoid colon at 20 cm also removed with the snare and retrieved.  No other lesions were identified.  Numerous diverticula were found in the sigmoid colon.  A retroflex through the anorectal junction showed moderate internal hemorrhoids.  The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1.  Sigmoid diverticulosis.,2.  Colonic polyps in the transverse colon and sigmoid colon, benign appearance, removed.,3.  Internal hemorrhoids.,4.  Otherwise normal colonoscopy to the terminal ileum.,RECOMMENDATIONS:,1.  Follow up biopsy report.,2.  Follow up with Dr. X as needed.,3.  Screening colonoscopy in 5 years.",gastroenterology
 Colonoscopy.  The Olympus video colonoscope then was introduced into the rectum and passed by directed vision to the cecum and into the terminal ileum. , Gastroenterology, Colonoscopy - 12 ,"PROCEDURE IN DETAIL: , Following instructions and completion of an oral colonoscopy prep, the patient, having been properly informed of, with signature consenting to total colonoscopy and indicated procedures, the patient received premedications of Vistaril 50 mg, Atropine 0.4 mg IM, and then intravenous medications of Demerol 50 mg and Versed 5 mg IV.  Perirectal inspection was normal.  The Olympus video colonoscope then was introduced into the rectum and passed by directed vision to the cecum and into the terminal ileum.  No abnormalities were seen of the terminal ileum, the ileocecal valve, cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, rectosigmoid and rectum.  Retroflexion exam in the rectum revealed no other abnormality and withdrawal terminated the procedure.","gastroenterology, ileocecal valve, cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, rectosigmoid, rectum, terminal ileum, olympus video colonoscope, flexure, colonoscopyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Colonoscopy.  The Olympus video colonoscope was inserted through the anus and was advanced in retrograde fashion through the sigmoid colon, descending colon, around the splenic flexure, into the transverse colon, around the hepatic flexure, down the ascending colon, into the cecum. ", Gastroenterology, Colonoscopy - 11 ,"MEDICATIONS:,1.  Versed intravenously.,2.  Demerol intravenously.,DESCRIPTION OF THE PROCEDURE: , After informed consent was obtained, the patient was placed in the left lateral decubitus position and sedated with the above medications.  The Olympus video colonoscope was inserted through the anus and was advanced in retrograde fashion through the sigmoid colon, descending colon, around the splenic flexure, into the transverse colon, around the hepatic flexure, down the ascending colon, into the cecum.  The cecum was identified by the presence of the appendiceal orifice and the ileocecal valve.  The colonoscope was then advanced through the ileocecal valve into the terminal ileum, which was normal on examination.  The scope was then pulled back into the cecum and then slowly withdrawn.  The mucosa was examined in detail.  The mucosa was entirely normal.  Upon reaching the rectum, retroflex examination of the rectum was normal.  The scope was then straightened out, the air removed and the scope withdrawn.  The patient tolerated the procedure well.  There were no apparent complications.,","gastroenterology, olympus, scope, sigmoid colon, descending colon, splenic flexure, transverse colon, hepatic flexure, ascending colon, ileocecal valve, ileocecal, mucosa, rectum, colonoscope, flexure, cecum, colonoscopyNOTE"
" Newly diagnosed stage II colon cancer, with a stage T3c, N0, M0 colon cancer, grade 1.  Although, the tumor was near obstructing, she was not having symptoms and in fact was having normal bowel movements.", Gastroenterology, Colon Cancer Consult ,"REASON FOR CONSULTATION: , I was asked by Dr. X to see the patient in consultation for a new diagnosis of colon cancer.,HISTORY OF PRESENT ILLNESS:,  The patient presented to medical attention after she noticed mild abdominal cramping in February 2007.  At that time, she was pregnant and was unsure if her symptoms might have been due to the pregnancy.  Unfortunately, she had miscarriage at about seven weeks.  She again had abdominal cramping, severe, in late March 2007.  She underwent colonoscopy on 04/30/2007 by Dr. Y.  Of note, she is with a family history of early colon cancers and had her first colonoscopy at age 35 and no polyps were seen at that time.,On colonoscopy, she was found to have a near-obstructing lesion at the splenic flexure.  She was not able to have the scope passed past this lesion.  Pathology showed a colon cancer, although I do not have a copy of that report at this time.,She had surgical resection done yesterday.  The surgery was laparoscopic assisted with anastomosis.  At the time of surgery, lymph nodes were palpable.,Pathology showed colon adenocarcinoma, low grade, measuring 3.8 x 1.7 cm, circumferential and invading in to the subserosal mucosa greater than 5 mm, 13 lymph nodes were negative for metastasis.  There was no angiolymphatic invasion noted.  Radial margin was 0.1 mm.  Other margins were 5 and 6 mm.  Testing for microsatellite instability is still pending.,Staging has already been done with a CT scan of the chest, abdomen, and pelvis.  This showed a mass at the splenic flexure, mildly enlarged lymph nodes there, and no evidence of metastasis to liver, lungs, or other organs.  The degenerative changes were noted at L5-S1.  The ovaries were normal.  An intrauterine device (IUD) was present in the uterus.,REVIEW OF SYSTEMS:,  She has otherwise been feeling well.  She has not had fevers, night sweats, or noticed lymphadenopathy.  She has not had cough, shortness of breath, back pain, bone pain, blood in her stool, melena, or change in stool caliber.  She was eating well up until the time of her surgery.  She is up-to-date on mammography, which will be due again in June.  She has no history of pulmonary, cardiac, renal, hepatic, thyroid, or central nervous system (CNS) disease.,ALLERGIES: , PENICILLIN, WHICH CAUSED HIVES WHEN SHE WAS A CHILD.,MEDICATIONS PRIOR TO ADMISSION:,  None.,PAST MEDICAL HISTORY: , No significant medical problem.  She has had three miscarriages, all of them at about seven weeks.  She has no prior surgeries.,SOCIAL HISTORY:  ,She smoked cigarettes socially while in her 20s.  A pack of cigarettes would last for more than a week.  She does not smoke now.  She has two glasses of wine per day, both red and white wine.  She is married and has no children.  An IUD was recently placed.  She works as an esthetician.,FAMILY HISTORY:  ,Father died of stage IV colon cancer at age 45.  This occurred when the patient was young and she is not sure of the rest of the paternal family history.  She does believe that aunts and uncles on that side may have died early.  Her brother died of pancreas cancer at age 44.  Another brother is aged 52 and he had polyps on colonoscopy a couple of years ago.  Otherwise, he has no medical problem.  Mother is aged 82 and healthy.  She was recently diagnosed with hemochromatosis.,PHYSICAL EXAMINATION: , ,GENERAL:  She is in no acute distress.,VITAL SIGNS:  The patient is afebrile with a pulse of 78, respirations 16, blood pressure 124/70, and pulse oximetry is 93% on 3 L of oxygen by nasal cannula.,SKIN:  Warm and dry.  She has no jaundice.,LYMPHATICS:  No cervical or supraclavicular lymph nodes are palpable.,LUNGS:  There is no respiratory distress.,CARDIAC:  Regular rate.,ABDOMEN:  Soft and mildly tender.  Dressings are clean and dry.,EXTREMITIES:  No peripheral edema is noted.  Sequential compression devices (SCDs) are in place.,LABORATORY DATA:,  White blood count of 11.7, hemoglobin 12.8, hematocrit 37.8, platelets 408, differential shows left shift, MCV is 99.6.  Sodium is 136, potassium 4.1, bicarb 25, chloride 104, BUN 5, creatinine 0.7, and glucose is 133.  Calcium is 8.8 and magnesium is 1.8.,IMPRESSION AND PLAN: , Newly diagnosed stage II colon cancer, with a stage T3c, N0, M0 colon cancer, grade 1.  She does not have high-risk factors such as high grade or angiolymphatic invasion, and adequate number of lymph nodes were sampled.  Although, the tumor was near obstructing, she was not having symptoms and in fact was having normal bowel movements.,A lengthy discussion was held with the patient regarding her diagnosis and prognosis.  Firstly, she has a good prognosis for being cured without adjuvant therapy.  I would consider her borderline for chemotherapy given her young age.  Referring to the database that had been online, she has a 13% chance of relapse in the next five years, and with aggressive chemotherapy (X-linked agammaglobulinemia (XLA) platinum-based), this would be reduced to an 8% risk of relapse with a 5% benefit.  Chemotherapy with 5-FU based regimen would have a smaller benefit of around 2.5%.,Plan was made to allow her to recuperate and then meet with her and her husband to discuss the pros and cons of adjuvant chemotherapy including what regimen she could consider including the side effects.  We did not review all that information today.,She has a family history of early colon cancer.  Her mother will be visiting in the weekend and plan is to obtain the rest of the paternal family history if we can.  Tumor is being tested for microsatellite instability and we will discuss this when those results are available.  She has one sibling and he is up-to-date on colonoscopy.  She does report multiple tubes of blood were drawn prior to her admission.  I will check with Dr. Y's office whether she has had a CEA and liver-associated enzymes assessed.  If not, those can be drawn tomorrow.",
" Still having diarrhea, decreased appetite.", Gastroenterology, Clostridium Difficile Colitis Followup ,"SUBJECTIVE:  ,The patient seen and examined feels better today.  Still having diarrhea, decreased appetite.  Good urine output 600 mL since 7 o'clock in the morning.  Afebrile.,PHYSICAL EXAMINATION,GENERAL:  Nonacute distress, awake, alert, and oriented x3.,VITAL SIGNS:  Blood pressure 102/64, heart rate of 89, respiratory rate of 12, temperature 96.8, and O2 saturation 94% on room air.,HEENT:  PERRLA, EOMI.,NECK:  Supple.,CARDIOVASCULAR:  Regular rate and rhythm.,RESPIRATORY:  Clear to auscultation bilaterally.,ABDOMEN:  Bowel sounds are positive, soft, and nontender. EXTREMITIES:  No edema.  Pulses present bilaterally.,LABORATORY DATA:  ,CBC, WBC count today down 10.9 from 17.3 yesterday 26.9 on admission, hemoglobin 10.2, hematocrit 31.3, and platelet count 370,000.  BMP, BUN of 28.3 from 32.2, creatinine 1.8 from 1.89 from 2.7.  Calcium of 8.2.  Sodium 139, potassium 3.9, chloride 108, and CO2 of 22.  Liver function test is unremarkable.,Stool positive for Clostridium difficile.  Blood culture was 131.  O2 saturation result is pending.,ASSESSMENT AND PLAN:,1.  Most likely secondary to Clostridium difficile colitis and urinary tract infection improving.  The patient hemodynamically stable, leukocytosis improved and today he is afebrile.,2.  Acute renal failure secondary to dehydration, BUN and creatinine improving.,3.  Clostridium difficile colitis, Continue Flagyl, evaluation Dr. X in a.m.,4.  Urinary tract infection, continue Levaquin for last during culture.,5.  Leucocytosis, improving.,6.  Minimal elevated cardiac enzyme on admission.  Followup with Cardiology recommendations.,7.  Possible pneumonia, continue vancomycin and Levaquin.,8.  The patient may be transferred to telemetry.","gastroenterology, decreased appetite, acute renal failure, urinary tract infection, leucocytosis, clostridium difficile colitis,"
" Colonoscopy due to rectal bleeding, constipation, abnormal CT scan, rule out inflammatory bowel disease.", Gastroenterology, Colonoscopy - 1 ,"INDICATION: ,  Rectal bleeding, constipation, abnormal CT scan, rule out inflammatory bowel disease.,PREMEDICATION: ,See procedure nurse NCS form.,PROCEDURE:  ,","gastroenterology, bleeding, ct scan, digital rectal exam, pentax video, rectal, cecal strap, cecum, colonic mucosa, colonoscope, colonoscopy, constipation, hemorrhoids, ileocecal valve, inflammatory bowel disease, lateral position, bowel disease, internal hemorrhoids, inflammatory"
 Genetic counseling for a strong family history of colon polyps.  She has had colonoscopies required every five years and every time she has polyps were found.  She reports that of her 11 brothers and sister 7 have had precancerous polyps.  , Gastroenterology, Colon Polyps - Genetic Counseling ,"REASON FOR CONSULT: , Genetic counseling.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 61-year-old female with a strong family history of colon polyps.  The patient reports her first polyps noted at the age of 50.  She has had colonoscopies required every five years and every time she has polyps were found.  She reports that of her 11 brothers and sister 7 have had precancerous polyps.  She does have an identical twice who is the one of the 11 who has never had a history of polyps.  She also has history of several malignancies in the family.  Her father died of a brain tumor at the age of 81.  There is no history of knowing whether this was a primary brain tumor or whether it is a metastatic brain involvement.  Her sister died at the age of 65 breast cancer.  She has two maternal aunts with history of lung cancer both of whom were smoker.  Also a paternal grandmother who was diagnosed with breast cancer at 86 and a paternal grandfather who had lung cancer.  There is no other cancer history.,PAST MEDICAL HISTORY:,  Significant for asthma.,CURRENT MEDICATIONS: , Include Serevent two puffs daily and Nasonex two sprays daily.,ALLERGIES: , Include penicillin.  She is also allergic seafood; crab and mobster.,SOCIAL HISTORY: , The patient is married.  She was born and raised in South Dakota.  She moved to Colorado 37 years ago.  She attended collage at the Colorado University.  She is certified public account.  She does not smoke.  She drinks socially.,REVIEW OF SYSTEMS:  ,The patient denies any dark stool or blood in her stool.  She has had occasional night sweats and shortness of breath, and cough associated with her asthma.  She also complains of some acid reflux as well as anxiety.  She does report having knee surgery for torn ACL on the left knee and has some arthritis in that knee.  The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:","gastroenterology, family history, strong family history, precancerous polyps, brain tumor, lung cancer, genetic counseling, colon polyps, polyps, "
 Iron deficiency anemia.  Diverticulosis in the sigmoid., Gastroenterology, Colonoscopy ,"PREOPERATIVE DIAGNOSIS:,  Iron deficiency anemia.,POSTOPERATIVE DIAGNOSIS:,  Diverticulosis.,PROCEDURE:,  Colonoscopy.,MEDICATIONS: , MAC.,PROCEDURE: , The Olympus pediatric variable colonoscope was introduced into the rectum and advanced carefully through the colon to the cecum identified by the ileocecal valve and the appendiceal orifice.  Preparation was good, although there was some residual material in the cecum that was difficult to clear completely.  The mucosa was normal throughout the colon.  No polyps or other lesions were identified, and no blood was noted.  Some diverticula were seen of the sigmoid colon with no luminal narrowing or evidence of inflammation.  A retroflex view of the anorectal junction showed no hemorrhoids.  The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1.  Diverticulosis in the sigmoid.,2.  Otherwise normal colonoscopy to the cecum.,RECOMMENDATIONS:,1.  Follow up with Dr. X as needed.,2.  Screening colonoscopy in 2 years.,3.  Additional evaluation for other causes of anemia may be appropriate.","gastroenterology, olympus, colonoscope, iron deficiency anemia, diverticulosis, sigmoid, cecum, anemia, colonoscopy"
 Placement of cholecystostomy tube under ultrasound guidance.  Acute acalculous cholecystitis., Gastroenterology, Cholecystostomy Tube Placement ,"PREOPERATIVE DIAGNOSIS:,  Acute acalculous cholecystitis.,POSTOPERATIVE DIAGNOSIS: , Acute acalculous cholecystitis.,PROCEDURE:,  Placement of cholecystostomy tube under ultrasound guidance.,ANESTHESIA: , Xylocaine 1% With Epinephrine.,INDICATIONS: , Patient is a pleasant 75-year-old gentleman who is about one week status post an acute MI who also has acute cholecystitis.  Because it is not safe to take him to the operating room for general anesthetic, I recommended he undergo the above-named procedure.  Procedure, purpose, risks, expected benefits, potential complications, and alternative forms of therapy were discussed with him and he was agreeable to surgery.,TECHNIQUE: , Patient was identified, then taken to the Radiology suite, where the area of interest was identified using ultrasound and prepped with Betadine solution, draped in sterile fashion.  After infiltration with 1% Xylocaine and after multiple attempts, the gallbladder was finally cannulated by Dr. Kindred using the Cook 18-French needle.  The guidewire was then placed and via Seldinger technique, a 10-French pigtail catheter was placed within the gallbladder, secured using the Cook catheter method, and dressings were applied and patient was taken to recovery room in stable condition.","gastroenterology, under ultrasound guidance, cholecystostomy tube, acalculous cholecystitis, catheter, cholecystostomy, ultrasound, acalculous, cholecystitis"
 Cholecystitis with choledocholithiasis.   Laparoscopic cholecystectomy with laparoscopy converted to open common bile duct exploration and stone extraction., Gastroenterology, Cholecystitis - Discharge Summary ,"REASON FOR ADMISSION: , Cholecystitis with choledocholithiasis.,DISCHARGE DIAGNOSES: , Cholecystitis, choledocholithiasis.,ADDITIONAL DIAGNOSES,1.  Status post roux-en-y gastric bypass converted to an open procedure in 01/07.,2.  Laparoscopic paraventral hernia in 11/07.,3.  History of sleep apnea with reversal after 100-pound weight loss.,4.  Morbid obesity with bmi of 39.4.,PRINCIPAL PROCEDURE:,  Laparoscopic cholecystectomy with laparoscopy converted to open common bile duct exploration and stone extraction.,HOSPITAL COURSE: , The patient is a 33-year-old female admitted with elevated bilirubin and probable common bile duct stone.  She was admitted through the emergency room with abdominal pain, elevated bilirubin, and gallstones on ultrasound with a dilated common bile duct.  She subsequently went for a HIDA scan to rule out cholecystitis.  Gallbladder was filled but was unable to empty into the small bowel consistent with the common bile duct blockage.  She was taken to the operating room that night for laparoscopic cholecystectomy.  We proceeded with laparoscopic cholecystectomy and during the cholangiogram there was no contrast.  It was able to be extravasated into the duodenum with the filling defect consistent with the distal common bile duct stone.  The patient had undergone a Roux-en-Y gastric bypass but could not receive an ERCP and stone extraction, therefore, common bile duct exploration was performed and a stone was extracted.  This necessitated conversion to an open operation.  She was transferred to the medical surgical unit postoperatively.  She had a significant amount of incisional pain following morning, but no nausea.  A Jackson-Pratt drain, which was left in place in two places showed serosanguineous fluid.  White blood cell count was down to 7500 and bilirubin decreased to 2.1.  Next morning she was started on a liquid diet.  Foley catheter was discontinued.  There was no evidence of bile leak from the drains.  She was advanced to a regular diet on postoperative day #3, which was 12/09/07.  The following morning she was tolerating regular diet.  Her bowels had begun to function, and she was afebrile with her pain control with oral pain medications.  Jackson-Pratt drain was discontinued from the wound.  The remaining Jackson-Pratt drain was left adjacent to her cystic duct.  Following morning, her laboratory studies were better.  Her bilirubin was down to normal and white blood cell count was normal with an H&H of 9 and 26.3.  Jackson-Pratt drain was discontinued, and she was discharged home.  Followup was in 3 days for staple removal.  She was given iron 325 mg p.o. t.i.d. and Lortab elixir 15 cc p.o. q.4 h. p.r.n. for pain.","gastroenterology, laparoscopy, common bile duct exploration, laparoscopic cholecystectomy, bile duct, choledocholithiasis, cholecystectomy, cholecystitis, laparoscopic, hernia "
 Laparoscopic cholecystectomy with cholangiogram., Gastroenterology, Cholecystectomy & Cholangiogram. ,"PREOPERATIVE DIAGNOSES:,1.  Cholelithiasis.,2.  Acute cholecystitis.,POSTOPERATIVE DIAGNOSES:,1.  Acute on chronic cholecystitis.,2.  Cholelithiasis.,PROCEDURE PERFORMED: , Laparoscopic cholecystectomy with cholangiogram.,ANESTHESIA: , General.,INDICATIONS: , This is a 38-year-old diabetic Hispanic female patient, with ongoing recurrent episodes of right upper quadrant pain, associated with nausea.  Ultrasound revealed cholelithiasis.  The patient also had somewhat thickened gallbladder wall.  The patient was admitted through emergency room last night with acute onset right upper quadrant pain.  Clinically, it was felt the patient had acute cholecystitis.  Laparoscopic cholecystectomy with cholangiogram was advised.  Procedure, indication, risk, and alternative were discussed with the patient in detail preoperatively and informed consent was obtained.,DESCRIPTION OF PROCEDURE: , The patient was put in supine position on the operating table under satisfactory general anesthesia, and abdomen was prepped and draped.  A small transverse incision was made just above the umbilicus under local anesthesia.  Fascia was opened vertically.  Stay sutures were placed in the fascia.  Peritoneal cavity was carefully entered.  Hasson cannula was inserted and peritoneal cavity was insufflated with CO2.,Laparoscopic camera was inserted, and the patient was placed in reverse Trendelenburg, rotated to the left.  A 11-mm trocar was placed in the subxiphoid space and two 5-mm in the right subcostal region.  Examination at this time showed no free fluid, no acute inflammatory changes.  Liver was grossly normal.  Gallbladder was noted to be thickened.  Gallbladder wall with a stone stuck in the neck of the gallbladder and pericholecystic edema, consistent with acute cholecystitis.,The fundus of the gallbladder was retracted superiorly, and dissection was carried at the neck of the gallbladder where a cystic duct was identified and isolated.  It was clipped distally and using C-arm fluoroscopy, intraoperative cystic duct cholangiogram was done, which was interpreted as normal.  There was slight dilatation noted at the junction of the right and left hepatic duct, but no filling defects or any other pathology was noted.  It was presumed that this was probably a congenital anomaly.  The cystic duct was clipped twice proximally and divided beyond the clips.  Cystic artery was identified, isolated, clipped twice proximally, once distally, and divided.,The gallbladder was then removed from its bed using cautery dissection and subsequently delivered through the umbilical port.  Specimen was sent for histopathology.  Subhepatic and subdiaphragmatic spaces were irrigated with sterile saline solution.  Hemostasis was good.  Trocars were removed under direct vision and peritoneal cavity was evacuated with CO2.  Umbilical area fascia was closed with 0-Vicryl figure-of-eight sutures, required extra sutures to close the fascial defect.  Some difficulty was encountered closing the fascia initially because of the patient's significant amount of subcutaneous fat.  In the end, the repair appears to be quite satisfactory.  Rest of the incisions closed with 3-0 Vicryl for the subcutaneous tissues and staples for the skin.  Sterile dressing was applied.,The patient transferred to recovery room in stable condition.","gastroenterology, cholelithiasis, acute cholecystitis, laparoscopic, cholecystectomy, cholangiogram, laparoscopic cholecystectomy, gallbladder,"
" Status post colonoscopy.  After discharge, experienced bloody bowel movements and returned to the emergency department for evaluation.", Gastroenterology, Blood per Rectum ,"CHIEF COMPLAINT:, Bright red blood per rectum ,HISTORY OF PRESENT ILLNESS: ,This 73-year-old woman had a recent medical history significant for renal and bladder cancer, deep venous thrombosis of the right lower extremity, and anticoagulation therapy complicated by lower gastrointestinal bleeding. Colonoscopy during that admission showed internal hemorrhoids and diverticulosis, but a bleeding site was not identified. Five days after discharge to a nursing home, she again experienced bloody bowel movements and returned to the emergency department for evaluation. ,REVIEW OF SYMPTOMS: ,No chest pain, palpitations, abdominal pain or cramping, nausea, vomiting, or lightheadedness. Positive for generalized weakness and diarrhea the day of admission. ,PRIOR MEDICAL HISTORY:, Long-standing hypertension, intermittent atrial fibrillation, and hypercholesterolemia. Renal cell carcinoma and transitional cell bladder cancer status post left nephrectomy, radical cystectomy, and ileal loop diversion 6 weeks prior to presentation, postoperative course complicated by pneumonia, urinary tract infection, and retroperitoneal bleed. Deep venous thrombosis 2 weeks prior to presentation, management complicated by lower gastrointestinal bleeding, status post inferior vena cava filter placement. ,MEDICATIONS: ,Diltiazem 30 mg tid, pantoprazole 40 mg qd, epoetin alfa 40,000 units weekly, iron 325 mg bid, cholestyramine. Warfarin discontinued approximately 10 days earlier. ,ALLERGIES: ,Celecoxib (rash).,SOCIAL HISTORY:, Resided at nursing home. Denied alcohol, tobacco, and drug use. ,FAMILY HISTORY:, Non-contributory.,PHYSICAL EXAM: ,Temp = 38.3C BP =146/52 HR= 113 RR = 18 SaO2 = 98% room air ,General: Pale, ill-appearing elderly female. ,HEENT: Pale conjunctivae, oral mucous membranes moist. ,CVS: Irregularly irregular, tachycardia. ,Lungs: Decreased breath sounds at the bases. ,Abdomen: Positive bowel sounds, soft, nontender, nondistended, gross blood on rectal exam. ,Extremities: No cyanosis, clubbing, or edema. ,Skin: Warm, normal turgor. ,Neuro: Alert and oriented. Nonfocal. ,LABS: ,CBC: ,WBC count: 6,500 per mL ,Hemoglobin: 10.3 g/dL ,Hematocrit:31.8% ,Platelet count: 248 per mL ,Mean corpuscular volume: 86.5 fL ,RDW: 18% ,CHEM 7: ,Sodium: 131 mmol/L ,Potassium: 3.5 mmol/L ,Chloride: 98 mmol/L ,Bicarbonate: 23 mmol/L ,BUN: 11 mg/dL ,Creatinine: 1.1 mg/dL ,Glucose: 105 mg/dL ,COAGULATION STUDIES: ,PT 15.7 sec ,INR 1.6 ,PTT 29.5 sec ,HOSPITAL COURSE: ,The patient received 1 liter normal saline and diltiazem (a total of 20 mg intravenously and 30 mg orally) in the emergency department. Emergency department personnel made several attempts to place a nasogastric tube for gastric lavage, but were unsuccessful. During her evaluation, the patient was noted to desaturate to 80% on room air, with an increase in her respiratory rate to 34 breaths per minute. She was administered 50% oxygen by nonrebreadier mask, with improvement in her oxygen saturation to 89%. Computed tomographic angiography was negative for pulmonary embolism. ",
 Laparoscopic resection of cecal polyp.  Local anesthetic was infiltrated into the right upper quadrant where a small incision was made.  Blunt dissection was carried down to the fascia which was grasped with Kocher clamps.  , Gastroenterology, Cecal Polyp Resection ,"PREOPERATIVE DIAGNOSIS:,  Cecal polyp.,POSTOPERATIVE DIAGNOSIS: , Cecal polyp.,PROCEDURE: , Laparoscopic resection of cecal polyp.,COMPLICATIONS: , None., ,ANESTHESIA:  ,General oral endotracheal intubation.,PROCEDURE:,  After adequate general anesthesia was administered the patient's abdomen was prepped and draped aseptically.  Local anesthetic was infiltrated into the right upper quadrant where a small incision was made.  Blunt dissection was carried down to the fascia which was grasped with Kocher clamps.  A bladed 11-mm port was inserted without difficulty.  Pneumoperitoneum was obtained using C02.  Under direct vision 2 additional, non-bladed, 11-mm trocars were placed, one in the left lower quadrant and one in the right lower quadrant.  There was some adhesion noted to the anterior midline which was taken down using the harmonic scalpel.  The cecum was visualized and found to have tattoo located almost opposite the ileocecal valve.  This was in what appeared to be an appropriate location for removal of this using the Endo GIA stapler without impinging on the ileocecal valve or the appendiceal orifice.  The appendix was somewhat retrocecal in position but otherwise looked normal.  The patient was also found to have ink marks in the peritoneal cavity diffusely indicating possible extravasation of dye.  There was enough however in the wall to identify the location of the polyp.  The lesion was grasped with a Babcock clamp and an Endo GIA stapler used to fire across this transversely. The specimen was then removed through the 12-mm port and examined on the back table.  The lateral margin was found to be closely involved with the specimen so I did not feel that it was clear.  I therefore lifted the lateral apex of the previous staple line and created a new staple line extending more laterally around the colon.  This new staple line was then opened on the back table and examined.  There was some residual polypoid material noted but the margins this time appeared to be clear.  The peritoneal cavity was then lavaged with antibiotic solution.  There were a few small areas of bleeding along the staple line which were treated with pinpoint electrocautery.  The trocars were removed under direct vision.  No bleeding was noted.  The bladed trocar site was closed using a figure-of-eight O Vicryl suture.  All skin incisions were closed with running 4-0 Monocryl subcuticular sutures.  Mastisol and Steri-Strips were placed followed by sterile Tegaderm dressing.  The patient tolerated the procedure well without any complications.","gastroenterology, polyp, laparoscopic resection, blunt dissection, kocher clamps, ileocecal valve, gia stapler, peritoneal cavity, cecal polyp, infiltrated, anesthetic "
" The patient is a very pleasant 72-year-old female with previous history of hypertension and also recent diagnosis of C. diff,  presents to the hospital with abdominal pain, cramping, and persistent diarrhea.", Gastroenterology, C. Diff Colitis Consult ,"REASON FOR CONSULT:  ,I was asked to see the patient for C. diff colitis.,HISTORY OF PRESENTING ILLNESS: , Briefly, the patient is a very pleasant 72-year-old female with previous history of hypertension and also recent diagnosis of C. diff for which she was admitted here in 5/2009, who presents to the hospital on 6/18/2009 with abdominal pain, cramping, and persistent diarrhea.  After admission, she had a CT of the abdomen done, which showed evidence of diffuse colitis and she was started on IV Flagyl and also on IV Levaquin.  She was also placed on IV Reglan because of nausea and vomiting.  In spite of the above, her white count still continues to be elevated today.  On questioning the patient, she states the nausea and vomiting has resolved, but the diarrhea still present, but otherwise denies any other specific complaints except for some weakness.,PAST MEDICAL HISTORY: , Hypertension, hyperlipidemia, recent C. diff colitis, which had resolved based on speaking to Dr. X.  Two weeks ago, he had seen the patient and she was clinically well.,PAST SURGICAL HISTORY:  ,Noncontributory.,SOCIAL HISTORY:  ,No history of smoking, alcohol, or drug use.  She lives at home.,HOME MEDICATIONS:  ,She is on atenolol and Mevacor.,ALLERGIES:  NO KNOWN DRUG ALLERGIES.,REVIEW OF SYSTEMS:  ,Positive for diarrhea and abdominal pain, otherwise main other complaints are weakness.  She denies any cough, sputum production, or dysuria at this time.  Otherwise, a 10-system review is essentially negative.,PHYSICAL EXAM:,GENERAL:  She is awake and alert, currently in no apparent distress.,VITAL SIGNS:  She has been afebrile since admission, temperature today 96.5, heart rate 80, respirations 18, blood pressure 125/60, and O2 sat is 98% on 2 L.,HEENT:  Pupils are round and reactive to light and accommodation.,CHEST:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  S1 and S2 are present.  No rales appreciated.,ABDOMEN:  She does have tenderness to palpation all over with some mild rebound tenderness also.  No guarding noted.  Bowel sounds present.,EXTREMITIES:  No clubbing, cyanosis, or edema.,CT of the abdomen and pelvis is also reviewed on the computer, which showed evidence of diffuse colitis.,LABORATORY: , White blood cell count today 21.5, hemoglobin 12.4, platelet count 284,000, and neutrophils 89.  UA on 6/18/2009 showed no evidence of UTI.  Sodium today 130, potassium 2.7, and creatinine 0.4.  AST and ALT on 6/20/2009 were normal.  Blood cultures from admission were negative.  Urine culture on admission was negative.  C. diff was positive.  Stool culture was negative.,ASSESSMENT:,1.  A 72-year-old female with Clostridium difficile colitis.,2.  Diarrhea secondary to above and also could be related Reglan, which was discontinued today.,3.  Leukocytosis secondary to above, mild improvement today though.,4.  Bilateral pleural effusion by CT of the chest, although could represent thickening.,5.  New requirement for oxygen, rule out pneumonia.,6.  Hypertension.,PLAN:,1.  Treat the C. diff aggressively especially given CT appearance and her continued leukocytosis and because of the Levaquin, which could have added additional antibiotic pressure, so I will restart the IV Flagyl.,2.  Continue p.o. vancomycin.  Add Florastor to help replenish the gut flora.,3.  Monitor WBCs closely and follow clinically and if there is any deterioration in her clinical status, I would recommend getting surgical evaluation immediately for surgery if needed.,4.  We will check a chest x-ray especially given her new requirement for oxygen.",
 Laparoscopic cholecystectomy.  Gallstone pancreatitis.  Video laparoscopy revealed dense omental adhesions surrounding the gallbladder circumferentially. , Gastroenterology, Cholecystectomy Laparoscopic ,"PREOPERATIVE DIAGNOSIS: ,Gallstone pancreatitis.,POSTOPERATIVE DIAGNOSIS: , Gallstone pancreatitis.,PROCEDURE PERFORMED: , Laparoscopic cholecystectomy.,ANESTHESIA: , General endotracheal and local injectable Marcaine.,ESTIMATED BLOOD LOSS: , Minimal.,SPECIMEN: , Gallbladder.,COMPLICATIONS:  ,None.,OPERATIVE FINDINGS: , Video laparoscopy revealed dense omental adhesions surrounding the gallbladder circumferentially.  These dense adhesions were associated with chronic inflammatory edematous changes.  The cystic duct was easily identifiable and seen entering into the gallbladder and clipped two proximally and one distally.  The cystic artery was an anomalous branch that was anterior to the cystic duct and was identified, clipped with two clips proximally and one distally.  The remainder of the evaluation of the abdomen revealed no evidence of nodularity or masses in the liver.  There was no evidence of adhesions from the abdominal wall to the liver.  The remainder of the abdomen was unremarkable.,BRIEF HISTORY:  ,This is a 17-year-old African-American female who presented to ABCD General Hospital on 08/20/2003 with complaints of intractable right upper quadrant abdominal pain.  She had been asked to follow up and scheduled for surgery previously.  Her pain had now been intractable associated with anorexia.  She was noted on physical examination to be afebrile; however, she was having severe right upper quadrant pain with examination as well as a Murphy's sign and voluntary guarding with examination.  Her transaminases were markedly elevated.  She also developed pancreatitis secondary to gallstones.  Her common bile duct was dilated to 1 cm with no evidence of wall thickening, but evidence of cholelithiasis.  She was seen by the gastroenterologist and underwent a sphincterotomy with balloon extraction of gallstones secondary to choledocholithiasis.  Following this, she was scheduled for operative laparoscopic cholecystectomy.  Her parents were explained the risks, benefits, and complications of the procedure.  She gave us informed consent to proceed with surgery.,OPERATIVE PROCEDURE:  ,The patient brought to the operative suite and placed in the supine position.  Preoperatively, the patient received IV antibiotics of Ancef, sequential compression devices and subcutaneous heparin.  The abdomen was prepped and draped in the normal sterile fashion with Betadine solution.  Utilizing a #15 blade scalpel, a transverse infraumbilical incision was created.  Utilizing a Veress needle with anterior traction on the anterior abdominal wall with a towel clamp, the Veress needle was inserted without difficulty.  Hanging water drop test was performed with notable air aspiration through the Veress needle and the saline passed through the Veress needle without difficulty.  The abdomen was then insufflated to 15 mmHg with carbon-dioxide.  Once the abdomen was sufficiently insufflated, a #10 mm bladed trocar was inserted into the abdomen without difficulty.  Video laparoscope was inserted and the above notable findings were identified in the operative findings.  The patient to proceed with laparoscopic cholecystectomy was decided and a subxiphoid port was placed.  A #15 bladed scalpel was used to make a transverse incision in the subxiphoid region within the midline.  The trocar was then inserted into the abdomen under direct visualization with the video laparoscope and seen to go to the right of falciform ligament.  Next, two 5 mm trocars were inserted under direct visualization, one in the midclavicular and one in the anterior midaxillary line.  These were inserted without difficulty.  The liver edge was lifted and revealed a markedly edematous gallbladder with severe omental adhesions encapsulating the gallbladder.  Utilizing Endoshears scissor, a plane was created circumferentially to the dome of the gallbladder to allow assistance and dissection of these dense adhesions.  Next, the omental adhesions adjacent to the infundibulum were taken down and allowed to expose the cystic duct.  A small vessel was seen anterior to the cystic duct and this was clipped two proximally and one distally and noted to be an anomalous arterial branch.  This was transected with Endoshears scissor and visualized the pulsatile branch with two clips securely in place.  Next, the cystic duct was carefully dissected with Maryland dissectors and was visualized clearly both anterior and posteriorly.  Endoclips were placed two proximally and one distally and then the cystic duct was transected with Endoshears scissor.,Once the clips were noted to be in place, utilizing electrocautery another Dorsey dissector was used to carefully dissect the gallbladder off the liver bed wall.  The gallbladder was removed and the bleeding from the gallbladder wall was easily controlled with electrocautery.  The abdomen was then irrigated with copious amounts of normal saline.  The gallbladder was grasped with a gallbladder grasper and removed from the subxiphoid port.  There was noted to be gallstones within the gallbladder.  Once the abdomen was re-insufflated after removing the gallbladder and copious irrigation was performed, all ports were then removed under direct visualization with no evidence of bleeding from the anterior abdominal wall.  Utilizing #0 Vicryl suture, a figure-of-eight was placed to the subxiphoid and infraumbilical fascia and this was approximated without difficulty.  The subxiphoid port was irrigated with copious amounts of normal saline prior to closure of the fascia.  A #4-0 Vicryl suture was used to approximate all incisions.  The incisions were then injected with local injectable 0.25% Marcaine.  All ports were then cleaned dry.  Steri-Strips were placed across and sterile pressure dressings were placed on top of this.  The patient tolerated the entire procedure well.  She was transferred to the Postanesthesia Care Unit in stable condition.  She will be followed closely in the postoperative course in General Medical Floor.","gastroenterology, gallstone, gallbladder, pancreatitis, anterior abdominal wall, video laparoscope, laparoscopic cholecystectomy, omental adhesions, veress needle, cystic duct, injectable, adhesions, cholecystectomy, laparoscopic, abdomen"
 Newly diagnosed cholangiocarcinoma.  The patient is noted to have an increase in her liver function tests on routine blood work.  Ultrasound of the abdomen showed gallbladder sludge and gallbladder findings consistent with adenomyomatosis. , Gastroenterology, Cholangiocarcinoma Consult ,"REASON FOR CONSULTATION:,  Newly diagnosed cholangiocarcinoma.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 77-year-old female who is noted to have an increase in her liver function tests on routine blood work in December 2009.  Ultrasound of the abdomen showed gallbladder sludge and gallbladder findings consistent with adenomyomatosis.  Common bile duct was noted to be 10 mm in size on that ultrasound.  She then underwent a CT scan of the abdomen in July 2010, which showed intrahepatic ductal dilatation with the common bile duct size being 12.7 mm.  She then underwent an MRI MRCP, which was notable for stricture of the distal common bile duct.  She was then referred to gastroenterology and underwent an ERCP.  On August 24, 2010, she underwent the endoscopic retrograde cholangiopancreatography.  She was noted to have a stricturing mass of the mid-to-proximal common bile duct consistent with cholangiocarcinoma.  A temporary biliary stent was placed across the biliary stricture.  Blood work was obtained during the hospitalization.  She was also noted to have an elevated CA99.  She comes in to clinic today for initial Medical Oncology consultation.  After she sees me this morning, she has a follow-up consultation with a surgeon.,PAST MEDICAL HISTORY:  ,Significant for hypertension and hyperlipidemia.  In July, she had eye surgery on her left eye for a muscle repair.  Other surgeries include left ankle surgery for a fractured ankle in 2000.,CURRENT MEDICATIONS: , Diovan 80/12.5 mg daily, Lipitor 10 mg daily, Lutein 20 mg daily, folic acid 0.8 mg daily and multivitamin daily.,ALLERGIES:  ,No known drug allergies.,FAMILY HISTORY: , Notable for heart disease.  She had three brothers that died of complications from open heart surgery.  Her parents and brothers all had hypertension.  Her younger brother died at the age of 18 of infection from a butcher's shop.  He was cutting Argentinean beef and contracted an infection and died within 24 hours.  She has one brother that is living who has angina and a sister who is 84 with dementia.  She has two adult sons who are in good health.,SOCIAL HISTORY: , The patient has been married to her second husband for the past ten years.  Her first husband died in 1995.  She does not have a smoking history and does not drink alcohol.,REVIEW OF SYSTEMS:  ,The patient reports a change in her bowels ever since she had the stent placed.  She has noted some weight loss, but she notes that that is due to not eating very well.  She has had some mild fatigue, but prior to her diagnosis she had absolutely no symptoms.  As mentioned above, she was noted to have abnormal alkaline phosphatase and total bilirubin, AST and ALT, which prompted the followup.  She has had some difficulty with her vision that has improved with her recent surgical procedure.  She denies any fevers, chills, night sweats.  She has had loose stools.  The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:", 
 Open cholecystectomy (attempted laparoscopic cholecystectomy)., Gastroenterology, Cholecystectomy - Open ,"PREOPERATIVE DIAGNOSIS (ES):,1. Cholelithiasis.,2. Cholecystitis.,POSTOPERATIVE DIAGNOSIS (ES):,1. Acute perforated gangrenous cholecystitis.,2. Cholelithiasis.,PROCEDURE:,1. Attempted laparoscopic cholecystectomy.,2. Open cholecystectomy.,ANESTHESIA:, General endotracheal anesthesia.,COUNTS:, Correct.,COMPLICATIONS:, None apparent.,ESTIMATED BLOOD LOSS:, 275 mL.,SPECIMENS:,1. Gallbladder.,2. Lymph node.,DRAINS:, One 19-French round Blake.,DESCRIPTION OF THE OPERATION:, After consent was obtained and the patient was properly identified, the patient was transported to the operating room and after induction of general endotracheal anesthesia, the patient was prepped and draped in a normal sterile fashion.,After infiltration with local, a vertical incision was made at the umbilicus and utilizing graspers, the underlying fascia was incised and was divided sharply. Dissecting further, the peritoneal cavity was entered. Once this done, a Hasson trocar was secured with #1 Vicryl and the abdomen was insufflated without difficulty. A camera was placed into the abdomen and there was noted to be omentum overlying the subhepatic space. A second trocar was placed in the standard fashion in the subxiphoid area; this was a 10/12 mm non-bladed trocar. Once this was done, a grasper was used to try and mobilize the omentum and a second grasper was added in the right costal margin; this was a 5-mm port placed, it was non-bladed and placed in the usual fashion under direct visualization without difficulty. A grasper was used to mobilize free the omentum which was acutely friable and after a significant time-consuming effort was made to mobilize the omentum, it was clear that the gallbladder was well incorporated by the omentum and it would be unsafe to proceed with a laparoscopy procedure and then the procedure was converted to open.,The trocars were removed and a right subcostal incision was made incorporating the 10/12 subxiphoid port. The subcutaneous space was divided with electrocautery, as well as the muscles and fascia. The Bookwalter retraction system was then set up and retractors were placed to provide exposure to the right subhepatic space. Then utilizing a right-angle and electrocautery, the omentum was freed from the gallbladder. An ensuing retrograde cholecystectomy was performed, in which, electrocautery and blunt dissection were used to mobilize the gallbladder from the gallbladder fossa; this was done down to the infundibulum. After meticulous dissection, the cystic artery was identified and it was ligated between 3-0 silks. Several other small ties were placed on smaller bleeding vessels and the cystic duct was identified, was skeletonized, and a 3-0 stick tie was placed on the proximal portion of it. After it was divided, the gallbladder was freed from the field.,Once this was done, the liver bed was inspected for hemostasis and this was achieved with electrocautery. Copious irrigation was also used. A 19-French Blake drain was placed in Morrison's pouch lateral to the gallbladder fossa and was secured in place with 2-0 nylon; this was a 19-French round Blake. Once this was done, the umbilical port was closed with #1 Vicryl in an interrupted fashion and then the wound was closed in two layers with #1 Vicryl in an interrupted fashion. The skin was closed with and absorbable stitch.,The patient was then awakened from anesthesia, extubated, and transported to the recovery room in stable condition.","gastroenterology, cholelithiasis, cholecystitis, gangrenous, cholecystectomy, laparoscopic, gallbladder, blake, omentum, hasson, electrocautery, gallbladder fossa, endotracheal, subhepatic, french, "
" Blood in toilet.  Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed.", Gastroenterology, Blood In Toilet ,"CHIEF COMPLAINT:  ,Blood in toilet.,HISTORY: , Ms. ABC is a 77-year-old female who is brought down by way of ambulance from XYZ Nursing Home after nursing staff had noted there to be blood in the toilet after she had been sitting on the toilet.  They did not note any urine or stool in the toilet and the patient had no acute complaints.  The patient is unfortunately a poor historian in that she has dementia and does not recall any of the events.  The patient herself has absolutely no complaints, such as abdominal pain or back pain, urinary and GI complaints.  There is no other history provided by the nursing staff from XYZ.  There apparently were no clots noted within there.  She does not have a history of being on anticoagulants.,PAST MEDICAL HISTORY: , Actually quite limited, includes that of dementia, asthma, anemia which is chronic, hypothyroidism, schizophrenia, positive PPD in the past.,PAST SURGICAL HISTORY:  ,Unknown.,SOCIAL HISTORY: , No tobacco or alcohol.,MEDICATIONS: , Listed in the medical records.,ALLERGIES:,  No known drug allergies.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Stable.,GENERAL:  This is a well-nourished, well-developed female who is alert, oriented in all spheres, pleasant, cooperative, resting comfortably, appearing otherwise healthy and well in no acute distress.,HEENT:  Visually normal.  Pupils are reactive.  TMs, canals, nasal mucosa, and oropharynx are intact.,NECK:  No lymphadenopathy or JVD.,HEART:  Regular rate and rhythm.  S1, S2.  No murmurs, gallops, or rubs.,LUNGS:  Clear to auscultation.  No wheeze, rales, or rhonchi.,ABDOMEN:  Benign, flat, soft, nontender, and nondistended.  Bowel sounds active.  No organomegaly or mass noted.,GU/RECTAL:  External rectum was normal.  No obvious blood internally.  There is no stool noted within the vault.  There is no gross amount of blood noted within the vault.  Guaiac was done and was trace positive.  Visual examination anteriorly during the rectal examination noted no blood within the vaginal region.,EXTREMITIES:  No significant abnormalities.,WORKUP: , CT abdomen and pelvis was negative.  CBC was entirely within normal limits without any signs of anemia with an H and H of 14 and 42%.  CMP also within normal limits.  PTT, PT, and INR were normal.  Attempts at getting the patient to give A urine were unsuccessful and the patient was very noncompliant, would not allow us to do any kind of Foley catheterization.,ER COURSE:,  Uneventful.  I have discussed the patient in full with Dr. X who agrees that she does not require any further workup or evaluation as an inpatient.  We have decided to send the patient back to XYZ with observation by the staff there.  She will have a CBC done daily for the next 3 days with results to Dr. X.  They are to call him if there is any recurrences of blood or worsening of symptoms and they are to do a urinalysis at XYZ for blood.,ASSESSMENT: , Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed.",
 Modified Barium swallow study evaluation to objectively evaluate swallowing function and safety.  The patient complained of globus sensation high in her throat particularly with solid foods and with pills.  She denied history of coughing and chocking with meals. , Gastroenterology, Barium Swallow Study Evaluation ,"HISTORY: , The patient is a 71-year-old female, who was referred for an outpatient modified barium swallow study to objectively evaluate her swallowing function and safety.  The patient complained of globus sensation high in her throat particularly with solid foods and with pills.  She denied history of coughing and chocking with meals.  The patient's complete medical history is unknown to me at this time.  The patient was cooperative and compliant throughout this evaluation.,STUDY:,  Modified barium swallow study was performed in the Radiology Suite in cooperation with Dr. X. The patient was seated upright at a 90-degree angle in a video imaging chair.  To evaluate her swallowing function and safety, she was administered graduated amounts of food and liquid mixed with barium in the form of thin liquids (teaspoon x3. cup sip x4); thickened liquid (cup sip x3); puree consistency (teaspoon x3); and solid consistency (1/4 cracker x1).  The patient was given 2 additional cup sips of thin liquid following the puree and solid food presentation.,ORAL STAGE:  ,The patient had no difficulty with bolus control and transport.  No spillage out lips.  The patient appears to have pocketing __________ particularly with puree and solid food between her right faucial pillars.  The patient did state that she had her tonsil taken out as a child and appears to be a diverticulum located in this state.  Further evaluation by an ENT is highly recommended based on the residual and pooling that occurred during this evaluation.  We were not able to clear out the residual with alternating cup sips and thin liquid.,PHARYNGEAL STAGE:  ,No aspiration or penetration occurred during this evaluation.  The patient's hyolaryngeal elevation and anterior movements are within the functional limits.  Epiglottic inversion is within functional limits.  She had no residual or pooling in the pharynx after the swallow.,CERVICAL ESOPHAGEAL STAGE:  ,The patient's upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus.,DIAGNOSTIC IMPRESSION:  ,The patient had no aspiration or penetration occurred during this evaluation.  She does appear to have a diverticulum in the area between her right faucial pillars.  Additional evaluation is needed by an ENT physician.,PLAN:  ,Based on this evaluation, the following is recommended:,1.  The patient's diet should consist regular consistency food with thin liquids.  She needs to take small bites and small sips to help decrease her risk of aspiration and penetration as well as reflux.,2.  The patient should be referred to an otolaryngologist for further evaluation of her oral cavity particularly the area between her faucial pillars.,The above recommendations and results of the evaluation were discussed with the patient as well as her daughter and both responded appropriately.,Thank you for the opportunity to be required the patient's medical care.  She is not in need of skilled speech therapy and is discharged from my services.","gastroenterology, globus sensation, oral stage, pharyngeal stage, cervical esophageal stage, consistency, otolaryngologist, barium swallow study evaluation, faucial pillars, swallow study, solid foods, evaluation, liquid, barium, oral, swallow, foods,"
" The patient is a 76-year-old male, with previous history of dysphagia, status post stroke.  A modified barium swallow study was ordered to objectively evaluate the patient's swallowing function and safety and to rule out aspiration.", Gastroenterology, Barium Swallow Study Evaluation - 1 ,"HISTORY:  ,The patient is a 76-year-old male, with previous history of dysphagia, status post stroke.  The patient stated that he was at Hospital, secondary to his stroke, where he had his initial modified barium swallow study.  The patient stated that the results of that modified revealed aspiration with thin liquids only.  He is currently eating and drinking without difficulty and he feels that he can return to a regular diet with thin liquids.  A modified barium swallow study was ordered to objectively evaluate the patient's swallowing function and safety and to rule out aspiration.,STUDY: , Modified barium swallow study was performed in the radiology suite in cooperation with Dr. X. The patient was seated upright and in a video-imaging chair throughout this assessment.,To evaluate the patient's swallowing function and safety, he was administered graduated amounts of liquid and food mixed with barium in the form of thin liquids (teaspoon x3, cup sip x3); nectar-thick liquid (teaspoon x2, cup sip x3); pureed consistency (teaspoon x3); solid consistency (1/4 cracker x1).,FINDINGS,ORAL STAGE: , The patient had no spillage out lips.  Oral residual after swallow with increased viscosity requiring multiple swallows to clear oral cavity.,The patient has reduced lingual retraction contributing to vallecula pooling after the swallow.  Trace premature spillage was noted with thin liquids during this assessment.,PHARYNGEAL STAGE: , Aspiration noted on cup sips of thin liquid.  Trace-to-mild penetration with teaspoon amounts of thin liquid during and after the swallow.  The penetration after the swallow occurred secondary to spillage on the piriform sinuses into the laryngeal vestibule.  The patient has incomplete laryngeal closure, which allowed the aspiration and penetration with thin liquids.  The patient had no aspiration or penetration occur with nectar-thick liquid, puree, and solid food.  The patient has a mildly reduced hyolaryngeal elevation and anterior movement that leads to incomplete epiglottic inversion that contributes to vallecula pooling.  Mild-to-moderate pooling in the vallecula after the swallow with liquids and puree, this residual did decrease with the solid feed presentation.  The patient has mild residual of pooling in the piriform sinuses after a swallow that did clear with sequential swallows.,CERVICAL ESOPHAGEAL STAGE: , The patient's upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus.,DIAGNOSTIC IMPRESSION: , Mild aspiration with cup sips of thin liquid, penetration during and after the swallow with teaspoon amounts of thin liquid.  No aspiration or penetration occurred with thick liquid, pureed, or solid food during this assessment.,PROGNOSTIC IMPRESSION: , With a modified diet, the patient's potential for swallowing safety is good.,PLAN:,Based on this evaluation, the following is recommended:,1.  The patient should be on a regular diet with nectar-thick liquids to help prevent aspiration and penetration.,2.  The patient should have unthickened water in between meals to help decrease his risk of dehydration.,3.  The patient should complete good oral care two times a day to decrease bacterial growth in mouth.,4.  The patient should be seated at a 90-degree angle when eating and drinking, as well as take small bites and small sips to help decrease risk of aspiration and penetration and reflux.,Thank you for the opportunity to evaluate the patient.  I look forward to working with him in the outpatient setting to improve his swallowing function and safety.  Outpatient skilled speech therapy is recommended for a trial of neuromuscular electrical stimulation therapy for muscle re-education, as well as to train patient to use swallowing techniques and maneuvers that should improve his swallowing function and safety.","gastroenterology, oral stage, pharyngeal stage, cervical esophageal stage, nectar-thick liquids, aspiration, modified barium swallow, barium swallow study, dysphagia status, cup sips, barium swallow, swallow, teaspoon, barium, swallowing, "
 Barium enema - history of encopresis and constipation., Gastroenterology, Barium Enema ,"EXAM: , Barium enema.,CLINICAL HISTORY: , A 4-year-old male with a history of encopresis and constipation.,TECHNIQUE:  ,A single frontal scout radiograph of the abdomen was performed.  A rectal tube was inserted in usual sterile fashion, and retrograde instillation of barium contrast was followed via spot fluoroscopic images.  A post-evacuation overhead radiograph of the abdomen was performed.,FINDINGS:,  The scout radiograph demonstrates a nonobstructive gastrointestinal pattern.  There are no suspicious calcifications seen or evidence of gross free intraperitoneal air.  The visualized lung bases and osseous structures are within normal limits.,The rectum and colon is of normal caliber throughout its course.  There is no evidence of obstruction, as contrast is seen to flow without difficulty into the right colon and cecum.  A small amount of contrast is seen to opacify small bowel loops on the post-evacuation image.  There is also opacification of a normal-appearing appendix documented.,IMPRESSION: , Normal barium enema.","gastroenterology, encopresis and constipation, scout radiograph, post evacuation, barium enema, encopresis, constipation, evacuation, colon, radiograph, contrast, enema, barium, "
 Laparoscopic appendectomy and peritoneal toilet and photos.  Pelvic inflammatory disease and periappendicitis., Gastroenterology, Appendectomy - Laparoscopic  ,"PREOPERATIVE DIAGNOSIS:,  Acute appendicitis.,POSTOPERATIVE DIAGNOSES:,1.  Pelvic inflammatory disease.,2.  Periappendicitis.,PROCEDURE PERFORMED:,1.  Laparoscopic appendectomy.,2.  Peritoneal toilet and photos.,ANESTHESIA:  ,General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  Less than 10 cc.,INDICATIONS FOR PROCEDURE: , The patient is a 31-year-old African-American female who presented with right lower quadrant abdominal pain presented with acute appendicitis.  She also had mild leukocytosis with bright blood cell count of 12,000.  The necessity for diagnostic laparoscopy was explained and possible appendectomy.  The patient is agreeable to proceed and signed preoperatively informed consent.,PROCEDURE: , The patient was taken to the operative suite and placed in the supine position under general anesthesia by Anesthesia Department.,The preoperative Foley, antibiotics, and NG tube are placed for decompression and the anterior abdominal wall was prepped and draped in the usual sterile fashion and infraumbilical incision is performed with a #10 blade scalpel with anterior and superior traction on the abdominal wall.  A Veress needle was introduced and 15 mm pneumoperitoneum is created with CO2 insufflation.  At this point, the Veress needle was removed and a 10 mm trocar is introduced intraperitoneally.  A second 5 mm port was introduced in the right upper quadrant under direct visualization and blunted graspers were introduced to bring the appendix into view.  With the aid of a laparoscope, the pelvis was visualized.  The ovaries are brought in views and photos are taken.  There is evidence of a purulence in the cul-de-sac and ________ with a right ovarian hemorrhagic cyst.  Attention was then turned on the right lower quadrant.  The retrocecal appendix is freed with peritoneal adhesions removed with Endoshears.  Attention was turned to the suprapubic area.  The 12 mm port was introduced under direct visualization and the mesoappendix was identified.  A 45 mm endovascular stapling device was fired across the mesoappendix and the base of the appendix sequentially with no evidence of bleeding or leakage from the staple line.  Next, ________ tube was used to obtain Gram stain and cultures of the pelvic fluid and a pelvic toilet was performed with copious irrigation of sterile saline.  Next, attention was turned to the right upper quadrant.  There is evidence of adhesions from the liver surface to the anterior abdominal wall consistent with Fitz-Hugh-Curtis syndrome also a prior pelvic inflammatory disease.  All free fluid is aspirated and patient's all port sites are removed under direct visualization and the appendix is submitted to pathology for final pathology.  Once the ports are removed the pneumoperitoneum is allowed to escape for patient's postoperative comfort and two larger port sites at the suprapubic and infraumbilical sites are closed with #0 Vicryl suture on a UR-6 needle.  Local anesthetic is infiltrated at L3 port sites for postoperative analgesia and #4-0 Vicryl subcuticular closure is performed with undyed Vicryl.  Steri-Strips are applied along with sterile dressings.  The patient was awakened from anesthesia without difficulty and transferred to recovery room with postoperative broad-spectrum IV antibiotics in the General Medical Floor.  Routine postoperative care will be continued on this patient.","gastroenterology, acute appendicitis, periappendicitis, peritoneal toilet, pelvic inflammatory disease, abdominal wall, direct visualization, toilet, appendectomy, mesoappendix, laparoscopic, port, inflammatory"
" Hematemesis in a patient with longstanding diabetes.   Submucosal hemorrhage consistent with trauma from vomiting and grade 2 esophagitis.  Mallory-Weiss tear, successful BICAP cautery. ", Gastroenterology, BICAP Cautery ,"PREOPERATIVE DIAGNOSIS: ,  Hematemesis in a patient with longstanding diabetes. ,POSTOPERATIVE DIAGNOSIS:  ,Mallory-Weiss tear, submucosal hemorrhage consistent with trauma from vomiting and grade 2 esophagitis.,PROCEDURE:  , The procedure, indications explained and he understood and agreed.  He was sedated with Versed 3, Demerol 25 and topical Hurricane spray to the oropharynx.  A bite block was placed.  The Pentax video gastroscope was advanced through the oropharynx into the esophagus under direct vision.  Esophagus revealed distal ulcerations.  Additionally, the patient had a Mallory-Weiss tear.  This was subjected to bicap cautery with good ablation.  The stomach was entered, which revealed areas of submucosal hemorrhage consistent with trauma from vomiting.  There were no ulcerations or erosions in the stomach.  The duodenum was entered, which was unremarkable.  The instrument was then removed.  The patient tolerated the procedure well with no complications.,IMPRESSION: , Mallory-Weiss tear, successful BICAP cautery. ,We will keep the patient on proton pump inhibitors.  The patient will remain on antiemetics and be started on a clear liquid diet.","gastroenterology, mallory-weiss tear, submucosal hemorrhage, esophagitis, vomiting, bicap cautery, mallory weiss, diabetes, esophagus, submucosal, hemorrhage, trauma, hematemesis,"
" Appendicitis, nonperforated.  Appendectomy.  A transverse right lower quadrant incision was made directly over the point of maximal tenderness. ", Gastroenterology, Appendectomy ,"PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS:,  Appendicitis, nonperforated.,PROCEDURE PERFORMED:,  Appendectomy.,ANESTHESIA: , General endotracheal.,PROCEDURE: , After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table.  General endotracheal anesthesia was induced without incident.  The patient was prepped and draped in the usual sterile manner.,A transverse right lower quadrant incision was made directly over the point of maximal tenderness.  Sharp dissection utilizing Bovie electrocautery was used to expose the external oblique fascia.  The fascia of the external oblique was incised in the direction of the fibers, and the muscle was spread with a clamp.  The internal oblique fascia was similarly incised and its muscular fibers were similarly spread.  The transversus abdominis muscle, transversalis fascia and peritoneum were incised sharply gaining entrance into the abdominal cavity without incident.  Upon entering the peritoneal cavity, the peritoneal fluid was noted to be clean.,The cecum was then grasped along the taenia with a moist gauze sponge and was gently mobilized into the wound.  After the appendix was fully visualized, the mesentery was divided between Kelly clamps and ligated with 2-0 Vicryl ties.  The base of the appendix was crushed with a clamp and then the clamp was reapplied proximally on the appendix.  The base was ligated with 2-0 Vicryl tie over the crushed area, and the appendix amputated along the clamp.  The stump of the appendix was cauterized and the cecum was returned to the abdomen.,The peritoneum was irrigated with warm sterile saline.  The mesoappendix and cecum were examined for hemostasis which was present.  The wound was closed in layers using 2-0 Vicryl for the peritoneum and 0 Vicryl for the internal oblique and external oblique layers.  The skin incision was approximated with 4-0 Monocryl in a subcuticular fashion.  The skin was prepped with benzoin, and Steri-Strips were applied.  A dressing was placed on the wound.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition.","gastroenterology, peritoneal cavity, peritoneal fluid, abdominal cavity, abdominis muscle, transversalis fascia, peritoneum, internal oblique fascia, vicryl ties, appendectomy, appendicitis, appendix,"
" Acute appendicitis, gangrenous.  Appendectomy.", Gastroenterology, Appendectomy - 1 ,"PREOPERATIVE DIAGNOSIS:,  Acute appendicitis.,POSTOPERATIVE DIAGNOSIS: , Acute appendicitis, gangrenous.,PROCEDURE: , Appendectomy.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room under urgent conditions.  After having obtained an informed consent, he was placed in the operating room and under anesthesia.  Followed by a time-out process, his abdominal wall was prepped and draped in the usual fashion.  Antibiotics had been given prior to incision.  A McBurney incision was performed and it carried out through the peritoneal cavity.  Immediately there was  purulent material seen in the area.  Samples were taken for culture and sensitivity of aerobic and anaerobic sets.  The appendix was markedly swollen particularly in its distal three-fourth, where the distal appendix showed an abscess formation and devitalization of the wall.  There was quite a bit of local peritonitis.  The mesoappendix was clamped, divided and ligated, and then the appendix was ligated and divided, and the stump buried with a pursestring suture of Vicryl and then a Z stitch.  The area was abundantly irrigated with normal saline and also the pelvis.  The distal foot of small bowel had been explored and because it delivered itself __________ the incision and showed no pathology.,Then the peritoneal and internal fascia were approximated with a suture of 0 Vicryl and then the incision was closed in layers and after each layer the wound was irrigated with normal saline.  The skin was closed with a combination of a subcuticular suture of fine Monocryl followed by the application of Dermabond.  The patient tolerated the procedure well.  Estimated blood loss was minimal, and the patient was sent to the recovery room for recovery in satisfactory condition.,","gastroenterology, mcburney incision, abdominal, small bowel, acute appendicitis, appendectomy, gangrenous, appendix, "
 The patient was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities.  The patient is currently NPO with G-tube to meet all of his hydration and nutritional needs.  A trial of Passy-Muir valve was completed to allow the patient to achieve hands-free voicing., Gastroenterology, Barium Swallow Study & Speech Evaluation ,"CURRENT MEDICATIONS:,  Lortab.,PREVIOUS MEDICAL HISTORY: , Cardiac stent in 2000.,PATIENT'S GOAL: , To eat again by mouth.,STUDY:  ,A trial of Passy-Muir valve was completed to allow the patient to achieve hands-free voicing and also to improve his secretion management.  A clinical swallow evaluation was not completed due to the severity of the patient's mucus and lack of saliva control.,The patient's laryngeal area was palpated during a dry swallow and he does have significantly reduced laryngeal elevation and radiation fibrosis.  The further evaluate of his swallowing function is safety; a modified barium swallow study needs to be concluded to objectively evaluate his swallow safety, and to rule out aspiration.  A trial of neuromuscular electrical stimulation therapy was completed to determine if this therapy protocol will be beneficial and improving the patient's swallowing function and safety.,For his neuromuscular electrical stimulation therapy, the type was BMR with a single mode cycle time is 4 seconds and 12 seconds off with frequency was 60 __________ with a ramp of 2 seconds, phase duration was 220 with an output of 99 milliamps.  Electrodes were placed on the suprahyoid/submandibular triangle with an upright body position, trial length was 10 minutes.  On a pain scale, the patient reported no pain with the electrical stimulation therapy.,FINDINGS:  ,The patient was able to tolerate a 5-minute placement of the Passy-Muir valve.  He reported no discomfort on the inhalation; however, he felt some resistance on exhalation.  Instructions were given on care placement and cleaning of the Passy-Muir valve.  The patient was instructed to buildup tolerance over the next several days of his Passy-Muir valve and to remove the valve at anytime or he is going to be sleeping or napping throughout the day.  The patient's voicing did improve with the Passy-Muir valve due to decreased leakage from his trach secondary to finger occlusion.  Mucus production also seemed to decrease when the Passy-Muir was placed.,On the dry swallow during this evaluation, the patient's laryngeal area is reduced and tissues around his larynx and showed radiation fibrosis.  The patient's neck range of motion appears to be adequate and within normal limits.,A trial of neuromuscular electrical stimulation therapy:,The patient tolerating the neuromuscular electrical stimulation, we did achieve poor passive response, but these muscles were contracting and the larynx was moving upon stimulation.  The patient was able to actively swallow with stimulation approximately 30% of presentation.,DIAGNOSTIC IMPRESSION: , The patient with a history of head and neck cancer status post radiation and chemotherapy with radiation fibrosis, which is impeding his swallowing abilities.  The patient would benefit from outpatient skilled speech therapy for neuromuscular electrical stimulation for muscle reeducation to improve his swallowing function and safety and he would benefit from a placement of a Passy-Muir valve to have hands-free communication.,PLAN OF CARE: , Outpatient skilled speech therapy two times a week to include neuromuscular electrical stimulation therapy, Passy-Muir placement and a completion of the modified barium swallow study.,SHORT-TERM GOALS (6 WEEKS):,1.  Completion of modified barium swallow study.,2.  The patient will coordinate volitional swallow with greater than 75% of the neuromuscular electrical stimulations.,3.  The patient will increase laryngeal elevation by 50% for airway protection.,4.  The patient will tolerate placement of Passy-Muir valve for greater than 2 hours during awaking hours.,5.  The patient will tolerate therapeutic feedings with the speech and language pathologist without signs and symptoms of aspiration.,6.  The patient will decrease mild facial restrictions to the anterior neck by 50% to increase laryngeal movement.,LONG-TERM GOALS (8 WEEKS):,1.  The patient will improve secretion management to tolerable levels.,2.  The patient will increase amount and oral consistency of p.o. intake tolerated without signs and symptoms of aspirations.,3.  The patient will be able to communicate without using finger occlusion with the assistance of a Passy-Muir valve.",
 , Gastroenterology, Barium Swallow Study & Speech Evaluation - 1 ,"SUBJECTIVE: , The patient is a 60-year-old female, who complained of coughing during meals.  Her outpatient evaluation revealed a mild-to-moderate cognitive linguistic deficit, which was completed approximately 2 months ago.  The patient had a history of hypertension and TIA/stroke.  The patient denied history of heartburn and/or gastroesophageal reflux disorder.  A modified barium swallow study was ordered to objectively evaluate the patient's swallowing function and safety and to rule out aspiration.,OBJECTIVE: , Modified barium swallow study was performed in the Radiology Suite in cooperation with Dr. ABC.  The patient was seated upright in a video imaging chair throughout this assessment.  To evaluate the patient's swallowing function and safety, she was administered graduated amounts of liquid and food mixed with barium in the form of thin liquid (teaspoon x2, cup sip x2); nectar-thick liquid (teaspoon x2, cup sip x2); puree consistency (teaspoon x2); and solid food consistency (1/4 cracker x1).,ASSESSMENT,ORAL STAGE:,  Premature spillage to the level of the valleculae and pyriform sinuses with thin liquid.  Decreased tongue base retraction, which contributed to vallecular pooling after the swallow.,PHARYNGEAL STAGE: , No aspiration was observed during this evaluation.  Penetration was noted with cup sips of thin liquid only.  Trace residual on the valleculae and on tongue base with nectar-thick puree and solid consistencies.  The patient's hyolaryngeal elevation and anterior movement are within functional limits.  Epiglottic inversion is within functional limits.,CERVICAL ESOPHAGEAL STAGE:  ,The patient's upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus.  Radiologist noted reduced peristaltic action of the constricted muscles in the esophagus, which may be contributing to the patient's complaint of globus sensation.,DIAGNOSTIC IMPRESSION:,  No aspiration was noted during this evaluation.  Penetration with cup sips of thin liquid.  The patient did cough during this evaluation, but that was noted related to aspiration or penetration.,PROGNOSTIC IMPRESSION: ,Based on this evaluation, the prognosis for swallowing and safety is good.,PLAN: , Based on this evaluation and following recommendations are being made:,1.  The patient to take small bite and small sips to help decrease the risk of aspiration and penetration.,2.  The patient should remain upright at a 90-degree angle for at least 45 minutes after meals to decrease the risk of aspiration and penetration as well as to reduce her globus sensation.,3.  The patient should be referred to a gastroenterologist for further evaluation of her esophageal function.,The patient does not need any skilled speech therapy for her swallowing abilities at this time, and she is discharged from my services.","gastroenterology, gastroesophageal reflux disorder, cognitive linguistic deficit, tia, stroke, swallowing function, swallow study, barium swallow study, globus sensation, esophageal, penetration"
 Laparoscopic appendectomy.  Acute suppurative appendicitis.  A CAT scan of the abdomen and pelvis was obtained revealing findings consistent with acute appendicitis.  There was no evidence of colitis on the CAT scan. , Gastroenterology, Appendectomy Laparoscopic - 1 ,"PREOPERATIVE DIAGNOSIS: , Acute appendicitis.,POSTOPERATIVE DIAGNOSIS:,  Acute suppurative appendicitis.,PROCEDURE PERFORMED: , Laparoscopic appendectomy.,ANESTHESIA: , General endotracheal and Marcaine 0.25% local.,INDICATIONS:,  This 29-year-old female presents to ABCD General Hospital Emergency Department on 08/30/2003 with history of acute abdominal pain.  On evaluation, it was noted that the patient has clinical findings consistent with acute appendicitis.  However, the patient with additional history of loose stools for several days prior to event.  Therefore, a CAT scan of the abdomen and pelvis was obtained revealing findings consistent with acute appendicitis.  There was no evidence of colitis on the CAT scan.  With this in mind and the patient's continued pain at present, the patient was explained the risks and benefits of appendectomy.  She agreed to procedure and informed consent was obtained.,GROSS FINDINGS: , The appendix was removed without difficulty with laparoscopic approach.  The appendix itself noted to have a significant inflammation about it.  There was no evidence of perforation of the appendix.,PROCEDURE DETAILS:,  The patient was placed in supine position.  After appropriate anesthesia was obtained and sterile prep and drape completed, a #10 blade scalpel was used to make a curvilinear infraumbilical incision.  Through this incision, a Veress needle was utilized to create a CO2 pneumoperitoneum of 15 mmHg.  The Veress needle was then removed.  A 10 mm trocar was then introduced through this incision into the abdomen.  A video laparoscope was then inserted and the above noted gross findings were appreciated upon evaluation.  Initially, bilateral ovarian cysts were appreciated, however, there was no evidence of acute disease on evaluation.  Photodocumentation was obtained.,A 5 mm port was then placed in the right upper quadrant.  This was done under direct visualization and a blunt grasper was utilized to mobilize the appendix.  Next, a 12 mm port was placed in the left lower quadrant lateral to the rectus musculature under direct visualization.  Through this port, the dissector was utilized to create a small window in the mesoappendix.  Next, an EndoGIA with GI staples was utilized to fire across the base of the appendix, which was done noting it to be at the base of the appendix.  Next, staples were changed to vascular staples and the mesoappendix was then cut and vessels were then ligated with vascular staples.  Two 6 X-loupe wires with EndoGIA were utilized in this prior portion of the procedure.  Next, an EndoCatch was placed through the 12 mm port and the appendix was placed within it.  The appendix was then removed from the 12 mm port site and taken off the surgical site.  The 12 mm port was then placed back into the abdomen and CO2 pneumoperitoneum was recreated.  The base of the appendix was reevaluated and noted to be hemostatic.  Aspiration of warm saline irrigant then done and noted to be clear.  There was a small adhesion appreciated in the region of the surgical site.  This was taken down with blunt dissection without difficulty.  There was no evidence of other areas of disease.  Upon re-exploration with a video laparoscope in the abdomen and after this noting the appendix base to be hemostatic and intact.  The instruments were removed from the patient and the port sites were then taken off under direct visualization.  The CO2 pneumoperitoneum was released into the air and the fascia was approximated in the 10 mm and 12 mm port sites with #0 Vicryl ligature x2.  Marcaine 0.25% was then utilized in all three incision sites and #4-0 Vicryl suture was used to approximate the skin and all three incision sites.  Steri-Strips and sterile dressings were applied.  The patient tolerated the procedure well and taken to Postoperative Care Unit in stable condition and monitored under General Medical Floor on IV antibiotics, pain medications, and return to diet.","gastroenterology, abdomen, pelvis, laparoscopic appendectomy, suppurative appendicitis, veress needle, acute appendicitis, appendix, appendectomy, pneumoperitoneum, laparoscopic, appendicitis"
 Possible free air under the diaphragm.  On a chest x-ray for what appeared to be shortness of breath she was found to have what was thought to be free air under the right diaphragm.  No intra-abdominal pathology., Gastroenterology, Air Under Diaphragm - Consult ,"REASON FOR CONSULTATION: , Possible free air under the diaphragm.,HISTORY OF PRESENT ILLNESS: , The patient is a 77-year-old female who is unable to give any information.  She has been sedated with Ativan and came into the emergency room obtunded and unable to give any history.  On a chest x-ray for what appeared to be shortness of breath she was found to have what was thought to be free air under the right diaphragm.,PAST MEDICAL HISTORY: , Significant for alcohol abuse.  Unable to really gather any other information because she is so obtunded.,PAST SURGICAL HISTORY:  ,Looking at the medical chart, she had an appendectomy, right hip fracture from a fall in 2005, and TAH/BSO.,MEDICATIONS:,  Unable to evaluate.,ALLERGIES: , UNABLE TO EVALUATE.,SOCIAL HISTORY:  ,Significant history of alcohol abuse, according to the emergency room physician, who sees her on a regular basis.,REVIEW OF SYSTEMS: , Unable to obtain.,PHYSICAL EXAM,VITAL SIGNS:  Temp 98.3, heart rate 82, respiratory rate 24, and blood pressure 141/70.,GENERAL:  She is a very obtunded female who upon arousal is not able to provide any information of any use.,HEENT:  Atraumatic.,NECK:  Soft and supple.,LUNGS:  Bilaterally diminished.,HEART:  Regular.,ABDOMEN:  Soft, and with deep palpation I am unable to arouse the patient, unable to elicit any tenderness.,LABORATORY STUDIES: , Show a normal white blood cell count with no shift.  Elevated AST at 138, with a normal ALT at 38.  Alkaline phosphatase of 96, bilirubin 0.8.  Sodium is 107, with 68 chloride and potassium of 2.8.,X-ray of the chest shows the possibility of free air; therefore, a CT scan was obtained because of the patient's physical examination, which shows no evidence of intra-abdominal pathology.  The etiology of the air under the diaphragm is actually a colonic air that is anterior superior to the dome of the diaphragm, near the dome of the liver.,ASSESSMENT: , No intra-abdominal pathology.,PLAN:,  Have her admitted to the medical service for treatment of her hyponatremia.",
 Laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair.  Patient with a 5.5-cm diameter nonfunctioning mass in his right adrenal., Gastroenterology, Adrenalectomy & Umbilical Hernia Repair ,"PREOPERATIVE DIAGNOSES,1.  Adrenal mass, right sided.,2.  Umbilical hernia.,POSTOPERATIVE DIAGNOSES,1.  Adrenal mass, right sided.,2.  Umbilical hernia.,OPERATION PERFORMED: , Laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair.,ANESTHESIA:  ,General.,CLINICAL NOTE: , This is a 52-year-old inmate with a 5.5 cm diameter nonfunctioning mass in his right adrenal.  Procedure was explained including risks of infection, bleeding, possibility of transfusion, possibility of further treatments being required.  Alternative of fully laparoscopic are open surgery or watching the lesion.,DESCRIPTION OF OPERATION:  ,In the right flank-up position, table was flexed.  He had a Foley catheter in place.  Incision was made from just above the umbilicus, about 5.5 cm in diameter.  The umbilical hernia was taken down.  An 11 mm trocar was placed in the midline, superior to the GelPort and a 5 mm trocar placed in the midaxillary line below the costal margin.  A liver retractor was placed to this.,The colon was reflected medially by incising the white line of Toldt.  The liver attachments to the adrenal kidney were divided and the liver was reflected superiorly.  The vena cava was identified.  The main renal vein was identified.  Coming superior to the main renal vein, staying right on the vena cava, all small vessels were clipped and then divided.  Coming along the superior pole of the kidney, the tumor was dissected free from top of the kidney with clips and Bovie.  The harmonic scalpel was utilized superiorly and laterally.  Posterior attachments were divided between clips and once the whole adrenal was mobilized, the adrenal vein and one large adrenal artery were noted, doubly clipped, and divided.  Specimen was placed in a collection bag, removed intact.,Hemostasis was excellent.,The umbilical hernia had been completely taken down.  The edges were freshened up.  Vicryl #1 was utilized to close the incision and 2-0 Vicryl was used to close the fascia of the trocar.,Skin closed with clips.,He tolerated the procedure well.  All sponge and instrument counts were correct.  Estimated blood loss less than 100 mL.,The patient was awakened, extubated, and returned to recovery room in satisfactory condition.","gastroenterology, adrenalectomy, laparoscopic hand-assisted, umbilical hernia repair, vena cava, renal vein, hernia repair, laparoscopic, umbilical, hernia,"
 The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent., Gastroenterology, Abdominal Pain - Consult ,"CHIEF COMPLAINT:,  Abdominal pain.,HISTORY OF PRESENT ILLNESS:,  The patient is a 71-year-old female patient of Dr. X. The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent.  She was seen 3 to 4 days ago at ABC ER and underwent evaluation and discharged and had a CT scan at that time and she was told it was ""normal.""  She was given oral antibiotics of Cipro and Flagyl.  She has had no nausea and vomiting, but has had persistent associated anorexia.  She is passing flatus, but had some obstipation symptoms with the last bowel movement two days ago.  She denies any bright red blood per rectum and no history of recent melena.  Her last colonoscopy was approximately 5 years ago with Dr. Y. She has had no definite fevers or chills and no history of jaundice.  The patient denies any significant recent weight loss.,PAST MEDICAL HISTORY:  ,Significant for history of atrial fibrillation, under good control and now in normal sinus rhythm and on metoprolol and also on Premarin hormone replacement.,PAST SURGICAL HISTORY: , Significant for cholecystectomy, appendectomy, and hysterectomy.  She has a long history of known grade 4 bladder prolapse and she has been seen in the past by Dr. Chip Winkel, I believe that he has not been re-consulted.,ALLERGIES: , SHE IS ALLERGIC OR SENSITIVE TO MACRODANTIN.,SOCIAL HISTORY: , She does not drink or smoke.,REVIEW OF SYSTEMS: , Otherwise negative for any recent febrile illnesses, chest pains or shortness of breath.,PHYSICAL EXAMINATION:,GENERAL:  The patient is an elderly thin white female, very pleasant, in no acute distress.,VITAL SIGNS:  Her temperature is 98.8 and vital signs are all stable, within normal limits.,HEENT:  Head is grossly atraumatic and normocephalic.  Sclerae are anicteric.  The conjunctivae are non-injected.,NECK:  Supple.,CHEST:  Clear.,HEART:  Regular rate and rhythm.,ABDOMEN:  Generally nondistended and soft.  She is focally tender in the left lower quadrant to deep palpation with a palpable fullness or mass and focally tender, but no rebound tenderness.  There is no CVA or flank tenderness, although some very minimal left flank tenderness.,PELVIC:  Currently deferred, but has history of grade 4 urinary bladder prolapse.,EXTREMITIES:  Grossly and neurovascularly intact.,LABORATORY VALUES:  ,White blood cell count is 5.3, hemoglobin 12.8, and platelet count normal.  Alkaline phosphatase elevated at 184.  Liver function tests otherwise normal.  Electrolytes normal.  Glucose 134, BUN 4, and creatinine 0.7.,DIAGNOSTIC STUDIES:,  EKG shows normal sinus rhythm.,IMPRESSION AND PLAN: , A 71-year-old female with greater than one-week history of abdominal pain now more localized to the left lower quadrant.  Currently is a nonacute abdomen.  The working diagnosis would be sigmoid diverticulitis.  She does have a history in the distant past of sigmoid diverticulitis.  I would recommend a repeat stat CT scan of the abdomen and pelvis and keep the patient nothing by mouth.  The patient was seen 5 years ago by Dr. Y in Colorectal Surgery.  We will consult her also for evaluation.  The patient will need repeat colonoscopy in the near future and be kept nothing by mouth now empirically.  The case was discussed with the patient's primary care physician, Dr. X. Again, currently there is no indication for acute surgical intervention on today's date, although the patient will need close observation and further diagnostic workup.",
" Excision of abscess, removal of foreign body.  Repair of incisional hernia.  Recurrent re-infected sebaceous cyst of abdomen.  Abscess secondary to retained foreign body and incisional hernia.", Gastroenterology, Abscess Excision ,"PREOPERATIVE DIAGNOSIS: , Recurrent re-infected sebaceous cyst of abdomen.,POSTOPERATIVE DIAGNOSES:,1.  Abscess secondary to retained foreign body.,2.  Incisional hernia.,PROCEDURES,1.  Excision of abscess, removal of foreign body.,2.  Repair of incisional hernia.,ANESTHESIA: , LMA.,INDICATIONS: , Patient is a pleasant 37-year-old gentleman who has had multiple procedures including a laparotomy related to trauma.  The patient has had a recurrently infected cyst of his mass at the superior aspect of his incision, which he says gets larger and then it drains internally, causing him to be quite ill.  He presented to my office and I recommended that he undergo exploration of this area and removal.  The procedure, purpose, risks, expected benefits, potential complications, and alternative forms of therapy were discussed with him and he was agreeable to surgery.,FINDINGS:,  The patient was found upon excision of the cyst that it contained a large Prolene suture, which is multiply knotted as it always is; beneath this was a very small incisional hernia, the hernia cavity, which contained omentum; the hernia was easily repaired.,DESCRIPTION OF PROCEDURE: , The patient was identified, then taken into the operating room, where after induction of an LMA anesthetic, his abdomen was prepped with Betadine solution and draped in sterile fashion.  The puncta of the wound lesion was infiltrated with methylene blue and peroxide.  The lesion was excised and the existing scar was excised using an ellipse and using a tenotomy scissors, the cyst was excised down to its base.  In doing so, we identified a large Prolene suture within the wound and followed this cyst down to its base at which time we found that it contained omentum and was in fact overlying a small incisional hernia.  The cyst was removed in its entirety, divided from the omentum using a Metzenbaum and tying with 2-0 silk ties.  The hernia repair was undertaken with interrupted 0 Vicryl suture with simple sutures.  The wound was then irrigated and closed with 3-0 Vicryl subcutaneous and 4-0 Vicryl subcuticular and Steri-Strips.  Patient tolerated the procedure well.  Dressings were applied and he was taken to recovery room in stable condition.","gastroenterology, sebaceous cyst, prolene suture, incisional hernia, incisional, abscess, hernia, abdomen, omentum, excision, cyst,"
" Patient status post gastric bypass surgery, developed nausea and right upper quadrant pain.", Gastroenterology, Admission History & Physical - Nausea ,"CHIEF COMPLAINT: , Nausea.,PRESENT ILLNESS: , The patient is a 28-year-old, who is status post gastric bypass surgery nearly one year ago.  He has lost about 200 pounds and was otherwise doing well until yesterday evening around 7:00-8:00 when he developed nausea and right upper quadrant pain, which apparently wrapped around toward his right side and back.  He feels like he was on it but has not done so.  He has overall malaise and a low-grade temperature of 100.3.  He denies any prior similar or lesser symptoms.  His last normal bowel movement was yesterday.  He denies any outright chills or blood per rectum.,PAST MEDICAL HISTORY: , Significant for hypertension and morbid obesity, now resolved.,PAST SURGICAL HISTORY: , Gastric bypass surgery in December 2007.,MEDICATIONS:  ,Multivitamins and calcium.,ALLERGIES: , None known.,FAMILY HISTORY:  ,Positive for diabetes mellitus in his father, who is now deceased.,SOCIAL HISTORY: , He denies tobacco or alcohol.  He has what sounds like a data entry computer job.,REVIEW OF SYSTEMS:  ,Otherwise negative.,PHYSICAL EXAMINATION:,  His temperature is 100.3, blood pressure 129/59, respirations 16, heart rate 84.  He is drowsy, but easily arousable and appropriate with conversation.  He is oriented to person, place, and situation.  He is normocephalic, atraumatic.  His sclerae are anicteric.  His mucous membranes are somewhat tacky.  His neck is supple and symmetric.  His respirations are unlabored and clear.  He has a regular rate and rhythm.  His abdomen is soft.  He has diffuse right upper quadrant tenderness, worse focally, but no rebound or guarding.  He otherwise has no organomegaly, masses, or abdominal hernias evident.  His extremities are symmetrical with no edema.  His posterior tibial pulses are palpable and symmetric.  He is grossly nonfocal neurologically.,STUDIES:,  His white blood cell count is 8.4 with 79 segs.  His hematocrit is 41.  His electrolytes are normal.  His bilirubin is 2.8.  His AST 349, ALT 186, alk-phos 138 and lipase is normal at 239.,ASSESSMENT: , Choledocholithiasis, ? cholecystitis.,PLAN: , He will be admitted and placed on IV antibiotics.  We will get an ultrasound this morning.  He will need his gallbladder out, probably with intraoperative cholangiogram.  Hopefully, the stone will pass this way.  Due to his anatomy, an ERCP would prove quite difficult if not impossible unless laparoscopic assisted.  Dr. X will see him later this morning and discuss the plan further.  The patient understands.","gastroenterology, gastric bypass surgery, nausea, choledocholithiasis, cholecystitis, ercp, gastric bypass, bypass surgery, "
 Laparoscopic appendectomy.  Acute appendicitis., Gastroenterology, Appendectomy Laparoscopic ,"PREOPERATIVE DIAGNOSIS: , Acute appendicitis.,POSTOPERATIVE DIAGNOSIS: , Acute appendicitis.,PROCEDURE: , Laparoscopic appendectomy.,ANESTHESIA: , General endotracheal.,INDICATIONS: , Patient is a pleasant 31-year-old gentleman who presented to the hospital with acute onset of right lower quadrant pain.  History as well as signs and symptoms are consistent with acute appendicitis as was his CAT scan.  I evaluated the patient in the emergency room and recommended that he undergo the above-named procedure.  The procedure, purpose, risks, expected benefits, potential complications, alternative forms of therapy were discussed with him and he was agreeable with surgery.,FINDINGS: , Patient was found to have acute appendicitis with an inflamed appendix, which was edematous, but essentially no suppuration.,TECHNIQUE:  ,The patient was identified and then taken into the operating room, where after induction of general endotracheal anesthesia, the abdomen was prepped with Betadine solution and draped in sterile fashion.  An infraumbilical incision was made and carried down by blunt dissection to the level of the fascia, which was grasped with an Allis clamp and two stay sutures of 2-0 Vicryl were placed on either side of the midline.  The fascia was tented and incised and the peritoneum entered by blunt finger dissection.  A Hasson cannula was placed and a pneumoperitoneum to 15 mmHg pressure was obtained.  Patient was placed in the Trendelenburg position, rotated to his left, whereupon under direct vision, the 12-mm midline as well as 5-mm midclavicular and anterior axillary ports were placed.  The appendix was easily visualized, grasped with a Babcock's.  A window was created in the mesoappendix between the appendix and the cecum and the Endo GIA was introduced and the appendix was amputated from the base of the cecum.  The mesoappendix was divided using the Endo GIA with vascular staples.  The appendix was placed within an Endo bag and delivered from the abdominal cavity.  The intra-abdominal cavity was irrigated.  Hemostasis was assured within the mesentery and at the base of the cecum.  All ports were removed under direct vision and then wounds were irrigated with saline antibiotic solution.  The infraumbilical defect was closed with a figure-of-eight 0 Vicryl suture.  The remaining wounds were irrigated and then everything was closed subcuticular with 4-0 Vicryl suture and Steri-Strips.  Patient tolerated the procedure well, dressings were applied, and he was taken to recovery room in stable condition.","gastroenterology, endo gia, babcock's, laparoscopic appendectomy, direct vision, abdominal cavity, acute appendicitis, appendectomy, hemostasis, laparoscopic, infraumbilical, appendix, appendicitis, endotracheal,"
 The patient is having recurrent attacks of imbalance rather than true vertigo following the history of head trauma and loss of consciousness.  Symptoms are not accompanied by tinnitus or deafness. , ENT - Otolaryngology, Vertigo Consult - 1 ,"Patient had a normal MRI and normal neurological examination on August 24, 2010.,Assessment for peripheral vestibular function follows:,Most clinical tests were completed with difficulty and poor cooperation.,OTOSCOPY:, showed bilateral intact tympanic membranes with central  Weber test and bilateral positive Rinne.,ROMBERG TEST:, maintained postural stability with difficulty.,Frenzel glasses examination: no spontaneous, end gaze nystagmus.,DIX-HALLPIKE:, showed no positional nystagmus excluding benign paroxysmal positional vertigo.,HEAD SHAKING AND VESTIBULOCULAR REFLEX [HALMAGYI TEST]:, were done with difficulty a short corrective saccades may give the possibility if having a decompensated vestibular hypofunction. ,IMPRESSION:, Decompensation vestibular hypofunction documented by further electronystagmography and caloric testing. ,PLAN:,  Booked for electronystagmography and advised to continue with her vestibular rehabilitation exercises, in addition to supportive medical treatment in the form of betahistine 24 mg twice a day.","ent - otolaryngology, tinnitus, deafness, imbalance, nystagmus, hypofunction, electronystagmography, vertigo, vestibular,"
" Incision and drainage (I&D) of abdominal abscess, excisional debridement of nonviable and viable skin, subcutaneous tissue and muscle, then removal of foreign body.", Gastroenterology, Abdominal Abscess I&D ,"PREOPERATIVE DIAGNOSIS: , Abdominal wall abscess.,POSTOPERATIVE DIAGNOSIS: , Abdominal wall abscess.,PROCEDURE: , Incision and drainage (I&D) of abdominal abscess, excisional debridement of nonviable and viable skin, subcutaneous tissue and muscle, then removal of foreign body.,ANESTHESIA: , LMA.,INDICATIONS: , Patient is a pleasant 60-year-old gentleman, who initially had a sigmoid colectomy for diverticular abscess, subsequently had a dehiscence with evisceration.  Came in approximately 36 hours ago with pain across his lower abdomen.  CT scan demonstrated presence of an abscess beneath the incision.  I recommended to the patient he undergo the above-named procedure.  Procedure, purpose, risks, expected benefits, potential complications, alternatives forms of therapy were discussed with him, and he was agreeable to surgery.,FINDINGS:,  The patient was found to have an abscess that went down to the level of the fascia.  The anterior layer of the fascia was fibrinous and some portions necrotic.  This was excisionally debrided using the Bovie cautery, and there were multiple pieces of suture within the wound and these were removed as well.,TECHNIQUE:  ,Patient was identified, then taken into the operating room, where after induction of appropriate anesthesia, his abdomen was prepped with Betadine solution and draped in a sterile fashion.  The wound opening where it was draining was explored using a curette.  The extent of the wound marked with a marking pen and using the Bovie cautery, the abscess was opened and drained.  I then noted that there was a significant amount of undermining.  These margins were marked with a marking pen, excised with Bovie cautery; the curette was used to remove the necrotic fascia.  The wound was irrigated; cultures sent prior to irrigation and after achievement of excellent hemostasis, the wound was packed with antibiotic-soaked gauze.  A dressing was applied.  The finished wound size was 9.0 x 5.3 x 5.2 cm in size.  Patient tolerated the procedure well.  Dressing was applied, and he was taken to recovery room in stable condition.","gastroenterology, excisional debridement, subcutaneous tissue, abdominal wall abscess, foreign body, abdominal abscess, bovie cautery, abdominal, i&d, wound, incision, abscess,"
 Congenital chylous ascites and chylothorax and rule out infradiaphragmatic lymphatic leak.   Diffuse intestinal and mesenteric lymphangiectasia.  , Gastroenterology, Abdominal Exploration ,"PREOPERATIVE DIAGNOSES:  ,1.  Congenital chylous ascites and chylothorax.,2.  Rule out infradiaphragmatic lymphatic leak.,POSTOPERATIVE DIAGNOSES: , Diffuse intestinal and mesenteric lymphangiectasia.,ANESTHESIA: , General.,INDICATION:  ,The patient is an unfortunate 6-month-old baby boy, who has been hospitalized most of his life with recurrent chylothoraces and chylous ascites.  The patient has been treated somewhat successfully with TPN and voluntary restriction of enteral nutrition, but he had repeated chylothoraces.  Last week, Dr. X took the patient to the operating room in hopes that with thoracotomy, a thoracic duct leak could be found, which would be successfully closed surgically.  However at the time of his thoracotomy exploration what was discovered was a large amount of transdiaphragmatic transition of chylous ascites coming from the abdomen.  Dr. X opened the diaphragm and could literally see a fountain of chylous fluid exiting through the diaphragmatic hole.  This was closed, and we decided that perhaps an abdominal exploration as a last stage effort would allow us to find an area of lymphatic leak that could potentially help the patient from this dismal prognostic disease.  We met with his parents and talked to them about this, and he is here today for that attempt.,OPERATIVE FINDINGS:  ,The patient's abdomen was relatively soft, minimally distended.  Exploration through supraumbilical transverse incision immediately revealed a large amount of chylous ascites upon entering into the peritoneal cavity.  What we found which explains the chronic chylous ascites and chylothorax was a diffuse lymphangiectatic picture involving the small bowel mesentery approximately two thirds to three quarters of the distal small bowel including all of the ileum, the cecum, and the portion of the ascending colon.  It appeared that any attempt to resect this area would have been met with failure because of the extensive lymphatic dilatation all the way down towards the root of the supramesenteric artery.  There was about one quarter to one third of the jejunum that did not appear to be grossly involved, but I did not think that resection of three quarters of the patient's small bowel would be viable surgical option.  Instead, we opted to close his abdomen and refer for potential small intestine transplantation procedure in the future if he is a candidate for that.,The lymphatic abnormality was extensive.  They were linear dilated lymphatic channels on the serosal surface of the bowel in the mesentery.  They were small aneurysm-like pockets of chyle all along the course of the mesenteric structures and in the mesentery medially adjacent to the bowel as well.  No other major retroperitoneal structure or correctable structure was identified.  Both indirect inguinal hernias were wide open and could be palpated from an internal aspect as well.,DESCRIPTION OF OPERATION:  ,The patient was brought from the Pediatric Intensive Care Unit to the operating room within an endotracheal tube im place and with enteral feeds established at full flow to provide maximum fat content and maximum lymphatic flow.  We conducted a surgical time-out and reiterated all of the patient's important identifying information and confirmed the operative plan as described above.  Preparation and draping of his abdomen was done with chlorhexidine based prep solution and then we opened his peritoneal cavity through a transverse supraumbilical incision dividing both rectus muscles and all layers of the abdominal wall fascia.  As the peritoneal cavity was entered, we divided the umbilical vein ligamentum teres remnant between Vicryl ties, and we were able to readily identify a large amount of chylous ascites that had been previously described.  The bowel was eviscerated, and then with careful inspection, we were able to identify this extensive area of intestinal and mesenteric lymphangiectasia that was a source of the patient's chylous ascites.  The small bowel from the ligament of Treitz to the proximal to mid jejunum was largely unaffected, but did not appear that resection of 75% of the small intestine and colon would be a satisfactory tradeoff for The patient, but would likely render him with significant short bowel and nutritional and metabolic problems.  Furthermore, it might burn bridges necessary for consideration of intestinal transplantation in the future if that becomes an option.  We suctioned free all of the chylous accumulations, replaced the intestines to their peritoneal cavity, and then closed the patient's abdominal incision with 4-0 PDS on the posterior sheath and 3-0 PDS on the anterior rectus sheath.  Subcuticular 5-0 Monocryl and Steri-Strips were used for skin closure.,The patient tolerated the procedure well.  He lost minimal blood, but did lose approximately 100 mL of chylous fluid from the abdomen that was suctioned free as part of the chylous ascitic leak.  The patient was returned to the Pediatric Intensive Care Unit with his endotracheal tube in place and to consider the next stage of management, which might be an attempted additional type of feeding or referral to an Intestinal Transplantation Center to see if that is an option for the patient because he has no universally satisfactory medical or surgical treatment for this at this time.","gastroenterology, intestinal, mesenteric, lymphangiectasia, ascites, chylothorax, lymphatic leak, infradiaphragmatic, abdominal exploration, congenital chylous, mesenteric lymphangiectasia, peritoneal cavity, chylous, abdominal, congenital, abdomen, lymphatic"
" Uvulopalatopharyngoplasty and tonsillectomy.   The patient with a history of obstructive sleep apnea who has been using CPAP, however, he was not tolerating used of the machine and requested a surgical procedure for correction of his apnea.", ENT - Otolaryngology, Uvulopalatopharyngoplasty & Tonsillectomy ,"PREOPERATIVE DIAGNOSIS:,  Obstructive sleep apnea.,POSTOPERATIVE DIAGNOSIS:  ,Obstructive sleep apnea.,PROCEDURE PERFORMED:,1.  Tonsillectomy.,2.  Uvulopalatopharyngoplasty.,ANESTHESIA:,  General endotracheal tube.,BLOOD LOSS: , Approximately 50 cc.,INDICATIONS: , The patient is a 41-year-old gentleman with a history of obstructive sleep apnea who has been using CPAP, however, he was not tolerating used of the machine and requested a surgical procedure for correction of his apnea.,PROCEDURE: , After all risks, benefits, and alternatives have been discussed with the patient, informed consent was obtained.  The patient was brought to the operative suite where he was placed in supine position and general endotracheal tube intubation was delivered by the Department of Anesthesia.  The patient was rotated 90 degrees away and a shoulder roll was placed and a McIvor mouthgag was inserted into the oral cavity.  Correct inspection and palpation did not reveal evidence of a bifid uvula or submucosal clots.  Attention was directed first to the right tonsil in which a curved Allis forceps was applied to the superior pole.  The needle-tip Bovie cautery was used to incise the mucosa of the anterior tonsillar pillar.  Once the tonsillar pillar was identified and the superior pole was released, the curved forceps with a straight Allis forceps and the dissection was carried down inferiorly, dissecting the tonsil free from all fascial attachments.  Once the tonsil was delivered from the oral cavity, hemostasis was obtained within the tonsillar fossa utilizing suction cautery.,Attention was then directed over to the left tonsil in which a similar procedure was performed.  Once all bleeding was controlled, the mucosa of both the hard and soft palate was anesthetized with a mixture of 1% lidocaine and 1:50000 epinephrine solution.  Now attention was directed to the posterior pillars.  A hemostat was used to clamp the posterior pillar, which was then taken down with Metzenbaum scissors.  The posterior pillar was then approximated to the anterior pillar with the use of #3-0 PDS suture so as to create a box shaped soft palate.  Now, the uvula was reflected onto the soft palate and #12 blade scalpel was used to incise the mucosa of the soft palate extending down onto the uvula.  The mucosa was dissected off with the use of Potts scissors.  Now the uvula was reflected onto the soft palate and sutured down in place with use of #3-0 PDS suture approximated with deep muscle layers.  Now the mucosa of the soft palate and the uvula were approximated with interrupted #3-0 PDS sutures.  Finally, #4-0 Vicryl sutures were placed intermittently between the PDS to further secure the uvula, which had been reflected onto the soft palate.  A final #3-0 PDS suture was used to further approximate the anterior and posterior tonsil pillars.  Final inspection did not reveal any further bleeding.  The mouth was then irrigated with saline and suctioned.  At this point, the procedure was complete.  He was awakened and taken to recovery room in stable condition.  He will be admitted as an observation patient to the Telemetry Floor for routine postoperative management.  Of note, IV Decadron was administered during the procedure.","ent - otolaryngology, endotracheal, metzenbaum, soft palate, obstructive sleep apnea, tonsillectomy, uvulopalatopharyngoplasty, obstructive, mucosa, uvula, palate,"
 Bilateral tympanostomy with myringotomy tube placement.    The patient is a 1-year-old male with a history of chronic otitis media with effusion and conductive hearing loss refractory to outpatient medical therapy. , ENT - Otolaryngology, Tympanostomy & Myringotomy Tube Placement ,"PREOPERATIVE DIAGNOSES:,1.  Chronic otitis media with effusion.,2.  Conductive hearing loss.,POSTOPERATIVE DIAGNOSES:,1.  Chronic otitis media with effusion.,2.  Conductive hearing loss.,PROCEDURE PERFORMED: , Bilateral tympanostomy with myringotomy tube placement _______ split tube 1.0 mm.,ANESTHESIA:  ,Total IV general mask airway.,ESTIMATED BLOOD LOSS:  ,None.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE:,  The patient is a 1-year-old male with a history of chronic otitis media with effusion and conductive hearing loss refractory to outpatient medical therapy.  After risks, complications, consequences, and questions were addressed with the family, a written consent was obtained for the procedure.,PROCEDURE:,  The patient was brought to the operative suite by Anesthesia.  The patient was placed on the operating table in supine position.  After this, the patient was then placed under general mask airway and the patient's head was then turned to the left.,The Zeiss operative microscope and medium-sized ear speculum were placed and the cerumen from the external auditory canals were removed with a cerumen loop to #5 suction.  After this, the tympanic membrane is then brought into direct visualization with no signs of any gross retracted pockets or cholesteatoma.  A myringotomy incision was then made within the posterior inferior quadrant and the middle ear was then suctioned with a #5 suction demonstrating dry contents.  A _____ split tube 1.0 mm was then placed in the myringotomy incision utilizing a alligator forcep.  Cortisporin Otic drops were placed followed by cotton balls.  Attention was then drawn to the left ear with the head turned to the right and the medium sized ear speculum placed.  The external auditory canal was removed off of its cerumen with a #5 suction which led to the direct visualization of the tympanic membrane.  The tympanic membrane appeared with no signs of retraction pockets, cholesteatoma or air fluid levels.  A myringotomy incision was then made within the posterior inferior quadrant with a myringotomy blade after which a _________ split tube 1.0 mm was then placed with an alligator forcep.  After this, the patient had Cortisporin Otic drops followed by cotton balls placed.  The patient was then turned back to Anesthesia and transferred to recovery room in stable condition and tolerated the procedure very well.  The patient will be followed up approximately in one week and was sent home with a prescription for Ciloxan ear drops to be used as directed and with instructions not to get any water in the ears.","ent - otolaryngology, chronic otitis media with effusion, conductive hearing loss, bilateral tympanostomy, myringotomy tube placement, cortisporin otic drops, otitis media, tympanostomy, tympanic, membrane, otitis, media, effusion, conductive, hearing, ear, tube, myringotomy"
 The patient's main complaint is vertigo. The patient is having recurrent attacks of vertigo and imbalance over the last few years with periods of free symptoms and no concurrent tinnitus or hearing impairment., ENT - Otolaryngology, Vertigo Consult ,"Assessment for peripheral vestibular function follows:,OTOSCOPY:, showed bilateral intact tympanic membranes with central  Weber test and bilateral positive Rinne.,ROMBERG TEST:, maintained postural stability.,FRENZEL GLASSES EXAMINATION:, no spontaneous, end gaze nystagmus.,HEAD SHAKING:, No provocation nystagmus.,DIX-HALLPIKE:, showed no positional nystagmus excluding benign paroxysmal positional vertigo.,VESTIBULOCULAR REFLEX [HALMAGYI TEST]:, showed corrective saccades giving the impression of decompensated vestibular hypofunction.,IMPRESSION: , The patient was advised to continue her vestibular rehabilitation exercises and the additional medical treatment of betahistine at 24 mg dose bid.  ,PLAN:  ,Planned for  electronystagmography to document the degree of vestibular hypofunction.,","ent - otolaryngology, electronystagmography, hearing impairment, imbalance, tinnitus, hypofunction, nystagmus, vestibular, vertigo,"
 Adenotonsillar hypertrophy and chronic otitis media.  Tympanostomy and tube placement and adenoidectomy., ENT - Otolaryngology, Tympanostomy ,"PREOPERATIVE DIAGNOSIS: , Adenotonsillar hypertrophy and chronic otitis media.,POSTOPERATIVE DIAGNOSIS:,  Adenotonsillar hypertrophy and chronic otitis media.,PROCEDURE PERFORMED:,1.  Tympanostomy and tube placement.,2.  Adenoidectomy.,ANESTHESIA:  ,General endotracheal.,DESCRIPTION OF PROCEDURE:  ,The patient was taken to the operating room, prepped and draped in the usual fashion.  After induction of general endotracheal anesthesia, the McIvor mouth gag was placed in the oral cavity and a tongue depressor applied.  Two #12-French red rubber Robinson catheters were placed, 1 in each nasal passage, and brought out through the oral cavity and clamped over a dental gauze roll placed on the upper lip to provide soft palate retraction.,Attention was directed to the nasopharynx.  With the Bovie set at 50 coag and the suction Bovie tip on the suction hose, the adenoid bed was fulgurated by beginning at the posterosuperior aspect of the nasopharynx at the apex of the choana placing the tip of the suction cautery deep at the root of the adenoids next to the roof of the nasopharynx and then in a linear fashion making serial passages through the base of the adenoid fossa in parallel lines until the entire nasopharynx and adenoid bed had been fulgurated moving from posterior to anterior.  The McIvor was relaxed and attention was then directed to the ears.,The left external auditory canal was examined under the operating microscope and cleaned of ceruminous debris.,An anteroinferior quadrant tympanostomy incision was made.  Fluid was suctioned from the middle ear space, and a tympanostomy tube was placed at the level of the incision and pushed into position with the Rosen needle.  Cortisporin ear drops were instilled into the canal, and a cotton ball was placed in the external meatus.,By a similar procedure, the opposite tympanostomy and tube placement were accomplished.,The patient tolerated the procedure well and left the operating room in good condition.","ent - otolaryngology, robinson catheters, palate, tongue, tympanostomy, adenoidectomy, chronic otitis media, oral cavity, adenotonsillar hypertrophy, tube placement, hypertrophy, nasopharynx, adenotonsillar,"
 Viral upper respiratory infection (URI) with sinus and eustachian congestion.  Patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain. , ENT - Otolaryngology, URI & Eustachian Congestion ,"HISTORY OF PRESENT ILLNESS: , Patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain.  She has had a dry cough and a fever as high as 100, but this has not been since the first day.  She denies any vomiting or diarrhea.  She did try some Tylenol Cough and Cold followed by Tylenol Cough and Cold Severe, but she does not think that this has helped.,FAMILY HISTORY: , The patient's younger sister has recently had respiratory infection complicated by pneumonia and otitis media.,REVIEW OF SYSTEMS:,  The patient does note some pressure in her sinuses.  She denies any skin rash.,SOCIAL HISTORY:,  Patient lives with her mother, who is here with her.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS:  Temp is 38.1, pulse is elevated at 101, other vital signs are all within normal limits.  Room air oximetry is 100%.,GENERAL:  Patient is a healthy-appearing, white female, adolescent who is sitting on the stretcher, and appears only mildly ill.,HEENT:  Head is normocephalic, atraumatic.  Pharynx shows no erythema, tonsillar edema, or exudate.  Both TMs are easily visualized and are clear with good light reflex and no erythema.  Sinuses do show some mild tenderness to percussion.,NECK:  No meningismus or enlarged anterior/posterior cervical lymph nodes.,HEART:  Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS:  Clear without rales, rhonchi, or wheezes.,SKIN:  No rash.,ASSESSMENT:,  Viral upper respiratory infection (URI) with sinus and eustachian congestion.,PLAN:,  I did educate the patient about her problem and urged her to switch to Advil Cold & Sinus for the next three to five days for better control of her sinus and eustachian discomfort.  I did urge her to use Afrin nasal spray for the next three to five days to further decongest her sinuses.  If she is unimproved in five days, follow up with her PCP for re-exam.","ent - otolaryngology, upper respiratory infection, eustachian congestion, erythema, uri, nasal, cough, eustachian, respiratory, sinus, congestion, infection, tonsillar"
" Tonsillectomy, uvulopalatopharyngoplasty, and septoplasty for obstructive sleep apnea syndrome with hypertrophy of tonsils and of uvula and soft palate with deviation of nasal septum", ENT - Otolaryngology, Tonsillectomy and Septoplasty ,"PREOPERATIVE DIAGNOSIS:,  Obstructive sleep apnea syndrome with hypertrophy of tonsils and of uvula and soft palate.,POSTOPERATIVE DIAGNOSIS:,  Obstructive sleep apnea syndrome with hypertrophy of tonsils and of uvula and soft palate with deviation of nasal septum.,OPERATION:,  Tonsillectomy, uvulopalatopharyngoplasty, and septoplasty.,ANESTHESIA:,  General anesthetics.,HISTORY: , This is a 51-year-old gentleman here with his wife.  She confirms the history of loud snoring at night with witnessed apnea.  The result of the sleep study was reviewed.  This showed moderate sleep apnea with significant desaturation.  The patient was unable to tolerate treatment with CPAP.  At the office, we observed large tonsils and elongation and thickening of the uvula as well as redundant soft tissue of the palate.  A tortuous appearance of the septum also was observed.  This morning, I talked to the patient and his wife about the findings.  I reviewed the CT images.  He has no history of sinus infections and does not recall a history of nasal trauma.  We discussed the removal of tonsils and uvula and soft palate tissue and the hope that this would help with his airway.  Depending on the findings of surgery, I explained that I might remove that bone spur that we are seeing within the nasal passage.  I will get the best look at it when he is asleep.  We discussed recovery as well.  He visited with Dr. XYZ about the anesthetic produce.,PROCEDURE:,:  General tracheal anesthetic was administered by Dr. XYZ and Mr. Radke.  Afrin drops were placed in both nostrils and a cottonoid soaked with Afrin was placed in each side of the nose.  A Crowe-Davis mouth gag was placed.  The tonsils were very large and touched the uvula.  The uvula was relatively long and very thick and there were redundant folds of soft palate mucosa and prominent posterior and anterior tonsillar pillars.  Also, there was a cryptic appearance of the tonsils but there was no acute redness or exudate.  Retraction of the soft palate permitted evaluation of the nasopharynx with the mirror and the choanae were patent and there was no adenoid tissue present.  A very crowded pharynx was appreciated.  The tonsils were first removed using electrodissection technique.  Hemostasis was achieved with the electrocautery and with sutures of 0 plain catgut.  The tonsil fossae were injected with 0.25% Marcaine with 1:200,000 epinephrine.  There already was more room in the pharynx, but the posterior pharyngeal wall was still obscured by the soft palate and uvula.  The uvula was grasped with the Alice clamp.  I palpated the posterior edge of the hard palate and calculated removal of about a third of the length of the soft palate.  We switched over from the Bayonet cautery to the blunt needle tip electrocautery.  The planned anterior soft palate incision was marked out with the electrocautery from the left anterior tonsillar pillar rising upwards and then extending horizontally across the soft palate to include all of the uvula and a portion of the soft palate, and the incision then extended across the midline and then inferiorly to meet the right anterior tonsillar pillar.  This incision was then deepened with the electrocautery on a cutting current.  The uvular artery just to the right of the midline was controlled with the suction electrocautery.  The posterior soft palate incision was made parallel to the anterior soft palate incision but was made leaving a longer length of mucosa to permit closure of the palatoplasty.  A portion of the redundant soft palate mucosa tissue also was included with the resection specimen and the tissue including the soft palate and uvula was included with the surgical specimen as the tonsils were sent to pathology.  The tonsil fossae were injected with 0.25% Marcaine with 1:200,000 epinephrine.  The soft palate was also injected with 0.25% Marcaine with 1:200,000 epinephrine.  The posterior tonsillar pillars were then brought forward to close to the anterior tonsillar pillars and these were sutured down to the tonsil bed with interrupted 0 plain catgut sutures.  The posterior soft palate mucosa was advanced forward and brought up to the anterior soft palate incision and closure of the soft palate wound was then accomplished with interrupted 3-0 chromic catgut sutures.  A much improved appearance of the oropharynx with a greatly improved airway was appreciated.  A moist tonsil sponge was placed into the nasopharynx and the mouth gag was removed.  I removed the cottonoids from both nostrils.  Speculum exam showed the inferior turbinates were large, the septum was tortuous and it angulated to the right and then sharply bent back to the left.  The septum was injected with 0.25% Marcaine with 1:200,000 epinephrine using a separate syringe and needle.  A #15 blade was used to make a left cheilion incision.,Mucoperichondrium and mucoperiosteum were elevated with the Cottle elevator.  When we reached the deflected portion of the vomer, this was separated from the septal cartilage with a Freer elevator.  The right-sided mucoperiosteum was elevated with the Freer elevator and then with Takahashi forceps and with the 4 mm osteotome, the deflected portion of the septal bone from the vomer was resected.  This tissue also was sent as a separate specimen to pathology.  The intraseptal space was irrigated with saline and suctioned.  The nasal septal mucosal flaps were then sutured together with a quilting suture of 4-0 plain catgut.  I observed no evidence of purulent secretion or polyp formation within the nostrils.  The inferior turbinates were then both outfractured using a knife handle, and now there was a much more patent nasal airway on both sides.  There was good support for the nasal tip and the dorsum and there was good hemostasis within the nose.  No packing was used in the nostrils.  Polysporin ointment was introduced into both nostrils.  The mouth gag was reintroduced and the pack removed from the nasopharynx.  The nose and throat were irrigated with saline and suctioned.  An orogastric tube was placed and a moderate amount of clear fluid suctioned from the stomach and this tube was removed.  Sponge and needle count were reported correct.  The mouth gag having been withdrawn, the patient was then awakened and returned to recovery room in a satisfactory condition.  He tolerated the operation excellently.  Estimated blood loss was about 15-20 cc.  In the recovery room, I observed that he was moving air well and I spoke with his wife about the findings of surgery.","ent - otolaryngology, obstructive sleep apnea syndrome, afrin drops, bayonet cautery, cpap, cottle elevator, crowe-davis, freer elevator, obstructive sleep apnea, tonsillectomy, hypertrophy, mouth gag, nasal, nasal passage, nasal septum, nasopharynx, nostrils, palate, pharynx, septal cartilage, septoplasty, sleep apnea, soft palate, tonsils, uvula, uvulopalatopharyngoplasty, hypertrophy of tonsils, anterior tonsillar pillars, soft palate incision, palate incision, tonsillar pillars, incision "
 Tracheostomy and thyroid isthmusectomy.  Ventilator-dependent respiratory failure and multiple strokes., ENT - Otolaryngology, Tracheostomy & Thyroid Isthmusectomy ,"PREOPERATIVE DIAGNOSES:,1.  Ventilator-dependent respiratory failure.,2.  Multiple strokes.,POSTOPERATIVE DIAGNOSES:,1.  Ventilator-dependent respiratory failure.,2.  Multiple strokes.,PROCEDURES PERFORMED:,1.  Tracheostomy.,2.  Thyroid isthmusectomy.,ANESTHESIA: , General endotracheal tube.,BLOOD LOSS: , Minimal, less than 25 cc.,INDICATIONS:,  The patient is a 50-year-old gentleman who presented to the Emergency Department who had had multiple massive strokes.  He had required ventilator assistance and was transported to the ICU setting.  Because of the numerous deficits from the stroke, he is expected to have a prolonged ventilatory course and he will be requiring long-term care.,PROCEDURE: , After all risks, benefits, and alternatives were discussed with multiple family members in detail, informed consent was obtained.  The patient was brought to the Operative Suite where he was placed in supine position and general anesthesia was delivered through the existing endotracheal tube.  The neck was then palpated and marked appropriately in the cricoid cartilage sternal notch and thyroid cartilage marked appropriately with felt-tip marker.  The skin was then anesthetized with a mixture of 1% lidocaine and 1:100,000 epinephrine solution.  The patient was prepped and draped in usual fashion.  The surgeons were gowned and gloved.  A vertical skin incision was then made with a #15 blade scalpel extending from approximately two fingerbreadths above the level of the sternum approximately 1 cm above the cricoid cartilage.  Blunt dissection was then carried down until the fascia overlying the strap muscles were identified.  At this point, the midline raphe was identified and the strap muscles were separated utilizing the Bovie cautery.  Once the strap muscles have been identified, palpation was performed to identify any arterial aberration.  A high-riding innominate was not identified.  At this point, it was recognized that the thyroid gland was overlying the trachea could not be mobilized.  Therefore, dissection was carried down through to the cricoid cartilage at which point hemostat was advanced underneath the thyroid gland, which was then doubly clamped and ligated with Bovie cautery.  Suture ligation with #3-0 Vicryl was then performed on the thyroid gland in a double interlocking fashion.  This cleared a significant portion of the trachea.  The overlying pretracheal fascia was then cleared with use of pressured forceps as well as Bovie cautery.  Now, a tracheal hook was placed underneath the cricoid cartilage in order to stabilize the trachea.  The second tracheal ring was identified.  The Bovie cautery reduced to create a tracheal window beneath the second tracheal ring that was inferiorly based.  At this point, the anesthetist was appropriately alerted to deflate the endotracheal tube cuff.  The airway was entered and inferior to the base, window was created.  The anesthetist then withdrew the endotracheal tube until the tip of the tube was identified.  At this point, a #8 Shiley tracheostomy tube was inserted freely into the tracheal lumen.  The balloon was inflated and the ventilator was attached.  He was immediately noted to have return of the CO2 waveform and was ventilating appropriately according to the anesthetist.  Now, all surgical retractors were removed.  The baseplate of the tracheostomy tube was sutured to the patient's skin with #2-0 nylon suture.  The tube was further secured around the patient's neck with IV tubing.  Finally, a drain sponge was placed.  At this point, procedure was felt to be complete.  The patient was returned to the ICU setting in stable condition where a chest x-ray is pending.","ent - otolaryngology, ventilator-dependent respiratory failure, multiple strokes, thyroid, thyroid isthmusectomy, ventilator dependent, respiratory failure, strap muscles, thyroid gland, endotracheal tube, cricoid cartilage, bovie cautery, tracheostomy, ventilator, strokes, cartilage, tracheal, isthmusectomy"
 Tonsillectomy and adenoidectomy.  Obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis., ENT - Otolaryngology, Tonsillectomy & Adenoidectomy - 3 ,"PREOPERATIVE DIAGNOSIS:,  Obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis.,POSTOPERATIVE DIAGNOSIS: , Obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis.,SURGICAL PROCEDURE PERFORMED: , Tonsillectomy and adenoidectomy.,ANESTHESIA: , General endotracheal technique.,SURGICAL FINDINGS:  ,A 4+/4+ cryptic and hypertrophic tonsils with 2+/3+ hypertrophic adenoid pads.,INDICATIONS: , We were requested to evaluate the patient for complaints of enlarged tonsils, which cause difficulty swallowing, recurrent pharyngitis, and sleep-induced respiratory disturbance.  She was evaluated and scheduled for an elective procedure.,DESCRIPTION OF SURGERY:  ,The patient was brought to the operative suite and placed supine on the operating room table.  General anesthetic was administered.  Once appropriate anesthetic findings were achieved, the patient was intubated and prepped and draped in the usual sterile manner for a tonsillectomy.  He was placed in semi-Rose ___ position and a Crowe Davis-type mouth gag was introduced into the oropharynx.  Under an operating headlight, the oropharynx was clearly visualized.  The right tonsil was grasped with the fossa triangularis and using electrocautery enucleation technique, was removed from its fossa.  This followed placing the patient in a suspension position using a McIvor-type mouth gag and a red rubber Robinson catheter via the right naris.  Once the right tonsil was removed, the left tonsil was removed in a similar manner, once again using a needle point Bovie dissection at 20 watts.  With the tonsils removed, it was possible to visualize the adenoid pads.  The oropharynx was irrigated and the adenoid pad evaluated with an indirect mirror technique.  The adenoid pad was greater than 2+/4 and hypertrophic.  It was removed with successive passes of electrocautery suction.  The tonsillar fossa was then once again hemostased with suction cautery, injected with 0.5% ropivacaine with 1:100,000 adrenal solution and then closed with 2-0 Monocryl on an SH needle.  The redundant soft tissue of the uvula was removed posteriorly and cauterized with electrocautery to prevent swelling of the uvula in the postoperative period.  The patient's oropharynx and nasopharynx were irrigated with copious amounts of normal saline contained with small amount of iodine, and she was recovered from her general endotracheal anesthetic.  She was extubated and left the operating room in good condition to the postoperative recovery room area.,Estimated blood loss was minimal.  There were no complications.  Specimens produced were right and left tonsils.  The adenoid pad was ablated with electrocautery.","ent - otolaryngology, obstructive adenotonsillar hypertrophy, pharyngitis, tonsillectomy, adenoidectomy, uvula, obstructive, adenotonsillar, hypertrophy, hypertrophic, fossa, tonsils, oropharynx, electrocautery, pads"
" Left canal wall down tympanomastoidectomy with ossicular chain reconstruction, microdissection, NIM facial nerve monitoring for three hours.", ENT - Otolaryngology, Tympanomastoidectomy ,"PREOPERATIVE DIAGNOSIS: , Left canal cholesteatoma.,POSTOPERATIVE DIAGNOSIS: , Left canal cholesteatoma.,OPERATIVE PROCEDURE:,1.  Left canal wall down tympanomastoidectomy with ossicular chain reconstruction.,2.  Microdissection.,3.  NIM facial nerve monitoring for three hours.,COMPLICATIONS:  ,None.,FINDINGS:,  There is an extremely large canal cholesteatoma, which eroded most of the posterior and superior canal wall.  There was a significant amount of myringosclerosis and tympanosclerosis.  There is some mild erosion of the lenticular process of the incus.  The facial nerve was normal.  We removed the incus, removed the head of the malleus, and placed a titanium-PORP from the stapes capitulum to a cartilage graft.,PROCEDURE: , The patient was taken to the operating room, placed under general anesthetic and intubated without difficulty.  The NIM facial nerve monitoring electrodes were positioned and monitoring was performed throughout the procedure.  There was no abnormal activity during this case.  We inspected the ear canal, identified the huge defect, which was completely filled with cerumen.  Through the ear canal, we removed as much as we could and then infiltrated the canal and postauricular area with 1:100,000 of epinephrine.,We prepped and draped the ear in a sterile fashion.  We reopened the previously used postauricular incision and dissected down the mastoid cortex.  We reflected the soft tissues anteriorly to the level of the ear canal and identified where the ear canal skin entered the defect in the mastoid bone.  A #6 cutting bur was used to drill down the mastoid cortex and identified this cholesteatoma which was then carefully dissected out.  We went all the way to the mastoid antrum.  We finished a complete mastoidectomy with identification of the tegmen, sigmoid sinus.  We removed the lateral aspect of the mastoid tip.  We lowered the facial ridge.  The incudostapedial joint was already membranous in nature, we went ahead and used the joint knife and removed the incus.  We separated the incus from the stapes and then removed it.  We used a malleus head nipper to remove the head of the malleus and then we continued to saucerize the entire mastoid cavity.,There was no cholesteatoma within the middle ear space, but there was roughly 40% surface area perforation.  The remaining portion of the tympanic membrane was extremely calcified and myringosclerotic; this was removed.  There was also a large focus of tympanosclerosis between the stapes crura, which was impinging the ability of the stapes to move.  We carefully dissected this out.  This did seem to improve the mobility of the stapes somewhat.  At this point, there was a near total perforation.  There was only a minimal amount of anterior remnant of the drum left.  We tried to go ahead and harvest the temporalis fascia, but there was really only wisps of this fascia in place.  He had already had a previous tympanoplasty, but even outside the areas where the graft was taken, the temporalis muscle was quite atrophied and lumpy, and I suspect this was due to his chronic disease and long history of corticosteroid usage.  We harvested a few pieces as best as we could.  We went ahead and did a meatoplasty by making a canal incision in the 6 o'clock and 12 o'clock positions.  We excised cartilage posteriorly and inferiorly to enlarge the meatus.  This cartilage was thin and used for cartilage tympanoplasty.  We placed some Gelfoam in the middle ear space and placed the cartilage on the top of it.  We did cut a titanium-PORP of the proper side and placed on top of the stapes capitulum to interface with the cartilage cap.  A few other small pieces of temporalis fascia were used to bulge through the surrounding edges of the cartilage and make sure that it was medial to any remnant of ear canal and tympanic membrane remnants.  We placed a layer of Gelfoam lateral to the graft, closed the postauricular incision in layers and put 2 Merocel packs in the ear.  Glasscock dressing was applied.  The patient was awakened from anesthesia and taken to the recovery room in stable condition.  He will be given antibiotics and pain medicines and he will be given instructions to follow up with me in one week.","ent - otolaryngology, cholesteatoma, gelfoam, glasscock dressing, microdissection, nim, canal, canal wall, cerumen, facial nerve, incus, myringosclerosis, ossicular chain reconstruction, titanium-porp, tympanomastoidectomy, tympanosclerosis, facial nerve monitoring, ear canal, cartilage, ear,"
 Tonsillectomy and adenoidectomy.  Chronic adenotonsillitis.  The patient is a 9-year-old Caucasian male with history of recurrent episodes of adenotonsillitis that has been refractory to outpatient antibiotic therapy. , ENT - Otolaryngology, Tonsillectomy & Adenoidectomy - 5 ,"POSTOPERATIVE DIAGNOSIS:,  Chronic adenotonsillitis.,PROCEDURE PERFORMED: , Tonsillectomy and adenoidectomy.,ANESTHESIA:  ,General endotracheal tube.,ESTIMATED BLOOD LOSS:,  Minimum, less than 5 cc.,SPECIMENS:,  Right and left tonsils 2+, adenoid pad 1+.  There was no adenoid specimen.,COMPLICATIONS: , None.,HISTORY: , The patient is a 9-year-old Caucasian male with history of recurrent episodes of adenotonsillitis that has been refractory to outpatient antibiotic therapy.  The patient has had approximately four to five episodes of adenotonsillitis per year for the last three to four years.,PROCEDURE: , Informed consent was properly obtained from the patient's parents and the patient was taken to the operating room #3 and was placed in a supine position.  He was placed under general endotracheal tube anesthesia by the Department of Anesthesia.  The bed was then rolled away from Department of Anesthesia.  A shoulder roll was then placed beneath the shoulder blades and a blue towel was then fashioned as a turban wrap.  The McIvor mouth gag was carefully positioned into the patient's mouth with attention to avoid the teeth.,The retractor was then opened and the oropharynx was visualized.  The adenoid pad was then visualized with a laryngeal mirror.  The adenoids appeared to be 1+ and non-obstructing.  There was no evidence of submucosal cleft palate palpable.  There was no evidence of bifid uvula.  A curved Allis clamp was then used to grasp the superior pole of the right tonsil.  The tonsil was then retracted inferiorly and medially.  Bovie cautery was used to make an incision on the mucosa of the right anterior tonsillar pillar to find the appropriate plane of dissection.  The tonsil was then dissected out within this plane using a Bovie.  Tonsillar sponge was re-applied to the tonsillar fossa.  Suction cautery was then used to adequately obtain hemostasis with the tonsillar fossa.  Attention was then directed to the left tonsil.  The curved Allis was used to grasp the superior pole of the left tonsil and it was retracted inferiorly and medially.  Bovie cautery was used to make an incision in the mucosa of the left anterior tonsillar pillar and define the appropriate plane of dissection.  The tonsil was then dissected out within this plane using the Bovie.  Next, complete hemostasis was achieved within the tonsillar fossae using suction cautery.  After adequate hemostasis was obtained, attention was directed towards the adenoid pad.  The adenoid pad was again visualized and appeared 1+ and was non-obstructing.  Decision was made to use suction cautery to cauterize the adenoids.  Using a laryngeal mirror under direct visualization, the adenoid pad was then cauterized with care to avoid the eustachian tube orifices as well as the soft palate and inferior turbinates.  After cauterization was complete, the nasopharynx was again visualized and tonsillar sponge was applied.  Adequate hemostasis was achieved.  The tonsillar fossae were again visualized and no evidence of bleeding was evident.  The throat pack was removed from the oropharynx and the oropharynx was suctioned.  There was no evidence of any further bleeding.  A flexible suction catheter was then used to suction out the nasopharynx to the oropharynx.  The suction catheter was also used to suction up the stomach.  Final look revealed no evidence of further bleeding and 10 mg of Decadron was given intraoperatively.,DISPOSITION:  ,The patient tolerated the procedure well and the patient was transported to the recovery room in stable condition.","ent - otolaryngology, chronic adenotonsillitis, tonsillectomy, adenoidectomy, adenoid, tonsils, tonsillar fossa, tonsillar fossae, suction cautery, adenotonsillitis, oropharynx, hemostasis, cautery, suction, tonsillar"
 Tonsillectomy.  Chronic tonsillitis., ENT - Otolaryngology, Tonsillectomy - 1 ,"PREOPERATIVE DIAGNOSIS:,  Chronic tonsillitis.,POSTOPERATIVE DIAGNOSIS: , Chronic tonsillitis.,PROCEDURE:  ,Tonsillectomy.,DESCRIPTION OF PROCEDURE: , Under general orotracheal anesthesia, a Crowe-Davis mouth gag was inserted and suspended.  Tonsils were removed by electrocautery dissection and the tonsillar beds were injected with Marcaine 0.25% plain.  A catheter was inserted in the nose and brought out from mouth.  The throat was irrigated with saline.  There was no further bleeding.  The patient was awakened and extubated and moved to the recovery room in satisfactory condition.","ent - otolaryngology, crowe-davis, mouth gag, chronic tonsillitis, tonsillitis, anesthesia, tonsillectomy"
 Tonsillectomy and adenoidectomy and Left superficial nasal cauterization.  Recurrent tonsillitis.  Deeply cryptic hypertrophic tonsils with numerous tonsillolith.  Residual adenoid hypertrophy and recurrent epistaxis., ENT - Otolaryngology, Tonsillectomy & Adenoidectomy - 4 ,"PREOPERATIVE DIAGNOSES,1.  Recurrent tonsillitis.,2.  Deeply cryptic hypertrophic tonsils with numerous tonsillolith.,3.  Residual adenoid hypertrophy and recurrent epistaxis.,POSTOPERATIVE DIAGNOSES,1.  Recurrent tonsillitis.,2.  Deeply cryptic hypertrophic tonsils with numerous tonsillolith.,3.  Residual adenoid hypertrophy and recurrent epistaxis.,FINAL DIAGNOSES,1.  Recurrent tonsillitis.,2.  Deeply cryptic hypertrophic tonsils with numerous tonsillolith.,3.  Residual adenoid hypertrophy and recurrent epistaxis.,OPERATION PERFORMED,1.  Tonsillectomy and adenoidectomy.,2.  Left superficial nasal cauterization.,DESCRIPTION OF OPERATION:,  The patient was brought to the operating room.  Endotracheal intubation carried out by Dr. X. The McIvor mouth gag was inserted and gently suspended.  Afrin was instilled in both sides of the nose and allowed to take effect for a period of time.  The hypertrophic tonsils were then removed by the suction and snare.  Deeply cryptic changes as expected were evident.  Bleeding was minimal and controlled with packing followed by electrocautery followed by extensive additional irrigation.  An inspection of the nasopharynx confirmed that the adenoids were in fact hypertrophic rubbery cryptic and obstructive.  They were shaved back, flushed with prevertebral fascia with curette.  Hemostasis established with packing followed by electrocautery.  In light of his history of recurring nosebleeds, both sides of the nose were carefully inspected.  A nasal endoscope was used to identify the plexus of bleeding, which was predominantly on the left mid portion of the septum that was controlled with broad superficial cauterization using a suction cautery device.  The bleeding was admittedly a bit of a annoyance.  An additional control was established by infiltrating slowly with a 1% Xylocaine with epinephrine around the perimeter of the bleeding site and then cauterizing the bleeding site itself.  No additional bleeding was then evident.  The oropharynx was reinspected, clots removed, the patient was extubated, taken to the recovery room in stable condition.  Discharge will be anticipated later in the day on Lortab plus amoxicillin plus Ponaris nose drops.  Office recheck anticipated if stable and doing well in three to four weeks.","ent - otolaryngology, tonsillitis, cryptic hypertrophic tonsils, tonsillolith, nasal cauterization, adenoid hypertrophy, hypertrophic tonsils, adenoidectomy, nasal, cauterization, hypertrophy, epistaxis, tonsils, hypertrophic, intubation, tonsillectomy"
 Tonsillectomy & adenoidectomy.  Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy.  , ENT - Otolaryngology, Tonsillectomy & Adenoidectomy - 2 ,"PREOPERATIVE DIAGNOSIS: , Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy.,POSTOPERATIVE DIAGNOSIS: , Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy.,OPERATION PERFORMED: , Tonsillectomy & adenoidectomy.,ANESTHESIA: , General endotracheal.,FINDINGS: , The tonsils were 3+ enlarged and cryptic.,DESCRIPTION OF OPERATION:,  Under general anesthesia with an endotracheal tube, the patient was placed in supine position.  A mouth gag was inserted and suspended from Mayo stand.  Red rubber catheter was placed through the nose and pulled up through the mouth with elevation of the palate.  The adenoid area was inspected.  The adenoids were small.  The left tonsil was grasped with a tonsil tenaculum.  The tonsil was removed with the Gold laser.  The apposite tonsil was removed in a similar manner.  Hemostasis was secured with electrocautery.  Both tonsillar fossae were injected with 0.25% Marcaine with adrenaline.  The patient tolerated the procedure well and left the operating room in good condition.","ent - otolaryngology, tonsil, gold laser, adenoids, chronic tonsillitis, adenoid hypertrophy, tonsillectomy, adenoidectomy, endotracheal, tonsillitis, symptomatic, hypertrophy"
"  Tonsillectomy and adenoidectomy.  McIvor mouth gag was placed in the oral cavity, and a tongue depressor applied.", ENT - Otolaryngology, Tonsillectomy & Adenoidectomy - 1  ,"PROCEDURE PERFORMED: , Tonsillectomy and adenoidectomy.,ANESTHESIA:,  General endotracheal.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and prepped and draped in the usual fashion after induction of general endotracheal anesthesia.  The McIvor mouth gag was placed in the oral cavity, and a tongue depressor applied.  Two #12-French red rubber Robinson catheters were placed, 1 in each nasal passage, and brought out through the oral cavity and clamped over a dental gauze roll placed on the upper lip to provide soft palate retraction.,The nasopharynx was inspected with a laryngeal mirror.  The adenoid tissue was fulgurated with the suction Bovie set at 35.  The catheters and the dental gauze roll were then removed.  The anterior tonsillar pillars were infiltrated with 0.5% Marcaine and epinephrine.  Using the radiofrequency wand, the tonsils were ablated bilaterally.  If bleeding occurred, it was treated with the wand on coag mode using a coag mode of 3 and an ablation mode of 9.  The tonsillectomy was completed.,The nasopharynx and nasal passages were suctioned free of debris, and the procedure was terminated.,The patient tolerated the procedure well and left the operating room in good condition.","ent - otolaryngology, tongue, nasal passage, palate, mcivor mouth gag, gauze roll, nasopharynx, tonsillectomy, adenoidectomy,"
 Tonsillectomy.   Tonsillitis.  McIvor mouth gag was placed in the oral cavity and a tongue depressor applied. , ENT - Otolaryngology, Tonsillectomy ,"PREOPERATIVE DIAGNOSIS: , Tonsillitis.,POSTOPERATIVE DIAGNOSIS:  ,Tonsillitis.,PROCEDURE PERFORMED:  ,Tonsillectomy.,ANESTHESIA: , General endotracheal.,DESCRIPTION OF PROCEDURE:  ,The patient was taken to the operating room and prepped and draped in the usual fashion.  After induction of general endotracheal anesthesia, the McIvor mouth gag was placed in the oral cavity and a tongue depressor applied.  Two #12-French red rubber Robinson catheters were placed, 1 in each nasal passage, and brought out through the oral cavity and clamped over a dental gauze roll on the upper lip to provide soft palate retraction.  The nasopharynx was inspected with the laryngeal mirror.,Attention was then directed to the right tonsil.  The anterior tonsillar pillar was infiltrated with 1.5 cc of 1% Xylocaine with 1:100,000 epinephrine, as was the left tonsillar pillar.  The right tonsil was grasped with the tenaculum and retracted out of its fossa.  The anterior tonsillar pillar was incised with the #12 knife blade.  The plica semilunaris was incised with the Metzenbaum scissors.  Using the Metzenbaum scissors and the Fisher knife, the tonsil was dissected free of its fossa onto an inferior pedicle around which the tonsillar snare was placed and applied.  The tonsil was removed from the fossa and the fossa packed with a cherry gauze sponge as previously described.  By a similar procedure, the opposite tonsillectomy was performed and the fossa was packed.,Attention was re-directed to the right tonsil.  The pack was removed and bleeding was controlled with the suction Bovie unit.  Bleeding was then similarly controlled in the left tonsillar fossa and the nasopharynx after removal of the packs.  The catheters were then removed.  The nasal passages and oropharynx were suctioned free of debris.  The procedure was terminated.,The patient tolerated the procedure well and left the operating room in good condition.","ent - otolaryngology, tongue, palate, mcivor mouth gag, anterior tonsillar, metzenbaum scissors, oral cavity, tonsillar pillar, tonsillectomy, metzenbaum, tonsillitis, pillar, tonsillar, fossa "
" Tonsillectomy, adenoidectomy, and removal of foreign body (rock) from right ear.", ENT - Otolaryngology, Tonsillectomy & Adenoidectomy ,"PREOPERATIVE DIAGNOSES:,  Hypertrophy of tonsils and adenoids, and also foreign body of right ear.,POSTOPERATIVE DIAGNOSES:,  Hypertrophy of tonsils and adenoids, and also foreign body of right ear.,OPERATIONS:,  Tonsillectomy, adenoidectomy, and removal of foreign body (rock) from right ear.,ANESTHESIA:,  General.,HISTORY: , The patient is 5-1/2 years old.  She is here this morning with her Mom.  She has very large tonsils and she snores at night and gets up frequently at night and does not sleep well.  At the office we saw the tonsils were very big.  There was a rock in the right ear and it was very deep in the canal, near the drum.  We will remove the foreign body under the same anesthetic.,PROCEDURE:,:  Natalie was placed under general anesthetic by the orotracheal route of administration, under Dr. XYZ and Ms. B.  I looked into the left ear under the microscope, took out a little wax and observed a normal eardrum.  On the right side, I took out some impacted wax and removed the rock with a large suction.  It was actually resting on the surface of the drum but had not scarred or damaged the drum.  The drum was intact with no evidence of middle ear fluid.  The microscope was set aside.  Afrin drops were placed in both nostrils.  The neck was gently extended and the Crowe-Davis mouth gag inserted.  The tonsils and adenoids were very large.  The uvula was intact.  Adenoidectomy was performed using the adenoid curette with a tonsil sponge placed into the nasopharynx.  Tonsillectomy accomplished by sharp and blunt dissection.  Hemostasis achieved with electrocautery and the tonsils beds injected with 0.25% Marcaine with 1:200,000 epinephrine.  Sutures of zero plain catgut next were used to re-approximate the posterior to the anterior tonsillar pillars, suturing these down to the tonsillar beds.  Sponge is removed from the nasopharynx.  The suction electrocautery was used for pinpoint hemostasis on the adenoid bed.  We made sure the cautery tip did not come into the contact with the soft palate or the eustachian tube orifices.  The nose and throat were then irrigated with saline and suctioned.  Excellent hemostasis was observed.  An orogastric tube was placed.  The stomach found to be empty.  The tube was removed, as was the mouth gag.  Sponge and needle count were reported correct.  The child was then awakened and prepared for her to return to the recovery room.  She tolerated the operation excellently.","ent - otolaryngology, tonsillectomy, afrin drops, crowe-davis, hypertrophy, adenoid bed, adenoidectomy, adenoids, canal, catgut, dissection, drum, ear, foreign body, middle ear, mouth gag, nasopharynx, orotracheal, suction electrocautery, throat, tonsils, uvula, wax, tonsils and adenoids"
 The patient had tympanoplasty surgery for a traumatic perforation of the right ear about six weeks ago.  , ENT - Otolaryngology, Status Post Tympanoplasty  ,"The right eardrum is intact showing a successful tympanoplasty.  I cleaned a little wax from the external meatus.  The right eardrum might be very slightly red but not obviously infected.  The left eardrum (not the surgical ear) has a definite infection with a reddened bulging drum but no perforation or granulation tissue.  Also some wax at the external meatus I cleaned with a Q-tip with peroxide.  The patient has no medical allergies.  Since he recently had a course of Omnicef we chose to put him on Augmentin (I checked and we did not have samples), so I phoned in a two-week course of Augmentin 400 mg chewable twice daily with food at Walgreens.  I looked at this throat which looks clear.  The nose only has a little clear mucinous secretions.  If there is any ear drainage, please use the Floxin drops.  I asked Mom to have the family doctor (or Dad, or me) check the ears again in about two weeks from now to be sure there is no residual infection.  I plan to see the patient again later this spring.","ent - otolaryngology, tympanoplasty surgery, traumatic perforation, external meatus, wax, external, perforation, eardrum, meatus, tympanoplasty, earNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Right argon laser assisted stapedectomy.  Bilateral conductive hearing losses with right stapedial fixation secondary to otosclerosis., ENT - Otolaryngology, Stapedectomy - Argon Lasor Assisted ,"PREOPERATIVE DIAGNOSIS: , Bilateral progressive conductive hearing losses with probable otosclerosis.,POSTOPERATIVE DIAGNOSIS: , Bilateral conductive hearing losses with right stapedial fixation secondary to otosclerosis.,OPERATION PERFORMED: , Right argon laser assisted stapedectomy.,DESCRIPTION OF OPERATION:  ,The patient was brought to the operating room.  Endotracheal intubation carried out by Dr. X. The patient's right ear was carefully prepped and then draped in the usual sterile fashion.  Slow infiltration of the external canal accomplished with 1% Xylocaine with epinephrine.  The earlobe was also infiltrated with the same solution.  A limited incision was made in the earlobe harvesting a small bit of fat from the earlobe that was diced and the donor site closed with interrupted sutures of 5-0 nylon.  This could later be removed in bishop.  A reinspection of the ear canal was accomplished.  A 65 Beaver blade was used to make incision both at 12 o'clock and at 6 o'clock.  Jordan round knife was used to incise the tympanomeatal flap with an adequate cuff for later reapproximation.  Elevation was carried down to the fibrous annulus.  An annulus elevator was used to complete the elevation beneath the annular ligament.  The tympanic membrane and the associated flap rotated anteriorly exposing the ossicular chain.  Palpation of the malleus revealed good mobility of both it and incus, but no movement of the stapes was identified.  Palpation with a fine curved needle on the stapes itself revealed no movement.  A house curette was used to takedown portions of the scutum with extreme care to avoid any inadvertent trauma to the chorda tympani.  The nerve was later hydrated with a small curved needle and an additional fluid to try to avoid inadvertent desiccation of it as well.  The self-retaining speculum holder was used to get secure visibility and argon laser then used to create rosette on the posterior cruse.  The stapes superstructure anteriorly was mobilized with a right angle hook at the incostapedial joint and the superstructure could then be downfractured.  The fenestration created in the footplate was nearly perfect for placement of the piston and therefore additional laser vaporization was not required in this particular situation.  A small bit of additional footplate was removed with a right angle hook to accommodate the 0.6 mm piston.  The measuring device was used and a 4.25 mm slim shaft wire Teflon piston chosen.  It was placed in the middle ear atraumatically with a small alligator forceps and was directed towards the fenestration in the footplate.  The hook was placed over the incus and measurement appeared to be appropriate.  A downbiting crimper was then used to complete the attachment of the prosthesis to the incus.  Prosthesis is once again checked for location and centering and appeared to be in ideal position.  Small pledgets of fat were placed around the perimeter of the piston in an attempt to avoid any postoperative drainage of perilymph.  A small pledget of fat was also placed on the top of the incudo-prosthesis junction.  The mobility appeared excellent.  The flap was placed back in its normal anatomic position.  The external canal packed with small pledgets of Gelfoam and antibiotic ointment.  She was then awakened and taken to the recovery room in a stable condition with discharge anticipated later this day to Bishop.  Sutures will be out in a week and a recheck in Reno in four to five weeks from now.","ent - otolaryngology, bilateral progressive conductive hearing loss, argon laser assisted, conductive hearing losses, intubation, argon, stapedectomy, otosclerosis, canal, earlobe, prosthesis, pledgets, laser"
" Left thoracoscopy and left thoracotomy with declaudication and drainage of lung abscesses, and multiple biopsies of pleura and lung.", ENT - Otolaryngology, Thoracoscopy/Thoracotomy ,"PREOPERATIVE DIAGNOSES:,  Empyema of the left chest and consolidation of the left lung.,POSTOPERATIVE DIAGNOSES:,  Empyema of the left chest, consolidation of the left lung, lung abscesses of the left upper lobe and left lower lobe.,OPERATIVE PROCEDURE: , Left thoracoscopy and left thoracotomy with declaudication and drainage of lung abscesses, and multiple biopsies of pleura and lung.,ANESTHESIA:,  General.,FINDINGS: , The patient has a complex history, which goes back about four months ago when she started having respiratory symptoms and one week ago she was admitted to another hospital with hemoptysis and on her evaluation there which included two CAT scans of chest she was found to have marked consolidation of the left lung with a questionable lung abscess or cavity with hydropneumothorax.  There was also noted to be some mild infiltrates of the right lung.  The patient had a 30-year history of cigarette smoking.  A chest tube was placed at the other hospital, which produced some brownish fluid that had foul odor, actually what was thought to be a fecal-like odor.  Then an abdominal CT scan was done, which did not suggest any communication of the bowel into the pleural cavity or any other significant abnormalities in the abdomen on the abdominal CT.  The patient was started on antibiotics and was then taken to the operating room, where there was to be a thoracoscopy performed.  The patient had a flexible fiberoptic bronchoscopy that showed no endobronchial lesions, but there was bloody mucous in the left main stem bronchus and this was suctioned out.  This was suctioned out with the addition of the use of saline ***** in the bronchus.  Following the bronchoscopy, a double lumen tube was placed, but it was not possible to secure the double lumen to the place so we did not proceed with the thoracoscopy on that day.,The patient was transferred for continued evaluation and treatment.  Today, the double lumen tube was placed and there was some erythema of the mucosa noted in the airways in the bronchi and also remarkably bloody secretions were also noted.  These were suctioned, but it was enough to produce a temporary obstruction of the left mainstem bronchus.  Eventually, the double lumen tube was secured and an attempt at a left thoracoscopy was performed after the chest tube was removed and digital dissection was carried out through that.  The chest tube tract, which was about in the sixth or seventh intercostal space, but it was not possible to dissect enough down to get a acceptable visualization through this tract.  A second incision for thoracoscopy was made about on the sixth intercostal space in the midaxillary line and again some digital dissection was carried out but it was not enough to be able to achieve an opening or space for satisfactory inspection of the pleural cavity.  Therefore the chest was opened and remarkable findings included a very dense consolidation of the entire lung such that it was very hard and firm throughout.  Remarkably, the surface of the lower lobe laterally was not completely covered with a fibrotic line, but it was more the line anterior and posterior and more of it over the left upper lobe.  There were many pockets of purulent material, which had a gray-white appearance to it.  There was quite a bit of whitish fibrotic fibrinous deposit on the parietal pleura of the lung especially the upper lobe.  The adhesions were taken down and they were quite bloody in some areas indicating that the process had been present for some time.  There seemed to be an abscess that was about 3 cm in dimension, all the lateral basilar segment of the lower lobe near the area where the chest tube was placed.  Many cultures were taken from several areas.  The most remarkable finding was a large cavity, which was probably about 11 cm in dimension, containing grayish pus and also caseous-like material, it was thought to be perhaps necrotic lung tissue, perhaps a deposit related to tuberculosis in the cavity.,The apex of the lung was quite densely adhered to the parietal pleura there and the adhesions were quite thickened and firm.,PROCEDURE AND TECHNIQUE:,  With the patient lying with the right side down on the operating table the left chest was prepped and draped in sterile manner.  The chest tube had been removed and initially a blunt dissection was carried out through the old chest tube tract, but then it was necessary to enlarge it slightly in order to get the Thoracoport in place and this was done and as mentioned above we could not achieve the satisfactory visualization through this.  Therefore, the next incision for Thoracoport and thoracoscopy insertion through the port was over the sixth intercostal space and a little bit better visualization was achieved, but it was clear that we would be unable to complete the procedure by thoracoscopy.  Therefore posterolateral thoracotomy incision was made, entering the pleural space and what is probably the sixth intercostal space.  Quite a bit of blunt and sharp and electrocautery dissection was performed to take down adhesions to the set of the fibrinous deposit on the pleural cavity.  Specimens for culture were taken and specimens for permanent histology were taken and a frozen section of one of the most quite dense.  Suture ligatures of Prolene were required.  When the cavity was encountered it was due to some compression and dissection of some of the fibrinous deposit in the upper lobe laterally and anterior and this became identified as a very thin layer in one area over this abscess and when it was opened it was quite large and we unroofed it completely and there was bleeding down in the depths of the cavity, which appeared to be from pulmonary veins and these were sutured with a ""tissue pledget"" of what was probably intercostal nozzle and endothoracic fascia with Prolene sutures.,Also as the upper lobe was retracted in caudal direction the tissue was quite dense and the superior branch of the pulmonary artery on the left side was torn and for hemostasis a 14-French Foley catheter was passed into the area of the tear and the balloon was inflated, which helped establish hemostasis and suturing was carried out again with utilizing a small pledget what was probably intercostal muscle and endothoracic fascia and this was sutured in place and the Foley catheter was removed.  The patch was sutured onto the pulmonary artery tear.  A similar maneuver was utilized on the pulmonary vein bleeding site down deep in the cavity.  Also on the pulmonary artery repair some ***** material was used and also thrombin, Gelfoam and Surgicel.  After reasonably good hemostasis was established pleural cavity was irrigated with saline.  As mentioned, biopsies were taken from multiple sites on the pleura and on the edge and on the lung.  Then two #24 Blake chest tubes were placed, one through a stab wound above the incision anteriorly and one below and one in the inferior pleural space and tubes were brought out through stab wounds necked into the skin with 0 silk.  One was positioned posteriorly and the other anteriorly and in the cephalad direction of the apex.  These were later connected to water-seal suction at 40 cm of water with negative pressure.,Good hemostasis was observed.  Sponge count was reported as being correct.  Intercostal nerve blocks at probably the fifth, sixth, and seventh intercostal nerves was carried out.  Then the sixth rib had been broken and with retraction the fractured ends were resected and rongeur used to smooth out the end fragments of this rib.  Metallic clip was passed through the rib to facilitate passage of an intracostal suture, but the bone was partially fractured inferiorly and it was very difficult to get the suture out through the inner cortical table, so that pericostal sutures were used with #1 Vicryl.  The chest wall was closed with running #1 Vicryl and then 2-0 Vicryl subcutaneous and staples on the skin.  The chest tubes were connected to water-seal drainage with 40 cm of water negative pressure.  Sterile dressings were applied.  The patient tolerated the procedure well and was turned in the supine position where the double lumen endotracheal tube was switched out with single lumen.  The patient tolerated the procedure well and was taken to the intensive care unit in satisfactory condition.","ent - otolaryngology, empyema, biopsies, bronchus, declaudication, endothoracic, hydropneumothorax, left lower lobe, left lung, left upper lobe, mainstem, pleura, thoracoscopy, thoracotomy, thoracotomy with declaudication, declaudication and drainage, double lumen tube, sixth intercostal space, lung abscesses, pleural cavity, intercostal space, upper lobe, double lumen, chest tube, cavity, tube, chest, lung, pulmonary, pleural, intercostal,"
 Underwent tonsillectomy and adenoidectomy two weeks ago. , ENT - Otolaryngology, Status Post T&A ,"SUBJECTIVE:,  A 6-year-old boy who underwent tonsillectomy and adenoidectomy two weeks ago.  Also, I cleaned out his maxillary sinuses.  Symptoms included loud snoring at night, sinus infections, throat infections, not sleeping well, and fatigue.  The surgery went well, and I had planned for him to stay overnight, but Mom reminds me that by about 8 p.m. the night nurse gotten him to take fluids well and we let him go home then that evening.  He finished up his Augmentin, by a day or two later he was off the Lortab.  Mom has not noticed any unusual voice change.  No swallowing difficulty except he does not like the taste of acidic foods such as tomato sauce.  He has not had any nasal discharge or ever had any bleeding.  He seems to be breathing better.,OBJECTIVE:,  Exam looks good.  The pharynx is well healed.  Tongue mobility is normal.  Voice sounds clear.  Nasal passages reveal no discharge or crusting.,RECOMMENDATION:,  I told Mom it is okay to use some ibuprofen in case his mouth or jaws are still sensitive.  He says it seems to hurt if he opens his mouth real wide such as when he brushes his teeth.  It is okay to chew gum and it is okay to eat crunchy foods such as potato chips.  The pathologist described the expected changes of chronic sinusitis and chronic hypertrophic tonsillitis and adenoiditis, and there were no atypical findings on the laboratories.,I am glad he has healed up well.  There are no other restrictions or limitations.  I told Mom, I had written to Dr. XYZ to let her know of the findings.  The child will continue his regular followup visits with his family doctor, and I told Mom I would be happy to see him anytime if needed.  He did very well after surgery and he seems to feel better and breathe a lot better after his throat and sinus procedure.","ent - otolaryngology, tonsillectomy and adenoidectomy, tonsillectomy, adenoidectomy, maxillary, nasal, sinuses,"
" Functional endoscopic sinus surgery, excision of nasopharyngeal mass via endoscopic technique, and excision of right upper lid skin lesion 1 cm in diameter with adjacent tissue transfer closure.", ENT - Otolaryngology, Sinus Surgery - Endoscopic ,"PREOPERATIVE DIAGNOSES:,1.  Nasopharyngeal mass.,2.  Right upper lid skin lesion.,POSTOPERATIVE DIAGNOSES:,1.  Nasopharyngeal tube mass.,2.  Right upper lid skin lesion.,PROCEDURES PERFORMED:,1.  Functional endoscopic sinus surgery.,2.  Excision of nasopharyngeal mass via endoscopic technique.,3.  Excision of right upper lid skin lesion 1 cm in diameter with adjacent tissue transfer closure.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 30 cc.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE: , The patient is a 51-year-old Caucasian female with a history of a nasopharyngeal mass discovered with patient's chief complaint of nasal congestion and chronic ear disease.  The patient had a fiberoptic nasopharyngoscopy performed in the office which demonstrated the mass and confirmed also on CT scan.  The patient also has had this right upper lid skin lesion which appears to be a cholesterol granuloma for numerous months.  It appears to be growing in size and is irregularly bordered.  After risks, complications, consequences, and questions were addressed to the patient, a written consent was obtained for the procedure.,PROCEDURE: , The patient was brought to the operating suite by Anesthesia and placed on the operating table in supine position.  After this, the patient was turned to 90 degrees by the Department of Anesthesia.  The right upper eyelid skin lesion was injected with 1% lidocaine with epinephrine 1:100,000 approximately 1 cc total.  After this, the patient's bilateral nasal passages were then packed with cocaine-soaked cottonoids of 10% solution of 4 cc total.  The patient was then prepped and draped in usual sterile fashion and the right upper lid skin was then first cut around the skin lesion utilizing a Superblade.  After this, the skin lesion was then grasped with a ________ in the  superior aspect and the skin lesion was cut and removed in the subcutaneous plane utilizing Westcott scissors.  After this, the ________ was then hemostatically controlled with monopolar cauterization.  The patient's skin was then reapproximated with a running #6-0 Prolene suture.  A Mastisol along with a single Steri-Strip was in place followed Maxitrol ointment.  Attention then was drawn to the nasopharynx.  The cocaine-soaked cottonoids were removed from the nasal passages bilaterally and zero-degree otoscope was placed all the way to the patient's nasopharynx.  The patient had a severely deviated nasal septum more so to the right than the left.  There appeared to be a spur on the left inferior aspect and also on the right posterior aspect.  The nasopharyngeal mass appeared polypoid in nature almost lymphoid tissue looking.  It was then localized with 1% lidocaine with epinephrine 1:100,000 of approximately 3 cc total.  After this, the lesion was then removed on the right side with the XPS blade.  The torus tubarius was noted on the left side with the polypoid lymphoid tissue involving this area completely.  This area was taken down with the XPS blade.  Prior to taking down this lesion with the XPS, multiple biopsies were taken with a straight biter.  After this, a cocaine-soaked cottonoid was placed back in the patient's left nasal passage region and the nasopharynx and the attention was then drawn to the right side.  The zero-degree otoscope was placed in the patient's right nasal passage and all the way to the nasopharynx.  Again, the XPS was then utilized to take down the nasopharyngeal mass in its entirety with some involvement overlying the torus tubarius.  After this, the patient was then hemostatically controlled with suctioned Bovie cauterization.  A FloSeal was then placed followed by bilateral Merocels and bacitracin-coated ointment.  The patient's Meroceles were then tied together to the patient's forehead and the patient was then turned back to the Anesthesia.  The patient was extubated in the operating room and was transferred to the recovery room in stable condition.  The patient tolerated the procedure well and sent home and with instructions to followup approximately in one week.  The patient will be sent home with a prescription for Keflex 500 mg one p.o. b.i.d, and Tylenol #3 one to two p.o. q.4-6h. pain #30.","ent - otolaryngology, nasopharyngeal tube mass, lymphoid tissue, torus tubarius, sinus surgery, nasal passages, nasopharyngeal mass, skin lesion, lesion, nasopharynx, endoscopic, nasopharyngeal,"
" Patient with postnasal drainage, sore throat, facial pain, coughing, headaches, congestion, snoring, nasal burning and teeth pain.", ENT - Otolaryngology, Sinus problems - Consult ,"CHIEF COMPLAINT:, Sinus problems.,SINUSITIS HISTORY:, The problem began 2 weeks ago and is constant. Symptoms include postnasal drainage, sore throat, facial pain, coughing, headaches and congestion. Additional symptoms include snoring, nasal burning and teeth pain. The symptoms are characterized as moderate to severe. Symptoms are worse in the evening and morning.,REVIEW OF SYSTEMS:,ROS General: General health is good.,ROS ENT: As noted in history of present Illness listed above.,ROS Respiratory: Patient denies any respiratory complaints, such as cough, shortness of breath, chest pain, wheezing, hemoptysis, etc.,ROS Gastrointestinal: Patient denies any nausea, vomiting, abdominal pain, dysphagia or any altered bowel movements.,ROS Respiratory: Complaints include coughing.,ROS Neurological: Patient complains of headaches. All other systems are negative.,PAST SURGICAL HISTORY:, Gallbladder 7/82. Hernia 5/79,PAST MEDICAL HISTORY:, Negative.,PAST SOCIAL HISTORY:, Marital Status: Married. Denies the use of alcohol. Patient has a history of smoking 1 pack of cigarettes per day and for the past 15 years. There are no animals inside the home.,FAMILY MEDICAL HISTORY:, Family history of allergies and hypertension.,CURRENT MEDICATIONS:, Claritin. Dilantin.,PREVIOUS MEDICATIONS UTILIZED:, Rhinocort Nasal Spray.,EXAM:,Exam Ear: Auricles/external auditory canals reveal no significant abnormalities bilaterally. TMs intact with no middle ear effusion and are mobile to insufflation.,Exam Nose: Intranasal exam reveals moderate congestion and purulent mucus.,Exam Oropharynx: Examination of the teeth/alveolar ridges reveals missing molar (s). Examination of the posterior pharynx reveals a prominent uvula and purulent postnasal drainage. The palatine tonsils are 2+ and cryptic.,Exam Neck: Palpation of anterior neck reveals no tenderness. Examination of the posterior neck reveals mild tenderness to palpation of the suboccipital muscles.,Exam Facial: There is bilateral maxillary sinus tenderness to palpation.,X-RAY / LAB FINDINGS:, Water's view x-ray reveals bilateral maxillary mucosal thickening.,IMPRESSION:, Acute maxillary sinusitis (461.0).  Snoring (786.09).,MEDICATION:, Augmentin. 875 mg bid. MucoFen 800 mg bid.,PLAN:,",
 A sample note on serous otitis media, ENT - Otolaryngology, SOM - Serous Otitis Media ,"Because children need hearing to learn speech, hearing loss from fluid in the middle ear can result in speech delay.  Children begin to speak some words by 18 months.  Children with fluid in both ears can show significant delay in their use of language.  In addition, young children learn to pronounce words by hearing them spoken.  When there is a hearing loss, even a mild one, the spoken words of parents and siblings are distorted to the child with fluid in the ears.  Identification of fluid in the middle ear is important, not only to prevent future speech problems, but to avoid permanent damage to the eardrum and the middle ear.  Most children will have at least one ear infection before the age of four.,With treatment, the ear infections clear up promptly.  Without the follow-up visit, fluid may still be present, even though the child has no complaints or symptoms.  Therefore, it is essential that ear infections be rechecked after initial treatment.  Usually, the presence of fluid results in a ""mild conductive hearing loss."" This could be as much as 30% hearing loss overall.  After the specialist confirms that fluid is present behind both eardrums, further medical treatment is often advised.  This may consist of additional antibiotics, decongestants, and in some cases, nasal sprays.  If fluid has been present for over 12 weeks, surgical drainage of the fluid is often indicated.  The decision to perform surgery should be based on the response to medical treatment, the degree of hearing loss and the appearance of the eardum itself under the surgical microscope.  Surgery which drains fluid involves a small incision in the eardrum, so that the fluid can be gently removed and a tube can be inserted.  The procedure, medically termed a myringotomy and tubes, or tympanostomy and tube, (BMT if Bilateral) or PET (Pressure Equalizing Tubes), is performed on children under general anesthesia.","ent - otolaryngology, tube, bmt, pet, pressure equalizing tubes, serous otitis media, eustachian tube, ear infections, otitis media, middle ear, hearing loss, ear, children, fluid, drain, eustachian, otitis, media, eardrum, infections, middle, loss, hearingNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Revision septoplasty, repair of internal nasal valve collapse using auricular cartilage, repair of bilateral external nasal valve collapse using auricular cartilage, harvest of right auricular cartilage.", ENT - Otolaryngology, Septoplasty ,"PREOPERATIVE DIAGNOSES:,1.  Nasal septal deviation.,2.  Bilateral internal nasal valve collapse.,3.  Bilateral external nasal valve collapse.,POSTOPERATIVE DIAGNOSES:,1.  Nasal septal deviation.,2.  Bilateral internal nasal valve collapse.,3.  Bilateral external nasal valve collapse.,PROCEDURES:,1.  Revision septoplasty.,2.  Repair of internal nasal valve collapse using auricular cartilage.,3.  Repair of bilateral external nasal valve collapse using auricular cartilage.,4.  Harvest of right auricular cartilage.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , Approximately 20 mL.,IV FLUIDS: , Include a liter of crystalloid fluid.,URINE OUTPUT: , None.,FINDINGS: , Include that of significantly deviated septum with postoperative changes and a significant septal spur along the floor.  There is also evidence of bilateral internal as well as external nasal valve collapse.,INDICATIONS:  ,The patient is a pleasant 49-year-old gentleman who had undergone a previous septorhinoplasty after significant trauma in his 20s.  He now presents with significant upper airway resistance and nasal obstruction and is unable to tolerate a CPAP machine.  Therefore, for repair of the above-mentioned deformities including the internal and external nasal valve collapse as well as straightening of the deviated septum, the risks and benefits of the procedure were discussed with him included but not limited to bleeding, infection, septal perforation, need for further surgeries, external deformity, and he desired to proceed with surgery.,DESCRIPTION OF THE PROCEDURE IN DETAIL:  ,The patient was taken to the operating room and laid supine upon the OR table.  After the induction of general endotracheal anesthesia, the nose was decongested using Afrin-soaked pledgets followed by the injection of % lidocaine with 1:100,000 epinephrine in the submucoperichondrial planes bilaterally.  Examination revealed significant deviation of the nasal septum and the bony cartilaginous junction as well as the large septal spur along the floor.  The caudal septum appeared to be now in adequate position.  There was evidence that there had been a previous caudal septal graft on the right nares and it was decided to leave this in place.  Following the evaluation of the nose, a hemitransfixion incision was made on the left revealing a large septal spur consisting primarily down on the floor of the left nostril creating nearly a picture of the vestibular stenosis on the side.  Very carefully, the mucoperichondrial flaps were elevated over this, and it was excised using an osteotome taking care to preserve the 1.5 cm dorsal and caudal strap of the nasal septum and keep it attached to the nasal spine.  Very carefully, the bony cartilaginous junction was identified and a small piece of the bone, where the spur was, was carefully removed.  Following this, it was noted that the cartilaginous region was satisfactory in quantity as well as quality to perform adequate grafting procedures.  Therefore, attention was turned to harvesting the right-sided auricular cartilage, which was done after the region had adequately been prepped and draped in a sterile fashion.  Postauricular incision using a #15 blade, the area of the submucoperichondrial plane was elevated in order to preserve the nice lining and identifiable portion of the cartilage taking care to preserve the ridge of the helix at all times.  This was very carefully harvested.  This area had been injected previously with 1% lidocaine and 1:100,000 epinephrine.  Following this, the cartilage was removed.  It was placed in saline, noted to be fashioned in the bilateral spreader graft and alar rim graft as well as a small piece of crush which was used to be placed along the top of the dorsal irregularity.  The spreader grafts were sutured in place using submucoperichondrial pockets.  After an external septorhinoplasty approach had been performed and reflection of the skin and soft tissue envelope had been performed, adequately revealing straight septum with significant narrowing with what appeared to be detached perhaps from his ipsilateral cartilages rather from his previous surgery.  These were secured in place in the pockets using a 5-0 PDS suture in a mattress fashion in two places.  Following this, attention was turned to placing the alar rim grafts where pockets were created along the caudal aspect of the lower lateral cartilage and just along the alar margin.  Subsequently, the alar rim grafts were placed and extended all the way to the piriform aperture.  This was sutured in place using a 5-0 self-absorbing gut suture.  The lower lateral cartilage has had some inherent asymmetry.  This may have been related to his previous surgery with some asymmetry of the dome; however, this was left in place as he did not desire any changes in the tip region, and there was adequate support.  An endodermal suture was placed just to reenforce the region using a 5-0 PDS suture.  Following all this, the area was closed using a mattress 4-0 plain gut on a Keith needle followed by the application of ***** 5-0 fast-absorbing gut to close the hemitransfixion incision.  Very carefully, the skin and subcutaneous tissue envelopes were reflected.  The curvilinear incision was closed using a Vicryl followed by interrupted 6-0 Prolene sutures.  The marginal incisions were then closed using 5-0 fast-absorbing gut.  Doyle splints were placed and secured down using a nylon suture.  They had ointment also placed on them.  Following this, nasopharynx was suctioned.  There were no further abnormalities noted and everything appeared to be in nice position.  Therefore, an external splint was placed after the application of Steri-Strips.  The patient tolerated the procedure well.  He was awakened in the operating room.  He was extubated and taken to the recovery room in stable condition.","ent - otolaryngology, nasal septal deviation, nasal septal, auricular cartilage, nasal, nasal obstruction, nasal valve, septoplasty, submucoperichondrial, upper airway, internal nasal valve, external nasal valve, hemitransfixion incision, revision septoplasty, septal spur, valve collapse, auricular, cartilage, collapse, septum, valve, "
" Septoplasty with partial inferior middle turbinectomy with KTP laser, sinus endoscopy with maxillary antrostomies, removal of tissue, with septoplasty and partial ethmoidectomy bilaterally.", ENT - Otolaryngology, Septoplasty & Turbinectomy ,"OPERATIVE DIAGNOSES: , Chronic sinusitis with deviated nasal septum and nasal obstruction and hypertrophied turbinates.,OPERATIONS PERFORMED: , Septoplasty with partial inferior middle turbinectomy with KTP laser, sinus endoscopy with maxillary antrostomies, removal of tissue, with septoplasty and partial ethmoidectomy bilaterally.,OPERATION: , The patient was taken to the operating room.  After adequate anesthesia via endotracheal intubation, the nose was prepped with Afrin nasal spray.  After this was done, 1% Xylocaine with 100,000 epinephrine was infiltrated in both sides of the septum and the mucoperichondrium.  After this, the sinus endoscope at 25-degrees was then used to examine the nasal cavity in the left nasal cavity and staying lateral to the middle turbinate.  A 45-degree forceps then used to open up the maxillary sinus.  There was some prominent tissue and just superior to this, the anterior ethmoid was opened.  The 45-degree forceps was then used to open the maxillary sinus ostium.  This was enlarged with backbiting rongeur.  After this was done, the tissue found in the ethmoid and maxillary sinus were removed and sent to pathology and labeled as left maxillary sinus mucosa.  After this was done, attention was then turned to the right nasal cavity staying laterally to the middle turbinate.  There was noted to have prominence in the anterior ethmoidal area.  This was then opened with 45-degree forceps.  This mucosa was then removed from the anterior area.  The maxillary sinus ostium was then opened with 45-degree forceps.  Tissue was removed from this area.  This was sent as right maxillary mucosa.  After this, the backbiting rongeur was then used to open up the ostium and enlarge the ostium on the right maxillary sinus.  Protecting the eyes with wet gauze and using KTP laser at 10 watts, the sinus endoscope was used for observation and the submucosal resection was done of both inferior turbinates as well as anterior portion of the middle turbinates bilaterally.  This was to open up to expose the maxillary ostium as well as other sinus ostium to minimize swelling and obstruction.  After this was completed, a septoplasty was performed.  The incision was made with a #15 blade Bard-Parker knife.  The flap was then elevated, overlying the spur that was protruding into the right nasal cavity.  This was excised with a #15 blade Bard-Parker knife.  The tissue was then laid back in position.  After this was laid back in position, the nasal cavity was irrigated with saline solution, suctioned well as well as the oropharynx.  , ,Surgicel with antibiotic ointment was placed in each nostril and sutured outside the nose with 3-0 nylon.  The patient was then awakened and taken to recovery room in good condition.","ent - otolaryngology, sinusitis, ktp laser, septoplasty, deviated, endoscopy, ethmoidectomy, hypertrophied, maxillary, nasal obstruction, nasal septum, sinus, turbinates, turbinectomy, partial ethmoidectomy, parker knife, sinus ostium, nasal cavity, maxillary sinus, ktp, mucosa, cavity, forceps, antrostomies, ostium, nasal"
 Acute supraglottitis with airway obstruction and parapharyngeal cellulitis and peritonsillar cellulitis., ENT - Otolaryngology, Progress Note - Supraglottitis ,"HISTORY: , A 59-year-old male presents in followup after being evaluated and treated as an in-patient by Dr. X for acute supraglottitis with airway obstruction and parapharyngeal cellulitis and peritonsillar cellulitis, admitted on 05/23/2008, discharged on 05/24/2008.  Please refer to chart for history and physical and review of systems and medical record.,PROCEDURES PERFORMED:  ,Fiberoptic laryngoscopy identifying about 30% positive Muller maneuver.  No supraglottic edema; +2/4 tonsils with small tonsil cyst, mid tonsil, left.,IMPRESSION:  ,1.  Resolving acute supraglottic edema secondary to pharyngitis and tonsillar cellulitis.,2.  Possible obstructive sleep apnea; however, the patient describes no known history of this phenomenon.,3.  Hypercholesterolemia.,4.  History of anxiety.,5.  History of coronary artery disease.,6.  Hypertension.,RECOMMENDATIONS: , Recommend continuing on Augmentin and tapered prednisone as prescribed by Dr. X.  Cultures are still pending and follow up with Dr. X in the next few weeks for re-evaluation.  I did discuss with the patient whether or not a sleep study would be beneficial and the patient denies any history of obstructive sleep apnea and wishes not to pursue this, but we will leave this open for him to talk with Dr. X on his followup, and he will pay more attention on his sleep pattern.","ent - otolaryngology, acute supraglottic edema, obstructive sleep apnea, acute supraglottitis, airway obstruction, parapharyngeal cellulitis, peritonsillar cellulitis, supraglottic edema, supraglottitis, tonsils, cellulitis "
 Revision rhinoplasty and left conchal cartilage harvest to correct nasal deformity., ENT - Otolaryngology, Revision Rhinoplasty. ,"PREOPERATIVE DIAGNOSIS: , Nasal deformity, status post rhinoplasty.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE:,  Revision rhinoplasty (CPT 30450).  Left conchal cartilage harvest (CPT 21235).,ANESTHESIA: , General.,INDICATIONS FOR THE PROCEDURE: , This patient is an otherwise healthy male who had a previous nasal fracture.  During his healing, perioperatively he did sustain a hockey puck to the nose resulting in a saddle-nose deformity with septal hematoma.  The patient healed status post rhinoplasty as a result but was left with a persistent saddle-nose dorsal defect.  The patient was consented for the above-stated procedure.  The risks, benefits, and alternatives were discussed.,DESCRIPTION OF PROCEDURE: ,The patient was prepped and draped in the usual sterile fashion.  The patient did have approximately 12 mL of Lidocaine with epinephrine 1% with 1:100,000 infiltrated into the nasal soft tissues.  In addition to this, cocaine pledgets were placed to assist with hemostasis.,At this point, attention was turned to the left ear.  Approximately 3 mL of 1% Lidocaine with 1:100,000 epinephrine was infiltrated into the subcutaneous tissues of the conchal bulb.  Betadine was utilized for preparation.  A 15 blade was used to incise along the posterior conchal area and a Freer elevator was utilized to lift the soft tissues off the conchal cartilage in a submucoperichondrial plane.  I then completed this along the posterior aspect of the conchal cartilage, was transected in the concha cavum and concha cymba, both were harvested.  These were placed aside in saline.  Hemostasis was obtained with bipolar electrocauterization.  Bovie electrocauterization was also employed as needed.  The entire length of the wound was then closed with 5-0 plain running locking suture.  The patient then had a Telfa placed both anterior and posterior to the conchal defect and placed in a sandwich dressing utilizing a 2-0 Prolene suture.  Antibiotic ointment was applied generously.,Next, attention was turned to opening and lifting the soft tissues of the nose.  A typical external columella inverted V gull-wing incision was placed on the columella and trailed into a marginal incision.  The soft tissues of the nose were then elevated using curved sharp scissors and Metzenbaums.  Soft tissues were elevated over the lower lateral cartilages, upper lateral cartilages onto the nasal dorsum.  At this point, attention was turned to osteotomies and examination of the external cartilages.,The patient did have very broad lower lateral cartilages leading to a bulbous tip.  The lower lateral cartilages were trimmed in a symmetrical fashion leaving at least 8 mm of lower lateral cartilage bilaterally along the lateral aspect.  Having completed this, the patient had medial and lateral osteotomies performed with a 2-mm osteotome.  These were done transmucosally after elevating the tract using a Cottle elevator.  Direct hemostasis pressure was applied to assist with bruising.,Next, attention was turned to tip mechanisms.  The patient had a series of double-dome sutures placed into the nasal tip.  Then, 5-0 Dexon was employed for intradomal suturing, 5-0 clear Prolene was used for interdomal suturing.  Having completed this, a 5-0 clear Prolene alar spanning suture was employed to narrow the superior tip area.,Next, attention was turned to dorsal augmentation.  A Gore-Tex small implant had been selected, previously incised.  This was taken to the back table and carved under sterile conditions.  The patient then had the implant placed into the super-tip area to assist with support of the nasal dorsum.  It was placed into a precise pocket and remained in the midline.,Next, attention was turned to performing a columella strut.  The cartilage from the concha was shaped into a strut and placed into a precision pocket between the medial footplate of the lower lateral cartilage.  This was fixed into position utilizing a 5-0 Dexon suture.,Having completed placement of all augmentation grafts, the patient was examined for hemostasis.  The external columella inverted gull-wing incision along the nasal tip was closed with a series of interrupted everting 6-0 black nylon sutures.  The entire marginal incisions for cosmetic rhinoplasty were closed utilizing a series of 5-0 plain interrupted sutures.,At the termination of the case, the ear was inspected and the position of the conchal cartilage harvest was hemostatic.  There was no evidence of hematoma, and the patient had a series of brown Steri-Strips and Aquaplast cast placed over the nasal dorsum.  The inner nasal area was then examined at the termination of the case and it seemed to be hemostatic as well.,The patient was transferred to the PACU in stable condition.  He was charged to home on antibiotics to prevent infection both from the left ear conchal cartilage harvest and also the Gore-Tex implant area.  He was asked to follow up in 4 days for removal of the bolster overlying the conchal cartilage harvest.","ent - otolaryngology, nasal deformity, rhinoplasty, conchal cartilage harvest, conchal bulb, conchal, submucoperichondrial, gull-wing incision, gore-tex, gull wing incision, lower lateral cartilages, revision rhinoplasty, nasal dorsum, cartilage harvest, conchal cartilage, cartilage, nasal, deformity, hemostasis, columella, harvest, cartilages"
 Open septorhinoplasty with placement of bilateral spreader grafts.  Bilateral lateral osteotomies., ENT - Otolaryngology, Septorhinoplasty ,"PREOPERATIVE DIAGNOSIS: , Acquired nasal septal deformity.,POSTOPERATIVE DIAGNOSIS: , Acquired nasal septal deformity.,PROCEDURES:,1.  Open septorhinoplasty with placement of bilateral spreader grafts.,2.  Placement of a radiated rib tip graft.,3.  Placement of a morcellized autogenous cartilage dorsal onlay graft.,4.  Placement of endogen, radiated collagen dorsal onlay graft.,5.  Placement of autogenous cartilage columellar strut graft.,6.  Bilateral lateral osteotomies.,7.  Takedown of the dorsal hump with repair of the bony and cartilaginous open roof deformities.,8.  Fracture of right upper lateral cartilage.,ANESTHESIA:  ,General endotracheal tube anesthesia.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:  ,100 mL.,URINE OUTPUT:,  Not recorded.,SPECIMENS:,  None.,DRAINS: , None.,FINDINGS:  ,1.  The patient had a marked dorsal hump, which was both bony and cartilaginous in nature.,2.  The patient had marked hypertrophy of his nasalis muscle bilaterally contributing to the soft tissue dorsal hump.,3.  The patient had a C-shaped deformity to the left before he had tip ptosis.,INDICATIONS FOR PROCEDURE: , The patient is a 22-year-old Hispanic male who is status post blunt trauma to the nose approximately 9 months with the second episode 2 weeks following and suffered a marked dorsal deformity.  The patient was evaluated, but did not complain of nasal obstruction, and his main complaint was his cosmetic deformity.  He was found to have a C-shaped deformity to the left as well as some tip ptosis.  The patient was recommended to undergo an open septorhinoplasty to repair of this cosmetic defect.,OPERATION IN DETAIL: , After obtaining a full consent from the patient, identified the patient, prepped with Betadine, brought to the operating room and placed in the supine position on the operating table.  The appropriate Esmarch was placed; and after adequate sedation, the patient was subsequently intubated without difficulty.  The endotracheal tube was then secured, and the table was then turned clockwise to 90 degrees.  Three Afrin-soaked cottonoids were then placed in nasal cavity bilaterally.  The septum was then injected with 3 mL of 1% lidocaine with 1:100,000 epinephrine in the subperichondrial plane bilaterally.  Then, 50 additional mL of 1% lidocaine with 1:100,000 epinephrine was then injected into the nose in preparation for an open rhinoplasty.,Procedure was begun by first marking a columellar incision.  This incision was made using a #15 blade.  A lateral transfixion incision was then made bilaterally using a #15 blade, and then, the columellar incision was completed using iris scissors with care not to injure the medial crura.  However, there was a dissection injury to the left medial crura.  Dissection was then taken in the subperichondrial plane over the lower lateral cartilages and then on to the upper lateral cartilage.  Once we reached the nasal bone, a Freer was used to elevate the tissue overlying the nasal bone in a subperiosteal fashion.  Once we had completed exposure of the bony cartilaginous structures, we appreciated a very large dorsal hump, which was made up of both a cartilaginous and bony portions.  There was also an obvious fracture of the right upper lateral cartilage.  There was also marked hypertrophy what appeared to be in the nasalis muscle in the area of the dorsal hump.  The skin was contributing to the patient's cosmetic deformity.  In addition, we noted what appeared to be a small mucocele coming from the area of the fractured cartilage on the right upper lateral cartilage.  This mucocele was attempted to be dissected free, most of which was removed via dissection.  We then proceeded to remove takedown of the dorsal hump using a Rubin osteotome.  The dorsal hump was taken down and passed off the table.  Examination of the specimen revealed the marking amount of scar tissue at the junction of the bone and cartilage.  This was passed off to use later for possible onlay grafts.  There was now a marked open roof deformity of the cartilage and bony sprue.  A septoplasty was then performed throughout and a Kelly incision on the right side.  Subperichondrial planes were elevated on the right side, and then, a cartilage was incised using a caudal and subperichondrial plane elevated on the left side.  A 2 x 3-cm piece of the cardinal cartilage was then removed with care to leave at least 1 cm dorsal and caudal septal strut.  This cartilage was passed down the table and then 2 columellar strut grafts measuring approximately 15 mm in length were then used and placed to close the bony and cartilaginous open roof deformities.  The spreader grafts were sewn in place using three interrupted 5-0 PDS sutures placed in the horizontal fashion bilaterally.  Once these were placed, we then proceeded to work on the bony open roof.  Lateral osteotomies were made with 2-mm osteotomes bilaterally.  The nasal bones were then fashioned medially to close the open roof deformity, and this reduced the width of the bony nasal dorsum.  We then proceeded to the tip.  A cartilaginous strut was then fashioned from the cartilaginous septum.  It was approximately 15 mm long.  This was placed, and a pocket was just formed between the medial crura.  This pocket was taken down to the nasal spine, and then, the strut graft was placed.  The intradermal sutures were then placed using interrupted 5-0 PDS suture to help to provide more tip projection and definition.  The intradermal sutures were then placed to help to align the nasal tip.  The cartilage strut was then sutured in place to the medial crura after elevating the vestibular skin off the medial crura in the area of the plane suturing.  Prior to the intradermal suturing, the vestibular skin was also taken off in the area of the dome.,The columellar strut was then sutured in place using interrupted 5-0 PDS suture placed in a horizontal mattress fashion with care to help repair the left medial crural foot.  The patient had good tip support after this maneuver.  We then proceeded to repair the septal deformity created by taking down the dorsal hump with the Rubin osteotome.  This was done by crushing the remaining cartilage in the morcellizer and then wrapping this crushed cartilage in endogen, which is a radiated collagen.  The autogenous cartilage was wrapped in endogen in a sandwich fashion, and then, a 4-0 chromic suture was placed through this to help with placement of the dorsal onlay graft.,The dorsal onlay was then sewn into position, and then, the 4-0 chromic suture was brought out through this externally to help the superior placement of the dorsal onlay graft.  Once we were happy with the position of the dorsal onlay graft, the graft was then sutured in place using two interrupted 4-0 fast-absorbing sutures inferiorly just above the superior edge of the lower lateral cartilages.  Once we were happy with the placement of this, we did need to take down some of the bony dorsal hump laterally, and this was done using a #6 and then followed with a #3 push grafts.  This wrapping was performed prior to placement of the dorsal onlay graft.,I went through content with the dorsal onlay graft and the closure of the roof deformities as well as placement of the columellar strut, we then felt the patient could use a bit more tip projection; and therefore, we fashioned a radiated rib into a small octagon; and this was sutured in place over the tip using two interrupted 5-0 PDS sutures.,At this point, we were happy with the test results, although the patient did have significant amount of fullness in the dorsal hump area due to soft tissue thick and fullness.  There do not appear to be any other pathology causing the patient dorsal hump and therefore, we felt we have achieved the best cosmetic result at this point.  The septum was reapproximated using a fast-absorbing 4-0 suture and a Keith needle placed in the mattress fashion.  The Kelly incision was closed using two interrupted 4-0 fast-absorbing gut suture.  Doyle splints were then placed within the nasal cavity and secured to the inferior septum using a 3-0 monofilament suture.  The columellar skin was reapproximated using interrupted 6-0 nylon sutures, and the marginal incision of the vestibular skin was closed using interrupted 4-0 chromic sutures.,At the end of the procedure, all sponge, needle, and instrument counts were correct.  A Denver external splint was then applied.  The patient was awakened, extubated, and transported to Anesthesia Care Unit in good condition.",
" Nasal endoscopy and partial rhinectomy due to squamous cell carcinoma, left nasal cavity.", ENT - Otolaryngology, Rhinectomy & Nasal Endoscopy ,"PREOPERATIVE DIAGNOSIS: , Squamous cell carcinoma, left nasal cavity.,POSTOPERATIVE DIAGNOSIS:,  Squamous cell carcinoma, left nasal cavity.,OPERATIONS PERFORMED:,1.  Nasal endoscopy.,2.  Partial rhinectomy.,ANESTHESIA:,  General endotracheal.,INDICATIONS: , This is an 81-year-old gentleman who underwent septorhinoplasty many years ago.  He also has a history of a skin lesion, which was removed from the nasal ala many years ago, the details of which he does not recall.  He has been complaining of tenderness and induration of his nasal tip for approximately two years and has been treated unsuccessfully for folliculitis and cellulitis of the nasal tip.  He was evaluated by Dr. A, who performed the septorhinoplasty, and underwent an intranasal biopsy, which showed histologic evidence of invasive squamous cell carcinoma.  The preoperative examination shows induration of the nasal tip without significant erythema.  There is focal tenderness just cephalad to the alar crease.  There is no lesion either externally or intranasally.,PROCEDURE AND FINDINGS: , The patient was taken to the operating room and placed in supine position.  Following induction of adequate general endotracheal anesthesia, the left nose was decongested with Afrin.  He was prepped and draped in standard fashion.  The left nasal cavity was examined by anterior rhinoscopy.  The septum was midline.  There was slight asymmetry of the nares.  No lesion was seen within the nasal cavity either in the area of the intercartilaginous area, which was biopsied by Dr. A, the septum, the lateral nasal wall, and the floor.  The 0-degree nasal endoscope was then used to examine the nasal cavity more completely.  No lesion was detectable.  A left intercartilaginous incision was made with a #15 blade since this was the area of previous biopsy by Dr. A.  The submucosal tissue was thickened diffusely, but there was no identifiable distinct or circumscribed lesion present.  Random biopsies of the submucosal tissue were taken and submitted to pathology for frozen section.  A diagnosis of diffuse invasive squamous cell carcinoma was rendered.  An alar incision was made with a #15 blade and the full-thickness incision was completed with the electrocautery.  The incision was carried more cephalad through the lower lateral cartilage up to the area of the upper lateral cartilage at the superior margin.  The full unit of the left nasal tip was excised completely and submitted to pathology after tagging and labeling it.  Frozen section examination again revealed diffuse squamous cell carcinoma throughout the soft tissues involving all margins.  Additional soft tissue was then taken from all margins tagging them for the pathologist.  The inferior margins were noted to be clear on the next frozen section report, but there was still disease present in the region of the upper lateral cartilage at its insertion with the nasal bone.  A Joseph elevator was used to elevate the periosteum off the maxillary process and off the inferior aspect of the nasal bone.  Additional soft tissue was taken in these regions along the superior margin.  The frozen section examination revealed persistent disease medially and additional soft tissue was taken and submitted to pathology.  Once all margins had been cleared histologically, additional soft tissue was taken from the entire wound.  A 5-mm chisel was used to take down the inferior aspect of the nasal bone and the medial-most aspect of the maxilla.  This was all submitted to pathology for routine permanent examination.  Xeroform gauze was then fashioned to cover the defect and was sutured along the periphery of the wound with interrupted 6-0 nylon suture to provide a barrier and moisture.  The anesthetic was then discontinued as the patient was extubated and transferred to the PACU in good condition having tolerated the procedure well.  Sponge and needle counts were correct.","ent - otolaryngology, nasal cavity, joseph elevator, squamous cell carcinoma, endoscopy, intranasally, maxilla, nasal ala, nasal tip, rhinectomy, septorhinoplasty, nasal endoscopy, lateral cartilage, frozen section, additional soft, squamous cell, cell carcinoma, nasal, cartilage, squamous, carcinoma, cavity, tissue "
" Open reduction and internal plate and screw fixation of depressed anterior table right frontal sinus, transconjunctival exploration of orbital floor, open reduction of nasal septum and nasal pyramid fracture with osteotomy.", ENT - Otolaryngology, Sinus Fractures Repairs ,"PREOPERATIVE DIAGNOSES:,1.  Depressed anterior table frontal sinus fracture on the right side.,2.  Right nasoorbital ethmoid fracture.,3.  Right orbital blowout fracture with entrapped periorbita.,4.  Nasal septal and nasal pyramid fracture with nasal airway obstruction.,POSTOPERATIVE DIAGNOSES:,1.  Depressed anterior table frontal sinus fracture on the right side.,2.  Right nasoorbital ethmoid fracture.,3.  Right orbital blowout fracture with entrapped periorbita.,4.  Nasal septal and nasal pyramid fracture with nasal airway obstruction.,OPERATION:,1.  Open reduction and internal plate and screw fixation of depressed anterior table right frontal sinus.,2.  Transconjunctival exploration of right orbital floor with release of entrapped periorbita.,3.  Open reduction of nasal septum and nasal pyramid fracture with osteotomy.,ANESTHESIA:,  General endotracheal anesthesia.,PROCEDURE: , The patient was placed in the supine position.  Under affects of general endotracheal anesthesia, head and neck were prepped and draped with pHisoHex solution and draped in the appropriate sterile fashion.  A gull-wing incision was drawn over the forehead scalp.  Hair was removed along the suture line and incision was made to skin and subcutaneous tissue of the scalp down to, but not including the pericranium.  An inferiorly based forehead flap was then elevated to the superior orbital rim.  The depression of the anterior table of the frontal sinus was noted.  An incision was made more posterior creating an inferiorly based pericranial flap.  The supraorbital nerve was axing from the supraorbital foramen and the supraorbital foramen was converted to a groove in order to allow further inferior displacement and positioning of the forehead flap.  These allowed exposure of the medial orbital wall on the right side.  The displaced fractures of the right medial orbital wall were repositioned through coronal approach.  ,Further reduction of the nose intranasally also allowed the ethmoid fracture to be aligned more appropriately in the medial wall.  The anterior table fracture was satisfactorily reduced.  Multiple 1.3-mm screws and plate fixation were utilized to recontour the anterior forehead.  A mucocele was removed from the frontal sinus and there was no significant destruction of the posterior wall.  A sinus seeker was utilized and passed into the nasofrontal duct without difficulty.  It was felt that the frontal sinus obliteration would not be necessary.,At this point, the pericranial flap was folded in a fan-folded fashion on top of the plate and screw and hardware and fixed in position with the sutures to remain better contour of the forehead.  At this point, the nose was significantly shifted to the left and an open reduction of the nasal fracture was performed by osteotomies, which were made medially, laterally, and percutaneous transverse osteotomy of the nasal bone on the right side.  There is significant depression of the nasal bone on the left side.  A medial osteotomy was performed on the left side mobilizing nasal pyramid satisfactorily.  There is a high septal deviation, which would not allow complete correction of the deviation.  It was felt that this would best be left for a later date.  Open reduction rhinoplasty could be performed with spread of cartilage grafting in order to straighten the septum high dorsally.  Local infiltration anesthesia 1% Xylocaine with 1:100,000 epinephrine was infiltrated in the conjunctival fornix of the right lower eyelid as well as the inferior orbital rim.  An incision was made in the palpebral conjunctiva and capsular palpebral fascia beneath the tarsal plate preseptal approach to the inferior orbital rim was performed in this fashion.  Dissection proceeded down to the inferior orbital rim and subperiosteal dissection was performed over the orbital floor.  Hemostasis was achieved with electrocautery.  There was entrapped periorbita, which was released to the fractures, which were repositioned, but not fixed in position.  The forced ductions were performed, which demonstrated release of the periorbit satisfactorily.  The conjunctival incision was closed with an interrupted simple 6-0 plain gut suture.  The nasal pyramid was satisfactorily mobilized as well as the nasal septum and brought back to midline position with the help of a Boies elevator for the septum.  The coronal incision was closed with interrupted 3-0 PDS suture for the galea and deep subcutaneous tissue and the skin closed with interrupted surgical staples.  Nose was dressed with Steri-Strips.  Mastisol Orthoplast splint was prepared after the Doyle splints were placed in the nose and secured with 3-0 Prolene suture and the nose packed with two Kennedy Merocel sponges.  A supportive mildly compressive dressing with fluffs, Kerlix, and 4-inch Ace were applied.  The patient tolerated the procedure well and was returned to recovery room in satisfactory condition.","ent - otolaryngology, frontal sinus, nasal septal, transconjunctival, anterior table, ethmoid, ethmoid fracture, gull-wing incision, nasal airway obstruction, nasal pyramid, nasoorbital, osteotomy, phisohex, periorbita, depressed anterior table, nasal pyramid fracture, sinus fractures, inferior orbital, pyramid fracture, entrapped periorbita, orbital, fractures, nasal, frontal, forehead, sinus,"
 Cosmetic rhinoplasty.  Request for cosmetic change in the external appearance of the nose., ENT - Otolaryngology, Rhinoplasty ,"PREOPERATIVE DIAGNOSES:,1.  Nasal obstruction secondary to deviated nasal septum.,2.  Bilateral turbinate hypertrophy.,PROCEDURE:,  Cosmetic rhinoplasty.  Request for cosmetic change in the external appearance of the nose.,ANESTHESIA: , General via endotracheal tube.,INDICATIONS FOR OPERATION:  ,The patient is a 26-year-old white female with longstanding nasal obstruction.  She also has concerns with regard to the external appearance of her nose and is requesting changes in the external appearance of her nose.  From her functional standpoint, she has severe left-sided nasal septal deviation with compensatory inferior turbinate hypertrophy.  From the aesthetic standpoint, the nose is over projected, lacks rotation, and has a large dorsal hump.  First we are going to straighten the nasal septum and reduce the size of the turbinates and then we will also take down the hump, rotate the tip of the nose, and de-project the nasal tip.  I explained to her the risks, benefits, alternatives, and complications for postsurgical procedure.  She had her questions asked and answered and requested that we proceed with surgery as outlined above.,PROCEDURE DETAILS: , The patient was taken to the operating room and placed in supine position.  The appropriate level of general endotracheal anesthesia was induced.  The face, head, and neck were sterilely prepped and draped.  The nose was anesthetized and vasoconstricted in the usual fashion.  Procedure began with a left hemitransfixion incision, which was brought down into the left intercartilaginous incision.  Right intercartilaginous incision was also made and the dorsum of the nose was elevated in the submucoperichondrial and subperiosteal plane.  Intact bilateral septomucoperichondrial flaps were elevated and a severe left-sided nasal septal deviation was corrected by detachment of the caudal nasal septum from the maxillary crest in a swinging door fashion and placing it back into the midline.  Posterior vomerine spur was divided superiorly and inferiorly and a large spur was removed.  Anterior and inferior one-third of each inferior turbinate was clamped, cut, and resected.  The upper lateral cartilages were divided from their attachments to the dorsal nasal septum and the cartilaginous septum was lowered by approximately 2 mm.  The bony hump of the nose was lowered with a straight osteotome by 4 mm.  Fading medial osteotomies were carried out and lateral osteotomies were then created in order to narrow the bony width of the nose.  The tip of the nose was then addressed via a retrograde dissection and removal of cephalic caudal semicircle cartilage medially at the tip.  The caudal septum was shortened by 2 mm in an angle in order to enhance rotation.  Medial crural footplates were reattached to the caudal nasal septum with a projection rotation control suture of #3-0 chromic.  The upper lateral cartilages were rejoined to the dorsal septum with a #4-0 plain gut suture.  No middle valves or bone grafts were necessary.  Intact mucoperichondrial flaps were closed with 4-0 plain gut suture and Doyle nasal splints were placed on either side of the nasal septum.  The middle meatus was filled with Surgicel and Cortisporin otic and external Denver splint was applied with sterile tape and Mastisol.  Excellent aesthetic and functional results were thus obtained and the patient was awakened in the operating room, taken to the recovery room in good condition.","ent - otolaryngology, nasal obstruction, cosmetic, dorsal hump, endotracheal tube, hemitransfixion incision, hypertrophy, intercartilaginous, intercartilaginous incision, nasal septum, nasal tip, septomucoperichondrial, submucoperichondrial, subperiosteal, turbinate, vomerine, spur, nasal septal, nasal, rhinoplasty, septum, "
" Patient with suspected nasal obstruction, possible sleep apnea. ", ENT - Otolaryngology, Recurrent nasal obstruction ,"CHIEF COMPLAINT: , Recurrent nasal obstruction.,HISTORY OF PRESENT ILLNESS:,  The patient is a 5-year-old male, who was last evaluated by Dr. F approximately one year ago for suspected nasal obstruction, possible sleep apnea.  Dr. F's assessment at that time was the patient not had sleep apnea and did not truly even seem to have allergic rhinitis.  All of his symptoms had resolved when he had seen Dr. F, so no surgical plan was made and no further followup was needed.  However, the patient reports again today with his mother that they are now having continued symptoms of nasal obstruction and questionable sleep changes.  Again, the mother gives a very confusing sleep history but it does not truly sound like the child is having apneic events that are obstructive in nature.  It sounds like he is snoring loudly and does have some nasal obstruction at nighttime.  He also is sniffing a lot through his nose.  He has been tried on some nasal steroids but they only use this on a p.r.n. basis about one or two days every month and we are unsure if that has even helped at all, probably not.  The child is not having any problems with his ears including ear infections or hearing.  He is also not having any problems with strep throat.,PAST MEDICAL HISTORY: , Eczema.,PAST SURGICAL HISTORY: , None.,MEDICATIONS:,  None.,ALLERGIES:,  No known drug allergies.,FAMILY HISTORY: , No family history of bleeding diathesis or anesthesia difficulties.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Weight 43 pounds, height 37 inches, temperature 97.4, pulse 65, and blood pressure 104/48.,GENERAL:  The patient is a well-nourished male in no acute distress.  Listening to his voice today in the clinic, he does not sound to have a hyponasal voice and has a wide range of consonant pronunciation.,NOSE:  Anterior rhinoscopy does demonstrate boggy turbinates bilaterally with minimal amount of watery rhinorrhea.,EARS:  The patient tympanic membranes are clear and intact bilaterally.  There is no middle ear effusion.,ORAL CAVITY:  The patient has 2+ tonsils bilaterally.  There are clearly nonobstructive.  His uvula is midline.,NECK:  No lymphadenopathy appreciated.,ASSESSMENT AND PLAN: , This is a 5-year-old male, who presents for repeat evaluation of a possible nasal obstruction, questionable sleep apnea.  Again, the mother gives a confusing sleep history but it does not really sound like he is having apneic events.  They deny any actual gasping events.  It sounds like true obstructive events.  He clearly has some symptoms at this point that would suggest possible allergic rhinitis or chronic rhinitis.  I think the most appropriate way to proceed would be to first try this child on a nasal corticosteroid and use it appropriately.  I have given them prescription for Nasacort Aqua one spray to each nostril twice a day.  I instructed them on correct way to use this and the importance to use it on a daily basis.  They may not see any benefit for several weeks.  I would like to evaluate him in six weeks to see how we are progressing.  If he continues to have problems, I think at that point we may consider performing a transnasal exam in the office to examine his adenoid bed and that would really be the only surgical option for this child.  He may also need an allergy evaluation at that point if he continues to have problems.  However, I would like to be fairly conservative in this child.  Should the mother still have concerns regarding his sleeping at our next visit or should his symptoms worsen (I did instruct her call us if it worsens), we may even need to pursue a sleep study just to settle that issue once and for all.  We will see him back in six weeks.","ent - otolaryngology, recurrent nasal obstruction, allergic rhinitis, apneic events, sleep apnea, nasal obstruction, nasal, apnea, allergic, obstruction, sleep, "
 An example of normal ENT exam., ENT - Otolaryngology, Sample Normal Exam - ENT ,"NASAL EXAM: , The nose is grossly in the midline with no evidence of fractures or dislocations.  The nasal septum is roughly in the midline with pale boggy mucosa and moderately enlarged inferior turbinates.  There is no pus or polyps in the nose on anterior rhinoscopy.  The airway appears adequate.  No external valve prolapses are observed.,THROAT EXAM: , The oral cavity is clear.  The tongue is clear with no lesions noted and with good symmetrical movement.  The parotid and submaxillary ducts are producing clear mucus with no evidence of stones or infection.  Palate is clear.  The tonsils are not prominent.,No overt neoplasms in the mouth are noted.  Lips are clear.  The voice is adequate no deficits or hoarseness.  The saliva is clear.,EARS:  ,Canals are clear.  Eardrums are clear, moving on insufflation and swallowing.  No discharge is noted in the canals.  Hearing appears adequate in normal tonal conversations.,NECK EXAM: , Neck is supple with no palpable masses.  No lymphadenopathy.  The thyroid gland is not palpable.  The trachea is in the midline.  The parotid and submaxillary glands are not enlarged, are symmetrical and are not tender.  The neck movement is adequate.,GROSS NEUROLOGICAL EXAM: , Cranial nerves II-XII are intact.  Extraocular movements are full with no restrictions.  Patient is alert and responsive.,EYE EXAM: , Sclerae are clear.  Conjunctivae are clear.  Pupils respond symmetrically to light.  Extraocular movements are complete and full.","ent - otolaryngology, ent exam, boggy mucosa, inferior turbinates, nasal septum, nose, oral cavity, rhinoscopy, submaxillary ducts, tongue, neck, submaxillary, parotid, parotid and submaxillary, extraocular movements, ent, nasal "
" A 3-year-old female for evaluation of chronic ear infections bilateral - OM (otitis media), suppurative without spontaneous rupture.  Adenoid hyperplasia bilateral.", ENT - Otolaryngology, Otitis Media - H&P ,"CHIEF COMPLAINT:,  This 3-year-old female presents today for evaluation of chronic ear infections bilateral.,ASSOCIATED SIGNS AND SYMPTOMS FOR OTITIS MEDIA: , Associated signs and symptoms include:  cough, fever, irritability and speech and language delay.  Duration (ENT):  Duration of symptom:  12 rounds of antibiotics for otitis media.  Quality of ear problems:  Quality of the pain is throbbing.,ALLERGIES: , No known medical allergies.,MEDICATIONS:,  None currently.,PMH:,  Past medical history is unremarkable.,PSH: , No previous surgeries.,SOCIAL HISTORY:,  Parent admits child is in a large daycare.,FAMILY HISTORY:,  Parent admits a family history of Alzheimer's disease associated with paternal grandmother.,ROS:,  Unremarkable with exception of chief complaint.,PHYSICAL EXAM:,  Temp:  99.6 Weight:  38 lbs.,Patient is a 3-year-old female who appears pleasant, in no apparent distress, her given age, well developed, well nourished and with good attention to hygiene and body habitus.,The child is accompanied by her mother who communicates well in English.,Head & Face:  Inspection of head and face shows no abnormalities.  Examination of salivary glands shows no abnormalities.  Facial strength is normal.,Eyes:  Pupil exam reveals PERRLA.,ENT:  Otoscopic examination reveals otitis media bilateral.,Hearing exam using tuning fork shows hearing to be diminished bilateral.,Inspection of left ear reveals drainage of a small amount.,Inspection of nasal mucosa, septum and turbinates reveals no abnormalities.,Frontal and maxillary sinuses all transilluminate well bilaterally.,Inspection of lips, teeth, gums, and palate reveals no gingival hypertrophy, no pyorrhea, healthy gums, healthy teeth and no abnormalities.,Inspection of the tongue reveals normal color, good motility and midline position.,Examination of oropharynx reveals no abnormalities.,Examination of nasopharynx reveals adenoid hypertrophy.,Neck:  Neck exam reveals no abnormalities.,Lymphatic:  No neck or supraclavicular lymphadenopathy noted.,Respiratory:  Chest inspection reveals chest configuration non-hyperinflated and symmetric expansion.  Auscultation of lungs reveal clear lung fields and no rubs noted.,Cardiovascular:  Heart auscultation reveals no murmurs, gallop, rubs or clicks.,Neurological/Psychiatric:  Testing of cranial nerves reveals no deficits.  Mood and affect normal and appropriate to situation.,TEST RESULTS:,  Audiometry test shows conductive hearing loss at 30 decibels and flat tympanogram.,IMPRESSION: , OM, suppurative without spontaneous rupture.  Adenoid hyperplasia bilateral.,PLAN:,  Patient scheduled for myringotomy and tubes, with adenoidectomy, using general anesthesia, as outpatient and scheduled for 08/07/2003.  Surgery will be performed at Children's Hospital.  Pre-operative consent form read and signed by parent.  Common risks and side effects of the procedure and anesthesia were mentioned.  Parent questions elicited and answered satisfactorily regarding planned procedure.  ,EDUCATIONAL MATERIAL PROVIDED: , Hospital preregistration, middle ear infection and myringtomy and tubes surgery.,PRESCRIPTIONS:,  Augmentin  Dosage:  400 mg-57 mg/5 ml powder for reconstitution  Sig:  One PO Q8h  Dispense:  1 Refills:  0  Allow Generic:  No",
 This patient is one-day postop open parathyroid exploration with subtotal parathyroidectomy and intraoperative PTH monitoring for parathyroid hyperplasia.  She has had an uneventful postoperative night. , ENT - Otolaryngology, Postop Parathyroid Exploration & Parathyroidectomy ,"SUMMARY:  ,This patient is one-day postop open parathyroid exploration with subtotal parathyroidectomy and intraoperative PTH monitoring for parathyroid hyperplasia.  She has had an uneventful postoperative night.  She put out 1175 mL of urine since surgery.  Her incision looks good.  IV site and extremities are unremarkable.,LABORATORY DATA:  ,Her calcium level was 7.5 this morning.  She has been on three Tums orally b.i.d. and I am increasing three Tums orally q.i.d. before meals and at bedtime.,PLAN:,  I will heparin lock her IV, advance her diet, and ambulate her.  I have asked her to increase her prednisone when she goes home.  She will double her regular dose for the next five days.  I will advance her diet.  I will continue to monitor her calcium levels throughout the day.  If they stabilize, I am hopeful that she will be ready for discharge either later today or tomorrow.  She will be given Lortab Elixir 2 to 4 teaspoons orally every four hours p.r.n. pain, dispensed #240 mL with one refill.  Her final calcium dosage will be determined prior to discharge.  I will plan to see her back in the office on the 12/30/08, and she has been instructed to call or return sooner for any problems.","ent - otolaryngology, parathyroid hyperplasia, parathyroid exploration, pth, hyperplasia, parathyroidectomy, parathyroidNOTE"
 Parotidectomy procedure, ENT - Otolaryngology, Parotidectomy ,,"ent - otolaryngology, parotidectomy, mixter clamp, auditory canal, buccal, buccinator, curved clamp, earlobe, fascia, fat layer, frontotemporal, mandibular, mastoid process, parotid, parotid duct, parotid gland, preauricular, preauricular incision, sternocleidomastoid, suction drain, temporoparotid, tied with vicryl sutures, vicryl, gland, nerve, sutures, incisionNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Fever, otitis media, and possible sepsis.", ENT - Otolaryngology, Otitis Media - Discharge Summary ,"ADMITTING DIAGNOSES:,1.  Fever.,2.  Otitis media.,3.  Possible sepsis.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 10-month-old male who was seen in the office 1 day prior to admission.  He has had a 2-day history of fever that has gone up to as high as 103.6 degrees F. He has also had intermittent cough, nasal congestion, and rhinorrhea and no history of rashes.  He has been taking Tylenol and Advil to help decrease the fevers, but the fever has continued to rise.  He was noted to have some increased workup of breathing and parents returned to the office on the day of admission.,PAST MEDICAL HISTORY: , Significant for being born at 33 weeks' gestation with a birth weight of 5 pounds and 1 ounce.,PHYSICAL EXAMINATION: , On exam, he was moderately ill appearing and lethargic.  HEENT:  Atraumatic, normocephalic.  Pupils are equal, round, and reactive to light.  Tympanic membranes were red and yellow, and opaque bilaterally.  Nares were patent.  Oropharynx was slightly moist and pink.  Neck was soft and supple without masses.  Heart is regular rate and rhythm without murmurs.  Lungs showed increased workup of breathing, moderate tachypnea.  No rales, rhonchi or wheezes were noted.  Abdomen:  Soft, nontender, nondistended.  Active bowel sounds.  Neurologic exam showed good muscle strength, normal tone.  Cranial nerves II through XII are grossly intact.,LABORATORY FINDINGS: , He had electrolytes, BUN and creatinine, and glucose all of which were within normal limits.  White blood cell count was 8.6 with 61% neutrophils, 21% lymphocytes, 17% monocytes, suggestive of a viral infection.  Urinalysis was completely unremarkable.  Chest x-ray showed a suboptimal inspiration, but no evidence of an acute process in the chest.,HOSPITAL COURSE: , The patient was admitted to the hospital and allowed a clear liquid diet.  Activity is as tolerates.  CBC with differential, blood culture, electrolytes, BUN, and creatinine, glucose, UA, and urine culture all were ordered.  Chest x-ray was ordered as well with 2 views to evaluate for a possible pneumonia.  Pulse oximetry checks were ordered every shift and as needed with O2 ordered per nasal cannula if O2 saturations were less that 94%.  Gave D5 and quarter of normal saline at 45 mL per hour, which was just slightly above maintenance rate to help with hydration.  He was given ceftriaxone 500 mg IV once daily to treat otitis media and possible sepsis, and I will add Tylenol and ibuprofen as needed for fevers.  Overnight, he did have his oxygen saturations drop and went into oxygen overnight.  His lungs remained clear, but because of the need for O2, we instituted albuterol aerosols every 6 hours to help maintain good lung function.  The nurses were instructed to attempt to wean O2 if possible and advance the diet.  He was doing clear liquids well and so I saline locked to help to accommodate improve the mobility with the patient.  He did well the following evening with no further oxygen requirement.  He continued to spike fevers but last fever was around 13:45 on the previous day.  At the time of exam, he had 100% oxygen saturations on room air with temperature of 99.3 degrees F. with clear lungs.  He was given additional dose of Rocephin when it was felt that it would be appropriate for him to be discharged that morning.,CONDITION OF THE PATIENT AT DISCHARGE: , He was at 100% oxygen saturations on room air with no further dips at night.  He has become afebrile and was having no further increased work of breathing.,DISCHARGE DIAGNOSES:,1.  Bilateral otitis media.,2.  Fever.,PLAN:  ,Recommended discharge.  No restrictions in diet or activity.  He was continued Omnicef 125 mg/5 mL one teaspoon p.o. once daily and instructed to follow up with Dr. X, his primary doctor, on the following Tuesday.  Parents were instructed also to call if new symptoms occurred or he had return if difficulties with breathing or increased lethargy.","ent - otolaryngology, sepsis, cough, nasal congestion, rhinorrhea, oxygen saturations, otitis media, otitis, breathing, lungs, oropharynx, fever"
" The patient is now on his third postoperative day for an open reduction and internal fixation for two facial fractures, as well as open reduction nasal fracture.  He is on his eighth hospital day.", ENT - Otolaryngology, ORIF Facial Fractures - Followup ,"Mr. ABC was transferred to room 123 this afternoon.  We discussed this with the nurses, and it was of course cleared by Dr. X.  The patient is now on his third postoperative day for an open reduction and internal fixation for two facial fractures, as well as open reduction nasal fracture.  He is on his eighth hospital day.,The patient had nasal packing in place, which was removed this evening.  This will make it much easier for him to swallow.  This will facilitate p.o. fluids and IMF diet.,Examination of the face revealed some decreased swelling today.  He had good occlusion with intact intermaxillary fixation.,His tracheotomy tube is in place.  It is a size 8 Shiley nonfenestrated.  He is being suctioned comfortably.,The patient is in need of something for sleep in the evening, so we have recommended Halcion 5 mg at bedtime and repeat of 5 mg in 1 hour if needed.,Tomorrow, we will go ahead and change his trach to a noncuffed or a fenestrated tube, so he may communicate and again this will facilitate his swallowing.  Hopefully, we can decannulate the tracheotomy tube in the next few days.,Overall, I believe this patient is doing well, and we will look forward to being able to transfer him to the prison infirmary.","ent - otolaryngology, fenestrated tube, nasal fracture, facial fractures, orif, tracheotomy, tube, fractures,"
" Sample normal ear, nose, mouth, and throat exam.", ENT - Otolaryngology, Normal ENT Exam ,"EARS, NOSE, MOUTH AND THROAT: , The nose is without any evidence of any deformity.  The ears are with normal-appearing pinna.  Examination of the canals is normal appearing bilaterally.  There is no drainage or erythema noted.  The tympanic membranes are normal appearing with pearly color, normal-appearing landmarks and normal light reflex.  Hearing is grossly intact to finger rubbing and whisper.  The nasal mucosa is moist.  The septum is midline.  There is no evidence of septal hematoma.  The turbinates are without abnormality.  No obvious abnormalities to the lips.  The teeth are unremarkable.  The gingivae are without any obvious evidence of infection.  The oral mucosa is moist and pink.  There are no obvious masses to the hard or soft palate.  The uvula is midline.  The salivary glands appear unremarkable.  The tongue is midline.  The posterior pharynx is without erythema or exudate.  The tonsils are normal appearing.","ent - otolaryngology, erythema, tympanic, mouth, throat, ears, mucosa, noseNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 A sample note on otitis media., ENT - Otolaryngology, Otitis Media ,"OTITIS MEDIA, is an infection of the middle ear space where the small bones and nerves of the ear connect to the eardrum on one side and the eustachian tube on the other.  The ear infection itself is not contagious but the respiratory infection preceding it is transmittable.  Otitis media is most often seen in infants and young children.  There are several causes including a viral or bacterial infection that spreads to the middle ear by way of the eustachian tubes, nasal allergy drainage blocking the sinuses or eustachian tubes, enlarged adenoids also blocking sinuses or eustachian tubes and eardrum rupture.  Many factors can increase the risk of an ear infection like recent upper respiratory tract illness, crowded living conditions, family history of ear infections, day care, smoking in household, altitude changes, cold weather and genetic factors.,SIGNS AND SYMPTOMS:,*  Irritability.,*  Ear pain, fullness, hearing loss.,*  Infants may pull on ear.,*  Fever.,*  Vomiting.,*  Discharge from ear.,*  Diarrhea.,TREATMENT:,*  Diagnosis is by physical exam and otoscopic exam.  Sometimes fluid from the ear is cultured.,*  Pain relievers, like acetaminophen (Tylenol).  Infant pain relievers are available.,*  Decongestant to relieve symptoms of upper respiratory tract infection.,*  Antibiotics when indicated for bacterial infection such as Amoxicillin or Zithromycin.  Finish ALL antibiotics as prescribed.  Do not stop the medication even if symptoms subside.,*  Avoid swimming until infection goes away.,*  Surgery is sometimes necessary to put in tubes through the eardrum to equalize pressure and drain fluids.,*  Surgery to remove adenoids if they are enlarged.,*  Reduce activity until symptoms subside.,Call doctor's office if symptoms do not improve within 2 days of treatment, and for convulsion, fever, ear swelling, dizziness, twitching facial muscles and severe headache.","ent - otolaryngology, ear, ear infection, otitis media, sinuses, drainage, ear pain, fullness, hearing loss, ear swelling, fever, bacterial infection, eustachian tubes, infection, eardrum, respiratory, otitis, media, eustachian, tubes,"
" Sample normal ear, nose, mouth, and throat exam.", ENT - Otolaryngology, Normal ENT Exam - 1 ,"EARS, NOSE, MOUTH AND THROAT,EARS/NOSE: , The auricles are normal to palpation and inspection without any surrounding lymphadenitis.  There are no signs of acute trauma.  The nose is normal to palpation and inspection externally without evidence of acute trauma.  Otoscopic examination of the auditory canals and tympanic membranes reveals the auditory canals without signs of mass lesion, inflammation or swelling.  The tympanic membranes are without disruption or infection.  Hearing intact bilaterally to normal level speech.  Nasal mucosa, septum and turbinate examination reveals normal mucous membranes without disruption or inflammation.  The septum is without acute traumatic lesions or disruption.  The turbinates are without abnormal swelling.  There is no unusual rhinorrhea or bleeding.  ,LIPS/TEETH/GUMS:  ,The lips are without infection, mass lesion or traumatic lesions.  The teeth are intact without obvious signs of infection.  The gingivae are normal to palpation and inspection.  ,OROPHARYNX:  ,The oral mucosa is normal.  The salivary glands are without swelling.  The hard and soft palates are intact.  The tongue is without masses or swelling with normal movement.  The tonsils are without inflammation.  The posterior pharynx is without mass lesion with good patent oropharyngeal airway.","ent - otolaryngology, oral mucosa, lips, hearing, auditory canals, tympanic membranes, traumatic lesions, mouth, throat, trauma, nose, membranes, inflammation, infection, swelling,"
" Left neck dissection.   Metastatic papillary cancer, left neck.  The patient had thyroid cancer, papillary cell type, removed with a total thyroidectomy and then subsequently recurrent disease was removed with a paratracheal dissection.", ENT - Otolaryngology, Neck Dissection ,"PREOPERATIVE DIAGNOSIS: , Metastatic papillary cancer, left neck.,POSTOPERATIVE DIAGNOSIS: , Metastatic papillary cancer, left neck.,OPERATION PERFORMED: , Left neck dissection.,ANESTHESIA:  ,General endotracheal.,INDICATIONS: , The patient is a very nice gentleman, who has had thyroid cancer, papillary cell type, removed with a total thyroidectomy and then subsequently recurrent disease was removed with a paratracheal dissection.  He now has evidence of lesion in the left mid neck and the left superior neck on ultrasound, which are suspicious for recurrent cancer.  Left neck dissection is indicated.,DESCRIPTION OF OPERATION: , The patient was placed on the operating room table in the supine position.  After adequate general endotracheal anesthesia was administered, the table was then turned.  A shoulder roll placed under the shoulders and the face was placed in an extended fashion.  The left neck, chest, and face were prepped with Betadine and draped in a sterile fashion.  A hockey stick skin incision was performed, extending a previous incision line superiorly towards the mastoid cortex through skin, subcutaneous tissue and platysma with Bovie electrocautery on cut mode.  Subplatysmal superior and inferior flaps were raised.  The dissection was left lateral neck dissection encompassing zones 1, 2A, 2B, 3, and the superior portion of 4.  The sternocleidomastoid muscle was unwrapped at its fascial attachment and this was taken back posterior to the XI cranial nerve into the superior posterior most triangle of the neck.  This was carried forward off of the deep rooted muscles including the splenius capitis and anterior and middle scalenes taken medially off of these muscles including the fascia of the muscles, stripped from the carotid artery, the X cranial nerve, the internal jugular vein and then carried anteriorly to the lateral most extent of the dissection previously done by Dr. X in the paratracheal region.  The submandibular gland was removed as well.  The X, XI, and XII cranial nerves were preserved.  The internal jugular vein and carotid artery were preserved as well.  Copious irrigation of the wound bed showed no identifiable bleeding at the termination of the procedure.  There were two obviously positive nodes in this neck dissection.  One was left medial neck just lateral to the previous tracheal dissection and one was in the mid region of zone 2.  A #10 flat fluted Blake drain was placed through a separate stab incision and it was secured to the skin with a 2-0 silk ligature.  The wound was closed in layers using a 3-0 Vicryl in a buried knot interrupted fashion for the subcutaneous tissue and the skin was closed with staples.  A fluff and Kling pressure dressing was then applied.  The patient was extubated in the operating room, brought to the recovery room in satisfactory condition.  There were no intraoperative complications.","ent - otolaryngology, metastatic papillary cancer, thyroidectomy, thyroid cancer, papillary cell type, dissection, neck, metastatic, paratracheal, papillary, cancer"
 Left midface elevation with nasolabial fold elevation and nasolabial fold z-plasty and right symmetrization midface elevation., ENT - Otolaryngology, Nasolabial Fold Elevation ,"PREOPERATIVE DIAGNOSIS:,  Left nasolabial fold scar deformity with effacement of alar crease.,POSTOPERATIVE DIAGNOSIS:,  Left nasolabial fold scar deformity with effacement of alar crease.,PROCEDURES PERFORMED:,1.  Left midface elevation with nasolabial fold elevation.,2.  Left nasolabial fold z-plasty and right symmetrization midface elevation.,ANESTHESIA: , General endotracheal intubation.,ESTIMATED BLOOD LOSS: , Less than 25 mL.,FLUIDS: , Crystalloid,CULTURES TAKEN: , None.,PATIENT'S CONDITION: , Stable.,IMPLANTS: , Coapt Endotine Midface B 4.5 bioabsorbable implants, reference #CFD0200197, lot #01447 used on the right and used on the left side.,IDENTIFICATION: , This patient is well known to the Stanford Plastic Surgery Service.  The patient is status post resection of the dorsal nasal sidewall skin cancer with nasolabial flap reconstruction with subsequent deformity.  In particular, the patient has had effacement of his alar crease with deepening of his nasolabial fold and notable asymmetry.  The patient was seen in consultation and felt to be a surgical candidate for improvement.  Risks and benefits of the operation were described to the patient in detail including, but not limited to bleeding, infection, scarring, possible damage to surrounding structures including neurovascular structures, need for revision of surgery, continued asymmetry, and anesthetic complication.  The patient understood these risks and benefits and consented to the operation.,PROCEDURE IN DETAIL: , The patient was taken to OR and placed supine on the operating table.  Dose of antibiotics was given to the patient.  Compression devices were placed on the lower extremities to prevent the knee embolic events.  The patient was turned to 180 degrees.  The ETT tube was secured and the area was then prepped and draped in usual sterile fashion.  A head wrap was then placed on the position and we then began our local.  Of note, the patient had previous incisions just lateral to his lateral canthus bilaterally and that were used for access.  Local consisting a 50:50 mix of 0.25% Marcaine with epinephrine and 1% lidocaine with epinephrine was then injected into the subperiosteal plane taking care to prevent injury to the infraorbital nerves.  This was done bilaterally.  We then marked the nasolabial fold and began with the elevation of the left midface.,We began with a lateral canthal-type incision extending out over his previous incision down to subcutaneous tissue.  We continued down to the lateral orbital rim until we identified periosteum.  We then pulled in a periosteal elevator and elevated the midface down over the zygoma elevating some lateral mesenteric attachments down over the buccal region until we felt we had reached pass the nasolabial folds medially.  Care was taken to preserve the infraorbital nerve and that was visualized after elevation.  We then released the periosteum distally and retracted up on the periosteum and noted improved contour of the nasolabial fold with increased bulk over the midface region over the zygoma.,We then used our Endotine Coapt device to engage the periosteum at the desired location and then elevated the midface and secured into position using the Coapt bioabsorbable screw.  After this was then carried out, we then clipped and cut as well as the end of the screw.  Satisfied with this, we then elevated the periosteum and secured it to reinforce our midface elevation to the lateral orbital rim and this was done using 3-0 Monocryl.  Several sutures were then used to anchor the orbicularis and deeper tissue to create additional symmetry.  Excess skin along the incision was then removed as well the skin from just lateral to the canthus.  Care was taken to leave the orbicularis muscle down.  We then continued closing our incision using absorbable plain gut 5-0 sutures for the subciliary-type incision and then continuing with interrupted 6-0 Prolenes lateral to the canthus.,We then turned our attention to performing the z-plasty portion of the case.  A z-plasty was designed along the previous scar where it was padding to the notable scar deformity and effacement of crease and the z-plasty was then designed to lengthen along the scar to improve the contour.  This was carried out using a 15 blade down to subcutaneous tissue.  The flaps were debulked slightly to reduce the amount of fullness and then transposed and sutured into place using chromic suture.  At this point, we then noted that he had improvement of the nasal fold but continued asymmetry with regards to improved bulk on the left side and less bulk on the right and it was felt that a symmetrization procedure was required to make more symmetry with the midface bilaterally and nasolabial folds bilaterally.  As such, we then carried out the dissection after injecting local as noted and we used a 15 blade scalpel to create our incision along the lateral canthus along its preexisting incision.  We carried this down to the lateral orbital rim again elevating the periosteum taking care to preserve infraorbital nerve.,At this point, we then released the periosteum distally just at the level of the nasolabial fold and placed our Endotine midface implant into the desired area and then elevated slightly just for symmetry only.  This was then secured in place using the bioabsorbable screw and then resected a very marginal amount of tissue just for removal of the dog ear deformity and closed the deeper layers of tissue using 3-0 PDS and then closing the extension to the subciliary area using 5-0 plain gut and then 6-0 Prolene lateral to the canthus.,At this point, we felt that we had achieved improved contour, improved symmetry, and decreased effacement of the nasolabial fold and alar crease.  Satisfied with our procedures, we then placed cool compresses on to the eyes.,The patient was then extubated and brought to the PACU in stable condition.,Dr. X was present and scrubbed for the entire case and actively participated during all key elements.  Dr. Y was available and participated in the portions of the case as well.",
" Nasal septoplasty, bilateral submucous resection of the inferior turbinates, and tonsillectomy and resection of soft palate.  Nasal septal deviation with bilateral inferior turbinate hypertrophy.  Tonsillitis with hypertrophy.  Edema to the uvula and soft palate.", ENT - Otolaryngology, Nasal Septoplasty & Tonsillectomy ,"PREOPERATIVE DIAGNOSES,1.  Nasal septal deviation with bilateral inferior turbinate hypertrophy.,2.  Tonsillitis with hypertrophy.,3.  Edema to the uvula and soft palate.,POSTOPERATIVE DIAGNOSES,1.  Nasal septal deviation with bilateral inferior turbinate hypertrophy.,2.  Tonsillitis with hypertrophy.,3.  Edema to the uvula and soft palate.,OPERATION PERFORMED,1.  Nasal septoplasty.,2.  Bilateral submucous resection of the inferior turbinates.,3.  Tonsillectomy and resection of soft palate.,ANESTHESIA: , General endotracheal.,INDICATIONS: , Chris is a very nice 38-year-old male with nasal septal deviation and bilateral inferior turbinate hypertrophy causing nasal obstruction.  He also has persistent tonsillitis with hypertrophy and tonsillolith and halitosis.  He also has developed tremendous edema to his posterior palate and uvula, which is causing choking.  Correction of these mechanical abnormalities is indicated.,DESCRIPTION OF OPERATION:  ,The patient was placed on the operating room table in the supine position.  After adequate general endotracheal anesthesia was administered, the right and left nasal septal mucosa and right and left inferior turbinates were anesthetized with 1% lidocaine with 1:100,000 epinephrine using approximately 10 mL.  Afrin-soaked pledgets were placed in the nasal cavity bilaterally.  The face was prepped with pHisoHex and draped in a sterile fashion.  A hemitransfixion incision was performed on the left with a #15 blade and submucoperichondrial and mucoperiosteal flap was raised with the Cottle elevator.  Anterior to the septal deflection, the septal cartilage was incised and an opposite-sided submucoperichondrial and mucoperiosteal flap was raised with the Cottle elevator.  The deviated portion of the nasal septal cartilage and bone was removed with a Takahashi forceps, and a large inferior septal spur was removed with a V-chisel.  Once the septum was reduced in the midline, the hemitransfixion incision was closed with a 4-0 Vicryl in an interrupted fashion.  The right and left inferior turbinates were trimmed in a submucous fashion using straight and curved turbinate scissors under direct visualization with a 4 mm 0 degree Storz endoscope.  Hemostasis was acquired by using suction electrocautery.  The turbinates were then covered with bacitracin ointment after cauterizing them and bacitracin ointment soaked Doyle splints were placed in the right and left nares and secured anteriorly to the columella with a 3-0 nylon suture.  The table was then turned.  A shoulder roll placed under the shoulders and the face was draped in a clean fashion.  A McIvor mouth gag was applied.  The tongue was retracted and the McIvor was gently suspended from the Mayo stand.  The left tonsil was grasped with a curved Allis forceps, retracted medially, and the anterior tonsillar pillar was incised with Bovie electrocautery.  The tonsil was removed from the superior pole to inferior pole using a Bovie electrocautery in its entirety in a subcapsular fashion.  The right tonsil was grasped in a similar fashion, retracted medially, and the anterior tonsillar pillar was incised with Bovie electrocautery.  The tonsil was removed from the superior pole to inferior pole using Bovie electrocautery in its entirety in a subcapsular fashion.  The inferior, middle, and superior pole vessels were further cauterized with suction electrocautery.  The extremely edematous portion of soft palate was resected using a right angle clamp and right angle scissor and was closed with 3-0 Vicryl in a figure-of-eight interrupted fashion.  Copious saline irrigation of the oral cavity was then performed.  There was no further identifiable bleeding at the termination of the procedure.  The estimated blood loss was less than 10 mL.  The patient was extubated in the operating room, brought to the recovery room in satisfactory condition.  There were no intraoperative complications.","ent - otolaryngology, nasal septal deviation, turbinate hypertrophy, nasal septoplasty, submucous resection, resection of soft palate, tonsillectomy, bilateral inferior turbinate, bovie electrocautery, nasal septal, inferior turbinates, turbinates, nasal, tonsillitis, electrocautery, hypertrophy,"
 Bilateral myringotomies with insertion of Santa Barbara T-tube., ENT - Otolaryngology, Myringotomy/Tube Insertion - 2 ,"PREOPERATIVE DIAGNOSES:  ,Tympanic membrane atelectasis and chronic eustachian tube dysfunction.,POSTOPERATIVE DIAGNOSES: , Tympanic membrane atelectasis and chronic eustachian tube dysfunction.,OPERATIVE PROCEDURE: , Bilateral myringotomies with insertion of Santa Barbara T-tube.,ANESTHESIA: , General mask.,FINDINGS:,  The patient is an 8-year-old white female with chronic eustachian tube dysfunction and TM atelectasis, was taken to the operating room for tubes.  At the time of surgery, she has had an extruding right Santa Barbara T-tube and severe left TM atelectasis with retraction.  There was a scant amount of fluid in both middle ear clefts.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed in supine position, and general mask anesthesia was established.  The right ear was draped in normal sterile fashion.  Cerumen was removed from the external canal.  The extruding Santa Barbara T-tube was identified and atraumatically removed.  A fresh Santa Barbara T-tube was atraumatically inserted and Ciloxan drops applied.,The attention was then directed to the left side where severe TM atelectasis was identified.  With a mask anesthetic, the eardrum elevated.  A radial incision was made in the inferior aspect of the tympanic membrane and middle ear fluid aspirated.  A Santa Barbara T-tube was then inserted without difficulty and 5 drops Ciloxan solution applied.  Anesthesia was then reversed and the patient taken to recovery room in satisfactory condition.","ent - otolaryngology, tympanic membrane, cerumen, ciloxan, santa barbara t-tube, tm atelectasis, atelectasis, eardrum, eustachian tube, eustachian tube dysfunction, middle ear, middle ear fluid, myringotomies, atelectasis and chronic eustachian, santa barbara t tube, myringotomies with insertion, chronic eustachian tube, barbara t tube, santa barbara, insertion, tube, tympanic "
" Nasal septal reconstruction, bilateral submucous resection of the inferior turbinates, and bilateral outfracture of the inferior turbinates.  Chronic nasal obstruction secondary to deviated nasal septum and inferior turbinate hypertrophy.", ENT - Otolaryngology, Nasal Septal Reconstruction ,"PREOPERATIVE DIAGNOSES:,1.  Chronic nasal obstruction secondary to deviated nasal septum.,2.  Inferior turbinate hypertrophy.,POSTOPERATIVE DIAGNOSES:,1.  Chronic nasal obstruction secondary to deviated nasal septum.,2.  Inferior turbinate hypertrophy.,PROCEDURE PERFORMED:,1.  Nasal septal reconstruction.,2.  Bilateral submucous resection of the inferior turbinates.,3.  Bilateral outfracture of the inferior turbinates.,ANESTHESIA:,  General endotracheal tube.,BLOOD LOSS: , Minimal less than 25 cc.,INDICATIONS: , The patient is a 51-year-old female with a history of chronic nasal obstruction.  On physical examination, she was derived to have a severely deviated septum with an S-shape deformity as well as turbinate hypertrophy present along the inferior turbinates contributing to the obstruction.,PROCEDURE:  ,After all risks, benefits, and alternatives have been discussed with the patient in detail, informed consent was obtained.  The patient was brought to the Operating Suite where she was placed in the supine position and general endotracheal intubation was delivered by the Department of Anesthesia.  The patient was rotated 90 degrees away.  Nasal pledgets saturated with 4 cc of 10% cocaine solution were inserted into the nasal cavities.  These were then removed and the nasal septum as well as the turbinates were localized with the mixture of 1% lidocaine with 1:100000 epinephrine solution.  The nasal pledgets were then reinserted as the patient was prepped in the usual fashion.  The nasal pledgets were again removed and the turbinates as well as an infraorbital nerve block was performed with 0.25% Marcaine solution.  The nasal vestibules were then cleansed with a pHisoHex solution.  A #15 blade scalpel was then used to make an incision along the length of the caudal septum.  The mucoperichondrial junction was then identified with the aid of cotton-tipped applicator as well as the stitch scissor.  Once the plane was identified, the mucosal flap on the left side of the septum was elevated with the aid of a Cottle.  At this point it should be mentioned that the patient's septum was significantly deviated with a large S-shape deformity obstructing both the right and left nasal cavity with the convex portion present in the left nasal cavity.  Again, the Cottle elevator was used to raise the mucosal flap down to the level of the septal spur.  At this point, the septal knife was used to make a crossover incision through the cartilage just anterior to the septal spur.  Again, the mucosal flap was elevated in the right nasal septum.  Now Knight scissors were used to remove the ascending portion of the nasal cartilage, which was then removed with a Takahashi forceps.  A Cottle elevator was used to further elevate the mucosal flap off the septal spur on the left side.  Removal of the spur was performed with the aid of the septal knife as well as a 3 mm straight chisel.  Once all ascending cartilage has been removed, inspection of the nasal cavity revealed patent passages with the exception of inferior turbinates that were very hypertrophied and was felt to be contributing to the patient's symptoms.  Therefore, the turbinates were again localized and a #15 blade scalpel was used to make a vertical incision dissected down to the chondral bone.  The XPS microdebrider with the inferior turbinate blade was then inserted through the incision and a submucous resection was performed by passing the microdebrider along the length of the bone.  Once the submucosal tissue had been resected, an outfracture procedure was performed so as to fully open the nasal passages.  Inspection revealed very patent and nonobstructive nasal passages.  Now the caudal incision was reapproximated with #4-0 chromic suture.  Finally, a #4-0 fast absorbing plain gut suture was used to approximate the mucosal surface of the septum in a running whipstitch fashion.  Finally, Merocel packing was placed and the patient was retuned to the Department of Anesthesia for awakening and taken to the recovery room without incident.","ent - otolaryngology, chronic nasal obstruction, nasal septum, inferior turbinate hypertrophy, nasal septal reconstruction, submucous resection, inferior turbinates, outfracture, nasal septal, nasal pledgets, nasal cavity, nasal obstruction, turbinate hypertrophy, mucosal flap, septal, septum, turbinates, nasal, cavity, chronic, hypertrophy, obstruction, mucosal,"
 Right middle ear exploration with a Goldenberg TORP reconstruction., ENT - Otolaryngology, Middle Ear Exploration ,"PREOPERATIVE DIAGNOSIS: , Right profound mixed sensorineural conductive hearing loss.,POSTOPERATIVE DIAGNOSIS:,  Right profound mixed sensorineural conductive hearing loss.,PROCEDURE PERFORMED:,  Right middle ear exploration with a Goldenberg TORP reconstruction.,ANESTHESIA:,  General ,ESTIMATED BLOOD LOSS:,  Less than 5 cc.,COMPLICATIONS:,  None.,DESCRIPTION OF FINDINGS:,  The patient consented to revision surgery because of the profound hearing loss in her right ear.  It was unclear from her previous operative records and CT scan as to whether or not she was a reconstruction candidate.  She had reports of stapes fixation as well as otosclerosis on her CT scan.,At surgery, she was found to have a mobile malleus handle, but her stapes was fixed by otosclerosis.  There was no incus.  There was no specific round window niche.  There was a very minute crevice; however, exploration of this area did not reveal a niche to a round window membrane.  The patient had a type of TORP prosthesis, which had tilted off the footplate anteriorly underneath the malleus handle.,DESCRIPTION OF THE PROCEDURE:,  The patient was brought to the operative room and placed in supine position.  The right face, ear, and neck prepped with ***** alcohol solution.  The right ear was draped in the sterile field.  External auditory canal was injected with 1% Xylocaine with 1:50,000 epinephrine.  A Fisch indwelling incision was made and a tympanomeatal flap was developed in a 12 o'clock to the 7 o'clock position.  Meatal skin was elevated, middle ear was entered.  This exposure included the oval window, round window areas.  There was a good cartilage graft in place and incorporated into the posterior superior ***** of the drum.  The previous prosthesis was found out of position as it had tilted out of position anteriorly, and there was no contact with the footplate.  The prosthesis was removed without difficulty.  The patient's stapes had an arch, but the ***** was atrophied.  Malleus handle was mobile.  The footplate was fixed.  Consideration have been given to performing a stapedectomy with a tissue seal and then returning later for prosthesis insertion; however, upon inspection of the round window area, there was found to be no definable round window niche, no round window membrane.  The patient was felt to have obliterated otosclerosis of this area along with the stapes fixation.  She is not considered to be a reconstruction candidate under the current circumstances.  No attempt was made to remove bone from the round window area.  A different style of Goldenberg TORP was placed on the footplate underneath the cartilage support in hopes of transferring some sound conduction from the tympanic membrane to the footplate.  The fit was secure and supported with Gelfoam in the middle ear.  The tympanomeatal flap was returned to anatomic position supported with Gelfoam saturated Ciprodex.  The incision was closed with #4-0 Vicryl and individual #5-0 nylon to the skin, and a sterile dressing was applied.","ent - otolaryngology, conductive hearing loss, goldenberg, meatal skin, torp, torp reconstruction, ear, ear exploration, handle, malleus, otosclerosis, sensorineural, stapedectomy, tympanomeatal, middle ear exploration, hearing loss, malleus handle, middle ear, middle"
 Removal of the old right pressure equalizing tube.  Myringotomy with placement of a left pressure equalizing tube., ENT - Otolaryngology, Myringotomy/Tube Insertion - 3 ,"PREOPERATIVE DIAGNOSES: ,1.  Chronic eustachian tube dysfunction.,2.  Retained right pressure equalization tube.,3.  Retracted left tympanic membrane.,4.  Dizziness.,POSTOPERATIVE DIAGNOSES:,1.  Chronic eustachian tube dysfunction.,2.  Retained right pressure equalization tube.,3.  Retracted left tympanic membrane.,4.  Dizziness.,PROCEDURE:,1.  Removal of the old right pressure equalizing tube with placement of a tube.  Tube used was Santa Barbara.,2.  Myringotomy with placement of a left pressure equalizing tube.  The tube used was Santa Barbara.,ANESTHESIA:,  General.,INDICATION: , This is a 98-year-old female whom I have known for several years.  She has a marginal hearing.  With the additional conductive loss secondary to the retraction of the tympanic membrane, her hearing aid and function deteriorated significantly.  So, we have kept sets of tubes in her ears at all times.  The major problem is that she has got small ear canals and a very sensitive external auditory canal; therefore it cannot tolerate even the wax cleaning in the clinic awake.,The patient was seen in the OR and tubes were placed.  There were no significant findings.,PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, she was brought to the neurosensory OR, placed under general anesthesia.  Mask airway was used.  IV had already been started.,On the right side, we removed the old tube and then cleaned the cerumen and found that it was larger than the side of the tube in perfection or perforation in tympanic membrane in the anterior inferior quadrant.  In the same area, a small Santa Barbara tube was placed.  This T-tube was cut to 80% of its original length for comfort and then positioned to point straight out and treated.  Three drops of ciprofloxacin eyedrops was placed in the ear canal.,On the left side, the tympanic membrane adhered and it was retracted and has some myringosclerosis.  Anterior, inferior incision was made.  Tympanic membrane bounced back to neutral position.  A Santa Barbara tube was cut to the 80% of the original length and placed in the hole.  Ciprofloxacin drops were placed in the ear.  Procedure completed.,ESTIMATED BLOOD LOSS: , None.,COMPLICATION: , None.,SPECIMEN:,  None.,DISPOSITION:,  To PACU in a stable condition.",
 Bilateral myringotomies and insertion of Shepard grommet draining tubes., ENT - Otolaryngology, Myringotomy/Tube Insertion - 1 ,"PREOPERATIVE DIAGNOSIS: , Bilateral chronic serous otitis media.,POSTOPERATIVE DIAGNOSIS: , Bilateral chronic serous otitis media.,OPERATION PERFORMED:,1.  Bilateral myringotomies.,2.  Insertion of Shepard grommet draining tubes.,ANESTHESIA: , General, by mask.,ESTIMATED BLOOD LOSS: , Less than 1 mL.,COMPLICATIONS:,  None.,FINDINGS:  ,The patient had a long history of persistent recurrent infections and was placed on antibiotics for the same.  At this point in time, he had a small amount of thick mucoid material in both middle ear spaces with middle ear mucosa somewhat inflamed, but no active acute infection at this point in time.,PROCEDURE:,  With the patient under adequate general anesthesia with the mask delivery of anesthesia, he had his ear canals cleaned utilizing an operating microscope and all foul cerumen had been removed from both sides.  Bilateral inferior radial myringotomies were performed, first on the right and then on the left.  Middle ear spaces were suctioned of small amount of thick mucoid material on both sides and then Shepard grommet draining tubes were inserted on either side.  Floxin drops were then instilled bilaterally to decrease any clotting within the tubes, and then cotton ball was placed in the external meatus bilaterally.  At this point, the patient was awakened and returned to the recovery room, satisfactory, with no difficulty encountered.","ent - otolaryngology, serous otitis media, floxin drops, shepard grommet, cerumen, cotton ball, middle ear, mucoid, myringotomies, tubes, shepard grommet draining tubes, serous otitis, shepard, grommet, insertion"
 Microsuspension direct laryngoscopy with biopsy.  Fullness in right base of the tongue and chronic right ear otalgia., ENT - Otolaryngology, Microsuspension Direct Laryngoscopy & Biopsy ,"PREOPERATIVE DIAGNOSES:,1.  Fullness in right base of the tongue.,2.  Chronic right ear otalgia.,POSTOPERATIVE DIAGNOSIS: , Pending pathology.,PROCEDURE PERFORMED: , Microsuspension direct laryngoscopy with biopsy.,ANESTHESIA: , General.,INDICATION:,  This is a 50-year-old female who presents to the office with a chief complaint of ear pain on the right side.  Exact etiology of her ear pain had not been identified.  A fiberoptic examination had been performed in the office.  Upon examination, she was noted to have fullness in the right base of her tongue.  She was counseled on the risks, benefits, and alternatives to surgery and consented to such.,PROCEDURE: , After informed consent was obtained, the patient was brought to the Operative Suite where she was placed in supine position.  General endotracheal tube intubation was delivered by the Department of Anesthesia.  The patient was rotated 90 degrees away where a shoulder roll was placed.  A tooth guard was then placed to protect the upper dentition.  The Dedo laryngoscope was then inserted into the oral cavity.  It was advanced on the right lateral pharyngeal wall until the epiglottis was brought into view.  At this point, it was advanced underneath the epiglottis until the vocal cords were seen.  At this point, it was suspended via the Lewy suspension arm from the Mayo stand.  At this point, the Zeiss microscope with a 400 mm lens was brought into the surgical field.  Inspection of the vocal cords underneath the microscope revealed them to be white and glistening without any mucosal abnormalities.  It should be mentioned that the right vocal cord did appear to be slightly more hyperemic, however, there were no mucosal abnormalities identified.  This was confirmed with a laryngeal probe as well as use of mirror evaluated in the subglottic portion as well as the ventricle.  At this point, the scope was desuspended and the microscope was removed.  The scope was withdrawn through the vallecular region.  Inspection of the vallecula revealed a fullness on the right side with a papillomatous type growth that appeared very friable.  Biopsies were obtained with straight-biting cup forceps.  Once hemostasis was achieved, the scope was advanced into the piriform sinuses.  Again in the right piriform sinus, there was noted to be studding along the right lateral wall of the piriform sinus.  Again, biopsies were performed and once hemostasis was achieved, the scope was further withdrawn down the lateral pharyngeal wall.  There were no mucosal abnormalities identified within the oropharynx.  The scope was then completely removed and a bimanual examination was performed.  No neck masses were identified.  At this point, the procedure was complete.  The mouth guard was removed and the patient was returned to Anesthesia for awakening and taken to the recovery room without incident.","ent - otolaryngology, microsuspension, laryngoscopy, otalgia, ear pain, fiberoptic, dedo laryngoscope, epiglottis, direct laryngoscopy, piriform sinuses, tongue, microscope, mucosal, abnormalities, fullness, ear, scope "
" Open reduction, nasal fracture with nasal septoplasty.", ENT - Otolaryngology, Nasal Septoplasty ,"PREOPERATIVE DIAGNOSES: , Nasal fracture and deviated nasal septum with obstruction.,POSTOPERATIVE DIAGNOSES: , Nasal fracture and deviated nasal septum with obstruction.,OPERATION:,  Open reduction, nasal fracture with nasal septoplasty.,ANESTHESIA: , General.,HISTORY: , This 16-year-old male fractured his nose playing basketball.  He has a left nasal obstruction and depressed left nasal bone.,DESCRIPTION OF PROCEDURE: , The patient was given general endotracheal anesthesia and monitored with pulse oximetry, EKG, and CO2 monitors.,The face was prepped with Betadine soap and solution and draped in a sterile fashion.  Nasal mucosa was decongested using Afrin pledgets as well as 1% Xylocaine, 1:100,000 epinephrine was injected into bilateral nasal septal mucoperichondrium and the nasal dorsum, lateral osteotomy sites.,Inspection revealed caudal portion of the cartilaginous septum lying crosswise across the nasal spine area and columella causing obstruction of the left nasal valve.  Further up, the cartilaginous septum was displaced to the left of the maxillary crest.  There was a large maxillary crest and supramaxillary crest had a large spur with the vomer bone touching the inferior turbinate.,There was a large deep groove horizontally on the right side corresponding to the left maxillary crest.,A left hemitransfixion incision was made.  Mucoperichondrium was elevated from left side of the cartilaginous septum and mucoperiosteum was elevated from the ethmoid plate.  Vomer and inferior tunnel was created at the floor of the left side of the nose to connect the anterior and inferior tunnels, which was rather difficult at the area of the vomerine spur, which was very sharp and touching the inferior turbinate.,The caudal cartilaginous septum, which was lying crosswise, was separated from the main cartilage leaving approximately 1 cm strut.  The right side mucoperichondrium was released from the cartilaginous septum as well as ethmoid plate and the maxillary crest area.,The caudal cartilaginous strut was sutured to the columella with interrupted #4-0 chromic catgut suture to bring it into the midline.,Further back, the cartilaginous septum anterior to the ethmoid plate was deviated to the left side, so it was freed from the maxillary crest, nasal dorsum, from the ethmoid plate, and was sutured in the midline with a transfixion #4-0 plain catgut sutures.,Further posteriorly, the ethmoid plate was deviated to the left side and portion of it was removed with Jansen-Middleton punch forceps.,The main deviation was also caused by the vomerine crest and the maxillary crest and supramaxillary cartilaginous cartilage.,This area was freed from the perichondrium on both sides.  The maxillary crest was removed with a gouge.  Vomer was partially removed with a gouge and the rest of the vomer was displaced back into the midline.,Thus, the deviated septum was corrected.  Left hemitransfixion incisions were closed with interrupted #4-0 chromic catgut sutures.  The septum was also filtered with #4-0 plain catgut sutures.,By valve, septal splints were tied to the septum bilaterally with a transfixion #5-0 nylon suture.,Next, the nasal bone suture deviated to the left side were corrected.  The right nasal bone was depressed and left nasal bone was wide.  Therefore, the nasal bones were refractured back into the midline by compressing the left nasal bone and elevating the right nasal bone with the nasal bone elevator through the nasal cavities.  The left intercartilaginous incision was made and the nasal bones were disimpacted subperiosteally and they were molded back into the midline.,Steri-Strips were applied to the nasal dorsal skin and a Denver type of splint was applied to the nasal dorsal to stabilize the nasal bones.,Nasal cavities were packed with Telfa gauze rolled on both sides with bacitracin ointment.  Approximate blood loss was 10 to 20 mL.","ent - otolaryngology, nasal fracture, deviated nasal septum, nasal septoplasty, nasal bones, ethmoid plate, cartilaginous septum, nasal bone, maxillary crest, septum, nasal, fracture, maxillary, cartilaginous, crest, "
" Suspension microlaryngoscopy, rigid bronchoscopy, dilation of tracheal stenosis.", ENT - Otolaryngology, Microlaryngoscopy ,"PREOPERATIVE DIAGNOSIS:,  Airway obstruction secondary to laryngeal subglottic stenosis.,POSTOPERATIVE DIAGNOSIS:  ,Airway obstruction secondary to laryngeal subglottic stenosis and tracheal stenosis.,OPERATION PERFORMED: , Suspension microlaryngoscopy, rigid bronchoscopy, dilation of tracheal stenosis.,INDICATIONS FOR SURGERY:  ,The patient is a 56-year-old white female with a history of relapsing polychondritis, which resulted in saddle nose deformity in glottic and subglottic stenosis for which she has undergone number of procedures in the past to the upper airway.  She currently is trach dependent for her airway because of glottic and subglottic stenosis, but she is having no significant problems breathing and talking around her trach tube and came for further evaluation.  Endoscopic reevaluation of her tube and nature of the proposed procedure done.  Risk and complications of bleeding, infection, alteration of with speech or swallowing, failure to improve her airway, and loss of voice.  Cardiorespiratory anesthetic results were discussed in length.  The patient states she understood and wished to proceed.,DESCRIPTION OF OPERATION:,  The patient was taken to the operating room and placed in the supine position.  Under adequate general endotracheal anesthesia, the patient's #5 metal tracheostomy tube was removed and a #5 laser-safe endotracheal tube was inserted.  The patient was then prepared for endoscopy.  The Kantor laryngoscope was then inserted.  Oral cavity, hypopharynx, larynx, and nasal cavity showed good dentition with good tongue, buccal cavity, and mucosa without lesions.  Larynx was then ***** short epiglottis.  Larynx was suspended with significant scarring beginning in the supraglottic area with loss of laryngeal contour beginning in the supraglottis with extensive scar tissue at the level of the false cord obliteration of ventricles and true cords.  This appeared to be stable, and airway was patent at the supraglottic and glottic level with some narrowing at the subglottic level with mild-to-moderate subglottic stenosis, otherwise this appeared to be stable.  However, distally, the level of the trach site examined with the microscope and 0 and 30-degree telescopes.  The patient noted to have marked narrowing with dense scarring posterolaterally on the left securing good visualization of the trach tube.  The laryngoscope was removed, and a 5 x 30 pediatric rigid bronchoscope was then passed.  The LP contact tip laser was utilized to vaporize the scar tissue and release the scar banding following which the scope was passed and further dilation carried out.  Mid and distal trachea were widely patent.  Trachea and mainstem bronchi were patent without obvious disease.  The patient did not appear to have any relapsing polychondritis with progressive scar tissue at the level of the trach site and the posterior trachea wall was significant.  This was further dilated and following which was removed and a new #5 metal tracheostomy tube inserted.  The patient tolerated the procedure well without complications and was taken to recovery room in satisfactory condition.","ent - otolaryngology, airway obstruction, oral cavity, bronchoscopy, buccal cavity, hypopharynx, laryngeal, larynx, microlaryngoscopy, nasal cavity, polychondritis, subglottic, tracheal stenosis, tracheostomy tube, scar tissue, subglottic stenosis, tracheal, airway, cavity, tube, scarring, stenosis, "
" Suspected mastoiditis ruled out, right acute otitis media, and severe ear pain resolving.  The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis.  ", ENT - Otolaryngology, Mastoiditis - Discharge Summary ,"DISCHARGE DIAGNOSES:  ,1.  Suspected mastoiditis ruled out.,2.  Right acute otitis media.,3.  Severe ear pain resolving.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis.  The child has had very severe ear pain and blood draining from the right ear.  The child had a temperature maximum of 101.4 in the ER.  The patient was admitted and started on IV Unasyn, which he tolerated well and required Morphine and Vicodin for pain control.  In the first 12 hours after admission, the patient's pain decreased and also swelling of his cervical area decreased.  The patient was evaluated by Dr. X from the ENT while in house.  After reviewing the CT scan, it was felt that the CT scan was not consistent with mastoiditis.  The child was continued on IV fluid and narcotics for pain as well as Unasyn until the time of discharge.  At the time of discharge his pain is markedly decreased about 2/10 and swelling in the area has improved.  The patient is also able to take p.o. well.,DISCHARGE PHYSICAL EXAMINATION:,GENERAL:  The patient is alert, in no respiratory distress.,VITAL SIGNS:  His temperature is 97.6, heart rate 83, blood pressure 105/57, respiratory rate 16 on room air.,HEENT:  Right ear shows no redness.  The area behind his ear is nontender.  There is a large posterior chains node that is nontender and the swelling in this area has decreased markedly.,NECK:  Supple.,CHEST:  Clear breath sounds.,CARDIAC:  Normal S1, S2 without murmur.,ABDOMEN:  Soft.  There is no hepatosplenomegaly or tenderness.,SKIN:  Warm and well perfused.,DISCHARGE WEIGHT: , 38.7 kg.,DISCHARGE CONDITION: , Good.,DISCHARGE DIET:,  Regular as tolerated.,DISCHARGE MEDICATIONS:  ,1.  Ciprodex Otic Solution in the right ear twice daily.,2.  Augmentin 500 mg three times daily x10 days.,FOLLOW UP:  ,1.  Dr. Y in one week (ENT).,2.  The primary care physician in 2 to 3 days.,TIME SPENT: , Approximate discharge time is 28 minutes.", 
" Bilateral myringotomies, insertion of PE tubes, and pharyngeal anesthesia.", ENT - Otolaryngology, Myringotomy/Tube Insertion ,"PREOPERATIVE DIAGNOSES:,  Chronic otitis media with effusion, conductive hearing loss, and recurrent acute otitis media.,POSTOPERATIVE DIAGNOSES:,  Chronic otitis media with effusion, conductive hearing loss, and recurrent acute otitis media.,OPERATION: , Bilateral myringotomies, insertion of PE tubes, and pharyngeal anesthesia.,ANESTHESIA:  ,General via facemask.,ESTIMATED BLOOD LOSS: , None.,COMPLICATIONS: , None.,INDICATIONS:  ,The patient is a one-year-old with history of chronic and recurrent episodes of otitis media with persistent middle ear effusions resistant to medical therapy.,PROCEDURE: , The patient was brought to the operating room, was placed in supine position.  General anesthesia was begun via face mask technique.  Once an adequate level of anesthesia was obtained, the operating microscope was brought, positioned and visualized the right ear canal.  A small amount of wax was removed with a loop.  A 4-mm operating speculum was then introduced.  An anteroinferior quadrant radial myringotomy was then performed.  A large amount of mucoid middle ear effusion was aspirated from the middle ear cleft.  Reuter bobbin PE tube was then inserted, followed by Floxin otic drops and a cotton ball in the external meatus.  Head was then turned to the opposite side, where similar procedure was performed.  Once again, the middle ear cleft had a mucoid effusion.  A tube was inserted to an anteroinferior quadrant radial myringotomy.,Anesthesia was then reversed and the patient was transported to the recovery room having tolerated the procedure well with stable signs.","ent - otolaryngology, bilateral myringotomies, insertion of pe tubes, chronic otitis media, conductive hearing loss, recurrent acute otitis media, reuter bobbin, radial myringotomy, ear cleft, pe tubes, middle ear, otitis media, effusion, otitis, media, ear, anesthesia"
" Direct laryngoscopy, rigid bronchoscopy and dilation of subglottic upper tracheal stenosis.", ENT - Otolaryngology, Laryngoscopy ,"PREOPERATIVE DIAGNOSIS,Subglottic upper tracheal stenosis.,POSTOPERATIVE DIAGNOSIS,Subglottic upper tracheal stenosis.,OPERATION PREFORMED,Direct laryngoscopy, rigid bronchoscopy and dilation of subglottic upper tracheal stenosis.,INDICATIONS FOR THE SURGERY,The patient is a 76-year-old white female with a history of subglottic upper tracheal stenosis.  She has had undergone multiple previous endoscopic procedures in the past; last procedure was in January 2007.  She returns with some increasing shortness of breath and dyspnea on exertion.  Endoscopic reevaluation is offered to her.  The patient has been considering laryngotracheal reconstruction; however, due to a recent death in the family, she has postponed this, but she has been having increasing symptoms.  An endoscopic treatment was offered to her.  Nature of the proposed procedure including risks and complications involving bleeding, infection, alteration of voice, speech, or swallowing, hoarseness changing permanently, recurrence of stenosis despite a surgical intervention, airway obstruction necessitating a tracheostomy now or in the future, cardiorespiratory, and anesthetic risks were all discussed in length.  The patient states she understood and wished to proceed.,DESCRIPTION OF THE OPERATION,The patient was taken to the operating room, placed on table in supine position.  Following adequate general anesthesia, the patient was prepared for endoscopy.  The top sliding laryngoscope was then inserted in the oral cavity, pharynx, and larynx examined. In the oral cavity, she had good dentition.  Tongue and buccal cavity mucosa were without ulcers, masses, or lesions.  The oropharynx was clear.  The larynx was then manually suspended.  Epiglottis area, epiglottic folds, false cords, true vocal folds with some mild edema, but otherwise, without ulcers, masses, or lesions, and the supraglottic and glottic airway were widely patent.  The larynx was manually suspended and a 5 x 30 pediatric rigid bronchoscope was passed through the vocal folds.  At the base of the subglottis, there was a narrowing and in the upper trachea, restenosis had occurred.  Moderate amount of mucoid secretions, these were suctioned, following which the area of stenosis was dilated.  Remainder of the bronchi was then examined.  The mid and distal trachea were widely patent.  Pale pink mucosa takeoff from mainstem bronchi were widely patent without ulcers, lesions, or evidence of scarring.  The scope was pulled back and removed and following this, a 6 x 30 pediatric rigid bronchoscope was passed through the larynx and further dilatation carried out.  Once this had been completed, dramatic improvement in the subglottic upper tracheal airway accomplished.  Instrumentation was removed and a #6 endotracheal tube, uncuffed, was placed to allow smooth emerge from anesthesia.  The patient tolerated the procedure well without complication.","ent - otolaryngology, stenosis, epiglottis, subglottic, bronchoscope, bronchoscopy, endoscopic, laryngoscopy, laryngotracheal reconstruction, larynx, oral cavity, pharynx, tracheal, true vocal folds, vocal, upper tracheal stenosis, subglottic upper tracheal, subglottic upper, upper tracheal, airway, cavity, patent, "
 Incision and drainage with bolster dressing placement of right ear recurrent auricular hematoma., ENT - Otolaryngology, I&D - Auricular Hematoma ,"PREOPERATIVE DIAGNOSIS: , Recurrent severe right auricular hematoma.,POSTOPERATIVE DIAGNOSIS: , Recurrent severe right auricular hematoma.,TITLE OF PROCEDURE:,  Incision and drainage with bolster dressing placement of right ear recurrent auricular hematoma.,ANESTHESIA: , Xylocaine 1% with 1:100,000 dilution of epinephrine totaling 2 mL.,COMPLICATIONS:,  None.,FINDINGS: , Approximately 5 mL of serosanguineous drainage.,PROCEDURE: , The patient underwent an incision and drainage procedure with stay suture placement on 05/28/2008 by me and also by Dr. X on 05/23/2008 for a large near 100% auricular hematoma.  She presents for suture removal; however, there is still fluid noted now at the antihelix fold above the concha bullosa below previous sutures placed by Dr. X.  It was recommended that this area be drained through the previous incision and drainage incision which has healed and wound care by the patient appears to be very poor if any at all being performed which may be complicating matters.  Consent was obtained.  The patient is aware that the complications with this ear area severe and auricular deformity is inevitable; however, quick prompt aggressive drainage addressing fluid collections offers a best chance for improvement from an already very difficult situation.,The area was prepped in the usual manner, localized and the previous incision was reopened with a curved hemostat and about 5 mL of serosanguineous drainage was noted.  A through-and-through Keith needle bolster dressing was applied with cottonoid pledget on both sides of the ear to help compression.  She tolerated this procedure very well.","ent - otolaryngology, bolster dressing placement, antihelix fold, incision and drainage, bolster dressing, auricular hematoma, auricular, hematoma, incision, drainage"
" Flexible nasal laryngoscopy.  Foreign body, left vallecula at the base of the tongue.   Airway is patent and stable.", ENT - Otolaryngology, Flexible Nasal Laryngoscopy ,"PREOPERATIVE DIAGNOSIS:  ,Oropharyngeal foreign body.,POSTOPERATIVE DIAGNOSES:,1.  Foreign body, left vallecula at the base of the tongue.,2.  Airway is patent and stable.,PROCEDURE PERFORMED: , Flexible nasal laryngoscopy.,ANESTHESIA:,  ______ with viscous lidocaine nasal spray.,INDICATIONS: , The patient is a 39-year-old Caucasian male who presented to ABCD General Hospital Emergency Department with acute onset of odynophagia and globus sensation.  The patient stated his symptoms began around mid night after returning home _________ ingesting some chicken.  The patient felt that he had ingested a chicken bone, tried to dislodge this with fluids and other solid foods as well as sticking his finger down his throat without success.  The patient subsequently was seen in the Emergency Department where it was discovered that the patient had a left vallecular foreign body.  Department of Otolaryngology was asked to consult for further evaluation and treatment of this foreign body.,PROCEDURE: , After verbal informed consent was obtained, the patient was placed in the upright position.  The fiberoptic nasal laryngoscope was inserted in the patient's right naris and then the left naris.  There was visualized some bilateral caudal spurring of the septum.  The turbinates were within normal limits.  There was some posterior nasoseptal deviation to the left.  The nasal laryngoscope was then inserted back into the right naris and it was advanced along the floor of the nasal cavity.  The nasal mucous membranes were pink and moist.  There was no evidence of mass, ulceration, lesion, or obstruction.,The scope was further advanced to the level of the nasopharynx where the eustachian tubes were visualized bilaterally.  There was evidence of some mild erythema in the right fossa Rosenmüller.  There was no evidence of mass lesion or ulceration in this area, however.  The eustachian tubes were patent without obstruction.  The scope was further advanced to the level of the oropharynx where the base of the tongue, vallecula, and epiglottis were visualized.  There was evidence of a 1.5 cm left vallecular white foreign body.  The rest of the oropharynx was without abnormality.  The epiglottis was within normal limits and was noted to be omega in shape.  There was no edema or erythema to the epiglottis.  The scope was then further advanced to the level of the hypopharynx to the level of the true vocal cords.  There was no evidence of erythema or edema of the posterior commissure, arytenoid cartilage, or superior surface of the vocal cords.  The laryngeal surface of the epiglottis was within normal limits.  There was no evidence of mass lesion or nodularity of the vocal cords.  The patient was asked to Valsalva and the piriform sinuses were observed without evidence of foreign body or mass lesion.  The patient did have complete glottic closure upon phonation and the airway was patent and stable throughout the exam.  The glottic aperture was completely patent with inspiration.  The anterior commissure, epiglottic folds, false vocal cords, and piriform sinuses were all within normal limits.  The scope was then removed without difficulty.  The patient tolerated the procedure well and remained in stable condition.,FINDINGS:,1.  A 1.5 cm white foreign body consistent with a chicken bone at the left vallecular region.  There is no evidence of supraglottic or piriform sinuses foreign body.,2.  Mild erythema of the right nasopharynx in the region of the fossa Rosenmüller.  No mass is appreciated at this time.,PLAN:,  The patient is to go to the operating room for direct laryngoscopy/microscopic suspension direct laryngoscopy for removal of foreign body under anesthesia this a.m.  Airway precautions were instituted.  The patient currently remained in stable condition.","ent - otolaryngology, oropharyngeal foreign body, flexible nasal laryngoscopy, nasal spray, foreign body, tongue, laryngoscopy, erythema, epiglottis, nasal, oropharyngeal"
" Microscopic suspension direct laryngoscopy with biopsy of left true vocal cord stripping.  Hoarseness, bilateral true vocal cord lesions, and leukoplakia.", ENT - Otolaryngology, Laryngoscopy & Vocal Cord Biopsy ,"PREOPERATIVE DIAGNOSES:,1.  Hoarseness.,2.  Bilateral true vocal cord lesions.,3.  Leukoplakia.,POSTOPERATIVE DIAGNOSES:,1.  Hoarseness.,2.  Bilateral true vocal cord lesions.,3.  Leukoplakia.,PROCEDURE PERFORMED:  ,Microscopic suspension direct laryngoscopy with biopsy of left true vocal cord stripping.,ANESTHESIA:,  General endotracheal.,ESTIMATED BLOOD LOSS:,  Minimal.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE:  The patient is a 33-year-old Caucasian male with a history of chronic hoarseness and bilateral true vocal cord lesions, and leukoplakia discovered on a fiberoptic nasal laryngoscopy in the office.  Discussed risks, complications, and consequences of a surgical biopsy of the left true vocal cord and consent was obtained.,PROCEDURE: , The patient was brought to operative suite by anesthesia, placed on the operating table in supine position.  After this, the patient was placed under general endotracheal intubation anesthesia and the operative table was turned 90 degrees by the Department of Anesthesia.  A shoulder roll was then placed followed by the patient being placed in reverse Trendelenburg.,After this, a mouthguard was placed in the upper teeth and a Dedo laryngoscope was placed in the patient's oral cavity and advanced through the oral cavity in the oropharynx down into the hypopharynx.  The patient's larynx was then brought into view with the true vocal cords hidden underneath what appeared to be redundant false vocal cords.  The left true vocal cord was then first addressed and appeared to have an extensive area of leukoplakia extending from the posterior one-third up to the anterior third.  The false vocal cord also appeared to be very full on the left side along with fullness in the subglottic region.  The patient's anterior commissure appeared to be clear.  The false cord on the right side also appeared to be very redundant and overshadowing the true vocal cord.  Once the true vocal cord was retracted laterally, there was revealed a second area of leukoplakia involving the right true vocal cord in the anterior one-third aspect.  The patient's subglottic region was very edematous and with redundant mucosal tissue.  The areas of leukoplakia appeared to be cobblestoned in appearance, irregularly bordered, and very hard to the touch.  The left true vocal cord was then first addressed, was stripped from posteriorly to anteriorly utilizing a #45 laryngeal forceps.  After this, the patient had pressure placed upon this area with tropical adrenaline and a rectal swab to maintain hemostasis.  The specimen was passed off the field and was sent to Pathology for evaluation.  Hemostasis was maintained on the left side.  Prior to taking this biopsy, the Louie arm was attached to the laryngoscope and then suspended on the Mayo stand.  The Zeiss operating microscope was then brought into view to directly visualize the vocal cords.  The biopsies were taken under direct visualization utilizing the Zeiss operating microscope.  After the specimen was taken and the laryngoscope was desuspended from the Mayo stand and Louie arm was removed, the scope was then pulled more cephalad and the piriform sinuses, valecula, and base of the tongue were all directly visualized, which appeared normal except for the left base of tongue appeared to be full.  This area was biopsied multiple times with a straight laryngeal forceps and passed off the field and sent to Pathology as specimen.  The scope was then pulled back into the superior aspect of hypopharynx into the oropharynx and the oral cavity demonstrated no signs of any gross lesions.  A bimanual examination was then performed, which again demonstrated a fullness on the left base of tongue region with no signs of any other gross lesions.  There were no signs of any palpable cervical lymphadenopathy.  The tooth guard was removed and the patient was then turned back to anesthesia.  The patient did receive intraoperatively 10 mg of Decadron.  The patient tolerated the procedure well and was extubated in the operating room.,The patient was transferred to recovery room in stable condition and tolerated the procedure well.  The patient will be sent home with prescriptions for Medrol DOSEPAK, Tylenol with Codeine, Elixir, and amoxicillin 250 mg per 5 cc.","ent - otolaryngology, direct laryngoscopy, zeiss operating microscope, vocal cord lesions, vocal cord, cord, vocal, microscopic, laryngoscopy, hoarseness, biopsy, leukoplakia"
" Squamous cell carcinoma of the larynx.  Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.", ENT - Otolaryngology, Laryngectomy & Thyroid Lobectomy ,"TITLE OF OPERATION:,  Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.,INDICATION FOR SURGERY: , A 58-year-old gentleman who has had a history of a T3 squamous cell carcinoma of his glottic larynx having elected to undergo a laser excision procedure in late 06/07.  Subsequently, biopsy confirmed tumor persistence in the right glottic region.  Risks, benefits, and alternatives of the surgical intervention versus possibility of chemoradiation therapy were discussed with the patient in detail.  Also concerned for a CT scan finding of possible cartilaginous invasion at the cricoid level.  The patient understood the issues regarding surgical intervention and wished to undergo a surgical intervention despite a clear understanding of risks, benefits, and alternatives.  He was accompanied by his wife and daughter.  Risks included, but were not limited to anesthesia, bleeding, infection, injury of the nerves including lower lip weakness, tongue weakness, tongue numbness, shoulder weakness, need for physical therapy, possibility of total laryngectomy, possibility of inability to speak or swallow, difficulty eating, wound care issues, failure to heal, need for additional treatment, and the patient understood all of these issues and they wished to proceed.,PREOP DIAGNOSIS: , Squamous cell carcinoma of the larynx.,POSTOP DIAGNOSIS: , Squamous cell carcinoma of the larynx.,PROCEDURE DETAIL: , After identifying the patient, the patient was placed supine on the operating room table.  After the establishment of the general anesthesia via oral endotracheal intubation, the patient had his eyes protected with Tegaderm.  A #6 endotracheal tube was placed initially.  Direct laryngoscopy was performed with a Lindholm laryngoscope.  A 0-degree endoscope was used to take pictures of what was apparently a recurrence of tumor along the right true vocal fold extending into the anterior arytenoid area and extending about 1 cm below into the subglottis.  Subsequently, a decision was then made to go ahead and perform the surgical intervention.  A hemi-apron incision was employed, and 1% lidocaine with 1:100,000 epinephrine was injected.  A shoulder roll was applied after the patient was prepped and draped in a sterile fashion.  Subsequently, a hemi-apron incision was performed.  Subplatysmal flaps were raised at the hyoid bone into the clavicle.  Attention was then turned to the right side, where a level 2, 3, 4 neck dissection was performed.  Submandibular fascia was appreciated inferiorly along the submandibular gland, this was incised allowing for identification of the digastric muscle.  Digastric tunnel was performed posteriorly to the level of the sternocleidomastoid muscle.  The fascia along the sternocleidomastoid muscle was then dissected along the anterior aspect until the cranial nerve XI was identified.  Level 2A contents were then dissected off the floor of the neck including levels 3 and 4.  Preservation of the phrenic nerve was obtained by identification, and subsequently cross-clamping fibrofatty tissue and lymph nodes just adjacent to the jugular vein inferiorly at level 4.  The specimen was then mobilized over the internal jugular vein with preservation of hypoglossal nerve.  Levels 2, 3, 4 neck dissection specimens were then labeled appropriately, attached with staples, and sent for histopathological evaluation.,Attention was then turned to attempting to perform a partial laryngectomy up front with a possibility of total laryngectomy as discussed.  Subsequently, the strap muscles were separated in the midline.  The trachea was identified in the midline.  The thyroid isthmus was plicated using the Harmonic scalpel, and attention was then turned to transecting the strap muscles at the superior aspect of the thyroid cartilage.  Once this was performed, sinuses were mobilized from the thyroid cartilage both on the right and left side respectively.  The cricothyroid joint was then freed on the left side and then on the right side with noting on the right side that this cartilage was a bit more irregular.  Attention was then turned to performing a cricothyrotomy.  Upon performing this, it was obvious that there was tumor just above the level of the cricothyrotomy incision.  A #7 anode tube was then placed in this area and secured.  Attention was then turned to performing the laryngotomy at the level of the petiole of epiglottis.  Subsequently, the cuts were made on the left side with visualization of the vocalis process and coming down to the level of the cricoid cartilage, and the thyroid cartilage was then intentionally fractured along the anterior spine.  It was evident that this tumor had extended more than 1 cm into the subglottic region.  Careful dissection of larynx from an inferior margin and portion of cricoid cartilage resection then was performed posteriorly, though it was evident that the cricoid cartilage was invaded.  Frozen section biopsy then confirmed this finding as read by Dr. X of Surgical Pathology.,In light of this finding with cartilaginous invasion and inability to preserve the cricoid cartilage, the patient's case was then converted into a total laryngectomy.  Subsequently, the trachea was transected at the level 3, 4 tracheal ring into cartilaginous space and anterior tracheal stoma was fashioned using 3-0 vertical mattress sutures for the skin.  A W-plasty was also performed to allow for enlargement of the stoma.  Attention was then turned to identifying the common parting wall of the trachea and the esophagus.  Attention was then turned to resecting the hyoid bone.  The remainder of the specimen cuts were made superior from sinus preserving a modest amount of pharyngeal mechanism.  The wound was copiously irrigated.  Subsequently, a tracheoesophageal puncture site was performed using a right-angled hemostat at about approximately 1 cm from the posterior tracheal wall superior aspect.  Once this was performed, a running 3-0 canal stitch was used to close the pharynx.  Subsequently, interrupted 4-0 chromic stitches were then used as reinforcement line from superior to inferior, and fibrin glue was applied.  Two #10 JP drains were placed on the right side and one on the left side and secured appropriately with 3-0 nylon.  The wound was then closed using interrupted 3-0 Vicryl for the platysma and staples for the skin.  The patient tolerated the procedure well and was brought to the Weinberg Intensive Care Unit with the endotracheal tube still in place to be decannulated later.","ent - otolaryngology, laryngectomy, neck dissection, tracheoesophageal, cricopharyngeal myotomy, thyroid lobectomy, squamous cell carcinoma, larynx, thyroid cartilage, cricoid cartilage, total laryngectomy, thyroid, cartilage"
" Functional endoscopic sinus surgery, bilateral maxillary antrostomy, bilateral total ethmoidectomy, bilateral nasal polypectomy, and right middle turbinate reduction. ", ENT - Otolaryngology, Ethmoidectomy & Nasal Polypectomy ,"PROCEDURES PERFORMED:,1.  Functional endoscopic sinus surgery.,2.  Bilateral maxillary antrostomy.,3.  Bilateral total ethmoidectomy.,4.  Bilateral nasal polypectomy.,5.  Right middle turbinate reduction.,ANESTHESIA:,  General endotracheal tube.,BLOOD LOSS:,  Approximately 50 cc.,INDICATION: , This is a 48-year-old female with a history of chronic sinusitis as well as nasal polyposis that have been refractory to outpatient medical management.  She has underwent sinus surgery in the past approximately 12 years ago with the CT evaluation revealed evidence of chronic mucosal thickening within the maxillary and ethmoid sinuses as well as the presence of polyposis within the nasal cavities bilaterally.,PROCEDURE:  ,After all risks, benefits, and alternatives have been discussed with the patient in detail, informed consent was obtained.  The patient was brought to the operative suite where she was placed in supine position and general anesthesia was delivered by the Department of Anesthesia.  The patient was rotated 90 degrees away where cotton pledgets saturated with 4 cc of 10% cocaine solution were inserted into the nasal cavity.  The nasal septum, as well as the turbinates were then localized with a mixture of 1% lidocaine with 1:100,000 epinephrine solution.  The patient was then prepped and draped in the usual fashion.,Attention was directed first to the left nasal cavity.  A zero-degree sinus endoscope was inserted into the nasal cavity down to the level of the nasopharynx.  The initial examination revealed a gross polypoid disease emanating from the sphenoid sinuses as well as off the supreme turbinate.  There was also polypoid disease present within the left middle meatus.  Nasopharynx was visualized with a patent eustachian tube.  At this point, the XPS micro debrider was used to take down all the polyps emanating from the inferior surface of the left middle turbinate as well as from the supreme turbinate.  The ostium to the sphenoid sinus was visualized and was not entered.  At this point, the left middle turbinate was localized and then medialized with the use of a freer elevator.  A ball-tip probe was then used to localize the openings for the natural maxillary ostium.  Side-biting forceps were used to take down the uncinate process and was further taken down with the use of the microdebrider.  The opening of the maxillary sinus was visualized.  The posterior fontanelle was taken down with the use of straight line forceps.  It should be mentioned that tissue was very thick and polypoid with chronic inflammatory changes evident.  The maxillary sinus ostia was then suctioned with Olive-tip suction and maxillary wash was performed.  The remainder of the anterior ethmoid was then cleaned again removing excess polypoid tissue.  The basal lamella was visualized and the posterior ethmoid air cells were then entered with use of the microdebrider as the surgical assistant palpated the patient's eyes for any vibration.  All polypoid tissue was collected in the microdebrider and sent as a surgical specimen.  Once all polypoid tissue has been removed, the cocaine pledgets were reinserted into the ethmoid air cells for hemostatic purposes.  Attention was then directed to the right nasal cavity.  Again, a sinus endoscope was inserted.  Inspection revealed a grossly hypertrophied turbinate.  It was felt that this enlarged and polypoid turbinate was contributing the patient's symptoms.  Therefore, the turbinate was localized and a hemostat was used to crush the mid portion of the turbinate, which was then resected with use of side-biting scissors as well the Takahashi forceps.  Sinus endoscope was then inserted all the way down through the nasopharynx.  Again, the eustachian tube was visualized without any obstructing lesions or masses.  Upon retraction, there was again polypoid tissue noted within the ethmoid sinuses.  The ball-tip probe was again used to locate the right maxillary ostium.  The side-biting forceps was used further take down the uncinate process.  The maxillary ostium was then widened with use of a XPS microdebrider.  A maxillary sinus wash was then performed.  Now, the attention was directed to the ethmoid air cells.  It should be mentioned again that the tissue of the anterior ethmoid was very thickened and polypoid.  This was again taken down with the use of XPS microdebrider while the surgical assistant carefully palpated the patient's eye.,Once all polypoid tissue have been removed, some bleeding that was encountered was controlled with the use of suction cautery in a very conservative manner.  Once all bleeding has been controlled, all surgical instruments were removed and Merocel packing was placed in the bilateral nasal cavities with the intent to remove in the recovery room.  At this point, the procedure was felt to be complete.  The patient was awakened and taken to the recovery room without incident.","ent - otolaryngology, endoscopic sinus surgery, maxillary antrostomy, ethmoidectomy, nasal polypectomy, turbinate reduction, sinus surgery, sinus endoscope, maxillary sinus, nasal cavity, polypoid tissue, sinus, maxillary, turbinate, polypoid, nasal, total, ostium, microdebrider,"
" Incompetent glottis.  Fat harvesting from the upper thigh, micro-laryngoscopy, fat injection thyroplasty.", ENT - Otolaryngology, Fat Harvesting ,"PREOPERATIVE DIAGNOSIS: , Incompetent glottis.,POSTOPERATIVE DIAGNOSIS:,  Incompetent glottis.,OPERATION PERFORMED:,1.  Fat harvesting from the upper thigh.,2.  Micro-laryngoscopy.,3.  Fat injection thyroplasty.,FINDINGS AND PROCEDURE: , With the patient in the supine position under adequate general endotracheal anesthesia, the operative area was prepped and draped in a routine fashion.  A 1-cm incision was made in the upper thigh, and approximately 5 cc of fat was liposuctioned from the subcutaneous space.  After this had been accomplished, the wound was closed with an interrupted subcuticular suture of 4-0 chromic and a light compression dressing was applied.,Next, the fat was placed in a urine strainer and copiously washed using 100 cc of PhysioSol containing 100 units of regular insulin.  After this had been accomplished, it was placed in a 3-cc BD syringe and, thence, into the Stasney fat injector device.  Next, a Dedo laryngoscope was used to visualize the larynx, and approximately *** cc of fat was injected into the right TA muscle and *** cc of fat into the left TA muscle.,The patient tolerated the procedure well and was returned to the recovery room in satisfactory condition.  Estimated blood loss was negligible.","ent - otolaryngology, dedo laryngoscope, physiosol, micro laryngoscopy, fat injection, fat harvesting, incompetent glottis, laryngoscopy, thyroplasty, glottis, thigh"
" Fiberoptic nasolaryngoscopy.  Dysphagia with no signs of piriform sinus pooling or aspiration.  Right parapharyngeal lesion, likely thyroid cartilage, nonhemorrhagic.", ENT - Otolaryngology, Fiberoptic Nasolaryngoscopy ,"PREOPERATIVE DIAGNOSES:,1.  Dysphagia.,2.  Right parapharyngeal hemorrhagic lesion.,POSTOPERATIVE DIAGNOSES:,1.  Dysphagia with no signs of piriform sinus pooling or aspiration.,2.  No parapharyngeal hemorrhagic lesion noted.,3.  Right parapharyngeal lesion, likely thyroid cartilage, nonhemorrhagic.,PROCEDURE PERFORMED: ,Fiberoptic nasolaryngoscopy.,ANESTHESIA: , None.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE: , The patient is a 93-year-old Caucasian male who was admitted to ABCD General Hospital on 08/07/2003 secondary to ischemic ulcer on the right foot.  ENT was asked to see the patient regarding postop dysphagia with findings at that time of the consultation on 08/17/03 with a fiberoptic nasolaryngoscopy, a right parapharyngeal hemorrhagic lesion possibly secondary to LMA intubation.  The patient subsequently resolved with his dysphagia and workup of Speech was obtained, which showed no aspiration, no pooling, minimal premature spillage with solids, but good protection of the airway.  This is a reevaluation of the right parapharyngeal hemorrhagic lesion that was noted prior.,PROCEDURE DETAILS: ,The patient was brought in the semi-Fowler's position, a fiberoptic nasal laryngoscope was then passed into the patient's right nasal passage, all the way to the nasopharynx.  The scope was then flexed caudally and advanced slowly through the nasopharynx into the oropharynx, and down to the hypopharynx.  The patient's oro and nasopharynx all appeared normal with no signs of any gross lesions, edema, or ecchymosis.,Within the hypopharynx although there was an area of fullness and on the right side around the level of the thyroid cartilage cornu that seemed to be prominent and within the lumen of the hypopharynx.  There were no signs of any obstruction.  The epiglottis, piriform sinuses, vallecula, and base of tongue all appeared normal with no signs of any gross lesions.  The patient with excellent phonation with good glottic closure upon phonation and no signs of any aspiration or pooling of secretions.  The scope was then pulled out and the patient tolerated the procedure well.  At this time, we will follow up as an outpatient and possibly there is a need for a microscopic suspension direct laryngoscopy for evaluation of this right parapharyngeal lesion.","ent - otolaryngology, parapharyngeal, dysphagia, sinus pooling, piriform, nasolaryngoscopy, fiberoptic, laryngoscope, nasopharynx, oropharynx, fiberoptic nasolaryngoscopy, hemorrhagic lesion, aspiration, cartilage, hypopharynx, lesion,"
 Persistent dysphagia.  Deviated nasal septum.  Inferior turbinate hypertrophy.  Chronic rhinitis. Conductive hearing loss.  Tympanosclerosis., ENT - Otolaryngology, ENT Consult ,"HISTORY:,  The patient is a 51-year-old female that was seen in consultation at the request of Dr. X on 06/04/2008 regarding chronic nasal congestion, difficulty with swallowing, and hearing loss.  The patient reports that she has been having history of recurrent sinus infection, averages about three times per year.  During the time that she gets the sinus infections, she has nasal congestion, nasal drainage, and also generally develops an ear infection as well.  The patient does note that she has been having hearing loss.  This is particular prominent in the right ear now for the past three to four years.  She does note popping after blowing the nose.  Occasionally, the hearing will improve and then it plugs back up again.  She seems to be plugged within the nasal passage, more on the right side than the left and this seems to be year round issue with her.  She tried Flonase nasal spray to see if this help with this and has been taking it, but has not seen a dramatic improvement.  She has had a history of swallowing issues and that again secondary to the persistent postnasal drainage.  She feels that she is having a hard time swallowing at times as well.  She has complained of a lump sensation in the throat that tends to come and go.  She denies any cough, no hemoptysis, no weight change.  No night sweats, fever or chills has been noted.  She is having at this time no complaints of tinnitus or vertigo.  The patient presents today for further workup, evaluation, and treatment of the above-listed symptoms.,REVIEW OF SYSTEMS:  ,ALLERGY/IMMUNOLOGIC:  History of seasonal allergies.  She also has severe allergy to penicillin and bee stings.,CARDIOVASCULAR:  Pertinent for hypercholesterolemia.,PULMONARY:  She has a history of cough, wheezing.,GASTROINTESTINAL:  Negative.,GENITOURINARY:  Negative.,NEUROLOGIC:  She has had a history of TIAs in the past.,VISUAL:  She does have history of vision change, wears glasses.,DERMATOLOGIC:  Negative.,ENDOCRINE:  Negative.,MUSCULOSKELETAL:  History of joint pain and bursitis.,CONSTITUTIONAL:  She has a history of chronic fatigue.,ENT:  She has had a history of cholesteatoma removal from the right middle ear and previous tympanoplasty with a progressive hearing loss in the right ear over the past few years according to the patient.,PSYCHOLOGIC:  History of anxiety, depression.,HEMATOLOGIC:  Easy bruising.,PAST SURGICAL HISTORY: , She has had right tympanoplasty in 1984.  She has had a left carotid endarterectomy, cholecystectomy, two C sections, hysterectomy, and appendectomy.,FAMILY HISTORY: , Mother, history of vaginal cancer and hypertension.  Brother, colon CA.  Father, hypertension.,CURRENT MEDICATIONS: , Aspirin 81 mg daily.  She takes vitamins one a day.  She is on Zocor, Desyrel, Flonase, and Xanax.  She also has been taking Chantix for smoking cessation.,ALLERGIES: , Penicillin causes throat swelling.  She also notes the bee sting allergy causes throat and tongue swelling.,SOCIAL HISTORY: , The patient is single.  She is unemployed at this time.  She is a smoker about a pack and a half for 38 years and notes rare alcohol use.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Her blood pressure 128/78, temperature is 98.6, pulse 80 and regular.,GENERAL:  The patient is an alert, cooperative, well-developed 51-year-old female.  She has a normal-sounding voice and good memory.,HEAD & FACE:  Inspected with no scars, lesions or masses noted.  Sinuses palpated and are normal.  Salivary glands also palpated and are normal with no masses noted.  The patient also has full facial function.,CARDIOVASCULAR:  Heart regular rate and rhythm without murmur.,RESPIRATORY:  Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.,EYES:  Extraocular muscles were tested and within normal limits.,EARS:  Right ear, the external ear is normal.  The ear canal is clean and dry.  The drum is intact.  She has got severe tympanosclerosis of the right tympanic membrane and Weber exam does lateralize to the right ear indicative of a conductive loss.  Left ear, the external ear is normal.  The ear canal is clean and dry.  The drum is intact and mobile with grossly normal hearing.  The audiogram does reveal normal hearing in the left ear.  She has got a mild conductive loss throughout all frequency ranges in the right ear with excellent discrimination scores noted bilaterally.  Tympanograms, there was no adequate seal obtained on the right side.  She has a normal type A tympanogram, left side.,NASAL:  Reveals a deviated nasal septum to the left, clear drainage, large inferior turbinates, no erythema.,ORAL:  Oral cavity is normal with good moisture.  Lips, teeth and gums are normal.  Evaluation of the oropharynx reveals normal mucosa, normal palates, and posterior oropharynx.  Examination of the larynx with a mirror reveals normal epiglottis, false and true vocal cords with good mobility of the cords.  The nasopharynx was briefly examined by mirror with normal appearing mucosa, posterior choanae and eustachian tubes.,NECK:  The neck was examined with normal appearance.  Trachea in the midline.  The thyroid was normal, nontender, with no palpable masses or adenopathy noted.,NEUROLOGIC:  Cranial nerves II through XII evaluated and noted to be normal.  Patient oriented times 3.,DERMATOLOGIC:  Evaluation reveals no masses or lesions.  Skin turgor is normal.,PROCEDURE: , Please note a fiberoptic laryngoscopy was also done at today's visit for further evaluation because of the patient's dysphagia and throat symptoms.  Findings do reveal moderately deviated nasal septum to the left, large inferior turbinates noted.  The nasopharynx does reveal moderate adenoid pad within this midline.  It is nonulcerated.  The larynx revealed both cords to be normal.  She does have mild lingual tonsillar hypertrophy as well.,IMPRESSION:  ,1.  Persistent dysphagia.  I think secondary most likely to the persistent postnasal drainage.,2.  Deviated nasal septum.,3.  Inferior turbinate hypertrophy.,4.  Chronic rhinitis.,5.  Conductive hearing loss, right ear with a history of cholesteatoma of the right ear.",
" Ethmoidectomy, antrostomy with polyp removal, turbinectomy, and septoplasty.", ENT - Otolaryngology, Endoscopic Sinus Surgery ,"PREOPERATIVE DIAGNOSIS:,1.  Left chronic anterior and posterior ethmoiditis.,2.  Left chronic maxillary sinusitis with polyps.,3.  Left inferior turbinate hypertrophy.,4.  Right anterior and posterior chronic ethmoiditis.,5.  Right chronic maxillary sinusitis with polyps.,6.  Right chronic inferior turbinate hypertrophic.,7.  Intranasal deformity causing nasal obstruction due to septal deviation.,POSTOPERATIVE DIAGNOSIS:,1.  Left chronic anterior and posterior ethmoiditis.,2.  Left chronic maxillary sinusitis with polyps.,3.  Left inferior turbinate hypertrophy.,4.  Right anterior and posterior chronic ethmoiditis.,5.  Right chronic maxillary sinusitis with polyps.,6.  Right chronic inferior turbinate hypertrophic.,7.  Intranasal deformity causing nasal obstruction due to septal deviation.,NAME OF OPERATION: , Bilateral endoscopic sinus surgery, including left anterior and posterior ethmoidectomy, left maxillary antrostomy with polyp removal, left inferior partial turbinectomy, right anterior and posterior ethmoidectomy, right maxillary antrostomy and polyp removal, right partial inferior turbinectomy, and septoplasty.,ANESTHESIA:,  General endotracheal.,ESTIMATED BLOOD LOSS: , Approximately 20 cc.,HISTORY OF PRESENT ILLNESS: , The patient is a 55-year-old female who has had chronic nasal obstruction secondary to nasal polyps and chronic sinusitis.  She also has a septal deviation mid posterior to the left compromising greater than 70% of her nasal airway.,PROCEDURE:  ,The patient was brought to the operating room and placed in the supine position.  After adequate endotracheal anesthesia was obtained, the skin was prepped and draped in sterile fashion.  Lidocaine 1% with 1:100,000 epinephrine was injected into the region of the anterior portion of the nasal septum.  Approximately 10 cc total was used.,A #15 blade and the Freer elevator were used to help make a standard hemitransfixion incision.  A mucoperichondrial flap was carefully elevated, and the junction with the cartilaginous bony septum was separated with the Freer elevator.  The bony deflection was removed using Jansen-Middleton forceps.  The cartilaginous deflection was created by freeing up the inferior attachments to the cartilaginous septum, placing it more on the midline maxillary crest.  The initial incision was placed in its anatomical position and secured with a 4-0 nylon suture for stabilization effect.,Attention then was directed toward the left side.  Lidocaine 1% with 1:100,000 epinephrine was injected in the region of the anterior portion of the left middle turbinate and uncinate process and polyps.  Approximately 10 cc total was used.  The polyps were removed using the Richards essential shaver to help identify the middle turbinate and uncinate process better.  The uncinate process was removed systematically superiorly to inferiorly with back-biting forceps.  Next, the maxillary antrostomy was identified and expanded with the back-biting forceps and showed polypoid accumulation in the mucosal disease on its opening site.  The sinus linings were edematous but did not have any polyps in the inferior, lateral, or superior aspects.,The anterior and posterior ethmoid air cells were entered primarily and dissected with the Richards essential shaver followed by the use of a 30-degree endoscope and up-biting forceps for the superior and lateral dissection.  Bright mucosal disease and small polypoid accumulations were noted through the sinuses also.  The inferior turbinates had some polypoid changes on them also and showed marked mucosal irritation and hypertrophy.  The mucosal polypoid accumulations were cleared using the Richards essential shaver.  The turbinate was partially resected from mucosally but with good shape to it.  It was not desirable to remove it in its entirety.  Any obvious bleeding points along the edge were controlled with the suction Bovie apparatus.,The same procedure and findings were noted on the right side with 1% lidocaine with 1:100,000 epinephrine injected into the anterior portion of the right middle turbinate, polyps, and uncinate process; 10 cc total were used.  The polyps were removed.  The Richards essential shaver was used to allow better exposure of the uncinate process.  The uncinate process was removed superiorly to inferiorly with back-biting side-biting forceps.,Next, a maxillary antrostomy was identified and expanded with the back-biting and side-biting forceps and showed all plate accumulations there also.  The anterior and posterior ethmoid air cells were then entered primarily and dissected with Richards essential shaver followed by the use of the 30-degree scope and up-biting forceps for the superior and lateral resection.  The inferior turbinates showed mucosal disease, polypoid accumulations, and changes.  These were removed using the Richards essential shaver followed by a submucosal resection of the hypertrophied portion of the turbinate.,Any obvious bleeding points were controlled with the suction Bovie apparatus.  A thorough irrigation was then carried out in the nasal cavity, and Gelfilm packing was used to coat the linings in the middle meatal regions.  The patient tolerated the procedure well and returned to the recovery room in stable condition.",
" Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, adenoid hypertrophy.", ENT - Otolaryngology, ENT Consult - 1 ,"CHIEF COMPLAINT: , Chronic otitis media, adenoid hypertrophy.,HISTORY OF PRESENT ILLNESS: , The patient is a 2-1/2-year-old, with a history of persistent bouts of otitis media, superimposed upon persistent middle ear effusions.  He also has a history of chronic mouth breathing and heroic snoring with examination revealing adenoid hypertrophy.  He is being admitted to the operating room at this time for adenoidectomy and bilateral myringotomy and insertion of PE tubes.,ALLERGIES:  ,None.,MEDICATIONS:,  Antibiotics p.r.n.,FAMILY HISTORY: , Diabetes, heart disease, hearing loss, allergy and cancer.,MEDICAL HISTORY: , Unremarkable.,SURGICAL HISTORY: , None.,SOCIAL HISTORY: , Some minor second-hand tobacco exposure.  There are no pets in the home.,PHYSICAL EXAMINATION:,  Ears are well retracted, immobile.  Tympanic membranes with effusions present bilaterally.  No severe congestions, thick mucoid secretions, no airflow.  Oral cavity:  Oropharynx 2 to 3+ tonsils.  No exudates.  Floor of mouth and tongue are normal.  Larynx and pharynx not examined.  Neck:  No nodes, masses or thyromegaly.  Lungs:  Reveal rare rhonchi, otherwise, clear.  Cardiac exam:  Regular rate and rhythm.  No murmurs.  Abdomen:  Soft, nontender.  Positive bowel sounds.  Neurologic exam:  Nonfocal.,IMPRESSION:  ,Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, adenoid hypertrophy.,PLAN: , The patient will be admitted to the operating room for adenoidectomy and bilateral myringotomy and insertion of PE tubes.","ent - otolaryngology, chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, adenoid hypertrophy, pe tubes, otitis media with effusion, adenoidectomy and bilateral myringotomy, eustachian tube dysfunction, insertion of pe, chronic otitis media, bilateral myringotomy, otitis media, adenoidectomy, myringotomy, adenoid, hypertrophy, otitis, media,"
" Severe tonsillitis, palatal cellulitis, and inability to swallow.", ENT - Otolaryngology, Exudative Tonsillitis ,"CHIEF COMPLAINT:  ,Severe tonsillitis, palatal cellulitis, and inability to swallow.,HISTORY OF PRESENT ILLNESS: , This patient started having sore throat approximately one week ago; however, yesterday it became much worse.  He was unable to swallow.  He complained to his parent.  He was taken to Med Care and did not get any better, and therefore presented this morning to ER, where seen and evaluated by Dr. X and concerned as whether he had an abscess either pharyngeal, palatal, or peritonsillar.  He was noted to have extreme tonsillitis with kissing tonsils, marked exudates especially right side and right palatal cellulitis.  A CT scan at ER did not show abscess.  He has not had airway compromise, but he has had difficulty swallowing.  He may have had a low-grade fever, but nothing marked at home.  His records from Hospital are reviewed as well as the pediatric notes by Dr. X. He did have some equivalent leukocytosis.  He had a negative monospot and negative strep screen.,PAST MEDICAL HISTORY:  ,The patient takes no medications, has had no illnesses or surgeries and he is generally in good health other than being significantly overweight.  He is a sophomore at High School.,FAMILY HISTORY:  ,Noncontributory to this illness.,SURGERIES: , None.,HABITS: , Nonsmoker, nondrinker.  Denies illicit drug use.,REVIEW OF SYSTEMS:,ENT:  The patient other than having dysphagia, the patient denies other associated ENT symptomatology.,GU:  Denies dysuria.,Orthopedic:  Denies joint pain, difficulty walking, etc.,Neuro:  Denies headache, blurry vision, etc.,Eyes:  Says vision is intact.,Lungs:  Denies shortness of breath, cough, etc.,Skin:  He states he has a rash, which occurred from penicillin that he was given IM yesterday at Covington Med Care.  Mildly itchy.  Mother has penicillin allergy.,Endocrine:  The patient denies any weight loss, weight gain, skin changes, fatigue, etc, essentially no symptoms of hyper or hypothyroidism.,Physical Exam:,General:  This is a morbidly obese white male adolescent, in no acute disease, alert and oriented x 4.  Voice is normal.  He is handling his secretions.  There is no stridor.,Vital Signs:  See vital signs in nurses notes.,Ears:  TM and EACs are normal.  External, normal.,Nose:  Opening clear.  External nose is normal.,Mouth:  Has bilateral marked exudates, tonsillitis, right greater than left.  Uvula is midline.  Tonsils are touching.  There is some redness of the right palatal area, but is not consistent with peritonsillar abscess.  Tongue is normal.  Dentition intact.  No mucosal lesions other than as noted.,Neck:  No thyromegaly, masses, or adenopathy except for some small minimally enlarged high jugular nodes.,Chest:  Clear to auscultation.,Heart:  No murmurs, rubs, or gallops.,Abdomen:  Obese.  Complete exam deferred.,Skin:  Visualized skin dry and intact, except for rash on his inner thighs and upper legs, which is red maculopapular and consistent with possible allergic reaction.,Neuro:  Cranial nerves II through XII are intact.  Eyes, pupils are equal, round, and reactive to light and accommodation, full range.,IMPRESSION: , Marked exudative tonsillitis, non-strep, non-mono, probably mixed anaerobic infection.  No significant prior history of tonsillitis.  Possible rash to PENICILLIN.,RECOMMENDATIONS: , I concur with IV clindamycin and IV Solu-Medrol as per Dr. X. I anticipate this patient may need several days of IV antibiotics and then be able to switch over to oral.  I do not insist that this patient will need surgical intervention since there is no evidence of abscess.  This one episode of severe tonsillitis does not mean the patient needs tonsillectomy, but if he continues to have significant tonsil problems after this he should be referred for ENT evaluation as an outpatient.  The patient's parents in the room had expressed good understanding, have a chance to ask questions.  At this time, I will see the patient back on an as needed basis.",
" Left ear cartilage graft, repair of nasal vestibular stenosis using an ear cartilage graft, cosmetic rhinoplasty, left inferior turbinectomy.", ENT - Otolaryngology, Ear Cartilage Graft ,"PREOPERATIVE DIAGNOSES:  ,1.  Posttraumatic nasal deformity.,2.  Nasal obstruction.,3.  Nasal valve collapse.,4.  Request for cosmetic change with excellent appearance of nose.,POSTOPERATIVE DIAGNOSES:,1.  Posttraumatic nasal deformity.,2.  Nasal obstruction.,3.  Nasal valve collapse.,4.  Request for cosmetic change with excellent appearance of nose.,OPERATIVE PROCEDURES:,1.  Left ear cartilage graft.,2.  Repair of nasal vestibular stenosis using an ear cartilage graft.,3.  Cosmetic rhinoplasty.,4.  Left inferior turbinectomy.,ANESTHESIA: , General via endotracheal tube.,INDICATIONS FOR OPERATION: , The patient is with symptomatic nasal obstruction and fixed nasal valve collapse following a previous nasal fracture and attempted repair.  We discussed with the patient the indications, risks, benefits, alternatives, and complications of the proposed surgical procedure, she had her questions asked and answered.  Preoperative imaging was performed in consultation with regard to aesthetic results and communicated via the computerized imager.  The patient had questions asked and answered.  Informed consent was obtained.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed in supine position.  The appropriate level of general endotracheal anesthesia was induced.  The patient was converted to the lounge chair position, and the nose was anesthetized and vasoconstricted in the usual fashion.  Procedure began with an inverted going incision and elevation of the skin of the nose in the submucoperichondrial plane over the medial crural footplates and lower lateral cartilages and up over the dorsum.  The septal angle was approached and submucoperichondrial flaps were elevated.  Severe nasal septal deviation to the right hand side and evidence of an old fracture with a separate alignment of the cartilaginous nose from the bony nose was encountered.  The upper laterals were divided and medial and lateral osteotomies were carried out.  Inadequate septal cartilage was noted to be present for use as spreader graft; therefore, left postauricular incision was made, and the conchal bowl cartilage graft was harvested, and it was closed with 3-0 running locking chromic with a sterile cotton ball pressure dressing applied.  Ear cartilage graft was then placed to put two spreader grafts on the left and one the right.  The two on the left extended all the way up to the caudal tip, the one on the right just primarily the medial wall.  It was placed in such a way to correct a caudal dorsal deviation of the nasal tip septum.  The upper lateral cartilage was noted to be of the same width and length in size.  Yet, the left lower cartilage was scarred and adherent to the upper lateral cartilage.  The upper lateral cartilages were noted to be excessive of uneven length with the right being much taller than the left and that was shortened to the same length.  The scar bands were released in the lower lateral cartilages to the upper lateral cartilages to allow free mobilization of the lower lateral cartilages.  A middle crus stitch was used to unite the domes, and then the nose was projected by suturing the medial crural footplates of the caudal septum in deep projected fashion.  Crushed ear cartilage was then placed in the pockets above the spreader grafts in the area of the deficient dorsal nasal height and the lateral nasal sidewall height.  The spreader brought an excellent aesthetic appearance to the nose.  We left more than 1 cm of dorsal and caudal support for the nasal tip and dorsum height.  Mucoperichondrial flaps were closed with 4-0 plain gut suture.  The skin was closed with 5-0 chromic and 6-0 fast absorbing gut.  Doyle splints were placed on each side of nasal septum and secured with 3-0 nylon and a Denver splint was applied.  The patient was awakened in the operating room and taken to the recovery room in good condition.","ent - otolaryngology, nasal deformity, nasal obstruction, nasal valve, cartilage, cartilaginous, crural, graft, nasal fracture, postauricular, rhinoplasty, septal cartilage, submucoperichondrial, turbinectomy, vestibular, ear cartilage graft, posttraumatic nasal deformity, vestibular stenosis, ear cartilage, cartilage graft, cartilages, caudal, nasal, nose, obstruction, repair, stenosis"
 Direct laryngoscopy and bronchoscopy., ENT - Otolaryngology, Direct Laryngoscopy ,"PREOPERATIVE DIAGNOSIS:,  Subglottic stenosis.,POSTOPERATIVE DIAGNOSIS: , Subglottic stenosis.,OPERATIVE PROCEDURES: , Direct laryngoscopy and bronchoscopy.,ANESTHESIA:,  General inhalation.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and placed supine on the operative table.  General inhalational anesthesia was administered through the patient's tracheotomy tube.  The small Parsons laryngoscope was inserted and the 2.9-mm telescope was used to inspect the airway.  There was an estimated 60-70% circumferential mature subglottic stenosis that extended from just under the vocal folds to approximately 3 mm below the vocal folds.  The stoma showed some suprastomal fibroma.  The remaining tracheobronchial passages were clear.  The patient's 3.5 neonatal tracheostomy tube was repositioned and secured with Velcro ties.  Bleeding was negligible.  There were no untoward complications.  The patient tolerated the procedure well and was transferred to recovery room in stable condition.","ent - otolaryngology, laryngoscopy and bronchoscopy, direct laryngoscopy, subglottic stenosis, bronchoscopy, laryngoscopy, subglottic, stenosis, "
 Right ear examination under anesthesia.  Right tympanic membrane perforation along with chronic otitis media., ENT - Otolaryngology, Ear Examination ,"PREOPERATIVE DIAGNOSIS: , Right tympanic membrane perforation.,POSTOPERATIVE DIAGNOSIS: , Right tympanic membrane perforation along with chronic otitis media.,PROCEDURE: , Right ear examination under anesthesia.,INDICATIONS: , The patient is a 15-year-old child with history of a right tympanic membrane perforation following tube placement as well as right conductive hearing loss.  Exam in the office revealed a posterior superior right marginal tympanic perforation.  Risks and benefits of surgery including risk of bleeding, general anesthesia, hearing loss as well as recurrent perforation were discussed with the mother.  The mother wished to proceed with surgery.,FINDINGS:,  The patient was brought to the room, placed in supine position, given general endotracheal anesthesia.  The postauricular crease was then injected with 1% Xylocaine with 1:200,000 epinephrine along with external meatus.  An area of the scalp was shaved above the ear and then also 1% Xylocaine with 1:200,000 epinephrine injected, a total of 4 mL local anesthetic was used.  The ear was then prepped and draped in the usual sterile fashion.  The microscope was then brought into view and examining the marginal perforation, the patient was noted to have large granuloma under the tympanic membrane at the anterior border of the drum.  The granulation tissue was debrided as much as possible.  Decision was made to cancel the tympanoplasty after debriding the middle ear space as much as possible.  The middle ear space was filled with Floxin drops.  The patient woke up anesthesia, extubated, and brought to recovery room in stable condition.  There were no intraoperative complications.  Needle and sponge was correct.  Estimated blood loss minimal.","ent - otolaryngology, chronic otitis media, middle ear space, tympanic membrane perforation, otitis media, hearing loss, middle ear, ear space, ear examination, membrane perforation, tympanic membrane, anesthesia, membrane, tympanic, ear, perforation, "
 Right ear pain with drainage - otitis media and otorrhea., ENT - Otolaryngology, Ear Pain - Drainage ,"CHIEF COMPLAINT:,  Right ear pain with drainage.,HISTORY OF PRESENT ILLNESS:,  This is a 12-year-old white male here with his mother for complaints of his right ear hurting.  Mother states he has been complaining for several days.  A couple of days ago she noticed drainage from the right ear.  The patient states it has been draining for several days and it has a foul smell to it.  He has had some low-grade fever.  The patient was seen in the office about a week ago with complaints of a sore throat, headache and fever.  The patient was evaluated for Strep throat which was negative and just had been doing supportive care.  He did have a recent airplane ride a couple of weeks ago also.  There has been no cough, shortness of breath or wheezing.  No vomiting or diarrhea.,PHYSICAL EXAM:,General:  He is alert in no distress.,Vital Signs:  Temperature:  99.1 degrees.,HEENT:  Normocephalic, atraumatic.  Pupils equal, round and react to light.  The left TM is clear.  The right TM is poorly visualized secondary to purulent secretions in the right ear canal.  There is no erythema of the ear canals.  Nares is patent.  Oropharynx is clear.  The patient does wear braces.,Neck:  Supple.,Lungs:  Clear to auscultation.,Heart:  Regular.  No murmur.,ASSESSMENT:,1.  Right otitis media.,2.  Right otorrhea.,PLAN:,  Ceftin 250 mg by mouth twice a day for 10 days.  Ciprodex four drops to the right ear twice a day.  The patient is to return to the office in two weeks for followup.","ent - otolaryngology, drainage, ear hurting, ear pain, otitis media, otorrhea, ear pain with drainage, otitis, media, ear,"
 Common CT Neck template., ENT - Otolaryngology, CT Neck ,"TECHNIQUE: , Sequential axial CT images were obtained from the base of the brain to the thoracic inlet following the uneventful administration of 100 CC Optiray 320 intravenous contrast.,FINDINGS:,  Scans through the base of the brain are unremarkable.  The oropharynx and nasopharynx are within normal limits.  The airway is patent.  The epiglottis and epiglottic folds are normal.  The thyroid, submandibular, and parotid glands enhance homogenously.  The vascular and osseous structures in the neck are intact.  There is no lymphadenopathy.  The visualized lung apices are clear.,IMPRESSION:  ,No acute abnormalities.","ent - otolaryngology, sequential axial ct images, optiray, parotid glands, epiglottic folds, epiglottis, base of the brain, ct neckNOTE"
" Repair of left ear laceration deformity Y-V plasty 2 cm.  Repair of right ear laceration deformity, complex repair 2 cm.", ENT - Otolaryngology, Ear Laceration Repair ,"PREOPERATIVE DIAGNOSIS:,  Bilateral ear laceration deformities.,POSTOPERATIVE DIAGNOSIS:,  Bilateral ear laceration deformities.,PROCEDURE:,1.  Repair of left ear laceration deformity Y-V plasty 2 cm.,2.  Repair of right ear laceration deformity, complex repair 2 cm.,ANESTHESIA: , 1% Xylocaine, 1:100,000 epinephrine local.,BRIEF CLINICAL NOTE: , This patient was brought to the operating room today for the above procedure.,OPERATIVE NOTE: , The patient was laid in supine position, adequately anesthetized with the above anesthesia, sterilely prepped and draped.  The left ear laceration deformity was very close to the bottom of her ear and therefore it was transected through the centrifugal edge of the ear lobe and pared.  The marsupialized epithelialized tracts were pared to raw tissue.  They were pared in a fashion to create a Y-V plasty with de-epithelialization of the distal V and overlap of the undermined from the proximal cephalad edge.  The 5-0 chromic sutures were used to approximate anteriorly, posteriorly, and anterior centrifugal edge in the Y-V plasty fashion to decrease the risk of notching.  Bacitracin, Band-Aid was placed.  Next, attention was turned to the contralateral ear where an elongated laceration deformity was pared of the marsupialized epithelialized edges anteriorly, posteriorly to create raw edges.  This was not taken through the edge of the lobe to decrease the risk of notch deformity.  The laceration was repaired anteriorly and posteriorly in a pleated fashion to decrease length of the incision and to decrease any deformity toward the edge or any dog-ear deformity toward the edge.  The 5-0 chromic sutures were used in interrupted fashion for this.  The patient tolerated the procedure well.  Band-Aid and bacitracin were placed.  She left the operating room in stable condition.","ent - otolaryngology, bilateral ear laceration, dog-ear deformity, ear laceration deformity, band aid, laceration deformity, ear laceration, laceration, deformity, ear, repair "
 13 years old complaining about severe ear pain - Chronic otitis media., ENT - Otolaryngology, Ear pain - Pediatric Consult ,"PRESENTATION: , Patient, 13 years old, comes to your office with his mother complaining about severe ear pain.  He awoke during the night with severe ear pain, and mom states that this is the third time this year he has had earaches.,HISTORY OF PRESENT ILLNESS:  ,Patient reports that he felt good after taking antibiotics with each earache episode and has recently started on the wrestling team.  Mom reports that patient has been afebrile with each of the earache episodes, and he has not had upper respiratory symptoms.  Patient denies any head trauma associated with wrestling practice.,BIRTH AND DEVELOPMENTAL HISTORY:,  Patient's mother reports a normal pregnancy with no complications, having received prenatal care from 12 weeks.  Vaginal delivery was uneventful with a normal perinatal course.  Patient sat alone at 6 months, crawled at 9 months, and walked at 13 months.  His verbal and motor developmental milestones were as expected.,FAMILY/SOCIAL HISTORY: , Patient lives with both parents and two siblings (brother - age 11 years, sister - age 15 years).  He reports enjoying school, remains active in scouts, and is very excited about being on the wresting team.  Mom reports that he has several friends, but she is concerned about the time required for the wrestling team.  Patient is in 8th grade this year and an A/B student.  Both siblings are healthy.  His Dad has hypertension and has frequent heartburn symptoms that he treats with over-the-counter (OTC) medications.  Mom is healthy and has asthma.,PAST MEDICAL HISTORY:  ,Patient has been seen in the clinic yearly for well child exams.  He has had no major illnesses or hospitalizations.  He had one emergency room visit 2 years ago for a knee laceration.  Patient has been healthy except for the past year when he had two episodes of otitis media not associated with respiratory infections.  He received antibiotic therapy (amoxicillin) for the otitis media and both episodes resolved without problems.  Patient's Mom states that he takes no prescribed medications or OTC medications, but he admits that he has been taking his dad's OTC Pepcid AE sometimes when he gets heartburn.  Upon further examination, he reports taking Pepcid when he eats pizza or Mexican food.  He does complain of sore throats sometimes and often feels burning in his throat when he goes to sleep at night after a late evening snack.,NUTRITIONAL HISTORY: , Patient eats cereal bars or pop tarts with milk for breakfast most days.  He takes his lunch (usually a sandwich and chips or yogurt and fruit) for lunch.  Mom or his sister cooks supper in the evening.  The family goes out to eat once or twice a week and he only gets ""fast food"" once or twice a week according to his Mom.  He says he eats ""a lot"" especially after a wrestling meet.,PHYSICAL EXAM:,Height/weight:  Patient weighs 109 pounds (60th percentile) and is 69 inches tall (93rd percentile).  He is following the growth pattern he established in infancy.,Vital signs:  BP 110/60, T 99.2, HR 70, R 16.,General:  Alert, cooperative but a bit shy.,Neuro:  DTRs symmetric, 2+, negative Romberg, able to perform simple calculations without difficulty, short-term memory intact.  He responds appropriately to verbal and visual cues, and movements are smooth and coordinated.,HEENT:  Normocephalic, PEERLA, red reflex present, optic disk and ocular vessels normal.  TMs deep red, dull, landmarks obscured, full bilaterally.  Post auricular and submandibular nodes on left are palpable and slightly tender.,Lungs:  CTA, breath sounds equal bilaterally, excursion and chest configuration normal.,Cardiac:  S1, S2 split, no murmurs, pulses equal bilaterally.,Abdomen:  Soft, rounded, reports no epigastric tenderness but states that heartburn begins in epigastric area and rises to throat.  Bowel sounds active in all quadrants.  No hepatosplenomegaly or tenderness.  No CVA tenderness.,Musculoskeletal:  Full range of motion, all extremities.  Spine straight, able to perform jumping jacks and duck walk without difficulty.,Genital:  Normal male, Tanner stage 4.  Rectal exam - small amount of soft stool, no fissures or masses.,LABS:  ,Stool negative for blood and H. pylori antigen.  Normal CBC and urinalysis.  A barium swallow and upper GI was scheduled for the following week.  It showed marked GE reflux.,ASSESSMENT: , The differential diagnoses for patient included (a) chronic otitis media/treatment failure, (b) peptic ulcer disease/gastritis, (c) gastro esophageal reflux disease (GERD) or carbonated beverage syndrome, (d) trauma.,CHRONIC OTITIS MEDIA. , Chronic otitis media due to a penicillin resistant organism would be the obvious diagnosis in this case.  It is rare for an adolescent to have otitis media with no precipitating factor (such as being on a swim team or otherwise exposed to unusual organisms or in an unusual environment).  It is certainly unusual for him to have three episodes in 1 year.,PEPTIC ULCER DISEASE.,  There were no symptoms of peptic ulcer disease, a negative H. pylori screen and lack of pain made this diagnosis less likely.  Trauma.  Trauma was a possibility, particularly since adolescent males frequently minimize symptoms especially if they might limit participation in a sport but patient maintained that he had not had an event where he struck his head or neck and that he always wore his helmet with ear padding.,GERD.,  The history of ""heartburn"" relieved by his father's medication was striking.  The positive study supported the diagnosis of GERD, which was severe and chronic enough to cause irritation of the mucosal surfaces exposed to the gastric juices and edema, inflammation in the inner ears.,PLAN:,  Patient and his Mom agreed to a trial of omeprazole 20 mg at bedtime for 2 weeks.  Patient was to keep a diary of any episodes of heartburn, including what foods seemed to aggravate it.  The clinician asked him to avoid using any antacid products in the meantime to gage the effectiveness of the medication.  He was also given a prescription for 10 days of Augmentin99 and a follow-up appointment for 2 weeks.  At his follow-up appointment he reported one episode after he ate a whole large pizza after wrestling practice but said it went away pretty quickly after he took his medication.  A 6-month follow up appointment was scheduled.",
" The patient is a 40-year-old female with a past medical history of repair of deviated septum with complication of a septal perforation.  At this time, the patient states that her septal perforation bothers her as she feels that she has very dry air through her nose as well as occasional epistaxis.", ENT - Otolaryngology, Deviated Septum Repair - Followup ,"CHIEF COMPLAINT: , Septal irritation.,HISTORY OF PRESENT ILLNESS: , The patient is a 39-year-old African-American female status post repair of septal deviation but unfortunately, ultimately ended with a large septal perforation.  The patient has been using saline nasal wash 2-3 times daily, however, she states that she still has discomfort in her nose with a ""stretching"" like pressure.  She says her nose is frequently dry and she occasionally has nosebleeds due to the dry nature of her nose.  She has no other complaints at this time.,PHYSICAL EXAM:,GENERAL:  This is a pleasant African-American female resting in the examination room chair in no apparent distress.,ENT:  External auditory canals are clear.  Tympanic membrane shows no perforation, is intact.,NOSE:  The patient has a slightly deviated right septum.  Septum has a large perforation in the anterior 2/3rd of the septum.  This appears to be well healed.  There is no sign of crusting in the nose.,ORAL CAVITY:  No lesions or sores.  Tonsils show no exudate or erythema.,NECK:  No cervical lymphadenopathy.,VITAL SIGNS:  Temperature 98 degrees Fahrenheit, pulse 77, respirations 18, blood pressure 130/73.,ASSESSMENT AND PLAN:  ,The patient is a 40-year-old female with a past medical history of repair of deviated septum with complication of a septal perforation.  At this time, the patient states that her septal perforation bothers her as she feels that she has very dry air through her nose as well as occasional epistaxis.  At this time, I counseled the patient on the risks and benefits of surgery.  She will consider surgery but at this time, would like to continue using the saline nasal wash as well as occasional Bactroban to the nose if there is occasional irritation or crusting, which she will apply with the edge of a Q-tip.  We will see her back in 3 weeks and if the patient does not feel relieved from the Bactroban as well as saline nasal spray wash, we will consider setting the patient for surgery at that time.","ent - otolaryngology, saline nasal wash, deviated septum, saline nasal, septal perforation, nose, septum, septal, perforation "
 CT maxillofacial for trauma.  CT examination of the maxillofacial bones was performed without contrast.  Coronal reconstructions were obtained for better anatomical localization., ENT - Otolaryngology, CT Maxillofacial ,"EXAM:  ,CT maxillofacial for trauma.,FINDINGS: , CT examination of the maxillofacial bones was performed without contrast.  Coronal reconstructions were obtained for better anatomical localization.,There is normal appearance to the orbital rims.  The ethmoid, sphenoid, and frontal sinuses are clear.  There is polypoid mucosal thickening involving the floor of the maxillary sinuses bilaterally.  There is soft tissue or fluid opacification of the ostiomeatal complexes bilaterally.  The nasal bones appear intact.  The zygomatic arches are intact.  The temporomandibular joints are intact and demonstrate no dislocations or significant degenerative changes.  The mandible and maxilla are intact.  There is soft tissue swelling seen involving the right cheek.,IMPRESSION:,1.  Mucosal thickening versus mucous retention cyst involving the maxillary sinuses bilaterally.  There is also soft tissue or fluid opacification of the ostiomeatal complexes bilaterally.,2.  Mild soft tissue swelling about the right cheek.","ent - otolaryngology, ethmoid, sphenoid, frontal sinuses, mandible, maxilla, ct examination, maxillofacial bones, mucosal thickening, maxillary sinuses, ct, maxillofacial"
 Postoperative hemorrhage. Examination under anesthesia with control of right parapharyngeal space hemorrhage.  The patient is a 35-year-old female with a history of a chronic pharyngitis and obstructive adenotonsillar hypertrophy. , ENT - Otolaryngology, Control of Parapharyngeal Hemorrhage ,"PREOPERATIVE DIAGNOSIS: , Postoperative hemorrhage.,POSTOPERATIVE DIAGNOSIS:,  Postoperative hemorrhage.,SURGICAL PROCEDURE:  ,Examination under anesthesia with control of right parapharyngeal space hemorrhage.,ANESTHESIA:  ,General endotracheal technique.,SURGICAL FINDINGS: , Right lower pole bleeder cauterized with electrocautery with good hemostasis.,INDICATIONS FOR SURGERY: , The patient is a 35-year-old female with a history of a chronic pharyngitis and obstructive adenotonsillar hypertrophy.  Previously, in the day she had undergone a tonsillectomy with adenoidectomy and was recovering without difficulty.  However, in the PACU after a coughing spell she began bleeding from the right oropharynx, and was taken back to the operative suite for control of hemorrhage.,DESCRIPTION OF SURGERY:  ,The patient was placed supine on the operating room table and general anesthetic was administered, once appropriate anesthetic findings achieved the patient was intubated and then prepped and draped in usual sterile manner for a parapharyngeal space hemorrhage.  A Crowe-Davis type mouth gag was introduced in the oropharynx and under operating headlight the oropharynx was clearly visualized.  There was a small bleeder present at the inferior mid pole of the right oropharynx in the tonsillar fossa, this area was cauterized with suction cautery and irrigated.  There was no other bleeding noted.  The patient was repositioned and the mouth gag, the tongue was rotated to the left side of the mouth and the right parapharyngeal space carefully examined.  There was a small amount of oozing noted in the right tonsillar bed, and this was cauterized with suction cautery.  No other bleeding was noted and the patient was recovered from general anesthetic.  She was extubated and left the operating room in good condition to postoperative recovery room area.  Prior to extubation the patient's tonsillar fossa were injected with a 6 mL of 0.25% Marcaine with 1:100,000 adrenalin solution to facilitate postoperative analgesia and hemostasis.","ent - otolaryngology, obstructive adenotonsillar hypertrophy, tonsillar fossa, suction cautery, postoperative hemorrhage, parapharyngeal space, anesthesia, oropharynx, parapharyngeal, tonsillectomy, hemorrhage,"
 Chronic headaches and pulsatile tinnitus., ENT - Otolaryngology, Consult - Pulsatile Tinnitus ,"HISTORY: , The patient is a 48-year-old female who was seen in consultation requested from Dr. X on 05/28/2008 regarding chronic headaches and pulsatile tinnitus.  The patient reports she has been having daily headaches since 02/25/2008.  She has been getting pulsations in the head with heartbeat sounds.  Headaches are now averaging about three times per week.  They are generally on the very top of the head according to the patient.  Interestingly, she denies any previous significant history of headaches prior to this.  There has been no nausea associated with the headaches.  The patient does note that when she speaks on the phone, the left ear has ""weird sounds.""  She feels a general fullness in the left ear.  She does note pulsation sounds within that left ear only.  This began on February 17th according to the patient.  The patient reports that the ear pulsations began following an air flight to Iowa where she was visiting family.  The patient does admit that the pulsations in the ears seem to be somewhat better over the past few weeks.  Interestingly, there has been no significant drop or change in her hearing.  She does report she has had dizzy episodes in the past with nausea, being off balance at times.  It is not associated with the pulsations in the ear.  She does admit the pulsations will tend to come and go and there had been periods where the pulsations have completely cleared in the ear.  She is denying any vision changes.  The headaches are listed as moderate to severe in intensity on average about three to four times per week.  She has been taking Tylenol and Excedrin to try to control the headaches and that seems to be helping somewhat.  The patient presents today for further workup, evaluation, and treatment of the above-listed symptoms.,REVIEW OF SYSTEMS: , ,ALLERGY/IMMUNOLOGIC:  Negative.,CARDIOVASCULAR:  Hypercholesterolemia.,PULMONARY:  Negative.,GASTROINTESTINAL:  Pertinent for nausea.,GENITOURINARY:  The patient is noted to be a living kidney donor and has only one kidney.,NEUROLOGIC:  History of dizziness and the headaches as listed above.,VISUAL:  Negative.,DERMATOLOGIC:  History of itching.  She has also had a previous history of skin cancer on the arm and back.,ENDOCRINE:  Negative.,MUSCULOSKELETAL:  Negative.,CONSTITUTIONAL:  She has had an increased weight gain and fatigue over the past year.,PAST SURGICAL HISTORY:,  She has had a left nephrectomy, C-sections, mastoidectomy, laparoscopy, and T&A.,FAMILY HISTORY:,  Father, history of cancer, hypertension, and heart disease.,CURRENT MEDICATIONS: , Tylenol, Excedrin, and she is on multivitamin and probiotic's.,ALLERGIES: , She is allergic to codeine and penicillin.,SOCIAL HISTORY: , She is married.  She works at Eye Center as a receptionist.  She denies tobacco at this time though she was a previous smoker, stopped four years ago, and she denies alcohol use.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Blood pressure 120/78, pulse 64 and regular, and the temperature is 97.4.,GENERAL:  The patient is an alert, cooperative, well-developed 48-year-old female with a normal-sounding voice and good memory.,HEAD & FACE:  Inspected with no scars, lesions or masses noted.  Sinuses palpated and are normal.  Salivary glands also palpated and are normal with no masses noted.  The patient also has full facial function.,CARDIOVASCULAR:  Heart regular rate and rhythm without murmur.,RESPIRATORY:  Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.,EYES:  Extraocular muscles were tested and within normal limits.,EARS:  There is an old mastoidectomy scar, left ear.  The ear canals are clean and dry.  Drums intact and mobile.  Weber exam is midline.  Grossly hearing is intact.  Please note audiologist not available at today's visit for further audiologic evaluation.,NASAL:  Reveals clear drainage.  Deviated nasal septum to the left, listed as mild to moderate.  Ostiomeatal complexes are patent and turbinates are healthy.  There was no mass or neoplasm within the nasopharynx noted on fiberoptic nasopharyngoscopy.  See fiberoptic nasopharyngoscopy separate exam.,ORAL:  Oral cavity is normal with good moisture.  Lips, teeth and gums are normal.  Evaluation of the oropharynx reveals normal mucosa, normal palates, and posterior oropharynx.  Examination of the larynx with a mirror reveals normal epiglottis, false and true vocal cords with good mobility of the cords.  The nasopharynx was briefly examined by mirror with normal appearing mucosa, posterior choanae and eustachian tubes.,NECK:  The neck was examined with normal appearance.  Trachea in the midline.  The thyroid was normal, nontender, with no palpable masses or adenopathy noted.,NEUROLOGIC:  Cranial nerves II through XII evaluated and noted to be normal.  Patient oriented times 3.,DERMATOLOGIC:  Evaluation reveals no masses or lesions.  Skin turgor is normal.,IMPRESSION:  ,1.  Pulsatile tinnitus, left ear with eustachian tube disorder as the etiology.  Consider, also normal pressure hydrocephalus.,2.  Recurrent headaches.,3.  Deviated nasal septum.,4.  Dizziness, again also consider possible Meniere disease.,RECOMMENDATIONS: , I did recommend the patient begin a 2 g or less sodium diet.  I have also ordered a carotid ultrasound study as part of the workup and evaluation.  She has had a recent CAT scan of the brain though this was without contrast.  It did reveal previous mastoidectomy, left temporal bone, but no other mass noted.  I have started her on Nasacort AQ nasal spray one spray each nostril daily as this is eustachian tube related.  Hearing protection devices should be used at all times as well.  I did counsel the patient if she has any upcoming airplane trips to use nasal decongestant or topical nasal decongestant spray prior to boarding the plane, and also using the airplane ear plugs as these can be effective at helping to prevent eustachian tube issues.  I am going to recheck her in three weeks.  If the pulsatile tinnitus at that time is not clear, we have discussed other treatment options including myringotomy or ear tube placement, which could be done here in the office.  She will be scheduled for a audio and tympanogram to be done as well prior to that procedure.",
" A 14-month-old with history of chronic recurrent episodes of otitis media, totalling 6 bouts, requiring antibiotics since birth. ", ENT - Otolaryngology, Chronic Otitis Media ,"CHIEF COMPLAINT:,  Chronic otitis media.,HISTORY OF PRESENT ILLNESS:,  This is a 14-month-old with history of chronic recurrent episodes of otitis media, totalling 6 bouts, requiring antibiotics since birth.  There is also associated chronic nasal congestion.  There had been no bouts of spontaneous tympanic membrane perforation, but there had been elevations of temperature up to 102 during the acute infection.  He is being admitted at this time for myringotomy and tube insertion under general facemask anesthesia.,ALLERGIES:,  None.,MEDICATIONS:,  None.,FAMILY HISTORY:,  Noncontributory.,MEDICAL HISTORY: , Mild reflux.,PREVIOUS SURGERIES:,  None.,SOCIAL HISTORY: , The patient is not in daycare.  There are no pets in the home.  There is no secondhand tobacco exposure.,PHYSICAL EXAMINATION: , Examination of ears reveals retracted poorly mobile tympanic membranes on the right side with a middle ear effusion present.  Left ear is still little bit black.  Nose, moderate inferior turbinate hypertrophy.  No polyps or purulence.  Oral cavity, oropharynx 2+ tonsils.  No exudates.  Neck, no nodes, masses or thyromegaly.  Lungs are clear to A&P.  Cardiac exam, regular rate and rhythm.  No murmurs.  Abdomen is soft and nontender.  Positive bowel sounds.,IMPRESSION: , Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, and wax accumulation.,PLAN:,  The patient will be admitted to the operating room for myringotomy and tube insertion under general facemask anesthesia.","ent - otolaryngology, chronic nasal congestion, tympanic membrane perforation, chronic otitis media, tube insertion, facemask anesthesia, otitis media, otitis, media,"
" Cauterization of epistaxis, left nasal septum.  Fiberoptic nasal laryngoscopy.  Atrophic dry nasal mucosa.  Epistaxis.  Atrophic laryngeal changes secondary to inhaled steroid use.", ENT - Otolaryngology, Cauterization - Epistaxis ,"PREOPERATIVE DIAGNOSIS: , Epistaxis and chronic dysphonia.,POSTOPERATIVE DIAGNOSES:,1.  Atrophic dry nasal mucosa.,2.  Epistaxis.,3.  Atrophic laryngeal changes secondary to inhaled steroid use.,PROCEDURE PERFORMED:,1.  Cauterization of epistaxis, left nasal septum.,2.  Fiberoptic nasal laryngoscopy.,ANESTHESIA: , Neo-Synephrine with lidocaine nasal spray.,FINDINGS:,1.  Atrophic dry cracked nasal mucosa.,2.  Atrophic supraglottic and glottic changes likely secondary to inhaled steroids and recent endotracheal tube intubation.,INDICATIONS: , The patient is a 37-year-old African-American female who was admitted to ABCD General Hospital with a left wrist abscess.  The patient was taken to the operating room for incision and drainage.  Postoperatively, the patient was placed on nasal cannula oxygen and developed subsequent epistaxis.  Upon evaluating the patient, the patient complains of epistaxis from the left naris as well as some chronic dysphonia that had become exacerbated after surgery.  The patient does report of having endotracheal tube intubation during anesthesia.  The patient also gives a history of inhaled steroid use for her asthma.,The patient was extubated after surgery without difficulty, but continued to have some difficulty and the Department of Otolaryngology was asked to evaluate the patient regarding epistaxis and dysphonia.,PROCEDURE DETAILS:,  After the procedure was described, the patient was placed in the seated position.  The fiberoptic nasal laryngoscope was then inserted into the patient's left naris.  The nasal mucosal membranes were dry and atrophic throughout.  There was no evidence of any mass lesions.  The nasal laryngoscope was then advanced towards the posterior aspect of the nasal cavity.  There was no evidence of mass, ulceration, lesion, or obstruction.  The nasolaryngoscopy continued to be advanced into the oropharynx and the vallecula and the base of the tongue were evaluated and were without evidence of mass lesion or ulceration.,The fiberoptic scope was further advanced and visualization of the larynx revealed some atrophic, dry, supraglottic, and glottic changes.  There was no evidence of any local mass lesion, nodule, or ulcerations.  There was no evidence of any erythema.  Upon phonation, the vocal cords approximated completely and upon inspiration, the true vocal cords were abducted in a normal fashion and was symmetric.  The airway was stable and patent throughout the entire examination.  The nasal laryngoscope was then slowly withdrawn from the supraglottic region and the scope was further advanced into the oropharynx and nasopharynx.  The eustachian tube was completely visualized and was patent without obstruction.  The scope was then further removed without difficulty.  The patient tolerated the procedure well and remained in stable condition.,RECOMMENDATIONS AND PLAN: , The patient would benefit from Ocean nasal spray as well as bacitracin ointment applied to the anterior naris.  At this time, we were unable to discontinue the patient's inhaled steroids that she is using for her asthma.  If this becomes possible in the future, this may provide her some relief of her chronic dysphonia.  The patient is to follow up with Department of Otolaryngology after discharge from the hospital for further evaluation of these problems.","ent - otolaryngology, laryngeal, inhaled steroid use, dry nasal mucosa, fiberoptic nasal laryngoscopy, nasal mucosa, atrophic, cauterization, mucosa, supraglottic, laryngoscope, fiberoptic, dysphonia, lesions, epistaxis,"
 Chronic adenotonsillitis with adenotonsillar hypertrophy.  Upper respiratory tract infection with mild acute laryngitis., ENT - Otolaryngology, Consult - Enlarged Tonsils ,"HISTORY: , The patient is a 15-year-old female who was seen in consultation at the request of Dr. X on 05/15/2008 regarding enlarged tonsils.  The patient has been having difficult time with having two to three bouts of tonsillitis this year.  She does average about four bouts of tonsillitis per year for the past several years.  She notes that throat pain and fever with the actual infections.  She is having no difficulty with swallowing.  She does have loud snoring, though there have been no witnessed observed sleep apnea episodes.  She is a mouth breather at nighttime, however.  The patient does feel that she has a cold at today's visit.  She has had tonsil problems again for many years.  She does note a history of intermittent hoarseness as well.  This is particularly prominent with the current cold that she has had.  She had been seen by Dr. Y in Muskegon who had also recommended a tonsillectomy, but she reports she would like to get the surgery done here in the Ludington area as this is much closer to home.  For the two tonsillitis, she is on antibiotics again on an average about four times per year.  They do seem to help with the infections, but they tend to continue to recur.  The patient presents today for further workup, evaluation, and treatment of the above-listed symptoms.,REVIEW OF SYSTEMS:,ALLERGY/IMMUNOLOGIC:  Negative.,CARDIOVASCULAR:  Negative.,PULMONARY:  Negative.,GASTROINTESTINAL:  Negative.,GENITOURINARY:  Negative.,NEUROLOGIC:  Negative.,VISUAL:  Negative.,DERMATOLOGIC:  Negative.,ENDOCRINE:  Negative.,MUSCULOSKELETAL:  Negative.,CONSTITUTIONAL:  Negative.,PAST SURGICAL HISTORY: , Pertinent for previous cholecystectomy.,FAMILY HISTORY:,  No family history of bleeding disorder.  She does have a sister with a current ear infection.  There is a family history of cancer, diabetes, heart disease, and hypertension.,CURRENT MEDICATIONS: , None.,ALLERGIES: , She has no known drug allergies.,SOCIAL HISTORY: , The patient is single.  She is a student.  Denies tobacco or alcohol use.,PHYSICAL EXAMINATION: ,VITAL SIGNS:  Pulse is 80 and regular, temperature 98.4, weight is 184 pounds.,GENERAL:  The patient is an alert, cooperative, obese, 15-year-old female, with a normal-sounding voice and good memory.,HEAD & FACE:  Inspected with no scars, lesions or masses noted.  Sinuses palpated and are normal.  Salivary glands also palpated and are normal with no masses noted.  The patient also has full facial function.,CARDIOVASCULAR:  Heart regular rate and rhythm without murmur.,RESPIRATORY:  Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.,EYES:  Extraocular muscles were tested and within normal limits.,EARS:  The external ears are normal.  The ear canals are clean and dry.  The drums are intact and mobile.  Hearing is grossly normal.  Tuning fork examination with normal speech reception thresholds noted.,NASAL:  She has clear drainage, large inferior turbinates, no erythema.,ORAL:  Her tongue, lip, floor of mouth are noted to be normal.  Oropharynx does reveal very large tonsils measuring 3+/4+; they were exophytic.  Mirror examination of the larynx reveals some mild edema of the larynx at this time.  The nasopharynx could not be visualized on mirror exam today.,NECK:  Obese, supple.  Trachea is midline.  Thyroid is nonpalpable.,NEUROLOGIC:  Cranial nerves II through XII evaluated and noted to be normal.  Patient oriented times 3.,DERMATOLOGIC:  Evaluation reveals no masses or lesions.  Skin turgor is normal.,IMPRESSION: , ,1.  Chronic adenotonsillitis with adenotonsillar hypertrophy.,2.  Upper respiratory tract infection with mild acute laryngitis.,3.  Obesity.,RECOMMENDATIONS: , We are going to go ahead and proceed with an adenotonsillectomy.  All risks, benefits, and alternatives regarding the surgery have been reviewed in detail with the patient and her family.  This includes risk of bleeding, infection, scarring, regrowth of the adenotonsillar tissue, need for further surgery, persistent sore throat, voice changes, etc.  The parents are agreeable to the planned procedure, and we will schedule this accordingly at Memorial Medical Center here within the next few weeks.  We will make further recommendations afterwards.",
" Recurrent jaw pain, described as numbness and tingling along the jaw, teeth, and tongue.", ENT - Otolaryngology, Consult - Jaw Pain ,"HISTORY:  ,The patient is a 53-year-old male who was seen for evaluation at the request of Dr. X regarding recurrent jaw pain.  This patient has been having what he described as numbness and tingling along the jaw, teeth, and tongue.  This numbness has been present for approximately two months.  It seems to be there ""all the time.""  He was seen by his dentist and after dental evaluation was noted to be ""okay.""  He had been diagnosed with a throat infection about a week ago and is finishing a course of Avelox at this time.  He has been taking cough drops and trying to increase his fluids.  He has recently stopped tobacco.  He has been chewing tobacco for about 30 years.  Again, there is concern regarding the numbness he has been having.  He has had a loss of sensation of taste as well.  Numbness seems to be limited just to the left lateral tongue and the jaw region and extends from the angle of the jaw to the lip.  He does report he has had about a 20-pound of weight gain over the winter, but notes he has had this in the past just simply from decreased activity.  He has had no trauma to the face.  He does note a history of headaches.  These are occasional and he gets these within the neck area when they do flare up.  The headaches are noted to be less than one or two times per month.  The patient does note he has a history of anxiety disorder as well.  He has tried to eliminate his amount of tobacco and he is actually taking Nicorette gum at this time.  He denies any fever or chills.  He is not having any dental pain with biting down.  He has had no jaw popping and no trismus noted.  The patient is concerned regarding this numbness and presents today for further workup, evaluation, and treatment.,REVIEW OF SYSTEMS: , Other than those listed above were otherwise negative.,PAST SURGICAL HISTORY: , Pertinent for hernia repair.,FAMILY HISTORY: , Pertinent for hypertension.,CURRENT MEDICATIONS:,  Tylenol.  He is on Nicorette gum.,ALLERGIES:  ,He is allergic to codeine, unknown reaction.,SOCIAL HISTORY:  ,The patient is single, self-employed carpenter.  He chews tobacco or having chewing tobacco for 30 years, about half a can per day, but notes he has been recently off, and he does note occasional moderate alcohol use.,PHYSICAL EXAMINATION: , ,VITAL SIGNS:  Blood pressure is 138/82, pulse 64 and regular, temperature 98.3, and weight is 191 pounds.,GENERAL:  The patient is an alert, cooperative, obese, 53-year-old male with a normal-sounding voice and good memory.,HEAD & FACE:  Inspected with no scars, lesions or masses noted.  Sinuses palpated and are normal.  Salivary glands also palpated and are normal with no masses noted.  The patient also has full facial function.,CARDIOVASCULAR:  Heart regular rate and rhythm without murmur.,RESPIRATORY:  Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.,EYES:  Extraocular muscles were tested and within normal limits.,EARS:  Both ears, external ears are normal.  The ear canals are clean and dry.  The drums are intact and mobile.  He does have moderate tympanosclerosis noted, no erythema.  Weber exam is midline.  Hearing is grossly intact and normal.,NASAL:  Reveals a deviated nasal septum to the left, moderate, clear drainage, and no erythema.,ORAL:  Oral cavity is normal with good moisture.  Lips, teeth and gums are normal.  Evaluation of the oropharynx reveals normal mucosa, normal palates, and posterior oropharynx.  Examination of the larynx with a mirror reveals normal epiglottis, false and true vocal cords with good mobility of the cords.  The nasopharynx was briefly examined by mirror with normal appearing mucosa, posterior choanae and eustachian tubes.,NECK:  The neck was examined with normal appearance.  Trachea in the midline.  The thyroid was normal, nontender, with no palpable masses or adenopathy noted.,NEUROLOGIC:  He does have slightly decreased sensation to the left jaw.  He is able to feel pressure on touch.  This extends also on to the left lateral tongue and the left intrabuccal mucosa.,DERMATOLOGIC:  Evaluation reveals no masses or lesions.  Skin turgor is normal.,PROCEDURE: , A fiberoptic nasopharyngoscopy was also performed.  See separate operative report in chart.  This does reveal a moderately deviated nasal septum to the left, large inferior turbinates, no mass or neoplasm noted.,IMPRESSION:  ,1.  Persistent paresthesia of the left manual teeth and tongue, consider possible neoplasm within the mandible.,2.  History of tobacco use.,3.  Hypogeusia with loss of taste.,4.  Headaches.,5.  Xerostomia.,RECOMMENDATIONS:,  I have ordered a CT of the head.  This includes sinuses and mandible.  This is primarily to evaluate and make sure there is not a neoplasm as the source of this numbness that he has had.  On the mucosal surface, I do not see any evidence of malignancy and no visible or palpable masses were noted.  I did recommend he increase his fluid intake.  He is to remain off the tobacco.  I have scheduled a recheck with me in the next two to three weeks to make further recommendations at that time.",
 Collar Tubes technique, ENT - Otolaryngology, Collar Tubes ,,"ent - otolaryngology, ototopical drops, tympanic, membrane, ear canals, cerumen, collar tubes, incision, myringotomy, collar, tubes, anesthesiaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Repair of bilateral cleft of the palate with vomer flaps., ENT - Otolaryngology, Cleft Repair ,"PREOPERATIVE DIAGNOSES: , Bilateral cleft lip and bilateral cleft of the palate.,POSTOPERATIVE DIAGNOSES: , Bilateral cleft lip and bilateral cleft of the palate.,PROCEDURE PERFORMED: , Repair of bilateral cleft of the palate with vomer flaps.,ESTIMATED BLOOD LOSS: , 40 mL.,COMPLICATIONS: , None.,ANESTHESIA: , General endotracheal anesthesia.,CONDITION OF THE PATIENT AT THE END OF THE PROCEDURE:,  Stable, extubated, and transferred to the recovery room in stable condition.,INDICATIONS FOR PROCEDURE:  ,The patient is a 10-month-old baby with a history of a bilateral cleft of the lip and palate.  The patient has undergone cleft lip repair, and she is here today for her cleft palate operation.  We have discussed with the mother the nature of the procedure, risks, and benefits; the risks included but not limited to the risk of bleeding, infection, dehiscence, scarring, the need for future revision surgeries.  We will proceed with surgery.,DETAILS OF THE PROCEDURE:,  The patient was taken into the operating room, placed in the supine position, and general anesthetic was administered.  A prophylactic dose of antibiotics was given.  The patient proceeded to have bilateral PE tube placement by Dr. X, from Ear, Nose, and Throat Surgery.  After he was done with his procedure, the head of the bed was turned 90 degrees.  The patient was positioned with a shoulder roll and doughnut.  A Dingman retractor was placed.  The operative area was infiltrated with lidocaine with epinephrine 1:200,000, a total of 3 mL, and then, I proceeded with the prepping and draping.  The patient was prepped and draped.  I proceeded to do the palate repair.  The nature of the palate repair was done in the same way on the both sides.  I will describe one side.  The other side was done exactly in the same manner.  The 2 hemiuvulas are placed, holding from a single hook and infiltrated with lidocaine with epinephrine 1:200,000, triangle in the nasal mucosa was previously marked.  This triangle of nasal mucosa was removed and excised.  This was done on both uvulas.  Then, an incision was done at the level of the palatal cleft at the junction of the nasal and oral mucosa.  A 1-mm cuff of oral mucosa was used to be able to approximate the nasal mucosa better.  Once the incision was done up to the level of the hard palate, the muscle was dissected off the surrounding tissue, 2 mm from the nasal and the oral mucosa.  Then, I proceeded to place an incision at the alveolopalatal junction with the help of 15-blade.  The incision starts at the maxillary tuberosity posteriorly and comes anteriorly at the alveolopalatal junction through the full thickness of mucoperiosteal flap.  Then the flap was lifted up with the help of a freer, and then the remaining of the incision medially was completed.  Hemostasis was achieved with help of electrocautery and Surgicel.  The mucoperiosteal flap was retracted posteriorly with the help of a freer elevator.  The greater auricular foramen was exposed, and the pedicle skeletonized to allow medial retraction of the mucoperiosteal flap.  Then an osteotomy was done at the level of the greater auricular foramen to allow mobilization of the pedicle medially as well as a small incision was done in the periosteum around the pedicle.  The pedicle carefully dissected to allow better mobilization of the mucoperiosteal flap medially.  This procedure was done on both sides in the same manner, and then __________ dissection was done including dissection of the hard palate from the nasal mucosa, it was evident that the nasal mucosa would not reach medially to be placed together.  At this point, the decision was made to proceed with vomer flaps.  The flaps are __________ infiltrated the vomer with the help of lidocaine with epinephrine after an incision in the manner of an open book.  The incision was done with a 15C blade.  The vomer flaps were dissected, and the mucosa was moved laterally to approximate to the nasal mucosa of the hard palate.  This was approximated on both sides with 5-0 chromic running and interrupted stitches, and I proceeded to the remaining of the posterior aspect of the nasal mucosa with a 5-0 chromic and a 4-0 chromic.  Then 2 stitches of 4-0 Vicryl were applied to the soft palate in the Delaire manner through the full thickness of the mucosa and muscle on one side, on the other side, and then coming back on the mucosa to evert the edges of the soft palate.  The remaining part of the soft palate was placed together with 4-0 Vicryl and 4-0 chromic interrupted stitches.  The throat pack was removed.  The palate was cleaned.  The Dingman retractor was removed, and a single stitch after infiltration of lidocaine without epinephrine at the level of the midline of the tongue was applied with 2-0 silk to the dorsal aspect of the tongue and attached to the right cheek with a piece of Tegaderm.  The patient tolerated the procedure without complications.  BSS is applied to the eye after removing the Tegaderm.  I was present and participated in all aspects of the procedure.  The sponge, needle, and instrument count were completed at the end of the procedure.  The patient tolerated the procedure without complications and was transferred to the recovery room in a stable condition.","ent - otolaryngology, bilateral cleft, cleft lip, oral mucosa, hard palate, soft palate, vomer flaps, mucoperiosteal flap, nasal mucosa, flaps, cleft, mucosa, palate, mucoperiosteal, bilateral, nasal,"
" Bilateral myringotomy and tube placement, tonsillectomy and adenoidectomy.", ENT - Otolaryngology, BMT & T&A ,"PREOPERATIVE DIAGNOSES: , Chronic otitis media and tonsillar adenoid hypertrophy.,POSTOPERATIVE DIAGNOSES:,  Chronic otitis media and tonsillar adenoid hypertrophy.,PROCEDURES:,  Bilateral myringotomy and tube placement, tonsillectomy and adenoidectomy.,INDICATIONS FOR PROCEDURE: , The patient is a 3-1/2-year-old child with history of recurrent otitis media as well as snoring and chronic mouth breathing.  Risks and benefits of surgery including risk of bleeding, general anesthesia, tympanic membrane perforation as well as persistent recurrent otitis media were discussed with the patient and parents and informed consent was signed by the parents.,FINDINGS:  ,The patient was brought to the operating room, placed in supine position, given general endotracheal anesthesia.  The left ear was then draped in a clean fashion.  Under microscopic visualization, the ear canal was cleaned of the wax.  Myringotomy incision was made in the anterior inferior quadrant.  There was no fluid in the middle ear space.  A Micron Bobbin tube was easily placed.  Floxin drops were placed in the ear.  The same was performed on the right side with similar findings.  The patient was then turned to be placed in Rose position.  The patient draped in clean fashion.  A small McIvor mouth gag was used to hold open the oral cavity.  The soft palate was palpated.  There was no submucous cleft felt.  Using a 1:1 mixture of 1% Xylocaine with 1:100,000 epinephrine and 0.25% Marcaine, both tonsillar pillars and the fossae injected with approximately 7 mL total.  Using a curved Allis the right tonsil was grasped and pulled medially.  Tonsil was dissected off the tonsillar fossa using a Coblator.  The left tonsil was removed in the similar fashion.  Hemostasis then achieved in tonsillar fossa using the Coblator on coagulation setting.  The soft palate was then retracted using red rubber catheter.  Under mirror visualization, the patient was found to have enlarged adenoids.  The adenoids were removed using the Coblator.  Hemostasis was also achieved using the Coblator on coagulation setting.  The rubber catheter was then removed.  Reexamining the oropharynx, small bleeding points were cauterized with the Coblator.  Stomach contents were then aspirated with saline sump.  The patient was woken up from anesthesia, extubated and brought to recovery room in stable condition.  There were no intraoperative complications.  Needle and sponge correct.  Estimated blood loss minimal.","ent - otolaryngology, bilateral myringotomy, tube placement, tonsillectomy, adenoidectomy, micron bobbin, myringotomy and tube, tonsillectomy and adenoidectomy, chronic otitis media, tonsillar adenoid, tonsillar fossa, rubber catheter, otitis media, adenoids, myringotomy, otitis, media, tonsillar, coblator, "
" Cleft soft palate.  Repair of cleft soft palate and excise accessory ear tag, right ear. ", ENT - Otolaryngology, Cleft Repair - Soft Palate ,"PREOPERATIVE DIAGNOSIS: , Cleft soft palate.,POSTOPERATIVE DIAGNOSIS: , Cleft soft palate.,PROCEDURES:,1.  Repair of cleft soft palate, CPT 42200.,2.  Excise accessory ear tag, right ear.,ANESTHESIA: , General.,DESCRIPTION OF PROCEDURE: , The patient was placed supine on the operating room table.  After anesthesia was administered, time out was taken to ensure correct patient, procedure, and site.  The face was prepped and draped in a sterile fashion.  The right ear tag was examined first.  This was a small piece of skin and cartilaginous material protruding just from the tragus.  The lesion was excised and injected with 0.25% bupivacaine with epinephrine and then excised using an elliptical-style incision.  Dissection was carried down the subcutaneous tissue to remove any cartilaginous attachment to the tragus.  After this was done, the wound was cauterized and then closed using interrupted 5-0 Monocryl.  Attention was then turned towards the palate.  The Dingman mouthgag was inserted and the palate was injected with 0.25% bupivacaine with epinephrine.  After giving this 5 minutes to take effect, the palate was incised along its margins.  The anterior oral mucosa was lifted off and held demonstrating the underlying levator muscle.  Muscle was freed up from its attachments at the junction of the hard palate and swept down so that it will be approximated across the midline.  The Z-plasties were then designed, so there would be opposing Z-plasties from the nasal mucosa compared to the oral mucosa.  The nasal mucosa was sutured first using interrupted 4-0 Vicryl.  Next, the muscle was reapproximated using interrupted 4-0 Vicryl with an attempt to overlap the muscle in the midline.  In addition, the remnant of the uvula tissue was found and was sutured in such a place that it would add some extra bulk to the nasal surface of the palate.  Following this, the oral layer of mucosa was repaired using an opposing Z-plasty compared to the nasal layer.  This was also sutured in place using interrupted 4-0 Vicryl.  The anterior and posterior open edges of the palatal were sewn together.  The patient tolerated the procedure well.  Suction of blood and mucus performed at the end of the case.  The patient tolerated the procedure well.,IMMEDIATE COMPLICATIONS: , None.,DISPOSITION:,  In satisfactory condition to recovery.","ent - otolaryngology, repair, tragus, oral mucosa, nasal mucosa, ear tag, soft palate, palate, cleft, soft"
 Bilateral myringotomy tubes and adenoidectomy., ENT - Otolaryngology, BMT & Adenoidectomy ,"PREOPERATIVE DIAGNOSIS: , Chronic otitis media.,POSTOPERATIVE DIAGNOSIS: , Chronic otitis media.,PROCEDURE PERFORMED: , Bilateral myringotomy tubes and adenoidectomy.,INDICATIONS FOR PROCEDURE:,  The patient is an 8-year-old child with history of recurrent otitis media.  The patient has had previous tube placement.  Tubes have since plugged and are no more functioning.  The patient has had recent recurrent otitis media.  Risks and benefits in terms of bleeding, anesthesia, and tympanic membrane perforation were discussed with the mother.  Mother wished to proceed with the surgery.,PROCEDURE IN DETAIL: , The patient was brought to the room, placed supine.  The patient was given general endotracheal anesthesia.  Starting on the left ear, under microscopic visualization, the ear was cleaned of wax.  A Bobbin tube was found stuck to the tympanic membrane.  This was removed.  After removing the tube the patient was found to have microperforation through which serous fluid was draining.  A fresh myringotomy was made in the anterior inferior quadrant.  More serous fluid was aspirated from middle ear space.  The new Bobbin tube was easily placed.  Floxin drops were placed in the ear.  In the right ear again under microscopic visualization, the ear was cleaned, the tube was removed off tympanic membrane.  There was no perforation seen; however, there was some granulation tissue on the surface of tympanic membrane.  A fresh myringotomy incision was made in the anterior inferior quadrant.  More serous fluid was drained out of middle ear space.  The tube was easily placed and Floxin drops were placed in the ear.  This completes tube portion of the surgery.  The patient was then turned and placed in the Rose position.  Shoulder roll was placed for neck extension.  Using a small McIvor mouth gag mouth was held open.  Using a rubber catheter the soft palate was retracted.  Under mirror visualization, the nasopharynx was examined.  The patient was found to have minimal adenoidal tissue.  This was removed using a suction Bovie.  The patient was then awakened from anesthesia, extubated and brought to recovery room in stable condition.  There were no intraoperative complications.  Needle and sponge count correct.  Estimated blood loss none.","ent - otolaryngology, chronic otitis media, bilateral myringotomy tubes, adenoidectomy, myringotomy tubes and adenoidectomy, middle ear space, bilateral myringotomy, bobbin tube, fresh myringotomy, serous fluid, otitis media, tympanic membrane, tubes, myringotomy, otitis, media, membrane, "
" T1 N3 M0 cancer of the nasopharynx, status post radiation therapy with 2 cycles of high dose cisplatin with radiation.", ENT - Otolaryngology, Cancer of the nasopharynx ,"DIAGNOSIS: , T1 N3 M0 cancer of the nasopharynx, status post radiation therapy with 2 cycles of high dose cisplatin with radiation, completed June, 2006; status post 2 cycles  carboplatin/5-FU given as adjuvant therapy, completed September, 2006; hearing loss related to chemotherapy and radiation; xerostomia; history of left upper extremity deep venous thrombosis.,PERFORMANCE STATUS:,  0.,INTERVAL HISTORY: , In the interim since his last visit he has done quite well.  He is working.  He did have an episode of upper respiratory infection and fever at the end of April which got better with antibiotics.  Overall when he compares his strength to six or eight months ago he notes that he feels much stronger.  He has no complaints other than mild xerostomia and treatment related hearing loss.,PHYSICAL EXAMINATION:,Vital Signs:  Height 65 inches, weight 150, pulse 76, blood pressure 112/74, temperature 95.4, respirations 18.,HEENT:  Extraocular muscles intact.  Sclerae not icteric.  Oral cavity free of exudate or ulceration.  Dry mouth noted.,Lymph:  No palpable adenopathy in cervical, supraclavicular or axillary areas.,Lungs:  Clear.,Cardiac:  Rhythm regular.,Abdomen:  Soft, nondistended.  Neither liver, spleen, nor other masses palpable.,Lower Extremities:  Without edema.,Neurologic:  Awake, alert, ambulatory, oriented, cognitively intact.,I reviewed the CT images and report of the study done on May 1.  This showed no evidence of metabolically active malignancy.,Most recent laboratory studies were performed last September and the TSH was normal.  I have asked him to repeat the TSH at the one year anniversary.,He is on no current medications.,In summary, this 57-year-old man presented with T1 N3 cancer of the nasopharynx and is now at 20 months post completion of all therapy.  He has made a good recovery.  We will continue to follow thyroid function and I have asked him to obtain a TSH at the one year anniversary in September and CBC in follow up.  We will see him in six months' time with a PET-CT.,He returns to the general care and direction of Dr. ABC.","ent - otolaryngology, radiation therapy with cycles, cancer of the nasopharynx, status post radiation, cisplatin with radiation, radiation therapy, hearing loss, hearing, cisplatin, xerostomia, cancer, radiation, nasopharynx,"
" Bilateral myringotomies, placement of ventilating tubes, nasal endoscopy, and adenoidectomy.", ENT - Otolaryngology, Bilateral Myringotomies ,"PREOPERATIVE DIAGNOSES,1.  Recurrent acute otitis media, bilateral middle ear effusions.,2.  Chronic rhinitis.,3.  Recurrent adenoiditis with adenoid hypertrophy.,POSTOPERATIVE DIAGNOSES,1.  Recurrent acute otitis media, bilateral middle ear effusions.,2.  Chronic rhinitis.,3.  Recurrent adenoiditis with adenoid hypertrophy.,FINAL DIAGNOSES,1.  Recurrent acute otitis media, bilateral middle ear effusions.,2.  Chronic rhinitis.,3.  Recurrent adenoiditis with adenoid hypertrophy.,4.  Acute and chronic adenoiditis.,OPERATIONS PERFORMED,1.  Bilateral myringotomies.,2.  Placement of ventilating tubes.,3.  Nasal endoscopy.,4.  Adenoidectomy.,DESCRIPTION OF OPERATIONS: , The patient was brought to the operating room, endotracheal intubation carried out by Dr. X. Both sides of the patient's nose were then sprayed with Afrin.  Ears were inspected then with the operating microscope.  The anterior inferior quadrant myringotomy incisions were performed.  Then, a modest amount of serous and a trace of mucoid material encountered that was evacuated.  The middle ear mucosa looked remarkably clean.  Armstrong tubes were inserted.  Ciprodex drops were instilled.  Ciprodex will be planned for two postoperative days as well.  Nasal endoscopy was carried out, and evidence of acute purulent adenoiditis was evident in spite of the fact that clinically the patient has shown some modest improvement following cessation of all milk products.  The adenoids were shaved back, flushed with curette through a traditional transoral route with thick purulent material emanating from the crypts, and representative cultures were taken.  Additional adenoid tissue was shaved backwards with the RADenoid shaver.  Electrocautery was used to establish hemostasis, and repeat nasal endoscopy accomplished.  The patient still had residual evidence of inter choanal adenoid tissue, and video photos were taken.  That remaining material was resected, guided by the nasal endoscope using the RADenoid shaver to remove the material and flush with the posterior nasopharynx.  Electrocautery again used to establish hemostasis.  Bleeding was trivial.  Extensive irrigation accomplished.  No additional bleeding was evident.  The patient was awakened, extubated, taken to the recovery room in a stable condition.  Discharge anticipated later in the day on Augmentin 400 mg twice daily, Lortab or Tylenol p.r.n. for pain.  Office recheck would be anticipated if stable and doing well in approximately two weeks.  Parents were instructed to call, however, regarding the outcome of the culture on Monday next week to ensure adequate antibiotic coverage before cessation of the antibiotic.","ent - otolaryngology, bilateral middle ear effusions, recurrent acute otitis media, chronic rhinitis, recurrent adenoiditis with adenoid hypertrophy, adenoiditis, bilateral myringotomies, ventilating tubes, nasal endoscopy, adenoidectomy, adenoid hypertrophy, myringotomies, otitis, media, hypertrophy, endoscopy, intubation, nasal,"
 Adenotonsillectomy.  Adenotonsillitis with hypertrophy.  The patient is a very nice patient with adenotonsillitis with hypertrophy and obstructive symptoms.  Adenotonsillectomy is indicated., ENT - Otolaryngology, Adenotonsillectomy - 2 ,"POSTOPERATIVE DIAGNOSIS:  Adenotonsillitis with hypertrophy.,OPERATION PERFORMED:  Adenotonsillectomy.,ANESTHESIA:  General endotracheal.,INDICATIONS:  The patient is a very nice patient with adenotonsillitis with hypertrophy and obstructive symptoms.  Adenotonsillectomy is indicated.,DESCRIPTION OF PROCEDURE:  The patient was placed on the operating room table in the supine position.  After adequate general endotracheal anesthesia was administered, table was turned and shoulder roll was placed on the shoulders and face was draped in clean fashion.  A McIvor mouth gag was applied.  The tongue was retracted anteriorly and the McIvor was gently suspended from a Mayo stand.  A red rubber Robinson catheter was inserted through the left naris and the soft palate was retracted superiorly.  The adenoids were removed with suction electrocautery under mere visualization.  The left tonsil was grasped with a curved Allis forceps, retracted medially and the anterior tonsillar pillar was incised with Bovie electrocautery.  The tonsil was removed from the superior and inferior pole using Bovie electrocautery in its entirety in the subcapsular fashion.  The right tonsil was grasped in the similar fashion and retracted medially and the anterior tonsillar pillar was incised with Bovie electrocautery.  The tonsil was removed from the superior pole and inferior pole using Bovie electrocautery in its entirety in the subcapsular fashion.  The inferior, middle and superior pole vessels were further cauterized with suction electrocautery.  Copious saline irrigation of the oral cavity was then performed.  There was no further identifiable bleeding at the termination of the procedure.  The estimated blood loss was less than 10 mL.  The patient was extubated in the operating room, brought to the recovery room in satisfactory condition.  There were no intraoperative complications.","ent - otolaryngology, hypertrophy, adenotonsillitis, tonsillar pillar, bovie electrocautery, adenotonsillectomyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Bilateral Myringotomy with placement of PE tubes, ENT - Otolaryngology, Bilateral Myringotomies - 2 ,"PREOPERATIVE DIAGNOSES: , Bilateral chronic otitis media,POSTOPERATIVE DIAGNOSES:,  Bilateral chronic otitis media,ANESTHESIA:,  General mask,NAME OF OPERATION:,  Bilateral Myringotomy with placement of PE tubes,PROCEDURE:,  The patient was taken to the operating room and placed in the supine position.  After adequate general inhalation anesthesia was obtained, the operating microscope with brought in for full use throughout the case.  First, the left and then the right tympanic membrane, was approached.  An anterior-inferior radial incision was made in the left tympanic membrane.  Suction revealed a substantial amount of mucopurulent drainage.  A Sheehy pressure equalization tube was placed in the myringotomy site.  Floxin drops were added.  The same procedure was repeated on the right side with similar findings noted of mucopurulent drainage.  The patient tolerated the procedure well and returned to the recovery room awake and in stable condition.","ent - otolaryngology, placement of pe tubes, bilateral chronic otitis media, chronic otitis media, bilateral myringotomy, pe tubes, chronic otitis, otitis media, tympanic membrane, mucopurulent drainage, tympanic, membrane, mucopurulent, myringotomy, tubes, "
 A sample note on bilateral myringotomy tubes, ENT - Otolaryngology, BMT - Bilateral Myringotomy Tubes ,"Parents often ask why the fluid cannot be drained without inserting a tube.  The need for the tube insertion is because the eardrum incision generally heals very rapidly (within a few days), which is not long enough for the swollen membranes in the middle ear to return to normal.  As soon as the eardrum heals, fluid will reaccumulate.  Tubes were first introduced because of this very problem.  There are many types of tubes, but all tubes serve the same function.  They keep the eardrum open, allow air to enter the middle ear space, and permit fluid in the middle ear to drain.  Most tubes will gradually be rejected by the ear and work their way out of the eardrum.  As they come out, the eardrum seals behind the tube.  Tubes will last four to six months in the eardrum before they come out.  Occasionally, the eardrum does not heal completely when the tube comes out.,The majority of children treated with tubes do not require further surgery.  They may have ear infections in the future, but most will clear up with medical treatment.  Some children are very prone to ear infections and have a tendency to accumulate fluid after each infection.  Children tend to outgrow this cycle by age 7 or 8.  In an ear, nose and throat specialty practice, this group comprises 10 to 15% of all children who have required tubes.  Occasionally the physician has to physically remove the tube from the ear drum.","ent - otolaryngology, eardrum, myringotomy, tubes, bilateral myringotomy tubes, myringotomy tubes, ear infections, middle ear, fluid, childrenNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Adenoidectomy.  Adenoid hypertrophy.  The McIvor mouth gag was placed in the oral cavity and the tongue depressor applied. , ENT - Otolaryngology, Adenoidectomy - 1 ,"PREOPERATIVE DIAGNOSIS: , Adenoid hypertrophy.,POSTOPERATIVE DIAGNOSIS: , Adenoid hypertrophy.,PROCEDURE PERFORMED:  ,Adenoidectomy.,ANESTHESIA: , General endotracheal.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and prepped and draped in the usual fashion after induction of general endotracheal anesthesia.  The McIvor mouth gag was placed in the oral cavity and the tongue depressor applied.  Two #12-French red rubber Robinson catheters were placed, 1 in each nasal passage, and brought out through the oral cavity and clamped over a dental gauze roll placed on the upper lip to provide soft palate retraction.  The nasopharynx was inspected with the laryngeal mirror.  Serial passages of the curettes were utilized to remove the nasopharyngeal tissue, following which the nasopharynx was packed with 2 cherry gauze sponges coated in a solution of 0.25% Neo-Synephrine and tannic acid powder.,Attention was then redirected to the oropharynx.  The McIvor was reopened, packs removed, and the bleeding was controlled with the suction Bovie unit.  The catheters were removed, and the nasal passages and oropharynx were suctioned free of debris.  The McIvor was then removed, and the procedure was terminated.,The patient tolerated the procedure well and left the operating room in good condition.","ent - otolaryngology, palate, nasal passage, mcivor mouth gag, oral cavity, nasal, nasopharynx, oropharynx, hypertrophy, oral, cavity, mcivor, tongue, adenoidectomy"
 Adenotonsillectomy.  Recurrent tonsillitis.  The adenoid bed was examined and was moderately hypertrophied.  Adenoid curettes were used to remove this tissue and packs placed. , ENT - Otolaryngology, Adenotonsillectomy - 1 ,"PREOPERATIVE DIAGNOSIS: , Recurrent tonsillitis.,POSTOPERATIVE DIAGNOSIS: , Recurrent tonsillitis.,PROCEDURE:  ,Adenotonsillectomy.,COMPLICATIONS:,  None.,PROCEDURE DETAILS:, The patient was brought to the operating room and, under general endotracheal anesthesia in supine position, the table turned and a McIvor mouthgag placed.  The adenoid bed was examined and was moderately hypertrophied.  Adenoid curettes were used to remove this tissue and packs placed.  Next, the right tonsil was grasped with a curved Allis and, using the gold laser, the anterior tonsillar pillar incised and, with this laser, dissection carried from the superior pole to the inferior pole and removed off the tonsillar muscular bed.  A similar procedure was performed on the contralateral tonsil.  Following meticulous hemostasis, saline was used to irrigate and no further bleeding noted.  The patient was then allowed to awaken and was brought to the recovery room in stable condition.","ent - otolaryngology, curved allis, tonsillitis, hypertrophied, curettes, tonsillar, adenoid, adenotonsillectomy, "
" Adenotonsillectomy, primary, patient under age 12.", ENT - Otolaryngology, Adenotonsillectomy ,"PREOPERATIVE DIAGNOSIS: , Chronic hypertrophic adenotonsillitis.,POSTOPERATIVE DIAGNOSIS: , Chronic hypertrophic adenotonsillitis.,OPERATIVE PROCEDURE:,  Adenotonsillectomy, primary, patient under age 12.,ANESTHESIA: , General endotracheal anesthesia.,PROCEDURE IN DETAIL: , This patient was brought from the holding area and did receive preoperative antibiotics of Cleocin as well as IV Decadron.  She was placed supine on the operating room table.  General endotracheal anesthesia was induced without difficulty.  In the holding area, her allergies were reviewed.  It is unclear whether she is actually allergic to penicillin.  Codeine caused her to be excitable, but she did not actually have an allergic reaction to codeine.  She might be allergic to BACTRIM and SULFA.  After positioning a small shoulder roll and draping sterilely, McIvor mouthgag, #3 blade was inserted and suspended from the Mayo stand.  There was no bifid uvula or submucous cleft.  She had 3+ cryptic tonsils with significant debris in the tonsillar crypts.  Injection at each peritonsillar area with 0.25% with Marcaine with 1:200,000 Epinephrine, approximately 1.5 mL total volume.  The left superior tonsillar pole was then grasped with curved Allis forceps.  _______ incision and dissection in the tonsillar capsule and hemostasis and removal of the tonsil was obtained with Coblation Evac Xtra Wand on 7/3.  Mouthgag was released, reopened, no bleeding was seen.  The right tonsil was then removed in the same fashion.  The mouthgag released, reopened, and no bleeding was seen.  Small red rubber catheter in the nasal passage was used to retract the soft palate.  She had mild-to-moderate adenoidal tissue residual.  It was removed with Coblation Evac Xtra gently curved Wand on 9/5.  Red rubber catheter was then removed.  Mouthgag was again released, reopened, no bleeding was seen.  Orogastric suction carried out with only scant clear stomach contents.  Mouthgag was then removed.  Teeth and lips were inspected and were in their preoperative condition.  The patient then awakened, extubated, and taken to recovery room in good condition.,TOTAL BLOOD LOSS FROM TONSILLECTOMY: , Less than 2 mL.,TOTAL BLOOD LOSS FROM ADENOIDECTOMY: , Less than 2 mL.,COMPLICATIONS: , No intraoperative events or complications occurred.,PLAN:,  Family will be counseled postoperatively.  Postoperatively, the patient will be on Zithromax oral suspension 500 mg daily for 5 to 7 days, Lortab Elixir for pain.  _______ and promethazine if needed for nausea and vomiting.","ent - otolaryngology, hypertrophic adenotonsillitis, adenotonsillitis, endotracheal anesthesia, coblation evac xtra wand, lortab elixir, red rubber catheter, total blood loss, adenotonsillectomy, forceps, mouthgag,"
 Adenoidectomy procedure, ENT - Otolaryngology, Adenoidectomy ,"ADENOIDECTOMY,PROCEDURE:,  The patient was brought into the operating room suite, anesthesia administered via endotracheal tube.  Following this the patient was draped in standard fashion.  The Crowe-Davis mouth gag was inserted in the oral cavity.  The palate and tonsils were inspected, the palate was suspended with a red rubber catheter passed through the right nostril.  Following this, the mirror was used to visualize the adenoid pad and an adenoid curet was seated against the vomer.  The adenoid pad was removed without difficulty.  The nasopharynx was packed.  Following this, the nasopharynx was unpacked, several discrete bleeding sites were gently coagulated with electrocautery and the nasopharynx and oral cavity were irrigated.  The Crowe-Davis was released.,The patient tolerated the procedure without difficulty and was in stable condition on transfer to recovery.","ent - otolaryngology, adenoidectomy, crowe-davis, adenoid pad, electrocautery, endotracheal tube, gently coagulated, mouth gag, nasopharynx, oral cavity, red rubber catheter, vomer, palate, tonsilsNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Bilateral myringotomies with Armstrong grommet tubes, Adenoidectomy, and Tonsillectomy.", ENT - Otolaryngology, Bilateral Myringotomies - 1 ,"PREOPERATIVE DIAGNOSES:,  OM, chronic, serous, simple or unspecified.  Adenoid hyperplasia.  Hypertrophy of tonsils.,POSTOPERATIVE DIAGNOSIS: , Same as preoperative diagnosis.,OPERATION: , Bilateral myringotomies with Armstrong grommet tubes, Adenoidectomy, and Tonsillectomy.,ANESTHESIA:,  General.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , Minimal.,DRAINS: , None.,CONSENT:,  The procedure, benefits, and risks were discussed in detail preoperatively.  The parentsagreed to proceed after all questions were answered.,TECHNIQUE: , The patient was brought to the operating room and placed in the supine position.  After general mask anesthesia was adequately obtained, the right external auditory canal was cleaned out under the microscope.  Serous fluid was aspirated from the middle ear space.  An Armstrong grommet tube was placed down through the incision and rotated into place.  The opposite ear was then cleaned out under the microscope.  Serous fluid was aspirated from the middle ear space.  An Armstrong grommet tube was placed down through the incision and rotated into place.  Cortisporin suspension was placed in both ear canals.,Then the patient was intubated.  A Crowe-Davis mouth gag was placed into the mouth and extended and hung on the Mayo stand.  The red rubber catheter was placed down through the nose and brought out through the mouth to retract the palate.  The adenoid fossa was visualized with the mirror.  The adenoids were removed using the microdebrider.  Two adenoid packs were placed.  The packs were removed one by one.  Using mirror and suction bovie, adequate hemostasis was achieved.,The tonsils were quite large and cryptic.  The tenaculum was placed on the superior pole of the right tonsil.  Cheesy material came out from the crypts.  The tonsils were retracted medially.  The bovie electrocautery was used to make an incision in the right anterior tonsillar pillar, and the plane was developed between the tonsil and the musculature.  The tonsil was completely dissected out of this plane, preserving both the anterior and posterior tonsillar pillars.  All bleeders were cauterized as they were encountered.  The tenaculum was then placed on the superior pole of the left tonsil.  Cheesy material came out from the crypts.  The tonsils were retracted medially.  The bovie electrocautery was used to make an incision in the left anterior tonsillar pillar, and the plane was developed between the tonsil and the musculature.  The tonsil was completely dissected out of this plane, preserving both the anterior and posterior tonsillar pillars.  All bleeders were cauterized as they were encountered.  Both tonsil beds were then re-cauterized, paying particular attention to the inferior and superior poles.,The stomach was evacuated with the nasogastric tube.  The patient was then awakened in the operating room, extubated and taken to the recovery room in satisfactory condition.","ent - otolaryngology, adenoid hyperplasia, om, adenoidectomy, tonsillectomy, auditory canal, serous fluid, crowe-davis mouth gag, tonsils, adenoidectomy and tonsillectomy, armstrong grommet tubes, bovie electrocautery, tonsillar pillar, bilateral myringotomies, armstrong, tubes, grommet, tonsillar, bilateral, myringotomies, tenaculum"
" Left thyroid mass.  Left total thyroid lumpectomy.  The patient with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole.", Endocrinology, Total Thyroid Lumpectomy ,"PREOPERATIVE DIAGNOSIS:,  Left thyroid mass.,POSTOPERATIVE DIAGNOSIS:,  Left thyroid mass.,PROCEDURE PERFORMED:,  Left total thyroid lumpectomy.,ANESTHESIA,:  General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,COMPLICATIONS:,  None.,INDICATIONS FOR PROCEDURE:,  The patient is a 76-year-old Caucasian female with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole.  The patient was then discussed the risks, complications, and consequences of a surgical procedure and a written consent was obtained.,PROCEDURE:  ,The patient is brought to the operative suite by Anesthesia.  The patient was placed on the operative table in supine position.  After this, the patient was placed under general endotracheal intubation anesthesia and the patient was then placed upon a shoulder roll.  After this, the skin incision was marked approximately two fingerbreadths above the sternal notch.  It was then localized with 1% lidocaine with epinephrine 1:1000 approximately 7 cc total.,After this, the patient was then prepped and draped in the usual sterile fashion and a #10 blade was then utilized to make a skin incision.  The subcutaneous tissue was then bluntly dissected utilizing a Ray-Tec sponge and a bear claw was then utilized to retract the upper incisional skin with counter retraction performed to allow a subplatysmal plane of skin flaps to be performed in superior and inferolateral directions.  After this, the midline was then identified and grasped on either side with a DeBakey forceps.  The raphe was noted and Bovie cauterization was utilized to cut down into this region.  The fine stats were utilized to further open this area with exposure and bisection of the sternothyroid muscle.  It was separated on the left side from the patient's sternothyroid muscle.  After this, the sternothyroid muscle was identified, grasped with the DeBakey forceps and infiltrated initially through its fascial plane with the Metzenbaum scissors.  Blunt dissection was then utilized to free the sternothyroid muscle from the thyroid gland in superior and inferior directions and laterally with the help of Kitners.  After this, the plane was rotated more anteriorly with the superior and inferior parathyroid glands identified.  The fat cap was noted to be attached on the superior parathyroid to the posterior aspect of the thyroid itself.  It was freed from the thyroid gland and reflected laterally and posteriorly.  The inferior parathyroid gland actually appeared to be attached also to the inferior aspect of the thyroid itself and was reflected laterally.  After this, the patient's thyroid gland was palpated noting a thyroid nodule in the posterior inferior aspect along with the calcification laterally.  The nodule appeared to be sort of rubbery in consistency and approximately 1 cm diameter.  As the gland was rotated more anteriorly, the recurrent laryngeal nerve on the left side was identified and further dissection along Berry's ligament on the medial aspect was performed.  The middle thyroid vein and inferior thyroid artery were both cauterized with a bipolar cautery and bisected.  After this, the gland was easily rotated anteriorly with further dissection carried up to the superior pole.  The superior pole was exposed with the help of a Richardson and Army-Navy retractors with cross-clamping and tying of the superior laryngeal artery and vein.  Further, the small bleeding vessels were identified and bipolared, and cut with the Metzenbaum scissors.  The superior pole was finally freed and the gland was rotated more anteriorly onto the anterior aspect of the trachea.  Berry's ligament was finally freed and the gland was cross-clamped on the opposing thyroid isthmus with a mosquito.  After this, the gland was cut with a Metzenbaum scissors and tied with a #3-0 undyed Vicryl tie.  The defect on the neck now was thoroughly irrigated with normal saline solution and further bleeding was controlled with bipolar cauterization.  Surgicel was then cut in small strips and three replaced in the lateral part of the neck.,The opposing side of the thyroid gland on the right was palpated with no noticeable nodules or masses.  The strap muscles were then reapproximated with #3-0 Vicryl on a SH, followed by reapproximation of the subcutaneous tissue with #4-0 Vicryl, followed by reapproximation of the skin by running subcuticular #5-0 Prolene and a #6-0 fast absorbing gut.  Mastisol, Steri-Strips, and bacitracin were placed followed by a sterile 4 x 4 dressing.  The patient was then turned back to Anesthesia, extubated in the operating room, and transferred to Recovery in stable condition.  The patient tolerated the procedure well and will be admitted to hospital for 23-hour observation and will be followed up in one week afterwards.","endocrinology, thyroid lumpectomy, thyroid uptake scan, thyroid mass nodule, total thyroid lumpectomy, parathyroid glands, berry's ligament, metzenbaum scissors, thyroid gland, thyroid mass, gland, thyroid, total,"
 Adenoidectomy and tonsillectomy and lingual frenulectomy.   Chronic adenotonsillitis and ankyloglossia., ENT - Otolaryngology, Adenoidectomy & Tonsillectomy & Lingual Frenulectomy ,"PREOPERATIVE DIAGNOSES:,1.  Chronic adenotonsillitis.,2.  Ankyloglossia,POSTOPERATIVE DIAGNOSES:,1.  Chronic adenotonsillitis.,2.  Ankyloglossia,PROCEDURE PERFORMED:,1.  Adenoidectomy and tonsillectomy.,2.  Lingual frenulectomy.,ANESTHESIA: , General endotracheal.,FINDINGS/SPECIMEN:,  Tonsil and adenoid tissue.,COMPLICATIONS: , None.,CONDITION:  ,The patient is stable and tolerated the procedure well, and sent to PACU.,HISTORY OF PRESENT ILLNESS: , This is a 3-year-old child with a history of adenotonsillitis.,PROCEDURE: , The patient was prepped and draped in the usual sterile fashion.  A curved hemostat was used to grasp the lingual frenulum.  The stat was removed and Metzenbaum scissors were used to free the lingual frenulum.  Cautery was used to allow hemostasis.  The patient was then turned.  McIvor mouth gag was inserted.  Tonsils and adenoids were exposed.  The patient's right tonsil was first grasped with a curved hemostat.  Needle tip cautery was used to free the superior pole of tonsil.  The tonsil was then grasped in medial superior aspect with a straight hemostat.  The tonsil fascia planes were identified with Bovie dissection along the plane.  The tonsil was freed from anterior pillar and posterior pillar.  Amputation occurred along the same plane as the patient's tongue.  Suction cautery was then used to allow for hemostasis.  The patient's adenoids were then viewed with an adenoid mirror.  An adenoid curet was used to remove the patient's adenoid tissue.  Specimen sent.  Suction cautery was used to allow for hemostasis.  Superior pole of left tonsil was then grasped with a curved hemostat.  Superior pole was freed using needle tip Bovie dissection.  Beginning with 15 desiccate, after superior pole was free, Bovie was switched to 15 fulgurate, and the tonsil was stripped from anterior and posterior pillars.  The tonsil was then amputated at the same plane as tongue base.  Hemostasis was achieved with using suction cautery.  Mouth gag was removed.  Dual position and occlusion were tested.  The patient was extubated and tolerated the procedure well and sent back to PACU.","ent - otolaryngology, adenotonsillitis, ankyloglossia, adenoidectomy, tonsillectomy, frenulectomy, tonsil, adenoid tissue, metzenbaum scissors, lingual frenulectomy, chronic adenotonsillitis, curved hemostat, suction cautery, hemostat, hemostasis, lingual, cautery"
 Tracheostomy and thyroid isthmusectomy.  Ventilator-dependent respiratory failure and multiple strokes., Endocrinology, Tracheostomy & Thyroid Isthmusectomy ,"PREOPERATIVE DIAGNOSES:,1.  Ventilator-dependent respiratory failure.,2.  Multiple strokes.,POSTOPERATIVE DIAGNOSES:,1.  Ventilator-dependent respiratory failure.,2.  Multiple strokes.,PROCEDURES PERFORMED:,1.  Tracheostomy.,2.  Thyroid isthmusectomy.,ANESTHESIA: , General endotracheal tube.,BLOOD LOSS: , Minimal, less than 25 cc.,INDICATIONS:,  The patient is a 50-year-old gentleman who presented to the Emergency Department who had had multiple massive strokes.  He had required ventilator assistance and was transported to the ICU setting.  Because of the numerous deficits from the stroke, he is expected to have a prolonged ventilatory course and he will be requiring long-term care.,PROCEDURE: , After all risks, benefits, and alternatives were discussed with multiple family members in detail, informed consent was obtained.  The patient was brought to the Operative Suite where he was placed in supine position and general anesthesia was delivered through the existing endotracheal tube.  The neck was then palpated and marked appropriately in the cricoid cartilage sternal notch and thyroid cartilage marked appropriately with felt-tip marker.  The skin was then anesthetized with a mixture of 1% lidocaine and 1:100,000 epinephrine solution.  The patient was prepped and draped in usual fashion.  The surgeons were gowned and gloved.  A vertical skin incision was then made with a #15 blade scalpel extending from approximately two fingerbreadths above the level of the sternum approximately 1 cm above the cricoid cartilage.  Blunt dissection was then carried down until the fascia overlying the strap muscles were identified.  At this point, the midline raphe was identified and the strap muscles were separated utilizing the Bovie cautery.  Once the strap muscles have been identified, palpation was performed to identify any arterial aberration.  A high-riding innominate was not identified.  At this point, it was recognized that the thyroid gland was overlying the trachea could not be mobilized.  Therefore, dissection was carried down through to the cricoid cartilage at which point hemostat was advanced underneath the thyroid gland, which was then doubly clamped and ligated with Bovie cautery.  Suture ligation with #3-0 Vicryl was then performed on the thyroid gland in a double interlocking fashion.  This cleared a significant portion of the trachea.  The overlying pretracheal fascia was then cleared with use of pressured forceps as well as Bovie cautery.  Now, a tracheal hook was placed underneath the cricoid cartilage in order to stabilize the trachea.  The second tracheal ring was identified.  The Bovie cautery reduced to create a tracheal window beneath the second tracheal ring that was inferiorly based.  At this point, the anesthetist was appropriately alerted to deflate the endotracheal tube cuff.  The airway was entered and inferior to the base, window was created.  The anesthetist then withdrew the endotracheal tube until the tip of the tube was identified.  At this point, a #8 Shiley tracheostomy tube was inserted freely into the tracheal lumen.  The balloon was inflated and the ventilator was attached.  He was immediately noted to have return of the CO2 waveform and was ventilating appropriately according to the anesthetist.  Now, all surgical retractors were removed.  The baseplate of the tracheostomy tube was sutured to the patient's skin with #2-0 nylon suture.  The tube was further secured around the patient's neck with IV tubing.  Finally, a drain sponge was placed.  At this point, procedure was felt to be complete.  The patient was returned to the ICU setting in stable condition where a chest x-ray is pending.","endocrinology, ventilator-dependent respiratory failure, multiple strokes, thyroid, thyroid isthmusectomy, ventilator dependent, respiratory failure, strap muscles, thyroid gland, endotracheal tube, cricoid cartilage, bovie cautery, tracheostomy, ventilator, strokes, cartilage, tracheal, isthmusectomy"
 Total thyroidectomy with removal of substernal extension on the left.  Thyroid goiter with substernal extension on the left., Endocrinology, Total Thyroidectomy ,"PREOPERATIVE DIAGNOSIS:  ,Thyroid goiter with substernal extension on the left.,POSTOPERATIVE DIAGNOSIS:,  Thyroid goiter with substernal extension on the left.,PROCEDURE PERFORMED:,  Total thyroidectomy with removal of substernal extension on the left.,THIRD ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , Approximately 200 cc.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE:,  The patient is a 54-year-old Caucasian male with a history of an enlarged thyroid gland who presented to the office initially with complaints of dysphagia and some difficulty in breathing while lying supine.  The patient subsequently then had a CT scan which demonstrated a very large thyroid gland, especially on the left side with substernal extension down to the level of the aortic arch.  The patient was then immediately set up for surgery.  After risks, complications, consequences, and questions were addressed with the patient, a written consent was obtained.,PROCEDURE:,  The patient was brought to the operative suite by Anesthesia and placed on the operative table in the supine position.  The patient was then placed under general endotracheal intubation anesthesia and the patient then had a shoulder roll placed.  After this, the patient then had the area marked initially.  The preoperative setting was then localized with 1% lidocaine and epinephrine 1:100,000 approximately 10 cc total.  After this, the patient was then prepped and draped in the usual sterile fashion.  A #15 Bard-Parker was then utilized to make a skin incision horizontally, approximately 5 cm on either side from midline.  After this, a blunt dissection was then utilized to dissect the subcutaneous fat from the platysmal muscle.  There appeared to be a natural dehiscence of the platysma in the midline.  A sub-platysmal dissection was then performed in the superior, inferior, and lateral directions with the help of a bear claw, Metzenbaum scissors and DeBakey forceps.  Any bleeding was controlled with monopolar cauterization.  After this, the two anterior large jugular veins were noted and resected laterally.  The patient's trachea appeared to be slightly deviated to the right with identification finally of the midline raphe, off midline to the right.  This was grasped on either side with a DeBakey forceps and dissected with monopolar cauterization and dissected with a Metzenbaum scissors.  After this was dissected, the sternohyoid muscles were resected laterally and separated from the sternothyroid muscles.  The sternothyroid muscles were then bluntly freed and dissected from the right thyroid gland.  After this, attention was then drawn to the left gland, where the sternothyroid muscle was dissected bluntly on this side utilizing finger dissection and Kitners.  The left thyroid gland was freed initially superiorly and worked inferiorly and laterally until the gland was pulled from the substernal region by blunt dissection and reflected and pulled anteriorly.  After this, the superior and inferior parathyroid glands were noted.  The dissection was carried very close to the thyroid gland to try to select these parathyroids posteriorly.  After this, the superior pole was then identified and the superior laryngeal artery and vein were cross clamped and tied with __________ undyed Vicryl tie.  The superior pole was finally freed and a small little feeding branched vessels from this area were cauterized with the bipolar cautery and cut with Metzenbaum scissors.  After this, the thyroid gland was further freed down to the level of the Berry's ligament inferiorly and the dissection was carried once again more superiorly.  The fine stats were then utilized to dissect along the superior aspect of the recurrent laryngeal nerve on the left side with freeing of the connective Berry's ligament tissue from the gland with the bipolar cauterization and the fine stat.  Finally, attention was then drawn back to the patient's right side where the gland was rotated more anteriorly with fine dissection utilizing a fine stat to reflect the superior and inferior parathyroid glands laterally and posteriorly.  The recurrent laryngeal nerve on this side was identified and further dissection was carried superiorly and anteriorly through this nerve to finally free the right side of the gland to Berry's ligament.  The middle thyroid vein and inferior thyroid arteries were cross clamped and tied with #2-0 undyed Vicryl ties and also bipolared with the bipolar cauterization bilaterally.  The Berry's ligament was then finally freed and the gland was then passed to scrub tech and passed off the field to Pathology.  The neck was then thoroughly irrigated with normal saline solution and further bleeding was controlled with bipolar cauterization.  After this, Surgicel was then placed in the bilateral neck regions and a #10 Jackson-Pratt drain was then placed within the left neck region with some extension over to the right neck region.  This was brought out through the inferior skin incision and secured to the skin with a #2-0 nylon suture.  The strap muscles were then reapproximated with a running #3-0 Vicryl suture followed by reapproximation of the platysma and subcutaneous tissue with a #4-0 undyed Vicryl.  The skin was then reapproximated with a #5-0 Prolene subcuticular along with a #6-0 fast over the top.  After this, Mastisol Steri-Strips and Bacitracin along with a sterile dressing and a __________ dressing were then placed.  The patient intraoperatively did have approximately 50 cc of bloody drainage from this area within the JP drain.  The patient was then turned back to Anesthesia, extubated in the operating room and transferred to Recovery in stable condition.  The patient tolerated the procedure well and remained stable throughout.","endocrinology, thyroid goiter, goiter, thyroid, total thyroidectomy, berry's ligament, dissection, gland, thyroidectomy, anesthesia, berry's, ligament, cauterization, extension, substernal,"
" This is a 55-year-old female with weight gain and edema, as well as history of hypothyroidism.  She also has a history of fibromyalgia, inflammatory bowel disease, Crohn disease, COPD, and disc disease as well as thyroid disorder.", Endocrinology, Weight Gain and Edema ,"HISTORY OF PRESENT ILLNESS:,  This is a 55-year-old female with a history of I-131-induced hypothyroidism years ago who presents with increased weight and edema over the last few weeks with a 25-pound weight gain.  She also has a history of fibromyalgia, inflammatory bowel disease, Crohn disease, COPD, and disc disease as well as thyroid disorder.  She has noticed increasing abdominal girth as well as increasing edema in her legs.  She has been on Norvasc and lisinopril for years for hypertension.  She has occasional sweats with no significant change in her bowel status.  She takes her thyroid hormone apart from her Synthroid.  She had been on generic for the last few months and has had difficulty with this in the past.,MEDICATIONS: , Include levothyroxine 300 mcg daily, albuterol, Asacol, and Prilosec.  Her amlodipine and lisinopril are on hold.,ALLERGIES:,  Include IV DYE, SULFA, NSAIDS, COMPAZINE, and DEMEROL.,PAST MEDICAL HISTORY:,  As above includes I-131-induced hypothyroidism, inflammatory bowel disease with Crohn, hypertension, fibromyalgia, COPD, and disc disease.,PAST SURGICAL HISTORY: , Includes a hysterectomy and a cholecystectomy.,SOCIAL HISTORY: , She does not smoke or drink alcohol.,FAMILY HISTORY: , Positive for thyroid disease but the sister has Graves disease, as well a sister with Hashimoto thyroiditis.,REVIEW OF SYSTEMS: , Positive for fatigue, sweats, and weight gain of 20 pounds.  Denies chest pain or palpitations.  She has some loosening stools, but denies abdominal pain.  Complains of increasing girth and increasing leg swelling.,PHYSICAL EXAMINATION:,GENERAL:  She is an obese female.,VITAL SIGNS:  Blood pressure 140/70 and heart rate 84.  She is afebrile.,HEENT:  She has no periorbital edema.  Extraocular movements were intact.  There was moist oral mucosa.,NECK:  Supple.  Her thyroid gland is atrophic and nontender.,CHEST:  Good air entry.,CARDIOVASCULAR:  Regular rate and rhythm.,ABDOMEN:  Benign.,EXTREMITIES:  Showed 1+ edema.,NEUROLOGIC:  She was awake and alert.,LABORATORY DATA:,  TSH 0.28, free T4 1.34, total T4 12.4 and glucose 105.,IMPRESSION/PLAN:,  This is a 55-year-old female with weight gain and edema, as well as history of hypothyroidism.  Hypothyroidism is secondary to radioactive iodine for Graves disease many years ago.  She is clinically and biochemically euthyroid.  Her TSH is mildly suppressed, but her free T4 is normal and with her weight gain I will not decrease her dose of levothyroxine.  I will continue on 300 mcg daily of Synthroid.  If she wanted to lose significant weight, I shall repeat thyroid function test in six weeks' time to ensure that she is not hyperthyroid.",
" Total thyroidectomy.  The patient is a female with a history of Graves disease.  Suppression was attempted, however, unsuccessful.  She presents today with her thyroid goiter. ", Endocrinology, Thyroidectomy - 1 ,"PREOPERATIVE DIAGNOSIS: , Thyroid goiter.,POSTOPERATIVE DIAGNOSIS:  ,Thyroid goiter.,PROCEDURE PERFORMED: , Total thyroidectomy.,ANESTHESIA:,1.  General endotracheal anesthesia.,2.  9 cc of 1% lidocaine with 1:100,000 epinephrine.,COMPLICATIONS:,  None.,PATHOLOGY: , Thyroid.,INDICATIONS:  ,The patient is a female with a history of Graves disease.  Suppression was attempted, however, unsuccessful.  She presents today with her thyroid goiter.  A thyroidectomy was indicated at this time secondary to the patient's chronic condition.  Indications, alternatives, risks, consequences, benefits, and details of the procedure including specifically the risk of recurrent laryngeal nerve paresis or paralysis or vocal cord dysfunction and possible trach were discussed with the patient in detail.  She agreed to proceed.  A full informed consent was obtained.,PROCEDURE: , The patient presented to ABCD General Hospital on 09/04/2003 with the history was reviewed and physical examinations was evaluated.  The patient was brought by the Department of Anesthesiology, brought back to surgical suite and given IV access and general endotracheal anesthesia.  A 9 cc of 1% lidocaine with 1:100,000 of epinephrine was infiltrated into the area of pre-demarcated above the suprasternal notch.  Time is allowed for full hemostasis to be achieved.  The patient was then prepped and draped in the normal sterile fashion.  A #10 blade was then utilized to make an incision in the pre-demarcated and anesthetized area.  Unipolar electrocautery was utilized for hemostasis.  Finger dissection was carried out in the superior and inferior planes.  Platysma was identified and dissected and a subplatysmal plane was created in the superior and inferior, medial and lateral directions using hemostat, Metzenbaum, and blunt dissection.  The strap muscles were identified.  The midline raphe was not easily identifiable at this time.  An incision was made through what appeared to be in the midline raphe and dissection was carried down to the thyroid.  Sternohyoid and sternothyroid muscles were identified and separated on the patient's right side and then subsequently on the left side.  It was noted at this time that the thyroid lobule on the right side is a bi-lobule.  Kitner blunt dissection was utilized to bluntly dissect the overlying thyroid fascia as well as strap muscles off the thyroid, force in the lateral direction.  This was carried down to the inferior and superior areas.  The superior pole of the right lobule was then identified.  A hemostat was placed in the cricothyroid groove and a Kitner was placed in this area.  A second Kitner was placed on lateral aspect of the superior pole and the superior pole of the right thyroid was retracted inferiorly.  Careful dissection was then carried out in a very meticulous fashion in the superior lobe and identified the appropriate vessels and cauterized with bipolar or ligated with the suture ligature.  This was carried out until the superior pole was identified.  Careful attention was made to avoid nerve injury in this area.  Dissection was then carried down again bluntly separating the inferior and superior lobes.  The bilobed right thyroid was then retracted medially.  The recurrent laryngeal nerve was then identified and tracked to its insertion.  The overlying vessels of the middle thyroid vein as well as the associated structures were then identified and great attention was made to perform a right careful meticulous dissection to remove the fascial attachments superficial to the recurrent laryngeal nerve off the thyroid.  When it was completed, this lobule was then removed from Berry's ligament.  There was noted to be no isthmus at this time and the entire right lobule was then sent to the Pathology for further evaluation.  Attention was then diverted to the patient's left side.  In a similar fashion, the sternohyoid and sternothyroid muscles were already separated.  Army-Navy as well as femoral retractors were utilized to lateralize the appropriate musculature.  The middle thyroid vein was identified.  Blunt dissection was carried out laterally to superiorly once again.  A hemostat was utilized to make an opening in the cricothyroid groove and a Kitner was then placed in this area.  Another Kitner was placed on the lateral aspect of the superior lobe of the left thyroid and retracted inferiorly.  Once again, a careful meticulous dissection was utilized to identify the appropriate structures in the superior pole of the left thyroid and suture ligature as well as bipolar cautery was utilized for hemostasis.  Once again, a careful attention was made not to injure the nerve in this area.  The superior pole was then freed appropriately and blunt dissection was carried down to lateral and inferior aspects.  The inferior aspect was then identified.  The inferior thyroid artery and vein were then identified and ligated.  The left thyroid was then medialized and the recurrent laryngeal nerve has been identified.  A careful dissection was then carried out to remove the fascial attachments superficial to the recurrent laryngeal nerve on the side as close to the thyroid gland as possible.  The thyroid was then removed from the Berry's ligament and it was then sent to Pathology for further evaluation.  Evaluation of the visceral space did not reveal any bleeding at this time.  This was irrigated and pinpoint areas were bipolored as necessary.  Surgicel was then placed bilaterally.  The strap muscles as well as the appropriate fascial attachments were then approximated with a #3-0 Vicryl suture in the midline.  The platysma was identified and approximated with a #4-0 Vicryl suture and the subdermal plane was approximated with a #4-0 Vicryl suture.  A running suture consisting of #5-0 Prolene suture was then placed and fast absorbing #6-0 was then placed in a running fashion.  Steri-Strips, Tincoban, bacitracin and a pressure gauze was then placed.  The patient was then admitted for further evaluation and supportive care.  The patient tolerated the procedure well.  The patient was transferred to Postanesthesia Care Unit in stable condition.","endocrinology, thyroid goiter, graves disease, thyroidectomy, total thyroidectomy, dissection, superior, kitner"
 Total thyroidectomy for goiter.  Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration., Endocrinology, Thyroidectomy  ,"TITLE OF OPERATION:  ,Total thyroidectomy for goiter.,INDICATION FOR SURGERY:  ,This is a 41-year-old woman who notes that compressive thyroid goiter and symptoms related to such who wishes to undergo surgery.  Risks, benefits, alternatives of the procedures were discussed in great detail with the patient.  Risks include but were not limited to anesthesia, bleeding, infection, injury to nerve, vocal fold paralysis, hoarseness, low calcium, need for calcium supplementation, tumor recurrence, need for additional treatment, need for thyroid medication, cosmetic deformity, and other.  The patient understood all these issues and they wished to proceed.,PREOP DIAGNOSIS: , Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,POSTOP DIAGNOSIS: , Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,ANESTHESIA: , General endotracheal.,PROCEDURE DETAIL: , After identifying the patient, the patient was placed supine in a operating room table.  After establishing general anesthesia via oral endotracheal intubation with a 6 Nerve Integrity monitoring system endotracheal tube.  The eyes were then tacked with Tegaderm.  The Nerve Integrity monitoring system, endotracheal tube was confirmed to be working adequately.  Essentially a 7 cm incision was employed in the lower skin crease of the neck.  A 1% lidocaine with 1:100,000 epinephrine were given.  Shoulder roll was applied.  The patient prepped and draped in a sterile fashion.  A 15-blade was used to make the incision.  Subplatysmal flaps were raised to the thyroid notch and sternal respectively.  The strap muscles were separated in the midline.  As we then turned to the left side where the sternohyoid muscle was separated from the sternothyroid muscle there was a very dense and firm thyroid mass on the left side.  The sternothyroid muscle was transected horizontally.  Similar procedure was performed on the right side.,Attention was then turned to identify the trachea in the midline.  Veins in this area and the pretracheal region were ligated with a harmonic scalpel.  Subsequently, attention was turned to dissecting the capsule off of the left thyroid lobe.  Again this was very firm in nature.  The superior thyroid pole was dissected in the superior third artery, vein, and the individual vessels were ligated with a harmonic scalpel.  The inferior and superior parathyroid glands were protected.  Recurrent laryngeal nerve was identified in the tracheoesophageal groove.  This had arborized early as a course underneath the inferior thyroid artery to a very small tiny anterior motor branch.  This was followed superiorly.  The level of cricothyroid membrane upon complete visualization of the entire nerve, Berry's ligament was transected and the nerve protected and then the thyroid gland was dissected over the trachea.  A prominent pyramidal level was also appreciated and dissected as well.,Attention was then turned to the right side.  There was significant amount of thyroid tissue that was very firm.  Multiple nodules were appreciated.  In a similar fashion, the capsule was dissected.  The superior and inferior parathyroid glands protected and preserved.  The superior thyroid artery and vein were individually ligated with the harmonic scalpel and the inferior thyroid artery was then ligated close to the thyroid gland capsule.  Once the recurrent laryngeal nerve was identified again on this side, the nerve had arborized early prior to the coursing underneath the inferior thyroid artery.  The anterior motor branch was then very fine, almost filamentous and stimulated at 0.5 milliamps, completely dissected toward the cricothyroid membrane with complete visualization.  A small amount of tissue was left at the Berry's ligament as the remainder of thyroid level was dissected over the trachea.  The entire thyroid specimen was then removed, marked with a stitch upon the superior pole.  The wound was copiously irrigated, Valsalva maneuver was given, bleeding points controlled.  The parathyroid glands appeared to be viable.  Both the anterior motor branches that were tiny were stimulated at 5 milliamps and confirmed to be working with the Nerve Integrity monitoring system.,Attention was then turned to burying the Surgicel on the wound bed on both sides.  The strap muscles were reapproximated in the midline using a 3-0 Vicryl suture of the sternothyroid horizontal transection and the strap muscles in the midline were then reapproximated.  The 1/8th inch Hemovac drain was placed and secured with a 3-0 nylon.  The incision was then closed with interrupted 3-0 Vicryl and Indermil for the skin.  The patient has a history of keloid formation and approximately 1 cubic centimeter of 40 mg per cubic centimeter Kenalog was injected into the incisional line using a tuberculin syringe and 25-gauge needle.  The patient tolerated the procedure well, was extubated in the operating room table, and sent to postanesthesia care unit in a good condition.  Upon completion of the case, fiberoptic laryngoscopy revealed intact bilateral true vocal fold mobility.","endocrinology, total thyroidectomy, goiter, multinodular thyroid goiter, multinodular, thyroid nodules, parathyroid glands, thyroid goiter, thyroid artery, thyroidectomy"
" Pancreatic and left adrenal lesions.  The adrenal lesion is a small lesion, appears as if probable benign adenoma, where as the pancreatic lesion is the cystic lesion, and neoplasm could not be excluded. ", Endocrinology, Lesions - Adrenal and Pancreatic ,"CHIEF COMPLAINT: , Both pancreatic and left adrenal lesions.,HISTORY OF PRESENT ILLNESS:,  This 60-year-old white male is referred to us by his medical physician with a complaint of recent finding of a both pancreatic lesion and lesions with left adrenal gland.  The patient's history dates back to at the end of the January of this past year when he began experiencing symptoms consistent with difficulty almost like a suffocating feeling whenever he would lie flat on his back.  He noticed whenever he would recline backwards, he would begin this feeling and it is so bad now that he can barely recline, very little before he has this feeling.  He is now sleeping in an upright position.  He was sent for CAT scan originally of his chest.  The CAT scan of the chest reveals a pneumonitis, but also saw a left adrenal nodule and a small pancreatic lesion.  He was subsequently was sent for a dedicated abdominal CAT scan and MRI.  The CAT scan revealed 1.8-cm lesion of his left adrenal gland, suspected to be a benign adenoma.  The pancreas showed pancreatic lesion towards the mid body tail aspect of the pancreas, approximately 1 cm, most likely of cystic nature.  Neoplasm could not be excluded.  He was referred to us for further assessment.  He denies any significant abdominal pain, any nausea or vomiting.  His appetite is fine.  He has had no significant changes in his bowel habits or any rectal bleeding or melena.  He has undergone a colonoscopy in September of last year and was found to have three adenomatous polyps.  He does have a history of frequent urination.  Has been followed by urologist for this.  There is no family history of pancreatic cancer.  There is a history of gallstone pancreatitis in the patient's sister.,PAST MEDICAL HISTORY:,  Significant for hypertension, type 2 diabetes mellitus, asthma, and high cholesterol.,ALLERGIES: , ENVIRONMENTAL.,MEDICATIONS:,  Include glipizide 5 mg b.i.d., metformin 500 mg b.i.d., Atacand 16 mg daily, metoprolol 25 mg b.i.d., Lipitor 10 mg daily, pantoprazole 40 mg daily, Flomax 0.4 mg daily, Detrol 4 mg daily, Zyrtec 10 mg daily, Advair Diskus 100/50 mcg one puff b.i.d., and fluticasone spray 50 mcg two sprays daily.,PAST SURGICAL HISTORY:,  He has not had any previous surgery.,FAMILY HISTORY: , His brothers had prostate cancer.  Father had brain cancer.  Heart disease in both sides of the family.  Has diabetes in his brother and sister.,SOCIAL HISTORY:,  He is a non-cigarette smoker and non-ETOH user.  He is single and he has no children.  He works as a payroll representative and previously did lot of work in jewelry business, working he states with chemical.,REVIEW OF SYSTEMS: , He denies any chest pain.  He admits to exertional shortness of breath.  He denies any GI problems as noted.  Has frequent urination as noted.  He denies any bleeding disorders or bleeding history.,PHYSICAL EXAMINATION:,GENERAL:  Presents as an obese 60-year-old white male, who appears to be in no apparent distress.,HEENT:  Unremarkable.,NECK:  Supple.  There is no mass, adenopathy or bruit.,CHEST:  Normal excursion.,LUNGS:  Clear to auscultation and percussion.,COR:  Regular.  There is no S3 or S4 gallop.  There is no obvious murmur.,HEART:  There is distant heart sounds.,ABDOMEN:  Obese.  It is soft.  It is nontender.  Examination was done as relatively sitting up as the patient was unable to recline.  Bowel sounds are present.  There is no obvious mass or organomegaly.,GENITALIA:  Deferred.,RECTAL:  Deferred.,EXTREMITIES:  Revealed about 1+ pitting edema.  Bilateral peripheral pulses are intact.,NEUROLOGIC:  Without focal deficits.  The patient is alert and oriented.,IMPRESSION:,  Both left adrenal and pancreatic lesions.  The adrenal lesion is a small lesion, appears as if probable benign adenoma, where as the pancreatic lesion is the cystic lesion, and neoplasm could not be excluded.  Given the location of these pancreatic lesions in the mid body towards the tail and size of 1 cm, the likelihood is an ERCP will be of no value and the likelihood is that it is too small to biopsy.  We are going to review x-rays with Radiology prior with the patient probably at some point will present for operative intervention.  Prior to that the patient will undergo an esophagogastroduodenoscopy.",
" Squamous cell carcinoma of the larynx.  Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.", Endocrinology, Laryngectomy & Thyroid Lobectomy ,"TITLE OF OPERATION:,  Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.,INDICATION FOR SURGERY: , A 58-year-old gentleman who has had a history of a T3 squamous cell carcinoma of his glottic larynx having elected to undergo a laser excision procedure in late 06/07.  Subsequently, biopsy confirmed tumor persistence in the right glottic region.  Risks, benefits, and alternatives of the surgical intervention versus possibility of chemoradiation therapy were discussed with the patient in detail.  Also concerned for a CT scan finding of possible cartilaginous invasion at the cricoid level.  The patient understood the issues regarding surgical intervention and wished to undergo a surgical intervention despite a clear understanding of risks, benefits, and alternatives.  He was accompanied by his wife and daughter.  Risks included, but were not limited to anesthesia, bleeding, infection, injury of the nerves including lower lip weakness, tongue weakness, tongue numbness, shoulder weakness, need for physical therapy, possibility of total laryngectomy, possibility of inability to speak or swallow, difficulty eating, wound care issues, failure to heal, need for additional treatment, and the patient understood all of these issues and they wished to proceed.,PREOP DIAGNOSIS: , Squamous cell carcinoma of the larynx.,POSTOP DIAGNOSIS: , Squamous cell carcinoma of the larynx.,PROCEDURE DETAIL: , After identifying the patient, the patient was placed supine on the operating room table.  After the establishment of the general anesthesia via oral endotracheal intubation, the patient had his eyes protected with Tegaderm.  A #6 endotracheal tube was placed initially.  Direct laryngoscopy was performed with a Lindholm laryngoscope.  A 0-degree endoscope was used to take pictures of what was apparently a recurrence of tumor along the right true vocal fold extending into the anterior arytenoid area and extending about 1 cm below into the subglottis.  Subsequently, a decision was then made to go ahead and perform the surgical intervention.  A hemi-apron incision was employed, and 1% lidocaine with 1:100,000 epinephrine was injected.  A shoulder roll was applied after the patient was prepped and draped in a sterile fashion.  Subsequently, a hemi-apron incision was performed.  Subplatysmal flaps were raised at the hyoid bone into the clavicle.  Attention was then turned to the right side, where a level 2, 3, 4 neck dissection was performed.  Submandibular fascia was appreciated inferiorly along the submandibular gland, this was incised allowing for identification of the digastric muscle.  Digastric tunnel was performed posteriorly to the level of the sternocleidomastoid muscle.  The fascia along the sternocleidomastoid muscle was then dissected along the anterior aspect until the cranial nerve XI was identified.  Level 2A contents were then dissected off the floor of the neck including levels 3 and 4.  Preservation of the phrenic nerve was obtained by identification, and subsequently cross-clamping fibrofatty tissue and lymph nodes just adjacent to the jugular vein inferiorly at level 4.  The specimen was then mobilized over the internal jugular vein with preservation of hypoglossal nerve.  Levels 2, 3, 4 neck dissection specimens were then labeled appropriately, attached with staples, and sent for histopathological evaluation.,Attention was then turned to attempting to perform a partial laryngectomy up front with a possibility of total laryngectomy as discussed.  Subsequently, the strap muscles were separated in the midline.  The trachea was identified in the midline.  The thyroid isthmus was plicated using the Harmonic scalpel, and attention was then turned to transecting the strap muscles at the superior aspect of the thyroid cartilage.  Once this was performed, sinuses were mobilized from the thyroid cartilage both on the right and left side respectively.  The cricothyroid joint was then freed on the left side and then on the right side with noting on the right side that this cartilage was a bit more irregular.  Attention was then turned to performing a cricothyrotomy.  Upon performing this, it was obvious that there was tumor just above the level of the cricothyrotomy incision.  A #7 anode tube was then placed in this area and secured.  Attention was then turned to performing the laryngotomy at the level of the petiole of epiglottis.  Subsequently, the cuts were made on the left side with visualization of the vocalis process and coming down to the level of the cricoid cartilage, and the thyroid cartilage was then intentionally fractured along the anterior spine.  It was evident that this tumor had extended more than 1 cm into the subglottic region.  Careful dissection of larynx from an inferior margin and portion of cricoid cartilage resection then was performed posteriorly, though it was evident that the cricoid cartilage was invaded.  Frozen section biopsy then confirmed this finding as read by Dr. X of Surgical Pathology.,In light of this finding with cartilaginous invasion and inability to preserve the cricoid cartilage, the patient's case was then converted into a total laryngectomy.  Subsequently, the trachea was transected at the level 3, 4 tracheal ring into cartilaginous space and anterior tracheal stoma was fashioned using 3-0 vertical mattress sutures for the skin.  A W-plasty was also performed to allow for enlargement of the stoma.  Attention was then turned to identifying the common parting wall of the trachea and the esophagus.  Attention was then turned to resecting the hyoid bone.  The remainder of the specimen cuts were made superior from sinus preserving a modest amount of pharyngeal mechanism.  The wound was copiously irrigated.  Subsequently, a tracheoesophageal puncture site was performed using a right-angled hemostat at about approximately 1 cm from the posterior tracheal wall superior aspect.  Once this was performed, a running 3-0 canal stitch was used to close the pharynx.  Subsequently, interrupted 4-0 chromic stitches were then used as reinforcement line from superior to inferior, and fibrin glue was applied.  Two #10 JP drains were placed on the right side and one on the left side and secured appropriately with 3-0 nylon.  The wound was then closed using interrupted 3-0 Vicryl for the platysma and staples for the skin.  The patient tolerated the procedure well and was brought to the Weinberg Intensive Care Unit with the endotracheal tube still in place to be decannulated later.","endocrinology, laryngectomy, neck dissection, tracheoesophageal, cricopharyngeal myotomy, thyroid lobectomy, squamous cell carcinoma, larynx, thyroid cartilage, cricoid cartilage, total laryngectomy, thyroid, cartilage"
" Chief complaint of chest pain, previously diagnosed with hyperthyroidism.", Endocrinology, Hyperthyroidism Following Pregnancy ,"HISTORY: , Patient is a 21-year-old white woman who presented with a chief complaint of chest pain.  She had been previously diagnosed with hyperthyroidism.  Upon admission, she had complaints of constant left sided chest pain that radiated to her left arm.  She had been experiencing palpitations and tachycardia.  She had no diaphoresis, no nausea, vomiting, or dyspnea.,She had a significant TSH of 0.004 and a free T4 of 19.3.  Normal ranges for TSH and free T4 are 0.5-4.7 µIU/mL and 0.8-1.8 ng/dL, respectively.  Her symptoms started four months into her pregnancy as tremors, hot flashes, agitation, and emotional inconsistency.  She gained 16 pounds during her pregnancy and has lost 80 pounds afterwards.  She complained of sweating, but has experienced no diarrhea and no change in appetite.  She was given isosorbide mononitrate and IV steroids in the ER.,FAMILY HISTORY:,  Diabetes, Hypertension, Father had a Coronary Artery Bypass Graph (CABG) at age 34.,SOCIAL HISTORY:,  She had a baby five months ago.  She smokes a half pack a day.  She denies alcohol and drug use.,MEDICATIONS:,  Citalopram 10mg once daily for depression; low dose tramadol PRN pain.,PHYSICAL EXAMINATION: , Temperature 98.4; Pulse 123; Respiratory Rate 16; Blood Pressure 143/74.,HEENT:  She has exophthalmos and could not close her lids completely.,Cardiovascular:  tachycardia.,Neurologic:  She had mild hyperreflexiveness.,LAB:,  All labs within normal limits with the exception of Sodium 133, Creatinine 0.2, TSH 0.004, Free T4 19.3 EKG showed sinus tachycardia with a rate of 122.  Urine pregnancy test was negative.,HOSPITAL COURSE: , After admission, she was given propranolol at 40mg daily and continued on telemetry.  On the 2nd day of treatment, the patient still complained of chest pain.  EKG again showed tachycardia.  Propranolol was increased from 40mg daily to 60mg twice daily., A I-123 thyroid uptake scan demonstrated an increased thyroid uptake of 90% at 4 hours and 94% at 24 hours.  The normal range for 4-hour uptake is 5-15% and 15-25% for 24-hour uptake.  Endocrine consult recommended radioactive I-131 for treatment of Graves disease.,Two days later she received 15.5mCi of I-131.  She was to return home after the iodine treatment.  She was instructed to avoid contact with her baby for the next week and to cease breast feeding.,ASSESSMENT / PLAN:,1. Treatment of hyperthyroidism.  Patient underwent radioactive iodine 131 ablation therapy.,2. Management of cardiac symptoms stemming from hyperthyroidism.  Patient was discharged on propranolol 60mg, one tablet twice daily.,3. Monitor patient for complications of I-131 therapy such as hypothyroidism.  She should return to Endocrine Clinic in six weeks to have thyroid function tests performed.  Long-term follow-up includes thyroid function tests at 6-12 month intervals.,4. Prevention of pregnancy for one year post I-131 therapy.  Patient was instructed to use 2 forms of birth control and was discharged an oral contraceptive, taken one tablet daily.,5. Monitor ocular health.  Patient was given methylcellulose ophthalmic, one drop in each eye daily.  She should follow up in 6 weeks with the Ophthalmology clinic.,6. Management of depression.  Patient will be continued on citalopram 10 mg.","endocrinology, hyperthyroidism, diabetes, hypertension, hospital course, thyroid function, tachycardia, pregnancy, "
 Return visit to the endocrine clinic for followup management of type 1 diabetes mellitus.  Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin., Endocrinology, Diabetes Mellitus Followup ,"PROBLEM LIST:,1.  Type 1 diabetes mellitus, insulin pump.,2.  Hypertension.,3.  Hyperlipidemia.,HISTORY OF PRESENT ILLNESS: , The patient is a 39-year-old woman returns for followup management of type 1 diabetes mellitus.  Her last visit was approximately 4 months ago.  Since that time, the patient states her health had been good and her glycemic control had been good, however, within the past 2 weeks she had a pump malfunction, had to get a new pump and was not certain of her pump settings and has been having some difficulty with glycemic control over the past 2 weeks.  She is not reporting any severe hypoglycemic events, but is having some difficulty with hyperglycemia both fasting and postprandial.  She is not reporting polyuria, polydipsia or polyphagia.  She is not exercising at this point and has a diet that is rather typical of woman with twins and a young single child as well.  She is working on a full-time basis and so eats on the run a lot, probably eats more than she should and not making the best choices, little time for physical activity.  She is keeping up with all her other appointments and has recently had a good eye examination.  She had lab work done at her previous visit and this revealed persistent hyperlipidemic state with a LDL of 144.,CURRENT MEDICATIONS:,1.  Zoloft 50 mg p.o. once daily.,2.  Lisinopril 40 mg once daily.,3.  Symlin 60 micrograms, not taking at this point.,4.  Folic acid 2 by mouth every day.,5.  NovoLog insulin via insulin pump about 90 units of insulin per day.,REVIEW OF SYSTEMS:,  She denies fever, chills, sweats, nausea, vomiting, diarrhea, constipation, abdominal pain, chest pain, shortness of breath, difficulty breathing, dyspnea on exertion or change in exercise tolerance.  She is not having painful urination or blood in the urine.  She is not reporting polyuria, polydipsia or polyphagia.,PHYSICAL EXAMINATION:,GENERAL:  Today showed a very pleasant, well-nourished woman, in no acute distress.  VITAL SIGNS:  Temperature not taken, pulse 98, respirations 20, blood pressure 148/89, and weight 91.19 kg.  THORAX:  Revealed lungs clear, PA and lateral without adventitious sounds.  CARDIOVASCULAR:  Demonstrated regular rate and rhythm.  S1 and S2 without murmur.  No S3, no S4 auscultated.  ABDOMEN:  Nontender.  EXTREMITIES:  Showed no clubbing, cyanosis or edema.  SKIN:  Intact and do not appear atrophic.  Deep tendon reflexes were 2+/4 without a delayed relaxation phase.,LABORATORY DATA:,  Dated 10/05/08 showed a total cholesterol of 223, triglyceride 140, HDL 54, and LDL 144.  The hemoglobin A1c was 6.4 and the spot urine for microalbumin was 9.2 micrograms of protein, 1 mg of creatinine.  Sodium 136, potassium 4.5, chloride 102, CO2 30 mEq, BUN 11 mg/dL, creatinine 0.6 mg, estimated GFR greater than 60, blood sugar 118, calcium 9.4, and her LFTs were unremarkable.  TSH is 1.07 and free T4 is 0.81.,ASSESSMENT AND PLAN:,1.  This is a return visit to the endocrine clinic for the patient, a 39-year-old woman with history as noted above.  Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin.  Basal rate is as follows, 12 a.m. 1.5, 02:30 a.m. 1.75, and 6 a.m. 1.5.  Her correction factor is 19.  Her carb/insulin ratio is 6.  Her active insulin time is 5 and her targets are at 12 a.m. 110 and 6 a.m. to midnight is 100.  We made adjustments to her pump and the plan will be to see her back in approximately 2 months.,2.  Hyperlipidemia.  The patient is not taking statin, therefore, we will prescribe Lipitor 20 mg one p.o. once daily.  Have her watch for side effects from the medication and plan to do a fasting lipid panel and CMP approximately 8 weeks from now.,3.  We will get a hemoglobin A1c and spot urine for albumin in 8 weeks as well.","endocrinology, endocrine clinic, insulin pump, diabetes mellitus, insulin, glycemic, fasting, polyuria, polydipsia, polyphagia, diabetes,"
 Thyroid mass diagnosed as papillary carcinoma.  The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary.  The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis., Endocrinology, Thyroid Mass Consult ,"REASON FOR CONSULTATION: , Thyroid mass diagnosed as papillary carcinoma.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 16-year-old young lady, who was referred from the Pediatric Endocrinology Department by Dr. X for evaluation and surgical recommendations regarding treatment of a mass in her thyroid, which has now been proven to be papillary carcinoma on fine needle aspiration biopsy.  The patient's parents relayed that they first noted a relatively small but noticeable mass in the middle portion of her thyroid gland about 2004.  An ultrasound examination had reportedly been done in the past and the mass is being observed.  When it began to enlarge recently, she was referred to the Pediatric Endocrinology Department and had an evaluation there.  The patient was referred for fine needle aspiration and the reports recently returned a diagnosis of papillary thyroid carcinoma.  The patient has not had any hoarseness, difficulty swallowing, or any symptoms of endocrine dysfunction.  She has no weight changes consistent with either hyper or hypothyroidism.  There is no family history of thyroid cancer in her family.  She has no notable discomfort with this lesion.  There have been no skin changes.  Historically, she does not have a history of any prior head and neck radiation or treatment of any unusual endocrinopathy.,PAST MEDICAL HISTORY:,  Essentially unremarkable.  The patient has never been hospitalized in the past for any major illnesses.  She has had no prior surgical procedures.,IMMUNIZATIONS: , Current and up to date.,ALLERGIES: , She has no known drug allergies.,CURRENT MEDICATIONS:  ,Currently taking no routine medications.  She describes her pain level currently as zero.,FAMILY HISTORY: , There is no significant family history, although the patient's father does note that his mother had a thyroid surgery at some point in life, but it was not known whether this was for cancer, but he suspects it might have been for goiter.  This was done in Tijuana.  His mom is from central portion of Mexico.  There is no family history of multiple endocrine neoplasia syndromes.,SOCIAL HISTORY:  ,The patient is a junior at Hoover High School.  She lives with her mom in Fresno.,REVIEW OF SYSTEMS: , A careful 12-system review was completely normal except for the problems related to the thyroid mass.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a 55.7 kg, nondysmorphic, quiet, and perhaps slightly apprehensive young lady, who was in no acute distress.  She was alert and oriented x3 and had an appropriate affect.,HEENT:  The head and neck examination is most significant.  There is mild amount of facial acne.  The patient's head, eyes, ears, nose, and throat appeared to be grossly normal.,NECK:  There is a slightly visible midline bulge in the region of the thyroid isthmus.  A firm nodule is present there, and there is also some nodularity in the right lobe of the thyroid.  This mass is relatively hard, slightly fixed, but not tethered to surrounding tissues, skin, or muscles that I can determine.  There are some shotty adenopathy in the area.  No supraclavicular nodes were noted.,CHEST:  Excursions are symmetric with good air entry.,LUNGS:  Clear.,CARDIOVASCULAR:  Normal.  There is no tachycardia or murmur noted.,ABDOMEN:  Benign.,EXTREMITIES:  Extremities are anatomically correct with full range of motion.,GENITOURINARY:  External genitourinary exam was deferred at this time and can be performed later during anesthesia.  This is same as too for her rectal examination.,SKIN:  There is no acute rash, purpura, or petechiae.,NEUROLOGIC:  Normal and no focal deficits.  Her voice is strong and clear.  There is no evidence of dysphonia or vocal cord malfunction.,DIAGNOSTIC STUDIES: , I reviewed laboratory data from the Diagnostics Lab, which included a mild abnormality in the AST at 11, which is slightly lower than the normal range.  T4 and TSH levels were recorded as normal.  Free thyroxine was normal, and the serum pregnancy test was negative.  There was no level of thyroglobulin recorded on this.  A urinalysis and comprehensive metabolic panel was unremarkable.  A chest x-ray was obtained, which I personally reviewed.  There is a diffuse pattern of tiny nodules in both lungs typical of miliary metastatic disease that is often seen in patients with metastatic thyroid carcinoma.,IMPRESSION/PLAN: , The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary.  The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis and is unfortunate in that it generally means a more advanced stage of disease.  I spent approximately 30 minutes with the patient and her family today discussing the surgical aspects of the treatment of this disease.  During this time, we talked about performing a total thyroidectomy to eradicate as much of the native thyroid tissue and remove the primary source of the cancer in anticipation of radioactive iodine therapy.  We talked about sentinel node dissection, and we spent significant amount of time talking about the possibility of hypoparathyroidism if all four of the parathyroid glands were damaged during this operation.  We also discussed the recurrent laryngeal and external laryngeal branches of the nerve supplying the vocal cord function and how they cane be damaged during the thyroidectomy as well.  I answered as many of the family's questions as they could mount during this stressful time with this recent information supplied to them.  I also did talk to them about the chest x-ray pattern, which was complete __________ as the film was just on the day prior to my clinic visit.  This will have some impact on the postoperative adjunctive therapy.  The radiologist commented about the risk of pulmonary fibrosis and the use of radioactive iodine in this situation, but it seems likely that is going to be necessary to attempt to treat this disease in the patient's case.  I did discuss with them the possibility of having to take large doses of calcium and vitamin D in the event of hypoparathyroidism if that does happen, and we also talked about possibly sparing parathyroid tissue and reimplanting it in a muscle belly either in the neck or forearm if that becomes a necessity.  All of the family's questions have been answered.  This is a very anxious and anxiety provoking time in the family.  I have made every effort to get the patient under schedule within the next 48 hours to have this operation done.  We are tentatively planning on proceeding this upcoming Friday afternoon with total thyroidectomy.",
" The patient with left completion hemithyroidectomy and reimplantation of the left parathyroid and left sternocleidomastoid region in the inferior 1/3rd region.  Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.", Endocrinology, Post Hemithyroidectomy ,"PREOPERATIVE DIAGNOSES: , Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.,POSTOPERATIVE DIAGNOSES: , Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.,PROCEDURE:  ,The patient with left completion hemithyroidectomy and reimplantation of the left parathyroid and left sternocleidomastoid region in the inferior 1/3rd region.,FINDINGS: , Normal-appearing thyroid gland with a possible lump in the inferior aspect, there was a parathyroid gland that by frozen section _________  was not thyroid, it was reimplanted to the left lower sternocleidomastoid region.,ESTIMATED BLOOD LOSS:  ,Approximately 10 mL.,FLUIDS: , Crystalloid only.,COMPLICATIONS: , None.,DRAINS: , Rubber band drain in the neck.,CONDITION:,  Stable.,PROCEDURE:  ,The patient placed supine under general anesthesia.  First, a shoulder roll was placed, 1% lidocaine and 1:100,000 epinephrine was injected into the old scar, natural skin fold, and Betadine prep.  Sterile dressing was placed.  The laryngeal monitoring was noted to be working fine.  Then, an incision was made in this area in a curvilinear fashion through the old scar, taken through the fat and the platysma level.  The strap muscles were found and there was scar tissue along the trachea and the strap muscles were elevated off of the left thyroid, the thyroid gland was then found.  Then, using bipolar cautery and a Coblation dissector, the thyroid gland inferiorly was dissected off and the parathyroid gland was left inferiorly and there was scar tissue that was released and laterally, the thyroid gland was released, then came into the Berry ligaments.  The Berry ligament was dissected off and the gland came off all the way to the superior and inferior thyroid vessels, which were crossed with the Harmonic scalpel and removed.  No bleeding was seen.  There was a small nick in the external jugular vein that was tied with a 4-0 Vicryl suture ligature.  After this was completed, on examining the specimen, there appeared to be a lobule on it and it was sent off as possibly parathyroid, therefore it was reimplanted in the left lower sternocleidomastoid region using the silk suture ligature.  After this was completed, no bleeding was seen.  The laryngeal nerve could be seen and intact and then Rubber band  drain was placed throughout the neck along the thyroid bed and 4-0 Vicryl was used to close the strap muscles in an interrupted fashion along with the platysma region and subcutaneous region and a running 5-0 nylon was used to close the skin and Mastisol and Steri-Strips were placed along the skin edges and then on awakening, both laryngeal nerves were working normally.  Procedure was then terminated at that time.","endocrinology, thyroid, rubber band drain, berry ligaments, papillary carcinoma, follicular variant, strap muscles, thyroid gland, sternocleidomastoid, parathyroid, hemithyroidectomy,"
 Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck.   Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side.  Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field., Endocrinology, Metastatic Lymphadenopathy & Thyroid Tissue Removal ,"TITLE OF OPERATION: , Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck.  Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side.  Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,INDICATION FOR SURGERY: , The patient is a 37-year-old gentleman well known to me with a history of medullary thyroid cancer sporadic in nature having undergone surgery in 04/07 with final pathology revealing extrafocal, extrathyroidal extension, and extranodal extension in the soft tissues of his medullary thyroid cancer.  The patient had been followed for a period of time and underwent rapid development of a left and right infraclavicular lymphadenopathy and central neck lymphadenopathy also with imaging studies to suggest superior mediastinal disease.  Fine-needle aspiration of the left and right infraclavicular lymph nodes revealed persistent medullary thyroid cancer.  Risks, benefits, and alternatives of the procedures discussed with in detail and the patient elected to proceed with surgery as discussed.  The risks included, but not limited to anesthesia, bleeding, infection, injury to nerve, lip, tongue, shoulder, weakness, tongue numbness, droopy eyelid, tumor comes back, need for additional treatment, diaphragm weakness, pneumothorax, need for chest tube, others.  The patient understood all these issues and did wish to proceed.,PROCEDURE DETAIL:  ,After identifying the patient, the patient was placed supine on the operating room table.  The patient was intubated with a number 7 nerve integrity monitor system endotracheal tube.  The eyes were protected with Tegaderm.  The patient was rotated to 180 degrees towards the operating surgeon.  The Foley catheter was placed into the bladder with good return of urine.  Attention then was turned to securing the nerve integrity monitor system endotracheal tube and this was confirmed to be working adequately.  A previous apron incision was incorporated and advanced over onto the right side to the mastoid tip.  The incision then was planned around the old scar to be excised.  A 1% lidocaine with 1 to 100,000 epinephrine was injected.  A shoulder roll was applied.  The incision was made, the apron flap was raised to the level of the mandible and mastoid tip bilaterally all the way down to the clavicle and sternal notch inferiorly.  Attention was then turned to performing the level 1 dissection on the left.  Subsequently the marginal mandibular nerve was identified over the facial notch of the mandible.  The facial artery and vein were individually ligated and marginal mandibular nerve traced superiorly and perifascial lymph nodes freed from the marginal mandibular nerve.  Level 1A lymph nodes of the submental region were dissected off the mylohyoid and digastric.  The submandibular gland was appreciated and retracted laterally.  The mylohyoid muscle appreciated.  The lingual nerve was appreciated and the submandibular ganglion was ligated.  The hypoglossal nerve was appreciated and protected and digastric tunnel was then made posteriorly and the lymph nodes posterior along the marginal mandibular nerve and into the parotid gland were then dissected and incorporated into the specimen for histopathologic analysis.  The marginal mandibular nerve stimulated at the completion of this portion of the procedure.  Attention was then turned to incising the fascia along the clavicle on the left side.  Dissection then ensued along the floor of the neck palpating a very large bulky lymph node before the neck was identified.  The brachial plexus and phrenic nerve were identified.  The internal jugular vein identified and the mass was freed from the floor of the neck with careful dissection and suture ligation of vessels.  Attention was then turned to the central neck.  The strap muscles were appreciated in the midline.  There was a large firm mass measuring approximately 3 cm that appeared to be superior to the strap musculature.  A careful dissection with incorporation of a portion of the sternal hyoid muscle in this area for a margin was then performed.  Attention was then turned to identify the carotid artery and the internal jugular vein on the left side.  This was traced inferiorly, internal jugular vein to the brachiocephalic vein.  Palpation deep to this area into the mediastinum and up against the trachea revealed a 1.5 cm lymph node mass.  Subsequently this was carefully dissected preserving the brachiocephalic vein and also the integrity of the trachea and the carotid artery and these lymph nodes were removed in full and sent for histopathologic analysis.  Attention was then turned to the right neck dissection.  A posterior flap on the right was raised to the anterior border of the trapezius.  The accessory nerve was identified in the posterior triangle and traced superiorly and inferiorly.  Attention was then turned to identifying the submandibular gland.  A digastric tunnel was performed back to the sternocleidomastoid muscle.  The fascia overlying the sternocleidomastoid muscle on the right side was incised and the omohyoid muscle was appreciated.  The omohyoid muscle was retracted inferiorly.  Penrose drain was placed around the inferior aspect of the sternocleidomastoid muscle.  Subsequently the internal jugular vein was identified.  The external jugular vein ligated about 1 cm above the clavicle.  Palpation in this area and the infraclavicular region on the right revealed a firm irregular lymph node complex.  Dissection along the floor of the neck then was performed to allow for mobilization.  The transverse cervical artery and vein were individually ligated to allow full mobilization of this mass.  Tissue between the phrenic nerve and the internal jugular vein was clamped and suture ligated.  The tissue was then brought posteriorly from the trapezius muscle to the internal jugular vein and traced superiorly.  The cervical rootlets were transected after the contribution, so the phrenic nerve all the way superiorly to the skull base.  The hypoglossal nerve was identified and protected as the lymph node packet was dissected over the internal jugular vein.  The wound was copiously irrigated.  Valsalva maneuver was given.  No bleeding points identified.  The wound was then prepared for closure.  Two number 10 JPs were placed through the left supraclavicular fossa in the previous drain sites and secured with 3-0 nylon.  The wound was closed  with interrupted 3-0 Vicryl for platysma, subsequently a 4-0 running Biosyn for the skin, and Indermil.  The patient tolerated the procedure well, was extubated on the operating room table, and sent to the postanesthesia care unit in good condition.","endocrinology, lymphadenopathy, thyroid, infraclavicular, fossa, lymph nodes, dissection, pretracheal, internal jugular vein, infraclavicular lymphadenopathy, metastatic lymphadenopathy, mandibular nerve, vein, nodes, neck, nerve, muscle, jugularNOTE"
 Patient today with ongoing issues with diabetic control., Endocrinology, Diabetes Mellitus - SOAP Note - 2 ,"SUBJECTIVE:,  I am asked to see the patient today with ongoing issues around her diabetic control.  We have been fairly aggressively, downwardly adjusting her insulins, both the Lantus insulin, which we had been giving at night as well as her sliding scale Humalog insulin prior to meals.  Despite frequent decreases in her insulin regimen, she continues to have somewhat low blood glucoses, most notably in the morning when the glucoses have been in the 70s despite decreasing her Lantus insulin from around 84 units down to 60 units, which is a considerable change.  What I cannot explain is why her glucoses have not really climbed at all despite the decrease in insulin.  The staff reports to me that her appetite is good and that she is eating as well as ever.  I talked to Anna today.  She feels a little fatigued.  Otherwise, she is doing well.,PHYSICAL EXAMINATION:  ,Vitals as in the chart.  The patient is a pleasant and cooperative.  She is in no apparent distress.,ASSESSMENT AND PLAN: , Diabetes, still with some problematic low blood glucoses, most notably in the morning.  To address this situation, I am going to hold her Lantus insulin tonight and decrease and then change the administration time to in the morning.  She will get 55 units in the morning.  I am also decreasing once again her Humalog sliding scale insulin prior to meals.  I will review the blood glucoses again next week.,","endocrinology, diabetic control, insulin prior to meals, low blood glucoses, sliding scale, lantus insulin, diabetes, mellitus, lantus, glucoses,"
" Left axillary dissection with incision and drainage of left axillary mass.  Right axillary mass excision and incision and drainage.   Bilateral axillary masses, rule out recurrent Hodgkin's disease.", Endocrinology, Axillary Dissection & Mass Excision ,"PREOPERATIVE DIAGNOSIS:,  Bilateral axillary masses, rule out recurrent Hodgkin's disease.,POSTOPERATIVE DIAGNOSIS:  ,Bilateral axillary masses, rule out recurrent Hodgkin's disease.,PROCEDURE PERFORMED:,1.  Left axillary dissection with incision and drainage of left axillary mass.,2.  Right axillary mass excision and incision and drainage.,ANESTHESIA: , LMA.,SPECIMENS:,  Left axillary mass with nodes and right axillary mass.,ESTIMATED BLOOD LOSS:  ,Less than 30 cc.,INDICATION: , This 56-year-old male presents to surgical office with history of bilateral axillary masses.  Upon evaluation, it was noted that the patient has draining bilateral masses with the left mass being approximately 8 cm in diameter upon palpation and the right being approximately 4 cm in diameter.  The patient had been continued on antibiotics preoperatively.  The patient with history of Hodgkin's lymphoma approximately 18 years ago and underwent therapy at that time and he was declared free of disease since that time.  Consent for possible recurrence of Hodgkin's lymphoma warranted exploration and excision of these masses.  The patient was explained the risks and benefits of the procedure and informed consent was obtained.,GROSS FINDINGS: , Upon dissection of the left axillary mass, the mass was removed in toto and noted to have a cavity within it consistent with an abscess.,No loose structures were identified and sent for frozen section, which upon intraoperative consultation with Pathology Department revealed no obvious evidence of lymphoma, however, the confirmed pathology report is pending at this time.  The right axillary mass was excised without difficulty without requiring full axillary dissection.,PROCEDURE: , The patient was placed in supine position after appropriate anesthesia was obtained and a sterile prep and drape complete.  A #10 blade scalpel was used to make an elliptical incision about the mass itself extending this incision further to aid in the mobilization of the mass.  Sharp dissection was utilized with Metzenbaum scissors about the mass to maintain the injury to the skin structure and upon showing out the mass, Bovie electrocautery was utilized adjacent to the wall structure to maintain hemostasis.  Identification of the axillary anatomy was made and care was made to avoid injury to nerve, vessel or musculature.  Once this mass was removed in toto, lymph node structures were as well delivered with this mass and sent to frozen section as well the specimen was sent to gram stain and culture.  Upon revaluation of the incisional site, it was noted to be hemostatic.  Warm lap sponge was then left in place at this site.  Next, attention was turned to the right axilla where a #10 blade scalpel was used to make a 4 cm incision about the mass including the cutaneous structures involved with the erythematous reaction.  This was as well removed in toto and sent to Pathology for gram stain and culture as well as pathologic evaluation.  This site was then made hemostatic as well with the aid of Bovie electrocautery and approximation of the deep dermal tissues after irrigation with warm saline was then done with #3-0 Vicryl suture followed by #4-0 Vicryl running subcuticular stitch.  Steri-Strips were applied.  Attention was returned back left axilla, which upon re-exploration was noted to be hemostatic and a #7 mm JP was then introduced making a skin stab inferior to the incision and bringing the end of the drain through this incision.  This was placed within the incision site, ________ drainage of the axillary potential space.  Approximation of the deep dermal tissues were then done with #3-0 Vicryl in an interrupted technique followed by #4-0 Vicryl with running subcuticular technique.  Steri-Strips and sterile dressings were applied.  JP bulb was then placed to suction and sterile dressings were applied to both axilla.  The patient tolerated the procedure well and sent to postanesthesia care unit in a stable condition.  He will be discharged to home upon ability of the patient to have pain tolerance with Vicodin 1-2 as needed every six hours for pain and continue on Keflex antibiotics until gram stain culture proves otherwise.","endocrinology, incision and drainage, axillary mass excision, axillary dissection, hodgkin's disease, axillary mass, mass, incision, axillary,"
 Urgent cardiac catheterization with coronary angiogram., Emergency Room Reports, Urgent Cardiac Cath ,"PROCEDURE: , Urgent cardiac catheterization with coronary angiogram.,PROCEDURE IN DETAIL: , The patient was brought urgently to the cardiac cath lab from the emergency room with the patient being intubated with an abnormal EKG and a cardiac arrest.  The right groin was prepped and draped in usual manner.  Under 2% lidocaine anesthesia, the right femoral artery was entered.  A 6-French sheath was placed.  The patient was already on anticoagulation.  Selective coronary angiograms were then performed using a left and a 3DRC catheter.  The catheters were reviewed.  The catheters were then removed and an Angio-Seal was placed.  There was some hematoma at the cath site.,RESULTS,1.  The left main was free of disease.,2.  The left anterior descending and its branches were free of disease.,3.  The circumflex was free of disease.,4.  The right coronary artery was free of disease.  There was no gradient across the aortic valve.,IMPRESSION: , Normal coronary angiogram.,","emergency room reports, cardiac catheterization, coronary angiogram, angiogram"
" Followup diabetes mellitus, type 1.", Endocrinology, Diabetes Mellitus - SOAP Note - 1 ,"CHIEF COMPLAINT:  ,Followup diabetes mellitus, type 1., ,SUBJECTIVE:,  Patient is a 34-year-old male with significant diabetic neuropathy.  He has been off on insurance for over a year.  Has been using NPH and Regular insulin to maintain his blood sugars.  States that he is deathly afraid of having a low blood sugar due to motor vehicle accident he was in several years ago.  Reports that his blood sugar dropped too low which caused the accident.  Since this point in time, he has been unwilling to let his blood sugars fall within a normal range, for fear of hypoglycemia. Also reports that he regulates his blood sugars with how he feels, rarely checking his blood sugar with a glucometer., ,Reports that he has been worked up extensively at hospital and was seeing an Endocrinologist at one time.  Reports that he had some indications of kidney damage when first diagnosed.  His urine microalbumin today is 100.  His last hemoglobin A1C drawn at the end of December is 11.9.  Reports that at one point, he was on Lantus which worked well and he did not worry about his blood sugars dropping too low. While using Lantus, he was able to get his hemoglobin A1C down to 7.  His last CMP shows an elevated alkaline phosphatase level of 168. He denies alcohol or drug use and is a non smoker.  Reports he quit drinking 3 years ago. I have discussed with patient that it would be appropriate to do an SGGT and hepatic panel today.  Patient also has a history of gastroparesis and impotence.  Patient requests Nexium and Viagra, neither of which are covered under the Health Plan.  , ,Patient reports that he was in a scooter accident one week ago, fell off his scooter, hit his head.  Was not wearing a helmet.  Reports that he did not go to the emergency room and had a headache for several days after this incident.  Reports that an ambulance arrived at the scene and he was told he had a scalp laceration and to go into the emergency room.  Patient did not comply.  Reports that the headache has resolved.  Denies any dizziness, nausea, vomiting, or other neurological abnormalities., ,PHYSICAL EXAMINATION: , WD, WN.  Slender, 34-year-old white male.  VITAL SIGNS:  Blood sugar 145, blood pressure 120/88, heart rate 104, respirations 16.  Microalbumin 100. SKIN:  There appears to be 2 skin lacerations on the left parietal region of the scalp, each approximately 1 inch long.  No signs of infection.  Wound is closed with new granulation tissue.  Appears to be healing well.  HEENT:  Normocephalic.  PERRLA.  EOMI.  TMs pearly gray with landmarks present.  Nares patent.  Throat with no redness or swelling.  Nontender sinuses.  NECK:  Supple.  Full ROM.  No LAD. CARDIAC:","endocrinology, diabetes mellitus, nph, regular insulin, sggt, diabetic neuropathy, dizziness, followup, glucometer, hypoglycemia, microalbumin, nausea, neurological, vomiting, mellitus type, blood sugars, blood, diabetes, mellitus, sugars"
" This 68-year-old man presents to the emergency department for three days of cough, claims that he has brought up some green and grayish sputum.  He says he does not feel short of breath.  He denies any fever or chills.", Emergency Room Reports, Viral Syndrome - ER Visit ,"SUBJECTIVE:  ,This 68-year-old man presents to the emergency department for three days of cough, claims that he has brought up some green and grayish sputum.  He says he does not feel short of breath.  He denies any fever or chills.,REVIEW OF SYSTEMS:,HEENT:  Denies any severe headache or sore throat.,CHEST:  No true pain.,GI:  No nausea, vomiting, or diarrhea.,PAST HISTORY:,  He states that he is on Coumadin because he had a cardioversion done two months ago for atrial fibrillation.  He also lists some other medications.  I do have his medications list.  He is on Pacerone, Zaroxolyn, albuterol inhaler, Neurontin, Lasix, and several other medicines.  Those are the predominant medicines.  He is not a diabetic.  The past history otherwise, he has had smoking history, but he quit several years ago and denies any COPD or emphysema.  No one else in the family is sick.,PHYSICAL EXAMINATION:,GENERAL:  The patient appears comfortable.  He did not appear to be in any respiratory distress.  He was alert.  I heard him cough once during the entire encounter.  He did not bring up any sputum at that time.,VITAL SIGNS:  His temperature is 98, pulse 71, respiratory rate 18, blood pressure 122/57, and pulse ox is 95% on room air.,HEENT:  Throat was normal.,RESPIRATORY:  He was breathing normally.  There was clear and equal breath sounds.  He was speaking in full sentences.  There was no accessory muscle use.,HEART:  Sounded regular.,SKIN:  Normal color, warm and dry.,NEUROLOGIC:  Neurologically he was alert.,IMPRESSION: , Viral syndrome, which we have been seeing in many cases throughout the week.  The patient asked me about antibiotics and I did not see a need to do this since he did not appear to have an infection other than viral given his normal temperature, normal pulse, normal respiratory rate, and near normal oxygen.  The patient being on Coumadin I explained to him that unless there was a solid reason to put him on antibiotics, he would be advised not to do so because antibiotics can alter the gut floor causing the INR to increase while on Coumadin which may cause serious bleeding.  The patient understands this.  I then asked him if the cough was annoying him, he said it was.  I offered him a cough syrup, which he agreed to take.  The patient was then discharged with Tussionex Pennkinetic a hydrocodone time-release cough syrup.  I told to check in three days, if the symptoms were not getting better.  The patient appeared to be content with this treatment and was discharged in approximately 30 to 45 minutes later.  His wife calls me very angry that I did not give him antibiotics.  I explained her exactly what I explained to him that they were not indicative at this time, and she became very upset saying that they came there specifically for antibiotics and I explained again that antibiotics are not indicated for viral infection and that I did not think he had a bacterial infection.,DIAGNOSIS: , Viral respiratory illness.","emergency room reports, sputum, short of breath, fever, chills, copd, emphysema, viral respiratory illness, green and grayish sputum, viral syndrome, respiratory rate, cough syrup, cough, antibiotics, inhaler,"
 Completion thyroidectomy with limited right paratracheal node dissection., Endocrinology, Completion Thyroidectomy ,"TITLE OF OPERATION:,  Completion thyroidectomy with limited right paratracheal node dissection.,INDICATION FOR SURGERY:,  A 49-year-old woman with a history of a left dominant nodule in her thyroid gland, who subsequently underwent left thyroid lobectomy and isthmusectomy, was found to have multifocal papillary thyroid carcinoma throughout her left thyroid lobe and isthmus.  Consideration given to completion thyroidectomy.  Risks, benefits, and alternatives of this procedure was discussed with the patient in great detail.  Risks included but were not limited to anesthesia, bleeding, infection, injury to nerves including vocal fold paralysis, hoarseness, low calcium, scar, cosmetic deformity, need for thyroid hormone replacement, and also need for further management.  The patient understood all of this and then wished to proceed.,PREOP DIAGNOSIS:,  Multifocal thyroid carcinoma and previous left thyroid lobectomy resection specimen.,POSTOP DIAGNOSIS: , Multifocal thyroid carcinoma and previous left thyroid lobectomy resection specimen.,PROCEDURE DETAIL:,  After identifying the patient, the patient was placed supine in the operating room table.  After establishment of general anesthesia via orotracheal intubation with a number 6 nerve integrity monitoring system endotracheal tube, the eyes were protected with Tegaderm.  Nerve integrity monitoring system endotracheal tube was confirmed to be working adequately and secured.  The previous skin incision for a thyroidectomy was then planned, then incorporated into an ellipse.  The patient was prepped and draped in a sterile fashion.  Subsequently, the ellipse around the previous incision was deformed.  The scar was then excised.  Subplatysmal flaps were raised to the thyroid notch and sternal notch respectively.  Strap muscles were isolated in the midline and dissected and mobilized from the thyroid lobe on the right side.  There was some dense fibrosis and inflammation surrounding the right thyroid lobe.  Careful dissection along the thyroid lobe allowed for identification of the superior thyroid artery and vein which were individually ligated with a Harmonic scalpel.  The right inferior and superior parathyroid glands were identified and preserved and recurrent laryngeal nerve was identified and traced superiorly, then preserved.  Of note is that there were multiple lymph nodes in the paratracheal region on the right side.  These lymph nodes were carefully dissected away from the recurrent laryngeal nerve, trachea, and the carotid artery, and sent as a separate specimen labeled right paratracheal lymph nodes.  The wound was copiously irrigated.  Valsalva maneuver was given.  Surgicel was placed in the wound bed.  Strap muscles were reapproximated in the midline with 3-0 Vicryl and incision was then closed with interrupted 3-0 Vicryl and Indermil for the skin.  The patient was extubated in the operating room table, sent to the postanesthesia care unit in good condition.","endocrinology, multifocal thyroid carcinoma, thyroid lobectomy, thyroid, papillary, thyroid lobe, isthmus, completion thyroidectomy, thyroidectomy, paratracheal, lobectomy, "
" Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth pain to both upper and lower teeth on the left side for approximately three days..", Emergency Room Reports, Toothache - ER Visit ,"CHIEF COMPLAINT:,  Toothache.,HISTORY OF PRESENT ILLNESS:  ,This is a 29-year-old male who has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled.  Complains of new tooth pain.  The patient states his current toothache is to both upper and lower teeth on the left side for approximately three days.  The patient states that he would have gone to see his regular dentist but he has missed so many appointments that they now do not allow him to schedule regular appointments, he has to be on standby appointments only.  The patient denies any other problems or complaints.  The patient denies any recent illness or injuries.  The patient does have OxyContin and Vicodin at home which he uses for his knee pain but he wants more pain medicines because he does not want to use up that medicine for his toothache when he wants to say this with me.,REVIEW OF SYSTEMS: , CONSTITUTIONAL:  No fever or chills.  No fatigue or weakness.  No recent weight change.  HEENT:  No headache, no neck pain, the toothache pain for the past three days as previously mentioned.  There is no throat swelling, no sore throat, no difficulty swallowing solids or liquids.  The patient denies any rhinorrhea.  No sinus congestion, pressure or pain, no ear pain, no hearing change, no eye pain or vision change.  CARDIOVASCULAR:  No chest pain.  RESPIRATIONS:  No shortness of breath or cough.  GASTROINTESTINAL:  No abdominal pain.  No nausea or vomiting.  GENITOURINARY:  No dysuria.  MUSCULOSKELETAL:  No back pain.  No muscle or joint aches.  SKIN:  No rashes or lesions.  NEUROLOGIC:  No vision or hearing change.  No focal weakness or numbness.  Normal speech.  HEMATOLOGIC/LYMPHATIC:  No lymph node swelling has been noted.,PAST MEDICAL HISTORY: , Chronic knee pain.,CURRENT MEDICATIONS: , OxyContin and Vicodin.,ALLERGIES:,  PENICILLIN AND CODEINE.,SOCIAL HISTORY: , The patient is still a smoker.,PHYSICAL EXAMINATION:,  VITAL SIGNS:  Temperature 97.9 oral, blood pressure is 146/83, pulse is 74, respirations 16, oxygen saturation 98% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished and well developed.  The patient is a little overweight but otherwise appears to be healthy.  The patient is calm, comfortable, in no acute distress, and looks well.  The patient is pleasant and cooperative.  HEENT:  Eyes are normal with clear conjunctiva and cornea bilaterally.  There is no icterus, injection, or discharge.  Pupils are 3 mm and equally round and reactive to light bilaterally.  There is no absence of light sensitivity or photophobia.  Extraocular motions are intact bilaterally.  Ears are normal bilaterally without any sign of infection.  There is no erythema, swelling of canals.  Tympanic membranes are intact without any erythema, bulging or fluid levels or bubbles behind it.  Nose is normal without rhinorrhea or audible congestion.  There is no tenderness over the sinuses.  NECK:  Supple, nontender, and full range of motion.  There is no meningismus.  No cervical lymphadenopathy.  No JVD.  Mouth and oropharynx shows multiple denture and multiple dental caries.  The patient has tenderness to tooth #12 as well as tooth #21.  The patient has normal gums.  There is no erythema or swelling.  There is no purulent or other discharge noted.  There is no fluctuance or suggestion of abscess.  There are no new dental fractures.  The oropharynx is normal without any sign of infection.  There is no erythema, exudate, lesion or swelling.  The buccal membranes are normal.  Mucous membranes are moist.  The floor of the mouth is normal without any abscess, suggestion of Ludwig's syndrome.  CARDIOVASCULAR:  Heart is regular rate and rhythm without murmur, rub, or gallop.  RESPIRATIONS:  Clear to auscultation bilaterally without shortness of breath.  GASTROINTESTINAL:  Abdomen is normal and nontender.  MUSCULOSKELETAL:  No abnormalities are noted to back, arms and legs.  The patient has normal use of his extremities.  SKIN:  No rashes or lesions.  NEUROLOGIC:  Cranial nerves II through XII are intact.  Motor and sensory are intact to the extremities.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is alert and oriented x4.  Normal mood and affect.  HEMATOLOGIC/LYMPHATIC:  No cervical lymphadenopathy is palpated.,EMERGENCY DEPARTMENT COURSE: , The patient did request a pain shot and the patient was given Dilaudid of 4 mg IM without any adverse reaction.,DIAGNOSES:,1.  ODONTALGIA.,2.  MULTIPLE DENTAL CARIES.,CONDITION UPON DISPOSITION:  ,Stable.,DISPOSITION: , To home.,PLAN: , The patient was given a list of local dental clinics that he can follow up with or he can choose to stay with his own dentist that he wishes.  The patient was requested to have reevaluation within two days.  The patient was given a prescription for Percocet and clindamycin.  The patient was given drug precautions for the use of these medicines.  The patient was offered discharge instructions on toothache but states that he already has it.  He declined the instructions.  The patient was asked to return to the emergency room, should he have any worsening of his condition or develop any other problems or symptoms of concern.","emergency room reports, odontalgi, multiple dental caries, dentist, dental disease, extensive dental disease, teeth pulled, lower teeth, cervical lymphadenopathy, dental caries, toothache, erythema, swelling, teeth, dental, "
 The patient has a possibly torsion detorsion versus other acute testicular problem. , Emergency Room Reports, Testicular Pain ,"CHIEF COMPLAINT: , Testicular pain.,HISTORY OF PRESENT ILLNESS:,  The patient is a 4-year-old boy with a history of abrupt onset of left testicular pain at 11:30 this morning.  He was unable to walk and would not stand upright, and had fairly significant discomfort, so the parents checked his panel because of it.  Because of this, they took him to Emergency Department, at which time, he had no swelling noted initially, but very painful.  He had no voiding or stooling problems.  No nausea, vomiting or fever.  Family denies trauma or dysuria.  At that time, he was going to get an ultrasound done, but the mother said that all of sudden the patient stated the pain had resolved.  He has had hot chocolate this morning at 10:30 in the morning and water around 2:30 in the morning.  He has not had any pain since but states that he has had pain in the past, not as long and states there was a twisting sensation.  He has no recent cold or flu, although he had rhinorrhea about 3 weeks ago.  He is on no medications and he is here for evaluation.,PAST MEDICAL HISTORY:,  The patient has no known allergies.  He is term delivery via spontaneous vaginal delivery.  He has had no problems or hospitalizations with circumcision.,PAST SURGICAL HISTORY: , He has had no previous surgeries.,REVIEW OF SYSTEMS:,  All 14-point review of systems were negative except for the above left testicular pain and the history of possible upper respiratory infection about 2 to 3 weeks ago.,IMMUNIZATIONS: , Up-to-date.,FAMILY HISTORY: , The patient lives at home with both parents who are Spanish speaking.  He is not in school.,MEDICATIONS:,  He is on no medications.,PHYSICAL EXAMINATION:,VITAL SIGNS:  On physical exam, weight is 15.9 kg.,GENERAL:  The patient is a cooperative little boy.,HEENT:  Normal head and neck exam.  No oral or nasal discharge.,NECK:  Without masses.,CHEST:  Without masses.,LUNGS:  Clear.,CARDIAC:  Without murmurs or gallops.,ABDOMEN:  Soft.  No masses or tenderness.  His scrotum did not have any swelling at the present time.  There was only minimal discomfort with palpation at the left inguinal area, but no masses were noted.  No palpable nodules such as appendix testis and no swelling was noted and he had mild epididymal swelling only.  His left testis was slightly harder than the right, but this was not very significant.,EXTREMITIES:  He had full range of motion in all 4 extremities.,SKIN:  Warm, pink, and dry.,NEUROLOGIC:  Grossly intact.,LABORATORY DATA: , Ultrasound was obtained today showing no blood flow or poor blood flow on the left except for increased blood flow to the epididymis on the study done at about 1330 hours, and second one done around 1630 hours was normal flow, possible increased flow on the left.  This is personally reviewed by me.  The right was normal.  No masses were appreciated.  There was some mild change in echotexture on the left on the initial study, which had apparently resolved on the second, but may be due to the technical aspects of the study.,ASSESSMENT/PLAN: , The patient has a possibly torsion detorsion versus other acute testicular problem.  If the patient has indeed testicular torsion, there is an increased possibility that it may reoccur again, actually within the first 24 to 36 hours and as such is recommended doing a left scrotal exploration with possible detorsion of left testis, possible orchiectomy if the testis is markedly abnormal or nonviable, which probably is not the case, and bilateral testes fixation if the torsion is found.  I discussed the pre and postsurgical care with the parents.  Procedure itself with potential complications, risks, benefits, and alternatives of surgery including that the torsion could occur again, although it is less likely after the surgical fixation procedure.  The parents understand and wished to proceed.  We will schedule this later today emergently.",
" The patient complaining of abdominal pain, has a long-standing history of diabetes treated with Micronase daily.", Endocrinology, Acute Cystitis & Diabetes Type II ,"HISTORY OF PRESENT ILLNESS: , The patient is a 45-year-old male complaining of abdominal pain.  The patient also has a long-standing history of diabetes which is treated with Micronase daily.,PAST MEDICAL HISTORY: , There is no significant past medical history noted today.,PHYSICAL EXAMINATION:,HEENT:  Patient denies ear abnormalities, nose abnormalities and throat abnormalities.,Cardio:  Patient has history of elevated cholesterol, but does not have ASHD, hypertension and PVD.,Resp:  Patient denies asthma, lung infections and lung lesions.,GI:  Patient denies colon abnormalities, gall bladder problems, liver abnormalities and peptic ulcer disease.,GU:  Patient has history of Urinary tract disorder, but does not have Bladder disorder and Kidney disorder.,Endocrine:  Patient has history of diabetes, but does not have hormonal irregularities and thyroid abnormalities.,Dermatology:  Patient denies allergic reactions, rashes and skin lesions.,MEDS:,  Micronase 2.5 mg Tab PO QAM #30.  Bactrim 400/80 Tab PO BID #30.,SOCIAL HISTORY:,  No known history of drug or alcohol abuse.  Work, diet, and exercise patterns are within normal limits.,FAMILY HISTORY:,  No significant family history.,REVIEW OF SYSTEMS:,  Non-contributory.,Vital Signs:  Height = 72 in.  Weight =184 lbs.  Upright BP = 120/80 mmHg.  Pulse = 80 bpm.  Resp =12 pm.  Patient is afebrile.,Neck:  The neck is supple.  There is no jugular venous distension.  The thyroid is nontender, or normal size and conto.,Lungs:  Lung expansion and excursions are symmetric.  The lungs are clear to auscultation and percussion.,Cardio:  There is a regular rhythm.  SI and S2 are normal.  No abnormal heart sounds are detected.  Blood pressure is equal bilaterally.,Abdomen:  Normal bowel sounds are present.  The abdomen is soft; The abdomen is nontender; without organomegaly; There is no CVA tenderness.  No hernias are noted.,Extremities:  There is no clubbing, cyanosis, or edema.,ASSESSMENT: , Diabetes type II uncontrolled.  Acute cystitis.,PLAN: , Endocrinology Consult, complete CBC.  ,RX: , Micronase 2.5 mg Tab PO QAM #30, Bactrim 400/80 Tab PO BID #30.",
 The patient had a syncopal episode last night.   She did not have any residual deficit.  She had a headache at that time.  She denies chest pains or palpitations., Emergency Room Reports, Syncope - ER Visit - 1 ,"REASON FOR VISIT:,  Syncope.,HISTORY:,  The patient is a 75-year-old lady who had a syncopal episode last night.  She went to her room with a bowl of cereal and then blacked out for a few seconds and then when she woke up, the cereal was on the floor.  She did not have any residual deficit.  She had a headache at that time.  She denies chest pains or palpitations.,PAST MEDICAL HISTORY: , Arthritis, first episode of high blood pressure today.  She had a normal stress test two years ago.,MEDICATIONS: , Her medication is one dose of hydrochlorothiazide today because her blood pressure was so high at 150/70.,SOCIAL HISTORY: , She does not smoke and she does not drink.  She lives with her daughter.,PHYSICAL EXAMINATION:,GENERAL:  Lady in no distress.,VITAL SIGNS:  Blood pressure 172/91, came down to 139/75, heart rate 91, and respirations 20.  Afebrile.,HEENT:  Head is normal.,NECK:  Supple.,LUNGS:  Clear to auscultation and percussion.,HEART:  No S3, no S4, and no murmurs.,ABDOMEN:  Soft.,EXTREMITIES:  Lower extremities, no edema.,DIAGNOSTIC DATA: , Her EKG shows sinus rhythm with nondiagnostic Q-waves in the inferior leads.,ASSESSMENT:  ,Syncope.,PLAN:  ,She had a CT scan of the brain that was negative today.  The blood pressure is high.  We will start Maxzide.  We will do an outpatient Holter and carotid Doppler study.  She has had an echocardiogram along with the stress test before and it was normal.  We will do an outpatient followup.","emergency room reports, residual deficit, headache, ct scan, syncopal episode, stress test, blood pressure, syncope, "
" Patient with a history of coronary artery disease, status post coronary artery bypass grafting presented to the emergency room following a syncopal episode.", Emergency Room Reports, Syncope - ER Visit ,"REASON FOR CONSULTATION:,  Syncope.,HISTORY OF PRESENT ILLNESS: , The patient is a 78-year-old lady followed by Dr. X in our practice with history of coronary artery disease, status post coronary artery bypass grafting in 2005 presented to the emergency room following a syncopal episode.  According to the patient and the daughter who was with her, she was shopping when she felt abdominal discomfort with nausea, profuse sweating, and passed out.  As soon as she was laid on the floor and her leg raised up, she woke up with no post-event confusion.  According to the daughter, she has had episodes of weakness, but no syncope.  She has blood pressure medications and has had some postural hypotensions, which has been managed by Dr. X. She also states there was a history of pulmonary embolism and the presentation at that time was very similar when she had a syncopal episode.  At that time, she was admitted at Hospital, had a V/Q scan, which was positive for PE.  Initial V/Q scan done at Hospital was negative.  She was anticoagulated with Coumadin resulting in severe GI bleed.  Anticoagulation was stopped and an IVC filter was placed at that time.  She has a history of malignant hypertension and has had a renal stent placed in February 2007.  She also has peripheral vascular disease with stent placements.  There is a history of spinal canal stenosis and iron deficiency anemia, currently on Procrit injections every two weeks done by Dr. Y. The patient denies any chest pain or any worsening of any shortness of breath.  There are no acute EKG changes or cardiac enzyme elevations.  She has had no stress test done following a bypass surgery.,PAST MEDICAL HISTORY,1.  Coronary artery disease, status post coronary artery bypass grafting.,2.  History of mitral regurgitation, unable to repair the valve.,3.  History of paroxysmal atrial fibrillation, on amiodarone.,4.  Gastroesophageal reflux disease.,5.  Hypertension.,6.  Hyperlipidemia.,7.  History of abdominal aortic aneurysm.,8.  Carotid artery disease, mild-to-moderate on recent carotid ultrasound.,9.  Peripheral vascular disease.,10.  Hypothyroidism.,11.  Pulmonary embolism.,PAST SURGICAL HISTORY,1.  Coronary artery bypass grafting.,2.  Hysterectomy.,3.  IVC filter.,4.  Tonsillectomy and adenoidectomy.,5.  Cosmetic surgery to breast and abdomen.,HOME MEDICATIONS,1.  Aspirin 81 mg once a day.,2.  Klor-Con 10 mEq once a day.,3.  Lasix 40 mg once a day.,4.  Levothyroxine 125 mcg once a day.,5.  Lisinopril 20 mg once a day.,6.  Pacerone 200 mg once a day.,7.  Protonix 40 mg once a day.,8.  Toprol 50 mg once a day.,9.  Vitamin B once a day.,10.  Zetia 10 mg once a day.,11.  Zyrtec 10 mg once a day.,ALLERGIES:,  CODEINE, ERYTHROMYCIN, SULFA, VICODIN, AND ZOCOR.,REVIEW OF SYSTEMS,CONSTITUTIONAL:  The patient denies any fevers, chills, recent weight gain or weight loss.  She has had abdominal symptoms with diarrhea.,EYES:  Decreased visual acuity.,ENT:  Sinus drainage.,CARDIOVASCULAR:  As described above.  Denies any chest pains.,RESPIRATORY:  He has chronic shortness of breath.  No cough or sputum production.,GI:  History of reflux symptoms.,GU:  No history of dysuria or hematuria.,ENDOCRINE:  No history of diabetes.,MUSCULOSKELETAL:  Denies arthritis, but has leg pain.,SKIN:  No history of rash.,PSYCHIATRIC:  No history of anxiety or depression.",
" Return visit to the endocrine clinic for acquired hypothyroidism, papillary carcinoma of the thyroid gland status post total thyroidectomy in 1992, and diabetes mellitus.", Endocrinology, Acquired Hypothyroidism Followup ,"PROBLEM LIST:,1.  Acquired hypothyroidism.,2.  Papillary carcinoma of the thyroid gland, status post total thyroidectomy in 1992.,3.  Diabetes mellitus.,4.  Insomnia with sleep apnea.,HISTORY OF PRESENT ILLNESS: , This is a return visit to the endocrine clinic for the patient with history as noted above.  She is 45 years old.  Her last visit was about 6 months ago.  Since that time, the patient states her health has remained unchanged.  Currently, primary complaint is one of fatigue that she feels throughout the day.  She states, however, she is doing well with CPAP and wakes up feeling refreshed but tends to tire out later in the day.  In terms of her thyroid issues, the patient states that she is not having signs or symptoms of thyroid excess or hypothyroidism.  She is not reporting temperature intolerance, palpitations, muscle weakness, tremors, nausea, vomiting, constipation, hyperdefecation or diarrhea.  Her weight has been stable.  She is not reporting proximal muscle weakness.,CURRENT MEDICATIONS:,1.  Levothyroxine 125 micrograms p.o. once daily.,2.  CPAP.,3.  Glucotrol.,4.  Avandamet.,5.  Synthroid.,6.  Byetta injected twice daily.,REVIEW OF SYSTEMS: , As stated in the HPI.  She is not reporting polyuria, polydipsia or polyphagia.  She is not reporting fevers, chills, sweats, visual acuity changes, nausea, vomiting, constipation or diarrhea.  She is not having any lightheadedness, weakness, chest pain, shortness of breath, difficulty breathing, orthopnea or dyspnea on exertion.,PHYSICAL EXAMINATION:,GENERAL:  She is an overweight, very pleasant woman, in no acute distress.  VITAL SIGNS:  Temperature 96.9, pulse 85, respirations not counted, blood pressure 135/65, and weight 85.7 kg.  NECK:  Reveals well healed surgical scar in the anteroinferior aspect of the neck.  There is no palpable thyroid tissue noted on this examination today.  There is no lymphadenopathy.  THORAX:  Reveals lungs that are clear, PA and lateral, without adventitious sounds.  CARDIOVASCULAR:  Demonstrated regular rate and rhythm.  S1 and S2 without murmur.  No S3, no S4 is auscultated.  EXTREMITIES:  Deep tendon reflexes 2+/4 without a delayed relaxation phase.  No fine resting tremor of the outstretched upper extremity.  SKIN, HAIR, AND NAILS:  All are unremarkable.,LABORATORY DATABASE: , Lab data on 08/29/07 showed the following:  Thyroglobulin quantitative less than 0.5 and thyroglobulin antibody less than 20, free T4 1.35, and TSH suppressed at 0.121.,ASSESSMENT AND PLAN:,This is a 45-year-old woman with history as noted above.,1.  Acquired hypothyroidism, status post total thyroidectomy for papillary carcinoma in 1992.,2.  Plan to continue following thyroglobulin levels.,3.  Plan to obtain a free T4, TSH, and thyroglobulin levels today.,4.  Have the patient call the clinic next week for followup and continued management of her hypothyroid state.,5.  Plan today is to repeat her thyroid function studies.  This case was discussed with Dr. X and the recommendation.  We are giving the patient today is for us to taper her medication to get her TSH somewhere between 0.41 or less.  Therefore, labs have been drawn.  We plan to see the patient back in approximately 6 months or sooner.  A repeat body scan will not been done, the one in 03/06 was negative.","endocrinology, thyroid function studies, thyroid gland, diabetes mellitus, papillary carcinoma, total thyroidectomy, acquired hypothyroidism, carcinoma, thyroidectomy, thyroglobulin, hypothyroidism, "
 A 19-year-old known male with sickle cell anemia comes to the emergency room on his own with 3-day history of back pain., Emergency Room Reports, Sickle Cell Anemia - ER Visit ,"HISTORY OF PRESENT ILLNESS: , This is a 19-year-old known male with sickle cell anemia.  He comes to the emergency room on his own with 3-day history of back pain.  He is on no medicines.  He does live with a room mate.  Appetite is decreased.  No diarrhea, vomiting.  Voiding well.  Bowels have been regular.  Denies any abdominal pain.  Complains of a slight headaches, but his main concern is back ache that extends from above the lower T-spine to the lumbosacral spine.  The patient is not sure of his immunizations.  The patient does have sickle cell and hemoglobin is followed in the Hematology Clinic.,ALLERGIES: , THE PATIENT IS ALLERGIC TO TYLENOL WITH CODEINE, but he states he can get morphine along with Benadryl.,MEDICATIONS: , He was previously on folic acid.  None at the present time.,PAST SURGICAL HISTORY: , He has had no surgeries in the past.,FAMILY HISTORY: , Positive for diabetes, hypertension and cancer.,SOCIAL HISTORY: , He denies any smoking or drug usage.,PHYSICAL EXAMINATION: , ,VITAL SIGNS:  On examination, the patient has a temp of 37 degrees tympanic, pulse was recorded at 37 per minute, but subsequently it was noted to be 66 per minute,  respiratory rate is 24 per minute and blood pressure is 149/66, recheck blood pressure was 132/72.,GENERAL:  He is alert, speaks in full sentences, he does not appear to be in distress.,HEENT:  Normal.,NECK:  Supple.,CHEST:  Clear.,HEART:  Regular.,ABDOMEN:  Soft.  He has pain over the mid to lower spine.,SKIN:  Color is normal.,EXTREMITIES:  He moves all extremities well.,NEUROLOGIC:  Age appropriate.,ER COURSE: , It was indicated to the patient that I will be drawing labs and giving him IV fluids.  Also that he will get morphine and Benadryl combination.  The patient was ordered a liter of NS over an hour, and was then maintained on D5 half-normal saline at 125 an hour.  CBC done showed white blood cells 4300, hemoglobin 13.1 g/dL, hematocrit 39.9%, platelets 162,000, segs 65.9, lymphs 27, monos 3.4.  Chemistries done were essentially normal except for a total bilirubin of 1.6 mg/dL, all of which was indirect.  The patient initially received morphine and diphenhydramine at 18:40 and this was repeated again at 8 p.m.  He received morphine 5 mg and Benadryl 25 mg.  I subsequently spoke to Dr. X and it was decided to admit the patient.,The patient initially stated that he wanted to be observed in the ER and given pain control and fluids and wanted to go home in the morning.  He stated that he has a job interview in the morning.  The resident service did come to evaluate him.  The resident service then spoke to Dr. X and it was decided to admit him on to the Hematology service for control of pain and IV hydration.  He is to be transitioned to p.o. medications about 4 a.m. and hopefully, he can be discharged in time to make his interview tomorrow.,IMPRESSION:  ,Sickle cell crisis.,DIFFERENTIAL DIAGNOSIS: , Veno-occlusive crisis, and diskitis.",
 A 93-year-old female called up her next-door neighbor to say that she was not feeling well.  The patient was given discharge instructions on dementia and congestive heart failure and asked to return to the emergency room should she have any new problems or symptoms of concern., Emergency Room Reports, Not Feeling Well - ER Visit ,"CHIEF COMPLAINT:  ,The patient does not have any chief complaint.,HISTORY OF PRESENT ILLNESS:,  This is a 93-year-old female who called up her next-door neighbor to say that she was not feeling well.  The next-door neighbor came over and decided that she should go to the emergency room to be check out for her generalized complaint of not feeling well.  The neighbor suspects that this may have been due to the patient taking too many of her Tylenol PM, which the patient has been known to do.  The patient was a little somnolent early this morning and was found only to be oriented x1 with EMS upon their arrival to the patient's house.  The patient states that she just simply felt funny and does not give any more specific details than this.  The patient denies any pain at any time.  She did not have any shortness of breath.  No nausea or vomiting.  No generalized weakness.  The patient states that all that has gone away since arrival here in the hospital, that she feels at her usual self, is not sure why she is here in the hospital, and thinks she should go.  The patient's primary care physician, Dr. X reports that the patient spoke with him yesterday and had complained of shortness of breath, nausea, dizziness, as well as generalized weakness, but the patient states that all this has resolved.  The patient was actually seen here two days ago for those same symptoms and was found to have exacerbation of her COPD and CHF.  The patient was discharged home after evaluation in the emergency room.  The patient does use home O2.,REVIEW OF SYSTEMS: , CONSTITUTIONAL:  The patient had complained of generalized fatigue and weakness two days ago in the emergency room and yesterday to her primary care physician.  The patient denies having any other symptoms today.  The patient denies any fever or chills.  Has not had any recent weight change.  HEENT:  The patient denies any headache.  No neck pain.  No rhinorrhea.  No sinus congestion.  No sore throat.  No any vision or hearing change.  No eye or ear pain.  CARDIOVASCULAR:  The patient denies any chest pain.  RESPIRATIONS:  No shortness of breath.  No cough.  No wheeze.  The patient did report having shortness of breath and wheeze with her presentation to the emergency room two days ago and shortness of breath to her primary care physician yesterday, but the patient states that all this has resolved.  GASTROINTESTINAL:  No abdominal pain.  No nausea or vomiting.  No change in the bowel movements.  There has not been any diarrhea or constipation.  No melena or hematochezia.  GENITOURINARY:  No dysuria, hematuria, urgency, or frequency.  MUSCULOSKELETAL:  No back pain.  No muscle or joint aches.  No pain or abnormalities to any portion of the body.  SKIN:  No rashes or lesions.  NEUROLOGIC:  The patient reported dizziness to her primary care physician yesterday over the phone, but the patient denies having any problems with dizziness over the past few days.  The patient denies any dizziness at this time.  No syncope or no near-syncope.  The patient denies any focal weakness or numbness.  No speech change.  No difficulty with ambulation.  The patient has not had any vision or hearing change.  PSYCHIATRIC:  The patient denies any depression.  ENDOCRINE:  No heat or cold intolerance.,PAST MEDICAL HISTORY:,  COPD, CHF, hypertension, migraines, previous history of depression, anxiety, diverticulitis, and atrial fibrillation.,PAST SURGICAL HISTORY:,  Placement of pacemaker and hysterectomy.,CURRENT MEDICATIONS: , The patient takes Tylenol PM for insomnia, Lasix, Coumadin, Norvasc, Lanoxin, Diovan, atenolol, and folic acid.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient used to smoke, but quit approximately 30 years ago.  The patient denies any alcohol or drug use although her son reports that she has had a long history of this in the past and the patient has abused prescription medication in the past as well according to her son.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Temperature 99.1 oral, blood pressure 139/65, pulse is 72, respirations 18, and oxygen saturation is 92% on room air and interpreted as low normal.  CONSTITUTIONAL:  The patient is well nourished and well developed.  The patient appears to be healthy.  The patient is calm, comfortable, in no acute distress, and looks well.  The patient is pleasant and cooperative.  HEENT:  Head is atraumatic, normocephalic, and nontender.  Eyes are normal with clear sclerae and cornea bilaterally.  Nose is normal without rhinorrhea or audible congestion.  Mouth and oropharynx are normal without any sign of infection.  Mucous membranes are moist.  NECK:  Supple and nontender.  Full range of motion.  There is no JVD.  No cervical lymphadenopathy.  No carotid artery or vertebral artery bruits.  CARDIOVASCULAR:  Heart is regular rate and rhythm without murmur, rub or gallop.  Peripheral pulses are +2.  The patient does have +1 bilateral lower extremity edema.  RESPIRATIONS:  The patient has coarse breath sounds bilaterally, but no dyspnea.  Good air movement.  No wheeze.  No crackles.  The patient speaks in full sentences without any difficulty.  The patient does not exhibit any retractions, accessory muscle use or abdominal breathing.  GASTROINTESTINAL:  Abdomen is soft, nontender, and nondistended.  No rebound or guarding.  No hepatosplenomegaly.  Normal bowel sounds.  No bruits, no mass, no pulsatile mass, and no inguinal lymphadenopathy.  MUSCULOSKELETAL:  No abnormalities noted to the back, arms or legs.  SKIN:  No rashes or lesions.  NEUROLOGICAL:  Cranial nerves II through XII are intact.  Motor is 5/5 and equal to bilateral arms and legs.  Sensory is intact to light touch.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is awake, alert, and oriented x3 although the patient first stated that the year was 1908, but did manage to correct herself up on addressing this with her.  The patient has normal mood and affect.  HEMATOLOGIC AND LYMPHATIC:  There is no evidence of lymphadenopathy.,EMERGENCY DEPARTMENT TESTING: , EKG is a rate of 72 with evidence of a pacemaker that has good capture.  There is no evidence of acute cardiac disease on the EKG and there is no apparent change in the EKG from 03/17/08.  CBC has no specific abnormalities of issue.  Chemistry has a BUN of 46 and creatinine of 2.25, glucose is 135, and an estimated GFR is 20.  The rest of the values are normal and unremarkable.  LFTs are all within normal limits.  Cardiac enzymes are all within normal limits.  Digoxin level is therapeutic at 1.6.  Chest x-ray noted cardiomegaly and evidence of congestive heart failure, but no acute change from her chest x-ray done two days ago.  CAT scan of the head did not identify any acute abnormalities.  I spoke with the patient's primary care physician, Dr. X who stated that he would be able to follow up with the patient within the next day.  I spoke with the patient's neighbor who contacted the ambulance service who stated that the patient just reported not feeling well and appeared to be a little somnolent and confused at the time, but suspected that she may have taken too many of her Tylenol PM as she often has done in the past.  The neighbor is XYZ and he says that he checks on her three times a day every day.  ABC is the patient's son and although he lives out of town he calls and checks on her every day as well.  He states that he spoke to her yesterday.  She sounded fine, did not express any other problems that she had apparently been in contact with her primary care physician.  She sounded her usual self to him.  Mr. ABC also spoke to the patient while she was here in the emergency room and she appears to be her usual self and has her normal baseline mental status to him.  He states that he will be able to check on her tomorrow as well.  Although it is of some concern that there may be problems with development of some early dementia, the patient is adamant about not going to a nursing home and has been placed in a Nursing Home in the past, but Dr. Y states that she has managed to be discharged after two previous nursing home placements.  The patient does have Home Health that checks on her as well as housing care in between the two services they share visits every single day  by them as well as the neighbor who checks on her three times a day and her son who calls her each day as well.  The patient although she lives alone, does appear to have good followup and the patient is adamant that she wishes to return home.,DIAGNOSES,1.  EARLY DEMENTIA.,2.",
" This is a 53-year-old man, who presented to emergency room with multiple complaints including pain from his hernia, some question of blood in his stool, nausea, and vomiting, and also left lower extremity pain. ", Emergency Room Reports, Pain from Hernia - ER Consult ,"HISTORY OF PRESENT ILLNESS:  ,This is a 53-year-old man, who presented to emergency room with multiple complaints including pain from his hernia, some question of blood in his stool, nausea, and vomiting, and also left lower extremity pain.  At the time of my exam, he states that his left lower extremity pain has improved considerably.  He apparently had more significant paresthesias in the past and now he feels that the paresthesias have improved considerably.  He does have a history of multiple medical problems including atrial fibrillation, he is on Coumadin, which is currently subtherapeutic, multiple CVAs in the past, peripheral vascular disease, and congestive heart failure.  He has multiple chronic history of previous ischemia of his large bowel in the past.,PHYSICAL EXAM,VITAL SIGNS:  Currently his temperature is 98.2, pulse is 95, and blood pressure is 138/98.,HEENT:  Unremarkable.,LUNGS:  Clear.,CARDIOVASCULAR:  An irregular rhythm.,ABDOMEN:  Soft.,EXTREMITIES:  His upper extremities are well perfused.  He has palpable radial and femoral pulses.  He does not have any palpable pedal pulses in either right or left lower extremity.  He does have reasonable capillary refill in both feet.  He has about one second capillary refill on both the right hand and left lower extremities and his left foot is perhaps little cool, but it is relatively warm.  Apparently, this was lot worst few hours ago.  He describes significant pain and pallor, which he feels has improved and certainly clinically at this point does not appear to be as significant.,IMPRESSION AND PLAN: , This gentleman with a history of multiple comorbidities as detailed above had what sounds clinically like acute exacerbation of chronic peripheral vascular disease, essentially related to spasm versus a small clot, which may have been lysed to some extent.  He currently has a viable extremity and viable foot, but certainly has significant making compromised flow.  It is unclear to me whether this is chronic or acute, and whether he is a candidate for any type of intervention.  He certainly would benefit from an angiogram to better to define his anatomy and anticoagulation in the meantime.  Given his potential history of recent lower GI bleeding, he has been evaluated by GI to see whether or not he is a candidate for heparinization.  We will order an angiogram for the next few hours and followup on those results to better define his anatomy and to determine whether or not if any interventions are appropriate.  Again, at this point, he has no pain, relatively rapid capillary refill, and relatively normal motor function suggesting a viable extremity.  We will follow him along closely.","emergency room reports, blood in stool, nausea, capillary refill, angiogram, hernia, extremity, "
 Patient presents to the emergency department (ED) with rectal bleeding and pain on defecation., Emergency Room Reports, Proctitis & Proctocolitis ,"PRESENTATION: , A 16-year-old male presents to the emergency department (ED) with rectal bleeding and pain on defecation.,HISTORY:,  A 16-year-old African American male presents to the ED with a chief complaint of rectal bleeding and pain on defecation.  The patient states that he was well until about three days prior to presentation when he first started to experience some pain when defecating.  The following day he noted increasing pain and first noted blood on the surface of his stool.  The pain worsened on the subsequent day with increasing bleeding as well as some mucopurulent anal discharge.  The patient denies any previous history of rectal bleeding or pain.  He also denies any previous sexually transmitted diseases (STDs) and states that he was screened for HIV infection eight months ago and was negative.  The patient does state that he has not felt well for the past week.  He states that he had felt ""feverish"" on several occasions but has not taken his temperature.  He has also complained of some abdominal discomfort with nausea and diarrhea as well as generalized myalgias and fatigue.  He thinks he has lost a few pounds but has not been weighing himself to determine the exact amount of weight loss.,The patient states that he has been sexually active since age 13.  He admits to eight previous partners and states that he ""usually"" uses a condom.  On further questioning, the patient states that of his eight partners, three were female and five were male.  His most recent sexual partner was a 38-year-old man whom he has been with for the past six months.  He states that he has been tested for STDs in the past but states that he only gave urine and blood for the testing.  He is unaware of the HIV status of his partner but assumes that the partner is uninfected because he looks healthy.  The patient also admits to one episode of sexual abuse at the age of 8 by a friend of the family.  As the man was a member of the family's church, the patient never felt comfortable disclosing this to any of the adults in his life.  He is very concerned about disclosure of his sexual behavior to his family, as they have expressed very negative comments concerning men who have sex with men.  He is accessing care in the ED unaccompanied by an adult.,PHYSICAL EXAM: , Thin but non-toxic young man with clear discomfort.,Pulse = 105,RR = 23,BP = 120/62,HEENT:  Several areas of white plaque-like material on the buccal mucosa.,Neck:  Multiple anterior/posterior cervical nodes in both anterior and posterior chains- 1-2 cm in diameter.,Lungs:  Clear to auscultation.,Cardiac:  Quiet precordium.,Nl S1/S2 with a II/VI systolic murmur. ,Abdomen:  Soft without hepatosplenomegaly.,GU:  Tanner V male with no external penile lesions.,Lymph:  2-3 cm axillary nodes bilaterally.,1-2 cm epitrochlear nodes.,Multiple 1-2 cm inguinal nodes.,Rectal:  Extremely painful digital exam.,+ gross blood and mucous.,LABORATORY EVALUATION:,Hbg = 12.  5 gm/dL,Hct = 32%,WBC = 3.9 thou/µL,Platelets = 120,000 thou/µL,76% neutrophils,19% lymphocytes,1% eosinophils,4% monocytes,ALT = 82 U/L,AST= 90 U/L,Erythrocyte sedimentation rate = 90,Electrolytes = normal,Gram stain of anal swab:  numerous WBCs,DIFFERENTIAL DIAGNOSIS: , This patient is presenting with acute rectal pain with bleeding and anal discharge.  The patient also presents with some constitutional symptoms including fever, fatigue, abdominal discomfort, and adenopathy on physical examination.  The following are in the differential diagnosis:  Acute Proctitis and  Proctocolitis.,ACUTE HIV SEROCONVERSION: , This subject is sexually active and reports inconsistent condom use.  Gastrointestinal symptoms have recently been reported commonly in patients with a history of HIV seroconversion.  The rectal symptoms of bleeding and pain are not common with HIV, and an alternative diagnosis would be required.,PERIRECTAL ABSCESS: , A patient with a history of receptive anal intercourse is at risk for developing a perirectal abscess either from trauma or a concurrent STD.  The patient could experience more systemic symptoms with fever and malaise, as found with this patient.  However, the physical examination did not reveal the typical localized area of pain and edema.,DIAGNOSIS:  ,The subject had rectal cultures obtained, which were positive for Neisseria gonorrhoeae.  An HIV ELISA was positive, as was the RNA PCR.,DISCUSSION: , This patient demonstrates a number of key issues to consider when caring for an adolescent or young adult.  First, the patient utilized the emergency department for care as opposed to identifying a primary care provider.  Although not ideal in many circumstances, testing for HIV infection is crucial when there is suspicion, since many newly diagnosed patients identify earlier contacts with health care providers when HIV counseling and testing were not performed.  Second, this young man has had both male and female sexual partners.  As young people explore their sexuality, asking about partners in an open, nonjudgmental manner without applying labels is integral to helping the young person discuss their sexual behaviors.  Assuming heterosexuality is a major barrier to disclosure for many young people who have same-sex attractions.  Third, screening for STDs must take into account sexual behaviors.  Although urine-based screening has expanded testing of young people, it misses anal and pharyngeal infections.  If a young person is only having receptive oral or anal intercourse, urine screening is insufficient to rule out STDs.  Fourth, this young man had both localized and systemic symptoms.  As his anal symptoms were most suggestive of a current STD, performing an HIV test should be part of the standard evaluation.  In addition, as acute infection is on the differential diagnosis, PCR testing should also be considered.  The care provided to this young man included the following.  He was treated presumptively for proctitis with both IM ceftriaxone as well as oral doxycycline to treat N gonorrhoeae and C trachomatis.  Ceftriaxone was chosen due to the recent reports of resistant N gonorrhoeae.  At the time of the diagnosis, the young man was given the opportunity to meet with the case manager from the adolescent-specific HIV program.  The case manager linked this young man directly to care after providing brief counseling and support.  The case manager maintained contact with the young man until his first clinical visit four days later.  Over the subsequent three months, the young man had two sets of laboratory testing to stage his HIV infection.,Set #1 CD4 T-lymphocyte count = 225 cells/mm3, 15% ,Quantitative RNA PCR = 75,000 copies/mL",
 Nausea and feeling faint.  She complains of some nausea.  She feels weak.  The patient is advised to put salt on her food for the next week.  , Emergency Room Reports, Nausea - ER Visit ,"CHIEF COMPLAINT: , Nausea and feeling faint.,HPI:  ,The patient is a 74-year-old white female brought in by husband.  The patient is a vague historian at times.  She reports her appetite has been fair over the last several days.  Today, she complains of some nausea.  She feels weak.  No other specific complaints.,REVIEW OF SYSTEMS:  ,The patient denies fever, chills, sweats, ear pain, URI symptoms, cough, dyspnea, chest pain, vomiting, diarrhea, abdominal pain, melena, hematochezia, urinary symptoms, headache, neck pain, back pain, weakness or paresthesias in extremities.,CURRENT MEDICATIONS:  ,Diovan, estradiol, Norvasc, Wellbutrin SR inhaler, and home O2.,ALLERGIES: , MORPHINE CAUSES VOMITING.,PAST MEDICAL HISTORY:  ,COPD and hypertension.,HABITS:  ,Tobacco use, averages two cigarettes per day.  Alcohol use, denies.,LAST TETANUS IMMUNIZATION: , Not sure.,LAST MENSTRUAL PERIOD: , Status post hysterectomy.,SOCIAL HISTORY:  ,The patient is married and retired.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Temperature 98.2, pulse is 105, respirations 20, and BP 137/80.  GENERAL:  A well developed, well nourished, alert, cooperative, nontoxic, and appears hydrated.  SKIN:  Warm, dry, and good color.  EYES:  EOMI.  PERRL.  MOUTH:  Clear.  Mucous membranes moist.  NECK:  Supple.  No JVD.  LUNGS:  Reveal faint expiratory wheeze heard in the posterior lung fields.  HEART:  Slightly tachycardic without murmur.  ABDOMEN:  Soft, positive bowel sounds, and nontender.  No rebound or guarding is appreciated.  BACK:  No CVA tenderness.  EXTREMITIES:  Moves all four extremities.  No pretibial edema.  NEURO:  Cranial nerves II to XII, motor, and cerebellar are grossly intact and nonfocal.,LABORATORY STUDIES: , WBC 9200, differential with 82 neutrophils, 8 lymphocytes, 6 monocytes, and 4 eosinophils.  Hemoglobin 10.7 and hematocrit 31.2 both are decreased.  Comprehensive medical profile normal except for decreased sodium of 129, decreased chloride of 92, calcium decreased 8.4, total protein decreased 6.1, and albumin decreased 3.2.  Amylase and lipase both normal.  Clean catch urinalysis is unremarkable.  Review of EMR indicates on 05/09/06 hemoglobin was 12.1, on 05/10/07 hemoglobin was 9.9, and today hemoglobin is 10.7.  It seems to indicate that the patient had previous problems with anemia.,RADIOLOGY STUDIES: , Chest x-ray indicates chronic changes, reviewed by me, official report is pending.,ED STUDIES: , O2 sat on room air is 92%, which is satisfactory for this patient with COPD.  Monitor indicates sinus tachycardia at rate 103.  No ectopy.,ED COURSE:  ,The patient was assessed for orthostatic vital sign changes and none were detected by the nurse.  The patient was given albuterol unit dose small volume nebulizer treatment.  Repeat lung exam reveals resolution of expiratory wheezing.  The patient later had normal saline lock started by the nurse.  She was given IV fluids of normal saline 1L wide open over approximately one hour.  She was able to void urine indicating that she is well hydrated.  Rectal examination was performed with female nurse in attendance.  Good sphincter tone.  No masses.  The rectal secretions were heme negative.  The patient was reassessed.  She feels slightly better.  Monitor now shows normal sinus rhythm, rate 81, no ectopy.  Blood pressure is 136/66.  The patient is stable and will be discharged.,MEDICAL DECISION MAKING: , This patient presents with the above history.  Laboratory evaluation today indicates the following problems, anemia and hyponatremia.  This could contribute the patient's feelings of tiredness and not feeling well.  There is no evidence of rectal bleeding at this time.  The patient was advised that she needs to follow up with Dr. X to further investigate these problems.  The patient is hemodynamically stable and will be discharged.,ASSESSMENT:,1.  Acute tiredness.,2.  Anemia of unknown etiology.,3.  Acute hyponatremia.,PLAN:  ,The patient is advised to put salt on her food for the next week.  Should be given discharge instruction sheet for anemia.  Recommend follow up with personal physician, Dr. X in two to three days for recheck.  Return to ED sooner if condition changes or worsen anyway.  Discharged in stable condition.",
 Penile injury and continuous bleeding from a penile laceration., Emergency Room Reports, Penile Injury ,"REASON FOR ADMISSION:,  Penile injury and continuous bleeding from a penile laceration.,HISTORY OF PRESENT ILLNESS:,  The patient is an 18-year-old detainee who was brought by police officers because of a penile injury and bleeding.  He is otherwise healthy.  He tried to insert a marble in his penis four days ago.  He told me that he grabbed the skin on the top of the penis and moved it away from the penis shaft and then using a toothbrush that he made in to a knife object he pierced the skin through from both sides and then kept moving the toothbrush to dilate and make a way for the marble.  Then he inserted a heart-shaped marble in one of the puncture wounds and inserted it under the skin and kept it there.  He was not significantly bleeding and essentially the bleeding stopped from both puncture wounds that he has.  Then today four days after that procedure, he was taking a bath today and he thinks because of the weight he felt a gush in his pants and he looked and he saw the bleeding come out.  He was bleeding so much that he started dripping to the sides of his legs.  So, he was brought to the hospital.  Actually after being seen by two nurses at the facility where he was at the detention center where he was at and they actually did the dressing twice and it was twice soaked with blood.  He came here and was continuously bleeding from that area that we had to change the dressing twice and he is actually still bleeding especially from one of the laceration, the one on the right side of the penis.  The marble also still can be felt underneath the skin.  There is no urethral bleeding.  He did urinate today without difficulty, without hematuria or dysuria.  There is pain in the lacerations.  No erythema in the skin or swelling in the penis and no other injuries.  He did this procedure for sexual pleasure as he said.,PAST MEDICAL HISTORY: , Unremarkable.,PAST SURGICAL HISTORY:  ,Tonsillectomy.,MEDICATION: , He took only ibuprofen.  No regular medication.,ALLERGIES: , None.,SOCIAL HISTORY:  ,He has been in detention for two months for immigration problems.  No drugs.  No alcohol.  No smoking.  He used to work in fast food chain.,FAMILY HISTORY: , Noncontributory to this illness.,REVIEW OF SYSTEMS: , Aside from the pain in the penis and continuous bleeding, he is basically asymptomatic and review of systems is unremarkable.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a young Hispanic male, lying in bed, appear comfortable in no apparent distress.,VITAL SIGNS:  Temperature 97.8, heart rate 99, respiratory rate 20, blood pressure 142/100, and saturation is 98% on room air.,ENT:  Sclerae nonicteric.  Pupils reactive to light.  Nostrils are normal.  Oral cavity is clear.,NECK:  Supple.  Trachea midline.  No JVD.,LUNGS:  Clear to auscultation bilaterally.,HEART:  Normal S1 and S2.  No murmurs or gallops.,ABDOMEN:  Soft, nontender, and nondistended.  Positive bowel sounds.,EXTREMITIES:  Pulses strong bilaterally.  No edema.,GENITAL:  Testicles appear normal.  The penis shaft has two lacerations on both sides, one of them is bleeding.  They measure about 5 to 6 mm on the right side, about 3 or 4 mm on the left side.  The one on the right side is bleeding much more than the other one.  There is a marble that can be felt and it is freely mobile underneath the skin of the dorsum of the penis.  There is no bleeding from the meatus or discharge and no other injuries were seen by inspection.,LABORATORY DATA:,  White count 11.1, hemoglobin 14.5, hematocrit 43.5, and platelets 303,000.  Coags unremarkable.  Glucose 106, creatinine 0.8, sodium 141, potassium 4, and calcium 9.7.  Urinalysis unremarkable.,IMPRESSION: , The patient with a penile laceration that is continuously bleeding from inserting a marble four days ago, which is still underneath the skin of the shaft of the penis.  No other injuries that can be seen and no other evidence of secondary bacterial infection at this time.  The patient is currently refusing removal of the marble and insisting on just repairing the laceration and he is having discussion with Dr. X.,PLAN:,1.  The patient will be admitted to the hospital and will follow Dr. X's recommendation.,2.  The patient was offered a repair of those lacerations, to stop the bleeding as well as the removal of the marble and he is currently considering that and discussing that with Dr. X.,3.  Prophylactic antibiotics to prevent infection.,4.  He has mild hypertension, which is likely due to stress and pain and also the leukocytosis probably can be explained by that.  This will be monitored.,5.  Monitor H&H to determine if he needs any transfusion at this time.  He does not need that.,6.  IV fluid for hydration and volume resuscitation at this time.,7.  Pain management.,8.  Topical care for the wound VAC after repair.,Time spent in evaluation and management of this patient including discussions about this procedure and the harm that can happen if he chooses to keep the penis including permanent damage and infection to the penis was 65 minutes.,I had clearly explained to the patient in detail about the possibility of permanent penile damage that could affect erection and future sexual functioning as well as significant infection if a foreign object was retained in the penis under the skin and he verbalized understanding of this.",
 Complete heart block with pacemaker malfunction and  a history of Shone complex., Emergency Room Reports, Shone complex ,"HISTORY AND PHYSICAL:  ,The patient is a 13-year-old, who has a history of Shone complex and has a complete heart block.  He is on the pacemaker.  He had a coarctation of the aorta and that was repaired when he was an infant.  He was followed in our Cardiology Clinic here and has been doing well.  However last night, he was sleeping, and he states he felt as if he has having a dream, and there was thunder in this dream, which woke him up.  He then felt that his defibrillator was going off and this has continued and feels like his heart rate is not normal.  Thus, his dad put him in the car and transported him here.  He has been evaluated here.  He had some scar tissue at one point when the internal pacemaker was not working properly and had to have that replaced.  It was 2 a.m. when he woke, and again, he was brought here by private vehicle.  He was well prior to going to bed.  No cough, cold, runny nose, fever.  No trauma has been noted.,PAST MEDICAL HISTORY:,  Shone complex, pacemaker dependent.,MEDICATIONS: , He is on no medications at this time.,ALLERGIES:,  He has no allergies.,IMMUNIZATIONS:,  Up to date.,SOCIAL HISTORY: , He lives with his parents.,FAMILY HISTORY: , Negative.,REVIEW OF SYSTEM: , Twelve asked, all negative, except as noted above.,PHYSICAL EXAMINATION:,GENERAL:  This is an awake, alert male, who appears to be in mild distress.,HEENT:  Pupils are equal, round, and reactive to light.  Extraocular movements are intact.  His TMs are clear.  His nares are clear.  The mucous membranes are pink and moist.  Throat is clear.,NECK:  Supple without lymphadenopathy or masses.  Trachea is midline.,LUNGS:  Clear.,HEART:  Shows bradycardia at 53.  He has good distal pulses.,ABDOMEN:  Soft, nontender.  Positive bowel sounds.  No guarding, no rebound.  No rashes are seen.,HOSPITAL COURSE:,  Initial blood pressure is 164/90.  He was moved in room 1.  He was placed on nasal cannula.  Pulse ox was 100%, which is normal.  We placed him on a monitor.  We did an EKG; it has not appear to be capturing his pacemaker at this time.  Shortly after the patient's arrival, the Medtronic technician came and worked out his pacemaker.  Medtronic representative informed me that the lead that he has in place has been recalled because it has been prone to microfractures, oversensing, and automatic defibrillation.  As noted, he was transferred to room 1, placed on a monitor, pulse ox.  An IV was placed.  A standard blood work was sent.  A chest x-ray was done showing normal heart size, lead appeared to be in placed.  There was no evidence of pulmonary edema.  His pacemaker did not appear to be capturing.  We placed him on transthoracic leads.  However, it is difficult to get good placement with these because of the area where his pacemaker was placed.  The Medtronic technician initially turned off his defibrillation mode and turned down his sensor.  However, we could not get our transthoracic pacer to capture his heart.  When the Medtronic representative turned off the pacemaker, the heart rate seemed to drop into the 40s.  The patient appeared to be in pain.  We placed it back on a rate of 60 at that time.  He has remained in sinus bradycardia, but no evidence of ectopic beats.  No widening of his QRS complex.  I spoke with Cardiology.  Cardiology service has come in, has evaluated him at bedside with me.  Again, we turned up the transthoracic pacer, but it is again not seem to be picking up, and his heart rate is still going with the Medtronic's internal pacemaker.  So with the ICU physician on call, Dr. X, he has agreed with taking this young man to the ICU.,An hour after presentation here, the ICU was ready for bed.  I accompanied the patient up to the ICU.  He remained awake and alert.  Initially, he was complaining of a lot of chest pain.  Once the defibrillator was turned off, he had no more pain.  He was transported to the Pediatrics PICU and delivered in stable condition.,LABORATORY DATA: , CBC was normal.  Chem-20 was normal as well.,IMPRESSION:  ,Complete heart block with pacemaker malfunction.,PLAN:  ,He is admitted to the ICU.,TIME SEEN: , Critical care time outside billable procedures was 45 minutes with this patient.  I should note that a 12-lead EKG was done here showing sinus bradycardia, normal intervals otherwise.",
 Methicillin-resistant Staphylococcus aureus (MRSA) infection.  A 14-day-old was seen by private doctor because of blister. , Emergency Room Reports, MRSA Infection - ER Visit ,"HISTORY OF PRESENT ILLNESS:,  A 14-day-old was seen by private doctor because of blister.  On Friday, she was noted to have a small blister near her umbilicus.  They went to their doctor on Saturday, culture was drawn.  It came back today, growing MRSA.  She has been doing well.  They put her on bacitracin ointment near the umbilicus.  That has about healed up.  However today, they noticed a small blister on her left temporal area.  They called the private doctor.  They direct called the Infectious Disease doctor here and was asked that they come into the hospital.  Mom states she has been diagnosed with MRSA on her buttocks as well and is on some medications.  The child has not had any fever.  She has not been lethargic or irritable.  She has been eating well up to 2 ounces every feed.  Eating well and sleeping well.  No other changes have been noted.,PAST MEDICAL HISTORY:,  She was born full term.  No complications.  Home with mom.  No hospitalization, surgeries, allergies.,MEDICATIONS: , As noted.,IMMUNIZATIONS: , Up-to-date.,FAMILY HISTORY: , Negative.,SOCIAL HISTORY: , No ill contacts.  No travel or changes in living condition.,REVIEW OF SYSTEMS:  ,Ten systems were asked, all of them were negative except as noted above.,PHYSICAL EXAMINATION:  ,GENERAL:  Awake, alert female, no acute distress at this time.,HEENT:  Fontanelle soft and flat.  PERRLA.  EOMI.  Conjunctivae are clear.  TMS are clear.  Nares are clear.  Mucous membranes pinks and moist.  Throat clear.  No oral lesions.,NECK:  Supple.,LUNGS:  Clear.,HEART:  Regular rate and rhythm.  Normal S1, S2.  No murmur.,ABDOMEN:  Soft, nontender.  Positive bowel sounds.  No guarding, no rebound.  No rashes seen.,EXTREMITIES:  Capillary refill is brisk.  Good distal pulses.,NEUROLOGIC:  Cranial nerves II through XII intact.  5/5 strength in all extremities.,SKIN:  Her umbilicus looks completely clear.  There is no evidence of erythema.  The area that the parents point where the blister was, appears to be well healed.  There is no evidence of lesion noted, at this time.  On her left temple area and just inside her hairline, there is a small vesicle.  It is not a pustule.  It is almost flat and it has minimal fluid underneath that.  There is no surrounding erythema, tenderness.  I have inspected the body, head to toe.  No other areas of lesions seen.,EMERGENCY DEPARTMENT COURSE: , I spoke with Infectious Disease, Dr. X.  He states, we should treat for MRSA with Bactrim p.o.  There has been no evidence of jaundice with this little girl.  Hibiclens and Bactroban.  I spoke with Dr. X's associate to call back after Dr. X recommended a Herpes culture be done, just for completeness and that was done.  Blood culture was done here to make sure she did not have MRSA in her blood, which clinically, she does not appear to have.  She was discharged in stable condition.,IMPRESSION: , Methicillin-resistant Staphylococcus aureus infection.,PLAN: ,  MRSA Instructions were given as above and antibiotics were prescribed.  To follow up with their doctor.",
" Multiple contusions and abdominal pain, status post motor vehicle collision. ", Emergency Room Reports, Motor Vehicle Accident ,"CHIEF COMPLAINT: , Motor vehicle accident.,HISTORY OF PRESENT ILLNESS: , This is a 32-year-old Hispanic female who presents to the emergency department today via ambulance.  The patient was brought by ambulance following a motor vehicle collision approximately 45 minutes ago.  The patient states that she was driving her vehicle at approximately 40 miles per hour.  The patient was driving a minivan.  The patient states that the car in front of her stopped too quickly and she rear-ended the vehicle ahead of her.  The patient states that she was wearing her seatbelt.  She was driving.  There were no other passengers in the van.  The patient states that she was restrained by the seatbelt and that her airbag deployed.  The patient denies hitting her head.  She states that she does have some mild pain on the left aspect of her neck.  The patient states that she believes she may have passed out shortly after the accident.  The patient states that she also has some pain low in her abdomen that she believes is likely due to the steering wheel or deployment on the airbag.  The patient denies any pain in her knees, ankles, or feet.  She denies any pain in her shoulders, elbows, and wrists.  The patient does state that she is somewhat painful throughout the bones of her pelvis as well.  The patient did not walk after this accident.  She was removed from her car and placed on a backboard and immobilized.  The patient denies any chest pain or difficulty breathing.  She denies any open lacerations or abrasions.  The patient has not had any headache, nausea or vomiting.  She has not felt feverish or chilled.  The patient does states that there is significant deformity to the front of the vehicle that she was driving, which again was a minivan.  There were no oblique vectors or force placed on this accident.  The patient had straight rear-ending of the vehicle in front of her.  The pain in her abdomen is most significant pain currently and she ranks it at 5 out of 10.  The patient states that her last menstrual cycle was at the end of May.  She does not believe that she could be pregnant.  She is taking oral birth control medications and also has an intrauterine device to prevent pregnancy as the patient is on Accutane.,PAST MEDICAL HISTORY:,  No significant medical history other than acne.,PAST SURGICAL HISTORY:,  None.,SOCIAL HABITS: ,  The patient denies tobacco, alcohol or illicit drug usage.,MEDICATIONS:,  Accutane.,ALLERGIES: , No known medical allergies.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL:  This is a Hispanic female who appears her stated age of 32 years.  She is well-nourished, well-developed, in no acute distress.  The patient is pleasant.  She is immobilized on a backboard and also her cervical spine is immobilized as well on a collar.  The patient is without capsular retractions, labored respirations or accessory muscle usage.  She responds well and spontaneously.,VITAL SIGNS:  Temperature 98.2 degrees Fahrenheit, blood pressure 129/84, pulse 75, respiratory rate 16, and pulse oximetry 97% on room air.,HEENT:  Head is normocephalic.  There is no crepitus.  No bony step-offs.  There are no lacerations on the scalp.  Sclerae are anicteric and noninjected.  Fundoscopic exam appears normal without papilledema.  External ocular movements are intact bilaterally without nystagmus or entrapment.  Nares are patent and free of mucoid discharge.  Mucous membranes are moist and free of exudate or lesions.,NECK:  Supple.  No thyromegaly.  No JVD.  No carotid bruits.  Trachea is midline.  There is no stridor.,HEART:  Regular rate and rhythm.  Clear S1 and S2.  No murmur, rub or gallop is appreciated.,LUNGS:  Clear to auscultation bilaterally.  No wheezes, rales, or rhonchi.,ABDOMEN:  Soft, nontender with the exception of mild-to-moderate tenderness in the bilateral lower pelvic quadrants.  There is no organomegaly here.  Positive bowel sounds are auscultated throughout.  There is no rigidity or guarding.  Negative CVA tenderness bilaterally.,EXTREMITIES:  No edema.  There are no bony abnormalities or deformities.,PERIPHERAL VASCULAR:  Capillary refill is less than two seconds in all extremities.  The patient does have intact dorsalis pedis and radial pulses bilaterally.,PSYCHIATRIC:  Alert and oriented to person, place, and time.  The patient recalls all events regarding the accident today.,NEUROLOGIC:  Cranial nerves II through XII are intact bilaterally.  No focal deficits are appreciated.  The patient has equal and strong distal and proximal muscle group strength in all four extremities.  The patient has negative Romberg and negative pronator drift.,LYMPHATICS:  No appreciable adenopathy.,MUSCULOSKELETAL:  The patient does have pain free range of motion at the bilateral ankles, bilateral knees, bilateral hips, bilateral shoulders, bilateral elbows, and bilateral wrists.  There are no bony abnormalities identified.  The patient does have some mild tenderness over palpation of the bilateral iliac crests.,SKIN:  Warm, dry, and intact.  No lacerations.  There are no abrasions other than a small abrasion on the patient's abdomen just inferior to the umbilicus.  No lacerations and no sites of trauma or bleeding are identified.,DIAGNOSTIC STUDIES: , The patient does have multiple x-rays done.  There is an x-ray of the pelvis, which shows normal pelvis and right hip.  There is also a CT scan of the cervical spine that shows no evidence of acute traumatic bony injury of the cervical spine.  There is some prevertibral soft tissue swelling from C5 through C7.  This is nonspecific and could be due to prominence of upper esophageal sphincter.  The CT scan of the brain without contrast shows no evidence of acute intracranial injury.  There is some mucus in the left sphenoid sinus.  The patient also has emergent CT scan without contrast of the abdomen.  The initial studies show some dependent atelectasis in both lungs.  There is also some low density in the liver, which could be from artifact or overlying ribs; however, a CT scan with contrast is indicated.  A CT scan with contrast is obtained and this is found to be normal without bleeding or intraabdominal or pelvic abnormalities.  The patient has laboratory studies done as well.  CBC is within normal limits without anemia, thrombocytopenia or leukocytosis.  The patient has a urine pregnancy test, which is negative and urinalysis shows no blood and is normal.,EMERGENCY DEPARTMENT COURSE: , The patient was removed from the backboard within the first half hour of her emergency department stay.  The patient has no significant bony deformities or abnormalities.  The patient is given a dose of Tylenol here in the emergency department for treatment of her pain.  Her pain is controlled with medication and she is feeling more comfortable and removed from the backboard.  The patient's CT scans of the abdomen appeared normal.  She has no signs of bleeding.  I believe, she has just a contusion and abrasion to her abdomen from the seatbelt and likely from the airbag as well.  The patient is able to stand and walk through the emergency department without difficulty.  She has no abrasions or lacerations.,ASSESSMENT AND PLAN:,  Multiple contusions and abdominal pain, status post motor vehicle collision.  Plan is the patient does not appear to have any intraabdominal or pelvic abnormities following her CT scans.  She has normal scans of the brain and her C-spine as well.  The patient is in stable condition.  She will be discharged with instructions to return to the emergency department if her pain increases or if she has increasing abdominal pain, nausea or vomiting.  The patient is given a prescription for Vicodin and Flexeril to use it at home for her muscular pain.",
 She is a 28-year-old G1 at approximately 8 plus weeks presented after intractable nausea and vomiting with blood-tinged vomit starting approximately worse over the past couple of days.  This is patient's fourth trip to the emergency room and second trip for admission., Emergency Room Reports, Nausea & Vomiting - ER Visit ,"HISTORY OF PRESENT ILLNESS: , She is a 28-year-old G1 at approximately 8 plus weeks presented after intractable nausea and vomiting with blood-tinged vomit starting approximately worse over the past couple of days.  This is patient's fourth trip to the emergency room and second trip for admission.,PAST MEDICAL HISTORY: , Nonsignificant.,PAST SURGICAL HISTORY: , None.,SOCIAL HISTORY: , No alcohol, drugs, or tobacco.,PAST OBSTETRICAL HISTORY:  ,This is her first pregnancy.,PAST GYNECOLOGICAL HISTORY: , Not pertinent.,While in the emergency room, the patient was found to have slight low sodium, potassium slightly elevated and her ALT of 93, AST of 35, total bilirubin is 1.2.  Her urine was 3+ ketones, 2+ protein, and 1+ esterase, and rbc too numerous to count with moderate amount of bacteria.  H and H stable at 14.1 and 48.7.  She was then admitted after giving some Phenergan and Zofran IV.  As started on IV, given hydration as well as given a dose of Rocephin to treat bladder infection.  She was admitted overnight, nausea and vomiting resolved to only one episode of vomiting after receiving Maalox, tolerated fluids as well as p.o. food.  Followup chemistry was obtained for AST, ALT and we will plan for discharge if lab variables resolve.,ASSESSMENT AND PLAN:,1.  This is a 28-year-old G1 at approximately 8 to 9 weeks gestation with one hyperemesis gravidarum admit for IV hydration and followup.,2.  Slightly elevated ALT, questionable, likely due to the nausea and vomiting.  We will recheck for followup.","emergency room reports, iv hydration, elevated alt, emergency, nausea, vomiting,"
" Patient started out having toothache, now radiating into his jaw and towards his left ear.  Ellis type II dental fracture.", Emergency Room Reports, Jaw Pain - ER Visit ,"CHIEF COMPLAINT: , Jaw pain.,HISTORY OF PRESENT ILLNESS:  ,This is a 58-year-old male who started out having toothache in the left lower side of the mouth that is now radiating into his jaw and towards his left ear.  Triage nurse reported that he does not believe it is his tooth because he has regular dental appointments, but has not seen a dentist since this new toothache began.  The patient denies any facial swelling.  No headache.  No swelling to the throat.  No sore throat.  No difficulty swallowing liquids or solids.  No neck pain.  No lymph node swelling.  The patient denies any fever or chills.  Denies any other problems or complaints.,REVIEW OF SYSTEMS:,  CONSTITUTIONAL:  No fever or chills.  No fatigue or weakness.  HEENT:  No headache.  No neck pain.  No eye pain or vision change.  No rhinorrhea.  No sinus congestion, pressure, or pain.  No sore throat.  No throat swelling.  The patient does have the toothache on the left lower side that radiates towards his left ear as previously described.  The patient does not have ear pain or hearing change.  No pressure in the ear.  CARDIOVASCULAR:  No chest pain.  RESPIRATIONS:  No shortness of breath.  GASTROINTESTINAL:  No nausea or vomiting.  No abdominal pain.  MUSCULOSKELETAL:  No back pain.  SKIN:  No rashes or lesions.  NEUROLOGIC:  No vision or hearing change.  No speech change.  HEMATOLOGIC/LYMPHATIC:  No lymph node swelling.,PAST MEDICAL HISTORY: , None.,PAST SURGICAL HISTORY:,  None.,CURRENT MEDICATIONS: , None.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient smokes marijuana.  The patient does not smoke cigarettes.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Temperature 98.2 oral, blood pressure is 168/84, pulse is 87, respirations 16, and oxygen saturation is 100% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished, well developed.  The patient appears to be healthy.  The patient is calm, comfortable in no acute distress, looks well.  The patient is pleasant and cooperative.  HEENT:  Head is atraumatic, normocephalic, and nontender.  Eyes are normal with clear cornea and conjunctivae bilaterally.  Nose, normal without rhinorrhea or audible congestion.  There is no tenderness over the sinuses.  Ears are normal without any sign of infection.  No erythema or swelling of the canals.  Tympanic membranes are intact and normal without any erythema, bulging, air fluid levels, or bubbles behind it.  MOUTH:  The patient has a dental fracture at tooth #18.  The patient states that the fracture is a couple of months old.  The patient does not have any obvious dental caries.  The gums are normal without any erythema, swelling, or evidence of infection.  There is no fluctuance or suggestion of abscess.  There is slight tenderness of the tooth #18.  The oropharynx is normal without any sign of infection.  There is no erythema, exudate, lesion, or swelling.  Mucous membranes are moist.  Floor of the mouth is normal without any tenderness or swelling.  No suggestion of abscess.  There is no pre or post auricular lymphadenopathy either.  NECK:  Supple.  Nontender.  Full range of motion.  No meningismus.  No cervical lymphadenopathy.  No JVD.  No carotid artery or vertebral artery bruits.  CARDIOVASCULAR:  Heart is regular rate and rhythm without murmur, rub, or gallop.  RESPIRATIONS:  Clear to auscultation bilaterally.  No shortness of breath.  GASTROINTESTINAL:  Abdomen is normal and nontender.  MUSCULOSKELETAL:  No abnormalities are noted to the back, arms, or legs.  The patient has normal use of the extremities.  SKIN:  No rashes or lesions.  NEUROLOGIC:  Cranial nerves II through XII are intact.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is alert and oriented x4.  Normal mood and affect.  No evidence of clinical intoxification.  HEMATOLOGIC/LYMPHATIC:  No lymphadenitis is palpated.,DIAGNOSES:,1.  ACUTE LEFT JAW PAIN.,2.  #18 DENTAL FRACTURE, WHICH IS AN ELLIS TYPE II FRACTURE.,3.  ELEVATED BLOOD PRESSURE.,CONDITION UPON DISPOSITION: , Stable.,DISPOSITION:,  Home.,PLAN: , We will have the patient follow up with his dentist Dr. X in three to five days for reevaluation.  The patient was encouraged to take Motrin 400 mg q.6h. as needed for pain.  The patient was given prescription for Vicodin for any breakthrough or uncontrolled pain.  He was given precautions for drowsiness and driving with the use of this medication.  The patient was also given a prescription for pen V.  The patient was given discharge instructions on toothache and asked to return to emergency room should he have any worsening of his condition, develop any other problems or symptoms of concern.","emergency room reports, jaw pain, dental appointment, ellis type ii fracture, ellis type, dental fracture, toothache, tenderness, pressure, erythema, "
" Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath. ", Emergency Room Reports, Melena - ICU Followup ,"HISTORY:,  Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath.  Please see dictated ICU transfer note yesterday detailing the need for emergent transfer transfusion and EGD in this patient.  Over the last 24 hours, the patient has received 2 units of packed red blood cells and his hematocrit and hemoglobin have returned to their baseline of approximately 11 appropriate for hemoglobin value.  He also underwent EGD earlier today with Dr. X.  I have discussed the case with him at length earlier this afternoon and the patient had symptoms of ulcerative esophagitis with no active bleeding.  Dr. X recommended to increase the doses of his proton pump inhibitor and to avoid NSAIDs in the future.  The patient today complains that he is still having issues with shortness of breath and wheezing and productive cough, now producing yellow-brown sputum with increasing frequency, but he has had no further episodes of melena since transfer to the ICU.  He is also complaining of some laryngitis and some pharyngitis, but is denying any abdominal complaints, nausea, or diarrhea.,PHYSICAL EXAMINATION,VITAL SIGNS:  Blood pressure is 100/54, heart rate 80 and temperature 98.8.  Is and Os negative fluid balance of 1.4 liters in the last 24 hours.,GENERAL:  This is a somnolent 68-year-old male, who arouses to voice, wakes up, seems to have good appetite, has continuing cough.  Pallor is improved.,EYES:  Conjunctivae are now pink.,ENT:  Oropharynx is clear.,CARDIOVASCULAR:  Reveals distant heart tones with regular rate and rhythm.,LUNGS:  Have coarse breath sounds with wheezes, rhonchi, and soft crackles in the bases.,ABDOMEN:  Soft and nontender with no organomegaly appreciated.,EXTREMITIES:  Showed no clubbing, cyanosis or edema.  Capillary refill time is now normal in the fingertips.,NEUROLOGICAL:  Cranial nerves II through XII are grossly intact with no focal neurological deficits.,LABORATORY DATA:,  Laboratories drawn at 1449 today, WBC 10, hemoglobin and hematocrit 11.5 and 33.1, and platelets 288,000.  This is up from 8.6 and 24.7.  Platelets are stable.  Sodium is 134, potassium 4.0, chloride 101, bicarb 26, BUN 19, creatinine 1.0, glucose 73, calcium 8.4, INR 0.96, iron 13%, saturations 4%, TIBC 312, TSH 0.74, CEA elevated at 8.6, ferritin 27.5 and occult blood positive.  EGD, final results pending per Dr. X's note and conversation with me earlier, ulcerative esophagitis without signs of active bleeding at this time.,IMPRESSION/PLAN,1.  Melena secondary to ulcerative esophagitis.  We will continue to monitor the patient overnight to ensure there is no further bleeding.  If there are no further episodes of melena and hemoglobin is stable or unchanged in the morning, the patient will be transferred back to medical floor for continuing treatment of his chronic obstructive pulmonary disease exacerbation.,2.  Chronic obstructive pulmonary disease exacerbation.  The patient is doing well, taking PO.  We will continue him on his oral Omnicef and azithromycin and continuing breathing treatments.  We will add guaifenesin and N-acetyl-cysteine in a hope to mobilize some of his secretions.  This does appear to be improving.  His white count is normalized and I am hopeful we can discharge him on oral antibiotics within the next 24 to 48 hours if there are no further complications.,3.  Elevated CEA.  The patient will need colonoscopy on an outpatient basis.  He has refused this today.  We would like to encourage him to do so.  Of note, the patient when he came in was on bloodless protocol, but with urging did accept the transfusion.  Similarly, I am hoping that with proper counseling, the patient will consent to further examination with colonoscopy given his guaiac-positive status, elevated CEA and risk factors.,4.  Anemia, normochromic normocytic with low total iron binding capacity.  This appears to be anemia of chronic disease.  However, this is likely some iron deficiency superimposed on top of this given his recent bleeding, with consider iron, vitamin C, folate and B12 supplementation and discharge given his history of alcoholic malnutrition and recent gastrointestinal bleeding.  Total critical care time spent today discussing the case with Dr. X, examining the patient, reviewing laboratory trends, adjusting medications and counseling the patient in excess is 35 minutes.","emergency room reports, anemia, gi bleeding, hemoglobin, ulcerative, esophagitis, obstructive pulmonary disease, icu followup, infection, obstructive, pulmonary, egd, melena, bleeding"
 Patient presents to the Emergency Department with complaint of a bleeding bump on his penis., Emergency Room Reports, Penile Mass - Emergency Visit ,"CHIEF COMPLAINT: , ""Bloody bump on penis."",HISTORY OF PRESENT ILLNESS: , This is a 29-year-old African-American male who presents to the Emergency Department today with complaint of a bleeding bump on his penis.  The patient states that he has had a large bump on the end of his penis for approximately a year and a half.  He states that it has never bled before.  It has never caused him any pain or has never been itchy.  The patient states that he is sexually active, but has been monogamous with the same person for the past 13 years.  He states that he believes that his sexual partner is monogamous as well and reciprocates in this practice.  The patient does state that last night he was ""trying to get some,"" meaning that he was engaging in sexual intercourse, at which time this bump bent backwards and ripped a portion of the skin on the tip of his penis.  The patient said that there is a large amount of blood from this injury.  This happened last night, but he was embarrassed to come to the Emergency Department yesterday when it was bleeding.  The patient has been able to get the bleeding to stop, but the large bump is still located on the end of his penis, and he is concerned that it will rip off, and does want it removed.  The patient denies any drainage or discharge from his penis.  He denies fevers or chills recently.  He also denies nausea or vomiting.  The patient has not had any discharge from his penis.  He has not had any other skin lesions on his penis that are new to him.  He states that he has had numerous bumps along the head of his penis and on the shaft of his penis for many years.  The patient has never had these checked out.  He denies fevers, chills, or night sweats.  He denies unintentional weight gain or loss.  He denies any other bumps, rashes, or lesions throughout the skin on his body.,PAST MEDICAL HISTORY:  ,No significant medical problems.,PAST SURGICAL HISTORY: , Surgery for excision of a bullet after being shot in the back.,SOCIAL HABITS: , The patient denies illicit drug usage.  He occasionally smokes tobacco and drinks alcohol.,MEDICATIONS: , None.,ALLERGIES: , No known medical allergies.,PHYSICAL EXAMINATION:  ,GENERAL:  This is an African-American male who appears his stated age of 29 years.  He is well nourished, well developed, in no acute distress.  The patient is pleasant.  He is sitting on a Emergency Department gurney.,VITAL SIGNS:  Temperature 98.4 degrees Fahrenheit, blood pressure of 139/78, pulse of 83, respiratory rate of 18, and pulse oximetry of 98% on room air.,HEART:  Regular rate and rhythm.  Clear S1, S2.  No murmur, rub, or gallop is appreciated.,LUNGS:  Clear to auscultation bilaterally.  No wheezes, rales, or rhonchi.,ABDOMEN:  Soft, nontender, nondistended, and positive bowel sounds throughout.,GENITOURINARY:  The patient's external genitalia is markedly abnormal.  There is a large pedunculated mass dangling from the glans of the penis at approximately the urethral meatus.  This pedunculated mass is approximately 1.5 x 2 cm in size and pedunculated by a stalk that is approximately 2 mm in diameter.  The patient appears to have condylomatous changes along the glans of the penis and on the shaft of the penis as well.  There are no open lesions at this point.  There is a small tear of the skin where the mass attaches to the glans near the urethral meatus.  Bleeding is currently stanch, and there is no sign of secondary infection at this time.  Bilateral testicles are descended and normal without pain or mass bilaterally.  There is no inguinal adenopathy.,EXTREMITIES:  No edema.,SKIN:  Warm, dry, and intact.  No rash or lesion.,DIAGNOSTIC STUDIES:  ,Non-emergency department courses.  It is thought that this patient should proceed directly with a referral to Urology for excision and biopsy of this mass.,ASSESSMENT AND PLAN: , Penile mass.  The patient does have a large pedunculated penile mass.  He will be referred to the urologist who is on-call today.  The patient will need this mass excised and biopsied.  The patient verbalized understanding the plan of followup and is discharged in satisfactory condition from the ER.,","emergency room reports, bump on penis, bleeding bump, glans, urethral meatus, penile mass, emergency department, penis, penile, pedunculated, bump, mass, "
" The patient is a 26-year-old gravida 2, para 1-0-0-1, at 28-1/7 weeks who presents to the emergency room with left lower quadrant pain, reports no bowel movement in two weeks as well as nausea and vomiting for the last 24 hours or so.  She states that she has not voided in the last 24 hours as well due to pain.", Emergency Room Reports, Left Lower Quadrant Pain - ER Visit ,"HISTORY OF PRESENT ILLNESS:,  The patient is a 26-year-old gravida 2, para 1-0-0-1, at 28-1/7 weeks who presents to the emergency room with left lower quadrant pain, reports no bowel movement in two weeks as well as nausea and vomiting for the last 24 hours or so.  She states that she has not voided in the last 24 hours as well due to pain.  She denies any leaking of fluid, vaginal bleeding, or uterine contractions.  She reports good fetal movement.  She denies any fevers, chills, or burning with urination.,REVIEW OF SYSTEMS: , Positive for back pain in her lower back only.  Her mother reports that she has been eating food without difficulty and that the current nausea and vomiting is much less than when she is not pregnant.  She continues to yell out for requesting pain medication and about how much ""it hurts."",PAST MEDICAL HISTORY:,1.  Irritable bowel syndrome.,2.  Urinary tract infections times three.  The patient is unsure if pyelo is present or not.,PAST SURGICAL HISTORY:,  Denies.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , Phenergan and Zofran twice a day.  Macrobid questionable.,GYN: , History of an abnormal Pap, group B within normal limits.  Denies any sexually transmitted diseases.,OB HISTORY: , G1 is a term spontaneous vaginal delivery without complications, now a 6-year-old.  G2 is current.  Gets her care at Lyndhurst.,SOCIAL HISTORY: , Denies tobacco and alcohol use.  She endorses marijuana use and a history of cocaine use five years ago.  Upon review of the Baptist lab systems, the patient has had multiple positive urine drug screens and as recently as February 2008 had a urine drug screen that was positive for benzodiazepines, barbiturates, opiates, and marijuana and as recently as 2005 with cocaine present as well.,PHYSICAL EXAM:,VITAL SIGNS:  Blood pressure 139/82, pulse 89, respirations 20, 98% on room air, 96 degrees Fahrenheit.  Fetal heart tones are 130s with moderate long-term variability.  No paper is available for the fetal heart monitor due to the misorder and audibly sounds reassuring.,GENERAL:  Appears sedated, trashing intermittently, and then falling asleep in mid sentence.,CARDIOVASCULAR:  Regular rate and rhythm.,PULMONARY:  Clear to auscultation bilaterally.,BACK:  Tender to palpation in her lower back bilaterally, but no CVA tenderness.,ABDOMEN:  Tender to palpation in left lower quadrant.  No guarding or rebound.  Normal bowel sounds.,EXTREMITIES:  Scar track marks from bilateral arms.,PELVIC:  External vaginal exam is closed, long, high, and posterior.  Stool was felt in the rectum.,LABS: , White count is 11.1, hemoglobin is 13.5, platelets are 279.  CMP is within normal limits with an AST of 17, ALT of 11, and creatinine of 0.6.  Urinalysis which is supposedly a cath specimen shows a specific gravity of 1.024, greater than 88 ketones, many bacteria, but no white blood cells or nitrites.,ASSESSMENT AND PLAN:  ,The patient is a 26-year-old gravida 2, para 1-0-0-1 at 28-1 weeks with left lower quadrant pain and likely constipation.  I spoke with Dr. X who is the physician on-call tonight, and he requests that she be transferred for continued fetal monitoring and further evaluation of this abdominal pain to Labor and Delivery.  Plans are made for transfer at this time.  This was discussed with Dr. Y who is in agreement with the plan.",
" Suspected mastoiditis ruled out, right acute otitis media, and severe ear pain resolving.  The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis.  ", Emergency Room Reports, Mastoiditis - Discharge Summary ,"DISCHARGE DIAGNOSES:  ,1.  Suspected mastoiditis ruled out.,2.  Right acute otitis media.,3.  Severe ear pain resolving.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis.  The child has had very severe ear pain and blood draining from the right ear.  The child had a temperature maximum of 101.4 in the ER.  The patient was admitted and started on IV Unasyn, which he tolerated well and required Morphine and Vicodin for pain control.  In the first 12 hours after admission, the patient's pain decreased and also swelling of his cervical area decreased.  The patient was evaluated by Dr. X from the ENT while in house.  After reviewing the CT scan, it was felt that the CT scan was not consistent with mastoiditis.  The child was continued on IV fluid and narcotics for pain as well as Unasyn until the time of discharge.  At the time of discharge his pain is markedly decreased about 2/10 and swelling in the area has improved.  The patient is also able to take p.o. well.,DISCHARGE PHYSICAL EXAMINATION:,GENERAL:  The patient is alert, in no respiratory distress.,VITAL SIGNS:  His temperature is 97.6, heart rate 83, blood pressure 105/57, respiratory rate 16 on room air.,HEENT:  Right ear shows no redness.  The area behind his ear is nontender.  There is a large posterior chains node that is nontender and the swelling in this area has decreased markedly.,NECK:  Supple.,CHEST:  Clear breath sounds.,CARDIAC:  Normal S1, S2 without murmur.,ABDOMEN:  Soft.  There is no hepatosplenomegaly or tenderness.,SKIN:  Warm and well perfused.,DISCHARGE WEIGHT: , 38.7 kg.,DISCHARGE CONDITION: , Good.,DISCHARGE DIET:,  Regular as tolerated.,DISCHARGE MEDICATIONS:  ,1.  Ciprodex Otic Solution in the right ear twice daily.,2.  Augmentin 500 mg three times daily x10 days.,FOLLOW UP:  ,1.  Dr. Y in one week (ENT).,2.  The primary care physician in 2 to 3 days.,TIME SPENT: , Approximate discharge time is 28 minutes.", 
 This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms., Emergency Room Reports, Itchy Rash - ER Visit ,"CHIEF COMPLAINT:,  Itchy rash.,HISTORY OF PRESENT ILLNESS: , This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms.  No facial swelling.  No tongue or lip swelling.  No shortness of breath, wheezing, or other associated symptoms.  He cannot think of anything that could have triggered this off.  There have been no changes in his foods, medications, or other exposures as far as he knows.  He states a couple of days ago he did work and was removing some insulation but does not remember feeling itchy that day.,PAST MEDICAL HISTORY: , Negative for chronic medical problems.  No local physician.  Has had previous back surgery and appendectomy, otherwise generally healthy.,REVIEW OF SYSTEMS: , As mentioned denies any oropharyngeal swelling.  No lip or tongue swelling.  No wheezing or shortness of breath.  No headache.  No nausea.  Notes itchy rash, especially on his torso and upper arms.,SOCIAL HISTORY: , The patient is accompanied with his wife.,FAMILY HISTORY: , Negative.,MEDICATIONS: , None.,ALLERGIES: , TORADOL, MORPHINE, PENICILLIN, AND AMPICILLIN.,PHYSICAL EXAMINATION: , VITAL SIGNS:  The patient was afebrile.  He is slightly tachycardic, 105, but stable blood pressure and respiratory rate.  GENERAL:  The patient is in no distress.  Sitting quietly on the gurney.  HEENT:  Unremarkable.  His oral mucosa is moist and well hydrated.  Lips and tongue look normal.  Posterior pharynx is clear.  NECK:  Supple.  His trachea is midline.  There is no stridor.  LUNGS:  Very clear with good breath sounds in all fields.  There is no wheezing.  Good air movement in all lung fields.  CARDIAC:  Without murmur.  Slight tachycardia.  ABDOMEN:  Soft, nontender.  SKIN:  Notable for a confluence erythematous, blanching rash on the torso as well as more of a blotchy papular, macular rash on the upper arms.  He noted some on his buttocks as well.  Remaining of the exam is unremarkable.,ED COURSE: , The patient was treated with epinephrine 1:1000, 0.3 mL subcutaneously along with 50 mg of Benadryl intramuscularly.  After about 15-20 minutes he states that itching started to feel better.  The rash has started to fade a little bit and feeling a lot more comfortable.,IMPRESSION:,  ACUTE ALLERGIC REACTION WITH URTICARIA AND PRURITUS.,ASSESSMENT AND PLAN: , The patient has what looks to be some type of allergic reaction, although the underlying cause is difficult to assess.  He will make sure he goes home to look around to see if there is in fact anything that changed recently that could have triggered this off.  In the meantime, I think he can be managed with some antihistamine over-the-counter.  He is responding already to Benadryl and the epinephrine that we gave him here.  He is told that if he develops any respiratory complaints, shortness of breath, wheezing, or tongue or lip swelling he will return immediately for evaluation.  He is discharged in stable condition.","emergency room reports, urticaria, pruritus, lip swelling, allergic reaction, itchy rash, torso, swelling, itchy, rash, "
 Urine leaked around the ostomy site for his right sided nephrostomy tube.  The patient had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure., Emergency Room Reports, Leaking Nephrostomy Tube ,"CHIEF COMPLAINT:  ,Leaking nephrostomy tube.,HISTORY OF PRESENT ILLNESS: , This 61-year-old male was referred in today secondary to having urine leaked around the ostomy site for his right sided nephrostomy tube.  The leaking began this a.m.  The patient denies any pain, does not have fever and has no other problems or complaints.  The patient had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure.  The patient states he feels like his usual self and has no other problems or concerns.  The patient denies any fever or chills.  No nausea or vomiting.  No flank pain, no abdominal pain, no chest pain, no shortness of breath, no swelling to the legs.,REVIEW OF SYSTEMS: , Review of systems otherwise negative and noncontributory.,PAST MEDICAL HISTORY: , Metastatic prostate cancer, anemia, hypertension.,MEDICATIONS: , Medication reconciliation sheet has been reviewed on the nurses' note.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient is a nonsmoker.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Temperature 97.7 oral, blood pressure 150/85, pulse is 91, respirations 16, oxygen saturation 97% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished, well developed, appears to be healthy, calm, comfortable, no acute distress, looks well.  HEENT:  Eyes are normal with clear sclerae and cornea.  NECK:  Supple, full range of motion.  CARDIOVASCULAR:  Heart has regular rate and rhythm without murmur, rub or gallop.  Peripheral pulses are +2.  No dependent edema.  RESPIRATIONS:  Clear to auscultation bilaterally.  No shortness of breath.  No wheezes, rales or rhonchi.  Good air movement bilaterally.  GASTROINTESTINAL:  Abdomen is soft, nontender, nondistended.  No rebound or guarding.  Normal benign abdominal exam.  MUSCULOSKELETAL:  The patient has nontender back and flank.  No abnormalities noted to the back other than the bilateral nephrostomy tubes.  The nephrostomy tube left has no abnormalities, no sign of infection.  No leaking of urine, nontender, nephrostomy tube on the right has a damp dressing, which has a small amount of urine soaked into it.  There is no obvious active leak from the ostomy site.  No sign of infection.  No erythema, swelling or tenderness.  The collection bag is full of clear urine.  The patient has no abnormalities on his legs.  SKIN:  No rashes or lesions.  No sign of infection.  NEUROLOGIC:  Motor and sensory are intact to the extremities.  The patient has normal ambulation, normal speech.  PSYCHIATRIC:  Alert and oriented x4.  Normal mood and affect.  HEMATOLOGIC AND LYMPHATIC:  No bleeding or bruising.,EMERGENCY DEPARTMENT COURSE:,  Reviewed the patient's admission record from one month ago when he was admitted for the placement of the nephrostomy tubes, both Dr. X and Dr. Y have been consulted and both had recommended nephrostomy tubes, there was not the name mentioned as to who placed the nephrostomy tubes.  There was no consultation dictated for this and no name was mentioned in the discharge summary, paged Dr. X as this was the only name that the patient could remember that might have been involved with the placement of the nephrostomy tubes.  Dr. A responded to the page and recommended __________ off a BMP and discussing it with Dr. B, the radiologist as he recalled that this was the physician who placed the nephrostomy tubes, paged Dr. X and received a call back from Dr. X.  Dr. X stated that he would have somebody get in touch with us about scheduling a time for which they will change out the nephrostomy tube to a larger and check a nephrogram at that time that came down and stated that they would do it at 10 a.m. tomorrow.  This was discussed with the patient and instructions to return to the hospital at 10 a.m. to have this tube changed out by Dr. X was explained and understood.,DIAGNOSES:,1.  WEAK NEPHROSTOMY SITE FOR THE RIGHT NEPHROSTOMY TUBE.,2.  PROSTATE CANCER, METASTATIC.,3.  URETERAL OBSTRUCTION.,The patient on discharge is stable and dispositioned to home.,PLAN: , We will have the patient return to the hospital tomorrow at 10 a.m. for the replacement of his right nephrostomy tube by Dr. X.  The patient was asked to return in the emergency room sooner if he should develop any new problems or concerns.","emergency room reports, nephrostomy site, ureteral obstruction, leaking nephrostomy tube, acute renal failure, bilateral nephrostomy, ureteral obstructions, nephrostomy tube, tube, nephrostomy, ureteral, prostate, leaking, urine, tubes, "
" Headache, improved.  Intracranial aneurysm.", Emergency Room Reports, Intracranial aneurysm - ER Visit ,"CHIEF COMPLAINT:,  Headache.,HPI: , This is a 24-year-old man who was seen here originally on the 13th with a headache and found to have a mass on CT scan.  He was discharged home with a follow up to neurosurgery on the 14th.  Apparently, an MRI the next day showed that the mass was an aneurysm and he is currently scheduled for an angiogram in preparation for surgery.  He has had headaches since the 13th and complains now of some worsening of his pain.  He denies photophobia, fever, vomiting, and weakness of the arms or legs.,PMH: , As above.,MEDS:,  Vicodin.,ALLERGIES:,  None.,PHYSICAL EXAM:  ,BP 180/110 Pulse 65 RR 18 Temp 97.5.,Mr. P is awake and alert, in no apparent distress.,HEENT:  Pupils equal, round, reactive to light, oropharynx moist, sclera clear.  ,Neck:  Supple, no meningismus.,Lungs:  Clear.,Heart:  Regular rate and rhythm, no murmur, gallop, or rub.  ,Abdomen:  Benign.,Neuro:  Awake and alert, motor strength normal, no numbness, normal gait, DTRs normal.  Cranial nerves normal.  ,COURSE IN THE ED:  ,Patient had a repeat head CT to look for an intracranial bleed that shows an unchanged mass, no blood, and no hydrocephalus.  I recommended an LP but he prefers not to have this done.  He received morphine for pain and his headache improved.  I've recommended admission but he has chosen to go home and come back in the morning for his scheduled angiogram.  He left the ED against my advice.  ,IMPRESSION: , Headache, improved.  Intracranial aneurysm.,PLAN: , The patient will return tomorrow am for his angiogram.","emergency room reports, angiogram, mass, ct scan, intracranial aneurysm, headache, aneurysm, intracranial, "
" An 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation.", Emergency Room Reports, Hypertension - Consult ,"HISTORY OF PRESENT ILLNESS: , The patient is an 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation although not seen recently and I was asked to perform cardiology consultation for her because there was concern for atrial fibrillation after a fall.  Basically the patient states that yesterday she fell and she is not certain about the circumstances, on her driveway, and on her left side hit a rock.  When she came to the emergency room, she was found to have a rapid atrial tachyarrhythmia, and was put on Cardizem with reportedly heart rate in the 50s, so that was stopped.  Review of EKGs from that time shows what appears to be multifocal atrial tachycardia with followup EKG showing wandering atrial pacemaker.  An ECG this morning showing normal sinus rhythm with frequent APCs.  Her potassium at that time was 3.1.  She does recall having palpitations because of the pain after the fall, but she states she is not having them since and has not had them prior.  She denies any chest pain nor shortness of breath prior to or since the fall.  She states clearly she can walk and she would be able to climb 2 flights of stairs without problems.,PAST CARDIAC HISTORY: , She is followed by Dr. X in our office and has a history of severe tricuspid regurgitation with mild elevation and PA pressure.  On 05/12/08, preserved left and right ventricular systolic function, aortic sclerosis with apparent mild aortic stenosis, and bi-atrial enlargement.  She has previously had a Persantine Myoview nuclear rest-stress test scan completed at ABCD Medical Center in 07/06 that was negative.  She has had significant mitral valve regurgitation in the past being moderate, but on the most recent echocardiogram on 05/12/08, that was not felt to be significant.  She has a history of hypertension and EKGs in our office show normal sinus rhythm with frequent APCs versus wandering atrial pacemaker.  She does have a history of significant hypertension in the past.  She has had dizzy spells and denies clearly any true syncope.  She has had bradycardia in the past from beta-blocker therapy.,MEDICATIONS ON ADMISSION:,1.  Multivitamin p.o. daily.,2.  Aspirin 325 mg once a day.,3.  Lisinopril 40 mg once a day.,4.  Felodipine 10 mg once a day.,5.  Klor-Con 20 mEq p.o. b.i.d.,6.  Omeprazole 20 mg p.o. daily presumably for GERD.,7.  MiraLax 17 g p.o. daily.,8.  Lasix 20 mg p.o. daily.,ALLERGIES: , PENICILLIN.  IT IS LISTED THAT TOPROL HAS CAUSED SHORTNESS OF BREATH IN HER OFFICE CHART AND I BELIEVE SHE HAS HAD SIGNIFICANT BRADYCARDIA WITH THAT IN THE PAST.,FAMILY HISTORY:,  She states her brother died of an MI suddenly in his 50s.,SOCIAL HISTORY: , She does not smoke cigarettes, abuse alcohol, nor use any illicit drugs.  She is retired from Morse Chain and delivering newspapers.  She is widowed.  She lives alone but has family members who live either on her property or adjacent to it.,REVIEW OF SYSTEMS: , She denies a history of stroke, cancer, vomiting of blood, coughing up blood, bright red blood per rectum, bleeding, stomach ulcers.  She does not recall renal calculi, nor cholelithiasis, denies asthma, emphysema, pneumonia, tuberculosis, sleep apnea, home oxygen use.  She does note occasional peripheral edema.  She is not aware of prior history of MI.  She denies diabetes.  She does have a history of GERD.  She notes feeling depressed at times because of living alone.  She denies rheumatologic conditions including psoriasis or lupus.  Remainder of review of systems is negative times 15 except as described above.,PHYSICAL EXAM:  ,Height 5 feet 0 inches, weight 123 pounds, temperature 99.2 degrees Fahrenheit, blood pressure has ranged from 160/87 with pulses recorded at being 144, and currently ranges 101/53 to 147/71, pulse 64, respiratory rate 20, O2 saturation 97%.  On general exam, she is a pleasant elderly woman who is hard of hearing, but is alert and interactive.  HEENT:  Shows cranium is  normocephalic and atraumatic.  She has moist mucosal membranes.  Neck veins were not distended.  There are no carotid bruits.  Lungs:  Clear to auscultation anteriorly without wheezes.  She is relatively immobile because of her left hip fracture.  Cardiac Exam:  S1, S2, regular rate, frequent ectopic beats, 2/6 systolic ejection murmur, preserved aortic component of the second heart sound.  There is also a soft holosystolic murmur heard.  There is no rub or gallop.  PMI is nondisplaced.  Abdomen is soft and nondistended.  Bowel sounds present.  Extremities without significant clubbing, cyanosis, and there is trivial to 1+ peripheral edema.  Pulses appear grossly intact.  Affect is appropriate.  Visible skin warm and perfused.  She is not able to move because of left hip fracture easily in bed.,DIAGNOSTIC STUDIES/LAB DATA: , Pertinent labs include chest x-ray with radiology report pending but shows only a calcified aortic knob.  No clear pulmonary vascular congestion.  Sodium 140, potassium 3.7, it was 3.1 on admission, chloride 106, bicarbonate 27, BUN 17, creatinine 0.9, glucose 150, magnesium was 2 on 07/13/06.  Troponin was 0.03 followed by 0.18.  INR is 0.93, white blood cell count 10.2, hematocrit 36, platelet count 115,000.,EKGs are reviewed.  Initial EKG done on 08/19/08 at 1832 shows MAT, heart rate of 104 beats per minute, no ischemic changes.  She had a followup EKG done at 20:37 on 08/19/08, which shows wandering atrial pacemaker and some lateral T-wave changes, not significantly changed from prior.  Followup EKG done this morning shows normal sinus rhythm with frequent APCs.,IMPRESSION:  ,She is an 84-year-old female with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension and mild aortic stenosis admitted after a fall with left hip fracture and she will require surgery.  Telemetry now reviewed, shows predominantly normal sinus rhythm with frequent APCs _____ earlier yesterday evening showed burst of multifocal atrial tachycardia and I suspect that was exacerbated by prior hypokalemia, which has been corrected.  There has been no atrial fibrillation documented.  I do not feel these troponins are significant given the stress or fall in prior multifocal atrial tachycardia with increased rate especially in the absence of chest pain or shortness of breath.  She actually describes feeling good exercise capacity prior to this fall.  Given favorable risk to benefit ratio for needed left hip surgery, I feel she may proceed with needed left hip surgery from a cardiac standpoint with continued verapamil, which has been started, which should help control the multifocal atrial tachycardia, which she had and would watch for heart rate with that.  Continued optimization of electrolytes.  The patient cannot take beta-blockers as previously Toprol reportedly caused shortness of breath, although, there was some report that it caused bradycardia so we would watch her heart rate on the verapamil.  The patient is aware of the cardiac risks, certainly it is moderate, and wishes to proceed with needed surgery.  I do not feel any further cardiac evaluation is needed at this time and the patient may followup with Dr. X after discharge.  Regarding her mild thrombocytopenia, I would defer that to hospitalist and continue proton pump inhibitors for history of gastroesophageal reflux disease, management of left hip fracture as per orthopedist.","emergency room reports, hypokalemia, shortness of breath, atrial tachycardia, sinus rhythm, hip fracture, atrial, tachycardia, rhythm, apcs, cardiac, regurgitation, aortic, hypertension, pulmonary, "
" The patient ingested tiki oil (kerosene, liquid paraffin, citronella oil) approximately two days prior to admission.  He subsequently developed progressive symptoms of dyspnea, pleuritic chest pain, hemoptysis with nausea and vomiting. ", Emergency Room Reports, Hydrocarbon Aspiration - ER Visit ,"SUBJECTIVE: , The patient is a 20-year-old Caucasian male admitted via ABCD Hospital Emergency Department for evaluation of hydrocarbon aspiration.  The patient ingested ""tiki oil"" (kerosene, liquid paraffin, citronella oil) approximately two days prior to admission.  He subsequently developed progressive symptoms of dyspnea, pleuritic chest pain, hemoptysis with nausea and vomiting.  He was seen in the ABCD Hospital Emergency Department, toxic appearing with an abnormal chest x-ray demonstrating bilateral lower lobe infiltrates, greater on the right.  He had a temperature of 38.3 with tachycardia approximating 130.  White count was 59,300 with a marked left shift.  Arterial blood gases showed pH 7.48, pO2 79, and pCO2 35.  He was admitted for further medical management.,PAST MEDICAL HISTORY:,  Aplastic crisis during childhood requiring splenectomy and a cholecystectomy at age 9.,DRUG ALLERGIES: , NONE KNOWN.,CURRENT MEDICATIONS: , None.,FAMILY HISTORY:  ,Noncontributory.,SOCIAL HISTORY:  ,The patient works at a local Christmas tree farm.  He smokes cigarettes approximately one pack per day.,REVIEW OF SYSTEMS:,  Ten-system review significant for nausea, vomiting, fever, hemoptysis, and pleuritic chest pain.,PHYSICAL EXAMINATION,GENERAL:  A toxic-appearing 20-year-old Caucasian male, in mild respiratory distress.,VITAL SIGNS:  Blood pressure 122/74, pulse 130 and regular, respirations 24, temperature 38.3, and oxygen saturation 93%.,SKIN:  No rashes, petechiae or ecchymoses.,HEENT:  Within normal limits.  Pupils are equally round and reactive to light and accommodation.  Ears clean.  Throat clean.,NECK:  Supple without thyromegaly.  Lymph nodes are nonpalpable.,CHEST:  Decreased breath sounds bilaterally, greater on the right, at the right base.,CARDIAC:  No murmur or gallop rhythm.,ABDOMEN:  Mild direct diffuse tenderness without rebound.  No detectable masses, pulsations or organomegaly.,EXTREMITIES:  No edema.  Pulses are equal and full bilaterally.,NEUROLOGIC:  Nonfocal.,DATABASE: , Chest x-ray, bilateral lower lobe pneumonia, greater on the right.  EKG, sinus tachycardia, rate of 130, normal intervals, no ST changes.  Arterial blood gases on 2 L of oxygen, pH 7.48, pO2 79, and pCO2 35.,BLOOD STUDIES: , Hematocrit is 43, WBC 59,300 with a left shift, and platelet count 394,000.  Sodium is 130, potassium 3.8, chloride 97, bicarbonate 24, BUN 14, creatinine 0.8, random blood sugar 147, and calcium 9.4.,IMPRESSION,1.  Hydrocarbon aspiration.,2.  Bilateral pneumonia with pneumonitis secondary to aspiration.,3.  Asplenic patient.,PLAN,1.  ICU monitoring.,2.  O2 protocol.,3.  Hydration.,4.  Antiemetic therapy.,5.  Parenteral antibiotics.,6.  Prophylactic proton pump inhibitors.,The patient will need ICU monitoring and Pulmonary Medicine evaluation pending clinical course.,",
" Presents to the ER with hematuria that began while sleeping last night.   He denies any pain, nausea, vomiting or diarrhea.", Emergency Room Reports, Hematuria - ER Visit ,"HISTORY OF PRESENT ILLNESS:,  The patient is an 85-year-old gentleman who follows as an outpatient with Dr. A.  He is known to us from his last admission.  At that time, he was admitted with a difficulty voiding and constipation.  His urine cultures ended up being negative.  He was seen by Dr. B and discharged home on Levaquin for five days.,He presents to the ER today with hematuria that began while he was sleeping last night.  He denies any pain, nausea, vomiting or diarrhea.  In the ER, a Foley catheter was placed and was irrigated with saline.  White count was 7.6, H and H are 10.8 and 38.7, and BUN and creatinine are of 27 and 1.9.  Urine culture is pending.  Chest x-ray is pending.  His UA did show lots of red cells.  The patient currently is comfortable.  CBI is running.  His urine is clear.,PAST MEDICAL HISTORY:,1.  Hypertension.,2.  High cholesterol.,3.  Bladder cancer.,4.  Bilateral total knee replacements.,5.  Cataracts.,6.  Enlarged prostate.,ALLERGIES:,  SULFA.,MEDICATIONS AT HOME:,1.  Atenolol.,2.  Cardura.,3.  Zegerid.,4.  Flomax.,5.  Levaquin.,6.  Proscar.,7.  Vicodin.,8.  Morphine.,9.  Phenergan.,10.  Ativan.,11.  Zocor.,12.  Prinivil.,13.  Hydrochlorothiazide.,14.  Folic acid.,15.  Digoxin.,16.  Vitamin B12.,17.  Multivitamin.,SOCIAL HISTORY: , The patient lives at home with his daughter.  He does not smoke, occasionally drinks alcohol.  He is independent with his activities of daily living.,REVIEW OF SYSTEMS:,  Not additionally rewarding.,PHYSICAL EXAMINATION:,GENERAL:  An awake and alert 85-year-old gentleman who is afebrile.,VITAL SIGNS:  BP of 162/60 and pulse oximetry of 98% on room air.,HEENT:  Pink conjunctivae.  Anicteric sclerae.  Oral mucosa is moist.,NECK:  Supple.,CHEST:  Clear to auscultation.,HEART:  Regular S1 and S2.,ABDOMEN:  Soft and nontender to palpation.,EXTREMITIES:  Without edema.,He has a Foley catheter in place.  His urine is clear.,LABORATORY DATA:,  Reviewed.,IMPRESSION:,1.  Hematuria.",
 Left hip fracture.  The patient is a 53-year-old female with probable pathological fracture of the left proximal femur., Emergency Room Reports, Hip Fracture - ER Consult ,"REASON FOR CONSULTATION: , Left hip fracture.,HISTORY OF PRESENT ILLNESS: , The patient is a pleasant 53-year-old female with a known history of sciatica, apparently presented to the emergency room due to severe pain in the left lower extremity and unable to bear weight.  History was obtained from the patient.  As per the history, she reported that she has been having back pain with left leg pain since past 4 weeks.  She has been using a walker for ambulation due to disabling pain in her left thigh and lower back.  She was seen by her primary care physician and was scheduled to go for MRI yesterday.  However, she was walking and her right foot got caught on some type of rug leading to place excessive weight on her left lower extremity to prevent her fall.  Since then, she was unable to ambulate.  The patient called paramedics and was brought to the emergency room.  She denied any history of fall.  She reported that she stepped the wrong way causing the pain to become worse.  She is complaining of severe pain in her lower extremity and back pain.  Denies any tingling or numbness.  Denies any neurological symptoms.  Denies any bowel or bladder incontinence.,X-rays were obtained which were remarkable for left hip fracture.  Orthopedic consultation was called for further evaluation and management.  On further interview with the patient, it is noted that she has a history of malignant melanoma, which was diagnosed approximately 4 to 5 years ago.  She underwent surgery at that time and subsequently, she was noted to have a spread to the lymphatic system and lymph nodes for which she underwent surgery in 3/2008.,PAST MEDICAL HISTORY: , Sciatica and melanoma.,PAST SURGICAL HISTORY:  ,As discussed above, surgery for melanoma and hysterectomy.,ALLERGIES: , NONE.,SOCIAL HISTORY: , Denies any tobacco or alcohol use.  She is divorced with 2 children.  She lives with her son.,PHYSICAL EXAMINATION:,GENERAL:  The patient is well developed, well nourished in mild distress secondary to left lower extremity and back pain.,MUSCULOSKELETAL:  Examination of the left lower extremity, there is presence of apparent shortening and external rotation deformity.  Tenderness to palpation is present.  Leg rolling is positive for severe pain in the left proximal hip.  Further examination of the spine is incomplete secondary to severe leg pain.  She is unable to perform a straight leg raising.  EHL/EDL 5/5.  2+ pulses are present distally.  Calf is soft and nontender.  Homans sign is negative.  Sensation to light touch is intact.,IMAGING:,  AP view of the hip is reviewed.  Only 1 limited view is obtained.  This is a poor quality x-ray with a lot of soft tissue shadow.  This x-ray is significant for basicervical-type femoral neck fracture.  Lesser trochanter is intact.  This is a high intertrochanteric fracture/basicervical.  There is presence of lytic lesion around the femoral neck, which is not well delineated on this particular x-ray.  We need to order repeat x-rays including AP pelvis, femur, and knee.,LABS:,  Have been reviewed.,ASSESSMENT: , The patient is a 53-year-old female with probable pathological fracture of the left proximal femur.,DISCUSSION AND PLAN: , Nature and course of the diagnosis has been discussed with the patient.  Based on her presentation without any history of obvious fall or trauma and past history of malignant melanoma, this appears to be a pathological fracture of the left proximal hip.  At the present time, I would recommend obtaining a bone scan and repeat x-rays, which will include AP pelvis, femur, hip including knee.  She denies any pain elsewhere.  She does have a past history of back pain and sciatica, but at the present time, this appears to be a metastatic bone lesion with pathological fracture.  I have discussed the case with Dr. X and recommended oncology consultation.,With the above fracture and presentation, she needs a left hip hemiarthroplasty versus calcar hemiarthroplasty, cemented type.  Indication, risk, and benefits of left hip hemiarthroplasty has been discussed with the patient, which includes, but not limited to bleeding, infection, nerve injury, blood vessel injury, dislocation early and late, persistent pain, leg length discrepancy, myositis ossificans, intraoperative fracture, prosthetic fracture, need for conversion to total hip replacement surgery, revision surgery, DVT, pulmonary embolism, risk of anesthesia, need for blood transfusion, and cardiac arrest.  She understands above and is willing to undergo further procedure.  The goal and the functional outcome have been explained.  Further plan will be discussed with her once we obtain the bone scan and the radiographic studies.  We will also await for the oncology feedback and clearance.,Thank you very much for allowing me to participate in the care of this patient.  I will continue to follow up.","emergency room reports, calcar, proximal femur, pathological fracture, hip, fracture, hemiarthroplasty, melanoma, "
 A male with known alcohol cirrhosis who presented to the emergency room after an accidental fall in the bathroom., Emergency Room Reports, Hepatic Encephalopathy ,"REASON FOR ADMISSION: , Hepatic encephalopathy.,HISTORY OF PRESENT ILLNESS: , The patient is a 51-year-old Native American male with known alcohol cirrhosis who presented to the emergency room after an accidental fall in the bathroom.  He said that he was doing fine prior to that and denied having any complaints.  He was sitting watching TV and he felt sleepy.  So, he went to the bathroom to urinate before going to bed and while he was trying to lift the seat, he tripped and fell and hit his head on the back.  His head hit the toilet seat.  Then, he started having bleeding and had pain in the area with headache.  He did not lose consciousness as far as he can tell.  He went and woke up his sister.  This happened somewhere between 10:30 and 11 p.m.  His sister brought a towel and covered the laceration on the back of his head and called EMS, who came to his house and brought him to the emergency room, where he was found to have a laceration on the back of his head, which was stapled and a CT of the head was obtained and ruled out any acute intracranial pathology.  On his lab work, his ammonia was found to be markedly elevated at 106.  So, he is being admitted for management of this.  He denied having any abdominal pain, change in bowel habits, GI bleed, hematemesis, melena, or hematochezia.  He said he has been taking his medicines, but he could not recall those.  He denied having any symptoms prior to this fall.  He said earlier today he also fell.  He also said that this was an accidental fall caused by problem with his walker.  He landed on his back at that time, but did not have any back pain afterwards.,PAST MEDICAL HISTORY:,1.  Liver cirrhosis caused by alcohol.  This is per the patient.,2.  He thinks he is diabetic.,3.  History of intracranial hemorrhage.  He said it was subdural hematoma.  This was traumatic and happened seven years ago leaving him with the right-sided hemiparesis.,4.  He said he had a seizure back then, but he does not have seizures now.,PAST SURGICAL HISTORY:,1.  He has a surgery on his stomach as a child.  He does not know the type.,2.  Surgery for a leg fracture.,3.  Craniotomy seven years ago for an intracranial hemorrhage/subdural hematoma.,MEDICATIONS: , He does not remember his medications except for the lactulose and multivitamins.,ALLERGIES: , Dilantin.,SOCIAL HISTORY: , He lives in Sacaton with his sister.  He is separated from his wife who lives in Coolidge.  He smokes one or two cigarettes a day.  Denies drug abuse.  He used to be a heavy drinker, quit alcohol one year ago and does not work currently.,FAMILY HISTORY:,  Negative for any liver disease.,REVIEW OF SYSTEMS:,GENERAL:  Denies fever or chills.  He said he was in Gilbert about couple of weeks ago for fever and was admitted there for two days.  He does not know the details.,ENT:  No visual changes.  No runny nose.  No sore throat.,CARDIOVASCULAR:  No syncope, chest pain, or palpitations.,RESPIRATORY:  No cough or hemoptysis.  No dyspnea.,GI:  No abdominal pain.  No nausea or vomiting.  No GI bleed.  History of alcoholic liver disease.,GU:  No dysuria, hematuria, frequency, or urgency.,MUSCULOSKELETAL:  Denies any acute joint pain or swelling.,SKIN:  No new skin rashes or itching.,CNS:  Had a seizure many years ago with no recurrences.  Left-sided hemiparesis after subdural hematoma from a fight/trauma.,ENDOCRINE:  He thinks he has diabetes but does not know if he is on any diabetic treatment.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 97.7, heart rate 83, respiratory rate 18, blood pressure 125/72, and saturation 98% on room air.,GENERAL:  The patient is lying in bed, appears comfortable, very pleasant Native American male in no apparent distress.,HEENT:  His skull has a scar on the left side from previous surgery.  On the back of his head, there is a laceration, which has two staples on.  It is still oozing minimally.  It is tender.  No other traumatic injury is noted.  Eyes, pupils react to light.  Sclerae anicteric.  Nostrils are normal.  Oral cavity is clear with no thrush or exudate.,NECK:  Supple.  Trachea midline.  No JVD.  No thyromegaly.,LYMPHATICS:  No cervical or supraclavicular lymphadenopathy.,LUNGS:  Clear to auscultation bilaterally.,HEART:  Normal S1 and S2.  No murmurs or gallops.  Regular rate and rhythm.,ABDOMEN:  Soft, distended, nontender.  No organomegaly or masses.,LOWER EXTREMITIES:  +1 edema bilaterally.  Pulses strong bilaterally.  No skin ulcerations noted.  No erythema.,SKIN:  Several spider angiomas noted on his torso and upper extremities consistent with liver cirrhosis.,BACK:  No tenderness by exam.,RECTAL:  No masses.  No abscess.  No rectal fissures.  Guaiac was performed by me and it was negative.,NEUROLOGIC:  He is alert and oriented x2.  He is slow to some extent in his response.  No asterixis.  Right-sided spastic hemiparesis with increased tone, increased reflexes, and weakness.  Increased tone noted in upper and lower extremities on the right compared to the left.  Deep tendon reflexes are +3 on the right and +2 on the left.  Muscle strength is decreased on the right, more pronounced in the lower extremity compared to the upper extremity.  The upper extremity is +4/5.  Lower extremity is 3/5.  The left side has a normal strength.  Sensation appears to be intact.  Babinski is upward on the right, equivocal on the left.,PSYCHIATRIC:  Flat affect.  Mood appeared to be appropriate.  No active hallucinations or psychotic symptoms.,LABORATORY DATA: ",
 Migraine headache - The patient was seen in the urgent care., Emergency Room Reports, Headache - Urgent Care Visit ,"CC: , Headache.,HPI: , This is a 15-year-old girl presenting with occipital headache for the last six hours.  She denies trauma.  She has been intermittently nauseated but has not vomited and has some photophobia.  Denies fever or change in vision.  She has no past history of headaches.  ,PMH: , None. ,MEDICATIONS:  ,Tylenol for pain.,ALLERGIES:,  None.,FAMILY HISTORY: , Grandmother died of cerebral aneurysm.  ,ROS:,  Negative.,PHYSICAL EXAM:  ,Vital Signs:  BP 102/60 P 70 RR 20 T 98.2 ,HEENT:  Throat is clear, nasopharynx clear, TMs clear, there is no lymphadenopathy, no tenderness to palpations, sinuses nontender. ,Neck:  Supple without meningismus. ,Chest:  Lungs clear; heart regular without murmur.,COURSE IN THE ED: , The patient was seen in the urgent care and examined.  At this time, her photophobia and nausea make migraine highly likely.  She is well appearing and we'll try Tylenol with codeine for her pain.  One day off school and follow up with her primary doctor.  ,IMPRESSION: , Migraine headache.  ,PLAN: , See above.","emergency room reports, photophobia, nausea, migraine headache, tylenol, migraine, headache, "
" Very high PT-INR.  she came in with pneumonia and CHF.  She was noticed to be in atrial fibrillation, which is a chronic problem for her.", Emergency Room Reports, High PT-INR - ER Visit ,"REASON FOR THE VISIT:,  Very high PT/INR.,HISTORY: , The patient is an 81-year-old lady whom I met last month when she came in with pneumonia and CHF.  She was noticed to be in atrial fibrillation, which is a chronic problem for her.  She did not want to have Coumadin started because she said that she has had it before and the INR has had been very difficult to regulate to the point that it was dangerous, but I convinced her to restart the Coumadin again.  I gave her the Coumadin as an outpatient and then the INR was found to be 12.  So, I told her to come to the emergency room to get vitamin K to reverse the anticoagulation.,PAST MEDICAL HISTORY:,1.  Congestive heart failure.,2.  Renal insufficiency.,3.  Coronary artery disease.,4.  Atrial fibrillation.,5.  COPD.,6.  Recent pneumonia.,7.  Bladder cancer.,8.  History of ruptured colon.,9.  Myocardial infarction.,10.  Hernia repair.,11.  Colon resection.,12.  Carpal tunnel repair.,13.  Knee surgery.,MEDICATIONS:,1.  Coumadin.,2.  Simvastatin.,3.  Nitrofurantoin.,4.  Celebrex.,5.  Digoxin.,6.  Levothyroxine.,7.  Vicodin.,8.  Triamterene and hydrochlorothiazide.,9.  Carvedilol.,SOCIAL HISTORY:  ,She does not smoke and she does not drink.,PHYSICAL EXAMINATION:,GENERAL:  Lady in no distress.,VITAL SIGNS:  Blood pressure 100/46, pulse of 75, respirations 12, and temperature 98.2.,HEENT:  Head is normal.,NECK:  Supple.,LUNGS:  Clear to auscultation and percussion.,HEART:  No S3, no S4, and no murmurs.,ABDOMEN:  Soft.,EXTREMITIES:  Lower extremities, no edema.,ASSESSMENT:,1.  Atrial fibrillation.,2.  Coagulopathy, induced by Coumadin.,PLAN: , Her INR at the office was 12.  I will repeat it, and if it is still elevated, I will give vitamin K 10 mg in 100 mL of D5W and then send her home and repeat the PT/INR next week.  I believe at this time that it is too risky to use Coumadin in her case because of her age and comorbidities, the multiple medications that she takes and it is very difficult to keep an adequate level of anticoagulation that is safe for her.  She is prone to a fall and this would be a big problem.  We will use one aspirin a day instead of the anticoagulation.  She is aware of the risk of stroke, but she is very scared of the anticoagulation with Coumadin and does not want to use the Coumadin at this time and I understand.  We will see her as an outpatient.",
 4-day-old with hyperbilirubinemia and heart murmur., Emergency Room Reports, Hyperbilirubinemia - 4-day-old ,"HISTORY: , The patient is a 4-day-old being transferred here because of hyperbilirubinemia and some hypoxia.  Mother states that she took the child to the clinic this morning since the child looked yellow and was noted to have a bilirubin of 23 mg%.  The patient was then sent to Hospital where she had some labs drawn and was noted to be hypoxic, but her oxygen came up with minimal supplemental oxygen.  She was also noted to have periodic breathing.  The patient is breast and bottle-fed and has been feeding well.  There has been no diarrhea or vomiting.  Voiding well.  Bowels have been regular.,According to the report from referring facility, because the patient had periodic breathing and was hypoxic, it was thought the patient was septic and she was given a dose of IM ampicillin.,The patient was born at 37 weeks' gestation to gravida 3, para 3 female by repeat C-section.  Birth weight was 8 pounds 6 ounces and the mother's antenatal other than was normal except for placenta previa.  The patient's mother apparently went into labor and then underwent a cesarean section.,FAMILY HISTORY: , Positive for asthma and diabetes and there is no exposure to second-hand smoke.,PHYSICAL EXAMINATION: , ,VITAL SIGNS:  The patient has a temperature of 36.8 rectally, pulse of 148 per minute, respirations 50 per minute, oxygen saturation is 96 on room air, but did go down to 90 and the patient was given 1 liter by nasal cannula.,GENERAL:  The patient is icteric, well hydrated.  Does have periodic breathing.  Color is pink and also icterus is noted, scleral and skin.,HEENT:  Normal.,NECK:  Supple.,CHEST:  Clear.,HEART:  Regular with a soft 3/6 murmur.  Femorals are well palpable.  Cap refill is immediate,ABDOMEN:  Soft, small, umbilical hernia is noted, which is reducible.,EXTERNAL GENITALIA:  Those of a female child.,SKIN:  Color icteric.  Nonspecific rash on the body, which is sparse.  The patient does have a cephalhematoma hematoma about 6 cm over the left occipitoparietal area.,EXTREMITIES:  The patient moves all extremities well.  Has a normal tone and a good suck.,EMERGENCY DEPARTMENT COURSE: , It was indicated to the parents that I would be repeating labs and also catheterize urine specimen.  Parents were made aware of the fact that child did have a murmur.  I spoke to Dr. X, who suggested doing an EKG, which was normal and since the patient will be admitted for hyperbilirubinemia, an echo could be done in the morning.  The case was discussed with Dr. Y and he will be admitting this child for hyperbilirubinemia.,CBC done showed a white count of 15,700, hemoglobin 18 gm%, hematocrit 50.6%, platelets 245,000, 10 bands, 44 segs, 34 lymphs, and 8 monos.  Chemistries done showed sodium of 142 mEq/L, potassium 4.5 mEq/L, chloride 104 mEq/L, CO2 28 mmol/L, glucose 75 mg%, BUN 8 mg%, creatinine 0.7 mg%, and calcium 8.0 mg%.  Total bilirubin was 25.4 mg, all of which was unconjugated.  CRP was 0.3 mg%.  Blood culture was drawn.  Catheterized urine specimen was normal.  Parents were kept abreast of what was going on all the time and the need for admission.  Phototherapy was instituted in the ER almost after the baby got to the emergency room.,IMPRESSION:,  Hyperbilirubinemia and heart murmur.,DIFFERENTIAL DIAGNOSES: , Considered breast milk, jaundice, ABO incompatibility, galactosemia, and ventricular septal defect.","emergency room reports, hypoxia, periodic breathing, heart murmur, urine specimen, yellow, bilirubin, heart, murmur, hyperbilirubinemia, "
" Head injury, anxiety, and hypertensive emergency.", Emergency Room Reports, Head Injury ,"CHIEF COMPLAINT:,  Head injury.,HISTORY: , This 16-year-old female presents to Children's Hospital via paramedic ambulance with a complaint at approximately 6 p.m. while she was at band practice using her flag device.  She struck herself in the head with the flag.  There was no loss of consciousness.  She did feel dizzy.  She complained of a headache.  She was able to walk.  She continued to participate in her flag practice.  She got dizzier.  She sat down for a while and walked and during the second period of walking, she had some episodes of diplopia, felt that she might faint and was assisted to the ground and was transported via paramedic ambulance to Children's Hospital for further evaluation.,PAST MEDICAL HISTORY: , Hypertension.,ALLERGIES:,  DENIED TO ME; HOWEVER, IT IS NOTED BEFORE SEVERAL ACCORDING TO MEDITECH.,CURRENT MEDICATIONS: , Enalapril.,PAST SURGICAL HISTORY: , She had some kind of an abdominal obstruction as an infant.,SOCIAL HISTORY: , She is here with mother and father who lives at home.  There is no smoking at home.  There is second-hand smoke exposure.,FAMILY HISTORY:  ,No noted family history of infectious disease exposure.,IMMUNIZATIONS:,  She is up-to-date on her shots, otherwise negative.,REVIEW OF SYSTEMS:  ,On the 10-plus systems reviewed with the section of those noted on the template.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Her temperature 100 degrees, pulse 86, respirations 20, and her initial blood pressure 166/116, and a weight of 55.8 kg.,GENERAL:  She is supine awake, alert, cooperative, and active child.,HEENT:  Head atraumatic, normocephalic.  Pupils equal, round, reactive to light.  Extraocular motions intact and conjugate.  Clear TMs, nose and oropharynx.  Moist oral mucosa without noted lesions.,NECK:  Supple, full painless nontender range motion.,CHEST:  Clear to auscultation, equal, stable to palpation.,HEART:  Regular without rubs or murmurs.,ABDOMEN:  No abdominal bruits are heard.,EXTREMITIES:  Equal femoral pulses are appreciated.  Equal radial and dorsalis pedis pulses are appreciated.  He moves all extremities without difficulty.  Nontender.  No deformity.  No swelling.,SKIN:  There was no significant bruising, lesions or rash about her abdomen.  No significant bruising, lesions or rash.,NEUROLOGIC:  Symmetric face and extremity motion.  Ambulates without difficulty.  She is awake, alert, and appropriate.,MEDICAL DECISION MAKING:,  The differential entertained includes head injury, anxiety, and hypertensive emergency.  She is evaluated in the emergency department with serial blood pressure examinations, which are noted to return to a more baseline state for her 130s/90s.  Her laboratory data shows a mildly elevated creatinine of 1.3.  Urine is within normal.  Urinalysis showing no signs of infection.  Head CT read by staff has no significant intracranial pathology.  No mass shift, bleed or fracture per Dr. X.  A 12-lead EKG reviewed preliminarily by myself noting normal sinus rhythm, normal axis rates of 90.  No significant ST-T wave changes.  No significant change from previous 09/2007 EKG.  Her headache has resolved.  She is feeling better.  I spoke with Dr. X at 0206 hours consulting Nephrology regarding this patient's presentation with the plan for home.  Follow up with her regular doctor.  Blood pressures have normalized for her.  She should return to emergency department on concern.  They are to call the family to Nephrology Clinic next week for optimization of her blood pressure control with a working diagnosis of head injury, hypertension, and syncope.",
 Gastrointestinal Bleed.  An 81-year-old presented to the emergency room after having multiple black tarry stools and a weak spell.  She woke yesterday morning had a very dark and smelly bowel movement. , Emergency Room Reports, Gastrointestinal Bleed - ER Visit ,"ADMITTING DIAGNOSIS: , Gastrointestinal bleed.,HISTORY OF PRESENT ILLNESS:  ,Ms. XYZ is an 81-year-old who presented to the emergency room after having multiple black tarry stools and a weak spell.  She states that she woke yesterday morning and at approximately 10:30 had a bowel movement.  She noticed it was very dark and smelly.  She said she felt okay.  She got up.  She proceeded to clean her house without any difficulty or problems and then at approximately 2 o'clock in the afternoon she went back to the bathroom at which point she had another large stool and had weak spell felt like she was going to pass out.  She is able to get to her phone, called EMS and when the EMS arrived they found her with some blood and some very dark stools.  She states that she was perfectly fine up until Monday when she had an incident where at the Southern University where she works where there was an altercation between a dorm resistant and a young male, which ensued.  She came to place her call, etc.  She said she noticed her stomach was hurting after that, continued to hurt and she took the day off on Tuesday and this happened yesterday.  She denies any nausea except for when she got weak.  She denies any vomiting or any other symptoms.,ALLERGIES:  ,She has no known drug allergies.,CURRENT MEDICATIONS:,1.  Lipitor, dose unknown.,2.  Paxil, dose unknown.,3.  Lasix, dose unknown.,4.  Toprol, dose unknown.,5.  Diphenhydramine p.r.n.,6.  Ibuprofen p.r.n.,7.  Daypro p.r.n.,PAST MEDICAL HISTORY:,1.  Non-insulin diabetes mellitus.,2.  History of congestive heart failure.,3.  History of hypertension.,4.  Depression.,5.  Arthritis.  She states she has not needed any medications and not taken ibuprofen or Daypro recently.,6.  Hyperlipidemia.,7.  Peptic ulcer disease diagnosed in 2005.,PAST SURGICAL HISTORY: , C-section and tonsillectomy.,FAMILY HISTORY: , Her mother had high blood pressure and coronary artery disease.,SOCIAL HISTORY:,  She is a nonsmoker.  She occasionally has a drink every few weeks.  She is divorced.  She has 2 sons.  She is houseparent at Southern University.,REVIEW OF SYSTEMS:  ,Negative for the last 24 to 48 hours as mentioned in her HPI.,PREVENTIVE CARE:  ,She had an EGD done in 09/05 at which point she was diagnosed with peptic ulcer disease and she also had a colonoscopy at that time which revealed two polyps in the transverse colon.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Currently was stable.  She is afebrile.,GENERAL:  She is alert, pleasant in no acute distress.  She does complain of some dizziness when she stands up.,HEENT:  Pupils equal, round and reactive to light.  Extraocular muscles intact.  Sclerae clear.  Oropharynx is clear.,NECK:  Supple.  Full range of motion.,CARDIOVASCULAR:  She is slightly tachycardic but otherwise normal.,LUNGS:  Clear bilaterally.,ABDOMEN:  Soft, nontender, and nondistended.  She has no hepatomegaly.,EXTREMITIES:  No clubbing, cyanosis, only trace edema.,LABORATORY DATA UPON ADMISSION:,  Her initial chem panel was within normal limits.  Her PT and PTT were normal.  Her initial hematocrit was 31.2 subsequently dropped to 26.9 and 25.6.  She is currently administered transfusion.  Platelet count was 125.  Her chem panel actually showed an elevated BUN of 16, creatinine of 1.7.  PT and PTT were normal.  Cardiac enzymes were negative and initial hemoglobin was 10.6 with hematocrit of 31.2 that subsequently fell to 25.6 and she is currently receiving blood.,IMPRESSION AND PLAN:,1.  Gastrointestinal bleed.",
 Patient dropped a weight on the dorsal aspects of his feet., Emergency Room Reports, Foot Pain ,"CHIEF COMPLAINT: , Foot pain.,HISTORY OF PRESENT ILLNESS: , This is a 17-year-old high school athlete who swims for the swimming team.  He was playing water polo with some of his teammates when he dropped a weight on the dorsal aspects of his feet.  He was barefoot at that time.  He had been in the pool practicing an hour prior to this injury.  Because of the contusions and abrasions to his feet, his athletic trainer brought in him to the urgent care.  He is able to bear weight; however, complains of pain in his toes.  The patient did have some avulsion of the skin across the second and third toes of the left foot with contusions across the second, third, and fourth toes and dorsum of the foot.  According to the patient, he was at his baseline state of health prior to this acute event.,PAST MEDICAL HISTORY: , Significant for attention deficit hyperactivity disorder.,PAST SURGICAL HISTORY:  ,Positive for wisdom tooth extraction.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:  ,He does not use alcohol, tobacco or illicit drugs.  He plays water polo for the school team.,IMMUNIZATION HISTORY: , All immunizations are up-to-date for age.,REVIEW OF SYSTEMS: , The pertinent review of systems is as noted above; the remaining review of systems was reviewed and is noted to be negative.,PRESENT MEDICATIONS: , Provigil, Accutane and Rozerem.,ALLERGIES:  ,None.,PHYSICAL EXAMINATION:,GENERAL:  This is a pleasant white male in no acute distress.,VITAL SIGNS:  He is afebrile.  Vitals are stable and within normal limits.,HEENT:  Negative for acute evidence of trauma, injury or infection.,LUNGS:  Clear.,HEART:  Regular rate and rhythm with S1 and S2.,ABDOMEN:  Soft.,EXTREMITIES:  There are some abrasions across the dorsum of the right foot including the second, third and fourth toes.  There is some mild tenderness to palpation.  However, there are no clinical fractures.  Distal pulses are intact.  The left foot notes superficial avulsion lacerations to the third and fourth digit.  There are no subungual hematomas.  Range of motion is decreased secondary to pain.  No obvious fractures identified.,BACK EXAM:  Nontender.,NEUROLOGIC EXAM:  He is alert, awake and appropriate without deficit.,RADIOLOGY: , AP, lateral, and oblique views of the feet were conducted per Radiology, which were negative for acute fractures and significant soft tissue swelling or bony injuries.,On reevaluation, the patient was resting comfortably.  He was informed of the x-ray findings.  The patient was discharged in the care of his mother with a preliminary diagnosis of bilateral foot contusions with superficial avulsion lacerations, not requiring surgical repair.,DISCHARGE MEDICATIONS: , Darvocet.,The patient's condition at discharge was stable.  All medications, discharge instructions and follow-up appointments were reviewed with the patient/family prior to discharge.  The patient/family understood the instructions and was discharged without further incident.",
 Muscle tension cephalgia.  Right trapezius and rhomboid muscle spasm., Emergency Room Reports, Headache - Emergency Visit ,"CHIEF COMPLAINT: , Headache.,HISTORY OF PRESENT ILLNESS:,  This is a 16-year-old white female who presents here to the emergency department in a private auto with her mother for evaluation of headache.  She indicates intense constant right frontal headache, persistent since onset early on Monday, now more than 48 hours ago.  Indicates pressure type of discomfort with throbbing component.  It is as high as a 9 on a 0 to 10 scale of intensity.  She denies having had similar discomfort in the past.  Denies any trauma.,Review of systems:  No fever or chills.  No sinus congestion or nasal drainage.  No cough or cold symptoms.  No head trauma.  Mild nausea.  No vomiting or diarrhea.  Other systems reviewed and are negative.,PMH: , Acne.  Psychiatric history is unremarkable.,PSH: , Right knee surgery.,SH: , The patient is single.  Living at home.  No smoking or alcohol.,FH: , Noncontributory.,ALLERGIES:  ,No drug allergies.,MEDICATIONS: , Accutane and Ovcon.,PHYSICAL EXAMINATION:,VITALS:  Temperature of 97.8 degrees F., pulse of 80, respiratory rate of 16, and blood pressure is 131/96.,GENERAL:  This is a 16-year-old white female.  She is awake, alert, and oriented x3.  She does appear bit uncomfortable.,HEAD:  Normocephalic and atraumatic.,EYES:  The pupils were equal and reactive to light.  Extraocular movements are intact.,ENT:  TMs are clear.  Nose and throat are unremarkable.,NECK:  There is no evidence of nuchal rigidity.  She does, however, have notable tenderness and spasm of the right trapezius and rhomboid muscles when she extends up to the right paracervical muscles.  Palpation clearly causes having exacerbation of her discomfort.,CHEST:  Thorax is unremarkable.,GI:  Abdomen is nontender.,MUSCLES:  Extremities are unremarkable.,NEURO:  Cranial nerves II through XII are grossly intact.  Motor and sensory are grossly intact.  ,SKIN:  Skin is warm and dry.,ED COURSE:,  The patient was given IV Norflex 60 mg, Zofran 4 mg, and morphine sulfate 4 mg and with that has significant improvement in her discomfort.,DIAGNOSES:,1.  Muscle tension cephalgia.,2.  Right trapezius and rhomboid muscle spasm.,PLAN: , Scripts were given for Darvocet-N 100 one every 4 to 6 hours #15, Soma one 4 times a day #20.  She was instructed to apply warm compresses and perform gentle massage.  Follow up with regular provider as needed.  Return if any problems.",
" The patient is an 88-year-old white female, household ambulator with a walker, who presents to the emergency department this morning after incidental fall at home.", Emergency Room Reports, Fall - ER Visit ,"HISTORY OF PRESENT ILLNESS:,  The patient is an 88-year-old white female, household ambulator with a walker, who presents to the emergency department this morning after incidental fall at home.  The patient states that she was on the ladder on Saturday and she stepped down after the ladder.  Felt some pain in her left hip.  Subsequently fell injuring her left shoulder.  It's unclear how long she was on the floor.  She was taken by EMS to Hospital where she was noted radiographically to have a left proximal humerus fracture and a nondisplaced left hip fracture.  Orthopedics was consulted.  Given the nature of the injury and the unclear events, an extensive workup was performed including a head CT and CT of the abdomen, which identified no evidence of intracranial injury and renal calculi only.  She presently is complaining of pain to the left shoulder.  She states she also has pain to the hip with motion of the leg.  She denies any numbness or paresthesias.  She states prior to this, she was relatively active within her home.  She does care for her daughter who has a mess.  The patient denies any other injuries.  Denies back pain.,PREVIOUS MEDICAL HISTORY:,  Extensive including coronary artery disease, peripheral vascular disease, status post MI, history of COPD, diverticular disease, irritable bowel syndrome, GERD, PMR, depressive disorder, and hypertension.,PREVIOUS SURGICAL HISTORY:,  Includes a repair of a right intertrochanteric femur fracture.,ALLERGIES,1.  PENICILLIN.,2.  SULFA.,3.  ACE INHIBITOR.,PRESENT MEDICATIONS,1.  Lipitor 20 mg q.d.,2.  Metoprolol 25 mg b.i.d.,3.  Plavix 75 mg once a day.,4.  Aspirin 325 mg.,5.  Combivent Aerosol two puffs twice a day.,6.  Protonix 40 mg q.d.,7.  Fosamax 70 mg weekly.,8.  Multivitamins including calcium and vitamin D.,9.  Hydrocortisone.,10.  Nitroglycerin.,11.  Citalopram 20 mg q.d.,SOCIAL HISTORY:,  She denies alcohol or tobacco use.  She is the caretaker for her daughter, who is widowed and lives at home.,FAMILY HISTORY:,  Not obtainable.,REVIEW OF SYSTEMS: , Patient is hard of hearing.  She also has vision problems.  Denies headache syndrome.  Presently, denies chest pain or shortness of breath.  She denies abdominal pain.  Presently, she has left hip pain and left shoulder pain.  No urinary frequency or dysuria.  No skin lesions.  She does have swelling to both lower extremities for the last several weeks.  She denies endocrinopathies.  Psychiatric issues include chronic depression.,PHYSICAL EXAMINATION,GENERAL:  The patient is alert and responsive.,EXTREMITIES:  The left upper extremity, there is moderate swelling and ecchymosis to the brachial compartment.  She is diffusely tender over the proximal humerus.  She is unable to actively elevate her arm due to pain.  The neurovascular exam to the left upper extremity is otherwise intact with a 1+ radial pulse.  She does have chronic degenerative change to the MP and IP joints of both hands.  The left lower extremity, the thigh compartment is supple.  She has pain with log rolling tenderness over the greater trochanter.  The patient has pain with any attempt at hip flexion passively or actively.  The knee range of motion between 5 and 60 degrees with no point specific tenderness, no joint effusion, and an intact extensive mechanism.  She has 2 to 3+ bilateral pitting edema pretibially and pedally.  The patient has a weak motor response to the left lower extremity.  She has a 1+ dorsalis pedis pulse.  Her sensory examination is intact plantarly and dorsally on the foot.,RADIOGRAPHS:,  Left shoulder series was performed which identifies a three-part valgus-impacted left proximal humerus fracture with displacement of the greater tuberosity fragment approximately 1 cm.  There is no evidence of dislocation.  There was an AP pelvis as well as left hip series, which identify a nondisplaced valgus-impacted type 1 femoral neck fracture.  There is also evidence of severe degenerative disk disease with degenerative scoliosis of the LS spine.  There is evidence of previous surgical repair of the right proximal femur with an intact intramedullary nail.,LABORATORY STUDIES: , Patient's H&H is 13 and 38.7, white blood cell count is 6.9, and there are 198,000 platelets.  Electrolytes, sodium 137, potassium 4.1, chloride 102, CO2 is 27, BUN is 20, and creatinine 0.62.  Urinalysis, the urine is clear yellow, 0 to 2 white cells, and no bacteria.,ASSESSMENT,1.  This is an 88-year-old household ambulator with a walker, status post fall with injuries to left shoulder and left hip.  The left shoulder fracture is a valgus-impacted proximal humerus fracture and the left hip is a nondisplaced type 1 femoral neck fracture.,2.  Extensive medical history including coronary artery disease, peripheral vascular disease, and chronic obstructive pulmonary disease on Plavix.,PLAN:,  I have discussed this case with the emergency room physician as well as the patient.  Patient should be admitted to medical service for medical clearance for surgery of her left hip, which will include a percutaneous screw fixation.  Since the patient is on Plavix, I recommend that the Plavix be discontinued and should be placed on Lovenox 30 mg subcu q.d. which may be stopped 24 hours before the procedure.  She will need cardiology clearance, which would include an echo in advance of the procedure.  I have explained the nature of the injuries to the patient, the recommended surgical procedures, and the postop course and rehabilitation required thereafter.  She presently understands and agrees with the plan.",
 Vaginal discharge with a foul odor., Emergency Room Reports, Gardnerella Bacterial Vaginosis ,"CHIEF COMPLAINT: , Vaginal discharge with a foul odor.,HISTORY OF PRESENT ILLNESS: , This is a 25-year-old African-American female who states that for the past week she has been having thin vaginal discharge which she states is gray in coloration.  The patient states that she has also had frequency of urination.  The patient denies any burning with urination.  She states that she is sexually active and does not use condoms.  She does have three sexual partners.  The patient states that she has had multiple yeast infections in the past and is concerned that she may have one again.  The patient also states that she has had sexually transmitted diseases in her teens, but has not had one in many years.  The patient does state that she has never had HIV testing.  The patient states that she has not had any vaginal bleeding and does not have any abdominal pain.  The patient denies fevers or chills, nausea or vomiting, headaches or head trauma.  The patient also denies skin rashes or lesions.  She does state, however, there is one area of roughened skin on her right forearm that she is concerned it may be an infection of the skin.  The patient is G2 P2.  She has had some irregular Pap smears in the past.  Her last Pap smear was approximately 6 to 12 months ago.  The patient has had frequent urinary tract infections in the past.,PAST MEDICAL HISTORY:,1.  Bronchitis.,2.  Urinary tract infections.,3.  Vaginal candidiasis.,PAST SURGICAL HISTORY: , Cyst removal of the right breast.,SOCIAL HISTORY: , The patient does smoke approximately half a pack of cigarettes per day.  She denies alcohol or illicit drug use.,MEDICATIONS: , None.,ALLERGIES:,  No known medical allergies.,PHYSICAL EXAMINATION:,GENERAL:  This is an African-American female who appears her stated age of 25 years.  She is well nourished, well developed, and in no acute distress.  The patient is pleasant.,VITAL SIGNS:  Afebrile.  Blood pressure is mildly over 96/68, pulse is 68, respiratory rate 12, and pulse oximetry of 98% on room air.,HEART:  Regular rate and rhythm.  Clear S1 and S2.  No murmur, rub or gallop is appreciated.,LUNGS:  Clear to auscultation bilaterally.  No wheezes, rales or rhonchi.,ABDOMEN:  Soft, nontender, nondistended.  Positive bowel sounds throughout.,SKIN:  Warm, dry and intact.  No rash or lesion.,PSYCH:  Alert and oriented to person, place, and time.,NEUROLOGIC:  Cranial nerves II through XII are intact bilaterally.  No focal deficits are appreciated.,GENITOURINARY:  The pelvic exam done shows external genitalia without abnormalities or lesions.  There is a white-to-yellow discharge.  Transformation zone is identified.  The cervix is mildly friable.  Vaginal vault is without lesions.  There is no adnexal tenderness.  No adnexal masses.  No cervical motion tenderness.  Cervical swabs and vaginal cultures are obtained.,DIAGNOSTIC STUDIES: , Urinalysis shows 3+ bacteria, however, there are no wbc's.  No squamous epithelial cells and no other signs of infection.  There is no glucose.  The patient's cervical swabs and cultures are obtained and there are positive clue cells.  Negative Trichomonas.  Negative fungal elements and Chlamydia and gonorrhea are pending at this time.  Urinalysis is sent for culture and sensitivity.,ASSESSMENT:,: Gardnerella bacterial vaginosis.,PLAN: , The patient will be treated with metronidazole 500 mg p.o. twice a day x7 days.  The patient will follow up with her primary care provider.,",
 Patient in ER with upper respiratory infection, Emergency Room Reports, ER Report - URI ,"HISTORY OF PRESENT ILLNESS:,  The patient is a two-and-a-half-month-old male who has been sick for the past three to four days.  His mother has described congested sounds with cough and decreased appetite.  He has had no fever.  He has had no rhinorrhea.  Nobody else at home is currently ill.  He has no cigarette smoke exposure.  She brought him to the emergency room this morning after a bad coughing spell.  He did not have any apnea during this episode.,PAST MEDICAL HISTORY:,  Unremarkable.  He has had his two-month immunizations.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 99.1, oxygen saturations 98%, respirations by the nurse at 64, however, at my examination was much slower and regular in the 40s.,GENERAL:  Sleeping, easily aroused, smiling, and in no distress.,HEENT:  Soft anterior fontanelle.  TMs are normal.  Moist mucous membranes.,LUNGS:  Equal and clear.,CHEST:  Without retraction.,HEART:  Regular in rate and rhythm without murmur.,ABDOMEN:  Benign.,DIAGNOSTIC STUDIES:,  Chest x-ray ordered by ER physician is unremarkable, but to me also.,ASSESSMENT:,  Upper respiratory infection.,TREATMENT: , Use the bulb syringe and saline nose drops if there is any mucus in the anterior nares.  Smaller but more frequent feeds.  Discuss proper sleeping position.  Recheck if there is any fever or if he is no better in the next three days.","emergency room reports, er, uri, emergency room, upper respiratory infection, respiratory, sick, fever, chest,"
 A 66-year-old patient who came to the emergency room because she was feeling dizzy and was found to be tachycardic and hypertensive., Emergency Room Reports, Feeling Dizzy - ER Visit  ,"REASON FOR CONSULTATION:,  This is a 66-year-old patient who came to the emergency room because she was feeling dizzy and was found to be tachycardic and hypertensive.,PAST MEDICAL HISTORY: , Hypertension.  The patient noncompliant,HISTORY OF PRESENT COMPLAINT: , This 66-year-old patient has history of hypertension and has not taken medication for several months.  She is a smoker and she drinks alcohol regularly.  She drinks about 5 glasses of wine every day.  Last drink was yesterday evening.  This afternoon, the patient felt palpitations and generalized weakness and came to the emergency room.  On arrival in the emergency room, the patient's heart rate was 121 and blood pressure was 195/83.  The patient received 5 mg of metoprolol IV, after which heart rate was reduced to the 70 and blood pressure was well controlled.  On direct questioning, the patient said she had been drinking a lot.  She had not had any withdrawal before.  Today is the first time she has been close to withdrawal.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No fever.,ENT:  Not remarkable.,RESPIRATORY:  No cough or shortness of breath.,CARDIOVASCULAR:  The patient denies chest pain.,GASTROINTESTINAL:  No nausea.  No vomiting.  No history of GI bleed.,GENITOURINARY:  No dysuria.  No hematuria.,ENDOCRINE:  Negative for diabetes or thyroid problems.,NEUROLOGIC:  No history of CVA or TIA.,Rest of review of systems is not remarkable.,SOCIAL HISTORY:  ,The patient is a smoker and drinks alcohol daily in considerable amounts.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL:  This is a 66-year-old lady with telangiectasia of the face.  She is not anxious at this moment and had no tremors.,CHEST:  Clear to auscultation.  No wheezing.  No crepitations.  Chest is tympanitic to percussion.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmur was appreciated.,ABDOMEN:  Soft and nontender.  Bowel sounds are positive.,EXTREMITIES:  There is no swelling.  No clubbing.  No cyanosis.,NEUROLOGIC:  The patient is alert and oriented x3.  Examination is nonfocal.,DIAGNOSTIC DATA: , EKG shows sinus tachycardia, no acute ST changes.,LABORATORY DATA: , White count is 6.3, hemoglobin is 12.4, hematocrit 38, and platelets 488,000.  Glucose is 124, BUN is 18, creatinine is 1.07, sodium is 146, and potassium is 3.4.  Liver enzymes are within normal limits.  TSH is normal.,ASSESSMENT AND PLAN:,1.  Uncontrolled hypertension.  We will start the patient on beta-blockers.  The patient is to see her primary physician within 1 week's time.,2.  Tachycardia, probable mild withdrawal to alcohol.  The patient is stable now.  We will discharge home with diazepam p.r.n.  The patient had been advised that she should not take alcohol if she takes the diazepam.,3.  Tobacco smoking disorder.  The patient has been counseled.  She is not contemplating quitting at this time.,DISPOSITION: , The patient is discharged home.,DISCHARGE MEDICATIONS:,1.  Atenolol 50 mg p.o. b.i.d.,2.  Diazepam 5 mg tablet 1 p.o. q.8h. p.r.n., total of 5 tablets.,3.  Thiamine 100 mg p.o. daily.",
" Patient running to catch a taxi and stumbled, fell and struck his face on the sidewalk.", Emergency Room Reports, Fall & Laceration ,"CC:,  Fall and laceration.,HPI: , Mr. B is a 42-year-old man who was running to catch a taxi when he stumbled, fell and struck his face on the sidewalk.  He denies loss of consciousness but says he was dazed for a while after it happened.  He complains of pain over the chin and right forehead where he has abrasions.  He denies neck pain, back pain, extremity pain or pain in the abdomen.,PMH: , Hypertension.,MEDS:,  None.,ROS: , As above.  Otherwise negative.,PHYSICAL EXAM: , This is a gentleman in full C-spine precautions on a backboard brought by EMS.  He is in no apparent distress.  ,Vital Signs:  BP 165/95 HR 80 RR 12 Temp 98.4 SpO2 95% ,HEENT:  No palpable step offs, there is blood over the right fronto-parietal area where there is a small 1cm laceration and surrounding abrasion.  Also, 2 cm laceration over the base of the chin without communication to the oro-pharynx.  No other trauma noted.  No septal hematoma.  No other facial bony tenderness.  ,Neck:  Nontender ,Chest:  Breathing comfortably; equal breath sounds.  ,Heart:  Regular rhythm.,Abd:  Benign.,Ext:  No tenderness or deformity; pulses are equal throughout; good cap refill ,Neuro:  Awake and alert; slight slurring of speech and cognitive slowing consistent with alcohol; moves all extremities; cranial nerves normal.  ,COURSE IN THE ED:,  Patient arrived and was placed on monitors.  An IV had been placed in the field and labs were drawn.  X-rays of the C spine show no fracture and I've removed the C-collar.  The lacerations were explored and no foreign body found.  They were irrigated and closed with simple interrupted sutures.  Labs showed normal CBC, Chem-7, and U/A except there was moderate protein in the urine.  The blood alcohol returned at 0.146.  A banana bag is ordered and his care will be turned over to Dr. G for further evaluation and care.","emergency room reports, loss of consciousness, laceration, fall, course in the ed, placed on monitors, fell and struck, abrasions,"
 Emergent fiberoptic bronchoscopy with lavage.   Status post multiple trauma/motor vehicle accident.  Acute respiratory failure.  Acute respiratory distress/ventilator asynchrony.  Hypoxemia.  Complete atelectasis of left lung.  Clots partially obstructing the endotracheal tube and completely obstructing the entire left main stem and entire left bronchial system., Emergency Room Reports, Fiberoptic Bronchoscopy with Lavage ,"PREOPERATIVE DIAGNOSES:,1.  Status post multiple trauma/motor vehicle accident.,2.  Acute respiratory failure.,3.  Acute respiratory distress/ventilator asynchrony.,4.  Hypoxemia.,5.  Complete atelectasis of left lung.,POSTOPERATIVE DIAGNOSES:,1.  Status post multiple trauma/motor vehicle accident.,2.  Acute respiratory failure.,3.  Acute respiratory distress/ventilator asynchrony.,4.  Hypoxemia.,5.  Complete atelectasis of left lung.,6.  Clots partially obstructing the endotracheal tube and completely obstructing the entire left main stem and entire left bronchial system.,PROCEDURE PERFORMED: ,Emergent fiberoptic plus bronchoscopy with lavage.,LOCATION OF PROCEDURE:  ,ICU.  Room #164.,ANESTHESIA/SEDATION:,  Propofol drip, Brevital 75 mg, morphine 5 mg, and Versed 8 mg.,HISTORY,:  The patient is a 44-year-old male who was admitted to ABCD Hospital on 09/04/03 status post MVA with multiple trauma and subsequently diagnosed with multiple spine fractures as well as bilateral pulmonary contusions, requiring ventilatory assistance.  The patient was noted with acute respiratory distress on ventilator support with both ventilator asynchrony and progressive desaturation.  Chest x-ray as noted above revealed complete atelectasis of the left lung.  The patient was subsequently sedated and received one dose of paralytic as noted above followed by emergent fiberoptic flexible bronchoscopy.,PROCEDURE DETAIL,:  A bronchoscope was inserted through the oroendotracheal tube, which was partially obstructed with blood clots.  These were lavaged with several aliquots of normal saline until cleared.  The bronchoscope required removal because the tissue/clots were obstructing the bronchoscope.  The bronchoscope was reinserted on several occasions until cleared and advanced to the main carina.  The endotracheal tube was noted to be in good position.  The bronchoscope was advanced through the distal trachea.  There was a white tissue completely obstructing the left main stem at the carina.  The bronchoscope was advanced to this region and several aliquots of normal saline lavage were instilled and suctioned.  Again this partially obstructed the bronchoscope requiring several times removing the bronchoscope to clear the lumen.  The bronchoscope subsequently was advanced into the left mainstem and subsequently left upper and lower lobes.  There was diffuse mucus impactions/tissue as well as intermittent clots.  There was no evidence of any active bleeding noted.  Bronchoscope was adjusted and the left lung lavaged until no evidence of any endobronchial obstruction is noted.  Bronchoscope was then withdrawn to the main carina and advanced into the right bronchial system.  There is no plugging or obstruction of the right bronchial system.  The bronchoscope was then withdrawn to the main carina and slowly withdrawn as the position of endotracheal tube was verified, approximately 4 cm above the main carina.  The bronchoscope was then completely withdrawn as the patient was maintained on ventilator support during and postprocedure.  Throughout the procedure, pulse oximetry was greater than 95% throughout.  There is no hemodynamic instability or variability noted during the procedure.  Postprocedure chest x-ray is pending at this time.","emergency room reports, multiple trauma, motor vehicle accident, acute respiratory failure, acute respiratory distress, ventilator asynchrony, hypoxemia, atelectasis, bronchoscopy, lavage, fiberoptic bronchoscopy, endotracheal tube, acute respiratory, asynchrony, bronchoscope, fiberoptic, endotracheal, bronchial, ventilatory, tube, respiratory, "
" Questionable foreign body, right nose.  Belly and back pain.   Mild constipation.", Emergency Room Reports, Foreign Body - Right Nose ,"CHIEF COMPLAINT:,  Questionable foreign body, right nose.  Belly and back pain.  ,SUBJECTIVE: , Mr. ABC is a 2-year-old boy, who is brought in by parents, stating that the child keeps complaining of belly and back pain.  This does not seem to be slowing him down.  They have not noticed any change in his urine or bowels.  They have not noted him to have any fevers or chills or any other illness.  They state he is otherwise acting normally.  He is eating and drinking well.  He has not had any other acute complaints, although they have noted a foul odor coming from his nose.  Apparently, he was seen here a few weeks ago for a foreign body in the right nose, which was apparently a piece of cotton; this was removed and placed on antibiotics.  His nose got better and then started to become malodorous again.  Mother restarted him on the remainder of the antibiotics and they are also stating that they think there is something still in there.  Otherwise, he has not had any runny nose, earache, no sore throat.  He has not had any cough, congestion.  He has been acting normally.  Eating and drinking okay.  No other significant complaints.  He has not had any pain with bowel movement or urination, nor have they noted him to be more frequently urinating, then again he is still on a diaper.,PAST MEDICAL HISTORY: , Otherwise negative.,ALLERGIES: , No allergies.,MEDICATIONS: , No medications other than recent amoxicillin.,SOCIAL HISTORY: , Parents do smoke around the house.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Stable.  He is afebrile.,GENERAL:  This is a well-nourished, well-developed 2-year-old little boy, who is appearing very healthy, normal for his stated age, pleasant, cooperative, in no acute distress, looks very healthy, afebrile and nontoxic in appearance.,HEENT:  TMs, canals are normal.  Left naris normal.  Right naris, there is some foul odor as well as questionable purulent drainage.  Examination of the nose, there was a foreign body noted, which was the appearance of a cotton ball in the right nose, that was obviously infected and malodorous.  This was removed and reexamination of the nose was done and there was absolutely no foreign body left behind or residual.  There was some erythema.  No other purulent drainage noted.  There was some bloody drainage.  This was suctioned and all mucous membranes were visualized and are negative.,NECK:  Without lymphadenopathy.  No other findings.,HEART:  Regular rate and rhythm.,LUNGS:  Clear to auscultation.,ABDOMEN:  His abdomen is entirely benign, soft, nontender, nondistended.  Bowel sounds active.  No organomegaly or mass noted.,BACK:  Without any findings.  Diaper area normal.,GU:  No rash or infections.  Skin is intact.,ED COURSE: , He also had a P-Bag placed, but did not have any urine.  Therefore, a straight catheter was done, which was done with ease without complication and there was no leukocytes noted within the urine.  There was a little bit of blood from catheterization but otherwise normal urine.  X-ray noted some stool within the vault.  Child is acting normally.  He is jumping up and down on the bed without any significant findings.,ASSESSMENT:,1.  Infected foreign body, right naris.,2.  Mild constipation.,PLAN:,  As far as the abdominal pain is concerned, they are to observe for any changes.  Return if worse, follow up with the primary care physician.  The right nose, I will place the child on amoxicillin 125 per 5 mL, 1 teaspoon t.i.d.  Return as needed and observe for more foreign bodies.  I suspect, the child had placed this cotton ball in his nose again after the first episode.", 
 Patient presents to the emergency room with complaints of mid-epigastric and right upper quadrant abdominal pain for the last 14 days., Emergency Room Reports, ER Report - Stomach Pain ,"CHIEF COMPLAINT:, Stomach pain for 2 weeks.,HISTORY OF PRESENT ILLNESS:, The patient is a 45yo Mexican man without significant past medical history who presents to the emergency room with complaints of mid-epigastric and right upper quadrant abdominal pain for the last 14 days. The pain was initially crampy and burning in character and was relieved with food intake. He also reports that it initially was associated with a sour taste in his mouth. He went to his primary care physician who prescribed cimetidine 400mg qhs x 5 days; however, this did not relieve his symptoms. In fact, the pain has worsened such that the pain now radiates to the back but is waxing and waning in duration. It is relieved with standing and ambulation and exacerbated when lying in a supine position. He reports a decrease in appetite associated with a 4 lb. wt loss over the last 2 wks. He does have nausea with only one episode of non-bilious, non-bloody emesis on day of admission. He reports a 2 wk history of subjective fever and diaphoresis. He denies any diarrhea, constipation, dysuria, melena, or hematochezia. His last bowel movement was during the morning of admission and was normal. He denies any travel in the last 9 years and sick contacts.,PAST MEDICAL HISTORY:, Right inguinal groin cyst removal 15 years ago. Unknown etiology. No recurrence.,PAST SURGICAL HISTORY:, Left femoral neck fracture with prosthesis secondary to a fall 4 years ago.,FAMILY HISTORY:, Mother with diabetes. No history of liver disease. No malignancies.,SOCIAL HISTORY:, The patient was born in central Mexico but moved to the United States 9 years ago. He is on disability due to his prior femoral fracture. He denies any tobacco or illicit drug use. He only drinks alcohol socially, no more than 1 drink every few weeks. He is married and has 3 healthy children. He denies any tattoos or risky sexual behavior.,ALLERGIES:, NKDA.,MEDICATIONS:, Tylenol prn (1-2 tabs every other day for the last 2 wks), Cimetidine 400mg po qhs x 5 days.,REVIEW OF SYSTEMS:,  No headache, vision changes. No shortness of breath. No chest pain or palpitations.,PHYSICAL EXAMINATION:,Vitals: T 100.9-102.7 BP 136/86 Pulse 117 RR 12 98% sat on room air,Gen: Well-developed, well-nourished, no apparent distress.,HEENT: Pupils equal, round and reactive to light. Anicteric. Oropharynx clear and moist.,Neck: Supple. No lymphadenopathy or carotid bruits. No thyromegaly or masses.,CHEST: Clear to auscultation bilaterally.,CV: Tachycardic but regular rhythm, normal S1/S2, no murmurs/rubs/gallops.,Abd: Soft, active bowel sounds. Tender in the epigastrium and right upper quadrant with palpation associated with slight guarding. No rebound tenderness. No hepatomegaly. No splenomegaly.,Rectal: Stool was brown and guaiac negative.,Ext: No cyanosis/clubbing/edema.,Neurological: He was alert and oriented x3. CN II-XII intact. Normal 2+ DTRs. No focal neurological deficit.,Skin: No jaundice. No skin rashes or lesions.,IMAGING DATA:,CT Abdomen with contrast ( 11/29/03 ):  There is a 6x6 cm multilobular hypodense mass seen at the level of the hepatic hilum and caudate lobe which is resulting in mass effect with dilatation of the intrahepatic radicals of the left lobe of the liver. The rest of the liver parenchyma is homogeneous. The gallbladder, pancreas, spleen, adrenal glands and kidneys are within normal limits. The retroperitoneal vascular structures are within normal limits. There is no evidence of lymphadenopathy, free fluid or fluid collections.,HOSPITAL COURSE:,  The patient was admitted to the hospital for further evaluation. A diagnostic procedure was performed.",
" Patient went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight, the patient ended up taking a total of six Ecstasy tablets.", Emergency Room Reports, Ecstasy Ingestion - ER Visit ,"CHIEF COMPLAINT:,  ""I took Ecstasy."",HISTORY OF PRESENT ILLNESS: , This is a 17-year-old female who went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight, the patient ended up taking a total of six Ecstasy tablets.  The patient upon returning to home was energetic and agitated and shaking and had one episode of nonbloody, nonbilious emesis.  Mother called the EMS service when the patient vomited.  On arrival here, the patient states that she no longer has any nausea and that she feels just fine.  The patient states she feels wired but has no other problems or complaints.  The patient denies any pain.  The patient does not have any auditory of visual hallucinations.  The patient denies any depression or suicidal ideation.  The patient states that the alcohol and the Ecstasy was done purely as a recreational thing and not as an attempt to harm herself.  The patient denies any homicidal ideation.  The patient denies any recent illness or recent injuries.  The mother states that the daughter appears to be back to her usual self now.,REVIEW OF SYSTEMS: , CONSTITUTIONAL:  No recent illness.  No fever or chills.  HEENT:  No headache.  No neck pain.  No vision change or hearing change.  No eye or ear pain.  No rhinorrhea.  No sore throat.  CARDIOVASCULAR:  No chest pain.  No palpitations or racing heart.  RESPIRATIONS:  No shortness of breath.  No cough.  GASTROINTESTINAL: One episode of nonbloody, nonbilious emesis this morning without any nausea since then.  The patient denies any abdominal pain.  No change in bowel movements.  GENITOURINARY:  No dysuria.  MUSCULOSKELETAL:  No back pain.  No muscle or joint aches.  SKIN:  No rashes or lesions.  NEUROLOGIC:  No dizziness, syncope, or near syncope.  PSYCHIATRIC:  The patient denies any depression, suicidal ideation, homicidal ideation, auditory hallucinations or visual hallucinations.  ENDOCRINE:  No heat or cold intolerance.,PAST MEDICAL HISTORY:,  None.,PAST SURGICAL HISTORY: , Appendectomy when she was 9 years old.,CURRENT MEDICATIONS: , Birth control pills.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient denies smoking cigarettes.  The patient does drink alcohol and also uses illicit drugs.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Temperature is 98.8 oral, blood pressure 140/86, pulse is 79, respirations 16, oxygen saturation 100% on room air and is interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished, and well developed, appears to be healthy.  The patient is calm and comfortable, in no acute distress and looks well.  The patient is pleasant and cooperative.  HEENT:  Head is atraumatic, normocephalic, and nontender.  Eyes are normal with clear cornea and conjunctiva bilaterally.  The patient does have dilated pupils of approximately 8 mm each and are equally round and reactive to light bilaterally.  No evidence of light sensitivity or photophobia.  Extraocular motions are intact bilaterally.  Nose is normal without rhinorrhea or audible congestion.  Ears are normal without any sign of infection.  Mouth and oropharynx are normal without any signs of infection.  Mucous membranes are moist.  NECK:  Supple and nontender.  Full range of motion.  There is no JVD.  CARDIOVASCULAR:  Heart is regular rate and rhythm without murmur, rub or gallop.  Peripheral pulses are +3 and bounding.  RESPIRATIONS:  Clear to auscultation bilaterally.  No shortness of breath.  No wheezes, rales or rhonchi.  Good air movement bilaterally.  GASTROINTESTINAL:  Abdomen is soft, nontender, normal and benign.  MUSCULOSKELETAL:  No abnormalities noted in back, arms, or legs.  The patient is normal use of her extremities.  SKIN:  No rashes or lesions.  NEUROLOGIC:  Cranial nerves II through XII are intact.  Motor and sensory are intact in all extremities.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is alert and oriented x4.  The patient does not have any smell of alcohol and does not exhibit any clinical intoxication.  The patient is quite pleasant, fully cooperative.  HEMATOLOGIC/LYMPHATIC: NO lymphadenitis is noted.  No bruising is noted.,DIAGNOSES:,1.  ECSTASY INGESTION.,2.  ALCOHOL INGESTION.,3.  VOMITING SECONDARY TO STIMULANT ABUSE.,CONDITION UPON DISPOSITION: , Stable disposition to home with her mother.,PLAN:,  I will have the patient followup with her physician at the ABC Clinic in two days for reevaluation.  The patient was advised to stop drinking alcohol, and taking Ecstasy as this is not only in the interest of her health, but was also illegal.  The patient is asked to return to the emergency room should she have any worsening of her condition, develop any other problems or symptoms of concern.","emergency room reports, nonbilious emesis, hallucinations, visual, auditory, ecstasy ingestion, suicidal ideation, homicidal ideation, ingestion, infection, alcohol, ecstasy, "
" The patient is 14 months old, comes in with a chief complaint of difficulty breathing.  ", Emergency Room Reports, Difficulty Breathing - ER Visit  ,"HISTORY:,  The patient is 14 months old, comes in with a chief complaint of difficulty breathing.  Difficulty breathing began last night.  He was taken to Emergency Department where he got some Xopenex, given a prescription for amoxicillin and discharged home.  They were home for about an hour when he began to get worse and they drove here to Children's Hospital.  He has a history of reactive airway disease.  He has been seen here twice in the last month on 10/04/2007 and 10/20/2007, both times with some wheezing.  He was diagnosed with pneumonia back on 06/12/2007 here in the Emergency Department but was not admitted at that time.  He has been on albuterol off and on over that period.  He has had fever overnight.  No vomiting, no diarrhea.  Increased work of breathing with retractions and audible wheezes noted and thus brought to the Emergency Department.  Normal urine output.  No rashes have been seen.,PAST MEDICAL HISTORY: , As noted above.  No hospitalizations, surgeries, allergies.,MEDICATIONS: , Xopenex.,IMMUNIZATIONS:,  Up-to-date.,BIRTH HISTORY:,  The child was full term, no complications, home with mom.  No surgeries.,FAMILY HISTORY: , Negative.,SOCIAL HISTORY: , No smokers or pets in the home.  No ill contacts, no travel, no change in living condition.,REVIEW OF SYSTEMS: , Ten are asked, all are negative, except as noted above.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temp 37.1, pulse 158, respiratory rate 48, 84% on room air indicating hypoxia.,GENERAL:  The child is awake, alert, in moderate respiratory distress.,HEENT:  Pupils equal, round, reactive to light.  Extraocular movements are intact.  The TMs are clear.  The nares show some dry secretions.  Audible congestion and wheezing is noted.  Mucous membranes are dry.  Throat is clear.  No oral lesions noted.,NECK:  Supple without lymphadenopathy or masses.  Trachea is midline.,LUNGS:  Show inspiratory and expiratory wheezes in all fields.  Audible wheezes are noted.  There are intercostal and subcostal retractions and suprasternal muscle use is noted.,HEART:  Shows tachycardia.  Regular rhythm.  Normal S1, S2.  No murmur.,ABDOMEN:  Soft, nontender.  Positive bowel sounds.  No guarding.  No rebound.  No hepatosplenomegaly.,EXTREMITIES:  Capillary refill is brisk.  Good distal pulses.,NEUROLOGIC:  Cranial nerves II through XII intact.  Moves all 4 extremities equally and normally.,HOSPITAL COURSE: , The child has an IV placed.  I felt the child was dehydrated on examination.  We gave 20 mL/kg bolus of normal saline over one hour.  The child was given Solu-Medrol 2 mg/kg IV.  He was initially started on unit dose albuterol and Atrovent but high-dose albuterol for continuous nebulization was ordered.,A portable chest x-ray was done showing significant peribronchial thickening bilaterally.  Normal heart size.  No evidence of pneumothorax.  No evidence of focal pneumonia.  After 3 unit dose of albuterol/Atrovent breathing treatments, there was much better air exchange bilaterally but still with inspiratory/expiratory wheezes and high-dose continuous albuterol was started at that time.  The child was monitored closely while on high-dose albuterol and slowly showed improvement resulting in only expiratory wheezes after one hour.  The child's pulse ox on breathing treatments with 100% oxygen was 100%.  Respiratory rate remained about 40 to 44 breaths per minute indicating tachypnea.  The child's color improved with oxygen therapy, and the capillary refill was always less than 2 seconds.,The child has failed outpatient therapy at this time.  After 90 minutes of continuous albuterol treatment, the child still has expiratory wheezes throughout.  After I removed the oxygen, the pulse ox was down at 91% indicating hypoxia.  The child has a normal level of alertness; however, has not had any vomiting here.  I spoke with Dr. X, on call for hospitalist service.  She has come down and evaluated the patient.  We both feel that since this child had two ER visits this last month, one previous ER visit within the last 5 hours, we should admit the child for continued albuterol treatments, IV steroids, and asthma teaching for the family.  The child is admitted in a stable condition.,DIFFERENTIAL DIAGNOSES:  ,Ruled out pneumothorax, pneumonia, bronchiolitis, croup.,TIME SPENT:  ,Critical care time outside billable procedures was 45 minutes with this patient.,IMPRESSION:  ,Status asthmaticus, hypoxia.,PLAN:  ,Admitted to Pediatrics.",
 This is a 27-year-old female who presents with a couple of days history of some dental pain.  She has had increasing swelling and pain to the left lower mandible area today., Emergency Room Reports, Dental Pain ,"CHIEF COMPLAINT:,  Dental pain.,HISTORY OF PRESENT ILLNESS:,  This is a 27-year-old female who presents with a couple of days history of some dental pain.  She has had increasing swelling and pain to the left lower mandible area today.  Presents now for evaluation.,PAST MEDICAL HISTORY: , Remarkable for chronic back pain, neck pain from a previous cervical fusion, and degenerative disc disease.  She has chronic pain in general and is followed by Dr. X.,REVIEW OF SYSTEMS: , Otherwise, unremarkable.  Has not noted any fever or chills.  However she, as mentioned, does note the dental discomfort with increasing swelling and pain.  Otherwise, unremarkable except as noted.,CURRENT MEDICATIONS: , Please see list.,ALLERGIES: , IODINE, FISH OIL, FLEXERIL, BETADINE.,PHYSICAL EXAMINATION: , VITAL SIGNS:  The patient was afebrile, has stable and normal vital signs.  The patient is sitting quietly on the gurney and does not look to be in significant distress, but she is complaining of dental pain.  HEENT:  Unremarkable.  I do not see any obvious facial swelling, but she is definitely tender all in the left mandible region.  There is no neck adenopathy.  Oral mucosa is moist and well hydrated.  Dentition looks to be in reasonable condition.  However, she definitely is tender to percussion on the left lower first premolar.  I do not see any huge cavity or anything like that.  No real significant gingival swelling and there is no drainage noted.  None of the teeth are tender to percussion.,PROCEDURE:,  Dental nerve block.  Using 0.5% Marcaine with epinephrine, I performed a left inferior alveolar nerve block along with an apical nerve block, which achieves good anesthesia.  I have then written a prescription for penicillin and Vicodin for pain.,IMPRESSION: , ACUTE DENTAL ABSCESS.,ASSESSMENT AND PLAN:  ,The patient needs to follow up with the dentist for definitive treatment and care.  She is treated symptomatically at this time for the pain with a dental block as well as empirically with antibiotics.  However, outpatient followup should be adequate.  She is discharged in stable condition.","emergency room reports, dental pain, dental abscess, dental block, nerve block, mandible, swelling, dental,"
 Patient complains of chest pain - possible esophageal reflux, Emergency Room Reports, ER Report - Chest Pain ,"CHIEF COMPLAINT:, The patient complains of chest pain. ,HISTORY OF PRESENT ILLNESS: ,The patient is a 20-year-old male who states that he has had two previous myocardial infarctions related to his use of amphetamines. The patient has not used amphetamines for at least four to five months, according to the patient; however, he had onset of chest pain this evening. ,The patient describes the pain as midsternal pain, a burning type sensation that lasted several seconds. The patient took one of his own nitroglycerin tablets without any relief. The patient became concerned and came into the emergency department. ,Here in the emergency department, the patient states that his pain is a 1 on a scale of 1 to 10. He feels much more comfortable. He denies any shortness of breath or dizziness, and states that the pain feels unlike the pain of his myocardial infarction. The patient has no other complaints at this time. ,PAST MEDICAL HISTORY:, The patient's past medical history is significant for status post myocardial infarction in February of 1995 and again in late February of 1995. Both were related to illegal use of amphetamines. ,ALLERGIES:, None. ,CURRENT MEDICATIONS:, Include nitroglycerin p.r.n. ,PHYSICAL EXAMINATION: ,VITAL SIGNS: Blood pressure 131/76, pulse 50, respirations 18, temperature 96.5. ,GENERAL: The patient is a well-developed, well-nourished white male in no acute distress. The patient is alert and oriented x 3 and lying comfortably on the bed. ,HEENT: Atraumatic, normocephalic. The pupils are equal, round, and reactive. Extraocular movements are intact. ,NECK: Supple with full range of motion. No rigidity or meningismus. ,CHEST: Nontender. ,LUNGS: Clear to auscultation. ,HEART: Regular rate and rhythm. No murmur, S3, or S4. ,ABDOMEN: Soft, nondistended, nontender with active bowel sounds. No masses or organomegaly. No costovertebral angle tenderness. ,EXTREMITIES: Unremarkable. ,NEUROLOGIC: Unremarkable. ,EMERGENCY DEPARTMENT LABS:, The patient had a CBC, minor chemistry, and cardiac enzymes, all within normal limits. Chest x-ray, as read by me, was normal. Electrocardiogram, as read by me, showed normal sinus rhythm with no acute ST or T-wave segment changes. There were no acute changes seen on the electrocardiogram. O2 saturation, as interpreted by me, is 99%. ,EMERGENCY DEPARTMENT COURSE: ,The patient had a stable, uncomplicated emergency department course. The patient received 45 cc of Mylanta and 10 cc of viscous lidocaine with complete relief of his chest pain. The patient had no further complaints and stated that he felt much better shortly thereafter. ,AFTERCARE AND DISPOSITION: ,The patient was discharged from the emergency department in stable, ambulatory, good condition with instructions to use Mylanta for his abdominal pain and to follow up with his regular doctor in the next one to two days. Otherwise, return to the emergency department as needed for any problem. The patient was given a copy of his labs and his electrocardiogram. The patient was advised to decrease his level of activity until then. The patient left with final diagnosis of: ,FINAL DIAGNOSIS: ,1. Evaluation of chest pain. ,2. Possible esophageal reflux.",
 A 48-year-old white married female presents in the emergency room after two days of increasing fever with recent diagnosis of urinary tract infection on outpatient treatment with nitrofurantoin., Emergency Room Reports, ER Report - Chest Pain & Fever ,"CHIEF COMPLAINT: , Chest pain and fever.,HISTORY OF PRESENT ILLNESS: , This 48-year-old white married female presents in the emergency room after two days of increasing fever with recent diagnosis of urinary tract infection on outpatient treatment with nitrofurantoin.  The patient noted since she began to feel poorly earlier on the day of admission, had an episode of substernal chest discomfort that was associated with nausea, dizziness, and sweating.  The patient does have a past medical history of diabetes and hypertension.  In addition, the patient complained of some neck and head discomfort for which she underwent a lumbar puncture in the emergency room; this was normal, causes turned out to be normal as well.  The patient denies nosebleed, visual changes, nausea, vomiting, diarrhea or changes in bowel habits.  She has not had any musculoskeletal or neurological deficits.  She denies any rashes or skin lesions.,PAST MEDICAL HISTORY:  ,Hypertension, diabetes, hyperlipidemia, particularly elevated triglycerides with a slightly elevated LDL at 81 with an new standard LDL of 74, diabetics with a bad family history for cardiovascular disease such as this patient does have, and postmenopausal hot flashes.,PAST SURGICAL HISTORY:  ,Cholecystectomy, appendectomy, oophorectomy.,FAMILY HISTORY: , Positive for coronary artery disease in her father and brother in their 40s.,SOCIAL HISTORY: , She is married and does not smoke or drink nor did she ever.,PHYSICAL EXAMINATION: , On admission, temperature 99.4 degrees F., blood pressure 137/60, pulse 90 and regular without ectopy, respiratory rate 20 without unusual respiratory effort.  In general, she is well developed, well nourished, oriented, and alert and in no apparent distress.  Head, ears, eyes, nose, and throat are unremarkable.  Neck is supple.  No neck vein distention is noted.  No bruits are heard.  Chest is clear to percussion and auscultation.  Heart has a regular rhythm and rate without murmurs or rubs or gallops.  Abdomen is soft, obese, and nontender.  Musculoskeletal is intact without deformity.  However, the patient did develop severe cramp behind her left knee during her treadmill testing.  Neurologic:  Cranial nerves are intact and she is nonfocal.  Skin is warm and dry without rash or lesions noted.,LABORATORY FINDINGS: , Glucose 162, BUN 14, creatinine 1.0, sodium 137, potassium 3.6, chloride 103, bicarbonate 23, protein 4.2.  Liver function panel is normal.  CK was 82.  MB fraction was 1.0.  Troponin was less than 0.1 on three occasions.  White count was 12,200 with a normal differential, hemoglobin was 12.1, platelet count 230,000.  Urinalysis showed positive nitrites, positive leukocyte esterase, 5 to 10 white cells per high power field, and 1+ bacteria rods.  Spinal fluid was clear with 11 red cells, glucose 75, protein 67, white count 0.  EKG was normal.,DIAGNOSES ON ADMISSION:,1.  Urinary tract infection.,2.  Chest pain of unclear etiology, rule out myocardial infarction.,3.  Neck and back pain of unclear etiology with a negative spinal tap.,4.  Hypertension.,5.  Diabetes type II, not treated with insulin.,6.  Hyperlipidemia treated with TriCor but not statins.,7.  Arthritis.,ADDITIONAL LABORATORY STUDIES:,  B-natriuretic peptide was 26.  Urine smear and culture negative on 24 and 48 hours.  Chest x-ray was negative.  Lipid panel - triglycerides 249, VLDL 49, HDL 33, LDL 81.,COURSE IN THE HOSPITAL: , The patient was placed on home medications.  This will be listed at the end of the discharge summary.  She was put on rule out acute myocardial infarction routine, and she did in fact rule out.  She had a stress test completed on the day of discharge which was normal, and she was discharged with a diagnoses of chest pain, acute myocardial infarction ruled out, urinary tract infection, fever secondary to UTI, diabetes mellitus type 2 non-insulin treated, hyperlipidemia with elevated triglycerides and an LDL elevated to 81 with new normal being less than 70.  She has a strong family history of early myocardial disease in the men in their 40s.,DISCHARGE MEDICATIONS:,1.  Enteric-coated aspirin 81 mg one daily.  This is new, as the patient was not taking aspirin at home.,2.  TriCor 48 mg one daily.,3.  Zantac 40 mg one daily.,4.  Lisinopril 20 mg one daily.,5.  Mobic 75 mg one daily for arthritis.,6.  Metformin 500 mg one daily.,7.  Macrodantin one two times a day for several more days.,8.  Zocor 20 mg one daily, which is a new addition.,9.  Effexor XR 37.5 mg one daily.,DIET: , ADA 1800-calorie diet.,ACTIVITY:,  As tolerated.  Continue water exercise five days a week.,DISPOSITION: , Recheck at Hospital with a regular physician there in 1 week.  Consider Byetta as an adjunct to her diabetic treatment and efforts to weight control.",
 This is a 25-year-old male with nonspecific right-sided chest/abdominal pain from an unknown etiology., Emergency Room Reports, ER Report - Rib Cage Pain ,"HISTORY:,  The patient is a 25-year-old gentleman who was seen in the emergency room at Children's Hospital today.  He brought his 3-month-old daughter in for evaluation but also wanted to be evaluated himself because he has had ""rib cage pain"" for the last few days.  He denies any history of trauma.  He does have increased pain with laughing.  Per the patient, he also claims to have an elevated temperature yesterday of 101.  Apparently, the patient did go to the emergency room at ABCD yesterday, but due to the long wait, he left without actually being evaluated and then thought that he might be seen today when he came to Children's.,PAST MEDICAL HISTORY: , The patient has a medical history significant for ""Staphylococcus infection"" that was being treated with antibiotics for 10 days.,CURRENT MEDICATIONS: , He states that he is currently taking no medications.,ALLERGIES:  ,He is not allergic to any medication.,PAST SURGICAL HISTORY: , He denies any past surgical history.,SOCIAL HISTORY: , The patient apparently has a history of methamphetamine use and cocaine use approximately 1 year ago.  He also has a history of marijuana used approximately 1 year ago.  He currently states that he is in a rehab program.,FAMILY HISTORY:,  Unknown by the patient.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature is 99.9, blood pressure is 108/65, pulse of 84, respirations are 16.,GENERAL:  He is alert and appeared to be in no acute distress.  He had normal hydration.,HEENT:  His pupils were equal, round, reactive.  Extraocular muscles intact.  He had no erythema or exudate noted in his posterior oropharynx.,NECK:  Supple with full range of motion.  No lymphadenopathy noted.,RESPIRATORY:  He had equal breath sounds bilaterally with no wheezes, rales, or rhonchi and no labored breathing; however, he did occasionally have pain with deep inspiration at the right side of his chest.,CARDIOVASCULAR:  Regular rate and rhythm.  Positive S1, S2.  No murmurs, rubs, or gallops noted.,GI:  Nontender, nondistended with normoactive bowel sounds.  No masses noted.,SKIN:  Appeared normal except on the left anterior tibial area where the patient had a healing skin lesion.  There were no vesicles, erythema or induration noted.,MUSCULOSKELETAL:  Nontender with normal range of motion.,NEURO/PSYCHE:  The patient was alert and oriented x3 with nonfocal neurological exam.,ASSESSMENT: , This is a 25-year-old male with nonspecific right-sided chest/abdominal pain from an unknown etiology.,PLAN: , Due to the fact that this patient is an adult male, we will transfer him to XYZ Medical Center for further evaluation.  I have spoken with XYZ Medical Center Dr. X who has accepted the patient for transfer.  He was advised that the patient will be coming in a private vehicle due to fact that he is completely stable and appears to be in no acute distress.  Dr. X was happy to accept the transfer and indicated that the patient should come to the emergency room area with the transport paperwork.  The plan was explained in detail to the patient who stated that he understood and would comply.  The appropriate paperwork was created and one copy was given to the patient.,CONDITION ON DISCHARGE: , At the time of discharge, he was stable, vital signs stable, in no acute distress.",
 Patient in ER complaining of shortness of breath (COPD), Emergency Room Reports, ER Report - COPD ,"CHIEF COMPLAINT:,  The patient is a 49-year-old Caucasian male transported to the emergency room by his wife, complaining of shortness of breath.,HISTORY OF PRESENT ILLNESS:, The patient is known by the nursing staff here to have a long history of chronic obstructive pulmonary disease and emphysema. He has made multiple visits in the past. Today, the patient presents himself in severe respiratory distress. His wife states that since his recent admission of three weeks ago for treatment of pneumonia, he has not seemed to be able to recuperate, and has persistent complaints of shortness of breath.,Today, his symptoms worsened and she brought him to the emergency room. To the best of her knowledge, there has been no fever. He has persistent chronic cough, as always. More complete history cannot be taken because of the patient’s acute respiratory decompensation.,PAST MEDICAL HISTORY:,  Hypertension and emphysema.,MEDICATIONS:,  Lotensin and some water pill as well as, presumably, an Atrovent inhaler.,ALLERGIES:,  None are known.,HABITS:,  The patient is unable to cooperate with the history.,SOCIAL HISTORY:,  The patient lives in the local area with his wife.,REVIEW OF BODY SYSTEMS:,  Unable, secondary to the patient’s condition.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 96 degrees, axillary. Pulse 128. Respirations 48. Blood pressure 156/100. Initial oxygen saturations on room air are 80.,GENERAL: Reveals a very anxious, haggard and exhausted-appearing male, tripoding, with labored breathing.,HEENT: Head is normocephalic and atraumatic.,NECK: The neck is supple without obvious jugular venous distention.,LUNGS: Auscultation of the chest reveals very distant and faint breath sounds, bilaterally, without obvious rales.,HEART: Cardiac examination reveals sinus tachycardia, without pronounced murmur.,ABDOMEN: Soft to palpation.,Extremities: Without edema.,DIAGNOSTIC DATA:,  White blood count 25.5, hemoglobin 14, hematocrit 42.4, 89 polys, 1 band, 4 lymphocytes. Chemistry panel within normal limits, with the exception of sodium of 124, chloride 81, CO2 44, BUN 6, creatinine 0.7, glucose 182, albumin 3.3 and globulin 4.1. Troponin is 0.11. Urinalysis reveals yellow clear urine. Specific gravity greater than 1.030 with 2+ ketones, 1+ blood and 3+ protein. No white cells and 0-2 red cells.,Chest x-ray suboptimal in quality, but without obvious infiltrates, consolidation or pneumothorax.,CRITICAL CARE NOTE:,  Critical care one hour.,Shortly after the patient’s initial assessment, the patient apparently began to complain of chest pain and appeared to the nurse to have mounting exhaustion and respiratory distress. Although O2 had been placed, elevating his oxygen saturations to the mid to upper 90s, he continued to complain of symptoms, as noted above. He became progressively more rapidly obtunded. The patient did receive one gram of magnesium sulfate shortly after his arrival, and the BiPAP apparatus was being readied for his use. However, the patient, at this point, became unresponsive, unable to answer questions, and preparations were begun for intubation. The BiPAP apparatus was briefly placed while supplies and medications were assembled for intubation. It was noted that even with the BiPAP apparatus, in the duration of time which was required for transfer of oxygen tubing to the BiPAP mask, the patient’s O2 saturations rapidly dropped to the upper 60 range.,All preparations for intubation having been undertaken, Succinylcholine was ordered, but was apparently unavailable in the department. As the patient was quite obtunded, and while the Dacuronium was being sought, an initial trial of intubation was carried out using a straight blade and a cupped 7.9 endotracheal tube. However, the patient had enough residual muscle tension to make this impractical and further efforts were held pending administration of Dacuronium 10 mg. After approximately two minutes, another attempt at intubation was successful. The cords were noted to be covered with purulent exudates at the time of intubation.,The endotracheal tube, having been placed atraumatically, the patient was initially then nebulated on 100% oxygen, and his O2 saturations rapidly rose to the 90-100% range.,Chest x-ray demonstrated proper placement of the tube. The patient was given 1 mg of Versed, with decrease of his pulse from the 140-180 range to the 120 range, with satisfactory maintenance of his blood pressure.,Because of a complaint of chest pain, which I myself did not hear, during the patient’s initial triage elevation, a trial of Tridil was begun. As the patient’s pressures held in the slightly elevated range, it was possible to push this to 30 mcg per minute. However, after administration of the Dacuronium and Versed, the patient’s blood pressure fell somewhat, and this medication was discontinued when the systolic pressure briefly reached 98.,Because of concern regarding pneumonia or sepsis, the patient received one gram of Rocephin intravenously shortly after the intubation. A nasogastric and Foley were placed, and an arterial blood gas was drawn by respiratory therapy. Dr. X was contacted at this point regarding further orders as the patient was transferred to the Intensive Care Unit to be placed on the ventilator there. The doctor’s call was transferred to the Intensive Care Unit so he could leave appropriate orders for the patient in addition to my initial orders, which included Albuterol or Atrovent q. 2h. and Levaquin 500 mg IV, as well as Solu-Medrol.,Critical care note terminates at this time.,EMERGENCY DEPARTMENT COURSE:,  See the critical care note.,MEDICAL DECISION MAKING (DIFFERENTIAL DIAGNOSIS):,  This patient has an acute severe decompensation with respiratory failure. Given the patient’s white count and recent history of pneumonia, the possibility of recurrence of pneumonia is certainly there. Similarly, it would be difficult to rule out sepsis. Myocardial infarction cannot be excluded.,COORDINATION OF CARE:,  Dr. X was contacted from the emergency room and asked to assume the patient’s care in the Intensive Care Unit.,FINAL DIAGNOSIS:,  Respiratory failure secondary to severe chronic obstructive pulmonary disease.,DISCHARGE INSTRUCTIONS:, The patient is to be transferred to the Intensive Care Unit for further management.",
 Significant pain in left lower jaw., Emergency Room Reports, Dental Pain - Emergency Visit ,"CHIEF COMPLAINT: , Dental pain.,HISTORY OF PRESENT ILLNESS: , This is a 45-year-old Caucasian female who states that starting last night she has had very significant pain in her left lower jaw.  The patient states that she can feel an area with her tongue and one of her teeth that appears to be fractured.  The patient states that the pain in her left lower teeth kept her up last night.  The patient did go to Clinic but arrived there later than 7 a.m., so she was not able to be seen there will call line for dental care.  The patient states that the pain continues to be very severe at 9/10.  She states that this is like a throbbing heart beat in her left jaw.  The patient denies fevers or chills.  She denies purulent drainage from her gum line.  The patient does believe that there may be an area of pus accumulating in her gum line however.  The patient denies nausea or vomiting.  She denies recent dental trauma to her knowledge.,PAST MEDICAL HISTORY:,1.  Coronary artery disease.,2.  Hypertension.,3.  Hypothyroidism.,PAST SURGICAL HISTORY:  ,Coronary artery stent insertion.,SOCIAL HABITS: , The patient denies alcohol or illicit drug usage.  Currently she does have a history of tobacco abuse.,MEDICATIONS:,1.  Plavix.,2.  Metoprolol.,3.  Synthroid.,4.  Potassium chloride.,ALLERGIES:,1.  Penicillin.,2.  Sulfa.,PHYSICAL EXAMINATION:,GENERAL:  This is a Caucasian female who appears of stated age of 45 years.  She is well-nourished, well-developed, in no acute distress.  The patient is pleasant but does appear to be uncomfortable.,VITAL SIGNS:  Afebrile, blood pressure 145/91, pulse of 78, respiratory rate of 18, and pulse oximetry of 98% on room air.,HEENT:  Head is normocephalic.  Pupils are equal, round and reactive to light and accommodation.  Sclerae are anicteric and noninjected.  Nares are patent and free of mucoid discharge.  Mucous membranes are moist and free of exudate or lesion.  Bilateral tympanic membranes are visualized and free of infection or trauma.  Dentition shows significant decay throughout the dentition.  The patient has had extraction of teeth 17, 18, and 19.  The patient's tooth #20 does have a small fracture in the posterior section of the tooth and there does appear to be a very minor area of fluctuance and induration located at the alveolar margin at this site.  There is no pus draining from the socket of the tooth.  No other acute abnormality to the other dentition is visualized.,DIAGNOSTIC STUDIES: , None.,PROCEDURE NOTE:  ,The patient does receive an injection of 1.5 mL of 0.5% bupivacaine for inferior alveolar nerve block on the left mandibular teeth.  The patient undergoes this all procedure without complication and does report some mild decrease of her pain with this and patient was also given two Vicodin here in the Emergency Department and a dose of Keflex for treatment of her dental infection.,ASSESSMENT:  ,Dental pain with likely dental abscess.  ,PLAN: , The patient was given a prescription for Vicodin.  She is also given prescription for Keflex, as she is penicillin allergic.  She has tolerated a dose of Keflex here in the Emergency Department well without hypersensitivity.  The patient is strongly encouraged to follow up with Dental Clinic on Monday, and she states that she will do so.  The patient verbalizes understanding of treatment plan and was discharged in satisfactory condition from the ER.,",
" Cerebrovascular accident (CVA).  The patient presents to the emergency room after awakening at 2:30 a.m. this morning with trouble swallowing, trouble breathing, and left-sided numbness and weakness. ", Emergency Room Reports, CVA Consult - ER Visit ,"ADMITTING DIAGNOSIS: , Cerebrovascular accident (CVA).,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old gentleman with a significant past medical history for nasopharyngeal cancer status post radiation therapy to his pharynx and neck in 1991 who presents to the emergency room after awakening at 2:30 a.m. this morning with trouble swallowing, trouble breathing, and left-sided numbness and weakness.  This occurred at 2:30 a.m.  His wife said that he had trouble speaking as well, but gradually the symptoms resolved but he was still complaining of a headache and at that point, he was brought to the emergency room.  He arrived at the emergency room here via private ambulance at 6:30 a.m. in the morning.  Upon initial evaluation, he did have some left-sided weakness and was complaining of a headache.  He underwent workup including a CT, which was negative and his symptoms slowly began to resolve.  He was initially admitted, placed on Plavix and aspirin.  However a few hours later, his symptoms returned and he had increasing weakness of his left arm and left leg as well as slurred speech.  Repeat CT scan again done reportedly was negative and he was subsequently heparinized and admitted.  He also underwent an echo, carotid ultrasound, and lab work in the emergency room.  Wife is at the bedside and denies he had any other symptoms previous to this.  He denied any chest pain or palpitations.  She does report that he is on a Z-Pak, got a cortisone shot, and some decongestant from Dr. ABC on Saturday because of congestion and that had gotten better.,ALLERGIES:  ,He has no known drug allergies.,CURRENT MEDICATIONS:,1.  Multivitamin.,2.  Ibuprofen p.r.n.,PAST MEDICAL HISTORY:,1.  Nasopharyngeal cancer.  Occurred in 1991.  Status post XRT of the nasopharyngeal area and his neck because of spread to the lymph nodes.,2.  Lumbar disk disease.,3.  Status post diskectomy.,4.  Chronic neck pain secondary to XRT.,5.  History of thalassemia.,6.  Chronic dizziness since his XRT in 1991.,PAST SURGICAL HISTORY: , Lumbar diskectomy, which is approximately 7 to 8 years ago, otherwise negative.,SOCIAL HISTORY: , He is a nonsmoker.  He occasionally has a beer.  He is married.  He works as a flooring installer.,FAMILY HISTORY:  ,Pertinent for father who died of an inoperable brain tumour.  Mother is obese, but otherwise negative history.,REVIEW OF SYSTEMS:  ,He reports he was in his usual state of health up until he awoke this morning.  He does states that yesterday his son cleaned the walk area with some ether and since then he has not quite been feeling right.  He is a right-handed male and normally wears glasses.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Stable.  His blood pressure was 156/97 in the emergency room, pulse is 73, respiratory rate 20, and saturation is 99%.,GENERAL:  He is alert, pleasant, and in no acute distress at this time.  He answers questions appropriately.,HEENT:  Pupils are equal, round, and reactive to light.  Extraocular muscles are intact.  Sclerae are clear.  TMs clear.  Oropharynx is clear.,NECK:  Supple with full range of motion.  He does have some increased density to neck, I assume, secondary to XRT.,CARDIOVASCULAR:  Regular rate and rhythm without murmur.,LUNGS:  Clear bilaterally.,ABDOMEN:  Soft, nontender, and nondistended.,EXTREMITIES:  Show no clubbing, cyanosis or edema.,NEUROLOGIC:  He does have a minimally slurred speech at present.  He does have a slight facial droop.  He has significant left upper extremity weakness approximately 3-4/5, left lower extremity weakness is approximately a 2-3/5 on the left.  Handgrip is about 4/5 on the left, right side is 5/5.,LABORATORY DATA:  ,His initial blood work, PT was 11 and PTT 27.  CBC is within normal limits except for hemoglobin of 12.9 and hematocrit of 39.1.  Chem panel is all normal.,EKG showed normal sinus rhythm, normal EKG.  CT of his brain, initially his first CT, which was done this morning at approximately 7 a.m. showed a normal CT.  Repeat CT done at approximately 3:30 p.m. this evening was reportedly also normal.  He underwent an echocardiogram in the emergency room, which was essentially normal.  He had a carotid ultrasound, which revealed total occlusion of the right internal carotid artery, 60% to 80% stenosis of the left internal carotid artery, and 60% stenosis of the left external carotid artery.,MPRESSION AND PLAN:,1.  Cerebrovascular accident, in progress.",
 Consultation for ICU management for a patient with possible portal vein and superior mesenteric vein thrombus leading to mesenteric ischemia., Emergency Room Reports, Consult - ICU Management ,"REASON FOR CONSULTATION: , ICU management.,HISTORY OF PRESENT ILLNESS: , The patient is a 43-year-old gentleman who presented from an outside hospital with complaints of right upper quadrant pain in the abdomen, which revealed possible portal vein and superior mesenteric vein thrombus leading to mesenteric ischemia.  The patient was transferred to the ABCD Hospital where he had a weeklong course with progressive improvement in his status after aggressive care including intubation, fluid resuscitation, and watchful waiting.  The patient clinically improved; however, his white count remained elevated with the intermittent fevers prompting a CT scan.  Repeat CT scan showed a loculated area of ischemic bowel with perforation in the left upper abdomen.  The patient was taken emergently to the operating room last night by the General Surgery Service where proximal half of the jejunum was noted to be liquified with 3 perforations.  This section of small bowel was resected, and a wound VAC placed for damage control.  Plan was to return the patient to the Operating Room tomorrow for further exploration and possible re-anastomosis of the bowel.  The patient is currently intubated, sedated, and on pressors for septic shock and in the down ICU.,PAST MEDICAL HISTORY:,  Prior to coming into the hospital for this current episode, the patient had hypertension, diabetes, and GERD.,PAST SURGICAL HISTORY:,  Included a cardiac cath with no interventions taken.,HOME MEDICATIONS:,  Include Lantus insulin as well as oral hypoglycemics.,CURRENT MEDS:,  Include Levophed, Ativan, fentanyl drips, cefepime, Flagyl, fluconazole, and vancomycin.  Nexium, Synthroid, hydrocortisone, and Angiomax, which is currently on hold.,REVIEW OF SYSTEMS:,  Unable to be obtained secondary to the patient's intubated and sedated status.,ALLERGIES: , None.,FAMILY HISTORY:,  Includes diabetes on his father side of the family.  No other information is provided.,SOCIAL HISTORY:,  Includes tobacco use as well as alcohol use.,PHYSICAL EXAMINATION:,GENERAL: The patient is currently intubated and sedated on Levophed drip.,VITAL SIGNS: Temperature is 100.6, systolic is 110/60 with MAP of 80, and heart rate is 120, sinus rhythm.,NEUROLOGIC: Neurologically, he is sedated, on Ativan with fentanyl drip as well.  He does arouse with suctioning, but is unable to open his eyes to commands.,HEAD AND NECK EXAMINATION: His pupils are equal, round, reactive, and constricted.  He has no scleral icterus.  His mucous membranes are pink, but dry.  He has an EG tube, which is currently 24-cm at the lip.  He has a left-sided subclavian vein catheter, triple lumen.,NECK: His neck is without masses or lymphadenopathy or JVD.,CHEST: Chest has diminished breath sounds bilaterally.,ABDOMEN: Abdomen is soft, but distended with a wound VAC in place.  Groins demonstrate a left-sided femoral outline.,EXTREMITIES: His bilateral upper extremities are edematous as well as his bilateral lower extremities; however, his right is more than it is in the left.  His toes are cool, and pulses are not palpable.,LABORATORY EXAMINATION: , Laboratory examination reveals an ABG of 7.34, CO2 of 30, O2 of 108, base excess of -8, bicarb of 16.1, sodium of 144, potassium of 6.5, chloride of 122, CO2 18, BUN 43, creatinine 2.0, glucose 172, calcium 6.6, phosphorus 1.1, mag 1.8, albumin is 1.6, cortisone level random is 22.  After stimulation with cosyntropin, they were still 22 and then 21 at 30 and 60 minutes respectively.  LFTs are all normal.  Amylase and lipase are normal.  Triglycerides are 73, INR is 2.2, PTT is 48.3, white count 20.7, hemoglobin 9.6, and platelets of 211.  UA was done, which also shows a specific gravity of 1.047, 1+ protein, trace glucose, large amount of blood, and many bacteria.  Chest x-rays performed and show the tip of the EG tube at level of the carina with some right upper lobe congestion, but otherwise clear costophrenic angles.  Tip of the left subclavian vein catheter is appropriate, and there is no pneumothorax noted.,ASSESSMENT AND PLAN:,  This is a 43-year-old gentleman who is acutely ill, in critical condition with mesenteric ischemia secondary to visceral venous occlusion.  He is status post small bowel resection.  We plan to go back to operating room tomorrow for further debridement and possible closure.  Neurologically, the patient initially had question of encephalopathy while in the hospital secondary to slow awakening after previous intubation; however, he did clear eventually, and was able to follow commands.  I did not suspect any sort of pathologic abnormality of his neurologic status as he has further CT scan of his brain, which was normal.  Currently, we will keep him sedated and on fentanyl drip to ease pain and facilitate ventilation on the respirator.  We will form daily sedation holidays to assess his neurologic status and avoid over sedating with Ativan.,1.  Cardiovascular.  The patient currently is in septic shock requiring vasopressors maintained on MAP greater than 70.  We will continue to try to wean the vasopressin after continued volume loading, also place SvO2 catheter to assess his oxygen delivery and consumption given his state of shock.  Currently, his rhythm is of sinus tachycardia, I do not suspect AFib or any other arrhythmia at this time.  If he does not improve as expected with volume resuscitation and with resolution of his sepsis, we will obtain an echocardiogram to assess his cardiac function.  Once he is off the vasopressors, we will try low-dose beta blockade as tolerated to reduce his rate.,2.  Pulmonology.  Currently, the patient is on full vent support with a rate of 20, tidal volume of 550, pressure support of 10, PEEP of 6, and FiO2 of 60.  We will wean his FiO2 as tolerated to keep his saturation greater than 90% and wean his PEEP as tolerated to reduce preload compromise.  We will keep the head of bed elevated and start chlorhexidine as swish and swallow for VAP prevention.,3.  Gastrointestinal.  The patient has known mesenteric venous occlusion secondary to the thrombus formation at the portal vein as well as the SMV.  He is status post immediate resection of jejunum leaving a blind proximal jejunum and blind distal jejunum.  We will maintain NG tube as he has a blind stump there, and we will preclude any further administration of any meds through this NG tube.  I will keep him on GI prophylaxis as he is intubated.  We will currently hold his TPN as he is undergoing a large amount of volume changes as well as he is undergoing electrolyte changes.  He will have a long-term TPN after this acute episode.  His LFTs are all normal currently.  Once he is postop tomorrow, we will restart the Angiomax for his venous occlusion.,4.  Renal.  The patient currently is in the acute renal insufficiency with anuria and an increase in his creatinine as well as his potassium.  His critical hyperkalemia which is requiring dosing of dextrose insulin, bicarb, and calcium; we will recheck his potassium levels after this cocktail.  He currently is started to make more urine since being volume resuscitated with Hespan as well as bicarb drip.  Hopefully given his increased urine output, he will start to eliminate some potassium and will not need dialysis.  We will re-consult Nephrology at this time.,5.  Endocrine.  The patient has adrenal insufficiency based on lack of stem to cosyntropin.  We will start hydrocortisone 50 q.6h.,6.  Infectious Disease.  Currently, the patient is on broad-spectrum antibiotic prophylaxis imperially.  Given his bowel ischemia, we will continue these, and appreciate ID service's input.,7.  Hematology.  Hematologically, the patient has a hypercoagulable syndrome, also had HIT secondary to his heparin administration.  We will restart the Angiomax once he is back from the OR tomorrow.  Currently, his INR is 2.2.  Therefore, he should be covered at the moment.  Appreciate the Hematology's input in this matter.,Please note the total critical care time spent at the bedside excluding central line placement was 1 hour.",
 A female with unknown gestational age who presents to the ED after a suicide attempt., Emergency Room Reports, Consult/ER Report - OB/GYN ,"The patient states that she has abnormal menstrual periods and cannot remember the first day of her last normal menstrual period.  She states that she had spotting for three months daily until approximately two weeks ago, when she believes that she passed a fetus.  She states that upon removal of a tampon, she saw a tadpole like structure and believed it to be a fetus.  However, she states she did not know that she was pregnant at this time.  She denies any abdominal pain or vaginal bleeding.  She states that the pregnancy is unplanned; however, she would desire to continue the pregnancy.,PAST MEDICAL HISTORY:  Diabetes mellitus which resolved after weight loss associated with gastric bypass surgery.,PAST SURGICAL HISTORY:,1.  Gastric bypass.,2.  Bilateral carpal tunnel release.,3.  Laparoscopic cholecystectomy.,4.  Hernia repair after gastric bypass surgery.,5.  Thoracotomy.,6.  Knee surgery.,MEDICATIONS:,1.  Lexapro 10 mg daily.,2.  Tramadol 50 mg tablets two by mouth four times a day.,3.  Ambien 10 mg tablets one by mouth at bedtime.,ALLERGIES:  AMOXICILLIN CAUSES THROAT SWELLING.  AVELOX CAUSES IV SITE SWELLING.,SOCIAL HISTORY:  The patient denies tobacco, ethanol, or drug use.  She is currently separated from her partner who is the father of her 21-month-old daughter.  She currently lives with her parents in Greenville.  However, she was visiting the estranged boyfriend in Wilkesboro, this week.,GYN HISTORY:  The patient denies history of abnormal Pap smears or STDs.,OBSTETRICAL HISTORY:  Gravida 1 was a term spontaneous vaginal delivery, complicated only by increased blood pressures at the time of delivery.  Gravida 2 is current.,REVIEW OF SYSTEMS:  The 14-point review of systems was negative with the exception as noted in the HPI.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure 134/45, pulse 130, respirations 28.  Oxygen saturation 100%.,GENERAL:  Patient lying quietly on a stretcher.  No acute distress.,HEENT:  Normocephalic, atraumatic.  Slightly dry mucous membranes.,CARDIOVASCULAR EXAM:  Regular rate and rhythm with tachycardia.,CHEST:  Clear to auscultation bilaterally.,ABDOMEN:  Soft, nontender, nondistended with positive bowel sounds.  No rebound or guarding.,SKIN:  Normal turgor.  No jaundice.  No rashes noted.,EXTREMITIES:  No clubbing, cyanosis, or edema.,NEUROLOGIC:  Cranial nerves II through XII grossly intact.,PSYCHIATRIC:  Flat affect.  Normal verbal response.,ASSESSMENT AND PLAN:  A 34-year-old Caucasian female, gravida 2 para 1-0-0-1, at unknown gestation who presents after suicide attempt.,1.  Given the substances taken, medications are unlikely to affect the development of the fetus.  There have been no reported human anomalies associated with Ambien or tramadol use.  There is, however, a 4% risk of congenital anomalies in the general population.,2.  Recommend quantitative HCG and transvaginal ultrasound for pregnancy dating.,3.  Recommend prenatal vitamins.,4.  The patient to follow up as an outpatient for routine prenatal care.,",
" Status post colonoscopy.  After discharge, experienced bloody bowel movements and returned to the emergency department for evaluation.", Emergency Room Reports, Blood per Rectum ,"CHIEF COMPLAINT:, Bright red blood per rectum ,HISTORY OF PRESENT ILLNESS: ,This 73-year-old woman had a recent medical history significant for renal and bladder cancer, deep venous thrombosis of the right lower extremity, and anticoagulation therapy complicated by lower gastrointestinal bleeding. Colonoscopy during that admission showed internal hemorrhoids and diverticulosis, but a bleeding site was not identified. Five days after discharge to a nursing home, she again experienced bloody bowel movements and returned to the emergency department for evaluation. ,REVIEW OF SYMPTOMS: ,No chest pain, palpitations, abdominal pain or cramping, nausea, vomiting, or lightheadedness. Positive for generalized weakness and diarrhea the day of admission. ,PRIOR MEDICAL HISTORY:, Long-standing hypertension, intermittent atrial fibrillation, and hypercholesterolemia. Renal cell carcinoma and transitional cell bladder cancer status post left nephrectomy, radical cystectomy, and ileal loop diversion 6 weeks prior to presentation, postoperative course complicated by pneumonia, urinary tract infection, and retroperitoneal bleed. Deep venous thrombosis 2 weeks prior to presentation, management complicated by lower gastrointestinal bleeding, status post inferior vena cava filter placement. ,MEDICATIONS: ,Diltiazem 30 mg tid, pantoprazole 40 mg qd, epoetin alfa 40,000 units weekly, iron 325 mg bid, cholestyramine. Warfarin discontinued approximately 10 days earlier. ,ALLERGIES: ,Celecoxib (rash).,SOCIAL HISTORY:, Resided at nursing home. Denied alcohol, tobacco, and drug use. ,FAMILY HISTORY:, Non-contributory.,PHYSICAL EXAM: ,Temp = 38.3C BP =146/52 HR= 113 RR = 18 SaO2 = 98% room air ,General: Pale, ill-appearing elderly female. ,HEENT: Pale conjunctivae, oral mucous membranes moist. ,CVS: Irregularly irregular, tachycardia. ,Lungs: Decreased breath sounds at the bases. ,Abdomen: Positive bowel sounds, soft, nontender, nondistended, gross blood on rectal exam. ,Extremities: No cyanosis, clubbing, or edema. ,Skin: Warm, normal turgor. ,Neuro: Alert and oriented. Nonfocal. ,LABS: ,CBC: ,WBC count: 6,500 per mL ,Hemoglobin: 10.3 g/dL ,Hematocrit:31.8% ,Platelet count: 248 per mL ,Mean corpuscular volume: 86.5 fL ,RDW: 18% ,CHEM 7: ,Sodium: 131 mmol/L ,Potassium: 3.5 mmol/L ,Chloride: 98 mmol/L ,Bicarbonate: 23 mmol/L ,BUN: 11 mg/dL ,Creatinine: 1.1 mg/dL ,Glucose: 105 mg/dL ,COAGULATION STUDIES: ,PT 15.7 sec ,INR 1.6 ,PTT 29.5 sec ,HOSPITAL COURSE: ,The patient received 1 liter normal saline and diltiazem (a total of 20 mg intravenously and 30 mg orally) in the emergency department. Emergency department personnel made several attempts to place a nasogastric tube for gastric lavage, but were unsuccessful. During her evaluation, the patient was noted to desaturate to 80% on room air, with an increase in her respiratory rate to 34 breaths per minute. She was administered 50% oxygen by nonrebreadier mask, with improvement in her oxygen saturation to 89%. Computed tomographic angiography was negative for pulmonary embolism. ",
 Chest tube insertion done by two physicians in ER - spontaneous pneumothorax secondary to barometric trauma., Emergency Room Reports, Chest Tube Insertion in ER ,"PREOPERATIVE DIAGNOSES:,1.  Right spontaneous pneumothorax secondary to barometric trauma.,2.  Respiratory failure.,3.  Pneumonia with sepsis.,POSTOPERATIVE DIAGNOSES:,1.  Right spontaneous pneumothorax secondary to barometric trauma.,2.  Respiratory failure.,3.  Pneumonia with sepsis.,INFORMED CONSENT: , Not obtained.  This patient is obtunded, intubated, and septic.  This is an emergent procedure with 2-physician emergency consent signed and on the chart.,PROCEDURE: , The patient's right chest was prepped and draped in sterile fashion.  The site of insertion was anesthetized with 1% Xylocaine, and an incision was made.  Blunt dissection was carried out 2 intercostal spaces above the initial incision site.  The chest wall was opened, and a 32-French chest tube was placed into the thoracic cavity, after examination with the finger, making sure that the thoracic cavity had been entered correctly.  The chest tube was placed.,A postoperative chest x-ray is pending at this time.,The patient tolerated the procedure well and was taken to the recovery room in stable condition.,ESTIMATED BLOOD LOSS:,  10 mL,COMPLICATIONS:,  None.,SPONGE COUNT: , Correct x2.","emergency room reports, spontaneous pneumothorax, barometric trauma, respiratory failure, sepsis, pneumonia, blunt dissection, chest wall, thoracic cavity, chest x-ray, chest tube insertion, chest tube, pneumothorax, tube, chest, insertion,"
" Patient had a piece of glass fall on to his right foot.  A 4-mm laceration.  Acute foot pain, now resolved.   The patient was given discharge instructions on wound care.", Emergency Room Reports, Cut on Foot - ER Visit ,"CHIEF COMPLAINT:,  Cut on foot.,HISTORY OF PRESENT ILLNESS:,  This is a 32-year-old male who had a piece of glass fall on to his right foot today.  The patient was concerned because of the amount of bleeding that occurred with it.  The bleeding has been stopped and the patient does not have any pain.  The patient has normal use of his foot, there is no numbness or weakness, the patient is able to ambulate well without any discomfort.  The patient denies any injuries to any other portion of his body.  He has not had any recent illness.  The patient has no other problems or complaints.,PAST MEDICAL HISTORY:,  Asthma.,CURRENT MEDICATION: , Albuterol.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient is a smoker.,PHYSICAL EXAMINATION:,  VITAL SIGNS:  Temperature 98.8 oral, blood pressure 132/86, pulse is 76, and respirations 16.  Oxygen saturation is 100% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well-nourished, well-developed, the patient appears to be healthy.  The patient is calm and comfortable in no acute distress and looks well.  The patient is pleasant and cooperative.  HEENT:  Head is atraumatic, normocephalic, and nontender.  Eyes are normal with clear conjunctiva and cornea bilaterally.  NECK:  Supple with full range of motion.  CARDIOVASCULAR:  Peripheral pulse is +2 to the right foot.  Capillary refills less than two seconds to all the digits of the right foot.  RESPIRATIONS:  No shortness of breath.  MUSCULOSKELETAL:  The patient has a 4-mm partial thickness laceration to the top of the right foot and about the area of the mid foot.  There is no palpable foreign body, no foreign body is visualized.  There is no active bleeding, there is no exposed deeper tissues and certainly no exposed tendons, bone, muscle, nerves, or vessels.  It appears that the laceration may have nicked a small varicose vein, which would have accounted for the heavier than usual bleeding that currently occurred at home.  The patient does not have any tenderness to the foot.  The patient has full range of motion to all the joints, all the toes, as well as the ankles.  The patient ambulates well without any difficulty or discomfort.  There are no other injuries noted to the rest of the body.  SKIN:  The 4-mm partial thickness laceration to the right foot as previously described.  No other injuries are noted.  NEUROLOGIC:  Motor is 5/5 to all the muscle groups of the right lower extremity.  Sensory is intact to light touch to all the dermatomes of the right foot.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is alert and oriented x4.  Normal mood and affect.  HEMATOLOGIC/LYMPHATIC:  No active bleeding is occurring at this time.  No evidence of bruising is noted to the body.,EMERGENCY DEPARTMENT COURSE:,  The patient had antibiotic ointment and a bandage applied to his foot.,DIAGNOSES:,1.  A 4-MM LACERATION TO THE RIGHT FOOT.,2.  ACUTE RIGHT FOOT PAIN, NOW RESOLVED.,CONDITION UPON DISPOSITION: , Stable.,DISPOSITION:,  To home.  The patient was given discharge instructions on wound care and asked to return to emergency room should he have any evidence or signs and symptoms of infection.  The patient was precautioned that there may still be a small piece of glass retained in the foot and that there is a possibility of infection or that the piece of glass may be extruded later on.","emergency room reports, foot pain, cut on foot, piece of glass, foreign body, active bleeding, foot, injuries, atraumatic, laceration, bleeding, body, "
 Status post a high-speed motor vehicle accident in which patient was ejected from the vehicle., Emergency Room Reports, Closed Head Injury ,"CHIEF COMPLAINT:,  Status post motor vehicle accident.,HISTORY OF PRESENT ILLNESS: , The patient is a 17-year-old white male who is status post a high-speed motor vehicle accident in which he was ejected from the vehicle.  He denies loss of consciousness, although the EMT people report that he did have loss of consciousness.  The patient was stable en route.  Upon arrival, he complained of headache.,PAST MEDICAL HISTORY:,  Medical:  None.  Surgical:  None.,REVIEW OF SYSTEMS: , CARDIAC:  No history.  PULMONARY:  Some morning cough.  (Patient is a smoker.),MEDICATIONS:,  None.,ALLERGIES:,  ALLERGIC TO PENICILLIN, CAUSES SKIN RASH.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure 120/80, pulse 82, respirations 20, temperature 36.8°.,HEENT:  Contusion over right occipital area.  Tympanic membranes benign.,NECK:  Nontender.,CHEST:  Atraumatic, nontender.,LUNGS:  Clear to auscultation and percussion.,ABDOMEN:  Flat, soft, and nontender.,BACK:  Atraumatic, nontender.,PELVIS:  Stable,EXTREMITIES:  Contusion over right forearm.  No bone deformity or crepitus.,RECTAL:  Normal sphincter tone; guaiac negative.,NEUROLOGIC:  Glasgow coma scale 15.  Pupils equal, round, reactive to light.  Patient moves all 4 extremities without focal deficit.,LABORATORY DATA: , Serial hematocrits 42.4, and 40.4.  White blood count 6.3.  Ethanol:  None.  Amylase 66.  Urinalysis normal.  PT 12.6, PTT 29.  Chem-7 panel within normal limits.,X-rays of cervical spine and lumbosacral spine within normal limits.  X-rays of pelvis and chest within normal limits.,ASSESSMENT:,1.  Closed head injury.,2.  Rule out intra-abdominal injury.,PLAN:,  The patient will be admitted to the trauma surgery service for continued evaluation and treatment for closed head injury as well as possible intra-abdominal injury.",
 2-month-old female - increased work of breathing., Emergency Room Reports, Bronchiolitis - 2-month-old ,"CHIEF COMPLAINT: , Increased work of breathing.,HISTORY OF PRESENT ILLNESS: , The patient is a 2-month-old female with a 9-day history of illness.  Per mom's report, the illness started 9 days ago with a dry cough.  The patient was eating normal up until approximately three days ago.  Mom was using a vaporizer at night, which she feels to have helped.  The patient's cough gradually worsened and three days ago, the patient had a significant increasing cough.  At that time, the patient also had significant increasing congestion.  Two days ago the patient was taken to the primary care physician's office and the patient was given Xopenex 2 puffs every 4 to 6 hours for home regimen, but this per mom's report, did not help the patient's symptoms.  On Wednesday evening, the patient's congestion and work of breathing increased and the patient was gagging after feedings.  The patient was brought to Children's Hospital Emergency Room at which time the patient was evaluated.  A chest x-ray was obtained and was noted to be normal.  The patient's saturations were noted to be normal and the patient was discharged home.  Last night, the patient was having multiple episodes of emesis after feedings with coughing and today was noted to have decreasing activity.  The patient had a 101 temperature on Wednesday evening, but has had no true fevers.  The patient has had a mild decrease in urine output today and secondary to the persistent increased work of breathing, coughing, and posttussive emesis, the patient was brought to Children's Hospital for reevaluation.,REVIEW OF SYSTEMS: , The remainder of the review of system is otherwise negative, all systems being reviewed, outside of pertinent positives as stated above.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,MEDICATIONS:  ,As above.,IMMUNIZATIONS:,  None.,PAST MEDICAL HISTORY:  ,No hospitalizations.  No surgeries.,BIRTH HISTORY: , The patient was born to a G8, P2, A6 mom via normal spontaneous vaginal delivery.  Birth weight 6 pounds 12 ounces.  Mom stated she had a uterine infection during her pregnancy and at the time of delivery, but the patient was only in the hospital for 24 hours with mom after delivery.  The patient was full term and mom was noted to have gestational diabetes controlled with diet during her pregnancy.,FAMILY HISTORY: , Brother, mother, and father all have asthma.  Mom was noted to have gestational diabetes.,SOCIAL HISTORY: , The patient lives with mother, father, and a brother.  There is one bird.  There are smokers in the household.  There are sick contacts.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature is 97.7 and pulse is 181, but the patient is fussy.  Respiratory rate ranged between 36 and 44.  The patient is saturating 100% on one-half liter and 89% on room air.,GENERAL APPEARANCE:  Nontoxic child, but with increased work of breathing.  No respiratory distress.,HEENT:  Head is normocephalic and atraumatic.  Anterior fontanelle flat.  Pupils are equal, round, and reactive to light bilaterally.  Tympanic membranes are clear bilaterally.  Nares are congested.  Mucous membranes are moist without erythema.,NECK:  Supple.  No lymphadenopathy.,CHEST:  Exhibits symmetric expansion and retractions.,LUNGS:  The patient has diffuse crackles bilaterally, but no wheezes, rales, or rhonchi.,CARDIOVASCULAR:  Heart has a 2/6 vibratory systolic ejection murmur, best heard over the left sternal boarder.,ABDOMEN:  Soft, nondistended, and nondistended.  Good bowel sounds noted in all 4 quadrants.,GU:  Normal female.  No discharge or erythema.,BACK:  Normal with a normal curvature.,EXTREMITIES:  A 2+ pulses in the bilateral upper lower extremities.  No evidence of clubbing, cyanosis, or edema.  Capillary refill less than 3 seconds.,LABORATORY DATA: , Labs in the emergency room include a CBC, which showed a white blood cell count of 20.8 with a hemoglobin of 10.7, hematocrit of 31.3 with platelet count of 715,000 with 40% neutrophils, 2 bands, and 70% monocytes.  A urinalysis obtained in the emergency room was noted to be negative.  CRP was noted to be 2.0.  The chest x-ray, reviewed by myself in the emergency room, showed no significant change from previous x-ray, but the patient does has some bronchial wall thickening.,ASSESSMENT AND PLAN: , This is a 2-month-old female who presents to Children's Hospital with examination consistent with bronchiolitis.  At this time, the patient will be placed on the bronchiolitis pathway providing this patient with aggressive suctioning and supplemental oxygen as needed.  Currently, at this time, I feel no respiratory treatments are indicated in this patient.  I hear no evidence of wheezing or reactive airway disease.  We will continue to monitor and reassess this patient closely for this as there is a strong family history of reactive airway disease; however, at this time, the patient will be monitored without any medications and the remainder of the clinical course will be determined by her presentation during the course of this illness.",
 Patient in ER due to colostomy failure - bowel obstruction., Emergency Room Reports, Colostomy Failure ,"CHIEF COMPLAINT:, Colostomy failure. ,HISTORY OF PRESENT ILLNESS:, This patient had a colostomy placed 9 days ago after resection of colonic carcinoma. Earlier today, he felt nauseated and stated that his colostomy stopped filling. He also had a sensation of ""heartburn."" He denies vomiting but has been nauseated. He denies diarrhea. He denies hematochezia, hematemesis, or melena. He denies frank abdominal pain or fever. ,PAST MEDICAL HISTORY:, As above. Also, hypertension. ,ALLERGIES:, ""Fleet enema."" ,MEDICATIONS:, Accupril and vitamins. ,REVIEW OF SYSTEMS:,SYSTEMIC: The patient denies fever or chills.,HEENT: The patient denies blurred vision, headache, or change in hearing.,NECK: The patient denies dysphagia, dysphonia, or neck pain.,RESPIRATORY: The patient denies shortness of breath, cough, or hemoptysis.,CARDIAC: The patient denies history of arrhythmia, swelling of the extremities, palpitations, or chest pain.,GASTROINTESTINAL: See above.,MUSCULOSKELETAL: The patient denies arthritis, arthralgias, or joint swelling.,NEUROLOGIC: The patient denies difficulty with balance, numbness, or paralysis.,GENITOURINARY: The patient denies dysuria, flank pain, or hematuria.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Blood pressure 183/108, pulse 76, respirations 16, temperature 98.7. ,HEENT: Cranial nerves are grossly intact. There is no scleral icterus. ,NECK: No jugular venous distention. ,CHEST: Clear to auscultation bilaterally. ,CARDIAC: Regular rate and rhythm. No murmurs. ,ABDOMEN: Soft, nontender, nondistended. Bowel sounds are decreased and high-pitched. There is a large midline laparotomy scar with staples still in place. There is no evidence of wound infection. Examination of the colostomy port reveals no obvious fecal impaction or site of obstruction. There is no evidence of infection. The mucosa appears normal. There is a small amount of nonbloody stool in the colostomy bag. There are no masses or bruits noted. ,EXTREMITIES: There is no cyanosis, clubbing, or edema. Pulses are 2+ and equal bilaterally. ,NEUROLOGIC: The patient is alert and awake with no focal motor or sensory deficit noted. ,MEDICAL DECISION MAKING:, Failure of colostomy to function may repre- sent an impaction; however, I did not appreciate this on physical examination. There may also be an adhesion or proximal impaction which I cannot reach, which may cause a bowel obstruction, failure of the shunt, nausea, and ultimately vomiting. ,An abdominal series was obtained, which confirmed this possibility by demonstrating air-fluid levels and dilated bowel. ,The CBC showed WBC of 9.4 with normal differential. Hematocrit is 42.6. I interpret this as normal. Amylase is currently pending. ,I have discussed this case with Dr. S, the patient's surgeon, who agrees that there is a possibility of bowel obstruction and the patient should be admitted to observation. Because of the patient's insurance status, the patient will actually be admitted to Dr. D on observation. I have discussed the case with Dr. P, who is the doctor on call for Dr. D. Both Dr. S and Dr. P have been informed of the patient's condition and are aware of his situation. ,FINAL IMPRESSION:, Bowel obstruction, status post colostomy. ,DISPOSITION:, Admission to observation. The patient's condition is good. He is hemodynamically stable.",
" Blood in toilet.  Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed.", Emergency Room Reports, Blood In Toilet ,"CHIEF COMPLAINT:  ,Blood in toilet.,HISTORY: , Ms. ABC is a 77-year-old female who is brought down by way of ambulance from XYZ Nursing Home after nursing staff had noted there to be blood in the toilet after she had been sitting on the toilet.  They did not note any urine or stool in the toilet and the patient had no acute complaints.  The patient is unfortunately a poor historian in that she has dementia and does not recall any of the events.  The patient herself has absolutely no complaints, such as abdominal pain or back pain, urinary and GI complaints.  There is no other history provided by the nursing staff from XYZ.  There apparently were no clots noted within there.  She does not have a history of being on anticoagulants.,PAST MEDICAL HISTORY: , Actually quite limited, includes that of dementia, asthma, anemia which is chronic, hypothyroidism, schizophrenia, positive PPD in the past.,PAST SURGICAL HISTORY:  ,Unknown.,SOCIAL HISTORY: , No tobacco or alcohol.,MEDICATIONS: , Listed in the medical records.,ALLERGIES:,  No known drug allergies.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Stable.,GENERAL:  This is a well-nourished, well-developed female who is alert, oriented in all spheres, pleasant, cooperative, resting comfortably, appearing otherwise healthy and well in no acute distress.,HEENT:  Visually normal.  Pupils are reactive.  TMs, canals, nasal mucosa, and oropharynx are intact.,NECK:  No lymphadenopathy or JVD.,HEART:  Regular rate and rhythm.  S1, S2.  No murmurs, gallops, or rubs.,LUNGS:  Clear to auscultation.  No wheeze, rales, or rhonchi.,ABDOMEN:  Benign, flat, soft, nontender, and nondistended.  Bowel sounds active.  No organomegaly or mass noted.,GU/RECTAL:  External rectum was normal.  No obvious blood internally.  There is no stool noted within the vault.  There is no gross amount of blood noted within the vault.  Guaiac was done and was trace positive.  Visual examination anteriorly during the rectal examination noted no blood within the vaginal region.,EXTREMITIES:  No significant abnormalities.,WORKUP: , CT abdomen and pelvis was negative.  CBC was entirely within normal limits without any signs of anemia with an H and H of 14 and 42%.  CMP also within normal limits.  PTT, PT, and INR were normal.  Attempts at getting the patient to give A urine were unsuccessful and the patient was very noncompliant, would not allow us to do any kind of Foley catheterization.,ER COURSE:,  Uneventful.  I have discussed the patient in full with Dr. X who agrees that she does not require any further workup or evaluation as an inpatient.  We have decided to send the patient back to XYZ with observation by the staff there.  She will have a CBC done daily for the next 3 days with results to Dr. X.  They are to call him if there is any recurrences of blood or worsening of symptoms and they are to do a urinalysis at XYZ for blood.,ASSESSMENT: , Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed.",
 Mother states he has been wheezing and coughing., Emergency Room Reports, Asthma in a 5-year-old ,"CHIEF COMPLAINT: , This 5-year-old male presents to Children's Hospital Emergency Department by the mother with ""have asthma.""  Mother states he has been wheezing and coughing.  They saw their primary medical doctor.  He was evaluated at the clinic, given the breathing treatment and discharged home, was not having asthma, prescribed prednisone and an antibiotic.  They told to go to the ER if he got worse.  He has had some vomiting and some abdominal pain.  His peak flows on the morning are normal at 150, but in the morning, they were down to 100 and subsequently decreased to 75 over the course of the day.,PAST MEDICAL HISTORY:,  Asthma with his last admission in 07/2007.  Also inclusive of frequent pneumonia by report.,IMMUNIZATIONS: , Up-to-date.,ALLERGIES: , Denied.,MEDICATIONS:  ,Advair, Nasonex, Xopenex, Zicam, Zithromax, prednisone, and albuterol.,PAST SURGICAL HISTORY: , Denied.,SOCIAL HISTORY: , Lives at home, here in the ED with the mother and there is no smoking in the home.,FAMILY HISTORY: , No noted exposures.,REVIEW OF SYSTEMS:  ,Documented on the template.  Systems reviewed on the template.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 98.7, pulse 105, respiration is 28, blood pressure 112/65, and weight of 16.5 kg.  Oxygen saturation low at 91% on room air.,GENERAL:  This is a well-developed male who is cooperative, alert, active with oxygen by facemask.,HEENT:  Head is atraumatic and normocephalic.  Pupils are equal, round, and reactive to light.  Extraocular motions are intact and conjugate.  Clear TMs, nose, and oropharynx.,NECK:  Supple.  Full painless nontender range of motion.,CHEST:  Tight wheezing and retractions heard bilaterally.,HEART:  Regular without rubs or murmurs.,ABDOMEN:  Soft, nontender.  No masses.  No hepatosplenomegaly.,GENITALIA:  Male genitalia is present on a visual examination.,SKIN:  No significant bruising, lesions or rash.,EXTREMITIES:  Moves all extremities without difficulty, nontender.  No deformity.,NEUROLOGIC:  Symmetric face, cooperative, and age appropriate.,MEDICAL DECISION MAKING:,  The differential entertained on this patient includes reactive airways disease, viral syndrome, and foreign body pneumonia.  He is evaluated in the emergency department with continuous high-dose albuterol, Decadron by mouth, pulse oximetry, and close observation.  Chest x-ray reveals bronchial thickening, otherwise no definite infiltrate.  She is further treated in the emergency department with continued breathing treatments.  At 0048 hours, he has continued tight wheezes with saturations 99%, but ED sats are 92% with coughing spells.  Based on the above, the hospitalist was consulted and accepts this patient for admission to the hospital with the working diagnosis of respiratory distress and asthma.",
" Acute foot or ankle sprain, possible small fracture.", Emergency Room Reports, Ankle pain ,"CHIEF COMPLAINT:,  Ankle pain.,HISTORY OF PRESENT ILLNESS:  ,The patient is a pleasant 17-year-old gentleman who was playing basketball today in gym.  Two hours prior to presentation, he started to fall and someone stepped on his ankle and kind of twisted his right ankle and he cannot bear weight on it now.  It hurts to move or bear weight.  No other injuries noted.  He does not think he has had injuries to his ankle in the past.,PAST MEDICAL HISTORY: , None.,PAST SURGICAL HISTORY: , None.,SOCIAL HISTORY: , He does not drink or smoke.,ALLERGIES: , Unknown.,MEDICATIONS: , Adderall and Accutane.,REVIEW OF SYSTEMS: , As above.  Ten systems reviewed and are negative.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 97.6, pulse 70, respirations 16, blood pressure 120/63, and pulse oximetry 100% on room air.,GENERAL:","emergency room reports, accutane, foot or ankle sprain, ankle sprain, ankle, sprain, splint, fracture, "
 Patient has prostate cancer with metastatic disease to his bladder.  The patient has had problems with hematuria in the past.  The patient was encouraged to drink extra water and was given discharge instructions on hematuria., Emergency Room Reports, Blood in Urine - ER Visit ,"CHIEF COMPLAINT: , Blood in urine.,HISTORY OF PRESENT ILLNESS:  ,This is a 78-year-old male who has prostate cancer with metastatic disease to his bladder and in several locations throughout the skeletal system including the spine and shoulder.  The patient has had problems with hematuria in the past, but the patient noted that this episode began yesterday, and today he has been passing principally blood with very little urine.  The patient states that there is no change in his chronic lower back pain and denies any incontinence of urine or stool.  The patient has not had any fever.  There is no abdominal pain and the patient is still able to pass urine.  The patient has not had any melena or hematochezia.  There is no nausea or vomiting.  The patient has already completed chemotherapy and is beyond treatment for his cancer at this time.  The patient is receiving radiation therapy, but it is targeted to the bones and intended to give symptomatic relief of his skeletal pain and not intended to treat and cure the cancer.  The patient is not enlisted in hospice, but the principle around the patient's current treatment management is focusing on comfort care measures.,REVIEW OF SYSTEMS: , CONSTITUTIONAL:  No fever or chills.  The patient does report generalized fatigue and weakness over the past several days.  HEENT:  No headache, no neck pain, no rhinorrhea, no sore throat.  CARDIOVASCULAR:  No chest pain.  RESPIRATIONS:  No shortness of breath or cough, although the patient does get easily winded with exertion over these past few days.  GASTROINTESTINAL:  The patient denies any abdominal pain.  No nausea or vomiting.  No changes in the bowel movement.  No melena or hematochezia.  GENITOURINARY:  A gross hematuria since yesterday as previously described.  The patient is still able to pass urine without difficulty.  The patient denies any groin pain.  The patient denies any other changes to the genital region.  MUSCULOSKELETAL:  The chronic lower back pain which has not changed over these past few days.  The patient does have multiple other joints, which cause him discomfort, but there have been no recent changes in these either.  SKIN:  No rashes or lesions.  No easy bruising.  NEUROLOGIC:  No focal weakness or numbness.  No incontinence of urine or stool.  No saddle paresthesia.  No dizziness, syncope or near-syncope.  ENDOCRINE:  No polyuria or polydipsia.  No heat or cold intolerance.  HEMATOLOGIC/LYMPHATIC:  The patient does not have a history of easy bruising or bleeding, but the patient has had previous episodes of hematuria.,PAST MEDICAL HISTORY: , Prostate cancer with metastatic disease as previously described.,PAST SURGICAL HISTORY: , TURP.,CURRENT MEDICATIONS:,  Morphine, Darvocet, Flomax, Avodart and ibuprofen.,ALLERGIES: , VICODIN.,SOCIAL HISTORY: , The patient is a nonsmoker.  Denies any alcohol or illicit drug use.  The patient does live with his family.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Temperature is 98.8 oral, blood pressure is 108/65, pulse is 109, respirations 16, oxygen saturation is 97% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished, well developed.  The patient appears to be pale, but otherwise looks well.  The patient is calm, comfortable.  The patient is pleasant and cooperative.  HEENT:  Eyes normal with clear conjunctivae and corneas.  Nose is normal without rhinorrhea or audible congestion.  Mouth and oropharynx normal without any sign of infection.  Mucous membranes are moist.  NECK:  Supple.  Full range of motion.  No JVD.  CARDIOVASCULAR:  Heart is mildly tachycardic with regular rhythm without murmur, rub or gallop.  Peripheral pulses are +2.  RESPIRATIONS:  Clear to auscultation bilaterally.  No shortness of breath.  No wheezes, rales or rhonchi.  Good air movement bilaterally.  GASTROINTESTINAL:  Abdomen is soft, nontender, nondistended.  No rebound or guarding.  No hepatosplenomegaly.  Normal bowel sounds.  No bruit.  No masses or pulsatile masses.  GENITOURINARY:  The patient has normal male genitalia, uncircumcised.  There is no active bleeding from the penis at this time.  There is no swelling of the testicles.  There are no masses palpated to the testicles, scrotum or the penis.  There are no lesions or rashes noted.  There is no inguinal lymphadenopathy.  Normal male exam.  MUSCULOSKELETAL:  Back is normal and nontender.  There are no abnormalities noted to the arms or legs.  The patient has normal use of the extremities.  SKIN:  The patient appears to be pale, but otherwise the skin is normal.  There are no rashes or lesions.  NEUROLOGIC:  Motor and sensory are intact to the extremities.  The patient has normal speech.  PSYCHIATRIC:  The patient is alert and oriented x4.  Normal mood and affect.  HEMATOLOGIC/LYMPHATIC:  There is no evidence of bruising noted to the body.  No lymphadenitis is palpated.,EMERGENCY DEPARTMENT TESTING:,  CBC was done, which had a hemoglobin of 7.7 and hematocrit of 22.6.  Neutrophils were 81%.  The RDW was 18.5, and the rest of the values were all within normal limits and unremarkable.  Chemistry had a sodium of 134, a glucose of 132, calcium is 8.2, and rest of the values are unremarkable.  Alkaline phosphatase was 770 and albumin was 2.4.  Rest of the values all are within normal limits of the LFTs.  Urinalysis was grossly bloody with a large amount of blood and greater than 50 rbc's.  The patient also had greater than 300 of the protein reading, moderate leukocytes, 30-50 white blood cells, but no bacteria were seen.  Coagulation profile study had a PT of 15.9, PTT of 43 and INR of 1.3.,EMERGENCY DEPARTMENT COURSE: , The patient was given normal saline 2 liters over 1 hour without any adverse effect.  The patient was given multiple doses of morphine to maintain his comfort while here in the emergency room without any adverse effect.  The patient was given Levaquin 500 mg by mouth as well as 2 doses of Phenergan over the course of his stay here in the emergency department.  The patient did not have an adverse reaction to these medicines either.  Phenergan resolved his nausea and morphine did relieve his pain and make him pain free.  I spoke with Dr. X, the patient's urologist, about most appropriate step for the patient, and Dr. X said he would be happy to care for the patient in the hospital and do urologic scopes if necessary and surgery if necessary and blood transfusion.  It was all a matter of what the patient wished to do given the advanced stage of his cancer.  Dr. X was willing to assist in any way the patient wished him to.  I spoke with the patient and his son about what he would like to do and what the options were from doing nothing from keeping him comfortable with pain medicines to admitting him to the hospital with the possibility of scopes and even surgery being done as well as the blood transfusion.  The patient decided to choose a middle ground in which he would be transfused with 2 units of blood here in the emergency room and go home tonight.  The patient's son felt comfortable with his father's choice.  This was done.  The patient was transfused 2 units of packed red blood cells after appropriately typed and match.  The patient did not have any adverse reaction at any point with his transfusion.  There was no fever, no shortness of breath, and at the time of disposition, the patient stated he felt a little better and felt like he had a little more strength.  Over the course of the patient's several-hour stay in the emergency room, the patient did end up developing enough problems with clotted blood in his bladder that he had a urinary obstruction.  Foley catheter was placed, which produced bloody urine and relieved the developing discomfort of a full bladder.  The patient was given a leg bag and the Foley catheter was left in place.,DIAGNOSES,1.  HEMATURIA.,2.  PROSTATE CANCER WITH BONE AND BLADDER METASTATIC DISEASE.,3.  SIGNIFICANT ANEMIA.,4.  URINARY OBSTRUCTION.,CONDITION ON DISPOSITION:  ,Fair, but improved.,DISPOSITION: , To home with his son.,PLAN: , We will have the patient follow up with Dr. X in his office in 2 days for reevaluation.  The patient was given a prescription for Levaquin and Phenergan tablets to take home with him tonight.  The patient was encouraged to drink extra water.  The patient was given discharge instructions on hematuria and asked to return to the emergency room should he have any worsening of his condition or develop any other problems or symptoms of concern.",
" Patient had a recurrent left arm pain after her stent, three days ago, and this persisted after two sublingual nitroglycerin.", Emergency Room Reports, Angina - Consult ,"HISTORY OF PRESENT ILLNESS: , The patient is a 68-year-old woman whom I have been following, who has had angina.  In any case today, she called me because she had a recurrent left arm pain after her stent, three days ago, and this persisted after two sublingual nitroglycerin when I spoke to her.  I advised her to call 911, which she did.  While waiting for 911, she was attended to by a physician who is her neighbor and he advised her to take the third nitroglycerin and that apparently relieved her pain.  By the time she presented here, she is currently pain-free and is feeling well.,PAST CARDIAC HISTORY: , The patient has been having arm pain for several months.  She underwent an exercise stress echocardiogram within the last several months with me, which was equivocal, but then she had a nuclear stress test which showed inferobasilar ischemia.  I had originally advised her for a heart catheterization but she wanted medical therapy, so we put her on a beta-blocker.  However, her arm pain symptoms accelerated and she had some jaw pain, so she presented to the emergency room.  On 08/16/08, she ended up having a cardiac catheterization and that showed normal left main 80%  mid LAD lesion, circumflex normal, and RCA totally occluded in the mid portion and there were collaterals from the left to the right, as well as right to right to that area.  The decision was made to transfer  her as she may be having collateral insufficiency from the LAD stenosis to the RCA vessel.  She underwent that with drug-eluting stents on 08/16/08, with I believe three or four total placed, and was discharged on 08/17/08.  She had some left arm discomfort on 08/18/08, but this was mild.  Yesterday, she felt very fatigued, but no arm pain, and today, she had arm pain after walking and again it resolved now completely after three sublingual nitroglycerin.  This is her usual angina.  She is being admitted with unstable angina post stent.,PAST MEDICAL HISTORY: , Longstanding hypertension, CAD as above, hyperlipidemia, and overactive bladder.,MEDICATIONS:,1.  Detrol LA 2 mg once a day.,2.  Prilosec for GERD 20 mg once a day.,3.  Glucosamine 500/400 mg once a day for arthritis.,4.  Multivitamin p.o. daily.,5.  Nitroglycerin sublingual as available to her.,6.  Toprol-XL 25 mg once a day which I started although she had been bradycardic, but she seems to be tolerating.,7.  Aspirin 325 mg once a day.,8.  Plavix 75 mg once a day.,9.  Diovan 160 mg once a day.,10.  Claritin 10 mg once a day for allergic rhinitis.,11.  Norvasc 5 mg once a day.,12.  Lipitor 5 mg once a day.,13.  Evista 60 mg once a day.,ALLERGIES: , ALLERGIES TO MEDICATIONS ARE NONE.  SHE DENIES ANY SHRIMP OR SEA FOOD ALLERGY.,FAMILY HISTORY: , Her father died of an MI in his 50s and a brother had his first MI and bypass surgery at 54.,SOCIAL HISTORY:  ,She does not smoke cigarettes, abuse alcohol, no use of illicit drugs.  She is divorced and lives alone and is a retired laboratory technician from Cornell Diagnostic Laboratory.,REVIEW OF SYSTEMS:,  She denies a history of stroke, cancer, vomiting up blood, coughing up blood, bright red blood per rectum, bleeding stomach ulcers, renal calculi, cholelithiasis, asthma, emphysema, pneumonia, tuberculosis, home oxygen use or sleep apnea, although she has been told in the past that she snores and there was some question of apnea in 05/08.  No morning headaches or fatigue.  No psychiatric diagnosis.  No psoriasis, no lupus.  Remainder of the review of systems is negative x14 systems except as described above.,PHYSICAL EXAMINATION:,GENERAL:  She is a pleasant elderly woman, currently in no acute distress.,VITAL SIGNS:  Height 4 feet 11 inches, weight 128 pounds, temperature 97.2 degrees Fahrenheit, blood pressure 142/70, pulse 47,  respiratory rate 16, and O2 saturation 100%,HEENT:  Cranium is normocephalic and atraumatic.  She has moist mucosal membranes.,NECK:  Veins are not distended.  There are no carotid bruits.,LUNGS:  Clear to auscultation and percussion without wheezes.,HEART:  S1 and S2, regular rate.  No significant murmurs, rubs or gallops.  PMI nondisplaced.,ABDOMEN:  Soft and nondistended.  Bowel sounds present.,EXTREMITIES:  Without significant clubbing, cyanosis or edema.  Pulses grossly intact.  Bilateral groins are inspected, status post as the right femoral artery was used for access for the diagnostic cardiac catheterization here and left femoral artery used for PCI and there is no evidence of hematoma or bruit and intact distal pulses.,LABORATORY DATA: , EKG reviewed which shows sinus bradycardia at the rate of 51 beats per minute and no acute disease.,Sodium 136, potassium 3.8, chloride 105, and bicarbonate 27.  BUN 16 and creatinine 0.9.  Glucose 110.  Magnesium 2.5.  ALT 107 and AST 65 and these were normal on 08/15/08.  INR is 0.89, PTT 20.9, white blood cell count 8.2, hematocrit 31 and it was 35 on 08/15/08, and platelet count 257,000.,IMPRESSION AND PLAN:  ,The patient is a 68-year-old woman with exertional angina, characterized with arm pain, who underwent recent left anterior descending percutaneous coronary intervention and has now had recurrence of that arm pain post stenting to the left anterior descending artery and it may be that she is continuing to have collateral insufficiency of the right coronary artery.  In any case, given this unstable presentation requiring three sublingual nitroglycerin before she was even pain free, I am going to admit her to the hospital and there is currently no evidence requiring acute reperfusion therapy.  We will continue her beta-blocker and I cannot increase the dose because she is bradycardic already.  Aspirin, Plavix, valsartan, Lipitor, and Norvasc.  I am going to add Imdur and watch headaches as she apparently had some on nitro paste before, and we will rule out MI, although there is a little suspicion.  I suppose it is possible that she has non-cardiac arm pain, but that seems less likely as it has been nitrate responsive and seems exertionally related and the other possibility may be that we end up needing to put in a pacemaker, so we can maximize beta-blocker use for anti-anginal effect.  My concern is that there is persistent right coronary artery ischemia, not helped by left anterior descending percutaneous coronary intervention, which was severely stenotic and she does have normal LV function.  She will continue the glucosamine for her arthritis, Claritin for allergies, and Detrol LA for urinary incontinence.,Total patient care time in the emergency department 75 minutes.  All this was discussed in detail with the patient and her daughter who expressed understanding and agreement.  The patient desires full resuscitation status.",
" The patient is a 17-year-old female, who presents to the emergency room with foreign body and airway compromise and was taken to the operating room.  She was intubated and fishbone.", Emergency Room Reports, Airway Compromise & Foreign Body - ER Visit ,"HISTORY OF PRESENT ILLNESS:,  The patient is a 17-year-old female, who presents to the emergency room with foreign body and airway compromise and was taken to the operating room.  She was intubated and fishbone.,PAST MEDICAL HISTORY: , Significant for diabetes, hypertension, asthma, cholecystectomy, and total hysterectomy and cataract.,ALLERGIES:  ,No known drug allergies.,CURRENT MEDICATIONS: , Prevacid, Humulin, Diprivan, Proventil, Unasyn, and Solu-Medrol.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: , Negative for illicit drugs, alcohol, and tobacco.,PHYSICAL EXAMINATION:  ,Please see the hospital chart.,LABORATORY DATA: , Please see the hospital chart.,HOSPITAL COURSE: , The patient was taken to the operating room by Dr. X who is covering for ENT and noted that she had airway compromise and a rather large fishbone noted and that was removed.  The patient was intubated and it was felt that she should be observed to see if the airway would improve upon which she could be extubated.  If not she would require tracheostomy.  The patient was treated with IV antibiotics and ventilatory support and at the time of this dictation, she has recently been taken to the operating room where it was felt that the airway sufficient and she was extubated.  She was doing well with good p.o.s, good airway, good voice, and desiring to be discharged home.  So, the patient is being prepared for discharge at this point.  We will have Dr. X evaluate her before she leaves to make sure I do not have any problem with her going home.  Dr. Y feels she could be discharged today and will have her return to see him in a week.","emergency room reports, diabetes, hypertension, asthma, cholecystectomy, fishbone, foreign body, airway compromise, airway,"
" Possible exposure to ant bait.  She is not exhibiting any symptoms and parents were explained that if she develops any vomiting, she should be brought back for reevaluation.", Emergency Room Reports, Ant Bait Exposure - ER Visit ,"CHIEF COMPLAINT: , Possible exposure to ant bait.,HISTORY OF PRESENT ILLNESS:,  This is a 14-month-old child who apparently was near the sink, got into the childproof cabinet and pulled out ant bait that had Borax in it.  It had 11 mL of this fluid in it.  She spilled it on her, had it on her hands.  Parents were not sure whether she ingested any of it.  So, they brought her in for evaluation.  They did not note any symptoms of any type.,PAST MEDICAL HISTORY: , Negative.  Generally very healthy.,REVIEW OF SYSTEMS: , The child has not been having any coughing, gagging, vomiting, or other symptoms.  Acting perfectly normal.  Family mostly noted that she had spilled it on the ground around her, had it on her hands, and on her clothes.  They did not witness that she ingested any, but did not see anything her mouth.,MEDICATIONS: , None.,ALLERGIES: , NONE.,PHYSICAL EXAMINATION: , VITAL SIGNS:  The patient was afebrile.  Stable vital signs and normal pulse oximetry.  GENERAL:  The child is very active, cheerful youngster, in no distress whatsoever.  HEENT:  Unremarkable.  Oral mucosa is clear, moist, and well hydrated.  I do not see any evidence of any sort of liquid on the face.  Her clothing did have the substance on the clothes, but I did not see any evidence of anything on her torso.  Apparently, she had some on her hands that has been wiped off.,EMERGENCY DEPARTMENT COURSE:,  I discussed the case with Poison Control and apparently this is actually relatively small quantity and it is likely to be a nontoxic ingestion if she even ingested, which should does not appear likely to be the case.,IMPRESSION: , Exposure to ant bait.,PLAN: , At this point, it is fairly unlikely that this child ingested any significant amount, if at all, which seems unlikely.  She is not exhibiting any symptoms and I explained to the parents that if she develops any vomiting, she should be brought back for reevaluation.  So, the patient is discharged in stable condition.","emergency room reports, borax, vomiting, exposure to ant bait, ant bait, exposure, symptoms,"
" A 6-year-old was laying down on one side, and he was crying and moaning, sent from the Emergency Room with the diagnosis of intracranial bleeding.", Emergency Room Reports, Altered Mental Status - ER Visit ,"CHIEF COMPLAINT: , Altered mental status.,HISTORY OF PRESENT ILLNESS: , This is a 6-year-old white male, who was sent from the Emergency Room with the diagnosis of intracranial bleeding.  The patient was found by the 8-year-old sister in the bathroom.  He was laying down on one side, and he was crying and moaning.  The sibling went and told the parents.  The parents rushed to the bathroom, they found him crying, and he was not moving the left side of his body.  He was initially alert, but his alertness diminished.  They decided to take him to the emergency room in Hospital, where a CT was done on his head, which showed a 4 x 4 x 2.5 cm bleed.  The emergency physician called our emergency room, and I decided to involve Neurosurgery, Mr. X, the physician assistant, who is on call for the Neurosurgery Services.  Collectively, they have made arrangements with the ICU attendings to have the child transported to our emergency room.  For a small stop, I am obtaining an MRI and then admitting to the ICU.  History was taken from the parents.  He had a history of gastroesophageal reflux disease, otherwise, a healthy child.,MEDICATIONS: , None.,ALLERGIES:,  No known drug allergies.,PAST SURGICAL HISTORY: , He had only tympanostomy tubes placed.,FAMILY MEDICAL HISTORY:,  Unremarkable.,PHYSICAL EXAMINATION:,GENERAL:  He was brought by our transport team.  While en route, he was not as alert as he was.  He was still oriented.  He had to be stimulated via sternal rub to wake up, and saturation went down to the 80s, and he was started on nasal cannula, and code 3 was initiated, and he was rushed to our emergency room.  When I saw him, he was lethargic, but arousable.  He could recognize where he was, and he could recognize also his parents well.,HEENT:  Pupils are 4 mm reactive to direct and indirect light.  No signs of trauma is seen on the head.  Throat is clear.,LUNGS:  Clear to auscultation.,HEART:  Regular rate and rhythm.,ABDOMEN:  Soft.,NEUROLOGIC:  He has left-sided weakness, but his cranial nerves II through XII are grossly intact.,EMERGENCY DEPARTMENT COURSE: , In the emergency room, at the time when I saw him, Dr. Y and Dr. Z were from the ICU and Anesthesia Services arrived also, and they evaluated the patient with me and pretty much they took care of the patient.  They decided to give him a dose of IV mannitol.  I ordered his labs, type and cross.  CBC is 15.6 white blood cell count, hemoglobin 12.8.  PT/PTT were ordered due to the bleed, which was seen intracerebrally.  They were 13.1 and 24.5 respectively.  Blood gas, I-STAT pH 7.36, pCO2 is 51.  This was a venous specimen.  The ICU attendings decided to do a rapid sequence intubation.  This was done in our emergency room by Dr. Y and Dr. Z.  The patient was sent to the MRI, and from where he was going to be admitted to the ICU in critical condition.,DIFFERENTIAL DIAGNOSES: , Arteriovenous malformation, stroke, traumatic injury.,IMPRESSION: , Intracerebral hemorrhage of uncertain etiology to be determined while inpatient.,TIME SPENT:,  I spent 30 minutes critical care time with the patient excluding any procedures.,","emergency room reports, arteriovenous malformation, stroke, traumatic injury, intracerebral hemorrhage, altered mental status, crying and moaning, mental status, intracranial bleeding, icu attendings, emergency, intracranial, neurosurgery, gastroesophageal, intracerebrally, bleeding, icu, "
 Possible free air under the diaphragm.  On a chest x-ray for what appeared to be shortness of breath she was found to have what was thought to be free air under the right diaphragm.  No intra-abdominal pathology., Emergency Room Reports, Air Under Diaphragm - Consult ,"REASON FOR CONSULTATION: , Possible free air under the diaphragm.,HISTORY OF PRESENT ILLNESS: , The patient is a 77-year-old female who is unable to give any information.  She has been sedated with Ativan and came into the emergency room obtunded and unable to give any history.  On a chest x-ray for what appeared to be shortness of breath she was found to have what was thought to be free air under the right diaphragm.,PAST MEDICAL HISTORY: , Significant for alcohol abuse.  Unable to really gather any other information because she is so obtunded.,PAST SURGICAL HISTORY:  ,Looking at the medical chart, she had an appendectomy, right hip fracture from a fall in 2005, and TAH/BSO.,MEDICATIONS:,  Unable to evaluate.,ALLERGIES: , UNABLE TO EVALUATE.,SOCIAL HISTORY:  ,Significant history of alcohol abuse, according to the emergency room physician, who sees her on a regular basis.,REVIEW OF SYSTEMS: , Unable to obtain.,PHYSICAL EXAM,VITAL SIGNS:  Temp 98.3, heart rate 82, respiratory rate 24, and blood pressure 141/70.,GENERAL:  She is a very obtunded female who upon arousal is not able to provide any information of any use.,HEENT:  Atraumatic.,NECK:  Soft and supple.,LUNGS:  Bilaterally diminished.,HEART:  Regular.,ABDOMEN:  Soft, and with deep palpation I am unable to arouse the patient, unable to elicit any tenderness.,LABORATORY STUDIES: , Show a normal white blood cell count with no shift.  Elevated AST at 138, with a normal ALT at 38.  Alkaline phosphatase of 96, bilirubin 0.8.  Sodium is 107, with 68 chloride and potassium of 2.8.,X-ray of the chest shows the possibility of free air; therefore, a CT scan was obtained because of the patient's physical examination, which shows no evidence of intra-abdominal pathology.  The etiology of the air under the diaphragm is actually a colonic air that is anterior superior to the dome of the diaphragm, near the dome of the liver.,ASSESSMENT: , No intra-abdominal pathology.,PLAN:,  Have her admitted to the medical service for treatment of her hyponatremia.",
 Acute episode of agitation.  She was complaining that she felt she might have been poisoned at her care facility., Emergency Room Reports, Agitation - ER Visit ,"HISTORY OF PRESENT ILLNESS:  This is a 91-year-old female who was brought in by family.  Apparently, she was complaining that she felt she might have been poisoned at her care facility.  The daughter who accompanied the patient states that she does not think anything is actually wrong, but she became extremely agitated and she thinks that is the biggest problem with the patient right now.  The patient apparently had a little bit of dry heaves, but no actual vomiting.  She had just finished eating dinner.  No one else in the facility has been ill.,PAST MEDICAL HISTORY: Remarkable for previous abdominal surgeries.  She has a pacemaker.  She has a history of recent collarbone fracture.,REVIEW OF SYSTEMS:  Very difficult to get from the patient herself.  She seems to deny any significant pain or discomfort, but really seems not particularly intent on letting me know what is bothering her.  She initially stated that everything was wrong, but could not specify any specific complaints.  Denies chest pain, back pain, or abdominal pain.  Denies any extremity symptoms or complaints.,SOCIAL HISTORY:  The patient is a nonsmoker.  She is accompanied here with daughter who brought her over here.  They were visiting the patient when this episode occurred.,MEDICATIONS:  Please see list.,ALLERGIES:  NONE.,PHYSICAL EXAMINATION:  VITAL SIGNS:  The patient is afebrile, actually has a very normal vital signs including normal pulse oximetry at 99% on room air.  GENERAL:  The patient is an elderly frail looking little lady lying on the gurney.  She is awake, alert, and not really wanted to answer most of the questions I asked her.  She does have a tremor with her mouth, which the daughter states has been there for ""many years"".  HEENT:  Eye exam is unremarkable.  Oral mucosa is still moist and well hydrated.  Posterior pharynx is clear.  NECK:  Supple.  LUNGS:  Actually clear with good breath sounds.  There are no wheezes, no rales, or rhonchi.  Good air movement.  CARDIAC:  Without murmur.  ABDOMEN:  Soft.  I do not elicit any tenderness.  There is no abdominal distention.  Bowel sounds are present in all quadrants.  SKIN:  Skin is without rash or petechiae.  There is no cyanosis.  EXTREMITIES:  No evidence of any trauma to the extremities.,EMERGENCY DEPARTMENT COURSE:  I had a long discussion with the family and they would like the patient receive something for agitation, so she was given 0.5 mg of Ativan intramuscularly.  After about half an hour, I came back to talk to the patient and the family, the patient states that she feels better.  Family states she seems more calm.  They do not want to pursue any further workup at this time.,IMPRESSION:  ACUTE EPISODE OF AGITATION.,PLAN:  At this time, I had reviewed the patient's records and it is not particularly enlightening as to what could have triggered off this episode.  The patient herself has good vital signs.  She does not seem to have any specific acute process going on and seemed to feel comfortable after the Ativan was given, a small quantity was given to the patient.  Family and daughter specifically did not want to pursue any workup at this point, which at this point I think is reasonable and we will have her follow up with ABC.  She is discharged in stable condition.","emergency room reports, acute episode of agitation, agitation, "
" The patient was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke.  The patient attended nine outpatient skilled speech therapy sessions.", Discharge Summary, Speech Therapy - Discharge Summary - 2 ,"The patient made some progress during therapy.  She accomplished two and a half out of her five short-term therapy goals.  We did complete an oral mechanism examination and clinical swallow evaluation, which showed her swallowing to be within functional limits.  The patient improved on her turn taking skills during conversation, and she was able to listen to a narrative and recall the main idea plus five details after a three-minute delay independently.  The patient continues to have difficulty with visual scanning in cancellation task, secondary to her significant left neglect.  She also did not accomplish her sustained attention goal, which required her to complete tasks greater than 80% accuracy for at least 15 minutes independently.  Thus she also continued to have difficulty with reading, comprehension, secondary to the significance of her left neglect.  The patient was initially authorized for 12 outpatient speech therapy sessions, but once again she only attended 9.  Her last session occurred on 01/09/09.  She has not made any additional followup sessions with me for over three weeks, so she is discharged from my services at this time.","discharge summary, outpatient speech therapy, swallow evaluation, swallowing, skilled speech therapy, hemisphere disorder, speech therapy, speechNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Patient is a three years old male who about 45 minutes prior admission to the emergency room ingested about two to three tablets of Celesta 40 mg per tablets., Emergency Room Reports, Accidental Celesta Ingestion - ER Visit ,"HISTORY OF PRESENT ILLNESS:,  Patient is a three years old male who about 45 minutes prior admission to the emergency room ingested about two to three tablets of Celesta 40 mg per tablets.  Mom called to the poison control center and the recommendation was to take the patient to the emergency room and be evaluated.  The patient was alert and did not vomit during the transport to the emergency room.  Mom left the patient and his little one-year-old brother in the room by themselves and she went outside of the house for a couple of minutes, and when came back, she saw the patient having the Celesta foils in his hands and half of tablet was moist and on the floor.  The patient said that the pills ""didn't taste good,"" so it is presumed that the patient actually ingested at least two-and-a-half tablets of Celesta, 40 mg per tablet.,PAST MEDICAL HISTORY:,  Baby was born premature and he required hospitalization, but was not on mechanical ventilation.  He doesn't have any hospitalizations after the new born.  No surgeries.,IMMUNIZATIONS: , Up-to-date.,ALLERGIES: , NOT KNOWN DRUG ALLERGIES.,PHYSICAL EXAMINATION,VITAL SIGNS:  Temperature 36.2 Celsius, pulse 112, respirations 24, blood pressure 104/67, weight 15 kilograms.,GENERAL:  Alert, in no acute distress.,SKIN:  No rashes.,HEENT:  Head:  Normocephalic, atraumatic.  Eyes:  EOMI, PERRL.  Nasal mucosa clear.  Throat and tonsils, normal.  No erythema, no exudates.,NECK:  Supple, no lymphadenopathy, no masses.,LUNGS:  Clear to auscultation bilateral.,HEART:  Regular rhythm and rate without murmur.  Normal S1, S2.,ABDOMEN:  Soft, nondistended, nontender, present bowel sounds, no hepatosplenomegaly, no masses.,EXTREMITIES:  Warm.  Capillary refill brisk.  Deep tendon reflexes present bilaterally.,NEUROLOGICAL:  Alert.  Cranial nerves II through XII intact.  No focal exam.  Normal gait.,RADIOGRAPHIC DATA: , Patient has had an EKG done at the admission and it was within normal limits for the age.,EMERGENCY ROOM COURSE: , Patient was under observation for 6 hours in the emergency room.  He had two more EKGs during observation in the emergency room and they were all normal.  His vital signs were monitored every hour and were within normal limits.  There was no vomiting, no diarrhea during observation.  Patient did not receive any medication or has had any other lab work besides the EKG.,ASSESSMENT AND PLAN: , Three years old male with accidental ingestion of Celesta.  Discharged home with parents, with a followup in the morning with his primary care physician.","emergency room reports, accidental ingestion of celesta, celesta, tablets, ingestion, "
" A 12-year-old  fell off his bicycle, not wearing a helmet, a few hours ago.  There was loss of consciousness.  The patient complains of neck pain.", Emergency Room Reports, Abrasions & Lacerations - ER Visit ,"HISTORY OF PRESENT ILLNESS: , This is a 12-year-old male, who was admitted to the Emergency Department, who fell off his bicycle, not wearing a helmet, a few hours ago.  There was loss of consciousness.  The patient complains of neck pain.,CHRONIC/INACTIVE CONDITIONS:,  None.,PERSONAL/FAMILY/SOCIAL HISTORY/ILLNESSES:,  None.,PREVIOUS INJURIES: , Minor.,MEDICATIONS: , None.,PREVIOUS OPERATIONS: , None.,ALLERGIES:  ,NONE KNOWN.,FAMILY HISTORY: , Negative for heart disease, hypertension, obesity, diabetes, cancer or stroke.,SOCIAL HISTORY: , The patient is single.  He is a student.  He does not smoke, drink alcohol or consume drugs.,REVIEW OF SYSTEMS,CONSTITUTIONAL:  The patient denies weight loss/gain, fever, chills.,ENMT:  The patient denies headaches, nosebleeds, voice changes, blurry vision, changes in/loss of vision.,CV:  The patient denies chest pain, SOB supine, palpitations, edema, varicose veins, leg pains.,RESPIRATORY:  The patient denies SOB, wheezing, sputum production, bloody sputum, cough.,GI:  The patient denies heartburn, blood in stools, loss of appetite, abdominal pain, constipation.,GU:  The patient denies painful/burning urination, cloudy/dark urine, flank pain, groin pain.,MS:  The patient denies joint pain/stiffness, backaches, tendon/ligaments/muscle pains/strains, bone aches/pains, muscle weakness.,NEURO:  The patient had a loss of consciousness during the accident.  He does not recall the details of the accident.  Otherwise, negative for blackouts, seizures, loss of memory, hallucinations, weakness, numbness, tremors, paralysis.,PSYCH:  Negative for anxiety, irritability, apathy, depression, sleep disturbances, appetite disturbances, suicidal thoughts.,INTEGUMENTARY:  Negative for unusual hair loss/breakage, skin lesions/discoloration, unusual nail breakage/discoloration.,PHYSICAL EXAMINATION,CONSTITUTIONAL:  Blood pressure 150/75, pulse rate 80, respirations 18, temperature 37.4, saturation 97% on room air.  The patient shows moderate obesity.,NECK:  The neck is symmetric, the trachea is in the midline, and there are no masses.  No crepitus is palpated.  The thyroid is palpable, not enlarged, smooth, moves with swallowing, and has no palpable masses.,RESPIRATIONS:  Normal respiratory effort.  There is no intercostal retraction or action by the accessory muscles.  Normal breath sounds bilaterally with no rhonchi, wheezing or rubs.,CARDIOVASCULAR:  The PMI is palpable at the 5ICS in the MCL.  No thrills on palpation.  S1 and S2 are easily audible.  No audible S3, S4, murmur, click or rub.  Abdominal aorta is not palpable.  No audible abdominal bruits.  Femoral pulses are 3+ bilaterally, without audible bruits.  Extremities show no edema or varicosities.,GASTROINTESTINAL:  No palpable tenderness or masses.  Liver and spleen are percussed but not palpable under the costal margins.  No evidence for umbilical or groin herniae.,LYMPHATIC:  No nodes over 3 mm in the neck, axillae or groins.,MUSCULOSKELETAL:  Normal gait and station.  The patient is on a stretcher.  Symmetric muscle strength and normal tone, without signs of atrophy or abnormal movements.,SKIN:  There is a hematoma in the forehead and one in the occipital scalp, and there are abrasions in the upper extremities and abrasions on the knees.  No induration or subcutaneous nodules to palpation.,NEUROLOGIC:  Normal sensation by touch.  The patient moves all four extremities.,PSYCHIATRIC:  Oriented to time, place, and person.  Appropriate mood and affect.,LABORATORY DATA:  Reviewed chest x-ray, which is normal, right hand x-ray, which is normal, and an MRI of the head, which is normal.,DIAGNOSES,1.  Concussion.,2.  Facial abrasion.,3.  Scalp laceration.,4.  Knee abrasions.,PLANS/RECOMMENDATIONS:,  Admitted for observation.",
" Total abdominal hysterectomy (TAH).  Severe menometrorrhagia unresponsive to medical therapy, severe anemia, and symptomatic fibroid uterus.  ", Discharge Summary, TAH - Discharge Summary ,"ADMISSION DIAGNOSES:,1.  Severe menometrorrhagia unresponsive to medical therapy.,2.  Severe anemia.,3.  Symptomatic fibroid uterus.,DISCHARGE DIAGNOSES:,1.  Severe menometrorrhagia unresponsive to medical therapy.,2.  Severe anemia.,3.  Symptomatic fibroid uterus.,4.  Extensive adenomyosis by pathological report.,OPERATION PERFORMED: , On 6/10/2009 total abdominal hysterectomy (TAH).,COMPLICATIONS:,  None.,BLOOD TRANSFUSIONS: , None.,INFECTIONS: , None.,SIGNIFICANT LAB AND X-RAY: , On admission hemoglobin and hematocrit was 10.5 and 32.8 respectively.  On discharge, hemoglobin and hematocrit 7.9 and 25.2.,HOSPITAL COURSE AND TREATMENT:  ,The patient was admitted to the surgical suite and taken to the operating room on 6/10/2009 where a total abdominal hysterectomy (TAH) with low intraoperative complication was performed.  The patient tolerated all procedures well.  On the 1st postoperative day, the patient was afebrile and all vital signs were stable.  On the 3rd postoperative day, the patient was ambulating with difficulty and tolerating clear liquid diet.  On the 4th postoperative day, the patient was complaining of pain in her back and abdomen as well as incisional wound tenderness.  On the 5th postoperative day, the patient was afebrile.  Vital signs were stable.  The patient was tolerating a diet and ambulating without difficulty.  The patient was desirous of going home.  The patient denied any abdominal pain or flank pain.  The patient had minimal incisional wound tenderness.  The patient was desirous of going home and was discharged home.,DISCHARGE CONDITION: , Stable.,DISCHARGE INSTRUCTIONS:,  Regular diet, bedrest x1 week with slow return to normal activity over the ensuing 4 to 6 weeks, pelvic rest for 6 weeks.  Motrin 600 mg tablets 1 tablet p.o. q.8h. p.r.n. pain, Colace 100 mg tablets 1 tablet p.o. daily p.r.n. constipation and ferrous sulfate 60 mg tablets 1 tablet p.o. daily, and multiple vitamin 1 tablet p.o. daily.  The patient is to return on Wednesday 6/17/2009 for removal of staples.  The patient was given a full explanation of her clinical condition.  The patient was given full and complete postoperative and discharge instructions.  All her questions were answered.","discharge summary, adenomyosis, total abdominal hysterectomy, fibroid uterus, postoperative day, hemoglobin, hematocrit, therapy, menometrorrhagia, anemia, fibroid, uterus, tah, hysterectomy, abdominal, "
 Hispanic male patient was admitted because of enlarged prostate and symptoms of bladder neck obstruction., Discharge Summary, Urology Discharge Summary ,"PROCEDURES:, Cystourethroscopy and transurethral resection of prostate.,COMPLICATIONS:, None.,ADMITTING DIAGNOSIS:, Difficulty voiding.,HISTORY:, This 67-year old Hispanic male patient was admitted because of enlarged prostate and symptoms of bladder neck obstruction.  Physical examination revealed normal heart and lungs.  Abdomen was negative for abnormal findings.  ,LABORATORY DATA:, BUN 19 and creatinine 1.1.  Blood group was A, Rh positive, Hemoglobin 13, Hematocrit 32.1, Prothrombin time 12.6 seconds, PTT 37.1.  Discharge  hemoglobin 11.4, and hematocrit 33.3.  Chest x-ray calcified old granulomatous disease, otherwise normal.  EKG was normal.  ,COURSE IN THE HOSPITAL:, The patient had a cysto and TUR of the prostate.  Postoperative course was uncomplicated. The pathology report is pending at the time of dictation.  He is being discharged in satisfactory condition with a good urinary stream, minimal hematuria, and on Bactrim DS one a day for ten days with a standard postprostatic surgery instruction sheet.  ,DISCHARGE DIAGNOSIS: , Enlarged prostate with benign bladder neck obstruction.  ,To be followed in my office in one week and by Dr. ABC next available as an outpatient.","discharge summary, tur, bun, cystourethroscopy, difficulty voiding, bladder neck obstruction, creatinine, cysto, enlarged prostate, transurethral resection of prostate, urinary stream, bladder neck, neck obstruction, prostate"
 Patient presents with a chief complaint of chest pain admitted to Coronary Care Unit due to acute inferior myocardial infarction., Emergency Room Reports, Acute Inferior Myocardial Infarction ,"CHIEF COMPLAINT: , Chest pain.,HISTORY OF PRESENT ILLNESS:,  The patient is a 40-year-old white male who presents with a chief complaint of ""chest pain"".,The patient is diabetic and has a prior history of coronary artery disease.  The patient presents today stating that his chest pain started yesterday evening and has been somewhat intermittent.  The severity of the pain has progressively increased.  He describes the pain as a sharp and heavy pain which radiates to his neck & left arm.  He ranks the pain a 7 on a scale of 1-10.  He admits some shortness of breath & diaphoresis.  He states that he has had nausea & 3 episodes of vomiting tonight.  He denies any fever or chills.  He admits prior episodes of similar pain prior to his PTCA in 1995.  He states the pain is somewhat worse with walking and seems to be relieved with rest.  There is no change in pain with positioning.  He states that he took 3 nitroglycerin tablets sublingually over the past 1 hour, which he states has partially relieved his pain.  The patient ranks his present pain a 4 on a scale of 1-10.  The most recent episode of pain has lasted one-hour.,The patient denies any history of recent surgery, head trauma, recent stroke, abnormal bleeding such as blood in urine or stool or nosebleed.,REVIEW OF SYSTEMS:,  All other systems reviewed & are negative.,PAST MEDICAL HISTORY:,  Diabetes mellitus type II, hypertension, coronary artery disease, atrial fibrillation, status post PTCA in 1995 by Dr. ABC.,SOCIAL HISTORY: , Denies alcohol or drugs.  Smokes 2 packs of cigarettes per day.  Works as a banker.,FAMILY HISTORY: , Positive for coronary artery disease (father & brother).,MEDICATIONS: , Aspirin 81 milligrams QDay.  Humulin N. insulin 50 units in a.m.  HCTZ 50 mg QDay.  Nitroglycerin 1/150 sublingually PRN chest pain.,ALLERGIES: , Penicillin.,PHYSICAL EXAM: , The patient is a 40-year-old white male.,General:  The patient is moderately obese but he is otherwise well developed & well nourished.  He appears in moderate discomfort but there is no evidence of distress.  He is alert, and oriented to person place and circumstance.  There is no evidence of respiratory distress.  The patient ambulates",
 The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent., Emergency Room Reports, Abdominal Pain - Consult ,"CHIEF COMPLAINT:,  Abdominal pain.,HISTORY OF PRESENT ILLNESS:,  The patient is a 71-year-old female patient of Dr. X. The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent.  She was seen 3 to 4 days ago at ABC ER and underwent evaluation and discharged and had a CT scan at that time and she was told it was ""normal.""  She was given oral antibiotics of Cipro and Flagyl.  She has had no nausea and vomiting, but has had persistent associated anorexia.  She is passing flatus, but had some obstipation symptoms with the last bowel movement two days ago.  She denies any bright red blood per rectum and no history of recent melena.  Her last colonoscopy was approximately 5 years ago with Dr. Y. She has had no definite fevers or chills and no history of jaundice.  The patient denies any significant recent weight loss.,PAST MEDICAL HISTORY:  ,Significant for history of atrial fibrillation, under good control and now in normal sinus rhythm and on metoprolol and also on Premarin hormone replacement.,PAST SURGICAL HISTORY: , Significant for cholecystectomy, appendectomy, and hysterectomy.  She has a long history of known grade 4 bladder prolapse and she has been seen in the past by Dr. Chip Winkel, I believe that he has not been re-consulted.,ALLERGIES: , SHE IS ALLERGIC OR SENSITIVE TO MACRODANTIN.,SOCIAL HISTORY: , She does not drink or smoke.,REVIEW OF SYSTEMS: , Otherwise negative for any recent febrile illnesses, chest pains or shortness of breath.,PHYSICAL EXAMINATION:,GENERAL:  The patient is an elderly thin white female, very pleasant, in no acute distress.,VITAL SIGNS:  Her temperature is 98.8 and vital signs are all stable, within normal limits.,HEENT:  Head is grossly atraumatic and normocephalic.  Sclerae are anicteric.  The conjunctivae are non-injected.,NECK:  Supple.,CHEST:  Clear.,HEART:  Regular rate and rhythm.,ABDOMEN:  Generally nondistended and soft.  She is focally tender in the left lower quadrant to deep palpation with a palpable fullness or mass and focally tender, but no rebound tenderness.  There is no CVA or flank tenderness, although some very minimal left flank tenderness.,PELVIC:  Currently deferred, but has history of grade 4 urinary bladder prolapse.,EXTREMITIES:  Grossly and neurovascularly intact.,LABORATORY VALUES:  ,White blood cell count is 5.3, hemoglobin 12.8, and platelet count normal.  Alkaline phosphatase elevated at 184.  Liver function tests otherwise normal.  Electrolytes normal.  Glucose 134, BUN 4, and creatinine 0.7.,DIAGNOSTIC STUDIES:,  EKG shows normal sinus rhythm.,IMPRESSION AND PLAN: , A 71-year-old female with greater than one-week history of abdominal pain now more localized to the left lower quadrant.  Currently is a nonacute abdomen.  The working diagnosis would be sigmoid diverticulitis.  She does have a history in the distant past of sigmoid diverticulitis.  I would recommend a repeat stat CT scan of the abdomen and pelvis and keep the patient nothing by mouth.  The patient was seen 5 years ago by Dr. Y in Colorectal Surgery.  We will consult her also for evaluation.  The patient will need repeat colonoscopy in the near future and be kept nothing by mouth now empirically.  The case was discussed with the patient's primary care physician, Dr. X. Again, currently there is no indication for acute surgical intervention on today's date, although the patient will need close observation and further diagnostic workup.",
" Syncope, end-stage renal disease requiring hemodialysis, congestive heart failure, and hypertension.", Discharge Summary, Renal Disease - Discharge Summary ,"ADMISSION DIAGNOSES:,1.  Syncope.,2.  End-stage renal disease requiring hemodialysis.,3.  Congestive heart failure.,4.  Hypertension.,DISCHARGE DIAGNOSES:,1.  Syncope.,2.  End-stage renal disease requiring hemodialysis.,3.  Congestive heart failure.,4.  Hypertension.,CONDITION ON DISCHARGE: , Stable.,PROCEDURE PERFORMED: , None.,HOSPITAL COURSE: , The patient is a 44-year-old African-American male who was diagnosed with end-stage renal disease requiring hemodialysis three times per week approximately four to five months ago.  He reports that over the past month, he has been feeling lightheaded when standing and has had three syncopal episodes during this time with return of consciousness after several minutes.  He reportedly had this even while seated and denied overt dizziness.  He reports this lightheadedness is made even worse when standing.  He has had these symptoms almost daily over the past month.  He does report some confusion when he awakens.  He reports that he loses consciousness for two to three minutes.  Denies any bowel or bladder loss, although he reports very little urine output secondary to his end-stage renal disease.  He denied any palpitations, warmth, or diaphoresis, which is indicative of vasovagal syncope.  There were no witnesses to his syncopal episodes.  He also denied any clonic activity and no history of seizures.  In the emergency room, the patient was given fluids and orthostatics were checked.  At that time, orthostatics were negative; however, due to the fact that fluid had been given before, it is impossible to rule out orthostatic hypotension.  The patient presented to the hospital on Coreg 12.5 mg b.i.d. and lisinopril 10 mg daily secondary to his hypertension, congestive heart failure with dilated cardiomyopathy and end-stage renal disease.  Regarding his syncopal episodes, he was admitted with likely orthostatic hypotension.  Cardiology was consulted and their recommendations were to reduce the lisinopril to 5 mg daily.  At that time, the Coreg had been held secondary to hypotension.  Cardiology also ordered a nuclear medicine myocardial perfusion stress test.  Regarding the end-stage renal disease, Nephrology was consulted as the patient was due for hemodialysis treatment the day following admission.  Nephrology was able to perform dialysis on the patient and Renal concurred that the presyncopal symptoms were likely due to decreased intravascular volume in the postdialytic time frame.  Renal agreed with decreasing his lisinopril to 5 mg daily and decreasing the Coreg to 6.25 mg b.i.d.  They reported that the Procrit should be continued.  As previously indicated regarding the dilated cardiomyopathy, Cardiology ordered a nuclear medicine stress test to be performed.  Also, regarding the patient's hypertension, he actually was noted to have hypotension on admission, and as previously stated, the Coreg was originally discontinued and then it was restarted at 6.25 mg b.i.d. and the patient tolerated this well.  The patient's hospital course remained uncomplicated until September 17, 2007, the day the nuclear medicine stress test was scheduled.  The patient stated that he was reluctant to proceed with the test and he was afraid of needles and the risks associated with the test although the procedure was explained to the patient and the risks of the procedure were quit low, the patient proceeded to discharge himself against medical advice.,DISCHARGE INSTRUCTIONS/MEDICATIONS:,The patient left AMA.  No specific discharge instructions and medications were given.  At the time of the patient leaving AMA, his medications were as follows:,1.  Aspirin 81 mg p.o. daily.,2.  Multivitamin, Nephrocaps one cap p.o. daily.,3.  Fosrenol 500 mg chewable t.i.d.,4.  Lisinopril 2.5 mg daily.,6.  Coreg 3.125 mg p.o. b.i.d.,7.  Procrit 10,000 units inject every Tuesday, Thursday, and Saturday.,8.  Heparin 5000 units q.8h. subcutaneous for DVT prophylaxis.","discharge summary, syncope, congestive heart failure, end-stage renal disease requiring hemodialysis, nuclear medicine, stress test, stage renal, renal disease, renal, disease, hemodialysis, "
 The patient was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety., Discharge Summary, Speech Therapy - Discharge Summary - 1 ,"HISTORY: , The patient is a 67-year-old female, was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.  At the onset of therapy, on 03/26/08, the patient was NPO with a G-tube and the initial speech and language evaluation revealed global aphasia with an aphasia quotient of 3.6/100 based on the Western Aphasia Battery.  Since the initial evaluation, the patient has attended 60 outpatient speech therapy sessions, which have focussed on her receptive communication, expressive language, multimodality communication skills, and swallowing function and safety.,SHORT-TERM GOALS:,1.  The patient met 3 out of 4 original short-term therapy goals, which were to complete a modified barium swallow study, which she did do and which revealed no aspiration.  At this time, the patient is eating and drinking and taking all medications by mouth; however, her G-tube is still present.  The patient was instructed to talk to the primary care physician about removal of her feeding tube.,2.  The patient will increase accuracy of yes-no responses to greater than 80% accuracy.  She did accomplish this goal.  The patient is also able to identify named objects with greater than 80% accuracy.,ADDITIONAL GOALS: , Following the completion of these goals, additional goals were established.  Based on reevaluation, the patient met 2 out of these 3 initial goals and she is currently able to read and understand simple sentences with greater than 90% accuracy independently and she is able to write 10 words related to basic wants and needs with greater than 80% accuracy independently.  The patient continues to have difficulty stating verbally, yes or no, to questions as well as accurately using head gestures and to respond to yes-no questions.  The patient continues to have marked difficulty with her expressive language abilities.  She is able to write simple words to help express her basic wants and needs.  She has made great strides; however, with her receptive communication, she is able to read words as well as short phrases and able to point to named objects and answer simple-to-moderate complex yes-no questions.  A reevaluation completed on 12/01/08, revealed an aphasia quotient of 26.4.  Once again, she made significant improvement and comprehension, but continues to have unintelligible speech.  An alternative communication device was discussed with the patient and her husband, but at this time, the patient does not want to utilize a communication device.  If, in the future, the patient continues to struggle with her expressive communication, an alternative augmented communication device would be a benefit to her.  Please reconsult at that time if and when the patient is ready to use a speech generating device.  The patient is discharged from my services at this time due to a plateau in her progress.  Numerous home activities were recommended to allow her to continue to make progress at home.","discharge summary, communication skills, g-tube, aphasia, language evaluation, western aphasia battery, skilled speech therapy, swallowing function, speech therapy, therapy, swallowing, aspiration, speech, communication,"
 The patient was discharged by court as a voluntary drop by prosecution. , Discharge Summary, Psychiatric Discharge Summary ,"DISCHARGE DISPOSITION:,  The patient was discharged by court as a voluntary drop by prosecution.  This was AMA against hospital advice.,DISCHARGE DIAGNOSES:,AXIS I:  Schizoaffective disorder, bipolar type.,AXIS II:  Deferred.,AXIS III:  Hepatitis C.,AXIS IV:  Severe.,AXIS V:  19.,CONDITION OF PATIENT ON DISCHARGE: , The patient remained disorganized.  The patient was suffering from prolactinemia secondary to medications.,DISCHARGE FOLLOWUP:  ,To be arranged per the patient as the patient was discharged by court.,DISCHARGE MEDICATIONS: , A 2-week supply of the following was phoned into the patient's pharmacy:  Seroquel 25 mg p.o. nightly.  Zyprexa 5 mg p.o. b.i.d.,MENTAL STATUS AT THE TIME OF DISCHARGE:,  Attitude was cooperative.  Appearance showed fair hygiene and grooming.  Psychomotor behavior showed restlessness.  No EPS or TD was noted.  Affect was restricted.  Mood remained anxious and speech was pressured.  Thoughts remained tangential, and the patient endorsed paranoid delusions.  The patient denied auditory hallucinations.  The patient denied suicidal or homicidal ideation, was oriented to person and place.  Overall, insight into her illness remained impaired.,HISTORY AND HOSPITAL COURSE: , The patient is a 22-year-old female with a history of bipolar affective disorder, was initially admitted for evaluation of increasing mood lability, disorganization, and inappropriate behaviors.  The patient reportedly was asking her father to have sex with her and tried to pull down her mother's pants.  The patient took her clothing off, was noted to be very disorganized sexually, and religiously preoccupied, and endorsed auditory hallucinations of voices telling her to calm herself and others.  The patient has a history of depression versus bipolar disorder, last hospitalized in Pierce County in 2008, but without recent treatment.  The patient on admission interview was noted to be labile and disorganized.  The patient was initiated on Risperdal M-Tab 2 mg p.o. b.i.d. for psychosis and mood lability, and also medically evaluated by Rebecca Richardson, MD.  The patient remained labile and suspicious during her hospital stay.  The patient continued to be sexually preoccupied and had poor insight into her need for treatment.  The patient denied further auditory hallucinations.  The patient was treated with Seroquel for persistent mood lability and psychosis.  The patient was noted to develop prolactinemia with Risperdal and this was changed to Zyprexa prior to discharge.  The patient remained disorganized, but was given a voluntary drop by prosecution against medical advice when she went to court on 01/11/2010.  The patient was discharged to return home to her parents and was referred to Community Mental Health Agencies.  The patient was thus discharged in symptomatic condition.","discharge summary, schizoaffective disorder, bipolar type, mood lability, disorganization, bipolar affective disorder, voluntary drop, auditory hallucinations, psychiatric, axis,"
 Discharge summary of a patient with depression and high risk behavior., Discharge Summary, Psychiatric Discharge Summary - 2 ,"DISCHARGE SUMMARY,SUMMARY OF TREATMENT PLANNING:,  This discharge is at the family's request.,IDENTIFIED PROBLEMS/OUTCOMES:,1.",
 Speech therapy discharge summary.  The patient was admitted for skilled speech therapy secondary to cognitive-linguistic deficits. , Discharge Summary, Speech Therapy - Discharge Summary ,"LONG-TERM GOALS:,  Both functional and cognitive-linguistic ability to improve safety and independence at home and in the community.  This goal has been met based on the patient and husband reports the patient is able to complete all activities, which she desires to do at home.  During the last reevaluation, the patient had a significant progress and all cognitive domains evaluated, which are attention, memory, executive functions, language, and visuospatial skill.  She continues to have an overall mild cognitive-linguistic deficit, but this is significantly improved from her initial evaluation, which showed severe impairment., ,The patient does no longer need a skilled speech therapy because she has accomplished all of her goals and her progress has plateaued.  The patient and her husband both agreed with the patient's discharge.","discharge summary, narrative, memory, executive function, attention, speech therapy, visuospatial, accuracy, linguistic, cognitive, speechNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit, hypertension, mild renal insufficiency, and anemia, which has been present chronically over the past year.", Discharge Summary, Pyelonephritis - Discharge Summary ,"ADMISSION DIAGNOSES:,1.  Pyelonephritis.,2.  History of uterine cancer and ileal conduit urinary diversion.,3.  Hypertension.,4.  Renal insufficiency.,5.  Anemia.,DISCHARGE DIAGNOSES:,1.  Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit.,2.  Hypertension.,3.  Mild renal insufficiency.,4.  Anemia, which has been present chronically over the past year.,HOSPITAL COURSE:,  The patient was admitted with suspected pyelonephritis.  Renal was consulted.  It was thought that there was a thick mucous plug in the Foley in the ileal conduit that was irrigated by Dr. X.  Her symptoms responded to IV antibiotics and she remained clinically stable.  Klebsiella was isolated in this urine, which was sensitive to Bactrim and she was discharged on p.o.  Bactrim.  She was scheduled on 08/07/2007 for further surgery.  She is to follow up with Dr. Y in 7-10 days.  She also complained of right knee pain and the right knee showed no sign of effusion.  She was exquisitely tender to touch of the patellar tendon.  It was thought that this did not represent intraarticular process.  She was advised to use ibuprofen over-the-counter two to three tabs t.i.d.","discharge summary, uterine cancer, renal insufficiency, pyelonephritis, mucous plugging, ileal conduit "
 Discharge summary of a patient with mood swings and oppositional and defiant behavior., Discharge Summary, Psychiatric Discharge Summary - 1 ,"DISCHARGE SUMMARY,SUMMARY OF TREATMENT PLANNING:,Two major problems were identified at the admission of this adolescent:,1.",
" Prematurity, 34 weeks' gestation, now 5 days old, group B streptococcus exposure, but no sepsis, physiologic jaundice, and feeding problem.", Discharge Summary, Prematurity - Discharge Summary ,"ADMITTING DIAGNOSES,1. Prematurity.,2. Appropriate for gestational age.,3. Maternal group B streptococcus positive culture.,DISCHARGE DIAGNOSES,1. Prematurity, 34 weeks' gestation, now 5 days old.,2. Group B streptococcus exposure, but no sepsis.,3. Physiologic jaundice.,4. Feeding problem.,HISTORY OF ILLNESS:  ,This is a 4-pound female infant born to a 26-year-old gravida 1, now para 1-0-0-1 lady with an EDC of November 19, 2003.  Group B streptococcus culture was positive on September 29, 2003, and betamethasone was given 1 dose prior to delivery.  Mother also received 1 dose of penicillin approximately 1-1/2 hours prior to delivery.  The infant delivered vaginally, had a double nuchal cord and required CPAP and free flow oxygen.  Her Apgars were 8 at 1 minute and 9 at 5 minutes.  At the end of delivery, it was noted there was a partial placental abruptio.,HOSPITAL COURSE:  ,The infant has had a basically uncomplicated hospital course.  She did not require oxygen.  She did have antibiotics, ampicillin and gentamicin for approximately 48 hours to cover for possible group B streptococcus.  The culture was negative and the antibiotics were stopped at 48 hours.,The infant was noted to have physiologic jaundice and her highest bilirubin was 7.1.  She was treated for approximately 24 hours with phototherapy and the bilirubin on October 15, 2003 was 3.4.,FEEDING: , The infant has had some difficulty with feeding, but at the time of discharge, she is taking approximately 30 mL every feeding and is taking Formula or breast milk, that is, ___ 24 calories per ounce.,PHYSICAL EXAMINATION:, ,VITAL SIGNS:  At discharge, reveals a well-developed infant whose temperature is 98.3, pulse 156, respirations 35, her weight is 1779 g (1% below her birthweight).,HEENT:  Head is normocephalic.  Eyes are without conjunctival injection.  Red reflex is elicited bilaterally.  TMs not well visualized.  Nose and throat are patent without palatal defect.,NECK:  Supple without clavicular fracture.,LUNGS:  Clear to auscultation.,HEART:  Regular rate without murmur, click or gallop present.,EXTREMITIES:  Pulses are 2/4 for brachial and femoral.  Extremities without evidence of hip defects.,ABDOMEN:  Soft, bowel sounds present.  No masses or organomegaly.,GENITALIA:  Normal female, but the clitoris is not covered by the labia majora.,NEUROLOGICAL:  The infant has good Moro, grasp, and suck reflexes.,INSTRUCTIONS FOR CONTINUING CARE,The infant will be discharged home.  She will have home health visits one time per week for 3 weeks, and she will be seen in followup at San Juan Pediatrics the week of October 20, 2003.  She is to continue feeding with either breast milk or Formula, that is, ___ to 24 calories per ounce.,CONDITION: , Her condition at discharge is good.",
" The patient has had abdominal pain associated with a 30-pound weight loss and then developed jaundice.  He had epigastric pain and was admitted to the hospital.  A thin-slice CT scan was performed, which revealed a pancreatic mass with involved lymph nodes and ring enhancing lesions consistent with liver metastases. ", Discharge Summary, Pancreatic Mass - Discharge Summary ,"HISTORY OF PRESENT ILLNESS: ,  The patient is a 48-year-old man who has had abdominal pain since October of last year associated with a 30-pound weight loss and then developed jaundice.  He had epigastric pain and was admitted to the hospital.  A thin-slice CT scan was performed, which revealed a 4 x 3 x 2 cm pancreatic mass with involved lymph nodes and ring enhancing lesions consistent with liver metastases.  The patient, additionally, had a questionable pseudocyst in the tail of the pancreas.  The patient underwent ERCP on 04/04/2007 with placement of a stent.  This revealed a strictured pancreatic duct, as well as strictured bile duct.  A 10-french x 9 cm stent was placed with good drainage.  The next morning, the patient felt quite a bit more comfortable.  He additionally had a modest drop in his bilirubin and other liver tests.  Of note, the patient has been having quite a bit of nausea during his admission.  This responded to Zofran.  It did not, initially, respond well to Phenergan, though after stent placement, he was significantly more comfortable and had less nausea, and in fact, had better response to the Phenergan itself.  At the time of discharge, the patient's white count was 9.4, hemoglobin 10.8, hematocrit 32 with a MCV of 79, platelet count of 585,000.  His sodium was 132, potassium 4.1, chloride 95, CO2 27, BUN of 8 with a creatinine of 0.3.  His bilirubin was 17.1, alk phos 273, AST 104, ALT 136, total protein 7.8 and albumin of 3.8.  He was tolerating a regular diet.  The patient had been on oral hypoglycemics as an outpatient, but in hospital, he was simply managed with an insulin sliding scale.  The patient will be transferred back to Pelican Bay, under the care of Dr. X at the infirmary.  He will be further managed for his diabetes there.  The patient will additionally undergo potential end of life meetings.  I discussed the potentials of chemotherapy with patient.  Certainly, there are modest benefits, which can be obtained with chemotherapy in metastatic pancreatic cancer, though at some cost with morbidity.  The patient will consider this and will discuss this further with Dr. X.  ,DISCHARGE MEDICATIONS:,1.  Phenergan 25 mg q.6. p.r.n.,2.  Duragesic patch 100 mcg q.3.d.,3.  Benadryl 25-50 mg p.o. q.i.d. for pruritus.,4.  Sliding scale will be discontinued at the time of discharge and will be reinstituted on arrival at Pelican Bay Infirmary.,5.  The patient had initially been on enalapril here.  His hypertension will be managed by Dr. X as well.  ,PLAN: , The patient should return for repeat ERCP if there are signs of stent occlusion such as fever, increased bilirubin, worsening pain.  In the meantime, he will be kept on a regular diet and activity per Dr. X.","discharge summary, abdominal pain, lymph nodes, weight loss, pancreatic mass, chemotherapy, abdominal, bilirubin, phenergan, stent, drainage, "
" Fever, otitis media, and possible sepsis.", Discharge Summary, Otitis Media - Discharge Summary ,"ADMITTING DIAGNOSES:,1.  Fever.,2.  Otitis media.,3.  Possible sepsis.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 10-month-old male who was seen in the office 1 day prior to admission.  He has had a 2-day history of fever that has gone up to as high as 103.6 degrees F. He has also had intermittent cough, nasal congestion, and rhinorrhea and no history of rashes.  He has been taking Tylenol and Advil to help decrease the fevers, but the fever has continued to rise.  He was noted to have some increased workup of breathing and parents returned to the office on the day of admission.,PAST MEDICAL HISTORY: , Significant for being born at 33 weeks' gestation with a birth weight of 5 pounds and 1 ounce.,PHYSICAL EXAMINATION: , On exam, he was moderately ill appearing and lethargic.  HEENT:  Atraumatic, normocephalic.  Pupils are equal, round, and reactive to light.  Tympanic membranes were red and yellow, and opaque bilaterally.  Nares were patent.  Oropharynx was slightly moist and pink.  Neck was soft and supple without masses.  Heart is regular rate and rhythm without murmurs.  Lungs showed increased workup of breathing, moderate tachypnea.  No rales, rhonchi or wheezes were noted.  Abdomen:  Soft, nontender, nondistended.  Active bowel sounds.  Neurologic exam showed good muscle strength, normal tone.  Cranial nerves II through XII are grossly intact.,LABORATORY FINDINGS: , He had electrolytes, BUN and creatinine, and glucose all of which were within normal limits.  White blood cell count was 8.6 with 61% neutrophils, 21% lymphocytes, 17% monocytes, suggestive of a viral infection.  Urinalysis was completely unremarkable.  Chest x-ray showed a suboptimal inspiration, but no evidence of an acute process in the chest.,HOSPITAL COURSE: , The patient was admitted to the hospital and allowed a clear liquid diet.  Activity is as tolerates.  CBC with differential, blood culture, electrolytes, BUN, and creatinine, glucose, UA, and urine culture all were ordered.  Chest x-ray was ordered as well with 2 views to evaluate for a possible pneumonia.  Pulse oximetry checks were ordered every shift and as needed with O2 ordered per nasal cannula if O2 saturations were less that 94%.  Gave D5 and quarter of normal saline at 45 mL per hour, which was just slightly above maintenance rate to help with hydration.  He was given ceftriaxone 500 mg IV once daily to treat otitis media and possible sepsis, and I will add Tylenol and ibuprofen as needed for fevers.  Overnight, he did have his oxygen saturations drop and went into oxygen overnight.  His lungs remained clear, but because of the need for O2, we instituted albuterol aerosols every 6 hours to help maintain good lung function.  The nurses were instructed to attempt to wean O2 if possible and advance the diet.  He was doing clear liquids well and so I saline locked to help to accommodate improve the mobility with the patient.  He did well the following evening with no further oxygen requirement.  He continued to spike fevers but last fever was around 13:45 on the previous day.  At the time of exam, he had 100% oxygen saturations on room air with temperature of 99.3 degrees F. with clear lungs.  He was given additional dose of Rocephin when it was felt that it would be appropriate for him to be discharged that morning.,CONDITION OF THE PATIENT AT DISCHARGE: , He was at 100% oxygen saturations on room air with no further dips at night.  He has become afebrile and was having no further increased work of breathing.,DISCHARGE DIAGNOSES:,1.  Bilateral otitis media.,2.  Fever.,PLAN:  ,Recommended discharge.  No restrictions in diet or activity.  He was continued Omnicef 125 mg/5 mL one teaspoon p.o. once daily and instructed to follow up with Dr. X, his primary doctor, on the following Tuesday.  Parents were instructed also to call if new symptoms occurred or he had return if difficulties with breathing or increased lethargy.","discharge summary, sepsis, cough, nasal congestion, rhinorrhea, oxygen saturations, otitis media, otitis, breathing, lungs, oropharynx, fever"
 Open reduction and internal fixation (ORIF) of right Schatzker III tibial plateau fracture with partial medial meniscectomy., Discharge Summary, ORIF - Discharge Summary ,"ADMISSION DIAGNOSIS: , Right tibial plateau fracture.,DISCHARGE DIAGNOSES: , Right tibial plateau fracture and also medial meniscus tear on the right side.,PROCEDURES PERFORMED:,  Open reduction and internal fixation (ORIF) of right Schatzker III tibial plateau fracture with partial medial meniscectomy.,CONSULTATIONS: , To rehab, Dr. X and to Internal Medicine for management of multiple medical problems including hypothyroid, diabetes mellitus type 2, bronchitis, and congestive heart failure.,HOSPITAL COURSE: , The patient was admitted and consented for operation, and taken to the operating room for open reduction and internal fixation of right Schatzker III tibial plateau fracture and partial medial meniscectomy performed without incidence.  The patient seemed to be recovering well.  The patient spent the next several days on the floor, nonweightbearing with CPM machine in place, developed a brief period of dyspnea, which seems to have resolved and may have been a combination of bronchitis, thick secretions, and fluid overload.  The patient was given nebulizer treatment and Lasix increased the same to resolve the problem.  The patient was comfortable, stabilized, breathing well.  On day #12, was transferred to ABCD.,DISCHARGE INSTRUCTIONS: , The patient is to be transferred to ABCD after open reduction and internal fixation of right tibial plateau fracture and partial medial meniscectomy.,DIET:,  Regular.,ACTIVITY AND LIMITATIONS: , Nonweightbearing to the right lower extremity.  The patient is to continue CPM machine while in bed along with antiembolic stockings.  The patient will require nursing, physical therapy, occupational therapy, and social work consults.,DISCHARGE MEDICATIONS: , Resume home medications, but increase Lasix to 80 mg every morning, Lovenox 30 mg subcu daily x2 weeks, Vicodin 5/500 mg one to two every four to six hours p.r.n. pain, Combivent nebulizer every four hours while awake for difficulty breathing, Zithromax one week 250 mg daily, and guaifenesin long-acting one twice a day b.i.d.,FOLLOWUP: , Follow up with Dr. Y in 7 to 10 days in office.,CONDITION ON DISCHARGE:,  Stable.","discharge summary, open reduction, internal fixation, schatzker iii tibial plateau fracture, meniscectomy, tibial plateau fracture, orif, schatzker, fixation, reduction, tibial, fracture, plateau,"
 Aspiration pneumonia and chronic obstructive pulmonary disease (COPD) exacerbation.  Acute respiratory on chronic respiratory failure secondary to chronic obstructive pulmonary disease exacerbation.  Systemic inflammatory response syndrome secondary to aspiration pneumonia.  No bacteria identified with blood cultures or sputum culture., Discharge Summary, Pneumonia & COPD - Discharge Summary ,"ADMISSION DIAGNOSES:,1.  Pneumonia, likely secondary to aspiration.,2.  Chronic obstructive pulmonary disease (COPD) exacerbation.,3.  Systemic inflammatory response syndrome.,4.  Hyperglycemia.,DISCHARGE DIAGNOSES:,1.  Aspiration pneumonia.,2.  Aspiration disorder in setting of severe chronic obstructive pulmonary disease.,3.  Chronic obstructive pulmonary disease (COPD) exacerbation.,4.  Acute respiratory on chronic respiratory failure secondary to chronic obstructive pulmonary disease exacerbation.,5.  Hypercapnia on admission secondary to chronic obstructive pulmonary disease.,6.  Systemic inflammatory response syndrome secondary to aspiration pneumonia.  No bacteria identified with blood cultures or sputum culture.,7.  Atrial fibrillation with episodic rapid ventricular rate, now rate control.,8.  Hyperglycemia secondary to poorly controlled type ii diabetes mellitus, insulin requiring.,9.  Benign essential hypertension, poorly controlled on admission, now well controlled on discharge.,10.  Aspiration disorder exacerbated by chronic obstructive pulmonary disease and acute respiratory failure.,11.  Hyperlipidemia.,12.  Acute renal failure on chronic renal failure on admission, now resolved.,HISTORY OF PRESENT ILLNESS:,  Briefly, this is 73-year-old white male with history of multiple hospital admissions for COPD exacerbation and pneumonia who presented to the emergency room on 04/23/08, complaining of severe shortness of breath.  The patient received 3 nebulizers at home without much improvement.  He was subsequently treated successfully with supplemental oxygen provided by normal nasal cannula initially and subsequently changed to BiPAP.,HOSPITAL COURSE:  ,The patient was admitted to the hospitalist service, treated with frequent small volume nebulizers, treated with IV Solu-Medrol and BiPAP support for COPD exacerbation.  The patient also noted with poorly controlled atrial fibrillation with a rate in the low 100s to mid 100s.  The patient subsequently received diltiazem, also received p.o. digoxin.  The patient subsequently responded well as well received IV antibiotics including Levaquin and Zosyn.  The patient made slow, but steady improvement over the course of his hospitalization.  The patient subsequently was able to be weaned off BiPAP during the day, but continued BiPAP at night and will continue with BiPAP if needed.  The patient may require a sleep study after discharge, but by the third day prior to discharge he was no longer utilizing BiPAP, was simply using supplemental O2 at night and was able to maintain appropriate and satisfactory O2 saturations on one-liter per minute supplemental O2 per nasal cannula.  The patient was able to participate with physical therapy, able to ambulate from his bed to the bathroom, and was able to tolerate a dysphagia 2 diet.  Note that speech therapy did provide a consultation during this hospitalization and his modified barium swallow was thought to be unremarkable and really related only to the patient's severe shortness of breath during meal time.  The patient's chest x-ray on admission revealed some mild vascular congestion and bilateral pleural effusions that appeared to be unchanged.  There was also more pronounced patchy alveolar opacity, which appeared to be, ""mass like"" in the right suprahilar region.  This subsequently resolved and the patient's infiltrate slowly improved over the course of his hospitalization.  On the day prior to discharge, the patient had a chest x-ray 2 views, which allowing for differences in technique revealed little change in the bibasilar infiltrates and atelectatic changes at the bases bilaterally.  This was compared with an examination performed 3 days prior.  The patient also had minimal bilateral effusions.  The patient will continue with clindamycin for the next 2 weeks after discharge.  Home health has been ordered and the case has been discussed in detail with Shaun Eagan, physician assistant at Eureka Community Health Center.  The patient was discharged as well on a dysphagia 2 diet, thin liquids are okay.  The patient discharged on the following medications.,DISCHARGE MEDICATIONS:,1.  Home oxygen 1 to 2 liters to maintain O2 saturations at 89 to 91% at all times.,2.  Ativan 1 mg p.o. t.i.d.,3.  Metformin 1000 mg p.o. b.i.d.,4.  Glucotrol 5 mg p.o. daily.,5.  Spiriva 1 puff b.i.d.,6.  Lantus 25 units subcu q.a.m.,7.  Cardizem CD 180 mg p.o. q.a.m.,8.  Advair 250/50 mcg, 1 puff b.i.d.  The patient is instructed to rinse with mouthwash after each use.,9.  Iron 325 mg p.o. b.i.d.,10.  Aspirin 325 mg p.o. daily.,11.  Lipitor 10 mg p.o. bedtime.,12.  Digoxin 0.25 mg p.o. daily.,13.  Lisinopril 20 mg p.o. q.a.m.,14.  DuoNeb every 4 hours for the next several weeks, then q.6 h. thereafter, dispensed 180 DuoNeb ampule's with one refill.,15.  Prednisone 40 mg p.o. q.a.m. x3 days followed by 30 mg p.o. q.a.m. x3 days, then followed by 20 mg p.o. q.a.m. x5 days, then 10 mg p.o. q.a.m. x14 days, then discontinue, #30 days supply given.  No refills.,16.  Clindamycin 300 mg p.o. q.i.d. x2 weeks, dispensed #64 with one refill.,The patient's aspiration pneumonia was discussed in detail.  He is agreeable to obtaining a chest x-ray PA and lateral after 2 weeks of treatment.  Note that this patient did not have community-acquired pneumonia.  His discharge diagnosis is aspiration pneumonia.  The patient will continue with a dysphagia 2 diet with thin liquids after discharge.  The patient discharged with home health.  A dietary and speech therapy evaluation has been ordered.  Speech therapy to treat for chronic dysphagia and aspiration in the setting of severe chronic obstructive pulmonary disease.,Total discharge time was greater than 30 minutes.",
" Contusion of the frontal lobe of the brain, closed head injury and history of fall, and headache, probably secondary to contusion.", Discharge Summary, Neurology - Discharge Summary ,"PRELIMINARY DIAGNOSES:,1.  Contusion of the frontal lobe of the brain.,2.  Closed head injury and history of fall.,3.  Headache, probably secondary to contusion.,FINAL DIAGNOSES:,1.  Contusion of the orbital surface of the frontal lobes bilaterally.,2.  Closed head injury.,3.  History of fall.,COURSE IN THE HOSPITAL: , This is a 29-year-old male, who fell at home.  He was seen in the emergency room due to headache.  CT of the brain revealed contusion of the frontal lobe near the falx.  The patient did not have any focal signs.  He was admitted to ABCD.  Neurology consultation was obtained.  Neuro checks were done.  The patient continued to remain stable, although he had some frontal headache.  He underwent an MRI to rule out extension of the contusion or the possibility of a bleed and the MRI of the brain without contrast revealed findings consistent with contusion of the orbital surface of the frontal lobes bilaterally near the interhemispheric fissure.  The patient remained clinically stable and his headache resolved.  He was discharged home on 11/6/2008.,PLAN: , Discharge the patient to home.,ACTIVITY:  ,As tolerated.,The patient has been advised to call if the headache is recurrent and Tylenol 650 mg 1 p.o. q.6 h. p.r.n. headache.  The patient has been advised to follow up with me as well as the neurologist in about 1 week.","discharge summary, interhemispheric, frontal lobe, head injury, brain, contusion"
" Occupational therapy discharge summary.  Traumatic brain injury, cervical musculoskeletal strain.", Discharge Summary, Occupational Therapy Discharge Summary ,"DIAGNOSES: , Traumatic brain injury, cervical musculoskeletal strain.,DISCHARGE SUMMARY: , The patient was seen for evaluation on 12/11/06 followed by 2 treatment sessions.  Treatment consisted of neuromuscular reeducation including therapeutic exercise to improve range of motion, strength, and coordination; functional mobility training; self-care training; cognitive retraining; caregiver instruction; and home exercise program.  Goals were not achieved, as the patient was admitted to inpatient rehabilitation center.,RECOMMENDATIONS: , Discharged from OT this date, as the patient has been admitted to Inpatient Rehabilitation Center.,Thank you for this referral.","discharge summary, musculoskeletal strain, occupational therapy, traumatic, brain, cervical, musculoskeletal, rehabilitation,"
" Atypical pneumonia, hypoxia, rheumatoid arthritis, and suspected mild stress-induced adrenal insufficiency.  This very independent 79-year old had struggled with cough, fevers, weakness, and chills for the week prior to admission.", Discharge Summary, Pneumonia - Discharge Summary ,"ADMISSION DIAGNOSES:,1.  Pneumonia, failed outpatient treatment.,2.  Hypoxia.,3.  Rheumatoid arthritis.,DISCHARGE DIAGNOSES:,1.  Atypical pneumonia, suspected viral.,2.  Hypoxia.,3.  Rheumatoid arthritis.,4.  Suspected mild stress-induced adrenal insufficiency.,HOSPITAL COURSE: , This very independent 79-year old had struggled with cough, fevers, weakness, and chills for the week prior to admission.  She was seen on multiple occasions at Urgent Care and in her physician's office.  Initial x-ray showed some mild diffuse patchy infiltrates.  She was first started on Avelox, but had a reaction, switched to Augmentin, which caused loose stools, and then three days prior to admission was given daily 1 g Rocephin and started on azithromycin.  Her O2 saturations drifted downward.  They were less than 88% when active; at rest, varied between 88% and 92%.  Decision was made because of failed outpatient treatment of pneumonia.  Her medical history is significant for rheumatoid arthritis.  She is on 20 mg of methotrexate every week as well as Remicade every eight weeks.  Her last dose of Remicade was in the month of June.  Hospital course was relatively unremarkable.  CT scan was performed and no specific focal pathology was seen.  Dr. X, pulmonologist was consulted.  He also was uncertain as to the exact etiology, but viral etiology was most highly suspected.  Because of her loose stools, C. difficile toxin was ordered, although that is pending at the time of discharge.  She was continued on Rocephin IV and azithromycin.  Her fever broke 18 hours prior to discharge, and O2 saturations improved, as did her overall strength and clinical status.  She was instructed to finish azithromycin.  She has two pills left at home.  She is to follow up with Dr. X in two to three days.  Because she is on chronic prednisone therapy, it was suspected that she was mildly adrenal insufficient from the stress of her pneumonia.  She is to continue the increased dose of prednisone at 20 mg (up from 5 mg per day).  We will consult her rheumatologist as to whether to continue her methotrexate, which we held this past Friday.  Methotrexate is known on some occasions to cause pneumonitis.","discharge summary, adrenal insufficiency, hypoxia, cough, fevers, weakness, chills, atypical pneumonia, loose stools, rheumatoid arthritis, azithromycin, arthritis, pneumonia, "
  Symptomatic thyroid goiter.  Total thyroidectomy., Discharge Summary, Post Thyroidectomy - Discharge Summary ,"ADMISSION DIAGNOSIS: , Symptomatic thyroid goiter.,DISCHARGE DIAGNOSIS:  ,Symptomatic thyroid goiter.,PROCEDURE PERFORMED DURING THIS HOSPITALIZATION: , Total thyroidectomy.,INDICATIONS FOR THE SURGERY:  ,Briefly, the patient is a 71-year-old female referred with increasingly symptomatic large nodular thyroid goiter.  She presented now after informed consent for the above procedure, understanding the inherent risks and complications and risk-benefit ratio.,HOSPITAL COURSE:  ,The patient underwent total thyroidectomy on 09/22/08, which she tolerated very well and remained stable in the postoperative period.  On postoperative day #1, she was tolerating her diet, began on thyroid hormone replacement, and remained afebrile with stable vital signs.  She required intravenous narcotics for pain control.  She was judged stable for discharge home on 09/25/08, tolerating a diet well, having no fever, stable vital signs, and good pain control.  The wound was clean and dry.  The drain was removed.  She was instructed to follow up in the surgical office within one week after discharge.  She was given prescription for Vicodin for pain and Synthroid thyroid hormone, and otherwise the appropriate wound care instructions per my routine wound care sheet.","discharge summary, nodular, symptomatic thyroid goiter, thyroidectomy, goiter, "
" Suspected mastoiditis ruled out, right acute otitis media, and severe ear pain resolving.  The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis.  ", Discharge Summary, Mastoiditis - Discharge Summary ,"DISCHARGE DIAGNOSES:  ,1.  Suspected mastoiditis ruled out.,2.  Right acute otitis media.,3.  Severe ear pain resolving.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis.  The child has had very severe ear pain and blood draining from the right ear.  The child had a temperature maximum of 101.4 in the ER.  The patient was admitted and started on IV Unasyn, which he tolerated well and required Morphine and Vicodin for pain control.  In the first 12 hours after admission, the patient's pain decreased and also swelling of his cervical area decreased.  The patient was evaluated by Dr. X from the ENT while in house.  After reviewing the CT scan, it was felt that the CT scan was not consistent with mastoiditis.  The child was continued on IV fluid and narcotics for pain as well as Unasyn until the time of discharge.  At the time of discharge his pain is markedly decreased about 2/10 and swelling in the area has improved.  The patient is also able to take p.o. well.,DISCHARGE PHYSICAL EXAMINATION:,GENERAL:  The patient is alert, in no respiratory distress.,VITAL SIGNS:  His temperature is 97.6, heart rate 83, blood pressure 105/57, respiratory rate 16 on room air.,HEENT:  Right ear shows no redness.  The area behind his ear is nontender.  There is a large posterior chains node that is nontender and the swelling in this area has decreased markedly.,NECK:  Supple.,CHEST:  Clear breath sounds.,CARDIAC:  Normal S1, S2 without murmur.,ABDOMEN:  Soft.  There is no hepatosplenomegaly or tenderness.,SKIN:  Warm and well perfused.,DISCHARGE WEIGHT: , 38.7 kg.,DISCHARGE CONDITION: , Good.,DISCHARGE DIET:,  Regular as tolerated.,DISCHARGE MEDICATIONS:  ,1.  Ciprodex Otic Solution in the right ear twice daily.,2.  Augmentin 500 mg three times daily x10 days.,FOLLOW UP:  ,1.  Dr. Y in one week (ENT).,2.  The primary care physician in 2 to 3 days.,TIME SPENT: , Approximate discharge time is 28 minutes.", 
 Discharge summary of a patient presenting with a large mass aborted through the cervix., Discharge Summary, Mullerian Adenosarcoma ,"PRINCIPAL DIAGNOSIS: , Mullerian adenosarcoma.  ,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old presenting with a large mass aborted through the cervix.,PHYSICAL EXAM:,CHEST:  Clear.  There is no heart murmur.,ABDOMEN:  Nontender.,PELVIC:  There is a large mass in the vagina.  ,HOSPITAL COURSE: , The patient went to surgery on the day of admission.  The postoperative course was marked by fever and ileus.  The patient regained bowel function.  She was discharged on the morning of the seventh postoperative day.,OPERATIONS: , July 25, 2006:  Total abdominal hysterectomy, bilateral salpingo-oophorectomy.,DISCHARGE CONDITION: , Stable.,  ,PLAN: , The patient will remain at rest initially with progressive ambulation thereafter.  She will avoid lifting, driving, stairs, or intercourse.  She will call me for fevers, drainage, bleeding, or pain.  Family history, social history, and psychosocial needs per the social worker.  The patient will follow up in my office in one week.,PATHOLOGY:,  Mullerian adenosarcoma.,MEDICATIONS:,  Percocet 5, #40, one q.3 h. p.r.n. pain.","discharge summary, cervix, fevers, drainage, bleeding, mullerian adenosarcoma, mullerian, adenosarcoma"
" Respiratory distress syndrome, intrauterine growth restriction, thrombocytopenia, hypoglycemia, retinal immaturity.  The baby is an ex-32 weeks small for gestational age infant with birth weight 1102.", Discharge Summary, Neonatal Discharge Summary - 1 ,"ADMITTING DIAGNOSES:,  Respiratory distress syndrome, intrauterine growth restriction, thrombocytopenia, hypoglycemia, retinal immaturity.,HISTORY OF PRESENTING ILLNESS: , The baby is an ex-32 weeks small for gestational age infant with birth weight 1102.  Baby was born at ABCD Hospital at 1333 on 07/14/2006.  Mother is a 20-year-old gravida 1, para 0 female who received prenatal care.  Prenatal course was complicated by low amniotic fluid index and hypertension.  She was evaluated for evolving preeclampsia and had a C-section secondary to the nonreassuring fetal status.  Baby delivered operatively, Apgar scores were 8 and 9 initially taken to level 2 satellite nursery and arrangements were to transfer to Children's Hospital.  Infant was transferred to Children's Hospital for higher level of care, stayed at Children's Hospital for approximately 2 weeks, and was transferred back to ABCD where he stayed until he was discharged on 08/16/2006.,HOSPITAL COURSE: , At the time of transfer to ABCD, these were the following issues.,FEEDING AND NUTRITION: , Baby was on TPN and p.o. feeds had been started and were advanced 1 ml q.6h.  Baby was tolerating p.o. feeds of expressed breast milk and baby began to experience some abdominal distention.  The p.o. feeds were held and IV D10 water was given.  Baby was started on Mylicon drops and glycerin suppositories.  Abdominal ultrasound showed gaseous distention without signs of obstruction.  OG tube was passed.  Baby improved after couple of days when p.o. feedings were restarted.  Baby was also given Reglan.  At the time of discharge, baby was tolerating p.o. feeds well of BM fortified with 22-cal NeoSure.  Feeding amounts at the time of discharge was between 35 to 50 mL per feed and weight was 1797 grams.,RESPIRATIONS: , At the time of admission, baby was not having any apnea spells, no bradycardia or desaturations, was saturating well on room air and continued to do well on room air until the time of discharge.,HYPOGLYCEMIA: , Baby began to experience hypoglycemic episodes on 07/24/2006.  Blood glucose level was as low as 46.  D10 was given initially as bolus.  Baby continued to experience hypoglycemic episodes.  Diazoxide was started 5 mg/kg per os every 8 hours and fingersticks were done to monitor blood glucose level.  The baby improved with diazoxide, hypoglycemic issues resolved and then began again.  Diazoxide was discontinued, but the hypoglycemic issues restarted.  The Diazoxide was restarted again.  Blood glucose level stabilized and then diazoxide was weaned off until daily dose of 6 mg/kg and then the diazoxide was discontinued.  At the time of discharge, blood glucose levels were not being stable for 24 hours.,CARDIOVASCULAR: , Infant was hemodynamically stable on admission from Madera.  Infant has a closed PDA.  Infant had two cardiac echograms done.  The lab showing normal antegrade flow across the right coronary artery as well as the left main and left anterior descending coronary artery, then the circumflex coronary artery.,CNS:,  Infant had a head ultrasound done to rule out intracranial abnormalities and intracranial hemorrhage.  The ultrasound was negative for intracranial hemorrhage.,INFECTIOUS DISEASE:,  The patient had been on antibiotics during the stay at Madera.  At the time of admission to the ABCD, the patient was not on any antibiotics and his clinically condition has remained stable.,HEMATOLOGY: , The patient is status post phototherapy at Madera and was started on iron.,OPHTHALMOLOGY: ,  Exam on 07/17/2006 showed immature retina.  The patient is to get followup exam after discharge.,DISCHARGE DIAGNOSIS: , Stable ex-32-weeks preemie.,DISCHARGE INSTRUCTIONS: , The patient has been educated on CPR measures.  Followup appointment has been made at Kid's Care.  Calcium challenge has been done.  The patient's parents are comfortable with feeding.  The patient has been discharged on NeoSure and expressed breast milk.,","discharge summary, delivered, preeclampsia, immaturity, intrauterine, prenatal, coronary artery, blood glucose, discharge, baby, coronary, intracranial, hypoglycemia, hypoglycemic, infant, "
" Discharge summary of patient with leiomyosarcoma and history of pulmonary embolism, subdural hematoma, pancytopenia, and pneumonia.", Discharge Summary, Leiomyosarcoma ,"ADMITTING DIAGNOSES:,1.  Leiomyosarcoma.,2.  History of pulmonary embolism.,3.  History of subdural hematoma.,4.  Pancytopenia.,5.  History of pneumonia.,PROCEDURES DURING HOSPITALIZATION:,1.  Cycle six of CIVI-CAD (Cytoxan, Adriamycin, and DTIC) from 07/22/2008 to 07/29/2008.,2.  CTA, chest PE study showing no evidence for pulmonary embolism.,3.  Head CT showing no evidence of acute intracranial abnormalities.,4.  Sinus CT, normal mini-CT of the paranasal sinuses.,HISTORY OF PRESENT ILLNESS:  ,Ms. ABC is a pleasant 66-year-old Caucasian female who first palpated a mass in the left posterior arm in spring of 2007.  The mass increased in size and she was seen by her primary care physician and referred to orthopedic surgeon.  MRI showed inflammation and was thought to be secondary to rheumatoid arthritis.  The mass increased in size.  She eventually underwent a partial resection found to have pathologic grade 2 leiomyosarcoma, margins were impossible to assess, but were likely positive.  She was evaluated by Dr. X and Dr. Y and a decision was made to proceed with preoperative chemotherapy.  She began treatment with CIVI-CAD in December 2007.  Her course was complicated by pulmonary embolus, pneumonia, and subdural hematoma while on anticoagulation.  She eventually underwent surgical resection on May 1, 2008 with small area of residual disease, but otherwise clear margins.,HOSPITAL COURSE:,1.  Leiomyosarcoma, the patient was admitted to Hem/Onco B Service under attending Dr. XYZ for cycle six of continuous IV infusion Cytoxan, Adriamycin, and DTIC, which she tolerated well.,2.  History of pulmonary embolism.  Upon admission, the patient reported an approximate two-week history of dyspnea on exertion and some mild chest pain.  She underwent a CTA, which showed no evidence of pulmonary embolism and the patient was started on prophylactic doses of Lovenox at 40 mg a day.  She had no further complaints throughout the hospitalization with any shortness of breath or chest pain.,3.  History of subdural hematoma, also on admission the patient noted some mild intermittent headaches that were fleeting in nature, several a day that would resolve on their own.  Her headaches were not responding to pain medication and so on 07/24/2008, we obtained a head CT that showed no evidence of acute intracranial abnormalities.  The patient also had a history of sinusitis and so a sinus CT scan was obtained, which was normal.,4.  Pancytopenia.  On admission, the patient's white blood count was 3.4, hemoglobin 11.3, platelet count 82, and ANC of 2400.  The patient's counts were followed throughout admission.  She did not require transfusion of red blood cells or platelets; however, on 07/26/2008 her ANC did dip to 900 and she was placed on neutropenic diet.  At discharge her ANC is back up to 1100 and she is taken off neutropenic diet.  Her white blood cell count at discharge was 1.4 and her hemoglobin was 11.2 with a platelet count of 140.,5.  History of pneumonia.  During admission, the patient did not exhibit any signs or symptoms of pneumonia.,DISPOSITION: , Home in stable condition.,DIET: , Regular and less neutropenic.,ACTIVITY: , Resume same activity.,FOLLOWUP:  ,The patient will have lab work at Dr. XYZ on 08/05/2008 and she will also return to the cancer center on 08/12/2008 at 10:20 a.m.  The patient is also advised to monitor for any fevers greater than 100.5 and should she have any further problems in the meantime to please call in to be seen sooner.","discharge summary, leiomyosarcoma, embolism, hematoma, pneumonia, acute intracranial abnormalities, white blood, platelet count, blood cells, neutropenic diet, subdural hematoma, pulmonary embolism, intracranial, pancytopenia, neutropenic, subdural, pulmonary, "
" Seizure, hypoglycemia, anemia, dyspnea, edema. colon cancer status post right hemicolectomy, hospital-acquired pneumonia, 
and congestive heart failure.", Discharge Summary, Multiple Medical Problems - Discharge Summary ,"ADMISSION DIAGNOSES:,1.  Seizure.,2.  Hypoglycemia.,3.  Anemia.,4.  Hypotension.,5.  Dyspnea.,6.  Edema.,DISCHARGE DIAGNOSES:,1.  Colon cancer, status post right hemicolectomy.,2.  Anemia.,3.  Hospital-acquired pneumonia.,4.  Hypertension.,5.  Congestive heart failure.,6.  Seizure disorder.,PROCEDURES PERFORMED:,1.  Colonoscopy.,2.  Right hemicolectomy.,HOSPITAL COURSE: , The patient is a 59-year-old female with multiple medical problems including diabetes mellitus requiring insulin for 26 years, previous MI and coronary artery disease, history of seizure disorder, GERD, bipolar disorder, and anemia.  She was admitted due to a seizure and myoclonic jerks as well as hypoglycemia and anemia.  Regarding the seizure disorder, Neurology was consulted.  Noncontrast CT of the head was negative.  Neurology felt that the only necessary intervention at that time would be to increase her Lamictal to 150 mg in the morning and 100 mg in the evening with gradual increase of the dosage until she was on 200 mg b.i.d.  Regarding the hypoglycemia, the patient has diabetic gastroparesis and was being fed on J-tube intermittent feedings throughout the night at the rate of 120 an hour.  Her insulin pump had a basal rate of roughly three at night during the feedings.  While in the hospital, the insulin pump rate was turned down to 1.5 and then subsequently decreased a few other times.  She seemed to tolerate the insulin pump rate well throughout her hospital course.  There were a few episodes of hypoglycemia as well as hyperglycemia, but the episode seem to be related to the patient's n.p.o. status and the changing rates of tube feedings throughout her hospital course.,At discharge, her endocrinologist was contacted.  It was decided to change her insulin pump rate to 3 units per hour from midnight till 6 a.m., from 0.8 units per hour from 6 a.m. until 8 a.m., and then at 0.2 units per hour from 8 a.m. until 6 p.m.  The insulin was to be NovoLog.  Regarding the anemia, the gastroenterologists were consulted regarding her positive Hemoccult stools.  A colonoscopy was performed, which found a mass at the right hepatic flexure.  General Surgery was then consulted and a right hemicolectomy was performed on the patient.  The patient tolerated the procedure well and tube feeds were slowly restarted following the procedure, and prior to discharge were back at her predischarge rates of 120 per hour.  Regarding the cancer itself, it was found that 1 out of 53 nodes were positive for cancer.  CT of the abdomen and pelvis revealed no metastasis, a CT of the chest revealed possible lung metastasis.  Later in hospital course, the patient developed a septic-like picture likely secondary to hospital-acquired pneumonia.  She was treated with Zosyn, Levaquin, and vancomycin, and tolerated the medications well.  Her symptoms decreased and serial chest x-rays were followed, which showed some resolution of the illness.  The patient was seen by the Infectious Disease specialist.  The Infectious Disease specialist recommended vancomycin to cover MRSA bacteria, which was found at the J-tube site.  At discharge, the patient was given three additional days of p.o. Levaquin 750 mg as well as three additional days of Bactrim DS every 12 hours.  The Bactrim was used to cover the MRSA at the J-tube site.  It was found that MRSA was sensitive to Bactrim.  Throughout her hospital course, the patient continued to receive Coreg 12.5 mg daily and Lasix 40 mg twice a day for her congestive heart failure, which remains stable.  She also received Lipitor for her high cholesterol.  Her seizure disorder remained stable and she was discharged on a dose of 100 mg in the morning and 150 mg at night.  The dosage increases can begin on an outpatient basis.,DISCHARGE INSTRUCTIONS/MEDICATIONS: , The patient was discharged to home.  She was told to shy away from strenuous activity.  Her discharge diet was to be her usual diet of isotonic fiber feeding through the J-tube at a rate of 120 per hour throughout the night.  The discharge medications were as follows:,1.  Coreg 12.5 mg p.o. b.i.d.,2.  Lipitor 10 mg p.o. at bedtime.,3.  Nitro-Dur patch 0.3 mg per hour one patch daily.,4.  Phenergan syrup 6.25 mg p.o. q.4h. p.r.n.,5.  Synthroid 0.175 mg p.o. daily.,6.  Zyrtec 10 mg p.o. daily.,7.  Lamictal 100 mg p.o. daily.,8.  Lamictal 150 mg p.o. at bedtime.,9.  Ferrous sulfate drops 325 mg, PEG tube b.i.d.,10.  Nexium 40 mg p.o. at breakfast.,11.  Neurontin 400 mg p.o. t.i.d.,12.  Lasix 40 mg p.o. b.i.d.,13.  Fentanyl 50 mcg patch transdermal q.72h.,14.  Calcium and vitamin D combination, calcium carbonate 500 mg/vitamin D 200 units one tab p.o. t.i.d.,15.  Bactrim DS 800mg/160 mg tablet one tablet q.12h. x3 days.,16.  Levaquin 750 mg one tablet p.o. x3 days.,The medications listed above, one listed as p.o. are to be administered via the J-tube.,FOLLOWUP:  ,The patient was instructed to see Dr. X in approximately five to seven days.  She was given a lab sheet to have a CBC with diff as well as a CMP to be drawn prior to her appointment with Dr. X.  She is instructed to follow up with Dr. Y if her condition changes regarding her colon cancer.  She was instructed to follow up with Dr. Z, her oncologist, regarding the positive lymph nodes.  We were unable to contact Dr. Z, but his telephone number was given to the patient and she was instructed to make a followup appointment.  She was also instructed to follow up with her endocrinologist, Dr. A, regarding any insulin pump adjustments, which were necessary and she was also instructed to follow up with Dr. B, her gastroenterologist, regarding any issues with her J-tube.,CONDITION ON DISCHARGE: , Stable.",
" Chronic laryngitis, hoarseness.  The patient was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.  ", Discharge Summary, Laryngitis - Discharge ,"DIAGNOSIS: , Chronic laryngitis, hoarseness.,HISTORY:  ,The patient is a 68-year-old male, was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.  The patient attended initial evaluation plus 3 outpatient speech therapy sessions, which focused on training the patient to complete resonant voice activities and to improve his vocal hygiene.  The patient attended therapy one time a week and was given numerous home activities to do in between therapy sessions.  The patient made great progress and he came in to discuss with an appointment on 12/23/08 stating that his voice had finally returned to ""normal"".,SHORT-TERM GOALS:,1.  To be independent with relaxation and stretching exercises and Lessac-Madsen Resonant Voice Therapy Protocol.,2.  He also met short-term goal therapy 3 and he is independent with resonant voice therapy tasks.,3.  We did not complete his __________ ratio during his last session; so, I am unsure if he had met his short-term goal number 2.,4.  To be referred for a videostroboscopy, but at this time, the patient is not in need of this evaluation.  However, in the future if hoarseness returns, it is strongly recommended that he be referred for a videostroboscopy prior to returning to additional outpatient therapy.,LONG-TERM GOALS:,1.  The patient did reach his long-term goal of improved vocal quality to return to prior level of function and to utilize his voice in all settings without vocal hoarseness or difficulty.,2.  The patient appears very pleased with his return of his normal voice and feels that he no longer needs outpatient skilled speech therapy.,The patient is discharged from my services at this time with a home program to continue to promote normal voicing.","discharge summary, vocal hygiene, voice activities, hoarseness, skilled speech therapy, chronic laryngitis, voice therapy, resonant voice, videostroboscopy, laryngitis "
"  The patient is an 1812 g baby boy born by vaginal delivery to a 32-year-old gravida 3, para 2 at 34 weeks of gestation.  Mother had two previous C-sections.", Discharge Summary, Neonatal Discharge Summary ,"HOSPITAL COURSE:,  The patient is an 1812 g baby boy born by vaginal delivery to a 32-year-old gravida 3, para 2 at 34 weeks of gestation.  Mother had two previous C-sections.  Baby was born at 5:57 on 07/30/2006.  Mother received ampicillin 2 g 4 hours prior to delivery.  Mother came with preterm contractions, with progressive active labor in spite of the terbutaline and magnesium sulfate.  Baby was born with Apgar scores of 8 and 9 at delivery.  Fluid was cleared.  Nuchal cord x1.  Prenatal was at ABC Valley.  Prenatal labs were O positive, antibody negative, rubella immune, RPR nonreactive.  Baby was suctioned on perineum with good support.  The baby was admitted to the NICU for prematurity and to rule out sepsis.  Baby's cry was good.  Color, tone, and __________ mild retractions.  CBC, CRP, blood cultures were done.  IV fluids of D10 at a rate of 6 mL an hour.  Ampicillin and gentamicin were started via protocol.  At the time of admission, the patient was stable on room air and has feeding issues.  Baby was fed EBM 22 and NeoSure per os.  Ampicillin and gentamicin were started per protocol but were discontinue when blood cultures came out negative after 48 hours.  The patient continues on feeding issues, will not suck properly, was kept in the NICU, and put on OG tube for a couple of days after which p.o. feeds were advanced.  Also, the baby was able to suck properly and was tolerating feeds.  The baby was fed EBM 22 and NeoSure was added a day before discharge.  At the time of discharge, baby was stable on room air, baby was tolerated p.o. foods and was sucking properly, was taking ad lib feeds and gaining weight.,ADMISSION DIAGNOSES:,  Respiratory distress, rule out sepsis and prematurity.,DISCHARGE DIAGNOSES:,  Stable, ex-34-week preemie.,Pediatrician after discharge will be Dr. X.,DISCHARGE INSTRUCTIONS: , To follow up with Dr. X in 2 to 3 days, an appointment was made for 08/14/2006.  CPR teaching was completed on 08/11/2006 to parents.  Formula feeding schedule with breast and NeoSure 2 to 3 ounces per feed.  Ad lib feeding on demand.","discharge summary, gestation, preemie, prematurity, sepsis, neosure, feeds, born, delivery, perineum, discharge,"
" Neck pain with right upper extremity radiculopathy and cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, and C6-C7 with stenosis.", Discharge Summary, Neck Pain - Discharge Summary ,"ADMISSION DIAGNOSES,1.  Neck pain with right upper extremity radiculopathy.,2.  Cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, and C6-C7 with stenosis.,DISCHARGE DIAGNOSES,1.  Neck pain with right upper extremity radiculopathy.,2.  Cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, and C6-C7 with stenosis.,OPERATIVE PROCEDURES,1.  Anterior cervical discectomy with decompression C4-C5, C5-C6, and C6-C7.,2.  Arthrodesis with anterior interbody fusion C4-C5, C5-C6, and C6-C7.,3.  Spinal instrumentation C4 through C7.,4.  Implant.,5.  Allograft.,COMPLICATIONS:,  None.,COURSE ON ADMISSION: , This is the case of a very pleasant 41-year-old Caucasian female who was seen in clinic as an initial consultation on 09/13/07 complaining of intense neck pain radiating to the right shoulder blade to top of the right shoulder in to the right upper extremity to the patient's hand.  The patient's symptoms have been persistent and had gotten worse with subjective weakness of the right upper extremity since its onset for several weeks now.  The patient has been treated with medications, which has been unrelenting.  The patient had imaging studies that showed evidence of cervical spondylosis with herniated disk and stenosis at C4-C5, C5-C6 and C6-C7.  The patient underwent liver surgery and postoperatively her main issue was that of some degree of on and off right shoulder pain and some operative site soreness, which was treated well with IV morphine.  The patient has resolution of the pain down the arm, but she does have some tingling of the right thumb and right index finger.  The patient apparently is doing well with slight dysphagia, we treated her with Decadron and we will send her home with Medrol.  The patient will have continued pain medication coverage with Darvocet and Flexeril.  The patient will follow up with me as scheduled.  Instructions have been given.","discharge summary, radiculopathy, cervical spondylosis, neck pain, anterior cervical discectomy, herniated nucleus pulposus, cervical, anterior, herniated,"
 Decreased ability to perform daily living activities secondary to right knee surgery., Discharge Summary, Knee Surgery - Discharge Summary ,"CHIEF COMPLAINT:,  Decreased ability to perform daily living activities secondary to right knee surgery.,HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old white female status post right total knee replacement secondary to degenerative joint disease performed by Dr. A at ABCD Hospital on 08/21/2007.  The patient was transfused with 2 units of autologous blood postoperatively.  She received DVT prophylaxis with a combination of Coumadin, Lovenox, SCD boots, and TED stockings.  The remainder of her postoperative course was uneventful.  She was discharged on 08/24/2007 from ABCD Hospital and admitted to the transitional care unit at XYZ Services for evaluation and rehabilitation.  The patient reports that her last bowel movement was on 08/24/2007 just prior to her discharge from ABCD Hospital.  She denies any urological symptoms such as dysuria, incomplete bladder emptying or other voiding difficulties.  She reports having some right knee pain, which is most intense at a ""certain position.""  The patient is unable to elaborate on which ""certain position"" causes her the most discomfort.,ALLERGIES:,  NKDA.,PAST MEDICAL HISTORY: , Hypertension, hypothyroidism, degenerative joint disease, GERD, anxiety disorder, Morton neuroma of her feet bilaterally, and distant history of migraine headaches some 30 years ago.,MEDICATIONS:,  On transfer, Celebrex, Coumadin, Colace, Synthroid, Lovenox, Percocet, Toprol XL, niacin, and trazodone.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 96.5, blood pressure 127/72, pulse 70, respiratory rate 20, 95% O2 saturation on room air.,GENERAL:  No acute distress at the time of the exam except as mentioned above complains of right knee pain at ""certain position."",HEENT:  Normocephalic.  Sclerae nonicteric.  EOMI.  Dentition in good repair.  Tongue is in midline with no evidence of thrush.,NECK:  No thyroid enlargement.  Trachea is midline.,LUNGS:  Clear to auscultation.,HEART:  Regular rate and rhythm.  Normal S1 and S2.,ABDOMEN:  Soft, nontender, and nondistended.  No organomegaly.,EXTREMITIES:  The right knee incision is intact.  Steri-Strips are in place.  There is some diffuse right knee edema and some limited ecchymosis as well.  No calf tenderness bilaterally.  Pedal pulses are palpable bilaterally.,MENTAL STATUS:  The patient appears slightly anxious during the interview and exam, but she was alert and oriented.,HOSPITAL COURSE: , As mentioned above, the patient was admitted on 08/24/2007 to the Transitional Care Unit at XYZ Services for evaluation and rehabilitation.  She was seen in consultation by Physical Therapy and Occupational Therapy and had begun her rehabilitation till recovery.  The patient had been properly instructed regarding using the CPM machine and she had been instructed as well to limit each CPM session to two hours.  Very early in her hospitalization, the patient enthusiastically used the CPM much longer than two hours and consequently had increased right knee pain.  She remarked that she had a better degree of flexibility, but she did report an increased need for pain management.  Additionally, she required Ativan and at one point scheduled the doses of Ativan to treat her known history of anxiety disorder.  On the fourth hospital day, she was noted to have some rashes about the right upper extremity and right side of her abdomen.  The patient reported that this rash was itchy.  She reports that she had been doing quite a bit of gardening just prior to surgery and this was most likely contact dermatitis, most likely due to her gardening activities preoperatively.  She was treated with betamethasone cream applied to the rash b.i.d.  The patient's therapy had progressed and she continued to make a good progress.  At one point, the patient reported some insomnia due to right knee pain.  She was switched from Percocet to oxycodone SR 20 mg b.i.d. and she had good pain control with this using the Percocet only for breakthrough pain.  The DVT prophylaxis was maintained with Lovenox 40 mg subcu daily until the INR was greater than 1.7 and it was discontinued on 08/30/2007 when the INR was 1.92 within therapeutic range.  The Coumadin was adjusted accordingly according to the INRs during her hospital course.  Early in the hospital course, the patient had reported right calf tenderness and a venous Doppler study obtained on 08/27/2007 showed no DVT bilaterally.  Initial laboratory data includes a UA on 08/28/2007, which was negative.  Additionally, CBC showed a white count of 6.3, hemoglobin was 12.1, hematocrit was 35.3, and platelets were 278,000.  Chemistries were within normal limits.  Creatinine was 0.8, BUN was 8, anion gap was slightly decreased at 5, fasting glucose was 102.  The remainder of chemistries was unremarkable.  The patient continued to make great progress with her therapies so much so that we are anticipating her discharge on Monday, 09/03/2007.,DISCHARGE DIAGNOSES:,1.  Status post right total knee replacement secondary to degenerative joint disease performed on 08/21/2007.,2.  Anxiety disorder.,3.  Insomnia secondary to pain and anxiety postoperatively.,4.  Postoperative constipation.,5.  Contact dermatitis secondary to preoperative gardening activities.,6.  Hypertension.,7.  Hypothyroidism.,8.  Gastroesophageal reflux disease.,9.  Morton neuroma of the feet bilaterally.,10.  Distant history of migraine headaches.,INSTRUCTIONS GIVEN TO THE PATIENT AT THE TIME OF DISCHARGE: , The patient is advised to continue taking the following medications:  Celebrex 200 mg daily, for one month, Colace 100 mg b.i.d. for one month, Protonix 40 mg b.i.d. for one month, Synthroid 137 mcg daily, Diprosone cream 0.05% cream b.i.d. to the right arm and right abdomen, oxycodone SR 20 mg p.o. q.12h. for five days, then decrease to oxycodone SR 10 mg p.o. q.12h. for five days, Percocet 5/325 mg one to two tablets q.6h. to be used p.r.n. for breakthrough pain, trazodone 50 mg p.o. at bedtime p.r.n. for two weeks, Ativan 0.25 mg b.i.d. for two weeks, and Toprol-XL 50 mg daily.  The patient will also take Coumadin and the dose will be adjusted according to the INRs, which will be obtained every Monday and Thursday with results being sent to Dr. A and his fax number is 831-5926.  At the present time, the patient is taking Coumadin 7 mg daily.  She will remain on Coumadin for 30 days.  An INR is to be obtained on 09/03/2007 and should the Coumadin dose be changed, an addendum will be dictated to accompany this discharge summary.  Finally, the patient has a followup appointment with Dr. A on 09/21/2007 at noon at his office.  The patient is encouraged to follow up with her primary care physician, Dr. B.  As mentioned above, the patient will be discharged on 09/03/2007 in stable and improved condition since she is status post right total knee replacement and has made good progress with her therapies and rehabilitation.",
" This is a 14-month-old baby boy Caucasian who came in with presumptive diagnosis of Kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated neutrophils and thrombocytosis, elevated CRP and ESR. ", Discharge Summary, Kawasaki Disease - Discharge Summary ,"ADMITTING DIAGNOSIS: , Kawasaki disease.,DISCHARGE DIAGNOSIS:,  Kawasaki disease, resolving.,HOSPITAL COURSE:,  This is a 14-month-old baby boy Caucasian who came in with presumptive diagnosis of Kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated neutrophils and thrombocytosis, elevated CRP and ESR.  When he was sent to the hospital, he had a fever of 102.  Subsequently, the patient was evaluated and based on the criteria, he was started on high dose of aspirin and IVIG.  Echocardiogram was also done, which was negative.  IVIG was done x1, and between 12 hours of IVIG, he spiked fever again; it was repeated twice, and then after second IVIG, he did not spike any more fever.  Today, his fever and his rash have completely resolved.  He does not have any conjunctivitis and no redness of mucous membranes.  He is more calm and quite and taking good p.o.; so with a very close followup and a cardiac followup, he will be sent home.,DISCHARGE ACTIVITIES:,  Ad-lib.,DISCHARGE DIET: , PO ad-lib.,DISCHARGE MEDICATIONS: , Aspirin high dose 340 mg q.6h. for 1 day and then aspirin low dose 40 mg q.d. for 14 days and then Prevacid also to prevent his GI from aspirin 15 mg p.o. once a day.  He will be followed by his primary doctor in 2 to 3 days.  Cardiology for echo followup in 4 to 6 weeks and instructed not to give any vaccine in less than 11 months because of IVIG, all the live virus vaccine, and if he gets any rashes, any fevers, should go to primary care doctor as soon as possible.","discharge summary, mucous membranes, conjunctivitis, ad lib, kawasaki disease, vaccine, fever, aspirin"
 Total vaginal hysterectomy.  Microinvasive carcinoma of the cervix., Discharge Summary, Hysterectomy - Discharge Summary - 2 ,"ADMISSION DIAGNOSIS: , Microinvasive carcinoma of the cervix.,DISCHARGE DIAGNOSIS: , Microinvasive carcinoma of the cervix.,PROCEDURE PERFORMED: , Total vaginal hysterectomy.,HISTORY OF PRESENT ILLNESS: , The patient is a 36-year-old, white female, gravida 7, para 5, last period mid March, status post tubal ligation.  She had an abnormal Pap smear in the 80s, which she failed to followup on until this year.  Biopsy showed a microinvasive carcinoma of the cervix and a cone biopsy was performed on 02/12/2007 also showing microinvasive carcinoma with a 1 mm invasion.  She has elected definitive therapy with a total vaginal hysterectomy.  She is aware of the future need of Pap smears.,PAST MEDICAL HISTORY: , Past history is significant for seven pregnancies, five term deliveries, and significant past history of tobacco use.,PHYSICAL EXAMINATION: , Physical exam is within normal limits with a taut normal size uterus and a small cervix, status post cone biopsy.,LABORATORY DATA AND DIAGNOSTIC STUDIES: , Chest x-ray was clear.  Discharge hemoglobin 10.8.,HOSPITAL COURSE: , She was taken to the operating room on 04/02/2007 where a total vaginal hysterectomy was performed under general anesthesia.  There was an incidental cystotomy at the time of the creation of the bladder flap.  This was repaired intraoperatively without difficulty.  Postoperative, she did very well.  Bowel and bladder function returned quickly.  She is ambulating well and tolerating a regular diet.,Routine postoperative instructions given and understood.  Followup will be in ten days for a cystogram and catheter removal with followup in the office at that time. ,DISCHARGE MEDICATIONS:,  Vicodin, Motrin, and Macrodantin at bedtime for urinary tract infection suppression.  ,DISCHARGE CONDITION: , Good.,Final pathology report was free of residual disease.","discharge summary, pap smear, total vaginal hysterectomy, hysterectomy, microinvasive, carcinoma, cervix,"
" Laparoscopic cholecystectomy.  Acute cholecystitis, status post laparoscopic cholecystectomy, end-stage renal disease on hemodialysis, hyperlipidemia, hypertension, congestive heart failure, skin lymphoma 5 years ago, and hypothyroidism.", Discharge Summary, Lap Chole - Discharge Summary ,"PROCEDURE:,  Laparoscopic cholecystectomy.,DISCHARGE DIAGNOSES:,1.  Acute cholecystitis.,2.  Status post laparoscopic cholecystectomy.,3.  End-stage renal disease on hemodialysis.,4.  Hyperlipidemia.,5.  Hypertension.,6.  Congestive heart failure.,7.  Skin lymphoma 5 years ago.,8.  Hypothyroidism.,HOSPITAL COURSE: , This is a 78-year-old female with past medical condition includes hypertension, end-stage renal disease, hyperlipidemia, hypothyroidism, and skin lymphoma who had a left AV fistula done about 3 days ago by Dr. X and the patient went later on home, but started having epigastric pain and right upper quadrant pain and mid abdominal pain, some nauseated feeling, and then she could not handle the pain, so came to the emergency room, brought by the family.  The patient's initial assessment, the patient's vital signs were stable, showed temperature 97.9, pulse was 106, and blood pressure was 156/85.  EKG was not available and ultrasound of the abdomen showed there is a renal cyst about 2 cm.  There is sludge in the gallbladder wall versus a stone in the gallbladder wall.  Thickening of the gallbladder wall with positive Murphy sign.  She has a history of cholecystitis.  Urine shows positive glucose, but negative for nitrite and creatinine was 7.1, sodium 131, potassium was 5.2, and lipase and amylase were normal.  So, the patient admitted to the Med/Surg floor initially and the patient was started on IV fluid as well as low-dose IV antibiotic and 2-D echocardiogram and EKG also was ordered.  The patient also had history of CHF in the past and recently had some workup done.  The patient does not remember initially.  Surgical consult also requested and blood culture and urine culture also ordered.  The same day, the patient was seen by Dr. Y and the patient should need cholecystectomy, but the patient also needs dialysis and also needs to be cleared by the cardiologist, so the patient later on seen by Dr. Z and cleared the patient for the surgery with moderate risk and the patient underwent laparoscopic cholecystectomy.  The patient also seen by nephrologist and underwent dialysis.  The patient's white count went down 6.1, afebrile.  On postop day #1, the patient started eating and also walking.  The patient also had chronic bronchitis.  The patient was later on feeling fine, discussed with surgery.  The patient was then able to discharge to home and follow with the surgeon in about 3-5 days.  Discharged home with Synthroid 0.5 mg 1 tablet p.o. daily, Plavix 75 mg p.o. daily, folic acid 1 mg p.o. daily, Diovan 80 mg p.o. daily, Renagel 2 tablets 800 mg p.o. twice a day, Lasix 40 mg p.o.  2 tablets twice a day, lovastatin 20 mg p.o. daily, Coreg 3.125 mg p.o. twice a day, nebulizer therapy every 3 hours as needed, also Phenergan 25 mg p.o. q.8 hours for nausea and vomiting, Pepcid 20 mg p.o. daily, Vicodin 1 tablet p.o. q.6 hours p.r.n. as needed, and Levaquin 250 mg p.o. every other day for the next 5 days.  The patient also had Premarin that she was taking, advised to discontinue because of increased risk of heart disease and stroke explained to the patient.  Discharged home.","discharge summary, end-stage renal disease, lymphoma, cholecystitis, congestive heart failure, skin lymphoma, gallbladder wall, laparoscopic cholecystectomy "
" Painful right knee status post total knee arthroplasty many years ago.   Status post poly exchange, right knee, total knee arthroplasty.", Discharge Summary, Knee Arthroplasty - Discharge Summary ,"ADMISSION DIAGNOSIS:,  Painful right knee status post total knee arthroplasty many years ago.  The patient had gradual onset of worsening soreness and pain in this knee.  X-ray showed that the poly seems to be worn out significantly in this area.,DISCHARGE DIAGNOSIS:,  Status post poly exchange, right knee, total knee arthroplasty.,CONDITION ON DISCHARGE:,  Stable.,PROCEDURES PERFORMED:,  Poly exchange total knee, right.,CONSULTATIONS: , Anesthesia managed femoral nerve block on the patient.,HOSPITAL COURSE:  ,The patient was admitted with revision right total knee arthroplasty and replacement of patellar and tibial poly components.  The patient recovered well after this.  Working with PT, she was able to ambulate with minimal assistance.  Nerve block was removed by anesthesia.  The patient did well on oral pain medications.  The patient was discharged home.  She is actually going to home with her son who will be able to assist her and look after her for anything she might need.  The patient is comfortable with this, understands the therapy regimen, and is very satisfied after the procedure.,DISCHARGE INSTRUCTIONS AND MEDICATIONS: , The patient is to be discharged home to the care of the son.  Diet is regular.  Activity, weight bear as tolerated right lower extremity.  Continue to do physical therapy exercises.  The patient will be discharged home on Coumadin 4 mg a day as the INR was 1.9 on discharge with twice weekly lab checks.  Vicodin 5/500 mg take one to two tablets p.o. q.4-6h.  Resume home medications.  Call the office or return to the emergency room for any concerns including increased redness, swelling, drainage, fever, or any concerns regarding operation or site of incision.  The patient is to follow up with Dr. ABC in two weeks.","discharge summary, painful right knee, total knee arthroplasty, poly exchange, femoral nerve block, patellar, tibial poly, knee arthroplasty, knee, arthroplasty,"
 A 66-year-old female with knee osteoarthrosis who failed conservative management., Discharge Summary, Knee Osteoarthrosis - Discharge Summary ,"PRINCIPAL DIAGNOSIS:,  Knee osteoarthrosis.,PRINCIPAL PROCEDURE: , Total knee arthroplasty.,HISTORY AND PHYSICAL:,  A 66-year-old female with knee osteoarthrosis.  Failed conservative management.  Risks and benefits of different treatment options were explained.  Informed consent was obtained.,PAST SURGICAL HISTORY: , Right knee surgery, cosmetic surgery, and carotid sinus surgery.,MEDICATIONS: , Mirapex, ibuprofen, and Ambien.,ALLERGIES: , QUESTIONABLE PENICILLIN ALLERGIES.,PHYSICAL EXAMINATION: , GENERAL:  Female who appears younger than her stated age.  Examination of her gait reveals she walks without assistive devices.,HEENT:  Normocephalic and atraumatic.,CHEST:  Clear to auscultation.,CARDIOVASCULAR:  Regular rate and rhythm.,ABDOMEN:  Soft.,EXTREMITIES:  Grossly neurovascularly intact.,HOSPITAL COURSE: , The patient was taken to the operating room (OR) on 03/15/2007.  She underwent right total knee arthroplasty.  She tolerated this well.  She was taken to the recovery room.  After uneventful recovery room course, she was brought to regular surgical floor.  Mechanical and chemical deep venous thrombosis (DVT) prophylaxis were initiated.  Routine postoperative antibiotics were administered.  Hemovac drain was discontinued on postoperative day #2.  Physical therapy was initiated.  Continuous passive motion (CPM) was also initiated.  She was able to spontaneously void.  She transferred to oral pain medication.  Incision remained clean, dry, and intact during the hospital course.  No pain with calf squeeze.  She was felt to be ready for discharge home on 03/19/2007.,DISPOSITION:  ,Discharged to home.,FOLLOW UP:,  Follow up with Dr. X in one week.  Prescriptions were written for Percocet and Coumadin.,INSTRUCTIONS: , Home physical therapy and PT and INR to be drawn at home for adjustment of Coumadin dosing.,","discharge summary, total knee arthroplasty, conservative management, knee arthroplasty, physical therapy, knee osteoarthrosis, arthroplasty, osteoarthrosis, knee, "
" Total vaginal hysterectomy.   Menometrorrhagia, dysmenorrhea, and small uterine fibroids.", Discharge Summary, Hysterectomy - Discharge Summary - 1 ,"ADMISSION DIAGNOSES:,1.  Menometrorrhagia.,2.  Dysmenorrhea.,3.  Small uterine fibroids.,DISCHARGE DIAGNOSES:,1.  Menorrhagia.,2.  Dysmenorrhea.,3.  Small uterine fibroids.,OPERATION PERFORMED:  ,Total vaginal hysterectomy.,BRIEF HISTORY AND PHYSICAL:  ,The patient is a 42 year-old white female, gravida 3, para 2, with two prior vaginal deliveries.  She is having increasing menometrorrhagia and dysmenorrhea.  Ultrasound shows a small uterine fibroid.  She has failed oral contraceptives and surgical therapy is planned.,PAST HISTORY: , Significant for reflux.,SURGICAL HISTORY:  ,Tubal ligation.,PHYSICAL EXAMINATION: , A top normal sized uterus with normal adnexa.,LABORATORY VALUES:  ,Her discharge hemoglobin is 12.4.,HOSPITAL COURSE: , She was taken to the operating room on 11/05/07 where a total vaginal hysterectomy was performed under general anesthesia.  Postoperatively, she has done well.  Bowel and bladder function have returned normally.  She is ambulating well, tolerating a regular diet.  Routine postoperative instructions given and said follow up will be in four weeks in the office.,DISCHARGE MEDICATIONS: , Preoperative meds plus Vicodin for pain.,DISCHARGE CONDITION: , Good.","discharge summary, dysmenorrhea, uterine fibroids, vaginal, total vaginal hysterectomy, menometrorrhagia, uterine, fibroids, "
" Hemiarthroplasty, right hip.  Fracture of the right femoral neck, also history of Alzheimer's dementia, hypothyroidism, and status post hemiarthroplasty of the hip.", Discharge Summary, Hemiarthroplasty - Discharge Summary ,"ADMISSION DIAGNOSES:  ,Fracture of the right femoral neck, also history of Alzheimer's dementia, and hypothyroidism.,DISCHARGE DIAGNOSES: , Fracture of the right femoral neck, also history of Alzheimer's dementia, hypothyroidism, and status post hemiarthroplasty of the hip.,PROCEDURE PERFORMED:  ,Hemiarthroplasty, right hip.,CONSULTATIONS:  ,Medicine for management of multiple medical problems including Alzheimer's.,HOSPITAL COURSE: , The patient was admitted on 08/06/2007 after a fall with subsequent fracture of the right hip.  The patient was admitted to Orthopedics and consulted Medicine.  The patient was actually taken to the operating room, consent signed by durable power of attorney, taken on 08/06/2007, had right hip hemiarthroplasty, recovered without incidence.  The patient had continued confusion and dementia, which is apparently his baseline secondary to his Alzheimer's.  Brief elevation of white count following the surgery, which did subside.  Studies, UA and blood culture were negative.  The patient was stable and was discharged to Heartland.,CONDITION ON DISCHARGE: , Stable.,DISCHARGE INSTRUCTIONS:,  Transfer to ABC for rehab and continued care.  Diabetic diet.  Activity, ambulate as tolerated with posterior hip precautions.  Rehab potential fair.  He will need nursing, Social Work, PT/OT, and nutrition consults.  Resume home meds, DVT prophylaxis, aspirin, and compression stockings.  Follow up Dr. X in one to two weeks; call 123-4567 for an appointment.","discharge summary, femoral neck, orthopedics, rehab, femoral, neck, fracture, dementia, hemiarthroplasty, hip,"
 Decreased ability to perform daily living activity secondary to recent right hip surgery., Discharge Summary, Hip Surgery - Discharge Summar ,"CHIEF COMPLAINT:,  Decreased ability to perform daily living activity secondary to recent right hip surgery.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 51-year-old white female who is status post right total hip replacement performed on 08/27/2007 at ABCD Hospital by Dr. A.  The patient had an unremarkable postoperative course, except low-grade fever of 99 to 100 postoperatively.  She was admitted to the Transitional Care Unit on 08/30/2007 at XYZ Services.  Prior to her discharge from ABCD Hospital, she had received DVT prophylaxis utilizing Coumadin and Lovenox and the INR goal is 2.0 to 3.0.  She presents reporting that her last bowel movement was on 08/26/2007 prior to surgery.  Otherwise, she reports some intermittent right calf discomfort and some postoperative right hip pain.,ALLERGIES:,  No known drug allergies.,PAST MEDICAL HISTORY:,  Anxiety, depression, osteoarthritis, migraine headaches associated with menstrual cycle, history of sciatic pain in the distant past, history of herniated disc, and status post appendectomy.,MEDICATIONS:  ,Medications taken at home are Paxil, MOBIC, and Klonopin.,MEDICATIONS ON TRANSFER: , Celebrex, Coumadin, Colace, Fiorinal, oxycodone, Klonopin, and Paxil.,FAMILY HISTORY:,  Noncontributory.,SOCIAL HISTORY: , The patient is married.  She lives with her husband and is employed as a school nurse for the School Department.  She had quit smoking cigarettes some 25 years ago and is a nondrinker.,REVIEW OF SYSTEMS:,  As mentioned above.  She has a history of migraine headaches associated with her menstrual cycle.  She wears glasses and has a history of floaters.  She reports a low-grade temperature of 99 to 100 postoperatively, mild intermittent cough, scratchy throat, (the symptoms may be secondary to intubation during surgery), intermittent right calf pain, which was described as sharp, but momentary with a negative Homans sign.  The patient denies any cardiopulmonary symptoms such as chest pain, palpitation, pain in the upper neck and down to her arm, difficulty breathing, shortness of breath, or hemoptysis.  She denies any nausea, vomiting, or diarrhea, but reports as being constipated with the last bowel movement being on 08/26/2007 prior to surgery.  She denies urinary symptoms such as dysuria, urinary frequency, incomplete bladder emptying or voiding difficulties.  First day of her last menstrual cycle was 08/23/207 and she reports that she is most likely not pregnant since her husband had a vasectomy years ago.,PHYSICAL EXAMINATION:,VITAL SIGNS:  At the time of admission, temperature 97.7, blood pressure 108/52, heart rate 94, respirations 18, and 95% O2 saturation on room air.,GENERAL:  No acute distress at the time of exam.,HEENT:  Normocephalic.  Sclerae are nonicteric.  EOMI.  Dentition is in good repair.,NECK:  Trachea is at the midline.,LUNGS:  Clear to auscultation.,HEART:  Regular rate and rhythm.,ABDOMEN:  Bowel sounds are heard throughout.  Soft and nontender.,EXTREMITIES:  Right hip incision is clean, intact, and no drainage is noted.  There is diffuse edema, which extends distally.  There is no calf tenderness per se bilaterally and Homans sign is negative.  There is no pedal edema.,MENTAL STATUS:  Alert and oriented x3, pleasant and cooperative during the exam.,LABORATORY DATA: , Initial workup included chemistry panel, which was unremarkable with the exception of a fasting glucose of 122 and an anion gap that was slightly decreased at 6.  The BUN was normal at 8, creatinine was 0.9, INR was 1.49.  CBC, had a white count of 5.7, hemoglobin was 9.2, hematocrit was 26.6, and platelets were 318,000.,IMPRESSION:,1.  Status post right total hip replacement.  The patient is admitted to the TCU at XYZ's Health Services and will be seen in consultation by Physical Therapy and Occupational Therapy.,2.  Postoperative anemia, Feosol 325 mg one q.d.,3.  Pain management.  Oxycodone SR 20 mg b.i.d., and oxycodone IR 5 mg one to two tablets q.4h., p.r.n. pain.  Additionally, she will utilize ice to help decrease edema.,4.  Depression and anxiety, Paxil 40 mg daily, Klonopin 1 mg q.h.s.,5.  Osteoarthritis, Celebrex 200 mg b.i.d.,6.  GI prophylaxis, Protonix 40 mg b.i.d.  Dulcolax suppository and lactulose will be used as a p.r.n. basis and Colace 100 mg b.i.d.,7.  DVT prophylaxis will be maintained with Arixtra 2.5 mg subcutaneously daily until the INR is greater than 1.7 and Coumadin will be adjusted according to the INR.  She will continue on 5 mg every day.,8.  Right leg muscle spasm/calf pain is stable at this time and we will reevaluate on a regular basis.  Monitor for any possibility of DVT.",
 Intrauterine pregnancy at term with previous cesarean.   Desired sterilization.  Status post repeat low transverse cesarean and bilateral tubal ligation., Discharge Summary, Intrauterine Pregnancy - Discharge Summary ,"ADMITTING DIAGNOSIS:,  Intrauterine pregnancy at term with previous cesarean.,SECONDARY DIAGNOSIS: , Desired sterilization.,DISCHARGE DIAGNOSES,1.  Intrauterine pregnancy at term with previous cesarean.,2.  Desired sterilization.,3.  Status post repeat low transverse cesarean and bilateral tubal ligation.,HISTORY: , The patient is a 35-year-old gravida 2, para 1-0-0-1 with intrauterine pregnancy on 08/30/09.  Pregnancy was uncomplicated.  She opted for a scheduled elective C-section and sterilization without any trial of labor.  All routine screening labs were normal and she underwent a high-resolution ultrasound during pregnancy.,PAST MEDICAL HISTORY: , Significant for postpartum depression after her last baby as well as a cesarean.,ALLERGIES:,  SHE HAS SEASONAL ALLERGIES.,MEDICATIONS:,  She is taking vitamins and iron.,PHYSICAL EXAMINATION,GENERAL:  An alert gravid woman in no distress.,ABDOMEN:  Gravid, nontender, non-irritable, with an infant in the vertex presentation.  Estimated fetal weight was greater than 10 pounds.,HOSPITAL COURSE:  ,On the first hospital day, the patient went to the operating room where repeat low transverse cesarean and tubal ligation were performed under spinal anesthesia with delivery of a viable female infant weighing 7 pounds 10 ounces and Apgars of 9 and 9.  There was normal placenta, normal pelvic anatomy.  There was 600 cc estimated blood loss.  Patient recovered uneventfully from her anesthesia and surgery.  She was able to ambulate and void.  She tolerated regular diet.  She passed flatus.  She was breast-feeding.  Postoperative hematocrit was 31.  On the second postoperative day, the patient was discharged home in satisfactory condition.,DISCHARGE MEDICATIONS: , Motrin and Percocet for pain.  Paxil for postpartum depression.  She was instructed to do no lifting, straining, or driving, to put nothing in the vagina and to see me in two weeks or with signs of severe pain, heavy bleeding, fever, or other problems.","discharge summary, cesarean, bilateral tubal ligation, low transverse cesarean, intrauterine, gravida, sterilization, pregnancy, "
 GI bleed.   Upper gastrointestinal bleed.  CBC revealed microcytic anemia., Discharge Summary, GI Bleed - Discharge Summary ,"CHIEF COMPLAINT:,  GI bleed.,HISTORY OF PRESENT ILLNESS:,  The patient is an 80-year-old white female with history of atrial fibrillation, on Coumadin, who presented as outpatient, complaining of increasing fatigue.  CBC revealed microcytic anemia with hemoglobin of 8.9.  Stool dark brown, strongly OB positive.  The patient denied any shortness of breath.  No chest pain.  No GI complaints.  The patient was admitted to ABCD for further evaluation.,PAST MEDICAL HISTORY:  ,Significant for atrial fibrillation, hypertension, osteoarthritis of the knees, hypercholesterolemia, non-insulin-dependent diabetes mellitus, asthma, and hypothyroidism.,PHYSICAL EXAMINATION:,GENERAL:  The patient is in no acute distress.,VITAL SIGNS:  Stable.,HEENT:  Benign.,NECK:  Supple.  No adenopathy.,LUNGS:  Clear with good air movement.,HEART:  Irregularly regular.  No gallops.,ABDOMEN:  Positive bowel sounds, soft, and nontender.  No masses or organomegaly.,EXTREMITIES:  1+ lower extremity edema bilaterally.,HOSPITAL COURSE: , The patient underwent upper endoscopy performed by Dr. A, which revealed erosive gastritis.  Colonoscopy did reveal diverticulosis as well as polyp, which was resected.  The patient tolerated the procedure well.  She was transfused, and prior to discharge hemoglobin was stable at 10.7.  The patient was without further GI complaints.  Coumadin was held during hospital stay and recommendations were given by GI to hold Coumadin for an additional three days after discharge then resume.  The patient was discharged with outpatient PMD, GI, and Cardiology followup.,DISCHARGE DIAGNOSES:,1.  Upper gastrointestinal bleed.,2.  Anemia.,3.  Atrial fibrillation.,4.  Non-insulin-dependent diabetes mellitus.,5.  Hypertension.,6.  Hypothyroidism.,7.  Asthma.,CONDITION UPON DISCHARGE: , Stable.,MEDICATIONS: , Feosol 325 mg daily, multivitamins one daily, Protonix 40 mg b.i.d., KCl 20 mEq daily, Lasix 40 mg b.i.d., atenolol 50 mg daily, Synthroid 80 mcg daily, Actos 30 mg daily, Mevacor 40 mg daily, and lisinopril 20 mg daily.,ALLERGIES:,  None.,DIET: , 1800-calorie ADA.,ACTIVITY: , As tolerated.,FOLLOWUP: , The patient to hold Coumadin through weekend.  Followup CBC and INR were ordered.  Outpatient followup as arranged.",
 The patient underwent a total vaginal hysterectomy., Discharge Summary, Hysterectomy - Discharge Summary ,"ADMISSION DIAGNOSES:,1.  Menorrhagia.,2.  Uterus enlargement.,3.  Pelvic pain.,DISCHARGE DIAGNOSIS: , Status post vaginal hysterectomy.,COMPLICATIONS: , None.,BRIEF HISTORY OF PRESENT ILLNESS: , This is a 36-year-old, gravida 3, para 3 female who presented initially to the office with abnormal menstrual bleeding and increase in flow during her period.  She also had symptoms of back pain, dysmenorrhea, and dysuria.  The symptoms had been worsening over time.  The patient was noted also to have increasing pelvic pain over the past 8 months and she was noted to have uterine enlargement upon examination.,PROCEDURE:,  The patient underwent a total vaginal hysterectomy.,HOSPITAL COURSE:  ,The patient was admitted on 09/04/2007 to undergo total vaginal hysterectomy.  The procedure preceded as planned without complication.  Uterus was sent for pathologic analysis.  The patient was monitored in the hospital, 2 days postoperatively.  She recovered quite well and vitals remained stable.,Laboratory studies, H&H were followed and appeared stable on 09/05/2007 with hemoglobin of 11.2 and hematocrit of 31.8.,The patient was ready for discharge on Monday morning of 09/06/2007.,LABORATORY FINDINGS: , Please see chart for full studies during admission.,DISPOSITION:  ,The patient was discharged to home in stable condition.  She was instructed to follow up in the office postoperatively.","discharge summary, menorrhagia, uterus enlargement, pelvic pain, total vaginal hysterectomy, vaginal hysterectomy, uterus, vaginal, hysterectomy,"
" Hypothermia.  Rule out sepsis, was negative as blood cultures, sputum cultures, and urine cultures were negative.  Organic brain syndrome.  Seizure disorder.  Adrenal insufficiency.  Hypothyroidism.  Anemia of chronic disease.", Discharge Summary, Hypothermia - Discharge Summary  ,"DIAGNOSIS AT ADMISSION: , Hypothermia.,DIAGNOSES ON DISCHARGE,1. Hypothermia.,2. Rule out sepsis, was negative as blood cultures, sputum cultures, and urine cultures were negative.,3. Organic brain syndrome.,4. Seizure disorder.,5. Adrenal insufficiency.,6. Hypothyroidism.,7. Anemia of chronic disease.,HOSPITAL COURSE:  ,The patient was admitted through the emergency room.  He was admitted to the Intensive Care Unit.  He was rewarmed and had blood, sputum, and urine cultures done.  He was placed on IV Rocephin.  His usual medications of Dilantin and Depakene were given.  The patient's hypertension was treated with fluid boluses.  The patient was empirically placed on Synthroid and hydrocortisone by Dr. X.  Blood work consisted of a chemistry panel that was unremarkable, except for decreased proteins.  H&H was stable at 33.3/10.9 and platelets of 80,000.  White blood cell counts were normal, differential was normal.  TSH was 3.41.  Free T4 was 0.9.  Dr. X felt this was consistent with secondary hypothyroidism and recommended Synthroid replacement.  A cortisol level was obtained prior to administration of hydrocortisone.  This was 10.9 and that was not a fasting level.  Dr. X felt because of his hypothyroidism and his hypothermia that he had secondary adrenal insufficiency and recommended hydrocortisone and Florinef.  The patient was eventually changed to prednisone 2.5 mg b.i.d. in addition to his Florinef 0.1 mg on Monday, Wednesday, and Friday.  The patient was started back on his tube feeds.  He tolerated these poorly with residuals.  Reglan was increased to 10 mg q.6 h. and erythromycin is being added.  The patient's temperature has been stable in the 94 to 95 range.  Other vital signs have been stable.  His urine output has been diminished.  An external jugular line was placed in the Intensive Care Unit.  The patient's legal guardian, Janet Sanchez in Albuquerque has requested he be transported there.  As per several physicians in Albuquerque and Dr. Y, an internist, we will accept him once we have a nursing home available to him.  He is being transported back to the nursing home today and discharge planners are working on getting him a nursing home in Albuquerque.  His prognosis is poor.","discharge summary, sepsis, organic brain syndrome, seizure disorder, anemia of chronic disease, adrenal insufficiency, blood, cultures"
 Patient discharged after laparoscopic Roux-en-Y gastric bypass., Discharge Summary, Gastric Bypass Summary ,"FINAL DIAGNOSES,1.  Morbid obesity, status post laparoscopic Roux-en-Y gastric bypass. ,2.  Hypertension. ,3.  Obstructive sleep apnea, on CPAP.,OPERATION AND PROCEDURE: , Laparoscopic Roux-en-Y gastric bypass.,BRIEF HOSPITAL COURSE SUMMARY:  ,This is a 30-year-old male, who presented recently to the Bariatric Center for evaluation and treatment of longstanding morbid obesity and associated comorbidities.  Underwent standard bariatric evaluation, consults, diagnostics, and preop Medifast induced weight loss in anticipation of elective bariatric surgery. ,Taken to the OR via same day surgery process for elective gastric bypass, tolerated well, recovered in the PACU, and sent to the floor for routine postoperative care.  There, DVT prophylaxis was continued with subcu heparin, early and frequent mobilization, and SCDs.  PCA was utilized for pain control, efficaciously, he utilized the CPAP, was monitored, and had no new cardiopulmonary complaints.  Postop day #1, labs within normal limits, able to clinically start bariatric clear liquids at 2 ounces per hour, this was tolerated well.  He was ambulatory, had no cardiopulmonary complaints, no unusual fever or concerning symptoms.  By the second postoperative day, was able to advance to four ounces per hour, tolerated this well, and is able to discharge in stable and improved condition today.  He had his drains removed today as well.,DISCHARGE INSTRUCTIONS: , Include re-appointment in the office in the next week, call in the interim if any significant concerning complaints.  Scripts left in the chart for omeprazole and Lortab.  Med rec sheet completed (on no meds).  He will maintain bariatric clear liquids at home, goal 64 ounces per day, maintain activity at home, but no heavy lifting or straining.  Can shower starting tomorrow, drain site care and wound care reviewed.  He will re-appoint in the office in the next week, certainly call in the interim if any significant concerning complaints.","discharge summary, medifast, laparoscopic roux-en-y gastric bypass, roux-en-y, bariatric clear liquids, gastric bypass, laparoscopic, gastric, bariatric, bypass, "
" Acute gastroenteritis, resolved.  Gastrointestinal bleed and chronic inflammation of the mesentery of unknown etiology.", Discharge Summary, Gastroenteritis - Discharge Summary ,"ADMITTING DIAGNOSES,1.  Acute gastroenteritis.,2.  Nausea.,3.  Vomiting.,4.  Diarrhea.,5.  Gastrointestinal bleed.,6.  Dehydration.,DISCHARGE DIAGNOSES,1.  Acute gastroenteritis, resolved.,2.  Gastrointestinal bleed and chronic inflammation of the mesentery of unknown etiology.,BRIEF H&P AND HOSPITAL COURSE: , This patient is a 56-year-old male, a patient of Dr. X with 25-pack-year history, also a history of diabetes type 2, dyslipidemia, hypertension, hemorrhoids, chronic obstructive pulmonary disease, and a left lower lobe calcified granuloma that apparently is stable at this time.  This patient presented with periumbilical abdominal pain with nausea, vomiting, and diarrhea for the past 3 days and four to five watery bowel movements a day with symptoms progressively getting worse.  The patient was admitted into the ER and had trop x1 done, which was negative and ECG showed to be of normal sinus rhythm.,Lab findings initially presented with a hemoglobin of 13.1, hematocrit of 38.6 with no elevation of white count.  Upon discharge, his hemoglobin and hematocrit stayed at 10.9 and 31.3 and he was still having stool guaiac positive blood, and a stool study was done which showed few white blood cells, negative for Clostridium difficile and moderate amount of occult blood and moderate amount of RBCs.  The patient's nausea, vomiting, and diarrhea did resolve during his hospital course.  Was placed on IV fluids initially and on hospital day #2 fluids were discontinued and was started on clear liquid diet and diet was advanced slowly, and the patient was able to tolerate p.o. well.  The patient also denied any abdominal pain upon day of discharge.  The patient was also started on prednisone as per GI recommendations.  He was started on 60 mg p.o.  Amylase and lipase were also done which were normal and LDH and CRP was also done which are also normal and LFTs were done which were also normal as well.,PLAN: , The plan is to discharge the patient home.  He can resume his home medications of Prandin, Actos, Lipitor, Glucophage, Benicar, and Advair.  We will also start him on a tapered dose of prednisone for 4 weeks.  We will start him on 15 mg p.o. for seven days.  Then, week #2, we will start him on 40 mg for 1 week.  Then, week #3, we will start him on 30 mg for 1 week, and then, 20 mg for 1 week, and then finally we will stop.  He was instructed to take tapered dose of prednisone for 4 weeks as per the GI recommendations.","discharge summary, nausea, vomiting, diarrhea, gastrointestinal bleed, mesentery, hemoglobin, hematocrit, gastrointestinal, periumbilical, gastroenteritis, hemorrhoids"
" Gastroenteritis versus bowel obstruction, gastroesophageal reflux, Goldenhar syndrome, and anemia, probably iron deficiency.", Discharge Summary, Goldenhar Syndrome - Discharge Summary  ,"ADMITTING DIAGNOSES,1.  Vomiting, probably secondary to gastroenteritis.,2.  Goldenhar syndrome.,3.  Severe gastroesophageal reflux.,4.  Past history of aspiration and aspiration pneumonia.,DISCHARGE DIAGNOSES,1.  Gastroenteritis versus bowel obstruction.,2.  Gastroesophageal reflux.,3.  Goldenhar syndrome.,4.  Anemia, probably iron deficiency.,HISTORY OF PRESENT ILLNESS:,  This is a 10-week-old female infant who has Goldenhar syndrome and has a gastrostomy tube in place and a J-tube in place.  She was noted to have vomiting approximately 18 to 24 hours prior to admission and was seen in the emergency department and then admitted.,Because of her Goldenhar syndrome and previous problems with aspiration, she is not fed my mouth, but does have a G-tube.  However, she has not been tolerating feedings through this prior to admission.,PHYSICAL EXAMINATION:,GENERAL:  At transfer to UNM on October 13, 2003 reveals a dysmorphic infant who is small and slightly cachectic.  Her left side of the face is deformed with microglia present, micrognathia present, and a moderate amount of torticollis.,VITAL SIGNS:  Presently, her temperature is 98, pulse 152, respirations 36, weight is 3.98 kg, pulse oximetry on room air is 95%.,HEENT:  Head is with anterior fontanelle open.  Eyes:  Red reflex elicited bilaterally.  Left ear is without an external ear canal and the right is not well visualized at this time.  Nose is presently without any discharge, and throat is nonerythematous.  NECK:  Neck with torticollis exhibited.,LUNGS:  Presently are clear to auscultation.,HEART:  Regular rate without murmur, click or gallop present.  ABDOMEN:  Moderately distended, but soft.  Bowel sounds are decreased, and there is a G-tube and a J-tube in place.  The skin surrounding the G-tube is moderately erythematous, but without any discharges present.  J-tube is with a dressing in place and well evaluated.,EXTREMITIES:  Grossly normal.  Hip defects are not checked at this time.,GENITALIA:  Normal female.,NEUROLOGIC:  The infant does have a suck reflex, feeding grasp-reflex, and a feeding Moro reflex.,SKIN:  Warm and dry and there is a macular area to the left ___ that is approximately 1 cm in length.,LABORATORY DATA: , WBC count on October 12, 2003 is 12,600 with 16 segs, 6 bands, 54 lymphocytes, 13% of which are noted to be reactive.  Hemoglobin is 10.4, hematocrit 30.8, and she has abnormal red blood cell morphology.  RDW is 13.1 and MCV is 91.  Sodium level is 138, potassium 5.4, chloride 103, CO2 23, BUN 7, creatinine 0.4, glucose 84, calcium 9.9, and at this dictation, the report on the abdominal flat plate is pending.,HOSPITAL COURSE:  ,The child was placed at bowel rest initially and then re-tried on full strength formula, but she did not tolerate.  She was again placed on bowel rest and her medications, Pepcid and Reglan, were given in an attempt to increase bowel motility.  Feedings were re-attempted with Pedialyte through the J-tube and these did not result in production of any stool and the child then began having vomiting again.  The vomitus was noted to be bilious in nature and with particulate matter present.,After consultation with Dr. X, it was determined the child probably needed further evaluation, and she had both of her drains placed to gravity and was kept n.p.o.  Her fluids have been D5 and 0.25 normal saline with 20 mEq/L of potassium chloride, which has run at her maintenance of 16 mL/h.,CONSULTATIONS: , With Dr. X and Dr. Y and the child is now ready for transport for continued diagnosis and treatment.  Her condition at discharge is stable.",
" Gastrointestinal bleed, source undetermined, but possibly due to internal hemorrhoids.  Poor prep with friable internal hemorrhoids, but no gross lesions, no source of bleed.", Discharge Summary, Gastrointestinal Bleed - Discharge Summary ,"DIAGNOSIS ON ADMISSION: , Gastrointestinal bleed.,DIAGNOSES ON DISCHARGE,1. Gastrointestinal bleed, source undetermined, but possibly due to internal hemorrhoids.,2. Atherosclerotic cardiovascular disease.,3. Hypothyroidism.,PROCEDURE:,  Colonoscopy.,FINDINGS:,  Poor prep with friable internal hemorrhoids, but no gross lesions, no source of bleed.,HOSPITAL COURSE:  ,The patient was admitted to the emergency room by Dr. X. He apparently had an NG tube placed in the emergency room with gastric aspirate revealing no blood.  Dr. Y Miller saw him in consultation and recommended a colonoscopy.  A bowel prep was done.  H&Hs were stable.  His most recent H&H was 38.6/13.2 that was this morning.  His H&H at admission was 41/14.3.  The patient had the bowel prep that revealed no significant bleeding.  His vital signs are stable.  He is continuing on his usual medications of Imdur, metoprolol, and Synthroid.  His Plavix is discontinued.  He is given IV Protonix.  I am hesitant to use Prilosec or Protonix because of his history of pancreatitis associated with Prilosec.,The patient's PT/INR was 1.03, PTT 25.8.  Chemistry panel was unremarkable.  The patient was given a regular diet after his colonoscopy today.  He tolerated it well and is being discharged home.  He will be followed closely as an outpatient.  He will continue his Pepcid 40 mg at night, Imdur, Synthroid, and metoprolol as prior to admission.  He will hold his Plavix for now.  They will call me for further dark stools and will avoid Pepto-Bismol.  They will follow up in the office on Thursday.","discharge summary, atherosclerotic cardiovascular disease, colonoscopy, gross lesions, bowel prep, gastrointestinal bleed, internal hemorrhoids, hemorrhoids, gastrointestinal, prep "
" Solitary left kidney with obstruction and hypertension and chronic renal insufficiency, plus a Pseudomonas urinary tract infection.", Discharge Summary, Discharge Summary - Urology & Nephrology  ,"ADMITTING DIAGNOSES:,  Solitary left kidney with obstruction, and hypertension, and chronic renal insufficiency.,DISCHARGE DIAGNOSES: , Solitary left kidney with obstruction and hypertension and chronic renal insufficiency, plus a Pseudomonas urinary tract infection.,PROCEDURES: , Cystoscopy under anesthesia, ureteroscopy, an attempted tube placement, stent removal with retrograde pyelography, percutaneous tube placement, and nephrostomy by Radiology.,PERTINENT LABORATORIES: , Creatinine of 1.4.  During the hospitalization it was decreased to 0.8 and Pseudomonas urinary tract infection, positive culture sensitive to ceftazidime and ciprofloxacin.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 3-1/2-year-old boy with a solitary kidney, had a ureteropelvic junction repair performed by Dr. Y, in the past, unfortunately, it was thought still be obstructed.  A stent was placed approximately 6 weeks ago after urethroscopic placement with some difficulty.  Plan was to remove the stent.  At the time of removal, we were unable to place another tube within the collecting system, and the patient was admitted for percutaneous nephrostomy placement.  He has had no recent cold or flu.  He has problems with hypertension for which he is on enalapril at home in addition to his Macrodantin prophylaxis.,PAST MEDICAL HISTORY: , The patient has no known allergies.  Multiple urinary tract infection, solitary kidney, and previous surgeries as mentioned above.,REVIEW OF SYSTEMS:,  A 14-organ system review of systems is negative except for the history of present illness.  He also has history of being a 34-week preemie twin.,ALLERGIES: , No known allergies.,FAMILY HISTORY: , Unremarkable without any bleeding or anesthetic problems.,SOCIAL HISTORY: , The patient lives at home with his parents, 2 brothers, and a sister.,IMMUNIZATIONS:,  Up-to-date.,MEDICATIONS: , On admission was Macrodantin, hydralazine, and enalapril.,PHYSICAL EXAMINATION:,GENERAL:  The patient is an active little boy.,HEENT:  The head and neck exam was grossly normal.  He had no oral, ocular, or nasal discharge.,LUNGS:  Exam was normal without wheezing.,HEART:  Without murmur or gallops.,ABDOMEN:  Soft, without mass or tenderness with a well-healed flank incision.,GU:  Uncircumcised male with bilaterally descended testes.,EXTREMITIES:  He has full range of motion in all 4 extremities.,SKIN:  Warm, pink, and dry.,NEUROLOGIC:  Grossly intact.,BACK:  He has normal back.  Normal gait.,HOSPITAL COURSE: , The patient was admitted to the hospital after inability to place a ureteral stent via ureteroscopy and cystoscopy.  He was made NPO.  He had a fever at first time with elevated creatinine.  He was also evaluated and treated by Dr. X, for fluid management, hypertensive management, and gave him some hydralazine and Lasix to improve his urine output, in addition to manage his blood pressure.  Once the percutaneous tube was placed, we found that his urine culture grew Pseudomonas, so he was kept on Fortaz, and was switched over to ciprofloxacin without difficulty.  He, otherwise, did well with continuing decrease his creatinine at the time of discharge to home.,The patient was discharged home in stable condition with ciprofloxacin, enalapril, and recommendation for followup in Urology in 1 to 2 weeks for the surgical correction in 2 to 3 weeks of repeat pyeloplasty or possible ureterocalicostomy.  The patient had draining nephrostomy tube without difficulty.,",
 Falls at home.  Anxiety and depression.  The patient had been increasingly anxious and freely admitted that she was depressed at home., Discharge Summary, Falls - Discharge Summary ,"CHIEF COMPLAINT:,  Falls at home.,HISTORY OF PRESENT ILLNESS:,  The patient is an 82-year-old female who fell at home and presented to the emergency room with increased anxiety.  Family members who are present state that the patient had been increasingly anxious and freely admitted that she was depressed at home.  They noted that she frequently came to the emergency room for ""attention.""  The patient denied any chest pain or pressure and no change to exercise tolerance.  The patient denied any loss of consciousness or incontinence.  She denies any seizure activity.  She states that she ""tripped"" at home.  Family states she frequently takes Darvocet for her anxiety and that makes her feel better, but they are afraid she is self medicating.  They stated that she has numerous medications at home, but they were not sure if she was taking them.  The patient been getting along for a number of years and has been doing well, but recently has been noting some decline primarily with regards to her depression.  The patient denied SI or HI.,PHYSICAL EXAMINATION:,GENERAL:  The patient is pleasant 82-year-old female in no acute distress.,VITAL SIGNS:  Stable.,HEENT:  Negative.,NECK:  Supple.  Carotid upstrokes are 2+.,LUNGS:  Clear.,HEART:  Normal S1 and S2.  No gallops.  Rate is regular.,ABDOMEN:  Soft.  Positive bowel sounds.  Nontender.,EXTREMITIES:  No edema.  There is some ecchymosis noted to the left great toe.  The area is tender; however, metatarsal is nontender.,NEUROLOGICAL:  Grossly nonfocal.,HOSPITAL COURSE: , A psychiatric evaluation was obtained due to the patient's increased depression and anxiety.  Continue Paxil and Xanax use was recommended.  The patient remained medically stable during her hospital stay and arrangements were made for discharge to a rehabilitation program given her recent falls.,DISCHARGE DIAGNOSES:,1.  Falls ,2.  Anxiety and depression.,3.  Hypertension.,4.  Hypercholesterolemia.,5.  Coronary artery disease.,6.  Osteoarthritis.,7.  Chronic obstructive pulmonary disease.,8.  Hypothyroidism.,CONDITION UPON DISCHARGE: , Stable.,DISCHARGE MEDICATIONS: , Tylenol 650 mg q.6h. p.r.n., Xanax 0.5 q.4h. p.r.n., Lasix 80 mg daily, Isordil 10 mg t.i.d., KCl 20 mEq b.i.d., lactulose 10 g daily, Cozaar 50 mg daily, Synthroid 75 mcg daily, Singulair 10 mg daily, Lumigan one drop both eyes at bed time, NitroQuick p.r.n., Pravachol 20 mg daily, Feldene 20 mg daily, Paxil 20 mg daily, Minipress 2 mg daily, Provera p.r.n., Advair 250/50 one puff b.i.d., Senokot one tablet b.i.d., Timoptic one drop OU daily, and verapamil 80 mg b.i.d.,ALLERGIES: , None.,ACTIVITY: , Per PT.,FOLLOW-UP: , The patient discharged to a skilled nursing facility for further rehabilitation.",
 A 31-year-old white female admitted to the hospital with pelvic pain and vaginal bleeding.  Right ruptured ectopic pregnancy with hemoperitoneum.   Anemia secondary to blood loss., Discharge Summary, Ectopic Pregnancy - Discharge Summary ,"HISTORY OF PRESENT ILLNESS: , This is the case of a 31-year-old white female admitted to the hospital with pelvic pain and vaginal bleeding.  The patient had a positive hCG with a negative sonogram and hCG titer of about 18,000.,HOSPITAL COURSE:,  The patient was admitted to the hospital with the diagnosis of a possible incomplete abortion, to rule out ectopic pregnancy or rupture of corpus luteal cyst.  The patient was kept in observation for 24 hours.  The sonogram stated there was no gestational sac, but there was a small mass within the uterus that could represent a gestational sac.  The patient was admitted to the hospital.  A repeat hCG titer done on the same day came back as 15,000, but then the following day, it came back as 18,000.  The diagnosis of a possible ruptured ectopic pregnancy was established.  The patient was taken to surgery and a laparotomy was performed with findings of a right ruptured ectopic pregnancy.  The right salpingectomy was performed with no complications.  The patient received 2 units of red packed cells.  On admission, her hemoglobin was 12.9, then in the afternoon it dropped to 8.1, and the following morning, it was 7.9.  Again, based on these findings, the severe abdominal pain, we made the diagnosis of ectopic and it was proved or confirmed at surgery.  The hospital course was uneventful.  There was no fever reported.  The abdomen was soft.  She had a normal bowel movement.  The patient was dismissed on 09/09/2007 to be followed in my office in 4 days.,FINAL DIAGNOSES:,1.  Right ruptured ectopic pregnancy with hemoperitoneum.,2.  Anemia secondary to blood loss.,PLAN: , The patient will be dismissed on pain medication and iron therapy.","discharge summary, anemia, blood loss, ruptured ectopic pregnancy, gestational sac, ectopic pregnancy, hemoperitoneum, gestational, ruptured, pregnancy, ectopic,"
" Discharge Summary of a patient with hematuria, benign prostatic hyperplasia, complex renal cyst versus renal cell carcinoma, and osteoarthritis.", Discharge Summary, Discharge Summary - Urology ,"ADMITTING DIAGNOSES:,1. Hematuria.,2. Benign prostatic hyperplasia.,3. Osteoarthritis.,DISCHARGE DIAGNOSES:,1. Hematuria, resolved.,2. Benign prostatic hyperplasia.,3. Complex renal cyst versus renal cell carcinoma or other tumor.,4. Osteoarthritis.,HOSPITAL COURSE:, This is a 77-year-old African-American male who was previously well until he began having gross hematuria and clots passing through his urethra on the day of admission. He stated that he never had blood in his urine before, however, he does have a past history of BPH and he had a transurethral resection of prostate more than 10 years ago. He was admitted to a regular bed. Dr. G of Urology was consulted for evaluation of his hematuria. During the workup for this, he had a CT of the abdomen and pelvis with and without contrast with early and late-phase imaging for evaluation of the kidneys and collecting system. At that time, he was shown to have multiple bilateral renal cysts with one that did not meet classification as a simple cyst and ultrasound was recommended.,He had an ultrasound done of the cyst which showed a 2.1 x 2.7 cm mass arising from the right kidney which, again, did not fit ultrasound criteria for a simple cyst and they recommended further evaluation by an MRI as this could be a hemorrhagic cyst or a solid mass or tumor, so an MRI was scheduled on the day of discharge for further evaluation of this. The report was not back at discharge. The patient had a cystoscopy and transurethral resection of prostate as well with entire resection of the prostate gland. Pathology on this specimen showed multiple portions of prostatic tissue which was primarily fibromuscular, and he was diagnosed with nonprostatic hyperplasia. His urine slowly cleared. He tolerated a regular diet with no difficulties in his activities of daily living, and his Foley was removed on the day of discharge.,He was started on ciprofloxacin, Colace, and Lasix after the transurethral resection and continued these for a short course. He is asked to continue the Colace as an outpatient for stool softening for comfort.,DISCHARGE MEDICATIONS:, Colace 100 mg 1 b.i.d.,DISCHARGE FOLLOWUP PLANNING:, The patient is to follow up with his primary care physician at ABCD, Dr. B or Dr. J, the patient is unsure of which, in the next couple weeks. He is to follow up with Dr. G of  Urology in the next week by phone in regards to the patient's MRI and plans for a laparoscopic partial renal resection biopsy. This is scheduled for the week after discharge potentially by Dr. G, and the patient will discuss the exact time later this week. The patient is to return to the emergency room or to our clinic if he has worsening hematuria again or no urine output.","discharge summary, bph, benign prostatic hyperplasia, hematuria, osteoarthritis, clots, cystoscopy, gross hematuria, kidney, renal cell carcinoma, renal cyst, simple cyst, prostatic hyperplasia, transurethral resection, discharge, summary, urology, transurethral, prostate, prostatic, hyperplasia, gross, benign, renal, cyst"
 A 48-year-old white married female presents in the emergency room after two days of increasing fever with recent diagnosis of urinary tract infection on outpatient treatment with nitrofurantoin., Discharge Summary, ER Report - Chest Pain & Fever ,"CHIEF COMPLAINT: , Chest pain and fever.,HISTORY OF PRESENT ILLNESS: , This 48-year-old white married female presents in the emergency room after two days of increasing fever with recent diagnosis of urinary tract infection on outpatient treatment with nitrofurantoin.  The patient noted since she began to feel poorly earlier on the day of admission, had an episode of substernal chest discomfort that was associated with nausea, dizziness, and sweating.  The patient does have a past medical history of diabetes and hypertension.  In addition, the patient complained of some neck and head discomfort for which she underwent a lumbar puncture in the emergency room; this was normal, causes turned out to be normal as well.  The patient denies nosebleed, visual changes, nausea, vomiting, diarrhea or changes in bowel habits.  She has not had any musculoskeletal or neurological deficits.  She denies any rashes or skin lesions.,PAST MEDICAL HISTORY:  ,Hypertension, diabetes, hyperlipidemia, particularly elevated triglycerides with a slightly elevated LDL at 81 with an new standard LDL of 74, diabetics with a bad family history for cardiovascular disease such as this patient does have, and postmenopausal hot flashes.,PAST SURGICAL HISTORY:  ,Cholecystectomy, appendectomy, oophorectomy.,FAMILY HISTORY: , Positive for coronary artery disease in her father and brother in their 40s.,SOCIAL HISTORY: , She is married and does not smoke or drink nor did she ever.,PHYSICAL EXAMINATION: , On admission, temperature 99.4 degrees F., blood pressure 137/60, pulse 90 and regular without ectopy, respiratory rate 20 without unusual respiratory effort.  In general, she is well developed, well nourished, oriented, and alert and in no apparent distress.  Head, ears, eyes, nose, and throat are unremarkable.  Neck is supple.  No neck vein distention is noted.  No bruits are heard.  Chest is clear to percussion and auscultation.  Heart has a regular rhythm and rate without murmurs or rubs or gallops.  Abdomen is soft, obese, and nontender.  Musculoskeletal is intact without deformity.  However, the patient did develop severe cramp behind her left knee during her treadmill testing.  Neurologic:  Cranial nerves are intact and she is nonfocal.  Skin is warm and dry without rash or lesions noted.,LABORATORY FINDINGS: , Glucose 162, BUN 14, creatinine 1.0, sodium 137, potassium 3.6, chloride 103, bicarbonate 23, protein 4.2.  Liver function panel is normal.  CK was 82.  MB fraction was 1.0.  Troponin was less than 0.1 on three occasions.  White count was 12,200 with a normal differential, hemoglobin was 12.1, platelet count 230,000.  Urinalysis showed positive nitrites, positive leukocyte esterase, 5 to 10 white cells per high power field, and 1+ bacteria rods.  Spinal fluid was clear with 11 red cells, glucose 75, protein 67, white count 0.  EKG was normal.,DIAGNOSES ON ADMISSION:,1.  Urinary tract infection.,2.  Chest pain of unclear etiology, rule out myocardial infarction.,3.  Neck and back pain of unclear etiology with a negative spinal tap.,4.  Hypertension.,5.  Diabetes type II, not treated with insulin.,6.  Hyperlipidemia treated with TriCor but not statins.,7.  Arthritis.,ADDITIONAL LABORATORY STUDIES:,  B-natriuretic peptide was 26.  Urine smear and culture negative on 24 and 48 hours.  Chest x-ray was negative.  Lipid panel - triglycerides 249, VLDL 49, HDL 33, LDL 81.,COURSE IN THE HOSPITAL: , The patient was placed on home medications.  This will be listed at the end of the discharge summary.  She was put on rule out acute myocardial infarction routine, and she did in fact rule out.  She had a stress test completed on the day of discharge which was normal, and she was discharged with a diagnoses of chest pain, acute myocardial infarction ruled out, urinary tract infection, fever secondary to UTI, diabetes mellitus type 2 non-insulin treated, hyperlipidemia with elevated triglycerides and an LDL elevated to 81 with new normal being less than 70.  She has a strong family history of early myocardial disease in the men in their 40s.,DISCHARGE MEDICATIONS:,1.  Enteric-coated aspirin 81 mg one daily.  This is new, as the patient was not taking aspirin at home.,2.  TriCor 48 mg one daily.,3.  Zantac 40 mg one daily.,4.  Lisinopril 20 mg one daily.,5.  Mobic 75 mg one daily for arthritis.,6.  Metformin 500 mg one daily.,7.  Macrodantin one two times a day for several more days.,8.  Zocor 20 mg one daily, which is a new addition.,9.  Effexor XR 37.5 mg one daily.,DIET: , ADA 1800-calorie diet.,ACTIVITY:,  As tolerated.  Continue water exercise five days a week.,DISPOSITION: , Recheck at Hospital with a regular physician there in 1 week.  Consider Byetta as an adjunct to her diabetic treatment and efforts to weight control.",
" This is a 46-year-old gentleman with end-stage renal disease (ESRD) secondary to diabetes and hypertension, who had been on hemodialysis and is also status post cadaveric kidney transplant with chronic rejection.", Discharge Summary, ESRD - Discharge Summary ,"ADMISSION DIAGNOSIS:,  End-stage renal disease (ESRD).,DISCHARGE DIAGNOSIS: , End-stage renal disease (ESRD).,PROCEDURE:,  Cadaveric renal transplant.,HISTORY OF PRESENT ILLNESS: , This is a 46-year-old gentleman with end-stage renal disease (ESRD) secondary to diabetes and hypertension, who had been on hemodialysis since 1993 and is also status post cadaveric kidney transplant in 1996 with chronic rejection.,PAST MEDICAL HISTORY:  ,1.  Diabetes mellitus diagnosed 12 years ago.,2.  Hypertension.,3.  Coronary artery disease with a myocardial infarct in September of 2006.,4.  End-stage renal disease.,PAST SURGICAL HISTORY: , Coronary artery bypass graft x5 in 1995 and cadaveric renal transplant in 1996.,SOCIAL HISTORY:  ,The patient denies tobacco or ethanol use.,FAMILY HISTORY:,  Hypertension.,PHYSICAL EXAMINATION:  ,GENERAL:  The patient was alert and oriented x3 in no acute distress, healthy-appearing male.,VITAL SIGNS:  Temperature 96.6, blood pressure 166/106, heart rate 83, respiratory rate 18, and saturations 96% on room air.,CARDIOVASCULAR:  Regular rate and rhythm.,PULMONARY:  Clear to auscultation bilaterally.,ABDOMEN:  Soft, nontender, and nondistended with positive bowel sounds.,EXTREMITIES:  No clubbing, cyanosis, or edema.,PERTINENT LABORATORY DATA: , White blood cell count 6.4, hematocrit 34.6, and platelet count 182.  Sodium 137, potassium 5.4, BUN 41, creatinine 7.9, and glucose 295.  Total protein 6.5, albumin 3.4, AST 51, ALT 51, alk phos 175, and total bilirubin 0.5.,COURSE IN HOSPITAL: , The patient was admitted postoperatively to the surgical intensive care unit.  Initially, the patient had a decrease in hematocrit from 30 to 25.  The patient's hematocrit stabilized at 25.  During the patient's stay, the patient's creatinine progressively decreased from 8.1 to a creatinine at the time of discharge of 2.3.  The patient was making excellent urine throughout his stay.  The patient's Jackson-Pratt drain was removed on postoperative day #1 and he was moved to the floor.  The patient was advanced in diet appropriately.  The patient was started on Prograf by postoperative day #2.  Initial Prograf levels came back high at 18.  The patient's Prograf doses were changed accordingly and today, the patient is deemed stable to be discharged home.  During the patient's stay, the patient received four total doses of Thymoglobulin.  Today, he will complete his final dose of Thymoglobulin prior to being discharged.  In addition, today, the patient has an elevated blood pressure of 198/96.  The patient is being given an extra dose of metoprolol for this blood pressure.  In addition, the patient has an elevated glucose of 393 and for this reason he has been given an extra dose of insulin.  These labs will be rechecked later today and once his blood pressure has decreased to systolic blood pressure less than 116 and his glucose has come down to a more normal level, he will be discharged to home.,DISCHARGE INSTRUCTIONS: , The patient is discharged with instructions to seek medical attention in the event if he develops fevers, chills, nausea, vomiting, decreased urine output, or other concerns.  He is discharged on a low-potassium diet with activity as tolerated.  He is instructed that he may shower; however, he is to undergo no underwater soaking activities for approximately two weeks.  The patient will be followed up in the Transplant Clinic at ABCD tomorrow, at which time, his labs will be rechecked.  The patient's Prograf levels at the time of discharge are pending; however, given that his Prograf dose was decreased, he will be followed tomorrow at the Renal Transplant Clinic.",
 A 3-year-old abrupt onset of cough and increased work of breathing., Discharge Summary, Discharge Summary - Respiratory Distress ,"ADMITTING DIAGNOSES:,1.  Respiratory distress.,2.  Reactive airways disease.,DISCHARGE DIAGNOSES:,1.  Respiratory distress.,2.  Reactive airways disease.,3.  Pneumonia.,HISTORY OF PRESENT ILLNESS: , The patient is a 3-year-old boy previously healthy who has never had a history of asthma or reactive airways disease who presented with a 36-hour presentation of URI symptoms, then had an abrupt onset of cough and increased work of breathing.  Child was brought to Children's Hospital and received nebulized treatments in the ER and the Hospitalist Service was contacted regarding admission.  The patient was seen and admitted through the emergency room.,He was placed on the hospitalist system and was started on continuous nebulized albuterol secondary to his respiratory distress.  He also received inhaled as well as systemic corticosteroids.  An x-ray was without infiltrate on initial review by the hospitalist, but there was a right upper lobe infiltrate versus atelectasis per the official radiology reading.  The patient was not started on any antibiotics and his fever resolved.  However, the CRP was relatively elevated at 6.7.  The CBC was normal with a white count of 9.6; however, the bands were 84%.  Given these results, which she is to treat the pneumonia as bacterial and discharge the child with amoxicillin and Zithromax.,He was taken off of continuous and he was not on room air all night.  In the morning, he still had some bilateral wheezing, but no tachypnea.,DISCHARGE PHYSICAL EXAMINATION: , ,GENERAL:  No acute distress, running around the room.,HEENT:  Oropharynx moist and clear.,NECK:  Supple without lymphadenopathy, thyromegaly or masses.,CHEST:  Bilateral basilar wheezing.  No distress.,CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs noted.  Well perfused peripherally.,ABDOMEN:  Bowel sounds present.  The abdomen is soft.  There is no hepatosplenomegaly, no masses.  Nontender to palpation.,GENITOURINARY:  Deferred.,EXTREMITIES:  Warm and well perfused.,DISCHARGE INSTRUCTIONS:,  As follows:,1.  Activity, regular.,2.  Diet is regular.,3.  Follow up with Dr. X in 2 days.,DISCHARGE MEDICATIONS:,1.  Xopenex MDI 2 puffs every 4 hours for 2 days and then as needed for cough or wheeze.,2.  QVAR 40, 2 puffs twice daily until otherwise instructed by the primary care provider.,3.  Amoxicillin 550 mg p.o. twice daily for 10 days.,4.  Zithromax 150 mg p.o. on day 1, then 75 mg p.o. daily for 4 more days.,Total time for this discharge 37 minutes.",
" The patient with multiple medical conditions including coronary artery disease, hypothyroidism, and severe peripheral vascular disease status post multiple revascularizations.", Discharge Summary, Discharge Summary - Peripheral vascular disease ,"ADMITTING DIAGNOSIS:,  A nonhealing right below-knee amputation.,DISCHARGE DIAGNOSIS:,  A nonhealing right below-knee amputation.,SECONDARY DIAGNOSES:,  Include:,1.  Peripheral vascular disease, bilateral carotid artery stenosis status post bilateral carotid endarterectomies.,2.  Peripheral vascular disease status post aortobifemoral bypass and bilateral femoropopliteal bypass grafting.,3.  Hypertension.,4.  Diverticulosis.,5.  Hypothyroidism.,6.  Chronic renal insufficiency.,7.  Status post open incision and drainage of an intestinal abscess at an unknown point.,DETERMINATION: , Status post right below-knee amputation.,OPERATIONS PERFORMED:,1.  Extensive debridement of right below-knee amputation with debridement of skin, subcutaneous tissue, muscle, and bone on July 17, 2008.,2.  Irrigation and debridement of right below-knee amputation wound on July 21, 2008, July 24, 2008, July 28, 2008, and August 1, 2008.,HISTORY OF PRESENT ILLNESS: , The patient is an 89-year-old gentleman with multiple medical conditions including coronary artery disease, hypothyroidism, and severe peripheral vascular disease status post multiple revascularizations, and a right below-knee amputation in June 2008 following a thrombosis of his right femoropopliteal bypass graft.  Following his amputation, he had poor wound healing.  He presented to the ED with pain in his right lower extremity on July 9, 2008.  Due to concern for infection at that time, he was started on oral Keflex and instructed to follow up with the Vascular Clinic as scheduled.  At his follow-up appointment, it was decided to re-admit The patient for debridement and revision of his stump wound.,HOSPITAL COURSE:,  Briefly, The patient underwent extensive debridement of his right below-knee amputation wound on July 17, 2008.  He underwent debridement of skin, subcutaneous tissue, muscle, and bone to remove the necrotic tissue from the stump.  A wound VAC. was also placed to help accelerate wound healing.  The patient's postoperative course was complicated initially by acute blood-loss anemia, requiring blood transfusion.  He returned to the OR on Monday, July 21, 2008 for irrigation and debridement of his right below-knee amputation and a wound VAC change.  Again, on July 24, 2008, and then again on July 28, 2008, The patient returned to the operating room for irrigation and debridement of his wound and wound VAC change.  Following his procedure on July 28, 2008, The patient began having recurrent episodes of diarrhea, prompting stool cultures and C. difficile assay to be sent.  He was also started on Flagyl, empirically.  C. difficile assay returned positive and the decision was made to continue Flagyl for a full 14-day course.  On July 31, 2008, the patient began experiencing shortness of breath and wheezing after standing to be weighed.  His vital signs remained stable.  However, his oxygen saturation dropped to 93%, improving only to 97% after an addition of 2 liters by nasal cannula.  A chest x-ray revealed bilateral pleural effusions and bibasilar atelectasis in addition to some pulmonary edema diffusely.  The patient's IV fluids were decreased.  He was given p.r.n. albuterol and infusion of Lasix, resulting in significant urine output.  His symptoms of shortness of breath gradually improved.  On August 1, 2008, he returned to the OR for final irrigation and debridement of his below-knee amputation.  Again, a wound VAC was placed.  Postoperatively, he did well.  His Foley catheter was removed.  His vital signs remained stable, and his respiratory status also remained stable.  Arrangements were made for home health and wound VAC care upon discharge.,DISCHARGE CONDITION: , The patient is resting comfortably.  He denies shortness of breath or chest pain.  He has mild bibasilar wheezing, but breathing is otherwise nonlabored.  All other exams normal.,DISCHARGE MEDICATIONS:,1.  Acetaminophen 325 mg daily.,2.  Albuterol 2 puffs every six hours as needed.,3.  Vitamin C 500 mg one to two times daily.,4.  Aspirin 81 mg daily.,5.  Symbicort 1 puff every morning and 1 puff every evening.,6.  Tums p.r.n.,7.  Calcium 600 mg plus vitamin D daily.,8.  Plavix 75 mg daily.,9.  Clorazepate dipotassium 7.5 mg every six hours as needed.,10.  Lexapro 10 mg daily at bedtime.,11.  Hydrochlorothiazide 25 mg one-half tablet daily.,12.  Ibuprofen 200 mg three pills as needed.,13.  Imdur 30 mg daily.,14.  Levoxyl 112 mcg daily.,15.  Ativan 0.5 mg one-half tablet every six hours as needed.,16.  Lopressor 50 mg one-half tablet twice daily.,17.  Flagyl 500 mg every six hours for 10 days.,18.  Multivitamin daily.,19.  Nitrostat 0.4 mg to take as directed.,20.  Omeprazole 20 mg daily.,21.  Oxycodone-acetaminophen 5/325 mg every four to six hours as needed for pain.,22.  Lyrica 25 mg daily at bedtime.,23.  Zocor 40 mg one-half tablet daily at bedtime.",
 The patient was admitted after undergoing a drawn out process with a small bowel obstruction., Discharge Summary, Discharge Summary - Respiratory Failure ,"DISCHARGE DIAGNOSIS:,1.  Respiratory failure improved.,2.  Hypotension resolved.,3.  Anemia of chronic disease stable.,4.  Anasarca improving.,5.  Protein malnourishment improving.,6.  End-stage liver disease.,HISTORY AND HOSPITAL COURSE:  ,The patient was admitted after undergoing a drawn out process with a small bowel obstruction.  His bowel function started to improve.  He was on TPN prior to coming to Hospital.  He has remained on TPN throughout his time here, but his appetite and his p.o. intake have improved some.  The patient had an episode while here where his blood pressure bottomed out requiring him to spend multiple days in the Intensive Care Unit on dopamine.  At one point, we were unsuccessful at weaning him off the dopamine, but after approximately 11 days, he finally started to tolerate weaning parameters, was successfully removed from dopamine, and has maintained his blood pressure without difficulty.  The patient also was requiring BiPAP to help with his oxygenation and it appeared that he developed a left-sided pneumonia.  This has been treated successfully with Zyvox and Levaquin and Diflucan.  He seems to be currently doing much better.  He is only using BiPAP in the evening.  As stated above, he is eating better.  He had some evidence of redness and exquisite swelling around his genital and lower abdominal region.  This may be mainly dependent edema versus anasarca.  The patient has been diuresed aggressively over the last 4 to 5 days, and this seems to have made some improvement in his swelling.  This morning, the patient denies any acute distress.  He states he is feeling good and understands that he is being discharged to another facility for continued care and rehabilitation.  He will be discharged to Garden Court skilled nursing facility.,DISCHARGE MEDICATIONS/INSTRUCTIONS:,  He is going to be going with Protonix 40 mg daily, metoclopramide 10 mg every 6 hours, Zyvox 600 mg daily for 5 days, Diflucan 150 mg p.o. daily for 3 days, Bumex 2 mg p.o. daily, Megace 400 mg p.o. b.i.d., Ensure 1 can t.i.d. with meals, and MiraLax 17 gm p.o. daily.  The patient is going to require physical therapy to help with assistance in strength training.  He is also going to need respiratory care to work with his BiPAP.  His initial settings are at a rate of 20, pressure support of 12, PEEP of 6, FIO2 of 40%.  The patient will need a sleep study, which the nursing home will be able to set up.,PHYSICAL EXAMINATION:,VITAL SIGNS:  On the day of discharge, heart rate 99, respiratory rate 20, blood pressure 102/59, temperature 98.2, O2 sat 97%.,GENERAL:  A well-developed white male who appears in no apparent distress.,HEENT:  Unremarkable.,CARDIOVASCULAR:  Positive S1, S2 without murmur, rubs, or gallops.,LUNGS:  Clear to auscultation bilaterally without wheezes or crackles.,ABDOMEN:  Positive for bowel sounds.  Soft, nondistended.  He does have some generalized redness around his abdominal region and groin.  This does appear improved compared to presentation last week.  The swelling in this area also appears improved.,EXTREMITIES:  Show no clubbing or cyanosis.  He does have some lower extremity edema, 2+ distal pedal pulses are present.,NEUROLOGIC:  The patient is alert and oriented to person and place.  He is alert and aware of surroundings.  We have not had any difficulties with confusion here lately.,MUSCULOSKELETAL:  The patient moves all extremities without difficulty.  He is just weak in general.,LABORATORY DATA: , Lab work done today shows the following:  White count 4.2, hemoglobin 10.2, hematocrit 30.6, and platelet count 184,000.  Electrolytes show sodium 139, potassium 4.1, chloride 98, CO2 26, glucose 79, BUN 56, and creatinine 1.4.  Calcium 8.8, phosphorus is a little high at 5.5, magnesium 2.2, albumin 3.9.,PLAN:  ,Discharge this gentleman from Hospital and admit him to Garden Court SNF where they can continue with his rehab and conditioning.  Hopefully, long-term planning will be discharge home.  He has a history of end-stage liver disease with cirrhosis, which may make him a candidate for hospice upon discharge.  The family initially wanted to bring the patient home, but he is too weak and requires too much assistance to adequately consider this option at this time.","discharge summary, respiratory failure, hypotension, anemia, anasarca, end-stage liver disease, drawn out process, bowel obstruction, blood pressure, dopamine, discharge, "
 Aftercare of multiple trauma from an motor vehicle accident., Discharge Summary, Discharge Summary - Multiple Trauma ,"ADMITTING DIAGNOSIS:,  Aftercare of multiple trauma from an motor vehicle accident.,DISCHARGE DIAGNOSES:,1.  Aftercare following surgery for injury and trauma.,2.  Decubitus ulcer, lower back.,3.  Alcohol induced persisting dementia.,4.  Anemia.,5.  Hypokalemia.,6.  Aftercare healing traumatic fracture of the lower arm.,7.  Alcohol abuse, not otherwise specified.,8.  Aftercare healing traumatic lower leg fracture.,9.  Open wound of the scalp.,10.  Cervical disk displacement with myelopathy.,11.  Episodic mood disorder.,12.  Anxiety disorder.,13.  Nervousness.,14.  Psychosis.,15.  Generalized pain.,16.  Insomnia.,17.  Pain in joint pelvic region/thigh.,18.  Motor vehicle traffic accident, not otherwise specified.,PRINCIPAL PROCEDURES:,  None.,HISTORY OF PRESENT ILLNESS: , As per Dr. X without any changes or corrections.,HOSPITAL COURSE:  ,This is a 50-year-old male, who is initially transferred from Medical Center after treatment for multiple fractures after a motor vehicle accident.  He had a left tibial plateau fracture, right forearm fracture with ORIF, head laceration, and initially some symptoms of head injury.  When he was initially transferred to HealthSouth, he was status post ORIF for his right forearm.  He had a brace placed in the left leg for his left tibial plateau fracture.  He was confused initially and initially started on rehab.  He was diagnosed with some acute psychosis and thought problems likely related to his alcohol abuse history.  He did well from orthopedic standpoint.  He did have a small sacral decubitus ulcer, which was well controlled with the wound care team and healed quite nicely.  He did have some anemia initially and he had dropped down in to the low 9, but he was 9.2 with his lowest on 06/11/2008, which had responded well to iron treatment and by the time of discharge, he was lower at 11.0.  He made slow progress from therapy.  His confusion gradually cleared.  He did have some problems with insomnia and was placed on Seroquel to help with both of his moods and other issues and he did quite well with this.  He did require some Ativan for agitation.  He was on chronic pain medications as an outpatient.  His medications were adjusted here and he did well with this as well.  The patient was followed throughout his entire stay with case management and discussions were made with them and the psychologist concerning the placement upon discharge to an acute alcohol rehab facility; however, the patient refused throughout this entire stay.  We did have orthopedic followup.  He was taken out of his right leg brace the week of 06/16/2008.  He did well with therapy.  Overall, he was doing much and much better.  He had progressed with the therapy to the point where that he was comfortable to go home and receive outpatient therapy and follow up with his primary care physician.  On 06/20/2008, with all parties in agreement, the patient was discharged to home in stable condition.,At the time of discharge, the patient's ambulatory status was much better.  He was using a wheeled walker.  He was able to bear weight on his left leg.  His pain level had been well controlled and his moods had improved dramatically.  He was no longer having any signs of agitation or confusion and he seemed to be at a stable baseline.  His anemia had resolved almost completely and he was doing quite well. ,MEDICATIONS: , On discharge included:,1.  Calcium with vitamin D 1 tablet twice a day.,2.  Ferrous sulfate 325 mg t.i.d.,3.  Multivitamin 1 daily.,4.  He was on nicotine patch 21 mg per 24 hour.,5.  He was on Seroquel 25 mg at bedtime.,6.  He was on Xenaderm for his sacral pressure ulcer.,7.  He was on Vicodin p.r.n. for pain.,8.  Ativan 1 mg b.i.d. for anxiety and otherwise he is doing quite well.,The patient was told to follow up with his orthopedist Dr. Y and also with his primary care physician upon discharge.",
" Patient with left renal cell carcinoma, left renal cyst, had robotic-Assisted laparoscopic left renal cyst decortication and cystoscopy.", Discharge Summary, Discharge Summary - Nephrology ,"ADMITTING DIAGNOSES:,  Left renal cell carcinoma, left renal cyst.,DISCHARGE DIAGNOSIS:,  Left renal cell carcinoma, left renal cyst.,SECONDARY DIAGNOSES:,1.  Chronic obstructive pulmonary disease.,2.  Coronary artery disease.,PROCEDURES: , Robotic-Assisted laparoscopic left renal cyst decortication and cystoscopy.,HISTORY OF PRESENT ILLNESS: , Mr. ABC is a 70-year-old male who has been diagnosed with a left renal cell carcinoma with multiple renal cysts.  He has undergone MRI of the abdomen on June 18, 2008 revealing an enhancing mass of the upper pole of the left kidney consistent with his history of renal cell carcinoma.  Of note, there are no other enhancing solid masses seen on this MRI.  After discussion of multiple management strategies with the patient including:,1.  Left partial nephrectomy.,2.  Left radical nephrectomy.,3.  Left renal cyst decortication.  The patient is likely to undergo the latter procedure.,HOSPITAL COURSE:  ,The patient was admitted to undergo left renal cyst decortication as well as a cystoscopy.  Intraoperatively, approximately four enlarged renal cysts and six smaller renal cysts were initially removed.  The contents were aspirated and careful dissection of the cyst wall was performed.  Multiple specimens of the cyst wall were sent for pathology.  Approximately one liter of cystic fluid was drained during the procedure.  The renal bed was inspected for hemostasis, which appear to be adequate.  There were no complications with the procedure.  Single JP drain was left in place.  Additionally, the patient underwent flexible cystoscopy, which revealed no gross strictures or any other abnormalities in the penile nor prostatic urethra.  Furthermore, no gross lesions were encountered in the bladder.  The patient left OR with transfer to the PACU and subsequently to the hospital floor.,The patient's postoperative course was relatively uneventful.  His diet and activity were gradually advanced without complication.  On postoperative day #2, he was passing flatus and has had bowel movements.  His Jackson-Pratt drain was discontinued on postoperative day #3 that being the day of discharge.  His Foley catheter was removed on the morning of discharge and the patient subsequently passed the voiding trial without difficultly.  At the time of discharge, he was afebrile.  His vital signs indicated hemodynamic stability and he had no evidence of infection.  The patient was instructed to follow up with Dr. XYZ on 8/12/2008 at 1:50 p.m. and was given prescription for pain medications as well as laxative.,DISPOSITION: , To home.,DISCHARGE CONDITION:,  Good.,MEDICATIONS:  ,Please see attached medication list.,INSTRUCTIONS: , The patient was instructed to contact Dr. XYZ's office for fever greater than 101.5, intractable pain, nausea, vomiting, or any other concerns.,FOLLOWUP: , The patient will follow up with Dr. XYZ for a postoperative check on 08/12/2008 at 1:50 p.m. and he was made aware of this appointment.","discharge summary, decortication, cystoscopy, pain, nausea, vomiting, renal cyst decortication, renal cell carcinoma, robotic assisted, renal cyst, renal, robotic, laparoscopic, nephrectomy, cysts, cell, carcinoma, discharge, "
 Diffuse Large B-cell Lymphoma, Discharge Summary, Discharge Summary - Lymphoma ,"DISCHARGE DIAGNOSES:,1.  Central nervous system lymphoma.,2.  Gram-negative bacteremia.,3.  Pancytopenia.,4.  Hypertension.,5.  Perianal rash.,6.  Diabetes mellitus.,7.  Hypoxia.,8.  Seizure prophylaxis.,9.  Acute kidney injury.,PROCEDURES DURING HOSPITALIZATION:,1.  Cycle five high-dose methotrexate.,2.  Rituxan weekly.,3.  Chest x-ray.,4.  Wound consult.,HISTORY OF PRESENT ILLNESS: , Ms. ABC is a pleasant 60-year-old Caucasian female who was diagnosed in April 2008 with diffuse large B-cell lymphoma after she developed visual saltation, changes, and confusion.  Further staging revealed borderline mediastinal pretracheal lymphadenopathy but was otherwise unremarkable.  She began high-dose methotrexate in mid May 2008; courses of methotrexate have been complicated by prolonged methotrexate levels, mental confusion, and mania.  During cycle three, repeat MRI showed interval worsening of disease, and Rituxan was added to her regimen.  Ms. ABC had a repeat MRI on July 24, 2008 prior to this admission, which showed significant improvement in her CNS disease.,HOSPITAL COURSE: , Ms. ABC was admitted to the Hematology B Service under attending Dr. Z.,1.  CNS lymphoma.  Upon admission, she was started on her Rituxan, which she tolerated well.  She was then hydrated with bicarbonate solution to a urine pH of 8.  She received methotrexate 5 g/m2.  24-hour creatinine was 0.9, 48-hour methotrexate level was elevated at 2.08.  This was likely secondary to the need to initiate treatment with antibiotics secondary to infection.  Her leucovorin was increased to 100 mg/m2.  72-hour methotrexate level was 0.58.  96-hour methotrexate was 0.16, and 19-hour was 0.08.  She continued additional four doses of oral leucovorin.  Her creatinine improved.  On day prior to discharge, she received her weekly dose of Rituxan.  She will return for Rituxan next week and then return for an appointment with Dr. X on August 18, 2008 with plans for admission for next cycle of methotrexate.,2.  Gram-negative bacteremia.  On the morning of June 27, 2008, Ms. ABC did spike a fever.  She was started on empiric antibiotics with cefepime and vancomycin.  Cultures were drawn peripherally and from the Port-A-Cath which both grew out Gram-negative rods within 12 hours.  After being initiated on IV antibiotics, she remained afebrile for the remainder of the hospitalization.  Both cultures eventually grew out Proteus mirabilis, which was pansensitive.  She had three additional blood cultures, which were all negative.  On the day prior to discharge, she was transitioned to oral Cipro and remained afebrile.  We had intended to send her home with oral antibiotics; however, by day of discharge, she was pancytopenic and it was decided that she should be discharged to complete a 14-day course of IV antibiotics with cefepime.  She will continue this with the assistance of home health services.  She was advised to follow neutropenic precautions and labs will be followed closely as an outpatient.  She understands if she develops a fever greater than 100.5, she should call to return immediately for admission.,3.  Pancytopenia.  On the day of discharge, the patient was pancytopenic with white count of 0.7, ANC of 500, hemoglobin 8.5, hematocrit 24.8, and platelet count 38, 000.  Her labs will be followed closely as an outpatient.  During the admission, we did obtain a HIT antibody, which was negative.  Heparin was held until this level was returned.  She was placed on Arixtra for prophylaxis against thrombus.  It is thought that her decreasing counts may be secondary to infection; however, if she continues to be pancytopenic, she will have a repeat bone marrow as an outpatient.,4.  Hypertension.  Blood pressure remained stable throughout the admission.  She will continue lisinopril daily.,5.  Perianal rash.  Upon admission, she was found to have worsening of a candidal rash in the perianal region.  A wound consult was obtained.  They recommended Aloe Vesta foam and Silver gel to the area topically.  She was also continued on Diflucan 200 mg daily.  She will complete a 10-day course.,6.  Diabetes mellitus.  At the time of admission, she was found to have hyperglycemia.  She was started on sliding scale insulin and eventually started on long-acting Lantus insulin.  She will be discharged with the regimen of Lantus 35 units at bedtime and continue the sliding scale as needed.,7.  Hypoxia.  She did have evidence of decreased saturations.  There was concern that she may have a pneumonia, which was treated with vancomycin for possible hospital acquired pneumonia; however, upon further review of the blood cultures improved, chest x-ray consistent with atelectasis and normal saturations that this was likely secondary to increased fluids associated with methotrexate and atelectasis from being confined to bed.,8.  Seizure prophylaxis.  She will continue Keppra twice daily.,9.  Acute kidney injury.  She did have a bump in the creatinine when methotrexate level was elevated.  This resolved by the time of discharge.  Creatinine on day of discharge is 0.9.  This will be followed as an outpatient.,DISPOSITION: , To home in stable condition with home health services.,DISCHARGE MEDICATIONS: , See separate sheet attached.,DIET:,  Neutropenic diabetic.,ACTIVITY: , Resume same activity.,FOLLOWUP: , With weekly lab work and plans for admission on August 18, 2008.  Ms. ABC was advised if she has any problems or concerns in the interim and needs to be seen sooner, she should call.",
" Mesothelioma, pleural effusion, atrial fibrillation, anemia, ascites, esophageal reflux, and history of deep venous thrombosis.", Discharge Summary, Discharge Summary - Mesothelioma - 1 ,"PRINCIPAL DIAGNOSIS:,  Mesothelioma.,SECONDARY DIAGNOSES:,  Pleural effusion, atrial fibrillation, anemia, ascites, esophageal reflux, and history of deep venous thrombosis.,PROCEDURES,1.  On August 24, 2007, decortication of the lung with pleural biopsy and transpleural fluoroscopy.,2.  On August 20, 2007, thoracentesis.,3.  On August 31, 2007, Port-A-Cath placement.,HISTORY AND PHYSICAL: , The patient is a 41-year-old Vietnamese female with a nonproductive cough that started last week.  She has had right-sided chest pain radiating to her back with fever starting yesterday.  She has a history of pericarditis and pericardectomy in May 2006 and developed cough with right-sided chest pain, and went to an urgent care center.  Chest x-ray revealed right-sided pleural effusion.,PAST MEDICAL HISTORY,1.  Pericardectomy.,2.  Pericarditis.,2.  Atrial fibrillation.,4.  RNCA with intracranial thrombolytic treatment.,5",
" Chest x-ray on admission, no acute finding, no interval change.  CT angiography, negative for pulmonary arterial embolism.  Chronic obstructive pulmonary disease exacerbation improving, on steroids and bronchodilators.", Discharge Summary, Discharge Summary - COPD ,"PROCEDURES:,1.  Chest x-ray on admission, no acute finding, no interval change.,2.  CT angiography, negative for pulmonary arterial embolism.,3.  Nuclear myocardial perfusion scan, abnormal.  Reversible defect suggestive of ischemia, ejection fraction of 55%.,DIAGNOSES ON DISCHARGE:,1.  Chronic obstructive pulmonary disease exacerbation improving, on steroids and bronchodilators.,2.  Coronary artery disease, abnormal nuclear scan, discussed with Cardiology Dr. X, who recommended to discharge the patient and follow up in the clinic.,3.  Diabetes mellitus type 2.,4.  Anemia, hemoglobin and hematocrit stable.,5.  Hypokalemia, replaced.,6.  History of coronary artery disease status post stent placement 2006-2008.,7.  Bronchitis.,HOSPITAL COURSE:  ,The patient is a 65-year-old American-native Indian male, past medical history of heavy tobacco use, history of diabetes mellitus type 2, chronic anemia, COPD, coronary artery disease status post stent placement, who presented in the emergency room with increasing shortness of breath, cough productive for sputum, and orthopnea.  The patient started on IV steroid, bronchodilator as well as antibiotics.,He also complained of chest pain that appears to be more pleuritic with history of coronary artery disease and orthopnea.  He was evaluated by Cardiology Dr. X, who proceeded with stress test.  Stress test reported positive for reversible ischemia, but Cardiology decided to follow up the patient in the clinic.  The patient's last cardiac cath was in 2008.,The patient clinically significantly improved and wants to go home.  His hemoglobin on admission was 8.8, and has remained stable.  He is afebrile, hemodynamically stable.,ALLERGIES: , LISINOPRIL AND PENICILLIN.,MEDICATIONS ON DISCHARGE:,1.  Prednisone tapering dose 40 mg p.o. daily for three days, then 30 mg p.o. daily for three days, then 20 mg p.o. daily for three days, then 10 mg p.o. daily for three days, and 5 mg p.o. daily for two days.,2.  Levaquin 750 mg p.o. daily for 5 more days.,3.  Protonix 40 mg p.o. daily.,4.  The patient can continue other current home medications at home.,FOLLOWUP APPOINTMENTS:,1.  Recommend to follow up with Cardiology Dr. X's office in a week.,2.  The patient is recommended to see Hematology Dr. Y in the office for workup of anemia.,3.  Follow up with primary care physician's office tomorrow.,SPECIAL INSTRUCTIONS:,1.  If increasing shortness of breath, chest pain, fever, any acute symptoms to return to emergency room.,2.  Discussed about discharge plan, instructions with the patient by bedside.  He understands and agreed.  Also discussed discharge plan instructions with the patient's nurse.",
 The patient is being discharged for continued hemodialysis and rehab., Discharge Summary, Discharge Summary - Hemodialysis ,"DISCHARGE DIAGNOSES:,1.  End-stage renal disease, on hemodialysis.,2.  History of T9 vertebral fracture.,3.  Diskitis.,4.  Thrombocytopenia.,5.  Congestive heart failure with ejection fraction of approximately 30%.,6.  Diabetes, type 2.,7.  Protein malnourishment.,8.  History of anemia.,HISTORY AND HOSPITAL COURSE: , The patient is a 77-year-old white male who presented to Hospital of Bossier on April 14, 2008.  The patient was found to have lumbar diskitis and was going to require extensive antibiotic therapy, which was the cause of need for continued hospitalization.  He also needed to continue with dialysis and he needed to improve his rehabilitation.  The patient tolerated his medication well and he was going through rehab fairly well without any significant troubles.  He did have some bouts of issues with constipation on and off throughout his hospitalization, but this seemed to come under control with more aggressive management.  The patient had remained afebrile.  He did also have a bout with some episodic confusion problems, which appeared to be more of a sundowner-type of a problem, but this too cleared with his stay here at Promise.  On the day of discharge, on May 9, 2008, the patient was in good spirits, was very clear and lucid.  He denied any complaints of pain.  He did have some trouble with sleep at night at times, but I think this was mainly tied into the fact that he sleeps a lot during the day.  The patient has increased his appetite some and has been eating some.  His vital signs remain stable.  His blood pressure on discharge was 126/63, heart rate is 80, respiratory rate of 20 and temperature was 98.3.  PPD was negative.  An SMS form was filled out in plan for his discharge and he was sent with medications that he had been receiving while here at Promise.,The patient and his family understood our plan and agreed with it.  He thanked us for the care that he received at Promise and thought that they did a fantastic job taking care of him.  He did not have any acute questions as to where he was going and what the next step of his care would be, but we did discuss this at length prior to date of discharge.,","discharge summary, end-stage renal disease, thrombocytopenia, anemia, hospitalization, hemodialysis and rehab, hemodialysis "
" Intractable migraine with aura.  The patient is discharged home.  Secondary diagnoses are Bipolar disorder, iron deficiency anemia, anxiety disorder, and history of tubal ligation.", Discharge Summary, Discharge Summary - Migraine ,"ADMITTING DIAGNOSIS: , Intractable migraine with aura.,DISCHARGE DIAGNOSIS:,  Migraine with aura.,SECONDARY DIAGNOSES:,1.  Bipolar disorder.,2.  Iron deficiency anemia.,3.  Anxiety disorder.,4.  History of tubal ligation.,PROCEDURES DURING THIS HOSPITALIZATION:,1.  CT of the head with and without contrast, which was negative.,2.  An MRA of the head and neck with and without contrast also negative.,3.  The CTA of the neck also read as negative.,4.  The patient also underwent a lumbar puncture in the Emergency Department, which was grossly unremarkable though an opening pressure was not obtained.,HOME MEDICATIONS:,1.  Vicodin 5/500 p.r.n.,2.  Celexa 40 mg daily.,3.  Phenergan 25 mg p.o. p.r.n.,4.  Abilify 10 mg p.o. daily.,5.  Klonopin 0.5 mg p.o. b.i.d.,6.  Tramadol 30 mg p.r.n.,7.  Ranitidine 150 mg p.o. b.i.d.,ALLERGIES:,  SULFA drugs.,HISTORY OF PRESENT ILLNESS: , The patient is a 25-year-old right-handed Caucasian female who presented to the emergency department with sudden onset of headache occurring at approximately 11 a.m. on the morning of the July 31, 2008.  She described the headache as worse in her life and it was also accompanied by blurry vision and scotoma.  The patient also perceived some swelling in her face.  Once in the Emergency Department, the patient underwent a very thorough evaluation and examination.  She was given the migraine cocktail.  Also was given morphine a total of 8 mg while in the Emergency Department.  For full details on the history of present illness, please see the previous history and physical.,BRIEF SUMMARY OF HOSPITAL COURSE:  ,The patient was admitted to the neurological service after her headache felt to be removed with the headache cocktail.  The patient was brought up to 4 or more early in the a.m. on the August 1, 2008 and was given the dihydroergotamine IV, which did allow some minimal resolution in her headache immediately.  At the time of examination this morning, the patient was feeling better and desired going home.  She states the headache had for the most part resolved though she continues to have some diffuse trigger point pain.,PHYSICAL EXAMINATION AT THE TIME OF DISCHARGE: , General physical exam was unremarkable.  HEENT:  Pupils were equal and respond to light and accommodation bilaterally.  Extraocular movements were intact.  Visual fields were intact to confrontation.  Funduscopic exam revealed no disc pallor or edema.  Retinal vasculature appeared normal.  Face is symmetric.  Facial sensation and strength are intact.  Auditory acuities were grossly normal.  Palate and uvula elevated symmetrically.  Sternocleidomastoid and trapezius muscles are full strength bilaterally.  Tongue protrudes in midline.  Mental status exam: revealed the patient alert and oriented x 4.  Speech was clear and language is normal.  Fund of knowledge, memory, and attention are grossly intact.  Neurologic exam:  Vasomotor system revealed full power throughout.  Normal muscle tone and bulk.  No pronator drift was appreciated.  Coordination was intact to finger-to-nose, heel-to-shin and rapid alternating movement.  No tremor or dysmetria.  Excellent sensory.  Sensation is intact in all modalities throughout. The patient does have notable trigger points diffusely including the occiput, trapezius bilaterally, lumbar, back, and sacrum.  Gait was assessed, the patient's routine and tandem gait were normal.  The patient is able to balance on heels and toes.  Romberg is negative.  Reflexes are 2+ and symmetric throughout.  Babinski reflexes are plantar.,DISPOSITION:,  The patient is discharged home.,INSTRUCTIONS FOR FOLLOWUP:  ,The patient is to followup with her primary care physician as needed.",
 Trauma/ATV accident resulting in left open humerus fracture., Discharge Summary, Discharge Summary - ATV Accident ,"ADMITTING DIAGNOSIS: , Trauma/ATV accident resulting in left open humerus fracture.,DISCHARGE DIAGNOSIS:,  Trauma/ATV accident resulting in left open humerus fracture.,SECONDARY DIAGNOSIS:,  None.,HISTORY OF PRESENT ILLNESS: , For complete details, please see dictated history and physical by Dr. X dated July 23, 2008.  Briefly, the patient is a 10-year-old male who presented to the Hospital Emergency Department following an ATV accident.  He was an unhelmeted passenger on ATV when the driver lost control and the ATV rolled over throwing the passenger and the driver approximately 5 to 10 meters.  The patient denies any loss of consciousness.  He was not amnestic to the event.  He was taken by family members to the Iredell County Hospital, where he was initially evaluated.  Due to the extent of his injuries, he was immediately transferred to Hospital Emergency Department for further evaluation.,HOSPITAL COURSE: , Upon arrival in the Hospital Emergency Department, he was noted to have an open left humerus fracture.  No other apparent injuries.  This was confirmed with radiographic imaging showing that the chest and pelvis x-rays were negative for any acute injury and that the cervical spine x-ray was negative for fracture malalignment.  The left upper extremity x-ray did demonstrate an open left distal humerus fracture.  The orthopedic surgery team was then consulted and upon their evaluation, the patient was taken emergently to the operating room for surgical repair of his left humerus fracture.  In the operating room, the patient was prepared for an irrigation and debridement of what was determined to be an open type 3 subcondylar left distal humerus fracture.  In the operating room, his upper extremity was evaluated for neurovascular status and great care was taken to preserve these structures.  Throughout the duration of the procedure, the patient had a palpable distal radial pulse.  The orthopedic team then completed an open reduction and internal fixation of the left supracondylar humerus fracture.  A wound VAC was then placed over the wound at the conclusion of the procedure.  The patient tolerated this procedure well and was returned to the Pediatric Intensive Care Unit for postsurgical followup and monitoring.  His diet was advanced and his pain was controlled with pain medication.  The day following his surgery, the patient was evaluated for a potential for closed head injury given the nature of his accident and the fact that he was not wearing a helmet during his accident.  A CT of the brain without contrast showed no acute intracranial abnormalities moreover his cervical spine was radiographically and clinically cleared and his C-collar was removed at that point.  Once his C spine had been cleared and the absence of a closed head injury was confirmed.  The patient was then transferred from the Intensive Care Unit to the General Floor bed.  His clinical status continued to improve and on July 26, 2008, he was taken back to the operating room for removal of the wound VAC and closure of his left upper extremity wound.  He again tolerated this procedure well on his return to the General Pediatrics Floor.  Throughout his stay, there was concern for compartment syndrome due to the nature and extent of his injuries.  However, frequent checks of his distal pulses indicated that he had strong peripheral pulses in the left upper extremity.  Moreover, the patient had no complaints of paresthesia.  There was no demonstration of pallor or pain on passive motion.  There was good capillary refill to the digits of the left hand.  By the date of the discharge, the patient was on a full pediatric select diet and was tolerating this well.  He had no abdominal tenderness and there were no abdominal injuries on exam or radiographic studies.  He was afebrile and his vital signs were stable and once cleared by Orthopedics, he was deemed appropriate for discharge.,PROCEDURES DURING THIS HOSPITALIZATION:,1.  Irrigation and debridement of open type 3 subcondylar left distal humerus fracture (July 23, 2008).,2.  Open reduction and internal fixation of the left supracondylar humerus fracture (July 23, 2008).,3.  Negative pressure wound dressing (July 23, 2008).,4.  Irrigation and debridement of left elbow fracture (July 26, 2008).,5.  CT of the brain without contrast (July 24, 2008).,DISPOSITION:  ,Home with parents.,INVASIVE LINES: , None.,DISCHARGE INSTRUCTIONS:  ,The patient was instructed that he can return home with his regular diet and he was asked not to do any strenuous activities, move furniture, lift heavy objects, or use his left upper extremity.  He was asked to followup with return appointment in one week to see Dr. Y in Orthopedics.  Additionally, he was told to call his pediatrician, if he develops any fevers, pain, loss of sensation, loss of pulse, or discoloration of his fingers, or paleness to his hand.","discharge summary, humerus fracture, trauma, irrigation and debridement, atv accident, upper extremity, humerus, fracture, orthopedic,"
 Patient suffered from morbid obesity for many years and made multiple attempts at nonsurgical weight loss without success. , Discharge Summary, Discharge Summary - Gastric Bypass ,"ADMISSION DIAGNOSIS:,  Morbid obesity.  BMI is 51.,DISCHARGE DIAGNOSIS: , Morbid obesity.  BMI is 51.,PROCEDURE: , Laparoscopic gastric bypass.,SERVICE: , Surgery.,CONSULT: , Anesthesia and pain.,HISTORY OF PRESENT ILLNESS: , Ms. A is a 27-year-old woman, who suffered from morbid obesity for many years.  She has made multiple attempts at nonsurgical weight loss without success.  She underwent a preoperative workup and clearance for gastric bypass and was found to be an appropriate candidate.  She underwent her procedure.,HOSPITAL COURSE: , Ms. A underwent her procedure.  She tolerated without difficulty.  She was admitted to the floor post procedure.  Her postoperative course has been unremarkable.  On postoperative day 1, she was hemodynamically stable, afebrile, normal labs, and she was started on a clear liquid diet, which she has tolerated without difficulty.  She has ambulated and had no complaints.  Today, on postoperative day 2, the patient continues to do well.  Pain controlled with p.o. pain medicine, ambulating without difficulty, tolerating a liquid diet.  At this point, it is felt that she is stable for discharge.  Her drain was discontinued.,DISCHARGE INSTRUCTIONS:,  Liquid diet x1 week, then advance to pureed and soft as tolerated.  No heavy lifting, greater than 10 pounds x4 weeks.  The patient is instructed to not engage in any strenuous activity, but maintain mobility.  No driving for 1 to 2 weeks.  She must be able to stop in an emergency and be off narcotic pain medicine.  She may shower.  She needs to keep her wounds clean and dry.  She needs to follow up in my office in 1 week for postoperative evaluation.  She is instructed to call for any problems of shortness of breath, chest pain, calf pain, temperature greater than 101.5, any redness, swelling, or foul smelling drainage from her wounds, intractable nausea, vomiting, and abdominal pain.  She is instructed just to resume her discharge medications.,DISCHARGE MEDICATIONS:,  She was given a scripts for Lortab Elixir, Flexeril, ursodiol, and Colace.","discharge summary, laparoscopic gastric bypass, gastric bypass, morbid obesity, liquid diet, bmi, discharge,"
 A patient with preoperative diagnosis of right pleural mass and postoperative diagnosis of mesothelioma., Discharge Summary, Discharge Summary - Mesothelioma ,"PREOPERATIVE DIAGNOSIS: , Right pleural mass.,POSTOPERATIVE DIAGNOSIS: , Mesothelioma.,PROCEDURES PERFORMED:,1.  Flexible bronchoscopy.,2.  Mediastinoscopy.,3.  Right thoracotomy.,4.  Parietal pleural biopsy.,CONSULTS:,Consults obtained during this hospitalization included:,1.  Radiation Oncology.,2.  Pulmonary Medicine.,3.  Medical Oncology.,4.  Cancer Center Team consult.,5.  Massage therapy consult.,HOSPITAL COURSE:,  The patient's hospital course was unremarkable.  Her pain was well controlled with an epidural that was placed by Anesthesia.  At the time of discharge, the patient was ambulatory.  She was discharged with home oxygen available.  She was discharged with albuterol nebulizer treatments, treatments were to be q.i.d.  She was discharged with a prescription for Vicodin for pain control.  She is to follow up with Dr. X in the office in one week with a chest x-ray.  She is instructed not to lift, push or pull anything greater than 10 pounds.  She is instructed not to drive until after she sees us in the office and is off her pain medications.","discharge summary, flexible bronchoscopy, mediastinoscopy, right thoracotomy, pleural biopsy, pleural mass, mesothelioma, oncology,"
 A 47-year-old female with a posttraumatic AV in the right femoral head., Discharge Summary, Discharge Summary - Hip Surgery ,"ADMITTING DIAGNOSIS:,  Posttraumatic AV in right femoral head.,DISCHARGE DIAGNOSIS:,  Posttraumatic AV in right femoral head.,SECONDARY DIAGNOSES PRIOR TO HOSPITALIZATION:,1.  Opioid use.,2.  Right hip surgery.,3.  Appendectomy.,4.  Gastroesophageal reflux disease.,5.  Hepatitis diagnosed by liver biopsy.,6.  Blood transfusion.,6.  Smoker.,7.  Trauma with multiple orthopedic procedures.,8.  Hip arthroscopy.,POSTOP COMORBIDITIES: , Postop acute blood loss anemia requiring transfusion and postop pain.,PROCEDURES DURING THIS HOSPITALIZATION:,  Right total hip arthroplasty and removal of hardware.,CONSULTS:,  Acute pain team consult.,DISPOSITION: , Home.,HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE:,  For details, please refer to clinic notes and OP notes.  In brief, the patient is a 47-year-old female with a posttraumatic AV in the right femoral head.  She came in consult with Dr. X who after reviewing the clinical and radiological findings recommended she undergo a right total hip arthroplasty and removal of old hardware.  After being explained the risks, benefits, alternative options, and possible outcomes of surgery, she was agreeable and consented to proceed and therefore on the day of her admission, she was sent to the operating room where she underwent a right total hip arthroplasty and removal of hardware without any complications.  She was then transferred to PACU for recovery and postop orthopedic floor for convalescence, physical therapy, and discharge planning.  DVT prophylaxis was initiated with Lovenox.  Postop pain was adequately managed with the aid of Acute Pain team.  Postop acute blood loss anemia was treated with blood transfusions to an adequate level of hemoglobin.  Physical therapy and occupational therapy were initiated and continued to work with her towards discharge clearance on the day of her discharge.,DISPOSITION:,  Home.  On the day of her discharge, she was afebrile, vital signs were stable.  She was in no acute distress.  Her right hip incision was clean, dry, and intact.  Extremity was warm and well perfused.  Compartments were soft.  Capillary refill less than two seconds.  Distal pulses were present.,PREDISCHARGE LABORATORY FINDINGS: , White count of 10.9, hemoglobin of 9.5, and BMP is pending.,DISCHARGE INSTRUCTIONS: , Continue diet as before.,ACTIVITY: , Weightbearing as tolerated in the right lower extremity as instructed.  Do not lift, drive, move furniture, do strenuous activity for six weeks.  Call Dr. X if there is increased temperature greater than 101.5, increased redness, swelling, drainage, increased pain that is not relieved by current pain regimen as per postop orthopedic discharge instruction sheet.,FOLLOW-UP APPOINTMENT:  Follow up with Dr. X in two weeks.",
 Patient with fever of unknown origin., Discharge Summary, Discharge Summary - 7 ,"REASON FOR ADMISSION: , Fever of unknown origin.,HISTORY OF PRESENT ILLNESS: , The patient is a 39-year-old woman with polymyositis/dermatomyositis on methotrexate once a week.  The patient has also been on high-dose prednisone for an urticarial rash.  The patient was admitted because of persistent high fevers without a clear-cut source of infection.  She had been having temperatures of up to 103 for 8-10 days.  She had been seen at Alta View Emergency Department a week prior to admission.  A workup there including chest x-ray, blood cultures, and a transthoracic echocardiogram had all remained nondiagnostic, and were normal.  Her chest x-ray on that occasion was normal.  After the patient was seen in the office on August 10, she persisted with high fevers and was admitted on August 11 to Cottonwood Hospital.  Studies done at Cottonwood:  CT scan of the chest, abdomen, and pelvis.  Results:  CT chest showed mild bibasilar pleural-based interstitial changes.  These were localized to mid and lower lung zones.  The process was not diffuse.  There was no ground glass change.  CT abdomen and pelvis was normal.  Infectious disease consultation was obtained.  Dr. XYZ saw the patient.  He ordered serologies for CMV including a CMV blood PCR.  Next serologies for EBV, Legionella, Chlamydia, Mycoplasma, Coccidioides, and cryptococcal antigen, and a PPD.  The CMV serology came back positive for IgM.  The IgG was negative.  The CMV blood PCR was positive, as well.  Other serologies and her PPD stayed negative.  Blood cultures stayed negative.,In view of the positive CMV, PCR, and the changes in her CAT scan, the patient was taken for a bronchoscopy.  BAL and transbronchial biopsies were performed.  The transbronchial biopsies did not show any evidence of pneumocystis, fungal infection, AFB.  There was some nonspecific interstitial fibrosis, which was minimal.  I spoke with the pathologist, Dr. XYZ and immunopathology was done to look for CMV.  The patient had 3 nucleoli on the biopsy specimens that stained positive and were consistent with CMV infection.  The patient was started on ganciclovir once her CMV serologies had come back positive.  No other antibiotic therapy was prescribed.  Next, the patient's methotrexate was held.,A chest x-ray prior to discharge showed some bibasilar disease, showing interstitial infiltrates.  The patient was given ibuprofen and acetaminophen during her hospitalization, and her fever resolved with these measures.,On the BAL fluid cell count, the patient only had 5 WBCs and 5 RBCs on the differential.  It showed 43% neutrophils, 45% lymphocytes.,Discussions were held with Dr. XYZ, Dr. XYZ, her rheumatologist, and with pathology.,DISCHARGE DIAGNOSES:,1.  Disseminated CMV infection with possible CMV pneumonitis.,2.  Polymyositis on immunosuppressive therapy (methotrexate and prednisone).,DISCHARGE MEDICATIONS:,1.  The patient is going to go on ganciclovir 275 mg IV q.12 h. for approximately 3 weeks.,2.  Advair 100/50, 1 puff b.i.d.,3.  Ibuprofen p.r.n. and Tylenol p.r.n. for fever, and will continue her folic acid.,4.  The patient will not restart for methotrexate for now.,She is supposed to follow up with me on August 22, 2007 at 1:45 p.m.  She is also supposed to see Dr. XYZ in 2 weeks, and Dr. XYZ in 2-3 weeks.  She also has an appointment to see an ophthalmologist in about 10 days' time.  This was a prolonged discharge, more than 30 minutes were spent on discharging this patient.","discharge summary, fever of unknown origin, blood cultures, transbronchial biopsies, infection, cmv, admission, illness, interstitial, fever, serologies, chest, nondiagnostic, methotrexate"
 Patient with complaint of symptomatic cholelithiasis., Discharge Summary, Discharge Summary - Cholelithiasis ,"ADMISSION DIAGNOSIS: , Symptomatic cholelithiasis.,DISCHARGE DIAGNOSIS:,  Symptomatic cholelithiasis.,SERVICE: , Surgery.,CONSULTS:,  None.,HISTORY OF PRESENT ILLNESS: , Ms. ABC is a 27-year-old woman who apparently presented with complaint of symptomatic cholelithiasis.  She was afebrile.  She was taken by Dr. X to the operating room.,HOSPITAL COURSE: , The patient underwent a procedure.  She tolerated without difficulty.  She had her pain controlled with p.o. pain medicine.  She was afebrile.  She is tolerating liquid diet.  It was felt that the patient is stable for discharge.  She did complain of bladder spasms when she urinated and she did say that she has a history of chronic UTIs.  We will check a UA and urine culture prior to discharge.  I will give her prescription for ciprofloxacin that she can take for 3 days presumptively and I have discharged her home with omeprazole and Colace to take over-the-counter for constipation and we will send her home with Percocet for pain.  Her labs were within normal limits.  She did have an elevated white blood cell count, but I believe this is just leukemoid reaction, but she is afebrile, and if she does have UTI, may also be related.  Her labs in terms of her bilirubin were within normal limits.  Her LFTs were slightly elevated, I do believe this is related to the cautery used on the liver bed.  They were 51 and 83 for the AST and ALT respectively.  I feel that she looks good for discharge.,DISCHARGE INSTRUCTIONS: , Clear liquid diet x48 hours and she can return to her Medifast, she may shower.  She needs to keep her wound clean and dry.  She is not to engage in any heavy lifting greater than 10 pounds x2 weeks.  No driving for 1 to 2 weeks.  She must be able to stop in an emergency and be off narcotic meds, no strenuous activity, but she needs to maintain mobility.  She can resume her medications per med rec sheets.,DISCHARGE MEDICATIONS: , As previously mentioned.,FOLLOWUP:,  We will follow up on both urinalysis and cultures.  She is instructed to follow up with Dr. X in 2 weeks.  She needs to call for any shortness of breath, temperature greater than 101.5, chest pain, intractable nausea, vomiting, and abdominal pain, any redness, swelling or foul smelling drainage from her wounds.","discharge summary, medifast, liquid diet, symptomatic cholelithiasis, symptomatic, cholelithiasis, discharge,"
 A white female with a history of fevers., Discharge Summary, Discharge Summary - 8 ,"DISCHARGE DIAGNOSES:,1.  Gram-negative rod bacteremia, final identification and susceptibilities still pending.,2.  History of congenital genitourinary abnormalities with multiple surgeries before the 5th grade.,3.  History of urinary tract infections of pyelonephritis.,OPERATIONS PERFORMED: , Chest x-ray July 24, 2007, that was normal.  Transesophageal echocardiogram July 27, 2007, that was normal.  No evidence of vegetations.  CT scan of the abdomen and pelvis July 27, 2007, that revealed multiple small cysts in the liver, the largest measuring 9 mm.  There were 2-3 additional tiny cysts in the right lobe.  The remainder of the CT scan was normal.,HISTORY OF PRESENT ILLNESS: , Briefly, the patient is a 26-year-old white female with a history of fevers.  For further details of the admission, please see the previously dictated history and physical.  ,HOSPITAL COURSE:,  Gram-negative rod bacteremia.  The patient was admitted to the hospital with suspicion of endocarditis given the fact that she had fever, septicemia, and Osler nodes on her fingers.  The patient had a transthoracic echocardiogram as an outpatient, which was equivocal, but a transesophageal echocardiogram here in the hospital was normal with no evidence of vegetations.  The microbiology laboratory stated that the Gram-negative rod appeared to be anaerobic, thus raising the possibility of organisms like bacteroides.  The patient does have a history of congenital genitourinary abnormalities which were surgically corrected before the fifth grade.  We did a CT scan of the abdomen and pelvis, which only showed some benign appearing cysts in the liver.  There was nothing remarkable as far as her kidneys, ureters, or bladder were concerned.  I spoke with Dr. XYZ of infectious diseases, and Dr. XYZ asked me to talk to the patient about any contact with animals, given the fact that we have had a recent outbreak of tularemia here in Utah.  Much to my surprise, the patient told me that she had multiple pet rats at home, which she was constantly in contact with.  I ordered tularemia and leptospirosis serologies on the advice of Dr. XYZ, and as of the day after discharge, the results of the microbiology still are not back yet.  The patient, however, appeared to be responding well to levofloxacin.  I gave her a 2-week course of 750 mg a day of levofloxacin, and I have instructed her to follow up with Dr. XYZ in the meantime.  Hopefully by then we will have a final identification and susceptibility on the organism and the tularemia and leptospirosis serologies will return.  A thought of ours was to add doxycycline, but again the patient clinically appeared to be responding to the levofloxacin.  In addition, I told the patient that it would be my recommendation to get rid of the rats.  I told her that if indeed the rats were carriers of infection and she received a zoonotic infection from exposure to the rats, that she could be in ongoing continuing danger and her children could also potentially be exposed to a potentially lethal infection.  I told her very clearly that she should, indeed, get rid of the animals.  The patient seemed reluctant to do so at first, but I believe with some coercion from her family, that she finally came to the realization that this was a recommendation worth following.,  ,DISPOSITION,DISCHARGE INSTRUCTIONS: , Activity is as tolerated.  Diet is as tolerated.,MEDICATIONS: , Levaquin 750 mg daily x14 days.,Followup is with Dr. XYZ of infectious diseases.  I gave the patient the phone number to call on Monday for an appointment.  Additional followup is also with Dr. XYZ, her primary care physician.  Please note that 40 minutes was spent in the discharge.","discharge summary, abdomen and pelvis, gram negative rod, congenital genitourinary, genitourinary abnormalities, transesophageal echocardiogram, infectious diseases, leptospirosis serologies, gram negative, ct scan, identification, infections, levofloxacin, additional, discharge"
  a pleasant 62-year-old male with cerebral palsy, Discharge Summary, Discharge Summary - Cerebral Palsy ,"DISCHARGE DIAGNOSES:,1.  Bilateral lower extremity cellulitis secondary to bilateral tinea pedis.,2.  Prostatic hypertrophy with bladder outlet obstruction.,3.  Cerebral palsy.,DISCHARGE INSTRUCTIONS: , The patient would be discharged on his usual Valium 10-20 mg at bedtime for spasticity, Flomax 0.4 mg daily, cefazolin 500 mg q.i.d., and Lotrimin cream between toes b.i.d. for an additional two weeks.  He will be followed in the office.,HISTORY OF PRESENT ILLNESS:,  This is a pleasant 62-year-old male with cerebral palsy.  The patient was recently admitted to Hospital with lower extremity cellulitis.  This resolved, however, recurred in both legs.  Examination at the time of this admission demonstrated peeling of the skin and excoriation between all of his toes on both feet consistent with tinea pedis.,PAST MEDICAL/FAMILY/SOCIAL HISTORY:,  As per the admission record.,REVIEW OF SYSTEMS: , As per the admission record.,PHYSICAL EXAMINATION:  ,As per the admission record.,LABORATORY STUDIES: , At the time of admission, his white blood cell count was 8200 with a normal differential, hemoglobin 13.6, hematocrit 40.6 with normal indices, and platelet count was 250,000.  Comprehensive metabolic profile was unremarkable, except for a nonfasting blood sugar of 137, lactic acid was 0.8.  Urine demonstrated 4-9 red blood cells per high-powered field with 2+ bacteria.  Blood culture and wound cultures were unremarkable.  Chest x-ray was unremarkable.,HOSPITAL COURSE: , The patient was admitted to the General Medical floor and treated with intravenous ceftriaxone and topical Lotrimin.  On this regimen, his lower extremity edema and erythema resolved quite rapidly.,Because of urinary frequency, a bladder scan was done suggesting about 600 cc of residual urine.  A Foley catheter was inserted and was productive of approximately 500 cc of urine.  The patient was prescribed Flomax 0.4 mg daily.  24 hours later, the Foley catheter was removed and a bladder scan demonstrated 60 cc of residual urine after approximately eight hours.,At the time of this dictation, the patient was ambulating minimally, however, not sufficiently to resume independent living.","discharge summary, bilateral lower extremity cellulitis, cerebral palsy, ambulating, bilateral tinea pedis, lower extremity cellulitis, cerebral, palsy, discharge,"
" A woman presented to the ER with complaints of nausea, vomiting, and epigastric discomfort, ongoing for about 4 to 5 months. ", Discharge Summary, Discharge Summary - 9 ,"DISCHARGE DIAGNOSIS:,1.  Epigastric pain.  Questionable gastritis, questionable underlying myocardial ischemia.,2.  Congestive heart failure exacerbation.,3.  Small pericardial effusion with no tamponade.,4.  Hypothyroidism.,5.  Questionable subacute infarct versus neoplasm in the pons.,6.  History of coronary artery disease, status post angioplasty and stent.,7.  Hypokalemia.,CLINICAL RESUME: , This 83 year-old woman who presented to the ER with complaints of nausea, vomiting, and epigastric discomfort, ongoing for about 4 to 5 months.  She has had extensive work up and had her gallbladder removed on April 22, 2007, and had an endoscopy, which had demonstrative gastric ulcer disease apparently about a year ago.  She has had abdominal CAT scan and gastric emptying studies which was normal.,A CT scan of the abdomen done on her May 9, 2007, which showed bilateral peripelvic renal cysts and a redundant sigmoid colon.  Otherwise unremarkable.  The patient follows with Dr. XYZ as an outpatient.  The patient had some worsening of her symptoms over the last few days and then came to the ER.  She was admitted.  Please refer to Dr. XYZ initial H&P for complete details.,HOSPITAL COURSE:,1.  Epigastric pain, nausea, and vomiting.  The patient was restituted with antiemetics and her symptoms improved.  It was not clear whether her nausea and abdominal pain were due to gastritis, peptic ulcer disease/gastric ischemia, or cardiac origin.  A brain MRI was also done which basically showed a tiny focus of abnormal enhancement in the pons, which could be subacute like infarct.  However, brain neoplasm could not be excluded.  Other workup including a CT angio did not show any evidence of acute pulmonary emboli.  It showed some moderate cardiomegaly with bilateral pleural effusions, and a small pericardial effusion.  The patient underwent Cardiolite stress test but finished only the resting studies, which was inconclusive.  She refused to complete the stress test.  She was seen by Dr. XYZ in consultation who recommended that the patient should have a small bowel follow through and eventually angiogram as an outpatient.,2.  Congestive heart failure exacerbation.  The patient was treated with ACE inhibitors, diuretics, Aldactone, and Lasix, and improved.  An echocardiogram done showed an ejection fraction of about 30% to 35%, mild water decrease in LV systolic function, with multiple segmental wall motion abnormalities, a small anterior pericardial effusion, but no electrocardiographic signs of cardiac tamponade.  There was some pseudo normal pattern of filling, mild MR and global hypokinesis of the LV.,3.  Small pericardial effusion.  The patient did not have any clinical or echocardiographic evidence of tamponade.,4.  Hypothyroidism.  TSH was quite elevated at 19.,5.  Questionable subacute infarct versus neoplasm in the pons on an MRI of the head.,6.  History of coronary artery disease/angioplasty and stents.,7.  Hyperkalemia.,8.  Patient was doing well.  She was back to her baseline and was refusing further workup and the patient was stable and it was felt she could be safely discharged home to have further testing done as an outpatient.,MEDICATIONS AND ADVICE ON DISCHARGE:,1.  She is to continue taking Coreg 12.5 mg p.o. b.i.d.,2.  Cozaar 50 mg p.o. daily.,3.  Aldactone 25 mg p.o. daily.,4.  Synthroid 0.075 mg p.o. daily.,5.  Carafate 1 gram p.o.  4 times a day.,6.  Claritin 10 mg p.o. daily.,7.  Lasix 20 mg p.o. daily.,8.  K-Dur 20 mEq p.o. daily.,9.  Prilosec 40 mg p.o. daily.,10.  Zofran 4 mg p.o. q.4-6 hourly p.r.n.,She is to follow up with her primary care physician, Dr. XYZ in 2 to 3 days' time.  She is to follow up with Dr. XYZ her cardiologist in 1 to 2 days' time.  She is to follow up with Dr. XYZ from GI as scheduled.  The patient was advised that she will need a small bowel follow through with angiogram which can be arranged by her gastroenterologist as an outpatient.  She was also advised that she would need a repeat MRI of her head in 2 to 3 months' time.  She will also need repeat echocardiogram done in one month for a pericardial effusion.  This can be arranged by her primary care physician.  Repeat TSH to be done in 6 weeks' time.,Over 35 minutes were spent in the patient discharged.",
" A white male veteran with multiple comorbidities, who has a history of bladder cancer diagnosed approximately two years ago by the VA Hospital. ", Discharge Summary, Discharge Summary - 6 ,"DISCHARGE DATE:  MM/DD/YYYY,HISTORY OF PRESENT ILLNESS:  Mr. ABC is a 60-year-old white male veteran with multiple comorbidities, who has a history of bladder cancer diagnosed approximately two years ago by the VA Hospital.  He underwent a resection there.  He was to be admitted to the Day Hospital for cystectomy.  He was seen in Urology Clinic and Radiology Clinic on MM/DD/YYYY.,HOSPITAL COURSE:  Mr. ABC presented to the Day Hospital in anticipation for Urology surgery.  On evaluation, EKG, echocardiogram was abnormal, a Cardiology consult was obtained.  A cardiac adenosine stress MRI was then proceeded, same was positive for inducible ischemia, mild-to-moderate inferolateral subendocardial infarction with peri-infarct ischemia.  In addition, inducible ischemia seen in the inferior lateral septum.  Mr. ABC underwent a left heart catheterization, which revealed two vessel coronary artery disease.  The RCA, proximal was 95% stenosed and the distal 80% stenosed.  The mid LAD was 85% stenosed and the distal LAD was 85% stenosed.  There was four Multi-Link Vision bare metal stents placed to decrease all four lesions to 0%.  Following intervention, Mr. ABC was admitted to 7 Ardmore Tower under Cardiology Service under the direction of Dr. XYZ.  Mr. ABC had a noncomplicated post-intervention hospital course.  He was stable for discharge home on MM/DD/YYYY with instructions to take Plavix daily for one month and Urology is aware of the same.,DISCHARGE EXAM:,VITAL SIGNS:  Temperature 97.4, heart rate 68, respirations 18, blood pressure 133/70.,HEART:  Regular rate and rhythm.,LUNGS:  Clear to auscultation.,ABDOMEN:  Obese, soft, nontender.  Lower abdomen tender when touched due to bladder cancer.,RIGHT GROIN:  Dry and intact, no bruit, no ecchymosis, no hematoma.  Distal pulses are intact.,DISCHARGE LABS:  CBC:  White count 5.4, hemoglobin 10.3, hematocrit 30, platelet count 132, hemoglobin A1c 9.1.  BMP:  Sodium 142, potassium 4.4, BUN 13, creatinine 1.1, glucose 211.  Lipid profile:  Cholesterol 157, triglycerides 146, HDL 22, LDL 106.,PROCEDURES:,1.  On MM/DD/YYYY, cardiac MRI adenosine stress.,2.  On MM/DD/YYYY, left heart catheterization, coronary angiogram, left ventriculogram, coronary angioplasty with four Multi-Link Vision bare metal stents, two placed to the LAD in two placed to the RCA.,DISCHARGE INSTRUCTIONS:  Mr. ABC is discharged home.  He should follow a low-fat, low-salt, low-cholesterol, and heart healthy diabetic diet.  He should follow post-coronary artery intervention restrictions.  He should not lift greater than 10 pounds for seven days.  He should not drive for two days.  He should not immerse in water for two weeks.  Groin site care reviewed with patient prior to being discharged home.  He should check groin for bleeding, edema, and signs of infection.  Mr. ABC is to see his primary care physician within one to two weeks, return to Dr. XYZ's clinic in four to six weeks, appointment card to be mailed him.  He is to follow up with Urology in their clinic on MM/DD/YYYY at 10 o'clock and then to scheduled CT scan at that time.,DISCHARGE DIAGNOSES:,1.  Coronary artery disease status post percutaneous coronary artery intervention to the right coronary artery and to the LAD.,2.  Bladder cancer.,3.  Diabetes.,4.  Dyslipidemia.,5.  Hypertension.,6.  Carotid artery stenosis, status post right carotid endarterectomy in 2004.,7.  Multiple resections of the bladder tumor.,8.  Distant history of appendectomy.,9.  Distant history of ankle surgery.","discharge summary, coronary artery disease, heart catheterization, artery disease, bare metal, metal stents, artery intervention, bladder cancer, coronary artery, veteran, surgery, cardiac, inducible, catheterization, ischemia, cancer, urology, stenosed, bladder, heart, artery, coronary, "
" The patient is a 53-year-old woman with history of hypertension, diabetes, and depression.  Serotonin syndrome secondary to high doses of Prozac and atypical chest pain with myocardial infarction ruled out.", Discharge Summary, Discharge Summary - 18 ,"ADMISSION DIAGNOSES:,1.  Atypical chest pain.,2.  Nausea.,3.  Vomiting.,4.  Diabetes.,5.  Hypokalemia.,6.  Diarrhea.,7.  Panic and depression.,8.  Hypertension.,DISCHARGE DIAGNOSES:,1.  Serotonin syndrome secondary to high doses of Prozac.,2.  Atypical chest pain with myocardial infarction ruled out.,3.  Diabetes mellitus.,4.  Hypertension.,5.  Diarrhea resolved.,ADMISSION SUMMARY: , The patient is a 53-year-old woman with history of hypertension, diabetes, and depression.  Unfortunately her husband left her 10 days prior to admission and she developed severe anxiety and depression.  She was having chest pains along with significant vomiting and diarrhea.  Of note, she had a nuclear stress test performed in February of this year, which was normal.  She was readmitted to the hospital to rule out myocardial infarction and for further evaluation.,ADMISSION PHYSICAL: , Significant for her being afebrile.  Apparently there was one temperature registered mildly high at 100.  Her blood pressure was 140/82, heart rate 83, oxygen saturation was 100%.  She was tearful.  HEART:  Heart sounds were regular.  LUNGS:  Clear.  ABDOMEN:  Soft.  Apparently there were some level of restlessness and acathexia.  She was also pacing.,ADMISSION LABS:  ,Showed CBC with a white count of 16.9, hematocrit of 46.9, platelets 318,000.  She had 80% neutrophils, no bands.  UA on 05/02 came out negative.  Chemistry panel shows sodium 138, potassium 3.5, creatinine 0.6, calcium 8.3, lactate 0.9, ALT was 39, AST 38, total bilirubin 0.6.  Her initial CK came out at 922.  CK-MB was low.  Troponin was 0.04.  She had a normal amylase and lipase.  Previous TSH few days prior was normal.  Chest x-ray was negative.,HOSPITAL COURSE:,1.  Serotonin syndrome.  After reevaluation of the patient including evaluation of the lab abnormalities it was felt that she likely had serotonin syndrome with obvious restlessness, increased bowel activity, agitation, and elevated white count and CPK.  She did not have fever, tremor or hyperreflexia.  Her CPK improved with IV fluids.  She dramatically improved with this discontinuation of her Prozac.  Her white count came back down towards normal.  At time of discharge, she was really feeling back to normal.,2.  Depression and anxiety with history of panic attacks exacerbated by her husband leaving her 2 weeks ago.  We discussed this.  Also, discussed the situation with a psychiatrist who is available on Friday and I discussed the situation with the patient.  In regards to her medications, we are discontinuing the Prozac and she is being reevaluated by Dr. X on Monday or Tuesday.  Cymbalta has been recommended as a good alternative medication for her.  The patient does have a counselor.  It is going to be difficult for her to go home alone.  I discussed the resources with her.  She has a daughter who will be coming to town in a couple of weeks, but she does have a friend that she can call and stay the next few days with.,3.  Hypertension.  She will continue on her usual medications.,4.  Diabetes mellitus.  She will continue on her usual medications.,5.  Diarrhea resolved.  Her electrolyte abnormalities resolved.  She had received fluid rehydration.,DISPOSITION:,  She is being discharged to home.  She will stay with a friend for a couple of days.  She will be following up with Dr. X on Monday or Tuesday.  Apparently Dr. Y has already discussed the situation and the plan with her.  She will continue on her usual medications except for discontinuing the Prozac.,DISCHARGE MEDICATIONS: , Include,1.  Omeprazole 20 mg daily.,2.  Temazepam 15 mg at night.,3.  Ativan 1 mg one-half to one three times a day as needed.,4.  Cozaar 50 daily.,5.  Prandin 1 mg before meals.,6.  Aspirin 81 mg.,7.  Multivitamin daily.,8.  Lantus 60 units at bedtime.,9.  Percocet 10/325 one to two at night for chronic pain.  She is running out of that, so we are calling a prescription for #10 of those.",
 Patient with increased shortness of breath of one day duration., Discharge Summary, Discharge Summary - 3 ,"DISCHARGE DIAGNOSES:,1. Chronic obstructive pulmonary disease with acute hypercapnic respiratory failure.,2. Chronic atrial fibrillation with prior ablation done on Coumadin treatment.,3. Mitral stenosis.,4. Remote history of lung cancer with prior resection of the left upper lobe.,5. Anxiety and depression.,HISTORY OF PRESENT ILLNESS:, Details are present in the dictated report.,BRIEF HOSPITAL COURSE:, The patient is a 71-year-old lady who came in with increased shortness of breath of one day duration. She denied history of chest pain or fevers or cough with purulent sputum at that time. She was empirically treated with a course of antibiotics of Avelox for ten days. She also received steroids, prednisolone 60 mg, and breathing treatments with albuterol, Ipratropium and her bronchodilator therapy was also optimized with theophylline. She continued to receive Coumadin for her chronic atrial fibrillation. Her heart rate was controlled and was maintained in the 60s-70s. On the third day of admission she developed worsening respiratory failure with fatigue, and hence was required to be intubated and ventilated. She was put on mechanical ventilation from 1/29 to 2/6/06. She was extubated on 2/6 and put on BI-PAP. The pressures were gradually increased from 10 and 5 to 15 of BI-PAP and 5 of E-PAP with FIO2 of 35% at the time of transfer to Kindred. Her bronchospasm also responded to the aggressive bronchodilation and steroid therapy.,DISCHARGE MEDICATIONS:, Prednisolone 60 mg orally once daily, albuterol 2.5 mg nebulized every 4 hours, Atrovent Respules to be nebulized every 6 hours, Pulmicort 500 micrograms nebulized twice every 8 hours, Coumadin 5 mg orally once daily, magnesium oxide 200 mg orally once daily.,TRANSFER INSTRUCTIONS:, The patient is to be strictly kept on bi-level PAP of 15 I-PAP/E-PAP of 5 cm and FIO2 of 35% for most of the times during the day. She may be put on nasal cannula 2 to 3 liters per minute with an O2 saturation of 90-92% at meal times only, and that is to be limited to 1-2 hours every meal. On admission her potassium had risen slightly to 5.5, and hence her ACE inhibitor had to be discontinued. We may restart it again at a later date once her blood pressure control is better if required.","discharge summary, chronic obstructive pulmonary disease, hypercapnic respiratory failure, atrial fibrillation, chronic atrial fibrillation, increased shortness of breath, shortness of breath, increased shortness, coumadin, atrial,"
 Patient with complaints of shortness of breath and was found to have acute COPD exacerbation., Discharge Summary, Discharge Summary - 2 ,"ADMISSION DIAGNOSIS (ES):,1. Chronic obstructive pulmonary disease.,2. Pneumonia.,3. Congestive heart failure.,4. Diabetes mellitus.,5. Neuropathy.,6. Anxiety.,7. Hypothyroidism.,8. Depression.,9. Hypertension.,DISCHARGE DIAGNOSIS (ES):,1. Severe chronic obstructive pulmonary disease.,2. Diabetes mellitus.,3. Hypothyroidism.,4. Altered mental status, less somnolent, likely secondary to medications, resolved.,5. Lower gastrointestinal bleed.,6. Status post episode of atrial fibrillation.,7. Status post diverticular bleed.,DISCHARGE MEDICATIONS:,1. Albuterol inhaler q.i.d.,2. Xanax 1 mg t.i.d.,3. Cardizem CD 120 mg daily.,4. Colace 100 mg b.i.d.,5. Iron sulfate 325 mg b.i.d.,6. NPH 10 units subcutaneous b.i.d.,7. Atrovent inhaler q.i.d.,8. Statin oral suspension p.o. q.i.d., swish and spit.,9. Paxil 10 mg daily.,10. Prednisone 20 mg daily.,11. Darvocet Darvocet-N 100, one q.4h PRN pain.,12. Metamucil one pack b.i.d.,13. Synthroid 50 mcg daily.,14. Nexium 40 mg daily.,HOSPITAL COURSE:, The patient was a 66-year-old who presented with complaints of shortness of breath and was found to have acute COPD exacerbation. She had previously been at outlying hospital and had left AMA after 10 sets of BiPAP use. Here she was able to be kept off BiPAP later and slowly improved her exacerbation of COPD with the assistance of pulmonary. She was thought to have bronchitis as well and was treated with antibiotics. During hospitalization she developed acute lower GI bleed and was transferred to intensive care unit and transfused packed red blood cells. GI was consulted, performed endoscopy, revealing diverticular disease of the sigmoid colon, with this being the suspected cause of hemorrhage. Plavix is being held for at least 10 days. Lovenox held as well. No further signs of bleeding. The patient's respiratory status did slowly improve to baseline. She is discharged and given the above noted medications. Followup with Dr. Pesce, of diagnostic pulmonary, in the outpatient setting. She will also followup with Dr. Pesce, in the outpatient setting.",
" The patient is a 93-year-old Caucasian female with a past medical history of chronic right hip pain, osteoporosis, hypertension, depression, and chronic atrial fibrillation admitted for evaluation and management of severe nausea and vomiting and urinary tract infection.", Discharge Summary, Discharge Summary - 19 ,"PRIMARY DISCHARGE DIAGNOSES:,1.  Urinary tract infection.,2.  Gastroenteritis with nausea and vomiting.,3.  Upper gastrointestinal bleed likely secondary to gastritis.,4.  Right hip osteoarthritic pain.,SECONDARY DISCHARGE DIAGNOSES:,1.  Hypertension.,2.  Gastroesophageal reflux disease.,3.  Chronic atrial fibrillation.,4.  Osteoporosis.,5.  Valvular heart disease.,HOSPITAL COURSE SUMMARY: , The patient is 93-year-old Caucasian female with a past medical history of hypertension, chronic atrial fibrillation, gastroesophageal reflux disease, osteoporosis and chronic right hip pain after total hip arthroplasty was admitted to our hospital for complaints of nausea and vomiting and urinary tract infection.  Over the course of her hospitalization, the patient was started on antibiotic regimen and proton pump inhibitors for an episode of coffee-ground emesis.  The patient was managed conservatively and was also provided with physical therapy for chronic right hip pain.,At the time of discharge, the patient continues to complain of right hip pain impairing ability to walk.  The patient denies any chest pain, nausea, vomiting, fever, chills, shortness of breath, abdominal pain or any urine or bowel problems.,PAST MEDICAL HISTORY: , Can be referred to the H&P dictated in the chart.,PAST SURGICAL HISTORY: , Can be referred to the H&P dictated in the chart.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  At the time of discharge temperature 36.6 degree Celsius, pulse rate of 77 per minute, respiratory rate 20 per minute, blood pressure 115/63, and oxygen saturation of 94% on room air.,GENERAL:  The patient is a thin built Caucasian female with no pallor, cyanosis or icterus.  She is alert and oriented x3.,HEENT:  No carotid bruits, JVD, lymphadenopathy or thyromegaly.  Pupils are equally reactive to light and accommodation.,BACK AND EXTREMITY:  Bilateral pitting edema and peripheral pulses are palpable.  The patient has right hip brace/immobilizer.,HEART:  Irregularly irregular heart rhythm, grade 2-3/6 systolic ejection murmur best heard over the aortic area and normal S1 and S2.,CHEST:  Auscultation revealed bibasilar crackles.,ABDOMEN:  Soft, nontender, no organomegaly and bowel sounds are present.,CNS:  Nonfocal.,LABORATORY STUDIES: , WBC 6.5, hemoglobin 12.5, hematocrit 38.9, platelet count 177,000, INR 1.2, sodium 141, potassium 3.6 and serum creatinine of 0.8.  Liver function tests were normal.  The patient's troponin was elevated at 0.05 at the time or presentation, but it trended down to 0.04 on the third set.  Urinalysis revealed trace protein, trace blood, and 10-20 WBCs.  Blood culture showed no growth till date.  Urine culture grew 50-100,000 colonies of Enterococcus susceptible to ampicillin and nitrofurantoin.,Chest x-ray showed enlarged heart with large intrathoracic hiatal hernia.  Lung parenchyma was otherwise clear.,Right hip x-ray showed that the prosthesis was in satisfactory position.  There was small gap between the cancellous bone and the long stem femoral component of the prosthesis, which is within normal limits.,DISCHARGE MEDICATIONS:,1.  Aspirin 81 mg orally once daily.,2.  Calcium with vitamin D two tablets orally once daily.,3.  Nexium 40 mg orally once daily.,4.  Multivitamins with minerals one capsule once daily.,5.  Zoloft 25 mg orally once daily.,6.  Norco 325/10 mg every 6-8 hours as needed for pain.,7.  Systane ophthalmic solution two drops in both eyes every two hours as needed.,8.  Herbal __________ by mouth everyday.,9.  Macrodantin 100 mg orally every six hours for seven days.,ALLERGIES:,  Penicillin.,PROGNOSIS: , Improved.,ASSESSMENT AND DISCHARGE PLAN:  ,The patient is a 93-year-old Caucasian female with a past medical history of chronic right hip pain, osteoporosis, hypertension, depression, and chronic atrial fibrillation admitted for evaluation and management of severe nausea and vomiting and urinary tract infection.,PROBLEM #1: ",
" The patient underwent a scalp skin biopsy with pathology specimen obtained.   At the time of discharge, the patient had improved.", Discharge Summary, Discharge Summary - 17 ,"FINAL DIAGNOSIS/REASON FOR ADMISSION:,1.  Acute right lobar pneumonia.,2.  Hypoxemia and hypotension secondary to acute right lobar pneumonia.,3.  Electrolyte abnormality with hyponatremia and hypokalemia - corrected.,4.  Elevated liver function tests, etiology undetermined.,5.  The patient has a history of moderate-to-severe dementia, Alzheimer's type.,6.  Anemia secondary to current illness and possible iron deficiency.,7.  Darkened mole on the scalp, status post skin biopsy, pending pathology report.,OPERATION AND PROCEDURE: , The patient underwent a scalp skin biopsy with pathology specimen obtained on 6/11/2009.  Dr. X performed the procedure, thoracentesis on 6/12/2009 both diagnostic and therapeutic.  Dr. Y's results pending.,DISPOSITION: , The patient discharged to long-term acute facility under the care of Dr. Z.,CONDITION ON DISCHARGE: , Clinically improved, however, requiring acute care.,CURRENT MEDICATIONS:  ,Include those on admission combined with IV Flagyl 500 mg every 8 hours and Levaquin 500 mg daily.,HOSPITAL SUMMARY: , This is one of several admissions for this 68-year-old female who over the initial 48 hours preceding admission had a complaint of low-grade fever, confusion, dizziness, and a nonproductive cough.  Her symptoms progressed and she presented to the emergency room at Brighton Gardens where a chest x-ray revealed evolving right lobar infiltrate.  She was started on antibiotics.  Infectious Disease was consulted.  She was initially begun on vancomycin.  Blood, sputum, and urine cultures were obtained; the results of which were negative for infection.  She was switched to IV Levaquin and received IV Flagyl for possible C. diff colitis as well as possible cholecystitis.  During her hospital stay, she initially was extremely relatively hypotensive with mild symptoms and she became dizzy with upright positioning.  Her systolic blood pressure was 60-70 mmHg despite rather aggressive IV fluid management up to 250 mL an hour.  She was seen in consultation by Dr. Y who monitored her fluid and pulmonary treatment.  Due to some elevated liver function tests, she was seen in consultation by Dr. X.  An ultrasound was negative; however, she did undergo CT scan of the chest and abdomen and there was a suspicion of fluid circling the gallbladder.  A HIDA scan was performed and revealed no evidence of gallbladder dysfunction.  Liver functions were monitored throughout her stay and while elevated, did reduce to approximately 1.5 times normal value.  She also was seen in consultation by Infectious Disease who followed her for several days and agreed with current management of antibiotics.  Over her week-stay, the patient was moderately hypoxemic with room air pulse oximetry of 90%.  She was placed on incentive spirometry and over the succeeding days, she did have improved pulmonary function.,LABORATORY TESTS: , Initially revealed a white count of 13,000, however, approximately 24 hours following admission her white count stabilized and in fact remained normal throughout her stay.  Blood cultures were negative at 5 days.  Sputum culture was negative.  Urine culture was negative and thoracentesis culture negative at 24 hours.  The patient did receive 2 units of packed red cells with the hemoglobin drop to 9 for cardiovascular support, as no evidence of GI bleeding was obtained.  Her most recent blood work on 6/14/2009 revealed a white count of 7000 and hemoglobin of 12.1 with a hematocrit of 36.8.  Her PT and PTT were normal.  Occult blood studies were negative for occult blood.  Hepatitis B antigen was negative.  Hepatitis A antibody IgM was negative.  Hepatitis B core IgM negative, and hepatitis C core antibody was negative.  At the time of discharge on 6/14/2009, sodium was 135, potassium was 3.7, calcium was 8.0, her ALT was 109, AST was 70, direct bilirubin was 0.2, LDH was 219, serum iron was 7, total iron unbound 183, and ferritin level was 267.,At the time of discharge, the patient had improved.  She complained of some back discomfort and lumbosacral back x-ray did reveal some evidence of mild degenerative disk disease with no obvious compression fracture acute noted and she will be followed by Dr. Z.","discharge summary, pneumonia, hypoxemia, hypotension, electrolyte abnormality, anemia, scalp skin biopsy, liver function tests, lobar pneumonia, infectious disease, skin biopsy, white count, cultures"
" A female with the past medical history of Ewing sarcoma, iron deficiency anemia, hypertension, and obesity.", Discharge Summary, Discharge Summary - 5 ,"DATE OF ADMISSION:,  MM/DD/YYYY.,DATE OF DISCHARGE: , MM/DD/YYYY.,REFERRING PHYSICIAN: , AB CD, M.D.,ATTENDING PHYSICIAN AT DISCHARGE:,  X Y, M.D.,ADMITTING DIAGNOSES:,1.  Ewing sarcoma.,2.  Anemia.,3.  Hypertension.,4.  Hyperkalemia.,PROCEDURES DURING HOSPITALIZATION:  ,Cycle seven Ifosfamide, mesna, and VP-16 chemotherapy.,HISTORY OF PRESENT ILLNESS: , Ms. XXX is a pleasant 37-year-old African-American female with the past medical history of Ewing sarcoma, iron deficiency anemia, hypertension, and obesity.  She presented initially with a left frontal orbital swelling to Dr. XYZ on MM/DD/YYYY.  A biopsy revealed small round cells and repeat biopsy on MM/DD/YYYY also showed round cells consistent with Ewing sarcoma, genetic analysis indicated a T1122 translocation.  MRI on MM/DD/YYYY showed a 4 cm soft tissue mass without bony destruction.  CT showed similar result.  The patient received her first cycle of chemotherapy on MM/DD/YYYY.  On MM/DD/YYYY, she was admitted to the ED with nausea and vomitting and was admitted to the Hematology and Oncology A Service following her first course of chemotherapy.  She had her last course of chemotherapy on MM/DD/YYYY followed by radiation treatment to the ethmoid sinuses on MM/DD/YYYY.,HOSPITAL COURSE: ,1.  Ewing sarcoma, she presented for cycle seven of VP-16, ifosfamide, and mesna infusions, which she tolerated well throughout the admission.,2.  She was followed for hemorrhagic cystitis with urine dipsticks and only showed trace amounts of blood in the urine throughout the admission.","discharge summary, iron deficiency anemia, hypertension and obesity, iron deficiency, urine, anemia, hypertension, chemotherapy, discharge, ewing, sarcoma,"
 Patient admitted after an extensive workup for peritoneal carcinomatosis from appendiceal primary., Discharge Summary, Discharge Summary - 4 ,"DATE OF ADMISSION: , MM/DD/YYYY.,DATE OF DISCHARGE: , MM/DD/YYYY.,ADMITTING DIAGNOSIS:, Peritoneal carcinomatosis from appendiceal primary.,DISCHARGE DIAGNOSIS:  , Peritoneal carcinomatosis from appendiceal primary.,SECONDARY DIAGNOSIS: , Diarrhea.,ATTENDING PHYSICIAN: , AB CD, M.D.,SERVICE: , General surgery C, Surgery Oncology.,CONSULTING SERVICES:,  Urology.,PROCEDURES DURING THIS HOSPITALIZATION:,  On MM/DD/YYYY, ,1.  Cystoscopy, bilaterally retrograde pyelograms, insertion of bilateral externalized ureteral stents.,2.  Exploratory laparotomy, right hemicolectomy, cholecystectomy, splenectomy, omentectomy, IPHC with mitomycin-C.,HOSPITAL COURSE: , The patient is a pleasant 56-year-old gentleman with no significant past medical history who after an extensive workup for peritoneal carcinomatosis from appendiceal primary was admitted on MM/DD/YYYY.  He was admitted to General Surgery C Service for a routine preoperative evaluation including baseline labs, bowel prep, urology consult for ureteral stent placement.  The patient was taken to the operative suite on MM/DD/YYYY and was first seen by Urology for a cystoscopy with bilateral ureteral stent placement.  Dr. XYZ performed an exploratory laparotomy, right hemicolectomy, cholecystectomy, splenectomy, omentectomy, and IPHC with mitomycin-C.  The procedure was without complications.  The patient was observed closely in the ICU for one day postoperatively for persistent tachycardia after extubation.  He was then transferred to the floor where he has done exceptionally well.,On postoperative day #2, the patient passed flatus and we were able to start a clear liquid diet.  We advanced him as tolerated to a regular health select diet by postoperative day #4.  His pain was well controlled throughout this hospitalization, initially with a PCA pump, which he very seldomly used.  He was then switched over to p.o. pain medicines and has required very little for adequate pain control.  By postoperative date #2, the patient had been out of bed and ambulating in the hallways.  The patient's only problem was with some mild diarrhea on postoperative days #3 and 4.  This was thought to be a result of his right hemicolectomy.  A C. diff toxin was sent and came back negative and he was started on Imodium to manage his diarrhea.  His post-splenectomy vaccines including pneumococcal, HiB, and meningococcal vaccines were administered during his hospitalization.,On the day of discharge, the patient was resting comfortably in the bed without complaints.  He had been afebrile throughout his hospitalization and his vital signs were stable.  Pertinent physical exam findings include that his abdomen was soft, nondistended and nontender with bowel sounds present throughout.  His midline incision is clean, dry, and intact and staples are in place.  He is just six days postop, he will go home with his staples in place and they will be removed on his follow-up appointment.,CONDITION AT DISCHARGE:  ,The patient was discharged in good and stable condition.,DISCHARGE MEDICATIONS:,1.  Multivitamins daily.,2.  Lovenox 40 mg in 0.4 mL solution inject subcutaneously once daily for 14 days.,3.  Vicodin 5/500 mg and take one tablet by mouth every four hours as needed for pain.,4.  Phenergan 12.5 mg tablets, take one tablet by mouth every six hours p.r.n. for nausea.,5.  Imodium A-D tablets take one tablet by mouth b.i.d. as needed for diarrhea.,DISCHARGE INSTRUCTIONS:,  The patient was instructed to contact us with any questions or concerns that may arise.  In addition, he was instructed to contact us, if he would have fevers greater than 101.4, chills, nausea or vomitting, continuing diarrhea, redness, drainage, or warmth around his incision site.  He will be seen in about one week's time in Dr. XYZ's clinic and his staples will be removed at that time.,FOLLOW-UP APPOINTMENT: , The patient will be seen by Dr. XYZ in clinic in one week's time.",
 A 94-year-old female from the nursing home with several days of lethargy and anorexia.  She was found to have evidence of UTI and also has renal insufficiency and digitalis toxicity., Discharge Summary, Discharge Summary - 12 ,"CURRENT HISTORY:,  A 94-year-old female from the nursing home with several days of lethargy and anorexia.  She was found to have evidence of UTI.  She also has renal insufficiency and digitalis toxicity.  She is admitted for further treatment.,Past medical history, social history, family history, physical examination can be seen on the admission H&P.,LABORATORIES ON ADMISSION: , White count 11,700, hemoglobin 12.8, hematocrit 37.2, BUN 91, creatinine 2.2, sodium 131, potassium 5.1.  Digoxin level of 4.1.,HOSPITAL COURSE: , The patient was admitted and intravenous fluids and antibiotics were administered.  Blood cultures were negative.  Urine cultures were nondiagnostic.  Renal function improved with creatinine down to 1 at the time of discharge.  Digoxin was restarted at a lower dose.  Her condition improved and she is stabilized and transferred back to assisted living in good condition.,PRIMARY DIAGNOSES:,1.  Urinary tract infection.,2.  Volume depletion.,3.  Renal insufficiency.,4.  Digitalis toxicity.,SECONDARY DIAGNOSES:,1.  Aortic valve stenosis.,2.  Congestive heart failure.,3.  Hypertension.,4.  Chronic anemia.,5.  Degenerative joint disease.,6.  Gastroesophageal reflux disease.,PROCEDURES:,  None.,COMPLICATIONS: , None.,DISCHARGE CONDITION: , Improved and stable.,DISCHARGE PLAN:  ,Physical activity:  With assistance.  ,Diet:  No restriction.  ,Medications:  Lasix 40 mg daily, lisinopril 5 mg daily, digoxin 0.125 mg daily, Augmentin 875 mg 1 tablet twice a day for 1 week, Nexium 40 mg daily, Elavil 10 mg at bedtime, Detrol 2 mg twice a day, potassium 10 mEq daily and diclofenac 50 mg twice a day.  ,Follow up:  She will see Dr. X in the office as scheduled.",
 Gastroenteritis and autism.  She developed constipation one week prior to admission and mother gave her MiraLax and her constipation improved. , Discharge Summary, Discharge Summary - 15 ,"FINAL DIAGNOSES:,1.  Gastroenteritis.,2.  Autism.,DIET ON DISCHARGE:,  Regular for age.,MEDICATIONS ON DISCHARGE: , Adderall and clonidine for attention deficit hyperactivity disorder.,ACTIVITY ON DISCHARGE: , As tolerated.,DISPOSITION ON DISCHARGE: , Follow up with Dr. X in ABC Office in 1 to 2 weeks.,HISTORY OF PRESENT ILLNESS: , This 10-and-4/12-year-old Caucasian female has autism and is enrolled at ABC School, and she takes Adderall and clonidine for her hyperactivity.  She developed constipation one week prior to admission and mother gave her MiraLax and her constipation improved.  She developed vomiting 3 days prior to admission, but did not have diarrhea.  She voided on the day of admission.  When she presented to the office, her weight was 124 pounds, which was approximately 10 pounds below previous weights and even had a weight of 151.5 pounds, 05/30/2007 and weight of 137.5 pounds, 09/11/2007 with mother giving no good explanation as to why she had lost all this weight.  She was admitted because of the persistent vomiting, but there was concern about the weight loss.,Physical examination on admission was unremarkable except for the obvious signs autistic spectrum disorder.,LABORATORY DATA:  ,Laboratory data included sedimentation rate of 12, magnesium level of 2.2, TSH of 2.63 with normal being 0.34 to 5.60, free T4 of 1.68 with normal being 0.58 to 1.64.  Chest x-ray and abdominal films were unremarkable.  Hemoglobin 14.5, hematocrit 43.5, platelet count 400,000, white blood count 11,800.  Urinalysis was negative for ketones.  Specific gravity 1.023, and negative for protein.  Sodium 137, potassium 3.4, chloride 103, CO2 20, BUN 21, creatinine 0.9, and anion gap 14, glucose 90, total protein 8.1, albumin 4.5, calcium 8.8, bilirubin 1.5, AST 26, ALT 16, alkaline phosphatase 118.  Thyroid peroxidase antibody studies are pending.,HOSPITAL COURSE:  ,The child was observed on IV fluids and advanced to clear liquids and then regular diet as tolerated.  On the second hospital day, mother was comfortable taking her to home.  Mother did not have a good explanation for the weight loss.  In the hospital, her weight was 124 pounds, her height 58 inches, temperature 98.0 degree F., pulse 123, respirations 18, blood pressure 148/94.  Follow up blood pressure were some of them were in the 125 to 70 range making us think her hypertension as labile and perhaps related to the excitement of the admission.,She seem quite happy and in no distress at the time of discharge.  We will follow up in the office and try to further evaluate her for the unexplained weight loss.  She has been taking the Adderall for at least a year, and the mother does not think the Adderall is the cause of the weight loss.  The free T4 is borderline high and probably bears repeating along with further studies for Graves disease as an outpatient.","discharge summary, gastroenteritis, autism, constipation, hyperactivity, blood pressure, weight loss, adderall"
" Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, hypertension, and cholecystitis.", Discharge Summary, Discharge Summary - 11 ,"ADMISSION DIAGNOSES: , Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, and hypertension.,DISCHARGE DIAGNOSES: , Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, hypertension, and cholecystitis.,PROCEDURE: , Laparoscopic cholecystectomy.,SERVICE: , Surgery.,HISTORY OF PRESENT ILLNESS:,  Ms. ABC is a 57-year-old woman.  She suffers from morbid obesity.  She also has diabetes and obstructive sleep apnea.  She was evaluated in the Bariatric Surgical Center for placement of a band.  During her workup, she was noted to have evidence of cholelithiasis.  It was felt that the patient would benefit from removal of her gallbladder prior to having band placement secondary to her diabetes and the risk of infection of the band.  The patient was scheduled to undergo her procedure on 12/31/09; however, at blood glucose check, the patient was noted to be hyperglycemic, her sugar was 438.  She was admitted to the hospital for treatment of her hyperglycemia.,HOSPITAL COURSE: , Ms. ABC was admitted to the hospital.  She was seen by Dr. A.  He put her on an insulin drip.  Her sugars slowly did come down to normal down to between 115 and 134.  On the next day, she was then taken to the operating room, where she underwent her laparoscopic cholecystectomy.  She was noted to be a difficult intubation for the procedure.  There were some indications of chronic cholecystitis, a little bit of edema, mild edema and adhesions of omentum around the gallbladder.  She underwent the procedure.  She tolerated without difficulty.  She was recovered in the Postoperative Care Unit and then returned to the floor.  Her blood sugar postprocedure was noted to be 233.  She was started back on a sliding scale insulin.  She continued to do well and was felt to be stable for discharge following the procedure.,DISCHARGE INSTRUCTIONS:  ,To return to the Medifast diet.  To continue with her blood glucose.  She needs to follow up with Dr. B, and she will see me next week on Friday.  We will determine if we will proceed with her lap band at that time.  She may shower.  She needs to keep her wounds clean and dry.  No heavy lifting.  No driving on narcotic pain medicines.  She needs to continue with her CPAP machine and continue to monitor her sugars.","discharge summary, medifast, hyperglycemia, laparoscopic cholecystectomy, medifast diet, cholecystitis, cholelithiasis, diabetes mellitus, hypertension, morbid obesity, obstructive sleep apnea, sleep apnea, diabetes,"
" Bradycardia, dizziness, diabetes, hypertension, abdominal pain, and sick sinus syndrome.", Discharge Summary, Discharge Summary - 13 ,"ADMITTING DIAGNOSES:,1.  Bradycardia.,2.  Dizziness.,3.  Diabetes.,4.  Hypertension.,5.  Abdominal pain.,DISCHARGE DIAGNOSIS:,  Sick sinus syndrome.  The rest of her past medical history remained the same.,PROCEDURES DONE: , Permanent pacemaker placement after temporary internal pacemaker.,HOSPITAL COURSE: , The patient was admitted to the intensive care unit.  Dr. X was consulted.  A temporary intracardiac pacemaker was placed.  Consultation was requested to Dr. Y. He considered the need to have a permanent pacemaker after reviewing electrocardiograms and telemetry readings.  The patient remained in sinus rhythm with severe bradycardias, but all of them one to one transmission.  This was considered to be a sick sinus syndrome.  Permanent pacemaker was placed on 09/05/2007 with right atrium appendage and right ventricular apex electrode placement.  This is a Medtronic pacemaker.  After this, the patient remained with pain in the left side of the chest in the upper area as expected, but well controlled.  Right femoral artery catheter was removed.  The patient remained with good pulses in the right lower extremity with no hematoma.  Other problem was the patient's blood pressure, which on 09/05/2007 was found at 180/90.  Medication was adjusted to benazepril 20 mg a day.  Norvasc 5 mg was added as well.  Her blood pressure has remained better, being today 144/74 and 129/76.,FINAL DIAGNOSES:  ,Sick sinus syndrome.  The rest of her past medical history remained without change, which are:,1.  Diabetes mellitus.,2.  History of peptic ulcer disease.,3.  Hypertension.,4.  Insomnia.,5.  Osteoarthritis.,PLAN: , The patient is discharged home to continue her previous home medications, which are:,1.  Actos 45 mg a day.,2.  Bisacodyl 10 mg p.o. daily p.r.n. constipation.,3.  Cosopt eye drops, 1 drop in each eye 2 times a day.,4.  Famotidine 20 mg 1 tablet p.o. b.i.d.,5.  Lotemax 0.5% eye drops, 1 drop in each eye 4 times a day.,6.  Lotensin (benazepril) increased to 20 mg a day.,7.  Triazolam 0.125 mg p.o. at bedtime.,8.  Milk of Magnesia suspension 30 mL daily for constipation.,9.  Tylenol No.  3, one to two tablets every 6 hours p.r.n. pain.,10.  Promethazine 25 mg IM every 6 hours p.r.n. nausea or vomiting.,11.  Tylenol 325 mg tablets every 4 to 6 hours as needed for pain.,12.  The patient will finish cefazolin 1 g IV every 6 hours, total 5 dosages after pacemaker placement.,DISCHARGE INSTRUCTIONS: , Follow up in the office in 10 days for staple removal.  Resume home activities as tolerated with no starch, sugar-free diet.",
" Cardiac arrest, severe congestive heart failure, acute on chronic respiratory failure, osteoporosis, and depression.", Discharge Summary, Death Summary - 2 ,"FINAL DIAGNOSES:,1.  Cardiac arrest.,2.  Severe congestive heart failure.,3.  Acute on chronic respiratory failure.,4.  Osteoporosis.,5.  Depression.,HISTORY OF PRESENT ILLNESS: , This 92-year-old lady with history of depression and chronic low back pain, osteoporosis, and congestive heart failure, was diagnosed having pneumonia approximately for at least 10 days prior to admission.  In the ER, she was given oral antibiotics.  She also saw me few days before admission coming for a followup.  She was doing fairly well.  She was thought to have congestive heart failure and she was advised to continue with her diuretics.  For the last few days, the patient started to have anorexia, she did not eat well, and she did not drink well.  Her family could not take care of her.  So, she was brought to the emergency room, where she was found to have rapid heart rate with a sinus tachycardia around 112 to 130s.  The ________ was found to be dry.  She was given 1 L of IV fluids and she was subsequently admitted in the hospital for further management.,COURSE IN THE HOSPITAL: , The patient stayed in the telemetry.  The patient had significant shortness of breath secondary to congestive heart failure with bilateral basilar crackles.  She was continued on IV antibiotics and general IV hydration was started initially because of low blood pressure and low perfusion status.  On subsequently improved and stopped and Lasix was started; Dr. X, cardiologist was also placed.  The patient's family wanted her to be a DNR and DNI.  They were allowing us to treat her aggressively medically for pneumonia and congestive heart failure.  However, the patient became extremely weak, mostly unresponsive.  At this time, the patient's family wanted a Hospice consult, which was requested.  By the time the Hospice could evaluate her, the patient's condition got deteriorated, she went into more bradycardiac and hypertension and subsequently expired.  Please see the hospital notes for complete details.","discharge summary, bradycardiac, hypertension, hospice, congestive heart failure, cardiac arrest, respiratory failure, "
" The patient is a 60-year-old female patient who off and on for the past 10 to 12 months has had almost daily diarrhea, nausea, inability to eat. ", Discharge Summary, Discharge Summary - 14 ,"HISTORY OF PRESENT ILLNESS: , The patient is a 60-year-old female patient who off and on for the past 10 to 12 months has had almost daily diarrhea, nausea, inability to eat.  She had an EGD and colonoscopy with Dr. ABC a few days prior to this admission.  Colonoscopy did reveal diverticulosis and EGD showed retained bile and possible gastritis.  Biopsies were done.  The patient presented to our emergency room for worsening abdominal pain as well as swelling of the right lower leg.,PAST MEDICAL HISTORY: , Extensive and well documented in prior charts.,PHYSICAL EXAMINATION: , Abdomen was diffusely tender.  Lungs clear.  Blood pressure 129/69 on admission.  At the time of admission, she had just a trace of bilateral lower edema.,LABORATORY STUDIES: , White count 6.7, hemoglobin 13, hematocrit 39.3.  Potassium of 3.2 on 08/15/2007.,HOSPITAL COURSE: , Dr. ABC apparently could not advance the scope into the cecum and therefore warranted a barium enema.  This was done and did not really show what the cecum on the barium enema.  There was some retained stool in that area and the patient had a somewhat prolonged hospital course on the remaining barium from the colon.  She did have some enemas.  She had persistent nausea, headache, neck pain throughout this hospitalization.  Finally, she did improve enough to the point where she could be discharged home.,DISCHARGE DIAGNOSIS: , Nausea and abdominal pain of uncertain etiology.,SECONDARY DIAGNOSIS:  ,Migraine headache.,COMPLICATIONS:  ,None.,DISCHARGE CONDITION: , Guarded.,DISCHARGE PLAN:  ,Follow up with me in the office in 5 to 7 days to resume all pre-admission medications.  Diet and activity as tolerated.","discharge summary, diarrhea, nausea, inability to eat, egd, colonoscopy, biopsies, barium enema, cecum, barium, admission,"
 Death summary of patient with advanced non-small cell lung carcinoma with left malignant pleural effusion status post chest tube insertion status post chemical pleurodesis., Discharge Summary, Death Summary - 1 ,"DISCHARGE DIAGNOSES:,1.  Advanced non-small cell lung carcinoma with left malignant pleural effusion status post chest tube insertion status post chemical pleurodesis.,2.  Respiratory failure secondary to above.,3.  Likely postobstructive pneumonia.,4.  Gastrointestinal bleed.,5.  Thrombocytopenia.,6.  Acute renal failure.,7.  Hyponatremia.,8.  Hypercalcemia, likely secondary to paraneoplastic syndrome from the non-small cell lung CA, possible metastases to the bones.,9.  Leukemoid reaction, likely secondary to malignancy.,10.  Elevated liver function tests.,HOSPITAL COURSE:,  This is a 53-year-old African American male patient of Dr. X who was admitted through the emergency room.  He has been having some right hip pain and cough.  The patient had a CT scan of the chest, which revealed a left pleural effusion, extensive mediastinal mass, left hilar adenopathy, causing complete obstruction of the left lower lobe and the lingula and the left pulmonary vein, and the multiple nodules on the right side of his chest.  These were all consistent with metastatic disease.  He was thus also a suspicion for osseous metastatic disease involving the right scapula with a left large pleural effusion.  The patient had severe shortness of breath, chest pain, a left-sided chest tube was inserted, and pleural effusion was positive for malignant cells.  The history of right hip pain could be secondary to metastatic disease.  The patient underwent bronchoscopy, which is positive for non-small cell lung CA.  The patient was seen by various consultants.  The patient underwent respiratory failure, requiring intubation, mechanical ventilatory support.  He was extubated, but had to be re-intubated because of respiratory failure.  Had a long discussion with the patient's wife and other family members.  The patient was seen by Dr. Y.  The patient was not in a condition to undergo any kind of chemotherapy, being on the ventilator.  The patient progressively got deteriorated.  The patient's family requested for DNR, withdrawal of the life support.  The patient was extubated, and he was pronounced expired on 08/21/08 at 01:40 hours.,I appreciate all consultants' input.","discharge summary, dnr, pronounced expired, extubated, death summary, lung carcinoma, pleural effusion,"
" Upper respiratory illness with apnea, possible pertussis.  a one plus-month-old female with respiratory symptoms for approximately a week prior to admission.  This involved cough, post-tussive emesis, and questionable fever.", Discharge Summary, Discharge Summary - 16 ,"ADMISSION DIAGNOSIS: , Upper respiratory illness with apnea, possible pertussis.,DISCHARGE DIAGNOSIS: , Upper respiratory illness with apnea, possible pertussis.,COMPLICATIONS: , None.,OPERATIONS: , None,BRIEF HISTORY AND PHYSICAL: , This is a one plus-month-old female with respiratory symptoms for approximately a week prior to admission.  This involved cough, post-tussive emesis, questionable fever, but only 99.7.  Their usual doctor prescribed amoxicillin over the phone.  The coughing persisted and worsened.  She went to the ER, where sats were normal at baseline, but dropped into the 80s with coughing spells.  They did witness some apnea.  They gave some Rocephin, did some labs, and the patient was transferred to hospital.,PHYSICAL EXAMINATION: , On admission, GENERAL:  Well-developed, well-nourished baby in no apparent distress. HEENT:  There was some nasal discharge.  Remainder of the HEENT was normal.  LUNG:  Had few rhonchi.  No retractions.  No significant coughing or apnea during the admission physical.  ABDOMEN:  Benign.  EXTREMITIES:  Were without any cyanosis.,SIGNIFICANT LABS AND X-RAYS:  ,She had a CBC done Garberville, which showed a white count of 12.4, with a differential of 10 segs, 82 lymphs, 8 monos, hemoglobin of 15, hematocrit 42, platelets 296,000, and a normal BMP.  An x-ray was done and I do not have an official interpretation, but to the admitting physician, Dr. X it showed no significant infiltrate.  Well at hospital, she had a rapid influenza swab done, which was negative.  She had a rapid RSV done, which is still not in the chart, but I believe I was told that it was negative.  She also had a pertussis PCR swab done and a pertussis culture done, neither of which has result in the chart.  I do know that the pertussis culture proved to be negative.,CONSULTATION: , Public Health Department was notified of a case of suspected pertussis.,HOSPITAL COURSE: , The baby was afebrile.  Required no oxygen in the hospital.  Actually fed reasonably well.  Did have one episode of coughing with slight emesis.  Appeared basically quite well between episodes.  Had no apnea witnessed and after overnight observation, the parents were anxious to go home.  The patient was started on Zithromax in the hospital.,CONDITION AND TREATMENT: , The patient was in stable condition and good condition on exam at the time and was discharged home on Zithromax to be followed up in the office within a week.,INSTRUCTIONS TO PATIENT:,  Include usual diet and to follow up within a week, but certainly sooner if the coughing is worse and there is cyanosis or apnea again.","discharge summary, emesis, cough, upper respiratory illness, respiratory illness, apnea, pertussis,"
 Patient with a history of a Nissen fundoplication performed six years ago for gastric reflux. , Discharge Summary, Discharge Summary - 10 ,"ADMITTING DIAGNOSES:,  Hiatal hernia, gastroesophageal reflux disease reflux.,DISCHARGE DIAGNOSES:,  Hiatal hernia, gastroesophageal reflux disease reflux.,SECONDARY DIAGNOSIS: , Postoperative ileus.,PROCEDURES DONE: , Hiatal hernia repair and Nissen fundoplication revision.,BRIEF HISTORY: , The patient is an 18-year-old male who has had a history of a Nissen fundoplication performed six years ago for gastric reflux.  Approximately one year ago, he was involved in a motor vehicle accident and CT scan at that time showed that he had a hiatal hernia.  Over the past year, this has caused him an increasing number of problems, including chest pain when he eats, and shortness of breath after large meals.  He is also having reflux symptoms again.  He presents to us for repair of the hiatal hernia and revision of the Nissen fundoplication.,HOSPITAL COURSE: , Mr. A was admitted to the adolescent floor by Brenner Children's Hospital after his procedure.  He was stable at that time.  He did complain of some nausea.  However, he did not have any vomiting at that time.  He had an NG tube in and was n.p.o.  He also had a PCA for pain management as well as Toradol.  On postoperative day #1, he complained of not being able to urinate, so a Foley catheter was placed.  Over the next several days, his hospital course proceeded as follows.  He continued to complain of some nausea; however, he did not ever have any vomiting.  Eventually, the Foley catheter was discontinued and he had excellent urine output without any complications.  He ambulated frequently.  He remained n.p.o. for three days.  He also had the NG tube in during that time.  On postoperative day #4, he began to have some flatus, and the NG tube was discontinued.  He was advanced to a liquid diet and tolerated this without any complications.  At this time, he was still using the PCA for pain control.  However, he was using it much less frequently than on days #1 and #2 postoperatively.  After tolerating the full liquid diet without any complications, he was advanced to a soft diet and his pain medications were transitioned to p.o. medications rather than the PCA.  The PCA was discontinued.  He tolerated the soft diet without any complications and continued to have flatus frequently.  On postoperative day #6, it was determined that he was stable for discharge to home as he was taking p.o. without any complications.  His pain was well controlled with p.o. pain medications.  He was passing gas frequently, had excellent urine output, and was ambulating frequently without any issues.,DISCHARGE CONDITION:,  Stable.,DISPOSITION: , Discharged to home.,DISCHARGE INSTRUCTIONS: , The patient was discharged to home with instructions for maintaining a soft diet.  It was also recommended that he does not drink any soda postoperatively.  He is instructed to keep his incision site clean and dry and it was also recommended that he avoid any heavy lifting.  He will be able to attend school when it starts in a few weeks.  However, he is not going to be able to play football in the near future.  He was given prescription for pain medication upon discharge.  He is instructed to contact Pediatric Surgery if he has any fevers, any nausea and vomiting, any chest pain, any constipation, or any other concerns.","discharge summary,"
" Cerebrovascular accident (CVA) with right arm weakness and MRI indicating acute/subacute infarct involving the left posterior parietal lobe without mass effect.  2.  Old coronary infarct, anterior aspect of the right external capsule.  Acute bronchitis with reactive airway disease.", Discharge Summary, CVA - Discharge Summary ,"DIAGNOSES ON ADMISSION,1.  Cerebrovascular accident (CVA) with right arm weakness.,2.  Bronchitis.,3.  Atherosclerotic cardiovascular disease.,4.  Hyperlipidemia.,5.  Thrombocytopenia.,DIAGNOSES ON DISCHARGE,1.  Cerebrovascular accident with right arm weakness and MRI indicating acute/subacute infarct involving the left posterior parietal lobe without mass effect.,2.  Old coronary infarct, anterior aspect of the right external capsule.,3.  Acute bronchitis with reactive airway disease.,4.  Thrombocytopenia most likely due to old coronary infarct, anterior aspect of the right external capsule.,5.  Atherosclerotic cardiovascular disease.,6.  Hyperlipidemia.,HOSPITAL COURSE: , The patient was admitted to the emergency room.  Plavix was started  in addition to baby aspirin.  He was kept on oral Zithromax for his cough.  He was given Xopenex treatment, because of his respiratory distress.  Carotid ultrasound was reviewed and revealed a 50 to 69% obstruction of left internal carotid.  Dr. X saw him in consultation and recommended CT angiogram.  This showed no significant obstructive lesion other than what was known on the ultrasound.  Head MRI was done and revealed the above findings.  The patient was begun on PT and improved.  By discharge, he had much improved strength in his right arm.  He had no further progressions.  His cough improved with oral Zithromax and nebulizer treatments.  His platelets also improved as well.  By discharge, his platelets was up to 107,000.  His H&H was stable at 41.7 and 14.6 and his white count was 4300 with a normal differential.  Chest x-ray revealed a mild elevated right hemidiaphragm, but no infiltrate.  Last chemistry panel on December 5, 2003, sodium 137, potassium 4.0, chloride 106, CO2 23, glucose 88, BUN 17, creatinine 0.7, calcium was 9.1.  PT/INR on admission was 1.03, PTT 34.7.  At the time of discharge, the patient's cough was much improved.  His right arm weakness has much improved.  His lung examination has just occasional rhonchi.  He was changed to a metered dose inhaler with albuterol.  He is being discharged home.  An echocardiogram revealed mild concentric LVH with normal left ventricular function with an EF of 57%, moderate left atrial enlargement and diastolic dysfunction with mild mitral regurgitation.  He will follow up in my office in 1 week.  He is to start PT and OT as an outpatient.  He is to avoid driving his car.  He is to notify, if further symptoms.  He has 2 more doses of Zithromax at home, he will complete.  His prognosis is good.","discharge summary, subacute infarct, atherosclerotic cardiovascular disease, cerebrovascular accident, coronary infarct, external capsule, cva, cerebrovascular, mri, bronchitis, cardiovascular, xopenex, atherosclerotic, accident"
" Acute cerebrovascular accident/left basal ganglia and deep white matter of the left parietal lobe, hypertension, urinary tract infection, and hypercholesterolemia.", Discharge Summary, Discharge Summary - 1 ,"DISCHARGE DIAGNOSES:,1. Acute cerebrovascular accident/left basal ganglia and deep white matter of the left parietal lobe.,2. Hypertension.,3. Urinary tract infection.,4. Hypercholesterolemia.,PROCEDURES:,1. On 3/26/2006, portable chest, single view. Impression: atherosclerotic change in the aortic knob.,2. On 3/26/2006, chest, portable, single view. Impression: Mild tortuosity of the thoracic aorta, maybe secondary to hypertension; right lateral costophrenic angle is not evaluated due to positioning of the patient.,3. On March 27, 2006, swallowing study: Normal swallowing study with minimal penetration with thin liquids.,4. On March 26, 2006, head CT without contrast: 1) Air-fluid level in the right maxillary sinus suggestive of acute sinusitis; 2) A 1.8-cm oval, low density mass in the dependent portion of the left maxillary sinus is consistent with a retention cyst; 3) Mucoparietal cell thickening in the right maxillary sinus and ethmoid sinuses.,4. IV contrast CT scan of the head is unremarkable.,5. On 3/26/2006, MRI/MRA of the neck and brain, with and without contrast: 1) Changes consistent with an infarct involving the right basal ganglia and deep white matter of the left parietal lobe, as described above; 2) Diffuse smooth narrowing of the left middle cerebral artery that may be a congenital abnormality. Clinical correlation is necessary.,6. On March 27th, echocardiogram with bubble study. Impression: Normal left ventricular systolic function with estimated left ventricular ejection fraction of 55%. There is mild concentric left ventricular hypertrophy. The left atrial size is normal with a negative bubble study.,7. On March 27, 2006, carotid duplex ultrasound showed: 1) Grade 1 carotid stenosis on the right; 2) No evidence of carotid stenosis on the left.,HISTORY AND PHYSICAL: ,This is a 56-year-old white male with a history of hypertension for 15 years, untreated. The patient woke up at 7: 15 a.m. on March 26 with the sudden onset of right-sided weakness of his arm, hand, leg and foot and also with a right facial droop, right hand numbness on the dorsal side, left face numbness and slurred speech. The patient was brought by EMS to emergency room. The patient was normal before he went to bed the prior night. He was given aspirin in the ER. The CT of the brain without contrast did not show any changes. He could not have a CT with contrast because the machine was broken. He went ahead and had the MRI/MRA of the brain and neck, which showed infarct involving the right basal ganglia and deep white matter of the left parietal lobe. Also, there is diffuse smooth narrowing of the left middle cerebral artery.,The patient was admitted to the MICU.,HOSPITAL COURSE PER PROBLEM LIST:,1. Acute cerebrovascular accident: The patient was not a candidate for tissue plasminogen activator. A neurology consult was obtained from Dr. S. She agrees with our treatment for this patient. The patient was on aspirin 325 mg and also on Zocor 20 mg once a day. We also ordered fasting blood lipids, which showed cholesterol of 165, triglycerides 180, HDL cholesterol 22, LDL cholesterol 107. Dr. Farber agreed to treat the risk factors, to not treat blood pressure for the first two weeks of the stroke. We put the patient on p.r.n. labetalol only for systolic blood pressure greater than 200, diastolic blood pressure greater than 120. The patient's blood pressure has been stable and he did not need any blood pressure medications. His right leg kept improving with increased muscle strength and it was 4-5/5, however, his right upper extremity did not improve much and was 0-1/5. His slurred speech has been improved a little bit. The patient started PT, OT and speech therapy on the second day of hospitalization. The patient was transferred out to a regular floor on the same day of admission based on his stable neurologic exam. Also, we added Aggrenox for secondary stroke prevention, suggested by Dr. F. Echocardiogram was ordered and showed normal left ventricular function with bubble study that was negative. Carotid ultrasound only showed mild stenosis on the right side. EKG did not show any changes, so the patient will be transferred to Siskin Rehabilitation Hospital today on Aggrenox for secondary stroke prevention. He will not need blood pressure treatment unless systolic is greater than 220, diastolic greater than 120, for the first week of his stroke. On discharge, on his neurologic exam, he has a right facial palsy from the eye below, he has right upper extremity weakness with 0-1/5 muscle strength, right leg is 4-5/5, improved slurred speech.,2. Hypertension: As I mentioned in item #1, see above, his blood pressure has been stable. This did not need any treatment.,3. Urinary tract infection: The patient had urinalysis on March 26th, which showed a large amount of leukocyte esterase, small amount of blood with red blood cells 34, white blood cells 41, moderate amount of bacteria. The patient was started on Cipro 250 mg p.o. b.i.d. on March 26th. He needs to finish seven days of antibiotic treatment for his UTI. Urine culture and sensitivity were negative.,4. Hypercholesterolemia: The patient was put on Zocor 20 mg p.o. daily. The goal LDL for this patient will be less than 70. His LDL currently is 107, HDL is 22, triglycerides 180, cholesterol is 165.,CONDITION ON DISCHARGE:, Stable.,ACTIVITY: ,As tolerated.,DIET:, Low-fat, low-salt, cardiac diet.,DISCHARGE INSTRUCTIONS:,1. Take medications regularly.,2. PT, OT, speech therapist to evaluate and treat at Siskin Rehab Hospital.,3. Continue Cipro for an additional two days for his UTI.,DISCHARGE MEDICATIONS:,1. Cipro 250 mg, one tablet p.o. b.i.d. for an additional two days.,2. Aggrenox, one tablet p.o. b.i.d.,3. Docusate sodium 100 mg, one cap p.o. b.i.d.,4. Zocor 20 mg, one tablet p.o. at bedtime.,5. Prevacid 30 mg p.o. once a day.,FOLLOW UP:,1. The patient needs to follow up with Rehabilitation Hospital after he is discharged from there.,2. The patient can call the Clinic if he needs a follow up appointment with us, or the patient can find a primary care physician since he has insurance.",
 Death summary of an 80-year-old patient with a history of COPD., Discharge Summary, Death Summary ,"CAUSE OF DEATH:,1.  Acute respiratory failure.,2.  Chronic obstructive pulmonary disease exacerbation.,SECONDARY DIAGNOSES:,1.  Acute respiratory failure, probably worsened by aspiration.,2.  Acute on chronic renal failure.,3.  Non-Q wave myocardial infarction.,4.  Bilateral lung masses.,5.  Occlusive carotid disease.,6.  Hypertension.,7.  Peripheral vascular disease.,HOSPITAL COURSE:  ,This 80-year-old patient with a history of COPD had had recurrent admissions over the past few months.  The patient was admitted again on 12/15/08, after he had been discharged the previous day.  Came in with acute on chronic respiratory failure, with CO2 of 57.  The patient was in rapid atrial fibrillation.  RVR with a rapid ventricular response of 160 beats per minute.  The patient was on COPD exacerbation and CHF due to rapid atrial fibrillation.  The patient's heart rate was controlled with IV Cardizem.  Troponin was consistent with non-Q wave MI.  The patient was treated medically transfer to catheterize the patient to evaluate her coronary artery disease.  Echocardiogram showed normal ejection fraction, normal left and right side, but stage 3 restrictive physiology.  There was also prosthetic aortic valve.  The patient was admitted to Intensive Care Unit and was intubated.  Pulmonary was managed by Critical Care, Dr. X.,The patient was successfully extubated.  Was tapered from IV steroids and put on p.o. steroids.  The patient's renal function has stabilized with a creatinine of between 2.1 and 2.3.  There was contemplation as to whether left heart catheterization should proceed since Nephrology was concerned about the patient's renal status.  Wife decided catheterization should be canceled and the patient managed conservatively.  The patient was transferred to the telemetry floor.  While in telemetry floor, the patient's renal function started deteriorating, went up from 2.08 to 2.67 in two days.  The patient had nausea and vomiting.  Was unable to tolerate p.o.  Was put on cautious hydration.  The patient went into acute respiratory distress.  Intubation showed the patient had aspirated.  He was in acute respiratory failure with bronchospasms and exacerbation of COPD.  X-ray of chest did not show any infiltrate, but showed dilatation of the stomach.  The patient was transferred to the Intensive Care Unit because of acute respiratory failure, was intubated by Critical Care, Dr. X.  The patient was put on the vent.  Overnight, the patient's condition did not improve.  Continued to be severely hypoxic.,The patient expired on the morning of 12/24/08 from acute respiratory failure.","discharge summary, myocardial infarction, intensive care unit, acute respiratory failure, death summary, atrial fibrillation, renal function, telemetry floor, respiratory failure, death, chronic, exacerbation, infarction, respiratory"
 Cognitive linguistic impairment secondary to stroke.  The patient was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.  , Discharge Summary, Cognitive Linguistic Impairment - Discharge ,"DIAGNOSIS: , Cognitive linguistic impairment secondary to stroke.,NUMBER OF SESSIONS COMPLETED:,  5,HOSPITAL COURSE:  ,The patient is a 73-year-old female who was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.  Based on the initial evaluation completed 12/29/08, the patient had mild difficulty with generative naming and auditory comprehension and recall.  The patient's skilled speech therapy was recommended for three times a week for 8 weeks to improve her overall cognitive linguistic abilities.  At this time, the patient has accomplished all 5 of her short-term therapy goals.  She is able to complete functional mass tasks with 100% accuracy independently.  She is able to listen to a narrative and recall the main idea plus at least five details after a 10 minute delay independently.,She is able to read a newspaper article and recall the main idea plus five details after a 15 minute delay independently.  She is able to state 15 items in a broad category within a minute and a half independently.  The patient is also able to complete deductive reasoning tasks to promote her mental flexibility with 100% accuracy independently.  The patient also met her long-term therapy goal of functional cognitive linguistic abilities to return to teaching and improve her independence and safety at home.  The patient is no longer in need of skilled speech therapy and is discharged from my services.  She did quite well in therapy and also agreed with this discharge.","discharge summary, stroke, linguistic deficits, speech therapy, skilled speech therapy, linguistic impairment, cognitive linguistic, cognitive, linguistic,"
" Patient had some cold symptoms, was treated as bronchitis with antibiotics.", Discharge Summary, Discharge Summary ,"DISCHARGE DIAGNOSES:,1.  Acute respiratory failure, resolved.,2.  Severe bronchitis leading to acute respiratory failure, improving.,3.  Acute on chronic renal failure, improved.,4.  Severe hypertension, improved.,5.  Diastolic dysfunction.,X-ray on discharge did not show any congestion and pro-BNP is normal.,SECONDARY DIAGNOSES:,1.  Hyperlipidemia.,2.  Recent evaluation and treatment, including cardiac catheterization, which did not show any coronary artery disease.,3.  Remote history of carcinoma of the breast.,4.  Remote history of right nephrectomy.,5.  Allergic rhinitis.,HOSPITAL COURSE:, This 83-year-old patient had some cold symptoms, was treated as bronchitis with antibiotics.  Not long after the patient returned from Mexico, the patient started having progressive shortness of breath, came to the emergency room with severe bilateral wheezing and crepitations.  X-rays however did not show any congestion or infiltrates and pro-BNP was within normal limits.  The patient however was hypoxic and required 4L nasal cannula.  She was admitted to the Intensive Care Unit.  The patient improved remarkably over the night on IV steroids and empirical IV Lasix.  Initial swab was positive for MRSA colonization., ,Discussed with infectious disease, Dr. X and it was decided no treatment was required for de-colonization.  The patient's breathing has improved.  There is no wheezing or crepitations and O2 saturation is 91% on room air.  The patient is yet to go for exercise oximetry.  Her main complaint is nasal congestion and she is now on steroid nasal spray.  The patient was seen by Cardiology, Dr. Z, who advised continuation of beta blockers for diastolic dysfunction.  The patient has been weaned off IV steroids and is currently on oral steroids, which she will be on for seven days.,DISPOSITION: , The patient has been discharged home.,DISCHARGE MEDICATIONS:,1.  Metoprolol 25 mg p.o. b.i.d.,2.  Simvastatin 20 mg p.o. daily.,NEW MEDICATIONS:,1.  Prednisone 20 mg p.o. daily for seven days.,2.  Flonase nasal spray daily for 30 days.,Results for oximetry pending to evaluate the patient for need for home oxygen.,FOLLOW UP:,  The patient will follow up with Pulmonology, Dr. Y in one week's time and with cardiologist, Dr. X in two to three weeks' time.","discharge summary, acute respiratory failure, bronchitis, acute on chronic renal failure, severe hypertension, diastolic dysfunction, cold symptoms, iv steroids, nasal spray, nasal, steroids, "
" Delivered pregnancy, cholestasis of pregnancy, fetal intolerance to labor, failure to progress.  Primary low transverse cesarean section.", Discharge Summary, Cholestasis Of Pregnancy  ,"FINAL DIAGNOSES:,  Delivered pregnancy, cholestasis of pregnancy, fetal intolerance to labor, failure to progress.,PROCEDURE: , Included primary low transverse cesarean section.,SUMMARY: , This 32-year-old gravida 2 was induced for cholestasis of pregnancy at 38-1/2 weeks.  The patient underwent a 2-day induction.  On the second day, the patient continued to progress all the way to the point of 9.5 cm at which point, she failed to progress.  During the hour or two of evaluation at 9.5 cm, the patient was also noted to have some fetal tachycardia and an occasional late deceleration.  Secondary to these factors, the patient was brought to the operative suite for primary low transverse cesarean section, which she underwent without significant complication.  There was a slightly enlarged blood loss at approximately 1200 mL, and postoperatively, the patient was noted to have a very mild tachycardia coupled with 100.3 degrees Fahrenheit temperature right at delivery.  It was felt that this was a sign of very early chorioamnionitis and therapeutic antibiotics were given throughout her stay.  The patient received 72 hours of antibiotics with there never being a temperature above 100.3 degrees Fahrenheit.  The maternal tachycardia resolved within a day.  The patient did well throughout the 3-day stay progressing to full diet, regular bowel movements, normal urination patterns.  The patient did receive 2 units of packed red cells on Sunday when attended to by my partner secondary to a hematocrit of 20%.  It should be noted, however, that this was actually an expected result with the initial hematocrit of 32% preoperatively.  Therefore, there was anemia but not an unexplained anemia.,PHYSICAL EXAMINATION ON DISCHARGE: , Includes the stable vital signs, afebrile state.  An alert and oriented patient who is desirous at discharge.  Full range of motion, all extremities; fully ambulatory.  Pulse is regular and strong.  Lungs are clear and the abdomen is soft and nontender with minimal tympany and a nontender fundus.  The incision is beautiful and soft and nontender.  There is scant lochia and there is minimal edema.,LABORATORY STUDIES: , Include hematocrit of 27% and the last liver function tests was within normal limits 48 hours prior to discharge.,FOLLOWUP: , For the patient includes pelvic rest, regular diet.  Follow up with me in 1 to 2 weeks.  Motrin 800 mg p.o. q.8h. p.r.n. cramps, Tylenol No.  3 one p.o. q.4h. p.r.n. pain, prenatal vitamin one p.o. daily, and topical triple antibiotic to incision b.i.d. to q.i.d.","discharge summary, delivered pregnancy, fetal intolerance, induction, pelvic rest, low transverse cesarean section, cholestasis of pregnancy, cesarean section, pregnancy, fetal, tachycardia, cholestasis"
 Cholecystitis with choledocholithiasis.   Laparoscopic cholecystectomy with laparoscopy converted to open common bile duct exploration and stone extraction., Discharge Summary, Cholecystitis - Discharge Summary ,"REASON FOR ADMISSION: , Cholecystitis with choledocholithiasis.,DISCHARGE DIAGNOSES: , Cholecystitis, choledocholithiasis.,ADDITIONAL DIAGNOSES,1.  Status post roux-en-y gastric bypass converted to an open procedure in 01/07.,2.  Laparoscopic paraventral hernia in 11/07.,3.  History of sleep apnea with reversal after 100-pound weight loss.,4.  Morbid obesity with bmi of 39.4.,PRINCIPAL PROCEDURE:,  Laparoscopic cholecystectomy with laparoscopy converted to open common bile duct exploration and stone extraction.,HOSPITAL COURSE: , The patient is a 33-year-old female admitted with elevated bilirubin and probable common bile duct stone.  She was admitted through the emergency room with abdominal pain, elevated bilirubin, and gallstones on ultrasound with a dilated common bile duct.  She subsequently went for a HIDA scan to rule out cholecystitis.  Gallbladder was filled but was unable to empty into the small bowel consistent with the common bile duct blockage.  She was taken to the operating room that night for laparoscopic cholecystectomy.  We proceeded with laparoscopic cholecystectomy and during the cholangiogram there was no contrast.  It was able to be extravasated into the duodenum with the filling defect consistent with the distal common bile duct stone.  The patient had undergone a Roux-en-Y gastric bypass but could not receive an ERCP and stone extraction, therefore, common bile duct exploration was performed and a stone was extracted.  This necessitated conversion to an open operation.  She was transferred to the medical surgical unit postoperatively.  She had a significant amount of incisional pain following morning, but no nausea.  A Jackson-Pratt drain, which was left in place in two places showed serosanguineous fluid.  White blood cell count was down to 7500 and bilirubin decreased to 2.1.  Next morning she was started on a liquid diet.  Foley catheter was discontinued.  There was no evidence of bile leak from the drains.  She was advanced to a regular diet on postoperative day #3, which was 12/09/07.  The following morning she was tolerating regular diet.  Her bowels had begun to function, and she was afebrile with her pain control with oral pain medications.  Jackson-Pratt drain was discontinued from the wound.  The remaining Jackson-Pratt drain was left adjacent to her cystic duct.  Following morning, her laboratory studies were better.  Her bilirubin was down to normal and white blood cell count was normal with an H&H of 9 and 26.3.  Jackson-Pratt drain was discontinued, and she was discharged home.  Followup was in 3 days for staple removal.  She was given iron 325 mg p.o. t.i.d. and Lortab elixir 15 cc p.o. q.4 h. p.r.n. for pain.","discharge summary, laparoscopy, common bile duct exploration, laparoscopic cholecystectomy, bile duct, choledocholithiasis, cholecystectomy, cholecystitis, laparoscopic, hernia "
" A 67-year-old male with COPD and history of bronchospasm, who presents with a 3-day history of increased cough, respiratory secretions, wheezings, and shortness of breath.", Discharge Summary, COPD - Discharge Summary ,"HISTORY OF PRESENT ILLNESS:  ,A 67-year-old male with COPD and history of bronchospasm, who presents with a 3-day history of increased cough, respiratory secretions, wheezings, and shortness of breath.  He was seen by me in the office on the day of admission and noted to be dyspneic with audible wheezing and he was admitted for acute asthmatic bronchitis, superimposed upon longstanding COPD.  Unfortunately over the past few months he has returned to pipe smoking.  At the time of admission, he denied fever, diaphoresis, nausea, chest pain or other systemic symptoms.,PAST MEDICAL HISTORY: , Status post artificial aortic valve implantation in summer of 2002 and is on chronic Coumadin therapy.  COPD as described above, history of hypertension, and history of elevated cholesterol.,PHYSICAL EXAMINATION: , Heart tones regular with an easily audible mechanical click.  Breath sounds are greatly diminished with rales and rhonchi over all lung fields.,LABORATORY STUDIES:  ,Sodium 139, potassium 4.5, BUN 42, and creatinine 1.7.  Hemoglobin 10.7 and hematocrit 31.7.,HOSPITAL COURSE: , He was started on intravenous antibiotics, vigorous respiratory therapy, intravenous Solu-Medrol.  The patient improved on this regimen.  Chest x-ray did not show any CHF.  The cortisone was tapered.  The patient's oxygenation improved and he was able to be discharged home.,DISCHARGE DIAGNOSES:  ,Chronic obstructive pulmonary disease and acute asthmatic bronchitis.,COMPLICATIONS: , None.,DISCHARGE CONDITION: , Guarded.,DISCHARGE PLAN: , Prednisone 20 mg 3 times a day for 2 days, 2 times a day for 5 days and then one daily, Keflex 500 mg 3 times a day and to resume his other preadmission medication, can be given a pneumococcal vaccination before discharge.  To follow up with me in the office in 4-5 days.","discharge summary, increased cough, respiratory secretions, wheezings, shortness of breath, acute asthmatic bronchitis, asthmatic bronchitis, respiratory, breath, asthmatic, copd,"
" Hysteroscopy, dilatation and curettage (D&C), and myomectomy.  Severe menometrorrhagia unresponsive to medical therapy, severe anemia, and fibroid uterus.", Discharge Summary, D&C - Discharge Summary ,"ADMISSION DIAGNOSES:,1.  Severe menometrorrhagia unresponsive to medical therapy.,2.  Severe anemia.,3.  Fibroid uterus.,DISCHARGE DIAGNOSES:,1.  Severe menometrorrhagia unresponsive to medical therapy.,2.  Severe anemia.,3.  Fibroid uterus.,OPERATIONS PERFORMED:,1.  Hysteroscopy.,2.  Dilatation and curettage (D&C).,3.  Myomectomy.,COMPLICATIONS: , Large endometrial cavity fibroid requiring careful dissection and excision.,BLOOD TRANSFUSIONS: , Two units of packed red blood cells.,INFECTION: , None.,SIGNIFICANT LAB AND X-RAY: , Posttransfusion of the 2nd unit showed her hematocrit of 25, hemoglobin of 8.3.,HOSPITAL COURSE AND TREATMENT: , The patient was admitted to the surgical suite and taken to the operating room where a dilatation and curettage (D&C) was performed.  Hysteroscopy revealed a large endometrial cavity fibroid.  Careful shaving and excision of this fibroid was performed with removal of the fibroid.  Hemostasis was noted completely at the end of this procedure.  Postoperatively, the patient has done well.  The patient was given a 2nd unit of packed red blood cells because of intraoperative blood loss.  The patient is now ambulating without difficulty and tolerating her diet.  The patient desires to go home.  The patient is discharged to home.,DISCHARGE CONDITION: , Stable.,DISCHARGE INSTRUCTIONS:  ,Regular diet, bedrest for 1 week with slow return to normal activities over the ensuing 2 to 3 weeks, pelvic rest for 6 weeks.  Vicodin tablets 1 tablet p.o. q.4-6 h. p.r.n. pain, multiple vitamin 1 tab p.o. daily, ferrous sulfate  tablets 1 tablet p.o. daily.  Ambulate with assistance at home only.  The patient is to return to see Dr. X p.r.n. plus Tuesday, 6/16/2009 for further followup care.  The patient was given full and complete postop and discharge instructions.  All her questions were answered.","discharge summary, (d&c), fibroid uterus, myomectomy, dilatation, curettage, menometrorrhagia, uterus, hysteroscopy, fibroid, "
 Chronic obstructive pulmonary disease (COPD) exacerbation and acute bronchitis., Discharge Summary, COPD & Bronchitis - Discharge Summary ,"DIAGNOSIS AT ADMISSION:,  Chronic obstructive pulmonary disease (COPD) exacerbation and acute bronchitis.,DIAGNOSES AT DISCHARGE,1.  Chronic obstructive pulmonary disease exacerbation and acute bronchitis.,2.  Congestive heart failure.,3.  Atherosclerotic cardiovascular disease.,4.  Mild senile-type dementia.,5.  Hypothyroidism.,6.  Chronic oxygen dependent.,7.  Do not resuscitate/do not intubate.,HOSPITAL COURSE: , The patient was admitted from the office by Dr. X.  She was placed on the usual medications that included Synthroid 0.05 mg a day, enalapril 5 mg a day, Imdur 30 mg a day, Lanoxin 0.125 mg a day, aspirin 81 mg a day, albuterol and Atrovent nebulizers q.4 h., potassium chloride 10 mEq 2 tablets per day, Lasix 40 mg a day, Humibid L.A.  600 mg b.i.d.  She was placed on oral Levaquin after a load of 500 mg and 250 mg a day.  She was given oxygen, encouraged to eat, and suctioned as needed.,Laboratory data included a urinalysis that had 0-2 WBCs per high power field and urine culture was negative, blood cultures x2 were negative, TSH was 1.7, and chem-7, sodium 134, potassium 4.4, chloride 93, CO2 34, glucose 105, BUN 17, creatinine 0.9, and calcium 9.1.  Digoxin was 1.3.  White blood cell count was 6100 with a normal differential, H&H 37.4/12.1, platelets 335,000.  Chest x-ray was thought to have prominent interstitial lung changes without acute infiltrate.  There is a question if there is mild fluid overload.,The patient improved with the above regimen.  By discharge, her lungs fell back to her baseline.  She had no significant shortness of breath.  Her O2 saturations were stable.  Her vital signs were stable.,She is discharged home to follow up with me in a week and a half.,Her daughter has been spoken to by phone and she will notify me if she worsens or has problems.,PROGNOSIS:  ,Guarded.","discharge summary, chronic obstructive pulmonary disease exacerbation, chronic obstructive pulmonary disease, pulmonary, copd, discharge, bronchitis,"
 Congestive heart failure (CHF) with left pleural effusion.  Anemia of chronic disease., Discharge Summary, CHF & Pleural Effusion - Discharge Summary ,"DIAGNOSIS AT ADMISSION: , Congestive heart failure (CHF) with left pleural effusion.,DIAGNOSES AT DISCHARGE,1.  Congestive heart failure (CHF) with pleural effusion.,2.  Hypertension.,3.  Prostate cancer.,4.  Leukocytosis.,5. Anemia of chronic disease.,HOSPITAL COURSE:  ,The patient was admitted to the emergency room by Dr. X. He has diuresed with IV Lasix.  He was placed on Prinivil, aspirin, oxybutynin, docusate, and Klor-Con.  Chest x-rays were followed.  He did have free flowing fluid in his left chest.  Radiology consultation was obtained for thoracentesis.  The patient was seen by Dr. Y. An echocardiogram was done.  This revealed an ejection fraction of 60% with diastolic dysfunction and periaortic stenosis with an opening of 1 cm3.  An adenosine sestamibi was done in March 2000, with a small fixed apical defect, but no ischemia.  Cardiac enzymes were negative.  Dr. Y recommended a beta-blocker with an ACE inhibitor; therefore, the lisinopril was discontinued.  The patient felt much better after the thoracentesis.  I do not have the details of this, i.e., the volumes.  No fluid was sent for routine studies.,LABORATORY AT DISCHARGE: , Sodium 134, potassium 4.2, chloride 99, CO2 26, glucose 182, BUN 17, and creatinine 1.0.  Glucose was elevated because of several doses of Solu-Medrol given to him because of bronchospams.  Magnesium was 1.8, calcium was 8.1.  Liver enzymes were unremarkable.  Cardiac enzymes were normal as mentioned.  PT/INR is 1.02, PTT 31.3, white blood cell count 15, 000 with a left shift.  This was presumed due to the corticosteroids.  H&H was 32.3/11.3 and platelets 352,000, and MCV was 99.  The patient's O2 saturations on room air were normal.,Vital signs were stable.,DISCHARGE MEDICATIONS: , He is being discharged home on Lasix 40 mg daily, potassium chloride 10 mEq daily, atenolol 25 mg daily, aspirin 5 grains daily, Ditropan 5 mg b.i.d., and Colace 100 mg b.i.d.,FOLLOWUP: , He will be followed in my office in 1 week.  He is to notify if recurrent fever or chills.,PROGNOSIS:  ,Guarded.","discharge summary, prostate cancer, anemia of chronic disease, congestive heart failure, pleural effusion, thoracentesis, chf, anemia"
" Multiple extensive subcutaneous abscesses, right thigh.  Massive open wound, right thigh, status post right excision of multiple subcutaneous abscesses, right thigh.", Discharge Summary, Chronic Abscesses - Discharge Summary ,"DISCHARGE DIAGNOSES,1.  Multiple extensive subcutaneous abscesses, right thigh.,2.  Massive open wound, right thigh, status post right excision of multiple subcutaneous abscesses, right thigh.,PROCEDURES PERFORMED,1.  On 03/05/08, by Dr. X, was massive debridement of soft tissue, right lateral thigh and hip.,2.  Soft tissue debridement on 03/16/08 of right thigh and hip by Dr. X.,3.  Split thickness skin graft to right thigh and right hip massive open wound on 04/01/08 by Dr. Y.,REASON FOR ADMISSION: , The patient is a 62-year-old male with a history of drug use.  He had a history of injection of heroin into his bilateral thighs.  Unfortunately, he developed chronic abscesses, open wounds on his bilateral thighs, much worse on his right than his left.  Decision was made to do a radical excision and then it is followed by reconstruction.,HOSPITAL COURSE:  ,The patient was admitted on 03/05/08 by Dr. X.  He was taken to the operating room.  He underwent a massive resection of multiple subcutaneous abscesses, heroin remnants, which left massive huge open wounds to his right thigh and hip.  This led to a prolonged hospital course.  The patient initially was treated with local wound care.  He was treated with broad spectrum antibiotics.  He ended up growing out different species of Clostridium.  Infectious Disease consult was obtained from Dr. Z.  He assisted in further antibiotic coverage throughout the rest of his hospitalization.  The patient also had significant hypoalbuminemia, decreased nutrition.  Given his large wounds, he did end up getting a feeding tube placement, and prior to grafting, he received significant feeding tube supplementation to help achieve adequate nutrition for healing.  The patient had this superior area what appeared to be further necrotic, infected soft tissue.  He went back to the OR on 03/16/08 and further resection done by Dr. X.  After this, his wound appeared to be free of infection.  He is treated with a wound VAC.  He slowly, but progressively had significant progress in his wound.  I went from a very poor-looking wound to a red granulated wound throughout its majority.  He was thought ready for skin grafting.  Note that the patient had serial ultrasounds given his high risk of DVT from this massive wound and need for decreased activity.  These were negative.  He was treated with SCDs to help decrease his risk.  On 04/01/08, the patient was taken to the operating room, was thought to have an adequate ________ grafting.  He underwent skin grafting to his right thigh and hip massive open wound.  Donor sites were truncated.  Postoperatively, the patient ended up with a vast majority of skin graft taking.  To unable to take, he was kept on IV antibiotics, strict bed rest, and limited range of motion of his hip.  He is continued on VAC dressing.  Graft progressively improved with this therapy.  Had another ultrasound, which was negative for DVT.  The patient was mobilized up out of his bed.  Infectious Disease recommendations were obtained.  Plan was to complete additional 10 days of antibiotics at discharge.  This will be oral antibiotics.  I would monitor his left side, which has significantly decreased inflammation and irritation or infection given the antibiotic coverage.  So, decision was not made to excise this, but instead monitor.  By 04/11/08, his graft looked good.  It was pink and filling in.  He looked stable for discharge.  The patient was discharged to home.,DISCHARGE INSTRUCTIONS: , Discharge to home.,CONDITION: , Stable.,Antibiotic Augmentin XR script was written.  He is okay to shower.  Donor site and graft site dressing instruction orders were given for Home Health and the patient.  His followup was arranged with Dr. X and myself.","discharge summary, multiple extensive subcutaneous abscesses, open wound, subcutaneous abscesses, multiple subcutaneous abscesses, skin grafting, thigh, wound, abscesses, wounds, subcutaneous, antibiotics,"
" A 49-year-old man with respiratory distress, history of coronary artery disease with prior myocardial infarctions, and recently admitted with pneumonia and respiratory failure.", Discharge Summary, Cardio/Pulmo Discharge Summary ,"ADMISSION DIAGNOSIS:,1. Respiratory arrest.,2 . End-stage chronic obstructive pulmonary disease.,3. Coronary artery disease.,4. History of hypertension.,DISCHARGE DIAGNOSIS:,1. Status post-respiratory arrest.,2. Chronic obstructive pulmonary disease.,3. Congestive heart failure.,4. History of coronary artery disease.,5. History of hypertension.,SUMMARY:,  The patient is a 49-year-old man who was admitted to the hospital in respiratory distress, and had to be intubated shortly after admission to the emergency room. The patient’s past history is notable for a history of coronary artery disease with prior myocardial infarctions in 1995 and 1999. The patient has recently been admitted to the hospital with pneumonia and respiratory failure. The patient has been smoking up until three to four months previously. On the day of admission, the patient had the sudden onset of severe dyspnea and called an ambulance. The patient denied any gradual increase in wheezing, any increase in cough, any increase in chest pain, any increase in sputum prior to the onset of his sudden dyspnea.,ADMISSION PHYSICAL EXAMINATION:,GENERAL: Showed a well-developed, slightly obese man who was in extremis.,NECK: Supple, with no jugular venous distension.,HEART: Showed tachycardia without murmurs or gallops.,PULMONARY: Status showed decreased breath sounds, but no clear-cut rales or wheezes.,EXTREMITIES: Free of edema.,HOSPITAL COURSE:,  The patient was admitted to the Special Care Unit and intubated. He received intravenous antibiotic therapy with Levaquin. He received intravenous diuretic therapy. He received hand-held bronchodilator therapy. The patient also was given intravenous steroid therapy with Solu-Medrol. The patient’s course was one of gradual improvement, and after approximately three days, the patient was extubated. He continued to be quite dyspneic, with wheezes as well as basilar rales. After pulmonary consultation was obtained, the pulmonary consultant felt that the patient’s overall clinical picture suggested that he had a,significant element of congestive heart failure. With this, the patient was placed on increased doses of Lisinopril and Digoxin, with improvement of his respiratory status. On the day of discharge, the patient had minimal basilar rales; his chest also showed minimal expiratory wheezes; he had no edema; his heart rate was regular; his abdomen was soft; and his neck veins were not distended. It was, therefore, felt that the patient was stable for further management on an outpatient basis.,DIAGNOSTIC DATA:,  The patient’s admission laboratory data was notable for his initial blood gas, which showed a pH of 7.02 with a pCO2 of 118 and a pO2 of 103. The patient’s electrocardiogram showed nonspecific ST-T wave changes. The patent’s CBC showed a white count of 24,000, with 56% neutrophils and 3% bands.,DISPOSITION:,  The patient was discharged home.,DISCHARGE INSTRUCTIONS:,  His diet was to be a 2 grams sodium, 1800 calorie ADA diet. His medications were to be Prednisone 20 mg twice per day, Theo-24 400 mg per day, Furosemide 40 mg 1-1/2 tabs p.o. per day; Acetazolamide 250 mg one p.o. per day, Lisinopril 20 mg. one p.o. twice per day, Digoxin 0.125 mg one p.o. q.d., nitroglycerin paste 1 inch h.s., K-Dur 60 mEq p.o. b.i.d. He was also to use a Ventolin inhaler every four hours as needed, and Azmacort four puffs twice per day. He was asked to return for follow-up with Dr. X in one to two weeks. Arrangements have been made for the patient to have an echocardiogram for further evaluation of his congestive heart failure later on the day of discharge.","discharge summary, ada diet, congestive heart failure, coronary artery disease, respiratory arrest, chest pain, chronic obstructive pulmonary disease, emergency room, hypertension, sputum, wheezing, respiratory distress, myocardial infarctions, respiratory failure, pulmonary disease, basilar rales, heart failure, infarctions, heart, wheezes, coronary, pulmonary, discharge, respiratory, "
 Complex open wound right lower extremity complicated by a methicillin-resistant staphylococcus aureus cellulitis.  The patient is a 52-year-old male who has had a very complex course secondary to a right lower extremity complex open wound. , Discharge Summary, Cellulitis - Discharge Summary ,"DISCHARGE DIAGNOSIS:  ,Complex open wound right lower extremity complicated by a methicillin-resistant staphylococcus aureus cellulitis.,ADDITIONAL DISCHARGE DIAGNOSES:,1.  Chronic pain.,2.  Tobacco use.,3.  History of hepatitis C.,REASON FOR ADMISSION:,  The patient is a 52-year-old male who has had a very complex course secondary to a right lower extremity complex open wound.  He has had prolonged hospitalizations because of this problem.  He was recently discharged when he was noted to develop as an outpatient swollen, red tender leg.  Examination in the emergency room revealed significant concern for significant cellulitis.  Decision was made to admit him to the hospital.,HOSPITAL COURSE:,  The patient was admitted on 03/26/08 and was started on IV antibiotics elevation, was also counseled to minimizing the cigarette smoking.  The patient had edema of his bilateral lower extremities.  The hospital consult was also obtained to address edema issue question was related to his liver hepatitis C.  Hospital consult was obtained.  This included an ultrasound of his abdomen, which showed just mild cirrhosis.  His leg swelling was thought to be secondary to chronic venostasis and with likely some contribution from his liver as well.  The patient eventually grew MRSA in a moderate amount.  He was treated with IV vancomycin.  Local wound care and elevation.  The patient had slow progress.  He was started on compression, and by 04/03/08 his leg got much improved, minimal redness and swelling was down with compression.  The patient was thought safe to discharge home.,DISCHARGE INSTRUCTIONS: , The patient was discharged on doxycycline 100 mg p.o. b.i.d. x10 days.  He was also given prescription for Percocet and OxyContin, picked up at my office.  He is instructed to do daily wound care and also wrap his leg with an Ace wrap.  Followup was arranged in a couple of weeks.,DISCHARGE CONDITION: , Stable.","discharge summary, chronic pain, methicillin-resistant staphylococcus aureus cellulitis, complex open wound, staphylococcus aureus, wound care, cellulitis, wound, hepatitis,"
 Bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy.  Chronic pain syndrome., Discharge Summary, Back & Leg Pain - Discharge Summary ,"ADMISSION DIAGNOSIS: , Bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy.,SECONDARY DIAGNOSIS:,  Chronic pain syndrome.,PRINCIPAL PROCEDURE: , L5 Gill procedure with interbody and posterolateral (360 degrees circumferential) arthrodesis using cages, bone graft, recombinant bone morphogenic protein, and pedicle fixation.  This was performed by Dr. X on 01/08/08.,BRIEF HISTORY OF HOSPITAL COURSE: , The patient is a man with a history of longstanding back, buttock, and bilateral leg pain.  He was evaluated and found to have bilateral pars defects at L5-S1 with spondylolysis and instability.  He was admitted and underwent an uncomplicated surgical procedure as noted above.  In the postoperative period, he was up and ambulatory.  He was taking p.o. fluids and diet well.  He was afebrile.  His wounds were healing well.  Subsequently, the patient was discharged home.,DISCHARGE MEDICATIONS: , Discharge medications included his usual preoperative pain medication as well as other medications.,FOLLOWUP:  ,At this time, the patient will follow up with me in the office in six weeks' time.  The patient understands discharge plans and is in agreement with the discharge plan.  He will follow up as noted","discharge summary, chronic pain syndrome, spinal instability, pars defects, radiculopathy, spondylolysis, leg"
 A lady was admitted to the hospital with chest pain and respiratory insufficiency.  She has chronic lung disease with bronchospastic angina., Discharge Summary, Chest Pain & Respiratory Insufficiency ,"We discovered new T-wave abnormalities on her EKG.  There was of course a four-vessel bypass surgery in 2001.  We did a coronary angiogram.  This demonstrated patent vein grafts and patent internal mammary vessel and so there was no obvious new disease.,She may continue in the future to have angina and she will have nitroglycerin available for that if needed.,Her blood pressure has been elevated and so instead of metoprolol, we have started her on Coreg 6.25 mg b.i.d.  This should be increased up to 25 mg b.i.d. as preferred antihypertensive in this lady's case.  She also is on an ACE inhibitor.,So her discharge meds are as follows:,1.  Coreg 6.25 mg b.i.d.,2.  Simvastatin 40 mg nightly.,3.  Lisinopril 5 mg b.i.d.,4.  Protonix 40 mg a.m.,5.  Aspirin 160 mg a day.,6.  Lasix 20 mg b.i.d.,7.  Spiriva puff daily.,8.  Albuterol p.r.n. q.i.d.,9.  Advair 500/50 puff b.i.d.,10.  Xopenex q.i.d. and p.r.n.,I will see her in a month to six weeks.  She is to follow up with Dr. X before that.","discharge summary, chest pain, respiratory insufficiency, chronic lung disease, bronchospastic angina, insufficiency, chest, angina, respiratory, bronchospastic"
" Bronchiolitis, respiratory syncytial virus positive; improved and stable.  Innocent heart murmur, stable.", Discharge Summary, Bronchiolitis - Discharge Summary ,"DIAGNOSES:,1.  Bronchiolitis, respiratory syncytial virus positive; improved and stable.,2.  Innocent heart murmur, stable.,HOSPITAL COURSE: , The patient was admitted for an acute onset of congestion.  She was checked for RSV, which was positive and admitted to the hospital for acute bronchiolitis.  She has always been stable on room air; however, because of her age and her early diagnosis, she was admitted for observation as RSV bronchiolitis typically worsens the third and fourth day of illness.  She was treated per pathway orders.  However, on the second day of admission, the patient was not quite eating well and parents live far away and she did have a little bit of trouble on first night of admission.  There was a heart murmur that was heard that sounded innocent, but yet there was no chest x-ray that was obtained.  We did obtain a chest x-ray, which did show a slight perihilar infiltrate in the right upper lobe.  However, the rest of the lungs were normal and the heart was also normal.  There were no complications during her hospitalization and she continued to be stable and eating better.  On day 2 of the admission, it was decided she was okay to go home.  Mother was advised regarding signs and symptoms of increased respiratory distress, which includes tachypnea, increased retractions, grunting, nasal flaring etc. and she was very comfortable looking for this.  During her hospitalization, albuterol MDI was given to the patient and more for mom to learn outpatient care.  The patient did receive a couple of doses, but she did not have any significant respiratory distress and she was discharged in improved condition.,DISCHARGE PHYSICAL EXAMINATION:,VITAL SIGNS:  She is afebrile.  Vital signs were stable within normal limits on room air.,GENERAL:  She is sleeping and in no acute distress.,HEENT:  Her anterior fontanelle was soft and flat.  She does have some upper airway congestion.,CARDIOVASCULAR:  Regular rate and rhythm with a 2-3/6 systolic murmur that radiates to bilateral axilla and the back.,EXTREMITIES:  Her femoral pulses were 2+ and her extremities were warm and well perfused with good capillary refill.,LUNGS:  Her lungs did show some slight coarseness, but good air movement with equal breath sounds.  She does not have any wheezes at this time, but she does have a few scattered crackles at bilateral bases.  She did not have any respiratory distress while she was asleep.,ABDOMEN:  Normal bowel sounds.  Soft and nondistended.,GENITOURINARY:  She is Tanner I female.,DISCHARGE WEIGHT:,  Her weight at discharge 3.346 kg, which is up 6 grams from admission.,DISCHARGE INSTRUCTIONS: , ,ACTIVITY:  No one should smoke near The patient.  She should also avoid all other exposures to smoke such as from fireplaces and barbecues.  She is to avoid contact with other infants since she is sick and they are to limit travel.  There should be frequent hand washings.,DIET:  Regular diet.  Continue breast-feeding as much as possible and encourage oral intake.,MEDICATIONS:  She will be sent home on albuterol MDI to be used as needed for cough, wheezes or dyspnea.,ADDITIONAL INSTRUCTIONS:,  Mom is quite comfortable with bulb suctioning the nose with saline and they know that they are to return immediately if she starts having difficulty breathing, if she stops breathing or she decides that she does not want to eat.,","discharge summary, bronchiolitis, respiratory syncytial virus, bulb suctioning, innocent heart murmur, chest x ray, syncytial virus, heart murmur, respiratory distress, lungs, "
 Discharge summary of a patient with a BRCA-2 mutation., Discharge Summary, BRCA-2 mutation ,"DISCHARGE DIAGNOSES:,  BRCA-2 mutation.  ,HISTORY OF PRESENT ILLNESS:  ,The patient is a 59-year-old with a BRCA-2 mutation.  Her sister died of breast cancer at age 32 and her daughter had breast cancer at age 27.,PHYSICAL EXAMINATION:  ,The chest was clear.  The abdomen was nontender.  Pelvic examination shows no masses.  No heart murmur.  ,HOSPITAL COURSE:  ,The patient underwent surgery on the day of admission.  In the postoperative course she was afebrile and unremarkable.  The patient regained bowel function and was discharged on the morning of the fourth postoperative day.,OPERATIONS AND PROCEDURES: , Total abdominal hysterectomy/bilateral salpingo-oophorectomy with resection of ovarian fossa peritoneum en bloc on July 25, 2006.,PATHOLOGY: , A 105-gram uterus without dysplasia or cancer.,CONDITION ON DISCHARGE: , Stable.,PLAN:  ,The patient will remain at rest initially with progressive ambulation after.  She will avoid lifting, driving or intercourse.  She will call me if any fevers, drainage, bleeding, or pain.  Follow up in my office in four weeks.  Family history, social history, psychosocial needs per the social worker.,DISCHARGE MEDICATIONS: , Percocet 5 #40 one every 3 hours p.r.n. pain.","discharge summary, brca-2 mutation, brca-2, mutation, breast cancer, brca mutation, breast, postoperative, peritoneum, brca, discharge, cancer,"
 Decreased ability to perform daily living activities secondary to exacerbation of chronic back pain., Discharge Summary, Back Pain - Discharge Summary ,"CHIEF COMPLAINT: , Decreased ability to perform daily living activities secondary to exacerbation of chronic back pain.,HISTORY OF PRESENT ILLNESS:,  The patient is a 45-year-old white male who was admitted with acute back pain.  The patient reports that he had chronic problem with back pain for approximately 20 years, but it has gotten progressively worse over the last 3 years.  On 08/29/2007, the patient had awoken and started his day as he normally does, but midday, he reports that he was in such severe back pain and he was unable to walk or stand upright.  He was seen at ABCD Hospital Emergency Room, was evaluated and admitted.  He was treated with IV analgesics as well as Decadron, after being evaluated by Dr. A.  It was decided that the patient could benefit from physical therapy, since he was unable to perform ADLs, and was transferred to TCU at St. Joseph Health Services on 08/30/2007.  He had been transferred with diagnosis of a back pain secondary to intravertebral lumbar disk disease, secondary to degenerative changes.  The patient reports that he has had a "" bulging disk"" for approximately 1 year.  He reports that he has history of testicular cancer in the distant past and the most recent bone scan was negative.  The bone scan was done at XYZ Hospital, ordered by Dr. B, the patient's oncologist.,ALLERGIES: , PENICILLIN, AMOXICILLIN, CEPHALOSPORIN, DOXYCYCLINE, IVP DYE, IODINE, and SULFA, all cause HIVES.,Additionally, the patient reports that he has HIVES when he comes in contact with SAP FROM THE MANGO TREE, and therefore, he avoids any mango product at all.,PAST MEDICAL HISTORY: , Status post right orchiectomy secondary to his testicular cancer 18 years ago approximately 1989, GERD, irritable bowel syndrome, seasonal asthma (fall and spring) triggered by postnasal drip, history of bilateral carpal tunnel syndrome, and status post excision of abdominal teratoma and incisional hernia.,FAMILY HISTORY:,  Noncontributory.,SOCIAL HISTORY: , The patient is employed in the finance department.  He is a nonsmoker.  He does consume alcohol on the weekend as much as 3 to 4 alcoholic beverages per day on the weekends.  He denies any IV drug use or abuse.,REVIEW OF SYSTEMS: , No chills, fever, shakes or tremors.  Denies chest pain palpitations, hemoptysis, shortness of breath, nausea, vomiting, diarrhea, constipation or hematemesis.  The patient reports that his last bowel movement was on 08/30/2007.  No urological symptoms such as dysuria, frequency, incomplete bladder emptying or voiding difficulties.  The patient does report that he has occasional intermittent ""numbness and tingling"" of his hands bilaterally as he has a history of bilateral carpal tunnel syndrome.  He denies any history of seizure disorders, but he did report that he had some momentary dizziness earlier, but that has since resolved.,PHYSICAL EXAMINATION:,VITAL SIGNS:  At the time of admission, temperature 98, blood pressure 176/97, pulse 86, respirations 20, and 95% O2 saturation on room air.  The patient weighs 260 pounds and is 5 feet and 10 inches tall by his report.,GENERAL:  The patient appears to be comfortable, in no acute distress.,HEENT:  Normocephalic.  Sclerae are nonicteric.  EOMI.  Tongue is at midline and no evidence of thrush.,NECK:  Trachea is at the midline.,LYMPHATICS:  No cervical or axillary nodes palpable.,LUNGS:  Clear to auscultation bilaterally.,HEART:  Regular rate and rhythm.  Normal S1 and S2.,ABDOMEN:  Obese, softly protuberant, and nontender.,EXTREMITIES:  There is no clubbing, cyanosis or edema.  There is no calf tenderness bilaterally.  Bilateral strength is 5/5 for the upper extremities bilaterally and he has 5/5 of left lower extremity.  The right lower extremity is 4-5/5.,MENTAL STATUS:  He is alert and oriented.  He was pleasant and cooperative during the examination.,ASSESSMENT:,1.  Acute on chronic back pain.  The patient is admitted to the TCU at St. Joseph Health Services for rehabilitation therapy.  He will be seen in consultation by Physical Therapy and Occupational Therapy.  He will continue a tapering dose of Decadron over the next 10 to 14 days and a tapering schedule has been provided, also Percocet 5/325 mg 1 to 2 tablets q.i.d. p.r.n. for pain.,2.  Status post right orchiectomy secondary to testicular cancer, stable at this time.  We will attempt to obtain copy of the most recent bone scan performed at XYZ Hospital ordered by Dr. B.,3.  Gastroesophageal reflux disease, irritable bowel syndrome, and gastrointestinal prophylaxis.  Colace 100 mg b.i.d., lactulose will be used on a p.r.n. basis, and Protonix 40 mg daily.,4.  Deep vein thrombosis prophylaxis will be maintained by the patient, continue to engage in his therapies including ambulating in the halls and doing leg exercises as well.,5.  Obesity.  As mentioned above, the patient's weighs 260 pounds with a height of 5 feet and 10 inches, and we had discussed possible weight loss plan, which he is interested in pursuing and a dietary consult has been requested.",
" Need for cardiac catheterization.  Coronary artery disease, chest pain, history of diabetes, history of hypertension, history of obesity,  a 1.1 cm lesion in the medial aspect of the right parietal lobe, and deconditioning.", Discharge Summary, Cardiac Transfer Summary ,"REASON FOR TRANSFER:,  Need for cardiac catheterization done at ABCD.,TRANSFER DIAGNOSES:,1.  Coronary artery disease.,2.  Chest pain.,3.  History of diabetes.,4.  History of hypertension.,5.  History of obesity.,6.  A 1.1 cm lesion in the medial aspect of the right parietal lobe.,7.  Deconditioning.,CONSULTATIONS: , Cardiology.,PROCEDURES:,1.  Echocardiogram.,2.  MRI of the brain.,3.  Lower extremity Duplex ultrasound.,HOSPITAL COURSE: , Please refer to my H&P for full details.  In brief, the patient is a  64-year-old male with history of diabetes, who presented with 6 hours of chest pressure.  He was brought in by a friend.  The friend states that the patient deteriorated over the last few weeks to the point that he is very short of breath with exertion.  He apparently underwent a cardiac workup 6 months ago that the patient states he barely passed.  His vital signs were stable on admission.  He was ruled out for myocardial infarction with troponin x2.  An echocardiogram showed concentric LVH with an EF of 62%.  I had Cardiology come to see the patient, who reviewed the records from Fountain Valley.  Based on his stress test in the past, Dr. X felt the patient needed to undergo a cardiac cath during his inpatient stay.,The patient on initial presentation complained of, what sounded like, amaurosis fugax.  I performed an MRI, which showed a 1 cm lesion in the right parietal lobe.  I was going to call Neurology at XYZ for evaluation.  However, secondary to his indication for transfer, this could be followed up at ABCD with Dr. Y.,The patient is now stable for transfer for cardiac cath.,Discharged to ABCD.,DISCHARGE CONDITION:,  Stable.,DISCHARGE MEDICATIONS:,1.  Aspirin 325 mg p.o. daily.,2.  Lovenox 40 mg p.o. daily.,3.  Regular Insulin sliding scale.,4.  Novolin 70/30, 15 units b.i.d.,5.  Metformin 500 mg p.o. daily.,6.  Protonix 40 mg p.o. daily.,DISCHARGE FOLLOWUP: , Followup to be arranged at ABCD after cardiac cath.",
" Counting calorie points, exercising pretty regularly, seems to be doing well", Diets and Nutritions, Dietary Consult - 4 ,"SUBJECTIVE:,  The patient is keeping a food journal that she brought in.  She is counting calorie points, which ranged 26 to 30 per day.  She is exercising pretty regularly.  She attends Overeaters Anonymous and her sponsor is helping her and told her to get some ideas on how to plan snacks to prevent hypoglycemia.  The patient requests information on diabetic exchanges.  She said she is feeling better since she has lost weight.,OBJECTIVE:,Vital Signs:  The patient's weight today is 209 pounds, which is down 22 pounds since I last saw her on 06/07/2004.  I praised her weight loss and her regular exercising.  I looked at her food journal.  I praised her record keeping.  I gave her a list of the diabetic exchanges and explained them.  I also gave her a food dairy sheet so that she could record exchanges.  I encouraged her to continue.,ASSESSMENT:,  The patient seems happy with her progress and she seems to be doing well.  She needs to continue.,PLAN:,  Followup is on a p.r.n. basis.  She is always welcome to call or return.","diets and nutritions, overeaters anonymous, diabetic exchanges, exercising pretty regularly, food journal, diabetic, exercising, exchanges, regularly"
" Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.", Diets and Nutritions, Dietary Consult - Weight Reduction ,"SUBJECTIVE:,  This is a 56-year-old female who comes in for a dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.  The patient states that her husband has been diagnosed with high blood cholesterol as well.  She wants some support with some dietary recommendations to assist both of them in healthier eating.  The two of them live alone now, and she is used to cooking for large portions.  She is having a hard time adjusting to preparing food for the two of them.  She would like to do less food preparation, in fact.  She is starting a new job this week.,OBJECTIVE:,  Her reported height is 5 feet 4 inches.  Today’s weight was 170 pounds.  BMI is approximately 29.  A diet history was obtained.  I instructed the patient on a 1200 calorie meal plan emphasizing low-saturated fat sources with moderate amounts of sodium as well.  Information on fast food eating was supplied, and additional information on low-fat eating was also supplied.,ASSESSMENT:,  The patient’s basal energy expenditure is estimated at 1361 calories a day.  Her total calorie requirement for weight maintenance is estimated at 1759 calories a day.  Her diet history reflects that she is making some very healthy food choices on a regular basis.  She does emphasize a lot of fruits and vegetables, trying to get a fruit or a vegetable or both at most meals.  She also is emphasizing lower fat selections.  Her physical activity level is moderate at this time.  She is currently walking for 20 minutes four or five days out of the week but at a very moderate pace with a friend.  We reviewed the efforts at weight reduction identifying 3500 calories in a pound of body fat and the need to gradually and slowly chip away at this number on a long-term basis for weight reduction.  We discussed the need to reduce calories from what her current patterns are and to hopefully increase physical activity slightly as well.  We discussed menu selection, as well as food preparation techniques.  The patient appears to have been influenced by the current low-carb, high-protein craze and had really limited her food selections based on that.  I was able to give her some more room for variety including some moderate portions of potatoes, pasta and even on occasion breading her meat as long as she prepares it in a low-fat fashion which was discussed.,PLAN:,  Recommend the patient increase the intensity and the duration of her physical activity with a goal of 30 minutes five days a week working at a brisk walk.  Recommend the patient reduce calories by 500 daily to support a weight loss of one pound a week.  This translates into a 1200-calorie meal plan.  I encouraged the patient to keep food records in order to better track calories consumed.  I recommended low fat selections and especially those that are lower in saturated fats.  Emphasis would be placed on moderating portions of meat and having more moderate snacks between meals as well.  This was a one-hour consultation.  I provided my name and number should additional needs arise.","diets and nutritions, hyperlipidemia, hypertension, gastroesophageal reflux disease, weight reduction, dietary recommendations, healthier eating, meal plan, dietary consultation, low fat, physical activity, weight, gastroesophageal, dietary, calories, food"
 Dietary consultation for gestational diabetes., Diets and Nutritions, Dietary Consult - Gestational Diabetes ,"SUBJECTIVE:,  This is a 38-year-old female who comes for dietary consultation for gestational diabetes.  Patient reports that she is scared to eat because of its impact on her blood sugars.  She is actually trying not to eat while she is working third shift at Wal-Mart.  Historically however, she likes to eat out with a high frequency.  She enjoys eating rice as part of her meals.  She is complaining of feeling fatigued and tired all the time because she works from 10 p.m. to 7 a.m. at Wal-Mart and has young children at home.  She sleeps two to four hours at a time throughout the day.  She has been testing for ketones first thing in the morning when she gets home from work.,OBJECTIVE:,  Today's weight:  155.5 pounds.  Weight from 10/07/04 was 156.7 pounds.  A diet history was obtained.  Blood sugar records for the last three days reveal the following:  fasting blood sugars 83, 84, 87, 77; two-hour postprandial breakfast 116, 107, 97; pre-lunch 85, 108, 77; two-hour postprandial lunch 86, 131, 100; pre-supper 78, 91, 100; two-hour postprandial supper 125, 121, 161; bedtime 104, 90 and 88.  I instructed the patient on dietary guidelines for gestational diabetes.  The Lily Guide for Meal Planning was provided and reviewed.  Additional information on gestational diabetes was applied.  A sample 2000-calorie meal plan was provided with a carbohydrate budget established.,ASSESSMENT:,  Patient's basal energy expenditure adjusted for obesity is estimated at 1336 calories a day.  Her total calorie requirements, including a physical activity factor as well as additional calories for pregnancy, totals to 2036 calories per day.  Her diet history reveals that she has somewhat irregular eating patterns.  In the last 24 hours when she was working at Wal-Mart, she ate at 5 a.m. but did not eat anything prior to that since starting work at 10 p.m.  We discussed the need for small frequent eating.  We identified carbohydrate as the food source that contributes to the blood glucose response.  We identified carbohydrate sources in the food supply, recognizing that they are all good for her.  The only carbohydrates she was asked to entirely avoid would be the concentrated forms of refined sugars.  In regard to use of her traditional foods of rice, I pulled out a one-third cup measuring cup to identify a 15-gram equivalent of rice.  We discussed the need for moderating the portion of carbohydrates consumed at one given time.  Emphasis was placed at eating with a high frequency with a goal of eating every two to four hours over the course of the day when she is awake.  Her weight loss was discouraged.  Patient was encouraged to eat more generously but with attention to the amount of carbohydrates consumed at a time.,PLAN:,  The meal plan provided has a carbohydrate content that represents 40 percent of a 2000-calorie meal plan.  The meal plan was devised to distribute her carbohydrates more evenly throughout the day.  The meal plan was meant to reflect an example for her eating, while the patient was encouraged to eat according to appetite and not to go without eating for long periods of time.  The meal plan is as follows:  breakfast 2 carbohydrate servings, snack 1 carbohydrate serving, lunch 2-3 carbohydrate servings, snack 1 carbohydrate serving, dinner 2-3 carbohydrate servings, bedtime snack 1-2 carbohydrate servings.  Recommend patient include a solid protein with each of her meals as well as with her snack that occurs before going to sleep.  Encouraged adequate rest.  Also recommend adequate calories to sustain weight gain of one-half to one pound per week.  If the meal plan reflected does not support slow gradual weight gain, then we will need to add more foods accordingly.  This was a one-hour consultation.  I provided my name and number should additional needs arise.","diets and nutritions, blood sugars, fatigued, total calorie, carbohydrate content, consultation for gestational diabetes, dietary consultation, weight gain, gestational diabetes, carbohydrate servings, meal planning, meals, weight, carbohydrate, dietary, servings, planning"
 Dietary consultation for diabetes during pregnancy., Diets and Nutritions, Dietary Consult - Diabetes - 1 ,"SUBJECTIVE:,  This is a 28-year-old female who comes for dietary consultation for diabetes during pregnancy.  Patient reports that she had gestational diabetes with her first pregnancy.  She did use insulin at that time as well.  She does not fully understand what ketones are.  She walks her daughter to school and back home each day which takes 20 minutes each way.  She is not a big milk drinker, but she does try to drink some.,OBJECTIVE:,  Weight is 238.3 pounds.  Weight from last week’s visit was 238.9 pounds.  Prepregnancy weight is reported at 235 pounds.  Height is 62-3/4 inches.  Prepregnancy BMI is approximately 42-1/2.  Insulin schedule is NovoLog 70/30, 20 units in the morning and 13 units at supper time.  Blood sugar records for the last week reveal the following:  Fasting blood sugars ranging from 92 to 104 with an average of 97, two-hour postprandial breakfast readings ranging from 172 to 196 with an average of 181, two-hour postprandial lunch readings ranging from 149 to 189 with an average of 168 and two-hour postprandial dinner readings ranging from 109 to 121 with an average of 116.  Overall average is 140.  A diet history was obtained.  Expected date of confinement is May 1, 2005.  Instructed the patient on dietary guidelines for gestational diabetes.  A 2300 meal plan was provided and reviewed.  The Lily Guide for Meal Planning was provided and reviewed.,ASSESSMENT:,  Patient’s basal energy expenditure adjusted for obesity is estimated at 1566 calories a day.  Her total calorie requirements, including physical activity factors as well as additional calories for pregnancy, totals 2367 calories a day.  Her diet history reveals that she is eating three meals a day and three snacks.  The snacks were just added last week following presence of ketones in her urine.  We identified carbohydrate sources in the food supply, recognizing that they are the foods that raise blood sugar the most.  We identified 15 gram equivalents of carbohydrate and established a carbohydrate budget.  We also discussed the goal of balancing food intake with blood sugar control and adequate caloric intake to sustain appropriate weight gain for the pregnancy of 1/2 a pound a week through the duration of the pregnancy.  We discussed the physiology of ketone production from inadequate calories or inadequate insulin and elevated blood sugars.  While a sample meal plan was provided reflecting the patient’s carbohydrate budget I emphasized the need for her to eat according to her appetite, but to work at consistency in the volume of carbohydrates consumed at a given meal or a given snack from day to day.  Patient was assured that we can titrate the insulin to match whatever eating pattern is suitable for her as long as she can do it on a consistent basis.  At the same time she was encouraged to continue to eliminate the more concentrated forms of refined carbohydrates.,PLAN:,  Recommend the patient work with the following meal plan with a carbohydrate budget representing approximately 45% of the calories from carbohydrate.  Breakfast:  Three carbohydrate servings.  Morning snack:  One carbohydrate serving.  Lunch:  Four carbohydrate servings.  Afternoon snack:  One carbohydrate serving.  Supper:  Four carbohydrate servings.  Bedtime snack:  One carbohydrate serving.  Encouraged patient to include some solid protein with each of her meals as well as with the bedtime snack.  Encouraged three servings of dairy products per day to meet nutritional needs for calcium during pregnancy.  Recommend patient include a fruit or a vegetable with most of her meals.  Also recommend including solid protein with each meal as well as with the bedtime snack.  Charlie Athene reviewed blood sugars at this consultation as well, and made the following insulin adjustment:  Morning 70/30, will increase from 20 units up to 24 units and evening 70/30, we will increase from 13 units up to 16 units.  Patient was encouraged to call in blood sugars at the end of the week if they are outside of the range of over 90 fasting and over 120 two-hour postprandial.  Provided my name and number should there be additional dietary questions.","diets and nutritions, diabetes during pregnancy, diabetes, insulin, gestational diabetes, adjusted for obesity, calorie requirements, dietary consultation, carbohydrate, postprandial, meal, calories, dietary, pregnancy, servings, snacks"
" Anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray.  Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy and moderate stenosis C5-6.", Discharge Summary, Anterior Cervical Discectomy & Fusion - Discharge Summary ,"FINAL DIAGNOSES:,1.  Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy.,2.  Moderate stenosis C5-6.,OPERATION: , On 06/25/07, anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray.,This is a 60-year-old white male who was in the office on 05/01/07 because of neck pain with left radiculopathy and ""tension headaches.""  In the last year or so, he has had more and more difficulty and more recently has developed tingling and numbness into the fingers of the left hand greater than right.  He has some neck pain at times and has seen Dr. X for an epidural steroid injection, which was very helpful.  More recently he saw Dr. Y and went through some physical therapy without much relief.,Cervical MRI scan was obtained and revealed a large right-sided disc herniation at C4-5 with significant midline herniations at C5-6 and a large left HNP at C6-7.  In view of the multiple levels of pathology, I was not confident that anything short of surgical intervention would give him significant relief.  The procedure and its risk were fully discussed and he decided to proceed with the operation.,HOSPITAL COURSE: , Following admission, the procedure was carried out without difficulty.  Blood loss was about 125 cc.  Postop x-ray showed good alignment and positioning of the cages, plate, and screws.  After surgery, he was able to slowly increase his activity level with assistance from physical therapy.  He had some muscle spasm and soreness between the shoulder blades and into the back part of his neck.  He also had some nausea with the PCA.  He had a low-grade fever to 100.2 and was started on incentive spirometry.  Over the next 12 hours, his fever resolved and he was able to start getting up and around much more easily.,By 06/27/07, he was ready to go home.  He has been counseled regarding wound care and has received a neck sheet for instruction.  He will be seen in two weeks for wound check and for a followup evaluation/x-rays in about six weeks.  He has prescriptions for Lortab 7.5 mg and Robaxin 750 mg.  He is to call if there are any problems.","discharge summary, slimlock, herniated nucleuses pulposus, anterior cervical discectomy, bengal cages, anterior, herniated, cervical, radiculopathy, discectomy, "
" Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome", Diets and Nutritions, Dietary Consult - Hyperlipidemia ,"SUBJECTIVE:,  This is a followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome.  The patient reports that she has worked hard for a number of weeks following the meal plan prescribed, but felt like she was gaining weight and not losing weight on it.  She is not sure that she was following it accurately.  She is trying to walk 1-1/2 to 2 miles every other day, but is increasing her time in the garden and doing other yard work as well.  Once she started experiencing some weight gain, she went back to her old South Beach Diet and felt like she was able to take some of that weight off.  However she realizes that the South Beach Diet is not a healthy diet for her and so is coming back for better instruction on safe weight loss and low-fat eating.,OBJECTIVE:,  Weight is 275 pounds.  Food records were reviewed.,ASSESSMENT:,  The patient experienced a weight gain of 2 pounds since our last consultation which was two months ago.  I did carefully review her food records and evaluated calories consumed.  While she was carefully tracking the volume of protein and carbohydrates, she was getting some excess calories from the fatty proteins selected.  Thus we rearranged her meal plan a little bit and talked about how to track her fat calories as well.  She was more open to reducing the amount of protein from the previous meal plan and increasing slightly the amount of carbohydrates.  While this still is not as much carbohydrate as I would normally recommend, I am certainly willing to work with her on how she feels her body best handles weight reduction.  We also discussed a snack that could be eliminated in the morning because she really is not hungry at that time.,PLAN:,  A new 1500 calorie meal plan was developed based on 35% of the calories coming from protein, 40% of the calories from carbohydrate, and 25% of the calories from fat.  This translates in to 10 servings at 15 grams a piece of carbohydrates throughout the day dividing them in to groups of two servings per meal and per snack.  This also translates in to 2 ounces of protein at breakfast, 6 ounces at lunch, 2 ounces in the afternoon snack, 6 ounces at supper, and 2 ounces in the evening snack.  We have eliminated the morning snack.  The patient will now track the grams of fat in her meats as well as added fats.  Her goal for total fats over the course of the day is no more than 42 grams of fat per day.  This was a half hour consultation.  We will plan to see the patient back in one month for support.","diets and nutritions, hyperlipidemia, hypertension, metabolic syndrome, meal, food records, south beach diet, dietary consultation, meal plan, carbohydrates, snack, dietary, calories, weight"
 Elevated cholesterol and is on medication to lower it., Diets and Nutritions, Dietary Consult - 1 ,"SUBJECTIVE:,  His brother, although he is a vegetarian, has elevated cholesterol and he is on medication to lower it.  The patient started improving his diet when he received the letter explaining his lipids are elevated.  He is consuming less cappuccino, quiche, crescents, candy from vending machines, etc.  He has started packing his lunch three to four times per week instead of eating out so much.  He is exercising six to seven days per week by swimming, biking, running, lifting weights one and a half to two and a half hours each time.  He is in training for a triathlon.  He says he is already losing weight due to his efforts.,OBJECTIVE:,  Height:  6 foot 2 inches.  Weight:  204 pounds on 03/07/05.  Ideal body weight:  190 pounds, plus or minus ten percent.  He is 107 percent standard of midpoint ideal body weight.  BMI:  26.189.  A 48-year-old male.  Lab on 03/15/05:  Cholesterol:  251.  LDL:  166.  VLDL:  17.  HDL:  68.  Triglycerides:  87.  I explained to the patient the dietary guidelines to help improve his lipids.  I recommend a 26 to 51 to 77 fat grams per day for a 10 to 20 to 30 percent fat level of 2,300 calories since he is interested in losing weight.  I went over the printed information sheet on lowering your cholesterol and that was given to him along with a booklet on the same topic to read.  I encouraged him to continue as he is doing.,ASSESSMENT:,  Basal energy expenditure 1960 x 1.44 activity factor is approximately 2,800 calories.  His 24-hour recall shows he is making many positive changes already to lower his fat and cholesterol intake.  He needs to continue as he is doing.  He verbalized understanding and seemed receptive.,PLAN:,  The patient plans to recheck his lipids through Dr. XYZ  I gave him my phone number and he is to call me if he has any further questions regarding his diet.","diets and nutritions, vegetarian, lipids, cholesterol intake, elevated cholesterol, losing weight, body weight, dietary, cholesterol"
" Incision and drainage, first metatarsal head, left foot with culture and sensitivity.", Discharge Summary, Abscess with Cellulitis - Discharge Summary ,"ADMITTING DIAGNOSIS:,  Abscess with cellulitis, left foot.,DISCHARGE DIAGNOSIS:,  Status post I&D, left foot.,PROCEDURES:,  Incision and drainage, first metatarsal head, left foot with culture and sensitivity.,HISTORY OF PRESENT ILLNESS:,  The patient presented to Dr. X's office on 06/14/07 complaining of a painful left foot.  The patient had been treated conservatively in office for approximately 5 days, but symptoms progressed with the need of incision and drainage being decided.,MEDICATIONS:,  Ancef IV.,ALLERGIES:,  ACCUTANE.,SOCIAL HISTORY:,  Denies smoking or drinking.,PHYSICAL EXAMINATION: , Palpable pedal pulses noted bilaterally.  Capillary refill time less than 3 seconds, digits 1 through 5 bilateral.  Skin supple and intact with positive hair growth.  Epicritic sensation intact bilateral.  Muscle strength +5/5, dorsiflexors, plantar flexors, invertors, evertors.  Left foot with erythema, edema, positive tenderness noted, left forefoot area.,LABORATORY: , White blood cell count never was abnormal.  The remaining within normal limits.  X-ray is negative for osteomyelitis.  On 06/14/07, the patient was taken to the OR for incision and drainage of left foot abscess.  The patient tolerated the procedure well and was admitted and placed on vancomycin 1 g q.12h after surgery and later changed Ancef 2 g IV every 8 hours.  Postop wound care consists of Aquacel Ag and dry dressing to the surgical site everyday and the patient remains nonweightbearing on the left foot.  The patient progressively improved with IV antibiotics and local wound care and was discharged from the hospital on 06/19/07 in excellent condition.,DISCHARGE MEDICATIONS: , Lorcet 10/650 mg, dispense 24 tablets, one tablet to be taken by mouth q.6h as needed for pain.  The patient was continued on Ancef 2 g IV via PICC line and home health administration of IV antibiotics.,DISCHARGE INSTRUCTIONS: , Included keeping the foot elevated with long periods of rest.  The patient is to wear surgical shoe at all times for ambulation and to avoid excessive ambulation.  The patient to keep dressing dry and intact, left foot.  The patient to contact Dr. X for all followup care, if any problems arise.  The patient was given written and oral instruction about wound care before discharge.  Prior to discharge, the patient was noted to be afebrile.  All vitals were stable.  The patient's questions were answered and the patient was discharged in apparent satisfactory condition.  Followup care was given via Dr. X' office.","discharge summary, accutane, metatarsal head left foot, abscess with cellulitis, culture and sensitivity, incision and drainage, metatarsal head, foot, cellulitis, ancef, abscess, incision, drainage,"
 Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983., Diets and Nutritions, Dietary Consult - Diabetes - 2 ,"SUBJECTIVE:,  The patient is a 79-year-old African-American female with a self reported height of 5 foot 3 inches and weight of 197 pounds.  She was diagnosed with type 2 diabetes in 1983.  She is not allergic to any medicines.,DIABETES MEDICATIONS:,  Her diabetes medications include Humulin insulin 70/30, 44 units at breakfast and 22 units at supper.  Also metformin 500 mg at supper.,OTHER MEDICATIONS: , Other medications include verapamil, Benicar, Toprol, clonidine, and hydrochlorothiazide.,ASSESSMENT:,  The patient and her daughter completed both days of diabetes education in a group setting.  Blood glucose records and food diaries are reviewed by the diabetes educator and the dietician.  Fasting blood sugars are 127, 80, and 80.  Two-hour postprandial breakfast reading was 105, two-hour postprandial lunch reading was 88, and two-hour postprandial dinner reading was 73 and 63.  Her diet was excellent.,Seven hours of counseling about diabetes mellitus was provided on this date.,Blood glucose values obtained at 10 a.m. were 84 and at 2.30 p.m. were 109.  Assessment of her knowledge is completed at the end of the counseling session.  She demonstrated increased knowledge in all areas and had no further questions.  She also completed an evaluation of the class.,The patient's feet were examined during the education session.  She had flat feet bilaterally.  Skin color was pink, temperature warm.  Pedal pulses 2+.  Her right second and third toes lay on each other.  Also, the same on her left foot.  However, there was no skin breakdown.  She had large bunions, medial aspect of the ball of both feet.  She had positive sensitivity to most areas of her feet, however, she had negative sensitivity to the medial and lateral aspect of the balls of her left foot.,During the education session, she set behavioral goals for self care.  First goal is to eat three meals a day and eat three snacks daily to improve her blood glucose levels.  Second goal is to eat a well balanced meal at 1200 calories in order to lose one-half pound of weight per week and improve her blood glucose control.  Third goal is to exercise by walking for 15 to 30 minutes a day, three to five days a week to increase her blood glucose control.  Her success in achieving these goals will be followed in three months by a letter from the diabetes education class.,RECOMMENDATIONS:,  Since she is doing so well with her diet changes, her blood sugars have been within normal limits and sometimes on the low side, especially considering the fact that she has low blood sugar unawareness.  She is to followup with Dr. XYZ for possible reduction in her insulin doses.","diets and nutritions, dietary consult, diabetes education, glucose control, blood sugars, blood glucose, dietary, diabetes,"
 The patient is brought in by an assistant with some of his food diary sheets., Diets and Nutritions, Dietary Consult - 3 ,"SUBJECTIVE:,  The patient is brought in by an assistant with some of his food diary sheets.  They wonder if the patient needs to lose anymore weight.,OBJECTIVE:,  The patient's weight today is 186-1/2 pounds, which is down 1-1/2 pounds in the past month.  He has lost a total of 34-1/2 pounds.  I praised this.  I went over his food diary and praised all of his positive food choices reported, especially his use of sugar-free Kool-Aid, sugar-free pudding, and diet pop.  I encouraged him to continue all of that, as well as his regular physical activity.,ASSESSMENT:,  The patient is losing weight at an acceptable rate.  He needs to continue keeping a food diary and his regular physical activity.,PLAN:,  The patient plans to see Dr. XYZ at the end of May 2005.  I recommended that they ask Dr. XYZ what weight he would like for the patient to be at.  Follow up will be with me June 13, 2005.","diets and nutritions, weight, kool-aid, food diary sheets, diary sheets, physical activity, food diary, dietary, sheets, diary, food"
" The patient has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.", Diets and Nutritions, Dietary Consult - 2 ,"SUBJECTIVE:,  The patient's assistant brings in her food diary sheets.  The patient says she stays active by walking at the mall.,OBJECTIVE:,  Weight today is 201 pounds, which is down 3 pounds in the past month.  She has lost a total of 24 pounds.  I praised this and encouraged her to continue.  I went over her food diary.  I praised her three-meal pattern and all of her positive food choices, especially the use of sugar-free Kool-Aid, sugar-free Jell-O, sugar-free lemonade, diet pop, as well as the variety of foods she is using in her three-meal pattern.  I encouraged her to continue all of this.,ASSESSMENT:,  The patient has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.  She needs to continue all this.,PLAN:,  Followup is set for 06/13/05 to check the patient's weight, her food diary, and answer any questions.","diets and nutritions, food diary sheets, active, balanced diet, three-meal pattern, weight loss, sugar free, food diary, dietary, weight, meal, diary, sheets, food"
" Skin biopsy, scalp mole.  Darkened mole status post punch biopsy, scalp lesion.  Rule out malignant melanoma with pulmonary metastasis.", Dermatology, Scalp Mole Skin Biopsy ,"PROCEDURE: , Skin biopsy, scalp mole.,INDICATION:  ,A 66-year-old female with pulmonary pneumonia, effusion, rule out metastatic melanoma to lung.,PROCEDURE NOTE: , The patient's scalp hair was removed with:,1.  K-Y jelly.,2.  Betadine prep locally.,3.  A 1% lidocaine with epinephrine local instilled.,4.  A 3 mm punch biopsy used to obtain biopsy specimen, which was sent to the lab.  To control bleeding, two 4-0 P3 nylon sutures were applied, antibiotic ointment on the wound.  Hemostasis was controlled.  The patient tolerated the procedure.,IMPRESSION:,  Darkened mole status post punch biopsy, scalp lesion, rule out malignant melanoma with pulmonary metastasis.,PLAN: , The patient will have sutures removed in 10 days.","dermatology, k-y jelly, darkened mole, scalp mole, skin biopsy, punch biopsy, melanoma,"
 Punch biopsy of right upper chest skin lesion., Dermatology, Punch Biopsy - 1 ,"PROCEDURE:,  Punch biopsy of right upper chest skin lesion.,ESTIMATED BLOOD LOSS:,  Minimal.,FLUIDS: , Minimal.,COMPLICATIONS:,  None.,PROCEDURE:,  The area around the lesion was anesthetized after she gave consent for her procedure.  Punch biopsy including some portion of lesion and normal tissue was performed.  Hemostasis was completed with pressure holding.  The biopsy site was approximated with non-dissolvable suture.  The area was hemostatic.  All counts were correct and there were no complications.  The patient tolerated the procedure well.  She will see us back in approximately five days.,","dermatology, punch biopsy, skin lesion, "
 Dietary consultation for carbohydrate counting for type I diabetes., Diets and Nutritions, Carbohydrate Counting ,"SUBJECTIVE:,  This is a 62-year-old female who comes for dietary consultation for carbohydrate counting for type I diabetes.  The patient reports that she was hospitalized over the weekend for DKA.  She indicates that her blood sugar on Friday night was 187 at bedtime and that when she woke up in the morning her blood sugar was 477.  She gave herself, in smaller increments, a total of 70 extra units of her Humalog.  Ten of those units were injectable; the others were in the forms of pump.  Her blood sugar was over 600 when she went to the hospital later that day.  She is here at this consultation complaining of not feeling well still because she has a cold.  She realizes that this is likely because her immune system was so minimized in the hospital.,OBJECTIVE:,  Current insulin doses on her insulin pump are boluses set at 5 units at breakfast, 6 units at lunch and 11 units at supper.  Her basal rates have not been changed since her last visit with Charla Yassine and totaled 30.5 units per 24 hours.  A diet history was obtained.  I instructed the patient on carbohydrate counting at 1 unit of insulin for every 10 g carbohydrate ratio was recommended.  A correction dose of approximately 1 unit of insulin to bring the blood sugars down 30 mg/dl was also recommended.  The Lilly guide for meal planning was provided and reviewed.  Additional carbohydrate counting book was provided.,ASSESSMENT:,  The patient was taught an insulin-to-carbohydrate ratio of 1 unit to 10 g of carbohydrates as recommended at the previous visit two years ago, which she does not recall.  It is based on the 500 rule which suggests this ratio.  We did identify carbohydrate sources in the food supply, recognizing 15-g equivalents.  We also identified the need to dose her insulin at the time that she is eating her carbohydrate sources.  She does seem to have a pattern of fixing blood sugars later in the day after they are elevated.  We discussed the other option of trying to eat a consistent amount of carbohydrates at meals from day to day and taking a consistent amount of insulin at those meals.  With this in mind, she was recommended to follow with three servings or 45 g of carbohydrate at breakfast, three servings or 45 g of carbohydrate at lunch and four servings or 60 g of carbohydrate at dinner.  Joanne Araiza joined our consultation briefly to discuss whether her pump was working appropriately.  The patient was given an 800 number for the pump to contact should there be any question about its failure to deliver insulin appropriately.,PLAN:,  Recommend the patient use 1 unit of insulin for every 10-g carbohydrate load consumed.  Recommend the patient either use this as a carbohydrate counting tool or work harder at keeping carbohydrate content consistent at meals from day to day.  This was a one-hour consultation.  Provided my name and number should additional needs arise.","diets and nutritions, insulin pump, carbohydrate load, immune system, dietary consultation, carbohydrate ratio, blood sugars, carbohydrate counting, carbohydrate, dietary, blood, counting, insulin"
" Maculopapular rash in kind of a linear pattern over arms, legs, and chest area which are consistent with a poison ivy or a poison oak.", Dermatology, Poison Ivy - SOAP ,"SUBJECTIVE:,  He is a 24-year-old male who said that he had gotten into some poison ivy this weekend while he was fishing.  He has had several cases of this in the past and he says that is usually takes quite awhile for him to get over it; he said that the last time he was here he got a steroid injection by Dr. Blackman; it looked like it was Depo-Medrol 80 mg.  He said that it worked fairly well, although it seemed to still take awhile to get rid of it.  He has been using over-the-counter Benadryl as well as cortisone cream on the areas of the rash and having a little bit of improvement, but this last weekend he must have gotten into some more poison ivy because he has got another outbreak along his chest, legs, arms and back.,OBJECTIVE:,Vitals:  Temperature is 99.2.  His weight is 207 pounds.,Skin:  Examination reveals a raised, maculopapular rash in kind of a linear pattern over his arms, legs and chest area which are consistent with a poison ivy or a poison oak.,ASSESSMENT AND ,PLAN:,  Poison ivy.  Plan would be Solu-Medrol 125 mg IM X 1.  Continue over-the-counter Benadryl or Rx allergy medicine that he was given the last time he was here, which is a one-a-day allergy medicine; he can not exactly remember what it is, which would also be fine rather than the over-the-counter Benadryl if he would like to use that instead.","dermatology, poison ivy, steroid injection, depo-medrol, maculopapular rash, poison oak, maculopapular, chest, ivy, poison"
" The skin biopsy was performed on the right ankle and right thigh.  The patient was consented for skin biopsy.  The complications, instructions as to how the procedure will be performed, and postoperative instructions were given to the patient. ", Dermatology, Skin Biopsy ,"PROCEDURE:  ,The site was cleaned with antiseptic.  A local anesthetic (2% lidocaine) was given at each site.  A 3 mm punch biopsy was performed in the left calf and left thigh, above the knee.  The site was then checked for bleeding.  Once hemostasis was achieved, a local antibiotic was placed and the site was bandaged.,The patient was not on any anticoagulant medications.  There were also no other medications which would affect the ability to conduct the skin biopsy.  The patient was further instructed to keep the site completely dry for the next 24 hours, after which a new Band-Aid and antibiotic ointment should be applied to the area.  They were further instructed to avoid getting the site dirty or infected.  The patient completed the procedure without any complications and was discharged home.,The biopsy will be sent for analysis.,The patient will follow up with Dr. X within the next two weeks to review her results.","dermatology, antiseptic, local anesthetic, hemostasis, punch biopsy, band-aid, skin biopsyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Mohs Micrographic Surgery for basal cell CA at medial right inferior helix., Dermatology, Mohs Micrographic Surgery - 2 ,"PREOP DIAGNOSIS: , Basal Cell CA.,POSTOP DIAGNOSIS:,  Basal Cell CA.,LOCATION:  ,Medial right inferior helix.,PREOP SIZE:,  1.4 x 1 cm,POSTOP SIZE: , 2.7 x 2 cm,INDICATION: , Poorly defined borders.,COMPLICATIONS: , None.,HEMOSTASIS: , Electrodessication.,PLANNED RECONSTRUCTION: , Wedge resection advancement flap.,DESCRIPTION OF PROCEDURE: , Prior to each surgical stage, the surgical site was tested for anesthesia and reanesthetized as needed, after which it was prepped and draped in a sterile fashion.,The clinically-apparent tumor was carefully defined and debulked prior to the first stage, determining the extent of the surgical excision.  With each stage, a thin layer of tumor-laden tissue was excised with a narrow margin of normal appearing skin, using the Mohs fresh tissue technique.  A map was prepared to correspond to the area of skin from which it was excised.  The tissue was prepared for the cryostat and sectioned.  Each section was coded, cut and stained for microscopic examination.  The entire base and margins of the excised piece of tissue were examined by the surgeon.  Areas noted to be positive on the previous stage (if applicable) were removed with the Mohs technique and processed for analysis.,No tumor was identified after the final stage of microscopically controlled surgery.  The patient tolerated the procedure well without any complication.  After discussion with the patient regarding the various options, the best closure option for each defect was selected for optimal functional and cosmetic results.","dermatology, medial right inferior helix, wedge resection advancement flap, tumor-laden tissue, mohs fresh tissue technique, mohs technique, mohs micrographic surgery, basal cell ca, micrographic surgery, basal cell, micrographic, helix, basal, cell, ca, mohs, tissue, stage,"
 Mohs Micrographic Surgery for basal cell CA at mid parietal scalp., Dermatology, Mohs Micrographic Surgery - 1 ,"PREOP DIAGNOSIS: , Basal Cell CA.,POSTOP DIAGNOSIS:,  Basal Cell CA.,LOCATION: , Mid parietal scalp.,PREOP SIZE:,  1.5 x 2.9 cm,POSTOP SIZE:,  2.7 x 2.9 cm,INDICATION:,  Poorly defined borders.,COMPLICATIONS:,  None.,HEMOSTASIS:, Electrodessication.,PLANNED RECONSTRUCTION:,  Simple Linear Closure.,DESCRIPTION OF PROCEDURE:,  Prior to each surgical stage, the surgical site was tested for anesthesia and reanesthetized as needed, after which it was prepped and draped in a sterile fashion.,The clinically-apparent tumor was carefully defined and debulked prior to the first stage, determining the extent of the surgical excision.  With each stage, a thin layer of tumor-laden tissue was excised with a narrow margin of normal appearing skin, using the Mohs fresh tissue technique.  A map was prepared to correspond to the area of skin from which it was excised.  The tissue was prepared for the cryostat and sectioned.  Each section was coded, cut and stained for microscopic examination.  The entire base and margins of the excised piece of tissue were examined by the surgeon.  Areas noted to be positive on the previous stage (if applicable) were removed with the Mohs technique and processed for analysis.,No tumor was identified after the final stage of microscopically controlled surgery.  The patient tolerated the procedure well without any complication.  After discussion with the patient regarding the various options, the best closure option for each defect was selected for optimal functional and cosmetic results.","dermatology, basal cell ca, basal cell, mohs technique, mohs, tumor-laden tissue, mohs fresh tissue technique, mohs micrographic surgery, micrographic surgery, parietal scalp, micrographic, basal, cell, ca, surgical, tumor, tissue, stage,"
 Comes in complaining that he was stung by a Yellow Jacket Wasp yesterday and now has a lot of swelling in his right hand and right arm., Dermatology, Wasp Sting - SOAP ,"SUBJECTIVE:,  He is a 29-year-old white male who is a patient of Dr. XYZ and he comes in today complaining that he was stung by a Yellow Jacket Wasp yesterday and now has a lot of swelling in his right hand and right arm.  He says that he has been stung by wasps before and had similar reactions.  He just said that he wanted to catch it early before he has too bad of a severe reaction like he has had in the past.  He has had a lot of swelling, but no anaphylaxis-type reactions in the past; no shortness of breath or difficultly with his throat feeling like it is going to close up or anything like that in the past; no racing heart beat or anxiety feeling, just a lot of localized swelling where the sting occurs.,OBJECTIVE:,Vitals:  His temperature is 98.4.  Respiratory rate is 18.  Weight is 250 pounds.,Extremities:  Examination of his right hand and forearm reveals that he has an apparent sting just around his wrist region on his right hand on the medial side as well as significant swelling in his hand and his right forearm; extending up to the elbow.  He says that it is really not painful or anything like that.  It is really not all that red and no signs of infection at this time.,ASSESSMENT:,  Wasp sting to the right wrist area.,PLAN:,1.  Solu-Medrol 125 mg IM X 1.,2.  Over-the-counter Benadryl, ice and elevation of that extremity.,3.  Follow up with Dr. XYZ if any further evaluation is needed.","dermatology, yellow jacket wasp, wasp sting, swelling, solu-medrol, lot of swelling, stung, sting, wasp, "
 Worrisome skin lesion.  A punch biopsy of the worrisome skin lesion was obtained.  Lesion was removed., Dermatology, Punch Biopsy - 2 ,"PREOPERATIVE DIAGNOSIS:,  Worrisome skin lesion, left hand.,POSTPROCEDURE DIAGNOSIS:,  Worrisome skin lesion, left hand.,PROCEDURE:,  The patient gave informed consent for his procedure.  After informed consent was obtained, attention was turned toward the area of interest, which was prepped and draped in the usual sterile fashion.,Local anesthetic medication was infiltrated around and into the area of interest.  There was an obvious skin lesion there and this gentleman has a history of squamous cell carcinoma.  A punch biopsy of the worrisome skin lesion was obtained with a portion of the normal tissue included.  The predominant portion of the biopsy was of the lesion itself.,Lesion was removed.  Attention was turned toward the area.  Pressure was held and the area was hemostatic.,The skin and the area were closed with 5-0 nylon suture.  All counts were correct.  The procedure was closed.  A sterile dressing was applied.  There were no complications.  The patient had no neurovascular deficits, etc., after this minor punch biopsy procedure.,","dermatology, skin lesion, squamous cell carcinoma, punch biopsy, "
 Methicillin-resistant Staphylococcus aureus (MRSA) infection.  A 14-day-old was seen by private doctor because of blister. , Dermatology, MRSA Infection - ER Visit ,"HISTORY OF PRESENT ILLNESS:,  A 14-day-old was seen by private doctor because of blister.  On Friday, she was noted to have a small blister near her umbilicus.  They went to their doctor on Saturday, culture was drawn.  It came back today, growing MRSA.  She has been doing well.  They put her on bacitracin ointment near the umbilicus.  That has about healed up.  However today, they noticed a small blister on her left temporal area.  They called the private doctor.  They direct called the Infectious Disease doctor here and was asked that they come into the hospital.  Mom states she has been diagnosed with MRSA on her buttocks as well and is on some medications.  The child has not had any fever.  She has not been lethargic or irritable.  She has been eating well up to 2 ounces every feed.  Eating well and sleeping well.  No other changes have been noted.,PAST MEDICAL HISTORY:,  She was born full term.  No complications.  Home with mom.  No hospitalization, surgeries, allergies.,MEDICATIONS: , As noted.,IMMUNIZATIONS: , Up-to-date.,FAMILY HISTORY: , Negative.,SOCIAL HISTORY: , No ill contacts.  No travel or changes in living condition.,REVIEW OF SYSTEMS:  ,Ten systems were asked, all of them were negative except as noted above.,PHYSICAL EXAMINATION:  ,GENERAL:  Awake, alert female, no acute distress at this time.,HEENT:  Fontanelle soft and flat.  PERRLA.  EOMI.  Conjunctivae are clear.  TMS are clear.  Nares are clear.  Mucous membranes pinks and moist.  Throat clear.  No oral lesions.,NECK:  Supple.,LUNGS:  Clear.,HEART:  Regular rate and rhythm.  Normal S1, S2.  No murmur.,ABDOMEN:  Soft, nontender.  Positive bowel sounds.  No guarding, no rebound.  No rashes seen.,EXTREMITIES:  Capillary refill is brisk.  Good distal pulses.,NEUROLOGIC:  Cranial nerves II through XII intact.  5/5 strength in all extremities.,SKIN:  Her umbilicus looks completely clear.  There is no evidence of erythema.  The area that the parents point where the blister was, appears to be well healed.  There is no evidence of lesion noted, at this time.  On her left temple area and just inside her hairline, there is a small vesicle.  It is not a pustule.  It is almost flat and it has minimal fluid underneath that.  There is no surrounding erythema, tenderness.  I have inspected the body, head to toe.  No other areas of lesions seen.,EMERGENCY DEPARTMENT COURSE: , I spoke with Infectious Disease, Dr. X.  He states, we should treat for MRSA with Bactrim p.o.  There has been no evidence of jaundice with this little girl.  Hibiclens and Bactroban.  I spoke with Dr. X's associate to call back after Dr. X recommended a Herpes culture be done, just for completeness and that was done.  Blood culture was done here to make sure she did not have MRSA in her blood, which clinically, she does not appear to have.  She was discharged in stable condition.,IMPRESSION: , Methicillin-resistant Staphylococcus aureus infection.,PLAN: ,  MRSA Instructions were given as above and antibiotics were prescribed.  To follow up with their doctor.",
 Patient comes in for initial evaluation of a hyperesthesia on his right abdomen., Dermatology, Hyperesthesia ,"SUBJECTIVE:,  This 49-year-old white male, established patient in dermatology, last seen in the office on 08/02/2002, comes in today for initial evaluation of a hyperesthesia on his right abdomen, then on his left abdomen, then on his left medial thigh.  It cleared for awhile.  This has been an intermittent problem.  Now it is back again on his right lower abdomen.  At first, it was thought that he may have early zoster.  This started six weeks before the holidays and is still going on, more so in the past eight days on his abdomen and right hip area.  He has had no treatment on this; there are no skin changes at all.  The patient bathes everyday but tries to use little soap.  The patient is married.  He works as an airplane mechanic.,FAMILY, SOCIAL, AND ALLERGY HISTORY:,  The patient has sinus and CVA.  He is a nonsmoker.  No known drug allergies.,CURRENT MEDICATIONS:,  Lipitor, aspirin, folic acid.,PHYSICAL EXAMINATION:,  The patient is well developed, appears stated age.  Overall health is good.  He does have psoriasis with some psoriatic arthritis, and his skin looks normal today.  On his trunk, he does have the hyperesthesia.  As you touch him, he winces.,IMPRESSION:,  Hyperesthesia, question etiology.,TREATMENT:,1.  Discussed condition and treatment with the patient.,2.  Discontinue hot soapy water to these areas.,3.  Increase moisturizing cream and lotion.,4.  I referred him to Dr. ABC or Dr. XYZ for neurology evaluation.  We did not see anything on skin today.  Return p.r.n. flare.","dermatology, abdomen, hyperesthesia, soapy water, moisturizing cream, initial evaluation"
 Excision of the left upper cheek actinic neoplasm and left lower cheek upper neck skin neoplasm with two-layer plastic closures, Dermatology, Excision - Actinic Neoplasm ,"PREOPERATIVE DIAGNOSES:,1.  Enlarging skin neoplasm, actinic neoplasm, left upper cheek, measures 1 cm x 1.5 cm.,2.  Enlarging 0.5 cm x 1 cm nevus of the left lower cheek neck region.,3.  A 1 cm x 1 cm seborrheic keratosis of the mid neck.,4.  A 1 cm x 1.5 cm verrucous seborrheic keratosis of the right auricular rim.,5.  A 1 cm x 1 cm actinic keratosis of the right mid cheek.,POSTOPERATIVE DIAGNOSES:,1.  Enlarging skin neoplasm, actinic neoplasm, left upper cheek, measures 1 cm x 1.5 cm.,2.  Enlarging 0.5 cm x 1 cm nevus of the left lower cheek neck region.,3.  A 1 cm x 1 cm seborrheic keratosis of the mid neck.,4.  A 1 cm x 1.5 cm verrucous seborrheic keratosis of the right auricular rim.,5.  A 1 cm x 1 cm actinic keratosis of the right mid cheek.,TITLE OF PROCEDURES:,1.  Excision of the left upper cheek actinic neoplasm defect measuring 1.5 cm x 1.8 cm with two-layer plastic closure.,2.  Excision of the left lower cheek upper neck, 1 cm x 1.5 cm skin neoplasm with two-layer plastic closure.,3.  Shave excision of the mid neck seborrheic keratosis that measured 1 cm x 1.5 cm.,4.  Shave excision of the right superior pinna auricular rim, 1 cm x 1.5 cm verrucous keratotic neoplasm.,5.  A 50% trichloroacetic acid treatment of the right mid cheek, 1 cm x 1 cm actinic neoplasm.,ANESTHESIA: , Local.  I used a total of 6 mL of 1% lidocaine with 1:100,000 epinephrine.,ESTIMATED BLOOD LOSS:,  Less than 30 mL.,COMPLICATIONS: , None.,COUNTS:  ,Sponge and needle counts were all correct.,PROCEDURE:,  The patient was evaluated preop and noted to be in stable condition.  Chart and informed consent were all reviewed preop.  All risks, benefits, and alternatives regarding the procedure have been reviewed in detail with the patient.  She is aware of risks include but not limited to bleeding, infection, scarring, recurrence of the lesion, need for further procedures, etc.  The areas of concern were marked with the marking pen.  Local anesthetic was infiltrated.  Sterile prep and drape were then performed.,I began excising the left upper cheek and left lower cheek neck lesions as listed above.  These were excised with the #15 blade.  The left upper cheek lesion measures 1 cm x 1.5 cm, defect after excision is 1.5 cm x 1.8 cm.  A suture was placed at the 12 o'clock superior margin.  Clinically, this appears to be either actinic keratosis or possible basal cell carcinoma.  The healthy margin of healthy tissue around this lesion was removed.  Wide underminings were performed and the lesion was closed in a two-layered fashion using 5-0 myochromic for the deep subcutaneous and 5-0 nylon for the skin.,The left upper neck lesion was also removed in the similar manner.  This is dark and black, appears to be either an intradermal nevus or pigmented seborrheic keratosis.  It was excised using a #15 blade down the subcutaneous tissue with the defect 1 cm x 1.5 cm.  After wide underminings were performed, a two-layer plastic closure was performed with 5-0 myochromic for the deep subcutaneous and 5-0 nylon for the skin.,The lesion of the mid neck and the auricular rim were then shave excised for the upper dermal layer with the Ellman radiofrequency wave unit.  These appeared to be clinically seborrheic keratotic neoplasms.,Finally proceeded with the right cheek lesion, which was treated with the 50% TCA.  This was also an actinic keratosis.  It is new in onset, just within the last week.  Once a light frosting was obtained from the treatment site, bacitracin ointment was applied.  Postop care instructions have been reviewed in detail.  The patient is scheduled a recheck in one week for suture removal.  We will make further recommendations at that time.",
 Incision and drainage (I&D) of buttock abscess.  , Dermatology, I&D - Buttock Abscess ,"PRINCIPAL DIAGNOSIS: , Buttock abscess, ICD code 682.5.,PROCEDURE PERFORMED:,  Incision and drainage (I&D) of buttock abscess.,CPT CODE: , 10061.,DESCRIPTION OF PROCEDURE:  ,Under general anesthesia, skin was prepped and draped in usual fashion.  Two incisions were made along the right buttock approximately 5 mm diameter.  Purulent material was drained and irrigated with copious amounts of saline flush.  A Penrose drain was placed.  Penrose drain was ultimately sutured forming a circular drain.  The patient's drain will be kept in place for a period of 1 week and to be taken as an outpatient basis.  Anesthesia, general endotracheal anesthesia.  Estimated blood loss approximately 5 mL.  Intravenous fluids 100 mL.  Tissue collected.  Purulent material from buttock abscess sent for usual cultures and chemistries.  Culture and sensitivity Gram stain.  A single Penrose drain was placed and left in the patient.  Dr. X attending surgeon was present throughout the entire procedure.","dermatology, incision and drainage, purulent material, penrose drain, buttock abscess, i&d, drainage"
" A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings.  Epidermal autograft on Integra to the back and application of allograft to areas of the lost Integra, not grafted on the back.", Dermatology, Epidermal Autograft ,"PREOPERATIVE DIAGNOSIS:,  A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings.,POSTOPERATIVE DIAGNOSIS:,  A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings.,PROCEDURES PERFORMED:,1.  Epidermal autograft on Integra to the back (3520 cm2).,2.  Application of allograft to areas of the lost Integra, not grafted on the back (970 cm2).,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:,  Approximately 50 cc.,BLOOD PRODUCTS RECEIVED:,  One unit of packed red blood cells.,COMPLICATIONS: , None.,INDICATIONS: , The patient is a 26-year-old male, who sustained a 60% total body surface area flame burn involving the head, face, neck, chest, abdomen, back, bilateral upper extremities, hands, and bilateral lower extremities.  He has previously undergone total burn excision with placement of Integra and an initial round of epidermal autografting to the bilateral upper extremities and hands.  His donor sites have healed particularly over his buttocks and he returns for a second round of epidermal autografting over the Integra on his back utilizing the buttock donor sites, the extent they will provide coverage.,OPERATIVE FINDINGS:,1.  Variable take of Integra, particularly centrally and inferiorly on the back.  A fair amount of lost Integra over the upper back and shoulders.,2.  No evidence of infection.,3.  Healthy viable wound beds prior to grafting.,PROCEDURE IN DETAIL:,  The patient was brought to the operating room and positioned supine.  General endotracheal anesthesia was uneventfully induced and an appropriate time out was performed.  He was then repositioned prone and perioperative IV antibiotics were administered.  He was prepped and draped in the usual sterile manner.  All staples were removed from the Integra and the adherent areas of Silastic were removed.  The entire wound bed was further prepped with scrub brushes and more Betadine followed by a sulfamylon solution.  Hemostasis of the wound bed was ensured using epinephrine-soaked Telfa pads.  Following dermal tumescence of the buttocks, epidermal autografts were harvested 8 one-thousandths of an inch using the air Zimmer dermatome.  These grafts were passed to the back table where they were meshed 3:1.  The donor sites were hemostased using epinephrine-soaked Telfa and lap pads.  Once all the  grafts were meshed, we brought them back up onto the field, positioned them over the wounds beginning inferiorly and moving cephalad where we had best areas of Integra engraftment.  We were happy with the lie of the grafts and they were stapled into place.  The grafts were then overlaid with Conformant 2, which was also stapled into place.  Utilizing all of his buttocks skin, we did not have enough to cover his entire back, so we elected to apply allograft to the cephalad and a few areas on his flanks where we had had poor Integra engraftment.  Allograft was thawed and meshed 1:1.  It was then brought up onto the field, trimmed to fit and stapled into place over the wound.  Once the entirety of the posterior wounds on his back were covered out with epidermal autograft or allograft sulfamylon soaked dressings were applied.  Donor sites on his buttocks were dressed in Acticoat and secured with staples.  He was then repositioned supine and extubated in the operating room having tolerated the procedure without any apparent complications.  He was transported to PACU in stable condition.","dermatology, flame burns, body surface area, epidermal autograft, autograft, integra, integra engraftment, wound, grafts, epidermal, allograft, "
 This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms., Dermatology, Itchy Rash - ER Visit ,"CHIEF COMPLAINT:,  Itchy rash.,HISTORY OF PRESENT ILLNESS: , This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms.  No facial swelling.  No tongue or lip swelling.  No shortness of breath, wheezing, or other associated symptoms.  He cannot think of anything that could have triggered this off.  There have been no changes in his foods, medications, or other exposures as far as he knows.  He states a couple of days ago he did work and was removing some insulation but does not remember feeling itchy that day.,PAST MEDICAL HISTORY: , Negative for chronic medical problems.  No local physician.  Has had previous back surgery and appendectomy, otherwise generally healthy.,REVIEW OF SYSTEMS: , As mentioned denies any oropharyngeal swelling.  No lip or tongue swelling.  No wheezing or shortness of breath.  No headache.  No nausea.  Notes itchy rash, especially on his torso and upper arms.,SOCIAL HISTORY: , The patient is accompanied with his wife.,FAMILY HISTORY: , Negative.,MEDICATIONS: , None.,ALLERGIES: , TORADOL, MORPHINE, PENICILLIN, AND AMPICILLIN.,PHYSICAL EXAMINATION: , VITAL SIGNS:  The patient was afebrile.  He is slightly tachycardic, 105, but stable blood pressure and respiratory rate.  GENERAL:  The patient is in no distress.  Sitting quietly on the gurney.  HEENT:  Unremarkable.  His oral mucosa is moist and well hydrated.  Lips and tongue look normal.  Posterior pharynx is clear.  NECK:  Supple.  His trachea is midline.  There is no stridor.  LUNGS:  Very clear with good breath sounds in all fields.  There is no wheezing.  Good air movement in all lung fields.  CARDIAC:  Without murmur.  Slight tachycardia.  ABDOMEN:  Soft, nontender.  SKIN:  Notable for a confluence erythematous, blanching rash on the torso as well as more of a blotchy papular, macular rash on the upper arms.  He noted some on his buttocks as well.  Remaining of the exam is unremarkable.,ED COURSE: , The patient was treated with epinephrine 1:1000, 0.3 mL subcutaneously along with 50 mg of Benadryl intramuscularly.  After about 15-20 minutes he states that itching started to feel better.  The rash has started to fade a little bit and feeling a lot more comfortable.,IMPRESSION:,  ACUTE ALLERGIC REACTION WITH URTICARIA AND PRURITUS.,ASSESSMENT AND PLAN: , The patient has what looks to be some type of allergic reaction, although the underlying cause is difficult to assess.  He will make sure he goes home to look around to see if there is in fact anything that changed recently that could have triggered this off.  In the meantime, I think he can be managed with some antihistamine over-the-counter.  He is responding already to Benadryl and the epinephrine that we gave him here.  He is told that if he develops any respiratory complaints, shortness of breath, wheezing, or tongue or lip swelling he will return immediately for evaluation.  He is discharged in stable condition.","dermatology, urticaria, pruritus, lip swelling, allergic reaction, itchy rash, torso, swelling, itchy, rash, "
 The patient presents for a followup for history of erythema nodosum., Dermatology, Erythema Nodosum - Consult ,"REASON FOR VISIT:,  The patient presents for a followup for history of erythema nodosum.,HISTORY OF PRESENT ILLNESS: , This is a 25-year-old woman who is attending psychology classes.  She was diagnosed with presumptive erythema nodosum in 2004 based on a biopsy consistent with erythema nodosum, but not entirely specific back in Netherlands.  At that point, she had undergone workup which was extensive for secondary diseases associated with erythema nodosum.  Part of her workup included a colonoscopy.  The findings were equivocal characterizes not clearly abnormal biopsies of the terminal ileum.,The skin biopsy, in particular, mentions some fibrosis, basal proliferation, and inflammatory cells in the subcutis.,Prior to the onset of her erythema nodosum, she had a tibia-fibula fracture several years before on the right, which was not temporarily associated with the skin lesions, which are present in both legs anyway.  Even, a jaw cosmetic surgery she underwent was long before she started developing her skin lesions.  She was seen in our clinic and by Dermatology on several occasions.  Apart from the first couple of visits when she presented stating a recurrent skin rash with a description suggestive of erythema nodosum in the lower extremities and ankle and there is discomfort pointing towards a possible inflammatory arthritis and an initial high sed rate of above 110 with an increased CRP.  In the following visits, no evident abnormality has been detected.  In the first visit, here some MTP discomfort detected.  It was thought that erythema nodosum may be present.  However, the evaluation of Dermatology did not concur and it was thought that the patient had venous stasis, which could be related to her prior fracture.  When she was initially seen here, a suspicion of IBD, sarcoid inflammatory arthropathy, and lupus was raised.  She had an equivocal rheumatoid fracture, but her CCP was negative.  She had an ANA, which was positive at 1:40 with a speckled pattern persistently, but the rest of the lupus serologies including double-stranded DNA, RNP, Smith, Ro, La were negative.  Her cardiolipin panel antibodies were negative as well.  We followed the IgM, IgG, and IgA being less than 10.  However, she did have a beta-2 glycoprotein 1 or an RVVT tested and this may be important since she has a livedo pattern.  It was thought that the onset of lupus may be the case.  It was thought that rheumatoid arthritis could not be the case since it is not associated with erythema nodosum.  For the fear of possible lymphoma, she underwent CT of the chest, abdomen, and pelvis.  It was done also in order to rule out sarcoid and the result was unremarkable.  Based on some changes in her bowel habits and evidence of B12 deficiency with a high methylmalonic and high homocystine levels along with a low normal B12 in addition to iron studies consistent with iron deficiency and an initially low MCV, the possibility of inflammatory bowel disease was employed.  The patient underwent an initially unrevealing colonoscopy and a capsule endoscopy, which was normal.  A second colonoscopy was done recently and microscopically no evidence of inflammatory bowel disease was seen.  However, eosinophil aggregations were noted in microscopy and this was told to be consistent with an allergic reaction or an emerging Crohn disease and I will need to discuss with Gastroenterology what is the significance of that.  Her possible B12 deficiency and iron deficiency were never addressed during her stay here in the United States.,In the initial appointment, she was placed on prednisone 40 mg, which was gradually titrated down this led to an exacerbation of her acne.  We decided to take her off prednisone due to adverse effects and start her on colchicine 0.6 mg daily.  While this kept things under control with the inflammatory markers being positive and no overt episodes of erythema nodosum, the patient still complains for sensitivity with less suspicious skin rash in the lower extremities and occasional ankle swelling and pain.  She was reevaluated by Dermatology for that and no evidence of erythema nodosum was felt to be present.  Out plan was to proceed with a DEXA scan, at some point check a vitamin D level, and order vitamin D and calcium over the counter for bone protection purposes.  However, the later was deferred until we have resolved the situation and find out what is the underlying cause of her disease.,Her past medical history apart from the tibia-fibular fracture and the jaw cosmetic surgery is significant for varicella and mononucleosis.,Her physical examination had shown consistently diffuse periarticular ankle edema and also venous stasis changes at least until I took over her care last August.  I have not been able to detect any erythema nodosum, however, a livedo pattern has been detected consistently.  She also has evidence of acne, which does not seem to be present at the moment.  She also was found to have a heart murmur present and we are going to proceed with an echocardiogram placed.,Her workup during the initial appointment included an ACE level, which was normal.  She also had a rather higher sed rate up to 30, but prior to that, per report, it was even higher, above 110.  Her RVVT was normal, her rheumatoid factor was negative.  Her ANA was 1:40, speckled pattern.  The double-stranded DNA was negative.  Her RNP and Smith were negative as well.  RO and LA were negative and cardiolipin antibodies were negative as well.  A urinalysis at the moment was completely normal.  A CRP was 2.3 in the initial appointment, which was high.  A CCP was negative.  Her CBC had shown microcytosis and hypochromia with a hematocrit of 37.7.  This improved later without any evidence of hypochromia, microcytosis or anemia with a hematocrit of 40.3.,The patient returns here today, as I mentioned, complaining of milder bouts of skin rash, which she calls erythema nodosum, which is accompanied by arthralgias, especially in the ankles.  I am mentioning here that photosensitivity rash was mentioned in the past.  She tells me that she had it twice back in Europe after skiing where her whole face was swollen.  Her acne has been very stable after she was taken off prednisone and was started on colchicine 0.6 daily.  Today we discussed about the effect of colchicine on a possible pregnancy.,MEDICATIONS: , Prednisone was stopped.  Vitamin D and calcium over the counter, we need to verify that.  Colchicine 0.6 mg daily which we are going to stop, ranitidine 150 mg as needed, which she does not take frequently.,FINDINGS:,  On physical examination, she is very pleasant, alert, and oriented x 3 and not in any acute distress.  There is some evidence of faint subcutaneous lesions in both shins bilaterally, but with mild tenderness, but no evidence of classic erythema nodosum.  Stasis dermatitis changes in both lower extremities present.  Mild livedo reticularis is present as well.,There is some periarticular ankle edema as well.  Laboratory data from 04/23/07, show a normal complete metabolic profile with a creatinine of 0.7, a CBC with a white count of 7880, hematocrit of 40.3, and platelets of 228.  Her microcytosis and hypochromia has resolved.  Her serum electrophoresis does not show a monoclonal abnormality.  Her vitamin D levels were 26, which suggests some mild insufficiency and she would probably benefit by vitamin D supplementation.  This points again towards some ileum pathology.  Her ANCA B and C were negative.  Her PF3 and MPO were unremarkable.  Her endomysial antibodies were negative.  Her sed rate at this time were 19.  The highest has been 30, but prior to her appointment here was even higher.  Her ANA continues to be positive with a titer of 1:40, speckled pattern.  Her double-stranded DNA is negative.  Her serum immunofixation confirmed the absence of monoclonal abnormality.  Her urine immunofixation was not performed.  Her IgG, IgA, and IgM levels are normal.  Her IgE levels are normal as well.  A urinalysis was not performed this time.  Her CRP is 0.4.  Her tissue transglutaminase antibodies are negative.  Her ASCA is normal and anti-OmpC was not tested.  Gliadin antibodies IgA is 12, which is in the borderline to be considered equivocal, but these are nonspecific.  I am reminding here that her homocystine levels have been 15.7, slightly higher, and that her methylmalonic acid was 385, which is obviously abnormal.  Her B12 levels were 216, which is rather low possibly indicating a B12 deficiency.  Her iron studies showed a ferritin of 15, a saturation of 9%, and an iron of 30.  Her TIBC was 345 pointing towards an iron deficiency anemia.  I am reminding you that her ACE levels in the past were normal and that she has a microcytosis.  Her radiologic workup including a thoracic, abdominal, and pelvic CT did not show any suspicious adenopathy, but only small aortocaval and periaortic nodes, the largest being 8 mm in short axis, likely reactive.  Her pelvic ultrasound showed normal uterus adnexa.  Her bladder was normal as well.  Subcentimeter inguinal nodes were found.  There was no large lytic or sclerotic lesion noted.  Her recent endoscopy was unremarkable, but the microscopy showed some eosinophil aggregation, which may be pointing towards allergy or an evolving Crohn disease.  Her capsule endoscopy was limited secondary to rapid transit.  There was only a tiny mucosal red spot in the proximal jejunum without active bleeding, 2 possible erosions were seen in the distal jejunum and proximal ileum.  However, no significant inflammation or bleeding was seen and this could be small bowel crisis.  Neither evidence of bleeding or inflammation were seen as well.  Specifically, the terminal ileum appeared normal.  Recent evaluation by a dermatologist did not verify the presence of erythema nodosum.,ASSESSMENT:,  This is a 25-year-old woman diagnosed with presumptive erythema nodosum in 2004.  She has been treated with prednisone as in the beginning she had also a wrist and ankle discomfort and high inflammatory markers.  Since I took over her care, I have not seen a clear-cut erythema nodosum being present.  No evidence of synovitis was there.  Her serologies apart from an ANA of 1:40 were negative.  She has a livedo pattern, which has been worrisome.  The issue here was a possibility of inflammatory bowel disease based on deficiency in vitamin B12 as indicated by high methylmalonic and homocystine levels and also iron deficiency.  She also has low vitamin D levels, which point towards terminal ileum pathology as well and she had a history of decreased MCV.  We never received the x-ray of her hands which she had and she never had a DEXA scan.  Lymphoma has been ruled out and we believe that inflammatory bowel disease, after repeated colonoscopies and the capsule endoscopy, has been ruled out as well.  Sarcoid is probably not the case since the patient did not have any lymphadenopathies and her ACE levels were normal.  We are going check a PPD to rule out tuberculosis.  We are going to order an RVVT and glycoprotein beta-1 levels in her workup to make sure that an antiphospholipid syndrome is not present given the livedo pattern.  An anti-intrinsic factor will be added as well.  Her primary care physician needs to workup the possible B12 and iron deficiency and also the vitamin D deficiency.  In the meanwhile, we feel that the patient should stop taking the colchicine and if she has a flare of her disease then she should present to her dermatologist and have the skin biopsy performed in order to have a clear-cut answer of what is the nature of this skin rash.  Regarding her heart murmur, we are going to proceed with an echocardiogram.  A PPD should be placed as well.  In her next appointment, we may fax a requisition for vitamin B replacement.,PROBLEMS/DIAGNOSES:,  1.  Recurrent erythema nodosum with ankle and wrist discomfort, ? arthritis.,2.  Iron deficiencies, according to iron studies.,3.  Borderline B12 with increased methylmalonic acid and homocystine.,4.  On chronic steroids; vitamin D and calcium is needed; she needs a DEXA scan.,5.  Typical ANCA, per records, were not verified here.  ANCA and ASCA were negative and the OmpC was not ordered.,6.  Acne.,7.  Recurrent arthralgia not present.  Rheumatoid factor, CCP negative, ANA 1:40 speckled.,8.  Livedo reticularis, beta 2-glycoprotein was not checked, we are going to check it today.  Needs vaccination for influenza and pneumonia.,9.  Vitamin D deficiency.  She needs replacement with ergocalciferol, but this may point towards ___________ pathology as this was not detected.,10.  Recurrent ankle discomfort which necessitates ankle x-rays.,PLANS:,  We can proceed with part of her workup here in clinic, PPD, echocardiogram, ankle x-rays, and anti-intrinsic factor antibodies.  We can start repleting her vitamin D with __________ weeks of ergocalciferol 50,000 weekly.  We can add an RVVT and glycoprotein to her workup in order to rule out any antiphospholipid syndrome.  She should be taking vitamin D and calcium after the completion of vitamin D replacement.  She should be seen by her primary care physician, have the iron and B12 deficiency worked up.  She should stop the colchicine and if the skin lesion recurs then she should be seen by her dermatologist.  Based on the physical examination, we do not suspect that the patient has the presence of any other disease associated with erythema nodosum.  We are going to add an amylase and lipase to evaluate her pancreatic function, RPR, HIV, __________ serologies.  Given the evidence of possible malabsorption it may be significant to proceed with an upper endoscopy to rule out Whipple disease or celiac disease which can sometimes be associated with erythema nodosum.  An anti-intrinsic factor would be added, as I mentioned.  I doubt whether the patient has Behcet disease given the absence of oral or genital ulcers.  She does not give a history of oral contraceptives or medications that could be related to erythema nodosum.  She does not have any evidence of lupus __________ mycosis.  Histoplasmosis coccidioidomycosis would be accompanied by other symptoms.  Hodgkin disease has probably been ruled out with a CAT scan.  However, we are going to add an LDH in future workup.  I need to discuss with her primary care physician regarding the need for workup of her vitamin B12 deficiency and also with her gastroenterologist regarding the need for an upper endoscopy.  The patient will return in 1 month.",
 Evaluation and recommendations regarding facial rhytids., Dermatology, Facial Rhytids ,"HISTORY: , This 57-year-old female who presented today for evaluation and recommendations regarding facial rhytids.  In summary, the patient is a healthy 57-year-old female, nonsmoker with no history of skin disease, who has predominant fullness in the submandibular region and mid face region and prominent nasolabial folds.,RECOMMENDATIONS: , I do believe a facelift procedure would be of maximum effect for the patient's areas of concern and a ""quick lift"" type procedure certainly would address these issues.  I went over risks and benefits with the patient along with the preoperative and postoperative care, and risks include but are not limited to bleeding, infection, discharge, scar formation, need for further surgery, facial nerve injury, numbness, asymmetry of face, problems with hypertrophic scarring, problems with dissatisfaction with anticipated results, and she states she will contact us later in the summer to possibly make arrangements for a quick lift through Memorial Medical Center.","dermatology, quick lift, hypertrophic scarring, facial rhytids, mid face region, nasolabial folds, liftNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Excision of left upper cheek skin neoplasm and left lower cheek skin neoplasm with two-layer closure.  Shave excision of the right nasal ala skin neoplasm., Dermatology, Excision - Skin Neoplasm  ,"PREOPERATIVE DIAGNOSES:,1.  Enlarging nevus of the left upper cheek.,2.  Enlarging nevus 0.5 x 1 cm, left lower cheek.,3.  Enlarging superficial nevus 0.5 x 1 cm, right nasal ala.,TITLE OF PROCEDURES:,1.  Excision of left upper cheek skin neoplasm 0.5 x 1 cm with two layer closure.,2.  Excision of the left lower cheek skin neoplasm 0.5 x 1 cm with a two layer plastic closure.,3.  Shave excision of the right nasal ala 0.5 x 1 cm skin neoplasm.,ANESTHESIA:  ,Local.  I used a total of 5 mL of 1% lidocaine with 1:100,000 epinephrine.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,COMPLICATIONS:,  None.,PROCEDURE: , The patient was evaluated preop and noted to be in stable condition.  Chart and informed consent were all reviewed preop.  All risks, benefits, and alternatives regarding the procedure have been reviewed in detail with the patient.  Risks including but not limited to bleeding, infection, scarring, recurrence of the lesion, need for further procedures have been all reviewed.  Each of these lesions appears to be benign nevi; however, they have been increasing in size.  The lesions involving the left upper and lower cheek appear to be deep.  These required standard excision with the smaller lesion of the right nasal ala being more superficial and amenable to a superficial shave excision.  Each of these lesions was marked.  The skin was cleaned with a sterile alcohol swab.  Local anesthetic was infiltrated.  Sterile prep and drape were then performed.,Began first excision of the left upper cheek skin lesion.  This was excised with the 15-blade full thickness.  Once it was removed in its entirety, undermining was performed, and the wound was closed with 5-0 myochromic for the deep subcutaneous, 5-0 nylon interrupted for the skin.,The lesion of the lower cheek was removed in a similar manner.  Again, it was excised with a 15 blade with two layer plastic closure.  Both these lesions appear to be fairly deep nevi.,The right nasal ala nevus was superficially shaved using the radiofrequency wave unit.  Each of these lesions was sent as separate specimens.  The patient was discharged from my office in stable condition.  He had minimal blood loss.  The patient tolerated the procedure very well.  Postop care instructions were reviewed in detail.  We have scheduled a recheck in one week and we will make further recommendations at that time.","dermatology, enlarging nevus, nevus, skin neoplasm, nasal ala, cheek skin neoplasm, shave excision, superficial, lesions, neoplasm, excision, cheek"
 Excision of the left temple keratotic neoplasm and left nasolabial fold defect and right temple keratotic neoplasm., Dermatology, Excision - Keratotic Neoplasm ,"PREOPERATIVE DIAGNOSES:,1.  Enlarging dark keratotic lesion of the left temple measuring 1 x 1 cm.,2.  Enlarging keratotic neoplasm of the left nasolabial fold measuring 0.5 x 0.5 cm.,3.  Enlarging seborrheic keratotic neoplasm of the right temple measuring 1 x 1 cm.,POSTOPERATIVE DIAGNOSES:,1.  Enlarging dark keratotic lesion of the left temple measuring 1 x 1 cm.,2.  Enlarging keratotic neoplasm of the left nasolabial fold measuring 0.5 x 0.5 cm.,3.  Enlarging seborrheic keratotic neoplasm of the right temple measuring 1 x 1 cm.,TITLE OF PROCEDURES:,1.  Excision of the left temple keratotic neoplasm, final defect 1.8 x 1.5 cm with two layer plastic closure.,2.  Excision of the left nasolabial fold defect 0.5 x 0.5 cm with single layer closure.,3.  Excision of the right temple keratotic neoplasm, final defect measuring 1.5 x 1.5 cm with two layer plastic closure.,ANESTHESIA: , Local using 3 mL of 1% lidocaine with 1:100,000 epinephrine.,ESTIMATED BLOOD LOSS: , Less than 30 mL.,COMPLICATIONS:,  None.,PROCEDURE: , The patient was evaluated preoperatively and noted to be in stable condition.  Informed consent was obtained from the patient.  All risks, benefits and alternatives regarding the surgery have been reviewed in detail with the patient.  This includes risks of bleeding, infection, scarring, recurrence of lesion, need for further procedures, etc.  Each of the areas was cleaned with a sterile alcohol swab.  Planned excision site was marked with a marking pen.  Local anesthetic was infiltrated.  Sterile prep and drape were then performed.,We began first with excision of the left temple followed by the left nasolabial and right temple lesions.  The left temple lesion is noted to be a dark black what appears to be a keratotic or possible seborrheic keratotic neoplasm.  However, it is somewhat deeper than the standard seborrheic keratosis.  The incision for removal of this lesion was placed within the relaxed skin tension line of the left temple region.  Once this was removed, wide undermining was performed and the wound was closed in a two layer fashion using 5-0 myochromic for the deep subcutaneous and 5-0 nylon for the skin.,Excision of left cheek was a keratotic nevus.  It was excised with a defect 0.5 x 0.5 cm.  It was closed in a single layer fashion 5-0 nylon.,The lesion of the right temple also dark black keratotic neoplasm was excised with the incision placed within the relaxed skin tension.  Once it was excised full-thickness, the defect measure 1.5 x 1.5 cm.  Wide undermine was performed and it was closed in a two layer fashion using 5-0 myochromic for the deep subcutaneous, 5-0 nylon that was used to close skin.  Sterile dressing was applied afterwards.  The patient was discharged in stable condition.  Postop care instructions reviewed in detail.  She is scheduled with me in one week and we will make further recommendations at that time.","dermatology, keratotic lesion, keratotic neoplasm, seborrheic keratotic neoplasm, seborrheic, keratotic, neoplasm, nasolabial, two layer plastic closure, nasolabial fold, excision, "
 Hand dermatitis., Dermatology, Dermatitis - SOAP ,"SUBJECTIVE:,  This is a 29-year-old Vietnamese female, established patient of dermatology, last seen in our office on 07/13/04.  She comes in today as a referral from ABC, D.O. for a reevaluation of her hand eczema.  I have treated her with Aristocort cream, Cetaphil cream, increased moisturizing cream and lotion, and wash her hands in Cetaphil cleansing lotion.  She comes in today for reevaluation because she is flaring.  Her hands are very dry, they are cracked, she has been washing with soap.  She states that the Cetaphil cleansing lotion apparently is causing some burning and pain because of the fissures in her skin.  She has been wearing some gloves also apparently.  The patient is single.  She is unemployed.,FAMILY, SOCIAL, AND ALLERGY HISTORY: , The patient has asthma, sinus, hives, and history of psoriasis.  No known drug allergies.,MEDICATIONS: , The patient is a nonsmoker.  No bad sunburns or blood pressure problems in the past.,CURRENT MEDICATIONS:,  Claritin and Zyrtec p.r.n.,PHYSICAL EXAMINATION:,  The patient has very dry, cracked hands bilaterally.,IMPRESSION:,  Hand dermatitis.,TREATMENT:,1.  Discussed further treatment with the patient and her interpreter.,2.  Apply Aristocort ointment 0.1% and equal part of Polysporin ointment t.i.d. and p.r.n. itch.,3.  Discontinue hot soapy water and wash her hands with Cetaphil cleansing lotion.,4.  Keflex 500 mg b.i.d. times two weeks with one refill.  Return in one month if not better; otherwise, on a p.r.n. basis and send Dr. XYZ a letter on this office visit.","dermatology, cetaphil cleansing lotion, hand dermatitis, aristocort, wash, ointment, hand, lotion, dermatitis"
" Excisional biopsy of actinic keratosis and skin nevus, two-layer and one-layer plastic closures, ", Dermatology, Biopsy - Actinic Keratosis ,"PREOPERATIVE DIAGNOSES:  ,1.  Left chest actinic keratosis, 2 cm.,2.  Left medial chest actinic keratosis, 1 cm.,3.  Left shoulder actinic keratosis, 1 cm.,POSTOPERATIVE DIAGNOSES:  ,1.  Left chest actinic keratosis, 2 cm.,2.  Left medial chest actinic keratosis, 1 cm.,3.  Left shoulder actinic keratosis, 1 cm.,TITLE OF PROCEDURES:  ,1.  Excisional biopsy of left chest 2 cm actinic keratosis.,2.  Two-layer plastic closure.,3.  Excisional biopsy of left chest medial actinic keratosis 1 cm with one-layer plastic closure.,4.  Excisional biopsy of left should skin nevus, 1 cm, one-layer plastic closure.,ANESTHESIA: , Xylocaine 1% with 1:100,000 dilution of epinephrine totaling 6 mL.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,PROCEDURE: , All areas were prepped, draped, and localized in the usual manner.  Afterwards, elliptical incisions were placed with a #15-blade scalpel and curved iris scissors and small bishop forceps were used for the dissection of the skin lesions.  After all were removed, they were closed with one-layer technique for the shoulder and medial lesion, and the larger left chest lesion was closed with two-layer closure using Monocryl 5-0 for subcuticular closure and 5-0 nylon for skin closure.  She tolerated this procedure very well, and postoperative care instructions were provided.  She will follow up next week for suture removal.  Of note, she had an episode of hemoptysis, which could not be explained prompting an emergency room visit, and I discussed if this continues we may wish to perform a fiberoptic laryngoscopy examination and possible further workup if a diagnosis cannot be made.","dermatology, two-layer plastic closure, one-layer plastic closure, skin nevus, actinic keratosis, plastic closures, keratosis, actinic, biopsy, forceps, layer, closures, chest"
" Temporal cheek-neck facelift  and submental suction assisted lipectomy to correct facial and neck skin ptosis and cheek, neck, and jowl lipotosis, and facial rhytides.", Dermatology, Cheek-Neck Facelift ,"PREOPERATIVE DIAGNOSIS: , Facial and neck skin ptosis.  Cheek, neck, and jowl lipotosis. Facial rhytides.,POSTOPERATIVE DIAGNOSIS:,  Same.,PROCEDURE: , Temporal cheek-neck facelift (CPT 15825).  Submental suction assisted lipectomy (CPT 15876).,ANESTHESIA: , General.,DESCRIPTION OF PROCEDURE: , This patient is a 65-year-old female who has progressive aging changes of the face and neck.  The patient demonstrates the deformities described above and has requested surgical correction.  The procedure, risks, limitations, and alternatives in this individual case have been very carefully discussed with the patient.  The patient has consented to surgery.,The patient was brought into the operating room and placed in the supine position on the operating table.  An intravenous line was started and anesthesia was maintained throughout the case.  The patient was monitored for cardiac, blood pressure, and oxygen saturation continuously.,The hair was prepared and secured with rubber bands and micropore tape along the incision line.  A marking pen had been used to outline the area of the incisions, which included the preauricular area to the level of the tragus, the post-tragal region, the post auricular region and into the hairline.  In addition, the incision was marked in the temporal area in the event of a temporal lift, then across the coronal scalp for the forehead lift.  The incision was marked in the submental crease for the submental lipectomy and liposuction.  The incision in the post auricular area extended up on the posterior aspect of the ear and ended near the occipital hairline.,The areas to be operated on were injected with 1% Lidocaine containing 1:100,000 Epinephrine.  This provided local anesthesia and vasoconstriction.  The total of Lidocaine used throughout the procedure was maintained at no more than 500mg.,SUBMENTAL SUCTION ASSISTED LIPECTOMY: , The incision was made, as previously outlined, in the submental crease in a transverse direction, through the skin and subcutaneous tissue, and hemostasis was obtained with bipolar cautery.  A Metzenbaum scissors was used to elevate the area in the submental region for about 2 or 3cm and making radial tunnels from the angle of the mandible all the way to the next angle of the mandible.  4mm liopsuction cannula was then introduced along these previously outlined tunnels into the jowl on both sides and down top the anterior border of the sternocleidomastoid laterally and just past the thyroid notch interiorly.  The tunnels were enlarged with a 6mm flat liposuction cannula.,Then with the Wells-Johnson liposuction machine 27-29 inches of underwater mercury suction was accomplished in all tunnels.  Care was taken not to turn the opening of the suction cannula up to the dermis, but it was rotated in and out taking a symmetrical amount of fat from each area.  A similar procedure was performed with the 4 mm cannula cleaning the area.  Bilateral areas were palpated for symmetry, and any remaining fat was then suctioned directly.,A triangular wedge of anterior platysma border was cauterized and excised at the cervical mental angle.  A plication stitch of 3-0 Vicryl was placed.,When a satisfactory visible result had been accomplished from the liposuction, the inferior flap was then advanced over anteriorly and the overlying skin excised in an incremental fashion.  5-0 plain catgut was used for closure in a running interlocking fashion.  The wound was cleaned at the end, dried, and Mastisol applied.  Then tan micropore tape was placed for support to the entire area.,FACE LIFT: , After waiting approximately 10-15 minutes for adequate vasoconstriction the post auricular incision was started at the earlobe and continued up on the posterior aspect of the ear for approximately 2cm just superior to the external auditory canal.  A gentle curve was then made, and again the incision was carried down to and into the posterior hairline paralleling the hair follicles and directed posteriorly towards the occipital region.  A preauricular incision was carried into the natural crease superior to the tragus, curved posterior to the tragus bilaterally then brought out inferiorly in the natural crease between the lobule and preauricular skin.  The incision was made in the temporal area beveling parallel with the hair follicles.  (The incision had been designed with curve underneath the sideburn in order to maintain the sideburn hair locations and then curved posteriorly.),The plane of dissection in the hairbearing area was kept deep to the roots of the hair follicles and superficial to the fascia of the temporalis muscle and sternocleidomastoid.  The dissection over the temporalis muscle was continued anteriorly towards the anterior hairline and underneath the frontalis to the supraorbital rim.  At the superior level of the zygoma and at the level of the sideburn, dissection was brought more superficially in order to avoid the nerves and vessels in the areas, specifically the frontalis branch of the facial nerve.,The facial flaps were then elevated with both blunt and sharp dissection with the Kahn facelift dissecting scissors in the post auricular region to pass the angle of the mandible.  This area of undermining was connected with an area of undermining starting with the temporal region extending in the preauricular area of the cheek out to the jowl.  Great care was taken to direct the plane of dissecting superficial to the parotid fascia or SMAS.  The entire dissection was carried in a radial fashion from the ear for approximately 4cm at the lateral canthal area to 8-10cm in the neck region.  When the areas of dissection had been connected carefully, hemostasis was obtained and all areas inspected.  At no point were muscle fibers or major vessels or nerves encountered in the dissection.,The SMAS was sharply incised in a semilunar fashion in front of the ear and in front of the anterior border of the SCM.  The SMAS flap was then advanced posteriorly and superiorly.  The SMAS was split at the level of the earlobe, and the inferior portion was sutured to the mastoid periosteum.  The excess SMAS was trimmed and excised from the portion anterior to the auricle.  The SMAS was then imbricated with 2-0 Surgidak interrupted sutures.,The area was then inspected for any bleeding points and careful hemostasis obtained.  The flaps were then rotated and advanced posteriorly and then superiorly, and incremental cuts were made and the suspension points in the pre and post auricular area were done with 2-0 Tycron suture.  The excess and redundant amount of skin were then excised and trimmed cautiously so as not to cause any downward pull on the ear lobule or any stretching of the scars in the healing period.  Skin closure was accomplished in the hairbearing areas with 5-0 Nylon in the preauricular tuft and 4-0 Nylon interrupted in the post auricular area.  The pre auricular area was closed first with 5-0 Dexon at the ear lobules, and 6-0 Nylon at the lobules, and 5-0 plain catgut in a running interlocking fashion.  5-0 Plain catgut was used in the post auricular area as well, leaving ample room for serosanguinous drainage into the dressing.  The post tragal incisin was closed with interrupted and running interlocking 5-0 plain catgut.  The exact similar procedure was repeated on the left side.,At the end of this procedure, all flaps were inspected for adequate capillary filling or any evidence of hematoma formation.  Any small amount of fluid was expressed post-auricularly.  A fully perforated bulb suction drain was placed under the flap and exited posterior to the hairline on each side prior to the suture closure.  A Bacitracin impregnated nonstick dressing was cut to conform to the pre and post auricular area and placed over the incision lines.,ABD padding over 4X4 gauze was used to cover the pre and post auricular areas.  This was wrapped around the head in a vertical circumferential fashion and anchored with white micropore tape in a non-constricting but secured fashion.  The entire dressing complex was secured with a pre-formed elastic stretch wrap device.  All branches of the facial nerve were checked and appeared to be functioning normally.,The procedures were completed without complication and tolerated well.  The patient left the operating room in satisfactory condition.  A follow-up appointment was scheduled, routine post-op medications prescribed, and post-op instructions given to the responsible party.,The patient was released to home in satisfactory condition.","dermatology, neck skin ptosis, lipotosis, rhytides, facelift, submental suction assisted lipectomy, pre and post auricular, cheek neck facelift, auricular region, neck facelift, cheek neck, post auricular, auricular, incision, postoperative, cheek, submental, dissection, neck, "
" First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.", Dermatology, Burn - Consult ,"CHIEF COMPLAINT: , Burn, right arm.,HISTORY OF PRESENT ILLNESS: , This is a Workers' Compensation injury.  This patient, a 41 year-old male, was at a coffee shop, where he works as a cook, and hot oil splashed onto his arm, burning from the elbow to the wrist on the medial aspect.  He has had it cooled, and presents with his friend to the Emergency Department for care.,PAST MEDICAL HISTORY:  ,Noncontributory.,MEDICATIONS:  ,None.,ALLERGIES:  ,None.,PHYSICAL EXAMINATION: , GENERAL:  Well-developed, well-nourished 21-year-old male adult who is appropriate and cooperative.  His only injury is to the right upper extremity.  There are first and second degree burns on the right forearm, ranging from the elbow to the wrist.  Second degree areas with blistering are scattered through the medial aspect of the forearm.  There is no circumferential burn, and I see no areas of deeper burn.  The patient moves his hands well.  Pulses are good.  Circulation to the hand is fine.,FINAL DIAGNOSIS:,1.  First-degree and second-degree burns, right arm secondary to hot oil spill.,2.  Workers' Compensation industrial injury.,TREATMENT: , The wound is cooled and cleansed with soaking in antiseptic solution.  The patient was ordered Demerol 50 mg IM for pain, but he refused and did not want pain medication.  A burn dressing is applied with Neosporin ointment.  The patient is given Tylenol No. 3, tabs #4, to take home with him and take one or two every four hours p.r.n. for pain.  He is to return tomorrow for a dressing change.  Tetanus immunization is up to date.  Preprinted instructions are given.  Workers' Compensation first report and work status report are completed.,DISPOSITION: , Home.","dermatology, burn, workers' compensation industrial injury, workers' compensation, degree"
" 1+ year, black female for initial evaluation of a lifelong history of atopic eczema.", Dermatology, Atopic Eczema ,"SUBJECTIVE:,  This 1+ year, black female, new patient in dermatology, sent in for consult from ABC Practice for initial evaluation of a lifelong history of atopic eczema.  The patient’s mom is from Tanzania.  The patient has been treated with Elidel cream b.i.d. for six months but apparently this has stopped working now and it seems to make her more dry and plus she has been using some Johnson's Baby Oil on her.  The patient is a well-developed baby.  Appears stated age.  Overall health is good.,FAMILY, SOCIAL, AND ALLERGY HISTORY: , The patient has eczema and a positive atopic family history.  No psoriasis.  No known drug allergies.,CURRENT MEDICATIONS:,  None.,PHYSICAL EXAMINATION:, The patient has eczematous changes today on her face, trunk, and extremities.,IMPRESSION:,  Atopic eczema.,TREATMENT:,1.  Discussed condition and treatment with Mom.,2.  Continue bathing twice a week.,3.  Discontinue hot soapy water.,4.  Discontinue Elidel for now.,5.  Add Aristocort cream 0.25%, Polysporin ointment, Aquaphor b.i.d. and p.r.n. itch.  We will see her in one month if not better otherwise on a p.r.n. basis.  Send a letter to ABC Practice program.","dermatology, elidel cream, johnson's baby oil, polysporin ointment, atopic eczema, eczema, eczematous, hot soapy water, atopic, elidel,"
" Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth pain to both upper and lower teeth on the left side for approximately three days..", Dentistry, Toothache - ER Visit ,"CHIEF COMPLAINT:,  Toothache.,HISTORY OF PRESENT ILLNESS:  ,This is a 29-year-old male who has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled.  Complains of new tooth pain.  The patient states his current toothache is to both upper and lower teeth on the left side for approximately three days.  The patient states that he would have gone to see his regular dentist but he has missed so many appointments that they now do not allow him to schedule regular appointments, he has to be on standby appointments only.  The patient denies any other problems or complaints.  The patient denies any recent illness or injuries.  The patient does have OxyContin and Vicodin at home which he uses for his knee pain but he wants more pain medicines because he does not want to use up that medicine for his toothache when he wants to say this with me.,REVIEW OF SYSTEMS: , CONSTITUTIONAL:  No fever or chills.  No fatigue or weakness.  No recent weight change.  HEENT:  No headache, no neck pain, the toothache pain for the past three days as previously mentioned.  There is no throat swelling, no sore throat, no difficulty swallowing solids or liquids.  The patient denies any rhinorrhea.  No sinus congestion, pressure or pain, no ear pain, no hearing change, no eye pain or vision change.  CARDIOVASCULAR:  No chest pain.  RESPIRATIONS:  No shortness of breath or cough.  GASTROINTESTINAL:  No abdominal pain.  No nausea or vomiting.  GENITOURINARY:  No dysuria.  MUSCULOSKELETAL:  No back pain.  No muscle or joint aches.  SKIN:  No rashes or lesions.  NEUROLOGIC:  No vision or hearing change.  No focal weakness or numbness.  Normal speech.  HEMATOLOGIC/LYMPHATIC:  No lymph node swelling has been noted.,PAST MEDICAL HISTORY: , Chronic knee pain.,CURRENT MEDICATIONS: , OxyContin and Vicodin.,ALLERGIES:,  PENICILLIN AND CODEINE.,SOCIAL HISTORY: , The patient is still a smoker.,PHYSICAL EXAMINATION:,  VITAL SIGNS:  Temperature 97.9 oral, blood pressure is 146/83, pulse is 74, respirations 16, oxygen saturation 98% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished and well developed.  The patient is a little overweight but otherwise appears to be healthy.  The patient is calm, comfortable, in no acute distress, and looks well.  The patient is pleasant and cooperative.  HEENT:  Eyes are normal with clear conjunctiva and cornea bilaterally.  There is no icterus, injection, or discharge.  Pupils are 3 mm and equally round and reactive to light bilaterally.  There is no absence of light sensitivity or photophobia.  Extraocular motions are intact bilaterally.  Ears are normal bilaterally without any sign of infection.  There is no erythema, swelling of canals.  Tympanic membranes are intact without any erythema, bulging or fluid levels or bubbles behind it.  Nose is normal without rhinorrhea or audible congestion.  There is no tenderness over the sinuses.  NECK:  Supple, nontender, and full range of motion.  There is no meningismus.  No cervical lymphadenopathy.  No JVD.  Mouth and oropharynx shows multiple denture and multiple dental caries.  The patient has tenderness to tooth #12 as well as tooth #21.  The patient has normal gums.  There is no erythema or swelling.  There is no purulent or other discharge noted.  There is no fluctuance or suggestion of abscess.  There are no new dental fractures.  The oropharynx is normal without any sign of infection.  There is no erythema, exudate, lesion or swelling.  The buccal membranes are normal.  Mucous membranes are moist.  The floor of the mouth is normal without any abscess, suggestion of Ludwig's syndrome.  CARDIOVASCULAR:  Heart is regular rate and rhythm without murmur, rub, or gallop.  RESPIRATIONS:  Clear to auscultation bilaterally without shortness of breath.  GASTROINTESTINAL:  Abdomen is normal and nontender.  MUSCULOSKELETAL:  No abnormalities are noted to back, arms and legs.  The patient has normal use of his extremities.  SKIN:  No rashes or lesions.  NEUROLOGIC:  Cranial nerves II through XII are intact.  Motor and sensory are intact to the extremities.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is alert and oriented x4.  Normal mood and affect.  HEMATOLOGIC/LYMPHATIC:  No cervical lymphadenopathy is palpated.,EMERGENCY DEPARTMENT COURSE: , The patient did request a pain shot and the patient was given Dilaudid of 4 mg IM without any adverse reaction.,DIAGNOSES:,1.  ODONTALGIA.,2.  MULTIPLE DENTAL CARIES.,CONDITION UPON DISPOSITION:  ,Stable.,DISPOSITION: , To home.,PLAN: , The patient was given a list of local dental clinics that he can follow up with or he can choose to stay with his own dentist that he wishes.  The patient was requested to have reevaluation within two days.  The patient was given a prescription for Percocet and clindamycin.  The patient was given drug precautions for the use of these medicines.  The patient was offered discharge instructions on toothache but states that he already has it.  He declined the instructions.  The patient was asked to return to the emergency room, should he have any worsening of his condition or develop any other problems or symptoms of concern.","dentistry, odontalgi, multiple dental caries, dentist, dental disease, extensive dental disease, teeth pulled, lower teeth, cervical lymphadenopathy, dental caries, toothache, erythema, swelling, teeth, dental, "
 Cauterization of peri and intra-anal condylomas.  Extensive perianal and intra-anal condyloma which are likely represent condyloma acuminata., Dermatology, Condyloma Cauterization ,"PREOPERATIVE DIAGNOSIS: , Extensive perianal and intra-anal condyloma.,POSTOPERATIVE DIAGNOSIS: , Extensive perianal and intra-anal condyloma.,PROCEDURE PERFORMED:,  Cauterization of peri and intra-anal condylomas.,ANESTHESIA:  ,IV sedation and local.,SPECIMEN: , Multiple condylomas were sent to pathology.,ESTIMATED BLOOD LOSS: , 10 cc.,BRIEF HISTORY: , This is a 22-year-old female, who presented to the office complaining of condylomas she had noted in her anal region.  She has noticed approximately three to four weeks ago.  She denies any pain but does state that there is some itching.  No other symptoms associated.,GROSS FINDINGS: , We found multiple extensive perianal and intra-anal condylomas, which are likely represent condyloma acuminata.,PROCEDURE: , After risks, benefits and complications were explained to the patient and a verbal consent was obtained, the patient was taken to the operating room.  After the area was prepped and draped, a local anesthesia was achieved with Marcaine.  Bovie electrocautery was then used to remove the condylomas taking care to achieve meticulous hemostasis throughout the course of the procedure.  The condylomas were removed 350 degrees from the perianal and intra-anal regions.  After all visible condylomas were removed, the area was again washed with acetic acid solution.  Any residual condylomas were then cauterized at this time.  The area was then examined again for any residual bleeding and there was none.,DISPOSITION: , The patient was taken to Recovery in stable condition.  She will be sent home with prescriptions for a topical lidocaine and Vicodin.  She will be instructed to do sitz bath b.i.d., and post-bowel movement.  She will follow up in the office next week.","dermatology, intra-anal, perianal, acuminata, cauterization, condyloma, anal,"
" Left buttock abscess, status post incision and drainage.   Recommended some local wound care", Dermatology, Buttock Abscess ,"CHIEF COMPLAINT: , Buttock abscess.,HISTORY OF PRESENT ILLNESS: , This patient is a 24-year-old African-American female who presented to the hospital with buttock pain.  She started off with a little pimple on the buttock.  She was soaking it at home without any improvement.  She came to the hospital on the first.  The patient underwent incision and drainage in the emergency department.  She was admitted to the hospitalist service with elevated blood sugars.  She has had positive blood cultures.  Surgery is consulted today for evaluation.,PAST MEDICAL HISTORY:  ,Diabetes type II, poorly controlled, high cholesterol.,PAST SURGICAL HISTORY: , C-section and D&C.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,MEDICATIONS: , Insulin, metformin, Glucotrol, and Lipitor.,FAMILY HISTORY: , Diabetes, hypertension, stroke, Parkinson disease, and heart disease.,REVIEW OF SYSTEMS: , Significant for pain in the buttock.  Otherwise negative.,PHYSICAL EXAMINATION:,GENERAL:  This is an overweight African-American female not in any distress.,VITAL SIGNS:  She has been afebrile since admission.  Vital signs have been stable.  Blood sugars have been in the 200 range.,HEENT:  Normal to inspection.,NECK:  No bruits or adenopathy.,LUNGS:  Clear to auscultation.,CV:  Regular rate and rhythm.,ABDOMEN:  Protuberant, soft, and nontender.,EXTREMITIES:  No clubbing, cyanosis or edema.,RECTAL EXAM:  The patient has a drained abscess on the buttock cheek.  There is some serosanguineous drainage.  There is no longer any purulent drainage.  The wound appears relatively clean.  I do not see a lot of erythema.,ASSESSMENT AND PLAN: , Left buttock abscess, status post incision and drainage.  I do not believe surgical intervention is warranted.  I have recommended some local wound care.  Please see orders for details.","dermatology, buttock pain, pimple, incision and drainage, local wound care, blood sugars, diabetes, buttock, abscess, "
 Extraction of teeth #2 and #19 and incision and drainage (I&D) of intraoral and extraoral of left mandibular dental abscess., Dentistry, Teeth Extraction & I&D - 1 ,"PREOPERATIVE DIAGNOSES: , Carious teeth #2 and #19 and left mandibular dental abscess.,POSTOPERATIVE DIAGNOSES:,  Carious teeth #2 and #19 and left mandibular dental abscess.,PROCEDURES:,  Extraction of teeth #2 and #19 and incision and drainage of intraoral and extraoral of left mandibular dental abscess.,ANESTHESIA: , General, oral endotracheal.,COMPLICATIONS: , None.,DRAINS: , Penrose 0.25 inch intraoral and vestibule and extraoral.,CONDITION:,  Stable to PACU.,DESCRIPTION OF PROCEDURE:,  Patient was brought to the operating room, placed on the table in the supine position and after demonstration of an adequate plane of general anesthesia via the oral endotracheal route, patient was prepped and draped in the usual fashion for an intraoral procedure.  In addition, the extraoral area on the left neck was prepped with Betadine and draped accordingly.  Gauze throat pack was placed and local anesthetic was administered in the left lower quadrant, total of 3.4 mL of lidocaine 2% with 1:100,000 epinephrine and Marcaine 1.7 mL of 0.5% with 1:200,000 epinephrine.  An incision was made with #15 blade in the left submandibular area through the skin and blunt dissection was accomplished with curved mosquito hemostat to the inferior border of the mandible.  No purulent drainage was obtained.  The 0.25 inch Penrose drain was then placed in the extraoral incision and it was secured with 3-0 silk suture.  Moving to the intraoral area, periosteal elevator was used to elevate the periosteum from the buccal aspect of tooth #19.  The area did not drain any purulent material.  The carious tooth #19 was then extracted by elevator and forceps extraction.  After the tooth was removed, the 0.25 inch Penrose drain was placed in a subperiosteal fashion adjacent to the extraction site and secured with 3-0 silk suture.  The tube was then repositioned to the left side allowing access to the upper right quadrant where tooth #2 was then extracted by routine elevator and forceps extraction.  After the extraction, the throat pack was removed.  An orogastric tube was then placed by Dr. X, and stomach contents were suctioned.  The pharynx was then suctioned with the Yankauer suction.  The patient was awakened, extubated, and taken to the PACU in stable condition.","dentistry, yankauer suction, orogastric tube, carious teeth, penrose drain, forceps extraction, dental abscess, incision, elevator, mandibular, dental, abscess, teeth, intraoral, extraction, drainage,"
 Extraction of teeth.  Incision and drainage (I&D) of left mandibular vestibular abscess adjacent to teeth #18 and #19., Dentistry, Teeth Extraction & I&D ,"PREOPERATIVE DIAGNOSES,1.  Carious teeth #2, #5, #12, #15, #18, #19, and #31.,2.  Left mandibular vestibular abscess.,POSTOPERATIVE DIAGNOSES,1.  Carious teeth #2, #5, #12, #15, #18, #19, and #31.,2.  Left mandibular vestibular abscess.,PROCEDURE,1.  Extraction of teeth #2.  #5, #12, #15, #18, #19, #31.,2.  Incision and drainage (I&D) of left mandibular vestibular abscess adjacent to teeth #18 and #19.,ANESTHESIA:,  General nasotracheal.,COMPLICATIONS: , None.,DRAIN:,  Quarter-inch Penrose drain place in left mandibular vestibule adjacent to teeth #18 and #19, secured with 3-0 silk suture.,CONDITION:,  The patient was taken to the PACU in stable condition.,INDICATION:,  Patient is a 32-year-old female who was admitted yesterday 03/04/10 with left facial swelling and a number of carious teeth which were also abscessed particularly those on the lower left and this morning, the patient was brought to the operating room for extraction of the carious teeth and incision and drainage of left vestibular abscess.,DESCRIPTION OF PROCEDURE:,  Patient was brought to the operating room, placed on the table in a supine position, and after demonstration of an adequate plane of general anesthesia via the nasotracheal route, patient was prepped and draped in the usual fashion for an intraoral procedure.  A gauze throat pack was placed and local anesthetic was administered in all four quadrants, a total of 6.8 mL of lidocaine 2% with 1:100,000 epinephrine, and 3.6 mL of Marcaine 0.5% with 1:200,000 epinephrine.  The area in the left vestibular area adjacent to the teeth #18 and #19 was aspirated with 5 cc syringe with an 18-guage needle and approximately 1 mL of purulent material was aspirated.  This was placed on the culture medium in the aerobic and anaerobic culture tubes and the tubes were then sent to the lab.  An incision was then made in the left mandibular vestibule adjacent to teeth #18 and #19.  The area was bluntly dissected with a curved hemostat and a small amount of approximately 3 mL of purulent material was drained.  Penrose drain was then placed using a curved hemostat.  The drain was secured with 3-0 silk suture.  The extraction of the teeth was then begun on the left side removing teeth #12, #15, #18 and #19 with forceps extraction, then moving to the right side teeth #2, #5, and #31 were removed with forceps extraction uneventfully.  After completion of the procedure, the throat pack was removed, the pharynx was suctioned.  The anesthesiologist then placed an orogastric tube and suctioned approximately 10 cc of stomach contents with the nasogastric tube.  The nasogastric tube was then removed.  Patient was then extubated and taken to the PACU in stable condition.","dentistry, mandibular, vestibular, abscess, throat pack, purulent material, forceps extraction, nasogastric tube, carious teeth, incision, teeth, nasogastric, carious, extraction"
 Acne with folliculitis., Dermatology, Acne - SOAP ,"SUBJECTIVE:,  The patient is a 49-year-old white female, established patient to Dermatology, last seen in the office on 08/10/2004.  She comes in today for reevaluation of her acne plus she has had what she calls a rash for the past two months now on her chest, stomach, neck, and back.  On examination, this is a flaring of her acne with small folliculitis lesions.  The patient has been taking amoxicillin 500 mg b.i.d. and using Tazorac cream 0.1, and her face is doing well, but she has been out of her medicine now for three days also.  She has also been getting photofacials at Healing Waters and was wondering about what we could offer as far as cosmetic procedures and skin care products, etc.  The patient is married.  She is a secretary.,FAMILY, SOCIAL, AND ALLERGY HISTORY:,  She has hay fever, eczema, sinus, and hives.  She has no melanoma or skin cancers or psoriasis.  Her mother had oral cancer.  The patient is a nonsmoker.  No blood tests.  Had some sunburn in the past.  She is on benzoyl peroxide and Daypro.,CURRENT MEDICATIONS:,  Lexapro, Effexor, Ditropan, aspirin, vitamins.,PHYSICAL EXAMINATION:,  The patient is well developed, appears stated age.  Overall health is good.  She has a couple of acne lesions, one on her face and neck but there are a lot of small folliculitis-like lesions on her abdomen, chest, and back.,IMPRESSION:,  Acne with folliculitis.,TREATMENT:,1.  Discussed condition and treatment with the patient.,2.  Continue the amoxicillin 500 mg two at bedtime.,3.  Add Septra DS every morning with extra water.,4.  Continue the Tazorac cream 0.1; it is okay to use on back and chest also.,5.  Referred to ABC clinic for an aesthetic consult.  Return in two months for followup evaluation of her acne.","dermatology, acne with folliculitis, tazorac cream, acne, tazorac, cream, folliculitis,"
" Removal of cystic lesion, removal of teeth, modified Le Fort I osteotomy.
", Dentistry, Teeth Extraction ,"PREOPERATIVE DIAGNOSES,1.  Basal cell nevus syndrome.,2.  Cystic lesion, left posterior mandible.,3.  Corrected dentition.,4.  Impacted teeth 1 and 16.,5.  Maxillary transverse hyperplasia.,POSTOPERATIVE DIAGNOSES,1.  Basal cell nevus syndrome.,2.  Cystic lesion, left posterior mandible.,3.  Corrected dentition.,4.  Impacted teeth 1 and 16.,5.  Maxillary transverse hyperplasia.,PROCEDURE,1.  Removal of cystic lesion, left posterior mandible.,2.  Removal of teeth numbers 4, 13, 20, and 29.,3.  Removal of teeth numbers 1 and 16.,4.  Modified Le Fort I osteotomy.,INDICATIONS FOR THE PROCEDURE:, The patient has undergone previous surgical treatment and had a diagnosis of basal cell nevus syndrome.  Currently our plan is to remove the impacted third molar teeth, to remove a cystic lesion left posterior mandible, to remove 4 second bicuspid teeth as requested by her orthodontist, and to weaken and her maxilla to allow expansion by a modified Le Fort osteotomy.,PROCEDURE IN DETAIL:, The patient was brought into the operating room, placed on the operating table in supine position.  Following treatment under adequate general anesthesia via the orotracheal route, the patient was prepped and draped in a manner consistent with intraoral surgical procedures.  The oral cavity was suctioned, was drained of fluid and a throat pack was placed.  General anesthesia nursing service was notified and which was removed at the end of the procedure.  Lidocaine 1% with epinephrine concentration in 1:100,000 was injected into the labial vestibule of the maxilla bilaterally as well as the lateral areas associated with the extractions sites in lower jaw and the left posterior mandible for a total of 11 mL.  A Bovie electrocautery was utilized to make a vestibular incision, beginning in the second molar region of the maxilla superior to the mucogingival junction extending to the area of the cuspid teeth.  Subperiosteal dissection revealed lateral aspect of the maxilla immediately posterior to the second molar tooth where the third molar tooth was identified and was bony crypt.  Following use of Cerebromaxillary osteotome, elevated, and underwent complete removal of the dental follicle.  Secondly, tooth number 4 was removed.  Tooth number 13 was removed, and the opposite third molar tooth was removed through an identical incision on the opposite side.  Surgeon then utilized a #15 saw to make a horizontal osteotomy through the lateral aspect of the maxilla from the target plates, anteriorly to the area of the buttress region cross the anterior maxilla to a point adjacent to the piriform rim, 5 mm superior to the nasal floor, bilaterally Cerebromaxillary osteotome utilized to separate the maxilla from the target placed posteriorly and a 5 mm Tessier osteotome through a vertical incision anteriorly between roots of teeth numbers 8 and 9.  This resulted in the alternate mobilization of the two halves of the maxilla, or to allow expansion.  These wounds were all irrigated with copious amounts of normal saline and with antibiotic containing solution, closed with 3-0 chromic suture in running fashion for watertight closure.  Attention was directed to the mandible where the left posterior mandible was approached through a lateral vestibular incision overlying the external oblique ridge and brought anteriorly in an old scar.  The surgeons utilized cautery osteotome to identify a cystic lesion associated with the left posterior mandible, which was approximately 1 cm in width and 2.5 to 3 cm in vertical dimension immediately adjacent to the neurovascular bundle.  This wound was then irrigated with copious amounts of normal saline and concentrated solution of clindamycin.  Closed primarily with a 3-0 Vicryl suture in running fashion for a watertight closure.  Teeth number 20 and 29 where removed and 3-0 chromic suture placed.  This concluded the procedure.  All cottonoids and other sponges, throat pack were removed.  No complications were encountered.  The aforementioned cystic lesion was sent with specimen no drains were placed.  The blood loss from this procedure was approximately 100 mL.,The patient was returned over the care of the anesthesia where she was extubated in the operating room, taken from the operating room to the recovery room with stable vital signs and spontaneous respirations.","dentistry, nevus syndrome, basal cell, mandible, teeth, hyperplasia, cystic lesion, osteotomy, le fort, le fort osteotomy, orotracheal route, bony crypt, watertight, removal of cystic lesion, le fort i osteotomy, aspect of the maxilla, modified le fort, molar tooth, posterior mandible, maxillary, molar, tooth,"
 Extraction of tooth #T and incision and drainage (I&D) of right buccal space infection.  Right buccal space infection and abscess tooth #T., Dentistry, Teeth Extraction & I&D - 2 ,"PREOPERATIVE DIAGNOSIS:,  Right buccal space infection and abscess tooth #T.,POSTOPERATIVE DIAGNOSIS: , Right buccal space infection and abscess tooth #T.,PROCEDURE:,  Extraction of tooth #T and incision and drainage (I&D) of right buccal space infection.,ANESTHESIA:,  General, oral endotracheal tube.,COMPLICATIONS: , None.,SPECIMENS:,  Aerobic and anaerobic cultures were sent.,IV FLUID: , 150 mL.,ESTIMATED BLOOD LOSS:,  10 mL.,PROCEDURE: , The patient was brought to the operating room, placed on the table in a supine position, and after demonstration of an adequate plane of general anesthesia via the oral endotracheal route, the patient was prepped and draped in the usual fashion for an intraoral procedure.  Gauze throat pack was placed and the right buccal vestibule was palpated and area of the abscess was located.  The abscess cavity was aspirated using a 5 mL syringe with an 18-gauge needle.  Approximately 1 mL of purulent material was aspirated that was placed on aerobic and anaerobic cultures.  Culture swabs and the tooth sent to the laboratory for culture and sensitivity testing.,The area in the buccal vestibule was then opened with approximately 1-cm incision.  Blunt dissection was then used to open up the abscess cavity and explore the abscess cavity.  A small amount of additional purulence was drained from it, approximately 1 mL and at this point, tooth #T was extracted by forceps extraction.  Periosteal elevator was used to explore the area near the extraction site.  This was continuous with abscess cavity, so the abscess cavity was allowed to drain into the extraction site.  No drain was placed.  Upon completion of the procedure, the throat pack was removed.  The pharynx was suctioned.  The stomach was also suctioned and the patient was then awakened, extubated, and taken to the recovery room in stable condition.","dentistry, buccal space, incision and drainage, throat pack, extraction site, tooth, i&d, drainage, infection, cavity, extraction, incision, buccal, abscess"
 Full-mouth extraction of teeth and alveoloplasty in all four quadrants., Dentistry, Teeth (full-mouth) Extraction ,"PREOPERATIVE DIAGNOSIS:, Nonrestorable teeth.,POSTOPERATIVE DIAGNOSIS:, Nonrestorable teeth.,PROCEDURE:, Full-mouth extraction of tooth #3,5,6, 7, 8, 9, 10, 11, 12, 13, 14, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 31, and alveoloplasty in all four quadrants.,ANESTHESIA:,  Nasotracheal general anesthesia.,IV FLUIDS:, A 700 mL of crystalloid.,EBL:, Minimum.,URINE:, Not recorded.,COMPLICATIONS:, None.,CONDITION:, Good.,DISPOSITION:,  The patient was extubated in OR, transferred to PACU for recovery and will be transferred for 23-hour observation and discharged on subsequent day.,BRIEF HISTORY OF THE PATIENT:, Indicated the patient for surgery.  The patient is a 41-year-old white female with multiple grossly decaying nonrestorable teeth.  After discussing treatment options, she decided she will like to have extraction of remaining teeth with subsequent placement of upper and lower complete dentures.,PAST MEDICAL HISTORY:, Positive for a narcotic abuse, presently on methadone treatment, hepatitis C, and headaches.,PAST SURGICAL HISTORY:, C-section x2.,MEDICATIONS,Right now include:,1.  Methadone.,2.  Beta-blocker.,3.  Xanax.,4.  Norco.,5.  Clindamycin.,ALLERGIES:, THE PATIENT IS ALLERGIC TO PENICILLIN.,PROCEDURE IN DETAIL:, The patient was greeted in preoperative holding area, subsequently transferred to OR #17 where the patient was intubated with anesthesia staff present.  The patient was prepped and draped in sterile fashion.  Local anesthesia consisting of 1% lidocaine and 1:100,000 epinephrine, total 15 mL were injected into the maxillomandible.  Throat pack was placed in the mouth after a thorough suction.,A full-thickness mucoperiosteal flap was reflected from the upper right to the upper left, tooth number 3,5,6,7,8,9,10,11,12,13, and 14 and were elevated and delivered.  Extraction sites were thoroughly curettaged and irrigated.  Bony undercuts were removed then smoothed with rongeurs and bone saw.  After thorough irrigation, the postsurgical site closed in a running fashion with 3-0 chromic sutures.  Subsequently, a full-thickness mucoperiosteal flap was reflected in the mandible, tooth numbers 31, 28, 27, 26, 25, 24, 23, 22, 21, 20, and 19 were elevated and delivered with simple forceps extractions.  Bony undercuts were removed with rongeurs and smoothed with bone saw.,Extraction sites were thoroughly irrigated and curettaged.  Wound was closed in continuous fashion 3-0 chromic.  After adequate hematosis was achieved, 0.5% Marcaine and 1:200,000 epinephrine was injected in the maxillomandible thus to heal to aid in hematosis and pain control.  Total of 8 mL were used.  Throat pack was subsequently removed.  Orogastric tube was passed to suction out the stomach.,The patient was subsequently extubated in OR and transferred to PACU for recovery.  The patient would be placed in 23-hour observation.",
 A simple note on Acne Vulgaris., Dermatology, Acne Vulgaris ,"ACNE VULGARIS,, commonly referred to as just acne, is a chronic inflammation of the skin that occurs most often during adolescence but can occur off and on throughout life.  The skin eruptions most often appear on the face, chest, back and upper arms and are more common in males than females.,SIGNS AND SYMPTOMS:,*  Blackheads the size of a pinhead.,*  Whiteheads similar to blackheads.,*  Pustules - lesions filled with pus.,*  Redness and inflamed skin.,*  Cysts - large, firm swollen lesions in severe acne.,*  Abscess - infected lesion that is swollen, tender, inflamed, filled with pus, also seen in severe acne.,CAUSES:,Oil glands in the skin become plugged for reasons unknown but during adolescence, sex-hormone changes play some role.  When oil backs up in the plugged gland, a bacteria normally present on skin causes an infection.  Acne is NOT caused by foods, uncleanliness or masturbation.  Cleaning the skin can decrease its severity but sexual activity has no effect on it.  A family history of acne can indicate if an individual will get acne and how severe it might be.  Currently, acne can't be prevented.,ACNE CAN BE BROUGHT ON OR MADE WORSE BY:,*  Hot or cold temperatures.,*  Emotional stress.,*  Oily skin.,*  Endocrine (hormone) disorder.,*  Drugs such as cortisones, male hormones, or oral contraceptives.,*  Some cosmetics.,*  Food sensitivities.  Again, foods do not cause acne but some certain ones may make it worse.  To discover any food sensitivities, eliminate suspicious foods from your diet and then start eating them again one at a time.  If acne worsens 2-3 days after consumption, then avoid this food.  Acne usually improves in summer so some foods may be tolerated in summer that can't be eaten in winter.,TREATMENT:,*  Most cases of acne respond well to treatment and will likely disappear once adolescence is over.  Even with adequate treatment, acne will tend to flare up from time to time and sometimes permanent facial scars or pitting of the skin may occur.,*  If your skin is oily, gently clean face with a fresh, clean wash cloth using unscented soap for 3- 5 minutes; an antibacterial soap may work better.  A previously used wet washcloth will harbor bacteria.  Don't aggressively scrub tender lesions as this may spread infection; be gentle.  Rinse the soap off for a good 1-2 minutes.  Dry face carefully with a clean towel and use an astringent such as rubbing alcohol that will remove the skin oil.,OTHER TIPS THAT MAY HELP ACNE:,*  Shampoo hair at least twice a week.  Keep hair off of face even while sleeping as hair can spread oil and bacteria.  If you have dandruff, use a dandruff shampoo.  Avoid cream hair rinses.,*  Wash sweat and skin oil off as soon as possible after sweating and exercising.,*  Use thinner, water-based cosmetics instead of the heavier oil-based ones.,*  Avoid skin moisturizers unless recommended by your doctor.,*  Do not squeeze, pick, rub or scratch your skin or the acne lesions.  This may damage the skin causing scarring and delay healing of acne.  Only a doctor should remove blackheads.,*  Keep from resting face on hands while reading, studying or watching TV.,*  Try to avoid pressing the phone receiver on you chin while talking on the phone.,*  Ultraviolet light may be a treatment recommended by your doctor but this is by no means a license to sunbathe!  Don't use the sun to treat acne.,*  Dermabrasion may be another option to treat acne scars.  This is a type of cosmetic surgery to help remove unsightly scars.,MEDICATIONS THAT MAY BE PRESCRIBED TO HELP ACNE INCLUDE:,*  Oral or topical antibiotics.,*  Cortisone injections into acne lesions.,*  Oral contraceptives.,*  Tretinoin, which may increase sun sensitivity and excessive dryness,  is not recommended during pregnancy.,*  Accutane (isotretinoin) is a powerful drug to treat acne but causes birth defects.  A woman taking this drug,must be on two types of birth control and have negative pregnancy tests.  This drug also increases sun,sensitivity.  Other more serious side effects can occur and your doctor will discuss those with you if Accutane is to be prescribed.,TETRACYCLINE:,Tetracycline is a very safe antibiotic.  It is not related to penicillin and an allergy to it is unusual.  There are several potential side effects:,1.  Tetracycline can cause nausea or heartburn.,2.  Tetracycline can cause vaginitis.,3.  Tetracycline can cause excessive sun burn.,CAUTIONS ON TETRACYCLINE:,1.  Do not take Tetracycline with milk or milk products (ice cream, cheese, yogurt, etc.).  This will cancel out the Tetracycline.  Separate the Tetracycline from these products by one and one-half hours before and after each capsule.  Do have a small amount of non milk-containing food in your stomach first to prevent nausea.,2.  Do not take Tetracycline if you are pregnant.",
" Acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use - Acne Vulgaris", Dermatology, Acne Vulgaris - H&P ,"CHIEF COMPLAINT (1/1): , This 19 year old female presents today complaining of acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use.  Location:  She indicates the problem location is the chin, right temple and left temple locally.  Severity:  Severity of condition is worsening.,Menses:  Onset:  13 years old.  Interval:  22-27 days.  Duration:  4-6 days.  Flow:  light.  Complications:  none.,ALLERGIES: , Patient admits allergies to penicillin resulting in difficulty breathing.,MEDICATION HISTORY:,  Patient is currently taking Alesse-28, 20 mcg-0.10 mg tablet usage started on 08/07/2001 medication was prescribed by Obstetrician-Gynecologist A.,PAST MEDICAL HISTORY:,  Female Reproductive Hx: (+) birth control pill use, Childhood Illnesses: (+) chickenpox, (+) measles.,PAST SURGICAL HISTORY:,  No previous surgeries.,FAMILY HISTORY: , Patient admits a family history of anxiety, stress disorder associated with mother.,SOCIAL HISTORY:,  Patient admits caffeine use She consumes 3-5 servings per day, Patient admits alcohol use Drinking is described as social, Patient admits good diet habits, Patient admits exercising regularly, Patient denies STD history.,REVIEW OF SYSTEMS:,  Integumentary: (+) periodic reddening of face, (+) acne problems, Allergic /,Immunologic: (-) allergic or immunologic symptoms, Constitutional Symptoms: (-) constitutional symptoms,such as fever, headache, nausea, dizziness.,PHYSICAL EXAM:,  Patient is a 19 year old female who appears pleasant, in no apparent distress, her given age, well developed, well nourished and with good attention to hygiene and body habitus.  Skin:  Examination of scalp shows no abnormalities.  Hair growth and distribution is normal.  Inspection of skin outside of affected area reveals no abnormalities.  Palpation of skin shows no abnormalities.  Inspection of eccrine and apocrine glands shows no evidence of hyperidrosis, chromidrosis or bromhidrosis.  Face shows keratotic papule.,IMPRESSION:,  Acne vulgaris.,PLAN:,  Recommended treatment is antibiotic therapy.  Patient received extensive counseling about acne.  She understands acne treatment is usually long-term.  Return to clinic in 4 week (s).,PATIENT INSTRUCTIONS:,  Patient received literature regarding acne vulgaris.  Discussed with the patient the prescription for Tetracycline and handed out information regarding the side effects and the proper method of ingestion.,PRESCRIPTIONS:,  Tetracycline  Dosage:  250 mg capsule  Sig:  BID  Dispense:  60  Refills:  0  Allow Generic:  Yes", 
" Open left angle comminuted angle of mandible, 802.35, and open symphysis of mandible, 802.36.  Open reduction, internal fixation (ORIF) of bilateral mandible fractures with multiple approaches, CPT code 21470, and surgical extraction of teeth #17, CPT code 41899.", Dentistry, ORIF - Mandible Fracture ,"PREOPERATIVE DIAGNOSIS:,  Open left angle comminuted angle of mandible, 802.35, and open symphysis of mandible, 802.36.,POSTOPERATIVE DIAGNOSIS:,  Open left angle comminuted angle of mandible, 802.35, and open symphysis of mandible, 802.36.,PROCEDURE:,  Open reduction, internal fixation (ORIF) of bilateral mandible fractures with multiple approaches, CPT code 21470, and surgical extraction of teeth #17, CPT code 41899.,ANESTHESIA: , General anesthesia via nasal endotracheal intubation.,FLUIDS: , 1800 mL of LR.,ESTIMATED BLOOD LOSS: , 150 mL.,HARDWARE:  ,A 2.3 titanium locking reconstruction plate from Leibinger on the symphysis and a 2.0 reconstruction plate on the left angle.,SPECIMEN: , None.,COMPLICATIONS: , None.,CONDITION: , The patient was extubated to the PACU, breathing spontaneously in excellent good condition.,INDICATIONS FOR THE PROCEDURE: , The patient is a 55-year-old male that he is 12 hour status post interpersonal violence in which he sustained bilateral mandible fractures and positive loss of consciousness.  He reported to the Hospital the day after his altercation complaining of mall occlusion and sore left shoulder.  He was worked up by the emergency department.  His head CT was cleared and his left shoulder was clear of any fractures or soft tissue damage.  Oral maxillary facial surgery was consulted to manage the mandible fracture.  After review of the CT and examination it was determined that the patient would benefit from open reduction, internal fixation of bilateral mandible fractures.  Risks, benefits, and alternative to treatment were thoroughly discussed with the patient and consent was obtained.,DESCRIPTION OF PROCEDURE:, The patient was brought to the operating room #2 at Hospital.  He was laid in supine position on the operating room table.  ASA monitors were attached and stated general anesthesia was induced with IV anesthetic and maintained with nasal endotracheal intubation and inflation anesthetics.,The patient was prepped and draped in the usual oral maxillofacial surgery fashion.  The surgeon approached the operating room table in a sterile fashion.  Approximately 10 mL of 1% lidocaine with 1:100,000 epinephrine was injected into oral vestibule in a nerve block fashion.  Erich arch bars were adapted to the maxilla and mandible, secured in the posterior teeth with 24-gauge surgical steel wire and 26-gauge surgical steel wire in the anterior.  This was done from second molar to second molar on both the maxilla and the mandible secondary to the patient missing multiple teeth.  The patient was manipulated up into maximum intercuspation.  He has a malocclusion with severe bruxism and so wear facets were lined up.  This was secured with 26-gauge surgical steel wire.  Attention was then directed to the symphysis extraorally.  Approximately 5 mL of 1% lidocaine with epinephrine was injected into the area of incision which paralleled the inferior border of the mandible 2 cm below the inferior border of the mandible.,After waiting appropriate time for local anesthesia using a 15 blade, a skin and platysma incision was made.  Then using a series of blunt and sharp dissections, the dissection was carried to the inferior border of the mandible.  The periosteum was incised and reflected with the periosteal elevator.  The fracture was noted and it was displaced.  Manipulation of the segments and checking with the occlusion intraorally, the fracture was aligned.  This was secured with 7-hole 2.3 titanium locking reconstruction plate with bicortical screws.  The wound was then packed with moist Ray-Tec and attention was directed intraorally to the left angle fracture.  Approximately 5 mL of 1% lidocaine with 1:100,000 epinephrine was injected into the left vestibule.  After waiting appropriate time for local anesthesia to take effect, using Bovie electrocautery, a sagittal split incision was made and the fracture was identified.  It was noted that the fracture went through tooth #17 and this needed to be extracted.  Taking a round bur, a buckle trough was made and the tooth was elevated and removed both distal and mesial roots.  The fracture was then reduced and lateral superior border plate 2-0 4 whole with monocortical screws was placed.  The fracture was noted to be well reduced.  The wound was then irrigated with copious amount of sterile water.  The patient was released for excellent intercuspation.  He was then manipulated up into the occlusion easily.  Wound was then closed with running 3-0 chromic gut suture.  Attention was then directed extraorally.  This was irrigated with copious amount of sterile water and closed in a layer fashion with 3-0 Vicryl, 4-0 Vicryl, and 5-0 Prolene on skin.  Attention was then again directed into the mouth.  The throat pack was removed and orogastric tube was placed and stomach content was evacuated.  The patient was then manipulated back up to maximum intercuspation and secured with interdental elastics and a pressure dressing was applied to the extraoral incisions.  At this point, the procedure was then determined to be over.,The patient was extubated and breathing spontaneously, transported to the PACU in excellent condition.","dentistry, mandible, endotracheal, leibinger, pacu, oral maxillary facial surgery, maxillofacial, buckle, round bur, lidocaine with epinephrine, surgical steel wire, bilateral mandible fractures, mandible fracture, orif, symphysis, fracture, "
" Open reduction and internal fixation of left atrophic mandibular fracture, removal of failed dental implant from the left mandible.  The patient fell following an episode of syncope and sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in fracture. ", Dentistry, ORIF Mandibular Fracture & Dental Implant Removal ,"PREOPERATIVE DIAGNOSES: , Open, displaced, infected left atrophic mandibular fracture; failed dental implant.,POSTOPERATIVE DIAGNOSES: , Open, displaced, infected left atrophic mandibular fracture; failed dental implant.,PROCEDURE PERFORMED: , Open reduction and internal fixation (ORIF) of left atrophic mandibular fracture, removal of failed dental implant from the left mandible.,ANESTHESIA: , General nasotracheal.,ESTIMATED BLOOD LOSS: , 125 mL.,FLUIDS GIVEN: , 1 L of crystalloids.,SPECIMEN: , Soft tissue from the fracture site sent for histologic diagnosis.,CULTURES: , Also sent for Gram stain, aerobic and anaerobic, culture and sensitivity.,INDICATIONS FOR THE PROCEDURE: , The patient is a 79-year-old male, who fell in his hometown, following an episode of syncope.  He sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in the above-mentioned fracture.  He was admitted to hospital in Harleton, Texas, where his initial evaluation showed the rib fractures have also showed a nodule on his right upper lobe as well as a mediastinal mass.  His mandible fracture was not noted initially.  The patient also has a history of prostate cancer and a renal cell carcinoma.  The patient at that point underwent a bronchoscopy with a biopsy of the mediastinal mass and the results of that biopsy are still pending.  The patient later saw a local oral surgeon.  He diagnosed his mandible fracture and advised him to seek treatment in Houston.  He presented to my office for evaluation on January 18, 2010, and he was found to have an extremely atrophic mandible with a fracture in the left parasymphysis region involving a failed dental implant, which had been placed approximately 15 years ago.  The patient had significant discomfort and could eat foods and drink fluids with difficulty.  Due to the nature of his fracture and the complex medical history, he was sent to the hospital for admission and following cardiac clearance, he was scheduled for surgery today.,PROCEDURE IN DETAIL: , The patient was taken to the operating room, and placed in a supine position.  Following a nasal intubation and induction of general anesthesia, the surgeon then scrubbed, gowned, and gloved in the normal sterile fashion.  The patient was then prepped and draped in a manner consistent with sterile procedures.  A marking pen was first used to outline the incision in the submental region and it was extended from the left mandibular body to the right mandibular body region, approximately 1.5 cm medial to the inferior border of the mandible.  A 1 mL of lidocaine 1% with 1:100,000 epinephrine was then infiltrated along the incision and then a 15-blade was used to incise through the skin and subcutaneous tissue.  A combination of sharp and blunt dissection was then used to carry the dissection superiorly to the inferior border of the mandible.  Electrocautery as well as 4.0 silk ties were used for hemostasis.  A 15-blade was then used to incise the periosteum along the inferior border of the mandible and it was reflected exposing the mandible as well as the fracture site.  The fracture site was slightly distracted allowing access to the dental implant within the bone and it was easily removed from the wound.  Cultures of this site were also obtained and then the granulation tissue from the wound was also curetted free of the wound and sent for a histologic diagnosis.  Manipulation of the mandible was then used to achieve an anatomic reduction and then an 11-hole Synthes reconstruction plate was then used to stand on the fracture site.  Since there was an area of weakness in the right parasymphysis region, in the location of another dental implant, the bone plate was extended posterior to that site.  When the plate was adapted to the mandible, it was then secured to the bone with 9 screws, each being 2 mm in diameter and each screw was placed bicortically.  All the screws were also locking screws.  Following placement of the screws, there was felt to be excellent stability of the fracture, so the wound was irrigated with a copious amount of normal saline.  The incision was closed in multiple layers with 4.0 Vicryl in the muscular and subcutaneous layers and 5.0 nylon in the skin.  A sterile dressing was then placed over the incision.  The patient tolerated the procedure well and was taken to the recovery room with spontaneous respirations and stable vital signs.  Estimated blood loss is 125 mL.","dentistry, atrophic mandibular fracture, dental implant, open reduction and internal fixation, orif, mandibular fracture, mandible, atrophic, mandibular, dental, implant,"
 Left facial cellulitis and possible odontogenic abscess.  Attempted incision and drainage (I&D) of odontogenic abscess., Dentistry, Odontogenic Abscess I&D ,"PREOPERATIVE DIAGNOSES:,1.  Left facial cellulitis.,2.  Possible odontogenic abscess of the #18, #19, and #20.,POSTOPERATIVE DIAGNOSES:,1.  Left facial cellulitis.,2.  Possible odontogenic abscess of the #18, #19, and #20.,PROCEDURE PERFORMED: , Attempted incision and drainage (I&D) of odontogenic abscess.,ANESTHESIA:  ,1% lidocaine plain approximately 5 cc total.,COMPLICATIONS: , The patient is very noncompliant with attempted procedure refusing further exam and treatment after localization and attempted FNA.  The attempted FNA was without any purulent aspirate although limited in the area of attempted examination.,INDICATIONS FOR THE PROCEDURE: , The patient is a 39-year-old Caucasian female who was admitted to ABCD General Hospital on 08/21/03 secondary to acute left facial cellulitis suspected to be secondary to odontogenic etiology.  The patient states that this was started approximately 24 hours ago.  The patient subsequently presented to ABCD General Hospital Emergency Room secondary to worsening of left face swelling and increasing in pain.  The patient admits to poor dental hygiene.  Denies any recent or dental abscesses in the past.  The patient is a substance abuser, does admit to smoking cocaine approximately three days ago.  The patient did have a CT scan of the face obtained with contrast demonstrated no signs of any acute abscess although a profuse amount of cellulitis was noted.  After risks, complications, consequences, and questions were discussed with the patient, a written consent was obtained for an I&D of a possible odontogenic abscess ________ on the CT scan.,PROCEDURE:  ,The patient was brought in upright and supine position.  Approximately 5 cc of 1% lidocaine without epinephrine was injected in the localized area along the buccogingival sulcus of the left side.  This was done at the base of #18, #19, and #20 teeth.  After this, the patient did have approximately 2 more mg of morphine given through the IV for pain control.  After this, the #18 gauge needle on a ________ syringe was then utilized to attempt a FNA at the base of #18 tooth and #19 with one stick placed.  There were no signs of any purulent drainage, although at this time the patient became very irate and noncompliant and refusing further examination.  The patient understood consequences of her actions.  Does state that she does not care at this time and just wants to be left alone.  At this time, the bed was actually placed back in its normal position and the patient will be continued on clindamycin 900 mg IV q.6h. along with pain control utilizing Toradol, morphine, and Vicodin.  The patient will also be started on Peridex oral rinse of 10 cc p.o. swish and spit t.i.d. and a K-pad to the left face.","dentistry, odontogenic, facial cellulitis, incision and drainage, fna, buccogingival, odontogenic abscess, abscess, drainage, i&d, cellulitis,"
 Letter on evaluation regarding extraction of mandibular left second molar tooth #18., Dentistry, Letter - Dentistry ,"XYZ, S.,RE:  ABC,Dear Dr. XYZ,On your kind referral, I had the pleasure of meeting and consulting with ABC on MM/DD/YYYY for evaluation regarding extraction of his mandibular left second molar tooth #18.  This previously root-canaled tooth, now failed, is scheduled for removal.  As per your request, I agree that placement of an implant in the #20 and #19 positions would allow for immediate functional replacement of the bridge which has recently been lost in this area.,I have given Mr. ABC an estimate for the surgical aspects of this case and suggested he combine this with your prosthetic or restorative fees in order to have a full understanding of the costs involved with this process.,We will plan to place two Straumann implants as per our normal protocol, one each in the #19 and 20 positions, with the #19 implant being a wide-neck, larger diameter implant.  I will plan on providing the prosthetic abutments, the lab analogue, and temporary healing cap at the end of the four-month integration period.  If you have any additional suggestions or concerns, please give me a call.,Best regards,,","dentistry, molar tooth, extraction, mandibular, straumann, wide-neck, placement, positions, prosthetic, implant, tooth"
" Autologous iliac crest bone graft to maxilla and mandible under general anesthetic.  Maxillary atrophy, severe mandibular atrophy, acquired facial deformity, and masticatory dysfunction.", Dentistry, Iliac Crest Bone Graft - Maxilla & Mandible ,"PREOPERATIVE DIAGNOSES:,1.  Maxillary atrophy.,2.  Severe mandibular atrophy.,3.  Acquired facial deformity.,4.  Masticatory dysfunction.,POSTOPERATIVE DIAGNOSES:,1.  Maxillary atrophy.,2.  Severe mandibular atrophy.,3.  Acquired facial deformity.,4.  Masticatory dysfunction.,PROCEDURE PERFORMED: , Autologous iliac crest bone graft to maxilla and mandible under general anesthetic.,Dr. X and company accompanied the patient to OR #6 at 7:30 a.m.  Nasal trachea intubation was performed per routine.  The bilateral iliac crest harvest was first performed by Dr. X and company under separate OR report.  Once the bone was harvested, surgical templets were used to recontour initially the maxillary graft and the mandibular graft.  Then, CAT scan models were used to find tune and adjust the bony contact regions for the maxillary tricortical block graft and the mandibular tricortical block graft.  Subsequent to the harvest of the bilateral ilium, the intraoral region was scrubbed per routine.  Surgical team scrubbed and gowned in usual fashion and the patient was draped.  Xylocaine 1%, 1:100,000 epinephrine 7 ml was infiltrated into the labial and palatal mucosa.  A primary incision was made in the maxilla starting on the patient's left tuberosity region along the crest of the residual ridge to the contralateral side in similar fashion.  Release incisions were made in the posterior region of the maxilla.,A full-thickness periosteal reflexion first exposed the palatal region.  The contents of the neurovascular canal from the greater palatine foramina were identified.  The hard palate was directly observed.  The facial tissues were then reflected exposing the lateral aspect of the maxilla, the zygomatic arch, the infraorbital nerve, artery and vein, the lateral piriform rim, the inferior piriform rim, and the remaining issue of the nasal spine.  Similar features were reflected on the contralateral side.  The area was re-contoured with rongeurs.  The block of bone, which was formed and harvested from the left ilium was then placed and found to be stable.  A surgical mallet then compressed this bone further into the region.  A series of five 2 mm diameter titanium screws measuring 14 mm to 16 mm long were then used to fixate the block of bone into the residual maxilla.  Particulate bone was then placed around the remaining block of bone.  A piece of AlloDerm mixed with Croften and patient's platelet-rich plasma, which was centrifuged from drawing 20 cc of blood was then mixed together and placed over the lateral aspect of the block.  The tissues were expanded then with a tissue Metzenbaum scissors and once the labial tissue was expanded, the tissues were approximated for primary closure without tension using interrupted and continuous sutures #3-0 Gore-Tex.  Attention was brought then to the mandible.  1% Xylocaine, 1:100,000 epinephrine was infiltrated in the labial mucosa 5 cc were given.  A primary incision was made between the mental foramina and the residual crest of the ridge and reflected first to the lingual area observing the superior genial tubercle in the facial area degloving the mentalis muscle and exposing the anterior body.  The anterior body was found to be approximately 3 mm in height.  A posterior tunnel was done first on the left side along the mylohyoid ridge and then under retromolar pad to the external oblique and the ridge was then degloved.  A tunnel was formed in the posterior region separating the mental nerve artery and vein from the flap and exposing that aspect of the body of the mandible.  A similar procedure was done on the contralateral side.  The tissues were stretched with tissue scissors and then a high speed instrumentation was used to decorticate the anterior mandible using a 1.6 mm twist drill and a pear shaped bur was used in the posterior region to begin original exploratory phenomenon of repair.  A block of bone was inserted between the mental foramina and fixative with three 16 cm screws first with a twist drill then followed with self-tapping 2 mm diameter titanium screws.  The block of bone was further re-contoured in situ.  Particulate bone was then injected into the posterior tunnels bilaterally.  A piece of AlloDerm was placed over those particulate segments.  The tissues were approximated for primary closure using #3-0 Gore-Tex suture both interrupted and horizontal mattress in form.  The tissues were compressed for about four minutes to allow platelet clots to form and to help adhere the flap.,The estimated blood loss in the harvest of the hip was 100 cc.  The estimated blood loss in the intraoral procedure was 220 cc.  Total blood loss for the procedure 320 cc.  The fluid administered 300 cc.  The urine out 180.  All sponges were counted encountered for as were sutures.  The patient was taken to Recovery at approximately 12 o'clock noon.","dentistry, autologous iliac crest bone graft, to, mandible, mandibular atrophy, maxillary atrophy, facial deformity, masticatory dysfunction, iliac crest bone graft, mental foramina, iliac crest, bone, autologous, maxillary, mandibular, maxilla"
 Excisional biopsy of skin nevus and two-layer plastic closure.  Trichloroacetic acid treatment to left lateral nasal skin 2.5 cm to treat actinic keratosis., Dermatology, Biopsy - Skin Nevus ,"PREOPERATIVE DIAGNOSES:  ,1.  Left back skin nevus 2 cm.,2.  Right mid back skin nevus 1 cm.,3.  Right shoulder skin nevus 2.5 cm.,4.  Actinic keratosis left lateral nasal skin 2.5 cm.,POSTOPERATIVE DIAGNOSES:  ,1.  Left back skin nevus 2 cm.,2.  Right mid back skin nevus 1 cm.,3.  Right shoulder skin nevus 2.5 cm.,4.  Actinic keratosis, left lateral nasal skin, 2.5 cm.,PATHOLOGY:  ,Pending.,TITLE OF PROCEDURES:  ,1.  Excisional biopsy of left back skin nevus 2 cm, two layer plastic closure.,2.  Excisional biopsy of mid back skin nevus 1 cm, one-layer plastic closure.,3.  Excisional biopsy of right shoulder skin nevus 2.5 cm, one-layer plastic closure.,4.  Trichloroacetic acid treatment to left lateral nasal skin 2.5 cm to treat actinic keratosis.,ANESTHESIA: , Xylocaine 1% with 1:100,000 dilution of epinephrine totaling 8 mL.,BLOOD LOSS: , Minimal.,COMPLICATIONS:,  None.,PROCEDURE:,  Consent was obtained.  The areas were prepped and draped and localized in the usual manner.  First attention was drawn to the left back.  An elliptical incision was made with a 15-blade scalpel.  The skin ellipse was then grasped with a Bishop forceps and curved Iris scissors were used to dissect the skin ellipse.  After dissection, the skin was undermined.  Radiofrequency cautery was used for hemostasis, and using a 5-0 undyed Vicryl skin was closed in the subcuticular plane and then skin was closed at the level of the skin with 4-0 nylon interrupted suture.,Next, attention was drawn to the mid back.  The skin was incised with a vertical elliptical incision with a 15-blade scalpel and then the mass was grasped with a Bishop forceps and excised with curved Iris scissors.  Afterwards, the skin was approximated using 4-0 nylon interrupted sutures.  Next, attention was drawn to the shoulder lesion.  It was previously marked and a 15-blade scalpel was used to make an elliptical incision into the skin.,Next, the skin was grasped with a small Bishop forceps and curved Iris scissors were used to dissect the skin ellipse and removed the skin.  The skin was undermined with the curved Iris scissors and then radio frequency treatment was used for hemostasis.,Next, subcuticular plain was closed with 5-0 undyed Vicryl interrupted suture.  Skin was closed with 4-0 nylon suture, interrupted.  Lastly, trichloroacetic acid chemical peel treatment to the left lateral nasal skin was performed.  Please refer to separate operative report for details.  The patient tolerated this procedure very well and we will follow up next week for postoperative re-evaluation or sooner if there are any problems.","dermatology, mid back skin nevus, actinic keratosis, trichloroacetic acid treatment, bishop forceps, skin nevus, plastic closure, curved iris, iris scissors, nasal skin, nevus, biopsy, nasal, forceps, "
" Right buccal and canine's base infection from necrotic teeth.  ICD9 CODE:  528.3.   Incision and drainage of multiple facial spaces; CPT Code:  40801.  Surgical removal of the following teeth.  The teeth numbers 1, 2, 3, 4, and 5.  CPT code:  41899 and dental code 7210.", Dentistry, Surgical Removal of Teeth ,"PREOPERATIVE DIAGNOSIS:,  Right buccal and canine's base infection from necrotic teeth.  ICD9 CODE:  528.3.,POSTOPERATIVE DIAGNOSIS: , Right buccal and canine's base infection from necrotic teeth.  ICD9 Code:  528.3.,PROCEDURE: , Incision and drainage of multiple facial spaces; CPT Code:  40801.  Surgical removal of the following teeth.  The teeth numbers 1, 2, 3, 4, and 5.  CPT code:  41899 and dental code 7210.,SPECIMENS: , Cultures and sensitivities were taken and sent for aerobic and anaerobic to the micro lab.,DRAINS:  ,A 1.5 inch Penrose drain placed in the right buccal and canine space.,ESTIMATED BLOOD LOSS:,  40 Ml.,FLUID:  ,700 mL of crystalloid.,COMPLICATIONS:  ,None.,CONDITION:  ,The patient was extubated breathing spontaneously to the PACU in good condition.,INDICATION FOR PROCEDURE:  ,The patient is a 41-year-old that has a recent history of toothache and tooth pain.  She saw her dentist in Sacaton before Thanksgiving who placed her on antibiotics and told her to return to the clinic for multiple teeth extractions.  The patient neglected to return to the dentist until this weekend for IV antibiotics and definitive treatment.  She noticed on Friday that her face was starting to swell up a little bit and it progressively got worse.  The patient was admitted to the hospital on Monday for IV antibiotics.  Oral surgery was consulted today to aid in the management of the increased facial swelling and tooth pain.  The patient was worked up preoperatively by anesthesia and Oromaxillary Facial Surgery.  It was determined that she would benefit from being having multiple teeth removed and drainage of the facial abscess under general anesthesia.  Risks, benefits, and alternatives of treatment were thoroughly discussed with the patient and consent was obtained.,DESCRIPTION OF PROCEDURE:,  The patient was taken to the operating room and laid on the operating room table on supine fashion.  ASA monitors were attached as stated.  General anesthesia was induced with IV anesthetic and maintained with a nasal endotracheal intubation and inhalation of anesthetics.  The patient was prepped and draped in usual oromaxillary facial surgery fashion.,An 18-gauze needle of 20 mL syringe was used to aspirate the pus out of the right buccal space.  This pus was then cultured and sent to micro lab for cultures and sensitivities.  Approximately 7 mL of 1% lidocaine with 1:1000 epinephrine was injected in the maxillary vestibule and palate.  After waiting appropriate time for local anesthesia to take affect a moist latex sponge was placed in the posterior oropharynx to throat pack throughout the case.  Mouth rinse was then poured into the oral cavity.  The mucosa was scrubbed with a tooth brush and peridex was evacuated with suction.  Using a #15 blade a clavicular incision from tooth #5 back to 1 with tuberosity release was performed.,A full thickness mucoperiosteal flap was developed and approximately 6 mL of pus was instantly drained from the buccal space.  It was noted on exam that the tooth #1 was fractured off to the gum line with gross decay.  Tooth #2, 3, 4, and 5 had pus leaking from the clavicular epithelium and had rampant decay on tooth #2 and 3 and some mobility on teeth #4 and 5.  It was decided that teeth #1 through 5 would be surgically removed to ensure that all potential teeth causing the abscess were removed.  Using a rongeur both buccal bone and the tooth 1, 2, 3, 4, and 5 were surgically removed.  The extraction sites were curetted with curettes and the bone was smoothed with the rongeur and the bone file.  Dissection was then carried further up in the canine space and the face was palpated extra orally from the temporalis muscle down to the infraorbital rim and more pus was expressed.  This site was then irrigated with copious amounts of sterile water.  There was still noted to be induration in the buccal mucosa so #15 blade was used anterior to Stensen duct.  A 2 cm incision was made and using a Hemostat blunt dissection in to the buccal mucosa was performed.  A little-to-no pus was received.  Using a half-inch Penrose the drain was placed up on the anterior border of the maxilla and zygoma and sutured in place with 2-0 Ethilon suture.  Remainder of the flap was left open to drain.  Further examination of the floor of mouth was soft.  The lateral pharynx was nonindurated or swollen.  At this point, the throat pack was removed and OG tube was placed and the stomach contents were evacuated.  The procedure was then determined to be over.  The patient was extubated, breathing spontaneously, and transferred to the PACU in excellent condition.","dentistry, cultures, buccal, teeth, canine, pacu, teeth extractions, oromaxillary facial, facial surgery, buccal space, throat pack, buccal mucosa, surgical removal, canine's base, necrotic teeth, cpt code, infection, oral, surgery, mucosa, anesthesia, facial, pus, toothache, "
" Patient started out having toothache, now radiating into his jaw and towards his left ear.  Ellis type II dental fracture.", Dentistry, Jaw Pain - ER Visit ,"CHIEF COMPLAINT: , Jaw pain.,HISTORY OF PRESENT ILLNESS:  ,This is a 58-year-old male who started out having toothache in the left lower side of the mouth that is now radiating into his jaw and towards his left ear.  Triage nurse reported that he does not believe it is his tooth because he has regular dental appointments, but has not seen a dentist since this new toothache began.  The patient denies any facial swelling.  No headache.  No swelling to the throat.  No sore throat.  No difficulty swallowing liquids or solids.  No neck pain.  No lymph node swelling.  The patient denies any fever or chills.  Denies any other problems or complaints.,REVIEW OF SYSTEMS:,  CONSTITUTIONAL:  No fever or chills.  No fatigue or weakness.  HEENT:  No headache.  No neck pain.  No eye pain or vision change.  No rhinorrhea.  No sinus congestion, pressure, or pain.  No sore throat.  No throat swelling.  The patient does have the toothache on the left lower side that radiates towards his left ear as previously described.  The patient does not have ear pain or hearing change.  No pressure in the ear.  CARDIOVASCULAR:  No chest pain.  RESPIRATIONS:  No shortness of breath.  GASTROINTESTINAL:  No nausea or vomiting.  No abdominal pain.  MUSCULOSKELETAL:  No back pain.  SKIN:  No rashes or lesions.  NEUROLOGIC:  No vision or hearing change.  No speech change.  HEMATOLOGIC/LYMPHATIC:  No lymph node swelling.,PAST MEDICAL HISTORY: , None.,PAST SURGICAL HISTORY:,  None.,CURRENT MEDICATIONS: , None.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient smokes marijuana.  The patient does not smoke cigarettes.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Temperature 98.2 oral, blood pressure is 168/84, pulse is 87, respirations 16, and oxygen saturation is 100% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished, well developed.  The patient appears to be healthy.  The patient is calm, comfortable in no acute distress, looks well.  The patient is pleasant and cooperative.  HEENT:  Head is atraumatic, normocephalic, and nontender.  Eyes are normal with clear cornea and conjunctivae bilaterally.  Nose, normal without rhinorrhea or audible congestion.  There is no tenderness over the sinuses.  Ears are normal without any sign of infection.  No erythema or swelling of the canals.  Tympanic membranes are intact and normal without any erythema, bulging, air fluid levels, or bubbles behind it.  MOUTH:  The patient has a dental fracture at tooth #18.  The patient states that the fracture is a couple of months old.  The patient does not have any obvious dental caries.  The gums are normal without any erythema, swelling, or evidence of infection.  There is no fluctuance or suggestion of abscess.  There is slight tenderness of the tooth #18.  The oropharynx is normal without any sign of infection.  There is no erythema, exudate, lesion, or swelling.  Mucous membranes are moist.  Floor of the mouth is normal without any tenderness or swelling.  No suggestion of abscess.  There is no pre or post auricular lymphadenopathy either.  NECK:  Supple.  Nontender.  Full range of motion.  No meningismus.  No cervical lymphadenopathy.  No JVD.  No carotid artery or vertebral artery bruits.  CARDIOVASCULAR:  Heart is regular rate and rhythm without murmur, rub, or gallop.  RESPIRATIONS:  Clear to auscultation bilaterally.  No shortness of breath.  GASTROINTESTINAL:  Abdomen is normal and nontender.  MUSCULOSKELETAL:  No abnormalities are noted to the back, arms, or legs.  The patient has normal use of the extremities.  SKIN:  No rashes or lesions.  NEUROLOGIC:  Cranial nerves II through XII are intact.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is alert and oriented x4.  Normal mood and affect.  No evidence of clinical intoxification.  HEMATOLOGIC/LYMPHATIC:  No lymphadenitis is palpated.,DIAGNOSES:,1.  ACUTE LEFT JAW PAIN.,2.  #18 DENTAL FRACTURE, WHICH IS AN ELLIS TYPE II FRACTURE.,3.  ELEVATED BLOOD PRESSURE.,CONDITION UPON DISPOSITION: , Stable.,DISPOSITION:,  Home.,PLAN: , We will have the patient follow up with his dentist Dr. X in three to five days for reevaluation.  The patient was encouraged to take Motrin 400 mg q.6h. as needed for pain.  The patient was given prescription for Vicodin for any breakthrough or uncontrolled pain.  He was given precautions for drowsiness and driving with the use of this medication.  The patient was also given a prescription for pen V.  The patient was given discharge instructions on toothache and asked to return to emergency room should he have any worsening of his condition, develop any other problems or symptoms of concern.","dentistry, jaw pain, dental appointment, ellis type ii fracture, ellis type, dental fracture, toothache, tenderness, pressure, erythema, "
 Full mouth dental rehabilitation in the operative room under general anesthesia., Dentistry, Full Mouth Dental Rehabilitation - 2 ,"OPERATION PERFORMED:,  Full mouth dental rehabilitation in the operative room under general anesthesia.,PREOPERATIVE DIAGNOSIS: , Severe dental caries.,POSTOPERATIVE DIAGNOSES:,1.  Severe dental caries.,2.  Non-restorable teeth.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , Minimal.,DURATION OF SURGERY: , 43 minutes.,BRIEF HISTORY:  ,The patient was first seen by me on 04/26/2007.  She had a history of open heart surgery at 11 months' of age.  She presented with severe anterior caries with most likely dental extractions needed.  Due to her young age, I felt that she would be best served in the safety of the hospital operating room.  After consultation with the mother, she agreed to have her treated in the safety of the hospital operating room at Children's Hospital.,OPERATIVE PREPARATION:  ,This child was brought to Hospital Day Surgery and is accompanied by her mother.  There I met with them and discussed the needs of the child, types of restorations to be performed, the risks and benefits of the treatment as well as the options and alternatives of the treatment.  After all their questions and concerns were addressed, I gave the informed consent to proceed with the treatment.  The patient's history and physical examination was reviewed.  Once she was cleared by Anesthesia and the child was taken back to the operating room.,OPERATIVE PROCEDURE:  ,The patient was placed on the surgical table in the usual supine position with all extremities protected.  Anesthesia was induced by mask.  The patient was then intubated with a nasal endotracheal tube and the tube was stabilized.  The head was wrapped and the eyes were taped shut for protection.  An angiocatheter was placed in the left hand and an IV was started.  The head and neck were draped with sterile towels, and the body was covered with a lead apron and sterile sheath.  A moist continuous throat pack was placed beyond the tonsillar pillars.  Plastic lip and cheek retractors were then placed.  Preoperative clinical photographs were taken.  Two posterior bitewing radiographs and two anterior periapical films were taken in the operating room with digital radiography.  After the radiographs were taken, the lead shield was removed.  Prophylaxis was then performed using prophy cup and fluoridated prophy paste.  The teeth were then rinsed well and the patient's oral cavity was suctioned clean.  Clinical and radiographic examinations followed and areas of decay were noted.  During the restorative phase, these areas of decay were entered into and removed.  Entry was made to the level of the dental-enamel junction and beyond as necessary to remove it.  Final caries was removed and was confirmed upon reaching hard, firm sounding dentin.  Teeth restored with amalgam had a dentin tubular seal placed prior to amalgam placement.  Non-restorable primary teeth would be extracted.,Upon conclusion of the restorative phase, the oral cavity was aspirated and found to be free of blood, mucus, and other debris.  The original treatment plan was verified with the actual treatment provided.  Postoperative clinical photographs were then taken.  The continuous gauze throat pack was removed with continuous suction with visualization.  Topical fluoride was then placed on the teeth.,At the end of the procedure, the child was undraped, extubated, and awakened in the operating room and taken to the recovery room breathing spontaneously with stable vital signs.,FINDINGS:  ,This young patient presented with mild generalized marginal gingivitis secondary to light generalized plaque accumulation and fair oral hygiene.  All primary teeth were present.  Dental caries were present on the following teeth:  Tooth D, E, F, and G caries on all surfaces; teeth J, lingual caries.  The remainder of her teeth and soft tissues were within normal limits.  The following restorations and procedures were performed:  Tooth D, E, F, and G were extracted and four sutures were placed one at each extraction site and tooth J lingual amalgam.,CONCLUSION:  ,The mother was informed of the completion of the procedure.  She was given a synopsis of the treatment provided as well as written and verbal instructions for postoperative care.  They will contact to my office in the event of immediate postoperative complications.  After full recovery, she was discharged from the recovery room in the care of her mother.","dentistry, full mouth dental rehabilitation, dental rehabilitation, full mouth, dental caries, non-restorable teeth, dental extractions, throat pack, oral cavity, restorative phase, primary teeth, dental, anesthesia, mouth, rehabilitation, prophylaxis, oral, amalgam, tooth, "
 Incision and drainage of right buccal space abscess and teeth extraction., Dentistry, I&D - Buccal Space Abscess ,"PREOPERATIVE DIAGNOSES,1.  Right buccal space abscess/cellulitis.,2.  Nonrestorable caries teeth #1, #29, and #32.,POSTOPERATIVE DIAGNOSES,1.  Right buccal space abscess/cellulitis.,2.  Nonrestorable caries teeth #1, #29, and #32.,PROCEDURE,1.  Incision and drainage of right buccal space abscess.,2.  Extraction of teeth #1, #29, and #32.,ANESTHESIA,GETA,EBL,20 mL.,IV FLUIDS,900 mL.,URINE OUTPUT,Not measured.,COMPLICATIONS,None.,SPECIMENS,1.  Aerobic culture was sent from the right buccal space abscess/cellulitis.,2.  Anaerobic culture from the same space was also obtained.,PROCEDURE IN DETAIL,The patient was identified in the appropriate holding area and transported to #13.  The patient was intubated by anesthesia orotracheally using a #7 ET tube.  The patient was induced in effective sleep using a propofol and gas inhalation anesthetics.  Following intubation, the patient's mouth was cleaned with chlorhexidine and a toothbrush following placement of a throat pack.  At that point, approximately 5 mL of 2% lidocaine with 1:20,000 epinephrine was injected for a right inferior alveolar block, as well as local infiltration in the right long buccal nerve area as well as the right cheek area.  Local infiltration also was done near the tooth #32.  At this point, a periosteal elevator was used to loosen up the gingival tissue of the teeth #1, #29, and #32; and all 3 teeth were extracted using simple extraction, using elevators and forceps.  In addition, the previous Penrose drain was removed by removing the suture, and the incision that was used for I&D on the previous day was extended laterally.  A hemostat was used to puncture through to the right buccal space.  Approximately, 2.5 to 3 mL of purulence was drained, and that was used for Gram stain and culture, as mentioned above.  Following copious irrigation of the area, following the extraction and following the incision and drainage, 2 quarter-inch Penrose drains were placed in the anterior as well as the posterior section of the incision into the buccal space.  At this point copious irrigation was done again, the throat pack was removed, and the procedure was ended.  Note that the patient was extubated without incident.  Dr. B was present for all critical aspects of patient care.","dentistry, abscess, #7 et tube, aerobic culture, anaerobic culture, extraction of teeth, geta, alveolar block, buccal space, caries, cellulitis, copious irrigation, extraction, teeth, nonrestorable caries teeth, buccal space abscess, nonrestorable caries, caries teeth, throat pack, buccal, "
 Closed reduction of mandible fractures with Erich arch bars and elastic fixation.  Left angle and right body mandible fractures., Dentistry, Mandible Fractures Closed Reduction ,"HISTORY OF PRESENT ILLNESS: , The patient is a 22-year-old male who sustained a mandible fracture and was seen in the emergency department at Hospital.  He was seen in my office today and scheduled for surgery today for closed reduction of the mandible fractures.,PREOPERATIVE DIAGNOSES: , Left angle and right body mandible fractures.,POSTOPERATIVE DIAGNOSES: , Left angle and right body mandible fractures.,PROCEDURE: , Closed reduction of mandible fractures with Erich arch bars and elastic fixation.,ANESTHESIA:,  General nasotracheal.,COMPLICATIONS:,  None.,CONDITION:,  Stable to PACU.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room and placed on the table in a supine position and after demonstration of an adequate plane of general anesthesia via the nasotracheal route, the patient was prepped and draped in the usual fashion for placement of arch bars.  Gauze throat pack was placed and upper and lower arch bars were placed on the maxillary and mandibular dentition with a 25-gauge circumdental wires.  After the placement of the arch bars, the occlusion was checked and found to be satisfactory and stable.  The throat pack was then removed.  An NG tube was then passed and approximately 50 cc of stomach contents were suctioned out.,The elastic fixation was then placed on the arch bars holding the patient in maxillomandibular fixation and at this point, the procedure was terminated and the patient was then awakened, extubated, and taken to the PACU in stable condition.","dentistry, closed reduction of mandible fractures, erich arch bars, elastic fixation, throat pack, arch bars, arch, erich, mandible, fractures"
 Full mouth dental rehabilitation in the operating room under general anesthesia., Dentistry, Full Mouth Dental Rehabilitation - 1 ,"OPERATION PERFORMED:,  Full mouth dental rehabilitation in the operating room under general anesthesia.,PREOPERATIVE DIAGNOSES:  ,1.  Severe dental caries.,2.  Hemophilia.,POSTOPERATIVE DIAGNOSES:  ,1.  Severe dental caries.,2.  Hemophilia.,3.  Nonrestorable teeth.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,DURATION OF SURGERY:  ,1 hour and 22 minutes.,BRIEF HISTORY:  ,The patient was first seen by me on 08/23/2007, who is 4-year-old with hemophilia, who received infusion on Tuesdays and Thursdays and he has a MediPort.  Mom reported history of high fever after surgery and he has one seizure previously.  He has history of trauma to his front teeth and physician put him on antibiotics.  He was only cooperative for having me do a visual examination on his anterior teeth.  Visual examination revealed severe dental caries and dental abscess from tooth #E and his maxillary anterior teeth needed to be extracted.  Due to his young age and hemophilia, I felt that he would be best served to be taken to the hospital operating room.,OTHER PREPARATION:  ,The child was brought to the Hospital Day Surgery accompanied by his mother.  There, I met with her and discussed the needs of the child, types of restoration to be performed, and the risks, and benefits of the treatment as well as the options and alternatives of the treatment.  After all her questions and concerns were addressed, she gave her informed consent to proceed with treatment.  The patient's history and physical examination was reviewed.  He was given factor for appropriately for his hemophilia prior to being taken back to the operating room.  Once he was cleared by Anesthesia, the child was taken back to the operating room.,OPERATIVE PROCEDURE:  ,The patient was placed on the surgical table in the usual supine position with all extremities protected.  Anesthesia was induced by mask.  The patient was then intubated with an oral tube and the tube was stabilized.  The head was wrapped and IV was started.  The head and neck were draped with sterile towels and the body was covered with a lead apron and sterile sheath.  A moist continuous throat pack was placed beyond tonsillar pillars.  Plastic lip and cheek retractors were then placed.  Preoperative clinical photographs were taken.  Two posterior bitewing radiographs and two anterior periapical films were taken in the operating room with digital radiograph.  After the radiographs were taken, the lead shield was removed.,Prophylaxis was then performed using a prophy cup and fluoridated prophy paste.  The patient's teeth were rinsed well.  The patient's oral cavity was suctioned clean.  Clinical and radiographic examination followed and areas of decay were noted.  During the restorative phase, these areas of decay were incidentally removed.  Entry was made to the level of the dental-enamel junction and beyond as necessary to remove it.  Final caries removal was confirmed upon reaching hard, firm and sound dentin.,Teeth restored with composite ___________  bonded with a one-step bonding agent.  Teeth restored with amalgam had a dentin tubular seal placed prior to amalgam placement.  Non-restorable primary teeth would be extracted.  The caries were extensive and invaded the pulp tissues, pulp therapy was initiated using ViscoStat and then IRM pulpotomies.  Teeth treated in such a manner would then be crowned with stainless steel crowns.,Upon conclusion of the restorative phase, the oral cavity was aspirated and found to be free of blood, mucus, and other debris.  The original treatment plan was verified with the actual treatment provided.  Postoperative clinical photographs were then taken.  The continuous gauze throat pack was removed with continuous suction with visualization.  Topical fluoride was then placed on the teeth.  At the end of the procedure, the child was undraped, extubated, and awakened in the operating room, was taken to the recovery room, breathing spontaneously with stable vital signs.,FINDINGS: , This young patient presented with mild generalized marginal gingivitis, secondary to light generalized plaque accumulation and fair oral hygiene.  All primary teeth were present.  Dental carries were present on the following teeth:  Tooth B, OL caries, tooth C, M, L, S caries, tooth B, caries on all surfaces, tooth E caries on all surfaces, tooth F caries on all surfaces, tooth T caries on all surfaces, tooth H, lingual and facial caries, tooth I, caries on all surfaces, tooth L caries on all surfaces, and tooth S, all caries.  The remainder of his teeth and soft tissues were within normal limits.  The following restoration and procedures were performed.  Tooth B, OL amalgam, tooth C, M, L, S composite, tooth D, E, F, and G were extracted, tooth H, and L and separate F composite.  Tooth I is stainless steel crown, tooth L pulpotomy and stainless steel crown and tooth S no amalgam.  Sutures were also placed at extraction site D, E, S, and G.,CONCLUSION:  ,The mother was informed of the completion of the procedure.  She was given a synopsis of the treatment provided as well as written and verbal instructions for postoperative care.  She is to contact to myself with an event of immediate postoperative complications and after full recovery, he was discharged from recovery room in the care of his mother.  She was also given prescription for Tylenol with Codeine Elixir for postoperative pain control.,", 
 Dental restoration.    Dental caries.  Cavities have been noted by his parents and pediatrician that have been noted to be pretty severe. , Dentistry, Dental Restoration ,"PREOPERATIVE DIAGNOSIS: , Dental caries.,POSTOPERATIVE DIAGNOSIS:,  Dental caries.,PROCEDURE: , Dental restoration.,CLINICAL HISTORY:  ,This 2-year, 10-month-old male has not had any prior dental treatment because of his unmanageable behavior in a routine dental office setting.  He was referred to me for that reason to be treated under general anesthesia for his dental work.  Cavities have been noted by his parents and pediatrician that have been noted to be pretty severe.  There are no contraindications to this procedure.  He is healthy.  His history and physical is in the chart.,PROCEDURE:  ,The patient was brought to the operating room at 10:15 and placed in the supine position.  Dr. X administered the general anesthetic after which 2 bite-wing and 2 periapical x-rays were exposed and developed and his teeth were examined.  A throat pack was then placed.  Tooth D had caries on the distal surface which was excavated and the tooth was restored with composite.  Teeth E and F had caries in the mesial and distal surfaces, these carious lesions were excavated and the teeth were restored with composite.  Tooth G had caries in the mesial surface which was excavated and the tooth was restored with composite.  Teeth I and L both had caries on the occlusal surfaces which were excavated and upon excavation of the caries in tooth I the pulp was perforated and a therapeutic pulpotomy was therefore necessary.  This was done using ferric sulfate and zinc oxide eugenol.  For final restorations, amalgam restorations were placed involving the occlusal surfaces both teeth I and L. A prophylaxis was done and topical fluoride applied and the excess was suctioned thoroughly.  The throat pack was removed and the patient was awakened and brought to the recovery room in good condition at 11:30.  There was no blood loss.","dentistry, cavities, carious lesions, throat pack, composite teeth, occlusal surfaces, dental restoration, dental caries, dental, teeth, caries, "
 Left masticator space infection secondary to necrotic tooth #17.  Extraoral incision and drainage of facial space infection and extraction of necrotic tooth #17., Dentistry, Extraoral I&D ,"PREOPERATIVE DIAGNOSIS:,  Left masticator space infection secondary to necrotic tooth #17.,POSTOPERATIVE DIAGNOSIS: , Left masticator space infection secondary to necrotic tooth #17.,SURGICAL PROCEDURE:,  Extraoral incision and drainage of facial space infection and extraction of necrotic tooth #17.,FLUIDS:  ,500 mL of crystalloid.,ESTIMATED BLOOD LOSS: , 60 mL.,SPECIMENS:,  Cultures and sensitivities, Aerobic and anaerobic were sent for micro studies.,DRAINS:,  One 0.25-inch Penrose placed in the medial aspect of the masticator space.,CONDITION: , Good, extubated, breathing spontaneously, to PACU.,INDICATIONS FOR PROCEDURE:  ,The patient is a 26-year-old Caucasian male with a 2-week history of a toothache and 5-day history of increasing swelling of his left submandibular region, presents to Clinic, complaining of difficulty swallowing and breathing.  Oral surgery was consulted to evaluate the patient.,After evaluation of the facial CT with tracheal deviation and abscess in the left muscular space, it was determined that the patient needed to be taken urgently to the operating room under general anesthesia and have the abscess incision and drainage and removal of tooth #17.  Risks, benefits, alternatives, treatments were thoroughly discussed with the patient and consent was obtained.,DESCRIPTION OF PROCEDURE:,  The patient was transported to operating room #4 at Clinic.  He was laid supine on the operating room table.  ASA monitors were attached and general anesthesia was induced with IV anesthetics and maintained with oral endotracheal intubation and inhalation of anesthetics.  The patient was prepped and draped in the usual oral and maxillofacial surgery fashion.,The surgeon approached the operating room table in sterile fashion.  Approximately 2 mL of 1% lidocaine with 1:100,000 epinephrine were injected into the left submandibular area in the area of the incision.  After waiting appropriate time for local anesthesia to take effect, an 18-gauge needle was introduced into the left masticator space and approximately 5 mL of pus was removed.  This was sent for aerobic and anaerobic micro.  Using a 15-blade, a 2-cm incision was made in the left submandibular region, then a hemostat was introduced in blunt dissection into the medial border of the mandible was performed.  The left masticator space was thoroughly explored as well as the left submandibular space and submental space.  Pus was drained from this site.  Copious amounts of sterile fluid were irrigated into the site.,Attention was then directed intraorally where a moistened Ray-Tec sponge was placed in the posterior oropharynx to act as a throat pack.  Approximately 4 mL of 1% lidocaine with 1:100,000 epinephrine were injected into the left inferior alveolar nerve block.  Using a 15-blade, a full-thickness mucoperiosteal flap was developed around tooth #17.  The tooth was elevated and delivered, and the lingual area of tooth #17 was explored and more pus was expressed.  This pus was evacuated intraorally __________ suction.  The extraction site and the left masticator space were irrigated, and it was noted that the irrigation was communicating with extraoral incision in the neck.,A 0.25-inch Penrose drain was placed in the lingual aspect of the mandible extraorally through the neck and secured with 2-0 silk suture.  A tack stitch intraorally with 3-0 chromic suture was placed.  The throat pack was then removed.  An orogastric tube was placed and removed all other stomach contents and then removed.  At this point, the procedure was then determined to be over.  The patient was extubated, breathing spontaneously, and transported to PACU in good condition.","dentistry, masticator space infection, extraoral, incision and drainage, ray-tec sponge, submandibular, space infection, necrotic tooth, masticator space, space, drainage, necrotic, incision, masticator, tooth, "
 Significant pain in left lower jaw., Dentistry, Dental Pain - Emergency Visit ,"CHIEF COMPLAINT: , Dental pain.,HISTORY OF PRESENT ILLNESS: , This is a 45-year-old Caucasian female who states that starting last night she has had very significant pain in her left lower jaw.  The patient states that she can feel an area with her tongue and one of her teeth that appears to be fractured.  The patient states that the pain in her left lower teeth kept her up last night.  The patient did go to Clinic but arrived there later than 7 a.m., so she was not able to be seen there will call line for dental care.  The patient states that the pain continues to be very severe at 9/10.  She states that this is like a throbbing heart beat in her left jaw.  The patient denies fevers or chills.  She denies purulent drainage from her gum line.  The patient does believe that there may be an area of pus accumulating in her gum line however.  The patient denies nausea or vomiting.  She denies recent dental trauma to her knowledge.,PAST MEDICAL HISTORY:,1.  Coronary artery disease.,2.  Hypertension.,3.  Hypothyroidism.,PAST SURGICAL HISTORY:  ,Coronary artery stent insertion.,SOCIAL HABITS: , The patient denies alcohol or illicit drug usage.  Currently she does have a history of tobacco abuse.,MEDICATIONS:,1.  Plavix.,2.  Metoprolol.,3.  Synthroid.,4.  Potassium chloride.,ALLERGIES:,1.  Penicillin.,2.  Sulfa.,PHYSICAL EXAMINATION:,GENERAL:  This is a Caucasian female who appears of stated age of 45 years.  She is well-nourished, well-developed, in no acute distress.  The patient is pleasant but does appear to be uncomfortable.,VITAL SIGNS:  Afebrile, blood pressure 145/91, pulse of 78, respiratory rate of 18, and pulse oximetry of 98% on room air.,HEENT:  Head is normocephalic.  Pupils are equal, round and reactive to light and accommodation.  Sclerae are anicteric and noninjected.  Nares are patent and free of mucoid discharge.  Mucous membranes are moist and free of exudate or lesion.  Bilateral tympanic membranes are visualized and free of infection or trauma.  Dentition shows significant decay throughout the dentition.  The patient has had extraction of teeth 17, 18, and 19.  The patient's tooth #20 does have a small fracture in the posterior section of the tooth and there does appear to be a very minor area of fluctuance and induration located at the alveolar margin at this site.  There is no pus draining from the socket of the tooth.  No other acute abnormality to the other dentition is visualized.,DIAGNOSTIC STUDIES: , None.,PROCEDURE NOTE:  ,The patient does receive an injection of 1.5 mL of 0.5% bupivacaine for inferior alveolar nerve block on the left mandibular teeth.  The patient undergoes this all procedure without complication and does report some mild decrease of her pain with this and patient was also given two Vicodin here in the Emergency Department and a dose of Keflex for treatment of her dental infection.,ASSESSMENT:  ,Dental pain with likely dental abscess.  ,PLAN: , The patient was given a prescription for Vicodin.  She is also given prescription for Keflex, as she is penicillin allergic.  She has tolerated a dose of Keflex here in the Emergency Department well without hypersensitivity.  The patient is strongly encouraged to follow up with Dental Clinic on Monday, and she states that she will do so.  The patient verbalizes understanding of treatment plan and was discharged in satisfactory condition from the ER.,",
 Carious teeth and periodontal disease affecting all remaining teeth and partial bony impacted tooth #32. Extraction of teeth., Dentistry, Carious Teeth Extraction ,"PREOPERATIVE DIAGNOSIS: , Carious teeth and periodontal disease affecting all remaining teeth.,POSTOPERATIVE DIAGNOSIS: , Carious teeth and periodontal disease affecting all remaining teeth and partial bony impacted tooth #32.,PROCEDURE: , Extraction of remaining teeth numbers 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, and 32.,ANESTHESIA:,  General, oral endotracheal.,COMPLICATIONS: , None.,CONDITION:,  Stable to PACU.,PROCEDURE:  Patient was brought to the operating room, placed on the table in the supine position and after demonstration of an adequate plane of general anesthesia, the patient was prepped and draped in the usual fashion for an intraoral procedure.  Gauze throat pack was placed and local anesthetic was administered in the upper and lower left quadrants and extraction of teeth was begun on the upper left quadrant teeth numbers 9, 10, 11, 12, 13, 14, 15, and 16 were removed with elevators and forceps extraction.  Moving to the lower quadrant on the left side, tooth numbers 17, 18, 19, 20, 21, 22, 23, and 24 were removed with elevators and routine forceps extraction.  The flaps were then closed with 3-0 gut sutures and upon completion of the two quadrants on the left side, the endotracheal tube was then relocated from the right side to the left side for access to the quadrants on the right.  Teeth numbers 2, 3, 4, 5, 7, and 8 were then removed with elevators and routine forceps extraction.  It was noted that tooth #6 was missing, could not be seen whether tooth #6 was palately impacted, but the tooth was not encountered.  On the lower right quadrant, teeth numbers 25, 26, 27, 28, 29, 30, and 31 were removed with elevators and routine forceps extraction.  Tooth #32 was partially bony impacted, but exposed, so it was removed by removing bone on buccal aspect with high-speed drill with a round bur.  Tooth was then luxated from the socket.  The flaps were then closed on both quadrants with 3-0 gut sutures.  The area was irrigated thoroughly with normal saline solution and a total of 8.5 mL of lidocaine 2% with 1:100, 000 epinephrine and 3.6 mL of bupivacaine 0.5% with epinephrine 1:200, 000.  Upon completion of the procedure, the throat pack was removed.  The pharynx was suctioned.  An oral gastric tube was passed and small amount of stomach contents were suctioned.  The patient was then extubated and taken to PACU in stable condition.","dentistry, intraoral procedure, partial bony impacted tooth, teeth extraction, forceps extraction, periodontal disease, carious teeth, periodontal, carious "
 Dental prophylaxis under general anesthesia., Dentistry, Dental Prophylaxis ,"OPERATION PERFORMED:  ,Dental prophylaxis under general anesthesia.,PREOPERATIVE DIAGNOSES:,1.  Impacted wisdom teeth.,2.  Moderate gingivitis.,POSTOPERATIVE DIAGNOSES:,1.  Impacted wisdom teeth.,2.  Moderate gingivitis.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS:  ,Minimal.,DURATION OF SURGERY:  ,One hour 17 minutes.,BRIEF HISTORY:  ,The patient was referred to me by Dr. X.  He contacted myself and stated that Angelica was going to have her wisdom teeth extracted in the setting of a hospital operating room at Hospital and he inquired if we could pair on the procedure and I could do her full mouth dental rehabilitation before the wisdom teeth were removed by him.  I agreed.  I saw her in my office and she was cooperative for full mouth set of radiographs in my office and a clinical examination.  This clinical and radiographic examination revealed no dental caries; however, she was in need of a good dental cleaning.,OPERATIVE PREPARATION:  ,The patient was brought to Hospital Day Surgery accompanied by her mother.  I met with them and discussed the needs of the child, types of restoration to be performed, and the risks and benefits of the treatment as well as the options and alternatives of the treatment.  After all their questions and concerns were addressed, they gave their informed consent to proceed with the treatment.  The patient's history and physical examination was reviewed.  Once she was cleared by Anesthesia, she was taken back to the operating room.,OPERATIVE PROCEDURE:  ,The patient was placed on the surgical table in the usual supine position with all extremities protected.  Anesthesia was induced by mask.  The patient was then intubated with a nasal endotracheal tube and the tube was stabilized.  The head was wrapped and the eyes were taped shut for protection.  An Angiocath was previously placed in preop.  The head and neck were draped in sterile towels, and the body was covered with lead apron and sterile sheath.  A moist continuous throat pack was placed beyond tonsillar pillars.  Plastic lip and cheek retractors were then placed.  Preoperative digital intraoral photographs were taken.  No digital radiographs were taken in the operating room, as I stated before I had a full set of digital radiographs taken in my office.  A prophylaxis was then performed using a Prophy cup and fluoridated Prophy paste after scaling and replaning was done.  She presented with moderate calculus on the buccal surfaces of her maxillary, first molars and lower molars.  She did not require any restorative dentistry.,Upon the conclusion of the restorative phase, the oral cavity was aspirated and found to be free of blood, mucus, and other debris.  The original treatment plan was verified with the actual treatment provided.  Postoperative clinical photographs were taken.  The continuous gauze throat pack was removed with continuous suction and visualization.  Topical fluoride was then placed on the teeth.,At the end of the procedure, the child was undraped, extubated, and awakened in the operating room, taken to the recovery room, breathing spontaneously with stable vital signs.,FINDINGS: , This patient presented in her permanent dentition.  Her teeth #1, 16, 17, and 32 were impacted and are going to be removed following my full mouth dental rehabilitation by Dr. Alexander.  Oral hygiene was fair.  There was generalized plaque and calculus throughout.  She did not have any caries, did not require any restorative dentistry.,CONCLUSION:,  Following my dental surgery, the patient continued to intubated and was prepped for oral surgery procedures by Dr. X and his associates.  There were no postop pain requirements.  I did not have any specific requirements for the patient or her mother and that will be handled by Dr. X and their instructions on soft foods, etc., and pain control will be managed by them.","dentistry, dental prophylaxis, impacted wisdom teeth, gingivitis, wisdom teeth, moderate gingivitis, dental rehabilitation, throat pack, digital radiographs, restorative dentistry, impacted, anesthesia, restorative, wisdom, oral, prophylaxis, teeth, dental, "
" Dentigerous cyst, left mandible associated with full bone impacted wisdom tooth #17.  Removal of benign cyst and extraction of full bone impacted tooth #17.", Dentistry, Bone Impacted Tooth Removal ,"PREOPERATIVE DIAGNOSIS: , Dentigerous cyst, left mandible associated with full bone impacted wisdom tooth #17.,POSTOPERATIVE DIAGNOSIS: , Dentigerous cyst, left mandible associated with full bone impacted wisdom tooth #17.,PROCEDURE:,  Removal of benign cyst and extraction of full bone impacted tooth #17.,ANESTHESIA:  ,General anesthesia with nasal endotracheal intubation.,SPECIMEN: , Cyst and section tooth #17.,ESTIMATED BLOOD LOSS:,  10 mL.,FLUIDS:,  1200 of Lactated Ringer's.,COMPLICATIONS: , None.,CONDITION: , The patient was extubated and transported to the PACU in good condition.  Breathing spontaneously.,INDICATION FOR PROCEDURE:  ,The patient is a 38-year-old Caucasian male who was referred to clinic to evaluate a cyst in his left mandible.  Preoperatively, a biopsy of the cyst was obtained and it was noted to be a benign dentigerous cyst.,After evaluation of the location of the cyst and the impacted wisdom tooth approximately the inferior border of the mandible, it was determined that the patient would benefit from removal of the cyst and removal of tooth #17 under general anesthesia in the operating room.  Risks, benefits, and alternatives of treatment were thoroughly discussed with the patient and consent was obtained.,DESCRIPTION OF PROCEDURE:,  The patient was taken to the operating room #1 at Hospital and laid in the supine fashion on the operating room table.  As stated, general anesthesia was induced with IV anesthetics and maintained with nasal endotracheal intubation and inhalation anesthetics.  The patient was prepped and draped in usual oro-maxillofacial surgery fashion.,Approximately, #6 mL of 2% lidocaine with 1:100,000 epinephrine was injected in the usual nerve block fashion.  After waiting appropriate time for local anesthesia to take effect, a moistened Ray-Tec sponge was placed in the posterior pharynx.  Peridex mouth rinse was used to prep the oral cavity.  This was removed with suction.,Using a #15 blade a sagittal split osteotomy incision was made along the left ramus.  A full-thickness mucoperiosteal flap was elevated and the crest of the bone was identified where the crown had super-erupted since the biopsy 6 weeks earlier.  Using a Hall drill, a buccal osteotomy was developed, the tooth was sectioned in half, fractured with an elevator and delivered in two pieces.  Using a double-ended curette, the remainder of the cystic lining was removed from the left mandible and sent to pathology with the tooth for review.,The area was irrigated with copious amounts of sterile water and closed with 3-0 chromic gut suture.  The throat pack was removed.  The procedure was then determined to be over, and the patient was extubated, breathing spontaneously, and transported to the PACU in good condition.","dentistry, dentigerous, wisdom tooth, extraction, bone impacted tooth, nasal endotracheal, dentigerous cyst, cyst, intubation, osteotomy, mandible, "
 Dental restorations and extractions.  Dental caries.  He has had multiple severe carious lesions that warrant multiple extractions at this time., Dentistry, Dental Restorations & Extractions ,"PREOPERATIVE DIAGNOSIS:,  Dental caries.,POSTOPERATIVE DIAGNOSIS: , Dental caries.,PROCEDURE: , Dental restorations and extractions.,CLINICAL HISTORY: , This 23-year-old male is a client of the ABC Center because of his disability, the nature of which is unclear to me at this time; however, he reportedly has several issues that qualify him as disabled.  He has had multiple severe carious lesions that warrant multiple extractions at this time.  It is also unclear to me as to how his prior or existing restorations were accomplished.  In any case, he has been cleared for the procedure today.  He has his history and physical in the chart.,PROCEDURE: , The patient was brought to the operating room at 11 o'clock and placed in the supine position.  Dr. X administered the general anesthetic, after which a throat pack was placed.  Available full mouth x-rays were reviewed.  These x-rays were taken at another location.  Teeth 2, 4, 10, 12, 13, 15, 18, 20, 27, and 31 were all in varying degrees of severe decay from complete destruction of the crowns to pulp exposures with periapical radiolucencies.  All of these aforementioned teeth were extracted using combinations of forceps and elevators.  Hemostasis in all of these sites was accomplished with direct pressure using gauze packs.  ,Tooth 5 had caries in the distal surface extending to the occlusal as well as another carious lesion in the buccal.  These carious lesions and his tooth were excavated, and the tooth was restored with amalgam involving these surfaces.  ,Tooth 6 had caries on the facial surface, which was excavated, and the tooth was restored with composite.  ,Tooth 7 had caries involving the distal surface.  ,Tooth 8 likewise had caries involving the distal surface, and both of these distal lesions extended into incisal area.  These carious lesions were excavated, and both of these teeth were restored with composite.  ,Tooth 9 had caries in a mesial surface and a buccal surface, which was excavated, and this tooth was restored with composite.  ,Tooth 28 caries in the mesial surface extending to the occlusal, which was excavated, and the tooth was restored with amalgam, and tooth 30 had carries in the buccal surface, which was excavated, and the tooth was restored with amalgam.  ,A prophylaxis was done, primarily using a rotating rubber cup and some minor scaling, and the mouth was irrigated and suctioned thoroughly.  The throat pack was removed, and the patient was awakened and brought to the recovery room in good condition at 1330 hours.  There was negligible blood loss.","dentistry, extractions, multiple extractions, mesial surface, buccal surface, dental restorations, dental caries, distal surface, composite tooth, carious lesions, tooth, dental, caries"
 This is a 27-year-old female who presents with a couple of days history of some dental pain.  She has had increasing swelling and pain to the left lower mandible area today., Dentistry, Dental Pain ,"CHIEF COMPLAINT:,  Dental pain.,HISTORY OF PRESENT ILLNESS:,  This is a 27-year-old female who presents with a couple of days history of some dental pain.  She has had increasing swelling and pain to the left lower mandible area today.  Presents now for evaluation.,PAST MEDICAL HISTORY: , Remarkable for chronic back pain, neck pain from a previous cervical fusion, and degenerative disc disease.  She has chronic pain in general and is followed by Dr. X.,REVIEW OF SYSTEMS: , Otherwise, unremarkable.  Has not noted any fever or chills.  However she, as mentioned, does note the dental discomfort with increasing swelling and pain.  Otherwise, unremarkable except as noted.,CURRENT MEDICATIONS: , Please see list.,ALLERGIES: , IODINE, FISH OIL, FLEXERIL, BETADINE.,PHYSICAL EXAMINATION: , VITAL SIGNS:  The patient was afebrile, has stable and normal vital signs.  The patient is sitting quietly on the gurney and does not look to be in significant distress, but she is complaining of dental pain.  HEENT:  Unremarkable.  I do not see any obvious facial swelling, but she is definitely tender all in the left mandible region.  There is no neck adenopathy.  Oral mucosa is moist and well hydrated.  Dentition looks to be in reasonable condition.  However, she definitely is tender to percussion on the left lower first premolar.  I do not see any huge cavity or anything like that.  No real significant gingival swelling and there is no drainage noted.  None of the teeth are tender to percussion.,PROCEDURE:,  Dental nerve block.  Using 0.5% Marcaine with epinephrine, I performed a left inferior alveolar nerve block along with an apical nerve block, which achieves good anesthesia.  I have then written a prescription for penicillin and Vicodin for pain.,IMPRESSION: , ACUTE DENTAL ABSCESS.,ASSESSMENT AND PLAN:  ,The patient needs to follow up with the dentist for definitive treatment and care.  She is treated symptomatically at this time for the pain with a dental block as well as empirically with antibiotics.  However, outpatient followup should be adequate.  She is discharged in stable condition.","dentistry, dental pain, dental abscess, dental block, nerve block, mandible, swelling, dental,"
 Cosmetic rhinoplasty.  Request for cosmetic change in the external appearance of the nose., Cosmetic / Plastic Surgery, Rhinoplasty ,"PREOPERATIVE DIAGNOSES:,1.  Nasal obstruction secondary to deviated nasal septum.,2.  Bilateral turbinate hypertrophy.,PROCEDURE:,  Cosmetic rhinoplasty.  Request for cosmetic change in the external appearance of the nose.,ANESTHESIA: , General via endotracheal tube.,INDICATIONS FOR OPERATION:  ,The patient is a 26-year-old white female with longstanding nasal obstruction.  She also has concerns with regard to the external appearance of her nose and is requesting changes in the external appearance of her nose.  From her functional standpoint, she has severe left-sided nasal septal deviation with compensatory inferior turbinate hypertrophy.  From the aesthetic standpoint, the nose is over projected, lacks rotation, and has a large dorsal hump.  First we are going to straighten the nasal septum and reduce the size of the turbinates and then we will also take down the hump, rotate the tip of the nose, and de-project the nasal tip.  I explained to her the risks, benefits, alternatives, and complications for postsurgical procedure.  She had her questions asked and answered and requested that we proceed with surgery as outlined above.,PROCEDURE DETAILS: , The patient was taken to the operating room and placed in supine position.  The appropriate level of general endotracheal anesthesia was induced.  The face, head, and neck were sterilely prepped and draped.  The nose was anesthetized and vasoconstricted in the usual fashion.  Procedure began with a left hemitransfixion incision, which was brought down into the left intercartilaginous incision.  Right intercartilaginous incision was also made and the dorsum of the nose was elevated in the submucoperichondrial and subperiosteal plane.  Intact bilateral septomucoperichondrial flaps were elevated and a severe left-sided nasal septal deviation was corrected by detachment of the caudal nasal septum from the maxillary crest in a swinging door fashion and placing it back into the midline.  Posterior vomerine spur was divided superiorly and inferiorly and a large spur was removed.  Anterior and inferior one-third of each inferior turbinate was clamped, cut, and resected.  The upper lateral cartilages were divided from their attachments to the dorsal nasal septum and the cartilaginous septum was lowered by approximately 2 mm.  The bony hump of the nose was lowered with a straight osteotome by 4 mm.  Fading medial osteotomies were carried out and lateral osteotomies were then created in order to narrow the bony width of the nose.  The tip of the nose was then addressed via a retrograde dissection and removal of cephalic caudal semicircle cartilage medially at the tip.  The caudal septum was shortened by 2 mm in an angle in order to enhance rotation.  Medial crural footplates were reattached to the caudal nasal septum with a projection rotation control suture of #3-0 chromic.  The upper lateral cartilages were rejoined to the dorsal septum with a #4-0 plain gut suture.  No middle valves or bone grafts were necessary.  Intact mucoperichondrial flaps were closed with 4-0 plain gut suture and Doyle nasal splints were placed on either side of the nasal septum.  The middle meatus was filled with Surgicel and Cortisporin otic and external Denver splint was applied with sterile tape and Mastisol.  Excellent aesthetic and functional results were thus obtained and the patient was awakened in the operating room, taken to the recovery room in good condition.","cosmetic / plastic surgery, nasal obstruction, cosmetic, dorsal hump, endotracheal tube, hemitransfixion incision, hypertrophy, intercartilaginous, intercartilaginous incision, nasal septum, nasal tip, septomucoperichondrial, submucoperichondrial, subperiosteal, turbinate, vomerine, spur, nasal septal, nasal, rhinoplasty, septum, "
" Bilateral open mandible fracture, open left angle and open symphysis fracture.  Closed reduction of mandible fracture with MMF.", Dentistry, Closed Reduction - Mandible Fracture ,"PREOPERATIVE DIAGNOSIS: , Bilateral open mandible fracture, open left angle and open symphysis fracture.,POSTOPERATIVE DIAGNOSIS: , Bilateral open mandible fracture, open left angle and open symphysis fracture.,PROCEDURE:  ,Closed reduction of mandible fracture with MMF.,ANESTHESIA: , General anesthesia via nasal endotracheal intubation.,FLUIDS: , 2 L of crystalloid.,ESTIMATED BLOOD LOSS: , Minimal.,HARDWARE: , None.,SPECIMENS: , None.,COMPLICATIONS: , None.,CONDITION:  ,The patient was extubated to PACU in good condition.,INDICATIONS FOR PROCEDURE: , The patient is a 17-year-old female who is 2 days status post an altercation in which she sustained multiple blows to the face.  She was worked up on Friday night, 2 days earlier at Hospital, was given palliative treatment and discharged and instructed to follow up as an outpatient with an oral surgeon and given a phone number to call.  The patient was worked up initially.  On initial exam, it was noted that the patient had a left V3 paresthesia.  She had a gross malocclusion.  On the facial CT and panoramic x-ray, it was noted to be a displaced left angle fracture and nondisplaced symphysis fracture.  Alternatives were discussed with the patient and it was determined she would benefit from being taken to the operating room under general anesthesia to have a closed reduction of her fractures.  Risks, benefits, and alternatives of treatment were thoroughly discussed with the patient and informed consent was obtained with the patient's mother.,DESCRIPTION OF PROCEDURE:, The patient was taken to the operating room #4 at Hospital and laid in a supine position on the operating room table.  Monitor was attached and general anesthesia was induced with IV anesthetics and maintained with nasal endotracheal intubation and inhalation anesthetics.  The patient was prepped and draped in the usual oromaxillofacial surgery fashion.,Surgeon approached the operating table in a sterile fashion.  Approximately 10 mL of 2% lidocaine with 1:100,000 epinephrine was injected into the oral vestibule in a nerve block fashion.  A moistened Ray-Tec sponge was placed in the posterior oropharynx and the mouth was prepped with Peridex mouthrinse, scrubbed with a toothbrush.  The Peridex was evacuated with Yankauer suction.  Erich arch bars were adapted to the maxilla from the first molar to the contralateral first molar and secured with 24-gauge surgical steel wire on the posterior teeth and 26-gauge surgical steel wire on the anterior teeth.  Same was done on the mandible.  The patient was then manipulated up in the maximum intercuspation and noted to be reproducible.  The throat pack was then removed.,The patient was remanipulated up to the maximum intercuspation and secured with interdental elastics.  At this point in time, the procedure was then determined to be over.,The patient was extubated and transferred to the PACU in good condition.","dentistry, open symphysis fracture, closed reduction, mmf, endotracheal, pacu, bilateral open mandible fracture, symphysis fracture, mandible fracture, fracture, intubation, angle, mandible, "
" Cervical facial rhytidectomy.  Quadrilateral blepharoplasty.  Autologous fat injection to the upper lip - donor site, abdomen.", Cosmetic / Plastic Surgery, Rhytidectomy & Blepharoplasty ,"PREOPERATIVE DIAGNOSIS:,  Ageing face.,POSTOPERATIVE DIAGNOSIS: , Ageing face.,OPERATIVE PROCEDURE:,1.  Cervical facial rhytidectomy.,2.  Quadrilateral blepharoplasty.,3.  Autologous fat injection to the upper lip.,OPERATIONS PERFORMED:,1.  Cervical facial rhytidectomy.,2.  Quadrilateral blepharoplasty.,3.  Autologous fat injection to the upper lip - donor site, abdomen.,INDICATION:  ,This is a 62-year-old female for the above-planned procedure.  She was seen in the preoperative holding area where the surgery was discussed accordingly and markings were applied.  Full informed consent noted and chemistries were on her chart and preoperative evaluation was negative.,PROCEDURE: , The patient was brought to the operative room under satisfaction, and she was placed supine on the OR table.  Administered general endotracheal anesthesia followed by sterile prep and drape at the patient's face and abdomen.  This included the neck accordingly.,Two platysmal sling application and operating headlight were utilized.  Hemostasis was controlled with the pinpoint cautery along with suction Bovie cautery.,The first procedure was performed was that of a quadrilateral blepharoplasty.  Markers were applied to both upper lids in symmetrical fashion.  The skin was excised from the right upper lid first followed by appropriate muscle resection.  Minimal fat removed from the medial upper portion of the eyelid.  Hemostasis was controlled with the quadrilateral tip needle; closure with a running 7-0 nylon suture.  Attention was then turned to the lower lid.  A classic skin muscle flap was created accordingly.  Fat was resected from the middle, medial, and lateral quadrant.  The fat was allowed to open drain the arcus marginalis for appropriate contour.  Hemostasis was controlled with the pinpoint cautery accordingly.  Skin was redraped with a conservative amount resected.  Running closure with 7-0 nylon was accomplished without difficulty.  The exact same procedure was repeated on the left upper and lower lid.,After completion of this portion of the procedure, the lag lid was again placed in the eyes.  Eye mass was likewise clamped.  Attention was turned to her face with plans for cervical facial rhytidectomy portion of the procedure.  The right face was first operated.  It was injected with a 0.25% Marcaine 1:200,000 adrenaline.  A submental incision was created followed by suction lipectomy and very minimal amounts of ***** in 3 mm and 2-mm suction cannula.  She had minimal subcutaneous extra fat as noted.  Attention was then turned to the incision which was in the temporal hairline in curvilinear fashion following the pretragal incision to the postauricular sulcus and into and along the post-occipital hairline.  The flap was elevated without difficulty with various facelift scissors.  Hemostasis was controlled again with a pinpoint cautery as well as suction Bovie cautery.,The exact same elevation of skin flap was accomplished on the left face followed by the anterosuperior submental space with approximately 4-cm incision.  Rectus plication in the midline with a running 4-0 Mersilene was followed by some transaction of the platysma above the hairline with coagulation, cutting, and cautery.  The submental incision was closed with a running 7-0 nylon over 5-0 Monocryl.,Attention was then turned to closure of the bilateral facelift incisions after appropriate SMAS plication.  The left side of face was first closed followed by interrupted SMAS plication utilizing 4-0 wide Mersilene.  The skin was draped appropriately and appropriate tissue was resected.  A 7-mm 9-0 French drain was utilized accordingly prior to closure of the skin with interrupted 4-0 Monocryl in the post-occipital region followed by running 5-0 nylon in the postauricular surface.  Preauricular interrupted 5-0 Monocryl was followed by running 7-0 nylon.  The hairline temporal incision was closed with running 5-0 nylon.  The exact same closure was accomplished on the right side of the face with a same size 7-mm French drain.,The patient's dressing consisted of Adaptic Polysporin ointment followed by Kerlix wrap with a 3-inch Ace.,The lips and mouth were sterilely prepped and draped accordingly after application of the head drape dressing as described.  Suction lipectomy was followed in the abdomen with sterile conditions were prepped and draped accordingly.  Approximately 2.5 to 3 cc of autologous fat was injected into the upper lip of the remaining cutaneous line with blunt tip dissector after having washed the fat with saline accordingly.  Tuberculin syringes were utilized on the injection utilizing a larger blunt tip needle for the actual injection procedure.  The incision site was closed with 7-0 nylon.,The patient tolerated the procedure well and was transferred to the recovery room in stable condition with Foley catheter in position.,The patient will be admitted for overnight short stay through the cosmetic package procedure.  She will be discharged in the morning.,Estimated blood loss was less than 75 cc.  No complications noted, and the patient tolerated the procedure well.","cosmetic / plastic surgery, ageing face, adaptic polysporin ointment, autologous fat injection, bovie cautery, kerlix wrap, smas plication, arcus marginalis, blepharoplasty, facelift, platysmal sling, quadrilateral, rhytidectomy, right upper lid, cervical facial rhytidectomy, pinpoint cautery, facial rhytidectomy, quadrilateral blepharoplasty, running nylon, autologous, "
 Nipple areolar reconstruction utilizing a full-thickness skin graft and mastopexy, Cosmetic / Plastic Surgery, Nipple Reconstruction ,"PREOPERATIVE DIAGNOSES,1.  Surgical absence of left nipple areola with personal history of breast cancer.,2.  Breast asymmetry.,POSTOPERATIVE DIAGNOSES,1.  Surgical absence of left nipple areola with personal history of breast cancer.,2.  Breast asymmetry.,PROCEDURE,1.  Left nipple areolar reconstruction utilizing a full-thickness skin graft from the left groin.,2.  Redo right mastopexy.,ANESTHESIA,General endotracheal.,COMPLICATIONS,None.,DESCRIPTION OF PROCEDURE IN DETAIL,The patient was brought to the operating room and placed on the table in the supine position and after suitable induction of general endotracheal anesthesia, the patient was placed in a frog-leg position and prepped and draped in usual fashion for the above-noted procedure.  The initial portion of the procedure was harvesting a full-thickness skin graft from the left groin region.  This was accomplished by ellipsing out a 42-mm diameter circle of skin just below the thigh, peroneal crease.  The defect was then closed with 3-0 Vicryl followed by 3-0 chromic suture in a running locked fashion.  The area was dressed with antibiotic ointment and then a Peri-Pad.  The patient's legs were brought out frog-leg back to the midline and sterile towels were placed over the opening in the drapes.  Surgical team's gloves were changed and then attention was turned to the planning of the left nipple flap.,A maltese cross pattern was employed with a 1-cm diameter nipple and a 42-mm diameter nipple areolar complex.  Once the maltese cross had been designed on the breast at the point where the nipple was to be placed, the areas of the portion of flap were de-epithelialized.  Then, when this had been completed, the dermis about the maltese cross was incised full thickness to allow mobilization of the flap to form the neonipple.  At this point, a Bovie electrocautery was used to control bleeding points and then 4-0 chromic suture was used to suture the arms of the flap together creating the nipple.  When this had been completed, the skin graft, which had been harvested from the left groin was brought onto the field where it was prepared by removing all subcutaneous tissue from the posterior aspect of the graft and carefully removing the hair follicles encountered within the graft.  At this point, the graft was sutured into position in the defect using 3-0 chromic in an interrupted fashion and then trimming the ellipse to an appropriate circle to fill the areola.  At this point, 4-0 chromic was used to run around the perimeter of the full-thickness skin graft and then at this point the nipple was delivered through a cruciate incision in the middle of the skin graft and then inset appropriately with 4-0 chromic.  The areolar skin graft was pie crusted.  Then, at this point, the area of areola was dressed with silicone gel sheeting.  A silo was placed over the neonipple with 3-0 nylon through the apex of the neonipple to support the nipple in an erect position.  Mastisol and Steri-Strips were then applied.,At this point, attention was turned to the right breast where a 2-cm wide ellipse transversely oriented and with its inferior most aspect just inferior to the transverse mastopexy incision line was made.  The skin was removed from the area and then a layered closure of 3-0 Vicryl followed by 3-0 PDS in a running subcuticular fashion was carried out.  When this had been completed, the Mastisol and Steri-Strips were applied to the transverse right breast incision.  Fluff dressings were applied to the right breast as well as the area around the silo on the left breast around the reconstructed nipple areola.  The patient was then placed in Surgi-Bra and then was taken from the operating room to the recovery room in good condition.","cosmetic / plastic surgery, nipple areola, breast asymmetry, general endotracheal, peri-pad, surgi-bra, breast cancer, frog-leg position, full-thickness skin graft, general endotracheal anesthesia, mastopexy, nipple areolar complex, nipple areolar reconstruction, nipple flap, prepped and draped, transverse mastopexy, areolar reconstruction, skin graft, graft, nipple, areolar, breast"
 Perlane injection for the nasolabial fold.  Restylane injection for the glabellar fold., Cosmetic / Plastic Surgery, Perlane & Restylane Injection ,"PREOPERATIVE DIAGNOSES:  ,1.  Nasolabial mesiolabial fold.,2.  Mid glabellar fold.,POSTOPERATIVE DIAGNOSES:  ,1.  Nasolabial mesiolabial fold.,2.  Mid glabellar fold.,TITLE OF PROCEDURES:  ,1.  Perlane injection for the nasolabial fold.,2.  Restylane injection for the glabellar fold.,ANESTHESIA:  ,Topical with Lasercaine.,COMPLICATIONS: , None.,PROCEDURE: , The patient was evaluated preop and noted to be in stable condition.  Chart and informed consent were all reviewed preop.  All risks, benefits, and alternatives regarding the procedure have been reviewed in detail with the patient.  This includes risk of bleeding, infection, scarring, need for further procedure, etc.  The patient did sign the informed consent form regarding the Perlane and Restylane.  She is aware of the potential risk of bruising.  The patient has had Cosmederm in the past and had had a minimal response with this.  Please note Lasercaine had to be applied 30 minutes prior to the procedure.  The excess Lasercaine was removed with a sterile alcohol swab.,Using the linear threading technique, I injected the deep nasolabial fold.  We used 2 mL of the Perlane for injection of the nasolabial mesiolabial fold.  They were carefully massaged into good position at the end of the procedure.  She did have some mild erythema noted.,I then used approximately 0.4 mL of the Restylane for injection of the mid glabellar site.  She has a resting line of the mid glabella that did not respond with previous Botox injection.  Once this was filled, the Restylane was massaged into the proper tissue plane.  Cold compressors were applied afterwards.  She is scheduled for a recheck in the next one to two weeks, and we will make further recommendations at that time.  Post Restylane and Perlane precautions have been reviewed with the patient as well.","cosmetic / plastic surgery, lasercaine, nasolabial mesiolabial fold, mid glabellar fold, perlane injection, restylane injection, nasolabial fold, mesiolabial fold, glabellar fold, injection, perlane, nasolabial, glabellar, restylane"
 Endoscopic subperiosteal midface lift using the endotine midface suspension device.  Transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad., Cosmetic / Plastic Surgery, Midface Lift & Blepharoplasty ,"PREOPERATIVE DIAGNOSES:,1.  Request for cosmetic surgery.,2.  Facial asymmetry following motor vehicle accident.,POSTOPERATIVE DIAGNOSES:,1.  Request for cosmetic surgery.,2.  Facial asymmetry following motor vehicle accident.,PROCEDURES:,1.  Endoscopic subperiosteal midface lift using the endotine midface suspension device.,2.  Transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad.,ANESTHESIA: , General via endotracheal tube.,INDICATIONS FOR OPERATION: , The patient is a 28-year-old country and western performer who was involved in a motor vehicle accident over a year ago.  Since that time, she is felt to have facial asymmetry, which is apparent in publicity photographs for her record promotions.  She had requested a procedure to bring about further facial asymmetry.  She was seen preoperatively by psychiatrist specializing in body dysmorphic disorder as well as analysis of the patient's requesting cosmetic surgery and was felt to be a psychiatrically good candidate.  She did have facial asymmetry with the bit of more fullness in higher cheekbone on the right as compared to the left.  Preoperative workup including CT scan failed to show any skeletal trauma.  The patient was counseled with regard to the risks, benefits, alternatives, and complications of the postsurgical procedure including but not limited to bleeding, infection, unacceptable cosmetic appearance, numbness of the face, change in sensation of the face, facial nerve paralysis, need for further surgery, need for revision, hair loss, etc., and informed consent was obtained.,PROCEDURE:,  The patient was taken to the operating room, placed in supine position after having been marked in the upright position while awake.  General endotracheal anesthesia was induced with a #6 endotracheal tube.  All appropriate measures were taken to preserve the vocal cords in a professional singer.  Local anesthesia consisting of 5/6th 1% lidocaine with 1:100,000 units of epinephrine in 1/6th 0.25% Marcaine was mixed and then injected in a regional field block fashion in the subperiosteal plane via the gingivobuccal sulcus injection on either side as well as into the temporal fossa at the level of the true temporal fascia.  The upper eyelids were injected with 1 cc of 1% Xylocaine with 1:100,000 units of epinephrine.  Adequate time for vasoconstriction and anesthesia was allowed to be obtained.  The patient was prepped and draped in the usual sterile fashion.  A 4-0 silk suture was placed in the right lower lid.  For traction, it was brought anteriorly.  The conjunctiva was incised with the needle tip Bovie with Jaeger lid plate protecting the cornea and globe.  A Q-Tip was then used to separate the orbicularis oculi muscle from the fat pad beneath and carried down to the bone.  The middle and medial fat pads were identified and a small amount of fat was removed from each to take care of the pseudofat herniation, which was present.  The inferior oblique muscle was identified, preserved, and protected throughout the procedure.  The transconjunctival incision was then closed with buried knots of 6-0 fast absorbing gut.  Contralateral side was treated in similar fashion with like results and throughout the procedure.  Lacri-Lube was in the eyes in order to maintain hydration.  Attention was next turned to the midface, where a temporal incision was made parallel to the nasojugal folds.  Dissection was carried out with the hemostat down to the true temporal fascia and the endoscopic temporal dissection dissector was used to elevate the true temporal fascia.  A 30-degree endoscope was used to visualize the fat pads, so that we knew we are in the proper plane.  Subperiosteal dissection was carried out over the zygomatic arch and Whitnall's tubercle and the temporal dissection was completed.,Next, bilateral gingivobuccal sulcus incisions were made and a Joseph elevator was used to elevate the periosteum of the midface and anterior face of the maxilla from the tendon of the masseter muscle up to Whitnall's tubercle.  The two dissection planes within joint in the subperiosteal fashion and dissection proceeded laterally out to the zygomatic neurovascular bundle.  It was bipolar electrocauteried and the tunnel was further dissected free and opened.  The endotine 4.5 soft tissue suspension device was then inserted through the temporal incision, brought down into the subperiosteal midface plane of dissection.  The guard was removed and the suspension spikes were engaged into the soft tissues.  The spikes were elevated superiorly such that a symmetrical midface elevation was carried out bilaterally.  The endotine device was then secured to the true temporal fascia with three sutures of 3-0 PDS suture.  Contralateral side was treated in similar fashion with like results in order to achieve facial symmetry and symmetry was obtained.  The gingivobuccal sulcus incisions were closed with interrupted 4-0 chromic and the scalp incision was closed with staples.  The sterile dressing was applied.  The patient was awakened in the operating room and taken to the recovery room in good condition.","cosmetic / plastic surgery, cosmetic surgery, jaeger lid plate, lacri-lube, q-tip, blepharoplasty, conjunctiva, facial asymmetry, fat pad, lower lid, midface lift, regional field block, temporal fascia, temporal fossa, vasoconstriction, true temporal fascia, gingivobuccal sulcus, gingivobuccal,"
 Split-thickness skin grafting a total area of approximately 15 x 18 cm on the right leg and 15 x 15 cm on the left leg., Cosmetic / Plastic Surgery, Skin Graft ,"DIAGNOSIS:,  Stasis ulcers of the lower extremities,OPERATION:,  Split-thickness skin grafting a total area of approximately 15 x 18 cm on the right leg and 15 x 15 cm on the left leg.,INDICATIONS:,  This 84-year old female presented recently with large ulcers of the lower extremities.  These were representing on the order of 50% or more of the circumference of her lower leg.  They were in a distribution to be consistent with stasis ulcers.  They were granulating nicely and she was scheduled for surgery.,FINDINGS:,  Large ulcers of lower extremities with size as described above.  These are irregular in shape and posterior and laterally on the lower legs.  There was no evidence of infection.  The ultimate skin grafting was quite satisfactory.,PROCEDURE: , Having obtained adequate general endotracheal anesthesia, the patient was prepped from the pubis to the toes.  The legs were examined and the wounds were Pulsavaced bilaterally with 3 liters of saline with Bacitracin.  The wounds were then inspected and there was adequate hemostasis and there was only minimal fibrinous debris that needed to be removed.  Once this was accomplished, the skin was harvested from the right thigh at approximately 0.013 inch.  This was meshed 1:1.5 and then stapled into position on the wounds.  The wounds were then dressed with a fine mesh gauze that was stapled into position as well as Kerlix soaked in Sulfamylon solution.,She was then dressed in additional Kerlix, followed by Webril, and splints were fashioned in a spiral fashion that avoided foot drop and stabilized them, and at the same time did not put pressure across the heels.  The donor site was dressed with Op-Site.  The patient tolerated the procedure well and returned to the recovery room in satisfactory condition.","cosmetic / plastic surgery, skin graft, lower extremities, split thickness skin grafting, skin grafting, kerlix, grafting, extremities, ulcers, leg, "
 Bilateral transaxillary subpectoral mammoplasty with saline-filled implants., Cosmetic / Plastic Surgery, Mammoplasty - 4 ,"DIAGNOSIS: , Bilateral hypomastia.,NAME OF OPERATION:,  Bilateral transaxillary subpectoral mammoplasty with saline-filled implants.,ANESTHESIA:,  General.,PROCEDURE: , After first obtaining a suitable level of general anesthesia with the patient in the supine position, the breasts were prepped with Betadine scrub and solution.  Sterile towels, sheets, and drapes were placed in the usual fashion for surgery of the breasts.  Following prepping and draping, the anterior axillary folds and the inframammary folds were infiltrated with a total of 20 cc of 0.5% Xylocaine with 1:200,000 units of epinephrine.,After a suitable hemostatic waiting period, transaxillary incisions were made, and dissection was carried down to the edge of the pectoralis fascia.  Blunt dissection was then used to form a bilateral subpectoral pocket.  Through the subpectoral pocket a sterile suction tip was introduced, and copious irrigation with sterile saline solution was used until the irrigant was clear.,Following completion of irrigation, 350-cc saline-filled implants were introduced.  They were first filled with 60 cc of saline and checked for gross leakage; none was evident.  They were over filled to 400 cc of saline each.  The patient was then placed in the seated position, and the left breast needed 10 cc of additional fluid for symmetry.,Following completion of the filling of the implants and checking the breasts for symmetry, the patient's wounds were closed with interrupted vertical mattress sutures of 4-0 Prolene.  Flexan dressings were applied followed by the patient's bra.,She seemed to tolerate the procedure well.","cosmetic / plastic surgery, bilateral transaxillary subpectoral mammoplasty, saline filled implants, subpectoral mammoplasty, mammoplasty, transaxillary, subpectoral, implants, breasts, saline, anesthesia"
 Left midface elevation with nasolabial fold elevation and nasolabial fold z-plasty and right symmetrization midface elevation., Cosmetic / Plastic Surgery, Nasolabial Fold Elevation ,"PREOPERATIVE DIAGNOSIS:,  Left nasolabial fold scar deformity with effacement of alar crease.,POSTOPERATIVE DIAGNOSIS:,  Left nasolabial fold scar deformity with effacement of alar crease.,PROCEDURES PERFORMED:,1.  Left midface elevation with nasolabial fold elevation.,2.  Left nasolabial fold z-plasty and right symmetrization midface elevation.,ANESTHESIA: , General endotracheal intubation.,ESTIMATED BLOOD LOSS: , Less than 25 mL.,FLUIDS: , Crystalloid,CULTURES TAKEN: , None.,PATIENT'S CONDITION: , Stable.,IMPLANTS: , Coapt Endotine Midface B 4.5 bioabsorbable implants, reference #CFD0200197, lot #01447 used on the right and used on the left side.,IDENTIFICATION: , This patient is well known to the Stanford Plastic Surgery Service.  The patient is status post resection of the dorsal nasal sidewall skin cancer with nasolabial flap reconstruction with subsequent deformity.  In particular, the patient has had effacement of his alar crease with deepening of his nasolabial fold and notable asymmetry.  The patient was seen in consultation and felt to be a surgical candidate for improvement.  Risks and benefits of the operation were described to the patient in detail including, but not limited to bleeding, infection, scarring, possible damage to surrounding structures including neurovascular structures, need for revision of surgery, continued asymmetry, and anesthetic complication.  The patient understood these risks and benefits and consented to the operation.,PROCEDURE IN DETAIL: , The patient was taken to OR and placed supine on the operating table.  Dose of antibiotics was given to the patient.  Compression devices were placed on the lower extremities to prevent the knee embolic events.  The patient was turned to 180 degrees.  The ETT tube was secured and the area was then prepped and draped in usual sterile fashion.  A head wrap was then placed on the position and we then began our local.  Of note, the patient had previous incisions just lateral to his lateral canthus bilaterally and that were used for access.  Local consisting a 50:50 mix of 0.25% Marcaine with epinephrine and 1% lidocaine with epinephrine was then injected into the subperiosteal plane taking care to prevent injury to the infraorbital nerves.  This was done bilaterally.  We then marked the nasolabial fold and began with the elevation of the left midface.,We began with a lateral canthal-type incision extending out over his previous incision down to subcutaneous tissue.  We continued down to the lateral orbital rim until we identified periosteum.  We then pulled in a periosteal elevator and elevated the midface down over the zygoma elevating some lateral mesenteric attachments down over the buccal region until we felt we had reached pass the nasolabial folds medially.  Care was taken to preserve the infraorbital nerve and that was visualized after elevation.  We then released the periosteum distally and retracted up on the periosteum and noted improved contour of the nasolabial fold with increased bulk over the midface region over the zygoma.,We then used our Endotine Coapt device to engage the periosteum at the desired location and then elevated the midface and secured into position using the Coapt bioabsorbable screw.  After this was then carried out, we then clipped and cut as well as the end of the screw.  Satisfied with this, we then elevated the periosteum and secured it to reinforce our midface elevation to the lateral orbital rim and this was done using 3-0 Monocryl.  Several sutures were then used to anchor the orbicularis and deeper tissue to create additional symmetry.  Excess skin along the incision was then removed as well the skin from just lateral to the canthus.  Care was taken to leave the orbicularis muscle down.  We then continued closing our incision using absorbable plain gut 5-0 sutures for the subciliary-type incision and then continuing with interrupted 6-0 Prolenes lateral to the canthus.,We then turned our attention to performing the z-plasty portion of the case.  A z-plasty was designed along the previous scar where it was padding to the notable scar deformity and effacement of crease and the z-plasty was then designed to lengthen along the scar to improve the contour.  This was carried out using a 15 blade down to subcutaneous tissue.  The flaps were debulked slightly to reduce the amount of fullness and then transposed and sutured into place using chromic suture.  At this point, we then noted that he had improvement of the nasal fold but continued asymmetry with regards to improved bulk on the left side and less bulk on the right and it was felt that a symmetrization procedure was required to make more symmetry with the midface bilaterally and nasolabial folds bilaterally.  As such, we then carried out the dissection after injecting local as noted and we used a 15 blade scalpel to create our incision along the lateral canthus along its preexisting incision.  We carried this down to the lateral orbital rim again elevating the periosteum taking care to preserve infraorbital nerve.,At this point, we then released the periosteum distally just at the level of the nasolabial fold and placed our Endotine midface implant into the desired area and then elevated slightly just for symmetry only.  This was then secured in place using the bioabsorbable screw and then resected a very marginal amount of tissue just for removal of the dog ear deformity and closed the deeper layers of tissue using 3-0 PDS and then closing the extension to the subciliary area using 5-0 plain gut and then 6-0 Prolene lateral to the canthus.,At this point, we felt that we had achieved improved contour, improved symmetry, and decreased effacement of the nasolabial fold and alar crease.  Satisfied with our procedures, we then placed cool compresses on to the eyes.,The patient was then extubated and brought to the PACU in stable condition.,Dr. X was present and scrubbed for the entire case and actively participated during all key elements.  Dr. Y was available and participated in the portions of the case as well.",
" Bilateral augmentation mammoplasty, breast implant, TCA peel to lesions, vein stripping.", Cosmetic / Plastic Surgery, Mammoplasty - 2 ,"PREOPERATIVE DIAGNOSES,Breast hypoplasia, melasma to the face, and varicose veins to the posterior aspect of the right distal thigh/popliteal fossa area.,PROCEDURES,1.  Bilateral augmentation mammoplasty, subglandular with a mammary gel silicone breast implant, 435 cc each.,2.  TCA peel to two lesions of the face and vein stripping to the right posterior thigh and popliteal fossa area.,ANESTHESIA,General endotracheal.,EBL,100 cc.,IV FLUIDS,2L.,URINE OUTPUT,Per Anesthesia.,INDICATION FOR SURGERY,The patient is a 48-year-old female who was seen in clinic by Dr. W and where she was evaluated for her small breasts as well as dark areas on her face and varicose veins to the back and posterior aspect of her right lower extremity.  She requested that surgical procedures to be performed for correction of these abnormalities.  As such, complications were explained to the patient including infection, bleeding, poor wound healing, and need for additional surgery.  The patient subsequently signed the consent and requested that Dr. W and associates to perform the procedure.,TECHNIQUE,The patient was brought to the operating room in supine position.  General anesthesia was induced and then the patient was placed on the operating table in a prone position.  The posterior thigh of the right lower extremity was prepped and draped in a sterile fashion.  First, multiple serial small incisions less than 1 cm in length were made to the posterior aspect of the right thigh and sequential stripping of the varicose veins was performed.  Once these varicose veins had been completely stripped and avulsed, then next the wounds were then irrigated and were cleaned with wet and dry, and all the incisions were closed with the use of 5-0 Monocryl buried interrupted sutures.  The incisions were then dressed with Mastisol, Steri-Strips, ABDs and a TED hose.  Next, the patient was then flipped back over onto the stretcher and placed on the operating table in a supine position.  The anterior chest was then prepped and draped in a sterile fashion.  Next, a 10 blade was placed through previous circumareolar incisions from a previous augmentation mammoplasty.  Dissection was carried out with a 10 blade and Bovie cautery until the pectoralis fascia was identified to both breasts.  Once the pectoralis muscle and fascia were identified, then a surgical plane was created in a subglandular layer.  The hemostasis was obtained to both breast pockets with the Bovie cautery and suction and irrigation was performed to bilateral breast pockets as well.  A sizer was used to identify the appropriate size of the silicone implant to be used.  This was determined to be approximately 435 cc bilaterally.  As such, two mammary gel silicone breast implants were placed in a subglandular muscle.  Additional dissection of the breast pockets were performed bilaterally and the patient was sequentially placed in the upright sitting position for evaluation of appropriate placement of the mammary gel silicone implants.  Once it was determined that the implants were appropriately selected and placed with the 435 cc silicon gel implant, the circumareolar incisions were closed in approximately 4-layered fashion closing the fascia, subcutaneous tissue, deep dermis, and a running dermal subcuticular for final skin closure.  This was performed with 3-0 Monocryl and then 4-0 Monocryl for running subcuticular.  The incisions were then dressed with Mastisol, Steri-Strips, and Xeroform and dressed with sample Kerlix.  Next, our attention was paid to the face where 25% TCA solution was applied to two locations; one on the left cheek and the other one on the right cheek, where a hyperpigmentation/melasma.  Several applications of the TCA peel was performed, and at the end of this, the frosting was noted to both spots.  At the end of the case, needle and instrument counts were correct.  Dr. W was present and scrubbed for the entire procedure.  The patient was extubated in the operating room and taken to the PACU in stable condition.","cosmetic / plastic surgery, breast hypoplasia, monocryl, pacu, tca, tca peel, ted hose, augmentation mammoplasty, breast implant, melasma, poor wound healing, popliteal fossa area, prepped and draped, silicone, varicose vein, vein stripping, mastisol steri strips, steri strips, circumareolar incisions, mammary gel, varicose veins, augmentation, breast, circumareolar, incisions, mammoplasty, mastisol, strips"
" Breast flap revision, nipple reconstruction, reduction mammoplasty, breast medial lesion enclosure.", Cosmetic / Plastic Surgery, Flap revision ,"PREOPERATIVE DIAGNOSES,1.  Acquired absence of bilateral breast status post previous bilateral DIEP flap reconstruction.,2.  Bilateral breast asymmetry.,3.  Right breast macromastia.,4.  Right abdominal scar deformity.,5.  Left abdominal scar deformity.,6.  A 1.3 cm lesion right inferior breast.,7.  Lesion measuring 0.5 cm right inferior breast lateral.,POSTOPERATIVE DIAGNOSES,1.  Acquired absence of bilateral breast status post previous bilateral DIEP flap reconstruction.,2.  Bilateral breast asymmetry.,3.  Right breast macromastia.,4.  Right abdominal scar deformity.,5.  Left abdominal scar deformity.,6.  A 1.3 cm lesion right inferior breast.,7.  Lesion measuring 0.5 cm right inferior breast lateral.,PROCEDURES,1.  Left breast flap revision.,2.  Right breast flap revision.,3.  Right breast reduction mammoplasty.,4.  Right nipple reconstruction.,5.  Left abdominal scar deformity.,6.  Right abdominal scar deformity.,7.  Excision of right breast medial lesion enclosure.,8.  Excision of right breast lateral lesion enclosure.,ANESTHESIA:,  General.,COMPLICATIONS:,  None.,DRAINS:,  None.,SPECIMENS:,  Right breast skin and lesions x2.,COMPLICATIONS:, None.,INDICATIONS:,  This patient is a 54-year-old white female who presents for a revision of her previous bilateral breast reconstruction.  The patient had asymmetry as well as right breast hypertrophy, and therefore, the procedures named above were indicated.  The patient was informed about the possible risks and complications of the above procedures and gave an informed consent.,PROCEDURE:,  The patient was brought to the operating room, placed supine on the operative table.  After adequate endotracheal anesthesia was established and IV prophylactic antibiotics were given, the chest and abdomen were prepped and draped in standard surgical fashion.,Attention was first turned to the left breast where liposuction was performed laterally to allow for better contour and minimize the outer quadrant.  The incision was made for this and was then closed with 5-0 Prolene interrupted suture.,Attention was then turned to the right breast where liposuction was also performed to reduce the medial superior and lateral quadrants.  Once this was performed, the vertical reduction mammoplasty was outlined.  Prior to that, the nipple reconstruction was performed with a keyhole pattern flap.  The flap was elevated with 15-blade and hemostasis was then obtained with the Bovie.  The flap was then sutured onto itself and secured with 5-0 Prolene interrupted sutures.  Then the lateral and medial limbs were undermined to close the defect and this was performed with 3-0 Monocryl interrupted sutures.  Subsequently, the reduction mastectomy skin was then excised sharply and passed up the table marked and sent to Pathology. ,Hemostasis was then obtained with the Bovie and then undermining was performed in the medial, superior, and lateral skin to allow for closure of the reduction incisions.  Once this was performed, a 3-0 Monocryl interrupted sutures were used to close the inferior limb.  Subsequently 2-0 PDS continuous suture was then placed in the periareolar area to close the defect, with a diameter that equaled the new nipple areolar complex.  Once this was performed, the remaining incision was then closed with 3-0 Monocryl followed by 4-0 Monocryl subcuticular sutures.  Subsequently, the 2 lesions were excised, the larger one which was medial and the lateral one that was smaller that were excised sharply, passed up the table and sent to Pathology.  They were closed in 2 layers using 3-0 Monocryl followed by 4-0 Monocryl subcuticular suture.,Attention was then turned to the abdominal scars where liposuction and tumescent solution of diluted epinephrine were used to minimize the amount of excision that was required.  Subsequently the extra skin was excised sharply in an elliptical fashion on the right side measuring approximately 10 x 3 cm, this was the superior and inferior skin, was when undermined and closure was performed after hemostasis was obtained with 3-0 Monocryl followed by 4-0 Monocryl subcuticular suture.,Attention was then turned to the contralateral left side where there was a larger defect.  There was a larger excision required measuring approximately 15 x 3 cm.  The superior and inferior edges of skin were undermined and closed primarily using 3-0 Monocryl followed by 4-0 Monocryl subcuticular sutures.  Steri-Strips were placed on all incisions followed by surgical bra.,The patient tolerated the procedure well and was extubated without complications and transferred to the recovery room in stable condition.  All instruments, needle counts, and sponges were correct at the end of the case.",
 Suction-assisted lipectomy - lipodystrophy of the abdomen and thighs., Cosmetic / Plastic Surgery, Lipectomy - Abdomen/Thighs ,"PREOPERATIVE DIAGNOSIS: , Lipodystrophy of the abdomen and thighs.,POSTOPERATIVE DIAGNOSIS:,  Lipodystrophy of the abdomen and thighs.,OPERATION: , Suction-assisted lipectomy.,ANESTHESIA:,  General.,FINDINGS AND PROCEDURE:,  With the patient under satisfactory general endotracheal anesthesia, the entire abdomen, flanks, perineum, and thighs to the knees were prepped and draped circumferentially in sterile fashion.  After this had been completed, a #15 blade was used to make small stab wounds in the lateral hips, the pubic area, and upper edge of the umbilicus.  Through these small incisions, a cannula was used to infiltrate lactated Ringers with 1000 cc was infiltrated initially into the abdomen.  A 3 and 4-mm cannulas were then used to carry out the liposuction of the abdomen removing a total of 1100 cc of aspirate, which was mostly fat, little fluid, and blood.  Attention was then directed to the thighs both inner and outer.  A total of 1000 cc was infiltrated in both lateral thighs only about 50 cc in the medial thighs.  After this had been completed, 3 and 4-mm cannulas were used to suction 650 cc from each side, approximately 50 cc in the inner thigh and 600 on each lateral thigh.  The patient tolerated the procedure very well.  All of this aspirate was mostly fat with little fluid and very little blood.  Wounds were cleaned and steri-stripped and dressing of ABD pads and ***** was then applied.  The patient tolerated the procedure very well and was sent to the recovery room in good condition.","cosmetic / plastic surgery, lipodystrophy, abd pads, suction-assisted lipectomy, abdomen, aspirate, lipectomy, perineum, steri-stripped, thighs, umbilicus, abdomen and thighs, abdomen/thighs, "
 Debulking of hemangioma of the nasal tip through an open rhinoplasty approach and rhinoplasty., Cosmetic / Plastic Surgery, Hemangioma Debulking & Rhinoplasty ,"PREOPERATIVE DIAGNOSIS: , Hemangioma, nasal tip.,POSTOPERATIVE DIAGNOSIS:,  Hemangioma, nasal tip.,PROCEDURE PERFORMED:  ,1.  Debulking of hemangioma of the nasal tip through an open rhinoplasty approach.,2.  Rhinoplasty.,ESTIMATED BLOOD LOSS:  ,Minimal.,FINDINGS: , Large hemangioma involving the midline of the columella separated the lower lateral cartilages at a level of the columella and the nasal domes.,CONDITION:  ,Condition of the patient at end of the procedure stable, transferred to recovery room.,INDICATIONS FOR THE PROCEDURE: , The patient is a 2-year-old female with a history of a nasal tip hemangioma.  The hemangioma has involved at her upper tongue.  There has not been any change in the last 6 months.  We have discussed with the parents the situation and decided to proceed with the debulking of the nasal tip hemangioma.  They understand the nature of the incision, the nature of the surgery, and the possibility of future revision surgeries.  They understand the risk of bleeding, infection, dehiscence, scarring, need for future revision surgery, and minor asymmetry.  They wished to proceed with surgery.,Because of the procedure, informed consent is obtained.  The patient is taken to operating room and placed in the supine position.  General anesthetic is administrated to an oroendotracheal tube.  The face is prepped and draped in the usual manner.  The incision is designed to the lower aspect of the hemangioma, which corresponds to the columella and upper lip junction and then the remaining of the incision is designed as an open rhinoplasty with bilateral rim incisions.  The area is infiltrated with lidocaine with epinephrine.  We waited 7 minutes for the hemostatic effect and proceeded with the incision.  The incision was then done with a 15 C blade starting at the columella and then going laterally to the level of the rim and the double hook is placed at the level of the dome and the intracartilage incision is done through the mucosa, then extended laterally and upward to follow the lower lateral cartilage.  This is done in both sides.  Further incision is done.  A small tenotomy scissors is used and with the help of retraction of the lower lateral cartilage, the hemangioma is separated gently from the lower lateral cartilage on both sides and I proceeded to leave that the central part of the incision lifting up the entire columella to the level of the nasal tip.  The hemangioma is removed and is found to be involving the medial aspects of both medial crura.  This gently separated from the medial crura and from the soft tissue care is taken not to remove the entire hemangioma from the skin as the nose not to devascularize the distal columella portion.  Hemostasis is achieved with electrocautery.  Then, we proceed to place some interdomal stitches with the help of a 6-0 clear nylon and intercrural stitches are placed and then an interdomal stitch, a single one was placed.  The skin is redraped and the nose found to have satisfactory shape.  The columellar piece was tailored on the lateral aspect corresponding to rim incisions to match the newly created width of the columella.  Portions of skin and hemangioma are taken laterally on both sides of the columella distally.  The skin was closed with 6-0 mild chromic stitches, including the portion at the level of the columella and rim incisions medially.  The remaining of the internal incisions are closed with 5-0 chromic interrupted stitches.  The nose is irrigated and suctioned.  The patient tolerated the procedure without complications.  I was present and participated in all aspects of the procedure.  Sponge and instrument count were complete at the end of the procedure.","cosmetic / plastic surgery, rhinoplasty approach, debulking of hemangioma, nasal domes, lower lateral cartilages, nasal tip, columella, hemangioma, debulking, cartilages, rhinoplasty, nasal,"
" Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.
", Cosmetic / Plastic Surgery, Liposuction ,"PREOPERATIVE DIAGNOSES:,1.  Deformity, right breast reconstruction.,2.  Excess soft tissue, anterior abdomen and flank.,3.  Lipodystrophy of the abdomen.,POSTOPERATIVE DIAGNOSES:,1.  Deformity, right breast reconstruction.,2.  Excess soft tissue, anterior abdomen and flank.,3.  Lipodystrophy of the abdomen.,PROCEDURES:,1.  Revision, right breast reconstruction.,2.  Excision, soft tissue fullness of the lateral abdomen and flank.,3.  Liposuction of the supraumbilical abdomen.,ANESTHESIA: , General.,INDICATION FOR OPERATION:,  The patient is a 31-year-old white female who previously has undergone latissimus dorsi flap and implant, breast reconstruction.  She now had lateralization of the implant with loss of medial fullness for which she desired correction.  It was felt that mobilization of the implant medially would provide the patient significant improvement and this was discussed with the patient at length.  The patient also had a small dog ear in the flank area on the right from the latissimus flap harvest, which was to be corrected.  She had also had liposuction of the periumbilical and infraumbilical abdomen with desire to have great improvement superiorly, was felt to be a candidate for such.  The above-noted procedure was discussed with the patient in detail.  The risks, benefits and potential complications were discussed.  She was marked in the upright position and then taken to the operating room for the above-noted procedure.,OPERATIVE PROCEDURE: , The patient was taken to the operating room and placed in the supine position.  Following adequate induction of general LMA anesthesia, the chest and abdomen was prepped and draped in the usual sterile fashion.  The supraumbilical abdomen was then injected with a solution of 5% lidocaine with epinephrine, as was the dog ear.  At this time, the superior central scar was then excised, dissection continued through the subcutaneous tissue, the underlying latissimus muscle until the capsule of the implant was reached.  This was then opened.  The implant was removed and placed on the back table in antibiotic solution.  Using Bovie cautery, the medial capsule was released and undermining was then performed with release of the muscle to the level of the proposed medial projection of the breast.  The inframammary fold medially was secured with 2-0 PDS suture to create greater takeoff point at this level which in the upright position and using a sizer produced a good form.  The lateral pocket was diminished by series of 2-0 PDS suture to provide medialization of the implant.  The implant was then placed back into the submuscular pocket with much improved positioning and medial fullness.  With this completed, the implant was again removed, antibiotic irrigation was performed.  A drain was placed and brought out through a separate inferior stab wound incision and hemostasis was confirmed.  The implant was then replaced and the wound was then closed in layers using 2-0 PDS running suture on the muscle and 3-0 Monocryl Dermabond subcuticular sutures.  The 2.5 cm dog ear was then excised into and including the subcutaneous tissue, even contouring was achieved and this was closed with two layers using 3-0 Monocryl suture.  Using a #3 cannula, a superior umbilical incision, liposuction was carried out into the supraumbilical abdomen, removing approximately 40 to 50 mL of fat with improved supraumbilical contours.  This was closed with 6-0 Prolene suture.  The patient was placed in a compressive garment after treating the incision with Dermabond, Steri-Strips and antibiotic ointment around the drain site and umbilicus.  A Kerlix dressing and a surgical bra was placed to the chest area.  A compressive garment was placed.  The patient was then aroused from anesthesia, extubated, and taken to the recovery room in stable condition.  Sponge, needle, lap, instrument counts were all correct.  The patient tolerated the procedure well.  There were no complications.  The estimated blood loss was approximately 25 mL.","cosmetic / plastic surgery, breast reconstruction, excess, lma anesthesia, lipodystrophy, liposuction, abdomen, drain site, flank, latissimus dorsi flap, soft tissue, supraumbilical, surgical bra, supraumbilical abdomen, reconstruction, breast, tissue, implant,"
 Bilateral reduction mammoplasty for bilateral macromastia, Cosmetic / Plastic Surgery, Mammoplasty - 1 ,"PREOPERATIVE DIAGNOSIS,Bilateral macromastia.,POSTOPERATIVE DIAGNOSIS,Bilateral macromastia.,OPERATION,Bilateral reduction mammoplasty.,ANESTHESIA,General.,FINDINGS,The patient had large ptotic breasts bilaterally and had had chronic difficulty with pain in the back and shoulder.  Right breast was slightly larger than the left this was repaired with a basic wise pattern reduction mammoplasty with anterior pedicle.,PROCEDURE,With the patient under satisfactory general endotracheal anesthesia, the entire chest was prepped and draped in usual sterile fashion.  A previously placed mark to identify the neo-nipple site was re-identified and carefully measured for asymmetry and appeared to be satisfactory.  A keyhole wire ring was then used to outline the basic wise pattern with 6-cm lamps inferiorly.  This was then carefully checked for symmetry and appeared to be satisfactory.  All marks were then completed and lightly incised on both breasts.  The right breast was approached first.  The neo-nipple site was de-epithelialized superiorly and then the inferior pedicle was de-epithelialized using cutting cautery.  After this had been completed, cutting cautery was used to carry down an incision along the inferior aspect of the periosteum starting immediately.  This was taken down to the prepectoral fashion dissected for short distance superiorly, and then blunt dissection was used to mobilize under the superior portion of the breast tissues to the lateral edge of the pectoral muscle.  There was very little bleeding with this procedure.  After this had been completed, attention was directed to the lateral side, and the inferior incision was made and taken down to the serratus.  Cautery dissection was then used to carry this up superiorly over the lateral edge of the pectoral muscle to communicate with the previous pocket.  After this had been completed, cutting cautery was used to cut around the inferior pedicle completely freeing the superior breast from the inferior breast.  Hemostasis was obtained with electrocautery.  After this had been completed, cutting cautery was used to cut along the superior edge of the redundant tissue and this was tapered under the superior flaps.  On the right side, there was a small palpable lobule, which had shown up on mammogram, but nothing except some fat density was identified.  This site had been previously marked carefully, and there were no unusual findings and the superior tissue was then sent out separately for pathology.  After this had been completed, final hemostasis obtained, and the wound was irrigated and a tagging suture placed to approximate the tissues.  The breast cleared and the nipple appeared good.,Attention was then directed to the left breast, which was completed in the similar manner.  After this had been completed, the patient was placed in a near upright position, and symmetry appeared good, but it was a bit poor on the lateral aspect of the right side, which was little larger and some suction lipectomy was carried out in this area.  After completion of this, 1860 grams had been removed from the right and 1505 grams was removed from the left.  Through separate stab wounds on the lateral aspect, 10-mm flat Blake drains were brought out and sutures were then placed **** and irrigated.  The wounds were then closed with interrupted 4-0 Monocryl on the deep dermis and running intradermal 4-0 Monocryl on the skin, packing sutures and staples were removed as they were approached.  The nipple was sutured with running intradermal 4-0 Monocryl.  Vascularity appeared good throughout.  After this had been completed, all wounds were cleaned and Steri-Stripped.  The patient tolerated the procedure well.  All counts were correct.  Estimated blood loss was less than 150 mL, and she was sent to recovery room in good condition.","cosmetic / plastic surgery, macromastia, estimated blood loss, monocryl, steri-stripped, dermis, inferior breast, mammoplasty, neo-nipple, prepped and draped, ptotic breasts, recovery room in good condition, reduction mammoplasty, superior breast, upright position, bilateral macromastia, incision, superiorly, breasts "
 Bilateral reduction mammoplasty with superior and inferiorly based dermal parenchymal pedicle with transposition of the nipple-areolar complex., Cosmetic / Plastic Surgery, Mammoplasty - 3 ,"PREOPERATIVE DIAGNOSES:,  Bilateral mammary hypertrophy with breast asymmetry, right breast larger than left.,POSTOPERATIVE DIAGNOSES:,  Bilateral mammary hypertrophy with breast asymmetry, right breast larger than left.,OPERATION:,  Bilateral reduction mammoplasty with superior and inferiorly based dermal parenchymal pedicle with transposition of the nipple-areolar complex with resection of 947 g in the larger right breast and 758 g in the smaller left breast.,ANESTHESIA:  ,General endotracheal anesthesia.,PROCEDURE IN DETAIL:  ,The patient was placed in the supine position under the effects of general endotracheal anesthesia.  The breasts were prepped and draped with DuraPrep and iodine solution and then draped in appropriate sterile fashion.  Markings were then made in the standing position preoperatively.  The nipple areolar complex was drawn at the level of the anterior projection of the inframammary fold along the central margin of the breast.  A McKissock ring was utilized as a pattern.  It was centered over the new nipple position and the medial and lateral flaps were drawn tangential to the pigmented areola at a 40-degree angle.  Medial and lateral flaps were drawn 8 cm in length.  At the most medial and lateral extremity inframammary folds, a line was drawn to the lower level at the medial and lateral flaps.  On the left side, the epithelialization was performed about the 45-mm nipple-areolar complex within the confines of the superior-medially based dermal parenchymal pedicle.  Resection of the skin, subcutaneous tissue, and glandular tissue was performed along the inframammary fold, and then cut was made medially and laterally.  The resection medially was perpendicular to the chest wall down to the areolar tissue overlying the pectoralis major muscle, and laterally, the resection was performed tangential to the chest wall, skin, subcutaneous tissue, and glandular tissue towards the axillary tail.  The pedicle was thinned as well, so it was 2-cm thick beneath the nipple-areolar complex and they were medially 4-cm thick at its base.  On the right side, 947 g of breast tissue was removed.  Hemostasis was achieved with electrocautery.  Identical procedure was performed on the opposite left side, again with a superiorly and inferiorly based dermal parenchymal pedicle with deepithelialization about the 45-mm diameter nipple-areolar complex.  Resection of the skin, subcutaneous tissue, and glandular tissue was performed medially down to the chest overlying the pectoralis major muscle and laterally tangential to the chest wall towards the axillary tail setting the pedicle as well beneath the nipple areolar complex.  Hemostasis was achieved with electrocautery.  With pedicle on the left, the breast issue on the left side was weighed at 758 g.  Hemostasis was achieved with cautery.  The patient was placed in the sitting position with wound partially closed and there appeared to be excellent symmetry between the right and left sides.  The nipple-areolar complex was transposed within the position and the medial and lateral flaps were brought together beneath the transposed nipple-areolar complex.  Closure was performed with interrupted 3-0 PDS suture for deep subcutaneous tissue and dermis.  Skin was closed with running subcuticular 4-0 Monocryl suture.  A Jackson-Pratt drain had been placed prior to final closure and secured with a 4-0 silk suture.  The wound had been irrigated prior to final closure as well with bacitracin irrigation solution prior to final cauterization.  Closure was performed with an anchor-shaped closure around the nipple-areolar complex, vertically of inframammary folds and across the inframammary folds.  Dressing was applied.  The suture line was treated with Dermabond.  The patient returned to the recovery room with 2 Jackson-Pratt drains, 1 on each side and IV Foley catheter with instructions to be seen in my office in 2 days.  The patient tolerated the procedure well and returned to the recovery room in satisfactory condition.","cosmetic / plastic surgery, bilateral mammary hypertrophy, duraprep, general endotracheal anesthesia, jackson-pratt drains, breast asymmetry, hypertrophy, inframammary folds, mammary, mammoplasty, nipple areolar complex, nipple-areolar complex, parenchymal, pedicle, prepped and draped, reduction mammoplasty, transposition, medial and lateral, based dermal, dermal parenchymal, parenchymal pedicle, subcutaneous tissue, nipple, areolar, inferiorly, subcutaneous, inframammary, breast, tissue, "
 Suction-assisted lipectomy of the breast with removal of 350 cc of breast tissue from both sides and two mastopexies., Cosmetic / Plastic Surgery, Lipectomy - Breast ,"PREOPERATIVE DIAGNOSIS,Mammary hypertrophy with breast ptosis.,POSTOPERATIVE DIAGNOSIS,Mammary hypertrophy with breast ptosis.,OPERATION,Suction-assisted lipectomy of the breast with removal of 350 cc of breast tissue from both sides and two mastopexies.,ANESTHESIA,General endotracheal anesthesia.,PROCEDURE,The patient was placed in the supine position.  Under effects of general endotracheal anesthesia, markings were made preoperatively for the mastopexy.  An eccentric circle was drawn around the nipple and a wedge drawn from the inferior border of the areola to the inframammary fold.  A stab incision was made bilaterally and tumescent infiltration of anesthesia, lactated ringers with 1 cc of epinephrine to 1000 cc of lactated ringers was infused with a tumescent blunt needle.  200 cc was infiltrated on each side.  This was followed by power-assisted liposuction and manual liposuction with removal of 350 cc of supernatant fat from both sides utilizing a radial tunneling technique with a 4-mm cannula.  This was followed by the epithelialization of skin between the inner circle corresponding to the diameter of the areola 4 cm diameter and the outer eccentric circle with a tangent at the 6 o'clock position.  This would result in an elevation of the nipple-areolar complex with transposition.  The epithelialization of the wedge inferiorly equalized the circumference distance between the inner circle and the outer circle.  Hemostasis was achieved with electrocautery.  After the epithelialization was performed on both sides, nipple-areolar complex was transposed to new nipple position and the wedge was closed with transposition of the nipple-areolar complex beneath the transposed nipple.  Closure was performed with interrupted 3-0 PDS suture on deep subcutaneous tissue and dermal skin closure with running subcuticular 4-0 Monocryl suture.  Dermabond was applied followed by Adaptic and Kerlix in the suturing spaces supportive mildly compressive dressing.  The patient tolerated the procedure well.  The patient was returned to recovery room in satisfactory condition.","cosmetic / plastic surgery, breast ptosis, dermabond, mammary hypertrophy, monocryl, anesthesia, breast tissue, endotracheal anesthesia, lipectomy, mastopexies, mastopexy, nipple, nipple-areolar complex, suction assisted lipectomy, nipple areolar complex, lactated ringers, nipple areolar, areolar complex, epithelialization, areolar, breast, "
 Quad blepharoplasty for blepharochalasia and lower lid large primary and secondary bagging., Cosmetic / Plastic Surgery, Blepharoplasty - Quad ,"PREOPERATIVE DIAGNOSES:,1.  Blepharochalasia.,2.  Lower lid large primary and secondary bagging.,POSTOPERATIVE DIAGNOSES:,1.  Blepharochalasia.,2.  Lower lid large primary and secondary bagging.,PROCEDURE: , Quad blepharoplasty.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Minimal.,CONDITION: , The patient did well.,PROCEDURE:  ,The patient had marks and measurements prior to surgery.  Additional marks and measurements were made at the time of surgery; these were again checked.  At this point, the area was injected with 0.5% lidocaine with 1:200,000 epinephrine.  Appropriate time waited for the anesthetic and epinephrine effect.,Beginning on the left upper lid, the skin excision was completed.  The muscle was opened, herniated, adipose tissue pad in the middle and medial aspect was brought forward, cross-clamped, excised, cauterized, and allowed to retract.  The eyes were kept irrigated and protected throughout the procedure.  Attention was turned to the opposite side.  Procedure was carried out in the similar manner.,At the completion, the wounds were then closed with a running 6-0 Prolene, skin adhesives, and Steri-Strips.  Attention was turned to the right lower lid.  A lash line incision was made.  A skin flap was elevated and the muscle was opened.  Large herniated adipose tissue pads were present in each of the three compartments.  They were individually elevated, cross-clamped, excised, cauterized, and allowed to retract.,At the completion, a gentle tension was placed on the facial skin and several millimeters of the skin excised.  Attention was turned to he opposite side.  The procedure was carried out as just described.  The contralateral side was reexamined and irrigated.  Hemostasis was good and it was closed with a running 6-0 Prolene.  The opposite side was closed in a similar manner.,Skin adhesives and Steri-Strips were applied.  The eyes were again irrigated and cool Swiss Eye compresses applied.  At the completion of the case, the patient was extubated in the operating room, breathing on her own, doing well, and transferred in good condition from operating room to recovering room.","cosmetic / plastic surgery, blepharochalasia, lower lid, swiss eye compresses, adipose tissue pad, bagging, blepharoplasty, lash line incision, quad blepharoplasty,"
" Temporal cheek-neck facelift  and submental suction assisted lipectomy to correct facial and neck skin ptosis and cheek, neck, and jowl lipotosis, and facial rhytides.", Cosmetic / Plastic Surgery, Cheek-Neck Facelift ,"PREOPERATIVE DIAGNOSIS: , Facial and neck skin ptosis.  Cheek, neck, and jowl lipotosis. Facial rhytides.,POSTOPERATIVE DIAGNOSIS:,  Same.,PROCEDURE: , Temporal cheek-neck facelift (CPT 15825).  Submental suction assisted lipectomy (CPT 15876).,ANESTHESIA: , General.,DESCRIPTION OF PROCEDURE: , This patient is a 65-year-old female who has progressive aging changes of the face and neck.  The patient demonstrates the deformities described above and has requested surgical correction.  The procedure, risks, limitations, and alternatives in this individual case have been very carefully discussed with the patient.  The patient has consented to surgery.,The patient was brought into the operating room and placed in the supine position on the operating table.  An intravenous line was started and anesthesia was maintained throughout the case.  The patient was monitored for cardiac, blood pressure, and oxygen saturation continuously.,The hair was prepared and secured with rubber bands and micropore tape along the incision line.  A marking pen had been used to outline the area of the incisions, which included the preauricular area to the level of the tragus, the post-tragal region, the post auricular region and into the hairline.  In addition, the incision was marked in the temporal area in the event of a temporal lift, then across the coronal scalp for the forehead lift.  The incision was marked in the submental crease for the submental lipectomy and liposuction.  The incision in the post auricular area extended up on the posterior aspect of the ear and ended near the occipital hairline.,The areas to be operated on were injected with 1% Lidocaine containing 1:100,000 Epinephrine.  This provided local anesthesia and vasoconstriction.  The total of Lidocaine used throughout the procedure was maintained at no more than 500mg.,SUBMENTAL SUCTION ASSISTED LIPECTOMY: , The incision was made, as previously outlined, in the submental crease in a transverse direction, through the skin and subcutaneous tissue, and hemostasis was obtained with bipolar cautery.  A Metzenbaum scissors was used to elevate the area in the submental region for about 2 or 3cm and making radial tunnels from the angle of the mandible all the way to the next angle of the mandible.  4mm liopsuction cannula was then introduced along these previously outlined tunnels into the jowl on both sides and down top the anterior border of the sternocleidomastoid laterally and just past the thyroid notch interiorly.  The tunnels were enlarged with a 6mm flat liposuction cannula.,Then with the Wells-Johnson liposuction machine 27-29 inches of underwater mercury suction was accomplished in all tunnels.  Care was taken not to turn the opening of the suction cannula up to the dermis, but it was rotated in and out taking a symmetrical amount of fat from each area.  A similar procedure was performed with the 4 mm cannula cleaning the area.  Bilateral areas were palpated for symmetry, and any remaining fat was then suctioned directly.,A triangular wedge of anterior platysma border was cauterized and excised at the cervical mental angle.  A plication stitch of 3-0 Vicryl was placed.,When a satisfactory visible result had been accomplished from the liposuction, the inferior flap was then advanced over anteriorly and the overlying skin excised in an incremental fashion.  5-0 plain catgut was used for closure in a running interlocking fashion.  The wound was cleaned at the end, dried, and Mastisol applied.  Then tan micropore tape was placed for support to the entire area.,FACE LIFT: , After waiting approximately 10-15 minutes for adequate vasoconstriction the post auricular incision was started at the earlobe and continued up on the posterior aspect of the ear for approximately 2cm just superior to the external auditory canal.  A gentle curve was then made, and again the incision was carried down to and into the posterior hairline paralleling the hair follicles and directed posteriorly towards the occipital region.  A preauricular incision was carried into the natural crease superior to the tragus, curved posterior to the tragus bilaterally then brought out inferiorly in the natural crease between the lobule and preauricular skin.  The incision was made in the temporal area beveling parallel with the hair follicles.  (The incision had been designed with curve underneath the sideburn in order to maintain the sideburn hair locations and then curved posteriorly.),The plane of dissection in the hairbearing area was kept deep to the roots of the hair follicles and superficial to the fascia of the temporalis muscle and sternocleidomastoid.  The dissection over the temporalis muscle was continued anteriorly towards the anterior hairline and underneath the frontalis to the supraorbital rim.  At the superior level of the zygoma and at the level of the sideburn, dissection was brought more superficially in order to avoid the nerves and vessels in the areas, specifically the frontalis branch of the facial nerve.,The facial flaps were then elevated with both blunt and sharp dissection with the Kahn facelift dissecting scissors in the post auricular region to pass the angle of the mandible.  This area of undermining was connected with an area of undermining starting with the temporal region extending in the preauricular area of the cheek out to the jowl.  Great care was taken to direct the plane of dissecting superficial to the parotid fascia or SMAS.  The entire dissection was carried in a radial fashion from the ear for approximately 4cm at the lateral canthal area to 8-10cm in the neck region.  When the areas of dissection had been connected carefully, hemostasis was obtained and all areas inspected.  At no point were muscle fibers or major vessels or nerves encountered in the dissection.,The SMAS was sharply incised in a semilunar fashion in front of the ear and in front of the anterior border of the SCM.  The SMAS flap was then advanced posteriorly and superiorly.  The SMAS was split at the level of the earlobe, and the inferior portion was sutured to the mastoid periosteum.  The excess SMAS was trimmed and excised from the portion anterior to the auricle.  The SMAS was then imbricated with 2-0 Surgidak interrupted sutures.,The area was then inspected for any bleeding points and careful hemostasis obtained.  The flaps were then rotated and advanced posteriorly and then superiorly, and incremental cuts were made and the suspension points in the pre and post auricular area were done with 2-0 Tycron suture.  The excess and redundant amount of skin were then excised and trimmed cautiously so as not to cause any downward pull on the ear lobule or any stretching of the scars in the healing period.  Skin closure was accomplished in the hairbearing areas with 5-0 Nylon in the preauricular tuft and 4-0 Nylon interrupted in the post auricular area.  The pre auricular area was closed first with 5-0 Dexon at the ear lobules, and 6-0 Nylon at the lobules, and 5-0 plain catgut in a running interlocking fashion.  5-0 Plain catgut was used in the post auricular area as well, leaving ample room for serosanguinous drainage into the dressing.  The post tragal incisin was closed with interrupted and running interlocking 5-0 plain catgut.  The exact similar procedure was repeated on the left side.,At the end of this procedure, all flaps were inspected for adequate capillary filling or any evidence of hematoma formation.  Any small amount of fluid was expressed post-auricularly.  A fully perforated bulb suction drain was placed under the flap and exited posterior to the hairline on each side prior to the suture closure.  A Bacitracin impregnated nonstick dressing was cut to conform to the pre and post auricular area and placed over the incision lines.,ABD padding over 4X4 gauze was used to cover the pre and post auricular areas.  This was wrapped around the head in a vertical circumferential fashion and anchored with white micropore tape in a non-constricting but secured fashion.  The entire dressing complex was secured with a pre-formed elastic stretch wrap device.  All branches of the facial nerve were checked and appeared to be functioning normally.,The procedures were completed without complication and tolerated well.  The patient left the operating room in satisfactory condition.  A follow-up appointment was scheduled, routine post-op medications prescribed, and post-op instructions given to the responsible party.,The patient was released to home in satisfactory condition.","cosmetic / plastic surgery, neck skin ptosis, lipotosis, rhytides, facelift, submental suction assisted lipectomy, pre and post auricular, cheek neck facelift, auricular region, neck facelift, cheek neck, post auricular, auricular, incision, postoperative, cheek, submental, dissection, neck, "
" Hairline biplanar temporal browlift, quadrilateral blepharoplasty, canthopexy, cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy.", Cosmetic / Plastic Surgery," Browlift, Blepharoplasty, & Rhytidectomy ","PREOPERATIVE DIAGNOSES:,1.  Eyebrow ptosis.,2.  Dermatochalasia of upper and lower eyelids with tear trough deformity of the lower eyelid.,3.  Cervical facial aging with submental lipodystrophy.,OPERATION:,1.  Hairline biplanar temporal browlift.,2.  Quadrilateral blepharoplasty with lateral canthopexy with arcus marginalis release and fat transposition over inferior orbital rim to lower eyelid.,3.  Cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy.,ASSISTANT:  ,None.,ANESTHESIA: , General endotracheal anesthesia.,PROCEDURE: , The patient was placed in a supine position and prepped with general endotracheal anesthesia.  Local infiltration anesthesia with 1% Xylocaine and 1:100,000 epinephrine was infiltrated in upper and lower eyelids.,Markings were made and fusiform ellipse of skin was resected from the upper eyelid.  The lower limb of the fusiform ellipse was at the superior palpebral fold.  A 9 mm of upper eyelid skin was resected at the widest portion of the lips, which extended from medial canthal area to the lateral orbital rim.  This was performed bilaterally and symmetrically and the skin was removed.  Incision was made through the pretarsal orbicularis with small amount of fat being removed from the medial and middle fat pocket.  An incision was made over the superior orbital rim.  Subperiosteal dissection was performed over the forehead.  The dissection proceeded medially.  The corrugator and procerus muscles were carefully dissected from the supratrochlear nerves on both right and left side and cauterized.,Hemostasis was achieved with electrocautery in this fashion.  A 4-cm incision was made, and the forehead at the hairline, subcutaneous dissection was performed and extended over the frontalis muscle for approximately 4 cm.  A subperiosteal dissection was performed after the fibers of the frontalis muscle were separated and subperiosteal dissection from the forehead lead the subperiosteal dissection from the upper eyelid.  The incision was made in the lower lid just beneath the lashline.  Subcutaneous dissection was performed over the pretarsal and preseptal muscle.  Dissection was then proceeded down to the inferior orbital rim.  The arcus marginalis was released and the lower eyelid fat was teased over the inferior orbital rim and sutured to the suborbicularis oculi fat and periosteum, which was separated from the inferior orbital rim.  The orbital fat was sutured to the suborbicularis oculi fat with multiple preplaced sutures of 5-0 Vicryl on a P2 needle.  The upper eyelid incision was closed with a running subcuticular 6-0 Prolene suture bilaterally.  The forehead was then elevated, and the nonhairbearing forehead skin was resected 1.5 cm wide raising the tail of the eyebrow.  The head of the eyebrow was felt to be elevated by the antagonistic frontalis muscle now that the accessory muscles specifically the corrugator and procerus and depressor supercilii were released and divided.,A lateral canthopexy was performed with 5-0 Prolene suture on a C1 double-arm tapered needle being passed from the lateral commissure of the eyelid to the small stab incision being passed to the medial superior orbital rim and sutured to tighten the lower lid.  The distal lateral resection of excessive lower eyelid skin was reduced at risk of eyelid malposition.  The lower lid incision was closed after the redundancy of skin measuring approximately 3 mm was resected on both sides.  Closure was performed with interrupted 6-0 silk suture for the lower lid.  The eyebrow hairline brow lift was closed with interrupted 4-0 PDS suture, deep subcutaneous tissue, and dermis, and the skin closed with a running 5-0 Prolene suture.,Attention then was directed to the cervical facial rhytidectomy and purse-string SMAS elevation with submental lipectomy.  Incisions were made in preauricular area, postauricular area, mastoid and occipital area.  Subcutaneous dissection was performed to the nasolabial fold and cheek and extending across the neck in the midline.  Submental lipectomy was performed through the incision in the submental crease.  Fat was directly removed from the fascia.,Hemostasis was achieved with electrocautery.  A SMAS elevation was performed with a purse-string suture of 2-0 PDS suture from temporalis fascia in front of the ear extending beneath the mandible and then brought back up to be sutured to the temporalis fascia.  This was performed bilaterally and symmetrically.  Hemostasis was achieved with electrocautery.  The cheek flap was brought back posteriorly and the cervical flap posteriorly and superiorly with redundant skin on the right massaged and closed.  The skin of the cheek and neck were resected which was redundant after the ***** posteriorly and superiorly in the neck and transversely in the cheek.,Closure was performed with interrupted 3-0 and 4-0 PDS suture of deep subcutaneous tissue and dermis of the skin was closed with a running 5-0 Prolene suture.  Drains were placed prior to final closure.  A 7-mm flat Jackson-Pratt was then secured with 3-0 silk suture.  Dressing consisting of fluffs and Kerlix and a 4-inch Ace were applied to support mildly compressive dressing.  Scleral eye protectors were removed.  Maxitrol eye ointment was placed followed by Swiss therapy eye pads.  The patient tolerated the procedure well, and she returned to recovery room in satisfactory condition with Foley catheter and Pneumatic compression stockings, TED hose, two Jackson-Pratt drains, and an IV.","cosmetic / plastic surgery, eyebrow ptosis, dermatochalasia, hairline, jackson-pratt, swiss therapy, arcus marginalis, blepharoplasty, browlift, canthopexy, fat transposition, inferior orbital rim, lipectomy, lipodystrophy, lower eyelid, purse-string, rhytidectomy, string smas elevation, suborbicularis oculi, frontalis muscle, pds suture, smas elevation, submental lipectomy, upper eyelid, subperiosteal dissection, lower lid, prolene suture, lower eyelids, orbital rim, lower, eyelids, sutured, subcutaneous, eyebrow, orbital,"
" A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings.  Epidermal autograft on Integra to the back and application of allograft to areas of the lost Integra, not grafted on the back.", Cosmetic / Plastic Surgery, Epidermal Autograft ,"PREOPERATIVE DIAGNOSIS:,  A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings.,POSTOPERATIVE DIAGNOSIS:,  A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings.,PROCEDURES PERFORMED:,1.  Epidermal autograft on Integra to the back (3520 cm2).,2.  Application of allograft to areas of the lost Integra, not grafted on the back (970 cm2).,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:,  Approximately 50 cc.,BLOOD PRODUCTS RECEIVED:,  One unit of packed red blood cells.,COMPLICATIONS: , None.,INDICATIONS: , The patient is a 26-year-old male, who sustained a 60% total body surface area flame burn involving the head, face, neck, chest, abdomen, back, bilateral upper extremities, hands, and bilateral lower extremities.  He has previously undergone total burn excision with placement of Integra and an initial round of epidermal autografting to the bilateral upper extremities and hands.  His donor sites have healed particularly over his buttocks and he returns for a second round of epidermal autografting over the Integra on his back utilizing the buttock donor sites, the extent they will provide coverage.,OPERATIVE FINDINGS:,1.  Variable take of Integra, particularly centrally and inferiorly on the back.  A fair amount of lost Integra over the upper back and shoulders.,2.  No evidence of infection.,3.  Healthy viable wound beds prior to grafting.,PROCEDURE IN DETAIL:,  The patient was brought to the operating room and positioned supine.  General endotracheal anesthesia was uneventfully induced and an appropriate time out was performed.  He was then repositioned prone and perioperative IV antibiotics were administered.  He was prepped and draped in the usual sterile manner.  All staples were removed from the Integra and the adherent areas of Silastic were removed.  The entire wound bed was further prepped with scrub brushes and more Betadine followed by a sulfamylon solution.  Hemostasis of the wound bed was ensured using epinephrine-soaked Telfa pads.  Following dermal tumescence of the buttocks, epidermal autografts were harvested 8 one-thousandths of an inch using the air Zimmer dermatome.  These grafts were passed to the back table where they were meshed 3:1.  The donor sites were hemostased using epinephrine-soaked Telfa and lap pads.  Once all the  grafts were meshed, we brought them back up onto the field, positioned them over the wounds beginning inferiorly and moving cephalad where we had best areas of Integra engraftment.  We were happy with the lie of the grafts and they were stapled into place.  The grafts were then overlaid with Conformant 2, which was also stapled into place.  Utilizing all of his buttocks skin, we did not have enough to cover his entire back, so we elected to apply allograft to the cephalad and a few areas on his flanks where we had had poor Integra engraftment.  Allograft was thawed and meshed 1:1.  It was then brought up onto the field, trimmed to fit and stapled into place over the wound.  Once the entirety of the posterior wounds on his back were covered out with epidermal autograft or allograft sulfamylon soaked dressings were applied.  Donor sites on his buttocks were dressed in Acticoat and secured with staples.  He was then repositioned supine and extubated in the operating room having tolerated the procedure without any apparent complications.  He was transported to PACU in stable condition.","cosmetic / plastic surgery, flame burns, body surface area, epidermal autograft, autograft, integra, integra engraftment, wound, grafts, epidermal, allograft, "
" Capsulotomy left breast and flat advancement V to Y, left breast, for correction of lower pole defect (breast assymetry) status post previous breast surgery.", Cosmetic / Plastic Surgery," Capsulotomy & Flat Advancement, Left Breast ","PREOPERATIVE DIAGNOSIS: , Breast assymetry, status post previous breast surgery.,POSTOPERATIVE DIAGNOSIS:  ,Breast assymetry, status post previous breast surgery.,OPERATION: , Capsulotomy left breast, flat advancement V to Y left breast for correction lower pole defect.,ANESTHESIA:,  LMA.,FINDINGS AND PROCEDURE:  ,The patient is a 35-year-old female who presents status post multiple breast surgeries with resultant flatness of the lower pole of the left breast.  The nipple inframammary fold distance is approximately 1.5 cm shorter than the fuller right breast.  The patient has bilateral Mentor-Smooth round moderate projection jell-filled mammary prosthesis, 225 cc.,The patient was marked in the upright position for mobilization of lateral skin flaps and increase in the length of the nipple inframammary fold distance.  She was then brought to the operating room and after satisfactory LMA anesthesia had been induced, the patient was prepped and draped in the usual manger.  The patient received a gram of Kefzol prior to beginning the procedure.  The previous inverted T-scar was excised down to the underlying capsule of the breast implant.  The breast was carefully dissected off of the underlying capsule.  Care being taken to preserve the vascular supply to the skin and breast flap.  When the anterior portion of the breast was dissected free of the underlying capsule, the posterior aspect of the capsule was then dissected off of the underlying pectoralis muscle.  A posterior incision was made on the backside of the capsule at the proximate middle portion of the capsule and then reflected inferiorly thereby creating a superior based capsular flap.  The lateral aspects of the capsule were then opened and the inferior edge of the capsule was then sutured to the underside of the inframammary flap with 2-0 Monocryl statures.  Care was taken to avoid as much exposure of the implant, as well as damage to the implant.  When the flap had been created and advanced, hemostasis was obtained and the area copiously irrigated with a solution of Bacitracin 50,000 units, Kefzol 1 g, gentamicin 80 mg, and 500 cc of saline.  The lateral skin both medially and laterally were then completely freed and the vertical incision of the inverted T was then extended the 2 cm and sutured with a trifurcation suture of 2-0 Biosyn.  This lengthened the vertical portion of the mastopexy scar to allow for descent of the implant and roundness of the inferior pole of the left breast.  The remainder of the inverted T was closed with interrupted sutures of 3 and 2-0 Biosyn and the skin was closed with continuous suture of 5-0 nylon.  Bacitracin and a standard breast dressing were applied.,The anesthesia was terminated and the patient was recovered in the operating room.  Sponge, instrument, needle count reported as corrected.  Estimated blood loss negligible.","cosmetic / plastic surgery, capsulotomy, biosyn, breast, breast assymetry, kefzol, mentor-smooth, breast surgeries, flat advancement, inframammary fold, lower pole defect, mammary, mammary prosthesis, nipple, breast surgery, assymetry, inframammary, capsule"
" Hypomastia.   Patient wants breast augmentation and liposuction of her abdomen, ", Cosmetic / Plastic Surgery, Breast Augmentation Consult ,"REASON FOR VISIT: , This is a cosmetic consultation.,HISTORY OF PRESENT ILLNESS:,  The patient is a very pleasant 34-year-old white female who is a nurse in the operating room.  She knows me through the operating room and has asked me to possibly perform cosmetic surgery on her.  She is very bright and well informed about cosmetic surgery.  She has recently had some neck surgery for a re-fusion of her neck and is currently on methadone for chronic pain regarding this.  Her current desires are that she obtain a breast augmentation and liposuction of her abdomen, and she came to me mostly because I offer transumbilical breast augmentation.  Her breasts are reportedly healthy without any significant problems.  Her weight is currently stable.,PAST MEDICAL AND SURGICAL HISTORY: ,  Negative.  Past surgical history is significant for a second anterior cervical fusion and diskectomy in 02/05 and in 09/06.  She has had no previous cosmetic or aesthetic surgery.,FAMILY HISTORY AND SOCIAL HISTORY:,  Significant for Huntington disease in her mother and diabetes in her father.  Her brother has an aneurysm.  She does occasionally smoke and has been trying to quit recently.  She is currently smoking about a pack a day.  She drinks about once a week.  She is currently a registered nurse, circulator, and scrub technician in the operating room at Hopkins.  She has no children.,REVIEW OF SYSTEMS:  ,A 12-system review is significant for some musculoskeletal pain, mostly around her neck and thoracic region.  She does have occasional rash on her chest and problems with sleep and anxiety that are related to her chronic pain.  She has considered difficult airway due to anterior cervical disk fusion and instability.  Her last mammogram was in 2000.  She has a size 38C breast.,MEDICATIONS: , Current medications are 5 mg of methadone three times a day and amitriptyline at night as needed.,ALLERGIES: , None.,FINDINGS: , On exam today, the patient has good posture, good physique, good skin tone.  She is tanned.  Her lower abdomen has some excess adiposity.  There is some mild laxity of the lower abdominal skin.  Her umbilicus is oval shaped and of adequate caliber for a transumbilical breast augmentation.  There was no piercing in that region.  Her breasts are C shaped.  They are not ptotic.  They have good symmetry with no evidence of tubular breast deformity.  She has no masses or lesions noted.  The nipples are of appropriate size and shape for a woman of her age.  Her scar on her neck from her anterior cervical disk fusion is well healed.  Hopefully, our scars would be similar to this.,IMPRESSION AND PLAN: , Hypomastia.  I think her general physique and body habitus would accommodate about 300 to 350 cubic centimeter implant nicely.  This would make her fill out her clothes much better, and I think transumbilical technique in her is a good option.  I have discussed with her the other treatment options, and she does not want scars around her breasts if at all possible.  I think her lower abdominal skin is of good tone.  I think suction lipectomy in this region would bring down her size and accentuate her waist nicely.  I am a little concerned about the lower abdominal skin laxity, and I will discuss with her further that in the near future if this continues to be a problem, she may need a mini tummy tuck.  I do think that a liposuction is a reasonable alternative and we could see how much skin tightening she gets after the adiposity is removed.  I will try to set this up in the near future.  I will try to set this up to get the instrumentation from the instrumentation rep for the transumbilical breast augmentation procedure.  Due to her neck issues, we may not be able to perform her surgery but I will check with Dr. X to see if she is comfortable giving her deep sedation and no general anesthetic with her neck being fused.","cosmetic / plastic surgery, breast augmentation and liposuction, liposuction of her abdomen, transumbilical breast augmentation, cosmetic surgery, abdominal skin, breast augmentation, augmentation, liposuction, cosmetic, transumbilical, breast,"
" Breast reconstruction post mastectomy.  A 51-year-old lady for mastectomy on the right side, who is interested in the possibility of breast reconstruction.", Cosmetic / Plastic Surgery, Breast Reconstruction ,"REASON FOR CONSULTATION:,  Breast reconstruction post mastectomy.,HISTORY OF PRESENT ILLNESS: , The patient is a 51-year-old lady, who had gone many years without a mammogram when she discovered a lump in her right breast early in February of this year.  She brought this to the attention of her primary care doctor and she soon underwent ultrasound and mammogram followed by needle biopsy, which revealed that there was breast cancer.  This apparently was positive in two separate locations within the suspicious area.  She also underwent MRI, which suggested that there was significant size to the area involved.  Her contralateral left breast appeared to be uninvolved.  She has had consultation with Dr. ABC and they are currently in place to perform a right mastectomy.,PAST MEDICAL HISTORY: , Positive for hypertension, which is controlled on medications.  She is a nonsmoker and engages in alcohol only moderately.,PAST SURGICAL HISTORY: , Surgical history includes uterine fibroids, some kind of cyst excision on her foot, and cataract surgery.,ALLERGIES: , None known.,MEDICATIONS: , Lipitor, ramipril, Lasix, and potassium.,PHYSICAL EXAMINATION: , On examination, the patient is a healthy looking 51-year-old lady, who is moderately overweight.  Breast exam reveals significant breast hypertrophy bilaterally with a double D breast size and significant shoulder grooving from her bra straps.  There are no any significant scars on the right breast as she has only undergone needle biopsy at this point.  Exam also reveals abdomen where there is moderate excessive fat, but what I consider a good morphology for a potential TRAM flap.,IMPRESSION:,  A 51-year-old lady for mastectomy on the right side, who is interested in the possibility of breast reconstruction.  We discussed the breast reconstruction options in some detail including immediate versus delayed reconstruction and autologous tissue versus implant reconstruction.  I think for a lady of this physical size and breast morphology that the likelihood of getting a good result with a tissue expander reconstruction is rather slim.  A further complicating factor is the fact that she may well be undergoing radiation after her mastectomy.  I would think this would make a simple tissue expander reconstruction virtually beyond the balance of consideration.  I have occasionally gotten away with tissue expanders with reasonable results in irradiated patients when they are thinner and smaller breasted, but in a heavier lady with large breasts, I think it virtually deemed to failure.  We therefore, mostly confine our discussion to the relative merits of TRAM flap breast reconstruction and latissimus dorsi reconstruction with implant.  In either case, the contralateral breast reduction would be part of the overall plan., ,The patient understands that the TRAM flap although not much more lengthy of a procedure is a little comfortable recovery.  Since we are sacrificing a rectus abdominus muscle that can be more discomfort and difficulties in healing both due to it being a respiratory muscle and to its importance in sitting up and getting out of bed.  In any case, she does prefer this option in order to avoid the need for an implant.  We discussed pros and cons of the surgery, including the risks such as infection, bleeding, scarring, hernia, or bulging of the donor site, seroma of the abdomen, and fat necrosis or even the skin slough in the abdomen.  We also discussed some of the potential flap complications including partial or complete necrosis of the TRAM flap itself.,PLAN: , The patient is definitely interested in undergoing TRAM flap reconstruction.  At the moment, we are planning to do it as an immediate reconstruction at the time of the mastectomy.  For this reason, I have made arrangements to do initial vascular delay procedure within the next couple of days.  We may cancel this if the chance of postoperative irradiation is high.  If this is the case, I think we can do a better job on the reconstruction if we defer it.  The patient understands this and will proceed according to the recommendations from Dr. ABC and from the oncologist.","cosmetic / plastic surgery, breast reconstruction, mastectomy, lump, breast, mammogram, needle biopsy, breast cancer, hypertrophy, tram flap, latissimus dorsi,"
 Blepharoplasty procedure, Cosmetic / Plastic Surgery, Blepharoplasty ,"BLEPHAROPLASTY,The patient was prepped and draped.  The upper lid skin was marked out in a lazy S fashion, and the redundant skin marked out with a Green forceps.  Then the upper lids were injected with 2% Xylocaine and 1:100,000 epinephrine and 1 mL of Wydase per 20 mL of solution.,The upper lid skin was then excised within the markings.  Gentle pressure was placed on the upper eyelids, and the fat in each of the compartments was teased out using a scissor and cotton applicator; and then the fat was cross clamped, cut, and the clamp cauterized.  This was done in the all compartments of the middle and medial compartments of the upper eyelid, and then the skin sutured with interrupted 6-0 nylon sutures.  The first suture was placed in the lower eyelid skin picking up the periorbital muscle and then the upper portion of the tarsus and then the upper lid skin.  This created a significant crisp, supratarsal fold.  The upper lid skin was closed in this fashion, and then attention was turned to the lower lid.,An incision was made under the lash line and slightly onto the lateral canthus.  The #15 blade was used to delineate the plane in the lateral portion of the incision, and then using a scissor the skin was cut at the marking.  Then the skin muscle flap was elevated with sharp dissection.  The fat was located and using a scissor the three eyelid compartments were opened.  Fat was teased out, cross clamped, the fat removed, and then the clamp cauterized.  Once this was done the skin was tailored to the lower lid incision site with mouth open and eyes in upward gaze, and then the excess skin removed.  The suture line was sutured with interrupted 6-0 silk sutures.  Once this was done the procedure was finished.,The patient left the OR in satisfactory condition.  The patient was given 50 mg of Demerol IM with 25 mg of Phenergan.","cosmetic / plastic surgery, blepharoplasty, green forceps, wydase, applicator, canthus, lash line, lazy s, lazy s fashion, muscle flap, periorbital muscle, prepped and draped, supratarsal fold, upper lid, upward gaze, upper lid skin, eyelidsNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Bilateral orbital frontozygomatic craniotomy with bilateral orbital advancement with Z-osteotomies and bilateral forehead reconstruction with autologous graft., Cosmetic / Plastic Surgery, Bilateral Orbital Frontozygomatic Craniotomy ,"PREOPERATIVE DIAGNOSIS: , Metopic synostosis with trigonocephaly.,POSTOPERATIVE DIAGNOSIS: , Metopic synostosis with trigonocephaly.,PROCEDURES PERFORMED: , ,1.  Bilateral orbital frontozygomatic craniotomy with bilateral orbital advancement with Z-osteotomies.,2.  Bone grafts.,3.  Bilateral forehead reconstruction with autologous graft.,ANESTHESIA: , General endotracheal anesthesia.,COMPLICATIONS:,  None.,CONDITION OF THE PATIENT AT THE END OF THE PROCEDURE: , Stable, transferred to recovery room.,ESTIMATED BLOOD LOSS: , 300 mL.,CRYSTALLOIDS: , Packed red blood cells 440 mL, FFP 100 mL.,URINARY OUTPUT: , 160 mL.,INDICATIONS FOR PROCEDURE: , The patient is a 9-month-old baby with a history of trigonocephaly and metopic synostosis.  We have discussed locations, the nature of trigonocephaly's repair, metopic synostosis repair with bilateral fronto-orbital advancement, forehead reconstruction, and bone graft.  We have discussed risks and benefits.  Risks included, but not limited to risk of bleeding, infection, dehiscence, scarring, need for future revision surgeries, minimal possibility of death, the alternatives, devastating bleeding, anesthesia, death, dehiscence, infection.  The parents understand, decide to proceed with surgery.  Informed consent was obtained and we proceed with surgery.,DESCRIPTION OF PROCEDURE: , The patient was taken into the operating room, placed in the supine position.  General anesthetic was administered.  Prophylactic dose of antibiotic was given.  Lines were placed by Anesthesia and then the head of the bed was turned to 100 degrees.  The patient was once more positioned and padded in the usual manner.  The incision was marked with the help of a marking pen and local anesthetic was infiltrated after prepping the area one time, then the definitive prep and draping of the area was done.,The procedure began with an incision through the full-thickness of the skin into the subcutaneous tissue down to the subgaleal plane.  The subgaleal plane was developed and reflected anteriorly and slightly posteriorly.  Hemostasis achieved with electrocautery.  Raney clips were applied to both flaps to prevent significant bleeding.  Then, we proceed with craniotomy part and Dr. Y proceeded with this part of the procedure.  I assisted her and this will be described in a different operative report.  Then, the area corresponding to the C-shaped osteotomy was marked and then we proceed in conjunction with Dr. Y to develop these osteotomies with the help of the Midas by retracting the contents of the skull at the level of the anterior fossa as well as the orbital contents with the help of a ribbon retractor.  The osteotomies were done with the Midas and some irrigation.  There was an osteotomy done at the level of the frontozygomatic suture just posterior to the frontozygomatic suture and then these osteotomies continued down intraorbitally and lateral through the zygoma to the level of the intraorbital rim.  This was done on both sides.  Hemostasis achieved with bone wax and electrocautery.  Once the osteotomies were completed, __________ of the osteotomy sites allowed advancements.  On the left side, there was a minor fracture to the superior orbital rim that was plated.  The bone grafts were customized placing these at the level of the sphenoid bone in the posterior aspect of the orbital rim.  The temporalis muscle was advanced and attached to the orbital rim with holes that have been drilled with Midas and a 3-0 Vicryl interrupted stitches.  The forehead flaps were attached with the help of absorbable mesh.  The forehead portions were applied to the fronto-orbital advancement of fronto-orbital piece with the help of Synthes mesh and 3-mm screws.  Hemostasis was checked.  The flaps were retracted back into position.,The wound was closed with 3-0 Vicryl interrupted sutures, 4-0 Vicryl interrupted stitches, and 5-0 running fast absorbing gut.  Dressing was applied with Xeroform, bacitracin, and ABDs and a burn net.  The patient tolerated the procedure well without complications and was transferred to the recovery room in stable condition.  I was present and participated in all aspects of the procedure.  Sponge, needle, and instrument counts were completed at the end of the procedure.","cosmetic / plastic surgery, metopic synostosis, craniotomy, z-osteotomies, orbital advancement, bone grafts, frontozygomatic, forehead reconstruction, autologous graft, bilateral orbital frontozygomatic craniotomy, orbital, osteotomies, forehead, "
" Left upper extremity amputation.  This 3-year-old male suffered amputation of his left upper extremity with complications of injury.  He presents at this time for further attempts at closure.  Left abdominal flap 5 x 5 cm to left forearm, debridement of skin, subcutaneous tissue, muscle, and bone, closure of wounds, placement of VAC negative pressure wound dressing.", Cosmetic / Plastic Surgery, Closure of Amputation Wounds ,"PREOPERATIVE DIAGNOSIS: , Left upper extremity amputation.,POSTOPERATIVE DIAGNOSIS: , Left upper extremity amputation.,PROCEDURES:,1.  Left abdominal flap 5 x 5 cm to left forearm.,2.  Debridement of skin, subcutaneous tissue, muscle, and bone.,3.  Closure of wounds, simple closure approximately 8 cm.,4.  Placement of VAC negative pressure wound dressing.,INDICATIONS: , This 3-year-old male suffered amputation of his left upper extremity with complications of injury.  He presents at this time for further attempts at closure.,OPERATIVE FINDINGS: , A clean wound to left upper extremity with partial dehiscence of previously closed wounds and also the closure was satisfactory.,DESCRIPTION OF PROCEDURE: , Under inhalational anesthesia, he was prepped and draped in usual fashion exposing left upper extremity and also exposing continuity of the left abdomen, chest, and groin.  He underwent systematic evaluation of his wound of his left upper extremity and we excised first the whole wound prior to doing some additional closure.  Some areas were dehisced and appeared to be because it was approximation of granulation tissue and as a result the edges were freshened up prior to approximating them.  In this fashion, simple closure was accomplished and its total length was approximately 8 cm.  It should be noted that prior to doing any procedure that appropriate timeout was performed and he received prophylactic antibiotics as indicated and did not require DVT prophylaxis.  At this time, once we accomplished debridement and simple closure removing skin, subcutaneous tissue, muscle and bone as well as closing the arm, we could design our flap for the abdomen.  The flap was designed as a slightly greater than 1:1 ellipse of skin from just below the costal margin.  This was elevated at the level of the external oblique and then laid on the left forearm.  The donor's site was closed using interrupted 4-0 Vicryl in the deep dermis and running subcuticular 4-0 Monocryl on the skin.  Steri-Strips were applied.  At this time, the flap was inset using again 4-0 Monocryl sutures and then ultimately the VAC negative pressure wound dressing was applied to help hold this in place and optimize the vascularization of the flap.  The patient tolerated the procedure well and he returned to the recovery room in satisfactory condition.","cosmetic / plastic surgery, abdominal flap, debridement, skin, subcutaneous tissue, muscle, bone, closure of wounds, vac, vac negative, upper extremity, closure, wounds, flap, extremity, amputation"
 Belly button piercing for insertion of belly button ring., Cosmetic / Plastic Surgery, Belly Button Piercing ,"PROCEDURE:,  Belly button piercing for insertion of belly button ring.,DESCRIPTION OF PROCEDURE:,  The patient was prepped after informed consent was given of risk of infection and foreign body reaction.  The area was marked by the patient and then prepped.  The area was injected with 2% Xylocaine 1:100,000 epinephrine.,Then a #14-gauge needle was inserted above the belly button and inserted up to the skin just above the actual umbilical area and the ring was inserted into the #14-gauge needle and pulled through.  A small ball was placed over the end of the ring.  This terminated the procedure.,The patient tolerated the procedure well.  Postop instructions were given regarding maintenance.  Patient left the office in satisfactory condition.","cosmetic / plastic surgery, belly button piercing, 2% xylocaine, belly button, postop instructions, the patient tolerated the procedure well, foreign body, gauge needle, needle, piercing, ring, satisfactory condition, umbilical, button piercing, belly, buttonNOTE"
 A well-child check with concern of some spitting up quite a bit., Consult - History and Phy., Well-Child Check - 5 ,"SUBJECTIVE:,  The patient presents with Mom for a first visit to our office for a well-child check with concern of some spitting up quite a bit.  Mom wants to make sure that this is normal.  The patient is nursing well every two to three hours.  She does have some spitting up on occasion.  It has happened two or three times with some curdled appearance x 1.  No projectile in nature, nonbilious.  Normal voiding and stooling pattern.  Growth and Development:  Denver II normal, passing all developmental milestones per age.  See Denver II form in the chart.,PAST MEDICAL HISTORY:,  Mom reports uncomplicated pregnancy with prenatal care provided by Dr. XYZ in Wichita, Kansas.  Delivery after induction secondary to postdate at St. Joseph Hospital.  Infant delivered by SVD with birth weight of 6 pounds 13 ounce.  Length of 19 inches.  Did well after delivery and dismissed to home with Mom.  Received hepatitis B #1 prior to dismissal.  No other hospitalizations.  No surgeries.  No known medical allergies.  No medications.  Mom has tried Mylicon drops on occasion.,FAMILY HISTORY: , Significant for cardiovascular disease, hypertension, diabetes mellitus and thyroid problems in maternal and paternal grandparents.  Healthy Mother, Father.  There is also history of breast, colon and ovarian cancer on the maternal side of the family, her grandmother who is present at visit today.  There is history of asthma in the patient's father.,SOCIAL HISTORY:,  The patient lives at home with 23-year-old mother, who is a homemaker and 24-year-old father, John, who is a supervisor at Excel.  The family lives in Bentley, Kansas.  No smoking in the home.  Family does have one pet cat.,REVIEW OF SYSTEMS:,  As per HPI, otherwise, negative.,OBJECTIVE:,  Weight:  7 pounds 12 ounces.  Height:  21 inches.  Head circumference:  35 cm.  Temperature:  97.2 degrees.,General:  Well-developed, well-nourished, cooperative, alert, interactive 2-week-old white female in no acute distress.,HEENT:  Atraumatic, normocephalic.  Anterior fontanel is soft and flat.  Pupils are equal, round and reactive.  Sclerae clear.  Red reflexes present bilaterally.  TMs are clear bilaterally.  Oropharynx:  Mucous membranes are moist and pink.,Neck:  Supple, no lymphadenopathy.,Chest:  Clear to auscultation bilaterally.  No wheeze or crackles.  Good air exchange.,Cardiovascular:  Regular rate and rhythm.  No murmur.  Good pulses bilaterally.,Abdomen:  Soft, nontender, nondistended.  Positive bowel sounds.  No mass nor organomegaly.,Genitourinary:  Tanner I female genitalia.  Femoral pulses are equal bilaterally.  No rash.,Extremities:  Full range of motion.  No cyanosis, clubbing or edema.  Negative Ortolani or Barlow maneuver.,Back:  Straight.  No scoliosis.,Integument:  Warm, dry and pink without lesions.,Neurologic:  Alert.  Good muscle tone and strength.,ASSESSMENT/PLAN:,1.  Well 2-week-old white female.,2.  Anticipatory guidelines for growth, diet, development, safety issues as well as immunizations and visitation schedule.  Gave 2-week well-child check handout and American Academy of Pediatrics book Birth to 5 years to Mom and family.,3.  Call the office or on-call physician if the patient has fever, feeding problems or breathing problems.  Otherwise plan to recheck at 1-month of age.","consult - history and phy., well-child check, denver ii, child check, growth, development, denver, cardiovascular, maternal, mother, spitting, father, child, check, asthma, family, mom, "
 Blunt trauma to the distal right thumb without fracture.  Worker’s Compensation Injury, Consult - History and Phy., Worker's Compensation Injury ,"CHIEF COMPLAINT:,  Worker’s compensation injury.,HISTORY OF PRESENT ILLNESS:,  The patient is a 21-year-old Hispanic female.  She comes in today with her boyfriend.  The patient speaks English fairly well, but her primary language is Spanish.  Her boyfriend does help to make sure that she understands what we are talking about.  The patient seems to understand our conversation fairly well.  She works at Norcraft and injured her right thumb on 09/10/2004 at 12:15 a.m.  She was pushing a cart and mashed her thumb between the cart and the wall.  This was at the finishing room in Norcraft.  She went ahead and went to work yesterday, which was the 14th, but was not able to work on the 13th.  She has swelling in her thumb.  It hurt only if it is pushed on.  It was the distal end of her thumb that was mashed.  She has not noticed any numbness or tingling or weakness.  She has not sought any treatment for this, is not taking any pain medications.  She did try soaking it in warm salt water and did not notice any improvement.,MEDICATIONS: , None.,ALLERGIES: , None.,PAST MEDICAL HISTORY:,  Possible history of chicken pox, otherwise no other medical illnesses.  She has never had any surgery.,FAMILY HISTORY: , Parents and two siblings are healthy.  She has had no children.,SOCIAL HISTORY:,  The patient is single.  She lives with her boyfriend and his father.  She works at Norcraft.  She wears seatbelt 30% of the time.  I encouraged her to use them all of the time.  She is a nonsmoker, nondrinker.,VACCINATIONS: , She thinks she got a tetanus vaccine in childhood, but does not know for sure.  She does not think she has had a tetanus booster recently.,REVIEW OF SYSTEMS:,Constitutional:  No fevers, chills, or sweats.,Neurologic:  She has had no numbness, tingling, or weakness.,Musculoskeletal:  As above in HPI.  No other difficulties.,PHYSICAL EXAMINATION:,General:  This is a well-developed, well-nourished, very pleasant Hispanic female, in no acute distress.,Vital Signs:  Weight:  121.4.  Blood pressure:  106/78.  Pulse:  64.  Respirations:  20.  Temperature:  96.,Extremities:  Examination of the right hand reveals the distal end of the thumb to be swollen especially just proximal to the nail bed.  The nail bed is pushed up.  I can see hematoma below the nail bed, although it does appear to be intact.  She has some blue fingernail polish on her nail also, but that is starting to come off.  She is able to bend her thumb normally at the DIP joint.  She has no discomfort doing that.  Sensation is intact over the entire thumb.  She has normal capillary refill.  There is some erythema and swelling noted especially over the posterior thumb just proximal to the nail bed.  I am not feeling any fluctuance.  I do not think it is a collection of pus.  There is no drainage.  She does have some small fissures in the skin where I think she did injure it with this smashing injury, but no deep lacerations at all.  It looks like there may be some mild cellulitis at the site of her injury.,LABORATORY:,  X-ray of the thumb was obtained and I do not see any sign of fracture or foreign body.,ASSESSMENT:,  Blunt trauma to the distal right thumb without fracture.  I think there is some mild cellulitis developing there.,PLAN:,1.  We will give a tetanus diphtheria booster.,2.  We will start Keflex 500 mg one p.o. q.i.d. x 7 days.  I would recommend that she can return to work, but she is not to do any work that requires the use of her right thumb.  I would like to see her back on Monday, the 20th in the morning and we can see how her thumb is doing at that time.  If she is noticing any difficulties with increased redness, increased warmth, increased pain, pus-like drainage, or any other difficulties, she is to go ahead and give us a call.  Otherwise I will be seeing her back on Monday.",
 A 3-month well-child check. , Consult - History and Phy., Well-Child Check - 6 ,"SUBJECTIVE:,  Patient presents with Mom and Dad for her 5-year 3-month well-child check.  Family has not concerns stating patient has been doing well overall since last visit.  Taking in a well-balanced diet consisting of milk and dairy products, fruits, vegetables, proteins and grains with minimal junk food and snack food.  No behavioral concerns.  Gets along well with peers as well as adults.  Is excited to start kindergarten this upcoming school year.  Does attend daycare.  Normal voiding and stooling pattern.  No concerns with hearing or vision.  Sees the dentist regularly.  Growth and development:  Denver II normal passing all developmental milestones per age in areas of fine motor, gross motor, personal and social interaction and speech and language development.  See Denver II form in the chart.,ALLERGIES:,  None.,MEDICATIONS: , None.,FAMILY SOCIAL HISTORY:,  Unchanged since last checkup.  Lives at home with mother, father and sibling.  No smoking in the home.,REVIEW OF SYSTEMS:,  As per HPI; otherwise negative.,OBJECTIVE:,Vital Signs:  Weight 43 pounds.  Height 42-1/4 inches.  Temperature 97.7.  Blood pressure 90/64.,General:  Well-developed, well-nourished, cooperative, alert and interactive 5-year -3month-old white female in no acute distress.,HEENT:  Atraumatic, normocephalic.  Pupils equal, round and reactive.  Sclerae clear.  Red reflex present bilaterally.  Extraocular muscles intact.  TMs clear bilaterally.  Oropharynx:  Mucous membranes moist and pink.  Good dentition.,Neck:  Supple, no lymphadenopathy.,Chest:  Clear to auscultation bilaterally.  No wheeze or crackles.  Good air exchange.,Cardiovascular:  Regular rate and rhythm.  No murmur.  Good pulses bilaterally.,Abdomen:  Soft, nontender.  Nondistended.  Positive bowel sounds.  No masses or organomegaly.,GU:  Tanner I female genitalia.  Femoral pulses equal bilaterally.  No rash.,Extremities:  Full range of motion.  No cyanosis, clubbing or edema.,Back:  Straight.  No scoliosis.,Integument:  Warm, dry and pink without lesions.,Neurological:  Alert.  Good muscle tone and strength.  Cranial nerves II-XII grossly intact.  DTRs 2+/4+ bilaterally.,ASSESSMENT/PLAN:,1. Well 5-year 3-month-old white female.,2. Anticipatory guidance for growth and diet development and safety issues as well as immunizations.  Will receive MMR, DTaP and IPV today.  Discussed risks and benefits as well as possible side effects and symptomatic treatment.  Gave 5-year well-child check handout to mom.  Completed school pre-participation physical.  Copy in the chart.  Completed vision and hearing screening.  Reviewed results with family.,3. Follow up in one year for next well-child check or as needed for acute care.","consult - history and phy., denver ii, child check, mom, diet, growth, denver, family, development, child, check, "
" Well-woman check up for a middle-aged woman, status post hysterectomy, recent urinary tract infection.", Consult - History and Phy., Well-woman checkup ,"CHIEF COMPLAINT:,  The patient comes for her well-woman checkup.,HISTORY OF PRESENT ILLNESS:,  She feels well.  She has had no real problems.  She has not had any vaginal bleeding.  She had a hysterectomy.  She has done fairly well from that time till now.  She feels like she is doing pretty well.  She remains sexually active occasionally.  She has not had any urinary symptoms.  No irregular vaginal bleeding.  She has not had any problems with vasomotor symptoms and generally, she just feels like she has been doing pretty well.  She sometimes gets a catch in her right hip and sometimes she gets heaviness in her calves.  She says the only thing that works to relieve that is to sleep on her tummy with her legs pulled up and they relax and she goes off to sleep.  She does not report any swelling or inflammation, or pain.  She had a recent urinary tract infection, took medication, and has not rechecked on that urinalysis.,MEDICATIONS: , Tetracycline 250 mg daily, Inderal LA 80 mg every other day.,ALLERGIES:,  Sulfa.,PAST MEDICAL HISTORY:,  She had rosacea.  She also has problems with “tremors” and for that she takes Inderal LA.  Hysterectomy in the past.,SOCIAL HISTORY:,  She drinks four cups of coffee a day.  No soda.  No chocolate.  She said her husband hurt his hand and shoulder, and she has been having to care of him pretty much.  They walk every evening for one hour.,FAMILY HISTORY:,  Her mother is in a nursing home; she had a stroke.  Her father died at age 86 in January 2004 of congestive heart failure.  She has two brothers, one has kidney failure, the other brother donated a kidney to his other brother, but this young man is now an alcoholic and drug addict.,REVIEW OF SYSTEMS:,  Patient denies headache or trauma.  No blurred or double vision.  Hearing is fine, no tinnitus, or infection.  Infrequent sore throat, no hoarseness, or cough.,Neck:  No stiffness, pain, or swelling.,Respiratory:  No shortness of breath, cough, or hemoptysis.,Cardiovascular:  No chest pain, ankle edema, palpitations, or hypertension.,GI:  No nausea, vomiting, diarrhea, constipation, melena, or jaundice.,GU:  No dysuria, frequency, urgency, or stress incontinence.,Locomotor:  No weakness, joint pain, tremor, or swelling.,GYN:  See HPI.,Integumentary:  Patient performs self-breast examinations and denies any breast masses or nipple discharge.  No recent skin or hair changes.,Neuropsychiatric:  Denies depression, anxiety, tearfulness, or suicidal thought.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Height:  62 inches.  Weight:  134 pounds.  Blood pressure:  116/74.  Pulse:  60.  Respirations:  12.  Age 59.,HEENT:  Head is normocephalic.  Eyes:  EOMs intact.  PERRLA.  Conjunctiva clear.  Fundi:  Discs flat, cups normal.  No AV nicking, hemorrhage or exudate.  Ears:  TMs intact.  Mouth:  No lesion.  Throat:  No inflammation.  She fell last winter on the ice and really cracked her head and has had some problems with headaches since then and she has not returned to her job which was very stressful and hard on her.  She wears glasses.,Neck:  Full range of motion.  No lymphadenopathy or thyromegaly.,Chest:  Clear to auscultation and percussion.,Heart:  Normal sinus rhythm, no murmur.,Integumentary:  Breasts are without masses, tenderness, nipple retraction, or discharge.  Reviewed self-breast examination.  No axillary nodes are palpable.,Abdomen:  Soft.  Liver, spleen, and kidneys are not palpable.  No masses felt, nontender.  Femoral pulses strong and equal.,Back:  No CVA or spinal tenderness.  No deformity noted.,Pelvic:  BUS negative.  Vaginal mucosa atrophic.  Cervix and uterus are absent.  No Pap was taken.  No adnexal masses.,Rectal:  Good sphincter tone.  No masses.  Stool guaiac negative.,Extremities:  No edema.  Pulses strong and equal.  Reflexes are intact.  Romberg and Babinski are negative.  She is oriented x 3.  Gait is normal.,ASSESSMENT:,  Middle-aged woman, status post hysterectomy, recent urinary tract infection.,PLAN:,  We will evaluate the adequacy of the therapy for her urinary tract infection with the urinalysis and culture.  I recommended mammogram and screening, hemoccult x 3, DEXA scan and screening, and she is fasting today.  We will screen with chem-12, lipid profile, and CBC because of her advancing age and notify of those results, as soon as they are available.  Continue same meds.  Recheck annually unless she has problems sooner.",
 A woman with a remote history of ileojejunal bypass followed by gastric banding to facilitate weight loss. , Consult - History and Phy., Wound Care Consult ,"TYPE OF CONSULTATION:,  Wound care consult.,HISTORY OF PRESENT ILLNESS:,  The patient is a 62-year-old woman with a past medical history significant for prior ileojejunal bypass for weight loss (1980) and then subsequent gastric banding (2002 Dr. X) who was transferred to this facility following a complicated surgical and postoperative course after takedown of the prior gastroplasty and bypass (07/08/2008, Dr. Y).  The patient has been followed by Cardiothoracic Surgery (Dr. Z) as an outpatient.  She had a history of daily postprandial vomiting, regurgitation, and heartburn.  She underwent a preop assessment of her GERD and postprandial vomiting including nuclear gastric emptying studies, which showed increased esophageal retention with normal gastric emptying.  Preoperative barium swallow demonstrated moderated esophageal dysmotility with incomplete emptying and a small hiatal hernia.  It was recommended that she undergo an exploratory laparotomy and possible redo fundoplication and possible gastrectomy.  She had already undergone multiple EGDs with dilatations without success.  She continued to have abdominal discomfort.,On 07/07/2008, she was admitted to hospital.  She underwent an exploratory laparotomy with esophagogastrectomy with esophagogastric anastomosis and Dor fundoplication, repair of hiatal hernia, small bowel resection x2 with primary anastomosis, extensive lysis of adhesions, insertion of a red-rubber J tube, and esophagogastroduodenoscopy.  She also had her ileojejunal bypass reversed.  Postoperatively, she was able to be extubated.  She was started on TPN, given the risk of not being able to tolerate enteral nutrition.  Her operative note confirmed that the stomach pouch was enlarged with outlet obstruction where the band was.  There was 2 hours of extensive lysis of adhesions.  It took 2 hours to identify the colon.  A defect was repaired in the transverse colon.  The bypass segment of the anastomosis was seen between the proximal jejunum and the distal ileum, which was divided and the proximal jejunum was reconnected to the atretic blind limb of the small bowel.  A red feeding tube was placed proximal to the anastomosis then tended to cross the anastomosis into the distal atretic small bowel for enteral feeds.  The hiatal hernia was repaired as noted.  The obstructed proximal gastric segment was resected.  An anastomosis was made between the proximal intestine and the stomach and distal esophagus with Dor fundoplication.  Omentectomy was performed due to devascularization.  The wound was able to be closed with staples.,Postoperatively, the patient was started on IV antibiotics.  She was able to be extubated.  However, on 07/14/2008, she coded with shortness of breath and chest pain.  She had respiratory failure, required endotracheal intubation and ICU management.  CT scan of the abdomen and the pelvis confirmed that she had an anastomotic leak.  Sputum cultures were positive ESBL Klebsiella.  Blood cultures were negative.  She was managed closely for sepsis with an elevated white cell count.  She was also febrile.  Her chest x-ray also showed left lower lobe consolidation.  She had scattered contrast material in the anterior abdomen and left upper quadrant due to the anastomotic leak.  Her antibiotics were adjusted.  Of note, the patient did have a JP drain placed out to the surface during her initial surgery.  Followup CT scan on 07/16/2008 confirmed the anastomosis as the likely site of a fistula, as there was continued extraluminal enteric contrast seen within anterior abdomen just beneath the peritoneum as well as the left upper quadrant adjacent to the spleen.  No enteric contrast was seen surrounding the patient's known GE junction leak.  A JP drain was noted at the posterior aspect of the fundoplication.  There was only a small amount of pelvic fluid.  Follow up scan again on 07/25/2008 showed no abscess formation.  On 08/05/2008, she did underwent an advancement of the #14 French red-rubber catheter feeding tube distal to the dehiscence of fistula into the distal small bowel.  At the beginning of the procedure, the catheter did appear to traverse through an anastomotic suture line in the wound dehiscence.  At some point during her course, the patient did undergo a second operative procedure, but I do not have any operative note at this time.  She subsequently was left with a large open abdominal defect, which was being managed by the wound care nurses, which at the time of her transfer to this facility was being managed with a ""wound manager system."" to low-continuous wall suction.  She was also transferred on tube feedings via the red rubber catheter 20 mL per hour.  She is only to have her tube feeds increased by 10 mL a week to ensure tolerance.  During her course, she was started on TPN.  She was transferred on TPN here.,At the time of her transfer, the patient was no longer on IV antibiotics.  She is on Fragmin for DVT prophylaxis.  During her course, she did have to undergo a tracheostomy.  This has subsequently been removed and this site is healing.  The tracheostomy was removed on 08/06/2008, I believe.  At the time of her tracheostomy (on 07/22/2008), the patient also underwent a flexible bronchoscopy, which showed some secretions in the left airway (right was clear), which did not appear to be purulent.  Of note also, pathology of her partial stomach resection showed Helicobacter pylori gastritis.  There were no other significant abnormalities noted in the small intestine or omentum.  On 08/11/2008, the patient was transferred to HealthSouth Monroeville LTAC for continued medical management, wound care, and rehab therapies.1,PAST MEDICAL HISTORY:  ,History of diabetes with peripheral neuropathy - on Lyrica and Cymbalta preoperatively.  History of hypothyroidism, history of B12 deficiency related to prior gastric surgeries, history of osteoarthritis, history of valvular disease (no details available), and cardiac arrhythmias.,PAST SURGICAL HISTORY:,  Status post bilateral total knee replacements, status post right rotator cuff repair, status post sigmoid colectomy - no further details available, status post right breast lumpectomy for benign lesion, history of bladder repair, status post hysterectomy/tonsillectomy/appendectomy, history of lumbar spinal fusion - no further details available.  History of MRSA in knees (previous surgery).,ALLERGIES:,  MULTIPLE INCLUDING TETRACYCLINE, ERYTHROMYCIN, MORPHINE, SULFA DRUGS, BETADINE, ADHESIVE TAPES, AND BANDAGE.,SOCIAL HISTORY:,  Prior to admission, the patient lived alone in a one storied dwelling.  She does have some equipment at home including a powered wheelchair, which she uses for longer distance.  She does have some ambulatory devices also.  She used to smoke, but quit about 10 years ago.  She smoked 1 to 2 packs a day from age 18 to 54.  She does not smoke.,FAMILY HISTORY:,  Remarkable for cardiac disease with early death of her father at age 43 and mother had Alzheimer.,REVIEW OF SYSTEMS: , According to her notes, the patient's weight 07/10/2008 was 256 pounds.  She has a BMI of 44 indicating morbid obesity.  She had had a significant weight loss in the 6 months prior to this of 7%.  As noted, she is on TPN and enteral feeds.  Her prealbumin level noted on 07/10/2008 was low at 7.  Prior to admission, the patient ate a regular diet, but had most likely weight loss and inadequate intake due to her chronic postprandial vomiting and esophageal dysmotility.  She is currently NPO with NG to suction.  The patient has no complaints of abdominal pain or discomfort at the time of this exam.  She was awake and alert.  MRSA screen on 07/14/2008 was negative.,PHYSICAL EXAMINATION:,General:  The patient is a morbidly obese woman, who is in no acute distress at the time of this exam.  She is lying comfortably on a low air loss mattress.  She had just been assisted with cleaning up and had no complaints of pain or discomfort.,Vital Signs:  Temperature is 98.9, pulse is 95, blood pressure is 123/69, and weight is 239 pounds.,HEENT:  Normocephalic/atraumatic.  Extraocular muscles intact.  Her mentation is good.,Neck:  Stout.  There is good range of motion.,Cor:  Regular rate and rhythm.  No murmurs appreciated.,Lungs:  Fairly clear anteriorly.,Abdomen:  Remarkable for a large open abdominal wound with a collection system in place covering the entire wound in midline.  There is a JP drain and a red rubber catheter present.  At present, the wound manager system is somewhat collapsed.  She had just been on her side.  It is connected to low continuous wall suction and removing fluid.,Musculoskeletal:  There is PICC line present in the right upper extremity.  No significant pedal edema.  Bilateral knee scars from prior surgeries.,Skin:  Reported intact at this time (not seen by me).,Neurological:  Cranial nerves II through XII grossly intact.  She is able to answer questions appropriately.  She is able to raise both arms over head.  She is able to raise her legs, but does need assistance.  She has fair bed mobility and requires much assistance for any turning.  Gait and transfers not tested.,SUMMARY: , In summary, the patient is a 62-year-old woman with a remote history of ileojejunal bypass followed by gastric banding to facilitate weight loss.  However, she subsequently developed reflux associated with postprandial vomiting, which was found to be secondary to esophageal retention.  On 07/08/2008, she underwent exploratory laparotomy with esophagogastrectomy with esophagogastric anastomosis and Dor fundoplication, hiatal hernia repair, small bowel resection, and lysis of adhesions.  She has had a fairly rocky postoperative course and has subsequently underwent some type of re-exploration after she was noted to have enteric contents draining from her JP drain with confirmed anastomotic leak.  She has undergone placement on an NG tube.  At present, she is on enteral feeds as well as TPN.  During all these, she also coded and had respiratory failure, requiring vent management, but this has improved.  Her trach has been removed and this site is healing.  From the wound standpoint, her largest problem at this point is the abdominal wound, which is open.  A wound manager system is currently in place, which is connected to low intermittent wall suction for drainage of the enteral contents still present. At present, the drainage is quite yellow in appearance.  She has no significant complaints of pain at this time.  At some point in her notes, there was mention of a negative pressure wound therapy being used to this wound, but this cannot be confirmed at this time.  I will plan to contact Dr. Z's office to see whether or not they wanted to resume a wound VAC system to this wound.  For now, we will continue with wound manager system.  We will need to keep track of in's and out's of drainage from this site.  Her fluid status will need to be monitored.  In an attempt to get her mobilized, we will need extra care to be sure that this wound dressing/management system stays in place.  She is eager and motivated to get mobilized.  We will plan to ask Plastic (Dr. A) to be involved in following this wound also.  Again, I will plan to call the surgeon's office for further directions.  She is to follow up with Dr. Z in 2 weeks.,Later in afternoon, I was able to reach Dr. Z's office.  I was called back by one of his nurses, who advised me that a wound VAC (negative pressure wound therapy) was not to be used on this wound.  They are using the wound manager system.  She did report that the confusion came about with the inability during her discharge summary dictation that she was only able to cite a ""wound VAC"" when describing the system that was in place on the patient.  She was using a formatted discharge summary program.  At present, the patient has had some leakage from the system.  According to my discussion with our wound care coordinator at this time, this system has been removed, with leakage repaired, and replaced with another wound manager system with suctioning continuing.  Pictures were also taken of the wound bed.  There were several staples apparently in place.  I was not present at the time that this system had to be changed.",
 1-year well child check., Consult - History and Phy., Well-Child Check - 4 ,"SUBJECTIVE:,  The patient presents with Mom and Dad for her 1-year well child check.  The family has no concerns stating the patient has been doing well overall since the last visit taking in a well-balanced diet consisting of formula transitioning to whole milk, fruits, vegetables, proteins and grains.  Normal voiding and stooling pattern.  No concerns with hearing or vision.  Growth and development:  Denver II normal passing all developmental milestones per age in areas of fine motor, gross motor, personal and social interaction as well as speech and language development.  See Denver II form in the chart.,PAST MEDICAL HISTORY:,  Allergies:  None.  Medications:  Tylenol this morning in preparation for vaccines and a multivitamin daily.,FAMILY SOCIAL HISTORY:,  Unchanged since last checkup.,REVIEW OF SYSTEMS:,  As per HPI; otherwise negative.,OBJECTIVE:,  Weight 24 pounds 1 ounce.  Height 30 inches.  Head circumference 46.5 cm.  Temperature afebrile.,General:  A well-developed, well-nourished, cooperative, alert and interactive 1-year-old white female smiling, happy and drooling.,HEENT:  Atraumatic, normocephalic.  Anterior fontanel is closed.  Pupils equally round and reactive.  Sclerae are clear.  Red reflex present bilaterally.  Extraocular muscles intact.  TMs are clear bilaterally.  Oropharynx:  Mucous membranes are moist and pink.  Good dentition.  Drooling and chewing with teething behavior today.  Neck is supple.  No lymphadenopathy.,Chest:  Clear to auscultation bilaterally.  No wheeze.  No crackles.  Good air exchange.,Cardiovascular:  Regular rate and rhythm.  No murmur.  Good pulses bilaterally.,Abdomen:  Soft, nontender.  Nondistended.  Positive bowel sounds.  No mass.  No organomegaly.,Genitourinary:  Tanner I female genitalia.  Femoral pulses equal bilaterally.  No rash.,Extremities:  Full range of motion.  No cyanosis, clubbing or edema.  Negative Ortolani and Barlow maneuver.,Back:  Straight.  No scoliosis.,Integument:  Warm, dry and pink without lesions.,Neurological:  Alert.  Good muscle tone and strength.  Cranial nerves II through XII are grossly intact.,ASSESSMENT AND PLAN:,1.  Well 1-year-old white female.,2.  Anticipatory guidance.  Reviewed growth, diet development and safety issues as well as immunizations.  Will receive Pediarix and HIB today.  Discussed risks and benefits as well as possible side effects and symptomatic treatment.  Will also obtain a screening CBC and lead level today via fingerstick and call the family with results as they become available.  Gave 1-year well child checkup handout to Mom and Dad.,3.  Follow up for the 15-month well child check or as needed for acute care.","consult - history and phy., well child check, denver ii, child check, checkup, check, child, "
 1-month-old for a healthy checkup - Well child check, Consult - History and Phy., Well-Child Check - 7 ,"SUBJECTIVE:,  This is a 1-month-old who comes in for a healthy checkup.  Mom says things are gone very well.  He is kind of acting like he has got a little bit of sore throat but no fevers.  He is still eating well.  He is up to 4 ounces every feeding.  He has not been spitting up.  Voiding and stooling well.,PAST MEDICAL HISTORY:,  Reviewed, very healthy.,CURRENT MEDICATIONS:,  None.,ALLERGIES TO MEDICINES:,  None.,DIETARY: , His formula fed on Enfamil Lipil.  Voiding and stooling well.  Growth chart reviewed with Mom.,DEVELOPMENTAL:,  He is starting to track with his eyes.  He is smiling a little bit, moving hands and feet symmetrically.,PHYSICAL EXAMINATION:,  In general well-developed, well-nourished male in no acute distress.,DERMATOLOGIC:  Without rash or lesion.,HEENT:  Head normocephalic and atraumatic.  Anterior fontanel soft and flat.  Eyes:  Pupils equal, round and reactive to light.  Extraocular movements intact.  Red reflexes present bilaterally.  Does appear to have conjugate gaze.  Ears:  Tympanic membranes are pink to gray, translucent, neutral position, normal light reflex and mobility.  Nares are patent, pink mucosa, moist.  Oropharynx clear with pink mucosa, normal moisture.,NECK:  Supple without masses.,CHEST:  Clear to auscultation and percussion with easy respirations and no accessory muscle use.,CARDIOVASCULAR:  Regular rate and rhythm without murmurs, rubs, heaves or gallops.,ABDOMEN:  Soft, nontender, nondistended without hepatosplenomegaly.,GU EXAM:  Normal Tanner I male.  Testes descended bilaterally.  No hernias noted.,EXTREMITIES:  Pink and warm.  Moving all extremities well.  No subluxation of the hips and leg creases appear symmetric.,NEUROLOGIC:  Alert, otherwise nonfocal.  2+ deep tendon reflexes at the knees.  Fixes and follows appropriately to both voice and face.,ASSESSMENT:,  Well child check.,PLAN:,1.  Diet, growth and safety discussed.,2.  Immunizations discussed and updated with hepatitis B.,3.  Return to clinic at two months of age.  Call if problems.", 
 A two week well-child check., Consult - History and Phy., Well-Child Check - 3 ,"SUBJECTIVE:,  Patient presents with Mom for first visit to the office for two week well-child check.  Mom has no concerns stating that patient has been doing well overall since dismissal from the hospital.  Nursing every two to three hours with normal voiding and stooling pattern.  She does have a little bit of some gas and Mom has been using Mylicon drops which are helpful.  She is burping well, hiccuping, sneezing and burping appropriately.  Growth and development:  Denver II normal passing all developmental milestones per age in areas of fine motor, gross motor, personal and social interaction and speech and language development.  See Denver II form in the chart.,PAST MEDICAL HISTORY:,  Mom reports uncomplicated pregnancy and delivery with prenatal care provided by Dr. Hoing.  Delivery at Newton Medical Center at 39 weeks, 5 days gestation.  Birth weight was 3160 g.  Length 49.5 cm.  Head circumference 33 cm.  Infant was delivered to 22-year-old A-positive mom who is G1 P0, now P1.  Infant did well after delivery and was dismissed to home with Mom the following day.  No other hospitalizations.  No surgeries.,ALLERGIES: , None.,MEDICATIONS:,  Gas drops p.r.n.,FAMILY HISTORY: , Significant for cardiovascular problems and hypertension as well as diabetes mellitus on the maternal side of the family.  History of cancer and asthma on the paternal side of the family.  Mom unsure of what type of cancer.,SOCIAL HISTORY:,  Patient lives at home with 22-year-old mother Aubrey Mizel and her parents Bud and Sue Mizel in Newton, Kansas.  Father of the baby, Shivanka Silva age 30, is a full-time student at WSU in Wichita, Kansas and does help with care of the newborn.  There is no smoking in the home.  Family does have one pet dog in home.,REVIEW OF SYSTEMS:,  As per HPI; otherwise negative.,OBJECTIVE:,Vital Signs:  Weight 7 pounds, 1-1/5 ounces.  Height 21 inches.  Head circumference 35.8 cm.  Temperature 97.7.,General:  Well-developed, well-nourished, cooperative, alert and interactive 2-week-old female in no acute distress.,HEENT:  Atraumatic, normocephalic.  Anterior fontanel soft and flat.  Pupils equal, round and reactive.  Sclerae clear.  Red reflex present bilaterally.  TMs clear bilaterally.  Oropharynx:  Mucous membranes moist and pink.,Neck:  Supple, no lymphadenopathy.,Chest:  Clear to auscultation bilaterally.  No wheeze or crackles.  Good air exchange.,Cardiovascular:  Regular rate and rhythm.  No murmur.  Good pulses bilaterally.,Abdomen:  Soft, nontender.  Nondistended.  Positive bowel sounds.  No masses or organomegaly.  Healing umbilicus.,GU:  Tanner I female genitalia.  Femoral pulses equal bilaterally.  No rash.,Extremities:  Full range of motion.  No cyanosis, clubbing or edema.  Negative Ortolani and Barlow maneuver.,Back:  Straight.  No scoliosis.  Some increased pigment over the sacrum.,Integument:  Warm, dry and pink without lesions.,Neurological:  Alert.  Good muscle tone and strength.,ASSESSMENT/PLAN:,1. Well 2-week-old mixed race Caucasian and Middle Eastern descent female.,2. Anticipatory guidance for growth and diet development and safety issues as well as immunizations and visitation schedule.  Gave two week well-child check handout to Mom.  Plan follow up for the one month well-child check or as needed for acute care.  Mom will call for feeding problems, breathing problems or fever.  Otherwise, plan to see at one month.",
 Consultation for wrist pain., Consult - History and Phy., Wrist Pain ,"CHIEF COMPLAINT:,  Left wrist pain.,HISTORY OF PRESENT PROBLEM:,","consult - history and phy., wrist pain, scapholunate, tenderness to palpation, three views, traumatic wrist injury, ulnar styloid nonunion, ulnar styloid, wrist, union, soreness, styloid, ulnar,"
 A 9-month well-child check., Consult - History and Phy., Well-Child Check - 2 ,"SUBJECTIVE:,  This 9-month-old Hispanic male comes in today for a 9-month well-child check.  They are visiting from Texas until the end of April 2004.  Mom says he has been doing well since last seen.  He is up-to-date on his immunizations per her report.  She notes that he has developed some bumps on his chest that have been there for about a week.  Two weeks ago he was diagnosed with left otitis media and was treated with antibiotics.  Mom says he has been doing fine since then.  She has no concerns about him.,PAST MEDICAL HISTORY:,  Significant for term vaginal delivery without complications.,MEDICATIONS: , None.,ALLERGIES:,  None.,SOCIAL HISTORY:,  Lives with parents.  There is no smoking in the household.,REVIEW OF SYSTEMS:,  Developmentally is appropriate.  No fevers.  No other rashes.  No cough or congestion.  No vomiting or diarrhea.  Eating normally.,OBJECTIVE:,  His weight is 16 pounds 9 ounces.  Height is 26-1/4 inches.  Head circumference is 44.75 cm.  Pulse is 124.  Respirations are 26.  Temperature is 98.1 degrees.  Generally, this is a well-developed, well-nourished, 9-month-old male, who is active, alert, and playful in no acute distress.,HEENT:  Normocephalic, atraumatic.  Anterior fontanel is soft and flat.  Tympanic membranes are clear bilaterally.  Conjunctivae are clear.  Pupils equal, round and reactive to light.  Nares without turbinate edema.  Oropharynx is nonerythematous.,NECK:  Supple, without lymphadenopathy, thyromegaly, carotid bruit, or JVD.,CHEST:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  Regular rate and rhythm, without murmur.,ABDOMEN:  Soft, nontender, nondistended, normoactive bowel sounds.  No masses or organomegaly to palpation.,GU:  Normal male external genitalia.  Uncircumcised penis.  Bilaterally descended testes.  Femoral pulses 2/4.,EXTREMITIES:  Moves all four extremities equally.  Minimal tibial torsion.,SKIN:  Without abnormalities other than five small molluscum contagiosum with umbilical herniation noted on chest.,ASSESSMENT/PLAN:,1.  Well-child check.  Is doing well.  Will recommend a followup well-child check at 1 year of age and immunizations at that time.  Discussed safety issues, including poisons, choking hazards, pet safety, appropriate nutrition with Mom.  She is given a parenting guide handout.,2.  Molluscum contagiosum.  Described the viral etiology of these.  Told her they are self limited, and we will continue to monitor at this time.,3.  Left otitis media, resolved.  Continue to monitor.  We will plan on following up in three months if they are still in the area, or p.r.n.","consult - history and phy., well-child check, otitis media, molluscum contagiosum, immunizations, developed, atraumatic, child, "
 Well child - Left lacrimal duct stenosis, Consult - History and Phy., Well-Child Check - 1 ,"CHIEF COMPLAINT:,  Well-child check.,HISTORY OF PRESENT ILLNESS:,  This is a 12-month-old female here with her mother for a well-child check.  Mother states she has been doing well.  She is concerned about drainage from her left eye.  Mother states she was diagnosed with a blocked tear duct on that side shortly after birth, and normally she has crusted secretions every morning.  She states it is worse when the child gets a cold.  She has been using massaging when she can remember to do so.  The patient is drinking whole milk without problems.  She is using solid foods three times a day.  She sleeps well without problems.  Her bowel movements are regular without problems.  She does not attend daycare.,DEVELOPMENTAL ASSESSMENT:,  Social:  She can feed herself with fingers.  She is comforted by parent’s touch.  She is able to separate and explore.  Fine motor:  She scribbles.  She has a pincer grasp.  She can drink from a cup.  Language:  She says dada.  She says one to two other words and she indicates her wants.  Gross motor:  She can stand alone.  She cruises.  She walks alone.  She stoops and recovers.,PHYSICAL EXAMINATION:,General:  She is alert, in no distress.,Vital signs:  Weight:  25th percentile.  Height:  25th percentile.  Head circumference:  50th percentile.,HEENT:  Normocephalic, atraumatic.  Pupils are equal, round, and reactive to light.  Left eye with watery secretions and crusted lashes.  Conjunctiva is clear.  TMs are clear bilaterally.  Nares are patent.  Mild nasal congestion present.  Oropharynx is clear.,Neck:  Supple.,Lungs:  Clear to auscultation.,Heart:  Regular.  No murmur.,Abdomen:  Soft.  Positive bowel sounds.  No masses.  No hepatosplenomegaly.,GU:  Female external genitalia.,Extremities:  Symmetrical.  Femoral pulses are 2+ bilaterally.  Full range of motion of all extremities.,Neurologic:  Grossly intact.,Skin:  Normal turgor.,Testing:  Hearing and vision assessments grossly normal.,ASSESSMENT:,1.  Well child.,2.  Left lacrimal duct stenosis.,PLAN:,  MMR #1 and Varivax #1 today.  VIS statements given to Mother after discussion.  Evaluation and treatment as needed with Dr. XYZ with respect to the blocked tear duct.  Anticipatory guidance for age.  She is to return to the office in three months.","consult - history and phy., well-child check, drainage, eye, lacrimal duct stenosis, lacrimal duct, mmr, varivax, vis statements, tear duct, lacrimal, percentile, mother, child, "
 Patient with morbid obesity., Consult - History and Phy., Weight Loss Evaluation ,"REASON FOR VISIT:,  Weight loss evaluation.,HISTORY OF PRESENT ILLNESS:,","consult - history and phy., medifast, obesity, weight loss, morbid obesity, weight loss evaluation, weight"
 Viral gastroenteritis.  Patient complaining of the onset of nausea and vomiting after she drank lots of red wine.  She denies any sore throat or cough.  She states no one else at home has been ill., Consult - History and Phy., Viral Gastroenteritis ,"HISTORY OF PRESENT ILLNESS: , Patient is a 40-year-old white female visiting with her husband complaining of the onset of nausea and vomiting approximately at 11 p.m. last night, after she states she drank ""lots of red wine.""  She states after vomiting, she felt ""fine through the night,"" but woke with more nausea and vomiting and diaphoresis.  She states she has vomited approximately 20 times today and has also had some slight diarrhea.  She denies any sore throat or cough.  She states no one else at home has been ill.  She has not taken anything for her symptoms.,MEDICATIONS: , Currently the patient is on fluoxetine for depression and Zyrtec for environmental allergies.,ALLERGIES: , SHE HAS NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY:,  The patient is married and is a nonsmoker, and lives with her husband, who is here with her.,REVIEW OF SYSTEMS,Patient denies any fever or cough.  She notes no blood in her vomitus or stool.  The remainder of her review of systems is discussed and all are negative.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS:  Temp is 37.6.  Other vital signs are all within normal limits.,GENERAL:  Patient is a healthy-appearing, middle-aged white female who is lying on the stretcher and appears only mildly ill.,HEENT:  Head is normocephalic and atraumatic.  Pharynx shows no erythema, tonsillar edema, or exudate.  NECK:  No enlarged anterior or posterior cervical lymph nodes.  There is no meningismus.,HEART:  Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS:  Clear without rales, rhonchi, or wheezes.,ABDOMEN:  Active bowel sounds.  Soft without any focal tenderness on palpation.  There are no masses, guarding, or rebound noted.,SKIN:  No rash.,EXTREMITIES:  No cyanosis, clubbing, or edema.,LABORATORY DATA: , CBC shows a white count of 12.9 with an elevation in the neutrophil count on differential.  Hematocrit is 33.8, but the indices are normochromic and normocytic.  BMP is remarkable for a random glucose of 147.  All other values are unremarkable.  LFTs are normal.  Serum alcohol is less than 5.,TREATMENT: , Patient was given 2 L of normal saline wide open as well as Compazine 5 mg IV x2 doses with resolution of her nausea.  She was given two capsules of Imodium with some apple juice, which she was able to keep down.  The patient did feel well enough to be discharged home.,ASSESSMENT:,  Viral gastroenteritis.,PLAN: , Rx for Compazine 10 mg tabs, dispense five, sig. one p.o. q.8h. p.r.n. for any recurrent nausea.  She was urged to use liquids only until the nausea has gone for 12 to 24 hours with slow advancement of her diet.  Imodium for any diarrhea, but no dairy products until the diarrhea has gone for at least 24 hours.  If she is unimproved in the next two days, she was urged to follow up with her PCP back home.","consult - history and phy., nausea, vomiting, viral gastroenteritis, wine, gastroenteritis, ill, "
" This is a 55-year-old female with weight gain and edema, as well as history of hypothyroidism.  She also has a history of fibromyalgia, inflammatory bowel disease, Crohn disease, COPD, and disc disease as well as thyroid disorder.", Consult - History and Phy., Weight Gain and Edema ,"HISTORY OF PRESENT ILLNESS:,  This is a 55-year-old female with a history of I-131-induced hypothyroidism years ago who presents with increased weight and edema over the last few weeks with a 25-pound weight gain.  She also has a history of fibromyalgia, inflammatory bowel disease, Crohn disease, COPD, and disc disease as well as thyroid disorder.  She has noticed increasing abdominal girth as well as increasing edema in her legs.  She has been on Norvasc and lisinopril for years for hypertension.  She has occasional sweats with no significant change in her bowel status.  She takes her thyroid hormone apart from her Synthroid.  She had been on generic for the last few months and has had difficulty with this in the past.,MEDICATIONS: , Include levothyroxine 300 mcg daily, albuterol, Asacol, and Prilosec.  Her amlodipine and lisinopril are on hold.,ALLERGIES:,  Include IV DYE, SULFA, NSAIDS, COMPAZINE, and DEMEROL.,PAST MEDICAL HISTORY:,  As above includes I-131-induced hypothyroidism, inflammatory bowel disease with Crohn, hypertension, fibromyalgia, COPD, and disc disease.,PAST SURGICAL HISTORY: , Includes a hysterectomy and a cholecystectomy.,SOCIAL HISTORY: , She does not smoke or drink alcohol.,FAMILY HISTORY: , Positive for thyroid disease but the sister has Graves disease, as well a sister with Hashimoto thyroiditis.,REVIEW OF SYSTEMS: , Positive for fatigue, sweats, and weight gain of 20 pounds.  Denies chest pain or palpitations.  She has some loosening stools, but denies abdominal pain.  Complains of increasing girth and increasing leg swelling.,PHYSICAL EXAMINATION:,GENERAL:  She is an obese female.,VITAL SIGNS:  Blood pressure 140/70 and heart rate 84.  She is afebrile.,HEENT:  She has no periorbital edema.  Extraocular movements were intact.  There was moist oral mucosa.,NECK:  Supple.  Her thyroid gland is atrophic and nontender.,CHEST:  Good air entry.,CARDIOVASCULAR:  Regular rate and rhythm.,ABDOMEN:  Benign.,EXTREMITIES:  Showed 1+ edema.,NEUROLOGIC:  She was awake and alert.,LABORATORY DATA:,  TSH 0.28, free T4 1.34, total T4 12.4 and glucose 105.,IMPRESSION/PLAN:,  This is a 55-year-old female with weight gain and edema, as well as history of hypothyroidism.  Hypothyroidism is secondary to radioactive iodine for Graves disease many years ago.  She is clinically and biochemically euthyroid.  Her TSH is mildly suppressed, but her free T4 is normal and with her weight gain I will not decrease her dose of levothyroxine.  I will continue on 300 mcg daily of Synthroid.  If she wanted to lose significant weight, I shall repeat thyroid function test in six weeks' time to ensure that she is not hyperthyroid.",
 Blood in urine - Transitional cell cancer of the bladder., Consult - History and Phy., Urology Consut - 1 ,"CHIEF COMPLAINT:,",
 Ventricular ectopy and coronary artery disease.   He is a 69-year-old gentleman with established history coronary artery disease and peripheral vascular disease with prior stent-supported angioplasty., Consult - History and Phy., Ventricular Ectopy - Consult ,"REASON FOR CONSULTATION:,  Ventricular ectopy and coronary artery disease.,HISTORY OF PRESENT ILLNESS:  ,I am seeing the patient upon the request of Dr. Y.  The patient is a very well known to me.  He is a 69-year-old gentleman with established history coronary artery disease and peripheral vascular disease with prior stent-supported angioplasty.  The patient had presented to the hospital after having coughing episodes for about two weeks on and off, and seemed to have also given him some shortness of breath.  The patient was admitted and being treated for pneumonia, according to him.  The patient denies any chest pain, chest pressure, or heaviness.  Denies any palpitations, fluttering, or awareness of heart activity.  However, on monitor, he was noticed to have PVCs random.  He had run off three beats consecutive one time at 12:46 p.m. today.  The patient denied any awareness of that or syncope.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No fever or chills.,EYES:  No visual disturbances.,ENT:  No difficulty swallowing.,CARDIOVASCULAR:  Prior history of chest discomfort in 08/2009 with negative stress study.,RESPIRATORY:  Cough and shortness of breath.,MUSCULOSKELETAL:  Positive for arthritis and neck pain.,GU:  Unremarkable.,NEUROLOGIC:  Otherwise unremarkable.,ENDOCRINE:  Otherwise unremarkable.,HEMATOLOGIC:  Otherwise unremarkable.,ALLERGIC:  Otherwise unremarkable.,PAST MEDICAL HISTORY:,1.  Positive for coronary artery disease since 2002.,2.  History of peripheral vascular disease for over 10 years.,3.  COPD.,4.  Hypertension.,PAST SURGICAL HISTORY:,  Right fem-popliteal bypass about eight years ago, neck fusion in the remote past, stent-supported angioplasty to unknown vessel in the heart.,MEDICATIONS AT HOME:,1.  Aspirin 81 mg daily.,2.  Clopidogrel 75 mg daily.,3.  Allopurinol 100 mg daily.,4.  Levothyroxine 100 mcg a day.,5.  Lisinopril 10 mg a day.,6.  Metoprolol 25 mg a day.,7.  Atorvastatin 10 mg daily.,ALLERGIES: , THE PATIENT DOES HAVE ALLERGY TO MEDICATION.  HE SAID HE CANNOT TAKE ASPIRIN BECAUSE OF INTOLERANCE FOR HIS STOMACH AND STOMACH UPSET, BUT NO TRUE ALLERGY TO ASPIRIN.,FAMILY HISTORY:,  No history of premature coronary artery disease.  One daughter has early onset diabetes and one child has asthma.,SOCIAL HISTORY: , He is married and retired.  He has nine children, 25 grandchildren.  He smokes one pack per day.  He smoked 50 pack years and had no intention of quitting according to him.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature of 97, heart rate of 90, blood pressure of 187/105.,HEENT:  Normocephalic and atraumatic.  No thyromegaly or lymphadenopathy.,NECK:  Supple.,CARDIOVASCULAR:  Upstroke is normal.  Distal pulse symmetrical.  Heart regular with a normal S1 with normally split S2.  There is an S4 at the apex.,LUNGS:  With decreased air entry.  No wheezes.,ABDOMINAL:  Benign.  No masses.,EXTREMITIES:  No edema, cyanosis, or clubbing.,NEUROLOGIC:  Awake, alert, and oriented x3.  No focal deficits.,IMAGING STUDIES: , Echocardiogram on 08/26/2009, showed mild biatrial enlargement, normal thickening of the left ventricle with mildly dilated ventricle, EF of 40%, mild mitral regurgitation, and diastolic dysfunction, grade 2.",
" The patient with recurrent nongranulomatous anterior iritis and most recently, pain in  left eye associated with headache and photophobia.", Consult - History and Phy., Uveitis ,"PAST MEDICAL HISTORY: , Significant for GERD, history of iron deficiency anemia, and asthma for which she takes an inhaler.,REVIEW OF SYSTEMS:,  Positive for only for left knee arthritis.  She has no exposure to tuberculosis or syphilis, she has no mouth or genital ulcers.  She has no skin rashes.  She has no connective tissue disorders.,PAST OCULAR HISTORY: , Significant for cataract and glaucoma surgery of the right eye.,PHYSICAL EXAMINATION: , On examination, visual acuity measures hand motions on the right and 20/25 in the left.  There is an afferent pupillary defect on the right.  On examination, there is a right hypertropia.  There is dense anterior chamber inflammation on the right eye with a stagnant aqueous.  There is either neovascularization on the iris or reactive iris vessels, it is difficult to discern.  This seems to be complete iris synechia to the anterior lens capsule.  There is a posterior chamber intraocular lens with an inflammatory debris on the anterior surface.  The anterior chamber appears narrow.  On the left, there is also dense inflammation at 4+ cell.  There is 1+ nuclear sclerosis.  Dilated fundus examination cannot be performed on the right secondary to intense inflammation.  On the left, there is no evidence of active posterior uveitis.  There is some inferior vitreous debris.,ASSESSMENT/PLAN:,  Chronic bilateral recurrent nongranulomatous diffuse uveitis.  Currently, there is very severe right eye inflammation and severe left eye.  I discussed at length with the patient that this will likely take an oral steroid to quite her down.  Since she has only one seeing eye, I am anxious to obtain a decreased inflammation as soon as possible.  She has been on oral steroids in the past.  We also discussed, considering the aggressive recurrent nature of this process, it is likely we will have to consider a steroid sparing agent to maintain longer term control of this recurrent process so that we do not use visual acuity in the left.  I anticipate we will likely start methotrexate in the near future.  In this acute phase, I have recommended oral steroids at a dose of 60 mg a day, hourly topical Pred Forte as well as atropine sulfate.  We will watch her closely in clinic.  I am sending a copy of this dictation to her primary care doctor, she said she has had a negative HLA-B27, rheumatoid factor, and ANA in the past.  At this stage, to be thorough I would ask Dr. X to assist us in repeating her chest x-ray, PPD if not current, and an RPR.  Additionally, in anticipation of need for methotrexate, it would be helpful to have a full liver function profile as well as hepatitis B and hepatitis C.","consult - history and phy., iritis, nongranulomatous, uveitis, eye inflammation, photophobia, recurrent nongranulomatous anterior iritis, headache and photophobia, anterior chamber, anterior, chamber, inflammation, "
" This is a 66-year-old male with signs and symptoms of benign prostatic hypertrophy, who has had recurrent urinary retention since his kidney transplant.  He passed his fill and pull study and was thought to self-catheterize in the event that he does incur urinary retention again.", Consult - History and Phy., Urinary Retention ,"CHIEF COMPLAINT:,  Urinary retention.,HISTORY OF PRESENT ILLNESS: , This is a 66-year-old gentleman status post deceased donor kidney transplant in 12/07, who has had recurrent urinary retention issues since that time.  Most recently, he was hospitalized on 02/04/08 for acute renal insufficiency, which was probably secondary to dehydration.  He was seen by urology again at this visit for urinary retention.  He had been seen by urology during a previous hospitalization and he passed his voiding trial at the time of his stent removal on 01/22/08.  Cystoscopy showed at that time obstructive BPH.  He was started on Flomax at the time of discharge from the hospital.  During the most recent readmission on 02/04/08, he went back into urinary retention and he had had a Foley placed at the outside hospital.,REVIEW OF SYSTEMS:,  Positive for blurred vision, nasal congestion, and occasional constipation.  Denies chest pain, shortness of breath or any rashes or lesions.  All other systems were reviewed and found to be negative.,PAST MEDICAL HISTORY:,1.  End-stage renal disease, now status post deceased donor kidney transplant in 12/07.,2.  Hypertension.,3.  History of nephrolithiasis.,4.  Gout.,5.  BPH.,6.  DJD.,PAST SURGICAL HISTORY:,1.  Deceased donor kidney transplant in 12/07.,2.  Left forearm and left upper arm fistula placements.,FAMILY HISTORY:  ,Significant for mother with an unknown type of cancer, possibly colon cancer or lung and prostate problems on his father side of the family.  He does not know whether his father side of the family had any history of prostate cancer.,HOME MEDICATIONS:,1.  Norvasc.,2.  Toprol 50 mg.,3.  Clonidine 0.2 mg.,4.  Hydralazine.,5.  Flomax.,6.  Allopurinol.,7.  Sodium bicarbonate.,8.  Oxybutynin.,9.  Coumadin.,10.  Aspirin.,11.  Insulin 70/30.,12.  Omeprazole.,13.  Rapamune.,14.  CellCept.,15.  Prednisone.,16.  Ganciclovir.,17.  Nystatin swish and swallow.,18.  Dapsone.,19.  Finasteride.,ALLERGIES:,  No known drug allergies.,PHYSICAL EXAMINATION:,GENERAL:  This is a well-developed, well-nourished male, in no acute distress.  VITAL SIGNS:  Temperature 98, blood pressure 129/72, pulse 96, and weight 175.4 pounds.  LUNGS:  Clear to auscultation bilaterally.  CARDIOVASCULAR:  Regular rate and rhythm with a 3/6 systolic murmur.  ABDOMEN:  Right lower quadrant incision site scar well healed.  Nontender to palpation.  Liver and spleen not enlarged.  No hernias appreciated.  PENIS:  Normal male genitalia.  No lesions appreciated on the penis.  Previous DRE showed the prostate of approximately 40 grams and no nodules.  Foley in place and draining clear urine.,The patient underwent fill and pull study, in which his bladder tolerated 120 ml of sterile water passively filling his bladder.  He spontaneously voided without the Foley 110 mL.,ASSESSMENT AND PLAN:  ,This is a 66-year-old male with signs and symptoms of benign prostatic hypertrophy, who has had recurrent urinary retention since the kidney transplant in 12/07.  He passed his fill and pull study and was thought to self-catheterize in the event that he does incur urinary retention again.  We discussed with Mr. Barker that he has a urologist closer to his home and he lives approximately 3 hours away; however, he desires to continue follow up with the urology clinic at MCG and has been set up for followup in 6 weeks.  He was also given a prescription for 6 months of Flomax and Proscar.  He did not have a PSA drawn today as he had a catheter in place, therefore his PSA could be falsely elevated.  He will have PSA level drawn either just before his visit for followup.",
 The patient's main complaint is vertigo. The patient is having recurrent attacks of vertigo and imbalance over the last few years with periods of free symptoms and no concurrent tinnitus or hearing impairment., Consult - History and Phy., Vertigo Consult ,"Assessment for peripheral vestibular function follows:,OTOSCOPY:, showed bilateral intact tympanic membranes with central  Weber test and bilateral positive Rinne.,ROMBERG TEST:, maintained postural stability.,FRENZEL GLASSES EXAMINATION:, no spontaneous, end gaze nystagmus.,HEAD SHAKING:, No provocation nystagmus.,DIX-HALLPIKE:, showed no positional nystagmus excluding benign paroxysmal positional vertigo.,VESTIBULOCULAR REFLEX [HALMAGYI TEST]:, showed corrective saccades giving the impression of decompensated vestibular hypofunction.,IMPRESSION: , The patient was advised to continue her vestibular rehabilitation exercises and the additional medical treatment of betahistine at 24 mg dose bid.  ,PLAN:  ,Planned for  electronystagmography to document the degree of vestibular hypofunction.,","consult - history and phy., electronystagmography, hearing impairment, imbalance, tinnitus, hypofunction, nystagmus, vestibular, vertigo,"
 Right distal ureteral calculus.  The patient had hematuria and a CT urogram showing a 1 cm non-obstructing calcification in the right distal ureter.  He had a KUB also showing a teardrop shaped calcification apparently in the right lower ureter.  , Consult - History and Phy., Ureteral Calculus - Consult ,"CHIEF COMPLAINT: , Right distal ureteral calculus.,HISTORY OF PRESENT ILLNESS:  ,The patient had hematuria and a CT urogram at ABC Radiology on 01/04/07 showing a 1 cm non-obstructing calcification in the right distal ureter.  He had a KUB also showing a teardrop shaped calcification apparently in the right lower ureter.  He comes in now for right ureteroscopy, Holmium laser lithotripsy, right ureteral stent placement.,PAST MEDICAL HISTORY:,1.  Prostatism.,2.  Coronary artery disease.,PAST SURGICAL HISTORY:,1.  Right spermatocelectomy.,2.  Left total knee replacement in 1987.,3.  Right knee in 2005.,MEDICATIONS:,1.  Coumadin 3 mg daily.,2.  Fosamax.,3.  Viagra p.r.n.,ALLERGIES: , NONE.,REVIEW OF SYSTEMS:,  CARDIOPULMONARY:  No shortness of breath or chest pain.  GI:  No nausea, vomiting, diarrhea or constipation.  GU:  Voids well.  MUSCULOSKELETAL:  No weakness or strokes.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL APPEARANCE:  An alert male in no distress.,HEENT:  Grossly normal.,NECK:  Supple.,LUNGS:  Clear.,HEART:  Normal sinus rhythm.  No murmur or gallop.,ABDOMEN:  Soft.  No masses.,GENITALIA:  Normal penis.  Testicles descended bilaterally.,RECTAL:  Examination benign.,EXTREMITIES:  No edema.,IMPRESSION: , Right distal ureteral calculus.,PLAN: , Right ureteroscopy, ureteral lithotripsy.  Risks and complications discussed with the patient.  He signed a true informed consent.  No guarantees or warrantees were given.",
 The patient is having recurrent attacks of imbalance rather than true vertigo following the history of head trauma and loss of consciousness.  Symptoms are not accompanied by tinnitus or deafness. , Consult - History and Phy., Vertigo Consult - 1 ,"Patient had a normal MRI and normal neurological examination on August 24, 2010.,Assessment for peripheral vestibular function follows:,Most clinical tests were completed with difficulty and poor cooperation.,OTOSCOPY:, showed bilateral intact tympanic membranes with central  Weber test and bilateral positive Rinne.,ROMBERG TEST:, maintained postural stability with difficulty.,Frenzel glasses examination: no spontaneous, end gaze nystagmus.,DIX-HALLPIKE:, showed no positional nystagmus excluding benign paroxysmal positional vertigo.,HEAD SHAKING AND VESTIBULOCULAR REFLEX [HALMAGYI TEST]:, were done with difficulty a short corrective saccades may give the possibility if having a decompensated vestibular hypofunction. ,IMPRESSION:, Decompensation vestibular hypofunction documented by further electronystagmography and caloric testing. ,PLAN:,  Booked for electronystagmography and advised to continue with her vestibular rehabilitation exercises, in addition to supportive medical treatment in the form of betahistine 24 mg twice a day.","consult - history and phy., tinnitus, deafness, imbalance, nystagmus, hypofunction, electronystagmography, vertigo, vestibular,"
 History and Physical for a 69-year-old Caucasian male complaining of difficulty breathing for 3 days., Consult - History and Phy., Trouble Breathing - H&P  ,"CHIEF COMPLAINT: , ""I have had trouble breathing for the past 3 days"",HISTORY: , 69-year-old Caucasian male complaining of difficulty breathing for 3 days.  He also states that he has been coughing accompanying with low-grade type fever.  He also admits to having intermittent headaches and bilateral chest pain that does not radiate to upper extremities and jaws but worse with coughing.  Patient initially had this type of episodes about 10 months ago but has intermittently getting worse since.,PMH: , DM, HTN, COPD, CAD,PSH:  ,CABG, appendectomy, tonsillectomy,FH:,  Non-contributory,SOCH: , Divorce and live alone, retired postal worker, has 3 children, 7 grandchildren.  He smokes 1 pack a day of Newport for 30 years and is a social drinker.  He denies any illicit drug use.,TRAVEL HISTORY: , Denies any recent travel overseas,ALLERGIES: , Denies any drug allergies,HOME MEDICATIONS:,  Advair 1 puff bid Lisinopril 10 mg qd Lopressor 50 mg bid Aspirin 81 mg qd Plavix 75 mg qd Multivitamins Feso4 1 tab qd Colace 100 mg qd,REVIEW OF SYSTEMS REVEALS:,  Same as above,PHYSICAL EXAM:,Vital signs are:  Temp.  99.3 F / BP 138/92, Resp.  22, P 88,General:  Patient is in mild acute respiratory distress,HEENT:,Head:  Atraumatic, normocephalic,,Eyes:",
 Viral upper respiratory infection (URI) with sinus and eustachian congestion.  Patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain. , Consult - History and Phy., URI & Eustachian Congestion ,"HISTORY OF PRESENT ILLNESS: , Patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain.  She has had a dry cough and a fever as high as 100, but this has not been since the first day.  She denies any vomiting or diarrhea.  She did try some Tylenol Cough and Cold followed by Tylenol Cough and Cold Severe, but she does not think that this has helped.,FAMILY HISTORY: , The patient's younger sister has recently had respiratory infection complicated by pneumonia and otitis media.,REVIEW OF SYSTEMS:,  The patient does note some pressure in her sinuses.  She denies any skin rash.,SOCIAL HISTORY:,  Patient lives with her mother, who is here with her.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS:  Temp is 38.1, pulse is elevated at 101, other vital signs are all within normal limits.  Room air oximetry is 100%.,GENERAL:  Patient is a healthy-appearing, white female, adolescent who is sitting on the stretcher, and appears only mildly ill.,HEENT:  Head is normocephalic, atraumatic.  Pharynx shows no erythema, tonsillar edema, or exudate.  Both TMs are easily visualized and are clear with good light reflex and no erythema.  Sinuses do show some mild tenderness to percussion.,NECK:  No meningismus or enlarged anterior/posterior cervical lymph nodes.,HEART:  Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS:  Clear without rales, rhonchi, or wheezes.,SKIN:  No rash.,ASSESSMENT:,  Viral upper respiratory infection (URI) with sinus and eustachian congestion.,PLAN:,  I did educate the patient about her problem and urged her to switch to Advil Cold & Sinus for the next three to five days for better control of her sinus and eustachian discomfort.  I did urge her to use Afrin nasal spray for the next three to five days to further decongest her sinuses.  If she is unimproved in five days, follow up with her PCP for re-exam.","consult - history and phy., upper respiratory infection, eustachian congestion, erythema, uri, nasal, cough, eustachian, respiratory, sinus, congestion, infection, tonsillar"
 Thyroid mass diagnosed as papillary carcinoma.  The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary.  The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis., Consult - History and Phy., Thyroid Mass Consult ,"REASON FOR CONSULTATION: , Thyroid mass diagnosed as papillary carcinoma.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 16-year-old young lady, who was referred from the Pediatric Endocrinology Department by Dr. X for evaluation and surgical recommendations regarding treatment of a mass in her thyroid, which has now been proven to be papillary carcinoma on fine needle aspiration biopsy.  The patient's parents relayed that they first noted a relatively small but noticeable mass in the middle portion of her thyroid gland about 2004.  An ultrasound examination had reportedly been done in the past and the mass is being observed.  When it began to enlarge recently, she was referred to the Pediatric Endocrinology Department and had an evaluation there.  The patient was referred for fine needle aspiration and the reports recently returned a diagnosis of papillary thyroid carcinoma.  The patient has not had any hoarseness, difficulty swallowing, or any symptoms of endocrine dysfunction.  She has no weight changes consistent with either hyper or hypothyroidism.  There is no family history of thyroid cancer in her family.  She has no notable discomfort with this lesion.  There have been no skin changes.  Historically, she does not have a history of any prior head and neck radiation or treatment of any unusual endocrinopathy.,PAST MEDICAL HISTORY:,  Essentially unremarkable.  The patient has never been hospitalized in the past for any major illnesses.  She has had no prior surgical procedures.,IMMUNIZATIONS: , Current and up to date.,ALLERGIES: , She has no known drug allergies.,CURRENT MEDICATIONS:  ,Currently taking no routine medications.  She describes her pain level currently as zero.,FAMILY HISTORY: , There is no significant family history, although the patient's father does note that his mother had a thyroid surgery at some point in life, but it was not known whether this was for cancer, but he suspects it might have been for goiter.  This was done in Tijuana.  His mom is from central portion of Mexico.  There is no family history of multiple endocrine neoplasia syndromes.,SOCIAL HISTORY:  ,The patient is a junior at Hoover High School.  She lives with her mom in Fresno.,REVIEW OF SYSTEMS: , A careful 12-system review was completely normal except for the problems related to the thyroid mass.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a 55.7 kg, nondysmorphic, quiet, and perhaps slightly apprehensive young lady, who was in no acute distress.  She was alert and oriented x3 and had an appropriate affect.,HEENT:  The head and neck examination is most significant.  There is mild amount of facial acne.  The patient's head, eyes, ears, nose, and throat appeared to be grossly normal.,NECK:  There is a slightly visible midline bulge in the region of the thyroid isthmus.  A firm nodule is present there, and there is also some nodularity in the right lobe of the thyroid.  This mass is relatively hard, slightly fixed, but not tethered to surrounding tissues, skin, or muscles that I can determine.  There are some shotty adenopathy in the area.  No supraclavicular nodes were noted.,CHEST:  Excursions are symmetric with good air entry.,LUNGS:  Clear.,CARDIOVASCULAR:  Normal.  There is no tachycardia or murmur noted.,ABDOMEN:  Benign.,EXTREMITIES:  Extremities are anatomically correct with full range of motion.,GENITOURINARY:  External genitourinary exam was deferred at this time and can be performed later during anesthesia.  This is same as too for her rectal examination.,SKIN:  There is no acute rash, purpura, or petechiae.,NEUROLOGIC:  Normal and no focal deficits.  Her voice is strong and clear.  There is no evidence of dysphonia or vocal cord malfunction.,DIAGNOSTIC STUDIES: , I reviewed laboratory data from the Diagnostics Lab, which included a mild abnormality in the AST at 11, which is slightly lower than the normal range.  T4 and TSH levels were recorded as normal.  Free thyroxine was normal, and the serum pregnancy test was negative.  There was no level of thyroglobulin recorded on this.  A urinalysis and comprehensive metabolic panel was unremarkable.  A chest x-ray was obtained, which I personally reviewed.  There is a diffuse pattern of tiny nodules in both lungs typical of miliary metastatic disease that is often seen in patients with metastatic thyroid carcinoma.,IMPRESSION/PLAN: , The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary.  The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis and is unfortunate in that it generally means a more advanced stage of disease.  I spent approximately 30 minutes with the patient and her family today discussing the surgical aspects of the treatment of this disease.  During this time, we talked about performing a total thyroidectomy to eradicate as much of the native thyroid tissue and remove the primary source of the cancer in anticipation of radioactive iodine therapy.  We talked about sentinel node dissection, and we spent significant amount of time talking about the possibility of hypoparathyroidism if all four of the parathyroid glands were damaged during this operation.  We also discussed the recurrent laryngeal and external laryngeal branches of the nerve supplying the vocal cord function and how they cane be damaged during the thyroidectomy as well.  I answered as many of the family's questions as they could mount during this stressful time with this recent information supplied to them.  I also did talk to them about the chest x-ray pattern, which was complete __________ as the film was just on the day prior to my clinic visit.  This will have some impact on the postoperative adjunctive therapy.  The radiologist commented about the risk of pulmonary fibrosis and the use of radioactive iodine in this situation, but it seems likely that is going to be necessary to attempt to treat this disease in the patient's case.  I did discuss with them the possibility of having to take large doses of calcium and vitamin D in the event of hypoparathyroidism if that does happen, and we also talked about possibly sparing parathyroid tissue and reimplanting it in a muscle belly either in the neck or forearm if that becomes a necessity.  All of the family's questions have been answered.  This is a very anxious and anxiety provoking time in the family.  I have made every effort to get the patient under schedule within the next 48 hours to have this operation done.  We are tentatively planning on proceeding this upcoming Friday afternoon with total thyroidectomy.",
 Patient referred for evaluation of tracheostomy tube placement and treatment recommendations., Consult - History and Phy., Tracheostomy Tube Consult ,"HISTORY:  ,I had the pleasure of meeting and evaluating the patient today, referred for evaluation of tracheostomy tube placement and treatment recommendations.  As you are well aware, he is a pleasant 64-year-old gentleman who unfortunately is suffering from end-stage COPD, who required tracheostomy tube placement about three months ago when being treated for acute exacerbation of COPD and having difficulty coming off ventilatory support.  He now resides in an extended care facility with a capped tracheostomy tube, and he unfortunately states he has had not had to use the tracheostomy tube since his discharge and admission to the extended care facility.  He requires constant oxygen administration and has been having no problems with shortness of breath, worsening, requiring opening the tracheostomy tube site.  He states there has been some tenderness associated with the tracheostomy tube and difficulty with swallowing and he wishes to have it removed.  Apparently there is no history of any airway issues while sleeping or need for uncapping the tube and essentially the tube has just remained present for months capped in his neck.  No history of any previous tracheostomy tube insertion.,PAST MEDICAL HISTORY: , COPD, history of hypercarbic hypoxemia, history of coronary artery disease, history of previous myocardial infarction, and history of liver cirrhosis secondary to alcohol use.,PAST SURGICAL HISTORY:  ,Tonsillectomy, adenoidectomy, cholecystectomy, appendectomy, hernia repair, and tracheostomy.,FAMILY HISTORY:  ,Strong for heart disease, coronary artery disease, hypertension, diabetes mellitus, and cerebrovascular accident.,CURRENT MEDICATIONS:,  Prevacid, folic acid, aspirin, morphine sulfate, Pulmicort, Risperdal, Colace, clonazepam, Lotrisone, Roxanol, Ambien, Zolpidem tartrate, simethicone, Robitussin, and prednisone.,ALLERGIES: , Nitroglycerin.,SOCIAL HISTORY: , The patient has a 25-year-smoking history, which I believe is quite heavy and he has a significant alcohol use in the past.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Age 64, blood pressure is 110/78, pulse 96, and temperature is 98.6.,GENERAL:  The patient was examined in his wheelchair, resting comfortably, in no acute distress.,HEAD:  Normocephalic.  No masses or lesions noted.,FACE:  No facial tenderness or asymmetry noted.,EYES:  Pupils are equal, round and reactive to light and accommodation bilaterally.  Extraocular movements are intact bilaterally.,EARS:  The tympanic membranes are intact bilaterally with a good light reflex.  The external auditory canals are clear with no lesions or masses noted.  Weber and Rinne tests are within normal limits.,NOSE:  The nasal cavities are patent bilaterally.  The nasal septum is midline.  There are no nasal discharges.  No masses or lesions noted.,THROAT:  The oral mucosa appears healthy.  Dental hygiene is maintained well.  No oropharyngeal masses or lesions noted.  No postnasal drip noted.,NECK:  The patient has a stable-appearing tracheostomy tube site and the stoma appears to be without signs of infection.  The previous incision was vertical in nature and there is no hypertrophic scar formation.  No adenopathy noted.  No stridor noted.,NEUROLOGIC:  Cranial nerve VII intact bilaterally.  No signs of tremor.,LUNGS:  Diminished breath sounds in all four quadrants.  No wheezes noted.,HEART:  Regular rate and rhythm.,PROCEDURE: , Limited bronchoscopy and then fiberoptic laryngoscopy.,IMPRESSION:  ,1.  End-stage chronic obstructive pulmonary disease with a history of respiratory failure requiring mechanical ventilatory support with tracheostomy tube placement.,2.  Difficulty tolerating tracheostomy tubes secondary to swallow discomfort and neck irritation with no further need for tracheostomy tube over the past few months with the patient tolerating capped tracheostomy tube 24 hours a day.,3.  History of coronary artery disease.,4.  History of myocardial infarction.,5.  History of cirrhosis of liver.,RECOMMENDATIONS: , I discussed with the patient in detail after fiberoptic laryngoscopy and limited bronchoscopy was performed in the office whether or not to pull out the tracheostomy tube.  His vocal cords moved well, and I do not see any signs of granuloma or airway obstruction either in the supraglottic or subglottic region, and I felt he would tolerate the tube being removed with close monitoring by nursing at his extended care facility.  I did impress the fact that I believe he probably will have other events requiring airway support, which could include intubation, and if the intubation is prolonged a tracheostomy may be needed.  Creation of a long-term tracheostoma may be beneficial whereas the patient would not need such a long tracheostomy tube, and I informed the patient there are other options other than the tube he has at the present time.  The patient still wished to have the tube removed and he is aware he may need to have it replaced or he may have trouble with the area healing or scarring or he could end up having an emergent airway situation with the tube gone, but wishes to have it removed, and I did remove it today.  Dressing was applied and we will see him back next week to make sure everything is healing properly.",
" Patient experienced a single episode of his vision decreasing.  During the episode, he felt nauseated and possibly lightheaded.  His wife was present and noted that he looked extremely pale.", Consult - History and Phy., TIA & Lumbar Stenosis ,"CHIEF COMPLAINT: , Transient visual loss lasting five minutes.,HISTORY OF PRESENT ILLNESS: , This is a very active and pleasant 82-year-old white male with a past medical history significant for first-degree AV block, status post pacemaker placement, hypothyroidism secondary to hyperthyroidism and irradiation, possible lumbar stenosis.  He reports he experienced a single episode of his vision decreasing ""like it was compressed from the top down with a black sheet coming down"".  The episode lasted approximately five minutes and occurred three weeks ago while he was driving a car.  He was able to pull the car over to the side of the road safely.  During the episode, he felt nauseated and possibly lightheaded.  His wife was present and noted that he looked extremely pale and ashen during the episode.  He went to see the Clinic at that time and received a CT scan, carotid Dopplers, echocardiogram, and neurological evaluation, all of which were unremarkable.  It was suggested at that time that he get a CT angiogram since he cannot have an MRI due to his pacemaker.  He has had no further similar events.  He denies any lesions or other visual change, focal weakness or sensory change, headaches, gait change or other neurological problem.,He also reports that he has been diagnosed with lumbar stenosis based on some mild difficulty arising from a chair for which an outside physician ordered a CT of his L-spine that reportedly showed lumbar stenosis.  The question has arisen as to whether he should have a CT myelogram to further evaluate this process.  He has no back pain or pain of any type, he denies bowel or bladder incontinence or frank lower extremity weakness.  He is extremely active and plays tennis at least three times a week.  He denies recent episodes of unexpected falls.,REVIEW OF SYSTEMS: , He only endorses hypothyroidism, the episode of visual loss described above and joint pain.  He also endorses having trouble getting out of a chair, but otherwise his review of systems is negative.  A copy is in his clinic chart.,PAST MEDICAL HISTORY:  ,As above.  He has had bilateral knee replacement three years ago and experiences some pain in his knees with this.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:,  He is retired from the social security administration x 20 years.  He travels a lot and is extremely active.  He does not smoke.  He consumes alcohol socially only.  He does not use illicit drugs.  He is married.,MEDICATIONS: , The patient has recently been started on Plavix by his primary care doctor, was briefly on baby aspirin 81 mg per day since the TIA-like event three weeks ago.  He also takes Proscar 5 mg q.d and Synthroid 0.2 mg q.d.,PHYSICAL EXAMINATION:,Vital Signs:  BP 134/80, heart rate 60, respiratory rate 16, and weight 244 pounds.  He denies any pain.,General:  This is a pleasant white male in no acute distress.,HEENT:  He is normocephalic and atraumatic.  Conjunctivae and sclerae are clear.  There is no sinus tenderness.,Neck:  Supple.,Chest:  Clear to auscultation.,Heart:  There are no bruits present.,Extremities:  Extremities are warm and dry.  Distal pulses are full.  There is no edema.,NEUROLOGIC EXAMINATION:,MENTAL STATUS:  He is alert and oriented to person, place and time with good recent and long-term memory.  His language is fluent.  His attention and concentration are good.,CRANIAL NERVES:  Cranial nerves II through XII are intact.  VFFTC, PERRL, EOMI, facial sensation and expression are symmetric, hearing is decreased on the right (hearing aid), palate rises symmetrically, shoulder shrug is strong, tongue protrudes in the midline.,MOTOR:  He has normal bulk and tone throughout.  There is no cogwheeling.  There is some minimal weakness at the iliopsoas bilaterally 4+/5 and possibly trace weakness at the quadriceps -5/5.  Otherwise he is 5/5 throughout including hip adductors and abductors.,SENSORY:  He has decreased sensation to vibration and proprioception to the middle of his feet only, otherwise sensory is intact to light touch, and temperature, pinprick, proprioception and vibration.,COORDINATION:  There is no dysmetria or tremor noted.  His Romberg is negative.  Note that he cannot rise from the chair without using his arms.,GAIT:  Upon arising, he has a normal step, stride, and toe, heel.  He has difficulty with tandem and tends to fall to the left.,REFLEXES:  2 at biceps, triceps, patella and 1 at ankles.,The patient provided a CT scan without contrast from his previous hospitalization three weeks ago, which is normal to my inspection.,He has had full labs for cholesterol and stroke for risk factors although he does not have those available here.,IMPRESSION:,1.  TIA.  The character of his brief episode of visual loss is concerning for compromise of the posterior circulation.  Differential diagnoses include hypoperfusion, stenosis, and dissection.  He is to get a CT angiogram to evaluate the integrity of the cerebrovascular system.  He has recently been started on Paxil by his primary care physician and this should be continued.  Other risk factors need to be evaluated; however, we will wait for the results to be sent from the outside hospital so that we do not have to repeat his prior workup.  The patient and his wife assure me that the workup was complete and that nothing was found at that time.,2.  Lumbar stenosis.  His symptoms are very mild and consist mainly of some mild proximal upper extremity weakness and very mild gait instability.  In the absence of motor stabilizing symptoms, the patient is not interested in surgical intervention at this time.  Therefore we would defer further evaluation with CT myelogram as he does not want surgery.,PLAN:,1.  We will get a CT angiogram of the cerebral vessels.,2.  Continue Plavix.,3.  Obtain copies of the workup done at the outside hospital.,4.  We will follow the lumbar stenosis for the time being.  No further workup is planned.",
 Consultation for evaluation of thrombocytopenia., Consult - History and Phy., Thrombocytopenia - Consult ,"REASON FOR CONSULTATION:,  Thrombocytopenia.,HISTORY OF PRESENT ILLNESS:,  Mrs. XXX is a 17-year-old lady who is going to be 18 in about 3 weeks.  She has been referred for the further evaluation of her thrombocytopenia.  This thrombocytopenia was detected on a routine blood test performed on the 10th of June 2006.  Her hemoglobin was 13.3 with white count of 11.8 at that time.  Her lymphocyte count was 6.7.  The patient, subsequently, had a CBC repeated on the 10th at Hospital where her hemoglobin was 12.4 with a platelet count of 26,000.  She had a repeat of her CBC again on the 12th of June 2006 with hemoglobin of 14, white count of 11.6 with an increase in the number of lymphocytes.  Platelet count was 38.  Her rapid strep screen was negative but the infectious mononucleosis screen is positive.  The patient had a normal platelet count prior too and she is being evaluated for this low platelet count.,The patient gives a history of feeling generally unwell for a couple of days towards the end of May.  She was fine for a few days after that but then she had sore throat and fever 2-3 days subsequent to that.  The patient continues to have sore throat.,She denies any history of epistaxis.  Denies any history of gum bleeding.  The patient denies any history of petechiae.  She denies any history of abnormal bleeding.  Denies any history of nausea, vomiting, neck pain, or any headaches at the present time.,The patient was accompanied by her parents.,PAST MEDICAL HISTORY: , Asthma.,CURRENT MEDICATIONS: , Birth control pills, Albuterol, QVAR and Rhinocort.,DRUG ALLERGIES: , None.,PERSONAL HISTORY: , She lives with her parents.,SOCIAL HISTORY:,  Denies the use of alcohol or tobacco.,FAMILY HISTORY: , Noncontributory.,OCCUPATION: , The patient is currently in school.,REVIEW OF SYSTEMS:,Constitutional:  The history of fever about 2 weeks ago.,HEENT:  Complains of some difficulty in swallowing.,Cardiovascular:  Negative.,Respiratory:  Negative.,Gastrointestinal:  No nausea, vomiting, or abdominal pain.,Genitourinary:  No dysuria or hematuria.,Musculoskeletal:  Complains of generalized body aches.,Psychiatric:  No anxiety or depression.,Neurologic:  Complains of episode of headaches about 2-3 weeks ago.,PHYSICAL EXAMINATION:  ,She was not in any distress.  She appears her stated age.  Temperature 97.9.  Pulse 84.  Blood pressure was 110/60.  Weighs 162 pounds.  Height of 61 inches.  Lungs - Normal effort.  Clear.  No wheezing.  Heart - Rate and rhythm regular.  No S3, no S4.  Abdomen - Soft.  Bowel sounds are present.  No palpable hepatosplenomegaly.  Extremities - Without any edema, pallor, or cyanosis.  Neurological:  Alert and oriented x 3.  No focal deficit.  Lymph Nodes - No palpable lymphadenopathy in the neck or the axilla.  Skin examination reveals few petechiae along the lateral aspect of the left thigh but otherwise there were no ecchymotic patches.,DIAGNOSTIC DATA: , The patient's CBC results from before were reviewed.  Her CBC performed in the office today showed hemoglobin of 13.7, white count of 13.3, lymphocyte count of 7.6, and platelet count of 26,000.,IMPRESSION: , ITP, the patient has a normal platelet count.,PLAN:,1.  I had a long discussion with family regarding the treatment of ITP.  In view of the fact that the patient's platelet count is 26,000 and she is asymptomatic, we will continue to monitor the counts.,2.  An ultrasound of the abdomen will be performed tomorrow.,3.  I have given her a requisition to obtain some blood work tomorrow.",
" A 54-year-old patient, here for evaluation of new-onset swelling of the tongue.", Consult - History and Phy., Tongue Swelling ,"REASON FOR ADMISSION: , A 54-year-old patient, here for evaluation of new-onset swelling of the tongue.,PAST MEDICAL HISTORY:,1.  Diabetes type II.,2.  High blood pressure.,3.  High cholesterol.,4.  Acid reflux disease.,5.  Chronic back pain.,PAST SURGICAL HISTORY:,1.  Lap-Band done today.,2.  Right foot surgery.,MEDICATIONS:,1.  Percocet on a p.r.n. basis.,2.  Keflex 500 mg p.o. t.i.d.,3.  Clonidine 0.2 mg p.o. b.i.d.,4.  Prempro, dose is unknown.,5.  Diclofenac 75 mg p.o. daily.,6.  Enalapril 10 mg p.o. b.i.d.,7.  Amaryl 2 mg p.o. daily.,8.  Hydrochlorothiazide 25 mg p.o. daily.,9.  Glucophage 100 mg p.o. b.i.d.,10.  Nifedipine extended release 60 mg p.o. b.i.d.,11.  Omeprazole 20 mg p.o. daily.,12.  Zocor 20 mg p.o. at bedtime.,ALLERGIES: , No known allergies.,HISTORY OF PRESENT COMPLAINT: , This 54-year-old patient had had Lap-Band at Tempe St Luke this morning.  She woke up at home this evening with massive swelling of the left side of the tongue.  The patient therefore came to the emergency room for evaluation.  The patient was almost intubated on clinical grounds.  Anesthesia was called to see the patient and they decided to give a trial of conservative management of Decadron and racemic epinephrine.,REVIEW OF SYSTEMS:,GENERAL:  The patient denies any itching of the skin or urticaria.  She has not noticed any new rashes.  She denies fever, chill, or malaise.,HEENT:  The patient denies vision difficulty.,RESPIRATORY:  No cough or wheezing.,CARDIOVASCULAR:  No palpitations or syncopal episodes.,GASTROINTESTINAL:  The patient denies swallowing difficulty.,Rest of the review of systems not remarkable.,SOCIAL HISTORY:  ,The patient does not smoke nor drink alcohol.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL:  Obese 54-year-old lady, not in acute distress at this time.,VITAL SIGNS:  On arrival in the emergency room, blood pressure was 194/122, pulse was 94, respiratory rate of 20, and temperature was 96.6.  O2 saturation was 95% on room air.,HEAD AND NECK:  Face is symmetrical.  Tongue is still swollen, especially on the left side.  The floor of the mouth is also indurated.  There is no cervical lymphadenopathy.  There is no stridor.,CHEST:  Clear to auscultation.  No wheezing.  No crepitations.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmurs appreciated.,ABDOMEN:  Benign.,EXTREMITIES:  There is no swelling.,NEUROLOGIC:  The patient is alert and oriented x3.  Examination is nonfocal.",
" Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth pain to both upper and lower teeth on the left side for approximately three days..", Consult - History and Phy., Toothache - ER Visit ,"CHIEF COMPLAINT:,  Toothache.,HISTORY OF PRESENT ILLNESS:  ,This is a 29-year-old male who has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled.  Complains of new tooth pain.  The patient states his current toothache is to both upper and lower teeth on the left side for approximately three days.  The patient states that he would have gone to see his regular dentist but he has missed so many appointments that they now do not allow him to schedule regular appointments, he has to be on standby appointments only.  The patient denies any other problems or complaints.  The patient denies any recent illness or injuries.  The patient does have OxyContin and Vicodin at home which he uses for his knee pain but he wants more pain medicines because he does not want to use up that medicine for his toothache when he wants to say this with me.,REVIEW OF SYSTEMS: , CONSTITUTIONAL:  No fever or chills.  No fatigue or weakness.  No recent weight change.  HEENT:  No headache, no neck pain, the toothache pain for the past three days as previously mentioned.  There is no throat swelling, no sore throat, no difficulty swallowing solids or liquids.  The patient denies any rhinorrhea.  No sinus congestion, pressure or pain, no ear pain, no hearing change, no eye pain or vision change.  CARDIOVASCULAR:  No chest pain.  RESPIRATIONS:  No shortness of breath or cough.  GASTROINTESTINAL:  No abdominal pain.  No nausea or vomiting.  GENITOURINARY:  No dysuria.  MUSCULOSKELETAL:  No back pain.  No muscle or joint aches.  SKIN:  No rashes or lesions.  NEUROLOGIC:  No vision or hearing change.  No focal weakness or numbness.  Normal speech.  HEMATOLOGIC/LYMPHATIC:  No lymph node swelling has been noted.,PAST MEDICAL HISTORY: , Chronic knee pain.,CURRENT MEDICATIONS: , OxyContin and Vicodin.,ALLERGIES:,  PENICILLIN AND CODEINE.,SOCIAL HISTORY: , The patient is still a smoker.,PHYSICAL EXAMINATION:,  VITAL SIGNS:  Temperature 97.9 oral, blood pressure is 146/83, pulse is 74, respirations 16, oxygen saturation 98% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished and well developed.  The patient is a little overweight but otherwise appears to be healthy.  The patient is calm, comfortable, in no acute distress, and looks well.  The patient is pleasant and cooperative.  HEENT:  Eyes are normal with clear conjunctiva and cornea bilaterally.  There is no icterus, injection, or discharge.  Pupils are 3 mm and equally round and reactive to light bilaterally.  There is no absence of light sensitivity or photophobia.  Extraocular motions are intact bilaterally.  Ears are normal bilaterally without any sign of infection.  There is no erythema, swelling of canals.  Tympanic membranes are intact without any erythema, bulging or fluid levels or bubbles behind it.  Nose is normal without rhinorrhea or audible congestion.  There is no tenderness over the sinuses.  NECK:  Supple, nontender, and full range of motion.  There is no meningismus.  No cervical lymphadenopathy.  No JVD.  Mouth and oropharynx shows multiple denture and multiple dental caries.  The patient has tenderness to tooth #12 as well as tooth #21.  The patient has normal gums.  There is no erythema or swelling.  There is no purulent or other discharge noted.  There is no fluctuance or suggestion of abscess.  There are no new dental fractures.  The oropharynx is normal without any sign of infection.  There is no erythema, exudate, lesion or swelling.  The buccal membranes are normal.  Mucous membranes are moist.  The floor of the mouth is normal without any abscess, suggestion of Ludwig's syndrome.  CARDIOVASCULAR:  Heart is regular rate and rhythm without murmur, rub, or gallop.  RESPIRATIONS:  Clear to auscultation bilaterally without shortness of breath.  GASTROINTESTINAL:  Abdomen is normal and nontender.  MUSCULOSKELETAL:  No abnormalities are noted to back, arms and legs.  The patient has normal use of his extremities.  SKIN:  No rashes or lesions.  NEUROLOGIC:  Cranial nerves II through XII are intact.  Motor and sensory are intact to the extremities.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is alert and oriented x4.  Normal mood and affect.  HEMATOLOGIC/LYMPHATIC:  No cervical lymphadenopathy is palpated.,EMERGENCY DEPARTMENT COURSE: , The patient did request a pain shot and the patient was given Dilaudid of 4 mg IM without any adverse reaction.,DIAGNOSES:,1.  ODONTALGIA.,2.  MULTIPLE DENTAL CARIES.,CONDITION UPON DISPOSITION:  ,Stable.,DISPOSITION: , To home.,PLAN: , The patient was given a list of local dental clinics that he can follow up with or he can choose to stay with his own dentist that he wishes.  The patient was requested to have reevaluation within two days.  The patient was given a prescription for Percocet and clindamycin.  The patient was given drug precautions for the use of these medicines.  The patient was offered discharge instructions on toothache but states that he already has it.  He declined the instructions.  The patient was asked to return to the emergency room, should he have any worsening of his condition or develop any other problems or symptoms of concern.","consult - history and phy., odontalgi, multiple dental caries, dentist, dental disease, extensive dental disease, teeth pulled, lower teeth, cervical lymphadenopathy, dental caries, toothache, erythema, swelling, teeth, dental, "
 Evaluation of possible tethered cord.  She underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age. , Consult - History and Phy., Tethered Cord Evaluation ,"REASON FOR VISIT: , The patient referred by Dr. X for evaluation of her possible tethered cord.,HISTORY OF PRESENT ILLNESS:,  Briefly, she is a 14-year-old right handed female who is in 9th grade, who underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age.  The last surgery was in 03/95.  She did well; however, in the past several months has had some leg pain in both legs out laterally, worsening at night and requiring Advil, Motrin as well as Tylenol PM.,Denies any new bowel or bladder dysfunction or increased sensory loss.  She had some patchy sensory loss from L4 to S1.,MEDICATIONS: , Singulair for occasional asthma.,FINDINGS: , She is awake, alert, and oriented x 3.  Pupils equal and reactive.  EOMs are full.  Motor is 5 out of 5.  She was able to toe and heel walk without any difficulties as well as tendon reflexes were 2 plus.  There is no evidence of clonus.  There is diminished sensation from L4 to S1, having proprioception.,ASSESSMENT AND PLAN: , Possible tethered cord.  I had a thorough discussion with the patient and her parents.  I have recommended a repeat MRI scan.  The prescription was given today.  MRI of the lumbar spine was just completed.  I would like to see her back in clinic.  We did discuss the possible symptoms of this tethering.","consult - history and phy., tethering, lipomyomeningocele repair, sensory loss, tethered cord, mri, cord, lipomyomeningocele, "
 A 92-year-old female had a transient episode of slurred speech and numbness of her left cheek for a few hours. , Consult - History and Phy., TIA - Cosult ,"REASON FOR CONSULTATION: , This 92-year-old female states that last night she had a transient episode of slurred speech and numbness of her left cheek for a few hours.  However, the chart indicates that she had recurrent TIAs x3 yesterday, each lasting about 5 minutes with facial drooping and some mental confusion.  She had also complained of blurred vision for several days.  She was brought to the emergency room last night, where she was noted to have a left carotid bruit and was felt to have recurrent TIAs.,CURRENT MEDICATIONS: , The patient is on Lanoxin, amoxicillin, Hydergine, Cardizem, Lasix, Micro-K and a salt-free diet.  ,SOCIAL HISTORY: , She does not smoke or drink alcohol.,FINDINGS:  ,Admission CT scan of the head showed a densely calcified mass lesion of the sphenoid bone, probably representing the benign osteochondroma seen on previous studies.  CBC was normal, aside from a hemoglobin of 11.2.  ECG showed atrial fibrillation.  BUN was 22, creatinine normal, CPK normal, glucose normal, electrolytes normal.,PHYSICAL EXAMINATION: , On examination, the patient is noted to be alert and fully oriented.  She has some impairment of recent memory.  She is not dysphasic, or apraxic.  Speech is normal and clear.  The head is noted to be normocephalic.  Neck is supple.  Carotid pulses are full bilaterally, with left carotid bruit.  Neurologic exam shows cranial nerve function II through XII to be intact, save for some slight flattening of the left nasolabial fold.  Motor examination shows no drift of the outstretched arms.  There is no tremor or past-pointing.  Finger-to-nose and heel-to-shin performed well bilaterally.  Motor showed intact neuromuscular tone, strength, and coordination in all limbs.  Reflexes 1+ and symmetrical, with bilateral plantar flexion, absent jaw jerk, no snout.  Sensory exam is intact to pinprick touch, vibration, position, temperature, and graphesthesia.,IMPRESSION: , Neurological examination is normal, aside from mild impairment of recent memory, slight flattening of the left nasolabial fold, and left carotid bruit.  She also has atrial fibrillation, apparently chronic.  In view of her age and the fact that she is in chronic atrial fibrillation, I would suspect that she most likely has had an embolic phenomenon as the cause of her TIAs.,RECOMMENDATIONS:,  I would recommend conservative management with antiplatelet agents unless a near occlusion of the carotid arteries is demonstrated, in which case you might consider it best to do an angiography and consider endarterectomy.  In view of her age, I would be reluctant to recommend Coumadin anticoagulation.  I will be happy to follow the patient with you.","consult - history and phy., atrial fibrillation, carotid bruit, slurred speech, numbness, calcified mass lesion, neurological examination, tias, carotid, benign,"
 Itchy red rash on feet - Tinea Pedis, Consult - History and Phy., Tinea Pedis - H&P ,"CHIEF COMPLAINT (1/1):  ,This 24 year-old female presents today complaining of itchy, red rash on feet.  Associated signs and symptoms:  Associated signs and symptoms include tingling, right.  Context:  Patient denies any previous history, related trauma or previous treatments for this condition.  Duration:  Condition has existed for 4 weeks.  Location:  She indicates the problem location is right great toe, right 2nd toe, right 3rd toe and right 4th toe.  Modifying factors:  Patient indicates ice improves condition.  Quality:  Quality of the itch is described by the patient as constant.  Severity:  Severity of condition is unbearable.  Timing (onset/frequency):  Onset was after leaving on sweaty socks.,ALLERGIES: , Patient admits allergies to adhesive tape resulting in severe rash.,MEDICATION HISTORY:,  None.,PAST MEDICAL HISTORY: , Childhood Illnesses: (+) chickenpox, (+) frequent ear infections.,PAST SURGICAL HISTORY:  ,Patient admits past surgical history of ear tubes.,SOCIAL HISTORY: , Patient admits alcohol use Drinking is described as social, Patient denies tobacco use, Patient denies illegal drug use, Patient denies STD history.,FAMILY HISTORY:,  Patient admits a family history of cataract associated with maternal grandmother,,headaches/migraines associated with maternal aunt.,REVIEW OF SYSTEMS:,  Unremarkable with exception of chief complaint.,PHYSICAL EXAM: , BP Sitting:  110/64 Resp:  18 HR:  66 Temp:  98.6,Patient is a 24 year old female who appears well developed, well nourished and with good attention to hygiene and body habitus.  Cardiovascular:  Skin temperature of the lower extremities is warm to cool, proximal to distal.,DP pulses palpable bilateral.,PT pulses palpable bilateral.,CFT immediate.,No edema observed.,Varicosities are not observed.  Skin:  Right great toe, right 2nd toe, right 3rd toe and right 4th toenail shows erythema and scaling.,Neurological:  Touch, pin, vibratory and proprioception sensations are normal.  Deep tendon reflexes normal.,Musculoskeletal:  Muscle strength is 5/5 for all groups tested.  Muscle tone is normal.  Inspection and palpation of bones, joints and muscles is unremarkable.,TEST RESULTS:,  No tests to report at this time,IMPRESSION: , Tinea pedis.,PLAN:  ,Obtained fungal culture of skin from right toes.  KOH prep performed revealed no visible microbes.,PRESCRIPTIONS:,  Lotrimin AF  Dosage:  1% cream  Sig:  apply qid  Dispense:  4oz tube Refills:  0  Allow Generic:  Yes",
 Newly diagnosed T-cell lymphoma.  The patient reports swelling in his left submandibular region that occurred all of a sudden about a month and a half ago. , Consult - History and Phy., T-Cell Lymphoma Consult ,"CHIEF COMPLAINT: , Newly diagnosed T-cell lymphoma.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 40-year-old gentleman who reports swelling in his left submandibular region that occurred all of a sudden about a month and a half ago.  He was originally treated with antibiotics as a possible tooth abscess.  Prior to this event, in March of 2010, he was treated for strep throat.  The pain at that time was on the right side.  About a month ago, he started having night sweats.  The patient reports feeling hot, when he went to bed he fall asleep and would wake up soaked.  All these symptoms were preceded by overwhelming fatigue and exhaustion.  He reports being under significant amount of stress as he and his mom just recently moved from their house to a mobile home.  With the fatigue, he has had some mild chest pain and shortness of breath, and has also noted a decrease in his appetite, although he reports his weight has been stable.  He also reports occasional headaches with some stabbing and pain in his feet and legs.  He also complains of some left groin pain.,PAST MEDICAL HISTORY: , Significant for HIV diagnosed in 2000.  He also had mononucleosis at that time.  The patient reports being on anti-hepatitis viral therapy period that was very intense.  He took the meds for about six months, he reports stopping, and prior to 2002 at one point during his treatment, he was profoundly weak and found to have hemoglobin less than 4 and required three units of packed red blood cells.  He reports no other history of transfusions.  He has history of spontaneous pneumothorax.  The first episode was 1989 on his right lung.  In 1990 he had a slow collapse of the left lung.  He reports no other history of pneumothoraces.  In 2003, he had shingles.  He went through antiviral treatment at that time and he also reports another small outbreak in 2009 that he treated with topical therapy.,FAMILY HISTORY: , Notable for his mother who is currently battling non-small cell lung cancer.  She is a nonsmoker.  His sister is Epstein-Barr virus positive.  The patient's mother also reports that she is Epstein-Barr virus positive.  His maternal grandfather died from complications from melanoma.  His mother also has diabetes.,SOCIAL HISTORY: , The patient is single.  He currently lives with his mother in house for several both in New York and here in Colorado.  His mother moved out to Colorado eight years ago and he has been out here for seven years.  He currently is self employed and does antiquing.  He has also worked as nurses' aide and worked in group home for the state of New York for the developmentally delayed.  He is homosexual, currently not sexually active.  He does have smoking history as about a thirteen and a half pack year history of smoking, currently smoking about a quarter of a pack per day.  He does not use alcohol or illicit drugs.,REVIEW OF SYSTEMS: , As mentioned above his weight has been fairly stable.  Although, he suffered from obesity as a young teenager, but through a period of anorexia, but his weight has been stable now for about 20 years.  He has had night sweats, chest pain, and is also suffering from some depression as well as overwhelming fatigue, stabbing, short-lived headaches and occasional shortness of breath.  He has noted some stool irregularity with occasional loose stools and new onset of pain predominantly in left neck.  He has had fevers as well.  The rest of his review of systems is negative.,PHYSICAL EXAM:,VITALS:","consult - history and phy., t-cell lymphoma, submandibular, tooth abscess, strep throat, submandibular region, lymphoma, neck, "
 Therapeutic recreation initial evaluation.  Patient is a 54-year-old male admitted with diagnosis of CVA with right hemiparesis., Consult - History and Phy., Therapeutic Recreation Initial Evaluation ,"HISTORY:,  Patient is a 54-year-old male admitted with diagnosis of CVA with right hemiparesis.,Patient is currently living in ABC with his son as this was closer his to his job.  At discharge, he will live with his spouse in a new job.  The home is single level with no steps.,Prior to admission, his wife reports that he was independent with all activities.  He was working full time for an oil company.,Past medical history includes hypertension and diabetes, mental status, and dysphagia.,Ability to follow instruction/rules:  Not able to identify cognitive status as of yet.,COMMUNICATION SKILLS: , No initiation of conversation.  He answered 1 yes/no question.,PHYSICAL STATUS:,  Fall/safety.  Aspiration precautions.,Endurance:  Ball activities 4 to 5 minutes.  Restorator 25 minutes.  Standing and rolling type of 3 minutes.,LEISURE LIFESTYLE:,Level of participation/activities involved in:  Reading and housework.,INFORMATION OBTAINED:,  Interview, observation, and chart review.,TREATMENT PLAN:  ,Treatment plan and goals were discussed with patient along with identification of results of FUNCTIONAL ASSESSMENT OF CHARACTERISTICS FOR THERAPEUTIC RECREATION identifying need for intervention in the following problem areas:  Patient scored 10/11 in physical domain due to decreased endurance.  He scored 11/11 in the cognitive and social domain.,Patient will attend 1 session per day focusing on:  Endurance activities.,Patient will attend 1-2 group sessions per week focusing on leisure awareness and postdischarge resources.,GOALS:,PATIENT GOALS: , Not able to identify, but cooperative with all activities.  He answered yes that he enjoyed the restorator.,SHORT TERM GOALS/ONE WEEK GOALS:,1.  Patient to increase tolerance for ball activities to 7 minutes.,2.  Patient provided to use the restorator as he enjoys and it is good for endurance.,LONG TERM GOALS:,  Patient to increase standing tolerance, standing leisure activities to 7 to 10 minutes.,Patient has concurred with the above treatment planning goals.","consult - history and phy., endurance, ball activities, therapeutic recreation, hemiparesis, tolerance, recreation, restorator, leisure, therapeutic, "
 The patient had a syncopal episode last night.   She did not have any residual deficit.  She had a headache at that time.  She denies chest pains or palpitations., Consult - History and Phy., Syncope - ER Visit - 1 ,"REASON FOR VISIT:,  Syncope.,HISTORY:,  The patient is a 75-year-old lady who had a syncopal episode last night.  She went to her room with a bowl of cereal and then blacked out for a few seconds and then when she woke up, the cereal was on the floor.  She did not have any residual deficit.  She had a headache at that time.  She denies chest pains or palpitations.,PAST MEDICAL HISTORY: , Arthritis, first episode of high blood pressure today.  She had a normal stress test two years ago.,MEDICATIONS: , Her medication is one dose of hydrochlorothiazide today because her blood pressure was so high at 150/70.,SOCIAL HISTORY: , She does not smoke and she does not drink.  She lives with her daughter.,PHYSICAL EXAMINATION:,GENERAL:  Lady in no distress.,VITAL SIGNS:  Blood pressure 172/91, came down to 139/75, heart rate 91, and respirations 20.  Afebrile.,HEENT:  Head is normal.,NECK:  Supple.,LUNGS:  Clear to auscultation and percussion.,HEART:  No S3, no S4, and no murmurs.,ABDOMEN:  Soft.,EXTREMITIES:  Lower extremities, no edema.,DIAGNOSTIC DATA: , Her EKG shows sinus rhythm with nondiagnostic Q-waves in the inferior leads.,ASSESSMENT:  ,Syncope.,PLAN:  ,She had a CT scan of the brain that was negative today.  The blood pressure is high.  We will start Maxzide.  We will do an outpatient Holter and carotid Doppler study.  She has had an echocardiogram along with the stress test before and it was normal.  We will do an outpatient followup.","consult - history and phy., residual deficit, headache, ct scan, syncopal episode, stress test, blood pressure, syncope, "
" A 6-year-old male who is a former 27-week premature infant, suffered an intraventricular hemorrhage requiring shunt placement, and as a result, has developmental delay and left hemiparesis. ", Consult - History and Phy., Status Epilepticus ,"CHIEF COMPLAINT:,  Status epilepticus.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 6-year-old male who is a former 27-week premature infant who suffered an intraventricular hemorrhage requiring shunt placement, and as a result, has developmental delay and left hemiparesis.  At baseline, he can put about 2 to 4 words together in brief sentences.  His speech is not always easily understood; however, he is in a special education classroom in kindergarten.  He ambulates independently, but falls often.  He has difficulty with his left side compared to the right, and prefers to use the right upper extremity more than the left.  Mother reports he postures the left upper extremity when running.  He is being followed by Medical Therapy Unit and has also been seen in the past by Dr. X.  He has not received Botox or any other interventions with regard to his cerebral palsy.,The patient did require one shunt revision, but since then his shunt has done well.,The patient developed seizures about 2 years ago.  These occurred periodically, but they are always in the same and with the involvement of the left side more than right and he had an eye deviation forcefully to the left side.  His events, however, always tend to be prolonged.  He has had seizures as long as an hour and a half.  He tends to require multiple medications to stop them.  He has been followed by Dr. Y and was started on Trileptal.  At one point, The patient was taken off his medication for presumed failure to prevent his seizures.  He was more recently placed on Topamax since March 2007.  His last seizures were in March and May respectively.  He is worked up to a dose of 25 mg capsules, 2 capsules twice a day or about 5 mg/kg/day at this point.,The patient was in his usual state of health until early this morning and was noted to be in seizure.  His seizure this morning was similar to the previous seizures with forced deviation of his head and eyes to the left side and convulsion more on the left side than the right.  Family administered Diastat 7.5 mg x1 dose.  They did not know they could repeat this dose.  EMS was called and he received lorazepam 2 mg and then in the emergency department, 15 mg/kg of fosphenytoin.  His seizures stopped thereafter, since that time, he had gradually become more alert and is eating, and is nearly back to baseline.  He is a bit off balance and tends to be a bit weaker on the left side compared to baseline postictally.,REVIEW OF SYSTEMS: , At this time, he is positive for a low-grade fever, he has had no signs of illness otherwise.  He does have some fevers after his prolonged seizures.  He denies any respiratory or cardiovascular complaints.  There is no numbness or loss of skills.  He has no rashes, arthritis or arthralgias.  He has no oropharyngeal complaints.  Visual or auditory complaints.,PAST MEDICAL HISTORY: , Also positive for some mild scoliosis.,SOCIAL HISTORY: , The patient lives at home with mother, father, and 2 other siblings.  There are no ill contacts.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a well-nourished, well-hydrated male, in no acute distress.,VITAL SIGNS:  His vital signs are stable and he is currently afebrile.,HEENT:  Atraumatic and normocephalic.  Oropharynx shows no lesions.,NECK:  Supple without adenopathy.,CHEST:  Clear to auscultation.,CARDIOVASCULAR:  Regular rate and rhythm, no murmurs.,ABDOMEN:  Benign without organomegaly.,EXTREMITIES:  No clubbing, cyanosis or edema.,NEUROLOGIC:  The patient is alert and will follow instructions.  His speech is very dysarthric and he tends to run his words together.  He is about 50% understandable at best.  He does put words and sentences together.  His cranial nerves reveal his pupils are equal, round, and reactive to light.  His extraocular movements are intact.  His visual fields are full.  Disks are sharp bilaterally.  His face shows left facial weakness postictally.  His palate elevates midline.  Vision is intact bilaterally.  Tongue protrudes midline.,Motor exam reveals clearly decreased strength on the left side at baseline.  His left thigh is abducted at the hip at rest with the right thigh and leg straight.  He has difficulty using the left arm and while reaching for objects, shows exaggerated tremor/dysmetria.  Right upper extremity is much more on target.  His sensations are intact to light touch bilaterally.  Deep tendon reflexes are 2+ and symmetric.  When sitting up, he shows some truncal instability and tendency towards decreased truncal tone and kyphosis.  He also shows some scoliotic curve of the spine, which is mild at this point.  Gait was not tested today.,IMPRESSION: , This is a 6-year-old male with recurrent status epilepticus, left hemiparesis, history of prematurity, and intraventricular hemorrhage.  He is on Topamax, which is at a moderate dose of 5 mg/kg a day or 50 mg twice a day.  At this point, it is not clear whether this medication will protect him or not, but the dose is clearly not at maximum, and he is tolerating the dose currently.  The plan will be to increase him up to 50 mg in the morning, and 75 mg at night for 2 weeks, and then 75 mg twice daily.  Reviewed the possible side effects of higher doses of Topamax, they will monitor him for language issues, cognitive problems or excessive somnolence.  I also discussed his imaging studies, which showed significant destruction of the cerebellum compared to other areas and despite this, the patient at baseline has a reasonable balance.  The plan from CT standpoint is to continue stretching program, continue with medical therapy unit.  He may benefit from Botox.,In addition, I reviewed the Diastat protocol with parents and given the patient tends to go into status epilepticus each time, they can administer Diastat immediately and not wait the standard 2 minutes or even 5 minutes that they were waiting before.  They are going to repeat the dose within 10 minutes and they can call EMS at any point during that time.  Hopefully at home, they need to start to abort these seizures or the higher dose of Topamax will prevent them.  Other medication options would include Keppra, Zonegran or Lamictal.,FOLLOWUP: , Followup has already been scheduled with Dr. Y in February and they will continue to keep that date for followup.",
 Sports physical with normal growth and development., Consult - History and Phy., Sports Physical - 1 ,"HISTORY: , This child is seen for a sports physical.,NUTRITIONAL HISTORY:,  She takes meats, vegetables, and fruits.  Eats well.  Has may be 1 to 2 cups a day of milk.  Her calcium intake could be better.  She does not drink that much pop but she likes koolaid.  Her stools are normal.  Brushes her teeth.  Sees a dentist.,DEVELOPMENTAL HISTORY: , She did well in school last year.  Hearing and vision, no problems.  She wears corrective lenses.  She will be in 8th grade and involved in volleyball, basketball, and she will be moving to Texas.  She did go to Burton this last year.  She also plays clarinet, and will be involved also in cheerleading.  She likes to swim in the summer time.  Her menarche was January 2004.  It occurs every 7 weeks.  No particular problems at this time.,OTHER ACTIVITIES:  ,TV time about 2 to 3 hours a day.  She does not use drugs, alcohol, or smoke, and denies sexual activity.,MEDICATIONS:,  Advair 250/50 b.i.d., Flonase b.i.d., Allegra q.d.  120 mg, Xopenex and albuterol p.r.n.,ALLERGIES:,  No known drug allergies.,OBJECTIVE:,Vital Signs:  Blood pressure:  98/60.  Temperature:  96.6 tympanic.  Weight:  107 pounds, which places her at approximately the 60th percentile for weight and the height is about 80th percentile at 64-1/2 inches.  Her body mass index is 18.1, which is 40th percentile.  Pulse:  68.,HEENT:  Normocephalic.  Fundi benign.  Pupils are equal and reactive to light and accommodation.  Conjunctivae were non-injected.  Her pupils were equal, and reactive to light and accommodation.  No strabismus.  She wears glasses.  Her vision was 20/20 in both eyes.  TMs are bilaterally clear.  Nonerythematous.  Hearing in the ears, she was able to pass 40 decibel to 30 decibel.  With the right ear, she has some problems, but the left ear she passed.  Throat was clear.  Nonerythematous.  Good dentition.,Neck:  Supple.  Thyroid normal sized.  No increased lymphadenopathy in the submandibular nodes and no axillary nodes.,Respiratory:  Clear.  No wheezes and no crackles.  No tachypnea and no retractions.,Cardiovascular:  Regular rate and rhythm.  S1 and S2 normal.  No murmur.,Abdomen:  Soft.  No organomegaly and no masses.  No hepatosplenomegaly.,GU:  Normal female genitalia.  Tanner stage III in breast and pubic hair development and she was given a breast exam.  Negative for any masses.,Skin:  Without rash.,Extremities:  Deep tendon reflexes 2+/4+ bilaterally and equal.,Neurological:  Romberg negative.,Back:  No scoliosis.,She had good circumduction at the shoulder joints and duck walk is normal.,ASSESSMENT:,  Sports physical with normal growth and development.,PLAN:,  If problems continue, she will need to have her hearing rechecked.  Hopefully in the school, there will be a screening mat.  She received her first hepatitis A vaccine and she needs to have a booster in 6 to 12 months.  We reviewed her immunizations for tetanus and her last acellular DPT was 11/25/1996.  When she goes to Texas, Mom has an appointment already to see an allergist but she needs to find a primary care physician and we will ask for record release.  We talked about her menarche.  Recommended the exam of the breast regularly.  Talked about other anticipatory guidance including sunscreen, use of seat belts, and drugs, alcohol, and smoking, and sexual activity and avoidance at her age and to continue on her present medications.  She also has had problems with her ankles in the past.  She had no limitation here, but we gave her some ankle strengthening exercise handouts while she was in the office.", 
" Patient with a history of coronary artery disease, status post coronary artery bypass grafting presented to the emergency room following a syncopal episode.", Consult - History and Phy., Syncope - ER Visit ,"REASON FOR CONSULTATION:,  Syncope.,HISTORY OF PRESENT ILLNESS: , The patient is a 78-year-old lady followed by Dr. X in our practice with history of coronary artery disease, status post coronary artery bypass grafting in 2005 presented to the emergency room following a syncopal episode.  According to the patient and the daughter who was with her, she was shopping when she felt abdominal discomfort with nausea, profuse sweating, and passed out.  As soon as she was laid on the floor and her leg raised up, she woke up with no post-event confusion.  According to the daughter, she has had episodes of weakness, but no syncope.  She has blood pressure medications and has had some postural hypotensions, which has been managed by Dr. X. She also states there was a history of pulmonary embolism and the presentation at that time was very similar when she had a syncopal episode.  At that time, she was admitted at Hospital, had a V/Q scan, which was positive for PE.  Initial V/Q scan done at Hospital was negative.  She was anticoagulated with Coumadin resulting in severe GI bleed.  Anticoagulation was stopped and an IVC filter was placed at that time.  She has a history of malignant hypertension and has had a renal stent placed in February 2007.  She also has peripheral vascular disease with stent placements.  There is a history of spinal canal stenosis and iron deficiency anemia, currently on Procrit injections every two weeks done by Dr. Y. The patient denies any chest pain or any worsening of any shortness of breath.  There are no acute EKG changes or cardiac enzyme elevations.  She has had no stress test done following a bypass surgery.,PAST MEDICAL HISTORY,1.  Coronary artery disease, status post coronary artery bypass grafting.,2.  History of mitral regurgitation, unable to repair the valve.,3.  History of paroxysmal atrial fibrillation, on amiodarone.,4.  Gastroesophageal reflux disease.,5.  Hypertension.,6.  Hyperlipidemia.,7.  History of abdominal aortic aneurysm.,8.  Carotid artery disease, mild-to-moderate on recent carotid ultrasound.,9.  Peripheral vascular disease.,10.  Hypothyroidism.,11.  Pulmonary embolism.,PAST SURGICAL HISTORY,1.  Coronary artery bypass grafting.,2.  Hysterectomy.,3.  IVC filter.,4.  Tonsillectomy and adenoidectomy.,5.  Cosmetic surgery to breast and abdomen.,HOME MEDICATIONS,1.  Aspirin 81 mg once a day.,2.  Klor-Con 10 mEq once a day.,3.  Lasix 40 mg once a day.,4.  Levothyroxine 125 mcg once a day.,5.  Lisinopril 20 mg once a day.,6.  Pacerone 200 mg once a day.,7.  Protonix 40 mg once a day.,8.  Toprol 50 mg once a day.,9.  Vitamin B once a day.,10.  Zetia 10 mg once a day.,11.  Zyrtec 10 mg once a day.,ALLERGIES:,  CODEINE, ERYTHROMYCIN, SULFA, VICODIN, AND ZOCOR.,REVIEW OF SYSTEMS,CONSTITUTIONAL:  The patient denies any fevers, chills, recent weight gain or weight loss.  She has had abdominal symptoms with diarrhea.,EYES:  Decreased visual acuity.,ENT:  Sinus drainage.,CARDIOVASCULAR:  As described above.  Denies any chest pains.,RESPIRATORY:  He has chronic shortness of breath.  No cough or sputum production.,GI:  History of reflux symptoms.,GU:  No history of dysuria or hematuria.,ENDOCRINE:  No history of diabetes.,MUSCULOSKELETAL:  Denies arthritis, but has leg pain.,SKIN:  No history of rash.,PSYCHIATRIC:  No history of anxiety or depression.",
 The patient is a 4-month-old who presented with supraventricular tachycardia and persistent cyanosis., Consult - History and Phy., Supraventricular Tachycardia - Consult ,"HISTORY: , The patient is a 4-month-old who presented today with supraventricular tachycardia and persistent cyanosis.  The patient is a product of a term pregnancy that was uncomplicated and no perinatal issues are raised.  Parents; however, did note the patient to be quite dusky since the time of her birth; however, were reassured by the pediatrician that this was normal.  The patient demonstrates good interval weight gain and only today presented to an outside hospital with significant duskiness, some irritability, and rapid heart rate.  Parents do state that she does appear to breathe rapidly, tires somewhat with the feeding with increased respiratory effort and diaphoresis.  The patient is exclusively breast fed and feeding approximately 2 hours.  Upon arrival at Children's Hospital, the patient was found to be in a narrow complex tachycardia with the rate in excess of 258 beats per minute with a successful cardioversion to sinus rhythm with adenosine.  The electrocardiogram following the cardioversion had demonstrated normal sinus rhythm with a right atrial enlargement, northwest axis, and poor R-wave progression, possible right ventricular hypertrophy.,FAMILY HISTORY:,  Family history is remarkable for an older sibling found to have a small ventricular septal defect that is spontaneously closed.,REVIEW OF SYSTEMS: , A complete review of systems including neurologic, respiratory, gastrointestinal, genitourinary are otherwise negative.,PHYSICAL EXAMINATION:,GENERAL:  Physical examination that showed a sedated, acyanotic infant who is in no acute distress.,VITAL SIGNS:  Heart rate of 170, respiratory rate of 65, saturation, it is nasal cannula oxygen of 74% with a prostaglandin infusion at 0.5 mcg/kg/minute.,HEENT:  Normocephalic with no bruit detected.  She had symmetric shallow breath sounds clear to auscultation.  She had full symmetrical pulses.,HEART:  There is normoactive precordium without a thrill.  There is normal S1, single loud S2, and a 2/6 continuous shunt type of murmur could be appreciated at the left upper sternal border.,ABDOMEN:  Soft.  Liver edge is palpated at 3 cm below the costal margin and no masses or bruits detected.,X-RAYS:,  Review of the chest x-ray demonstrated a normal situs, normal heart size, and adequate pulmonary vascular markings.  There is a prominent thymus.  An echocardiogram demonstrated significant cyanotic congenital heart disease consisting of normal situs, a left superior vena cava draining into the left atrium, a criss-cross heart with atrioventricular discordance of the right atrium draining through the mitral valve into the left-sided morphologic left ventricle.  The left atrium drained through the tricuspid valve into a right-sided morphologic right ventricle.  There is a large inlet ventricular septal defect as pulmonary atresia.  The aorta was malopposed arising from the right ventricle in the anterior position with the left aortic arch.  There was a small vertical ductus as a sole source of pulmonary artery blood flow.  The central pulmonary arteries appeared confluent although small measuring 3 mm in the diameter.  Biventricular function is well maintained.,FINAL IMPRESSION: , The patient has significant cyanotic congenital heart disease physiologically with a single ventricle physiology and ductal-dependent pulmonary blood flow and the incidental supraventricular tachycardia now in the sinus rhythm with adequate ventricular function.  The saturations are now also adequate on prostaglandin E1.,RECOMMENDATION: , My recommendation is that the patient be continued on prostaglandin E1.  The patient's case was presented to the cardiothoracic surgical consultant, Dr. X.  The patient will require further echocardiographic study in the morning to further delineate the pulmonary artery anatomy and confirm the central confluence.  A consideration will be made for diagnostic cardiac catheterization to fully delineate the pulmonary artery anatomy prior to surgical intervention.  The patient will require some form of systemic to pulmonary shunt, modified pelvic shunt or central shunt as a durable source of pulmonary blood flow.  Further surgical repair was continued on the size and location of the ventricular septal defect over the course of the time for consideration of possible Rastelli procedure.  The current recommendation is for proceeding with a central shunt and followed then by bilateral bidirectional Glenn shunt with then consideration for a septation when the patient is 1 to 2 years of age.  These findings and recommendations were reviewed with the parents via a Spanish interpreter.","consult - history and phy., congenital heart disease, cyanotic, ductal-dependent, pulmonary blood flow, ventricular septal defect, blood flow, supraventricular tachycardia, tachycardia, ventricular, supraventricular, shunt, heart, pulmonary,"
 The patient was undergoing a routine physical examination and was found to have right supraclavicular lymphadenopathy.  She returned for followup examination and again was noted to have right supraclavicular lymphadenopathy.  She is now referred to the thoracic surgery clinic for evaluation., Consult - History and Phy., Supraclavicular Lymphadenopathy ,"On review of systems, the patient admits to hypertension and occasional heartburn.  She undergoes mammograms every six months, which have been negative for malignancy.  She denies fevers, chills, weight loss, fatigue, diabetes mellitus, thyroid disease, upper extremity trauma, night sweats, DVT, pulmonary embolism, anorexia, bone pain, headaches, seizures, angina, peripheral edema, claudication, orthopnea, PND, coronary artery disease, rheumatoid arthritis, rashes, upper extremity edema, cat scratches, cough, hemoptysis, shortness of breath, dyspnea at two flights of stairs, hoarseness, GI bleeding, change in bowel habits, dysphagia, ulcers, hematuria, or history of TB exposure.  She has had negative PPD.,PAST MEDICAL HISTORY:,  Hypertension.,PAST SURGICAL HISTORY:,  Right breast biopsy - benign.,SOCIAL HISTORY: , She was born and raised in Baltimore.  She has not performed farming or kept birds or cats.,Tobacco: None.,Ethanol: ,Drug Use: ,Occupation:  She is a registered nurse at Spring Grove Hospital.,Exposure: Negative to asbestos.,FAMILY HISTORY:,  Mother with breast cancer.,ALLERGIES: , Percocet and morphine causing temporary hypotension.,MEDICATIONS: , Caduet 10 mg p.o. q.d., Coreg CR 40 mg p.o. q.d., and Micardis HCT 80 mg/12.5 mg p.o. q.d.,PHYSICAL EXAMINATION: ,BP:  133/72",
 Consult and Spinal fluid evaluation in a 15-day-old, Consult - History and Phy., Spinal fluid evaluation ,"HISTORY:  ,This 15-day-old female presents to Children's Hospital and transferred from Hospital Emergency Department for further evaluation.  Information is obtained in discussion with the mother and the grandmother in review of previous medical records.  This patient had the onset on the day of presentation of a jelly-like red-brown stool started on Tuesday morning.  Then, the patient was noted to vomit after feeds.  The patient was evaluated at Hospital with further evaluation with laboratory data showing a white blood cell count elevated at 22.2; hemoglobin 14.1; sodium 138; potassium 7.2, possibly hemolyzed; chloride 107; CO2 23; BUN 17; creatinine 1.2; and glucose of 50, which was repeated and found to be stable in that range.  The patient underwent a barium enema, which was read by the radiologist as negative.  The patient was transferred to Children's Hospital for further evaluation after being given doses of ampicillin, cefotaxime, and Rocephin.,PAST MEDICAL HISTORY: , Further, the patient was born in Hospital.  Birth weight was 6 pounds 4 ounces.  There was maternal hypertension.  Mother denies group B strep or herpes.  Otherwise, no past medical history.,IMMUNIZATIONS: , None today.,MEDICATIONS: , Thrush medicine identified as nystatin.,ALLERGIES: , Denied.,PAST SURGICAL HISTORY: , Denied.,SOCIAL HISTORY:  ,Here with mother and grandmother, lives at home.  There is no smoking at home.,FAMILY HISTORY: , None noted exposures.,REVIEW OF SYSTEMS:  ,The patient is fed Enfamil, bottle-fed.  Has had decreased feeding, has had vomiting, has had diarrhea, otherwise negative on the 10 plus systems reviewed.,PHYSICAL EXAMINATION:,VITAL SIGNS/GENERAL:  On physical examination, the initial temperature 97.5, pulse 140, respirations 48 on this 2 kg 15-day-old female who is small, well-developed female, age appropriate.,HEENT: Head is atraumatic and normocephalic with a soft and flat anterior fontanelle.  Pupils are equal, round, and reactive to light.  Grossly conjugate.  Bilateral red reflex appreciated bilaterally.  Clear TMs, nose, and oropharynx.  There is a kind of abundant thrush and white patches on the tongue.,NECK:  Supple, full, painless, and nontender range of motion.,CHEST:  Clear to auscultation, equal, and stable.,HEART:  Regular without rubs or murmurs, and femoral pulses are appreciated bilaterally.,ABDOMEN:  Soft and nontender.  No hepatosplenomegaly or masses.,GENITALIA:  Female genitalia is present on a visual examination.,SKIN:  No significant bruising, lesions, or rash.,EXTREMITIES:  Moves all extremities, and nontender.  No deformity.,NEUROLOGICALLY:  Eyes open, moves all extremities, grossly age appropriate.,MEDICAL DECISION MAKING: , The differential entertained on this patient includes upper respiratory infection, gastroenteritis, urinary tract infection, dehydration, acidosis, and viral syndrome.  The patient is evaluated in the emergency department laboratory data, which shows a white blood cell count of 13.1, hemoglobin 14.0, platelets 267,000, 7 stabs, 68 segs, 15 lymphs, and 9 monos.  Serum electrolytes not normal.  Sodium 138, potassium 5.0, chloride 107, CO2 acidotic at 18, glucose normal at 88, and BUN markedly elevated at 22 as is the creatinine of 1.4.  AST and ALT were elevated as well at 412 and 180 respectively.  A cath urinalysis showing no signs of infection.  Spinal fluid evaluation, please see procedure note below.  White count 0, red count 2060.  Gram stain negative.,PROCEDURE NOTE: , After discussion of the risks, benefits, and indications, and obtaining informed consent with the family and their agreement to proceed, this patient was placed in the left lateral position and using aseptic Betadine preparation, sterile draping, and sterile technique pursued throughout, this patient's L4- L5 interspace was anesthetized with the 1% lidocaine solution following the above sterile preparation, entered with a 22-gauge styletted spinal needle of approximately 0.5 mL clear CSF, they were very slow to obtain.  The fluid was obtained, the needle was removed, and sterile bandage was placed.  The fluid was sent to laboratory for further evaluation (aunt and grandmother) were present throughout the period of time during this procedure and the procedure was tolerated well.  An i-STAT initially obtained showed somewhat of an acidosis with a base excess of -12.  A repeat i-STAT after a bolus of normal saline and a second bolus of normal saline, her maintenance rate of D5 half showed a base excess of -11, which is slowly improving, but not very fast.  Based on the above having this patient consulted to the Hospitalist Service at 2326 hours of request, this patient was consulted to PICU with the plan that the patient need to have continued IV fluids.  Showing signs of dehydration, a third bolus of normal saline was provided, twice maintenance D5 half was continued.  The patient was admitted to the Hospitalist Service for continued IV fluids.  The patient maintains to have clear lungs, has been feeding well here in the department, took virtually a whole small bottle of the appropriate formula.  She has not had any vomiting, is burping.  The patient is admitted for continued close observation and rehydration due to the working diagnoses of gastroenteritis, metabolic acidosis, and dehydration.  Critical care time on this patient is less than 30 minutes, exclusive, otherwise time has been spent evaluating this patient according to this patient's care and admission to the Hospitalist Service.",
" Status post brain tumor with removal.  The patient did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.  ", Consult - History and Phy., Speech Therapy Evaluation - 1 ,"DIAGNOSIS: , Status post brain tumor with removal.,SUBJECTIVE:  ,The patient is a 64-year-old female with previous medical history of breast cancer that has metastasized to her lung, liver, spleen, and brain, status post radiation therapy.  The patient stated that on 10/24/08 she had a brain tumor removed with subsequent left-sided weakness.  The patient was readmitted to ABC Hospital on 12/05/08 and was found to have massive swelling in the brain and a second surgery was performed to reduce the swelling.  The patient remained at the acute rehab at ABC until she was discharged home on 01/05/09.  The patient did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.  The patient also complains of difficulty with word retrieval and slurring of speech.  The patient denies any difficulty with swallowing at this time.,OBJECTIVE:  ,Portions of the cognitive linguistic quick test was administered.  An oral mechanism exam was performed.  A motor speech protocol was completed.,The cognitive linguistic subtests of recalling personal facts, symbol cancellation, confrontational naming, clock drawing, story retelling, generative naming, design and memory, and completion of mazes was administered.,The patient was 100% accurate with recalling personal facts, completion of the symbol cancellation tasks, and with confrontational naming.  She had no difficulty with the clock drawing task; however, she has considerable hand tremors, which makes writing difficult.  In the storytelling task, she scored within normal limits.  She was also within normal limits for generative naming.  She did have difficulty with the design, memory, and mazes subtests.  She was unable to complete the second maze during the allotted time.  The design generation subtest was also completed.  She was able to draw four unique designs, and toward the end of the tasks was no longer able to recall the stated direction.,ORAL MECHANISM EXAMINATION:,  The patient has mild left facial droop with decreased nasolabial fold.  Tongue is at midline, and lingual range of motion and strength are within functional limit.  The patient does complain of biting her tongue on occasion, but denied biting the inside of her cheeks.  Her AMRs are judged to be within functional limit.  Her rate of speech is decreased with a monotonous vocal quality.  The decreased rate may be a compensation for decreased word retrieval ability.  The patient's speech is judged to be 100% intelligible without background noise.,DIAGNOSTIC IMPRESSION:  ,The patient has mild cognitive linguistic deficits in the areas of higher level cognitive function seen in mental flexibility, memory, and executive function.,PLAN OF CARE:,  Outpatient skilled speech therapy two times a week for four weeks to include cognitive linguistic treatment.,SHORT-TERM GOALS (THREE WEEKS):,1.  The patient will complete deductive reasoning and mental flexibility tasks with greater than 90% accuracy, independently.,2.  The patient will complete perspective memory test with 100% accuracy using compensatory strategy.,3.  The patient will complete visual perceptual activities, which focus on scanning, flexibility, and problem solving with greater than 90% accuracy with minimal cueing.,4.  The patient will listen to and/or read a lengthy narrative and be able to recall at least 6 details after a 15-minute delay, independently.,PATIENT'S GOAL:  ,To improve functional independence and cognitive abilities.,LONG-TERM GOAL (FOUR WEEKS):  ,Functional cognitive linguistic abilities to improve safety and independence at home and to decrease burden of care on caregiver.,","consult - history and phy., linguistic skills, memory, mental flexibility, deductive reasoning, skilled speech therapy, speech therapy, cognitive linguistic, therapy, linguistic, speech, cognitive, "
" Healthy checkups and sports physical - 12 years old - Healthy Tanner III male, developing normally.", Consult - History and Phy., Sports Physical - 3 ,"SUBJECTIVE:,  This is a 12-year-old male who comes in for healthy checkups and sports physical.  No major concerns today.  He is little bit congested at times.  He has been told he is allergic to grasses.  They have done over-the-counter Claritin and that seems to help but he is always sniffling mother reports.  He has also got some dryness on his face as far as the skin and was wondering what cream he could put on.,PAST MEDICAL HISTORY:,  Otherwise, reviewed.  Very healthy.,CURRENT MEDICATIONS:,  Claritin p.r.n.,ALLERGIES TO MEDICINES:,  None.,FAMILY SOCIAL HISTORY:,  Everyone else is healthy at home currently.,DIETARY:,  He is on whole milk and does a variety of foods.  Growth chart is reviewed with mother.  Voids and stools well.,DEVELOPMENTAL:,  He is in seventh grade and going out for cross-country and track.  He is supposed to be wearing glasses, is not today.  We did not test his vision because he recently saw the eye doctor though we did discuss the need for him to wear glasses with mother.  His hearing was normal today and no concerns with speech.,PHYSICAL EXAMINATION:,General:  A well-developed, well-nourished male in no acute distress.,Dermatologic:  Without rash or lesion.,HEENT:  Head normocephalic and atraumatic.  Eyes:  Pupils equal, round and reactive to light.  Extraocular movements intact.  Red reflexes are present bilaterally.  Optic discs are sharp with normal vasculature.  Ears:  Tympanic membranes are gray, translucent with normal light reflex.  Nares are very congested.  Turbinates swollen and boggy.,Neck:  Supple without masses.,Chest:  Clear to auscultation and percussion, easy respirations.  No accessory muscle use.,Cardiovascular:  Regular rate and rhythm without murmurs, rubs, heaves or gallops.,Back:  Symmetric with no scoliosis or kyphosis noted.  Normal flexibility.  Femoral pulses 2+ and symmetric.,Abdomen:  Soft, nontender, nondistended without hepatosplenomegaly.,GU Exam:  Normal Tanner III male.  Testes descended bilaterally.  No abnormal rash, discharge, or scars.,Extremities:  Pink and warm.  Moves all extremities well with normal function and strength in the arms and legs.  Normal balance, station, and gait.  Normal speech.,Neurologic:  Nonfocal with normal speech, station, gait, and balance.,ASSESSMENT:,  Healthy Tanner III male, developing normally.,PLAN:,1.  Diet, growth, safety, drugs, violence, and social competence all discussed.,2.  Immunizations reviewed.,3.  We will place him on Clarinex 5 mg once daily, some Rhinocort-AQ nasal spray one spray each nostril once daily and otherwise discussed the importance of him wearing glasses.,4.  Return to clinic p.r.n. and at two to three years for a physical, otherwise return p.r.n.",
" Patient with postnasal drainage, sore throat, facial pain, coughing, headaches, congestion, snoring, nasal burning and teeth pain.", Consult - History and Phy., Sinus problems - Consult ,"CHIEF COMPLAINT:, Sinus problems.,SINUSITIS HISTORY:, The problem began 2 weeks ago and is constant. Symptoms include postnasal drainage, sore throat, facial pain, coughing, headaches and congestion. Additional symptoms include snoring, nasal burning and teeth pain. The symptoms are characterized as moderate to severe. Symptoms are worse in the evening and morning.,REVIEW OF SYSTEMS:,ROS General: General health is good.,ROS ENT: As noted in history of present Illness listed above.,ROS Respiratory: Patient denies any respiratory complaints, such as cough, shortness of breath, chest pain, wheezing, hemoptysis, etc.,ROS Gastrointestinal: Patient denies any nausea, vomiting, abdominal pain, dysphagia or any altered bowel movements.,ROS Respiratory: Complaints include coughing.,ROS Neurological: Patient complains of headaches. All other systems are negative.,PAST SURGICAL HISTORY:, Gallbladder 7/82. Hernia 5/79,PAST MEDICAL HISTORY:, Negative.,PAST SOCIAL HISTORY:, Marital Status: Married. Denies the use of alcohol. Patient has a history of smoking 1 pack of cigarettes per day and for the past 15 years. There are no animals inside the home.,FAMILY MEDICAL HISTORY:, Family history of allergies and hypertension.,CURRENT MEDICATIONS:, Claritin. Dilantin.,PREVIOUS MEDICATIONS UTILIZED:, Rhinocort Nasal Spray.,EXAM:,Exam Ear: Auricles/external auditory canals reveal no significant abnormalities bilaterally. TMs intact with no middle ear effusion and are mobile to insufflation.,Exam Nose: Intranasal exam reveals moderate congestion and purulent mucus.,Exam Oropharynx: Examination of the teeth/alveolar ridges reveals missing molar (s). Examination of the posterior pharynx reveals a prominent uvula and purulent postnasal drainage. The palatine tonsils are 2+ and cryptic.,Exam Neck: Palpation of anterior neck reveals no tenderness. Examination of the posterior neck reveals mild tenderness to palpation of the suboccipital muscles.,Exam Facial: There is bilateral maxillary sinus tenderness to palpation.,X-RAY / LAB FINDINGS:, Water's view x-ray reveals bilateral maxillary mucosal thickening.,IMPRESSION:, Acute maxillary sinusitis (461.0).  Snoring (786.09).,MEDICATION:, Augmentin. 875 mg bid. MucoFen 800 mg bid.,PLAN:,",
" Global aphasia.  The patient is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.   ", Consult - History and Phy., Speech Therapy Evaluation ,"MEDICAL DIAGNOSIS:,  Strokes.,SPEECH AND LANGUAGE THERAPY DIAGNOSIS:  ,Global aphasia.,SUBJECTIVE:  ,The patient is a 44-year-old female who is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.  The patient's sister-in-law was present throughout this assessment and provided all the patient's previous medical history.  Based on the sister-in-law's report, the patient had a stroke on 09/19/08.  The patient spent 6 weeks at XY Medical Center, where she was subsequently transferred to XYZ for therapy for approximately 3 weeks.  ABCD brought the patient to home the Monday before Thanksgiving, because they were not satisfied with the care the patient was receiving at a skilled nursing facility in Tucson.  The patient's previous medical history includes a long history of illegal drug use to include cocaine, crystal methamphetamine, and marijuana.  In March of 2008, the patient had some type of potassium issue and she was hospitalized at that time.  Prior to the stroke, the patient was not working and ABCD reported that she believes the patient completed the ninth grade, but she did not graduate from high school.  During the case history, I did pose several questions to the patient, but her response was often ""no.""  She was very emotional during this evaluation and crying occurred multiple times.,OBJECTIVE:  ,To evaluate the patient's overall communication ability, a Western Aphasia Battery was completed.  Also tests were not done due to time constraint and the patient's severe difficulty and emotional state.  Speech automatic tests were also completed to determine if the patient had any functional speech.,ASSESSMENT:,  Based on the results of the Weston aphasia battery, the patient's deficits most closely resemble global aphasia.  On the spontaneous speech subtest, the patient responded ""no"" to all questions asked except for how are you today where she gave a thumbs-up.  She provided no responses to picture description task and it is unclear if the patient was unable to follow the direction or if she was unable to see the picture clearly.  The patient's sister-in-law did state that the patient wore glasses, but she currently does not have them and she did not know the extent the patient's visual deficit.,On the auditory verbal comprehension portion of the Western Aphasia Battery, the patient answered ""no"" to all ""yes/no"" questions.  The auditory word recognition subtest, the patient had 5 out of 60 responses correct.  With the sequential command, she had 10 out of 80 corrects.  She was able to shut her eyes, point to the window, and point to the pen after directions.  With repetition subtest, she repeated bed correctly, but no other stimuli.  At this time, the patient became very emotional and repeatedly stated ""I can't"".  During the naming subtest of the Western Aphasia Battery, the patient's responses contained numerous paraphasias and her speech was often unintelligible due to jargon.  The word fluency test was not administered and the patient scored 2 out of 10 on the sentence completion task and 0 out of 10 on the responsive speech.  In regards to speech automatics, the patient is able to count from 1 to 9 accurately; however, stated 7 instead of 10 at the end of the task.  She is not able to state the days of the week or months in the year or her name at this time.  She cannot identify the day on calendar and was unable to verbally state the date or month.,DIAGNOSTIC IMPRESSION:  ,The patient's communication deficits most closely resemble global aphasia where she has difficulty with both receptive as well as expressive communication.  She does perseverate and is very emotional due to probable frustration.  Outpatient skilled speech therapy is recommended to improve the patient's functional communication skills.,PATIENT GOAL: , Her sister-in-law stated that they would like to improve upon the patient's speech to allow her to communicate more easily at home.,PLAN OF CARE: , Outpatient skilled speech therapy two times a week for the next 12 weeks.  Therapy to include aphasia treatment and home activities.,SHORT-TERM GOALS (8 WEEKS):,1.  The patient will answer simple ""yes/no"" questions with greater than 90% accuracy with minimal cueing.,2.  The patient will be able to complete speech automatic tasks with greater than 80% accuracy without models or cueing.,3.  The patient will be able to complete simple sentence completion and/or phrase completion with greater than 80% accuracy with minimal cueing.,4.  The patient will be able to follow simple one-step commands with greater than 80% accuracy with minimal cueing.,5.  The patient will be able to name 10 basic everyday objects with greater than 80% accuracy with minimal cueing.,SHORT-TERM GOALS (12 WEEKS):,  Functional communication abilities to allow the patient to express her basic wants and needs.","consult - history and phy., speech automatic tasks, minimal cueing, sentence completion, western aphasia battery, skilled speech therapy, global aphasia, speech therapy, speech, aphasia, "
 Well-child check and school physical., Consult - History and Phy., School Physical - 2 ,"CHIEF COMPLAINT:,  Well-child check and school physical.,HISTORY OF PRESENT ILLNESS:,  This is a 9-year-old African-American male here with his mother for a well-child check.  Mother has no concerns at the time of the visit.  She states he had a pretty good school year.  He still has some fine motor issues, especially writing, but he is receiving help with that and math.  He continues to eat well.  He could do better with milk intake, but Mother states he does eat cheese and yogurt.  He brushes his teeth daily.  He has regular dental visits every six months.  Bowel movements are without problems.  He is having some behavior issues, and sometimes he tries to emulate his brother in some of his negative behaviors.,DEVELOPMENTAL ASSESSMENT:,  Social:  He has a sense of humor.  He knows his rules.  He does home chores.  Fine motor:  He is as mentioned before.  He can draw a person with six parts.  Language:  He can tell time.  He knows the days of the week.  He reads for pleasure.  Gross motor:  He plays active games.  He can ride a bicycle.,REVIEW OF SYSTEMS:,  He has had no fever and no vision problems.  He had an eye exam recently with Dr. Crum.  He has had some headaches which precipitated his vision exam.  No earache or sore throat.  No cough, shortness of breath or wheezing.  No stomachache, vomiting or diarrhea.  No dysuria, urgency or frequency.  No excessive bleeding or bruising.,MEDICATIONS:,  No daily medications.,ALLERGIES:,  Cefzil.,IMMUNIZATIONS:,  His immunizations are up to date.,PHYSICAL EXAMINATION:,General:  He is alert and in no distress, afebrile.,HEENT:  Normocephalic, atraumatic.  Pupils equal, round and react to light.  TMs are clear bilaterally.  Nares:  Patent.  Oropharynx is clear.,Neck:  Supple.,Lungs:  Clear to auscultation.,Heart:  Regular.  No murmur.,Abdomen:  Soft.  Positive bowel sounds.  No masses.  No hepatosplenomegaly.,GU:  Tanner III.,Extremities:  Symmetrical.  Femoral pulses 2+ bilaterally.  Full range of motion of all extremities.,Back:  No scoliosis.,Neurological:  Grossly intact.,Skin:  Normal turgor.  No rashes.,Hearing:  Grossly normal.,ASSESSMENT:,  Well child.,PLAN:,  Anticipatory guidance for age.  He is to return to the office in one year.",
" History of abdominal pain, obstipation, and distention with nausea and vomiting - paralytic ileus and mechanical obstruction.", Consult - History and Phy., Small Bowel Obstruction ,"CHIEF COMPLAINT:,  Patient AF is a 50-year-old hepatitis C positive African-American man presenting with a 2-day history of abdominal pain and distention with nausea and vomiting.,HISTORY OF PRESENT ILLNESS: , AF's symptoms began 2 days ago, and he has not passed gas or had any bowel movements.  He has not eaten anything, and has vomited 8 times.  AF reports 10/10 pain in the LLQ.,PAST MEDICAL HISTORY:,  AF's past medical history is significant for an abdominal injury during the Vietnam War which required surgery, and multiple episodes of small bowel obstruction and abdominal pain.  Other elements of his history include alcoholism, cocaine abuse, alcoholic hepatitis, hepatitis C positive, acute pancreatitis, chronic pancreatitis, appendicitis, liver hematoma/contusion, Hodgkin's Disease, constipation, diarrhea, paralytic ileus, anemia, multiple blood transfusions, chorioretinitis, pneumonia, and ""crack chest pain"" ,PAST SURGICAL HISTORY: , AF has had multiple abdominal surgeries, including Bill Roth Procedure Type 1 (partial gastrectomy) during Vietnam War, at least 2 exploratory laparotomies and enterolysis procedures (1993; 2000), and appendectomy,MEDICATIONS:,  None.,ALLERGIES:,  Iodine, IV contrast (anaphylaxis), and seafood/shellfish.,FAMILY HISTORY:,  Noncontributory.,SOCIAL HISTORY:,  AF was born and raised in San Francisco.  His father was an alcoholic.  He currently lives with his sister, and does not work; he collects a pension.,HEALTH-RELATED BEHAVIORS:,  AF reports that he smokes 1 to 2 cigarettes per day, and drinks 40 ounces of beer per day.,REVIEW OF SYSTEMS: , Noncontributory, except that patient reports a 6 pound weight loss since his symptoms began, and reports multiple transfusions for anemia.,PHYSICAL EXAM:,Vital Signs:  T:  37.1",
 Sepsis.  The patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter., Consult - History and Phy., Sepsis - Consult ,"REASON FOR ADMISSION: , Sepsis.,HISTORY OF PRESENT ILLNESS:  ,The patient is a pleasant but demented 80-year-old male, who lives in board and care, who presented with acute onset of abdominal pain.  In the emergency room, the patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter.  The patient is unable to provide further history.  The patient's son is at the bedside and confirmed his history.  The patient was given IV antibiotics in the emergency room.  He was also given some hydration.,PAST MEDICAL HISTORY:,1.  History of CAD.,2.  History of dementia.,3.  History of CVA.,4.  History of nephrolithiasis.,ALLERGIES: , NONE.,MEDICATIONS:,1.  Ambien.,2.  Milk of magnesia.,3.  Tylenol.,4.  Tramadol.,5.  Soma.,6.  Coumadin.,7.  Zoloft.,8.  Allopurinol.,9.  Digoxin.,10.  Namenda.,11.  Zocor.,12.  BuSpar.,13.  Detrol.,14.  Coreg.,15.  Colace.,16.  Calcium.,17.  Zantac.,18.  Lasix.,19.  Seroquel.,20.  Aldactone.,21.  Amoxicillin.,FAMILY HISTORY:  ,Noncontributory.,SOCIAL HISTORY: , The patient lives in a board and care.  No tobacco, alcohol or IV drug use.,REVIEW OF SYSTEMS: , As per the history of present illness, otherwise unremarkable.,PHYSICAL EXAMINATION:,VITAL SIGNS:  The patient is currently afebrile.  Pulse 52, respirations 20, blood pressure 104/41, and saturating 98% on room air.,GENERAL:  The patient is awake.  Not oriented x3, in no acute distress.,HEENT:  Pupils are equal, round, and reactive to light and accommodation.  Extraocular movements are intact.  Mucous membranes are dry.,NECK:  Supple.  No thyromegaly.  No jugular venous distention.,HEART:  Irregularly irregular, brady.,LUNGS:  Clear to auscultation bilaterally anteriorly.,ABDOMEN:  Positive normoactive bowel sounds.  Soft.  Tenderness in the suprapubic region without rebound.,EXTREMITIES:  No clubbing, cyanosis or edema in upper and lower extremities.",
" Sick sinus syndrome, atrial fibrillation, pacemaker dependent, mild cardiomyopathy with ejection fraction 40% and no significant decompensation, and dementia of Alzheimer's disease with short and long term memory dysfunction", Consult - History and Phy., Sick Sinus Syndrome ,"HISTORY OF PRESENT ILLNESS: , The patient is an 85-year-old gentleman who has a history of sick sinus syndrome for which he has St. Jude permanent pacemaker.  Pacemaker battery has reached end of life and the patient is dependent on his pacemaker with 100% pacing in the right ventricle.  He also has a fairly advanced degree of Alzheimer's dementia and is living in an assisted care facility.  The patient is unable to make his own health care decision and his daughter ABC has medical power of attorney.  The patient's dementia has resulted in the patient's having sufficient and chronic anger and his daughter that he refuses to speak with her, refuses to be in a same room with her.  For this reason the Casa Grande Regional Medical Center would obtain surgical and anesthesia consent from the patient's daughter in the fashion keeps the patient and daughter separated.  Furthermore it is important to note that his degree of dementia has disabled the patient to adequately self monitor his status following surgery for significant changes and to seek appropriate medical care, hence he will be admitted after the pacemaker exchange.,PAST MEDICAL HISTORY:,1.  Sick sinus syndrome, pacemaker dependence with 100% with right ventricular pacing.,2.  Dementia of Alzheimer's disease.,3.  Gastroesophageal reflux disease.,4.  Multiple pacemaker implantation and exchanges.,FAMILY HISTORY: , Unobtainable.,SOCIAL HISTORY: , The patient resides full time at ABC supervised living facility.  He is nonsmoker, nondrinker.  He uses wheelchair and moves himself about with his feet.  He is independent of activities of daily living and dependent on independent activities of daily living.,ALLERGIES TO MEDICATIONS: , No known drug allergies.,MEDICATIONS:  ,Omeprazole 20 mg p.o. daily, furosemide 20 mg p.o. daily, citalopram 20 mg p.o. daily, loratadine 10 mg p.o. p.r.n.,REVIEW OF SYSTEMS: , A 10 systems review negative for chest pain, pressure, shortness of breath, paroxysmal nocturnal dyspnea, orthopnea, syncope, near-syncopal episodes.  Negative for recent falls.  Positive for significant memory loss.  All other review of systems is negative.,PHYSICAL EXAMINATION:,GENERAL:  The patient is an 85-year-old gentleman in no acute distress, sitting in the wheelchair.,VITAL SIGNS:  Blood pressure is 118/68, pulse is 80 and regular, respirations 16, weight is 200 pounds, oxygen saturation is 90% on room air.,HEENT:  Head atraumatic and normocephalic.  Eyes, pupils are equal and reactive to light and accommodate bilaterally, free from focal lesions.  Ears, nose, mouth, and throat.,NECK:  Supple.  No lymphadenopathy, thyromegaly, or thyroid masses appreciated.,CARDIOVASCULAR:  No JVD or no jugular venous distention.  No carotid bruits bilaterally.  Pacemaker pocket right upper thorax with healed surgical incisions.  S1 and S2 are normal.  No S3 or S4.  There are no murmurs.  No heaves or thrills, gout, or gallops.  Trace edema at dorsum of his feet and ankles.  Femoral pulses are present without bruits, posterior tibial pulses would be palpable bilaterally.,RESPIRATORY:  Breath sounds are clear but diminished throughout AP diameters expanded.  The patient speaks in full sentences.  No wheezing, no accessory muscles used for breathing.,GASTROINTESTINAL:  Abdomen is soft and nontender.  Bowel sounds are active in all 4 quadrants.  No palpable pulses.  No abdominal bruit is appreciated.  No hepatosplenomegaly.,GENITOURINARY:  Nonfocal.,MUSCULOSKELETAL:  Muscle strength in lower extremities is 4/5 bilaterally.  Upper extremities are 5/5 bilaterally with adequate range of motion.,SKIN:  Warm and dry.  No obvious rashes, lesions, or ulcerations. ,NEUROLOGIC:  Alert, not oriented to place and date.  His speech is clear.  There are no focal motor or sensory deficits.,PSYCHIATRIC:  Talkative, pleasant affect with limited impulse control, severe short-term memory loss.,LABORATORY DATA:,  Blood work dated 12/15/08, white count 4.7, hemoglobin 11.9, hematocrit 33.9, and platelets 115,000.  BUN 19, creatinine 1.15, glucose 94, potassium 4.5, sodium 140, and calcium 8.6.,DIAGNOSTIC DATA:,  St. Jude pacemaker interrogation dated 11/10/08 shows single chamber pacemaker and VVIR mode, implant date 08/2000, 100% paced in right ventricle, battery status is ERI.  A 12-lead ECG 12/15/08 shows 100% paced rhythm with rate of 80.  No Q waves at the baseline of atrial fibrillation.  Last measured ejection fraction 40% 12/08 with no significant decompensation.,IMPRESSION/PLAN:,1.  Sick sinus syndrome.,2.  Atrial fibrillation.,3.  Pacemaker dependent.,4.  Mild cardiomyopathy with ejection fraction 40% and no significant decompensation.,5.  Pacemaker battery end of life requiring exchange.,6.  Dementia of Alzheimer's disease with short and long term memory dysfunction.  The dementia disables the patient from recognizing changes in his health status in knowing if he needed to seek appropriate health care.  Dementia also renders the patient incapable informed consent, schedule the patient for pacemaker.  I explain the patient and reimplantation with any device in the surgical suite.  He will require anesthesia assistance for adequate sedation as the patient possesses behavioral risk secondary to his advanced dementia.,7.  Admit the patient after surgery for postoperative care and monitoring.",
" Severe back pain and sleepiness.  The patient, because of near syncopal episode and polypharmacy, almost passed out for about 3 to 4 minutes with a low blood pressure.", Consult - History and Phy., Sleepiness - Consult ,"CHIEF COMPLAINT: , Severe back pain and sleepiness.,The patient is not a good historian and history was obtained from the patient's husband at bedside.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 76-year-old obese Caucasian female with past medical conditions that includes hypertension, history of urinary incontinence, dementia, and chronic back pain, basically brought by the husband to the emergency room because of having excruciating back pain.  As per the husband, the patient has this back pain for about almost 1 year and seeing Dr. X in Neurosurgery and had an epidural injection x2, and then the patient's pain somewhat got better between, but last time the patient went to see Dr. X, the patient given injection and the patient passed out, so the doctor stopped giving any other epidural injection.  The patient has severe pain and all in all, the patient cries at home.  As per the husband, the patient woke up in the morning with severe pain, unable to eat, drink today, and crying in the morning, so brought her to the emergency room for further evaluation.  The patient denied any history of fever, cough, chest pain, diarrhea, dysuria or polyuria.  While I was examining the patient, the patient explained about possible diagnosis and treatment plan and possible nursing home discharge for pain control.  The patient passed out for about 3 to 4 minutes, unable to respond to even painful stimuli.  The patient's heart rate went down to 50s and blood pressure was 92 systolic, so the patient was later on given IV fluid and blood pressure checked.  The patient woke up after 5 to 6 minutes, so the patient was later on evaluated for admission because of near syncopal episode.,PAST MEDICAL CONDITIONS:,  Include hypertension, dementia, urinary incontinence, chronic back pain, and degenerative joint disease of the spine.  No history of diabetes, stroke or coronary artery disease.,SURGICAL HISTORY: , Include left total hip replacement many years ago, history of hysterectomy, and appendectomy in the young age.,ALLERGIES: , DENIED.,CURRENT MEDICATIONS: , According to the list shows the patient takes hydrocodone 10/325 mg every 6 hours, Flexeril 10 mg p.o. at bedtime, and Xanax 0.25 mg p.o. 4 times a day.  The patient also takes Neurontin 200 mg 3 times a day, propranolol 10 mg twice a day, oxybutynin 5 mg p.o. twice a day, Namenda 10 mg p.o. daily, and Aricept 10 mg p.o. daily.,SOCIAL HISTORY: , She lives with her husband, usually walks with a walker and wheelchair-bound, does not walk much as per the husband knows.  No history of alcohol abuse or smoking.,PHYSICAL EXAMINATION:,GENERAL:  Currently lying in the bed without apparent distress, very lethargic.,VITAL SIGNS:  Pulse rate of 55, blood pressure is 92/52, after IV fluid came up to 105/58.,CHEST:  Shows bilateral air entry present, clear to auscultate.,HEART:  S1 and S2 regular.,ABDOMEN:  Soft, nondistended, and nontender.,EXTREMITIES:  Shows the patient's straight leg raising to be only up to 30% causing the patient severe back pain.,IMAGING: , The patient's x-ray of the lumbosacral spine done shows there is a L1 compression fracture with some osteophyte formation in the lumbar spine suggestive of degenerative joint disease.,LABORATORY DATA: , The patient's lab test is not done currently, but previous lab test done in 3/2009 seems to be in acceptable range.,IMPRESSION: , The patient, because of near syncopal episode and polypharmacy, almost passed out for about 3 to 4 minutes in front of me with a low blood pressure.,1.  Vasovagal syncope versus polypharmacy because of 3 to 4 medications and muscle relaxants.,2.  Osteoporosis of the spine with L1 compression fracture causing the patient severe pain.,3.  Hypertension, now hypotension.,4.  Incontinence of the bladder.,5.  Dementia, most likely Alzheimer type.,PLAN AND SUGGESTION: , Initial plan was to send the patient to the nursing home, but because of the patient's low blood pressure and heart rate low, we will admit the patient to DOU for 23-hour observation, start the patient on IV fluid, normal saline, 20 mEq KCl, and Protonix 40 mg, and we will also continue the patient's Namenda and Aricept.  I will hold the patient's hydrocodone.  I will hold the Flexeril and I will also hold gabapentin at this moment.  We will give the patient's pain control with Percocet and very minimal morphine sulfate as needed.  Also give the patient calcium with vitamin D and physical therapy.  We will also order a blood test and further management will be based on the patient's all test results.  I also explained to the husband that tomorrow if the patient is better and more alert and awake, then we will send her to the nursing care versus home, it depends on the pain control.",
 Consultation for right shoulder pain., Consult - History and Phy., Shoulder Pain Consult ,"CHIEF COMPLAINT:,  Right shoulder pain.,HISTORY OF PRESENT PROBLEM:","consult - history and phy., shoulder pain, history of present problem:, cortisone shot, no numbness or tingling, rhomboids, scapula, shoulder impingement, focal findings, shoulder,"
" Well-child check sports physical - Well child asthma with good control, allergic rhinitis.", Consult - History and Phy., Sports Physical - 2 ,"CHIEF COMPLAINT:,  Well-child check sports physical.,HISTORY OF PRESENT ILLNESS:,  This is a 14-1/2-year-old white male known to have asthma and allergic rhinitis.  He is here with his mother for a well-child check.  Mother states he has been doing well with regard to his asthma and allergies.  He is currently on immunotherapy and also takes Advair 500/50 mg, Flonase, Claritin and albuterol inhaler as needed.  His last exacerbation was 04/04.  He has been very competitive in his sports this spring and summer and has had no issues since that time.  He eats well from all food groups.  He has very good calcium intake.  He will be attending Maize High School in the ninth grade.  He has same-sex and opposite-sex friends.  He has had a girlfriend in the past.  He denies any sexual activity.  No use of alcohol, cigarettes or other drugs.  His bowel movements are without problems.  His immunizations are up to date.  His last tetanus booster was in 07/03.,CURRENT MEDICATIONS:,  As above.,ALLERGIES: , He has no known medication allergies.,REVIEW OF SYSTEMS:,Constitutional:  He has had no fever.,HEENT:  No vision problems.  No eye redness, itching or drainage.  No earache.  No sore throat or congestion.,Cardiovascular:  No chest pain.,Respiratory:  No cough, shortness of breath or wheezing.,GI:  No stomachache, vomiting or diarrhea.,GU:  No dysuria, urgency or frequency.,Hematological:  No excessive bruising or bleeding.  He did have a minor concussion in 06/04 while playing baseball.,PHYSICAL EXAMINATION:,General:  He is alert and in no distress.,Vital signs:  He is afebrile.  His weight is at the 75th percentile.  His height is about the 80th percentile.,HEENT:  Normocephalic.  Atraumatic.  Pupils are equal, round and reactive to light.  TMs are clear bilaterally.  Nares patent.  Nasal mucosa is mildly edematous and pink.  No secretions.  Oropharynx is clear.,Neck:  Supple.,Lungs:  Good air exchange bilaterally.,Heart:  Regular.  No murmur.,Abdomen:  Soft.  Positive bowel sounds.  No masses.  No hepatosplenomegaly.,GU:  Male.  Testes descended bilaterally.  Tanner IV.  No hernia appreciated.,Extremities:  Symmetrical.  Femoral pulses 2+ bilaterally.  Full range of motion of all extremities.,Back:  No scoliosis.,Neurological:  Grossly intact.,Skin:  Normal turgor.  Minor sunburn on upper back.,Neurological:  Grossly intact.,ASSESSMENT:,1.  Well child.,2.  Asthma with good control.,3.  Allergic rhinitis, stable.,PLAN:,  Hearing and vision assessment today are both within normal limits.  Will check an H&H today.  Continue all medications as directed.  Prescription written for albuterol inhaler, #2, one for home and one for school to be used for rescue.  Anticipatory guidance for age.  He is to return to the office in one year or sooner if needed.",
  This patient was seen in clinic for a school physical., Consult - History and Phy., School Physical - 1 ,"SUBJECTIVE:,  This patient was seen in clinic for a school physical.,NUTRITIONAL HISTORY:,  She eats well, takes meats, vegetables, and fruits, but her calcium intake is limited.  She does not drink a whole lot of pop.  Her stools are normal.  Brushes her teeth, sees a dentist.,Developmental History:  Hearing and vision is okay.  She did well in school last year.  She will be going to move to Texas, will be going to Bowie High School.  She will be involved in cheerleading, track, volleyball, and basketball.  She will be also playing the clarinet and will be a freshman in that school.  Her menarche was 06/30/2004.,PAST MEDICAL HISTORY:,  She is still on medications for asthma.  She has a problem with her eye lately, this has been bothering her, and she also has had a rash in the left leg.  She had been pulling weeds on 06/25/2004 and then developed a rash on 06/27/2004.,Review of her immunizations, her last tetanus shot was 06/17/2003.,MEDICATIONS:  ,Advair 100/50 b.i.d., Allegra 60 mg b.i.d., Flonase q.d., Xopenex, Intal, and albuterol p.r.n.,ALLERGIES: , No known drug allergies.,OBJECTIVE:,Vital Signs:  Weight:  112 pounds about 40th percentile.  Height:  63-1/4 inches, also the 40th percentile.  Her body mass index was 19.7, 40th percentile.  Temperature:  97.7 tympanic.  Pulse:  80.  Blood pressure:  96/64.,HEENT:  Normocephalic.  Fundi benign.  Pupils equal and reactive to light and accommodation.  No strabismus.  Her vision was 20/20 in both eyes and each with contacts.  Hearing:  She passed that test.  Her TMs are bilaterally clear and nonerythematous.  Throat was clear.  Good mucous membrane moisture and good dentition.,Neck:  Supple.  Thyroid normal sized.  No increased lymphadenopathy in the submandibular nodes and no axillary nodes.,Abdomen:  No hepatosplenomegaly.,Respiratory:  Clear.  No wheezes.  No crackles.  No tachypnea.  No retractions.,Cardiovascular:  Regular rate and rhythm.  S1 and S2 normal.  No murmur.,Abdomen:  Soft.  No organomegaly and no masses.,GU:  Normal female genitalia.  Tanner stage 3, breast development and pubic hair development.  Examination of the breasts was negative for any masses or abnormalities or discharge from her areola.,Extremities:  She has good range of motion of upper and lower extremities.  Deep tendon reflexes were 2+/4+ bilaterally and equal.  Romberg negative.,Back:  No scoliosis.  She had good circumduction at shoulder joint and her duck walk was normal.,SKIN:  She did have some rash on the anterior left thigh region and also some on the right lower leg that had Kebner phenomenon and maculopapular vesicular eruption.  No honey crusting was noted on the skin.  She also had some mild rash on the anterior abdominal area near the panty line similar to that rash.  It was raised and blanch with pressure, it was slightly erythematous.,ASSESSMENT AND PLAN:,1.  Sports physical.,2.  The patient received her first hepatitis A vaccine.  She will get a booster in 6 to 12 months.  Prescription for Atarax 10 mg tablets one to two tablets p.o. q.4-6h. p.r.n. and a prescription for Elocon ointment to be applied topically, except for the face, once a day with a refill.  She will be following up with an allergist as soon as she gets to Texas and needs to find a primary care physician.  We talked about anticipatory guidance including breast exam, which we have reviewed with her today, seatbelt use, and sunscreen.  We talked about avoidance of drugs and alcohol and sexual activity.  Continue on her present medications and if her rash is not improved and goes to the neck or the face, she will need to be on PO steroid medication, but presently that was held and moved to treatment with Atarax and Elocon.  Also talked about cleaning her clothes and bedding in case she has any poison ivy oil that is harboring on any clothing.","consult - history and phy., school physical, calcium intake, hearing and vision, hepatitis a vaccine, booster, anticipatory guidance, developmental, percentile, physical, school, rash, "
" A 71-year-old female who I am seeing for the first time.  She has a history of rheumatoid arthritis for the last 6 years.  She is not on DMARD, but as she recently had a surgery followed by a probable infection.", Consult - History and Phy., Rheumatoid Arthritis - Consult ,"HISTORY OF PRESENT ILLNESS: , A 71-year-old female who I am seeing for the first time.  She has a history of rheumatoid arthritis for the last 6 years.  She was followed by another rheumatologist.  She says she has been off and on, on prednisone and Arava.  The rheumatologist, as per the patient, would not want her to be on a long-term medicine, so he would give her prednisone and then switch to Arava and then switch her back to prednisone.  She says she had been on prednisone for the last 6 to 9 months.  She is on 5 mg a day.  She recently had a left BKA and there was a question of infection, so it had to be debrided.  I was consulted to see if her prednisone is to be continued.  The patient denies any joint pains at the present time.  She says when this started she had significant joint pains and was unable to walk.  She had pain in the hands and feet.  Currently, she has no pain in any of her joints.,REVIEW OF SYSTEMS: , Denies photosensitivity, oral or nasal ulcer, seizure, psychosis, and skin rashes.,PAST MEDICAL HISTORY: , Significant for hypertension, peripheral vascular disease, and left BKA.,FAMILY HISTORY:  ,Noncontributory.,SOCIAL HISTORY: , Denies tobacco, alcohol or illicit drugs.,PHYSICAL EXAMINATION:,VITAL SIGNS:  BP 130/70, heart rate 80, and respiratory rate 14.,HEENT:  EOMI.  PERRLA.,NECK:  Supple.  No JVD.  No lymphadenopathy.,CHEST:  Clear to auscultation.,HEART:  S1 and S2.  No S3, no murmurs.,ABDOMEN:  Soft and nontender.  No organomegaly.,EXTREMITIES:  No edema.,NEUROLOGIC:  Deferred.,ARTICULAR:  She has swelling of bilateral wrists, but no significant tenderness.,LABORATORY DATA:,  Labs in chart was reviewed.,ASSESSMENT AND PLAN:,  A 71-year-old female with a history of rheumatoid arthritis, on longstanding prednisone.  She is not on DMARD, but as she recently had a surgery followed by a probable infection, I will hold off on that.  As she has no pain, I have decreased the prednisone to 2.5 mg a day starting tomorrow if she is to go back to her nursing home tomorrow.  If in a couple of weeks her symptoms stay the same, then I would discontinue the prednisone.  I would defer that to Dr. X.  If she flares up at that point, prednisone may have to be restarted with a DMARD, so that eventually she could stay off the prednisone.  I discussed this at length with the patient and she is in full agreement with the plan.  I explained to her that if she is to be discharged, if she wishes, she could follow up with me in clinic or if she goes back to Victoria, then see her rheumatologist over there.","consult - history and phy., prednisone, joint pains, rheumatoid arthritis, arthritis, dmard, rheumatologist, rheumatoid, pains, "
" Renal failure evaluation for possible dialysis therapy.  Acute kidney injury of which etiology is unknown at this time, with progressive azotemia unresponsive to IV fluids.", Consult - History and Phy., Renal Failure Evaluation ,"REASON FOR CONSULTATION:,  Renal failure evaluation for possible dialysis therapy.,HISTORY OF PRESENT ILLNESS:,  This is a 47-year-old gentleman, who works offshore as a cook, who about 4 days ago noted that he was having some swelling in his ankles and it progressively got worse over the past 3 to 4 days, until he was swelling all the way up to his mid thigh bilaterally.  He also felt like he could not make much urine, and his wife, who is a nurse instructed him to force fluids.  While he was there, he was drinking cranberry juice, some Powerade, but he also has a history of weightlifting and had been taking on a creatine protein drink on a daily basis for some time now.  He presented here with very decreased urine output until a Foley catheter was placed and about 500 mL was noted in his bladder.  He did have a CPK level of about 234 while his BUN and creatinine on admission were 109 and 6.9.  Despite IV hydration fluids, his potassium has gone up from 5.4 to 6.1.  He did not put out any significant urine and his weight was documented at 103 kg.  He was given a dose of Kayexalate.  His potassium came down to like about 5.9 and urine studies were ordered.  His urinalysis did show that he had microscopic hematuria and proteinuria and his protein-creatinine ratio was about 9 gm of protein consistent with nephrotic range proteinuria.  He did have a low albumin of 1.9.  He denied any nonsteroidal usage, any recreational drug abuse, and his urine drug screen was unremarkable, and he denied any history of hypertension or any other medical problems.  He has not had any blood work except for drug screens that are required by work and no work up by any primary care physician because he has not seen one for primary care.  He is very concerned because his mother and father were both on dialysis, which he thinks were due to diabetes and both parents have expired.  He denied any hemoptysis, gross hematuria, melena, hematochezia, hemoptysis, hematemesis, no seizures, no palpitations, no pruritus, no chest pain.  He did have a decrease in his appetite, which all started about Thursday.  We were asked to see this patient in consultation by Dr. X because of his renal failure and the need for possible dialysis therapy.  He was significantly hypertensive on admission with a blood pressure of 162/80.,PAST MEDICAL HISTORY: , Unremarkable.,PAST SURGICAL HISTORY: , Unremarkable.,FAMILY HISTORY: , Both mother and father were on dialysis of end-stage renal disease.,SOCIAL HISTORY: , He is married.  He does smoke despite understanding the risks associated with smoking a pack every 6 days.  Does not drink alcohol or use any recreational drug use.  He was on no prescribed medications.  He did have a fairly normal PSA of about 119 and I had ordered a renal ultrasound which showed fairly normal-sized kidneys and no evidence of hydronephrosis or mass, but it was consistent with increased echogenicity in the cortex, findings representative of medical renal disease.,PHYSICAL EXAMINATION:,Vital signs:  Blood pressure is 153/77, pulse 66, respiration 18, temperature 98.5.,General:  He was alert and oriented x 3, in no apparent distress, well-developed male.,HEENT:  Normocephalic, atraumatic.  Pupils are equal, round, and reactive to light.  Extraocular muscles intact.,Neck:  Supple.  No JVD, adenopathy, or bruit.,Chest:  Clear to auscultation.,Heart:  Regular rate and rhythm without a rub.,Abdomen:  Soft, nontender, nondistended.  Positive bowel sounds.,Extremities:  Showed no clubbing, cyanosis.  He did have 2+ pretibial edema in both lower extremities.,Neurologic:  No gross focal findings.,Skin:  Showed no active skin lesions.,LABORATORY DATA: , Sodium 138, potassium 6.1, chloride 108, CO2 22, glucose 116, BUN 111, creatinine 7.29, estimated GFR 10 mL/minute.  Calcium 7.4 with an albumin of 1.9.  Mag normal at 2.2.  Urine culture negative at 12 hours.  His Random urine sodium was low at 12.  Random urine protein was 4756, and creatinine in the urine was 538.  Urine drug screen was unremarkable.  Troponin was within normal limits.  Phosphorus slightly elevated at 5.7.  CPK level was 234, white blood cells 6.5, hemoglobin 12.2, platelet count 188,000 with 75% segs.  PT 10.0, INR 1.0, PTT at 27.3.  B-natriuretic peptide 718.  Urinalysis showed 3+ protein, 4+ blood, negative nitrites, and trace leukocytes, 5 to 10 wbc's, greater than 100 rbc's, occasional fine granular casts, and moderate transitional cells.,IMPRESSION:,1.  Acute kidney injury of which etiology is unknown at this time, with progressive azotemia unresponsive to IV fluids.,2.  Hyperkalemia due to renal failure, slowly improving with Kayexalate.,3.  Microscopic hematuria with nephrotic range proteinuria, more consistent with a glomerulonephropathy nephritis.,4.  Hypertension.,PLAN: , I will give him Kayexalate 15 gm p.o. q.6h. x 2 more doses since he is responding and his potassium is already down to 5.2.  I will also recheck a urinalysis, consult the surgeon in the morning for temporary hemodialysis catheter placement, and consult case managers to start work on a transfer to ABCD Center per the patient and his wife's request, which will occur after his second dialysis treatment if he remains stable.  We will get a BMP, phosphorus, mag, CBC in the morning since he was given 80 mg of Lasix for fluid retention.  We will also give him 10 mg of Zaroxolyn p.o.  Discontinue all IV fluids.  Check an ANCA hepatitis profile, C3 and C4 complement levels along with CH 50 level.  I did discuss with the patient and his wife the need for kidney biopsy and they would like the kidney biopsy to be performed closer to home at Ochsner where his family is, since he only showed up here because of the nearest hospital located to his offshore job.  I do agree with getting him transferred once he is stable from his hyperkalemia and he starts his dialysis.,I appreciate consult.  I did discuss with him the importance of the kidney biopsies to direct treatment, finding the underlying etiology of his acute renal failure and to also give him prognostic factors of renal recovery.",
" Request for consultation to evaluate stomatitis, possibly methotrexate related.", Consult - History and Phy., Request For Consultation ,"REASON FOR CONSULTATION:, Please evaluate stomatitis, possibly methotrexate related.,HISTORY OF PRESENT ILLNESS:, The patient is a very pleasant 57-year old white female, a native of Cuba, being seen for evaluation and treatment of sores in her mouth that she has had for the last 10-12 days.  The patient has a long history of severe and debilitating rheumatoid arthritis for which she has had numerous treatments, but over the past ten years she has been treated with methotrexate quite successfully.  Her dosage has varied somewhere between 20 and 25 mg per week.  About the beginning of this year, her dosage was decreased from 25 mg to 20 mg, but because of the flare of the rheumatoid arthritis, it was increased to 22.5 mg per week.  She has had no problems with methotrexate as far as she knows.  She also took an NSAID about a month ago that was recently continued because of the ulcerations in her mouth.  About two weeks ago, just about the time the stomatitis began she was placed on an antibiotic for suspected upper respiratory infection.  She does not remember the name of the antibiotic.  Although she claims she remembers taking this type of medication in the past without any problems.  She was on that medication three pills a day for three to four days.  She notes no other problems with her skin.  She remembers no allergic reactions to medication.  She has no previous history of fever blisters.  ,PHYSICAL EXAMINATION:, Reveals superficial erosions along the lips particularly the lower lips.  The posterior buccal mucosa along the sides of the tongue and also some superficial erosions along the upper and lower gingiva.  Her posterior pharynx was difficult to visualize, but I saw no erosions on the areas today.  There did however appear to be one small erosion on the soft palate.  Examination of the rest of her skin revealed no areas of dermatitis or blistering.  There were some macular hyperpigmentation on the right arm where she has had a previous burn, plus the deformities from her rheumatoid arthritis on her hands and feet as well as scars on her knees from total joint replacement surgeries.  ,IMPRESSION: , Erosive stomatitis probably secondary to methotrexate even though the medication has been used for ten years without any problems.  Methotrexate may produce an erosive stomatitis and enteritis after such a use. The patient also may have an enteritis that at this point may have become more quiescent as she notes that she did have some diarrhea about the time her mouth problem developed. She has had no diarrhea today, however. She has noted no blood in her stools and has had no episodes of nausea or vomiting.  ,I am not as familiar with the NSAID causing an erosive stomatitis.  I understand that it can cause gastrointestinal upset, but given the choice between the two, I would think the methotrexate is the most likely etiology for the stomatitis.  ,RECOMMENDED THERAPY: ,I agree with your therapeutic regimen regarding this condition with the use of prednisone and folic acid.  I also agree that the methotrexate must be discontinued in order to produce a resolution of this patients’ skin problem. However, in my experience, this stomatitis may take a number of weeks to go away completely if a patient been on methotrexate, for an extended period of time, because the medication is stored within the liver and in fatty tissue.  Topically I have prescribed Lidex gel, which I find works extremely well in stomatitis conditions.  It can be applied t.i.d.  ,Thank you very much for allowing me to share in the care of this pleasant patient.  I will follow her with you as needed.","consult - history and phy., stomatitis, nsaid, blistering, blisters, buccal mucosa, dermatitis, erosive stomatitis, gastrointestinal, methotrexate, mouth, rheumatoid arthritis, stomatitis conditions, superficial erosions, upper respiratory infection, illness, medication"
 Patient presents for treatment of suspected rheumatoid arthritis., Consult - History and Phy., Rheumatoid Arthritis - H&P ,"CHIEF COMPLAINT:,  This 26 year old male presents today for treatment of suspected rheumatoid arthritis.  Associated signs and symptoms include aching, joint pain, and symmetrical joint swelling bilateral.  Patient denies any previous history, related trauma or previous treatments for this condition.  Condition has existed for 2 weeks.  He indicates the problem location is the right hand and left hand.  Patient indicates no modifying factors.  Severity of condition is slowly worsening.  Onset was unknown.,ALLERGIES:,  Patient admits allergies to aspirin resulting in GI upset, disorientation.,MEDICATION HISTORY: , Patient is currently taking amoxicillin-clavulanate 125 mg-31.25 mg tablet, chewable medication was prescribed by A. General Practitioner MD, Adrenocot 0.5 mg tablet medication was prescribed by A. General Practitioner MD.,PAST MEDICAL HISTORY:,  Past medical history is unremarkable.,PAST SURGICAL HISTORY: , Patient admits past surgical history of (+) appendectomy in 1989.,FAMILY HISTORY: , Patient admits a family history of rheumatoid arthritis associated with maternal grandmother.,SOCIAL HISTORY:  ,Patient denies alcohol use.  Patient denies illegal drug use.  Patient denies STD history.  Patient denies tobacco use.,REVIEW OF SYSTEMS: , Neurological: (+) paralysis Musculoskeletal: (+) joint pain (+) joint swelling (+) stiffness Cardiovascular: (+) ankle swelling Neurological: (-) numbness,Musculoskeletal: (-) back pain (chronic) (-) decreased ROM (-) episodic weakness,Cardiovascular: (-) chest pressure Respiratory: (-) breathing difficulties, respiratory symptoms (-) sleep apnea,PHYSICAL EXAM: , BP Standing:  120/84 HR:  79 Temp:  98.6 Height:  5 ft.  8 in.  Weight:  168 lbs.  Patient is a 26 year old male who appears pleasant, in no apparent distress, his given age, well developed, well nourished and with good attention to hygiene and body habitus.  Skin:  No skin rash, subcutaneous nodules, lesions or ulcers observed.  Palpation of skin shows no abnormalities.,HEENT:  Inspection of head and face shows no abnormalities.  Hair growth and distribution is normal.  Examination of scalp shows no abnormalities.  Conjunctiva and lids reveal no signs or symptoms of infection.  Pupil exam reveals round and reactive pupils without afferent pupillary defect.  Ocular motility exam reveals gross orthotropia with full ductions and versions bilateral.  Bilateral retinas reveal normal color, contour, and cupping.  Inspection of ears reveals no abnormalities.  Otoscopic examination reveals no abnormalities.  Examination of oropharynx reveals no abnormalities and tissues pink and moist.  ENT:  Inspection of ears reveals no abnormalities.  Examination of larynx reveals no abnormalities.  Inspection of nose reveals no abnormalities.,Neck:  Neck exam reveals neck supple and trachea that is midline, without adenopathy or crepitance palpable.  Thyroid examination reveals no abnormalities and smooth and symmetric gland with no enlargement, tenderness or masses noted.  Lymphatic:  Neck lymph nodes are normal.,Respiratory:  Assessment of respiratory effort reveals even respirations without use of accessory muscles and no intercostal retractions noted.  Chest inspection reveals chest configuration non-hyperinflated and symmetric expansion.  Auscultation of lungs reveals clear lung fields and no rubs noted.,Cardiovascular:  Heart auscultation reveals normal S1 and S2 and no murmurs, gallop, rubs or clicks.  Examination of peripheral vascular system reveals full to palpation, varicosities absent, extremities warm to touch and no edema.,Abdomen:  Abdominal contour is slightly rounded.  Abdomen soft, nontender, bowel sounds present x 4 without palpable masses.  Palpation of liver reveals no abnormalities.  Palpation of spleen reveals no abnormalities.,Musculoskeletal:  Gait and station examination reveals normal arm swing, with normal heel-toe and tandem walking.  Inspection and palpation of bones, joints and muscles is unremarkable.  Muscle strength is 5/5 for all groups tested.  Muscle tone is normal.,Neurologic/Psychiatric:  Psychiatric:  Oriented to person, place and time.  Mood and affect normal and appropriate to situation.  Testing of cranial nerves reveals no deficits.  Coordination is good.  Touch, pin, vibratory and proprioception sensations are normal.  Deep tendon reflexes normal.,TEST & X-RAY RESULTS:,  Rheumatoid factor:  52 U/ml.  Sed rate:  31 mm/hr.  C4 complement:  19 mg/dl.,IMPRESSION: , Rheumatoid arthritis.,PLAN:,  ESR ordered; automated.  Ordered RBC.  Ordered quantitative rheumatoid factor.  Return to clinic in 2 week (s).,PRESCRIPTIONS:,  Vioxx Dosage:  12.5 mg tablet Sig:  BID Dispense:  30 Refills:  2 Allow Generic:  No",
" Shoulder pain, right shoulder diffusely - Rotator cuff syndrome, right.", Consult - History and Phy., Rotator cuff syndrome - H&P ,"CHIEF COMPLAINT:  ,This 18 year old male presents today with shoulder pain right.  Location:  He indicates the problem location is the right shoulder diffusely.  Quality:  Quality of the pain is described by the patient as aching, throbbing and tolerable.  Patient relates pain on a scale from 0 to 10 as 5/10.  Severity:  The severity has worsened over the past 3 months.  Timing (onset/frequency):  Onset was gradual and after pitching a baseball game.  Modifying Factors:  Patient's condition is aggravated by throwing.  He participates with difficulty in basketball.  Past conservative treatments include NSAID and muscle relaxant medications.,ALLERGIES: , No known medical allergies.,MEDICATION HISTORY:,  None.,PAST MEDICAL HISTORY:  ,Childhood Illnesses: (+) strep throat (+) mumps (+) chickenpox,PAST SURGICAL HISTORY:,  No previous surgeries.,FAMILY HISTORY:,  Patient admits a family history of arthritis associated with mother.,SOCIAL HISTORY: , Patient denies smoking, alcohol abuse, illicit drug use and STDs.,REVIEW OF SYSTEMS:,Musculoskeletal: (+) joint or musculoskeletal symptoms (+) stiffness in AM.,Psychiatric: (-) psychiatric or emotional difficulties.,Eyes: (-) visual disturbance or change.,Neurological: (-) neurological symptoms or problems Endocrine: (-) endocrine-related symptoms.,Allergic / Immunologic: (-) allergic or immunologic symptoms.,Ears, Nose, Mouth, Throat: (-) symptoms involving ear, nose, mouth, or throat.,Gastrointestinal: (-) GI symptoms.,Genitourinary: (-) GU symptoms.,Constitutional Symptoms: (-) constitutional symptoms such as fever, headache, nausea, dizziness.,Cardiovascular: (-) cardiovascular problems or chest symptoms.,Respiratory: (-)breathing difficulties, respiratory symptoms.,Physical Exam:  BP Standing:  116/68 Resp:  16 HR:  68 Temp:  98.1 Height:  5 ft.  11 in.  Weight:  165 lbs.  Patient is a 18 year old male who appears pleasant, in no apparent distress, his given age, well developed, well nourished and with good attention to hygiene and body habitus.  Oriented to person, place and time.  Right shoulder shows evidence of swelling and tenderness.  Radial pulses are 2 /4, bilateral.  Brachial pulses are 2 /4, bilateral.,Appearance:  Normal.,Tenderness:  Anterior - moderate, Biceps - none, Posterior - moderate and Subacromial - moderate right.,Range of Motion:  Right shoulder ROM shows decreased flexion, decreased extension, decreased adduction, decreased abduction, decreased internal rotation, decreased external rotation.  L shoulder normal.,Strength:  External rotation - fair.  Internal rotation - poor right.,AC Joint:  Pain with ABD and cross-chest - mild right.,Rotator Cuff:  Impingement - moderate.  Painful arc - moderate right.,Instability:  None.,TEST & X-RAY RESULTS:,  X-rays of the shoulder were performed.  X-ray of right shoulder reveals cuff arthropathy present.,IMPRESSION: , Rotator cuff syndrome, right.,PLAN: , Diagnosis of a rotator cuff tendinitis and shoulder impingement were discussed.  I noted that this is a very common condition resulting in significant difficulties with use of the arm.  Several treatment options and their potential benefits were described.  Nonsteroidal anti-inflammatories can be helpful but typically are slow acting.  Cortisone shots can be very effective and are quite safe.  Often more than one injection may be required.  Physical therapy can also be helpful, particularly if there is any loss of shoulder mobility or strength.  If these treatments fail to resolve symptoms, an MRI or shoulder arthrogram may be required to rule out a rotator cuff tear.  Injected shoulder joint and with Celestone Soluspan 1.0 cc .  Ordered x-rays of shoulder right.,PRESCRIPTIONS:,  Vioxx Dosage:  25 mg tablet Sig:  TID Dispense:  60 Refills:  0 Allow Generic:  Yes,PATIENT INSTRUCTIONS:,  Patient was instructed to restrict activity.  Patient was given instructions on RICE therapy.",
" Patient with a history of coronary artery disease, congestive heart failure, COPD, hypertension, and renal insufficiency.", Consult - History and Phy., Renal Insufficiency - Consult ,"REASON FOR CONSULT:, Renal insufficiency.,HISTORY OF PRESENT ILLNESS:, A 48-year-old African-American male with a history of coronary artery disease, COPD, congestive heart failure with EF of 20%-25%, hypertension, renal insufficiency, and recurrent episodes of hypertensive emergency, admitted secondary to shortness of breath and productive cough. The patient denies any chest pain, palpitations, syncope, or fever. Denied any urinary disturbances, difficulty, burning micturition, hematuria, or back pain. Nephrology is consulted regarding renal insufficiency.,REVIEW OF SYSTEMS:, Reviewed entirely and negative except for HPI.,PAST MEDICAL HISTORY:, Hypertension, congestive heart failure with ejection fraction of 20%-25% in December 2005, COPD, mild diffuse coronary artery disease, and renal insufficiency.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,MEDICATIONS:, Clonidine 0.3 p.o. q.8, aspirin 325 daily, hydralazine 100 q.8, Lipitor 20 at bedtime, Toprol XL 100 daily.,FAMILY HISTORY:, Noncontributory.,SOCIAL HISTORY:, The patient denies any alcohol, IV drug abuse, tobacco, or any recreational drugs.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 180/110. Temperature 98.1. Pulse rate 60. Respiratory rate 23. O2 sat 95% on room air.,GENERAL: A 48-year-old African-American male in no acute distress.,HEENT: Pupils equal, round, and reactive to light and accommodation. No pallor or icterus.,NECK: No JVD, bruit, or lymphadenopathy.,HEART: S1 and S2, regular rate and rhythm, no murmurs, rubs, or gallops.,LUNGS: Clear. No wheezes or crackles.,ABDOMEN: Soft, nontender, nondistended, no organomegaly, bowel sounds present.,EXTREMITIES: No cyanosis, clubbing, or edema.,CNS: Exam is nonfocal.,LABS:, WBC 7, H and H 13 and 40, platelets 330, PT 12, PTT 26, CO2 20, BUN 27, creatinine 3.1, cholesterol 174, BNP 973, troponin 0.18. Previous creatinine levels were 2.7 in December. Urine drug screen positive for cocaine.,ASSESSMENT:, A 48-year-old African-American male with a history of coronary artery disease, congestive heart failure, COPD, hypertension, and renal insufficiency with:,1. Hypertensive emergency.,2. Acute on chronic renal failure.,3. Urine drug screen positive.,4. Question CHF versus COPD exacerbation.,PLAN:,1. Most likely, renal insufficiency is a chronic problem. Hypertensive etiology worsened by the patient's chronic cocaine abuse.,2. Control blood pressure with medications as indicated. Hypertensive emergency most likely related to cocaine drug abuse.,Thank you for this consult. We will continue to follow the patient with you.",
" Recurrent abscesses in the thigh, as well as the pubic area for at least about 2 years.   In the past, Accutane has been used.", Consult - History and Phy., Recurrent Abscesses - Consult ,"REASON FOR CONSULTATION: , Recurrent abscesses in the thigh, as well as the pubic area for at least about 2 years.,HISTORY OF PRESENT ILLNESS:,  A 23-year-old female who is approximately 5 months' pregnant, who has had recurrent abscesses in the above-mentioned areas.  She would usually have pustular type of lesion that would eventually break and would be quite painful.  The drainage would be malodorous.  It would initially not be infected as far as she knows, but then could eventually become infected.  She stated that this first started after she had her first born about 2 years ago.  She had recurrences of these abscesses and had pain, actually hospitalized at Hospital approximately a year and a half ago for about 1-1/2 months.  She was treated with multiple courses of antibiotics.  She had biopsies done.  She was seen by Dr. X.  Reportedly, she had a HIV test done that was negative.  She had been seen by a dermatologist who said that she had a problem with her sweat glands.  She has been on multiple courses of antibiotics.  She never had any fevers.  She has pain, drainage, and reportedly there was some bleeding in the area of the perineum/vaginal area.,PAST MEDICAL HISTORY:,1.  History of recurrent abscesses in the perineum, upper medial thigh, and the vulva area for about 2 years.  Per her report, a dermatologist had told her that she had an overactive sweat gland, and I believe she probably has hidradenitis suppurativa.  Probably, she has had Staphylococcus infection associated with it as well.,2.  Reported history of asthma.,GYNECOLOGIC HISTORY: , G3, P1.  She is currently 5 months' pregnant.,ALLERGIES: , None.,MEDICATIONS: , Her medication had been Augmentin.,SOCIAL HISTORY: , She is followed by a gynecologist in Bartow.  She is not an alcohol or tobacco user.  She is not married.  She has a 2-year-old child.,FAMILY HISTORY:  ,Noncontributory.,REVIEW OF SYSTEMS: , The patient has been complaining of diarrhea about 5 or 6 times a day for several weeks now.,PHYSICAL EXAMINATION,GENERAL:",
" Acute renal failure, suspected, likely due to multi-organ system failure syndrome.", Consult - History and Phy., Renal Failure - Consult ,"REASON FOR CONSULTATION:, Acute renal failure.,HISTORY: , Limited data is available; I have reviewed his admission notes. Apparently this man was found down by a family member, was taken to Medical Center, and subsequently flown here. He has got respiratory failure, multi-organ system failure syndrome, and has renal insufficiency, as well. Markers of renal function have been fairly stable. I do not presently see indicators that he historically has been oliguric. The BUN and creatinine have been fairly stable. It is not clear whether he was taking his lisinopril up until the time of his demise, and it is also not clear whether he was taking his diuretic. Earlier thoughts had been that he could have had rhabdomyolysis, but the highest CPK I find recorded is 1500, the phosphorus is not elevated, though I acknowledge the serum calcium is low. I see no markers of myoglobinuria nor serum level of myoglobin. He has received IV fluid resuscitation, good broad-spectrum antibiotic coverage, continues mechanically ventilated, and is on parenteral nutrition.,PAST MEDICAL HISTORY:, Not obtained from the patient, but is reviewed in other physician's notes and seems notable for probably atherosclerotic cardiovascular disease wherein he was taking Imdur and digoxin, reportedly. A suggestion of hypertensive disease versus BPH, he was on terazosin. Suggestion of CHF versus hypertension versus volume overload, treated with Lasix. He was iron, I presume for anemia. He was on potassium, lisinopril and aspirin.,ALLERGIES:, OTHER PHYSICIAN'S NOTES INDICATE NO KNOWN ALLERGIES.,FAMILY HISTORY:, Not available.,SOCIAL HISTORY:, Not available.,REVIEW OF SYSTEMS:, Not available.,PHYSICAL EXAMINATION:,GENERAL: An older white male who is intubated, edematous, and appears uncomfortable.,HEENT: Male pattern baldness. Pupils equally round, no icterus. Intubated. OG tube in place.,NECK: Not tested for suppleness, no carotid bruits are heard. Neck vein distention is not seen.,LUNGS: He has diffuse expiratory wheezing anteriorly, laterally and posteriorly. I would describe the wheezes as coarse. I hear no present rales. Breath sounds otherwise are symmetrical.,HEART: Heart tones regular to auscultation, currently without audible rub or gallop sounds.,BREASTS: Not enlarged.,ABDOMEN: On plane. Bowel sounds presently are normal. Abdomen, I believe, is soft on plane, normal bowel sounds, no bruits, no liver edge felt, no HJR, no spleen tip, no suprapubic fullness.,GU: Catheter draining a dark yellow urine.,EXTREMITIES: Very edematous. Pulses not palpable. Cyanosis not observed. Fungal changes are not observed.,NEUROLOGICAL: Not otherwise assessed.,LABORATORY DATA:, Reviewed.,IMPRESSION:,1. Acute renal failure, suspected. Likely due to multi-organ system failure syndrome, with antecedent lisinopril use at home and at time of demise. He also reportedly was on Lasix prior to hospitalization, ? hypovolemia as a consequence.,2. Multi-organ system failure/systemic inflammatory response syndrome, with septic shock.,3. I am under-whelmed presently with the diagnosis of rhabdomyolysis, if the maximum CK recorded is 1500.,4. Antecedent hypoxemia, with renal hypoperfusion.,5. Diffuse aspiration pneumonitis suggested.,DISCUSSION/PLAN: ,I think the renal function will follow the patient. Supportive care, attention to stability of a euvolemic state, will be important at this time. He is currently nonoliguric, has apparently stable, diffuse, bilateral wheezing, with adequate gas exchange. He is on TPN, antimicrobials, and has been on vasopressive agents. Blood pressures are close to acceptable, he may now be wearing off his lisinopril, assuming he was taking it prior to admission.,I would use diuretics to maintain central euvolemia. Recorded I's are substantially O's during the course of the hospitalization, I presume as part of his resuscitation effort. No central pressures or monitoring of same is currently available. I will follow with you. No present indication for hemodialysis. Antimicrobials are being handled by others.",
" A 40-year-old male seen today for a 90-day revocation admission.  Noncompliant with medications, refusing oral or IM medications, became agitated.  History of hyperlipidemia with elevated triglycerides.", Consult - History and Phy., Revocation Admission ,"IDENTIFYING DATA:,  This is a 40-year-old male seen today for a 90-day revocation admission.  He had been reported by his case manager as being noncompliant with medications, refusing oral or IM medications, became agitated, had to be taken to ABCD for evaluation, admitted at that time to auditory hallucinations and confusion and was committed for admission at this time.  He has a psychiatric history of schizophrenia, was previously admitted here at XYZ on 12/19/2009, had another voluntary admission in ABCD in 1998.,MEDICATIONS: , Listed as Invega and Risperdal.,ALLERGIES: , None known to medications.,PAST MEDICAL HISTORY:  ,The only identified problem in his chart is that he is being treated for hyperlipidemia with gemfibrozil.  The patient is unaware and cannot remember what medications he had been taking or whether he had been taking them at all as an outpatient.,FAMILY HISTORY: , Listed as unknown in the chart as far as other psychiatric illnesses.  The patient himself states that his parents are deceased and that he raised himself in the Philippines.,SOCIAL HISTORY:,  He immigrated to this country in 1984, although he lists himself as having a green card still at this time.  He states he lives on his own.  He is a single male with no history of marriage or children and that he had high school education.  His recreational drug use in the chart indicates that he has had a history of methamphetamines.  The patient denies this at this time.  He also denies current alcohol use.  He does smoke.  He is unable to tell me of any PCP.  He is in counseling service with his case manager being XYZ.,LEGAL HISTORY:  ,  He had an assault in December 2009, which led to his previous detention.  It is unknown whether he is under legal constraints at this time.,OBJECTIVE FINDINGS:  ,VITAL SIGNS: , Blood pressure is 125/75.  His weight is 197 with height 5 feet 4 inches.,GENERAL:,  He is cooperative, although disorganized and focusing entirely and telling me that he is here because there was some confusion in how he took his medications.  He does not endorse any voices at this time.,HEENT: , His head exam is normal with normal scalp.  HEENT is unremarkable.  Pupils equal and reactive to light and accommodation.  TMs are normal.,NECK:,  Unremarkable with no masses or tenderness.,CARDIOVASCULAR:,  Normal S1 and S2.  No murmurs.,LUNGS:,  Clear.,ABDOMEN:  ,Negative with no scars.,GU:  ,Not done.,RECTAL:,  Not done.,DERM:,  He does have a scarring of acne lesions, both face and back.,EXTREMITIES:,  Otherwise negative.,NEUROLOGIC: , Cranial nerves II through X normal.  Reflexes are normal and gait is unremarkable.,LABORATORY DATA: , His labs done at ABCD showed his CMP to be normal with an elevated white count of 17.2.  Chest x-ray was indicated as being done and normal as was a UA and he did apparently receive hydration in the hospital with IV fluids.,ASSESSMENT: , History of hyperlipidemia with elevated triglycerides.  We will maintain his gemfibrozil 600 b.i.d. and for health maintenance issues, we will also maintain just a vitamin daily and we will obtain recheck on his labs and lipid levels in one week after treatment is initiated.",
" Patient with suspected nasal obstruction, possible sleep apnea. ", Consult - History and Phy., Recurrent nasal obstruction ,"CHIEF COMPLAINT: , Recurrent nasal obstruction.,HISTORY OF PRESENT ILLNESS:,  The patient is a 5-year-old male, who was last evaluated by Dr. F approximately one year ago for suspected nasal obstruction, possible sleep apnea.  Dr. F's assessment at that time was the patient not had sleep apnea and did not truly even seem to have allergic rhinitis.  All of his symptoms had resolved when he had seen Dr. F, so no surgical plan was made and no further followup was needed.  However, the patient reports again today with his mother that they are now having continued symptoms of nasal obstruction and questionable sleep changes.  Again, the mother gives a very confusing sleep history but it does not truly sound like the child is having apneic events that are obstructive in nature.  It sounds like he is snoring loudly and does have some nasal obstruction at nighttime.  He also is sniffing a lot through his nose.  He has been tried on some nasal steroids but they only use this on a p.r.n. basis about one or two days every month and we are unsure if that has even helped at all, probably not.  The child is not having any problems with his ears including ear infections or hearing.  He is also not having any problems with strep throat.,PAST MEDICAL HISTORY: , Eczema.,PAST SURGICAL HISTORY: , None.,MEDICATIONS:,  None.,ALLERGIES:,  No known drug allergies.,FAMILY HISTORY: , No family history of bleeding diathesis or anesthesia difficulties.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Weight 43 pounds, height 37 inches, temperature 97.4, pulse 65, and blood pressure 104/48.,GENERAL:  The patient is a well-nourished male in no acute distress.  Listening to his voice today in the clinic, he does not sound to have a hyponasal voice and has a wide range of consonant pronunciation.,NOSE:  Anterior rhinoscopy does demonstrate boggy turbinates bilaterally with minimal amount of watery rhinorrhea.,EARS:  The patient tympanic membranes are clear and intact bilaterally.  There is no middle ear effusion.,ORAL CAVITY:  The patient has 2+ tonsils bilaterally.  There are clearly nonobstructive.  His uvula is midline.,NECK:  No lymphadenopathy appreciated.,ASSESSMENT AND PLAN: , This is a 5-year-old male, who presents for repeat evaluation of a possible nasal obstruction, questionable sleep apnea.  Again, the mother gives a confusing sleep history but it does not really sound like he is having apneic events.  They deny any actual gasping events.  It sounds like true obstructive events.  He clearly has some symptoms at this point that would suggest possible allergic rhinitis or chronic rhinitis.  I think the most appropriate way to proceed would be to first try this child on a nasal corticosteroid and use it appropriately.  I have given them prescription for Nasacort Aqua one spray to each nostril twice a day.  I instructed them on correct way to use this and the importance to use it on a daily basis.  They may not see any benefit for several weeks.  I would like to evaluate him in six weeks to see how we are progressing.  If he continues to have problems, I think at that point we may consider performing a transnasal exam in the office to examine his adenoid bed and that would really be the only surgical option for this child.  He may also need an allergy evaluation at that point if he continues to have problems.  However, I would like to be fairly conservative in this child.  Should the mother still have concerns regarding his sleeping at our next visit or should his symptoms worsen (I did instruct her call us if it worsens), we may even need to pursue a sleep study just to settle that issue once and for all.  We will see him back in six weeks.","consult - history and phy., recurrent nasal obstruction, allergic rhinitis, apneic events, sleep apnea, nasal obstruction, nasal, apnea, allergic, obstruction, sleep, "
" A 68-year-old male with history of bilateral hernia repair, who presents with 3 weeks of diarrhea and 1 week of rectal bleeding.  He states that he had some stomach discomfort in the last 4 weeks.  ", Consult - History and Phy., Rectal Bleeding - Consult ,"REASON FOR ADMISSION: , Rectal bleeding.,HISTORY OF PRESENT ILLNESS:  ,The patient is a very pleasant 68-year-old male with history of bilateral hernia repair, who presents with 3 weeks of diarrhea and 1 week of rectal bleeding.  He states that he had some stomach discomfort in the last 4 weeks.  He has had some physical therapy for his lower back secondary to pain after hernia repair.  He states that the pain worsened after this.  He has had previous history of rectal bleeding and a colonoscopy approximately 8 years ago that was normal.  He denies any dysuria.  He denies any hematemesis.  He denies any pleuritic chest pain.  He denies any hemoptysis.,PAST MEDICAL HISTORY:,1.  History of bilateral hernia repair by Dr. X in 8/2008.,2.  History of rectal bleeding.,ALLERGIES: , NONE.,MEDICATIONS:,1.  Cipro.,2.  Lomotil.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: , No tobacco, alcohol or IV drug use.,REVIEW OF SYSTEMS: , As per the history of present illness otherwise unremarkable.,PHYSICAL EXAMINATION:,VITAL SIGNS:  The patient is afebrile.  Pulse 117, respirations 18, and blood pressure 117/55.  Saturating 98% on room air.,GENERAL:  The patient is alert and oriented x3.,HEENT:  Pupils are equal, round, and reactive to light and accommodation.  Extraocular movements are intact.  Oropharynx is clear without exudates.,NECK:  Supple.  No thyromegaly.  No jugular venous distention.,HEART:  Tachycardic.  Regular rhythm without murmurs, rubs or gallops.,LUNGS:  Clear to auscultation bilaterally both anteriorly and posteriorly.,ABDOMEN:  Positive bowel sounds.  Soft and nontender with no guarding.,EXTREMITIES:  No clubbing, cyanosis or edema in the upper or lower extremities.,NEUROLOGIC:  Nonfocal.,LABORATORY STUDIES:,  Sodium 131, potassium 3.9, chloride 94, CO2 25, BUN 15, creatinine 0.9, glucose 124, INR 1.2, troponin less than 0.04, white count 17.5, hemoglobin 12.3, and platelet count 278 with 91% neutrophils.  EKG shows sinus tachycardia.,PROBLEM LIST:,1.  Colitis.,2.  Sepsis.,3.  Rectal bleeding.,RECOMMENDATIONS:,1.  GI consult with Dr. Y's group.,2.  Continue Levaquin and Flagyl.,3.  IV fluids.,4.  Send for fecal WBCs, O&P, and C. diff.,5.  CT of the abdomen and pelvis to rule out abdominal pathology.,6.  PPI for PUD prophylaxis.",
 Obstructive sleep apnea syndrome.  Loud snoring.  Schedule an overnight sleep study., Consult - History and Phy., Pulmonary Consultation - 1 ,"CHIEF COMPLAINT:,  Rule out obstructive sleep apnea syndrome.,Sample Patient is a pleasant, 61-year-old, obese, African-American male with a past medical history significant for hypertension, who presents to the Outpatient Clinic with complaints of loud snoring and witnessed apnea episodes by his wife for at least the past five years.  He denies any gasping, choking, or coughing episodes while asleep at night.  His bedtime is between 10 to 11 p.m., has no difficulty falling asleep, and is usually out of bed around 7 a.m. feeling refreshed.  He has two to three episodes of nocturia per night.  He denies any morning symptoms.  He has mild excess daytime sleepiness manifested by dozing off during boring activities.,PAST MEDICAL HISTORY:,  Hypertension, gastritis, and low back pain.,PAST SURGICAL HISTORY:,  TURP.,MEDICATIONS:,  Hytrin, Motrin, Lotensin, and Zantac.,ALLERGIES:,  None.,FAMILY HISTORY:,  Hypertension.,SOCIAL HISTORY:,  Significant for about a 20-pack-year tobacco use, quit in 1991.  No ethanol use or illicit drug use.  He is married.  He has one dog at home.  He used to be employed at Budd Automotors as a die setter for about 37 to 40 years.,REVIEW OF SYSTEMS:,  His weight has been steady over the years.  Neck collar size is 17½"".  He denies any chest pain, cough, or shortness of breath.  Last chest x-ray within the past year, per his report, was normal.,PHYSICAL EXAM:,  A pleasant, obese, African-American male in no apparent respiratory distress.  T:  98.  P:  90.  RR:  20.  BP:  156/90.  O2 saturation:  97% on room air.  Ht:  5' 5"".  Wt:  198 lb.  HEENT:  A short thick neck, low-hanging palate, enlarged scalloped tongue, narrow foreshortened pharynx, clear nares, and no JVD.  CARDIAC:  Regular rate and rhythm without any adventitious sounds.  CHEST:  Clear lungs bilaterally. ABDOMEN:  An obese abdomen with active bowel sounds.  EXTREMITIES:  No cyanosis, clubbing, or edema.  NEUROLOGIC:  Non-focal.,IMPRESSION:,1.  Probable obstructive sleep apnea syndrome.,2.  Hypertension.,3.  Obesity.,4.  History of tobacco use.,PLAN:,1.  We will schedule an overnight sleep study to evaluate obstructive sleep apnea syndrome.,2.  Encouraged weight loss.,3.  Check TSH.,4.  Asked not to drive and engage in any activity that could endanger himself or others while sleepy.,5.  Asked to return to the clinic one week after sleep the study is done.",
" A 16-month-old with history of penile swelling for 4 days, had circumcision 1 week ago.", Consult - History and Phy., Pubic Cellulitis ,"DIAGNOSIS: , Pubic cellulitis.,HISTORY OF PRESENT ILLNESS:,  A 16-month-old with history of penile swelling for 4 days.  The patient was transferred for higher level of care.  This 16-month-old had circumcision 1 week ago and this is the third circumcision this patient underwent.  Apparently, the patient developed adhesions and the patient had surgery for 2 more occasions for removal of the adhesions.  This time, the patient developed fevers 3 days after the surgery with edema and erythema around the circumcision and it has spread to the pubic area.  The patient became febrile with 102 to 103 fever, treated with Tylenol with Codeine and topical antibiotics.  The patient was transferred to Children's Hospital for higher level of care.,REVIEW OF SYSTEMS: , ,ENT:  Denies any runny nose.  ,EYES:  No apparent discharge.  ,FEEDING:  Good feeding.  ,CARDIOVASCULAR:  There is no cyanosis or edema.  ,RESPIRATORY:  Denies any cough or wheezing.  ,GI:  Positive for constipation, no bowel movements for 2 days.  ,GU:  Positive dysuria for the last 2 days and penile discharge for the last 2 days with foul smelling.  ,NEUROLOGIC:  Denies any lethargy or seizure.  ,MUSCULOSKELETAL:  No pain or swelling.  ,SKIN:  Erythema and edema in the pubic area for the last 3 days.  All the rest of systems are negative except as noted above.,At the emergency room, the patient had a second dose of clindamycin.  The transfer labs are as follows:  15.7 for WBC, H&H 12.0 and 36.  One blood culture.  We will follow the results.  He is status post Rocephin and Cleocin.,PAST MEDICAL HISTORY: , Denied.  ,PAST SURGICAL HISTORY:,  The patient underwent 3 circumcisions since birth, the last 2 had been for possible removal of adhesions.,IMMUNIZATIONS: , He is behind with his immunizations.  He is due for his 16-month-old immunizations.,ACTIVITY: , NKDA.,BIRTH HISTORY: , Born to a 21-year-old, first baby, born NSVD, 8 pounds 10 ounces, no complications.,DEVELOPMENTAL:,  He is walking and speaking about 15 words.,FAMILY HISTORY: , Noncontributory.,MEDICATIONS: , Tylenol with Codeine q.6h.,SOCIAL HISTORY: , He lives with both parents and both of them smoke.  There are no pets.,SICK CONTACTS: , Mom has some upper respiratory infection.,DIET: , Regular diet.,PHYSICAL EXAMINATION: , ,VITAL SIGNS:  Temperature max at ER is 102, heart rate 153.,GENERAL:  This patient is alert, arousable, big boy.,HEENT:  Head:  Normocephalic, atraumatic.  Pupils are equal, round, and reactive to light.  Mucous membranes are moist.,NECK:  Supple.,CHEST:  Clear to auscultation bilaterally.  Good air exchange.,ABDOMEN:  Soft, nontender, nondistended.,EXTREMITIES:  Full range of movement.  No deformities.",
 Patient with complaints of significant coughing and wheezing., Consult - History and Phy., Pulmonary Consultation - 2 ,"PAST MEDICAL HISTORY:,  Unremarkable, except for diabetes and atherosclerotic vascular disease.,ALLERGIES:,  PENICILLIN.,CURRENT MEDICATIONS:,  Include Glucovance, Seroquel, Flomax, and Nexium.,PAST SURGICAL HISTORY: , Appendectomy and exploratory laparotomy.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:  ,The patient is a non-smoker.  No alcohol abuse.  The patient is married with no children.,REVIEW OF SYSTEMS:,  Significant for an old CVA.,PHYSICAL EXAMINATION:,  The patient is an elderly male alert and cooperative.  Blood pressure 96/60 mmHg.  Respirations were 20.  Pulse 94.  Afebrile.  O2 was 94% on room air.  HEENT:  Normocephalic and atraumatic.  Pupils are reactive.  Oral mucosa is grossly normal.  Neck is supple.  Lungs:  Decreased breath sounds.  Disturbed breath sounds with poor exchange.  Heart:  Regular rhythm.  Abdomen:  Soft and nontender.  No organomegaly or masses.  Extremities:  No cyanosis, clubbing, or edema.,LABORATORY DATA: , Oropharyngeal evaluation done on 11/02/2006 revealed mild oropharyngeal dysphagia with no evidence of laryngeal penetration or aspiration with food or liquid.  Slight reduction in tongue retraction resulting in mild residual remaining in the palatal sinuses, which clear with liquid swallow and double-saliva swallow.,ASSESSMENT:,1.  Cough probably multifactorial combination of gastroesophageal reflux and recurrent aspiration.,2.  Old CVA with left hemiparesis.,3.  Oropharyngeal dysphagia.,4.  Diabetes.,PLAN:,  At the present time, the patient is recommended to continue on a regular diet, continue speech pathology evaluation as well as perform double-swallow during meals with bolus sensation.  He may use Italian lemon ice during meals to help clear sinuses as well.  The patient will follow up with you.  If you need any further assistance, do not hesitate to call me.","consult - history and phy., pulmonary evaluation, cough, wheezing, congestion, coughing and wheezing, breath sounds, oropharyngeal dysphagia, pulmonary, breath, sounds, dysphagia, aspiration, sinuses, oropharyngeal, coughing, swallowing, "
" Records review.  The patient developed shooting pain about the right upper extremity into his hand from his elbow down to the hand.  Any type of rotation and pulling muscle did cause numbness of the middle, ring, and small finger.", Consult - History and Phy., Records Review - Epicondylitis ,"ALLOWED CONDITIONS:,  Lateral epicondylitis, right elbow,EMPLOYER:,  ABCD,REQUESTED ALLOWANCE:,  Carpal tunnel syndrome right.,Mr. XXXX is a 41-year-old male employed by ABCD as a car disassembler to make Hurst Limousines injured his right elbow on September 11, 2007, while stripping cars.  He does state he was employed for such company for the last five years.  His work includes lots of pulling, pushing, and working in weird angles.  He does state on the date of injury, he was not doing anything additional.,TREATMENT HISTORY: , Thereafter, he developed shooting pain about the right upper extremity into his hand from his elbow down to the hand.  Any type of rotation and pulling muscle did cause numbness of the middle, ring, and small finger.  He was initially seen by Dr. X on October 18, 2007, at the Occupational Health Facility.  He utilized a tennis elbow brace, but did continue to experience symptomatology into the middle, ring, and small finger.  He was placed on light duty for the next couple of months.  Mr. XXXX suffered another work injury to the right shoulder on October 11, 2007.  He did undergo arthroscopic rotator cuff repair by Dr. Y in December of 2007.  Thereafter, he continued to work in a light duty type of basis for the next few months.,An EMG and nerve conduction study was performed in December of 2008, which demonstrated evidence of carpal tunnel syndrome.  He was able to return to work doing more of a light duty type of position.,The injured worker has also seen Dr. Y once again subsequent to the EMG and nerve conduction study on December 3, 2008.  It was felt that the injured worker would benefit from decompression of the carpal tunnel and an ulnar nerve transposition.  The injured worker subsequently was placed in a no work status thereafter.,At the present time, the injured worker does complain of light tingling into the small, ring, and middle finger.  There are times when the whole hand becomes very numb.  He does not use and do any type of lifting with regards to the right hand secondary to the discomfort.  His pain does vary between a 4 on a scale of 1 to 10.  He denies any weakness.  He does not awaken at night with the symptomatology.  Doing his job is the only causation as related to the carpal tunnel syndrome and the cubital tunnel type symptoms.  He does state that he is right-handed.,In addition, he does note numbness and tingling as related to the left hand.  He has not had any type of EMG and nerve conduction study as related to the left upper extremity.,CURRENT MEDICATIONS: , None.,ALLERGIES:,  Zyrtec.,SURGERIES: , Left shoulder surgery.,SOCIAL HISTORY: , The injured worker denies tobacco or alcohol consumption.,PHYSICAL EXAMINATION:,  Healthy-appearing 41-year-old male, who is 5 feet 8 inches, weighs 205 pounds.  He does not appear to be in distress at this time.,On examination of the right upper extremity, one can appreciate no evidence of swelling, discoloration or ecchymosis.  The range of motion of the right wrist reveals flexion is 50 degrees, dorsiflexion 60 degrees, ulnar deviation 30 degrees, radial deviation 20 degrees.  Tinel's and Phalen's tests were positive.  Reverse Phalen's test was negative.  There is diminished sensation in distribution of the thumb, index, middle, and ring finger.  The intrinsic function did appear to be intact.  The injured worker does not demonstrate any evidence of difficulties as related to extension of the middle, ring, and index finger as related to the elbow.  The range of motion of the right elbow reveals flexion 140 degrees, extension 0 degrees, pronation and supination 80 degrees.  Tinel's test is negative as related to the elbow and the ulnar nerve.,There is noted to be satisfactory strength as related to major motor groups of the right upper extremity.,RECORDS REVIEW:  ,1.  First report of injury, difficulty as related to both hands.,2.  Number of notes of Occupational Health Clinic.  It was felt that the injured worker did indeed suffer from median nerve entrapment at the wrist and ulnar nerve entrapment at the right elbow with the associated right lateral epicondylitis.,3.  December 20, 2007, operative note of Dr. Y.  At which time, the injured worker underwent arthroscopic rotator cuff repair, subacromial decompression, partial synovectomy of the anterior compartment, limited debridement of the partial superior-sided subscapularis tear without evidence of subacromial impingement.,4.  November 17, 2008, EMG and nerve conduction study, which demonstrated moderate right median neuropathy plus carpal tunnel syndrome.,ASSESSMENT: , Please state your opinion for the following questions based upon your review of the enclosed medical records on January 23, 2009, examination of the claimant.,Please indicate whether the restriction given on December 3, 2008, is the result of the allowed condition of lateral epicondylitis.,It should be noted on physical examination that the symptomatology as related to the lateral epicondylitis have very much resolved as of January 23, 2009.  Resisted extension of the middle finger and wrist do not cause any pain about the lateral epicondylar region.  It also should be noted that really there is no significant weakness as related to the function of the right upper extremity.  Also noted is there is an absence of tenderness as related to the lateral epicondylar region.,QUESTION:  ,Has the claimant reached maximum medical improvement for the allowed conditions of lateral epicondylitis? Please explain.,ANSWER:  ,Based upon the examination on January 23, 2009, the injured worker has indeed reached maximum medical improvement as related to the diagnosis of lateral epicondylitis.  This is based upon review of the medical records, evidence-based medicine, and the Official Disability Guidelines.,QUESTION:  ,Please indicate whether the allowed condition of lateral epicondylitis has temporarily and totally disabled the claimant from December 8, 2008 through February 1, 2009, and continuing.  Please explain.,ANSWER:  ,There is insufficient medical evidence and it is my opinion to state that the allowed condition of lateral epicondylitis is not temporarily and totally disabling the claimant from December 8, 2008 through February 1, 2009, and continuing.  As mentioned the symptomatology referable to the lateral epicondylar region has very much resolved based upon the examination performed on January 23, 2009.,QUESTION:  ,If it is your opinion that the claimant is temporarily and totally disabled due to allowed condition of lateral epicondylitis, please indicate what treatment the claimant must undergo in order to achieve a plateau of maximum medical improvement.  Please also give an estimated time for maximum medical improvement.,ANSWER:  ,The injured worker has indeed reached maximum medical improvement as related to the elbow.  There is no question that the injured worker is not temporarily and totally disabled due to the allowed condition of lateral epicondylitis.  At the time of the exam, the injured worker has indeed reached maximum medical improvement as related to lateral epicondylitis as described previously.,QUESTION:  ,Is the claimant suffering from carpal tunnel syndrome, right?",
" This 61-year-old retailer who presents with acute shortness of breath, hypertension, found to be in acute pulmonary edema.   No confirmed prior history of heart attack, myocardial infarction, heart failure. ", Consult - History and Phy., Pulmonary Edema - Consult ,"HISTORY:  ,This 61-year-old retailer who presents with acute shortness of breath, hypertension, found to be in acute pulmonary edema.  No confirmed prior history of heart attack, myocardial infarction, heart failure.  History dates back to about six months of intermittent shortness of breath, intermittent very slight edema with shortness of breath.  The blood pressure was up transiently last summer when this seemed to start and she was asked not to take Claritin-D, which she was taking for what she presumed was allergies.  She never had treated hypertension.  She said the blood pressure came down.  She is obviously very hypertensive this evening.  She has some mid scapular chest discomfort.  She has not had chest pain, however, during any of the other previous symptoms and spells.,CARDIAC RISKS:,  Does not smoke, lipids unknown.  Again, no blood pressure elevation, and she is not diabetic.,FAMILY HISTORY:,  Negative for coronary disease.  Dad died of lung cancer.,DRUG SENSITIVITIES:,  Penicillin.,CURRENT MEDICATIONS: , None.,SURGICAL HISTORY:,  Cholecystectomy and mastectomy for breast cancer in 1992, no recurrence.,SYSTEMS REVIEW: , Did not get headaches or blurred vision.  Did not suffer from asthma, bronchitis, wheeze, cough but short of breath as described above.  No reflux, abdominal distress.  No other types of indigestion, GI bleed.  GU:  Negative.  She is unaware of any kidney disease.  Did not have arthritis or gout.  No back pain or surgical joint treatment.  Did not have claudication, carotid disease, TIA.  All other systems are negative.,PHYSICAL FINDINGS,VITAL SIGNS:  Presenting blood pressure was 170/120 and her pulse at that time was 137.  Temperature was normal at 97, and she was obviously in major respiratory distress and hypoxemic.  Saturation of 86%.  Currently, blood pressure 120/70, heart rate is down to 100.,EYES:  No icterus or arcus.,DENTAL:  Good repair.,NECK:  Neck veins, cannot see JVD, at this point, carotids, no bruits, carotid pulse brisk.,LUNGS:  Fine and coarse rales, lower two thirds of chest.,HEART:  Diffuse cardiomegaly without a sustained lift, first and second heart sounds present, second is split.  There is loud third heart sound.  No murmur.,ABDOMEN:  Overweight, guess you would say obese, nontender, no liver enlargement, no bruits.,SKELETAL:  No acute joints.,EXTREMITIES:  Good pulses.  No edema.,NEUROLOGICALLY:  No focal weakness.,MENTAL STATUS:  Clear.,DIAGNOSTIC DATA: , 12-lead ECG, left bundle-branch block.,LABORATORY DATA:,  All pending.,RADIOGRAPHIC DATA: , Chest x-ray, pulmonary edema, cardiomegaly.,IMPRESSION,1.  Acute pulmonary edema.,2.  Physical findings of dilated left ventricle.,3.  Left bundle-branch block.,4.  Breast cancer in 1992.,PLAN:  ,Admit.  Aggressive heart failure management.  Get echo.  Start ACE and Coreg.  Diuresis of course underway.",
 Patient did undergo surgical intervention as related to the right knee and it was noted that the reconstruction had failed.   A screw had come loose., Consult - History and Phy., Records Review - Orthopedic ,"Thereafter, he was evaluated and it was felt that further reconstruction as related to the anterior cruciate ligament was definitely not indicated.  On December 5, 2008, Mr. XXXX did undergo a total knee replacement arthroplasty performed by Dr. X.,Thereafter, he did an extensive course of physical therapy, work hardening, and a work conditioning type program.,At the present time, he does complain of significant pain and swelling as related to the right knee.  He is unable to crawl and/or kneel.  He does state he is able to walk a city block and in fact, he is able to do 20 minutes of a treadmill.  Stairs are a significant problem.  His pain is a 5 to 6 on a scale of 1 to 10.,He is better when he is resting, sitting, propped up, and utilizing his ice.  He is much worse when he is doing any type of physical activity.,He has denied having any previous history of similar problems.,CURRENT MEDICATIONS:  ,Over-the-counter pain medication.,ALLERGIES: , NKA.,SURGERIES: , Numerous surgeries as related to the right lower extremity.,SOCIAL HISTORY: , He does admit to one half pack of cigarette consumption per day.  He denies any alcohol consumption.,PHYSICAL EXAMINATION:  ,On examination today, he is 28-year-old male who is 6 feet 1, weighs 250 pounds.  He does not appear to be in distress at this time.  One could appreciate 1-2/4 intraarticular effusion.  The range of motion is 0 to a 110 degrees of flexion.  I could not appreciate any evidence of instability medial, lateral, anterior or posterior.  Crepitus is noted with regards to range of motion testing.  His strength is 4 to 5 as related to the quadriceps and hamstring.,There is atrophy as related to the right thigh.  The patient is able to stand from a seated position and sit from a standing position without difficulty.,RECORDS REVIEW:,1.  First report of injury.,2.  July 17, 2002, x-rays of the right knee were negative.,3.  Notes of the Medina General Hospital Occupational Health, Steven Rodgers, M.D.,4.  August 5, 2002, an MRI scan of the right knee which demonstrated peripheral tear of the posterior horn of the medial",
 Increasing oxygen requirement.  Baby boy has significant pulmonary hypertension.  , Consult - History and Phy., Pulmonary Hypertension - Pediatric Consult ,"INDICATION FOR CONSULTATION: , Increasing oxygen requirement.,HISTORY: , Baby boy, XYZ, is a 29-3/7-week gestation infant.  His mother had premature rupture of membranes on 12/20/08.  She then presented to the Labor and Delivery with symptoms of flu.  The baby was then induced and delivered.  The mother had a history of premature babies in the past.  This baby was doing well, and then, we had a significant increasing oxygen requirement from room air up to 85%.  He is now on 60% FiO2.,PHYSICAL FINDINGS,GENERAL:  He appears to be pink, well perfused, and slightly jaundiced.,VITAL SIGNS:  Pulse 156, 56 respiratory rate, 92% sat, and 59/28 mmHg blood pressure.,SKIN:  He was pink.,He was on the high-frequency ventilator with good wiggle.,His echocardiogram showed normal structural anatomy.  He has evidence for significant pulmonary hypertension.  A large ductus arteriosus was seen with bidirectional shunt.  A foramen ovale shunt was also noted with bidirectional shunt.  The shunting for both the ductus and the foramen ovale was equal left to right and right to left.,IMPRESSION: , My impression is that baby boy, XYZ, has significant pulmonary hypertension.  The best therapy for this is to continue oxygen.  If clinically worsens, he may require nitric oxide.  Certainly, Indocin should not be used at this time.  He needs to have lower pulmonary artery pressures for that to be considered.,Thank you very much for allowing me to be involved in baby XYZ's care.","consult - history and phy., high-frequency ventilator, structural anatomy, foramen ovale, oxygen requirement, hypertension, pulmonary "
 She was admitted following an overdose of citalopram and warfarin.  The patient has had increasing depression and has been under stress as a result of dissolution of her second marriage., Consult - History and Phy., Psychiatric Consult - 2 ,"HISTORY OF PRESENT ILLNESS:,  This is a 41-year-old registered nurse (R.N.).  She was admitted following an overdose of citalopram and warfarin.  The patient has had increasing depression and has been under stress as a result of dissolution of her second marriage.  She notes starting in January, her husband of five years seemed to be quite withdrawn.  It turned out, he was having an affair with one of her best friends and he subsequently moved in with this woman.  The patient is distressed, as over the five years of their marriage, she has gotten herself into considerable debt supporting him and trying to find a career that would work for him.  They had moved to ABCD where he had recently been employed as a restaurant manager.  She also moved her mother and son out there and is feeling understandably upset that he was being dishonest and deceitful with her.  She has history of seasonal affective disorder, winter depressions, characterized by increased sleep, increased irritability, impatience, and fatigue.  Some suggestion on her part that her father may have had some mild bipolar disorder and including the patient has a cyclical and recurrent mood disorder.  In January, she went on citalopram.  She reports since that time, she has lost 40 pounds of weight, has trouble sleeping at night, thinks perhaps her mood got worse on the citalopram, which is possible, though it is also possible that the progressive nature of getting divorce than financial problems has contributed to her worsening mood.,PAST AND DEVELOPMENTAL HISTORY: , She was born in XYZ.  She describes the family as being somewhat dysfunctional.  Father was a truckdriver.  She is an only child.  She reports that she had a history of anorexia and bulimia as a teenager.  In her 20s, she served six years in Naval Reserve.  She was previously married for four years.  She described that as an abusive relationship.  She had a history of being in counseling with ABC, but does not think this therapist, who is now by her estimate 80 years old, is still in practice.,PHYSICAL EXAMINATION:  ,GENERAL:  This is an alert and cooperative woman.,VITAL SIGNS:  Temperature 98.1, pulse 60, respirations 18, blood pressure 95/54, oxygen saturation 95%, and weight is 132.,PSYCHIATRIC:  She makes good eye contact.  Speech is normal in rate, volume, grammar, and vocabulary.  There is no thought disorder.  She denies being suicidal.  Her affect is appropriate for material being discussed.  She has a sense of future, wants to get back to work, has plans to return to counseling.  She appeared to have normal orientation, concentration, memory, and judgment.,Medical history is notable for factor V Leiden deficiency, history of pulmonary embolus, restless legs syndrome.  She has been off her Mirapex.  I did encourage her to go back on the Mirapex, which would likely lead to some improvement in mood by facilitating better sleep.,The patient at this time can contract for safety.  She has made plans for outpatient counseling this Saturday and we will get a referral to a psychiatrist for which she is agreeable to following up with.,LABORATORY DATA: , INR, which is still 8.8.  In 1998, she had a normal MRI.  Electrolytes, BUN, creatinine, and CBC were all normal.,DIAGNOSES:  ,1.  Seasonal depressive disorder.,2.  Restless legs syndrome.,3.  Overdose of citalopram and warfarin.,RECOMMENDATIONS: , The patient reports she has been feeling better since discontinuing antidepressants.  I, therefore, recommend she stay off antidepressants at present.  If needed, she can take Prozac, which has been effective for her in the past and she plans to see a psychiatrist for consultation.  She does give a fairly good history of seasonal depression and given that her mood has improved in the past with Prozac, this will be an appropriate agent to try as needed in the future, but given the situational nature of the depression, she primarily appears to need counseling.,Please feel free to contact me at digital pager if there is additional information I can provide.","consult - history and phy., citalopram, depressive disorder, overdose, warfarin, restless legs syndrome, disorder, mood"
 Pediatric Gastroenterology - Rectal Bleeding Consult., Consult - History and Phy., Rectal Bleeding - 1-year-old ,"HISTORY OF PRESENT ILLNESS:,  This is a 1-year-old male patient who was admitted on 12/23/2007 with a history of rectal bleeding.  He was doing well until about 2 days prior to admission and when he passes hard stools, there was bright red blood in the stool.  He had one more episode that day of stool; the stool was hard with blood in it.  Then, he had one episode of rectal bleeding yesterday and again one stool today, which was soft and consistent with dark red blood in it.  No history of fever, no diarrhea, no history of easy bruising.  Excessive bleeding from minor cut.  He has been slightly fussy.,PAST MEDICAL HISTORY:  ,Nothing significant.,PREGNANCY DELIVERY AND NURSERY COURSE: , He was born full term without complications.,PAST SURGICAL HISTORY: , None.,SIGNIFICANT ILLNESS AND REVIEW OF SYSTEMS: , Negative for heart disease, lung disease, history of cancer, blood pressure problems, or bleeding problems.,DIET:,  Regular table food, 24 ounces of regular milk.  He is n.p.o. now.,TRAVEL HISTORY: , Negative.,IMMUNIZATION: , Up-to-date.,ALLERGIES: , None.,MEDICATIONS: , None, but he is on IV Zantac now.,SOCIAL HISTORY: , He lives with parents and siblings.,FAMILY HISTORY:,  Nothing significant.,LABORATORY EVALUATION: , On 12/24/2007, WBC 8.4, hemoglobin 7.6, hematocrit 23.2 and platelets 314,000.  Sodium 135, potassium 4.7, chloride 110, CO2 20, BUN 6 and creatinine 0.3.  Albumin 3.3.  AST 56 and ALT 26.  CRP less than 0.3.  Stool rate is still negative.,DIAGNOSTIC DATA: , CT scan of the abdomen was read as normal.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Temperature 99.5 degrees Fahrenheit, pulse 142 per minute and respirations 28 per minute.  Weight 9.6 kilogram.,GENERAL:  He is alert and active child in no apparent distress.,HEENT:  Atraumatic and normocephalic.  Pupils are equal, round and reactive to light.  Extraocular movements, conjunctivae and sclerae fair.  Nasal mucosa pink and moist.  Pharynx is clear.,NECK:  Supple without thyromegaly or masses.,LUNGS:  Good air entry bilaterally.  No rales or wheezing.,ABDOMEN:  Soft and nondistended.  Bowel sounds positive.  No mass palpable.,GENITALIA:  Normal male.,RECTAL:  Deferred, but there was no perianal lesion.,MUSCULOSKELETAL:  Full range of movement.  No edema.  No cyanosis.,CNS:  Alert, active and playful.,IMPRESSION: , A 1-year-old male patient with history of rectal bleeding.  Possibilities include Meckel's diverticulum, polyp, infection and vascular malformation.,PLAN:,  To proceed with Meckel scan today.  If Meckel scan is negative, we will consider upper endoscopy and colonoscopy.  We will start colon clean out if Meckel scan is negative.  We will send his stool for C. diff toxin, culture, blood for RAST test for cow milk, soy, wheat and egg.  Monitor hemoglobin.",
" Patient felt dizzy, had some cold sweats, mild shortness of breath, no chest pain, no nausea or vomiting, but mild diarrhea, and sat down and lost consciousness for a few seconds.", Consult - History and Phy., Pulmonary Embolism ,"REASON FOR CONSULTATION: , Pulmonary embolism.,HISTORY:,  The patient is a 78-year-old lady who was admitted to the hospital yesterday with a syncopal episode that happened for the first time in her life.  The patient was walking in a store when she felt dizzy, had some cold sweats, mild shortness of breath, no chest pain, no nausea or vomiting, but mild diarrhea, and sat down and lost consciousness for a few seconds.  At that time, her daughter was with her.  No tonic-clonic movements.  No cyanosis.  The patient woke up on her own.  The patient currently feels fine, has mild shortness of breath upon exertion, but this is her usual for the last several years.  She cannot get up one flight of stairs, but feels short of breath.  She gets exerted and thinks to take a shower.  She does not have any chest pain, no fever or syncopal episodes.,PAST MEDICAL HISTORY,1.  Pulmonary embolism diagnosed one year ago.  At that time, she has had an IVC filter placed due to massive GI bleed from diverticulosis and gastric ulcers.  Paroxysmal atrial fibrillation and no anticoagulation due to history of GI bleed.,2.  Coronary artery disease status post CABG at that time.  She has had to stay in the ICU according to the daughter for 3 weeks due to again lower GI bleed.,3.  Mitral regurgitation.,4.  Gastroesophageal reflux disease.,5.  Hypertension.,6.  Hyperlipidemia.,7.  History of aortic aneurysm.,8.  History of renal artery stenosis.,9.  Peripheral vascular disease.,10.  Hypothyroidism.,PAST SURGICAL HISTORY,1.  CABG.,2.  Hysterectomy.,3.  IVC filter.,4.  Tonsillectomy.,5.  Adenoidectomy.,6.  Cosmetic surgery.,7.  Renal stent.,8.  Right femoral stent.,HOME MEDICATIONS,1.  Aspirin.,2.  Potassium.,3.  Lasix.,4.  Levothyroxine.,5.  Lisinopril.,6.  Pacerone.,7.  Protonix.,8.  Toprol.,9.  Vitamin B.,10.  Zetia.,11.  Zyrtec.,ALLERGIES:,  SULFA,SOCIAL HISTORY: , She used to be a smoker, not anymore.  She drinks 2 to 3 glasses of wine per week.  She is retired.,REVIEW OF SYSTEMS: , She has a history of snoring, choking for breath at night, and dry mouth in the morning.,PHYSICAL EXAMINATION,GENERAL APPEARANCE:  In no acute distress.,VITAL SIGNS:  Temperature 98.6, respirations 18, pulse 61, blood pressure 155/57, and oxygen saturation 93-98% on room air.,HEENT:  No lymph nodes or masses.,NECK:  No jugular venous distension.,LUNGS:  Clear to auscultation bilaterally.",
 Psychiatric History and Physical - Patient with schizoaffective disorder., Consult - History and Phy., Psych H&P - 2 ,"HISTORY OF PRESENT ILLNESS:,  The patient is a 69-year-old single Caucasian female with a past medical history of schizoaffective disorder, diabetes, osteoarthritis, hypothyroidism, GERD, and dyslipidemia who presents to the emergency room with the complaint of ""manic"" symptoms due to recent medication adjustments.  The patient had been admitted to St. Luke's Hospital on Month DD, YYYY for altered mental status and at that time, the medical team discontinued Zyprexa and lithium.  In the emergency room, the patient reported elevated mood, pressured speech, irritability, decreased appetite, and impulsivity.  She also added that over the past three days, she felt more confused and reported having blackouts as well as hallucinations about white lines and dots on her arms and face from the medication changes.  She was admitted voluntarily to the inpatient unit and medications were not restarted for her.  On the unit this morning, the patient is loud and nonredirectable, she is singing loudly and speaking in a very pressured manner.  She reports that she would like to speak with Dr. A, the neurologist who saw her at St. Luke's, because she ""trust him.""  The patient is somewhat reluctant to answer questions stating that she has answered enough of people's questions; however, she is talkative and reports that she feels as though she needs a sedative.  The patient reports that she is originally from Brooklyn, New York, and she moved down to Houston about a year ago to be with her daughter.  She also expressed frustration over the fact that her daughter wanted her removed from the apartment she was in initially and had her placed in a nursing home due to inability to care for herself.  The patient also complains that her daughter is ""trying to tell me what medications to take.""  The patient sees Dr. B in the Woodlands for outpatient care.,PAST PSYCHIATRIC HISTORY:,  Per chart.  The patient has been mentally ill for over 30 years with past diagnoses of bipolar disorder, schizoaffective disorder, and schizophrenia.  She has been stable on lithium and Zyprexa according to her daughter and was recently taken off those medications, changed to Seroquel, and the daughter reports that she has decompensated since then.  It is not known whether the patient has had prior psychiatric inpatient admissions; however, she denies that she has.,MEDICATIONS: ,1.  Seroquel 100 mg, 1 p.o. b.i.d.,2.  Risperdal 1 mg tab, 1 p.o. t.i.d.,3.  Actos 30 mg, 1 p.o. daily.,4.  Lipitor 10 mg, 1 p.o. at bedtime.,5.  Gabapentin 100 mg, 1 p.o. b.i.d.,6.  Glimepiride 2 mg, 1 p.o. b.i.d.,7.  Levothyroxine 25 mcg, 1 p.o. q.a.m.,8.  Protonix 40 mg, 1 p.o. daily.,ALLERGIES: , No known drug allergies.,FAMILY HISTORY:,  Per chart; her mother died of stroke, father with alcohol abuse and diabetes, one sister with diabetes, and one uncle died of leukemia.,SOCIAL HISTORY:,  The patient is from Brooklyn, New York and moved to Houston approximately one year ago.  She lived independently in an apartment until about one month ago when her daughter moved her into a nursing home.  She has been married once, but her spouse left her when her three children were young.  Her children are ages 47, 49, and 51.  She had one year of college, and she currently is retired after working in New York public schools for 20 or more years.  She reports that her spouse was physically abusive to her.  She reports occasional alcohol use and quit smoking 11 years ago.,MENTAL STATUS EXAM:  ,GENERAL:  The patient is an obese, white female who appears older than stated age, seated in a chair wearing large dark glasses.,BEHAVIOR:  The patient is singing loudly and joking with interviewers.  She is pleasant, but non-cooperative with interview.,SPEECH:  Increased volume, rate, and tone.  Normal in flexion and articulation.  MOTOR:  Agitated.,MOOD:  Okay.,AFFECT:  Elevated and congruent.,THOUGHT PROCESSES:  Tangential and logical at times.,THOUGHT CONTENTS:  Denies suicidal or homicidal ideation.  Denies auditory or visual hallucination.  Positive grandiose delusions and positive paranoid delusions.,INSIGHT:  Poor to fair.,JUDGMENT:  Impaired.  The patient is alert and oriented to person, place, date, year, but not day of the week.,LABORATORY DATA:,  Sodium 144, potassium 4.2, chloride 106, bicarbonate 27, glucose 183, BUN 23, creatinine 1.1, and calcium 10.6.  Acetaminophen level 3.3 and salicylate level less than 0.14.  WBC 7.41, hemoglobin 13.8, hematocrit 43.1, and platelets 229,000.  Urinalysis within normal limits.,PHYSICAL EXAMINATION:,GENERAL:  Alert and oriented, in no acute distress.,VITAL SIGNS:  Blood pressure 152/92, heart rate 81, and temperature 97.2.,HEENT:  Normocephalic and atraumatic.  PERRLA.  EOMI.  MMM.  OP clear.,NECK:  Supple.  No LAD, no JVD, and no bruits.,CHEST:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  Regular rate and rhythm.  S1 and S2 heard.  No murmurs, rubs, or gallops.,ABDOMEN:  Obese, soft, nontender, and nondistended.  Positive bowel sounds x4.,EXTREMITIES:  No cyanosis, clubbing, or edema.,ASSESSMENT:,  This is a 69-year-old Caucasian female with a past medical history of schizoaffective disorder, diabetes, hypothyroidism, osteoarthritis, dyslipidemia, and GERD who presents to the emergency room with complaints of inability to sleep, irritability, elevated mood, and impulsivity over the past 3 days, which she attributes to a recent change in medication after an admission to St. Luke's Hospital during which time the patient was taken off her usual medications of lithium and Zyprexa.  The patient is manic and disinhibited and is unable to give a sufficient interview at this time.,AXIS I:  Schizoaffective disorder.,AXIS II:  Deferred.,AXIS III:  Diabetes, hypothyroidism, osteoarthritis, gastroesophageal reflux disease, and dyslipidemia.,AXIS IV:  Family strife and recent relocation.,AXIS V:  GAF equals 25.,PLAN:  ",
 Psychiatric History and Physical - Patient with major depression, Consult - History and Phy., Psych H&P - 1 ,"HISTORY OF PRESENT ILLNESS: , This 40-year-old white single man was hospitalized at XYZ Hospital in the mental health ward, issues were filled up by his sister and his mother.  The issues involved include the fact that for the last 10 years he has been on disability for psychiatric reasons and has been not working, and in the last several weeks to month he began to call his family talking about the fact that he had been sexually abused by brother.  He has been in outpatient therapy with Jeffrey Silverberg for the past 10 years and Mr. Silverberg became concerned about his behavior, called the family and told them to have him put in the hospital, and at one point called the police because the patient was throwing cellphones and having tantrums in his office.,The history includes the fact that the patient is the 3rd of 4 children.  A brother who is approximately 8 years older, sexually abused brother who is 4 years older.  The brother who is 8 years older lives in California and will contact the family, has had minimal contact for many years.,That brother in California is gay.  The brother who is 4 years older, sexually abused, the patient from age 8 to 12 on a regular basis.  He said, he told his mother several years ago, but she did nothing about it.,The patient finished high school and with some struggle completed college at the University of Houston.  He has a sister who is approximately a year and half younger than he is, who was sexually abused by the brothers will, but only on one occasion.  She has been concerned about patient's behavior and was instrumental in having him committed.,Reportedly, the patient ran away from home at the age of 12 or 13 because of the abuse, but was not able to tell his family what happened.,He had no or minimal psychiatric treatment growing up and after completing college worked in retail part time.,He states he injured his back about 10 yeas ago.  He told he had disk problems but never had surgery.  He subsequently was put on psychiatric disability for depression, states he has been unable to get out of bed at times and isolates and keeps to himself.,He has been on a variety of different medications including Celexa 40 mg and ADD medication different times, and reportedly has used amphetamines in the past, although he denies it at this time.  He minimizes any alcohol use which appears not to be a problem, but what does appear to be a problem is he isolates, stays at home, has been in situations where he brings in people he does not know well and he runs the risk of getting himself physically harmed.,He has never been psychiatrically hospitalized before.,MENTAL STATUS EXAMINATION:,  Revealed a somewhat disheveled 40-year-old man who was clearly quite depressed and somewhat shocked at his family's commitment.  He says he has not seen them on a regular basis because every time he sees them he feels hurt and acknowledged that he called up the brother who abused him and told the brother's wife what had happened.  The brother has a child and wife became very upset with him.,Normocephalic.  Pleasant, cooperative, disheveled man with about 37 to 40, thoughts were somewhat guarded.  His affect was anxious and depressed and he denied being suicidal, although the family said that he has talked about it at times.,Recent past memory were intact.,DIAGNOSES:,Axis I:  Major depression rule out substance abuse.,Axis II:  Deferred at this time.,Axis III:  Noncontributory.,Axis IV:  Family financial and social pressures.,Axis V:  Global Assessment of Functioning 40.,RECOMMENDATION:,  The patient will be hospitalized to assess.,Along the issues, the fact that he is been living in disability in the fact that his family has had to support him for all this time despite the fact that he has had a college degree.  He says he has had several part time jobs, but never been able to sustain employment, although he would like to.","consult - history and phy., history of present illness:, global assessment of functioning, mental status examination, major depression, psychiatric, abuse, behavior, depression, mental health, mental health ward, psychiatric disability, sexually abused, substance abuse, health, "
" Bipolar disorder, apparently stable on medications.  Mild organic brain syndrome, presumably secondary to her chronic inhalant, paint, abuse.", Consult - History and Phy., Psychiatric Consult - 1 ,"HISTORY OF PRESENT ILLNESS:,  This is a 53-year-old widowed woman, she lives at ABC Hotel.  She presented with a complaint of chest pain, evaluations revealed severe aortic stenosis.  She has been refusing cardiac catheter and she may well need aortic valve replacement.  She states that she does not want heart surgery or valve replacement.  She has a history of bipolar disorder and has been diagnosed at times with schizophrenia.  She is on Depakote 500 mg three times a day and Geodon 80 mg twice a day.  The patient receives mental health care through the XYZ Health System and there is a psychiatrist who makes rounds at the ABC Hotel.  She denies hallucinations, psychosis, paranoia, and suicidal ideation at this time.  States that she does not want surgery because the chest pain that was a presenting complaint has gone away that she did not feel her problem is severe enough to require surgery, and medical records does show in this obese individual that cardiac surgery would present substantial risks and for this individual with the chronic mental illness and behavioral problems of a chronic nature, surgery does present some additional risks.  The patient notes that she has a long history of substance abuse, primarily inhalation of paint vapors that she had more than 100 incarcerations in the XYZ County Jail related to offenses related to her lifestyle at that time such as shoplifting, violation of orders to abstain from substance abuse and the longest confinement of these was 100 days.,The patient is able to write a fairly reasonable explanation for why she does not want to pursue medical care.,PAST AND DEVELOPMENTAL HISTORY: , She was born in XYZ.  She is a high-school graduate from ABCD High School.  She did have an abusive childhood.  She is married four times.  She notes she developed depression when a number of her children died.,PHYSICAL EXAMINATION:  ,GENERAL: , This is an obese woman in bed.  She is somewhat restless and moving during the interview.,VITAL SIGNS,:  Temperature of 97.3, pulse 70, respirations 18, blood pressure 113/68, and oxygen saturation 94% on 3 L of oxygen.,PSYCHIATRY:  ,Speech is normal, rate, volume, grammar, and vocabulary consistent with her educational level.  There is no overt thought disorder.  She does not appear psychotic.  She is not suicidal on formal testing.  She gives the date as Sunday, 05/19/2007 when it is the 20th and 207 when it is 2007.  She is oriented to place.  She can memorize four times, repeats two at five minutes, gets the other two with category hints, this places short-term memory in normal limits.  She had difficulty with serial three subtractions, counting on her fingers and had difficulty naming the months in reverse order stating, ""December, November, September, October, June, July, August, September,"" but recognizes this was not right and then said, ""March, April, May.""  She is able to name objects appropriately.,LABORATORY DATA: , Chest x-ray showing no acute changes.  Carotid duplex shows no stenosis.  Electrolytes and liver function tests are normal.  TSH normal.  Hematocrit 31%.  Triglycerides 152.,DIAGNOSES:  ,1.  Bipolar disorder, apparently stable on medications.,2.  Mild organic brain syndrome, presumably secondary to her chronic inhalant, paint, abuse.,3.  Aortic stenosis.,4.  Sleep apnea.,5.  Obesity.,6.  Anemia.,7.  Gastroesophageal reflux disease.,RECOMMENDATIONS:,  It is my impression at present that the patient retains ability to make decisions on her own behalf.  Given this lady's underlying mental problems, I would recommend that her treating physicians discuss her circumstances with physicians who round on her at the ABC Hotel.  While she may well need surgery and cardiac catheter, she may be more willing to accept this in the context of some continued encouragement from care providers who usually provide care for her.  She clearly at this time wants to leave this hospital; she normally gets her care through XYZ Health.  Again, in summary, I would consider her to retain the ability to make decisions on her own behalf.,Please feel free to contact me at digital pager if additional information is needed.","consult - history and phy., organic brain syndrom, substance abuse, bipolar disorder, mental, abuse, "
" Psychiatric consultation has been requested as the patient has been noncompliant with treatment, leave the unit, does not return when requested, and it was unclear as to whether this is secondary to confusion or willful behavior.", Consult - History and Phy., Psychiatric Consult ,"HISTORY OF PRESENT ILLNESS:  ,This is a 23-year-old married man who had an onset of aplastic anemia in December, underwent a bone marrow transplant in the end of March, has developed very severe graft-versus-host reaction.  Psychiatric consultation has been requested as the patient has been noncompliant with treatment, leave the unit, does not return when requested, and it was unclear as to whether this is secondary to confusion or willful behavior.,The patient gives a significant history of behavioral problems from late adolescence until the onset of illness, states he had lot of trouble with law, he was convicted of assault, he was also arrested with small amount of cannabis, states he served one year incarcerated in ABCD that was about two years ago.  Gives an ongoing history of substance abuse until one year ago when he went into a drug rehabilitation program, he was discharged from that on 05/28/2006 and states he has been clean and sober since then.  Prior to going to rehabilitation, he was using intravenous heroin couple of times a week since age 17, which would have been over a period of about five years, reports heavy use of cannabis, smoking pot up to five times a day if he could.  He would drink up to half of a fifth of rum on a daily basis when available.,The patient is currently on Lexapro 10 mg in the morning and diazepam 10 mg at bedtime.  He complained of some depressive and some anxiety symptoms, but these do not appear to be out of proportion to his medical issues and, for this individual, the frustrations of his treatments.  He would have a limited support system here in Colorado.  He married in January and states that the marriage is not going particularly well, being young, sick, and hospitalized, has not helped his relationship with his new wife who apparently is expecting a child in July.  I would recommend some couples counseling as a part of their treatment here.,The patient was fairly drowsy during the interview and full past and developmental history was not obtained.  The patient's comment is that he grew up all over, that his parents had separated, that he lived with his mother, that he dropped out of school in eleventh grade, at that time was living in XYZ area because he did not like school.,PHYSICAL EXAMINATION:  ,GENERAL: , This is a cooperative man, speech is soft and difficult to understand.  There is no thought disorder and no hallucination.  He denies being suicidal, but does express at times feelings about giving up on his treatments and primarily complaints about feeling that he is treated like a child and confined in the hospital.,VITAL SIGNS: , Temperature 97.2, pulse 117, respirations 16, blood pressure 127/74, oxygen saturation 97%, and weight is 154 pounds.,PSYCHIATRY:,  There is no thought disorder, no paranoia, no delusions, and no psychotic symptoms.  Activities of daily living (ADLs) appear intact.  On formal testing, he is oriented to place.  He can give a reasonable recitation of his medical history.  He is oriented to the year, knows it is the 15th, but gave the month as June instead of May.  He can memorize four items, repeats three out of four at five minutes, gives the fourth through the category, which places short-term memory in normal limits.  He can do serial three subtractions accurately, can name objects appropriately.,LABORATORY DATA:,  Sodium of 135, BUN of 24, and glucose 119.  GGT of 355, ALT of 97, LDH of 703, and alk phos of 144.  FK506 is 28.8, which is elevated tacrolimus level.  Hematocrit 29% and white count is 7000.,DIAGNOSES:  ,AXIS I:,  Depressive disorder secondary to the underlying medical condition of graft-versus-host reaction.,AXIS II: , Personality disorder, not otherwise specified (NOS).,AXIS III: , History of polysubstance abuse, in remission.,RECOMMENDATIONS:  ,1.  This patient appears to retain the ability to make decisions on his own behalf.  I think he is mentally competent.  Unfortunately, his impulsive low frustration personality dynamics do not fit well with the demands and requirements for treatment of this chronic illness.  If the patient refuses treatment, he understands that the consequences of this would likely be hastened mortality and he does state that he does not want to die.,2.  The patient does complain of depressed mood, also of anxiety.  We did discuss medications.  He appeared somewhat sedated at the time of my interview.  I would recommend that we try Seroquel 25 mg twice daily on an as-needed basis to see if this diminishes anxiety.  I will have Dr. X followup with him.,Please feel free to contact me at digital pager if additional information is needed.,My overall recommendation would be that the patient be on some random urine drug screening, that he use cell phone if he goes off the unit, to be called back up when treatments are scheduled, and hopefully he will be agreeable to complying with this.","consult - history and phy., noncompliant, confusion, graft versus host reaction, psychiatric consultation, willful behavior, cannabis, "
 Psychiatric consultation for management of pain medications., Consult - History and Phy., Psych Consult - Pain Meds ,"REASON FOR CONSULTATION: , Management of pain medications.,HISTORY OF PRESENT ILLNESS: , This is a 60-year-old white male with history of coronary artery disease, status post CABG in 1985 with subsequent sternal dehiscence with rewiring in December 2005 and stent placement in LAD region in 2005, who developed sudden chest pain and was taken to San Jacinto via ambulance where he was diagnosed with acute MI and then went into atrial fibrillation.  An intraaortic balloon pump was placed for cardiogenic shock, and then he was transferred to the ABCD Hospital on October 22, 2006, for continued critical care.  He was in a state of cardiogenic shock and multiorgan system failure including respiratory failure and acute renal insufficiency when he was transferred.  He is currently on dialysis due to end-stage renal disease and has a tracheostomy.  He is receiving fentanyl since he has been here for back pain, leg pain, abdominal pain, and pain in the feet.  He states that he is currently in pain and the fentanyl only helps for about an hour or so before the pain resumes.  He currently rates his pain as 7 out of 10.  He denies a depressed mood or anxiety and states that he knows he is getting better.  He describes his sleep as erratic and states that he will sleep for 1 hour after giving fentanyl IV and then will wake up until he gets another fentanyl.  He has PEG for tube feeding.  He has weakness on left side of his body as well as both legs since his MI.  He has been switched from fentanyl IV q.2h. to the fentanyl patch today.  He also has been started on Seroquel 12.5 mg p.o. at bedtime and will receive his first dose on the evening of Monday, February 12, 2007.  He denies any other psychiatric symptoms including auditory or visual hallucinations or delusions.  His wife was present in the room and both him and his wife seemed to be offended by the suggestion of any psychiatric history or any psychiatric problems.,PAST MEDICAL HISTORY:,1.  DVT in December 2005.,2.  Three MI's (1996, 2005, and 2006).,3.  Diabetes for 5 years.,4.  Coronary artery disease for 10 years.,PAST SURGERIES:,1.  Appendectomy as a child.,2.  CABG x3, November 2005.,3.  Sternal rewiring, December 2005.,MEDICATIONS:,1.  Restoril 7.5 mg p.o. at bedtime p.r.n.,2.  Acetaminophen 650 mg p.o. q.6h. p.r.n. fever.,3.  Aspirin 81 mg p.o. daily.,4.  Bisacodyl suppository 10 mg per rectum daily.,5.  Erythropoietin injection 100 mcg subcutaneously every week at 5 p.m.,6.  Esomeprazole 40 mg IV q.12h.,7.  Fentanyl patch 25 mcg per hour.,8.  Transderm patch every 72 hours.,9.  Heparin IV.,10.  Lactulose 30 mL p.o. daily p.r.n. constipation.,11.  Metastron injection 4 mg IV q.6h. p.r.n. nausea.,12.  Seroquel 12 mg p.o. at bedtime.,13.  Saliva substitute 30 mL spray p.o. q.3h. p.r.n. dry mouth.,14.  Simethicone drops 80 mg per G-tube p.r.n. gas pain.,15.  Bactrim suspension p.o. daily.,16.  Insulin medium dose sliding scale.,17.  Albumin 25% IV p.r.n. hemodialysis.,18.  Ipratropium solution for nebulizer.,ALLERGIES:,  No known drug allergies.,PAST PSYCHIATRIC HISTORY:,  The patient denies any past psychiatric problems.  No medications.  He denies any outpatient visits or inpatient hospitalizations for psychiatric reasons.,SOCIAL HISTORY:,  He lives with his wife in New Jersey.  He has 2 children.  One son in Texas City and 1 daughter in Florida.  He is a master mechanic for a trucking company since 1968.  He retired in the May 2006.  The highest level of education that he received was 1 year in college.,Ethanol, tobacco, or drugs; he smoked 2 packs per day for 40 years, but quit in 1996.  He occasionally has a beer, but denies any continuous use of alcohol.  He denies any illicit drug use.,FAMILY HISTORY:,  Both parents died with myocardial infarctions.  He has 2 sisters and a brother with diabetes mellitus and coronary artery disease.  He denies any history of psychiatric problems in family.,MENTAL STATUS EXAMINATION:,  The patient was sitting in his bed in hospital gown with tracheostomy and receiving tube feeding.  The patient's appearance was appropriate with fair-to-good grooming and hygiene.  He had little-to-no psychomotor activity secondary to weakness post MI.  He had good eye contact.  His speech was of decreased rate volume and flexion secondary to tracheostomy.  The patient was cooperative.  He described his mood is not good in congruent stable and appropriate affect with decreased range.  His thought process is logical and goal directed.  His thought content was negative for delusions, phobias, obsessions, suicidal ideation, or homicidal ideation.  He denied any perceptional disturbances including any auditory or visual hallucinations.  He was alert and oriented x3.,Mini mental status exams not completed.,ASSESSMENT:,AXIS I:  Pain with physical symptoms and possibly psychological symptoms.,AXIS II:  Deferred.,AXIS III:  See above.",
" A 30-year-old white male with a history of schizophrenia, chronic paranoid, was admitted for increasing mood lability, paranoia, and agitation.", Consult - History and Phy., Psych Consult - Paranoia ,"IDENTIFYING DATA: , The patient is a 30-year-old white male with a history of schizophrenia, chronic paranoid, was admitted for increasing mood lability, paranoia, and agitation.,CHIEF COMPLAINT: , ""I am not sure."" The patient has poor insight into hospitalization and need for treatment.,HISTORY OF PRESENT ILLNESS: , The patient has a history of schizophrenia and chronic paranoid, for which she has received treatment in Houston, Texas.  According to mental health professionals, the patient had been noncompliant with medications for approximately two weeks.  The patient had taken an airplane from Houston to Seattle, but became agitated, paranoid, expressing paranoid delusions that the stewardess and pilots were trying to reject him and was deplaned in Seattle.  The patient was taken to the local shelter where he remained labile, breaking a window, and was taken to jail.  The patient has now been discharged from jail but involuntarily detained for persistent paranoia and disorganization (no jail hold).,PAST PSYCHIATRIC HISTORY: , History of schizophrenia, chronic paranoid.  The patient as noted has been treated in Houston but has not had recent treatment or medications.,PAST MEDICAL HISTORY:  ,No acute medical problems noted.,CURRENT MEDICATIONS: , None.  The patient was most recently treated with Invega and Abilify according to his records.,FAMILY SOCIAL HISTORY: , The patient resides with his father in Houston.  The patient has no known history of substances abuse.  The patient as noted was in jail prior to admission after breaking a window at the local shelter but has no current jail hold.,FAMILY PSYCHIATRIC HISTORY:,  Need to increase database.,MENTAL STATUS EXAMINATION:,Attitude:  Calm and cooperative.,Appearance:  Shows poor hygiene and grooming.,Psychomotor:  Behavior is within normal limits without agitation or retardation.  No EPS or TDS noted.,Affect:  Is suspicious.,Mood:  Anxious but cooperative.,Speech:  Shows normal rate and rhythm.,Thoughts:  Disorganized,Thought Content:  Remarkable for paranoia ""they want to hurt me."",Psychosis:  The patient endorses paranoid delusions as above.  The patient denies auditory hallucinations.,Suicidal/Homicidal Ideation:  The patient denies on admission.,Cognitive Assessment:  Grossly intact.  The patient is alert and oriented x 3.,Judgment:  Poor, shown by noncompliance with treatment.,Assets:  Include stable physical status.,Limitations:  Include recurrent psychosis.,FORMULATION:  ,The patient with a history of schizophrenia was admitted for increasing mood lability and psychosis due to noncompliance with treatment.,INITIAL IMPRESSION:,AXIS I:  Schizophrenia, chronic paranoid.,AXIS II:  None.,AXIS III:  None.,AXIS IV:  Severe.,AXIS V:  10.,ESTIMATED LENGTH OF STAY: , 12 days.,PLAN:  ,The patient will be restarted on Invega and Abilify for psychosis.  The patient will also be continued on Cogentin for EPS.  Increased database will be obtained.",
 Psychiatric consultation for substance abuse., Consult - History and Phy., Psych Consult - Substance abuse ,"REASON FOR CONSULT: , Substance abuse.,HISTORY OF PRESENT ILLNESS: , The patient is a 42-year-old white male with a history of seizures who was brought to the ER in ABCD by his sister following cocaine and nitrous oxide use.  The patient says he had been sober from any illicit substance for 15 months prior to most recent binge, which occurred approximately 2 days ago.  The patient is unable to provide accurate history as to amount use in this most recent binge or time period it was used over.  The patient had not used cocaine for 15 years prior to most recent usage but had used alcohol and nitrous oxide up until 15 months ago.  The patient says he was depressed and agitated.  He says he used cocaine by snorting and nitrous oxide but denies other drug usage.  He says he experienced visual hallucinations while intoxicated, but has not had hallucinations since being in the hospital.  The patient states he has had cocaine-induced seizures several times in the past but is not able to provide an accurate history as to the time period of the seizure.  The patient denies suicidal ideation, homicidal ideation, auditory hallucinations, visual hallucinations, or tactile hallucinations.  The patient is A&O x3.,PAST PSYCHIATRIC HISTORY:,  Substance abuse as per HPI.  The patient went to a well sober for 15 months.,PAST MEDICAL HISTORY:,  Seizures.,PAST SURGICAL HISTORY:,  Shoulder injury.,SOCIAL HISTORY:,  The patient lives alone in an apartment uses prior to sobriety 15 months ago.  He was a binge drinker, although unable to provide detail about frequency of binges.  The patient does not work since brother became ill 3 months ago when he quit his job to care for him.,FAMILY HISTORY:,  None reported.,MEDICATIONS OUTPATIENT:,  Seroquel 100 mg p.o. daily for insomnia.,MEDICATIONS INPATIENT:,1.  Gabapentin 300 mg q.8h.,2.  Seroquel 100 mg p.o. q.h.s.,3.  Seroquel 25 mg p.o. q.8h. p.r.n.,4.  Phenergan 12.5 mg IV q.4h. p.r.n.,5.  Acetaminophen 650 mg q.4h. p.r.n.,6.  Esomeprazole 40 mg p.o. daily. ,MENTAL STATUS EXAMINATION: , The patient is a 42-year-old male who appears stated age, dressed in a hospital gown.  The patient shows psychomotor agitation and is somewhat irritable.  The patient makes fair eye contact and is cooperative.  He had answers my questions with ""I do not know.""  Mood ""depressed"" and ""agitated.""  Affect is irritable.  Thought process logical and goal directed with thought content.  He denies suicidal ideation, homicidal ideation, auditory hallucinations, visual hallucinations, or tactile hallucinations.  Insight and judgment are both fair.  The patient seems to understand why he is in the hospital and patient says he will return to Alcoholics Anonymous and will try to stay sober in all substances following discharge.  The patient is A&O x3.,ASSESSMENT:,AXIS I:  Substance withdrawal, substance abuse, and substance dependence.,AXIS II:  Deferred.,AXIS III:  History of seizures.,AXIS IV:  Lives alone and unemployed.,AXIS V:  55.,IMPRESSION:,  The patient is a 42-year-old white male who recently had a cocaine binge following 15 months of sobriety.  The patient is experiencing mild symptoms of cocaine withdrawal.,RECOMMENDATIONS:,1.  Gabapentin 300 mg q.8h. for agitation and history of seizures.,2.  Reassess this afternoon for reduction in agitation and withdrawal seizures.,Thank you for the consult.  Please call with further questions.",
" Patient with a history of PTSD, depression, and substance abuse.", Consult - History and Phy., Psych Consult - Psychosis  ,"IDENTIFYING DATA:,  Psychosis.,HISTORY OF PRESENT ILLNESS: , The patient is a 28-year-old Samoan female who was her grandmother's caretaker.  Her grandmother unfortunately had passed away recently and then the patient had developed erratic behavior.  She had lived with her parents and son, but parents removed son from the home, secondary to the patient's erratic behavior.  Recently, she was picked up by Kent Police Department ""leaping on Highway 99."",PAST MEDICAL HISTORY: , PTSD, depression, and substance abuse.,PAST SURGICAL HISTORY:  ,Unknown.,ALLERGIES:,  Unknown.,MEDICATIONS: , Unknown.,REVIEW OF SYSTEMS: , Unable to obtain secondary to the patient being in seclusion.,OBJECTIVE:,  Vital signs that were previously taken revealed a blood pressure of 152/86, pulse of 106, respirations of 18, and temperature is 97.6 degrees Fahrenheit.  General appearance, HEENT, and history and physical examination was unable to be obtained today, as patient was put into seclusion.,LABORATORY DATA: , Laboratory reviewed reveals a BMP, slightly elevated glucose at 100.2.  Previous urine tox was positive for THC.  Urinalysis was negative, but did note positive UA wbc's.  CBC, slightly elevated leukocytosis at 12.0, normal range is 4 to 11.,ASSESSMENT AND PLAN:,AXIS I:  Psychosis.  Inpatient Psychiatric Team to follow.,AXIS II:  Deferred.,AXIS III:  We were unable to perform physical examination on the patient today secondary to her being in seclusion.  Laboratory was reviewed revealing leukocytosis, possibly secondary to a UTI.  We will wait until the patient is out of seclusion to perform examination.  Should she have some complaints of dysuria or any suprapubic pain, then we will begin on appropriate antimicrobial therapy.  We will followup with the patient should any new medical issues arise.","consult - history and phy., ptsd, depression, psychosis, psychiatric, substance abuse, erratic behavior, behavior, axis,"
 The patient was found by outpatient case manager to be unresponsive and incontinent of urine and feces at his father's home., Consult - History and Phy., Psych Consult - Psychosis - 1 ,"IDENTIFYING DATA: , This is a 26-year-old Caucasian male of unknown employment, who has been living with his father.,CHIEF COMPLAINT AND/OR REACTION TO HOSPITALIZATION: , The patient is unresponsive.,HISTORY OF PRESENT ILLNESS: , The patient was found by outpatient case manager to be unresponsive and incontinent of urine and feces at his father's home.  It is unknown how long the patient has been decompensated after a stay at Hospital.,PAST PSYCHIATRIC HISTORY: , Inpatient ITA stay at Hospital one year ago, outpatient at Valley Cities, but currently not engaged in treatment.,MEDICAL HISTORY: , Due to the patient being unresponsive and very little information available in the chart, the only medical history that we can identify is to observe that the patient is quite thin for height.  He is likely dehydrated, as it appears that he has not had food or fluids for quite some time.,CURRENT MEDICATIONS:,  Prior to admission, we do not have that information.  He has been started on Ativan 2 mg p.o. or IM if he refuses the p.o. and this would be t.i.d. to treat the catatonia.,SOCIAL AND DEVELOPMENTAL HISTORY:  ,The patient has been living in his father's home and this is all the information that we have available from the chart.,SUBSTANCE AND ALCOHOL HISTORY:  ,It is unknown with the exception of nicotine use.,LEGAL HISTORY: , Unknown.,GENETIC PSYCHIATRIC HISTORY: , Unknown.,MENTAL STATUS EXAM:,Attitude:  The patient is unresponsive.,Appearance:  He is lying in bed in the fetal position with a blanket over his head.,Psychomotor:  Catatonic.,EPS/TD:  Unable to assess though his limbs are quite contracted.,Affect:  Unresponsive.,Mood:  Unresponsive.,Speech:  Unresponsive.,Thought Process And Thought Content:  Unresponsive.,Psychosis:  Unable to elicit information to make this assessment.,Suicidal/Homicidal:  Also unable to elicit this information.,Cognitive Assessment:  Unable to elicit.,Judgment And Insight:  Unable to elicit.,Assets:  The patient is young.,Limitations:  Severe decompensation.,FORMULATION:  ,This is a 26-year-old Caucasian male with a diagnosis of psychosis, NOS, admitted with catatonia.,DIAGNOSES:,AXIS I:  Psychosis, NOS.,AXIS II:  Deferred.,AXIS III:  Dehydration.,AXIS IV:  Severe.,AXIS V:  10.,ESTIMATED LENGTH OF STAY: , 10 to 14 days.,RECOMMENDATIONS AND PLAN:,1.  Stabilize medically from the dehydration per internal medicine.,2.  Medications, milieu therapy to assist with re-compensation.",
 A 45-year-old white male with a history of schizophrenia and AIDS.  He was admitted for disorganized and assaultive behaviors while off all medications for the last six months., Consult - History and Phy., Psych Consult - Schizophrenia ,"IDENTIFYING DATA:,  The patient is a 45-year-old white male.  He is unemployed, presumably on disability and lives with his partner.,CHIEF COMPLAINT: , ""I'm in jail because I was wrongly arrested."" The patient is admitted on a 72-hour Involuntary Treatment Act for grave disability.,HISTORY OF PRESENT ILLNESS: , The patient has minimal insight into the circumstances that resulted in this admission.  He reports being diagnosed with AIDS and schizophrenia for some time, but states he believes that he has maintained his stable baseline for many months of treatment for either condition.  Prior to admission, the patient was brought to Emergency Room after he attempted to shoplift from a local department store, during which he apparently slapped his partner.  The patient was disorganized with police and emergency room staff, and he was ultimately detained on a 72-hour Involuntary Treatment Act for grave disability.,On the interview, the patient is still disorganized and confused.  He believes that he has been arrested and is in jail.  Reports a history of mental health treatment, but denies benefiting from this in the past and does not think that it is currently necessary.,I was able to contact his partner by telephone.  His partner reports the patient is paranoid and has bizarre behavior at baseline over the time that he has known him for the last 16 years, with occasional episodes of symptomatic worsening, from which he spontaneously recovers.  His partner estimates the patient spends about 20% of the year in episodes of worse symptoms.  His partner states that in the last one to two months, the patient has become worse than he has ever seen him with increased paranoia above the baseline and he states the patient has been barricading himself in his house and unplugging all electrical appliances for unclear reasons.  He also reports the patient has been sleeping less and estimates his average duration to be three to four hours a night.  He also reports the patient has been spending money impulsively in the last month and has actually incurred overdraft charges on his checking account on three different occasions recently.  He also reports that the patient has been making threats of harm to him and that His partner no longer feels that he is safe having him at home.  He reports that the patient has been eating regularly with no recent weight loss.  He states that the patient is observed responding to internal stimuli, occasionally at baseline, but this has gotten worse in the last few months.  His partner was unaware of any obvious medical changes in the last one to two months coinciding with onset of recent symptomatic worsening.  He reports of the patient's longstanding poor compliance with treatment of his mental health or age-related conditions and attributes this to the patient's dislike of taking medicine.  He also reports that the patient has expressed the belief in the past that he does not suffer from either condition.,PAST PSYCHIATRIC HISTORY: , The patient's partner reports that the patient was diagnosed with schizophrenia in his 20s and he has been hospitalized on two occasions in the 1980s and that there was a third admission to a psychiatric facility, but the date of this admission is currently unknown.  The patient was last enrolled in an outpatient mental health treatment in mid 2009.  He dropped out of care about six months ago when he moved with his partner.  His partner reports the patient was most recently prescribed Seroquel, which, though the patient denied benefiting from, his partner felt was ""useful, but not dosed high enough."" Past medication trials that the patient reports include Haldol and lithium, neither of which he found to be particularly helpful.,MEDICAL HISTORY: , The patient reports being diagnosed with HIV and AIDS in 1994 and believes this was secondary to unprotected sexual contact in the years prior to his diagnosis.  He is currently followed at Clinic, where he has both an assigned physician and a case manager, but treatment compliance has been poor with no use of antiretroviral meds in the last year.  The patient is fairly vague on his history of AIDS related conditions, but does identify the following:  Thrush, skin lesions, and lung infections; additional details of these problems are not currently known.,CURRENT MEDICATIONS: , None.,ALLERGIES:,  No known drug allergies.,SOCIAL AND DEVELOPMENTAL HISTORY: , The patient lives with his partner.  He is unemployed.  Details of his educational and occupational history are not currently known.  His source of finances is also unknown, though social security disability is presumed.,SUBSTANCE AND ALCOHOL HISTORY: , The patient smoked one to two packs per day for most of the last year, but has increased this to two to three packs per day in the last month.  His partner reports that the patient consumed alcohol occasionally, but denies any excessive or binge use recently.  The patient reports smoking marijuana a few times in his life, but not recently.  Denies other illicit substance use.,LEGAL HISTORY:  ,Unknown.,GENETIC PSYCHIATRIC HISTORY:,  Also unknown.,MENTAL STATUS EXAM:,Attitude:  The patient demonstrates only variable cooperation with interview, requires frequent redirection to respond to questions.  His appearance is cachectic.  The patient is poorly groomed.,Psychomotor:  There is no psychomotor agitation or retardation.  No other observed extrapyramidal symptoms or tardive dyskinesia.,Affect:  His affect is fairly detached.,Mood:  Describes his mood is ""okay."",Speech:  His speech is normal rate and volume.  Tone, his volume was decreased initially, but this improved during the course of the interview.,Thought Process:  His thought processes are markedly tangential.,Thought content:  The patient is fairly scattered.  He will provide history with frequent redirection, but he does not appear to stay on one topic for any length of time.  He denies currently auditory or visual hallucinations, though his partner says that this is a feature present at baseline.  Paranoid delusions are elicited.,Homicidal/Suicidal Ideation:  He denies suicidal or homicidal ideation.  Denies previous suicide attempts.,Cognitive Assessment:  Cognitively, he is alert and oriented to person and year only.  His memory is intact to names of his Madison Clinic providers.,Insight/Judgment:  His insight is absent as evidenced by his repeated questioning of the validity of his AIDS and mental health diagnoses.  His judgment is poor as evidenced by his longstanding pattern of minimal engagement in treatment of his mental health and physical health conditions.,Assets:  His assets include his housing and his history of supportive relationship with his partner over many years.,Limitations:  His limitations include his AIDS and his history of poor compliance with treatment.,FORMULATION:  ,The patient is a 45-year-old white male with a history of schizophrenia and AIDS.  He was admitted for disorganized and assaultive behaviors while off all medications for the last six months.  It is unclear to me how much his presentation is a direct expression of an AIDS-related condition, though I suspect the impact of his HIV status is likely to be substantial.,DIAGNOSES:,AXIS I:  Schizophrenia by history.  Rule out AIDS-induced psychosis.  Rule out AIDS-related cognitive disorder.,AXIS II:  Deferred.,AXIS III:  AIDS (stable by his report).  Anemia.,AXIS IV:  Relationship strain and the possibility that he may be unable to return to his home upon discharge; minimal engagement in mental health and HIV-related providers.,AXIS V:  Global Assessment Functioning is currently 15.,PLAN: , I will attempt to increase the database, will specifically request records from the last mental health providers.  The Internal Medicine Service will evaluate and treat any acute medical issues that could be helpful to collaborate with his providers at Clinic regarding issues related to his AIDS diagnosis.  With the patient's permission, I will start quetiapine at a dose of 100 mg at bedtime, given the patient's partner report of partial, but response to this agent in the past.  I anticipate titrating further for effect during the course of his admission.",
 Psychiatric Consultation of patient with recurring depression., Consult - History and Phy., Psych Consult - Depression - 1 ,"CC: , ""Five years ago, I stopped drinking and since that time, I have had severe depression.  I was doing okay when I stopped my medications in April for a few weeks, but then I got depressed again.  I started lithium three weeks ago."",HPI:  ,The patient is a 45-year-old married white female without children currently working as a billing analyst for Northwest Natural.  The patient has had one psychiatric hospitalization for seven days in April of 1999.  The patient now presents with recurrent depressive symptoms for approximately four months.  The patient states that she has decreased energy, suicidal ideation, suicide plan, feelings of guilt, feelings of extreme anger, psychomotor agitation, and increased appetite.  The patient states her sleep is normal and her ability to concentrate is normal.  The patient states that last night she had an argument with her husband in which he threaten to divorce her.  The patient went into the rest room, tried to find a razor blade, could not find one but instead found a scissor and cut her arm moderately with some moderate depth.  She felt better after doing so and put a bandage over the wound and did not report to her husband or anybody else what she had done.  The patient reports that she has had increased tension with her husband as of recent.  She notes that approximately a week ago she struck her husband several times.  She states that he has never hit her but instead pushed her back after she was hitting him.  She reports no history of abuse in the past.  The patient identifies recent stressors as having ongoing conflict at work with her administrator with them ""cracking down on me."" The patient also notes that her longstanding therapy will be temporarily interrupted by the therapist having a child.  She states that her recent depression seems to coincide with her growing knowledge that her therapist was pregnant.  The patient states that she has a tremendous amount of anger towards her therapist for discontinuing or postponing treatment.  She states that she feels ""abandoned."" The patient notes that it does raise issues with her past, where she had a child at the age of 17 who she gave away for adoption and a second child that she was pregnant by the age of 42 that she aborted at the request of her husband.  The patient states she saw her therapist most recently last Friday.  She sees the therapy weekly and indicates the therapy helps, although she is unable to specify how.  When asked for specifics of what she has learned from the therapy, the patient was unable to reply.  It appears that she is very concrete and has difficulty with symbolization and abstractions and self-observation.  The patient reports that at her last visit her therapist was concerned that she may be suicidal and was considering hospitalization.  The patient, at that point, stated that she would be safe through Monday despite having made a gesture last night.  At present, the patient's mood is reactive and for much of the session she appears angry and irritated with me but at the end of the session, after I have given her my assessment, she appears calmed and not depressed.  When asked if she is suicidal at present, she states no.  The patient does not want to go into the hospital.  The patient also indicates at the end of the session she felt hopeful.  The patient reports her current sleep is about eight hours per night.  She states that longest she has been able to stay awake in the past has been 24 hours.  She states that during periods where she feels up she sleeps perhaps six hours per night.  The patient reports no spending sprees and no reports no sexual indiscretions.  The patient states that her sexuality does increase when she is feeling better but not enormously so.  The patient denies any history of delusions or hallucinations.  The patient denies any psychosis.  The patient states that she does have mood swings and that the upstate lasts for a couple of weeks at longest.  She states that more predominately she has depression.  The patient states that she does not engage in numerous projects when she is in an upstate although does imagine doing so.  The patient notes that suicidality and depression seems to often arise around disputes with her husband and/or feelings of abandonment.  The patient indicates some satisfaction when she is called on her behavior ""I need to answer for my actions."" The patient gives a substantial history of alcohol abuse lasting up to about five years ago when she was hospitalized.  Most typically, the patient will drink at least a bottle of wine per day.  The patient has attended AA but at present going once a week, although she states that she is not engaged as she has been in the past; and when asked if she may be in early relapse, she indicates that yes that is a very real possibility.  The patient states she is not working through any of the steps at present.,PPH: , The patient denies any sexual abuse as a child.  She states that she was disciplined primarily by her father with spankings.  She states that on occasion her mother would use a belt to spank her or with her hand or with a spoon.  The patient has been seeing Dr. A for the past five years.  Prior to that she was admitted to a hospital for her suicide attempt.  The patient also has one short treatment experienced with the Day Treatment Program here in Portland.  The patient states that it was not useful as it focused on group work with pts that she did not feel any similarity with.  The patient, also as a child, had a history of cutting behaviors.  The patient was admitted to the hospital after lacerating her arm.,MEDICAL HISTORY:  ,The patient has hypothyroidism and last had her TSH drawn a week ago but does not know the results.  Janet Green is her primary physician.  The patient also has had herniated disc in the neck and a sinus inflammation, both of which were treated surgically.,CURRENT MEDICATIONS: , The patient currently is taking Synthroid 75 mcg per day and lithium 1200 mg p.o. q.d. The patient started the lithium approximately three weeks ago and has not had a recent lithium level or kidney function test.,ALLERGIES: , No known drug allergies.,SUBSTANCE HISTORY: , The patient has been sober for five years.  She drank one bottle of wine per day as per HPI.  History of drinking for approximately 25 years.  The patient does not currently have a sponsor.  The patient experimented with amphetamines, cocaine, marijuana approximately 16 years ago.,SOCIAL HISTORY: , The patient's mother is age 66, father is age 70, and she has a brother age 44.  Her brother has been incarcerated numerous times for assaults and has difficulty with anger and rage.  He made a suicide attempt at age 17.  The patient's father is a machinist who she describes as somewhat narcissistic and with alcohol abuse problem.  He also has arthritis.  The patient's mother is arthritic.  She states that her mother stopped working at middle age after being laid off and appears somewhat reclusive.,EDUCATIONAL HISTORY: , The patient was educated through high school and has two years of Night College.  The patient states that she grew up and was raised in Portland but notes her childhood was primarily lonely.  She states she was unliked and unpopular child because she was ""shy"" and ""not smart enough."" The patient denies having secrets.  The patient reports that this is her second marriage, which has lasted two years.  Her first marriage lasted I believe it was five years.  The patient also had a relationship in recovery for four years, which ended after they went ""different directions."",MSE:,  The patient is middle-aged white female, dressed in a red sweater with a white shirt, full patterned skirt, and open sandals.  The patient is suspicious and somewhat confrontative early in the session.  She asked me regarding my cancellation policy, why I require seven days and not 24 hours.  The patient also is irritated with paper required of her.  Psychomotor is increased slightly.  The patient makes strong eye contact.  Speech is normal rate, rhythm, and volume.  Mood is ""irritated."" Affect is irritated, angry, demanding, attempting to wrest control from me, depressed, frustrated.  Thought is directed.  Content is nondelusional.  There are no auditory and no visual hallucinations.  The patient has no homicidal ideation.  The patient does endorse suicidal ideations.  Regarding plan, the patient notes that cutting herself hurts too much therefore she would like to take some benzodiazepines or barbiturates but has access to none.  The patient states that she will not try to hurt herself currently and that she poses no risk at present.  The patient notes that she does not want to go to the hospital at present.  The patient is alert and oriented x 3.  Recall is three for three at five minutes.  Proverbs are concrete.  She has fair impulse control, poor judgment, and poor insight.,FORMULATION:  ,The patient is a 45-year-old married white female with no children now presenting with recurrent depressive symptoms and active suicidal ideation and planning.  The patient reports longstanding depressive symptoms that were subthreshold punctuated by periods of more severe depression.  The patient also reports some up periods, which do not meet most criteria for a bipolar disorder or manic states.  The patient notes that current depression started with approximately the same time that she became aware that her therapist was pregnant.  She notes that the current depression is atypical in that it is primarily anger based and she does not have the typical hypersomnia that she gets.  The patient reports being unable to express anger to her therapist and being unable to discuss her feeling regarding the pregnancy.  The patient also states that she feels abandoned with the upcoming discontinuation of treatment while the therapist is giving birth and thereafter.  Symptoms are consistent with a longstanding dysthymia and reoccurring depression.  In addition, diagnosis is highly complicated by presence of a strong personality disorder component, most likely borderline personality disorder.  This latter diagnosis seems to be the most active at this time with the patient acutely reacting to perceived therapist's absence and departure.  This is exacerbated by instability in the patient's marital life.,DIAGNOSIS:,Axis I:  Dysthymia.  Major depression, moderate severity, recurrent, with partial remission.,Axis II:  Borderline personality disorder.,Axis III:  Hypothyroidism and cervical disc herniation and sinus surgery.,Axis IV:  Medical access.  Marital discord.,Axis V:  A GAF of 30.,PLAN:  ,The patient is unlikely to have bipolar disorder.  We will recommend the patient's thyroid be rechecked to ensure she is currently euthymic.  We would recommend continued weekly or twice weekly insight oriented psychotherapy with aggressive exploration of the patient's reaction to her therapist's departure.  We would also recommend dialectical behavioral therapy while the therapist is on leave.  We would recommend continued treatment with SSRIs for dysthymia and depression.  We would suggest prescribing long acting antidepressant such as Prozac, given the patient's ambivalence regarding medications.  Prozac should be pushed to minimum of 40 mg, which the patient has already tolerated in the past, but most likely up to 60 or 80 mg.  We might also supplement the Prozac with a (anti-sleep medication).,Time spent with the patient was 1.5 hours.",
 Psychiatric consultation of patient with lethargy., Consult - History and Phy., Psych Consult - Lethargy ,"REASON FOR CONSULTATION: , Lethargy.,HISTORY OF PRESENT ILLNESS:,  The patient is a 62-year-old white female with a past medical history of left frontal glioblastoma with subsequent craniotomy infection for PE, DVT, hyperlipidemia, and hypertension who is according to the patient's daughter expressing signs of depression.  Symptoms began on February 5, 2007, upon receiving the unexpected news, the patient would need three to four more days of chemotherapy and radiation therapy for her glioblastoma, described as a sudden onset of symptoms including hypersomnia (18 to 20 hours per day), drastic decrease in energy level, anhedonia, feelings of hopelessness and helplessness, psychomotor retardation, and past history of suicidal ideations.  The patient's appetite is unknown since she had been fed by NG tube after being diagnosed with neuromuscular oropharyngeal dysphagia.  Prior to receiving the news for needing more cancer therapy, the patient was described as being ""fine,"" participating in physical therapy and talking regularly as she was looking forward to leaving the hospital.  Now, the patient has become angry, socially withdrawn, not wanting to see anyone including her own grandchildren, and not participating in physical therapy.  Has been on a daily dose of Lexapro since January 08, 2007, was increased from 10 mg to 20 mg on January 24, 2007, which is her current dose.  Has been on Provigil 100 mg b.i.d. since February 06, 2007, but has not noticed an impact.  Had been on Zyprexa 2.5 mg p.o. q.p.m. from December 20, 2006, to February 01, 2007, but has been discontinued.  Currently, the patient has not displayed any manic symptoms, auditory or visual hallucinations, or symptoms of anxiety.  Also, denies any homicidal ideations.,PAST PSYCHIATRIC HISTORY:,  Was prescribed Prozac for depression, felt during husband's successful battle with prostate cancer.  Never been diagnosed with psychiatric illness.  Displayed some psychotic symptoms, status post craniotomy while in ICU, treated with Zyprexa and Xanax during hospitalization in 2006.,PAST MEDICAL HISTORY:,  Craniotomy November 2006 with subsequent CSF infection of enterobacter, status post glioblastoma multiforme, PE, DVT, hypertension, SIADH, and IVC filter.  No history of thyroid problems, seizures, strokes, or traumatic head injuries.,HOME MEDICATIONS:,  Norvasc 5 mg daily, TriCor 145 mg daily, aspirin one tablet daily, Tylenol, and glucosamine chondroitin sulfate.,CURRENT MEDICATIONS:,  Norvasc 10 mg p.o. daily, Decadron injection 6 mg IV q.12h., Colace 100 mg liquid b.i.d., Cardura 2 mg p.o. daily, Lexapro 20 mg p.o. daily, Lopressor 50 mg p.o. q.12h., Flagyl 500 mg via PEG tube q.8h., modafinil 100 mg p.o. b.i.d., Lovenox 60 mg subcu q.12h., insulin sliding scale, Tylenol suppositories 650 mg rectal q.4h. p.r.n., and Ambien 5 mg p.o. q.h.s. p.r.n.,ALLERGIES:,  PHENYTOIN (STEVENS-JOHNSON SYNDROME), CODEINE, NOVOCAIN, UNKNOWN ALLERGY.,FAMILY MEDICAL HISTORY:,  Father had lung cancer, was smoker for 40 years.  Father's aunt have heart disease.,SOCIAL AND DEVELOPMENTAL HISTORY:,  Currently lives with husband of 40 years in League City, has a Masters in Education, is a retired reading specialist which she did it for 33 years.  Has one younger brother, one daughter.  Denies use of tobacco, alcohol and illicit drugs.  The child as per daughter was picked on and has a strained relationship with her mother, but they still are communicating.,MENTAL STATUS EXAMINATION:,  The patient is a 62-year-old white female, lying in hospital bed, with gown on, eyes closed, short shaven hair, and golf ball-sized indentation in the anterior fontanelle from craniotomy.  Psychomotor retardation, poor eye contact, speech low volume, slow rate, poor flexion, essentially unresponsive, and somnolent during interview.  Poor concentration, mood unknown (the patient did not respond to questions), affect flat, thought process logical and goal directed, thought content unable to assess from the patient but the patient's daughter denied delusions and homicidal ideations.  Positive for passive suicidal ideations and perceptions.  No auditory or visual hallucinations.  Sensorium stuporous, did not answer orientation questions.  Memory information, intelligence, judgment, and insight unknown.,Mini-Mental status examination unable to be performed.,ASSESSMENT:,  A 62-year-old white female status post craniotomy for glioblastoma multiforme with subsequent CNS infection and currently has been displaying symptoms of depression for the past seven days and hence was told she needed more chemotherapy and radiation therapy.,Axis I:  Depression, NOS.  Rule out depression secondary to general medical condition.,Axis II:  Deferred.,Axis III:  Craniotomy with subsequent CSF infection, PE, DVT, and hypertension.,Axis IV:  Hospitalization.,Axis V:  11.,PLAN:,  Continue Lexapro 20 mg p.o. daily.  Discontinue Provigil, begin Ritalin 5 mg p.o. q.a.m. and q. noon.,Thank you for the consultation.",
" A 41-year-old African-American male with a history of bipolar affective disorder, was admitted for noncompliance to the outpatient treatment and increased mood lability.", Consult - History and Phy., Psych Consult - Bipolar Affective Disorder ,"IDENTIFYING DATA: , The patient is a 41-year-old African-American male with a history of bipolar affective disorder, was admitted for noncompliance to the outpatient treatment and increased mood lability.,CHIEF COMPLIANT: , ""I'm here because I'm different."" The patient exhibits poor insight into illness and need for treatment.,HISTORY OF PRESENT ILLNESS: , The patient has a history of bipolar affective disorder and poor outpatient compliance.  According to mental health professionals, he had not been compliant with medications or outpatient followup, and over the past several weeks, the patient had become increasingly labile.  The patient had expressed grandiose delusions that he is Martin Luther King, and was found recently at a local church agitated throwing a pew and a lectern and required Tasering by police.  On admission interview, the patient remains euphoric with poor insight.,PAST PSYCHIATRIC HISTORY: , History of bipolar affective disorder.  The patient has been treated with Depakote and Seroquel, but has had no recent treatment or followup.  Dates of previous hospitalizations are not known.,PAST MEDICAL HISTORY: , None known.,CURRENT MEDICATIONS: , None.,FAMILY SOCIAL HISTORY: , Unemployed.  The patient resides independently.  The patient denies recent substance abuse, although tox screen was positive for benzodiazepines.,LEGAL HISTORY: , Need to increase database.,FAMILY PSYCHIATRIC HISTORY: , Need to increase database.,MENTAL STATUS EXAMINATION:  ,Attitude:  Suspicious, but cooperative.,Appearance:  Shows appropriate hygiene and grooming.,Psychomotor Behavior:  Within normal limits.  No agitation or retardation.  No EPS or TDS noted.,Affect:  Labile.,Mood:  Euphoric.,Speech:  Pressured.,Thoughts:  Disorganized.,Thought Content:  Remarkable for grandiose delusions as noted.  The patient denies auditory hallucinations.,Psychosis:  Grandiose delusions as noted above.,Suicidal/Homicidal Ideation:  The patient denies on admission.,Cognitive Assessment:  Grossly intact.  The patient is oriented x 3.,Judgment:  Poor shown by noncompliance to the outpatient treatment.,Assets:  Include stable physical status.,Limitations:  Include recurrent psychosis.,FORMULATION: , The patient with a history of bipolar affective disorder, was admitted for increasing mood lability and noncompliance to the outpatient treatment.,INITIAL IMPRESSION:,AXIS I:  BAD, manic with psychosis.,AXIS II:  None.,AXIS III:  None known.,AXIS IV:  Severe.,AXIS V:  10.,ESTIMATED LENGTH OF STAY: , 12 days.,PLAN: , The patient will be restarted on Depakote for mood lability and Seroquel for psychosis and his response will be monitored closely.  The patient will be evaluated for more structural outpatient followup following stabilization.",
 Psychiatric Consultation of patient with major depression disorder., Consult - History and Phy., Psych Consult - Depression - 2 ,"REASON FOR CONSULT:,  Depression.,HPI:,  The patient is an 87-year-old white female admitted for low back pain status post hip fracture sustained a few days before Thanksgiving in 2006.  The patient was diagnosed and treated for a T9 compression fraction with vertebroplasty.  Soon after discharge, the patient was readmitted with severe mid low back pain and found to have a T8 compression fracture.  This was also treated with vertebroplasty.  The patient is now complaining of back pain that fluctuates at time, acknowledging her pain medication works but not all the time.  Her pain is in her upper back around her shoulder blades.  The patient says lying down with the heated pad lessens the pain and that any physical activity increases it.  MRI on January 29, 2007, was positive for possible meningioma to the left of anterior box.,The patient reports of many depressive symptoms, has lost all interest in things she used to do (playing cards, reading).  Has no energy to do things she likes, but does participate in physical therapy, cries often and what she believes for no reason.  Does not see any future for herself.  Reports not being able to concentrate on anything saying she gets distracted by thoughts of how she does not want to live anymore.  Admits to decreased appetite, feeling depressed, and always wanting to be alone.  Claims that before her initial hospitalization for her hip fracture, she was highly active, enjoyed living independently at Terrace.  Denies suicidal ideations and homicidal ideations, but that she did not mind dying, and denies any manic symptoms including decreased need to sleep, inflated self-worth, and impulsivity.  Denies auditory and visual hallucinations.  No paranoid, delusions, or other abnormalities of thought content.  Denies panic attacks, flashbacks, and other feelings of anxiety.  Does admit to feeling restless at times.  Is concerned with her physical appearance while in the hospital, i.e., her hair looking ""awful."",PAST MEDICAL HISTORY:,  Hypertension, cataracts, hysterectomy, MI, osteoporosis, right total knee replacement in April 2004, hip fracture, and newly diagnosed diabetes.  No history of thyroid problems, seizures, strokes, or head injuries.,CURRENT MEDICATIONS:,  Norvasc 10 mg p.o. daily, aspirin 81 mg p.o. daily, Lipitor 20 mg p.o. daily, Klonopin 0.5 mg p.o. b.i.d., digoxin 0.125 mg p.o. daily, Lexapro 10 mg p.o. daily, TriCor 145 mg p.o. each bedtime, Lasix 20 mg p.o. daily, Ismo 20 mg p.o. daily, lidocaine patch, Zestril, Prinivil 40 mg p.o. daily, Lopressor 75 mg p.o. b.i.d., Starlix 120 mg p.o. t.i.d., Pamelor 25 mg p.o. each bedtime, polyethylene glycol 17 g p.o. every other day, potassium chloride 20 mEq p.o. t.i.d., Norco one tablet p.o. q.4h. p.r.n., Zofran 4 mg IV q.6h.,HOME MEDICATIONS:,  Unknown.,ALLERGIES:,  CODEINE (HALLUCINATIONS).,FAMILY MEDICAL HISTORY:,  Unremarkable.,PAST PSYCHIATRIC HISTORY:,  Unremarkable.  Never taken any psychiatric medications or have ever had a family member with psychiatric illness.,SOCIAL/DEVELOPMENTAL HISTORY:,  Unremarkable childhood.  Married for 40 plus years, widowed in 1981.  Worked as administrative assistant in UTMB Hospitals VP's office.  Two children.  Before admission, lived in the Terrace Independent Living Center.  Was happy and very active while living there.  Had friends in the Terrace and would not mind going back there after discharge.  Occasional glass of wine at dinner.  Denies ever using illicit drugs and tobacco.,MENTAL STATUS EXAM:,  The patient is an 87-year-old white female with appropriate appearance, wearing street clothes while lying in bed with her eyes tightly closed.  Slight decrease in motor activity.  Normal eye contact.  Speech, low volume and rate.  Good articulation and inflexion.  Normal concentration.  Mood, labile, tearful at times, depressed, then euthymic.  Affect, mood congruent, full range.  Thought process, logical and goal directed.  Thought content, no delusions, suicidal or homicidal ideations.  Perception, no auditory or visual hallucinations.  Sensorium, alert, and oriented x3.  Memory, fair.  Information and intelligence, average.  Judgment and insight, fair.,MINI MENTAL STATUS EXAM,:  A 28/30.  Could not remember two out of the three recalled words.,ASSESSMENT:,  The patient is an 87-year-old white female with recent history of hip fracture and two thoracic compression fractures.  The patient reports being high functioning prior to admission and says her depression symptoms have occurred while being in the hospital.,Axis I:  Major depression disorder.,Axis II:  Deferred.,Axis III:  Osteoporosis, hypertension, hip fracture, possible diabetes, meningioma, MI, and right total knee replacement.,Axis IV:  Lives independently at Terrace, difficulty walking, hospitalization.,Axis V:  45.,PLAN:,  Continue Lexapro 10 mg daily and Pamelor 25 mg each bedtime monitor for adverse effects of TCA and worsening of depressive symptoms.  Discussed about possible inpatient psychiatric care.,Thank you for the consultation.",
 Psychiatric consultation for alcohol withdrawal and dependance., Consult - History and Phy., Psych Consult - Alcohol Withdrawal ,"REASON FOR CONSULT:,  Evaluation of alcohol withdrawal and dependance as well as evaluation of anxiety.,HISTORY OF PRESENT ILLNESS: , This is a 50-year-old male who was transferred from Sugar Land ER to ABCD Hospital for admission to the MICU for acute alcohol withdrawal.  The patient had been on a drinking binge for the past 12 days prior to admission and had not been eating.  He reported that he called 911 secondary to noticing bilious vomiting and dry heave.  The patient has been drinking for the past 25 years and has noted it to be a problem for at least the past 3 years.  He has been away from work secondary to alcohol cravings and drinking.  He has also experienced marital and family conflict as a result of his drinking habit.  On average, the patient drinks 5 to 8 glasses or cups of vodka or rum per day, and on the weekend, he tends to drink more heavily.  He reports a history of withdrawal symptoms, but denied history of withdrawal seizures.  His longest period of sobriety was one year, and this was due to the assistance of attending AA meetings.  The patient reports problems with severe insomnia, more so late insomnia and low self esteem as a result of feeling guilty about what he has done to his family due to his drinking habit.  He reports anxiety that is mostly related to concern about his wife's illness and fear of his wife leaving him secondary to his drinking habits.  He denies depressive symptoms.  He denies any psychotic symptoms or perceptual disturbances.  There are no active symptoms of withdrawal at this time.,PAST PSYCHIATRIC HISTORY: , There are no previous psychiatric hospitalizations or evaluations.  The patient denies any history of suicidal attempts.  There is no history of inpatient rehabilitation programs.  He has attended AA for periodic moments throughout the past few years.  He has been treated with Antabuse before.,PAST MEDICAL HISTORY:,  The patient has esophagitis, hypertension, and fatty liver (recently diagnosed).,MEDICATIONS: , His outpatient medications include Lotrel 30 mg p.o. q.a.m. and Restoril 30 mg p.o. q.h.s.,Inpatient medications are Vitamin supplements, potassium chloride, Lovenox 40 mg subcutaneously daily, Lactulose 30 mL q.8h., Nexium 40 mg IV daily, Ativan 1 mg IV p.r.n. q.6-8h.,ALLERGIES:,  No known drug allergies.,FAMILY HISTORY: , Distant relatives with alcohol dependance.  No other psychiatric illnesses in the family.,SOCIAL HISTORY:,  The patient has been divorced twice.  He has two daughters one from each marriage, ages 15 and 22.  He works as a geologist at Petrogas.  He has limited contact with his children.  He reports that his children's mothers have turned them against him.  He and his wife have experienced marital discord secondary to his alcohol use.  His wife is concerned that he may loose his job because he has skipped work before without reporting to his boss.  There are no other illicit drugs except alcohol that the patient reports.,PHYSICAL EXAMINATION:,  VITAL SIGNS:  Temperature 98, pulse 89, and respiratory rate 20, and blood pressure is 129/83.,MENTAL STATUS EXAMINATION:,  This is a well-groomed male.  He appears his stated age.  He is lying comfortably in bed.  There are no signs of emotional distress.  He is pleasant and engaging.  There are no psychomotor abnormalities.  No signs of tremulousness.  His speech is with normal rate, volume, and inflection.  Mood is reportedly okay.  Affect euthymic.  Thought content, no suicidal or homicidal ideations.  No delusions.  Thought perception, there are no auditory or visual hallucinations.  Thought process, Logical and goal directed.  Insight and judgment are fair.  The patient knows he needs to stop drinking and knows the hazardous effects that drinking will have on his body.,LABORATORY DATA:,  CBC:  WBC 5.77, H&H 14 and 39.4 respectively, and platelets 102,000.  BMP:  Sodium 140, potassium 3, chloride 104, bicarbonate 26, BUN 13, creatinine 0.9, glucose 117, calcium 9.5, magnesium 2.1, phosphorus 2.9, PT 13.4, and INR 1.0.  LFTs:  ALT 64, AST 69, direct bilirubin 0.5, total bilirubin 1.3, protein 5.8, and albumin 4.2.  PFTs within normal limits.,IMAGING:,  CAT scan of the abdomen and pelvis reveals esophagitis and fatty liver.  No splenomegaly.,ASSESSMENT:,  This is a 50-year-old male with longstanding history of alcohol dependence admitted secondary to alcohol withdrawal found to have derangement in liver function tests and a fatty liver.  The patient currently has no signs of withdrawal.  The patient's anxiety is likely secondary to situation surrounding his wife and their marital discord and the effect of chronic alcohol use.  The patient had severe insomnia that is likely secondary to alcohol use.  Currently, there are no signs of primary anxiety disorder in this patient.,DIAGNOSES:,  Axis I:  Alcohol dependence.,Axis II:  Deferred.,Axis III:  Fatty liver, esophagitis, and hypertension.,Axis IV:  Marital discord, estranged from children.,Axis V:  Global assessment of functioning equals 55.,RECOMMENDATIONS:,1.  Continue to taper off p.r.n. Ativan and discontinue all Ativan prior to discharge, benzodiazepine use, also on the same receptor as alcohol and prolonged use can cause relapse in the patient.  Discontinue outpatient Restoril.  The patient has been informed of the hazards of using benzodiazepines along with alcohol.,2.  Continue Alcoholics Anonymous meetings to maintain abstinence.,3.  Recommend starting Campral 666 mg p.o. t.i.d. to reduce alcohol craving.,4.  Supplement with multivitamin, thiamine, and folate upon discharge and before.  Marital counseling strongly advised as well as individual therapy for patient once sobriety is reached.  Referral has been given to the patient and his wife for the sets of counseling #713-263-0829.,5.  Alcohol education and counseling provided during consultation.,6.  Trazodone 50 mg p.o. q.h.s. for insomnia.,7.  Follow up with PCP in 1 to 2 weeks.",
 Psychiatric Consultation of patient with dementia., Consult - History and Phy., Psych Consult - Dementia ,"REASON FOR CONSULT,:  Dementia.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 33-year-old black female, referred to the hospital by a neurologist in Tyler, Texas for disorientation and illusions.  Symptoms started in June of 2006, when the patient complained of vision problems and disorientation.  The patient was seen wearing clothes inside out along with other unusual behaviors.  In August or September of 2006, the patient reported having a sudden onset of headaches, loss of vision, and talking sporadically without making any sense.  The patient sought treatment from an ophthalmologist.  We did not find any abnormality in the Behavior Center in Tyler, Texas.  The Behavior Center referred the patient to Dr. Abc, a neurologist in Tyler, who then referred the patient to this hospital.,According to the mother, the patient has had no past major medical or psychiatric illnesses.  The patient was functioning normally before June 2006, working as accounting tech after having completed 2 years of college.  She reports of worsening in symptoms, mainly unable to communicate about auditory or visual hallucinations or any symptoms of anxiety.  Currently, the patient lives with mother and requires her assistance to perform ADLs and the patient has become ataxic since November 2006.  Sleeping patterns and the amount is unknown.  Appetite is okay.,PAST PSYCHIATRIC HISTORY:,  The patient was diagnosed with severe depression in November 2006 at the Behavior Center in Tyler, Texas, where she was given Effexor.  She stopped taking it soon after, since they worsened her eye vision and balance.,PAST MEDICAL HISTORY: , In 2001 diagnosed with Meniere disease, was treated such that she could function normally in everyday activities including work.  No current medications.  Denies history of seizures, strokes, diabetes, hypertension, heart disease, or head injury.,FAMILY MEDICAL HISTORY:  ,Father's grandmother was diagnosed with Alzheimer disease in her 70s with symptoms similar to the patient described by the patient's mother.  Both, the mother's father and father's mother had ""nervous breakdowns"" but at unknown dates.,SOCIAL HISTORY: , The patient lives with a mother, who takes care of the patient's ADLs.  The patient completed school, up to two years in college and worked as accounting tech for eight years.  Denies use of alcohol, tobacco, or illicit drugs.,MENTAL STATUS EXAMINATION: , The patient is 33-year-old black female wearing clean clothes, a small towel on her head and over a wheel chair with her head rested on a pillow and towel.  Decreased motor activity, but did blink her eyes often, but arrhythmically.  Poor eye contact.  Speech illogic.  Concentration was not able to be assessed.  Mood is unknown.  Flat and constricted affect.  Thought content, thought process and perception could not be assessed.  Sensorial memory, information, intelligence, judgment, and insight could not be evaluated due to lack of communication by the patient.,MINI-MENTAL STATUS EXAM: , Unable to be performed.,AXIS I:  Rapidly progressing early onset of dementia, rule out dementia secondary to general medical condition, rule out dementia secondary to substance abuse.,AXIS II:  Deferred.,AXIS III:  Deferred.,AXIS IV:  Deferred.,AXIS V:  1.,ASSESSMENT: , The patient is a 32-year-old black female with rapid and early onset of dementia with no significant past medical history.  There is no indication as to what precipitated these symptoms, as the mother is not aware of any factors and the patient is unable to communicate.  The patient presented with headaches, vision forms, and disorientation in June 2006.  She currently presents with ataxia, vision loss, and illusions.,PLAN: , Wait for result of neurological tests.  Thank you very much for the consultation.","consult - history and phy., reason for consult:, concentration, dementia, mood, psychiatric consultation, sensorial memory, affect, disorientation, illusions, information, insight, intelligence, judgment, loss of vision, motor activity, neurologist, thought process, unusual behaviors, mental status examination, consultation, headaches, "
" The patient is admitted on a 72-hour involuntary treatment for dangerousness to others after repeated assaultive behaviors at Hospital Emergency Room, the morning prior to admission.", Consult - History and Phy., Psych Consult - Assaultive Behavior ,"IDENTIFYING DATA:  ,The patient is a 40-year-old white male.  He is married, on medical leave from his job as a tree cutter, and lives with his wife and five children.,CHIEF COMPLAINT AND REACTION TO HOSPITALIZATION:  ,The patient is admitted on a 72-hour involuntary treatment for dangerousness to others after repeated assaultive behaviors at Hospital Emergency Room, the morning prior to admission.,HISTORY OF PRESENT ILLNESS:  ,The patient was very sleepy this morning, only minimally cooperative with interview.  Additional information taken from the emergency room records that accompanied him from Hospital yesterday as well as from his wife, who I contacted by telephone.  The patient was apparently at his stable baseline when discharged from the Hospital on 01/21/10, status post back surgery following a work-related injury.  The patient returned to Emergency Room on the evening prior to admission complaining of severe back pain.  His ER course is notable for yelling, spitting, and striking multiple staff members.  The patient was originally to be admitted for pain control, but when he threatened to leave, he was referred to MHPs, who subsequently detained him for 72 hours for dangerousness to others.  On interview, the patient reports only hazy memories of these incidences and states this behavior was secondary to his pain and his medications.  He was contrite about the violence.  When his wife was contacted by telephone, she agreed with this assessment and reports that he has a history of domestic violence usually in the setting of alcohol and illicit substance intoxication, but denies any events in the last 3 years.,His wife reports that after discharge from the hospital, on 01/21/10, he was prescribed Percocet, Soma, hydroxyzine, and Valium.  He essentially exhausted his approximately 10 days' supply of these agents on the morning of 01/23/10, and as above believes that this was responsible for his presentation yesterday.  She reports that she has been in contact with him since his arrival in our facility and reports that he is ""back to normal."" She denies feeling that he currently represents a threat to her or her five children.  She was unaware of his mental health history, but denies that he has received care for any condition since they were married three years ago.,PAST PSYCHIATRIC HISTORY: , The patient has a history of Involuntary Treatment Act of 72 hours in our facility in 2004 or 2005 for assaultive behaviors; however, these records are not currently available for review.  The patient denies any outpatient mental health treatment before or since this hospitalization.  He describes his mental health diagnosis of bipolar affective disorder; however, he denies a history of dramatic mood swings in the absence of illicit substances or alcohol intoxication.,PAST MEDICAL HISTORY:,  Notable for status post back surgery, discharged from Hospital on 01/21/10.,MEDICATIONS:,  From discharge from Hospital on 01/21/10, include Percocet, Valium, Soma, and Vistaril, doses and frequency are not currently known.  His wife reports that he was discharged with approximately 10 days' supply of these agents.,SOCIAL AND DEVELOPMENTAL HISTORY:  ,The patient is employed as a tree cutter, currently on medical leave for the last 2 months following a back injury.  He lives with his wife and children.  He has a history of domestic violence, but not recently.  Other details of occupational, educational history not currently known.,SUBSTANCE AND ALCOHOL HISTORY:,  Records indicate a previous history of methamphetamine and alcohol abuse/dependence.  The wife states that he has not consumed either since 12/07.  Of note, urine tox screen at Hospital was positive for marijuana.,LEGAL HISTORY:  ,The patient has been charged with domestic violence in the past, but his wife denies any repeat instances since in the last 3 years.  It is not known whether the patient is currently on probation.,GENETIC PSYCHIATRIC HISTORY: , Unknown.,MENTAL STATUS EXAMINATION:,Attitude:  The patient is only minimally cooperative with interview secondary to being sleepy, and after repeated attempts to ask questions, he rolled over and went to bed.,Appearance: He is unkempt and there are multiple visible tattoos on his biceps.,Psychomotor:  There is no obvious psychomotor agitation or retardation.  There are no obvious extrapyramidal symptoms of tardive dyskinesia.,Affect:  His affect is notably restricted probably due to the fact that he is sleepy.,Mood:  Describes his mood as ""okay."",Speech:  Speech is normal rate, volume, and tone.,Thought Processes:  His thought processes appear to be linear.,Thought Content:  His thought content is notable for his expressions of contrition about violence at Hospital last night.  He denies suicidal or homicidal ideation.,Cognitive Assessment:  Cognitively, he is alert and oriented to person, place, and date but not situation.  Attributes this to not really remembering the events at Hospital that resulted in this hospitalization.,Judgment and Insight:  His insight and judgment are both appear to be improving.,Assets:  Include his supportive wife and the fact he has been able to remain alcohol and methamphetamine sobriety for the last 3 years.,Limitations:  Include his back injury and possible need for improvement of health treatment engagement.,FORMULATION:  ,This is a 40-year-old white male, who was admitted for an acute agitation in the setting of misuse of prescribed opiates, Soma, hydroxyzine, and Valium.  He appears much improved from his condition at Hospital last night and I suspect that his behavior is most likely attributed to delirium and this since resolved.  He reports historical diagnosis of bipolar affective disorder, however, the details of this diagnosis are not currently available for review.,DIAGNOSES:,AXIS I:  Delirium, resolved (recent mental status changes likely secondary to misuse of prescribed opiates, Soma, Valium, and hydroxyzine.)  Rule out bipolar affective disorder.,AXIS II:  Deferred.,AXIS III:  Chronic pain status post back surgery.,AXIS IV:  Appears to be moderate.  He is currently on medical leave from his job.,AXIS V:  Global Assessment of Functioning is currently 50 (his GAF was 20 approximately 24 hours ago).,ESTIMATED LENGTH OF STAY:,  Three days.,PLAN:,  I will hold psychiatric medications for now given the patient's fairly rapid improvement as he cleared from the condition, I suspect is likely due to misuse of prescribed medications.  The patient will be placed on CIWA protocol given that one of the medications he overused was Valium.  Of note, he does not currently appear to be withdrawing and I anticipate that his CIWA will be discontinued prior to discharge.  I would like to increase the database regarding the details of his historical diagnosis of bipolar affective disorder before pursuing referrals for outpatient mental health care.  The internal medicine service will evaluate for treatment for any underlying medical problems specifically to provide recommendations regarding pain management.",
 Psychiatric Consultation of patient with altered mental status., Consult - History and Phy., Psych Consult - Altered Mental Status ,"REASON FOR CONSULT:,  Altered mental status.,HPI:,  The patient is 77-year-old Caucasian man with benign prostatic hypertrophy, status post cardiac transplant 10 years ago who was admitted to the Physical Medicine and Rehab Service for inpatient rehab after suffering a right cerebellar infarct last month.  Last night, he became confused and he eloped from the unit.  When he was found, he became combative.  This a.m., he continued to be aggressive and required administration of four-point soft restraints in addition to Haldol 1 mg intramuscularly.  There was also documentation of him having paranoid thoughts that his wife was going out spending his money instead of being with him in the hospital.  Given this presentation, Psychiatry was consulted to evaluate and offer management recommendations.,The patient states that he does remember leaving the unit looking for his wife, but does not recall becoming combative, needing restrains and emergency medications.  He reports feeling fine currently, denying any complaints.  The patient's wife notes that her husband might be confused and disoriented due to being in the hospital environment.  She admits that he has some difficulty with memory for sometime and becomes irritable when she is not around.  However, he has never become as combative as he has this particular episode.,He negates any symptoms of depression or anxiety.  He also denies any hallucinations or delusions.  He endorses problems with insomnia.  At home, he takes temazepam.  His wife and son note that the temazepam makes him groggy and disoriented at times when he is at home.,PAST PSYCHIATRIC HISTORY:,  He denies any prior psychiatric treatment or intervention.  However, he was placed on Zoloft 10 years ago after his heart transplant, in addition to temazepam for insomnia.  During this hospital course, he was started on Seroquel 20 mg p.o. q.h.s. in addition to Aricept 5 mg daily.  He denies any history of suicidal or homicidal ideations or attempts.,PAST MEDICAL HISTORY:,1.  Heart transplant in 1997.,2.  History of abdominal aortic aneurysm repair.,3.  Diverticulitis.,4.  Cholecystectomy.,5.  Benign prostatic hypertrophy.,ALLERGIES:,  MORPHINE AND DEMEROL.,MEDICATIONS:,1.  Seroquel 50 mg p.o. q.h.s., 25 mg p.o. q.a.m.,2.  Imodium 2 mg p.o. p.r.n., loose stool.,3.  Calcium carbonate with vitamin D 500 mg b.i.d.,4.  Prednisone 5 mg p.o. daily.,5.  Bactrim DS Monday, Wednesday, and Friday.,6.  Flomax 0.4 mg p.o. daily.,7.  Robitussin 5 mL every 6 hours as needed for cough.,8.  Rapamune 2 mg p.o. daily.,9.  Zoloft 50 mg p.o. daily.,10.  B vitamin complex daily.,11.  Colace 100 mg b.i.d.,12.  Lipitor 20 mg p.o. q.h.s.,13.  Plavix 75 mg p.o. daily.,14.  Aricept 5 mg p.o. daily.,15.  Pepcid 20 mg p.o. daily.,16.  Norvasc 5 mg p.o. daily.,17.  Aspirin 325 mg p.o. daily.,SOCIAL HISTORY:,  The patient is a retired paster and missionary to Mexico.  He is still actively involved in his church.  He denies any history of alcohol or substance abuse.,MENTAL STATUS EXAMINATION:,  He is an average-sized white male, casually dressed, with wife and son at bedside.  He is pleasant and cooperative with good eye contact.  He presents with paucity of speech content; however, with regular rate and rhythm.  He is tremulous which is worse with posturing also some increased motor tone noted.  There is no evidence of psychomotor agitation or retardation.  His mood is euthymic and supple and reactive, appropriate to content with reactive affect appropriate to content.  His thoughts are circumstantial but logical.  He defers most of his responses to his wife.  There is no evidence of suicidal or homicidal ideations.  No presence of paranoid or bizarre delusions.  He denies any perceptual abnormalities and does not appear to be responding to internal stimuli.  His attention is fair and his concentration impaired.  He is oriented x3 and his insight is fair.  On mini-mental status examination, he has scored 22 out of 30.  He lost 1 for time, lost 1 for immediate recall, lost 2 for delayed recall, lost 4 for reverse spelling and could not do serial 7s.  On category fluency, he was able to name 17 animals in one minute.  He was unable to draw clock showing 2 minutes after 10.  His judgment seems limited.,LABORATORY DATA:,  Calcium 8.5, magnesium 1.8, phosphorous 3, pre-albumin 27, PTT 24.8, PT 14.1, INR 1, white blood cell count 8.01, hemoglobin 11.5, hematocrit 35.2, and platelet count 255,000.  Urinalysis on January 21, 2007, showed trace protein, trace glucose, trace blood, and small leukocyte esterase.,DIAGNOSTIC DATA:,  MRI of brain with and without contrast done on January 21, 2007, showed hemorrhagic lesion in right cerebellar hemisphere with diffuse volume loss and chronic ischemic changes.,ASSESSMENT:,AXIS I:,1.  Delirium resulting due to general medical condition versus benzodiazepine ,intoxication/withdrawal.,2.  Cognitive disorder, not otherwise specified, would rule out vascular dementia.,3.  Depressive disorder, not otherwise specified.",
 Psychiatric Consultation of patient with anxiety., Consult - History and Phy., Psych Consult - Anxiety ,"REASON FOR CONSULT:, Anxiety.,CHIEF COMPLAINT:,  ""I felt anxious yesterday."",HPI:,  A 69-year-old white female with a history of metastatic breast cancer, depression, anxiety, recent UTI, and obstructive uropathy, admitted to the ABCD Hospital on February 6, 2007, for lightheadedness, weakness, and shortness of breath.  The patient was consulted by Psychiatry for anxiety.  I know this patient from a previous consult.  During this recent admission, the patient has experienced anxiety and had a panic attack yesterday with ""syncopal episodes.""  She was given Ativan 0.25 mg on a p.r.n. basis with relief after one to two hours.  The patient was seen by Abc, MD, and Def, Ph.D.  The laboratories were reviewed and were positive for UTI, and anemia is also present.  The TSH level was within normal limits.  She previously responded well to trazodone for depression, poor appetite, and decreased sleep and anxiety.  A low dose of Klonopin was also helpful for sedation.,PAST MEDICAL HISTORY:,  Metastatic breast cancer to bone.  The patient also has a history of hypertension, hypothyroidism, recurrent UTI secondary to obstruction of left ureteropelvic junction, cholelithiasis, chronic renal insufficiency, Port-A-Cath placement, and hydronephrosis.,PAST PSYCHIATRIC HISTORY:,  The patient has a history of depression and anxiety.  She was taking Remeron 15 mg q.h.s., Ambien 5 mg q.h.s. on a p.r.n. basis, Ativan 0.25 mg every 6 hours on a p.r.n. basis, and Klonopin 0.25 mg at night while she was at home.,FAMILY HISTORY:,  There is a family history of colorectal cancer, lung cancer, prostate cancer, cardiac disease, and Alzheimer disease in the family.,SOCIAL HISTORY:,  The patient is married and lives at home with her husband.  She has a history of smoking one pack per day for 18 years.  The patient quit in 1967.  According to the chart, the patient also drinks wine everyday for the last 50 years, usually one to two drinks per day.,MEDICATIONS:,1.  Klonopin 0.25 mg p.o. every evening.,2.  Fluconazole 200 mg p.o. daily.,3.  Synthroid 125 mcg p.o. everyday.,4.  Remeron 15 mg p.o. at bedtime.,5.  Ceftriaxone IV 1 g in 1/2 NS every 24 hours.,P.R.N. MEDICATIONS:,1.  Tylenol 650 mg p.o. every 4 hours.,2.  Klonopin 0.5 mg p.o. every 8 hours.,3.  Promethazine 12.5 mg every 4 hours.,4.  Ambien 5 mg p.o. at bedtime.,ALLERGIES:,No known drug allergies,LABORATORY DATA:,These laboratories were done on February 6,2007, sodium 137, potassium 3.9, chloride 106, bicarbonate 21, BUN 35, creatinine 1.5, glucose 90.  White blood cell 5.31, hemoglobin 11.2, hematocrit 34.7, platelet count 152000.  TSH level 0.88.  The urinalysis was positive for UTI.,MENTAL STATUS EXAMINATION:,GENERAL APPEARANCE:  The patient is dressed in a hospital gown.  She is lying in bed during the interview.  She is well groomed with good hygiene.,MOTOR ACTIVITY:  No psychomotor retardation or agitation noted.  Good eye contact.,ATTITUDE:  Pleasant and cooperative.,ATTENTION AND CONCENTRATION:  Normal.  The patient does not appear to be distracted during the interview.,MOOD:  Okay.,AFFECT:  Mood congruent normal affect.,THOUGHT PROCESS:  Logical and goal directed.,THOUGHT CONTENT:  No delusions noted.,PERCEPTION:  Did not assess.,MEMORY:  Not tested.,SENSORIUM:  Alert.,JUDGMENT:  Good.,INSIGHT:  Good.,IMPRESSION:,1.  AXIS I:  Possibly major depression or generalized anxiety disorder.,2.  AXIS II:  Deferred.,3.  AXIS III:  Breast cancer with metastasis, hydronephrosis secondary to chronic uteropelvic junction obstruction status post stent placement, hypothyroidism.,4.  AXIS IV:  Interpersonal stressors.",
" The patient with pseudotumor cerebri without papilledema, comes in because of new onset of headaches. ", Consult - History and Phy., Pseudotumor Cerebri ,"REASON FOR VISIT:  ,The patient is a 38-year-old woman with pseudotumor cerebri without papilledema who comes in because of new onset of headaches.  She comes to clinic by herself.,HISTORY OF PRESENT ILLNESS: , Dr. X has cared for her since 2002.  She has a Codman-Hakim shunt set at 90 mmH2O.  She last saw us in clinic in January 2008 and at that time we recommended that she followup with Dr. Y for medical management of her chronic headaches.  We also recommended that the patient see a psychiatrist regarding her depression, which she stated that she would followup with that herself.  Today, the patient returns to clinic because of acute onset of headaches that she has had since her shunt was adjusted after an MRI on 04/18/08.  She states that since that time her headaches have been bad.  They woke her up at night.  She has not been able to sleep.  She has not had a good sleep cycle since that time.  She states that the pain is constant and is worse with coughing, straining, and sneezing as well as on standing up.  She states that they feel a little bit better when lying down.  Medication shave not helped her.  She has tried taking Imitrex as well as Motrin 800 mg twice a day, but she states it has not provided much relief.  The pain is generalized, but also noted to be quite intense in the frontal region of her head.  She also reports ringing in the ears and states that she just does not feel well.  She reports no nausea at this time.  She also states that she has been experiencing intermittent blurry vision and dimming lights as well.  She tells me that she has an appointment with Dr. Y tomorrow.  She reports no other complaints at this time.,MAJOR FINDINGS:,  On examination today, this is a pleasant 38-year-old woman who comes back from the clinic waiting area without difficulty.  She is well developed, well nourished, and kempt.,Vital Signs:  Blood pressure 153/86, pulse 63, and respiratory rate 16.,Cranial Nerves:  Intact for extraocular movements.  Facial movement, hearing, head turning, tongue, and palate movements are all intact.  I did not know any papilledema on exam bilaterally.,I examined her shut site, which is clean, dry, and intact.  She did have a small 3 mm to 4 mm round scab, which was noted farther down from her shunt reservoir.  It looks like there is a little bit of dry blood there.,ASSESSMENT:,  The patient appears to have had worsening headaches since shunt adjustment back after an MRI.,PROBLEMS/DIAGNOSES:,1.  Pseudotumor cerebri without papilledema.,2.  Migraine headaches.,PROCEDURES:,  I programmed her shunt to 90 mmH2O.,PLAN:,  It was noted that the patient began to have an acute onset of headache pain after her shunt adjustment approximately a week and a half ago.  I had programmed her shunt back to 90 mmH2O at that time and confirmed it with an x-ray.  However, the picture of the x-ray was not the most desirable picture.  Thus, I decided to reprogram the shunt back to 90 mmH2O today and have the patient return to Sinai for a skull x-ray to confirm the setting at 90.  In addition, she told me that she is scheduled to see Dr. Y tomorrow, so she should followup with him and also plan on contacting the Wilmer Eye Institute to setup an appointment.  She should followup with the Wilmer Eye Institute as she is complaining of blurry vision and dimming of the lights occasionally.,Total visit time was approximately 60 minutes and about 10 minutes of that time was spent in counseling the patient.","consult - history and phy., migraine headaches, pseudotumor cerebri without papilledema, onset of headaches, blurry vision, shunt adjustment, pseudotumor cerebri, headaches, pseudotumor, cerebri, papilledema"
" Adenocarcinoma of the prostate, Erectile dysfunction - History & Physical", Consult - History and Phy., Prostate Adenocarcinoma - H&P ,"HISTORY OF PRESENT ILLNESS: , The patient is a 62-year old male with a Gleason score 8 adenocarcinoma of the prostate involving the left and right lobes.  He has a PSA of 3.1, with a prostate gland size of 41 grams.  This was initially found on rectal examination with a nodule on the right side of the prostate, showing enlargement relative to the left.  He has undergone evaluation with a bone scan that showed a right parietal lesion uptake and was seen by Dr. XXX and ultimately underwent an open biopsy that was not malignant.  Prior to this, he has also had a ProstaScint scan that was negative for any metastatic disease.  Again, he is being admitted to undergo a radical prostatectomy, the risks, benefits, and alternatives of which have been discussed, including that of bleeding, and a blood transfusion.,PAST MEDICAL HISTORY: , Coronary stenting.  History of high blood pressure, as well.  He has erectile dysfunction and has been treated with Viagra.,MEDICATIONS: , Lisinopril, Aspirin, Zocor, and Prilosec.,ALLERGIES:,  Penicillin.,SOCIAL HISTORY:,  He is not a smoker.  He does drink six beers a day.,REVIEW OF SYSTEMS: , Remarkable for his high blood pressure and drug allergies, but otherwise unremarkable, except for some obstructive urinary symptoms, with an AUA score of 19.,PHYSICAL EXAMINATION:,HEENT:  Examination unremarkable.,Breasts:  Examination deferred.,Chest:  Clear to auscultation.,Cardiac:  Regular rate and rhythm.,Abdomen:  Soft and nontender.  He has no hernias.,Genitourinary:  There is a normal-appearing phallus, prominence of the right side of prostate.,Extremities:  Examination unremarkable.,Neurologic:  Examination nonfocal.,IMPRESSION:,1.  Adenocarcinoma of the prostate.,2.  Erectile dysfunction.,PLAN:  ,The patient will undergo a bilateral pelvic lymphadenectomy and radical retropubic prostatectomy.  The risks, benefits, and alternatives of this have been discussed.  He understands and asks that I proceed ahead.  We also discussed bleeding and blood transfusions, and the risks, benefits and alternatives thereof.","consult - history and phy., gleason score, gleason, prostate gland, prostascint, retropubic prostatectomy, adenocarcinoma of the prostate, erectile dysfunction, adenocarcinoma, radical, prostatectomy, erectile, dysfunction, prostate, "
 The patient was referred due to a recent admission for pseudoseizures., Consult - History and Phy., Pseudoseizures ,"REASON FOR REFERRAL: , The patient was referred to me by Dr. X of the Hospitalist Service at Children's Hospital due to a recent admission for pseudoseizures.  This was a 90-minute initial intake completed on 10/19/2007 with the patient's mother.  I have reviewed with her the boundaries of confidentiality and the treatment consent form, and she stated that she had understood these concepts.,PRESENTING PROBLEM: , It is reported that the patient was recently hospitalized and has been hospitalized in 2 occasions for pseudoseizure activity.  These were confirmed by video EEG and consist of trembling, shaking, and things of that nature.  She does have a history of focal seizures and perhaps simple seizures, which were diagnosed when she was 5 years old, but the seizure activity that was documented during the hospital stay is of a significant different quality.  I had met with them in the hospital and introduced myself and gathered some basic background information, but this is a supplement to that information, which is contained within this chart.  It was reported to me that she has been under considerable stress.  First of all, it should be noted that the patient is developmentally delayed.  Although she is 17 years old, she operates at about a fourth grade level.  Mother reported that The patient becomes stressed because she thinks that everyone is against her, that she cannot do anything unless someone is there, that she needs a lot of direction, that she gets confused easily, that she thinks that people become angry at her, that she misinterprets what people are saying and thinks that they are upset.  It is reported, the patient feels that her mother yells at her, and that is mad at her often.  It was reported that in addition she recently has had change in her visitation with her father, that she within the last 6 months, has started seeing her father every other weekend after he had been discharged from prison.  She reported that what is stress for her is that sometimes he does not always show up for visits or is late and that upsets her a lot and that she is upset when she has to leave him, also additional stressor is at school.  She reports that she has no friends that she feels unwanted and picked on.  She gets confused easily at school, worries about things, and believes that the teachers become angry with her.  In regards to her mood, mother reported that she is usually happy, unless things do not go her way, and then, she becomes upset and says that nobody cares about her.  She sits in the couch, she become angry, does not speak.  Mother sends her to her room, and she calms down, takes a couple of deep breaths, and that passes.  It is reported that the patient has ""always been this way"" and that is not a change in her behavior.  Mother did think that she did seem a little more depressed, that she seems more lonely.  Over the last few months, she has seemed a little bit more down because she does not have any friends and that she is bored.  Mother reported that she frequently complains of being bored, but has always been this way.  No sleep disturbance was noted.  No changes in weight.  No suicidal ideation.  No deficits in energy were noted.  Mother did report that she does tend to worry, but her worries tend to be because she gets confused, does not understand what she needs to do, and is quite rigid, but mother did not feel that the worry was actually affecting her functioning on a daily basis.,DEVELOPMENTAL HISTORY:,  The patient was the 5 pound 12 ounce product of an unplanned pregnancy and normal spontaneous vaginal delivery.  She was delivered at 36 weeks' gestation.  Mother reported that she received prenatal care.  Difficulties during the pregnancy were denied.  The use of drugs, alcohol, tobacco during the pregnancy were denied.  No eating or sleeping difficulties during the perinatal period were reported.  Temperament was described as easy.  The patient is described as a cuddly baby.  In terms of serious injuries, they were denied.  Serious illnesses:  She has been diagnosed since age 5 with seizures.  Mother was not able to tell me the exact kind of seizures, but it would appear from I could gather that they are focal seizures and possibly simple-to-complex partial seizures.  The patient does not have a history of allergy or toileting problems.  She is currently taking Trileptal 450 mg b.i.d., and she is currently taking Depakote, although she is going to be weaned off the Depakote by her neurologist.  She is taking Prevacid and ibuprofen.  The neurologist that she sees is Dr. Y here at Children's Hospital.,FAMILY BACKGROUND:,  In terms of family background, the patient lives with her mother age 38 and her mother's partner, who is age 40, and with her 16-year-old sister who does not have any developmental delays.  Mother had been married to the patient's father, but they were together as a couple beginning 1990, married in 1997, separated in 2002, and divorced in 2003; he lives in the ABC area and visits them every other Saturday, but there are no overnight visits.  The paternal grandparents are both living here in California, but are separated.  They are 3 paternal uncles and 2 paternal aunts.  In terms of the maternal family, maternal grandmother and grandfather are deceased.  Maternal grandfather deceased in 1991 due to cancer.  Maternal grandmother deceased in 2001 due to cancer.  There are 5 maternal aunts and 2 maternal uncles, all who live in California.  She reported that the patient is particularly close to her maternal aunt, whose name is Carmen.  Mother's partner had been married previously; he has 2 children from that relationship, a 23-year-old, and a 20-year-old female, who really are not part of the patient's daily life.  In terms of other family background, it was reported that the mother's partner gets frustrated with The patient, does not completely understand the degree of her delay and how that may affect her ability to do things as well as her interpretation of things.  The sister was described as having some resentment towards her older sister, that she feels like she was just to watch out for her, care for her, and that sister has always wanted to follow her around and do the things that she does.  The biological father allegedly was in jail for a year due to drug possession.  Mother reported that he had a problem with methamphetamine.  In addition, she reported there is an accusation that he had molested their niece; however, she stated that there was a trial, and he was found to be not guilty of that.  She stated there was no evidence that he had ever molested the patient or her sister.  There had been quite a bit of chaos in the family when the mother and father were together.  There was a lot of arguing.  There were a lot of moves, there was domestic violence both from father to mother and mother to father consisting mostly of pushing and shoving by mother's report.  The patient did observe this.  After the separation, it was reported that there were continued difficulties that the father took the patient and her sister from school without mother's knowledge and had filed to get custody of them and actually ended up having custody of them for a month, and told the patient and her sister that the mother had abandoned them.  Mother reported that they went to court, and there was a court order giving the mother custody back after the father went to jail.  Mother stated that was approximately 5 years ago.  In terms of current, mother reports that she currently works 2 jobs from 8 to 5 on Monday and Friday and from 6 to 10 on Monday, Wednesday's, and Friday's, but she does have the weekends off.  The patient was reported also to have a job through her school on several weeknights.,Mother reported that she graduated from high school, had a year of college.  She was an average student, had learning difficulties in reading.  No psychological or drug or alcohol history was reported by mother.  In terms of the biological father, mother stated that he graduated from high school, had a couple of years of college, was a good student, no learning problems or psychological problems for him were reported.  Mother reported that he had a history of methamphetamine use.,Other psychiatric history in the family was denied.,SOCIAL HISTORY: , She reported that the patient feels like she does not have any friends, that she is lonely and bored, really does not do much for fun.  Her fun consists primarily of doing crafts with mother, sewing, painting, drawing, beadwork, and things like that.  It was reported that she really feels that she is bored and does not have much to do.,ACADEMIC BACKGROUND:  ,The patient is in the 11th grade at High School.  She has 2 regular education classes, mother could not tell me what they were, but the rest of her classes are special education.  Mother could not tell me what her IQ was, although she noticed she works at about a 4th or 5th grade level.  Mother reported that the terminology most often used with the patient was developmental delay.  Her counselor's name is Mr. XYZ, but she reported that overall she is a good student, but she does have sometimes some difficulties at school, becoming upset or angry regarding the little things that she does not seem to understand.  It is reported that the patient feels that she has no friends at school that she is lonely, and that is she does not really care for school.  She reported that the patient is involved in a work program through the school where she works at Pet Extreme on Mondays and Wednesdays from 3 to 8 p.m. where she stocks shelves.  It is reported that she does not like to go to school because she feels like nobody likes her.  She is not involved in any kind of clubs or groups at school.  Mother reported that she is also not receiving CVRC services.,PREVIOUS COUNSELING: , Mother reported that she has been in counseling before, but mother could not give me any information about that, who did the counseling, or what it was about.  She does receive evidently some peer counseling at school because she gets upset and needs help in calming down.,DIAGNOSTIC SUMMARY AND IMPRESSION:,  It appears that the patient best qualifies for a diagnosis of conversion disorder, and information from Neurology suggests that the ""seizure episodes"" are not true seizures, but appear to be pseudoseizures.  The patient is experiencing quite bit of stress with a lot of changes in her life, also difficulty in functioning likely due to her developmental delay makes it difficult for her to understand.,PLAN:,  My plan is to meet with the patient in approximately 1 to 2 weeks to complete a clinical interview with her, and then to begin teaching coping skills as well as explore ways for reducing her stress.,DSM IV DIAGNOSES:  ,AXIS I:  Conversion disorder (300.11).,AXIS II:  Diagnoses deferred.,AXIS III:  Seizure disorder.,AXIS IV:  Problems with primary support group, peer problems, and educational problems.,AXIS V:  Global assessment of functioning equals 60.","consult - history and phy., conversion disorder, global assessment of functioning, primary support group, peer problems, developmental delays, seizures, developmentally, axis, pseudoseizures, "
" Adenocarcinoma of the prostate.  The patient underwent a transrectal ultrasound and biopsy and was found to have a Gleason 3+4 for a score of 7, 20% of the tissue removed from the left base. ", Consult - History and Phy., Prostate Adenocarcinoma ,"ADMISSION DIAGNOSIS:  ,Adenocarcinoma of the prostate.,HISTORY:,  The patient is a 71-year-old male whose personal physician, Dr. X identified a change in the patient's PSA from 7/2008 (4.2) to 4/2009 (10.5).  The patient underwent a transrectal ultrasound and biopsy and was found to have a Gleason 3+4 for a score of 7, 20% of the tissue removed from the left base.  The patient also had Gleason 6 in the right lobe, midportion, as well as the left apical portion.  He underwent a bone scan which was normal and cystoscopy which was normal and renal ultrasound that was normal.,SURGICAL HISTORY: , Appendectomy.,MEDICAL HISTORY:,  Atrial fibrillation.,MEDICATIONS:,  Coumadin and lisinopril.,SOCIAL HISTORY:  ,Smokes none.  Alcohol none.,ALLERGIES:,  NONE.,REVIEW OF SYSTEMS: , The patient relates no recent weight gain, weight loss, night sweats, fevers or chills.  Eyes:  No change in vision or diplopia.  Ears:  No tinnitus or vertigo.  Mouth:  No dysphagia.  Pulmonary:  No chronic cough or shortness of breath.  Cardiac:  No angina or palpitations.  GI:  No nausea, vomiting, diarrhea or constipation.  Musculoskeletal:  No arthritides or myalgias.  Hematopoietic:  No easy bleeding or bruising.  Skin:  No chronic ulcers or persistent itch.,PHYSICAL EXAMINATION:,GENERAL:  The patient is well developed and well nourished.,HEENT:  Head is normocephalic.  Eyes, pupils are equal.  Conjunctivae are pink.  Sclerae are anicteric.,NECK:  There is no adenopathy.,PULMONARY:  Respirations are unlabored.,HEART:  Regular rhythm.,ABDOMEN:  Liver, spleen, kidney, and bladder are not palpable.  There are no discernible masses.  There are no peritoneal signs.,GENITALIA:  The penis has no plaques.  Meatus is on the glans.  Scrotal skin is healthy.  Testicles are fair consistency.  Epididymides are nontender.,RECTAL:  The prostate is +1 to 2/4.  There are no areas that are suspicious for tumor.  Consistency is even.  Sidewalls are sharp.  Seminal vesicles are not palpable.,MUSCULOSKELETAL:  The upper and lower extremities are symmetric bilaterally.,NEUROLOGIC:  There are no gross focal neurologic abnormalities.,IMPRESSION:,1.  Adenocarcinoma of the prostate.,2.  Atrial fibrillation.,PLAN: , The patient's wife and I have discussed his treatment options, which include primarily radiation and surgery.  He has _________ surviving prostate cancer by Dr. Y.  He is aware of incontinency, both total and partial.  We discussed erectile dysfunction.  We have discussed bleeding, infection, injury to the rectum, injury to vessels and nerves, deep vein thrombosis, pulmonary embolus, MI, stroke, and death.  He had no questions at the conclusion of the conversation and he does know that in his age group, though a nerve-sparing procedure will be performed, preserving any erectile function is highly unlikely.  He had no questions at the conclusion of our last conversation.",
 Cardiology consultation regarding preoperative evaluation for right hip surgery.  Patient with a history of coronary artery disease status post bypass surgery, Consult - History and Phy., Preop Cardiac Consult ,"HISTORY OF PRESENT ILLNESS: , I was kindly asked to see Ms. ABC by Dr. X for cardiology consultation regarding preoperative evaluation for right hip surgery.  She is a patient with a history of coronary artery disease status post bypass surgery in 1971 who tripped over her oxygen last p.m. she states and fell.  She suffered a right hip fracture and is being considered for right hip replacement.  The patient denies any recent angina, but has noted more prominent shortness of breath.,Past cardiac history is significant for coronary artery disease status post bypass surgery, she states in 1971, I believe it was single vessel.  She has had stress test done in our office on September 10, 2008, which shows evidence of a small apical infarct, no area of ischemia, and compared to study of December of 2005, there is no significant change.  She had a transthoracic echocardiogram done in our office on August 29, 2008, which showed normal left ventricular size and systolic function, dilated right ventricle with septal flattening of the left ventricle consistent with right ventricular pressure overload, left atrial enlargement, severe tricuspid regurgitation with estimated PA systolic pressure between 75-80 mmHg consistent with severe pulmonary hypertension, structurally normal aortic and mitral valve.  She also has had some presumed atrial arrhythmias that have not been sustained.  She follows with Dr. Y my partner at Cardiology Associates.,PAST MEDICAL HISTORY:  ,Other medical history includes severe COPD and she is oxygen dependent, severe pulmonary hypertension, diabetes, abdominal aortic aneurysm, hypertension, dyslipidemia.  Last ultrasound of her abdominal aorta done June 12, 2009 states that it was fusiform, infrarenal shaped aneurysm of the distal abdominal aorta measuring 3.4 cm unchanged from prior study on June 11, 2008.,MEDICATIONS:,  As an outpatient:,1.  Lanoxin 0.125 mg, 1/2 tablet once a day.,2.  Tramadol 50 mg p.o. q.i.d. as needed.,3.  Verapamil 240 mg once a day.,4.  Bumex 2 mg once a day.,5.  ProAir HFA.,6.  Atrovent nebs b.i.d.,7.  Pulmicort nebs b.i.d.,8.  Nasacort 55 mcg, 2 sprays daily.,9.  Quinine sulfate 325 mg p.o. q.h.s. p.r.n.,10.  Meclizine 12.5 mg p.o. t.i.d. p.r.n.,11.  Aldactone 25 mg p.o. daily.,12.  Theo-24 200 mg p.o., 2 in the morning.,13.  Zocor 40 mg once a day.,14.  Vitamin D 400 units twice daily.,15.  Levoxyl 125 mcg once a day.,16.  Trazodone 50 mg p.o. q.h.s. p.r.n.,17.  Janumet 50/500, 1 tablet p.o. b.i.d.,ALLERGIES: , To medications are listed as:,1.  LEVAQUIN.,2.  AZITHROMYCIN.,3.  ADHESIVE TAPE.,4.  BETA BLOCKERS.  When I talked to the patient about the BETA BLOCKER, she states that they made her more short of breath in the past.,She denies shrimp, seafood or dye allergy.,FAMILY HISTORY:  ,Significant for heart problems she states in her mother and father.,SOCIAL HISTORY:  ,She used to smoke cigarettes and smoked from the age of 14 to 43 and quit at the time of her bypass surgery.  She does not drink alcohol nor use illicit drugs.  She lives alone and is widowed.  She is a retired custodian at University.  Of note, she is accompanied with her verbal consent by her daughter and grandson at the bedside.,REVIEW OF SYSTEMS:  ,Unable to obtain as the patient is somnolent from her pain medication, but she is alert and able to answer my direct questions.,PHYSICAL EXAM: , Height 5'2"", weight 160 pounds, temperature is 99.5 degrees ranging up to 101.6, blood pressure 137/67 to 142/75, pulse 92, respiratory rate 16, O2 saturation 93-89%.  On general exam, she is an elderly, chronically ill appearing woman in no acute distress.  She is able to lie flat, she does have pain if she moves.  HEENT shows the cranium is normocephalic, atraumatic.  She has dry mucosal membranes.  Neck veins are not distended.  There are no carotid bruits.  Visible skin is warm and she appears pale.  Affect appropriate and she is somnolent from her pain medications, but arouses easily and answers my direct questions appropriately.  Lungs are clear to auscultation anteriorly, no wheezes.  Cardiac exam S1, S2 regular rate, soft holosystolic murmur heard over the tricuspid region.  No rub nor gallop.  PMI is nondisplaced, unable to appreciate RV heave.  Abdomen soft, mildly distended, appears benign.  Extremities with trivial peripheral edema.  Pulses grossly intact.  She has quite a bit of pain at the right hip fracture.,DIAGNOSTIC/LABORATORY DATA:  ,Sodium 135, potassium 4.7, chloride 99, bicarbonate 33, BUN 22, creatinine 1.3, glucose 149, troponin was 0.01 followed by 0.04.  Theophylline level 16.6 on January 23, 2009.  TSH 0.86 on March 10, 2009.  INR 1.06.  White blood cell count 9.5, hematocrit 35, platelet count 160.,EKG done July 16, 2009 at 7:31:15, shows sinus rhythm, which showed PR interval of about 118 milliseconds, nonspecific T wave changes.  When compared to EKG done July 15, 2009 at 1948, previously there more frequent PVCs seen.  This ECG appears similar to the ones she has had done previously in our office including on June 11, 2009, although the T wave changes are a bit more prominent, which is a nonspecific finding.,IMPRESSION: , She is an 81-year-old woman with severe O2 requiring chronic obstructive pulmonary disease with evidence of right heart overload, as well as known coronary artery disease status post single-valve bypass in 1971 suffering a right hip fracture for whom a right hip replacement is being considered.  I have had a long discussion with the patient, as well as her daughter and grandson at the bedside today.  There are no clear absolute cardiac contraindications that I can see.  Of note at the time of this dictation a chest x-ray report is pending.  With that being said, however, she is extremely high risk more from a pulmonary than cardiac standpoint.  We did also however review that untreated hip fractures themselves have very high morbidity and mortality incidences.  The patient is deciding on surgery and is clearly aware that she is very high risk for proposed surgery, as well as if she were to not pursue surgery.,PLAN/RECOMMENDATIONS:,1.  The patient is going to decide on surgery.  If she does have the right hip surgery, I would recommend overnight observation in the intensive care unit.,2.  Optimize pulmonary function and pursue aggressive DVT prophylaxis.,3.  Continue digoxin and verapamil.  Again, the patient describes clear INTOLERANCE TO BETA BLOCKERS by her history.",
 Consult for subcutaneous emphysema and a small right-sided pneumothorax secondary to trauma., Consult - History and Phy., Pneumothorax & Subcutaneous Emphysema ,"REASON FOR CONSULTATION:,  Pneumothorax and subcutaneous emphysema.,HISTORY OF PRESENT ILLNESS: , The patient is a 48-year-old male who was initially seen in the emergency room on Monday with complaints of scapular pain.  The patient presented the following day with subcutaneous emphysema and continued complaints of pain as well as change in his voice.  The patient was evaluated with a CT scan of the chest and neck which demonstrated significant subcutaneous emphysema, a small right-sided pneumothorax, but no other findings.  The patient was admitted for observation.,PAST SURGICAL HISTORY: , Hernia repair and tonsillectomy.,ALLERGIES: , Penicillin.,MEDICATIONS: , Please see chart.,REVIEW OF SYSTEMS:,  Not contributory.,PHYSICAL EXAMINATION:,GENERAL:  Well developed, well nourished, lying on hospital bed in minimal distress.,HEENT:  Normocephalic and atraumatic.  Pupils are equal, round, and reactive to light.  Extraocular muscles are intact.,NECK:  Supple.  Trachea is midline.,CHEST:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  Regular rate and rhythm.,ABDOMEN:  Soft, nontender, and nondistended.  Normoactive bowel sounds.,EXTREMITIES:  No clubbing, edema, or cyanosis.,SKIN:  The patient has significant subcutaneous emphysema of the upper chest and anterior neck area although he states that the subcutaneous emphysema has improved significantly since yesterday.,DIAGNOSTIC STUDIES:,  As above.,IMPRESSION: , The patient is a 48-year-old male with subcutaneous emphysema and a small right-sided pneumothorax secondary to trauma.  These are likely a result of either a parenchymal lung tear versus a small tracheobronchial tree rend.,RECOMMENDATIONS:,  At this time, the CT Surgery service has been consulted and has left recommendations.  The patient also is awaiting bronchoscopy per the Pulmonary Service.  At this time, there are no General Surgery issues.","consult - history and phy., trauma, tracheobronchial, bronchoscopy, scapular pain, subcutaneous emphysema, pneumothorax, subcutaneous, emphysema, "
 Patient with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung. , Consult - History and Phy., Pneumoconiosis ,"HISTORY OF PRESENT ILLNESS: , This is a 91-year-old male with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung.  The patient also has a positive history of smoking in the past.  At the present time, he is admitted for continued,management of respiratory depression with other medical complications.  The patient was treated for multiple problems at Jefferson Hospital prior to coming here including abdominal discomfort due to a ureteral stone with resultant hydronephrosis and hydroureter.  In addition, he also developed cardiac complications including atrial fibrillation.  The patient was evaluated by the cardiologist as well as the pulmonary service and Urology.  He had a cystoscopy performed and a left ureteral stone was removed as well as insertion of a left ureteral stent on 07/23/2008.  He subsequently underwent cardiac arrest and he was resuscitated at that time.  He was intubated and placed on mechanical ventilatory support.  Subsequent weaning was unsuccessful.  He then had a tracheostomy placed.,CURRENT MEDICATIONS:,1.  Albuterol.,2.  Pacerone.,3.  Theophylline,4.  Lovenox.,5.  Atrovent.,6.  Insulin.,7.  Lantus.,8.  Zestril.,9.  Magnesium oxide.,10.  Lopressor.,11.  Zegerid.,12.  Tylenol as needed.,ALLERGIES:,  PENICILLIN.,PAST MEDICAL HISTORY:,1.  History of coal miner's disease.,2.  History of COPD.,3.  History of atrial fibrillation.,4.  History of coronary artery disease.,5.  History of coronary artery stent placement.,6.  History of gastric obstruction.,7.  History of prostate cancer.,8.  History of chronic diarrhea.,9.  History of pernicious anemia.,10.  History of radiation proctitis.,11.  History of anxiety.,12.  History of ureteral stone.,13.  History of hydronephrosis.,SOCIAL HISTORY: , The patient had been previously a smoker.  No other could be obtained because of tracheostomy presently.,FAMILY HISTORY: , Noncontributory to the present condition and review of his previous charts.,SYSTEMS REVIEW: , The patient currently is agitated.  Rapidly moving his upper extremities.  No other history regarding his systems could be elicited from the patient.,PHYSICAL EXAM:,General:  The patient is currently agitated with some level of distress.  He has rapid respiratory rate.  He is responsive to verbal commands by looking at the eyes.,Vital Signs:  As per the monitors are stable.,Extremities:  Inspection of the upper extremities reveals extreme xerosis of the skin with multiple areas of ecchymosis and skin tears some of them to the level of stage II especially over the dorsum of the hands and forearm areas.  There is also edema of the forearm extending up to the mid upper arm area.  Palpation of the upper extremities reveals fibrosis more prominent on the right forearm area with the maximum edema in the elbow area on the ulnar aspect.  There is also scabbing of some of the possibly from earlier skin tears in the upper side forearm area.,IMPRESSION:,1.  Ulceration of bilateral upper extremities.,2.  Cellulitis of upper extremities.,3.  Lymphedema of upper extremities.,4.  Other noninfectious disorders of lymphatic channels.,5.  Ventilatory-dependent respiratory failure.",
 A white female presents for exam and Pap., Consult - History and Phy., Physical Exam and Pap - 1 ,"SUBJECTIVE:,  This 45-year-old gravida 3, para 2, SAB 1 white female presents for exam and Pap.  Last Pap was a year ago and normal.  LMP was 08/29/2004.  Her cycles are usually regular, although that one came about a week early.  Her husband has had a vasectomy.  Overall, she is feeling well.,Health history form was reviewed.  There has been no change in her personal history.  She notes that a brother who was treated 12 years ago for a brain tumor has had a recurrence and had surgery again.  Social history is unchanged.,HEALTH HABITS: , She states that for a while she was really exercising regularly and eating lots of fruits and vegetables.  Right now, she is not doing nearly as well.  She has perhaps two dairy servings daily, trying to cut down.  She is not exercising at all and fruit and vegetable intake varies.  She is a nonsmoker.  Last cholesterol was in 2003 and was normal.  She had a mammogram which was normal recently.  She is current on her tetanus update.,REVIEW OF SYSTEMS:,HEENT:  She feels as though she may have some allergies at night.  Most of her symptoms occur then, not during the day.  She will wake up with some congestion, sneezing, and then rhinorrhea.  Currently, she uses Tylenol Sinus.  Today, her symptoms are much better.  We did have rain this morning.,Respiratory and CV:  Negative.,GI:  She tends to have a little gas which is worse when she is eating more fruits and vegetables.  She had been somewhat constipated but that is better.,GU:  Negative.,Dermatologic:  She noticed an area of irritation on her right third finger on the ulnar side at the PIP joint.  It was very sensitive to water.  It seems to be slowly improving.,OBJECTIVE:,Vital Signs:  Her weight was 154 pounds, which is down 2 pounds.  Blood pressure 104/66.,General:  She is a well-developed, well-nourished, pleasant white female in no distress.,Neck:  Supple without adenopathy.  No thyromegaly or nodules palpable.,Lungs:  Clear to A&P.,Heart:  Regular rate and rhythm without murmurs.,Breasts:  Symmetrical without masses, nipple, or skin retraction, discharge, or axillary adenopathy.,Abdomen:  Soft without organomegaly, masses, or tenderness.,Pelvic:  Reveals no external lesions.  The cervix is parous.  Pap smear done.  Uterus is anteverted and normal in size, shape, and consistency, and nontender.  No adnexal enlargement.,Extremities:  Examination of her right third finger shows an area of eczematous dermatitis approximately 2 cm in length on the ulnar side.,ASSESSMENT:,1.  Normal GYN exam.,2.  Rhinitis, primarily in the mornings.  Vasomotor versus allergic.,3.  Eczematous dermatitis on right third finger.,PLAN:,1.  Discussed vasomotor rhinitis.  I suggested she try Ayr Nasal saline gel.  Another option would be a steroid spray and a sample of Nasonex is given to use two sprays in each nostril daily.,2.  Exam with Pap annually.,3.  Hydrocortisone cream to be applied to the area of eczematous dermatitis.,4.  Discussed nutrition and exercise.  I recommended at least five fruits and vegetables daily, no more than three dairy servings daily, and regular exercise at least three times a week.",
 Post-surgical medical management; right total knee replacement., Consult - History and Phy., Postop Medical Management ,"REASON FOR CONSULTATION: , Post-surgical medical management.,PROCEDURE DONE: , Right total knee replacement.,MEDICAL HISTORY:,1.  Arthritis of the right knee.,2.  Hypertension.,PAST SURGICAL HISTORY: , Hysterectomy, Cesarean section, left hip arthroplasty, and breast biopsy.,MEDICATIONS: , Hyzaar 12.5 mg p.o. daily, Femara 2.5 mg p.o. daily, Fosamax 70 mg p.o. every week, aspirin 81 mg p.o. daily, and vitamin.,ALLERGIES: , MORPHINE.,HISTORY OF PRESENT COMPLAINT: , This 84-year-old patient with history of arthritis underwent right total knee replacement yesterday.  The patient is admitted today to the surgical floor for postoperative management.  The patient tolerated the procedure well.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No fever, chills, or malaise.,ENT:  Unremarkable.,RESPIRATORY:  The patient denies shortness of breath, cough, or wheezing.,CARDIOVASCULAR:  No known heart problems.  No orthopnea, palpitations, syncopal episode, or pedal swelling.,GASTROINTESTINAL:  She denies nausea or vomiting.  No history of GI bleed.,GENITOURINARY:  No dysuria, no hematuria.,ENDOCRINE:  Negative for diabetes or thyroid problems.,NEUROLOGICAL:  No history of seizure or TIA.  Cognitive function is intact.,SOCIAL HISTORY:  ,The patient does not smoke.  She consumes alcohol moderately.,FAMILY HISTORY:  ,Positive for cancer.,PHYSICAL EXAMINATION:,GENERAL:  This is an 84-year-old lady who looks young for her age.,VITAL SIGNS:  Blood pressure of 138/53, pulse is 73, respiratory rate of 20, and O2 saturation is 95% on room air.  She is afebrile.,HEAD AND NECK:  Face is symmetrical.  Cranial nerves are intact.  No distended neck veins.  No palpable neck masses.,CHEST:  Clear to auscultation.  No wheezing.  No crepitations.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmur is appreciated.,ABDOMEN:  Soft and nontender.  Bowel sounds are positive.,EXTREMITIES:  There is no pedal swelling.,LABORATORY DATA:  ,Hemoglobin has dropped from 12.6 to 10.2.  Hematocrit is 30.  Glucose is 125.  BUN is 15.9, creatinine is 0.6, sodium is 134, and potassium is 3.8.,ASSESSMENT AND PLAN:,1.  Right knee arthritis status post right total knee replacement.  The patient tolerated the procedure well.,2.  Anemia due to stated operative blood loss, would not require transfusion at this point.,3.  Hypertension, under control.  Continue current home medications.,4.  Deep vein thrombosis risk, prophylaxis as per surgeon.,5.  Gastrointestinal prophylaxis.,6.  Debility.  Continue physical therapy and occupational therapy.",
" Before surgery, the patient's blood pressure was 181/107.  The patient received IV labetalol.  Blood pressure improved, but postsurgery, the patient's blood pressure went up again to 180/100. ", Consult - History and Phy., Perioperative Elevated Blood Pressure ,"REASON FOR CONSULTATION:,  Perioperative elevated blood pressure.,PAST MEDICAL HISTORY:,1.  Graves disease.,2.  Paroxysmal atrial fibrillation, has been in normal sinus rhythm for several months, off medication.,3.  Diverticulosis.,4.  GERD.,5.  High blood pressure.,6.  Prostatic hypertrophy, status post transurethral resection of the prostate.,PAST SURGICAL HISTORY: , Bilateral inguinal hernia repair, right shoulder surgery with reconstruction, both shoulders rotator cuff repair, left knee arthroplasty, and transurethral resection of prostate.,HISTORY OF PRESENTING COMPLAINT:  ,This 71-year-old gentleman with the above history, underwent laser surgery for the prostate earlier today.  Before surgery, the patient's blood pressure was 181/107.  The patient received IV labetalol.  Blood pressure improved, but postsurgery, the patient's blood pressure went up again to 180/100.  Currently, blood pressure is 158/100, goes up to 155 systolic when he is talking.  On further questioning, the patient denies shortness of breath, chest pain, palpitations, or dizziness.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No recent fever or general malaise.,ENT:  Unremarkable.,RESPIRATORY:  No cough or shortness of breath.,CARDIOVASCULAR:  No chest pain.,GASTROINTESTINAL:  No nausea or vomiting.,GENITOURINARY:  The patient has prostatic hypertrophy, had laser surgery earlier today.,ENDOCRINE:  Negative for diabetes, but positive for Graves disease.,MEDICATIONS:  ,The patient takes Synthroid and aspirin.  Aspirin had been discontinued about 1 week ago.  He used to be on atenolol, lisinopril, and terazosin, both of which have been discontinued by his cardiologist, Dr. X several months ago.,PHYSICAL EXAMINATION:,GENERAL:  A 71-year-old gentleman, not in acute distress.,CHEST:  Clear to auscultation.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmur was appreciated.,ABDOMEN:  Benign.,EXTREMITIES:  There is no swelling.,NEUROLOGICAL:  The patient is alert and oriented x3.  Examination is nonfocal.,ASSESSMENT AND PLAN:,1.  Perioperative hypertension.  We will restart lisinopril at half the previous dose.  He will be on 20 mg p.o. daily.  If blood pressure remains above systolic of 150 within 3 days, the patient should increase lisinopril to 40 mg p.o. daily.  The patient should see his primary physician, Dr. Y in 2 weeks' time.  If blood pressure, however, remains above 150 systolic despite 40 mg of lisinopril, the patient should make an appointment to see his primary physician in a week's time.,2.  Prostatic hypertrophy, status post laser surgery.  The patient tolerated the procedure well.,3.  History of Graves disease.,4.  History of atrial fibrillation.  The patient is in normal sinus rhythm.,DISPOSITION:  ,The patient is stable to be discharged to home.  Nurse should observe for 1 hour after lisinopril to make sure the blood pressure does not go too low.",
" Preeclampsia, status post delivery with Cesarean section with uncontrolled blood pressure.  The patient is a 38-year-old female admitted following a delivery.  The patient had a cesarean section.  Following this, the patient was treated for her blood pressure.  She was sent home and she came back again apparently with uncontrolled blood pressure.", Consult - History and Phy., Preeclampsia ,"REASON FOR CONSULTATION: , Management of blood pressure.,HISTORY OF PRESENT ILLNESS: , The patient is a 38-year-old female admitted following a delivery.  The patient had a cesarean section.  Following this, the patient was treated for her blood pressure.  She was sent home and she came back again apparently with uncontrolled blood pressure.  She is on multiple medications, unable to control the blood pressure.  From cardiac standpoint, the patient denies any symptoms of chest pain, or shortness of breath.  She complains of fatigue and tiredness.  The child had some congenital anomaly, was transferred to Hospital, where the child has had surgery.  The patient is in intensive care unit.,CORONARY RISK FACTORS:,  History of hypertension, history of gestational diabetes mellitus, nonsmoker, and cholesterol is normal.  No history of established coronary artery disease and family history noncontributory for coronary disease.,FAMILY HISTORY: , Nonsignificant.,SURGICAL HISTORY:  ,No major surgery except for C-section.,MEDICATIONS:,  Presently on Cardizem and metoprolol were discontinued.  Started on hydralazine 50 mg t.i.d., and labetalol 200 mg b.i.d., hydrochlorothiazide, and insulin supplementation.,ALLERGIES: , None.,PERSONAL HISTORY: , Nonsmoker.  Does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY:,  Hypertension, gestational diabetes mellitus, pre-eclampsia, this is her third child with one miscarriage.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No history of fever, rigors, or chills.,HEENT:  No history of cataract, blurry vision, or glaucoma.,CARDIOVASCULAR:  No congestive heart.  No arrhythmia.,RESPIRATORY:  No history of pneumonia or valley fever.,GASTROINTESTINAL:  No epigastric discomfort, hematemesis, or melena.,UROLOGIC:  No frequency or urgency.,MUSCULOSKELETAL:  No arthritis or muscle weakness.,SKIN:  Nonsignificant.,NEUROLOGICAL:  No TIA.  No CVA.  No seizure disorder.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 86, blood pressure 175/86, afebrile, and respiratory rate 16 per minute.,HEENT:  Atraumatic and normocephalic.,NECK:  Neck veins are flat.,LUNGS:  Clear.,HEART:  S1 and S2 regular.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema.  Pulses palpable.,LABORATORY DATA: , EKG shows sinus tachycardia with nonspecific ST-T changes.  Labs were noted.  BUN and creatinine within normal limits.,IMPRESSION:,1.  Preeclampsia, status post delivery with Cesarean section with uncontrolled blood pressure.,2.  No prior history of cardiac disease except for borderline gestational diabetes mellitus.,RECOMMENDATIONS:,1.  We will get an echocardiogram for assessment left ventricular function.,2.  The patient will start on labetalol and hydralazine to see how see fairs.,3.  Based on response to medication, we will make further adjustments.  Discussed with the patient regarding plan of care, fully understands and consents for the same.  All the questions answered in detail.",
" The patient is a 16-month-old boy, who had a circumcision performed approximately 4 days before he developed penile swelling and fever and discharge. ", Consult - History and Phy., Penile Cellulitis ,"CHIEF COMPLAINT:  ,Penile cellulitis status post circumcision.,HISTORY OF PRESENT ILLNESS: , The patient is a 16-month-old boy, who had a circumcision performed approximately 4 days before he developed penile swelling and fever and discharge.  The child initially had a newborn circumcision at about 1 week of life and then developed a concealed or buried penis with extra skin and tightness of the skin.  He underwent a second circumcision with a general anesthetic approximately 8 to 9 days ago.  The mother states that on Thursday, he developed fairly significant swelling, scrotum was also swollen, the suprapubic region was swollen, and he was having a purulent discharge and a fairly significant fever to 102 to 103.  He was seen at Hospital, transferred to Children's Hospital for further care.  Since being hospitalized, his cultures apparently have grown Staph but is unknown yet whether it is methicillin-resistant.  He has been placed on clindamycin, and he is now currently afebrile and with marked improvement according to the mother.  I was requested a consultation by Dr. X because of the appearance of penis.  The patient has been voiding without difficulty throughout.,PAST MEDICAL HISTORY: , The patient has no known allergies.  He was a term delivery via vaginal delivery.  Surgeries; he has had 2 circumcisions.  No other hospitalizations.  He has had no heart murmurs, seizures, asthma, or bronchitis.,REVIEW OF SYSTEMS: , A 14-point review of systems was negative with the exception of the penile and scrotal cellulitis and the surgeries as mentioned.  He also had an ear infection about 1 to 2 weeks before his circumcision.,SOCIAL HISTORY: , The patient lives with both parents and no siblings.  There are smokers at home.,MEDICATIONS: , Clindamycin and bacitracin ointment.  Also Bactrim.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Weight is 14.9 kg.,GENERAL:  The patient was sleepy but easily arousable.,HEAD AND NECK:  Grossly normal.  His neck and chest are without masses.,NARES:  He had some crusted nares; otherwise, no other discharge.,LUNGS:  Clear.,CARDIAC:  Without murmurs or gallops.,ABDOMEN:  Soft without masses or tenderness.,GU:  He has a fairly prominent suprapubic fat pad, and he is quite a large child in any event; however, there were no signs of erythema.  There was some induration around the penis; however, there were no signs of active infection.  He has a buried appearance of the penis after recent circumcision with a normal appearing glans.  The tissue itself, however, was quite dull and is soft or readily retractable at this time.  The scrotum was normal, and there was no erythema, there was no tenderness.  Both testes were descended without hydroceles.,EXTREMITIES:  He has full range of motion of all 4 extremities.,SKIN:  Warm, pink, and dry.,NEUROLOGIC:  Grossly intact.,BACK:  Normal.,IMPRESSION/PLAN: , The patient had a recent circumcision with a fairly prominent suprapubic fat pad but also has a penile and suprapubic cellulitis.  This is being treated, but it is most likely Staph and pending sensitivities.  I talked to the mother and told her that at this point the swelling that is present is a mixture of the resolving cellulitis from a suprapubic fat pad.  I recommended that he be treated most likely with Bactrim for a 10-day course at home, bacitracin, or some antibiotics ointment to the penis with each diaper change for the next 2 to 3 weeks with sitz bath once or twice a day.  I told the mother that initially the tissues are going to be quite dull because of the infection and the recent surgery, but she ultimately will have to gently retract the skin to keep it from adhering again because of the prominent suprapubic fat pad, which makes it more likely.  Otherwise, it is a fairly healthy-appearing tissue at the present time and she knows the reasons that he cannot be discharged once the hospitalist service believes that it is appropriate to do so.  He has a scheduled followup appointment with his urologist  and he should keep that appointment or followup sooner if there is any other problem arising.","consult - history and phy., newborn circumcision, suprapubic fat pad, penile cellulitis, penile swelling, cellulitis, penis, penile, suprapubic, circumcision, "
" The patient is an 84-year-old female presented to emergency room with shortness of breath, fatigue, and tiredness.  Low-grade fever was noted last few weeks.  The patient also has chest pain described as dull aching type in precordial region.  No relation to exertion or activity.  No aggravating or relieving factors. ", Consult - History and Phy., Pericardial Effusion ,"REASON FOR CONSULTATION:,  Pericardial effusion.,HISTORY OF PRESENT ILLNESS: , The patient is an 84-year-old female presented to emergency room with shortness of breath, fatigue, and tiredness.  Low-grade fever was noted last few weeks.  The patient also has chest pain described as dull aching type in precordial region.  No relation to exertion or activity.  No aggravating or relieving factors.  A CT of the chest was done, which shows pericardial effusion.  This consultation is for the same.  The patient denies any lightheadedness or dizziness.  No presyncope or syncope.  Activity is fairly stable.,CORONARY RISK FACTORS: , History of borderline hypertension.  No history of diabetes mellitus.  Nonsmoker.  Cholesterol status is within normal limits.  No history of established coronary artery disease.  Family history noncontributory.,FAMILY HISTORY: , Nonsignificant.,PAST SURGICAL HISTORY:  ,Hysterectomy and bladder surgery.,MEDICATIONS AT HOME:  ,Aspirin and thyroid supplementation.,ALLERGIES:,  None.,PERSONAL HISTORY:,  She is a nonsmoker.  She does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY:,1.  Hypothyroidism.,2.  Borderline hypertension.,3.  Arthritis.,4.  Presentation at this time with chest pain and shortness of breath.,REVIEW OF SYSTEMS,CONSTITUTIONAL:  Weakness, fatigue, and tiredness.,HEENT:  No history of cataract, blurring of vision, or glaucoma.,CARDIOVASCULAR:  Chest pain.  No congestive heart failure.  No arrhythmia.,RESPIRATORY:  No history of pneumonia in the past, valley fever.,GASTROINTESTINAL:  Epigastric discomfort.  No hematemesis or melena.,UROLOGICAL:  Frequency.  No urgency.  No hematuria.,MUSCULOSKELETAL:  Arthritis and muscle weakness.,CNS:  No TIA.  No CVA.  No seizure disorder.,ENDOCRINE:  Nonsignificant.,HEMATOLOGICAL:  Nonsignificant.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse of 86, blood pressure 93/54, afebrile, respiratory rate 16 per minute.,HEENT:  Atraumatic and normocephalic.,NECK:  Supple.  Neck veins flat.  No significant carotid bruit.,LUNGS:  Air entry bilaterally fair.,HEART:  PMI displaced.  S1 and S2 regular.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema.  Pulses palpable.  No clubbing or cyanosis.,CNS:  Grossly intact.,LABORATORY DATA:  ,White count of 20 and H&H 13 and 39.  BUN and creatinine within normal limits.  Cardiac enzyme profile negative.,RADIOGRAPHIC STUDIES: , CT of the chest preliminary report, pericardial effusion.  Echocardiogram shows pericardial effusion, which appears to be chronic.  There is no evidence of hemodynamic compromise.,IMPRESSION:,1.  The patient is an 84-year-old female admitted with chest pain and shortness of breath, possibly secondary to pulmonary disorder.  She has elevated white count, possible infection.,2.  Pericardial effusion without any hemodynamic compromise, could be chronic.",
" A white female who presents for complete physical, Pap and breast exam.", Consult - History and Phy., Physical Exam and Pap -2 ,"SUBJECTIVE:,  The patient is a 68-year-old white female who presents for complete physical, Pap and breast exam.  Her last Pap smear was 05/02/2002.  Her only complaint is that she has had some occasional episodes of some midchest pain that seems to go to her back, usually occurs at rest.  Has awakened her at night on occasion and only last about 15 to 20 minutes.  Denies nausea, vomiting, diaphoresis or shortness of breath with it.  This has not happened in almost two months.  She had a normal EKG one year ago.  Otherwise, has been doing quite well.  Did quite well with her foot surgery with Dr. Clayton.,PAST MEDICAL HISTORY:,  Reactive airway disease; rheumatoid arthritis, recent surgery on her hands and feet; gravida 4, para 5, with one set of twins, all vaginal deliveries; iron deficiency anemia; osteoporosis; and hypothyroidism.,MEDICATIONS:,  Methotrexate 2.5 mg five weekly, Fosamax 70 mg weekly, folic acid daily, amitriptyline 15 mg daily, Synthroid 0.088 mg daily, calcium two in the morning and two at noon, multivitamin daily, baby aspirin daily and Colace one to three b.i.d.,ALLERGIES:,  None.,SOCIAL HISTORY:,  She is married.  Denies tobacco, alcohol and drug use.  She is not employed outside the home.,FAMILY HISTORY: , Unremarkable.,REVIEW OF SYSTEMS:,  HEENT, pulmonary, cardiovascular, GI, GU, musculoskeletal, neurologic, dermatologic, constitutional and psychiatric are all negative except for HPI.,OBJECTIVE:,Vital Signs:  Weight 146.  Blood pressure 100/64.  Pulse 80.  Respirations 16.  Temperature 97.7.,General:  She is a well-developed, well-nourished white female in no acute distress.,HEENT:  Grossly within normal limits.,Neck:  Supple.  No lymphadenopathy.  No thyromegaly.,Chest:  Clear to auscultation bilaterally.,Cardiovascular:  Regular rate and rhythm.,Abdomen:  Positive bowel sounds, soft and nontender.  No hepatosplenomegaly.,Breasts:  No nipple discharge.  No lumps or masses palpated.  No dimpling of the skin.  No axillary lymph nodes palpated.  Self-breast exam discussed and encouraged.,Pelvic:  Normal female genitalia.  Atrophic vaginal mucosa.  No cervical lesions.  No cervical motion tenderness.  No adnexal tenderness or masses palpated.,Rectal:  Normal sphincter tone.  No stool present in the vault.  No rectal masses palpated.,Extremities:  No cyanosis, clubbing or edema.  She does have obvious rheumatoid arthritis of her hands.,Neurologic:  Grossly intact.,ASSESSMENT/PLAN:,1.  Chest pain.  The patient will evaluate when it happens next; what she has been eating, what activities she has been performing.  She had normal ECG one year ago.  In fact this does not sound cardiac in nature.  We will not do further cardiac workup at this time.  Did discuss with her she may be having some GI reflux type symptoms.,2.  Hypothyroidism.  We will recheck TSH to make sure she is on the right amount of medication at this time, making adjustments as needed.,3.  Rheumatoid arthritis.  Continue her methotrexate as prescribed by Dr. Mortensen, and follow up with Dr. XYZ as needed.,4.  Osteoporosis.  It is time for her to have a repeat DEXA at this time and that will be scheduled.,5.  Health care maintenance, Pap smear was obtained today.  The patient will be scheduled for mammogram.",
" A 7-year-old white male started to complain of pain in his fingers, elbows, and neck.  This patient may have had reactive arthritis.  ", Consult - History and Phy., Pediatric Rheumatology Consult ,"HISTORY:  ,We had the pleasure of seeing the patient today in our Pediatric Rheumatology Clinic.  He was sent here with a chief complaint of joint pain in several joints for few months.  This is a 7-year-old white male who has no history of systemic disease, who until 2 months ago, was doing well and 2 months ago, he started to complain of pain in his fingers, elbows, and neck.  At this moment, this is better and is almost gone, but for several months, he was having pain to the point that he would cry at some point.  He is not a complainer according to his mom and he is a very active kid.  There is no history of previous illness to this or had gastrointestinal problems.  He has problems with allergies, especially seasonal allergies and he takes Claritin for it.  Other than that, he has not had any other problem.  Denies any swelling except for that doctor mentioned swelling on his elbow.  There is no history of rash, no stomach pain, no diarrhea, no fevers, no weight loss, no ulcers in his mouth except for canker sores.  No lymphadenopathy, no eye problems, and no urinary problems.,MEDICATIONS: , His medications consist only of Motrin only as needed and Claritin currently for seasonal allergies and rhinitis.,ALLERGIES: , He has no allergies to any drugs.,BIRTH HISTORY:  ,Pregnancy and delivery with no complications.  He has no history of hospitalizations or surgeries.,FAMILY HISTORY: , Positive for arthritis in his grandmother.  No history of pediatric arthritis.  There is history of psoriasis in his dad.,SOCIAL HISTORY: , He lives with mom, dad, brother, sister, and everybody is healthy.  They live in Easton.  They have 4 dogs, 3 cats, 3 mules and no deer.  At school, he is in second grade and he is doing PE without any limitation.,PHYSICAL EXAMINATION: ,VITAL SIGNS:  Temperature is 98.7, pulse is 96, respiratory rate is 24, height is 118.1 cm, weight is 22.1 kg, and blood pressure is 61/44.,GENERAL:  He is alert, active, in no distress, very cooperative.,HEENT:  He has no facial rash.  No lymphadenopathy.  Oral mucosa is clear.  No tonsillitis.  His ear canals are clear and pupils are reactive to light and accommodation.,CHEST:  Clear to auscultation.,HEART:  Regular rhythm and no murmur.,ABDOMEN:  Soft, nontender with no visceromegaly.,MUSCULOSKELETAL:  Shows no limitation in any of his joints or active swelling today.  He has no tenderness either in any of his joints.  Muscle strength is 5/5 in proximal muscles.,LABORATORY DATA:,  Includes an arthritis panel.  It has normal uric acid, sedimentation rate of 2, rheumatoid factor of 6, and antinuclear antibody that is negative and C-reactive protein that is 7.1.  His mother stated that this was done while he was having symptoms.,ASSESSMENT AND PLAN: , This patient may have had reactive arthritis.  He is seen frequently and the patient has family history of psoriatic arthritis or psoriasis.  I do not see any problems at this moment on his laboratories or on his physical examination.  This may have been related to recent episode of viral infection or infection of some sort.  Mother was oriented about the finding and my recommendation is to observe him and if there is any recurrence of the symptoms or persistence of swelling or limitation in any of his joints, I will be glad to see him back.,If you have any question on further assessment and plan, please do no hesitate to contact us.","consult - history and phy., rheumatology, pediatric, reactive arthritis, psoriatic arthritis, psoriasis, joints, swelling, arthritis, "
" A middle-aged white female undergoing autologous stem cell transplant for multiple myeloma, now with paroxysmal atrial fibrillation.", Consult - History and Phy., Paroxysmal Atrial Fibrillation ,"INDICATION: , Paroxysmal atrial fibrillation.,HISTORY OF PRESENT ILLNESS:  ,The patient is a pleasant 55-year-old white female with multiple myeloma.  She is status post chemotherapy and autologous stem cell transplant.  Latter occurred on 02/05/2007.  At that time, she was on telemetry monitor and noticed to be in normal sinus rhythm.,As part of study protocol for investigational drug for prophylaxis against mucositis, she had electrocardiogram performed on 02/06/2007.  This demonstrated underlying rhythm of atrial fibrillation with rapid ventricular response at 125 beats per minute.  She was subsequently transferred to telemetry for observation.  Cardiology consultation was requested.  Prior to formal consultation, the patient did have an echocardiogram performed on 02/06/2007, which showed a structurally normal heart with normal left ventricular (LV) systolic function, ejection fraction of 60%, aortic sclerosis without stenosis, a trivial pericardial effusion with no evidence for immunocompromise and mild tricuspid regurgitation with normal pulmonary atrial pressures.  Overall, essentially normal heart.,At the time of my evaluation, the patient felt somewhat jittery and nervous, but otherwise asymptomatic.,PAST MEDICAL HISTORY:,  Multiple myeloma, diagnosed in June of 2006, status post treatment with thalidomide and Coumadin.  Subsequently, with high-dose chemotherapy followed by autologous stem cell transplant.,PAST SURGICAL HISTORY: , Cosmetic surgery of the nose and forehead.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,CURRENT MEDICATIONS,1.  Acyclovir 400 mg p.o. b.i.d.,2.  Filgrastim 300 mcg subcutaneous daily.,3.  Fluconazole 200 mg daily.,4.  Levofloxacin 250 mg p.o. daily.,5.  Pantoprazole 40 mg daily.,6.  Ursodiol 300 mg p.o. b.i.d.,7.  Investigational drug is directed ondansetron 24 mg p.r.n.,FAMILY HISTORY: , Unremarkable.  Father and mother both alive in their mid 70s.  Father has an unspecified heart problem and diabetes.  Mother has no significant medical problems.  She has one sibling, a 53-year-old sister, who has a pacemaker implanted for unknown reasons.,SOCIAL HISTORY: , The patient is married.  Has four adult children.  Good health.  She is a lifetime nonsmoker, social alcohol drinker.,REVIEW OF SYSTEMS: , Prior to treatment for her multiple myeloma, she was able to walk four miles nonstop.  Currently, she has dyspnea on exertion on the order of one block.  She denies any orthopnea or paroxysmal nocturnal dyspnea.  She denies any lower extremity edema.  She has no symptomatic palpitations or tachycardia.  She has never had presyncope or syncope.  She denies any chest pain whatsoever.  She denies any history of coagulopathy or bleeding diathesis.  Her oncologic disorder is multiple myeloma.  Pulmonary review of systems is negative for recurrent pneumonias, bronchitis, reactive airway disease, exposure to asbestos or tuberculosis.  Gastrointestinal (GI) review of systems is negative for known gastroesophageal reflux disease, GI bleed, and hepatobiliary disease.  Genitourinary review of systems is negative for nephrolithiasis or hematuria.  Musculoskeletal review of systems is negative for significant arthralgias or myalgias.  Central nervous system (CNS) review of systems is negative for tic, tremor, transient ischemic attack (TIA), seizure, or stroke.  Psychiatric review of systems is negative for known affective or cognitive disorders.,PHYSICAL EXAMINATION,GENERAL:  This is a well-nourished, well-developed white female who appears her stated age and somewhat anxious.,VITAL SIGNS:  She is afebrile at 97.4 degrees Fahrenheit with a heart rate ranging from 115 to 150 beats per minute, irregularly irregular.  Respirations are 20 breaths per minute and blood pressure ranges from 90/59 to 107/68 mmHg.  Oxygen saturation on room air is 94%.,HEENT:  Benign being normocephalic and atraumatic.  Extraocular motions are intact.  Her sclerae are anicteric and conjunctivae are noninjected.  Oral mucosa is pink and moist.,NECK:  Jugular venous pulsations are normal.  Carotid upstrokes are palpable bilaterally.  There is no audible bruit.  There is no lymphadenopathy or thyromegaly at the base of the neck.,CHEST:  Cardiothoracic contour is normal.  Lungs, clear to auscultation in all lung fields.,CARDIAC:  Irregularly irregular rhythm and rate.  S1, S2 without a significant murmur, rub, or gallop appreciated.  Point of maximal impulse is normal, no right ventricular heave.,ABDOMEN:  Soft with active bowel sounds.  No organomegaly.  No audible bruit.  Nontender.,LOWER EXTREMITIES:  Nonedematous.  Femoral pulses were deferred.,LABORATORY DATA: , EKG, electrocardiogram showed underlying rhythm of atrial fibrillation with a rate of 125 beats per minute.  Nonspecific ST-T wave abnormality is seen in the inferior leads only.,White blood cell count is 9.8, hematocrit of 30 and platelets 395.  INR is 0.9.  Sodium 136, potassium 4.2, BUN 43 with a creatinine of 2.0, and magnesium 2.9.  AST and ALT 60 and 50.  Lipase 343 and amylase 109.  BNP 908.  Troponin was less than 0.02.,IMPRESSION: , A middle-aged white female undergoing autologous stem cell transplant for multiple myeloma, now with paroxysmal atrial fibrillation.,Currently enrolled in a blinded study, where she may receive a drug for prophylaxis against mucositis, which has at least one reported incident of acceleration of preexisting tachycardia.,RECOMMENDATIONS,1.  Atrial fibrillation.  The patient is currently hemodynamically stable, tolerating her dysrhythmia.  However, given the risk of thromboembolic complications, would like to convert to normal sinus rhythm if possible.  Given that she was in normal sinus rhythm approximately 24 hours ago, this is relatively acute onset within the last 24 hours.  We will initiate therapy with amiodarone 150 mg intravenous (IV) bolus followed by mg/minute at this juncture.  If she does not have spontaneous cardioversion, we will consider either electrical cardioversion or anticoagulation with heparin within 24 hours from initiation of amiodarone.,As part of amiodarone protocol, please check TSH.  Given her preexisting mild elevation of transaminases, we will follow LFTs closely, while on amiodarone.,2.  Thromboembolic risk prophylaxis, as discussed above.  No immediate indication for anticoagulation.  If however she does not have spontaneous conversion within the next 24 hours, we will need to initiate therapy.  This was discussed with Dr. X.  Preference would be to run intravenous heparin with PTT of 45 during her thrombocytopenic nadir and initiation of full-dose anticoagulation once nadir is resolved.,3.  Congestive heart failure.  The patient is clinically euvolemic.  Elevated BNP possibly secondary to infarct or renal insufficiency.  Follow volume status closely.  Follow serial BNPs.,4.  Followup.  The patient will be followed while in-house, recommendations made as clinically appropriate.",
 Pain management for post-laminectomy low back syndrome and radiculopathy.  , Consult - History and Phy., Pain Management Consult - 1 ,"Mr. XYZ forgot his hearing aids at home today and is severely hearing impaired and most of the interview had to be conducted with me yelling at him at the top of my voice.  For all these reasons, this was not really under the best circumstances and I had to curtail the amount of time I spent trying to get a history because of the physical effort required in extracting information from this patient.  The patient was seen late because he had not filled in the patient questionnaire.  To summarize the history here, Mr. XYZ who is not very clear on events from the past, sustained a work-related injury some time in 1998.  At that time, he was driving an 18-wheeler truck.  The patient indicated that he slipped off the rear of his truck while loading vehicles to his trailer.  He experienced severe low back pain and eventually a short while later, underwent a fusion of L4-L5 and L5-S1.  The patient had an uneventful hospital course from the surgery, which was done somewhere in Florida by a surgeon, who he does not remember.  He was able to return to his usual occupation, but then again had a second work-related injury in May of 2005.  At that time, he was required to boat trucks to his rig and also to use a chain-pulley system to raise and lower the vehicles.  Mr. XYZ felt a popping sound in his back and had excruciating low back pain and had to be transported to the nearest hospital.  He was MRI'ed at that time, which apparently showed a re-herniation of an L5-S1 disc and then, he somehow ended up in Houston, where he underwent fusion by Dr. W from L3 through S2.  This was done on 12/15/2005.  Initially, he did fairly well and was able to walk and move around, but then gradually the pain reappeared and he started getting severe left-sided leg pain going down the lateral aspect of the left leg into his foot.  He is still complaining of the severe pain right now with tingling in the medial two toes of the foot and significant weakness in his left leg.  The patient was referred to Dr. A, pain management specialist and Dr. A has maintained him on opioid medications consisting of Norco 10/325 mg for breakthrough pain and oxycodone 30 mg t.i.d. with Lunesta 3 mg q.h.s. for sleep, Carisoprodol 350 mg t.i.d., and Lyrica 100 mg q.daily.  The patient states that he is experiencing no side effects from medications and takes medications as required.  He has apparently been drug screened and his drug screening has been found to be normal.  The patient underwent an extensive behavioral evaluation on 05/22/06 by TIR Rehab Center.  At that time, it was felt that Mr. XYZ showed a degree of moderate level of depression.  There were no indications in the evaluation that Mr. XYZ showed any addictive or noncompliant type behaviors.  It was felt at that time that Mr. XYZ would benefit from a brief period of individual psychotherapy and a course of psychotropic medications.  Of concern to the therapist at that time was the patient's untreated and unmonitored hypertension and diabetes.  Mr. XYZ indicated at that time, they had not purchased any prescription medications or any of these health-related issues because of financial limitations.  He still apparently is not under really good treatment for either of these conditions and on today's evaluation, he actually denies that he had diabetes.  The impression was that the patient had axis IV diagnosis of chronic functional limitations, financial loss, and low losses with no axis III diagnosis.  This was done by Rhonda Ackerman, Ph.D., a psychologist.  It was also suggested at that time that the patient should quit smoking.  Despite these evaluations, Mr. XYZ really did not get involved in psychotherapy and there was poor attendance of these visits, there was no clearance given for any surgical interventions and it was felt that the patient has benefited from the use of SSRIs.  Of concern in June of 2006 was that the patient had still not stopped smoking despite warnings.  His hypertension and diabetes were still not under good control and the patient was assessed at significant risk for additional health complications including stroke, reduced mental clarity, and future falls.  It was felt that any surgical interventions should be put on hold at that time.  In September of 2006, the patient was evaluated at Baylor College of Medicine in the Occupational Health Program.  The evaluation was done by a physician at that time, whose report is clearly documented in the record.  Evaluation was done by Dr. B.  At present, Mr. XYZ continues on with his oxycodone and Norco.  These were prescribed by Dr. A two and a half weeks ago and the patient states that he has enough medication left to last him for about another two and a half weeks.  The patient states that there has been no recent change in either the severity or the distribution of his pain.  He is unable to sleep because of pain and his activities of daily living are severely limited.  He spends most of his day lying on the floor, watching TV and occasionally will walk a while.  ***** from detailed questioning shows that his activities of daily living are practically zero.  The patient denies smoking at this time.  He denies alcohol use or aberrant drug use.  He obtains no pain medications from no other sources.  Review of MRI done on 02/10/06 shows laminectomies at L3 through S1 with bilateral posterior plates and pedicle screws with granulation tissue around the thecal sac and around the left L4-5 and S1 nerve roots, which appear to be retracted posteriorly.  There is a small right posterior herniation at L1-L2.,PAST MEDICAL HISTORY:,  Significant for hypertension, hypercholesterolemia and non-insulin-dependent diabetes mellitus.  The patient does not know what medications he is taking for diabetes and denies any diabetes.  CABG in July of 2006 with no preoperative angina, shortness of breath, or myocardial infarction.  History of depression, lumbar fusion surgery in 2000, left knee surgery 25 years ago.,SOCIAL HISTORY:,  The patient is on disability.  He does not smoke.  He does not drink alcohol.  He is single.  He lives with a girlfriend.  He has minimal activities of daily living.  The patient cannot recollect when last a urine drug screen was done.,REVIEW OF SYSTEMS:,  No fevers, no headaches, chest pain, nausea, shortness of breath, or change in appetite.  Depressive symptoms of crying and decreased self-worth have been noted in the past.  No neurological history of strokes, epileptic seizures.  Genitourinary negative.  Gastrointestinal negative.  Integumentary negative.  Behavioral, depression.,PHYSICAL EXAMINATION:,  The patient is short of hearing.  His cognitive skills appear to be significantly impaired.  The patient is oriented x3 to time and place.  Weight 185 pounds, temperature 97.5, blood pressure 137/92, pulse 61.  The patient is complaining of pain of a 9/10.,Musculoskeletal:  The patient's gait is markedly antalgic with predominant weightbearing on the left leg.  There is marked postural deviation to the left.  Because of pain, the patient is unable to heel-toe or tandem gait.  Examination of the neck and cervical spine are within normal limits.  Range of motion of the elbow, shoulders are within normal limits.  No muscle spasm or abnormal muscle movements noted in the neck and upper extremities.  Head is normocephalic.  Examination of the anterior neck is within normal limits.  There is significant muscle wasting of the quadriceps and hamstrings on the left, as well as of the calf muscles.  Skin is normal.  Hair distribution normal.  Skin temperature normal in both the upper and lower extremities.  The lumbar spine curvature is markedly flattened.  There is a well-healed central scar extending from T12 to L1.  The patient exhibits numerous positive Waddell's signs on exam of the low back with inappropriate flinching and wincing with even the lightest touch on the paraspinal muscles.  Examination of the paraspinal muscles show a mild to moderate degree of spasm with a significant degree of tenderness and guarding, worse on the left than the right.  Range of motion testing of the lumbar spine is labored in all directions.  It is interesting that the patient cannot flex more than 5  in the standing position, but is able to sit without any problem.  There is a marked degree of sciatic notch tenderness on the left.  No abnormal muscle spasms or muscle movements were noted.  Patrick's test is negative bilaterally.  There are no provocative facetal signs in either the left or right quadrants of the lumbar area.  Neurological exam:  Cranial nerves II through XII are within normal limits.  Neurological exam of the upper extremities is within normal limits with good motor strength and normal biceps, triceps and brachioradialis reflexes.  Neurological exam of the lower extremities shows a 2+ right patellar reflex and -1 on the left.  There is no ankle clonus.  Babinski is negative.  Sensory testing shows a minimal degree of sensory loss on the right L5 distribution.  Muscle testing shows decreased L4-L5 on the left with extensor hallucis longus +2/5.  Ankle extensors are -3 on the left and +5 on the right.  Dorsiflexors of the left ankle are +2 on the left and +5 on the right.  Straight leg raising test is positive on the left at about 35 .  There is no ankle clonus.  Hoffman's test and Tinel's test are normal in the upper extremities.,Respiratory:  Breath sounds normal.  Trachea is midline.,Cardiovascular:  Heart sounds normal.  No gallops or murmurs heard.  Carotid pulses present.  No carotid bruits.  Peripheral pulses are palpable.,Abdomen:  Hernia site is intact.  No hepatosplenomegaly.  No masses.  No areas of tenderness or guarding.,IMPRESSION:,1.  Post-laminectomy low back syndrome.,2.  Left L5-S1 radiculopathy.,3.  Severe cognitive impairment with minimal ***** for rehabilitation or return to work.,4.  Opioid dependence for pain control.,TREATMENT PLAN:,  The patient will continue on with his medications prescribed by Dr. Chang and I will see him in two weeks' time and probably suggest switching over from OxyContin to methadone.  I do not think this patient is a good candidate for spinal cord stimulation due to his grasp of exactly what is happening and his cognitive impairment.  I will get a behavioral evaluation from Mr. Tom Welbeck and refer the patient for ongoing physical therapy.  The prognosis here for any improvement or return to work is zero.","consult - history and phy., pain management, opioid dependence, patrick's test, behavioral evaluation, cognitive impairment, low back syndrome, motor strength, pain control, physical therapy, radiculopathy, spinal cord stimulation, activities of daily living, neurological exam, laminectomy, hearing, diabetes, muscle, syndrome,"
" Penile discharge, infected-looking glans.  A 67-year-old male with multiple comorbidities with penile discharge and pale-appearing glans. It seems that the patient has had multiple catheterizations recently and has history of peripheral vascular disease. ", Consult - History and Phy., Penile Discharge ,"CHIEF COMPLAINT: , Penile discharge, infected-looking glans.,HISTORY OF PRESENT ILLNESS: , The patient is a 67-year-old African-American male, who was recently discharged from the hospital on July 21, 2008 after being admitted for altered mental status and before that after undergoing right above knee amputation for wet gangrene.  The patient was transferred to Nursing Home and presents today from the nursing home with complaints of bleeding from the right AKA stump and penile discharge.  As per the patient during his hospitalizations over here, he had indwelling Foley catheter for a few days and when he was discharged at the nursing home he was discharged without the catheter.  However, the patient was brought back to the ED today when he suffered fall yesterday and started bleeding from his stump.  While placing the catheter in the ED on retraction of foreskin purulent discharge was seen from the penis and the glans appeared infected, so urology consult was placed.,REVIEW OF SYSTEMS: , Negative except as in the HPI.,PAST MEDICAL HISTORY: , Significant for end-stage renal disease on dialysis, hypertension, peripheral vascular disease, coronary artery disease, congestive heart failure, diabetes, and hyperlipidemia.,PAST SURGICAL HISTORY:  ,Right AKA,MEDICATIONS:,  Novolin, Afrin, Nephro-Vite, Neurontin, lisinopril, furosemide, Tums, labetolol, Plavix, nitroglycerin, Aricept, omeprazole, oxycodone, Norvasc, Renagel, and morphine.,ALLERGIES: , PENICILLIN and ADHESIVE TAPE.,FAMILY HISTORY: , Significant for hypertension, hyperlipidemia, diabetes, chronic renal insufficiency, and myocardial infarction.,SOCIAL HISTORY: , The patient lives alone.  He is unemployed, disabled.  He has history of tobacco use in the past.  He denies alcohol or drug abuse.,PHYSICAL EXAMINATION:,GENERAL:  A well-appearing African-American male lying comfortably in bed, in acute distress.,NECK:  Supple.,LUNGS:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  S1 and S2, normal.,ABDOMEN:  Soft, nondistended, and nontender.,GENITOURINARY:  Penis is not circumcised.  Currently, indwelling Foley catheter in place.  On retraction of the foreskin, pale-looking glans tip with areas of yellow-white tissue.  The proximal glans appeared pink.  The patient currently has indwelling Foley catheter and glans slightly tender to touch.  However, no purulent discharge was seen on compression of the glans.  Otherwise on palpation, no other deformity noticed.  Bilateral testes descended.  No palpable abnormality.  No evidence of infection in his perineal area.,EXTREMITIES:  Right AKA.,NEUROLOGIC:  Awake, alert, and oriented.  No sensory or motor deficit.,LABORATORY DATA: , I independently reviewed the lab work done on the patient.  The patient had a UA done in the ED which showed few bacteria, white blood cells 6 to 12, and a few epithelial cells which were negative.  His basic metabolic panel with creatinine of 7.2 and potassium of 5, otherwise normal.  CBC with a white blood cell count of 11.5, hemoglobin of 9.5, and INR of 1.13.,IMPRESSION: , A 67-year-old male with multiple comorbidities with penile discharge and pale-appearing glans.  It seems that the patient has had multiple catheterizations recently and has history of peripheral vascular disease.  I think it is due to chronic ischemic changes.,RECOMMENDATIONS: , Our recommendation would be:,1.  To remove the Foley catheter.,2.  Local hygiene.,3.  Local application of bacitracin ointment.,4.  Antibiotic for urinary tract infection.,5.  Follow up as needed.  Of note, it was explained to the patient that the appearance of this glans may improve or may get worsened but at this point, there is no indication to operate on him.  If increased purulent discharge, the patient was asked to call us sooner, otherwise follow up as scheduled.",
" A 3-year-old female for evaluation of chronic ear infections bilateral - OM (otitis media), suppurative without spontaneous rupture.  Adenoid hyperplasia bilateral.", Consult - History and Phy., Otitis Media - H&P ,"CHIEF COMPLAINT:,  This 3-year-old female presents today for evaluation of chronic ear infections bilateral.,ASSOCIATED SIGNS AND SYMPTOMS FOR OTITIS MEDIA: , Associated signs and symptoms include:  cough, fever, irritability and speech and language delay.  Duration (ENT):  Duration of symptom:  12 rounds of antibiotics for otitis media.  Quality of ear problems:  Quality of the pain is throbbing.,ALLERGIES: , No known medical allergies.,MEDICATIONS:,  None currently.,PMH:,  Past medical history is unremarkable.,PSH: , No previous surgeries.,SOCIAL HISTORY:,  Parent admits child is in a large daycare.,FAMILY HISTORY:,  Parent admits a family history of Alzheimer's disease associated with paternal grandmother.,ROS:,  Unremarkable with exception of chief complaint.,PHYSICAL EXAM:,  Temp:  99.6 Weight:  38 lbs.,Patient is a 3-year-old female who appears pleasant, in no apparent distress, her given age, well developed, well nourished and with good attention to hygiene and body habitus.,The child is accompanied by her mother who communicates well in English.,Head & Face:  Inspection of head and face shows no abnormalities.  Examination of salivary glands shows no abnormalities.  Facial strength is normal.,Eyes:  Pupil exam reveals PERRLA.,ENT:  Otoscopic examination reveals otitis media bilateral.,Hearing exam using tuning fork shows hearing to be diminished bilateral.,Inspection of left ear reveals drainage of a small amount.,Inspection of nasal mucosa, septum and turbinates reveals no abnormalities.,Frontal and maxillary sinuses all transilluminate well bilaterally.,Inspection of lips, teeth, gums, and palate reveals no gingival hypertrophy, no pyorrhea, healthy gums, healthy teeth and no abnormalities.,Inspection of the tongue reveals normal color, good motility and midline position.,Examination of oropharynx reveals no abnormalities.,Examination of nasopharynx reveals adenoid hypertrophy.,Neck:  Neck exam reveals no abnormalities.,Lymphatic:  No neck or supraclavicular lymphadenopathy noted.,Respiratory:  Chest inspection reveals chest configuration non-hyperinflated and symmetric expansion.  Auscultation of lungs reveal clear lung fields and no rubs noted.,Cardiovascular:  Heart auscultation reveals no murmurs, gallop, rubs or clicks.,Neurological/Psychiatric:  Testing of cranial nerves reveals no deficits.  Mood and affect normal and appropriate to situation.,TEST RESULTS:,  Audiometry test shows conductive hearing loss at 30 decibels and flat tympanogram.,IMPRESSION: , OM, suppurative without spontaneous rupture.  Adenoid hyperplasia bilateral.,PLAN:,  Patient scheduled for myringotomy and tubes, with adenoidectomy, using general anesthesia, as outpatient and scheduled for 08/07/2003.  Surgery will be performed at Children's Hospital.  Pre-operative consent form read and signed by parent.  Common risks and side effects of the procedure and anesthesia were mentioned.  Parent questions elicited and answered satisfactorily regarding planned procedure.  ,EDUCATIONAL MATERIAL PROVIDED: , Hospital preregistration, middle ear infection and myringtomy and tubes surgery.,PRESCRIPTIONS:,  Augmentin  Dosage:  400 mg-57 mg/5 ml powder for reconstitution  Sig:  One PO Q8h  Dispense:  1 Refills:  0  Allow Generic:  No",
" Peripheral effusion on the CAT scan.  The patient is a 70-year-old Caucasian female with prior history of lung cancer, status post upper lobectomy.  She was recently diagnosed with recurrent pneumonia and does have a cancer on the CAT scan, lung cancer with metastasis. ", Consult - History and Phy., Peripheral Effusion - Consult ,"REASON FOR CONSULT: , Peripheral effusion on the CAT scan.,HISTORY OF PRESENT ILLNESS: , The patient is a 70-year-old Caucasian female with prior history of lung cancer, status post upper lobectomy.  She was recently diagnosed with recurrent pneumonia and does have a cancer on the CAT scan, lung cancer with metastasis.  The patient had a visiting nurse for Christmas and started having abdominal pain, nausea and vomiting for which, she was admitted.  She had a CAT scan of the abdomen done, showed moderate pericardial effusion for which cardiology consult was requested.  She had an echo done, which shows moderate pericardial effusion with early tamponade.  The patient has underlying shortness of breath because of COPD, emphysema and chronic cough.  However, denies any dizziness, syncope, presyncope, palpitation.  Denies any prior history of coronary artery disease.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , At this time, she is on hydromorphone p.r.n., erythromycin, ceftriaxone, calcium carbonate, Ambien.  She is on oxygen and nebulizer.,PAST MEDICAL HISTORY: , History of COPD, emphysema, pneumonia, and lung cancer.,PAST SURGICAL HISTORY:  ,Hip surgery and resection of the lung cancer 10 years ago.,SOCIAL HISTORY:,  Still smokes, but less than before.  Drinks socially.,FAMILY HISTORY:,  Noncontributory.,REVIEW OF SYSTEMS: , Denies any syncope, presyncope, palpitations, shortness of breath, cough, nausea, vomiting, or diarrhea.,PHYSICAL EXAMINATION:,GENERAL:  The patient is comfortable not in any distress.,VITAL SIGNS:  Blood pressure 121/79, Pulse rate 94, respiratory rate 19, and temperature 97.6.,HEENT:  Atraumatic and normocephalic.,NECK:  Supple.  No JVD.  No carotid bruit.,CHEST:  Breath sounds vesicular.  Clear on auscultation.,HEART:  PMI could not be localized.  S2 and S2 regular.  No S3, no S4.  No murmur.,ABDOMEN:  Soft and nontender.  Positive bowel sounds.,EXTREMITIES:  No cyanosis, clubbing, or edema.  Pulse 2+.,CNS:  Alert, awake, and oriented x3.,EKG shows normal sinus rhythm, low voltage.,LABORATORY DATA: , White cell count 7.3, hemoglobin 12.9, hematocrit 38.1, and platelet at 322,000.  Sodium 135, potassium 5, BUN 6, creatinine 1.2, glucose 71, alkaline phosphatase 263, total protein 5.3, lipase 414, and amylase 57.,DIAGNOSTIC STUDIES:,  Chest x-ray shows left upper lobe airspace disease consistent with pneumonia _______.  CT abdomen showed diffuse replacement of the _______ metastasis, hepatomegaly, perihepatic ascites, moderate pericardial effusion, small left _______ sigmoid diverticulosis.,ASSESSMENT:,1.  Moderate peripheral effusion with early tamponade, probably secondary to lung cancer.,2.  Lung cancer with metastasis most likely.,3.  Pneumonia.,4.  COPD.,PLAN: , We will get CT surgery consult for pericardial window.  Continue present medication.",
 Patient with back and hip pain., Consult - History and Phy., Orthopedic Consult - 5 ,"Chief Complaint:, Back and hip pain.,History of Present Illness:, The patient is a 73 year old Caucasian male with a history of hypertension, end-stage renal disease secondary to reflux nephropathy / restriction of bladder neck requiring hemodialysis and eventual cadaveric renal transplant now on chronic immunosuppression, peripheral vascular disease with non-healing ulcer of right great toe, and peripheral neuropathy who initially presented to his primary care physician in May 2001 with complaints of low back pain and bilateral hip pain. The pain was described as a constant pain in the middle to lower back and hips. The pain was exacerbated by climbing stairs and in the morning after sleeping. He reported occasional radiation of pain from back into buttocks (greatest on the right side). He has history of chronic feet and leg numbness and paraesthesias related to his neuropathy, but he denied any recent changes in these symptoms in relation to the back pain. He denied any history of trauma. He was treated symptomatically with Acetaminophen with only some relief. He continued to complain intermittently of pain in his back and hips, and occasionally even in his elbows during the next 8 months. In January 2002, plain pelvic films showed no fracture or dislocation of the hips. Elbow films also showed no acute injury, but there were some erosions along the posterior aspect of the olecranon. An MRI was performed of his lumbar spine which showed degenerative disk disease, spondylosis, and annular bulging/herniation at L4-L5 with resultant encroachment on the neural foramen. He was evaluated by neurosurgery, who felt he should not have surgery at this time. His pain continued and progressively worsened, becoming unresponsive to medical therapy including narcotics,In May 2002, as part of a vascular work-up for the patient’s non-healing right toe, an MRA showed extensive vascular disease in the vessels of both legs below the knees and evidence of bilateral trochanteric bursitis. It also revealed an abnormal enhancing lesion in the left proximal femur, the left iliac bone, the right iliac bone, and possibly the right tibia.,Past Medical History:,End stade renal disease secondary to reflux nephropathy,a. numerous related urinary tract infections,b. hemodialysis (1983-1988),c. s/p cadaveric renal transplant (1988),d. baseline creatinine about 2.3.,Hypertension,Peripheral vascular disease,a. history of right foot infected toenail and non-healing ulcer since 2000; receiving hyperbaric oxygen therapy; recent surgery on infected toe in March, 2002,Peripheral Neuropathy,Chronic anemia (on Epogen injections),History of several partial small bowel obstructions - six times during the last 10 years,Past Surgical History:,1. Tonsillectomy and adenoidectomy (1943),2. Left ureter re-implantation (1960),3. Repair of splenic artery aneurysm (1968),4. Left arm AV fistula graft placement and numerous procedures for dialysis access (1983-1988),5. Cadaveric renal transplant (1988),6. Cataract surgery in bilateral eyes,Medications:,1. Imuran 100mg po QD,2. Prednisone 7.5mg po QD,3. Aspirin 81mg po QD,4. Trental 400mg po TID,5. Norvasc 5mg po BID,6. Prinivil 20mg po BID,7. Hydralazine 50mg po Q6H,8. Clonidine TTS III on Thursdays,9. Terasozin 5mg po BID,10. Elavil 30mg po QHS,11. Vicodin 1-2tabs po Q6H prn,12. Epoetin SR 10,000Units SQ QM and F,13. Sodium bicarbonate 648mg po QD,14. Calcium carbonate 2gm po QID,15. Docusate sodium 100mg po QD,16. Chocolate Ensure one can po QID,17. Multivitamin,18. Vitamin E,Social History:, The patient is married with five children and lives with his wife. He is a retired engineer and real estate broker. He denies tobacco use. He drinks alcohol occasionally with up to three drinks a week. No history of drug abuse.,Allergies:, No known drug allergies.,Family History:",
 Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left., Consult - History and Phy., Pain Management Consult - 2 ,"HPI - WORKERS COMP:, The current problem began on or about 2/10/2000. The symptoms were sudden in onset. According to the patient, the current problem is a result of a work injury involving lifting approximately 40 pounds. Pain location (lower body): left hip. The patient describes the pain as dull, aching and stabbing. The severity of the pain ranges from mild to severe. The pain is severe occasionally. It is present constantly. The pain is made worse by sitting, riding in a car, twisting and lifting. The pain is made better by rest. The patient's symptoms appear to be soft tissue (spine), myofascial (spine) and musculoskeletal (spine) in origin. Sleep alteration because of pain: positive and wakes up after getting to sleep nightly. Systemic signs/symptoms relevant or potentially relevant to the spine: none. Patient reports the following symptoms: depressed mood, loss of interest or pleasure in all or most activities, insomnia, inability to concentrate, fatigue and loss of energy.,WORK STATUS:,",
 Patient with chronic pain plus lumbar disk replacement with radiculitis and myofascial complaints. , Consult - History and Phy., Orthopedic Consult - 4 ,"CHIEF COMPLAINT: , Chronic low back, left buttock and leg pain.,HISTORY OF PRESENT ILLNESS: , This is a pleasant 49-year-old gentleman post lumbar disc replacement from January 2005.  Unfortunately, the surgery and interventional procedures have not been helpful in alleviating his pain.  He has also tried acupuncture, TENS unit, physical therapy, chiropractic treatment and multiple neuropathic medications including Elavil, Topamax, Cymbalta, Neurontin, and Lexapro, which he discontinued either due to side effects or lack of effectiveness in decreasing his pain.  Most recently, he has had piriformis injections, which did give him a brief period of relief; however, he reports that the Botox procedure that was done on March 8, 2006 has not given him any relief from his buttock pain.  He states that approximately 75% of his pain is in his buttock and leg and 25% in his back.  He has tried to increase in his activity with walking and does note increased spasm with greater activity in the low back.  He rated his pain today as 6/10, describing it is shooting, sharp and aching.  It is increased with lifting, prolonged standing or walking and squatting, decreased with ice, reclining and pain medication.  It is constant but variable in degree.  It continues to affect activities and sleep at night as well as mood at times.  He is currently not satisfied completely with his level of pain relief.,MEDICATIONS: , Kadian 30 mg b.i.d., Zanaflex one-half to one tablet p.r.n. spasm, and Advil p.r.n.,ALLERGIES:,  No known drug allergies.,REVIEW OF SYSTEMS:,  Complete multisystem review was noted and signed in the chart.,SOCIAL HISTORY:,  Unchanged from prior visit.,PHYSICAL EXAMINATION: , Blood pressure 123/87, pulse 89, respirations 18, and weight 220 lbs.  He is a well-developed obese male in no acute distress.  He is alert and oriented x3, and displays normal mood and affect with no evidence of acute anxiety or depression.  He ambulates with normal gait and has normal station.  He is able to heel and toe walk.  He denies any sensory changes.,ASSESSMENT & PLAN: , This is a pleasant 49-year-old with chronic pain plus lumbar disk replacement with radiculitis and myofascial complaints.  We discussed treatment options at length and he is willing to undergo a trial of Lyrica.,He is sensitive to medications based on his past efforts and is given a prescription for 150 mg that he will start at bedtime.  We discussed the up taper schedule and he understands that he will have to be on this for some time before we can decide whether or not it is helpful to him.  We also briefly touched on the possibility of a spinal cord stimulator trial if this medication is not helpful to him.  He will call me if there are any issues with the new prescription and follow in four weeks for reevaluation.","consult - history and phy., radiculitis, myofascial, acupuncture, tens unit, physical therapy, chiropractic treatment, lumbar disk replacement, lumbar disk, disk replacement, orthopedic"
" Low back pain, lumbar degenerative disc disease, lumbar spondylosis, facet and sacroiliac joint syndrome, lumbar spinal stenosis primarily bilateral recess, intermittent lower extremity radiculopathy, DJD of both knees, bilateral pes anserinus bursitis, and chronic pain syndrome.", Consult - History and Phy., Orthopedic Consult - 1 ,"SUBJECTIVE:,  The patient comes back to see me today.  She is a pleasant 73-year-old Caucasian female who had seen Dr. XYZ with low back pain, lumbar degenerative disc disease, lumbar spondylosis, facet and sacroiliac joint syndrome, lumbar spinal stenosis primarily bilateral recess, intermittent lower extremity radiculopathy, DJD of both knees, bilateral pes anserinus bursitis, and chronic pain syndrome.  Dr. XYZ had performed right and left facet and sacroiliac joint injections, subsequent right L3 to S1 medial branch blocks and radiofrequency ablation on the right from L3 to S1.  She was subsequently seen with some mid back pain and she had right T8-T9 and T9-T10 facet injections on 10/28/2004.  She was last seen on 04/08/2005 with recurrent pain in her low back on the right.  Dr. XYZ repeated her radiofrequency ablation on the right side from L3-S1 on 05/04/2005.,The patient comes back to see me today.  She states that the radiofrequency ablation has helped her significantly there, but she still has one spot in her low back that seems to be hurting her on the right, and seems to be pointing to her right sacroiliac joint.  She is also complaining of pain in both knees.  She says that 20 years ago she had a cortisone shot in her knees, which helped her significantly.  She has not had any x-rays for quite some time.  She is taking some Lortab 7.5 mg tablets, up to four daily, which help her with her pain symptoms.  She is also taking Celebrex through Dr. S’ office.,PAST MEDICAL HISTORY:,  Essentially unchanged from my visit of 04/08/2005.,PHYSICAL EXAMINATION:,General:  Reveals a pleasant Caucasian female.,Vital Signs:  Height is 5 feet 5 inches.  Weight is 183 pounds.  She is afebrile.,HEENT:  Benign.,Neck:  Shows functional range of movements with a negative Spurling's.,Musculoskeletal:  Examination shows degenerative joint disease of both knees, with medial and lateral joint line tenderness, with tenderness at both pes anserine bursa.  Straight leg raises are negative bilaterally.  Posterior tibials are palpable bilaterally.,Skin and Lymphatics:  Examination of the skin does not reveal any additional scars, rashes, cafe au lait spots or ulcers.  No significant lymphadenopathy noted.,Spine:  Examination shows decreased lumbar lordosis with tenderness that seems to be in her right sacroiliac joint.  She has no other major tenderness.  Spinal movements are limited but functional.,Neurological:  She is alert and oriented with appropriate mood and affect.  She has normal tone and coordination.  Reflexes are 2+ and symmetrical.  Sensation is intact to pinprick.,FUNCTIONAL EXAMINATION:,  Gait has a normal stance and swing phase with no antalgic component to it.,IMPRESSION:,1.  Low back syndrome with lumbar degenerative disc disease, lumbar spinal stenosis, and facet joint syndrome on the right L4-5 and L5-S1.,2.  Improved, spinal right L3-S1 radiofrequency ablation.,3.  Right sacroiliac joint sprain/strain, symptomatic.,4.  Left lumbar facet joint syndrome, stable.,6.  Right thoracic facet joint syndrome, stable.,7.  Lumbar spinal stenosis, primarily lateral recess with intermittent lower extremity radiculopathy, stable.,8.  Degenerative disc disease of both knees, symptomatic.,9.  Pes anserinus bursitis, bilaterally symptomatic.,10.  Chronic pain syndrome.,RECOMMENDATIONS:,  Dr. XYZ and I discussed with the patient her pathology.  She has some symptoms in her low back on the right side at the sacroiliac joint.  Dr. XYZ will plan having her come in and injecting her right sacroiliac joint under fluoroscopy.  She is also having pain in both knees.  We will plan on x-rays of both knees, AP and lateral, and plan on seeing her back on Monday or Friday for possible intraarticular and/or pes anserine bursa injections bilaterally.  I explained the rationale for each of these injections, possible complications and she wishes to proceed.  In the interim, she can continue on Lortab and Celebrex.  We will plan for the follow up following these interventions, sooner if needed.  She voiced understanding and agreement.  Physical exam findings, history of present illness, and recommendations were performed with and in agreement with Dr. Goel's findings.","consult - history and phy., low back pain, lumbar degenerative disc disease, lumbar spondylosis, facet, sacroiliac joint syndrome, lumbar spinal stenosis, intermittent lower extremity radiculopathy, djd of both knees, bilateral pes anserinus bursitis, chronic pain syndrome, degenerative disc disease, pes anserinus bursitis, pes anserine bursa, sacroiliac joint, joint syndrome, degenerative disc, lumbar spinal, bilateral recess, lumbar, joint, intermittent, djd, orthopedic, pes, spinal, spondylosis, sacroiliac, syndrome, "
" This is a 53-year-old man, who presented to emergency room with multiple complaints including pain from his hernia, some question of blood in his stool, nausea, and vomiting, and also left lower extremity pain. ", Consult - History and Phy., Pain from Hernia - ER Consult ,"HISTORY OF PRESENT ILLNESS:  ,This is a 53-year-old man, who presented to emergency room with multiple complaints including pain from his hernia, some question of blood in his stool, nausea, and vomiting, and also left lower extremity pain.  At the time of my exam, he states that his left lower extremity pain has improved considerably.  He apparently had more significant paresthesias in the past and now he feels that the paresthesias have improved considerably.  He does have a history of multiple medical problems including atrial fibrillation, he is on Coumadin, which is currently subtherapeutic, multiple CVAs in the past, peripheral vascular disease, and congestive heart failure.  He has multiple chronic history of previous ischemia of his large bowel in the past.,PHYSICAL EXAM,VITAL SIGNS:  Currently his temperature is 98.2, pulse is 95, and blood pressure is 138/98.,HEENT:  Unremarkable.,LUNGS:  Clear.,CARDIOVASCULAR:  An irregular rhythm.,ABDOMEN:  Soft.,EXTREMITIES:  His upper extremities are well perfused.  He has palpable radial and femoral pulses.  He does not have any palpable pedal pulses in either right or left lower extremity.  He does have reasonable capillary refill in both feet.  He has about one second capillary refill on both the right hand and left lower extremities and his left foot is perhaps little cool, but it is relatively warm.  Apparently, this was lot worst few hours ago.  He describes significant pain and pallor, which he feels has improved and certainly clinically at this point does not appear to be as significant.,IMPRESSION AND PLAN: , This gentleman with a history of multiple comorbidities as detailed above had what sounds clinically like acute exacerbation of chronic peripheral vascular disease, essentially related to spasm versus a small clot, which may have been lysed to some extent.  He currently has a viable extremity and viable foot, but certainly has significant making compromised flow.  It is unclear to me whether this is chronic or acute, and whether he is a candidate for any type of intervention.  He certainly would benefit from an angiogram to better to define his anatomy and anticoagulation in the meantime.  Given his potential history of recent lower GI bleeding, he has been evaluated by GI to see whether or not he is a candidate for heparinization.  We will order an angiogram for the next few hours and followup on those results to better define his anatomy and to determine whether or not if any interventions are appropriate.  Again, at this point, he has no pain, relatively rapid capillary refill, and relatively normal motor function suggesting a viable extremity.  We will follow him along closely.","consult - history and phy., blood in stool, nausea, capillary refill, angiogram, hernia, extremity, "
 A lady with symptoms consistent with possible oligoarticular arthritis of her knees., Consult - History and Phy., Oligoarticular Arthritis - 2 ,"HISTORY: , A is a young lady, who came here with a diagnosis of seizure disorder and history of Henoch-Schonlein purpura with persistent proteinuria.  A was worked up for collagen vascular diseases and is here to find out the results.  Also was recommended to take 7.5 mg of Mobic every day for her joint pains.  She states that she continues with some joint pain and feeling tired all the time.  Mother states that also her seizure has continued without any control so far.  She is having some studies in the next few days.  She is mostly stiff on her legs, neck, and also on her hands.  The rest of the review of systems is in the chart.,PHYSICAL EXAMINATION: , ,VITAL SIGNS:  Temperature today is 99.2 degrees Fahrenheit, weight is 45.9 kg, blood pressure is 123/59, height is 149.5 cm, and pulse is 94.,HEENT:  She has no facial rashes, no lymphadenopathy, no alopecia, no oral ulcerations.  Pupils are reactive to accommodation.  Funduscopic examination is within normal limits.,NECK:  No neck masses.,CHEST:  Clear to auscultation.,HEART:  Regular rhythm with no murmur.,ABDOMEN:  Soft, nontender with no visceromegaly.,SKIN:  No rashes today.,MUSCULOSKELETAL:  Examination shows good range of motion with no swelling or tenderness in any of her joints of the upper extremities, but she does have minus/plus swelling of her knees with flexion contracture bilaterally on both.,LABORATORY DATA: , Laboratories were not done recently, but we have some lab results from the previous evaluation that basically is negative for any collagen vascular disease, but shows some evidence of decreased calcium and vitamin D levels.,ASSESSMENT: , This is a patient, who today presents with symptoms consistent with possible oligoarticular arthritis of her knees with also arthralgias and deficiency in vitamin D.  She also has chronic proteinuria and seizure disorder.  My recommendation is to start her on vitamin D and calcium supplements, and also increase the Mobic to 50 mg, which is one of the few things she can tolerate with all the medication she is taking.  We are going to refer her to physical therapy and see her back in 2 months for followup.  The plan was discussed with A and her parents and they have no further questions.","consult - history and phy., arthralgias, deficiency, vitamin d, collagen vascular diseases, seizure disorder, vascular diseases, joint pains, oligoarticular arthritis, arthritis, oligoarticular,"
" Toenails are discolored, thickened, and painful - Onychomycosis", Consult - History and Phy., Onychomycosis - H&P ,"CHIEF COMPLAINT (1/1):, This 59 year old female presents today complaining that her toenails are discolored, thickened, and painful. Duration: Condition has existed for 6 months. Severity: Severity of condition is worsening.,ALLERGIES: ,Patient admits allergies to dairy products, penicillin.,MEDICATION HISTORY:, None.,PAST MEDICAL HISTORY:, Past medical history is unremarkable.,PAST SURGICAL HISTORY:, Patient admits past surgical history of eye surgery in 1999.,SOCIAL HISTORY:, Patient denies alcohol use, Patient denies illegal drug use, Patient denies STD history, Patient denies tobacco use.,FAMILY HISTORY:, Unremarkable.,REVIEW OF SYSTEMS:, Psychiatric: (+) poor sleep pattern, Respiratory: (+) breathing difficulties, respiratory symptoms.,PHYSICAL EXAM:, Patient is a 59 year old female who appears well developed, well nourished and with good attention to hygiene and body habitus. Toenails 1-5 bilateral appear crumbly, discolored - yellow, friable and thickened.,Cardiovascular: DP pulses palpable bilateral. PT pulses palpable bilateral. CFT immediate. No edema observed.  Varicosities are not observed.,Skin: Skin temperature of the lower extremities is warm to cool, proximal to distal. No skin rash, subcutaneous nodules, lesions or ulcers observed.,Neurological: Touch, pin, vibratory and proprioception sensations are normal. Deep tendon reflexes normal.,Musculoskeletal: Muscle strength is 5/5 for all groups tested. Muscle tone is normal. Inspection and palpation of bones, joints and muscles is unremarkable.,TEST RESULTS:, No tests to report at this time.,IMPRESSION:, Onychomycosis.,PLAN:, Debrided 10 nails.,PRESCRIPTIONS:, Penlac Dosage: 8% Topical Solution Sig:",
" Medical management, status post left total knee arthroplasty.", Consult - History and Phy., Orthopedic Consult ,"REASON FOR CONSULT: , Medical management, status post left total knee arthroplasty.,PAST MEDICAL HISTORY:,1.  Polyarthritis.,2.  Acromegaly.,3.  Hypothyroidism.,4.  Borderline hypertension.,5.  Obesity.,PAST SURGICAL HISTORY: , Hernia repair, resection of tumor, right thumb arthrodesis, carpal tunnel decompression, bilateral hip replacement, right total knee replacement about 2 months ago, open reduction of left elbow fracture.,REVIEW OF SYSTEMS:,CONSTITUTIONAL SYMPTOMS:  No fever or recent general malaise.,ENT:  Not remarkable.,RESPIRATORY:  No cough or shortness of breath.,CARDIOVASCULAR:  The patient denies any heart problems.  No orthopnea.  No palpitations.  No syncopal episodes.,GASTROINTESTINAL:  No nausea.  No vomiting.  No history of GI bleed.,GENITOURINARY:  No dysuria, no hematuria.,ENDOCRINE:  The patient is status post pituitary tumor resection and is on supplemental hormone.,MEDICATIONS:  Depo-Testosterone 200 mg IM q.3 weekly, prednisone 1 tablet p.o. daily, octreotide IM on a monthly basis, morphine extended release 50 mg p.o. b.i.d., Synthroid 100 mcg p.o. daily, desmopressin 1 tablet p.o. every bedtime, aspirin/oxycodone on a p.r.n. basis, aspirin on p.r.n. basis.,ALLERGIES: , IBUPROFEN AND TYLENOL.,SOCIAL HISTORY: , The patient does not smoke nor drink alcohol.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION,GENERAL:  Obese, 57-year-old gentleman, not in acute distress.,VITAL SIGNS:  Blood pressure of 105/55, pulse is 90.  He is afebrile.  O2 saturation is 95% on room air.,HEAD AND NECK:  Face symmetrical.  Cranial nerves are intact.  No distended neck veins.  No palpable neck masses.,CHEST:  Clear to auscultation.  No wheezing.  No crepitations.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmur was appreciated.,ABDOMEN:  Benign.,EXTREMITIES:  The left knee is in closed dressing.  The lower extremities are still numb from spinal anesthesia.,ASSESSMENT AND PLAN:,1.  Polyarthritis, status post left total knee replacement.  The patient tolerated the procedure well.,2.  Acromegaly, status post pituitary resection.  Continue supplemental hormones.,3.  Borderline hypertension, blood pressure is under control with monitoring.,4.  Deep venous thrombosis prophylaxis as per surgeon.,5.  Anemia due to repeated blood loss with monitor hemoglobin and hematocrit.",
" Degenerative disk disease of the right hip, low back pain with lumbar scoliosis post laminectomy syndrome, lumbar spinal stenosis, facet and sacroiliac joint syndrome, and post left hip arthroplasty.", Consult - History and Phy., Orthopedic Consult - 2 ,"SUBJECTIVE:,  The patient comes back to see me today.  She is a pleasant 77-year-old Caucasian female who had seen Dr. XYZ with right leg pain.  She has a history of prior laminectomy for spinal stenosis.  She has seen Dr. XYZ with low back pain and lumbar scoliosis post laminectomy syndrome, lumbar spinal stenosis, and clinical right L2 radiculopathy, which is symptomatic.  Dr. XYZ had performed two right L2-L3 transforaminal epidural injections, last one in March 2005.  She was subsequently seen and Dr. XYZ found most of her remaining symptoms are probably coming from her right hip.  An x-ray of the hip showed marked degenerative changes with significant progression of disease compared to 08/04/2004 study.  Dr. XYZ had performed right intraarticular hip injection on 04/07/2005.  She was last seen on 04/15/2005.  At that time, she had the hip injection that helped her briefly with her pain.  She is not sure whether or not she wants to proceed with hip replacement.  We recommend she start using a cane and had continued her on some pain medicines.,The patient comes back to see me today.  She continues to complain of significant pain in her right hip, especially with weightbearing or with movement.  She said she had made an appointment to see an orthopedic surgeon in Newton as it is closer and more convenient for her.  She is taking Ultracet or other the generic it sounds like, up to four times daily.  She states she can take this much more frequently as she still has significant pain symptoms.  She is using a cane to help her ambulate.,PAST MEDICAL HISTORY:,  Essentially unchanged from her visit of 04/15/2005.,PHYSICAL EXAMINATION:,General:  Reveals a pleasant Caucasian female.,Vital Signs:  Height is 5 feet 4 inches.  Weight is 149 pounds.  She is afebrile.,HEENT:  Benign.,Neck:  Shows functional range of movements with a negative Spurling's.,Musculoskeletal:  Examination shows some mild degenerative joint disease of both knees with grade weakness of her right hip flexors and half-grade weakness of her right hip adductors and right quadriceps, as compared to the left.  Straight leg raises are negative bilaterally.  Posterior tibials are palpable bilaterally.,Skin and Lymphatics:  Examination of the skin does not reveal any additional scars, rashes, cafe au lait spots or ulcers.  No significant lymphadenopathy noted.,Spine:  Examination shows lumbar scoliosis with surgical scar with no major tenderness.  Spinal movements are limited but functional.,Neurological:  She is alert and oriented with appropriate mood and affect.  She has normal tone and coordination.  Reflexes are 2+ and symmetrical.  Sensations are intact to pinprick.,FUNCTIONAL EXAMINATION:,  Gait has a normal stance and swing phase with no antalgic component to it.,IMPRESSION:,1.  Degenerative disk disease of the right hip, symptomatic.,2.  Low back syndrome, lumbar spinal stenosis, clinically right L2 radiculopathy, stable.,3.  Low back pain with lumbar scoliosis post laminectomy syndrome, stable.,4.  Facet and sacroiliac joint syndrome on the right, stable.,5.  Post left hip arthroplasty.,6.  Chronic pain syndrome.,RECOMMENDATIONS:,  The patient is symptomatic primarily on her right hip and is planning on seeing an orthopedic surgeon for possible right hip replacement.  In the interim, her Ultracet is not quite taking care of her pain.  I have asked her to discontinue it and we will start her on Tylenol #3, up to four times a day.  I have written a prescription for this for 120 tablets and two refills.  The patient will call for the refills when she needs them.  I will plan further follow up in six months, sooner if needed.  She voiced understanding and is in agreement with this plan.  Physical exam findings, history of present illness and recommendations were performed with and in agreement with Dr. Goel's findings.","consult - history and phy., scoliosis, lumbar, laminectomy, spinal stenosis, radiculopathy, chronic pain syndrome, low back pain, facet and sacroiliac joint, degenerative disk disease, sacroiliac joint syndrome, lumbar spinal stenosis, disk disease, sacroiliac joint, hip arthroplasty, hip injection, hip replacement, lumbar scoliosis, injections, hip, orthopedic, "
 Occupational medicine consult with questions-answers and records review., Consult - History and Phy., Occupational Medicine Consult - 3 ,"ALLOWED CONDITIONS:,  Sprain of left knee and leg.,CONTESTED CONDITION:,  Left knee tear medial meniscus, left knee ACL tear.,EMPLOYER:,  YYYY,REQUESTING PARTY:,  XXXX,Mr. XXXXXX is a xx-year-old male who was evaluated for an independent medical examination on September 20, 2007, because of an injury sustained to the left leg.  The injured worker does state that he was working as a processor for the ABCD Company on July 18, 2007, when he injured his left knee.  He does state he was working in a catwalk when he stepped up.  He noticed his sight glass was not open on the tank.  He then stepped straight down and his knee went sideways.  His knee popped and he sat down secondary to discomfort.  At that time he could not do any type of activity secondary to the pain.  The nurse called the ambulance subsequent to this injury and he was taken to Bethesda North.  X-rays were obtained which demonstrated no evidence of fracture.  Thereafter, he was referred to X who he saw on July 19, 2007.  It was felt that a MRI scan about the knee needed to be obtained and it was obtained on July 24.  It was noted that there was evidence of an anterior cruciate ligament tear and a slight medial meniscal tear.  On his second visit, it was felt that arthroscopic surgery intervention was indicated as related to the left knee.,On September 7, 2007, he underwent surgical intervention at ABC for the anterior cruciate reconstruction as well as the partial medial meniscectomy.,At the present time, he is progressing along with physical therapy.  He is utilizing one crutch.,He does admit to significant bruising and swelling about the left lower extremity.  If he does indeed move too fast, the discomfort is increased.  His pain about the left knee is approximately 6 to 7 on a scale of 1 to 10.,He has had injuries to the right knee in which he wrecked his bicycle and did have some type of fracture bone spur when he was 13 years of age.,He underwent arthroscopic surgery as related to the right knee at that time and really did quite well.,His next appointment with Dr. X is on October 4, 2007.,The injured worker denies any previous history of similar problems as related to the left knee.,MEDICATIONS: , Glucophage, Lipitor, Actos, Benicar, glimepiride, and Januvia.,SURGICAL HISTORY:,  Arthroscopic surgery of the left knee and arthroscopic surgery of the right knee.,SOCIAL HISTORY:,  The patient denies alcohol consumption.  He does smoke approximately one and a half packs of cigarettes per day.  His education is that of 12th grade.,PHYSICAL EXAMINATION: , This is a healthy appearing 34-year-old male who is 5 feet 9 inches and weighs 285 pounds.  He does not appear to be in distress at this time.  Examination is limited to the left knee.  One could appreciate a healed scar as related to the inferior pole inferior to the patella.  There are healed arthroscopic scars as well.  The range of motion of left knee reveals 50 to 70 degrees of flexion.  There is evidence of medial and lateral joint line discomfort.  Anterior Lachman's test was negative.  No evidence of atrophy is noted.  There is weakness with aggressive function about the quadriceps and hamstring musculature.,The patient is ambulating with one crutch at this time.,There is mild degree of swelling as related to the left knee.  Deep tendon reflexes are +2/+2 bilaterally symmetrical.  Sensory examination was normal as related to the foot, but abnormal as related to the left knee.,I did review pictures that were taken at the time of the surgery, which demonstrates the meniscectomy and the anterior cruciate ligament reconstruction.,MEDICAL RECORDS REVIEW:,1.  July 18, 2007, x-rays of the left knee demonstrated evidence of a small suprapatellar joint effusion.  It should be noted that the exam demonstrated evidence of medial and lateral joint line discomfort.  There was specific mention of intraarticular effusion.,2.  On July 27, 2007, MRI scan of the left knee was obtained, which demonstrated evidence of the complete tear of the mid to distal ACL.  Findings suggestive of a chronic injury.  Grade I sprain of the MCL was noted.  Contusion __________ plateau medial femoral condyle and lateral femoral condyle was noted.  There was evidence of a small peripheral longitudinal tear of the posterior horn of medial meniscus.  Chondromalacia of the lateral femoral condyle and patella was noted.  It should be noted that the changes of degeneration of the cartilages of the injured worker's knee and the chronic anterior cruciate ligament changes were noted related to the July 18, 2007, injury.,3.  July 18, 2007, first report of injury, occupational disease, and/or death.,4.  Evaluations of ABCD Hospital.  It should be noted that the mechanism of injury was such that he was walking down the stairs when his left knee locked up.,5.  July 18, 2007, x-rays of the left knee were obtained, which demonstrated the evidence of no acute fracture or significant osteoarthritis.  There is evidence there maybe a small suprapatellar joint effusion.,6.  Notes from the office of Dr. X. It should be noted on physical examination his range of motion is 8 to 20 degrees.,7.  Physical therapy prescription for __________ Orthopedics and Sports Medicine Corporation.,8.  August 10, 2007, requests for arthroscopic anterior cruciate ligament reconstruction with patellar tendon.,9.  Physician narrative of August 24, 2007.  It is noted that the injured worker did indeed have evidence of hypertension, hyperlipidemia, and diabetes.  His BMI was 42.  This was felt __________ pre-injury MRI scan.,Following your review of the medical information and your physical examination, please answer the following questions as these pertain to the allowed conditions.  Please express your opinion based upon a reasonable degree of medical probability.,QUESTION: ,Mr. XXXXXX has filed an application for the additional allowance of left knee tear of the medial meniscus and left knee ACL tear.,Based on the current objective findings, mechanism of injury, or and medical records or diagnosis studies, does the medical evidence support the existence of any of the requested conditions.,ANSWER: ,The MRI sustains and verifies that these conditions do indeed exist subsequent to the injury of July 18, 2007.,QUESTION: ,If you find any of these conditions exist, are they a direct and proximate result of the July 18, 2007, injury.,ANSWER: ,There is mention of degeneration as related to the knee prior to this episode.  This is not surprising considering the individual's weight.  There is no question degeneration as related to anterior cruciate ligament and the meniscus has been occurring for a lengthy period of time.  There has been an aggravation of this condition.  Without having a MRI to review prior to this injury, I believe, it would be safe to assume that there has been aggravation of a pre-existing condition as related to the left knee and __________ meniscal and anterior cruciate ligament pathology.  Thus there is definitely evidence of an aggravation of a pre-existing condition but not necessarily a direct and proximate result of the July 18, 2007, injury.,QUESTION: ",
" Back pain and right leg pain.  Small cell lung cancer with metastasis at the lower lumbar spine, pelvis, and both femurs", Consult - History and Phy., Orthopedic Consult - 3 ,"CHIEF COMPLAINT:,  Back pain and right leg pain.  The patient has a three-year history of small cell lung cancer with metastases.,HISTORY OF PRESENT ILLNESS:,  The patient is on my schedule today to explore treatment of the above complaints.  She has a two-year history of small cell lung cancer, which she says has spread to metastasis in both femurs, her lower lumbar spine, and her pelvis.  She states she has had numerous chemotherapy and radiation treatments and told me that she has lost count.  She says she has just finished a series of 10 radiation treatments for pain relief.  She states she continues to have significant pain symptoms.  Most of her pain seems to be in her low back on the right side, radiating down the back of her right leg to her knee.  She has also some numbness in the bottom of her left foot, and some sharp pain in the left foot at times.  She complains of some diffuse, mid back pain.  She describes the pain as sharp, dull, and aching in nature.  She rates her back pain as 10, her right leg pain as 10, with 0 being no pain and 10 being the worst possible pain.  She states that it seems to be worse while sitting in the car with prolonged sitting, standing, or walking.  She is on significant doses of narcotics.  She has had multiple CT scans looking for metastasis.,PAST MEDICAL HISTORY:,  Significant for cancer as above.  She also has a depression.,PAST SURGICAL HISTORY:,  Significant for a chest port placement.,CURRENT MEDICATIONS:,  Consist of Duragesic patch 250 mcg total, Celebrex 200 mg once daily, iron 240 mg twice daily, Paxil 20 mg daily, and Percocet.  She does not know of what strength up to eight daily.  She also is on warfarin 1 mg daily, which she states is just to keep her chest port patent.  She is on Neurontin 300 mg three times daily.,HABITS:,  She smokes one pack a day for last 30 years.  She drinks beer approximately twice daily.  She denies use of recreational drugs.,SOCIAL HISTORY:,  She is married.  She lives with her spouse.,FAMILY HISTORY: , Significant for two brothers and father who have cancer.,REVIEW OF SYSTEMS:,  Significant mainly for her pain complaints.  For other review of systems the patient seems stable.,PHYSICAL EXAMINATION:,General:  Reveals a pleasant somewhat emaciated Caucasian female.,Vital Signs:  Height is 5 feet 2 inches.  Weight is 130 pounds.  She is afebrile.,HEENT:  Benign.,Neck:  Shows functional range of movements with a negative Spurling's.,Chest:  Clear to auscultation.,Heart:  Regular rate and rhythm.,Abdomen:  Soft, regular bowel sounds.,Musculoskeletal:  Examination shows functional range of joint movements.  No focal muscle weakness.  She is deconditioned.,Neurologic:  She is alert and oriented with appropriate mood and affect.  The patient has normal tone and coordination.  Reflexes are 2+ in both knees and absent at both ankles.  Sensations are decreased distally in the left foot, otherwise intact to pinprick.,Spine:  Examination of her lumbar spine shows normal lumbar lordosis with fairly functional range of movement.  The patient had significant tenderness at her lower lumbar facet and sacroiliac joints, which seems to reproduce a lot of her low back and right leg complaints.,FUNCTIONAL EXAMINATION: , Gait has a normal stance and swing phase with no antalgic component to it.,INVESTIGATION: , She has had again multiple scans including a whole body bone scan, which showed abnormal uptake involving the femurs bilaterally.  She has had increased uptake in the sacroiliac joint regions bilaterally.  CT of the chest showed no evidence of recurrent metastatic disease.  CT of the abdomen showed no evidence of metastatic disease.  MRI of the lower hip joints showed heterogenous bone marrow signal in both proximal femurs.  CT of the pelvis showed a trabecular pattern with healed metastases.  CT of the orbits showed small amount of fluid in the mastoid air cells on the right, otherwise normal CT scan.  MR of the brain showed no acute intracranial abnormalities and no significant interval changes.,IMPRESSION:,1.  Small cell lung cancer with metastasis at the lower lumbar spine, pelvis, and both femurs.,2.  Symptomatic facet and sacroiliac joint syndrome on the right.,3.  Chronic pain syndrome.,RECOMMENDATIONS:,  Dr. XYZ and I discussed with the patient her pathology.  Dr. XYZ explained her although she does have lung cancer metastasis, she seems to be symptomatic with primarily pain at her lower lumbar facet and sacroiliac joints on the right.  Secondary to the patient's significant pain complaints today, Dr. XYZ will plan on injecting her right sacroiliac and facet joints under fluoroscopy today.  I explained the rationale for the procedure, possible complications, and she voiced understanding and wished to proceed.  She understands that she is on warfarin therapy and that we generally do not perform injections while they are on this.  We have asked for stat protime today.  She is on a very small dose, she states she has had previous biopsies while on this before, and did not have any complications.  She is on significant dose of narcotics already, however, she continues to have pain symptoms.  Dr. XYZ advised that if she continues to have pain, even after this injection, she could put on an extra 50 mcg patch and take a couple of extra Percocet if needed.  I will plan on evaluating her in the Clinic on Tuesday.  I have also asked that she stop her Paxil, and we plan on starting her on Cymbalta instead.  She voiced understanding and is in agreement with this plan.  I have also asked her to get an x-ray of the lumbar spine for further evaluation.  Physical exam, findings, history of present illness, and recommendations were performed with and in agreement with Dr. G's findings.  Peripheral neuropathy of her left foot is most likely secondary to her chemo and radiation treatments.",
" Organic brain syndrome in the setting of multiple myeloma.  The patient is a 56-year-old male with the history of multiple myeloma, who has been admitted for complains of being dehydrated and was doing good until this morning, was found to be disoriented and confused, was not able to communicate properly, and having difficulty leaving out the words. ", Consult - History and Phy., Organic Brain Syndrome ,"REASON FOR CONSULT:,  Organic brain syndrome in the setting of multiple myeloma.,SOURCE OF HISTORY:  ,The patient himself is not able to give a good history.  History has obtained through discussion with Dr. X over the phone and the nurse taking care of the patient despite reviewing the chart on the floor.,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old male with the history of multiple myeloma, who has been admitted for complains of being dehydrated and was doing good until this morning, was found to be disoriented and confused, was not able to communicate properly, and having difficulty leaving out the words.  Not a very clear history at this time and the patient himself is not able to give any history despite no family member was present in the room.  Neurology consult was called to evaluate any organic brain syndrome in the setting of multiple myeloma.  The patient since the morning has improved, but still not completely back to the baseline.  Even I evaluated the patient previously, hence not very sure about his baseline.,PAST MEDICAL HISTORY:,  History of IgG subtype multiple myeloma.,SURGICAL HISTORY:,  Nothing significant.,PSYCHIATRIC HISTORY:  ,Nothing significant.,SOCIAL HISTORY:  ,No history of any smoking, alcohol or drug abuse.,ALLERGIES: , CODEINE AND FLAGYL.,IMMUNIZATION HISTORY: , Nothing significant.,FAMILY HISTORY: , Unobtainable.,REVIEW OF SYSTEMS:  ,The patient was considered to ask question for systemic review including neurology, psychiatry, sleep, ENT, ophthalmology, pulmonary, cardiology, gastroenterology, genitourinary, hematology, rheumatology, dermatology, allergy/immunology, endocrinology, toxicology, oncology, and found to be positive for the symptoms mentioned in the history of the presenting illness.  The patient himself is not able to give any history only source is the chart.  For details, please review the chart.,PHYSICAL EXAMINATION,VITAL SIGNS:  Blood pressure of 97/54, heart rate of 97, respiratory rate of 19, and temperature 98.5.  The patient on supplemental oxygen was FiO2 on 2 L 96%.  Limited physical examination.,HEENT:  Head, normocephalic and atraumatic.  Throat clear.  No discharge from the ear and the nose.  No discoloration of conjunctivae and the sclerae.,NECK:  Supple.  No signs of any meningismus.  Though a limited examination, the patient does appear to have arthritic changes, questioning contracture deformities, as not able to follow the commands to show full range of motion.  No bruit auscultated over the neck and the orbits.,LUNGS:  Clear to auscultation.,HEART:  Normal heart sounds.,ABDOMEN:  Benign.,EXTREMITIES:  No edema, clubbing or cyanosis.  No rash.  No leptomeningeal or neurocutaneous disorder.,NEUROLOGIC:  Examination is limited.  Mental state examination, the patient is awake, alert, and oriented to himself, not able follow commands, and give a proper history, and still appeared to be confuse and disoriented.  Cranial nerve examination limited, but apparently nonfocal.  Motor examination is very limited except for the grips, which were strong enough.  I was not able to obtain much.  Deep tendon reflexes were not reliable.  Toes equivocal and downgoing.  Sensory examination is not reliable, though intact for painful stimuli with limited examination.  Coordination could not be tested.  Gait could not be tested.,IMPRESSION:,  History of multiple myeloma and altered mental status in multiple myeloma setting.  Rule out brain metastasis including lepto-meningismus, possible transient ischemic attack related to hyperviscosity syndrome or provoked seizure related to ischemia, and delirium related to any electrolyte imbalance or underlying infarction.,PLAN AND RECOMMENDATIONS: , The patient is to continue with current level of management.  I will review the chart before ordering any further testing that may include a CT scan of the brain, if has not been ordered, EEG, urine test, and the latest CBC with diff. to rule out any urinary tract infection or indication of any other seen of infection.  No other intervention at this time.  The patient may be started on aspirin, if it is okay with Dr. X.",
 Occupational medicine consult with questions-answers and records review., Consult - History and Phy., Occupational Medicine Consult - 2 ,"ALLOWED CONDITIONS:,  726.31 right medial epicondylitis; 354.0 right carpal tunnel syndrome.,CONTESTED CONDITIONS:,  354.2 right cubital tunnel syndrome.,EMPLOYER:,  ABCD,  ,I examined Xxxxx today for the allowed conditions and also the contested conditions listed above.  I obtained her history from company medical records and performed an examination.  She is a 38-year-old laborer who states that she was injured on April 26, 2006, which according to the FROI (the injury occurred over a period of time from performing normal job processes such as putting bumpers on cars, gas caps and doors on cars).  She denies having any symptoms prior to the accident April 26, 2006.  She is right handed.  She used a tennis elbow brace, hand exercises, physical therapy, and Vicodin.  She received treatment from Dr. X and also Dr. Y,DIAGNOSTIC STUDIES:,  June 27, 2006, EMG and nerve conduction velocity right upper extremity showed a moderate right carpal tunnel syndrome.  No evidence of a right cervical radiculopathy or ulnar neuropathy at the wrist or elbow.  January 29, 2007, EMG right upper extremity was normal and there was a normal nerve conduction velocity.  At the time of the examination, she complained of a constant pain in the olecranon and distal triceps with tingling in the right long, ring and small fingers, and night pain.  The pain was accentuated by gripping or opening the jar.  She is taking four Aleve a day and currently does not have any other treatment.,RECORDS REVIEWED: , Injury and illness incident report, US Healthworks records; Z physician review; Y office notes; X office notes who noted that on examination of the right elbow that the ulnar nerve subluxed with flexion and extension of the elbow.,EXAMINATION: , Examination of her right elbow revealed no measurable atrophy of the upper arm.  She was markedly tender over the medial epicondyle, but also the olecranon and distal process and she was exquisitely tender over the ulnar nerve.  I did not detect subluxation of the ulnar nerve with flexion and extension.  With this, she was extremely tender in this area.  There is no instability of the elbow.  Range of motion was 0 to 145 degrees, flexion 90 degrees of pronation and supination.  The elbow flexion test was positive.  There is normal motor power in the elbow and also on the right hand, specifically in the ulnar intrinsics.  There was diminished sensation on the right ring and small fingers, specifically the ulnar side of the ring finger of the entire small finger.  There was no wasting of the intrinsics.  No clawing of the hand.  Examination of the right wrist revealed extension 45 degrees, flexion 45 degrees, radial deviation 15 degrees, and ulnar deviation 35 degrees.  She was tender over the dorsum of the hand over the ulnar head and the volar aspect of the wrist.  Wrist flexion causes paresthesias on the right ring and small fingers.  Grasp was weak.  There was no sign of causalgia, but no measurable atrophy of the forearm.  No reflex changes.,QUESTION:,  Ms. Xxxxx has filed an application of additional allowance of right cubital tunnel syndrome.  Based on the current objective findings, mechanism of injury, medical records or diagnostic studies, does the medical evidence support the existence of the requested condition?,ANSWER:,  Yes.  She has a positive elbow flexion test and she is markedly tender over the ulnar nerve at the elbow and also has diminished sensation in the ulnar nerve distribution, specifically in the entire right small finger and the ulnar half of the ring finger.  I did not find the subluxation of the ulnar nerve with flexion and extension with Dr. X did previously find on his examination.,QUESTION: , If you find these conditions exist, are they a direct and proximate result of April 26, 2006, injury?,ANSWER: , Yes.  Repeated flexion and extension would irritate the ulnar nerve particularly if it was subluxing which it could very well have which Dr. X objectively identified on his examination.  Therefore, I believe it is a direct and proximate result of April 26, 2006, injury.,QUESTION: , Do you find that Ms. Xxxxx's injury or disability is caused by natural deterioration of tissue, organ or part of the body?,ANSWER: , No.,QUESTION:,  In addition, if you find that the condition exists, are there non-occupational activities or intervening injuries that could have contributed to Ms. Xxxxx's condition?,ANSWER: , It is possible that direct injury to the ulnar nerve at the elbow could cause this syndrome; however, there is no history of this and the records do not indicate an injury of this type.,QUESTION: ,",
 Occupational medicine consult with questions-answers., Consult - History and Phy., Occupational Medicine Consult - 1 ,"ALLOWED CONDITIONS:,  Left knee strain, meniscus tear left knee.,CONTESTED CONDITION:,  Osteoarthritis of the left knee.,EMPLOYER:,  ABCD.,I examined Xxxxx today September 14, 2007, for the above allowed conditions and also the contested condition of osteoarthritis of his left knee.  He is a 57-year-old assembly worker who was injured on June 13, 2007, which according to his FROI was due to ""repairing cars, down on knees to work on concrete floors.""  In addition, he slipped on an air hose on the floor at work on March 7, 2007, re-injuring his left knee.  He developed pain and swelling in his left knee.  He denies having any difficulties with his left knee prior to the injury of June 13, 2002.,DIAGNOSTIC STUDIES: , August 2, 2002, MRI of the left knee showed low-grade chondromalacia of the left patellofemoral joint space and a posterior horn tear of the medial meniscus, likely degenerative in nature, and also grade II to III chondromalacia of the medial joint space.  On June 26, 2007, MRI of his left knee was referred to in the injury management report of June 19, 2007, as showing osteoarthritis of the medial compartment has advanced.  He brought with him copies of x-rays taken July 16, 2007, of his left knee, which I reviewed and which showed marked narrowing of the medial compartment of his left knee with spurs on the margins of the joint medially and also spurs on the patella.  There was subluxation of the tibia on the femur with standing.,After his injury, he received treatment from Dr. X for patellofemoral syndrome with knee sleeve.  He also received treatment from Dr. Y also for left knee sprain and patellar pain.  He also did exercise, does use a knee sleeve and Aleve.  On December 5, 2002, he underwent arthroscopy of the left knee by Dr. Z who did a partial resection of a torn medial meniscus.  He also noticed grade III chondromalacia of the patella as well as the torn medial meniscus.  He states that he was asymptomatic until he slipped on an air hose while at work on March 7, 2007, and again developed pain and swelling in his left knee.  Standing aggravates his pain.  He has had one injection of cortisone by Dr. Z about a month ago, which has helped his pain.  He takes one hydrocodone 7.5/750 mg daily.,Examination of his left knee revealed there was bilateral varus deformity, healed arthroscopy incisional scars, there was a 1/2 atrophy of the left calf.  There was patellar crepitus with knee motion.  There was no motor weakness or reflex changes.  He walked without a limp and could stand on his heels and toes equally well.  There was no instability of the knee and no effusion.  Range of motion was 0 to 120 degrees.,QUESTION: , Xxxxx has recently filed to reactivate this claim.  Please give me your opinion as to whether Xxxxx's current clinical presentation is related to the industrial injury stated above.,ANSWER:, Yes.  His original MRI of August 2, 2002, did show low-grade chondromalacia of the patellofemoral joint and also grade II to III chondromalacia of the medial joint space, which was the beginning of osteoarthritis.  Also, it is well known that torn medial meniscus can result in osteoarthritis of the knee; therefore, the osteoarthritis is related to his original injury of June 13, 2007, specifically to the torn medial meniscus.,QUESTION:  ,Do I believe that claim #123 should be reactivated to allow for treatment of the allowed conditions as stated?,ANSWER:, Yes, I believe it should be reactivated to allow treatment of the contested condition of osteoarthritis of his left knee.,QUESTION:,  Xxxxx has filed an application for additional allowance of osteoarthritis of the left knee.  Based on the current objective findings, mechanism of injury, medical records, and diagnostic studies, does the medical evidence support the existence of the requested condition?,ANSWER: ,Yes.  Please see the discussion in the answer to question no one.  In addition, x-rays of July 16, 2007, do reveal medial compartment and patellofemoral compartment osteoarthritis of the left knee.,QUESTION: , If you find this condition exists, is it a direct and proximate result of the June 13, 2002, injury?,ANSWER:, Yes.  See discussion in answer to question number one.,QUESTION: , Do you find that Xxxxx's injury or disability was caused by the natural deterioration of tissue, an organ or part of body?,ANSWER: ,No.  I believe the osteoarthritis was the result of the torn medial meniscus as discussed under question number one.,QUESTION: , In addition, if you find the condition exists, are there non-occupational activities or intervening injuries, which could have contributed to Xxxxx's condition?,ANSWER:, No.  He does not give any history of any intervening injuries.,If you opine the requested condition should be additionally recognized, please include the condition as an allowed condition in the discussion of the following questions.,QUESTION:,  Based on the objective findings is the request for 10 sessions of physical therapy per C-9 dated July 27, 2007, medically necessary and appropriate for the allowed conditions of the claim of osteoarthritis of left knee?,ANSWER:,  Yes.,",
 Pelvic Pain and vaginal discharge, Consult - History and Phy., OB/GYN Consultation - 4 ,"CHIEF COMPLAINT - REASON FOR VISIT: ,Pelvic Pain and vaginal discharge.,ABNORMAL PAP HISTORY:, Date of abnormal pap:  1998. Findings: High grade squamous intraepithelial lesions. Previous colposcopic exam and biopsies showed mild dysplasia or CIN 1. Patient is sexually active and has had 1 partner. There is no history of STD’s.,PELVIC PAIN HISTORY:, The patient complains of a gradual onset of pelvic pain 1 year ago and states condition is recurrent. Location of pain is left lower quadrant. Severity is moderately severe, intermittent and lasts for 2 hours. Quality of pain is crampy, sharp and variable.  Pain requires NSAIDs. Menstrual quality is light, flow lasts for 7 days and interval lasts for 28 days. There was no radiation of pain.,VAGINITIS HISTORY:, Symptoms have lasted for 2 weeks and persistent.  Discharge appears thin, white and with odor. Denies any itching sensation. Denies irritation. The patient denies any self treatment.,PERSONAL / SOCIAL HISTORY:, Tobacco history: Smoke’s 1 pack of cigarettes per day.  Denies the past history of alcohol. Denies past / present illegal drug use of any kind. Marital Status: Married.,PAST MEDICAL HISTORY:, Negative.,FAMILY MEDICAL HISTORY:, Negative.,ALLERGIES:, No known drug allergies/Intolerances.,CURRENT MEDICATIONS:, There are no current medications.,PAST SURGICAL HISTORY:, D & C.  1993,REVIEW OF SYSTEMS:,Gastrointestinal: The patient has no history of gastrointestinal problems and denies any present problems.,Genitourinary: Patient denies any genitourinary problems.,Gynecological: Refer to current history.,Pulmonary: Denies cough, dyspnea, tachypnea, hemoptysis.,GU: Denies frequency, nocturia and hematuria.,Neuro: Denies any problems, no seizures, no numbness, no dizziness.,PHYSICAL EXAMINATION:,Vital Signs: Weight:  104. BP:  100/70.,Chest: Lungs have equal bilateral expansion and are clear to percussion and auscultation.,Cardiovascular / Heart: Regular heart rate and rhythm without murmur or gallop.,Breast: No palpable masses.  No dimpling or retraction. No discharge. No axillary lymphadenopathy.,Abdomen: Tenderness is located in the left upper quadrant. Tenderness is mild. Bowel sounds are normal. No masses palpated.,Gynecologic: Inspection reveals the external genitalia to be normal anatomically. Cervix appears inflamed, bloody discharge and without aceto-white areas. Vagina appears normal. Vaginal discharge was white and watery.  Uterus is normal anteverted. The uterus is normal size and shape, tender to movement and movable. Bladder not tender. ,Rectal: No additional findings.,LAB / TESTS:, Hgb: 17.1 U/A: pH 6.0, spgr 1.025, trace protein, trace blood,IMPRESSION / DIAGNOSIS,1. Endometritis / Endomyometritis (615.9). ,2. Cervicitis - Endocervicitis (616.0). ,3. Pelvic Pain (625.9).,PLAN:, Pap smear done. Take metronidazole first then the Doxycycline. Return in three weeks for reevaluation.,MEDICATIONS PRESCRIBED: ,Metronidazole 500 mg #14 1 BID for 7 days.  Doxycycline 100 mg #14 1 BID.",
 A 17-year-old male with oligoarticular arthritis of his right knee., Consult - History and Phy., Oligoarticular Arthritis - 1 ,"HISTORY:,  A is here for a follow up appointment at our Pediatric Rheumatology Clinic as well as the CCS Clinic.  A is a 17-year-old male with oligoarticular arthritis of his right knee.  He had a joint injection back in 03/2007 and since then he has been doing relatively well.  He is taking Indocin only as needed even though he said he has pain regularly, and he said that his knee has not changed since the beginning, but he said he only takes the medicine when he has pain, which is not every day, but almost every day.  He denies any swelling more than what it was before, and he denies any other joints are affected at this moment.  Denies any fevers or any rashes.,PHYSICAL EXAMINATION:,  On physical examination, his temperature is 98.6, weight is 104.6 kg; which is 4.4 kg less than before, 108/70 is his blood pressure, weight is 91.0 kg, and his pulse is 80.  He is alert, active, and oriented in no distress.  He has no facial rashes, no lymphadenopathy, no alopecia.  Funduscopic examination is within normal limit.  He has no cataracts and symmetric pupils to light and accommodation.  His chest is clear to auscultation.  The heart has a regular rhythm with no murmur.  The abdomen is soft and nontender with no :  visceromegaly.  Musculoskeletal examination showed good range of motion of all his upper extremities with no swelling or tenderness.  Lower extremities:  He still has some weakness of the knees, hip areas, and the calf muscles.  He does have minus/plus swelling of the right knee with a very hypermobile patella.  There is no limitation in his range of motion, and the swelling is very minimal with some mild tenderness.,In terms of his laboratories, they were not done today.,ASSESSMENT: , This is a 17-year-old male with oligoarticular arthritis.  He is HLA-B27 negative.,PLAN:,  In terms of the plan, I discussed with him what things he should be taking and the fact that since he has persistent symptoms, he should be on medication every day.  I am going to switch him to Indocin 75 mg SR just to give more sustained effect to his joints, and if he does not respond to this or continue with the symptoms, we may need to get an MRI.  We will see him back in three months.  He was evaluated by our physical therapist, who gave him some recommendations in terms of exercise for his lower extremities.  Future plans for A may include physical therapy and more stronger medications as well as imaging studies with an MRI.  Today he received his flu shot.  Discussed this with A and his aunt and they had no further questions.","consult - history and phy., rheumatology, rheumatology clinic, lower extremities, oligoarticular arthritis, arthritis, oligoarticular, knee, swelling,"
 Consultation for an ASCUS Pap smear., Consult - History and Phy., OB/GYN Consultation - 3 ,"Pap smear in November 2006 showed atypical squamous cells of undetermined significance.  She has a history of an abnormal Pap smear.  At that time, she was diagnosed with CIN 3 as well as vulvar intraepithelial neoplasia.  She underwent a cone biopsy that per her report was negative for any pathology.  She had no vulvar treatment at that time.  Since that time, she has had normal Pap smears.  She denies abnormal vaginal bleeding, discharge, or pain.  She uses Yaz for birth control.  She reports one sexual partner since 1994 and she is a nonsmoker.,She states that she has a tendency to have yeast infections and bacterial vaginosis.  She is also being evaluated for a possible interstitial cystitis because she gets frequent urinary tract infections.  She had a normal mammogram done in August 2006 and a history of perirectal condyloma that have been treated by Dr. B.  She also has a history of chlamydia when she was in college.,PAST MEDICAL HX: , Depression.,PAST SURGICAL HX: , None.,MEDICATIONS: , Lexapro 10 mg a day and Yaz.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,OB HX: , Normal spontaneous vaginal delivery at term in 2001 and 2004, Abc weighed 8 pounds 7 ounces and Xyz weighed 10 pounds 5 ounces.,FAMILY HX:  ,Maternal grandfather who had a MI which she reports is secondary to tobacco and alcohol use.  He currently has metastatic melanoma, mother with hypertension and depression, father with alcoholism.,SOCIAL HX:,  She is a public relations consultant.  She is a nonsmoker, drinks infrequent alcohol and does not use drugs.  She enjoys horseback riding and teaches jumping.,PE: , VITALS: Height: 5 feet 6 inches.  Weight: 139 lb.  BMI: 22.4.  Blood Pressure: 102/58.  GENERAL: She is well-developed and well-nourished with normal habitus and no deformities.  She is alert and oriented to time, place, and person and her mood and affect is normal.  NECK: Without thyromegaly or lymphadenopathy.  LUNGS: Clear to auscultation bilaterally.  HEART: Regular rate and rhythm without murmurs.  BREASTS: Deferred.  ABDOMEN: Soft, nontender, and nondistended.  There is no organomegaly or lymphadenopathy.  PELVIC: Normal external female genitalia.  Vulva, vagina, and urethra, within normal limits.  Cervix is status post cone biopsy; however, the transformation zone grossly appears normal and cervical discharge is clear and normal in appearance.  GC and chlamydia cultures as well as a repeat Pap smear were done.,Colposcopy is then performed without and with acetic acid.  This shows an entirely normal transformation zone, so no biopsies are taken.  An endocervical curettage is then performed with Cytobrush and curette and sent to pathology.  Colposcopy of the vulva is then performed again with acetic acid.  There is a thin strip of acetowhite epithelium located transversely on the clitoral hood that is less than a centimeter in diameter.  There are absolutely no abnormal vessels within this area.  The vulvar colposcopy is completely within normal limits.,A/P: , ASCUS Pap smear with history of a cone biopsy in 1993 and normal followup.,We will check the results of the Pap smear, in addition we have ordered DNA testing for high-risk HPV.  We will check the results of the ECC.  She will return in two weeks for test results.  If these are normal, she will need two normal Pap smears six months apart, and I think followup colposcopy for the vulvar changes.","consult - history and phy., lmp, ascus, pap smear, abnormal pap smear, atypical, bacterial vaginosis, chlamydia, cone biopsy, infection, interstitial cystitis, intraepithelial, mammogram, neoplasia, perirectal condyloma, squamous, vaginal bleeding, vulvar, yeast infection, pap smears, pap, ob/gyn, colposcopy, smear,"
" Female referred for evaluation of an abnormal colposcopy, low-grade Pap with suspicious high-grade features.", Consult - History and Phy., OB/GYN Consultation - 1 ,"PAST MEDICAL HX: , Significant for asthma, pneumonia, and depression.,PAST SURGICAL HX: , None.,MEDICATIONS:,  Prozac 20 mg q.d.  She desires to be on the NuvaRing.,ALLERGIES:,  Lactose intolerance.,SOCIAL HX: , She denies smoking or alcohol or drug use.,PE:,  VITALS: Stable.  Weight: 114 lb.  Height: 5 feet 2 inches.  GENERAL: Well-developed, well-nourished female in no apparent distress.  HEENT: Within normal limits. NECK: Supple without thyromegaly.  HEART: Regular rate and rhythm.  LUNGS: Clear to auscultation.  ABDOMEN: Soft and nontender.  There is no rebound or guarding.  No palpable masses and no peritoneal signs.  EXTREMITIES: Within normal limits.  SKIN: Warm and dry.  GU: External genitalia is without lesion.  Vaginal is clean without discharge.  Cervix appears normal; however, a colposcopy was performed using acetic acid, which showed a thick acetowhite ring around the cervical os and extending into the canal.  BIMANUAL: Reveals significant cervical motion tenderness and fundal tenderness.  She had no tenderness in her adnexa.  There are no palpable masses.,A:,  Although unlikely based on the patient's exam and pain, I have to consider subclinical pelvic inflammatory disease.  GC and chlamydia was sent and I treated her prophylactically with Rocephin 250 mg and azithromycin 1000 mg.  Repeat biopsies were not performed based on her colposcopy as well as her previous Pap and colposcopy by Dr. A.  A LEEP is a reasonable approach even in this 16-year-old.,P:,  We will schedule LEEP in the near future.  Even though she has already been exposed HPV Gardasil would still be beneficial in this patient to help prevent recurrence of low-grade lesions as well as high-grade lesions.  Now, we have her given her first shot.","consult - history and phy., gravida, ecc, external genitalia, hpv, leep, pap, acetowhite, biopsies, blood with urination, cervical os, colposcopy, intraepithelial, right lower quadrant, squamous, suspicious, vaginal discharge, low grade pap, low grade,"
 Occupational medicine consult with questions-answers and records review., Consult - History and Phy., Occupational Medicine Consult ,"ALLOWED CONDITION: , Right shoulder sprain and right rotator cuff tear (partial).,CONTESTED CONDITION:,  AC joint arthrosis right aggravation.,DISALLOWED CONDITION: ,",
" Normal review of systems template.  No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter.", Consult - History and Phy., Normal ROS Template - 3 ,"HEENT:,  No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter.,RESPIRATORY: , No shortness of breath, wheezing, dyspnea, pulmonary disease, tuberculosis or past pneumonias.,CARDIOVASCULAR: , No history of palpitations, irregular rhythm, chest pain, hypertension, hyperlipidemia, diaphoresis, congestive heart failure, heart catheterization, stress test or recent cardiac tests.,GASTROINTESTINAL:,  No history of rectal bleeding, appetite change, abdominal pain, hiatal hernia, ulcer, jaundice, change in bowel habits or liver problems, and no history of inflammatory bowel problems.,GENITOURINARY: , No dysuria, hematuria, frequency, incontinence or colic.,NERVOUS SYSTEM: , No gait problems, strokes, numbness or muscle weakness.,PSYCHIATRIC: , No history of emotional lability, depression or sleep disturbances.,ONCOLOGIC:,  No history of any cancer, change in moles or rashes.  No history of weight loss.  The patient has a good energy level.,ALLERGIC/LYMPH: , No history of systemic allergy, abnormal lymph nodes or swelling.,MUSCULOSKELETAL: , No fractures, motor weakness, arthritis or other joint pains.","consult - history and phy., review of systems, tinnitus, sinusitis, sore, mouth, hoarseness, goiter, heart, appetite, bowel, weakness, loss, swelling,"
 Consultation because of irregular periods and ovarian cyst., Consult - History and Phy., OB/GYN Consultation - 2 ,"She started her periods at age 13.  She is complaining of a three-month history of lower abdominal pain for which she has been to the emergency room twice.  She describes the pain as bilateral, intermittent, and non-radiating.  It decreases slightly when she eats and increases with activity.  She states the pain when it comes can last for half-a-day.  It is not associated with movement, but occasionally the pain was so bad that it was associated with vomiting.  She has tried LactAid, which initially helped, but then the pain returned.  She has tried changing her diet and Pepcid AC.  She was seen at XYZ where blood work was done.  At that time, she had a normal white count and a normal H&H.  She was given muscle relaxants, which did not work.,Approximately two weeks ago, she was seen in the emergency room at XYZ where a pelvic ultrasound was done.  This showed a 1.9 x 1.4-cm cyst on the right with no free fluid.  The left ovary and uterus appeared normal.  Two days later, the pain resolved and she has not had a recurrence.  She denies constipation and diarrhea.  She has had some hot flashes, but has not taken her temperature.,In addition, she states that her periods have been very irregular coming between four and six weeks.  They are associated with cramping which she is not happy about.,She has never had a pelvic exam.  She states she is not sexually active and declined having her mother leave the room, so she was not questioned regarding this without her mother present.  She is very interested in not having pain with her periods and if this was a cyst that caused her pain, she is interested in starting birth control pills to prevent this from happening again.,PAST MEDICAL HX:  ,Pneumonia in 2002, depression diagnosed in 2005, and seizures as an infant.,PAST SURGICAL HX:  ,Plastic surgery on her ear after a dog bite in 1997.,MEDICATIONS:  ,Zoloft 50 mg a day and LactAid.,ALLERGIES:  ,NO KNOWN DRUG ALLERGIES.,SOCIAL HX: , She enjoys cooking and scrapbooking.  She does have a boyfriend; again she states she is not sexually active.  She also states that she exercises regularly, does not smoke cigarettes, use drugs, or drink alcohol.,FAMILY HX: , Significant for her maternal grandfather with adult-onset diabetes, a maternal grandmother with hypertension, mother with depression, and a father who died of colon cancer at 32 years of age.  She also has a paternal great grandfather who was diagnosed with colon cancer.,PE: , VITALS: Height: 5 feet 5 inches.  Weight: 190 lb.  Blood Pressure: 120/88.  GENERAL: She is well-developed, well-nourished with normal habitus and no deformities.  NECK: Without thyromegaly or lymphadenopathy.  LUNGS: Clear to auscultation bilaterally.  HEART: Regular rate and rhythm without murmurs.  ABDOMEN: Soft, nontender, and nondistended.  There is no organomegaly or lymphadenopathy.  PELVIC: Deferred.,A/P: , Abdominal pain, unclear etiology.  I expressed my doubt that her pain was secondary to this 1.9-cm ovarian cyst given the fact that there was no free fluid surrounding this.  However, given that she has irregular periods and they are painful for her, I think it is reasonable to start her on a low-dose birth control pill.  She has no personal or familial contraindications to start this.  She was given a prescription for Lo/Ovral, dispensed 30 with refill x 4.  She will come back in six weeks for blood pressure check as well as in six months to followup on her pain and her bleeding patterns.,If she should have the recurrence of her pain, I have advised her to call.","consult - history and phy., irregular periods, lactaid, abdominal pain, birth control pills, cyst, ovarian cyst, ovaries, ovary, pelvic exam, sexually active, uterus, lymphadenopathy, pelvic, irregular, periods"
 A 93-year-old female called up her next-door neighbor to say that she was not feeling well.  The patient was given discharge instructions on dementia and congestive heart failure and asked to return to the emergency room should she have any new problems or symptoms of concern., Consult - History and Phy., Not Feeling Well - ER Visit ,"CHIEF COMPLAINT:  ,The patient does not have any chief complaint.,HISTORY OF PRESENT ILLNESS:,  This is a 93-year-old female who called up her next-door neighbor to say that she was not feeling well.  The next-door neighbor came over and decided that she should go to the emergency room to be check out for her generalized complaint of not feeling well.  The neighbor suspects that this may have been due to the patient taking too many of her Tylenol PM, which the patient has been known to do.  The patient was a little somnolent early this morning and was found only to be oriented x1 with EMS upon their arrival to the patient's house.  The patient states that she just simply felt funny and does not give any more specific details than this.  The patient denies any pain at any time.  She did not have any shortness of breath.  No nausea or vomiting.  No generalized weakness.  The patient states that all that has gone away since arrival here in the hospital, that she feels at her usual self, is not sure why she is here in the hospital, and thinks she should go.  The patient's primary care physician, Dr. X reports that the patient spoke with him yesterday and had complained of shortness of breath, nausea, dizziness, as well as generalized weakness, but the patient states that all this has resolved.  The patient was actually seen here two days ago for those same symptoms and was found to have exacerbation of her COPD and CHF.  The patient was discharged home after evaluation in the emergency room.  The patient does use home O2.,REVIEW OF SYSTEMS: , CONSTITUTIONAL:  The patient had complained of generalized fatigue and weakness two days ago in the emergency room and yesterday to her primary care physician.  The patient denies having any other symptoms today.  The patient denies any fever or chills.  Has not had any recent weight change.  HEENT:  The patient denies any headache.  No neck pain.  No rhinorrhea.  No sinus congestion.  No sore throat.  No any vision or hearing change.  No eye or ear pain.  CARDIOVASCULAR:  The patient denies any chest pain.  RESPIRATIONS:  No shortness of breath.  No cough.  No wheeze.  The patient did report having shortness of breath and wheeze with her presentation to the emergency room two days ago and shortness of breath to her primary care physician yesterday, but the patient states that all this has resolved.  GASTROINTESTINAL:  No abdominal pain.  No nausea or vomiting.  No change in the bowel movements.  There has not been any diarrhea or constipation.  No melena or hematochezia.  GENITOURINARY:  No dysuria, hematuria, urgency, or frequency.  MUSCULOSKELETAL:  No back pain.  No muscle or joint aches.  No pain or abnormalities to any portion of the body.  SKIN:  No rashes or lesions.  NEUROLOGIC:  The patient reported dizziness to her primary care physician yesterday over the phone, but the patient denies having any problems with dizziness over the past few days.  The patient denies any dizziness at this time.  No syncope or no near-syncope.  The patient denies any focal weakness or numbness.  No speech change.  No difficulty with ambulation.  The patient has not had any vision or hearing change.  PSYCHIATRIC:  The patient denies any depression.  ENDOCRINE:  No heat or cold intolerance.,PAST MEDICAL HISTORY:,  COPD, CHF, hypertension, migraines, previous history of depression, anxiety, diverticulitis, and atrial fibrillation.,PAST SURGICAL HISTORY:,  Placement of pacemaker and hysterectomy.,CURRENT MEDICATIONS: , The patient takes Tylenol PM for insomnia, Lasix, Coumadin, Norvasc, Lanoxin, Diovan, atenolol, and folic acid.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient used to smoke, but quit approximately 30 years ago.  The patient denies any alcohol or drug use although her son reports that she has had a long history of this in the past and the patient has abused prescription medication in the past as well according to her son.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Temperature 99.1 oral, blood pressure 139/65, pulse is 72, respirations 18, and oxygen saturation is 92% on room air and interpreted as low normal.  CONSTITUTIONAL:  The patient is well nourished and well developed.  The patient appears to be healthy.  The patient is calm, comfortable, in no acute distress, and looks well.  The patient is pleasant and cooperative.  HEENT:  Head is atraumatic, normocephalic, and nontender.  Eyes are normal with clear sclerae and cornea bilaterally.  Nose is normal without rhinorrhea or audible congestion.  Mouth and oropharynx are normal without any sign of infection.  Mucous membranes are moist.  NECK:  Supple and nontender.  Full range of motion.  There is no JVD.  No cervical lymphadenopathy.  No carotid artery or vertebral artery bruits.  CARDIOVASCULAR:  Heart is regular rate and rhythm without murmur, rub or gallop.  Peripheral pulses are +2.  The patient does have +1 bilateral lower extremity edema.  RESPIRATIONS:  The patient has coarse breath sounds bilaterally, but no dyspnea.  Good air movement.  No wheeze.  No crackles.  The patient speaks in full sentences without any difficulty.  The patient does not exhibit any retractions, accessory muscle use or abdominal breathing.  GASTROINTESTINAL:  Abdomen is soft, nontender, and nondistended.  No rebound or guarding.  No hepatosplenomegaly.  Normal bowel sounds.  No bruits, no mass, no pulsatile mass, and no inguinal lymphadenopathy.  MUSCULOSKELETAL:  No abnormalities noted to the back, arms or legs.  SKIN:  No rashes or lesions.  NEUROLOGICAL:  Cranial nerves II through XII are intact.  Motor is 5/5 and equal to bilateral arms and legs.  Sensory is intact to light touch.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is awake, alert, and oriented x3 although the patient first stated that the year was 1908, but did manage to correct herself up on addressing this with her.  The patient has normal mood and affect.  HEMATOLOGIC AND LYMPHATIC:  There is no evidence of lymphadenopathy.,EMERGENCY DEPARTMENT TESTING: , EKG is a rate of 72 with evidence of a pacemaker that has good capture.  There is no evidence of acute cardiac disease on the EKG and there is no apparent change in the EKG from 03/17/08.  CBC has no specific abnormalities of issue.  Chemistry has a BUN of 46 and creatinine of 2.25, glucose is 135, and an estimated GFR is 20.  The rest of the values are normal and unremarkable.  LFTs are all within normal limits.  Cardiac enzymes are all within normal limits.  Digoxin level is therapeutic at 1.6.  Chest x-ray noted cardiomegaly and evidence of congestive heart failure, but no acute change from her chest x-ray done two days ago.  CAT scan of the head did not identify any acute abnormalities.  I spoke with the patient's primary care physician, Dr. X who stated that he would be able to follow up with the patient within the next day.  I spoke with the patient's neighbor who contacted the ambulance service who stated that the patient just reported not feeling well and appeared to be a little somnolent and confused at the time, but suspected that she may have taken too many of her Tylenol PM as she often has done in the past.  The neighbor is XYZ and he says that he checks on her three times a day every day.  ABC is the patient's son and although he lives out of town he calls and checks on her every day as well.  He states that he spoke to her yesterday.  She sounded fine, did not express any other problems that she had apparently been in contact with her primary care physician.  She sounded her usual self to him.  Mr. ABC also spoke to the patient while she was here in the emergency room and she appears to be her usual self and has her normal baseline mental status to him.  He states that he will be able to check on her tomorrow as well.  Although it is of some concern that there may be problems with development of some early dementia, the patient is adamant about not going to a nursing home and has been placed in a Nursing Home in the past, but Dr. Y states that she has managed to be discharged after two previous nursing home placements.  The patient does have Home Health that checks on her as well as housing care in between the two services they share visits every single day  by them as well as the neighbor who checks on her three times a day and her son who calls her each day as well.  The patient although she lives alone, does appear to have good followup and the patient is adamant that she wishes to return home.,DIAGNOSES,1.  EARLY DEMENTIA.,2.",
" Negative for any nausea, vomiting, fevers, chills, or weight loss.", Consult - History and Phy., Normal ROS Template - 4 ,"GENERAL:  Negative for any nausea, vomiting, fevers, chills, or weight loss.,NEUROLOGIC:  Negative for any blurry vision, blind spots, double vision, facial asymmetry, dysphagia, dysarthria, hemiparesis, hemisensory deficits, vertigo, ataxia.,HEENT:  Negative for any head trauma, neck trauma, neck stiffness, photophobia, phonophobia, sinusitis, rhinitis.,CARDIAC:  Negative for any chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, peripheral edema.,PULMONARY:  Negative for any shortness of breath, wheezing, COPD, or TB exposure.,GASTROINTESTINAL:  Negative for any abdominal pain, nausea, vomiting, bright red blood per rectum, melena.,GENITOURINARY:  Negative for any dysuria, hematuria, incontinence.,INTEGUMENTARY:  Negative for any rashes, cuts, insect bites.,RHEUMATOLOGIC:  Negative for any joint pains, photosensitive rashes, history of vasculitis or kidney problems.,HEMATOLOGIC:  Negative for any abnormal bruising, frequent infections or bleeding.","consult - history and phy., review of systems, trauma, neck, dyspnea, rashes, nausea, vomiting, "
" Normal review of systems template.  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.", Consult - History and Phy., Normal ROS Template - 5 ,"REVIEW OF SYSTEMS,GENERAL:  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.,INTEGUMENTARY:  Negative rash, negative jaundice.,HEMATOPOIETIC:  Negative bleeding, negative lymph node enlargement, negative bruisability.,NEUROLOGIC:  Negative headaches, negative syncope, negative seizures, negative weakness, negative tremor.  No history of strokes, no history of other neurologic conditions.,EYES:  Negative visual changes, negative diplopia, negative scotomata, negative impaired vision.,EARS:  Negative tinnitus, negative vertigo, negative hearing impairment.,NOSE AND THROAT:  Negative postnasal drip, negative sore throat.,CARDIOVASCULAR:  Negative chest pain, negative dyspnea on exertion, negative palpations, negative edema.  No history of heart attack, no history of arrhythmias, no history of hypertension.,RESPIRATORY:  No history of shortness of breath, no history of asthma, no history of chronic obstructive pulmonary disease, no history of obstructive sleep apnea.,GASTROINTESTINAL:  Negative dysphagia, negative nausea, negative vomiting, negative hematemesis, negative abdominal pain.,GENITOURINARY:  Negative frequency, negative urgency, negative dysuria, negative incontinence.  No history of STDs.  **No history of OB/GYN problems.,MUSCULOSKELETAL:  Negative myalgia, negative joint pain, negative stiffness, negative weakness, negative back pain.,PSYCHIATRIC:  See psychiatric evaluation.,ENDOCRINE:  No history of diabetes mellitus, no history of thyroid problems, no history of endocrinologic abnormalities.","consult - history and phy., respiratory, gastrointestinal, integumentary, hematopoietic, night sweats, negative allergies, negative weakness, neurologic, throat, weakness"
 Initial obstetrical examination - Normal first pregnancy.  Inadequate naternal nutrition., Consult - History and Phy., OB/GYN - H&P ,"CHIEF COMPLAINT,:  This 32 year-old female presents today for an initial obstetrical examination.  Home pregnancy test was positive.,The patient indicates fetal activity is not yet detected (due to early stage of pregnancy).  LMP:  02/13/2002 EDD:  11/20/2002 GW:  8.0 weeks.  Patient has been trying to conceive for 6 months.,Menses:  Onset:  12 years old.  Interval:  24-26 days.  Duration:  4-6 days.  Flow:  moderate.  Complications:  PMS - mild.,Last Pap smear taken on 11/2/2001.  Contraception:  Patient is currently using none.,ALLERGIES:,  Patient admits allergies to venom - bee/wasp resulting in difficulty breathing, severe rash, pet dander resulting in nasal stuffiness.  Medication History:  None.,PAST MEDICAL HISTORY:,  Past medical history is unremarkable.  Past Surgical History:  Patient admits past surgical history of tonsillectomy in 1980.  Social History:  Patient admits alcohol use Drinking is described as social, Patient denies illegal drug use, Patient denies STD history, Patient denies tobacco use.,FAMILY HISTORY:,  Patient admits a family history of cancer of breast associated with mother.,REVIEW OF SYSTEMS:,Neurological: (+) unremarkable.,Respiratory: (+) difficulty sleeping, (-) breathing difficulties, respiratory symptoms.,Psychiatric: (+) anxious feelings.,Cardiovascular: (-) cardiovascular problems or chest symptoms.,Genitourinary: (-) decreased libido, (-) vaginal dryness, (-) vaginal bleeding.  Diet is high in empty calories, high in fats and low in fiber.,PHYSICAL EXAM:,  BP Standing:  126/84 Resp:  22 HR:  78 Temp:  99.1 Height:  5 ft.  6 in.  Weight:  132 lbs.,Pre-Gravid Weight is 125 lbs.,Patient is a 32 year old female who appears pleasant, in no apparent distress, her given age, well developed,,well nourished and with good attention to hygiene and body habitus.,Oriented to person, place and time.,Mood and affect normal and appropriate to situation.,HEENT:Head & Face:  Examination of head and face is unremarkable.,Skin:  No skin rash, subcutaneous nodules, lesions or ulcers observed.  No edema observed.,Cardiovascular:  Heart auscultation reveals no murmurs, gallop, rubs or clicks.,Respiratory:  Lungs CTA.,Breast:  Chest (Breasts):  Breast inspection and palpation shows no abnormal findings.,Abdomen:  Abdomen soft, nontender, bowel sounds present x 4 without palpable masses.,Genitourinary:  External genitalia are normal in appearance.  Examination of urethra shows no abnormalities.  Examination of vaginal vault reveals no abnormalities.  Cervix shows no pathology.  Uterine portion of bimanual exam reveals contour normal, shape regular and size normal.  Adnexa and parametria show no masses, tenderness, organomegaly or nodularity.  Examination of anus and perineum shows no abnormalities.,TEST RESULTS: , Urine pregnancy test:  positive. CBC results within normal limits.  Blood type:  O positive.  Rh:  positive.  FBS:  88 mg/dl.,IMPRESSION:,  Pregnancy, normal first.  Maternal nutrition is inadequate for protein and poor and high in empty calories and junk foods and sweets.,PLAN:,  Pap smear submitted for manual screening.  Ordered CBC.  Ordered blood type.  Ordered hemoglobin.  Ordered Rh.,Ordered fasting blood glucose.,COUNSELING:,  Counseling was given regarding adverse effects of alcohol, physical activity and sexual activity.  Educational supplies dispensed to patient.,Return to clinic in 4 week (s).,PRESCRIPTIONS:,  NatalCare Plus Dosage:  Prenatal Multivitamins tablet Sig:  QD Dispense:  60 Refills:  4 Allow Generic:  Yes,PATIENT INSTRUCTIONS:,  Patient received written information regarding pre-eclampsia and eclampsia.  Patient was instructed to restrict activity.  Patient instructed to limit caffeine use.  Patient instructed to limit salt intake.",
" There was no weight loss, fevers, chills, sweats.  There is no blurring of the vision, itching, throat or neck pain, or neck fullness.  There is no vertigo or hoarseness or painful swallowing. ", Consult - History and Phy., Normal ROS Template - 1 ,"REVIEW OF SYSTEMS,There was no weight loss, fevers, chills, sweats.  There is no blurring of the vision, itching, throat or neck pain, or neck fullness.  There is no vertigo or hoarseness or painful swallowing.  There is no chest pain, shortness of breath, paroxysmal nocturnal dyspnea, or chest pain with exertion.  There is no shortness of breath and no cough or hemoptysis.  No melena, nausea, vomiting, dysphagia, abdominal pain, diarrhea, constipation or blood in the stools.  No dysuria, hematuria or excessive urination.  No muscle weakness or tenderness.  No new numbness or tingling.  No arthralgias or arthritis.  There are no rashes.  No excessive fatigability, loss of motor skills or sensation.  No changes in hair texture, change in skin color, excessive or decreased appetite.  No swollen lymph nodes or night sweats.  No headaches.  The rest of the review of systems is negative.","consult - history and phy., weight loss, fevers, chills, sweats, melena, nausea, vomiting, dysphagia, abdominal pain, diarrhea, constipation, itching throat, neck fullness, painful swallowing, breath, loss, neckNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Normal review of systems template.  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.", Consult - History and Phy., Normal ROS Template - 2 ,"GENERAL:,  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.,INTEGUMENTARY: , Negative rash, negative jaundice.,HEMATOPOIETIC: , Negative bleeding, negative lymph node enlargement, negative bruisability.,NEUROLOGIC: , Negative headaches, negative syncope, negative seizures, negative weakness, negative tremor.  No history of strokes, no history of other neurologic conditions.,EYES:,  Negative visual changes, negative diplopia, negative scotomata, negative impaired vision.,EARS: , Negative tinnitus, negative vertigo, negative hearing impairment.,NOSE AND THROAT:  ,Negative postnasal drip, negative sore throat.,CARDIOVASCULAR: , Negative chest pain, negative dyspnea on exertion, negative palpations, negative edema.  No history of heart attack, no history of arrhythmias, no history of hypertension.,RESPIRATORY:,  No history of shortness of breath, no history of asthma, no history of chronic obstructive pulmonary disease, no history of obstructive sleep apnea.,GASTROINTESTINAL: , Negative dysphagia, negative nausea, negative vomiting, negative hematemesis, negative abdominal pain.,GENITOURINARY: , Negative frequency, negative urgency, negative dysuria, negative incontinence.  No history of STDs.,MUSCULOSKELETAL:,  Negative myalgia, negative joint pain, negative stiffness, negative weakness, negative back pain.,PSYCHIATRIC: , See psychiatric evaluation.,ENDOCRINE: , No history of diabetes mellitus, no history of thyroid problems, no history of endocrinologic abnormalities.","consult - history and phy., nose and throat, cardiovascular, integumentary, negative weakness, neurologic, throat, psychiatric, weakness, "
 Most commonly used phrases in physical exam., Consult - History and Phy., Normal Physical Exam Template - 7 ,"EYES: , The conjunctivae are clear.  The lids are normal appearing without evidence of chalazion or hordeolum.  The pupils are round and reactive.  The irides are without any obvious lesions noted.  Funduscopic examination shows sharp disk margins.  There are no exudates or hemorrhages noted.  The vessels are normal appearing.,EARS, NOSE, MOUTH AND THROAT:,  The nose is without any evidence of any deformity.  The ears are with normal-appearing pinna.  Examination of the canals is normal appearing bilaterally.  There is no drainage or erythema noted.  The tympanic membranes are normal appearing with pearly color, normal-appearing landmarks and normal light reflex.  Hearing is grossly intact to finger rubbing and whisper.  The nasal mucosa is moist.  The septum is midline.  There is no evidence of septal hematoma.  The turbinates are without abnormality.  No obvious abnormalities to the lips.  The teeth are unremarkable.  The gingivae are without any obvious evidence of infection.  The oral mucosa is moist and pink.  There are no obvious masses to the hard or soft palate.  The uvula is midline.  The salivary glands appear unremarkable.  The tongue is midline.  The posterior pharynx is without erythema or exudate.  The tonsils are normal appearing.,NECK:,  The neck is nontender and supple.  The trachea is midline.  The thyroid is without any evidence of thyromegaly.  No obvious adenopathy is noted to the neck.,RESPIRATORY: , The patient has normal respiratory effort.  There is normal lung excursion.  Percussion of the chest is without any obvious dullness.  There is no tactile fremitus or egophony noted.  There is no tenderness to the chest wall or ribs.  There are no obvious abnormalities.  The lungs are clear to auscultation.  There are no wheezes, rales or rhonchi heard.  There are no obvious rubs noted.,CARDIOVASCULAR: , There is a normal PMI on palpation.  I do not hear any obvious abnormal sounds.  There are no obvious murmurs.  There are no rubs or gallops noted.  The carotid arteries are without bruit.  No obvious thrill is palpated. There is no evidence of enlarged abdominal aorta to palpation.  There is no abdominal mass to suggest enlargement of the aorta.  Good strong femoral pulses are palpated.  The pedal pulses are intact.  There is no obvious edema noted to the extremities.  There is no evidence of any varicosities or phlebitis noted.,GASTROINTESTINAL: , The abdomen is soft.  Bowel sounds are present in all quadrants.  There are no obvious masses.  There is no organomegaly, and no liver or spleen is palpable.  No obvious hernia is noted.  The perineum and anus are normal in appearance.  There is good sphincter tone and no obvious hemorrhoids are noted.  There are no masses.  On digital examination, there is no evidence of any tenderness to the rectal vault; no lesions are noted.  Stool is brown and guaiac negative.,GENITOURINARY (FEMALE): , The external genitalia is normal appearing with no obvious lesions, no evidence of any unusual rash.  The vagina is normal in appearance with normal-appearing mucosa.  The urethra is without any obvious lesions or discharge.  The cervix is normal in color with no obvious cervical discharge.  There are no obvious cervical lesions noted.  The uterus is nontender and small, and there is no evidence of any adnexal masses or tenderness.  The bladder is nontender to palpation.  It is not enlarged.,GENITOURINARY (MALE): , Normal scrotal contents are noted.  The testes are descended and nontender.  There are no masses and no swelling to the epididymis noted.  The penis is without any lesions.  There is no urethral discharge.  Digital examination of the prostate reveals a nontender, non-nodular prostate.,BREASTS:,  The breasts are normal in appearance.  There is no puckering noted.  There is no evidence of any nipple discharge.  There are no obvious masses palpable.  There is no axillary adenopathy.  The skin is normal appearing over the breasts.,LYMPHATICS: , There is no evidence of any adenopathy to the anterior cervical chain.  There is no evidence of submandibular nodes noted.  There are no supraclavicular nodes palpable.  The axillae are without any abnormal nodes.  No inguinal adenopathy is palpable.  No obvious epitrochlear nodes are noted.,MUSCULOSKELETAL/EXTREMITIES: , The patient has normal gait and station.  The patient has normal muscle strength and tone to all extremities.  There is no obvious evidence of any muscle atrophy.  The joints are all stable.  There is no evidence of any subluxation or laxity to any of the joints.  There is no evidence of any dislocation.  There is good range of motion of all extremities without any pain or tenderness to the joints or extremities.  There is no evidence of any contractures or crepitus.  There is no evidence of any joint effusions.  No obvious evidence of erythema overlying any of the joints is noted.  There is good range of motion at all joints.  There are normal-appearing digits.  There are no obvious lesions to any of the nails or nail beds.,SKIN:,  There is no obvious evidence of any rash.  There are no petechiae, pallor or cyanosis noted.  There are no unusual nodules or masses palpable.,NEUROLOGIC: , The cranial nerves II XII are tested and are intact.  Deep tendon reflexes are symmetrical bilaterally.  The toes are downgoing with normal Babinskis.  Sensation to light touch is intact and symmetrical.  Cerebellar testing reveals normal finger nose, heel shin.  Normal gait.  No ataxia.,PSYCHIATRIC:  ,The patient is oriented to person, place and time.  The patient is also oriented to situation.  Mood and affect are appropriate for the present situation.  The patient can remember 3 objects after 3 minutes without any difficulties.  Remote memory appears to be intact.  The patient seems to have normal judgment and insight into the situation.","consult - history and phy., ears, nose, mouth, neck, respiratory, cardiovascular, eyes, gastrointestinal, genitourinary, breasts, lymphatics, musculoskeletal, extremities, skin, neurologic, psychiatric, normal appearing, physical exam, examination, "
" Normal review of systems template.  The patient denies fever, fatigue, weakness, weight gain or weight loss.", Consult - History and Phy., Normal ROS Template ,"REVIEW OF SYSTEMS,GENERAL/CONSTITUTIONAL: , The patient denies fever, fatigue, weakness, weight gain or weight loss.,HEAD, EYES, EARS, NOSE AND THROAT:,  Eyes - The patient denies pain, redness, loss of vision, double or blurred vision, flashing lights or spots, dryness, the feeling that something is in the eye and denies wearing glasses.  Ears, nose, mouth and throat.  The patient denies ringing in the ears, loss of hearing, nosebleeds, loss of sense of smell, dry sinuses, sinusitis, post nasal drip, sore tongue, bleeding gums, sores in the mouth, loss of sense of taste, dry mouth, dentures or removable dental work, frequent sore throats, hoarseness or constant feeling of a need to clear the throat when nothing is there, waking up with acid or bitter fluid in the mouth or throat, food sticking in throat when swallows or painful swallowing.,CARDIOVASCULAR: , The patient denies chest pain, irregular heartbeats, sudden changes in heartbeat or palpitation, shortness of breath, difficulty breathing at night, swollen legs or feet, heart murmurs, high blood pressure, cramps in his legs with walking, pain in his feet or toes at night or varicose veins.,RESPIRATORY: , The patient denies chronic dry cough, coughing up blood, coughing  up mucus, waking at night coughing or choking, repeated pneumonias, wheezing or night sweats.,GASTROINTESTINAL: , The patient denies decreased appetite, nausea, vomiting, vomiting blood or coffee ground material, heartburn, regurgitation, frequent belching, stomach pain relieved by food, yellow jaundice, diarrhea, constipation, gas, blood in the stools, black tarry stools or hemorrhoids.,GENITOURINARY:  ,The patient denies difficult urination, pain or burning with urination, blood in the urine, cloudy or smoky urine, frequent need to urinate, urgency, needing to urinate frequently at night, inability to hold the urine, discharge from the penis, kidney stones, rash or ulcers, sexual difficulties, impotence or prostate trouble, no sexually transmitted diseases.,MUSCULOSKELETAL: , The patient denies arm, buttock, thigh or calf cramps.  No joint or muscle pain.  No muscle weakness or tenderness.  No joint swelling, neck pain, back pain or major orthopedic injuries.,SKIN AND BREASTS:  ,The patient denies easy bruising, skin redness, skin rash,  hives, sensitivity to sun exposure, tightness, nodules or bumps, hair loss, color changes in the hands or feet with cold, breast lump, breast pain or nipple discharge.,NEUROLOGIC: , The patient denies headache, dizziness, fainting, muscle spasm, loss of consciousness, sensitivity or pain in the hands and feet or memory loss.,PSYCHIATRIC:  ,The patient denies depression with thoughts of suicide, voices in ?? head telling ?? to do things and has not been seen for psychiatric counseling or treatment.,ENDOCRINE: , The patient denies intolerance to hot or cold temperature, flushing, fingernail changes, increased thirst, increased salt intake or decreased sexual desire.,HEMATOLOGIC/LYMPHATIC:  ,The patient denies anemia, bleeding tendency or clotting tendency.,ALLERGIC/IMMUNOLOGIC: , The patient denies rhinitis, asthma, skin sensitivity, latex allergies or sensitivity.","consult - history and phy., cardiovascular, ears, eyes, gastrointestinal, head, nose, respiratory, review of systems, denies fever, blood, tongue, loss, "
" Normal physical exam template.  Normocephalic.  Negative lesions, negative masses.", Consult - History and Phy., Normal Physical Exam Template - 4 ,"GENERAL:  ,XXX,VITAL SIGNS: , Blood pressure XXX, pulse XXX, temperature XXX, respirations XXX.  Height XXX, weight XXX.,HEAD: , Normocephalic.  Negative lesions, negative masses.,EYES: , PERLA, EOMI.  Sclerae clear.  Negative icterus, negative conjunctivitis.,ENT:,  Negative nasal hemorrhages, negative nasal obstructions, negative nasal exudates.  Negative ear obstructions, negative exudates.  Negative inflammation in external auditory canals.  Negative throat inflammation or masses.,SKIN: , Negative rashes, negative masses, negative ulcers.  No tattoos.,NECK:,  Negative palpable lymphadenopathy, negative palpable thyromegaly, negative bruits.,HEART:,  Regular rate and rhythm.  Negative rubs, negative gallops, negative murmurs.,LUNGS:,  Clear to auscultation.  Negative rales, negative rhonchi, negative wheezing.,ABDOMEN: , Soft, nontender, adequate bowel sounds.  Negative palpable masses, negative hepatosplenomegaly, negative abdominal bruits.,EXTREMITIES: , Negative inflammation, negative tenderness, negative swelling, negative edema, negative cyanosis, negative clubbing.  Pulses adequate bilaterally.,MUSCULOSKELETAL:,  Negative muscle atrophy, negative masses.  Strength adequate bilaterally.  Negative movement restriction, negative joint crepitus, negative deformity.,NEUROLOGIC: , Cranial nerves I through XII intact.  Negative gait disturbance.  Balance and coordination intact.  Negative Romberg, negative Babinski.  DTRs equal bilaterally.,GENITOURINARY:  ,Deferred.,", 
" Normal physical exam template.  Well developed, well nourished, in no acute distress.", Consult - History and Phy., Normal Physical Exam Template - 3 ,"PHYSICAL EXAMINATION,GENERAL APPEARANCE: , Well developed, well nourished, in no acute distress.,VITAL SIGNS:,  ***,SKIN:  ,Inspection of the skin reveals no rashes, ulcerations or petechiae.,HEENT:,  The sclerae were anicteric and conjunctivae were pink and moist.  Extraocular movements were intact and pupils were equal, round, and reactive to light with normal accommodation.  External inspection of the ears and nose showed no scars, lesions, or masses.  Lips, teeth, and gums showed normal mucosa.  The oral mucosa, hard and soft palate, tongue and posterior pharynx were normal.,NECK:  ,Supple and symmetric.  There was no thyroid enlargement, and no tenderness, or masses were felt.,CHEST: , Normal AP diameter and normal contour without any kyphoscoliosis.,LUNGS: , Auscultation of the lungs revealed normal breath sounds without any other adventitious sounds or rubs.,CARDIOVASCULAR:  ,There was a regular rate and rhythm without any murmurs, gallops, rubs.  The carotid pulses were normal and 2+ bilaterally without bruits.  Peripheral pulses were 2+ and symmetric.,ABDOMEN:  ,Soft and nontender with normal bowel sounds.  The liver span was approximately 5-6 cm in the right midclavicular line by percussion.  The liver edge was nontender.  The spleen was not palpable.  There were no inguinal or umbilical hernias noted.  No ascites was noted.,RECTAL:  ,Normal perineal exam.  Sphincter tone was normal.  There was no external hemorrhoids or rectal masses.  Stool Hemoccult was negative.  The prostate was normal size without any nodules appreciated (men only).,LYMPH NODES: , No lymphadenopathy was appreciated in the neck, axillae or groin.,MUSCULOSKELETAL: , Gait was normal.  There was no tenderness or effusions noted.  Muscle strength and tone were normal.,EXTREMITIES: , No cyanosis, clubbing or edema.,NEUROLOGIC:  ,Alert and oriented x 3.  Normal affect.  Gait was normal.  Normal deep tendon reflexes with no pathological reflexes.  Sensation to touch was normal.", 
" Normal physical exam template.  This is a well-developed and well-nourished.  The pupils were equal, round and reactive to light.  Extraocular movements are intact.", Consult - History and Phy., Normal Physical Exam Template - 2 ,"GENERAL APPEARANCE: , This is a well-developed and well-nourished, ??,VITAL SIGNS: , Blood pressure ??, heart rate ?? and regular, respiratory rate ??, temperature is ?? degrees Fahrenheit.  Height is ?? feet ?? inches.  Weight is ?? pounds.  This yields a body mass index of ??.,HEAD, EYES, EARS, NOSE AND THROAT:,  The pupils were equal, round and reactive to light.  Extraocular movements are intact.  Sclera are nonicteric.  Ears, nose, mouth and throat - Externally the ears and nose are normal.  The mucous membranes are moist and midline.,NECK:  ,The neck is supple without masses.  No thyromegaly, no carotid bruits, no adenopathy.,LUNGS:  ,There is a normal respiratory effort.  Bilateral breath sounds are clear.  No wheezes or rales or rhonchi.,CARDIAC: , Normal cardiac impulse location.  S1 and S2 are normal.  No rubs, murmurs or gallops.  A regular rate and rhythm.  There are no abdominal aortic bruits.  The carotid, brachial, radial, femoral, popliteal and dorsalis pedis pulses are 2+ and equal bilaterally.,EXTREMITIES: , The extremities are without clubbing, cyanosis, or edema.,CHEST: , The chest examination is unremarkable.,BREASTS:  ,The breasts show no masses or tenderness.  No axillary adenopathy.,ABDOMEN:,  The abdomen is flat, soft, nontender, no organomegaly, no masses, normal bowel sounds are present.,RECTAL: , Examination was deferred.,LYMPHATIC: , No neck, axillary or groin adenopathy was noted.,SKIN EXAMINATION:,  Unremarkable.,MUSCULOSKELETAL EXAMINATION: , Grossly normal.,NEUROLOGIC: , The cranial nerves two through twelve are grossly intact.  Patellar and biceps reflexes are normal.,PSYCHIATRIC: , The patient is awake, alert and oriented times three.  Judgment and insight are good.  Affect is appropriate.",
 An example normal physical exam, Consult - History and Phy., Normal Physical Exam Template - 1 ,"GENERAL: , Vital signs and temperature as documented in nursing notes.  The patient appears stated age and is adequately developed.,EYES:,  Pupils are equal, round, reactive to light and accommodation.  Lids and conjunctivae reveal no gross abnormality.,ENT:  ,Hearing appears adequate.  No obvious asymmetry or deformity of the ears and nose.,NECK: , Trachea midline.  Symmetric with no obvious deformity or mass; no thyromegaly evident.,RESPIRATORY:,  The patient has normal and symmetric respiratory effort.  Lungs are clear to auscultation.,CARDIOVASCULAR: , S1, S2 without significant murmur.,ABDOMEN: , Abdomen is flat, soft, nontender.  Bowel sounds are active.  No masses or pulsations present.,EXTREMITIES: , Extremities reveal no remarkable dependent edema or varicosities.,MUSCULOSKELETAL:  ,The patient is ambulatory with normal and symmetric gait.  There is adequate range of motion without significant pain or deformity.,SKIN: , Essentially clear with no significant rash or lesions.  Adequate skin turgor.,NEUROLOGICAL: , No acute focal neurologic changes.,PSYCHIATRIC:,  Mental status, judgment and affect are grossly intact and normal for age.","consult - history and phy., vital signs, equal, round, reactive, normal physical exam, physical exam, "
" Normal physical exam template.  Normal appearance for chronological age, does not appear chronically ill.", Consult - History and Phy., Normal Physical Exam Template - 6 ,"VITAL SIGNS:,  Reveal a blood pressure of *, temperature of *, respirations *, and pulse of *.,CONSTITUTIONAL: , Normal appearance for chronological age, does not appear chronically ill.,HEENT: , The pupils are equal and reactive.  Funduscopic examination is normal.  Posterior pharynx is normal.  Tympanic membranes are clear.,NECK:  ,Trachea is midline.  Thyroid is normal.  The neck is supple.  Negative nodes.,RESPIRATORY:,  Lungs are clear to auscultation bilaterally.  The patient has a normal respiratory rate, no signs of consolidation and no egophony.  There are no retractions or secondary muscle use.  Good bilateral breath sounds are noted.,CARDIOVASCULAR: , No jugular venous distention or carotid bruits.  No increase in heart size to percussion.  There is no murmur.  Normal S1 and S2 sounds are noted without gallop.,ABDOMEN: , Soft to palpation in all four quadrants.  There is no organomegaly and no rebound tenderness.  Bowel sounds are normal.  Obturator and psoas signs are negative.,GENITOURINARY: , No bladder tenderness, negative flank pain.,MUSCULOSKELETAL:,  Extremities are normal with good motor tone and strength, normal reflexes, and normal joint strength and sensation.,NEUROLOGIC: , Normal Glasgow Coma Scale.  Cranial nerves II through XII appear grossly intact.  Normal motor and cerebellar tests.  Reflexes are normal.,HEME/LYMPH:  ,No abnormal lymph nodes, no signs of bleeding, skin purpura, petechiae or hemorrhage.,PSYCHIATRIC: , Normal with no overt depression or suicidal ideations.","consult - history and phy., jugular venous distention, flank, bladder, normal physical exam, neck, nodes, respiratory, tenderness, motor, strength, reflexes, sounds, "
 An example of a physical exam, Consult - History and Phy., Normal Physical Exam Template ,"GENERAL: , Alert, well developed, in no acute distress.,MENTAL STATUS: , Judgment and insight appropriate for age.  Oriented to time, place and person.  No recent loss of memory.  Affect appropriate for age.,EYES:  ,Pupils are equal and reactive to light.  No hemorrhages or exudates.  Extraocular muscles intact.,EAR, NOSE AND THROAT: , Oropharynx clean, mucous membranes moist.  Ears and nose without masses, lesions or deformities.  Tympanic membranes clear bilaterally.  Trachea midline.  No lymph node swelling or tenderness.,RESPIRATORY:  ,Clear to auscultation and percussion.  No wheezing, rales or rhonchi.,CARDIOVASCULAR: , Heart sounds normal.  No thrills.  Regular rate and rhythm, no murmurs, rubs or gallops.,GASTROINTESTINAL: , Abdomen soft, nondistended.  No pulsatile mass, no flank tenderness or suprapubic tenderness.  No hepatosplenomegaly.,NEUROLOGIC: , Cranial nerves II-XII grossly intact.  No focal neurological deficits.  Deep tendon reflexes +2 bilaterally.  Babinski negative.  Moves all extremities spontaneously.  Sensation intact bilaterally.,SKIN: , No rashes or lesions.  No petechia.  No purpura.  Good turgor.  No edema.,MUSCULOSKELETAL: , No cyanosis or clubbing.  No gross deformities.  Capable of free range of motion without pain or crepitation.  No laxity, instability or dislocation.,BONE: , No misalignment, asymmetry, defect, tenderness or effusion.  Capable of from of joint above and below bone.,MUSCLE:  ,No crepitation, defect, tenderness, masses or swellings.  No loss of muscle tone or strength.,LYMPHATIC:,  Palpation of neck reveals no swelling or tenderness of neck nodes.  Palpation of groin reveals no swelling or tenderness of groin nodes.","consult - history and phy., mental status, ear, nose and throat, abdomen soft, nondistended, cranial nerves ii-xii grossly intact, physical exam, "
" Normal Physical Exam Template.  Well developed, well nourished, alert, in no acute distress. ", Consult - History and Phy., Normal Physical Exam Template - 5 ,"GENERAL: , Well developed, well nourished, alert, in no acute distress.  GCS 50, nontoxic.,VITAL SIGNS: , Blood pressure *, pulse *, respirations *, temperature * degrees F.  Pulse oximetry *%.,HEENT: , Eyes: Lids and conjunctiva.  No lesions.  Pupils equal, round, reactive to light and accommodation.  Irises symmetrical, undilated.  Funduscopic exam reveals no hemorrhages or discopathy.  Ears, Nose, Mouth, and throat:  External ears without lesions.  Nares patent.  Septum midline.  Tympanic membranes without erythema, bulging or retraction.  Canals without lesion.  Hearing is grossly intact.  Lips, teeth, gums, palate without lesion.  Posterior oropharynx:  No erythema.  No tonsillar enlargement, crypt formation or abscess.,NECK:  ,Supple and symmetric.  No masses. Thyroid midline, non enlarged.  No JVD.  Neck is nontender.  Full range of motion without pain.,RESPIRATORY: , Good respiratory effort.  Clear to auscultation.  Clear to percussion.  Chest:  Symmetrical rise and fall.  Symmetrical expansion.  No egophony or tactile fremitus.,CARDIOVASCULAR:,  Regular rate and rhythm.  No murmur, gallops, clicks, heaves or rub.  Cardiac palpation within normal limits.  Pulses equal at carotid.  Femoral and pedal pulses:  No peripheral edema.,GASTROINTESTINAL:  ,No tenderness or mass.  No hepatosplenomegaly.  No hernia.  Bowel sounds equal times four quadrants.  Abdomen is nondistended.  No rebound, guarding, rigidity or ecchymosis.,MUSCULOSKELETAL: , Normal gait and station.  No pathology to digits or nails.  Extremities move times four.  No tenderness or effusion.  Range of motion adequate.  Strength and tone equal bilaterally, stable.,BACK: , Nontender on midline.  Full range of motion with flexion, extension and sidebending.,SKIN:,  Inspection within normal limits.  Well hydrated.  No diaphoresis.  No obvious wound.,LYMPH:,  Cervical lymph nodes.  No lymphadenopathy.,NEUROLOGICAL:  ,Cranial nerves II-XII grossly intact.  DTRs symmetric 2 out of 4 bilateral upper and lower extremity, elbow, patella and ankle.  Motor strength 4/4 bilateral upper and lower extremity.  Straight leg raise is negative bilaterally.,PSYCHIATRIC: , Judgment and insight adequate.  Alert and oriented times three.  Memory and mood within normal limits.  No delusions, hallucinations.  No suicidal or homicidal ideation.","consult - history and phy., respiratory, abdomen, normal physical exam, pulses, tenderness, strength, lymph, extremity, midline, range, motion, lesions, symmetrical, "
 Normal newborn infant physical exam.  A well-developed infant in no acute respiratory distress., Consult - History and Phy., Normal Newborn Infant Physical Exam ,"GENERAL: , A well-developed infant in no acute respiratory distress.,VITAL SIGNS:  ,Initial temperature was XX, pulse XX, respirations XX.  Weight XX grams, length XX cm, head circumference XX cm.,HEENT:  ,Head is normocephalic with anterior fontanelle open, soft, and non-bulging.  Eyes:  Red reflex elicited bilaterally.  TMs occluded with vernix and not well visualized.  Nose and throat are patent without palatal defect.,NECK: , Supple without clavicular fracture.,LUNGS:,  Clear to auscultation.,HEART:,  Regular rate without murmur, click, or gallop present.  Pulses are 2/4 for brachial and femoral.,ABDOMEN:,  Soft with bowel sounds present.  No masses or organomegaly.,GENITALIA: , Normal.,EXTREMITIES: , Without evidence of hip defects.,NEUROLOGIC:  ,The infant has good Moro, grasp, and suck reflexes.,SKIN: , Warm and dry without evidence of rash.","consult - history and phy., fontanelle, normocephalic, newborn infant, physical exam, acute respiratory, newborn, respiratory, distress, head, infant,"
 An example/template for a routine normal male ROS., Consult - History and Phy., Normal Male ROS Template - 1 ,"REVIEW OF SYSTEMS:,CONSTITUTIONAL:  Patient denies fevers, chills, sweats and weight changes.,EYES:  Patient denies any visual symptoms.,EARS, NOSE, AND THROAT:  No difficulties with hearing.  No symptoms of rhinitis or sore throat.,CARDIOVASCULAR:  Patient denies chest pains, palpitations, orthopnea and paroxysmal nocturnal dyspnea.,RESPIRATORY:  No dyspnea on exertion, no wheezing or cough.,GI:  No nausea, vomiting, diarrhea, constipation, abdominal pain, hematochezia or melena.,GU:  No urinary hesitancy or dribbling.  No nocturia or urinary frequency.  No abnormal urethral discharge.,MUSCULOSKELETAL:  No myalgias or arthralgias.,NEUROLOGIC:  No chronic headaches, no seizures.  Patient denies numbness, tingling or weakness.,PSYCHIATRIC:  Patient denies problems with mood disturbance.  No problems with anxiety.,ENDOCRINE:  No excessive urination or excessive thirst.,DERMATOLOGIC:  Patient denies any rashes or skin changes.","consult - history and phy., review of systems, normal male ros, normal male, male ros, male, ros, throat, urinary "
" Normal female review of systems template.  Negative for fever, weight change, fatigue, or aching.", Consult - History and Phy., Normal Female ROS Template ,"CONSTITUTIONAL:,  Normal; negative for fever, weight change, fatigue, or aching.,HEENT:,  Eyes normal; Negative for glasses, cataracts, glaucoma, retinopathy, irritation, or visual field defects.  Ears normal; Negative for hearing or balance problems.  Nose normal; Negative for runny nose, sinus problems, or nosebleeds.  Mouth normal; Negative for dental problems, dentures, or bleeding gums.  Throat normal; Negative for hoarseness, difficulty swallowing, or sore throat.,CARDIOVASCULAR:,  Normal; Negative for angina, previous MI, irregular heartbeat, heart murmurs, bad heart valves, palpitations, swelling of feet, high blood pressure, orthopnea, paroxysmal nocturnal dyspnea, or history of stress test, arteriogram, or pacemaker implantation.,PULMONARY: , Normal; Negative for cough, sputum, shortness of breath, wheezing, asthma, or emphysema.,GASTROINTESTINAL: , Normal; Negative for pain, vomiting, heartburn, peptic ulcer disease, change in stool, rectal pain, hernia, hepatitis, gallbladder disease, hemorrhoids, or bleeding.,GENITOURINARY:, Normal female OR male; Negative for incontinence, UTI, dysuria, hematuria, vaginal discharge, abnormal bleeding, breast lumps, nipple discharge, skin or nipple changes, sexually transmitted diseases, incontinence, yeast infections, or itching.,SKIN: , Normal; Negative for rashes, keratoses, skin cancers, or acne.,MUSCULOSKELETAL: , Normal; Negative for back pain, joint pain, joint swelling, arthritis, joint deformity, problems with ambulation, stiffness, osteoporosis, or injuries.,NEUROLOGIC: , Normal; Negative for blackouts, headaches, seizures, stroke, or dizziness.,PSYCHIATRIC: , Normal; Negative for anxiety, depression, or phobias.,ENDOCRINE:,  Normal; Negative for diabetes, thyroid, or problems with cholesterol or hormones.,HEMATOLOGIC/LYMPHATIC: , Normal; Negative for anemia, swollen glands, or blood disorders.,IMMUNOLOGIC: , Negative; Negative for steroids, chemotherapy, or cancer.,VASCULAR:,  Normal; Negative for varicose veins, blood clots, atherosclerosis, or leg ulcers.","consult - history and phy., cough, sputum, shortness of breath, fever, weight, fatigue, aching, nose, throat, swelling, disease, incontinence, bleeding, heartbeat, blood, joint, "
 Template for History and Physical for a newborn., Consult - History and Phy., Normal Newborn H&P Template ,"HISTORY OF PRESENT ILLNESS: , This is a ** week gestational age ** delivered by ** at ** on **.  Gestational age was determined by last menstrual period and consistent with ** trimester ultrasound.  ** rupture of membranes occurred ** prior to delivery and amniotic fluid was clear.  The baby was vertex presentation.  The baby was dried, stimulated, and bulb suctioned.  Apgar scores of ** at one minute and ** at five minutes.,PAST MEDICAL HISTORY,MATERNAL HISTORY:,  The mother is a **-year-old, G**, P** female with blood type **.  She is rubella immune, hepatitis surface antigen negative, RPR nonreactive, HIV negative.  Mother was group B strep **.  Mother's past medical history is **.,PRENATAL CARE: , Mother began prenatal care in the ** trimester and had at least ** documented prenatal visits.  She did not smoke, drink alcohol, or use illicit drugs during pregnancy.,SURGICAL HISTORY: , **,MEDICATIONS:,  Medications taken during this pregnancy were **.,ALLERGIES: , **,FAMILY HISTORY: , **,SOCIAL HISTORY: , **,PHYSICAL EXAMINATION,VITAL SIGNS:  Temperature **, heart rate **, respiratory rate **.  Dextrose stick **.  Ballard score by the RN is ** weeks.  Birth weight is ** grams, which is the ** percentile for gestational age.  Length is ** centimeters which is ** percentile for gestational age.  Head circumference is ** centimeters which is ** percentile for gestational age.,GENERAL:  **Alert, active, nondysmorphic-appearing infant in no acute distress.,HEENT:  Anterior fontanelle open and flat.  Positive bilateral red reflexes.,Ears have normal shape and position with no pits or tags.  Nares patent.  Palate intact.  Mucous membranes moist.,NECK:  Full range of motion.,CARDIOVASCULAR:  Normal precordium, regular rate and rhythm.  No murmurs.  Normal femoral pulses.,RESPIRATORY;  Clear to auscultation bilaterally.  No retractions.,ABDOMEN:  Soft, nondistended.  Normal bowel sounds.  No hepatosplenomegaly.  Umbilical stump is clean, dry, and intact.,GENITOURINARY:  Normal tanner I **.  Anus patent.,MUSCULOSKELETAL:  Negative Barlow and Ortolani.  Clavicles intact.  Spine straight.  No sacral dimple or hair tuft.  Leg lengths grossly symmetric.  Five fingers on each hand and five toes on each foot.,SKIN:  Warm and pink with brisk capillary refill.  No jaundice.,NEUROLOGICAL:  Normal tone.  Normal root, suck, grasp, and Moro reflexes.  Moves all extremities equally.,DIAGNOSTIC STUDIES,LABORATORY DATA:,  **,ASSESSMENT: , Full term, appropriate for gestational age **.,PLAN:,1.  Routine newborn care.,2.  Anticipatory guidance.,3.  Hepatitis B immunization prior to discharge.,",
 An example/template for a routine normal male physical exam., Consult - History and Phy., Normal Male Exam Template - 3 ,"PHYSICAL EXAMINATION,GENERAL: , The patient is awake and alert, in no apparent distress, appropriate, pleasant and cooperative.  No dysarthria is noted.  No discomfort on presentation is noted.  ,HEAD: , Atraumatic, normocephalic. Pupils are equal, round and reactive to light.  Extraocular muscles are intact.  Sclerae are white without injection or icterus.  Fundi are without papilledema, hemorrhages or exudates with normal vessels.  ,EARS: , The ear canals are patent without edema, exudate or drainage.  Tympanic membranes are intact with a normal cone of light.  No bulging or erythema to indicate infection is present.  There is no hemotympanum.  Hearing is grossly intact.  ,NOSE:,  Without deformity, bleeding or discharge.  No septal hematoma is noted.  ,ORAL CAVITY:,  No swelling or abnormality to the lip or teeth.  Oral mucosa is pink and moist.  No swelling to the palate or pharynx.  Uvula is midline.  The pharynx is without exudate or erythema.  No edema is seen of the tonsils.  The airway is completely patent.  The voice is normal.  No stridor is heard.  ,NECK: , No signs of meningismus.  No Brudzinski or Kernig sign is present.  No adenopathy is noted.  No JVD is seen.  No bruits are auscultated.  Trachea is midline.  ,CHEST: , Symmetrical with equal breath sounds.  Equal excursion.  No hyperresonance or dullness to percussion is noted.  There is no tenderness on palpation of the chest.  ,LUNGS:  ,Clear to auscultation bilaterally.  No rales, rhonchi or wheezes are appreciated.  Good air movement is auscultated in all 4 lung fields.  ,HEART:,  Regular rate and rhythm.  No murmur.  No S3, S4 or rub is auscultated.  Point of maximal impulse is strong and in normal position.  Abdominal aorta is not palpable.  The carotid upstroke is normal.  ,ABDOMEN:  ,Soft, nontender and nondistended.  Normal bowel sounds are auscultated.  No organomegaly is appreciated.  No masses are palpated.  No tympany is noted on percussion.  No guarding, rigidity or rebound tenderness is seen on exam.  Murphy and McBurney sign is negative.  There is no Rovsing, obturator or psoas sign present.  No hepatosplenomegaly and no hernias are noted.  ,RECTAL:,  Normal tone.  No masses.  Soft, brown stool in the vault.  Guaiac negative.  ,GENITOURINARY:,  Penis is normal without lesion or urethral discharge.  Scrotum is without edema.  The testes are descended bilaterally.  No masses are palpated.  There is no tenderness.  ,EXTREMITIES: , No clubbing, cyanosis or edema.  Pulses are strong and equal in the femoral and dorsalis pedis arteries, bounding and equal.  No deformity or signs of trauma.  All joints are stable without laxity.  There is good range of motion of all joints without tenderness or discomfort.  Homan sign is negative.  No atrophy or contractures are noted.  ,SKIN: , No rashes.  No jaundice.  Pink and warm with good turgor.  Good color.  No erythema or nodules noted.  No petechia, bulla or ecchymosis.  ,NEUROLOGIC: , Cranial nerves II through XII are grossly intact.  Muscle strength is graded 5/5 in the upper and lower extremities bilaterally.  Deep tendon reflexes are symmetrical in the upper and lower extremities bilaterally. Babinski is downgoing bilaterally.  Sensation is intact to light touch and vibration.  Gait is normal.  Romberg, finger-to-nose, rapid alternating movements and heel-to-shin are all normal.  There is no ataxia seen on gait testing.  Tone is normal.  No pronator drift is seen.  ,PSYCHIATRIC:  ,The patient is oriented x4.  Mood and affect are appropriate.  Memory is intact with good short- and long-term memory recall.  No dysarthria is noted.  Remote memory is intact.  Judgment and insight appear normal.,",
 An example/template for a routine normal male physical exam., Consult - History and Phy., Normal Male Exam Template - 4 ,"VITAL SIGNS:,  Blood pressure *, pulse *, respirations *, temperature *.,GENERAL APPEARANCE: , Alert and in no apparent distress, calm, cooperative, and communicative.,HEENT:,  Eyes:  EOMI.  PERRLA.  Sclerae nonicteric.  No lesions lids, lashes, brows, or conjunctivae noted.  Funduscopic examination unremarkable.  No papilledema, glaucoma, or cataracts.  Ears:  Normal set and shape with normal hearing and normal TMs. Nose and Sinus:  Unremarkable.  Mouth, Tongue, Teeth, and Throat:  Negative except for dental work.,NECK: , Supple and pain free without carotid bruit, JVD, or significant cervical adenopathy.  Trachea is midline without stridor, shift, or subcutaneous emphysema.  Thyroid is palpable, nontender, not enlarged, and free of nodularity.,CHEST: , Lungs bilaterally clear to auscultation and percussion.,HEART: , S1 and S2.  Regular rate and rhythm without murmur, heave, click, lift, thrill, rub, or gallop.  PMI is nondisplaced.  Chest wall is unremarkable to inspection and palpation.  No axillary or supraclavicular adenopathy detected.,BREASTS: , Normal male breast tissue.,ABDOMEN:,  No hepatosplenomegaly, mass, tenderness, rebound, rigidity, or guarding.  No widening of the aortic impulse and intraabdominal bruit on auscultation.,EXTERNAL GENITALIA: , Normal for age.  Normal penis with bilaterally descended testes that are normal in size, shape, and contour, and without evidence of hernia or hydrocele.,RECTAL:,  Negative to 7 cm by gloved digital palpation with Hemoccult-negative stool and normal-sized prostate that is free of nodularity or tenderness.  No rectal masses palpated.,EXTREMITIES: , Good distal pulse and perfusion without evidence of edema, cyanosis, clubbing, or deep venous thrombosis.  Nails of the hands and feet, and creases of the palms and soles are unremarkable.  Good active and passive range of motion of all major joints.,BACK: , Normal to inspection and percussion.  Negative for spinous process tenderness or CVA tenderness.  Negative straight-leg raising, Kernig, and Brudzinski signs.,NEUROLOGIC: , Nonfocal for cranial and peripheral nervous systems, strength, sensation, and cerebellar function.  Affect is normal.  Speech is clear and fluent.  Thought process is lucid and rational.  Gait and station are unremarkable.,SKIN:  ,Unremarkable for any premalignant or malignant condition with normal changes for age.","consult - history and phy., digital palpation, hemoccult-negative, heent, palpation, breasts, male, tenderness, tongue, "
 Sample/template for a normal male multisystem exam., Consult - History and Phy., Normal Male Exam Template ,"MULTISYSTEM EXAM,CONSTITUTIONAL:  ,The vital signs showed that the patient was afebrile; blood pressure and heart rate were within normal limits.  The patient appeared alert.,EYES:  ,The conjunctiva was clear.  The pupil was equal and reactive.  There was no ptosis.  The irides appeared normal.,EARS, NOSE AND THROAT:  ,The ears and the nose appeared normal in appearance.  Hearing was grossly intact.  The oropharynx showed that the mucosa was moist.  There was no lesion that I could see in the palate, tongue. tonsil or posterior pharynx.,NECK:  ,The neck was supple.  The thyroid gland was not enlarged by palpation.,RESPIRATORY:  ,The patient's respiratory effort was normal.  Auscultation of the lung showed it to be clear with good air movement.,CARDIOVASCULAR:  ,Auscultation of the heart revealed S1 and S2 with regular rate with no murmur noted.  The extremities showed no edema.,GASTROINTESTINAL: , The abdomen was soft, nontender with no rebound, no guarding, no enlarged liver or spleen.  Bowel sounds were present.,GU: , The scrotal elements were normal.  The testes were without discrete mass.  The penis showed no lesion, no discharge.,LYMPHATIC:  ,There was no appreciated node that I could feel in the groin or neck area.,MUSCULOSKELETAL:  ,The head and neck by inspection showed no obvious deformity.  Again, the extremities showed no obvious deformity.  Range of motion appeared to be normal for the upper and lower extremities.,SKIN: , Inspection of the skin and subcutaneous tissues appeared to be normal.  The skin was pink, warm and dry to touch.,NEUROLOGIC:  ,Deep tendon reflexes were symmetrical at the patellar area.  Sensation was grossly intact by touch.,PSYCHIATRIC: , The patient was oriented to time, place and person.  The patient's judgment and insight appeared to be normal.","consult - history and phy., within normal limits, conjunctiva, eyes, ears, nose, throat, male, multisystem, heart, respiratory, auscultation, extremities, oropharynx, neck, tongue, "
" Sample normal ear, nose, mouth, and throat exam.", Consult - History and Phy., Normal ENT Exam ,"EARS, NOSE, MOUTH AND THROAT: , The nose is without any evidence of any deformity.  The ears are with normal-appearing pinna.  Examination of the canals is normal appearing bilaterally.  There is no drainage or erythema noted.  The tympanic membranes are normal appearing with pearly color, normal-appearing landmarks and normal light reflex.  Hearing is grossly intact to finger rubbing and whisper.  The nasal mucosa is moist.  The septum is midline.  There is no evidence of septal hematoma.  The turbinates are without abnormality.  No obvious abnormalities to the lips.  The teeth are unremarkable.  The gingivae are without any obvious evidence of infection.  The oral mucosa is moist and pink.  There are no obvious masses to the hard or soft palate.  The uvula is midline.  The salivary glands appear unremarkable.  The tongue is midline.  The posterior pharynx is without erythema or exudate.  The tonsils are normal appearing.","consult - history and phy., erythema, tympanic, mouth, throat, ears, mucosa, noseNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 An example/template for a routine normal female physical exam., Consult - History and Phy., Normal Female Exam Template - 2 ,"VITAL SIGNS: , Blood pressure *, pulse *, respirations *, temperature *.,GENERAL APPEARANCE:,  Alert and in no apparent distress, calm, cooperative, and communicative.,HEENT: , Eyes:  EOMI.  PERRLA.  Sclerae nonicteric.  No lesions of lids, lashes, brows, or conjunctivae noted.  Funduscopic examination unremarkable.  Ears:  Normal set, shape, TMs, canals and hearing.  Nose and Sinuses:  Negative.  Mouth, Tongue, Teeth, and Throat:  Negative except for dental work.,NECK: , Supple and pain free without bruit, JVD, adenopathy or thyroid abnormality.,CHEST:,  Lungs are bilaterally clear to auscultation and percussion.,HEART: , S1 and S2.  Regular rate and rhythm without murmur, heave, click, lift, thrill, rub, or gallop.  PMI nondisplaced.  Chest wall unremarkable to inspection and palpation.  No axillary or supraclavicular adenopathy detected.,BREASTS:,  In the seated and supine position unremarkable.,ABDOMEN: , No hepatosplenomegaly, mass, tenderness, rebound, rigidity, or guarding.  No widening of the aortic impulse and no intraabdominal bruit auscultated.,EXTERNAL GENITALIA: , Normal for age.,RECTAL: , Negative to 7 cm by gloved digital palpation with Hemoccult-negative stool.,EXTREMITIES: , Good distal pulse and perfusion without evidence of edema, cyanosis, clubbing, or deep venous thrombosis.  Nails of the hands and feet, and creases of the palms and soles are unremarkable.  Good active and passive range of motion of all major joints.,BACK:,  Normal to inspection and percussion.  Negative for spinous process tenderness or CVA tenderness.  Negative straight-leg raising, Kernig, and Brudzinski signs.,NEUROLOGIC:,  Nonfocal for cranial and peripheral nervous systems, strength, sensation, and cerebellar function.  Affect is normal.  Speech is clear and fluent.  Thought process is lucid and rational.  Gait and station are unremarkable.,SKIN: , Unremarkable for any premalignant or malignant condition with normal changes for age.","consult - history and phy., heent, general appearance, hepatosplenomegaly, mass, tenderness, rebound, rigidity, pulse, bruit, adenopathy, chest, percussion, inspection, palpation, signs, tongue, "
 An example/template for a routine normal male physical exam., Consult - History and Phy., Normal Male Exam Template - 1 ,"MALE PHYSICAL EXAMINATION,HEENT:  Pupils equal, round and reactive to light and accommodation.  Extraocular movements are intact.  Sclerae are anicteric.  TMs are clear bilaterally.  Oropharynx is clear without erythema or exudate.,NECK:  Supple without lymphadenopathy or thyromegaly.  Carotids are silent.  There is no jugular venous distention.,CHEST:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  Regular rate and rhythm without S3, S4.  No murmurs or rubs are appreciated.,ABDOMEN:  Soft, nontender, nondistended with positive bowel sounds.  No masses, hepatomegaly or splenomegaly are appreciated.,GU:  Normal **circumcised male.  No discharge or hernias.  No testicular masses.,RECTAL EXAM:  Normal rectal tone.  Prostate is smooth and not enlarged.  Stool is Hemoccult negative.,EXTREMITIES:  Reveal no clubbing, cyanosis, or edema.  Peripheral pulses are +2 and equal bilaterally in all four extremities.,JOINT EXAM:  Reveals no tenosynovitis.,NEUROLOGIC:  Cranial nerves II through XII are grossly intact.  Motor strength is 5/5 and equal in all four extremities.  Deep tendon reflexes are +2/4 and equal bilaterally.  Patient is alert and oriented times 3.,PSYCHIATRIC:  Grossly normal.,DERMATOLOGIC:  No lesions or rashes.","consult - history and phy., male exam, physical exam, normal, normal male, physical, male, sclerae, extremities, intact, oropharynx "
 An example/template for a routine normal male physical exam., Consult - History and Phy., Normal Male Exam Template - 2 ,"MALE PHYSICAL EXAMINATION,Eye:  Eyelids normal color, no edema.  Conjunctivae with no erythema, foreign body, or lacerations.  Sclerae normal white color, no jaundice.  Cornea clear without lesions.  Pupils equally responsive to light.  Iris normal color, no lesions.  Anterior chamber clear.  Lacrimal ducts normal.  Fundi clear.,Ear:  External ear has no erythema, edema, or lesions.  Ear canal unobstructed without edema, discharge, or lesions.  Tympanic membranes clear with normal light reflex.  No middle ear effusions.,Nose:  External nose symmetrical.  No skin lesions.  Nares open and free of lesions.  Turbinates normal color, size and shape.  Mucus clear.  No internal lesions.,Throat:  No erythema or exudates.  Buccal mucosa clear.  Lips normal color without lesions.  Tongue normal shape and color without lesion.  Hard and soft palate normal color without lesions.  Teeth show no remarkable features.  No adenopathy.  Tonsils normal shape and size.  Uvula normal shape and color.,Neck:  Skin has no lesions.  Neck symmetrical.  No adenopathy, thyromegaly, or masses.  Normal range of motion, nontender.  Trachea midline.,Chest:  Symmetrical.  Clear to auscultation bilaterally.  No wheezing, rales or rhonchi.  Chest nontender.  Normal lung excursion.  No accessory muscle use.,Cardiovascular:  Heart has regular rate and rhythm with no S3 or S4.  Heart rate is normal.,Abdominal:  Soft, nontender, nondistended, bowel sounds present.  No hepatomegaly, splenomegaly, masses, or bruits.,Genital:  Penis normal shape without lesions.  Testicles normal shape and contour without tenderness.  Epididymides normal shape and contour without tenderness.  Rectum normal tone to sphincter.  Prostate normal shape and contour without nodules.  Stool hemoccult negative.  No external hemorrhoids.  No skin lesions.,Musculoskeletal:  Normal strength all muscle groups.  Normal range of motion all joints.  No joint effusions.  Joints normal shape and contour.  No muscle masses.,Foot:  No erythema.  No edema.  Normal range of motion all joints in the foot.  Nontender.  No pain with inversion, eversion, plantar or dorsiflexion.,Ankle:  Anterior and posterior drawer test negative.  No pain with inversion, eversion, dorsiflexion, or plantar flexion.  Collateral ligaments intact.  No joint effusion, erythema, edema, crepitus, ecchymosis, or tenderness.,Knee:  Normal range of motion.  No joint effusion, erythema, nontender.  Anterior and posterior drawer tests negative.  Lachman's test negative.  Collateral ligaments intact.  Bursas nontender without edema.,Wrist:  Normal range of motion.  No edema or effusion, nontender.  Negative Tinel and Phalen tests.  Normal strength all muscle groups.,Elbow:  Normal range of motion.  No joint effusion or erythema.  Normal strength all muscle groups.  Nontender.  Olecranon bursa flat and nontender, no edema.  Normal supination and pronation of forearm.  No crepitus.,Hip:  Negative swinging test.  Trochanteric bursa nontender.  Normal range of motion.  Normal strength all muscle groups.  No pain with eversion and inversion.  No crepitus.  Normal gait.,Psychiatric:  Alert and oriented times four.  No delusions or hallucinations, no loose associations, no flight of ideas, no tangentiality.  Affect is appropriate.  No psychomotor slowing or agitation.  Eye contact is appropriate.","consult - history and phy., male exam, normal, physical exam, normal range of motion, male physical, nontender, lesions, dorsiflexion, sclerae, contour, muscle, erythema, joints, edema, shape,"
 An example/template for a routine normal female physical exam., Consult - History and Phy., Normal Female Exam Template - 1 ,"PHYSICAL EXAMINATION,GENERAL:  ,The patient is awake and alert, in no apparent distress, appropriate, pleasant and cooperative.  No dysarthria is noted.  No discomfort on presentation is noted.,HEAD: , Atraumatic, normocephalic.  Pupils are equal, round and reactive to light.  Extraocular muscles are intact.  Sclerae are white without injection or icterus.  Fundi are without papilledema, hemorrhages or exudates with normal vessels.,EARS:  ,The ear canals are patent without edema, exudate or drainage.  Tympanic membranes are intact with a normal cone of light.  No bulging or erythema to indicate infection is present.  There is no hemotympanum.  Hearing is grossly intact.,NOSE: , Without deformity, bleeding or discharge.  No septal hematoma is noted.,ORAL CAVITY: , No swelling or abnormality to the lip or teeth.  Oral mucosa is pink and moist.  No swelling to the palate or pharynx.  Uvula is midline.  The pharynx is without exudate or erythema.  No edema is seen of the tonsils.  The airway is completely patent.  The voice is normal.  No stridor is heard.,NECK: , No signs of meningismus.  No Brudzinski or Kernig sign is present.  No adenopathy is noted.  No JVD is seen.  No bruits are auscultated.  Trachea is midline.,CHEST: , Symmetrical with equal breath sounds.  Equal excursion.  No hyperresonance or dullness to percussion is noted.  There is no tenderness on palpation of the chest.,LUNGS: , Clear to auscultation bilaterally.  No rales, rhonchi or wheezes are appreciated.  Good air movement is auscultated in all 4 lung fields.,HEART: , Regular rate and rhythm.  No murmur.  No S3, S4 or rub is auscultated.  Point of maximal impulse is strong and in normal position.  Abdominal aorta is not palpable.  The carotid upstroke is normal.,ABDOMEN: , Soft, nontender and nondistended.  Normal bowel sounds are auscultated.  No organomegaly is appreciated.  No masses are palpated.  No tympany is noted on percussion.  No guarding, rigidity or rebound tenderness is seen on exam.  Murphy and McBurney sign is negative.  There is no Rovsing, obturator or psoas sign present.  No hepatosplenomegaly and no hernias are noted.,RECTAL: , Normal tone.  No masses.  Soft, brown stool in the vault.  Guaiac negative.,GENITOURINARY: , External genitalia without erythema, exudate or discharge.  Vaginal vault is without discharge.  Cervix is of normal color without lesion.  The os is closed.  There is no bleeding noted.  Uterus is noted to be of normal size and nontender.  No cervical motion tenderness is seen.  No masses are palpated.  The adnexa are without masses or tenderness.,EXTREMITIES: , No clubbing, cyanosis or edema.  Pulses are strong and equal in the femoral and dorsalis pedis arteries, bounding and equal.  No deformity or signs of trauma.  All joints are stable without laxity.  There is good range of motion of all joints without tenderness or discomfort.  Homan sign is negative.  No atrophy or contractures are noted.,SKIN: , No rashes.  No jaundice.  Pink and warm with good turgor.  Good color.  No erythema or nodules noted.  No petechia, bulla or ecchymosis.,NEUROLOGIC: , Cranial nerves II through XII are grossly intact.  Muscle strength is graded 5/5 in the upper and lower extremities bilaterally.  Deep tendon reflexes are symmetrical in the upper and lower extremities bilaterally.  Babinski is downgoing bilaterally.  Sensation is intact to light touch and vibration.  Gait is normal.  Romberg, finger-to-nose, rapid alternating movements and heel-to-shin are all normal.  There is no ataxia seen on gait testing.  Tone is normal.  No pronator drift is seen.,PSYCHIATRIC:  ,The patient is oriented x4.  Mood and affect are appropriate.  Memory is intact with good short- and long-term memory recall.  No dysarthria is noted.  Remote memory is intact.  Judgment and insight appear normal.",
 Normal child physical exam template., Consult - History and Phy., Normal Child Exam Template ,"CHILD PHYSICAL EXAMINATION,VITAL SIGNS:  Birth weight is ** grams, length **, occipitofrontal circumference **.  Character of cry was lusty.,GENERAL APPEARANCE:  Well.,BREATHING:  Unlabored.,SKIN:  Clear.  No cyanosis, pallor, or icterus.  Subcutaneous tissue is ample.,HEAD:  Normal.  Fontanelles are soft and flat.  Sutures are opposed.,EYES:  Normal with red reflex x2.,EARS:  Patent.  Normal pinnae, canals, TMs.,NOSE:  Patent nares.,MOUTH:  No cleft.,THROAT:  Clear.,NECK:  No masses.,CHEST:  Normal clavicles.,LUNGS:  Clear bilaterally.,HEART:  Regular rate and rhythm without murmur.,ABDOMEN:  Soft, flat.  No hepatosplenomegaly.  The cord is three vessel.,GENITALIA:  Normal ** genitalia **with testes descended bilaterally.,ANUS:  Patent.,SPINE:  Straight and without deformity.,EXTREMITIES:  Equal movements.,MUSCLE TONE:  Good.,REFLEXES:  Moro, grasp, and suck are normal.,HIPS:  No click or clunk.","consult - history and phy., child physical examination, physical, genitalia, child, "
 Sample/template for a normal female multisystem exam, Consult - History and Phy., Normal Female Exam Template ,"MULTISYSTEM EXAM,CONSTITUTIONAL: , The vital signs showed that the patient was afebrile; blood pressure and heart rate were within normal limits.  The patient appeared alert.,EYES: , The conjunctiva was clear.  The pupil was equal and reactive.  There was no ptosis.  The irides appeared normal.,EARS, NOSE AND THROAT: , The ears and the nose appeared normal in appearance.  Hearing was grossly intact.  The oropharynx showed that the mucosa was moist.  There was no lesion that I could see in the palate, tongue. tonsil or posterior pharynx.,NECK: , The neck was supple.  The thyroid gland was not enlarged by palpation.,RESPIRATORY:  ,The patient's respiratory effort was normal.  Auscultation of the lung showed it to be clear with good air movement.,CARDIOVASCULAR: , Auscultation of the heart revealed S1 and S2 with regular rate with no murmur noted.  The extremities showed no edema.,BREASTS:  ,Breast inspection showed them to be symmetrical with no nipple discharge.  Palpation of the breasts and axilla revealed no obvious mass that I could appreciate.,GASTROINTESTINAL:  ,The abdomen was soft, nontender with no rebound, no guarding, no enlarged liver or spleen.  Bowel sounds were present.,GU:  ,The external genitalia appeared to be normal.  The pelvic exam revealed no adnexal masses.  The uterus appeared to be normal in size and there was no cervical motion tenderness.,LYMPHATIC:  ,There was no appreciated node that I could feel in the groin or neck area.,MUSCULOSKELETAL:  ,The head and neck by inspection showed no obvious deformity.  Again, the extremities showed no obvious deformity.  Range of motion appeared to be normal for the upper and lower extremities.,SKIN:,  Inspection of the skin and subcutaneous tissues appeared to be normal.  The skin was pink, warm and dry to touch.,NEUROLOGIC: , Deep tendon reflexes were symmetrical at the patellar area.  Sensation was grossly intact by touch.,PSYCHIATRIC:  ,The patient was oriented to time, place and person.  The patient's judgment and insight appeared to be normal.", 
" New diagnosis of non-small cell lung cancer stage IV metastatic disease.  At this point, he and his wife ask about whether this is curable disease and it was difficult to inform that this was not curable disease but would be treatable.", Consult - History and Phy., Non-Small Cell Lung Cancer - Consult ,"REASON FOR CONSULTATION:,  New diagnosis of non-small cell lung cancer.,HISTORY OF PRESENT ILLNESS: , ABCD is a very nice 47-year-old gentleman without much past medical history who has now been diagnosed with a new non-small cell lung cancer stage IV metastatic disease.  We are consulted at this time to discuss further treatment options.,ABCD and his wife state that his history goes back to approximately 2-2-1/2 weeks ago when he developed some left-sided flank pain.  Initially, he did not think much of this and tried to go about doing work and everything else but the pain gradually worsened.  Eventually this prompted him to present to the emergency room.  A CT scan was done there, and he was found to have a large left adrenal mass worrisome for metastatic disease.  At that point, he was transferred to XYZ Hospital for further evaluation.  On admission on 12/19/08, a CT scan of the chest, abdomen, and pelvis was done for full staging purposes.  The CT scan of the chest showed an abnormal soft tissue mass in the right paratracheal region, extending into the precarinal region, the subcarinal region, and the right hilum.  This was causing some compression on the inferior aspect of the SVC and also some narrowing of the right upper lobe pulmonary artery.  There was an abnormal lymph node noted in the AP window and left hilar region.  There was another spiculated mass within the right upper lobe measuring 2.0 x 1.5 cm.  There was also an 8 mm non-calcified nodule noted in the posterior-inferior aspect of the left upper lobe suspicious for metastatic disease.  There were areas of atelectasis particularly in the right base.  There was also some mild ground glass opacity within the right upper lobe adjacent to the right hilum potentially representing focal area of pulmonary edema versus small infarction related to the right upper lobe pulmonary artery narrowing.  There was a small lucency adjacent to the medial aspect of the left upper lobe compatible with a small pneumothorax.  In the abdomen, there was a mass involved in the left adrenal gland as well as a nodule involving the right adrenal gland both of which appeared necrotic compatible with metastatic tumor.  All other structures appeared normal.  On 12/22/08, a CT-guided biopsy of the left adrenal mass was performed.  Pathology from this returned showing metastatic poorly differentiated non-small cell carcinoma.  At this point, we have been consulted to discuss further treatment options.,On further review, ABCD states that he has may be had a 20 pound weight loss over the last couple of months which he relates to anorexia or decreased appetite.  He has not ever had a chronic smoker's cough and still does not have a cough.  He has no sputum production or hemoptysis.  He and his wife are very anxious about this diagnosis.,PAST MEDICAL HISTORY: , He denies any history of heart disease, lung disease, kidney disease, liver disease, hepatitis major infection, seizure disorders or other problems.,PAST SURGICAL HISTORY: , He denies having any surgeries.,ALLERGIES: , No known drug allergies.,MEDICATIONS:,  At home he takes no medication except occasional aspirin or ibuprofen, recently for his flank pain.  He does take a multivitamin on occasion.,SOCIAL HISTORY:  He has about a 30-pack-a-year history of smoking.  He used to drink alcohol heavily and has a history of getting a DUI about a year-and-half ago resulting in him having his truck-driving license revoked.  Since that time he has worked with printing press.  He is married and has two children, both of whom are grown in their 20s, but are now living at home.,FAMILY HISTORY: , His mother died for alcohol-related complications.  He otherwise denies any history of cancers, bleeding disorders, clotting disorders, or other problems.,REVIEW OF SYSTEMS: , GENERAL/CONSTITUTIONAL:  He has lost about 20 pounds of weight as described above.  He also has a trouble with fatigue.  No lightheadedness or dizziness.  HEENT:  He denies any new or changing headache, change in vision, double vision, or loss of vision, ringing in his ears, loss of hearing in one year.  He does not take care of his teeth very well but currently he has no mouth, jaw, or teeth pain.  RESPIRATORY:  He has had some little bit of dyspnea on exertion but otherwise denies shortness of breath at rest.  No cough, congestion, wheezing, hemoptysis, and sputum production.  CVS:  He denies any chest pains, palpitations, PND, orthopnea, or swelling of his lower extremities.  GI:  He denies any odynophagia, dysphagia, heartburn on a regular basis, abdominal pain, abdominal swelling, diarrhea, blood in his stool, or black tarry stools.  He has been somewhat constipated recently.  GU:  He denies any burning with urination, kidney stones, blood in his urine, dysuria, difficulty getting his urine out or other problems.  MUSCULOSKELETAL:  He denies any new bony aches or pains including back pain, hip pain, and rib pain.  No muscle aches, no joint swelling, and no history of gout.  SKIN:  No rashes, no bruising, petechia, non-healing wounds, or ulcerations.  He has had no nail or hair changes.  HEM:  He denies any bloody nose, bleeding gums, easy bruising, easy bleeding, swollen lymphs or bumps.  ENDOCRINE:  He denies any tremor, shakiness, history of diabetes, thyroid problems, new or enlarging stretch marks, exophthalmos, insomnia, or tremors.  NEURO:  He denies any mental status changes, anxiety, confusion, depression, hallucinations, loss of feeling in her arm or leg, numbness or tingling in hands or feet, loss of balance, syncope, seizures, or loss of coordination.,PHYSICAL EXAMINATION,VITAL SIGNS:  His T-max is 98.8.  His pulse is 85, respirations 18, and blood pressure 126/80 saturating over 90% on room air.,GENERAL:  No acute distress, pleasant gentleman who appears stated age.,HEENT:  NC/AT.  Sclerae anicteric.  Conjunctiva clear.  Oropharynx is clear without erythema, exudate, or discharge.,NECK:  Supple.  Nontender.  No elevated JVP.  No carotid bruits.  No thyromegaly.  No thyroid nodules.  Carotids are 2+ and symmetric.,BACK:  Spine is straight.  No spinal tenderness.  No CVA tenderness.  No presacral edema.,CHEST:  Clear to auscultation and percussion bilaterally.  No wheezes, rales, or rhonchi.  Normal symmetric chest wall expansion with inspiration.,CVS:  Regular rate and rhythm.  No murmurs, gallops, or rubs.,ABDOMEN:  Soft, nontender, nondistended.  No hepatosplenomegaly.  No guarding or rebound.  No masses.  Normoactive bowel sounds.,EXTREMITIES:  No cyanosis, clubbing, or edema.  No joint swelling.  Full range of motion.,SKIN:  No rashes, wounds, ulcerations, bruises, or petechia.,NEUROLOGIC:  Cranial nerves II through XII are intact.  He has intact sensation to light touch throughout.  He has 2+ deep tendon reflexes bilaterally in the biceps, triceps, brachioradialis, patellar and ankle reflexes.  He is alert and oriented x3.,LABORATORY DATA: , His white blood cell count is 9.4, hemoglobin 13.0, hematocrit 38%, and platelets 365,000.  The differential shows 73% neutrophils, 17% lymphocytes, 7.6% monocytes, 1.9% eosinophils, and 0.7% basophils.  Chemistry shows sodium 138, potassium 3.8, chloride 104, CO2 of 31, BUN 9, creatinine 1.0, glucose 104, calcium 12.3, alkaline phosphatase 104, AST 16, ALT 12, total protein 7.6, albumin 3.5, total bilirubin 0.5, ionized calcium 1.7.  His INR is 1.0 with the PT of 11.4 and a PTT of 31.3.,IMAGINING DATA:,  MRI of the brain on 12/23/08 - this shows some mild white matter disease, question of minimal pontine ischemic gliosis as well as a small incidental venous angioma in the left posterior frontal deep white matter.  There is no evidence of cerebral metastasis, hemorrhage, or acute infarction.,ASSESSMENT/PLAN: , ABCD is a very nice 47-year-old gentleman without much past medical history, who now presents with metastatic non-small cell lung cancer.  At this point, he and his wife ask about whether this is curable disease and it was difficult to inform that this was not curable disease but would be treatable.  His wife particularly had a very hard time with this prognosis.  They preferred not to know the exact average as to how long someone lives with this disease.  I did offer chemotherapy as a way to treat this disease.  Chemotherapy has been associated both with palliation of symptoms as well as prolong survival.  At this point, he has an excellent functional status and I think he would tolerate chemotherapy quite well.,In terms of chemotherapy, I talked briefly about the side affects including but not limited to GI upset, diarrhea, nausea, vomiting, mucositis, fatigue, loss of appetite, low blood counts including the possible need for transfusion as well as the risk of infections, which in some rare cases can be fatal.  I would likely use carboplatin and gemcitabine.  This would be both medications given on day 1 with a dose of gemcitabine on day 8.  This cycle will be repeated after 1-week break so that the cycle lasts 21 days.  The goal will be to complete 6 cycles of this as long as he is responding and tolerating the medication.,In terms of staging Mr. ABCD'S had all the appropriate staging.  A PET-CT scan could be done, but at this point would not provide much mean full information beyond the CT scans that we have.,At this point, his biggest issue is pain and he is getting a pain consult to help control his pain.  He will be ready to be discharged from the hospital once his pain is under better control.  As this is the holiday weekend, I do not have a way of scheduling a followup appointment with them, but I did give he and his wife my card and instructed them to call on Monday.  At that point, we will get him in and I will also begin working on making arrangements for his chemotherapy.,Thank you very much for this interesting consult.",
" A 2-1/2-year-old female with history of febrile seizures, now with concern for spells of unclear etiology, but somewhat concerning for partial complex seizures and to a slightly lesser extent nonconvulsive generalized seizures.", Consult - History and Phy., New Onset Seizure ,"REASON FOR CONSULTATION: , New-onset seizure.,HISTORY OF PRESENT ILLNESS: , The patient is a 2-1/2-year-old female with a history of known febrile seizures, who was placed on Keppra oral solution at 150 mg b.i.d. to help prevent febrile seizures.  Although this has been a very successful treatment in terms of her febrile seizure control, she is now having occasional brief periods of pauses and staring, where she becomes unresponsive, but does not lose her postural tone.  The typical spell according to dad last anywhere from 10 to 15 seconds, mom says 3 to 4 minutes, which likely means probably somewhere in the 30- to 40-second period of time.  Mom did note that an episode had happened outside of a store recently, was associated with some perioral cyanosis, but there has never been a convulsive activity noted.  There have been no recent changes in her Keppra dosing and she is currently only at 20 mg/kg per day, which is overall a low dose for her.,PAST MEDICAL HISTORY: , Born at 36 weeks' gestation by C-section delivery at 8 pounds 3 ounces.  She does have a history of febrile seizures and what parents reported an abdominal migraine, but on further questioning, it appears to be more of a food intolerance issue.,PAST SURGICAL HISTORY: , She has undergone no surgical procedures.,FAMILY MEDICAL HISTORY: , There is a strong history of epilepsy on the maternal side of family including mom with some nonconvulsive seizure during childhood and additional seizures in maternal great grandmother and a maternal great aunt.  There is no other significant neurological history on the paternal side of the family.,SOCIAL HISTORY: , Currently lives with her mom, dad, and two siblings.  She is at home full time and does not attend day care.,REVIEW OF SYSTEMS:  ,Clear review of 10 systems are taken and revealed no additional findings other than those mentioned in the history of present illness.,PHYSICAL EXAMINATION:,Vital Signs:  Weight was 15.6 kg.  She was afebrile.  Remainder of her vital signs were stable and within normal ranges for her age as per the medical record.,General:  She was awake, alert, and oriented.  She was in no acute distress, only slightly flustered when trying to place the EEG leads.,HEENT:  Showed normocephalic and atraumatic head.  Her conjunctivae were nonicteric and sclerae were clear.  Her eye movements were conjugate in nature.  Her tongue and mucous membranes were moist.,Neck:  Trachea appeared to be in the midline.,Chest:  Clear to auscultation bilaterally without crackles, wheezes or rhonchi.,Cardiovascular:  Showed a normal sinus rhythm without murmur.,Abdomen:  Showed soft, nontender, and nondistended, with good bowel sounds.  There was no hepatomegaly or splenomegaly, or other masses noted on examination.,Extremities:  Showed IV placement in the right upper extremity with appropriate restraints from the IV.  There was no evidence of clubbing, cyanosis or edema throughout.  She had no functional deformities in any of her peripheral limbs.,Neurological:  From neurological standpoint, her cranial nerves were grossly intact throughout.  Her strength was good in the bilateral upper and lower extremities without any distal to proximal variation.  Her overall resting tone was normal.  Sensory examination was grossly intact to light touch throughout the upper and lower extremities.  Reflexes were 1+ in bilateral patella.  Toes were downgoing bilaterally.  Coordination showed accurate striking ability and good rapid alternating movements.  Gait examination was deferred at this time due to EEG lead placement.,ASSESSMENT:,  A 2-1/2-year-old female with history of febrile seizures, now with concern for spells of unclear etiology, but somewhat concerning for partial complex seizures and to a slightly lesser extent nonconvulsive generalized seizures.,RECOMMENDATIONS,1.  For now, we will go ahead and try to capture EEG as long as she tolerates it; however, if she would require sedation, I would defer the EEG until further adjustments to seizure medications are made and we will see her response to these medications.,2.  As per the above, I will increase her Keppra to 300 mg p.o. b.i.d. bringing her to a total daily dose of just under 40 mg/kg per day.  If further spells are noted, we may increase upwards again to around 4.5 to 5 mL each day.,3.  I do not feel like any specific imaging needs to be done at this time until we see her response to the medication and review her EEG findings.  EEG, hopefully, will be able to be reviewed first thing tomorrow morning; however, I would not delay discharge the patient to wait on the EEG results.  The patient has been discharged and we will contact the family as an outpatient.,4.  The patient will need followup arrangement with me in 5 to 6 weeks' time, so we may recheck and see how she is doing and arrange for further followup then.",
" Sample normal ear, nose, mouth, and throat exam.", Consult - History and Phy., Normal ENT Exam - 1 ,"EARS, NOSE, MOUTH AND THROAT,EARS/NOSE: , The auricles are normal to palpation and inspection without any surrounding lymphadenitis.  There are no signs of acute trauma.  The nose is normal to palpation and inspection externally without evidence of acute trauma.  Otoscopic examination of the auditory canals and tympanic membranes reveals the auditory canals without signs of mass lesion, inflammation or swelling.  The tympanic membranes are without disruption or infection.  Hearing intact bilaterally to normal level speech.  Nasal mucosa, septum and turbinate examination reveals normal mucous membranes without disruption or inflammation.  The septum is without acute traumatic lesions or disruption.  The turbinates are without abnormal swelling.  There is no unusual rhinorrhea or bleeding.  ,LIPS/TEETH/GUMS:  ,The lips are without infection, mass lesion or traumatic lesions.  The teeth are intact without obvious signs of infection.  The gingivae are normal to palpation and inspection.  ,OROPHARYNX:  ,The oral mucosa is normal.  The salivary glands are without swelling.  The hard and soft palates are intact.  The tongue is without masses or swelling with normal movement.  The tonsils are without inflammation.  The posterior pharynx is without mass lesion with good patent oropharyngeal airway.","consult - history and phy., oral mucosa, lips, hearing, auditory canals, tympanic membranes, traumatic lesions, mouth, throat, trauma, nose, membranes, inflammation, infection, swelling,"
 A patient with non-Q-wave myocardial infarction.  No definite chest pains.  The patient is breathing okay.  The patient denies orthopnea or PND., Consult - History and Phy., Non-Q-wave Myocardial Infarction ,"REASON FOR CONSULT: , A patient with non-Q-wave myocardial infarction.,HISTORY OF PRESENT ILLNESS: , The patient is a pleasant 52-year-old gentleman with a history of diabetes mellitus, hypertension, and renal failure, on dialysis, who presented with emesis, dizziness, and nausea for the last few weeks.  The patient reports having worsening emesis and emesis a few times.  No definite chest pains.  The patient is breathing okay.  The patient denies orthopnea or PND.,PAST MEDICAL HISTORY:,1.  Diabetes mellitus.,2.  Hypertension.,3.  Renal failure, on dialysis.,MEDICATIONS:,  Aspirin, Coreg, doxazosin, insulin, metoclopramide, simvastatin, and Starlix.,ALLERGIES:  ,NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient denies tobacco, alcohol or drug use.,FAMILY HISTORY: , Negative for early atherosclerotic heart disease.,REVIEW OF SYSTEMS: , General:  The patient denies fever or chills.  Pulmonary:  The patient denies hemoptysis.  Cardiovascular:  Refer to HPI.  GI:  The patient denies hematemesis or melena.  The rest of systems review is negative.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse 71, blood pressure 120/70, and respiratory rate 18.,GENERAL:  A well-nourished, well-developed male in no acute distress.,HEENT:  Normocephalic, atraumatic.  Pupils seem to be equal, round, and reactive.  Extraocular muscles are full, but the patient has left eye ptosis.,NECK:  Supple without JVD or lymphadenopathy.,LUNGS:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  PMI is displaced 0.5 cm lateral to the midclavicular line.  Regular rate and rhythm, S1, S2.  No definite S3, 2/6 holosystolic murmur at the apex radiating to the axilla.,ABDOMEN:  Positive bowel sounds, nondistended and nontender.  No hepatosplenomegaly.,EXTREMITIES:  Trace pedal edema.,EKG shows atrial fibrillation with rapid ventricular response at 164 with old anteroseptal myocardial infarction and old inferior wall myocardial infarction.  Subsequent EKG in sinus rhythm shows sinus rhythm with old inferior wall myocardial infarction and probable anteroseptal myocardial infarction with Q-waves in V1, V2, and up to V3.,LABORATORY EXAM: , WBC 28,800, hemoglobin 13.6, hematocrit 40, and platelets 266,000.  PT 11.3, INR 1.1, and PTT 24.1.  Sodium 126, potassium 4.3, chloride 86, CO2 26, glucose 371, BUN 80, and creatinine 8.4.  CK was 261, then 315, and then 529 with CK-MB of 8.06, then 8.69, and then 24.6.  Troponin was 0.051, then 0.46, and then 19.8 this morning.,IMPRESSION:,1.  Paroxysmal atrial fibrillation.  The heart rate was slowed down with IV Cardizem, the patient converted to sinus rhythm.  The patient is currently in sinus rhythm.,2.  Emesis.  The etiology is unclear.  The patient reports that the emesis is better.  The patient is just having some nausea.,3.  Non-Q-wave myocardial infarction.  EKG shows atrial fibrillation with old anteroseptal myocardial infarction and old inferior wall myocardial infarction.,4.  Diabetes mellitus.,5.  Renal failure.,6.  Hypertension.,7.  Hypercholesterolemia.,PLAN:,1.  We will start amiodarone to keep from going back into atrial fibrillation.,2.  Echocardiogram.,3.  Aspirin and IV heparin.,4.  Serial CK-MB and troponin.,5.  Cardiac catheterization, possible percutaneous coronary intervention.  The risks, benefits, and alternatives were explained to the patient through a translator.  The patient understands and wishes to proceed.,6.  IV Integrilin.",
" The patient comes in for a neurology consultation regarding her difficult headaches, tunnel vision, and dizziness. ", Consult - History and Phy., Neuropsychological Evaluation - 5 ,"PROBLEMS AND ISSUES:,1.  Headaches, nausea, and dizziness, consistent with a diagnosis of vestibular migraine, recommend amitriptyline for prophylactic treatment and Motrin for abortive treatment.,2.  Some degree of peripheral neuropathy, consistent with diabetic neuropathy, encouraged her to watch her diet and exercise daily.,HISTORY OF PRESENT ILLNESS: , The patient comes in for a neurology consultation regarding her difficult headaches, tunnel vision, and dizziness.  I obtained and documented a full history and physical examination.  I reviewed the new patient questionnaire, which she completed prior to her arrival today.  I also reviewed the results of tests, which she had brought with her.,Briefly, she is a 60-year-old woman initially from Ukraine, who had headaches since age 25.  She recalls that in 1996 when her husband died her headaches became more frequent.  They were pulsating.  She was given papaverine, which was successful in reducing the severity of her symptoms.  After six months of taking papaverine, she no longer had any headaches.  In 2004, her headaches returned.  She also noted that she had ""zig-zag lines"" in her vision.  Sometimes she would not see things in her peripheral visions.  She had photophobia and dizziness, which was mostly lightheadedness.  On one occasion she almost had a syncope.  Again she has started taking Russian medications, which did help her.  The dizziness and headaches have become more frequent and now occur on average once to twice per week.  They last two hours since she takes papaverine, which stops the symptoms within 30 minutes.,PAST MEDICAL HISTORY: ,Her past medical history is significant for injury to her left shoulder, gastroesophageal reflux disorder, diabetes, anxiety, and osteoporosis.,MEDICATIONS:,  Her medications include hydrochlorothiazide, lisinopril, glipizide, metformin, vitamin D, Centrum multivitamin tablets, Actos, lorazepam as needed, Vytorin, and Celexa.,ALLERGIES: , She has no known drug allergies.,FAMILY HISTORY:  ,There is family history of migraine and diabetes in her siblings.,SOCIAL HISTORY: , She drinks alcohol occasionally.,REVIEW OF SYSTEMS: , Her review of systems was significant for headaches, pain in her left shoulder, sleeping problems and gastroesophageal reflex symptoms.  Remainder of her full 14-point review of system was unremarkable.,PHYSICAL EXAMINATION:,  On examination, the patient was pleasant.  She was able to speak English fairly well.  Her blood pressure was 130/84.  Heart rate was 80.  Respiratory rate was 16.  Her weight was 188 pounds.  Her pain score was 0/10.  Her general exam was completely unremarkable.  Her neurological examination showed subtle weakness in her left arm due to discomfort and pain.  She had reduced vibration sensation in her left ankle and to some degree in her right foot.  There was no ataxia.  She was able to walk normally.  Reflexes were 2+ throughout.,She had had a CT scan with constant, which per Dr. X's was unremarkable.  She reports that she had a brain MRI two years ago which was also unremarkable.,IMPRESSION AND PLAN:,  The patient is a delightful 60-year-old chemist from Ukraine who has had episodes of headaches with nausea, photophobia, and dizziness since her 20s.  She has had some immigration problems in recent months and has experienced increased frequency of her migraine symptoms.  Her diagnosis is consistent with vestibular migraine.  I do not see evidence of multiple sclerosis, Ménière's disease, or benign paroxysmal positional vertigo.,I talked to her in detail about the importance of following a migraine diet.  I gave her instructions including a list of foods times, which worsen migraine.  I reviewed this information for more than half the clinic visit.  I would like to start her on amitriptyline at a dose of 10 mg at time.  She will take Motrin at a dose of 800 mg as needed for her severe headaches.,She will make a diary of her migraine symptoms so that we can find any triggering food items, which worsen her symptoms.  I encouraged her to walk daily in order to improve her fitness, which helps to reduce migraine symptoms.","consult - history and phy., nausea, dizziness, migraine, peripheral neuropathy, diabetic neuropathy, neuropathy, positional vertigo, photophobia and dizziness, neurology consultation, tunnel vision, vestibular migraine, migraine symptoms, headaches, photophobia, ataxia, "
" Patient was referred for a neuropsychological evaluation after a recent hospitalization for possible transient ischemic aphasia.  Two years ago, a similar prolonged confusional spell was reported as well.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.", Consult - History and Phy., Neuropsychological Evaluation - 3 ,"REASON FOR REFERRAL:,  The patient is a 76-year-old Caucasian gentleman who works full-time as a tax attorney.  He was referred for a neuropsychological evaluation by Dr. X after a recent hospitalization for possible transient ischemic aphasia.  Two years ago, a similar prolonged confusional spell was reported as well.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.,RELEVANT BACKGROUND INFORMATION: , Historical information was obtained from a review of available medical records and clinical interview with the patient.  A summary of pertinent information is presented below.  Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM: , The patient was brought to the Hospital Emergency Department on 09/30/09 after experiencing an episode of confusion for which he has no recall the previous day.  He has no recollection of the event.  The following information is obtained from his medical record.  On 09/29/09, he reportedly went to a five-hour meeting and stated several times ""I do not feel well"" and looked ""glazed.""  He does not remember anything from midmorning until the middle of the night and when his wife came home, she found him in bed at 6 p.m., which is reportedly unusual.  She thought he was warm and had chills.  He later returned to his baseline.  He was seen by Dr. X in the hospital on 09/30/09 and reported to him at that time that he felt that he had returned entirely to baseline.  His neurological exam at that time was unremarkable aside from missing one of three items on recall for the Mini-Mental Status Examination.  Due to mild memory complaints from himself and his wife, he was referred for more extensive neuropsychological testing.  Note that reportedly when his wife found him in bed, he was shaking and feeling nauseated, somewhat clammy and kept saying that he could not remember anything and he was repeating himself, asking the same questions in an agitated way, so she brought him to the emergency room.  The patient had an episode two years ago of transient loss of memory during which he was staring blankly while sitting at his desk at work and the episode lasted approximately two hours.  He was hospitalized at Hospital at that time as well and evaluation included negative EEG, MRI showing mild atrophy, and a neurological consultation, which did not result in a specific diagnosis, but during this episode he was also reportedly nauseous.  He was also reportedly amnestic for this episode.,In 2004, he had a sense of a funny feeling in his neck and electrodes in his head and had an MRI at that time which showed some small vessel changes.,During this interview, the patient reported that other than a coworker noticing a few careless errors in his completion of some documents and his wife reporting some mild memory changes that he had not noticed any significant decline.  He thought that his memory abilities were similar to those of his peers of his same age.  When I asked about this episode, he said he had no recall of it at all and that he ""felt fine the whole time.""  He appeared to be somewhat questioning of the validity of reports that he was amnestic and confused at that time.  So, The patient reported some age related ""memory lapses"" such as going into a room and forgetting why, sometimes putting something down and forgetting where he had put it.  However, he reported that these were entirely within normal expectations and he denied any type of impairment in his ability to continue to work full-time as a tax attorney other than his wife and one coworker, he had not received any feedback from his children or friends of any problems.  He denied any missed appointments, any difficulty scheduling and maintaining appointments.  He does not have to recheck information for errors.  He is able to complete tasks in the same amount of time as he always has.  He reported that he has not made additional errors in tasks that he completed.  He said he does write everything down, but has always done things that way.  He reported that he works in a position that requires a high level of attentiveness and knowledge and that will become obvious very quickly if he was having difficulties or making mistakes.  He did report some age related changes in attention as well, although very mild and he thought these were normal and not more than he would expect for his age.  He remains completely independent in his ADLs.  He denied any difficulty with driving or maintaining any activities that he had always participated in.  He is also able to handle their finances.  He did report significant stress recently particularly in relation to his work environment.,PAST MEDICAL HISTORY:,  Includes coronary artery disease, status post CABG in 1991, radical prostate cancer, status post radical prostatectomy, nephrectomy for the same cancer, hypertension, lumbar surgery done twice previously, lumbar stenosis many years ago in the 1960s and 1970s, now followed by Dr. Y with another lumbar surgery scheduled to be done shortly after this evaluation, and hyperlipidemia.  Note that due to back pain, he had been taking Percocet daily prior to his hospitalization.,CURRENT MEDICATIONS: , Celebrex 200 mg, levothyroxine 0.025 mg, Vytorin 10/40 mg, lisinopril 10 mg, Coreg 10 mg, glucosamine with chondroitin, prostate 2.2, aspirin 81 mg, and laxative stimulant or stool softener.  Note that medical records say that he was supposed to be taking Lipitor 40 mg, but it is not clear if he was doing so and also there was no specific reason found for why he was taking the levothyroxine.,OTHER MEDICAL HISTORY: , Surgical history is significant for hernia repair in 2007 as well.  The patient reported drinking an occasional glass of wine approximately two days of the week.  He quit smoking cigarettes 25 to 30 years ago and he was diagnosed with cancer.  He denied any illicit drug use.  Please add that his prostatectomy was done in 1993 and nephrectomy in 1983 for carcinoma.  He also had right carpal tunnel surgery in 2005 and has cholelithiasis.  Upon discharge from the hospital, the patient's sleep deprived EEG was recommended.,MRI completed on 09/30/09 showed ""mild cerebral and cerebellar atrophy with no significant interval change from a prior study dated June 15, 2007.  No evidence of acute intracranial processes identified.  CT scan was also unremarkable showing only mild cerebral and cerebellar atrophy.  EEG was negative.  Deferential diagnosis was transient global amnesia versus possible seizure disorder.  Note that he also reportedly has some hearing changes, but has not followed up with an evaluation for hearing aid.,FAMILY MEDICAL HISTORY:, Reportedly significant for TIAs in his mother, although the patient did not report this during our evaluation and so that she had no memory problems or dementia when she passed away of old age at the age of 85.  In addition, his father had a history of heart disease and passed away at the age of 75.  He has one sister with diabetes and thought his mom might have had diabetes as well.,SOCIAL HISTORY:,  The patient obtained a law degree from the University of Baltimore.  He did not complete his undergraduate degree from the University of Maryland because he was able to transfer his credits in order to attend law school at that time.  He reported that he did not obtain very good grades until he reached law school, at which point he graduated in the top 10 of his class and had no problem passing the Bar.  He thought that effort and motivation were important to his success in his school and he had not felt very motivated previously.  He reported that he repeated math classes ""every year of school"" and attended summer school every year due to that.  He has worked as a tax attorney for the past 48 years and reported having a thriving practice with clients all across the country.  He served also in the U.S.  Coast Guard between 1951 and 1953.  He has been married for the past 36 years to his wife, Linda, who is a homemaker.  They have four children and he reported having good relationship with them.  He described being very active.  He goes for dancing four to five times a week, swims daily, plays golf regularly and spends significant amounts of time socializing with friends.,PSYCHIATRIC HISTORY: , The patient denied any history of psychological or psychiatric treatment.  He reported that some stressors occasionally contribute to mildly low mood at this time, but that these are transient.,TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II), Token Test, Sentence Repetition, Visual Naming, Controlled Oral Word Association, Spelling Test, Aural Comprehension, Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Test",
 Neurologic examination sample.  , Consult - History and Phy., Neurologic Examination ,"NEUROLOGICAL EXAMINATION: , At present the patient is awake, alert and fully oriented.  There is no evidence of cognitive or language dysfunction.  Cranial nerves:  Visual fields are full.  Funduscopic examination is normal.  Extraocular movements full.  Pupils equal, round,  react to light.  There is no evidence of nystagmus noted.  Fifth nerve function is normal.  There is no facial asymmetry noted.  Lower cranial nerves are normal.  ,Manual motor testing reveals good tone and bulk throughout.  There is no evidence of pronator drift or decreased fine finger movements.  Muscle strength is 5/5 throughout.  Deep tendon reflexes are 2+ throughout with downgoing toes.  Sensory examination is intact to all modalities including stereognosis, graphesthesia.,TESTING OF STATION AND GAIT:, The patient is able to walk toe-heel and tandem walk.  Finger-to-nose and heel-to-shin moves are normal.  Romberg sign negative.  I appreciate no carotid bruits or cardiac murmurs.,Noncontrast CT scan of the head shows no evidence of acute infarction, hemorrhage or extra-axial collection.","consult - history and phy., station, motor testing, nerve function, neurologic examination, cranial nerves, cranial, extraocular, movementsNOTE"
 Sample for Neuropsychological Evaluation, Consult - History and Phy., Neuropsychological Evaluation - 1 ,"REASON FOR EVALUATION: , The patient is a 37-year-old white single male admitted to the hospital through the emergency room.  I had seen him the day before in my office and recommended him to go into the hospital.  He had just come from a trip to Taho in Nevada and he became homicidal while there.  He started having thoughts about killing his mother.  He became quite frightened by that thought and called me during the weekend we were able to see him on that Tuesday after talking to him.,HISTORY OF PRESENT ILLNESS: , This is a patient that has been suffering from a chronic psychotic condition now for a number of years.  He began to have symptoms when he was approximately 18 or 19 with auditory and visual hallucinations and paranoid delusions.  He was using drugs and smoking marijuana at that time has experimenting with LXV and another drugs too.  The patient has not used any drugs since age 25.  However, he has continued having intense and frequent psychotic bouts.  I have seen him now for approximately one year.  He has been quite refractory to treatment.  We tried different types of combination of medications, which have included Clozaril, Risperdal, lithium, and Depakote with partial response and usually temporary.  The patient has had starting with probably has had some temporary relief of the symptoms and they usually do not last more than a few days.  The dosages that we have used have been very high.  He has been on Clozaril 1200 mg combined with Risperdal up to 9 mg and lithium at a therapeutic level.  However, he has not responded.,He has delusions of antichrist.  He strongly believes that the dogs have a home in the neighborhood are communicating with him and criticizing him and he believes that all the people can communicate to him with telepathy including the animals.  He has paranoid delusions.  He also gets homicidal like prior to this admission.,PAST PSYCHIATRIC HISTORY:,  As mentioned before, this patient has been psychotic off and on for about 20 years now.  He has had years in which he did better on Clozaril and also his other medications.,With typical anti-psychotics, he has done well at times, but he eventually gets another psychotic bout.,PAST MEDICAL HISTORY: , He has a history of obesity and also of diabetes mellitus.  However, most recently, he has not been treated for diabetes since his last regular weight since he stopped taking Zyprexa.  The patient has chronic bronchitis.  He smokes cigarettes constantly up to 60 a day.,DRUG HISTORY:,  He stopped using drugs when he was 25.  He has got a lapse, but he was more than 10 years and he has been clean ever since then.  As mentioned before, he smokes cigarettes quite heavily and which has been a problem for his health since he also has chronic bronchitis.,PSYCHOSOCIAL STATUS: , The patient lives with his mother and has been staying with her for a few years now.  We have talked to her.  She is very supportive.  His only sister is also very supportive of him.  He has lived in the ABCD houses in the past.  He has done poorly in some of them.,MENTAL STATUS EXAMINATION:,  The patient appeared alert, oriented to time, place, and person.  His affect is flat.  He talked about auditory hallucinations, which are equivocal in nature.  He is not homicidal in the hospital as he was when he was at home.  His voice and speech are normal.  He believes in telepathy.  His memory appears intact and his intelligence is calculated as average.,INITIAL DIAGNOSES:,AXIS I:  Schizophrenia.,AXIS II:  Deferred.,AXIS III:  History of diabetes mellitus, obesity, and chronic bronchitis.,AXIS IV:  Moderate.,AXIS V:  GAF of 35 on admission.,INITIAL TREATMENT AND PLAN:,  Since, the patient has been on high dosages of medications, we will give him a holiday and a structured environment.  We will put him on benzodiazepines and make a decision anti-psychotic later.  We will make sure that he is safe and that he addresses his medical needs well.","consult - history and phy., neuropsychological, gaf, schizophrenia, anti-psychotic, chronic psychotic condition, delusions, hallucination, homicidal, marijuana, psychological, psychotic, smokes cigarettes, smoking, neuropsychological evaluation, clozaril, bronchitis, axis, "
" Approximately one and a half years ago, patient fell down while walking in the living room from the bedroom.  At that time, he reports both legs gave away on him and he fell.  He reported that he had some lightheadedness just before he fell and was slightly confused, but was aware of what was happening around him.", Consult - History and Phy., Neurologic Consultation - 5 ,"HISTORY OF PRESENT ILLNESS: ,The patient is a 79-year-old right-handed man who reports that approximately one and a half years ago, he fell down while walking in the living room from the bedroom.  At that time, he reports both legs gave away on him and he fell.  He reported that he had some lightheadedness just before he fell and was slightly confused, but was aware of what was happening around him.  He was able to get up shortly after falling and according to the patient and his son, subsequently returned back to normal.,He was then well until the 3rd of July 2008 when his legs again gave way on him.  This was not preceded by lightheadedness.  He was rushed to the hospital and was found to have pneumonia, and the fall was blamed on the pneumonia.  He started using a walker from that time, prior to that he was able to walk approximately two miles per day.  He again had a fall in August of 2008 after his legs gave way.  Again, there was no lightheadedness associated with this.  He was again found to have pneumonia and again was admitted to hospital after which he went to rehabilitation and was able to use his walker again after this.  He did not, however, return to the pre-July baseline.  In October of 2008, after another fall, he was found to have pneumonia again and shingles.  He is currently in a Chronic Rehabilitation Unit.  He cannot use a walker and uses a wheelchair for everything.  He states that his hands have been numb, involving all the fingers of both hands for the past three weeks.  He is also losing muscle bulk in his hands and has noticed some general weakness of his hands.  He does, however, note that strength in his hands has not been normal since July 2008, but it is clearly getting worse.  He has been aware of some fasciculations in his legs starting in August 2008, these are present both in the lower legs and the thighs.  He does not report any cramps, problems with swallowing or problems with breathing.  He reports that he has had constipation alternating with diarrhea, although there has been no loss of control of either his bowel or bladder.  He has had some problems with blood pressure drops, and does feel presyncopal when he stands.  He also reports that he has no feeling in his feet, and that his feet feel like sponges.  This has been present for about nine months.  He has also lost joint position sense in his feet for approximately nine months.,PAST MEDICAL HISTORY:,1.  Pneumonia.  He has had recurrent episodes of pneumonia, which started at approximately age 20.  These have been treated repeatedly over the years, and on average he has tended to have an episode of pneumonia once every five years, although this has been far more frequent in the past year.  He is usually treated with antibiotics and then discharged.  There is no known history of bronchiectasis, inherited lung disease or another chronic pulmonary cause for the repeated pneumonia.,2.  He has had a catheter placed for urinary retention, his urologist has told him that he thinks that this may be due to prostate enlargement.  The patient does not have any history of diabetes and does not report any other medical problems.  He has lost approximately 18 pounds in the past month.,3.  He had an appendectomy in the 1940s.,4.  He had an ankle resection in 1975.,SOCIAL HISTORY:  ,The patient stopped smoking 27 years ago, he smoked approximately two packs a day with combined cigarettes and cigars.  He has not smoked for the past 27 years.  He hardly ever uses alcohol.  He is currently retired.,FAMILY HISTORY: , There is no family history of neuropathy, pes cavus, foot deformities, or neuromuscular diseases.  His aunt has a history of type II diabetes.,CURRENT MEDICATIONS: , Fludrocortisone 0.1 mg p.o. q.d., midodrine 5 mg p.o. q.i.d., Cymbalta 30 mg p.o. per day, Prilosec 20 mg p.o. per day, Lortab 10 mg p.o. per day, Amoxil 500 mg p.o. per day, vitamin B12 1000 mcg weekly, vitamin D 1000 units per day, Metamucil p.r.n., enteric-coated aspirin once a day, Colace 200 mg p.o. q.d., Senokot three tablets p.o. p.r.n., Reglan 10 mg p.o. q.6h., Xanax 0.25 mg p.o. q.8h. p.r.n., Ambien 5 mg p.o. q.h.s. p.r.n. and Dilaudid 2 mg tablets p.o. q.3h. p.r.n., Protonix 40 mg per day, and Megace 400 mg per day.,ALLERGIES:,  He has no medication or food allergies.,REVIEW OF SYSTEMS:,  Please see the health questionnaire and clinical notes from today.,GENERAL PHYSICAL EXAMINATION:,VITAL SIGNS:  BP was 137/60, P was 89, and his weight could not be measured because he was in a wheelchair.  His pain score was 0.,APPEARANCE:  No acute distress.  He is pleasant and well-groomed.,HEENT:  Atraumatic, normocephalic.  No carotid bruits appreciated.,LUNGS:  There were few coarse crackles in both lung bases.,CARDIOVASCULAR:  Revealed a normal first and second heart sound, with no third or fourth heart sound and no murmurs.  The pulse was regular and of normal volume.,ABDOMEN:  Soft with no masses and normal bowel sounds.  There were no carotid bruits.,EXTREMITIES:  No contractures appreciated.,NEUROLOGICAL EXAM:,MSE:  His orientation, language, calculations, 100-7 tests were all normal.  There was atrophy and fasciculations in both the arms and legs.,CRANIAL NERVES:  Cranial nerve examination was normal with the exception that there was some mild atrophy of his tongue and possible fasciculations.  His palatal movement was normal and gag reflex was normal.,MOTOR:  Strength was decreased in all muscle groups as follows:  Deltoid 4/4, biceps 4+/4+, triceps 5/5, wrist extensors 4+/4+, finger extensors 4-/4-, finger flexors 4-/4-, interossei 4-/4-, hip flexors 4+/4+, hip extensors 4+/4+, knee extensors 4/4, and knee flexors 4/4.  Foot dorsiflexion, plantar flexion, eversion, toe extension and toe flexion was all 0 to 1.  There was atrophy in both hands and general atrophy of the lower limb muscles.  The feet were both cold and showed dystrophic features.  Fasciculations were present mainly in the hands.  There was evidence of dysmetria and past pointing in the left hand.,REFLEXES:  Reflexes were 0 in all sites in the arms and legs.  The jaw reflex was 2+.  Vibration was severely decreased at the elbow and wrist and was absent in the fingers.  Vibration was absent in the toes and ankle bilaterally and was severely decreased at the knee.  Joint position sense was absent in the toes and severely decreased in the fingers.  Pin perception was absent in the feet and was decreased to the upper thighs.  Pin was decreased or absent in the fingers and decreased above the elbows.  The same distribution of sensory loss was found with monofilament testing.,COORDINATION:  Coordination was barely normal in the right hand.  Rapid alternating movements were decreased in the left hand greater than the right hand.  The patient was unable to stand and therefore gait, Romberg's test and balance could not be assessed.,DIAGNOSTIC STUDIES: , Previous diagnostic studies and patient reports.  There were extensive patient reports, all of which were reviewed.  A previous x-ray study of the lateral chest performed in October 2008 showed poor inspiration with basilar atelectasis and an infiltrate.  An x-ray of the cervical, thoracic and lumbar spine showed some evidence of lumbar spinal stenosis.  A CTA of the neck with and without contrast performed in November 2008 showed minor stenosis in the left carotid, a mild hard and soft plaque in the right carotid with approximately 55% stenosis.  The posterior circulation showed a slightly dominant right vertebral artery with no stenosis.  There was no significant stenosis, but there was minor extracranial stenosis noted.  An MRI of the brain with and without contrast performed in November 2008 showed no evidence of an acute infarct, major vascular occlusion, and no abnormal enhancement with gadolinium administration.  There was also no significant sinusitis or mastoiditis.  This was an essentially normal brain MRI.  A CBC performed in January 2009 showed an elevated white cell count of 11.3, a low red cell count of 3.43, elevated MCH of 32.4 and the rest of the study was normal.  An electrolyte study performed in January 2009 showed a sodium which was low at 127, a calcium which was low at 8.3, and a low protein of 5.2 and albumin of 3.1.  The glucose was 86.  TSH performed in January 2009 was 1.57, which is within the normal range.  Vitamin B12 was greater than a 1000, which is normal and the folate was 18.2, which was normal.  A myocardial stress study performed in December 2008 showed normal myocardial perfusion with Persantine Cardiolite SPECT.  The ECG was non-diagnostic.  There was normal regional wall motion of the left ventricle.  The left ventricular ejection fraction was 68%, which is within the normal range for males.  A CT of the lumbar spine without contrast performed in December 2008 showed a broad-based disc bulge at L1-L2, L2-L3, L3-L4 and L4-L5.  At L5-S1, in addition to the broad-based disc bulge, there was also an osteophyte complex and evidence of flavum hypertrophy without canal stenosis.  There was severe bilateral neural foraminal stenosis at L5-S1 and moderate neural foraminal stenosis at L1-L4.  An echocardiogram was performed in November 2008 and showed mild left atrial enlargement, normal left ventricular systolic function, mild concentric left ventricular hypertrophy, scleral degenerative changes in the aortic and mitral apparatus, mild mitral regurgitation, mild tricuspid regurgitation and mild to moderate aortic regurgitation.,DIAGNOSTIC IMPRESSION:  ,The patient presents with a severe neuropathy with marked large fiber sensory as well as motor findings.  He is diffusely weak as well as atrophic in all muscle groups both in his upper and lower extremities, although he is disproportionately weak in his lower extremities.  His proprioceptive and vibratory loss is severe in both the distal upper and lower extremities, signifying that he either has a severe sensory neuropathy or has involvement of the dorsal root ganglia.  According to the history, which was carefully checked, the initial onset of these symptoms goes back one and a half years, although there has only been significant progression in his condition since July 2008.  As indicated below, further diagnostic studies including a detailed nerve conduction and EMG test today showed evidence of a severe sensory, motor, and axonal neuropathy and in addition there was evidence of a diffuse polyradiculopathy.  There was no involvement of the tongue on EMG.  The laboratory testing as indicated below failed to show a specific cause for the neuropathy.  We are still, however, waiting for the paraneoplastic antibodies, which were send out lab to the Mayo Clinic.  This type of very severe sensorimotor neuropathy with significant proprioceptive loss may be seen in several conditions including peripheral nerve vasculitis due to a variety of disorders such as SLE, Sjogren's, rheumatoid arthritis, and mixed connective tissue disease.  In addition, it may also be seen with certain toxins, particularly chemotherapeutic agents.  The patient did not receive any of these.  It may also be seen as part of a paraneoplastic syndrome.  Although the patient does not have any specific clinical symptoms of a cancer, it is noted that he has had an 18-pound weight loss in the past month and does have a remote history of smoking.  We have requested that he obtain a CT of his chest, abdomen and pelvis while he is in Acute Rehabilitation.  The verbal reports of these possibly did not show any evidence of a cancer.  We did also request that he obtain a gallium scan to see if there was any evidence of an unsuspected neoplasm.  The patient did undergo a nerve and muscle biopsy, this was a radial nerve and biceps muscle biopsy from the left arm.  This showed evidence of severe axonal loss.  There was no evidence of a vasculitis.  The vessels did show some mild intimal changes that would be consistent with atherosclerosis.  There were a few perivascular changes; however, there was no clear evidence of a necrotizing vasculitis even on multiple sections.  The muscle biopsy showed severe muscle fiber atrophy, with evidence of fiber grouping.  Again, there was no evidence of inflammation or vasculitis.  Evaluation so far has also shown no evidence of an amyloid neuropathy, no evidence of a monoclonal gammopathy, of sarcoidosis, and again there is no past history of a significant toxin or infective cause for the neuropathy.  Specifically, there is no history of HIV exposure.  We would await the results of the gallium scan and of the paraneoplastic antibodies to see if these are helpful in making a diagnosis.  At this point, because of the severity and the axonal nature of the neuropathy, there is no specific therapy that will reverse the course of the illness, unless we find a specific etiology that can be stopped or reversed.  I have discussed these issues at length with the patient and with his son.  We also addressed whether or not there might be a previously undiagnosed inherited neuropathy.  I think this is unlikely given the short history and the rapid progression of the disorder.,There is also no family history that we can detect a neuropathy, and the patient does not have the typical phenotype for a chronic inherited neuropathy such as Charcot-Marie-Tooth disease type 2.  However, since I have only seen the patient on one occasion and do not know what his previous examination showed two years ago, I cannot be certain that there may not have been the presence of a neuropathy preceding this.,PLAN:,1.  Nerve conduction and EMG will be performed today.  The results were indicated above.,2.  The following laboratory studies were requested including electrolytes, CBC, thyroid function tests, B12, ANA, C-reactive protein, complement, cryoglobulins, double-stranded DNA antibodies, folate level, hemoglobin A1c, immunofixation electrophoresis, P-ANCA, C-ANCA, protein electrophoresis, rheumatoid factor, paraneoplastic antibody studies requested from the Mayo Clinic, B12.  These studies showed minor changes, which included a low sodium level of 129 as previously noted, a low creatinine of 0.74, low calcium of 8.6, low total protein of 5.7.  The B12 was greater than 2000.  The immunoelectrophoresis, ANA, double-stranded DNA, ANCA, hemoglobin A1c, folate, cryoglobulins, complement, C-reactive protein were all normal or negative.  The B12 level was greater than 2000.  Liver function tests were normal.  The glucose was 90.  ESR was 10.  Hemoglobin A1c was 5.5.,3.  A left radial sensory and left biceps biopsy were requested and have been performed and interpreted as indicated above.,4.  CT of chest, abdomen and pelvis.,5.  Whole body gallium scan for evidence of an underlying neoplasm.,6.  The patient will go to the Rehabilitation Facility for Acute Rehabilitation and Training.,7.  We have not made any changes to his medication.  He does have some mild orthostatic changes; however, he is adequately controlled with midodrine at a dose of 2.5 mg three times a day as needed up to 5 mg four times a day.  Usually, he uses a lower dose of 2.5 three times a day to 5 mg three times a day.,8.  Followup will be as determined by the family.",
" A neuropsychological evaluation to assess neuropsychological factors, clarify areas of strength and weakness, and to assist in therapeutic program planning in light of episodes of syncope.", Consult - History and Phy., Neuropsychological Evaluation - 2 ,"REASON FOR REFERRAL:  ,The patient was referred for a neuropsychological evaluation by Dr. X.  A comprehensive evaluation was requested to assess neuropsychological factors, clarify areas of strength and weakness, and to assist in therapeutic program planning in light of episodes of syncope.,BRIEF SUMMARY & IMPRESSIONS:,RELEVANT HISTORY:,Historical information was obtained from a review of available medical records and an interview with ,the patient.,The patient presented to Dr. X on August 05, 2008 as she had been recently hospitalized for prolonged episodes of syncope.  She was referred to Dr. X for diagnostic differentiation for possible seizures or other causes of syncope.  The patient reports an extensive neurological history.  Her mother used alcohol during her pregnancy with the patient.  In spite of exposure to alcohol in utero, the patient reported that she achieved ""honors in school"" and ""looked smart.""  She reported that she began to experience migraines at 11 years of age.  At 15 years of age, she reported that she was thought to have hydrocephalus.  She reported that she will frequently ""bang her head against the wall"" to relieve the pain.  The patient gave birth to her daughter at 17 years of age.  At 18 years of age, she received a spinal tap as a procedure to determine the cause of her severe headaches.  She reported, in 1995 to 1996 she experienced a severe head injury, as she was struck by a car as a pedestrian and ""thrown two and a half city blocks.""  The patient reported that she could recall before being hit, but could not recall the activities of that same day or the following day.  She reported that she had difficulty walking following this head injury, but received rehabilitation for approximately one month.  Her migraines became more severe following the head injury.  In 1998, she reportedly was experiencing episodes of syncope where she would experience a headache with photophobia, phonophobia, and flashing lights.  Following the syncope episode, she would experience some confusion.  These episodes reportedly were related to her donating plasma.,The patient also reported that her ex-husband stated that she frequently jerked and would shake in her sleep.  She reported that upon awakening, she would feel off balanced and somewhat confused.  These episodes diminished from 2002 to June 2008.  When making dinner, she suddenly dropped and hit the back of her head on refrigerator.  She reported that she was unconscious for five to six minutes.  A second episode occurred on July 20th when she lost consciousness for may be a full day.  She was admitted to Sinai Hospital and assessed by a neurologist.  Her EEG and head CT were considered to be completely normal.  She did not report any typical episodes during the time of her 36-hour EEG.  She reported that her last episode of syncope occurred prior to her being hospitalized.  She stated that she had an aura of her ears ringing, vision being darker and ""tunnel vision"" (vision goes smaller to a pinpoint), and she was ""spazzing out"" on the floor.  During these episodes, she reports that she cannot talk and has difficulty understanding.,The patient also reports that she has experienced some insomnia since she was 6 years old.  She reported that she was a heavy drinker until about 1998 or 1999 and that she would drink a gallon daily of Jack Daniel.  She stopped the use of alcohol and that time she experienced a suicide attempt.  In 2002, she was diagnosed with bipolar disorder and was started on medication.  At the time of the neuropsychological evaluation, she had stopped taking her medicine as she felt that she was now in remission and could manage her symptoms herself.  The patient's medical history is also significant for postpartum depression.,The patient reported that she has been experiencing difficulty with cognitive abilities of attention/concentration, spelling, tangential and slow thinking, poor sequencing memory for events, and variable verbal memory.  She reported that she sometimes has difficulty understanding what people say, specifically she has difficulty understanding jokes.  She finds that she often has difficulty with expressing her thoughts, as she is very tangential.  She experiences episodes of not recalling what she was speaking of or remembering what activities she was trying to perform.  She reported that she had a photographic memory for directions.  She said that she experienced a great deal of emotional lability, but in general her personality has become more subdued.  At the present time, her daughter has now moved on to college.  The patient is living with her biological mother.  Although she is going through divorce, she reported that it was not really stressful.  She reported that she spends her day driving other people around and trying to be helpful to them.,At the time of the neuropsychological evaluation, the patient's medication included Ativan, Imitrex, Levoxyl, vitamin B12, albuterol metered dose inhaler as needed, and Zofran as needed.  (It should be noted that The patient by the time of the feedback on September 19, 2008 had resumed taking her Trileptal for bipolar disorder.).  The patient's familial medical history is significant for alcohol abuse, diabetes, hypertension, and high cholesterol.,TESTS ADMINISTERED:,Clinical Interview,Cognistat,Mattis Dementia Rating Scale,Wechsler Adult Intelligence Scale - III (WAIS-III),Wechsler Abbreviated Scale of Intelligence (WASI),Selected Subtests from the Delis Kaplan Executive Function System (DKEFS),  Trail Making Test,  Verbal Fluency (Letter Fluency & Category Fluency),  Design Fluency,  Color-Word Interference Test,  Tower,Wisconsin Card Sorting Test (WCST),Stroop Test,Color Trails,Trails A & B,Test of Variables of Attention,Multilingual Aphasia Examination II,  Token Test,  Sentence Repetition,  Visual Naming,  Controlled Oral Word Association,  Spelling Test,  Aural Comprehension,  Reading Comprehension,Boston Naming Test-2 (BNT-2),Animal Naming Test,The Beery-Buktenica Developmental Test of Visual-Motor Integration (VMI),The Beery-Buktenica Developmental Test of Motor Coordination,The Beery-Buktenica Developmental Test of Visual Perception,Judgment Line Orientation,Grooved Pegboard,Purdue Pegboard,Finger Tapping Test,Rey Complex Figure,Wechsler Memory Scale -III (WMS-III),California Verbal Learning Test",
 Patient demonstrated mild cognitive deficits on a neuropsychological screening evaluation during a followup appointment for stroke., Consult - History and Phy., Neuropsychological Evaluation ,"REASON FOR REFERRAL: , Ms. A is a 60-year-old African-American female with 12 years of education who was referred for neuropsychological evaluation by Dr. X after she demonstrated mild cognitive deficits on a neuropsychological screening evaluation during a followup appointment with him for stroke in July.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.,RELEVANT BACKGROUND INFORMATION:,  Historical information was obtained from a review of available medical records and clinical interview with Ms. A.  A summary of pertinent information is presented below.  Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM:,  Ms. A presented to the ABC Hospital emergency department on 07/26/2009 reporting that after she had woken up that morning she noticed numbness and weakness in her left hand, slurred speech, and left facial droop.  Neurological evaluation with Dr. X confirmed left hemiparesis.  Brain CT showed no evidence of intracranial hemorrhage or mass effect and that she received TPA and had moderate improvement in left-sided weakness.  These symptoms were thought to be due to a right middle cerebral artery stroke.  She was transferred to the ICU for monitoring.  Ultrasound of the carotids showed 20% to 30% stenosis of the right ICA and 0% to 19% stenosis of the left ICA.  On 07/29/2009, she was admitted for acute inpatient rehabilitation for the treatment of residual functional deficits of her acute ischemic right MCA/CVA.  At discharge on 08/06/2009, she was mainly on supervision for all ADLs and walking with a rolling walker, but tolerating increased ambulation with a cane.  She was discharged home with recommendations for outpatient physical therapy.  She returned to the Sinai ER on 08/2009/2009 due to reported left arm pain, numbness, and weakness, which lasted 10 to 15 minutes and she reported that it felt ""just like the stroke.""  Brain CT on 08/2009/2009 was read as showing ""mild chronic microvascular ischemic change of deep white matter,"" but no acute or significant interval change compared to her previous scan.  Neurological examination with Dr. Y was within normal limits, but she was admitted for a more extensive workup.  Due to left arm pain an ultrasound was completed on her left upper extremity, but it did not show deep vein thrombosis.,Followup CT on 08/10/2009 showed no significant interval change.  MRI could not be completed due to the patient's weight.  She was discharged on 08/11/2009 in stable condition after it was determined that this event was not neurological in origin; however, note that Ms. A referred to this as a second stroke.,Ms. A presented for a followup outpatient neurological evaluation with Dr. X on 09/22/2009, at which time a brief neuropsychological screening was also conducted.  She demonstrated significant impairments in confrontation naming, abstract verbal reasoning, and visual and verbal memory and thus a more comprehensive evaluation was suggested due to her intent to return to her full-time work duty.  During the current interview, Ms. A reported that she noticed mild memory problems including some difficultly remembering conversations, events, and at times forgetting to take her medications.  She also reported mild difficulty finding words in conversation, solving novel problems and tasks (e.g. difficulty learning to use her camcorder), but overall denied significant cognitive deficits in attention, concentration, language or other areas of cognitive functioning.  When asked about her return to work, she said that she was still on light duty due to limited physical activity because of residual left leg weakness.  She reported that no one had indicated to her that she appeared less capable of performing her job duties, but said that she was also receiving fewer files to process and enter data into the computer at the Social Security Agency that she works at.  Note also that she had some difficulty explaining exactly what her job involved.  She also reported having problems falling asleep at work and that she is working full-time although on light duty.,OTHER MEDICAL HISTORY:  ,As mentioned, Ms. A continues to have some residual left leg weakness and continues to use a rolling walker for ambulation, but she reported that her motor functioning had improved significantly.  She was diagnosed with sleep apnea approximately two years ago and was recently counseled by Dr. X on the need to use her CPAP because she indicated she never used it at night.  She reported that since her appointment with Dr. X, she has been using it ""every other night.""  When asked about daytime fatigue, Ms. A initially denied that she was having any difficulties, but repeatedly indicated that she was falling asleep at work and thought that it was due to looking at a computer screen.  She reported at times ""snoring"" and forgetting where she is at and said that a supervisor offered to give her coffee at one point.  She receives approximately two to five hours of sleep per night.  Other current untreated risk factors include obesity and hypercholesterolemia.  Her medical history is also significant for hypertension, asthma, abdominal adenocarcinoma status post hysterectomy with bilateral salpingo-oophorectomy, colonic benign polyps status post resection, benign lesions of the breast status post lumpectomy, and deep vein thrombosis in the left lower extremity status post six months of anticoagulation (which she had discontinued just prior to her stroke).,CURRENT MEDICATIONS: , Aspirin 81 mg daily, Colace 100 mg b.i.d., Lipitor 80 mg daily, and albuterol MDI p.r.n.,SUBSTANCE USE:,  Ms. A denied drinking alcohol or using illicit drugs.  She used to smoke a pack of cigarettes per day, but quit five to six years ago.,FAMILY MEDICAL HISTORY: , Ms. A had difficulty providing information on familial medical history.  She reported that her mother died three to four years ago from lung cancer.  Her father has gout and blood clots.  Siblings have reportedly been treated for asthma and GI tumors.  She was unsure of familial history of other conditions such as hypertension, high cholesterol, stroke, etc.,SOCIAL HISTORY: , Ms. A completed high school degree.  She reported that she primarily obtained B's and C's in school.  She received some tutoring for algebra in middle school, but denied ever having been held back a grade failing any classes or having any problems with attention or hyperactivity.,She currently works for the Social Security Administration in data processing.  As mentioned, she has returned to full-time work, but continues to perform only light duties due to her physical condition.  She is now living on her own.  She has never driven.  She reported that she continues to perform ADLs independently such as cooking and cleaning.  She lost her husband in 2005 and has three adult daughters.  She previously reported some concerns that her children wanted her to move into assisted living, but she did not discuss that during this current evaluation.  She also reported number of other family members who had recently passed away.  She has returned to activities she enjoys such as quire, knitting, and cooking and plans to go on a cruise to the Bahamas at the end of October.,PSYCHIATRIC HISTORY: , Ms. A did not report a history of psychological or psychiatric treatment.  She reported that her current mood was good, but did describe some anxiety and nervousness about various issues such as her return to work, her upcoming trip, and other events.  She reported that this only ""comes and goes."",TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II),  Token Test,  Sentence Repetition,  Visual Naming,  Controlled Oral Word Association,  Spelling Test,  Aural Comprehension,  Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Test",
" Muscle twitching, clumsiness, progressive pain syndrome, and gait disturbance.  Probable painful diabetic neuropathy.  Symptoms are predominantly sensory and severely dysfunctioning, with the patient having inability to ambulate independently as well as difficulty with grip and temperature differentiation in his upper extremities.  ", Consult - History and Phy., Neurologic Consultation - 4 ,"REASON FOR NEUROLOGICAL CONSULTATION:,  Muscle twitching, clumsiness, progressive pain syndrome, and gait disturbance.,HISTORY OF PRESENT ILLNESS: , The patient is a 62-year-old African-American male with a significant past medical history of diabetes, hypertension, previous stroke in 2002 with minimal residual right-sided weakness as well as two MIs, status post pacemaker insertion who first presented with numbness in his lower extremities in 2001.  He states that since that time these symptoms have been progressive and now involving his legs above his knees as well as his hands.  More recently, he describes a burning sensation along with numbness.  This has become a particular problem and of all the problems he has he feels that pain is his primary concern.  Over the last six months, he has noticed that he cannot feel hot objects in his hands and that objects slip out of his hands.  He denies any weakness per se, just clumsiness and decreased sensation.  He has also been complaining of brief muscle jerks, which occur in both hands and his shoulders.  This has been a fairly longstanding problem, and again has become more prevalent recently.  He does not have any tremor.  He denies any neck pain.  He walks with the aid of a walker because of unsteadiness with gait.,Recently, he has tried gabapentin, but this was not effective for pain control.  Oxycodone helps somewhat and gives him at least three hours pain relief.  Because of the pain, he has significant problems with fractured sleep.  He states he has not had a good night's sleep in many years.  About six months ago, after an MI and pacemaker insertion, he was transferred to a nursing facility.  At that facility, his insulin was stopped.  Since then he has only been on oral medication for his diabetes.  He denies any back pain, neck pain, change in bowel or bladder function, or specific injury pre-dating these symptoms., ,PAST MEDICAL HISTORY: , Diabetes, hypertension, coronary artery disease, stroke, arthritis, GERD, and headaches.,MEDICATIONS: , Trazodone, simvastatin, hydrochlorothiazide, Prevacid, lisinopril, glipizide, and gabapentin.,FAMILY HISTORY: , Discussed above and documented on the chart.,SOCIAL HISTORY: , Discussed above and documented on the chart.  He does not smoke.  He lives in a senior citizens building with daily nursing aids.  He previously was a security guard, but is currently on disability.,REVIEW OF SYSTEMS: , Discussed above and documented on the chart.,PHYSICAL EXAMINATION: , On examination, blood pressure 150/80, pulse of 80, respiratory rate 22, and weight 360 pounds.  Pain scale 7/10.  A full general and neurological examination was performed on the patient and is documented on the chart.,The patient is obese with significant ankle edema.,Neurological examination reveals normal cognitive exam and normal cranial nerve examination.  Motor examination reveals mild atrophy in bilateral FDIs, but still has a strong grip.  Individual muscle strength is close to normal with only subtle weakness found in ankle plantar and dorsiflexion.  Tone and bulk are normal.  Sensory examination reveals a severe decrease to all modalities in his lower extremities from just above the knees distally.  He has no vibration sense at his knees.  Similarly, there is decrease to all sensory modalities in his both upper extremities from just above the wrist distally.  The only reflexes I could obtain with trace reflexes in his biceps.  Remaining reflexes were unelicitable.  No Babinski.  The patient walks normally with the aid of a cane.  He has severe sensory ataxia with inability to walk unaided.  Positive Romberg with eyes open and closed.,IMPRESSION AND PLAN:,1.  Probable painful diabetic neuropathy.  Symptoms are predominantly sensory and severely dysfunctioning, with the patient having inability to ambulate independently as well as difficulty with grip and temperature differentiation in his upper extremities.  He has relative preservation of motor function.  Because these symptoms are progressive and, by report, he came off his insulin, suggesting somewhat mild diabetes, I would like to rule out other causes of progressive neuropathy.,2.  He has history of myoclonic jerks.  I did not see any on my examination today and I feel that these are benign and probably secondary to his severe insomnia, which he states is secondary to the painful neuropathy.  I would like to rule out other causes such as hepatic encephalopathy., ,I have recommended the following:,1.  EMG/nerve conduction study to assess severity of neuropathy and to characterize neuropathy.,2.  Blood work, looking for other causes of neuropathy and myoclonus, to include CBC, CMP, TSH, LFT, B12, RPR, ESR, Lyme titer, and HbA1c, and ammonia level.,3.  Neurontin and oxycodone have not been effective, and I have recommended Cymbalta starting at 30 mg q.d. for five days and then increasing to 60 mg q.d.  Side effect profile of this medication was discussed with the patient.,4.  I have explained to him that progression of diabetic neuropathy is closely related to diabetic control and I have recommended tight diabetic control.,5.  I will see him at followup at the EMG.",
 The patient is a 58-year-old African-American right-handed female with 16 years of education who was referred for a neuropsychological evaluation by Dr. X.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning., Consult - History and Phy., Neuropsychological Evaluation - 4 ,"REASON FOR REFERRAL:,  The patient is a 58-year-old African-American right-handed female with 16 years of education who was referred for a neuropsychological evaluation by Dr. X. She is presenting for a second opinion following a recent neuropsychological evaluation that was ordered by her former place of employment that suggested that she was in the ""early stages of a likely dementia"" and was thereafter terminated from her position as a psychiatric nurse.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.  Note that this evaluation was undertaken as a clinical exam and intended for the purposes of aiding with treatment planning.  The patient was fully informed about the nature of this evaluation and intended use of the results.,RELEVANT BACKGROUND INFORMATION:  ,Historical information was obtained from a review of available medical records and clinical interview with the patient.  A summary of pertinent information is presented below.  Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM:,  The patient reported that she had worked as a nurse supervisor for Hospital Center for four years.  She was dismissed from this position in September 2009, although she said that she is still under active status technically, but is not able to work.  She continues to receive some compensation through FMLA hours.  She said that she was told that she had three options, to resign, to apply for disability retirement, and she had 90 days to complete the process of disability retirement after which her employers would file for charges in order for her to be dismissed from State Services.  She said that these 90 days are up around the end of November.  She said the reason for her dismissal was performance complaints.  She said that they began ""as soon as she arrived and that these were initially related to problems with her taking too much sick time off secondary to diabetes and fibromyalgia management and at one point she needed to obtain a doctor's note for any days off.  She said that her paperwork was often late and that she received discipline for not disciplining her staff frequently enough for tardiness or missed workdays.  She described it as a very chaotic and hectic work environment in which she was often putting in extra time.  She said that since September 2008 she only took two sick days and was never late to work, but that she continued to receive a lot of negative feedback.,In July of this year, she reportedly received a letter from personnel indicating that she was being referred to a state medical doctor because she was unable to perform her job duties and due to excessive sick time.  Following a brief evaluation with this doctor whose records we do not have, she was sent to a neuropsychologist, Dr. Y, Ph.D.  He completed a Comprehensive Independent Medical Evaluation on 08/14/2009.  She said that on 08/27/2009, she returned to see the original doctor who told her that based on that evaluation she was not able to work anymore.  Please note that we do not have copies of any of her work-related correspondence.  The patient never received a copy of the neuropsychological evaluation because she was told that it was ""too derogatory.""  A copy of that evaluation was provided directly to this examiner for the purpose of this evaluation.  To summarize, the results indicated ""diagnostically, The patient presents cognitive deficits involving visual working memory, executive functioning, and motor functioning along with low average intellectual functioning that is significantly below her memory functioning and below expectation based on her occupational and academic history.  This suggests that her intellectual functioning has declined.""  It concluded that ""results overall suggest early stages of a likely dementia or possibly the effects of diabetes, although her deficits are greater than expected for diabetes-related executive functioning problems and peripheral neuropathy…  The patient' deficits within the current test battery suggest that she would not be able to safely and effectively perform the duties of a nurse supervisor without help handling documentary demands and some supervision of her visual processing.  The prognosis for improvement is not good, although she might try stimulant medication if compatible with her other.  Following her dismissal, The patient presented to her primary physician, Henry Fein, M.D., who referred her to Dr. X for a second opinion regarding her cognitive deficits.  His neurological examination on 09/23/2009 was unremarkable.  The patient scored 20/30 on the Mini-Mental Status Exam missing one out of three words on recall, but was able to do so with prompting.  A repeat neurocognitive testing was suggested in order to assess for subtle deficits in memory and concentration that were not appreciated on this gross cognitive measure.,IMAGING STUDIES: , MRI of the brain on 09/14/2009 was unremarkable with no evidence of acute intracranial abnormality or abnormal enhancing lesions.  Note that the MRI was done with and without gadolinium contrast.,CURRENT FUNCTIONING:  ,The patient reported that she had experienced some difficulty completing paperwork on time due primarily to the chaoticness of the work environment and the excessive amount of responsibility that was placed upon her.  When asked about changes in cognitive functioning, she denied noticing any decline in problem solving, language, or nonverbal skills.  She also denied any problems with attention and concentration or forgetfulness or memory problems.  She continues to independently perform all activities of daily living.  She is in charge of the household finances, has had no problems paying bills on time, has had no difficulties with driving or accidents, denied any missed appointments and said that no one has provided feedback to her that they have noticed any changes in her cognitive functioning.  She reported that if her children had noticed anything they definitely would have brought it to her attention.  She said that she does not currently have a lawyer and does not intend to return to her previous physician.  She said she has not yet proceeded with the application for disability retirement because she was told that her doctors would have to fill out that paperwork, but they have not claimed that she is disabled and so she is waiting for the doctors at her former workplace to initiate the application.  Other current symptoms include excessive fatigue.  She reported that she was diagnosed with chronic fatigue syndrome in 1991, but generally symptoms are under better control now, but she still has difficulty secondary to fibromyalgia.  She also reported having fallen approximately five times within the past year.  She said that this typically occurs when she is climbing up steps and is usually related to her right foot ""like dragging.""  Dr. X's physical examination revealed no appreciable focal peripheral deficits on motor or sensory testing and notes that perhaps these falls are associated with some stiffness and pain of her right hip and knee, which are chronic symptoms from her fibromyalgia and osteoarthritis.  She said that she occasionally bumps into objects, but denied noticing it happening one on any particular part of her body.  Muscle pain secondary to fibromyalgia reportedly occurs in her neck and shoulders down both arms and in her left hip.,OTHER MEDICAL HISTORY: , The patient reported that her birth and development were normal.  She denied any significant medical conditions during childhood.  As mentioned, she now has a history of fibromyalgia.  She also experiences some restriction in the range of motion with her right arm.  MRI of the C-spine 04/02/2009 showed a hemangioma versus degenerative changes at C7 vertebral body and bulging annulus with small central disc protrusion at C6-C7.  MRI of the right shoulder on 06/04/2009 showed small partial tear of the distal infraspinatus tendon and prominent tendinopathy of the distal supraspinatus tendon.  As mentioned, she was diagnosed with chronic fatigue syndrome in 1991.  She thought that this may actually represent early symptoms of fibromyalgia and said that symptoms are currently under control.  She also has diabetes, high blood pressure, osteoarthritis, tension headaches, GERD, carpal tunnel disease, cholecystectomy in 1976, and ectopic pregnancy in 1974.  Her previous neuropsychological evaluation referred to an outpatient left neck cystectomy in 2007.  She has some difficulty falling asleep, but currently typically obtains approximately seven to eight hours of sleep per night.  She did report some sleep disruption secondary to unusual dreams and thought that she talked to herself and could sometimes hear herself talking in her sleep.,CURRENT MEDICATIONS:,  NovoLog, insulin pump, metformin, metoprolol, amlodipine, Topamax, Lortab, tramadol, amitriptyline, calcium plus vitamin D, fluoxetine, pantoprazole, Naprosyn, fluticasone propionate, and vitamin C.,SUBSTANCE USE: , The patient reported that she rarely drinks alcohol and she denied smoking or using illicit drugs.  She drinks two to four cups of coffee per day.,SOCIAL HISTORY:  ,The patient was born and raised in North Carolina.  She was the sixth of nine siblings.  Her father was a chef.  He completed third grade and died at 60 due to complications of diabetes.  Her mother is 93 years old.  Her last job was as a janitor.  She completed fourth grade.  She reported that she has no cognitive problems at this time.  Family medical history is significant for diabetes, heart disease, hypertension, thyroid problems, sarcoidosis, and possible multiple sclerosis and depression.  The patient completed a Bachelor of Science in Nursing through State University in 1979.  She denied any history of problems in school such as learning disabilities, attentional problems, difficulty learning to read, failed grades, special help in school or behavioral problems.  She was married for two years.  Her ex-husband died in 1980 from acute pancreatitis secondary to alcohol abuse.  She has two children ages 43 and 30.  Her son whose age is 30 lives nearby and is in consistent contact with her and she is also in frequent contact and has a close relationship with her daughter who lives in New York.  In school, the patient reported obtaining primarily A's and B's.  She said that her strongest subject was math while her worst was spelling, although she reported that her grades were still quite good in spelling.  The patient worked for Hospital Center for four years.  Prior to that, she worked for an outpatient mental health center for 2-1/2 years.  She was reportedly either terminated or laid off and was unsure of the reason for that.  Prior to that, she worked for Walter P. Carter Center reportedly for 21 years.  She has also worked as an OB nurse in the past.  She reported that other than the two instances reported above, she had never been terminated or fired from a job.  In her spare time, the patient enjoys reading, participating in women's groups doing puzzles, playing computer games.,PSYCHIATRIC HISTORY: , The patient reported that she sought psychotherapy on and off between 1991 and 1997 secondary to her chronic fatigue.  She was also taking Prozac during that time.  She then began taking Prozac again when she started working at secondary to stress with the work situation.  She reported a chronic history of mild sadness or depression, which was relatively stable.  When asked about her current psychological experience, she said that she was somewhat sad, but not dwelling on things.  She denied any history of suicidal ideation or homicidal ideation.,TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II), Token Test, Sentence Repetition, Visual Naming, Controlled Oral Word Association, Spelling Test, Aural Comprehension, Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Test",
 Neurologic consultation and follow-up., Consult - History and Phy., Neurologic Consultation - 1 ,"SOCIAL HISTORY, FAMILY HISTORY, AND PAST MEDICAL HISTORY:, Reviewed.  There are no changes, otherwise.,REVIEW OF SYSTEMS:,  Fatigue, pain, difficulty with sleep, mood fluctuations, low stamina, mild urgency frequency and hesitancy, preponderance of lack of stamina, preponderance of pain particularly in the left shoulder.,EXAMINATION: , The patient is alert and oriented.  Extraocular movements are full.  The face is symmetric.  The uvula is midline.  Speech has normal prosody.  Today there is much less guarding of the left shoulder.  In the lower extremities, iliopsoas, quadriceps, femoris and tibialis anterior are full.  The gait is narrow based and noncircumductive.  Rapid alternating movements are slightly off bilaterally.  The gait does not have significant slapping characteristics.  Sensory examination is largely unremarkable.  Heart, lungs, and abdomen are within normal limits.,IMPRESSION: , Mr. ABC is doing about the same.  We discussed the issue of adherence to Copaxone.  In order to facilitate this, I would like him to take Copaxone every other day, but on a regular rhythm.  His wife continues to inject him.  He has not been able to start himself on the injections.,Greater than 50% of this 40-minute appointment was devoted to counseling.","consult - history and phy., neurologic consultation, stamina, preponderance, neurologic, consultation, copaxone,"
 Neurologic consultation was requested to assess and assist with seizure medication., Consult - History and Phy., Neurologic Consultation - 3 ,"HISTORY: , Neurologic consultation was requested to assess and assist with her seizure medication.  The patient is a 3-year 3 months old girl with refractory epilepsy.  She had been previously followed by XYZ, but has been under the care of the UCSF epilepsy program and recently by Dr. Y.  I reviewed her pertinent previous neurology evaluations at CHCC and also interviewed mom.,The patient had seizure breakthrough in August 2007, which requires inpatient admission, Thanksgiving and then after that time had seizures every other day, up-to-date early December.  She remained seizure-free until 12/25/2007 when she had a breakthrough seizure at home treated with Diastat.  She presented to our ER today with prolonged convulsive seizure despite receiving 20 mg of Diastat at home.  Mom documented 103 temperature at home.  In the ER, this was 101 to 102 degrees Fahrenheit.  I reviewed the ER notes.  At 0754 hours, she was having intermittent generalized tonic-clonic seizures despite receiving a total of 1.5 mg of lorazepam x5.  UCSF fellow was contacted.  She was given additional fosphenytoin and had a total dose of 15 mg/kg administered.  Vital weight was 27.  Seizures apparently had stopped.  The valproic acid level obtained at 0835 hours was 79.  According to mom, her last dose was at 6 p.m. and she did not receive her morning dose.  Other labs slightly showed leukocytosis with white blood cell count 21,000 and normal CMP.,Previous workup here showed an EEG on 2005, which showed a left posterior focus.  MRI on June 2007 and January 2005 were within normal limits.  Mom describes the following seizure types:,1.  Eye blinking with unresponsiveness.,2.  Staring off to one side.,3.  Focal motor activity in one arm and recently generalized tonic seizure.,She also said that she was supposed to see Dr. Y this Friday, but had postponed it to some subsequent time when results of genetic testing would be available.  She was being to physicians' care as Dr. Z had previously being following her last UCSF.,She had failed most of the first and second line anti-epileptic drugs.  These include Keppra, Lamictal, Trileptal, phenytoin and phenobarbital.  These are elicited to allergies, but she has not had any true allergic reactions to these.  Actually, it has resulted in an allergic reaction resulting in rash and hypotension.,She also had been treated with Clobazam.  Her best control is with her current regimen of valproic acid and Tranxene.  Other attempts to taper Topamax, but this resulted increased seizures.  She also has oligohidrosis during this summertime.,CURRENT MEDICATIONS: , Include Diastat 20 mg; Topamax 25 mg b.i.d., which is 3.3 per kilo per day; Tranxene 15 mg b.i.d.; Depakote 125 mg t.i.d., which is 25 per kilo per day.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Weight 15 kg.,GENERAL:  The patient was awake, she appeared sedated and postictal.,NECK:  Supple.,NEUROLOGICAL:  She had a few brief myoclonic jerks of her legs during drowsiness, but otherwise no overt seizure, no seizure activity nor involuntary movements were observed.,She was able to follow commands such as when I request that she gave mom a kiss.  She acknowledged her doll.  Left fundus is sharp.  She resisted the rest of the exam.  There was no obvious lateralized findings.,ASSESSMENT:,  Status epilepticus resolved.  Triggered by a febrile illness, possibly viral.  Refractory remote symptomatic partial epilepsy.,IMPRESSION: , I discussed the maximizing Depakote to mom and she concurred.  I recommend increasing her maintenance dose to one in the morning, one in the day, and two at bedtime.  For today, she did give an IV Depacon 250 mg and the above dosage can be continued IV until she is taking p.o.  Dr. X agreed with the changes and orders were written for this.  She can continue her current doses of Topamax and Tranxene.  This can be given by NG if needed.  Topamax can be potentially increased to 25 mg in the morning and 50 mg at night.  I will be available as needed during the rest of her hospitalization.  Mom will call contact Dr. Y an update him about the recent changes.","consult - history and phy., eye blinking, status epilepticus, seizure medication, valproic acid, allergic reactions, neurologic consultation, seizure, neurologic, seizures,"
" Patient has trouble with walking and balance, with bladder control, and with thinking and memory.", Consult - History and Phy., Neurologic Consultation - 2 ,"REASON FOR VISIT:  ,The patient is a 76-year-old man referred for neurological consultation by Dr. X.  The patient is companied to clinic today by his wife and daughter.  He provides a small portion of his history; however, his family provides virtually all of it.,HISTORY OF PRESENT ILLNESS: , He has trouble with walking and balance, with bladder control, and with thinking and memory.  When I asked him to provide me detail, he could not tell me much more than the fact that he has trouble with his walking and that he has trouble with his bladder.  He is vaguely aware that he has trouble with his memory.,According to his family, he has had difficulty with his gait for at least three or four years.  At first, they thought it was weakness and because of he was on the ground (for example, gardening) he was not able to get up by himself.  They did try stopping the statin that he was taking at that time, but because there was no improvement over two weeks, they resumed the statin.  As time progressed, he developed more and more difficulty.  He started to shuffle.  He started using a cane about two and a half years ago and has used a walker with wheels in the front since July of 2006.  At this point, he frequently if not always has trouble getting in or out of the seat.  He frequently tends to lean backwards or sideways when sitting.  He frequently if not always has trouble getting in or out a car, always shuffles or scuffs his feet, always has trouble turning or changing direction, always has trouble with uneven surfaces or curbs, and always has to hold on to someone or something when walking.  He has not fallen in the last month.  He did fall earlier, but there seemed to be fewer opportunities for him to fall.  His family has recently purchased a lightweight wheelchair to use if he is traveling long distances.  He has no stairs in his home, however, his family indicates that he would not be able to take stairs.  His handwriting has become smaller and shakier.,In regard to the bladder, he states, ""I wet the bed.""  In talking with his family, it seems as if he has no warning that he needs to empty his bladder.  He was diagnosed with a small bladder tumor in 2005.  This was treated by Dr. Y.  Dr. X does not think that the bladder tumor has anything to do with the patient's urinary incontinence.  The patient has worn a pad or undergarment for at least one to one and a half years.  His wife states that they go through two or three of them per day.  He has been placed on medications; however, they have not helped.,He has no headaches or sensation of head fullness.,In regard to the thinking and memory, at first he seemed forgetful and had trouble with dates.  Now he seems less spontaneous and his family states he seems to have trouble expressing himself.  His wife took over his medications about two years ago.  She stopped his driving about three years ago.  She discovered that his license had been expired for about a year and she was concerned enough at that time that she told him he could drive no more.  Apparently, he did not object.  At this point, he frequently has trouble with memory, orientation, and everyday problems solving at home.  He needs coaching for his daily activities such as reminders to brush his teeth, put on his clothes, and so forth.  He is a retired office machine repairman.  He is currently up and active about 12 hours a day and sleeping or lying down about 12 hours per day.,He has not had PT or OT and has not been treated with medications for Parkinson's disease or Alzheimer's disease.  He has been treated for the bladder.  He has not had lumbar puncture.,Past medical history and review of all 14 systems from the form they completed for this visit that I reviewed with them is negative with the exception that he has had hypertension since 1985, hypercholesterolemia since 1997, and diabetes since 1998.  The bladder tumor was discovered in 2005 and was treated noninvasively.  He has lost weight from about 200 pounds to 180 pounds over the last two or three years.  He had a period of depression in 1999 and was on Prozac for a while, but this was then stopped.  He used to drink a significant amount of alcohol.  This was problematic enough that his wife was concerned.  She states he stopped when she retired and she was at home all day.,SOCIAL HISTORY:  ,He quit smoking in 1968.  His current weight is 183 pounds.  His tallest height is 5 feet 10 inches.,FAMILY HISTORY:  ,His grandfather had arthritis.  His father had Parkinson's disease.  His mother had heart disease and a sister has diabetes.,He does not have a Living Will and indicates he would wish his wife to make decisions for him if he could not make them for himself.,REVIEW OF HYDROCEPHALUS RISK FACTORS: , None.,ALLERGIES: , None.,MEDICATIONS: , Metformin 500 mg three times a day, Lipitor 10 mg per day, lisinopril 20 mg per day, metoprolol 50 mg per day, Uroxatral 10 mg per day, Detrol LA 4 mg per day, and aspirin 81 mg per day.,PHYSICAL EXAM: , On examination today, this is a pleasant 76-year-old man who is guided back from the clinic waiting area walking with his walker.  He is well developed, well nourished, and kempt.,Vital Signs:  His weight is 180 pounds.,Head:  The head is normocephalic and atraumatic.  The head circumference is 59 cm, which is the ,75-90th percentile for an adult man whose height is 178 cm.,Spine:  The spine is straight and not tender.  I can easily palpate the spinous processes.  There is no scoliosis.,Skin:  No neurocutaneous stigmata.,Cardiovascular Examination:  No carotid or vertebral bruits.,Mental Status:  Assessed for orientation, recent and remote memory, attention span, concentration, language, and fund of knowledge.  The Mini-Mental State Exam score was 17/30.  He did not know the year, season, or day of the week nor did he know the building or specialty or the floor.  There was a tendency for perseveration during the evaluation.  He could not copy the diagram of intersecting pentagons.,Cranial Nerve Exam:  No evidence of papilledema.  The pupillary light reflex is intact as are extraocular movements without nystagmus, facial expression and sensation, hearing, head turning, tongue, and palate movement.,Motor Exam:  Normal bulk and strength, but the tone is marked by significant paratonia.  There is no atrophy, fasciculations, or drift.  There is tremulousness of the outstretched hands.,Sensory Exam:  Is difficult to interpret.  Either he does not understand the test or he is mostly guessing.,Cerebellar Exam:  Is intact for finger-to-nose, heel-to-knee, and rapid alternating movement tests.  There is no dysarthria.,Reflexes:  Trace in the arms, 2+ at the knees, and 0 at the ankles.  It is not certain whether there is a Babinski sign or simply withdrawal.,Gait:  Assessed using the Tinetti assessment tool that shows a balance score of 7-10/16 and a gait score of 2-5/12 for a total score of 9-15/28, which is significantly impaired.,REVIEW OF X-RAYS: , I personally reviewed the MRI scan of the brain from December 11, 2007 at Advanced Radiology.  It shows the ventricles are enlarged with a frontal horn span of 5.0 cm.  The 3rd ventricle contour is flat.  The span is enlarged at 12 mm.  The sylvian aqueduct is patent.  There is a pulsation artifact.  The corpus callosum is effaced.  There are extensive T2 signal abnormalities that are confluent in the corona radiata.  There are also scattered T2 abnormalities in the basal ganglia.  There is a suggestion of hippocampal atrophy.  There is also a suggestion of vermian atrophy.,ASSESSMENT: , The patient has a clinical syndrome that raises the question of idiopathic normal pressure hydrocephalus.  His examination today is notable for moderate-to-severe dementia and moderate-to-severe gait impairment.  His MRI scan raises the question of hydrocephalus, however, is also consistent with cerebral small vessel disease.,PROBLEMS/DIAGNOSES:,1.  Possible idiopathic normal pressure hydrocephalus (331.5).,2.  Probable cerebral small-vessel disease (290.40 & 438).,3.  Gait impairment (781.2).,4.  Urinary urgency and incontinence (788.33).,5.  Dementia.,6.  Hypertension.,7.  Hypercholesterolemia.",
" Neurogenic bladder, in a patient catheterizing himself 3 times a day, changing his catheter 3 times a week", Consult - History and Phy., Neurogenic Bladder - Consult ,"HISTORY OF PRESENT ILLNESS: , The patient presents today as a consultation from Dr. ABC's office regarding the above.  He has history of neurogenic bladder, and on intermittent self-catheterization 3 times a day.  However, June 24, 2008, he was seen in the ER, and with fever, weakness, possible urosepsis.  He had a blood culture, which was positive for Staphylococcus epidermidis, as well as urine culture noted for same bacteria.  He was treated on IV antibiotics, Dr. XYZ also saw the patient.  Discharged home.  Not taking any antibiotics.  Today in the office, the patient denies any dysuria, gross hematuria, fever, chills.  He is catheterizing 3 times a day, changing his catheter weekly.  Does have history of renal transplant, which has been followed by Dr. X and is on chronic steroids.  Renal ultrasound, June 23, 2008, was noted for mild hydronephrosis of renal transplant with fluid in the pericapsular space.  Creatinine, July 7, 2008 was 2.0, BUN 36, and patient tells me this is being followed by Dr. X.  No interval complaints today, no issues with catheterization or any gross hematuria.,IMPRESSION:  ,1.  Neurogenic bladder, in a patient catheterizing himself 3 times a day, changing his catheter 3 times a week, we again reviewed the technique of catheterization, and he has no issues with this.,2.  Recurrent urinary tract infection, in a patient who has been hospitalized twice within the last few months, he is on steroids for renal transplant, which has most likely been overall reducing his immune system.  He is asymptomatic today.  No complaints today.,PLAN:,  Following a detailed discussion with the patient, we elected to proceed with intermittent self-catheterization, changing catheter weekly, and technique has been discussed as above.  Based on the recent culture, we will place him on Keflex nighttime prophylaxis, for the next three months or so.  He will call if any concerns.  Follow up as previously scheduled in September for re-assessment.  All questions answered.  The patient is seen and evaluated by myself.","consult - history and phy., neurogenic bladder, catheterizing, catheter, urinary tract infection, self-catheterization, intermittent self catheterization, renal transplant, catheterization,"
 , Consult - History and Phy., Neuro Consult - Depression & Dementia ,"Subsequently, the patient developed a moderately severe depression.  She was tried on various medications, which caused sweating, nightmares and perhaps other side effects.  She was finally put on Effexor 25 mg two tablets h.s. and trazodone 100 mg h.s., and has done fairly well, although she still has significant depression.,Her daughter brought her in today to be sure that she does not have dementia.  There is no history of memory loss.  There is no history of focal neurologic symptoms or significant headaches.,The patient's complaints, according to the daughter, include not wanted to go out in public, shamed regarding her appearance (25-pound weight loss over the past year), eating poorly, not doing things unless asked, hiding food to prevent having to eat it, nervousness, and not taking a shower.  She has no focal neurologic deficits.  She does complain of constipation.  She has severe sleep maintenance insomnia and often sleeps only 2 hours before awakening frequently for the rest of the night.,The patient was apparently visiting her daughter in northern California in December 2003.  She was taken to her daughter's primary care physician.  She underwent vitamin B12 level, RPR, T4 and TSH, all of which were normal.,On 05/15/04, the patient underwent MRI scan of the brain.  I reviewed the scan in the office today.  This shows moderate cortical and central atrophy and also shows mild-to-moderate deep white matter ischemic changes.,PAST MEDICAL HISTORY: , The patient has generally been in reasonably good physical health.  She did have a ""nervous breakdown"" in 1975 after the death of her husband.  She was hospitalized for several weeks and was treated with ECT.  This occurred while she was living in Korea.,She does not smoke or drink alcoholic beverages.  She has had no prior surgeries.  There is a past history of hypertension, but this is no longer present.,FAMILY HISTORY: , Negative for dementia.  Her mother died of a stroke at the age of 62.,PHYSICAL EXAMINATION:,Vital Signs:  Blood pressure 128/80, pulse 84, temperature 97.4 F, and weight 105 lbs (dressed).,General:  Well-developed, well-nourished Korean female in no acute distress.,Head:  Normocephalic, without evidence of trauma or bruits.,Neck:  Supple, with full range of motion.  No spasm or tenderness.  Carotid pulsations are of normal volume and contour bilaterally without bruits.  No thyromegaly or adenopathy.,Extremities:  No clubbing, cyanosis, edema, or deformity.  Range of motion full throughout.,NEUROLOGICAL EXAMINATION:,Mental Status:  The patient is awake, alert and oriented to time, place, and person and generally appropriate.  She exhibits mild psychomotor retardation and has a flat or depressed affect.  She knows the current president of Korea and the current president of the United States.  She can recall 3 out of 3 objects after 5 minutes.  Calculations are performed fairly well with occasional errors.  There is no right-left confusion, finger agnosia, dysnomia or aphasia.,Cranial Nerves:,II:",
 Nephrology Consultation - Patient with renal failure., Consult - History and Phy., Nephrology Consultation - 1 ,"REASON FOR CONSULTATION: , Renal failure.,HISTORY OF PRESENT ILLNESS:,  Thank you for referring Ms. Abc to ABCD Nephrology.  As you know she is a 51-year-old lady who was found to have a creatinine of 2.4 on a recent hospital admission to XYZ Hospital.  She had been admitted at that time with chest pain and was subsequently transferred to University of A and had a cardiac catheterization, which did not show any coronary artery disease.  She also was found to have a urinary tract infection at that time and this was treated with ciprofloxacin.  Her creatinine both at XYZ Hospital and University of A was elevated at 2.4.  I do not have the results from the prior years.  A repeat creatinine on 08/16/06 was 2.3.  The patient reports that she had gastric bypass surgery in 1975 and since then has had chronic diarrhea and recurrent admissions to the hospital with nausea, vomiting, diarrhea, and dehydration.  She also mentioned that lately she has had a lot of urinary tract infections without any symptoms and was in the emergency room four months ago with a urinary tract infection.  She had bladder studies a long time ago.  She complains of frequency of urination for a long time but denies any dysuria, urgency, or hematuria.  She also mentioned that she was told sometime in the past that she had kidney stones but does not recall any symptoms suggestive of kidney stones.  She denies any nonsteroidal antiinflammatory drug use.  She denies any other over-the-counter medication use.  She has chronic hypokalemia and has been on potassium supplements recently.  She is unsure of the dose.  ,PAST MEDICAL HISTORY: ,1.  Hypertension on and off for years.  She states she has been treated intermittently but lately has again been off medications.,2.  Gastroesophageal reflux disease.,3.  Gastritis.,4.  Hiatal hernia.,5.  H. pylori infection x3 in the last six months treated.,6.  Chronic hypokalemia secondary to chronic diarrhea.,7.  Recurrent admissions with nausea, vomiting, and dehydration.  ,8.  Renal cysts found on a CAT scan of the abdomen.,9.  No coronary artery disease with a recent cardiac catheterization with no significant coronary artery disease.  ,10.  Stomach bypass surgery 1975 with chronic diarrhea.,11.  History of UTI multiple times recently.,12.  Questionable history of kidney stones.,13.  History of gingival infection secondary to chronic steroid use, which was discontinued in July 2001.,14.  Depression.,15.  Diffuse degenerative disc disease of the spine.,16.  Hypothyroidism.,17.  History of iron deficiency anemia in the past.  ,18.  Hyperuricemia.  ,19.  History of small bowel resection with ulcerative fibroid.  ,20.  Occult severe GI bleed in July 2001.,PAST SURGICAL HISTORY: ,  The patient has had multiple surgeries including gastric bypass surgery in 1975, tonsils and adenoidectomy as a child, multiple tubes in the ears as a child, a cyst removed in both breasts, which were benign, a partial hysterectomy in 1980, history of sinus surgery, umbilical hernia repair in 1989, cholecystectomy in 1989, right ear surgery in 1989, disc surgery in 1991, bilateral breast cysts removal in 1991 and 1992, partial intestinal obstruction with surgery in 1992, pseudomyxoma peritonei in 1994, which was treated with chemotherapy for nine months, left ovary resection and fallopian tube removal in 1994, right ovarian resection and appendectomy and several tumor removals in 1994, surgery for an abscess in the rectum in 1996, fistulectomy in 1996, lumbar hemilaminectomy in 1999, cyst removal from the right leg and from the shoulder in 2000, cyst removed from the right side of the neck in 2003, lymph node resection in the neck April 24 and biopsy of a tumor in the neck and was found to be a schwannoma of the brachial plexus, and removal of brachial plexus tumor August 4, 2005.  ,CURRENT MEDICATIONS: ,1.  Nexium 40 mg q.d.,2.  Synthroid 1 mg q.d. ,3.  Potassium one q.d., unsure about the dose.  ,4.  No history of nonsteroidal drug use.,ALLERGIES:",
 The patient is a 55-year-old gentleman who presents for further evaluation of right leg weakness., Consult - History and Phy., Neuro Consult - Leg Weakness ,"HISTORY OF PRESENT ILLNESS: , The patient is a 55-year-old gentleman who presents for further evaluation of right leg weakness.  He has difficulty recollecting the exact details and chronology of his problem.  To the best of his recollection, he thinks that about six months ago he developed weakness of his right leg.  He describes that he is reaching to get something from a cabinet and he noticed that he was unable to stand on his right toe.  Since that time, he has had difficulty pushing off when he walks.  He has mild tingling and numbness in his toes, but this has been a chronic problem and nothing new since he has developed the weakness.  He has chronic mild back pain, but this has been persistent for many years and has not changed.  He has experienced cramps in both calves for the past year.  This dissipated about two months ago.  He does not think that his left leg is weak.  He does not have any bowel or bladder incontinence.  There is no radicular pain.  He does not think that the problem is progressive, meaning that the weakness that he perceives in his right leg is no different than when it was six months ago.,He first sought medical attention for this problem in October.  He then saw you a couple of months later.  He has undergone an EMG and nerve conduction studies.  Unfortunately, he cannot undergo an MRI of his spine because he has an ear implant.  He has had a CT scan that shows degenerative changes, but nothing obviously abnormal.,In addition, the patient has hyperCKemia.  He tells me that he has had an elevated CK prior to starting taking stat medications, although this is not entirely clear to me.  He thinks that he is not taking Lipitor for about 15 months and thought that his CK was in the 500 or 600s prior to starting it.  Once it was started, it increased to about 800 and then came down to about 500 when it was stopped.  He then had a recent bump again up to the 1000 and since Lipitor has been stopped, his CK apparently has returned to about the 500 or 600s.  I do no have any laboratory data to support these statements by the patient, but he seems to be up to speed on this.  More recently, he has been started taking Zetia.  He does not have any proximal weakness.  He denies any myalgias., ,PAST MEDICAL HISTORY:,  He has coronary artery disease and has received five stents.  He has hypertension and hypercholesterolemia.  He states that he was diagnosed with diabetes based on the results of an abnormal oral glucose tolerance test.  He believes that his glucose shot up to over 300 with this testing.  He does not take any medications for this and his blood glucoses are generally normal when he checks it.  He has had plastic surgery on his face from an orbital injury.  He also had an ear graft when he developed an ear infection during his honeymoon., ,CURRENT MEDICATIONS:, He takes amlodipine, Diovan, Zetia, hydrochlorothiazide, Lovaza (fish oil), Niaspan, aspirin, and Chantix.  , ,ALLERGIES:,  He has no known drug allergies., ,SOCIAL HISTORY:,  He lives with his wife.  He works at Shepherd Pratt doing network engineering.  He smokes a pack of cigarettes a day and is working on quitting.  He drinks four alcoholic beverages per night.  Prior to that, he drank significantly more.  He denies illicit drug use.  He was athletic growing up., ,FAMILY HISTORY:,  His mother died of complications from heart disease.  His father died of heart disease in his 40s.  He has two living brothers.  One of them he does not speak too much with and does not know about his medical history.  The other is apparently healthy.  He has one healthy child.  His maternal uncles apparently had polio.  When I asked him to tell me further details about this, he states that one of them had to wear crutches due to severe leg deformans and then the other had leg deformities in only one leg.  He is fairly certain that they had polio.  He is unaware of any other family members with neurological conditions.,REVIEW OF SYSTEMS: , He has occasional tinnitus.  He has difficulty sleeping.  Otherwise, a complete review of systems was obtained and was negative except for as mentioned above.  This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:, ,Vital Signs:",
 Neurologic consultation was requested to evaluate her seizure medication and lethargy., Consult - History and Phy., Neurologic Consultation ,"REASON FOR CONSULTATION: , Neurologic consultation was requested by Dr. X to evaluate her seizure medication and lethargy.,HISTORY OF PRESENT ILLNESS: , The patient is well known to me.  She has symptomatic partial epilepsy secondary to a static encephalopathy, cerebral palsy, and shunted hydrocephalus related to prematurity.  She also has a history of factor V Leiden deficiency.  She was last seen at neurology clinic on 11/16/2007.  At that time, instructions were given to mom to maximize her Trileptal dose if seizures continue.  She did well on 2 mL twice a day without any sedation.  This past Friday, she had a 25-minute seizure reportedly.  This consisted of eye deviation, unresponsiveness, and posturing.  Diastat was used and which mom perceived was effective.  Her Trileptal dose was increased to 3 mL b.i.d. yesterday.,According to mom since her shunt revision on 12/18/2007, she has been sleepier than normal.  She appeared to be stable until this past Monday about six days ago, she became more lethargic and had episodes of vomiting and low-grade fevers.  According to mom, she had stopped vomiting since her hospitalization.  Reportedly, she was given a medication in the emergency room.  She still is lethargic, will not wake up spontaneously.  When she does awaken however, she is appropriate, and interacts with them.  She is able to eat well; however her overall p.o. intake has been diminished.  She has also been less feisty as her usual sounds.  She has been seizure free since her admission.,LABORATORY DATA: , Pertinent labs obtained here showed the following:  CRP is less than 0.3, CMP normal, and CBC within normal limits.  CSF cultures so far is negative.  Dr. Limon's note refers to a CSF, white blood cell count of 2, 1 RBC, glucose of 55, and protein of 64.  There are no imaging studies in the computer.  I believe that this may have been done at Kaweah Delta Hospital and reviewed by Dr. X, who indicated that there was no evidence of shunt malfunction or infection.,CURRENT MEDICATIONS: , Trileptal 180 mg b.i.d., lorazepam 1 mg p.r.n., acetaminophen, and azithromycin.,PHYSICAL EXAMINATION:,GENERAL:  The patient was asleep, but easily aroused.  There was a brief period of drowsiness, which she had some jerky limb movements, but not seizures.  She eventually started crying and became agitated.  She made attempts to sit by bending her neck forward.  Fully awake, she sucks her bottle eagerly.,HEENT:  She was obviously visually impaired.  Pupils were 3 mm, sluggishly reactive to light.,EXTREMITIES:  Bilateral lower extremity spasticity was noted.  There was increased flexor tone in the right upper extremity.  IV was noted on the left hand.,ASSESSMENT:  ,Seizure breakthrough due to intercurrent febrile illness.  Her lethargy could be secondary to a viral illness with some component of medication effect since her Trileptal dose was increased yesterday and these are probable explanations if indeed shunt malfunction has been excluded.,I concur with Dr. X's recommendations.  I do not recommend any changes in Trileptal for now.  I will be available while she remains hospitalized.,","consult - history and phy., lethargy, encephalopathy, cerebral palsy, shunted hydrocephalus, seizure breakthrough, shunt malfunction, neurologic consultation, neurologic, seizure, trileptal"
" This is a 3-week-old, NSVD, Caucasian baby boy transferred from ABCD Memorial Hospital for rule out sepsis and possible congenital heart disease. ", Consult - History and Phy., Neonatal Consult ,"INFORMANT:,  Dad on phone.  Transferred from ABCD Memorial Hospital, rule out sepsis.,HISTORY:  ,This is a 3-week-old, NSVD, Caucasian baby boy transferred from ABCD Memorial Hospital for rule out sepsis and possible congenital heart disease.  The patient had a fever of 100.1 on 09/13/2006 taken rectally, and mom being a nurse, took the baby to the hospital and he was admitted for rule out sepsis.  All the sepsis workup was done, CBC, UA, LP, and CMP, and since a murmur was noted 2/5, he also had an echo done.  The patient was put on ampicillin and cefotaxime.  Echo results came back and they showed patent foramen ovale/ASD with primary pulmonary stenosis and then considering severe congenital heart disease, he was transferred here on vancomycin, ampicillin, and cefotaxime.  The patient was n.p.o. when he came in.  He was on 3/4 L of oxygen.  According to the note, it conveyed that he had some subcostal retractions.  On arriving here, baby looks very healthy.  He has no subcostal retractions.  He is not requiring any oxygen and he is positive for urine and stool.  The stool is although green in color, and in the morning today, he spiked a fever of 100.1, but right now he is afebrile.  ED called that case is a direct admit.,REVIEW OF SYSTEMS:  ,The patient supposedly had fever, some weight loss, poor appetite.  The day he had fever, no rash, no ear pain, no congestion, no rhinorrhea, no throat pain, no neck pain, no visual changes, no conjunctivitis, no cough, no dyspnea, no vomiting, no diarrhea, and no dysuria.  According to mom, baby felt floppy on the day of fever and he also used to have stools every day 4 to 6 which is yellowish-to-green in color, but today the stool we noticed was green in color.  He usually has urine 4 to 5 a day, but the day he had fever, his urine also was low.  Mom gave baby some Pedialyte.,PAST MEDICAL HISTORY:,  None.,HOSPITALIZATIONS:,  Recent transfer from ABCD for the rule out sepsis and heart disease.,BIRTH HISTORY:  ,Born on 08/23/2006 at Memorial Hospital, NSVD, no complications.  Hospital stay 24 hours.  Breast-fed, no formula, no jaundice, 7 pounds 8 ounces.,FAMILY HISTORY:,  None.,SURGICAL HISTORY: , None.,SOCIAL HISTORY:  ,Lives with mom and dad.  Dad is a service manager at GMC; 4-year-old son, who is healthy; and 2 cats, 2 dogs, 3 chickens, 1 frog.  They usually visit to a ranch, but not recently.  No sick contact and no travel.,MEDICATIONS: , Has been on vancomycin, cefotaxime, and ampicillin.,ALLERGIES:,  No allergies.,DIET:,  Breast feeds q.2h.,IMMUNIZATIONS: , No immunizations.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 99, pulse 158, respiratory rate 68, blood pressure 87/48, oxygen 100% on room air.,MEASUREMENTS:  Weight 3.725 kg.,GENERAL:  Alert and comfortable and sleeping.,SKIN:  No rash.,HEENT:  Intact extraocular movements.  PERRLA.  No nasal discharge.  No nasal cannula, but no oxygen is flowing active, and anterior fontanelle is flat.,NECK:  Soft, nontender, supple.,CHEST:  CTAP.,GI:  Bowel sounds present.  Nontender, nondistended.,GU:  Bilaterally descended testes.,BACK:  Straight.,NEUROLOGIC:  Nonfocal.,EXTREMITIES:  No edema.  Bilateral pedal pulses present and upper arm pulses are also present.,LABORATORY DATA:,  As drawn on 09/13/2006 at ABCD showed WBC 4.2, hemoglobin 11.8, hematocrit 34.7, platelets 480,000.  Sodium 140, potassium 4.9, chloride 105, bicarbonate 28, BUN 7, creatinine 0.4, glucose 80, CRP 0.5.  Neutrophils 90, bands 7, lymphocytes 27, monocytes 12, and eosinophils 4.  Chest x-ray done on 09/13/2006 read as mild left upper lobe infiltrate, but as seen here, and discussed with Dr. X, we did not see any infiltrate and CBG was normal.  UA and LP results are pending.  Also pending are cultures for blood, LP, and urine.,ASSESSMENT AND PLAN: , This is a 3-week-old Caucasian baby boy admitted for rule out sepsis and congenital heart disease.,INFECTIOUS DISEASE/PULMONARY: , Afebrile with so far 20-hour blood cultures, LP and urine cultures are negative.  We will get all the results from ABCD and until then we will continue to rule out sepsis protocol and put the patient on ampicillin and cefotaxime.  The patient could be having fever due to mild gastroenteritis or urinary tract infection, so to rule out all these things we have to wait for all the results.,CVS: , He had a grade 2/5 murmur status post echo, which showed a patent foramen ovale, as well as primary pulmonary stenosis.  These are the normal findings in a newborn as discussed with Dr. Y, so we will just observe the patient.  He does not need any further workup.,GASTROINTESTINAL: ",
" The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma of the right adrenal gland with favorable Shimada histology and history of stage 2 left adrenal neuroblastoma, status post gross total resection.", Consult - History and Phy., Neuroblastoma - Consult ,"REASON FOR VISIT:,  The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma here for ongoing management of his disease and the visit is supervised by Dr. X.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-month-old with neuroblastoma, which initially presented on the left when he was 6 weeks old and was completely resected.  It was felt to be stage 2.  It was not N-Myc amplified and had favorable Shimada histology.  In followup, he was found to have a second primary in his right adrenal gland, which was biopsied and also consistent with neuroblastoma with favorable Shimada histology.  He is now being treated with chemotherapy per protocol P9641 and not on study.  He last received chemotherapy on 05/21/07, with carboplatin, cyclophosphamide, and doxorubicin.  He received G-CSF daily after his chemotherapy due to neutropenia that delayed his second cycle.  In the interval since he was last seen, his mother reports that he had a couple of days of nasal congestion, but it is now improving.  He is not acted ill or had any fevers.  He has had somewhat diminished appetite, but it seems to be improving now.  He is peeing and pooping normally and has not had any diarrhea.  He did not have any appreciated nausea or vomiting.  He has been restarted on fluconazole due to having redeveloped thrush recently.,REVIEW OF SYSTEMS: , The following systems reviewed and negative per pathology except as noted above.  Eyes, ears, throat, cardiovascular, GI, genitourinary, musculoskeletal skin, and neurologic., PAST MEDICAL HISTORY:,  Reviewed as above and otherwise unchanged.,FAMILY HISTORY:,  Reviewed and unchanged.,SOCIAL HISTORY: , The patient's parents continued to undergo a separation and divorce.  The patient spends time with his father and his family during the first part of the week and with his mother during the second part of the week.,MEDICATIONS:  ,1.  Bactrim 32 mg by mouth twice a day on Friday, Saturday, and Sunday.,2.  G-CSF 50 mcg subcutaneously given daily in his thighs alternating with each dose.,3.  Fluconazole 37.5 mg daily.,4.  Zofran 1.5 mg every 6 hours as needed for nausea.,ALLERGIES: , No known drug allergies.,FINDINGS: , A detailed physical exam revealed a very active and intractable, well-nourished 11-month-old male with weight 10.5 kilos and height 76.8 cm.  Vital Signs:  Temperature is 35.3 degrees Celsius, pulse is 121 beats per minute, respiratory rate 32 breaths per minute, blood pressure 135/74 mmHg.  Eyes:  Conjunctivae are clear, nonicteric.  Pupils are equally round and reactive to light.  Extraocular muscle movements appear intact with no strabismus.  Ears:  TMs are clear bilaterally.  Oral Mucosa:  No thrush is appreciated.  No mucosal ulcerations or erythema.  Chest:  Port-a-Cath is nonerythematous and nontender to VP access port.  Respiratory:  Good aeration, clear to auscultation bilaterally.  Cardiovascular:  Regular rate, normal S1 and S2, no murmurs appreciated.  Abdomen is soft, nontender, and no organomegaly, unable to appreciate a right-sided abdominal mass or any other masses.  Skin:  No rashes.  Neurologic:  The patient walks without assistance, frequently falls on his bottom.,LABORATORY STUDIES: , CBC and comprehensive metabolic panel were obtained and they are significant for AST 51, white blood cell count 11,440, hemoglobin 10.9, and platelets 202,000 with ANC 2974.  Medical tests none.  Radiologic studies are none.,ASSESSMENT: , This patient's disease is life threatening, currently causing moderately severe side effects.,PROBLEMS DIAGNOSES:  ,1.  Neuroblastoma of the right adrenal gland with favorable Shimada histology.,2.  History of stage 2 left adrenal neuroblastoma, status post gross total resection.,3.  Immunosuppression.,4.  Mucosal candidiasis.,5.  Resolving neutropenia.,PROCEDURES AND IMMUNIZATIONS:,  None.,PLANS:  ,1.  Neuroblastoma.  The patient will return to the Pediatric Oncology Clinic on 06/13/07 to 06/15/07 for his third cycle of chemotherapy.  I will plan for restaging with CT of the abdomen prior to the cycle.,2.  Immunosuppression.  The patient will continue on his Bactrim twice a day on Thursday, Friday, and Saturday.  Additionally, we will tentatively plan to have him continue fluconazole since this is his second episode of thrush.,3.  Mucosal candidiasis.  We will continue fluconazole for thrush.  I am pleased that the clinical evidence of disease appears to have resolved.  For resolving neutropenia, I advised Gregory's mother about it is okay to discontinue the G-CSF at this time.  We will plan for him to resume G-CSF after his next chemotherapy and prescription has been sent to the patient's pharmacy.,PEDIATRIC ONCOLOGY ATTENDING: , I have reviewed the history of the patient.  This is an 11-month-old with neuroblastoma who received chemotherapy with carboplatin, cyclophosphamide, and doxorubicin on 05/21/07 for cycle 2 of POG-9641 due to his prior history of neutropenia, he has been on G-CSF.  His ANC is nicely recovered.  He will have a restaging CT prior to his next cycle of chemotherapy and then return for cycle 3 chemotherapy on 06/13/07 to 06/15/07.  He continues on fluconazole for recent history of thrush.  Plans are otherwise documented above.",
" A female admitted with jaundice and a pancreatic mass who was noted to have a new murmur, bacteremia, and fever. ", Consult - History and Phy., Murmur & Bacteremia. ,"REASON FOR CONSULTATION: , New murmur with bacteremia.,HISTORY OF PRESENT ILLNESS:,  The patient is an 84-year-old female admitted with jaundice and a pancreatic mass who was noted to have a new murmur, bacteremia, and fever.  The patient states that apart from the fever, she was having no other symptoms and denies any previous cardiac history.  She denies any orthopnea or paroxysmal nocturnal dyspnea.  Denies any edema, chest pain, palpitations, or syncope.  She has had TIAs in the past, but none recently.,PAST MEDICAL HISTORY:,  Significant for diabetes, hypertension, and TIA.,MEDICATIONS: , Include:,1.  Acidophilus supplement.,2.  Cholestyramine.,3.  Creon 20 three times daily.,4.  Diovan 160 mg twice daily.,6.  Lantus 10 daily.,7.  Norvasc 5 mg daily.,8.  NovoLog 70/30, 10 units at 12 noon daily.,9.  Pamelor 15 mL every evening.,10.  Vitamin D3 one tablet weekly.,ALLERGIES: , THE PATIENT IS ALLERGIC TO CODEINE, COREG, AND VANCOMYCIN.,FAMILY HISTORY:  ,The patient's daughter apparently has history of a murmur, but no diagnosis of congenital heart disease.  The patient's father died in his 80s of CHF.,SOCIAL HISTORY: , The patient denies ever having smoked, denies any significant alcohol use, and lives with her daughter in Pasadena.,REVIEW OF SYSTEMS: , The patient has had fever and chills.  She has also had some jaundice.  Denies any nausea or vomiting.  Denies any chest pain or abdominal pain.  Denies orthopnea, paroxysmal nocturnal dyspnea or edema.  She has had TIAs in the past, but denies any recent neurological symptoms such as motor weakness or focal sensory deficits.  Denies melena or hematochezia.  All other systems were reviewed and were found to be negative.,PHYSICAL EXAMINATION,GENERAL:  An elderly Caucasian female, awake and alert, and in no distress.,VITAL SIGNS:  Temperature is 98.8, heart rate 96, sinus, blood pressure 138/55, respiratory rate 20, and oxygen saturation 92%.,HEAD AND NECK:  Her head is atraumatic.  She is normocephalic.  Her neck is supple.  There is no JVD.  No palpable adenopathy or thyromegaly.  There is some icterus of the sclerae bilaterally.  Oral mucosa is moist.,CHEST:  Symmetrical expansion with normal percussion note.  There are no inspiratory crackles or expiratory wheeze.,CARDIAC:  Heart sounds S1 and S2 are regular.  There is a 2/6 systolic murmur heard through the precordium.  There is no gallop or rub.  There is no palpable thrill or retrosternal lift.,ABDOMEN:  Soft, nondistended, and nontender with normal bowel sounds.  No audible bruits.,EXTREMITIES:  No pitting edema, no clubbing, no cyanosis, and peripheral pulses are 2+.,NEUROLOGIC:  She exhibits no focal motor or sensory findings.,LABORATORY DATA: , The patient's sodium was 133, potassium 2.8, chloride 99, bicarbonate 31, glucose 75, BUN 12, creatinine 0.8, calcium 8.6, total bilirubin 3.2, AST 63, and ALT 43.  White count 5.4, hemoglobin 9.1, hematocrit 26.6, and platelet count 128,000.  Lipase less than 10.,DIAGNOSTIC IMAGING: , The patient had a CT scan of the abdomen that demonstrated a pancreatic mass with biliary obstruction.  Previous biliary stent was present.,EKG shows normal sinus rhythm.  There are no acute ST-T changes.,ASSESSMENT: , This is an 84-year-old female with newly found murmur.  No previous history of heart disease.  This murmur has occurred in the setting of fever and bacteremia.  The patient also has a pancreatic mass with jaundice, history of hypertension, and now has hyponatremia and hypokalemia.,PLAN:  ,The patient should undergo an echocardiogram to assess for the possibility of endocarditis, which may be contributing to her symptoms.  Blood pressure control should be maintained with Diovan and Norvasc.  Potassium should be replaced, and hyponatremia should be on proactive.",
 The patient is admitted with a diagnosis of acute on chronic renal insufficiency., Consult - History and Phy., Nephrology Consultation - 4 ,"HISTORY: , The patient is a 61-year-old male patient.  I was asked to evaluate this patient because of the elevated blood urea and creatinine.  The patient has ascites, pleural effusion, hematuria, history of coronary artery disease, pulmonary nodules, history of congestive heart failure status post AICD.  The patient has a history of exposure to asbestos in the past, history of diabetes mellitus of 15 years duration, hypertension, and peripheral vascular disease.  The patient came in with a history of abdominal distention of about one to two months with bruises on the right flank about two days status post fall.  The patient has been having increasing distention of the abdomen and frequent nosebleeds.,PAST MEDICAL HISTORY:,  As above.,PAST SURGICAL HISTORY: , The patient had a pacemaker placed.,ALLERGIES: , NKDA.,REVIEW OF SYSTEMS: , Showed no history of fever, no chills, no weight loss.  No history of sore throat.  No history of any ascites.  No history of nausea, vomiting, or diarrhea.  No black stools.  No history of any rash.  No back pain.  No leg pain.  No neuropsychiatric problems.,FAMILY HISTORY: , History of hypertension, diabetes present.,SOCIAL HISTORY:,  He is a nonsmoker, nonalcoholic, and not a drug user.,PHYSICAL EXAMINATION,VITAL SIGNS:  Blood pressure is 124/66, heart rate around 68 per minute, and temperature 96.4.,HEENT:  The patient is atraumatic and normocephalic.  Pupils are equal and reactive to light.  Extraocular muscles are intact.,NECK:  Supple.  No JVD and no thyromegaly.,HEART:  S1 and S2 heard.  No murmurs or extra sounds.,ABDOMEN:  Distention of the abdomen present.,EXTREMITIES:  No pedal edema.,LABORATORY: , His lab investigation showed WBC of 6.2, H&H is 11 and 34.  PT, PTT, and INR is normal.  Urinalysis showed 2+ protein and 3+ blood, and 5 to 10 rbc's.  Potassium is 5.3, BUN of 39, and creatinine of 1.9.  Liver function test, ALT was 12, AST 15, albumin 3, TSH of 4.8, and T3 of 1.33.,IMPRESSION AND PLAN:  ,The patient is admitted with a diagnosis of acute on chronic renal insufficiency, rule out hepatorenal insufficiency could be secondary to congestive heart failure, cardiac cirrhosis, rule out possibility of ascites secondary to mesothelioma because the patient has got history of exposure to asbestos and has got pulmonary nodule, rule out diabetic nephropathy could be secondary to hypertensive nephrosclerosis.  The patient has hematuria could be secondary to benign prostatic hypertrophy, rule out malignancy.  We will do urine for cytology.  We will do a renal ultrasound, and 24-hour urine collection for protein/creatinine, creatinine clearance, immunofixation, serum electrophoresis, serum uric acid, serum iron, TIBC, and serum ferritin levels.  We will send a PSA level and if needed may be a urology consult.","consult - history and phy., mesothelioma, ascites, pleural effusion, hematuria, history of coronary artery disease, pulmonary nodules, congestive heart failure, aicd, hepatorenal insufficiency, pulmonary nodule, diabetic nephropathy, chronic renal insufficiency, nodules, serum, insufficiency, "
" Patient with end-stage renal disease secondary to hypertension, a reasonable candidate for a kidney transplantation.", Consult - History and Phy., Nephrology Consultation - 3 ,"PAST MEDICAL/SURGICAL HISTORY: , Briefly, his past medical history is significant for hypertension of more than 5 years, asthma, and he has been on Advair and albuterol.  He was diagnosed with renal disease in 02/2008 and has since been on hemodialysis since 02/2008.  His past surgical history is only significant for left AV fistula on the wrist done in 04/2008.  He still has urine output.  He has no history of blood transfusion.,PERSONAL AND SOCIAL HISTORY: , He is a nonsmoker.  He denies any alcohol.  No illicit drugs.  He used to work as the custodian at the nursing home, but now on disability since 03/2008.  He is married with 2 sons, ages 5 and 17 years old.,FAMILY HISTORY:,  No similar illness in the family, except for hypertension in his one sister and his mom, who died at 61 years old of congestive heart failure.  His father is 67 years old, currently alive with asthma.  He also has one sister who has hypertension.  The rest of the 6 siblings are alive and well.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , Singulair 10 mg once daily, Cardizem 365 mg once daily, Coreg 25 mg once daily, hydralazine 100 mg three times a day, Lanoxin 0.125 mg once daily, Crestor 10 mg once daily, lisinopril 10 mg once daily, Phoslo 3 tablets with meals, and Advair 250 mg inhaler b.i.d.,REVIEW OF SYSTEMS: , Significant only for asthma.  No history of chest pain normal MI.  He has hypertension.  He occasionally will develop colds especially with weather changes.  GI:  Negative.  GU:  Still making urine about 1-3 times per day.  Musculoskeletal:  Negative.  Skin:  He complains of dry skin.  Neurologic:  Negative.  Psychiatry:  Negative.  Endocrine:  Negative.  Hematology:  Negative.,PHYSICAL EXAMINATION: , A pleasant 41-year-old African-American male who stands 5 feet 6 inches and weighs about 193 pounds.  HEENT:  Anicteric sclera, pink conjunctiva, no cervical lymphadenopathy.  Chest:  Equal chest expansion.  Clear breath sounds.  Heart:  Distinct heart sounds, regular rhythm with no murmur.  Abdomen:  Soft, nontender, flabby, no organomegaly.  Extremities:  Poor peripheral pulses.  No cyanosis and no edema.,ASSESSMENT AND PLAN:,  This is a 49-year old African-American male who was diagnosed with end-stage renal disease secondary to hypertension.  He is on hemodialysis since 02/2008.  Overall, I think that he is a reasonable candidate for a kidney transplantation and should undergo a complete pretransplant workup with pulmonary clearance because of his chronic asthma.  Other than that, I think that he is a reasonable candidate for transplant.,I would like to thank you for allowing me to participate in the care of your patient.  Please feel free to contact me if there are any questions regarding his case.","consult - history and phy., kidney transplantation, pretransplant, transplant clinic, renal disease, secondary, kidney, hemodialysis, renal, asthma, transplantation, hypertension"
" Patient with a diagnosis of pancreatitis, developed hypotension and possible sepsis and respiratory, as well as renal failure.", Consult - History and Phy., Nephrology Consultation - 2 ,"HISTORY:,  The patient was in the intensive care unit setting; he was intubated and sedated.  The patient is a 55-year-old patient, who was admitted secondary to a diagnosis of pancreatitis, developed hypotension and possible sepsis and respiratory as well as renal failure and found to be intubated.  He has been significantly hypotensive during his stay in the intensive care unit and has had minimal urine output.  His creatinine has gone from 2.1 to 4.2 overnight and the patient also developed florid acidosis and hypokalemia.  Nephrology input has been requested for management of acute renal failure and acidosis.,PAST MEDICAL HISTORY:,1.  Pancreatitis.,2.  Poison ivy.  The patient has recently been on oral steroids.,3.  Hypertension.,MEDICATIONS: , Include Ambien, prednisone, and blood pressure medication, which is not documented in the record at the moment.,INPATIENT MEDICATIONS: , Include Protonix IV, half-normal saline at 125 mL an hour, D5W with 3 ounces of bicarbonate at 150 mL an hour.  The patient was initially on dopamine, which has now been discontinued.  The patient remains on Levophed and Invanz 1 g IV q.24 h.,PHYSICAL EXAMINATION:,  Vitals, emergency room presentation, the blood pressure was 82/45.  His blood pressure in the ICU had dipped down into the 60s systolic, most recent blood pressure is 108/67 and he has been maintained on 100% FiO2.  The patient has had minimal urine output since admission.  HEENT, the patient is intubated at the moment.  Neck examination, no overt lymph node enlargement.  No jugular venous distention.  Lungs examination is benign in terms of crackles.  The patient has some harsh breath sounds secondary to being intubated.  CVS, S1 and S2 are fairly regular at the moment.  There is no pericardial rub.  Abdominal examination, obese, but benign.  Extremity examination reveals no lower extremity edema.  CNS, the patient is intubated and sedated.,LABORATORY DATA: , Blood work, sodium 152, potassium 2.7, bicarbonate 13, BUN 36, and creatinine 4.2.  The patient's BUN and creatinine yesterday were 23 and 2.1 respectively.  H&H of 17.7 and 51.6, white cell count of 8.4 from earlier on this morning.  The patient's liver function tests are all out of whack and his alkaline phosphatase is 226, ALT is 539, CK 1103, INR 1.66, and ammonia level of 55.  Latest ABGs show a pH of 7.04, bicarbonate of 10.7, pCO2 of 40.3, and pO2 of 120.7.,ASSESSMENT:,1.  Acute renal failure, which in all probability is secondary to acute tubular necrosis and sepsis and significant hypotension, but the patient is at the moment on 100% FiO2.  He has been given intravenous fluid at a high rate to replete intravascular volume and to hopefully address his acidosis.  The patient also has significant acidosis and his creatinine has increased from 2.1 to 4.2 overnight.  Given the fact that he would need dialytic support for his electrolyte derangements and for volume control, I would suggest continuous venovenous hemodiafiltration as opposed to conventional hemodialysis as the patient will not be able to tolerate conventional hemodialysis given his hemodynamic instability.,2.  Hypotension, which is significant and is related to his sepsis.  Now the patient has been maintained on Levophed and high rate of intravenous fluid at the moment.,3.  Acidosis, which is again secondary to his renal failure.  The patient was administered intravenous bicarbonate as mentioned above.  Dialytic support in the form of continuous venovenous hemodiafiltration was highly recommended for possible correction of his electrolyte derangements.,4.  Pancreatitis, which has been managed by his gastroenterologist.,5.  Sepsis, the patient is on broad-spectrum antibiotic therapy.,6.  Hypercalcemia.  The patient has been given calcium chloride.  We will need to watch for rebound hypercalcemia.,7.  Hypoalbuminemia.,8.  Hypokalemia, which has been repleted.,RECOMMENDATIONS: , Again include continuation of IV fluid and bicarbonate infusion as well as transfer to the Piedmont Hospital for continuous venovenous hemodiafiltration.","consult - history and phy., intubated, consultation, hypercalcemia, hypoalbuminemia, iv fluid, nephrology, acidosis, creatinine, hemodiafiltration, hypokalemia, hypotension, intravenous, pancreatitis, renal failure, respiratory, urine output, continuous venovenous hemodiafiltration, electrolyte derangements, conventional hemodialysis, continuous venovenous, venovenous hemodiafiltration, blood pressure, venovenous, bicarbonate, sepsis, "
 Patient status post vehicular trauma.  Low Back syndrome and Cervicalgia., Consult - History and Phy., Neck & Lower Back Pain - Consult ,"CHIEF COMPLAINT:, Neck and lower back pain.,VEHICULAR TRAUMA HISTORY:, Date of incident: 1/15/2001. The patient was the driver of a small sports utility vehicle and was wearing a seatbelt. The patient’s vehicle was proceeding through an intersection and was struck by another vehicle from the left side and forced off the road into a utility pole. The other vehicle had reportedly been driven by a drunk driver and ran a traffic signal. Estimated impact speed was 80 m.p.h. The driver of the other vehicle was reportedly cited by police. The patient was transiently unconscious and came to the scene. There was immediate onset of headaches, neck and lower back pain. The patient was able to exit the vehicle and was subsequently transported by Rescue Squad to St. Thomas Memorial Hospital, evaluated in the emergency room and released.,NECK AND LOWER BACK PAIN HISTORY:, The patient relates the persistence of pain since the motor vehicle accident. Symptoms began immediately following the MVA. Because of persistent symptoms, the patient subsequently sought chiropractic treatment. Neck pain is described as severe. Neck pain remains localized and is non-radiating. There are no associated paresthesias. Back pain originates in the lumbar region and radiates down both lower extremities. Back pain is characterized as worse than the neck pain. There are no associated paresthesias.",
 Initial evaulation - neck and back pain., Consult - History and Phy., Neck & Back Pain ,"CHIEF COMPLAINT:,  Neck pain, thoracalgia, low back pain, bilateral lower extremity pain.,HISTORY OF PRESENT ILLNESS:,  Ms. XYZ is a fairly healthy 69-year-old Richman, Roseburg resident who carries a history of chronic migraine, osteoarthritis, hypothyroidism, hyperlipidemia, and mitral valve prolapse.  She has previously been under the care of Dr. Ninan Matthew in the 1990s and takes Maxalt on a weekly basis and nadolol, omeprazole and amitriptyline for treatment of her migraines, which occur about once a week.  She is under the care of Dr. Bonaparte for hyperlipidemia and hypothyroidism.  She has a long history of back and neck pain with multiple injuries in the 1960s, 1970s, 1980s and 1990s.  In 2000, she developed ""sciatica"" mostly in her right lower extremity.,She is seen today with no outside imaging, except with MRI of her cervical spine and lumbar spine dated February of 2004.  Her cervical MRI reveals an 8 mm central spinal canal at C6-7, multilevel foraminal stenosis, though her report is not complete as we do not have all the pages.  Her lumbar MRI reveals lumbar spinal stenosis at L4-5 with multilevel facet arthropathy and spondylitic changes.,The patient has essentially three major pain complaints.,Her first pain complaint is one of a long history of axial neck pain without particular radicular symptoms.  She complains of popping, clicking, grinding and occasional stiffness in her neck, as well as occasional periscapular pain and upper trapezius myofascial pain and spasms with occasional cervicalgic headaches.  She has been told by Dr. Megahed in the past that she is not considered a surgical candidate.  She has done physical therapy twice as recently as three years ago for treatment of her symptoms.  She complains of occasional pain and stiffness in both hands, but no particular numbness or tingling.,Her next painful complaint is one of midthoracic pain and thoracalgia features with some right-sided rib pain in a non-dermatomal distribution.  Her rib pain was not preceded by any type of vesicular rash and is reproducible, though is not made worse with coughing.  There is no associated shortness of breath.  She denies inciting trauma and also complains of pain along the costochondral and sternochondral junctions anteriorly.  She denies associated positive or negative sensory findings, chest pain or palpitations, dyspnea, hemoptysis, cough, or sputum production.  Her weight has been stable without any type of constitutional symptoms.,Her next painful complaint is one of axial low back pain with early morning pain and stiffness, which improves somewhat later in the day.  She complains of occasional subjective weakness to the right lower extremity.  Her pain is worse with sitting, standing and is essentially worse in the supine position.  Five years ago, she developed symptoms radiating in an L5-S1 distribution and within the last couple of years, began to develop numbness in the same distribution.  She has noted some subjective atrophy as well of the right calf.  She denies associated bowel or bladder dysfunction, saddle area hypoesthesia, or falls.  She has treated her back symptoms with physical therapy as well.,She is intolerant to any type of antiinflammatory medications as well and has a number of allergies to multiple medications.  She participates in home physical therapy, stretching, hand weights, and stationary bicycling on a daily basis.  Her pain is described as constant, shooting, aching and sharp in nature and is rated as a 4-5/10 for her average and current levels of pain, 6/10 for her worst pain, and 3/10 for her least pain.  Exacerbating factors include recumbency, walking, sleeping, pushing, pulling, bending, stooping, and carrying.  Alleviating factors including sitting, applying heat and ice.,PAST MEDICAL HISTORY:,  As per above and includes hyperlipidemia, hypothyroidism, history of migraines, acid reflux symptoms, mitral valve prolapse for which she takes antibiotic prophylaxis.,PAST SURGICAL HISTORY:,  Cholecystectomy, eye surgery, D&C.,MEDICATIONS:,  Vytorin, Synthroid, Maxalt, nadolol, omeprazole, amitriptyline and 81 mg aspirin.,ALLERGIES:,  Multiple.  All over-the-counter medications.  Toradol, Robaxin, Midrin, Darvocet, Naprosyn, Benadryl, Soma, and erythromycin.,FAMILY HISTORY:,  Family history is remarkable for a remote history of cancer. Family history of heart disease and osteoarthritis.,SOCIAL HISTORY:,  The patient is retired.  She is married with three grown children.  Has a high school level education.  Does not smoke, drink, or utilize any illicit substances.,OSWESTRY PAIN INVENTORY:,  Significant impact on every aspect of her quality of life.  She would like to become more functional.,REVIEW OF SYSTEMS:,  A thirteen-point review of systems was surveyed including constitutional, HEENT, cardiac, pulmonary, GI, GU, endocrine, integument, hematological, immunological, neurological, musculoskeletal, psychological and rheumatological.  Cardiac, swelling in the extremities, hyperlipidemia, history of palpitation, varicose veins.  Pulmonary review of systems negative.  GI review of systems is positive for irritable bowel and acid reflux symptoms.  Genitourinary, occasional stress urinary incontinence and history of remote hematuria.  She is postmenopausal and on hormone replacement.  Endocrine is positive for a low libido and thyroid disorder.  Integument:  Dry skin, itching and occasional rashes.  Immunologic is essentially negative.  Musculoskeletal:  As per HPI.  HEENT:  Jaw pain, popping, clicking, occasional hoarseness, dysphagia, dry mouth, and prior history of toothache.  Neurological:  As per history of present illness.  Constitutional:  As history of present illness.,PHYSICAL EXAMINATION:,  Weight 180 pounds, temp 97.6, pulse 56, BP 136/72.  The patient walks with a normal gait pattern.  There is no antalgia, spasticity, or ataxia.  She can alternately leg stand without difficulty, as well as tandem walk, stand on the heels and toes without difficulty.  She can flex her lumbar spine and touch the floor with her fingertips.  Lumbar extension and ipsilateral bending provoke her axial back pain.  There is tenderness over the PSIS on the right and no particular pelvic asymmetry.,Head is normocephalic and atraumatic.  Cranial nerves II through XII are grossly intact.  Cervical range of motion is slightly limited in extension, but is otherwise intact to flexion and lateral rotation.  The neck is supple.  The trachea is midline.  The thyroid is not particularly enlarged.  Lungs are clear to auscultation.  Heart has regular rate and rhythm with normal S1, S2.  No murmurs, rubs, or gallops.  The abdomen is nontender, nondistended, without palpable organomegaly, guarding, rebound, or pulsatile masses.  Skin is warm and dry to the touch with no discernible cyanosis, clubbing or edema.  I can radial, dorsalis pedis and posterior tibial pulses.  The nailbeds on her feet have trophic changes.  Brisk capillary refill is evident over both upper extremities.,Musculoskeletal examination reveals medial joint line tenderness of both knees with some varus laxity of the right lower extremity.  She has chronic osteoarthritic changes evident over both hands.  There is mild restriction of range of motion of the right shoulder, but no active impingement signs.,Inspection of the axial skeleton reveals a cervicothoracic head-forward posture with slight internal rotation of the upper shoulders.  Palpation of the axial skeleton reveals mild midline tenderness at the lower lumbar levels one fingerbreadth lateral to the midline.  There is no midline spinous process tenderness over the cervicothoracic regions.  Palpation of the articular pillars is met with mild provocation of pain.  Palpation of the right posterior, posterolateral and lateral borders of the lower ribs is met with mild provocable tenderness.  There is also tenderness at the sternochondral and costochondral junctions of the right, as well as the left bilaterally.  The xiphoid process is not particularly tender.  There is no dermatomal sensory abnormality in the thoracic spine appreciated.  Mild facetal features are evident over the sacral spine with extension and lateral bending at the level of the sacral ala.,Neurological examination of the upper and lower extremities reveals 3/5 reflexes of the biceps, triceps, brachioradialis, and patellar bilaterally.  I cannot elicit S1 reflexes.  There are no long tract signs.  Negative Hoffman's, negative Spurling's, no clonus, and negative Babinski.  Motor examination of the upper, as well as lower extremities appears to be intact throughout.  I may be able to detect a slight hand of atrophy of the right calf muscles, but this is truly unclear and no measurement was made.,SUMMARY OF DIAGNOSTIC IMAGING:,  As per above.,IMPRESSION:,1.  Osteoarthritis.,2.  Cervical spinal stenosis.,3.  Lumbar spinal stenosis.,4.  Lumbar radiculopathy, mostly likely at the right L5-S1 levels.,5.  History of mild spondylolisthesis of the lumbosacral spine at L4-L5 and right sacroiliac joint dysfunction.,6.  Chronic pain syndrome with myofascial pain and spasms of the trapezius and greater complexes.,PLAN:  ,The natural history and course of the disease was discussed in detail with Mr. XYZ.  Greater than 80 minutes were spent facet-to-face at this visit.  I have offered to re-image her cervical and lumbar spine and have included a thoracic MR imaging and rib series, as well as cervicolumbar flexion and extension views to evaluate for mobile segment and/or thoracic fractures.  I do not suspect any sort of intrathoracic comorbidity such as a neoplasm or mass, though this was discussed.  Pending the results of her preliminary studies, this should be ruled out.  I will see her in followup in about two weeks with the results of her scans.",
 A very pleasant 66-year-old woman with recurrent metastatic ovarian cancer.  , Consult - History and Phy., Metastatic Ovarian Cancer - Consult ,"REASON FOR CONSULTATION:,  Metastatic ovarian cancer.,HISTORY OF PRESENT ILLNESS: , Mrs. ABCD is a very nice 66-year-old woman who is followed in clinic by Dr. X for history of renal cell cancer, breast cancer, as well as ovarian cancer, which was initially diagnosed 10 years ago, but over the last several months has recurred and is now metastatic.  She last saw Dr. X in clinic towards the beginning of this month.  She has been receiving gemcitabine and carboplatin, and she receives three cycles of this with the last one being given on 12/15/08.  She was last seen in clinic on 12/22/08 by Dr. Y.  At that point, her white count was 0.9 with the hemoglobin of 10.3, hematocrit of 30%, and platelets of 81,000.  Her ANC was 0.5.  She was started on prophylactic Augmentin as well as Neupogen shots.  She has also had history of recurrent pleural effusions with the knee for thoracentesis.  She had two of these performed in November and the last one was done about a week ago.,Over the last 2 or 3 days, she states she has been getting more short of breath.  Her history is somewhat limited today as she is very tired and falls asleep readily.  Her history comes from herself but also from the review of the records.  Overall, her shortness of breath has been going on for the past few weeks related to her pleural effusions.  She was seen in the emergency room this time and on chest x-ray was found to have a new right-sided pulmonic consolidative infiltrate, which was felt to be possibly related to pneumonia.  She specifically denied any fevers or chills.  However, she was complaining of chest pain.  She states that the chest pain was located in the substernal area, described as aching, coming and going and associated with shortness of breath and cough.  When she did cough, it was nonproductive.  While in the emergency room on examination, her vital signs were stable except that she required 5 liters nasal cannula to maintain oxygen saturations.  An EKG was performed, which showed sinus rhythm without any evidence of Q waves or other ischemic changes.  The chest x-ray described above showed a right lower lobe infiltrate.  A V/Q scan was done, which showed a small mismatched defect in the left upper lobe and a mass defect in the right upper lobe.  The findings were compatible with an indeterminate study for a pulmonary embolism.  Apparently, an ultrasound of the lower extremities was done and was negative for DVT.  There was apparently still some concern that this might be pulmonary embolism and she was started on Lovenox.  There was also concern for pneumonia and she was started on Zosyn as well as vancomycin and admitted to the hospital.,At this point, we have been consulted to help follow along with this patient who is well known to our clinic.,PAST MEDICAL HISTORY,1.  Ovarian cancer - This was initially diagnosed about 10 years ago and treated with surgical resection including TAH and BSO.  This has recurred over the last couple of months with metastatic disease.,2.  History of breast cancer - She has been treated with bilateral mastectomy with the first one about 14 years and the second one about 5 years ago.  She has had no recurrent disease.,3.  Renal cell carcinoma - She is status post nephrectomy.,4.  Hypertension.,5.  Anxiety disorder.,6.  Chronic pain from neuropathy secondary to chemotherapy from breast cancer treatment.,7.  Ongoing tobacco use.,PAST SURGICAL HISTORY,1.  Recent and multiple thoracentesis as described above.,2.  Bilateral mastectomies.,3.  Multiple abdominal surgeries.,4.  Cholecystectomy.,5.  Remote right ankle fracture.,ALLERGIES:,  No known drug allergies.,MEDICATIONS: , At home,,1.  Atenolol 50 mg daily,2.  Ativan p.r.n.,3.  Clonidine 0.1 mg nightly.,4.  Compazine p.r.n.,5.  Dilaudid p.r.n.,6.  Gabapentin 300 mg p.o. t.i.d.,7.  K-Dur 20 mEq p.o. daily.,8.  Lasix unknown dose daily.,9.  Norvasc 5 mg daily.,10.  Zofran p.r.n.,SOCIAL HISTORY: , She smokes about 6-7 cigarettes per day and has done so for more than 50 years.  She quit smoking about 6 weeks ago.  She occasionally has alcohol.  She is married and has 3 children.  She lives at home with her husband.  She used to work as a unit clerk at XYZ Medical Center.,FAMILY HISTORY:,  Both her mother and father had a history of lung cancer and both were smokers.,REVIEW OF SYSTEMS: , GENERAL/CONSTITUTIONAL:  She has not had any fever, chills, night sweats, but has had fatigue and weight loss of unspecified amount.  HEENT:  She has not had trouble with headaches; mouth, jaw, or teeth pain; change in vision; double vision; or loss of hearing or ringing in her ears.  CHEST:  Per the HPI, she has had some increasing dyspnea, shortness of breath with exertion, cough, but no sputum production or hemoptysis.  CVS:  She has had the episodes of chest pains as described above but has not had, PND, orthopnea lower extremity swelling or palpitations.  GI:  No heartburn, odynophagia, dysphagia, nausea, vomiting, diarrhea, constipation, blood in her stool, and black tarry stools.  GU:  No dysuria, burning with urination, kidney stones, and difficulty voiding.  MUSCULOSKELETAL:  No new back pain, hip pain, rib pain, swollen joints, history of gout, or muscle weakness.  NEUROLOGIC:  She has been diffusely weak but no lateralizing loss of strength or feeling.  She has some chronic neuropathic pain and numbness as described above in the past medical history.  She is fatigued and tired today and falls asleep while talking but is easily arousable.  Some of this is related to her lack of sleep over the admission thus far.,PHYSICAL EXAMINATION,VITAL SIGNS:  Her T-max is 99.3.  Her pulse is 54, her respirations is 12, and blood pressure 118/61.,GENERAL:  Somewhat fatigued appearing but in no acute distress.,HEENT:  NC/AT.  Sclerae anicteric.  Conjunctiva clear.  Oropharynx is clear without any erythema, exudate, or discharge.,NECK:  Supple.  Nontender.  No elevated JVP.  No thyromegaly.  No thyroid nodules.,CHEST:  Clear to auscultation and percussion bilaterally with decreased breath sounds on the right.,CVS:  Regular rate and rhythm.  No murmurs, gallops or rubs.  Normal S1 and S2.  No S3 or S4.,ABDOMEN:  Soft, nontender, nondistended.  Normoactive bowel sounds.  No guarding or rebound.  No hepatosplenomegaly.  No masses.",
" A 6-mm left intrarenal stone, nonobstructing, by ultrasound and IVP. ", Consult - History and Phy., Microhematuria - Consult ,"HISTORY OF PRESENT ILLNESS: , The patient presents today as a consultation from Dr. ABC's office regarding the above.  He was seen a few weeks ago for routine followup, and he was noted for microhematuria.  Due to his history of kidney stone, renal ultrasound as well as IVP was done.  He presents today for followup.  He denies any dysuria, gross hematuria or flank pain issues.  Last stone episode was over a year ago.  No history of smoking.  Daytime frequency 3 to 4 and nocturia 1 to 2, good stream, empties well with no incontinence.,Creatinine 1.0 on June 25, 2008, UA at that time was noted for 5-9 RBCs, renal ultrasound of 07/24/2008 revealed 6 mm left intrarenal stone, with no hydronephrosis.  IVP same day revealed a calcification over the left kidney, but without bilateral hydronephrosis.  The calcification previously noted on the ureter appears to be outside the course of the ureter.  Otherwise unremarkable.  This is discussed.,IMPRESSION:  ,1.  A 6-mm left intrarenal stone, nonobstructing, by ultrasound and IVP.  The patient is asymptomatic.  We have discussed surgical intervention versus observation.  He indicates that this stone is not bothersome, prefers observation, need for hydration with a goal of making over 2 liters of urine within 24 hours is discussed.,2.  Microhematuria, we discussed possible etiologies of this, and the patient is agreeable to cystoscopy in the near future.  Urine sent for culture and sensitivity.,PLAN: , As above.  The patient will follow up for cystoscopy, urine sent for cytology, continue hydration.  Call if any concern.  The patient is seen and evaluated by myself.","consult - history and phy., intrarenal stone, ivp, ultrasound, microhematuria, hydration, kidney stone, renal ultrasound"
 Patient with stable expressive aphasia and decreased vision., Consult - History and Phy., Multiple Meningiomas ,"CC:, Stable expressive aphasia and decreased vision.,HX:, This 72y/o woman was diagnosed with a left sphenoid wing meningioma on 6/3/80. She was 59 years old at the time and presented with a 6 month history of increasing irritability and left occipital-nuchal headaches. One month prior to that presentation she developed leftward head turning, and 3 days prior to presentation had an episode of severe dysphasia. A HCT (done locally) revealed a homogenously enhancing lesion of the left sphenoid wing. Skull X-rays showed deviation of the pineal to the right. She was transferred to UIHC and was noted to have a normal neurologic exam (per Neurosurgery note). Angiography demonstrated a highly vascular left temporal/sphenoid wing tumor. She under went left temporal craniotomy and ""complete resection"" of the tumor which on pathologic analysis was consistent with a meningioma.,The left sphenoid wing meningioma recurred and was excised 9/25/84. There was regrowth of this tumor seen on HCT, 1985. A 6/88 HCT revealed the left sphenoid meningioma and a new left tentorial meningioma. HCT in 1989 revealed left temporal/sphenoid, left tentorial, and new left frontal lesions. On 2/14/91 she presented with increasing lethargy and difficulty concentrating. A 2/14/91, HCT revealed increased size and surrounding edema of the left frontal meningioma. The left frontal and temporal meningiomas were excised on 2/25/91. These tumors all recurred and a left parietal lesion developed. She underwent resection of the left frontal meningioma on 11/21/91 due to right sided weakness and expressive aphasia. The weakness partially resolved and though the speech improved following resection it did not return to normal. In May 1992 she experienced 3 tonic-clonic type seizures, all of which began with a Jacksonian march up the RLE then RUE before generalizing. Her Phenobarbital prophylaxis which she had been taking since her 1980 surgery was increased. On 12/7/92, she underwent a left fronto-temporo-parieto-occipital craniotomy and excision of five meningiomas. Postoperatively she developed worsened right sided weakness and expressive aphasia. The weakness and aphasia improved by 3/93, but never returned to normal.","consult - history and phy., sphenoid wing meningioma, sphenoid wing, expressive aphasia, meningiomas, aphasia, sphenoidNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" The patient is with multiple neurologic and nonneurologic symptoms including numbness, gait instability, decreased dexterity of his arms and general fatigue.  His neurological examination is notable for sensory loss in a length-dependent fashion in his feet and legs with scant fasciculations in his calves.", Consult - History and Phy., Multiple Neurological Symptoms ,"HISTORY OF PRESENT ILLNESS: , The patient is a 63-year-old left-handed gentleman who presents for further evaluation of multiple neurological symptoms.  I asked him to discuss each symptom individually as he had a very hard time describing the nature of his problems.  He first mentioned that he has neck pain.  He states that he has had this for at least 15 years.  It is worse with movement.  It has progressed very slowly over the course of 15 years.  It is localized to the base of his neck and is sharp in quality.  He also endorses a history of gait instability.  This has been present for a few years and has been slightly progressively worsening.  He describes that he feels unsteady on his feet and ""walks like a duck.""  He has fallen about three or four times over the past year and a half.,He also describes that he has numbness in his feet.  When I asked him to describe this in more detail, the numbness is actually restricted to his toes.  Left is slightly more affected than the right.  He denies any tingling or paresthesias.  He also described that he is slowly losing control of his hands.  He thinks that he is dropping objects due to weakness or incoordination in his hands.  This has also been occurring for the past one to two years.  He has noticed that buttoning his clothes is more difficult for him.  He also does not have any numbness or tingling in the hands.  He does have a history of chronic low back pain.,At the end of the visit, when I asked him which symptom was most bothersome to him, he actually stated that his fatigue was most troublesome.  He did not even mention this on the initial part of my history taking.  When I asked him to describe this further, he states that he experiences a general exhaustion.  He basically lays in bed all day everyday.  I asked him if he was depressed, he states that he is treated for depression.  He is unsure if this is optimally treated.  As I just mentioned, he stays in bed almost all day long and does not engage in any social activities.  He does not think that he is necessarily sad.  His appetite is good.  He has never undergone any psychotherapy for depression.,When I took his history, I noticed that he is very slow in responding to my questions and also had a lot of difficulty recalling details of his history as well as names of physicians who he had seen in the past.  I asked if he had ever been evaluated for cognitive difficulties and he states that he did undergo testing at Johns Hopkins a couple of years ago.  He states that the results were normal and that specifically he did not have any dementia.,When I asked him when he was first evaluated for his current symptoms, he states that he saw Dr. X several years ago.  He believes that he was told that he had neuropathy but that it was unclear if it was due to his diabetes.  He told me that more recently he was evaluated by you after Dr. Y referred him for this evaluation.  He also saw Dr. Z for neurosurgical consultation a couple of weeks ago.  He reports that she did not think there was any surgical indication in his neck or back at this point in time.,PAST MEDICAL HISTORY: , He has had diabetes for five years.  He also has had hypercholesterolemia.  He has had Crohn's disease for 25 or 30 years.  He has had a colostomy for four years.  He has arthritis, which is reportedly related to the Crohn's disease.  He has hypertension and coronary artery disease and is status post stent placement.  He has depression.  He had a kidney stone removed about 25 years ago.,CURRENT MEDICATIONS: , He takes Actos, Ambien, baby aspirin, Coreg, Entocort, folic acid, Flomax, iron, Lexapro 20 mg q.h.s., Lipitor, Pentasa, Plavix, Protonix, Toprol, Celebrex and Zetia.,ALLERGIES: , He states that Imuran caused him to develop tachycardia.,SOCIAL HISTORY:,  He previously worked with pipeline work, but has been on disability for five years.  He is unsure which symptoms led him to go on disability.  He has previously smoked about two packs of cigarettes daily for 20 years, but quit about 20 years ago.  He denies alcohol or illicit drug use.  He lives with his wife.  He does not really have any hobbies.,FAMILY HISTORY: , His father died of a cerebral hemorrhage at age 49.  His mother died in her 70s from complications of congestive heart failure.  He has one sister who died during a cardiac surgery two years ago.  He has another sister with diabetes.  He has one daughter with hypercholesterolemia.  He is unaware of any family members with neurological disorders.,REVIEW OF SYSTEMS: , He has dyspnea on exertion.  He states that he was evaluated by a pulmonologist and had a normal evaluation.  He has occasional night sweats.  His hearing is poor.  He occasionally develops bloody stools, which he attributes to his Crohn's disease.  He also was diagnosed with sleep apnea.  He does not wear his CPAP machine on a regular basis.  He has a history of anemia.  Otherwise, a complete review of systems was obtained and was negative except for as mentioned above.  This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:,Vital Signs:  Blood pressure 160/86 HR 100 RR 16 Wt 211 pounds Pain 3/10,General Appearance:  He is well appearing in no acute distress.  He has somewhat of a flat affect.,Cardiovascular:  He has a regular rhythm without murmurs, gallops, or rubs.  There are no carotid bruits.,Chest:  The lungs are clear to auscultation bilaterally.,Skin:  There are no rashes or lesions.,Musculoskeletal:  He has no joint deformities or scoliosis.,NEUROLOGICAL EXAMINATION:,Mental Status:  His speech is fluent without dysarthria or aphasia.  He is alert and oriented to name, place, and date.  Attention, concentration, and fund of knowledge are intact.  He has 3/3 object registration and 1/3 recall in 5 minutes.,Cranial Nerves:  Pupils are equal, round, and reactive to light and accommodation.  Visual fields are full.  Optic discs are normal.  Extraocular movements are intact without nystagmus.  Facial sensation is normal.  There is no facial, jaw, palate, or tongue weakness.  Hearing is grossly intact.  Shoulder shrug is full.,Motor:  He has normal muscle bulk and tone.  There is no atrophy.  He has few fasciculations in his calf muscles bilaterally.  Manual muscle testing reveals MRC grade 5/5 strength in all proximal and distal muscles of the upper and lower extremities.  There is no action or percussion myotonia or paramyotonia.,Sensory:  He has absent vibratory sensation at the left toe.  This is diminished at the right toe.  Joint position sense is intact.  There is diminished sensation to light touch and temperature at the feet to the knees bilaterally.  Pinprick is intact.  Romberg is absent.  There is no spinal sensory level.,Coordination:  This is intact by finger-nose-finger or heel-to-shin testing.  He does have a slight tremor of the head and outstretched arms.,Deep Tendon Reflexes:  They are 2+ at the biceps, triceps, brachioradialis, patellas, and ankles.  Plantar reflexes are flexor.  There is no ankle clonus, finger flexors, or Hoffman's signs.  He has crossed adductors bilaterally.,Gait and Stance:  He has a slightly wide-based gait.  He has some difficulty with toe walking, but he is able to walk on his heels and tandem walk.  He has difficulty with toe raises on the left.,RADIOLOGIC DATA: , MRI of the cervical spine, 09/30/08:  Chronic spondylosis at C5-C6 causing severe bilateral neuroforamining and borderline-to-mold cord compression with normal cord signal.  Spondylosis of C6-C7 causing mild bilateral neuroforamining and left paracentral disc herniation causing borderline cord compression.,Thoracic MRI spine without contrast:  Minor degenerative changes without stenosis.,I do not have the MRI of the lumbar spine available to review.,LABORATORY DATA: , 10/07/08:  Vitamin B1 210 (87-280), vitamin B6 6, ESR 6, AST 25, ALT 17, vitamin B12 905, CPK 226 (0-200), T4 0.85, TSH 3.94, magnesium 1.7, RPR nonreactive, CRP 4, Lyme antibody negative, SPEP abnormal (serum protein electrophoresis), but no paraprotein by manifestation, hemoglobin A1c 6.0, aldolase 3.9 and homocystine 9.0.,ASSESSMENT: , The patient is a 63-year-old gentleman with multiple neurologic and nonneurologic symptoms including numbness, gait instability, decreased dexterity of his arms and general fatigue.  His neurological examination is notable for sensory loss in a length-dependent fashion in his feet and legs with scant fasciculations in his calves.  He has fairly normal or very mild increased reflexes including notably the presence of normal ankle jerks.,I think that the etiology of his symptoms is multifactorial.  He probably does have a mild peripheral neuropathy, but the sparing of ankle jerks suggested either the neuropathy is mild or that there is a superimposed myelopathic process such as a cervical or lumbosacral myelopathy.  He really is most concerned about the fatigue and I think it is possible due to suboptimally treated depression and suboptimally treated sleep apnea.  Whether he has another underlying muscular disorder such as a primary myopathy remains to be seen.,RECOMMENDATIONS:,1.  I scheduled him for repeat EMG and nerve conduction studies to evaluate for evidence of neuropathy or myopathy.,2.  I will review his films at our spine conference tomorrow although I am confident in Dr. Z's opinion that there is no surgical indication.,3.  I gave him a prescription for physical therapy to help with gait imbalance training as well as treatment for his neck pain.,4.  I believe that he needs to undergo psychotherapy for his depression.  It may also be worthwhile to adjust his medications, but I will defer to his primary care physician for managing this or for referring him to a therapist.  The patient is very open about proceeding with this suggestion.,5.  He does need to have his sleep apnea better controlled.  He states that he is not compliant because the face mask that he uses does not fit him well.  This should also be addressed.",
" Loculated left effusion, multilobar pneumonia.  Patient  had a diagnosis of multilobar pneumonia along with arrhythmia and heart failure as well as renal insufficiency. ", Consult - History and Phy., Multilobar Pneumonia ,"REASON FOR CONSULTATION: , Loculated left effusion, multilobar pneumonia.","consult - history and phy., neck bruits, nasal cannula, rhythm, pneumonia, chest tube, fluid collection, pleural effusion, multilobar pneumonia, pleural, loculations, multilobar,"
" Mesothelioma versus primary lung carcinoma, Chronic obstructive pulmonary disease, paroxysmal atrial fibrillation, malignant pleural effusion, status post surgery as stated above, and anemia of chronic disease.", Consult - History and Phy., Mesothelioma - Consult ,"REASON FOR CONSULTATION: , Mesothelioma.,HISTORY OF PRESENT ILLNESS: , The patient is a 73-year-old pleasant Caucasian male who is known to me from his previous hospitalization.  He has also been seen by me in the clinic in the last few weeks.  He was admitted on January 18, 2008, with recurrent malignant pleural effusion.  On the same day, he underwent VATS and thoracoscopic drainage of the pleural effusion with right pleural nodule biopsy, lysis of adhesions, and directed talc insufflation by Dr. X.  He was found to have 2.5L of bloody pleural effusions, some loculated pleural effusion, adhesions, and carcinomatosis in the parenchyma.  His hospital course here has been significant for dyspnea, requiring ICU stay.  He also had a chest tube, which was taken out few days ago.  He has also had paroxysmal atrial fibrillation, for which he has been on amiodarone by cardiologist.  The biopsy from the pleural nodule done on the right on January 18, 2008, shows malignant epithelioid neoplasm consistent with mesothelioma.  Immunohistochemical staining showed tumor cells positive for calretinin and focally positive for D2-40, MOC-31.  Tumor cells are negative for CDX-2, and monoclonal CEA.,The patient at this time reports that overall he has been feeling better with decrease in shortness of breath and cough over the last few days.  He does have edema in his lower extremities.  He is currently on 4L of oxygen.  He denies any nausea, vomiting, abdominal pain, recent change in bowel habit, melena, or hematochezia.  No neurological or musculoskeletal signs or symptoms.  He reports that he is able to ambulate to the bathroom, but gets short of breath on exertion.  He denies any other complaints.,PAST MEDICAL HISTORY:,  Left ventricular systolic dysfunction as per the previous echocardiogram done in December 2007, history of pneumonia in December 2007, admitted to XYZ Hospital.  History of recurrent pleural effusions, status post pleurodesis and locally advanced non-small cell lung cancer as per the biopsy that was done in XYZ Hospital.,ALLERGIES:,  No known drug allergies.,CURRENT MEDICATIONS:  ,In the hospital are amiodarone, diltiazem, enoxaparin, furosemide, methylprednisolone, pantoprazole, Zosyn, p.r.n. acetaminophen, and hydrocodone.,SOCIAL HISTORY: , The patient is married and lives with his spouse.  He has history of tobacco smoking and also reports history of alcohol abuse.  No history of illicit drug abuse.,FAMILY HISTORY:  ,Significant for history of ?cancer? in the mother and history of coronary artery disease in the father.,REVIEW OF SYSTEMS: , As stated above.  He denies any obvious asbestos exposure, as far as he can remember.,PHYSICAL EXAMINATION,GENERAL:  He is awake, alert, in no acute distress.  He is currently on 4L of oxygen by nasal cannula.,VITAL SIGNS:  Blood pressure 97/65 mmHg, respiration is 20 per minute, pulse is 72 per minute, and temperature 98.3 degrees Fahrenheit.,HEENT:  No icterus or sinus tenderness.  Oral mucosa is moist.,NECK:  Supple.  No lymphadenopathy.,LUNGS:  Clear to auscultation except few diffuse wheezing present bilaterally.,CARDIOVASCULAR:  S1 and S2 normal.,ABDOMEN:  Soft, nondistended, and nontender.  No hepatosplenomegaly.  Bowel sounds are present in all four quadrants.,EXTREMITIES:  Bilateral pedal edema is present in both the extremities.  No signs of DVT.,NEUROLOGICAL:  Grossly nonfocal.,INVESTIGATION:,  Labs done on January 28, 2008, showed BUN of 23 and creatinine of 0.9.  Liver enzymes checked on January 17, 2008, were unremarkable.  CBC done on January 26, 2008, showed WBC of 19.8, hemoglobin of 10.7, hematocrit of 30.8, and platelet count of 515,000.  Chest x-ray from yesterday shows right-sided Port-A-Cath, diffuse right lung parenchymal and pleural infiltration without change, mild pulmonary vascular congestion.,ASSESSMENT,1.  Mesothelioma versus primary lung carcinoma, two separate reports as for the two separate biopsies done several weeks apart.,2.  Chronic obstructive pulmonary disease.,3.  Paroxysmal atrial fibrillation.,4.  Malignant pleural effusion, status post surgery as stated above.,5.  Anemia of chronic disease.,RECOMMENDATIONS,1.  Compare the slides from the previous biopsy done in December at XYZ Hospital with recurrent pleural nodule biopsy slides.  I have discussed regarding this with Dr. Y in Pathology here at Methodist XYZ Hospital.  I will try to obtain the slides for comparison from XYZ Hospital for comparison and immunohistochemical staining.,2.  I will also discuss with Dr. X and also with intervention radiologist at XYZ Hospital regarding the exact sites of the two biopsies.,3.  Once the results of the above are available, I will make further recommendations regarding treatment.  The patient has significantly decreased performance status with dyspnea on exertion and is being planned for transfer to Triumph Hospital for rehab, which I agree with.,4.  Continue present care.,Discussed regarding the above in great details with the patient and his wife and daughter and answered the questions to their satisfaction.  They clearly understand the above.  They also understand his very poor performance status at this time, and the risks and benefits of delaying chemotherapy due to this.",
" The patient with gradual onset of a headache problem, located behind both eyes.", Consult - History and Phy., Migraine without Aura - Consult ,"CHIEF COMPLAINT:, Headaches.,HEADACHE HISTORY:, The patient describes the gradual onset of a headache problem. The headache first began 2 months ago. The headaches are located behind both eyes. The pain is characterized as a sensation of pressure. The intensity is moderately severe, making normal activities difficult. Associated symptoms include sinus congestion and photophobia. The headache may be brought on by stress, lack of sleep and alcohol. The patient denies vomiting and jaw pain.,PAST MEDICAL HISTORY:, No significant past medical problems.,PAST SURGICAL HISTORY:, ,No significant past surgical history.,FAMILY MEDICAL HISTORY:, ,There is a history of migraine in the family. The condition affects the patient’s brother and maternal grandfather.,ALLERGIES:, Codeine.,CURRENT MEDICATIONS:, See chart.,PERSONAL/SOCIAL HISTORY:, Marital status: Married. The patient smokes 1 pack of cigarettes per day.  Denies use of alcohol.,NEUROLOGIC DRUG HISTORY:, The patient has had no help with the headaches from over-the-counter analgesics.,REVIEW OF SYSTEMS:,ROS General: Generally healthy. Weight is stable.,ROS Head and Eyes: Patient has complaints of headaches. Vision can best be described as normal.,ROS Ears Nose and Throat: The patient notes some sinus congestion.,ROS Cardiovascular: The patient has no history of any cardiovascular problems and denies any present problems.,ROS Gastrointestinal: The patient has no history of gastrointestinal problems and denies any present problems.,ROS Musculoskeletal: No muscle cramps, no joint back or limb pain. The patient denies any past or present problem related to the musculoskeletal system.,EXAM:,Exam General Appearance: The patient was alert and cooperative, and did not appear acutely or chronically ill.,Sex and Race: Male, Caucasian.,Exam Mental Status: Serial 7’s were performed normally. The patient was oriented with regard to time, place and situation.,Three out of three objects were readily recalled after several minutes. The patient correctly identified the president and past president. The patient could repeat 7 digits forward and 4 digits reversed without difficulty. The patient’s affect and emotional response was normal and appropriate. The patient related the clinical history in a coherent, organized fashion.,Exam Cranial Nerves: Sense of smell was intact.,Exam Neck: Neck range of motion was normal in all directions. There was no evidence of cervical muscle spasm.  No radicular symptoms were elicited by neck motions. Shoulder range of motion was normal bilaterally. There were no areas of tenderness. Tests of neurovascular compression were negative. There were no carotid bruits.,Exam Back: Back range of motion was normal in all directions.,Exam Sensory: Position and vibratory sense was normal.,Exam Reflexes: Active and symmetrical. There were no pathological reflexes.,Exam Coordination: The patient’s gait had no abnormal components. Tandem gait was performed normally.,Exam Musculoskeletal: Peripheral pulses palpably normal. There is no edema or significant varicosities.  No lesions identified.,IMPRESSION DIAGNOSIS: ,Migraine without aura (346.91),COMMENTS:, The patient has evolved into a chronic progressive course. Medications Prescribed: Therapeutic trial of Inderal 40mg - 1/2 tab b.i.d. x 1 week, then 1 tab. b.i.d. x 1 week then 1 tab t.i.d.,OTHER TREATMENT:, The patient was given a thorough explanation of the role of stress in migraine, and given a number of suggestions about implementing appropriate changes in lifestyle.,RATIONALE FOR TREATMENT PLAN:, The treatment plan chosen is the most effective and should result in the most beneficial outcome for the patient. There are no reasonable alternatives.,FOLLOW UP INSTRUCTIONS:",
" Newly diagnosed mantle cell lymphoma, admitted now to start chemotherapy.  She will start treatment with hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone.", Consult - History and Phy., Mantle Cell Lymphoma - Consult ,"CHIEF COMPLAINT:,  Newly diagnosed mantle cell lymphoma.,HISTORY OF PRESENT ILLNESS: , The patient is a 47-year-old woman who presented with abdominal pain in September 2006.  On chest x-ray, she had a possible infiltrate and it was thought she might have pneumonia and she was treated with antibiotics and prednisone.  Symptoms improved temporarily, but did not completely resolve.  By the end of September, her pain had worsened and she was seen in the emergency room at ABC.  Chest x-ray was compatible with pleurisy and she was treated with Percocet.  Few days later, she was seen and given a prescription for Ultram because Percocet was causing nausea.  Eventually, she was seen by Dr. X and noted to have splenomegaly.  Repeat ultrasound was done and showed the spleen enlarged at 19 cm.  In retrospect, this was not changed in comparison to an ultrasound that was done in September.  She underwent positron emission tomography (PET) scanning, which showed diffuse hypermetabolic lymph nodes measuring 1 to 2 cm in diameter, as well as a hypermetabolic spleen that was enlarged.,The patient underwent lymph node biopsy on the right neck on 10/27/2006.  Pathology is consistent with mantle cell lymphoma.,On 10/31/2006, she had a bone marrow biopsy.  This does show involvement of bone marrow with lymphoma.,She was noted to have circulating lymphoma cells on peripheral smear as well.,Although CBC was normal, MCV was low and the ferritin was assessed and was low at 8, consistent with iron deficiency.,ALLERGIES:,  NONE.,MEDICATIONS:  ,1.  Estradiol/Prometrium.  ,2.  Ultram p.r.n.  ,3.  Baby aspirin.  ,4.  Lunesta for sleep.  ,5.  She has been started on iron supplements.,PAST MEDICAL HISTORY:  ,1.  Tubal ligation in 1986.,2.  Possible cyst removed from the left neck in 1991.,3.  Tonsillectomy.,4.  Migraines, which are rare.,SOCIAL HISTORY: , She does not smoke cigarettes and drinks alcohol only occasionally.  She is married and has two children, ages 24 and 20.  She works as a project administrator.,FAMILY HISTORY:  ,Father is deceased.  He had emphysema and colon cancer at age 68.  Mother has arrhythmia and hypertension.  Her sister has hypertension and her brother is healthy.,PHYSICAL EXAMINATION:  ,GENERAL:  She is in no acute distress.,VITAL SIGNS:  Her weight is 168 pounds, and she is afebrile with a normal blood pressure and pulse.,HEENT:  The oropharynx is benign.,SKIN:  The skin is warm and dry and shows no jaundice.,NECK:  There is shotty adenopathy in the neck.,CARDIAC:  Regular rate without murmur.,LUNGS:  Clear to auscultation bilaterally.,ABDOMEN:  Soft and nontender and shows the spleen palpable about 10 cm below the right costal margin.,EXTREMITIES:  No peripheral edema is noted.,LABORATORY DATA: , CBC and chemistry panel are pending.  CBC was normal last week.  PT/INR was normal as well.,IMPRESSION:,  Newly diagnosed mantle cell lymphoma, admitted now to start chemotherapy.  She will start treatment with hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone.  Toxicities have already been discussed with her including myelosuppression, mucositis, diarrhea, nausea, alopecia, the low risk for cardiac toxicity, bladder toxicity, neuropathy, constipation, etc.  Written materials were provided to her last week.,PLAN: , Plan will be to add Rituxan a little later in her course because she has circulating lymphoma cells.  She will be started on allopurinol today as well as hydration further to avoid the possibility of tumor lysis syndrome.,Plan will be to have her evaluated for bone marrow transplant in first remission.  I will have Dr. Y see her while she is in the hospital.,The patient is anxious, and will be given Ativan as needed.  We will discontinue aspirin for now, but continue estradiol/Prometrium.,Iron deficiency will be treated with oral iron supplements and we will follow her counts.  She may well have gastrointestinal (GI) involvement, which is not uncommon with mantle cell lymphoma.  After she undergoes remission, we will consider colonoscopy for biopsies prior to proceeding to transplant.",
 Progressive loss of color vision OD., Consult - History and Phy., Meningioma ,"CC: ,Progressive loss of color vision OD,HX:, 58 y/o female presents with a one year history of progressive loss of color vision. In the past two months she has developed blurred vision and a central scotoma OD. There are no symptoms of photopsias, diplopia, headache, or eye pain. There are no other complaints. There have been mild fluctuations of her symptoms, but her vision has never returned to its baseline prior to symptom onset one year ago.,EXAM: ,Visual acuity with correction: 20/25+1 OD; 20/20-1 OS. Pupils were 3.5mm OU. There was a 0.8 log unit RAPD OD. Intraocular pressures were 25 and 24, OD and OS respectively; and there was an increase to 27 on upgaze OD, but no increase on upgaze OS. Optic disk pallor was evident OD, but not OS. Additionally, there was a small area of peripheral chorioretinal scarring in the inferotemporal area of the right eye. Foveal flicker fusion occurred at a frequency of 21.9 OD and 30.7 OS. Color plate testing scores: 6/14 OD and 10/14 OS. Goldman visual field examination showed an enlarged and deepened blind spot with an infero-temporal defect especially in the smaller diopters.,IMPRESSION ON 2/6/89: ,Optic neuropathy/atrophy OD, rule out mass lesion affecting optic nerve. Particular attention was paid to the area of the optic canal, cavernous sinus and sphenoid sinus.,BRAIN CT W/CONTRAST, 2/13/89:, Enhancing calcified lesion in the posterior aspect of the right optic nerve, probable meningioma.,MRI ORBITS W/ AND W/OUT GADOLINIUM CONTRAST, 4/26/89:, 7x3mm irregular soft tissue mass just inferior and lateral to the optic nerve OD. The mass is just proximal to the orbital apex. There is relatively homogeneous enhancement of the mass. The findings are most consistent with meningioma.,MRI 1995:, Mild enlargement of tumor with possible slight extension into the right cavernous sinus.,COURSE: ,Resection and biopsy were deferred due to risk of blindness, and suspicion that the tumor was a slow growing meningioma. 3 years after initial evaluation Hertel measurements indicated a 3mm proptosis OD. Visual field testing revealed gradual worsening of deficits seen on her initial Goldman visual field exam. There was greater red color desaturation of the temporal field OD. Visual acuity had decreased from 20/20 to 20/64, OD. All other deficits seen on her initial exam remained stable or slightly worsened. By 1996 she continued to be followed at 6 months intervals and had not undergone surgical resection.","consult - history and phy., goldman visual field examination, loss of color vision, visual field examination, visual acuity, cavernous sinus, color vision, visual field, optic nerve, meningioma,"
 Mental status changes after a fall.  She sustained a concussion with postconcussive symptoms and syndrome that has resolved. , Consult - History and Phy., Mental Status Changes - Consult ,"CHIEF COMPLAINT: , Mental status changes after a fall.,HISTORY: , Ms. ABC is a 76-year-old female with Alzheimer's, apparently is normally very talkative, active, independent, but with advanced Alzheimer's.  Apparently, she tripped backwards hitting her head on a wheelchair and, had although no loss consciousness, had altered mental status changes.  She was very confused, incomprehensible speech, and was not responding appropriately.  She was transported here stable, with no significant changes.  She ultimately upon arrival here was unchanged in that she was not responding appropriately.  She would have garbled speech, somewhat inappropriate at times, and unable to follow commands.  No other history was able to be obtained.  All pertinent history is documented within the records.  Physical examination also documented in the records, essentially as above.,PHYSICAL EXAMINATION: , HEENT:  Without any obvious signs of trauma.  Pupils are equal and reactive.  Extraocular movements are difficult to assess with her eyes closed, but she will open to voice.  TMs, canals are normal without any signs of hemotympanum.  Nasal mucosa and oropharynx are normal.,NECK:  Nontender, full range of motion, was not examined initially, a collar was placed.,HEART:  Regular.,LUNGS:  Clear.,CHEST/BACK/ABDOMEN:  Without trauma.,SKIN:  With multiple excoriations from scratching and itching.,NEUROLOGIC:  Otherwise she has good sensation, withdrawals to pain.  When lifting the arm, she will hold them up and draw, let them down slowly.  With movement of the legs, she did straighten them back out slowly.  DTRs were intact and equal bilaterally.  Otherwise, the remainder of the examination was unable to be done because of patient's non-cooperation and mental status change.,LABORATORY DATA: , CT scan of the head was negative as was cervical spine.  She has a history of being on Coumadin.  Her INR is 1.92, CBC was with a white count of 3.8, 50% neutrophils, 8% bands.  CMP did note a potassium, which was elevated at 5.9, troponin was normal, mag is 2.5, valproic acid level 24.3.,ASSESSMENT AND PLAN: , Ms. ABC is a 76-year-old female with multiple medical problems who has sustained a head injury with mental status changes that on repeat examination now at approximately 1930 hours, has completely resolved.  It is likely she sustained a concussion with postconcussive symptoms and syndrome that has resolved.  At this time, she has some other abnormalities in her lab work and I recommend she be admitted for observation and further investigation.  I have discussed this with her son, he agrees.  Otherwise, she has improved significantly.  The patient was discussed with XYZ, who will admit the patient for further evaluation and treatment.","consult - history and phy., alzheimer's, no loss consciousness, mental status,"
" Marginal zone lymphoma (MALT-type lymphoma).  A mass was found in her right breast on physical examination.  she had a mammogram and ultrasound, which confirmed the right breast mass.", Consult - History and Phy., Marginal Zone Lymphoma ,"CHIEF COMPLAINT: , Marginal zone lymphoma.,HISTORY OF PRESENT ILLNESS: , This is a very pleasant 46-year-old woman, who I am asked to see in consultation for a newly diagnosed marginal zone lymphoma (MALT-type lymphoma).  A mass was found in her right breast on physical examination.  On 07/19/10, she had a mammogram and ultrasound, which confirmed the right breast mass.  On 07/30/10, she underwent a biopsy, which showed a marginal zone lymphoma (MALT-type lymphoma).,Overall, she is doing well.  She has a good energy level and her ECOG performance status is 0.  She denies any fevers, chills, or night sweats.  No lymphadenopathy.  No nausea or vomiting.  She has normal bowel and bladder habits.  No melena or hematochezia.,CURRENT MEDICATIONS:  ,Macrobid 100 mg q.d.,ALLERGIES:  ,Sulfa, causes nausea and vomiting.,REVIEW OF SYSTEMS: , As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1.  She is status post a left partial nephrectomy as a new born.,2.  In 2008 she had a right ankle fracture.,SOCIAL HISTORY: , She has a 20-pack year history of tobacco use.  She has rare alcohol use.  She has no illicit drug use.  She is in the process of getting divorced.  She has a 24-year-old son in the area and 22-year-old daughter.,FAMILY HISTORY:  ,Her mother had uterine cancer.  Her father had liver cancer.,PHYSICAL EXAM:,VIT:",
" Patient with Hypertension, atrial fibrillation, large cardioembolic stroke initially to the right brain requesting medical management", Consult - History and Phy., Medical Management Consult Request ,"CONSULT REQUEST FOR:, Medical management.,The patient has been in special procedures now for over 2 hours and I am unable to examine.,HISTORY OF PRESENT ILLNESS:, Obtained from Dr. A on an 81-year-old white female, who is right handed, who by history, had a large stroke to the right brain, causing left body findings, last night. She was unfortunately outside of the window for emergent treatment and had a negative CT scan of the head. Was started on protocol medication and that is similar to TPA, which is an investigational study.,During the evaluation she was found to be in atrial fibrillation on admission with hypertension that was treated with labetalol en route. Her heart rate was 130. She was brought down with Cardizem. She received the study drug in the night and about an hour later thought to have another large stroke effecting the opposite side of the brain, that the doctors and company think is probably cardioembolic and not related to the study drug, as TPA has no obvious known association with this.,At that time the patient became comatose and required emergent intubation and paralyzation. Her diastolic at that time rose up to 190, likely the result of the acute second stroke. She is currently in arteriogram and a clot has been extracted from the proximal left carotid, but there is still distal clot that they are working on. Dr. A has updated the family to her extremely guarded and critical prognosis.,At present, it is not known yet, we do not have the STAT echocardiogram, if she has a large clot in the heart or if she could have a patent foramen ovale clot in the legs that has been passed to the heart. Echo that is pending, and cannot be done till the patient is out of arteriogram, which is her lifesaving procedure right now.,REVIEW OF SYSTEMS:, Complete review of systems is unobtainable at present. From what I can tell, is that she is scheduled for an upcoming bladder distension surgery and I do not know if this is why she is off Coumadin for chronic AFib or what, at this point. Tremor for 3-4 years, diagnosed as early Parkinson's.,PAST MEDICAL HISTORY:, GERD, hypertension times 20 years, arthritis, Parkinson's, TIA, chronic atrial fibrillation, on Coumadin three years.,PAST SURGICAL HISTORY:, Cholecystectomy, TAH 33, gallstones, back surgery 1998, thoracotomy for unknown reason at present.,ALLERGIES:, MORPHINE, SULFAS (RASH), PROZAC.,MEDICATIONS AT HOME: Lanoxin 0.25 daily; Inderal LA 80 daily; MOBIC 7.5 daily; Robaxin 750 q.8; aspirin 80 one daily; acyclovir dose unknown daily; potassium, dose unknown; oxazepam 15 mg daily; aspirin 80 one daily; ibuprofen PRN; Darvocet-N 100 PRN.,SOCIAL HISTORY:, She does not drink or smoke. Lives in Fayetteville, Tennessee.,FAMILY HISTORY:, Mother died of cancer, unknown type. Dad died of an MI.,VACCINATION STATUS: Unknown.,PHYSICAL EXAMINATION:,VITAL SIGNS: On arrival were temperature 97.1, blood pressure 174/100, heart rate 100, 97%, respirations 15.,GENERAL: She was apparently alert and able to give history on arrival. Currently do not have any available vital signs or physical exam, as I cannot get to the patient.,LABORATORY: ,Reviewed and are remarkable for white count of 13 with 76 neutrophils. BMP is normal, except for a blood sugar of 157, hemoglobin A1c is pending. TSH 2.1, cholesterol 165, Digoxin 1.24, CPK 57. ABG 7.47/32/459 on 100%. Magnesium 1.5. ESR 9, coags normal.,EKG is pending my review.,Chest x-ray is read as mild cardiomegaly and atherosclerotic aorta.,Chest x-ray, shoulder films and CT scan of the head: I have reviewed. Chest x-ray has good ET tube placement. She has mild cardiomegaly. Some mild interstitial opacities consistent with OGD and minimal amount of atherosclerosis of the aorta.,CT scan of the head: I do not see any active bleeding.,X-rays of the shoulders appear intact to me and we are awaiting radiologies final approval on those.,ASSESSMENT/PLAN/PROBLEMS:,1. Large cardioembolic stroke initially to the right brain, with devastating effects, and now stroke into the left brain as well, with fluctuating mental status. Obviously she is in critical condition and stable with multiple strokes. One must also wonder if she could have a large clot burden below the heart and patent foramen ovale, etc. We need STAT records from her prior cardiologist and prior echocardiogram report to see exactly what are the details. I have ordered a STAT echo and to have the group that sees her read it, that if he has a large clot burdened in the heart or has distal clot with a PFO we may be able to better prognosticate at this point. Obviously, she cannot have any anticoagulants, except for the study drug, at present, which is her only chance and hopefully they will be able to retrieve most of the clot with emergency retrieval device as activated heroically, by Dr. A and interventional radiology.,2. Hypertension/atrial fibrillation: This will be a difficult management and the fact that she has been on a beta-blocker for Parkinson's, she may have withdrawal to the beta-blockers as we remove this. Given her atrial fibrillation, I do agree the safest agent right now is to use a Cardizem drip as needed and would use it for systolic greater than 160 to 180, or diastolics greater than 90 to 100. Also, would use it to control the atrial fibrillation. We would, however, be very cautious not to put her in heart block with the Digoxin and the beta-blocker on board. Weighing all risks and benefits, I think that given the fact that she has a beta-blocker on board and Digoxin, we would like to avoid the beta-blocker for vasospasm protection and will favor using calcium channel blocker for now. If, however, we run into trouble with this, I would prefer to switch her to Brevibloc or an Esmolol drip and see how she does, as she may withdraw from the beta-blocker. I will be watching this closely and managing the hypertension as I see fit at the moment, based on all factors. Will also ask cardiology if she has one that sees her here, to help guide this. Her Digoxin level is appropriate, as well as a TSH. I do not feel that we need to work this up further, other than the STAT echo and ultrasound of the leg.,3. Respiratory failure requiring ventilator: I have discussed this with Dr. Devlin, we do not feel the need to hyperventilate her at present. We will keep her comfortable on the breathing machine and try to keep her pH in a normal range, around 7.4, and her CO2 in the 30 to 40 range. If she has brain swelling, we will need to hyperventilate her to a pCO2 of 30 and a pH of 7.5, to optimize the cardiac arrhythmia potential of alkalosis weighed with the control of brain swelling.,4. Optimize electrolytes as you can.,5. Deep vein thrombosis prophylaxis for now, with thigh-high TED hose, possibly SCDs, although I do not have experience with the vampire/venom to know if we need to worry about DIC which the SCDs may worsen. Will follow daily CBCs for that.,6. Nutrition: Will go ahead and start a low dose of tube feeds and hope that she does survive.,I will defer all updates to the family for the next 24 to 48 hours to Dr. Devlin's expertise, given her unknown and fluctuating neurologic prognosis.,Thank you so much for allowing us to participate in her care. We will be happy to do all medication treatment until the point that I feel that I would need any help from critical care. I believe that we will be able to manage her fully at this point, for simplicity sake.",
" Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.", Consult - History and Phy., Major Depressive Disorder - IME Consult ,"IDENTIFYING DATA:  ,Mr. T is a 45-year-old white male.,CHIEF COMPLAINT: , Mr. T presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.  His confidence and self-esteem are significantly low.  He stated he has excessive somnolence, his energy level is extremely low, motivation is low, and he has a lack for personal interests.  He has had suicidal ideation, but this is currently in remission.  Furthermore, he continues to have hopeless thoughts and crying spells.  Mr. T stated these symptoms appeared approximately two months ago.,HISTORY OF PRESENT ILLNESS: , On March 25, 2003, Mr. T was fired from his job secondary, to an event at which he stated he was first being harassed by another employee."" This other, employee had confronted Mr. T with a very aggressive, verbal style, where this employee had placed his face directly in front of Mr. T was spitting on him, and called him ""bitch."" Mr. T then retaliated, and went to hit the other employee.  Due to this event, Mr. T was fired.  It should be noted that Mr. T stated he had been harassed by this individual for over a year and had reported the harassment to his boss and was told to ""deal with it."",There are no other apparent stressors in Mr. T's life at this time or in recent months.  Mr. T stated that work was his entire life and he based his entire identity on his work ethic.  It should be noted that Mr. T was a process engineer for Plum Industries for the past 14 years.,PAST PSYCHIATRIC HISTORY:,  There is no evidence of any psychiatric hospitalizations or psychiatric interventions other than a recent visit to Mr. T's family physician, Dr. B at which point Mr. T was placed on Lexapro with an unknown dose at this time.  Mr. T is currently seeing Dr. J for psychotherapy where he has been in treatment since April, 2003.,PAST PSYCHIATRIC REVIEW OF SYSTEMS:,  Mr. T denied any history throughout his childhood, adolescence, and early adulthood for depressive, anxiety, or psychotic disorders.  He denied any suicide attempts, or profound suicidal or homicidal ideation.  Mr. T furthermore stated that his family psychiatric history is unremarkable.,SUBSTANCE ABUSE HISTORY:,  Mr. T stated he used alcohol following his divorce in 1993, but has not used it for the last two years.  No other substance abuse was noted.,LEGAL HISTORY: , Currently, charges are pending over the above described incident.,MEDICAL HISTORY: , Mr. T denied any hospitalizations, surgeries, or current medications use for any heart disease, lung disease, liver disease, kidney disease, gastrointestinal disease, neurological disease, closed head injury, endocrine disease, infectious, blood or muscles disease other than stating he has a hiatal hernia and hypercholesterolemia.,PERSONAL AND SOCIAL HISTORY: , Mr. T was born in Dwyne, Missouri, with no complications associated with his birth.  Originally, he was raised by both parents, but they separated at an early age.  When he was about seven years old, he was raised by his mother and stepfather.  He did not sustain a relationship with his biological father from that time on.  He stated his parents moved a lot, and because this many times he was picked on in his new environments, Mr. T stated he was, at times, a rebellious teenager, but he denied any significant inability to socialize, and denied any learning disabilities or the need for special education.,Mr. T stated his stepfather was somewhat verbally abusive, and that he committed suicide when Mr. T was 18 years old.  He graduated from high school and began work at Dana Corporation for two to three years, after which he worked as an energy, auditor for a gas company.  He then became a homemaker while his wife worked for Chrysler for approximately two years.  Mr. T was married for eleven years, and divorced in 1993.  He has a son who is currently 20 years old.  After being a home maker, Mr. T worked for his mother in a restaurant, and moved on from there to work for Borg-Warner corporation for one to two years before beginning at Plum Industries, where he worked for 14 years and worked his way up to lead engineer.,Mental Status Exam:  Mr. T presented with a hyper vigilant appearance, his eye contact was appropriate to the interview, and his motor behavior was tense.  At times he showed some involuntary movements that would be more akin to a resting tremor.  There was no psychomotor retardation, but there was some mild psychomotor excitement.  His speech was clear, concise, but pressured.  His attitude was overly negative and his mood was significant for moderate depression, anxiety, anhedonia and loneliness, and mild evidence of anger.  There was no evidence of euphoria or diurnal mood variation.  His affective expression was restricted range, but there was no evidence of lability.  At times, his affective tone and facial expressions were inappropriate to the interview.  There was no evidence of auditory, visual, olfactory, gustatory, tactile or visceral hallucinations.  There was no evidence of illusions, depersonalizations, or derealizations.  Mr. T presented with a sequential and goal directed stream of thought.  There was no evidence of incoherence, irrelevance, evasiveness, circumstantiality, loose associations, or concrete thinking.  There was no evidence of delusions; however, there was some ambivalence, guilt, and self-derogatory thoughts.  There was evidence of concreteness for similarities and proverbs.  His intelligence was average.  His concentration was mildly impaired, and there was no evidence of distractibility.  He was oriented to time, place, person and situation.  There was no evidence of clouded consciousness or dissociation.  His memory was intact for immediate, recent, and remote events.,He presented with poor appetite, easily fatigued, and decreased libidinal drive, as well as excessive somnolence.  There was a moderate preoccupation with his physical health pertaining to his headaches.  His judgment was poor for finances, family relations, social relations, employment, and, at this time, he had no future plans.  Mr. T's insight is somewhat moderate as he is aware of his contribution to the problem.  His motivation for getting well is good as he accepts offered treatment, complies with recommended treatment, and seeks effective treatments.  He has a well-developed empathy for others and capacity for affection.,There was no evidence of entitlement, egocentricity, controllingness, intimidation, or manipulation.  His credibility seemed good.  There was no evidence for potential self-injury, suicide, or violence.  The reliability and completeness of information was very good, and there were no barriers to communication.  The information gathered was based on the patient's self-report and objective testing and observation.  His attitude toward the examiner was neutral and his attitude toward the examination process was neutral.  There was no evidence for indices of malingering as there was no marked discrepancy between claimed impairment and objective findings, and there was no lack of cooperation with the evaluation or poor compliance with treatment, and no evidence of antisocial personality disorder.,IMPRESSIONS: , Major Depressive Disorder, single episode,RECOMMENDATIONS AND PLAN: , I recommend Mr. T continue with psychopharmacologic care as well as psychotherapy.  At this time, the excessive amount of psychiatric symptoms would impede Mr. T from seeking employment.  Furthermore, it appears that the primary precipitating event had occurred on March 25, 2003, when Mr. T was fired from his job after being harassed for over a year.  As Mr. T placed his entire identity and sense of survival on his work, this was a deafening blow to his psychological functioning.  Furthermore, it only appears logical that this would precipitate a major depressive episode.","consult - history and phy., muscle tremor, headaches, excessive nervousness, poor concentration, independent medical evaluation, psychopharmacologic, poor ability to focus, major depressive disorder, tremor, depressive, psychiatric, "
 Patient with sudden onset dizziness and RUE clumsiness.  Giant Left MCA Aneurysm., Consult - History and Phy., MCA Aneurysm ,"HX: ,This 46y/o RHM with HTN was well until 2 weeks prior to exam when he experienced sudden onset dizziness and RUE clumsiness. The symptoms resolved within 10 min. He did well until the afternoon of admission when while moving the lawn he experienced lightheadedness, RUE dysfunction and expressive aphasia (could not get the words out). His wife took him to his local MD, and on the way there his symptoms resolved. His aphasia recurred at his physician's office and a CT scan of the brain revealed a left temporal mass. He was transferred to UIHC.,PMH:, HTN for many years,MEDS:, Vasotec and Dyazide,SHX/FHX:, ETOH abuse (quit '92), 30pk-yr Cigarettes (quit '92),EXAM:, BP158/92, HR91, RR16,MS: Speech fluent without dysarthria,CN: no deficits noted,Motor: no weakness or abnormal tone noted,Sensory: no deficits noted,Coord: normal,Station: no drift,Gait ND,Reflexes: 3+ throughout. Plantars down-going bilaterally.,Gen exam: unremarkable,STUDIES:, WBC14.3K, Na 132, Cl 94, CO2 22, Glucose 129.,CT Brain without contrast: Calcified 2.5 x 2.5cm mass arising from left sylvian fissure/temporal lobe.,MRI Brain, 8/31/92: right temporo-parietal mass with mixed signal on T1 and T2 images. It has a peripheral dark rim on T1 and T2 with surrounding edema. This suggests a component of methemoglobin and hemosiderin within it. Slight peripheral enhancement was identified. There are two smaller foci of enhancement in the posterior parietal lobe on the right. There is nonspecific white matter foci within the pons and right thalamus. Impression: right temporoparietal hemorrhage, suggesting aneurysm or mass. The two smaller foci may suggest metastasis. The white matter changes probably reflect microvascular disease.,3 Vessel cerebroangiogram, 8/31/92: Lobulated fusiform aneurysm off a peripheral branch of the left middle cerebral artery with slow flow into the vessel distal to the aneurysm.,COURSE:, The aneurysm was felt to be inoperable and he was discharged home on Dilantin, ASA, and Diltiazem.","consult - history and phy., mca aneurysm, rue clumsiness, white matter, aneurysm, mca, dizziness, aphasia, matter, clumsiness, brain, peripheral, "
" Problems with seizures, hemiparesis, has been to the hospital, developed C-diff, and is in the nursing home currently. ", Consult - History and Phy., Malignant Meningioma - Consult ,"REASON FOR VISIT: , This is a new patient evaluation for Mr. A. There is a malignant meningioma.  He is referred by Dr. X.,HISTORY OF PRESENT ILLNESS: , He said he has had two surgeries in 07/06 followed by radiation and then again in 08/07.  He then had a problem with seizures, hemiparesis, has been to the hospital, developed C-diff, and is in the nursing home currently.  He is unable to stand at the moment.  He is unable to care for himself. ,I reviewed the information that was sent down with him from the nursing home which includes his medical history.,MEDICATIONS:  ,Keppra 1500 twice a day and Decadron 6 mg four times a day.  His other medicines include oxycodone, an aspirin a day, Prilosec, Dilantin 300 a day, and Flagyl.,FINDINGS:,  On examination, he is lying on the stretcher.  He has oxygen on and has periods of spontaneous hyperventilation.  He is unable to lift his right arm or right leg.  He has an expressive dysphasia and confusion.,I reviewed the imaging studies from summer from the beginning of 10/07, end of 10/07 as well as the current MRI he had last week.  This shows that he has had progression of disease with recurrence along the surface of the brain and there is significant brain edema.  This is a malignant meningioma by diagnosis.,ASSESSMENT/PLAN: , In summary, Mr. A has significant disability and is not independent currently.  I believe that because of this that the likelihood of benefit from surgery is small and there is a very good chance that he would not be able to recover from surgery.  I do not think that surgery will help his quality of life and a need to control the tumor would be dependent on another therapy impacting the tumor.  Given that there are not good therapies and chemotherapy would be the option at the moment, and he certainly is not in a condition where chemotherapy would be given, I believe that surgery would not be in his best interest.  I discussed this both with him, although it is not clear to me how much he understood, as well as his family.","consult - history and phy., seizures, hemiparesis, tumor, seizures hemiparesis, malignant meningioma, chemotherapy, malignant, meningioma, aspirin"
" Abdominal pain right lower quadrant, radiating around her side to her right flank.  Etiology is unclear.  ", Consult - History and Phy., Lower Quadrant Pain ,"REASON:,  Right lower quadrant pain.,HISTORY OF PRESENT ILLNESS:  ,The patient is a pleasant 48-year-old female with an approximately 24-hour history of right lower quadrant pain, which she describes as being stabbed with a knife, radiating around her side to her right flank.  She states that is particularly bad when up and walking around, goes away when she is lying down.  She has no nausea or vomiting, no dysuria, no fever or chills, though she said she did feel warm.  She states that she feels a bit like she did when she had her gallbladder removed nine years ago.  Additionally, I should note that the patient is currently premenopausal with irregular menses, going anywhere from one to two months between cycles.  She has no abnormal vaginal discharge, and she is sexually active.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,MEDICATIONS,1.  Hydrochlorothiazide 25 mg p.o. daily.,2.  Lisinopril 10 mg p.o. daily.,3.  Albuterol p.r.n.,PAST MEDICAL HISTORY:  ,Hypertension and seasonal asthma.,PAST SURGICAL HISTORY: , Left bilateral breast biopsy for benign disease.  Cholecystitis/cholecystectomy following tubal pregnancy 22 years ago.,FAMILY HISTORY: , Mother is alive and well.  Father with coronary artery disease.  She has siblings who have increased cholesterol.,SOCIAL HISTORY:  ,The patient does not smoke.  She quit 25 years ago.  She drinks one beer a day.  She works as a medical transcriptionist.,REVIEW OF SYSTEMS: , Positive for an umbilical hernia, but otherwise negative with the exception of what is noted above.,PHYSICAL EXAMINATION,GENERAL:  Reveals a morbidly obese female who is alert and oriented x3, pleasant and well groomed, and in mild discomfort.,VITAL SIGNS:  Her temperature is 38.7, pulse 113, respirations 18, and blood pressure 144/85.,HEENT:  Normocephalic and atraumatic.  Sclerae are without icterus.  Conjunctivae are not injected.,NECK:  Neck is supple.  Carotids 2+.  Trachea is midline.  Carotids are without bruits.,LYMPH NODES:  There is no cervical, supraclavicular, or occipital adenopathy.,LUNGS:  Clear to auscultation.,CARDIAC:  Regular rate and rhythm.,ABDOMEN:  Soft.  No hepatosplenomegaly.  She has a positive Rovsing sign and a positive obturator sign.  She is tender in the right lower quadrant with mild rebound and no guarding.,EXTREMITIES:  Reveal 2+ femoral, popliteal, dorsalis pedis, and posterior tibial pulses.  She has only trace edema with varicosities around the bilateral ankles.,CNS:  Without gross neurologic deficits.,INTEGUMENTARY:  Skin integrity is excellent.,DIAGNOSTICS: , Urine, specific gravity is 1.010, blood is 50, leukocytes 1+, white blood cells 10 to 25, rbc's 2 to 5, and 2 to 5 squamous epithelial cells.  White blood cell count is 20,000 with 75 polys and 16 lymphs.  H&H is 13.7 and 39.7.  Total bilirubin 1.3, direct bilirubin 0.2, and alk phos 98.  Sodium 138, potassium 3.1, chloride 101, CO2 26, calcium 9.5, glucose 103, BUN 16, and creatinine 0.91.  Lipase is 19.  CAT scan is negative for acute appendicitis.  In fact, it mentions that the appendix is not discretely identified.  There are no focal inflammatory masses, abscess, ascites, or pneumoperitoneum.,IMPRESSION: , Abdominal pain right lower quadrant, etiology is unclear.,PLAN:,  Plan is to admit the patient.  Recheck the white blood cell count in the morning.  Re-examine her and further plan is pending, the results of that evaluation.",
" Low back pain, lumbar radiculopathy, degenerative disc disease, lumbar spinal stenosis, history of anemia, high cholesterol, and hypothyroidism.", Consult - History and Phy., Lumbar Radiculopathy - Consult ,"FAMILY HISTORY:,  Her father died from leukemia.  Her mother died from kidney and heart failure.  She has two brothers; five sisters, one with breast cancer; two sons; and a daughter.  She describes cancer, hypertension, nervous condition, kidney disease, high cholesterol, and depression in her family.,SOCIAL HISTORY:,  She is divorced.  She does not have support at home.  She denies tobacco, alcohol, and illicit drug use.,ALLERGIES: , Hypaque dye when she had x-rays for her kidneys.,MEDICATIONS: , Prempro q.d., Levoxyl 75 mcg q.d., Lexapro 20 mg q.d., Fiorinal as needed, currently she is taking it three times a day, and aspirin as needed.  She also takes various supplements including multivitamin q.d., calcium with vitamin D b.i.d., magnesium b.i.d., Ester-C b.i.d., vitamin E b.i.d., flax oil and fish oil b.i.d., evening primrose 1000 mg b.i.d., Quercetin 500 mg b.i.d., Policosanol 20 mg two a day, glucosamine chondroitin three a day, coenzyme-Q 10 30 mg two a day, holy basil two a day, sea vegetables two a day, and very green vegetables.,PAST MEDICAL HISTORY:,  Anemia, high cholesterol, and hypothyroidism.,PAST SURGICAL HISTORY:,  In 1979, tubal ligation and three milk ducts removed.  In 1989 she had a breast biopsy and in 2007 a colonoscopy.  She is G4, P3, with no cesarean section.,REVIEW OF SYSTEMS:  ,HEENT:  For headaches and sore throat.  Musculoskeletal:  She is right handed with joint pain, stiffness, and decreased range of motion.  Cardiac:  For heart murmur.  GI:  Negative and noncontributory.  Respiratory:  Negative and noncontributory.  Urinary:  Negative and noncontributory.  Hem-Onc:  Negative and noncontributory.  Vascular:  Negative and noncontributory.  Psychiatric:  Negative and noncontributory.  Genital:  Negative and noncontributory.  She denies any bowel or bladder dysfunction or loss of sensation in her genital area.,PHYSICAL EXAMINATION: , She is 5 feet 2 inches tall.  Current weight is 132 pounds, weight one year ago was 126 pounds.  BP is 122/68.  On physical exam, patient is alert and oriented with normal mentation and appropriate speech, in no acute distress.  General, a well-developed and well-nourished female in no acute distress.  HEENT exam, head is atraumatic and normocephalic.  Eyes, sclerae are anicteric.  Teeth good dentition.  Cranial nerves II, III, IV, and VI, vision is intact, visual fields are full to confrontation, EOMs full bilaterally, and pupils are equal, round, and reactive to light.  Cranial nerves V and VII, normal facial sensation and symmetrical facial movement.  Cranial nerve VIII, hearing intact.  Cranial nerves IX, X, and XII, tongue protrudes midline and palate elevates symmetrically.,Cranial nerve XI, strong and symmetrical shoulder shrugs against resistance.  Cardiac, regular rate and rhythm.  Chest and lungs are clear bilaterally.  Skin is warm and dry, normal turgor and texture.  No rashes or lesions are noted.  General musculoskeletal exam reveals no gross deformities, fasciculations, or atrophy.  Peripheral vascular, no cyanosis, clubbing, or edema.  Examination of the low back reveals some mild paralumbar spasms.  She is nontender to palpation of her spinous processes, SI joints, and paralumbar musculature.  She does have some poking sensation to deep palpation into the left buttock where she describes some zinging sensation.  Deep tendon reflexes are 2+ bilateral knees and ankles.  No ankle clonus is elicited.  Babinski, toes are downgoing.  Straight leg raising is negative bilaterally.  Strength on manual exam is 5/5 and equal bilateral lower extremity.  She is able to ambulate on her toes and her heels without any difficulty.  She is able to get up standing on one foot on to the toes.  She does have some difficulty getting up on to her heels when standing on one foot.  She has trouble with this on the left and right.  She complains of increased pain while doing this as well.  She also has positive Patrick/FABER on the right with pain with internal and external rotation, negative on the left.  Sensation is intact.  She has good accuracy to pinprick, dull versus sharp.,FINDINGS: , The patient brings in lumbar spine MRI dated November 20, 2007, which demonstrates degenerative disc disease throughout.  At L4-L5, there is an annular disc bulge with fissuring with facet arthrosis and ligamentum flavum hypertrophy yielding moderate central stenosis and neuroforaminal narrowing but the nerves do not appear to be impinged.  At L5-S1, in the right neuroforamina, there appears to be soft tissue density just lateral and posterior to the nerve root, which may cause some displacement, but it is unclear.  This could represent a facet synovial cyst.  This is lateral to the facet.  She does not have x-rays for review.  She has had hip and knee x-rays taken but does not bring them in with her.,ASSESSMENT: , Low back pain, lumbar radiculopathy, degenerative disc disease, lumbar spinal stenosis, history of anemia, high cholesterol, and hypothyroidism.,PLAN: , We discussed treatment options with this patient including:,1  Do nothing.,2.  Conservative therapies.,3.  Surgery.,She seems to have some issues with her right hip, so I would like for her to fax us over the report of her hip and knee x-rays.  We will also order some x-rays of her lumbar spine as well as lower extremity EMG.,At this point, the patient has not exhausted conservative measures and would like to start with epidural steroid injections, so we will go ahead and send her out for that.  After she has gotten her second epidural injection, she will return to the office for a followup visit to see how she is doing.  All questions and concerns were addressed.  If she should have any further questions, concerns, or complications, she will contact our office immediately.  Otherwise, we will see her as scheduled.  Case was reviewed and discussed with Dr. L.","consult - history and phy., back pain, hip pain, low back pain, x-rays, lumbar spinal stenosis, degenerative disc disease, spinal stenosis, lumbar spine, lumbar radiculopathy, cranial nerves, lumbar, degenerative, anemia, "
" Marginal B-cell lymphoma, status post splenectomy.  Testicular swelling - possible epididymitis or possible torsion of the testis.", Consult - History and Phy., Lymphoma - Consult ,"HISTORY OF PRESENT ILLNESS:,  The patient has a known case of marginal B-cell lymphoma for which he underwent splenectomy two years ago.  The patient, last year, developed a diffuse large B-cell lymphoma which was treated with CHOP/reduction.  The patient again went into complete remission.  The patient has been doing well until recently, few days ago, late last week, when he developed swelling of the left testicle.  The patient states he has been having fever and chills for the last few days.  The patient felt weak and felt unwell.  The patient with these complaints came to the emergency room.  The patient has been having fever and chills and the patient states that the pain in the left testicle is rather severe.  No history of trauma to the testicle.,PAST MEDICAL HISTORY:,1.  Status post splenectomy.,2.  History of marginal B-cell lymphoma.,3.  History of diffuse large cell lymphoma.,ALLERGIES: , None.,PERSONAL HISTORY: , Used to smoke and drink alcohol but at present does not.,FAMILY HISTORY:,  Noncontributory.,REVIEW OF SYSTEMS:,HEENT:  Has slight headache.,CARDIOVASCULAR:  No history of hypertension, MI, etc.,RESPIRATORY:  No history of cough, asthma, TB, shortness of breath.,GI:  Unremarkable.,GU:  As above, has developed painful swelling of the left testicle over the last few days.,ENDOCRINE:  Known case of type II diabetes mellitus.,PHYSICAL EXAMINATION:,HEENT:  No conjunctival pallor or icterus.,NECK:  No adenopathy.  No carotid bruits.,LUNGS:  Clear.,HEART:  No gallop or murmur.,ABDOMEN:",
" Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, and pharmacologic thrombolysis following placement of a vena caval filter.", Consult - History and Phy., Lymphoblastic Leukemia - Consult ,"CHIEF COMPLAINT: , Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, right iliac vein and inferior vena cava (IVC), status post balloon angioplasty, and mechanical and pharmacologic thrombolysis following placement of a vena caval filter.,HISTORY OF PRESENT ILLNESS: , The patient was transferred here the evening of 02/23/2007 from Hospital with a new diagnosis of high-risk acute lymphoblastic leukemia based on confirmation by flow cytometry of peripheral blood lymphoblasts that afternoon.  History related to this illness probably dates back to October of 2006 when he had onset of swelling and discomfort in the left testicle with what he described as a residual ""lump"" posteriorly.  The left testicle has continued to be painful off and on since.  In early November, he developed pain in the posterior part of his upper right leg, which he initially thought was related to skateboarding and muscle strain.  Physical therapy was prescribed and the discomfort temporarily improved.  In December, he noted onset of increasing fatigue.  He used to work out regularly, lifting lifts, doing abdominal exercises, and playing basketball and found he did not have energy to pursue these activities.  He has lost 10 pounds since December and feels his appetite has decreased.  Night sweats and cough began in December, for which he was treated with a course of Augmentin.  However, both of these problems have continued.  He also began taking Accutane for persistent acne in December (this agent was stopped on 02/19/2007).  Despite increasing fatigue and lethargy, he continues his studies at University of Denver, has a biology major (he aspires to be an ophthalmologist).,The morning of 02/19/2007, he awakened with severe right inguinal and right lower quadrant pain.  He was seen in Emergency Room where it was noted that he had an elevated WBC of 18,000.  CT scan of the abdomen was obtained to rule out possible appendicitis and on that CT, a large clot in the inferior vena cava extending to the right iliac and femoral veins was found.  He promptly underwent appropriate treatment in interventional radiology with the above-noted angioplasty and placement of a vena caval filter followed by mechanical and pharmacologic thrombolysis.  Repeat ultrasound there on 02/20/2007 showed no evidence of deep venous thrombosis (DVT).  Continuous intravenous unfractionated heparin infusion was continued.  Because there was no obvious cause of this extensive thrombosis, occult malignancy was suspected.  Appropriate blood studies were obtained and he underwent a PET/CT scan as part of his diagnostic evaluation.  This study showed moderately increased diffuse bone marrow metabolic activity.  Because the WBC continued to rise and showed a preponderance of lymphocytes, the smear was reviewed by pathologist, Sheryl Asplund, M.D., and flow cytometry was performed on the peripheral blood.  These studies became available the afternoon of 02/23/2007, and confirmed the diagnosis of precursor-B acute lymphoblastic leukemia.  The patient was transferred here after stopping of the continuous infusion heparin and receiving a dose of Lovenox 60 mg subcutaneously for further diagnostic evaluation and management of the acute lymphoblastic leukemia (ALL).,ALLERGIES: , NO KNOWN DRUG ALLERGIES.  HE DOES SEEM TO REACT TO CERTAIN ADHESIVES.,CURRENT MEDICATIONS:  ,1.  Lovenox 60 mg subcutaneously q.12h. initiated.,2.  Coumadin 5 mg p.o., was administered on 02/19/2007 and 02/22/2007.,3.  Protonix 40 mg intravenous (IV) daily.,4.  Vicodin p.r.n.,5.  Levaquin 750 mg IV on 02/23/2007.,IMMUNIZATIONS: , Up-to-date.,PAST SURGICAL HISTORY:  ,The treatment of the thrombosis as noted above on 02/19/2007 and 02/20/2007.,FAMILY HISTORY:  ,Two half-brothers, ages 26 and 28, both in good health.  Parents are in good health.  A maternal great-grandmother had a deep venous thrombosis (DVT) of leg in her 40s.  A maternal great-uncle developed leukemia around age 50.  A maternal great-grandfather had bone cancer around age 80.  His paternal grandfather died of colon cancer at age 73, which he had had since age 68.  Adult-onset diabetes is present in distant relatives on both sides.,SOCIAL HISTORY:  ,The patient is a student at the University majoring in biology.  He lives in a dorm there.  His parents live in Breckenridge.  He admits to having smoked marijuana off and on with friends and drinking beer off and on as well.,REVIEW OF SYSTEMS: , He has had emesis off and on related to Vicodin and constipation since 02/19/2007, also related to pain medication.  He has had acne for about two years, which he describes as mild to moderate.  He denied shortness of breath, chest pain, hemoptysis, dyspnea, headaches, joint pains, rashes, except where he has had dressings applied, and extremity pain except for the right leg pain noted above.,PHYSICAL EXAMINATION:  ,GENERAL:  Alert, cooperative, moderately ill-appearing young man.,VITAL SIGNS:  At the time of admission, pulse was 94, respirations 20, blood pressure 120/62, temperature 98.7, height 171.5 cm, weight 63.04 kg, and pulse oximetry on room air 95%.,HAIR AND SKIN:  Mild facial acne.,HEENT:  Extraocular muscles (EOMs) intact.  Pupils equal, round, and reactive to light and accommodation (PERRLA), fundi normal.,CARDIOVASCULAR:  A 2/6 systolic ejection murmur (SEM), regular sinus rhythm (RSR).,LUNGS:  Clear to auscultation with an occasional productive cough.,ABDOMEN:  Soft with mild lower quadrant tenderness, right more so than left; liver and spleen each decreased 4 cm below their respective costal margins.,MUSCULOSKELETAL:  Mild swelling of the dorsal aspect of the right foot and distal right leg.  Mild tenderness over the prior catheter entrance site in the right popliteal fossa and mild tenderness over the right medial upper thigh.,GENITOURINARY:  Testicle exam disclosed no firm swelling with mild nondiscrete fullness in the posterior left testicle.,NEUROLOGIC:  Exam showed him to be oriented x4.  Normal fundi, intact cranial nerves II through XII with downgoing toes, symmetric muscle strength, and decreased patellar deep tendon reflexes (DTRs).,LABORATORY DATA:  ,White count 25,500 (26 neutrophils, 1 band, 7 lymphocytes, 1 monocyte, 1 myelocyte, 64 blasts), hemoglobin 13.3, hematocrit 38.8, and 312,000 platelets.  Electrolytes, BUN, creatinine, phosphorus, uric acid, AST, ALT, alkaline phosphatase, and magnesium were all normal.  LDH was elevated to 1925 units/L (upper normal 670), and total protein and albumin were both low at 6.2 and 3.4 g/dL respectively.  Calcium was also slightly low at 8.8 mg/dL.  Low molecular weight heparin test was low at 0.27 units/mL.  PT was 11.8, INR 1.2, and fibrinogen 374.  Urinalysis was normal.,ASSESSMENT: , 1.  Newly diagnosed high-risk acute lymphoblastic leukemia.,2.  Deep vein thrombosis of the distal iliac and common femoral/right femoral and iliac veins, status post vena caval filter placement and mechanical and thrombolytic therapy, on continued anticoagulation.,3.  Probable chronic left epididymitis.,PLAN: , 1.  Proceed with diagnostic bone marrow aspirate/biopsy and lumbar puncture (using a #27-gauge pencil-tip needle for minimal trauma) as soon as these procedures can be safely done with regard to the anticoagulation status.,2.  Prompt reassessment of the status of the deep venous thrombosis with Doppler studies.,3.  Ultrasound/Doppler of the testicles.,4.  Maintain therapeutic anticoagulation as soon as the diagnostic procedures for ALL can be completed.,",
 Low back pain and right lower extremity pain - Lumbar spine herniated nucleus pulposus., Consult - History and Phy., Lumbar Spine HNP - Consult ,"CHIEF COMPLAINT:, Low back pain and right lower extremity pain. The encounter reason for today's consultation is for a second opinion regarding evaluation and treatment of the aforementioned symptoms.,HPI - LUMBAR SPINE:, The patient is a male and 39 years old. The current problem began on or about 3 months ago. The symptoms were sudden in onset. According to the patient, the current problem is a result of a fall. The date of injury was 3 months ago. There is no significant history of previous spine problems. Medical attention has been obtained through the referral source. Medical testing for the current problem includes the following: no recent tests. Treatment for the current problem includes the following: activity modification, bracing, medications and work modification. The following types of medications are currently being used for the present spine problem: narcotics, non-steroidal anti-inflammatories and muscle relaxants. The following types of medications have been used in the past: steroids. In general, the current spine problem is much worse since its onset.,PAST SPINE HISTORY:, Unremarkable.,PRESENT LUMBAR SYMPTOMS:, Pain location: lower lumbar. The patient describes the pain as sharp. The pain ranges from none to severe. The pain is severe frequently. It is present intermittently and most of the time daily. The pain is made worse by flexion, lifting, twisting, activity, riding in a car and sitting. The pain is made better by laying in the supine position, medications, bracing and rest. Sleep alteration because of pain: wakes up after getting to sleep frequently and difficulty getting to sleep frequently. Pain distribution: the lower extremity pain is greater than the low back pain. The patient's low back pain appears to be discogenic in origin. The pain is much worse since its onset.,PRESENT RIGHT LEG SYMPTOMS:, Pain location: S1 dermatome (see the Pain Diagram). The patient describes the pain as sharp. The severity of the pain ranges from none to severe. The pain is severe frequently. It is present intermittently and most of the time daily. The pain is made worse by the same things that make the low back pain worse. The pain is made better by the same things that make the low back pain better. Sleep alteration because of pain: wakes up after getting to sleep frequently and difficulty getting to sleep frequently. The patient's symptoms appear to be radicular in origin. The pain is much worse since its onset.,PRESENT LEFT LEG SYMPTOMS:, None.,NEUROLOGIC SIGNS/SYMPTOMS:, The patient denies any neurologic signs/symptoms. Bowel and bladder function are reported as normal.",
" Patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI.  The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion.", Consult - History and Phy., Lung Cancer & MI - Hospice Cosult ,"REASON FOR CONSULT: , I was asked to see this patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI.,HISTORY OF PRESENT ILLNESS: , The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion.  Her daughter who accompanies her is very attentive whom I had met previously during drainage of a malignant hemorrhagic pericardial effusion last month.  The patient has been feeling well for the last several weeks, per the daughter, but today per the personal aide, became agitated and uncomfortable at about 2:30 p.m.  At about 7 p.m., the patient began vomiting, was noted to be short of breath by her daughter with garbled speech, arms flopping, and irregular head movements.  Her daughter called 911 and her symptoms seemed to improve.  Then, she began vomiting.  When the patient's daughter asked her if she had chest pain, the patient said yes.,She came to the emergency room, an EKG showed inferior ST-elevation MI.  I was called immediately and knowing her history, especially, her hospice status with recent hemorrhagic pericardial effusion, I felt thrombolytic was contraindicated and she would not be a candidate for aggressive interventional therapy with PCI/CABG.  She was begun after discussion with the oncologist, on heparin drip and has received morphine, nitro, and beta-blocker, and currently states that she is pain free.  Repeat EKG shows normalization of her ST elevation in the inferior leads as well as normalization of prior reciprocal changes.,PAST MEDICAL HISTORY: , Significant for metastatic non-small-cell lung cancer.  In early-to-mid December, she had an admission and was found to have a malignant pericardial effusion with tamponade requiring urgent drainage.  We did repeat an echo several weeks later and that did not show any recurrence of the pericardial effusion.  She is on hospice from the medical history, atrial fibrillation, hypertension, history of multiple CVA.,MEDICATIONS: , Medications as an outpatient:,1.  Amiodarone 200 mg once a day.,2.  Roxanol concentrate 5 mg three hours p.r.n. pain.,ALLERGIES:  ,CODEINE.  NO SHRIMP, SEAFOOD, OR DYE ALLERGY.,FAMILY HISTORY: , Negative for cardiac disease.,SOCIAL HISTORY: , She does not smoke cigarettes.  She uses alcohol.  No use of illicit drugs.  She is divorced and lives with her daughter.  She is a retired medical librarian from Florida.,REVIEW OF SYSTEMS:  ,Unable to be obtained due to the patient's aphasia.,PHYSICAL EXAMINATION: , Height 5 feet 3, weight of 106 pounds, temperature 97.1 degrees, blood pressure ranges from 138/82 to 111/87, pulse 61, respiratory rate 22.  O2 saturation 100%.  On general exam, she is an elderly woman with now marked aphasia, which per her daughter waxes and wanes, was more pronounced and she nods her head up and down when she says the word, no, and conversely, she nods her head side-to-side when she uses the word yes with some discordance in her head gestures with vocalization.  HEENT shows the cranium is normocephalic and atraumatic.  She has dry mucosal membrane.  She now has a right facial droop, which per her daughter is new.  Neck veins are not distended.  No carotid bruits visible.  Skin:  Warm, well perfused.  Lungs are clear to auscultation anteriorly.  No wheezes.  Cardiac exam:  S1, S2, regular rate.  No significant murmurs.  PMI is nondisplaced.  Abdomen:  Soft, nondistended.  Extremities:  Without edema, on limited exam.  Neurological exam seems to show only the right facial droop.,DIAGNOSTIC/LABORATORY DATA: , EKGs as reviewed above.  Her last ECG shows normalization of prior ST elevation in the inferior leads with Q waves and first-degree AV block, PR interval 280 milliseconds.  Further lab shows sodium 135, potassium 4.2, chloride 98, bicarbonate 26, BUN 9, creatinine 0.8, glucose 162, troponin 0.17, INR 1.27, white blood cell count 1.3, hematocrit 31, platelet count of 179.,Chest x-ray, no significant pericardial effusion.,IMPRESSION: , The patient is a 69-year-old woman with metastatic non-small-cell lung cancer with a recent hemorrhagic pericardial effusion, now admitted with cerebrovascular accident and transient inferior myocardial infarction, which appears to be canalized.  I will discuss this in detail with the patient and her daughter, and clearly, her situation is quite guarded with likely poor prognosis, which they are understanding of.,RECOMMENDATIONS:,1.  I think it is reasonable to continue heparin, but clearly she would be at risk for hemorrhagic pericardial effusion recurrence.,2.  Morphine is appropriate, especially for preload reduction and other comfort measures as appropriate.,3.  Would avoid other blood thinners including Plavix, Integrilin, and certainly, she is not a candidate for a thrombolytic with which the patient and her daughter are in agreement with after a long discussion.,Other management as per the medical service.  I have discussed the case with Dr. X of the hospitalist service who will be admitting the patient.",
" Lumbar muscle strain and chronic back pain.  Patient has a history of chronic back pain, dating back to an accident that he states he suffered two years ago.", Consult - History and Phy., Lower back pain ,"HISTORY OF PRESENT ILLNESS:,  Patient is a 50-year-old white male complaining of continued lower back pain.  Patient has a history of chronic back pain, dating back to an accident that he states he suffered two years ago.  He states he helped a friend unload a motorcycle from a vehicle two-and-a-half days ago, after which he ""felt it"" in his lower back.  The following day (two days ago), he states he rode to Massachusetts and Maine to pick up clients.  He feels that this aggravated his chronic back pain as well.  He also claims to have a screw in his right hip from a previous surgery to repair a pelvic fracture.  He is being prescribed Ultram, Celebrex, gabapentin, and amitriptyline by his PCP for his chronic back pain.  He states that his PCP has informed him that he does not prescribe opiate medications for chronic back pain.,The patient did self-refer to another physician, who suggested that he follow up at a pain clinic for his chronic back pain to discuss other alternatives, particularly the medications that the patient feels that he needs.  Patient states he did not do this because he was feeling well at that time.,The patient did present to our emergency room last night, at which time he saw Dr. X.  He was given a prescription for 12 Vicodin as well as some to take home last night.  The patient has not picked up his prescription as of yet and informed the triage nurse that he was concerned that he would not have enough to last through the weekend.  Patient states he also has methadone and Darvocet at home from previous prescription and is wondering if he should restart these medicines.  He is on several medications, the list of which is attached to the chart.,MEDICATIONS: , In addition to the aforementioned medications, he is on Cymbalta, pantoprazole, and a multivitamin.,ALLERGIES:,  HE IS ALLERGIC TO RELAFEN (ITCHING).,SOCIAL HISTORY: , The patient is married and lives with his wife.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse is elevated at 105.  Temp and other vitals signs are all within normal limits.,GENERAL:  Patient is a middle-aged white male who is sitting on the stretcher in no acute distress.,BACK:  Exam of the back shows some generalized tenderness on palpation of the musculature surrounding the lumbar spine, more so on the right than on the left.  There is a well-healed upper lumbar incision from his previous L1-L2 fusion.  There is no erythema, ecchymosis, or soft-tissue swelling.  Mobility is generally very good without obvious signs of discomfort.,HEART:  Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS:  Clear without rales, rhonchi, or wheezes.,MUSCULOSKELETAL:  With the patient supine, there is some discomfort in the lower back with bent-knee flexion of both hips as well as with straight leg abduction of the left leg.  There is some mild discomfort on internal and external rotation of the hips as well.  DTRs are 1+ at the knees and trace at the ankles.,I explained to the patient that he is suffering from a chronic condition and as his PCP has made it clear that he is unwilling to prescribe opiate medication, which the patient feels that he needs, and he is obligated to follow up at the pain clinic as suggested by the other physician even if he is having a ""good day.""  I explained to him that if he did not investigate other alternatives to what his PCP is willing to prescribe, then on a ""bad day,"" he will have nowhere else to turn.  I explained to him that some emergency physicians do chose to use opiates for a short term as Dr. X did last night.  It is unclear if the patient is looking for a different opiate medication, but I do not think it is wise to give him more, particularly as he has not even filled the prescription that was given to him last night.  I did suggest that he not restart his methadone and Darvocet at this time as he is already on five different medications for his back (Celebrex, tramadol, amitriptyline, gabapentin, and the Vicodin that he was given last night).  I did suggest that we could try a different anti-inflammatory if he felt that the Celebrex is not helping.  The patient is agreeable to this.,ASSESSMENT,1.  Lumbar muscle strain.,2.  Chronic back pain.,PLAN: , At this point in time, I felt that it was safe for the patient to transition to heat to his back which he may use as often as possible.  Rx for Voltaren 75 mg tabs, dispensed 20, sig. one p.o. q.12h. for pain instead of Celebrex.  He may continue with his other medications as directed but not the methadone or Darvocet.  I did urge him to reschedule his pain clinic appointment as he was urged to do originally.  If unimproved this week, he should follow up with Dr. Y.","consult - history and phy., back pain, lumbar muscle strain, chronic back pain, illness, lower, medications, "
" Briefly, the patient has a lumbosacral polyradiculopathy that is temporally related to the epidural anesthesia given to her in October of 2008.", Consult - History and Phy., Lumbosacral Polyradiculopathy ,"HISTORY OF PRESENT ILLNESS: , The patient is a 35-year-old woman who reports that on the 30th of October 2008, she had a rupture of her membranes at nine months of pregnancy, and was admitted to hospital and was given an epidural anesthetic.  I do not have the records from this hospital admission, but apparently the epidural was administered for approximately 14 to 18 hours.  She was sitting up during the epidural.,She did not notice any difference in her lower extremities at the time she had the epidural; however, she reports that she was extremely sleepy and may not have been aware of any change in strength or sensation in her lower extremities at that time.  She delivered on the 31st of October, by Cesarean section, because she had failed to progress and had pyrexia.,She also had a Foley catheter placed at that time.  On the 1st of November 2008, they began to mobilize her and it was at that time that she first noticed that she could not walk.  She was aware that she could not move her legs at all, and then within a few days, she was aware that she could move toes in the left foot but could not move her right foot at all.  Since that time, there has been a gradual improvement in strength to the point that she now has limited movement in her left leg and severely restricted movement in her right leg.  She is not able to walk by herself, and needs assistance to stand.  She was discharged from hospital after the Cesarean section on the 3rd of November.  Unfortunately, we do not have the records and we do not know what the discussion was between the anesthesiologist and the patient at the time of discharge.  She was then seen at ABC Hospital on November 05, 2008.  She had an MRI scan of her spine, which showed no evidence of an abnormality, specifically there were no cord changes and no evidence of a hematoma.  She also had an EMG study at that time by Dr. X, which was abnormal but not diagnostic and this was repeated again in December.  At the present time, she also complains of a pressure in both her legs and in her thighs.  She complains that her right foot hurts and that she has some hyperesthesia there.  She has been taking gabapentin to try to reduce the discomfort, although she is on a very low dose and the effect is minimal.  She has no symptoms in her arms, her bowel and bladder function is normal, and her bulbar function is normal.  There is no problem with her vision, swallowing, or respiratory function.,PAST MEDICAL HISTORY: , Unremarkable except as noted above.  She has seasonal allergies.,CURRENT MEDICATIONS:,  Gabapentin 300 mg b.i.d., Centrum once a day, and another multivitamin.,ALLERGIES: , She has no medication allergies, but does have seasonal allergies.,FAMILY HISTORY: , There is a family history of diabetes and hypertension.  There is no family history of a neuropathy or other neurological disease.  She has one child, a son, born on October 31, 2008.,SOCIAL HISTORY: , The patient is a civil engineer, who currently works from home.  She is working approximately half time because of limitations imposed on her by her disability, need to attend frequent physical therapy, and also the needs of looking after her baby.  She does not smoke and does not drink and has never done either.,GENERAL PHYSICAL EXAMINATION:,VITAL SIGNS:  P 74, BP 144/75, and a pain score of 0.,GENERAL:  Her general physical examination was unremarkable.,CARDIOVASCULAR:  Normal first and second heart sound, regular pulse with normal volume.,RESPIRATORY:  Unremarkable, both lung bases were clear, and respiration was normal.,GI:  Unremarkable, with no organomegaly and normal bowel sounds.,NEUROLOGICAL EXAM:,MSE:  The patient's orientation was normal, fund of knowledge was normal, memory was normal, speech was normal, calculation was normal, and immediate and long-term recall was normal.  Executive function was normal.,CRANIAL NERVES:  The cranial nerve examination II through XII was unremarkable.  Both disks were normal, with normal retina.  Pupils were equal and reactive to light.  Eye movements were full.  Facial sensation and strength was normal.  Bulbar function was normal.  The trapezius had normal strength.,MOTOR:  Muscle tone showed a slight increase in tone in the lower extremities, with normal tone in the upper extremities.  Muscle strength was 5/5 in all muscle groups in the upper extremities.  In the lower extremities, the hip flexors were 1/5 bilaterally, hip extensors were 1/5 bilaterally, knee extension on the right was 1/5 and on the left was 3-/5, knee flexion was 2/5 on the right and 3-/5 on the left, foot dorsiflexion was 0/5 on the right and 1/5 on the left, foot plantar flexion was 4-/5 on the right and 4+/5 on the left, toe extension was 0/5 on the right and 4-/5 on the left, toe flexion was 4-/5 on the right and 4+/5 on the left.,REFLEXES:  Reflexes in the upper extremities were 2+ bilaterally.  In the lower extremities, they were 0 bilaterally at the knee and ankles.  The abdominal reflexes were present above the umbilicus and absent below the umbilicus.  The plantar responses were mute.  The jaw reflex was normal.,SENSATION:  Vibration was moderately decreased in the right great toe and was mildly decreased in the left great toe.  There was a sensory level to light touch at approximately T7 posteriorly and approximately T9 anteriorly.  There was a range of sensation, but clearly there was a decrease in sensation below this level but not complete loss of sensation.  To pain, the sensory level is even less clear, but appeared to be at about T7 on the right side.  In the lower extremities, there was a slight decrease in pin and light touch in the right great toe compared to the left.  There was no evidence of allodynia or hyperesthesia.  Joint position sense was mildly reduced in the right toe and normal on the left.,COORDINATION:  Coordination for rapid alternating movements and finger-to-nose testing was normal.  Coordination could not be tested in the lower extremities.,GAIT:  The patient was unable to stand and therefore we were unable to test gait or Romberg's.  There was no evidence of focal back tenderness.,REVIEW OF OUTSIDE RECORDS: , I have reviewed the records from ABC Hospital, including the letter from Dr. Y and the EMG report dated 12/17/2008 from Dr. X. The EMG report shows evidence of a lumbosacral polyradiculopathy below approximately T6.  The lower extremity sensory responses are essentially normal; however, there is a decrease in the amplitude of the motor responses with minimal changes in latency.  I do have the MRI of lumbar spine report from 11/06/2008 with and without contrast.  This showed a minimal concentric disc bulge of L4-L5 without disc herniation, but was otherwise unremarkable.  The patient brought a disc with a most recent MRI study; however, we were unable to open this on our computers.  The verbal report is that the study was unremarkable except for some gadolinium enhancement in the lumbar nerve roots.  A Doppler of the lower extremities showed no evidence of deep venous thrombosis in either lower extremity.  Chest x-ray showed some scoliosis on the lumbar spine, curve to the left, but no evidence of other abnormalities.  A CT pelvis study performed on November 07, 2008 showed some nonspecific fluid in the subcutaneous fat of the back, posterior to L4 and L5 levels; however, there were no pelvic masses or other abnormalities.  We were able to obtain an update of the report from the MRI of the lumbar spine with and without contrast dated 12/30/2008.  The complete study included the cervical, thoracic, and lumbar spine.  There was diffuse enhancement of the nerve roots of the cauda equina that had increased in enhancement since prior exam in November.  It was also reported that the patient was given intravenous methylprednisolone and this had had no effect on strength in her lower extremities.,IMPRESSION: , The patient has a condition that is temporarily related to the epidural injection she was given at the end of October 2008, prior to her Cesarean section.  It appears she became aware of weakness within two days of the administration of the epidural, she was very tired during the epidural and may have missed some change in her neurological function.  She was severely weak in both lower extremities, slightly worse on the right than the left.  There has been some interval improvement in her strength since the beginning of November 2008.  Her EMG study from the end of December is most consistent with a lumbosacral polyradiculopathy.  The MRI findings of gadolinium enhancement in the lumbar nerve roots would be most consistent with an inflammatory radiculitis most likely related to the epidural anesthesia or administration of the epidural.  There had been no response to IV methylprednisolone given to her at ABC.  The issue of having a lumbar puncture to look for evidence of inflammatory cells or an elevated protein had been discussed with her at both ABC and by myself.  The patient did not wish to consider a lumbar puncture because of concerns that this might worsen her condition.  At the present time, she is able to stand with aid but is unable to walk.  There is no evidence on her previous EMG of a demyelinating neuropathy.,RECOMMENDATIONS:,1.  The diagnostic issues were discussed with the patient at length.  She is informed that this is still early in the course of the problem and that we expect her to show some improvement in her function over the next one to two years, although it is unclear as to how much function she will regain.,2.  She is strongly recommended to continue with vigorous physical therapy, and to continue with the plan to mobilize her as much as possible, with the goal of trying to get her ambulatory.  If she is able to walk, she will need bilateral AFOs for her ankles, to improve her overall mobility.  I am not prescribing these because at the present time she does not need them.,3.  We discussed increasing the dose of gabapentin.  The paresthesias that she has may indicate that she is actually regaining some sensory function, although there is a concern that as recovery continues, she may be left with significant neuropathic pain.  If this is the case, I have advised her to increase her gabapentin dose from 300 mg b.i.d. gradually up to 300 mg four times a day and then to 600 mg to 900 mg four times a day.  She may need other neuropathic pain medications as needed.  She will determine whether her current symptoms are significant enough to require this increase in dosage.,4.  The patient will follow up with Dr. Y and his team at ABC Hospital.  She will also continue with physical therapy within the ABC system.",
" New patient consultation - Low back pain, degenerative disc disease, spinal stenosis, diabetes, and history of prostate cancer status post radiation.", Consult - History and Phy., Low Back Pain - Consult ,"FAMILY HISTORY: , His parents are deceased.  He has two brothers ages 68 and 77 years old, who are healthy.  He has siblings, a brother and a sister who were twins who died at birth.  He has two sons 54 and 57 years old who are healthy.  He describes history of diabetes and heart attack in his family.,SOCIAL HISTORY:  ,He is married and has support at home.  He denies tobacco and illicit drug use and drinks two to three alcoholic beverages a day and up to four to nine per week.,ALLERGIES:,  Garamycin.,MEDICATIONS: , Insulin 20 to 25 units twice a day.  Lorazepam 0.05 mg, he has a history of using this medication, but most recently stopped taking it.  Glipizide 5 mg with each meal, Advair 250 as needed, aspirin q.h.s., cod liver oil b.i.d., Centrum AZ q.d.,PAST MEDICAL HISTORY:  ,The patient has been diabetic for 35 years, has been insulin-dependent for the last 20 years.  He also has a history of prostate cancer, which was treated by radiation.  He says his PSA is at 0.01.,PAST SURGICAL HISTORY:,  In 1985, he had removal of a testicle due to enlarged testicle, he is not quite sure of the cause but he states it was not cancer.,REVIEW OF SYSTEMS: , Musculoskeletal:  He is right-handed.  Respiratory:  For shortness of breath.  Urinary:  For frequent urination.  GI:  He denies any bowel or bladder dysfunction.  Genital:  He denies any loss of sensation or erectile problems.  HEENT:  Negative and noncontributory.  Hem-Onc:  Negative and noncontributory.  Cardiac:  Negative and noncontributory.  Vascular:  Negative and noncontributory.  Psychiatric:  Negative and noncontributory.,PHYSICAL EXAMINATION: , He is 5 feet 10 inches tall.  Current weight is 204 pounds, weight one year ago was 212.  BP is 130/66.  Pulse is 78.  On physical exam, the patient is alert and oriented with normal mentation and appropriate speech, in no acute distress.  HEENT exam, head is atraumatic and normocephalic.  Eyes, sclerae are anicteric.  Teeth, poor dentition.  Cranial nerves II, III, IV, and VI, vision intact, visual fields full to confrontation, EOMs full bilaterally, and pupils are equal, round, and reactive to light.  Cranial nerves V and VII, normal facial sensation and symmetrical facial movements.  Cranial nerve VIII, hearing is intact.  Cranial nerves IX, X, and XII, tongue protrudes midline and palate elevates symmetrically.  Cardiac, regular rate, a holosystolic murmur is also noted which is about grade 1 to 2.  Chest and lungs are clear bilaterally.  Skin is warm and dry, normal turgor and texture.  No rashes or lesions are noted.  Peripheral vascular, no cyanosis, clubbing, or edema is noted.  General musculoskeletal exam reveals no gross deformities, fasciculations, or atrophy.  Station and gait are appropriate.  He ambulates well without any difficulties or assistance.  No antalgic or spastic gait is noted.  Examination of the low back reveals no paralumbar spasms.  He is nontender to palpation over his spinous process, SI joints, or paralumbar musculature.  Deep tendon reflexes are 2+ bilaterally at the knees and 1+ at the ankles.  No ankle clonus is elicited.  Babinski, toes are downgoing.  Sensation is intact.,He does have some decreased sensation to pinprick, dull versus sharp over the right lower extremity compared to that of the left.  Strength is 5/5 and equal bilateral lower extremities.  He is able to ambulate on his toes and his heels without any weakness noted.  He has negative straight leg raising bilaterally.,FINDINGS:,  The patient brings in lumbar spine MRI for 11/15/2007, which demonstrates degenerative disc disease throughout.  At L4-L5 and L5-S1 he has severe disc space narrowing.  At L3-L4, he has degenerative changes of the facet with ligamentum flavum hypertrophy and annular disc bulge, which caused moderate neuroforaminal narrowing.  At L4-L5, degenerative changes within the facets with ligamentum flavum hypertrophy as well causing neuroforaminal narrowing and central stenosis.  At L5-S1, there is an annular disc bulge more to the right causing right-sided neuroforaminal stenosis, which is quite severe compared to that on the left.,ASSESSMENT: , Low back pain, degenerative disc disease, spinal stenosis, diabetes, and history of prostate cancer status post radiation.,PLAN: , We discussed treatment options with this patient including:,1.  Do nothing.,2.  Conservative therapies.,3.  Surgery.,The patient states that his pain is very well tolerated by minimizing his activity and would like to do just pain management with some pain pills only as needed.  We went ahead and obtained an EKG in the office today due to the fact that I heard a murmur on exam.  I did phone the patient's primary care doctor, Dr. O.  Unfortunately Dr. O is out of the country, and I did speak with Dr. K, who is covering for Dr. O.  I informed Dr. K that the patient had a new-onset murmur and that I did have some concerns for the patient does not recollect having this diagnosis before, so I obtained an EKG.  A copy was provided to the patient and the patient was referred back to his primary care physician for workup.  He was also released from our care at this time to a p.r.n. basis, but the patient does not wish to proceed with any neurosurgical intervention nor any conservative measures besides medications, which he will receive from his primary doctor.,All questions and concerns were addressed.  If he should have any further questions, concerns, or complications, he will contact our office immediately.  Otherwise, we will see him p.r.n.  Warning signs and symptoms were gone over with him.  Case was reviewed and discussed with Dr. L.","consult - history and phy., back pain, ligamentum flavum hypertrophy, annular disc bulge, degenerative disc disease, spinal stenosis, cranial nerves, degenerative, "
" A 21-month-old male presented for delayed motor development, ""jaw quivering"" and ""lazy eye."" ", Consult - History and Phy., Lobar Holoprosencephaly ,"CC: ,Delayed motor development.,HX:, This 21 month old male presented for delayed motor development, ""jaw quivering"" and ""lazy eye."" He was an 8 pound 10 ounce product of a full term, uncomplicated pregnancy-labor-spontaneous vaginal delivery to a G3P3 married white female mother. There had been no known toxic intrauterine exposures. He had no serious illnesses or hospitalizations since birth. He sat independently at 7 months, stood at 11 months, crawled at 16 months, but did not cruise until 18 months.,He currently cannot walk and easily falls. His gait is reportedly marked by left ""intoeing."" His upper extremity strength and coordination reportedly appear quite normal and he is able to feed himself, throw and transfer objects easily. He knows greater than 20 words and speaks two-word phrases.,No seizures or unusual behavior were reported except for ""quivering"" movement of his jaw. This has occurred since birth. In addition the parents have noted transient left exotropia.,PMH: ,As above.,FHX:, Many family members with ""lazy eye."" No other neurologic diseases declared.,9 and 5 year old sisters who are healthy.,SHX:, lives with parents and sisters.,EXAM:, BP83/67 HR122 36.4C Head circumference 48.0cm Weight 12.68kg (70%) Height 86.0cm (70%),MS: fairly cooperative.,CN: Minimal transient esotropia OS. Tremulous quivering of jaw--increased with crying. No obvious papilledema, though difficult to evaluate due to patient movement.,Motor: sat independently with normal posture and no truncal ataxia. symmetric and normal strength and muscle bulk throughout.,Sensory: withdrew to vibration.,Coordination: unremarkable in BUE.,Station: no truncal ataxia.,Gait: On attempting to walk, his right foot rotated laterally at almost 70degrees. Both lower extremities could rotate outward to 90degrees. There was marked passive eversion at the ankles as well.,Reflexes: 2+/2+ throughout.,Musculoskeletal: pes planovalgus bilaterally.,COURSE: ,CK normal. The parents decided to forego an MRI in 8/90. The patient returned 12/11/92 at age 4 years. He was ambulatory and able to run awkwardly. His general health had been good, but he showed signs developmental delay. Formal evaluation had tested his IQ at 87 at age 3.5 years. He was weakest on tasks requiring visual/motor integration and fine motor and visual discrimination skills. He was 6 months delayed in cognitive development at that time. On exam, age 4 years, he displayed mild right ankle laxity on eversion and inversion, but normal gait. The rest of the neurological exam was normal. Head circumference was 49.5cm (50%) and height and weight were in the 90th percentile. Fragile X analysis and karyotyping were unremarkable.","consult - history and phy., delayed motor development, jaw quivering, head circumference, truncal ataxia, delayed motor, motor development, lazy eye, jaw, quivering, delayed, intrauterine, "
 Patient with a 1-year history of progressive anterograde amnesia, Consult - History and Phy., Limbic Encephalitis ,"CC:, Rapidly progressive amnesia.,HX: ,This 63 y/o RHM presented with a 1 year history of progressive anterograde amnesia. On presentation he could not remember anything from one minute to the next. He also had some retrograde memory loss, in that he could not remember the names of his grandchildren, but had generally preserved intellect, language, personality, and calculating ability. He underwent extensive evaluation at the Mayo Clinic and an MRI there revealed increased signal on T2 weighted images in the mesiotemporal lobes bilaterally. There was no mass affect. The areas mildly enhanced with gadolinium.,PMH:, 1) CAD; MI x 2 (1978 and 1979). 2) PVD; s/p aortic endarterectomy (3/1991). 3)HTN. 4)Bilateral inguinal hernia repair.,FHX/SHX:, Mother died of a stroke at age 58. Father had CAD and HTN. The patient quit smoking in 1991, but was a heavy smoker (2-3ppd) for many years. He had been a feed salesman all of his adult life.,ROS:, Unremarkable. No history of cancer.,EXAM:, BP 136/75 HR 73 RR12 T36.6,MS: Alert but disoriented to person, place, time. He could not remember his birthdate, and continually asked the interviewer what year it was. He could not remember when he married, retired, or his grandchildren's names. He scored 18/30 on the Follutein's MMSE with severe deficits in orientation and memory. He had moderate difficulty naming. He repeated normally and had no constructional apraxia. Judgement remained good.,CN: unremarkable.,Motor: Full strength throughout with normal muscle tone and bulk.,Sensory: Intact to LT/PP/PROP,Coordination: unremarkable.,Station: No pronator drift, truncal ataxia or Romberg sign.,Gait: unremarkable.,Reflexes: 3+ throughout with downgoing plantar responses bilaterally.,Gen Exam: unremarkable.,STUDIES:, MRI Brain revealed hyperintense T2 signal in the mesiotemporal regions bilaterally, with mild enhancement on the gadolinium scans. MRI and CT of the chest and CT of the abdomen showed no evidence of lymphadenopathy or tumor. EEG was normal awake and asleep. Antineuronal antibody screening was unremarkable. CSF studies were unremarkable and included varicella zoster, herpes zoster, HIV and HTLV testing, and cytology. The patient underwent stereotactic brain biopsy at the Mayo Clinic which showed inflammatory changes, but no organism or etiology was concluded. TFT, B12, VDRL, ESR, CRP, ANA, SPEP and Folate studies were unremarkable. Neuropsychologic testing revealed severe anterograde memory (verbal and visual)loss, and less severe retrograde memory loss. Most other cognitive abilities were well preserved and the findings were consistent with mesiotemporal dysfunction bilaterally.,IMPRESSION:, Limbic encephalitis secondary to cancer of unknown origin.,He was last seen 7/26/96. MMSE 20/30 and category fluency 20 . Disinhibited affect. Mild right grasp reflex. The clinical course was benign and non-progressive, and unusual for such a diagnosis, though not unheard of .","consult - history and phy., mri brain, progressive anterograde amnesia, retrograde memory loss, limbic encephalitis, anterograde amnesia, memory loss, limbic, encephalitis, amnesia, anterograde, memory, "
" Pancreatic and left adrenal lesions.  The adrenal lesion is a small lesion, appears as if probable benign adenoma, where as the pancreatic lesion is the cystic lesion, and neoplasm could not be excluded. ", Consult - History and Phy., Lesions - Adrenal and Pancreatic ,"CHIEF COMPLAINT: , Both pancreatic and left adrenal lesions.,HISTORY OF PRESENT ILLNESS:,  This 60-year-old white male is referred to us by his medical physician with a complaint of recent finding of a both pancreatic lesion and lesions with left adrenal gland.  The patient's history dates back to at the end of the January of this past year when he began experiencing symptoms consistent with difficulty almost like a suffocating feeling whenever he would lie flat on his back.  He noticed whenever he would recline backwards, he would begin this feeling and it is so bad now that he can barely recline, very little before he has this feeling.  He is now sleeping in an upright position.  He was sent for CAT scan originally of his chest.  The CAT scan of the chest reveals a pneumonitis, but also saw a left adrenal nodule and a small pancreatic lesion.  He was subsequently was sent for a dedicated abdominal CAT scan and MRI.  The CAT scan revealed 1.8-cm lesion of his left adrenal gland, suspected to be a benign adenoma.  The pancreas showed pancreatic lesion towards the mid body tail aspect of the pancreas, approximately 1 cm, most likely of cystic nature.  Neoplasm could not be excluded.  He was referred to us for further assessment.  He denies any significant abdominal pain, any nausea or vomiting.  His appetite is fine.  He has had no significant changes in his bowel habits or any rectal bleeding or melena.  He has undergone a colonoscopy in September of last year and was found to have three adenomatous polyps.  He does have a history of frequent urination.  Has been followed by urologist for this.  There is no family history of pancreatic cancer.  There is a history of gallstone pancreatitis in the patient's sister.,PAST MEDICAL HISTORY:,  Significant for hypertension, type 2 diabetes mellitus, asthma, and high cholesterol.,ALLERGIES: , ENVIRONMENTAL.,MEDICATIONS:,  Include glipizide 5 mg b.i.d., metformin 500 mg b.i.d., Atacand 16 mg daily, metoprolol 25 mg b.i.d., Lipitor 10 mg daily, pantoprazole 40 mg daily, Flomax 0.4 mg daily, Detrol 4 mg daily, Zyrtec 10 mg daily, Advair Diskus 100/50 mcg one puff b.i.d., and fluticasone spray 50 mcg two sprays daily.,PAST SURGICAL HISTORY:,  He has not had any previous surgery.,FAMILY HISTORY: , His brothers had prostate cancer.  Father had brain cancer.  Heart disease in both sides of the family.  Has diabetes in his brother and sister.,SOCIAL HISTORY:,  He is a non-cigarette smoker and non-ETOH user.  He is single and he has no children.  He works as a payroll representative and previously did lot of work in jewelry business, working he states with chemical.,REVIEW OF SYSTEMS: , He denies any chest pain.  He admits to exertional shortness of breath.  He denies any GI problems as noted.  Has frequent urination as noted.  He denies any bleeding disorders or bleeding history.,PHYSICAL EXAMINATION:,GENERAL:  Presents as an obese 60-year-old white male, who appears to be in no apparent distress.,HEENT:  Unremarkable.,NECK:  Supple.  There is no mass, adenopathy or bruit.,CHEST:  Normal excursion.,LUNGS:  Clear to auscultation and percussion.,COR:  Regular.  There is no S3 or S4 gallop.  There is no obvious murmur.,HEART:  There is distant heart sounds.,ABDOMEN:  Obese.  It is soft.  It is nontender.  Examination was done as relatively sitting up as the patient was unable to recline.  Bowel sounds are present.  There is no obvious mass or organomegaly.,GENITALIA:  Deferred.,RECTAL:  Deferred.,EXTREMITIES:  Revealed about 1+ pitting edema.  Bilateral peripheral pulses are intact.,NEUROLOGIC:  Without focal deficits.  The patient is alert and oriented.,IMPRESSION:,  Both left adrenal and pancreatic lesions.  The adrenal lesion is a small lesion, appears as if probable benign adenoma, where as the pancreatic lesion is the cystic lesion, and neoplasm could not be excluded.  Given the location of these pancreatic lesions in the mid body towards the tail and size of 1 cm, the likelihood is an ERCP will be of no value and the likelihood is that it is too small to biopsy.  We are going to review x-rays with Radiology prior with the patient probably at some point will present for operative intervention.  Prior to that the patient will undergo an esophagogastroduodenoscopy.",
 The patient comes in today because of feeling lightheaded and difficulty keeping his balance., Consult - History and Phy., Lightheadedness ,"HISTORY OF PRESENT ILLNESS:  ,The patient comes in today because of feeling lightheaded and difficulty keeping his balance.  He denies this as a spinning sensation that he had had in the past with vertigo.  He just describes as feeling very lightheaded.  It usually occurs with position changes such as when he stands up from the sitting position or stands up from a lying position.  It tends to ease when he sits down again, but does not totally resolve for another 15 to 30 minutes and he feels shaky and weak all over.  Lorazepam did not help this sensation.  His blood pressure has been up lately and his dose of metoprolol was increased.  They feel these symptoms have gotten worse since metoprolol was increased.,PAST MEDICAL HISTORY: , Detailed on our H&P form.  Positive for elevated cholesterol, diabetes, glaucoma, cataracts, hypertension, heart disease, vertigo, stroke in May of 2005, congestive heart failure, CABG, and cataract removed right eye.,CURRENT MEDICATIONS: , Detailed on the H&P form.,PHYSICAL EXAMINATION: , His blood pressure sitting down was 180/80 with a pulse rate of 56.  Standing up blood pressure was 160/80 with a pulse rate of 56.  His general exam and neurological exam were detailed on our H&P form.  Pertinent positives on his neurological exam were decreased sensation in his left face, and left arm and leg.,IMPRESSION AND PLAN:  ,This lightheaded, he exquisitely denies vertigo, the vertigo that he has had in the past.  He states this is more of a lightheaded type feeling.  He did have a mild blood pressure drop here in the office.  We are also concerned that bradycardia might be contributing to his feeling of lightheadedness.  We are going to suggest that he gets a Holter monitor and he should speak to his general practitioner as well as his cardiologist regarding the lightheaded feeling.,We will schedule him for the Holter monitor and refer him back to his cardiologist.","consult - history and phy., lightheaded feeling, feeling lightheaded, pulse rate, neurological exam, holter monitor, blood pressure, balance, vertigo, lightheadedness, "
 Urine leaked around the ostomy site for his right sided nephrostomy tube.  The patient had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure., Consult - History and Phy., Leaking Nephrostomy Tube ,"CHIEF COMPLAINT:  ,Leaking nephrostomy tube.,HISTORY OF PRESENT ILLNESS: , This 61-year-old male was referred in today secondary to having urine leaked around the ostomy site for his right sided nephrostomy tube.  The leaking began this a.m.  The patient denies any pain, does not have fever and has no other problems or complaints.  The patient had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure.  The patient states he feels like his usual self and has no other problems or concerns.  The patient denies any fever or chills.  No nausea or vomiting.  No flank pain, no abdominal pain, no chest pain, no shortness of breath, no swelling to the legs.,REVIEW OF SYSTEMS: , Review of systems otherwise negative and noncontributory.,PAST MEDICAL HISTORY: , Metastatic prostate cancer, anemia, hypertension.,MEDICATIONS: , Medication reconciliation sheet has been reviewed on the nurses' note.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient is a nonsmoker.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Temperature 97.7 oral, blood pressure 150/85, pulse is 91, respirations 16, oxygen saturation 97% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished, well developed, appears to be healthy, calm, comfortable, no acute distress, looks well.  HEENT:  Eyes are normal with clear sclerae and cornea.  NECK:  Supple, full range of motion.  CARDIOVASCULAR:  Heart has regular rate and rhythm without murmur, rub or gallop.  Peripheral pulses are +2.  No dependent edema.  RESPIRATIONS:  Clear to auscultation bilaterally.  No shortness of breath.  No wheezes, rales or rhonchi.  Good air movement bilaterally.  GASTROINTESTINAL:  Abdomen is soft, nontender, nondistended.  No rebound or guarding.  Normal benign abdominal exam.  MUSCULOSKELETAL:  The patient has nontender back and flank.  No abnormalities noted to the back other than the bilateral nephrostomy tubes.  The nephrostomy tube left has no abnormalities, no sign of infection.  No leaking of urine, nontender, nephrostomy tube on the right has a damp dressing, which has a small amount of urine soaked into it.  There is no obvious active leak from the ostomy site.  No sign of infection.  No erythema, swelling or tenderness.  The collection bag is full of clear urine.  The patient has no abnormalities on his legs.  SKIN:  No rashes or lesions.  No sign of infection.  NEUROLOGIC:  Motor and sensory are intact to the extremities.  The patient has normal ambulation, normal speech.  PSYCHIATRIC:  Alert and oriented x4.  Normal mood and affect.  HEMATOLOGIC AND LYMPHATIC:  No bleeding or bruising.,EMERGENCY DEPARTMENT COURSE:,  Reviewed the patient's admission record from one month ago when he was admitted for the placement of the nephrostomy tubes, both Dr. X and Dr. Y have been consulted and both had recommended nephrostomy tubes, there was not the name mentioned as to who placed the nephrostomy tubes.  There was no consultation dictated for this and no name was mentioned in the discharge summary, paged Dr. X as this was the only name that the patient could remember that might have been involved with the placement of the nephrostomy tubes.  Dr. A responded to the page and recommended __________ off a BMP and discussing it with Dr. B, the radiologist as he recalled that this was the physician who placed the nephrostomy tubes, paged Dr. X and received a call back from Dr. X.  Dr. X stated that he would have somebody get in touch with us about scheduling a time for which they will change out the nephrostomy tube to a larger and check a nephrogram at that time that came down and stated that they would do it at 10 a.m. tomorrow.  This was discussed with the patient and instructions to return to the hospital at 10 a.m. to have this tube changed out by Dr. X was explained and understood.,DIAGNOSES:,1.  WEAK NEPHROSTOMY SITE FOR THE RIGHT NEPHROSTOMY TUBE.,2.  PROSTATE CANCER, METASTATIC.,3.  URETERAL OBSTRUCTION.,The patient on discharge is stable and dispositioned to home.,PLAN: , We will have the patient return to the hospital tomorrow at 10 a.m. for the replacement of his right nephrostomy tube by Dr. X.  The patient was asked to return in the emergency room sooner if he should develop any new problems or concerns.","consult - history and phy., nephrostomy site, ureteral obstruction, leaking nephrostomy tube, acute renal failure, bilateral nephrostomy, ureteral obstructions, nephrostomy tube, tube, nephrostomy, ureteral, prostate, leaking, urine, tubes, "
" The patient is a 26-year-old gravida 2, para 1-0-0-1, at 28-1/7 weeks who presents to the emergency room with left lower quadrant pain, reports no bowel movement in two weeks as well as nausea and vomiting for the last 24 hours or so.  She states that she has not voided in the last 24 hours as well due to pain.", Consult - History and Phy., Left Lower Quadrant Pain - ER Visit ,"HISTORY OF PRESENT ILLNESS:,  The patient is a 26-year-old gravida 2, para 1-0-0-1, at 28-1/7 weeks who presents to the emergency room with left lower quadrant pain, reports no bowel movement in two weeks as well as nausea and vomiting for the last 24 hours or so.  She states that she has not voided in the last 24 hours as well due to pain.  She denies any leaking of fluid, vaginal bleeding, or uterine contractions.  She reports good fetal movement.  She denies any fevers, chills, or burning with urination.,REVIEW OF SYSTEMS: , Positive for back pain in her lower back only.  Her mother reports that she has been eating food without difficulty and that the current nausea and vomiting is much less than when she is not pregnant.  She continues to yell out for requesting pain medication and about how much ""it hurts."",PAST MEDICAL HISTORY:,1.  Irritable bowel syndrome.,2.  Urinary tract infections times three.  The patient is unsure if pyelo is present or not.,PAST SURGICAL HISTORY:,  Denies.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , Phenergan and Zofran twice a day.  Macrobid questionable.,GYN: , History of an abnormal Pap, group B within normal limits.  Denies any sexually transmitted diseases.,OB HISTORY: , G1 is a term spontaneous vaginal delivery without complications, now a 6-year-old.  G2 is current.  Gets her care at Lyndhurst.,SOCIAL HISTORY: , Denies tobacco and alcohol use.  She endorses marijuana use and a history of cocaine use five years ago.  Upon review of the Baptist lab systems, the patient has had multiple positive urine drug screens and as recently as February 2008 had a urine drug screen that was positive for benzodiazepines, barbiturates, opiates, and marijuana and as recently as 2005 with cocaine present as well.,PHYSICAL EXAM:,VITAL SIGNS:  Blood pressure 139/82, pulse 89, respirations 20, 98% on room air, 96 degrees Fahrenheit.  Fetal heart tones are 130s with moderate long-term variability.  No paper is available for the fetal heart monitor due to the misorder and audibly sounds reassuring.,GENERAL:  Appears sedated, trashing intermittently, and then falling asleep in mid sentence.,CARDIOVASCULAR:  Regular rate and rhythm.,PULMONARY:  Clear to auscultation bilaterally.,BACK:  Tender to palpation in her lower back bilaterally, but no CVA tenderness.,ABDOMEN:  Tender to palpation in left lower quadrant.  No guarding or rebound.  Normal bowel sounds.,EXTREMITIES:  Scar track marks from bilateral arms.,PELVIC:  External vaginal exam is closed, long, high, and posterior.  Stool was felt in the rectum.,LABS: , White count is 11.1, hemoglobin is 13.5, platelets are 279.  CMP is within normal limits with an AST of 17, ALT of 11, and creatinine of 0.6.  Urinalysis which is supposedly a cath specimen shows a specific gravity of 1.024, greater than 88 ketones, many bacteria, but no white blood cells or nitrites.,ASSESSMENT AND PLAN:  ,The patient is a 26-year-old gravida 2, para 1-0-0-1 at 28-1 weeks with left lower quadrant pain and likely constipation.  I spoke with Dr. X who is the physician on-call tonight, and he requests that she be transferred for continued fetal monitoring and further evaluation of this abdominal pain to Labor and Delivery.  Plans are made for transfer at this time.  This was discussed with Dr. Y who is in agreement with the plan.",
" Lightheaded, dizziness, and palpitation.  This morning, the patient experienced symptoms of lightheaded, dizziness, felt like passing out; however, there was no actual syncope.  During the episode, the patient describes symptoms of palpitation and fluttering of chest.  She relates the heart was racing.  By the time when she came into the Emergency Room, her EKG revealed normal sinus rhythm.  No evidence of arrhythmia.", Consult - History and Phy., Lightheaded & Dizziness ,"REASON FOR CONSULTATION: , Lightheaded, dizziness, and palpitation.,HISTORY OF PRESENT ILLNESS: , The patient is a 50-year-old female who came to the Emergency Room.  This morning, the patient experienced symptoms of lightheaded, dizziness, felt like passing out; however, there was no actual syncope.  During the episode, the patient describes symptoms of palpitation and fluttering of chest.  She relates the heart was racing.  By the time when she came into the Emergency Room, her EKG revealed normal sinus rhythm.  No evidence of arrhythmia.  The patient had some cardiac workup in the past, results are as mentioned below.  Denies any specific chest pain.  Activities fairly stable.  She is actively employed.  No other cardiac risk factor in terms of alcohol consumption or recreational drug use, caffeinated drink use or over-the-counter medication usage.,CORONARY RISK FACTORS: , No history of hypertension or diabetes mellitus.  Nonsmoker.  Cholesterol normal.  No history of established coronary artery disease and family history noncontributory.,FAMILY HISTORY: , Nonsignificant.,SURGICAL HISTORY: , Tubal ligation.,MEDICATIONS: , On pain medications, ibuprofen.,ALLERGIES:,  SULFA.,PERSONAL HISTORY: , She is a nonsmoker.  Does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY: , History of chest pain in the past.  Had workup done including nuclear myocardial perfusion scan, which was reportedly abnormal.  Subsequently, the patient underwent cardiac catheterization in 11/07, which was also normal.  An echocardiogram at that time was also normal.  At this time, presentation with lightheaded, dizziness, and palpitation.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No history of fever, rigors, or chills.,HEENT:  No history of cataract, blurry vision, or glaucoma.,CARDIOVASCULAR:  As above.,RESPIRATORY:  Shortness of breath.  No pneumonia or valley fever.,GASTROINTESTINAL:  No epigastric discomfort, hematemesis or melena.,UROLOGICAL:  No frequency or urgency.,MUSCULOSKELETAL:  Nonsignificant.,NEUROLOGICAL:  No TIA.  No CVA.  No seizure disorder.,ENDOCRINE/HEMATOLOGIC:  Nonsignificant.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 69, blood pressure 127/75, afebrile, and respiratory rate 16 per minute.,HEENT:  Atraumatic and normocephalic.,NECK:  Neck veins flat.  No carotid bruits.  No thyromegaly.  No lympyhadenopathy.,LUNGS:  Air entry bilaterally fair.,HEART:  PMI normal.  S1 and S2 regular.,ABDOMEN:  Soft and nontender.  Bowel sounds present.,EXTREMITIES:  No edema.  Pulses palpable.  No clubbing or cyanosis.,CNS:  Benign.,PSYCHOLOGICAL:  Normal.,MUSCULOSKELETAL:  Nonsignificant.,EKG: , Normal sinus rhythm, incomplete right bundle-branch block.,LABORATORY DATA:,  H&H stable.  BUN and creatinine within normal limits.  Cardiac enzyme profile negative.  Chest x-ray unremarkable.,IMPRESSION:,1.  Lightheaded, dizziness in a 50-year-old female.  No documented arrhythmia with the symptoms of palpitation.,2.  Normal cardiac structure by echocardiogram a year and half ago.,3.  Normal cardiac catheterization in 11/07.,4.  Negative workup so far for acute cardiac event in terms of EKG, cardiac enzyme profile.",
" Left knee pain and stiffness.  Bilateral knee degenerative joint disease (DJD).  Significant back pain, status post lumbar stenosis surgery with pain being controlled on methadone 10 mg b.i.d.", Consult - History and Phy., Knee DJD - Consult ,"CHIEF COMPLAINT: , Left knee pain and stiffness.,HISTORY OF PRESENT ILLNESS: , The patient is a 57-year-old with severe bilateral knee DJD, left greater than right, with significant pain and limitations because of both.  He is able to walk approximately a 1/2-mile a day but is limited because of his knees.  Stairs are negotiated 1 at a time.  His problems with bilateral knee DJD have been well documented.  He had arthroscopy in the 1991/199two time frame for both of these.  He has been on long-standing conservative course for these including nonsteroidals, narcotics, injections.  At this point because of his progressive and persistent limitations he has opted for total joint surgery on the left side.  He does have other arthritic complaints including multiple back surgeries for spinal stenosis including decompression and epidural steroids.  Significant pain is handled by narcotic medication.  His attending physician is Dr. X.,PAST MEDICAL HISTORY: , Hypertension.,PRIOR SURGERIES:,1.  Inguinal hernia on the left.,2.  Baker's cyst.,3.  Colon cancer removal.,4.  Bilateral knee scopes.,5.  Right groin hernia.,6.  Low back surgery for spinal stenosis.,7.  Status post colon cancer second surgery.,MEDICATIONS:,1.  Ambien 12.5 mg nightly.,2.  Methadone 10 mg b.i.d.,3.  Lisinopril 10 mg daily.,IV MEDICATIONS FOR PAIN:  ,Demerol appears to work the best.,ALLERGIES: , Levaquin and Cipro cause rashes; ibuprofen causes his throat to swell, Fortaz causes an unknown reaction.,REVIEW OF SYSTEMS:  ,He does have paresthesias down into his thighs secondary to spinal stenosis.,SOCIAL HISTORY: , Married.  He is retired, being a Pepsi-Cola driver secondary to his back and knees.,HABITS: , No tobacco or alcohol.  Chewed until 2003.,RECREATIONAL PURSUITS:  ,Golfs, gardens, woodworks.,FAMILY HISTORY:,1.  Cancer.,2.  Coronary artery disease.,PHYSICAL EXAMINATION:,GENERAL APPEARANCE:  A pleasant, cooperative 57-year-old white male.,VITAL SIGNS:  Height 5' 9"", weight 167.  Blood pressure 148/86.  Pulse 78 per minute and regular.,HEENT:  Unremarkable.  Extraocular movements are full.  Cranial nerves II-XII intact.,NECK:  Supple.,CHEST:  Clear.,CARDIOVASCULAR:  Regular rhythm.  Normal S1 and 2.,ABDOMEN:  No organomegaly.  No tenderness.  Normal bowel sounds.,NEUROLOGIC:  Intact.,MUSCULOSKELETAL:  Left knee reveals a range of -10 degrees extension, 126 flexion.  His extensor mechanism is intact.  There is mild varus.  He has good stability at 30 degrees of flexion.  Lachman's and posterior drawer are negative.  He has good muscle turgor.  Dorsalis pedis pulse 2+.,DIAGNOSTICS:  ,X-rays revealed severe bilateral knee DJD with joint space narrowing medially as well as the patellofemoral joint with large osteophytes, left greater than right.,IMPRESSION:,1.  Bilateral knee degenerative joint disease.,2.  Significant back pain, status post lumbar stenosis surgery with pain being controlled on methadone 10 mg b.i.d.",
 Consult for laparoscopic gastric bypass., Consult - History and Phy., Laparoscopic Gastric Bypass Consult - 1 ,"HISTORY OF PRESENT ILLNESS: , I have seen ABC today.  He is a very pleasant gentleman who is 42 years old, 344 pounds.  He is 5'9"".  He has a BMI of 51.  He has been overweight for ten years since the age of 33, at his highest he was 358 pounds, at his lowest 260.  He is pursuing surgical attempts of weight loss to feel good, get healthy, and begin to exercise again.  He wants to be able to exercise and play volleyball.  Physically, he is sluggish.  He gets tired quickly.  He does not go out often.  When he loses weight he always regains it and he gains back more than he lost.  His biggest weight loss is 25 pounds and it was three months before he gained it back.  He did six months of not drinking alcohol and not taking in many calories.  He has been on multiple commercial weight loss programs including Slim Fast for one month one year ago and Atkin's Diet for one month two years ago.,PAST MEDICAL HISTORY: , He has difficulty climbing stairs, difficulty with airline seats, tying shoes, used to public seating, difficulty walking, high cholesterol, and high blood pressure.  He has asthma and difficulty walking two blocks or going eight to ten steps.  He has sleep apnea and snoring.  He is a diabetic, on medication.  He has joint pain, knee pain, back pain, foot and ankle pain, leg and foot swelling.  He has hemorrhoids.,PAST SURGICAL HISTORY: , Includes orthopedic or knee surgery.,SOCIAL HISTORY: , He is currently single.  He drinks alcohol ten to twelve drinks a week, but does not drink five days a week and then will binge drink.  He smokes one and a half pack a day for 15 years, but he has recently stopped smoking for the past two weeks.,FAMILY HISTORY: , Obesity, heart disease, and diabetes.  Family history is negative for hypertension and stroke.,CURRENT MEDICATIONS:,  Include Diovan, Crestor, and Tricor.,MISCELLANEOUS/EATING HISTORY:  ,He says a couple of friends of his have had heart attacks and have had died.  He used to drink everyday, but stopped two years ago.  He now only drinks on weekends.  He is on his second week of Chantix, which is a medication to come off smoking completely.  Eating, he eats bad food.  He is single.  He eats things like bacon, eggs, and cheese, cheeseburgers, fast food, eats four times a day, seven in the morning, at noon, 9 p.m., and 2 a.m.  He currently weighs 344 pounds and 5'9"".  His ideal body weight is 160 pounds.  He is 184 pounds overweight.  If he lost 70% of his excess body weight that would be 129 pounds and that would get him down to 215.,REVIEW OF SYSTEMS: , Negative for head, neck, heart, lungs, GI, GU, orthopedic, or skin.  He also is positive for gout.  He denies chest pain, heart attack, coronary artery disease, congestive heart failure, arrhythmia, atrial fibrillation, pacemaker, pulmonary embolism, or CVA.  He denies venous insufficiency or thrombophlebitis.  Denies shortness of breath, COPD, or emphysema.  Denies thyroid problems, hip pain, osteoarthritis, rheumatoid arthritis, GERD, hiatal hernia, peptic ulcer disease, gallstones, infected gallbladder, pancreatitis, fatty liver, hepatitis, rectal bleeding, polyps, incontinence of stool, urinary stress incontinence, or cancer.  He denies cellulitis, pseudotumor cerebri, meningitis, or encephalitis.,PHYSICAL EXAMINATION:  ,He is alert and oriented x 3.  Cranial nerves II-XII are intact.  Neck is soft and supple.  Lungs:  He has positive wheezing bilaterally.  Heart is regular rhythm and rate.  His abdomen is soft.  Extremities:  He has 1+ pitting edema.,IMPRESSION/PLAN:,  I have explained to him the risks and potential complications of laparoscopic gastric bypass in detail and these include bleeding, infection, deep venous thrombosis, pulmonary embolism, leakage from the gastrojejuno-anastomosis, jejunojejuno-anastomosis, and possible bowel obstruction among other potential complications.  He understands.  He wants to proceed with workup and evaluation for laparoscopic Roux-en-Y gastric bypass.  He will need to get a letter of approval from Dr. XYZ.  He will need to see a nutritionist and mental health worker.  He will need an upper endoscopy by either Dr. XYZ.  He will need to go to Dr. XYZ as he previously had a sleep study.  We will need another sleep study.  He will need H. pylori testing, thyroid function tests, LFTs, glycosylated hemoglobin, and fasting blood sugar.  After this is performed, we will submit him for insurance approval.","consult - history and phy., laparoscopic gastric bypass, heart attacks, body weight, pulmonary embolism, potential complications, sleep study, weight loss, gastric bypass, anastomosis, loss, sleep, laparoscopic, gastric, bypass, heart, pounds, weight,"
 Consult for laparoscopic gastric bypass., Consult - History and Phy., Laparoscopic Gastric Bypass Consult - 2 ,"PAST MEDICAL HISTORY:, He has difficulty climbing stairs, difficulty with airline seats, tying shoes, used to public seating, and lifting objects off the floor.  He exercises three times a week at home and does cardio.  He has difficulty walking two blocks or five flights of stairs.  Difficulty with snoring.  He has muscle and joint pains including knee pain, back pain, foot and ankle pain, and swelling.  He has gastroesophageal reflux disease.,PAST SURGICAL HISTORY:, Includes reconstructive surgery on his right hand 13 years ago.  ,SOCIAL HISTORY:, He is currently single.  He has about ten drinks a year.  He had smoked significantly up until several months ago.  He now smokes less than three cigarettes a day.,FAMILY HISTORY:, Heart disease in both grandfathers, grandmother with stroke, and a grandmother with diabetes.  Denies obesity and hypertension in other family members.,CURRENT MEDICATIONS:, None.,ALLERGIES:,  He is allergic to Penicillin.,MISCELLANEOUS/EATING HISTORY:, He has been going to support groups for seven months with Lynn Holmberg in Greenwich and he is from Eastchester, New York and he feels that we are the appropriate program.  He had a poor experience with the Greenwich program.  Eating history, he is not an emotional eater.  Does not like sweets.  He likes big portions and carbohydrates.  He likes chicken and not steak.  He currently weighs 312 pounds.  Ideal body weight would be 170 pounds.  He is 142 pounds overweight.  If ,he lost 60% of his excess body weight that would be 84 pounds and he should weigh about 228.,REVIEW OF SYSTEMS: ,Negative for head, neck, heart, lungs, GI, GU, orthopedic, and skin.  Specifically denies chest pain, heart attack, coronary artery disease, congestive heart failure, arrhythmia, atrial fibrillation, pacemaker, high cholesterol, pulmonary embolism, high blood pressure, CVA, venous insufficiency, thrombophlebitis, asthma, shortness of breath, COPD, emphysema, sleep apnea, diabetes, leg and foot swelling, osteoarthritis, rheumatoid arthritis, hiatal hernia, peptic ulcer disease, gallstones, infected gallbladder, pancreatitis, fatty liver, hepatitis, hemorrhoids, rectal bleeding, polyps, incontinence of stool, urinary stress incontinence, or cancer.  Denies cellulitis, pseudotumor cerebri, meningitis, or encephalitis.,PHYSICAL EXAMINATION:, He is alert and oriented x 3.  Cranial nerves II-XII are intact.  Afebrile.  Vital Signs are stable.","consult - history and phy., laparoscopic gastric bypass, weight loss programs, gastric bypass, atkin's diet, weight watcher's, body weight, laparoscopic gastric, weight loss, pounds, months, weight, laparoscopic, band, loss, diets, overweight, lost"
 The patient with an L5 compression fracture.is to come to the hospital for bilateral L5 kyphoplasty.  The patient has a history of back and buttock pain for some time. , Consult - History and Phy., Kyphoplasty - Consult ,"HISTORY: , The patient is to come to the hospital for bilateral L5 kyphoplasty.  The patient is an 86-year-old female with an L5 compression fracture.,The patient has a history of back and buttock pain for some time.  She was found to have an L5 compression fracture.  She was treated conservatively over several months, but did not improve.  Unfortunately, she has continued to have significant ongoing back pain and recent CT scan has shown a sclerosis with some healing of her L5 compression fracture, but without complete healing.  The patient has had continued pain and at this time, is felt to be a candidate for kyphoplasty.,She denies bowel or bladder incontinence.  She does complain of back pain.  She has been wearing a back brace and corset.  She does not have weakness.,PAST MEDICAL HISTORY:,  The patient has a history of multiple medical problems including hypothyroidism, hypertension, and gallbladder difficulties.,PAST SURGICAL HISTORY:,  She has had multiple previous surgeries including bowel surgery, hysterectomy, rectocele repair, and appendectomy.  She also has a diagnosis of polymyalgia rheumatica.,CURRENT MEDICATIONS: , She is on multiple medications currently.,ALLERGIES: , SHE IS ALLERGIC TO CODEINE, PENICILLIN, AND CEPHALOSPORINS.,FAMILY HISTORY: , The patient's parents are deceased.,PERSONAL AND SOCIAL HISTORY: , The patient lives locally.  She is a widow.  She does not smoke cigarettes or use illicit drugs.,PHYSICAL EXAMINATION: , GENERAL:  The patient is an elderly frail white female in no distress.  LUNGS:  Clear.  HEART:  Sounds are regular.  ABDOMEN:  She has a protuberant abdomen.  She has tenderness to palpation in the lumbosacral area.  Sciatic notch tenderness is not present.  Straight leg raise testing evokes back pain.  NEUROLOGICAL:  She is awake, alert, and oriented.  Speech is intact.  Comprehension is normal.  Strength is intact in the upper extremities.  She has giveaway strength in the lower extremities.  Reflexes are diminished at the knees and ankles.  Gait is otherwise normal.,DATA REVIEWED: , Plain studies of the lumbar spine show an L5 compression fracture.  A CT scan has shown some healing of this fracture.  She has degenerative change at the L4-L5 level with a very slight spondylolisthesis at this level.,ASSESSMENT AND PLAN: , The patient is a woman with a history of longstanding back, buttock, and leg pain.  She has a documented L5 compression fracture, which has not healed despite appropriate conservative treatments.  At this point, I believe the patient is a good candidate for L5 kyphoplasty.  I have discussed the procedure with her and I have reviewed with her and her family risks, benefits, and alternatives to surgery.  Risks of surgery including but not limited to bleeding, infection, stroke, paralysis, death, failure to improve, spinal fluid leak, need for further surgery, cement extravasation, failure to improve her pain, and other potential complications have all been discussed.  The patient understands the issues involved.  She requested that we proceed with surgery as noted above and will come to the hospital for this surgery on 01/18/08.","consult - history and phy., leg pain, lumbar spine, l5 compression fracture, compression fracture, kyphoplasty, buttock, surgery, fracture,"
 A 13-year-old new patientfor evaluation of thoracic kyphosis.   Family history of kyphosis in a maternal aunt and grandfather.  She was noted by her parents to have round back posture., Consult - History and Phy., Kyphosis ,"REASON FOR VISIT: , Kyphosis.,HISTORY OF PRESENT ILLNESS: , The patient is a 13-year-old new patient is here for evaluation of thoracic kyphosis.  The patient has a family history in a maternal aunt and grandfather of kyphosis.  She was noted by her parents to have round back posture.  They have previously seen another orthopedist who recommended observation at this time.  She is here for a second opinion in regards to kyphosis.  The patient denies any pain in her back or any numbness, tingling, or weakness in her upper or lower extremities.  No problems with her bowels or bladder.,PAST MEDICAL HISTORY: , None.,PAST SURGICAL HISTORY: , Bilateral pinning of her ears.,SOCIAL HISTORY:  ,She is currently an eighth grader at Middle School and is interested in basketball.  She lives with both of her parents and has a 9-year-old brother.  She had menarche beginning in September.,FAMILY HISTORY:  ,Of kyphosis in great grandmother and second cousin.,REVIEW OF SYSTEMS: , She is in her usual state of health and is negative except otherwise as mentioned in the history of present illness.,MEDICATIONS: , She is currently on Zyrtec, Flonase, and Ceftin for an ear infection.,ALLERGIES: , No known drug allergies.,FINDINGS: , On physical exam, she is alert, oriented, and in no acute distress standing 63 inches tall.  In regards to her back, her skin is intact with no rashes, lesions, and/or no dimpling or hair spots.  No cafe au lait spots.  She is not tender to palpation from her occiput to her sacrum.  There is no evidence of paraspinal muscle spasm.  On forward bending, there is a mild kyphosis.  She is not able to touch her toes indicating her hamstring tightness.  She has a full 5 out of 5 in all muscle groups.  Her lower extremities including iliopsoas, quadriceps, gastroc-soleus, tibialis anterior, and extensor hallucis longus.  Her sensation intact to light touch in L1 through L2 dermatomal distributions.  She has symmetric limb lengths as well bilaterally from both the coronal and sagittal planes.,X-rays today included PA and lateral sclerosis series.  She has approximately 46 degree kyphosis.,ASSESSMENT: , Kyphosis.,PLANS:  ,The patient's kyphosis is quite mild.  While this is likely in the upper limits of normal or just it is normal for an adolescent and still within normal range as would be expected return at home.  At this time, three options were discussed with the parents including observation, physical therapy, and bracing.  At this juncture, given that she has continued to grow, they are Risser 0.  She may benefit from continued observation with physical therapy, bracing would be a more aggressive option certainly that thing would be lost with following at this time.  As such, she was given a prescription for physical therapy for extension based strengthening exercises, flexibility range of motion exercises, postural training with no forward bending.  We will see her back in 3 months' time for repeat radiographs at that time including PA and lateral standing of scoliosis series.  Should she show evidence of continued progression of her kyphotic deformity, discussions of bracing would be held at time.  We will see her back in 3 months' time for repeat evaluation.","consult - history and phy., thoracic kyphosis, round back posture, physical therapy, kyphosis, patientfor, orthopedist, "
 This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms., Consult - History and Phy., Itchy Rash - ER Visit ,"CHIEF COMPLAINT:,  Itchy rash.,HISTORY OF PRESENT ILLNESS: , This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms.  No facial swelling.  No tongue or lip swelling.  No shortness of breath, wheezing, or other associated symptoms.  He cannot think of anything that could have triggered this off.  There have been no changes in his foods, medications, or other exposures as far as he knows.  He states a couple of days ago he did work and was removing some insulation but does not remember feeling itchy that day.,PAST MEDICAL HISTORY: , Negative for chronic medical problems.  No local physician.  Has had previous back surgery and appendectomy, otherwise generally healthy.,REVIEW OF SYSTEMS: , As mentioned denies any oropharyngeal swelling.  No lip or tongue swelling.  No wheezing or shortness of breath.  No headache.  No nausea.  Notes itchy rash, especially on his torso and upper arms.,SOCIAL HISTORY: , The patient is accompanied with his wife.,FAMILY HISTORY: , Negative.,MEDICATIONS: , None.,ALLERGIES: , TORADOL, MORPHINE, PENICILLIN, AND AMPICILLIN.,PHYSICAL EXAMINATION: , VITAL SIGNS:  The patient was afebrile.  He is slightly tachycardic, 105, but stable blood pressure and respiratory rate.  GENERAL:  The patient is in no distress.  Sitting quietly on the gurney.  HEENT:  Unremarkable.  His oral mucosa is moist and well hydrated.  Lips and tongue look normal.  Posterior pharynx is clear.  NECK:  Supple.  His trachea is midline.  There is no stridor.  LUNGS:  Very clear with good breath sounds in all fields.  There is no wheezing.  Good air movement in all lung fields.  CARDIAC:  Without murmur.  Slight tachycardia.  ABDOMEN:  Soft, nontender.  SKIN:  Notable for a confluence erythematous, blanching rash on the torso as well as more of a blotchy papular, macular rash on the upper arms.  He noted some on his buttocks as well.  Remaining of the exam is unremarkable.,ED COURSE: , The patient was treated with epinephrine 1:1000, 0.3 mL subcutaneously along with 50 mg of Benadryl intramuscularly.  After about 15-20 minutes he states that itching started to feel better.  The rash has started to fade a little bit and feeling a lot more comfortable.,IMPRESSION:,  ACUTE ALLERGIC REACTION WITH URTICARIA AND PRURITUS.,ASSESSMENT AND PLAN: , The patient has what looks to be some type of allergic reaction, although the underlying cause is difficult to assess.  He will make sure he goes home to look around to see if there is in fact anything that changed recently that could have triggered this off.  In the meantime, I think he can be managed with some antihistamine over-the-counter.  He is responding already to Benadryl and the epinephrine that we gave him here.  He is told that if he develops any respiratory complaints, shortness of breath, wheezing, or tongue or lip swelling he will return immediately for evaluation.  He is discharged in stable condition.","consult - history and phy., urticaria, pruritus, lip swelling, allergic reaction, itchy rash, torso, swelling, itchy, rash, "
" Right knee injury suggestive of a recurrent anterior cruciate ligament tear, possible internal derangement.  While playing tennis she had a non-contact injury in which she injured the right knee.  She had immediate pain and swelling. ", Consult - History and Phy., Knee Injury ,"HISTORY OF PRESENT ILLNESS: , The patient is an 18-year-old girl brought in by her father today for evaluation of a right knee injury.  She states that approximately 3 days ago while playing tennis she had a non-contact injury in which she injured the right knee.  She had immediate pain and swelling.  At this time, she complains of pain and instability in the knee.  The patient's past medical history is significant for having had an ACL injury to the knee in 2008.  She underwent anterior cruciate ligament reconstruction by Dr. X at that time, subsequently in the same year she developed laxity of the graft due in part to noncompliance and subsequently, she sought attention from Dr. Y who performed a revision ACL reconstruction at the end of 2008.  The patient states she rehabbed the knee well after that and did fine with good stability of the knee until this recent injury.,PAST MEDICAL HISTORY:,  She claims no chronic illnesses.,PAST SURGICAL HISTORY: , She had an anterior cruciate ligament reconstruction in 03/2008, and subsequently had a revision ACL reconstruction in 12/2008.  She has also had arm surgery when she was 6 years old.,MEDICATIONS: , She takes no medications on a regular basis,ALLERGIES: , She is allergic to Keflex and has skin sensitivity to Steri-Strips.,SOCIAL HISTORY:  ,The patient is single.  She is a full-time student at University.  Uses no tobacco, alcohol, or illicit drugs.  She exercises weekly, mainly tennis and swelling.,REVIEW OF SYSTEMS:  ,Significant for recent weight gain, occasional skin rashes.  The remainder of her systems negative.,PHYSICAL EXAMINATION,GENERAL:  The patient is 4 foot 10 inches tall, weighs 110 pounds.,EXTREMITIES:  She ambulates with some difficulty with a marked limp on the right side.  Inspection of the knee reveals a significant effusion in the knee.  She has difficulty with passive range of motion of the knee secondary to pain.  She does have tenderness to palpation at the medial joint line and has a positive Lachman's exam.,NEUROVASCULAR:  She is neurovascularly intact.,IMPRESSION: , Right knee injury suggestive of a recurrent anterior cruciate ligament tear, possible internal derangement.,PLAN: , The patient will be referred for an MRI of the right knee to evaluate the integrity of her revision ACL graft.  In the meantime, she will continue to use ice as needed.  Moderate her activities and use crutches.  She will follow up as soon as the MRI is performed.","consult - history and phy., acl graft, acl reconstruction, knee, anterior cruciate ligament, internal derangement, contact injury, knee injury, injury, cruciate, acl, anterior,"
" Patient started out having toothache, now radiating into his jaw and towards his left ear.  Ellis type II dental fracture.", Consult - History and Phy., Jaw Pain - ER Visit ,"CHIEF COMPLAINT: , Jaw pain.,HISTORY OF PRESENT ILLNESS:  ,This is a 58-year-old male who started out having toothache in the left lower side of the mouth that is now radiating into his jaw and towards his left ear.  Triage nurse reported that he does not believe it is his tooth because he has regular dental appointments, but has not seen a dentist since this new toothache began.  The patient denies any facial swelling.  No headache.  No swelling to the throat.  No sore throat.  No difficulty swallowing liquids or solids.  No neck pain.  No lymph node swelling.  The patient denies any fever or chills.  Denies any other problems or complaints.,REVIEW OF SYSTEMS:,  CONSTITUTIONAL:  No fever or chills.  No fatigue or weakness.  HEENT:  No headache.  No neck pain.  No eye pain or vision change.  No rhinorrhea.  No sinus congestion, pressure, or pain.  No sore throat.  No throat swelling.  The patient does have the toothache on the left lower side that radiates towards his left ear as previously described.  The patient does not have ear pain or hearing change.  No pressure in the ear.  CARDIOVASCULAR:  No chest pain.  RESPIRATIONS:  No shortness of breath.  GASTROINTESTINAL:  No nausea or vomiting.  No abdominal pain.  MUSCULOSKELETAL:  No back pain.  SKIN:  No rashes or lesions.  NEUROLOGIC:  No vision or hearing change.  No speech change.  HEMATOLOGIC/LYMPHATIC:  No lymph node swelling.,PAST MEDICAL HISTORY: , None.,PAST SURGICAL HISTORY:,  None.,CURRENT MEDICATIONS: , None.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient smokes marijuana.  The patient does not smoke cigarettes.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Temperature 98.2 oral, blood pressure is 168/84, pulse is 87, respirations 16, and oxygen saturation is 100% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished, well developed.  The patient appears to be healthy.  The patient is calm, comfortable in no acute distress, looks well.  The patient is pleasant and cooperative.  HEENT:  Head is atraumatic, normocephalic, and nontender.  Eyes are normal with clear cornea and conjunctivae bilaterally.  Nose, normal without rhinorrhea or audible congestion.  There is no tenderness over the sinuses.  Ears are normal without any sign of infection.  No erythema or swelling of the canals.  Tympanic membranes are intact and normal without any erythema, bulging, air fluid levels, or bubbles behind it.  MOUTH:  The patient has a dental fracture at tooth #18.  The patient states that the fracture is a couple of months old.  The patient does not have any obvious dental caries.  The gums are normal without any erythema, swelling, or evidence of infection.  There is no fluctuance or suggestion of abscess.  There is slight tenderness of the tooth #18.  The oropharynx is normal without any sign of infection.  There is no erythema, exudate, lesion, or swelling.  Mucous membranes are moist.  Floor of the mouth is normal without any tenderness or swelling.  No suggestion of abscess.  There is no pre or post auricular lymphadenopathy either.  NECK:  Supple.  Nontender.  Full range of motion.  No meningismus.  No cervical lymphadenopathy.  No JVD.  No carotid artery or vertebral artery bruits.  CARDIOVASCULAR:  Heart is regular rate and rhythm without murmur, rub, or gallop.  RESPIRATIONS:  Clear to auscultation bilaterally.  No shortness of breath.  GASTROINTESTINAL:  Abdomen is normal and nontender.  MUSCULOSKELETAL:  No abnormalities are noted to the back, arms, or legs.  The patient has normal use of the extremities.  SKIN:  No rashes or lesions.  NEUROLOGIC:  Cranial nerves II through XII are intact.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is alert and oriented x4.  Normal mood and affect.  No evidence of clinical intoxification.  HEMATOLOGIC/LYMPHATIC:  No lymphadenitis is palpated.,DIAGNOSES:,1.  ACUTE LEFT JAW PAIN.,2.  #18 DENTAL FRACTURE, WHICH IS AN ELLIS TYPE II FRACTURE.,3.  ELEVATED BLOOD PRESSURE.,CONDITION UPON DISPOSITION: , Stable.,DISPOSITION:,  Home.,PLAN: , We will have the patient follow up with his dentist Dr. X in three to five days for reevaluation.  The patient was encouraged to take Motrin 400 mg q.6h. as needed for pain.  The patient was given prescription for Vicodin for any breakthrough or uncontrolled pain.  He was given precautions for drowsiness and driving with the use of this medication.  The patient was also given a prescription for pen V.  The patient was given discharge instructions on toothache and asked to return to emergency room should he have any worsening of his condition, develop any other problems or symptoms of concern.","consult - history and phy., jaw pain, dental appointment, ellis type ii fracture, ellis type, dental fracture, toothache, tenderness, pressure, erythema, "
" Pneumatosis coli in the cecum.  Possible ischemic cecum with possible metastatic disease, bilateral hydronephrosis on atrial fibrillation, aspiration pneumonia, chronic alcohol abuse, acute renal failure, COPD, anemia with gastric ulcer.", Consult - History and Phy., Ischemic Cecum - Consult ,"REASON FOR CONSULTATION: , Pneumatosis coli in the cecum.,HISTORY OF PRESENT ILLNESS:  ,The patient is an 87-year-old gentleman who was admitted on 10/27/07 with weakness and tiredness with aspiration pneumonia.  The patient is very difficult to obtain information from; however, he appears to be having frequent nausea and vomiting with an aspiration pneumonia and abdominal discomfort.  In addition, this hospitalization, he has undergone an upper endoscopy, which found a small ulcer after dropping his hematocrit and becoming anemic.  He had a CT scan on Friday, 11/02/07, which apparently showed pneumatosis and his cecum worrisome for ischemic colitis as well as bilateral hydronephrosis and multiple liver lesions, which could be metastatic disease versus cysts.  In discussions with the patient, he had multiple bowel movements yesterday and is currently passing flatus and has epigastric pain.,PAST MEDICAL HISTORY:  ,Obtained from the medical chart.  Chronic obstructive pulmonary disease, history of pneumonia, and aspiration pneumonia, osteoporosis, alcoholism, microcytic anemia.,MEDICATIONS: , Per his current medical chart.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient had a long history of smoking but quit many years ago.  He does have chronic alcohol use.,PHYSICAL EXAMINATION:,GENERAL:  A very thin white male who is dyspneic and having difficulty breathing at the moment.,VITAL SIGNS:  Afebrile.  Heart rate in the 100s to 120s at times with atrial fibrillation.  Respiratory rate is 17-20.  Blood pressure 130s-150s/60s-70s.,NECK:  Soft and supple, full range of motion.,HEART:  Regular.,ABDOMEN:  Distended with tenderness mainly in the upper abdomen but very difficult to localize due to his difficulty providing information.  He does appear to have tenderness but does not have rebound and does not have peritoneal signs.,DIAGNOSTICS: , A CT scan done on 11/02/07 shows pneumatosis in the cecum with an enlarged cecum filled with stool and air fluid levels with chronically dilated small bowel.,ASSESSMENT: , Possible ischemic cecum with possible metastatic disease, bilateral hydronephrosis on atrial fibrillation, aspiration pneumonia, chronic alcohol abuse, acute renal failure, COPD, anemia with gastric ulcer.,PLAN: , The patient appears to have pneumatosis from a CT scan 2 days ago.  Nothing was done about it at that time as the patient appeared to not be symptomatic, but he continues to have nausea and vomiting with abdominal pain, but the fact that pneumatosis was found 2 days ago and the patient has survived this long indicates this may be a benign process at the moment, and I would recommend getting a repeat CT scan to assess it further to see if there is worsening of pneumatosis versus resolution to further evaluate the liver lesions and make decisions regarding planning at that time.  The patient has frequent desaturations secondary to his aspiration pneumonia, and any surgical procedure or any surgical intervention would certainly require intubation, which would then necessitate long-term ventilator care as he is not someone who would be able to come off of a ventilator very well in his current state.  So we will look at the CT scan and make decisions based on the findings as far as that is concerned.","consult - history and phy., ischemic cecum, metastatic disease, bilateral hydronephrosis, chronic alcohol abuse, acute renal failure, copd, anemia, gastric ulcer, pneumatosis coli, cecum, aspiration pneumonia, aspiration, ischemic, atrial, metastatic, hydronephrosis, fibrillation, pneumatosis, pneumonia, "
" Intractable epilepsy, here for video EEG.", Consult - History and Phy., Intractable Epilepsy ,"CHIEF COMPLAINT:,  Intractable epilepsy, here for video EEG.,HISTORY OF PRESENT ILLNESS: , The patient is a 9-year-old male who has history of global developmental delay and infantile spasms.  Ultimately, imaging study shows an MRI with absent genu of the corpus callosum and thinning of the splenium of the corpus callosum, showing a pattern of cerebral dysgenesis.  He has had severe global developmental delay, and is nonverbal.  He can follow objects with his eyes, but has no ability to interact with his environment to any great degree.  He has noted if any purposeful use of the hands.  He has abnormal movements constantly, which are more choreiform and dystonic.  He has spastic quadriparesis, which is variable at times.  The patient is unable to sit or stand, and receives all his nutrition via G-tube.,The patient began having seizures in infancy presenting as infantile spasms.  I began seeing him at 20 months of age.  At that point, he had undergone workup in Seattle, Washington and then was seeing Dr. X, child neurologist in Mexico, who started Vigabatrin for infantile spasms.  The patient had benefit from this medication, and was doing well at that time with regard to that seizure type.  He initially was on phenobarbital, which failed to give him benefit.  He continued on phenobarbital; however, for a long period time thereafter.  The patient then began having more tonic seizures after his episodic spasms had subsided, and failed several medication trials including valproic acid, Topamax, and Zonegran at least briefly.  Upon starting Lamictal, he began to have benefit and then actually had 1-year seizure freedom before having an isolated seizure or 2.  Over the next 6 months to a year, he only had few further seizures, and was doing well in a general sense.  It was more recently that he began having new seizure events that have not responded to higher doses of Lamictal up to 15 mg/kg/day.  These events manifest as tonic spells with eye deviation and posturing.  Mother reports flexion of the upper extremities, extension with lower extremities.  During that time, he is not able to cry or say any sounds.  These events last from seconds to minutes, and occur at least multiple times per week.  There are times where he has none for a few days and other times where he has multiple days in a row with events.  He has another event manifesting as flexion of the upper extremities and extension lower extremities where he turns red and cries throughout.  He may vomit after these episodes, then seems to calm down.  It is unclear whether this is a seizure or whether the patient is still responsive.,MEDICATIONS:,  The patient's medications include Lamictal for a total of 200 mg twice a day.  It is a 150 mg tablet and 25 mg tablets.  He is on Zonegran using 25 mg capsules 2 capsules twice daily, and baclofen 10 mg three times day.  He has other medications including the Xopenex and Atrovent.,REVIEW OF SYSTEMS: , At this time is negative any fevers, nausea, vomiting, diarrhea, abdominal complaints, rashes, arthritis, or arthralgias.  No respiratory or cardiovascular complaints.  He has no change in his skills at this point.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a slender male who is microcephalic.  He has EEG electrodes in place and is on the video EEG at that time.,HEENT:  His oropharynx shows no lesions.,NECK:  Supple without adenopathy.,CHEST:  Clear to auscultation.,CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs.,ABDOMEN:  Benign with G-tube in place.,EXTREMITIES:  Reveal no clubbing, cyanosis, or edema.,NEUROLOGICAL:  The patient is alert and has bilateral esotropia.  He is able to fix and follow objects briefly.  He is unable to reach for objects.  He exhibits constant choreiform movements when excited.  These are more prominent in the upper extremities and lower extremities.  He has some dystonic posture with flexion of the wrist and fingers bilaterally.  He also has plantar flexion at the ankles bilaterally.  His cranial nerves reveal that his pupils are equal, round, and reactive to light.  Extraocular movements are intact other than bilateral esotropia.  His face moves symmetrically.  Palate elevates in midline.  Hearing appears intact bilaterally.,Motor exam reveals dystonic and variable tone, overall there is mild in spasticity both upper and lower extremities as described above.  He has clonus at the ankles bilaterally, and some valgus contracture of the ankles.  His sensation is intact to light touch bilaterally.  Deep tendon reflexes are 2 to 3+ bilaterally.,IMPRESSION/PLAN: , This is a 9-year-old male with congenital brain malformation and intractable epilepsy.  He has microcephaly as well as dystonic cerebral palsy.  He had a re-emergence of seizures, which are difficult to classify, although some sound like tonic episodes and others are more concerning for non-epileptic phenomenon, such as discomfort.  He is admitted for video EEG to hopefully capture both of these episodes and further clarify the seizure type or types.  He will remain hospitalized for probably at least 48 hours to 72 hours.  He could be discharged sooner if multiple events are captured.  His medications, we will continue his current dose of Zonegran and Lamictal for now.  Both of these medications are very long acting, discontinuing them while in the hospital may simply result in severe seizures after discharge.","consult - history and phy., brain malformation, congenital, intractable epilepsy, global developmental delay, video eeg, seizures, intractable, eeg, "
 Iron deficiency anemia.  She underwent a bone marrow biopsy which showed a normal cellular marrow with trilineage hematopoiesis., Consult - History and Phy., Iron deficiency anemia ,"CHIEF COMPLAINT: , Iron deficiency anemia.,HISTORY OF PRESENT ILLNESS: , This is a very pleasant 19-year-old woman, who was recently hospitalized with iron deficiency anemia.  She was seen in consultation by Dr. X.  She underwent a bone marrow biopsy on 07/21/10, which showed a normal cellular marrow with trilineage hematopoiesis.  On 07/22/10, her hemoglobin was 6.5 and therefore she was transfused 2 units of packed red blood cells.  Her iron levels were 5 and her percent transferrin was 2.  There was no evidence of hemolysis.  Of note, she had a baby 5 months ago; however she does not describe excessive bleeding at the time of birth.  She currently has an IUD, so she is not menstruating.  She was discharged from the hospital on iron supplements.  She denies any fevers, chills, or night sweats.  No lymphadenopathy.  No nausea or vomiting.  No change in bowel or bladder habits.  She specifically denies melena or hematochezia.,CURRENT MEDICATIONS: , Iron supplements and Levaquin.,ALLERGIES: , Penicillin.,REVIEW OF SYSTEMS:,  As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:  ,She is status post birth of a baby girl 5 months ago.  She is G1, P1.  She is currently using an IUD for contraception.,SOCIAL HISTORY: , She has no tobacco use.  She has rare alcohol use.  No illicit drug use.,FAMILY HISTORY: , Her maternal grandmother had stomach cancer.  There is no history of hematologic malignancies.,PHYSICAL EXAM:,GEN:","consult - history and phy., trilineage hematopoiesis, cellular marrow, bone marrow biopsy, iron deficiency anemia, bone marrow, anemia, hemoglobin, lymphadenopathy, deficiency, tobacco, "
 Right iliopsoas hematoma with associated femoral neuropathy following cardiac catherization., Consult - History and Phy., Iliopsoas Hematoma - 2 ,"CC: ,RLE weakness.,HX: ,This 42y/o RHM was found 2/27/95 slumped over the steering wheel of the Fed Ex truck he was driving. He was cyanotic and pulseless according to witnesses. EMT evaluation revealed him to be in ventricular fibrillation and he was given epinephrine, lidocaine, bretylium and electrically defibrillated and intubated in the field. Upon arrival at a local ER his cardiac rhythm deteriorated and he required more than 9 counter shocks (defibrillation) at 360 joules per shock, epinephrine and lidocaine. This had no effect. He was then given intracardiac epinephrine and a subsequent electrical defibrillation placed him in atrial fibrillation. He was then taken emergently to cardiac catherization and was found to have normal coronary arteries. He was then admitted to an intensive care unit and required intraortic balloon pump pressure support via the right gorin. His blood pressure gradually improved and his balloon pump was discontinued on 5/5/95. Recovery was complicated by acute renal failure and liver failure. Initail CK=13,780, the CKMB fraction was normal at 0.8.,On 3/10/95, the patient experienced CP and underwent cardiac catherization. This time he was found to have a single occlusion in the distal LAD with association inferior hypokinesis. Subsequent CK=1381 and CKMB=5.4 (elevated). The patient was amnestic to the event and for 10 days following the event. He was transferred to UIHC for cardiac electrophysiology study.,MEDS: ,Nifedipine, ASA, Amiodarone, Capoten, Isordil, Tylenol, Darvocet prn, Reglan prn, Coumadin, KCL, SLNTG prn, CaCO3, Valium prn, Nubain prn.,PMH:, hypercholesterolemia.,FHX:, Father alive age 69 with h/o TIAs. Mother died age 62 and had CHF, A-Fib, CAD. Maternal Grandfather died of an MI and had h/o SVT. Maternal Grandmother had h/o SVT.,SHX: ,Married, 7 children, driver for Fed Ex. Denied tobacco/ETOH/illicit drug use.,EXAM: ,BP112/74 HR64 RR16 Afebrile.,MS: A&O to person, place and time. Euthymic with appropriate affect.,CN: unremarkable.,Motor: Hip flexion 3/5, Hip extension 5/5, Knee flexion5/5, Knee extension 2/5, Plantar flexion, extension, inversion and eversion 5/5. There was full strength thoughout BUE.,Sensory: decreased PP/Vib/LT/TEMP about anterior aspect of thigh and leg in a femoral nerve distribution.,Coord: poor and slowed HKS on right due to weakness.,Station: no drift or Romberg sign.,Gait: difficulty bearing weight on RLE.,Reflexes: 1+/1+ throughout BUE. 0/2 patellae. 2/2 archilles. Plantar responses were flexor, bilaterally.,COURSE:, MRI Pelvis, 3/28/95, revealed increased T1 weighted signal within the right iliopsoas suggestive of hematoma. An intra-osseous lipoma was incidentally notice in the right sacrum. Neuropsychologic assessment showed moderately compromised anterograde verbal memory, and temporal orientation and retrograde recall were below expectations. These findings were consistent with mesial temporal dysfunction secondary to anoxic injury and were mild in lieu of his history. He underwent implantation of a Medtronic internal cardiac difibrillator. His cardiac electrophysiology study found no inducible ventricular tachycardia or fibrillation. He suffered mild to moderate permanent RLE weakness, especially involving the quadriceps. His femoral nerve compression had been present to long to warrant decompression. EMG/NCV studies revealed severe axonal degeneration.","consult - history and phy., cardiac electrophysiology study, iliopsoas hematoma, rle weakness, balloon pump, femoral nerve, cardiac catherization, hematoma, iliopsoas, catherization, epinephrine, fibrillation, cardiac, "
" A 10-day-old Caucasian female with bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then.", Consult - History and Phy., Infantile Spasms ,"CHIEF COMPLAINT:,  Arm and leg jerking.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 10-day-old Caucasian female here for approximately 1 minute bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then.  Mom denies any apnea, perioral cyanosis, or color changes.  These movements are without any back arching.  They mainly occur during sleep, so mom is unaware of any eye rolling.  Mom is able to wake the patient up during this periods and stop the patient's extremity movements.,Otherwise, this patient has been active, breast-feeding well, although she falls asleep at the breast.  She is currently taking in 15 to 20 minutes of breast milk every 2 to 3 hours.  She is having increased diapers up to 8 wet and 6 to 7 dirty-yellow stools per day.,REVIEW OF SYSTEMS:,  Negative fever, negative fussiness, tracks with her eyes, some sneezing and hiccups.  This patient has developed some upper airway congestion in the past day.  She has not had any vomiting or diarrhea.  Per mom, she does not spit up, and mom is also unable to notice any relationship between these movements and feeds.  This patient has not had any rashes.  Mom was notified by the nurses at birth that her temperature may be low of approximately 97.5 degrees Fahrenheit.  Otherwise, the above history of present illness and other review of systems negative.,BIRTH/PAST MEDICAL HISTORY: , The patient was an 8 pound 11 ounce baby, ex-41-weeker born via vaginal delivery without vacuum assist or forceps.  There were no complications during pregnancy such as diabetes or hypertension.  Prenatal care started at approximately 3 weeks, and mom maintained all visits.  She also denies any smoking, alcohol, or drug use during the pregnancy.  Mom was GBS status positive, but denies any other infections such as urinary tract infections.  She did not have any fever during labor and received inadequate intrapartum antibiotics prophylaxis.  After delivery, this patient did not receive antibiotics secondary to ""borderline labs.""  She was jaundiced after birth and received photo treatments.  Her discharge bilirubin level was approximately 11.  Mom and child stayed in the hospital for approximately 3-1/2 days.,Mom denies any history of sexually transmitted disease in her or dad.  She specifically denies any blistering, herpetic genital lesions.  She does have a history though of human papillomavirus warts (vaginal), removed 20 years ago.,PAST SURGICAL HISTORY:,  Negative.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , None.,SOCIAL HISTORY: , At home live mom, dad, and 18-, 16-, 14-, 12-year-old brothers, and a 3-year-old sister.  All the residents at home are sick currently with cold, cough, runny nose, except for mom.  At home also live 2 dogs and 2 outside cats.  Mom denies any recent travel history, especially during the recent holidays and no smoke exposures.,FAMILY HISTORY:,  Dad is with a stepdaughter with seizures starting at 14 years old, on medications currently.  The patient's 16-year-old brother has incessant nonsustained ventricular tachycardia.  The maternal grandmother is notable for hypertension and diabetes.  There are no other children in the family who see a specialist or no child death less than 1 year of age.,PHYSICAL EXAMINATION:",
" Right shoulder impingement syndrome, right suprascapular neuropathy.", Consult - History and Phy., Impairment Rating ,"CHIEF COMPLAINT: , Right shoulder pain.,HISTORY: , The patient is a pleasant, 31-year-old, right-handed, white female who injured her shoulder while transferring a patient back on 01/01/02.  She formerly worked for Veteran's Home as a CNA.  She has had a long drawn out course of treatment for this shoulder.  She tried physical therapy without benefit and ultimately came to a subacromion decompression in November 2002.  She had ongoing pain and was evaluated by Dr. X who felt that she had a possible brachial plexopathy.  He also felt she had a right superficial radial neuritis and blocked this with resolution of her symptoms.  He then referred her to ABCD who did EMG testing, demonstrating a right suprascapular neuropathy although a C5 radiculopathy could not be ruled out.  MRI testing on the cervical spine was then done which was negative for disk herniation and she underwent suprascapular nerve decompression of the scapular notch on 12/18/03.  She finally went to an anterior axillary nerve block because of ongoing pain in the anterior shoulder again by Dr. X.  She comes to me for impairment rating.  She has no chronic health problems otherwise, fevers, chills, or general malaise.  She is not working.  She is right-hand dominant.  She denies any prior history of injury to her shoulder.,PAST MEDICAL HISTORY:,  Negative aside from above.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:  ,Please see above.,REVIEW OF SYSTEMS:,  Negative aside from above.,PHYSICAL EXAMINATION:  ,A pleasant, age appropriate woman, moderately overweight, in no apparent distress.  Normal gait and station, normal posture, normal strength, tone, sensation and deep tendon reflexes with the exception of 4+/5 strength in the supraspinatus musculature on the right.  She has decreased motion in the right shoulder as follows.  She has 160 degrees of flexion, 155 degrees of abduction, 35 degrees of extension, 25 degrees of adduction, 45 degrees of internal rotation and 90 degrees of external rotation.  She has a positive impingement sign on the right.,ASSESSMENT:,  Right shoulder impingement syndrome, right suprascapular neuropathy.,DISCUSSION: , With a reasonable degree of medical certainty, she is at maximum medical improvement and she does have an impairment based on AMA Guide to the Evaluation of Permanent Impairment, Fifth Edition.  The reason for this impairment is the incident of 01/01/02.  For her suprascapular neuropathy, she is rated as a grade IV motor deficit which I rate as a 13% motor deficit.  This is multiplied by a maximum upper extremity impairment for involvement of the suprascapular nerve of 16% which produces a 2% impairment of the upper extremity when the two values are multiplied together, 2% impairment of the upper extremity.  For her lack of motion in the shoulder she also has additional impairment on the right.  She has a 1% impairment of the upper extremity due to lack of shoulder flexion.  She has a 1% impairment of the upper extremity due to lack of shoulder abduction.  She has a 1% impairment of the upper extremity due to lack of shoulder adduction.  She has a 1% impairment of the upper extremity due to lack of shoulder extension.  There is no impairment for findings in shoulder external rotation.  She has a 3% impairment of the upper extremity due to lack of shoulder internal rotation.  Thus the impairment due to lack of motion in her shoulder is a 6% impairment of the upper extremity.  This combines with the 2% impairment of the upper extremity due to weakness in the suprascapular nerve root distribution to produce an 8% impairment of the upper extremity which in turn is a 5% impairment of the whole person based on the AMA Guide to the Evaluation of Permanent Impairment, Fifth Edition, stated with a reasonable degree of medical certainty.","consult - history and phy., ama guide, evaluation of permanent impairment, impairment rating, permanent impairment, suprascapular nerve, suprascapular neuropathy, injured, extremity, shoulder, impairment, neuropathy, suprascapular,"
" Chief complaint of chest pain, previously diagnosed with hyperthyroidism.", Consult - History and Phy., Hyperthyroidism Following Pregnancy ,"HISTORY: , Patient is a 21-year-old white woman who presented with a chief complaint of chest pain.  She had been previously diagnosed with hyperthyroidism.  Upon admission, she had complaints of constant left sided chest pain that radiated to her left arm.  She had been experiencing palpitations and tachycardia.  She had no diaphoresis, no nausea, vomiting, or dyspnea.,She had a significant TSH of 0.004 and a free T4 of 19.3.  Normal ranges for TSH and free T4 are 0.5-4.7 µIU/mL and 0.8-1.8 ng/dL, respectively.  Her symptoms started four months into her pregnancy as tremors, hot flashes, agitation, and emotional inconsistency.  She gained 16 pounds during her pregnancy and has lost 80 pounds afterwards.  She complained of sweating, but has experienced no diarrhea and no change in appetite.  She was given isosorbide mononitrate and IV steroids in the ER.,FAMILY HISTORY:,  Diabetes, Hypertension, Father had a Coronary Artery Bypass Graph (CABG) at age 34.,SOCIAL HISTORY:,  She had a baby five months ago.  She smokes a half pack a day.  She denies alcohol and drug use.,MEDICATIONS:,  Citalopram 10mg once daily for depression; low dose tramadol PRN pain.,PHYSICAL EXAMINATION: , Temperature 98.4; Pulse 123; Respiratory Rate 16; Blood Pressure 143/74.,HEENT:  She has exophthalmos and could not close her lids completely.,Cardiovascular:  tachycardia.,Neurologic:  She had mild hyperreflexiveness.,LAB:,  All labs within normal limits with the exception of Sodium 133, Creatinine 0.2, TSH 0.004, Free T4 19.3 EKG showed sinus tachycardia with a rate of 122.  Urine pregnancy test was negative.,HOSPITAL COURSE: , After admission, she was given propranolol at 40mg daily and continued on telemetry.  On the 2nd day of treatment, the patient still complained of chest pain.  EKG again showed tachycardia.  Propranolol was increased from 40mg daily to 60mg twice daily., A I-123 thyroid uptake scan demonstrated an increased thyroid uptake of 90% at 4 hours and 94% at 24 hours.  The normal range for 4-hour uptake is 5-15% and 15-25% for 24-hour uptake.  Endocrine consult recommended radioactive I-131 for treatment of Graves disease.,Two days later she received 15.5mCi of I-131.  She was to return home after the iodine treatment.  She was instructed to avoid contact with her baby for the next week and to cease breast feeding.,ASSESSMENT / PLAN:,1. Treatment of hyperthyroidism.  Patient underwent radioactive iodine 131 ablation therapy.,2. Management of cardiac symptoms stemming from hyperthyroidism.  Patient was discharged on propranolol 60mg, one tablet twice daily.,3. Monitor patient for complications of I-131 therapy such as hypothyroidism.  She should return to Endocrine Clinic in six weeks to have thyroid function tests performed.  Long-term follow-up includes thyroid function tests at 6-12 month intervals.,4. Prevention of pregnancy for one year post I-131 therapy.  Patient was instructed to use 2 forms of birth control and was discharged an oral contraceptive, taken one tablet daily.,5. Monitor ocular health.  Patient was given methylcellulose ophthalmic, one drop in each eye daily.  She should follow up in 6 weeks with the Ophthalmology clinic.,6. Management of depression.  Patient will be continued on citalopram 10 mg.","consult - history and phy., hyperthyroidism, diabetes, hypertension, hospital course, thyroid function, tachycardia, pregnancy, "
 Left Iliopsoas hematoma.  Gait difficulty., Consult - History and Phy., Iliopsoas Hematoma - 1 ,"CC: ,Gait difficulty.,HX: ,This 59 y/o RHF was admitted with complaint of gait difficulty. The evening prior to admission she noted sudden onset of LUE and LLE weakness. She felt she favored her right leg, but did not fall when walking. She denied any associated dysarthria, facial weakness, chest pain, SOB, visual change, HA, nausea or vomiting.,PMH:, tonsillectomy, adenoidectomy, skull fx 1954, HTN, HA.,MEDS: ,none on day of exam.,SHX: ,editorial assistant at newspaper, 40pk-yr Tobacco, no ETOH/Drugs.,FHX: ,noncontributory,ADMIT EXAM: ,P95 R20, T36.6, BP169/104,MS: A&O to person, place and time. Speech fluent and without dysarthria, Naming-comprehension-reading intact. Euthymic with appropriate affect.,CN: Pupils 4/4 decreasing to 2/2 on exposure to light, Fundi flat, VFFTC, EOMI, Face symmetric with intact sensation, Gag-shrug-corneal reflexes intact, Tongue ML with full ROM,Motor: Full strength throughout right side. Mildly decreased left grip and left extensor hallucis longus. Biceps/Triceps/Wrist flexors and extensor were full strength on left. However she demonstrated mild LUE pronator drift and had difficulty standing on her LLE despite full strength on bench testing of the LLE.,Sensory: No deficit to PP/T/Vib/Prop/ LT,Coord: decreased speed and magnitude of FNF, Finger tapping and HKS, on left side only.,Station: mild LUE upward drift.,Gait: tendency to drift toward the left. Difficulty standing on LLE.,Reflexes were symmetric, plantar responses were flexor bilaterally.,Gen exam unremarkable.,COURSE: ,Admit Labs: ESR, PT/PTT, GS, UA, EKG, and HCT were unremarkable. Hgb 13.9, Hct 41%, Plt 280k, WBC 5.5.,The patient was diagnosed with a probable lacunar stroke and entered into the TOAST study (Trial of ORG10172[a low molecular weight heparin] in Acute Stroke Treatment).,Carotid Duplex: 16-49%RICA and 0-15%LICA stenosis with anterograde vertebral artery flow, bilaterally. Transthoracic echocardiogram showed mild mitral regurgitation, mild tricuspid regurgitation and a left to right shunt. There was no evidence of blood clot.,Hospital course: 5 days after admission the patient began to complain of proximal LLE and left flank pain. On exam, she had weakness of the quadriceps and hip flexors of the LLE. Her pain increased with left hip flexion. In addition, she complained of paresthesias about the lateral aspect of the medial anterior left thigh; and upon on sensory testing, she had decreased PP/TEMP sensation in a left femoral nerve distribution. She denied any back/neck pain and the rest of her neurologic exam remained unchanged from admission.,Abdominal CT Scan, 2/4/96, revealed a large left retroperitoneal iliopsoas hematoma.,Hgb 8.9g/dl. She was transfused with 4 units of pRBCs. She underwent surgical decompression and evacuation of the hematoma via a posterior flank approach on 2/6/96. Her postoperative course was uncomplicated. She was discharged home on ASA.,At follow-up, on 2/23/96, she complained of left sided paresthesias (worse in the LLE than in the LUE) and feeling of ""swollen left foot."" These symptoms had developed approximately 1 month after her stroke. Her foot looked normal and her UE strength was 5/4+ proximally and distally, and LE strength 5/4+ proximally and 5/5- distally. She was ambulatory. There was no evidence of LUE upward drift. A somatosensory evoked potential study revealed an absent N20 and normal P14 potentials. This was suggestive of a lesion involving the right thalamus which might explain her paresthesia/dysesthesia as part of a Dejerine-Roussy syndrome.",
" Nonischemic cardiomyopathy, branch vessel coronary artery disease, congestive heart failure - NYHA Class III, history of nonsustained ventricular tachycardia, hypertension, and hepatitis C.", Consult - History and Phy., Hypertension & Cardiomyopathy ,"PROBLEMS LIST:,1.  Nonischemic cardiomyopathy.,2.  Branch vessel coronary artery disease.,3.  Congestive heart failure, NYHA Class III.,4.  History of nonsustained ventricular tachycardia.,5.  Hypertension.,6.  Hepatitis C.,INTERVAL HISTORY: , The patient was recently hospitalized for CHF exacerbation and was discharged with increased medications.  However, he did not fill his prescriptions and came back with persistent shortness of breath on exertion and on rest.  He has history of orthopnea and PND.  He has gained a few pounds of weight but denied to have any palpitation, presyncope, or syncope.,REVIEW OF SYSTEMS: , Positive for right upper quadrant pain.  He has occasional nausea, but no vomiting.  His appetite has decreased.  No joint pain, TIA, seizure or syncope.  Other review of systems is unremarkable.,I reviewed his past medical history, past surgical history, and family history.,SOCIAL HISTORY: , He has quit smoking, but unfortunately was positive for cocaine during last hospital stay in 01/08.,ALLERGIES: , He has no known drug allergies.,MEDICATIONS:,  I reviewed his medication list in the chart.  He states he is compliant, but he was not taking the revised dose of medications as per discharge orders and prescription.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse 91 per minute and regular, blood pressure 151/102 in the right arm and 152/104 in the left arm, weight 172 pounds, which is about 6 pounds more than last visit in 11/07.  HEENT:  Atraumatic and normocephalic.  No pallor, icterus or cyanosis.  NECK:  Supple.  Jugular venous distention 5 cm above the clavicle present.  No thyromegaly.  LUNGS:  Clear to auscultation.  No rales or rhonchi.  Pulse ox was 98% on room air.  CVS:  S1 and S2 present.  S3 and S4 present.  ABDOMEN:  Soft and nontender.  Liver is palpable 5 cm below the right subcostal margin.  EXTREMITIES:  No clubbing or cyanosis.  A 1+ edema present.,ASSESSMENT AND PLAN:,  The patient has hypertension, nonischemic cardiomyopathy, and branch vessel coronary artery disease.  Clinically, he is in NYHA Class III.  He has some volume overload and was not unfortunately taking Lasix as prescribed.  I have advised him to take Lasix 40 mg p.o. b.i.d.  I also increased the dose of hydralazine from 75 mg t.i.d. to 100 mg t.i.d.  I advised him to continue to take Toprol and lisinopril.  I have also added Aldactone 25 mg p.o. daily for survival advantage.  I reinforced the idea of not using cocaine.  He states that it was a mistake, may be somebody mixed in his drink, but he has not intentionally taken any cocaine.  I encouraged him to find a primary care provider.  He will come for a BMP check in one week.  I asked him to check his blood pressure and weight.  I discussed medication changes and gave him an updated list.  I have asked him to see a gastroenterologist for hepatitis C.  At this point, his Medicaid is pending.  He has no insurance and finds hard to find a primary care provider.  I will see him in one month.  He will have his fasting lipid profile, AST, and ALT checked in one week.","consult - history and phy., congestive heart failure, hypertension, cardiomyopathy, coronary artery disease, ventricular tachycardia, nonischemic cardiomyopathy, branch vessel, nyha class, nonischemic, tachycardia, orthopnea,"
" Local reaction secondary to insect sting.  Patient was stung by a bee on his right hand, left hand, and right knee at approximately noon today. ", Consult - History and Phy., Insect Sting ,"HISTORY OF PRESENT ILLNESS:,  Patient is a 76-year-old white male who presents with his wife stating that he was stung by a bee on his right hand, left hand, and right knee at approximately noon today.  He did not note any immediate reaction.  Since that time, he has noted some increasing redness and swelling to his left hand, but he denies any generalized symptoms such as itching, hives, or shortness of breath.  He denies any sensation of tongue swelling or difficulty swallowing.,The patient states he was stung approximately one month ago without any serious reaction.  He did windup taking Benadryl at that time.  He has not taken anything today for his symptoms, but he is on hydrochlorothiazide and metoprolol for hypertension as well as a baby aspirin each day.,ALLERGIES: , HE DOES HAVE MEDICATION INTOLERANCES TO SULFA DRUGS (HEADACHE), MORPHINE (NAUSEA AND VOMITING), AND TORADOL (ULCER).,SOCIAL HISTORY: , Patient is married and is a nonsmoker and lives with his wife, who is here with him.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS:  Temp and vital signs are all within normal limits.,GENERAL:  In general, the patient is an elderly white male who is sitting on the stretcher in no acute distress.,HEENT:  Head is normocephalic and atraumatic.  The face shows no edema.  The tongue is not swollen and the airway is widely patent.,NECK:  No stridor.,HEART:  Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS:  Clear without rales, rhonchi, or wheezes.,EXTREMITIES:  Upper extremities, there is some edema and erythema to the dorsum of the left hand in the region of the distal third to fifth metacarpals.  There was some slight edema of the fourth digit, on which he still is wearing his wedding band.  The right hand shows no reaction.  The right knee is not swollen either.,The left fourth digit was wrapped in a rubber tourniquet to express the edema and using some Surgilube, I was able to remove his wedding band without any difficulty.  Patient was given Claritin 10 mg orally for what appears to be a simple local reaction to an insect sting.  I did explain to him that his swelling and redness may progress over the next few days.,ASSESSMENT: , Local reaction secondary to insect sting.,PLAN: , The patient was reassured that this is not a serious reaction to an insect sting and he should not progress to such a reaction.  I did urge him to use Claritin 10 mg once daily until the redness and swelling has gone.  I did explain that the swelling may worsen over the next two to three days, it may produce a large local reaction, but that anti-histamines were still the mainstay of therapy for such a reaction.  If he is not improved in the next four days, follow up with his PCP for a re-exam.","consult - history and phy., stung by a bee, local reaction, insect sting, reaction, insect, bee, knee, edema, sting, swelling, hand"
" A 1-month-26-day-old with failure-to-thrive. was only at her birth weight, and was noted to have murmur.", Consult - History and Phy., Infant Not Gaining Weight ,"CHIEF COMPLAINT:,  Not gaining weight.,HISTORY OF PRESENT ILLNESS:,  The patient is a 1-month-26-day-old African-American female in her normal state of health until today when she was taken to her primary care physician's office to establish care and to follow up on her feeds.  The patient appeared to have failure-to-thrive. was only at her birth weight but when eating one may be possibly gaining 2 ounces every 3-4 hours, and was noted to have a murmur.  At this point, the Hospitalist Service was contacted for admission.  The patient was directly admitted to Children's Hospital Explore Ward.,In the explore ward, she was noted to be in mild respiratory distress and has some signs and symptoms of heart failure and had a prominent murmur, so an echo was done at bedside, which did show a moderately-sized patent ductus arteriosus and very small VSD and some mild signs and symptoms of congestive heart failure.  The patient was also seen by Dr. X of Cardiology Service and a plan was then obtained.,PAST MEDICAL/BIRTH HISTORY: , The patient was born at term repeat C-section to a 27-year-old G3, P2 African-American female.  Pregnancy was not complicated by hypertension, diabetes, drugs, alcohol abuse or smoking.  Birthweight was 7 pounds 4 ounces at Community Hospital.  The mother did have a repeat C-section.  There is no rupture of membranes or group B strep status.  The prenatal care began in the second month of pregnancy and was otherwise uncomplicated.  Mother denies any sexual transmitted diseases or other significant illness.  The patient was discharged home on day of life #3 without any complications.,ALLERGIES:,  No known drug allergies.,DIET: , The patient only takes Enfamil 20 calories, 1-3 ounces per history every 3-4 hours.,ELIMINATION: , The patient urinates 3-4 times a day and has a bowel movement 3-4 times a day.,FAMILY HISTORY/SOCIAL HISTORY: , The patient lives with the mother.  She has 2 older male siblings.  All were reported good health.  Family history is negative for any congenital heart disease, syndromes, hypertension, sickle cell anemia or sickle cell trait and no significant positive PPD contacts and history of second-hand smoke exposures.,REVIEW OF SYSTEMS:  ,GENERAL:  The patient has been reported to have normal activity and normal cry with no significant weight loss per mom's report, but conversely no significant weight gain.  Mother does not report that she sweats whenever she eats or has any episodes of cyanosis.  ,HEENT:  Denies any significant nasal congestion or cough.  ,RESPIRATORY:  Denies any difficulty breathing or wheezing.  ,CARDIOVASCULAR:  As per above.  GI:  No history of any persistent vomiting or diarrhea.  ,GU:  Denies any decreased urinary output.  ,MUSCULOSKELETAL:  Negative.  ,NEUROLOGICAL:  Negative.  ,SKIN:  Negative.,All other systems reviewed are negative.,PHYSICAL EXAMINATION:,GENERAL:  The patient is examined in her room, our next floor.  She is crying very vigorously, especially when I examined but she is consolable.,VITAL SIGNS:  Temperature currently is 96.3, heart rate 137, respirations 36, blood pressure 105/61 while crying.,HEENT:  Normocephalic.  The patient has a possible right temporoparietal bossing noted and slightly irregular shaped trapezoidal-shaped head.  The anterior fontanelle is soft and flat.  Pupils are equal, reactive to light and accommodation, but there is some mild hypertelorism.  There is also some mild posterior rotation of the ears.  Oropharynx, mucous membranes are pink and moist.  There is a slightly high arched palate.,NECK:  Significant for possible mild reddening of the neck.,LUNGS:  Significant for perihilar crackles.  Mild tachypnea is noted.  O2 saturations are currently 97% on room air.  There is mild intercostal retraction.,CARDIOVASCULAR:  Heart has regular rate and rhythm.  Peripheral pulses are only 1+.  Capillary refills less than 3-4 seconds.,EXTREMITIES:  Slightly cool to touch.  There is 2-3/6 systolic murmur along the left sternal border.  Does radiate to the axilla and to the back.,ABDOMEN:  Soft, slightly distended, but nontender.  The liver edge is palpable 4 cm below right costal margin.  The spleen tip is also palpable.,GU:  Normal female external genitalia is noted.,MUSCULOSKELETAL:  The patient has poor fat deposits in her extremities.  Strength is only 2/4.  She had normal number of fingers and toes.,SKIN:  Significant for slight mottling.  There are very poor subcutaneous fat deposits in her skin.,LABORATORY DATA: , The i-STAT only shows sodium 135, potassium on a heel stick was 6.3, hemoglobin and hematocrit are 14 and 41, and white count was 1.4.  CBG on i-STAT showed the pH of 7.34 with CO2 of 55, O2 sat of 51, CO2 of 29 with the base excess of 4.  Chest x-ray shows bilateral infiltrates and significant cardiomegaly consistent with congenital heart disease and mild congestive heart failure.,ASSESSMENT: , This is an almost 2-month-old presents with:,1.  Failure-to-thrive.,2.  Significant murmur and patent ductus arteriosus.,3.  Congestive heart failure.,PLAN:  ,At present, we are going to admit and monitor closely tonight.  We will get a chest x-ray and start Lasix at 1 mg/kg twice daily.  We will also get a CBC and check a blood culture and further workup as necessary.",
" This is a 69-year-old white woman with Huntington disease, who presents with the third suicide attempt in the past two months. ", Consult - History and Phy., Huntington's Disease - Consult ,"CHIEF COMPLAINT: , ""A lot has been thrown at me."",The patient is interviewed with husband in room.,HISTORY OF PRESENT ILLNESS: , This is a 69-year-old Caucasian woman with a history of Huntington disease, who presented to Hospital four days ago after an overdose of about 30 Haldol tablets 5 mg each and Tylenol tablet 325 mg each, 40 tablets.  She has been on the medical floor for monitoring and is medically stable and was transferred to the psychiatric floor today.  The patient states she had been thinking about suicide for a couple of weeks.  Felt that her Huntington disease had worsened and she wanted to spare her family and husband from trouble.  Reports she has been not socializing with her family because of her worsening depression.  Husband notes that on Monday after speaking to Dr. X, they had been advised to alternate the patient's Pamelor (nortriptyline) to every other day because the patient was reporting dry mouth.  They did as they have instructed and husband feels this may have had some factor on her worsening depression.  The patient decided to ingest the pills when her husband went to work on Friday.  She thought Friday would be a good day because there would be less medical people working so her chances of receiving medical care would be lessened.  Her husband left around 7 in the morning and returned around 11 and found her sleeping.  About 30 minutes after his arrival, he found the empty bottles and woke up the patient to bring her to the hospital.,She says she wishes she would have died, but is happy she is alive and is currently not suicidal because she notes her sons may be have to be tested for the Huntington gene.  She does not clearly explain how this has made her suicidality subside.,This is the third suicide attempt in the last two months for this patient.  About two months ago, the patient took an overdose of Tylenol and some other medication, which the husband and the patient are not able to recall.  She was taken to Southwest Memorial Hermann Hospital.  A few weeks ago, the patient tried to shoot herself and the gun was fired and there is a blow-hole in the floor.  Husband locked the gun after that and she was taken to Bellaire Hospital.  The patient has had three psychiatric admissions in the past two months, two to Southwest Memorial and one to Bellaire Hospital for 10 days.  She sees Dr. X once or twice weekly.  He started seeing her after her first suicide attempt.,The patient's husband and the patient state that until March 2009, the patient was independent, was driving herself around and was socially active.  Since then she has had worsening of her Huntington symptoms including short-term memory loss.  At present, the patient could not operate the microwave or operate her cell phone and her husband says that she is progressively more withdrawn, complains about anxiety, and complains about shortness of breath.  The patient notes that she has had depressive symptoms of quitting social life, the patient being withdrawn for the past few months and excessive worry about her Huntington disease.,The patient's mother passed away 25 years ago from Huntington's.  Her grandmother passed away 50 years ago and two brothers also passed away of Huntington's.  The patient has told her husband that she does not want to go that way.  The patient denies auditory or visual hallucinations, denies paranoid ideation.  The husband and the patient deny any history of manic or hypomanic symptoms in the past.,PAST PSYCHIATRIC HISTORY: , As per the HPI, this is her third suicide attempt in the last two months and started seeing Dr. X.  She has a remote history of being on Lexapro for depression.,MEDICATIONS: , Her medications on admission, alprazolam 0.5 mg p.o. b.i.d., Artane 2 mg p.o. b.i.d., Haldol 2.5 mg p.o. t.i.d., Norvasc 10 mg p.o. daily, nortriptyline 50 mg p.o. daily.  Husband has stated that the patient's chorea becomes better when she takes Haldol.  Alprazolam helps her with anxiety symptoms.,PAST MEDICAL HISTORY: , Huntington disease, symptoms of dementia and hypertension.  She has an upcoming appointment with the Neurologist.  Currently, does have a primary care physician and _______ having an outpatient psychiatrist, Dr. X, and her current Neurologist, Dr. Y.,ALLERGIES: , CODEINE AND KEFLEX.,FAMILY MEDICAL HISTORY:  ,Strong family history for Huntington disease as per the HPI.  Mother and grandmother died of Huntington disease.  Two young brothers also had Huntington disease.,FAMILY PSYCHIATRIC HISTORY: , The patient denies history of depression, bipolar, schizophrenia, or suicide attempts.,SOCIAL HISTORY:  ,The patient lives with her husband of 48 years.  She used to be employed as a registered nurse.  Her husband states that she does have a pattern of self-prescribing for minor illness, but does not think that she has ever taken muscle relaxants or sedative medications without prescriptions.  She rarely drinks socially.  She denies any illicit substance usage.  Her husband reportedly gives her medication daily.  Has been proactive in terms of seeking mental health care and medical care.  The patient and husband report that from March 2009, she has been relatively independent, more socially active.,MENTAL STATUS EXAM:  ,This is an elderly woman appearing stated age.  Alert and oriented x4 with poor eye contact.  Appears depressed, has psychomotor retardation, and some mild involuntary movements around her lips.  She is cooperative.  Her speech is of low volume and slow rate and rhythm.  Her mood is sad.  Her affect is constricted.  Her thought process is logical and goal-directed.  Her thought content is negative for current suicidal ideation.  No homicidal ideation.  No auditory or visual hallucinations.  No command auditory hallucinations.  No paranoia.  Insight and judgment are fair and intact.,LABORATORY DATA:,  A CT of the brain without contrast, without any definite evidence of acute intracranial abnormality.  U-tox positive for amphetamines and tricyclic antidepressants.  Acetaminophen level 206.7, alcohol level 0.  The patient had a leukocytosis with white blood cell of 15.51, initially TSH 1.67, T4 10.4.,ASSESSMENT: , This is a 69-year-old white woman with Huntington disease, who presents with the third suicide attempt in the past two months.  She took 30 tablets of Haldol and 40 tablets of Tylenol.  At present, the patient is without suicidal ideation.  She reports that her worsening depression has coincided with her worsening Huntington disease.  She is more hopeful today, feels that she may be able to get help with her depression.,The patient was admitted four days ago to the medical floor and has subsequently been stabilized.  Her liver function tests are within normal limits.,AXIS I:  Major depressive disorder due to Huntington disease, severe.  Cognitive disorder, NOS.,AXIS II:  Deferred.,AXIS III:  Hypertension, Huntington disease, status post overdose.,AXIS IV:  Chronic medical illness.,AXIS V:  30.,PLAN,1.  Safety.  The patient would be admitted on a voluntary basis to Main-7 North.  She will be placed on every 15-minute checks with suicidal precautions.,2.  Primary psychiatric issues/medical issues.  The patient will be restarted as per written by the consult service for Prilosec 200 mg p.o. daily, nortriptyline 50 mg p.o. nightly, Haldol 2 mg p.o. q.8h., Artane 2 mg p.o. daily, Xanax 0.5 mg p.o. q.12h., fexofenadine 180 mg p.o. daily, Flonase 50 mcg two sprays b.i.d., amlodipine 10 mg p.o. daily, lorazepam 0.5 mg p.o. q.6h. p.r.n. anxiety and agitation.,3.  Substance abuse.  No acute concern for alcohol or benzo withdrawal.,4.  Psychosocial.  Team will update and involve family as necessary.,DISPOSITION: , The patient will be admitted for evaluation, observation, treatment.  She will participate in the milieu therapy with daily rounds, occupational therapy, and group therapy.  We will place occupational therapy consult and social work consults.",
 Probable Coumadin hypersensitivity., Consult - History and Phy., Hypersensitivity to Coumadin ,"PROBLEM:,  Probable Coumadin hypersensitivity.,HISTORY OF PRESENT ILLNESS:,  The patient is an 82-year-old Caucasian female admitted to the Hospital for elective total left knee arthroplasty.  At the time of admission, the patient has a normal prothrombin time and INR of 13.4 seconds and 1.09 respectively and postoperatively, she was placed on Coumadin which is the usual orthopedic surgery procedure for reducing the risk of postoperative thromboembolic activity.  However, the patient's prothrombin time and INR rapidly rose to supratherapeutic levels.  Even though Coumadin was discontinued on 01/21/09, the patient's prothrombin time and INR has continued to rise.  Her prothrombin time is now 83.3 seconds with an INR of 6.52.  Hematology/Oncology consult was requested for recommendation regarding further evaluation and management.,SOCIAL HISTORY: , The patient is originally from Maine.  She has lived in Arizona for 4 years.  She has had 2 children; however, only one is living.  She had one child died from complications of ulcerative colitis.  She has been predominantly a homemaker during her life, but has done some domestic cleaning work in the past.,CHILDHOOD HISTORY: , Negative for rheumatic fever.  The patient has usual childhood illnesses.,ALLERGIES:  ,No known drug allergies.,FAMILY HISTORY: , The patient's mother died from gastric cancer.  She had a brother who died from mesothelioma.  He did have a positive asbestos exposure working in the shipyards.  The patient's father died from motor vehicle accident.  She had a sister who succumbed to pneumonia as a complication to Alzheimer disease.,HABITS: , No use of ethanol, tobacco, illicit, or recreational substances.,ADULT MEDICAL PROBLEMS: , The patient has a history of diabetes mellitus, hypertension, and hypercholesterolemia, which is all consistent with the metabolic syndrome X.  In addition, the patient's husband, who is present, knows that she has early dementia and has problems with memory and difficulty in processing new information.,SURGERIES: , The patient's only surgery is the aforementioned left knee arthroplasty and bilateral cataract surgery, otherwise negative.,MEDICATIONS: , The patient's medications on admission include:,1.  Fosamax.,2.  TriCor.,3.  Gabapentin.,4.  Hydrochlorothiazide.,5.  Labetalol.,6.  Benicar.,7.  Crestor.,8.  Detrol.,REVIEW OF SYSTEMS: , Unable to obtain review of systems as the patient was given a dose of morphine for postoperative pain and she is a bit obtunded at this time.  She is arousable, but not particularly conversant.,OBSERVATIONS:,GENERAL:  The patient is a drowsy, but arousable, nonconversant, elderly Caucasian female.,HEENT:  Pupils were equal, round, and reactive to light and accommodation.  Extraocular muscles are grossly intact.  Oropharynx benign.,NECK:  Supple.  Full range of motion without bruits or thyromegaly.,LUNGS:  Clear to auscultation and percussion.,BACK:  Without spine or CVA tenderness.,HEART:  Regular rate and rhythm without murmurs, rubs, thrills, or heaves.,ABDOMEN:  Soft and nontender.  Positive bowel sounds without mass or visceromegaly.,LYMPHATIC:  No appreciable adenopathy.,EXTREMITIES:  The patient has some postoperative fullness involving her left knee.  She has a dressing over the left knee.,SKIN:  Without lesions.,NEURO:  Unable to assess in light of post morphine obtunded state.,ASSESSMENT: , Hypersensitivity to Coumadin.,PLAN: , Gave the patient vitamin K at this time.  Literature suggested oral vitamin K is actually more efficacious than parenteral.  However, in light of the fact that the patient is obtunded and is not taking anything right now in the way of oral food or fluids, we will give this to her in an IM fashion.  Repeat prothrombin time and INR in a.m.  Once she has come down to a more therapeutic range, I would initiate low-molecular weight heparin in the form of Fragmin one time a day or Lovenox on a b.i.d. schedule for 4 to 6 weeks postoperatively.",
 Status post left hip fracture and hemiarthroplasty.   Rehab transfer as soon as medically cleared., Consult - History and Phy., Hip Fracture - Rehab Consult ,"ADMISSION DIAGNOSIS: , Left hip fracture.,CHIEF COMPLAINT: , Diminished function, secondary to the above.,HISTORY: , This pleasant 70-year-old gentleman had a ground-level fall at home on 05/05/03 and was brought into ABCD Medical Center, evaluated by Dr. X and brought in for orthopedic stay.  He had left hip fracture identified on x-rays at that time.  Pain and inability to ambulate brought him in.  He was evaluated and then underwent medical consultation as well, where they found a history of resolving pneumonia, hypertension, chronic obstructive pulmonary disease, congestive heart failure, hypothyroidism, depression, anxiety, seizure and chronic renal failure, as well as anemia.  His medical issues are under good control.  The patient underwent left femoral neck fixation with hemiarthroplasty on that left side on 05/06/03.  The patient has had some medical issues including respiratory insufficiency, perioperative anemia, pneumonia, and hypertension.  Cardiology has followed closely, and the patient has responded well to medical treatment, as well as physical therapy and occupational therapy.  He is gradually tolerating more activities with less difficulties, made good progress and tolerated more consistent and more prolonged interventions.,PAST MEDICAL HISTORY: , Positive for congestive heart failure, chronic renal insufficiency, azotemia, hyperglycemia, coronary artery disease, history of paroxysmal atrial fibrillation.  Remote history of subdural hematoma precluding the use of Coumadin.  History of depression, panic attacks on Doxepin.  Perioperative anemia.  Swallowing difficulties.,ALLERGIES:,  Zyloprim, penicillin, Vioxx, NSAIDs.,CURRENT MEDICATIONS,1.  Heparin.,2.  Albuterol inhaler.,3.  Combivent.,4.  Aldactone.,5.  Doxepin.,6.  Xanax.,7.  Aspirin.,8.  Amiodarone.,9.  Tegretol.,10.  Synthroid.,11.  Colace.,SOCIAL HISTORY: , Lives in a 1-story home with 1 step down; wife is there.  Speech and language pathology following with current swallowing dysfunction.  He is minimum assist for activities of daily living, bed mobility.,REVIEW OF SYSTEMS:,  Currently negative for headache, nausea and vomiting, fevers, chills or shortness of breath or chest pain.,PHYSICAL EXAMINATION,HEENT:  Oropharynx clear.,CV:  Regular rate and rhythm without murmurs, rubs or gallops.,LUNGS:  Clear to auscultation bilaterally.,ABDOMEN:  Nontender, nondistended.  Bowel sounds positive.,EXTREMITIES:  Without clubbing, cyanosis, or edema.,NEUROLOGIC:  There are no focal motor or sensory losses to the lower extremities.  Bulk and tone normal in the lower extremities.  Wound site has healed well with staples out.,IMPRESSION ,1.  Status post left hip fracture and hemiarthroplasty.,2.  History of panic attack, anxiety, depression.,3.  Myocardial infarction with stent placement.,4.  Hypertension.,5.  Hypothyroidism.,6.  Subdural hematoma.,7.  Seizures.,8.  History of chronic obstructive pulmonary disease.  Recent respiratory insufficiency.,9.  Renal insufficiency.,10.  Recent pneumonia.,11.  O2 requiring.,12.  Perioperative anemia.,PLAN: , Rehab transfer as soon as medically cleared.",
 Likely molluscum contagiosum (genital warts) caused by HPV.  It is not clear where this came from but it is most likely sexually transmitted., Consult - History and Phy., HPV Consult ,"He has no voiding complaints and no history of sexually transmitted diseases.,PAST MEDICAL HISTORY: , None.,PAST SURGICAL HISTORY: , Back surgery with a fusion of L5-S1.,MEDICATIONS: , He does take occasional Percocet for his back discomfort.,ALLERGIES:,  HE HAS NO ALLERGIES.,SOCIAL HISTORY:,  He is a smoker.  He takes rare alcohol.  His employment is that he does dynamite work and actually putting in the dynamite in large holes for destroying ground to that pipeline can be laid.  He travels to anywhere for his work.  He is married with one son.,FAMILY HISTORY: , Negative for prostate cancer, kidney cancer, bladder cancer, enlarged prostate or kidney disease.,REVIEW OF SYSTEMS:,  Negative for tremors, headaches, dizzy spells, numbness, tingling, feeling hot or cold, tired or sluggishness, abdominal pain, nausea or vomiting, indigestion, heartburn, fevers, chills, weight loss, wheezing, frequent cough, shortness of breath, chest pain, varicose veins, high blood pressure, skin rash, joint pain, ear infections, sore throat, sinus problems, hay fever, blood clotting problems, depressive affect or eye problems.,PHYSICAL EXAMINATION,GENERAL:  The patient is afebrile.  His vital signs are stable.  He is 177 pounds, 5 feet, 8 inches.  Blood pressure 144/66.  He is healthy appearing.  He is alert and oriented x 3.,HEART:  Regular rate and rhythm.,LUNGS:  Clear to auscultation.,ABDOMEN:  Soft and nontender.  His penis is circumcised.  He has a pedunculated cauliflower-like lesion on the dorsum of the penis at approximately 12 o'clock.  It is very obvious and apparent.  He also has a mildly raised brown lesion that the patient states has been there ever since he can remember and has not changed in size or caliber.  His testicles are descended bilaterally.  There are no masses.,ASSESSMENT AND PLAN: , This is likely molluscum contagiosum (genital warts) caused by HPV.  I did state to the patient that this is likely a viral infection that could have had a long incubation period.  It is not clear where this came from but it is most likely sexually transmitted.  He is instructed that he should use protected sex from this point on in order to try and limit the transmission.  Regarding the actual lesion itself, I did mention that we could apply a cream of Condylox, which could take up to a month to work.  I also offered him C02 laser therapy for the genital warts, which is an outpatient procedure.  The patient is very interested in something quick and effective such as a CO2 laser procedure.  I did state that the recurrence rate is significant and somewhere as high as 20% despite enucleating these lesions.  The patient understood this and still wished to proceed.  There is minimal risk otherwise except for those inherent in laser injury and accidental injury.  The patient understood and wished to proceed.","consult - history and phy., sexually transmitted, molluscum contagiosum, genital warts, hpv,"
" An 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation.", Consult - History and Phy., Hypertension - Consult ,"HISTORY OF PRESENT ILLNESS: , The patient is an 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation although not seen recently and I was asked to perform cardiology consultation for her because there was concern for atrial fibrillation after a fall.  Basically the patient states that yesterday she fell and she is not certain about the circumstances, on her driveway, and on her left side hit a rock.  When she came to the emergency room, she was found to have a rapid atrial tachyarrhythmia, and was put on Cardizem with reportedly heart rate in the 50s, so that was stopped.  Review of EKGs from that time shows what appears to be multifocal atrial tachycardia with followup EKG showing wandering atrial pacemaker.  An ECG this morning showing normal sinus rhythm with frequent APCs.  Her potassium at that time was 3.1.  She does recall having palpitations because of the pain after the fall, but she states she is not having them since and has not had them prior.  She denies any chest pain nor shortness of breath prior to or since the fall.  She states clearly she can walk and she would be able to climb 2 flights of stairs without problems.,PAST CARDIAC HISTORY: , She is followed by Dr. X in our office and has a history of severe tricuspid regurgitation with mild elevation and PA pressure.  On 05/12/08, preserved left and right ventricular systolic function, aortic sclerosis with apparent mild aortic stenosis, and bi-atrial enlargement.  She has previously had a Persantine Myoview nuclear rest-stress test scan completed at ABCD Medical Center in 07/06 that was negative.  She has had significant mitral valve regurgitation in the past being moderate, but on the most recent echocardiogram on 05/12/08, that was not felt to be significant.  She has a history of hypertension and EKGs in our office show normal sinus rhythm with frequent APCs versus wandering atrial pacemaker.  She does have a history of significant hypertension in the past.  She has had dizzy spells and denies clearly any true syncope.  She has had bradycardia in the past from beta-blocker therapy.,MEDICATIONS ON ADMISSION:,1.  Multivitamin p.o. daily.,2.  Aspirin 325 mg once a day.,3.  Lisinopril 40 mg once a day.,4.  Felodipine 10 mg once a day.,5.  Klor-Con 20 mEq p.o. b.i.d.,6.  Omeprazole 20 mg p.o. daily presumably for GERD.,7.  MiraLax 17 g p.o. daily.,8.  Lasix 20 mg p.o. daily.,ALLERGIES: , PENICILLIN.  IT IS LISTED THAT TOPROL HAS CAUSED SHORTNESS OF BREATH IN HER OFFICE CHART AND I BELIEVE SHE HAS HAD SIGNIFICANT BRADYCARDIA WITH THAT IN THE PAST.,FAMILY HISTORY:,  She states her brother died of an MI suddenly in his 50s.,SOCIAL HISTORY: , She does not smoke cigarettes, abuse alcohol, nor use any illicit drugs.  She is retired from Morse Chain and delivering newspapers.  She is widowed.  She lives alone but has family members who live either on her property or adjacent to it.,REVIEW OF SYSTEMS: , She denies a history of stroke, cancer, vomiting of blood, coughing up blood, bright red blood per rectum, bleeding, stomach ulcers.  She does not recall renal calculi, nor cholelithiasis, denies asthma, emphysema, pneumonia, tuberculosis, sleep apnea, home oxygen use.  She does note occasional peripheral edema.  She is not aware of prior history of MI.  She denies diabetes.  She does have a history of GERD.  She notes feeling depressed at times because of living alone.  She denies rheumatologic conditions including psoriasis or lupus.  Remainder of review of systems is negative times 15 except as described above.,PHYSICAL EXAM:  ,Height 5 feet 0 inches, weight 123 pounds, temperature 99.2 degrees Fahrenheit, blood pressure has ranged from 160/87 with pulses recorded at being 144, and currently ranges 101/53 to 147/71, pulse 64, respiratory rate 20, O2 saturation 97%.  On general exam, she is a pleasant elderly woman who is hard of hearing, but is alert and interactive.  HEENT:  Shows cranium is  normocephalic and atraumatic.  She has moist mucosal membranes.  Neck veins were not distended.  There are no carotid bruits.  Lungs:  Clear to auscultation anteriorly without wheezes.  She is relatively immobile because of her left hip fracture.  Cardiac Exam:  S1, S2, regular rate, frequent ectopic beats, 2/6 systolic ejection murmur, preserved aortic component of the second heart sound.  There is also a soft holosystolic murmur heard.  There is no rub or gallop.  PMI is nondisplaced.  Abdomen is soft and nondistended.  Bowel sounds present.  Extremities without significant clubbing, cyanosis, and there is trivial to 1+ peripheral edema.  Pulses appear grossly intact.  Affect is appropriate.  Visible skin warm and perfused.  She is not able to move because of left hip fracture easily in bed.,DIAGNOSTIC STUDIES/LAB DATA: , Pertinent labs include chest x-ray with radiology report pending but shows only a calcified aortic knob.  No clear pulmonary vascular congestion.  Sodium 140, potassium 3.7, it was 3.1 on admission, chloride 106, bicarbonate 27, BUN 17, creatinine 0.9, glucose 150, magnesium was 2 on 07/13/06.  Troponin was 0.03 followed by 0.18.  INR is 0.93, white blood cell count 10.2, hematocrit 36, platelet count 115,000.,EKGs are reviewed.  Initial EKG done on 08/19/08 at 1832 shows MAT, heart rate of 104 beats per minute, no ischemic changes.  She had a followup EKG done at 20:37 on 08/19/08, which shows wandering atrial pacemaker and some lateral T-wave changes, not significantly changed from prior.  Followup EKG done this morning shows normal sinus rhythm with frequent APCs.,IMPRESSION:  ,She is an 84-year-old female with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension and mild aortic stenosis admitted after a fall with left hip fracture and she will require surgery.  Telemetry now reviewed, shows predominantly normal sinus rhythm with frequent APCs _____ earlier yesterday evening showed burst of multifocal atrial tachycardia and I suspect that was exacerbated by prior hypokalemia, which has been corrected.  There has been no atrial fibrillation documented.  I do not feel these troponins are significant given the stress or fall in prior multifocal atrial tachycardia with increased rate especially in the absence of chest pain or shortness of breath.  She actually describes feeling good exercise capacity prior to this fall.  Given favorable risk to benefit ratio for needed left hip surgery, I feel she may proceed with needed left hip surgery from a cardiac standpoint with continued verapamil, which has been started, which should help control the multifocal atrial tachycardia, which she had and would watch for heart rate with that.  Continued optimization of electrolytes.  The patient cannot take beta-blockers as previously Toprol reportedly caused shortness of breath, although, there was some report that it caused bradycardia so we would watch her heart rate on the verapamil.  The patient is aware of the cardiac risks, certainly it is moderate, and wishes to proceed with needed surgery.  I do not feel any further cardiac evaluation is needed at this time and the patient may followup with Dr. X after discharge.  Regarding her mild thrombocytopenia, I would defer that to hospitalist and continue proton pump inhibitors for history of gastroesophageal reflux disease, management of left hip fracture as per orthopedist.","consult - history and phy., hypokalemia, shortness of breath, atrial tachycardia, sinus rhythm, hip fracture, atrial, tachycardia, rhythm, apcs, cardiac, regurgitation, aortic, hypertension, pulmonary, "
 Non-healing surgical wound to the left posterior thigh. Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg., Consult - History and Phy., Hypergranulation - Consult ,"CHIEF COMPLAINT:,  Non-healing surgical wound to the left posterior thigh.,HISTORY OF PRESENT ILLNESS: , This is a 49-year-old white male who sustained a traumatic injury to his left posterior thighthis past year while in ABCD.  He sustained an injury from the patellar from a boat while in the water.  He was air lifted actually up to XYZ Hospital and underwent extensive surgery.  He still has an external fixation on it for the healing fractures in the leg and has undergone grafting and full thickness skin grafting closure to a large defect in his left posterior thigh, which is nearly healed right in the gluteal fold on that left area.  In several areas right along the graft site and low in the leg, the patient has several areas of hypergranulation tissue.  He has some drainage from these areas.  There are no signs and symptoms of infection.  He is referred to us to help him get those areas under control.,PAST MEDICAL HISTORY:,  Essentially negative other than he has had C. difficile in the recent past.,ALLERGIES:,  None.,MEDICATIONS: , Include Cipro and Flagyl.,PAST SURGICAL HISTORY: , Significant for his trauma surgery noted above.,FAMILY HISTORY: , His maternal grandmother had pancreatic cancer.  Father had prostate cancer.  There is heart disease in the father and diabetes in the father.,SOCIAL HISTORY:,  He is a non-cigarette smoker and non-ETOH user.  He is divorced.  He has three children.  He has an attorney.,REVIEW OF SYSTEMS:,CARDIAC:  He denies any chest pain or shortness of breath.,GI:  As noted above.,GU:  As noted above.,ENDOCRINE:  He denies any bleeding disorders.,PHYSICAL EXAMINATION:,GENERAL:  He presents as a well-developed, well-nourished 49-year-old white male who appears to be in no significant distress.,HEENT:  Unremarkable.,NECK:  Supple.  There is no mass, adenopathy, or bruit.,CHEST:  Normal excursion.,LUNGS:  Clear to auscultation and percussion.,COR:  Regular.  There is no S3, S4, or gallop.  There is no murmur.,ABDOMEN:  Soft.  It is nontender.  There is no mass or organomegaly.,GU:  Unremarkable.,RECTAL:  Deferred.,EXTREMITIES:  His right lower extremity is unremarkable.  Peripheral pulse is good.  His left lower extremity is significant for the split thickness skin graft closure of a large defect in the posterior thigh, which is nearly healed.  The open areas that are noted above __________ hypergranulation tissue both on his gluteal folds on the left side.  There is one small area right essentially within the graft site, and there is one small area down lower on the calf area.  The patient has an external fixation on that comes out laterally on his left thigh.  Those pin sites look clean.,NEUROLOGIC:  Without focal deficits.  The patient is alert and oriented.,IMPRESSION: , Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg.,PLAN:,  Plan would be for chemical cauterization of these areas.  Series of treatment with chemical cauterization till these are closed.",
 Patient comes in for initial evaluation of a hyperesthesia on his right abdomen., Consult - History and Phy., Hyperesthesia ,"SUBJECTIVE:,  This 49-year-old white male, established patient in dermatology, last seen in the office on 08/02/2002, comes in today for initial evaluation of a hyperesthesia on his right abdomen, then on his left abdomen, then on his left medial thigh.  It cleared for awhile.  This has been an intermittent problem.  Now it is back again on his right lower abdomen.  At first, it was thought that he may have early zoster.  This started six weeks before the holidays and is still going on, more so in the past eight days on his abdomen and right hip area.  He has had no treatment on this; there are no skin changes at all.  The patient bathes everyday but tries to use little soap.  The patient is married.  He works as an airplane mechanic.,FAMILY, SOCIAL, AND ALLERGY HISTORY:,  The patient has sinus and CVA.  He is a nonsmoker.  No known drug allergies.,CURRENT MEDICATIONS:,  Lipitor, aspirin, folic acid.,PHYSICAL EXAMINATION:,  The patient is well developed, appears stated age.  Overall health is good.  He does have psoriasis with some psoriatic arthritis, and his skin looks normal today.  On his trunk, he does have the hyperesthesia.  As you touch him, he winces.,IMPRESSION:,  Hyperesthesia, question etiology.,TREATMENT:,1.  Discussed condition and treatment with the patient.,2.  Discontinue hot soapy water to these areas.,3.  Increase moisturizing cream and lotion.,4.  I referred him to Dr. ABC or Dr. XYZ for neurology evaluation.  We did not see anything on skin today.  Return p.r.n. flare.","consult - history and phy., dermatology, abdomen, hyperesthesia, soapy water, moisturizing cream, initial evaluation"
" Caudate Nuclei atrophy, bilaterally, in patient with Huntington Disease.", Consult - History and Phy., Huntington's Disease ,"CC:, Slowing of motor skills and cognitive function.,HX: ,This 42 y/o LHM presented on 3/16/93 with gradually progressive deterioration of motor and cognitive skills over 3 years. He had difficulty holding a job. His most recent employment ended 3 years ago as he was unable to learn the correct protocols for the maintenance of a large conveyer belt. Prior to that, he was unable to hold a job in the mortgage department of a bank as could not draw and figure property assessments. For 6 months prior to presentation, he and his wife noted (his) increasingly slurred speech and slowed motor skills (i.e. dressing himself and house chores). His walk became slower and he had difficulty with balance. He became anhedonic and disinterested in social activities, and had difficulty sleeping for frequent waking and restlessness. His wife noticed ""fidgety movements"" of his hand and feet.,He was placed on trials of Sertraline and Fluoxetine for depression 6 months prior to presentation by his local physician. These interventions did not appear to improve his mood and affect.,MEDS:, Fluoxetine.,PMH: ,1)Right knee arthroscopic surgery 3 yrs ago. 2)Vasectomy.,FHX:, Mother died age 60 of complications of Huntington Disease (dx at UIHC). MGM and two MA's also died of Huntington Disease. His 38 y/o sister has attempted suicide twice.,He and his wife have 2 adopted children.,SHX: ,unemployed. 2 years of college education. Married 22 years.,ROS: ,No history of Dopaminergic or Antipsychotic medication use.,EXAM:, Vital signs normal.,MS: A&O to person, place, and time. Dysarthric speech with poor respiratory control.,CN: Occasional hypometric saccades in both horizontal directions. No vertical gaze abnormalities noted. Infrequent spontaneous forehead wrinkling and mouth movements. The rest of the CN exam was unremarkable.,Motor: Full strength throughout and normal muscle tone and bulk. Mild choreiform movements were noted in the hands and feet.,Sensory: unremarkable.,Coord: unremarkable.,Station/Gait: unremarkable, except that during tandem walking mild dystonic and choreiform movements of BUE became more apparent.,Reflexes: 2/2 throughout. Plantar responses were flexor, bilaterally.,There was no motor impersistence on tongue protrusion or hand grip.,COURSE:, He was thought to have early manifestations of Huntington Disease. A HCT was unremarkable. Elavil 25mg qhs was prescribed. Neuropsychologic assessment revealed mild anterograde memory loss only.,His chorea gradually worsened during the following 4 years. He developed motor impersistence and more prominent slowed saccadic eye movements. His mood/affect became more labile.,6/5/96 genetic testing revealed a 45 CAg trinucleotide repeat band consistent with Huntington Disease. MRI brain, 8/23/96, showed caudate nuclei atrophy, bilaterally.",
" The patient had hematuria, and unable to void.  The patient had a Foley catheter, which was not in the urethra, possibly inflated in the prostatic urethra, which was removed. ", Consult - History and Phy., Hematuria & Urinary Retention ,"REASON FOR CONSULTATION:,  Hematuria and urinary retention.,BRIEF HISTORY: , The patient is an 82-year-old, who was admitted with the history of diabetes, hypertension, hyperlipidemia, coronary artery disease, presented with urinary retention and pneumonia.  The patient had hematuria, and unable to void.  The patient had a Foley catheter, which was not in the urethra, possibly inflated in the prostatic urethra, which was removed.  Foley catheter was repositioned 18 Coude was used.  About over a liter of fluids of urine was obtained with light pink urine, which was irrigated.  The bladder and the suprapubic area returned to normal after the Foley placement.  The patient had some evidence of clots upon irrigation.  The patient has had a chest CT, which showed possible atelectasis versus pneumonia.,PAST MEDICAL HISTORY:  ,Coronary artery disease, diabetes, hypertension, hyperlipidemia, Parkinson's, and CHF.,FAMILY HISTORY:  ,Noncontributory.,SOCIAL HISTORY: , Married and lives with wife.,HABITS:,  No smoking or drinking.,REVIEW OF SYSTEMS: , Denies any chest pain, denies any seizure disorder, denies any nausea, vomiting.  Does have suprapubic tenderness and difficulty voiding.  The patient denies any prior history of hematuria, dysuria, burning, or pain.,PHYSICAL EXAMINATION:,VITAL SIGNS:  The patient is afebrile.  Vitals are stable.,GENERAL:  The patient is a thin gentleman,GENITOURINARY:  Suprapubic area was distended and bladder was palpated very easily.  Prostate was 1+.  Testes are normal.,LABORATORY DATA: , The patient's white counts are 20,000.  Creatinine is normal.,ASSESSMENT AND PLAN:,1.  Pneumonia.,2.  Dehydration.,3.  Retention.,4.  BPH.,5.  Diabetes.,6.  Hyperlipidemia.,7.  Parkinson's.,8.  Congestive heart failure.,About 30 minutes were spent during the procedure and the Foley catheter was placed, Foley was irrigated and significant amount of clots were obtained.  Plan is for urine culture, antibiotics.  Plan is for renal ultrasound to rule out any pathology.  The patient will need cystoscopy and evaluation of the prostate.  Apparently, the patient's PSA is 0.45, so the patient is at low to no risk of prostate cancer at this time.  Continued Foley catheter at this point.  We will think about starting the patient on alpha-blockers once the patient's over all medical condition is improved and stable.",
 Left hip fracture.  The patient is a 53-year-old female with probable pathological fracture of the left proximal femur., Consult - History and Phy., Hip Fracture - ER Consult ,"REASON FOR CONSULTATION: , Left hip fracture.,HISTORY OF PRESENT ILLNESS: , The patient is a pleasant 53-year-old female with a known history of sciatica, apparently presented to the emergency room due to severe pain in the left lower extremity and unable to bear weight.  History was obtained from the patient.  As per the history, she reported that she has been having back pain with left leg pain since past 4 weeks.  She has been using a walker for ambulation due to disabling pain in her left thigh and lower back.  She was seen by her primary care physician and was scheduled to go for MRI yesterday.  However, she was walking and her right foot got caught on some type of rug leading to place excessive weight on her left lower extremity to prevent her fall.  Since then, she was unable to ambulate.  The patient called paramedics and was brought to the emergency room.  She denied any history of fall.  She reported that she stepped the wrong way causing the pain to become worse.  She is complaining of severe pain in her lower extremity and back pain.  Denies any tingling or numbness.  Denies any neurological symptoms.  Denies any bowel or bladder incontinence.,X-rays were obtained which were remarkable for left hip fracture.  Orthopedic consultation was called for further evaluation and management.  On further interview with the patient, it is noted that she has a history of malignant melanoma, which was diagnosed approximately 4 to 5 years ago.  She underwent surgery at that time and subsequently, she was noted to have a spread to the lymphatic system and lymph nodes for which she underwent surgery in 3/2008.,PAST MEDICAL HISTORY: , Sciatica and melanoma.,PAST SURGICAL HISTORY:  ,As discussed above, surgery for melanoma and hysterectomy.,ALLERGIES: , NONE.,SOCIAL HISTORY: , Denies any tobacco or alcohol use.  She is divorced with 2 children.  She lives with her son.,PHYSICAL EXAMINATION:,GENERAL:  The patient is well developed, well nourished in mild distress secondary to left lower extremity and back pain.,MUSCULOSKELETAL:  Examination of the left lower extremity, there is presence of apparent shortening and external rotation deformity.  Tenderness to palpation is present.  Leg rolling is positive for severe pain in the left proximal hip.  Further examination of the spine is incomplete secondary to severe leg pain.  She is unable to perform a straight leg raising.  EHL/EDL 5/5.  2+ pulses are present distally.  Calf is soft and nontender.  Homans sign is negative.  Sensation to light touch is intact.,IMAGING:,  AP view of the hip is reviewed.  Only 1 limited view is obtained.  This is a poor quality x-ray with a lot of soft tissue shadow.  This x-ray is significant for basicervical-type femoral neck fracture.  Lesser trochanter is intact.  This is a high intertrochanteric fracture/basicervical.  There is presence of lytic lesion around the femoral neck, which is not well delineated on this particular x-ray.  We need to order repeat x-rays including AP pelvis, femur, and knee.,LABS:,  Have been reviewed.,ASSESSMENT: , The patient is a 53-year-old female with probable pathological fracture of the left proximal femur.,DISCUSSION AND PLAN: , Nature and course of the diagnosis has been discussed with the patient.  Based on her presentation without any history of obvious fall or trauma and past history of malignant melanoma, this appears to be a pathological fracture of the left proximal hip.  At the present time, I would recommend obtaining a bone scan and repeat x-rays, which will include AP pelvis, femur, hip including knee.  She denies any pain elsewhere.  She does have a past history of back pain and sciatica, but at the present time, this appears to be a metastatic bone lesion with pathological fracture.  I have discussed the case with Dr. X and recommended oncology consultation.,With the above fracture and presentation, she needs a left hip hemiarthroplasty versus calcar hemiarthroplasty, cemented type.  Indication, risk, and benefits of left hip hemiarthroplasty has been discussed with the patient, which includes, but not limited to bleeding, infection, nerve injury, blood vessel injury, dislocation early and late, persistent pain, leg length discrepancy, myositis ossificans, intraoperative fracture, prosthetic fracture, need for conversion to total hip replacement surgery, revision surgery, DVT, pulmonary embolism, risk of anesthesia, need for blood transfusion, and cardiac arrest.  She understands above and is willing to undergo further procedure.  The goal and the functional outcome have been explained.  Further plan will be discussed with her once we obtain the bone scan and the radiographic studies.  We will also await for the oncology feedback and clearance.,Thank you very much for allowing me to participate in the care of this patient.  I will continue to follow up.","consult - history and phy., calcar, proximal femur, pathological fracture, hip, fracture, hemiarthroplasty, melanoma, "
" Presents to the ER with hematuria that began while sleeping last night.   He denies any pain, nausea, vomiting or diarrhea.", Consult - History and Phy., Hematuria - ER Visit ,"HISTORY OF PRESENT ILLNESS:,  The patient is an 85-year-old gentleman who follows as an outpatient with Dr. A.  He is known to us from his last admission.  At that time, he was admitted with a difficulty voiding and constipation.  His urine cultures ended up being negative.  He was seen by Dr. B and discharged home on Levaquin for five days.,He presents to the ER today with hematuria that began while he was sleeping last night.  He denies any pain, nausea, vomiting or diarrhea.  In the ER, a Foley catheter was placed and was irrigated with saline.  White count was 7.6, H and H are 10.8 and 38.7, and BUN and creatinine are of 27 and 1.9.  Urine culture is pending.  Chest x-ray is pending.  His UA did show lots of red cells.  The patient currently is comfortable.  CBI is running.  His urine is clear.,PAST MEDICAL HISTORY:,1.  Hypertension.,2.  High cholesterol.,3.  Bladder cancer.,4.  Bilateral total knee replacements.,5.  Cataracts.,6.  Enlarged prostate.,ALLERGIES:,  SULFA.,MEDICATIONS AT HOME:,1.  Atenolol.,2.  Cardura.,3.  Zegerid.,4.  Flomax.,5.  Levaquin.,6.  Proscar.,7.  Vicodin.,8.  Morphine.,9.  Phenergan.,10.  Ativan.,11.  Zocor.,12.  Prinivil.,13.  Hydrochlorothiazide.,14.  Folic acid.,15.  Digoxin.,16.  Vitamin B12.,17.  Multivitamin.,SOCIAL HISTORY: , The patient lives at home with his daughter.  He does not smoke, occasionally drinks alcohol.  He is independent with his activities of daily living.,REVIEW OF SYSTEMS:,  Not additionally rewarding.,PHYSICAL EXAMINATION:,GENERAL:  An awake and alert 85-year-old gentleman who is afebrile.,VITAL SIGNS:  BP of 162/60 and pulse oximetry of 98% on room air.,HEENT:  Pink conjunctivae.  Anicteric sclerae.  Oral mucosa is moist.,NECK:  Supple.,CHEST:  Clear to auscultation.,HEART:  Regular S1 and S2.,ABDOMEN:  Soft and nontender to palpation.,EXTREMITIES:  Without edema.,He has a Foley catheter in place.  His urine is clear.,LABORATORY DATA:,  Reviewed.,IMPRESSION:,1.  Hematuria.",
 Markedly elevated PT INR despite stopping Coumadin and administering vitamin K. Patient with a history of iron-deficiency anemia due to chronic blood loss from colitis. , Consult - History and Phy., Hematology Consult - 1 ,"HISTORY OF PRESENT ILLNESS:,  The patient is well known to me for a history of iron-deficiency anemia due to chronic blood loss from colitis.  We corrected her hematocrit last year with intravenous (IV) iron.  Ultimately, she had a total proctocolectomy done on 03/14/2007 to treat her colitis.  Her course has been very complicated since then with needing multiple surgeries for removal of hematoma.  This is partly because she was on anticoagulation for a right arm deep venous thrombosis (DVT) she had early this year, complicated by septic phlebitis.,Chart was reviewed, and I will not reiterate her complex history.,I am asked to see the patient again because of concerns for coagulopathy.,She had surgery again last month to evacuate a pelvic hematoma, and was found to have vancomycin resistant enterococcus, for which she is on multiple antibiotics and followed by infectious disease now.,She is on total parenteral nutrition (TPN) as well.,LABORATORY DATA:,  Labs today showed a white blood count of 7.9, hemoglobin 11.0, hematocrit 32.8, and platelets 1,121,000.  MCV is 89.  Her platelets have been elevated for at least the past week, with counts initially at the 600,000 to 700,000 range and in the last couple of day rising above 1,000,000.  Her hematocrit has been essentially stable for the past month or so.  White blood count has improved.,PT has been markedly elevated and today is 44.9 with an INR of 5.0.  This is despite stopping Coumadin on 05/31/2007, and with administration of vitamin K via the TPN, as well as additional doses IV.  The PT is slightly improved over the last few days, being high at 65.0 with an INR of 7.3 yesterday.,PTT has not been checked since 05/18/2007 and was normal then at 28.,LFTs have been elevated.  ALT is 100, AST 57, GGT 226, alkaline phosphatase 505, albumin low at 3.3, uric acid high at 4.9, bilirubin normal, LDH normal, and pre-albumin low at 16.  Creatinine is at 1.5, with an estimated creatinine clearance low at 41.7.  Other electrolytes are fairly normal.,B12 was assessed on 05/19/2007 and was normal at 941.  Folic acid was normal.  Iron saturation has not been checked since March, and was normal then.  Ferritin has not been checked in a couple of months.,CURRENT MEDICATIONS: , Erythropoietin 45,000 units every week, started 05/16/2007.  She is on heparin flushes, loperamide, niacin, pantoprazole, Diovan, Afrin nasal spray, caspofungin, daptomycin, Ertapenem, fentanyl or morphine p.r.n. pain, and Compazine or Zofran p.r.n. nausea.,PHYSICAL EXAMINATION: ,GENERAL:  She is alert, and frustrated with her prolonged hospital stay.  She notes that she had epistaxis a few days ago, requiring nasal packing and fortunately that had resolved now.,VITAL SIGNS:  Today, temperature is 98.5, pulse 99, respirations 16, blood pressure 105/65, and pulse is 95.  She is not requiring oxygen.,SKIN:  No significant ecchymoses are noted.,ABDOMEN:  Ileostomy is in place, with greenish black liquid output.  Midline surgical scar has healed well, with a dressing in place in the middle, with no bleeding noted.,EXTREMITIES:  She has no peripheral edema.,CARDIAC:  Regular rate.,LYMPHATICS:  No adenopathy is noted.,LUNGS:  Clear bilaterally.,IMPRESSION AND PLAN:,  Markedly elevated PT/INR despite stopping Coumadin and administering vitamin K.  I will check mixing studies to see if she has deficiency, which could be due to poor production given her elevated LFTs, decreased albumin, and decreased pre-albumin.,It is possible that she has an inhibitor, which would have to be an acquired inhibitor, generally presenting with an elevated PTT and not PT.  I will check a PTT and check mixing studies if that is prolonged.  It is doubtful that she has a lupus anticoagulant since she has been presenting with bleeding symptoms rather than clotting.  I agree with continuing off of anticoagulation for now.,She has markedly elevated platelet count.  I suspect this is likely reactive to infection, and not from a new myeloproliferative disorder.,Anemia has been stable, and is multifactorial.  Given her decreased creatinine clearance, I agree with erythropoietin support.  She was iron deficient last year, and with her multiple surgeries and poor p.o. intake, may have become iron deficient again.  She has had part of her small bowel removed, so there may be a component of poor absorption as well.  If she is iron deficient, this may contribute also to her elevated platelet counts.  I will check a ferritin.  This may be difficult to interpret because of inflammation.  If it is decreased, plan will be to add iron supplementation intravenously.  If it is elevated, we could consider a bone marrow biopsy to evaluate her iron stores, and also assess her myelopoiesis given the markedly elevated platelet counts.,She needs continued treatment as you are for her infections.,I will discuss the case with Dr. X as well since there is a question as to whether she might need additional surgery.  She is not a surgical candidate now with her elevated PT/INR.",
" Leukocytosis, acute deep venous thrombosis, right lower extremity with bilateral pulmonary embolism, on intravenous heparin complicated with acute renal failure for evaluation.", Consult - History and Phy., Hematology Consult ,"REASON FOR CONSULTATION:,  Acute deep venous thrombosis, right lower extremity with bilateral pulmonary embolism, on intravenous heparin complicated with acute renal failure for evaluation.,HISTORY OF PRESENTING ILLNESS:  ,Briefly, this is a 36-year-old robust Caucasian gentleman with no significant past medical or surgical history, who works as a sales representative, doing a lot of traveling by plane and car and attending several sales shows, developed acute shortness of breath with an episode of syncope this weekend and was brought in by paramedics to Hospital.  A V/Q scan revealed multiple pulmonary perfusion defects consistent with high probability pulmonary embolism.  A Doppler venous study of the lower extremity also revealed nonocclusive right popliteal vein thrombosis.  A CT of the abdomen and pelvis revealed normal-appearing liver, spleen, and pancreas; however, the right kidney appeared smaller compared to left and suggesting possibility of renal infarct.  Renal function on admission was within normal range; however, serial renal function showed rapid increase in creatinine to 5 today.  He has been on intravenous heparin and hemodialysis is being planned for tomorrow.  Reviewing his history, there is no family members with hypercoagulable state or prior history of any thrombotic complication.  He denies any recent injury to his lower extremity and in fact denied any calf pain or swelling.,PAST MEDICAL AND SURGICAL HISTORY:  ,Unremarkable.,SOCIAL HISTORY: , He is married and has 1 son.  He has a brother who is healthy.  There is no history of tobacco use or alcohol use.,FAMILY HISTORY:,  No family history of hypercoagulable condition.,MEDICATIONS:  ,Advil p.r.n.,ALLERGIES: , NONE.,REVIEW OF SYSTEMS: , Essentially unremarkable except for sudden onset dyspnea on easy exertion complicated with episode of syncope.  He denied any hemoptysis.  He denied any calf swelling or pain.  Lately, he has been traveling and has been sitting behind a desk for a long period of time.,PHYSICAL EXAMINATION:,GENERAL:  He is a robust young gentleman, awake, alert, and hemodynamically stable.,HEENT:  Sclerae anicteric.  Conjunctivae normal.  Oropharynx normal.,NECK:  No adenopathy or thyromegaly.  No jugular venous distention.,HEART:  Regular.,LUNGS:  Bilateral air entry.,ABDOMEN:  Obese and benign.,EXTREMITIES:  No calf swelling or calf tenderness appreciated.,SKIN:  No petechiae or ecchymosis.,NEUROLOGIC:  Nonfocal.,LABORATORY FINDINGS:,  Blood count obtained showed a white count of 16.8, hemoglobin 14.8 g percent, hematocrit 44.6%, MCV 94, and platelet count 209,000.  Liver profile normal.  Thyroid study revealed a TSH of 1.3.  Prothrombin time/INR 1.5, partial thromboplastin time 78.6 seconds.  Renal function, BUN 44 and creatinine 5.7.  Echocardiogram revealed left ventricular hypertrophy with ejection fraction of 65%, no intramural thrombus noted.,IMPRESSION:,1.  Bilateral pulmonary embolism, most consistent with emboli from right lower extremity, on intravenous heparin, rule out hereditary hypercoagulable state.,2.  Leukocytosis, most likely leukemoid reaction secondary to acute pulmonary embolism/renal infarction, doubt presence of myeloproliferative disorder.,3.  Acute renal failure secondary to embolic right renal infarction.,4.  Obesity.,PLAN: , From hematologic standpoint, we will await hypercoagulable studies, which have all been sent on admission to see if a hereditary component is at play.  For now, we will continue intravenous heparin and subsequent oral anticoagulation with Coumadin.  In view of worsening renal function, may need temporary hemodialysis until renal function improves.  I discussed at length with the patient's wife at the bedside.",
" Closed head injury with evidence of axonal injury vs. vascular injury to the left substantia nigra, right subdural hematoma and possible subarachnoid hemorrhage, vascular/ischemic injury in the right occipital lobe-right basal ganglia/caudate nucleus-right frontal lobe, and right temporal lobe contusion.", Consult - History and Phy., Head Trauma ,"CC: ,Depressed mental status.,HX: ,29y/o female fell down a flight of stairs on 2/20/95, striking the right side of her head. She then walked over to and lay down on a living room couch. She was found there, the next morning, by her boyfriend, poorly responsive and amidst a coffee ground like emesis. She was taken to a local ER and HCT revealed a right supraorbital fracture, right SDH and left SAH. Spine X-rays revealed a T12 vertebral body fracture. There were retinal hemorrhages, OU. She continued to be minimally responsive and was transferred to UIHC for lack of insurance and for neurologic/neurosurgical care.,MEDS:, (on transfer): Dilantin, Zantac, Proventil MDI, Tylenol.,PMH:, 1)pyelonephritis, 2) multiple STD's, 3) Polysubstance Abuse (ETOH, MJ, Amphetamine), 4)G5P4.,FHX:, unknown.,SHX: ,polysubstance abuse. smoked 1 pack per day for 15years.,EXAM: ,BP127/97, HR83, RR25, 37.2C,MS: Minimal to no spontaneous speech. Unresponsive to verbal commands. Lethargic and somnolent. Groaned ""yes"" inappropriately.,CN: Pupils 4/4 decreasing to 2/2 on exposure to light. VFFTT. Retinal hemorrhages, OU. EOM difficult to assess. Facial movement appeared symmetric. Tongue midline. Corneal and gag responses were intact.,MOTOR: no spontaneous movement. withdrew extremities to noxious stimulation (e.g. deep nail bed pressure).,Sensory: withdrew to noxious stimuli.,Coord/Station/Gait: not tested.,Reflexes: 2+/2+ BUE. 2/2 BLE. Babinski signs were present, bilaterally.,HEENT: Periorbital and upper lid ecchymoses about the right eye. Scleral hemorrhage, OD.,GEN EXAM: mild bruising of the extremities.,COURSE: ,2/27/95 HCT revealed a small liner high attenuation area lateral to the right parietal lobe with subtle increased attenuation of the tentorium cerebelli. These findings were felt to represent a right subdural hematoma and possible subarachnoid hemorrhage.,2/28/95 brain MRI revealed: 1)a small right-sided SDH, 2) Abnormal signal in the right occipital lobe with effacement of the gyri and sulci in the right PCA division most likely representing ischemic/vascular injury, 3)abnormal signal within the right basal ganglia/caudate nucleus consistent with ischemia, 4) abnormal signal in the uncal portion of the right frontal lobe consistent with contusion, 5) small parenchymal hemorrhage in the inferior anterior right temporal lobe, and 6) opacification of the right maxillary sinus.,EEG, 2/28/95, was abnormal with occasional sharp transients in the left temporal region, and irregular (more or less continuous) right greater than left delta slow waves and decreased background activity in the right hemisphere: the findings were consistent with focal pathology on the right, seizure tendency in the left temporal region, and bilateral cerebral dysfunction. By the time of discharge, 4/17/95, she was verbalizing one or two words and required assistance with feeding and ambulation. She could not function independently.","consult - history and phy., closed head injury, axonal injury, vascular injury, substantia nigra, subdural hematoma, subarachnoid hemorrhage, vascular, ischemic, injury, occipital lobe, retinal hemorrhages, temporal region, axonal, hemorrhages, hemorrhage, "
 Patient presents with gross hematuria that started this morning., Consult - History and Phy., Hematuria - Consult ,"HISTORY OF PRESENT ILLNESS:,  This is a 77-year-old male, who presents with gross hematuria that started this morning.  The patient is a difficult historian, does have a speech impediment, slow to answer questions, but daughter was able to answer lot of questions too.  He is complaining of no other pain.  He denies any abdominal pain.  Denies any bleeding anywhere else.  Denies any bruising.  He had an episode similar to this a year ago where it began the same with hematuria.  He was discharged after a workup in the hospital, in the emergency room, with Levaquin.  Three days later, he returned with a very large hematoma to his left neck and a coagulopathy with significant bleeding.  His H and H was down in the 6 level.  He received blood transfusions.  He was diagnosed with a malignancy, coagulopathy, and sounds like was in critical condition.  Family actually states that they were told that he was unlikely to live through that event, but he did.  Since then, he has had no bleeding.  The patient has had no fever.  No cough.  No chest pain or shortness of breath.  No bleeding gums.  No blurred vision.  No headache.  No recent falls or trauma.  He has had no nausea or vomiting.  No diarrhea.  No blood in the stool or melena.  No leg or calf pain.  No joint pain.  No rashes.  No swollen glands.  He has no numbness, weakness or tingling to his extremities.  No acute anxiety or depression.,PAST MEDICAL HISTORY: , Has prostate cancer.,MEDICATION: , He is receiving Lupron injection by Dr. Y. The only other medication that he takes is Tramadol.,SOCIAL HISTORY: , He does not smoke or drink.,PHYSICAL EXAMINATION:,Vital Signs:  Are all reviewed on triage.,General:  He is alert.  Answers slowly with a speech impediment, but answers appropriately.,HEENT:  Pupils equal, round, and reactive to light.  Normal extraocular muscles.  Nonicteric sclerae.  Conjunctivae are not pale.  His oropharynx is clear.  His mucous membranes are moist.,Heart:  Regular rate and rhythm, with no murmurs.,Lungs:  Clear.,Abdomen:  Soft, nontender, nondistended.  Normal bowel sounds.  No organomegaly or mass.,Extremities:  No calf tenderness, erythema or warmth.  He has no bruises noted.,Neurological:  Cranial nerves II through XII are intact.  He has 5/5 strength throughout.  ,GU:  Normal.,LABORATORY DATA:  ,The patient did on urinalysis have few red blood cells.  His urine was also grossly red, although no blood clots or gross blood was noted.  It was more of a red fluid.  He had a mild decrease in H and H at 12.1 and 34.6.  His white count was normal at 7.2.  His PT was elevated at 15.9.  PTT elevated at 36.4.  INR is 1.4.  His comprehensive metabolic profile is normal except for BUN of 19.,CONDITION: , The patient is stable at this time, although because of the history of the same happening and the patient beginning in the same fashion his history of coagulopathy, the patient is discussed with Dr. X and he is admitted for orders.  Also we will consult Dr. Y, see orders for further.","consult - history and phy., prostate cancer, bleeding, gross hematuria, speech impediment, hematuria, coagulopathy, blood,"
" Patient with right-sided arm weakness with speech difficulties, urinary tract infection, dehydration, and diabetes mellitus type 2", Consult - History and Phy., H&P - Weakness ,"CHIEF COMPLAINT:, Right-sided weakness.,HISTORY OF PRESENT ILLNESS:, The patient was doing well until this morning when she was noted to have right-sided arm weakness with speech difficulties. She was subsequently sent to ABC Medical Center for evaluation and treatment. At ABC, the patient was seen by Dr. H including labs and a head CT which is currently pending. The patient has continued to have right-sided arm and hand weakness, and has difficulty expressing herself. She does seem to comprehend words. The daughter states the patient is in the Life Care Center, and she believes this started this morning. The patient denies headache, visual changes, chest pain and shortness of breath. These changes have been constant since onset this morning, have not improved or worsened, and the patient notes no modifying factors.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,MEDICATIONS:, Medications are taken from the paperwork from Life Care Center and include: Lortab 3-4 times a day for pain, Ativan 0.25 mg by mouth every 12 hours p.r.n. pain, Depakote ER 250 mg p.o. q nightly, Actos 15 mg p.o. t.i.d., Lantus 35 units subcu q nightly, Glipizide 10 mg p.o. q day, Lanoxin 0.125 mg p.o. q day, Lasix 40 mg p.o. q day, Lopressor 50 mg p.o. b.i.d., insulin sliding scale, Lunesta 1 mg p.o. q nightly, Sorbitol 15 mg p.o. q day, Zoloft 50 mg p.o. q nightly, Dulcolax as needed for constipation.,PAST MEDICAL HISTORY:, Significant for moderate to severe aortic stenosis, urinary tract infection, hypertension, chronic kidney disease (although her creatinine is near normal).,SOCIAL HISTORY:, The patient lives at Life Care Center. She does not smoke, drink or use intravenous drugs.,FAMILY HISTORY:, Negative for cerebrovascular accident or cardiac disease.,REVIEW OF SYSTEMS:, As in HPI. Patient and daughter also deny weight loss, fevers, chills, sweats, nausea, vomiting, abdominal pain. She has had some difficulty expressing herself, but seems to comprehend speech as above. The patient has had a history of chronic urinary tract infections and her drainage is similar to past episodes when she has had such infection.,PHYSICAL EXAMINATION:,VITAL SIGNS: The patient is currently with a temperature of 99.1, blood pressure 138/59, pulse 69, respirations 15. She is 95% on room air.,GENERAL: This is a pleasant elderly female who appears stated age, in mild distress.,HEENT: Oropharynx is dry.,NECK: Supple with no jugular venous distention or thyromegaly.,RESPIRATORY: Clear to auscultation. No wheezes, rubs or crackles.,CARDIOVASCULAR: A 4/6 systolic ejection murmur best heard at the 2nd right intercostal space with radiation to the carotids.,ABDOMEN: Soft. Normal bowel sounds.,EXTREMITIES: No clubbing, cyanosis or edema. She does have bilateral above knee amputations.,NEUROLOGIC: Strength 2/5 in her right hand, 4/5 in her left hand. She does have mild right facial droop and an expressive aphasia.,VASCULAR: The patient has good capillary refill in her fingertips.,LABORATORY DATA:, BUN 52, creatinine 1.3. Normal coags. Glucose 220. White blood cell count 10,800. Urinalysis has 608 white cells, 625 RBCs. Head CT is currently pending. EKG shows normal sinus rhythm with mild ST-depression and biphasic T-waves diffusely.,ASSESSMENT AND PLAN:,1. Right-sided weakness with an expressive aphasia, at this time concerning for a left-sided middle cerebral artery cerebrovascular accident/transient ischemic attach given the patient's serious vascular disease. At this point we will hydrate, treat her urinary tract infection, check an MRI, ultrasound of her carotids, and echocardiogram to reevaluate valvular and left ventricular function. Start antiplatelet therapy and ask Neuro to see the patient.,2. Urinary tract infection. Will treat with ceftriaxone, check urine culture data and adjust as needed.,3. Dehydration. Will hydrate with IV fluids and follow p.o. intake while holding diuretics.,4. Diabetes mellitus type 2 uncontrolled. Her sugar is 249. We will continue Lantus insulin and sliding scale coverage, and check hemoglobin A1c to gauge prior control.,5. Prophylaxis. Will institute low molecular weight heparin and follow activity levels.",
" New patient visit for right hand pain.  Punched the wall 3 days prior to presentation, complained of ulnar-sided right hand pain, and was seen in the emergency room. ", Consult - History and Phy., Hand Pain - Consult ,"REASON FOR VISIT:  ,New patient visit for right hand pain.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 28-year-old right-hand dominant gentleman, who punched the wall 3 days prior to presentation.  He complained of ulnar-sided right hand pain and was seen in the emergency room.  Reportedly, he had some joints in his hand pushed back and placed by somebody in emergency room.  Today, he admits that his pain is much better.  Currently, since that time he has been in the splint with minimal pain.  He has had no numbness, tingling or other concerning symptoms.,PAST MEDICAL HISTORY:, Negative.,SOCIAL HISTORY:  ,The patient is a nonsmoker and does not use illegal drugs.  Occasionally drinks.,REVIEW OF SYSTEMS: , A 12-point review of systems is negative.,MEDICATIONS:,  None.,ALLERGIES: , No known drug allergies.,FINDINGS: , On physical exam, he has swelling and tenderness over the ulnar dorsum of his hand.  He has a normal cascade.  He has 70 degrees of MCP flexion and full IP flexion and extension.  He has 3 to 5 strength in his grip and intrinsics.  He has intact sensation to light touch in the radial, ulnar, and median nerve distribution.  Two plus radial pulse.,X-rays taken from today were reviewed, include three views of the right hand.  They show possible small fractures of the base of the fourth and third metacarpals.  Joint appears to be located.  A 45-degree oblique view was obtained and confirmed adduction of the CMC joints of the fourth and fifth metacarpals.  His injury films from 09/15/07 were reviewed and demonstrated what appears to be CMC dislocations of the third and fourth metacarpals.,ASSESSMENT: , Status post right third and fourth metacarpal carpometacarpal dislocations.,PLANS: , The patient was placed into a short-arm cast and intrinsic plus.  I would like him to wear this for 2 weeks and then follow up with us.  At that time, we will transition him to an OT splint and begin range of motion activities of the fingers and wrist.  We should see him back in 2 weeks' time at which time he should obtain three views of the right hand and a 45-degree oblique view out of cast.","consult - history and phy., hand pain, pain, hand, metacarpals"
" An 85-year-old female with diarrhea, vomiting, and abdominal pain.", Consult - History and Phy., H&P - Gen Med - 1  ,"CHIEF COMPLAINT:, Diarrhea, vomiting, and abdominal pain.,HISTORY OF PRESENT ILLNESS:, The patient is an 85-year-old female who presents with a chief complaint as described above. The patient is a very poor historian and is extremely hard of hearing, and therefore, very little history is available. She was found by EMS sitting on the toilet having diarrhea, and apparently had also just vomited. Upon my questioning of the patient, she can confirm that she has been sick to her stomach and has vomited. She cannot tell me how many times. She is also unable to describe the vomitus. She also tells me that her belly has been hurting. I am unable to get any further history from the patient because, again, she is an extremely poor historian and very hard of hearing.,PAST MEDICAL HISTORY:, Per the ER documentation is hypertension, diverticulosis, blindness, and sciatica.,MEDICATIONS:, Lorazepam 0.5 mg, dosing interval is not noted; Tylenol PM; Klor-Con 10 mEq; Lexapro; calcium with vitamin D.,ALLERGIES:, SHE IS ALLERGIC TO PENICILLIN.,FAMILY HISTORY:, Unknown.,SOCIAL HISTORY:, Also unknown.,REVIEW OF SYSTEMS:, Unobtainable secondary to the patient's condition.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse 80. Respiratory rate 18. Blood pressure 130/80. Temperature 97.6.,GENERAL: Elderly black female who is initially sleeping upon my evaluation, but is easily arousable.,NECK: No JVD. No thyromegaly.,EARS, NOSE, AND THROAT: Her oropharynx is dry. Her hearing is very diminished.,CARDIOVASCULAR: Regular rhythm. No lower extremity edema.,GI: Mild epigastric tenderness to palpation without guarding or rebound. Bowel sounds are normoactive.,RESPIRATORY: Clear to auscultation bilaterally with a normal effort.,SKIN: Warm, dry, no erythema.,NEUROLOGICAL: The patient attempts to answer questions when asked, but is very hard of hearing. She is seen to move all extremities spontaneously.,DIAGNOSTIC DATA:, White count 9.6, hemoglobin 15.9, hematocrit 48.2, platelet count 345, PTT 24, PT 13.3, INR 0.99, sodium 135, potassium 3.3, chloride 95, bicarb 20, BUN 54, creatinine 2.2, glucose 165, calcium 10.3, magnesium 2.5, total protein 8.2, albumin 3.8, AST 33, ALT 26, alkaline phosphatase 92. Cardiac isoenzymes negative x1. EKG shows sinus rhythm with a rate of 96 and a prolonged QT interval.,ASSESSMENT AND PLAN:,1. Pancreatitis. Will treat symptomatically with morphine and Zofran, and also IV fluids. Will keep NPO.,2. Diarrhea. Will check stool studies.,3. Volume depletion. IV fluids.,4. Hyperglycemia. It is unknown whether the patient is diabetic. I will treat her with sliding scale insulin.,5. Hypertension. If the patient takes blood pressure medications, it is not listed on the only medication listing that is available. I will prescribe clonidine as needed.,6. Renal failure. Her baseline is unknown. This is at least partly prerenal. Will replace volume with IV fluids and monitor her renal function.,7. Hypokalemia. Will replace per protocol.,8. Hypercalcemia. This is actually rather severe when adjusted for the patient's low albumin. Her true calcium level comes out to somewhere around 12. For now, I will just treat her with IV fluids and Lasix, and monitor her calcium level.,9. Protein gap. This, in combination with the calcium, may be suggestive of multiple myeloma. It is my understanding that the family is seeking hospice placement for the patient right now. I would have to discuss with the family before undertaking any workup for multiple myeloma or other malignancy.",
 Newly diagnosed head and neck cancer.  The patient was recently diagnosed with squamous cell carcinoma of the base of the tongue bilaterally and down extension into the right tonsillar fossa., Consult - History and Phy., Head & Neck Cancer Consult ,"REASON FOR CONSULTATION:,  Newly diagnosed head and neck cancer.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 61-year-old gentleman who was recently diagnosed with squamous cell carcinoma of the base of the tongue bilaterally and down extension into the right tonsillar fossa.  He was also noted to have palpable level 2 cervical lymph nodes.  His staging is T3 N2c M0 Stage IV invasive squamous cell carcinoma of the head and neck.  The patient comes in to the clinic today after radiation Oncology consultation.  His Otolaryngologist performed a direct laryngoscopy with biopsy on July 29, 2010.  The patient reports that in December-January timeframe, he had noted some difficulty swallowing and ear pain.  He had a work up by his local physician that was relatively negative, and he was treated for gastroesophageal reflux disease.  His symptoms continued to progress, and he developed difficulty with his speech, dysphagia, otalgia and odynophagia.  He was then referred to Dr. X and examination revealed a mass at the right base of the tongue that extended across the midline to include the left base of the tongue as well as posterior extension involved in the right tonsillar fossa.  He was noted to have bilateral neck nodes.  His biopsy was positive for squamous cell carcinoma.,PAST MEDICAL HISTORY:,  Significant for mild hypertension.  He has had cataract surgery, gastroesophageal reflux disease and a history of biceps tendon tear.,ALLERGIES: ,  Penicillin.,CURRENT MEDICATIONS: , Lisinopril/hydrochlorothiazide 20/25 mg q.d., alprazolam 0.5 mg q.d., omeprazole 20 mg b.i.d., Lortab 7.5/500 mg q 4h p.r.n.,FAMILY HISTORY: , Significant for father who has stroke and grandfather with lung cancer.,SOCIAL HISTORY: , The patient is married but has been separated from his wife for many years, they remain close, and they have two adult sons.  He is retired from the Air Force, currently works for Lockheed Martin.  He was born and raised in New York.  He does have a smoking history, about a 20 pack-year history and he reports quitting on July 27.  He does drink alcohol socially. No use of illicit drugs.,REVIEW OF SYSTEMS:  ,The patient's chief complaint is fatigue.  He has difficulty swallowing and dysphagia.  He is responding well to Lortab and Tylenol for pain control.  He denies any chest pain, shortness of breath, fevers, chills and night sweats.  The rest of his review of systems is negative.,PHYSICAL EXAM:,VITALS:",
 Intractable nausea and vomiting/history of diabetic gastroparesis/multiple endoscopies revealing gastritis and esophagitis. , Consult - History and Phy., H&P - Nausea & Vomiting ,"CHIEF COMPLAINT:, Intractable nausea and vomiting.,HISTORY OF PRESENT ILLNESS:, This is a 43-year-old black female who was recently admitted and discharged yesterday for the same complaint. She has a long history of gastroparesis dating back to 2000, diagnosed by gastroscopy. She also has had multiple endoscopies revealing gastritis and esophagitis. She has been noted in the past multiple times to be medically noncompliant with her medication regimen. She also has very poorly controlled hypertension, diabetes mellitus and she also underwent a laparoscopic right adrenalectomy due to an adrenal adenoma in January, 2006. She presents to the emergency room today with elevated blood pressure and extreme nausea and vomiting. She was discharged on Reglan and high-dose PPI yesterday, and was instructed to take all of her medications as prescribed. She states that she has been compliant, but her symptoms have not been controlled. It should be noted that on her hospital admission she would have times where she would feel extremely sick to her stomach, and then soon after she would be witnessed going outside to smoke.,PAST MEDICAL HISTORY:,1. Diabetes mellitus (poorly controlled).,2. Hypertension (poorly controlled).,3. Chronic renal insufficiency.,4. Adrenal mass.,5. Obstructive sleep apnea.,6. Arthritis.,7. Hyperlipidemia.,PAST SURGICAL HISTORY:,1. Removal of ovarian cyst.,2. Hysterectomy.,3. Multiple EGDs with biopsies over the last six years. Her last EGD was in June, 2005, which showed esophagitis and gastritis.,4. Colonoscopy in June, 2005, showing diverticular disease.,5. Cardiac catheterization in February, 2002, showing normal coronary arteries and no evidence of renal artery stenosis.,6. Laparoscopic adrenalectomy in January, 2006.,MEDICATIONS:,1. Reglan 10 mg orally every 6 hours.,2. Nexium 20 mg orally twice a day.,3. Labetalol.,4. Hydralazine.,5. Clonidine.,6. Lantus 20 units at bedtime.,7. Humalog 30 units before meals.,8. Prozac 40 mg orally daily.,SOCIAL HISTORY:, She has a 27 pack year smoking history. She denies any alcohol use. She does have a history of chronic marijuana use.,FAMILY HISTORY:, Significant for diabetes and hypertension.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,REVIEW OF SYSTEMS:,HEENT: See has had headaches, and some dizziness. She denies any vision changes.,CARDIAC: She denies any chest pain or palpitations.,RESPIRATORY: She denies any shortness of breath.,GI: She has had persistent nausea and vomiting. She denies diarrhea, melena or hematemesis.,NEUROLOGICAL: She denies any neurological deficits.,All other systems were reviewed and were negative unless otherwise mentioned in HPI.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure: 220/130. Heart rate: 113. Respiratory rate: 18. Temperature: 98.,GENERAL: This is a 43-year-old obese African-American female who appears in no acute distress. She has a depressed mood and flat affect, and does not answer questions elaborately. She will simply state that she does not feel well.,HEENT: Normocephalic, atraumatic, anicteric. PERRLA. EOMI. Mucous membranes moist. Oropharynx is clear.,NECK: Supple. No JVD. No lymphadenopathy.,LUNGS: Clear to auscultation bilaterally, nonlabored.,HEART: Regular rate and rhythm. S1 and S2. No murmurs, rubs, or gallops.",
" History of diabetes, osteoarthritis, atrial fibrillation, hypertension, asthma, obstructive sleep apnea on CPAP, diabetic foot ulcer, anemia, and left lower extremity cellulitis.", Consult - History and Phy., H&P - Gen Med - 2 ,"HISTORY OF PRESENT ILLNESS:, The patient is a 71-year-old Caucasian female with a history of diabetes, osteoarthritis, atrial fibrillation, hypertension, asthma, obstructive sleep apnea on CPAP, diabetic foot ulcer, anemia and left lower extremity cellulitis. She was brought in by the EMS service to Erlanger emergency department with pulseless electrical activity. Her husband states that he was at home with his wife, when she presented to him complaining of fever and chills. She became acutely unresponsive. She was noted to have worsening of her breathing. She took several of her MDIs and then was placed on her CPAP. He went to notify EMS and when he returned, she was found to not be breathing. He stated that she was noted to have no breathing in excess of 10 minutes. He states that the EMS system arrived at the home and she was found not breathing. The patient was intubated at the scene and upon arrival to Erlanger Medical Center, she was found to have pupils fixed and dilated. She was seen by me in the emergency department and was on Neo-Synephrine, dopamine with a blood pressure of 97/22 with a rapid heart rate and again, in an unresponsive state.,REVIEW OF SYSTEMS:, Review of systems was not obtainable.,PAST MEDICAL HISTORY:, Diabetes, osteoarthritis, hypertension, asthma, atrial fibrillation, diabetic foot ulcer and anemia.,PAST SURGICAL HISTORY:, Noncontributory to above.,FAMILY HISTORY:, Mother with history of coronary artery disease.,SOCIAL HISTORY:, The patient is married. She uses no ethanol, no tobacco and no illicits. She has a very support family unit.,MEDICATIONS:, Augmentin; Detrol LA; lisinopril.,IMMUNIZATIONS:, Immunizations were up to date for influenza, negative for Pneumovax.,ALLERGIES:, PENICILLIN.,LABORATORY AT PRESENTATION:, White blood cell count 11, hemoglobin 10.5, hematocrit 32.2, platelets 175,000. Sodium 148, potassium 5.2, BUN 30, creatinine 2.2 and glucose 216. PT was 22.4.,RADIOLOGIC DATA:, Chest x-ray revealed a diffuse pulmonary edema.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 97/52, pulse of 79, respirations 16, O2 sat 100%.,HEENT: The patient's pupils were again, fixed and dilated and intubated on the monitor.,CHEST: Poor air movement bilateral with bilateral rales.,CARDIOVASCULAR: Regular rate and rhythm.,ABDOMEN: The abdomen was obese, nondistended and nontender.,EXTREMITIES: Left diabetic foot had oozing pus drainage from the foot.,GU: Foley catheter was in place.,IMPRESSION AND PLAN:,1. Acute cardiac arrest with pulseless electrical activity with hypotensive shock and respiratory failure: Will continue ventilator support. Will rule out pulmonary embolus, rule out myocardial infarction. Continue pressors. The patient is currently on dopamine, Neo-Synephrine and Levophed.,2. Acute respiratory distress syndrome: Will continue ventilatory support.,3. Questionable sepsis: Will obtain blood cultures, intravenous vancomycin and Rocephin given.,4. Hypotensive shock: Will continue pressors. Will check random cortisol. Hydrocortisone was added.,Further inpatient management for this patient will be provided by Dr. R. The patient's status was discussed with her daughter and her husband. The husband states that his wife has been very ill in the past with multiple admissions, but he had never seen her as severely ill as with this event. He states that she completely was not breathing at all and he is aware of the severity of her illness and the gravity of her current prognosis. Will obtain the assistance with cardiology with this admission and will continue pressors and supportive therapy. The family will make an assessment and final decision concerning her long-term management after a 24 hour period.",
" This is a 62-year-old woman with hypertension, diabetes mellitus, prior stroke who has what sounds like Guillain-Barre syndrome, likely the Miller-Fisher variant.", Consult - History and Phy., Guillain-Barre Syndrome ,"CHIEF COMPLAINT: , Followup of hospital discharge for Guillain-Barre syndrome.,HISTORY OF PRESENT ILLNESS: , This is a 62-year-old right-handed woman with hypertension, diabetes mellitus, a silent stroke involving right basal ganglia who was in her usual state of baseline health until late June of 2006 when she had onset of blurred vision, diplopia, and possible weakness in the right greater than left arm and left-sided ptosis.  She was admitted to the hospital.  The MRI showed only an old right basal ganglion infarct.  She subsequently had a lumbar puncture, which showed increased protein, and an EMG/nerve conduction study performed by Dr. X on July 3rd, showed early signs of AIDP.  The patient was treated with intravenous gamma globulin and had some mild improvement in her symptoms.  Her vital capacities were normal during the hospitalization.  Her chest x-ray was negative for any acute process.  She was discharged to rehab from July 12, 2006 to July 20, 2006.  She made some progress in which she notes that her walking is definitely better.  However, she notes that she still has some problems with eye movement and her vision.  This is possibly her main problem.  She also reports tightness and pain in her mid back.,REVIEW OF SYSTEMS:,  Documented in the clinic note.  The patient has problems with diabetes, double vision, blurry vision, muscle pain, weakness, trouble walking, and headaches about two to three times per week.,PAST MEDICAL HISTORY:,1.  Hypertension.,2.  Diabetes mellitus.,3.  Stroke involving the right basal ganglion.,4.  Guillain-Barre syndrome diagnosed in June of 2006.,5.  Bilateral knee replacements.,6.  Total abdominal hysterectomy and cholecystectomy.,FAMILY HISTORY:,  Multiple family members have diabetes mellitus.,SOCIAL HISTORY:,  The patient is retired on disability due to her knee replacements.  She does not smoke, drink or use any illicit drugs.,MEDICATIONS:,  Percocet 5/325 mg 4-6 hours p.r.n., Neurontin 100 mg per day, insulin, Protonix 40 mg per day, Toprol-XL 50 mg q.d., Norvasc 10 mg q.d., glipizide ,10 mg q.d., fluticasone 50 mcg nasal spray, Lasix 20 mg b.i.d., and Zocor 1 mg q.d.,ALLERGIES: , No known drug allergies.,PHYSICAL EXAMINATION: , Blood pressure 122/74, heart rate 68, respiratory rate 16, and weight 228 pounds.  Pain scale 5/10.  Please see the written note for details.  General exam is benign other than mild obesity.  On neuro examination, mental status is normal.  Cranial nerves are significant for full visual fields and pupils are equal and reactive.  However, extraocular movements are very limited.  She has some adduction of the left eye and she has minimal upgaze of both eyes, but otherwise the eyes do not move.  Face is symmetric.  Sensation is intact.  Tongue and uvula are in midline.  Palate is elevated symmetrically.  Shoulder shrug is strong.  The patient's muscle exam shows normal bulk and tone throughout.  She has no weakness of the left upper extremity.  In the right upper extremity, she has only about 2/5 strength in the right shoulder, but is otherwise 5/5.  There is no drift or orbit.  Reflexes are absent throughout.  Sensory exam is intact to light touch, pinprick, vibration, and proprioception is normal.  There is no dysmetria.  Gait is somewhat limited possibly by her vision and possibly also by her balance problems.,PERTINENT DATA:,  As reviewed previously.,DISCUSSION: , This is a 62-year-old woman with hypertension, diabetes mellitus, prior stroke who has what sounds like Guillain-Barre syndrome, likely the Miller-Fisher variant.  The patient has shown some improvement with IVIG and continues to show some gradual improvement.  I discussed with the patient the course of disease, which is often weeks to about a month or so of worsening followed by many months of gradual improvement.,I told her that it is possible she may not recover 100%, but that certainly there is still plenty of time for her to have additional recovery over what she has right now.  She is scheduled to see an ophthalmologist.  I think it is reasonable for close followup of her visual symptoms progress.  However, I certainly would not take any corrective measures at this point as I suspect her vision will improve gradually.,I discussed with the patient that with respect to her back pain certainly the Neurontin is relatively at low dose and this could be increased further.  I wanted her to start taking the Neurontin 300 mg per day and then 300 mg b.i.d. after one week.  She will call me in approximately three weeks' time to let me know how she is doing and if needed we will titrate up further.,She was apparently given some baclofen by her internist and I think this is not unreasonable.  I definitely hope to get her off the Percocet in the future.,IMPRESSION:,1.  Guillain-Barre Miller-Fisher variant.,2.  Hypertension.,3.  Diabetes mellitus.,4.  Stroke.,RECOMMENDATIONS:,1.  The patient is to start taking aspirin 162 mg per day.,2.  Followup with ophthalmology.,3.  Increase Neurontin to 300 mg per day x 1 week and then 300 mg b.i.d.,4.  Followup by phone in three to four weeks.,5.  Followup in this clinic in approximately two months' time.,6.  Call for any questions or problems.",
" Irritable baby, 6-week-old, with fever for approximately 24 hours.", Consult - History and Phy., H&P - Infant with fever ,"CHIEF COMPLAINT:, Irritable baby with fever for approximately 24 hours.,HISTORY OF PRESENT ILLNESS:, This 6-week-old infant was doing well until about 48 hours prior to admission, developed irritability, fussiness, a little bit of vomiting, and then fever up to 103-degrees. The child was brought into the emergency room and a complete septic workup was done, and the child is being treated in a rule out sepsis protocol.,PAST MEDICAL HISTORY:, This child was born by term pregnancy, spontaneous vaginal delivery, to a mother who was a teenager. He is bottle fed and he has had his hepatitis B vaccine. He lives in a home where there are smokers. This is his first illness.,PAST SURGICAL HISTORY:, He has had no previous surgeries.,MEDICATION (S):, He takes no medications on a regular basis.,REVIEW OF SYSTEMS:, Positive for those things mentioned already in the past medical history and history of present illness.,FAMILY HISTORY:, The family history is noncontributory.,SOCIAL HISTORY:, This child lives with his mother and father, both are teenagers, unmarried, who are not well educated. Grandmother is a heavy smoker.,PHYSICAL EXAMINATION:,VITAL SIGNS: The vital signs are stable, the patient is febrile at 101-degrees.,HEAD, EYES, EARS, NOSE, AND THROAT/GENERAL: The anterior fontanelle is not bulging. The rest of the examination is within normal limits. The neck is supple, no nuchal rigidity noted, though this child is irritable and fussy, and whines and cries where ever you make touch him. He has an irritable disposition no matter what you do to him, and whines even while at rest.,HEART: The heart rate is rapid, but there was no murmur noted.,LUNGS: The lungs are clear.,ABDOMEN: The abdomen is without mass, distention, or visceromegaly.,GENITOURINARY/RECTAL: Examination within normal limits.,EXTREMITIES: The extremities are normal. No Kernig's or Brudzinski sign.,NEUROLOGIC: Cranial nerves II through XII are intact, no focal deficits. As I mentioned before, the child is extremely irritable, fussy, and has a great deal of general inconsolability.,SKIN: The child, in addition, has a skin pattern of cutis marmorata, which I think is a bit more exaggerated since the child is febrile and has some peripheral vasodilatation.,CLINICAL IMPRESSION (S):, Likely viral syndrome, viral meningitis, flu syndrome.,PLAN:, Continue the septic workup protocol, supportive care with IV fluids, and Tylenol as needed for fever, and continue the antibiotics until spinal fluid cultures and blood cultures are negative for 48 hours. In addition, I believe that the rapid heart rate is a sinus tachycardia, and is related to the child's illness, irritability, and his fever. In addition, there were no intracranial bruits noted.",
 H&P for a female with Angina pectoris., Consult - History and Phy., H&P - Cardio (Angina) ,"CHIEF COMPLAINT (1/1):, This 62 year old female presents today for evaluation of angina.,Associated signs and symptoms: Associated signs and symptoms include chest pain, nausea, pain radiating to the arm and pain radiating to the jaw.,Context: The patient has had no previous treatments for this condition.,Duration: Condition has existed for 5 hours.,Quality: Quality of the pain is described by the patient as crushing.,Severity: Severity of condition is severe and unchanged.,Timing (onset/frequency): Onset was sudden and with exercise. Patient has the following coronary risk factors: smoking 1 packs/day for 40 years and elevated cholesterol for 5 years. Patient's elevated cholesterol is not being treated with medication. Menopause occurred at age 53.,ALLERGIES:, No known medical allergies.,MEDICATION HISTORY:, Patient is currently taking Estraderm 0.05 mg/day transdermal patch.,PMH:, Past medical history unremarkable.,PSH:, No previous surgeries.,SOCIAL HISTORY:, Patient admits tobacco use She relates a smoking history of 40 pack years.,FAMILY HISTORY:, Patient admits a family history of heart attack associated with father (deceased).,ROS:, Unremarkable with exception of chief complaint.,PHYSICAL EXAMINATION:,General: Patient is a 62 year old female who appears pleasant, her given age, well developed,,oriented, well nourished, alert and moderately overweight.,Vital Signs: BP Sitting: 174/92 Resp: 28 HR: 88 Temp: 98.6 Height: 5 ft. 2 in. Weight: 150 lbs.,HEENT: Inspection of head and face shows head that is normocephalic, atraumatic, without any gross or neck masses. Ocular motility exam reveals muscles are intact. Pupil exam reveals round and equally reactive to light and accommodation. There is no conjunctival inflammation nor icterus. Inspection of nose reveals no abnormalities. Inspection of oral mucosa and tongue reveals no pallor or cyanosis. Inspection of the tongue reveals normal color, good motility and midline position. Examination of oropharynx reveals the uvula rises in the midline. Inspection of lips, teeth, gums, and palate reveals healthy teeth, healthy gums, no gingival,hypertrophy, no pyorrhea and no abnormalities.,Neck: Neck exam reveals neck supple and trachea that is midline, without adenopathy or crepitance palpable.,Thyroid examination reveals smooth and symmetric gland with no enlargement, tenderness or masses noted.,Carotid pulses are palpated bilaterally, are symmetric and no bruits auscultated over the carotid and vertebral arteries. Jugular veins examination reveals no distention or abnormal waves were noted. Neck lymph nodes are not noted.,Back: Examination of the back reveals no vertebral or costovertebral angle tenderness and no kyphosis or scoliosis noted.,Chest: Chest inspection reveals intercostal interspaces are not widened, no splinting, chest contours are normal and normal expansion. Chest palpation reveals no abnormal tactile fremitus.,Lungs: Chest percussion reveals resonance. Assessment of respiratory effort reveals even respirations without use of accessory muscles and diaphragmatic movement normal. Auscultation of lungs reveal diminished breath sounds bibasilar.,Heart: The apical impulse on heart palpation is located in the left border of cardiac dullness in the midclavicular line, in the left fourth intercostal space in the midclavicular line and no thrill noted. Heart auscultation reveals rhythm is regular, normal S1 and S2, no murmurs, gallop, rubs or clicks and no abnormal splitting of the second heart sound which moves normally with respiration. Right leg and left leg shows evidence of edema +6.,Abdomen: Abdomen soft, nontender, bowel sounds present x 4 without palpable masses. Palpation of liver reveals no abnormalities with respect to size, tenderness or masses. Palpation of spleen reveals no abnormalities with respect to size, tenderness or masses. Examination of abdominal aorta shows normal size without presence of systolic bruit.,Extremities: Right thumb and left thumb reveals clubbing.,Pulses: The femoral, popliteal, dorsalis, pedis and posterior tibial pulses in the lower extremities are equal and normal. The brachial, radial and ulnar pulses in the upper extremities are equal and normal. Examination of peripheral vascular system reveals varicosities absent, extremities warm to touch, edema present - pitting and pulses are full to palpation. Femoral pulses are 2 /4, bilateral. Pedal pulses are 2 /4, bilateral.,Neurological: Testing of cranial nerves reveals nerves intact. Oriented to person, place and time. Mood and affect normal and appropriate to situation.Deep tendon reflexes normal. Touch, pin, vibratory and proprioception sensations are normal. Babinski reflex is absent. Coordination is normal. Speech is not aphasic. Musculoskeletal: Muscle strength is 5/5 for all groups tested. Gait and station examination reveals midposition without abnormalities.,Skin: No skin rash, subcutaneous nodules, lesions or ulcers observed. Skin is warm and dry with normal turgor and there is no icterus.,Lymphatics: No lymphadenopathy noted.,IMPRESSION:, Angina pectoris, other and unspecified.,PLAN:, ,DIAGNOSTIC & LAB ORDERS:, Ordered serum creatine kinase isoenzymes (CK isoenzymes). Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report. The following cardiac risk factor modifications are recommended: quit smoking and reduce LDL cholesterol to below 120 mg/dl.,PATIENT INSTRUCTIONS:",
 Dysarthria.  Probable brainstem glioma., Consult - History and Phy., Glioma - 1 ,"CC:, Dysarthria,HX: ,This 52y/o RHF was transferred from a local hospital to UIHC on 10/28/94 with a history of progressive worsening of vision, dysarthria, headache, and incoordination beginning since 2/94. Her husband recalled her first difficulties became noticeable after a motor vehicle accident in 2/94. She was a belted passenger in a car struck at a stop. There was no reported head or neck injury or alteration of consciousness. She was treated and released from a local ER the same day. Her husband noted the development of mild dysarthria, incoordination, headache and exacerbation of preexisting lower back pain within 2 week of the accident. In 4/94 she developed stress urinary incontinence which spontaneously resolved in June. In 8/94, her HA changed from a dull constant aching in the bitemporal region to a sharper constant pain in the nuchal/occipital area. She also began experiencing increased blurred vision, worsening dysarthria and difficulty hand writing. In 9/94 she was evaluated by a local physician. Examination then revealed incoordination, generalized fatigue, and dysarthria. Soon after this she became poorly arousable and increasingly somnolent. She had difficulty walking and generalized weakness. On 10/14/94, she lost the ability to walk by herself. Evaluation at a local hospital revealed: 1)Normal electronystagmography, 2)two lumbar punctures which revealed some atypical mononuclear cells suggestive of ""tumor or reactive lymphocytosis."" One of these CSF analysis showed: Glucose 16, Protein 99, WBC 14, RBC 114. Echocardiogram was normal. Bone marrow biopsy was normal except for decreased iron. Abdominal-Pelvic CT scan, CXR, Mammogram, PPD, ANA, TFT, and RPR were unremarkable. A 10/31/94 MRI brain scan a 5x10mm area of increased signal on T2 weighted images in the right remporal lobe lateral to the anterior aspect of the temporal horn, right posterolateral aspect of the midbrain, pons, and bilateral inferior surface of the cerebellum involving gray and white matter. These areas did not enhance with gadolinium contrast on T1 weighted images.,MEDS: ,none.,PMH:, 1)G3P3, 2)last menses one year ago.,FHX:, Mother suffered stroke in her 70's. DM and Htn in family.,SHX:, Married, Secretary, No h/o tobacco/ETOH/illicit drug use.,ROS:, no weight loss, fever, chills, nightsweats, cough, dysphagia.,EXAM:, BP139/74, HR 90, RR20, 36.8C,MS: Drowsy to somnolent, occasionally ""giddy."" Oriented to person, place, time. Minimal dysarthric speech, but appropriate. MMSE 27/30 (copy of exam not in chart).,CN: Pupils 4/4 decreasing to 2/2 on exposure to light. Optic disks were flat and without sign of papilledema. VFFTC. EOM intact. No nystagmus. The rest of the CN exam was unremarkable.,Motor: 5/5 strength throughout. Normal muscle tone and bulk.,Sensory: No deficit to LT/PP/VIB/PROP.,Coord: difficulty with RAM in BUE, and ataxia on FNF and HKS in all extremities.,Station: Romberg sign present.,Gait: unsteady, wide-based, with notable difficulty on TW, TT and HW.,Reflexes: 2/2 BUE, 0/1 patellae, trace at both archilles, Plantars responses were flexor, bilaterally.,Gen Exam: unremarkable.,COURSE:, CSF analysis by lumbar puncture, 10/31/94: Protein 131mg/dl (normal 15-45), Albumin 68 (normal 14-20), IgG10mg/dl (normal <6.2), IgG index -O.1mg/24hr (normal),,No oligoclonal bands seen, WBC 33 (19lymphocytes, 1 neutrophil), RBC 29, Glucose 13, Cultures (bacteria, fungal, AFB) were negative, crytococcal Ag negative. The elevated CSF total protein, IgG, and albumin suggested breakdown of the blood brain barrier or blockage of CSF flow. The normal IgG synthesis rate and lack of oligoclonal banding did not suggest demylination. A second CSF analysis on 11/2/94 revealed similar findings; and in addition Anti-purkinje cell and Anti-neuronal antibodies (Yo and Ho) were not found; Beta-2 microglobulin was 1.8 (normal); histoplasmosis Ag negative. Serum ACE, SPEP, Urine histoplasmin were negative.,Neuropsychologic assessment, 10/28/94, raised a question of a demential syndrome, but given her response style on the MMPI (marked defensiveness, with unwillingness to admit to even very common human faults) prevented such a diagnosis. Severe defects in memory, fine motor skills, and constructional praxis were noted.,Chest-Abdominal-Pelvic CT scans were negative. 11/4/94 cerebral angiogram noted variable caliber in the RMCA, LACA and Left AICA distributions. It was intially thought that thismight be suggestive of a vasculopathy and she was treated with a short course of IV steroids. Temporal artery biopsy was unremarkable.,She underwent multiple MRI brain scans at UIHC: 11/4/94, 11/9/94, 11/16/94. All scans consistently showed increase in T2 signal in the brainstem, cerebellar peduncles and temporal lobes bilaterally. These areas did not enhance with gadolinium contrast. These findings were felt most suggestive of glioma.,She underwent left temporal lobe brain biopsy on 11/10/94: This study was inconclusive and showed evidence of atypical mononuclear cells and lymphocytes in the perivascular and subarachnoid spaces. Despite cytologic atypia the cells were felt to be reactive in nature, since immunohistochemical stains failed to disclose lymphoid clonality or non-leukocytic phenomena. Little sign of vasculopathy or tumor was found. Bacterial, fungal , HSV, CMV and AFB cultures were negative. HSV, and VZV antigen was negative.,Her neurological state progressively worsened throughout her hospital stay. By time of discharge, 12/2/94, she was very somnolent and difficult to arouse and required NGT feeding and 24hour supportive care. She was made DNR after family request prior to transfer to a care facility.",
 Nausea and abdominal pain after eating - Gall bladder disease - Laparoscopic cholecystectomy scheduled., Consult - History and Phy., GI Consultation - 4 ,"CHIEF COMPLAINT:, Nausea and abdominal pain after eating.,GALL BLADDER HISTORY:, The patient is a 36 year old white female.  Patient's complaints are fatty food intolerance, dark colored urine, subjective chills, subjective low-grade fever, nausea and sharp stabbing pain. The patient's symptoms have been present for 3 months. Complaints are relieved with lying on right side and antacids. Prior workup by referring physicians have included abdominal ultrasound positive for cholelithiasis without CBD obstruction. Laboratory studies that are elevated include total bilirubin and elevated WBC.,PAST MEDICAL HISTORY:, No significant past medical problems.,PAST SURGICAL HISTORY:, Diagnostic laparoscopic exam for pelvic pain/adhesions.,ALLERGIES:, No known drug allergies.,CURRENT MEDICATIONS:, No current medications.,OCCUPATIONAL /SOCIAL HISTORY:, Marital status: married. Patient states smoking history of 1 pack per day. Patient quit smoking 1 year ago. Admits to no history of using alcohol. States use of no illicit drugs.,FAMILY MEDICAL HISTORY:, There is no significant, contributory family medical history.,OB GYN HISTORY:, LMP: 5/15/1999. Gravida: 1. Para: 1.  Date of last pap smear: 1/15/1998.,REVIEW OF SYSTEMS:,Cardiovascular: Denies angina, MI history, dysrhythmias, palpitations, murmur, pedal edema, PND, orthopnea, TIA's, stroke, amaurosis fugax.,Pulmonary: Denies cough, hemoptysis, wheezing, dyspnea, bronchitis, emphysema, TB exposure or treatment.,Neurological: Patient admits to symptoms of seizures and ataxia.,Skin: Denies scaling, rashes, blisters, photosensitivity.,PHYSICAL EXAMINATION:,Appearance: Healthy appearing. Moderately overweight.,HEENT: Normocephalic. EOM's intact. PERRLA. Oral pharynx without lesions.,Neck: Neck mobile. Trachea is midline.,Lymphatic: No apparent cervical, supraclavicular, axillary or inguinal adenopathy.,Breast: Normal appearing breasts bilaterally, nipples everted.  No nipple discharge, skin changes.,Chest: Normal breath sounds heard bilaterally without rales or rhonchi.  No pleural rubs. No scars.,Cardiovascular: Regular heart rate and rhythm without murmur or gallop.,Abdominal: Bowel sounds are high pitched.,Extremities: Lower extremities are normal in color, touch and temperature. No ischemic changes are noted. Range of motion is normal.,Skin: Normal color, temperature, turgor and elasticity; no significant skin lesions.,IMPRESSION DIAGNOSIS:  ,  Gall Bladder Disease. Abdominal Pain.,DISCUSSION:, Laparoscopic Cholecystectomy handout was given to the patient, reviewed with them and questions answered. The patient has given both verbal and written consent for the procedure.,PLAN:, We will proceed with Laparoscopic Cholecystectomy with intraoperative cholangiogram.,MEDICATIONS PRESCRIBED:,",
 Headache and diplopia., Consult - History and Phy., Granulomatous Inflammation ,"CC:, Headache and diplopia.,HX:, This 39 y/o African American female began experiencing severe constant pressure pain type headaches beginning the last week of 8/95. The pain localized to bifronto-temporal regions of the head and did not radiate. There was no associated nausea, vomiting, photophobia or phonophobia. The HA's occurred daily; and throughout daylight hours. They diminished at bedtime, but occasionally awakened her in the morning.,Several days following the onset of her HA's, she began experiencing numbness and tingling about the right side of her face. These symptoms improved, but did not completely resolved.,Several days after the onset of facial paresthesias, she began to experience binocular horizontal diplopia. The diplopia resolved when covering either eye, and worsened upon looking toward the right. Coincidentally, she began veering toward the right when walking. She denied any weakness. She had had chronic unsteadiness for many years since developing juvenile rheumatoid arthritis. She was unsure whether her unsteadiness was due to poor depth perception in light of her diplopia.,The patient was admitted locally 9/2/95. HCT, 9/2/95 and Brain MRI with gadolinium, 9/3/95, were ""unremarkable."" Lumbar puncture (done locally),9/3/95: Opening pressure 27cm H20, CSF analysis ( protein 14.0, glucose 66, O WBC, 3 RBC, VDRL non-reactive, Lyme titer unremarkable, Myelin basic protein 1.0 (normal <4.0), and there was no evidence of oligoclonal bands. ESR=76. On 9/11/95 ESR=110. Acetylcholine receptor binding and blocking antibodies were negative. 9/4/95, ANA and RF were negative. 7/94, ANA and RF were negative, and ESR=60.,MEDS: ,Tylenol 500mg q5-6hrs. No known Allergies.,PMH:, 1)Juvenile Rheumatoid Arthritis diagnosed at age 10 years; now in remission. 2)Right #5 finger reattachment as child due to traumatic amputation.,FHX: ,Mother died age 42 of unknown type cancer. Father died age 62 of unknown type cancer. 4 sisters, one brother and 2 half-brothers. One of the half-brothers has asthma.,SHX: ,Single, lives with sister, and denies Tobacco/ETOH/illicit drug use.,EXAM:, BP141/84, HR99, RR14, 36.8C, Wt. 82kg Ht. 152.,MS: A&O to person, place, time. Speech fluent; without dysarthria. Mood euthymic with appropriate affect.,CN: Decreased abduction, OD. In neutral gaze, the right eye deviated slightly lateral of midline. In addition, she had mild proptosis, OD. The right eye was nontender to palpation during extraocular movement. Visual fields were full to confrontation. Optic disks appeared flat. Face was symmetric with full movement and sensation. Gag, shoulder shrug and corneal responses were intact, bilaterally. Tongue was midline with full ROM.,MOTOR: 5/5 strength throughout with normal muscle bulk and tone.,SENSORY: Unremarkable.,COORD: Unremarkable FNF/HKS/RAM.,STATION: Unremarkable. NO Romberg's sign or drift.,GAIT: Narrow based gait. Able to TT and HW without difficulty. Mild difficulty with TW.,REFLEXES: 2+/2+ Throughout all 4 extremities. Flexor plantar responses, bilaterally.,Musculoskeletal: Swan neck deformities of the #2 and #3 digits of both hands.,GEN EXAM: unremarkable, except for obvious sign of right finger reattachment (mentioned above).,COURSE: ,Repeat lumbar puncture yielded: Opening pressure 20.25cm H20, protein 22, glucose 62, 2RBC, 1WBC. CSF cytology, ACE, cultures (bacterial, fungal, AFB), gram stain, cryptococcal antigen, and VDRL were negative. Serum ACE, TSH, FT4 were unremarkable.,Neuroophthalmology confirmed her right CN6 palsy and proptosis (OD); and noted her complaint of paresthesias in the V1 and V2 distribution. They saw no evidence of papilledema. Visual field testing was unremarkable. MRI Brain/orbit/neck with gadolinium, 10/20/95, revealed abnormal enhancing signal in the right cavernous sinus and sinus mucosal thickening in both maxillary sinuses/ethmoid sinuses/frontal sinuses. CXR, 10/20/95, showed a lobulated mass arising from the right hilum. The mass appeared to obstruct the right middle lobe, causing partial collapse of this lobe. Chest CT with contrast, 10/23/95, revealed a 3.2x4.5x4.0cm mass in the right hilar region with impingement on the right lower bronchus. There appeared to be calcification as well as low attenuation regions within the mass. No lymphadenopathy was noted. She underwent bronchoscopy with bronchial brushing and transbronchial aspirate of the right lung on 10/24/95: no tumor cells were identified, GMS stains were negative and there was no evidence of viral changes, fungus or PCP by culture or molecular assay. She underwent right maxillary sinus biopsy and right middle lobe wedge resection and lymph node biopsy on 11/2/95: Caseating granulomatous inflammation with associated inflammatory pseudotumor was found in both sinus and lung biopsy specimens. No sign of cancer was found. Tissue cultures (bacterial, fungal, AFB) were negative times 3. The patients case was discussed at Head and Neck Oncology Tumor Board and a differential diagnosis of Sarcoidosis, Histoplasmosis, Wegener's Granulomatosis, were considered. Urine Histoplasmosis Antigen testing on 11/8/95 was 0.9units (normal<1.0): repeat testing on 12/13/95 was 0.8units. ANCA serum titers on 11/8/95 were <1:40 (normal). PPD testing was negative 11/95 (with positive candida and mumps controls).,The etiology of this patient's illness was not discovered. She was last seen 4/96 and her diplopia and right CN6 palsy had moderately improved.",
 Headache.  Right frontal lobe glioma., Consult - History and Phy., Glioma - 2 ,"CC:, Headache,HX: ,37 y/o RHF presented to her local physician with a one month history of intermittent predominantly left occipital headaches which were awakening her in the early morning hours. The headachese were dull to throbbing in character. She was initially treated with Parafon-forte for tension type headaches, but the pain did not resolve. She subsequently underwent HCT in early 12/90 which revealed a right frontal mass lesion.,PMH: ,1)s/p tonsillectomy. 2)s/p elective abortion.,FHX:, Mother with breast CA, MA with ""bone cancer."" AODM both sides of family.,SHX: ,Denied tobacco or illicit drug use. Rarely consumes ETOH. Married with 2 teenage children.,EXAM: ,VItal signs unremarkable.,MS: Alert and oriented to person, place, time. Lucid thought process per NSG note.,CN: unremarkable.,Motor: full strength with normal muscle bulk and tone.,Sensory: unremarkable.,Coordination: unremarkable.,Station/Gait: unremarkable.,Reflexes: unremarkable.,Gen. Exam: unremarkable.,COURSE:, MRI Brain: large solid and cystic right frontal lobe mass with a large amount of surrounding edema. There is apparent tumor extension into the corpus callosum across the midline. Tumor extension is also suggested in the anterior limb of the interanl capsule on the right. There is midline mass shift to the left with effacement of the anterior horn of the right lateral ventricle. The MRI findings are most consistent with glioblastoma.,The patient underwent right frontal lobectomy. The pathological diagnosis was xanthomatous astrocytoma. The literature at the time was not clear as to optimal treatment protocol. People have survived as long as 25 years after diagnosis with this type of tumor. XRT was deferred until 11/91 when an MRI and PET Scan suggested extension of the tumor. She then received 5580 cGy of XRT in divided segments. She developed olfactory auras shortly after lobectomy at was treated with PB with subsequent improvement. She was treated with BCNU chemotherapy protocol in 1992.","consult - history and phy., frontal lobe, tumor extension, glioma, headache, lobectomy, astrocytoma, "
 Asked to see the patient in regards to a brain tumor.  She was initially diagnosed with a glioblastoma multiforme.  She presented with several lesions in her brain and a biopsy confirmed the diagnosis. , Consult - History and Phy., Glioblastoma Multiforme - Consult ,"REASON FOR CONSULTATION: , We were asked to see the patient in regards to a brain tumor.,HISTORY OF PRESENT ILLNESS: ,She was initially diagnosed in September of this year with a glioblastoma multiforme.  She presented with several lesions in her brain and a biopsy confirmed the diagnosis.  She was seen by Dr. X in our group.  Because of her living arrangement, she elected to have treatment through the hospital radiation department and oncology department.  Details of her treatment are not available at the time of this dictation.  Her family has a packet of Temodar 100-mg pills.  She is admitted now with increasing confusion.  A CT shows increase in size of the lesions compared to the preoperative scan.  We are asked to comment on her treatment at this point.  She herself is confused and is unable to provide further history.  ,PAST MEDICAL HISTORY: , From her old chart:  No known past medical history prior to the diagnosis.,SOCIAL HISTORY:  ,She was living alone and is now living in assisted living.  ,MEDICATIONS,1.  Dilantin 300 mg daily.,2.  Haloperidol 1 mg h.s.,3.  Dexamethasone 4 mg q.i.d. ,4.  Docusate 100 mg b.i.d.,5.  Pen-VK 500 mg daily.,6.  Ibuprofen 600 mg daily.,7.  Zantac 150 mg twice a day.,8.  Temodar 100 mg daily.,9.  Magic Mouthwash daily.,10.  Tylenol #3 as needed.,REVIEW OF SYSTEMS,:  Unable.,PHYSICAL EXAMINATION,GENERAL:  Elderly woman, confused.  ,HEENT:  Normal conjunctivae.  Ears and nose normal.  Mouth normal.,NECK:  Supple.,CHEST: Clear.,HEART:  Normal.,ABDOMEN: Soft, positive bowel sounds.,NEUROLOGIC:  Alert, cranial nerves intact.  Left arm slightly weak.  Left leg slightly weak.,IMPRESSION AND PLAN:,  Glioblastoma multiforme, uncertain as to where she is in cancer treatment.  Given the number of pills in the patient's family's hands, it sounds like she has only been treated recently and therefore it is not surprising that she is showing increased problems related to increased size of the tumor.  We will have to talk with Dr. Y in the Clinic to get a better handle on her treatment regimen.  At this point, I will hold Temodar today and consider restarting it tomorrow if we can get her treatment plan clarified.",
" Progressive low-grade glioma, now more than 20 years since initially diagnosed.  She is status post craniotomy for debulking and has done well with the surgery.", Consult - History and Phy., Glioma - Consult ,"REASON FOR CONSULTATION: , Glioma.,HISTORY OF PRESENT ILLNESS:,  The patient is a 71-year-old woman who was initially diagnosed with a brain tumor in 1982.  She underwent radiation therapy for this, although craniotomy was not successful for a biopsy because of seizure activity during the surgery.  She did well for the next 10 years or so, and developed Parkinson disease, possibly related to radiation therapy.  She has been followed by neurology, Dr. Z, to treat seizure activity.  She has a vagal stimulator in place to help control her seizure activity.,Over the last few months, she has had increasing weakness on the right side.  She has been living in a nursing home.  She has not been able to walk, and she has not been able to write for the past three to four years.,MRI scan done on 11/13/2006 showed increase in size of the abdominal area and the left parietal region.  There was slight enhancement and appearance was consistent with a medium- to low-grade tumor anterior to the motor cortex.,Surgery was performed during this admission to remove some of the posterior part of the tumor.  She tolerated the procedure well.  She has noticed no worsening or improvement in her weakness.  Pathology shows a low- to intermediate-grade glioma.  The second opinion by Dr. A is still pending.,The patient is feeling well today.  She is not having headache, and reports no new neurologic symptoms.  She has not had leg swelling, cough, shortness of breath, or chest pain.,CURRENT MEDICATIONS:  ,1.  Ambien p.r.n.  ,2.  Vicodin p.r.n.  ,3.  Actonel every Sunday.  ,4.  Colace.  ,5.  Felbatol 1200 mg b.i.d.  ,6.  Heparin injections for prophylaxis.  ,7.  Maalox p.r.n.  ,8.  Mirapex 0.5 mg t.i.d.  ,9.  Protonix 40 mg daily.  ,10.  Tylenol p.r.n.  ,11.  Zanaflex 4-mg tablet, one-half tablet daily and 6 mg at bedtime.  ,12.  She has Zofran p.r.n., albuterol inhaler q.i.d., and Aggrenox, which she is to start.,The rest of the history is mostly from the chart.,ALLERGIES: , SHE IS ALLERGIC TO PENICILLIN.,PAST MEDICAL HISTORY:  ,1.  Parkinson's, likely secondary to radiation therapy.,2.  History of prior stroke.,3.  Seizure disorder secondary to her brain tumor.,4.  History of urinary incontinence.,5.  She has had hip fractures x2, which have required surgical pinning.,6.  Appendectomy.,7.  Cholecystectomy.,SOCIAL HISTORY:,  Shows that she does not smoke cigarettes or drink alcohol.  She lives in a nursing home.,FAMILY HISTORY:,  Shows a family history of breast cancer.,PHYSICAL EXAMINATION:,  ,GENERAL:  Today, she is sitting up in the chair, alert, and appropriate.  She tends to lean towards the right.  The right arm and hand are noticeably weaker than the left.  She is quite thin.,VITAL SIGNS:  Temperature is 98.5, blood pressure is 138/75, pulse is 76, respirations are 16, and pulse oximetry is 92% on room air.,HEENT:  There is a craniotomy incision on the left parietal region, clean, and dry with stitches still in place.  The oropharynx shows no thrush or mucositis.,LUNGS:  Clear bilaterally to auscultation.,CARDIAC:  Exam shows regular rate.,ABDOMEN:  Soft.,EXTREMITIES:  No peripheral edema or evidence of deep venous thrombosis (DVT) is noted on the lower extremities.,IMPRESSION AND PLAN:,  Progressive low-grade glioma, now more than 20 years since initially diagnosed.  She is status post craniotomy for debulking and has done well with the surgery.,We reviewed the phase II trials that have used Temodar in the setting of grade 2 gliomas.  Although, complete responses are rare, it is quite common to have partial response and/or stable disease, and most patients had improved quality of life indices including many patients who benefit from decreased seizure activity.  We discussed using Temodar after she heals from her surgery.  Toxicities would include fatigue, nausea, and myelosuppression primarily.",
" Weakness, malaise dyspnea on exertion, 15-pound weight loss - Bilateral pneumonia, hepatitis, renal insufficiency, ", Consult - History and Phy., Gen Med H&P - 2 ,"HISTORY OF PRESENT ILLNESS: , This is a 43-year-old black man with no apparent past medical history who presented to the emergency room with the chief complaint of weakness, malaise and dyspnea on exertion for approximately one month.  The patient also reports a 15-pound weight loss.  He denies fever, chills and sweats.  He denies cough and diarrhea.  He has mild anorexia.,PAST MEDICAL HISTORY:,  Essentially unremarkable except for chest wall cysts which apparently have been biopsied by a dermatologist in the past, and he was given a benign diagnosis.  He had a recent PPD which was negative in August 1994.,MEDICATIONS: , None.,ALLERGIES: , No known drug allergies.,SOCIAL HISTORY: , He occasionally drinks and is a nonsmoker.  The patient participated in homosexual activity in Haiti during 1982 which he described as ""very active."" Denies intravenous drug use.  The patient is currently employed.,FAMILY HISTORY:,  Unremarkable.,PHYSICAL EXAMINATION:,GENERAL:  This is a thin, black cachectic man speaking in full sentences with oxygen.,VITAL SIGNS:  Blood pressure 96/56, heart rate 120.  No change with orthostatics.  Temperature 101.6 degrees Fahrenheit.  Respirations 30.,HEENT:  Funduscopic examination normal.  He has oral thrush.,LYMPH:  He has marked adenopathy including right bilateral epitrochlear and posterior cervical nodes.,NECK:  No goiter, no jugular venous distention.,CHEST:  Bilateral basilar crackles, and egophony at the right and left middle lung fields.,HEART:  Regular rate and rhythm, no murmur, rub or gallop.,ABDOMEN:  Soft and nontender.,GENITOURINARY:  Normal.,RECTAL:  Unremarkable.,SKIN:  The patient has multiple, subcutaneous mobile nodules on the chest wall that are nontender.  He has very pale palms., ,LABORATORY AND X-RAY DATA: , Sodium 133, potassium 5.3, BUN 29, creatinine 1.8.  Hemoglobin 14, white count 7100, platelet count 515.  Total protein 10, albumin 3.1, AST 131, ALT 31.  Urinalysis shows 1+ protein, trace blood.  Total bilirubin 2.4, direct bilirubin 0.1.  Arterial blood gases:  pH 7.46, pC02 32, p02 46 on room air.  Electrocardiogram shows normal sinus rhythm.  Chest x-ray shows bilateral alveolar and interstitial infiltrates.,IMPRESSION:,1.  Bilateral pneumonia; suspect atypical pneumonia, rule out Pneumocystis carinii pneumonia and tuberculosis.,2.  Thrush.,3.  Elevated unconjugated bilirubins.,4.  Hepatitis.,5.  Elevated globulin fraction.,6.  Renal insufficiency.,7.  Subcutaneous nodules.,8.  Risky sexual behavior in 1982 in Haiti.,PLAN:,1.  Induced sputum, rule out Pneumocystis carinii pneumonia and tuberculosis.,2.  Begin intravenous Bactrim and erythromycin.,3.  Begin prednisone.,4.  Oxygen.,5.  Nystatin swish and swallow.,6.  Dermatologic biopsy of lesions.,7.  Check HIV and RPR.,8.  Administer Pneumovax, tetanus shot and Heptavax if indicated.",
 GI Consultation for Chrohn's disease., Consult - History and Phy., GI Consultation - 3 ,"PROBLEM:  ,Prescription evaluation for Crohn's disease., ,HISTORY: , This is a 46-year-old male who is here for a refill of Imuran.  He is taking it at a dose of 100 mg per day.  He is status post resection of the terminal ileum and has experienced intermittent obstructive symptoms for the past several years.  In fact, he had an episode three weeks ago in which he was seen at the emergency room after experiencing sudden onset of abdominal pain and vomiting. An x-ray was performed, which showed no signs of obstruction per his report.  He thinks that the inciting factor of this incident was too many grapes eaten the day before.  He has had similar symptoms suggestive of obstruction when eating oranges or other high-residue fruits in the past.  The patient's normal bowel pattern is loose stools and this is unchanged recently.  He has not had any rectal bleeding. He asks today about a rope-like vein on his anterior right arm that has been a little tender and enlarged after he was in the emergency room and they had difficulty with IV insertion.  He has not had any fever, red streaking up the arm, or enlargement of lymph nodes.  The tenderness has now completely resolved.  , ,He had a colonoscopy performed in August of 2003, by Dr. S.  An anastomotic stricture was found at the terminal ileum/cecum junction.  Dr. S recommended that if the patient experienced crampy abdominal pain or other symptoms of obstruction, that he may consider balloon dilation.  No active Crohn's disease was found during the colonoscopy.  , ,Earlier this year, he experienced a non-specific hepatitis with elevation of his liver function tests.  At that time he was taking a lot of Tylenol for migraine-type headaches.  Under Dr. S's recommendation, he stopped the Imuran for one month and reduced his dose of Tylenol.  Since that time his liver enzymes have normalized and he has restarted the Imuran with no problems.  , ,He also reports heartburn that is occurring on a slightly more frequent basis than it has in the past.  It used to occur once a week only, but has now increased in frequency to twice a week.  He takes over-the-counter H2 blockers as needed, as well as Tums.  He associates the onset of his symptoms with eating spicy Mexican food., ,PAST MEDICAL HISTORY: , Reviewed and unchanged.,ALLERGIES: , No known allergies to medications.,OPERATIONS: , Unchanged.,ILLNESSES: , Crohn's disease, vitamin B12 deficiency.,MEDICATIONS:,  Imuran, Nascobal, Vicodin p.r.n., ,REVIEW OF SYSTEMS: , Dated 08/04/04 is reviewed and noted.  Please see pertinent GI issues as discussed above.  Otherwise unremarkable., ,PHYSICAL EXAMINATION:  , GENERAL:  Pleasant male in no acute distress.  Well nourished and well developed. SKIN: indurated, cord-like superficial vein on the right anterior forearm, approx. 3 cm in length.  Non-tender to palpation. No erythema or red streaking.  No edema. LYMPH:  No epitrochlear or axillary lymph node enlargement or tenderness on the right side. , ,DATA REVIEWED: Labs from June 8th and July 19th reviewed.  Liver function tests normal with AST 14 and ALT 44.  WBCs were slightly low at 4.8.  Hemoglobin dropped slightly from 14.1 on 6/8 to 12.9 on 7/19. Hematocrit dropped slightly as well from 43.2 on 6/804 to 40.0 on 7/19/04.  These results were reviewed by Dr. S and lab results letter sent., ,IMPRESSION:  ,1. Crohn's disease, status post terminal ileum resection, on Imuran.  Intermittent symptoms of bowel obstruction.  Last episode three weeks ago.,2.  History of non-specific hepatitis while taking high doses of Tylenol.  Now resolved. ,2.  Increased frequency of reflux symptoms.,3.  Superficial thrombophlebitis, resolving. ,4.  Slightly low H&H., ,PLAN:  ,1.  We discussed Dr. S's recommendation that the patient undergo balloon dilation for recurrent bowel obstruction type symptoms.  The patient emphatically states that he does not want to consider dilation at this time.  The patient is strongly encouraged to call us when he does experience any obstructive symptoms, including abdominal pain, nausea, vomiting, or change in bowel habits.  He states understanding of this. Advised to maintain low residue diet to avoid obstructions. ,2.  Continue with liver panel and ABC every month per Dr. S's instructions.,3.  Continue Imuran 100 mg per day.,4.  Continue to minimize Tylenol use.  The patient is wondering if he can take another type of medication for migraines that is not Tylenol or antiinflammatories or aspirin.  Dr. S is consulted and agrees that Imitrex is an acceptable alternative for migraine headaches since he does not have advanced liver disease. The patient will make an appointment with his primary care provider to discuss this further. ,5.  Reviewed the importance of prophylactic treatment of reflux-type symptoms.  Encouraged the patient to take over-the-counter H2 blockers on a daily basis to prevent symptoms from occurring.  The patient will try this and if he remains symptomatic, then he will call our office and a prescription for Zantac 150 mg per day will be provided.  Reviewed the potential need for upper endoscopy should his symptoms continue or become more frequent.  He does not want to undergo any type of procedure such as that at this time.,6.",
" History and Physical - A history of stage IIIC papillary serous adenocarcinoma of the ovary, presented to the office today left leg pain (left leg DVT).", Consult - History and Phy., Gen Med H&P - 1 ,"CHIEF COMPLAINT:, Left leg pain.,HISTORY OF PRESENT ILLNESS:, The patient is a 59-year-old gravida 1, para 0-0-1-0, with a history of stage IIIC papillary serous adenocarcinoma of the ovary who presented to the office today with left leg pain that started on Saturday. The patient noticed the pain in her left groin and left thigh and also noticed swelling in that leg. A Doppler ultrasound of her leg that was performed today noted a DVT. She is currently on course one, day 14 of 21 of Taxol and carboplatin. She is scheduled for intraperitoneal port placement for intraperitoneal chemotherapy to begin next week. She denies any chest pain or shortness of breath, nausea, vomiting, or dysuria. She has a positive appetite and ambulates without difficulty.,PAST MEDICAL HISTORY:,1. Gastroesophageal reflux disease.,2. Mitral valve prolapse.,3. Stage IIIC papillary serous adenocarcinoma of the ovaries.,PAST SURGICAL HISTORY:,1. A D and C.,2. Bone fragment removed from her right arm.,3. Ovarian cancer staging.,OBSTETRICAL HISTORY:, Spontaneous miscarriage at 3 months approximately 30 years ago.,GYNECOLOGICAL HISTORY: ,The patient started menses at age 12; she states that they were regular and occurred every month. She finished menopause at age 58. She denies any history of STDs or abnormal Pap smears. Her last mammogram was in April 2005 and was within normal limits.,FAMILY HISTORY:,1. A sister with breast carcinoma who was diagnosed in her 50s.,2. A father with gastric carcinoma diagnosed in his 70s.,3. The patient denies any history of ovarian, uterine, or colon cancer in her family.,SOCIAL HISTORY:, No tobacco, alcohol, or drug abuse.,MEDICATIONS:,1. Prilosec.,2. Tramadol p.r.n.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 97.3, pulse 91, respiratory rate 18, blood pressure 142/46, O2 saturation 99% on room air.,GENERAL: Alert, awake, and oriented times three, no apparent distress, a well-developed, well-nourished white female.,HEENT: Normocephalic and atraumatic. The oropharynx is clear. The pupils are equal, round, and reactive to light.,NECK: Good range of motion, nontender, no thyromegaly.,CHEST: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi.,CARDIOVASCULAR: Regular rate and rhythm with a 2/6 systolic ejection murmur on her left side.,ABDOMEN: Positive bowel sounds, soft, nontender, nondistended, no hepatosplenomegaly, a well-healing midline incision.,EXTREMITIES: 2+ pulses bilaterally, right leg without swelling, nontender, no erythema, negative Homans' sign bilaterally, left thigh swollen, erythematous, and warm to the touch compared to the right. Her left groin is slightly tender to palpation.,LYMPHATICS: No axillary, groin, clavicular, or mandibular nodes palpated.,LABORATORY DATA:, White blood cell count 15.5, hemoglobin 11.4, hematocrit 34.5, platelets 159, percent neutrophils 88%, absolute neutrophil count 14,520. Sodium 142, potassium 3.3, chloride 103, CO2 26, BUN 15, creatinine 0.9, glucose 152, calcium 8.7. PT 13.1, PTT 28, INR 0.97.,ASSESSMENT AND PLAN:, Miss Bolen is a 59-year-old gravida 1, para 0-0-1-0 with stage IIIC papillary serous adenocarcinoma of the ovary. She is postop day 21 of an exploratory laparotomy with ovarian cancer staging. She is currently with a left leg DVT.,1. The patient is doing well and is currently without any complaints. We will start Lovenox 1 mg per kg subcu daily and Coumadin 5 mg p.o. daily. The patient will receive INR in the morning; the goal was obtain an INR between 2.5 and 3.0 before the Lovenox is instilled. The patient is scheduled for port placement for intraperitoneal chemotherapy and this possibly may be delayed.,2. Aranesp 200 mcg subcu was given today. The patient's absolute neutrophil count is 14,520.",
" Patient with several medical problems - numbness, tingling, and a pain in the toes.", Consult - History and Phy., Gen Med Consult - 6 ,"SUBJECTIVE:,  The patient is in with several medical problems.  She complains of numbness, tingling, and a pain in the toes primarily of her right foot described as a moderate pain.  She initially describes it as a sharp quality pain, but is unable to characterize it more fully.  She has had it for about a year, but seems to be worsening.  She has little bit of paraesthesias in the left toe as well and seem to involve all the toes of the right foot.  They are not worse with walking.  It seems to be worse when she is in bed.  There is some radiation of the pain up her leg.  She also continues to have bilateral shoulder pains without sinus allergies.  She has hypothyroidism.  She has thrombocythemia, insomnia, and hypertension.,PAST MEDICAL HISTORY:,  Surgeries include appendectomy in 1933, bladder obstruction surgery in 1946, gallbladder surgery in 1949, another gallbladder surgery in 1954, C-section in 1951, varicose vein surgery in 1951 and again in 1991, thyroid gland surgery in 1964, hernia surgery in 1967, bilateral mastectomies in 1968 for benign disease, hysterectomy leaving her ovaries behind in 1970, right shoulder surgery x 4 and left shoulder surgery x 2 between 1976 and 1991, and laparoscopic bowel adhesion removal in October 2002.  She had a Port-A-Cath placed in June 2003, left total knee arthroplasty in June 2003, and left hip pinning due to fracture in October 2003, with pins removed in May 2004.  She has had a number of colonoscopies; next one is being scheduled at the end of this month.  She also had a right total knee arthroplasty in 1993.  She was hospitalized for synovitis of the left knee in April 2004, for zoster and infection of the left knee in May 2003, and for labyrinthitis in June 2004.,ALLERGIES: , Sulfa, aspirin, Darvon, codeine, NSAID, amoxicillin, and quinine.,CURRENT MEDICATIONS:,  Hydroxyurea 500 mg daily, Metamucil three teaspoons daily, amitriptyline 50 mg at h.s., Synthroid 0.1 mg daily, Ambien 5 mg at h.s., triamterene/hydrochlorothiazide 75/50 daily, and Lortab 5/500 at h.s. p.r.n.,SOCIAL HISTORY:,  She is a nonsmoker and nondrinker.  She has been widowed for 18 years.  She lives alone at home.  She is retired from running a restaurant.,FAMILY HISTORY:,  Mother died at age 79 of a stroke.  Father died at age 91 of old age.  Her brother had prostate cancer.  She has one brother living.  No family history of heart disease or diabetes.,REVIEW OF SYSTEMS:,General:  Negative.,HEENT:  She does complain of some allergies, sneezing, and sore throat.  She wears glasses.,Pulmonary history:  She has bit of a cough with her allergies.,Cardiovascular history:  Negative for chest pain or palpitations.  She does have hypertension.,GI history:  Negative for abdominal pain or blood in the stool.,GU history:  Negative for dysuria or frequency.  She empties okay.,Neurologic history:  Positive for paresthesias to the toes of both feet, worse on the right.,Musculoskeletal history:  Positive for shoulder pain.,Psychiatric history:  Positive for insomnia.,Dermatologic history:  Positive for a spot on her right cheek, which she was afraid was a precancerous condition.,Metabolic history:  She has hypothyroidism.,Hematologic history:  Positive for essential thrombocythemia and anemia.,OBJECTIVE:,General:  She is a well-developed, well-nourished, elderly female in no acute distress.,Vital Signs:  Her age is 81.  Temperature:  98.0.  Blood pressure:  140/70.  Pulse:  72.  Weight:  127.,HEENT:  Head was normocephalic.  Pupils equal, round, and reactive to light.  Extraocular movements are intact.  Fundi are benign.  TMs, nares, and throat were clear.,Neck:  Supple without adenopathy or thyromegaly.,Lungs:  Clear.,Heart:  Regular rate and rhythm without murmur, click, or rub.  No carotid bruits are heard.,Abdomen:  Normal bowel sounds.  It is soft and nontender without hepatosplenomegaly or mass.,Breasts:  Surgically absent.  No chest wall mass was noted, except for the Port-A-Cath in the left chest.  No axillary adenopathy is noted.,Extremities:  Examination of the extremities reveals no ankle edema or calf tenderness x 2 in lower extremities.  There is a cyst on the anterior portion of the right ankle.  Pedal pulses were present.,Neurologic:  Cranial nerves II-XII grossly intact and symmetric.  Deep tendon reflexes were 1 to 2+ bilaterally at the knees.  No focal neurologic deficits were observed.,Pelvic:  BUS and external genitalia were atrophic.  Vaginal rugae were atrophic.  Cervix was surgically absent.  Bimanual exam confirmed the absence of uterus and cervix and I could not palpate any ovaries.,Rectal:  Exam confirmed there is brown stool present in the rectal vault.,Skin:  Clear other than actinic keratosis on the right cheek.,Psychiatric:  Affect is normal.,ASSESSMENT:,1.  Peripheral neuropathy primarily of the right foot.,2.  Hypertension.,3.  Hypothyroidism.,4.  Essential thrombocythemia.,5.  Allergic rhinitis.,6.  Insomnia.,PLAN:",
" Comprehensive Evaluation - Diabetes, hypertension, irritable bowel syndrome, and insomnia.", Consult - History and Phy., Gen Med Consult - 9 ,"SUBJECTIVE:,  The patient is well-known to me.  He comes in today for a comprehensive evaluation.  Really, again he borders on health crises with high blood pressure, diabetes, and obesity.  He states that he has reached a critical decision in the last week that he understands that he cannot continue with his health decisions as they have been made, specifically the lack of exercise, the obesity, the poor eating habits, etc.  He knows better and has been through some diabetes training.  In fact, interestingly enough, with his current medications which include the Lantus at 30 units along with Actos, glyburide, and metformin, he achieved ideal blood sugar control back in August 2004.  Since that time he has gone off of his regimen of appropriate eating, and has had sugars that are running on average too high at about 178 over the last 14 days.  He has had elevated blood pressure.  His other concerns include allergic symptoms.  He has had irritable bowel syndrome with some cramping.  He has had some rectal bleeding in recent days.  Also once he wakes up he has significant difficulty in getting back to sleep.  He has had no rectal pain, just the bleeding associated with that.,MEDICATIONS/ALLERGIES:,  As above.,PAST MEDICAL/SURGICAL HISTORY: , Reviewed and updated - see Health Summary Form for details.,FAMILY AND SOCIAL HISTORY:,  Reviewed and updated - see Health Summary Form for details.,REVIEW OF SYSTEMS:,  Constitutional, Eyes, ENT/Mouth, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin/Breasts, Neurologic, Psychiatric, Endocrine, Heme/Lymph, Allergies/Immune all negative with the following exceptions:  None.,PHYSICAL EXAMINATION:,VITAL SIGNS:  As above.,GENERAL:  The patient is alert, oriented, well-developed, obese male who is in no acute distress.,HEENT:  PERRLA.  EOMI.  TMs clear bilaterally.  Nose and throat clear.,NECK:  Supple without adenopathy or thyromegaly.  Carotid pulses palpably normal without bruit.,CHEST:  No chest wall tenderness or breast enlargement.,HEART:  Regular rate and rhythm without murmur, clicks, or rubs.,LUNGS:  Clear to auscultation and percussion.,ABDOMEN:  Significantly obese without any discernible organomegaly.  GU:  Normal male genitalia without testicular abnormalities, inguinal adenopathy, or hernia.,RECTAL:  Smooth, nonenlarged prostate with just some irritation around the rectum itself.  No hemorrhoids are noted.,EXTREMITIES:  Some slow healing over the tibia.  Without clubbing, cyanosis, or edema.  Peripheral pulses within normal limits.,NEUROLOGIC:  Cranial nerves II-XII intact.  Strength, sensation, coordination, and reflexes all within normal limits.,SKIN:  Noted to be normal.  No subcutaneous masses noted.,LYMPH SYSTEM:  No lymphadenopathy noted.,BACK:  He has pain in his back in general.,ASSESSMENT/PLAN:,1.  Diabetes and hypertension, both under less than appropriate control.  In fact, we discussed increasing the Lantus.  He appears genuine in his desire to embark on a substantial weight-lowering regime, and is going to do that through dietary control.  He knows what needs to be done with the absence of carbohydrates, and especially simple sugar.  He will also check a hemoglobin A1c, lipid profile, urine for microalbuminuria and a chem profile.  I will need to recheck him in a month to verify that his sugars and blood pressure have come into the ideal range.  He has allergic rhinitis for which Zyrtec can be used.,2.  He has irritable bowel syndrome.  We will use Metamucil for that which also should help stabilize the stools so that the irritation of the rectum is lessened.  For the bleeding I would like to obtain a sigmoidoscopy.  It is bright red blood.,3.  For his insomnia, I found there is very little in the way of medications that are going to fix that, however I have encouraged him in good sleep hygiene.  I will look forward to seeing him back in a month.  I will call him with the results of his lab.  His medications were made out.  We will use some Elocon cream for his seborrheic dermatitis of the face.  Zyrtec and Flonase for his allergic rhinitis.", 
" GI Consultation due to rectal bleeding, positive celiac sprue panel", Consult - History and Phy., GI Consultation - 1 ,"PROBLEM:  ,Rectal bleeding, positive celiac sprue panel.,HISTORY:  ,The patient is a 19-year-old Irish-Greek female who ever since elementary school has noted diarrhea, constipation, cramping, nausea, vomiting, bloating, belching, abdominal discomfort, change in bowel habits.  She noted that her symptoms were getting increasingly worse and so she went for evaluation and was finally tested for celiac sprue and found to have a positive tissue transglutaminase as well as antiendomysial antibody.  She has been on a gluten-free diet for approximately one week now and her symptoms are remarkably improved.  She actually has none of these symptoms since starting her gluten-free diet.  She has noted intermittent rectal bleeding with constipation, on the toilet tissue.  She feels remarkably better after starting a gluten-free diet.,ALLERGIES: , No known drug allergies.,OPERATIONS: , She is status post a tonsillectomy as well as ear tubes.,ILLNESSES: , Questionable kidney stone.,MEDICATIONS: , None.,HABITS: , No tobacco.  No ethanol.,SOCIAL HISTORY: , She lives by herself.  She currently works in a dental office.,FAMILY HISTORY: , Notable for a mother who is in good health, a father who has joint problems and questionable celiac disease as well.  She has two sisters and one brother.  One sister interestingly has inflammatory arthritis.,REVIEW OF SYSTEMS:  ,Notable for fever, fatigue, blurred vision, rash and itching; her GI symptoms that were discussed in the HPI are actually resolved in that she started the gluten-free diet.  She also notes headaches, anxiety, heat and cold intolerance, excessive thirst and urination.  Please see symptoms summary sheet dated April 18, 2005.,PHYSICAL EXAMINATION:  , GENERAL:  She is a well-developed pleasant 19 female.  She has a blood pressure of 120/80, a pulse of 70, she weighs 170 pounds.  She has anicteric sclerae.  Pink conjunctivae.  PERRLA.  ENT:  MMM.  NECK:  Supple.  LUNGS: Clear to auscultation.","consult - history and phy., bleeding, abdominal discomfort, belching, bloating, bowel, celiac sprue, change in bowel habits, constipation, cramping, diarrhea, gluten-free, nausea, rectal, vomiting, inflammatory arthritis, rectal bleeding, gi, inflammatory, sprue, celiac, gluten, diet, "
" The patient is a 61-year-old lady who was found down at home and was admitted for respiratory failure, septic shock, acute renal failure as well as metabolic acidosis.", Consult - History and Phy., Gen Med Consult - 53 ,"HISTORY OF PRESENT ILLNESS: , Goes back to yesterday, the patient went out for dinner with her boyfriend.  The patient after coming home all the family members had some episodes of diarrhea; it is unclear how many times the patient had diarrhea last night.  She was found down on the floor this morning, soiled her bowel movements.  Paramedics were called and the patient was brought to the emergency room.  The patient was in the emergency room noted to be in respiratory failure, was intubated.  The patient was in septic shock with metabolic acidosis and no blood pressure and very rapid heart rate with acute renal failure.  The patient was started on vasopressors.  The patient was started on IV fluids as well as IV antibiotic.  The CT of the abdomen showed ileus versus bowel distention without any actual bowel obstruction or perforation.  A General Surgery consultation was called who did not think the patient was a surgical candidate and needed an acute surgical procedure.  The patient underwent an ultrasound of the abdomen, which did not show any evidence of cholecystitis or cholelithiasis.  The patient was also noted to have acute rhabdomyolysis on the workup in the emergency room.,PAST MEDICAL HISTORY:  ,Significant for history of osteoporosis, hypertension, tobacco dependency, anxiety, neurosis, depression, peripheral arterial disease, peripheral neuropathy, and history of uterine cancer.,PAST SURGICAL HISTORY:  ,Significant for hysterectomy, bilateral femoropopliteal bypass surgeries as well as left eye cataract surgery and appendicectomy.,SOCIAL HISTORY: , She lives with her boyfriend.  The patient has a history of heavy tobacco and alcohol abuse for many years.,FAMILY HISTORY: , Not available at this current time.,REVIEW OF SYSTEMS: , As mentioned above.,PHYSICAL EXAMINATION:,GENERAL:  She is intubated, obtunded, gangrenous ears with gangrenous fingertips.,VITAL SIGNS:  Blood pressure is absent, heart rate of 138 per minute, and the patient is on the ventilator.,HEENT:  Examination shows head is atraumatic, pupils are dilated and very, very sluggishly reacting to light.  No oropharyngeal lesions noted.,NECK:  Supple.  No JVD, distention or carotid bruit.  No lymphadenopathy.,LUNGS:  Bilateral crackles and bruits.,ABDOMEN:  Distended, unable to evaluate if this is tender.  No hepatosplenomegaly.  Bowel sounds are very hyperactive.,LOWER EXTREMITIES:  Show no edema.  Distal pulses are decreased.,OVERALL NEUROLOGICAL:  Examination cannot be assessed.,LABORATORY DATA: , The database was available at this point of time.  WBC count is elevated at 19,000 with the left shift, hemoglobin of 17.7, and hematocrit of 55.8 consistent with severe dehydration.  PT INR is prolonged at 1.7 and aPTT is prolonged at 60.  Sodium was 143, BUN of 36, and creatinine of 2.5.  The patient's blood gas shows pH of 7.05, pO2 of 99.6, and pCO2 of 99.6.  Bicarb is 16.5.,ASSESSMENT AND EVALUATION:,1.  Septicemia with septic shock.,2.  Metabolic acidosis.,3.  Respiratory failure.,4.  Anuria.,5.  Acute renal failure.,The patient has no blood pressure at this point in time.  The patient is on IV fluids.  The patient is on vasopressors due to ventilator support, bronchodilators as well as IV antibiotics.  Her overall prognosis is extremely poor.  This was discussed with the patient's niece who is at bedside and will become indicated with her daughter when she arrives who is on the plane right now from Iowa.  The patient will be maintained on these supports at this point in time, but prognosis is poor.",
" GI Consultation for chronic abdominal pain, nausea, vomiting, abnormal liver function tests.", Consult - History and Phy., GI Consultation - 2 ,"PROBLEM:  ,Chronic abdominal pain, nausea, vomiting, abnormal liver function tests., ,HISTORY: , The patient is a 23-year-old female referred for evaluation due to a chronic history of abdominal pain and extensive work-up for abnormal liver function tests and this chronic nausea and vomiting referred here for further evaluation due to the patient's recent move from Eugene to Portland.  The patient is not a great historian.  Most of the history is obtained through the old history and chart that the patient has with her.  According to what we can make out, she began experiencing nausea, vomiting, recurrent epigastric and right upper quadrant pain in 2001.  She was initially seen by Dr. A back in September 2001 for abdominal pain, nausea and vomiting.  During those times, it was suspected that part of her symptoms may be secondary to biliary disease and underwent a cholecystectomy performed in Oregon by Dr.  A in August 2001.  It was assumed that this was caused by biliary dyskinesia.  Previous to that, an upper endoscopy was performed by Dr. B in July 2001 that showed to be mild gastritis secondary to anti-inflammatory use.  Postoperatively she continued to have nausea and vomiting, right upper quadrant abdominal pain and epigastric pain similar to her gallbladder pain in the past.",
 Right-sided facial droop and right-sided weakness.  Recent cerebrovascular accident.  he CT scan of the head did not show any acute events with the impression of a new-onset cerebrovascular accident., Consult - History and Phy., Gen Med Consult - 7 ,"CHIEF COMPLAINT:,  Right-sided facial droop and right-sided weakness.,HISTORY OF PRESENT ILLNESS: , The patient is an 83-year-old lady, a resident of a skilled nursing facility, with past medical history of a stroke and dementia with expressive aphasia, was found today with a right-sided facial droop, and was transferred to the emergency room for further evaluation.  While in the emergency room, she was found to having the right-sided upper extremity weakness and right-sided facial droop.  The CT scan of the head did not show any acute events with the impression of a new-onset cerebrovascular accident, will be admitted to monitor bed for observation and treatment and also she was recently diagnosed with urinary tract infection, which was resistant to all oral medications.,ALLERGIES: , SHE IS ALLERGIC TO PENICILLIN.,SOCIAL HISTORY: , She is a nondrinker and nonsmoker and currently lives at the skilled nursing facility.,FAMILY HISTORY: , Noncontributory.,PAST MEDICAL HISTORY:,1.  Cerebrovascular accident with expressive aphasia and lower extremity weakness.,2.  Abnormality of gait and wheelchair bound secondary to #1.,3.  Hypertension.,4.  Chronic obstructive pulmonary disease, on nasal oxygen.,5.  Anxiety disorder.,6.  Dementia.,PAST SURGICAL HISTORY: , Status post left mastectomy secondary to breast cancer and status post right knee replacement secondary to osteoarthritis.,REVIEW OF SYSTEMS: , Because of the patient's inability to communicate, is not obtainable, but apparently, she has urine incontinence and also stool incontinence, and is wheelchair bound.,PHYSICAL EXAMINATION:,GENERAL:  She is an 83-year-old patient, awake, and non-communicable lady, currently in bed, follows commands by closing and opening her eyes.,VITAL SIGNS:  Temperature is 99.6, pulse is 101, respirations 18, and blood pressure is in the 218/97.,HEENT:  Pupils are equal, round, and reactive to light.  External ocular muscles are intact.  Conjunctivae anicteric.  There is a slight right-sided facial droop.  Oropharynx is clear with the missing teeth on the upper and the lower part.  Tympanic membranes are clear.,NECK:  Supple.  There is no carotid bruit.  No cervical adenopathy.,CARDIAC:  Regular rate and rhythm with 2/6 systolic murmur, more at the apex.,LUNGS:  Clear to auscultation.,ABDOMEN:  Soft and no tenderness.  Bowel sound is present.,EXTREMITIES:  There is no pedal edema.  Both knees are passively extendable with about 10-15 degrees of fixed flexion deformity on both sides.,NEUROLOGIC:  There is right-sided slight facial droop.  She moves both upper extremities equally.  She has withdrawal of both lower extremities by touching her sole of the feet.,SKIN:  There is about 2 cm first turning to second-degree pressure ulcer on the right buttocks.,LABORATORY DATA: , The CT scan of the head shows brain atrophy with no acute events.  Sodium is 137, potassium 3.7, chloride 102, bicarbonate 24, BUN of 22, creatinine 0.5, and glucose of 92.  Total white blood cell count is 8.9000, hemoglobin 14.4, hematocrit 42.7, and the platelet count of 184,000.  The urinalysis was more than 100 white blood cells and 10-25 red blood cells.  Recent culture showed more than 100,000 colonies of E. coli, resistant to most of the tested medications except amikacin, nitrofurantoin, imipenem, and meropenem.,ASSESSMENT:,1.  Recent cerebrovascular accident with right-sided weakness.,2.  Hypertension.,3.  Dementia.,4.  Anxiety.,5.  Urinary tract infection.,6.  Abnormality of gait secondary to lower extremity weakness.,PLAN: , We will keep the patient NPO until a swallowing evaluation was done.  We will start her on IV Vasotec every 4 hours p.r.n. systolic blood pressure more than 170.  Neuro check every 4 hours for 24 hours.  We will start her on amikacin IV per pharmacy.  We will start her on Lovenox subcutaneously 40 mg every day and we will continue with the Ecotrin as swallowing evaluation was done.  Resume home medications, which basically include Aricept 10 mg p.o. daily, Diovan 160 mg p.o. daily, multivitamin, calcium with vitamin D, Ecotrin, and Tylenol p.r.n.  I will continue with the IV fluids at 75 mL an hour with a D5 normal saline at the range of 75 mL an hour and adding potassium 10 mEq per 1000 mL and I would follow the patient on daily basis.",
" Comprehensive Evaluation - Generalized anxiety and hypertension, both under fair control.", Consult - History and Phy., Gen Med Consult - 8 ,"SUBJECTIVE:,  The patient comes in today for a comprehensive evaluation.  She is well-known to me.  I have seen her in the past multiple times.,PAST MEDICAL HISTORY/SOCIAL HISTORY/FAMILY HISTORY: , Noted and reviewed today.  They are on the health care flow sheet.  She has significant anxiety which has been under fair control recently.  She has a lot of stress associated with a son that has some challenges.  There is a family history of hypertension and strokes.,CURRENT MEDICATIONS:,  Currently taking Toprol and Avalide for hypertension and anxiety as I mentioned.,REVIEW OF SYSTEMS:,  Significant for occasional tiredness.  This is intermittent and currently not severe.  She is concerned about the possibly of glucose abnormalities such diabetes.  We will check a glucose, lipid profile and a Hemoccult test also and a mammogram.  Her review of systems is otherwise negative.,PHYSICAL EXAMINATION:,VITAL SIGNS:  As above.,GENERAL:  The patient is alert, oriented, in no acute distress.,HEENT:  PERRLA.  EOMI.  TMs clear bilaterally.  Nose and throat clear.,NECK:  Supple without adenopathy or thyromegaly.  Carotid pulses palpably normal without bruit.,CHEST:  No chest wall tenderness.,BREAST EXAM:  No asymmetry, skin changes, dominant masses, nipple discharge, or axillary adenopathy.,HEART:  Regular rate and rhythm without murmur, clicks, or rubs.,LUNGS:  Clear to auscultation and percussion.,ABDOMEN:  Soft, nontender, bowel sounds normoactive.  No masses or organomegaly.,GU:  External genitalia without lesions.  BUS normal.  Vulva and vagina show just mild atrophy without any lesions.  Her cervix and uterus are within normal limits.  Ovaries are not really palpable.  No pelvic masses are appreciated.,RECTAL:  Negative.,BREASTS:  No significant abnormalities.,EXTREMITIES:  Without clubbing, cyanosis, or edema.  Pulses within normal limits.,NEUROLOGIC:  Cranial nerves II-XII intact.  Strength, sensation, coordination, and reflexes all within normal limits.,SKIN:  Noted to be normal.  No subcutaneous masses noted.,LYMPH SYSTEM:  No lymphadenopathy.,ASSESSMENT:,  Generalized anxiety and hypertension, both under fair control.,PLAN:,  We will not make any changes in her medications.  I will have her check a lipid profile as mentioned, and I will call her with that.  Screening mammogram will be undertaken.  She declined a sigmoidoscopy at this time.  I look forward to seeing her back in a year and as needed.", 
 Patient with swelling of lips and dysphagia and Arthritis., Consult - History and Phy., Gen Med Consult - 5 ,"CHIEF COMPLAINT: , Swelling of lips causing difficulty swallowing.,HISTORY OF PRESENT ILLNESS:, This patient is a 57-year old white Cuban woman with a long history of rheumatoid arthritis.  She has received methotrexate on a weekly basis as an outpatient for many years.  Approximately two weeks ago, she developed a respiratory infection for which she received antibiotics.  She developed some ulcerations of the mouth and was instructed to discontinue the methotrexate approximately ten days ago.  She showed some initial improvement, but over the last 3-5 days has had malaise, a low-grade fever, and severe oral ulcerations with difficulty in swallowing although she can drink liquids with less difficulty.  ,The patient denies any other problems at this point except for a flare of arthritis since discontinuing the methotrexate.  She has rather diffuse pain involving both large and small joints.  ,MEDICATIONS:, Prednisone 7.5 mg p.o. q.d., Premarin 0.125 mg p.o. q.d., and Dolobid 1000 mg p.o. q.d., recently discontinued because of questionable allergic reaction.  HCTZ 25 mg p.o. q.o.d., Oral calcium supplements.  In the past she has been on penicillin, azathioprine, and hydroxychloroquine, but she has not had Azulfidine, cyclophosphamide, or chlorambucil. ,ALLERGIES: ,None by history.  ,FAMILY/SOCIAL HISTORY:, Noncontributory.,PHYSICAL EXAMINATION:, This is a chronically ill appearing female, alert, oriented, and cooperative.  She moves with great difficulty because of fatigue and malaise.  Vital signs: Blood pressure 107/80, heart rate: 100 and regular, respirations 22.  HEENT: Normocephalic. No scalp lesions.  Dry eyes with conjuctival injections.  Mild exophthalmos.  Dry nasal mucosa.  Marked cracking and bleeding of her lips with erosion of the mucosa.  She has a large ulceration of the mucosa at the bite margin on the left.  She has some scattered ulcerations on her hard and soft palette.  Tonsils not enlarged.  No visible exudate.  She has difficulty opening her mouth because of pain.  SKIN: She has some mild ecchymoses on her skin and some erythema; she has patches but no obvious skin breakdown.  She has some fissuring in the buttocks crease.  PULMONARY: Clear to percussion in auscultation.  CARDIOVASCULAR: No murmurs or gallops noted.  ABDOMEN: Protuberant no organomegaly and positive bowel sounds.  NEUROLOGIC EXAM: Cranial nerves II through XII are grossly intact. Diffuse hyporeflexia.  MUSCULOSKELATAL: Erosive, destructive changes in the elbows, wrist and hands consistent with rheumatoid arthritis.  She also has bilateral total knee replacements with stovepipe legs and parimalleolar pitting adema 1+.  I feel no pulse distally in either leg.  ,PROBLEMS: ,1.  Swelling of lips and dysphagia with questionable early Stevens-Johnson syndrome.,2.  Rheumatoid Arthritis class 3, stage 4.,3.  Flare of arthritis after discontinuing methotrexate.,4.  Osteoporosis with compression fracture.,5.  Mild dehydration.,6.  Nephrolithiasis.,PLAN:, Patient is admitted for IV hydration and treatment of oral ulcerations.  We will obtain a dermatology consult.  IV leucovorin will be started, and the patient will be put on high-dose corticosteroids.","consult - history and phy., swelling, iv hydration, osteoporosis, swelling of lips, allergic reaction, arthritis, difficulty swallowing, leucovorin, low-grade fever, methotrexate, respiratory infection, rheumatoid arthritis, flare of arthritis, rheumatoid, mucosa, dysphagia,"
" A female with a past medical history of chronic kidney disease, stage 4; history of diabetes mellitus; diabetic nephropathy; peripheral vascular disease, status post recent PTA of right leg, admitted to the hospital because of swelling of the right hand and left foot.", Consult - History and Phy., Gen Med Consult - 49 ,"HISTORY OF PRESENT ILLNESS: , This is a 70-year-old female with a past medical history of chronic kidney disease, stage 4; history of diabetes mellitus; diabetic nephropathy; peripheral vascular disease, status post recent PTA of right leg, admitted to the hospital because of swelling of the right hand and left foot.  The patient says that the right hand was very swollen, very painful, could not move the fingers, and also, the left foot was very swollen and very painful, and again could not move the toes, came to emergency room, diagnosed with gout and gouty attacks.  I was asked to see the patient regarding chronic kidney disease.,PAST MEDICAL HISTORY:,1.  Diabetes mellitus type 2.,2.  Diabetic nephropathy.,3.  Chronic kidney disease, stage 4.,4.  Hypertension.,5.  Hypercholesterolemia and hyperlipidemia.,6.  Peripheral vascular disease, status post recent, last week PTA of right lower extremity.,SOCIAL HISTORY:,  Negative for smoking and drinking.,CURRENT HOME MEDICATIONS:,  NovoLog 20 units with each meal, Lantus 30 units at bedtime, Crestor 10 mg daily, Micardis 80 mg daily, Imdur 30 mg daily, Amlodipine 10 mg daily, Coreg 12.5 mg b.i.d., Lasix 20 mg daily, Ecotrin 325 mg daily, and calcitriol 0.5 mcg daily.,REVIEW OF SYSTEMS: , The patient denies any complaints, states that the right hand and left foot was very swollen and very painful, and came to emergency room.  Also, she could not urinate and states as soon as they put Foley in, 500 mL of urine came out.  Also they started her on steroids and colchicine, and the pain is improving and the swelling is getting better.  Denies any fever and chills.  Denies any dysuria, frequency or hematuria.  States that the urine output was decreased considerably, and she could not urinate.  Denies any cough, hemoptysis or sputum production.  Denies any chest pain, orthopnea or paroxysmal nocturnal dyspnea.,PHYSICAL EXAMINATION:,General:  The patient is alert and oriented, in no acute distress.,Vital Signs:  Blood pressure 126/67, temperature 97.9, pulse 71, and respirations 20.  The patient's weight is 105.6 kg.,Head:  Normocephalic.,Neck:  Supple.  No JVD.  No adenopathy.,Chest:  Symmetric.  No retractions.,Lungs:  Clear.,Heart:  RRR with no murmur.,Abdomen:  Obese, soft, and nontender.  No rebound.  No guarding.,Extremity:  She has 2+ pretibial edema bilaterally at the lower extremity, but also the left foot, in dorsum of left foot and also right hand is swollen and very tender to move the toes and also fingers in those extremities.,LAB TESTS: , Showed that urine culture is negative up to date.  The patient's white cell is 12.7, hematocrit 26.1.  The patient has 90% segs and 0% bands.  Serum sodium 133, potassium 5.9, chloride 100, bicarb 21, glucose 348, BUN 57, creatinine is 2.39, calcium 8.9, and uric acid yesterday was 10.9.  Sed rate was 121.  BNP was 851.  Urinalysis showed 15 to 20 white cells, 3+ protein, 3+ blood with 25 to 30 red blood cells also.,IMPRESSION:,1.  Urinary tract infection.,2.  Acute gouty attack.,3.  Diabetes mellitus with diabetic nephropathy.,4.  Hypertension.,5.  Hypercholesterolemia.,6.  Peripheral vascular disease, status post recent PTA in the right side.,7.  Chronic kidney disease, stage 4.,PLAN: , At this time is I agree with treatment.  We will add allopurinol 50 mg daily.  This is secondary to the patient is already on colchicine, and also we will discontinue Micardis, we will increase Lasix to 40 b.i.d., and we will follow with the lab results.",
" An 86-year-old female with persistent abdominal pain, nausea and vomiting, during evaluation in the emergency room, was found to have a high amylase, as well as lipase count and she is being admitted for management of acute pancreatitis.", Consult - History and Phy., Gen Med Consult - 50 ,"CHIEF COMPLAINT: , Abdominal pain.,HISTORY OF PRESENT ILLNESS: , This is an 86-year-old female who is a patient of Dr. X, who was transferred from ABCD Home due to persistent abdominal pain, nausea and vomiting, which started around 11:00 a.m. yesterday.  During evaluation in the emergency room, the patient was found to have a high amylase as well as lipase count and she is being admitted for management of acute pancreatitis.,PAST MEDICAL HISTORY:,  Significant for dementia of Alzheimer type, anxiety, osteoarthritis, and hypertension.,ALLERGIES: , THE PATIENT IS ALLERGIC TO POLLENS.,MEDICATIONS: , Include alprazolam 0.5 mg b.i.d. p.r.n., mirtazapine 30 mg p.o. daily, Aricept 10 mg p.o. nightly, Namenda 10 mg p.o. b.i.d., Benicar 40 mg p.o. daily, and Claritin 10 mg daily p.r.n.,FAMILY HISTORY: , Not available.,PERSONAL HISTORY:  ,Not available.,SOCIAL HISTORY:  ,Not available.  The patient lives at a skilled nursing facility.,REVIEW OF SYSTEMS:  ,She has moderate-to-severe dementia and is unable to give any information about history or review of systems.,PHYSICAL EXAMINATION:,GENERAL:  She is awake and alert, able to follow few simple commands, resting comfortably, does not appear to be in any acute distress.,VITAL SIGNS:  Temperature of 99.5, pulse 82, respirations 18, blood pressure of 150/68, and pulse ox is 90% on room air.,HEENT:  Atraumatic.  Pupils are equal and reactive to light.  Sclerae and conjunctivae are normal.  Throat without any pharyngeal inflammation or exudate.  Oral mucosa is normal.,NECK:  No jugular venous distention.  Carotids are felt normally.  No bruit appreciated.  Thyroid gland is not palpable.  There are no palpable lymph nodes in the neck or the supraclavicular region.,HEART:  S1 and S2 are heard normally.  No murmur appreciated.,LUNGS:  Clear to auscultation.,ABDOMEN:  Soft, diffusely tender.  No rebound or rigidity.  Bowel sounds are heard.  Most of the tenderness is located in the epigastric region.,EXTREMITIES:  Without any pedal edema, normal dorsalis pedis pulsations bilaterally.,BREASTS:  Normal.,BACK:  The patient does not have any decubitus or skin changes on her back.,LABS DONE AT THE TIME OF ADMISSION: , WBC of 24.3, hemoglobin and hematocrit 15.3 and 46.5, MCV 89.3, and platelet count of 236,000.  PT 10.9, INR 1.1, PTT of 22.  Urinalysis with positive nitrite, 5 to 10 wbc's, and 2+ bacteria.  Sodium 134, potassium 3.6, chloride 97, bicarbonate 27, calcium 8.8, BUN 25, creatinine 0.9, albumin of 3.4, alkaline phosphatase 109, ALT 121, AST 166, amylase 1797, and lipase over 3000.  X-ray of abdomen shows essentially normal abdomen with possible splenic granulomas and degenerative spine changes.  CT of the abdomen revealed acute pancreatitis, cardiomegaly, and right lung base atelectasis.  Ultrasound of the abdomen revealed echogenic liver with fatty infiltration.  Repeat CBC from today showed white count to be 21.6, hemoglobin and hematocrit 13.9 and 41.1, platelet count is normal, 89% segments and 2% bands.  Sodium 132, potassium 4.0, chloride 98, bicarbonate 22, glucose 184, ALT 314, AST 382, amylase 918, and lipase 1331.  The cultures are pending at this time.  EKG shows sinus rhythm, rate about 90 per minute, multiple ventricular premature complexes are noted.  Troponin 0.004 and myoglobin is 39.6.,ASSESSMENT:,1.  Acute pancreatitis.,2.  Leukocytosis.,3.  Urinary tract infection.,4.  Hyponatremia.,5.  Dementia.,6.  Anxiety.,7.  History of hypertension.,8.  Abnormal electrocardiogram.,9.  Osteoarthrosis.,PLAN:,  Admit the patient to medical floor, NPO, IV antibiotics, IV fluids, hold p.o. medications, GI consult, pain control, Zofran IV p.r.n., bedrest, DVT prophylaxis, check blood and urine cultures.  I have left a message for the patient's son to call me back.",
"  The patient is a 35-year-old lady who was admitted with chief complaints of chest pain, left-sided with severe chest tightness after having an emotional argument with her boyfriend.   The patient has a long history of psychological disorders.", Consult - History and Phy., Gen Med Consult - 54 ,"HISTORY OF PRESENT ILLNESS: , The patient is a 35-year-old lady who was admitted with chief complaints of chest pain, left-sided with severe chest tightness after having an emotional argument with her boyfriend.  The patient has a long history of psychological disorders.  As per the patient, she also has a history of supraventricular tachycardia and coronary artery disease, for which the patient has had workup done in ABC Medical Center.  The patient was evaluated in the emergency room.  The initial cardiac workup was negative.  The patient was admitted to telemetry unit for further evaluation.  In the emergency room, the patient was also noted to have a strongly positive drug screen including methadone and morphine.  The patient's EKG in the emergency room was normal and the patient had some relief from her chest pain after she got some nitroglycerin.,PAST MEDICAL HISTORY: , As mentioned above is significant for history of seizure disorder, migraine headaches, coronary artery disease, CHF, apparently coronary stenting done, mitral valve prolapse, supraventricular tachycardia, pacemaker placement, colon cancer, and breast cancer.  None of the details of these are available.,PAST SURGICAL HISTORY: , Significant for history of lumpectomy on the left breast, breast augmentation surgery, cholecystectomy, cardiac ablation x3, left knee surgery as well as removal of half the pancreas.,CURRENT MEDICATIONS AT HOME: , Included Dilantin 400 mg daily, Klonopin 2 mg 3 times a day, Elavil 300 mg at night, nitroglycerin sublingual p.r.n., Thorazine 300 mg 3 times a day, Neurontin 800 mg 4 times a day, and Phenergan 25 mg as tolerated.,OB HISTORY: , Her last menstrual period was 6/3/2009.  The patient is admitting to having a recent abortion done.  She is not too sure whether the abortion was completed or not, has not had a followup with her OB/GYN.,FAMILY HISTORY:  ,Noncontributory.,SOCIAL HISTORY:  ,She lives with her boyfriend.  The patient has history of tobacco abuse as well as multiple illicit drug abuse.,REVIEW OF SYSTEMS:  As mentioned above.,PHYSICAL EXAMINATION:,GENERAL:  She is alert, awake, and oriented.,VITAL SIGNS:  Her blood pressure is about 132/72, heart rate of about 87 per minute, respiratory rate of 16.,HEENT:  Shows head is atraumatic.  Pupils are round and reactive to light.  Extraocular muscles are intact.  No oropharyngeal lesions noted.,NECK:  Supple, no JV distention, no carotid bruits, and no lymphadenopathy.,LUNGS:  Clear to auscultation bilaterally.,CARDIAC:  Reveals regular rate and rhythm.,ABDOMEN:  Soft, nontender, nondistended.  Bowel sounds are normally present.,LOWER EXTREMITIES:  Shows no edema.  Distal pulses are 2+.,NEUROLOGICAL:  Grossly nonfocal.,LABORATORY DATA: , The database that is available at this point of time, WBC count is normal, hemoglobin and hematocrit are normal.  Sodium, potassium, chloride, glucose, bicarbonate, BUN and creatinine, and liver function tests are normal.  The patient's 3 sets of cardiac enzymes including troponin-I, CPK-MB, and myoglobulin have been normal.  EKG is normal, sinus rhythm without any acute ST-T wave changes.  As mentioned before, the patient's toxicology screen was positive for morphine, methadone, and marijuana.  The patient also had a head CT done in the emergency room, which was fairly unremarkable.  The patient's beta-hCG level was marginally elevated at about 48.,ASSESSMENT AND EVALUATION:,1.  Chest pains, appear to be completely noncardiac.  The patient does seem to have a psychosomatic component to her chest pain.  There is no evidence of acute coronary syndrome or unstable angina at this point of time.,2.  Possible early pregnancy.  The patient's case was discussed with OB/GYN on-call over the phone.  Some of the medications have to be held secondary to potential danger.  The patient will follow up on an outpatient basis with her primary OB/GYN as well as PCP for the workup of her pregnancy as well as continuation of the pregnancy and prenatal visits.,3.  Migraine headaches for which the patient has been using her routine medications and the headaches seem to be under control.  Again, this is an outpatient diagnosis.  The patient will follow up with her PCP for control of migraine headache.,Overall prognosis is too soon to predict.,The plan is to discharge the patient home secondary to no evidence of acute coronary syndrome.",
" Abdominal pain, nausea and vomiting, rule out recurrent small bowel obstruction.  The patient is an 89-year-old white male who developed lower abdominal pain, which was constant, onset approximately half an hour after dinner on the evening prior to admission.", Consult - History and Phy., Gen Med Consult - 51 ,"CHIEF COMPLAINT: , Abdominal pain.,HISTORY OF PRESENT ILLNESS:  ,The patient is an 89-year-old white male who developed lower abdominal pain, which was constant, onset approximately half an hour after dinner on the evening prior to admission.  He described the pain as 8/10 in severity and the intensity varied.  The symptoms persisted and he subsequently developed nausea and vomiting at 3 a.m. in the morning of admission.  The patient vomited twice and he states that he did note a temporary decrease in pain following his vomiting.  The patient was brought to the emergency room approximately 4 a.m. and evaluation including the CT scan, which revealed dilated loops of bowel without obvious obstruction.  The patient was subsequently admitted for possible obstruction.  The patient does have a history of previous small bowel obstruction approximately 20 times all but 2 required hospitalization, but all resolved with conservative measures (IV fluid, NG tube decompression, bowel rest.)  He has had previous abdominal surgeries including colon resection for colon CA and cholecystectomy as well as appendectomy.,PAST HISTORY: , Hypertension treated with Cozaar 100 mg daily and Norvasc 10 mg daily.  Esophageal reflux treated with Nexium 40 mg daily.  Allergic rhinitis treated with Allegra 180 mg daily.  Sleep disturbances, depression and anxiety treated with Paxil 25 mg daily, Advair 10 mg nightly and Ativan 1 mg nightly.  Glaucoma treated with Xalatan drops.  History of chronic bronchitis with no smoking history for which he uses p.r.n. Flovent and Serevent.,PREVIOUS SURGERIES:  ,Partial colon resection of colon carcinoma in 1961 with no recurrence, cholecystectomy 10 years ago, appendectomy, and glaucoma surgery.,FAMILY HISTORY: , Father died at age 85 of ""old age,"" mother died at age 89 of ""old age.""  Brother died at age 92 of old age, 2 brothers died in their 70s of Parkinson disease.  Son is at age 58 and has a history of hypertension, hypercholesterolemia, rheumatoid arthritis, and glaucoma.,SOCIAL HISTORY:  ,The patient is widowed and a retired engineer.  He denies cigarettes smoking or alcohol intake.,REVIEW OF SYSTEMS: , Denies fevers or weight loss.  HEENT:  Denies headaches, visual abnormality, decreased hearing, tinnitus, rhinorrhea, epistaxis or sore throat.  Neck:  Denies neck stiffness, no pain or masses in the neck.  Respiratory:  Denies cough, sputum production, hemoptysis, wheezing or shortness of breath.  Cardiovascular:  Denies chest pain, angina pectoris, DOE, PND, orthopnea, edema or palpitation.  Gastrointestinal:  See history of the present illness.  Urinary:  Denies dysuria, frequency, urgency or hematuria.  Neuro:  Denies seizure, syncope, incoordination, hemiparesis or paresthesias.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a well-developed, well-nourished elderly white male who is currently in no acute distress after receiving analgesics.,HEENT:  Atraumatic, normocephalic.  Eyes, EOMs full, PERRLA.  Fundi benign.  TMs normal.  Nose clear.  Throat benign.,NECK:  Supple with no adenopathy.  Carotid upstrokes normal with no bruits.  Thyroid is not enlarged.,LUNGS:  Clear to percussion and auscultation.,HEART:  Regular rate, normal S1 and S2 with no murmurs or gallops.  PMI is nondisplaced.,ABDOMEN:  Mildly distended with mild diffuse tenderness.  There is no rebound or guarding.  Bowel sounds are hypoactive.,EXTREMITIES:  No cyanosis, clubbing or edema.  Pulses are strong and intact throughout.,GENITALIA:  Atrophic male, no scrotal masses or tenderness.  Testicles are atrophic.  No hernia is noted.,RECTAL:  Unremarkable, prostate was not enlarged and there were no nodules or tenderness.,LAB DATA:,  WBC 12.1, hemoglobin and hematocrit 16.9/52.1, platelets 277,000.  Sodium 137, potassium 3.9, chloride 100, bicarbonate 26, BUN 27, creatinine 1.4, glucose 157, amylase 103, lipase 44.  Alkaline phosphatase, AST and ALT are all normal.  UA is negative.,Abdomen and pelvic CT showed mild stomach distention with multiple fluid-filled loops of bowel, no obvious obstruction noted.,IMPRESSION:,1.  Abdominal pain, nausea and vomiting, rule out recurrent small bowel obstruction.,2.  Hypertension.,3.  Esophageal reflux.,4.  Allergic rhinitis.,5.  Glaucoma.,PLAN: , The patient is admitted to the medical floor.  He has been kept NPO and will be given IV fluids.  He will also be given antiemetic medications with Zofran and an analgesic as necessary.  General surgery consultation was obtained.  Abdominal series x-ray will be done.",
" For evaluation of left-sided chest pain, 5 days post abdominal surgery.", Consult - History and Phy., Gen Med Consult - 45 ,"REASON FOR CONSULT: , For evaluation of left-sided chest pain, 5 days post abdominal surgery.,PAST MEDICAL HISTORY:, None.,HISTORY OF PRESENT COMPLAINT: , This 87-year-old patient has been admitted in this hospital on 12/03/08.  The patient underwent laparoscopic appendicectomy by Dr. X.  The patient had postoperative paralytic ileus, which has resolved.  The patient had developed left-sided chest pain yesterday.  In the postoperative period, the patient has had fluid retention, had gain about 25 pounds, and he had swelling of the lower extremities.,REVIEW OF SYSTEMS:,CONSTITUTIONAL SYMPTOMS:  No recent fever.,ENT:  Unremarkable.,RESPIRATORY:  He denies cough but develop this left-sided chest pain, which does not increase with inspiration, pain is located on the left posterior axillary line and over the fourth and fifth rib.,CARDIOVASCULAR:  No known heart problems.,GASTROINTESTINAL:  The patient denies nausea or vomiting.  He is status post laparoscopic appendicectomy, and he is tolerating oral diet.,GENITOURINARY:  No dysuria, no hematuria.,ENDOCRINE:  Negative for diabetes or thyroid problems.,NEUROLOGIC:  No history of CVA or TIA.,Rest of review of systems unremarkable.,SOCIAL HISTORY:  ,The patient is a nonsmoker.  He denies use of alcohol.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL:  An 87-year-old gentleman, not toxic looking.,HEAD AND NECK:  Oral mucosa is moist.,CHEST:  Clear to auscultation.  No wheezing.  No crepitations.  There is reproducible tenderness over the left posterior-lateral axis.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmurs appreciated.,ABDOMEN:  Slightly distended.  Bowel sounds are positive.,EXTREMITIES:  He has 2+ to 3+ pedal swelling.,NEUROLOGIC:  The patient is alert and oriented x3.  Examination is nonfocal.,LABORATORY DATA: , White count is 12,500, hemoglobin is 13, hematocrit is 39, and platelets 398,000.  Glucose is 123, total protein is 6, and albumin is 2.9.,ASSESSMENT AND PLAN:,1.  Ruptured appendicitis.  The patient is 6 days post surgery.  He is tolerating oral fluids and moving bowels.,2.  Left-sided chest pain, need to rule out PE by distance of pretty low probability.  The patient, however, has low-oxygen saturation.  We will do ultrasound of the lower extremity and if this is positive we would proceed with the CT angiogram.,3.  Fluid retention, manage as per surgeon.,4.  Paralytic ileus, resolving.,5.  Leukocytosis, we will monitor.",
" Pneumonia in the face of fairly severe Crohn disease with protein-losing enteropathy and severe malnutrition with anasarca.  He also has anemia and leukocytosis, which may be related to his Crohn disease as well as his underlying pneumonia.", Consult - History and Phy., Gen Med Consult - 46 ,"DIAGNOSES:,1.  Pneumonia.,2.  Crohn disease.,3.  Anasarca.,4.  Anemia.,CHIEF COMPLAINT: , I have a lot of swelling in my legs.,HISTORY:  ,The patient is a 41-year-old gentleman with a long history of Crohn disease.  He has been followed by Dr. ABC, his primary care doctor, but he states that he has had multiple gastroenterology doctors and has not seen one in the past year to 18 months.  He has been treated with multiple different medications for his Crohn disease and most recently has been taking pulses of steroids off and on when he felt like he was having symptoms consistent with crampy abdominal pain, increased diarrhea, and low-grade fevers.  This has helped in the past, but now he developed symptoms consistent with pneumonia and was admitted to the hospital.  He has been treated with IV antibiotics and is growing Streptococcus.  At this time, he seems relatively stable although slightly dyspneic.  Other symptoms include lower extremity edema, pain in his ankles and knees, and actually symptoms of edema in his entire body including his face and upper extremities.  At this time, he continues to have symptoms consistent with diarrhea and malabsorption.  He also has some episodes of nausea and vomiting at times.  He currently has a cough and symptoms of dyspnea.  Further review of systems was not otherwise contributory.,MEDICATIONS:,1.  Prednisone.,2.  Effexor.,3.  Folic acid.,4.  Norco for pain.,PAST MEDICAL HISTORY: , As mentioned above, but he also has anxiety and depression.,PAST SURGICAL HISTORY:,1.  Small bowel resections.,2.  Appendectomy.,3.  A vasectomy.,ALLERGIES:  ,He has no known drug allergies.,SOCIAL HISTORY:  ,He does smoke two packs of cigarettes per day.  He has no alcohol or drug use.  He is a painter.,FAMILY HISTORY:  ,Significant for his father who died of IPF and irritable bowel syndrome.,REVIEW OF SYSTEMS: , As mentioned in the history of present illness and further review of systems is not otherwise contributory.,PHYSICAL EXAMINATION:,GENERAL:  He is a thin appearing man in very mild respiratory distress when his oxygen is off.,VITAL SIGNS:  His respiratory rate is approximately 18 to 20, his blood pressure is 100/70, his pulse is 90 and regular, he is afebrile currently at 96, and weight is approximately 163 pounds.,HEENT:  Sclerae anicteric.  Conjunctivae normal.  Nasal and oropharynx are clear.,NECK:  Supple.  No jugular venous pressure distention is noted.  There is no adenopathy in the cervical, supraclavicular or axillary areas.,CHEST:  Reveals some crackles in the right chest, in the base, and in the upper lung fields.  His left is relatively clear with decreased breath sounds.,HEART:  Regular rate and rhythm.,ABDOMEN:  Slightly protuberant.  Bowel sounds are present.  He is slightly tender and it is diffuse.  There is no organomegaly and no ascites appreciable.,EXTREMITIES:  There is a mild scrotal edema and in his lower extremities he has 2 to 3+ edema at pretibial and lateral feet.,DERMATOLOGIC:  Shows thin skin.  No ecchymosis or petechiae.,LABORATORY STUDIES: , Laboratory studies are pertinent for a total protein of 3 and albumin of 1.3.  There is no M-spike observed.  His B12 is 500 with a folic acid of 11.  His white count is 21 with a hemoglobin of 10, and a platelet count 204,000.,IMPRESSION AT THIS TIME:,1.  Pneumonia in the face of fairly severe Crohn disease with protein-losing enteropathy and severe malnutrition with anasarca.,2.  He also has anemia and leukocytosis, which may be related to his Crohn disease as well as his underlying pneumonia.,ASSESSMENT AND PLAN: , At this time, I believe evaluation of protein intake and dietary supplement will be most appropriate.  I believe that he needs a calorie count.  We will check on a sedimentation rate, C-reactive protein, LDH, prealbumin, thyroid, and iron studies in the morning with his laboratory studies that are already ordered.  I have recommended strongly to him that when he is out of the hospital, he return to the care of his gastroenterologist.  I will help in anyway that I can to improve the patient's laboratory abnormalities.  However, his lower extremity edema is primarily due to his marked hypoalbuminemia and I do not believe that diuretics will help him at this time.  I have explained this in detail to the patient and his family.  Everybody expresses understanding and all questions were answered.  At this time, follow him up during his hospital stay and plan to see him in the office as well.",
" Anxiety, alcohol abuse, and chest pain.   This is a 40-year-old male with digoxin toxicity secondary to likely intentional digoxin overuse.  Now, he has had significant block with EKG changes as stated. ", Consult - History and Phy., Gen Med Consult - 52 ,"CHIEF COMPLAINT: , Anxiety, alcohol abuse, and chest pain.,HISTORY OF PRESENT ILLNESS:,  This is a pleasant 40-year-old male with multiple medical problems, basically came to the hospital yesterday complaining of chest pain.  The patient states that he complained of this chest pain, which is reproducible, pleuritic in both chest radiating to the left back and the jaw, complaining of some cough, nausea, questionable shortness of breath.  The patient describes the pain as aching, sharp and alleviated with pain medications, not alleviated with any nitrates.  Aggravated by breathing, coughing, and palpation over the area.  The pain was 9/10 in the emergency room and he was given some pain medications in the ER and was basically admitted.  Labs were drawn, which were essentially, potassium was about 5.7 and digoxin level was drawn, which was about greater than 5.  The patient said that he missed 3 doses of digoxin in the last 3 days after being discharged from Anaheim Memorial and then took 3 tablets together.  The patient has a history prior digoxin overdose of the same nature.,MEDICATIONS:,  Digoxin 0.25 mg, metoprolol 50 mg, Naprosyn 500 mg, metformin 500 mg, lovastatin 40 mg, Klor-Con 20 mEq, Advair Diskus, questionable Coreg.,PAST MEDICAL HISTORY: , MI in the past and atrial fibrillation, he said that he has had one stent put in, but he is not sure.  The last cardiologist he saw was Dr. X and his primary doctor is Dr. Y.,SOCIAL HISTORY:,  History of alcohol use in the past.,He is basically requesting for more and more pain medications.  He states that he likes Dilaudid and would like to get the morphine changed to Dilaudid.  His pain is tolerable.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Stable.,GENERAL:  Alert and oriented x3, no apparent distress.,HEENT:  Extraocular muscles are intact.,CVS:  S1, S2 heard.,CHEST:  Clear to auscultation bilaterally.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema or clubbing.,NEURO:  Grossly intact.  Tender to palpate over the left chest, no obvious erythema or redness, or abnormal exam is found.,EKG basically shows atrial fibrillation, rate controlled, nonspecific ST changes.,ASSESSMENT AND PLAN:,1.  This is a 40-year-old male with digoxin toxicity secondary to likely intentional digoxin overuse.  Now, he has had significant block with EKG changes as stated.  Continue to follow the patient clinically at this time.  The patient has been admitted to ICU and will be changed to DOU.,2.  Chronic chest pain with a history of myocardial infarction in the past, has been ruled out with negative cardiac enzymes.  The patient likely has opioid dependence and requesting more and more pain medications.  He is also bargaining for pain medications with me.  The patient was advised that he will develop more opioid dependence and I will stop the pain medications for now and give him only oral pain medications in the anticipation of the discharge in the next 1 or 2 days.  The patient was likely advised to also be seen by a pain specialist as an outpatient after being referred.  We will try to verify his pain medications from his primary doctor and his pharmacy.  The patient said that he has been on Dilaudid and Vicodin ES and Norco and all these medications in the past.","consult - history and phy., anxiety, alcohol abuse, chest pain, digoxin toxicity, digoxin overuse, atrial fibrillation, opioid dependence, toxicity, dilaudid, "
 The patient had temperature of 104 degrees F.  It has been spiking ever since and she has had left sacroiliac type hip pain.  She does have degenerative disk disease of her lumbar spine but no hip pathology.  She has swollen inguinal nodes bilaterally., Consult - History and Phy., Gen Med Consult - 47 ,"HISTORY OF PRESENT ILLNESS: , This is a 76-year-old female that was admitted with fever, chills, and left pelvic pain.  The patient was well visiting in ABC, with her daughter that evening.  She had pain in her left posterior pelvic and low back region.  They came back to XYZ the following day.  By the time they got here, she was in severe pain and had fever.  They came straight to the emergency room.  She was admitted.  She had temperature of 104 degrees F.  It has been spiking ever since and she has had left sacroiliac type hip pain.  Multiple blood studies have been done including cultures, febrile agglutinins, etc.  She has had run a higher blood glucose to the normal and she has been on sliding scale insulin.  She was not known previously to be a diabetic.  All x-rays have not been helpful as far as to determine the etiology of her discomfort.  MRIs of the lumbar spine and the pelvis and both thighs have been unremarkable for any inflammatory process.  She does have degenerative disk disease of her lumbar spine but no hip pathology.  She has swollen inguinal nodes bilaterally.,PAST MEDICAL HISTORY AND REVIEW OF SYSTEMS: , She was not known to be a diabetic until this admission.  She had been hypertensive.  She has been on medications and has been controlled.  She has not had hyperlipidemia.  She has had no thyroid problems.  There has been no asthma, bronchitis, TB, emphysema or pneumonia.  No tuberculosis.  She has had no breast tumors.  She has had no chest pain or cardiac problems.  She has had gallbladder surgery.  She has not had any gastritis or ulcers.  She has had no kidney disease.  She has had a hysterectomy.  She has had 9 pregnancies and 8 living children.  She had A&P repair.  She had a sacral abscess after a spinal.  It sounds to me like she had a pilonidal cyst, which took about 3 operations to heal.  There have been fractures and no significant arthritis.  She has been quite active at her ranch in Mexico.  She raises goats and cattle.  She drives a tractor and in short, has been very active.,PHYSICAL EXAMINATION:,  She is a short female, alert.  She is shivering.  She has ice in her axilla and behind her neck.  She is febrile to 101 degrees F. She is alert.  Her complaint is that of hip pain in the posterior sacroiliac joint area.  She moves both her upper extremities well.  She can move her right leg well.  She actually can move her left hip and knee without much discomfort but the pain radiates from her sacroiliac joint.  She cannot stand, sit or turn without severe pain.  She has normal knee reflexes.  No ankle reflexes.  She has bounding tibial pulses.  No sensory deficit.  She says she knows when she has to void.  She has a healed scar in the upper sacral region.  There is some bruising around the buttocks but the daughter says that is from her being in bed lying on her back.,PLAN: , My plan is to do a triple-phase bone scan.  I am suspecting an infection possibly in the left sacroiliac joint.  It is probably some type of bacterium, the etiology of which is undetermined.  She has had a normal white count despite her fever.  There has been a history of brucellosis in the past, but her titers at this time are negative.  Continue medication which included antibiotics and also the Motrin and Darvocet.,","consult - history and phy., inflammatory, degenerative, fever, lumbar spine, sacroiliac joint, inguinal, sacroiliac, hip,"
 An 80-year-old female with recent complications of sepsis and respiratory failure who is now receiving tube feeds., Consult - History and Phy., Gen Med Consult - 44 ,"PAST MEDICAL HISTORY:  Include:,1.  Type II diabetes mellitus.,2.  Hypertension.,3.  Hyperlipidemia.,4.  Gastroesophageal reflux disease.,5.  Renal insufficiency.,6.  Degenerative joint disease, status post bilateral hip and bilateral knee replacements.,7.  Enterocutaneous fistula.,8.  Respiratory failure.,9.  History of atrial fibrillation.,10.  Obstructive sleep apnea.,11.  History of uterine cancer, status post total hysterectomy.,12.  History of ventral hernia repair for incarcerated hernia.,SOCIAL HISTORY:  The patient has been admitted to multiple hospitals over the last several months.,FAMILY HISTORY:  Positive for diabetes mellitus type 2 in both mother and her sister.,MEDICATIONS:  Currently include,,1.  Albuterol inhaler q.4 h.,2.  Paradox swish and spit mouthwash twice a day.,3.  Digoxin 0.125 mg daily.,4.  Theophylline 50 mg q.6 h.,5.  Prozac 20 mg daily.,6.  Lasix 40 mg daily.,7.  Humulin regular high dose sliding scale insulin subcu. q.6 h.,8.  Atrovent q.4 h.,9.  Lantus 12 units subcu. q.12 h.,10.  Lisinopril 10 mg daily.,11.  Magnesium oxide 400 mg three times a day.,12.  Metoprolol 25 mg twice daily.,13.  Nitroglycerin topical q.6 h.,14.  Zegerid 40 mg daily.,15.  Simvastatin 10 mg daily.,ALLERGIES:  Percocet, Percodan, oxycodone, and Duragesic.,REVIEW OF SYSTEMS:  The patient currently denies any pain, denies any headache or blurred vision.  Denies chest pain or shortness of breath.  She denies any nausea or vomiting.  Otherwise, systems are negative.,PHYSICAL EXAM:,General:  The patient is awake, alert, and oriented.  She is in no apparent respiratory distress.,Vital Signs:  Temperature 97.6, blood pressure is 139/53, pulse 100, respirations 24.  The patient has a tracheostomy in place.  She will also have an esophageal gastric tube in place.,Cardiac:  Regular rate and rhythm without audible murmurs, rubs or gallops.  Lungs are clear to auscultation bilaterally with slightly diminished breath sounds on the bases.  No adventitious sounds are noted.,Abdomen:  Obese.  There is an open wound on the ventral abdomen overlying the midline abdominal incision from previous surgery.  The area is covered with bandage with serosanguineous fluid.  Abdomen is nontender to palpation.  Bowel sounds are heard in all 4 quadrants.,Extremities:  Bilateral lower extremities are edematous and very cool to touch.,LABORATORY DATA:  Pending.  Capillary blood sugars thus far have been 132 and 135.,ASSESSMENT:  This is an 80-year-old female with an unfortunate past medical history with recent complications of sepsis and respiratory failure who is now receiving tube feeds.,PLAN:  For her diabetes mellitus, we will continue the patient on her current regimen of Lantus 12 units subcu. q.12 h. and Regular Insulin at a high dose sliding scale every 6 hours.  The patient had been previously controlled on this.  We will continue to check her sugars every 6 hours and adjust insulin as necessary.",
" A 69-year-old female with past history of type II diabetes, atherosclerotic heart disease, hypertension, carotid stenosis. ", Consult - History and Phy., Gen Med Consult - 43 ,"HISTORY:,  A 69-year-old female with past history of type II diabetes, atherosclerotic heart disease, hypertension, carotid stenosis.  The patient was status post coronary artery bypass surgery aortic valve repair at Shadyside Hospital.  The patient subsequently developed CVA.  She also developed thrombosis of the right arm, which ultimately required right hand amputation.  She was stabilized and eventually transferred to HealthSouth for further management.,PHYSICAL EXAMINATION:,Vital Signs:  Pulse of 90 and blood pressure 150/70.,Heart:  Sounds were heard, grade 2/6 systolic murmur at the precordium.,Chest:  Clinically clear.,Abdomen:  Some suprapubic tenderness.  Evidence of right lower arm amputation.,The patient was started on Prevacid 30 mg daily, levothyroxine 75 mcg a day, Toprol 25 mg twice a day, Zofran 4 mg q.6 h, Coumadin dose at 5 mg and was adjusted.  She was given a pain control using Vicodin and Percocet, amiodarone 200 mg a day, Lexapro 20 mg a day, Plavix 75 mg a day, fenofibrate 145 mg, Lasix 20 mg IV twice a day, Lantus 50 units at bedtime and Humalog 10 units a.c. and sliding scale insulin coverage.  Wound care to the right heel was supervised by Dr. X.  The patient initially was fed through NG tube, which was eventually discontinued.  Physical therapy was ordered.  The patient continued to do well.  She was progressively ambulated.  Her meds were continuously adjusted.  The patient's insulin was eventually changed from Lantus to Levemir 25 units twice a day.  Dr. Y also followed the patient closely for left heel ulcer.,LABORATORY DATA: , The latest cultures from left heel are pending.  Her electrolytes revealed sodium of 135 and potassium of 3.2.  Her potassium was switched to K-Dur 40 mEq twice a day.  Her blood chemistries are otherwise closely monitored.  INRs were obtained and were therapeutic.  Throughout her hospitalization, multiple cultures were also obtained.  Urine cultures grew Klebsiella.  She was treated with appropriate antibiotics.  Her detailed blood work is as in the chart.  Detailed radiological studies are as in the chart.  The patient made a steady progress and eventually plans were made to transfer the patient to ABC furthermore aggressive rehabilitation.,FINAL DIAGNOSES:,1.  Atherosclerotic heart disease, status post coronary artery bypass graft.,2.  Valvular heart disease, status post aortic valve replacement.,3.  Right arm arterial thrombosis, status post amputation right lower arm.,4.  Hypothyroidism.,5.  Uncontrolled diabetes mellitus, type 2.,6.  Urinary tract infection.,7.  Hypokalemia.,8.  Heparin-induced thrombocytopenia.,9.  Peripheral vascular occlusive disease.,10.  Paroxysmal atrial fibrillation.,11.  Hyperlipidemia.,12.  Depression.,13.  Carotid stenosis.","consult - history and phy., arterial thrombosis, valvular heart disease, atherosclerotic heart disease, type ii diabetes, hypertension, carotid stenosis, heart disease, diabetes, carotid, stenosis, bypass, amputation, heart, atherosclerotic, "
" The patient presents to the office today with complaints of extreme fatigue, discomfort in the chest and the back that is not related to any specific activity.  Stomach gets upset with pain. ", Consult - History and Phy., Gen Med Consult - 48 ,"HISTORY:,  The patient presents today for medical management.  The patient presents to the office today with complaints of extreme fatigue, discomfort in the chest and the back that is not related to any specific activity.  Stomach gets upset with pain.  She has been off her supplements for four weeks with some improvement.  She has loose bowel movements.  She complains of no bladder control.  She has pain in her hips.  The peripheral neuropathy is in both legs, her swelling has increased and headaches in the back of her head.,DIAGNOSES:,1.  Type II diabetes mellitus.,2.  Generalized fatigue and weakness.,3.  Hypertension.,4.  Peripheral neuropathy with atypical symptoms.,5.  Hypothyroidism.,6.  Depression.,7.  Long-term use of high-risk medications.,8.  Postmenopausal age-related symptoms.,9.  Abdominal pain with nonspecific irritable bowel type symptoms, intermittent diarrhea.,CURRENT MEDICATIONS: , Her list of medicines is as noted on 04/22/03.  There is a morning and evening lift.,PAST SURGICAL HISTORY:,  As listed on 04/22/04 along with allergies 04/22/04.,FAMILY HISTORY: , Basically unchanged.  Her father died of an MI at 65, mother died of a stroke at 70.  She has a brother, healthy.,SOCIAL HISTORY:  ,She has two sons and an adopted daughter.  She is married long term, retired from Avon.  She is a nonsmoker, nondrinker.,REVIEW OF SYSTEMS:,GENERAL:  Certainly at the present time on general exam no fever, sweats or chills and no significant weight change.  She is 189 pounds currently and she was 188 pounds in January.,HEENT:  HEENT, there is no marked decrease in visual or auditory function.  ENT, there is no change in hearing or epistaxis, sore throat or hoarseness.,RESPIRATORY:  Chest, there is no history of palpitations, PND or orthopnea.  The chest pains are nonspecific, tenderness to palpation has been reported.  There is no wheezing or cough reported.,CARDIOVASCULAR:  No PND or orthopnea.  Thromboembolic disease history.,GASTROINTESTINAL:  Intermittent symptoms of stomach pain, they are nonspecific.  No nausea or vomiting noted.  Diarrhea is episodic and more related to nerves.,GENITOURINARY:  She reports there is generally poor bladder control, no marked dysuria, hematuria or history of stones.,MUSCULOSKELETAL:  Peripheral neuropathy and generalized muscle pain, joint pain that are sporadic.,NEUROLOGICAL:  No marked paralysis, paresis or paresthesias.,SKIN:  No rashes, itching or changes in the nails.,BREASTS:  No report of any lumps or masses.,HEMATOLOGY AND IMMUNE:  No bruising or bleeding-type symptoms.,PHYSICAL EXAMINATION:,WEIGHT:  189 pounds.  BP:  140/80.  PULSE:  76.  RESPIRATIONS:  20.  GENERAL APPEARANCE:  Well developed, well nourished.  No acute distress.,HEENT:  Head is normocephalic.  Ears, nose, and throat, normal conjunctivae.  Pupils are reactive.  Ear canals are patent.  TMs are normal.  Nose, nares patent.  Septum midline.  Oral mucosa is normal in appearance.  No tonsillar lesions, exudate or asymmetry.  Neck, adequate range of motion.  No thyromegaly or adenopathy.,CHEST:  Symmetric with clear lungs clear to auscultation and percussion.,HEART:  Rate and rhythm is regular.  S1 and S2 audible.  No appreciable murmur or gallop.,ABDOMEN:  Soft.  No masses, guarding, rigidity, tenderness or flank pain.,GU:  No examined.,EXTREMITIES:  No cyanosis, clubbing or edema currently.,SKIN AND INTEGUMENTS:  Intact.  No lesions or rashes.,NEUROLOGIC:  Nonfocal to cranial nerve testing II through XII, motor, sensory, gait and random motion.,Additional information, the patient has been off metformin for few months and this is not part of her medication list.,IMPRESSION:,",
 Patient with a diagnosis of stroke., Consult - History and Phy., Gen Med Consult - 40 ,"CHIEF COMPLAINT:, Altered mental status.,HISTORY OF PRESENT ILLNESS:, The patient is a 69-year-old male transferred from an outlying facility with diagnosis of a stroke. History is taken mostly from the emergency room record. The patient is unable to give any history and no family member is present for questioning. When asked why he came to the emergency room, the patient replies that it started about 2 PM yesterday. However, he is unable to tell me exactly what started at 2 PM yesterday. The patient's speech is clear, but he speaks nonsensically using words in combinations that don't make any sense. No other history of present illness is available.,PAST MEDICAL HISTORY:, Per the emergency room record, significant for atrial fibrillation, hypertension, and hyperlipidemia.,PAST SURGICAL HISTORY:, Unknown.,FAMILY HISTORY:, Unknown.,SOCIAL HISTORY:, The patient denies smoking and drinking.,MEDICATIONS:, Per the emergency room record, medications are Lotensin 20 mg daily, Toprol 50 mg daily, Plavix 75 mg daily and aspirin 81 mg daily.,ALLERGIES:, UNKNOWN.,REVIEW OF SYSTEMS:, Unobtainable secondary to the patient's condition.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature: 97.9. Pulse: 79. Respiratory rate: 20. Blood pressure: 117/84.,GENERAL: Well-developed, well-nourished male in no acute distress.,HEENT: Eyes: Pupils are equal, round and reactive. There is no scleral icterus. Ears, nose and throat: His oropharynx is moist. His hearing is normal.,NECK: No JVD. No thyromegaly.,CARDIOVASCULAR: Irregular rhythm. No lower extremity edema.,RESPIRATORY: Clear to auscultation bilaterally with normal effort.,ABDOMEN: Nontender. Nondistended. Bowel sounds are positive.,MUSCULOSKELETAL: There is no clubbing of the digits. The patient's strength is 5/5 throughout.,NEUROLOGICAL: Babinski's are downgoing bilaterally. Deep tendon reflexes are 2+ throughout.,LABORATORY DATA:, By report, head CT from the outlying facility was negative. An EKG showed atrial fibrillation with a rate of 75. There is no indication of any acute cardiac ischemia. A chest x-ray shows no acute pulmonary process, but does show cardiomegaly.,Labs are as follows: White count 9.4, hemoglobin 17.2, hematocrit 52.5, platelet count 219. PTT 24, PT 13, INR 0.96. Sodium 135, potassium 3.6, chloride 99, bicarb 27, BUN 13, creatinine 1.4, glucose 161, calcium 9, magnesium 1.9, total protein 7, albumin 3.7, AST 22, ALT 41, alkaline phosphatase 85, total bilirubin 0.7, total cholesterol 193. Cardiac isoenzymes are negative times one with a troponin of 0.09.,ASSESSMENT AND PLAN:,1. Probable stroke. The patient has an expressive aphasia. He does not have dysarthria, however. Also, his strength is not affected. I suspect that the patient has had strokes or TIAs in the past because he was taking aspirin and Plavix at home. Head CT is reportedly negative. I will ask our radiologist to re-read the head CT. I will also order MRI and MRA, carotid Doppler ultrasound and echocardiogram in addition to a fasting lipid profile. I will consult neurology to evaluate and continue his aspirin and Plavix.,2. Atrial fibrillation. The patient's rate is controlled currently. I will continue him on his amiodarone 200 mg twice daily and consult CHI to evaluate him.,3. Hypertension. I will continue his home medications and add clonidine as needed.,4. Hyperlipidemia. The patient takes no medications for this currently. I will check a fasting lipid profile.,5. Hyperglycemia. It is unknown whether the patient has a history of diabetes. His glucose is currently 171. I will start him on sliding scale insulin for now and monitor closely.,6. Renal insufficiency. It is also unknown whether the patient has a history of this and what his baseline creatinine might be. Currently he has only mild renal insufficiency. This does not appear to be prerenal. Will monitor for now.",
" Backache, stomachache, and dysuria for the last two days - Urinary dysuria, left flank pain, pharyngitis.", Consult - History and Phy., Gen Med Consult - 41 ,"SUBJECTIVE:,  The patient complains of backache, stomachache, and dysuria for the last two days.  Fever just started today and cough.  She has history of kidney stones less than a year ago and had a urinary tract infection at that time.  Her back started hurting last night.,PAST MEDICAL HISTORY:,  She denies sexual activities since two years ago.  Her last menstrual period was 06/01/2004.  Her periods have been irregular.  She started menarche at 10 years of age and she is still irregular and it runs in Mom’s side of the family.  Mom and maternal aunt have had total hysterectomies.  She also is diagnosed with abnormal valve has to be on SBE prophylaxis, sees Dr. XYZ Allen.  She avoids decongestants.  She is limited on her activity secondary to her heart condition.,MEDICATION:,  Cylert.,ALLERGIES: , No known drug allergies.,OBJECTIVE:,Vital Signs:  Blood pressure is 124/72.  Temperature 99.2.  Respirations 20 unlabored.  Weight:  137 pounds.,HEENT:  Normocephalic.  Conjunctivae noninjected.  No mattering noted.  Her TMs are bilaterally clear, nonerythematous.  Throat clear, good mucous membrane moisture, but she did have erythema and edema at her posterior soft palate.,Neck:  Supple.  Increased lymphadenopathy noted in the submandibular nodes, but no axillary nodes and no hepatosplenomegaly.,Respiratory:  Clear.  No wheezes, no crackles, no tachypnea, and no retractions.,Cardiovascular:  Regular rate and rhythm.  S1 and S2 normal, no murmur.,Abdomen:  Soft.  No organomegaly.  She did have exquisite tenderness to palpation of the left upper quadrant and flank area, but the spleen was not palpable.  She has no suprapubic tenderness.,Extremities:  She has good range of motion of upper and lower extremities.  Good ambulation.,Her UA was positive for 2+ leukocyte esterase, positive nitrites, 1+ protein, 2+ ketones, 4+ blood, greater than 50 white blood cells, 10-20 rbc’s, and 1+ bacteria.  Culture and sensitivity is pending.  Her Strep test is negative.  Culture is pending.,ASSESSMENT:,1.  Urinary dysuria.,2.  Left flank pain.,3.  Pharyngitis.,PLAN:,  A 1 g of Rocephin IM was given.  Call Dr. B's office tomorrow morning incase a second IM dose is needed.  If not then she will fill a prescription for Omnicef 300 mg capsule 1 p.o. b.i.d. for 10 days total and then we will await the culture and sensitivity results to see if this is appropriate drug.  Push fluids.  Await strep culture report.  Follow up with Dr. XYZ if no better or symptoms worsen.","consult - history and phy., backache, stomachache, dysuria, cylert, urinary dysuria, pharyngitis, culture and sensitivity, tenderness, urinary, infection, "
" Patient with one-week history of increased progressive shortness of breath, orthopnea for the past few nights, mild increase in peripheral edema, and active wheezing with dyspnea.  Medifast does fatigue", Consult - History and Phy., Gen Med Consult - 42 ,"HISTORY AND CLINICAL DATA:  ,The patient is an 88-year-old gentleman followed by Dr. X, his primary care physician, Dr. Y for the indication of CLL and Dr. Z for his cardiovascular issues.  He presents to the Care Center earlier today with approximately a one-week history of increased progressive shortness of breath, orthopnea over the course of the past few nights, mild increase in peripheral edema, and active wheezing with dyspnea presenting this morning.,He reports no clear-cut chest discomfort or difficulty with angina.  He has had no dizziness, lightheadedness, no near or true syncope, nothing supportive of CVA, TIA, nor peripheral vascular claudication.,REVIEW OF SYSTEMS:,  General review of system is significant for difficulty with intermittent constipation, which has been problematic recently.  He reports no fever, shaking chills, nothing supportive of GI or GU blood loss, no productive or nonproductive cough.,PAST MEDICAL HISTORY:,  Remarkable for hypertension, diabetes, prostate cancer, status post radium seed implant, COPD, single vessel coronary disease, esophageal reflux, CLL, osteopenia, significant hearing loss, anxiety, and degenerative joint disease.,SOCIAL HISTORY: , Remarkable for being married, retired, quit smoking in 1997, rare use of alcohol, lives locally with his wife.,MEDICATIONS AT HOME:,  Include, Lortab 7.5 mg up to three times daily for chronic arthritic discomfort, Miacalcin nasal spray once daily, omeprazole 20 mg daily, Diovan 320 mg daily, Combivent two puffs t.i.d., folate, one adult aspirin daily, glyburide 5 mg daily, atenolol 50 mg daily, furosemide 40 mg daily, amlodipine 5 mg daily, hydralazine 50 mg p.o. t.i.d., in addition to Tekturna 150 mg daily, Zoloft 25 mg daily.,ALLERGIES:  ,He has known history of allergy to clonidine, Medifast does fatigue.,DIAGNOSTIC AND LABORATORY DATA: , Chest x-ray upon presentation to the Ellis Emergency Room this evening demonstrate significant congestive heart failure with moderate-sized bilateral pleural effusions.,A 12-lead EKG, sinus rhythm at a rate of 68 per minute, right bundle-branch block type IVCV with moderate nonspecific ST changes.  Low voltage in the limb leads.,WBC 29,000, hemoglobin 10.9, hematocrit 31, platelets 187,000.  Low serum sodium at 132, potassium 4, BUN 28, creatinine 1.2, random glucose 179.  Low total protein 5.7.  Magnesium level 2.3, troponin 0.404 with the B-natriuretic peptide of 8200.,PHYSICAL EXAMINATION:  ,He is an elderly gentleman, who appears to be in no acute distress, lying comfortably flat at 30 degrees, measured pressure of 150/80 with a pulse of 68 and regular.  JVD difficult to assess.  Normal carotids with obvious bruits.  Conjunctivae pink.  Oropharynx clear.  Mild kyphosis.  Diffusely depressed breath sounds halfway up both posterior lung fields.  No active wheezing.  Cardiac Exam:  Regular, soft, 1-2/6 early systolic ejection murmur best heard at the base.  Abdomen:  Soft, nontender, protuberant, benign.  Extremities:  2+ bilateral pitting edema to the level of the knees.  Neuro Exam:  Appears alert, oriented x3.  Appropriate manner and affect, exceedingly hard of hearing.,OVERALL IMPRESSION:,  An 88-year-old white male with the following major medical issues:,1.  Presentation consists with subclinical congestive heart failure possibly systolic, no recent echocardiogram available for review.,2.  Hypertension with suboptimal controlled currently.,3.  Diabetes.,4.  Prostate CA, status post radium seed implant.,5.  COPD, on metered-dose inhaler.,6.  CLL followed by Dr. Y.,7.  Single-vessel coronary disease, no recent anginal quality chest pain, no changes in ECG suggestive of acute ischemia; however, initial troponin 0.4 - to be followed with serial enzyme determinations and telemetry.,8.  Hearing loss, anxiety.,9.  Significant degenerative joint disease.,PLAN:,1.  Admit to A4 with telemetry, congestive heart failure pathway, intravenous diuretic therapy.,2.  Strict I&O, Foley catheter has already been placed.,3.  Daily BMP.,4.  Two-dimensional echocardiogram to assess left ventricular systolic function.  Serum iron determination to exclude the possibility of a subclinical ischemic cardiac event.  Further recommendations will be forthcoming pending his clinical course and hospital.",
 Consultation for jaw pain., Consult - History and Phy., Gen Med Consult - 4 ,"CHIEF COMPLAINT:,  Jaw pain this morning.,BRIEF HISTORY OF PRESENT ILLNESS:,  This is a very nice 53-year-old white male with no previous history of heart disease, was admitted to rule out MI and coronary artery disease.  The patient has history of hypercholesterolemia, presently on Lipitor 20 mg a day and hyperthyroidism, on Synthroid 0.088 mg per day.  Also, history of chronic diverticulitis with recent bouts.  The patient has been doing well, seen in my office at the end of December for complete physical examination.  I had ordered a stress test for him, then delayed due to a family illness.  However, denies any chest pain or chest tightness with exertion.  The patient was doing well.  He was watching television yesterday afternoon or p.m. and fell asleep holding his head in his left hand.  He awoke and noticed pain in the jaw and neck area, on both sides, but no shortness of breath, diaphoresis, nausea, or chest pain.  He is able to go to sleep, woke up this morning with same discomfort, decided to call our office, talked to our triage nurse, who instructed to come to the emergency room for possibility of just having a cardiac event.  The patient's pain resolved.  He was given nitroglycerin in the emergency room drawing his blood pressure 67/32.  Blood pressure quickly came back to normal with the patient's reverse Trendelenburg.,FAMILY HISTORY: , Strongly positive for heart disease in his father.  He had a bypass at age 60.  Both parents are alive.  Both have dementia.  His father has history of coronary artery disease and multiple vascular strokes.  He is in his 80s.  His mother is 80, also with dementia.  The patient does not smoke or drink.,PAST MEDICAL HISTORY:,  Remarkable for tonsillectomies.,MEDICATIONS:,  Synthroid and Lipitor.,ALLERGIES:,  PENICILLIN AND BIAXIN.,REVIEW OF SYSTEMS:,  Noncontributory.,PHYSICAL EXAMINATION:,VITAL SIGNS:  The patient's blood pressure is 113/74, pulse rate is 72, respiratory rate is 18.  He is afebrile.,GENERAL:  He is well-developed, well-nourished white male, in no acute distress.,HEENT:  Pupils equal, round, and reactive to light and accommodation.  Extraocular movements were intact.  Throat was clear.,NECK:  Supple.  There is no organomegaly or thyromegaly.  Carotids are +2 without bruits.,CHEST:  Lungs are clear to auscultation and percussion.,CV:  Without any murmurs or gallops.,ABDOMEN:  Soft.  There is no hepatosplenomegaly.  Bowel sounds are active.  No tenderness.,EXTREMITIES:  No cyanosis, clubbing, or edema.  Peripheral pulses 2+.,NEUROLOGICAL:  Intact.  Motor exam is 5/5.,LABORATORY STUDIES:,  EKG is within normal limits, good sinus rhythm.  His axis is somewhat leftward.  CBC and BMP were normal and cardiac enzymes were negative x1.,IMPRESSION:,1.  Jaw pain, sounds musculoskeletal.  We will rule out angina equivalent.,2.  Hypercholesterolemia.,3.  Hypothyroidism.,PLAN: , Lipitor and thyroid have been ordered.  His chest pain unit protocol for the stress thallium that will be done in the morning.  If test is negative, we will discharge home.  If positive, we will consult Cardiology.  The patient requests Dr. ABC.",
" Patient admitted with abdominal pain, nausea and vomiting.", Consult - History and Phy., Gen Med Consult - 38 ,"Chief Complaint:, Abdominal pain, nausea and vomiting.,History of Present Illness:, A 50-year-old Asian female comes to The Methodist Hospital on January 2, 2001, complaining of a 3-day history of abdominal pain. The pain is described as crampy in the central part of her abdomen, and is associated with nausea and vomiting during the previous 24 hours. The patient denied passing any stool or gas per rectum for the previous 24 hours. She had been admitted recently to the hospital from December 19 to December 23, 2000, with a three-week history of fevers to 101.8, diaphoresis, anorexia, malaise and skin ""lumps"". She described a total of three ""lumps"". The first one started as a pin-sized lesion that grew up and then disappeared, the other two didn't resolve. They were described as ""erythematous nodular lesions on the extensor surface of the left arm."" A punch biopsy was obtained from these skin lesions, showing deep dermis and subcutaneous adipose tissue that contained ""multiple granulomas composed of histiocytes and multinucleated giant cells without caseating necrosis"". However, one granuloma in the deep dermis, showed a hint of central necrosis. Special stains for acid - fast bacilli and fungi were reported as negative. No atypia or malignancy was noted. A CT scan of the chest was obtained on December 19, 2000 and showed numerous masses with spiculated borders bilaterally, predominately in the upper lobes and superior segments of the lower lobes. No cavitary lesions, mediastinal masses or definite hilar adenopathy were reported. The patient underwent bronchoscopy and transbronchial biopsy which showed fragments of bronchial mucosa and wall with underlying lung parenchyma. Minimal to mild interstitial lymphocytes with a few microfoci of neutrophils were seen. They were also able to appreciate intra-alveolar fibrinous exudates. One of the blood cultures drawn on December 19, 2000 grew Streptococcus mitis.,The patient was discharged on ethambutol 1200 mg po qd, clarithromycin 500 mg po bid, ampicillin 500 mg po q 6h and fluconazole 200 mg po qd.,Past Medical History:,1. Post-streptococcal glomerulonephritis at age 10.,2. End stage renal disease diagnosed in 1994, on peritoneal dialysis until 1996.,3. Cadaveric transplant in October 1996,4. Steroid induced diabetes mellitus,5. Hypertension,Past Surgical History:,1. Total abdominal hysterectomy in January 1996,2. Cesarean section X2 in 1996 and 1997,3. Appendectomy in 1971,4. Insertion of peritoneal dialysis catheter in 1994,5. Cadaveric transplant in October 1996,Social History:,The patient denies a history of smoking, drinking or intravenous drug use. She came to the United States in 1973. She works as a nurse in a newborn nursery. Her hobby is gardening. She traveled to Las Vegas on May 2000 and stayed for 6 months. She denied ill contacts or pets.,Allergies:, Ciprofloxacin and Enteric coated aspirin,Medications:, prednisone 20 mg po qd, enalapril 2.5 mg po qd, clonidine patch TTS 3 1/week, Prograf 5 mg po bid, ranitidine 150 mg po bid, furosemide 40 mg po bid, atorvastatin 10 mg po qd, multivitamins 1 tab po qd, estrogen patch, fluconazole 200 mg po qd, metformin 500 mg po bid, glyburide 10 mg po qd, clarithromycin 500 mg po bid, ethambutol 1200 mg po qd, ampicillin 500 mg po q 6h.,Family History:, She described a family history of hypertension. Her mother died after a myocardial infarction at age 59. Her father was diagnosed with congestive heart failure and had a pacemaker placed.,Review of systems:, Non-contributory. The patient denied fever, chills, ulcers, liver disease or history of gallstones.,Vaccines: The patient was vaccinated with BCG before starting elementary school in the Philippines.,Physical Examination:, At the time of the examination the patient was alert and oriented times three and in no acute distress. She was well nourished.,BP 106/60 lying down; HR 86; RR 12; T 96.1° F; Hgt. =5' 2""; Wgt. =121 lbs.,SKIN: There was no rash or skin lesions.,HEENT: She had no oral lesions and moist mucous membranes. No icterus was noted.,NECK: Her neck was supple without lymphadenopathy or thyromegaly.,LUNGS: Crackles at the right lower base with normal respiratory excursion and no dullness to percussion.,HEART: IV/VI crescendo - decrescendo systolic murmur was heard at the second intercostal space with radiation to the neck.,ABDOMEN: The abdomen was distended. Bowel sounds were normal. No hepatosplenomegaly, tenderness or rebound tenderness could be detected during the examination.,EXTREMITIES: No cyanosis, clubbing or edema was noted.,RECTAL: Normal rectal exam. Guaiac negative.,NEUROLOGIC: Normal and non-focal.,Hospital Course:,  The patient was admitted and a nasogastric tube was placed. IV fluids were started. A KUB was obtained showing an abnormal bowel gas pattern. Multiple loops of distended bowel were noted in the mid abdomen. Air and feces were noted within the colon in the right side. An Abdominal CT scan was obtained. There was a small amount of perihepatic fluid noted. The liver and spleen were normal. The kidneys were atrophic. The gallbladder was moderately distended. There was marked dilatation of the small bowel proximally and distally. There was gas and contrast material in the colon. A diagnostic procedure was performed.",
" Patient with hypertension, dementia, and depression.", Consult - History and Phy., Gen Med Consult - 33 ,"MEDICAL PROBLEM LIST:,1.  Status post multiple cerebrovascular accidents and significant left-sided upper extremity paresis in 2006.,2.  Dementia and depression.,3.  Hypertension.,4.  History of atrial fibrillation.  The patient has been in sinus rhythm as of late.  The patient is not anticoagulated due to fall risk.,5.  Glaucoma.,6.  Degenerative arthritis of her spine.,7.  GERD.,8.  Hypothyroidism.,9.  Chronic rhinitis (the patient declines nasal steroids).,10.  Urinary urge incontinence.,11.  Chronic constipation.,12.  Diabetes type II, 2006.,13.  Painful bunions on feet bilaterally.,CURRENT MEDICINES: , Aspirin 81 mg p.o. daily, Cymbalta 60 mg p.o. daily, Diovan 80 mg p.o. daily, felodipine 5 mg p.o. daily, omeprazole 20 mg daily, Toprol-XL 100 mg daily, Levoxyl 50 mcg daily, Lantus insulin 12 units subcutaneously h.s., simvastatin 10 mg p.o. daily, AyrGel to both nostrils twice daily, Senna S 2 tablets twice daily, Timoptic 1 drop both eyes twice daily, Tylenol 1000 mg 3 times daily, Xalatan 0.005% drops 1 drop both eyes at bedtime, and Tucks to rectum post BMs.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.  ACE INHIBITOR MAY HAVE CAUSED A COUGH.,CODE STATUS:,  Do not resuscitate, healthcare proxy, palliative care orders in place.,DIET:,  No added salt, no concentrated sweets, thin liquids.,RESTRAINTS:,  None.  The patient has declined use of chair check and bed check.,INTERVAL HISTORY: , Overall, the patient has been doing reasonably well.  She is being treated for some hemorrhoids, which are not painful for her.  There has been a note that she is constipated.,Her blood glucoses have been running reasonably well in the morning, perhaps a bit on the high side with the highest of 188.  I see a couple in the 150s.  However, I also see one that is in the one teens and a couple in the 120s range.,She is not bothered by cough or rib pain.  These are complaints, which I often hear about.,Today, I reviewed Dr. Hudyncia's note from psychiatry.  Depression responded very well to Cymbalta, and the plan is to continue it probably for a minimum of 1 year.,She is not having problems with breathing.  No neurologic complaints or troubles.  Pain is generally well managed just with Tylenol.,PHYSICAL EXAMINATION: , Vitals:  As in chart.  The patient is pleasant and cooperative.  She is in no apparent distress.  Her lungs are clear to auscultation and percussion.  Heart sounds regular to me.  Abdomen:  Soft.  Extremities without any edema.  At the rectum, she has a couple of large hemorrhoids, which are not thrombosed and are not tender.,ASSESSMENT AND PLAN:,1.  Hypertension, good control, continue current.,2.  Depression, well treated on Cymbalta.  Continue.,3.  Other issues seem to be doing pretty well.  These include blood pressure, which is well controlled.  We will continue the medicines.  She is clinically euthyroid.  We check that occasionally.  Continue Tylenol.,4.  For the bowels, I will increase the intensity of regimen there.  I have a feeling she would not tolerate either the FiberCon tablets or Metamucil powder in a drink.  I will try her on annulose and see how she does with that.",
 A male patient presented for evaluation of chronic abdominal pain., Consult - History and Phy., Gen Med Consult - 34 ,"Chief Complaint:, Chronic abdominal pain.,History of Present Illness:, 23-year-old Hispanic male who presented for evaluation of chronic abdominal pain. Patient described the pain as dull, achy, constant and located at the epigastric area with some radiation to the back. There are also occasional episodes of stabbing epigastric pain unrelated to meals lasting only minutes. Patient noted that the pain started approximately six months prior to this presentation. He self medicated ""with over the counter"" antacids and obtained some relief so he did not seek medical attention at that time.,Two months prior to current presentation, he had worsening of his pain as well as occasional nausea and vomiting. At this time the patient was found to be H. pylori positive by serology and was treated with triple therapy for two weeks and continued on omeprazole without relief of his pain.,The patient felt he had experienced a twenty-pound weight loss since his symptoms began but he also admitted to poor appetite. He stated that he had two to three loose bowel movements a day but denied melena or bright red blood per rectum. Patient denied NSAID use, ethanol abuse or hematemesis. Position did not affect the quality of the pain. Patient denied fever or flushing. He stated he was a very active and healthy individual prior to these recent problems.,Past Medical History:, No significant past medical history.,Past Surgical History:, No prior surgeries.,Allergies:, No known drug allergies.,Medications:, Omeprazole 40 mg once a day. Denies herbal medications.,Family History:, Mother, father and siblings were alive and well.,Social History:, He is employed as a United States Marine officer, artillery repair specialist. He was a social drinker in the past but quit altogether two years ago. He never used tobacco products or illicit/intravenous drugs.,Physical Examination:, The patient was a thin male in no apparent distress. His oral temperature was 98.2 Fahrenheit, blood pressure was 114/67 mmHg, pulse rate of 91 beats per minute and regular, respiratory rate was 14 and his pulse oximetry on room air was 98%. Patient was 52 kg in weight and 173 cm height.,SKIN: No skin rashes, lesions or jaundice. He had one tattoo on each upper arm.,HEENT: Head was normocephalic and atraumatic. Pupils were equal, round and reactive. Anicteric sclerae. Tympanic membranes had a normal appearance. Normal funduscopic examination. Oral mucosa was moist and pink. Oral/pharynx was clear.,NECK: No lymphadenopathy. No carotid bruits. Trachea midline. Thyroid non-palpable. No jugular venous distension.,CHEST: Lungs were clear bilaterally with good air movement.,HEART: Regular rate and rhythm. Normal S1 and S2 with no murmurs, gallops or rubs. PMI was non-displaced.,ABDOMEN: Abdomen was flat. Normal active bowel sounds. Liver span percussed sixteen centimeters, six centimeters below R costal margin with irregular border that was mildly tender to palpation. Slightly tender to palpation in epigastric area. There was no splenomegaly. No abdominal masses were appreciated. No CVA tenderness was noted.,RECTAL: No perirectal lesions were found. Normal sphincter tone and no rectal masses. Prostate size was normal without nodules. Guaiac positive.,GENITALIA: Testes descended bilaterally, no penile lesions or discharge.,EXTREMITIES: No clubbing, cyanosis, or edema. No peripheral lymphadenopathy was noted.,NEUROLOGIC: Alert and oriented times three. Cranial nerves II to XII appeared intact. No muscle weakness or sensory deficits. DTRs equal and normal.,Radiology/Studies: 2 view CXR: Mild elevation right diaphragm.,CT of abdomen and pelvis: Too numerous to count bilobar liver masses up to about 8 cm. Extensive mass in the pancreatic body and tail, peripancreatic region and invading the anterior aspect of the left kidney. Question of vague splenic masses. No definite abnormality of the moderately distended gallbladder, bile ducts, right kidney, poorly seen adrenals, bowel or bladder. Evaluation of the retroperitoneum limited by paucity of fat.,Patient underwent several diagnostic procedures and soon after he was transferred to Houston Veterans Administration Medical Center to be near family and to continue work-up and treatment. At the HVAMC these diagnostic procedures were reviewed.",
 Patient with confusion and hallucinations., Consult - History and Phy., Gen Med Consult - 35 ,"Chief Complaint:, Confusion and hallucinations.,History of Present Illness:, The patient was a 27-year-old Hispanic man who presented to St. Luke's Episcopal Hospital with a five day history of confusion and hallucinations. The patient was doing well until three months prior to admission when he developed wheezing and shortness of breath upon exertion. He was seen by his primary care physician and was prescribed Salmeterol and Fluticasone nasal inhaler for presumed asthma. His wheezing improved with treatment.,Over the five days prior to admission, his family noticed the patient's increasing confusion and bizarre behavior. The patient was intermittently unable to recognize his family members or surroundings. He was restless and anxious, paced the floor at night, and complained of insomnia. He stated he was unable to sleep because he feared his family was trying to hurt him. When he did sleep, he described night terrors. He also complained of both auditory and visual hallucinations. He stated the voices ""told him to do good things"". He denied any previous history of depression or manic episodes. The patient denied suicidal or homicidal ideation. He admitted he had recently lost weight although he was unable to quantify how much. He stated his appetite was good, but he had not been eating for fear of being poisoned.,The patient denied having headaches or a history of trauma. He denied fevers or chills but he complained of recent night sweats. He denied nausea, vomiting, diarrhea, or dysuria. He denied chest pain, palpitations, or episodic flushing; but he complained of lightheadedness. He denied orthopnea or paroxysmal nocturnal dyspnea. The shortness of breath symptoms had resolved.,Past Medical History:, None. No history of hypertension or of cardiac, renal, lung, or liver disease.,Past Surgical History:, None,Past Psychological History: None,Social History:, The patient was from Brazil. He moved to the United States one year ago. He denied any history of tobacco, alcohol, or illicit drug use. He was married and monogamous. He worked as an engineer/manager, and stated that his job was ""very stressful"". He had recently been admitted to an MBA program. The patient denied recent travel or exposures of any kind.,Family History:, The patient had a second-degree relative with a history of depression and ""nervous breakdown"".,Allergies:, There were no known drug allergies.,Medications:, Prescribed medications were Salmeterol inhaler, prn; and Fluticasone nasal inhaler. The patient was taking no over the counter or alternative medicines.,Physical Examination:, The patient was a 27-year-old Hispanic man who presented with symptoms of confusion and hallucinations. He was a thin man but appeared to be well developed and well nourished. The patient paced the room during the examination. He appeared anxious and distracted. He was coherent, yet he had poor concentration and was unable to cooperate fully with the examination. The patient had a pulse rate of 110 beats per minute and blood pressure of 186/101 mm Hg when reclining; and a pulse rate of 122 beats per minute and blood pressure of 166/92 mm Hg when standing. His oral temperature was 100.8 degrees Fahrenheit, and his respiratory rate was 12 breaths per minute.,HEENT: Conjunctivae were pink; sclerae anicteric; mucous membranes moist and pink without lesions.,NECK: The neck was supple, normal jugular venous pressure, no carotid bruits, no thyromegaly.,LUNGS: The lungs were clear to auscultation bilaterally; no wheezes, rales or rhonchi.,HEART: The heart had a regular rhythm, tachycardic, II/VI systolic ejection murmur LUSB, no rubs or gallops, PMI nondisplaced, hyperdynamic precordium.,ABDOMEN: The abdomen was soft, nontender and nondistended; normoactive bowel sounds, no hepatosplenomegaly, no masses; positive bruit heard throughout mid-abdomen, positive bilateral femoral bruits.,EXTREMITIES: No clubbing, cyanosis, or edema; 2+ pulses.,GENITOURINARY: Normal male phallus, no testicular masses.,RECTAL: Guaiac negative, no masses.,LYMPH NODES: Negative in the anterior and posterior clavicular, supraclavicular, axillary, and inguinal regions.,SKIN: Acneiform eruption over back and trunk, no papules or vesicles.,NEUROLOGICAL EXAMINATION: The patient was alert and oriented to self and year, but not to month or place. He had difficulty with mathematics and following commands (when asked to stand on his heels, the patient stood on his toes and turned on the television). Cranial nerves II-XII intact, motor 5/5 throughout all extremities; reflexes 2+ and symmetrical throughout. Sensory: Intact to light touch, vibration, proprioception, and temperature. Cerebellar: intact finger to nose, no ataxia. Romberg negative.,PSYCHOLOGICAL EXAMINATION: The patient's mood was elevated and euphoric; affect was appropriate; his speech was normal in rate, volume, and tone.,Hospital Course:, The patient was admitted to St. Luke's Episcopal Hospital and a workup for his altered mental status was begun. The following studies were performed:,Twelve-lead EKG: sinus tachycardia.,CXR (PA/lat): normal cardiac silhouette and normal lung fields.,CT scan of head without contrast: ventricles were normal in size and position. There was no evidence of mass or hemorrhage.,Lumbar puncture: clear, colorless; WBC--0; RBC--56; protein--45; glucose--126; VDRL--negative; cryptococcal Ag--negative; cultures--negative.,MRI with gadolinium: no discrete areas of abnormal signal intensity.,EEG: no focal or epileptiform activity.,The patient was treated with haldol and risperidone for his agitation, and further diagnostic testing was performed.",
" Patient with abdominal pain, nausea, vomiting, fever, altered mental status.", Consult - History and Phy., Gen Med Consult - 39 ,"Chief Complaint:, Abdominal pain, nausea, vomiting, fever, altered mental status.,History of Present Illness:, 55 yo WM with reactive airways disease, allergic rhinitis who was in his usual state of health until he underwent a dental extraction with administration of cephalexin 1 week prior to admission. Approximately one day after the dental procedure, he began having nausea, and abdominal pain along with fatigue. The abdominal pain was described as pressure-like and was located in the epigastrium and periumbilical regions. He initially attributed the symptoms to a side effect of the antibiotic he was taking. However, with worsening of his symptoms, he presented to the ER 5 days after dental extraction.,At that time his vitals were T 99.9 ° HR 115 RR 18 BP 182/101. His exam was notable for mild tenderness in the central abdomen. Laboratory evaluation was notable for WBC 15.6, Hgb 13.1, Plt 189, 16% bands, 68% PMNs. Na 127, K4.7, Cl 88, CO2 29, BUN 19, Cr 1.5, Glucose 155, Ca 9.6, alk phos 125, t bili 0.7, ALT 29, nl amylase and lipase. UA with 100 protein, lg blood, 53 RBC, 2 WBC. Plain films done at that time revealed dilation of small bowel loops in mid-abdomen up to 3.5cm in diameter, thought to be most consistent with a paralytic ileus. The patient was discharged home with diagnosis of medication-induced gastroenteritis vs. UTI. He was instructed to stop his current antibiotic but start Levaquin, and he was given Vicodin, and phenergan for symptomatic relief.,Over the next 2 days, the patient began having fevers, non-bloody emesis, diarrhea, and confusion in addition to his persistent nausea, and abdominal pain. On the night of presentation, the patient was found by a cousin in his bathroom lethargic and disoriented. EMS was called and patient was taken to the ER. In the ER, the pt was diaphoretic, unable to answer questions appropriately, hypotensive, and febrile, with some response of bp to multiple IVF boluses (4L). He received acetaminophen, and ceftriaxone 2g IV after blood cultures were obtained and an LP was performed in the ER. He was then admitted to the ICU for further evaluation and management.,Past Medical History:,Asthma,Allergic Rhinitis,Medications:,loratadine,beclomethasone nasal,fluticasone/salmeterol inhaled,Montelukast,cephalexin,hydrocodone,Allergies:, PCN, but has tolerated cephalosporins in the past.,Social History:, No tobacco use, occasional EtOH, no known drug use, works as a real estate agent.,Family History:, HTN, father with SLE, uncle with Addison’s Disease.,Physical Exam:,T 102.9 ° HR 145 RR 22 BP 99/50 98% on room air, (orthostatics were not performed due to patient’s mental status),I/O: minimal urine output after Foley insertion,Gen: lethargic, mild tachypnea,HEENT: no evidence of trauma, sclerae anicteric, pupils are equal round and reactive to light, oropharynx clear, MM dry.,Neck: supple, without increased JVP, lymphadenopathy or bruits. No thyromegaly,Chest: coarse rhonchi bilaterally,CV: tachycardia, regular, no murmurs, gallops, rubs,Abd: hypoactive bowel sounds, soft, slightly distended, mild tenderness throughout. No rebound, no masses or hepatosplenomegaly.,Ext: no cyanosis, clubbing, or edema. 2+ pulses bilateral distal extremities, no petechiae or splinter hemorrhages.,Neuro: lethargic, but arousable, oriented to person, but not to place, or time. He was not able to answer questions appropriately. Moved all extremities equally but was uncooperative with exam. 2+ DTRs bilaterally, no Babinski reflex.,Skin: no rash, ecchymosis, or petechiae,STUDIES:,EKG: sinus tachycardia, normal axis, isolated Q in III, no TWI or ST elevations or depressions,CXR: Heart normal in size, pulmonary vasculature unremarkable, subsegmental atelectasis in the lower lobes. Acromioclavicular osteoarthritis bilaterally. Lucent lesion in the subchondral bone of the R humeral head, likely a degenerative subchondral cyst.,AXR: Minimal dilation of the small bowel loops in the mid abdomen measuring up to 3cm, no mass lesion or free air visible.,MRI brain pre and post gadolinium: No evidence of hemorrhage, abnormal enhancement, mass lesions, mass effect or edema. The ventricles, sulci, and cisterns are age appropriate in size and configuration. There is no evidence for restricted diffusion. There is mucosal thickening lining the walls of the left maxillary sinus, also containing an air fluid level with two different levels within it, most likely from proteinaceous differences. There is mucosal thickening along the posterior wall of the right maxillary sinus. Mucosal thickening is identified along the walls of the sphenoid sinus, ethmoid sinuses and frontal sinus. Sinusitis with chronic and acute features.,Echo: EF 50%, mild LV concentric hypertrophy, otherwise normal chamber sizes and function,TEE: Normal valves, no thrombi, PFO with R to L shunt, trivial MR, trivial TR,RLE Ultrasound with Dopplers – total deep venous obstruction in distal external iliac, common femoral, profunda femoral, and femoral vein, partial DVT in popliteal and posterior tibial veins, and total DVT greater saphenous vein. No venous obstruction on the L LE. R calf 34cm, R thigh 42 cm, L calf 31cm, L thigh 39cm.,CT Abdomen (initial ER visit): Trace bilateral pleural fluid, findings in liver compatible with diffuse fatty infiltration, 3.5cm non calcified R adrenal mass was noted, along with an edematous L adrenal with no discrete mass. There was retroperitoneal edema around the lower abdominal aorta with perinephric stranding, no stone or obstruction. Moderate fullness of small bowel loops was noted, most consistent with a paralytic ileus.,Hospital Course:, The patient developed right lower extremity swelling and was diagnosed with deep venous thrombosis. Diagnostic studies were performed.",
 Patient coughing up blood and with severe joint pain., Consult - History and Phy., Gen Med Consult - 36 ,"Chief Complaint:, coughing up blood and severe joint pain.,History of Present Illness:,  The patient is a 37 year old African American woman with history of chronic allergic rhinitis who presents to an outpatient clinic with severe pain in multiple joints and hemoptysis for 1 day. The patient was at her baseline state of health until 2 months prior to admission when her usual symptoms of allergic rhinitis worsened. In addition to increased nasal congestion and drainage, she also began having generalized fatigue, malaise, and migratory arthralgias involving bilateral wrists, shoulders, elbows, knees, ankles, and finger joints. She also had intermittent episodes of swollen fingers that prevented her from making a fist. Patient denied recent flu-like illness, fever, chills, myalgias, or night sweats. Four weeks after the onset of arthralgias patient developed severe bilateral eye dryness and redness without any discharge. She was evaluated by an ophthalmologist and diagnosed with conjunctivitis. She was given eye drops that did not relieve her eye symptoms. Two weeks prior to admission patient noted the onset of rust colored urine. No bright red blood or clots in the urine. She denied having dysuria, decreased urine output, abdominal pain, flank pain, or nausea/vomiting. Patient went to a community ER, and had a CT Scan of the abdomen that was negative for kidney stones. She was discharged from the ER with Bactrim for possible UTI. During the next week patient had progressively worsening arthralgias to the point where she could hardly walk. On the day of admission, she developed a cough productive of bright red blood associated with shortness of breath and nausea, but no chest pain or dizziness. This prompted the patient to go see her primary care physician. After being seen in clinic, she was transferred to St. Luke’s Episcopal Hospital for further evaluation.,Past Medical History:, Allergic rhinitis, which she has had for many years and treated with numerous medications. No history of diabetes, hypertension, or renal disease. No history tuberculosis, asthma, or upper airway disease.,Past Surgical History:, Appendectomy at age 21. C-Section 8 years ago.,Ob/Gyn: G2P2; last menstrual period 3 weeks ago. Heavy menses due to fibroids.,Social History:, Patient is married and lives with her husband and 2 children. Works in a business office. Denies any tobacco, alcohol, or illicit drug use of any kind. No history of sexually transmitted diseases. Denies exposures to asbestos, chemicals, or industrial gases. No recent travel. No recent sick contacts.,Family History:, Mother and 2 maternal aunts with asthma. No history of renal or rheumatologic diseases.,Medications:, Allegra 180mg po qd, Zyrtec 10mg po qd, Claritin 10mg po qd,No herbal medication use.,Allergies:, No known drug allergies.,Review of systems:, No rashes, headache, photophobia, diplopia, or oral ulcers. No palpitations, orthopnea or PND. No diarrhea, constipation, melena, bright red blood per rectum, or pale stool. No jaundice. Decreased appetite, but no weight loss.,Physical Examination:,VS: T 100.2F BP 132/85 P 111 RR 20 O2 Sat 95% on room air,GEN: Well-developed woman in no apparent distress.,SKIN: No rashes, nodules, ecchymoses, or petechiae.,LYMPH NODES: No cervical, axillary, or inguinal lymphadenopathy.,HEENT: Pupils equally round and reactive to light. Extra-ocular movements intact. Anicteric sclerae. Erythematous sclerae and pale conjunctivae. Dry mucous membranes. No oropharyngeal lesions. Bilateral tympanic membranes clear. No nasal deformities.,NECK: Supple. No increased jugular venous pressure. No thyromegaly.,CHEST: Decreased breath sounds throughout bilateral lung fields with occasional diffuse crackles. No wheezes or rales.,CV: Tachycardic. Regular rhythm. No murmurs, gallops, or rubs.,ABDOMEN: Soft with normal active bowel sounds. Non-distended and non-tender. No masses palpated. No hepatosplenomegaly.,RECTAL: Brown stool. Guaiac negative.,EXT: No clubbing, cyanosis, or edema. 2+ pulses bilaterally. Tenderness and mild swelling of bilateral wrists, MCPs and PIPs with decreased range of motion and grip function. Bilateral wrists warm without erythema. Bilateral elbows, knees, and ankles tender to palpation with decreased range of motion, but no erythema, warmth, or swelling of these joints.,NEURO: Cranial nerves intact. 2+ DTRs bilaterally and symmetrically. Motor strength and sensation are within normal limits.,STUDIES:,Chest X-ray (10/03):,Suboptimal inspiratory effort. No evidence of pneumonic consolidation, pleural effusion, pneumothorax, or pulmonary edema. Cardiomediastinal silhouette is unremarkable.,CT Scan of Chest (10/03):,Prominence of the bronchovascular markings bilaterally with a nodular configuration. There are mixed ground glass interstitial pulmonary infiltrates throughout both lungs with a perihilar predominance. Aortic arch is of normal caliber. The pulmonary arteries are of normal caliber. There is right paratracheal lymphadenopathy. There is probable bilateral hilar lymphadenopathy. Trachea and main stem bronchi are normal. The heart is of normal size.,Renal Biopsy:,Microscopic Description : Ten glomeruli are present. There are crescents in eight of the glomeruli. Some of the glomeruli show focal areas of apparent necrosis with fibrin formation. The interstitium consists of a fairly dense infiltrate of lymphocytes, plasma cells with admixed eosinophils. The tubules for the most part are unremarkable. No vasculitis is identified.,Immunofluorescence Description : There are no staining for IgG, IgA, IgM, C3, Kappa, Lambda, C1q, or albumin.,Electron Microscopic Description : Mild to moderate glomerular, tubular, and interstitial changes. Mesangium has multifocal areas with increased matrix and cells. There is focal mesangial interpositioning with the filtration membrane. Interstitium has multifocal areas with increased collagen. There are focal areas with interstitial aggregate of fibrin. Within the collagen substrate are infiltrates of lymphocytes, plasma cells, eosinophils, and macrophages. The glomerular sections evaluated show no electron-dense deposits in the filtration membrane or mesangium.,Microscopic Diagnosis: Pauci-immune crescentic glomerulonephritis with eosinophilic interstitial infiltrate.",
 Patient with complaint of dark urine and generalized weakness., Consult - History and Phy., Gen Med Consult - 37 ,"Chief Complaint:, Dark urine and generalized weakness.,History of Present Illness:,40 year old Hispanic male presented to the emergency room complaining of generalized weakness, fatigue and dark urine for one week. In addition, he stated that his family had noticed yellowing of his skin and eyes, though he himself had not noticed.,He did complain of subjective fever and chills along with occasional night sweats during the prior week or so and he noted anorexia for 3-4 weeks leading to 26 pound weight loss (213 lbs. to 187 lbs.). He was nauseated but denied vomiting. He did admit to intermittent abdominal discomfort which he could not localize. In addition, he denied any history of liver disease, but had undergone cholecystectomy many years previous.,Past Medical History:, DM II-HbA1c unknown,Past Surgical History:, Cholecystectomy without complication,Family History:, Mother with diabetes and hypertension. Father with diabetes. Brother with cirrhosis (etiology not documented).,Social History:, He was unemployed and denied any alcohol or drug use. He was a prior “mild” smoker, but quit 10 years previous.,Medications:, Insulin (unknown dosage),Allergies:, No known drug allergies.,Physical Exam:,Temperature: 98.2,Blood pressure:118/80,Heart rate: 95,Respiratory rate: 18,GEN: Middle age Latin-American Male, jaundice, alert and oriented to person/place/time.,HEENT: Normocephalic, atraumatic. Icteric sclerae, pupils equal, round and reactive to light. Clear oropharynx.,NECK: Supple, without jugular venous distension, lymphadenopathy, thyromegaly or carotid bruits.,CV: Regular rate and rhythm, normal S1 and S2. No murmurs, gallops or rubs,PULM: Clear to auscultation bilaterally without rhonchi, rales or wheezes,ABD: Soft with mild RUQ tenderness to deep palpation, Murphy’s sign absent. Bowel sounds present. Hepatomegaly with liver edge 3 cm below costal margin. Splenic tip palpable.,RECTAL: Guaiac negative,EXT: Shotty inguinal lymphadenopathy bilaterally, largest node 2cm,NEURO: Strength 5/5 throughout, sensation intact, reflexes symmetric. No focal abnormality identified. No asterixis,SKIN: Jaundice, no rash. No petechiae, gynecomastia or spider angiomata.,Hospital Course:,The patient was admitted to the hospital to begin workup of liver failure. Initial labs were considered to be consistent with an obstructive pattern, so further imaging was obtained. A CT scan of the abdomen and pelvis revealed lymphadenopathy and a markedly enlarged liver. His abdominal pain was controlled with mild narcotics and he was noted to have decreasing jaundice by hospital day 4. An US guided liver biopsy revealed only acute granulomatous inflammation and fibrosis. The overall architecture of the liver was noted to be well preserved.,Gastroenterology was consulted for EGD and ERCP. The EGD was normal and the ERCP showed normal biliary anatomy without evidence of obstruction. In addition, they performed an endoscopic ultrasound-guided fine needle aspiration of two lymph-nodes, one in the subcarinal region and one near the celiac plexus. Again, pathologic results were insufficient to make a tissue diagnosis.,By the second week of hospitalization, the patient was having intermittent low-grade fevers and again experiencing night-sweats. He remained jaundice. Given the previous negative biopsies, surgery was consulted to perform an excisional biopsy of the right groin lymph node, which revealed no evidence of carcinoma, negative AFB and GMS stains and a single noncaseating granuloma.,By his fourth week of hospitalization, he remained ill with evidence of ongoing liver failure. Surgery performed an open liver biopsy and lymph node resection.,STUDIES (HISTORICAL):,CT abdomen: Multiple enlarged lymph nodes near the porta hepatis and peri-pancreatic regions. The largest node measures 3.5 x 3.0 cm. The liver is markedly enlarged (23cm) with a heterogenous pattern of enhancement. The spleen size is at the upper limit of normal. Pancreas, adrenal glands and kidneys are within normal limits. Visualized portions of the lung parenchyma are grossly normal.,CT neck: No abnormalities noted,CT head: No intracranial abnormalities,RUQ US (for biopsy): Heterogenous liver with lymphadenopathy.,ERCP: No filling defect noted; normal pancreatic duct visualized. Normal visualization of the biliary tree, no strictures. Normal exam.",
 Examination due to blood-borne pathogen exposure., Consult - History and Phy., Gen Med Consult - 3 ,"CHIEF COMPLAINT:, Blood-borne pathogen exposure., ,HISTORY OF PRESENT ILLNESS: ,The patient is a 54-year-old right-handed male who works as a phlebotomist and respiratory therapist at Hospital. The patient states that he was attempting to do a blood gas. He had his finger of the left hand over the pulse and was inserting a needle using the right hand. He did have a protective clothing including use of gloves at the time of the incident. As he advanced the needle, the patient jerked away, this caused him to pull out of the arm and inadvertently pricked the tip of his index finger. The patient was seen and evaluated at the emergency department at the time of incident and had baseline studies drawn, and has been followed by employee health for his injury. The source patient was tested for signs of disease and was found to be negative for HIV, but was found to be a carrier for hepatitis C. The patient has had periodic screening including a blood tests and returns now for his final exam., ,REVIEW OF SYSTEMS: ,The patient prior to today has been very well without any signs or symptoms of viral illness, but yesterday he began to experience symptoms of nausea, had an episode of vomiting last night. Has low appetite. There were no fevers, chills, or malaise. No headache. No congestion or cold. No coughing. He had no sore throat. There was no chest pain or troubled breathing. He did have abdominal symptoms as described above but no abdominal pain. There were no urinary symptoms. No darkening of the skin or eyes. He had no yellowing or darkening of the urine. He had no rash to the skin. There was no local infection at the side of the fingerstick. All other systems were negative., ,PAST MEDICAL HISTORY: ,Significant for degenerative disc disease in the back., ,MEDICATIONS: ,Nexium., ,ALLERGIES:, IV contrast., ,CURRENT WORK STATUS:, He continues on full duty work., ,PHYSICAL EXAMINATION:, The patient was awake and alert. He was seated upright. He did not appear ill or toxic, and was well hydrated. His temperature was 97.2 degrees, pulse was 84, respirations 14 and unlabored, and blood pressure 102/70. HEENT exam, the sclerae were clear. Ocular movements were full and intact. His oropharynx was clear. There was no pharyngeal erythema. No tonsillar enlargement. His neck was supple and nontender. He had no masses. There was no adenopathy in his cervical or axillary chain. Breath sounds were clear and equal without wheeze or rales. Heart tones were regular without murmur or gallop. His abdomen was soft, flat, and nontender. There was no enlargement of the liver or spleen. His extremities were without rash or edema. He had normal gait and balance without ataxia., ,ASSESSMENT: ,The patient presents for evaluation after a contaminated needlestick to the index finger. The source patient was tested and found to be negative for HIV. However, he did test positive for hepatitis C. He was described as a carrier without active disease. The patient has been followed with periodic evaluation including blood testing. He has completed a 3 shot series for hepatitis B and had titers drawn that showed protected antibodies. He also was up-to-date on his immunization including tetanus. The patient has been well during this time except for the onset of a intestinal illness being investigated with some squeakiness and vomiting. He had no other symptoms that were suggestive of acute hepatitis. His abdominal exam was normal. He had no generalized lymphadenopathy and no fever. Blood tests were drawn on 02/07/2005. The results of which were reviewed with the patient. His liver function test was normal at 18. His hepatitis C and HIV, both of which were negative. He had no local signs of infection, and otherwise has been doing well except for his acute intestinal illness as described above., ,IMPRESSION:, Blood-borne pathogen exposure secondary to contaminated needlestick., ,PLAN: ,The patient is now six months out from his injury. He had negative lab studies. There were no physical findings that were suggestive of disease transmission. He was counseled on ways to prevent exposure in the future including use of protective gear including gloves, which he states that he always does. He was counseled that ways to prevent transmission or exposure to intimate contacts., ,WORK STATUS:, He was released to regular work., ,CONDITION: ,He was reassured that no signs of disease transmission had occurred as result of his injury. He therefore was found to be medically stationary without signs of impairment of today's date.",
" Patient with osteoarthritis and osteoporosis with very limited mobility, depression, hypertension, hyperthyroidism, right breast mass, and chronic renal insufficiency", Consult - History and Phy., Gen Med Consult - 32 ,"PROBLEM LIST:,1.  Generalized osteoarthritis and osteoporosis with very limited mobility.,2.  Adult failure to thrive with history of multiple falls, none recent.,3.  Degenerative arthritis of the knees with chronic bilateral knee pain.,4.  Chronic depression.,5.  Hypertension.,6.  Hyperthyroidism.,7.  Aortic stenosis with history of CHF and bilateral pleural effusions.,8.  Right breast mass, slowly enlarging.  Patient refusing workup.,9.  Status post ORIF of the right wrist, now healed.,10.  Anemia of chronic disease.,11.  Hypoalbuminemia.,12.  Chronic renal insufficiency.,CURRENT MEDICATIONS:,  Acetaminophen 325 mg 2 tablets twice daily, Coreg 6.25 mg twice daily, Docusate sodium 100 mg 1 cap twice daily, ibuprofen 600 mg twice daily with food, Lidoderm patch 5% to apply 1 patch to both knees every morning and off in the evening, one vitamin daily, ferrous sulfate 325 mg daily, furosemide 20 mg q.a.m., Tapazole 5 mg daily, potassium chloride 10 mEq daily, Zoloft 50 mg daily, Ensure t.i.d., and p.r.n. medications.,ALLERGIES:,  NKDA.,CODE STATUS:,  DNR, healthcare proxy, durable power of attorney.,DIET:,  Regular with regular consistency with thin liquids and ground meat.,RESTRAINTS: , None.  She does have a palm protector in her right hand.,INTERVAL HISTORY:,  No significant change over the past month has occurred.  The patient mainly complains about pain in her back.  On a scale from 1 to 10, it is 8 to 10, worse at night before she goes to bed.  She is requesting something more for the pain.  Other than that, she complains about her generalized pain.  There has been no significant change in her weight.  No fever or chills.  No complaint of headaches or visual changes, chest pain, shortness of breath, dyspnea on exertion, orthopnea, or PND.  No hemoptysis or night sweats.  No change in her bowels, abdominal pain, bright red rectal bleeding, or melena.  No nausea or vomiting.  Her appetite is fair.  She is a picky eater but definitely likes her candy.  There has been no change in her depression.  It seems to be stable on the Zoloft 50 mg daily, which she has been on since October 17, 2006.  She denies feeling depressed to me but complains of being bored, stating she just sits and watches TV or sometimes may go to activities but not very seldom due to her back pain.  No history of seizures.  She denies any tremors.  She is hyperthyroid and is on replacement.,PHYSICAL EXAMINATION: , An elderly female, sitting in a wheelchair, in no acute distress, very kyphotic.  She is very pleasant and alert.  Vital signs per chart.  Skin is normal in texture and turgor for her age.  She does have dry lips, which she picks at and was picking at her lips while I was talking with her.  HEENT:  Normocephalic, atraumatic.  She has nevi above her left eye, which she states she has had since birth and has not changed.  Pupils are equal, round and reactive to light and accommodation.  No exophthalmos or lid lag.  Anicteric sclerae.  Conjunctivae pink, nasal passages clear.  She is edentulous but does have her upper dentures in.  No mucosal ulcerations.  External ears normal.  Neck is supple.  No increased JVD, cervical or supraclavicular adenopathy.  No thyromegaly or masses.  Trachea is midline.  Her chest is very kyphotic, clear to A&P.  Heart:  Regular rate and rhythm with a 2-3/6 systolic murmur heard best at the left sternal border.  Abdomen:  Soft.  Good bowel sounds.  Nontender.  Unable to appreciate any organomegaly or masses as she is sitting in a wheelchair.  Extremities are without edema, cyanosis, clubbing, or tremor.  She does have Lidoderm patches over both of her knees and is wearing a brace in her right hand.,LABORATORY TESTS: , Albumin was 3.2 on 12/06/06.  Dietary is aware.  Electrolytes done 11/28/06, her sodium was 144, potassium 4.4, chloride 109, bicarbonate 26, anion gap 9, BUN 28, creatinine 1.2, GFR 44.  Digoxin was done and was less than 0.9, but she is not on digoxin.  CBC showed a white count of 7400, hemoglobin 11.1, hematocrit 35.9, MCV of 95.2, and platelet count of 252,000.  Her TSH was 1.52.  No changes were made in her Tapazole.,ASSESSMENT AND PLAN:,  We will continue present therapy except we will add Tylenol No.  3 to take 1 tablet before bed as needed for her back pain.  If she does develop drowsiness from this, then the CNS side effects will help her sleep.  During the day, her daughter likes the patient to remain alert and will use the ibuprofen at that time as long as she does not develop any GI symptoms.  We will make sure that she is taking the ibuprofen with food.  No further laboratory tests will be done at this time.",
" Patient was confused, had garbled speech, significantly worse from her baseline, and had decreased level of consciousness.", Consult - History and Phy., Gen Med Consult - 31 ,"CHIEF COMPLAINT:,  A 74-year-old female patient admitted here with altered mental status.,HISTORY OF PRESENT ILLNESS:,  The patient started the last 3-4 days to do poorly.  She was more confused, had garbled speech, significantly worse from her baseline.  She has also had decreased level of consciousness since yesterday.  She has had aphasia which is baseline but her aphasia has gotten significantly worse.  She eventually became unresponsive and paramedics were called.  Her blood sugar was found to be 40 because of poor p.o. intake.  She was given some D50 but that did not improve her mental status, and she was brought to the emergency department.  By the time she came to the emergency department, she started having some garbled speech.  She was able to express her husband's name and also recognize some family members, but she continued to be more somnolent when she was in the emergency department.  When seen on the floor, she is more awake, alert.,PAST MEDICAL HISTORY: , Significant for recurrent UTIs as she was recently to the hospital about 3 weeks ago for urinary tract infection.  She has chronic incontinence and bladder atony, for which eventually it was decided for the care of the patient to put a Foley catheter and leave it in place.  She has had right-sided CVA.  She has had atrial fibrillation status post pacemaker.  She is a type 2 diabetic with significant neuropathy.  She has also had significant pain on the right side from her stroke.  She has a history of hypothyroidism.  Past surgical history is significant for cholecystectomy, colon cancer surgery in 1998.  She has had a pacemaker placement.  ,REVIEW OF SYSTEMS:,GENERAL:  No recent fever, chills.  No recent weight loss.,PULMONARY:  No cough, chest congestion.,CARDIAC:  No chest pain, shortness of breath.,GI:  No abdominal pain, nausea, vomiting.  No constipation.  No bleeding per rectum or melena.,GENITOURINARY:  She has had frequent urinary tract infection but does not have any symptoms with it.  ENDOCRINE:  Unable to assess because of patient's bed-bound status.,MEDICATIONS:  ,Percocet 2 tablets 4 times a day, Neurontin 1 tablet b.i.d.  600 mg, Cipro recently started 500 b.i.d., Humulin N 30 units twice a day.  The patient had recently reduced that to 24 units.  MiraLax 1 scoop nightly, Avandia 4 mg b.i.d., Flexeril 1 tablet t.i.d., Synthroid 125 mcg daily, Coumadin 5 mg.  On the medical records, it shows she is also on ibuprofen, Lasix 40 mg b.i.d., Lipitor 20 mg nightly, Reglan t.i.d.  5 mg, Nystatin powder.  She is on oxygen chronically.,SOCIAL/FAMILY HISTORY: , She is married, lives with her husband, has 2 children that passed away and 4 surviving children.  No history of tobacco use.  No history of alcohol use.  Family history is noncontributory.,PHYSICAL EXAMINATION:,GENERAL:  She is awake, alert, appears to be comfortable.,VITAL SIGNS:  Blood pressure 111/43, pulse 60 per minute, temperature 37.2.  Weight is 98 kg.  Urine output is so far 1000 mL.  Her intake has been fairly similar.  Blood sugars are 99 fasting this morning.  ,HEENT:  Moist mucous membranes.  No pallor,NECK:  Supple.  She has a rash on her neck.  ,HEART:  Regular rhythm, pacemaker could be palpated.,CHEST:  Clear to auscultation.,ABDOMEN:  Soft, obese, nontender.,EXTREMITIES:  Bilateral lower extremities edema present.  She is able to move the left side more efficiently than the right.  The power is about 5 x 5 on the left and about 3-4 x 5 on the right.  She has some mild aphasia.,DIAGNOSTIC STUDIES: , BUN 48, creatinine 2.8.  LFTs normal.  She is anemic with a hemoglobin of 9.6, hematocrit 29.  INR 1.1, pro time 14.  Urine done in the emergency department showed 20 white cells.  It was initially cloudy but on the floor it has cleared up.  Cultures from the one done today are pending.  The last culture done on August 20 showed guaiac negative status and prior to that she has had mixed cultures.  There is a question of her being allergic to Septra that was used for her last UTI.,IMPRESSION/PLAN:,1.  Cerebrovascular accident as evidenced by change in mental status and speech.  She seems to have recovered at this point.  We will continue Coumadin.  The patient's family is reluctant in discontinuing Coumadin but they do express the patient since has overall poor quality of life and had progressively declined over the last 6 years, the family has expressed the need for her to be on hospice and just continue comfort care at home.,2.  Recurrent urinary tract infection.  Will await culture at this time, continue Cipro.,3.  Diabetes with episode of hypoglycemia.  Monitor blood sugar closely, decrease the dose of Humulin N to 15 units twice a day since intake is poor.  At this point, there is no clear evidence of any benefit from Avandia but will continue that for now.,4.  Neuropathy, continue Neurontin 600 mg b.i.d., for pain continue the Percocet that she has been on.,5.  Hypothyroidism, continue Synthroid.,6.  Hyperlipidemia, continue Lipitor.,7.  The patient is not to be resuscitated.  Further management based on the hospital course.",
 Patient was found to have decrease in mental alertness, Consult - History and Phy., Gen Med Consult - 30 ,"CHIEF COMPLAINT: , Mental changes today.,HISTORY OF PRESENT ILLNESS: , This patient is a resident from Mazatlan, Mexico, visiting her son here in Utah, with a history of diabetes.  She usually does not take her meal on time, and also not having her regular meals lately.  The patient usually still takes her diabetic medication.  Today, the patient was found to have decrease in mental alertness, but no other GI symptoms.  Some sweating and agitation, but no fever or chills.  No other rash.  Because of the above symptoms, the patient was treated in the emergency department here.  She was found to glucose in 30 range, and hypertension.  There was some question whether she also take her blood pressure medication or not.  Because of the above symptoms, the patient was admitted to the hospital for further care.  The patient was given labetalol IV and also Norvasc blood pressure, and also some glucose supplement.  At this time, the patient's glucose was in the 175 range.,PAST MEDICAL HISTORY: , Diabetes, hypertension.,PAST SURGICAL HISTORY:,  None.,FAMILY HISTORY: , Unremarkable.,ALLERGIES: , No known drug allergies.,MEDICATIONS:,  In Spanish label.  They are the diabetic medication, and also blood pressure medication.  She also takes aspirin a day.,SOCIAL HISTORY:  ,The patient is a Mazatlan, Mexico resident, visiting her son here.,PHYSICAL EXAMINATION:,GENERAL:  The patient appears to be no acute distress, resting comfortably in bed, alert, oriented x3, and coherent through interpreter.,HEENT:  Clear, atraumatic, normocephalic.  No sinus tenderness.  No obvious head injury or any laceration.  Extraocular movements are intact.  Dry mucosal linings.,HEART:  Regular rate and rhythm, without murmur.  Normal S1, S2.,LUNGS:  Clear.  No rales.  No wheeze.  Good excursion.,ABDOMEN:  Soft, active bowel sounds in 4 quarters, nontender, no organomegaly.,EXTREMITIES:  No edema, clubbing, or cyanosis.  No rash.,LABORATORY FINDINGS: , On Admission:  CPK, troponin are negative.  CMP is remarkable for glucose of 33.  BMP is remarkable for BUN of 60, creatinine is 4.3, potassium 4.7.  Urinalysis shows specific gravity of 10.30.  CT of the brain showed no hemorrhage.  Chest x-ray showed no acute cardiomegaly or any infiltrates.,IMPRESSION:,1.  Hypoglycemia due to not eating her meals on a regular basis.,2.  Hypertension.,3.  Renal insufficiency, may be dehydration, or diabetic nephropathy.,PLAN: , Admit the patient to the medical ward, IV fluid, glucometer checks, and adjust the blood pressure medication and also diabetic medication.",
 A 12-year-old young man with sinus congestion., Consult - History and Phy., Gen Med Consult - 22 ,"SUBJECTIVE:,  This is a 12-year-old young man who comes in with about 10 days worth of sinus congestion.  He does have significant allergies including ragweed.  The drainage has been clear.  He had a little bit of a headache yesterday.  He has had no fever.  No one else is ill at home currently.,CURRENT MEDICATIONS:,  Advair and Allegra.  He has been taking these regularly.  He is not sure the Allegra is working for him anymore.  He does think though better than Claritin.,PHYSICAL EXAM:,General:  Alert young man in no distress.,HEENT:  TMs clear and mobile.  Pharynx clear.  Mouth moist.  Nasal mucosa pale with clear discharge.,Neck:  Supple without adenopathy.,Heart:  Regular rate and rhythm without murmur.,Lungs:  Lungs clear, no tachypnea, wheezing, rales or retractions.,Abdomen:  Soft, nontender, without masses or splenomegaly.,ASSESSMENT:,  I think this is still his allergic rhinitis rather than a sinus infection.,PLAN:,  Change to Zyrtec 10 mg samples were given.  He is not using nasal spray, but he has some at home.  He should restart this.  Continue to watch his peak flows to make sure his asthma does not come under poor control.  Call if any further problems.","consult - history and phy., allergic rhinitis, sinus infection, sinus congestion, congestion, sinus"
" Patient complaining of headaches, neck pain, and lower back pain over the last 2-3 weeks.", Consult - History and Phy., Gen Med Consult - 24 ,"CHIEF COMPLAINT:, Headache and pain in the neck and lower back.,HISTORY OF PRESENT ILLNESS:, The patient is a 34 year old white man with AIDS (CD4 -67, VL -341K) and Castleman’s Disease who presents to the VA Hospital complaining of headaches, neck pain, and lower back pain over the last 2-3 weeks. He was hospitalized 3 months prior to his current presentation with abdominal pain and diffuse lymphadenopathy. Excisional lymph node biopsy during that admission showed multicentric Castleman’s Disease. He was started on cyclophosphamide and prednisone and his lymphadenopathy dramatically improved. His hospitalization was complicated by the development of acute renal failure from tumor lysis syndrome and he required hemodialysis for only a few sessions. The patient was discharged on HAART and later returned for 2 cycles of modified CHOP chemotherapy.,Approximately five weeks prior to his current presentation, the patient was involved in a motor vehicle accident at 40 mph. He said he was not wearing his seatbelt and had hit his head on the roof of the car. He did not lose consciousness. The patient went to the VA ER but left against medical advice prior to being fully evaluated. Records showed that the patient had complained of some neck soreness but he was able to move his neck without any difficulty.,Two weeks later, the patient started having headaches, neck and lower back pain during a road trip with his family to Mexico . He returned to Houston and approximately one week prior to admission, the patient presented to the VA ER for further evaluation. Spinal films were unremarkable and the patient was sent home on pain medications with a diagnosis of muscle strain. The patient followed up with his primary care physician and was admitted for further workup.,On the day of admission, the patient complains of severe pain that is worse in the lower back than in the neck. The pain is 7-8 out of 10 and does not radiate. He also complains of diffuse headaches and intermittent blurriness of his vision. He complains of having a very stiff neck that hurts when he bends it. He denies any fevers, chills, or night sweats. He denies any numbness or tingling of his extremities and he denies any bowel or bladder incontinence. None of the medications that he takes provides adequate relief of his pain.,Regarding his AIDS and Castleman’s Disease, his lymphadenopathy have completely resolved by physical exam. He no longer has any of the symptoms from his previous hospitalization. He is scheduled to have his next cycle of chemotherapy during the week of his current admission. He has been noncompliant with his HAART and has been off the medications for >3 weeks.,Past Medical History:, HIV diagnosed 11 years ago. No history of opportunistic infections. Recently diagnosed with Castleman’s Disease (9/03) from excisional lymph node biopsy s/p cyclophosphamide/prednisone ( 9/25/03 ) and modified CHOP ( 10/15/03 , 11/10/03 ). Last CD4 count is 67 and viral load is 341K (9/03). Currently is off HAART x 3 weeks because of noncompliance.,PAST SURGICAL HISTORY:, Excisional lymph node biopsy (9/03).,FAMILY HISTORY:, There was no history of hypertension, coronary artery disease, stroke, cancer or diabetes.,SOCIAL HISTORY:, Patient is single and he lives alone. He is heterosexual and has a history of sexual encounter with prostitutes in Japan. He works as a plumber over the last 5 years. He smokes and drinks occasionally and denies any history of IV drug use. No blood transfusion. No history of incarceration. Recently traveled to Mexico .,MEDICATION:, Tylenol #3 q6h prn, ibuprofen 800 mg q8h prn, methocarbamol 750 mg qid.,ALLERGIES:, ,  Sulfa (rash).,REVIEW OF SYSTEMS:, The patient complains of feeling weak and fatigued. He has no appetite over the past week and has lost 8 pounds during this period. No chest pain, palpitations, shortness of breath or coughing. He denies any nausea, vomiting, or abdominal pain. No focal neuro deficits. Otherwise, as stated in HPI.,PHYSICAL EXAM:,VS: T 98 BP 121/89 P 80 R 20 O2 Sat 100% on room air.,Ht: 5'9"" Wt: 159 lbs.,GEN: Well developed man in no apparent distress. Alert and Oriented X 3.,HEENT: Pupils equally round and reactive to light. Extra-ocular movements intact. Anicteric. Papilledema present bilaterally. Moist mucous membranes. No oropharyngeal lesions.,NECK: Stiff, difficulty with neck flexion; no lymphadenopathy,LUNGS: Clear to auscultation bilaterally.,CV: Regular rate and rhythm. No murmurs, gallops, rubs.,ABD: Soft with active bowel sounds. Nontender/Nondistended. No rebound or guarding. No hepatosplenomegaly.,EXT: No clubbing, cyanosis, or edema. 2+ pulses bilaterally.,BACK: No point tenderness to spine,NEURO: Cranial nerves intact. 2+ DTRs bilaterally and symmetrically. Motor strength and sensation within the normal limits.,LYMPH: No cervical, axillary, or inguinal lymph nodes palpated,SKIN: warm, no rashes, no lesions,STUDIES:,C-spine/lumbosacral spine (11/30):  Within normal limits.,CXR (12/8):  Normal heart size, no infiltrate. Hila and mediastinum are not enlarged.,CT Head with and without contrast (12/8): Ventriculomegaly and potentially minor hydrocephalus. Otherwise normal CT scan of the brain. No evidence of abnormal enhancement of the brain or mass lesions within the brain or dura.,HOSPITAL COURSE:,  The patient was admitted to the medicine floor and a lumbar puncture was performed. The opening pressure was greater than 55. The CSF results are shown in the table. A diagnostic study was sent.",
 Patient in with mom for possible ear infection., Consult - History and Phy., Gen Med Consult - 23 ,"SUBJECTIVE:,  Mom brings the patient in today for possible ear infection.  He is complaining of left ear pain today.  He was treated on 04/14/2004, with amoxicillin for left otitis and Mom said he did seem to get better but just started complaining of the left ear pain today.  He has not had any fever but the congestion has continued to be very thick and purulent.  It has never really resolved.  He has a loose, productive-sounding cough but not consistently and not keeping him up at night.  No wheezing or shortness of breath.,PAST MEDICAL HISTORY:,  He has had some wheezing in the past but nothing recently.,FAMILY HISTORY: , All siblings are on antibiotics for ear infections and URIs.,OBJECTIVE:,General:  The patient is a 5-year-old male.  Alert and cooperative.  No acute distress.,Neck:  Supple without adenopathy.,HEENT:  Ear canals clear.  TMs, bilaterally, have distorted light reflexes but no erythema.  Gray in color.  Oropharynx pink and moist with a lot of postnasal discharge.  Nares are swollen and red.  Thick, purulent drainage.  Eyes are a little puffy.,Chest:  Respirations regular, nonlabored.,Lungs:  Clear to auscultation throughout.,Heart:  Regular rhythm without murmur.,Skin:  Warm, dry, pink.  Moist mucus membranes.  No rash.,ASSESSMENT:,  Ongoing purulent rhinitis.  Probable sinusitis and serous otitis.,PLAN:,  Change to Omnicef two teaspoons daily for 10 days.  Frequent saline in the nose.  Also, there was some redness around the nares with a little bit of yellow crusting.  It appeared to be the start of impetigo, so hold off on the Rhinocort for a few days and then restart.  Use a little Neosporin for now.","consult - history and phy., ear infection, productive-sounding cough, purulent rhinitis, serous otitis, sinusitis, wheezing, ear, amoxicillin,"
 The patient brought in by EMS with a complaint of a decreased level of consciousness., Consult - History and Phy., Gen Med Consult - 28 ,"HISTORY OF PRESENT ILLNESS: , The patient is an 85-year-old male who was brought in by EMS with a complaint of a decreased level of consciousness.  The patient apparently lives with his wife and was found to have a decreased status since the last one day.  The patient actually was seen in the emergency room the night before for injuries of the face and for possible elderly abuse.  When the Adult Protective Services actually went to the patient's house, he was found to be having decreased consciousness for a whole day by his wife.  Actually the night before, he fell off his wheelchair and had lacerations on the face.  As per his wife, she states that the patient was given an entire mg of Xanax rather than 0.125 mg of Xanax, and that is why he has had decreased mental status since then.  The patient's wife is not able to give a history.  The patient has not been getting Sinemet and his other home medications in the last 2 days.  ,PAST MEDICAL HISTORY:  ,Parkinson disease.,MEDICATIONS:,  Requip, Neurontin, Sinemet, Ambien, and Xanax.,ALLERGIES: , No known drug allergies.,SOCIAL HISTORY: , The patient lives with his wife.,PHYSICAL EXAMINATION:,GENERAL:","consult - history and phy., level of consciousness, parkinson disease, altered mental status, dehydration, elderly abuse, decreased level of consciousness, ems, parkinson, consciousness, xanax, sinemet, decreased, "
 Patient with a past medical history of atrial fibrillation and arthritis complaining of progressively worsening shortness of breath., Consult - History and Phy., Gen Med Consult - 25 ,"CHIEF COMPLAINT:, ""I can’t walk as far as I used to."",HISTORY OF PRESENT ILLNESS:, The patient is a 66-year-old African American gentleman with a past medical history of atrial fibrillation and arthritis who presented c/o progressively worsening shortness of breath. The patient stated that he had been in his usual state of health six years ago at which time he had been able to walk more than five blocks without difficulty. Approximately five years prior to admission, he began to note a decreased tolerance to exercise. This progressed with a gradual worsening in his functional capacity such that he is presently unable to walk for more than 25 feet. Over the two years prior to admission, he has been having a gradually worsening non-productive cough associated with shortness of breath. His shortness of breath is worse when he lies flat, and he periodically wakes at night gasping for air. He sleeps with three pillows. He has also noted swelling of his legs and states that he has had two episodes of syncope at home for which he has not sought medical attention. Approximately one month prior to admission he was seen in an outside clinic where he states that he was started on medications for heart failure. He stated that he had had a brother who died of heart failure at age 72.,He did report that he had had an episode of hemoptysis approximately 2 years prior to admission for which he did not seek medical attention. He denied any history of chest pain and did not report any history of myocardial infarction. He denied fever, chills, and night sweats. He denied diarrhea, dysuria, hematuria, urgency and frequency. He denied any history of rash. He had been diagnosed with osteoarthritis of the knees and had undergone arthroscopy years prior to admission.,PAST MEDICAL HISTORY :,  Atrial fibrillation on anticoagulation, osteoarthritis of the knees bilaterally, h/o retinal tear.,PAST SURGICAL HISTORY :,  Hernia repair, bilateral arthroscopic evaluation, h/o surgical correction of retinal tear.,FAMILY HISTORY:, The Father of the patient died at age 69 with a CVA. The Mother of the patient died at age 79 when her ""heart stopped"". There were 12 siblings. Four siblings have died, two due to diabetes, one cause unknown, and one brother died at age 72 with heart failure. The patient has four children with no known medical problems.,SOCIAL HISTORY:, The patient retired one year PTA due to his disability. He was formerly employed as an electronic technician for the US postal service. The patient lives with his wife and daughter in an apartment. He denied any smoking history. He used to drink alcohol rarely but stopped entirely with the onset of his symptoms. He denied any h/o drug abuse. He denied any recent travel history.,MEDICATIONS:,1.  Spironolactone 25 mg po qd.,2.  Digoxin 0.125 mg po qod.,3.  Coumadin 3 mg Monday and Tuesday and 4.5 mg Saturday and Sunday.,4.  Metolazone 10 mg po qd.,5.  Captopril 25 mg po tid.,6.  Torsemide 40 mg po qam and 20 mg po qpm.,7.  Carvedilol 3.125 mg po bid.,ALLERGIES:, No known drug allergies.,REVIEW OF SYSTEMS:, No headaches. No visual, hearing, or swallowing difficulties. No changes in bowel or urinary habits.,PHYSICAL EXAM:,Temperature: 98.4 degrees Fahrenheit.,Blood pressure: 134/84.,Heart rate: 98 beats per minute.,Respiratory rate: 18 breaths per minute.,Pulse oximetry: 92% on 2L O 2 via nasal canula.,GEN: Elderly gentleman lying in bed in mild respiratory distress, thin, tired appearing, wife and daughter present at bedside, articulate.,HEENT: The right eye was opacified. The left pupil was reactive to light. There was mild bitemporal wasting. The tongue was moist. There was no lymphadenopathy. The sclerae were anicteric. The oropharynx was clear. The conjunctivae were pink.,NECK: The neck was supple with 15 cm of jugular venous distension.,HEART: Irregularly irregular. No murmurs, gallops, rubs. No displaced PMI.,LUNGS: Breath sounds were absent over two thirds of the right lower lung field. There were trace crackles at the left base.,ABDOMEN: Soft, nontender, nondistended, bowel sounds were present. There was no hepatosplenomegaly. No rebound or guarding.,EXT: Bilateral pitting edema to the thighs with diminished peripheral pulses bilaterally.,NEURO: The patient was alert and oriented x three. Cranial nerves were intact. The DTRs were 2+ bilaterally and symmetrically. Motor strength and sensation were within normal limits.,LYMPH: No cervical, axillary, or inguinal lymph nodes were present.,SKIN: Warm, no rashes, no lesions; no tattoos.,MUSCULOSKELETAL: No synovitis. There were no joint deformities. Full range of motion b/l throughout.,STUDIES:,CXR: Large right sided pleural effusion. A small pleural effusion with atelectatic changes are seen on the left. The heart size is borderline.,ECHO: LV size is normal. There is severe concentric LV hypertrophy. Global hypokinesis. LV function is severely depressed. Estimate EF is 20-24%. There is RV hypertrophy. RV size is mildly enlarged. RV function is severely depressed. RV wall motion is severely hypokinetic. LA size is moderately enlarged. RA size is mildly enlarged. Trace aortic regurgitation. Moderate tricuspid regurgitation. Estimated PA systolic pressure is 46-51 mmHg, assuming a mean RAP of 15-20mmHg. Small anterior and posterior pericardial effusion.,HOSPITAL COURSE:, The patient was admitted to the hospital for workup and management. A diagnostic procedure was performed.",
" Nausea, vomiting, diarrhea, and fever.", Consult - History and Phy., Gen Med Consult - 27 ,"CHIEF COMPLAINT: , Nausea, vomiting, diarrhea, and fever.,HISTORY OF PRESENT ILLNESS: , This patient is a 76-year-old woman who was treated with intravenous ceftriaxone and intravenous clindamycin at a care facility for pneumonia.  She has developed worsening confusion, fever, and intractable diarrhea.  She was brought to the emergency department for evaluation.  Diagnostic studies in the emergency department included a CBC, which revealed a white blood cell count of 23,500, and a low potassium level of 2.6.  She was admitted to the hospital for treatment of profound hypokalemia, dehydration, intractable diarrhea, and febrile illness.,PAST MEDICAL HISTORY: , Recent history of pneumonia, urosepsis, dementia, amputation, osteoporosis, and hypothyroidism.,MEDICATIONS:  ,Synthroid, clindamycin, ceftriaxone, Remeron, Actonel, Zanaflex, and hydrocodone.,SOCIAL HISTORY: , The patient has been residing at South Valley Care Center.,REVIEW OF SYSTEMS: , The patient is unable answer review of systems.,PHYSICAL EXAMINATION:,GENERAL:  This is a very elderly, cachectic woman lying in bed in no acute distress.,HEENT:  Examination is normocephalic and atraumatic.  The pupils are equal, round and reactive to light and accommodation.  The extraocular movements are full.,NECK:  Supple with full range of motion and no masses.,LUNGS:  There are decreased breath sounds at the bases bilaterally.,CARDIOVASCULAR:  Regular rate and rhythm with normal S1 and S2, and no S3 or S4.,ABDOMEN:  Soft and nontender with no hepatosplenomegaly.,EXTREMITIES:  No clubbing, cyanosis or edema.,NEUROLOGIC:  The patient moves all extremities but does not communicate.,DIAGNOSTIC STUDIES: , The CBC shows a white blood cell count of 23,500, hemoglobin 13.0, hematocrit 36.3, and platelets 287,000.  The basic chemistry panel is remarkable for potassium 2.6, calcium 7.5, and albumin 2.3.,IMPRESSION/PLAN:,1.  Elevated white count.  This patient is admitted to the hospital for treatment of a febrile illness.  There is concern that she has a progression of pneumonia.  She may have aspirated.  She has been treated with ceftriaxone and clindamycin.  I will follow her oxygen saturation and chest x-ray closely.  She is allergic to penicillin.  Therefore, clindamycin is the appropriate antibiotic for possible aspiration.,2.  Intractable diarrhea.  The patient has been experiencing intractable diarrhea.  I am concerned about Clostridium difficile infection with possible pseudomembranous colitis.  I will send her stool for Clostridium difficile toxin assay.  I will consider treating with metronidazole.,3.  Hypokalemia.  The patient's profound hypokalemia is likely secondary to her diarrhea.  I will treat her with supplemental potassium.,4.  DNR status:  I have ad a discussion with the patient's daughter, who requests the patient not receive CPR or intubation if her clinical condition or of the patient does not respond to the above therapy.  ,", 
" A 2-year-old little girl with stuffiness, congestion, and nasal drainage. - Allergic rhinitis", Consult - History and Phy., Gen Med Consult - 21 ,"SUBJECTIVE:,  The patient is a 2-year-old little girl who comes in with concerns about stuffiness, congestion and nasal drainage.  She does take Zyrtec on a fairly regular basis.  Mom is having some allergy trouble herself right now.  She does not know her colors.  She knows some of her shapes.  She speaks in sentences.  She is not showing much interest in the potty.  She is in the 80th percentile for height and weight, and still over 95th percentile for head circumference.  Mom has no other concerns.,ALLERGIES:,  Eggs and peanuts.,OBJECTIVE:,General:  Alert, very talkative little girl.,HEENT:  TMs clear and mobile.  Eyes:  PERRL.  Fundi benign.  Pharynx clear.  Mouth moist.  Nasal mucosa is pale with clear discharge.,Neck:  Supple without adenopathy.,Heart:  Regular rate and rhythm without murmur.,Lungs:  Clear.  No tachypnea, wheezing, rales or retractions.,Abdomen:  Soft and nontender without mass or organomegaly.,GU:  Normal female genitalia.  Tanner stage I.,Extremities:  No clubbing, cyanosis or edema.  Pulses 2+ and equal.,Hips:  Intact.,Neurological:  Normal.  DTRs are 2+.  Gait was normal.,Skin:  Warm and dry.  No rashes noted.,ASSESSMENT:,  Allergic rhinitis.  Otherwise healthy 2-year-old young lady.,PLAN:,  In addition to her Zyrtec, I put her on Nasonex spray one spray each nostril daily.  If this works for her, certainly she can do it through the ragweed season.  Otherwise she is doing well.  I talked about ways to improve her potty training.  She is a very good eater.  I will see her yearly or p.r.n.  Unfortunately she is not able to get the flu shot due to her egg allergy.","consult - history and phy., allergic rhinitis, nasal drainage, stuffiness, congestion, drainage,"
" 11-year-old female.  History of congestion, possibly enlarged adenoids.  ", Consult - History and Phy., Gen Med Consult - 20 ,"SUBJECTIVE:,  This is an 11-year-old female who comes in for two different things.  1.  She was seen by the allergist.  No allergies present, so she stopped her Allegra, but she is still real congested and does a lot of snorting.  They do not notice a lot of snoring at night though, but she seems to be always like that.  2.  On her right great toe, she has got some redness and erythema.  Her skin is kind of peeling a little bit, but it has been like that for about a week and a half now.,PAST MEDICAL HISTORY:,  Otherwise reviewed and noted.,CURRENT MEDICATIONS:,  None.,ALLERGIES TO MEDICINES:,  None.,FAMILY SOCIAL HISTORY:,  Everyone else is healthy at home.,REVIEW OF SYSTEMS:,  She has been having the redness of her right great toe, but also just a chronic nasal congestion and fullness.  Review of systems is otherwise negative.,PHYSICAL EXAMINATION:,General:  Well-developed female, in no acute distress, afebrile.,HEENT:  Sclerae and conjunctivae clear.  Extraocular muscles intact.  TMs clear.  Nares patent.  A little bit of swelling of the turbinates on the left.  Oropharynx is essentially clear.  Mucous membranes are moist.,Neck:  No lymphadenopathy.,Chest:  Clear.,Abdomen:  Positive bowel sounds and soft.,Dermatologic:  She has got redness along the lateral portion of her right great toe, but no bleeding or oozing.  Some dryness of her skin.  Her toenails themselves are very short and even on her left foot and her left great toe the toenails are very short.,ASSESSMENT:,1.  History of congestion, possibly enlarged adenoids, or just her anatomy.,2.  Ingrown toenail, but slowly resolving on its own.,PLAN:,1.  For the congestion, we will have ENT evaluate.  Appointment has been made with Dr. XYZ for in a couple of days.,2.  I told her just Neosporin for her toe, letting the toenail grow out longer.  Call if there are problems.","consult - history and phy., enlarged adenoids, adenoids, oropharynx, congestion, toenails, toe, "
 Patient with intermittent episodes of severe nausea and abdominal pain., Consult - History and Phy., Gen Med Consult - 29 ,"CHIEF COMPLAINT: , This is a previously healthy 45-year-old gentleman.  For the past 3 years, he has had some intermittent episodes of severe nausea and abdominal pain.  On the morning of this admission, he had the onset of severe pain with nausea and vomiting and was seen in the emergency department, where Dr. XYZ noted an incarcerated umbilical hernia.  He was able to reduce this, with relief of pain.  He is now being admitted for definitive repair.,PAST MEDICAL HISTORY: , Significant only for hemorrhoidectomy.  He does have a history of depression and hypertension.,MEDICATIONS: , His only medications are Ziac and Remeron.,ALLERGIES:,  No allergies.,FAMILY HISTORY: , Negative for cancer.,SOCIAL HISTORY:,  He is single.  He has 2 children.  He drinks 4-8 beers per night and smokes half a pack per day for 30 years.  He was born in Salt Lake City.  He works in an electronic assembly for Harmony Music.  He has no history of hepatitis or blood transfusions.,PHYSICAL EXAMINATION:,GENERAL:  Examination shows a moderate to markedly obese gentleman in mild distress since his initial presentation to the emergency department.,HEENT:  No scleral icterus.,NECK:  No cervical, supraclavicular, or axillary adenopathy.,LUNGS:  Clear.,HEART:  Regular.  No murmurs or gallops.,ABDOMEN:  As noted, obese with mildly visible bulging in the umbilicus at the superior position.  With gentle traction, we were able to feel both herniated contents, which when reduced, reveals an approximately 2-cm palpable defect in the umbilicus.,DIAGNOSTIC STUDIES:  ,Normal sinus rhythm on EKG, prolonged QT.  Chest x-ray was negative.  The abdominal x-rays were read as being negative.  His electrolytes were normal.  Creatinine was 0.9.  White count was 6.5, hematocrit was 48, and platelet count was 307.,ASSESSMENT AND PLAN:,  Otherwise previously healthy gentleman, who presents with an incarcerated umbilical hernia, now for repair with mesh.","consult - history and phy., sinus rhythm, ekg, prolonged qt, platelet count, hematocrit, umbilical hernia, emergency department, healthy, incarcerated, intermittent, "
 Initial clinic visit for foreign body in left eye., Consult - History and Phy., Gen Med Consult - 2 ,"HISTORY OF PRESENT ILLNESS:, This is the initial clinic visit for a 41-year-old worker who is seen for a foreign body to his left eye.  He states that he was doing his normal job when he felt a foreign body sensation.  He attempted to flush this at work, but has had persistent pain which has progressively worsened throughout the course of the day.  He has no significant blurriness of vision or photophobia.",
 Patient presents complaining of abdominal pain and discomfort for 3 weeks., Consult - History and Phy., Gen Med Consult - 26 ,"CHIEF COMPLAINT:, Abdominal pain and discomfort for 3 weeks.,HISTORY OF PRESENT ILLNESS:, ,The patient is a 38 year old white female with no known medical problems who presents complaining of abdominal pain and discomfort for 3 weeks. She had been in her normal state of health when she started having this diffuse abdominal pain and discomfort which is mostly located in the epigastrium and right upper quadrant. She also complains of indigestion and right scapular pain during this same period. None of these complaints are alleviated or aggravated by food. She denies any NSAIDs use. The patient went to an outside hospital where a right upper quadrant ultrasound showed no gallbladder disease, but was suspicious for a liver mass. A CT and MRI of the abdomen and pelvis showed a 12.5 X 10.9 X 11.1 cm right suprarenal mass and a 7.1 X 5.4 X 6.5 cm intrahepatic mass in the region of the dome of the liver. CT of the chest revealed multiple small (<5 mm) bilateral lung nodules. Total body bone scan had no abnormal uptake. She was transferred to Methodist for further care.,The patient reports having a good appetite and denies any weight loss. She denies having any fever or chills. She has noticed increasing dyspnea with moderate exercise, but not at rest. She denies having palpitations. She occasionally has nausea, but no vomiting, constipation, or diarrhea. Over the last 2 months, she has noticed increasing facial hair and a mustache.,There is an extensive family history of colon and other cancers in her family. She was told there is a genetic defect in her family but cannot recall the name of the syndrome. She had a colonoscopy and a polyp removed at the age of 14 years old. Her last colonoscopy was 2 months ago and was unremarkable.,PAST MEDICAL HISTORY :, None.  No history of hypertension, diabetes, heart disease, liver disease or cancer.,PAST SURGICAL HISTORY:, Bilateral tubal ligation in 2001, colon polyp removed at 14 years old.,GYN HISTORY:, Gravida 2, Para 2, Ab 0. Menstrual periods have been regular, last menstrual period almost 1 month ago. No menorrhagia. Never had a mammogram. Has yearly Pap smears which have all been normal.,FAMILY HISTORY:, Mother is 61 years old and brother is 39 years old, both alive and well. Father died at 48 of colon cancer and questionable pancreatic cancer. One paternal uncle died at 32 of colon cancer and bile duct cancer. One paternal uncle had colon cancer in his 40s. Thirty cancers are noted on the father’s side of the family, many are colon; two women had breast cancer. The family was told that there is a genetic syndrome in the family, but no one remembers the name of the syndrome.,SOCIAL HISTORY:, No tobacco, alcohol or illicit drug use. Patient is born and raised in Oklahoma . No known exposures. Married with 2 children.,MEDICATION:,  None.,REVIEW OF SYSTEMS:,  No headaches. No visual, hearing, or swallowing difficulties. No cough or hemoptysis. No chest pain, PND, orthopnea. No changes in bowel or urinary habits. Otherwise, as stated in HPI.,PHYSICAL EXAM:,VS: T 97.6 BP 121/85 P 84 R 18 O2 Sat 100% on room air,GEN: Pleasant, thin woman in mild distress secondary to abdominal pain and discomfort.,HEENT: Pupils equally round and reactive to light. Extra-ocular movements intact. Anicteric. Sclerae clear. Pink conjunctiva. Moist mucous membranes. No oropharyngeal lesions.,NECK: Supple, no masses, jugular venous distention or bruits.,LUNGS: Clear to auscultation bilaterally.,HEART: Regular rate and rhythm. No murmurs, gallops, rubs.,BREASTS: Symmetric, no skin changes, no discharge, no masses,ABDOMEN: Soft with active bowel sounds. There is minimal diffuse tenderness on examination. No masses palpated. There is fullness in the right upper quadrant with negative Murphy’s sign. No rebound or guarding. The liver span is 12 cm by percussion, but not palpable below the costal margin. No splenomegaly.,PELVIC: not done,EXT: No clubbing, cyanosis, or edema. 2+ pulses bilaterally.,NEURO: Cranial nerves intact. 2+ DTRs bilaterally and symmetrically. Motor strength and sensation within the normal limits.,LYMPH: No cervical, axillary, or inguinal lymph nodes palpated,SKIN: warm, no rashes, no lesions; no tattoos,STUDIES:,CT Chest:  Multiple bilateral small (<5 mm) pulmonary nodules, no mediastinal mass or hilar adenopathy.,MRI Abdomen: 12.5 x 10.9 x 11.1 cm suprarenal mass, 7.1 x 5.4 x 6.5 cm intrahepatic lesion in the region of the dome of the liver, abnormal signal intensity within the inferior vena cava at the level of porta hepatic worrisome for thrombus.,Total Body Bone Scan: No abnormal uptake.,HOSPITAL COURSE:, ,The patient was transferred from an outside hospital for further workup and management. She was taken to the Operating Room for abdominal exploration. A liver biopsy was done.",
 1-year-old male who comes in with a cough and congestion.  Clinical sinusitis and secondary cough., Consult - History and Phy., Gen Med Consult - 18 ,"SUBJECTIVE:,  This is a 1-year-old male who comes in with a cough and congestion for the past two to three weeks.  Started off as a congestion but then he started coughing about a week ago.  Cough has gotten worsen.  Mother was also worried.  He had Pop Can just three days ago and she never found the top of that and was wondering if he had swallowed that, but his breathing has not gotten worse since that happened.  He is not running any fevers.,PAST MEDICAL HISTORY:,  Otherwise, reviewed.  Fairly healthy.,CURRENT MEDICATIONS:,  None.,ALLERGIES TO MEDICINES:,  None.,FAMILY SOCIAL HISTORY:,  The sister is in today with clinical sinusitis.  Mother and father have been healthy.,REVIEW OF SYSTEMS:,  He has been congested for about three weeks ago.  Coughing now but no fevers.  No vomiting.  Review of systems is otherwise negative.,PHYSICAL EXAMINATION:,General:  Well-developed male in no acute distress, afebrile.,Vital Signs:  Weight:  22 pounds 6 ounces.,HEENT:  Sclerae and conjunctivae are clear.  Extraocular muscles are intact.  TMs are clear.  Nares are very congested.  Oropharynx has drainage in the back of the throat.  Mucous membranes are moist.  Mild erythema though.,Neck:  Some shotty lymphadenopathy.  Full range of motion.  Supple.,Chest:  Clear.  No crackles.  No wheezes.,Cardiovascular:  Regular rate and rhythm.  Normal S1, S2.,Abdomen:  Positive bowel sounds and soft.,Dermatologic:  Clear.  Tone is good.  Capillary refill less than 3 seconds.,RADIOLOGY:,  Chest x-ray:  No foreign body noted as well.  No signs of pneumonia.,ASSESSMENT:,  Clinical sinusitis and secondary cough.,PLAN:,  Amoxicillin a teaspoon twice daily for 10 days.  Plenty of fluids.  Tylenol and Motrin p.r.n., as well as oral decongestant and if coughing is not improving.","consult - history and phy., congestion, cough, sinusitis and secondary cough, cough and congestion, secondary cough, clinical sinusitis, male, sinusitis, "
" An 18-month-old white male here with his mother for complaint of intermittent fever for the past five days. - Allergic rhinitis, fever history, sinusitis resolved, and teething.", Consult - History and Phy., Gen Med Consult - 17 ,"CHIEF COMPLAINT:,  Fever.,HISTORY OF PRESENT ILLNESS:,  This is an 18-month-old white male here with his mother for complaint of intermittent fever for the past five days.  Mother states he just completed Amoxil several days ago for a sinus infection.  Patient does have a past history compatible with allergic rhinitis and he has been taking Zyrtec serum.  Mother states that his temperature usually elevates at night.  Two days his temperature was 102.6.  Mother has not taken it since, and in fact she states today he seems much better.  He is cutting an eye tooth that causes him to be drooling and sometimes fussy.  He has had no vomiting or diarrhea.  There has been no coughing.  Nose secretions are usually discolored in the morning, but clear throughout the rest of the day.  Appetite is fine.,PHYSICAL EXAMINATION:,General:  He is alert in no distress.,Vital Signs:  Afebrile.,HEENT:  Normocephalic, atraumatic.  Pupils equal, round and react to light.  TMs are clear bilaterally.  Nares patent.  Clear secretions present.  Oropharynx is clear.,Neck:  Supple.,Lungs:  Clear to auscultation.,Heart:  Regular, no murmur.,Abdomen:  Soft.  Positive bowel sounds.  No masses.  No hepatosplenomegaly.,Skin:  Normal turgor.,ASSESSMENT:,1.  Allergic rhinitis.,2.  Fever history.,3.  Sinusitis resolved.,4.  Teething.,PLAN:,  Mother has been advised to continue Zyrtec as directed daily.  Supportive care as needed.  Reassurance given and he is to return to the office as scheduled.","consult - history and phy., sinusitis, fever, intermittent fever, allergic rhinitis, fever history, teething,"
" 2-year-old female who comes in for just rechecking her weight, her breathing status, and her diet.", Consult - History and Phy., Gen Med Consult - 19 ,"SUBJECTIVE:,  This is a 2-year-old female who comes in for just rechecking her weight, her breathing status, and her diet.  The patient is in foster care, has a long history of the prematurity, born at 22 weeks.  She has chronic lung disease, is on ventilator, but doing sprints, has been doing very well, is up to 4-1/2 hours sprints twice daily and may go up 15 minutes every three days or so; which she has been tolerating fairly well as long as they kind of get her distracted towards the end, otherwise, she does get sort of tachypneic.  She is on 2-1/2 liters of oxygen and does require that.  Her diet has been fluctuating.  They have been trying to figure out what works best with her.  She has been on some Pediasure for the increased calories but that really makes her distended in the abdomen and constipates her.  They have been doing more pureed foods and that seems to loosen her up, so they have been doing more Isomil 24 cal and baby foods and not so much Pediasure.  She was hospitalized a couple of weeks back for the distension she had in the abdomen.  Dr. XYZ has been working with her G-tube, increasing her Mic-key button size, but also doing some silver nitrate applications, and he is going to evaluate her again next week, but they are happy with the way her G-tube site is looking.  She also has been seen Dr. Eisenbaum, just got of new pair of glasses this week and sees him in another couple of weeks for reevaluation.,CURRENT MEDICATIONS:,  Flagyl, vitamins, Zyrtec, albuterol, and some Colace.,ALLERGIES TO MEDICINES: , None.,FAMILY SOCIAL HISTORY:,  As mentioned, she is in foster care.  Foster mom is actually going to be out of town for a week the 19th through the 23rd, so she will probably be hospitalized in respite care because there are no other foster care situations that can handle the patient.  Biological Mom and Grandma do visit on Thursdays for about an hour.,REVIEW OF SYSTEMS:,  The patient has been eating fairly well, sleeping well, doing well with her sprints.  A little difficulty with her stools hard versus soft as mentioned with the diet situation up in HPI.,PHYSICAL EXAMINATION:,Vital Signs:  She is 28 pounds 8 ounces today, 33-1/2 inches tall.  She is on 2-1/2 liters, but she is not the vent currently, she is doing her sprints, and her respiratory rate is around 40.,HEENT:  Sclerae and conjunctivae are clear.  TMs are clear.  Nares are patent.  Oropharynx is clear.  Trach site is clear of any signs of infection.,Chest:  Coarse.  She has got little bit of wheezing going on, but she is moving air fairly well.,Abdomen:  Positive bowel sounds and soft.  The G-tube site looks fairly clean today and healthy.  No signs of infection.  Her tone is good.  Capillary refill is less than three seconds.,ASSESSMENT:,  A 2-year-old with chronic lung disease, doing the sprints, some bowel difficulties, also just weight gain issues because of the high-energy expenditure with the sprints that she is doing.,PLAN:,  At this point is to continue with the Isomil and pureed baby foods, a little bit of Pediasure.  They are going to see Dr. XYZ towards the end of this month and follow up with Dr. Eisenbaum.  I would like to see her in approximately six weeks again, but we do need to keep a close check on her weight and call if there are problems beforehand.  She is just doing wonderful progression on her development.  Each time I see her, I am very impressed, that relayed to foster mom.  Approximately 25 minutes spent with the patient, most of it counseling.","consult - history and phy., chronic lung disease, signs of infection, breathing status, foster mom, foster care, pediasure"
 Short-term memory loss (probable situational) and anxiety stress issues., Consult - History and Phy., Gen Med Consult - 16 ,"CHIEF COMPLAINT:,  Here with a concern of possibly issues of short-term memory loss.  She is under exceeding amount of stress over the last 5 to 10 years.  She has been a widow over the last 11 years.  Her husband died in an MVA from a drunk driver accident.  She had previously worked at the bank in Conway Springs in Norwich and had several other jobs related to accounting or management services.  She does have an MBA in business.  Currently, she works at T-Mobile Customer Service, and there is quite a bit of technical knowledge, deadlines, and stress related to that job as well.  She feels she has trouble at times absorbing all that she needs to learn as far as the computer skills, protocols, customer service issues, etc.  She describes the job is very demanding and high stress.  She denies any history of weakness, lethargy, or dizziness.  No history of stroke.,CURRENT MEDICATIONS:,  Vioxx 25 mg daily, HCTZ 25 mg one-half tablet daily, Zoloft 100 mg daily, Zyrtec 10 mg daily.,ALLERGIES TO MEDICATIONS: , Naprosyn.,SOCIAL HISTORY, FAMILY HISTORY, PAST MEDICAL HISTORY AND SURGICAL HISTORY: , She has had hypertension very well controlled and history of elevated triglycerides.  She has otherwise been generally healthy.  Nonsmoker.  Please see notes dated 06/28/2004.,REVIEW OF SYSTEMS:,  Review of systems is otherwise negative.,PHYSICAL EXAMINATION:,Vital Signs:  Age:  60.  Weight:  192 pounds.  Blood pressure:  134/80.  Temperature:  97.8 degrees.,General:  A very pleasant 60-year-old white female in no acute distress.  Alert, ambulatory and nonlethargic.,HEENT:  PERRLA.  EOMs are intact.  TMs are clear bilaterally.  Throat is clear.,Neck:  Supple.  No cervical adenopathy.,Lungs:  Clear without wheezes or rales.,Heart:  Regular rate and rhythm.,Abdomen:  Soft nontender to palpation.,Extremities:  Moving all extremities well.,IMPRESSION:,1.  Short-term memory loss, probable situational.,2.  Anxiety stress issues.,PLAN:,  Thirty-minute face-to-face appointment in counseling with the patient.  At length discussion on her numerous stress issues which can certainly cause a loss of concentration and inability to learn.  The current job she is at does sound extremely stressful and demanding.  I think her stress reactions to these as far as feeling frustrated are within normal limits.  We did complete a mini mental state exam including clock drawing, sentence writing, signature, etc.  She does score a maximum score of 30/30 and all other tasks were completed without difficulty or any hesitation.  I did spend quite a bit of time reassuring her as well.  She is currently on Zoloft 100 mg which I think is an appropriate dose.  We will have her continue on that.  She did verbalize understanding and that she actually felt better after our discussion concerning these issues.  At some point in time; however, I would possibly recommend job change if this one would persist as far as the stress levels.  She is going to think about that.","consult - history and phy., short-term memory loss, anxiety, short term memory loss, memory loss, stress issues, situational, memory, stress, "
 Complaint of mood swings and tearfulness., Consult - History and Phy., Gen Med Consult - 15 ,"HISTORY OF PRESENT ILLNESS:,  A 50-year-old female comes to the clinic with complaint of mood swings and tearfulness.  This has been problematic over the last several months and is just worsening to the point where it is impairing her work.  Her boss asks her if she was actually on drugs in which she said no.  She stated may be she needed to be, meaning taking some medications.  The patient had been prescribed Wellbutrin in the past and responded well to it; however, at that time it was prescribed for obsessive-compulsive type disorder relating to overeating and therefore her insurance would not cover the medication.  She has not been on any other antidepressants in the past.  She is not having any suicidal ideation but is having difficulty concentrating, rapid mood swings with tearfulness, and insomnia.  She denies any hot flashes or night sweats.  She underwent TAH with BSO in December of 2003.,FAMILY HISTORY: , Benign breast lump in her mother; however, her paternal grandmother had breast cancer.  The patient denies any palpitations, urinary incontinence, hair loss, or other concerns.  She was recently treated for sinusitis.,ALLERGIES:,  She is allergic to Sulfa.,CURRENT MEDICATIONS:,  Recently finished Minocin and Duraphen II DM.,PHYSICAL EXAMINATION:,General:  A well-developed and well-nourished female, conscious, alert, oriented times three in no acute distress.  Mood is dysthymic.  Affect is tearful.,Skin:  Without rash.,Eyes:  PERRLA.  Conjunctivae are clear.,Neck:  Supple with adenopathy or thyromegaly.,Lungs:  Clear.,Heart:  Regular rate and rhythm without murmur.,ASSESSMENT:,1.  Postsurgical menopause.,2.  Mood swings.,PLAN:,  I spent about 30 minutes with the patient discussing treatment options.  I do believe that her moods would greatly benefit from hormone replacement therapy; however, she is reluctant to do this because of family history of breast cancer.  We will try starting her back on Wellbutrin XL 150 mg daily.  She may increase to 300 mg daily after three to seven days.  Samples provided initially.  If she is not obtaining adequate relief from medication alone, we will then suggest that we explore the use of hormone replacement therapy.  I also recommended increasing her exercise.  We will also obtain some screening lab work including CBC, UA, TSH, chemistry panel, and lipid profile.  Follow up here in two weeks or sooner if any other problems.  She is needing her annual breast exam as well.","consult - history and phy., tearfulness, mood swings, menopause, postsurgical menopause, mood swings and tearfulness, hormone replacement therapy, breast cancer, wellbutrin,"
" Consult for hypertension and a med check.  History of osteoarthritis, osteoporosis, hypothyroidism, allergic rhinitis and kidney stones.", Consult - History and Phy., Gen Med Consult - 13 ,"SUBJECTIVE:,  The patient is a 76-year-old white female who presents to the clinic today originally for hypertension and a med check.  She has a history of hypertension, osteoarthritis, osteoporosis, hypothyroidism, allergic rhinitis and kidney stones.  Since her last visit she has been followed by Dr. Kumar.  Those issues are stable.  She has had no fever or chills, cough, congestion, nausea, vomiting, chest pain, chest pressure.,PAST MEDICAL HISTORY:,  She has an intolerance to Prevacid.,CURRENT MEDICATIONS:,  Evista 60 daily, Levothroid 0.05 mg daily, Claritin 10 daily, Celebrex 200 daily, HCTZ 25 daily and amitriptyline p.r.n.,PAST SURGICAL HISTORY:,  Bilateral mastectomies, tonsillectomy, EGD, flex sig in 2001 and a heart cath.,FAMILY HISTORY: , Father passed away at 81; mother of multiple myeloma at 83.,SOCIAL HISTORY:,  She is married.  A 76-year-old who used to smoke a pack a day and quit in 1985.  She is retired.,REVIEW OF SYSTEMS:,  Essentially negative in HEENT, chest, cardiovascular, GI, GU, musculoskeletal, or neurologic.,OBJECTIVE:,  Temperature is 97.5 degrees.  Blood pressure is 168/70.  Pulse is 88.  Weight is 129 pounds.,GENERAL:  She is an elderly 76-year-old in no acute distress.,HEENT:  Atraumatic.  Extraocular muscles were intact.  Pupils equal, round and reactive to light and accommodation.  Tympanic membranes are clear, dry and intact.  Sinuses and throat are clear.  Neck is soft, supple.  No meningeal signs are present.  No thyromegaly is present.,CHEST:  Clear to auscultation.,CARDIOVASCULAR:  Regular rate and rhythm without murmur.,ABDOMEN:  Soft, nontender.  Bowel sounds are positive.  No organomegaly or peritoneal signs are present.,EXTREMITIES:  Moving all extremities.  Peripheral pulses are normal.  No edema is present.,NEUROLOGIC:  Alert and oriented.  Cranial nerves II-XII grossly intact.  Strength 5+/5 globally.  Reflexes 2+/IV globally.  Romberg is negative.  There is no numbness, tingling, weakness or other neurologic deficit present.,BREASTS:  Surgically absent but there are no lumps, lesions, masses, discharge or adenopathy present.,BACK:  Straight.,SKIN:  Clear.,GENITALIA:  Deferred as she has been followed by Dr. XYZ many times this year.  She does have a history of some elevated cholesterol.,ASSESSMENT:,1.  Hypertension, suboptimal control.,2.  Hypothyroidism.,3.  Arthritis.,4.  Allergic rhinitis.,5.  History of kidney stones.,6.  Osteoporosis.,PLAN:,1.  CBC, complete metabolic profile, UA for hypertension.,2.  Chest x-ray for history of breast cancer.,3.  DEXA scan, full body for osteoporosis.,4.  Flex is up to date.,5.  Pneumovax has been given in the last five years.,6.  Lipid profile for elevated cholesterol.,7.  Refill meds.,8.  Follow up every three to six months for blood pressure check or sooner p.r.n. problems.",
 Feeling weak and shaky - Dyspnea on exertion and history of diabetes, Consult - History and Phy., Gen Med Consult - 12 ,"CHIEF COMPLAINT:,  Weak and shaky.,HISTORY OF PRESENT ILLNESS:,  The patient is a 75-year-old, Caucasian female who comes in today with complaint of feeling weak and shaky.  When questioned further, she described shortness of breath primarily with ambulation.  She denies chest pain.  She denies cough, hemoptysis, dyspnea, and wheeze.  She denies syncope, presyncope, or palpitations.  Her symptoms are fairly longstanding but have been worsening as of late.,PAST MEDICAL HISTORY:,  She has had a fairly extensive past medical history but is a somewhat poor historian and is unable to provide details about her history.  She states that she has underlying history of heart disease but is not able to elaborate to any significant extent.  She also has a history of hypertension and type II diabetes but is not currently taking any medication.  She has also had a history of pulmonary embolism approximately four years ago, hyperlipidemia, peptic ulcer disease, and recurrent urinary tract infections.  Surgeries include an appendectomy, cesarean section, cataracts, and hernia repair.,CURRENT MEDICATIONS:,  She is on two different medications, neither of which she can remember the name and why she is taking it.,ALLERGIES: , She has no known medical allergies.,FAMILY HISTORY:,  Remarkable for coronary artery disease, stroke, and congestive heart failure.,SOCIAL HISTORY:,  She is a widow, lives alone.  Denies any tobacco or alcohol use.,REVIEW OF SYSTEMS:,  Dyspnea on exertion.  No chest pain or tightness, fever, chills, sweats, cough, hemoptysis, or wheeze, or lower extremity swelling.,PHYSICAL EXAMINATION:,General:  She is alert but seems somewhat confused and is not able to provide specific details about her past history.,Vital Signs:  Blood pressure:  146/80.  Pulse:  68.  Weight:  147 pounds.,HEENT:  Unremarkable.,Neck:  Supple without JVD, adenopathy, or bruit.,Chest:  Clear to auscultation.,Cardiovascular:  Regular rate and rhythm.,Abdomen:  Soft.,Extremities:  No edema.,LABORATORY:,  O2 sat 100% at rest and with exertion.  Electrocardiogram was normal sinus rhythm.  Nonspecific S-T segment changes.  Chest x-ray pending.,ASSESSMENT/PLAN:,1.  Dyspnea on exertion, uncertain etiology.  Mother would be concerned about the possibility of coronary artery disease given the patient’s underlying risk factors.  We will have the patient sign a release of records so that we can review her previous history.  Consider setting up for a stress test.,2.  Hypertension, blood pressure is acceptable today.  I am not certain as to what, if the patient’s is on any antihypertensive agents.  We will need to have her call us what the names of her medications, so we can see exactly what she is taking.,3.  History of diabetes.  Again, not certain as to whether the patient is taking anything for this particular problem when she last had a hemoglobin A1C.  I have to obtain some further history and review records before proceeding with treatment recommendations.",
 Gastrointestinal Bleed.  An 81-year-old presented to the emergency room after having multiple black tarry stools and a weak spell.  She woke yesterday morning had a very dark and smelly bowel movement. , Consult - History and Phy., Gastrointestinal Bleed - ER Visit ,"ADMITTING DIAGNOSIS: , Gastrointestinal bleed.,HISTORY OF PRESENT ILLNESS:  ,Ms. XYZ is an 81-year-old who presented to the emergency room after having multiple black tarry stools and a weak spell.  She states that she woke yesterday morning and at approximately 10:30 had a bowel movement.  She noticed it was very dark and smelly.  She said she felt okay.  She got up.  She proceeded to clean her house without any difficulty or problems and then at approximately 2 o'clock in the afternoon she went back to the bathroom at which point she had another large stool and had weak spell felt like she was going to pass out.  She is able to get to her phone, called EMS and when the EMS arrived they found her with some blood and some very dark stools.  She states that she was perfectly fine up until Monday when she had an incident where at the Southern University where she works where there was an altercation between a dorm resistant and a young male, which ensued.  She came to place her call, etc.  She said she noticed her stomach was hurting after that, continued to hurt and she took the day off on Tuesday and this happened yesterday.  She denies any nausea except for when she got weak.  She denies any vomiting or any other symptoms.,ALLERGIES:  ,She has no known drug allergies.,CURRENT MEDICATIONS:,1.  Lipitor, dose unknown.,2.  Paxil, dose unknown.,3.  Lasix, dose unknown.,4.  Toprol, dose unknown.,5.  Diphenhydramine p.r.n.,6.  Ibuprofen p.r.n.,7.  Daypro p.r.n.,PAST MEDICAL HISTORY:,1.  Non-insulin diabetes mellitus.,2.  History of congestive heart failure.,3.  History of hypertension.,4.  Depression.,5.  Arthritis.  She states she has not needed any medications and not taken ibuprofen or Daypro recently.,6.  Hyperlipidemia.,7.  Peptic ulcer disease diagnosed in 2005.,PAST SURGICAL HISTORY: , C-section and tonsillectomy.,FAMILY HISTORY: , Her mother had high blood pressure and coronary artery disease.,SOCIAL HISTORY:,  She is a nonsmoker.  She occasionally has a drink every few weeks.  She is divorced.  She has 2 sons.  She is houseparent at Southern University.,REVIEW OF SYSTEMS:  ,Negative for the last 24 to 48 hours as mentioned in her HPI.,PREVENTIVE CARE:  ,She had an EGD done in 09/05 at which point she was diagnosed with peptic ulcer disease and she also had a colonoscopy at that time which revealed two polyps in the transverse colon.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Currently was stable.  She is afebrile.,GENERAL:  She is alert, pleasant in no acute distress.  She does complain of some dizziness when she stands up.,HEENT:  Pupils equal, round and reactive to light.  Extraocular muscles intact.  Sclerae clear.  Oropharynx is clear.,NECK:  Supple.  Full range of motion.,CARDIOVASCULAR:  She is slightly tachycardic but otherwise normal.,LUNGS:  Clear bilaterally.,ABDOMEN:  Soft, nontender, and nondistended.  She has no hepatomegaly.,EXTREMITIES:  No clubbing, cyanosis, only trace edema.,LABORATORY DATA UPON ADMISSION:,  Her initial chem panel was within normal limits.  Her PT and PTT were normal.  Her initial hematocrit was 31.2 subsequently dropped to 26.9 and 25.6.  She is currently administered transfusion.  Platelet count was 125.  Her chem panel actually showed an elevated BUN of 16, creatinine of 1.7.  PT and PTT were normal.  Cardiac enzymes were negative and initial hemoglobin was 10.6 with hematocrit of 31.2 that subsequently fell to 25.6 and she is currently receiving blood.,IMPRESSION AND PLAN:,1.  Gastrointestinal bleed.",
 Complaint of left otalgia (serous otitis) and headache.  History of atopic dermatitis., Consult - History and Phy., Gen Med Consult - 14 ,"HISTORY OF PRESENT ILLNESS:,  A 49-year-old female with history of atopic dermatitis comes to the clinic with complaint of left otalgia and headache.  Symptoms started approximately three weeks ago and she was having difficulty hearing, although that has greatly improved.  She is having some left-sided sinus pressure and actually went to the dentist because her teeth were hurting; however, the teeth were okay.  She continues to have some left-sided jaw pain.  Denies any headache, fever, cough, or sore throat.  She had used Cutivate cream in the past for the atopic dermatitis with good results and is needing a refill of that.  She has also had problems with sinusitis in the past and chronic left-sided headache.,FAMILY HISTORY:,  Reviewed and unchanged.,ALLERGIES: , To cephalexin.,CURRENT MEDICATIONS:,  Ibuprofen.,SOCIAL HISTORY:,  She is a nonsmoker.,REVIEW OF SYSTEMS:,  As above.  No nausea, vomiting, or diarrhea.,PHYSICAL EXAMINATION:,General:  A well-developed and well-nourished female, conscious, alert, and in no acute distress.,Vital Signs:  Weight:  121 pounds.  Temperature:  97.9 degrees.,Skin:  Reveals scattered erythematous plaques with some mild lichenification on the nuchal region and behind the knees.,Eyes:  PERRLA.  Conjunctivae are clear.,Ears:  Left TM with some effusion.  Right TM is clear.  Canals are clear.  External auricles are nontender to manipulation.,Nose:  Nasal mucosa is pink and moist without discharge.,Throat:  Nonerythematous.  No tonsillar hypertrophy or exudate.,Neck:  Supple without adenopathy or thyromegaly.,Lungs:  Clear.  Respirations are regular and unlabored.,Heart:  Regular rate and rhythm at rate of 100 beats per minute.,ASSESSMENT:,1.  Serous otitis.,2.  Atopic dermatitis.,PLAN:,1.  Nasacort AQ two sprays each nostril daily.,2.  Duraphen II one b.i.d.,3.  Refills Cutivate cream 0.05% to apply to affected areas b.i.d.  Recheck p.r.n.",
" Infection (folliculitis), pelvic pain, mood swings, and painful sex (dyspareunia).", Consult - History and Phy., Gen Med Consult - 11 ,"CHIEF COMPLAINT:,1.  Infection.,2.  Pelvic pain.,3.  Mood swings.,4.  Painful sex.,HISTORY OF PRESENT ILLNESS:,  The patient is a 29-year-old female who is here today with the above-noted complaints.  She states that she has been having a lot of swelling and infection in her inner thigh area with the folliculitis she has had in the past.  She is requesting antibiotics.  She has been squeezing them and some of them are very bruised and irritated.  She also states that she is having significant pelvic pain and would like to go back and see Dr. XYZ again.  She also states that she took herself off of lithium, but she has been having significant mood swings, anger outbursts and not dealing with the situation well at all.  She also has had some psychiatric evaluation, but she states that she did not feel like herself on the medication, so she took herself off.  She states she does not wish to be on any medication at the current time.  She otherwise states that sex is so painful that she is unable to have sex with her husband, even though she ""wants to."",PAST MEDICAL HISTORY:,  Significant for cleft palate.,ALLERGIES:,  She is allergic to Lortab.,CURRENT MEDICATIONS:,  None.,REVIEW OF SYSTEMS:,  Please see history of present illness.,Psychiatric:  She has had some suicidal thoughts, but no plans.  She denies being suicidal at the current time.,Cardiopulmonary:  She has not had any chest pain or shortness of breath.,GI:  Denies any nausea or vomiting.,Neurological:  No numbness, weakness or tingling.,PHYSICAL EXAMINATION:,General:  The patient is a well-developed, well-nourished, 29-year-old female who is in no acute distress.,Vital signs:  Weight:  160 pounds.  Blood pressure:  100/60.  Pulse:  62.,Psychiatric:  I did spend over 25 minutes face-to-face with the patient talking about the situation she was in and the medication and her discontinuing use of that.,Extremities:  Her inner thighs are covered with multiple areas of folliculitis and mild abscesses.  They are bruised from her squeezing them.  We talked about that in detail.,ASSESSMENT:,1.  Folliculitis.,2.  Pelvic pain.,3.  Mood swings.,4.  Dyspareunia.,PLAN:,1.  I would like her to go to the lab and get a CBC, chem-12, TSH and UA.,2.  We will put her on cephalexin 500 mg three times a day.,3.  We will send her back to see Dr. XYZ regarding the pelvic pain per her request.,4.  We will get her an appointment with a psychiatrist for evaluation and treatment.,5.  She is to call if she has any further problems or concerns.  Otherwise I will see her back for her routine care or sooner if there are any further issues.",
 Checkup - Joints hurting all over - Arthralgias that are suspicious for inflammatory arthritis., Consult - History and Phy., Gen Med Consult - 10 ,"CHIEF COMPLAINT:,  Joints are hurting all over and checkup.,HISTORY OF PRESENT ILLNESS:,  A 77-year-old white female who is having more problems with joint pain.  It seems to be all over decreasing her mobility, hands and wrists.  No real swelling but maybe just a little more uncomfortable than they have been.  The Daypro generic does not seem to be helping at all.  No fever or chills.  No erythema.,She actually is doing better.  Her diarrhea now has settled down and she is having less urinary incontinence, less pedal edema.  Blood sugars seem to be little better as well.,The patient also has gotten back on her Zoloft because she thinks she may be depressed, sleeping all the time, just not herself and really is disturbed that she cannot be more mobile in things.  She has had no polyuria, polydipsia, or other problems.  No recent blood pressure checks.,PAST MEDICAL HISTORY:,  Little over a year ago, the patient was found to have lumbar discitis and was treated with antibiotics and ended up having debridement and instrumentation with Dr. XYZ and is doing really quite well.  She had a pulmonary embolus with that hospitalization.,PAST SURGICAL HISTORY:,  She has also had a hysterectomy, salpingoophorectomy, appendectomy, tonsillectomy, two carpal tunnel releases.  She also has had a parathyroidectomy but still has had some borderline elevated calcium.  Also, hypertension, hyperlipidemia, as well as diabetes.  She also has osteoporosis.,SOCIAL HISTORY:,  The patient still smokes about a third of a pack a day, also drinks only occasional alcoholic drinks.  The patient is married.  She has three grown sons, all of which are very successful in professional positions.  One son is a gastroenterologist in San Diego, California.,MEDICATIONS:,  Nifedipine-XR 90 mg daily, furosemide 20 mg half tablet b.i.d., lisinopril 20 mg daily, gemfibrozil 600 mg b.i.d., Synthroid 0.1 mg daily, Miacalcin one spray in alternate nostrils daily, Ogen 0.625 mg daily, Daypro 600 mg t.i.d., also Lortab 7.5 two or three a day, also Flexeril occasionally, also other vitamin.,ALLERGIES: , She had some adverse reactions to penicillin, sulfa, perhaps contrast medium, and some mycins.,FAMILY HISTORY:,  As far as heart disease there is none in the family.  As far as cancer two cousins had breast cancer.  As far as diabetes father and grandfather had type II diabetes.  Son has type I diabetes and is struggling with that at the moment.,REVIEW OF SYSTEMS:,General:  No fever, chills, or night sweats.  Weight stable.,HEENT:  No sudden blindness, diplopia, loss of vision, i.e., in one eye or other visual changes.  No hearing changes or ear problems.  No swallowing problems or mouth lesions.,Endocrine:  Hypothyroidism but no polyuria or polydipsia.  She watches her blood sugars.  They have been doing quite well.,Respiratory:  No shortness of breath, cough, sputum production, hemoptysis or breathing problems.,Cardiovascular:  No chest pain or chest discomfort.  No paroxysmal nocturnal dyspnea, orthopnea, palpitations, or heart attacks.,GI:  As mentioned, has had diarrhea though thought to be possibly due to Clostridium difficile colitis that now has gotten better.  She has had some irritable bowel syndrome and bowel abnormalities for years.,GU:  No urinary problems, dysuria, polyuria or polydipsia, kidney stones, or recent infections.  No vaginal bleeding or discharge.,Musculoskeletal:  As above.,Hematological:  She has had some anemia in the past.,Neurological:  No blackouts, convulsions, seizures, paralysis, strokes, or headaches.,PHYSICAL EXAMINATION:,Vital Signs:  Weight is 164 pounds.  Blood pressure:  140/64.  Pulse:  72.  Blood pressure repeated by me with the patient sitting taken on the right arm is 148/60, left arm 136/58; these are while sitting on the exam table.,General:  A well-developed pleasant female who is comfortable in no acute distress otherwise but she does move slowly.,HEENT:  Skull is normocephalic.  TMs intact and shiny with good auditory acuity to finger rub.  Pupils equal, round, reactive to light and accommodation with extraocular movements intact.  Fundi benign.  Sclerae and conjunctivae were normal.,Neck:  No thyromegaly or cervical lymphadenopathy.  Carotids are 2+ and equal bilaterally and no bruits present.,Lungs:  Clear to auscultation and percussion with good respiratory movement.  No bronchial breath sounds, egophony, or rales are present.,Heart:  Regular rhythm and rate with no murmurs, gallops, rubs, or enlargement.  PMI normal position.  All pulses are 2+ and equal bilaterally.,Abdomen:  Obese, soft with no hepatosplenomegaly or masses.,Breasts:  No predominant masses, discharge, or asymmetry.,Pelvic Exam:  Normal external genitalia, vagina and cervix.  Pap smear done.  Bimanual exam shows no uterine enlargement and is anteroflexed.  No adnexal masses or tenderness.  Rectal exam is normal with soft brown stool Hemoccult negative.,Extremities:  The patient does appear to have some doughiness of all of the MCP joints of the hands and the wrists as well.  No real erythema.  There is no real swelling of the knees.  No new pedal edema.,Lymph nodes:  No cervical, axillary, or inguinal adenopathy.,Neurological:  Cranial nerves II-XII are grossly intact.  Deep tendon reflexes are 2+ and equal bilaterally.  Cerebellar and motor function intact in all extremities.  Good vibratory and positional sense in all extremities and dermatomes.  Plantar reflexes are downgoing bilaterally.,LABORATORY:  ,CBC shows a hemoglobin of 10.5, hematocrit 35.4, otherwise normal.  Urinalysis is within normal limits.  Chem profile showed a BUN of 54, creatinine 1.4, glucose 116, calcium was 10.8, cholesterol 198, triglycerides 171, HDL 43, LDL 121, TSH is normal, hemoglobin A1C is 5.3.,ASSESSMENT:,1.  Arthralgias that are suspicious for inflammatory arthritis, but certainly seems to be more active and bothersome.  I think we need to look at this more closely.,2.  Diarrhea that seems to have resolved.  Whether this is related to the above is unclear.,3.  Diabetes mellitus type II, really fairly well controlled.",
 Return to work & Fit for duty evaluation., Consult - History and Phy., Gen Med Consult - 1 ,"HISTORY OF PRESENT ILLNESS: ,This is the initial clinic visit for a 29-year-old man who is seen for new onset of right shoulder pain.  He states that this began approximately one week ago when he was lifting stacks of cardboard.  The motion that he describes is essentially picking up a stack of cardboard at his waist level, twisting to the right and delivering it at approximately waist level.  Sometimes he has to throw the stacks a little bit as well.  He states he felt a popping sensation on 06/30/04.  Since that time, he has had persistent shoulder pain with lifting activities.  He localizes the pain to the posterior and to a lesser extent the lateral aspect of the shoulder.  He has no upper extremity .  , ,REVIEW OF SYSTEMS: ,Focal lateral and posterior shoulder pain without a suggestion of any cervical radiculopathies.  He denies any chronic cardiac, pulmonary, GI, GU, neurologic, musculoskeletal, endocrine abnormalities.  , ,MEDICATIONS: , Claritin for allergic rhinitis.  , ,ALLERGIES: , None.  , ,PHYSICAL EXAMINATION:, Blood pressure 120/90, respirations 10, pulse 72, temperature 97.2.  He is sitting upright, alert and oriented, and in no acute distress.  Skin is warm and dry. Gross neurologic examination is normal.  ENT examination reveals normal oropharynx, nasopharynx, and tympanic membranes.  Neck: Full range of motion with no adenopathy or thyromegaly.  Cardiovascular:  Regular rate and rhythm.  Lungs:  Clear.  Abdomen: Soft.","consult - history and phy., return to work, consult, fit for duty, cleared for work, muscular, paresthesias, shoulder, shoulder pain, strain, waist, x-rays, waist level, neurologic, abnormalities, impingement, examination, "
 Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery. , Consult - History and Phy., Gastric Bypass Discussion - 3 ,"PAST MEDICAL HISTORY:,  Significant for hypertension.  The patient takes hydrochlorothiazide for this.  She also suffers from high cholesterol and takes Crestor.  She also has dry eyes and uses Restasis for this.  She denies liver disease, kidney disease, cirrhosis, hepatitis, diabetes mellitus, thyroid disease, bleeding disorders, prior DVT, HIV and gout.  She also denies cardiac disease and prior history of cancer.,PAST SURGICAL HISTORY: , Significant for tubal ligation in 1993.  She had a hysterectomy done in 2000 and a gallbladder resection done in 2002.,MEDICATIONS: , Crestor 20 mg p.o. daily, hydrochlorothiazide 20 mg p.o. daily, Veramist spray 27.5 mcg daily, Restasis twice a day and ibuprofen two to three times a day.,ALLERGIES TO MEDICATIONS: , Bactrim which causes a rash.  The patient denies latex allergy.,SOCIAL HISTORY: , The patient is a life long nonsmoker.  She only drinks socially one to two drinks a month.  She is employed as a manager at the New York department of taxation.  She is married with four children.,FAMILY HISTORY: , Significant for type II diabetes on her mother's side as well as liver and heart failure.  She has one sibling that suffers from high cholesterol and high triglycerides.,REVIEW OF SYSTEMS: , Positive for hot flashes.  She also complains about snoring and occasional slight asthma.  She does complain about peripheral ankle swelling and heartburn.  She also gives a history of hemorrhoids and bladder infections in the past.  She has weight bearing joint pain as well as low back degenerating discs.  She denies obstructive sleep apnea, kidney stones, bloody bowel movements, ulcerative colitis, Crohn's disease, dark tarry stools and melena.,PHYSICAL EXAMINATION:  ,On examination temperature is 97.7, pulse 84, blood pressure 126/80, respiratory rate was 20.  Well nourished, well developed in no distress.  Eye exam, pupils equal round and reactive to light.  Extraocular motions intact.  Neuro exam deep tendon reflexes 1+ in the lower extremities.  No focal neuro deficits noted.  Neck exam nonpalpable thyroid, midline trachea, no cervical lymphadenopathy, no carotid bruit.  Lung exam clear breath sounds throughout without rhonchi or wheezes however diminished.  Cardiac exam regular rate and rhythm without murmur or bruit.  Abdominal exam positive bowel sounds, soft, nontender, obese, nondistended abdomen.  No palpable tenderness.  No right upper quadrant tenderness.  No organomegaly appreciated.  No obvious hernias noted.  Lower extremity exam +1 edema noted.  Positive dorsalis pedis pulses.,ASSESSMENT: , The patient is a 56-year-old female who presents to the bariatric surgery service with a body mass index of 41 with obesity related comorbidities.  The patient is interested in gastric bypass surgery.  The patient appears to be an excellent candidate and would benefit greatly in the management of her comorbidities.,PLAN: , In preparation for surgery will obtain the usual baseline laboratory values including baseline vitamin levels.  Will proceed with our usual work up with an upper GI series as well as consultations with the dietician and the psychologist preoperatively.  I have recommended six weeks of Medifast for the patient to obtain a 10% preoperative weight loss.","consult - history and phy., weight watchers, roux en y, atkins, medifast, meridia, south beach, cabbage, diets, laparoscopic roux en y gastric bypass surgery, rice, weight loss, six weeks of medifast, weight loss modalities, body mass index, gastric bypass surgery, bariatric surgery, gastric bypass,"
 Patient scheduled for laparoscopic gastric bypass. , Consult - History and Phy., Gastric Bypass Discussion - 2 ,"HISTORY: , The patient is scheduled for laparoscopic gastric bypass.  The patient has been earlier seen by Dr. X, her physician.  She has been referred to us from Family Practice.  In short, she is a 33-year-old lady with a BMI of 43, otherwise healthy with unsuccessful nonsurgical methods of weight loss. ,She was on laparoscopic gastric bypass for weight loss. ,She meets the National Institute of Health Criteria.  She is very well educated and motivated and has no major medical contraindications for the procedure.,PHYSICAL EXAMINATION:,  On physical examination today, she weighs 216 pounds with a BMI of 43.5, pulse is 96, temperature is 97.6, blood pressure is 122/80.  Lungs are clear.  Abdomen is soft, nontender.  There is stigmata for morbid obesity.  She has cesarean section scars in the lower abdomen with no herniation. ,DISCUSSION: , I had a long talk with the patient about laparoscopic gastric bypass, possible open including risks, benefits, alternatives, need for long-term followup, need to adhere to dietary and exercise guidelines.  I also explained to her complications including rare cases of death secondary to DVT, PE, leak , peritonitis, sepsis, shock, multisystem organ failure, need for re-operation including for leak or bleeding, gastrostomy or jejunostomy for feeding, rare case of respiratory failure requiring mechanical ventilation, etc., with myocardial infarction, pneumonia, atelectasis in the postoperative period were also discussed. ,Short-term complications of gastric bypass including gastrojejunal stricture requiring endoscopic dilatation, marginal ulcer secondary to smoking or anti-inflammatory drug intake which can progress on to perforation or bleeding, small bowel obstruction secondary to internal hernia or adhesions, signs and symptoms of which were discussed.  The patient would alert us for earlier intervention.  Symptomatic gallstone formation secondary to rapid weight loss were also discussed.  How to avoid it by taking ursodiol were also discussed.  Long-term complications of gastric bypass including hair loss, excess skin, multivitamin and mineral deficiencies, protein-calorie malnutrition, weight regain, weight plateauing, need for major lifestyle and exercise and habit changes, avoiding pregnancy in the first two years, etc., were all stressed.  The patient understands.  She wants to go to surgery. ,In preparation of surgery, she will undergo very low-calorie diet through Medifast to decrease the size of the liver to make laparoscopic approach more successful and also to optimize her cardiopulmonary and metabolic comorbidities.  She will also see a psychologist, nutritionist, and exercise physiologist for a multidisciplinary effort for short and long-term success for weight loss surgery.  I will see her two weeks before the plan of surgery for further discussion and any other questions at that point of time.","consult - history and phy., medifast, laparoscopic gastric bypass, short-term complications, long-term complications, gastric bypass, complications of gastric bypass, weight loss, "
 Pediatric Gastroenterology - History of gagging., Consult - History and Phy., Gagging - 3-year-old ,"HISTORY OF PRESENT ILLNESS: , This is a 3-year-old female patient, who was admitted today with a history of gagging.  She was doing well until about 2 days ago, when she developed gagging.  No vomiting.  No fever.  She has history of constipation.  She normally passes stool every two days after giving an enema.  No rectal bleeding.  She was brought to the Hospital with some loose stool.  She was found to be dehydrated.  She was given IV fluid bolus, but then she started bleeding from G-tube site.  There was some fresh blood coming out of the G-tube site.  She was transferred to PICU.  She is hypertensive.  Intensivist Dr. X requested me to come and look at her, and do upper endoscopy to find the site of bleeding.,PAST MEDICAL HISTORY: , PEHO syndrome, infantile spasm, right above knee amputation, developmental delay, G-tube fundoplication.,PAST SURGICAL HISTORY: , G-tube fundoplication on 05/25/2007.  Right above knee amputation.,ALLERGIES:,  None.,DIET: , She is NPO now, but at home she is on PediaSure 4 ounces 3 times a day through G-tube, 12 ounces of water per day.,MEDICATIONS: , Albuterol, Pulmicort, MiraLax 17 g once a week, carnitine, phenobarbital, Depakene and Reglan.,FAMILY HISTORY:,  Positive for cancer.,PAST LABORATORY EVALUATION: , On 12/27/2007; WBC 9.3, hemoglobin 7.6, hematocrit 22.1, platelet 132,000.  KUB showed large stool with dilated small and large bowel loops.  Sodium 140, potassium 4.4, chloride 89, CO2 21, BUN 61, creatinine 2, AST 92 increased, ALT 62 increased, albumin 5.3, total bilirubin 0.1.  Earlier this morning, she had hemoglobin of 14.5, hematocrit 41.3, platelets 491,000.  PT 58 increased, INR 6.6 increased, PTT 75.9 increased.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Temperature 99 degrees Fahrenheit, pulse 142 per minute, respirations 34 per minute, weight 8.6 kg.,GENERAL:  She is intubated.,HEENT:  Atraumatic.  She is intubated.,LUNGS:  Good air entry bilaterally.  No rales or wheezing.,ABDOMEN:  Distended.  Decreased bowel sounds.,GENITALIA:  Grossly normal female.,CNS:  She is sedated.,IMPRESSION: , A 3-year-old female patient with history of passage of blood through G-tube site with coagulopathy.  She has a history of G-tube fundoplication, developmental delay, PEHO syndrome, which is progressive encephalopathy optic atrophy.,PLAN:  ,Plan is to give vitamin K, FFP, blood transfusion.  Consider upper endoscopy.  Procedure and informed consent discussed with the family.","consult - history and phy., g-tube, peho syndrome, tube site, gagging, constipation, endoscopy, peho, hemoglobin, hematocrit, intubated, bleeding, blood, fundoplication, tube, "
" Foreign body of the left fifth fingernail (wooden splinter).  He attempted to remove it with tweezers at home, but was unsuccessful.  He is requesting we attempt to remove this for him.", Consult - History and Phy., Foreign Body - Fingernail ,"HISTORY OF PRESENT ILLNESS:,  Patient is a 72-year-old white male complaining of a wooden splinter lodged beneath his left fifth fingernail, sustained at 4 p.m. yesterday.  He attempted to remove it with tweezers at home, but was unsuccessful.  He is requesting we attempt to remove this for him.,The patient believes it has been over 10 years since his last tetanus shot, but states he has been allergic to previous immunizations primarily with ""horse serum.""  Consequently, he has declined to update his tetanus immunization.,MEDICATIONS: , He is currently on several medications, a list of which is attached to the chart, and was reviewed.  He is not on any blood thinners.,ALLERGIES: , HE IS ALLERGIC ONLY TO TETANUS SERUM.,SOCIAL HISTORY: , Patient is married and is a nonsmoker and lives with his wife.  ,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS:  Temp and vital signs are all within normal limits.,GENERAL:  The patient is a pleasant elderly white male who is sitting on the stretcher in no acute distress.,EXTREMITIES:  Exam of the left fifth finger shows a 5- to 6-mm splinter lodged beneath the medial aspect of the nail plate.  It does not protrude beyond the end of the nail plate.  There is no active bleeding.  There is no edema or erythema of the digit tip.  Flexion and extension of the DIP joint is intact.  The remainder of the hand is unremarkable.,TREATMENT: , I did attempt to grasp the end of the splinter with splinter forceps, but it is brittle and continues to break off.  In order to better grasp the splinter, will require penetration beneath the nail plate, which the patient cannot tolerate due to pain.  Consequently, the base of the digit tip was prepped with Betadine, and just distal to the DIP joint, a digital block was applied with 1% lidocaine with complete analgesia of the digit tip.  I was able to grasp the splinter and remove this.  No further foreign body was seen beneath the nail plate and the area was cleansed and dressed with bacitracin and bandage.,ASSESSMENT: , Foreign body of the left fifth fingernail (wooden splinter).,PLAN: , Patient was urged to clean the area b.i.d. with soap and water and to dress with bacitracin and a Band-Aid.  If he notes increasing redness, pain, or swelling, he was urged to return for re-evaluation.","consult - history and phy., horse serum, wooden splinter, foreign body, nail plate, grasp, fingernail, splinter,"
" Gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7", Consult - History and Phy., Gastric Bypass Discussion - 1 ,"HISTORY OF PRESENT ILLNESS: , In short, the patient is a 55-year-old gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7 with comorbidities of hypertension, atrial fibrillation, hyperlipidemia, possible sleep apnea, and also osteoarthritis of the lower extremities.  He is also an ex-smoker.  He is currently smoking and he is planning to quit and at least he should do this six to eight days before for multiple reasons including decreasing the DVT, PE rates and marginal ulcer problems after surgery, which will be discussed later on. ,PHYSICAL EXAMINATION: , On physical examination today, he weighs 514.8 pounds, he has gained 21 pounds since the last visit with us.  His pulse is 78, temperature is 97.5, blood pressure is 132/74.  Lungs are clear.  He is a pleasant gentleman with stigmata of supermorbid obesity expected of his size.  Abdomen is soft, nontender.  No incisions.  No umbilical hernia, no groin hernia, has a large abdominal pannus.  No hepatosplenomegaly.  Lower extremities; no pedal edema.  No calf tenderness.  Deep tendon reflexes are normal.  Lungs are clear.  S1, S2 is heard.  Regular rate and rhythm. ,DISCUSSION:,  I had a long talk with the patient about laparoscopic gastric bypass possible open including risks, benefits, alternatives, need for long-term followup, need to adhere to dietary and exercise guidelines.  I also explained to him complications including rare cases of death secondary to DVT, PE, leak, peritonitis, sepsis shock, multisystem organ failure, need for reoperations, need for endoscopy for bleeding or leak, operations which could be diagnostic laparoscopy, exploratory laparotomy, drainage procedure, gastrostomy, jejunostomy for feeding, bleeding requiring blood transfusion, myocardial infarction, pneumonia, atelectasis, respiratory failure requiring mechanical ventilation, rarely tracheostomy, rare cases of renal failure requiring dialysis, etc., were all discussed. ,All these are going to be at high risk for this patient secondary to his supermorbid obese condition. ,I also explained to him specific gastric bypass related complications including gastrojejunal stricture requiring endoscopic dilatation, marginal ulcer secondary to smoking or antiinflammatory drug intake, which can progress on to perforation or bleeding, small bowel obstruction secondary to internal hernia or adhesions, signs and symptoms of which are described, so the patient could alert us for earlier intervention, symptomatic gallstone formation during rapid weight loss, how to avoid it by taking ursodiol, which will be prescribed in the postoperative period. ,Long-term complication of gastric bypass including hair loss, excess skin, multivitamin and mineral deficiencies, protein-calorie malnutrition, weight regain, weight plateauing, psychosocial and marital issues, addiction transfer, etc., were all discussed with the patient.  The patient is at higher risk than usual set of patients secondary to his supermorbid obesity of BMI nearing 70 and also major cardiopulmonary and metabolic comorbidities.  Smoking of course does not help and increase the risk for cardiopulmonary complications and is at increased risk for cardiac risk.  He will be seen by cardiologist, pulmonologist.  He will also undergo long Medifast dieting under our guidance, which is a very low-calorie diet to decrease the size of the liver and also to optimize his cardiopulmonary and metabolic comorbidities.  He will also see a psychologist, nutritionist, and exercise physiologist in preparation for surgery for a multidisciplinary approach for short and long-term success. ,Especially for him in view of his restricted mobility, supermorbid obesity status, and possibility of a pulmonary hypertension secondary to sleep apnea, he has been advised to have retrievable IVC filter and also will go home on Lovenox.  He also needs to start exercising to increase his flexibility and muscle tone before surgery and also to start getting the habit of doing so.  All these were discussed with the patient.  The patient understands.  He wants to go to surgery.  All questions were answered.  I will see him in few weeks before the planned date of surgery.","consult - history and phy., medifast, medifast dieting, hypertension, atrial fibrillation, hyperlipidemia, sleep apnea, morbid obesity, metabolic comorbidities, weight loss, supermorbid obesity, gastric bypass, bypass, "
" Abscess of the left foot, etiology unclear at this time.  Possibility of foreign body.", Consult - History and Phy., Foot Infection Management ,"REASON FOR CONSULTATION:  ,Management for infection of the left foot.,HISTORY: , The patient is a 26-year-old short Caucasian male who appears in excellent health, presented a week ago as he felt some pain in the ball of his left foot.  He noticed a small dark spot.  He did not remember having had any injuries to that area specifically no puncture wounds.  He had not been doing any outdoor works or activities.  No history of working outdoors, has not been to the beach or to the lake, has not been out of town.  His swelling progressed so he went to see Dr. X 4 days ago.  The area was debrided in the office and he was placed on Keflex.  It was felt that may be he had a foreign body, but nothing was found in the office and x-ray was negative for opaque foreign bodies.  His foot got worse with more swelling and at this time purulent, too red and was admitted to the hospital today, is scheduled for surgical exploration this evening.  Ancef and Cipro were prescribed today.  He denies any fever, chills, red streaks, lymphadenitis.  He had a tetanus shot in 2002 most recently.  He had childhood asthma.  He uses alcohol socially.  He works full time.  He is an electrician.,ALLERGIES:,  ACCUTANE.,PHYSICAL EXAMINATION,GENERAL:  Well-developed, well-nourished adult Caucasian male in no acute distress.,VITAL SIGNS:  His weight is 190 pounds, height 69 inches, temperature 98, respirations 20, pulse 78, and blood pressure 143/63, O2 sat 98% on room air.,HEENT:  Mouth unremarkable.,NECK:  Supple.,LUNGS:  Clear.,HEART:  Regular rate rhythm.  No murmur or gallop.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  Left foot on the plantar side by the head of the first metatarsal has an open wound of about 10 mm in diameter with thick reddish purulent discharge and surrounding edema.  There is bloodied blister around it.  The area is tender to touch, warm with a slight edema of the rest of the foot with very faint erythema.  There is some mild intertrigo between the fourth and fifth left toes.  Palpable pedal pulses.  Leg unremarkable.  No femoral or inguinal lymphadenopathy.,LABORATORY: , Labs show white cell count of 6300, hemoglobin 13.6, platelet count of _____ with 80 monos, 17 eos _____, creatinine 1.3, BUN of 16, glucose 110.  Calcium, ferritin, albumin, bilirubin, ALT, AST, alkaline phosphatase are normal.  PT and PTT normal and the sed rate was 35 mm per hour.,IMPRESSION:  ,Abscess of the left foot, etiology unclear at this time.  Possibility of foreign body.,RECOMMENDATIONS/PLAN: , He is going to be discharged in about half-an-hour.  Cultures, Gram stain, fungal cultures, and smear to be obtained.  I have changed his antibiotic to vancomycin plus Maxipime.  He is currently on tetanus immunizations so no need for booster at this time.,","consult - history and phy., accutane, possibility of foreign body, foot etiology, foreign body, infection, foot, abscess,"
 Foul-smelling urine and stomach pain after meals., Consult - History and Phy., Foul-Smelling Urine ,"CHIEF COMPLAINT:,  Foul-smelling urine and stomach pain after meals.,HISTORY OF PRESENT ILLNESS:,  Stomach pain with most meals x one and a half years and urinary symptoms for same amount of time.  She was prescribed Reglan, Prilosec, Pepcid, and Carafate at ED for her GI symptoms and Bactrim for UTI.  This visit was in July 2010.,REVIEW OF SYSTEMS:,  HEENT:  No headaches.  No visual disturbances, no eye irritation.  No nose drainage or allergic symptoms.  No sore throat or masses.  Respiratory:  No shortness of breath.  No cough or wheeze.  No pain.  Cardiac:  No palpitations or pain.  Gastrointestinal:  Pain and cramping.  Denies nausea, vomiting, or diarrhea.  Has some regurgitation with gas after meals.  Genitourinary:  ""Smelly"" urine.  Musculoskeletal:  No swelling, pain, or numbness.,MEDICATION ALLERGIES:,  No known drug allergies.,PHYSICAL EXAMINATION:,General:  Unremarkable.,HEENT:  PERRLA.  Gaze conjugate.,Neck:  No nodes.  No thyromegaly.  No masses.,Lungs:  Clear.,Heart:  Regular rate without murmur.,Abdomen:  Soft, without organomegaly, without guarding or tenderness.,Back:  Straight.  No paraspinal spasm.,Extremities:  Full range of motion.  No edema.,Neurologic:  Cranial nerves II-XII intact.  Deep tendon reflexes 2+ bilaterally.,Skin:  Unremarkable.,LABORATORY STUDIES:,  Urinalysis was done, which showed blood due to her period and moderate leukocytes.,ASSESSMENT:,1.  UTI.,2.  GERD.,3.  Dysphagia.,4.  Contraception consult.,PLAN:,1.  Cipro 500 mg b.i.d. x five days.  Ordered BMP, CBC, and urinalysis with microscopy.,2.  Omeprazole 20 mg daily and famotidine 20 mg b.i.d.,3.  Prescriptions same as #2.  Also referred her for a barium swallow series to rule out a stricture.,4.  Ortho Tri-Cyclen Lo.,",
 Consultation for left foot pain., Consult - History and Phy., Foot pain Consultation ,"CHIEF COMPLAINT:, Left foot pain.,HISTORY:, XYZ is a basketball player for University of Houston who sustained an injury the day prior. They were traveling. He came down on another player's foot sustaining what he describes as an inversion injury. Swelling and pain onset immediately. He was taped but was able to continue playing He was examined by John Houston, the trainer, and had tenderness around the navicular so was asked to come over and see me for evaluation. He has been in a walking boot. He has been taped firmly. Pain with weightbearing activities. He is limping a bit. No significant foot injuries in the past. Most of his pain is located around the dorsal aspect of the hindfoot and midfoot. ,PHYSICAL EXAM:, He does have some swelling from the hindfoot out toward the midfoot. His arch is maintained. His motion at the ankle and subtalar joints is preserved. Forefoot motion is intact. He has pain with adduction and abduction across the hindfoot. Most of this discomfort is laterally. His motor strength is grossly intact. His sensation is intact, and his pulses are palpable and strong. His ankle is not tender. He has minimal to no tenderness over the ATFL. He has no medial tenderness along the deltoid or the medial malleolus. His anterior drawer is solid. His external rotation stress is not painful at the ankle. His tarsometatarsal joints, specifically 1, 2 and 3, are nontender. His maximal tenderness is located laterally along the calcaneocuboid joint and along the anterior process of the calcaneus. Some tenderness over the dorsolateral side of the talonavicular joint as well. The medial talonavicular joint is not tender.,RADIOGRAPHS:, Those done of his foot weightbearing show some changes over the dorsal aspect of the navicular that appear chronic. I don't see a definite fracture. The tarsometarsal joints are anatomically aligned. Radiographs of his ankle again show changes along the dorsal talonavicular joint but no other fractures identified. Review of an MR scan of the ankle dated 12/01/05 shows what looks like some changes along the lateral side of the calcaneocuboid joint with disruption of the lateral ligament and capsular area. Also some changes along the dorsal talonavicular joint. I don't see any significant marrow edema or definitive fracture line. ,IMPRESSION:,  Left Chopart joint sprain.,PLAN:,  I have spoken to XYZ about this. Continue with ice and boot for weightbearing activities. We will start him on a functional rehab program and progress him back to activities when his symptoms allow. He is clear on the prolonged duration of recovery for these hindfoot type injuries.","consult - history and phy., foot pain, calcaneocuboid joint, dorsal aspect, dorsal talonavicular joint, foot injuries, hindfoot, midfoot, rehab program, walking boot, weightbearing, talonavicular joint, dorsal, talonavicular, ankle, foot, tenderness"
 Complete eye examination - Normal eye and vision exam., Consult - History and Phy., Eye Examination - H&P ,"CHIEF COMPLAINT:,  This 26-year-old male presents today for a complete eye examination.,ALLERGIES:,  Patient admits allergies to aspirin resulting in disorientation, GI upset.,MEDICATION HISTORY:,  Patient is currently taking amoxicillin-clavulanate 125 mg-31.25 mg tablet, chewable medication was prescribed by A. General Practitioner MD, Adrenocot 0.5 mg tablet medication was prescribed by A. General Practitioner MD, Vioxx 12.5 mg tablet (BID).,PMH: , Past medical history is unremarkable.,PAST SURGICAL HISTORY:,  Patient admits past surgical history of (+) appendectomy in 1989.,SOCIAL HISTORY:,  Patient denies alcohol use.  Patient denies illegal drug use.  Patient denies STD history.  Patient denies tobacco use.,FAMILY HISTORY:,  Unremarkable.,REVIEW OF SYSTEMS:,Eyes: (-) dry eyes (-) eye or vision problems (-) blurred vision.,Constitutional Symptoms: (-) constitutional symptoms such as fever, headache, nausea, dizziness.,Musculoskeletal: (-) joint or musculoskeletal symptoms.,EYE EXAM:,  Patient is a pleasant, 26-year-old male in no apparent distress who looks his given age, is well developed and nourished with good attention to hygiene and body habitus.,Pupils:  Pupil exam reveals round and equally reactive to light and accommodation.,Motility:  Ocular motility exam reveals gross orthotropia with full ductions and versions bilateral.,Visual Fields:  Confrontation VF exam reveals full to finger confrontation O.U.,IOP:  IOP Method:  applanation tonometry OD:  10 mmHg Medications:  Alphagan; 0.2% Condition:  improving.,Keratometry:,OD:  K1 35.875K2 35.875,OS:  K1 35.875K2 41.875,Lids/Orbit:  Bilateral eyes reveal normal position without infection.  Bilateral eyelids reveals white and quiet.,Slit Lamp:  Corneal epithelium is intact with normal tear film and without stain.  Stroma is clear and avascular.  Corneal endothelium is smooth and of normal appearance.,Anterior Segment:  Bilateral anterior chambers reveal no cells or flare with deep chamber.,Lens:  Bilateral lenses reveals transparent lens that is in normal position.,Posterior Segment:  Posterior segment was dilated bilateral.  Bilateral retinas reveal normal color, contour, and cupping.,Retina:  Bilateral retinas reveals flat with normal vasculature out to the far periphery.  Bilateral retinas reveal normal reflex and color.,VISUAL ACUITY:,Visual acuity - uncorrected:  OD:  20/10 OS:  20/10 OU:  20/15.,REFRACTION:,Lenses - final:,OD:  +0.50 +1.50 X 125 Prism 1.75,OS:  +6.00 +3.50 X 125 Prism 4.00 BASE IN Fresnel,Add:  OD:  +1.00 OS:  +1.00,OU:  Far VA 20/25,TEST RESULTS:,  No tests to report at this time.,IMPRESSION:,  Eye and vision exam normal.,PLAN:,  Return to clinic in 12 month (s).,PATIENT INSTRUCTIONS:",
" Questionable foreign body, right nose.  Belly and back pain.   Mild constipation.", Consult - History and Phy., Foreign Body - Right Nose ,"CHIEF COMPLAINT:,  Questionable foreign body, right nose.  Belly and back pain.  ,SUBJECTIVE: , Mr. ABC is a 2-year-old boy, who is brought in by parents, stating that the child keeps complaining of belly and back pain.  This does not seem to be slowing him down.  They have not noticed any change in his urine or bowels.  They have not noted him to have any fevers or chills or any other illness.  They state he is otherwise acting normally.  He is eating and drinking well.  He has not had any other acute complaints, although they have noted a foul odor coming from his nose.  Apparently, he was seen here a few weeks ago for a foreign body in the right nose, which was apparently a piece of cotton; this was removed and placed on antibiotics.  His nose got better and then started to become malodorous again.  Mother restarted him on the remainder of the antibiotics and they are also stating that they think there is something still in there.  Otherwise, he has not had any runny nose, earache, no sore throat.  He has not had any cough, congestion.  He has been acting normally.  Eating and drinking okay.  No other significant complaints.  He has not had any pain with bowel movement or urination, nor have they noted him to be more frequently urinating, then again he is still on a diaper.,PAST MEDICAL HISTORY: , Otherwise negative.,ALLERGIES: , No allergies.,MEDICATIONS: , No medications other than recent amoxicillin.,SOCIAL HISTORY: , Parents do smoke around the house.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Stable.  He is afebrile.,GENERAL:  This is a well-nourished, well-developed 2-year-old little boy, who is appearing very healthy, normal for his stated age, pleasant, cooperative, in no acute distress, looks very healthy, afebrile and nontoxic in appearance.,HEENT:  TMs, canals are normal.  Left naris normal.  Right naris, there is some foul odor as well as questionable purulent drainage.  Examination of the nose, there was a foreign body noted, which was the appearance of a cotton ball in the right nose, that was obviously infected and malodorous.  This was removed and reexamination of the nose was done and there was absolutely no foreign body left behind or residual.  There was some erythema.  No other purulent drainage noted.  There was some bloody drainage.  This was suctioned and all mucous membranes were visualized and are negative.,NECK:  Without lymphadenopathy.  No other findings.,HEART:  Regular rate and rhythm.,LUNGS:  Clear to auscultation.,ABDOMEN:  His abdomen is entirely benign, soft, nontender, nondistended.  Bowel sounds active.  No organomegaly or mass noted.,BACK:  Without any findings.  Diaper area normal.,GU:  No rash or infections.  Skin is intact.,ED COURSE: , He also had a P-Bag placed, but did not have any urine.  Therefore, a straight catheter was done, which was done with ease without complication and there was no leukocytes noted within the urine.  There was a little bit of blood from catheterization but otherwise normal urine.  X-ray noted some stool within the vault.  Child is acting normally.  He is jumping up and down on the bed without any significant findings.,ASSESSMENT:,1.  Infected foreign body, right naris.,2.  Mild constipation.,PLAN:,  As far as the abdominal pain is concerned, they are to observe for any changes.  Return if worse, follow up with the primary care physician.  The right nose, I will place the child on amoxicillin 125 per 5 mL, 1 teaspoon t.i.d.  Return as needed and observe for more foreign bodies.  I suspect, the child had placed this cotton ball in his nose again after the first episode.", 
" Left flank pain, ureteral stone.", Consult - History and Phy., Flank Pain - Consult - 1 ,"REASON FOR CONSULTATION: , Left flank pain, ureteral stone.,BRIEF HISTORY: , The patient is a 76-year-old female who was referred to us from Dr. X for left flank pain.  The patient was found to have a left ureteral stone measuring about 1.3 cm in size per the patient's history.  The patient has had pain in the abdomen and across the back for the last four to five days.  The patient has some nausea and vomiting.  The patient wants something done for the stone.  The patient denies any hematuria, dysuria, burning or pain.  The patient denies any fevers.,PAST MEDICAL HISTORY: , Negative.,PAST SURGICAL HISTORY:  ,Years ago she had surgery that she does not recall.,MEDICATIONS: , None.,ALLERGIES: , None.,REVIEW OF SYSTEMS: , Denies any seizure disorder, chest pain, denies any shortness of breath, denies any dysuria, burning or pain, denies any nausea or vomiting at this time.  The patient does have a history of nausea and vomiting, but is doing better.,PHYSICAL EXAMINATION:,VITAL SIGNS:  The patient is afebrile.  Vitals are stable.,HEART:  Regular rate and rhythm.,ABDOMEN:  Soft, left-sided flank pain and left lower abdominal pain.,The rest of the exam is benign.,LABORATORY DATA: , White count of 7.8, hemoglobin 13.8, and platelets 234,000.  The patient's creatinine is 0.92.,ASSESSMENT:,1.  Left flank pain.,2.  Left ureteral stone.,3.  Nausea and vomiting.,PLAN: , Plan for laser lithotripsy tomorrow.  Options such as watchful waiting, laser lithotripsy, and shockwave lithotripsy were discussed.  The patient has a pretty enlarged stone.  Failure of the procedure if the stone is significantly impacted into the ureteral wall was discussed.  The patient understood that the success of the surgery may be or may not be 100%, that she may require shockwave lithotripsy if we are unable to get the entire stone out in one sitting.  The patient understood all the risk, benefits of the procedure and wanted to proceed.  Need for stent was also discussed with the patient.  The patient will be scheduled for surgery tomorrow.  Plan for continuation of the antibiotics, obtain urinalysis and culture, and plan for KUB to evaluate for the exact location of the stone prior to surgery tomorrow.","consult - history and phy., flank pain, ureteral stone, shockwave lithotripsy, shockwave, nausea, vomiting, lithotripsy, ureteral, stone, "
 Patient returns for his first followup after shunt surgery., Consult - History and Phy., First Followup - Shunt Surgery ,"REASON FOR VISIT:,  Mr. A is an 86-year-old man who returns for his first followup after shunt surgery.,HISTORY OF PRESENT ILLNESS:  ,I have followed Mr. A since May 2008.  He presented with eight to ten years of progressive gait impairment, cognitive impairment, and decreased bladder control.  We established a diagnosis of adult hydrocephalus with the spinal catheter protocol in June of 2008 and ,Mr. A underwent shunt surgery performed by Dr. X on August 1st.  A Medtronic Strata programmable shunt in the ventriculoperitoneal configuration programmed at level 2.0 was placed.,Mr. A comes today with his daughter, Pam and together they give his history.,Mr. A has had no hospitalizations or other illnesses since I last saw him.  With respect to his walking, his daughter tells me that he is now able to walk to the dining room just fine, but could not before his surgery.  His balance has improved though he still has some walking impairment.  With respect to his bladder, initially there was some improvement, but he has leveled off and he wears a diaper.,With respect to his cognition, both Pam and the patient say that his thinking has improved.  The other daughter, Patty summarized it best according to two of them.  She said, ""I feel like I can have a normal conversation with him again.""  Mr. A has had no headaches and no pain at the shunt site or at the abdomen.,MEDICATIONS: , Plavix 75 mg p.o. q.d., metoprolol 25 mg p.o. q.d., Flomax 0.4 mg p.o. q.d., Zocor 20 mg p.o. q.d., Detrol LA 4 mg p.o. q.d., lisinopril 10 mg p.o. q.d., Imodium daily, Omega-3, fish oil, and Lasix.,MAJOR FINDINGS:,  Mr. A is a pleasant and cooperative man who is able to converse easily though his daughter adds some details.,Vital Signs:  Blood pressure 124/80, heart rate is 64, respiratory rate is 18, weight 174 pounds, and pain is 0/10.,The shunt site was clean, dry, and intact and confirmed at a setting of 2.0.,Mental Status:  Tested for recent and remote memory, attention span, concentration, and fund of knowledge.  He scored 26/30 on the MMSE when tested with spelling and 25/30 when tested with calculations.  Of note, he was able to get two of the three memory words with cuing and the third one with multiple choice.  This was a slight improvement over his initial score of 23/30 with calculations and 24/30 with spelling and at that time he was unable to remember any memory words with cuing and only one with multiple choice.,Gait:  Tested using the Tinetti assessment tool.  He was tested without an assistive device and received a gait score of 6-8/12 and a balance of score of 12/16 for a total score of 18-20/28.  This has slightly improved from his initial score of 15-17/28.,Cranial Nerves:  Pupils are equal.  Extraocular movements are intact.  Face symmetric.  No dysarthria.,Motor:  Normal for bulk and strength.,Coordination:  Slow for finger-to-nose.,IMAGING: , CT scan was reviewed from 10/15/2008.  It shows a frontal horn span at the level of foramen of Munro of 4.6 cm with a 3rd ventricular contour that is flat with the span of 10 mm.  By my reading, there is a tiny amount of blood in the right frontal region with just a tiny subdural collection.  This was not noticed by the radiologist who stated no extraaxial fluid collections.  There is also substantial small vessel ischemic change.,ASSESSMENT: , Mr. A has made some improvement since shunt surgery.,PROBLEMS/DIAGNOSES:,1.  Adult hydrocephalus (331.5).,2.  Gait impairment (781.2).,3.  Urinary incontinence and urgency (788.33).,4.  Cognitive impairment (290.0).,PLAN:,  I had a long discussion with Mr. A and his daughter.  We are all pleased that he has started to make some improvement with his hydrocephalus because I believe I see a tiny fluid collection in the right parietal region, I would like to leave the setting at 2.0 for another three months before we consider changing the shunt.  I do not believe that this tiny amount of fluid is symptotic and it was not documented by the radiologist when he read the CT scan.,Mr. A asked me about whether he will be able to drive again.  Unfortunately, I think it is unlikely that his speed of movement will improve to a level that he will be able to pass a driver's safety evaluation, however, occasionally patients surprise me by improving enough over 9 to 12 months that they are able to pass such a test.  I would certainly be happy to recommend such a test if I believe ,Mr. A is likely to pass it and he is always welcome to enroll in a driver's safety program without my recommendation, however, I think it is exceeding unlikely that he has the capability of passing this rigorous test at this time.  I also think it is quite likely he will not regain sufficient speed of motion to pass such a test.",
" First Pap smear, complaining of irregular periods.  - Menorrhagia, pelvic pain, dysmenorrhea, and irregular periods.", Consult - History and Phy., First Pap smear. ,"CHIEF COMPLAINT:,  The patient comes for her first Pap smear, complaining of irregular periods.,HISTORY OF PRESENT ILLNESS:,  The patient wishes to discuss considering something to help with her menstrual cramping and irregular periods.  She notes that her periods are out of weck.  She says that she has cramping and pain before her period starts.  Sometimes, she is off her period for two weeks and then she bleeds for two whole weeks.  She usually has her periods lasting seven days, usually comes on the 19th of each month and now it seems to have changed.  The cramping is worse.  She said her flow has increased.  She has to change her pad every half to one hour and uses a super tampon sometimes.  She usually has four days of hard flow and then she might have 10 days where she will have to wear a mini pad.  She also notes that her headaches have been worsening a little bit.  She has had quite a bit of stress.  She had a headache on Wednesday again after having had one on the weekend.  She said she usually only has an occasional headache and that is not too bad but now she has developed what she would consider to be a migraine and she has not had serious headaches like this and it seems to be worsening and coming a little bit more regularly, and she has not figure out what to do to get rid of them.  She avoids caffeine.  She only eats chocolate when she is near her period and she usually drinks one can of cola a day.,MEDICATIONS: , None.,ALLERGIES:,  None.,SOCIAL HISTORY:,  She is a nonsmoker.  She is not sexually active.,PAST MEDICAL HISTORY:,  She has had no surgery or chronic illnesses.,FAMILY HISTORY:,  Mother has hypertension, depression.  Father has had renal cysts and sometimes some stomach problems.  Both of her parents have problems with their knees.,REVIEW OF SYSTEMS:,  Patient denies headache or trauma.  No blurred or double vision.  Hearing is fine, no tinnitus or infection.  Infrequent sore throat, no hoarseness or cough.,HEENT:  See HPI.,Neck:  No stiffness, pain or swelling.,Respiratory:  No shortness of breath, cough or hemoptysis.  She is a nonsmoker.,Cardiovascular:  No chest pain, ankle edema, palpitations or hypertension.,GI:  No nausea, vomiting, diarrhea, constipation, melena or jaundice.,GU:  No dysuria, frequency, urgency or stress incontinence.,Locomotor:  No weakness, joint pain, tremor or swelling.,GYN:  See HPI.,Integumentary:  Patient performs self-breast examinations and denies any breast masses or nipple discharge.  No recent skin or hair changes.,Neuropsychiatric:  Denies depression, anxiety, tearfulness or suicidal thought.,PHYSICAL EXAMINATION:,VITALS:  Height 64.5 inches.  Weight:  162 pounds.  Blood pressure 104/72.  Pulse:  72.  Respirations:  16.  LMP:  08/21/04.  Age:  19.,HEENT:  Head is normocephalic.  Eyes:  EOMs intact.  PERRLA.  Conjunctiva clear.  Fundi:  Discs flat, cups normal.  No AV nicking, hemorrhage or exudate.  Ears:  TMs intact.  Mouth:  No lesion.  Throat:  No inflammation.,Neck:  Full range of motion.  No lymphadenopathy or thyromegaly.,Chest:  Clear to auscultation and percussion.,Heart:  Normal sinus rhythm, no murmur.,Integumentary:  Breasts are without masses, tenderness, nipple retraction or discharge.  Reviewed self-breast examination.  No axillary nodes are palpable.,Abdomen:  Soft.  Liver, spleen, and kidneys are not palpable.  No masses felt, nontender.  Femoral pulses strong and equal.,Back:  No CVA or spinal tenderness.  No deformity noted.,Pelvic:  BUS negative.  Vaginal mucosa pink, scanty discharge.  Cervix without lesion.  Pap was taken.  Uterus normal size.  Adnexa:  No masses.  She does have some pain on palpation of the uterus.,Rectal:  Good sphincter tone.  No masses.  Stool is guaiac negative.,Extremities:  No edema.  Pulses strong and equal.  Reflexes are intact.,Rectal:  No mass.,ASSESSMENT:,  Menorrhagia, pelvic pain, dysmenorrhea, and irregular periods.,PLAN:,  We will evaluate with a CBC, urinalysis and culture, and TSH.  The patient has what she describes as migraine headaches of a new onset.  Because of the pelvic pain, dysmenorrhea, and menorrhagia, we will also evaluate with a pelvic sonogram.  We will evaluate with a CT scan of the brain with and without contrast.  We will try Anaprox DS one every 12 hours for the headache.  At this point, she could also use that for menstrual cramping.  Prescription written for 20 tablets.  If her lab findings, sonographic findings, and CT of the brain are normal, we would consider trying birth control pills to regulate her periods and reduce the cramping and excessive flow.  The lab x-ray and urinalysis results will be reported to her as soon as they are available.",
 Patient presents for further evaluation of feet and hand cramps. He describes that the foot cramps are much more notable than the hand ones.  He reports that he develops muscle contractions of his toes on both feet.  These occur exclusively at night., Consult - History and Phy., Feet & Hand Cramping ,"HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old right-handed gentleman who presents for further evaluation of feet and hand cramps.  He states that for the past six months he has experienced cramps in his feet and hands.  He describes that the foot cramps are much more notable than the hand ones.  He reports that he develops muscle contractions of his toes on both feet.  These occur exclusively at night.  They may occur about three times per week.  When he develops these cramps, he stands up to relieve the discomfort.  He notices that the toes are in an extended position.  He steps on the ground and they seem to ""pop into place.""  He develops calf pain after he experiences the cramp.  Sometimes they awaken him from his sleep.,He also has developed cramps in his hands although they are less severe and less frequent than those in his legs.  These do not occur at night and are completely random.  He notices that his thumb assumes a flexed position and sometimes he needs to pry it open to relieve the cramp.,He has never had any symptoms like this in the past.  He started taking Bactrim about nine months ago.  He had taken this in the past briefly, but has never taken it as long as he has now.  He cannot think of any other possible contributing factors to his symptoms.,He has a history of HIV for 21 years.  He was taking antiretroviral medications, but stopped about six or seven years ago.  He reports that he was unable to tolerate the medications due to severe stomach upset.  He has a CD4 count of 326.  He states that he has never developed AIDS.  He is considering resuming antiretroviral treatment.,PAST MEDICAL HISTORY:,  He has diabetes, but this is well controlled.  He also has hepatitis C and HIV.,CURRENT MEDICATIONS: , He takes insulin and Bactrim.,ALLERGIES: , He has no known drug allergies.,SOCIAL HISTORY: , He lives alone.  He recently lost his partner.  This happened about six months ago.  He denies alcohol, tobacco, or illicit drug use.  He is now retired.  He is very active and walks about four miles every few days.,FAMILY HISTORY: , His father and mother had diabetes.,REVIEW OF SYSTEMS: , A complete review of systems was obtained and was negative except for as mentioned above.  This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:,Vital Signs:  Blood pressure 130/70",
 The patient presents for a followup for history of erythema nodosum., Consult - History and Phy., Erythema Nodosum - Consult ,"REASON FOR VISIT:,  The patient presents for a followup for history of erythema nodosum.,HISTORY OF PRESENT ILLNESS: , This is a 25-year-old woman who is attending psychology classes.  She was diagnosed with presumptive erythema nodosum in 2004 based on a biopsy consistent with erythema nodosum, but not entirely specific back in Netherlands.  At that point, she had undergone workup which was extensive for secondary diseases associated with erythema nodosum.  Part of her workup included a colonoscopy.  The findings were equivocal characterizes not clearly abnormal biopsies of the terminal ileum.,The skin biopsy, in particular, mentions some fibrosis, basal proliferation, and inflammatory cells in the subcutis.,Prior to the onset of her erythema nodosum, she had a tibia-fibula fracture several years before on the right, which was not temporarily associated with the skin lesions, which are present in both legs anyway.  Even, a jaw cosmetic surgery she underwent was long before she started developing her skin lesions.  She was seen in our clinic and by Dermatology on several occasions.  Apart from the first couple of visits when she presented stating a recurrent skin rash with a description suggestive of erythema nodosum in the lower extremities and ankle and there is discomfort pointing towards a possible inflammatory arthritis and an initial high sed rate of above 110 with an increased CRP.  In the following visits, no evident abnormality has been detected.  In the first visit, here some MTP discomfort detected.  It was thought that erythema nodosum may be present.  However, the evaluation of Dermatology did not concur and it was thought that the patient had venous stasis, which could be related to her prior fracture.  When she was initially seen here, a suspicion of IBD, sarcoid inflammatory arthropathy, and lupus was raised.  She had an equivocal rheumatoid fracture, but her CCP was negative.  She had an ANA, which was positive at 1:40 with a speckled pattern persistently, but the rest of the lupus serologies including double-stranded DNA, RNP, Smith, Ro, La were negative.  Her cardiolipin panel antibodies were negative as well.  We followed the IgM, IgG, and IgA being less than 10.  However, she did have a beta-2 glycoprotein 1 or an RVVT tested and this may be important since she has a livedo pattern.  It was thought that the onset of lupus may be the case.  It was thought that rheumatoid arthritis could not be the case since it is not associated with erythema nodosum.  For the fear of possible lymphoma, she underwent CT of the chest, abdomen, and pelvis.  It was done also in order to rule out sarcoid and the result was unremarkable.  Based on some changes in her bowel habits and evidence of B12 deficiency with a high methylmalonic and high homocystine levels along with a low normal B12 in addition to iron studies consistent with iron deficiency and an initially low MCV, the possibility of inflammatory bowel disease was employed.  The patient underwent an initially unrevealing colonoscopy and a capsule endoscopy, which was normal.  A second colonoscopy was done recently and microscopically no evidence of inflammatory bowel disease was seen.  However, eosinophil aggregations were noted in microscopy and this was told to be consistent with an allergic reaction or an emerging Crohn disease and I will need to discuss with Gastroenterology what is the significance of that.  Her possible B12 deficiency and iron deficiency were never addressed during her stay here in the United States.,In the initial appointment, she was placed on prednisone 40 mg, which was gradually titrated down this led to an exacerbation of her acne.  We decided to take her off prednisone due to adverse effects and start her on colchicine 0.6 mg daily.  While this kept things under control with the inflammatory markers being positive and no overt episodes of erythema nodosum, the patient still complains for sensitivity with less suspicious skin rash in the lower extremities and occasional ankle swelling and pain.  She was reevaluated by Dermatology for that and no evidence of erythema nodosum was felt to be present.  Out plan was to proceed with a DEXA scan, at some point check a vitamin D level, and order vitamin D and calcium over the counter for bone protection purposes.  However, the later was deferred until we have resolved the situation and find out what is the underlying cause of her disease.,Her past medical history apart from the tibia-fibular fracture and the jaw cosmetic surgery is significant for varicella and mononucleosis.,Her physical examination had shown consistently diffuse periarticular ankle edema and also venous stasis changes at least until I took over her care last August.  I have not been able to detect any erythema nodosum, however, a livedo pattern has been detected consistently.  She also has evidence of acne, which does not seem to be present at the moment.  She also was found to have a heart murmur present and we are going to proceed with an echocardiogram placed.,Her workup during the initial appointment included an ACE level, which was normal.  She also had a rather higher sed rate up to 30, but prior to that, per report, it was even higher, above 110.  Her RVVT was normal, her rheumatoid factor was negative.  Her ANA was 1:40, speckled pattern.  The double-stranded DNA was negative.  Her RNP and Smith were negative as well.  RO and LA were negative and cardiolipin antibodies were negative as well.  A urinalysis at the moment was completely normal.  A CRP was 2.3 in the initial appointment, which was high.  A CCP was negative.  Her CBC had shown microcytosis and hypochromia with a hematocrit of 37.7.  This improved later without any evidence of hypochromia, microcytosis or anemia with a hematocrit of 40.3.,The patient returns here today, as I mentioned, complaining of milder bouts of skin rash, which she calls erythema nodosum, which is accompanied by arthralgias, especially in the ankles.  I am mentioning here that photosensitivity rash was mentioned in the past.  She tells me that she had it twice back in Europe after skiing where her whole face was swollen.  Her acne has been very stable after she was taken off prednisone and was started on colchicine 0.6 daily.  Today we discussed about the effect of colchicine on a possible pregnancy.,MEDICATIONS: , Prednisone was stopped.  Vitamin D and calcium over the counter, we need to verify that.  Colchicine 0.6 mg daily which we are going to stop, ranitidine 150 mg as needed, which she does not take frequently.,FINDINGS:,  On physical examination, she is very pleasant, alert, and oriented x 3 and not in any acute distress.  There is some evidence of faint subcutaneous lesions in both shins bilaterally, but with mild tenderness, but no evidence of classic erythema nodosum.  Stasis dermatitis changes in both lower extremities present.  Mild livedo reticularis is present as well.,There is some periarticular ankle edema as well.  Laboratory data from 04/23/07, show a normal complete metabolic profile with a creatinine of 0.7, a CBC with a white count of 7880, hematocrit of 40.3, and platelets of 228.  Her microcytosis and hypochromia has resolved.  Her serum electrophoresis does not show a monoclonal abnormality.  Her vitamin D levels were 26, which suggests some mild insufficiency and she would probably benefit by vitamin D supplementation.  This points again towards some ileum pathology.  Her ANCA B and C were negative.  Her PF3 and MPO were unremarkable.  Her endomysial antibodies were negative.  Her sed rate at this time were 19.  The highest has been 30, but prior to her appointment here was even higher.  Her ANA continues to be positive with a titer of 1:40, speckled pattern.  Her double-stranded DNA is negative.  Her serum immunofixation confirmed the absence of monoclonal abnormality.  Her urine immunofixation was not performed.  Her IgG, IgA, and IgM levels are normal.  Her IgE levels are normal as well.  A urinalysis was not performed this time.  Her CRP is 0.4.  Her tissue transglutaminase antibodies are negative.  Her ASCA is normal and anti-OmpC was not tested.  Gliadin antibodies IgA is 12, which is in the borderline to be considered equivocal, but these are nonspecific.  I am reminding here that her homocystine levels have been 15.7, slightly higher, and that her methylmalonic acid was 385, which is obviously abnormal.  Her B12 levels were 216, which is rather low possibly indicating a B12 deficiency.  Her iron studies showed a ferritin of 15, a saturation of 9%, and an iron of 30.  Her TIBC was 345 pointing towards an iron deficiency anemia.  I am reminding you that her ACE levels in the past were normal and that she has a microcytosis.  Her radiologic workup including a thoracic, abdominal, and pelvic CT did not show any suspicious adenopathy, but only small aortocaval and periaortic nodes, the largest being 8 mm in short axis, likely reactive.  Her pelvic ultrasound showed normal uterus adnexa.  Her bladder was normal as well.  Subcentimeter inguinal nodes were found.  There was no large lytic or sclerotic lesion noted.  Her recent endoscopy was unremarkable, but the microscopy showed some eosinophil aggregation, which may be pointing towards allergy or an evolving Crohn disease.  Her capsule endoscopy was limited secondary to rapid transit.  There was only a tiny mucosal red spot in the proximal jejunum without active bleeding, 2 possible erosions were seen in the distal jejunum and proximal ileum.  However, no significant inflammation or bleeding was seen and this could be small bowel crisis.  Neither evidence of bleeding or inflammation were seen as well.  Specifically, the terminal ileum appeared normal.  Recent evaluation by a dermatologist did not verify the presence of erythema nodosum.,ASSESSMENT:,  This is a 25-year-old woman diagnosed with presumptive erythema nodosum in 2004.  She has been treated with prednisone as in the beginning she had also a wrist and ankle discomfort and high inflammatory markers.  Since I took over her care, I have not seen a clear-cut erythema nodosum being present.  No evidence of synovitis was there.  Her serologies apart from an ANA of 1:40 were negative.  She has a livedo pattern, which has been worrisome.  The issue here was a possibility of inflammatory bowel disease based on deficiency in vitamin B12 as indicated by high methylmalonic and homocystine levels and also iron deficiency.  She also has low vitamin D levels, which point towards terminal ileum pathology as well and she had a history of decreased MCV.  We never received the x-ray of her hands which she had and she never had a DEXA scan.  Lymphoma has been ruled out and we believe that inflammatory bowel disease, after repeated colonoscopies and the capsule endoscopy, has been ruled out as well.  Sarcoid is probably not the case since the patient did not have any lymphadenopathies and her ACE levels were normal.  We are going check a PPD to rule out tuberculosis.  We are going to order an RVVT and glycoprotein beta-1 levels in her workup to make sure that an antiphospholipid syndrome is not present given the livedo pattern.  An anti-intrinsic factor will be added as well.  Her primary care physician needs to workup the possible B12 and iron deficiency and also the vitamin D deficiency.  In the meanwhile, we feel that the patient should stop taking the colchicine and if she has a flare of her disease then she should present to her dermatologist and have the skin biopsy performed in order to have a clear-cut answer of what is the nature of this skin rash.  Regarding her heart murmur, we are going to proceed with an echocardiogram.  A PPD should be placed as well.  In her next appointment, we may fax a requisition for vitamin B replacement.,PROBLEMS/DIAGNOSES:,  1.  Recurrent erythema nodosum with ankle and wrist discomfort, ? arthritis.,2.  Iron deficiencies, according to iron studies.,3.  Borderline B12 with increased methylmalonic acid and homocystine.,4.  On chronic steroids; vitamin D and calcium is needed; she needs a DEXA scan.,5.  Typical ANCA, per records, were not verified here.  ANCA and ASCA were negative and the OmpC was not ordered.,6.  Acne.,7.  Recurrent arthralgia not present.  Rheumatoid factor, CCP negative, ANA 1:40 speckled.,8.  Livedo reticularis, beta 2-glycoprotein was not checked, we are going to check it today.  Needs vaccination for influenza and pneumonia.,9.  Vitamin D deficiency.  She needs replacement with ergocalciferol, but this may point towards ___________ pathology as this was not detected.,10.  Recurrent ankle discomfort which necessitates ankle x-rays.,PLANS:,  We can proceed with part of her workup here in clinic, PPD, echocardiogram, ankle x-rays, and anti-intrinsic factor antibodies.  We can start repleting her vitamin D with __________ weeks of ergocalciferol 50,000 weekly.  We can add an RVVT and glycoprotein to her workup in order to rule out any antiphospholipid syndrome.  She should be taking vitamin D and calcium after the completion of vitamin D replacement.  She should be seen by her primary care physician, have the iron and B12 deficiency worked up.  She should stop the colchicine and if the skin lesion recurs then she should be seen by her dermatologist.  Based on the physical examination, we do not suspect that the patient has the presence of any other disease associated with erythema nodosum.  We are going to add an amylase and lipase to evaluate her pancreatic function, RPR, HIV, __________ serologies.  Given the evidence of possible malabsorption it may be significant to proceed with an upper endoscopy to rule out Whipple disease or celiac disease which can sometimes be associated with erythema nodosum.  An anti-intrinsic factor would be added, as I mentioned.  I doubt whether the patient has Behcet disease given the absence of oral or genital ulcers.  She does not give a history of oral contraceptives or medications that could be related to erythema nodosum.  She does not have any evidence of lupus __________ mycosis.  Histoplasmosis coccidioidomycosis would be accompanied by other symptoms.  Hodgkin disease has probably been ruled out with a CAT scan.  However, we are going to add an LDH in future workup.  I need to discuss with her primary care physician regarding the need for workup of her vitamin B12 deficiency and also with her gastroenterologist regarding the need for an upper endoscopy.  The patient will return in 1 month.",
" Severe tonsillitis, palatal cellulitis, and inability to swallow.", Consult - History and Phy., Exudative Tonsillitis ,"CHIEF COMPLAINT:  ,Severe tonsillitis, palatal cellulitis, and inability to swallow.,HISTORY OF PRESENT ILLNESS: , This patient started having sore throat approximately one week ago; however, yesterday it became much worse.  He was unable to swallow.  He complained to his parent.  He was taken to Med Care and did not get any better, and therefore presented this morning to ER, where seen and evaluated by Dr. X and concerned as whether he had an abscess either pharyngeal, palatal, or peritonsillar.  He was noted to have extreme tonsillitis with kissing tonsils, marked exudates especially right side and right palatal cellulitis.  A CT scan at ER did not show abscess.  He has not had airway compromise, but he has had difficulty swallowing.  He may have had a low-grade fever, but nothing marked at home.  His records from Hospital are reviewed as well as the pediatric notes by Dr. X. He did have some equivalent leukocytosis.  He had a negative monospot and negative strep screen.,PAST MEDICAL HISTORY:  ,The patient takes no medications, has had no illnesses or surgeries and he is generally in good health other than being significantly overweight.  He is a sophomore at High School.,FAMILY HISTORY:  ,Noncontributory to this illness.,SURGERIES: , None.,HABITS: , Nonsmoker, nondrinker.  Denies illicit drug use.,REVIEW OF SYSTEMS:,ENT:  The patient other than having dysphagia, the patient denies other associated ENT symptomatology.,GU:  Denies dysuria.,Orthopedic:  Denies joint pain, difficulty walking, etc.,Neuro:  Denies headache, blurry vision, etc.,Eyes:  Says vision is intact.,Lungs:  Denies shortness of breath, cough, etc.,Skin:  He states he has a rash, which occurred from penicillin that he was given IM yesterday at Covington Med Care.  Mildly itchy.  Mother has penicillin allergy.,Endocrine:  The patient denies any weight loss, weight gain, skin changes, fatigue, etc, essentially no symptoms of hyper or hypothyroidism.,Physical Exam:,General:  This is a morbidly obese white male adolescent, in no acute disease, alert and oriented x 4.  Voice is normal.  He is handling his secretions.  There is no stridor.,Vital Signs:  See vital signs in nurses notes.,Ears:  TM and EACs are normal.  External, normal.,Nose:  Opening clear.  External nose is normal.,Mouth:  Has bilateral marked exudates, tonsillitis, right greater than left.  Uvula is midline.  Tonsils are touching.  There is some redness of the right palatal area, but is not consistent with peritonsillar abscess.  Tongue is normal.  Dentition intact.  No mucosal lesions other than as noted.,Neck:  No thyromegaly, masses, or adenopathy except for some small minimally enlarged high jugular nodes.,Chest:  Clear to auscultation.,Heart:  No murmurs, rubs, or gallops.,Abdomen:  Obese.  Complete exam deferred.,Skin:  Visualized skin dry and intact, except for rash on his inner thighs and upper legs, which is red maculopapular and consistent with possible allergic reaction.,Neuro:  Cranial nerves II through XII are intact.  Eyes, pupils are equal, round, and reactive to light and accommodation, full range.,IMPRESSION: , Marked exudative tonsillitis, non-strep, non-mono, probably mixed anaerobic infection.  No significant prior history of tonsillitis.  Possible rash to PENICILLIN.,RECOMMENDATIONS: , I concur with IV clindamycin and IV Solu-Medrol as per Dr. X. I anticipate this patient may need several days of IV antibiotics and then be able to switch over to oral.  I do not insist that this patient will need surgical intervention since there is no evidence of abscess.  This one episode of severe tonsillitis does not mean the patient needs tonsillectomy, but if he continues to have significant tonsil problems after this he should be referred for ENT evaluation as an outpatient.  The patient's parents in the room had expressed good understanding, have a chance to ask questions.  At this time, I will see the patient back on an as needed basis.",
 Left flank pain and unable to urinate., Consult - History and Phy., Flank Pain - Consult ,"CHIEF COMPLAINT: , Left flank pain and unable to urinate.,HISTORY: , The patient is a 46-year-old female who presented to the emergency room with left flank pain and difficulty urinating.  Details are in the history and physical.  She does have a vague history of a bruised left kidney in a motor vehicle accident.  She feels much better today.  I was consulted by Dr. X.,MEDICATIONS:,  Ritalin 50 a day.,ALLERGIES: , To penicillin.,PAST MEDICAL HISTORY: , ADHD.,SOCIAL HISTORY:,  No smoking, alcohol, or drug abuse.,PHYSICAL EXAMINATION: , She is awake, alert, and quite comfortable.  Abdomen is benign.  She points to her left flank, where she was feeling the pain.,DIAGNOSTIC DATA: , Her CAT scan showed a focal ileus in left upper quadrant, but no thickening, no obstruction, no free air, normal appendix, and no kidney stones.,LABORATORY WORK: , Showed white count 6200, hematocrit 44.7.  Liver function tests and amylase were normal.  Urinalysis 3+ bacteria.,IMPRESSION:,1.  Left flank pain, question etiology.,2.  No evidence of surgical pathology.,3.  Rule out urinary tract infection.,PLAN:,1.  No further intervention from my point of view.,2.  Agree with discharge and followup as an outpatient.  Further intervention will depend on how she does clinically.  She fully understood and agreed.","consult - history and phy., flank pain, unable to urinate, urinary tract infection, flank, "
" This 62-year-old white female has essential tremor and mild torticollis.  Tremor not bothersome for most activities of daily living, but she does have a great difficulty writing, which is totally illegible. ", Consult - History and Phy., Essential Tremor & Torticollis ,"REASON FOR CONSULT: , Essential tremor and torticollis.,HISTORY OF PRESENT ILLNESS: , This is a 62-year-old right-handed now left-handed white female with tremor since 5th grade.  She remembers that the tremors started in her right hand around that time subsequently later on in early 20s she was put on propranolol for the tremor and more recently within the last 10 years she has been put on primidone and clonazepam.  She thinks that her clonazepam is helping her a lot especially with anxiety and stress, and this makes the tremor better.  She has a lot of trouble with her writing because of tremor but does not report as much problem with other activities of daily living like drinking from a cup and doing her day-to-day activity.  Since around 6 to 7 years, she has had a head tremor, which is mainly ""no- no"" and occasional voice tremor also.  Additionally, the patient has been diagnosed with migraine headaches without aura, which are far and few apart.  She also has some stress incontinence.  Last MRI brain was done in 2001 reportedly normal.,CURRENT MEDICATIONS:,1.  Klonopin 0.5 mg twice a day.,2.  Primidone 100 mg b.i.d.,3.  Propranolol long-acting 80 mg once in the morning.,PAST MEDICAL HISTORY: , Essential tremor, cervical dystonia, endometriosis, migraine headaches without aura, left ear sensorineural deafness, and basal cell carcinoma resection on the nose.,PAST SURGICAL HISTORY: , L5-S1 lumbar laminectomy in 1975, exploratory laparotomy in 1967, tonsillectomy and adenoidectomy, and anal fissure surgery in 1975.,FAMILY HISTORY: , Both parents have ET and hypertension.  Maternal cousin with lupus.,SOCIAL HISTORY: , Denies any smoking or alcohol.  She is married since 44 years, has 3 children.  She used to work as a labor and delivery nurse up until early 2001 when she retired.,REVIEW OF SYSTEMS: , No fever, chills, nausea or vomiting.  No visual complaints.  She complains of hearing decreased on the left.  No chest pain or shortness of breath.  No constipation.  She does give a history of urge incontinence.  No rashes.  No depressive symptoms.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure is 131/72, pulse is 50, and weight is 71.3 kg.  HEENT:  PERRLA.  EOMI.  CARDIOVASCULAR:  S1 and S2 normal.  Regular rate and rhythm.  She does have a rash over the right ankle with a prior basal cell carcinoma was resected.  NEUROLOGIC:  Alert and oriented x4.  Speech shows a voice tremor occasionally.  Language is intact.  Cranial nerves II through XII intact.  Motor examination showed 5/5 power in all extremities with minimal increased tone.  Sensory examination was intact to light touch.  Reflexes were brisk bilaterally, but they were equal and both toes were downgoing.  Her coordination showed minimal intentional component to bilateral finger-to-nose.  Gait was intact.  Lot of swing on Romberg's.  The patient did have a tremor both upper extremities, right more than left.  She did have a head tremor, which was no-no variety, and she had a minimal torticollis with her head twisted to the left.,ASSESSMENT AND PLAN: , This 62-year-old white female has essential tremor and mild torticollis.  Tremor not bothersome for most activities of daily living, but she does have a great difficulty writing, which is totally illegible.  The patient did not wish to change any of her medication doses at this point.  We will go ahead and check MRI brain, and we will get the films later.  We will see her back in 3 months.  Also, the patient declined any possible Botox for the mild torticollis she has at this point.","consult - history and phy., clonazepam, difficulty writing, head tremor, voice tremor, migraine headaches, mri brain, essential tremor, torticollis, carcinoma,"
 Fall with questionable associated loss of consciousness.  Left parietal epidural hematoma., Consult - History and Phy., Epidural Hematoma ,"CC:, Fall with questionable associated loss of consciousness.,HX: ,This 81 y/o RHM fell down 20 steps on the evening of admission, 1/10/93, while attempting to put his boots on at the top of the staircase. He was evaluated locally and was amnestic to the event at the time of examination. A HCT scan was obtained and he was transferred to UIHC, Neurosurgery.,MEDS:, Lasix 40mg qd, Zantac 150mg qd, Lanoxin 0.125mg qd, Capoten 2.5mg bid, Salsalate 750mg tid, ASA 325mg qd, ""Ginsana"" (Ginseng) 100mg bid.,PMH: ,1)Atrial fibrillation, 2)Right hemisphere stroke, 11/22/88, with associated left hemiparesis and amaurosis fugax. This was followed by a RCEA, 12/1/88 for 98% stenosis. The stroke symptoms/signs resolved. 3)DJD, 4)Right TKR 2-3 years ago, 5)venous stasis; with no h/o DVT, 6)former participant in NASCET, 7)TURP for BPH. No known allergies.,FHX:, Father died of an MI at unknown age, Mother died of complications of a dental procedure. He has one daughter who is healthy.,SHX:, Married. Part-time farmer. Denied tobacco/ETOH/illicit drug use.,EXAM: ,BP157/86, HR100 and irregular, RR20, 36.7C, 100%SaO2,MS: A&O to person, place, time. Speech fluent and without dysarthria.,CN: Pupils 3/3 decreasing to 2/2 on exposure to light. EOM intact. VFFTC. Optic disks were flat. Face was symmetric with symmetric movement. The remainder of the CN exam was unremarkable.,Motor: 5/5 strength throughout with normal muscle tone and bulk.,Sensory: unremarkable.,Coord: unremarkable.,Station/Gait: not mentioned in chart.,Reflexes: symmetric. Plantar responses were flexor, bilaterally.,Gen Exam: CV:IRRR without murmur. Lungs: CTA. Abdomen: NT, ND, NBS.,HEENT: abrasion over the right forehead.,Extremity: distal right leg edema/erythema (just above the ankle). tender to touch.,COURSE:, 1/10/93, (outside)HCT was reviewed, It revealed a left parietal epidural hematoma. GS, PT/PTT, UA, and CBC were unremarkable. RLE XR revealed a fracture of the right lateral malleolus for which he was casted. Repeat HCTs showed no change in the epidural hematoma and he was discharged home on DPH.","consult - history and phy., loss of consciousness, parietal epidural hematoma, parietal epidural, epidural hematoma, consciousness, epidural, hematoma, "
 Fall/loss of consciousness., Consult - History and Phy., Epidural Fluid Collection ,"CC:, Fall/loss of consciousness.,HX: ,This 44y/o male fell 15-20feet from a construction site scaffold landing on his head on a cement sidewalk. He was transported directly from the scene, approximately one mile east of UIHC. The patient developed labored breathing and an EMT attempted to intubate the patient in the UIHC ER garage, but upon evaluation in the ER, was found to be in his esophagus and was immediately replaced into the trachea. Replacement of the ET tube required succinylcholine. The patient remained in a C-collar during the procedure. Once in the ER the patient had a 15min period of bradycardia.,MEDS: ,none prior to accident.,PMH:, No significant chronic or recent illness. s/p left knee arthroplasty. h/o hand fractures.,FHX:, Unremarkable.,SHX:, Married. Rare cigarette use/Occasional Marijuana use/Social ETOH use per wife.,EXAM:, BP156/79. HR 74 RR (Ambu Bag ventilation via ET tube) 34.7C 72-100% O2Sat.,MS: Unresponsive to verbal stimulation. No spontaneous verbalization.,CN: Does not open/close eyes to command or spontaneously. Pupils 9/7 and nonreactive.,Corneas -/+. Gag +/+. Oculocephalic and Oculovestibular reflexes not performed.,Motor: minimal spontaneous movement of the 4 extremities.,Sensory: withdraws LUE and BLE to noxious stimulation.,Coord/Station/Gait: Not tested.,Reflexes: 1-2+ and symmetric throughout. Babinski signs were present bilaterally.,HEENT: severe facial injury with brain parenchyma and blood from the right nostril. Severe soft tissue swelling about side of head.,Gen Exam: CV: RRR without murmur. Lungs: CTA. Abdomen: distended after ET tube misplacement.,COURSE: ,HCT upon arrival, 10/29/92, revealed: Extensive parenchymal contusions in right fronto-parietal area. Pronounced diffuse brain swelling seemingly obliterates the mesencephalic cistern and 4th ventricle. Considerable mass effect is exerted upon the right lateral ventricle, near totally obliterating its contour. Massive subcutaneous soft tissue swelling is present along the right anterolateral parietal area. There are extensive fractures of the following: two component horizontal fractures throughout the floor of the right middle cranial fossa which includes the squamous and petrous portions of the temporal bone, as well as the greater wing of the sphenoid. Comminuted fractures of the aqueous portion of the temporal bone and parietal bone is noted on the right. Extensive comminution of the right half of the frontal bone and marked displacement is seen. Comminuted fractures of the medial wall of the right orbit and ethmoidal air cells is seen with near total opacification of the air cells. The medial and lateral walls of the maxillary sinus are fractured and minimally displaced, as well as the medial wall of the left maxillary sinus. The right zygomatic bone is fractured at its articulation with the sphenoid bone and displaced posteriorly.,Portable chest, c-spine and abdominal XRays were unremarkable, but limited studies. Abdominal CT was unremarkable.,Hgb 10.4g/dl, Hct29%, WBC17.4k/mm3, Plt 190K. ABG:7.28/48/46 on admission. Glucose 131.,The patient was hyperventilated, Mannitol was administered (1g/kg), and the patient was given a Dilantin loading dose. He was taken to surgery immediately following the above studies to decompress the contused brain and remove bony fragments from multiple skull fractures. The patient remained in a persistent vegetative state at UIHC, and upon the request of this wife his feeding tube was discontinued. He later expired.","consult - history and phy., loss of consciousness, soft tissue swelling, medial wall, maxillary sinus, sphenoid, collection, tube, bone, "
 This is a 25-year-old male with nonspecific right-sided chest/abdominal pain from an unknown etiology., Consult - History and Phy., ER Report - Rib Cage Pain ,"HISTORY:,  The patient is a 25-year-old gentleman who was seen in the emergency room at Children's Hospital today.  He brought his 3-month-old daughter in for evaluation but also wanted to be evaluated himself because he has had ""rib cage pain"" for the last few days.  He denies any history of trauma.  He does have increased pain with laughing.  Per the patient, he also claims to have an elevated temperature yesterday of 101.  Apparently, the patient did go to the emergency room at ABCD yesterday, but due to the long wait, he left without actually being evaluated and then thought that he might be seen today when he came to Children's.,PAST MEDICAL HISTORY: , The patient has a medical history significant for ""Staphylococcus infection"" that was being treated with antibiotics for 10 days.,CURRENT MEDICATIONS: , He states that he is currently taking no medications.,ALLERGIES:  ,He is not allergic to any medication.,PAST SURGICAL HISTORY: , He denies any past surgical history.,SOCIAL HISTORY: , The patient apparently has a history of methamphetamine use and cocaine use approximately 1 year ago.  He also has a history of marijuana used approximately 1 year ago.  He currently states that he is in a rehab program.,FAMILY HISTORY:,  Unknown by the patient.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature is 99.9, blood pressure is 108/65, pulse of 84, respirations are 16.,GENERAL:  He is alert and appeared to be in no acute distress.  He had normal hydration.,HEENT:  His pupils were equal, round, reactive.  Extraocular muscles intact.  He had no erythema or exudate noted in his posterior oropharynx.,NECK:  Supple with full range of motion.  No lymphadenopathy noted.,RESPIRATORY:  He had equal breath sounds bilaterally with no wheezes, rales, or rhonchi and no labored breathing; however, he did occasionally have pain with deep inspiration at the right side of his chest.,CARDIOVASCULAR:  Regular rate and rhythm.  Positive S1, S2.  No murmurs, rubs, or gallops noted.,GI:  Nontender, nondistended with normoactive bowel sounds.  No masses noted.,SKIN:  Appeared normal except on the left anterior tibial area where the patient had a healing skin lesion.  There were no vesicles, erythema or induration noted.,MUSCULOSKELETAL:  Nontender with normal range of motion.,NEURO/PSYCHE:  The patient was alert and oriented x3 with nonfocal neurological exam.,ASSESSMENT: , This is a 25-year-old male with nonspecific right-sided chest/abdominal pain from an unknown etiology.,PLAN: , Due to the fact that this patient is an adult male, we will transfer him to XYZ Medical Center for further evaluation.  I have spoken with XYZ Medical Center Dr. X who has accepted the patient for transfer.  He was advised that the patient will be coming in a private vehicle due to fact that he is completely stable and appears to be in no acute distress.  Dr. X was happy to accept the transfer and indicated that the patient should come to the emergency room area with the transport paperwork.  The plan was explained in detail to the patient who stated that he understood and would comply.  The appropriate paperwork was created and one copy was given to the patient.,CONDITION ON DISCHARGE: , At the time of discharge, he was stable, vital signs stable, in no acute distress.",
 Persistent dysphagia.  Deviated nasal septum.  Inferior turbinate hypertrophy.  Chronic rhinitis. Conductive hearing loss.  Tympanosclerosis., Consult - History and Phy., ENT Consult ,"HISTORY:,  The patient is a 51-year-old female that was seen in consultation at the request of Dr. X on 06/04/2008 regarding chronic nasal congestion, difficulty with swallowing, and hearing loss.  The patient reports that she has been having history of recurrent sinus infection, averages about three times per year.  During the time that she gets the sinus infections, she has nasal congestion, nasal drainage, and also generally develops an ear infection as well.  The patient does note that she has been having hearing loss.  This is particular prominent in the right ear now for the past three to four years.  She does note popping after blowing the nose.  Occasionally, the hearing will improve and then it plugs back up again.  She seems to be plugged within the nasal passage, more on the right side than the left and this seems to be year round issue with her.  She tried Flonase nasal spray to see if this help with this and has been taking it, but has not seen a dramatic improvement.  She has had a history of swallowing issues and that again secondary to the persistent postnasal drainage.  She feels that she is having a hard time swallowing at times as well.  She has complained of a lump sensation in the throat that tends to come and go.  She denies any cough, no hemoptysis, no weight change.  No night sweats, fever or chills has been noted.  She is having at this time no complaints of tinnitus or vertigo.  The patient presents today for further workup, evaluation, and treatment of the above-listed symptoms.,REVIEW OF SYSTEMS:  ,ALLERGY/IMMUNOLOGIC:  History of seasonal allergies.  She also has severe allergy to penicillin and bee stings.,CARDIOVASCULAR:  Pertinent for hypercholesterolemia.,PULMONARY:  She has a history of cough, wheezing.,GASTROINTESTINAL:  Negative.,GENITOURINARY:  Negative.,NEUROLOGIC:  She has had a history of TIAs in the past.,VISUAL:  She does have history of vision change, wears glasses.,DERMATOLOGIC:  Negative.,ENDOCRINE:  Negative.,MUSCULOSKELETAL:  History of joint pain and bursitis.,CONSTITUTIONAL:  She has a history of chronic fatigue.,ENT:  She has had a history of cholesteatoma removal from the right middle ear and previous tympanoplasty with a progressive hearing loss in the right ear over the past few years according to the patient.,PSYCHOLOGIC:  History of anxiety, depression.,HEMATOLOGIC:  Easy bruising.,PAST SURGICAL HISTORY: , She has had right tympanoplasty in 1984.  She has had a left carotid endarterectomy, cholecystectomy, two C sections, hysterectomy, and appendectomy.,FAMILY HISTORY: , Mother, history of vaginal cancer and hypertension.  Brother, colon CA.  Father, hypertension.,CURRENT MEDICATIONS: , Aspirin 81 mg daily.  She takes vitamins one a day.  She is on Zocor, Desyrel, Flonase, and Xanax.  She also has been taking Chantix for smoking cessation.,ALLERGIES: , Penicillin causes throat swelling.  She also notes the bee sting allergy causes throat and tongue swelling.,SOCIAL HISTORY: , The patient is single.  She is unemployed at this time.  She is a smoker about a pack and a half for 38 years and notes rare alcohol use.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Her blood pressure 128/78, temperature is 98.6, pulse 80 and regular.,GENERAL:  The patient is an alert, cooperative, well-developed 51-year-old female.  She has a normal-sounding voice and good memory.,HEAD & FACE:  Inspected with no scars, lesions or masses noted.  Sinuses palpated and are normal.  Salivary glands also palpated and are normal with no masses noted.  The patient also has full facial function.,CARDIOVASCULAR:  Heart regular rate and rhythm without murmur.,RESPIRATORY:  Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.,EYES:  Extraocular muscles were tested and within normal limits.,EARS:  Right ear, the external ear is normal.  The ear canal is clean and dry.  The drum is intact.  She has got severe tympanosclerosis of the right tympanic membrane and Weber exam does lateralize to the right ear indicative of a conductive loss.  Left ear, the external ear is normal.  The ear canal is clean and dry.  The drum is intact and mobile with grossly normal hearing.  The audiogram does reveal normal hearing in the left ear.  She has got a mild conductive loss throughout all frequency ranges in the right ear with excellent discrimination scores noted bilaterally.  Tympanograms, there was no adequate seal obtained on the right side.  She has a normal type A tympanogram, left side.,NASAL:  Reveals a deviated nasal septum to the left, clear drainage, large inferior turbinates, no erythema.,ORAL:  Oral cavity is normal with good moisture.  Lips, teeth and gums are normal.  Evaluation of the oropharynx reveals normal mucosa, normal palates, and posterior oropharynx.  Examination of the larynx with a mirror reveals normal epiglottis, false and true vocal cords with good mobility of the cords.  The nasopharynx was briefly examined by mirror with normal appearing mucosa, posterior choanae and eustachian tubes.,NECK:  The neck was examined with normal appearance.  Trachea in the midline.  The thyroid was normal, nontender, with no palpable masses or adenopathy noted.,NEUROLOGIC:  Cranial nerves II through XII evaluated and noted to be normal.  Patient oriented times 3.,DERMATOLOGIC:  Evaluation reveals no masses or lesions.  Skin turgor is normal.,PROCEDURE: , Please note a fiberoptic laryngoscopy was also done at today's visit for further evaluation because of the patient's dysphagia and throat symptoms.  Findings do reveal moderately deviated nasal septum to the left, large inferior turbinates noted.  The nasopharynx does reveal moderate adenoid pad within this midline.  It is nonulcerated.  The larynx revealed both cords to be normal.  She does have mild lingual tonsillar hypertrophy as well.,IMPRESSION:  ,1.  Persistent dysphagia.  I think secondary most likely to the persistent postnasal drainage.,2.  Deviated nasal septum.,3.  Inferior turbinate hypertrophy.,4.  Chronic rhinitis.,5.  Conductive hearing loss, right ear with a history of cholesteatoma of the right ear.",
" Management of end-stage renal disease (ESRD), the patient on chronic hemodialysis, being admitted for chest pain.", Consult - History and Phy., End Stage Renal Disease - Consult ,"REASON FOR CONSULTATION: , Management of end-stage renal disease (ESRD), the patient on chronic hemodialysis, being admitted for chest pain.,HISTORY OF PRESENT ILLNESS:,  This is a 66-year-old Native American gentleman, a patient of Dr. X, my associate, who has a past medical history of coronary artery disease, status post stent placement, admitted with chest pressure around 4 o'clock last night.  He took some nitroglycerin tablets at home with no relief.  He came to the ER.  He is going to have a coronary angiogram done today by Dr. Y. I have seen this patient first time in the morning, approximately around the 4 o'clock.  This is a late entry dictation.  Presently lying in bed, but he feels fine.  Denies any chest pain, shortness of breath, nausea, vomiting, abdominal pain, diarrhea.  Denies hematuria, dysuria, or bright red blood per rectum.,PAST MEDICAL HISTORY:,1.  Coronary artery disease, status post stent placement two years ago.,2.  Diabetes mellitus for the last 12 years.,3.  Hypertension.,4.  End-stage renal disease.,5.  History of TIA in the past.,PAST SURGICAL HISTORY:,1.  As mentioned above.,2.  Cholecystectomy.,3.  Appendectomy.,4.  Right IJ PermaCath placement.,5.  AV fistula graft in the right wrist.,PERSONAL AND SOCIAL HISTORY:,  He smoked 2 to 3 packets per day for at least last 10 years.  He quit smoking roughly about 20 years ago.  Occasional alcohol use.,FAMILY HISTORY: , Noncontributory.,ALLERGIES:  ,No known drug allergies.,MEDICATIONS AT HOME: , Metoprolol, Plavix, Rocaltrol, Lasix, Norvasc, Zocor, hydralazine, calcium carbonate, and loratadine.,PHYSICAL EXAMINATION,GENERAL:  He is alert, seems to be in no apparent distress.,VITAL SIGNS:  Temperature 98.2, pulse 61, respiratory 20, and blood pressure 139/63.,HEENT:  Atraumatic and normocephalic.,NECK:  No JVD, no thyromegaly, supra and infraclavicular lymphadenopathy.,LUNGS:  Clear to auscultation.  Air entry bilateral equal.,HEART:  S1 and S2.  No pericardial rub.,ABDOMEN:  Soft and nontender.  Normal bowel sounds.,EXTREMITIES:  No edema.,NEUROLOGIC:  The patient is alert without focal deficit.,LABORATORY DATA:,  Laboratory data shows hemoglobin 13, hematocrit 38.4, sodium 130, potassium 4.2, chloride 96.5, carbonate 30, BUN 26, creatinine 6.03, and glucose 162.,IMPRESSION:,1.  End-stage renal disease, plan for dialysis today.,2.  Diabetes mellitus.,3.  Chest pain for coronary angiogram today.,4.  Hypertension, blood pressure stable.,PLAN: , Currently follow the patient.  Dr. Z is going to assume the care.",
 Encephalopathy related to normal-pressure hydrocephalus., Consult - History and Phy., Encephalopathy  - Rehab Consult  ,"ADMITTING DIAGNOSIS: , Encephalopathy related to normal-pressure hydrocephalus.,CHIEF COMPLAINT:,  Diminished function secondary to above.,HISTORY:  ,This pleasant gentleman was recently admitted to ABCD Medical Center and followed by the neurosurgical staff, including Dr. X, where normal-pressure hydrocephalus was diagnosed.  He had a shunt placed and was stabilized medically.  He has gotten a return of function to the legs and was started on some early therapy.  Significant functional limitations have been identified and ongoing by the rehab admission team.  Significant functional limitations have been ongoing.  He will need to be near-independent at home for periods of time, and he is brought in now for rehabilitation to further address functional issues, maximize skills and safety and allow a safe disposition home.,PAST MEDICAL HISTORY: , Positive for prostate cancer, intermittent urinary incontinence and left hip replacement.,ALLERGIES: , No known drug allergies.,CURRENT MEDICATIONS,1.  Tylenol as needed.  ,2.  Peri-Colace b.i.d.,SOCIAL HISTORY:,  He is a nonsmoker and nondrinker.  Prior boxer.  He lives in a home where he would need to be independent during the day.  Family  relatives intermittently available.  Goal is to return home to an independent fashion to that home setting.,FUNCTIONAL HISTORY: , Prior to admission was independent with activities of daily living and ambulatory skills.  Presently, he has resumed therapies and noted to have supervision levels for most activities of daily living.  Memory at minimal assist.  Walking at supervision., REVIEW OF SYSTEMS:  ,Negative for headaches, nausea, vomiting, fevers, chills, shortness of breath or chest pain currently.  He has had some dyscoordination recently and headaches on a daily basis, most days, although the Tylenol does seem to control that pain.,PHYSICAL EXAMINATION,VITAL SIGNS:  The patient is afebrile with vital signs stable.,HEENT:  Oropharynx clear, extraocular muscles are intact.,CARDIOVASCULAR:  Regular rate and rhythm, without murmurs, rubs or gallops.,LUNGS:  Clear to auscultation bilaterally.,ABDOMEN:  Nontender, nondistended,  positive bowel sounds.,EXTREMITIES:  Without clubbing, cyanosis, or edema.  The calves are soft and nontender bilaterally.,NEUROLOGIC:  No focal, motor or sensory losses through the lower extremities.  He moves upper and lower extremities well.  Bulk and tone normal in the upper and lower extremities.  Cognitively showing intact with appropriate receptive and expressive skills.,IMPRESSION ,",
" Abnormal serum PSA of 16 ng/ml, dribbling urine, inability to empty bladder, nocturia, urinary hesitancy and slow urine stream.", Consult - History and Phy., Elevated PSA - H&P ,"CHIEF COMPLAINT:, This 61-year-old male presents today with recent finding of abnormal serum PSA of 16 ng/ml. Associated signs and symptoms: Associated signs and symptoms include dribbling urine, inability to empty bladder, nocturia, urinary hesitancy and urine stream is slow.  Timing (onset/frequency): Onset was 6 months ago. Patient denies fever and chills and denies flank pain.,ALLERGIES: ,Patient admits allergies to adhesive tape resulting in severe rash. Patient denies an allergy to anesthesia.,MEDICATION HISTORY:, Patient is not currently taking any medications.,PAST MEDICAL HISTORY:, Childhood Illnesses: (+) asthma, Cardiovascular Hx: (-) angina, Renal / Urinary Hx: (-) kidney problems.,PAST SURGICAL HISTORY:, Patient admits past surgical history of appendectomy in 1992.,SOCIAL HISTORY:, Patient admits alcohol use, Drinking is described as heavy, Patient denies illegal drug use, Patient denies STD history, Patient denies tobacco use.,FAMILY HISTORY:, Patient admits a family history of gout attacks associated with father.,REVIEW OF SYSTEMS:, Unremarkable with exception of chief complaint.,PHYSICAL EXAM: ,BP Sitting: 120/80 Resp: 20 HR: 72 Temp: 98.6,The patient is a pleasant, 61-year-old male in no apparent distress who looks his given age, is well-developed and nourished with good attention to hygiene and body habitus.,Neck: Neck is normal and symmetrical, without swelling or tenderness. Thyroid is smooth and symmetric with no enlargement, tenderness or masses noted.,Respiratory: Respirations are even without use of accessory muscles and no intercostal retractions noted. Breathing is not labored, diaphragmatic, or abdominal. Lungs clear to auscultation with no rales, rhonchi, wheezes, or rubs noted.,Cardiovascular: Normal S1 and S2 without murmurs, gallop, rubs or clicks.  Peripheral pulses full to palpation, no varicosities, extremities warm with no edema or tenderness.,Gastrointestinal: Abdominal organs, bladder, kidney: No abnormalities, without masses, tenderness, or rigidity. Hernia: absent; no inguinal, femoral, or ventral hernias noted. Liver and/or Spleen: no abnormalities, tenderness, or masses noted. Stool specimen not indicated.,Genitourinary: Anus and perineum: no abnormalities. No fissures, edema, dimples, or tenderness noted.,Scrotum: no abnormalities. No lesions, rash, or sebaceous cyst noted.,Epididymides: no abnormalities, masses, or spermatocele, without enlargement, induration, or tenderness.,Testes: symmetrical; no abnormalities, tenderness, hydrocele, or masses noted.,Urethral Meatus: no abnormalities; no hypospadias, lesions, polyps, or discharge noted.,Penis: no abnormalities; circumcised; no phimosis, Peyronie's, condylomata, or lumps noted.,Prostate: size 60 gr, RT>LT and firm.,Seminal Vesicles: no abnormalities; symmetrical; no tenderness, induration, or nodules noted.,Sphincter tone: no abnormalities; good tone; without hemorrhoids or masses.,Skin/Extremities: Skin is warm and dry with normal turgor and there is no icterus. No skin rash, subcutaneous nodules, lesions or ulcers observed.,Neurological/Psychiatric: Oriented to person, place and time. Mood and affect normal, appropriate to situation, without depression, anxiety, or agitation.,TEST RESULTS:, No tests to report at this time.,IMPRESSION: ,Elevated prostate specific antigen (PSA).,PLAN:, Cystoscopy in the office.,DIAGNOSTIC & LAB ORDERS:, Ordered serum creatinine. Urinalysis and C & S ordered using clean-catch specimen. Ordered free prostate specific antigen (PSA). Ordered ultrasound of prostate.,I have discussed the findings of this follow-up evaluation with the patient. The discussion included a complete verbal explanation of any changes in the examination results, diagnosis and current treatment plan. Discussed the possibility of a TURP surgical procedure; risks, complications, benefits, and alternative measures discussed. There are no activity restrictions . Instructed Ben to avoid caffeinated or alcoholic beverages and excessively spiced foods. Questions answered. If any questions should arise after returning home I have encouraged the patient to feel free to call the office at 327-8850.,PRESCRIPTIONS: , Proscar Dosage: 5 mg tablet Sig: once daily Dispense: 30 Refills: 0 Allow Generic: No,PATIENT INSTRUCTIONS:,  Patient completed benign prostatic hypertrophy questionnaire.",
" Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, adenoid hypertrophy.", Consult - History and Phy., ENT Consult - 1 ,"CHIEF COMPLAINT: , Chronic otitis media, adenoid hypertrophy.,HISTORY OF PRESENT ILLNESS: , The patient is a 2-1/2-year-old, with a history of persistent bouts of otitis media, superimposed upon persistent middle ear effusions.  He also has a history of chronic mouth breathing and heroic snoring with examination revealing adenoid hypertrophy.  He is being admitted to the operating room at this time for adenoidectomy and bilateral myringotomy and insertion of PE tubes.,ALLERGIES:  ,None.,MEDICATIONS:,  Antibiotics p.r.n.,FAMILY HISTORY: , Diabetes, heart disease, hearing loss, allergy and cancer.,MEDICAL HISTORY: , Unremarkable.,SURGICAL HISTORY: , None.,SOCIAL HISTORY: , Some minor second-hand tobacco exposure.  There are no pets in the home.,PHYSICAL EXAMINATION:,  Ears are well retracted, immobile.  Tympanic membranes with effusions present bilaterally.  No severe congestions, thick mucoid secretions, no airflow.  Oral cavity:  Oropharynx 2 to 3+ tonsils.  No exudates.  Floor of mouth and tongue are normal.  Larynx and pharynx not examined.  Neck:  No nodes, masses or thyromegaly.  Lungs:  Reveal rare rhonchi, otherwise, clear.  Cardiac exam:  Regular rate and rhythm.  No murmurs.  Abdomen:  Soft, nontender.  Positive bowel sounds.  Neurologic exam:  Nonfocal.,IMPRESSION:  ,Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, adenoid hypertrophy.,PLAN: , The patient will be admitted to the operating room for adenoidectomy and bilateral myringotomy and insertion of PE tubes.","consult - history and phy., chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, adenoid hypertrophy, pe tubes, otitis media with effusion, adenoidectomy and bilateral myringotomy, eustachian tube dysfunction, insertion of pe, chronic otitis media, bilateral myringotomy, otitis media, adenoidectomy, myringotomy, adenoid, hypertrophy, otitis, media,"
" Elevated BNP.  Diastolic heart failure, not contributing to his present problem. Chest x-ray and CAT scan shows possible pneumonia.  The patient denies any prior history of coronary artery disease but has a history of hypertension.", Consult - History and Phy., Elevated BNP - Consult ,"REASON FOR REFERRAL: , Elevated BNP.,HISTORY OF PRESENT ILLNESS:,  The patient is a 95-year-old Caucasian male visiting from out of state, admitted because of the fall and could not get up and has a cough with dark color sputum, now admitted with pneumonia and a fall and the patient's BNP level was high, for which Cardiology consult was requested.  The patient denies any chest pain or shortness of breath.  Chest x-ray and CAT scan shows possible pneumonia.  The patient denies any prior history of coronary artery disease but has a history of hypertension.,ALLERGIES: , No known drug allergies.,MEDICATIONS:,  At this time, he is on:,1.  Atrovent and albuterol nebulizers.,2.  Azithromycin.,3.  Potassium chloride 10 mEq p.o. daily.,4.  Furosemide 20 mg IV daily.,5.  Enoxaparin 40 mg daily.,6.  Lisinopril 10 mg p.o. daily.,7.  Ceftriaxone.,PAST MEDICAL HISTORY: , History of hypertension.,PAST SURGICAL HISTORY:,  History of abdominal surgery.,SOCIAL HISTORY: , He does not smoke.  Drinks occasionally.,FAMILY HISTORY:  ,Noncontributory.,REVIEW OF SYSTEMS: , Denies chest pain, PND, or orthopnea.  He has cough.  No fever.  No abdominal pain.  No syncope, near-syncope, or palpitation.  All other systems were reviewed.,PHYSICAL EXAMINATION:,GENERAL:  The patient is comfortable, not in distress.,VITAL SIGNS:  His blood pressure is 118/50, pulse rate 76, respiratory rate 18, and temperature 98.1.,HEENT:  Atraumatic, normocephalic.  Eyes PERRLA.,NECK:  Supple.  No JVD.  No carotid bruit.,CHEST:  Clear.,HEART:  S1 and S2, regular.  No S3.  No S4.  No murmur.,ABDOMEN:  Soft, nontender.  Positive bowel sounds.,EXTREMITIES:  No cyanosis, clubbing, or edema.  Pulse 2+.,CNS:  Alert, awake, and oriented x3.,DIAGNOSTIC DATA:,  EKG shows sinus tachycardia, nonspecific ST-T changes, nonspecific intraventricular conduction delay.  CT chest shows bilateral pleural effusion, compressive atelectasis, pneumonic infiltrate noted in the right lower lobe.  Loculated pleural effusion in the left upper lobe.  No PE.  Chest x-ray shows bilateral lower lobe patchy opacities concerning for atelectasis or pneumonia.,LABORATORY DATA: , Sodium 139, potassium 4.1, BUN 26, creatinine 0.9, BNP 331, troponin less than 0.05.  White cell count 7.1, hemoglobin 11.5, hematocrit 35.2, platelet 195,000.,ASSESSMENT:,1.  Pneumonia.,2.  Diastolic heart failure, not contributing to his present problem.,3.  Hypertension, controlled.,4.  History of falls.,PLAN: , We will continue IV low-dose diuretics, continue lisinopril, continue IV antibiotics.  No further cardiac workup at this time.",
" Left elbow pain.  Fracture of the humerus, spiral.  Possible nerve injuries to the radial and median nerve, possibly neurapraxia.", Consult - History and Phy., Elbow Pain - Consult ,"CHIEF COMPLAINT: , Left elbow pain.,HISTORY OF PRESENT ILLNESS:  ,This 17-year-old male was fighting with some other kids in Juvenile Hall when he felt some pain in his left elbow, causing sudden pain.  He also has pain in his left ankle, but he is able to walk normally.  He has had previous pain in his left knee.  He denies any passing out, any neck pain at this time even though he did get hit in the head.  He has no chest or abdominal pain.  Apparently, no knives or guns were involved.,PAST MEDICAL HISTORY: , He has had toe problems and left knee pain in the past.,REVIEW OF SYSTEMS: , No coughing, sputum production, dyspnea or chest pain.  No vomiting or abdominal pain.  No visual changes.  No neurologic deficits other than some numbness in his left hand.,SOCIAL HISTORY: , He is in Juvenile Hall for about 25 more days.  He is a nonsmoker.,ALLERGIES: , MORPHINE.,CURRENT MEDICATIONS:  ,Abilify.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Stable.  HEENT:  PERRLA.  EOMI.  Conjunctivae anicteric.  Skull is normocephalic.  He is not complaining of bruising.  HEENT:  TMs and canals are normal.  There is no Battle sign.  NECK:  Supple.  He has good range of motion.  Spinal processes are normal to palpation.  LUNGS:  Clear.  CARDIAC:  Regular rate.  No murmurs or rubs.  EXTREMITIES:  Left elbow is tender.  He does not wish to move it at all.  Shoulder and clavicle are within normal limits.  Wrist is normal to inspection.  He does have some pain to palpation.  Hand has good capillary refill.  He seems to have decreased sensation in all three dermatomes.  He has moderately good abduction of all fingers.  He has moderate opponens strength with his thumb.  He has very good extension of all of his fingers with good strength.,We did an x-ray of his elbow.  He has a spiral fracture of the distal one-third of the humerus, about 13 cm in length.  The proximal part looks like it is in good position.  The distal part has about 6 mm of displacement.  There is no significant angulation.  The joint itself appears to be intact.  The fracture line ends where it appears above the joint.  I do not see any extra blood in the joint.  I do not see any anterior or posterior Siegert sign.,I spoke with Dr. X.  He suggests we go ahead and splint him up and he will follow the patient up.  At this point, it does not seem like there needs to be any surgical revision.  The chance of a compartment syndrome seems very low at this time.,Using 4-inch Ortho-Glass and two assistants, we applied a posterior splint to immobilize his fingers, hand, and wrist all the way up to his elbow to well above the elbow.,He had much better comfort once this was applied.  There was good color to his fingers and again, much better comfort.,Once that was on, I took some 5-inch Ortho-Glass and put in extra reinforcement around the elbow so he would not be moving it, straightening it or breaking the fiberglass.,We then gave him a sling.,We gave him #2 Vicodin p.o. and #4 to go.  Gave him a prescription for #15 more and warned him to take it only at nighttime and use Tylenol or Motrin, and ice in the daytime.,I gave him the name and telephone number of Dr. X whom they can follow up with.  They were warned to come back here if he has increasing neurologic deficits in his hands or any new problems.,DIAGNOSES:,1.  Fracture of the humerus, spiral.,2.  Possible nerve injuries to the radial and median nerve, possibly neurapraxia.,3.  Psychiatric disorder, unspecified.,DISPOSITION:  The patient will follow up as mentioned above.  They can return here anytime as needed.", 
 13 years old complaining about severe ear pain - Chronic otitis media., Consult - History and Phy., Ear pain - Pediatric Consult ,"PRESENTATION: , Patient, 13 years old, comes to your office with his mother complaining about severe ear pain.  He awoke during the night with severe ear pain, and mom states that this is the third time this year he has had earaches.,HISTORY OF PRESENT ILLNESS:  ,Patient reports that he felt good after taking antibiotics with each earache episode and has recently started on the wrestling team.  Mom reports that patient has been afebrile with each of the earache episodes, and he has not had upper respiratory symptoms.  Patient denies any head trauma associated with wrestling practice.,BIRTH AND DEVELOPMENTAL HISTORY:,  Patient's mother reports a normal pregnancy with no complications, having received prenatal care from 12 weeks.  Vaginal delivery was uneventful with a normal perinatal course.  Patient sat alone at 6 months, crawled at 9 months, and walked at 13 months.  His verbal and motor developmental milestones were as expected.,FAMILY/SOCIAL HISTORY: , Patient lives with both parents and two siblings (brother - age 11 years, sister - age 15 years).  He reports enjoying school, remains active in scouts, and is very excited about being on the wresting team.  Mom reports that he has several friends, but she is concerned about the time required for the wrestling team.  Patient is in 8th grade this year and an A/B student.  Both siblings are healthy.  His Dad has hypertension and has frequent heartburn symptoms that he treats with over-the-counter (OTC) medications.  Mom is healthy and has asthma.,PAST MEDICAL HISTORY:  ,Patient has been seen in the clinic yearly for well child exams.  He has had no major illnesses or hospitalizations.  He had one emergency room visit 2 years ago for a knee laceration.  Patient has been healthy except for the past year when he had two episodes of otitis media not associated with respiratory infections.  He received antibiotic therapy (amoxicillin) for the otitis media and both episodes resolved without problems.  Patient's Mom states that he takes no prescribed medications or OTC medications, but he admits that he has been taking his dad's OTC Pepcid AE sometimes when he gets heartburn.  Upon further examination, he reports taking Pepcid when he eats pizza or Mexican food.  He does complain of sore throats sometimes and often feels burning in his throat when he goes to sleep at night after a late evening snack.,NUTRITIONAL HISTORY: , Patient eats cereal bars or pop tarts with milk for breakfast most days.  He takes his lunch (usually a sandwich and chips or yogurt and fruit) for lunch.  Mom or his sister cooks supper in the evening.  The family goes out to eat once or twice a week and he only gets ""fast food"" once or twice a week according to his Mom.  He says he eats ""a lot"" especially after a wrestling meet.,PHYSICAL EXAM:,Height/weight:  Patient weighs 109 pounds (60th percentile) and is 69 inches tall (93rd percentile).  He is following the growth pattern he established in infancy.,Vital signs:  BP 110/60, T 99.2, HR 70, R 16.,General:  Alert, cooperative but a bit shy.,Neuro:  DTRs symmetric, 2+, negative Romberg, able to perform simple calculations without difficulty, short-term memory intact.  He responds appropriately to verbal and visual cues, and movements are smooth and coordinated.,HEENT:  Normocephalic, PEERLA, red reflex present, optic disk and ocular vessels normal.  TMs deep red, dull, landmarks obscured, full bilaterally.  Post auricular and submandibular nodes on left are palpable and slightly tender.,Lungs:  CTA, breath sounds equal bilaterally, excursion and chest configuration normal.,Cardiac:  S1, S2 split, no murmurs, pulses equal bilaterally.,Abdomen:  Soft, rounded, reports no epigastric tenderness but states that heartburn begins in epigastric area and rises to throat.  Bowel sounds active in all quadrants.  No hepatosplenomegaly or tenderness.  No CVA tenderness.,Musculoskeletal:  Full range of motion, all extremities.  Spine straight, able to perform jumping jacks and duck walk without difficulty.,Genital:  Normal male, Tanner stage 4.  Rectal exam - small amount of soft stool, no fissures or masses.,LABS:  ,Stool negative for blood and H. pylori antigen.  Normal CBC and urinalysis.  A barium swallow and upper GI was scheduled for the following week.  It showed marked GE reflux.,ASSESSMENT: , The differential diagnoses for patient included (a) chronic otitis media/treatment failure, (b) peptic ulcer disease/gastritis, (c) gastro esophageal reflux disease (GERD) or carbonated beverage syndrome, (d) trauma.,CHRONIC OTITIS MEDIA. , Chronic otitis media due to a penicillin resistant organism would be the obvious diagnosis in this case.  It is rare for an adolescent to have otitis media with no precipitating factor (such as being on a swim team or otherwise exposed to unusual organisms or in an unusual environment).  It is certainly unusual for him to have three episodes in 1 year.,PEPTIC ULCER DISEASE.,  There were no symptoms of peptic ulcer disease, a negative H. pylori screen and lack of pain made this diagnosis less likely.  Trauma.  Trauma was a possibility, particularly since adolescent males frequently minimize symptoms especially if they might limit participation in a sport but patient maintained that he had not had an event where he struck his head or neck and that he always wore his helmet with ear padding.,GERD.,  The history of ""heartburn"" relieved by his father's medication was striking.  The positive study supported the diagnosis of GERD, which was severe and chronic enough to cause irritation of the mucosal surfaces exposed to the gastric juices and edema, inflammation in the inner ears.,PLAN:,  Patient and his Mom agreed to a trial of omeprazole 20 mg at bedtime for 2 weeks.  Patient was to keep a diary of any episodes of heartburn, including what foods seemed to aggravate it.  The clinician asked him to avoid using any antacid products in the meantime to gage the effectiveness of the medication.  He was also given a prescription for 10 days of Augmentin99 and a follow-up appointment for 2 weeks.  At his follow-up appointment he reported one episode after he ate a whole large pizza after wrestling practice but said it went away pretty quickly after he took his medication.  A 6-month follow up appointment was scheduled.",
" Abnormal cardiac enzyme profile.  The patient is a 66-year-old gentleman, was brought into emergency room with obtundation.  The patient was mechanically ventilated originally.  His initial diagnosis was septic shock.  His labs showed elevated cardiac enzyme profile. ", Consult - History and Phy., Elevated Cardiac Enzymes ,"REASON FOR CONSULTATION:,  Abnormal cardiac enzyme profile.,HISTORY OF PRESENT ILLNESS:,  The patient is a 66-year-old gentleman, was brought into emergency room with obtundation.  The patient was mechanically ventilated originally.  His initial diagnosis was septic shock.  His labs showed elevated cardiac enzyme profile.  This is a consultation for evaluation of the same.  The patient is unable to give history.  History obtained through the family members.  As per the patient's son, he does not have history of cardiac disease.  He lives in Utah, presently spending few months in Arizona.  As I understand, he has been followed by a physician back in Utah and believes that he had some workup done from cardiac standpoint which has been negative so far.  No prior history of chest pain, shortness of breath as per the family members.,CORONARY RISK FACTORS: , History of hypertension, no history of diabetes mellitus, ex-smoker, cholesterol status borderline elevated, no prior history of coronary artery disease, and family history noncontributory.,FAMILY HISTORY: , Nonsignificant.,SURGICAL HISTORY: , Foot surgery as per the family members.,MEDICATIONS:,1.  Vitamin supplementation.,2.  Prednisone.,3.  Cyclobenzaprine.,4.  Losartan 50 mg daily.,5.  Nifedipine 90 mg daily.,6.  Lasix.,7.  Potassium supplementation.,ALLERGIES:,  SULFA.,PERSONAL HISTORY:,  He is an ex-smoker.  Does not consume alcohol.,PAST MEDICAL HISTORY: , Pulmonary fibrosis, on prednisone, oxygen-dependent cellulitis status post foot surgery with infection recuperating from the same.  Presentation today with respiratory acidosis, septicemia and septic shock, presently on mechanical ventilation.  No prior cardiac history.  Elevated cardiac enzyme profile.,REVIEW OF SYSTEMS: , Limited.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 94, blood pressure 98/57, respiratory rate as per setting.,HEENT:  Atraumatic and normocephalic.,NECK:  Supple.  Neck veins flat.,LUNGS:  Air entry bilaterally clear, rales are scattered.,HEART:  PMI displaced.  S1, S2 regular.  Systolic murmur, grade 2/6.,ABDOMEN:  Soft, nontender.,EXTREMITIES:  Chronic skin changes, markings in the lower extremities noted.  Pulses found palpable.  Dressing also noted.,LABORATORY AND DIAGNOSTIC DATA: , EKG, normal sinus rhythm with wide complex.  Labs, white count of 20,000, H&H 10 and 33, platelets of 163, INR 1.36, BUN of 158, creatinine 8.7, potassium 7.3, of bicarbonate is 11.  Cardiac enzyme profile, troponin 0.05, total CK 312, myoglobin 1423.  Chest x-ray, no acute changes.,IMPRESSION:,1.  The patient is a 66-year-old gentleman with pulmonary fibrosis, on prednisone, oxygen dependent with respiratory acidosis.,2.  Septicemia, septic shock secondary to cellulitis of the leg.,3.  Acute renal shutdown.,4.  Elevated cardiac enzyme profile without prior cardiac history possibly due to sepsis and also acute renal failure.,RECOMMENDATIONS:,1.  Echocardiogram to assess LV function to rule out any cardiac valvular involvement.,2.  Aggressive medical management including dialysis.,3.  From cardiac standpoint, conservative treatment at this juncture.  His cardiac enzyme profile could be elevated secondary to sepsis and also underlying renal failure.,4.  Explained to patient's family in detail regarding condition which is critical which they are aware of.",
" Patient went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight, the patient ended up taking a total of six Ecstasy tablets.", Consult - History and Phy., Ecstasy Ingestion - ER Visit ,"CHIEF COMPLAINT:,  ""I took Ecstasy."",HISTORY OF PRESENT ILLNESS: , This is a 17-year-old female who went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight, the patient ended up taking a total of six Ecstasy tablets.  The patient upon returning to home was energetic and agitated and shaking and had one episode of nonbloody, nonbilious emesis.  Mother called the EMS service when the patient vomited.  On arrival here, the patient states that she no longer has any nausea and that she feels just fine.  The patient states she feels wired but has no other problems or complaints.  The patient denies any pain.  The patient does not have any auditory of visual hallucinations.  The patient denies any depression or suicidal ideation.  The patient states that the alcohol and the Ecstasy was done purely as a recreational thing and not as an attempt to harm herself.  The patient denies any homicidal ideation.  The patient denies any recent illness or recent injuries.  The mother states that the daughter appears to be back to her usual self now.,REVIEW OF SYSTEMS: , CONSTITUTIONAL:  No recent illness.  No fever or chills.  HEENT:  No headache.  No neck pain.  No vision change or hearing change.  No eye or ear pain.  No rhinorrhea.  No sore throat.  CARDIOVASCULAR:  No chest pain.  No palpitations or racing heart.  RESPIRATIONS:  No shortness of breath.  No cough.  GASTROINTESTINAL: One episode of nonbloody, nonbilious emesis this morning without any nausea since then.  The patient denies any abdominal pain.  No change in bowel movements.  GENITOURINARY:  No dysuria.  MUSCULOSKELETAL:  No back pain.  No muscle or joint aches.  SKIN:  No rashes or lesions.  NEUROLOGIC:  No dizziness, syncope, or near syncope.  PSYCHIATRIC:  The patient denies any depression, suicidal ideation, homicidal ideation, auditory hallucinations or visual hallucinations.  ENDOCRINE:  No heat or cold intolerance.,PAST MEDICAL HISTORY:,  None.,PAST SURGICAL HISTORY: , Appendectomy when she was 9 years old.,CURRENT MEDICATIONS: , Birth control pills.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient denies smoking cigarettes.  The patient does drink alcohol and also uses illicit drugs.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Temperature is 98.8 oral, blood pressure 140/86, pulse is 79, respirations 16, oxygen saturation 100% on room air and is interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished, and well developed, appears to be healthy.  The patient is calm and comfortable, in no acute distress and looks well.  The patient is pleasant and cooperative.  HEENT:  Head is atraumatic, normocephalic, and nontender.  Eyes are normal with clear cornea and conjunctiva bilaterally.  The patient does have dilated pupils of approximately 8 mm each and are equally round and reactive to light bilaterally.  No evidence of light sensitivity or photophobia.  Extraocular motions are intact bilaterally.  Nose is normal without rhinorrhea or audible congestion.  Ears are normal without any sign of infection.  Mouth and oropharynx are normal without any signs of infection.  Mucous membranes are moist.  NECK:  Supple and nontender.  Full range of motion.  There is no JVD.  CARDIOVASCULAR:  Heart is regular rate and rhythm without murmur, rub or gallop.  Peripheral pulses are +3 and bounding.  RESPIRATIONS:  Clear to auscultation bilaterally.  No shortness of breath.  No wheezes, rales or rhonchi.  Good air movement bilaterally.  GASTROINTESTINAL:  Abdomen is soft, nontender, normal and benign.  MUSCULOSKELETAL:  No abnormalities noted in back, arms, or legs.  The patient is normal use of her extremities.  SKIN:  No rashes or lesions.  NEUROLOGIC:  Cranial nerves II through XII are intact.  Motor and sensory are intact in all extremities.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is alert and oriented x4.  The patient does not have any smell of alcohol and does not exhibit any clinical intoxication.  The patient is quite pleasant, fully cooperative.  HEMATOLOGIC/LYMPHATIC: NO lymphadenitis is noted.  No bruising is noted.,DIAGNOSES:,1.  ECSTASY INGESTION.,2.  ALCOHOL INGESTION.,3.  VOMITING SECONDARY TO STIMULANT ABUSE.,CONDITION UPON DISPOSITION: , Stable disposition to home with her mother.,PLAN:,  I will have the patient followup with her physician at the ABC Clinic in two days for reevaluation.  The patient was advised to stop drinking alcohol, and taking Ecstasy as this is not only in the interest of her health, but was also illegal.  The patient is asked to return to the emergency room should she have any worsening of her condition, develop any other problems or symptoms of concern.","consult - history and phy., nonbilious emesis, hallucinations, visual, auditory, ecstasy ingestion, suicidal ideation, homicidal ideation, ingestion, infection, alcohol, ecstasy, "
" A 50-year-old white male with dog bite to his right leg with a history of pulmonary fibrosis, status post bilateral lung transplant several years ago.", Consult - History and Phy., Dog Bite ,"CHIEF COMPLAINT:,  Dog bite to his right lower leg.,HISTORY OF PRESENT ILLNESS:,  This 50-year-old white male earlier this afternoon was attempting to adjust a cable that a dog was tied to.  Dog was a German shepherd, it belonged to his brother, and the dog spontaneously attacked him.  He sustained a bite to his right lower leg.  Apparently, according to the patient, the dog is well known and is up-to-date on his shots and they wanted to confirm that.  The dog has given no prior history of any reason to believe he is not a healthy dog.  The patient himself developed a puncture wound with a flap injury.  The patient has a flap wound also below the puncture wound, a V-shaped flap, which is pointing towards the foot.  It appears to be viable.  The wound is open about may be roughly a centimeter in the inside of the flap.  He was seen by his medical primary care physician and was given a tetanus shot and the wound was cleaned and wrapped, and then he was referred to us for further assessment.,PAST MEDICAL HISTORY:  ,Significant for history of pulmonary fibrosis and atrial fibrillation.  He is status post bilateral lung transplant back in 2004 because of the pulmonary fibrosis.,ALLERGIES:  ,There are no known allergies.,MEDICATIONS:,  Include multiple medications that are significant for his lung transplant including Prograf, CellCept, prednisone, omeprazole, Bactrim which he is on chronically, folic acid, vitamin D, Mag-Ox, Toprol-XL, calcium 500 mg, vitamin B1, Centrum Silver, verapamil, and digoxin.,FAMILY HISTORY: , Consistent with a sister of his has ovarian cancer and his father had liver cancer.  Heart disease in the patient's mother and father, and father also has diabetes.,SOCIAL HISTORY:,  He is a non-cigarette smoker.  He has occasional glass of wine.  He is married.  He has one biological child and three stepchildren.  He works for ABCD.,REVIEW OF SYSTEMS:,  He denies any chest pain.  He does admit to exertional shortness of breath.  He denies any GI or GU problems.  He denies any bleeding disorders.,PHYSICAL EXAMINATION,GENERAL:  Presents as a well-developed, well-nourished 50-year-old white male who appears to be in mild distress.,HEENT:  Unremarkable.,NECK:  Supple.  There is no mass, adenopathy or bruit.,CHEST:  Normal excursion.,LUNGS:  Clear to auscultation and percussion.,COR:  Regular.  There is no S3 or S4 gallop.  There is no obvious murmur.,ABDOMEN:  Soft.  It is nontender.  Bowel sounds are present.  There is no tenderness.,SKIN:  He does have like a Chevron incisional scar across his lower chest and upper abdomen.  It appears to be well healed and unremarkable.,GENITALIA:  Deferred.,RECTAL:  Deferred.,EXTREMITIES:  He has about 1+ pitting edema to both legs and they have been present since the surgery.  In the right leg, he has an about midway between the right knee and right ankle on the anterior pretibial area, he has a puncture wound that measures about may be centimeter around that appears to be relatively clean, and just below that about may be 3 cm below, he has a flap traumatic injury that measures about may be 4 cm to the point of the flap.  The wound is spread apart about may be a centimeter all along that area and it is relatively clean.  There was some bleeding when I removed the dressing and we were able to pretty much control that with pressure and some silver nitrate.  There were exposed subcutaneous tissues, but there was no exposed tendons that we could see, etc.  The flap appeared to be viable.,NEUROLOGIC:  Without focal deficits.  The patient is alert and oriented.,IMPRESSION:,  A 50-year-old white male with dog bite to his right leg with a history of pulmonary fibrosis, status post bilateral lung transplant several years ago.  He is on multiple medications and he is on chronic Bactrim.  We are going to also add some fluoroquinolone right now to protect the skin and probably going to obtain an Infectious Disease consult.  We will see him back in the office early next week to reassess his wound.  He is to keep the wound clean with the moist dressing right now.  He may shower several times a day.",
" Patient reports a rotational sensation upon arising from the bed or chair that lasts for several minutes and requires her to sit back down and stay in one place.  She gets similar symptoms when she rolls over in bed.  At times, she also feels as though she is going to pass out.  These sensations stop if she just sits in one place or lies down for several minutes.", Consult - History and Phy., Dizziness - Recurrent ,"CHIEF COMPLAINT:,  Recurrent dizziness x1 month.,HISTORY OF PRESENT ILLNESS:,  This is a 77-year-old African-American female with multiple medical problems including CHF (O2 dependent), atrial fibrillation, diabetes mellitus, hypothyroidism, possible stroke, multiple joint disease including gout, arthritis, both rheumatoid and DJD, who presents with a complaint of one month of dizziness.  She reports a rotational sensation upon arising from the bed or chair that lasts for several minutes and requires her to sit back down and stay in one place.  She gets similar symptoms when she rolls over in bed.  She is not able to describe what direction she feels like she is spinning.  At times, she also feels as though she is going to pass out.  These sensations stop if she just sits in one place or lies down for several minutes.  She does note that it is worse when she turns to the right and when she turns to the left.  She also complains that she gets similar sensations when she looks up.  She denies any recent fever, chills, earache, diplopia, dysarthria, dysphagia, other change in vision, or recent new headaches.  She also notes occasional tinnitus to her right ear.,PAST MEDICAL HISTORY:,1.  CHF (uses portable oxygen).,2.  Atrial fibrillation.,3.  Gout.,4.  Arthritis (DJD/rheumatoid).,5.  Diabetes mellitus.,6.  Hypothyroidism.,7.  Hypertension.,8.  GERD.,9.  Possible stroke treated in 2003 at University of Maryland with acute onset of presyncopal sensations, sharp pains in the left side of her head and right-sided hemiparesis and numbness.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: , She is married.  She does not smoke, use alcohol or use illicit drugs.,MEDICATIONS: , Please see medication sheet in the chart.  It includes potassium, Pravachol, Prevacid, Synthroid, Diovan, Amaryl, Vitamin B12, Coreg, Coumadin, furosemide, Actos, aspirin, colchicine, Cipro, Percocet, Ultram (has held the latter two medications for the past two weeks due to concerns of exacerbating dizziness).,REVIEW OF SYSTEMS:,  Please see note in chart essentially entirely positive including cardiovascular problems of shortness of breath, PND and palpitations, chronic lack of energy, weight gain, the dizziness for which she presented.  Tinnitus in the right ear.  Diabetes and hypothyroidism.  Chronic nausea.  Chronic severe musculoskeletal pains to all extremities as well as to chest and abdomen and back.  Right-sided numbness as well as complaints of bilateral lower extremity numbness and difficulty walking.  She says her mood is sad and may be depressed and she is also extremely anxious.  She has chronic shortness of breath and coughs easily when has to breathe deeply.  She also endorses poor sleep.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Sitting BP 112/84 with a pulse of 84, standing after two minutes 130/90 with a pulse of 66.  Respiratory rate is 20.  Weight is 257 pounds.  Pain scale is 7.,GENERAL:  This is a somewhat anxious elderly African-American female who tends to amplify findings on examination.  It is a difficult examination due to the fact that no matter where the patient was touched she would wince in pain and withdraw.  She is obese.,HEENT:  She is normocephalic and atraumatic.  Conjunctivae and sclerae are clear.  Tympanic membranes were visualized bilaterally.  There is tenderness to palpation of any sinus region.  There are no palpable cervical nodes.,NECK:  Supple although she complains of pain when rotating her neck.,CHEST:  Clear to auscultation bilaterally.,HEART:  Heart sounds are distant.  There are no carotid bruits.,EXTREMITIES:  She has 1-2+ pitting edema to the mid shins bilaterally.,NEUROLOGIC EXAMINATION:,MENTAL STATUS:  She is alert and oriented x3.  Her speech is fluent; however, she is extremely tangential.  She is unable to give a cogent medical history including details of hospitalization one month ago when she was admitted for a gout attack and urinary tract infection and underwent several days of rehabilitation.,CRANIAL NERVES:  Cranial nerves are intact throughout; specifically there is no nystagmus, her gaze is conjugate, there is no diplopia, visual fields are full to confrontation, pupils are equal, round and reactive to light and accommodation, extraocular movements are intact, facial sensation and expression are symmetric, vestibuloocular reflexes are intact, hearing is intact to finger rub bilaterally, palate rises symmetrically, normal cough, shoulder shrug is symmetric which shows easy breakaway give, and tongue protrudes in the midline.,MOTOR:  This is a limited exam due to easy breakaway gait and pain that appears exaggerated to movement of any extremity.  There is suggestion of some mild right-sided paresis; however, the degree was inconsistent and her phasic strength is estimated at 4-4+ throughout.  Her tone is normal throughout.,SENSORY:  She appears to have diffuse light tough and pinprick and temperature to the right arm and proximal leg.  She also reports that she is numb in both feet; however, sensation testing of light tough, pinprick and vibration was intact.,COORDINATION:  There is no obvious dysmetria.,GAIT:  She uses a walker to stand up, and several near falls when asked to stand unassisted and can only ambulate with a walker.  There are some mild right lower extremity circumduction present.,REFLEXES:  Biceps 1, triceps trace, brachioradialis 1, patella and ankle absent.  Toes are equivocal.,OTHER:  Barany maneuver was attempted; however, when the patient was placed supine she immediately began screaming, ""Oh my back, oh my back"", and was unable to complete the maneuver.  Brief inspection of her eyes failed to show any nystagmus at that time.,IMPRESSION AND PLAN:,  This is a 77-year-old African-American female with multiple medical problems who presents with episodic positionally related dizziness of unclear etiology.  Most certainly there is significant exaggeration of the underlying problem and her neurological examination is compounded by much functional overlay, limiting the interpretation of my findings.  I suspect this is just a mild benign positional vertigo, although I cannot rule out vertebrobasilar compromise.  I agree with symptomatic treatment with Antivert.,We will schedule her for CT of head, CT angiogram to evaluate for possible brain stroke and vertebrobasilar insufficiency.  In addition, we will attempt to get further objective data by ENG testing.  I will see the patient again after these tests are completed and she has a trial of the Antivert.",
 Patient with episode of lightheadedness and suddenly experienced vertigo., Consult - History and Phy., Dural AVM ,"CC: ,Vertigo.,HX: ,This 61y/o RHF experienced a 2-3 minute episode of lightheadedness while driving home from the dentist in 5/92. In 11/92, while eating breakfast, she suddenly experienced vertigo. This was immediately followed by nausea and several episodes of vomiting. The vertigo lasted 2-3minutes. She retired to her room for a 2 hour nap after vomiting. When she awoke, the symptoms had resolved. On 1/13/93 she had an episode of right arm numbness lasting 4-5hours. There was no associated weakness, HA, dysarthria, dysphagia, visual change, vertigo or lightheadedness.,OUTSIDE RECORDS:, 12/16/92 Carotid Doppler (RICA 30-40%, LICA 10-20%). 12/4/92, brain MRI revealed a right cerebellar hypodensity consistent with infarct.,MEDS:, Zantac 150mg bid, Proventil MDI bid, Azmacort MDI bid, Doxycycline 100mg bid, Premarin 0.625mg qd, Provera 2.5mg qd. ASA 325mg qd.,PMH:, 1)MDD off antidepressants since 6/92. 2)asthma. 3)allergic rhinitis. 4)chronic sinusitis. 5)s/p Caldwell-Luc 1978, and nasal polypectomy. 6) GERD. 7)h/o elevated TSH. 8)hypercholesterolemia 287 on 11/20/93. 9)h/o heme positive stool: BE 11/24/92 and UGI 11/25/92 negative.,FHX: ,Father died of a thoracic aortic aneurysm, age 71. Mother died of stroke, age 81.,SHX:, Married. One son deceased. Salesperson. Denied tobacco/ETOH/illicit drug use.,EXAM,: BP (RUE)132/72 LUE (136/76). HR67 RR16 Afebrile. 59.2kg.,MS: A&O to person, place, time. Speech fluent and without dysarthria. Thought lucid.,CN: unremarkable.,Motor: 5/5 strength throughout with normal muscle bulk and tone.,Sensory: No deficits appreciated.,Coord: unremarkable.,Station: no pronator drift, truncal ataxia, or Romberg sign.,Gait: not done.,Reflexes: 2/2 throughout BUE and at patellae. 1/1 at Achilles. Plantar responses were flexor, bilaterally.,Gen Exam: Obese.,COURSE: ,CBC, GS, PT/PTT, UA were unremarkable. The patient was admitted with a working diagnosis of posterior circulation TIA and history of cerebellar stroke. She was placed on Ticlid 250mg bid. HCT,1/15/93: low density focus in the right medial and posterior cerebellar hemisphere. MRI and MRA, 1/18/93, revealed a well circumscribed lesion within the posterior aspect of the right cerebellar hemisphere suggestive of vascular malformation (e.g. cavernous angioma. An abnormal vascular blush was seen on the MRA. This area appeared to be supplied by one of the external carotid arteries (which one is was not specified). this finding maybe suggestive of a vascular malformation. 1/20/93 Cerebral Angiogram: The right cerebellar hemisphere lesion seen on MRI as a possible cavernous angioma was not seen on angiography. Upon review of the MRI and HCT the lesion was felt to probably represent an old infarction with hemosiderin deposition. The ""vascular blush"" seen on MRA was no visualized on angiography. The patient was discharged home on 1/25/93.","consult - history and phy., avm, episode of lightheadedness, vascular malformation, cavernous angioma, vascular blush, cerebellar hemisphere, malformation, cavernous, angioma, angiography, lightheadedness, hemisphere, vertigo, cerebellar, "
 Right ear pain with drainage - otitis media and otorrhea., Consult - History and Phy., Ear Pain - Drainage ,"CHIEF COMPLAINT:,  Right ear pain with drainage.,HISTORY OF PRESENT ILLNESS:,  This is a 12-year-old white male here with his mother for complaints of his right ear hurting.  Mother states he has been complaining for several days.  A couple of days ago she noticed drainage from the right ear.  The patient states it has been draining for several days and it has a foul smell to it.  He has had some low-grade fever.  The patient was seen in the office about a week ago with complaints of a sore throat, headache and fever.  The patient was evaluated for Strep throat which was negative and just had been doing supportive care.  He did have a recent airplane ride a couple of weeks ago also.  There has been no cough, shortness of breath or wheezing.  No vomiting or diarrhea.,PHYSICAL EXAM:,General:  He is alert in no distress.,Vital Signs:  Temperature:  99.1 degrees.,HEENT:  Normocephalic, atraumatic.  Pupils equal, round and react to light.  The left TM is clear.  The right TM is poorly visualized secondary to purulent secretions in the right ear canal.  There is no erythema of the ear canals.  Nares is patent.  Oropharynx is clear.  The patient does wear braces.,Neck:  Supple.,Lungs:  Clear to auscultation.,Heart:  Regular.  No murmur.,ASSESSMENT:,1.  Right otitis media.,2.  Right otorrhea.,PLAN:,  Ceftin 250 mg by mouth twice a day for 10 days.  Ciprodex four drops to the right ear twice a day.  The patient is to return to the office in two weeks for followup.","consult - history and phy., drainage, ear hurting, ear pain, otitis media, otorrhea, ear pain with drainage, otitis, media, ear,"
 Dysphagia and hematemesis while vomiting.  Diffuse esophageal dilatation/hematemesis, Consult - History and Phy., Dysphagia & Hematemesis ,"CHIEF COMPLAINT: , Dysphagia and hematemesis while vomiting.,HISTORY OF PRESENT ILLNESS: , This is a 53-year-old African American female with 15 years known history of HIV and hepatitis B, and known history of compensated heart failure, COPD, who presented today with complaint of stuck food in her esophagus, bloody cough, and bloody vomiting since 4 o'clock this vomiting, when she ate eggplant parmigiana meal.  The back and chest pain is 8/10, no radiation and is constant.  She denied fever, abdominal pain, or dysphagia before current event eating bones or fish.  This is the first episode of hematemesis and feeling of globus pallidus.  In the emergency room, the patient was treated with nitropaste, morphine, and Lopressor with positive results for chest pain.  CAT scan of the chest showed diffuse esophageal dilatation with residual food in it, no mediastinal air was identified.,REVIEW OF SYSTEMS: , The patient denied diarrhea, abdominal pain, fever, weight loss, dysphagia before this event.  Denied any exertional chest pain or shortness of breath.  No headache, limb weakness.  No joint pain or muscle ache.  No dysuria.,PAST MEDICAL HISTORY:  ,Remarkable for:,1.  Asthma.,2.  Hepatitis C - 1995.,3.  HIV, known since 1995 and followed up by Dr. X, ABCD Medical Center, the last visit was 08/09.  The patient does not take HIV medications against medical advice.,4.  Hypertension, known since 2008.,5.  Negative PPD test, 10/08.,PAST SURGICAL HISTORY: , Remarkable for hysterectomy in 2001, pilonidal cyst surgery in 2005.,FAMILY HISTORY: , Mother deceased at age 68 of cirrhosis.  She had history of alcohol abuse.  Father deceased at age 45, also has a history of alcohol abuse, cardiac disease, and hypertension.,ALLERGIES: , Not known allergies.,MEDICATIONS AT HOME: , Lisinopril 5 mg daily; metoprolol 25 mg twice daily; furosemide 40 mg once daily; Isentress 400 mg once daily, the patient does not take this medication for the last 3 months; Norvir 100 mg once daily; Prezista 400 mg once daily.  The patient does not take her HIV medications for the last 2 to 3 months.  Occasionally, she takes inhalation of albuterol and Ambien 10 mg once daily.,SOCIAL HISTORY: , She is single, lives with her 21-year-old daughter, works as CNA, smokes one pack per day for the last 8 years.  She had periods when she quit smoking and started again 2-1/2 years ago.  She denied alcohol abuse and she was using cocaine in the past, last time she used cocaine 10 years ago.,PHYSICAL EXAMINATION: , Temperature 99.8, pulse 106, respiratory rate 18, blood pressure 162/97, saturation 99 on room air.  African American female, not in acute respiratory distress, but uncomfortable, and showing some signs of back discomfort.  Oriented x3, mildly drowsy, calm and cooperative.  Eyes, EOMI, PERRLA.  Tympanic membranes normal appearance bilaterally.  External canal, no erythema or discharge.  Nose, no erythema or discharge.  Throat, dry mucous, no exudates.  No ulcers in oral area.  Full upper denture and extensive decayed lower teeth.  No cervical lymphadenopathy, no carotid bruits bilaterally.  Heart:  RRR, S1 and S2 appreciated.  No additional sounds or murmurs were auscultated.  Lung:  Good air entrance bilaterally.  No rales or rhonchi.  Abdomen:  Soft, nontender, nondistended.  No masses or organomegaly were palpated.  Legs:  No signs of DVT, peripheral pulses full, posterior dorsalis pedis 2+.  Skin:  No rashes or other lesions, warm and well perfused.  Nails:  No clubbing.  No other signs of skin infection.  Neurological exam:  Cranial nerves II through XII grossly intact.  No motor or sensory deficit was found.,CAT scan of the chest, which was done at 8 o'clock in the morning on 01/12/10.  Impression:  Cardiomegaly, normal aorta, large distention of esophagus containing food.  Chest x-ray:  Cardiomegaly, no evidence of CHF or pneumonia.  EKG:  Normal sinus rhythm, no signs of ischemia.,LABORATORY DATA: , Hemoglobin 10.4, hematocrit 30.6, white blood cells 7.3, neutrophils 75, platelets 197.  Sodium 140, potassium 3.1, chloride 104, bicarb 25, glucose 113, BUN 19, creatinine 1.1, GFR 55, calcium 8.8, total protein 8.1, albumin 3.1, globulin 5.0, bilirubin 0.3, alk phos 63, GOT 23, GPT 22, lipase 104, amylase 85, protime 10.2, INR 1, PTT 25.8.  Urine:  Negative for ketones, protein, glucose, blood, and nitrite, bacteria 2+.  Troponin 0.040.  BNP 1328.,PLAN:,1.  Diffuse esophageal dilatation/hematemesis.  We will put her n.p.o., we will give IV fluid, half normal saline D5 100 mL per hour.  I discussed the case with Dr. Y, gastroenterologist.  The patient planned for EGD starting today.  Differential diagnosis may include foreign body, achalasia, Candida infection, or CMV esophagitis.  We will treat according to the EGD findings.  We will give IV Nexium 40 mg daily for GI prophylaxis.  We will hold all p.o. medication.,2.  CHF.  Cardiomegaly on x-ray.  She is clinically stable.  Lungs are clear.  No radiological sign of CHF exacerbation.  We will restart lisinopril and metoprolol after EGD study will be completed.,3.  HIV - follow up by Dr. X, (ABCD Medical Center).  The last visit was on 08/08.  The patient was not taking her HIV medications for the last 3 months and does not know her CD4 number or viral load.  We will check CD4 number and viral load.  We will contact Dr. X (ID specialist in ABCD Med).,4.  Hypertension.  We will control blood pressor with Lopressor 5 mg IV p.r.n.  If blood pressure more than 160/90, we will hold metoprolol and lisinopril.,5.  Hepatitis C, known since 1995.  The patient does not take any treatment.,6.  Tobacco abuse.  The patient refused nicotine patch.,7.  GI prophylaxis as stated above; and DVT prophylaxis, compression socks.  We will restrain from using heparin or Lovenox.,ADDENDUM: , The patient was examined by Dr. Y, gastroenterologist, who ordered a CAT scan with oral contrast, which showed persistent distention of the esophagus with elementary debris within the lumen of the esophagus.  There is no evidence of leakage of the oral contrast.  There is decrease in size of periaortic soft tissue density around the descending aorta, this is associated with increase in very small left pleural effusion in the intervening time.  There is no evidence of pneumomediastinum or pneumothorax, lungs are clear, contrast is present in stomach.  After procedure, the patient had profuse vomiting with bloody content and spiked fever 102.  The patient felt relieved after vomiting.  The patient was started on aztreonam 1 g IV every 8 hours, Flagyl 500 mg IV every 8 hours.  ID consult was called and thoracic surgeon consult was ordered.",
 A 12-year-old with discoid lupus on the control with optimal regimen., Consult - History and Phy., Discoid Lupus ,"HISTORY:  ,A is 12-year-old female who comes today for follow-up appointment and a CCS visit.  She has the diagnosis of discoid lupus and we have been following her for her conditions, her treatments, and also to watch her for any development of her systemic lupus.  A has been doing well with just Plaquenil alone and mother said that during the summer, the rash gets brighter, but now that it is getting darker and she is at school, the rash is starting to become lighter again.  She has been using her cream, which is hydrocortisone at night and applying it with no problems.  She denies any hair losses, denies any decrease in appetite, actually, she has been gaining some weight.  She denies any ulcerations in her mouth, eye problems, or any lumps in her body.  She denies any fevers or any problems with the urine.,PHYSICAL EXAMINATION: ,VITAL SIGNS:  Today temperature is 100.1, weight is 73.5 kg, blood pressure is 121/61, height is 158, and pulse is 84.,GENERAL:  She is alert, active, and oriented in no distress.,HEENT:  She had a head full of hair with no bald spots.  She has a macular rash on her cheeks bilaterally with hyperpigmented circles.  No scales, no excoriations, and no palpable erythema.  Oral mucosa is clear with no ulcerations.,NECK:  Soft with no masses.  She does have acanthosis nigricans on the base of the neck.,CHEST:  Clear to auscultation.,HEART:  Regular rhythm with no murmur.,ABDOMEN:  Soft and nontender with no visceromegaly.,MUSCULOSKELETAL:  Shows no limitation, swelling, or tenderness in any of her joints.,SKIN:  Shows a discoid rash with macules approximately 1 cm in diameter in different shapes and size, but most of them are about 1 cm in diameter, which are hyperpigmented.  No erythema, no purpura, no petechiae, and no raised borders.  They look more like cigarette points.  She has this in her upper extremities especially in the forearms and also on her lower extremities, on the legs, but just very few lesions and very light.  She has some periungual erythema, as well as some palmar erythema, but this is minimal.,LABORATORY DATA:,  Laboratories today done, we have a CBC with a white blood cell count of 7.9, hemoglobin is 14.3, platelet count is 321,000, sed rate is only 11, and CMP shows no abnormalities.  Pending is antinuclear antibody complement level.,ASSESSMENT: , She is 12-year-old with discoid lupus on the control with optimal regimen.  We are going to switch her to Protopic at night, especially in the face.  Continue on Plaquenil, get some laboratories and wait for the results.  Diet evaluation today because of the gaining weight and acanthosis nigricans, and will see her back in about 3 months for follow-up.  Future plans will be depending on whether or not she evolves into a full-blown lupus.  I discussed the plan with her mother and they had no further questions.","consult - history and phy., lupus, systemic lupus, acanthosis nigricans, discoid lupus, extremities, rash, erythema, discoid,"
" He awoke one morning and had double vision.  He states when he closed each eye, the double vision dissipated.  The double vision entirely dissipated within one hour.   The next day he woke up and he had double vision again. ", Consult - History and Phy., Diplopia ,"HISTORY OF PRESENT ILLNESS: , The patient is a 53-year-old right-handed gentleman who presents to the clinic for further evaluation of diplopia.  He states that he was in his usual state of health when he awoke one morning in January 2009.  He had double vision.  He states when he closed each eye, the double vision dissipated.  The double vision entirely dissipated within one hour.  He was able to drive.  However, the next day he woke up and he had double vision again.  Over the next week, the double vision worsened in intensity and frequency and by the second week, it was severe.  He states that he called Sinai Hospital and spoke to a physician who recommended that he come in for evaluation.  He was seen by a primary care physician who sent him for an ophthalmologic evaluation.  He was seen and referred to the emergency department for an urgent MRI to evaluate for possible aneurysm.  The patient states that he had a normal MRI and was discharged to home.,For the next month, the double vision improved, although he currently still experiences constant diplopia.  Whereas in the past, when he would see two objects, they were very far apart in a horizontal plane; now they are much closer together.  He still does not drive.  He also is not working due to the double vision.  There is no temporal fluctuation to the double vision.  More recently, over the past month, he has developed right supraorbital pain.  It actually feels like there is pain under his right lid.  He denies any dysphagia, dysarthria, weakness, numbness, tingling, or any other neurological symptoms.,There is a neurology consultation in the computer system.  Dr. X saw the patient on February 2, 2009, when he was in the emergency department.  He underwent an MRI that showed a questionable 3 mm aneurysm of the medial left supraclinoid internal carotid artery, but there were no abnormalities on the right side.  MRV was negative and MRI of the brain with and without contrast was also negative.  He also had an MRI of the orbit with and without contrast that was normal.  His impression was that the patient should follow up for a possible evaluation of myasthenia gravis or other disorder.,At the time of the examination, it was documented that he had right lid ptosis.  He had left gaze diplopia.  The pupils were equal, round, and reactive to light.  His neurological examination was otherwise entirely normal.  According to Dr. X's note, the ophthalmologist who saw him thought that there was ptosis of the right eye as well as an abnormal pupil.  There was also right medial rectus as well as possibly other extraocular abnormalities.  I do not have the official ophthalmologic consultation available to me today.,PAST MEDICAL HISTORY: , The patient denies any previous past medical history.  He currently does not have a primary care physician as he is uninsured.,MEDICATIONS:,  He does not take any medications.,ALLERGIES: , He has no known drug allergies.,SOCIAL HISTORY: , The patient lives with his wife.  He was an IT software developer, but he has been out of work for several months.  He smokes less than a pack of cigarettes daily.  He denies alcohol or illicit drug use.,FAMILY HISTORY: , His mother died of a stroke in her 90s.  His father had colon cancer.  He is unaware of any family members with neurological disorders.,REVIEW OF SYSTEMS: , A complete review of systems was obtained and was negative except for as mentioned above.  This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:,Vital Signs:  BP 124/76",
 A 63-year-old man with a dilated cardiomyopathy presents with a chief complaint of heart failure.  He has noted shortness of breath with exertion and occasional shortness of breath at rest. , Consult - History and Phy., Dilated Cardiomyopathy - Consult ,"REASON FOR VISIT: , I have been asked to see this 63-year-old man with a dilated cardiomyopathy by Dr. X at ABCD Hospital.  He presents with a chief complaint of heart failure.,HISTORY OF PRESENT ILLNESS: , In retrospect, he has had symptoms for the past year of heart failure.  He feels in general ""OK,"" but is stressed and fatigued.  He works hard running 3 companies.  He has noted shortness of breath with exertion and occasional shortness of breath at rest.  There has been some PND, but he sleeps on 1 pillow.  He has no edema now, but has had some mild leg swelling in the past.  There has never been any angina and he denies any palpitations, syncope or near syncope.  When he takes his pulse, he notes some irregularity.  He follows no special diet.  He gets no regular exercise, although he has recently started walking for half an hour a day.  Over the course of the past year, these symptoms have been slowly getting worse.  He gained about 20 pounds over the past year.,There is no prior history of either heart failure or other heart problems.,His past medical history is remarkable for a right inguinal hernia repair done in 1982.  He had trauma to his right thumb.  There is no history of high blood pressure, diabetes mellitus or heart murmur.,On social history, he lives in San Salvador with his wife.  He has a lot of stress in his life.  He does not smoke, but does drink.  He has high school education.,On family history, mother is alive at age 89.  Father died at 72 of heart attack.  He has 2 brothers and 1 sister all of whom are healthy, although the oldest suffered a myocardial infarction.  He has 3 healthy girls and 9 healthy grandchildren.,A complete review of systems was performed and is negative aside from what is mentioned in the history of present illness.,MEDICATIONS: , Aspirin 81 mg daily and chlordiazepoxide and clidinium - combination pill at 5 mg/2.5 mg 1 tablet daily for stress.,ALLERGIES: , Denied.,MAJOR FINDINGS:,  On my comprehensive cardiovascular examination, he is 5 feet 8 inches and weighs 231 pounds.  His blood pressure is 120/70 in each arm seated.  His pulse is 80 beats per minute and regular.  He is breathing 1two times per minute and that is unlabored.  Eyelids are normal.  Pupils are round and reactive to light.  Conjunctivae are clear and sclerae are anicteric.  There is no oral thrush or central cyanosis.  Neck is supple and symmetrical without adenopathy or thyromegaly.  Jugular venous pressure is normal.  Carotids are brisk without bruits.  Lungs are clear to auscultation and percussion.  The precordium is quiet.  The rhythm is regular.  The first and second heart sounds are normal.  He does have a fourth heart sound and a soft systolic murmur.  The precordial impulse is enlarged.  Abdomen is soft without hepatosplenomegaly or masses.  He has no clubbing, cyanosis or peripheral edema.  Distal pulses are normal throughout both arms and both legs.  On neurologic examination, his mentation is normal.  His mood and affect are normal.  He is oriented to person, place, and time.,DATA: , His EKG shows sinus rhythm with left ventricular hypertrophy.,A metabolic stress test shows that he was able to exercise for 5 minutes and 20 seconds to 90% of his maximum predicted heart rate.  His peak oxygen consumption was 19.7 mL/kg/min, which is consistent with mild cardiopulmonary disease.,Laboratory data shows his TSH to be 1.33.  His glucose is 97 and creatinine 0.9.  Potassium is 4.3.  He is not anemic.  Urinalysis was normal.,I reviewed his echocardiogram personally.  This shows a dilated cardiomyopathy with EF of 15%.  The left ventricular diastolic dimension is 6.8 cm.  There are no significant valvular abnormalities.,He had a stress thallium.  His heart rate response to stress was appropriate.  The thallium images showed no scintigraphic evidence of stress-induced myocardial ischemia at 91% of his maximum age predicted heart rate.  There is a fixed small sized mild-to-moderate intensity perfusion defect in the distal inferior wall and apex, which may be an old infarct, but certainly does not account for the degree of cardiomyopathy.  We got his post-stress EF to be 33% and the left ventricular cavity appeared to be enlarged.  The total calcium score will put him in the 56 percentile for subjects of the same age, gender, and race/ethnicity.,ASSESSMENTS: , This appears to be a newly diagnosed dilated cardiomyopathy, the etiology of which is uncertain.,PROBLEMS DIAGNOSES:  ,1.  Dilated cardiomyopathy.,2.  Dyslipidemia.,PROCEDURES AND IMMUNIZATIONS: , None today.,PLANS: , I started him on an ACE inhibitor, lisinopril 2.5 mg daily, and a beta-blocker, carvedilol 3.125 mg twice daily.  The dose of these drugs should be up-titrated every 2 weeks to a target dose of lisinopril of 20 mg daily and carvedilol 25 mg twice daily.  In addition, he could benefit from a loop diuretic such as furosemide.  I did not start this as he is planning to go back home to San Salvador tomorrow.  I will leave that up to his local physicians to up-titrate the medications and get him started on some furosemide.,In terms of the dilated cardiomyopathy, there is not much further that needs to be done, except for family screening.  All of his siblings and his children should have an EKG and an echocardiogram to make sure they have not developed the same thing.  There is a strong genetic component of this.,I will see him again in 3 to 6 months, whenever he can make it back here.  He does not need a defibrillator right now and my plan would be to get him on the right doses of the right medications and then recheck an echocardiogram 3 months later.  If his LV function has not improved, he does have New York Heart Association Class II symptoms and so he would benefit from a prophylactic ICD.,Thank you for asking me to participate in his care.,MEDICATION CHANGES:,  See the above.",
 Difficulty with both distance vision and with fine print at near., Consult - History and Phy., Difficulty Distance Vision & Fine Print at Near ,"REASON FOR VISIT: , Mr. ABC is a 61-year-old Caucasian male who presents to us today as a new patient.  He states that he has difficulty with both his distance vision and also with fine print at near.,HISTORY OF PRESENT ILLNESS:,  Mr. ABC states that over the last year, he has had increasing difficulty with distance vision particularly when he is driving.  He is also having trouble when he is reading.  He does occasionally wear over-the-counter reading glasses, which do help with his near vision.,Past ocular history is significant for astigmatism for which he wore glasses since he was 18 years old.  However, Mr. ABC mentioned today that he has not worn his glasses for the last few years.,His past medical history is significant for hypertension, low serum testosterone level, hypercholesterolemia, GERD, depression, actinic keratoses, and a history of Pityrosporum folliculitis.,His family history is significant for diabetes in both parents.  He states that his mother is seen by Mrs. Goldberg, but he is not aware of her ocular history.  He has no known family history of glaucoma, age-related macular degeneration or hereditary blindness.,MEDICATIONS: , Wellbutrin XL 450 mg daily, Ritalin long-acting 60 mg daily, hydrochlorothiazide at an unknown dose, Vytorin at an unknown dose, and aspirin.,ALLERGIES: , No known drug allergies.,FINDINGS:,  Visual acuity today without correction was 20/20 -2 pinholing to 20/16 in the right eye, and 20/40 +2 pinholing to 20/16 in the left eye.  Near vision unaided was J2 in both eyes.,Manifest refraction today following pharmacological dilation was -0.50, +0.50 times 155 in the right eye revealing a vision of 20/16.  Manifest refraction was -1.00, +0.25 times 005 revealing a vision of 20/16 in the left eye.  The add was +2 in both eyes.  Visual fields are full to finger counting in both eyes.,Extraocular movements were within normal limits.  Intraocular pressure by applanation was 16 mmHg in the right eye and 18 mmHg in the left eye measured at 11.30 in the morning.,Examination of the anterior segment was unremarkable in both eyes except for mild nuclear sclerotic opacities in both eyes.,Dilated fundus examination of the right eye revealed a sharp and pink optic disc with a healthy rim and cup-to-disc ratio of 0.7; however, there was central excavation of the disc, but no disc hemorrhages were noted.  On examination of the macula, there were drusen scattered temporally.  Examination of the vasculature was normal.  Peripheral retinal examination was entirely normal.,On funduscopic examination of the left eye, there was a sharp and pink disc with a healthy rim, but with central excavation and a cup-to-disc ratio of 0.6.  Of note, there were no disc hemorrhages.  On examination of the macula, there was scattered tiny drusen centrally and superiorly.  Examination of the vasculature was entirely normal.  Peripheral fundus examination was unremarkable.,ASSESSMENT:,1.  Age-related macular degeneration category three (right greater than sign left).,2.  Glaucoma suspect based on disc appearance (increased cup-to-disc ratio and disc asymmetry).,3.  Presbyopia and astigmatism.,4.  Non-visually significant cataracts bilaterally.,PLANS:,1.  The above diagnoses and management plans each were discussed with the patient who expressed understanding.,2.  Commence Ocuvite PreserVision capulets one tablet twice a day by mouth for age-related macular degeneration.,3.  Humphrey visual field and disc photographs today for baseline documentation in view of glaucoma suspicion.,4.  Followup in Glaucoma Clinic arranged in 4 months' time with repeat Humphrey visual fields at this time for reevaluation and comparison.,5.  Follow up with Mrs. Braithwaite in the Comprehensive Eye Service Clinic for undilated refraction.,6.  We will follow up this gentleman in our clinic in 12 months' time; however, I have asked him to return to us soon should he develop any worsening ocular symptoms in the interim.",
 Dietary consultation for weight reduction secondary to diabetes., Consult - History and Phy., Dietary Consultation - 2 ,"SUBJECTIVE:,  This is a 54-year-old female who comes for dietary consultation for weight reduction secondary to diabetes.  She did attend diabetes education classes at Abc Clinic.  She comes however, wanting to really work at weight reduction.  She indicates that she has been on the Atkins' diet for about two years and lost about ten pounds.  She is now following a veggie diet which she learned about in Poland originally.  She has been on it for three weeks and intends to follow it for another three weeks.  This does not allow any fruits or grains or starchy vegetables or meats.  She does eat nuts for protein.  She is wanting to know if she is at risk of having a severe low blood sugar reaction in this form of diet.  She also wants to know that if she gets skinny enough, if the diabetes will go away.  Her problem time, blood sugar wise, is in the morning.  She states that if she eats too much in the evening that her blood sugars are always higher the next morning.,OBJECTIVE:,  Weight:  189 pounds.  Reported height:  5 feet 5 inches.  BMI is approximately 31-1/2.  Diabetes medications include metformin 500 mg daily.  Lab from 5/12/04:  Hemoglobin A1C was 6.4%.,A diet history was obtained.  I instructed the patient on dietary guidelines for weight reduction.  A 1200-calorie meal plan was recommended.,ASSESSMENT:,  Patient's diet history reflects that she is highly restricting carbohydrates in her food intake.  She does not have blood sugar records with her for me to review, but we discussed strategies for improving blood sugar control in the morning.  This primarily included a recommendation of including some solid protein with her bedtime snack which could be done in the form of nuts.  She is doing some physical activity two to three times a week.  This includes aerobic walking with weights on her arms and her ankles.  She is likely going to need to increase frequency in this area to help support weight reduction.  Her basal metabolic rate was estimated at 1415 calories a day.  Her total calorie requirements for weight maintenance are estimated at 1881 calories a day.  A 1200-calorie meal plan should support a weight loss of at least one pound a week.,PLAN:,  Recommend patient increase the frequency of her walking to five days a week.  Encouraged a 30-minute duration.  Also recommend patient include some solid protein with her bedtime snack to help address fasting blood sugar elevations.  And lastly, I encouraged caloric intake of just under 1200 calories daily.  Recommend keeping food records and tracking caloric intake.  It is unlikely that her blood sugars would drop significantly low on the current dose of Glucophage.  However, I encouraged her to be careful not to reduce calories below 1000 calories daily.  She may want to consider a multivitamin as well.  This was a one-hour consultation.","consult - history and phy., consultation, atkins' diet, blood sugar reaction, diabetes, diabetes education, diabetes education classes, diet history, dietary consultation, dietary guidelines, meal plan, protein, veggie diet, weight reduction, caloric intake, blood sugar, reduction, sugar, calories, blood, dietary, weight,"
 Disseminated intravascular coagulation and Streptococcal pneumonia with sepsis.  Patient presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation., Consult - History and Phy., Disseminated Intravascular Coagulation ,"DIAGNOSES:,1.  Disseminated intravascular coagulation.,2.  Streptococcal pneumonia with sepsis.,CHIEF COMPLAINT: , Unobtainable as the patient is intubated for respiratory failure.,CURRENT HISTORY OF PRESENT ILLNESS: , This is a 20-year-old female who presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation.  At this time, she is being treated aggressively with mechanical ventilation and other supportive measures and has developed disseminated intravascular coagulation with prolonged partial thromboplastin time, prothrombin time, low fibrinogen, and elevated D-dimer.  At this time, I am being consulted for further evaluation and recommendations for treatment.  The nurses report that she has actually improved clinically over the last 24 hours.  Bleeding has been a problem; however, it seems to have been abrogated at this time with factor replacement as well as platelet infusion.  There is no prior history of coagulopathy.,PAST MEDICAL HISTORY:  ,Otherwise nondescript as is the past surgical history.,SOCIAL HISTORY:  ,There were possible illicit drugs.  Her family is present, and I have discussed her case with her mother and sister.,FAMILY HISTORY:  ,Otherwise noncontributory.,REVIEW OF SYSTEMS: , Not otherwise pertinent.,PHYSICAL EXAMINATION:,GENERAL:  She is a sedated, young black female in no acute distress, lying in bed intubated.,VITAL SIGNS:  She has a rate of 67, blood pressure of 100/60, and the respiratory rate per the ventilator approximately 14 to 16.,HEENT:  Her sclerae showed conjunctival hemorrhage.  There are no petechiae.  Her nasal vestibules are clear.  Oropharynx has ET tube in place.,NECK:  No jugular venous pressure distention.,CHEST:  Coarse breath sounds bilaterally.,HEART:  Regular rate and rhythm.,ABDOMEN:  Soft and nontender with good bowel sounds.  There was some oozing around the site of her central line.,EXTREMITIES:  No clubbing, cyanosis, or edema.  There is no evidence of compromise arterial blood flow at the digits or of her hands or feet.,LABORATORY STUDIES:  ,The DIC parameters with a platelet count of approximately 50,000, INR of 2.4, normal PTT at this time, fibrinogen of 200, and a D-dimer of 13.,IMPRESSION/PLAN:  ,At this time is disseminated intravascular coagulation from sepsis from pneumococcal disease.  My recommendation for the patient is to continue factor replacement as you are.  It seems that her clinical course is reversing and simple factor replacement is probably is the best measure at this time.  There is no indication at this point for Xigris.  However, if her coagulopathy does not resolve within the next 24 hours and continue to improve with an elevated fibrinogen, normalization of her coagulation times, I would consider low-dose continuous infusion heparin for abrogation of consumption of coagulation routines and continued supportive infusions.  I will repeat her laboratory studies in the morning and give more recommendations at that time.","consult - history and phy., intravascular, coagulation, pneumonia, thromboplastin time, prothrombin time, disseminated intravascular coagulation, streptococcal pneumonia, intravascular coagulation, infusion, coagulopathy, fibrinogen, respiratory, oropharynx, sepsis, disseminated, "
" Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.", Consult - History and Phy., Dietary Consult - Weight Reduction ,"SUBJECTIVE:,  This is a 56-year-old female who comes in for a dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.  The patient states that her husband has been diagnosed with high blood cholesterol as well.  She wants some support with some dietary recommendations to assist both of them in healthier eating.  The two of them live alone now, and she is used to cooking for large portions.  She is having a hard time adjusting to preparing food for the two of them.  She would like to do less food preparation, in fact.  She is starting a new job this week.,OBJECTIVE:,  Her reported height is 5 feet 4 inches.  Today’s weight was 170 pounds.  BMI is approximately 29.  A diet history was obtained.  I instructed the patient on a 1200 calorie meal plan emphasizing low-saturated fat sources with moderate amounts of sodium as well.  Information on fast food eating was supplied, and additional information on low-fat eating was also supplied.,ASSESSMENT:,  The patient’s basal energy expenditure is estimated at 1361 calories a day.  Her total calorie requirement for weight maintenance is estimated at 1759 calories a day.  Her diet history reflects that she is making some very healthy food choices on a regular basis.  She does emphasize a lot of fruits and vegetables, trying to get a fruit or a vegetable or both at most meals.  She also is emphasizing lower fat selections.  Her physical activity level is moderate at this time.  She is currently walking for 20 minutes four or five days out of the week but at a very moderate pace with a friend.  We reviewed the efforts at weight reduction identifying 3500 calories in a pound of body fat and the need to gradually and slowly chip away at this number on a long-term basis for weight reduction.  We discussed the need to reduce calories from what her current patterns are and to hopefully increase physical activity slightly as well.  We discussed menu selection, as well as food preparation techniques.  The patient appears to have been influenced by the current low-carb, high-protein craze and had really limited her food selections based on that.  I was able to give her some more room for variety including some moderate portions of potatoes, pasta and even on occasion breading her meat as long as she prepares it in a low-fat fashion which was discussed.,PLAN:,  Recommend the patient increase the intensity and the duration of her physical activity with a goal of 30 minutes five days a week working at a brisk walk.  Recommend the patient reduce calories by 500 daily to support a weight loss of one pound a week.  This translates into a 1200-calorie meal plan.  I encouraged the patient to keep food records in order to better track calories consumed.  I recommended low fat selections and especially those that are lower in saturated fats.  Emphasis would be placed on moderating portions of meat and having more moderate snacks between meals as well.  This was a one-hour consultation.  I provided my name and number should additional needs arise.","consult - history and phy., hyperlipidemia, hypertension, gastroesophageal reflux disease, weight reduction, dietary recommendations, healthier eating, meal plan, dietary consultation, low fat, physical activity, weight, gastroesophageal, dietary, calories, food"
 Dietary consultation for gestational diabetes., Consult - History and Phy., Dietary Consult - Gestational Diabetes ,"SUBJECTIVE:,  This is a 38-year-old female who comes for dietary consultation for gestational diabetes.  Patient reports that she is scared to eat because of its impact on her blood sugars.  She is actually trying not to eat while she is working third shift at Wal-Mart.  Historically however, she likes to eat out with a high frequency.  She enjoys eating rice as part of her meals.  She is complaining of feeling fatigued and tired all the time because she works from 10 p.m. to 7 a.m. at Wal-Mart and has young children at home.  She sleeps two to four hours at a time throughout the day.  She has been testing for ketones first thing in the morning when she gets home from work.,OBJECTIVE:,  Today's weight:  155.5 pounds.  Weight from 10/07/04 was 156.7 pounds.  A diet history was obtained.  Blood sugar records for the last three days reveal the following:  fasting blood sugars 83, 84, 87, 77; two-hour postprandial breakfast 116, 107, 97; pre-lunch 85, 108, 77; two-hour postprandial lunch 86, 131, 100; pre-supper 78, 91, 100; two-hour postprandial supper 125, 121, 161; bedtime 104, 90 and 88.  I instructed the patient on dietary guidelines for gestational diabetes.  The Lily Guide for Meal Planning was provided and reviewed.  Additional information on gestational diabetes was applied.  A sample 2000-calorie meal plan was provided with a carbohydrate budget established.,ASSESSMENT:,  Patient's basal energy expenditure adjusted for obesity is estimated at 1336 calories a day.  Her total calorie requirements, including a physical activity factor as well as additional calories for pregnancy, totals to 2036 calories per day.  Her diet history reveals that she has somewhat irregular eating patterns.  In the last 24 hours when she was working at Wal-Mart, she ate at 5 a.m. but did not eat anything prior to that since starting work at 10 p.m.  We discussed the need for small frequent eating.  We identified carbohydrate as the food source that contributes to the blood glucose response.  We identified carbohydrate sources in the food supply, recognizing that they are all good for her.  The only carbohydrates she was asked to entirely avoid would be the concentrated forms of refined sugars.  In regard to use of her traditional foods of rice, I pulled out a one-third cup measuring cup to identify a 15-gram equivalent of rice.  We discussed the need for moderating the portion of carbohydrates consumed at one given time.  Emphasis was placed at eating with a high frequency with a goal of eating every two to four hours over the course of the day when she is awake.  Her weight loss was discouraged.  Patient was encouraged to eat more generously but with attention to the amount of carbohydrates consumed at a time.,PLAN:,  The meal plan provided has a carbohydrate content that represents 40 percent of a 2000-calorie meal plan.  The meal plan was devised to distribute her carbohydrates more evenly throughout the day.  The meal plan was meant to reflect an example for her eating, while the patient was encouraged to eat according to appetite and not to go without eating for long periods of time.  The meal plan is as follows:  breakfast 2 carbohydrate servings, snack 1 carbohydrate serving, lunch 2-3 carbohydrate servings, snack 1 carbohydrate serving, dinner 2-3 carbohydrate servings, bedtime snack 1-2 carbohydrate servings.  Recommend patient include a solid protein with each of her meals as well as with her snack that occurs before going to sleep.  Encouraged adequate rest.  Also recommend adequate calories to sustain weight gain of one-half to one pound per week.  If the meal plan reflected does not support slow gradual weight gain, then we will need to add more foods accordingly.  This was a one-hour consultation.  I provided my name and number should additional needs arise.","consult - history and phy., blood sugars, fatigued, total calorie, carbohydrate content, consultation for gestational diabetes, dietary consultation, weight gain, gestational diabetes, carbohydrate servings, meal planning, meals, weight, carbohydrate, dietary, servings, planning"
 Dietary consultation for a woman with polycystic ovarian syndrome and hyperlipidemia., Consult - History and Phy., Dietary Consultation - 1 ,"SUBJECTIVE:,  This is a followup dietary consultation for polycystic ovarian syndrome and hyperlipidemia.  The patient reports that she has resumed food record keeping which she feels like it has given her greater control.  Her physical activity level has remained high.  Her struggle times are in the mid-afternoon if she has not had enough food to eat, as well as in the evening after dinner.,OBJECTIVE:, Vital Signs:  Weight is 189-1/2 pounds.  Food records were reviewed,ASSESSMENT:,  The patient has experienced a weight loss of 1-1/2 pounds in the last month.  She is commended for these efforts.  We have reviewed food records identifying that she has done a nice job keeping a calorie count for the last two or three weeks.  We discussed the value of this and how it was very difficulty to resume it, however, after she suspended the record keeping.  We also discussed its reflection that she is not getting very many fruits and vegetables on a regular basis.  We identified some ways of preventing her from feeling sluggish and having problems with low blood sugar in the middle of the afternoon by routinely planning an afternoon snack that can prevent these symptoms.  This will likely be around 2:30 or 3 p.m. for her.  We also discussed strategies for evening snacking to help put some definition and boundaries to the snacking.,PLAN:,  I recommended the patient routinely include an afternoon snack around 2:30 to 3 p.m.  It will be helpful if this snack includes some protein such as nuts or low-fat cheese.  She is also encouraged to continue with her record keeping for food choices and calorie points.  I also recommended she maintain her high level of physical activity.  Will plan to follow the patient in one month for ongoing support.  This was a 30-minute consultation.","consult - history and phy., dietary consultation, calorie count, calorie points, consultation, food choices, food record, hyperlipidemia, low-fat cheese, many fruits and vegetables, physical activity, polycystic ovarian syndrome, snack, dietary, polycystic, food, afternoon"
" Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome", Consult - History and Phy., Dietary Consult - Hyperlipidemia ,"SUBJECTIVE:,  This is a followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome.  The patient reports that she has worked hard for a number of weeks following the meal plan prescribed, but felt like she was gaining weight and not losing weight on it.  She is not sure that she was following it accurately.  She is trying to walk 1-1/2 to 2 miles every other day, but is increasing her time in the garden and doing other yard work as well.  Once she started experiencing some weight gain, she went back to her old South Beach Diet and felt like she was able to take some of that weight off.  However she realizes that the South Beach Diet is not a healthy diet for her and so is coming back for better instruction on safe weight loss and low-fat eating.,OBJECTIVE:,  Weight is 275 pounds.  Food records were reviewed.,ASSESSMENT:,  The patient experienced a weight gain of 2 pounds since our last consultation which was two months ago.  I did carefully review her food records and evaluated calories consumed.  While she was carefully tracking the volume of protein and carbohydrates, she was getting some excess calories from the fatty proteins selected.  Thus we rearranged her meal plan a little bit and talked about how to track her fat calories as well.  She was more open to reducing the amount of protein from the previous meal plan and increasing slightly the amount of carbohydrates.  While this still is not as much carbohydrate as I would normally recommend, I am certainly willing to work with her on how she feels her body best handles weight reduction.  We also discussed a snack that could be eliminated in the morning because she really is not hungry at that time.,PLAN:,  A new 1500 calorie meal plan was developed based on 35% of the calories coming from protein, 40% of the calories from carbohydrate, and 25% of the calories from fat.  This translates in to 10 servings at 15 grams a piece of carbohydrates throughout the day dividing them in to groups of two servings per meal and per snack.  This also translates in to 2 ounces of protein at breakfast, 6 ounces at lunch, 2 ounces in the afternoon snack, 6 ounces at supper, and 2 ounces in the evening snack.  We have eliminated the morning snack.  The patient will now track the grams of fat in her meats as well as added fats.  Her goal for total fats over the course of the day is no more than 42 grams of fat per day.  This was a half hour consultation.  We will plan to see the patient back in one month for support.","consult - history and phy., hyperlipidemia, hypertension, metabolic syndrome, meal, food records, south beach diet, dietary consultation, meal plan, carbohydrates, snack, dietary, calories, weight"
 Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983., Consult - History and Phy., Dietary Consult - Diabetes - 2 ,"SUBJECTIVE:,  The patient is a 79-year-old African-American female with a self reported height of 5 foot 3 inches and weight of 197 pounds.  She was diagnosed with type 2 diabetes in 1983.  She is not allergic to any medicines.,DIABETES MEDICATIONS:,  Her diabetes medications include Humulin insulin 70/30, 44 units at breakfast and 22 units at supper.  Also metformin 500 mg at supper.,OTHER MEDICATIONS: , Other medications include verapamil, Benicar, Toprol, clonidine, and hydrochlorothiazide.,ASSESSMENT:,  The patient and her daughter completed both days of diabetes education in a group setting.  Blood glucose records and food diaries are reviewed by the diabetes educator and the dietician.  Fasting blood sugars are 127, 80, and 80.  Two-hour postprandial breakfast reading was 105, two-hour postprandial lunch reading was 88, and two-hour postprandial dinner reading was 73 and 63.  Her diet was excellent.,Seven hours of counseling about diabetes mellitus was provided on this date.,Blood glucose values obtained at 10 a.m. were 84 and at 2.30 p.m. were 109.  Assessment of her knowledge is completed at the end of the counseling session.  She demonstrated increased knowledge in all areas and had no further questions.  She also completed an evaluation of the class.,The patient's feet were examined during the education session.  She had flat feet bilaterally.  Skin color was pink, temperature warm.  Pedal pulses 2+.  Her right second and third toes lay on each other.  Also, the same on her left foot.  However, there was no skin breakdown.  She had large bunions, medial aspect of the ball of both feet.  She had positive sensitivity to most areas of her feet, however, she had negative sensitivity to the medial and lateral aspect of the balls of her left foot.,During the education session, she set behavioral goals for self care.  First goal is to eat three meals a day and eat three snacks daily to improve her blood glucose levels.  Second goal is to eat a well balanced meal at 1200 calories in order to lose one-half pound of weight per week and improve her blood glucose control.  Third goal is to exercise by walking for 15 to 30 minutes a day, three to five days a week to increase her blood glucose control.  Her success in achieving these goals will be followed in three months by a letter from the diabetes education class.,RECOMMENDATIONS:,  Since she is doing so well with her diet changes, her blood sugars have been within normal limits and sometimes on the low side, especially considering the fact that she has low blood sugar unawareness.  She is to followup with Dr. XYZ for possible reduction in her insulin doses.","consult - history and phy., dietary consult, diabetes education, glucose control, blood sugars, blood glucose, dietary, diabetes,"
 The patient is brought in by an assistant with some of his food diary sheets., Consult - History and Phy., Dietary Consult - 3 ,"SUBJECTIVE:,  The patient is brought in by an assistant with some of his food diary sheets.  They wonder if the patient needs to lose anymore weight.,OBJECTIVE:,  The patient's weight today is 186-1/2 pounds, which is down 1-1/2 pounds in the past month.  He has lost a total of 34-1/2 pounds.  I praised this.  I went over his food diary and praised all of his positive food choices reported, especially his use of sugar-free Kool-Aid, sugar-free pudding, and diet pop.  I encouraged him to continue all of that, as well as his regular physical activity.,ASSESSMENT:,  The patient is losing weight at an acceptable rate.  He needs to continue keeping a food diary and his regular physical activity.,PLAN:,  The patient plans to see Dr. XYZ at the end of May 2005.  I recommended that they ask Dr. XYZ what weight he would like for the patient to be at.  Follow up will be with me June 13, 2005.","consult - history and phy., weight, kool-aid, food diary sheets, diary sheets, physical activity, food diary, dietary, sheets, diary, food"
" The patient has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.", Consult - History and Phy., Dietary Consult - 2 ,"SUBJECTIVE:,  The patient's assistant brings in her food diary sheets.  The patient says she stays active by walking at the mall.,OBJECTIVE:,  Weight today is 201 pounds, which is down 3 pounds in the past month.  She has lost a total of 24 pounds.  I praised this and encouraged her to continue.  I went over her food diary.  I praised her three-meal pattern and all of her positive food choices, especially the use of sugar-free Kool-Aid, sugar-free Jell-O, sugar-free lemonade, diet pop, as well as the variety of foods she is using in her three-meal pattern.  I encouraged her to continue all of this.,ASSESSMENT:,  The patient has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.  She needs to continue all this.,PLAN:,  Followup is set for 06/13/05 to check the patient's weight, her food diary, and answer any questions.","consult - history and phy., food diary sheets, active, balanced diet, three-meal pattern, weight loss, sugar free, food diary, dietary, weight, meal, diary, sheets, food"
 Dietary consultation for diabetes during pregnancy., Consult - History and Phy., Dietary Consult - Diabetes - 1 ,"SUBJECTIVE:,  This is a 28-year-old female who comes for dietary consultation for diabetes during pregnancy.  Patient reports that she had gestational diabetes with her first pregnancy.  She did use insulin at that time as well.  She does not fully understand what ketones are.  She walks her daughter to school and back home each day which takes 20 minutes each way.  She is not a big milk drinker, but she does try to drink some.,OBJECTIVE:,  Weight is 238.3 pounds.  Weight from last week’s visit was 238.9 pounds.  Prepregnancy weight is reported at 235 pounds.  Height is 62-3/4 inches.  Prepregnancy BMI is approximately 42-1/2.  Insulin schedule is NovoLog 70/30, 20 units in the morning and 13 units at supper time.  Blood sugar records for the last week reveal the following:  Fasting blood sugars ranging from 92 to 104 with an average of 97, two-hour postprandial breakfast readings ranging from 172 to 196 with an average of 181, two-hour postprandial lunch readings ranging from 149 to 189 with an average of 168 and two-hour postprandial dinner readings ranging from 109 to 121 with an average of 116.  Overall average is 140.  A diet history was obtained.  Expected date of confinement is May 1, 2005.  Instructed the patient on dietary guidelines for gestational diabetes.  A 2300 meal plan was provided and reviewed.  The Lily Guide for Meal Planning was provided and reviewed.,ASSESSMENT:,  Patient’s basal energy expenditure adjusted for obesity is estimated at 1566 calories a day.  Her total calorie requirements, including physical activity factors as well as additional calories for pregnancy, totals 2367 calories a day.  Her diet history reveals that she is eating three meals a day and three snacks.  The snacks were just added last week following presence of ketones in her urine.  We identified carbohydrate sources in the food supply, recognizing that they are the foods that raise blood sugar the most.  We identified 15 gram equivalents of carbohydrate and established a carbohydrate budget.  We also discussed the goal of balancing food intake with blood sugar control and adequate caloric intake to sustain appropriate weight gain for the pregnancy of 1/2 a pound a week through the duration of the pregnancy.  We discussed the physiology of ketone production from inadequate calories or inadequate insulin and elevated blood sugars.  While a sample meal plan was provided reflecting the patient’s carbohydrate budget I emphasized the need for her to eat according to her appetite, but to work at consistency in the volume of carbohydrates consumed at a given meal or a given snack from day to day.  Patient was assured that we can titrate the insulin to match whatever eating pattern is suitable for her as long as she can do it on a consistent basis.  At the same time she was encouraged to continue to eliminate the more concentrated forms of refined carbohydrates.,PLAN:,  Recommend the patient work with the following meal plan with a carbohydrate budget representing approximately 45% of the calories from carbohydrate.  Breakfast:  Three carbohydrate servings.  Morning snack:  One carbohydrate serving.  Lunch:  Four carbohydrate servings.  Afternoon snack:  One carbohydrate serving.  Supper:  Four carbohydrate servings.  Bedtime snack:  One carbohydrate serving.  Encouraged patient to include some solid protein with each of her meals as well as with the bedtime snack.  Encouraged three servings of dairy products per day to meet nutritional needs for calcium during pregnancy.  Recommend patient include a fruit or a vegetable with most of her meals.  Also recommend including solid protein with each meal as well as with the bedtime snack.  Charlie Athene reviewed blood sugars at this consultation as well, and made the following insulin adjustment:  Morning 70/30, will increase from 20 units up to 24 units and evening 70/30, we will increase from 13 units up to 16 units.  Patient was encouraged to call in blood sugars at the end of the week if they are outside of the range of over 90 fasting and over 120 two-hour postprandial.  Provided my name and number should there be additional dietary questions.","consult - history and phy., diabetes during pregnancy, diabetes, insulin, gestational diabetes, adjusted for obesity, calorie requirements, dietary consultation, carbohydrate, postprandial, meal, calories, dietary, pregnancy, servings, snacks"
 One-week history of decreased vision in the left eye.  Past ocular history includes cataract extraction with lens implants in both eyes., Consult - History and Phy., Decreased Vision Consult ,"She has a past ocular history including cataract extraction with lens implants in both eyes in 2001 and 2003.  She also has a history of glaucoma diagnosed in 1990 and macular degeneration.  She has been followed in her home country and is here visiting family.  She had the above-mentioned observation and was brought in on an urgent basis today.,Her past medical history includes hypertension and hypercholesterolemia and hypothyroidism.,Her medications include V-optic 0.5% eye drops to both eyes twice a day and pilocarpine 2% OU three times a day.  She took both the drops this morning.  She also takes Eltroxin which is for hypothyroidism, Plendil for blood pressure, and pravastatin.,She is allergic to Cosopt.,She has a family history of blindness in her brother as well as glaucoma and hypertension.,Her visual acuity today at distance without correction are 20/25 in the right and count fingers at 3 feet in the left eye.  Manifest refraction showed no improvement in either eye.  The intraocular pressures by applanation were 7 on the right and 18 in the left eye.  Gonioscopy showed grade 4 open angles in both eyes.  Humphrey visual field testing done elsewhere showed diffuse reduction in sensitivity in both eyes.  The lids were normal OU.  She has mild dry eye OU.  The corneas are clear OU.  The anterior chamber is deep and quiet OU.  Irides appear normal.  The lenses show well centered posterior chamber intraocular lenses OU.,Dilated fundus exam shows clear vitreous OU.  The optic nerves are normal in size.  They both appear to have mild pallor.  The optic cups in both eyes are shallow.  The cup-to-disc ratio in the right eye is not overtly large, would estimated 0.5 to 0.6; however, she does have very thin rim tissue inferotemporally in the right eye.  In the left eye, the glaucoma appears to be more advanced to the larger cup-to-disc ratio and a thinner rim tissue.,The macula on the right shows drusen with focal areas of RPE atrophy.  I do not see any evidence of neovascularization such as subretinal fluid, lipid or hemorrhage.  She does have a punctate area of RPE atrophy which is just adjacent to the fovea of the right eye.  In the left eye, she has also several high-risk drusen, but no evidence of neovascularization.  The RPE in the left eye does appear to be more diffusely abnormal although these changes do appear somewhat mild.  I do not see any dense or focal areas of frank RPE atrophy or hypertrophy.,The peripheral retinas are attached in both eyes.,Ms. ABC has pseudophakia OU which is stable and she is doing well in this regard.  She has glaucoma which likely is worse in the left eye and also likely explains her poor vision in the left eye.  The intraocular pressure in the mid-to-high teens in the left eye is probably high for her.  She has allergic reaction to Cosopt.  I will recommend starting Xalatan OS nightly.  I think the intraocular pressure in the right eye is acceptable and is probably a stable pressure for her OD.  She will need followup in the next 1 or 2 months after returning home to Israel later this week after starting the new medication which is Xalatan.,Regarding the macular degeneration, she has had high-risk changes in both eyes.  The vision in the right eye is good, but she does have a very concerning area of RPE atrophy just adjacent to the fovea of the right eye.  I strongly recommend that she see a retina specialist before returning to Israel in order to fully discuss prophylactic measures to prevent worsening of her macular degeneration in the right eye.","consult - history and phy., cataract extraction, lens implants, decreased vision, macular degeneration, intraocular pressures, rpe atrophy, eye, degeneration, glaucoma, macular, vision, "
" Counting calorie points, exercising pretty regularly, seems to be doing well", Consult - History and Phy., Dietary Consult - 4 ,"SUBJECTIVE:,  The patient is keeping a food journal that she brought in.  She is counting calorie points, which ranged 26 to 30 per day.  She is exercising pretty regularly.  She attends Overeaters Anonymous and her sponsor is helping her and told her to get some ideas on how to plan snacks to prevent hypoglycemia.  The patient requests information on diabetic exchanges.  She said she is feeling better since she has lost weight.,OBJECTIVE:,Vital Signs:  The patient's weight today is 209 pounds, which is down 22 pounds since I last saw her on 06/07/2004.  I praised her weight loss and her regular exercising.  I looked at her food journal.  I praised her record keeping.  I gave her a list of the diabetic exchanges and explained them.  I also gave her a food dairy sheet so that she could record exchanges.  I encouraged her to continue.,ASSESSMENT:,  The patient seems happy with her progress and she seems to be doing well.  She needs to continue.,PLAN:,  Followup is on a p.r.n. basis.  She is always welcome to call or return.","consult - history and phy., overeaters anonymous, diabetic exchanges, exercising pretty regularly, food journal, diabetic, exercising, exchanges, regularly"
 This is a 27-year-old female who presents with a couple of days history of some dental pain.  She has had increasing swelling and pain to the left lower mandible area today., Consult - History and Phy., Dental Pain ,"CHIEF COMPLAINT:,  Dental pain.,HISTORY OF PRESENT ILLNESS:,  This is a 27-year-old female who presents with a couple of days history of some dental pain.  She has had increasing swelling and pain to the left lower mandible area today.  Presents now for evaluation.,PAST MEDICAL HISTORY: , Remarkable for chronic back pain, neck pain from a previous cervical fusion, and degenerative disc disease.  She has chronic pain in general and is followed by Dr. X.,REVIEW OF SYSTEMS: , Otherwise, unremarkable.  Has not noted any fever or chills.  However she, as mentioned, does note the dental discomfort with increasing swelling and pain.  Otherwise, unremarkable except as noted.,CURRENT MEDICATIONS: , Please see list.,ALLERGIES: , IODINE, FISH OIL, FLEXERIL, BETADINE.,PHYSICAL EXAMINATION: , VITAL SIGNS:  The patient was afebrile, has stable and normal vital signs.  The patient is sitting quietly on the gurney and does not look to be in significant distress, but she is complaining of dental pain.  HEENT:  Unremarkable.  I do not see any obvious facial swelling, but she is definitely tender all in the left mandible region.  There is no neck adenopathy.  Oral mucosa is moist and well hydrated.  Dentition looks to be in reasonable condition.  However, she definitely is tender to percussion on the left lower first premolar.  I do not see any huge cavity or anything like that.  No real significant gingival swelling and there is no drainage noted.  None of the teeth are tender to percussion.,PROCEDURE:,  Dental nerve block.  Using 0.5% Marcaine with epinephrine, I performed a left inferior alveolar nerve block along with an apical nerve block, which achieves good anesthesia.  I have then written a prescription for penicillin and Vicodin for pain.,IMPRESSION: , ACUTE DENTAL ABSCESS.,ASSESSMENT AND PLAN:  ,The patient needs to follow up with the dentist for definitive treatment and care.  She is treated symptomatically at this time for the pain with a dental block as well as empirically with antibiotics.  However, outpatient followup should be adequate.  She is discharged in stable condition.","consult - history and phy., dental pain, dental abscess, dental block, nerve block, mandible, swelling, dental,"
" Cerebrovascular accident (CVA).  The patient presents to the emergency room after awakening at 2:30 a.m. this morning with trouble swallowing, trouble breathing, and left-sided numbness and weakness. ", Consult - History and Phy., CVA Consult - ER Visit ,"ADMITTING DIAGNOSIS: , Cerebrovascular accident (CVA).,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old gentleman with a significant past medical history for nasopharyngeal cancer status post radiation therapy to his pharynx and neck in 1991 who presents to the emergency room after awakening at 2:30 a.m. this morning with trouble swallowing, trouble breathing, and left-sided numbness and weakness.  This occurred at 2:30 a.m.  His wife said that he had trouble speaking as well, but gradually the symptoms resolved but he was still complaining of a headache and at that point, he was brought to the emergency room.  He arrived at the emergency room here via private ambulance at 6:30 a.m. in the morning.  Upon initial evaluation, he did have some left-sided weakness and was complaining of a headache.  He underwent workup including a CT, which was negative and his symptoms slowly began to resolve.  He was initially admitted, placed on Plavix and aspirin.  However a few hours later, his symptoms returned and he had increasing weakness of his left arm and left leg as well as slurred speech.  Repeat CT scan again done reportedly was negative and he was subsequently heparinized and admitted.  He also underwent an echo, carotid ultrasound, and lab work in the emergency room.  Wife is at the bedside and denies he had any other symptoms previous to this.  He denied any chest pain or palpitations.  She does report that he is on a Z-Pak, got a cortisone shot, and some decongestant from Dr. ABC on Saturday because of congestion and that had gotten better.,ALLERGIES:  ,He has no known drug allergies.,CURRENT MEDICATIONS:,1.  Multivitamin.,2.  Ibuprofen p.r.n.,PAST MEDICAL HISTORY:,1.  Nasopharyngeal cancer.  Occurred in 1991.  Status post XRT of the nasopharyngeal area and his neck because of spread to the lymph nodes.,2.  Lumbar disk disease.,3.  Status post diskectomy.,4.  Chronic neck pain secondary to XRT.,5.  History of thalassemia.,6.  Chronic dizziness since his XRT in 1991.,PAST SURGICAL HISTORY: , Lumbar diskectomy, which is approximately 7 to 8 years ago, otherwise negative.,SOCIAL HISTORY: , He is a nonsmoker.  He occasionally has a beer.  He is married.  He works as a flooring installer.,FAMILY HISTORY:  ,Pertinent for father who died of an inoperable brain tumour.  Mother is obese, but otherwise negative history.,REVIEW OF SYSTEMS:  ,He reports he was in his usual state of health up until he awoke this morning.  He does states that yesterday his son cleaned the walk area with some ether and since then he has not quite been feeling right.  He is a right-handed male and normally wears glasses.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Stable.  His blood pressure was 156/97 in the emergency room, pulse is 73, respiratory rate 20, and saturation is 99%.,GENERAL:  He is alert, pleasant, and in no acute distress at this time.  He answers questions appropriately.,HEENT:  Pupils are equal, round, and reactive to light.  Extraocular muscles are intact.  Sclerae are clear.  TMs clear.  Oropharynx is clear.,NECK:  Supple with full range of motion.  He does have some increased density to neck, I assume, secondary to XRT.,CARDIOVASCULAR:  Regular rate and rhythm without murmur.,LUNGS:  Clear bilaterally.,ABDOMEN:  Soft, nontender, and nondistended.,EXTREMITIES:  Show no clubbing, cyanosis or edema.,NEUROLOGIC:  He does have a minimally slurred speech at present.  He does have a slight facial droop.  He has significant left upper extremity weakness approximately 3-4/5, left lower extremity weakness is approximately a 2-3/5 on the left.  Handgrip is about 4/5 on the left, right side is 5/5.,LABORATORY DATA:  ,His initial blood work, PT was 11 and PTT 27.  CBC is within normal limits except for hemoglobin of 12.9 and hematocrit of 39.1.  Chem panel is all normal.,EKG showed normal sinus rhythm, normal EKG.  CT of his brain, initially his first CT, which was done this morning at approximately 7 a.m. showed a normal CT.  Repeat CT done at approximately 3:30 p.m. this evening was reportedly also normal.  He underwent an echocardiogram in the emergency room, which was essentially normal.  He had a carotid ultrasound, which revealed total occlusion of the right internal carotid artery, 60% to 80% stenosis of the left internal carotid artery, and 60% stenosis of the left external carotid artery.,MPRESSION AND PLAN:,1.  Cerebrovascular accident, in progress.",
 A 10 years of age carries a diagnosis of cystic fibrosis, Consult - History and Phy., Cystic Fibrosis ,"INTERVAL HISTORY:,  ABC who is 10 years of age and carries a diagnosis of cystic fibrosis, seen in the clinic today for routine follow-up visit.  He was accompanied by his adopted mother.  He is attending the fourth grade and has not missed significant days for illness.  He has a chronic cough that has been slightly increased for the prior 4 days.  Sputum is not produced.  Sinuses are described as clear.  He is an eager eater, eating a regular diet of increased calorie and protein.  He also was taking Resource just for kid juice boxes as well as chocolate milkmaid with half-and-half.  Belly complaints are denied.  He has 2 to 3 bowel movements per day.  He does need a flu vaccine.,MEDICATIONS: , Albuterol premix via nebulizer as needed, albuterol MDI 2 puffs b.i.d., therapy Vest daily, Creon 20 two with meals and snacks,  A-dec 2 tablets daily, Prevacid 15 mg daily, Advair 100/50 one inhalation twice daily, and MiraLax p.r.n.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Respiratory rate 20 and pulse 91.  Temperature is 100.0 per tympanic membrane.  Oximetry is 98% on room air.  Height is 128 cm, which is an increase of 1.0 cm from prior visit.  Weight is 24.5 kg, which is an increase of 500 grams from prior visit.,GENERAL:  He is a cooperative school-aged boy in no apparent distress.,HEENT:  Tympanic membranes clear, throat with minimal postnasal drip.,CHEST:  Significant for 1+ hyperinflation.  Lungs are auscultated with good air entry and clear breath sounds.,CARDIAC:  Regular sinus rhythm without murmur.,ABDOMEN:  Palpated as soft, without hepatosplenomegaly.,EXTREMITIES:  Not clubbed.,CHART REVIEW: , This chart was thoroughly reviewed prior to this conference by X, RN, BSN.  Review of chart indicates that mother has good adherence to treatment plan indicated by medications being refilled in a timely fashion as well as clinic contact documented with appropriate concerns.,DISCUSSION:  PHYSICIAN: , X did note that mother reported that the patient had discontinued the Pulmozyme due to CCS reasons.  He is not sure what this would be since CCS Pulmozyme is a covered benefit on CCS for children with cystic fibrosis.  This situation will be looked into with the hope of restarting soon.  Other than that the patient seems to be doing well.  A flu shot was given.,NURSE: , X, RN, BSN, did note that the patient was doing quite well.  Reinforcement of current medication regime was supplied.  No other needs identified at this time.,RESPIRATORY CARE: , X, RCP, did review appropriate sequencing of medications with the patient and family.  Once again, she was concerned the lack of Pulmozyme due to mom stating CCS issues.  At this time, they have increased the Vest use to twice daily and are doing 30-minute treatments.,DIETICIAN: , X, RD, CDE, notes that the patient is 89% of his ideal body weight, which is a nutritional failure per cystic fibrosis guidelines.  This is despite the fact that he has an excellent appetite.  Mom reports he is taking his enzymes consistently as well as vitamins.  He does have problems meeting his goal for resource drinks per day.  Since the patient has been struggling to gain weight this past year, we will need to monitor his nutritional status and weight trend very closely.  A variety of additional high calorie items were discussed with mom.,SOCIAL WORK: , X, LCSW, notes that mom has recently gradually from respiratory therapy school and has accepted a position here at Children's Hospital.  The patient is doing well in school.  With the exception of issues with CCS authorization, there appears to be no pressing social needs at this time.,IMPRESSION: , ,1.  Cystic fibrosis.,2.  Poor nutritional status.,PLAN:  ,1.  Give flu vaccine 0.5 mg IM now, this was done.,2.  Continue all other medications and treatment.,3.  Evaluate/investigate rationale for no authorization of Pulmozyme with CCS.,4.  Needs to augment current high-calorie diet to give more nutrition.  To follow advice by a dietician.,5.  Continue all the medication treatments before.,6.  To continue off and ongoing psychosocial nutritional counseling as necessary.",
 A male referred to Wheelchair Clinic for evaluation for a new wheelchair.  , Consult - History and Phy., Consult for New Wheelchair ,"HISTORY OF PRESENT ILLNESS:,  This 42-year-old male was referred to Wheelchair Clinic for evaluation for a new wheelchair.  The client has a power wheelchair at home and it is two years old.  However, he is unable to transfer throughout the community.  The client does have two teenage children for which he does need to keep up with.  He has a quickie revolution manual wheelchair that is greater than seven years old and in a complete state of repair.  His past medical history includes TIA, complete spinal cord injury resulting from a gunshot wound in 1995, diabetes mellitus, right forearm fracture, bilateral hip fracture, right fifth tendon repair, left great toe surgery, and spinal surgery.,SOCIAL HISTORY: , The patient lives with his wife and two children, ages 15 and 16 in a single floor apartment with rear entry.  The client does not work; however, he does fix some type of computers as his hobby.  His wife transports him in an oversized four-door vehicle.,FUNCTIONAL STATUS:, The patient is modified and independent for all transfers utilizing the lateral technique.  However, he does require a sideboard for tub transfers as well as car transfers.  He is independent with his bed mobility.  He is unable to ambulate due to his level of injury.  At home, he does have an extended tub bench for showering.  His wheelchair mobility has succeeded to modified independent level as well as wheelchair management and pressure release.  He is dependent for community mobility with his manual wheelchair.  The patient is unable to function, propel with ultra lightweight manual wheelchair throughout the community therefore putting him at the dependent level for this activity.,ACTIVITY OF DAILY LIVING: , The patient is independent with his self care, completing this from the bed or chair level.  He self casts every four to six hours a day independently and as previously mentioned completes this from the chair.  Instrumental ADLs completed with assistance from his wife.  He stays indoors 12 plus hours.  His cognition is alert and oriented x 4.,PHYSICAL EXAMINATION:,EXTREMITIES:  Upper extremity range of motion is within functional limits, has 4-5 strength proximally and 5/5 distally.  He is right hand dominant.  Sitting posture reveals sacral sitting with a partially flexible posterior pelvic tilt.  When taken out of his posterior tilt the client has loosed his trunk control.  He has decreased postural control as he is unable to elevate his upper extremities greater than 90 degrees in unsupported sit.,His skin integrity is currently intact.  His vision is within normal limits.  Lower extremity range of motion is within normal limits with 0-5 strength throughout.,EQUIPMENT RECOMMENDATION: , The patient was seen at clinic for evaluation for a new sitting system. He is unable to ambulate due to his level of injury.  He is able to propel in ultra lightweight manual wheelchair.  However, he does have difficulty propelling throughout the community when trying to maintain his level of activities with two teenage children.  Therefore the following ultra lightweight wheelchair with powered six wheels is recommended.,1.  Invacare Crossfire T6.  As previously mentioned the client is unable to ambulate secondary to spinal cord injury.  He does require manual wheelchair for all forms of mobility.  He is very active in his wheelchair.  He completes his self care as well as his __________ from the chair.  He has two teenage children and he participates in community activities with.  The patient also fixes computers at the wheelchair level.,2.  Emotion power six wheels.  The client has a history of right forearm fracture as well as fifth tendon repair.  He has 4/5 shoulder strength bilaterally.  He is an active computer user making it extremely difficult for him to propel his wheelchair over the varied terrain.  Due to the patient's young age, he has many years that he will be depending on his upper extremities for all transfers and wheelchair mobility.  It is important to be proactive in order to minimize the wear and tear on the joint as he already has upper extremity pain from repetitively propelling.,3.  Flat-free inserts.  The patient is at risk for flats due to his level of activity.  He does require maintenance free wheelchair as he is unable to ambulate.,4.  Removable covers.  This is required for increased apprehension specifically in the winter.,5.  Extra battery pack.  This will allow the client to always have available power for these wheels.  This is required as he is an extremely active user.,6.  V-front end.  This set up will keep his lower extremities close and prohibit external rotation and abduction of his lower extremities.,7.  Frog leg suspension.  This is required in order to absorb the shock in order to prevent his lower extremity from displacing from the foot plate.,8.  Ergonomic seat with a tapered front end.  This style will support the client at his widest point which is his pelvis/thigh/back of the knee.,9.  Adjustable height push handles.  This will accommodate various heights of the caregivers when pushed or bend up and down the stairs.,10.  Soft roll caster.  The client needs the extra width of a caster in order for use of community mobility rolling over the cracks as well as the stone in the community.,11.  Plastic coated hand ends.  This is required for increased __________ with propulsion.,12.  Frame protector.  This will protect his skin, specifically his lateral shins.,13.  Positioning strap.  This is required for pelvic positioning and safety.,14.  Folding side guards.  These will protect the clothing, however, may also be folded it in order to be moved out of the way for transfers.,15.  Anti-tipper.  These will prevent posterior tipping with all ramp and threshold use.,16.  3 inch locking Star cushion.  The client is currently utilizing an air cushion without skin issues.  The locking mechanism is required for stability with all of his transfers.,The above chair was decided upon after a safe and independent trial.  This report will serve as the letter of medical necessity.  We have staff who will follow up with the vendor and the patient to ensure that he has an appropriate effective manual wheelchair with power assist wheels.  This request for consultation is greatly appreciated.,",
 A female with unknown gestational age who presents to the ED after a suicide attempt., Consult - History and Phy., Consult/ER Report - OB/GYN ,"The patient states that she has abnormal menstrual periods and cannot remember the first day of her last normal menstrual period.  She states that she had spotting for three months daily until approximately two weeks ago, when she believes that she passed a fetus.  She states that upon removal of a tampon, she saw a tadpole like structure and believed it to be a fetus.  However, she states she did not know that she was pregnant at this time.  She denies any abdominal pain or vaginal bleeding.  She states that the pregnancy is unplanned; however, she would desire to continue the pregnancy.,PAST MEDICAL HISTORY:  Diabetes mellitus which resolved after weight loss associated with gastric bypass surgery.,PAST SURGICAL HISTORY:,1.  Gastric bypass.,2.  Bilateral carpal tunnel release.,3.  Laparoscopic cholecystectomy.,4.  Hernia repair after gastric bypass surgery.,5.  Thoracotomy.,6.  Knee surgery.,MEDICATIONS:,1.  Lexapro 10 mg daily.,2.  Tramadol 50 mg tablets two by mouth four times a day.,3.  Ambien 10 mg tablets one by mouth at bedtime.,ALLERGIES:  AMOXICILLIN CAUSES THROAT SWELLING.  AVELOX CAUSES IV SITE SWELLING.,SOCIAL HISTORY:  The patient denies tobacco, ethanol, or drug use.  She is currently separated from her partner who is the father of her 21-month-old daughter.  She currently lives with her parents in Greenville.  However, she was visiting the estranged boyfriend in Wilkesboro, this week.,GYN HISTORY:  The patient denies history of abnormal Pap smears or STDs.,OBSTETRICAL HISTORY:  Gravida 1 was a term spontaneous vaginal delivery, complicated only by increased blood pressures at the time of delivery.  Gravida 2 is current.,REVIEW OF SYSTEMS:  The 14-point review of systems was negative with the exception as noted in the HPI.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure 134/45, pulse 130, respirations 28.  Oxygen saturation 100%.,GENERAL:  Patient lying quietly on a stretcher.  No acute distress.,HEENT:  Normocephalic, atraumatic.  Slightly dry mucous membranes.,CARDIOVASCULAR EXAM:  Regular rate and rhythm with tachycardia.,CHEST:  Clear to auscultation bilaterally.,ABDOMEN:  Soft, nontender, nondistended with positive bowel sounds.  No rebound or guarding.,SKIN:  Normal turgor.  No jaundice.  No rashes noted.,EXTREMITIES:  No clubbing, cyanosis, or edema.,NEUROLOGIC:  Cranial nerves II through XII grossly intact.,PSYCHIATRIC:  Flat affect.  Normal verbal response.,ASSESSMENT AND PLAN:  A 34-year-old Caucasian female, gravida 2 para 1-0-0-1, at unknown gestation who presents after suicide attempt.,1.  Given the substances taken, medications are unlikely to affect the development of the fetus.  There have been no reported human anomalies associated with Ambien or tramadol use.  There is, however, a 4% risk of congenital anomalies in the general population.,2.  Recommend quantitative HCG and transvaginal ultrasound for pregnancy dating.,3.  Recommend prenatal vitamins.,4.  The patient to follow up as an outpatient for routine prenatal care.,",
 The patient was referred after he was hospitalized for what eventually was diagnosed as a conversion disorder. , Consult - History and Phy., Conversion Disorder ,"REASON FOR REFERRAL:  ,The patient was referred to me by Dr. X of Children's Hospital after he was hospitalized for what eventually was diagnosed as a conversion disorder.  I had met the patient and his mother in the hospital and had begun getting information regarding his symptoms and background at that time.  After his discharge, the patient was scheduled to see me for followup services.  This was a 90-minute intake that was completed on 10/10/2007 with the patient's mother.  I reviewed with her the treatment consent form as well as the boundaries of confidentiality, and she stated that she understood these concepts.,PRESENTING PROBLEMS:,  Please see the inpatient hospital progress note contained in his chart for additional background information.  The patient's mother reported that he continues with his conversion episodes.  She noted that they are occurring approximately 6 times a day.  They consist primarily of tremors, arching his back, and, by her report, doing some gang signs during the episode.  She reported that the conversion reactions had decreased after his hospitalization, and he had none for 3 days, but then, they began picking up again.  From information gathered from mother, it would suggest that she frequently does ""status checks,"" where she asks him how he is doing, and that after she began checking on him more that he began having more conversion reactions.  In terms of what she does when he has a conversion reaction, she reported that primarily that she tries to keep him safe.  She puts a sheath under him because the carpeting is dirty.  She removes any furniture, she wraps his legs together so they do not knock together, she sits with him and she gives him attention and says ""calm down, breathe"" and after it is over, she continues to tell him to be calm and to breathe.  She denied that she gives them any more attention.  I strongly encouraged her to stop doing status checks, as this likely is reinforcing the behavior.  I also noted that while he certainly needs to be kept safe, that she does not want to give a lot of attention to this behavior, and that over time we will teach him ways of coping with this independently.  In regards to his mood, she reported that his mood is quite good.  She denied any sadness or irritability.  She denied anhedonia.  She reports that he is a little bit hard to get up in the morning.  He is going to bed at about 11, getting up at 8 or 9.  No changes in weight or eating were noted.  No changes in concentration, suicidal ideation, and any suicidal history was denied.  She denied symptoms of anxiety, although she did note that she thought he worried a little about going to school and some financial stress.  Other symptoms of psychopathology were denied.,DEVELOPMENTAL HISTORY: , The patient was reportedly a 7 pounds 12 ounces product of an unplanned and uncomplicated pregnancy and planned cesarean delivery.  Mother reported that she did receive prenatal care.  The use of alcohol, drugs, or tobacco during the pregnancy were denied.  She denied that he had any feeding or sleeping problems in the perinatal period.  She described him as a fussy and active baby, but he was described as a cuddly baby.  She noted that the pediatricians never expressed any concerns regarding his developmental milestones.  SHE REPORTED THAT HE IS ALLERGIC TO PENICILLIN.  Serious injures or toileting problems were denied as were a history of seizures.,FAMILY BACKGROUND: , The patient currently lives with his mother who is age 57 and with her partner who is age 40.  They have been together since 1994, and he is the only father figure that the patient has even known.  The father was previously in a relationship that resulted in an 11-year-old daughter who visits the patient's home every other weekend.  The patient's father's whereabouts are unknown.  There is no information on his family.  Mother stated that he discontinued his involvement in her life when she was about 3 months pregnant with the patient, and the patient has never met him.  As noted, there is no information on the paternal side of the family.  In terms of the mother's side of family, the maternal grandfather died in his 60s due to what mother described as ""hardening of the arteries,"" and the maternal grandmother died in 2003 due to stroke.  There were 4 maternal aunts, one of them died at age 9 months from pneumonia, one of them died at 19 years old from what was described as a brain tumor, and there are 3 maternal uncles.  In terms of family relationships, it was reported that overall the patient tends to get along fairly well with his parents, who reported that the patient and her partner tend to compete for mother's attention, and she noted this is difficult at times.  She reported that the patient and her partner do not really do anything together.  Mother reported that there is no domestic violence in the home, but there is some marital conflict, and this is may be difficult for The patient, as it is carried on in Spanish, and he does not speak Spanish.  There also is some stress in the home due to the stepdaughter, as there are some concerns that her mother may be involved in drugs.  The mother reported that she attended high school, did not attend any college.  She denied learning problems.  She denied psychological problems or any drug/alcohol history.  In terms of the biological father, she reported he did not graduate from high school.  She did not know of learning problems, psychological problems.  She denied that he had a drug/alcohol history.  There is a family history of alcoholism in one of the maternal uncles as well as in the maternal grandfather.  It should be noted that the patient and his family live in a small 4-bedroom apartment, where privacy is very difficult.,SOCIAL BACKGROUND:,  She reported that the patient is able to make and keep friends, but he enjoys lifting weights, skateboarding, and that he recently had an opportunity to do rock climbing, he really enjoyed that.  I encouraged her to have him involved in physical activity, as this is good for discharge the stress, to encourage the weightlifting, as well as the skateboarding.  Mother is going to check further information regarding the rock climbing that the patient had been involved in, which was at it sounds like by her description as some sort of boys' and girls' type of club.  Abuse of drugs or alcohol were denied.  The patient was not described as being sexually active.,ACADEMIC BACKGROUND: , The patient is currently in the 10th grade.  At present, he is on independent studies, which began after his hospitalization.  The mother reported that the teacher, who had come to school saw one of his episodes, and stated that, they would not want him to be attending school.  I spoke with her very clearly and directly regarding the fact that it was probably not best for the patient to be on independent studies, that he needed to be returned to his normal school environment.  He has never had an episode at school, and he needs to be back with his peers, back in a regular environment, where he is under normal expectations.  I spoke with her regarding my concerns, regarding the fact that he is unsupervised during the day, and we do not want this turning into one big long vacation, where he is not getting his work done, and he gets himself in trouble.  Normally, he would be attending at High School.  The mother stated that she would contact them as well as check into possibly a 504-Plan.  She reported that he really does not to go back to High School.  He says, the ""kids are bad;"" however, she denied that he has any history of fighting.  She noted that he is stressed by the school, there have been some peer problems, possibly some bullying.  I noted these need to be addressed with the school, as she had not done so.  She stated that she would speak with a counselor.  She noted, however, that he has a history of not liking school and avoiding going to school.  She noted that he is somewhat behind in his work due to the hospitalization.  His grades traditionally are C's.  She denied any Special Education Services.,PREVIOUS COUNSELING: , Denied.,DIAGNOSTIC SUMMARY AND IMPRESSION: , Similar to my impression at the hospital, it would appear that the patient clearly qualifies for a diagnosis of conversion disorder.  It appears that there are multiple stressors in the family, and that the mother is reinforcing his conversion reaction.  I am also very concerned regarding the fact that he is not attending school and want him back in the normal school environment as quickly as possible.  My plan is to meet the patient at the next session to update the information regarding his functioning and to begin to teach him skills for reducing his stress and relaxing.,DSM-IV DIAGNOSES:  ,AXIS I:  Conversion disorder (300.11).,AXIS II:  No diagnosis (V71.09).,AXIS III:  No diagnosis.,AXIS IV:  Problems with primary support group, educational problems, and peer problems.,AXIS V:  Global Assessment of Functioning equals 60.","consult - history and phy., developmental history, academic background, global assessment of functioning, normal school environment, conversion reactions, conversion disorder, conversion, background, environment, peers, disorder, axis,"
 Patient presents for a colostomy reversal as well as repair of an incisional hernia. , Consult - History and Phy., Consult for Colostomy Reversal ,"CHIEF COMPLAINT: , ""I want my colostomy reversed."",HISTORY OF PRESENT ILLNESS: , Mr. A is a pleasant 43-year-old African-American male who presents to our clinic for a colostomy reversal as well as repair of an incisional hernia.  The patient states that in November 2007, he presented to High Point Regional Hospital with sharp left lower quadrant pain and was emergently taken to Surgery where he woke up with a ""bag.""  According to some notes that were faxed to our office from the surgeon in High Point who performed his initial surgery, Dr. X, the patient had diverticulitis with perforated sigmoid colon, and underwent a sigmoid colectomy with end colostomy and Hartmann's pouch.  The patient was unaware of his diagnosis; therefore, we discussed that with him today in clinic.  The patient also complains of the development of an incisional hernia since his surgery in November.  He was seen back by Dr. X in April 2008 and hopes that Dr. X may reverse his colostomy and repair his hernia since he did his initial surgery, but because the patient has lost his job and has no insurance, he was referred to our clinic by Dr. X.  Currently, the patient does state that his hernia bothers him more so than his colostomy, and if it were not for the hernia then he may just refrain from having his colostomy reversed; however, the hernia has grown in size and causing him significant discomfort.  He feels that he always has to hold his hand over the hernia to prevent it from prolapsing and causing him even more discomfort.,PAST MEDICAL AND SURGICAL HISTORY:,1.  Gastroesophageal reflux disease.,2.  Question of hypertension.,3.  Status post sigmoid colectomy with end colostomy and Hartmann's pouch in November 2007 at High Point Regional.,4.  Status post cholecystectomy.,7.  Status post unknown foot surgery.,MEDICATIONS:,  None.,ALLERGIES: , No known drug allergies.,SOCIAL HISTORY: , The patient lives in Greensboro.  He smokes one pack of cigarettes a day and has done so for 15 years.  He denies any IV drug use and has an occasional alcohol.,FAMILY HISTORY:  ,Positive for diabetes, hypertension, and coronary artery disease.,REVIEW OF SYSTEMS: , Please see history of present illness; otherwise, the review of systems is negative.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 95.9, pulse 67, blood pressure 135/79, and weight 208 pounds.,GENERAL:  This is a pleasant African-American male appearing his stated age in no acute distress.,HEENT:  Normocephalic, atraumatic.  Pupils are equal, round, and reactive to light and accommodation.  Moist mucous membranes.  Extraocular movements intact.,NECK:  Supple, no JVD, and no lymphadenopathy.,CARDIOVASCULAR:  Regular rate and rhythm.,LUNGS:  Clear to auscultation bilaterally.,ABDOMEN:  Soft, nontender, and nondistended with a left lower quadrant stoma.  The stoma is pink, protuberant, and productive.  The patient also has a midline incisional hernia approximately 6 cm in diameter.  It is reducible.  Otherwise, there are no further hernias or masses noted.,EXTREMITIES:  No clubbing, cyanosis or edema.,ASSESSMENT AND PLAN:  ,This is a 43-year-old gentleman who underwent what sounds like a sigmoid colectomy with end colostomy and Hartmann's pouch in November of 2007 secondary to perforated colon from diverticulitis.  The patient presents for reversal of his colostomy as well as repair of his incisional hernia.  I have asked the patient to return to High Point Regional and get his medical records including the operative note and pathology results from his initial surgery so that I would have a better idea of what was done during his initial surgery.  He stated that he would try and do this and bring the records to our clinic on his next appointment.  I have also set him up for a barium enema to study the rectal stump.  He will return to us in two weeks at which time we will review his radiological studies and his medical records from the outside hospital and determine the best course of action from that point.  This was discussed with the patient as well as his sister and significant other in the clinic today.  They were in agreement with this plan.  We also called the social worker to come and help the patient get more ostomy appliances, as he stated that he had no more and he was having to reuse the existing ostomy bag.  To my understanding, his social worker, as well as the ostomy nurses were able to get him some assistance with this.,",
" A 52-year-old female who said she has had 1 week of nausea and vomiting, which is moderate-to-severe.", Consult - History and Phy., Consult - Vomiting & Nausea ,"CHIEF COMPLAINT:,  Vomiting and nausea.,HPI: , The patient is a 52-year-old female who said she has had 1 week of nausea and vomiting, which is moderate-to-severe.  She states she has it at least once a day.  It can be any time, but can also be postprandial.  She states she will vomit up some dark brown-to-green fluid.  There has been no hematemesis.  She states because of the nausea and vomiting, she has not been able to take much in the way of PO intake over the past week.  She states her appetite is poor.  The patient has lost 40 pounds of weight over the past 16 months.  She states for the past few days, she has been getting severe heartburn.  She used Tums over-the-counter and that did not help.  She denies having any dysphagia or odynophagia.  She is not having any abdominal pain.  She has no diarrhea, rectal bleeding, or melena.  She has had in the past, which was remote.  She did have some small amounts of rectal bleeding on the toilet tissue only if she passed a harder stool.  She has a history of chronic constipation for most of her life but she definitely has a bowel movement every 3 to 4 days and this is unchanged.  The patient states she has never had any endoscopy or barium studies of the GI tract.,The patient is anemic and her hemoglobin is 5.7 and she is thrombocytopenic with the platelet count of 34.  She states she has had these abnormalities since she has been diagnosed with breast cancer.  She states that she has metastatic breast cancer and that is in her rib cage and spine and she is getting hormonal chemotherapy for this and she is currently under the care of an oncologist.  The patient also has acute renal failure at this point.  The patient said she had a PET scan done about a week ago.,PAST MEDICAL HISTORY:,  Metastatic breast cancer to her rib cage and spine, hypothyroidism, anemia, thrombocytopenia, hypertension, Bells palsy, depression, uterine fibroids, hysterectomy, cholecystectomy, breast lumpectomy, and thyroidectomy.,ALLERGIES: , No known drug allergies.,MEDICINES:,  She is on Zofran, Protonix, fentanyl patch, Synthroid, Ativan, and Ambien.,SOCIAL HISTORY:  ,The patient is divorced and is a homemaker.  No smoking or alcohol.,FAMILY HISTORY:,  Negative for any colon cancer or polyps.  Her father died of mesothelioma, mother died of Hodgkin lymphoma.,SYSTEMS REVIEW: , No fevers, chills or sweats.  She has no chest pain, palpitations, coughing or wheezing.  She does get shortness of breath, no hematuria, dysuria, arthralgias, myalgias, rashes, jaundice, bleeding or clotting disorders.  The rest of the system review is negative as per the HPI.,PHYSICAL EXAM: , Temperature 98.4, blood pressure 95/63, heart rate 84, respiratory rate of 18, and weight is 108 kg.  GENERAL APPEARANCE:  The patient was comfortable in bed.  Skin exam is negative for any rashes or jaundice.  LYMPHATICS:  There is no palpable lymphadenopathy of the cervical or the supraclavicular area.  HEENT:  She has some mild ptosis of the right eye.  There is no icterus.  The patient's conjunctivae and sclerae are normal.  Pupils are equal, round, and reactive to light and accommodation.  No lesions of the oral mucosa or mucosa of the pharynx.  NECK:  Supple.  Carotids are 2+.  No thyromegaly, masses or adenopathy.  HEART:  Has regular rhythm.  Normal S1 and S2.  She has a 2/6 systolic ejection murmur.  No rubs or gallops.  Lungs are clear to percussion and auscultation.  Abdomen is obese, it may be mildly distended.  There is no increased tympany.  The patient does have hepatosplenomegaly.  There is no obvious evidence of ascites.  The abdomen is nontender, bowel sounds are present.  The extremities show some swelling and edema of the ankle regions bilaterally.  Legs are in SCDs.  No cyanosis or clubbing.  For the rectal exam, it shows brown stool that is very trace heme positive at most.  For the neuro exam, she is awake, alert, and oriented x3.  Memory intact.  No focal deficits.  Insight and judgment are intact.,X-RAY AND LABORATORY DATA:  ,She came in, white count 9.2, hemoglobin 7.2, hematocrit 22.2, MCV of 87, platelet count is 47,000.  Calcium is 8.1, sodium 134, potassium 5.3, chloride 102, bicarbonate 17, BUN of 69, creatinine of 5.2, albumin 2.2, ALT 28, bilirubin is 2.2, alkaline phosphatase is 359, AST is 96, and lipase is 30.  Today, her hemoglobin is 5.7, TSH is 1.1, platelet count is 34,000, alkaline phosphatase is 303, and bilirubin of 1.7.,IMPRESSION,1.  The patient has one week of nausea and vomiting with decreased p.o. intake as well as dehydration.  This could be on the basis of her renal failure.  She may have a viral gastritis.  The patient does have a lot of gastroesophageal reflux disease symptoms recently.  She could have peptic mucosal inflammation or peptic ulcer disease.,2.  The patient does have hepatosplenomegaly.  There is a possibility she could have liver metastasis from the breast cancer.,3.  She has anemia as well as thrombocytopenia.  The patient states this is chronic.,4.  A 40-pound weight loss.,5.  Metastatic breast cancer.,6.  Increased liver function tests.  Given her bone metastasis, the elevated alkaline phosphatase may be from this as opposed to underlying liver disease.,7.  Chronic constipation.,8.  Acute renal failure.,PLAN:  ,The patient will be on a clear liquid diet.  She will continue on the Zofran.  She will be on IV Protonix.  The patient is going to be transfused packed red blood cells and her hemoglobin and hematocrit will be monitored.  I obtained the result of the abdominal x-rays she had done through the ER.  The patient has a consult pending with the oncologist to see what her PET scan show.  There is a renal consult pending.  I am going to have her get a total abdominal ultrasound to see if there is any evidence of liver metastasis and also to assess her kidneys.  Her laboratory studies will be followed.  Based upon the patient's medical condition and including her laboratory studies including a platelet count, we talked about EGD versus upper GI workup per upper GI symptoms.  I discussed informed consent for EGD.  I discussed the indications, risks, benefits, and alternatives.  The risks reviewed included, but were not limited to an allergic reaction or side effect to medicines, cardiopulmonary complications, bleeding, infection, perforation, and needing to get admitted for antibiotics or blood transfusion or surgery.  The patient voices her understanding of the above.  She wants to think about what she wants to do.  Overall, this is a very ill patient with multiorgan involvement.",
" A gentleman with a long history of heroin abuse, trying to get off the heroin, last use shortly prior to arrival including cocaine.  The patient does have a history of alcohol abuse, but mostly he is concerned about the heroin abuse.", Consult - History and Phy., Detox from Heroin ,"CHIEF COMPLAINT:,  Detox from heroin.,HISTORY OF PRESENT ILLNESS: , This is a 52-year-old gentleman with a long history of heroin abuse, who keeps relapsing, presents once again, trying to get off the heroin, last use shortly prior to arrival including cocaine.  The patient does have a history of alcohol abuse, but mostly he is concerned about the heroin abuse.,PAST MEDICAL HISTORY: , Remarkable for chronic pain.  He has had multiple stab wounds, gunshot wounds, and a variety of other injuries that resulted him having chronic pain and he states that is what triggers of him getting on heroin to try to get out of pain.  He has previously been followed by ABC but has not seen him for several years.,REVIEW OF SYSTEMS:  ,The patient states that he did use heroin as well as cocaine earlier today and feels under the influence.  Denies any headache or visual complaints.  No hallucinations.  No chest pain, shortness of breath, abdominal pain or back pain.  Denies any abscesses.,SOCIAL HISTORY: , The patient is a smoker.  Admits to heroin use, alcohol abuse as well.  Also admits today using cocaine.,FAMILY HISTORY:,  Noncontributory.,MEDICATIONS: , He has previously been on analgesics and pain medications chronically.  Apparently, he just recently got out of prison.  He has previously also been on Klonopin and lithium.  He was previously on codeine for this pain.,ALLERGIES: , NONE.,PHYSICAL EXAMINATION: , VITAL SIGNS:  The patient is afebrile.  He is markedly hypertensive, 175/104 and pulse 117 probably due to the cocaine onboard.  His respiratory rate is normal at 18.  GENERAL:  The patient is a little jittery but lucid, alert, and oriented to person, place, time, and situation.  HEENT:  Unremarkable.  Pupils are actually moderately dilated about 4 to 5 mm, but reactive.  Extraoculars are intact.  His oropharynx is clear.  NECK:  Supple.  His trachea is midline.  LUNGS:  Clear.  He has good breath sounds and no wheezing.  No rales or rhonchi.  Good air movement and no cough.  CARDIAC:  Without murmur.  ABDOMEN:  Soft and nontender.  He has multiple track marks, multiple tattoos, but no abscesses.  NEUROLOGIC:  Nonfocal.,IMPRESSION: , MEDICAL EXAMINATION FOR THE PATIENT WHO WILL BE DETOXING FROM HEROIN.,ASSESSMENT AND PLAN:  ,At this time, I think the patient can be followed up at XYZ.  I have written a prescription of clonidine and Phenergan for symptomatic relief and this has been faxed to the pharmacy.  I do not think he needs any further workup at this time.  He is discharged otherwise in stable condition.","consult - history and phy., phenergan, detox from heroin, alcohol abuse, heroin abuse, detox, heroin, alcohol, cocaine, abuse,"
 Elevated cholesterol and is on medication to lower it., Consult - History and Phy., Dietary Consult - 1 ,"SUBJECTIVE:,  His brother, although he is a vegetarian, has elevated cholesterol and he is on medication to lower it.  The patient started improving his diet when he received the letter explaining his lipids are elevated.  He is consuming less cappuccino, quiche, crescents, candy from vending machines, etc.  He has started packing his lunch three to four times per week instead of eating out so much.  He is exercising six to seven days per week by swimming, biking, running, lifting weights one and a half to two and a half hours each time.  He is in training for a triathlon.  He says he is already losing weight due to his efforts.,OBJECTIVE:,  Height:  6 foot 2 inches.  Weight:  204 pounds on 03/07/05.  Ideal body weight:  190 pounds, plus or minus ten percent.  He is 107 percent standard of midpoint ideal body weight.  BMI:  26.189.  A 48-year-old male.  Lab on 03/15/05:  Cholesterol:  251.  LDL:  166.  VLDL:  17.  HDL:  68.  Triglycerides:  87.  I explained to the patient the dietary guidelines to help improve his lipids.  I recommend a 26 to 51 to 77 fat grams per day for a 10 to 20 to 30 percent fat level of 2,300 calories since he is interested in losing weight.  I went over the printed information sheet on lowering your cholesterol and that was given to him along with a booklet on the same topic to read.  I encouraged him to continue as he is doing.,ASSESSMENT:,  Basal energy expenditure 1960 x 1.44 activity factor is approximately 2,800 calories.  His 24-hour recall shows he is making many positive changes already to lower his fat and cholesterol intake.  He needs to continue as he is doing.  He verbalized understanding and seemed receptive.,PLAN:,  The patient plans to recheck his lipids through Dr. XYZ  I gave him my phone number and he is to call me if he has any further questions regarding his diet.","consult - history and phy., vegetarian, lipids, cholesterol intake, elevated cholesterol, losing weight, body weight, dietary, cholesterol"
" Patient had a piece of glass fall on to his right foot.  A 4-mm laceration.  Acute foot pain, now resolved.   The patient was given discharge instructions on wound care.", Consult - History and Phy., Cut on Foot - ER Visit ,"CHIEF COMPLAINT:,  Cut on foot.,HISTORY OF PRESENT ILLNESS:,  This is a 32-year-old male who had a piece of glass fall on to his right foot today.  The patient was concerned because of the amount of bleeding that occurred with it.  The bleeding has been stopped and the patient does not have any pain.  The patient has normal use of his foot, there is no numbness or weakness, the patient is able to ambulate well without any discomfort.  The patient denies any injuries to any other portion of his body.  He has not had any recent illness.  The patient has no other problems or complaints.,PAST MEDICAL HISTORY:,  Asthma.,CURRENT MEDICATION: , Albuterol.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient is a smoker.,PHYSICAL EXAMINATION:,  VITAL SIGNS:  Temperature 98.8 oral, blood pressure 132/86, pulse is 76, and respirations 16.  Oxygen saturation is 100% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well-nourished, well-developed, the patient appears to be healthy.  The patient is calm and comfortable in no acute distress and looks well.  The patient is pleasant and cooperative.  HEENT:  Head is atraumatic, normocephalic, and nontender.  Eyes are normal with clear conjunctiva and cornea bilaterally.  NECK:  Supple with full range of motion.  CARDIOVASCULAR:  Peripheral pulse is +2 to the right foot.  Capillary refills less than two seconds to all the digits of the right foot.  RESPIRATIONS:  No shortness of breath.  MUSCULOSKELETAL:  The patient has a 4-mm partial thickness laceration to the top of the right foot and about the area of the mid foot.  There is no palpable foreign body, no foreign body is visualized.  There is no active bleeding, there is no exposed deeper tissues and certainly no exposed tendons, bone, muscle, nerves, or vessels.  It appears that the laceration may have nicked a small varicose vein, which would have accounted for the heavier than usual bleeding that currently occurred at home.  The patient does not have any tenderness to the foot.  The patient has full range of motion to all the joints, all the toes, as well as the ankles.  The patient ambulates well without any difficulty or discomfort.  There are no other injuries noted to the rest of the body.  SKIN:  The 4-mm partial thickness laceration to the right foot as previously described.  No other injuries are noted.  NEUROLOGIC:  Motor is 5/5 to all the muscle groups of the right lower extremity.  Sensory is intact to light touch to all the dermatomes of the right foot.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is alert and oriented x4.  Normal mood and affect.  HEMATOLOGIC/LYMPHATIC:  No active bleeding is occurring at this time.  No evidence of bruising is noted to the body.,EMERGENCY DEPARTMENT COURSE:,  The patient had antibiotic ointment and a bandage applied to his foot.,DIAGNOSES:,1.  A 4-MM LACERATION TO THE RIGHT FOOT.,2.  ACUTE RIGHT FOOT PAIN, NOW RESOLVED.,CONDITION UPON DISPOSITION: , Stable.,DISPOSITION:,  To home.  The patient was given discharge instructions on wound care and asked to return to emergency room should he have any evidence or signs and symptoms of infection.  The patient was precautioned that there may still be a small piece of glass retained in the foot and that there is a possibility of infection or that the piece of glass may be extruded later on.","consult - history and phy., foot pain, cut on foot, piece of glass, foreign body, active bleeding, foot, injuries, atraumatic, laceration, bleeding, body, "
" Consult for generalized body aches, cough, nausea, and right-sided abdominal pain for two days - Bronchitis.", Consult - History and Phy., Cough & Abdominal Pain ,"CHIEF COMPLAINT: , Cough and abdominal pain for two days.,HISTORY OF PRESENT ILLNESS: , This is a 76-year-old female who has a history of previous pneumonia, also hypertension and macular degeneration, who presents with generalized body aches, cough, nausea, and right-sided abdominal pain for two days.  The patient stated that the abdominal pain was only associated with coughing.  The patient reported that the cough is dry in nature and the patient had subjective fevers and chills at home.,PAST MEDICAL HISTORY:  ,Significant for pneumonia in the past, pleurisy, macular degeneration, hypertension, and phlebitis.,PAST SURGICAL HISTORY:  ,The patient had bilateral cataract extractions in 2007, appendectomy as a child, and three D&Cs in the past secondary to miscarriages.,MEDICATIONS: , On presentation included hydrochlorothiazide 12.5 mg p.o. daily, aspirin 81 mg p.o. daily, and propranolol 40 mg p.o. daily.  The patient also takes multivitamin and Lutein over-the-counter for macular degeneration.,ALLERGIES: , THE PATIENT HAS NO KNOWN DRUG ALLERGIES.,FAMILY HISTORY:,  Mother died at the age of 59 due to stomach cancer and father died at the age of 91 years old.,SOCIAL HISTORY:,  The patient quit smoking 17 years ago; prior to that had smoked one pack per day for 44 years.  Denies any alcohol use.  Denies any IV drug use.,PHYSICAL EXAMINATION:  ,GENERAL:  This is a 76-year-old female, well nourished.  VITAL SIGNS:  On presentation included a temperature of 100.1, pulse of 144 with a blood pressure of 126/77, the patient is saturating at 95% on room air, and has respiratory rate of 20.  HEENT:  Anicteric sclerae.  Conjunctivae pink.  Throat was clear.  Mucosal membranes were dry.  CHEST:  Coarse breath sounds bilaterally at the bases.  CARDIAC:  S1 and S2.  No murmurs, rubs or gallops.  No evidence of carotid bruits.  ABDOMEN:  Positive bowel sounds, presence of soreness on examination in the abdomen on palpation.  There is no rebound or guarding.  EXTREMITIES:  No clubbing, cyanosis or edema.,HOSPITAL COURSE: , The patient had a chest x-ray, which showed increased markings present bilaterally likely consistent with chronic lung changes.  There is no evidence of effusion or consolidation.  Degenerative changes were seen in the shoulder.  The patient also had an abdominal x-ray, which showed nonspecific bowel gas pattern.  Urinalysis showed no evidence of infection as well as her influenza A&B were negative.  Preliminary blood cultures have been with no growth to date status post 48 hours.  The patient was started on cefepime 1 g IV q.12h. and given IV hydration.  She has also been on Xopenex nebs q.8h. round the clock and in regards to her hypertension, she was continued on her hydrochlorothiazide and propranolol.  In terms of prophylactic measures, she received Lovenox subcutaneously for DVT prophylaxis.  Currently today, she feels much improved with still only a mild cough.  The patient has been afebrile for two days, saturating at 97% on room air with a respiratory rate of 18.  Her white count on presentation was 13.6 and yesterday's white count was 10.3.,FINAL DIAGNOSIS:,  Bronchitis.,DISPOSITION: , The patient will be going home.,MEDICATIONS: , Hydrochlorothiazide 12.5 mg p.o. daily, propranolol 40 mg p.o. daily.  Also, Avelox 400 mg p.o. daily x10 days, guaifenesin 10 cc p.o. q.6h. p.r.n. for cough, and aspirin 81 mg p.o. daily.,DIET:,  To follow a low-salt diet.,ACTIVITY:,  As tolerated.,FOLLOWUP:  ,To follow up with Dr. ABC in two weeks.",
" Cerebral palsy, worsening seizures.  A pleasant 43-year-old female with past medical history of CP since birth, seizure disorder, complex partial seizure with secondary generalization and on top of generalized epilepsy, hypertension, dyslipidemia, and obesity. ", Consult - History and Phy., Consult - Seizures - 1 ,"CHIEF COMPLAINT: , Worsening seizures.,HISTORY OF PRESENT ILLNESS:  ,A pleasant 43-year-old female with past medical history of CP since birth, seizure disorder, complex partial seizure with secondary generalization and on top of generalized epilepsy, hypertension, dyslipidemia, and obesity.  The patient stated she was in her normal state of well being when she was experiencing having frequent seizures.  She lives in assisted living.  She has been falling more frequently.  The patient was driving a scooter and apparently was hitting into the wall with unresponsiveness in association with this.  There was no head trauma, but apparently she was doing that many times and there was no responsiveness.  The patient has no memory of the event.  She is now back to her baseline.  She states her seizures are worse in the setting of stress, but it is not clear to her why this has occurred.  She is on Carbatrol 300 mg b.i.d. and she has been very compliant and without any problems.  The patient is admitted for EMU monitoring for the characterization of these episodes and for the possibility of complex partial epilepsy syndrome or better characterization of this current syndrome.,PAST MEDICAL HISTORY:  ,Include dyslipidemia and hypertension.,FAMILY HISTORY:  ,Positive for stroke and sleep apnea.,SOCIAL HISTORY: , No smoking or drinking.  No drugs.,MEDICATIONS AT HOME: , Include, Avapro, lisinopril, and dyslipidemia medication, she does not remember.,REVIEW OF SYSTEMS:,  The patient does complain of gasping for air, witnessed apneas, and dry mouth in the morning.  The patient also has excessive daytime sleepiness with EDS of 16.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Last blood pressure 130/85, respirations 20, and pulse 70.,GENERAL:  Normal.,NEUROLOGICAL:  As follows.  Right-handed female, normal orientation, normal recollection to 3 objects.  The patient has underlying MR. Speech, no aphasia, no dysarthria.  Cranial nerves, funduscopic intact without papilledema.  Pupils are equal, round, and reactive to light.  Extraocular movements intact.  No nystagmus.  Her mood is intact.  Symmetric face sensation.  Symmetric smile and forehead.  Intact hearing.  Symmetric palate elevation.  Symmetric shoulder shrug and tongue midline.  Motor 5/5 proximal and distal.  The patient does have limp on the right lower extremity.  Her Babinski is hyperactive on the left lower extremity, upgoing toes on the left.  Sensory, the patient does have sharp, soft touch, vibration intact and symmetric.  The patient has trouble with ambulation.  She does have ataxia and uses a walker to ambulate.  There is no bradykinesia.  Romberg is positive to the left.  Cerebellar, finger-nose-finger is intact.  Rapid alternating movements are intact.  Upper airway examination, the patient has a Friedman tongue position with 4 oropharyngeal crowding.  Neck more than 16 to 17 inches, BMI elevated above 33.  Head and neck circumference very high.,IMPRESSION:,1.  Cerebral palsy, worsening seizures.,2.  Hypertension.,3.  Dyslipidemia.,4.  Obstructive sleep apnea.,5.  Obesity.,RECOMMENDATIONS:,1.  Admission to the EMU, drop her Carbatrol 200 b.i.d., monitor for any epileptiform activity.  Initial time of admission is 3 nights and 3 days.,2.  Outpatient polysomnogram to evaluate for obstructive sleep apnea followed by depression if clinically indicated.  Continue her other medications.,3.  Consult Dr. X for hypertension, internal medicine management.,4.  I will follow this patient per EMU protocol.", 
" Nonhealing right ankle stasis ulcer.  A 52-year-old native American-Indian man with hypertension, chronic intermittent bipedal edema, and recurrent leg venous ulcers was admitted for scheduled vascular surgery. ", Consult - History and Phy., Consult - Stasis Ulcer ,"REASON FOR THE CONSULT:,  Nonhealing right ankle stasis ulcer.,HISTORY OF PRESENT ILLNESS: , This is a 52-year-old native American-Indian man with hypertension, chronic intermittent bipedal edema, and recurrent leg venous ulcers, who was admitted on 01/27/09 for scheduled vascular surgery per Dr. X. I was consulted for nonhealing right ankle stasis ulcer.  There is a concern that the patient had a low-grade fever of 100.2 early this morning.  The patient otherwise feels well.  He was not even aware of the fever.  He does have some ankle pain, worse on the right than the left.  Old medical records were reviewed.  He has multiple hospitalizations for leg cellulitis.  Multiple wound cultures have repeatedly grown Pseudomonas, Enterococcus, and Stenotrophomonas in the past.  Klebsiella and Enterobacter have also grown in the few wound cultures at some point.  The patient has been following up at the wound center as an outpatient and was referred to Dr. X for definitive surgical management.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No malaise.  Positive recent low-grade fevers.  No chills.,HEENT:  No acute change in visual acuity, no diplopia, no acute hearing disturbances, and no sinus congestion.  No sore throat.,CARDIAC:  No chest pain or cough.,GASTROINTESTINAL:  No nausea, vomiting or diarrhea.,All other systems were reviewed and were negative.,PAST MEDICAL HISTORY:  ,Hypertension, exploratory laparotomy in 2004 for abdominal obstruction, cholecystectomy in 2005, chronic intermittent bipedal edema, venous insufficiency, chronic recurrent stasis ulcers.,SOCIAL HISTORY: , The patient admits to heavy alcohol drinking in the past, quit several years ago.  He is also a former cigarette smoker, quit several years ago.,ALLERGIES:,  None known.,CURRENT MEDICATIONS:,  Primaxin, daptomycin, clonidine, furosemide, potassium chloride, lisinopril, metoprolol, ranitidine, Colace, amlodipine, zinc sulfate, Lortab p.r.n., multivitamins with minerals.,PHYSICAL EXAMINATION:,CONSTITUTIONAL/VITAL SIGNS:  Heart rate 73, respiratory rate 20, blood pressure 104/67, temperature 98.3, and oxygen saturation 92% on room air.,GENERAL APPEARANCE:  The patient is awake, alert, and not in cardiorespiratory distress.  Height 6 feet 1.5 inches, body weight 125.26 kilos.,EYES:  Pink conjunctivae, anicteric sclerae.  Pupils equal, brisk reaction to light.,EARS, NOSE, MOUTH AND THROAT:  Intact gross hearing.  Moist oral mucosa.  No oral lesions.,NECK:  No palpable neck masses.  Thyroid is not enlarged on inspection.,RESPIRATORY:  Regular inspiratory effort.  No crackles or wheezes.,CARDIOVASCULAR:  Regular cardiac rhythm.  No thrills or rubs.,GASTROINTESTINAL:  Normoactive bowel sounds.  Soft.  No guarding or rigidity.,LYMPHATIC:  No cervical lymphadenopathy.,MUSCULOSKELETAL:  Good range of motion of upper and lower extremities.,SKIN:  There is hyperpigmentation involving the distal calf of both legs.  There is an open wound on the right medial,malleolar area measuring 9 x 5cm with minimal serous drainage.  Periwound is hyperpigmented with a hint of erythema extending proximally to the medial aspect, distal third of the right lower leg.  There is warmth, but minimal tenderness on palpation of this area.  There is also a wound on the right lateral malleolar area measuring 4 x 3 cm, another open wound on the left medial malleolar area measuring 7 x 4 cm.  Wound edges are poorly defined.,PSYCHIATRIC:  Appropriate mood and affect, oriented x3.  Fair judgment and insight.,LABORATORY RESULTS: , White blood cell count from 01/28/09 is 5.8 with 64% neutrophils, H&H 11.3/33.8, and platelet count 176,000.  BUN and creatinine 9.2/0.52.  Albumin 3.6, AST 25, ALT 9, alk phos 87, and total bilirubin 0.6.  One wound culture from right leg wound culture from 01/27/09 noted with young growth.  Left leg wound culture from 01/27/09 also with young growth.,RADIOLOGY:,  Chest x-ray done on 01/28/09 showed chronic bibasilar subsegmental atelectasis likely related to elevated hemidiaphragm secondary to chronic ileus.  No absolute findings.,IMPRESSION:,1.  Fevers.,2.  Right leg/ankle cellulitis.,3.  Chronic recurrent bilateral ankle venous ulcers.,4.  Multiple previous wound cultures positive for Pseudomonas, Enterococcus, and Stenotrophomonas.,5.  Hypertension.,RECOMMENDATIONS:,1.  We have ordered 2 sets of blood cultures.,2.  Agree with daptomycin and Primaxin IV.,3.  Follow up result of wound cultures.,4.  I will order an MRI of the right ankle to check for underlying osteomyelitis.,Additional ID recommendations as appropriate upon followup.",
" Patient was brought in the Emergency Room following an episode of syncope.  The patient relates that he may have had a seizure activity prior to that.  Prior to the episode, he denies having any symptoms of chest pain or shortness of breath. ", Consult - History and Phy., Consult - Syncope ,"REASON FOR CONSULTATION: , Syncope.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 69-year-old gentleman, a good historian, who relates that he was brought in the Emergency Room following an episode of syncope.  The patient relates that he may have had a seizure activity prior to that.  Prior to the episode, he denies having any symptoms of chest pain or shortness of breath.  No palpitation.  Presently, he is comfortable, lying in the bed.  As per the patient, no prior cardiac history.,CORONARY RISK FACTORS: , History of hypertension.  No history of diabetes mellitus.  Nonsmoker.  Cholesterol status is borderline elevated.  No history of established coronary artery disease.  Family history noncontributory.,PAST MEDICAL HISTORY:  ,Hypertension, hyperlipidemia, recently diagnosed with Parkinson's, as a Parkinson's tremor, admitted for syncopal evaluation.,PAST SURGICAL HISTORY: ,Back surgery, shoulder surgery, and appendicectomy.,FAMILY HISTORY: , Nonsignificant.,MEDICATIONS:,1.  Pain medications.,2.  Thyroid supplementation.,3.  Lovastatin 20 mg daily.,4.  Propranolol 20 b.i.d.,5.  Protonix.,6.  Flomax.,ALLERGIES:,  None.,PERSONAL HISTORY:,  He is married.  Nonsmoker.  Does not consume alcohol.  No history of recreational drug use.,REVIEW OF SYSTEMS,CONSTITUTIONAL:  No weakness, fatigue, or tiredness.,HEENT:  No history of cataract or glaucoma.,CARDIOVASCULAR:  No congestive heart failure.  No arrhythmias.,RESPIRATORY:  No history of pneumonia or valley fever.,GASTROINTESTINAL:  No nausea, vomiting, hematemesis, or melena.,UROLOGICAL:  No frequency or urgency.,MUSCULOSKELETAL:  Arthritis and muscle weakness.,SKIN:  Nonsignificant.,NEUROLOGIC:  No TIA or CVA.  No seizure disorder.,ENDOCRINE/HEMATOLOGIC:  Nonsignificant.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse of 93, blood pressure of 158/93, afebrile, and respiratory rate 16 per minute.,HEENT:  Atraumatic and normocephalic.,NECK:  Neck veins are flat.  No significant carotid bruits.,LUNGS:  Air entry is bilaterally decreased.,HEART:  PMI is displaced.  S1 and S2 are regular.,ABDOMEN:  Soft and nontender.  Bowel sounds are present.,EXTREMITIES:  No edema.  Pulses are palpable.  No clubbing or cyanosis.  The patient is moving all extremities; however, the patient has tremors.,RADIOLOGICAL DATA: , EKG reveals normal sinus rhythm with underlying nonspecific ST-T changes secondary to tremors.,LABORATORY DATA: , H&H stable.  White count of 14.  BUN and creatinine are within normal limits.  Cardiac enzyme profile is negative.  Ammonia level is elevated at 69.  CT angiogram of the chest, no evidence of pulmonary embolism.  Chest x-ray is negative for acute changes.  CT of the head, unremarkable, chronic skin changes.  Liver enzymes are within normal limits.,IMPRESSION:,1.  The patient is a 69-year-old gentleman, admitted with syncopal episode and possible seizure disorder.",
 Consultation - an 87-year-old white female with weakness and a history of polymyositis., Consult - History and Phy., Consult - Weankness & Polymyositis ,"REASON FOR CONSULTATION:, Regarding weakness and a history of polymyositis.,HISTORY OF PRESENT ILLNESS:, The patient is an 87-year-old white female who gives a history of polymyositis diagnosed in 1993. The patient did have biopsy of the quadriceps muscle performed at that time which, per her account, did show an abnormality. She was previously followed by Dr. C, neurology, over several years but was last followed up in the last three to four years. She is also seeing Dr. R at rheumatology in the past. Initially, she was treated with steroids but apparently was intolerant of that. She was given other therapy but she is unclear of the details of that. She has had persistent weakness of the bilateral lower extremities and has ambulated with the assistance of a walker for many years. She has also had a history of spine disease though the process there is not known to me at this time.,She presented on February 1, 2006 with productive cough, fevers and chills, left flank rash and pain there as well as profound weakness. Since admission, she has been diagnosed with a left lower lobe pneumonic process as well as shingles and is on therapy for both. She reports that strength in the proximal upper extremities has remained good. However, she has no grip strength. Apparently, this has been progressive over the last several years as well. She also presently has virtually no strength in the lower extremities and that is worse within the last few days. Prior to admission, she has had cough with mild shortness of breath. Phlegm has been dark in color. She has had reflux and occasional dysphagia. She has also had constipation but no other GI issues. She has no history of seizure or stroke like symptoms. She occasionally has headaches. No vision changes. Other than the left flank skin changes, she has had no other skin issues. She does have a history of DVT but this was 30 to 40 years ago. No history of dry eyes or dry mouth. She denies chest pain at present.,PAST MEDICAL AND SURGICAL HISTORY:, Hysterectomy, cholecystectomy, congestive heart failure, hypertension, history of DVT, previous colonoscopy that was normal, renal artery stenosis.,MEDICATIONS:, Medications prior to admission: Os-Cal, Zyrtec, potassium, Plavix, Bumex, Diovan.,CURRENT MEDICATIONS:, Acyclovir, azithromycin, ceftriaxone, Diovan, albuterol, Robitussin, hydralazine, Atrovent.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY:, She is a widow. She has 8 children that are healthy with the exception of one who has coronary artery disease and has had bypass. She also has a son with lumbar spine disease. No tobacco, alcohol or IV drug abuse.,FAMILY HISTORY:, No history of neurologic or rheumatologic issues.,REVIEW OF SYSTEMS:, As above.,PHYSICAL EXAMINATION:,VITAL SIGNS: She is afebrile. Current temperature 98. Respirations 16, heart rate 80 to 90. Blood pressure 114/55.,GENERAL APPEARANCE: She is alert and oriented and in no acute distress. She is pleasant. She is reclining in the bed.,HEENT: Pupils are reactive. Sclera are clear. Oropharynx is clear.,NECK: No thyromegaly. No lymphadenopathy.,CARDIOVASCULAR: Heart is regular rate and rhythm.,RESPIRATORY: Lungs have a few rales only.,ABDOMEN: Positive bowel sounds. Soft, nontender, nondistended. No hepatosplenomegaly.,EXTREMITIES: No edema.,SKIN: Left flank dermatome with vesicular rash that is red and raised consistent with zoster.,JOINTS: No synovitis anywhere. Strength is 5/5 in the proximal upper extremities. Proximal lower extremities are 0 out of 5. She has no grip strength at present.,NEUROLOGICAL: Cranial nerves II through XII grossly intact. Reflexes 2/4 at the biceps, brachial radialis, triceps. Nil out of four at the patella and Achilles bilaterally. Sensation seems normal. Chest x-ray shows COPD, left basilar infiltrate, cardiomegaly, atherosclerotic changes.,LABORATORY DATA:, White blood cell count 6.1, hemoglobin 11.9, platelets 314,000. Sed rate 29 and 30. Electrolytes: Sodium 134, potassium 4.9, creatinine 1.2, normal liver enzymes. TSH is slightly elevated at 5.38. CPK 36, BNP 645. Troponin less than 0.04.,IMPRESSION:,1. The patient has a history of polymyositis, apparently biopsy proven with a long standing history of bilateral lower extremity weakness. She has experienced dramatic worsening in the last 24 hours of the lower extremity weakness. This in the setting of an acute illness, presumably a pneumonic process.,2. She also gives a history of spine disease though the details of that process are not available either.,The question raised at this time is of recurrence in inflammatory myopathy which would need to include not only polymyositis but also inclusion body myositis versus progressive spine disease versus weakness secondary to acute illness versus neuropathic process versus other.,3. Zoster of the left flank.,4. Left lower lobe pneumonic process.,5. Elevation of the thyroid stimulating hormone.,RECOMMENDATIONS:,1. I have asked Dr. C to see the patient and he has done so tonight. He is planning for EMG nerve conduction study in the morning.,2. I would consider further spine evaluation pending review of the EMG nerve conduction study.,3. Agree with supportive care being administered thus far and will follow along with you.",
" Sepsis, possible SBP.  A 53-year-old Hispanic man with diabetes, morbid obesity, hepatitis C, cirrhosis, history of alcohol and cocaine abuse presented in the emergency room for ground-level fall secondary to weak knees.  He complained of bilateral knee pain, but also had other symptoms including hematuria and epigastric pain for at least a month. ", Consult - History and Phy., Consult - Sepsis ,"REASON FOR THE CONSULT: , Sepsis, possible SBP.,HISTORY OF PRESENT ILLNESS: , This is a 53-year-old Hispanic man with diabetes, morbid obesity, hepatitis C, cirrhosis, history of alcohol and cocaine abuse, who presented in the emergency room on 01/07/09 for ground-level fall secondary to weak knees.  He complained of bilateral knee pain, but also had other symptoms including hematuria and epigastric pain for at least a month.  He ran out of prescription medications 1 month ago.  In the ER he was initially afebrile, but then spiked up to 101.3 with heart rate of 130, respiratory rate of 24.  White blood cell count was slightly low at 4 and platelet count was only 22,000.  Abdominal ultrasound showed mild-to-moderate ascites.  He was given 1 dose of Zosyn and then started on levofloxacin and Flagyl last night.  Dr. X was called early this morning due to hypotension, SBP in the 70s.  He then changed antibiotic regiment to vancomycin and doripenem.,PAST MEDICAL HISTORY: , Hepatitis C, cirrhosis, coronary artery disease, hyperlipidemia, chronic venous stasis, gastroesophageal reflux disease, history of exploratory laparotomy for stab wounds, chronic recurrent leg wounds, and hepatic encephalopathy.,SOCIAL HISTORY: , The patient is a former smoker, reportedly quit in 2007.  He used cocaine in the past, reportedly quit in 2005.  He also has a history of alcohol abuse, but apparently quit more than 10 years ago.,ALLERGIES:,  None known.,CURRENT MEDICATIONS: , Vancomycin, doripenem, thiamine, Protonix, potassium chloride p.r.n., magnesium p.r.n., Zofran. p.r.n., norepinephrine drip, and vitamin K.,REVIEW OF SYSTEMS: , Not obtainable as the patient is drowsy and confused.,PHYSICAL EXAMINATION:,CONSTITUTIONAL/VITAL SIGNS:  Heart rate 101, respiratory rate 17, blood pressure 92/48, temperature 97.5, and oxygen saturation 98% on 2 L nasal cannula.,GENERAL APPEARANCE:  The patient is drowsy.  Morbidly obese.  Height 5 feet 8 inches, body weight 182 kilos.,EYES:  Slightly pale conjunctivae, icteric sclerae.  Pupils equal, brisk reaction to light.,EARS, NOSE, MOUTH AND THROAT:  Intact gross hearing.  Moist oral mucosa.  No oral lesions.,NECK:  No palpable neck masses.  Thyroid is not enlarged on inspection.,RESPIRATORY:  Regular inspiratory effort.  No crackles or wheezes.,CARDIOVASCULAR:  Regular cardiac rhythm.  No rales or rubs.  Positive bipedal edema, 2+, right worse than left.,GASTROINTESTINAL:  Globular abdomen.  Soft.  No guarding, no rigidity.  Tender on palpation of n right upper quadrant and epigastric area.  Mildly tender on palpation of right upper quadrant and epigastric area.,LYMPHATIC:  No cervical lymphadenopathy.,SKIN:  Positive diffuse jaundice.  No palpable subcutaneous nodules.,PSYCHIATRIC:  Poor judgment and insight.,LABORATORY DATA: , White blood cell count from 01/08/09 is 9 with 68% neutrophils, 20% bands, H&H 9.7/28.2, platelet count 24,000.  INR 3.84, PTT more than 240.  BUN and creatinine 26.8/1.2.  AST 76, ALT 27, alkaline phosphatase 48, total bilirubin 17.85.  Total CK 1198.6, LDH 873.2.  Troponin 0.09, myoglobin 2792.  Urinalysis from 01/07/09 shows small leucocyte esterase, positive nitrites, 1 to 3 wbc's, 0 to 1 rbc's, 2+ bacteria.  Two sets of blood cultures from 01/07/09 still pending.,RADIOLOGY:,  Chest x-ray from 01/07/09 did not show any pathologic abnormalities of the heart, mediastinum, lung fields, bony or soft tissue structures.  Left knee x-rays on 01/07/09 showed advanced osteoarthritis.  Abdominal ultrasound on 01/07/09 showed mild-to-moderate ascites, mild prominence of the gallbladder with thickened ball and pericholecystic fluid.  Preliminary report of CAT scan of the abdomen showed changes consistent to liver cirrhosis and portal hypertension with mild ascites, splenomegaly, and dilated portal/splenic and superior mesenteric vein.  Appendix was not clearly seen, but there was no evidence of pericecal inflammation.,IMPRESSION:,1.  Septic shock.,2.  Possible urinary tract infection.,3.  Ascites, rule out spontaneous bacterial peritenonitis.,4.  Hyperbilirubinemia, consider cholangitis.,5.  Alcoholic liver disease.,6.  Thrombocytopenia.,7.  Hepatitis C.,8.  Cryoglobulinemia.,RECOMMENDATIONS:,1.  Continue with vancomycin and doripenem at this point.,2.  Agree with paracentesis.,3.  Send ascitic fluid for cell count, differential and cultures.,4.  Follow up with result of blood cultures.,5.  We will get urine culture from the specimen on admission.,6.  The patient needs hepatitis A vaccination.,Additional ID recommendations as appropriate upon followup.",
 Patient referred for evaluation of her left temporal lobe epilepsy., Consult - History and Phy., Consult - Seizures ,"REASON FOR CONSULTATION:  ,Followup of seizures.,HISTORY OF PRESENT ILLNESS:,  This is a 47-year-old African-American female, well known to the neurology service, who has been referred to me for the first time evaluation of her left temporal lobe epilepsy that was diagnosed in August of 2002.  At that time, she had one generalized tonic-clonic seizure.  Apparently she had been having several events characterized by confusion and feeling unsteady lasting for approximately 60 seconds.  She said these events were very paroxysmal in the sense they suddenly came on and would abruptly stop.  She had two EEGs at that time, one on August 04, 2002 and second on November 01, 2002, both of which showed rare left anterior temporal sharp waves during drowsiness and sleep.  She also had an MRI done on September 05, 2002, with and without contrast that was negative.  Her diagnosis was confirmed by Dr. X at Johns Hopkins Hospital who reviewed her studies as well as examined the patient and felt that actually her history and findings were consistent with diagnosis of left temporal lobe epilepsy.  She was initially started on Trileptal, but had some problems with the medication subsequently Keppra, which she said made her feel bad and subsequently changed in 2003 to lamotrigine, which she has been taking since then.  She reports no seizures in the past several years.  She currently is without complaint.,In terms of seizure risk factors she denies head trauma, history of CNS infection, history of CVA, childhood seizures, febrile seizures.  There is no family history of seizures.,PAST MEDICAL HISTORY: , Significant only for hypertension and left temporal lobe epilepsy.,FAMILY HISTORY: , Remarkable only for hypertension in her father.  Her mother died in a motor vehicle accident.,SOCIAL HISTORY:  ,She works running a day care at home.  She has three children.  She is married.  She does not smoke, use alcohol or illicit drugs.,REVIEW OF SYSTEMS: , Please see note in chart.  Only endorses weight gain and the history of seizures, as well as some minor headaches treated with over-the-counter medications.,CURRENT MEDICATIONS:  ,Lamotrigine 150 mg p.o. b.i.d., verapamil, and hydrochlorothiazide.,ALLERGIES: , Flagyl and aspirin.,PHYSICAL EXAMINATION: , Blood pressure is 138/88, heart rate is 76, respiratory rate is 18, and weight is 224 pounds, pain scale is none.,General Examination:  Please see note in chart, which is essentially unremarkable except mild obesity.,NEUROLOGICAL EXAMINATION: , Again, please see note in chart.  Mental status is normal, cranial nerves are intact, motor is normal bulk and tone throughout with no weakness appreciated in upper and lower extremities bilaterally.  There is no drift and there are no abnormalities to orbit.  Sensory examination, light touch, and temperature intact at all distal extremities.  Cerebellar examination, she has normal finger-to-nose, rapid alternating movements, heel-to-shin, and foot tap.,She rises easily from the chair.  She has normal step, stride, arm swing, toe, heel, and tandem.  Deep tendon reflexes are 2 and equal at biceps, brachioradialis, patella, and 1 at the ankles.,She was seen in the emergency room for chest pain one month ago.  CT of the head was performed, which I reviewed, dated September 07, 2006.  The findings were within the range of normal variation.  There is no evidence of bleeding, mass, lesions, or any evidence of atrophy.,IMPRESSION: , This is a pleasant 47-year-old African-American female with what appears to be cryptogenic left temporal lobe epilepsy that is very well controlled on her current dose of lamotrigine.,PLAN:,1.  Continue lamotrigine 150 mg p.o. b.i.d.,2.  I discussed with the patient the option of a trial of medications.  We need to repeat her EEG as well as her MRI prior to weaning her medications.  The patient wants to continue her lamotrigine at this time.  I concur.,3.  The patient will be following up with me in six months.,",
 Consult for prostate cancer, Consult - History and Phy., Consult - Prostate Cancer ,"CONSULT FOR PROSTATE CANCER,The patient returned for consultation for his newly diagnosed prostate cancer.  The options including radical prostatectomy with or without nerve sparing were discussed with him with the risks of bleeding, infection, rectal injury, impotence, and incontinence.  These were discussed at length.  Alternative therapies including radiation therapy; either radioactive seed placement, conformal radiation therapy, or the HDR radiation treatments were discussed with the risks of bladder, bowel, and rectal injury and possible impotence were discussed also.  There is a risk of rectal fistula.  Hormonal therapy is usually added to the radiation therapy options and this has the risk of osteoporosis, gynecomastia, hot flashes and impotency.  Potency may not recover after the hormone therapy has been completed.  Cryosurgery was discussed with the risks of urinary retention, stricture formation, incontinence and impotency.  There is a risk of rectal fistula.  He would need to have a suprapubic catheter for about two weeks and may need to learn self-intermittent catheterization if he cannot void adequately.  Prostate surgery to relieve obstruction and retention after radioactive seeds or cryosurgery has a higher risk of urinary incontinence.  Observation therapy was discussed with him in addition.  I answered all questions that were put to me and I think he understands the options that are available.  I spoke with the patient for over 60 minutes concerning these options.","consult - history and phy., prostate cancer, cryosurgery, hdr radiation, prostate surgery, bladder, bleeding, bowel, consultation, impotence, incontinence, infection, prostatectomy, radiation therapy, radical, rectal, rectal fistula, rectal injury, prostate cancer consult, cancer, radiation, prostateNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Patient with family history of colon cancer and has rectal bleeding on a weekly basis and also heartburn once every 1 or 2 weeks. , Consult - History and Phy., Consult - Rectal Bleeding ,"PRESENT ILLNESS: , The patient is a very pleasant 69-year-old Caucasian male whom we are asked to see primarily because of a family history of colon cancer, but the patient also has rectal bleeding on a weekly basis and also heartburn once every 1 or 2 weeks.  The patient states that he had his first colonoscopy 6 years ago and it was negative.  His mother was diagnosed with colon cancer probably in her 50s, but she died of cancer of the esophagus at age 86.  The patient does have hemorrhoidal bleed about once a week.  Otherwise, he denies any change in bowel habits, abdominal pain, or weight loss.  He gets heartburn mainly with certain food such as raw onions and he has had it for years.  It will typically occur every couple of weeks.  He has had no dysphagia.  He has never had an upper endoscopy.,MEDICAL HISTORY: , Remarkable for hypertension, adult-onset diabetes mellitus, hyperlipidemia, and restless legs syndrome.,SURGICAL HISTORY: , Appendectomy as a child and cholecystectomy in 2003.,MEDICATIONS:  ,His medications are lisinopril 40 mg daily, hydrochlorothiazide 25 mg daily, metformin 1000 mg twice a day, Januvia 100 mg daily, clonazepam 10 mg at bedtime for restless legs syndrome, Crestor 10 mg nightly, and Flomax 0.4 mg daily.,ALLERGIES: , No known drug allergies.,SOCIAL HISTORY: , The patient is retired.  He is married.  He had 4 children.  He quite smoking 25 years ago after a 35-year history of smoking.  He does not drink alcohol.,FAMILY HISTORY: , Mother had colon cancer in her 50s, esophageal cancer in her 80s.  Her mother smoked and drank.  Father got a mesothelioma at age 65.  There is a brother of 65 with hypertension.,REVIEW OF SYSTEMS: , He has had prostatitis with benign prostatic hypertrophy.  He has some increased urinary frequency from a history of prostatitis.  He has the heartburn, which is diet dependent and the frequent rectal bleeding.  He also has restless legs syndrome at night.  No cardio or pulmonary complaints.  No weight loss.,PHYSICAL EXAMINATION: , Reveals a well-developed, well-nourished man in no acute distress.  BP 112/70.  Pulse 80 and regular.  Respirations non-labored.  Height 5 feet 7-1/2 inches.  Weight 209 pounds.  HEENT exam:  Sclerae are anicteric.  Pupils equal, conjunctivae clear.  No gross oropharyngeal lesions.  Neck is supple without lymphadenopathy, thyromegaly, or JVD.  Lungs are clear to percussion and auscultation.  Heart sounds are regular without murmur, gallop, or rub.  The abdomen is soft and nontender.  There are no masses.  There is no hepatosplenomegaly.  The bowel sounds are normal.  Rectal examination:  Deferred.  Extremities have no clubbing, cyanosis or edema.  Skin is warm and dry.  The patient is alert and oriented with a pleasant affect and no gross motor deficits.,IMPRESSION:,1.  Family history of colon cancer.,2.  Rectal bleeding.,3.  Heartburn and a family history of esophageal cancer.,PLAN:,  I agree with the indications for repeat colonoscopy, which should be done at least every 5 years.  Also, discussed IRC to treat bleeding and internal hemorrhoids if he is deemed to be an appropriate candidate at the time of his colonoscopy and the patient was agreeable.  I am also a little concerned about his family history of esophageal cancer and his personal history of heartburn and suggested that we check him once for Barrett's esophagus.  If he does not have it now then it should not be a significant risk in the future.  The indications and benefits of EGD, colonoscopy, and IRC were discussed.  The risks including sedation, bleeding, infection, and perforation were discussed.  The importance of a good bowel prep so as to minimize missing any lesions was discussed.  His questions were answered and informed consent obtained.  It was a pleasure to care for this nice patient.","consult - history and phy., heartburn, family history of esophageal cancer, repeat colonoscopy, colonoscopy, egd, irc, barrett's esophagus, restless legs syndrome, esophageal cancer, rectal bleeding, colon cancer, rectal, bleeding, cancer, "
 Chronic headaches and pulsatile tinnitus., Consult - History and Phy., Consult - Pulsatile Tinnitus ,"HISTORY: , The patient is a 48-year-old female who was seen in consultation requested from Dr. X on 05/28/2008 regarding chronic headaches and pulsatile tinnitus.  The patient reports she has been having daily headaches since 02/25/2008.  She has been getting pulsations in the head with heartbeat sounds.  Headaches are now averaging about three times per week.  They are generally on the very top of the head according to the patient.  Interestingly, she denies any previous significant history of headaches prior to this.  There has been no nausea associated with the headaches.  The patient does note that when she speaks on the phone, the left ear has ""weird sounds.""  She feels a general fullness in the left ear.  She does note pulsation sounds within that left ear only.  This began on February 17th according to the patient.  The patient reports that the ear pulsations began following an air flight to Iowa where she was visiting family.  The patient does admit that the pulsations in the ears seem to be somewhat better over the past few weeks.  Interestingly, there has been no significant drop or change in her hearing.  She does report she has had dizzy episodes in the past with nausea, being off balance at times.  It is not associated with the pulsations in the ear.  She does admit the pulsations will tend to come and go and there had been periods where the pulsations have completely cleared in the ear.  She is denying any vision changes.  The headaches are listed as moderate to severe in intensity on average about three to four times per week.  She has been taking Tylenol and Excedrin to try to control the headaches and that seems to be helping somewhat.  The patient presents today for further workup, evaluation, and treatment of the above-listed symptoms.,REVIEW OF SYSTEMS: , ,ALLERGY/IMMUNOLOGIC:  Negative.,CARDIOVASCULAR:  Hypercholesterolemia.,PULMONARY:  Negative.,GASTROINTESTINAL:  Pertinent for nausea.,GENITOURINARY:  The patient is noted to be a living kidney donor and has only one kidney.,NEUROLOGIC:  History of dizziness and the headaches as listed above.,VISUAL:  Negative.,DERMATOLOGIC:  History of itching.  She has also had a previous history of skin cancer on the arm and back.,ENDOCRINE:  Negative.,MUSCULOSKELETAL:  Negative.,CONSTITUTIONAL:  She has had an increased weight gain and fatigue over the past year.,PAST SURGICAL HISTORY:,  She has had a left nephrectomy, C-sections, mastoidectomy, laparoscopy, and T&A.,FAMILY HISTORY:,  Father, history of cancer, hypertension, and heart disease.,CURRENT MEDICATIONS: , Tylenol, Excedrin, and she is on multivitamin and probiotic's.,ALLERGIES: , She is allergic to codeine and penicillin.,SOCIAL HISTORY: , She is married.  She works at Eye Center as a receptionist.  She denies tobacco at this time though she was a previous smoker, stopped four years ago, and she denies alcohol use.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Blood pressure 120/78, pulse 64 and regular, and the temperature is 97.4.,GENERAL:  The patient is an alert, cooperative, well-developed 48-year-old female with a normal-sounding voice and good memory.,HEAD & FACE:  Inspected with no scars, lesions or masses noted.  Sinuses palpated and are normal.  Salivary glands also palpated and are normal with no masses noted.  The patient also has full facial function.,CARDIOVASCULAR:  Heart regular rate and rhythm without murmur.,RESPIRATORY:  Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.,EYES:  Extraocular muscles were tested and within normal limits.,EARS:  There is an old mastoidectomy scar, left ear.  The ear canals are clean and dry.  Drums intact and mobile.  Weber exam is midline.  Grossly hearing is intact.  Please note audiologist not available at today's visit for further audiologic evaluation.,NASAL:  Reveals clear drainage.  Deviated nasal septum to the left, listed as mild to moderate.  Ostiomeatal complexes are patent and turbinates are healthy.  There was no mass or neoplasm within the nasopharynx noted on fiberoptic nasopharyngoscopy.  See fiberoptic nasopharyngoscopy separate exam.,ORAL:  Oral cavity is normal with good moisture.  Lips, teeth and gums are normal.  Evaluation of the oropharynx reveals normal mucosa, normal palates, and posterior oropharynx.  Examination of the larynx with a mirror reveals normal epiglottis, false and true vocal cords with good mobility of the cords.  The nasopharynx was briefly examined by mirror with normal appearing mucosa, posterior choanae and eustachian tubes.,NECK:  The neck was examined with normal appearance.  Trachea in the midline.  The thyroid was normal, nontender, with no palpable masses or adenopathy noted.,NEUROLOGIC:  Cranial nerves II through XII evaluated and noted to be normal.  Patient oriented times 3.,DERMATOLOGIC:  Evaluation reveals no masses or lesions.  Skin turgor is normal.,IMPRESSION:  ,1.  Pulsatile tinnitus, left ear with eustachian tube disorder as the etiology.  Consider, also normal pressure hydrocephalus.,2.  Recurrent headaches.,3.  Deviated nasal septum.,4.  Dizziness, again also consider possible Meniere disease.,RECOMMENDATIONS: , I did recommend the patient begin a 2 g or less sodium diet.  I have also ordered a carotid ultrasound study as part of the workup and evaluation.  She has had a recent CAT scan of the brain though this was without contrast.  It did reveal previous mastoidectomy, left temporal bone, but no other mass noted.  I have started her on Nasacort AQ nasal spray one spray each nostril daily as this is eustachian tube related.  Hearing protection devices should be used at all times as well.  I did counsel the patient if she has any upcoming airplane trips to use nasal decongestant or topical nasal decongestant spray prior to boarding the plane, and also using the airplane ear plugs as these can be effective at helping to prevent eustachian tube issues.  I am going to recheck her in three weeks.  If the pulsatile tinnitus at that time is not clear, we have discussed other treatment options including myringotomy or ear tube placement, which could be done here in the office.  She will be scheduled for a audio and tympanogram to be done as well prior to that procedure.",
 The patient needs refills on her Xanax, Consult - History and Phy., Consult - Smoking Cessation  ,"CHIEF COMPLAINT: , I need refills.,HISTORY OF PRESENT ILLNESS:,  The patient presents today stating that she needs refills on her Xanax, and she would also like to get something to help her quit smoking.  She is a new patient today.  She states that she has mesothelioma in the lining of her stomach and that it does cause her some problems with eating and it causes some chronic pain.  She states that she is under the care of a cancer specialist; however, she just recently moved back to this area and is trying to find a doctor a little closer than his office.  She states that she has tried several different things to help her quit smoking and she has failed everything and had heard good results about Chantix and wanted to give it a try.,OBJECTIVE:  ,Well developed and well nourished.  She does not appear to be in any acute distress.  Cardiovascular:  Regular rhythm.  No murmurs, gallops, or rubs.  Capillary refill less than 3 seconds.  Peripheral pulses are 2+ bilaterally.  Respiratory:  Her lungs are clear to auscultation bilaterally with good effort.  No tenderness to palpation over chest wall.  Musculoskeletal:  She has full range of motion of all four extremities.  No tenderness to palpation over long bones.  Skin:  Warm and dry.  No rashes or lesions.  Neuro:  Alert and oriented x3.  Cranial nerves II-XII are grossly intact.  No focal deficits.,PLAN: , I did refill her medications.  I have requested that she have her primary doctor forward her records to me.  I have discussed Chantix and its use and success rate.  She was given a prescription, as well as a coupon.  She is to watch for any worsening signs or symptoms.  She verbalized understanding of discharge instructions and prescriptions.  I would like to see her back to proceed with her preventive health measures.","consult - history and phy., quit smoking, chantix, mesothelioma, smoking, xanax, refills"
 Patient comes for discussion of a screening colonoscopy. , Consult - History and Phy., Consult - Screening Colonoscopy ,"HISTORY:,  A is a 55-year-old who I know well because I have been taking care of her husband.  She comes for discussion of a screening colonoscopy.  Her last colonoscopy was in 2002, and at that time she was told it was essentially normal.  Nonetheless, she has a strong family history of colon cancer, and it has been almost four to five years so she wants to have a repeat colonoscopy.  I told her that the interval was appropriate and that it made sense to do so.  She denies any significant weight change that she cannot explain.  She has had no hematochezia.  She denies any melena.  She says she has had no real change in her bowel habit but occasionally does have thin stools.,PAST MEDICAL HISTORY:,  On today's visit we reviewed her entire health history.  Surgically she has had a stomach operation for ulcer disease back in 1974, she says.  She does not know exactly what was done.  It was done at a hospital in California which she says no longer exists.  This makes it difficult to find out exactly what she had done.  She also had her gallbladder and appendix taken out in the 1970s at the same hospital.  Medically she has no significant problems and no true medical illnesses.  She does suffer from some mild gastroparesis, she says.,MEDICATIONS: , Reglan 10 mg once a day.,ALLERGIES: , She denies any allergies to medications but is sensitive to medications that cause her to have ulcers, she says.,SOCIAL HISTORY: , She still smokes one pack of cigarettes a day.  She was counseled to quit.  She occasionally uses alcohol.  She has never used illicit drugs.  She is married, is a housewife, and has four children.,FAMILY HISTORY: , Positive for diabetes and cancer.,REVIEW OF SYSTEMS: , Essentially as mentioned above.,PHYSICAL EXAMINATION:,GENERAL:  A is a healthy appearing female in no apparent distress.,VITAL SIGNS:  Her vital signs reveal a weight of 164 pounds, blood pressure 140/90, temperature of 97.6 degrees F.,HEENT:  No cervical bruits, thyromegaly, or masses.  She has no lymphadenopathy in the head and neck, supraclavicular, or axillary spaces bilaterally.,LUNGS:  Clear to auscultation bilaterally with no wheezes, rubs, or rhonchi.,HEART:  Regular rate and rhythm without murmur, rub, or gallop.,ABDOMEN:  Soft, nontender, nondistended.,EXTREMITIES:  No cyanosis, clubbing, or edema, with good pulses in the radial arteries bilaterally.,NEURO:  No focal deficits, is intact to soft touch in all four.,ASSESSMENT AND RECOMMENDATIONS: , In light of her history and physical, clearly the patient would be well served with an upper and lower endoscopy.  We do not know what the anatomy is, and if she did have an antrectomy, she needs to be checked for marginal ulcers.  She also complains of significant reflux and has not had an upper endoscopy in over five to six years as well.  I discussed the risks, benefits, and alternatives to upper and lower endoscopy, and these include over sedation, perforation, and dehydration, and she wants to proceed.,We will schedule her for an upper and lower endoscopy at her convenience.","consult - history and phy., screening colonoscopy, colonoscopy, hematochezia, screening, endoscopy, "
 The patient is an 84-year-old man who returns for revaluation of possible idiopathic normal pressure hydrocephalus., Consult - History and Phy., Consult - Normal Pressure Hydrocephalus ,"REASON FOR VISIT: , The patient is an 84-year-old man who returns for revaluation of possible idiopathic normal pressure hydrocephalus.  He is accompanied by his wife and daughter.,HISTORY OF PRESENT ILLNESS:,  I first saw him nearly a year ago on December 20, 2007.  At that time, he had had a traumatic deterioration over the course of approximately eight months.  This included severe cognitive impairment, gait impairment, and incontinence.  He had actually been evaluated at Hospital with CSF drainage via a temporary spinal catheter, but there was no response that was noted.  When I saw him, there were findings consistent with cervical stenosis and I ordered an MRI scan of the cervical spine.  I subsequently referred him to Dr. X, who performed a cervical laminectomy and instrumented fusion on July 16, 2008.  According to his notes this went well.,According to the family, there has not been any improvement.,With regard to the gait and balance, they actually think that he is worse now than he was a year ago.  He is virtually unable to walk at all.  He needs both a walker and support from an assistant to be able to stand or walk.  Therefore, he is always in the wheelchair.,He is completely incontinent.  He never indicates his need to the go to the bathroom.  On the other hand when asked, he will indicate that he needs to go.  He wears a Depends undergarment all the time.,He has no headaches.,His thinking and memory are worse.  For the most part, he is apathetic.  He does not talk very much.  He lives in a skilled nursing facility in the Alzheimer's section.  He does have some daytime activities.  He takes a nap once a day.  He does not read very much.  On the other hand, he did recently exercise the right to vote in the presidential election.  He needs full assistance at the nursing home.,MEDICATIONS:,  From the list by the nursing home are Aricept 10 mg in the evening, carbidopa/levodopa 25/100 mg three times a day, citalopram (Celexa) 40 mg daily, Colace 100 mg twice a day, finasteride (Proscar) 5 mg once a day, Flomax (tamsulosin) 0.4 mg once a day, multivitamin with iron once a day, omeprazole (Prilosec) 20 mg once a day, senna 8.6 mg twice a day, Tylenol 650 mg as needed, and promethazine 25 mg as needed.,PHYSICAL EXAM: , On examination today, this is a pleasant 81-year-old man who is brought back from the clinic waiting area in a wheelchair.  He is well developed, well nourished, and kempt.,Vital Signs:  Temperature 96.7, pulse 62, respirations 16, and blood pressure 123/71.,Head:  The head is normocephalic and atraumatic.,Mental Status:  Assessed for orientation, recent and remote memory, attention span, concentration, language, and fund of knowledge.  The Mini-Mental State Exam score was 14/30.  He was not at all oriented.  He did know we were at Sinai Hospital on the second floor.  He could spell 'world' forward, but was mute when asked to spell backwards.  He was mute when asked to recall 3/3 objects for delayed recall.  He could not copy a diagram of intersecting pentagons.  For comparison, the Mini-Mental State exam score last December was 20/30 when attention was tested by having him spell 'world' backwards and 28/30 when tested with serial 7 subtractions.  Additionally, there are times when he stutters or stammers.  I do not see any paraphasic errors.  There is some evidence of ideomotor apraxia.  He is also stimulus bound.  There is a tendency to mimic.,Cranial Nerve Exam:  There is no upgaze that I can elicit today.  The horizontal gaze and down gaze are intact.  This is a change from a year ago.  The muscles of facial expiration are intact as are hearing, head turning, cough, tongue, and palate movement.,Motor Exam:  Normal bulk and strength.  The tone is characterized by paratonia.  There is no atrophy, fasciculations, drift, or tremor.,Sensory Exam:  Intact to light touch.,Cerebellar Exam:  Intact for finger-to-nose testing that he can perform only by mimicking, but not by following verbal commands.,Gait:  Severely impaired.  When in the wheelchair, he leans to one side.  He cannot getup on his own.  He needs assistance.  Once up, he can bear weight, but cannot maintain his balance.  This would amount to a Tinetti score of zero.,REVIEW OF X-RAYS: , I personally reviewed the CT scan of the brain from November 1, 2008 and compared it to the MRI scan from a year ago.  The ventricles appear larger to me now in comparison to a year ago.  The frontal horn span is now 6 cm, whereas previously it was about 5.5 cm.  The 3rd ventricular span is about 15 mm.  There is no obvious atrophy, although there may be some subtle bilateral perisylvian atrophy.  The scan from a year ago showed that there was a patent sylvian aqueduct.,ASSESSMENT:,  The patient has had worsening of his gait, his dementia, and his incontinence.  The new finding for me today is the limited upgaze.  This would be consistent either with progressive supranuclear palsy, which was one of the differential diagnoses a year ago, or it could be consistent with progressive enlargement of the ventricles.,PROBLEMS/DIAGNOSES:,1.  Question of idiopathic normal pressure hydrocephalus (331.5).,2.  Possible supranuclear palsy.,3.  Severe gait impairment.,4.  Urinary urgency and incontinence.,5.  Dementia.,PLAN: , I had a long talk with him and his family.  Even though he has already had a trial of CSF drainage via spinal catheter at Hospital over a year ago, I offered this test to them again.  I do so on the basis that there is further enlargement of the ventricles on the scan.  His family and I discussed the facts that it is not likely to be only hydrocephalus.  Instead we are trying to answer the question of whether hydrocephalus is contributing sufficiently to his symptoms that progressing with shunt surgery would make a difference.  I have advised them to think it over for a day and contact my office to see whether they would wish to proceed.  I gave them a printed prescription of the protocol including its rationale, risks, benefits, and alternatives.  I specifically mentioned the 3% chance of infection, which mean a 97% chance of no infection.",
" A 50-year-old female whose 51-year-old sister has a history of multiple colon polyps, which may slightly increase her risk for colon cancer in the future.", Consult - History and Phy., Consult - Multiple Colon Polyps ,"HISTORY OF PRESENT ILLNESS: , See chart attached.,MEDICATIONS: , Tramadol 50 mg every 4 to 6 hours p.r.n., hydrocodone 7.5 mg/500 mg every 6 hours p.r.n., zolpidem 10 mg at bedtime, triamterene 37.5 mg, atenolol 50 mg, vitamin D, TriCor 145 mg, simvastatin 20 mg, ibuprofen 600 mg t.i.d., and Lyrica 75 mg.,FAMILY HISTORY: , Mother is age 78 with history of mesothelioma.  Father is alive, but unknown medical history as they have been estranged.  She has a 51-year-old sister with history of multiple colon polyps.  She has 2 brothers, 1 of whom has schizophrenia, but she knows very little about their medical history.  To the best of her knowledge, there are no family members with stomach cancer or colon cancer.,SOCIAL HISTORY: , She was born in Houston, Texas and moved to Florida about 3 years ago.  She is divorced.  She has worked as a travel agent.  She has 2 sons ages 24 and 26, both of whom are alive and well.  She smokes a half a pack of cigarettes per day for more than 35 years.  She does not consume alcohol.,REVIEW OF SYSTEMS: , As per the form filled out in our office today is positive for hypertension, weakness in arms and legs, arthritis, pneumonia, ankle swelling, getting full quickly after eating, loss of appetite, weight loss, which is stated as fluctuating up and down 4 pounds, trouble swallowing, heartburn, indigestion, belching, nausea, diarrhea, constipation, change in bowel habits, change in consistency, rectal bleeding, hemorrhoids, abdominal discomfort and cramping associated with constipation, hepatitis A or infectious hepatitis in the past, and smoking and alcohol as previously stated.  Otherwise, review of systems is negative for strokes, paralysis, gout, cataracts, glaucoma, respiratory difficulties, tuberculosis, chest pain, heart disease, kidney stones, hematuria, rheumatic fever, scarlet fever, cancer, diabetes, thyroid disease, seizure disorder, blood transfusions, anemia, jaundice, or pruritus.,PHYSICAL EXAMINATION:  ,Weight 152 pounds.  Height is 5 feet 3 inches.  Blood pressure 136/80.  Pulse 68.  In general:  She is a well-developed and well-nourished female who ambulates with the assistance of a cane.  Neurologically nonfocal.  Awake, alert, and oriented x 3.  HEENT:  Head normocephalic, atraumatic.  Sclerae anicteric.  Conjunctivae are pink.  Mouth is moist without any obvious oral lesions.  Neck is supple.  There is no submandibular, submaxillary, axillary, supraclavicular, or epitrochlear adenopathy appreciable.  Lungs are clear to auscultation bilaterally.  Heart:  Regular rate and rhythm without obvious gallops or murmurs.  Abdomen is soft, nontender with good bowel sounds.  No organomegaly or masses are appreciable.  Extremities are without clubbing, cyanosis, and/or edema.  Skin is warm and dry.  Rectal was deferred and will be done at the time of the colonoscopy.,IMPRESSION:,1.  A 50-year-old female whose 51-year-old sister has a history of multiple colon polyps, which may slightly increase her risk for colon cancer in the future.,2.  Reports of recurrent bright red blood per rectum, mostly on the toilet paper over the past year.  Bleeding most likely consistent with internal hemorrhoids; however, she needs further evaluation for colon polyps or colon cancer.,3.  Alternations between constipation and diarrhea for the past several years with some lower abdominal cramping and discomfort particularly associated with constipation.  She is on multiple medications including narcotics and may have developed narcotic bowel syndrome.,4.  A long history of pyrosis, dyspepsia, nausea, and belching for many years relieved by antacids.  She may likely have underlying gastroesophageal reflux disease.,5.  A 1-year history of some early satiety and fluctuations in her weight up and down 4 pounds.  She may also have some GI dysmotility including gastroparesis.,6.  Report of dysphagia to solids over the past several years with a history of a bone spur in her cervical spine.  If this bone spur is pressing anteriorly, it could certainly cause recurrent symptoms of dysphagia.  Differential also includes peptic stricture or Schatzki's ring, and even remotely, the possibility of an esophageal malignancy.,7.  A history of infectious hepatitis in the past with some recent mild elevations in AST and ALT levels without clear etiology.  She may have some reaction to her multiple medications including her statin drugs, which can cause mild elevations in transaminases.  She may have some underlying fatty liver disease and differential could include some form of viral hepatitis such as hepatitis B or even C.,PLAN:,1.  We have asked her to follow up with her primary care physician with regard to this recent elevation in her transaminases.  She will likely have the lab tests repeated in the future, and if they remain persistently elevated, we will be happy to see her in the future for further evaluation if her primary care physician would like.,2.  Discussed reflux precautions and gave literature for further review.,3.  Schedule an upper endoscopy with possible esophageal dilatation, as well as colonoscopy with possible infrared coagulation of suspected internal hemorrhoids.  Both procedures were explained in detail including risks and complications such as adverse reaction to medication, as well as respiratory embarrassment, infection, bleeding, perforation, and possibility of missing a small polyp or tumor.,4.  Alternatives including upper GI series, flexible sigmoidoscopy, barium enema, and CT colonography were discussed; however, the patient agrees to proceed with the plan as outlined above.,5.  Due to her sister's history of colon polyps, she will likely be advised to have a repeat colonoscopy in 5 years or perhaps sooner pending the results of her baseline examination.,","consult - history and phy., mesothelioma, risk for colon cancer, constipation, diarrhea, multiple colon polyps, colon cancer, colon polyps, colon, cancer, polyps, "
 The patient admitted with palpitations and presyncope., Consult - History and Phy., Consult - Palpitations & Presyncope ,"HISTORY OF PRESENT ILLNESS: , The patient is a charming and delightful 46-year-old woman admitted with palpitations and presyncope.,The patient is active and a previously healthy young woman, who has had nine years of occasional palpitations.  Symptoms occur three to four times per year and follow no identifiable pattern.  She has put thought and effort in trying to identify precipitating factors or circumstances but has been unable to do so.  Symptoms can last for an hour or more and she feels as if her heart is going very rapidly but has never measured her heart rate.  The last two episodes, the most recent of which was yesterday, were associated with feeling of darkness descending as if a shade was being pulled down in front of her vision.  On neither occasion did she lose consciousness.,Yesterday, she had a modestly active morning taking a walk with her dogs and performing her normal routines.  While working on a computer, she had a spell.  Palpitations persisted for a short time thereafter as outlined in the hospital's admission note prompting her to seek evaluation at the hospital.  She was in sinus rhythm on arrival and has been asymptomatic since.,No history of exogenous substance abuse, alcohol abuse, or caffeine abuse.  She does have a couple of sodas and at least one to two coffees daily.  She is a nonsmoker.  She is a mother of two.  There is no family history of congenital heart disease.  She has had no history of thoracic trauma.  No symptoms to suggest thyroid disease.,No known history of diabetes, hypertension, or dyslipidemia.  Family history is negative for ischemic heart disease.,Remote history is significant for an ACL repair, complicated by contact urticaria from a neoprene cast.,No regular medications prior to admission.,The only allergy is the neoprene reaction outlined above.,PHYSICAL EXAMINATION: , Vital signs as charted.  Pupils are reactive.  Sclerae nonicteric.  Mucous membranes are moist.  Neck veins not distended.  No bruits.  Lungs are clear.  Cardiac exam is regular without murmurs, gallops, or rubs.  Abdomen is soft without guarding, rebound masses, or bruits.  Extremities well perfused.  No edema.  Strong and symmetrical distal pulses.,A 12-lead EKG shows sinus rhythm with normal axis and intervals.  No evidence of preexcitation.,LABORATORY STUDIES: , Unremarkable.  No evidence of myocardial injury.  Thyroid function is pending.,Two-dimensional echocardiogram shows no evidence of clinically significant structural or functional heart disease.,IMPRESSION/PLAN: , Episodic palpitations over a nine-year period.  Outpatient workup would be appropriate.  Event recorder should be obtained and the patient can be seen again in the office upon completion of that study.  Suppressive medication (beta-blocker or Cardizem) was discussed with the patient for symptomatic improvement, though this would be unlikely to be a curative therapy.  The patient expresses a preference to avoid medical therapy if possible.,Thank you for this consultation.  We will be happy to follow her both during this hospitalization and following discharge.  Caffeine avoidance was discussed as well.,ADDENDUM: , During her initial evaluation, a D-dimer was mildly elevated to 5.  CT scan showed no evidence of pulmonary embolus.  Lower extremity venous ultrasound is pending; however, in the absence of embolization to the pulmonary vasculature, this would be an unlikely cause of palpitations.  In addition, no progression over the nine-year period that she has been symptomatic suggests that this is an unlikely cause.,","consult - history and phy., presyncope, palpitations, episodic palpitations, beta-blocker, ultrasound, palpitations and presyncope, sinus rhythm, heart disease, heart"
" Recurrent jaw pain, described as numbness and tingling along the jaw, teeth, and tongue.", Consult - History and Phy., Consult - Jaw Pain ,"HISTORY:  ,The patient is a 53-year-old male who was seen for evaluation at the request of Dr. X regarding recurrent jaw pain.  This patient has been having what he described as numbness and tingling along the jaw, teeth, and tongue.  This numbness has been present for approximately two months.  It seems to be there ""all the time.""  He was seen by his dentist and after dental evaluation was noted to be ""okay.""  He had been diagnosed with a throat infection about a week ago and is finishing a course of Avelox at this time.  He has been taking cough drops and trying to increase his fluids.  He has recently stopped tobacco.  He has been chewing tobacco for about 30 years.  Again, there is concern regarding the numbness he has been having.  He has had a loss of sensation of taste as well.  Numbness seems to be limited just to the left lateral tongue and the jaw region and extends from the angle of the jaw to the lip.  He does report he has had about a 20-pound of weight gain over the winter, but notes he has had this in the past just simply from decreased activity.  He has had no trauma to the face.  He does note a history of headaches.  These are occasional and he gets these within the neck area when they do flare up.  The headaches are noted to be less than one or two times per month.  The patient does note he has a history of anxiety disorder as well.  He has tried to eliminate his amount of tobacco and he is actually taking Nicorette gum at this time.  He denies any fever or chills.  He is not having any dental pain with biting down.  He has had no jaw popping and no trismus noted.  The patient is concerned regarding this numbness and presents today for further workup, evaluation, and treatment.,REVIEW OF SYSTEMS: , Other than those listed above were otherwise negative.,PAST SURGICAL HISTORY: , Pertinent for hernia repair.,FAMILY HISTORY: , Pertinent for hypertension.,CURRENT MEDICATIONS:,  Tylenol.  He is on Nicorette gum.,ALLERGIES:  ,He is allergic to codeine, unknown reaction.,SOCIAL HISTORY:  ,The patient is single, self-employed carpenter.  He chews tobacco or having chewing tobacco for 30 years, about half a can per day, but notes he has been recently off, and he does note occasional moderate alcohol use.,PHYSICAL EXAMINATION: , ,VITAL SIGNS:  Blood pressure is 138/82, pulse 64 and regular, temperature 98.3, and weight is 191 pounds.,GENERAL:  The patient is an alert, cooperative, obese, 53-year-old male with a normal-sounding voice and good memory.,HEAD & FACE:  Inspected with no scars, lesions or masses noted.  Sinuses palpated and are normal.  Salivary glands also palpated and are normal with no masses noted.  The patient also has full facial function.,CARDIOVASCULAR:  Heart regular rate and rhythm without murmur.,RESPIRATORY:  Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.,EYES:  Extraocular muscles were tested and within normal limits.,EARS:  Both ears, external ears are normal.  The ear canals are clean and dry.  The drums are intact and mobile.  He does have moderate tympanosclerosis noted, no erythema.  Weber exam is midline.  Hearing is grossly intact and normal.,NASAL:  Reveals a deviated nasal septum to the left, moderate, clear drainage, and no erythema.,ORAL:  Oral cavity is normal with good moisture.  Lips, teeth and gums are normal.  Evaluation of the oropharynx reveals normal mucosa, normal palates, and posterior oropharynx.  Examination of the larynx with a mirror reveals normal epiglottis, false and true vocal cords with good mobility of the cords.  The nasopharynx was briefly examined by mirror with normal appearing mucosa, posterior choanae and eustachian tubes.,NECK:  The neck was examined with normal appearance.  Trachea in the midline.  The thyroid was normal, nontender, with no palpable masses or adenopathy noted.,NEUROLOGIC:  He does have slightly decreased sensation to the left jaw.  He is able to feel pressure on touch.  This extends also on to the left lateral tongue and the left intrabuccal mucosa.,DERMATOLOGIC:  Evaluation reveals no masses or lesions.  Skin turgor is normal.,PROCEDURE: , A fiberoptic nasopharyngoscopy was also performed.  See separate operative report in chart.  This does reveal a moderately deviated nasal septum to the left, large inferior turbinates, no mass or neoplasm noted.,IMPRESSION:  ,1.  Persistent paresthesia of the left manual teeth and tongue, consider possible neoplasm within the mandible.,2.  History of tobacco use.,3.  Hypogeusia with loss of taste.,4.  Headaches.,5.  Xerostomia.,RECOMMENDATIONS:,  I have ordered a CT of the head.  This includes sinuses and mandible.  This is primarily to evaluate and make sure there is not a neoplasm as the source of this numbness that he has had.  On the mucosal surface, I do not see any evidence of malignancy and no visible or palpable masses were noted.  I did recommend he increase his fluid intake.  He is to remain off the tobacco.  I have scheduled a recheck with me in the next two to three weeks to make further recommendations at that time.",
 Consultation for ICU management for a patient with possible portal vein and superior mesenteric vein thrombus leading to mesenteric ischemia., Consult - History and Phy., Consult - ICU Management ,"REASON FOR CONSULTATION: , ICU management.,HISTORY OF PRESENT ILLNESS: , The patient is a 43-year-old gentleman who presented from an outside hospital with complaints of right upper quadrant pain in the abdomen, which revealed possible portal vein and superior mesenteric vein thrombus leading to mesenteric ischemia.  The patient was transferred to the ABCD Hospital where he had a weeklong course with progressive improvement in his status after aggressive care including intubation, fluid resuscitation, and watchful waiting.  The patient clinically improved; however, his white count remained elevated with the intermittent fevers prompting a CT scan.  Repeat CT scan showed a loculated area of ischemic bowel with perforation in the left upper abdomen.  The patient was taken emergently to the operating room last night by the General Surgery Service where proximal half of the jejunum was noted to be liquified with 3 perforations.  This section of small bowel was resected, and a wound VAC placed for damage control.  Plan was to return the patient to the Operating Room tomorrow for further exploration and possible re-anastomosis of the bowel.  The patient is currently intubated, sedated, and on pressors for septic shock and in the down ICU.,PAST MEDICAL HISTORY:,  Prior to coming into the hospital for this current episode, the patient had hypertension, diabetes, and GERD.,PAST SURGICAL HISTORY:,  Included a cardiac cath with no interventions taken.,HOME MEDICATIONS:,  Include Lantus insulin as well as oral hypoglycemics.,CURRENT MEDS:,  Include Levophed, Ativan, fentanyl drips, cefepime, Flagyl, fluconazole, and vancomycin.  Nexium, Synthroid, hydrocortisone, and Angiomax, which is currently on hold.,REVIEW OF SYSTEMS:,  Unable to be obtained secondary to the patient's intubated and sedated status.,ALLERGIES: , None.,FAMILY HISTORY:,  Includes diabetes on his father side of the family.  No other information is provided.,SOCIAL HISTORY:,  Includes tobacco use as well as alcohol use.,PHYSICAL EXAMINATION:,GENERAL: The patient is currently intubated and sedated on Levophed drip.,VITAL SIGNS: Temperature is 100.6, systolic is 110/60 with MAP of 80, and heart rate is 120, sinus rhythm.,NEUROLOGIC: Neurologically, he is sedated, on Ativan with fentanyl drip as well.  He does arouse with suctioning, but is unable to open his eyes to commands.,HEAD AND NECK EXAMINATION: His pupils are equal, round, reactive, and constricted.  He has no scleral icterus.  His mucous membranes are pink, but dry.  He has an EG tube, which is currently 24-cm at the lip.  He has a left-sided subclavian vein catheter, triple lumen.,NECK: His neck is without masses or lymphadenopathy or JVD.,CHEST: Chest has diminished breath sounds bilaterally.,ABDOMEN: Abdomen is soft, but distended with a wound VAC in place.  Groins demonstrate a left-sided femoral outline.,EXTREMITIES: His bilateral upper extremities are edematous as well as his bilateral lower extremities; however, his right is more than it is in the left.  His toes are cool, and pulses are not palpable.,LABORATORY EXAMINATION: , Laboratory examination reveals an ABG of 7.34, CO2 of 30, O2 of 108, base excess of -8, bicarb of 16.1, sodium of 144, potassium of 6.5, chloride of 122, CO2 18, BUN 43, creatinine 2.0, glucose 172, calcium 6.6, phosphorus 1.1, mag 1.8, albumin is 1.6, cortisone level random is 22.  After stimulation with cosyntropin, they were still 22 and then 21 at 30 and 60 minutes respectively.  LFTs are all normal.  Amylase and lipase are normal.  Triglycerides are 73, INR is 2.2, PTT is 48.3, white count 20.7, hemoglobin 9.6, and platelets of 211.  UA was done, which also shows a specific gravity of 1.047, 1+ protein, trace glucose, large amount of blood, and many bacteria.  Chest x-rays performed and show the tip of the EG tube at level of the carina with some right upper lobe congestion, but otherwise clear costophrenic angles.  Tip of the left subclavian vein catheter is appropriate, and there is no pneumothorax noted.,ASSESSMENT AND PLAN:,  This is a 43-year-old gentleman who is acutely ill, in critical condition with mesenteric ischemia secondary to visceral venous occlusion.  He is status post small bowel resection.  We plan to go back to operating room tomorrow for further debridement and possible closure.  Neurologically, the patient initially had question of encephalopathy while in the hospital secondary to slow awakening after previous intubation; however, he did clear eventually, and was able to follow commands.  I did not suspect any sort of pathologic abnormality of his neurologic status as he has further CT scan of his brain, which was normal.  Currently, we will keep him sedated and on fentanyl drip to ease pain and facilitate ventilation on the respirator.  We will form daily sedation holidays to assess his neurologic status and avoid over sedating with Ativan.,1.  Cardiovascular.  The patient currently is in septic shock requiring vasopressors maintained on MAP greater than 70.  We will continue to try to wean the vasopressin after continued volume loading, also place SvO2 catheter to assess his oxygen delivery and consumption given his state of shock.  Currently, his rhythm is of sinus tachycardia, I do not suspect AFib or any other arrhythmia at this time.  If he does not improve as expected with volume resuscitation and with resolution of his sepsis, we will obtain an echocardiogram to assess his cardiac function.  Once he is off the vasopressors, we will try low-dose beta blockade as tolerated to reduce his rate.,2.  Pulmonology.  Currently, the patient is on full vent support with a rate of 20, tidal volume of 550, pressure support of 10, PEEP of 6, and FiO2 of 60.  We will wean his FiO2 as tolerated to keep his saturation greater than 90% and wean his PEEP as tolerated to reduce preload compromise.  We will keep the head of bed elevated and start chlorhexidine as swish and swallow for VAP prevention.,3.  Gastrointestinal.  The patient has known mesenteric venous occlusion secondary to the thrombus formation at the portal vein as well as the SMV.  He is status post immediate resection of jejunum leaving a blind proximal jejunum and blind distal jejunum.  We will maintain NG tube as he has a blind stump there, and we will preclude any further administration of any meds through this NG tube.  I will keep him on GI prophylaxis as he is intubated.  We will currently hold his TPN as he is undergoing a large amount of volume changes as well as he is undergoing electrolyte changes.  He will have a long-term TPN after this acute episode.  His LFTs are all normal currently.  Once he is postop tomorrow, we will restart the Angiomax for his venous occlusion.,4.  Renal.  The patient currently is in the acute renal insufficiency with anuria and an increase in his creatinine as well as his potassium.  His critical hyperkalemia which is requiring dosing of dextrose insulin, bicarb, and calcium; we will recheck his potassium levels after this cocktail.  He currently is started to make more urine since being volume resuscitated with Hespan as well as bicarb drip.  Hopefully given his increased urine output, he will start to eliminate some potassium and will not need dialysis.  We will re-consult Nephrology at this time.,5.  Endocrine.  The patient has adrenal insufficiency based on lack of stem to cosyntropin.  We will start hydrocortisone 50 q.6h.,6.  Infectious Disease.  Currently, the patient is on broad-spectrum antibiotic prophylaxis imperially.  Given his bowel ischemia, we will continue these, and appreciate ID service's input.,7.  Hematology.  Hematologically, the patient has a hypercoagulable syndrome, also had HIT secondary to his heparin administration.  We will restart the Angiomax once he is back from the OR tomorrow.  Currently, his INR is 2.2.  Therefore, he should be covered at the moment.  Appreciate the Hematology's input in this matter.,Please note the total critical care time spent at the bedside excluding central line placement was 1 hour.",
" The patient is a 36-year-old female with past medical history of migraine headaches, who was brought to the ER after she was having uncontrolled headaches.  In the ER, the patient had a CT scan done, which was reported negative, and lumbar puncture with normal pressure and the cell count, and was admitted for followup.", Consult - History and Phy., Consult - Migraine ,"HISTORY OF PRESENT ILLNESS: , The patient is a 36-year-old female with past medical history of migraine headaches, who was brought to the ER after she was having uncontrolled headaches.  In the ER, the patient had a CT scan done, which was reported negative, and lumbar puncture with normal pressure and the cell count, and was admitted for followup.  Neurology consult was called to evaluate the patient in view of the current symptomatology.  The headaches were refractory to the treatment.  The patient has been on Topamax and Maxalt in the past, but did not work and according to the patient she got more confused.,PAST MEDICAL HISTORY: , History of migraine.,PAST SURGICAL HISTORY:  ,Significant for partial oophorectomy, appendectomy, and abdominoplasty.,SOCIAL HISTORY:  ,No history of any smoking, alcohol, or drug abuse.  The patient is a registered nurse by profession.,MEDICATIONS: , Currently taking no medication.,ALLERGIES: , No known allergies.,FAMILY HISTORY:,  Nothing significant.,REVIEW OF SYSTEMS: , The patient was considered to ask systemic review including neurology, psychiatry, sleep, ENT, ophthalmology, pulmonary, cardiology, gastroenterology, genitourinary, hematology, rheumatology, dermatology, allergy, immunology, endocrinology, toxicology, oncology, and was found to be positive for the symptoms mentioned in the history of the presenting illness.,PHYSICAL EXAMINATION,VITAL SIGNS:  Blood pressure of 115/66, heart rate of 69, respiratory rate of 13, temperature normal, and pulse oximetry 98% on room air at the time of initial evaluation.,HEENT:  Head, normocephalic, atraumatic.  Neck supple.  Throat clear.  No discharge from the ears or nose.  No discoloration of conjunctivae and sclerae.  No bruits auscultated over temple, orbits, or the neck.,LUNGS:  Clear to auscultation.,CARDIOVASCULAR:  Normal heart sounds.,ABDOMEN:  Benign.,EXTREMITIES:  No edema, clubbing or cyanosis.,SKIN:  No rash.  No neurocutaneous disorder.,MENTAL STATUS:  The patient is awake, alert and oriented to place and person.  Speech is fluent.  No language deficits.  Mood normal.  Affect is clear.  Memory and insight is normal.  No abnormality with thought processing and thought content.  Cranial nerve examination intact II through XII.  Motor examination:  Normal bulk, tone and power.  Deep tendon reflexes symmetrical.  Downgoing toes.  No sign of any myelopathy.  Cortical sensation intact.  Peripheral sensation grossly intact.  Vibratory sense not tested.  Gait not tested.  Coordination is normal with no dysmetria.,IMPRESSION: , Intractable headaches, by description to be migraines.  Complicated migraines by clinical criteria.  Rule out sinusitis.  Rule out vasculitis including temporal and arthritis, lupus, polyarthritis, moyamoya disease, Takayasu and Kawasaki disease.,PLAN AND RECOMMENDATIONS: , The patient to be given a trial of the prednisone with a plan to taper off in 6 days, as she already had received 50 mg today.  Depakote as a part of migraine prophylaxis and Fioricet on p.r.n. basis.,The patient to get vasculitis workup, as it has not been ordered by the primary care physician initially.  The patient already had MRI of the brain and the cervical spine.  MRI of the brain reported negative and cervical spine as shown signs of disk protrusion at C5 and C6 level, which will not explain of the temporal headache.  Plan and followup discussed with the patient in detail.",
 Marked right hydronephrosis without hydruria. , Consult - History and Phy., Consult - Hydronephrosis ,"CHIEF COMPLAINT:,  Right hydronephrosis.,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old female who has a history of uterine cancer, breast cancer, mesothelioma.  She is scheduled to undergo mastectomy in two weeks.  In September 1999, she was diagnosed with right breast cancer and underwent lumpectomy and axillary node dissection and radiation.  Again, she is scheduled for mastectomy in two weeks.  She underwent a recent PET scan for Dr. X, which revealed marked hydronephrosis on the right possibly related to right UPJ obstruction and there is probably a small nonobstructing stone in the upper pole of the right kidney.  There was no dilation of the right ureter noted.  Urinalysis today is microscopically negative.,PAST MEDICAL HISTORY: , Uterine cancer, mesothelioma, breast cancer, diabetes, hypertension.,PAST SURGICAL HISTORY: , Lumpectomy, hysterectomy.,MEDICATIONS:,  Diovan HCT 80/12.5 mg daily, metformin 500 mg daily.,ALLERGIES:,  None.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:,  She is retired.  Does not smoke or drink.,REVIEW OF SYSTEMS:,  I have reviewed his review of systems sheet and it is on the chart.,PHYSICAL EXAMINATION:,  Please see the physical exam sheet I completed.  Abdomen is soft, nontender, nondistended, no palpable masses, no CVA tenderness.,IMPRESSION AND PLAN: , Marked right hydronephrosis without hydruria.  She believes she had a CT scan of the abdomen and pelvis at Hospital in 2005.  I will try to obtain the report to see if the right kidney was evaluated at that time.  She will need evaluation with an IVP and renal scan to determine the point of obstruction and renal function of the right kidney.  She is quite anxious about her upcoming surgery and would like to delay any evaluation of this until the surgery is completed.  She will call us back to schedule the x-rays.  She understands the great importance and getting back in touch with us to schedule these x-rays due to the possibility that it may be somehow related to the cancer.  There is also a question of a stone present in the kidney.  She voiced a complete understanding of that and will call us after she recovers from her surgery to schedule these tests.","consult - history and phy., hydruria, hydronephrosis, review of systems, uterine cancer, breast cancer, mesothelioma, mastectomy, kidney, cancer,"
" The patient had several episodes where she felt like her face was going to twitch, which she could suppress it with grimacing movements of her mouth and face.", Consult - History and Phy., Consult - Facial Twitching ,"REASON FOR REFERRAL: , Facial twitching.,HISTORY OF PRESENT ILLNESS: , The patient had several episodes where she felt like her face was going to twitch, which she could suppress it with grimacing movements of her mouth and face.  She reports she is still having right posterior head pressure like sensations approximately one time per week.  These still are characterized by a tingling, pressure like sensation that often has a feeling as though water is running down on her hair.  This has also decreased in frequency occurring approximately one time per week and seems to respond to over-the-counter analgesics such as Aleve.  Lastly during conversation today, she brought again the problem of daydreaming at work and noted that she occasionally falls asleep when sitting in non-stimulating environments or in front of the television.  She states that she feels fatigued all the time and does not get good sleep.  She describes it as insomnia, but upon questioning she works from 4 till mid night and then gets home and cannot go to sleep for approximately two hours and wakes up reliably by 9.00 a.m. each morning and sleeps no more than five to six hours ever, but usually five hours.  Her sleep is relatively uninterrupted except for the need to get up and go to the bathroom.  She thinks she may snore, but she is not sure.  She does not recall any events of awakening and gasping for breath.,PAST MEDICAL HISTORY: , Please see my earlier notes in chart.,FAMILY HISTORY:  ,Please see my earlier notes in chart.,SOCIAL HISTORY: , Please see my earlier notes in charts.,REVIEW OF SYSTEMS:  ,Today, she mainly endorses the tingling sensation in the right posterior head often bilateral as well as a diagnosis of depression and persistent somewhat sad mood, poor sleep, and possible snoring; otherwise, the 10-system review is negative.,PHYSICAL EXAMINATION:,General Examination:  Unremarkable mainly for mild-to-moderate obesity with a weight of 258 pounds.  Otherwise, general examination is unremarkable.,NEUROLOGICAL EXAMINATION:  ,As before is nonfocal.  Please see note in chart for details.,PERTINENT FINDINGS: , Since the last evaluation, she has had an MRI performed, which was largely unremarkable except for a 1.2 cm lobular T2 hyperintense abnormality at the right clivus and petrous carotid canal, which does not enhance.  The nature of this lesion is unclear.  Certainly, this abnormality would not explain her left facial twitching and is unlikely to be involved with the right posterior sensory changes she experiences.,LABS: , She was supposed to have Lyme titers and thyroid tests as well as fasting glucose, which were not done; however, in light of her improvement these may not need to be performed at this time.,IMPRESSION:,1.  Left facial twitching-appears to be improving.  Most likely, this is a peripheral nerve injury related to her abscess as previously described.  In light of her negative MRI and clinical improvement, we discussed options and elected to just observe for now.,2.  Posterior pressure like headache, also appears to be improving.  The etiology is unclear, but as it responds nicely to nonsteroidal antiinflammatories and is decreasing, no further evaluation is needed.,3.  Probable circadian sleep disorder related to her nighttime work schedule and awakening at 9.00 a.m. with insufficient sleep.  There is also the possibility of consistent obstructive sleep apnea and if symptoms worsen then we should consider doing a sleep study.  For the time being, sleep hygiene measures were discussed with the patient including trying to sleep later at least till 10.00 a.m. or 10.30 to get a full-night sleep.  She is on vacation next week and is going to try to see if this will help.  We also discussed as before weight loss and exercise, which could be helpful.,4.  Right clivus and petrous lesion of unknown etiology.  We will repeat the MRI at four months to see for interval change.,5.  The patient voiced understanding of these plans and will be following up with me in five months.","consult - history and phy., grimacing, headache, clivus and petrous, facial twitching, sleep, facial, twitching, "
 Patient with complaint of left knee pain.  Patient is obese and will be starting Medifast Diet., Consult - History and Phy., Consult - Knee Pain ,"CHIEF COMPLAINT:,  Left knee pain.,SUBJECTIVE: , This is a 36-year-old white female who presents to the office today with a complaint of left knee pain.  She is approximately five days after a third Synvisc injection.  She states that the knee is 35% to 40 % better, but continues to have a constant pinching pain when she full weight bears, cannot handle having her knee in flexion, has decreased range of motion with extension.  Rates her pain in her knee as a 10/10.  She does alternate ice and heat.  She is using Tylenol No. 3 p.r.n. and ibuprofen OTC p.r.n. with minimal relief.,ALLERGIES,1.  PENICILLIN.,2.  KEFLEX.,3.  BACTRIM.,4.  SULFA.,5.  ACE BANDAGES.,MEDICATIONS,1.  Toprol.,2.  Xanax.,3.  Advair.,4.  Ventolin.,5.  Tylenol No.  3.,6.  Advil.,REVIEW OF SYSTEMS:,  Will be starting the Medifast diet, has discussed this with her PCP, who encouraged her to have gastric bypass, but the patient would like to try this Medifast diet first.  Other than this, denies any further problems with her eyes, ears, nose, throat, heart, lungs, GI, GU, musculoskeletal, nervous system, except what is noted above and below.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse 72, blood pressure 130/88, respirations 16, height 5 feet 6.5 inches.,GENERAL:  This is a 36-year-old white female who is A&O x3, in no apparent distress with a pleasant affect.  She is well developed, well nourished, appears her stated age.,EXTREMITIES:  Orthopedic evaluation of the left knee reveals there to be well-healed portholes.  She does have some medial joint line swelling.  Negative ballottement.  She has significant pain to palpation of the medial joint line, none of the lateral joint line.  She has no pain to palpation on the popliteal fossa.  Range of motion is approximately -5 degrees to 95 degrees of flexion.  It should be noted that she has extreme hyperextension on the right with 95+ degrees of flexion on the right.  She has a click with McMurray.  Negative anterior-posterior drawer.  No varus or valgus instability noted.  Positive patellar grind test.  Calf is soft and nontender.  Gait is stable and antalgic on the left.,ASSESSMENT,1.  Osteochondral defect, torn meniscus, left knee.,2.  Obesity.,PLAN: , I have encouraged the patient to work on weight reduction, as this will only benefit her knee.  I did discuss treatment options at length with the patient, but I think the best plan for her would be to work on weight reduction.  She questions whether she needs a total knee; I don't believe she needs total knee replacement.  She may, however, at some point need an arthroscopy.  I have encouraged her to start formal physical therapy and a home exercise program.  Will use ice or heat p.r.n.  I have given her refills on Tylenol No.  3, Flector patch, and Relafen not to be taken with any other anti-inflammatory.  She does have some abdominal discomfort with the anti-inflammatories, was started on Nexium 20 mg one p.o. daily.  She will follow up in our office in four weeks.  If she has not gotten any relief with formal physical therapy and the above-noted treatments, we will discuss with Dr. X whether she would benefit from another knee arthroscopy.  The patient shows a good understanding of this treatment plan and agrees.","consult - history and phy., medifast, medifast diet, obesity, gastric bypass, knee pain, weight reduction, knee, "
 Patient with mid-epigastric abdominal pain.  Sonogram revealed gallstones., Consult - History and Phy., Consult - Laparoscopic Cholecystectomy  ,"PAST MEDICAL HISTORY: , Significant for arthritis in her knee, anxiety, depression, high insulin levels, gallstone attacks, and PCOS.,PAST SURGICAL HISTORY: , None.,SOCIAL HISTORY: , Currently employed.  She is married.  She is in sales.  She does not smoke.  She drinks wine a few drinks a month.,CURRENT MEDICATIONS: , She is on Carafate and Prilosec.  She was on metformin, but she stopped it because of her abdominal pains.,ALLERGIES: , She is allergic to PENICILLIN.,REVIEW OF SYSTEMS:,  Negative for heart, lungs, GI, GU, cardiac, or neurologic.  Denies specifically asthma, allergies, high blood pressure, high cholesterol, diabetes, chronic lung disease, ulcers, headache, seizures, epilepsy, strokes, thyroid disorder, tuberculosis, bleeding, clotting disorder, gallbladder disease, positive liver disease, kidney disease, cancer, heart disease, and heart attack.,PHYSICAL EXAMINATION: , She is afebrile.  Vital Signs are stable.  HEENT:  EOMI.  PERRLA.  Neck is soft and supple.  Lungs clear to auscultation.  She is mildly tender in the abdomen in the right upper quadrant.  No rebound.  Abdomen is otherwise soft.  Positive bowel sounds.  Extremities are nonedematous.  Ultrasound reveals gallstones, no inflammation, common bile duct in 4 mm.,IMPRESSION/PLAN: , I have explained the risks and potential complications of laparoscopic cholecystectomy in detail including bleeding, infection, deep venous thrombosis, pulmonary embolism, cystic leak, duct leak, possible need for ERCP, and possible need for further surgery among other potential complications.  She understands and we will proceed with the surgery in the near future.,","consult - history and phy., laparoscopic cholecystectomy, mid epigastric, epigastric abdominal, potential complications, laparoscopic, cholecystectomy, epigastric, abdomen, surgery, gallstones, disease, abdominal"
 Patient with a past medical history of hypertension for 15 years., Consult - History and Phy., Consult - Hypertension ,"HISTORY OF PRESENT ILLNESS:,  The patient is a 74-year-old white woman who has a past medical history of hypertension for 15 years, history of CVA with no residual hemiparesis and uterine cancer with pulmonary metastases, who presented for evaluation of recent worsening of the hypertension.  According to the patient, she had stable blood pressure for the past 12-15 years on 10 mg of lisinopril.  In August of 2007, she was treated with doxorubicin and, as well as Procrit and her blood pressure started to go up to over 200s.  Her lisinopril was increased to 40 mg daily.  She was also given metoprolol and HCTZ two weeks ago, after she visited the emergency room with increased systolic blood pressure.  Denies any physical complaints at the present time.  Denies having any renal problems in the past.,PAST MEDICAL HISTORY:,  As above plus history of anemia treated with Procrit.  No smoking or alcohol use and lives alone.,FAMILY HISTORY:,  Unremarkable.,PRESENT MEDICATIONS: , As above.,REVIEW OF SYSTEMS: , Cardiovascular:  No chest pain.  No palpitations.  Pulmonary:  No shortness of breath, cough, or wheezing.  Gastrointestinal:  No nausea, vomiting, or diarrhea.  GU:  No nocturia.  Denies having gross hematuria.  Salt intake is minimal.  Neurological:  Unremarkable, except for history of old CVA.,PHYSICAL EXAMINATION: , Blood pressure today is 182/78.  Examination of the head is unremarkable.  Neck is supple with no JVD.  Lungs are clear.  There is no abdominal bruit.  Extremities 1+ edema bilaterally.,LABORATORY DATA:,  Urinalysis done in the office shows 1+ proteinuria; same is shown by urinalysis done at Hospital.  The creatinine is 0.8.  Renal ultrasound showed possible renal artery stenosis and a 2 cm cyst in the left kidney.  MRA of the renal arteries was essentially unremarkable with no suspicion for renal artery stenosis.,IMPRESSION AND PLAN:,  Accelerated hypertension.  No clear-cut etiology for recent worsening since renal artery stenosis was ruled out by negative MRA.  I could only blame Procrit initiation, as well as possible fluid retention as a cause of the patient's accelerated hypertension.  She was started on hydrochlorothiazide less than two weeks ago with some improvement in her hypertension.  At this point, I would not pursue a diagnosis of renal artery stenosis.  Since she is maxed out on lisinopril and her pulse is 60, I would not increase beta-blocker or ACE inhibitor.  I will continue HCTZ at 24 mg daily.  The patient was also given a sample of Tekturna, which would hopefully improve her systolic blood pressure.  The patient was told to be stick with her salt intake.  She will report to me in 10 days with the result of her blood pressure.  She will also repeat an SMA7 to rule out possible hyperkalemia due to Tekturna.","consult - history and phy., hypertension, ace inhibitor, accelerated hypertension, hctz, mra of the renal arteries, procrit, sma7, anemia, beta-blocker, doxorubicin, hemiparesis, history of cva, hyperkalemia, no abdominal bruit, uterine cancer, renal artery stenosis, artery stenosis, blood pressure, blood, pressure, renal,"
" Coronary artery disease, prior bypass surgery.  The patient has history of elevated PSA and BPH.  He had a prior prostate biopsy and he recently had some procedure done, subsequently developed urinary tract infection, and presently on antibiotic.  From cardiac standpoint, the patient denies any significant symptom except for fatigue and tiredness.", Consult - History and Phy., Consult - Coronary Artery Disease ,"REASON FOR CONSULTATION:,  Coronary artery disease (CAD), prior bypass surgery.,HISTORY OF PRESENT ILLNESS: , The patient is a 70-year-old gentleman who was admitted for management of fever.  The patient has history of elevated PSA and BPH.  He had a prior prostate biopsy and he recently had some procedure done, subsequently developed urinary tract infection, and presently on antibiotic.  From cardiac standpoint, the patient denies any significant symptom except for fatigue and tiredness.  No symptoms of chest pain or shortness of breath.,His history from cardiac standpoint as mentioned below.,CORONARY RISK FACTORS: , History of hypertension, history of diabetes mellitus, nonsmoker.  Cholesterol elevated.  History of established coronary artery disease in the family and family history positive.,FAMILY HISTORY: , Positive for coronary artery disease.,SURGICAL HISTORY: , Coronary artery bypass surgery and a prior angioplasty and prostate biopsies.,MEDICATIONS:,1.  Metformin.,2.  Prilosec.,3.  Folic acid.,4.  Flomax.,5.  Metoprolol.,6.  Crestor.,7.  Claritin.,ALLERGIES:,  DEMEROL, SULFA.,PERSONAL HISTORY: , He is married, nonsmoker, does not consume alcohol, and no history of recreational drug use.,PAST MEDICAL HISTORY:,  Significant for multiple knee surgeries, back surgery, and coronary artery bypass surgery with angioplasty, hypertension, hyperlipidemia, elevated PSA level, BPH with questionable cancer.  Symptoms of shortness of breath, fatigue, and tiredness.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No history of fever, rigors, or chills except for recent fever and rigors.,HEENT:  No history of cataract or glaucoma.,CARDIOVASCULAR:  As above.,RESPIRATORY:  Shortness of breath.  No pneumonia or valley fever.,GASTROINTESTINAL:  Nausea and vomiting.  No hematemesis or melena.,UROLOGICAL:  Frequency, urgency.,MUSCULOSKELETAL:  No muscle weakness.,SKIN:  None significant.,NEUROLOGICAL:  No TIA or CVA.  No seizure disorder.,PSYCHOLOGICAL:  No anxiety or depression.,ENDOCRINE:  As above.,HEMATOLOGICAL:  None significant.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 75, blood pressure 130/68, afebrile, and respiratory rate 16 per minute.,HEENT:  Atraumatic, normocephalic.,NECK:  Veins flat.  No significant carotid bruits.,LUNGS:  Air entry bilaterally fair.,HEART:  PMI displaced.  S1 and S2 regular.,ABDOMEN:  Soft, nontender.  Bowel sounds present.,EXTREMITIES:  No edema.  Pulses are palpable.  No clubbing or cyanosis.,CNS:  Benign.,EKG: ",
" Congestive heart failure (CHF).  The patient is a 75-year-old gentleman presented through the emergency room.  Symptoms are of shortness of breath, fatigue, and tiredness.  Main complaints are right-sided and abdominal pain.  Initial blood test in the emergency room showed elevated BNP suggestive of congestive heart failure. ", Consult - History and Phy., Consult - Congestive Heart Failure ,"REASON FOR CONSULTATION: , Congestive heart failure.,HISTORY OF PRESENT ILLNESS: , The patient is a 75-year-old gentleman presented through the emergency room.  Symptoms are of shortness of breath, fatigue, and tiredness.  Main complaints are right-sided and abdominal pain.  Initial blood test in the emergency room showed elevated BNP suggestive of congestive heart failure.  Given history and his multiple risk factors and workup recently, which has been as mentioned below, the patient was admitted for further evaluation.  Incidentally, his x-ray confirms pneumonia.,CORONARY RISK FACTORS: , History of hypertension, no history of diabetes mellitus, active smoker, cholesterol elevated, questionable history of coronary artery disease, and family history is positive.,FAMILY HISTORY: , Positive for coronary artery disease.,PAST SURGICAL HISTORY: , The patient denies any major surgeries.,MEDICATIONS:  ,Aspirin, Coumadin adjusted dose, digoxin, isosorbide mononitrate 120 mg daily, Lasix, potassium supplementation, gemfibrozil 600 mg b.i.d., and metoprolol 100 mg b.i.d.,ALLERGIES: , None reported.,PERSONAL HISTORY:,  Married, active smoker, does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY: , Hypertension, hyperlipidemia, smoking history, coronary artery disease, cardiomyopathy, COPD, and presentation as above.  The patient is on anticoagulation on Coumadin, the patient does not recall the reason.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  Weakness, fatigue, and tiredness.,HEENT:  History of blurry vision and hearing impaired.  No glaucoma.,CARDIOVASCULAR:  Shortness of breath, congestive heart failure, and arrhythmia.  Prior history of chest pain.,RESPIRATORY:  Bronchitis and pneumonia.  No valley fever.,GASTROINTESTINAL:  No nausea, vomiting, hematemesis, melena, or abdominal pain.,UROLOGICAL:  No frequency or urgency.,MUSCULOSKELETAL:  No arthritis or muscle weakness.,SKIN:  Non-significant.,NEUROLOGICAL:  No TIA.  No CVA or seizure disorder.,ENDOCRINE:  Non-significant.,HEMATOLOGICAL:  Non-significant.,PSYCHOLOGICAL:  Anxiety.  No depression.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 60, blood pressure of 129/73, afebrile, and respiratory rate 16 per minute.,HEENT:  Atraumatic and normocephalic.,NECK:  Supple.  Neck veins flat.,LUNGS:  Air entry bilaterally decreased in the basilar areas with scattered rales, especially right side greater than left lung.,HEART:  PMI displaced.  S1 and S2, regular.  Systolic murmur.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  Trace edema of the ankle.  Pulses are feebly palpable.  Clubbing plus.  No cyanosis.,CNS:  Grossly intact.,MUSCULOSKELETAL:  Arthritic changes.,PSYCHOLOGICAL:  Normal affect.,LABORATORY AND DIAGNOSTIC DATA: , EKG shows sinus bradycardia, intraventricular conduction defect.  Nonspecific ST-T changes.,Laboratories noted with H&H 10/32 and white count of 7.  INR 1.8.  BUN and creatinine within normal limits.  Cardiac enzyme profile first set 0.04, BNP of 10,000.,Nuclear myocardial perfusion scan with adenosine in the office done about a couple of weeks ago shows ejection fraction of 39% with inferior reversible defect.,IMPRESSION: , The patient is a 75-year-old gentleman admitted for:",
 Chronic adenotonsillitis with adenotonsillar hypertrophy.  Upper respiratory tract infection with mild acute laryngitis., Consult - History and Phy., Consult - Enlarged Tonsils ,"HISTORY: , The patient is a 15-year-old female who was seen in consultation at the request of Dr. X on 05/15/2008 regarding enlarged tonsils.  The patient has been having difficult time with having two to three bouts of tonsillitis this year.  She does average about four bouts of tonsillitis per year for the past several years.  She notes that throat pain and fever with the actual infections.  She is having no difficulty with swallowing.  She does have loud snoring, though there have been no witnessed observed sleep apnea episodes.  She is a mouth breather at nighttime, however.  The patient does feel that she has a cold at today's visit.  She has had tonsil problems again for many years.  She does note a history of intermittent hoarseness as well.  This is particularly prominent with the current cold that she has had.  She had been seen by Dr. Y in Muskegon who had also recommended a tonsillectomy, but she reports she would like to get the surgery done here in the Ludington area as this is much closer to home.  For the two tonsillitis, she is on antibiotics again on an average about four times per year.  They do seem to help with the infections, but they tend to continue to recur.  The patient presents today for further workup, evaluation, and treatment of the above-listed symptoms.,REVIEW OF SYSTEMS:,ALLERGY/IMMUNOLOGIC:  Negative.,CARDIOVASCULAR:  Negative.,PULMONARY:  Negative.,GASTROINTESTINAL:  Negative.,GENITOURINARY:  Negative.,NEUROLOGIC:  Negative.,VISUAL:  Negative.,DERMATOLOGIC:  Negative.,ENDOCRINE:  Negative.,MUSCULOSKELETAL:  Negative.,CONSTITUTIONAL:  Negative.,PAST SURGICAL HISTORY: , Pertinent for previous cholecystectomy.,FAMILY HISTORY:,  No family history of bleeding disorder.  She does have a sister with a current ear infection.  There is a family history of cancer, diabetes, heart disease, and hypertension.,CURRENT MEDICATIONS: , None.,ALLERGIES: , She has no known drug allergies.,SOCIAL HISTORY: , The patient is single.  She is a student.  Denies tobacco or alcohol use.,PHYSICAL EXAMINATION: ,VITAL SIGNS:  Pulse is 80 and regular, temperature 98.4, weight is 184 pounds.,GENERAL:  The patient is an alert, cooperative, obese, 15-year-old female, with a normal-sounding voice and good memory.,HEAD & FACE:  Inspected with no scars, lesions or masses noted.  Sinuses palpated and are normal.  Salivary glands also palpated and are normal with no masses noted.  The patient also has full facial function.,CARDIOVASCULAR:  Heart regular rate and rhythm without murmur.,RESPIRATORY:  Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.,EYES:  Extraocular muscles were tested and within normal limits.,EARS:  The external ears are normal.  The ear canals are clean and dry.  The drums are intact and mobile.  Hearing is grossly normal.  Tuning fork examination with normal speech reception thresholds noted.,NASAL:  She has clear drainage, large inferior turbinates, no erythema.,ORAL:  Her tongue, lip, floor of mouth are noted to be normal.  Oropharynx does reveal very large tonsils measuring 3+/4+; they were exophytic.  Mirror examination of the larynx reveals some mild edema of the larynx at this time.  The nasopharynx could not be visualized on mirror exam today.,NECK:  Obese, supple.  Trachea is midline.  Thyroid is nonpalpable.,NEUROLOGIC:  Cranial nerves II through XII evaluated and noted to be normal.  Patient oriented times 3.,DERMATOLOGIC:  Evaluation reveals no masses or lesions.  Skin turgor is normal.,IMPRESSION: , ,1.  Chronic adenotonsillitis with adenotonsillar hypertrophy.,2.  Upper respiratory tract infection with mild acute laryngitis.,3.  Obesity.,RECOMMENDATIONS: , We are going to go ahead and proceed with an adenotonsillectomy.  All risks, benefits, and alternatives regarding the surgery have been reviewed in detail with the patient and her family.  This includes risk of bleeding, infection, scarring, regrowth of the adenotonsillar tissue, need for further surgery, persistent sore throat, voice changes, etc.  The parents are agreeable to the planned procedure, and we will schedule this accordingly at Memorial Medical Center here within the next few weeks.  We will make further recommendations afterwards.",
" A 37-year-old admitted through emergency, presented with symptoms of chest pain, described as a pressure-type dull ache and discomfort in the precordial region.  Also, shortness of breath is noted without any diaphoresis.  Symptoms on and off for the last 3 to 4 days especially when he is under stress.  No relation to exertional activity.  No aggravating or relieving factors. ", Consult - History and Phy., Consult - Chest Pain - 1 ,"REASON FOR CONSULTATION:,  Chest pain.,HISTORY OF PRESENT ILLNESS: , The patient is a 37-year-old gentleman admitted through emergency room.  He presented with symptoms of chest pain, described as a pressure-type dull ache and discomfort in the precordial region.  Also, shortness of breath is noted without any diaphoresis.  Symptoms on and off for the last 3 to 4 days especially when he is under stress.  No relation to exertional activity.  No aggravating or relieving factors.  His history is significant as mentioned below.  His workup so far has been negative.,CORONARY RISK FACTORS:,  No history of hypertension or diabetes mellitus.  Active smoker.  Cholesterol status, borderline elevated.  No history of established coronary artery disease.  Family history positive.,FAMILY HISTORY: , His father died of coronary artery disease.,SURGICAL HISTORY: , No major surgery except for prior cardiac catheterization.,MEDICATIONS AT HOME:,  Includes pravastatin, Paxil, and BuSpar.,ALLERGIES:,  None.,SOCIAL HISTORY: , Active smoker.  Does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY: , Hyperlipidemia, smoking history, and chest pain.  He has been, in October of last year, hospitalized.  Subsequently underwent cardiac catheterization.  The left system was normal.  There was a question of a right coronary artery lesion, which was thought to be spasm.  Subsequently, the patient did undergo nuclear and myocardial perfusion scan, which was normal.  The patient continues to smoke actively since in last 3 to 4 days especially when he is stressed.  No relation to exertional activity.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No history of fever, rigors, or chills.,HEENT:  No history of cataract, blurring vision, or glaucoma.,CARDIOVASCULAR:  As above.,RESPIRATORY:  Shortness of breath.  No pneumonia or valley fever.,GASTROINTESTINAL:  No epigastric discomfort, hematemesis, or melena.,UROLOGICAL:  No frequency or urgency.,MUSCULOSKELETAL:  No arthritis or muscle weakness.,CNS:  No TIA.  No CVA.  No seizure disorder.,ENDOCRINE:  Nonsignificant.,HEMATOLOGICAL:  Nonsignificant.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 75, blood pressure of 112/62, afebrile, and respiratory rate 16 per minute.,HEENT:  Head is atraumatic and normocephalic.  Neck veins flat.,LUNGS:  Clear.,HEART:  S1 and S2, regular.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema.  Pulses palpable.  No clubbing or cyanosis.,CNS:  Benign.,PSYCHOLOGICAL:  Normal.,MUSCULOSKELETAL:  Within normal limits.,DIAGNOSTIC DATA: , EKG, normal sinus rhythm.  Chest x-ray unremarkable.,LABORATORY DATA: , First set of cardiac enzyme profile negative.  H&H stable.  BUN and creatinine within normal limits.,IMPRESSION:,1.  Chest pain in a 37-year-old gentleman with negative cardiac workup as mentioned above, questionably right coronary spasm.,2.  Hyperlipidemia.,3.  Negative EKG and cardiac enzyme profile.,RECOMMENDATIONS:",
 The patient is a 63-year-old white male who was admitted to the hospital with CHF and lymphedema., Consult - History and Phy., Consult - CHF & Lymphedema ,"HISTORY OF PRESENT ILLNESS:,  The patient is a 63-year-old white male who was admitted to the hospital with CHF and lymphedema.  He also has a history of obesity, hypertension, sleep apnea, chronic low back pain, cataracts, and past history of CA of the lung.  This consultation was made for better control of his blood sugars.  On questioning, the patient says that he does not have diabetes.  He says that he has never been told about diabetes except during his last admission at Jefferson Hospital.  Apparently, he was started on glipizide at that time.  His blood sugars since then have been good and he says when he went back to Jefferson three weeks later, he was told that he does not have a sugar problem.  He is not sure.  He is not following any specific diet.  He says ""my doctor wants me to lose 30-40 pounds in weight"" and he would not mind going on a diet.  He has a long history of numbness of his toes.  He denies any visual problems.,PAST MEDICAL HISTORY: , As above that includes CA of the lung, COPD, bilateral cataracts.  He has had chronic back pain.  There is also a history of bilateral hip surgeries, penile implant and removal, umbilical hernia repair, and back pain with two surgeries with details of which are unknown.,SOCIAL HISTORY: , The patient has been a smoker since the age of 10.  So, he was smoking 2-3 packs per day.  Since being started on Chantix, he says he has cut it down to half a pack per day.  He does not abuse alcohol.,MEDICATIONS: ,1.  Glipizide 5 mg p.o. daily.,2.  Theophylline.,3.  Z-Pak.,4.  Chantix.,5.  Januvia 100 mg daily.,6.  K-Lor.,7.  OxyContin.,8.  Flomax.,9.  Lasix.,10.  Advair.,11.  Avapro.,12.  Albuterol sulfate.,13.  Vitamin B tablet.,14.  OxyContin and oxycodone for pain.,FAMILY HISTORY: , Positive for diabetes mellitus in the maternal grandmother.,REVIEW OF SYSTEMS: , As above.  He says he has had numbness of toes for a long time.  He denies any visual problems.  His legs have been swelling up from time to time for a long time.  He also has history of COPD and gets short of breath with minimal activity.  He is also not able to walk due to his weight.  He has had ulcers on his legs, which he gets discharge from.  He has chronic back pain and takes OxyContin.  He denies any constipation, diarrhea, abdominal pain, nausea or vomiting.  There is no chest pain.  He does get short of breath on walking.,PHYSICAL EXAMINATION:,The patient is a well-built, obese, white male in no acute distress.,Vital signs:  Pulse rate of 89 per minute and regular.  Blood pressure of 113/69, temperature is 98.4 degrees Fahrenheit, and respirations are 18.,HEENT:  Head is normocephalic and atraumatic.  Eyes, PERRLA.  EOMs intact.  Fundi were not examined.,Neck:  Supple.  JVP is low.  Trachea central.  Thyroid small in size.  No carotid bruits.,Heart:  Shows normal sinus rhythm with S1 and S2.,Lungs:  Show bilateral wheezes with decreased breath sounds at the bases.,Abdomen:  Soft and obese.  No masses.  Bowel sounds are present.,Extremities:  Show bilateral edema with changes of chronic venostasis.  He does have some open weeping sores.  Pulses could not be palpated due to leg swelling.,IMPRESSION/PLAN:,1.  Diabetes mellitus, type 2, new onset.  At this time, the patient is on Januvia as well as glipizide.  His blood sugar right after eating his supper was 101.  So, I am going to discontinue glipizide, continue on Januvia, and add no-concentrated sweets to the diet.  We will continue to follow his blood sugars closely and make adjustments as needed.,2.  Neuropathy, peripheral, query etiology.  We will check TSH and B12 levels.,3.  Lymphedema.,4.  Recurrent cellulitis.,5.  Obesity, morbid.,6.  Tobacco abuse.  He was encouraged to cut his cigarettes down to 5 cigarettes a day.  He says he feels like smoking after meals.  So, we will let him have it after meals first thing in the morning and last thing at night.,7.  Chronic venostasis.,8.  Lymphedema.  We would check his lipid profile also.,9.  Hypertension.,10.  Backbone pain, status post back surgery.,11.  Status post hernia repair.,12.  Status post penile implant and removal.,13.  Umbilical hernia repair.",
" Patient with multiple problems, main one is chest pain at night.", Consult - History and Phy., Consult - Chest Pain ,"CHIEF COMPLAINT:,  Multiple problems, main one is chest pain at night.,HISTORY OF PRESENT ILLNESS:,  This is a 60-year-old female with multiple problems as numbered below:,1.  She reports that she has chest pain at night.  This happened last year exactly the same.  She went to see Dr. Murphy, and he did a treadmill and an echocardiogram, no concerns for cardiovascular disease, and her symptoms resolved now over the last month.  She wakes in the middle of the night and reports that she has a pressure.  It is mild-to-moderate in the middle of her chest and will stay there as long she lies down.  If she gets up, it goes away within 15 minutes.  It is currently been gone on for the last week.  She denies any fast heartbeats or irregular heartbeats at this time.,2.  She has been having stomach pains that started about a month ago.  This occurs during the daytime.  It has no relationship to foods.  It is mild in nature, located in the mid epigastric area.  It has been better for one week as well.,3.  She continues to have reflux, has noticed that if she stops taking Aciphex, then she has symptoms.  If she takes her Aciphex, she seems that she has the reflux belching, burping, and heartburn under control.,4.  She has right flank pain when she lies down.  She has had this off and on for four months.  It is a dull achy pain.  It is mild in nature.,5.  She has some spots on her shoulder that have been present for a long time, but over the last month have been getting bigger in size and is elevated whereas they had not been elevated in the past.  It is not painful.,6.  She has had spots in her armpits initially on the right side and then going to the left side.  They are not itchy.,7.  She is having problems with urgency of urine.  When she has her bladder full, she suddenly has an urge to use the restroom, and sometimes does not make it before she begins leaking.  She is wearing a pad now.,8.  She is requesting a colonoscopy for screening as well.  She is wanting routine labs for following her chronic leukopenia, also is desiring a hepatitis titer.,9.  She has had pain in her thumbs when she is trying to do fine motor skills, has noticed this for the last several months.  There has been no swelling or redness or trauma to these areas.,REVIEW OF SYSTEMS:,  She has recently been to the eye doctor.  She has noticed some hearing loss gradually.  She denies any problems with swallowing.  She denies episodes of shortness of breath, although she has had a little bit of chronic cough.  She has had normal bowel movements.  Denies any black or bloody stools, diarrhea, or constipation.  Denies seeing blood in her urine and has had no urinary problems other than what is stated above.  She has had no problems with edema or lower extremity numbness or tingling.,SOCIAL HISTORY:,  She works at nursing home.  She is a nonsmoker.  She is currently trying to lose weight.  She is on the diet and has lost several pounds in the last several months.  She quit smoking in 1972.,FAMILY HISTORY: , Her father has type I diabetes and heart disease.  She has a brother who had heart attack at the age of 52.  He is a smoker.,PAST MEDICAL HISTORY:,  Episodic leukopenia and mild irritable bowel syndrome.,CURRENT MEDICATIONS:,  Aciphex 20 mg q.d. and aspirin 81 mg q.d.,ALLERGIES:,  No known medical allergies.,OBJECTIVE:,Vital Signs:  Weight:  142 pounds.  Blood pressure:  132/78.  Pulse:  72.,General:  This is a well-developed adult female who is awake, alert, and in no acute distress.,HEENT:  Her pupils are equally round and reactive to light.  Conjunctivae are white.  TMs look normal bilaterally.  Oropharynx appears to be normal.  Dentition is excellent.,Neck:  Supple without lymphadenopathy or thyromegaly.,Lungs:  Clear with normal respiratory effort.,Heart:  Regular rhythm and rate without murmur.  Radial pulses are normal bilaterally.,Abdomen:  Soft, nontender, and nondistended without organomegaly.,Extremities:  Examination of the hands reveals some tenderness at the base of her thumbs bilaterally as well as at the PIP joint and DIP joint.  Her armpits are examined.  She has what appears to be a tinea versicolor rash present in the armpits bilaterally.  She has a lesion on her left shoulder, which is 6 mm in diameter.  It has diffuse borders and is slightly red.  It has two brown spots in it.  In her lower extremities, there is no cyanosis or edema.  Pulses at the radial and posterior tibial pulses are normal bilaterally.  Her gait is normal.,Psychiatric:  Her affect is pleasant and positive.,Neurological:  She is grossly intact.  Her speech seems to be clear.  Her coordination of upper and lower extremities is normal.,ASSESSMENT/PLAN:,1.  Chest pain.  At this point, because of Dr. Murphy’s evaluation last year and the symptoms exactly the same, I think this is noncardiac.  My intonation is that this is reflux.  I am going have her double her Aciphex or increase it to b.i.d., and I am going to have her see Dr. XYZ for possible EGD if he thinks that would be appropriate.  She is to let me know if her symptoms are getting worse or if she is having any severe episodes.,2.  Stomach pain, uncertain at this point, but I feel like this is probably related as well to chest pain.,3.  Suspicious lesions on the left shoulder.  We will do a punch biopsy and set her up for an appointment for that.,4.  Tinea versicolor in the axillary area.  I have prescribed selenium sulfide lotion to apply 10 minutes a day for seven days.,5.  Cystocele.  We will have her see Dr. XYZ for further discussion of repair due to her urinary incontinence.,6.  History of leukopenia.  We will check a CBC.,7.  Pain in the thumbs, probably arthritic in nature, observe for now.,8.  Screening.  We will have her see Dr. XYZ for discussion of colon cancer screening.,9.  Gastroesophageal reflux disease.  I have increased Aciphex to b.i.d. for now.",
 The patient has been suffering from intractable back and leg pain., Consult - History and Phy., Consult - Back & Leg Pain ,"Her axial back pain is greatly improved, but not completely eradicated.  There is absolutely no surgery at this point in time that would be beneficial for her axial back pain due to her lumbar internal disc disruption.,PAST MEDICAL HISTORY:,  Significant for anxiety disorder.,PAST SURGICAL HISTORY: , Foot surgery, abdominal surgery, and knee surgery.,CURRENT MEDICATIONS:,  Lipitor and Lexapro.,ALLERGIES: , She is allergic to sulfa medications.,SOCIAL HISTORY: , She is married, retired.  Denies tobacco or ethanol use.,FAMILY HISTORY:,  Father died of mesothelioma.  Mother gastric problems.,REVIEW OF SYSTEMS: , No recent history of night sweats, fevers, weight loss, visual changes, loss of consciousness, convulsion, or dysphagia.  Otherwise, review of systems is unremarkable, and a detailed history can be found in the patient's chart.,PHYSICAL EXAMINATION:,  Physical exam can be found in great detail in the patient's chart.,ASSESSMENT AND PLAN:  ,The patient is suffering from multilevel lumbar internal disc disruption as well as an element of lumbar facet joint syndrome.  Her lumbar facet joints were denervated approximately 6 months ago.  The denervation procedure helped her axial back pain approximately 40% when standing.  With extension and rotation it helped her axial back pain approximately 70%.  She is now able to swing a golf club.  She was unable to swing a golf club due to the rotational movements before her rhizotomy.  She is currently playing golf.  Her L4 radicular symptoms have resolved since her therapeutic transforaminal injection.,I am going to have her fitted with a low profile back brace and I am starting her on diclofenac 75 mg p.o. b.i.d.  We will follow her up in 1 month's time.,","consult - history and phy., multilevel lumbar internal disc disruption, denervation procedure, lumbar facet joint syndrome, swing a golf, lumbar internal disc, internal disc disruption, lumbar internal, internal disc, disc disruption, intractable, surgery, disc, lumbar"
 Patient presents with complaint of lump in the upper outer quadrant of the right breast, Consult - History and Phy., Consult - Breast Cancer ,"CHIEF COMPLAINT / REASON FOR THE VISIT:, Patient has been diagnosed to have breast cancer.,BREAST CANCER HISTORY:, Patient presented with the following complaints: Lump in the upper outer quadrant of the right breast that has been present for the last 4 weeks. The lump is painless and the skin over the lump is normal. Patient denies any redness, warmth, edema and nipple discharge. Patient had a mammogram recently and was told to have a mass measuring 2 cm in the UOQ and of the left breast. Patient had an excisional biopsy of the mass and subsequently axillary nodal sampling.,PATHOLOGY:, Infiltrating ductal carcinoma, Estrogen receptor 56, Progesterone receptor 23, S-phase fraction 2., Her 2 neu 0 and all nodes negative.,STAGE:, Stage I.,TNM STAGE:, T1, N0 and M0.,SURGERY:, S/P lumpectomy left breast and Left axillary node sampling. Patient is here for further recommendation.,PAST MEDICAL HISTORY:, Osteoarthritis for 5 years. ASHD for 10 years. Kidney stones recurrent for 10 years.,SCREENING TEST HISTORY:,  Last rectal exam was done on 10/99. Last mammogram was done on 12/99. Last gynecological exam was done on 10/99. Last PAP smear was done on 10/99. Last chest x-ray was done on 10/99. Last F.O.B. was done on 10/99-X3. Last sigmoidoscopy was done on 1998. Last colonoscopy was done on 1996.,IMMUNIZATION HISTORY:, Last flu vaccine was given on 1999. Last pneumonia vaccine was given on 1996.,FAMILY MEDICAL HISTORY:, Father age 85, history of cerebrovascular accident (stroke) and hypertension. Mother history of CHF and emphysema that died at the age of 78. No brothers and sisters. 1 son healthy at age 54.,PAST SURGICAL HISTORY:, Appendectomy. Biopsy of the left breast 1996 - benign.",
 Patient with a history of right upper pons and right cerebral peduncle infarction., Consult - History and Phy., Consult - Cerebral Peduncle Infarction ,"FAMILY HISTORY AND SOCIAL HISTORY:,  Reviewed and remained unchanged.,MEDICATIONS:,  List remained unchanged including Plavix, aspirin, levothyroxine, lisinopril, hydrochlorothiazide, Lasix, insulin and simvastatin.,ALLERGIES:,  She has no known drug allergies.,FALL RISK ASSESSMENT: , Completed and there was no history of falls.,REVIEW OF SYSTEMS:  ,Full review of systems again was pertinent for shortness of breath, lack of energy, diabetes, hypothyroidism, weakness, numbness and joint pain.  Rest of them was negative.,PHYSICAL EXAMINATION:,Vital Signs:  Today, blood pressure was 170/66, heart rate was 66, respiratory rate was 16, she weighed 254 pounds as stated, and temperature was 98.0.,General:  She was a pleasant person in no acute distress.,HEENT:  Normocephalic and atraumatic.  No dry mouth.  No palpable cervical lymph nodes.  Her conjunctivae and sclerae were clear.,NEUROLOGICAL EXAMINATION:,  Remained unchanged.,Mental Status:  Normal.,Cranial Nerves:  Mild decrease in the left nasolabial fold.,Motor:  There was mild increased tone in the left upper extremity.  Deltoids showed 5-/5.  The rest showed full strength.  Hip flexion again was 5-/5 on the left.  The rest showed full strength.,Reflexes:  Reflexes were hypoactive and symmetrical.,Gait:  She was mildly abnormal.  No ataxia noted.  Wide-based, ambulated with a cane.,IMPRESSION: , Status post cerebrovascular accident involving the right upper pons extending into the right cerebral peduncle with a mild left hemiparesis, has been clinically stable with mild improvement.  She is planned for surgical intervention for the internal carotid artery.,RECOMMENDATIONS: , At this time, again we discussed continued use of antiplatelet therapy and statin therapy to reduce her risk of future strokes.  She will continue to follow with endocrinology for diabetes and thyroid problems.  I have recommended a strict control of her blood sugar, optimizing cholesterol and blood pressure control, regular exercise and healthy diet and I have discussed with Ms. A and her daughter to give us a call for post surgical recovery.  I will see her back in about four months or sooner if needed.","consult - history and phy., internal carotid artery, cerebral peduncle infarction, carotid artery, blood pressure, upper pons, infarction, cerebral, peduncle, "
" The patient is a 57-year-old female with invasive ductal carcinoma of the left breast, T1c, Nx, M0 left breast carcinoma.", Consult - History and Phy., Consult - Breast Cancer - 1 ,"CHIEF COMPLAINT: , Left breast cancer.,HISTORY:,  The patient is a 57-year-old female, who I initially saw in the office on 12/27/07, as a referral from the Tomball Breast Center.  On 12/21/07, the patient underwent image-guided needle core biopsy of a 1.5 cm lesion at the 7 o'clock position of the left breast (inferomedial).  The biopsy returned showing infiltrating ductal carcinoma high histologic grade.  The patient stated that she had recently felt and her physician had felt a palpable mass in that area prior to her breast imaging.  She prior to that area, denied any complaints.  She had no nipple discharge.  No trauma history.  She has had been on no estrogen supplementation.  She has had no other personal history of breast cancer.  Her family history is positive for her mother having breast cancer at age 48.  The patient has had no children and no pregnancies.  She denies any change in the right breast.  Subsequent to the office visit and tissue diagnosis of breast cancer, she has had medical oncology consultation with Dr. X and radiation oncology consultation with Dr. Y.  I have discussed the case with Dr. X and Dr. Y, who are both in agreement with proceeding with surgery prior to adjuvant therapy.  The patient's metastatic workup has otherwise been negative with MRI scan and CT scanning.  The MRI scan showed some close involvement possibly involving the left pectoralis muscle, although thought to also possibly represent biopsy artifact.  CT scan of the neck, chest, and abdomen is negative for metastatic disease.,PAST MEDICAL HISTORY:,  Previous surgery is history of benign breast biopsy in 1972, laparotomy in 1981, 1982, and 1984, right oophorectomy in 1984, and ganglion cyst removal of the hand in 1987.,MEDICATIONS:,  She is currently on omeprazole for reflux and indigestion.,ALLERGIES:,  SHE HAS NO KNOWN DRUG ALLERGIES.,REVIEW OF SYSTEMS:,  Negative for any recent febrile illnesses, chest pains or shortness of breath.  Positive for restless leg syndrome.  Negative for any unexplained weight loss and no change in bowel or bladder habits.,FAMILY HISTORY:,  Positive for breast cancer in her mother and also mesothelioma from possible asbestosis or asbestos exposure.,SOCIAL HISTORY:  ,The patient works as a school teacher and teaching high school.,PHYSICAL EXAMINATION,GENERAL:  The patient is a white female, alert and oriented x 3, appears her stated age of 57.,HEENT:  Head is atraumatic and normocephalic.  Sclerae are anicteric.,NECK:  Supple.,CHEST:  Clear.,HEART:  Regular rate and rhythm.,BREASTS:  Exam reveals an approximately 1.5 cm relatively mobile focal palpable mass in the inferomedial left breast at the 7 o'clock position, which clinically is not fixed to the underlying pectoralis muscle.  There are no nipple retractions.  No skin dimpling.  There is some, at the time of the office visit, ecchymosis from recent biopsy.  There is no axillary adenopathy.  The remainder of the left breast is without abnormality.  The right breast is without abnormality.  The axillary areas are negative for adenopathy bilaterally.,ABDOMEN:  Soft, nontender without masses.  No gross organomegaly.  No CVA or flank tenderness.,EXTREMITIES:  Grossly neurovascularly intact.,IMPRESSION: , The patient is a 57-year-old female with invasive ductal carcinoma of the left breast, T1c, Nx, M0 left breast carcinoma.,RECOMMENDATIONS: , I have discussed with the patient in detail about the diagnosis of breast cancer and the surgical options, and medical oncologist has discussed with her issues about adjuvant or neoadjuvant chemotherapy.  We have decided to recommend to the patient breast conservation surgery with left breast lumpectomy with preoperative sentinel lymph node injection and mapping and left axillary dissection.  The possibility of further surgery requiring wider lumpectomy or even completion mastectomy was explained to the patient.  The procedure and risks of the surgery were explained to include, but not limited to extra bleeding, infection, unsightly scar formation, the possibility of local recurrence, the possibility of left upper extremity lymphedema was explained.  Local numbness, paresthesias or chronic pain was explained.  The patient was given an educational brochure and several brochures about the diagnosis and treatment of breast cancers.  She was certainly encouraged to obtain further surgical medical opinions prior to proceeding.  I believe the patient has given full informed consent and desires to proceed with the above.", 
" Patient with a history of mesothelioma and likely mild dementia, most likely Alzheimer type.", Consult - History and Phy., Consult - Alzheimer disease  ,"The patient states that she has been doing fairly well at home.  She balances her own checkbook.  She does not do her own taxes, but she has never done so in the past.  She states that she has no problems with cooking meals, getting her own meals, and she is still currently driving.  She denies burning any dishes because she forgot them on the stove or forgetting what she is doing in the middle of a task or getting lost while she is driving around or getting lost in her own home.  She states that she is very good remembering the names of her family members and does not forget important birthdays such as the date of birth of her grandchildren.  She is unfortunately living alone, and although she seems to miss her grandchildren and is estranged from her son, she denies any symptoms of frank depression.  There is unfortunately no one available to us to corroborate how well she is doing at home.  She lives alone and takes care of herself and does not communicate very much with her brother and sister.  She also does not communicate very much with her son who lives in Santa Cruz or her grandchildren.  She denied any sort of personality change, paranoid ideas or hallucinations.  She does appear to have headaches that can be severe about four times a month and have primarily photophobia and some nausea and occasionally emesis associated with it.  When these headaches are very severe, she goes to the emergency room to get a single shot.  She is unclear if this is some sort of a migraine medication or just a primary pain medication.  She takes Fiorinal for these headaches and she states that this helps greatly.  She denies visual or migraine symptoms.,REVIEW OF SYSTEMS: , Negative for any sort of focal neurologic deficits such as weakness, numbness, visual changes, dysarthria, diplopia or dysphagia.  She also denies any sort of movement disorders, tremors, rigidities or clonus.  Her personal opinion is that some of her memory problems may be due to simply to her age and/or nervousness.  She is unclear as if her memory is any worse than anyone else in her age group.,PAST MEDICAL HISTORY: , Significant for mesothelioma, which was diagnosed seemingly more than 20 to 25 years ago.  The patient was not sure of exactly when it was diagnosed.  This has been treated surgically by debulking operations for which she states that she has undergone about 10 operations.  The mesothelioma is in her abdomen.  She does not know of any history of having lung mesothelioma.  She states that she has never gotten chemotherapy or radiation for her mesothelioma.  Furthermore, she states that her last surgical debulking was more than 10 years ago and her disease has been fairly stable.  She does have a history of three car accidents that she says were all rear-enders where she was hit while essentially in a stopped position.  These have all occurred over the past five years.  She also has a diagnosis of dementing illness, possibly Alzheimer disease from her previous neurology consultation.  This diagnosis was given in March 2006.,MEDICATIONS:,  Fiorinal, p.r.n. aspirin, unclear if baby or full sized, Premarin unclear of the dose.,ALLERGIES:, NONE.,SOCIAL HISTORY:,  Significant for her being without a companion at this point.  She was born in Munich, Germany.  She immigrated to of America in 1957 after her family had to move to Eastern Germany, which was under Russian occupation at that time.  She is divorced.  She used to work as a secretary and later worked as a clerical worker at IBM.  She stopped working more than 20 years ago due to complications from her mesothelioma.  She denies any significant tobacco, alcohol or illicit drugs.  She is bilingual speaking, German and English.  She has known English from before her teens.  She has the equivalent of a high school education in Germany.  She has one brother and one sister, both of whom are healthy and she does not spend much time communicating with them.  She has one son who lives in Santa Cruz.  He has grandchildren.  She is trying to contact with her grandchildren.,FAMILY HISTORY: , Significant for lung, liver, and prostate cancer.  Her mother died in her 80s of ""old age,"" but it appears that she may have had a mild dementing illness at that time.  Whatever that dementing illness was, appears to have started mostly in her 80s per the patient.  No one else appears to have Alzheimer disease including her brother and sister.,PHYSICAL EXAMINATION: , Her blood pressure is 152/92, pulse 80, and weight 80.7 kg.  She is alert and well nourished in no apparent distress.  She occasionally fumbles with questions of orientation, missing the day and the date.  She also did not know the name of the hospital, she thought it was O'Connor and she thought she was in Orange County and also did not know the floor of the hospital that we are in.  She lost three points for recall.  Even with prompting, she could not remember the objects that she was given to remember.  Her Mini Mental Score was 22/30.  There were no naming problems or problems with repetition.  There were also no signs of dysarthria.  Her pupils were bilaterally reactive to light and accommodation.  Her extraocular movements were intact.  Her visual fields were full to confrontation.  Her sensations of her face, arm, and leg were normal.  There were no signs of neglect with double simultaneous stimulation.  Tongue was midline.  Her palate was symmetric.  Her face was symmetric as well.  Strength was approximately 5/5.  She did have some right knee pain and she had a mildly antalgic gait due to her right knee pain.  Her reflexes were symmetric and +2 except for her toes, which were +1 to trace.  Her plantar reflexes were mute.  Her sensation was normal for pain, temperature, and vibration.  There were no signs of ataxia on finger-to-nose and there was no dysdiadochokinesia.  Gait was narrow and she could toe walk briefly and heel walk without difficulty.,SUMMARY:,  Ms. A is a pleasant 72-year-old right-handed woman with a history of mesothelioma that appears stable at this time and likely mild dementia, most likely Alzheimer type.  We tactfully discussed the patient's diagnosis with her, and she felt reassured.  We told her that this most likely was in the earlier stages of disease and she would benefit from trying Aricept.  She stated that she did not have the prescription anymore from her outpatient neurology consult for the Aricept, so we wrote her another prescription for Aricept.  The patient herself seemed very concerned about the stigma of the disease, but our lengthy discussion, expressed genuine understanding as to why her outpatient physician had reported her to DMV.  It was explicitly told to not drive by her outpatient neurologist and we concur with this assessment.  She will follow up with us in the next six months and will call us if she has any problems with the Aricept.  She was written for Aricept to start at 5 mg for three weeks, and if she has no side effects which typically are GI side effects, then she can go up to 10 mg a day.  We also reviewed with Ms. A the findings for outpatient MRI, which showed some mild atrophy per report and also that her metabolic workup, which included an RPR, TSH, and B12 were all within normal limits.,","consult - history and phy., neurology consultation, dementing illness, alzheimer disease, dementia, alzheimer, mesothelioma,"
 Patient with past medical history significant for coronary artery disease status post bypass grafting surgery and history of a stroke with residual left sided hemiplegia., Consult - History and Phy., Consult - Atrial Fibrillation ,"REASON FOR CONSULTATION:,  Atrial fibrillation.,HISTORY OF PRESENT ILLNESS:,  The patient is a 78-year-old, Hispanic woman with past medical history significant for coronary artery disease status post bypass grafting surgery and history of a stroke with residual left sided hemiplegia.  Apparently, the patient is a resident of Lake Harris Port Square long-term facility after her stroke.  She was found to have confusion while in her facility.  She then came to the emergency room and found to have a right sided acute stroke.  12-lead EKG performed on August 10, 2009, found to have atrial fibrillation.  Telemetry also revealed atrial fibrillation with rapid ventricular response.  Currently, the telemetry is normal sinus rhythm.  Because of the finding of atrial fibrillation, cardiology was consulted.,The patient is a poor historian.  She did not recall why she is in the hospital, she said she had a stroke.  She reported no chest discomfort, no shortness of breath, no palpitations.,The following information was obtained from the patient's chart:,PAST MEDICAL HISTORY:,1.  Coronary artery disease status post bypass grafting surgery.  Unable to obtain the place, location, anatomy, and the year it was performed.,2.  Carotid artery stenosis status post right carotid artery stenting.  Again, the time was unknown.,3.  Diabetes.,4.  Hypertension.,5.  Hyperlipidemia.,6.  History of stroke with left side hemiplegia.,ALLERGIES: , No known drug allergies.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:,  The patient is a resident of Lake Harris Port Square.  She has no history of alcohol use.,CURRENT MEDICATIONS: , Please see attached list including hydralazine, Celebrex, Colace, metformin, aspirin, potassium, Lasix, Levaquin, Norvasc, insulin, Plavix, lisinopril, and Zocor.,REVIEW OF SYSTEMS: , Unable to obtain.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure 133/44, pulse 98, O2 saturation is 98% on room air.  Temperature 99, respiratory rate 16.,GENERAL:  The patient is sitting in the chair at bedside.  Appears comfortable.  Left facial droop.  Left side hemiplegia.,HEAD AND NECK:  No JVP seen.  Right side carotid bruit heard.,CHEST:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  PMI not displaced, regular rhythm.  Normal S1 and S2.  Positive S4.  There is a 2/6 systolic murmur best heard at the left lower sternal border.,ABDOMEN:  Soft.,EXTREMITIES:  Not edematous.,DATA:,  A 12-lead EKG performed on August 9, 2009, revealed atrial fibrillation with a ventricular rate of 96 beats per minute, nonspecific ST wave abnormality.,Review of telemetry done the last few days, currently the patient is in normal sinus rhythm at the rate of 60 beats per minute.  Atrial fibrillation was noted on admission noted August 8 and August 10; however, there was normal sinus rhythm on August 10.,LABORATORY DATA: , WBC 7.2, hemoglobin 11.7.  The patient's hemoglobin was 8.2 a few days ago before blood transfusion.  Chemistry-7 within normal limits.  Lipid profile:  Triglycerides 64, total cholesterol 106, HDL 26, LDL 17.  Liver function tests are within normal limits.  INR was 1.1.,A 2D echo was performed on August 11, 2009, and revealed left ventricle normal in size with EF of 50%.  Mild apical hypokinesis.  Mild dilated left atrium.  Mild aortic regurgitation, mitral regurgitation, and tricuspid regurgitation.  No intracardiac masses or thrombus were noted.  The aortic root was normal in size.,ASSESSMENT AND RECOMMENDATIONS:,1.  Paroxysmal atrial fibrillation.  It is unknown if this is a new onset versus a paroxysmal atrial fibrillation.  Given the patient has a recurrent stroke, anticoagulation with Coumadin to prevent further stroke is indicated.  However, given the patient's current neurologic status, the safety of falling is unclear.  We need to further discuss with the patient's primary care physician, probably rehab physician.  If the patient's risk of falling is low, then Coumadin is indicated.  However, if the patient's risk for falling is high, then a course using aspirin and Plavix will be recommended.  Transesophageal echocardiogram probably will delineate possible intracardiac thrombus better, however will not change our current management.  Therefore, I will not recommend transesophageal echocardiogram at this point.  Currently, the patient's heart rate is well controlled, antiarrhythmic agent is not recommended at this point.,2.  Carotid artery stenosis.  The patient underwent a carotid Doppler ultrasound on this admission and found to have a high-grade increased velocity of the right internal carotid artery.  It is difficult to assess the severity of the stenosis given the history of possible right carotid stenting.  If clinically indicated, CT angio of the carotid will be indicated to assess for stent patency.  However, given the patient's current acute stroke, revascularization is not indicated at this time.,3.  Coronary artery disease.  Clinically stable.  No further test is indicated at this time.",
" Atrial fibrillation and shortness of breath.  The patient is an 81-year-old gentleman with shortness of breath, progressively worsening, of recent onset. History of hypertension, no history of diabetes mellitus, ex-smoker, cholesterol status elevated, no history of established coronary artery disease, and family history positive.", Consult - History and Phy., Consult - Atrial Fibrillation - 1 ,"REASON FOR CONSULTATION: , Atrial fibrillation and shortness of breath.,HISTORY OF PRESENTING ILLNESS: , The patient is an 81-year-old gentleman.  The patient had shortness of breath over the last few days, progressively worse.  Yesterday he had one episode and got concerned and came to the Emergency Room, also orthopnea and paroxysmal dyspnea.  Coronary artery disease workup many years ago.  He also has shortness of breath, weakness, and tiredness.,CORONARY RISK FACTORS: , History of hypertension, no history of diabetes mellitus, ex-smoker, cholesterol status elevated, no history of established coronary artery disease, and family history positive.,FAMILY HISTORY: , Positive for coronary artery disease.,SURGICAL HISTORY: , Knee surgery, hip surgery, shoulder surgery, cholecystectomy, and appendectomy.,MEDICATIONS: , Thyroid supplementation, atenolol 25 mg daily, Lasix, potassium supplementation, lovastatin 40 mg daily, and Coumadin adjusted dose.,ALLERGIES: , ASPIRIN.,PERSONAL HISTORY:,  Married, ex-smoker, and does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY: , Hypertension, hyperlipidemia, atrial fibrillation chronic, on anticoagulation.,SURGICAL HISTORY: , As above.,PRESENTATION HISTORY: , Shortness of breath, weakness, fatigue, and tiredness.  The patient also relates history of questionable TIA in 1994.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  Weakness, fatigue, tiredness.,HEENT:  No history of cataracts, blurry vision or glaucoma.,CARDIOVASCULAR:  Arrhythmia, congestive heart failure, no coronary artery disease.,RESPIRATORY:  Shortness of breath.  No pneumonia or valley fever.,GASTROINTESTINAL:  Nausea, no vomiting, hematemesis, or melena.,UROLOGICAL:  Some frequency, urgency, no hematuria.,MUSCULOSKELETAL:  Arthritis, muscle weakness.,SKIN:  Chronic skin changes.,CNS:  History of TIA.  No CVA, no seizure disorder.,ENDOCRINE:  Nonsignificant.,HEMATOLOGICAL:  Nonsignificant.,PSYCHOLOGICAL:  No anxiety or depression.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 67, blood pressure 159/49, afebrile, and respiratory rate 18 per minute.,HEENT:  Atraumatic and normocephalic.,NECK:  Neck veins flat.  No significant carotid bruits.,LUNGS:  Air entry bilaterally fair, decreased in basal areas.  No rales or wheezes.,HEART:  PMI displaced.  S1 and S2 regular.,ABDOMEN:  Soft and nontender.  Bowel sounds present.,EXTREMITIES:  Chronic skin changes.  Pulses are palpable.  No clubbing or cyanosis.,CNS:  Grossly intact.,LABORATORY DATA: , H&H stable 30 and 39, INR of 1.86, BUN and creatinine within normal limits, potassium normal limits.  First set of cardiac enzymes profile negative.  BNP 4810.,Chest x-ray confirms unremarkable findings.  EKG reveals atrial fibrillation, nonspecific ST-T changes.,IMPRESSION:",
" A 5-month-old infant with cold, cough, and runny nose for 2 days.  Mom states she had no fever.  Her appetite was good but she was spitting up a lot.", Consult - History and Phy., Congestion & Cough - 5-month-Old ,"CHIEF COMPLAINT: , Congestion and cough.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 5-month-old infant who presented initially on Monday with a cold, cough, and runny nose for 2 days.  Mom states she had no fever.  Her appetite was good but she was spitting up a lot.  She had no difficulty breathing and her cough was described as dry and hacky.  At that time, physical exam showed a right TM, which was red.  Left TM was okay.  She was fairly congested but looked happy and playful.  She was started on Amoxil and Aldex and we told to recheck in 2 weeks to recheck her ear.  Mom returned to clinic again today because she got much worse overnight.  She was having difficulty breathing.  She was much more congested and her appetite had decreased significantly today.  She also spiked a temperature yesterday of 102.6 and always having trouble sleeping secondary to congestion.,ALLERGIES: , She has no known drug allergies.,MEDICATIONS:  ,None except the Amoxil and Aldex started on Monday.,PAST MEDICAL HISTORY:  ,Negative.,SOCIAL HISTORY: , She lives with mom, sister, and her grandparent.,BIRTH HISTORY: , She was born, normal spontaneous vaginal delivery at Woman's weighing 7 pounds 3 ounces.  No complications.  Prevented, she passed her hearing screen at birth.,IMMUNIZATIONS: , Also up-to-date.,PAST SURGICAL HISTORY: , Negative.,FAMILY HISTORY:  ,Noncontributory.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Her respiratory rate was approximately 60 to 65.,GENERAL:  She was very congested and she looked miserable.  She had no retractions at this time.,HEENT:  Her right TM was still red and irritated with no light reflex.  Her nasal discharge was thick and whitish yellow.  Her throat was clear.  Her extraocular muscles were intact.,NECK:  Supple.  Full range of motion.,CARDIOVASCULAR EXAM:  She was tachycardic without murmur.,LUNGS:  Revealed diffuse expiratory wheezing.,ABDOMEN:  Soft, nontender, and nondistended.,EXTREMITIES:  Showed no clubbing, cyanosis or edema.,LABORATORY DATA:  ,Her chem panel was normal.  RSV screen is positive.  Chest x-ray and CBC are currently pending.,IMPRESSION AND PLAN:  ,RSV bronchiolitis with otitis media.  Admit for oral Orapred, IV Rocephin, nebulizer treatments and oxygen as needed.",
 She is sent for evaluation of ocular manifestations of systemic connective tissue disorders.  Denies any eye problems and history includes myopia with astigmatism., Consult - History and Phy., Connective Tissue Disorder ,"Her past medical history includes a presumed diagnosis of connective tissue disorder.  She has otherwise, good health.  She underwent a shoulder ligament repair for joint laxity.,She does not take any eye medications and she takes Seasonale systemically.  She is allergic to penicillin.,The visual acuity today, distance with her current prescription was 20/30 on the right and 20/20 on the left eye.  Over refraction on the right eye showed -0.50 sphere with acuity of 20/20 OD.  She is wearing -3.75 +1.50 x 060 on the right and -2.50 +0.25 x 140, OS.  Intraocular pressures are 13 OU and by applanation.  Confrontation, visual fields, extraocular movement, and pupils are normal in both eyes.  Gonioscopy showed normal anterior segment angle morphology in both eyes.  She does have some fine iris strength crossing the angle, but the angle is otherwise open 360 degrees in both eyes.,The lids were normal in both eyes.  Conjunctivae were quite, OU.  Cornea were clear in both eyes.  The anterior chamber is deep and quiet, OU.  She has clear lenses, which are in good position, OU.  Dilated fundus exam shows moderately optically clear vitreous, OU.  The optic nerves are normal in size.  The cup-to-disc ratios were approximately 0.4, OU.  The nerve fiber layers are excellent, OU.  The macula, vessels, and periphery were normal in both eyes.  No evidence of peripheral retinal degeneration is present in either eye.,Ms. ABC has optically clear vitreous.  She does not have any obvious risk factors for retinal detachment at present such as peripheral retinal degeneration and her anterior chamber angles are normal in both eyes.,She does have moderate myopia, however.,This combination of findings suggests and is consistent with her systemic connective tissue disorder such as a Stickler syndrome or a variant of Stickler syndrome.,I discussed with her the symptoms of retinal detachment and advised her to contact us immediately if they occur.  Otherwise, I can see her in 1 to 2 years.","consult - history and phy., systemic connective tissue disorder, stickler syndrome, anterior chamber angles, retinal degeneration, connective tissue disorder, vitreous, degeneration, detachment, myopia, optically, astigmatism, eyes"
 A 2-month-old female with 1-week history of congestion and fever x2 days., Consult - History and Phy., Congestion & Fever - 2-month-old ,"CHIEF COMPLAINT:,  A 2-month-old female with 1-week history of congestion and fever x2 days.,HISTORY OF PRESENT ILLNESS:,  The patient is a previously healthy 2-month-old female, who has had a cough and congestion for the past week.  The mother has also reported irregular breathing, which she describes as being rapid breathing associated with retractions.  The mother states that the cough is at times paroxysmal and associated with posttussive emesis.  The patient has had short respiratory pauses following the coughing events.  The patient's temperature has ranged between 102 and 104.  She has had a decreased oral intake and decreased wet diapers.  The brother is also sick with URI symptoms, and the patient has had no diarrhea.  The mother reports that she has begun to regurgitate after her feedings.  She did not do this previously.,MEDICATIONS: , None.,SMOKING EXPOSURE: , None.,IMMUNIZATIONS: , None.,DIET:  ,Similac 4 ounces every 2 to 3 hours.,ALLERGIES:,  No known drug allergies.,PAST MEDICAL HISTORY:  ,The patient delivered at term.  Birth weight was 6 pounds 1 ounce.  Postnatal complications:  Neonatal Jaundice.  The patient remained in the hospital for 3 days.  The in utero ultrasounds were reported to be normal.,PRIOR HOSPITALIZATIONS: , None.,FAMILY/SOCIAL HISTORY: , Family history is positive for asthma and diabetes.  There is also positive family history of renal disease on the father's side of the family.,DEVELOPMENT: , Normal.  The patient tests normal on the newborn hearing screen.,REVIEW OF SYSTEMS:  GENERAL: , The patient has had fever, there have been no chills.  SKIN:  No rashes.  HEENT:  Mild congestion x1 week.  Cough, at times paroxysmal, no cyanosis.  The patient turns red in the face during coughing episodes, posttussive emesis.  CARDIOVASCULAR:  No cyanosis.  GI:  Posttussive emesis, decreased oral intake.  GU:  Decreased urinary output.  ORTHO:  No current issues.  NEUROLOGIC:  No change in mental status.  ENDOCRINE:  There is no history of weight loss.  DEVELOPMENT:  No loss of developmental milestones.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Weight is 4.8 kg, temperature 100.4, heart rate is 140, respiratory rate 30, and saturations 100%.,GENERAL:  This is a well-appearing infant in no acute distress.,HEENT:  Shows anterior fontanelle to be open and flat.  Pupils are equal and reactive to light with red reflex.  Nares are patent.  Oral mucosa is moist.  Posterior pharynx is clear.  Hard palate is intact.  Normal gingiva.,HEART:  Regular rate and rhythm without murmur.,LUNGS:  A few faint rales.  No retractions.  No stridor.  No wheezing on examination.  Mild tachypnea.,EXTREMITIES:  Warm, good perfusion.  No hip clicks.,NEUROLOGIC:  The patient is alert.  Normal tone throughout.  Deep tendon reflexes are 2+/4.  No clonus.,SKIN:  Normal.,LABORATORY DATA:,  CBC shows a white count of 12.4, hemoglobin 10.1, platelet count 611,000; 38 segs 3 bands, 42 lymphocytes, and 10 monocytes.  Electrolytes were within normal limits.  C-reactive protein 0.3.  Chest x-ray shows no acute disease with the exception of a small density located in the retrocardiac area on the posterior view.  UA shows 10 to 25 bacteria.,ASSESSMENT/PLAN:  ,This is a 2-month-old, who presents with fever, paroxysmal cough and episodes of respiratory distress.  The patient is currently stable in the emergency room.  We will admit the patient to the pediatric floor.  We will send out pertussis PCR.  We will also follow results of urine culture and that the urine dip shows 10 to 25 bacteria.  The patient will be followed up for signs of sepsis, apnea, urinary tract infection, and pneumonia.  We will wait for a radiology reading on the chest x-ray to determine if the density seen on the lateral film is a normal variant or represents pathology.",
 Abnormal EKG and rapid heart rate.  The patient came to the emergency room.  Initially showed atrial fibrillation with rapid ventricular response.  It appears that the patient has chronic atrial fibrillation.  She denies any specific chest pain.  Her main complaint is shortness of breath and symptoms as above., Consult - History and Phy., Consult - Abnormal EKG ,"REASON FOR CONSULTATION: , Abnormal EKG and rapid heart rate.,HISTORY OF PRESENT ILLNESS: , The patient is an 86-year-old female.  From the last few days, she is not feeling well, fatigue, tiredness, weakness, nausea, no vomiting, no hematemesis or melena.  The patient relates to have some low-grade fever.  The patient came to the emergency room.  Initially showed atrial fibrillation with rapid ventricular response.  It appears that the patient has chronic atrial fibrillation.  As per the medications, they are not very clear.  Husband has gone out to brief her medications.  She denies any specific chest pain.  Her main complaint is shortness of breath and symptoms as above.,CORONARY RISK FACTORS: , No hypertension or diabetes mellitus.  Nonsmoker.  Cholesterol status is normal.  Questionable history of coronary artery disease.  Family history noncontributory.,FAMILY HISTORY:,  Nonsignificant.,PAST SURGICAL HISTORY: , Questionable coronary artery bypass surgery versus valve replacement.,MEDICATIONS: , Unclear at this time, but she does take Coumadin.,ALLERGIES: , ASPIRIN.,PERSONAL HISTORY: , She is married, nonsmoker.  Does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY: , Symptoms as above, atrial fibrillation, history of open heart surgery, possible bypass surgery; however, after further query, husband relates that she may had just a valve surgery.,REVIEW OF SYSTEMS,CONSTITUTIONAL:  Weakness, fatigue, and tiredness.,HEENT:  No history of cataract, history of blurry vision and hearing impairment.,CARDIOVASCULAR:  Irregular heart rhythm with congestive heart failure, questionable coronary artery disease.,RESPIRATORY:  Shortness of breath, questionable pneumonia.  No valley fever.,GASTROINTESTINAL:  No nausea, no vomiting, hematemesis or melena.,UROLOGICAL:  No frequency or urgency.,MUSCULOSKELETAL:  Arthritis, muscle weakness.,CNS:  No TIA.  No CVA.  No seizure disorder.,SKIN:  Nonsignificant.,PSYCHOLOGIC:  Anxiety and depression.,ALLERGIES:  Nonsignificant except as mentioned above for medications.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse of 122, blood pressure 148/78, afebrile, and respiratory rate 18 per minute.,HEENT AND NECK:  Neck is supple.  Atraumatic and normocephalic.  Neck veins are flat.  No thyromegaly.,LUNGS:  Air entry bilaterally fair.  Decreased breath sounds especially in the right basilar areas.  Few crackles.,HEART:  Normal S1 and S2, irregular.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema.  Pulse is palpable.  No clubbing or cyanosis.,CNS:  Grossly intact.,MUSCULOSKELETAL:  Arthritic changes.,PSYCHOLOGICAL:  None significant.,DIAGNOSTIC DATA: , EKG, atrial fibrillation with rapid ventricular response, and nonspecific ST-T changes.  INR of 4.5, H and H 10 and 30.  BUN and creatinine are within normal limits.  Chest x-ray confirmed right lower lobe patchy infiltrate, and trace of pneumonia.,IMPRESSION:,1.  The patient is an 86-year-old female who has questionable bypass surgery, questionable valve surgery with a rapid atrial heart rate, chronic atrial fibrillation with rapid ventricular response, exacerbated by most likely underlying pneumonia by chest x-ray findings.,2.  Symptoms as above.,RECOMMENDATIONS:,1.  We will start her on a low dose of beta-blocker for rate control and antibiotic for pneumonia.  Once, if she is stable, we will consider further cardiac workup.,2.  We will also obtain an echocardiogram to assess valves such as whether she had a prior valve surgery versus coronary artery bypass surgery.",
 Routine colorectal cancer screening.  He occasionally gets some loose stools.  , Consult - History and Phy., Colon Cancer Screening ,"HISTORY AND REASON FOR CONSULTATION:, For evaluation of this patient for colon cancer screening.,HISTORY OF PRESENT ILLNESS:, Mr. A is a 53-year-old gentleman who was referred for colon cancer screening.  The patient said that he occasionally gets some loose stools.  Other than that, there are no other medical problems. ,PAST MEDICAL HISTORY:, The patient does not have any serious medical problems at all.  He denies any hypertension, diabetes, or any other problems.  He does not take any medications.,PAST SURGICAL HISTORY: ,Surgery for deviated nasal septum in 1996.,ALLERGIES:, No known drug allergies.,SOCIAL HISTORY: ,Does not smoke, but drinks occasionally for the last five years.,FAMILY HISTORY:, There is no history of any colon cancer in the family.,REVIEW OF SYSTEMS:, Denies any significant diarrhea.  Sometimes he gets some loose stools.  Occasionally there is some constipation.  Stools caliber has not changed.  There is no blood in stool or mucus in stool.  No weight loss.  Appetite is good.  No nausea, vomiting, or difficulty in swallowing.  Has occasional heartburn.,PHYSICAL EXAMINATION:, The patient is alert and oriented x3.  Vital signs: Weight is 214 pounds.  Blood pressure is 111/70.  Pulse is 69 per minute.  Respiratory rate is 18.  HEENT: Negative.  Neck: Supple.  There is no thyromegaly.  Cardiovascular: Both heart sounds are heard.  Rhythm is regular.  No murmur.  Lungs: Clear to percussion and auscultation.  Abdomen: Soft and nontender.  No masses felt.  Bowel sounds are heard.  Extremities: Free of any edema.,IMPRESSION: ,Routine colorectal cancer screening.,RECOMMENDATIONS:, Colonoscopy.  I have explained the procedure of colonoscopy with benefits and risks, in particular the risk of perforation, hemorrhage, and infection.  The patient agreed for it.  We will proceed with it.  I also explained to the patient about conscious sedation.  He agreed for conscious sedation.","consult - history and phy., colon cancer screening, loose stools, colorectal, colonoscopy,"
" Congestion, tactile temperature.", Consult - History and Phy., Congestion - 21-day-old ,"CHIEF COMPLAINT:,  Congestion, tactile temperature.,HISTORY OF PRESENT ILLNESS: , The patient is a 21-day-old Caucasian male here for 2 days of congestion - mom has been suctioning yellow discharge from the patient's nares, plus she has noticed some mild problems with his breathing while feeding (but negative for any perioral cyanosis or retractions).  One day ago, mom also noticed a tactile temperature and gave the patient Tylenol.,Baby also has had some decreased p.o. intake.  His normal breast-feeding is down from 20 minutes q.2h. to 5 to 10 minutes secondary to his respiratory congestion.  He sleeps well, but has been more tired and has been fussy over the past 2 days.  The parents noticed no improvement with albuterol treatments given in the ER.  His urine output has also decreased; normally he has 8 to 10 wet and 5 dirty diapers per 24 hours, now he has down to 4 wet diapers per 24 hours.  Mom denies any diarrhea.  His bowel movements are yellow colored and soft in nature.,The parents also noticed no rashes, just his normal neonatal acne.  The parents also deny any vomiting, apnea.,EMERGENCY ROOM COURSE: , In the ER, the patient received a lumbar puncture with CSF fluid sent off for culture and cell count.  This tap was reported as clear, then turning bloody in nature.  The patient also received labs including a urinalysis and urine culture, BMP, CBC, CRP, blood culture.  This patient also received as previously noted, 1 albuterol treatment, which did not help his respiratory status.  Finally, the patient received 1 dose of ampicillin and cefotaxime respectively each.,REVIEW OF SYSTEMS: , See above history of present illness.  Mom's nipples are currently cracked and bleeding.  Mom has also noticed some mild umbilical discharge as well as some mild discharge from the penile area.  He is status post a circumcision.  Otherwise, review of systems is negative.,BIRTH/PAST MEDICAL HISTORY: , The patient was an 8 pounds 13 ounces' term baby born 1 week early via a planned repeat C-section.  Mom denies any infections during pregnancy, except for thumb and toenail infections, treated with rubbing alcohol (mom denies any history of boils in the family).  GBS status was negative.  Mom smoked up to the last 5 months of the pregnancy.  Mom and dad both deny any sexually transmitted diseases or genital herpetic lesions.  Mom and baby were both discharged out of the hospital last 48 hours.  This patient has received no hospitalizations so far.,PAST SURGICAL HISTORY:,  Circumcision.,ALLERGIES: , No known drug allergies.,MEDICATIONS:,  Tylenol.,IMMUNIZATIONS:,  None of the family members this year have received a flu vaccine.,SOCIAL HISTORY:,  At home lives mom, dad, a 2-1/2-year-old brother, and a 5-1/2-year-old maternal stepbrother.  Both brothers at home are sick with cold symptoms including diarrhea and vomiting.  The brother (2-1/2-year-old) was seen in the ER tonight with this patient and discharged home with an albuterol prescription.  A nephew of the mom with an ear infection.  Mom also states that she herself was sick with the flu soon after delivery.  There has been recent travel exposure to dad's family over the Christmas holidays.  At this time, there is also exposure to indoor cats and dogs.  This patient also has positive smoking exposure coming from mom.,FAMILY HISTORY: , Paternal grandmother has diabetes and hypertension, paternal grandfather has emphysema and was a smoker.  There are no children needing the use of a pediatric subspecialist or any childhood deaths less than 1 year of age.,PHYSICAL EXAMINATION:  ,VITALS:  Temperature max is 99, heart rate was 133 to 177, blood pressure is 114/43 (while moving), respiratory rate was 28 to 56 with O2 saturations 97 to 100% on room air.  Weight was 4.1 kg.,GENERAL:  Not in acute distress, sneezing, positive congestion with breaths taken.,HEENT:  Normocephalic, atraumatic head.  Anterior fontanelle was soft, open, and flat.  Bilateral red reflexes were positive.  Oropharynx is clear with palate intact, negative rhinorrhea.,CARDIOVASCULAR:  Heart was regular rate and rhythm with a 2/6 systolic ejection murmur heard best at the upper left sternal border, vibratory in nature.  Capillary refill was less than 3 seconds.,LUNGS:  Positive upper airway congestion, transmitted sounds; negative retractions, nasal flaring, or wheezes.,ABDOMEN:  Bowel sounds are positive, nontender, soft, negative hepatosplenomegaly.  Umbilical site was with scant dried yellow discharge.,GU:  Tanner stage 1 male, circumcised.  There was mild hyperemia to the penis with some mild yellow dried discharge.,HIPS:  Negative Barlow or Ortolani maneuvers.,SKIN:  Positive facial erythema toxicum.,LABORATORY DATA: , CBC drawn showed a white blood cell count of 14.5 with a differential of 25 segmental cells, 5% bands, 54% lymphocytes.  The hemoglobin was 14.4, hematocrit was 40.  The platelet count was elevated at 698,000.  A CRP was less than 0.3.,A hemolyzed BMP sample showed a sodium of 139, potassium of 5.6, chloride 105, bicarb of 21, and BUN of 4, creatinine 0.4, and a glucose of 66.,A cath urinalysis was negative.,A CSF sample showed 0 white blood cells, 3200 red blood cells (again this was a bloody tap per ER personnel), CSF glucose was 41, CSF protein was 89.  A Gram stain showed rare white blood cells, many red blood cells, no organisms.,ASSESSMENT: , A 21-day-old with:,1.  Rule out sepsis.,2.  Possible upper respiratory infection.,Given the patient's multiple sick contacts, he is possibly with a viral upper respiratory infection causing his upper airway congestion plus probable fever.  The bacterial considerations although to consider in this child include group B streptococcus, E. coli, and Listeria.  We should also consider herpes simplex virus, although these 3200 red blood cells from his CSF could be due to his bloody tap in the ER.  Also, there is not a predominant lymphocytosis of his CSF sample (there is 0 white blood cell count in the cell count).,Also to consider in this child is RSV.  The patient though has more congested, nasal breathing more than respiratory distress, for example retractions, desaturations, or accessory muscle use.  Also, there is negative apnea in this patient.,PLAN:  ,1.  We will place this patient on the rule out sepsis pathway including IV antibiotics, ampicillin and gentamicin for at least 48 hours.,2.  We will follow up with his blood, urine, and CSF cultures.",
" Newly diagnosed stage II colon cancer, with a stage T3c, N0, M0 colon cancer, grade 1.  Although, the tumor was near obstructing, she was not having symptoms and in fact was having normal bowel movements.", Consult - History and Phy., Colon Cancer Consult ,"REASON FOR CONSULTATION: , I was asked by Dr. X to see the patient in consultation for a new diagnosis of colon cancer.,HISTORY OF PRESENT ILLNESS:,  The patient presented to medical attention after she noticed mild abdominal cramping in February 2007.  At that time, she was pregnant and was unsure if her symptoms might have been due to the pregnancy.  Unfortunately, she had miscarriage at about seven weeks.  She again had abdominal cramping, severe, in late March 2007.  She underwent colonoscopy on 04/30/2007 by Dr. Y.  Of note, she is with a family history of early colon cancers and had her first colonoscopy at age 35 and no polyps were seen at that time.,On colonoscopy, she was found to have a near-obstructing lesion at the splenic flexure.  She was not able to have the scope passed past this lesion.  Pathology showed a colon cancer, although I do not have a copy of that report at this time.,She had surgical resection done yesterday.  The surgery was laparoscopic assisted with anastomosis.  At the time of surgery, lymph nodes were palpable.,Pathology showed colon adenocarcinoma, low grade, measuring 3.8 x 1.7 cm, circumferential and invading in to the subserosal mucosa greater than 5 mm, 13 lymph nodes were negative for metastasis.  There was no angiolymphatic invasion noted.  Radial margin was 0.1 mm.  Other margins were 5 and 6 mm.  Testing for microsatellite instability is still pending.,Staging has already been done with a CT scan of the chest, abdomen, and pelvis.  This showed a mass at the splenic flexure, mildly enlarged lymph nodes there, and no evidence of metastasis to liver, lungs, or other organs.  The degenerative changes were noted at L5-S1.  The ovaries were normal.  An intrauterine device (IUD) was present in the uterus.,REVIEW OF SYSTEMS:,  She has otherwise been feeling well.  She has not had fevers, night sweats, or noticed lymphadenopathy.  She has not had cough, shortness of breath, back pain, bone pain, blood in her stool, melena, or change in stool caliber.  She was eating well up until the time of her surgery.  She is up-to-date on mammography, which will be due again in June.  She has no history of pulmonary, cardiac, renal, hepatic, thyroid, or central nervous system (CNS) disease.,ALLERGIES: , PENICILLIN, WHICH CAUSED HIVES WHEN SHE WAS A CHILD.,MEDICATIONS PRIOR TO ADMISSION:,  None.,PAST MEDICAL HISTORY: , No significant medical problem.  She has had three miscarriages, all of them at about seven weeks.  She has no prior surgeries.,SOCIAL HISTORY:  ,She smoked cigarettes socially while in her 20s.  A pack of cigarettes would last for more than a week.  She does not smoke now.  She has two glasses of wine per day, both red and white wine.  She is married and has no children.  An IUD was recently placed.  She works as an esthetician.,FAMILY HISTORY:  ,Father died of stage IV colon cancer at age 45.  This occurred when the patient was young and she is not sure of the rest of the paternal family history.  She does believe that aunts and uncles on that side may have died early.  Her brother died of pancreas cancer at age 44.  Another brother is aged 52 and he had polyps on colonoscopy a couple of years ago.  Otherwise, he has no medical problem.  Mother is aged 82 and healthy.  She was recently diagnosed with hemochromatosis.,PHYSICAL EXAMINATION: , ,GENERAL:  She is in no acute distress.,VITAL SIGNS:  The patient is afebrile with a pulse of 78, respirations 16, blood pressure 124/70, and pulse oximetry is 93% on 3 L of oxygen by nasal cannula.,SKIN:  Warm and dry.  She has no jaundice.,LYMPHATICS:  No cervical or supraclavicular lymph nodes are palpable.,LUNGS:  There is no respiratory distress.,CARDIAC:  Regular rate.,ABDOMEN:  Soft and mildly tender.  Dressings are clean and dry.,EXTREMITIES:  No peripheral edema is noted.  Sequential compression devices (SCDs) are in place.,LABORATORY DATA:,  White blood count of 11.7, hemoglobin 12.8, hematocrit 37.8, platelets 408, differential shows left shift, MCV is 99.6.  Sodium is 136, potassium 4.1, bicarb 25, chloride 104, BUN 5, creatinine 0.7, and glucose is 133.  Calcium is 8.8 and magnesium is 1.8.,IMPRESSION AND PLAN: , Newly diagnosed stage II colon cancer, with a stage T3c, N0, M0 colon cancer, grade 1.  She does not have high-risk factors such as high grade or angiolymphatic invasion, and adequate number of lymph nodes were sampled.  Although, the tumor was near obstructing, she was not having symptoms and in fact was having normal bowel movements.,A lengthy discussion was held with the patient regarding her diagnosis and prognosis.  Firstly, she has a good prognosis for being cured without adjuvant therapy.  I would consider her borderline for chemotherapy given her young age.  Referring to the database that had been online, she has a 13% chance of relapse in the next five years, and with aggressive chemotherapy (X-linked agammaglobulinemia (XLA) platinum-based), this would be reduced to an 8% risk of relapse with a 5% benefit.  Chemotherapy with 5-FU based regimen would have a smaller benefit of around 2.5%.,Plan was made to allow her to recuperate and then meet with her and her husband to discuss the pros and cons of adjuvant chemotherapy including what regimen she could consider including the side effects.  We did not review all that information today.,She has a family history of early colon cancer.  Her mother will be visiting in the weekend and plan is to obtain the rest of the paternal family history if we can.  Tumor is being tested for microsatellite instability and we will discuss this when those results are available.  She has one sibling and he is up-to-date on colonoscopy.  She does report multiple tubes of blood were drawn prior to her admission.  I will check with Dr. Y's office whether she has had a CEA and liver-associated enzymes assessed.  If not, those can be drawn tomorrow.",
 A woman presents for neurological evaluation with regards to a diagnosis of multiple sclerosis., Consult - History and Phy., Comprehensive Neurological Evaluation ,"As you know, the patient is a 50-year-old right-handed Caucasian female, who works as an independent contractor and as a human resources consultant.,Her neurological history first begins in December of 1987, when she had a rather sudden onset of slurred speech and the hesitancy when she started to walk.  She had HMO insurance at that time and saw a neurologist, whose name she does not recall.  She thinks that she underwent MRI scan of the brain and possibly visual evoked response and brainstem auditory evoked response tests.  She was told that all the tests were normal and no diagnosis was made.,The slurred speech resolved after a few weeks, but her gait hesitancy persisted for a number of years and then finally partially improved.  She also began to note that she would fatigue after very prolonged walking.,In about 1993, she developed bladder urgency and frequency along with some nocturia.  She saw a urologist and underwent urodynamic testing.  She was diagnosed as having ""overactive bladder"", but the cause of this was never determined.  She was treated with medications, possibly Ditropan, without much benefit.  She also developed a dry mouth from the medication and so she discontinued it.,Also in about 1993, she began to note an uncomfortable ""stiffness"" in her feet and slight swelling of the ankles.  Apparently, the swelling was not visible by others.  She saw multiple physicians and was told that it was ""not arthritis"", but no definite diagnosis was ever established.  She saw at least two rheumatologists on several occasions and blood tests were all normal.  No clear-cut diagnosis was ever made and the patient simply learned to live with these symptoms.,However, over time she noted that the symptoms in her legs seemed to worsen somewhat.  She states from time-to-time she could ""barely walk"".  She felt as if her balance is impaired and she felt as if she were ""walking on stilts"".  She tried arch supports from a podiatrist without any benefit.  She began to tire more easily when walking.,In 2002 she was seen by a podiatrist, who noticed an abnormal gait and recommended that she see a neurologist.,In the fall of 2002, she was seen by Dr. X.  He ordered an MRI scan of her brain and lumbar spine.  He also did some sort of nerve testing and possibly visual evoked response testing.  After reviewing everything, he diagnosed multiple sclerosis.  However, prior to starting her on immunomodulatory therapy, he referred her for a second opinion to Dr. Y, in January of 2003.  Dr. Y confirmed the diagnosis of multiple sclerosis.,The patient then returned to Dr. X and was started on Avonex.  She continued on it for about six months.  However, it made her feel much more stiff and delayed and so she finally stopped it.  She also recalled being tried on baclofen by Dr. X, but again it did not benefit her and made her feel slightly dizzy.  So, she discontinued it also.,At that point in time, she decided to try a program of ""good nutrition, vitamin supplements, and fish oil"".,In December 2004 and extending up to February 2005, she began to note progressively more severe swelling and stiffness in the distal lower extremities.  She began to have to use a cane.  She was seen in neurological consultation by Dr. Z.  She was treated with a Medrol Dosepak.  Her spasticity and swelling seemed to improve dramatically.  However, within about two weeks symptoms were back to baseline.,She was then treated with intravenous Solu-Medrol 500 mg daily for five days followed by a prednisone or Medrol taper (July 2005).  This seemed to be less helpful than the oral steroids, but was partially beneficial.  However, it wore off once again.,A repeat MRI scan of the brain in April 2005 was said to ""look better"".  She was started on Zanaflex for her lower extremity spasticity without benefit.,Finally six days ago, she was restarted on oral prednisone 10 mg tablets.  She takes one-half tablet daily and this again has seemed to reduce the swelling and stiffness in her legs.  She continues on the prednisone in the same dosage for relief of the spasticity.,She has not been on any other immunomodulatory agents.,The patient does note some complaints of mild heat sensitivity and mild easy fatigability.  There is no history of diplopia, dysarthria, aphasia, focal weakness, numbness, paresthesias, cognitive dysfunction, or memory dysfunction.,PAST MEDICAL HISTORY: , Essentially noncontributory.,ALLERGIES:,  The patient is allergic to LOBSTER and VICODIN.  She feels that she is probably allergic to IODINE.,SOCIAL HISTORY:,  She does not smoke.  She takes one glass of wine per day.,PAST SURGICAL HISTORY: , She has not had any prior surgeries.  Her general health has been excellent except for the above-indicated problems.,REVIEW OF OUTSIDE RADIOLOGICAL STUDIES:,  The patient brought with her today MRI scans of the brain, thoracic spine, and lumbosacral spine performed on 11/14/02 on a 1.5-Tesla magnet.  There are numerous T2 hyperintense lesions in the periventricular and subcortical white matter of the brain and at least one lesion is in the corpus callosum.  There appear to be Dawson's fingers.  The MRI of the thoracic and lumbosacral spines did not reveal any significant abnormalities.,Also available are the MRI scans of the brain, cervical spine, thoracic spine, and lumbosacral spine performed on a 0.35-Tesla magnet on 04/22/05.  The MRI of the brain shows that one of the prior lesions has resolved and there appear to be one or two more lesions.,However, the quality of the newer scan is only 0.35-Tesla and is suboptimal.  Visualization of the cord is also suboptimal, but there are no clear-cut extraaxial or complexities of the spinal cord.  It is difficult to be certain that there are no intra-axial lesions, but I could not clearly see one.,PHYSICAL EXAMINATION:,Vital signs:  Blood pressure 151/88, pulse 92, temperature 99.5ºF, and weight 124 lb (dressed).,General:  Well-developed, well-nourished female in no acute distress.,Head:  Normocephalic, without evidence of trauma or bruits.,Neck:  Supple, with full range of motion.  No spasm or tenderness.  Carotid pulsations are of normal volume and contour bilaterally without bruits.  No thyromegaly or adenopathy.,Extremities:  No clubbing, cyanosis, edema, or deformity.  Range of motion full throughout.,NEUROLOGICAL EXAMINATION:,Mental Status:  Awake, alert, oriented to time, place, and person; appropriate.  Recent and remote memory intact.  No evidence of right-left confusion, finger agnosia, dysnomia or aphasia.,CRANIAL NERVES,:,II:  Visual fields full to confrontation.  Fundi benign.,III, IV, VI:  Extraocular movements full throughout, without nystagmus.  No ptosis.  Pupils equal, round and react briskly to light and accommodation.,V:  Normal sensation to light touch and pinprick bilaterally.  Corneal reflexes equal bilaterally.  Motor function normal.,VII:  No facial asymmetry.,VIII:  Hears finger rub bilaterally.  Weber and Rinne tests normal.,IX & X:  Palate elevates symmetrically bilaterally with phonation.  Gag reflex equal bilaterally.,XI:  Sternocleidomastoid and upper trapezius normal tone, bulk and strength bilaterally.,XII:  Tongue midline without atrophy or fasciculations.  Rapid alternating movements normal.  No dysarthria.,Motor:  Tone, bulk, and strength are normal in both upper extremities.  In the lower extremities, there is moderate spasticity on the right and moderately severe spasticity on the left.  There are bilateral Achilles' contractures more so on the left than the right and also a slight left knee flexion contracture.,Strength in the lower extremities is rated as follows on a 5-point scale (right/left):  Iliopsoas 4+/5-, quadriceps 5-/5-, tibialis anterior 4+/4+, and gastrocnemius 5/5.  There are no tremors, fasciculations or abnormal involuntary movements.",
 Genetic counseling for a strong family history of colon polyps.  She has had colonoscopies required every five years and every time she has polyps were found.  She reports that of her 11 brothers and sister 7 have had precancerous polyps.  , Consult - History and Phy., Colon Polyps - Genetic Counseling ,"REASON FOR CONSULT: , Genetic counseling.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 61-year-old female with a strong family history of colon polyps.  The patient reports her first polyps noted at the age of 50.  She has had colonoscopies required every five years and every time she has polyps were found.  She reports that of her 11 brothers and sister 7 have had precancerous polyps.  She does have an identical twice who is the one of the 11 who has never had a history of polyps.  She also has history of several malignancies in the family.  Her father died of a brain tumor at the age of 81.  There is no history of knowing whether this was a primary brain tumor or whether it is a metastatic brain involvement.  Her sister died at the age of 65 breast cancer.  She has two maternal aunts with history of lung cancer both of whom were smoker.  Also a paternal grandmother who was diagnosed with breast cancer at 86 and a paternal grandfather who had lung cancer.  There is no other cancer history.,PAST MEDICAL HISTORY:,  Significant for asthma.,CURRENT MEDICATIONS: , Include Serevent two puffs daily and Nasonex two sprays daily.,ALLERGIES: , Include penicillin.  She is also allergic seafood; crab and mobster.,SOCIAL HISTORY: , The patient is married.  She was born and raised in South Dakota.  She moved to Colorado 37 years ago.  She attended collage at the Colorado University.  She is certified public account.  She does not smoke.  She drinks socially.,REVIEW OF SYSTEMS:  ,The patient denies any dark stool or blood in her stool.  She has had occasional night sweats and shortness of breath, and cough associated with her asthma.  She also complains of some acid reflux as well as anxiety.  She does report having knee surgery for torn ACL on the left knee and has some arthritis in that knee.  The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:","consult - history and phy., family history, strong family history, precancerous polyps, brain tumor, lung cancer, genetic counseling, colon polyps, polyps, "
" Delivered pregnancy, cholestasis of pregnancy, fetal intolerance to labor, failure to progress.  Primary low transverse cesarean section.", Consult - History and Phy., Cholestasis Of Pregnancy  ,"FINAL DIAGNOSES:,  Delivered pregnancy, cholestasis of pregnancy, fetal intolerance to labor, failure to progress.,PROCEDURE: , Included primary low transverse cesarean section.,SUMMARY: , This 32-year-old gravida 2 was induced for cholestasis of pregnancy at 38-1/2 weeks.  The patient underwent a 2-day induction.  On the second day, the patient continued to progress all the way to the point of 9.5 cm at which point, she failed to progress.  During the hour or two of evaluation at 9.5 cm, the patient was also noted to have some fetal tachycardia and an occasional late deceleration.  Secondary to these factors, the patient was brought to the operative suite for primary low transverse cesarean section, which she underwent without significant complication.  There was a slightly enlarged blood loss at approximately 1200 mL, and postoperatively, the patient was noted to have a very mild tachycardia coupled with 100.3 degrees Fahrenheit temperature right at delivery.  It was felt that this was a sign of very early chorioamnionitis and therapeutic antibiotics were given throughout her stay.  The patient received 72 hours of antibiotics with there never being a temperature above 100.3 degrees Fahrenheit.  The maternal tachycardia resolved within a day.  The patient did well throughout the 3-day stay progressing to full diet, regular bowel movements, normal urination patterns.  The patient did receive 2 units of packed red cells on Sunday when attended to by my partner secondary to a hematocrit of 20%.  It should be noted, however, that this was actually an expected result with the initial hematocrit of 32% preoperatively.  Therefore, there was anemia but not an unexplained anemia.,PHYSICAL EXAMINATION ON DISCHARGE: , Includes the stable vital signs, afebrile state.  An alert and oriented patient who is desirous at discharge.  Full range of motion, all extremities; fully ambulatory.  Pulse is regular and strong.  Lungs are clear and the abdomen is soft and nontender with minimal tympany and a nontender fundus.  The incision is beautiful and soft and nontender.  There is scant lochia and there is minimal edema.,LABORATORY STUDIES: , Include hematocrit of 27% and the last liver function tests was within normal limits 48 hours prior to discharge.,FOLLOWUP: , For the patient includes pelvic rest, regular diet.  Follow up with me in 1 to 2 weeks.  Motrin 800 mg p.o. q.8h. p.r.n. cramps, Tylenol No.  3 one p.o. q.4h. p.r.n. pain, prenatal vitamin one p.o. daily, and topical triple antibiotic to incision b.i.d. to q.i.d.","consult - history and phy., delivered pregnancy, fetal intolerance, induction, pelvic rest, low transverse cesarean section, cholestasis of pregnancy, cesarean section, pregnancy, fetal, tachycardia, cholestasis"
" Clogged AV shunt.  The patient complains of fatigue, nausea, vomiting and fever.", Consult - History and Phy., Clogged AV Shunt - Consult ,"REASON FOR CONSULTATION: , Clogged AV shunt.,HISTORY OF PRESENT ILLNESS:,  This is a 32-year-old African-American male who came to ABCD General Hospital with the above chief complaint.  The patient complains of fatigue, nausea, vomiting and fever.  The patient states that the shunt was placed in February, although according to medical records it was placed in April and it has been periodically clogging since its placement.  The patient had dialysis today, which is Saturday, for approximately one hour before the shunt no longer worked.  The patient had been seen in the Emergency Room yesterday, 08/29/03, by Dr. X for the same problem.  At that time, Dr. X felt that the patient should use the AV fistula during dialysis and after the fistula is able to be used, the PermCath on the right subclavian should be removed.  As mentioned above, he had dialysis today and they were unable to use AV fistula as well as the PermCath read ""did not work"".  The patient has had dialysis since January secondary to hypertension-induced renal failure.  He takes dialysis Monday, Wednesday, and Friday at the ABCD Dialysis Center.  He also was seen at XYZ and he had an apparent thrombectomy with reversal done a few days ago.  The patient's history at this point is a little sketchy; however, he states that he left AMA.  All other systems are reviewed and are negative.,PAST MEDICAL HISTORY: , Significant for heart attack, chronic renal failure with dialysis, CHF, hypertension, and PermCath.,PAST SURGICAL HISTORY: , AV fistula on the left arm and a PermCath.,ALLERGIES: , Penicillin.,MEDICATIONS: , Include metoprolol 100 mg two tablets b.i.d., Tylenol #3, Accupril 20 mg q.d., digoxin, Renocaps, aspirin, and Combivent.,SOCIAL HISTORY: , Half pack of tobacco x3 years.  No alcohol, occasional marijuana, and no IV drug use.  He lives alone, single and no children.,PHYSICAL EXAMINATION: , Vital signs:  In Emergency Room, temperature 98.2, pulse 83, respirations 20, blood pressure 146/84 and 99% on room air.  General:  This is an alert and oriented African-American male x3 and in no acute distress.  The patient is extremely lethargic and had to be aroused multiple times to answer questions.  Mucous membranes are moist.  HEENT:  Head is normocephalic and atraumatic.  There is no scleral icterus noted.  Pupils are equal, round, and reactive to light.  Extraocular muscles are intact.  Cardiovascular:  Shows a heart rate that is regular with a laterally displaced point of maximum intensity.  There is no murmur, gallop, or rub noted.  Lungs:  Clear to auscultation bilaterally.  No wheeze, rhonchi or rales.  Abdomen:  Soft, nontender and nondistended.  Bowel sounds are present.  Extremities:  Show left forearm with an incision that is well healed from a left AV fistula.  There is a distal thrill palpable and there is some tenderness over the incisional area.  There is no erythema or pus noted.  Other extremities show peripheral pulses present and no edema.,LABORATORY VALUES: , Sodium 139, potassium 3.9, chloride 92, CO2 33, BUN 36, creatinine 9.2, and glucose 131.  Digoxin 0.6, white count is 5.8, hemoglobin 11.7, hematocrit 34.9 and platelets are 252.,IMPRESSION:,1.  Nonfunctional AV fistula.,2.  End-stage renal disease.,3.  Hypertension.,4.  Status post MI.,5.  Clogged PermCath.,PLAN:,1.  Give the patient TPA to the shunt, PermCath in both feet.,2.  To board for Tuesday for shunt repair if needed.,3.  To dialyze as soon as possible.,4.  To review previous operative report.,5.  The patient will be contacted in the morning and told whether to go to dialysis or not.",
" A 14-month-old with history of chronic recurrent episodes of otitis media, totalling 6 bouts, requiring antibiotics since birth. ", Consult - History and Phy., Chronic Otitis Media ,"CHIEF COMPLAINT:,  Chronic otitis media.,HISTORY OF PRESENT ILLNESS:,  This is a 14-month-old with history of chronic recurrent episodes of otitis media, totalling 6 bouts, requiring antibiotics since birth.  There is also associated chronic nasal congestion.  There had been no bouts of spontaneous tympanic membrane perforation, but there had been elevations of temperature up to 102 during the acute infection.  He is being admitted at this time for myringotomy and tube insertion under general facemask anesthesia.,ALLERGIES:,  None.,MEDICATIONS:,  None.,FAMILY HISTORY:,  Noncontributory.,MEDICAL HISTORY: , Mild reflux.,PREVIOUS SURGERIES:,  None.,SOCIAL HISTORY: , The patient is not in daycare.  There are no pets in the home.  There is no secondhand tobacco exposure.,PHYSICAL EXAMINATION: , Examination of ears reveals retracted poorly mobile tympanic membranes on the right side with a middle ear effusion present.  Left ear is still little bit black.  Nose, moderate inferior turbinate hypertrophy.  No polyps or purulence.  Oral cavity, oropharynx 2+ tonsils.  No exudates.  Neck, no nodes, masses or thyromegaly.  Lungs are clear to A&P.  Cardiac exam, regular rate and rhythm.  No murmurs.  Abdomen is soft and nontender.  Positive bowel sounds.,IMPRESSION: , Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, and wax accumulation.,PLAN:,  The patient will be admitted to the operating room for myringotomy and tube insertion under general facemask anesthesia.","consult - history and phy., chronic nasal congestion, tympanic membrane perforation, chronic otitis media, tube insertion, facemask anesthesia, otitis media, otitis, media,"
 Newly diagnosed cholangiocarcinoma.  The patient is noted to have an increase in her liver function tests on routine blood work.  Ultrasound of the abdomen showed gallbladder sludge and gallbladder findings consistent with adenomyomatosis. , Consult - History and Phy., Cholangiocarcinoma Consult ,"REASON FOR CONSULTATION:,  Newly diagnosed cholangiocarcinoma.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 77-year-old female who is noted to have an increase in her liver function tests on routine blood work in December 2009.  Ultrasound of the abdomen showed gallbladder sludge and gallbladder findings consistent with adenomyomatosis.  Common bile duct was noted to be 10 mm in size on that ultrasound.  She then underwent a CT scan of the abdomen in July 2010, which showed intrahepatic ductal dilatation with the common bile duct size being 12.7 mm.  She then underwent an MRI MRCP, which was notable for stricture of the distal common bile duct.  She was then referred to gastroenterology and underwent an ERCP.  On August 24, 2010, she underwent the endoscopic retrograde cholangiopancreatography.  She was noted to have a stricturing mass of the mid-to-proximal common bile duct consistent with cholangiocarcinoma.  A temporary biliary stent was placed across the biliary stricture.  Blood work was obtained during the hospitalization.  She was also noted to have an elevated CA99.  She comes in to clinic today for initial Medical Oncology consultation.  After she sees me this morning, she has a follow-up consultation with a surgeon.,PAST MEDICAL HISTORY:  ,Significant for hypertension and hyperlipidemia.  In July, she had eye surgery on her left eye for a muscle repair.  Other surgeries include left ankle surgery for a fractured ankle in 2000.,CURRENT MEDICATIONS: , Diovan 80/12.5 mg daily, Lipitor 10 mg daily, Lutein 20 mg daily, folic acid 0.8 mg daily and multivitamin daily.,ALLERGIES:  ,No known drug allergies.,FAMILY HISTORY: , Notable for heart disease.  She had three brothers that died of complications from open heart surgery.  Her parents and brothers all had hypertension.  Her younger brother died at the age of 18 of infection from a butcher's shop.  He was cutting Argentinean beef and contracted an infection and died within 24 hours.  She has one brother that is living who has angina and a sister who is 84 with dementia.  She has two adult sons who are in good health.,SOCIAL HISTORY: , The patient has been married to her second husband for the past ten years.  Her first husband died in 1995.  She does not have a smoking history and does not drink alcohol.,REVIEW OF SYSTEMS:  ,The patient reports a change in her bowels ever since she had the stent placed.  She has noted some weight loss, but she notes that that is due to not eating very well.  She has had some mild fatigue, but prior to her diagnosis she had absolutely no symptoms.  As mentioned above, she was noted to have abnormal alkaline phosphatase and total bilirubin, AST and ALT, which prompted the followup.  She has had some difficulty with her vision that has improved with her recent surgical procedure.  She denies any fevers, chills, night sweats.  She has had loose stools.  The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:", 
" Lump in the chest wall.   Probably an old fracture of the area with callus formation, need to rule out the possibility of a tumor. ", Consult - History and Phy., Chest Wall Lump - Consult ,"CHIEF COMPLAINT:,  Lump in the chest wall.,HISTORY OF PRESENT ILLNESS: , This is a 56-year-old white male who has been complaining of having had a lump in the chest for the past year or so and it has been getting larger and tender according to the patient.  It is tender on palpation and also he feels like, when he takes a deep breath also, it hurts.,CHRONIC/INACTIVE CONDITIONS,1.  Hypertension.,2.  Hyperlipidemia.,3.  Glucose intolerance.,4.  Chronic obstructive pulmonary disease?,5.  Tobacco abuse.,6.  History of anal fistula.,ILLNESSES:,  See above.,PREVIOUS OPERATIONS: , Anal fistulectomy, incision and drainage of perirectal abscess, hand surgery, colonoscopy, arm nerve surgery, and back surgery.,PREVIOUS INJURIES: , He had a broken ankle in the past.  They questioned the patient who is a truck driver whether he has had an auto accident in the past, he said that he has not had anything major.  He said he bumped his head once, but not his chest, although he told the nurse that a car fell on his chest that is six years ago.  He told me that he hit a moose once, but he does not remember hitting his chest.,ALLERGIES: , TO BACTRIM, SIMVASTATIN, AND CIPRO.,CURRENT MEDICATIONS,1.  Lisinopril.,2.  Metoprolol.,3.  Vitamin B12.,4.  Baby aspirin.,5.  Gemfibrozil.,6.  Felodipine.,7.  Levitra.,8.  Pravastatin.,FAMILY HISTORY: , Positive for hypertension, diabetes, and cancer.  Negative for heart disease, obesity or stroke.,SOCIAL HISTORY:  ,The patient is married.  He works as a truck driver and he drives in town.  He smokes two packs a day and he has two beers a day he says, but not consuming illegal drugs.,REVIEW OF SYSTEMS,CONSTITUTIONAL:  Denies weight loss/gain, fever or chills.,ENMT:  Denies headaches, nosebleeds, voice changes, blurry vision or changes in/loss of vision.,CV:  See history of present illness.  Denies chest pain, SOB supine, palpitations, edema, varicose veins or leg pains.,RESPIRATORY:  He has a chronic cough.  Denies shortness of breath, wheezing, sputum production or bloody sputum.,GI:  Denies heartburn, blood in stools, loss of appetite, abdominal pain or constipation.,GU:  Denies painful/burning urination, cloudy/dark urine, flank pain or groin pain.,MS:  Denies joint pain/stiffness, backaches, tendon/ligaments/muscle pains/strains, bone aches/pains or muscle weakness.,NEURO:  Denies blackouts, seizures, loss of memory, hallucinations, weakness, numbness, tremors or paralysis.,PSYCH:  Denies anxiety, irritability, apathy, depression, sleep disturbances, appetite disturbances or suicidal thoughts.,INTEGUMENTARY:  Denies unusual hair loss/breakage, skin lesions/discoloration or unusual nail breakage/discoloration.,PHYSICAL EXAMINATION,CONSTITUTIONAL:  Blood pressure 140/84, pulse rate 100, respiratory rate 20, temperature 97.2, height 5 feet 10 inches, and weight 218 pounds.  The patient is well developed, well nourished, and with fair attention to grooming.  The patient is moderately overweight.,NECK:  The neck is symmetric, the trachea is in the midline, and there are no masses.  No crepitus is palpated.  The thyroid is palpable, not enlarged, smooth, moves with swallowing, and has no palpable masses.,RESPIRATION:  Normal respiratory effort.  There is no intercostal retraction or action by the accessory muscles.  Normal breath sounds bilaterally with no rhonchi, wheezing or rubs.  There is a localized 2-cm diameter hard mass in relationship to the costosternal cartilages in the lower most position in the left side, just adjacent to the sternum.,CARDIOVASCULAR:  The PMI is palpable at the 5ICS in the MCL.  No thrills on palpation.  S1 and S2 are easily audible.  No audible S3, S4, murmur, click, or rub.  Carotid pulses 2+ without bruits.  Abdominal aorta is not palpable.  No audible abdominal bruits.  Femoral pulses are 2+ bilaterally, without audible bruits.  Extremities show no edema or varicosities.",
 A routine return appointment for a 71-year-old woman with chronic atrial fibrillation.  Chief complaint today is shortness of breath., Consult - History and Phy., Chronic Atrial Fibrillation ,"REASON FOR VISIT:,  This is a routine return appointment for this 71-year-old woman with chronic atrial fibrillation.  Her chief complaint today is shortness of breath.,HISTORY OF PRESENT ILLNESS:,  I last saw her in 09/2008.  Since then, she has been admitted to ABCD Hospital from 11/05/2008 through 11/08/2008 for a near syncopal episode.  She was found to have a fast heart rate in the atrial fibrillation.  She was also found to be in heart failure and so they diuresed her.  They wanted to send her home on furosemide 40 mg daily, but unfortunately they never gave her a prescription for this and so she now is not on any furosemide and since being discharged she has regained fluid to no one's great surprise.  My plan advent is to control her heart rate.  This has been a bit difficult with her retaining fluid.  We will try again to diurese her as an outpatient and go forward from there with rate control and anticoagulation.  She may need to have a pacemaker placed and her AV node ablated if this does not work.,She notes the shortness of breath and wheezing at nights.  I think these are manifestations of heart failure.  She has peripheral edema.  She is short of breath when she tries to walk a city block.  I believe she takes her medications as directed, but I am never sure she actually is taking them correctly.  In any case, she did not bring her medications with her today.,Today, she had an ECG which shows atrial fibrillation with a ventricular response of 117 beats per minute.  There is a nonspecific IVCD.  This is unchanged from her last visit except that her heart rate is faster.  In addition, I reviewed her echocardiogram done at XYZ.  Her ejection fraction is 50% and she has paradoxical septal motion.  Her right ventricular systolic pressure is normal.  There are no significant valvular abnormalities.,MEDICATIONS:  ,1.  Fosamax - 70 mg weekly.,2.  Lisinopril - 20 mg daily.,3.  Metformin - 850 mg daily.,4.  Amlodipine - 5 mg daily.,5.  Metoprolol - 150 mg twice daily.,6.  Warfarin - 5 mg daily.,7.  Furosemide - none.,8.  Potassium - none.,9.  Magnesium oxide - 200 mg daily.,ALLERGIES: , Denied.,MAJOR FINDINGS:,  On my comprehensive cardiovascular examination, she again looks the same which is in heart failure.  Her blood pressure today was 130/60 and her pulse 116 blood pressure and regular.  She is 5 feet 11 inches and her weight is 167 pounds, which is up from 158 pounds from when I saw her last visit.  She is breathing 1two times per minute and it is unlabored.  Eyelids are normal.  She has vitiligo.  Pupils are round and reactive to light.  Conjunctivae are clear and sclerae are anicteric.  There is no oral thrush or central cyanosis.  She has marked keloid formation on both sides of her neck, the left being worse than the right.  The jugular venous pressure is elevated.  Carotids are brisk are without bruits.  Lungs are clear to auscultation and percussion.  The precordium is quiet.  The rhythm is irregularly irregular.  She has a variable first and second heart sounds.  No murmurs today.  Abdomen is soft without hepatosplenomegaly or masses, although she does have hepatojugular reflux.  She has no clubbing or cyanosis, but does have 1+ peripheral edema.  Distal pulses are good.  On neurological examination, her mentation is normal.  Her mood and affect are normal.  She is oriented to person, place, and time.,ASSESSMENTS: , She has chronic atrial fibrillation and heart failure now.,PROBLEMS DIAGNOSES:  ,1.  Chronic atrial fibrillation, anticoagulated and the plan is rate control.,2.  Heart failure and she needs more diuretic.,3.  High blood pressure controlled.,4.  Hyperlipidemia.,5.  Diabetes mellitus type 2.,6.  Nonspecific intraventricular conduction delay.,7.  History of alcohol abuse.,8.  Osteoporosis.,9.  Normal left ventricular function.,PROCEDURES AND IMMUNIZATIONS: , None today.,PLANS: , I have restarted her Lasix at 80 mg daily and I have asked her to return in about 10 days to the heart failure clinic.  There, I would like them to recheck her heart rate and if still elevated, and she is truly on 150 mg of metoprolol twice a day, one could switch her amlodipine from 5 mg daily to diltiazem 120 mg daily.  If this does not work, in terms of controlling her heart rate, then she will need to have a pacemaker and her AV node ablated.,Thank you for asking me to participate in her care.,MEDICATION CHANGES: , See the above.",
 Patient with palpitations and rcent worsening of chronic chest discomfort., Consult - History and Phy., Chest discomfort & palpitations - Consult. ,"CHIEF COMPLAINT:, Palpitations.,CHEST PAIN / UNSPECIFIED ANGINA PECTORIS HISTORY:, The patient relates the recent worsening of chronic chest discomfort. The quality of the pain is sharp and the problem started 2 years ago. Pain radiates to the back and condition is best described as severe. Patient denies syncope. Beyond baseline at present time. Past work up has included 24 hour Holter monitoring and echocardiography. Holter showed PVCs.,PALPITATIONS HISTORY:, Palpitations - frequent, 2 x per week. No caffeine, no ETOH. + stress. No change with Inderal.,VALVULAR DISEASE HISTORY:, Patient has documented mitral valve prolapse on echocardiography in 1992.,PAST MEDICAL HISTORY:, No significant past medical problems. Mitral Valve Prolapse.,FAMILY MEDICAL HISTORY:, CAD.,OB-GYN HISTORY:, The patients last child birth was 1997. Para 3. Gravida 3.,SOCIAL HISTORY:, Denies using caffeinated beverages, alcohol or the use of any tobacco products.,ALLERGIES:, No known drug allergies/Intolerances.,CURRENT MEDICATIONS:, Inderal 20 prn.,REVIEW OF SYSTEMS:, Generally healthy. The patient is a good historian.,ROS Head and Eyes: Denies vision changes, light sensitivity, blurred vision, or double vision.,ROS Ear, Nose and Throat: The patient denies any ear, nose or throat symptoms.,ROS Respiratory: Patient denies any respiratory complaints, such as cough, shortness of breath, chest pain, wheezing, hemoptysis, etc.,ROS Gastrointestinal: Patient denies any gastrointestinal symptoms, such as anorexia, weight loss, dysphagia, nausea, vomiting, abdominal pain, abdominal distention, altered bowel movements, diarrhea, constipation, rectal bleeding, hematochezia.,ROS Genitourinary: Patient denies any genito-urinary complaints, such as hematuria, dysuria, frequency, urgency, hesitancy, nocturia, incontinence.,ROS Gynecological: Denies any gynecological complaints, such as vaginal bleeding, discharge, pain, etc.,ROS Musculoskeletal: The patient denies any past or present problems related to the musculoskeletal system.,ROS Extremities: The patient denies any extremities complaints.,ROS Cardiovascular: As per HPI.,EXAMINATION:,Exam Abdomen/Flank: The abdomen is soft without tenderness or palpable masses. No guarding, rigidity or rebound tenderness. The liver and spleen are not palpable. Bowel sounds are active and normal.,Exam Extremities: Lower extremities are normal in color, touch and temperature. No ischemic changes are noted.,Range of motion is normal. There is no cyanosis, clubbing or edema.,General: Healthy appearing, well developed,. The patient is in no acute distress.,Exam Skin Negative to inspection or palpation. There are no obvious lesions or new rashes noted. Non-diaphoretic.,Exam Ears Canals are clear. Throat is not injected. Tonsils are not swollen or injected.,Exam Neck: There is no thyromegaly, carotid bruits, lymphadenopathy, or JVD. Neck is supple.,Exam Respiratory: Normal breath sounds are heard bilaterally. There is no wheezing. There is no use of accessory muscles.,Exam Cardiovascular: Regular heart rate and rhythm, Normal S1 and S2 without murmur, gallops or rubs.,IMPRESSION / DIAGNOSIS:, Mitral Valve Prolapse. Palpitations.,TESTS ORDERED:, Cardiac tests: Echocardiogram.,MEDICATION PRESCRIBED:, ,Cardizem 30-60 qid prn.",
" This is a 48-year-old black male with stage IV chronic kidney disease likely secondary to HIV nephropathy, although there is no history of renal biopsy, who has been noncompliant with the Renal Clinic and presents today for followup at the recommendation of his Infection Disease doctors.", Consult - History and Phy., Chronic Kidney Disease - Consult ,"HISTORY OF PRESENT ILLNESS: , This is a 48-year-old black male with stage IV chronic kidney disease, likely secondary to HIV nephropathy who presents to clinic for followup having missed prior clinic appointments.  He was last seen in this clinic on 05/29/2007 by Dr. X.  This is the first time that I have met the patient.  The patient's history of renal insufficiency dates back to 06/2006 when he was hospitalized for an HIV-associated complication.  He is unclear of the exact reason for his hospitalization at that time, but he was diagnosed with renal insufficiency and was followed in our Renal Clinic for approximately one year.  He had a baseline creatinine during that time of between 3.2 to 3.3.  When he was initially diagnosed with renal insufficiency, he had been noncompliant with his HAART regimen.  Since that time, he has been very compliant with treatment for his HIV and is seeing Dr. Y in our Infectious Disease Clinic.  He is currently on three-drug antiretroviral therapy.  His last CD4 count in 03/2008 was 350.  He has had no HIV complications since he was last seen in our clinic.  The patient is also followed by Dr. Z at the outpatient VA Clinic, here in ABCD, although he has not seen her in approximately one year.  The patient has an AV fistula that was placed in late 2006.  The latest blood work that I have is from 06/11/2008 and shows a serum creatinine of 3.8, which represents a GFR of 22 and a potassium of 5.9.  These laboratories were drawn by his infectious disease doctor and the results prompted their recommendation for him to return to our clinic for further evaluation.  The only complaint that the patient has at this time is some difficulty sleeping.  He was given Ambien by his primary care doctor, but this has not helped significantly with his difficulty sleeping.  He says that he has trouble getting to sleep.  The Ambien will allow him to sleep for about two hours, and then he is awake again.  He is tired during the day, but is not taking any daytime naps.  He has no history of excessive snoring or apneic periods.  He has no history of falling asleep at work or while driving.  He has never had a formal sleep study.  He does continue to work in sales at a local butcher shop.,REVIEW OF SYSTEMS:  ,He denies any change in his appetite.  He has actually gained some weight in recent months.  He denies any nausea, vomiting, or abdominal discomfort.  He denies any pruritus.  He denies any lower extremity edema.  All other systems are reviewed and negative.,PAST MEDICAL HISTORY:,1.  Stage IV chronic kidney disease with most recent GFR of 22.,2.  HIV diagnosed in 09/2006 with the most recent CD4 count of 350 in 03/2008.,3.  Hyperlipidemia.,4.  Hypertension.,5.  Secondary hyperparathyroidism.,6.  Status post right upper extremity AV fistula in the fall of 2006.,7.  History of a right brachial plexus palsy.,8.  Recent lower back pain, status post lumbar steroid injection.,ALLERGIES:,  HE SAYS THAT VITAMIN D HAS CAUSED HEADACHES.,MEDICATIONS:,1.  Kaletra daily.,2.  Epivir one daily.,3.  Ziagen two daily.,4.  Lasix 20 mg b.i.d.,5.  Valsartan 20 mg b.i.d.,6.  Ambien 10 mg q.h.s.,SOCIAL HISTORY: , He lives here in ABCD.  He is employed at the sales counter of a local butcher shop.  He continues to smoke one pack of cigarettes daily, as he has for the past 28 years.  He denies any alcohol or illicit substances.,FAMILY HISTORY:,  His mother is deceased.  He said that she had some type of paralysis before she died.  His father is deceased at age 64 of a head and neck cancer.  He has a 56-year-old brother with type-two diabetes and blindness secondary to diabetic retinopathy.  He has a 41-year-old brother who has hypertension.  He has a sister who has thyroid disease.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Weight is 191 pounds.  His temperature is 97.1.  Pulse is 94.  Blood pressure by automatic cuff 173/97, by manual cuff 180/90.,HEENT:  His oropharynx is clear without thrush or ulceration.,NECK:  Supple without lymphadenopathy or thyromegaly.,HEART:  Regular with normal S1 and S2.  There are no murmurs, rubs, or gallops.  He has no JVD.,LUNGS:  Clear to auscultation bilaterally without wheezes, rhonchi, or crackles.,ABDOMEN:  Soft, nontender, nondistended, without abdominal bruit or organomegaly.,MUSCULOSKELETAL:  He has difficulty with abduction of his right shoulder.,ACCESS:  He has a right forearm AV fistula with an audible bruit and a palpable thrill.  There is no sign of stenosis.  The vascular access looks like it is ready to use.,EXTREMITIES:  No peripheral edema.,SKIN:  No bruises, petechiae, or rash.,LABS:  ,Sodium was 140, potassium 5.9, chloride 114, bicarbonate 18.  BUN is 49, creatinine 4.3.  GFR is 19.  Albumin 3.2.  Protein 7.  AST 17, ALT 16, alkaline phosphatase 106.  Total bilirubin 0.4.  Calcium 9.1., phosphorus 4.7, PTH of 448.  The corrected calcium was 9.7.  WBC is 8.9, hemoglobin 13.4, platelet 226.  Total cholesterol 234, triglycerides 140, LDL 159, HDL 47.  His ferritin is 258, iron is 55, and percent sat is 24.,IMPRESSION:  ,This is a 48-year-old black male with stage IV chronic kidney disease likely secondary to HIV nephropathy, although there is no history of renal biopsy, who has been noncompliant with the Renal Clinic and presents today for followup at the recommendation of his Infection Disease doctors.,RECOMMENDATIONS:,1.  Renal.  His serum creatinine is progressively worsening.  His creatinine was 3.2 the last time we saw him in 05/2007 and today is 4.3.  This represents a GFR of 19.  This is stage IV chronic kidney disease.  He does have vascular access and this appears to be ready to use.  He is having some difficulty sleeping and it is possible that this represents some early signs of uremia.  Otherwise, he has no signs or symptoms of uremia at this time.  I am going to touch base with the dialysis educator and try to get The patient in to the dialysis teaching classes.  He has already received some literature for the dialysis teaching, but has not yet enrolled in the classes.  I have encouraged him to continue to exercise his right forearm.  I am also going to contact the transplant coordinator and see if he can be evaluated for possible transplant.  Given his progression of his chronic kidney disease, I will anticipate that he will need to start dialysis soon.,2.  Hypertension.  I have added labetolol 100 mg b.i.d. to his antihypertensive regimen.  He shows no signs at this point of volume overload, although if he does demonstrate this in the future, his Lasix could be increased.  Goal blood pressure would be less than 130/80.,3.  Hyperkalemia.  I am going to instruct him in a low-potassium diet and decrease his valsartan to 20 mg daily.  I will have him return in one week to recheck his potassium.  If his potassium continues to remain elevated, he may require initiation of dialysis for this.,4.  Bone metabolism.  His PTH is elevated and I am going to add PhosLo 800 mg t.i.d. with meals.  His corrected calcium is 9.7, and I would like to avoid calcium-containing phosphate bonders in this situation.,5.  Acid base.  His bicarbonate is 18 and I will initiate the sodium bicarbonate 650 mg three tablets t.i.d.,6.  Anemia.  His hemoglobin is at goal for this stage of chronic kidney disease.  His iron stores are adequate.",
" Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.", Consult - History and Phy., Chronic Sinusitis ,"HISTORY:,  I had the pleasure of meeting and evaluating the patient referred today for evaluation and treatment of chronic sinusitis.  As you are well aware, she is a pleasant 50-year-old female who states she started having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.  She states she really has sinus problems, but this infection has been rather severe and she notes she has not had much improvement with antibiotics.  She had a CT of her paranasal sinuses identifying mild mucosal thickening of right paranasal sinuses with occlusion of the ostiomeatal complex on the right and turbinate hypertrophy was also noted when I reviewed the films and there is some minimal nasal septum deviation to the left.  She currently is not taking any medication for her sinuses.  She also has noted that she is having some problems with her balance and possible hearing loss or at least ear popping and fullness.  Her audiogram today demonstrated mild high frequency sensorineural hearing loss, normal tympanometry, and normal speech discrimination.  She has tried topical nasal corticosteroid therapy without much improvement.  She tried Allegra without much improvement and she believes the Allegra may have caused problems with balance to worsen.  She notes her dizziness to be much worse if she does quick positional changes such as head turning or sudden movements, no ear fullness, pressure, humming, buzzing or roaring noted in her ears.  She denies any previous history of sinus surgery or nasal injury.  She believes she has some degree of allergy symptoms.,PAST MEDICAL HISTORY:  ,Seasonal allergies, possible food allergies, chronic sinusitis, hypertension and history of weight change.  She is currently 180 pounds.,PAST SURGICAL HISTORY:,  Lower extremity vein stripping, tonsillectomy and adenoidectomy.,FAMILY HISTORY: , Strong for heart disease and alcoholism.,CURRENT MEDICATIONS: , DynaCirc.,ALLERGIES: , Egg-based products cause hives.,SOCIAL HISTORY:  ,The patient used to smoke cigarettes for about 20 years, one-half pack a day.  She currently does not, which was encouraged to continue.  She rarely drinks any alcohol-containing beverages.,PHYSICAL EXAMINATION: ,VITAL SIGNS:  Age 50, blood pressure is 136/74, pulse 84, temperature is 98.4, weight is 180 pounds, and height is 5 feet 3 inches.,GENERAL:  The patient is healthy appearing; alert and oriented to person, place and time; responds appropriately; in no acute distress.,HEAD:  Normocephalic.  No masses or lesions noted.,FACE:  No facial tenderness or asymmetry noted.,EYES:  Pupils are equal, round and reactive to light and accommodation bilaterally.  Extraocular movements are intact bilaterally.  No nystagmus.,EARS:  During Hallpike examination, the patient did not become dizzy until she would be placed back into sitting in the upright position.  No nystagmus was appreciated; however, the patient did subjectively report dizziness, which was repeated twice.  No evidence of any orthostatic hypotension was noted during the exam.  Tympanic membranes were noted to be intact.  No signs of middle ear effusion or ear canal inflammation.,NOSE:  The patient appears congested.  Turbinate hypertrophy is noted.  There are no signs of any acute sinusitis.  Septum is midline, slightly deviated to the left.,THROAT:  There is clear postnasal drip.  Oral hygiene is good.  No masses or lesions noted.  Both vocal cords move well to midline.,NECK:  The neck is supple with no adenopathy or masses palpated.  The trachea is midline.  The thyroid gland is of normal size with no nodules.,LUNGS:  Clear to auscultation bilaterally.  No wheeze noted.,HEART:  Regular rate and rhythm.  No murmur noted.,NEUROLOGIC:  Facial nerve is intact bilaterally.  The remaining cranial nerves are intact without focal deficit.,PROCEDURE: , Fiberoptic nasopharyngoscopy identifying turbinate hypertrophy and nasal septum deviation to the left, more significant posteriorly.,IMPRESSION:  ,1.  Probable increasing problems with allergic rhinitis and chronic sinusitis, both contributing to the patient's symptoms.,2.  Subjective dizziness, etiology uncertain; however, consider positional vertigo versus vestibular neuronitis as possible ear causes of dizziness, cannot rule out systemic, central or medication or causes at this time.,3.  Inferior turbinate hypertrophy.,4.  Nasal septum deformity.,RECOMMENDATIONS:,  An ENG was ordered to evaluate vestibular function.  She was placed on Veramyst nasal spray two sprays each nostril daily and even twice daily if symptoms are worsening.  A Medrol Dosepak was prescribed as directed.  The patient was given instruction on use of nasal saline irrigation to be used twice daily and Clarinex 5 mg daily was recommended.  After the patients' ENG examination, we will see the patient back for further evaluation and treatment recommendations.  In light of the patient's atypical dizziness symptoms, I cannot rule out other pathology at this time, and I informed her if there are any acute changes or problems with regards to her balance or any other acute changes, which she attributes associated with her dizziness, she most likely should pursue an emergent visit to the emergency room.,Thank you for allowing me to participate with the care of your patient.",
" Chest pain, possible syncopal spells.  She has been having multiple cardiovascular complaints including chest pains, which feel like cramps and sometimes like a dull ache, which will last all day long.", Consult - History and Phy., Chest Pain - Cardiac Consult ,"REASON FOR REFERRAL:,  Chest pain, possible syncopal spells.,She is a very pleasant 31-year-old mother of two children with ADD.,She was doing okay until January of 2009 when she had a partial hysterectomy.  Since then she just says ""things have changed"".  She just does not want to go out anymore and just does not feel the same.  Also, at the same time, she is having a lot of household stressors with both of her children having ADD and ODD and she feels she does not get enough support from her husband.  Her 11-year-old is having a lot of trouble at school and she often has to go there to take care of problems.,In this setting, she has been having multiple cardiovascular complaints including chest pains, which feel ""like cramps"" and sometimes like a dull ache, which will last all day long.  She is also tender in the left breast area and gets numbness in her left hand.  She has also had three spells of ""falling"", she is not really clear on whether these are syncopal, but they sound like they could be as she sees spots before her eyes.  Twice it happened, when getting up quickly at night and another time in the grocery store.  She suffered no trauma.  She has no remote history of syncope.  Her weight has not changed in the past year.,MEDICATIONS: , Naprosyn, which she takes up to six a day.,ALLERGIES:,  Sulfa.,SOCIAL HISTORY: , She does not smoke or drink.  She is married with two children.,REVIEW OF SYSTEMS:,  Otherwise unremarkable.,PEX:,  BP:  130/70 without orthostatic changes.  PR:  72.  WT:  206 pounds.  She is a healthy young woman.  No JVD.  No carotid bruit.  No thyromegaly.  Cardiac:  Regular rate and rhythm.  There is no significant murmur, gallop, or rub.  Chest:  Mildly tender in the upper pectoral areas bilaterally (breast exam was not performed).  Lungs:  Clear.  Abdomen:  Soft.  Moderately overweight.  Extremities:  No edema and good distal pulses.,EKG: , Normal sinus rhythm, normal EKG.,ECHOCARDIOGRAM (FOR SYNCOPE): , Essentially normal study.,IMPRESSION:,1.  Syncopal spells - These do sound, in fact, to be syncopal.  I suspect it is simple orthostasis/vasovagal, as her EKG and echocardiogram looks good.  I have asked her to drink plenty of fluids and to not to get up suddenly at night.  I think this should take care of the problem.  I would not recommend further workup unless these spells continue, at which time I would recommend a tilt-table study.,2.  Chest pains - Atypical for cardiac etiology, undoubtedly due to musculoskeletal factors from her emotional stressors.  The Naprosyn is not helping that much, I gave her a prescription for Flexeril and instructed her in its use (not to drive after taking it).,RECOMMENDATIONS:,1.  Reassurance that her cardiac checkup looks excellent, which it does.,2.  Drink plenty of fluids and arise slowly from bed.,3.  Flexeril 10 mg q 6 p.r.n.,4.  I have asked her to return should the syncopal spells continue.","consult - history and phy., chest pain, syncopal, echocardiogram, ekg, cardiac etiology, syncopal spells, rhythm, flexeril, cardiac, chest, "
" Cervical spondylosis and kyphotic deformity.  She had a nerve conduction study and a diagnosis of radiculopathy was made.  She had an MRI of lumbosacral spine, which was within normal limits.  She then developed a tingling sensation in the right middle toe. ", Consult - History and Phy., Cervical Spondylosis - Neuro Consult ,"REASON FOR NEUROLOGICAL CONSULTATION: , Cervical spondylosis and kyphotic deformity.  The patient was seen in conjunction with medical resident Dr. X. I personally obtained the history, performed examination, and generated the impression and plan.,HISTORY OF PRESENT ILLNESS: ,The patient is a 45-year-old African-American female whose symptoms first started some one and a half years ago with pain in the left shoulder and some neck pain.  This has subsequently resolved.  She started vigorous workouts in November 2005.  In March of this year, she suddenly could not feel her right foot on the bathroom floor and subsequently went to her primary care physician.  By her report, she had a nerve conduction study and a diagnosis of radiculopathy was made.  She had an MRI of lumbosacral spine, which was within normal limits.  She then developed a tingling sensation in the right middle toe.  Symptoms progressed to sensory symptoms of her knees, elbows, and left middle toe.  She then started getting sensory sensations in the left hand and arm.  She states that she feels a little bit wobbly at the knees and that she is slightly dragging her left leg.  Symptoms have been mildly progressive.  She is unaware of any trigger other than the vigorous workouts as mentioned above.  She has no associated bowel or bladder symptoms.  No particular position relieves her symptoms.,Workup has included two MRIs of the C-spine, which were personally reviewed and are discussed below.  She saw you for consultation and the possibility of surgical decompression was raised.  At this time, she is somewhat reluctant to go through any surgical procedure.,PAST MEDICAL HISTORY:,1.  Ocular migraines.,2.  Myomectomy.,3.  Infertility.,4.  Hyperglycemia.,5.  Asthma.,6.  Hypercholesterolemia.,MEDICATIONS: , Lipitor, Pulmicort, Allegra, Xopenex, Patanol, Duac topical gel, Loprox cream, and Rhinocort.,ALLERGIES: , Penicillin and aspirin.,Family history, social history, and review of systems are discussed above as well as documented in the new patient information sheet.  Of note, she does not drink or smoke.  She is married with two adopted children.  She is a paralegal specialist.  She used to exercise vigorously, but of late has been advised to stop exercising and is currently only walking.,REVIEW OF SYSTEMS: , She does complain of mild blurred vision, but these have occurred before and seem associated with headaches.,PHYSICAL EXAMINATION: , On examination, blood pressure 138/82, pulse 90, respiratory rate 14, and weight 176.5 pounds.  Pain scale is 0.  A full general and neurological examination was personally performed and is documented on the chart.  Of note, she has a normal general examination.  Neurological examination reveals normal cognition and cranial nerve examination including normal jaw jerk.  She has mild postural tremor in both arms.  She has mild decreased sensation in the right palm and mild decreased light touch in the right palm and decreased vibration sense in both distal lower extremities.  Motor examination reveals no weakness to individual muscle testing, but on gait she does have a very subtle left hemiparesis.  She has hyperreflexia in her lower extremities, worse on the left.  Babinski's are downgoing.,PERTINENT DATA:  ,MRI of the brain from 05/02/06 and MRI of the C-spine from 05/02/06 and 07/25/06 were personally reviewed.  MRI of the brain is broadly within normal limits.  MRI of the C-spine reveals large central disc herniation at C6-C7 with evidence of mild cord compression and abnormal signal in the cord suggesting cord edema.  There is also a fairly large disc at C3-C4 with cord deformity and partial effacement of the subarachnoid space.  I do not appreciate any cord edema at this level.,IMPRESSION AND PLAN:  ,The patient is a 45-year-old female with cervical spondylosis with a large C6-C7 herniated disc with mild cord compression and signal change at that level.  She has a small disc at C3-C4 with less severe and only subtle cord compression.  History and examination are consistent with signs of a myelopathy.,Results were discussed with the patient and her mother.  I am concerned about progressive symptoms.  Although she only has subtle symptoms now, we made her aware that with progression of this process, she may have paralysis.  If she is involved in any type of trauma to the neck such as motor vehicle accident, she could have an acute paralysis.  I strongly recommended to her and her mother that she followup with you as soon as possible for surgical evaluation.  I agree with the previous physicians who have told her not to exercise as I am sure that her vigorous workouts and weight training since November 2005 have contributed to this problem.  I have recommended that she wear a hard collar while driving.  The results of my consultation were discussed with you telephonically.","consult - history and phy., kyphotic, cervical, radiculopathy, myelopathy, kyphotic deformity, cord compression, cervical spondylosis, toe, spondylosis, cord, "
" Cardiomyopathy and hypotension.  A lady with dementia, coronary artery disease, prior bypass, reduced LV function, and recurrent admissions for diarrhea and hypotension several times.", Consult - History and Phy., Cardiomyopathy & Hypotension - Consult ,"REASON FOR CONSULTATION:,  Cardiomyopathy and hypotension.,HISTORY OF PRESENT ILLNESS:,  I am seeing the patient upon the request of Dr. X.  The patient is very well known to me, an 81-year-old lady with dementia, a native American with coronary artery disease with prior bypass, reduced LV function, recurrent admissions for diarrhea and hypotension several times in November and was admitted yesterday because of having diarrhea with hypotension and acute renal insufficiency secondary to that.  Because of her pre-existing coronary artery disease and cardiomyopathy with EF of about 30%, we were consulted to evaluate the patient.  The patient denies any chest pain or chest pressure.  Denies any palpitations.  No bleeding difficulty.  No dizzy spells.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No fever or chills.,EYES:  No visual disturbances.,ENT:  No difficulty swallowing.,CARDIOVASCULAR:  Basically, no angina or chest pressure.  No palpitations.,RESPIRATORY:  No wheezes.,GI:  No abdominal pain, although she had diarrhea.,GU:  No specific symptoms.,MUSCULOSKELETAL:  Have sores on the back.,NEUROLOGIC:  Have dementia.,All other systems are otherwise unremarkable as far as the patient can give me information.,PAST MEDICAL HISTORY:,1.  Positive for coronary artery disease for about two to three years.,2.  Hypertension.,3.  Anemia.,4.  Chronic renal insufficiency.,5.  Congestive heart failure with EF of 25% to 30%.,6.  Osteoporosis.,7.  Compression fractures.,8.  Diabetes mellitus.,9.  Hypothyroidism.,PAST SURGICAL HISTORY:,1.  Coronary artery bypass grafting x3 in 2008.,2.  Cholecystectomy.,3.  Amputation of the right second toe.,4.  ICD implantation.,CURRENT MEDICATIONS AT HOME:,1.  Amoxicillin.,2.  Clavulanic acid or Augmentin every 12 hours.,3.  Clopidogrel 75 mg daily.,4.  Simvastatin 20 mg daily.,5.  Sodium bicarbonate 650 mg twice daily.,6.  Gabapentin 300 mg.,7.  Levothyroxine once daily.,8.  Digoxin 125 mcg daily.,9.  Fenofibrate 145 mg daily.,10.  Aspirin 81 mg daily.,11.  Raloxifene once daily.,12.  Calcium carbonate and alendronate.,13.  Metoprolol 25 mg daily.,14.  Brimonidine ophthalmic once daily.,ALLERGIES: , She has no known allergies.,FAMILY HISTORY: ",
" The patient has a previous history of aortic valve disease, status post aortic valve replacement, a previous history of paroxysmal atrial fibrillation, congestive heart failure, a previous history of transient ischemic attack with no residual neurologic deficits.", Consult - History and Phy., Cardiac Consultation - 7 ,"HISTORY OF PRESENT ILLNESS: , The patient is a 41-year-old African-American male previously well known to me.  He has a previous history of aortic valve disease, status post aortic valve replacement on 10/15/2007, for which he has been on chronic anticoagulation.  There is a previous history of paroxysmal atrial fibrillation and congestive heart failure, both of which have been stable prior to this admission.  He has a previous history of transient ischemic attack with no residual neurologic deficits.,The patient has undergone surgery by Dr. X for attempted nephrolithotomy.  The patient has experienced significant postoperative bleeding, for which it has been necessary to discontinue all anticoagulation.  The patient is presently seen at the request of Dr. X for management of anticoagulation and his above heart disease.,PAST MEDICAL AND SURGICAL HISTORY:,1.  Type I diabetes mellitus.,2.  Hyperlipidemia.,3.  Hypertension.,4.  Morbid obesity.,5.  Sleep apnea syndrome.,6.  Status post thyroidectomy for thyroid carcinoma.,REVIEW OF SYSTEMS:,General:  Unremarkable.,Cardiopulmonary:  No chest pain, shortness of breath, palpitations, or dizziness.,Gastrointestinal:  Unremarkable.,Genitourinary:  See above.,Musculoskeletal:  Unremarkable.,Neurologic:  Unremarkable.,FAMILY HISTORY: , There are no family members with coronary artery disease.  His mother has congestive heart failure.,SOCIAL HISTORY:  ,The patient is married.  He lives with his wife.  He is employed as a barber.  He does not use alcohol, tobacco, or illicit drugs.,MEDICATIONS PRIOR TO ADMISSION:,1.  Clonidine 0.3 mg b.i.d.,2.  Atenolol 50 mg daily.,3.  Simvastatin 80 mg daily.,4.  Furosemide 40 mg daily.,5.  Metformin 1000 mg b.i.d.,6.  Hydralazine 25 mg t.i.d.,7.  Diovan 320 mg daily.,8.  Lisinopril 40 mg daily.,9.  Amlodipine 10 mg daily.,10.  Lantus insulin 50 units q.p.m.,11.  KCl 20 mEq daily.,12.  NovoLog sliding scale insulin coverage.,13.  Warfarin 7.5 mg daily.,14.  Levothyroxine 0.2 mg daily.,15.  Folic acid 1 mg daily.,ALLERGIES: , None.,PHYSICAL EXAMINATION:,General:  A well-appearing, obese black male.,Vital Signs:  BP 140/80, HR 88, respirations 16, and afebrile.,HEENT:  Grossly normal.,Neck:  Normal.  Thyroid, normal.  Carotid, normal upstroke, no bruits.,Chest:  Midline sternotomy scar.,Lungs:  Clear.,Heart:  PMI fifth intercostal space mid clavicular line.  Normal S1 and prosthetic S2.  No murmur, rub, gallop, or click.,Abdomen:  Soft and nontender.  No palpable mass or hepatosplenomegaly.",
 Patient reports a six to eight-week history of balance problems with later fatigue and weakness., Consult - History and Phy., Cervical Cord Lesion - Consult ,"HISTORY OF PRESENT ILLNESS:, This is a 58-year-old male who reports a six to eight-week history of balance problems with fatigue and weakness. He has had several falls recently. He apparently had pneumonia 10 days prior to the onset of the symptoms. He took a course of amoxicillin for this. He complained of increased symptoms with more and more difficulty with coordination. He fell at some point near the onset of the symptoms, but believes that his symptoms had occurred first. He fell from three to five feet and landed on his back. He began seeing a chiropractor approximately five days ago and had adjustments of the neck and lumbar spine, although he clearly had symptoms prior to this.,He has had mid and low back pain intermittently. He took a 10-day course of Cipro believing that he had a UTI. He denies, however, any bowel or bladder problems. There is no incontinence and he does not feel that he is having any difficulty voiding.,PAST SURGICAL HISTORY:, He has a history of surgery on the left kidney, when it was ""rebuilt."" He has had knee surgery, appendectomy and right inguinal hernia repair.,MEDICATIONS:, His only home medications had been Cipro and Aleve. However, he does take aspirin and several over the counter supplements including a multivitamin with iron, ""natural"" potassium, Starlix and the aspirin.,ALLERGIES:, HE HAS NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY:, He smokes one-and-one-half-packs of cigarettes per day and drinks alcohol at least several days per week. He is employed in sales, which requires quite a bit of walking, but he is not doing any lifting. He had been a golfer in the past.,PAST MEDICAL HISTORY:, He has had documented cervical spondylosis, apparently with an evaluation over 15 years ago.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 156/101, pulse was 88, respirations 18. He is afebrile.,MENTAL STATUS: He is alert.,CRANIAL NERVES: His pupils were reactive to light. He had a dense left cataract present. The right disk margin appears sharp. His eye movements were full. The face was symmetric. Pain and temperature sensation were intact over both sides of the face. The tongue was midline.,NECK: His neck was supple.,MUSCULOSKELETAL: He has intact strength and normal tone in the upper extremities. He had increased tone in both lower extremities. He had hip flexion of 4/5 on the left. He had intact strength on the right lower extremity, although had slight hammertoe deformity bilaterally.,NEUROLOGIC: His reflexes were 2+ in the upper extremities, 3+ at the knees and 1+ at the ankles. He withdrew to plantar stimulation on the left, but did not have a Babinski response clearly present. He had intact finger-to-nose testing. Marked impairment in heel-to-shin testing. He was able to sit unassisted. He stood with assistance, but had a markedly ataxic gait. On sensory exam, he had a slight distal gradient to pin and vibratory sense in both lower extremities, but also had a decrease in sensation to pin over the right lower extremity compared to the left.,CARDIOVASCULAR: He had no carotid bruits. His heart rhythm was regular.,BACK: There was no focal back pain present. He did have a slight sensory level at the upper T spine at approximately T3, both anteriorly and posteriorly.,RADIOLOGIC DATA:, MRI by my view showed essentially unremarkable T spine. The MRI of his C spine showed significant spondylosis in the mid and lower C spine with spondylolisthesis at C7-T1. There is an abnormal signal in the cord which begins at approximately this level, but descends approximately 2 cm. There is slight enhancement at the mid-portion of the lesion. This appears to be an intrinsic lesion to the cord, not clearly associated with mild to moderate spinal stenosis at the level of the spondylolisthesis.,LABORATORY: ,His initial labs were unremarkable.,IMPRESSION: ,Cervical cord lesion at the C7 to T2 level of unclear etiology. Consider a transverse myelitis, tumor, contusion or ischemic lesion.,PLAN:, Will check labs including sedimentation rate, MRI of the brain, chest x-ray. He will probably need a lumbar puncture. He also appears to have a mild peripheral neuropathy, which I suspect is an independent problem. We will request labs for this.",
" Patient with right-sided chest pain, borderline elevated high blood pressure, history of hyperlipidemia, and obesity.", Consult - History and Phy., Cardiac Consultation - 4 ,"REASON FOR CONSULTATION:,  Cardiac evaluation.,HISTORY: , This is a 42-year old Caucasian male with no previous history of hypertension, diabetes mellitus, rheumatic fever, rheumatic heart disease, or gout.  Patient used to take medicine for hyperlipidemia and then that was stopped.  He used to live in Canada and he moved to Houston four months ago.  He started complaining of right-sided upper chest pain, starts at the right neck and goes down to the right side.  It lasts around 10-15 minutes at times.  It is 5/10 in quality.  It is not associated with shortness of breath, nausea, vomiting, or sweating.  It is not also associated with food.  He denies exertional chest pain, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, or pedal edema.  No palpitations, syncope or presyncope.  He said he has been having little cough at night and he went to see an allergy doctor who prescribed several medications for him and told him that he has asthma.  No fever, chills, cough, hemoptysis, hematemesis or hematochezia.  His EKG shows normal sinus rhythm, normal EKG.,PAST MEDICAL HISTORY:,  Unremarkable, except for hyperlipidemia.,SOCIAL HISTORY: , He said he quit smoking 20 years ago and does not drink alcohol.,FAMILY HISTORY: , Positive for high blood pressure and heart disease.  His father died in his 50s with an acute myocardial infarction.,MEDICATION:,  Ranitidine 300 mg daily, Flonase 50 mcg nasal spray as needed, Allegra 100 mg daily, Advair 500/50 bid.,ALLERGIES:,  No known allergies.,REVIEW OF SYSTEMS:,  As mentioned above,EXAMINATION:,  This is a 42-year old male awake, alert, and oriented x3 in no acute distress.,Wt:  238",
" To evaluate exercise-induced chest pain, palpitations, dizzy spells, shortness of breath, and abnormal EKG.", Consult - History and Phy., Cardiac Consultation - 2 ,"CHIEF REASON FOR CONSULTATION:,  Evaluate exercise-induced chest pain, palpitations, dizzy spells, shortness of breath, and abnormal EKG.,HISTORY OF PRESENT ILLNESS:,  This 72-year-old female had a spell of palpitations that lasted for about five to ten minutes.  During this time, patient felt extremely short of breath and dizzy.  Palpitations lasted for about five to ten minutes without any recurrence.  Patient also gives history of having tightness in the chest after she walks briskly up to a block.  Chest tightness starts in the retrosternal area with radiation across the chest.  Chest tightness does not radiate to the root of the neck or to the shoulder, lasts anywhere from five to ten minutes, and is relieved with rest.  Patient gives history of having hypertension for the last two months.  Patient denies having diabetes mellitus, history suggestive of previous myocardial infarction, or cerebrovascular accident.,MEDICATIONS: , ,1.  Astelin nasal spray.,2.  Evista 60 mg daily.,3.  Lopressor 25 mg daily.,4.  Patient was given a sample of Diovan 80 mg daily for the control of hypertension from my office.,PAST HISTORY:,  The patient underwent right foot surgery and C-section.,FAMILY HISTORY:,  The patient is married, has six children who are doing fine.  Father died of a stroke many years ago.  Mother had arthritis.,SOCIAL HISTORY:, The patient does not smoke or take any drinks.  ,ALLERGIES:,  THE PATIENT IS NOT ALLERGIC TO ANY MEDICATIONS.,REVIEW OF SYSTEMS:,  Otherwise negative.  ,PHYSICAL EXAMINATION: , ,GENERAL:  Well-built, well-nourished white female in no acute distress. ,VITAL SIGNS:  Blood pressure is 160/80.  Respirations 18 per minute.  Heart rate 70 beats per minute.  Patient weighs 133 pounds, height 64 inches.  BMI is 22.,HEENT:  Head normocephalic.  Eyes, no evidence of anemia or jaundice.  Oral hygiene is good.,NECK:  Supple.  No cervical lymphadenopathy. Carotid upstroke is good. No bruit heard over the carotid or subclavian arteries.  Trachea in midline. Thyroid not enlarged.  JVP flat at 45°.,CHEST:  Chest is symmetrical on both sides, moves well with respirations.  Vesicular breath sounds heard over the lung fields.  No wheezing, crepitation, or pleural friction rub heard.  ,CARDIOVASCULAR SYSTEM:  PMI felt in fifth left intercostal space within midclavicular line. First and second heart sounds are normal in character.  There is a II/VI systolic murmur best heard at the apex.  There is no diastolic murmur or gallop heard.,ABDOMEN:  Soft.  There is no hepatosplenomegaly or ascites.  No bruit heard over the aorta or renal vessels.,EXTREMITIES:  No pedal edema.  Femoral arterial pulsations are 3+, popliteal 2+.  Dorsalis pedis and posterior tibialis are 1+ on both sides.,NEURO:  Normal.,EKG from Dr. Xyz's office shows normal sinus rhythm, ST and T wave changes.  Lipid profile, random blood sugar, BUN, creatinine, CBC, and LFTs are normal.,IMPRESSION:,",
 Preoperative cardiac evaluation in the patient with chest pain in the setting of left hip fracture., Consult - History and Phy., Cardiac Consultation - 6 ,"INDICATIONS: , Preoperative cardiac evaluation in the patient with chest pain in the setting of left hip fracture.,HISTORY OF PRESENT ILLNESS:,  The patient is a 78-year-old white female with no prior cardiac history.  She sustained a mechanical fall with a subsequent left femoral neck fracture.  She was transferred to XYZ Hospital for definitive care.  In the emergency department of XYZ, the patient described six to seven seconds of sharp chest pain without radiation, without associated symptoms.  Electrocardiogram was obtained, which showed nonspecific ST-segment flattening in the high lateral leads I, aVL.  She also had a left axis deviation.  Serial troponins were obtained.  She has had four negative troponins since admission.  Due to age and chest pain history, a cardiology consultation was requested preoperatively.,At the time of my evaluation, the patient complained of left hip pain, but no chest pain, dyspnea, or symptomatic dysrhythmia.,PAST MEDICAL HISTORY:,1.  Mesothelioma.,2.  Recurrent urinary tract infections.,3.  Gastroesophageal reflux disease/gastritis.,4.  Osteopenia.,5.  Right sciatica.,6.  Hypothyroidism.,7.  Peripheral neuropathy.,8.  Fibromyalgia.,9.  Chart review also suggests she has atherosclerotic heart disease and pneumothorax.  The patient denies either of these.,PAST SURGICAL HISTORY:,1.  Tonsillectomy.,2.  Hysterectomy.,3.  Appendectomy.,4.  Thyroidectomy.,5.  Coccygectomy.,6.  Cystoscopies times several.,7.  Bladder neck resuspension.,8.  Multiple breast biopsies.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,MEDICATIONS:,  At the time of evaluation include, 1.  Cefazolin 1 g intravenous (IV).  2.  Morphine sulfate.  3.  Ondansetron p.r.n.,OUTPATIENT MEDICATIONS: , 1.  Robaxin.  2.  Detrol 4 mg q.h.s.  3.  Neurontin 300 mg p.o. t.i.d.  4.  Armour Thyroid 90 mg p.o. daily.  5.  Temazepam, dose unknown p.r.n.  6.  Chloral hydrate, dose unknown p.r.n.,FAMILY HISTORY: , Mother had myocardial infarction in her 40s, died of heart disease in her 60s, specifics not known.  She knows nothing of her father's history.  She has no siblings.  There is no other history of premature atherosclerotic heart disease in the family.,SOCIAL HISTORY: , The patient is married, lives with her husband.  She is a lifetime nonsmoker, nondrinker.  She has not been getting regular exercise for approximately two years due to chronic sciatic pain.,REVIEW OF SYSTEMS: ,GENERAL:  The patient is able to walk one block or less prior to the onset of significant leg pain.  She ever denies any cardiac symptoms with this degree of exertion.  She denies any dyspnea on exertion or chest pain with activities of daily living.  She does sleep on two to three pillows, but denies orthopnea or paroxysmal nocturnal dyspnea.  She does have chronic lower extremity edema.  Her husband states that she has had prior chest pain in the past, but this has always been attributed to gastritis.  She denies any palpitations or tachycardia.  She has remote history of presyncope, no true syncope.,HEMATOLOGIC:  Negative for bleeding diathesis or coagulopathy.,ONCOLOGIC:  Remarkable for past medical history.,PULMONARY:  Remarkable for childhood pneumonia times several.  No recurrent pneumonias, bronchitis, reactive airway disease as an adult.,GASTROINTESTINAL:  Remarkable for past medical history.,GENITOURINARY:  Remarkable for past medical history.,MUSCULOSKELETAL:  Remarkable for past medical history.,CENTRAL NERVOUS SYSTEM:  Negative for tic, tremor, transient ischemic attack (TIA), seizure, or stroke.,PSYCHIATRIC:  Remarkable for history of depression as an adolescent, she was hospitalized at State Mental Institution as a young woman.  No recurrence.,PHYSICAL EXAMINATION:,GENERAL:  This is a well-nourished, well-groomed elderly white female who is appropriate and articulate at the time of evaluation.,VITAL SIGNS:  She has had a low-grade temperature of 100.4 degrees Fahrenheit on 11/20/2006, currently 99.6.  Pulse ranges from 123 to 86 beats per minute.  Blood pressure ranges from 124/65 to 152/67 mmHg.  Oxygen saturation on 2 L nasal cannula was 94%.,HEENT:  Exam is benign.  Normocephalic and atraumatic.  Extraocular motions are intact.  Sclerae anicteric.  Conjunctivae noninjected.  She does have bilateral arcus senilis.  Oral mucosa is pink and moist.",
" Patient with atrial fibrillation with slow ventricular response, partially due to medications.", Consult - History and Phy., Cardiac Consultation - 3 ,"HISTORY OF PRESENT ILLNESS:, The patient is known to me secondary to atrial fibrillation with slow ventricular response, partially due to medications, at least when I first saw him in the office on 01/11/06. He is now 77 years old. He is being seen on the Seventh Floor. The patient is in Room 7607. The patient has a history of recent adenocarcinoma of the duodenum that was found to be inoperable, since it engulfed the porta hepatis. The workup began with GI bleeding. He was seen in my office on 01/11/06 for preop evaluation due to leg edema. A nonocclusive DVT was diagnosed in the proximal left superficial femoral vein. Both legs were edematous, and bilateral venous insufficiency was also present. An echocardiogram demonstrated an ejection fraction of 50%. The patient was admitted to the hospital and treated with a Greenfield filter since anticoagulant was contraindicated. Additional information on the echocardiogram, where a grossly dilated left atrium, moderately severely dilated right atrium. The rhythm was, as stated before, atrial fibrillation with slow atrioventricular conduction and an intraventricular conduction delay on the monitor strip. There was mild to moderate tricuspid regurgitation, mild pulmonic insufficiency. The ejection fraction was considered low normal, since it was estimated 50 to 54%. The patient received blood while in the hospital due to anemia. The leg edema improved while lying down, suggesting that the significant element of venous insufficiency was indeed present. The patient, who was diabetic, received consultation by Dr. R. He was also a chronic hypertensive and was treated for that with ACE inhibitors. The atrial fibrillation was slow, and no digitalis or beta blockers were recommended at the same time. As a matter of fact, they were discontinued. Now, the patient denied any shortness of breath or chest pain throughout this hospitalization, and cardiac nuclear studies performed earlier demonstrated no reversible ischemia.,ALLERGIES:, THE PATIENT HAS NO KNOWN DRUG ALLERGIES.,His diabetes was suspected to be complicated with neuropathy due to tingling in both feet. He received his immunizations with flu in 2005 but did not receive Pneumovax.,SOCIAL HISTORY:, The patient is married. He had 1 child who died at the age of 26 months of unknown etiology. He quit smoking 6 years ago but dips (smokeless) tobacco.,FAMILY HISTORY:, Mother had cancer, died at 70. Father died of unknown cause, and brother died of unknown cause.,FUNCTIONAL CAPACITY:, The patient is wheelchair bound at the time of his initial hospitalization. He is currently walking in the corridor with assistance. Nocturia twice to 3 times per night.,REVIEW OF SYSTEMS:,OPHTHALMOLOGIC: Uses glasses.,ENT: Complains of occasional sinusitis.,CARDIOVASCULAR: Hypertension and atrial fibrillation.,RESPIRATORY: Normal.,GI: Colon bleeding. The patient believes he had ulcers.,GENITOURINARY: Normal.,MUSCULOSKELETAL: Complains of arthritis and gout.,INTEGUMENTARY: Edema of ankles and joints.,NEUROLOGICAL: Tingling as per above. Denies any psychiatric problems.,ENDOCRINE: Diabetes, NIDDM.,HEMATOLOGIC AND LYMPHATIC: The patient does not use any aspirin or anticoagulants and is not of anemia.,LABORATORY:, Current EKG demonstrates atrial fibrillation with incomplete left bundle branch block pattern. Q waves are noticed in the inferior leads. Nonprogression of the R-wave from V1 to V4 with small R-waves in V5 and V6 are suggestive of an old anterior and inferior infarcts. Left ventilator hypertrophy and strain is suspected.,PHYSICAL EXAMINATION:,GENERAL: On exam, the patient is alert, oriented and cooperative. He is mildly pale. He is an elderly gentleman who is currently without diaphoresis, pallor, jaundice, plethora, or icterus.,VITAL SIGNS: Blood pressure is 159/69 with a respiratory rate of 20, pulse is 67 and irregularly irregular. Pulse oximetry is 100.,NECK: Without JVD, bruit, or thyromegaly. The neck is supple.,CHEST: Symmetric. There is no heave or retraction.,HEART: The heart sounds are irregular and no significant murmurs could be auscultated.,LUNGS: Clear to auscultation.,ABDOMEN: Exam was deferred.,LEGS: Without edema. Pulses: Dorsalis pedis pulse was palpated bilaterally.,MEDICATIONS:, Current medications include enalapril, low dose enoxaparin, Fentanyl patches. He is no longer on fluconazole. He is on a sliding scale as per Dr. Holden. He is on lansoprazole (Prevacid), Toradol, piperacillin/tazobactam, hydralazine p.r.n., Zofran, Dilaudid, Benadryl, and Lopressor p.r.n.,ASSESSMENT AND PLAN:, The patient is a very pleasant elderly gentleman with intractable/inoperable malignancy. His cardiac issues are chronic and most likely secondary to long term hypertension and diabetes. He has chronic atrial fibrillation. I do not envision a scenario whereby he will become a candidate for management of this arrhythmia beyond weight control. He is also not a candidate for anticoagulation, which is, in essence, a part and parcel of the weight control. Reason being is high likelihood for GI bleeding, especially given the diagnosis of invasive malignancy with involvement of multiple organs and lymph nodes. At this point, I agree with the notion of hospice care. If his atrioventricular conduction becomes excessive, occasional nondihydropyridine calcium channel blocker such as diltiazem or beta blockers would be appropriate; otherwise, I would keep him off those medications due to evidence of slow conduction in the presence of digitalis and beta blockers.",
 Cardiac evaluation and treatment in a patient who came in the hospital with abdominal pain., Consult - History and Phy., Cardiac Consultation - 5 ,"REASON FOR REFERRAL: , Cardiac evaluation and treatment in a patient who came in the hospital with abdominal pain.,HISTORY:,  This is a 77-year-old white female patient whom I have known for the last about a year or so who has underlying multiple medical problems including hypertension, hyperlipidemia, diabetes mellitus, coronary artery disease status post aortocoronary bypass surgery about eight years ago at Halifax Medical Center where she had triple vessel bypass surgery with left internal mammary artery to the left anterior descending artery, saphenous vein graft to the left circumflex and right coronary arteries.  Since then, she has generally done well.  She used to be seeing another cardiologist and apparently she had a stress test in September 2008 and she was otherwise cardiac catheterization and coronary angiography, but the patient declined to have one done and since then she has been on medical therapy.,The patient had been on medical therapy at home and generally doing well.  Recently, she had no leg swelling, undue exertional dyspnea, orthopnea, or paroxysmal nocturnal dyspnea.  She denies any rest or exertional chest discomfort.  Yesterday evening, she had her dinner and she was sitting around and she felt discomfort in the chest at about 7:00 p.m.  The discomfort was a crampy pain in the left lower quadrant area, which seemed to radiating to the center of the abdomen and to the right side and it was off and on lasting for a few minutes at a time and then subsiding.  Later on she was nauseous, but she did not have any vomiting.  She denied any diarrhea.  No history of fever or chills.  Since the pain seemed to persist, the patient came to the hospital emergency room at 11:35 p.m. where she was seen and admitted for the same.  She was given morphine, Zofran, Demerol, another Zofran, and Reglan as well as Demerol again and she was given intravenous fluids.  Subsequently, her pain finally went away and she does not have any pain since about 7:00 a.m. this morning.  The patient was admitted however for further workup and treatment.  At the time of my examination this afternoon, the patient is sitting, lying in bed and comfortable and has no abdominal pain of any kind.  She has not been fed any food, however.  The patient also had had pelvis and abdominal CT scan performed, which has been described to be partial small bowel obstruction, internal hernia, volvulus or adhesion most likely in the left flank area.  The patient has had left nephrectomy and splenectomy, which has been described.  A 1.5-mm solid mass is described to be in the lower pole of the kidney.  The patient also has been described to have diverticulosis without diverticulitis on this finding.,Currently however, the patient has no clinical symptoms according to her.,PAST MEDICAL HISTORY:,  She has had hypertension and hyperlipidemia for the last 15 years, diabetes mellitus for the last eight years, and coronary artery disease for last about eight years or so.  She had a chest and back pain about eight years ago for about two weeks and then subsequently she was reported to be evaluated.  She has a small myocardial infarction and then she was under the care of Dr. A and she had aortocoronary bypass surgery at Halifax Medical Center by Dr. B, which was a three-vessel bypass surgery with left internal mammary artery to the left descending artery and saphenous vein graft to the left circumflex and distal right coronary artery respectively.,She had had nuclear stress test with Dr. C on September 3, 2008, which was described to be abnormal with ischemic defects, but I do not think the patient had any further cardiac catheterization and coronary angiography after that.  She has been treated medically.,This patient also had an admission to this hospital in May 2008 also for partial small bowel obstruction and cholelithiasis and sigmoid diverticulosis.  She was described to have had a hemorrhagic cyst of the right kidney.  She has mild arthritis for the last 10 or 15 years.  She has a history of GERD for the last 20 years, and she also has a history of peptic ulcer disease in the duodenum, but never had any bleeding.  She has a history of diverticulosis as mentioned.  No history of TIA or CVA.  She has one kidney.  She was in a car accident in 1978 and afterwards she had to have left nephrectomy as well as splenectomy because of rupture.  The patient has a history of pulmonary embolism once about eight years ago after her aortocoronary bypass surgery.  She describes this to be a clot on left lung.  I am not sure if she had any long-term treatment, however.,In the past, the patient had aortocoronary bypass surgery in 2003 and incisional hernia surgery in 1979 as well as hysterectomy in 1979 and she had splenectomy and nephrectomy as described in 1978.,FAMILY HISTORY: , Her father died at age of 65 of massive heart attack and mother died at age of 62 of cancer.  She had a one brother who died of massive heart attack in his 50s, a brother died at the age of 47 of cancer, and another brother died in his 60s of possible rupture of appendix.,SOCIAL HISTORY: , The patient is a widow.  She lives alone.  She does have three daughters, two of them live in Georgia and one lives in Tennessee.  She did smoke in the past up to one to one and a half packs of cigarettes per day for about 10 years, but she quit long time ago.  She never drank any alcohol.  She likes to drink one or two cups of tea in a day.,ALLERGIES: , PAXIL.,MEDICATIONS:,  Her home medications prior to coming in include some of the following medications, although the exact list is not available in the chart at this stage, but they have been on glyburide, Januvia, lisinopril, metformin, metoprolol, simvastatin, ranitidine, meloxicam, and furosemide.,REVIEW OF SYSTEMS:,  Appetite is good.  She sleeps good at night.  She has no headaches and she has mild joint pains from arthritis.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse 90 per minute and regular, blood pressure 140/90 mmHg, respirations 18, and temperature of 98.5 degree Fahrenheit.  Moderate obesity is present.,CARDIAC:  Carotid upstroke is slightly diminished, but no clear bruit heard.,LUNGS:  Slightly decreased air entry at both bases.  No rales or rhonchi heard.,CARDIOVASCULAR:  PMI in the left fifth intercostal space in the midclavicular line.  Regular heart rhythm.  S1 and S2 normal.  S4 is present.  No S3 heard.  Short ejection systolic murmur grade I/VI is present at the left lower sternal border of the apex, peaking in LV systole, no diastolic murmur heard.,ABDOMEN:  Soft, obese, no tenderness, no masses felt.  Bowel sounds are present.,EXTREMITIES:  Bilateral trace edema.  The extremities are heavy.  There is no pitting at this stage.  No clubbing or cyanosis.  Distal pulses are fair.,CENTRAL NERVOUS SYSTEM:  Without any obvious focal deficits.,LABORATORY DATA: , Includes an electrocardiogram, which shows normal sinus rhythm, left atrial enlargement, and right bundle branch block.  This is overall unchanged compared to previous electrocardiogram, which also has the same present.  Nuclear stress test from 2008 was described to show ejection fraction of 49% and inferior and posterolateral ischemia.  Otherwise, laboratory data includes on this patient at this stage WBC 18.3, hemoglobin 15.5, hematocrit is 47.1, and platelet count is 326,000.  Electrolytes, sodium 137, potassium 5.2, chloride 101, CO2 27, BUN 34, creatinine 1.2, calcium 9.5, and magnesium 1.7.  AST and ALT are normal.  Albumin is 4.1.  Lipase and amylase are normal.  INR is 0.92.  Urinalysis is relatively unremarkable except for trace protein.  Chest x-ray has been described to show elevated left hemidiaphragm and median sternotomy sutures.  No infiltrates seen.  Abdomen and pelvis CAT scan findings are as described before with suggestion of partial small bowel obstruction and internal hernia.  Volvulus or adhesions have been considered.  Left nephrectomy and splenectomy demonstrated right kidney has a 1.5 cm solid mass at the lower pole suspicious for neoplasm according to the radiologist's description and there is diverticulosis.,IMPRESSION:,1.  Coronary artery disease and prior aortocoronary bypass surgery, currently clinically the patient without any angina.,2.  Possible small old myocardial infarction.,3.  Hypertension with hypertensive cardiovascular disease.,4.  Non-insulin-dependent diabetes mellitus.,5.  Moderate obesity.,6.  Hyperlipidemia.,7.  Chronic non-pitting leg edema.,8.  Arthritis.,9.  GERD and positive history of peptic ulcer disease.,CONCLUSION:,1.  Past left nephrectomy and splenectomy after an accident and injury and rupture of the spleen.,2.  Abnormal nuclear stress test in September 2008, but no further cardiac studies performed, such as cardiac catheterization.,3.  Lower left quadrant pain, which could be due to diverticulosis.,4.  Diverticulosis and partial bowel obstruction.,RECOMMENDATION:,1.  At this stage, the patient's cardiac medication should be continued if the patient is allowed p.o. intake.",
" Patient with a history of atrial fibrillation in the past, more recently who has had atrial flutter.  The patient has noted some lightheadedness as well as chest discomfort and shortness of breath when atrial flutter recurred.", Consult - History and Phy., Cardiac Consult & Cardioversion ,"HISTORY OF PRESENT ILLNESS: , Mr. A is a 50-year-old gentleman with a history of atrial fibrillation in the past, more recently who has had atrial flutter, who estimates he has had six cardioversions since 10/09, and estimates that he has had 12 to 24 in his life beginning in 2006 when the atrial fibrillation first emerged.  He, since 10:17 p.m. on 01/17/10, noted recurrence of his atrial fibrillation, called our office this morning, that is despite being on flecainide, atenolol, and he is maintained on Coumadin.,The patient has noted some lightheadedness as well as chest discomfort and shortness of breath when atrial flutter recurred and we see that on his 12-lead EKG here.  Otherwise, no chest pain.,PAST MEDICAL HISTORY: , Significant for atrial fibrillation/atrial flutter and again he had atrial fibrillation more persistently in 2006, but more recently it has been atrial flutter and that is despite use of antiarrhythmics including flecainide.  He completed a stress test in my office within the past several weeks that was normal without evidence of ischemia.  Other medical history is significant for hyperlipidemia.,MEDICATIONS:,As outpatient,,1.  Atenolol 25 mg once a day.,2.  Altace 2.5 mg once a day.,3.  Zocor 20 mg once a day.,4.  Flecainide 200 in the morning and 100 in the evening.,5.  Coumadin as directed by our office.,ALLERGIES: , TO MEDICATIONS ARE NONE.  HE DENIES SHRIMP, SEA FOOD OR DYE ALLERGY.,FAMILY HISTORY: , He has a nephew who was his sister's son who passed away at age 22 reportedly from an MI, but was reported to have hypertrophic cardiomyopathy as well.  The patient has previously met with the electrophysiologist, Dr. X, at General Hospital and it sounds like he had a negative EP study.,SOCIAL HISTORY: , The patient does not smoke cigarettes, abuse alcohol nor drink any caffeine.  No use of illicit drugs.  He has been married for 22 years and he is actually accompanied throughout today's cardiology consultation by his wife.  He is not participating in regular exercises now because he states since starting flecainide, he has gotten sluggish.  He is employed as an attorney and while he states that overall his mental stress is better, he has noted more recent mental stress this past weekend when he was taking his daughter back to college.,REVIEW OF SYSTEMS: , He denies any history of stroke, cancer, vomiting of blood, coughing up blood, bright red blood per rectum, bleeding stomach ulcers, renal calculi.  There are some questions especially as his wife has told me that he may have obstructive sleep apnea and not had a formal sleep study.,PHYSICAL EXAM: , Blood pressure 156/93, pulse is 100, respiratory rate 18.  On general exam, he is a pleasant overweight gentleman, in no acute distress.  HEENT:  Shows cranium is normocephalic and atraumatic.  He has moist mucosal membranes.  Neck veins are not distended.  There are no carotid bruits.  Visible skin warm and perfused.  Affect appropriate.  He is quite oriented and pleasant.  No significant kyphoscoliosis on recumbent back exam.  Lungs are clear to auscultation anteriorly.  No wheezes.  No egophony.  Cardiac Exam:  S1, S2.  Regular rate, controlled.  No significant murmurs, rubs or gallops.  PMI is nondisplaced.  Abdomen is soft, nondistended, appears benign.  Extremities without significant edema.  Pulses grossly intact.,DIAGNOSTIC STUDIES/LAB DATA:,  Initial ECG shows atrial flutter.,IMPRESSION: , Mr. A is a 50-year-old gentleman with a history of paroxysmal atrial fibrillation in the past, more recently is having breakthrough atrial flutter despite flecainide and we had performed a transesophageal echocardiogram-guided cardioversion for him in late 12/20/09, who now has another recurrence within the past 41 hours or so.  I have reviewed again with him in detail regarding risks, benefits, and alternatives of proceeding with cardioversion, which the patient is in favor of.  After in depth explanation of the procedure with him that there would be more definitive resumption of normal sinus rhythm by using electrocardioversion with less long-term side effects, past the acute procedure, alternatives being continued atrial flutter with potential for electrophysiologic consultation for ablation and/or heart rate control with anticoagulation, which the patient was not interested nor was I primarily recommending as the next step, and risks including, but not limited to and the patient was aware and this was all done in the presence of his wife that this is not an all-inclusive list, but the risks include but not limited to oversedation from conscious sedation, risk of aspiration pneumonia from regurgitation of stomach contents, which would be less likely as I did confirm with the patient that he had been n.p.o. for greater than 15 hours, risk of induction of other arrhythmias including tachyarrhythmias requiring further management including cardioversion or risk of bradyarrhythmias, in the past when we had a cardioverter with 150 joules, he did have a 5.5-second pause especially while he is on antiarrhythmic therapy, statistically less significant risk of CVA, although we cannot really make that null.  The patient expressed understanding of this risk, benefit, and alternative analysis.  I invited questions from him and his wife and once their questions were answered to their self-stated satisfaction, we planned to go forward with the procedure.,PROCEDURE NOTE:  ,The patient received a total of 7 mg of Versed and 50 micrograms of fentanyl utilizing titrate-down sedation with good effect and this was after the appropriate time-out procedure had been done as per the Medical Center universal protocol with appropriate identification of the patient, position, procedure documentation, procedure indication, and there were no questions.  The patient did actively participate in this time-out procedure.  After the universal protocol was done, he then received the cardioversion attempt with 50 joules using ""lollipop posterior patch"" with hands-driven paddle on the side, which was 50 joules of synchronized biphasic energy.  There was successful resumption of normal sinus rhythm, in fact this time there was not a significant pause as compared to when he had this done previously in late 12/09 and this sinus rhythm was confirmed by a 12-lead EKG.,IMPRESSION: , Cardioversion shows successful resumption of normal sinus rhythm from atrial flutter and that is while the patient has been maintained on Coumadin and his INR is 3.22.  We are going to watch him and discharge him from the Medical Center area on his current flecainide of 200 mg in the morning and 100 mg in the evening, atenolol 25 mg once a day, Coumadin _____ as currently being diagnosed.  I had previously discussed with the patient and he was agreeable with meeting with his electrophysiologist again, Dr. X, at Electrophysiology Unit at General Hospital and I will be planning to place a call for Dr. X myself.  Again, he has no ischemia on this most recent stress test and I suppose in the future it may be reasonable to get obstructive sleep apnea evaluation and that may be one issue promulgating his symptoms.,I had previously discussed the case with Dr. Y who is the patient's general cardiologist as well as updated his wife at the patient's bedside regarding our findings.",
" A woman with history of coronary artery disease, has had coronary artery bypass grafting x2 and percutaneous coronary intervention with stenting x1.  She also has a significant history of chronic renal insufficiency and severe COPD.  ", Consult - History and Phy., Cardiac Consultation ,"HISTORY OF PRESENT ILLNESS: , The patient is a 71-year-old woman with history of coronary artery disease for which she has had coronary artery bypass grafting x2 and percutaneous coronary intervention with stenting x1.  She also has a significant history of chronic renal insufficiency and severe COPD.  The patient and her husband live in ABC but they have family in XYZ.  She came to our office today as she is in the area visiting her family.  She complains of having shortness of breath for the past month that has been increasingly getting worse.  She developed a frequent nonproductive cough about 2 weeks ago.  She has also had episodes of paroxysmal nocturnal dyspnea, awaking in the middle of the night, panicking from dyspnea and shortness of breath.  She has also gained about 15 pounds in the past few months and has significant peripheral edema.  In the office, she is obviously dyspnea and speaking in 2 to 3 word sentences.,PAST MEDICAL HISTORY: , Coronary artery disease, anemia secondary to chronic renal insufficiency, stage IV chronic kidney disease, diabetic nephropathy, hypertension, hyperlipidemia, COPD, insulin-dependent diabetes, mild mitral valve regurgitation, severe tricuspid valve regurgitation, sick sinus syndrome, gastritis, and heparin-induced thrombocytopenia.,PAST SURGICAL HISTORY: , Status post pacemaker implantation, status post CABG x4 in 1999 and status post CABG x2 in 2003, status post PCA stenting x1 to the left anterior descending artery, cholecystectomy, back surgery, bladder surgery, and colonic polypectomies.,SOCIAL HISTORY:  ,The patient is married.  Lives with her husband.  They are retired from ABC.,MEDICATIONS:,1.  Plavix 75 mg p.o. daily.,2.  Aspirin 81 mg p.o. daily.,3.  Isosorbide mononitrate 60 mg p.o. daily.,4.  Colace 100 mg p.o. b.i.d.,5.  Atenolol 50 mg p.o. daily.,6.  Lantus insulin 15 units subcutaneously every evening.,7.  Protonix 40 mg p.o. daily.,8.  Furosemide 40 mg p.o. daily.,9.  Norvasc 5 mg p.o. daily.,ALLERGIES: , SHE IS ALLERGIC TO HEPARIN AGENTS, WHICH CAUSE HEPARIN-INDUCED THROMBOCYTOPENIA.,REVIEW OF SYSTEMS,CONSTITUTIONAL:  Positive for generalized fatigue and malaise.,HEAD AND NECK:  Negative for diplopia, blurred vision, visual disturbances, hearing loss, tinnitus, epistaxis, vertigo, sinusitis, and gum or oral lesions.,CARDIOVASCULAR:  Positive for epigastric discomfort x2 weeks, negative for palpitations, syncope or near-syncopal episodes, chest pressure, and chest pain.,RESPIRATORY:  Positive for dyspnea at rest, paroxysmal nocturnal dyspnea, orthopnea, and frequent nonproductive cough.  Negative for wheezing.,ABDOMEN:  Negative for abdominal pain, bloating, nausea, vomiting, constipation, melena, or hematemesis.,GENITOURINARY:  Negative for dysuria, polyuria, hematuria, or incontinence.,MUSCULOSKELETAL:  Negative for recent trauma, stiffness, deformities, muscular weakness, or atrophy.,SKIN:  Negative for rashes, petechiae, and hair or nail changes.  Positive for easy bruising on forearms.,NEUROLOGIC:  Negative for paralysis, paresthesias, dysphagia, or dysarthria.,PSYCHIATRIC:  Negative for depression, anxiety, or mood swings.,All other systems reviewed are negative.,PHYSICAL EXAMINATION,VITAL SIGNS:  Her blood pressure in the office was 188/94, heart rate 70, respiratory rate 18 to 20, and saturations 99% on room air.  Her height is 63 inches.  She is weighs 195 pounds and her BMI is 34.6.,CONSTITUTIONAL:  A 71-year-old woman in significant distress from shortness of breath and dyspnea at rest.,HEENT:  Eyes:  Pupils are reactive.  Sclera is nonicteric.  Ears, nose, mouth, and throat.,NECK:  Supple.  No lymphadenopathy.  No thyromegaly.  Swallow is intact.,CARDIOVASCULAR:  Positive JVD at 45 degrees.  Heart tones are distant.  S1 and S2.  No murmurs.,EXTREMITIES:  Have 3+ edema in the feet and ankles bilaterally that extends up to her knees.  Femoral pulses are weakly palpable.  Posterior tibial pulses are not palpable.  Capillary refill is somewhat sluggish.,RESPIRATORY:  Breath sounds are clear with some bilateral basilar diminishment.  No rales and no wheezing.  Speaking in 2 to 3 word sentences.  Diaphragmatic excursions are limited.  AP diameter is expanded.,ABDOMEN:  Soft and nontender.  Active bowel sounds x4 quadrants.  No hepatosplenomegaly.  No masses are appreciated.,GENITOURINARY:  Deferred.,MUSCULOSKELETAL:  Adequate range of motion along with extremities.,SKIN:  Warm and dry.  No lesions or ulcerations are noted.,NEUROLOGIC:  Alert and oriented x3.  Head is normocephalic and atraumatic.  No focal, motor, or sensory deficits.,PSYCHIATRIC:  Normal affect.,IMPRESSION,1.  Coronary artery disease.",
" T1 N3 M0 cancer of the nasopharynx, status post radiation therapy with 2 cycles of high dose cisplatin with radiation.", Consult - History and Phy., Cancer of the nasopharynx ,"DIAGNOSIS: , T1 N3 M0 cancer of the nasopharynx, status post radiation therapy with 2 cycles of high dose cisplatin with radiation, completed June, 2006; status post 2 cycles  carboplatin/5-FU given as adjuvant therapy, completed September, 2006; hearing loss related to chemotherapy and radiation; xerostomia; history of left upper extremity deep venous thrombosis.,PERFORMANCE STATUS:,  0.,INTERVAL HISTORY: , In the interim since his last visit he has done quite well.  He is working.  He did have an episode of upper respiratory infection and fever at the end of April which got better with antibiotics.  Overall when he compares his strength to six or eight months ago he notes that he feels much stronger.  He has no complaints other than mild xerostomia and treatment related hearing loss.,PHYSICAL EXAMINATION:,Vital Signs:  Height 65 inches, weight 150, pulse 76, blood pressure 112/74, temperature 95.4, respirations 18.,HEENT:  Extraocular muscles intact.  Sclerae not icteric.  Oral cavity free of exudate or ulceration.  Dry mouth noted.,Lymph:  No palpable adenopathy in cervical, supraclavicular or axillary areas.,Lungs:  Clear.,Cardiac:  Rhythm regular.,Abdomen:  Soft, nondistended.  Neither liver, spleen, nor other masses palpable.,Lower Extremities:  Without edema.,Neurologic:  Awake, alert, ambulatory, oriented, cognitively intact.,I reviewed the CT images and report of the study done on May 1.  This showed no evidence of metabolically active malignancy.,Most recent laboratory studies were performed last September and the TSH was normal.  I have asked him to repeat the TSH at the one year anniversary.,He is on no current medications.,In summary, this 57-year-old man presented with T1 N3 cancer of the nasopharynx and is now at 20 months post completion of all therapy.  He has made a good recovery.  We will continue to follow thyroid function and I have asked him to obtain a TSH at the one year anniversary in September and CBC in follow up.  We will see him in six months' time with a PET-CT.,He returns to the general care and direction of Dr. ABC.","consult - history and phy., radiation therapy with cycles, cancer of the nasopharynx, status post radiation, cisplatin with radiation, radiation therapy, hearing loss, hearing, cisplatin, xerostomia, cancer, radiation, nasopharynx,"
 Dietary consultation for carbohydrate counting for type I diabetes., Consult - History and Phy., Carbohydrate Counting ,"SUBJECTIVE:,  This is a 62-year-old female who comes for dietary consultation for carbohydrate counting for type I diabetes.  The patient reports that she was hospitalized over the weekend for DKA.  She indicates that her blood sugar on Friday night was 187 at bedtime and that when she woke up in the morning her blood sugar was 477.  She gave herself, in smaller increments, a total of 70 extra units of her Humalog.  Ten of those units were injectable; the others were in the forms of pump.  Her blood sugar was over 600 when she went to the hospital later that day.  She is here at this consultation complaining of not feeling well still because she has a cold.  She realizes that this is likely because her immune system was so minimized in the hospital.,OBJECTIVE:,  Current insulin doses on her insulin pump are boluses set at 5 units at breakfast, 6 units at lunch and 11 units at supper.  Her basal rates have not been changed since her last visit with Charla Yassine and totaled 30.5 units per 24 hours.  A diet history was obtained.  I instructed the patient on carbohydrate counting at 1 unit of insulin for every 10 g carbohydrate ratio was recommended.  A correction dose of approximately 1 unit of insulin to bring the blood sugars down 30 mg/dl was also recommended.  The Lilly guide for meal planning was provided and reviewed.  Additional carbohydrate counting book was provided.,ASSESSMENT:,  The patient was taught an insulin-to-carbohydrate ratio of 1 unit to 10 g of carbohydrates as recommended at the previous visit two years ago, which she does not recall.  It is based on the 500 rule which suggests this ratio.  We did identify carbohydrate sources in the food supply, recognizing 15-g equivalents.  We also identified the need to dose her insulin at the time that she is eating her carbohydrate sources.  She does seem to have a pattern of fixing blood sugars later in the day after they are elevated.  We discussed the other option of trying to eat a consistent amount of carbohydrates at meals from day to day and taking a consistent amount of insulin at those meals.  With this in mind, she was recommended to follow with three servings or 45 g of carbohydrate at breakfast, three servings or 45 g of carbohydrate at lunch and four servings or 60 g of carbohydrate at dinner.  Joanne Araiza joined our consultation briefly to discuss whether her pump was working appropriately.  The patient was given an 800 number for the pump to contact should there be any question about its failure to deliver insulin appropriately.,PLAN:,  Recommend the patient use 1 unit of insulin for every 10-g carbohydrate load consumed.  Recommend the patient either use this as a carbohydrate counting tool or work harder at keeping carbohydrate content consistent at meals from day to day.  This was a one-hour consultation.  Provided my name and number should additional needs arise.","consult - history and phy., insulin pump, carbohydrate load, immune system, dietary consultation, carbohydrate ratio, blood sugars, carbohydrate counting, carbohydrate, dietary, blood, counting, insulin"
" To evaluate recurrent episodes of uncomfortable feeling in arm at rest, as well as during exertion.", Consult - History and Phy., Cardiac Consultation - 1 ,"CHIEF REASON FOR CONSULTATION:,  Evaluate recurrent episodes of uncomfortable feeling in the left upper arm at rest, as well as during exertion for the last one month.,HISTORY OF PRESENT ILLNESS:,  This 57-year-old black female complains of having pain and discomfort in the left upper arm, especially when she walks and after heavy meals.  This lasts anywhere from a few hours and is not associated with shortness of breath, palpitations, dizziness, or syncope.  Patient does not get any chest pain or choking in the neck or pain in the back.  Patient denies history of hypertension, diabetes mellitus, enlarged heart, heart murmur, history suggestive of previous myocardial infarction, or acute rheumatic polyarthritis during childhood.  Her exercise tolerance is one to two blocks for shortness of breath and easy fatigability.,MEDICATIONS:,  Patient does not take any specific medications.,PAST HISTORY:,  The patient underwent hysterectomy in 1986.,FAMILY HISTORY:,  The patient is married, has four children who are doing fine.  Family history is positive for hypertension, congestive heart failure, obesity, cancer, and cerebrovascular accident.,SOCIAL HISTORY:, The patient smokes one pack of cigarettes per day and takes drinks on social occasions.",
" The patient is a very pleasant 72-year-old female with previous history of hypertension and also recent diagnosis of C. diff,  presents to the hospital with abdominal pain, cramping, and persistent diarrhea.", Consult - History and Phy., C. Diff Colitis Consult ,"REASON FOR CONSULT:  ,I was asked to see the patient for C. diff colitis.,HISTORY OF PRESENTING ILLNESS: , Briefly, the patient is a very pleasant 72-year-old female with previous history of hypertension and also recent diagnosis of C. diff for which she was admitted here in 5/2009, who presents to the hospital on 6/18/2009 with abdominal pain, cramping, and persistent diarrhea.  After admission, she had a CT of the abdomen done, which showed evidence of diffuse colitis and she was started on IV Flagyl and also on IV Levaquin.  She was also placed on IV Reglan because of nausea and vomiting.  In spite of the above, her white count still continues to be elevated today.  On questioning the patient, she states the nausea and vomiting has resolved, but the diarrhea still present, but otherwise denies any other specific complaints except for some weakness.,PAST MEDICAL HISTORY: , Hypertension, hyperlipidemia, recent C. diff colitis, which had resolved based on speaking to Dr. X.  Two weeks ago, he had seen the patient and she was clinically well.,PAST SURGICAL HISTORY:  ,Noncontributory.,SOCIAL HISTORY:  ,No history of smoking, alcohol, or drug use.  She lives at home.,HOME MEDICATIONS:  ,She is on atenolol and Mevacor.,ALLERGIES:  NO KNOWN DRUG ALLERGIES.,REVIEW OF SYSTEMS:  ,Positive for diarrhea and abdominal pain, otherwise main other complaints are weakness.  She denies any cough, sputum production, or dysuria at this time.  Otherwise, a 10-system review is essentially negative.,PHYSICAL EXAM:,GENERAL:  She is awake and alert, currently in no apparent distress.,VITAL SIGNS:  She has been afebrile since admission, temperature today 96.5, heart rate 80, respirations 18, blood pressure 125/60, and O2 sat is 98% on 2 L.,HEENT:  Pupils are round and reactive to light and accommodation.,CHEST:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  S1 and S2 are present.  No rales appreciated.,ABDOMEN:  She does have tenderness to palpation all over with some mild rebound tenderness also.  No guarding noted.  Bowel sounds present.,EXTREMITIES:  No clubbing, cyanosis, or edema.,CT of the abdomen and pelvis is also reviewed on the computer, which showed evidence of diffuse colitis.,LABORATORY: , White blood cell count today 21.5, hemoglobin 12.4, platelet count 284,000, and neutrophils 89.  UA on 6/18/2009 showed no evidence of UTI.  Sodium today 130, potassium 2.7, and creatinine 0.4.  AST and ALT on 6/20/2009 were normal.  Blood cultures from admission were negative.  Urine culture on admission was negative.  C. diff was positive.  Stool culture was negative.,ASSESSMENT:,1.  A 72-year-old female with Clostridium difficile colitis.,2.  Diarrhea secondary to above and also could be related Reglan, which was discontinued today.,3.  Leukocytosis secondary to above, mild improvement today though.,4.  Bilateral pleural effusion by CT of the chest, although could represent thickening.,5.  New requirement for oxygen, rule out pneumonia.,6.  Hypertension.,PLAN:,1.  Treat the C. diff aggressively especially given CT appearance and her continued leukocytosis and because of the Levaquin, which could have added additional antibiotic pressure, so I will restart the IV Flagyl.,2.  Continue p.o. vancomycin.  Add Florastor to help replenish the gut flora.,3.  Monitor WBCs closely and follow clinically and if there is any deterioration in her clinical status, I would recommend getting surgical evaluation immediately for surgery if needed.,4.  We will check a chest x-ray especially given her new requirement for oxygen.",
" Left buttock abscess, status post incision and drainage.   Recommended some local wound care", Consult - History and Phy., Buttock Abscess ,"CHIEF COMPLAINT: , Buttock abscess.,HISTORY OF PRESENT ILLNESS: , This patient is a 24-year-old African-American female who presented to the hospital with buttock pain.  She started off with a little pimple on the buttock.  She was soaking it at home without any improvement.  She came to the hospital on the first.  The patient underwent incision and drainage in the emergency department.  She was admitted to the hospitalist service with elevated blood sugars.  She has had positive blood cultures.  Surgery is consulted today for evaluation.,PAST MEDICAL HISTORY:  ,Diabetes type II, poorly controlled, high cholesterol.,PAST SURGICAL HISTORY: , C-section and D&C.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,MEDICATIONS: , Insulin, metformin, Glucotrol, and Lipitor.,FAMILY HISTORY: , Diabetes, hypertension, stroke, Parkinson disease, and heart disease.,REVIEW OF SYSTEMS: , Significant for pain in the buttock.  Otherwise negative.,PHYSICAL EXAMINATION:,GENERAL:  This is an overweight African-American female not in any distress.,VITAL SIGNS:  She has been afebrile since admission.  Vital signs have been stable.  Blood sugars have been in the 200 range.,HEENT:  Normal to inspection.,NECK:  No bruits or adenopathy.,LUNGS:  Clear to auscultation.,CV:  Regular rate and rhythm.,ABDOMEN:  Protuberant, soft, and nontender.,EXTREMITIES:  No clubbing, cyanosis or edema.,RECTAL EXAM:  The patient has a drained abscess on the buttock cheek.  There is some serosanguineous drainage.  There is no longer any purulent drainage.  The wound appears relatively clean.  I do not see a lot of erythema.,ASSESSMENT AND PLAN: , Left buttock abscess, status post incision and drainage.  I do not believe surgical intervention is warranted.  I have recommended some local wound care.  Please see orders for details.","consult - history and phy., buttock pain, pimple, incision and drainage, local wound care, blood sugars, diabetes, buttock, abscess, "
" First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.", Consult - History and Phy., Burn - Consult ,"CHIEF COMPLAINT: , Burn, right arm.,HISTORY OF PRESENT ILLNESS: , This is a Workers' Compensation injury.  This patient, a 41 year-old male, was at a coffee shop, where he works as a cook, and hot oil splashed onto his arm, burning from the elbow to the wrist on the medial aspect.  He has had it cooled, and presents with his friend to the Emergency Department for care.,PAST MEDICAL HISTORY:  ,Noncontributory.,MEDICATIONS:  ,None.,ALLERGIES:  ,None.,PHYSICAL EXAMINATION: , GENERAL:  Well-developed, well-nourished 21-year-old male adult who is appropriate and cooperative.  His only injury is to the right upper extremity.  There are first and second degree burns on the right forearm, ranging from the elbow to the wrist.  Second degree areas with blistering are scattered through the medial aspect of the forearm.  There is no circumferential burn, and I see no areas of deeper burn.  The patient moves his hands well.  Pulses are good.  Circulation to the hand is fine.,FINAL DIAGNOSIS:,1.  First-degree and second-degree burns, right arm secondary to hot oil spill.,2.  Workers' Compensation industrial injury.,TREATMENT: , The wound is cooled and cleansed with soaking in antiseptic solution.  The patient was ordered Demerol 50 mg IM for pain, but he refused and did not want pain medication.  A burn dressing is applied with Neosporin ointment.  The patient is given Tylenol No. 3, tabs #4, to take home with him and take one or two every four hours p.r.n. for pain.  He is to return tomorrow for a dressing change.  Tetanus immunization is up to date.  Preprinted instructions are given.  Workers' Compensation first report and work status report are completed.,DISPOSITION: , Home.","consult - history and phy., burn, workers' compensation industrial injury, workers' compensation, degree"
" Suspicious calcifications upper outer quadrant, left breast.  Left breast excisional biopsy with preoperative guidewire localization and intraoperative specimen radiography.", Consult - History and Phy., Breast Calcifications - Preop Consult  ,"REASON FOR HOSPITALIZATION:  ,Suspicious calcifications upper outer quadrant, left breast.,HISTORY OF PRESENT ILLNESS: , The patient is a 78-year-old woman who had undergone routine screening mammography on 06/04/08.  That study disclosed the presence of punctate calcifications that were felt to be in a cluster distribution in the left breast mound at the 2 o'clock position.  Additional imaging studies confirmed the suspicious nature of these calcifications.  The patient underwent a stereotactic core needle biopsy of the left breast 2 o'clock position on 06/17/08.  The final histologic diagnosis of the tissue removed during that procedure revealed focal fibrosis.  No calcifications could be identified in examination of the biopsy material including radiograph taken of the preserved tissue.,Two days post stereotactic core needle biopsy, however, the patient returned to the breast center with severe swelling and pain and mass in the left breast.  She underwent sonographic evaluation and was found to have a development of false aneurysm formation at the site of stereotactic core needle biopsy.  I was called to see the patient in the emergency consultation in the breast center.  At the same time, Dr. Y was consulted in Interventional Radiology.  Dr. Z and Dr. Y were able to identify the neck of the false aneurysm in the left breast mound and this was injected with ultrasound guidance with thrombin material.  This resulted in immediate occlusion of the false aneurysm.  The patient was seen in my office for followup appointment on 06/24/08.  At that time, the patient continued to have signs of a large hematoma and extensive ecchymosis, which resulted from the stereotactic core needle biopsy.  There was, however, no evidence of reforming of the false aneurysm.  There was no evidence of any pulsatile mass in the left breast mound or on the left chest wall.,I discussed the issues with the patient and her husband.  The underlying problem is that the suspicious calcifications, which had been identified on mammography had not been adequately sampled with the stereotactic core needle biopsy; therefore, the histologic diagnosis is not explanatory of the imaging findings.  For this reason, the patient was advised to have an excisional biopsy of this area with guidewire localization.  Since the breast mound was significantly disturbed from the stereotactic core needle biopsy, the decision was to postpone any surgical intervention for at least three to four months.  The patient now returns to undergo the excision of the left breast tissue with preoperative guidewire localization to identify the location of suspicious calcifications.,The patient has a history of prior stereotactic core needle biopsy of the left breast, which was performed on 01/27/04.  This revealed benign histologic findings.  The family history is positive involving a daughter who was diagnosed with breast cancer at the age of 40.  Other than her age, the patient has no other risk factors for development of breast cancer.  She is not receiving any hormone replacement therapy.  She has had five children with the first pregnancy occurring at the age of 24.  Other than her daughter, there are no other family members with breast cancer.  There are no family members with a history of ovarian cancer.,PAST MEDICAL HISTORY: , Other hospitalizations have occurred for issues with asthma and pneumonia.,PAST SURGICAL HISTORY: , Colon resection in 1990 and sinus surgeries in 1987, 1990 and 2005.,CURRENT MEDICATIONS:,1.  Plavix.,2.  Arava.,3.  Nexium.,4.  Fosamax.,5.  Advair.,6.  Singulair.,7.  Spiriva.,8.  Lexapro.,DRUG ALLERGIES:,  ASPIRIN, PENICILLIN, IODINE AND CODEINE.,FAMILY HISTORY:, Positive for heart disease, hypertension and cerebrovascular accidents.  Family history is positive for colon cancer affecting her father and a brother.  The patient has a daughter who was diagnosed with breast cancer at age 40.,SOCIAL HISTORY: , The patient does not smoke.  She does have an occasional alcoholic beverage.,REVIEW OF SYSTEMS:  ,The patient has multiple medical problems, for which she is under the care of Dr. X.  She has a history of chronic obstructive lung disease and a history of gastroesophageal reflux disease.  There is a history of anemia and there is a history of sciatica, which has been caused by arthritis.  The patient has had skin cancers, which have been treated with local excision.,PHYSICAL EXAMINATION:,GENERAL:  The patient is an elderly aged female who is alert and in no distress.,HEENT:  Head, normocephalic.  Eyes, PERRL.  Sclerae are clear.  Mouth, no oral lesions.,NECK:  Supple without adenopathy.,HEART:  Regular sinus rhythm.,CHEST:  Fair air entry bilaterally.  No wheezes are noted on examination.,BREASTS:  Normal topography bilaterally.  There are no palpable abnormalities in either breast mound.  Nipple areolar complexes are normal.  Specifically, the left breast upper outer quadrant near the 2 o'clock position has no palpable masses.  The previous tissue changes from the stereotactic core needle biopsy have resolved.  Axillary examination normal bilaterally without suspicious lymphadenopathy or masses.,ABDOMEN:  Obese.  No masses.  Normal bowel sounds are present.,BACK:  No CVA tenderness.,EXTREMITIES:  No clubbing, cyanosis or edema.,ASSESSMENT:,1.  Left breast mound clustered calcifications, suspicious by imaging located in the upper outer quadrant at the 2 o'clock position.,2.  Prior stereotactic core needle biopsy of the left breast did not resolve the nature of the calcifications, this now requires excision of the tissue with preoperative guidewire localization.,3.  History of chronic obstructive lung disease and asthma, controlled with medications.,4.  History of gastroesophageal reflux disease, controlled with medications.,5.  History of transient ischemic attack managed with medications.,6.  History of osteopenia and osteoporosis, controlled with medications.,7.  History of anxiety controlled with medications.,PLAN: , Left breast excisional biopsy with preoperative guidewire localization and intraoperative specimen radiography.  This will be performed on an outpatient basis.",
 The patient was admitted for symptoms that sounded like postictal state.  CT showed edema and slight midline shift.  MRI of the brain shows large inhomogeneous infiltrating right frontotemporal neoplasm surrounding the right middle cerebral artery., Consult - History and Phy., Brain Tumor - Consult ,"REASON FOR CONSULTATION: , I was asked by Dr. X to see the patient in regard to his likely recurrent brain tumor.,HISTORY OF PRESENT ILLNESS: , The patient was admitted for symptoms that sounded like postictal state.  He was initially taken to Hospital.  CT showed edema and slight midline shift, and therefore he was transferred here.  He has been seen by Hospitalists Service.  He has not had a recurrent seizure.  Electroencephalogram shows slowing.  MRI of the brain shows large inhomogeneous infiltrating right frontotemporal neoplasm surrounding the right middle cerebral artery.  There is inhomogeneous uptake consistent with potential necrosis.  He also has had a SPECT image of his brain, consistent with neoplasm, suggesting relatively high-grade neoplasm.  The patient was diagnosed with a brain tumor in 1999.  All details are still not available to us.  He underwent a biopsy by Dr. Y. One of the notes suggested that this was a glioma, likely an oligodendroglioma, pending a second opinion at Clinic.  That is not available on the chart as I dictate.,After discussion of treatment issues with radiation therapist and Dr. Z (medical oncologist), the decision was made to treat him primarily with radiation alone.  He tolerated that reasonably well.  His wife says it's been several years since he had a scan.  His behavior had not been changed, until it changed as noted earlier in this summary.,PAST MEDICAL HISTORY: , He has had a lumbar fusion.  I believe he's had heart disease.  Mental status changes are either due to the tumor or other psychiatric problems.,SOCIAL HISTORY:,  He is living with his wife, next door to one of his children.  He has been disabled since 2001, due to the back problems.,REVIEW OF SYSTEMS: , No headaches or vision issues.  Ongoing heart problems, without complaints.  No weakness, numbness or tingling, except that related to his chronic neck pain.  No history of endocrine problems.  He has nocturia and urinary frequency.,PHYSICAL EXAMINATION: , Blood pressure 146/91, pulse 76.  Normal conjunctivae.  Ears, nose, throat normal.  Neck is supple.  Chest clear.  Heart tones normal.  Abdomen soft.  Positive bowel sounds.  No hepatosplenomegaly.  No adenopathy in the neck, supraclavicular or axillary regions.  Neurologically alert.  Cranial nerves are intact.  Strength is 5/5 throughout.,LABORATORY WORK: , White blood count 10.4, hemoglobin 16, platelets not noted.  Sodium 137, calcium 9.1.,IMPRESSION AND PLAN:,  Likely recurrent low-grade tumor, possibly evolved to a higher grade, given the MRI and SPECT findings.  Dr. X's note suggests discussing the situation in the tumor board on Wednesday.  He is stable enough.  The pause in his care would not jeopardize his current status.  It would be helpful to get old films and pathology from Abbott Northwestern.  However, he likely will need a re-biopsy, as he is highly suspicious for recurrent tumor and radiation necrosis.  Optimizing his treatment would probably be helped by knowing his current grade of tumor.","consult - history and phy., spect, electroencephalogram, middle cerebral artery, brain tumor, inhomogeneous, frontotemporal, neoplasm, recurrent"
 Patient has prostate cancer with metastatic disease to his bladder.  The patient has had problems with hematuria in the past.  The patient was encouraged to drink extra water and was given discharge instructions on hematuria., Consult - History and Phy., Blood in Urine - ER Visit ,"CHIEF COMPLAINT: , Blood in urine.,HISTORY OF PRESENT ILLNESS:  ,This is a 78-year-old male who has prostate cancer with metastatic disease to his bladder and in several locations throughout the skeletal system including the spine and shoulder.  The patient has had problems with hematuria in the past, but the patient noted that this episode began yesterday, and today he has been passing principally blood with very little urine.  The patient states that there is no change in his chronic lower back pain and denies any incontinence of urine or stool.  The patient has not had any fever.  There is no abdominal pain and the patient is still able to pass urine.  The patient has not had any melena or hematochezia.  There is no nausea or vomiting.  The patient has already completed chemotherapy and is beyond treatment for his cancer at this time.  The patient is receiving radiation therapy, but it is targeted to the bones and intended to give symptomatic relief of his skeletal pain and not intended to treat and cure the cancer.  The patient is not enlisted in hospice, but the principle around the patient's current treatment management is focusing on comfort care measures.,REVIEW OF SYSTEMS: , CONSTITUTIONAL:  No fever or chills.  The patient does report generalized fatigue and weakness over the past several days.  HEENT:  No headache, no neck pain, no rhinorrhea, no sore throat.  CARDIOVASCULAR:  No chest pain.  RESPIRATIONS:  No shortness of breath or cough, although the patient does get easily winded with exertion over these past few days.  GASTROINTESTINAL:  The patient denies any abdominal pain.  No nausea or vomiting.  No changes in the bowel movement.  No melena or hematochezia.  GENITOURINARY:  A gross hematuria since yesterday as previously described.  The patient is still able to pass urine without difficulty.  The patient denies any groin pain.  The patient denies any other changes to the genital region.  MUSCULOSKELETAL:  The chronic lower back pain which has not changed over these past few days.  The patient does have multiple other joints, which cause him discomfort, but there have been no recent changes in these either.  SKIN:  No rashes or lesions.  No easy bruising.  NEUROLOGIC:  No focal weakness or numbness.  No incontinence of urine or stool.  No saddle paresthesia.  No dizziness, syncope or near-syncope.  ENDOCRINE:  No polyuria or polydipsia.  No heat or cold intolerance.  HEMATOLOGIC/LYMPHATIC:  The patient does not have a history of easy bruising or bleeding, but the patient has had previous episodes of hematuria.,PAST MEDICAL HISTORY: , Prostate cancer with metastatic disease as previously described.,PAST SURGICAL HISTORY: , TURP.,CURRENT MEDICATIONS:,  Morphine, Darvocet, Flomax, Avodart and ibuprofen.,ALLERGIES: , VICODIN.,SOCIAL HISTORY: , The patient is a nonsmoker.  Denies any alcohol or illicit drug use.  The patient does live with his family.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Temperature is 98.8 oral, blood pressure is 108/65, pulse is 109, respirations 16, oxygen saturation is 97% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished, well developed.  The patient appears to be pale, but otherwise looks well.  The patient is calm, comfortable.  The patient is pleasant and cooperative.  HEENT:  Eyes normal with clear conjunctivae and corneas.  Nose is normal without rhinorrhea or audible congestion.  Mouth and oropharynx normal without any sign of infection.  Mucous membranes are moist.  NECK:  Supple.  Full range of motion.  No JVD.  CARDIOVASCULAR:  Heart is mildly tachycardic with regular rhythm without murmur, rub or gallop.  Peripheral pulses are +2.  RESPIRATIONS:  Clear to auscultation bilaterally.  No shortness of breath.  No wheezes, rales or rhonchi.  Good air movement bilaterally.  GASTROINTESTINAL:  Abdomen is soft, nontender, nondistended.  No rebound or guarding.  No hepatosplenomegaly.  Normal bowel sounds.  No bruit.  No masses or pulsatile masses.  GENITOURINARY:  The patient has normal male genitalia, uncircumcised.  There is no active bleeding from the penis at this time.  There is no swelling of the testicles.  There are no masses palpated to the testicles, scrotum or the penis.  There are no lesions or rashes noted.  There is no inguinal lymphadenopathy.  Normal male exam.  MUSCULOSKELETAL:  Back is normal and nontender.  There are no abnormalities noted to the arms or legs.  The patient has normal use of the extremities.  SKIN:  The patient appears to be pale, but otherwise the skin is normal.  There are no rashes or lesions.  NEUROLOGIC:  Motor and sensory are intact to the extremities.  The patient has normal speech.  PSYCHIATRIC:  The patient is alert and oriented x4.  Normal mood and affect.  HEMATOLOGIC/LYMPHATIC:  There is no evidence of bruising noted to the body.  No lymphadenitis is palpated.,EMERGENCY DEPARTMENT TESTING:,  CBC was done, which had a hemoglobin of 7.7 and hematocrit of 22.6.  Neutrophils were 81%.  The RDW was 18.5, and the rest of the values were all within normal limits and unremarkable.  Chemistry had a sodium of 134, a glucose of 132, calcium is 8.2, and rest of the values are unremarkable.  Alkaline phosphatase was 770 and albumin was 2.4.  Rest of the values all are within normal limits of the LFTs.  Urinalysis was grossly bloody with a large amount of blood and greater than 50 rbc's.  The patient also had greater than 300 of the protein reading, moderate leukocytes, 30-50 white blood cells, but no bacteria were seen.  Coagulation profile study had a PT of 15.9, PTT of 43 and INR of 1.3.,EMERGENCY DEPARTMENT COURSE: , The patient was given normal saline 2 liters over 1 hour without any adverse effect.  The patient was given multiple doses of morphine to maintain his comfort while here in the emergency room without any adverse effect.  The patient was given Levaquin 500 mg by mouth as well as 2 doses of Phenergan over the course of his stay here in the emergency department.  The patient did not have an adverse reaction to these medicines either.  Phenergan resolved his nausea and morphine did relieve his pain and make him pain free.  I spoke with Dr. X, the patient's urologist, about most appropriate step for the patient, and Dr. X said he would be happy to care for the patient in the hospital and do urologic scopes if necessary and surgery if necessary and blood transfusion.  It was all a matter of what the patient wished to do given the advanced stage of his cancer.  Dr. X was willing to assist in any way the patient wished him to.  I spoke with the patient and his son about what he would like to do and what the options were from doing nothing from keeping him comfortable with pain medicines to admitting him to the hospital with the possibility of scopes and even surgery being done as well as the blood transfusion.  The patient decided to choose a middle ground in which he would be transfused with 2 units of blood here in the emergency room and go home tonight.  The patient's son felt comfortable with his father's choice.  This was done.  The patient was transfused 2 units of packed red blood cells after appropriately typed and match.  The patient did not have any adverse reaction at any point with his transfusion.  There was no fever, no shortness of breath, and at the time of disposition, the patient stated he felt a little better and felt like he had a little more strength.  Over the course of the patient's several-hour stay in the emergency room, the patient did end up developing enough problems with clotted blood in his bladder that he had a urinary obstruction.  Foley catheter was placed, which produced bloody urine and relieved the developing discomfort of a full bladder.  The patient was given a leg bag and the Foley catheter was left in place.,DIAGNOSES,1.  HEMATURIA.,2.  PROSTATE CANCER WITH BONE AND BLADDER METASTATIC DISEASE.,3.  SIGNIFICANT ANEMIA.,4.  URINARY OBSTRUCTION.,CONDITION ON DISPOSITION:  ,Fair, but improved.,DISPOSITION: , To home with his son.,PLAN: , We will have the patient follow up with Dr. X in his office in 2 days for reevaluation.  The patient was given a prescription for Levaquin and Phenergan tablets to take home with him tonight.  The patient was encouraged to drink extra water.  The patient was given discharge instructions on hematuria and asked to return to the emergency room should he have any worsening of his condition or develop any other problems or symptoms of concern.",
" Breast reconstruction post mastectomy.  A 51-year-old lady for mastectomy on the right side, who is interested in the possibility of breast reconstruction.", Consult - History and Phy., Breast Reconstruction ,"REASON FOR CONSULTATION:,  Breast reconstruction post mastectomy.,HISTORY OF PRESENT ILLNESS: , The patient is a 51-year-old lady, who had gone many years without a mammogram when she discovered a lump in her right breast early in February of this year.  She brought this to the attention of her primary care doctor and she soon underwent ultrasound and mammogram followed by needle biopsy, which revealed that there was breast cancer.  This apparently was positive in two separate locations within the suspicious area.  She also underwent MRI, which suggested that there was significant size to the area involved.  Her contralateral left breast appeared to be uninvolved.  She has had consultation with Dr. ABC and they are currently in place to perform a right mastectomy.,PAST MEDICAL HISTORY: , Positive for hypertension, which is controlled on medications.  She is a nonsmoker and engages in alcohol only moderately.,PAST SURGICAL HISTORY: , Surgical history includes uterine fibroids, some kind of cyst excision on her foot, and cataract surgery.,ALLERGIES: , None known.,MEDICATIONS: , Lipitor, ramipril, Lasix, and potassium.,PHYSICAL EXAMINATION: , On examination, the patient is a healthy looking 51-year-old lady, who is moderately overweight.  Breast exam reveals significant breast hypertrophy bilaterally with a double D breast size and significant shoulder grooving from her bra straps.  There are no any significant scars on the right breast as she has only undergone needle biopsy at this point.  Exam also reveals abdomen where there is moderate excessive fat, but what I consider a good morphology for a potential TRAM flap.,IMPRESSION:,  A 51-year-old lady for mastectomy on the right side, who is interested in the possibility of breast reconstruction.  We discussed the breast reconstruction options in some detail including immediate versus delayed reconstruction and autologous tissue versus implant reconstruction.  I think for a lady of this physical size and breast morphology that the likelihood of getting a good result with a tissue expander reconstruction is rather slim.  A further complicating factor is the fact that she may well be undergoing radiation after her mastectomy.  I would think this would make a simple tissue expander reconstruction virtually beyond the balance of consideration.  I have occasionally gotten away with tissue expanders with reasonable results in irradiated patients when they are thinner and smaller breasted, but in a heavier lady with large breasts, I think it virtually deemed to failure.  We therefore, mostly confine our discussion to the relative merits of TRAM flap breast reconstruction and latissimus dorsi reconstruction with implant.  In either case, the contralateral breast reduction would be part of the overall plan., ,The patient understands that the TRAM flap although not much more lengthy of a procedure is a little comfortable recovery.  Since we are sacrificing a rectus abdominus muscle that can be more discomfort and difficulties in healing both due to it being a respiratory muscle and to its importance in sitting up and getting out of bed.  In any case, she does prefer this option in order to avoid the need for an implant.  We discussed pros and cons of the surgery, including the risks such as infection, bleeding, scarring, hernia, or bulging of the donor site, seroma of the abdomen, and fat necrosis or even the skin slough in the abdomen.  We also discussed some of the potential flap complications including partial or complete necrosis of the TRAM flap itself.,PLAN: , The patient is definitely interested in undergoing TRAM flap reconstruction.  At the moment, we are planning to do it as an immediate reconstruction at the time of the mastectomy.  For this reason, I have made arrangements to do initial vascular delay procedure within the next couple of days.  We may cancel this if the chance of postoperative irradiation is high.  If this is the case, I think we can do a better job on the reconstruction if we defer it.  The patient understands this and will proceed according to the recommendations from Dr. ABC and from the oncologist.","consult - history and phy., breast reconstruction, mastectomy, lump, breast, mammogram, needle biopsy, breast cancer, hypertrophy, tram flap, latissimus dorsi,"
" Evaluation of pain and symptoms related to a recurrent bunion deformity in bilateral feet - recurrent bunion deformity, right forefoot & pes planovalgus deformity, bilateral feet.", Consult - History and Phy., Bunion & Pes Planovalgus Deformity ,"HISTORY OF PRESENT ILLNESS: , The patient is a 57-year-old female being seen today for evaluation of pain and symptoms related to a recurrent bunion deformity in bilateral feet, right greater than left.  The patient states she is having increasing symptoms of pain and discomfort associated with recurrence of bunion deformity on the right foot and pain localized to the second toe and MTP joint of the right foot as well.  The patient had prior surgery performed approximately 13 years ago.  She states that since the time of the original surgery the deformity has slowly recurred, and she has noticed progressive deformity in the lesser toes at the second and third toes of the left foot and involving the second toe of the right foot.  The patient is employed on her feet as a hospital employee and states that she does wear a functional orthotic which does provide some relief of forefoot pain although not complete.,PAST MEDICAL HISTORY, FAMILY HISTORY, SOCIAL HISTORY & REVIEW OF SYSTEMS:,  See Patient History sheet, which was reviewed with the patient and is signed in the chart.  Past medical history on the patient, past surgical history, current medications, drug-related allergies and social history have all been updated and reviewed, and enclosed in the chart.,PHYSICAL EXAMINATION: , Physical exam reveals a pleasant, 57-year-old female who is 5 feet 4 inches and 150 pounds.  She has palpable pulses.  Neurologic sensation is intact.  Examination of the extremities shows the patient as having well-healed surgical sites from her arthroplasty, second digits bilaterally and prior bunionectomy.  There is a recurrence of bunion deformity noted on both great toes although the patient notes to have reasonably good range of movement.  She has particular pain in the second MTP joint of the right foot and demonstrates a mild claw-toe deformity of the second and third toes to the left foot, and to a lesser degree the second toe to the right.  Gait analysis:  The patient stands and walks with a rather severe pes planus and has generalized hypermobility noted in the feet.,X-RAY INTERPRETATION:,  X-rays taken today; three views to the right foot shows presence of internal K-wire and wire from prior bunionectomy.  Biomechanical analysis shows 15 degree intermetatarsal angle and approximately 45 degree hallux abducto valgus angle.  No evidence of arthrosis in the joint is noted.  Significant shift to the fibular sesamoid is present.,ASSESSMENT:,1.  Recurrent bunion deformity, right forefoot.,2.  Pes planovalgus deformity, bilateral feet.,PLAN/TREATMENT:,1.  Today, we did review remaining treatment options with the patient including the feasibility of conservative versus surgical treatment.  The patient would require an open wedge osteotomy to reduce the intermetatarsal angle with the lateral release and a decompression osteotomy  at the second metatarsal.  Anticipated length of healing was noted for the patient as were potential risks and complications.  The patient ultimately would probably require surgery on her left foot at a later date as well.,2.  The patient will explore her ability to get out of work for the above-mentioned period of time and will be in touch with regards regarding scheduling at a later date.,3.  All questions were answered.","consult - history and phy., x-rays, pain, mtp joint, pes planovalgus deformity, pes planovalgus, bunion deformity, planovalgus, forefoot, foot, deformity, bunionectomy, bunion"
 Recurrent bladder tumor.  The patient on recent followup cystoscopy for transitional cell carcinomas of the bladder neck was found to have a 5-cm area of papillomatosis just above the left ureteric orifice., Consult - History and Phy., Bladder Tumor ,"CHIEF COMPLAINT:,  Recurrent bladder tumor.,HISTORY OF PRESENT ILLNESS: , The patient is a 79-year-old woman, the patient of Dr. X, who on recent followup cystoscopy for transitional cell carcinomas of the bladder neck was found to have a 5-cm area of papillomatosis just above the left ureteric orifice.  The patient underwent TUR of several transitional cell carcinomas of the bladder on the bladder neck in 2006.  This was followed by bladder instillation of BCG.  At this time, the patient denies any voiding symptoms or hematuria.  The patient opting for TUR and electrofulguration of the recurrent tumors.,ALLERGIES: , None known.,MEDICATIONS: , Atenolol 5 mg daily.,OPERATIONS: , Status post bilateral knee replacements and status post TUR of bladder tumors.,REVIEW OF SYSTEMS: , Other than some mild hypertension, the patient is in very, very good health.  No history of diabetes, shortness of breath or chest pain.,PHYSICAL EXAMINATION: , Well-developed and well-nourished woman, alert and oriented.  Her lungs are clear.  Heart, regular sinus rhythm.  Back, no CVA tenderness.  Abdomen, soft and nontender.  No palpable masses.,IMPRESSION: , Recurrent bladder tumors.,PLAN: , The patient to have CBC, chem-6, PT, PTT, EKG, and chest x-ray beforehand.","consult - history and phy., bladder neck, voiding symptoms, hematuria, transitional cell carcinomas, ureteric orifice, bladder tumor, bladder, cystoscopy, papillomatosis, transitional, carcinomas, orifice,"
" Blood in toilet.  Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed.", Consult - History and Phy., Blood In Toilet ,"CHIEF COMPLAINT:  ,Blood in toilet.,HISTORY: , Ms. ABC is a 77-year-old female who is brought down by way of ambulance from XYZ Nursing Home after nursing staff had noted there to be blood in the toilet after she had been sitting on the toilet.  They did not note any urine or stool in the toilet and the patient had no acute complaints.  The patient is unfortunately a poor historian in that she has dementia and does not recall any of the events.  The patient herself has absolutely no complaints, such as abdominal pain or back pain, urinary and GI complaints.  There is no other history provided by the nursing staff from XYZ.  There apparently were no clots noted within there.  She does not have a history of being on anticoagulants.,PAST MEDICAL HISTORY: , Actually quite limited, includes that of dementia, asthma, anemia which is chronic, hypothyroidism, schizophrenia, positive PPD in the past.,PAST SURGICAL HISTORY:  ,Unknown.,SOCIAL HISTORY: , No tobacco or alcohol.,MEDICATIONS: , Listed in the medical records.,ALLERGIES:,  No known drug allergies.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Stable.,GENERAL:  This is a well-nourished, well-developed female who is alert, oriented in all spheres, pleasant, cooperative, resting comfortably, appearing otherwise healthy and well in no acute distress.,HEENT:  Visually normal.  Pupils are reactive.  TMs, canals, nasal mucosa, and oropharynx are intact.,NECK:  No lymphadenopathy or JVD.,HEART:  Regular rate and rhythm.  S1, S2.  No murmurs, gallops, or rubs.,LUNGS:  Clear to auscultation.  No wheeze, rales, or rhonchi.,ABDOMEN:  Benign, flat, soft, nontender, and nondistended.  Bowel sounds active.  No organomegaly or mass noted.,GU/RECTAL:  External rectum was normal.  No obvious blood internally.  There is no stool noted within the vault.  There is no gross amount of blood noted within the vault.  Guaiac was done and was trace positive.  Visual examination anteriorly during the rectal examination noted no blood within the vaginal region.,EXTREMITIES:  No significant abnormalities.,WORKUP: , CT abdomen and pelvis was negative.  CBC was entirely within normal limits without any signs of anemia with an H and H of 14 and 42%.  CMP also within normal limits.  PTT, PT, and INR were normal.  Attempts at getting the patient to give A urine were unsuccessful and the patient was very noncompliant, would not allow us to do any kind of Foley catheterization.,ER COURSE:,  Uneventful.  I have discussed the patient in full with Dr. X who agrees that she does not require any further workup or evaluation as an inpatient.  We have decided to send the patient back to XYZ with observation by the staff there.  She will have a CBC done daily for the next 3 days with results to Dr. X.  They are to call him if there is any recurrences of blood or worsening of symptoms and they are to do a urinalysis at XYZ for blood.,ASSESSMENT: , Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed.",
" Patient with a history of gross hematuria.  CT scan was performed, which demonstrated no hydronephrosis or upper tract process; however, there was significant thickening of the left and posterior bladder wall.", Consult - History and Phy., Bladder Cancer ,"CHIEF COMPLAINT: , Bladder cancer.,HISTORY OF PRESENT ILLNESS:,  The patient is a 68-year-old Caucasian male with a history of gross hematuria.  The patient presented to the emergency room near his hometown on 12/24/2007 for evaluation of this gross hematuria.  CT scan was performed, which demonstrated no hydronephrosis or upper tract process; however, there was significant thickening of the left and posterior bladder wall.  Urology referral was initiated and the patient was sent to be evaluated by Dr. X. He eventually underwent a bladder biopsy on 01/18/08, which demonstrated high-grade transitional cell carcinoma without any muscularis propria in the specimen.  Additionally, the patient underwent workup for a right adrenal lesion, which was noted on the initial CT scan.  This workup involved serum cortisol analysis as well as potassium and aldosterone and ACTH level measurement.  All of this workup was found to be grossly negative.  Secondary to the absence of muscle in the specimen, the patient was taken back to the operating room on 02/27/08 by Dr. X and the tumor was noted to be very large with significant tumor burden as well as possible involvement of the bladder neck.  At that time, the referring urologist determined the tumor to be too large and risky for local resection, and the patient was referred to ABCD Urology for management and diagnosis.  The patient presents today for evaluation by Dr. Y.,PAST MEDICAL HISTORY: , Includes condyloma, hypertension, diabetes mellitus, hyperlipidemia, undiagnosed COPD, peripheral vascular disease, and claudication.  The patient denies coronary artery disease.,PAST SURGICAL HISTORY:,  Includes bladder biopsy on 01/18/08 without muscularis propria in the high-grade TCC specimen and a gun shot wound in 1984 followed by exploratory laparotomy x2.  The patient denies any bowel resection or GU injury at that time; however, he is unsure.,CURRENT MEDICATIONS:,1.  Metoprolol 100 mg b.i.d.,2.  Diltiazem 120 mg daily.,3.  Hydrocodone 10/500 mg p.r.n.,4.  Pravastatin 40 mg daily.,5.  Lisinopril 20 mg daily.,6.  Hydrochlorothiazide 25 mg daily.,FAMILY HISTORY: , Negative for any GU cancer, stones or other complaints.  The patient states he has one uncle who died of lung cancer.  He denies any other family history.,SOCIAL HISTORY: , The patient smokes approximately 2 packs per day times greater than 40 years.  He does drink occasional alcohol approximately 5 to 6 alcoholic drinks per month.  He denies any drug use.  He is a retired liquor store owner.,PHYSICAL EXAMINATION:,GENERAL:  He is a well-developed, well-nourished Caucasian male, who appears slightly older than stated age.  VITAL SIGNS:  Temperature is 96.7, blood pressure is 108/57, pulse is 75, and weight of 193.8 pounds.  HEAD AND NECK:  Normocephalic atraumatic.  LUNGS:  Demonstrate decreased breath sounds globally with small rhonchi in the inferior right lung, which is clear somewhat with cough.  HEART:  Regular rate and rhythm.  ABDOMEN:  Soft and nontender.  The liver and spleen are not palpably enlarged.  There is a large midline defect covered by skin, of which the fascia has numerous holes poking through.  These small hernias are of approximately 2 cm in diameter at the largest and are nontender.  GU:  The penis is circumcised and there are no lesions, plaques, masses or deformities.  There is some tenderness to palpation near the meatus where 20-French Foley catheter is in place.  Testes are bilaterally descended and there are no masses or tenderness.  There is bilateral mild atrophy.  Epididymidis are grossly within normal limits bilaterally.  Spermatic cords are grossly within normal limits.  There are no palpable inguinal hernias.  RECTAL:  The prostate is mildly enlarged with a small focal firm area in the midline near the apex.  There is however no other focal nodules.  The prostate is grossly approximately 35 to 40 g and is globally firm.  Rectal sphincter tone is grossly within normal limits and there is stool in the rectal vault.  EXTREMITIES:  Demonstrate no cyanosis, clubbing or edema.  There is dark red urine in the Foley bag collection.,LABORATORY EXAM:,  Review of laboratory from outside facility demonstrates creatinine of 2.38 with BUN of 42.  Additionally, laboratory exam demonstrates a grossly normal serum cortisol, ACTH, potassium, aldosterone level during lesion workup.  CT scan was reviewed from outside facility, report states there is left kidney atrophy without hydro or stones and there is thickened left bladder wall and posterior margins with a balloon inflated in the prostate at the time of the exam.  There is a 3.1 cm right heterogeneous adrenal nodule and there are no upper tract lesions or stones noted.,IMPRESSION:,  Bladder cancer.,PLAN:  ,The patient will undergo a completion TURBT on 03/20/08 with bilateral retrograde pyelograms at the time of surgery.  Preoperative workup and laboratory as well as paper work were performed in clinic today with Dr. Y. The patient will be scheduled for anesthesia preop.  The patient will have urine culture redrawn from his Foley or penis at the time of preoperative evaluation with anesthesia.  The patient was counseled extensively approximately 45 minutes on the nature of his disease and basic prognostic indicators and need for additional workup and staging.  The patient understands these instructions and also agrees to quit smoking prior to his next visit.  This patient was seen in evaluation with Dr. Y who agrees with the impression and plan.","consult - history and phy., retrograde pyelogram, bladder biopsy, muscularis propria, bladder cancer, gross hematuria, bladder wall, ct scan, bladder, hematuria, "
" Hypomastia.   Patient wants breast augmentation and liposuction of her abdomen, ", Consult - History and Phy., Breast Augmentation Consult ,"REASON FOR VISIT: , This is a cosmetic consultation.,HISTORY OF PRESENT ILLNESS:,  The patient is a very pleasant 34-year-old white female who is a nurse in the operating room.  She knows me through the operating room and has asked me to possibly perform cosmetic surgery on her.  She is very bright and well informed about cosmetic surgery.  She has recently had some neck surgery for a re-fusion of her neck and is currently on methadone for chronic pain regarding this.  Her current desires are that she obtain a breast augmentation and liposuction of her abdomen, and she came to me mostly because I offer transumbilical breast augmentation.  Her breasts are reportedly healthy without any significant problems.  Her weight is currently stable.,PAST MEDICAL AND SURGICAL HISTORY: ,  Negative.  Past surgical history is significant for a second anterior cervical fusion and diskectomy in 02/05 and in 09/06.  She has had no previous cosmetic or aesthetic surgery.,FAMILY HISTORY AND SOCIAL HISTORY:,  Significant for Huntington disease in her mother and diabetes in her father.  Her brother has an aneurysm.  She does occasionally smoke and has been trying to quit recently.  She is currently smoking about a pack a day.  She drinks about once a week.  She is currently a registered nurse, circulator, and scrub technician in the operating room at Hopkins.  She has no children.,REVIEW OF SYSTEMS:  ,A 12-system review is significant for some musculoskeletal pain, mostly around her neck and thoracic region.  She does have occasional rash on her chest and problems with sleep and anxiety that are related to her chronic pain.  She has considered difficult airway due to anterior cervical disk fusion and instability.  Her last mammogram was in 2000.  She has a size 38C breast.,MEDICATIONS: , Current medications are 5 mg of methadone three times a day and amitriptyline at night as needed.,ALLERGIES: , None.,FINDINGS: , On exam today, the patient has good posture, good physique, good skin tone.  She is tanned.  Her lower abdomen has some excess adiposity.  There is some mild laxity of the lower abdominal skin.  Her umbilicus is oval shaped and of adequate caliber for a transumbilical breast augmentation.  There was no piercing in that region.  Her breasts are C shaped.  They are not ptotic.  They have good symmetry with no evidence of tubular breast deformity.  She has no masses or lesions noted.  The nipples are of appropriate size and shape for a woman of her age.  Her scar on her neck from her anterior cervical disk fusion is well healed.  Hopefully, our scars would be similar to this.,IMPRESSION AND PLAN: , Hypomastia.  I think her general physique and body habitus would accommodate about 300 to 350 cubic centimeter implant nicely.  This would make her fill out her clothes much better, and I think transumbilical technique in her is a good option.  I have discussed with her the other treatment options, and she does not want scars around her breasts if at all possible.  I think her lower abdominal skin is of good tone.  I think suction lipectomy in this region would bring down her size and accentuate her waist nicely.  I am a little concerned about the lower abdominal skin laxity, and I will discuss with her further that in the near future if this continues to be a problem, she may need a mini tummy tuck.  I do think that a liposuction is a reasonable alternative and we could see how much skin tightening she gets after the adiposity is removed.  I will try to set this up in the near future.  I will try to set this up to get the instrumentation from the instrumentation rep for the transumbilical breast augmentation procedure.  Due to her neck issues, we may not be able to perform her surgery but I will check with Dr. X to see if she is comfortable giving her deep sedation and no general anesthetic with her neck being fused.","consult - history and phy., breast augmentation and liposuction, liposuction of her abdomen, transumbilical breast augmentation, cosmetic surgery, abdominal skin, breast augmentation, augmentation, liposuction, cosmetic, transumbilical, breast,"
 Modified Barium swallow study evaluation to objectively evaluate swallowing function and safety.  The patient complained of globus sensation high in her throat particularly with solid foods and with pills.  She denied history of coughing and chocking with meals. , Consult - History and Phy., Barium Swallow Study Evaluation ,"HISTORY: , The patient is a 71-year-old female, who was referred for an outpatient modified barium swallow study to objectively evaluate her swallowing function and safety.  The patient complained of globus sensation high in her throat particularly with solid foods and with pills.  She denied history of coughing and chocking with meals.  The patient's complete medical history is unknown to me at this time.  The patient was cooperative and compliant throughout this evaluation.,STUDY:,  Modified barium swallow study was performed in the Radiology Suite in cooperation with Dr. X. The patient was seated upright at a 90-degree angle in a video imaging chair.  To evaluate her swallowing function and safety, she was administered graduated amounts of food and liquid mixed with barium in the form of thin liquids (teaspoon x3. cup sip x4); thickened liquid (cup sip x3); puree consistency (teaspoon x3); and solid consistency (1/4 cracker x1).  The patient was given 2 additional cup sips of thin liquid following the puree and solid food presentation.,ORAL STAGE:  ,The patient had no difficulty with bolus control and transport.  No spillage out lips.  The patient appears to have pocketing __________ particularly with puree and solid food between her right faucial pillars.  The patient did state that she had her tonsil taken out as a child and appears to be a diverticulum located in this state.  Further evaluation by an ENT is highly recommended based on the residual and pooling that occurred during this evaluation.  We were not able to clear out the residual with alternating cup sips and thin liquid.,PHARYNGEAL STAGE:  ,No aspiration or penetration occurred during this evaluation.  The patient's hyolaryngeal elevation and anterior movements are within the functional limits.  Epiglottic inversion is within functional limits.  She had no residual or pooling in the pharynx after the swallow.,CERVICAL ESOPHAGEAL STAGE:  ,The patient's upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus.,DIAGNOSTIC IMPRESSION:  ,The patient had no aspiration or penetration occurred during this evaluation.  She does appear to have a diverticulum in the area between her right faucial pillars.  Additional evaluation is needed by an ENT physician.,PLAN:  ,Based on this evaluation, the following is recommended:,1.  The patient's diet should consist regular consistency food with thin liquids.  She needs to take small bites and small sips to help decrease her risk of aspiration and penetration as well as reflux.,2.  The patient should be referred to an otolaryngologist for further evaluation of her oral cavity particularly the area between her faucial pillars.,The above recommendations and results of the evaluation were discussed with the patient as well as her daughter and both responded appropriately.,Thank you for the opportunity to be required the patient's medical care.  She is not in need of skilled speech therapy and is discharged from my services.","consult - history and phy., globus sensation, oral stage, pharyngeal stage, cervical esophageal stage, consistency, otolaryngologist, barium swallow study evaluation, faucial pillars, swallow study, solid foods, evaluation, liquid, barium, oral, swallow, foods,"
" The patient is a 76-year-old male, with previous history of dysphagia, status post stroke.  A modified barium swallow study was ordered to objectively evaluate the patient's swallowing function and safety and to rule out aspiration.", Consult - History and Phy., Barium Swallow Study Evaluation - 1 ,"HISTORY:  ,The patient is a 76-year-old male, with previous history of dysphagia, status post stroke.  The patient stated that he was at Hospital, secondary to his stroke, where he had his initial modified barium swallow study.  The patient stated that the results of that modified revealed aspiration with thin liquids only.  He is currently eating and drinking without difficulty and he feels that he can return to a regular diet with thin liquids.  A modified barium swallow study was ordered to objectively evaluate the patient's swallowing function and safety and to rule out aspiration.,STUDY: , Modified barium swallow study was performed in the radiology suite in cooperation with Dr. X. The patient was seated upright and in a video-imaging chair throughout this assessment.,To evaluate the patient's swallowing function and safety, he was administered graduated amounts of liquid and food mixed with barium in the form of thin liquids (teaspoon x3, cup sip x3); nectar-thick liquid (teaspoon x2, cup sip x3); pureed consistency (teaspoon x3); solid consistency (1/4 cracker x1).,FINDINGS,ORAL STAGE: , The patient had no spillage out lips.  Oral residual after swallow with increased viscosity requiring multiple swallows to clear oral cavity.,The patient has reduced lingual retraction contributing to vallecula pooling after the swallow.  Trace premature spillage was noted with thin liquids during this assessment.,PHARYNGEAL STAGE: , Aspiration noted on cup sips of thin liquid.  Trace-to-mild penetration with teaspoon amounts of thin liquid during and after the swallow.  The penetration after the swallow occurred secondary to spillage on the piriform sinuses into the laryngeal vestibule.  The patient has incomplete laryngeal closure, which allowed the aspiration and penetration with thin liquids.  The patient had no aspiration or penetration occur with nectar-thick liquid, puree, and solid food.  The patient has a mildly reduced hyolaryngeal elevation and anterior movement that leads to incomplete epiglottic inversion that contributes to vallecula pooling.  Mild-to-moderate pooling in the vallecula after the swallow with liquids and puree, this residual did decrease with the solid feed presentation.  The patient has mild residual of pooling in the piriform sinuses after a swallow that did clear with sequential swallows.,CERVICAL ESOPHAGEAL STAGE: , The patient's upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus.,DIAGNOSTIC IMPRESSION: , Mild aspiration with cup sips of thin liquid, penetration during and after the swallow with teaspoon amounts of thin liquid.  No aspiration or penetration occurred with thick liquid, pureed, or solid food during this assessment.,PROGNOSTIC IMPRESSION: , With a modified diet, the patient's potential for swallowing safety is good.,PLAN:,Based on this evaluation, the following is recommended:,1.  The patient should be on a regular diet with nectar-thick liquids to help prevent aspiration and penetration.,2.  The patient should have unthickened water in between meals to help decrease his risk of dehydration.,3.  The patient should complete good oral care two times a day to decrease bacterial growth in mouth.,4.  The patient should be seated at a 90-degree angle when eating and drinking, as well as take small bites and small sips to help decrease risk of aspiration and penetration and reflux.,Thank you for the opportunity to evaluate the patient.  I look forward to working with him in the outpatient setting to improve his swallowing function and safety.  Outpatient skilled speech therapy is recommended for a trial of neuromuscular electrical stimulation therapy for muscle re-education, as well as to train patient to use swallowing techniques and maneuvers that should improve his swallowing function and safety.","consult - history and phy., oral stage, pharyngeal stage, cervical esophageal stage, nectar-thick liquids, aspiration, modified barium swallow, barium swallow study, dysphagia status, cup sips, barium swallow, swallow, teaspoon, barium, swallowing, "
 Bladder instillation for chronic interstitial cystitis., Consult - History and Phy., Bladder Instillation ,"CHIEF COMPLAINT:,  The patient comes for bladder instillation for chronic interstitial cystitis.,SUBJECTIVE:,  The patient is crying today when she arrives in the office saying that she has a lot of discomfort.  These bladder instillations do not seem to be helping her.  She feels anxious and worried.  She does not think she can take any more pain.  She is debating whether or not to go back to Dr. XYZ and ask for the nerve block or some treatment modality to stop the pain because she just cannot function on a daily basis and care for her children unless she gets something done about this, and she fears these bladder instillations because they do not seem to help.  They seem to be intensifying her pain.  She has the extra burden of each time she comes needing to have pain medication one way or another, thus then we would not allow her to drive under the influence of the pain medicine.  So, she has to have somebody come with her and that is kind of troublesome to her.  We discussed this at length.  I did suggest that it was completely appropriate for her to decide.  She will terminate these if they are that uncomfortable and do not seem to be giving her any relief, although I did tell her that occasionally people do have discomfort with them and then after the completion of the instillations, they do better and we have also had some people who have had to terminate the instillations because they were too uncomfortable and they could not stand it and they went on to have some other treatment modality.  She had Hysterectomy in the past.,MEDICATIONS: , Premarin 1.25 mg daily, Elmiron 100 mg t.i.d., Elavil 50 mg at bedtime, OxyContin 10 mg three tablets three times a day, Toprol XL 25 mg daily.,ALLERGIES:,  Compazine and Allegra.,OBJECTIVE:,Vital Signs:  Weight:  140 pounds.  Blood pressure:  132/90.  Pulse:  102.  Respirations:  18.  Age:  27.,PLAN:,  We discussed going for another evaluation by Dr. XYZ and seeking his opinion.  She said that she called him on the phone the other day and told him how miserable she was and he told her that he really thought she needed to complete.  The instillations give that a full trial and then he would be willing to see her back.  As we discussed these options and she was encouraged to think it over and decide what she would like to do for I could not makeup her mind for her.  She said she thought that it was unreasonable to quit now when she only had two or three more treatments to go, but she did indicate that the holiday weekend coming made her fearful and if she was uncomfortable after today’s instillation which she did choose to take then she would choose to cancel Friday’s appointment, also that she would not feel too badly over the holiday weekend.  I thought that was reasonable and agreed that that would work out.,PROCEDURE:,:  She was then given 10 mg of morphine subcutaneously because she did not feel she could tolerate the discomfort in the instillation without pain medicine.  We waited about 20 minutes.  The bladder was then instilled and the urethra was instilled with lidocaine gel which she tolerated and then after a 10-minute wait, the bladder was instilled with DMSO, Kenalog, heparin, and sodium bicarbonate, and the catheter was removed.  The patient retained the solution for one hour, changing position every 15 minutes and then voided to empty the bladder.  She seemed to tolerate it moderately well.  She is to call and let me know what she wishes to do about the Friday scheduled bladder instillation if she tolerated this then she is going to consider trying it.  If not, she will cancel and will start over next week or she will see Dr. Friesen.","consult - history and phy., urethra, dmso, bladder, chronic interstitial cystitis, interstitial cystitis, bladder instillation, instillation, instillations,"
" A woman presenting to our clinic for the first time for evaluation of hip pain, right greater than left, of greater than 2 years duration.  The pain is located laterally as well as anteriorly into the groin. ", Consult - History and Phy., Bilateral Hip Pain ,"HISTORY OF PRESENT ILLNESS:  ,The patient is a 38-year-old woman presenting to our clinic for the first time for evaluation of hip pain, right greater than left, of greater than 2 years duration.  The patient states that she began with right hip pain getting steadily worse over the last 2 years and has now developed some pain in the left hip.  The pain is located laterally as well as anteriorly into the groin.  She states that the pain is present during activities such as walking, and she does get some painful popping and clicking in the right hip.  She is here for evaluation for the first time.  She sought no previous medical attention for this.,PAST MEDICAL HISTORY:  ,Significant for depression and reflux disease.,PAST SURGICAL HISTORY: , Cesarean section x 2.,CURRENT MEDICATIONS: , Listed in the chart and reviewed with the patient.,ALLERGIES:  ,The patient has no known drug allergies.,SOCIAL HISTORY:  ,The patient is married.  She is employed as an office manager.  She does smoke cigarettes, one pack per day for the last 20 years.  She consumes alcohol 3 to 5 drinks daily.  She uses no illicit drugs.  She exercises monthly mainly walking and low impact aerobics.  She also likes to play softball.,REVIEW OF SYSTEMS: , Significant for occasional indigestion and nausea as well as anxiety and depression.  The remainder of the systems negative.,PHYSICAL EXAMINATION: , The patient is 5 foot, 2 inches tall, weighs 155 pounds.  The patient ambulates independently without an assist device with normal stance and gait.  Inspection of the hips reveals normal contour and appearance and good symmetry.  The patient is able to do an active straight leg raise against gravity and against resistance bilaterally.  She has no significant trochanteric tenderness.  She does, however, have some tenderness in the groin bilaterally.  There is no crepitus present with passive or active range of motion of the hips.  She is grossly neurologically intact in the bilateral lower extremities.,DIAGNOSTIC DATA:,  X-rays performed today in the clinic include an AP view of the pelvis and a frog-leg lateral of the right hip.  There are no acute findings.  No fractures or dislocations.  There are minimal degenerative changes noted in the joint.  There is, however, the suggestion of an exostosis on the superior femoral neck, which could be consistent with femoroacetabular impingement.,IMPRESSION: , Bilateral hip pain, right worse than left, possibly suggesting femoroacetabular impingement based on x-rays and her clinical picture is also consistent with possible labral tear.,PLAN:,  After discussing possible diagnoses with the patient, I have recommended that we get MRI arthrograms of the bilateral hips to evaluate the anatomy and especially concentrating on the labrum in the right hip.  We will get that done as soon as possible.  In the meantime, she is asked to moderate her activities.  She will follow up as soon as the MRIs are performed.","consult - history and phy., bilateral hip pain, femoroacetabular, impingement, hip,"
 Patient presented to the Bariatric Surgery Service for consideration of laparoscopic Roux-en-Y gastric bypass. , Consult - History and Phy., Bariatric Consult - Surgical Weight Loss - 4 ,"HISTORY OF PRESENT ILLNESS:,  Ms. A is a 55-year-old female who presented to the Bariatric Surgery Service for consideration of laparoscopic Roux-en-Y gastric bypass.  The patient states that she has been overweight for approximately 35 years and has tried multiple weight loss modalities in the past including Weight Watchers, NutriSystem, Jenny Craig, TOPS, cabbage diet, grape fruit diet, Slim-Fast, Richard Simmons, as well as over-the-counter measures without any long-term sustainable weight loss.  At the time of presentation to the practice, she is 5 feet 6 inches tall with a weight of 285.4 pounds and a body mass index of 46.  She has obesity-related comorbidities, which includes hypertension and hypercholesterolemia.,PAST MEDICAL HISTORY:,  Significant for hypertension, for which the patient takes Norvasc and Lopressor for.  She also suffers from high cholesterol and is on lovastatin for this.  She has depression, for which she takes citalopram.  She also stated that she had a DVT in the past prior to her hysterectomy.  She also suffers from thyroid disease in the past though this is unclear, the nature of this.,PAST SURGICAL HISTORY: , Significant for cholecystectomy in 2008 for gallstones.  She also had a hysterectomy in 1994 secondary to hemorrhage.  The patient denies any other abdominal surgeries.,MEDICATIONS: , Norvasc 10 mg p.o. daily, Lopressor tartrate 50 mg p.o. b.i.d., lovastatin 10 mg p.o. at bedtime, citalopram 10 mg p.o. daily, aspirin 500 mg three times a day, which is currently stopped, vitamin D, Premarin 0.3 mg one tablet p.o. daily, currently stopped, omega-3 fatty acids, and vitamin D 50,000 units q. weekly.,ALLERGIES: , The patient denies allergies to medications and to latex.,SOCIAL HISTORY: , The patient is a homemaker.  She is married, with 2 children aged 22 and 28.  She is a lifelong nonsmoker and nondrinker.,FAMILY HISTORY:  ,Significant for high blood pressure and diabetes as well as cancer on her father side.  He did pass away from congestive heart failure.  Mother suffers from high blood pressure, cancer, and diabetes.  Her mother has passed away secondary to cancer.  She has two brothers one passed away from brain cancer.,REVIEW OF SYSTEMS: , Significant for ankle swelling.  The patient also wears glasses for vision and has dentures.  She does complain of shortness of breath with exertion.  She also suffers from hemorrhoids and frequent urination at night as well as weightbearing joint pain.  The patient denies ulcerative colitis, Crohn disease, bleeding diathesis, liver disease, or kidney disease.  She denies chest pain, cardiac disease, cancer, and stroke.,PHYSICAL EXAMINATION:  ,The patient is a well-nourished, well-developed female, in no distress.  Eye Exam:  Pupils equal and reactive to light.  Extraocular motions are intact.  Neck Exam:  No cervical lymphadenopathy.  Midline trachea.  No carotid bruits.  Nonpalpable thyroid.  Neuro Exam:  Gross motor strength in the upper and lower extremities, equal bilaterally with no focal neuro deficits noted.  Lung Exam:  Clear breath sounds without rhonchi or wheezes.  Cardiac Exam:  Regular rate and rhythm without murmur or bruits.  Abdominal Exam:  Positive bowel sounds.  Soft, nontender, obese, and nondistended abdomen.  Lap cholecystectomy scars noted.  No obvious hernias.  No organomegaly appreciated.  Lower extremity Exam:  Edema 1+.  Dorsalis pedis pulses 2+.,ASSESSMENT:  ,The patient is a 55-year-old female with a body mass index of 46, suffering from obesity-related comorbidities including hypertension and hypercholesterolemia, who presents to the practice for consideration of gastric bypass surgery.  The patient appears to be an excellent candidate for surgery and would benefit greatly from surgical weight loss in the management of her obesity-related comorbidities.,PLAN: , In preparation for surgery, we will obtain the usual baseline laboratory values including baseline vitamin levels.  I recommended the patient undergo an upper GI series prior to surgery due to find her upper GI anatomy.  Also the patient will meet with the dietitian and psychologist as per her usual routine.  I have recommended approximately six to eight weeks of Medifast for the patient to obtain a 10% preoperative weight loss in preparation for surgery.","consult - history and phy., jenny craig, medifast, nutrisystem, richard simmons, slim-fast, tops, weight watchers, cabbage diet, grape fruit diet, roux-en-y, laparoscopic roux-en-y gastric bypass, weight loss modalities, surgical weight loss, body mass index, weight loss,"
 The patient was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities.  The patient is currently NPO with G-tube to meet all of his hydration and nutritional needs.  A trial of Passy-Muir valve was completed to allow the patient to achieve hands-free voicing., Consult - History and Phy., Barium Swallow Study & Speech Evaluation ,"CURRENT MEDICATIONS:,  Lortab.,PREVIOUS MEDICAL HISTORY: , Cardiac stent in 2000.,PATIENT'S GOAL: , To eat again by mouth.,STUDY:  ,A trial of Passy-Muir valve was completed to allow the patient to achieve hands-free voicing and also to improve his secretion management.  A clinical swallow evaluation was not completed due to the severity of the patient's mucus and lack of saliva control.,The patient's laryngeal area was palpated during a dry swallow and he does have significantly reduced laryngeal elevation and radiation fibrosis.  The further evaluate of his swallowing function is safety; a modified barium swallow study needs to be concluded to objectively evaluate his swallow safety, and to rule out aspiration.  A trial of neuromuscular electrical stimulation therapy was completed to determine if this therapy protocol will be beneficial and improving the patient's swallowing function and safety.,For his neuromuscular electrical stimulation therapy, the type was BMR with a single mode cycle time is 4 seconds and 12 seconds off with frequency was 60 __________ with a ramp of 2 seconds, phase duration was 220 with an output of 99 milliamps.  Electrodes were placed on the suprahyoid/submandibular triangle with an upright body position, trial length was 10 minutes.  On a pain scale, the patient reported no pain with the electrical stimulation therapy.,FINDINGS:  ,The patient was able to tolerate a 5-minute placement of the Passy-Muir valve.  He reported no discomfort on the inhalation; however, he felt some resistance on exhalation.  Instructions were given on care placement and cleaning of the Passy-Muir valve.  The patient was instructed to buildup tolerance over the next several days of his Passy-Muir valve and to remove the valve at anytime or he is going to be sleeping or napping throughout the day.  The patient's voicing did improve with the Passy-Muir valve due to decreased leakage from his trach secondary to finger occlusion.  Mucus production also seemed to decrease when the Passy-Muir was placed.,On the dry swallow during this evaluation, the patient's laryngeal area is reduced and tissues around his larynx and showed radiation fibrosis.  The patient's neck range of motion appears to be adequate and within normal limits.,A trial of neuromuscular electrical stimulation therapy:,The patient tolerating the neuromuscular electrical stimulation, we did achieve poor passive response, but these muscles were contracting and the larynx was moving upon stimulation.  The patient was able to actively swallow with stimulation approximately 30% of presentation.,DIAGNOSTIC IMPRESSION: , The patient with a history of head and neck cancer status post radiation and chemotherapy with radiation fibrosis, which is impeding his swallowing abilities.  The patient would benefit from outpatient skilled speech therapy for neuromuscular electrical stimulation for muscle reeducation to improve his swallowing function and safety and he would benefit from a placement of a Passy-Muir valve to have hands-free communication.,PLAN OF CARE: , Outpatient skilled speech therapy two times a week to include neuromuscular electrical stimulation therapy, Passy-Muir placement and a completion of the modified barium swallow study.,SHORT-TERM GOALS (6 WEEKS):,1.  Completion of modified barium swallow study.,2.  The patient will coordinate volitional swallow with greater than 75% of the neuromuscular electrical stimulations.,3.  The patient will increase laryngeal elevation by 50% for airway protection.,4.  The patient will tolerate placement of Passy-Muir valve for greater than 2 hours during awaking hours.,5.  The patient will tolerate therapeutic feedings with the speech and language pathologist without signs and symptoms of aspiration.,6.  The patient will decrease mild facial restrictions to the anterior neck by 50% to increase laryngeal movement.,LONG-TERM GOALS (8 WEEKS):,1.  The patient will improve secretion management to tolerable levels.,2.  The patient will increase amount and oral consistency of p.o. intake tolerated without signs and symptoms of aspirations.,3.  The patient will be able to communicate without using finger occlusion with the assistance of a Passy-Muir valve.",
" The patient has a manic disorder, is presently psychotic with flight of ideas, tangential speech, rapid pressured speech and behavior, impulsive behavior.   Bipolar affective disorder, manic state.  Rule out depression.", Consult - History and Phy., Bipolar Affective Disorder - Consult ,"IDENTIFYING DATA:  ,The patient is a 35-year-old Caucasian female who speaks English.,CHIEF COMPLAINT:  ,The patient has a manic disorder, is presently psychotic with flight of ideas, believes, ""I can fly,"" tangential speech, rapid pressured speech and behavior, impulsive behavior.  Last night, she tried to turn on the garbage disposal and put her hand in it, in the apartment shared by her husband.  She then turned on the oven and put her head in the oven and then tried to climb over the second storied  balcony.  All of these behaviors were interrupted by her husband who called 911.  He reports that she has not slept in 3 to 5 days and has not taken her meds in at least that time period.,HISTORY OF PRESENT ILLNESS:  ,The patient was treated most recently at ABCD Hospital and decompensated during that admission resulting in her 90-day LR being revoked.  After leaving ABCD approximately 01/25/2010, she stopped taking her Abilify and lithium.  Her husband states that he restrained her from jumping, ""so she would not kill herself,"" and this was taken as a statement in his affidavit.  The patient was taken to X Hospital, medically cleared, given Ativan 2 mg p.o. and transferred on an involuntary status to XYZ Hospital.  She arrives here and is today pacing on the unit and in and out of the large TV room area.  She is friendly towards the patients although sometimes raises her voice and comes too close to other patients in a rapid manner.  She is highly tangential, delusional, and disorganized.  She refused to sign all admit papers and a considerable part of her immediate history is unknown.,PAST PSYCHIATRIC HISTORY:  ,The patient was last admitted to XYZ Hospital on January 14, 2009, and discharged on January 23, 2009.  Please see the excellent discharge summary of Dr. X regarding this admission for information, which the patient is unable to give at the present.  She is currently treated by Dr. Y.  She has been involuntarily detained at least 7 times and revoked at least 6 times.  She was on XYZ Inpatient in 2001 and in 01/2009.  She states that she ""feels invincible"" when she becomes manic and this is also the description given by her husband.,MEDICAL HISTORY:  ,The patient has a history of a herniated disc in 1999.,MEDICATIONS: , Current meds, which are her outpatient meds, which she is not taking at the moment are lithium 300 mg p.o.  AM and 600 mg p.o. q.p.m., Abilify 15 mg p.o. per day, Lyrica 100 mg p.o. per day, it is not clear if she is taking Geodon as the record is conflicting in this regard.  She is being given Vicodin, is not sure who the prescriber for that medication is and it is presumably due to her history of herniated disc.  Of note, she also has a history of abusing Vicodin.,ALLERGIES:  ,Said to be PENICILLIN, LAMICTAL, and ZYPREXA.,SOCIAL AND DEVELOPMENTAL HISTORY: , The patient lives with her husband.  There are no children.  She reportedly has a college education and has 2 brothers.,SUBSTANCE AND ALCOHOL HISTORY: , Per ABCD information, the patient has a history of abusing opiates, benzodiazepines, and Vicodin.  The X Hospital tox screen of last night was positive for opiates.  Her lithium level per last night at X Hospital was 0.42 mEq/L.  She smokes nicotine, the amount is not known although she has asked and received Nicorette gum.,LEGAL HISTORY: , She had a 90-day LR, which was revoked at ABCD Hospital, 12/ 25/2009, when she quickly deteriorated.,MENTAL STATUS EXAM:,ATTITUDE: ,The patient's attitude is agitated when asked questions, loud and evasive.,APPEARANCE:,  Disheveled and moderately well nourished.,PSYCHOMOTOR: , Restless with erratic sudden movements.,EPS:,  None.,AFFECT: , Hyperactive, hostile, and labile.,MOOD: , Her mood is agitated, suspicious, and angry.,SPEECH:  ,Circumstantial and sometimes intelligible when asked simple direct questions and at other points becomes completely tangential describing issues which are not real.,THOUGHT CONTENT: , Delusional, disorganized, psychotic, and paranoid.  Suicidal ideation, the patient refuses to answer the questions, but the record shows a past history of suicide attempt.,COGNITIVE ASSESSMENT:  ,The patient was said on her nursing admit to be oriented to place and person, but could not answer that question for me, and appeared to think that she may still be at ABCD Hospital.  Her recent, intermediate, and remote memory are impaired although there is a lack of cooperation in this testing.,JUDGMENT AND INSIGHT:,  Nil.  When asked, are there situations when you lose control, she refuses to answer.  When asked, are meds helpful, she refuses to answer.  She refuses to give her family information nor release of information to contact them.,ASSETS:,  The patient has an outpatient psychiatrist and she does better or is more stable when taking her medications.,LIMITATIONS:,  The patient goes off her medications routinely, behaves unsafely and in a potentially suicidal manner.,FORMULATION,:  The patient has bipolar affective disorder in a manic state at present.  She also may be depressed and is struggling with marital issues.,DIAGNOSES:",
 Evaluation for bariatric surgery., Consult - History and Phy., Bariatric Consult - Surgical Weight Loss - 3 ,"PAST MEDICAL HISTORY: , Her medical conditions driving her toward surgery include hypercholesterolemia, hypertension, varicose veins, prior history of stroke.  She denies any history of cancer.  She does have a history of hepatitis which I will need to further investigate.  She complains of multiple joint pains, and heavy snoring.,PAST SURGICAL HISTORY: , Includes hysterectomy in 1995 for fibroids and varicose vein removal.  She had one ovary removed at the time of the hysterectomy as well.,SOCIAL HISTORY:,  She is a single mother of one adopted child.,FAMILY HISTORY:  ,There is a strong family history of heart disease and hypertension, as well as diabetes on both sides of her family.  Her mother is alive.  Her father is deceased from alcohol.  She has five siblings.,MEDICATIONS: , As you know she takes the following medications for her diabetes, insulin 70 units/6 units times four years, aspirin 81 mg a day, Actos 15 mg, Crestor 10 mg and CellCept 500 mg two times a day.,ALLERGIES: , She has no known drug allergies.,PHYSICAL EXAM: , She is a 54-year-old obese female.  She does not appear to have any significant residual deficits from her stroke.  There may be slight left arm weakness.,ASSESSMENT/PLAN:,  We will have her undergo routine nutritional and psychosocial assessment.  I suspect that we can significantly improve the situation with her insulin and oral hypoglycemia, as well as hypertension, with significant weight loss.  She is otherwise at increased risk for future complications given her history, and weight loss will be a good option.  We will see her back in the office once she completes her preliminary workup and submit her for approval to the insurance company.","consult - history and phy., evaluation for bariatric surgery, bariatric surgery, varicose veins, weight loss, varicose, veins, diabetes, bariatric, surgical, loss, surgery, hypertension, weight,"
 , Consult - History and Phy., Barium Swallow Study & Speech Evaluation - 1 ,"SUBJECTIVE: , The patient is a 60-year-old female, who complained of coughing during meals.  Her outpatient evaluation revealed a mild-to-moderate cognitive linguistic deficit, which was completed approximately 2 months ago.  The patient had a history of hypertension and TIA/stroke.  The patient denied history of heartburn and/or gastroesophageal reflux disorder.  A modified barium swallow study was ordered to objectively evaluate the patient's swallowing function and safety and to rule out aspiration.,OBJECTIVE: , Modified barium swallow study was performed in the Radiology Suite in cooperation with Dr. ABC.  The patient was seated upright in a video imaging chair throughout this assessment.  To evaluate the patient's swallowing function and safety, she was administered graduated amounts of liquid and food mixed with barium in the form of thin liquid (teaspoon x2, cup sip x2); nectar-thick liquid (teaspoon x2, cup sip x2); puree consistency (teaspoon x2); and solid food consistency (1/4 cracker x1).,ASSESSMENT,ORAL STAGE:,  Premature spillage to the level of the valleculae and pyriform sinuses with thin liquid.  Decreased tongue base retraction, which contributed to vallecular pooling after the swallow.,PHARYNGEAL STAGE: , No aspiration was observed during this evaluation.  Penetration was noted with cup sips of thin liquid only.  Trace residual on the valleculae and on tongue base with nectar-thick puree and solid consistencies.  The patient's hyolaryngeal elevation and anterior movement are within functional limits.  Epiglottic inversion is within functional limits.,CERVICAL ESOPHAGEAL STAGE:  ,The patient's upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus.  Radiologist noted reduced peristaltic action of the constricted muscles in the esophagus, which may be contributing to the patient's complaint of globus sensation.,DIAGNOSTIC IMPRESSION:,  No aspiration was noted during this evaluation.  Penetration with cup sips of thin liquid.  The patient did cough during this evaluation, but that was noted related to aspiration or penetration.,PROGNOSTIC IMPRESSION: ,Based on this evaluation, the prognosis for swallowing and safety is good.,PLAN: , Based on this evaluation and following recommendations are being made:,1.  The patient to take small bite and small sips to help decrease the risk of aspiration and penetration.,2.  The patient should remain upright at a 90-degree angle for at least 45 minutes after meals to decrease the risk of aspiration and penetration as well as to reduce her globus sensation.,3.  The patient should be referred to a gastroenterologist for further evaluation of her esophageal function.,The patient does not need any skilled speech therapy for her swallowing abilities at this time, and she is discharged from my services.","consult - history and phy., gastroesophageal reflux disorder, cognitive linguistic deficit, tia, stroke, swallowing function, swallow study, barium swallow study, globus sensation, esophageal, penetration"
 Evaluation for elective surgical weight loss via the Lap-Band as opposed to gastric bypass., Consult - History and Phy., Bariatric Consult - Surgical Weight Loss - 2 ,"PAST MEDICAL HISTORY:  ,She had a negative stress test four to five years ago.  She gets short of breath in walking about 30 steps.  She has had non-insulin dependent diabetes for about eight years now.  She has a left knee arthritis and history of hemorrhoids.,PAST SURGICAL HISTORY: , Pertinent for laparoscopic cholecystectomy, tonsillectomy, left knee surgery, and right breast lumpectomy.,PSYCHOLOGICAL HISTORY: , Negative except that she was rehabilitated for alcohol addiction in 1990.,SOCIAL HISTORY: , The patient is married.  She is an office manager for a gravel company.  Her spouse is also overweight.  She drinks on a weekly basis and she smokes,about two packs of cigarettes over a week's period of time.  She is doing this for about 35 years.,FAMILY HISTORY: , Diabetes and hypertension.,MEDICATIONS:,  Include Colestid 1 g daily, Actos 30 mg daily, Amaryl 2 mg daily, Soma, and meloxicam for her back pain.,ALLERGIES:,  She has no allergies; however, she does get tachycardic with caffeine, Sudafed, or phenylpropanolamine.,REVIEW OF SYSTEMS: , Otherwise, negative.,PHYSICAL EXAM: , This is a pleasant female in no acute distress.  Alert and oriented x 3.  HEENT:  Normocephalic, atraumatic.  Extraocular muscles intact, nonicteric sclerae.  Chest is clear.  Abdomen is obese, soft, nontender and nondistended.  Extremities show no edema, clubbing or cyanosis.,ASSESSMENT/PLAN: , This is a 51-year-old female with a BMI of 43 who is interested in the Lap-Band as opposed to gastric bypass.  ABC will be asking for a letter of medical necessity from XYZ.  She will also need an EKG and clearance for surgery.  She will also see my nutritionist and social worker and once this is completed, we will submit her to her insurance company for approval.","consult - history and phy., elective surgical weight loss, surgical weight loss, weight loss, lap band, gastric bypass, loss, weight, lap, band, lost, gained, diabetes, gastric, bypass, overweight, surgical"
 Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band., Consult - History and Phy., Bariatric Consult - Surgical Weight Loss - 1 ,"PAST MEDICAL HISTORY: , She has a history of hypertension and shortness of breath.,PAST SURGICAL HISTORY: , Pertinent for cholecystectomy.,PSYCHOLOGICAL HISTORY: , Negative.,SOCIAL HISTORY: , She is single.  She drinks alcohol once a week.  She does not smoke.,FAMILY HISTORY: , Pertinent for obesity and hypertension.,MEDICATIONS: , Include Topamax 100 mg twice daily, Zoloft 100 mg twice daily, Abilify 5 mg daily, Motrin 800 mg daily, and a multivitamin.,ALLERGIES: , She has no known drug allergies.,REVIEW OF SYSTEMS: , Negative.,PHYSICAL EXAM:  ,This is a pleasant female in no acute distress.  Alert and oriented x 3.  HEENT:  Normocephalic, atraumatic.  Extraocular muscles intact, nonicteric sclerae.  Chest is clear to auscultation bilaterally.  Cardiovascular is normal sinus rhythm.  Abdomen is obese, soft, nontender and nondistended.  Extremities show no edema, clubbing or cyanosis.,ASSESSMENT/PLAN:  ,This is a 34-year-old female with a BMI of 43 who is interested in surgical weight via the gastric bypass as opposed to Lap-Band.  ABC will be asking for a letter of medical necessity from Dr. XYZ.  She will also see my nutritionist and social worker and have an upper endoscopy.  Once this is completed, we will submit her to her insurance company for approval.","consult - history and phy., elective surgical weight loss, surgical weight loss, weight loss, loss, weight, bmi, surgical, pounds,"
" Acute renal failure, probable renal vein thrombosis, hypercoagulable state, and deep venous thromboses with pulmonary embolism.", Consult - History and Phy., Azotemia Consult ,"REASON FOR CONSULTATION: , Azotemia.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 36-year-old gentleman admitted to the hospital because he passed out at home.,Over the past week, he has been noticing increasing shortness of breath.  He also started having some abdominal pain; however, he continued about his regular activity until the other day when he passed out at home.  His wife called paramedics and he was brought to the emergency room.,The patient has had a workup at this time which shows bilateral pulmonary infarcts.  He has been started on heparin and we are asked to see him because of increasing BUN and creatinine.,The patient has no past history of any renal problems.  He feels that he has been in good health until this current episode.  His appetite has been good.  He denies swelling in his feet or ankles.  He denies chest pain.  He denies any problems with bowel habits.  He denies any unexplained weight loss.  He denies any recent change in bowel habits or recent change in urinary habits.,PHYSICAL EXAMINATION:,GENERAL:  A gentleman seen who appears his stated age.,VITAL SIGNS:  Blood pressure is 130/70.,CHEST:  Chest expands equally bilaterally.  Breath sounds are heard bilaterally.,HEART:  Had a regular rhythm, no gallops or rubs.,ABDOMEN:  Obese.  There is no organomegaly.  There are no bruits.  There is no peripheral edema.  He has good pulse in all 4 extremities.  He has good muscle mass.,LABORATORY DATA: , The patient's current chemistries include a hemoglobin of 14.8, white count of 16.3, his sodium 133, potassium 5.1, chloride 104, CO2 of 19, a BUN of 26, and a creatinine of 3.5.  On admission to the hospital, his creatinine on 6/27/2009 was 0.9.,The patient has had several studies including a CAT scan of his abdomen, which shows poor perfusion to his right kidney.,IMPRESSION:,1.  Acute renal failure, probable renal vein thrombosis.,2.  Hypercoagulable state.,3.  Deep venous thromboses with pulmonary embolism.,DISCUSSION: , We are presented with a 36-year-old gentleman who has been in good health until this current event.  He most likely has a hypercoagulable state and has bilateral pulmonary emboli.  Most likely, the patient has also had emboli to his renal veins and it is causing renal vein thrombosis.,Interestingly, the urine protein was obtained which is not that elevated and I would suspect that it would have been higher.  Unfortunately, the patient has been exposed to IV dye and my anxiety is that this too is contributing to his current problem.,The patient's urine output is about 30 to 40 mL per hour.,Several chemistries have been ordered.  A triple renal scan has been ordered.,I reviewed all of this with the patient and his wife.  Hopefully under his current anticoagulation, there will be some resolution of his renal vein thrombosis.  If not and his renal failure progresses, we are looking at dialytic intervention.  Both he and his wife were aware of this.  ,Thank you very much for asking to see this acutely ill gentleman in consultation with you.","consult - history and phy., urine output, deep venous thromboses, renal failure, pulmonary embolism, renal, azotemia, hypercoagulable, vein, thrombosis, pulmonary, "
 A 74-year-old woman for Cardiology consultation regarding atrial fibrillation and anticoagulation after a fall.  The patient denies any chest pain nor clear shortness of breath., Consult - History and Phy., Atrial Fibrillation - Consult ,"HISTORY OF PRESENT ILLNESS:,  I was kindly asked to see Ms. ABC who is a 74-year-old woman for cardiology consultation regarding atrial fibrillation and anticoagulation after a fall.,The patient is somnolent at this time, but does arouse, but is unable to provide much history.  By review of the chart, it appears that she fell, which is what she states when she got up out of a rocking chair and could not get herself off the floor.  She states that 1-1/2 hours later she was able to get herself off the floor.,The patient denies any chest pain nor clear shortness of breath.,PAST MEDICAL HISTORY: , Includes, end-stage renal disease from hypertension.  She follows up with Dr. X in her office and has been known to have a small-to-moderate sized pericardial effusion since 11/07 that has apparently been followed and it appears that the patient was not interested in having diagnostic pericardiocentesis done.  She had an echocardiogram today (please see also that report), which shows stable and small-to-moderate sized pericardial effusion without tamponade, normal left ventricular ejection fraction at 55% with mild concentric left ventricular hypertrophy, mildly dilated right ventricular size, normal right ventricular ejection fraction, moderate mitral regurgitation and severe tricuspid regurgitation with severe pulmonary hypertension, estimated PA systolic pressure of 71 mmHg when compared to the prior echocardiogram done 08/29/07, previously the mitral regurgitation was mild and previously the PA systolic pressure was estimated at 90 mmHg.  Other findings were not significantly changed including pericardial effusion description.  She has a history of longstanding hypertension.  She has been on hemodialysis since 1997 for renal failure, history of mini-strokes documented several years ago, history of seizure disorder, she has a history of right upper extremity edema and right breast enlargement from right subclavian vein occlusion.  She has a history of hypertension, depression, hyperlipidemia, on Sensipar for tertiary hyperparathyroidism.,PAST SURGICAL HISTORY: , Includes, cholecystectomy, post fistula in the left arm, which has failed, and right arm, which is being used including number of operative procedures to the fistula.  She follows up with Dr. Y regarding neurovascular surgery.,MEDICATIONS: , On admission:,1.  Norvasc 10 mg once a day.,2.  Aspirin 81 mg once a day.,3.  Colace 200 mg two at bedtime.,4.  Labetalol 100 mg p.o. b.i.d.,5.  Nephro-Vite one tablet p.o. q.a.m.,6.  Dilantin 100 mg p.o. t.i.d.,7.  Renagel 1600 mg p.o. t.i.d.,8.  Sensipar 120 mg p.o. every day.,9.  Sertraline 100 mg p.o. nightly.,10.  Zocor 20 mg p.o. nightly.,ALLERGIES: , TO MEDICATIONS PER CHART ARE NONE.,FAMILY HISTORY:  ,Unable to obtain as the patient becomes quite sleepy when I am talking.,SOCIAL HISTORY:  ,Unable to obtain as the patient becomes quite sleepy when I am talking.,REVIEW OF SYSTEMS: , Unable to obtain as the patient becomes quite sleepy when I am talking.,PHYSICAL EXAM:  ,Temperature 99.2, blood pressure ranges from 88/41 to 108/60, pulse 70, respiratory rate, 20, O2 saturation 98%.  Height is 5 feet 1 inch, weight 147 pounds.  On general exam, she is a pleasant elderly woman who does arouse to voice, but then becomes quite sleepy and apparently that is an improvement from when she was admitted.  HEENT shows the cranium is normocephalic and atraumatic.  She has moist mucosal membranes.  Neck veins are difficult to assess, but do not appear clinically distended.  No carotid bruits.  Lungs are clear to auscultation anteriorly.  No wheezes.  Cardiac exam:  S1, S2 regular rate, 3/6 holosystolic murmur heard with radiation from the left apex towards the left axilla.  No rub, no gallop.  PMI is nondisplaced.  Abdomen:  Soft, nondistended.  CVA is benign.  Extremities with no significant edema.  Pulses appear grossly intact.  She has evidence of right upper extremity edema, which is apparently chronic.,DIAGNOSTIC DATA/LAB DATA: , EKGs are reviewed including from 07/07/09 at 08:31 a.m., which shows atrial fibrillation with left anterior fascicular block, poor R-wave progression when compared to one done on 07/06/09 at 18:25, there is really no significant change.  The atrial fibrillation appears present since at least on EKG done on 11/02/07 and this EKG is not significantly changed from the most recent one.  Echocardiogram results as above.  Chest x-ray shows mild pulmonary vascular congestion.  BNP shows 3788.  Sodium 136, potassium 4.5, chloride 94, bicarbonate 23, BUN 49, creatinine 5.90.  Troponin was 0.40 followed by 0.34.  INR 1.03 on 05/18/07.  White blood cell count 9.4, hematocrit 42, platelet count 139.,IMPRESSION: , Ms. ABC is a 74-year-old woman admitted to the hospital with a fall and she has a history of vascular dementia, so her history is somewhat unreliable it seems and she is somnolent at that time.  She does have chronic atrial fibrillation again documented at least present since 2007 and I found an EKG report by Dr. X, which shows atrial fibrillation on 08/29/07 per her report.  One of the questions we were asked was whether the patient would be a candidate for Coumadin.  Clearly given her history of small mini-strokes, I think Coumadin would be appropriate given this chronic atrial fibrillation, but the main issue is the fall risk.  If not felt to be significant fall risk then I would strongly recommend Coumadin as the patient herself states that she has only fallen twice in the past year.  I would defer that decision to Dr. Z and Dr. XY who know the patient well and it may be that physical therapy consult is appropriate to help adjudicate.,RECOMMENDATIONS:,1.  Fall assessment as per Dr. Z and Dr. XY with possible PT consult if felt appropriate and if the patient is not felt to be at significant fall risk, would put her on Coumadin.  Given her history of small strokes as documented in the chart and her chronic atrial fibrillation, she does have reasonable heart rate control on current labetalol.,2.  The patient has elevated BNP and I suspect that is due to her severe pulmonary hypertension and renal failure and in the light of normal LV function, I would not make any further evaluation of that other than aggressive diuresis.,3.  Regarding this minimal troponin elevation, I do not feel this is a diagnosis especially in the setting of pulmonary hypertension and her small-to-moderate sized stable pericardial effusion again that has been longstanding since 2007 from what I can tell and there is no evidence of tamponade.  I would defer to her usual cardiologist Dr. X whether an outpatient stress evaluation is appropriate for risk stratification.  I did find that the patient had a prior cardiac stress test in 08/07 where they felt that there was some subtle reversibility of the anterior wall, but it was felt that it may be artifact rather than true ischemia with normal LV function seen on that study as well.,4.  Continue Norvasc for history of hypertension as well as labetalol.,5.  The patient is felt to be a significant fall risk and will at least continue her aspirin 81 mg once a day for secondary CVA, thromboprophylaxis (albeit understanding that it is inferior to Coumadin).,6.  Continue Dilantin for history of seizures.",
" The patient is a 21-year-old Caucasian male, who attempted suicide by trying to jump from a moving car, which was being driven by his mother. ", Consult - History and Phy., Attempted Suicide - Consult ,"IDENTIFYING DATA: , The patient is a 21-year-old Caucasian male, who attempted suicide by trying to jump from a moving car, which was being driven by his mother.  Additionally, he totaled his own car earlier in the day, both of which occurrences occurred approximately 72 hours before arriving at ABCD Hospital.  He says he had a ""panic attack leading to the car wreck"" and denies that any of his behavior was suicidal in nature responding, ""I was just trying to scare my mother."",CHIEF COMPLAINT: , The patient does say, ""I screwed up my whole life and wrecked my car."" The patient claims he is med compliant, although his mother, and stepfather saying he is off his meds.  He had a two-day stay at XYZ Hospital for medical clearance after his car accident, and no injuries were found other than a sore back, which was negative by x-ray and CT scan.,PRESENT ILLNESS:  ,The patient is on a 72-your involuntary hold for danger to self and grave disability.  He has a history of bipolar disorder with mania and depression with anxiety and panic attacks.  Today, he went to involuntary court hearing and was released by the court.  He is now being discharged from second floor ABCD Psychiatric Hospital.,PAST PSYCHIATRIC HISTORY:,  Listed extensively in his admission note and will not be repeated.,MEDICAL HISTORY: , Includes migraine headaches and a history of concussion.  He describes ""allergy"" to Haldol medication.,OUTPATIENT CARE: , The patient sees a private psychiatrist, Dr. X.  Followup with Dr. X is arranged in four days' time and the patient is discharged with four days of medication.  This information is known to Dr. X.,DISCHARGE MEDICATIONS:,The patient is discharged with:,1.  Klonopin 1 mg t.i.d. p.r.n.,2.  Extended-release lithium 450 mg b.i.d.,3.  Depakote 1000 mg b.i.d.,4.  Seroquel 1000 mg per day.,SOCIAL HISTORY:  ,The patient lives with his girlfriend on an on-and-off basis and is unclear if they will be immediately moving back in together.,SUBSTANCE ABUSE: , The patient was actively tox screen positive for benzodiazepines, cocaine, and marijuana.  The patient had an inpatient stay in 2008 at ABC Lodge for drug abuse treatment.,MENTAL STATUS EXAM:,  Notable for lack of primary psychotic symptoms, some agitation, and psychomotor hyperactivity, uncooperative behavior regarding his need for ongoing acute psychiatric treatment and stabilization.  There is an underlying hostile oppositional message in his communications.,FORMULATION: , The patient is a 21-year-old male with a history of bipolar disorder, anxiety, polysubstance abuse, and in addition ADHD.  His recent behavior is may be at least in part associated with active polysubstance abuse and also appears to be a result of noncompliance with meds.,DIAGNOSES:,AXIS I:,1.  Bipolar disorder.,2.  Major depression with anxiety and panic attacks.,3.  Polysubstance abuse, benzodiazepines, and others street meds.,4.  ADHD.,AXIS II: , Deferred at present, but consider personality disorder traits.,AXIS III:,  History of migraine headaches and past history of concussion.,AXIS IV: , Stressors are moderate.,AXIS V: , GAF is 40.,PLAN: , The patient is released from the hospital secondary to court evaluation, which did not extend his involuntary stay.  He has an appointment in four days with his outpatient psychiatrist, Dr. X.  He has four days' worth of medications and agrees to no self-harm or harm of others.  Additionally, he agrees to let staff know or authorities know if he becomes acutely unsafe.  His mother and stepfather have been informed of the patient's discharge and the followup plan.",
 Patient complaining of cough and blood mixed with sputum production with a past medical history significant for asbestos exposure., Consult - History and Phy., Asbestos Exposure - Hemoptysis ,"REASON FOR CONSULTATION: , Hemoptysis.,HISTORY OF PRESENT ILLNESS: , The patient is an 80-year-old African-American male, very well known to my service, with a past medical history significant for asbestos exposure.  The patient also has a very extensive cardiac history that would be outlined below.  He is being admitted with worsening shortness of breath and constipation.  He is also complaining of cough and blood mixed with sputum production, but there is no fever.,PAST MEDICAL HISTORY,1.  Benign prostatic hypertrophy.,2.  Peptic ulcer disease.,3.  Atrial fibrillation.,4.  Coronary artery disease.,5.  Aortic valve replacement in 1991, St. Jude mechanical valve #23.,6.  ICD implantation.,7.  Peripheral vascular disease.,8.  CABG in 1991 and 1998.,9.  Congestive heart failure, EF 40%.,10.  Asbestos exposure.,MEDICATIONS,1.  Coumadin 6 mg alternating with 9 mg.,2.  Prevacid 30 mg once a day.,3.  Diovan 160 mg every day.,4.  Flomax 0.4 mg every day.,5.  Coreg 25 mg in the morning and 12.5 mg at night.,6.  Aldactone 25 mg a day.,7.  Lasix 20 mg a day.,8.  Zocor 40 mg every day.,ALLERGIES,1. DARVOCET.,2. CLONIDINE.,PHYSICAL EXAMINATION,GENERAL:  The patient is an elderly male; awake, alert, and oriented, in no acute distress.,VITAL SIGNS:  Blood pressure is 136/80, pulse is 70, respiratory rate is 20, temperature 99.3, pulse oximetry 96% on 2 L nasal cannula.,HEENT:  Significant for peripheral cyanosis.,NECK:  Supple.,LUNGS:  Bibasilar crackles with decreased breath sounds in the left base.,CARDIOVASCULAR:  Regular rate and rhythm with murmur and metallic click.,ABDOMEN:  Soft and benign.,EXTREMITIES:  1+ cyanosis.  No clubbing.  No edema.,LABORATORY DATA:,  Shows a white count of 6.9, hemoglobin 10.6, hematocrit 31.2, and platelet count 160,000.  CK 266, PTT 37, PT 34, and INR 3.7.  Sodium 141, potassium 4.2, chloride 111, CO2 23, BUN 18, creatinine 1.7, glucose 91, calcium 8.6, total protein 6.1, albumin 3.3, total bilirubin 1.4, alkaline phosphatase 56, and troponin I 0.085 and 0.074.,DIAGNOSTIC STUDIES: , Chest x-ray shows previous sternotomy with ICD implantation and aortic valve mechanical implant with left-sided opacification of the diaphragm worrisome for pleural effusion.,ASSESSMENT,1.  Hemoptysis.,2.  Acute bronchitis.,3.  Coagulopathy.,4.  Asbestos exposure.,5.  Left pleural effusion.,RECOMMENDATIONS,1.  Antibiotics.",
 Questionable need for antibiotic therapy for possible lower extremity cellulitis., Consult - History and Phy., Antibiotic Therapy Consult ,"REASON FOR CONSULTATION: , Questionable need for antibiotic therapy for possible lower extremity cellulitis.,HISTORY OF PRESENT ILLNESS: , The patient is a 51-year-old Caucasian female with past medical history of morbid obesity and chronic lower extremity lymphedema.  She follows up at the wound care center at Hospital.  Her lower extremity edema is being managed there.  She has had multiple episodes of cellulitis of the lower extremities for which she has received treatment with oral Bactrim and ciprofloxacin in the past according to her.  As her lymphedema was not improving on therapy at that facility, she was referred for admission to Long-Term Acute Care Facility for lymphedema management.  She at present has a stage II ulcer on the lower part of the medial aspect of left leg without any drainage and has slight erythema of bilateral lower calf and shin areas.  Her measurements for lymphedema wraps have been taken and in my opinion, it is going to be started in a day or two.,I have been consulted to rule out the possibility of lower extremity cellulitis that may require antibiotic therapy.,PAST MEDICAL HISTORY:,  Positive for morbid obesity, chronic lymphedema of the lower extremities, at least for the last three years, spastic colon, knee arthritis, recurrent cellulitis of the lower extremities.  She has had a hysterectomy and a cholecystectomy in the remote past.,SOCIAL HISTORY: , The patient lives by herself and has three pet cats.  She is an ex-smoker, quit smoking about five years ago.  She occasionally drinks a glass of wine.  She denies any other recreational drugs use.  She recently retired from State of Pennsylvania as a psychiatric aide after 32 years of service.,FAMILY HISTORY: , Positive for mother passing away at the age of 38 from heart problems and alcoholism, dad passed away at the age of 75 from leukemia.  One of her uncles was diagnosed with leukemia.,ALLERGIES: , ADHESIVE TAPE ALLERGIES.,REVIEW OF SYSTEMS:,  At present, the patient is admitted with a nonresolving bilateral lower extremity lymphedema, which is a little bit more marked on the right lower extremity compared to the left.  She denies any nausea, vomiting or diarrhea.  She denies any pain, tenderness, increased warmth or drainage from the lower extremities.  Denies chest pain, cough or phlegm production.  All other systems reviewed were negative.,PHYSICAL EXAMINATION:,General:  A 51-year-old morbidly obese Caucasian female who is not in any acute hemodynamic distress at present.,Vital signs:  Her maximum recorded temperature since admission today is 96.8, pulse is 65 per minute, respiratory rate is 18 to 20 per minute, blood pressure is 150/54, I do not see a recorded weight at present.,HEENT:  Pupils are equal, round, and reactive to light.  Extraocular movements intact.  Head is normocephalic and external ear exam is normal.,Neck:  Supple.  There is no palpable lymphadenopathy.,Cardiovascular system:  Regular rate and rhythm of the heart without any appreciable murmur, rub or gallop.  Heart sounds are little distant secondary to thick chest wall.,Lungs:  Clear to auscultation and percussion bilaterally.,Abdomen:  Morbidly obese, soft, nontender, nondistended, there is no percussible organomegaly, there is no evidence of lymphedema on the abdominal pannus.  There is no evidence of cutaneous candidiasis in the inguinal folds.  There is no palpable lymphadenopathy in the inguinal and femoral areas.,Extremities:  Bilateral lower extremities with evidence of extensive lymphedema, there is slight pinkish discoloration of the lower part of calf and shin areas, most likely secondary to stasis dermatosis.  There is no increased warmth or tenderness, there is no skin breakdown except a stage II chronic ulcer on the lower medial aspect of the right calf area.  It has minimal serosanguineous drainage and there is no surrounding erythema.  Therefore, in my opinion, there is no current evidence of cellulitis or wound infection.  There is no cyanosis or clubbing.  There is no peripheral stigmata of endocarditis.,Central nervous system:  The patient is alert and oriented x3, cranial nerves II through XII are intact, and there is no focal deficit appreciated.,LABORATORY DATA: , White cell count is 7.4, hemoglobin 12.9, hematocrit 39, platelet count of 313,000, differential is normal with 51% neutrophils, 37% lymphocytes, 9% monocytes and 3% eosinophils.  The basic electrolyte panel is within normal limits and the renal function is normal with BUN of 17 and creatinine of 0.5.  Liver function tests are also within normal limits.,The nasal screen for MRSA is negative.  Urine culture is negative so far from admission.  Urinalysis was negative for pyuria, leucocyte esterase, and nitrites.,IMPRESSION AND PLAN:,  A 51-year-old Caucasian female with multiple medical problems mentioned above including history of morbid obesity and chronic lower extremity lymphedema.  Admitted for inpatient management of bilateral lower extremity lymphedema.  I have been consulted to rule out possibility of active cellulitis and wound infection.,At present, I do not find evidence of active cellulitis that needs antibiotic therapy.  In my opinion, lymphedema wraps could be initiated.  We will continue to monitor her legs with lymphedema wraps changes 2 to 3 times a week.  If she develops any cellulitis, then appropriate antibiotic therapy will be initiated. ,Her stage II ulcer on the right leg does not look infected.  I would recommend continuation of wound care along with lymphedema wraps.,Other medical problems will continue to be followed and treated by Dr. X's group during this hospitalization.  Dr. Y from Plastic Surgery and Lymphedema Management Clinic is following.,I appreciate the opportunity of participating in this patient's care.  If you have any questions, please feel free to call me at any time.  I will continue to follow the patient along with you 2-3 times per week during this hospitalization at the Long-Term Acute Care Facility.",
" The patient is a very pleasant 62-year-old African American female with a history of hypertension, hypercholesterolemia, and CVA, referred for evaluation and management of atrial fibrillation.", Consult - History and Phy., Atrial Fibrillation Management ,"REASON FOR CONSULTATION: , Atrial fibrillation management.,HISTORY OF PRESENT ILLNESS: ,The patient is a very pleasant 62-year-old African American female with a history of hypertension, hypercholesterolemia, and CVA, referred by Dr. X for evaluation and management of atrial fibrillation.  The patient states that on Monday during routine Holt exam, it was detected by Dr. X that her heart was irregular on exam.  EKG obtained after that revealed atrial fibrillation, and subsequently the patient was started on Coumadin as well as having Toprol and referred for evaluation.  The patient states that for the last 3 years, she has had episodes of her heart racing.  It may last for minutes up to most 1 hour, and it will occasionally be related to eating a heavy meal or her caffeine or chocolate intake.  Denies dyspnea, diaphoresis, presyncope or syncope with the events, and she has had no episodes of chest pain.  They subsequently resolve on their own and do not limit her in anyway.  However, she states that for the last several years may be up to 7 years that she can recollect that she has been fatigued, and over the past couple of years, her symptoms have become more severe.  She said she can walk no more than 25 feet without becoming tired.  She states that she has to rest then her symptoms will go away, but she has been limited from that standpoint.  Denies peripheral edema, PND, orthopnea, abdominal pain, swelling, recent fever or chills.  She actually today has no complaints, and states that she has been compliant with her medications and has started taking her Coumadin as directed.,PAST MEDICAL HISTORY:,1.  Hypertension.,2.  Myocardial infarction in 2003.,3.  Left heart catheterization at University Hospital.,4.  Hypercholesterolemia.,5.  Arthritis.,6.  CVA in 2002 and in 2003 with right eye blindness.,PAST SURGICAL HISTORY:,1.  Left total knee replacement in 2002.,2.  Left lower quadrant abscess drainage in 12/07,FAMILY MEDICAL HISTORY: , Significant for lung and brain cancer.  There is no history that she is aware of cardiovascular disease in her family nor has any family member had sudden cardiac death.,SOCIAL HISTORY: , She is retired as a cook in a school cafeteria, where she worked for 34 years.  She retired 7 years ago because of low back pain.  She used to smoke 2-1/2 packs per day for 32 years, but quit in 1995.  Denies alcohol, and denies IV or illicit drug use.,ALLERGIES: , No known drug allergies.,MEDICATIONS:,1.  Coumadin 5 mg a day.,2.  Toprol-XL 50 mg a day.,3.  Aspirin 81 mg a day.,4.  Hydrochlorothiazide 25 mg a day.,5.  Plendil 10 mg daily.,6.  Lipitor 40 mg daily.,REVIEW OF SYSTEMS:  ,As above stating that following her stroke, she has right eye blindness, but she does have some minimal vision in her periphery.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure 138/66, pulse 96, and weight 229 pounds or 104 kg.  GENERAL:  A well-developed, well-nourished, middle-aged African American female in no acute distress.  NECK:  Supple.  No JVD.  No carotid bruits.  CARDIOVASCULAR:  Irregularly irregular rate and rhythm.  Normal S1 and S2.  No murmurs, gallops or rubs.  LUNGS:  Clear to auscultation bilaterally.  ABDOMEN:  Bowel sounds positive, soft, nontender, and nondistended.  No masses.  EXTREMITIES:  No clubbing, cyanosis or edema.  Pulses 2+ bilaterally.,LABORATORY DATA: , EKG today revealed atrial fibrillation with nonspecific lateral T-wave abnormalities and a rate of 94.,IMPRESSION:  ,The patient is a very pleasant 62-year-old African American female with atrial fibrillation of unknown duration with symptoms of paroxysmal episodes of palpitations, doing well today.,RECOMMENDATIONS:,1.  Her rate is suboptimally controlled, we will increase her Toprol-XL to 75 mg per day.,2.  We will obtain a transthoracic echocardiogram to evaluate her LV function as well as her valvular function.,3.  We will check a thyroid function panel.,4.  We will continue Coumadin as directed and to follow up with Dr. X for INR management.,5.  Given the patient's history of a stroke in her age and recurrent atrial fibrillation, the patient should be continued on Coumadin indefinitely.,6.  Depending upon the results of her transthoracic echocardiogram, the patient may benefit from repeat heart catheterization.  We will await results of transthoracic echocardiogram.,7.  We will arrange for the patient to wear a Holter monitor to monitor the rate controlled on a 24-hour period.  She will then return to the electrophysiology clinic in 1 month for followup visit with Dr. Y.,The patient was seen, discussed, and examined with Dr. Y in electrophysiology.",
" Possible exposure to ant bait.  She is not exhibiting any symptoms and parents were explained that if she develops any vomiting, she should be brought back for reevaluation.", Consult - History and Phy., Ant Bait Exposure - ER Visit ,"CHIEF COMPLAINT: , Possible exposure to ant bait.,HISTORY OF PRESENT ILLNESS:,  This is a 14-month-old child who apparently was near the sink, got into the childproof cabinet and pulled out ant bait that had Borax in it.  It had 11 mL of this fluid in it.  She spilled it on her, had it on her hands.  Parents were not sure whether she ingested any of it.  So, they brought her in for evaluation.  They did not note any symptoms of any type.,PAST MEDICAL HISTORY: , Negative.  Generally very healthy.,REVIEW OF SYSTEMS: , The child has not been having any coughing, gagging, vomiting, or other symptoms.  Acting perfectly normal.  Family mostly noted that she had spilled it on the ground around her, had it on her hands, and on her clothes.  They did not witness that she ingested any, but did not see anything her mouth.,MEDICATIONS: , None.,ALLERGIES: , NONE.,PHYSICAL EXAMINATION: , VITAL SIGNS:  The patient was afebrile.  Stable vital signs and normal pulse oximetry.  GENERAL:  The child is very active, cheerful youngster, in no distress whatsoever.  HEENT:  Unremarkable.  Oral mucosa is clear, moist, and well hydrated.  I do not see any evidence of any sort of liquid on the face.  Her clothing did have the substance on the clothes, but I did not see any evidence of anything on her torso.  Apparently, she had some on her hands that has been wiped off.,EMERGENCY DEPARTMENT COURSE:,  I discussed the case with Poison Control and apparently this is actually relatively small quantity and it is likely to be a nontoxic ingestion if she even ingested, which should does not appear likely to be the case.,IMPRESSION: , Exposure to ant bait.,PLAN: , At this point, it is fairly unlikely that this child ingested any significant amount, if at all, which seems unlikely.  She is not exhibiting any symptoms and I explained to the parents that if she develops any vomiting, she should be brought back for reevaluation.  So, the patient is discharged in stable condition.","consult - history and phy., borax, vomiting, exposure to ant bait, ant bait, exposure, symptoms,"
  Antibiotic management for a right foot ulcer and possible osteomyelitis., Consult - History and Phy., Antibiotic Management Consult ,"REASON FOR CONSULTATION: , Antibiotic management for a right foot ulcer and possible osteomyelitis.,HISTORY OF PRESENT ILLNESS:,  The patient is a 68-year-old Caucasian male with past medical history of diabetes mellitus.  He was doing fairly well until last week while mowing the lawn, he injured his right foot.  He presented to the Hospital Emergency Room.  Cultures taken from the wound on 06/25/2008, were reported positive for methicillin-sensitive Staphylococcus aureus (MSSA).  The patient was started on intravenous antibiotic therapy with Levaquin and later on that was changed to oral formulation.  The patient underwent debridement of the wound on 07/29/2008.  Apparently, MRI and a bone scan was performed at that facility, which was reported negative for osteomyelitis.  The patient was then referred to the wound care center at General Hospital.  From there, he has been admitted to Long-Term Acute Care Facility for wound care with wound VAC placement.  On exam, he has a lacerated wound on the plantar aspect of the right foot, which extends from the second metatarsal area to the fifth metatarsal area, closed with the area of the head of these bones.  The wound itself is deep and stage IV and with exam of her gloved finger in my opinion, the third metatarsal bone is palpable, which leads to the clinical diagnosis of osteomyelitis.  The patient has serosanguineous drainage in this wound and it tracks under the skin in all directions except distal.,PAST MEDICAL HISTORY: , Positive for:,1.  Diabetes mellitus.,2.  Osteomyelitis of the right fifth toe, which was treated with intravenous antibiotic therapy for 6 weeks about 5 years back.,FAMILY HISTORY: , Positive for mother passing away in her late 60s from heart attack, father had liver cancer, and passed away from that.  One of his children suffers from hypothyroidism, 2 grandchildren has cerebral palsy secondary to being prematurely born.,ALLERGIES: , No known drug allergies.,REVIEW OF SYSTEMS: , Positive findings of the foot that have been mentioned above.  All other systems reviewed were negative.,PHYSICAL EXAMINATION:,General:  A 68-year-old Caucasian male who was not in any acute hemodynamic distress at present.,Vital Signs:  Show a maximum recorded temperature of 98, pulse is rating between 67 to 80 per minute, respiratory rate is 20 per minute, blood pressure is varying between 137/63 to 169/75.,HEENT:  Pupils equal, round, reactive to light.  Extraocular movements intact.  Head is normocephalic.  External ear exam is normal.,Neck:  Supple.  There is no palpable lymphadenopathy.,Cardiovascular:  Regular rate and rhythm of the heart without any appreciable murmur, rub or gallop.,Lungs:  Clear to auscultation and percussion bilaterally.,Abdomen:  Soft, nontender, and nondistended without any organomegaly and bowel sounds are positive.  There is no palpable lymphadenopathy in the inguinal and femoral area.,Extremities:  There is no cyanosis, clubbing or edema.  There is no peripheral stigmata of endocarditis.  On the plantar aspect of the distal part of the right foot, the patient has a lacerated wound, which extends from the second metatarsal area to the fifth metatarsal area.  Tracking under the skin is palpable with a gloved finger in all direction except the distal one.  On the proximal tracking, the area of the wound, the third metatarsal bone is palpable.  Therefore, clinically, the patient has diagnoses of osteomyelitis.,Central nervous system:  The patient is alert, oriented x3.  Cranial nerves II through XII are intact.  There is no focal deficit appreciated.,LABORATORY DATA:,  No laboratory or radiological data is available at present in the chart.,IMPRESSION/PLAN: , A 68-year-old Caucasian male with history of diabetes mellitus who had an accidental lawn mower-associated injury on the right foot.  He has undergone debridement on 07/29/2008.  Culture results from the debridement procedure are not available.  Wound cultures from 07/25/2008 showed methicillin-sensitive Staphylococcus aureus.,From the Infectious Disease point of view, the patient has the following problems, and I would recommend following treatments strategy.,1.  Right foot infected ulcer with clinical evidence of osteomyelitis.  Even if the MRI and bone scan are negative, the treatment should be guided with diagnosis on clinical counts in my opinion.  Cultures have been reported positive for methicillin-sensitive Staphylococcus aureus.  Therefore, I would discontinue the current antibiotic regimen of oral Levaquin, Zyvox, and intravenous Zosyn, and start the patient on intravenous Ancef 2 g q.8 h.  We will need to continue this treatment for 6 weeks for treatment of osteomyelitis and deep wound infection.  I would also recommend continuation of wound care and wound VAC placement that would start tomorrow.  We will get a PICC line placed to complete the 6-week course of intravenous antibiotic therapy.,2.  We would check labs including CBC with differential, chemistry 7 panel, LFTs, ESR, and C-reactive protein levels every Monday and chemistry 7 panel and CBC every Thursday for the duration of antibiotic therapy.,3.  I will continue to monitor wound healing 2 to 3 times a week.  Wound care will be managed by the wound care team at the Long-Term Acute Care Facility.,4.  The treatment plan was discussed in detail with the patient and his daughter who was visiting him when I saw him.,5.  Other medical problems will continue to be followed and treated by Dr. X's group during this hospitalization.,6.  I appreciate the opportunity of participating in this patient's care.  If you have any questions please feel free to call me at any time.  I will continue to follow the patient along with you for the next few days during this hospitalization.  We would also try to get the results of the deep wound cultures from 07/29/2008, MRI, and bone scan from Hospital.",
 The patient was running and twisted her right ankle - right ankle sprain., Consult - History and Phy., Ankle Pain - Consult ,"IDENTIFICATION: , The patient is a 15-year-old female.,CHIEF COMPLAINT: , Right ankle pain.,HISTORY OF PRESENT ILLNESS:,  The patient was running and twisted her right ankle.  There were no other injuries.  She complains of right ankle pain on the lateral aspect.  She is brought in by her mother.  Her primary care physician is Dr. Brown.,REVIEW OF SYSTEMS:,  Otherwise negative except as stated above.,PAST MEDICAL HISTORY:,  None.,PAST SURGICAL HISTORY: , None.,MEDICATIONS:,  None.,SOCIAL HISTORY: , Mother appears loving and caring.  There is no evidence of abuse.,ALLERGIES:,  No known drug allergies.,PHYSICAL EXAMINATION: , General:  The patient is alert and oriented x4 in mild distress without diaphoresis.  She is nonlethargic and nontoxic.  Vitals:  Within normal limits.  The right ankle shows no significant swelling.  There is no ecchymosis.  There is no significant tenderness to palpation.  The ankle has good range of motion.  The foot is nontender.  Vascular:  +2/2 dorsalis pedis pulse.  All compartments are soft.  Capillary refill less than 2 seconds.,DIAGNOSTIC TEST:,  The patient had an x-ray of the right ankle, which interpreted by myself shows no acute fracture or dislocation.,MEDICAL DECISION MAKING: , Due to the fact this patient has no evidence of an ankle fracture, she can be safely discharged to home.  She is able to walk on it without significant pain, thus I recommend rest for 1 week and follow up with the doctor if she has persistent pain.  She may need to see a specialist, but at this time this is a very mild ankle injury.  There is no significant physical finding, and I foresee no complications.  I will give her 1 week off of PE.,MORBIDITY/MORTALITY:,  I expect no acute complications.  A full medical screening exam was done and no emergency medical condition exists upon discharge.,COMPLEXITY:,  Moderate.  The differential includes fracture, contusion, abrasion, laceration, and sprain.,ASSESSMENT:,  Right ankle sprain.,PLAN:,  Discharge the patient home and have her follow up with her doctor in 1 week if symptoms persist.  She is advised to return immediately p.r.n. severe pain, worsening, not better, etc.",
 Patient experiences a dull pain in his upper outer arm.  It occurs on a daily basis.  He also experiences an achy sensation in his right hand radiating to the fingers.  There is no numbness or paresthesias in the hand or arm., Consult - History and Phy., Arm Pain - Neuro Consult ,"HISTORY OF PRESENT ILLNESS:  ,The patient is a 58-year-old right-handed gentleman who presents for further evaluation of right arm pain.  He states that a little less than a year ago he developed pain in his right arm.  It is intermittent, but has persisted since that time.  He describes that he experiences a dull pain in his upper outer arm.  It occurs on a daily basis.  He also experiences an achy sensation in his right hand radiating to the fingers.  There is no numbness or paresthesias in the hand or arm.,He has had a 30-year history of neck pain.  He sought medical attention for this problem in 2006, when he developed ear pain.  This eventually led to him undergoing an MRI of the cervical spine, which showed some degenerative changes.  He was then referred to Dr. X for treatment of neck pain.  He has been receiving epidural injections under the care of Dr. X since 2007.  When I asked him what symptom he is receiving the injections for, he states that it is for neck pain and now the more recent onset of arm pain.  He also has taken several Medrol dose packs, which has caused his blood sugars to increase.  He is taking multiple other pain medications.  The pain does not interfere significantly with his quality of life, although he has a constant nagging pain.,PAST MEDICAL HISTORY: , He has had diabetes since 2003.  He also has asthma, hypertension, and hypercholesterolemia.,CURRENT MEDICATIONS: , He takes ACTOplus, albuterol, AndroGel, Astelin, Diovan, Dolgic Plus, aspirin 81 mg, fish oil, Lipitor, Lorazepam, multivitamins, Nasacort, Pulmicort, ranitidine, Singulair, Viagra, Zetia, Zyrtec, and Uroxatral.  He also uses Lidoderm patches and multiple eye drops and creams.,ALLERGIES:,  He states that Dyazide, Zithromax, and amoxicillin cause him to feel warm and itchy.,FAMILY HISTORY:,  His father died from breast cancer.  He also had diabetes.  He has a strong family history of diabetes.  His mother is 89.  He has a sister with diabetes.  He is unaware of any family members with neurological disorders.,SOCIAL HISTORY:,  He lives alone.  He works full time in Human Resources for the State of Maryland.  He previously was an alcoholic, but quit in 1984.  He also quit smoking cigarettes in 1984, after 16 years of smoking.  He has a history of illicit drug use, but denies IV drug use.  He denies any HIV risk factors and states that his last HIV test was over two years ago.,REVIEW OF SYSTEMS: , He has intermittent chest discomfort.  He has chronic tinnitus.  He has urinary dribbling.  Otherwise, a complete review of systems was obtained and was negative except for as mentioned above.  This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:,Vital Signs:  HR 72. RR 16.,General Appearance:  Patient is well appearing, in no acute distress.,Cardiovascular:  There is a regular rhythm without murmurs, gallops, or rubs.  There are no carotid bruits.,Chest:  The lungs are clear to auscultation bilaterally.,Skin:  There are no rashes or lesions.,NEUROLOGICAL EXAMINATION:,Mental Status:  Speech is fluent without dysarthria or aphasia.  The patient is alert and oriented to name, place, and date.  Attention, concentration, registration, recall, and fund of knowledge are all intact.,Cranial Nerves:  Pupils are equal, round, and reactive to light and accommodation.  Optic discs are normal.  Visual fields are full.  Extraocular movements are intact without nystagmus.  Facial sensation is normal.  There is no facial, jaw, palate, or tongue weakness.  Hearing is grossly intact.  Shoulder shrug is full.,Motor:  There is normal muscle bulk and tone.  There is no atrophy or fasciculations.  There is no action or percussion myotonia or paramyotonia.  Manual muscle testing reveals MRC grade 5/5 strength in all proximal and distal muscles of the upper and lower extremities.,Sensory:  Sensation is intact to light touch, pinprick, temperature, vibratory sensation, and joint position sense.  Romberg is absent.,Coordination:  There is no dysmetria or ataxia on finger-nose-finger or heel-to-shin testing.,Deep Tendon Reflexes:  Deep tendon reflexes are 2+ at the biceps, triceps, brachioradialis, patellas and ankles.  Plantar reflexes are flexor.  There are no finger flexors, Hoffman's sign, or jaw jerk.,Gait and Stance:  Casual gait is normal.  Heel, toe, and tandem walking are all normal.,RADIOLOGIC DATA:,  MRI of the cervical spine, 05/19/08:  I personally reviewed this film, which showed narrowing of the foramen on the right at C4-C5 and other degenerative changes without central stenosis.,IMPRESSION:  ,The patient is a 58-year-old gentleman with one-year history of right arm pain.  He also has a longstanding history of neck pain.  His neurological examination is normal.  He has an MRI that shows some degenerative changes.  I do believe that his symptoms are probably referable to his neck.  However, I do not think that they are severe enough for him to undergo surgery at this point in time.  Perhaps another course of physical therapy may be helpful for him.  I probably would not recommend anymore invasive procedure, such as a spinal stimulator, as this pain really is minimal.  We could still try to treat him with neuropathic pain medications.,RECOMMENDATIONS:,1.  I scheduled him to return for an EMG and nerve conduction studies to determine whether there is any evidence of nerve damage, although I think the likelihood is low.,2.  I gave him a prescription for Neurontin.  I discussed the side effects of the medication with him.,3.  We can discuss his case tomorrow at Spine Conference to see if there are any further recommendations.",
" Patient had a recurrent left arm pain after her stent, three days ago, and this persisted after two sublingual nitroglycerin.", Consult - History and Phy., Angina - Consult ,"HISTORY OF PRESENT ILLNESS: , The patient is a 68-year-old woman whom I have been following, who has had angina.  In any case today, she called me because she had a recurrent left arm pain after her stent, three days ago, and this persisted after two sublingual nitroglycerin when I spoke to her.  I advised her to call 911, which she did.  While waiting for 911, she was attended to by a physician who is her neighbor and he advised her to take the third nitroglycerin and that apparently relieved her pain.  By the time she presented here, she is currently pain-free and is feeling well.,PAST CARDIAC HISTORY: , The patient has been having arm pain for several months.  She underwent an exercise stress echocardiogram within the last several months with me, which was equivocal, but then she had a nuclear stress test which showed inferobasilar ischemia.  I had originally advised her for a heart catheterization but she wanted medical therapy, so we put her on a beta-blocker.  However, her arm pain symptoms accelerated and she had some jaw pain, so she presented to the emergency room.  On 08/16/08, she ended up having a cardiac catheterization and that showed normal left main 80%  mid LAD lesion, circumflex normal, and RCA totally occluded in the mid portion and there were collaterals from the left to the right, as well as right to right to that area.  The decision was made to transfer  her as she may be having collateral insufficiency from the LAD stenosis to the RCA vessel.  She underwent that with drug-eluting stents on 08/16/08, with I believe three or four total placed, and was discharged on 08/17/08.  She had some left arm discomfort on 08/18/08, but this was mild.  Yesterday, she felt very fatigued, but no arm pain, and today, she had arm pain after walking and again it resolved now completely after three sublingual nitroglycerin.  This is her usual angina.  She is being admitted with unstable angina post stent.,PAST MEDICAL HISTORY: , Longstanding hypertension, CAD as above, hyperlipidemia, and overactive bladder.,MEDICATIONS:,1.  Detrol LA 2 mg once a day.,2.  Prilosec for GERD 20 mg once a day.,3.  Glucosamine 500/400 mg once a day for arthritis.,4.  Multivitamin p.o. daily.,5.  Nitroglycerin sublingual as available to her.,6.  Toprol-XL 25 mg once a day which I started although she had been bradycardic, but she seems to be tolerating.,7.  Aspirin 325 mg once a day.,8.  Plavix 75 mg once a day.,9.  Diovan 160 mg once a day.,10.  Claritin 10 mg once a day for allergic rhinitis.,11.  Norvasc 5 mg once a day.,12.  Lipitor 5 mg once a day.,13.  Evista 60 mg once a day.,ALLERGIES: , ALLERGIES TO MEDICATIONS ARE NONE.  SHE DENIES ANY SHRIMP OR SEA FOOD ALLERGY.,FAMILY HISTORY: , Her father died of an MI in his 50s and a brother had his first MI and bypass surgery at 54.,SOCIAL HISTORY:  ,She does not smoke cigarettes, abuse alcohol, no use of illicit drugs.  She is divorced and lives alone and is a retired laboratory technician from Cornell Diagnostic Laboratory.,REVIEW OF SYSTEMS:,  She denies a history of stroke, cancer, vomiting up blood, coughing up blood, bright red blood per rectum, bleeding stomach ulcers, renal calculi, cholelithiasis, asthma, emphysema, pneumonia, tuberculosis, home oxygen use or sleep apnea, although she has been told in the past that she snores and there was some question of apnea in 05/08.  No morning headaches or fatigue.  No psychiatric diagnosis.  No psoriasis, no lupus.  Remainder of the review of systems is negative x14 systems except as described above.,PHYSICAL EXAMINATION:,GENERAL:  She is a pleasant elderly woman, currently in no acute distress.,VITAL SIGNS:  Height 4 feet 11 inches, weight 128 pounds, temperature 97.2 degrees Fahrenheit, blood pressure 142/70, pulse 47,  respiratory rate 16, and O2 saturation 100%,HEENT:  Cranium is normocephalic and atraumatic.  She has moist mucosal membranes.,NECK:  Veins are not distended.  There are no carotid bruits.,LUNGS:  Clear to auscultation and percussion without wheezes.,HEART:  S1 and S2, regular rate.  No significant murmurs, rubs or gallops.  PMI nondisplaced.,ABDOMEN:  Soft and nondistended.  Bowel sounds present.,EXTREMITIES:  Without significant clubbing, cyanosis or edema.  Pulses grossly intact.  Bilateral groins are inspected, status post as the right femoral artery was used for access for the diagnostic cardiac catheterization here and left femoral artery used for PCI and there is no evidence of hematoma or bruit and intact distal pulses.,LABORATORY DATA: , EKG reviewed which shows sinus bradycardia at the rate of 51 beats per minute and no acute disease.,Sodium 136, potassium 3.8, chloride 105, and bicarbonate 27.  BUN 16 and creatinine 0.9.  Glucose 110.  Magnesium 2.5.  ALT 107 and AST 65 and these were normal on 08/15/08.  INR is 0.89, PTT 20.9, white blood cell count 8.2, hematocrit 31 and it was 35 on 08/15/08, and platelet count 257,000.,IMPRESSION AND PLAN:  ,The patient is a 68-year-old woman with exertional angina, characterized with arm pain, who underwent recent left anterior descending percutaneous coronary intervention and has now had recurrence of that arm pain post stenting to the left anterior descending artery and it may be that she is continuing to have collateral insufficiency of the right coronary artery.  In any case, given this unstable presentation requiring three sublingual nitroglycerin before she was even pain free, I am going to admit her to the hospital and there is currently no evidence requiring acute reperfusion therapy.  We will continue her beta-blocker and I cannot increase the dose because she is bradycardic already.  Aspirin, Plavix, valsartan, Lipitor, and Norvasc.  I am going to add Imdur and watch headaches as she apparently had some on nitro paste before, and we will rule out MI, although there is a little suspicion.  I suppose it is possible that she has non-cardiac arm pain, but that seems less likely as it has been nitrate responsive and seems exertionally related and the other possibility may be that we end up needing to put in a pacemaker, so we can maximize beta-blocker use for anti-anginal effect.  My concern is that there is persistent right coronary artery ischemia, not helped by left anterior descending percutaneous coronary intervention, which was severely stenotic and she does have normal LV function.  She will continue the glucosamine for her arthritis, Claritin for allergies, and Detrol LA for urinary incontinence.,Total patient care time in the emergency department 75 minutes.  All this was discussed in detail with the patient and her daughter who expressed understanding and agreement.  The patient desires full resuscitation status.",
 History and Physical for right ankle sprain, Consult - History and Phy., Ankle Sprain - H&P ,"CHIEF COMPLAINT:,  Right ankle sprain.,HISTORY OF PRESENT ILLNESS: , This is a 56-year-old female who fell on November 26, 2007 at 11:30 a.m. while at work.  She did not recall the specifics of her injury but she thinks that her right foot inverted and subsequently noticed pain in the right ankle.  She describes no other injury at this time.,PAST MEDICAL HISTORY: , Hypertension and anxiety.,PAST SURGICAL HISTORY: , None.,MEDICATIONS: , She takes Lexapro and a blood pressure pill, but does not know anything more about the names and the doses.,ALLERGIES:,  No known drug allergies.,SOCIAL HISTORY: , The patient lives here locally.  She does not report any significant alcohol or illicit drug use.  She works full time.,FAMILY HISTORY:,  Noncontributory.,REVIEW OF SYSTEMS:,Pulm:  No cough, No wheezing, No shortness of breath,CV:  No chest pain or palpitations,GI:  No abdominal pain.  No nausea, vomiting, or diarrhea.,PHYSICAL EXAM:,GENERAL APPEARANCE:  No acute distress,VITAL SIGNS:  Temperature 97.8, blood pressure 122/74, heart rate 76, respirations 24, weight 250 lbs, O2 sat 95% on R.A.,NECK:  Supple.  No lymphadenopathy.  No thyromegaly.,CHEST:  Clear to auscultation bilaterally.,HEART:  Regular rate and rhythm.  No murmurs.,ABDOMEN:  Non-distended, nontender, normal active bowel sounds.,EXTREMITIES:  No Clubbing, No Cyanosis, No edema.,MUSCULOSKELETAL:  The spine is straight and there is no significant muscle spasm or tenderness there.  Both knees appear to be non-traumatic with no deformity or significant tenderness.  The right ankle has some swelling just below the right lateral malleolus and the dorsum of the foot is tender.  There is decreased range of motion and some mild ecchymosis noted around the ankle.,DIAGNOSTIC DATA: , X-ray of the right ankle reveals no acute fracture by my observation.  Radiologic interpretation is pending., ,IMPRESSION:,  Right ankle sprain.,PLAN:,1.  Motrin 800 mg t.i.d.,2.  Tylenol 1 gm q.i.d. as needed.,3.  Walking cast is prescribed.,4.  I told the patient to call back if any problems.  The next morning she called back complaining of worsening pain and I called in some Vicodin ES 1-2 p.o. q.  8 hours p.r.n. pain #60 with no refills.",
" Refractory anemia that is transfusion dependent.  At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion.", Consult - History and Phy., Anemia - Consult ,"DIAGNOSIS:,  Refractory anemia that is transfusion dependent.,CHIEF COMPLAINT: , I needed a blood transfusion.,HISTORY: , The patient is a 78-year-old gentleman with no substantial past medical history except for diabetes.  He denies any comorbid complications of the diabetes including kidney disease, heart disease, stroke, vision loss, or neuropathy.  At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion.  He reports that he has no signs or symptom of bleeding and had a blood transfusion approximately two months ago and actually several weeks before that blood transfusion, he had a transfusion for anemia.  He has been placed on B12, oral iron, and Procrit.  At this time, we are asked to evaluate him for further causes and treatment for his anemia.  He denies any constitutional complaints except for fatigue, malaise, and some dyspnea.  He has no adenopathy that he reports.  No fevers, night sweats, bone pain, rash, arthralgias, or myalgias.,PAST MEDICAL HISTORY:  ,Diabetes.,PAST SURGICAL HISTORY:,  Hernia repair.,ALLERGIES: , He has no allergies.,MEDICATIONS: , Listed in the chart and include Coumadin, Lasix, metformin, folic acid, diltiazem, B12, Prevacid, and Feosol.,SOCIAL HISTORY: , He is a tobacco user.  He does not drink.  He lives alone, but has family and social support to look on him.,FAMILY HISTORY:,  Negative for blood or cancer disorders according to the patient.,PHYSICAL EXAMINATION:,GENERAL:  He is an elderly gentleman in no acute distress.  He is sitting up in bed eating his breakfast.  He is alert and oriented and answering questions appropriately.,VITAL SIGNS:  Blood pressure of 110/60, pulse of 99, respiratory rate of 14, and temperature of 97.4.  He is 69 inches tall and weighs 174 pounds.,HEENT:  Sclerae show mild arcus senilis in the right.  Left is clear.  Pupils are equally round and reactive to light.  Extraocular movements are intact.  Oropharynx is clear.,NECK:  Supple.  Trachea is midline.  No jugular venous pressure distention is noted.  No adenopathy in the cervical, supraclavicular, or axillary areas.,CHEST:  Clear.,HEART:  Regular rate and rhythm.,ABDOMEN:  Soft and nontender.  There may be some fullness in the left upper quadrant, although I do not appreciate a true spleen with inspiration.,EXTREMITIES:  No clubbing, but there is some edema, but no cyanosis.,NEUROLOGIC:  Noncontributory.,DERMATOLOGIC:  Noncontributory.,CARDIOVASCULAR:  Noncontributory.,IMPRESSION: , At this time is refractory anemia, which is transfusion dependent.  He is on B12, iron, folic acid, and Procrit.  There are no sign or symptom of blood loss and a recent esophagogastroduodenoscopy, which was negative.  His creatinine was 1.  My impression at this time is that he probably has an underlying myelodysplastic syndrome or bone marrow failure.  His creatinine on this hospitalization was up slightly to 1.6 and this may contribute to his anemia.,RECOMMENDATIONS:  ,At this time, my recommendation for the patient is that he undergoes further serologic evaluation with reticulocyte count, serum protein, and electrophoresis, LDH, B12, folate, erythropoietin level, and he should undergo a bone marrow aspiration and biopsy.  I have discussed the procedure in detail which the patient.  I have discussed the risks, benefits, and successes of that treatment and usefulness of the bone marrow and predicting his cause of refractory anemia and further therapeutic interventions, which might be beneficial to him.  He is willing to proceed with the studies I have described to him.  We will order an ultrasound of his abdomen because of the possible fullness of the spleen, and I will probably see him in follow up after this hospitalization.,As always, we greatly appreciate being able to participate in the care of your patient.  We appreciate the consultation of the patient.",
" Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.", Consult - History and Phy., Allergy Evaluation Consult ,"HISTORY: , A 34-year-old male presents today self-referred at the recommendation of Emergency Room physicians and his nephrologist to pursue further allergy evaluation and treatment.  Please refer to chart for history and physical, as well as the medical records regarding his allergic reaction treatment at ABC Medical Center for further details and studies.  In summary, the patient had an acute event of perioral swelling, etiology uncertain, occurring on 05/03/2008 requiring transfer from ABC Medical Center to XYZ Medical Center due to a history of renal failure requiring dialysis and he was admitted and treated and felt that his allergy reaction was to Keflex, which was being used to treat a skin cellulitis dialysis shunt infection.  In summary, the patient states he has some problems with tolerating grass allergies, environmental and inhalant allergies occasionally, but has never had anaphylactic or angioedema reactions.  He currently is not taking any medication for allergies.  He is taking atenolol for blood pressure control.  No further problems have been noted upon his discharge and treatment, which included corticosteroid therapy and antihistamine therapy and monitoring.,PAST MEDICAL HISTORY:,  History of urticaria, history of renal failure with hypertension possible source of renal failure, history of dialysis times 2 years and a history of hypertension.,PAST SURGICAL HISTORY:,  PermCath insertion times 3 and peritoneal dialysis.,FAMILY HISTORY: , Strong for heart disease, carcinoma, and a history of food allergies, and there is also a history of hypertension.,CURRENT MEDICATIONS: , Atenolol, sodium bicarbonate, Lovaza, and Dialyvite.,ALLERGIES: , Heparin causing thrombocytopenia.,SOCIAL HISTORY: , Denies tobacco or alcohol use.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Age 34, blood pressure 128/78, pulse 70, temperature is 97.8, weight is 207 pounds, and height is 5 feet 7 inches.,GENERAL:  The patient is healthy appearing; alert and oriented to person, place and time; responds appropriately; in no acute distress.,HEAD:  Normocephalic.  No masses or lesions noted.,FACE:  No facial tenderness or asymmetry noted.,EYES:  Pupils are equal, round and reactive to light and accommodation bilaterally.  Extraocular movements are intact bilaterally.,EARS:  The tympanic membranes are intact bilaterally with a good light reflex.  The external auditory canals are clear with no lesions or masses noted.  Weber and Rinne tests are within normal limits.,NOSE:  The nasal cavities are patent bilaterally.  The nasal septum is midline.  There are no nasal discharges.  No masses or lesions noted.,THROAT:  The oral mucosa appears healthy.  Dental hygiene is maintained well.  No oropharyngeal masses or lesions noted.  No postnasal drip noted.,NECK:  The neck is supple with no adenopathy or masses palpated.  The trachea is midline.  The thyroid gland is of normal size with no nodules.,NEUROLOGIC:  Facial nerve is intact bilaterally.  The remaining cranial nerves are intact without focal deficit.,LUNGS:  Clear to auscultation bilaterally.  No wheeze noted.,HEART:  Regular rate and rhythm.  No murmur noted.,IMPRESSION:  ,1.  Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.,2.  Renal failure requiring dialysis.,3.  Hypertension.,RECOMMENDATIONS:  ,RAST allergy testing for both food and environmental allergies was performed, and we will get the results back to the patient with further recommendations to follow.  If there is any specific food or inhalant allergen that is found to be quite high on the sensitivity scale, we would probably recommend the patient to avoid the offending agent to hold off on any further reactions.  At this point, I would recommend the patient stopping any further use of cephalosporin antibiotics, which may be the cause of his allergic reaction, and I would consider this an allergy.  Being on atenolol, the patient has a more difficult time treating acute anaphylaxis, but I do think this is medically necessary at this time and hopefully we can find specific causes for his allergic reactions.  An EpiPen was also prescribed in the event of acute angioedema or allergic reaction or sensation of impending allergic reaction and he is aware he needs to proceed directly to the emergency room for further evaluation and treatment recommendations after administration of an EpiPen.",
" Comprehensive annual health maintenance examination, dyslipidemia, tinnitus in left ear, and hemorrhoids.", Consult - History and Phy., Annual Health Maintenance Exam ,"HISTORY OF PRESENT ILLNESS:  ,This 59-year-old white male is seen for comprehensive annual health maintenance examination on 02/19/08, although this patient is in excellent overall health.  Medical problems include chronic tinnitus in the left ear with moderate hearing loss for many years without any recent change, dyslipidemia well controlled with niacin, history of hemorrhoids with occasional external bleeding, although no problems in the last 6 months, and also history of concha bullosa of the left nostril, followed by ENT associated with slight septal deviation.  There are no other medical problems.  He has no symptoms at this time and remains in excellent health.,PAST MEDICAL HISTORY: , Otherwise noncontributory.  There is no operation, serious illness or injury other than as noted above.,ALLERGIES: , There are no known allergies.,FAMILY HISTORY: , Father died of an MI at age 67 with COPD and was a heavy smoker.  His mother is 88, living and well, status post lung cancer resection.  Two brothers, living and well.  One sister died at age 20 months of pneumonia.,SOCIAL HISTORY:,  The patient is married.  Wife is living and well.  He jogs or does Cross Country track 5 times a week, and weight training twice weekly.  No smoking or significant alcohol intake.  He is a physician in allergy/immunology.,REVIEW OF SYSTEMS:,  Otherwise noncontributory.  He has no gastrointestinal, cardiopulmonary, genitourinary or musculoskeletal symptomatology.  No symptoms other than as described above.,PHYSICAL EXAMINATION:,GENERAL:  He appears alert, oriented, and in no acute distress with excellent cognitive function.  VITAL SIGNS:  His height is 6 feet 2 inches, weight is 181.2, blood pressure is 126/80 in the right arm, 122/78 in the left arm, pulse rate is 68 and regular, and respirations are 16.  SKIN:  Warm and dry.  There is no pallor, cyanosis or icterus.  HEENT:  Tympanic membranes benign.  The pharynx is benign.  Nasal mucosa is intact.  Pupils are round, regular, and equal, reacting equally to light and accommodation.  EOM intact.  Fundi reveal flat discs with clear margins.  Normal vasculature.  No hemorrhages, exudates or microaneurysms.  No thyroid enlargement.  There is no lymphadenopathy.  LUNGS:  Clear to percussion and auscultation.  Normal sinus rhythm.  No premature beat, murmur, S3 or S4.  Heart sounds are of good quality and intensity.  The carotids, femorals, dorsalis pedis, and posterior tibial pulsations are brisk, equal, and active bilaterally.  ABDOMEN:  Benign without guarding, rigidity, tenderness, mass or organomegaly.  NEUROLOGIC:  Grossly intact.  EXTREMITIES:  Normal.  GU:  Genitalia normal.  There are no inguinal hernias.  There are mild hemorrhoids in the anal canal.  The prostate is small, if any normal to mildly enlarged with discrete margins, symmetrical without significant palpable abnormality.  There is no rectal mass.  The stool is Hemoccult negative.,IMPRESSION:,1.  Comprehensive annual health maintenance examination.,2.  Dyslipidemia.,3.  Tinnitus, left ear.,4.  Hemorrhoids.,PLAN:,  At this time, continue niacin 1000 mg in the morning, 500 mg at noon, and 1000 mg in the evening; aspirin 81 mg daily; multivitamins; vitamin E 400 units daily; and vitamin C 500 mg daily.  Consider adding lycopene, selenium, and flaxseed to his regimen.  All appropriate labs will be obtained today.  Followup fasting lipid profile and ALT in 6 months.","consult - history and phy., tinnitus, dyslipidemia, annual health maintenance, health, hemorrhoids, benign"
 Possible free air under the diaphragm.  On a chest x-ray for what appeared to be shortness of breath she was found to have what was thought to be free air under the right diaphragm.  No intra-abdominal pathology., Consult - History and Phy., Air Under Diaphragm - Consult ,"REASON FOR CONSULTATION: , Possible free air under the diaphragm.,HISTORY OF PRESENT ILLNESS: , The patient is a 77-year-old female who is unable to give any information.  She has been sedated with Ativan and came into the emergency room obtunded and unable to give any history.  On a chest x-ray for what appeared to be shortness of breath she was found to have what was thought to be free air under the right diaphragm.,PAST MEDICAL HISTORY: , Significant for alcohol abuse.  Unable to really gather any other information because she is so obtunded.,PAST SURGICAL HISTORY:  ,Looking at the medical chart, she had an appendectomy, right hip fracture from a fall in 2005, and TAH/BSO.,MEDICATIONS:,  Unable to evaluate.,ALLERGIES: , UNABLE TO EVALUATE.,SOCIAL HISTORY:  ,Significant history of alcohol abuse, according to the emergency room physician, who sees her on a regular basis.,REVIEW OF SYSTEMS: , Unable to obtain.,PHYSICAL EXAM,VITAL SIGNS:  Temp 98.3, heart rate 82, respiratory rate 24, and blood pressure 141/70.,GENERAL:  She is a very obtunded female who upon arousal is not able to provide any information of any use.,HEENT:  Atraumatic.,NECK:  Soft and supple.,LUNGS:  Bilaterally diminished.,HEART:  Regular.,ABDOMEN:  Soft, and with deep palpation I am unable to arouse the patient, unable to elicit any tenderness.,LABORATORY STUDIES: , Show a normal white blood cell count with no shift.  Elevated AST at 138, with a normal ALT at 38.  Alkaline phosphatase of 96, bilirubin 0.8.  Sodium is 107, with 68 chloride and potassium of 2.8.,X-ray of the chest shows the possibility of free air; therefore, a CT scan was obtained because of the patient's physical examination, which shows no evidence of intra-abdominal pathology.  The etiology of the air under the diaphragm is actually a colonic air that is anterior superior to the dome of the diaphragm, near the dome of the liver.,ASSESSMENT: , No intra-abdominal pathology.,PLAN:,  Have her admitted to the medical service for treatment of her hyponatremia.",
" The patient is a 17-year-old female, who presents to the emergency room with foreign body and airway compromise and was taken to the operating room.  She was intubated and fishbone.", Consult - History and Phy., Airway Compromise & Foreign Body - ER Visit ,"HISTORY OF PRESENT ILLNESS:,  The patient is a 17-year-old female, who presents to the emergency room with foreign body and airway compromise and was taken to the operating room.  She was intubated and fishbone.,PAST MEDICAL HISTORY: , Significant for diabetes, hypertension, asthma, cholecystectomy, and total hysterectomy and cataract.,ALLERGIES:  ,No known drug allergies.,CURRENT MEDICATIONS: , Prevacid, Humulin, Diprivan, Proventil, Unasyn, and Solu-Medrol.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: , Negative for illicit drugs, alcohol, and tobacco.,PHYSICAL EXAMINATION:  ,Please see the hospital chart.,LABORATORY DATA: , Please see the hospital chart.,HOSPITAL COURSE: , The patient was taken to the operating room by Dr. X who is covering for ENT and noted that she had airway compromise and a rather large fishbone noted and that was removed.  The patient was intubated and it was felt that she should be observed to see if the airway would improve upon which she could be extubated.  If not she would require tracheostomy.  The patient was treated with IV antibiotics and ventilatory support and at the time of this dictation, she has recently been taken to the operating room where it was felt that the airway sufficient and she was extubated.  She was doing well with good p.o.s, good airway, good voice, and desiring to be discharged home.  So, the patient is being prepared for discharge at this point.  We will have Dr. X evaluate her before she leaves to make sure I do not have any problem with her going home.  Dr. Y feels she could be discharged today and will have her return to see him in a week.","consult - history and phy., diabetes, hypertension, asthma, cholecystectomy, fishbone, foreign body, airway compromise, airway,"
 The patient is a 74-year-old woman who presents for neurological consultation for possible adult hydrocephalus.  Mild gait impairment and mild cognitive slowing., Consult - History and Phy., Adult Hydrocephalus ,"REASON FOR VISIT: , The patient is a 74-year-old woman who presents for neurological consultation referred by Dr. X.  She is accompanied to the appointment by her husband and together they give her history.,HISTORY OF PRESENT ILLNESS: , The patient is a lovely 74-year-old woman who presents with possible adult hydrocephalus.  Danish is her native language, but she has been in the United States for many many years and speaks fluent English, as does her husband.,With respect to her walking and balance, she states ""I think I walk funny.""  Her husband has noticed over the last six months or so that she has broadened her base and become more stooped in her pasture.  Her balance has also gradually declined such that she frequently touches walls and furniture to stabilize herself.  She has difficulty stepping up on to things like a scale because of this imbalance.  She does not festinate.  Her husband has noticed some slowing of her speed.  She does not need to use an assistive device.  She has occasional difficulty getting in and out of a car.  Recently she has had more frequent falls.  In March of 2007, she fell when she was walking to the bedroom and broke her wrist.  Since that time, she has not had any emergency room trips, but she has had other falls.,With respect to her bowel and bladder, she has no issues and no trouble with frequency or urgency.,The patient does not have headaches.,With respect to thinking and memory, she states she is still able to pay the bills, but over the last few months she states, ""I do not feel as smart as I used to be.""  She feels that her thinking has slowed down.  Her husband states that he has noticed, she will occasionally start a sentence and then not know what words to use as she is continuing.,The patient has not had trouble with syncope.  She has had past episodes of vertigo, but not recently.,PAST MEDICAL HISTORY:  ,Significant for hypertension diagnosed in 2006, reflux in 2000, insomnia, but no snoring or apnea.  She has been on Ambien, which is no longer been helpful.  She has had arthritis since year 2000, thyroid abnormalities diagnosed in 1968, a hysterectomy in 1986, and a right wrist operation after her fall in 2007 with a titanium plate and eight screws.,FAMILY HISTORY: , Her father died with heart disease in his 60s and her mother died of colon cancer.  She has a sister who she believes is probably healthy.  She has had two sons one who died of a blood clot after having been a heavy smoker and another who is healthy.  She has two normal vaginal deliveries.,SOCIAL HISTORY:  ,She lives with her husband.  She is a nonsmoker and no history of drug or alcohol abuse.  She does drink two to three drinks daily.  She completed 12th grade.,ALLERGIES: , Codeine and sulfa.,She has a Living Will and if unable to make decisions for herself, she would want her husband, Vilheim to make decisions for her.,MEDICATIONS,:  Premarin 0.625 mg p.o. q.o.d., Aciphex 20 mg p.o. q. daily, Toprol 50 mg p.o. q. daily, Norvasc 5 mg p.o. q. daily, multivitamin, Caltrate plus D, B-complex vitamins, calcium and magnesium, and vitamin C daily.,MAJOR FINDINGS: , On examination today, this is a pleasant and healthy appearing woman.,VITAL SIGNS:  Blood pressure 154/72, heart rate 87, and weight 153 pounds.  Pain is 0/10.,HEAD:  Head is normocephalic and atraumatic.  Head circumference is 54 cm, which is in the 10-25th percentile for a woman who is 5 foot and 6 inches tall.,SPINE:  Spine is straight and nontender.  Spinous processes are easily palpable.  She has very mild kyphosis, but no scoliosis.,SKIN:  There are no neurocutaneous stigmata.,CARDIOVASCULAR EXAM:  Regular rate and rhythm.  No carotid bruits.  No edema.  No murmur.  Peripheral pulses are good.  Lungs are clear.,MENTAL STATUS:  Assessed for recent and remote memory, attention span, concentration, and fund of knowledge.  She scored 30/30 on the MMSE when attention was tested with either spelling or calculations.  She had no difficulty with visual structures.,CRANIAL NERVES:  Pupils are equal.  Extraocular movements are intact.  Face is symmetric.  Tongue and palate are midline.  Jaw muscles strong.  Cough is normal.  SCM and shrug 5 and 5.  Visual fields intact.,MOTOR EXAM:  Normal for bulk, strength, and tone.  There was no drift or tremor.,SENSORY EXAM:  Intact for pinprick and proprioception.,COORDINATION:  Normal for finger-to-nose.,REFLEXES:  Are 2+ throughout.,GAIT:  Assessed using the Tinetti assessment tool.  She was fairly quick, but had some unsteadiness and a widened base.  She did not need an assistive device.  I gave her a score of 13/16 for balance and 9/12 for gait for a total score of 22/28.,REVIEW OF X-RAYS: , MRI was reviewed from June 26, 2008.  It shows mild ventriculomegaly with a trace expansion into the temporal horns.  The frontal horn span at the level of foramen of Munro is 3.8 cm with a flat 3rd ventricular contour and a 3rd ventricular span of 11 mm.  The sylvian aqueduct is patent.  There is no pulsation artifact.  Her corpus callosum is bowed and effaced.  She has a couple of small T2 signal abnormalities, but no significant periventricular signal change.,ASSESSMENT:  ,The patient is a 74-year-old woman who presents with mild progressive gait impairment and possible slowing of her cognition in the setting of ventriculomegaly suggesting possible adult hydrocephalus.,PROBLEMS/DIAGNOSES:,1.  Possible adult hydrocephalus (331.5).,2.  Mild gait impairment (781.2).,3.  Mild cognitive slowing (290.0).,PLAN: , I had a long discussion with the patient her husband.,I think it is possible that the patient is developing symptomatic adult hydrocephalus.  At this point, her symptoms are fairly mild.  I explained to them the two methods of testing with CSF drainage.  It is possible that a large volume lumbar puncture would reveal whether she is likely to respond to shunt and I described that test.  About 30% of my patients with walking impairment in a setting of possible adult hydrocephalus can be diagnosed with a large volume lumbar puncture.  Alternatively, I could bring her into the hospital for four days of CSF drainage to determine whether she is likely to respond to shunt surgery.  This procedure carries a 2% to 3% risk of meningitis.  I also explained that it would be reasonable to start with an outpatient lumbar puncture and if that is not sufficient we could proceed with admission for the spinal catheter protocol.",
 Acute episode of agitation.  She was complaining that she felt she might have been poisoned at her care facility., Consult - History and Phy., Agitation - ER Visit ,"HISTORY OF PRESENT ILLNESS:  This is a 91-year-old female who was brought in by family.  Apparently, she was complaining that she felt she might have been poisoned at her care facility.  The daughter who accompanied the patient states that she does not think anything is actually wrong, but she became extremely agitated and she thinks that is the biggest problem with the patient right now.  The patient apparently had a little bit of dry heaves, but no actual vomiting.  She had just finished eating dinner.  No one else in the facility has been ill.,PAST MEDICAL HISTORY: Remarkable for previous abdominal surgeries.  She has a pacemaker.  She has a history of recent collarbone fracture.,REVIEW OF SYSTEMS:  Very difficult to get from the patient herself.  She seems to deny any significant pain or discomfort, but really seems not particularly intent on letting me know what is bothering her.  She initially stated that everything was wrong, but could not specify any specific complaints.  Denies chest pain, back pain, or abdominal pain.  Denies any extremity symptoms or complaints.,SOCIAL HISTORY:  The patient is a nonsmoker.  She is accompanied here with daughter who brought her over here.  They were visiting the patient when this episode occurred.,MEDICATIONS:  Please see list.,ALLERGIES:  NONE.,PHYSICAL EXAMINATION:  VITAL SIGNS:  The patient is afebrile, actually has a very normal vital signs including normal pulse oximetry at 99% on room air.  GENERAL:  The patient is an elderly frail looking little lady lying on the gurney.  She is awake, alert, and not really wanted to answer most of the questions I asked her.  She does have a tremor with her mouth, which the daughter states has been there for ""many years"".  HEENT:  Eye exam is unremarkable.  Oral mucosa is still moist and well hydrated.  Posterior pharynx is clear.  NECK:  Supple.  LUNGS:  Actually clear with good breath sounds.  There are no wheezes, no rales, or rhonchi.  Good air movement.  CARDIAC:  Without murmur.  ABDOMEN:  Soft.  I do not elicit any tenderness.  There is no abdominal distention.  Bowel sounds are present in all quadrants.  SKIN:  Skin is without rash or petechiae.  There is no cyanosis.  EXTREMITIES:  No evidence of any trauma to the extremities.,EMERGENCY DEPARTMENT COURSE:  I had a long discussion with the family and they would like the patient receive something for agitation, so she was given 0.5 mg of Ativan intramuscularly.  After about half an hour, I came back to talk to the patient and the family, the patient states that she feels better.  Family states she seems more calm.  They do not want to pursue any further workup at this time.,IMPRESSION:  ACUTE EPISODE OF AGITATION.,PLAN:  At this time, I had reviewed the patient's records and it is not particularly enlightening as to what could have triggered off this episode.  The patient herself has good vital signs.  She does not seem to have any specific acute process going on and seemed to feel comfortable after the Ativan was given, a small quantity was given to the patient.  Family and daughter specifically did not want to pursue any workup at this point, which at this point I think is reasonable and we will have her follow up with ABC.  She is discharged in stable condition.","consult - history and phy., acute episode of agitation, agitation, "
" A 12-year-old  fell off his bicycle, not wearing a helmet, a few hours ago.  There was loss of consciousness.  The patient complains of neck pain.", Consult - History and Phy., Abrasions & Lacerations - ER Visit ,"HISTORY OF PRESENT ILLNESS: , This is a 12-year-old male, who was admitted to the Emergency Department, who fell off his bicycle, not wearing a helmet, a few hours ago.  There was loss of consciousness.  The patient complains of neck pain.,CHRONIC/INACTIVE CONDITIONS:,  None.,PERSONAL/FAMILY/SOCIAL HISTORY/ILLNESSES:,  None.,PREVIOUS INJURIES: , Minor.,MEDICATIONS: , None.,PREVIOUS OPERATIONS: , None.,ALLERGIES:  ,NONE KNOWN.,FAMILY HISTORY: , Negative for heart disease, hypertension, obesity, diabetes, cancer or stroke.,SOCIAL HISTORY: , The patient is single.  He is a student.  He does not smoke, drink alcohol or consume drugs.,REVIEW OF SYSTEMS,CONSTITUTIONAL:  The patient denies weight loss/gain, fever, chills.,ENMT:  The patient denies headaches, nosebleeds, voice changes, blurry vision, changes in/loss of vision.,CV:  The patient denies chest pain, SOB supine, palpitations, edema, varicose veins, leg pains.,RESPIRATORY:  The patient denies SOB, wheezing, sputum production, bloody sputum, cough.,GI:  The patient denies heartburn, blood in stools, loss of appetite, abdominal pain, constipation.,GU:  The patient denies painful/burning urination, cloudy/dark urine, flank pain, groin pain.,MS:  The patient denies joint pain/stiffness, backaches, tendon/ligaments/muscle pains/strains, bone aches/pains, muscle weakness.,NEURO:  The patient had a loss of consciousness during the accident.  He does not recall the details of the accident.  Otherwise, negative for blackouts, seizures, loss of memory, hallucinations, weakness, numbness, tremors, paralysis.,PSYCH:  Negative for anxiety, irritability, apathy, depression, sleep disturbances, appetite disturbances, suicidal thoughts.,INTEGUMENTARY:  Negative for unusual hair loss/breakage, skin lesions/discoloration, unusual nail breakage/discoloration.,PHYSICAL EXAMINATION,CONSTITUTIONAL:  Blood pressure 150/75, pulse rate 80, respirations 18, temperature 37.4, saturation 97% on room air.  The patient shows moderate obesity.,NECK:  The neck is symmetric, the trachea is in the midline, and there are no masses.  No crepitus is palpated.  The thyroid is palpable, not enlarged, smooth, moves with swallowing, and has no palpable masses.,RESPIRATIONS:  Normal respiratory effort.  There is no intercostal retraction or action by the accessory muscles.  Normal breath sounds bilaterally with no rhonchi, wheezing or rubs.,CARDIOVASCULAR:  The PMI is palpable at the 5ICS in the MCL.  No thrills on palpation.  S1 and S2 are easily audible.  No audible S3, S4, murmur, click or rub.  Abdominal aorta is not palpable.  No audible abdominal bruits.  Femoral pulses are 3+ bilaterally, without audible bruits.  Extremities show no edema or varicosities.,GASTROINTESTINAL:  No palpable tenderness or masses.  Liver and spleen are percussed but not palpable under the costal margins.  No evidence for umbilical or groin herniae.,LYMPHATIC:  No nodes over 3 mm in the neck, axillae or groins.,MUSCULOSKELETAL:  Normal gait and station.  The patient is on a stretcher.  Symmetric muscle strength and normal tone, without signs of atrophy or abnormal movements.,SKIN:  There is a hematoma in the forehead and one in the occipital scalp, and there are abrasions in the upper extremities and abrasions on the knees.  No induration or subcutaneous nodules to palpation.,NEUROLOGIC:  Normal sensation by touch.  The patient moves all four extremities.,PSYCHIATRIC:  Oriented to time, place, and person.  Appropriate mood and affect.,LABORATORY DATA:  Reviewed chest x-ray, which is normal, right hand x-ray, which is normal, and an MRI of the head, which is normal.,DIAGNOSES,1.  Concussion.,2.  Facial abrasion.,3.  Scalp laceration.,4.  Knee abrasions.,PLANS/RECOMMENDATIONS:,  Admitted for observation.",
 Patient had a markedly abnormal stress test with severe chest pain after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only., Consult - History and Phy., Abnormal Stress Test ,"HISTORY OF PRESENT ILLNESS: , Mr. ABC is a 60-year-old gentleman who had a markedly abnormal stress test earlier today in my office with severe chest pain after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only.  He required 3 sublingual nitroglycerin in total (please see also admission history and physical for full details).,The patient underwent cardiac catheterization with myself today which showed mild-to-moderate left main distal disease of 30%, moderate proximal LAD with a severe mid-LAD lesion of 99%, and a mid-left circumflex lesion of 80% with normal LV function and some mild luminal irregularities in the right coronary artery with some moderate stenosis seen in the mid to distal right PDA.,I discussed these results with the patient, and he had been relating to me that he was having rest anginal symptoms, as well as nocturnal anginal symptoms, and especially given the severity of the mid left anterior descending lesion, with a markedly abnormal stress test, I felt he was best suited for transfer for PCI.  I discussed the case with Dr. X at Medical Center who has kindly accepted the patient in transfer.,CONDITION ON TRANSFER: , Stable but guarded.  The patient is pain-free at this time.,MEDICATIONS ON TRANSFER:,1.  Aspirin 325 mg once a day.,2.  Metoprolol 50 mg once a day, but we have had to hold it because of relative bradycardia which he apparently has a history of.,3.  Nexium 40 mg once a day.,4.  Zocor 40 mg once a day, and there is a fasting lipid profile pending at the time of this dictation.  I see that his LDL was 136 on May 3, 2002.,5.  Plavix 600 mg p.o. x1 which I am giving him tonight.,Other medical history is inclusive for obstructive sleep apnea for which he is unable to tolerate positive pressure ventilation, GERD, arthritis,DISPOSITION:  ,The patient and his wife have requested and are agreeable with transfer to Medical Center, and we are enclosing the CD ROM of his images.","consult - history and phy., standard bruce, nitroglycerin, abnormal stress test, st depressions, anginal symptoms, stress test, lad, anginal, stress"
" Acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use - Acne Vulgaris", Consult - History and Phy., Acne Vulgaris - H&P ,"CHIEF COMPLAINT (1/1): , This 19 year old female presents today complaining of acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use.  Location:  She indicates the problem location is the chin, right temple and left temple locally.  Severity:  Severity of condition is worsening.,Menses:  Onset:  13 years old.  Interval:  22-27 days.  Duration:  4-6 days.  Flow:  light.  Complications:  none.,ALLERGIES: , Patient admits allergies to penicillin resulting in difficulty breathing.,MEDICATION HISTORY:,  Patient is currently taking Alesse-28, 20 mcg-0.10 mg tablet usage started on 08/07/2001 medication was prescribed by Obstetrician-Gynecologist A.,PAST MEDICAL HISTORY:,  Female Reproductive Hx: (+) birth control pill use, Childhood Illnesses: (+) chickenpox, (+) measles.,PAST SURGICAL HISTORY:,  No previous surgeries.,FAMILY HISTORY: , Patient admits a family history of anxiety, stress disorder associated with mother.,SOCIAL HISTORY:,  Patient admits caffeine use She consumes 3-5 servings per day, Patient admits alcohol use Drinking is described as social, Patient admits good diet habits, Patient admits exercising regularly, Patient denies STD history.,REVIEW OF SYSTEMS:,  Integumentary: (+) periodic reddening of face, (+) acne problems, Allergic /,Immunologic: (-) allergic or immunologic symptoms, Constitutional Symptoms: (-) constitutional symptoms,such as fever, headache, nausea, dizziness.,PHYSICAL EXAM:,  Patient is a 19 year old female who appears pleasant, in no apparent distress, her given age, well developed, well nourished and with good attention to hygiene and body habitus.  Skin:  Examination of scalp shows no abnormalities.  Hair growth and distribution is normal.  Inspection of skin outside of affected area reveals no abnormalities.  Palpation of skin shows no abnormalities.  Inspection of eccrine and apocrine glands shows no evidence of hyperidrosis, chromidrosis or bromhidrosis.  Face shows keratotic papule.,IMPRESSION:,  Acne vulgaris.,PLAN:,  Recommended treatment is antibiotic therapy.  Patient received extensive counseling about acne.  She understands acne treatment is usually long-term.  Return to clinic in 4 week (s).,PATIENT INSTRUCTIONS:,  Patient received literature regarding acne vulgaris.  Discussed with the patient the prescription for Tetracycline and handed out information regarding the side effects and the proper method of ingestion.,PRESCRIPTIONS:,  Tetracycline  Dosage:  250 mg capsule  Sig:  BID  Dispense:  60  Refills:  0  Allow Generic:  Yes", 
" Patient status post gastric bypass surgery, developed nausea and right upper quadrant pain.", Consult - History and Phy., Admission History & Physical - Nausea ,"CHIEF COMPLAINT: , Nausea.,PRESENT ILLNESS: , The patient is a 28-year-old, who is status post gastric bypass surgery nearly one year ago.  He has lost about 200 pounds and was otherwise doing well until yesterday evening around 7:00-8:00 when he developed nausea and right upper quadrant pain, which apparently wrapped around toward his right side and back.  He feels like he was on it but has not done so.  He has overall malaise and a low-grade temperature of 100.3.  He denies any prior similar or lesser symptoms.  His last normal bowel movement was yesterday.  He denies any outright chills or blood per rectum.,PAST MEDICAL HISTORY: , Significant for hypertension and morbid obesity, now resolved.,PAST SURGICAL HISTORY: , Gastric bypass surgery in December 2007.,MEDICATIONS:  ,Multivitamins and calcium.,ALLERGIES: , None known.,FAMILY HISTORY:  ,Positive for diabetes mellitus in his father, who is now deceased.,SOCIAL HISTORY: , He denies tobacco or alcohol.  He has what sounds like a data entry computer job.,REVIEW OF SYSTEMS:  ,Otherwise negative.,PHYSICAL EXAMINATION:,  His temperature is 100.3, blood pressure 129/59, respirations 16, heart rate 84.  He is drowsy, but easily arousable and appropriate with conversation.  He is oriented to person, place, and situation.  He is normocephalic, atraumatic.  His sclerae are anicteric.  His mucous membranes are somewhat tacky.  His neck is supple and symmetric.  His respirations are unlabored and clear.  He has a regular rate and rhythm.  His abdomen is soft.  He has diffuse right upper quadrant tenderness, worse focally, but no rebound or guarding.  He otherwise has no organomegaly, masses, or abdominal hernias evident.  His extremities are symmetrical with no edema.  His posterior tibial pulses are palpable and symmetric.  He is grossly nonfocal neurologically.,STUDIES:,  His white blood cell count is 8.4 with 79 segs.  His hematocrit is 41.  His electrolytes are normal.  His bilirubin is 2.8.  His AST 349, ALT 186, alk-phos 138 and lipase is normal at 239.,ASSESSMENT: , Choledocholithiasis, ? cholecystitis.,PLAN: , He will be admitted and placed on IV antibiotics.  We will get an ultrasound this morning.  He will need his gallbladder out, probably with intraoperative cholangiogram.  Hopefully, the stone will pass this way.  Due to his anatomy, an ERCP would prove quite difficult if not impossible unless laparoscopic assisted.  Dr. X will see him later this morning and discuss the plan further.  The patient understands.","consult - history and phy., gastric bypass surgery, nausea, choledocholithiasis, cholecystitis, ercp, gastric bypass, bypass surgery, "
" The patient complaining of abdominal pain, has a long-standing history of diabetes treated with Micronase daily.", Consult - History and Phy., Acute Cystitis & Diabetes Type II ,"HISTORY OF PRESENT ILLNESS: , The patient is a 45-year-old male complaining of abdominal pain.  The patient also has a long-standing history of diabetes which is treated with Micronase daily.,PAST MEDICAL HISTORY: , There is no significant past medical history noted today.,PHYSICAL EXAMINATION:,HEENT:  Patient denies ear abnormalities, nose abnormalities and throat abnormalities.,Cardio:  Patient has history of elevated cholesterol, but does not have ASHD, hypertension and PVD.,Resp:  Patient denies asthma, lung infections and lung lesions.,GI:  Patient denies colon abnormalities, gall bladder problems, liver abnormalities and peptic ulcer disease.,GU:  Patient has history of Urinary tract disorder, but does not have Bladder disorder and Kidney disorder.,Endocrine:  Patient has history of diabetes, but does not have hormonal irregularities and thyroid abnormalities.,Dermatology:  Patient denies allergic reactions, rashes and skin lesions.,MEDS:,  Micronase 2.5 mg Tab PO QAM #30.  Bactrim 400/80 Tab PO BID #30.,SOCIAL HISTORY:,  No known history of drug or alcohol abuse.  Work, diet, and exercise patterns are within normal limits.,FAMILY HISTORY:,  No significant family history.,REVIEW OF SYSTEMS:,  Non-contributory.,Vital Signs:  Height = 72 in.  Weight =184 lbs.  Upright BP = 120/80 mmHg.  Pulse = 80 bpm.  Resp =12 pm.  Patient is afebrile.,Neck:  The neck is supple.  There is no jugular venous distension.  The thyroid is nontender, or normal size and conto.,Lungs:  Lung expansion and excursions are symmetric.  The lungs are clear to auscultation and percussion.,Cardio:  There is a regular rhythm.  SI and S2 are normal.  No abnormal heart sounds are detected.  Blood pressure is equal bilaterally.,Abdomen:  Normal bowel sounds are present.  The abdomen is soft; The abdomen is nontender; without organomegaly; There is no CVA tenderness.  No hernias are noted.,Extremities:  There is no clubbing, cyanosis, or edema.,ASSESSMENT: , Diabetes type II uncontrolled.  Acute cystitis.,PLAN: , Endocrinology Consult, complete CBC.  ,RX: , Micronase 2.5 mg Tab PO QAM #30, Bactrim 400/80 Tab PO BID #30.",
" Abnormal echocardiogram findings and followup.  Shortness of breath, congestive heart failure, and valvular insufficiency.   The patient complains of shortness of breath, which is worsening.  The patient underwent an echocardiogram, which shows severe mitral regurgitation and also large pleural effusion.", Consult - History and Phy., Abnormal Echocardiogram ,"REASON FOR CONSULTATION:  ,Abnormal echocardiogram findings and followup.  Shortness of breath, congestive heart failure, and valvular insufficiency.,HISTORY OF PRESENT ILLNESS:  ,The patient is an 86-year-old female admitted for evaluation of abdominal pain and bloody stools.  The patient has colitis and also diverticulitis, undergoing treatment.  During the hospitalization, the patient complains of shortness of breath, which is worsening.  The patient underwent an echocardiogram, which shows severe mitral regurgitation and also large pleural effusion.  This consultation is for further evaluation in this regard.  As per the patient, she is an 86-year-old female, has limited activity level.  She has been having shortness of breath for many years.  She also was told that she has a heart murmur, which was not followed through on a regular basis.,CORONARY RISK FACTORS: , History of hypertension, no history of diabetes mellitus, nonsmoker, cholesterol status unclear, no prior history of coronary artery disease, and family history noncontributory.,FAMILY HISTORY:  ,Nonsignificant.,PAST SURGICAL HISTORY: , No major surgery.,MEDICATIONS: , Presently on Lasix, potassium supplementation, Levaquin, hydralazine 10 mg b.i.d., antibiotic treatments, and thyroid supplementation.,ALLERGIES:  ,AMBIEN, CARDIZEM, AND IBUPROFEN.,PERSONAL HISTORY:,  She is a nonsmoker.  Does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY:  ,Basically GI pathology with diverticulitis, colitis, hypothyroidism, arthritis, questionable hypertension, no prior history of coronary artery disease, and heart murmur.,REVIEW OF SYSTEMS,CONSTITUTIONAL:  Weakness, fatigue, and tiredness.,HEENT:  History of cataract, blurred vision, and hearing impairment.,CARDIOVASCULAR:  Shortness of breath and heart murmur.  No coronary artery disease.,RESPIRATORY:  Shortness of breath.  No pneumonia or valley fever.,GASTROINTESTINAL:  No nausea, vomiting, hematemesis, or melena.,UROLOGICAL:  No frequency or urgency.,MUSCULOSKELETAL:  Arthritis and severe muscle weakness.,SKIN:  Nonsignificant.,NEUROLOGICAL:  No TIA or CVA.  No seizure disorder.,ENDOCRINE/HEMATOLOGICAL:  As above.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse of 84, blood pressure of 168/74, afebrile, and respiratory rate 16 per minute.,HEENT/NECK:  Head is atraumatic and normocephalic.  Neck veins flat.  No significant carotid bruits appreciated.,LUNGS:  Air entry bilaterally fair.  No obvious rales or wheezes.,HEART:  PMI displaced.  S1, S2 with systolic murmur at the precordium, grade 2/6.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  Chronic skin changes.  Feeble pulses distally.  No clubbing or cyanosis.,DIAGNOSTIC DATA: , EKG:  Normal sinus rhythm.  No acute ST-T changes.,Echocardiogram report was reviewed.,LABORATORY DATA:,  H&H 13 and 39.  BUN and creatinine within normal limits.  Potassium within normal limits.  BNP 9290.,IMPRESSION:,1.  The patient admitted for gastrointestinal pathology, under working treatment.,2.  History of prior heart murmur with echocardiogram findings as above.  Basically revealed normal left ventricular function with left atrial enlargement, large pleural effusion, and severe mitral regurgitation and tricuspid regurgitation.,RECOMMENDATIONS:,1.  From cardiac standpoint, conservative treatment.  Possibility of a transesophageal echocardiogram to assess valvular insufficiency adequately well discussed extensively.,2.  After extensive discussion, given her age 86, limited activity level, and no intention of undergoing any treatment in this regard from a surgical standpoint, the patient does not wish to proceed with a transesophageal echocardiogram.,3.  Based on the above findings, we will treat her medically with ACE inhibitors and diuretics and see how she fares.  She has a normal LV function.",
 The patient was referred due to concerns regarding behavioral acting out as well as encopresis., Consult - History and Phy., Adjustment Disorder & Encopresis ,"REASON FOR REFERRAL:,  The patient was referred to me by Dr. X of the Clinic due to concerns regarding behavioral acting out as well as encopresis.  This is a 90-minute initial intake completed on 10/03/2007.  I met with the patient's mother individually for the entire session.  I reviewed with her the treatment, consent form, as well as the boundaries of confidentiality, and she stated that she understood these concepts.,PRESENTING PROBLEMS: , Mother reported that her primary concern in regard to the patient had to do with his oppositionality.  She was more ambivalent regarding addressing the encopresis.  In regards to his oppositionality, she reported that the onset of his oppositionality was approximately at 4 years of age, that before that he had been a very compliant and happy child, and that he has slowly worsened over time.  She noted that the oppositionality occurred approximately after his brother, who has multiple medical problems, was born.  At that time, mother had spent 2 months back East with the brother due to his feeding issues and will have to go again next year.  She reported that in terms of the behaviors that he loses his temper frequently, he argues with her that he defies her authority that she has to ask him many times to do things, that she has to repeat instructions, that he ignores her, that he whines, and this is when he is told to do something that he does not want to do.  She reported that he deliberately annoys other people, that he can be angry and resentful.  She reported that he does not display these behaviors with the father nor does he display them at home, but they are specific to her.  She reported that her response to him typically is that she repeats what she wants him to do many, many times, that eventually she gets upset.  She yells at him, talks with him, and tries to make him go and do what she wants him to do.  Mother also noted that she probably ignores some his misbehaviors.  She stated that the father tends to be more firm and more direct with him, and that, the father sometimes thinks that the mother is too easy on him.  In regards to symptoms of depression, she denied symptoms of depression, noting that he tends to only become unhappy when he has to do something that he does not want to do, such as go to school or follow through on a command.  She denied any suicidal ideation.  She denied all symptoms of anxiety.  PTSD was denied.  ADHD symptoms were denied, as were all other symptoms of psychopathology.,In regards to the encopresis, she reported that he has always soiled, he does so 2 to 3 times a day.  She reported that he is concerned about this issue.  He currently wears underwear and had a pull-up.  She reported that he was seen at the Gastroenterology Department here several years ago, and has more recently been seen at the Diseases Center, seen by Dr. Y, reported that the last visit was several months ago, that he is on MiraLax.  He does sit on the toilet may be 2 times a day, although that is not consistent.  Mother believes that he is probably constipated or impacted again.  He refuses to eat any fiber.  In regards to what happens when he soils, mother basically takes full responsibility.  She cleans and changes his underwear, thinks of things that she has tried, she mostly gets frustrated, makes negative comments, even though she knows that he really cannot help it.  She has never provided him with any sort of rewards, because she feels that this is something he just needs to learn to do.  In regards to other issues, she noted that he becomes frustrated quite easily, especially around homework, that when mother has to correct him, or when he has had difficulty doing something that he becomes upset, that he will cry, and he will get angry.  Mother's response to him is that either she gets agitated and raises her voice, tells him to stop etc.  Mother reported it is not only with homework, but also with other tasks, such as if he is trying to build with his LEGOs and things do not go well.,DEVELOPMENTAL BACKGROUND: , The patient was reported to be the 8 pound 12 ounce product of a planned and noncomplicated pregnancy and emergency cesarean delivery.  The patient presented in a breech position.  Mother denied the use of drugs, alcohol, or tobacco during the pregnancy.  No sleeping or eating issues were present in the perinatal period.  Temperament was described as easy.  He was described as a cuddly baby.  No concerns expressed regarding his developmental milestones.  No serious injuries reported.  No hospitalizations or surgeries.  No allergies.  The patient has been encopretic for all of his life.  He currently is taking MiraLax.,FAMILY BACKGROUND: , The patient lives with his mother who is age 37, and is primarily a homemaker, but does work approximately 48 hours a month as a beautician; with his father, age 35, who is a police officer; and also, with his younger brother who is age 3, and has significant medical problems as will be noted in a moment.  Mother and father have been together since 1997, married in 1999.  The maternal grandmother and grandfather are living and are together, and live in the Central California Coast Area.  There is one maternal aunt, age 33, and then, two adopted maternal aunt and uncle, age 18 and age 13.  In regards to the father's side of the family, the paternal grandparents are divorced.  Grandfather was in Arkansas, grandmother lives in Dos Palos.  The patient does not see his grandfather.  Mother stated that her relationship with her child was as described, that he very much stresses her out, that she wishes that he was not so defiant, that she finds him to be a very stressful child to deal with.  In regards to the relationship with the father, it was reported that the father tends to leave most of the parenting over to the mother, unless she specifically asks him to do something, and then, he will follow through and do it.  He will step in and back mother up in terms of parenting, tell the child not to speak to his mother that way etc.  Mother reported that he does spend some time with the children, but not as much as mother would like him to, but occasionally, he will go outside and do things with them.  The mother reported that sometimes she has a problem in interfering with his parenting, that she steps in and defends The patient.  It was reported that mother stated that she tries the parenting technique, primarily of yelling and tried time-out, although her description suggests that she is not doing time-out correctly, as he simply gets up from his time-out, and she does not follow through.  Mother reported that she and the patient are very much alike in temperament, and this has made things more difficult.  Mother tends to be stubborn and gets angry easily also.  Mother reported becoming fatigued in her parenting, that she lets him get away with things sometimes because she does not want to punish him all day long, sometimes ignores problems that she probably should not ignore.  There was reported to be jealousy between The patient and his brother, B.  B evidently has some heart problems and feeding issues, and because of that, tends to get more attention in terms of his medical needs, and that the patient is very jealous of that attention and feels that B is favored and that he get things that The patient does not get, and that there is some tension between the brothers.  They do play well together; however, The patient does tend to be somewhat intrusive, gets in his space, and then, B will hit him.  Mother reported that she graduated from high school, went to Community College, and was an average student.  No learning problems.  Mother has a history of depression.  She has currently been taking 100 mg of Zoloft administered by her primary medical doctor.  She is not receiving counseling.  She has been on the medications for the last 5 years.  Her dosage has not been changed in a year.  She feels that she is getting more irritable and more angry.  I  encouraged her to see a primary medical doctor.  Mother has no drug or alcohol history.  Father graduated from high school, went to the Police Academy, average student.  No learning problems, no psychological problems, no drug or alcohol problems are reported.  In terms of extended family, maternal grandmother as well as maternal great grandfather have a history of depression.  Other psychiatric symptoms were denied in the family.,Mother reported that the marriage is generally okay, that there is some arguing.  She reported that it was in the normal range.,ACADEMIC BACKGROUND: , The patient attends the Roosevelt Elementary School, where he is in a regular first grade classroom with Mrs. The patient.  This is in the Kingsburg Unified School District.  No behavior problems, academic problems were reported.  He does not receive special education services.,SOCIAL HISTORY: , The patient was described as being able to make and keep friends, but at this point in time, there has been no teasing regarding smell from the encopresis.  He does have kids over to play at the house.,PREVIOUS COUNSELING:,  Denied.,DIAGNOSTIC SUMMARY AND IMPRESSION: , My impression is that the patient has a long history of constipation and impaction, which has been treated medically, but it would appear that the mother has not followed through consistently with the behavioral component of toilet sitting, increased fiber, regular medication, so that the problem has likely continued.  She also has not used any sort of rewards as a way to encourage him, in the encopresis.  The patient clearly qualifies for a diagnosis of disruptive behavior disorder, not otherwise specified, and possibly oppositional defiant disorder.  It would appear that mother needs help in her parenting, and that she tends to mostly use yelling and anger as a way, and tends to repeat herself a lot, and does not have a strategy for how to follow through and to deal with defiant behavior.  Also, mother and father, may not be on the same page in terms of parenting.,PLAN:,  In terms of my plan, I will meet with the child in the next couple of weeks.  I also asked the mother to bring the father in, so he could be involved in the treatment also, and I gave the mother a behavioral checklist to be completed by herself and the father as well as the teacher.,DSM IV DIAGNOSES:  ,AXIS I:  Adjustment disorder with disturbance of conduct (309.3).  Encopresis, without constipation, overflow incontinence (307.7),AXIS II:  No diagnoses (V71.09).,AXIS III:  No diagnoses.,AXIS IV:  Problems with primary support group.,AXIS V:  Global assessment of functioning equals 65.","consult - history and phy., developmental background, axis, dsm iv, adjustment disorder, behavioral, adjustment, depression, oppositionality, encopresis, "
 Patient presents with a chief complaint of chest pain admitted to Coronary Care Unit due to acute inferior myocardial infarction., Consult - History and Phy., Acute Inferior Myocardial Infarction ,"CHIEF COMPLAINT: , Chest pain.,HISTORY OF PRESENT ILLNESS:,  The patient is a 40-year-old white male who presents with a chief complaint of ""chest pain"".,The patient is diabetic and has a prior history of coronary artery disease.  The patient presents today stating that his chest pain started yesterday evening and has been somewhat intermittent.  The severity of the pain has progressively increased.  He describes the pain as a sharp and heavy pain which radiates to his neck & left arm.  He ranks the pain a 7 on a scale of 1-10.  He admits some shortness of breath & diaphoresis.  He states that he has had nausea & 3 episodes of vomiting tonight.  He denies any fever or chills.  He admits prior episodes of similar pain prior to his PTCA in 1995.  He states the pain is somewhat worse with walking and seems to be relieved with rest.  There is no change in pain with positioning.  He states that he took 3 nitroglycerin tablets sublingually over the past 1 hour, which he states has partially relieved his pain.  The patient ranks his present pain a 4 on a scale of 1-10.  The most recent episode of pain has lasted one-hour.,The patient denies any history of recent surgery, head trauma, recent stroke, abnormal bleeding such as blood in urine or stool or nosebleed.,REVIEW OF SYSTEMS:,  All other systems reviewed & are negative.,PAST MEDICAL HISTORY:,  Diabetes mellitus type II, hypertension, coronary artery disease, atrial fibrillation, status post PTCA in 1995 by Dr. ABC.,SOCIAL HISTORY: , Denies alcohol or drugs.  Smokes 2 packs of cigarettes per day.  Works as a banker.,FAMILY HISTORY: , Positive for coronary artery disease (father & brother).,MEDICATIONS: , Aspirin 81 milligrams QDay.  Humulin N. insulin 50 units in a.m.  HCTZ 50 mg QDay.  Nitroglycerin 1/150 sublingually PRN chest pain.,ALLERGIES: , Penicillin.,PHYSICAL EXAM: , The patient is a 40-year-old white male.,General:  The patient is moderately obese but he is otherwise well developed & well nourished.  He appears in moderate discomfort but there is no evidence of distress.  He is alert, and oriented to person place and circumstance.  There is no evidence of respiratory distress.  The patient ambulates",
 A 5-month-old boy brought by his parents because of 2 days of cough. , Consult - History and Phy., A 5-month-old boy with cough ,"CHIEF COMPLAINT:,  A 5-month-old boy with cough.,HISTORY OF PRESENT ILLNESS:,  A 5-month-old boy brought by his parents because of 2 days of cough.  Mother took him when cough started 2 days go to Clinic where they told the mother he has viral infection and gave him Tylenol, but yesterday at night cough got worse and he also started having fever.  Mother did not measure it.,REVIEW OF SYSTEMS:,  No vomiting.  No diarrhea.  He had runny nose started with the cough two days ago.  No skin rash.  No cyanosis.  Pulling on his right ear.  Feeding, he is bottle-fed 2 ounces every 2 hours.  Mother states he urinates like 5 to 6 times a day, stools 1 time a day.  He is still feeding good to mom.,IMMUNIZATIONS: , He received first set of shot and due for the second set on 01/17/2008.,BIRTH HISTORY:,  He was premature at 33 weeks born at Hospital kept in NICU for 2 weeks for feeding problem as the mother said.  Mother had good prenatal care at 4 weeks for more than 12 visits.  No complications during pregnancy.  Rupture of membranes happened two days before the labor.  Mother received the antibiotics, but she is not sure, if she received steroids also or not.,FAMILY HISTORY: , No history of asthma or lung disease.,SOCIAL HISTORY: , Lives with parents and with two siblings, one 18-year-old and the other is 14-year-old in house, in Corrales.  They have animals, but outside the house and father smokes outside house.  No sick contacts as the mother said.,PAST MEDICAL HISTORY:,  No hospitalizations.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,MEDICATIONS: , No medications.,History of 2 previous ear infection, last one was in last November treated with ear drops, because there was pus coming from the right ear as the mother said.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Temperature 100.1, heart rate 184, respiratory rate 48.  Weight 7 kg.,GENERAL:  In no acute distress.,HEAD:  Normocephalic and atraumatic.  Open, soft, and flat anterior fontanelle.,NECK:  Supple.,NOSE:  Dry secretions.,EAR:  Right ear full of yellowish material most probably pus and necrotic tissue.  Tympanic membrane bilaterally visualized.,MOUTH:  No pharyngitis.  No ulcers.  Moist mucous membranes.,CHEST:  Bilateral audible breath sound.  No wheezes.  No palpitation.,HEART:  Regular rate and rhythm with no murmur.,ABDOMEN:  Soft, nontender, and nondistended.,GENITOURINARY:  Tanner I male with descended testes.,EXTREMITIES:  Capillary refill less than 2 seconds.,LABS:,  White blood cell 8.1, hemoglobin 10.5, hematocrit 30.9, and platelets 380,000.  CRP 6, segments 41, and bands 41.  RSV positive.  Chest x-ray evidenced bronchiolitis with hyperinflation and bronchial wall thickening in the central hilar region.  Subsegmental atelectasis in the right upper lobe and left lung base.,ASSESSMENT:,  A 5-month-old male with 2 days of cough and 1 day of fever.  Chest x-ray shows bronchiolitis with atelectasis, and RSV antigen is positive.,DIAGNOSES: , Respiratory syncytial virus bronchiolitis with right otitis externa.,PLAN: , Plan was to admit to bronchiolitis pathway, and ciprofloxacin for right otitis externa eardrops twice daily.,",
 Work restrictions and disability evaluation , Chiropractic, Permanent & Stationary Report ,"PRESENT COMPLAINTS: , The patient is reporting ongoing, chronic right-sided back pain, pain that radiates down her right leg intermittently.  She is having difficulty with bending and stooping maneuvers.  She cannot lift heavy objects.  She states she continues to have pain in her right neck and pain in her right upper extremity.  She has difficulty with pushing and pulling and lifting with her right arm.  She describes an intermittent tingling sensation in the volar aspect of her right hand.  She states she has diminished grip strength in her right hand because of wrist pain complaints.  She states that the Wellbutrin samples I had given her previously for depression seem to be helping.  Her affect appears appropriate.  She reports no suicidal ideation.  She states she continues to use Naprosyn as an anti-inflammatory, Biofreeze ointment over her neck and shoulder and back areas of complaints.  She also takes Imitrex occasionally for headache complaints related to her neck pain.  She also takes Flexeril occasionally for back spasms and Darvocet for pain.  She is asking for a refill on some of her medications today.  She is relating a VAS pain score regarding her lower back at a 6-7/10 and regarding her neck about 3/10, and regarding her right upper extremity about a 4/10., ,PHYSICAL EXAMINATION: , She is afebrile.  Blood pressure is 106/68, pulse of 64, respirations of 20.  Her physical exam is unchanged from 03/21/05.  Her orthopedic exam reveals full range of motion of the cervical spine.  Cervical compression test is negative.  Valsalva's maneuver is negative.  Hoffmann's sign is negative.  DTRs are +1 at the biceps, brachioradialis and trapezius bilaterally.  Her sensation is grossly intact to the upper extremity dermatomes.  Motor strength appears 5/5 strength in the upper extremity muscle groups tested.,Phalen's and Tinel's signs are negative at both wrists.  Passive range of motion of the right wrist is painful for her.  Passive range of motion of the left wrist is non painful.  Active range of motion of both wrists and hands are full.  She is right hand dominant.  Circumferential measurements were taken in her upper extremities.  She is 11"" in the right biceps, 10 1/2"" in the left biceps.  She is 9 3/4"" in both right and left forearms.  Circumferential measurements were also taken of the lower extremities.  She is 21"" at both the right and left thighs, 15"" in both the right and left calves.  Jamar dynamometry was assessed on three tries in this right-hand-dominant individual.  She is 42/40/40 pounds on the right hand with good effort, and on the left is 60/62/60 pounds, suggesting a loss of at least 20% to 25% pre-injury grip strength in the right dominant hand.  , ,Examination of her lumbar trunk reveals decreased range of motion, flexion allowing her fingertips about 12"" from touching the floor.  Lumbar extension is to 30 degrees.  The right SLR is limited to about 80 degrees, provoking back pain, with a positive Bragard's maneuver, causing pain to radiate to the back of the thigh.  The left SLR is to 90 degrees without back pain.  DTRs are +1 at the knees and ankles.  Toes are downgoing to plantar reflexes bilaterally.  Sensation is grossly intact in the lower extremity dermatomes.  Motor strength appears 5/5 strength in the lower extremity muscle groups tested., ,IMPRESSION: , (1)  Sprain/strain injury to the lumbosacral spine with lumbar disc herniation at L5-S1, with radicular symptoms in the right leg. (2)  Cervical sprain/strain with myofascial dysfunction. (3)  Thoracic sprain/strain with myofascial dysfunction. (4)  Probable chronic tendonitis of the right wrist.  She has negative nerve conduction studies of the right upper extremity. (5)  Intermittent headaches, possibly migraine component, possibly cervical tension cephalalgia-type headaches or cervicogenic headaches., ,TREATMENT / PROCEDURE: , I reviewed some neck and back exercises. , ,RX:, I dispensed Naprosyn 500 mg b.i.d. as an anti-inflammatory.  I refilled Darvocet N-100, one tablet q.4-6 hours prn pain, #60 tablets, and Flexeril 10 mg t.i.d. prn spasms, #90 tablets, and dispensed some Wellbutrin XL tablets, 150-mg XL tablet q.a.m., #30 tablets., ,PLAN / RECOMMENDATIONS:,  I told the patient to continue her medication course per above.  It seems to be helping with some of her pain complaints.  I told her I will pursue trying to get a lumbar epidural steroid injection authorized for her back and right leg symptoms.  I told her in my opinion I would declare her Permanent and Stationary as of today, on 04/18/05 with regards to her industrial injuries of 05/16/03 and 02/10/04.  , ,I understand her industrial injury of 05/16/03 is related to an injury at Home Depot where she worked as a credit manager.  She had a stack of screen doors fall, hitting her on the head, weighing about 60 pounds, knocking her to the ground.  She had onset of headaches and neck pain, and pain complaints about her right upper extremity.  She also has a second injury, dated 02/10/04, when apparently a co-worker was goofing around and apparently kicked her in the back accidentally, causing severe onset of back pain.  , ,FACTORS FOR DISABILITY:,OBJECTIVE:  ,1.  She exhibits decreased range of motion in the lumbar trunk.,2.  She has an abnormal MRI revealing a disc herniation at L5-S1.,3.  She exhibits diminished grip strength in the right arm and upper extremity., ,SUBJECTIVE: ,1.  Based on her headache complaints alone, would be considered occasional and minimal to slight at best. ,2.  With regards to her neck pain complaints, these would be considered occasional and slight at best. ,3.  Regarding her lower back pain complaints, would be considered frequent and slight at rest, with an increase to a moderate level of pain with repetitive bending and stooping and heavy lifting, and prolonged standing. ,4.  Regarding her right upper extremity and wrist pain complaints, these would be considered occasional and slight at rest, but increasing to slight to moderate with repetitive gripping, grasping, and torquing maneuvers of her right upper extremity. ,LOSS OF PRE-INJURY CAPACITY: , The patient advises that prior to her industrial dates of injury she was capable of repetitively bending and stooping and lifting at least 60 pounds.  She states she now has difficulty lifting more than 10 or 15 pounds without exacerbating back pain.  She has trouble trying to repetitively push or pull, torque, twist and lift with the right upper extremity, due to wrist pain, which she did not have prior to her industrial injury dates.  She also relates headaches, which she did not have prior to her industrial injury.  , ,WORK RESTRICTIONS AND DISABILITY: , I would find it reasonable to place some permanent restrictions on this patient.  It is my opinion she has a disability precluding heavy work, which contemplates the individual has lost approximately half of her pre-injury capacity for performing such activities as bending, stooping, lifting, pushing, pulling and climbing or other activities involving comparable physical effort.  The patient should probably no lift more than 15 to 20 pounds maximally.  She should probably not repetitively bend or stoop.  She should avoid repetitive pushing, pulling or torquing maneuvers, as well as gripping and grasping maneuvers of the right hand.  She should probably not lift more than 10 pounds repetitively with the right upper extremity.  I suspect that prior to her industrial she could lift repetitively and push, pull, torque and twist at least 20 to 25 pounds with the right upper extremity.  , ,CAUSATION AND APPORTIONMENT:, With regards to issues of causation, they appear appropriate to her industrial injuries and histories given per the 05/16/03 and the 02/10/04 injuries., ,With regards issues of apportionment, it is my opinion that 100% of her pain complaints are industrially related to her industrial injuries of 05/16/03 and 02/10/04.  There does not appear to be any apportionable issues here.",
 Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left., Chiropractic, Pain Management Consult - 2 ,"HPI - WORKERS COMP:, The current problem began on or about 2/10/2000. The symptoms were sudden in onset. According to the patient, the current problem is a result of a work injury involving lifting approximately 40 pounds. Pain location (lower body): left hip. The patient describes the pain as dull, aching and stabbing. The severity of the pain ranges from mild to severe. The pain is severe occasionally. It is present constantly. The pain is made worse by sitting, riding in a car, twisting and lifting. The pain is made better by rest. The patient's symptoms appear to be soft tissue (spine), myofascial (spine) and musculoskeletal (spine) in origin. Sleep alteration because of pain: positive and wakes up after getting to sleep nightly. Systemic signs/symptoms relevant or potentially relevant to the spine: none. Patient reports the following symptoms: depressed mood, loss of interest or pleasure in all or most activities, insomnia, inability to concentrate, fatigue and loss of energy.,WORK STATUS:,",
 Qualified medical evaluation report of a patient with back pain., Chiropractic, Qualified Medical Evaluation Report ,"HISTORY OF INJURY AND PRESENT COMPLAINTS: , The patient is a 59-year-old gentleman.  He is complaining chiefly of persistent lower back pain.  He states the pain is of a rather constant nature.  He describes it as a rather constant dull ache, sometimes rather sharp and stabbing in nature, most localized to the right side of his back more so than the left side of his lower back.  He states he has difficulty with prolonged standing or sitting.  He can only stand for about 5-10 minutes, then he has to sit down.  He can only sit for about 15-20 minutes, he has to get up and move about because it exacerbates his back pain.  He has difficulty with bending and stooping maneuvers.  He describes an intermittent radiating pain down his right leg, down from the right gluteal hip area to the back of the thigh to the calf and the foot.  He gets numbness along the lateral aspect of the foot itself.  He also describes chronic pain complaints with associated tension in the back of his neck.  He states the pain is of a constant nature in his neck.  He states he gets pain that radiates into the right shoulder girdle area and the right forearm.  He describes some numbness along the lateral aspect of the right forearm.  He states he has trouble trying to use his arm at or above shoulder height.  He has difficulty pushing, pulling, gripping, and grasping with the right upper extremity.  He describes pain at the anterior aspect of his shoulder, in particular.  He denies any headache complaints.  He is relating his above complaints to two industrial injuries that he sustained while employed with Frito Lay Company as a truck driver or delivery person.  He relates an initial injury that occurred on 06/29/1994, when apparently he was stepping out of the cab of his truck.  He lost his footing and fell.  He reached out to grab the hand railing.  He fell backwards on his back and his right shoulder.  He had immediate onset of shoulder pain, neck pain, and low back pain.  He had pain into his right leg.  He initially came under the care of Dr. H, an occupational physician in Modesto.  Initially, he did not obtain any MRIs or x-rays.  He did undergo some physical therapy and received some medications.  Dr. H referred him to Dr. Q, a chiropractor for three visits, which the patient was not certain was very helpful.  The patient advises he then changed treating physicians to Dr. N, D.C., whom he had seen previously for some back pain complaints back in 1990.  He felt that the chiropractic care was helping his back, neck, and shoulder pain complaints somewhat.  He continues with rather persistent pain in his right shoulder.  He underwent an MRI of the right shoulder performed on 08/16/1994 which revealed prominent impingement with biceps tenosynovitis as well as supraspinatus tendonitis superimposed by a small pinhole tear of the rotator cuff.  The patient was referred to Dr. P, an orthopedic surgeon who suggested some physical therapy for him and some antiinflammatories.  He felt that the patient might require a cortisone injection or possibly a surgical intervention.  The patient also underwent an MRI of the cervical spine on 08/03/1994, which again revealed multilevel degenerative disc disease in his neck.  There is some suggestion of bilateral neuroforaminal encroachment due to degenerative changes and disc bulges, particularly at C5-6 and C6-7 levels.  The patient was also seen by Dr. P, a neurologist for a Neurology consult.  It is unclear to me as to whether or not Dr. P had performed an EMG or nerve conduction studies of his upper or lower extremities.  The patient was off work for approximately six months following his initial injury date that occurred on 06/29/1994.  He returned back to regular duty.  Dr. N declared him permanent and stationary on 04/04/1995.  The patient then had a recurrence or flare-up or possibly new injury, again, particularly to his lower back while working for Frito Lay on 03/29/1997, when he was loading some pallets on the back of a trailer.  At that time, he returned to see Dr. N for chiropractic care, who is his primary treating physician.  Dr. N took him off work again.  He was off work again for approximately another six months, during which time, he was seen by Dr. M, M.D., a neurosurgeon.  He had a new MRI of his lumbar spine performed.  The MRI was performed on 05/20/1997.  It revealed L4-5 disc space narrowing with prominent disc bulge with some mild spinal stenosis.  The radiologist had noted he had a prior disc herniation at this level with some improvement from prior exam.  Dr. M saw him on 09/18/1997 and noted that there was some improvement in his disc herniation at the L4-5 level following a more recent MRI exam of 05/20/1997, from previous MRI exam of 1996 which revealed a rather prominent right-sided L4-5 disc herniation.  Dr. M felt that there was no indication for a lumbar spine surgery, but he mentioned with regards to his cervical spine, he felt that EMG studies of the right upper extremity should be obtained and he may require a repeat MRI of the cervical spine, if the study was positive.  The patient did undergo some nerve conduction studies of his lower extremities with Dr. K, M.D., which suggested a possible abnormal EMG with evidence of possible L5 radiculopathy, both right and left.  Unfortunately, I had no medical reports from Dr. P suggesting that he may have performed nerve conduction studies or EMGs of the upper and lower extremities.  The patient did see Dr. R for a neurosurgical consult.  Dr. R evaluated both his neck and lower back pain complaints on several occasions.  Dr. R suggested that the patient try some cervical epidural steroid injections and lumbar selective nerve root blocks.  The patient underwent these injections with Dr. K.  The patient reported only very slight relief temporarily with regards to his back and leg symptoms following the injections.  It is not clear from the medical record review whether the patient ever had a cervical epidural steroid injection; it appears that he had some selective nerve root blocks performed in the lumbar spine.  Dr. R on 12/15/2004 suggested that the patient had an MRI of the cervical spine revealing a right-sided C5-6 herniated nucleus pulposus which would explain his C-6 distribution numbness.  The patient also was noted to have a C4-5 with rather severe degenerative disc disease.  He felt the patient might be a candidate for a two-level ACDF at C4-5 and C5-6.  Dr. R in another report of 08/11/2004 suggested that the patient's MRI of 05/25/2004 of the lumbar spine reveals multilevel degenerative disc disease.  He had an L4-5 slight anterior spondylolisthesis, this may be a transitional vertebrae at the L6 level as well, with lumbarization of S1.  He felt that his examination suggested a possible right S1 radiculopathy with discogenic back pain.  He would suggest right-sided S1 selective nerve root blocks to see if this would be helpful; if not, he might be a candidate for a lumbar spine fusion, possibly a Dynesys or a fusion or some major spine surgery to help resolve his situation., ,The patient relates that he really prefers a more conservative approach of treatment regarding his neck, back, and right shoulder symptoms.  He continued to elect chiropractic care which he has found helpful, but apparently the insurance carrier is no longer authorizing chiropractic care for him.  He is currently taking no medications to manage his pain complaints.  He states regarding his work status, he was off work again for another six months following the 03/29/1997 injury.  He returned back to work and continued to work regular duty up until about a year ago, at which time, he was taken back off work again and placed on TTD status by Dr. N, his primary treating physician.  The patient states he has not been back to work since.  He has since applied for social security disability and now is receiving social security disability benefits.  The patient states he has tried some Myox therapy with Dr. H on 10 sessions, which he found somewhat helpful.  Overall, the patient does not feel that he could return back to his usual and customary work capacity as a delivery driver for Frito Lay.,",
 Initial evaulation - neck and back pain., Chiropractic, Neck & Back Pain ,"CHIEF COMPLAINT:,  Neck pain, thoracalgia, low back pain, bilateral lower extremity pain.,HISTORY OF PRESENT ILLNESS:,  Ms. XYZ is a fairly healthy 69-year-old Richman, Roseburg resident who carries a history of chronic migraine, osteoarthritis, hypothyroidism, hyperlipidemia, and mitral valve prolapse.  She has previously been under the care of Dr. Ninan Matthew in the 1990s and takes Maxalt on a weekly basis and nadolol, omeprazole and amitriptyline for treatment of her migraines, which occur about once a week.  She is under the care of Dr. Bonaparte for hyperlipidemia and hypothyroidism.  She has a long history of back and neck pain with multiple injuries in the 1960s, 1970s, 1980s and 1990s.  In 2000, she developed ""sciatica"" mostly in her right lower extremity.,She is seen today with no outside imaging, except with MRI of her cervical spine and lumbar spine dated February of 2004.  Her cervical MRI reveals an 8 mm central spinal canal at C6-7, multilevel foraminal stenosis, though her report is not complete as we do not have all the pages.  Her lumbar MRI reveals lumbar spinal stenosis at L4-5 with multilevel facet arthropathy and spondylitic changes.,The patient has essentially three major pain complaints.,Her first pain complaint is one of a long history of axial neck pain without particular radicular symptoms.  She complains of popping, clicking, grinding and occasional stiffness in her neck, as well as occasional periscapular pain and upper trapezius myofascial pain and spasms with occasional cervicalgic headaches.  She has been told by Dr. Megahed in the past that she is not considered a surgical candidate.  She has done physical therapy twice as recently as three years ago for treatment of her symptoms.  She complains of occasional pain and stiffness in both hands, but no particular numbness or tingling.,Her next painful complaint is one of midthoracic pain and thoracalgia features with some right-sided rib pain in a non-dermatomal distribution.  Her rib pain was not preceded by any type of vesicular rash and is reproducible, though is not made worse with coughing.  There is no associated shortness of breath.  She denies inciting trauma and also complains of pain along the costochondral and sternochondral junctions anteriorly.  She denies associated positive or negative sensory findings, chest pain or palpitations, dyspnea, hemoptysis, cough, or sputum production.  Her weight has been stable without any type of constitutional symptoms.,Her next painful complaint is one of axial low back pain with early morning pain and stiffness, which improves somewhat later in the day.  She complains of occasional subjective weakness to the right lower extremity.  Her pain is worse with sitting, standing and is essentially worse in the supine position.  Five years ago, she developed symptoms radiating in an L5-S1 distribution and within the last couple of years, began to develop numbness in the same distribution.  She has noted some subjective atrophy as well of the right calf.  She denies associated bowel or bladder dysfunction, saddle area hypoesthesia, or falls.  She has treated her back symptoms with physical therapy as well.,She is intolerant to any type of antiinflammatory medications as well and has a number of allergies to multiple medications.  She participates in home physical therapy, stretching, hand weights, and stationary bicycling on a daily basis.  Her pain is described as constant, shooting, aching and sharp in nature and is rated as a 4-5/10 for her average and current levels of pain, 6/10 for her worst pain, and 3/10 for her least pain.  Exacerbating factors include recumbency, walking, sleeping, pushing, pulling, bending, stooping, and carrying.  Alleviating factors including sitting, applying heat and ice.,PAST MEDICAL HISTORY:,  As per above and includes hyperlipidemia, hypothyroidism, history of migraines, acid reflux symptoms, mitral valve prolapse for which she takes antibiotic prophylaxis.,PAST SURGICAL HISTORY:,  Cholecystectomy, eye surgery, D&C.,MEDICATIONS:,  Vytorin, Synthroid, Maxalt, nadolol, omeprazole, amitriptyline and 81 mg aspirin.,ALLERGIES:,  Multiple.  All over-the-counter medications.  Toradol, Robaxin, Midrin, Darvocet, Naprosyn, Benadryl, Soma, and erythromycin.,FAMILY HISTORY:,  Family history is remarkable for a remote history of cancer. Family history of heart disease and osteoarthritis.,SOCIAL HISTORY:,  The patient is retired.  She is married with three grown children.  Has a high school level education.  Does not smoke, drink, or utilize any illicit substances.,OSWESTRY PAIN INVENTORY:,  Significant impact on every aspect of her quality of life.  She would like to become more functional.,REVIEW OF SYSTEMS:,  A thirteen-point review of systems was surveyed including constitutional, HEENT, cardiac, pulmonary, GI, GU, endocrine, integument, hematological, immunological, neurological, musculoskeletal, psychological and rheumatological.  Cardiac, swelling in the extremities, hyperlipidemia, history of palpitation, varicose veins.  Pulmonary review of systems negative.  GI review of systems is positive for irritable bowel and acid reflux symptoms.  Genitourinary, occasional stress urinary incontinence and history of remote hematuria.  She is postmenopausal and on hormone replacement.  Endocrine is positive for a low libido and thyroid disorder.  Integument:  Dry skin, itching and occasional rashes.  Immunologic is essentially negative.  Musculoskeletal:  As per HPI.  HEENT:  Jaw pain, popping, clicking, occasional hoarseness, dysphagia, dry mouth, and prior history of toothache.  Neurological:  As per history of present illness.  Constitutional:  As history of present illness.,PHYSICAL EXAMINATION:,  Weight 180 pounds, temp 97.6, pulse 56, BP 136/72.  The patient walks with a normal gait pattern.  There is no antalgia, spasticity, or ataxia.  She can alternately leg stand without difficulty, as well as tandem walk, stand on the heels and toes without difficulty.  She can flex her lumbar spine and touch the floor with her fingertips.  Lumbar extension and ipsilateral bending provoke her axial back pain.  There is tenderness over the PSIS on the right and no particular pelvic asymmetry.,Head is normocephalic and atraumatic.  Cranial nerves II through XII are grossly intact.  Cervical range of motion is slightly limited in extension, but is otherwise intact to flexion and lateral rotation.  The neck is supple.  The trachea is midline.  The thyroid is not particularly enlarged.  Lungs are clear to auscultation.  Heart has regular rate and rhythm with normal S1, S2.  No murmurs, rubs, or gallops.  The abdomen is nontender, nondistended, without palpable organomegaly, guarding, rebound, or pulsatile masses.  Skin is warm and dry to the touch with no discernible cyanosis, clubbing or edema.  I can radial, dorsalis pedis and posterior tibial pulses.  The nailbeds on her feet have trophic changes.  Brisk capillary refill is evident over both upper extremities.,Musculoskeletal examination reveals medial joint line tenderness of both knees with some varus laxity of the right lower extremity.  She has chronic osteoarthritic changes evident over both hands.  There is mild restriction of range of motion of the right shoulder, but no active impingement signs.,Inspection of the axial skeleton reveals a cervicothoracic head-forward posture with slight internal rotation of the upper shoulders.  Palpation of the axial skeleton reveals mild midline tenderness at the lower lumbar levels one fingerbreadth lateral to the midline.  There is no midline spinous process tenderness over the cervicothoracic regions.  Palpation of the articular pillars is met with mild provocation of pain.  Palpation of the right posterior, posterolateral and lateral borders of the lower ribs is met with mild provocable tenderness.  There is also tenderness at the sternochondral and costochondral junctions of the right, as well as the left bilaterally.  The xiphoid process is not particularly tender.  There is no dermatomal sensory abnormality in the thoracic spine appreciated.  Mild facetal features are evident over the sacral spine with extension and lateral bending at the level of the sacral ala.,Neurological examination of the upper and lower extremities reveals 3/5 reflexes of the biceps, triceps, brachioradialis, and patellar bilaterally.  I cannot elicit S1 reflexes.  There are no long tract signs.  Negative Hoffman's, negative Spurling's, no clonus, and negative Babinski.  Motor examination of the upper, as well as lower extremities appears to be intact throughout.  I may be able to detect a slight hand of atrophy of the right calf muscles, but this is truly unclear and no measurement was made.,SUMMARY OF DIAGNOSTIC IMAGING:,  As per above.,IMPRESSION:,1.  Osteoarthritis.,2.  Cervical spinal stenosis.,3.  Lumbar spinal stenosis.,4.  Lumbar radiculopathy, mostly likely at the right L5-S1 levels.,5.  History of mild spondylolisthesis of the lumbosacral spine at L4-L5 and right sacroiliac joint dysfunction.,6.  Chronic pain syndrome with myofascial pain and spasms of the trapezius and greater complexes.,PLAN:  ,The natural history and course of the disease was discussed in detail with Mr. XYZ.  Greater than 80 minutes were spent facet-to-face at this visit.  I have offered to re-image her cervical and lumbar spine and have included a thoracic MR imaging and rib series, as well as cervicolumbar flexion and extension views to evaluate for mobile segment and/or thoracic fractures.  I do not suspect any sort of intrathoracic comorbidity such as a neoplasm or mass, though this was discussed.  Pending the results of her preliminary studies, this should be ruled out.  I will see her in followup in about two weeks with the results of her scans.",
 Consultation for left foot pain., Chiropractic, Foot pain Consultation ,"CHIEF COMPLAINT:, Left foot pain.,HISTORY:, XYZ is a basketball player for University of Houston who sustained an injury the day prior. They were traveling. He came down on another player's foot sustaining what he describes as an inversion injury. Swelling and pain onset immediately. He was taped but was able to continue playing He was examined by John Houston, the trainer, and had tenderness around the navicular so was asked to come over and see me for evaluation. He has been in a walking boot. He has been taped firmly. Pain with weightbearing activities. He is limping a bit. No significant foot injuries in the past. Most of his pain is located around the dorsal aspect of the hindfoot and midfoot. ,PHYSICAL EXAM:, He does have some swelling from the hindfoot out toward the midfoot. His arch is maintained. His motion at the ankle and subtalar joints is preserved. Forefoot motion is intact. He has pain with adduction and abduction across the hindfoot. Most of this discomfort is laterally. His motor strength is grossly intact. His sensation is intact, and his pulses are palpable and strong. His ankle is not tender. He has minimal to no tenderness over the ATFL. He has no medial tenderness along the deltoid or the medial malleolus. His anterior drawer is solid. His external rotation stress is not painful at the ankle. His tarsometatarsal joints, specifically 1, 2 and 3, are nontender. His maximal tenderness is located laterally along the calcaneocuboid joint and along the anterior process of the calcaneus. Some tenderness over the dorsolateral side of the talonavicular joint as well. The medial talonavicular joint is not tender.,RADIOGRAPHS:, Those done of his foot weightbearing show some changes over the dorsal aspect of the navicular that appear chronic. I don't see a definite fracture. The tarsometarsal joints are anatomically aligned. Radiographs of his ankle again show changes along the dorsal talonavicular joint but no other fractures identified. Review of an MR scan of the ankle dated 12/01/05 shows what looks like some changes along the lateral side of the calcaneocuboid joint with disruption of the lateral ligament and capsular area. Also some changes along the dorsal talonavicular joint. I don't see any significant marrow edema or definitive fracture line. ,IMPRESSION:,  Left Chopart joint sprain.,PLAN:,  I have spoken to XYZ about this. Continue with ice and boot for weightbearing activities. We will start him on a functional rehab program and progress him back to activities when his symptoms allow. He is clear on the prolonged duration of recovery for these hindfoot type injuries.","chiropractic, foot pain, calcaneocuboid joint, dorsal aspect, dorsal talonavicular joint, foot injuries, hindfoot, midfoot, rehab program, walking boot, weightbearing, talonavicular joint, dorsal, talonavicular, ankle, foot, tenderness"
 Evaluation for chronic pain program, Chiropractic, Knee & Back Pain ,"REASON FOR EVALUATION:,",
 The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent., Consult - History and Phy., Abdominal Pain - Consult ,"CHIEF COMPLAINT:,  Abdominal pain.,HISTORY OF PRESENT ILLNESS:,  The patient is a 71-year-old female patient of Dr. X. The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent.  She was seen 3 to 4 days ago at ABC ER and underwent evaluation and discharged and had a CT scan at that time and she was told it was ""normal.""  She was given oral antibiotics of Cipro and Flagyl.  She has had no nausea and vomiting, but has had persistent associated anorexia.  She is passing flatus, but had some obstipation symptoms with the last bowel movement two days ago.  She denies any bright red blood per rectum and no history of recent melena.  Her last colonoscopy was approximately 5 years ago with Dr. Y. She has had no definite fevers or chills and no history of jaundice.  The patient denies any significant recent weight loss.,PAST MEDICAL HISTORY:  ,Significant for history of atrial fibrillation, under good control and now in normal sinus rhythm and on metoprolol and also on Premarin hormone replacement.,PAST SURGICAL HISTORY: , Significant for cholecystectomy, appendectomy, and hysterectomy.  She has a long history of known grade 4 bladder prolapse and she has been seen in the past by Dr. Chip Winkel, I believe that he has not been re-consulted.,ALLERGIES: , SHE IS ALLERGIC OR SENSITIVE TO MACRODANTIN.,SOCIAL HISTORY: , She does not drink or smoke.,REVIEW OF SYSTEMS: , Otherwise negative for any recent febrile illnesses, chest pains or shortness of breath.,PHYSICAL EXAMINATION:,GENERAL:  The patient is an elderly thin white female, very pleasant, in no acute distress.,VITAL SIGNS:  Her temperature is 98.8 and vital signs are all stable, within normal limits.,HEENT:  Head is grossly atraumatic and normocephalic.  Sclerae are anicteric.  The conjunctivae are non-injected.,NECK:  Supple.,CHEST:  Clear.,HEART:  Regular rate and rhythm.,ABDOMEN:  Generally nondistended and soft.  She is focally tender in the left lower quadrant to deep palpation with a palpable fullness or mass and focally tender, but no rebound tenderness.  There is no CVA or flank tenderness, although some very minimal left flank tenderness.,PELVIC:  Currently deferred, but has history of grade 4 urinary bladder prolapse.,EXTREMITIES:  Grossly and neurovascularly intact.,LABORATORY VALUES:  ,White blood cell count is 5.3, hemoglobin 12.8, and platelet count normal.  Alkaline phosphatase elevated at 184.  Liver function tests otherwise normal.  Electrolytes normal.  Glucose 134, BUN 4, and creatinine 0.7.,DIAGNOSTIC STUDIES:,  EKG shows normal sinus rhythm.,IMPRESSION AND PLAN: , A 71-year-old female with greater than one-week history of abdominal pain now more localized to the left lower quadrant.  Currently is a nonacute abdomen.  The working diagnosis would be sigmoid diverticulitis.  She does have a history in the distant past of sigmoid diverticulitis.  I would recommend a repeat stat CT scan of the abdomen and pelvis and keep the patient nothing by mouth.  The patient was seen 5 years ago by Dr. Y in Colorectal Surgery.  We will consult her also for evaluation.  The patient will need repeat colonoscopy in the near future and be kept nothing by mouth now empirically.  The case was discussed with the patient's primary care physician, Dr. X. Again, currently there is no indication for acute surgical intervention on today's date, although the patient will need close observation and further diagnostic workup.",
 Consultation for wrist pain., Chiropractic, Wrist Pain ,"CHIEF COMPLAINT:,  Left wrist pain.,HISTORY OF PRESENT PROBLEM:,","chiropractic, wrist pain, scapholunate, tenderness to palpation, three views, traumatic wrist injury, ulnar styloid nonunion, ulnar styloid, wrist, union, soreness, styloid, ulnar,"
 MRI report Cervical Spine (Chiropractic Specific), Chiropractic, MRI Cervical Spine - Chiropractic Specific ,"FINDINGS:,Normal foramen magnum.,Normal brainstem-cervical cord junction. There is no tonsillar ectopia. Normal clivus and craniovertebral junction. Normal anterior atlantoaxial articulation.,C2-3: There is disc desiccation but no loss of disc space height, disc displacement, endplate spondylosis or uncovertebral joint arthrosis. Normal central canal and intervertebral neural foramina.,C3-4: There is disc desiccation with a posterior central disc herniation of the protrusion type. The small posterior central disc protrusion measures 3 x 6mm (AP x transverse) in size and is producing ventral thecal sac flattening. CSF remains present surrounding the cord. The residual AP diameter of the central canal measures 9mm. There is minimal right-sided uncovertebral joint arthrosis but no substantial foraminal compromise.,C4-5: There is disc desiccation, slight loss of disc space height with a right posterior lateral pre-foraminal disc osteophyte complex with right-sided uncovertebral and apophyseal joint arthrosis. The disc osteophyte complex measures approximately 5mm in its AP dimension. There is minimal posterior annular bulging measuring approximately 2mm. The AP diameter of the central canal has been narrowed to 9mm. CSF remains present surrounding the cord. There is probable radicular impingement upon the exiting right C5 nerve root.,C5-6: There is disc desiccation, moderate loss of disc space height with a posterior central disc herniation of the protrusion type. The disc protrusion measures approximately 3 x 8mm (AP x transverse) in size. There is ventral thecal sac flattening with effacement of the circumferential CSF cleft. The residual AP diameter of the central canal has been narrowed to 7mm. Findings indicate a loss of the functional reserve of the central canal but there is no cord edema. There is bilateral uncovertebral and apophyseal joint arthrosis with moderate foraminal compromise.,C6-7: There is disc desiccation, mild loss of disc space height with 2mm of posterior annular bulging. There is bilateral uncovertebral and apophyseal joint arthrosis (left greater than right) with probable radicular impingement upon the bilateral exiting C7 nerve roots.,C7-T1, T1-2: There is disc desiccation with no disc displacement. Normal central canal and intervertebral neural foramina.,T3-4: There is disc desiccation with minimal 2mm posterior annular bulging but normal central canal and CSF surrounding the cord.,IMPRESSION:,Multilevel degenerative disc disease with uncovertebral joint arthrosis with foraminal compromise as described above.,C3-4 posterior central disc herniation of the protrusion type but no cord impingement.,C4-5 right posterior lateral disc osteophyte complex with right-sided uncovertebral and apophyseal joint arthrosis with probable radicular impingement upon the right C5 nerve root.,C5-6 degenerative disc disease with a posterior central disc herniation of the protrusion type producing borderline central canal stenosis with effacement of the circumferential CSF cleft indicating a limited functional reserve of the central canal.,C6-7 degenerative disc disease with annular bulging and osseous foraminal compromise with probable impingement upon the bilateral exiting C7 nerve roots.,T3-4 degenerative disc disease with posterior annular bulging.","chiropractic, exiting c nerve roots, loss of disc space, posterior central disc herniation, herniation of the protrusion, uncovertebral and apophyseal joint, intervertebral neural foramina, ventral thecal sac, thecal sac flattening, disc osteophyte complex, disc space height, central disc herniation, apophyseal joint arthrosis, posterior annular bulging, degenerative disc disease, posterior central disc, csf cleft, osteophyte complex, radicular impingement, disc disease, central disc, annular bulging, disc desiccation, joint arthrosis, central canal, cervical, degenerative, csf, foraminal, bulging, impingement, protrusion, uncovertebral, arthrosis, canal"
 Pain management for post-laminectomy low back syndrome and radiculopathy.  , Chiropractic, Pain Management Consult - 1 ,"Mr. XYZ forgot his hearing aids at home today and is severely hearing impaired and most of the interview had to be conducted with me yelling at him at the top of my voice.  For all these reasons, this was not really under the best circumstances and I had to curtail the amount of time I spent trying to get a history because of the physical effort required in extracting information from this patient.  The patient was seen late because he had not filled in the patient questionnaire.  To summarize the history here, Mr. XYZ who is not very clear on events from the past, sustained a work-related injury some time in 1998.  At that time, he was driving an 18-wheeler truck.  The patient indicated that he slipped off the rear of his truck while loading vehicles to his trailer.  He experienced severe low back pain and eventually a short while later, underwent a fusion of L4-L5 and L5-S1.  The patient had an uneventful hospital course from the surgery, which was done somewhere in Florida by a surgeon, who he does not remember.  He was able to return to his usual occupation, but then again had a second work-related injury in May of 2005.  At that time, he was required to boat trucks to his rig and also to use a chain-pulley system to raise and lower the vehicles.  Mr. XYZ felt a popping sound in his back and had excruciating low back pain and had to be transported to the nearest hospital.  He was MRI'ed at that time, which apparently showed a re-herniation of an L5-S1 disc and then, he somehow ended up in Houston, where he underwent fusion by Dr. W from L3 through S2.  This was done on 12/15/2005.  Initially, he did fairly well and was able to walk and move around, but then gradually the pain reappeared and he started getting severe left-sided leg pain going down the lateral aspect of the left leg into his foot.  He is still complaining of the severe pain right now with tingling in the medial two toes of the foot and significant weakness in his left leg.  The patient was referred to Dr. A, pain management specialist and Dr. A has maintained him on opioid medications consisting of Norco 10/325 mg for breakthrough pain and oxycodone 30 mg t.i.d. with Lunesta 3 mg q.h.s. for sleep, Carisoprodol 350 mg t.i.d., and Lyrica 100 mg q.daily.  The patient states that he is experiencing no side effects from medications and takes medications as required.  He has apparently been drug screened and his drug screening has been found to be normal.  The patient underwent an extensive behavioral evaluation on 05/22/06 by TIR Rehab Center.  At that time, it was felt that Mr. XYZ showed a degree of moderate level of depression.  There were no indications in the evaluation that Mr. XYZ showed any addictive or noncompliant type behaviors.  It was felt at that time that Mr. XYZ would benefit from a brief period of individual psychotherapy and a course of psychotropic medications.  Of concern to the therapist at that time was the patient's untreated and unmonitored hypertension and diabetes.  Mr. XYZ indicated at that time, they had not purchased any prescription medications or any of these health-related issues because of financial limitations.  He still apparently is not under really good treatment for either of these conditions and on today's evaluation, he actually denies that he had diabetes.  The impression was that the patient had axis IV diagnosis of chronic functional limitations, financial loss, and low losses with no axis III diagnosis.  This was done by Rhonda Ackerman, Ph.D., a psychologist.  It was also suggested at that time that the patient should quit smoking.  Despite these evaluations, Mr. XYZ really did not get involved in psychotherapy and there was poor attendance of these visits, there was no clearance given for any surgical interventions and it was felt that the patient has benefited from the use of SSRIs.  Of concern in June of 2006 was that the patient had still not stopped smoking despite warnings.  His hypertension and diabetes were still not under good control and the patient was assessed at significant risk for additional health complications including stroke, reduced mental clarity, and future falls.  It was felt that any surgical interventions should be put on hold at that time.  In September of 2006, the patient was evaluated at Baylor College of Medicine in the Occupational Health Program.  The evaluation was done by a physician at that time, whose report is clearly documented in the record.  Evaluation was done by Dr. B.  At present, Mr. XYZ continues on with his oxycodone and Norco.  These were prescribed by Dr. A two and a half weeks ago and the patient states that he has enough medication left to last him for about another two and a half weeks.  The patient states that there has been no recent change in either the severity or the distribution of his pain.  He is unable to sleep because of pain and his activities of daily living are severely limited.  He spends most of his day lying on the floor, watching TV and occasionally will walk a while.  ***** from detailed questioning shows that his activities of daily living are practically zero.  The patient denies smoking at this time.  He denies alcohol use or aberrant drug use.  He obtains no pain medications from no other sources.  Review of MRI done on 02/10/06 shows laminectomies at L3 through S1 with bilateral posterior plates and pedicle screws with granulation tissue around the thecal sac and around the left L4-5 and S1 nerve roots, which appear to be retracted posteriorly.  There is a small right posterior herniation at L1-L2.,PAST MEDICAL HISTORY:,  Significant for hypertension, hypercholesterolemia and non-insulin-dependent diabetes mellitus.  The patient does not know what medications he is taking for diabetes and denies any diabetes.  CABG in July of 2006 with no preoperative angina, shortness of breath, or myocardial infarction.  History of depression, lumbar fusion surgery in 2000, left knee surgery 25 years ago.,SOCIAL HISTORY:,  The patient is on disability.  He does not smoke.  He does not drink alcohol.  He is single.  He lives with a girlfriend.  He has minimal activities of daily living.  The patient cannot recollect when last a urine drug screen was done.,REVIEW OF SYSTEMS:,  No fevers, no headaches, chest pain, nausea, shortness of breath, or change in appetite.  Depressive symptoms of crying and decreased self-worth have been noted in the past.  No neurological history of strokes, epileptic seizures.  Genitourinary negative.  Gastrointestinal negative.  Integumentary negative.  Behavioral, depression.,PHYSICAL EXAMINATION:,  The patient is short of hearing.  His cognitive skills appear to be significantly impaired.  The patient is oriented x3 to time and place.  Weight 185 pounds, temperature 97.5, blood pressure 137/92, pulse 61.  The patient is complaining of pain of a 9/10.,Musculoskeletal:  The patient's gait is markedly antalgic with predominant weightbearing on the left leg.  There is marked postural deviation to the left.  Because of pain, the patient is unable to heel-toe or tandem gait.  Examination of the neck and cervical spine are within normal limits.  Range of motion of the elbow, shoulders are within normal limits.  No muscle spasm or abnormal muscle movements noted in the neck and upper extremities.  Head is normocephalic.  Examination of the anterior neck is within normal limits.  There is significant muscle wasting of the quadriceps and hamstrings on the left, as well as of the calf muscles.  Skin is normal.  Hair distribution normal.  Skin temperature normal in both the upper and lower extremities.  The lumbar spine curvature is markedly flattened.  There is a well-healed central scar extending from T12 to L1.  The patient exhibits numerous positive Waddell's signs on exam of the low back with inappropriate flinching and wincing with even the lightest touch on the paraspinal muscles.  Examination of the paraspinal muscles show a mild to moderate degree of spasm with a significant degree of tenderness and guarding, worse on the left than the right.  Range of motion testing of the lumbar spine is labored in all directions.  It is interesting that the patient cannot flex more than 5  in the standing position, but is able to sit without any problem.  There is a marked degree of sciatic notch tenderness on the left.  No abnormal muscle spasms or muscle movements were noted.  Patrick's test is negative bilaterally.  There are no provocative facetal signs in either the left or right quadrants of the lumbar area.  Neurological exam:  Cranial nerves II through XII are within normal limits.  Neurological exam of the upper extremities is within normal limits with good motor strength and normal biceps, triceps and brachioradialis reflexes.  Neurological exam of the lower extremities shows a 2+ right patellar reflex and -1 on the left.  There is no ankle clonus.  Babinski is negative.  Sensory testing shows a minimal degree of sensory loss on the right L5 distribution.  Muscle testing shows decreased L4-L5 on the left with extensor hallucis longus +2/5.  Ankle extensors are -3 on the left and +5 on the right.  Dorsiflexors of the left ankle are +2 on the left and +5 on the right.  Straight leg raising test is positive on the left at about 35 .  There is no ankle clonus.  Hoffman's test and Tinel's test are normal in the upper extremities.,Respiratory:  Breath sounds normal.  Trachea is midline.,Cardiovascular:  Heart sounds normal.  No gallops or murmurs heard.  Carotid pulses present.  No carotid bruits.  Peripheral pulses are palpable.,Abdomen:  Hernia site is intact.  No hepatosplenomegaly.  No masses.  No areas of tenderness or guarding.,IMPRESSION:,1.  Post-laminectomy low back syndrome.,2.  Left L5-S1 radiculopathy.,3.  Severe cognitive impairment with minimal ***** for rehabilitation or return to work.,4.  Opioid dependence for pain control.,TREATMENT PLAN:,  The patient will continue on with his medications prescribed by Dr. Chang and I will see him in two weeks' time and probably suggest switching over from OxyContin to methadone.  I do not think this patient is a good candidate for spinal cord stimulation due to his grasp of exactly what is happening and his cognitive impairment.  I will get a behavioral evaluation from Mr. Tom Welbeck and refer the patient for ongoing physical therapy.  The prognosis here for any improvement or return to work is zero.","chiropractic, pain management, opioid dependence, patrick's test, behavioral evaluation, cognitive impairment, low back syndrome, motor strength, pain control, physical therapy, radiculopathy, spinal cord stimulation, activities of daily living, neurological exam, laminectomy, hearing, diabetes, muscle, syndrome,"
" Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.", Chiropractic, Chiropractic Initial Evaluation - 1 ,"HISTORY OF PRESENT COMPLAINT: ,Ms. Abc initially visited our office for the purpose of consultation and examination on December 1, 2004. Ms. Abc states that on November 16, 2004, she was in a parking lot, she was walking to her car, and stepped into a pothole. The patient reports that she fell backwards. The patient landed on her back and hit her head as well. The patient reports sudden, severe left ankle pain and low back pain as well as neck pain in the back of her head. The patient was unable to get up due to severe pain. The patient was afraid that she broke her left ankle. The patient eventually got up and went to her car. The patient went home and symptoms got worse. A few days later, the patient went to the hospital on November 21, 2004. The patient had x-rays of the lumbar spine, left ankle, and left foot. The patient was seen at Healthcare System. She was next seen by Rapid Rehabilitation on December 1, 2004.,",
 Chiropractic IME with answers to questions from Insurance Company., Chiropractic, Chiropractic IME - 1 ,"P.O. Box 12345,City, State ,RE: EXAMINEE : Abc,CLAIM NUMBER : 12345-67890,DATE OF INJURY : April 20, 2003,DATE OF EXAMINATION : August 26, 2003,EXAMINING PHYSICIANS : Y Z, DC,Prior to the beginning of the examination, it is explained to the examinee that this examination is intended for evaluative purposes only, and that it is not intended to constitute a general medical examination. It is explained to the examinee that the traditional doctor-patient relationship does not apply to this examination, and that a written report will be provided to the agency requesting this examination. It has also been emphasized to the examinee that he should not attempt any physical activity beyond his tolerance, in order to avoid injury.,CHIEF COMPLAINTS: , Improved focal lower back pain.,HISTORY: , Abc is a 26-year-old man who immigrated to this country approximately six years ago. He speaks ""un poquito"" English and an interpreter is provided. He has worked for the last four years at Floragon Forest Products, where he normally functions as a ""stacker."" He indicates that another worker was on vacation, and because of this he was put on another job in which he separated logs using a picaroon. He was doing this on April 20, 2003, and was pulling on the picaroon when it gave way, and he fell backwards landing on a metal step, which was approximately 1 foot off of the ground. He demonstrates that he came down square on the step and did not fall backwards or hyperextend over it. He did not hit his upper back or neck or shoulders, and only sat down on the step as described. He had ""a little"" pain in his back at that time, but was able to get up and continue working. He completed his shift that day and returned to work the following day. He had the next two days off. He says that his symptoms persisted and increased, and on April 25, 2003, he went to the First Choice Physicians Chiropractic and Rehab Clinic, where he came under the care of Dr. Abcd, DC. The file contains an entrance form completed by Mr. Abc which indicates at the bottom under ""previous occurrence of the same pain"" a notation of ""Yes, but it was not really the same, it was just a little and tolerable."" There is an additional note on the side which states ""no pain prior to this injury or on that day, occasional (but low back)."" Saw this notation, he says today that he did not state this and that the form was done by ""Edna"" at Dr. Abcd's office.,Mr. Abc was initially treated three times a week and states that this has now been reduced to twice per week. He does not know how long the chiropractic treatment is to continue. Initially, he has been seen by Dr. Xyz on three occasions, the last being on August 15, 2003. Dr. Xyz has basically referred him back to Dr. Abcd for continued chiropractic management.,Mr. Abc has now returned to his normal job as a stacker and is able to do that with no significant increased pain. He does mention, however, that bending over, picking up anything particularly heavy is bothersome; however, he does not normally have to do that. He denies any new accident or injury that would be contributory either as a result of his work or outside activities or any motor vehicle accident. He does not participate physically in any sports or hobbies that would be a factor.,PRESENT COMPLAINTS: , Mr. Abc indicates at this time that he is overall better in that initially he had difficulty ""moving."" He grades his current overall level of pain as a 2 to 4 on a scale from 0 to 10, stating that the worst he had was at 6-7. He now has ""good and bad days"" which depends on his activity level noting that he is better over the weekend. He localizes his pain to the midline lumbosacral region. He states that initially he did experience some diffuse radiation into both lower extremities, but that this has now resolved. He occasionally will notice some tightness behind both knees, but again no radicular type of distribution. He denies any focal muscular weakness or sphincter disturbance. His quality of the pain at this time is a ""tightness"" which bothers him, again, primarily with bending at the waist and lifting. He is able to do his normal activities of life, including his work without any significant problem, noting again only increased pain with bending and lifting.,PAST HISTORY: , Mr. Abc denies any prior similar complaints or treatments. He denies any previous specific lower back injury. He has enjoyed essentially good lifetime health and denies any concurrent medical conditions or problems. He has seasonal allergies only with no known drug hypersensitivities. He has not been hospitalized overnight and has had no surgeries in his life. He currently takes OTC Advil and Tylenol for lower back pain, but no prescriptive medication. He does not smoke, drink, or use street drugs of any type. Review of systems and family history are generally noncontributory.,SOCIO-ECONOMIC HISTORY: , Mr. Abc, as indicated, was born and reared in Mexico and immigrated into this country six years ago.,Education: He has our equivalent of a high school education in Mexico with no additional formal education in United States.,Military History: He has no military experience in his life.,Work History: He currently is doing his normal work activities as a stacker without arbitrary restrictions or limitations. He is not receiving any Workers Compensation or other benefits at this time.,PHYSICAL EXAMINATION: , Abc presents as a cooperative and straightforward 26-year-old Hispanic male. He has a very thin body habitus with a reported height of 5 feet 7 inches and weight of 125 pounds. He is right hand dominant. He is noted to sit comfortably throughout the history taking process conversant with the interpreter and myself without observable guarding or postural conversation or motion. He did stand readily to full upright with equal weightbearing and exhibits normal spinal posture with double hips and shoulders. Lumbar lordosis is normal. He ambulates without a limp or lift, and is able to walk on heels and toes and perform a full squat and rise and hop without difficulty with some expression of increased lower back pain. Waddell's testing is negative on compression and traction with some slight increased lower back pain on passive rotation.,Kemp's maneuver of posterolateral bending has some increased localized lumbosacral pain, but no radiation distally into the buttocks or lower extremities.,Active lumbar ranges of motion with double inclinometer are:,Flexion 70 degrees.,Extension 20 degrees.,Side bending symmetric at 28 degrees.,He complains of lower back pain at the extremes of flexion only. Motion palpation reveals full mobility without any detectable intrasegmental fixation with normal symmetry and alignment.,Tendon reflexes are 2+ and symmetric at the knees and ankles without sensory loss to pinprick. Babinski's are neutral, and there is no clonus.,Manual muscle testing reveals 5/5 strength at the hips, knees, and ankles without give-way or complaint.,Supine passive straight leg raising is limited by hamstring tightness to 66 degrees bilaterally, but causes no expression of lower back pain or radiation. Cross leg with rotation hip joint motion is full on either side without reported hip or back pain. Hip flexion is symmetric at 130 degrees, again without complaint. Leg lengths appeared visually symmetric. Mid calf girth is 11-1/2 inches bilaterally. Five inches above the knees measured 13 inches right and left. The seated SLR is done to 90 degrees, and he brings his fingertips 2 inches from his toes, showing good flexibility at the waist despite the hamstring tightness noted in the supine straight leg raising test.,In the prone position, he has good gluteal strength on either side with Yeoman's test causing some increased lumbosacral pain but no focal sacroiliac involvement. No sacroiliac fixation is identified. Hibbs test is negative on either side.,On palpation, he reports midline tenderness at L5-S1 without additional areas of tenderness noted even to very firm palpatory pressure in the entirety of the lumbar spine over the pelvis. He indicates no focal or sacroiliac, sciatic notch, or trochanteric tenderness on either side. No definitive muscular spasm is noted in the lumbar paraspinal musculature.,Mr. Abc tolerated the examination process without apparent or expressed ill effect. ,IMAGING STUDIES:,  AP and lateral lumbar/pelvic views dated May 15, 2003 are reviewed. The films are negative for recent fracture or pathology. There appears to be a transitional lumbosacral area with a spatulated transverse process of L1 and slight narrowing of the lumbosacral disc space. No additional abnormalities are identified. The hip and sacroiliac articulations appear well preserved. Disc spacing in the rest of the lumbar spine appears normal, and no significant degenerative changes are identified. Soft tissue appeared normal without paraspinal mass or abnormality.,DIAGNOSIS: , Lumbosacral contusion/strain relative to the April 20, 2003 industrial accident - objectively resolved.,SUMMARY: , Discussion and recommendations in response to questions posed in your August 15, 2003 letter:,1. What is your diagnosis of the worker's condition as a result of the injury? Please provide objective medical findings that support your diagnosis. Please indicate if the objective findings are reproducible, measurable, or observable, and how.,The diagnosis of the workers condition secondary to the described April 20, 2003 fall is by history a lumbosacral contusion/strain. This impression is primarily made based on his history noting that at this time, he has no abnormal objective findings.,2. In your opinion, is the work injury a contributing cause of the diagnosis? If so, is the work injury the material contributing cause of the diagnosis? Please provide an explanation for your opinion.,It would appear that the work injury was the major contributing cause of the diagnosis.,3. Are there any off work factors that may have caused or contributed to the worker's current complaints or condition? (Such as idiopathic causes, predisposition, congenital abnormalities, off work injuries, etc.).",
 Chiropractic Evaluation for neck and low back pain following a car accident., Chiropractic, Chiropractic Initial Evaluation - 2 ,"SUBJECTIVE COMPLAINTS: ,Constant pain in the bilateral regions of the neck increased by forward movement rotating laterally, bending the neck. He also has pain and tightness in his low back increased on the left. His pain level is 7/10. He also states that since the accident, he has experienced tension headaches that began in the suboccipital region referring to the top of his head. He has also experienced anxiety and nervousness.,PHYSICAL EXAMINATION: ,Height is 5'10"". Weight is 270 pounds.,Visual Evaluation: The patient has anterior head carriage with rounded shoulders. He does not seem to be in any extreme distress. He has slight antalgic head position to the right.,Dynamometer Testing (grip strength) in pounds: The patient is right hand dominant. Right hand 110, 105, and 98. Left hand 80, 70, and 85.,Neurological: Sensation was normal in the upper and lower extremities. Motor strength +5/5 bilaterally in the upper extremities. Reflexes: Upper extremities +2/2 bilaterally, lower extremities patellar +0/2 bilaterally, and S1 +2/2 bilaterally.,Cervical spine range of motion:,Flexion 50/50 with moderate discomfort on the left.,Extension 50/60 with moderate discomfort on the left.,Right lateral bending 40/45 with moderate discomfort on the left.,Left lateral bending 40/45 with moderate discomfort on the right.,Right rotation 70/80 with moderate pain in the left.,Left rotation 70/80 with moderate pain in the left.,Lumbosacral range of motion:,Flexion 60/60.,Extension 25/25.,Right lateral bending 25/25.,Left lateral bending 25/25 with pain in the left.,Right rotation 30/30 with moderate discomfort in the right.,Left rotation 30/30.,Orthopedic Tests: Axial compression negative with moderate pain bilaterally. Shoulder distraction negative with moderate pain bilaterally. Maigne's test negative bilaterally. Valsalva normal and swallow test normal. Heel walk normal. Toe walk normal. Sitting root normal. SLR normal. Patrick-Faber's normal. Iliac compression caused moderate pain in the left.,RADIOLOGY FINDINGS:, X-rays of the cervical and lumbar will be taken today.,DIAGNOSES:,1.  Cervical spine sprain/strain.,2.  Lumbar spine sprain/strain.,3.  Tension headaches.,CAUSATION:  ,The patient's symptoms appeared to have come on as a result of the motor vehicle accident consistent with the one described in this report. His history, subjective, and objective findings show evidence from a medical viewpoint that his condition is due to the current injury only and no contributing factors are present from preexisting conditions. The patient's condition is a result of a bony/soft tissue injury that has resulted in an undetermined impairment at this time.,PROGNOSIS: ,The likelihood of nearly complete symptomatic relief within 90 days is excellent.  The patient should reach maximum medical improvement in three or four months.,TREATMENT/PLAN: ,After completing an initial examination evaluation, I have selected the plan of treatment that should return this patient to a pre-injury status and minimize the possibility of future residuals. Treatment will consist of chiropractic manipulation, chiropractic physical therapy, and observation, decreasing in frequency as the patient's condition allows. I feel it is too early to determine whether this patient will have any residuals or permanent disability.",
 Ventricular ectopy and coronary artery disease.   He is a 69-year-old gentleman with established history coronary artery disease and peripheral vascular disease with prior stent-supported angioplasty., Cardiovascular / Pulmonary, Ventricular Ectopy - Consult ,"REASON FOR CONSULTATION:,  Ventricular ectopy and coronary artery disease.,HISTORY OF PRESENT ILLNESS:  ,I am seeing the patient upon the request of Dr. Y.  The patient is a very well known to me.  He is a 69-year-old gentleman with established history coronary artery disease and peripheral vascular disease with prior stent-supported angioplasty.  The patient had presented to the hospital after having coughing episodes for about two weeks on and off, and seemed to have also given him some shortness of breath.  The patient was admitted and being treated for pneumonia, according to him.  The patient denies any chest pain, chest pressure, or heaviness.  Denies any palpitations, fluttering, or awareness of heart activity.  However, on monitor, he was noticed to have PVCs random.  He had run off three beats consecutive one time at 12:46 p.m. today.  The patient denied any awareness of that or syncope.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No fever or chills.,EYES:  No visual disturbances.,ENT:  No difficulty swallowing.,CARDIOVASCULAR:  Prior history of chest discomfort in 08/2009 with negative stress study.,RESPIRATORY:  Cough and shortness of breath.,MUSCULOSKELETAL:  Positive for arthritis and neck pain.,GU:  Unremarkable.,NEUROLOGIC:  Otherwise unremarkable.,ENDOCRINE:  Otherwise unremarkable.,HEMATOLOGIC:  Otherwise unremarkable.,ALLERGIC:  Otherwise unremarkable.,PAST MEDICAL HISTORY:,1.  Positive for coronary artery disease since 2002.,2.  History of peripheral vascular disease for over 10 years.,3.  COPD.,4.  Hypertension.,PAST SURGICAL HISTORY:,  Right fem-popliteal bypass about eight years ago, neck fusion in the remote past, stent-supported angioplasty to unknown vessel in the heart.,MEDICATIONS AT HOME:,1.  Aspirin 81 mg daily.,2.  Clopidogrel 75 mg daily.,3.  Allopurinol 100 mg daily.,4.  Levothyroxine 100 mcg a day.,5.  Lisinopril 10 mg a day.,6.  Metoprolol 25 mg a day.,7.  Atorvastatin 10 mg daily.,ALLERGIES: , THE PATIENT DOES HAVE ALLERGY TO MEDICATION.  HE SAID HE CANNOT TAKE ASPIRIN BECAUSE OF INTOLERANCE FOR HIS STOMACH AND STOMACH UPSET, BUT NO TRUE ALLERGY TO ASPIRIN.,FAMILY HISTORY:,  No history of premature coronary artery disease.  One daughter has early onset diabetes and one child has asthma.,SOCIAL HISTORY: , He is married and retired.  He has nine children, 25 grandchildren.  He smokes one pack per day.  He smoked 50 pack years and had no intention of quitting according to him.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature of 97, heart rate of 90, blood pressure of 187/105.,HEENT:  Normocephalic and atraumatic.  No thyromegaly or lymphadenopathy.,NECK:  Supple.,CARDIOVASCULAR:  Upstroke is normal.  Distal pulse symmetrical.  Heart regular with a normal S1 with normally split S2.  There is an S4 at the apex.,LUNGS:  With decreased air entry.  No wheezes.,ABDOMINAL:  Benign.  No masses.,EXTREMITIES:  No edema, cyanosis, or clubbing.,NEUROLOGIC:  Awake, alert, and oriented x3.  No focal deficits.,IMAGING STUDIES: , Echocardiogram on 08/26/2009, showed mild biatrial enlargement, normal thickening of the left ventricle with mildly dilated ventricle, EF of 40%, mild mitral regurgitation, and diastolic dysfunction, grade 2.",
 Chiropractic IME with old files review.  Detailed Thoracic Spine Examination., Chiropractic, Chiropractic IME - 2 ,"DATE OF INJURY : October 4, 2000,DATE OF EXAMINATION : September 5, 2003,EXAMINING PHYSICIAN : X Y, MD,Prior to the beginning of the examination, it is explained to the examinee that this examination is intended for evaluative purposes only, and that it is not intended to constitute a general medical examination. It is explained to the examinee that the traditional doctor-patient relationship does not apply to this examination, and that a written report will be provided to the agency requesting this examination. It has also been emphasized to the examinee that he should not attempt any physical activity beyond his tolerance, in order to avoid injury.,CHIEF COMPLAINT:  ,Aching and mid back pain.,HISTORY OF PRESENT INJURY: , Based upon the examinee's perspective: ,Mr. Abc is a 52-year-old self-employed, independent consultant for DEMILEE-USA. He is also a mechanical engineer. He reports that he was injured in a motor vehicle accident that occurred in October 4, 2000. At that time, he was employed as a purchasing agent for IBIKEN-USA. On the date of the motor vehicle accident, he was sitting in the right front passenger's seat, wearing seat and shoulder belt safety harnesses, in his 1996 or 1997 Volvo 850 Wagon automobile driven by his son. The vehicle was completely stopped and was ""slammed from behind"" by a van. The police officer, who responded to the accident, told Mr. Abc that the van was probably traveling at approximately 30 miles per hour at the time of impact.,During the impact, Mr. Abc was restrained in the seat and did not contact the interior surface of the vehicle. He experienced immediate mid back pain. He states that the Volvo automobile sustained approximately $4600 in damage.,He was transported by an ambulance, secured by a cervical collar and backboard to the emergency department. An x-ray of the whole spine was obtained, and he was evaluated by a physician's assistant. He was told that it would be ""okay to walk."" He was prescribed pain pills and told to return for reevaluation if he experienced increasing pain.,He returned to the Kaiser facility a few days later, and physical therapy was prescribed. Mr. Abc states that he was told that ""these things can take a long time."" He indicates that after one year he was no better. He then states that after two years he was no better and worried if the condition would never get better.,He indicates he saw an independent physician, a general practitioner, and an MRI was ordered. The MRI study was completed at ABCD Hospital. Subsequently, Mr. Abc returned and was evaluated by a physiatrist. The physiatrist reexamined the original thoracic spine x-rays that were taken on October 4, 2000, and stated that he did not know why the radiologist did not originally observe vertebral compression fractures. Mr. Abc believes that he was told by the physiatrist that it involved either T6-T7 or T7-T8.,Mr. Abc reports that the physiatrist told him that little could be done besides participation in core strengthening. Mr. Abc describes his current exercise regimen, consisting of cycling, and it was deemed to be adequate. He was told, however, by the physiatrist that he could also try a Pilates type of core exercise program.,The physiatrist ordered a bone scan, and Mr. Abc is unsure of the results. He does not have a formal follow up scheduled with Kaiser, and is awaiting re-contact by the physiatrist.,He denies any previous history of symptomatology or injuries involving his back.,CURRENT SYMPTOMS:  ,He reports that he has the same mid back pain that has been present since the original injury. It is located in the same area, the mid thoracic spine area. It is described as a pain and an ache and ranges from 3/10 to 6/10 in intensity, and the intensity varies, seeming to go in cycles. The pain has been staying constant.,When I asked whether or not the pain have improved, he stated that he was unable to determine whether or not he had experienced improvement. He indicates that there may be less pain, or conversely, that he may have developed more of a tolerance for the pain. He further states that ""I can power through it."" ""I have learned how to manage the pain, using exercise, stretching, and diversion techniques."" It is primary limitation with regards to the back pain involves prolonged sitting. After approximately two hours of sitting, he has required to get up and move around, which results in diminishment of the pain. He indicates that prior to the motor vehicle accident, he could sit for significantly longer periods of time, 10 to 12 hours on a regular basis, and up to 20 hours, continuously, on an occasional basis.,He has never experienced radiation of the pain from the mid thoracic spine, and he has never experienced radicular symptoms of radiation of pain into the extremities, numbness, tingling, or weakness.,Again, aggravating activities include prolonged sitting, greater than approximately two hours.,Alleviating activities include moving around, stretching, and exercising. Also, if he takes ibuprofen, it does seem to help with the back pain.,He is not currently taking medications regularly, but list that he takes occasional ibuprofen when the pain is too persistent.,He indicates that he received several physical therapy sessions for treatment, and was instructed in stretching and exercises. He has subsequently performed the prescribed stretching and exercises daily, for nearly three years.,With regards to recreational activities, he states that he has not limited his activities due to his back pain.,He denies bowel or bladder dysfunction.,FILES REVIEW:  ,October 4, 2000: An ambulance was dispatched to the scene of a motor vehicle accident on South and Partlow Road. The EMS crew arrived to find a 49-year-old male sitting in the front passenger seat of a vehicle that was damaged in a rear-end collision and appeared to have minimal damage. He was wearing a seatbelt and he denied loss of consciousness. He also denied a pertinent past medical history. They noted pain in the lower cervical area, mid thoracic and lumbar area. They placed him on a backboard and transported him to Medical Center.,October 4, 2000: He was seen in the emergency department of Medical Center. The provider is described as ""unknown."" The history from the patient was that he was the passenger in the front seat of a car that was stopped and rear-ended. He stated that he did not exit the car because of pain in his upper back. He reported he had been wearing the seatbelt and harness at that time. He denied a history of back or neck injuries. He was examined on a board and had a cervical collar in place. He was complaining of mid back pain. He denied extremity weakness. Sensory examination was intact. There was no tenderness with palpation or flexion in the neck. The back was a little tender in the upper thoracic spine area without visible deformity. There were no marks on the back. His x-ray was described as ""no acute bony process."" Listed visit diagnosis was a sprain-thoracic, and he was prescribed hydrocodone/acetaminophen tablets and Motrin 800 mg tablets.,October 4, 2000: During the visit, a Clinician's Report of Disability document was signed by Dr. M, authorizing time loss from October 4, 2000, through October 8, 2000. The document also advised no heavy lifting, pushing, pulling, or overhead work for two weeks. During this visit, a thoracic spine x-ray series, two views, was obtained and read by Dr. JR. The findings demonstrate no evidence of acute injury. No notable arthritic findings. The pedicles and paravertebral soft tissues appear unremarkable.,November 21, 2000: An outpatient progress note was completed at Kaiser, and the clinician of record was Dr. H. The history obtained documents that Mr. Abc continued to experience the same pain that he first noted after the accident, described as a discomfort in the mid thoracic spine area. It was non-radiating and described as a tightness. He also reported that he was hearing clicking noises that he had not previously heard. He denied loss of strength in the arms. The physical examination revealed good strength and normal deep tendon reflexes in the arms. There was minimal tenderness over T4 through T8, in an approximate area. The visit diagnosis listed was back pain. Also described in the assessment was residual pain from MVA, suspected bruised muscles. He was prescribed Motrin 800 mg tablets and an order was sent to physical therapy. Dr. N also documents that if the prescribed treatment measures were not effective, then he would suggest a referral to a physiatrist. Also, the doctor wanted him to discuss with physical therapy whether or not they thought that a chiropractor would be beneficial.,December 4, 2000: He was seen at Kaiser for a physical therapy visit by Philippe Justel, physical therapist. The history obtained from Mr. Abc is that he was not improving. Symptoms described were located in the mid back, centrally. The examination revealed mild tenderness, centrally at T3-T8, with very poor segmental mobility. The posture was described as rigid T/S in flexion. Range of motion was described as within normal limits, without pain at the cervical spine and thoracic spine. The plan listed included two visits per week for two weeks, for mobilization. It is also noted that the physical therapist would contact the MD regarding a referral to a chiropractor.,December 8, 2000: He was seen at Kaiser for a physical therapy visit by Mr. Justel. It was noted that the subjective category of the document revealed that there was no real change. It was noted that Mr. Abc tolerated the treatment well and that he was to see a chiropractor on Monday.,December 11, 2000: He presented to the Chiropractic Wellness Center. There is a form titled 'Chiropractic Case History,' and it documents that Mr. Abc was involved in a motor vehicle accident, in which he was rear-ended in October. He has had mid back pain since that time. The pain is worsened with sitting, especially at a computer. The pain decreases when he changes positions, and sometimes when he walks. Mr. Abc reports that he occasionally takes 800 mg doses of ibuprofen. He reported he went to physical therapy treatment on two occasions, which helped for a few hours only. He did report that he had a previous history of transitory low back pain.,During the visit, he completed a modified Oswestry Disability Questionnaire, and a WC/PI Subjective Complaint Form. He listed complaints of mid and low back pain of a sore and aching character. He rated the pain at grade 3-5/10, in intensity. He reported difficulty with sitting at a table, bending forward, or stooping. He reported that the pain was moderate and comes and goes.,During the visit at the Chiropractic Wellness Center, a spinal examination form was completed. It documents palpation tenderness in the cervical, thoracic, and lumbar spine area and also palpation tenderness present in the suboccipital area, scalenes, and trapezia. Active cervical range of motion measured with goniometry reveals pain and restriction in all planes. Active thoracic range of motion measured with inclinometry revealed pain and restriction in rotation bilaterally. Active lumbosacral range of motion measured with inclinometry reveals pain with lumbar extension, right lateral flexion, and left lateral flexion.,December 11, 2000: He received chiropractic manipulation treatment, and he was advised to return for further treatment at a frequency of twice a week.,December 13, 2000: He returned to the Chiropractic Wellness Center to see Joe Smith, DC, and it is documented that his middle back was better.,December 13, 2000: A personal injury patient history form is completed at the Chiropractic Wellness Center. Mr. Abc reported that on October 4, 2000, he was driving his 1996 Volvo 850 vehicle, wearing seat and shoulder belt safety harnesses, and completely stopped. He was rear-ended by a vehicle traveling at approximately 30 miles per hour. The impact threw him back into his seat, and he felt back pain and determined that it was not wise to move about. He reported approximate damage to his vehicle of $4800. He reported continuing mid and low back pain, of a dull and semi-intense nature. He reported that he was an export company manager for IBIKEN-USA, and that he missed two full days of work, and missed 10-plus partial days of work. He stated that he was treated initially after the motor vehicle accident at Kaiser and received painkillers and ibuprofen, which relieved the pain temporarily. He specifically denied ever experiencing similar symptoms.,December 26, 2000: A no-show was documented at the Chiropractic Wellness Center.,April 5, 2001: He received treatment at the Chiropractic Wellness Center. He reported that two weeks previously, his mid back pain had worsened.,April 12, 2001: He received chiropractic treatment at the Chiropractic Wellness Center.,April 16, 2001: He did not show up for his chiropractic treatment.,April 19, 2001: He did not show up for his chiropractic treatment.,April 26, 2001: He received chiropractic manipulation treatment at the Chiropractic Wellness Center. He reported that his mid back pain increased with sitting at the computer. At the conclusion of this visit, he was advised to return to the clinic as needed.,September 6, 2002: An MRI of the thoracic spine was completed at ABCD Hospital and read by Dr. RL, radiologist. Dr. D noted the presence of minor anterior compression of some mid thoracic vertebrae of indeterminate age, resulting in some increased kyphosis. Some of the mid thoracic discs demonstrate findings consistent with degenerative disc disease, without a significant posterior disc bulging or disc herniation. There are some vertebral end-plate abnormalities, consistent with small Schmorl's nodes, one on the superior aspect of T7, which is compressed anteriorly, and on the inferior aspect of T6.,May 12, 2003: He was seen at the Outpatient Clinic by Dr. L, internal medicine specialist. He was there for a health screening examination, and listed that his only complaints are for psoriasis and chronic mid back pain, which have been present since a 2000 motor vehicle accident. Mr. Abc reported that an outside MRI showed compression fractures in the thoracic spine. The history further documents that Mr. Abc is an avid skier and volunteers on the ski patrol. The physical examination revealed that he was a middle-aged Caucasian male in no acute distress. The diagnosis listed from this visit is back pain and psoriasis. Dr. L documented that he spent one hour in the examination room with the patient discussing what was realistic and reasonable with regard to screening testing. Dr. L also stated that since Mr. Abc was experiencing chronic back pain, he advised him to see a physiatrist for evaluation. He was instructed to bring the MRI to the visit with that practitioner.,June 10, 2003: He was seen at the Physiatry Clinic by Dr. R, physiatrist. The complaint listed is mid back pain. In the subjective portion of the chart note, Dr. R notes that Mr. Abc is involved in the import/export business, and that he is physically active in cycling, skiing, and gardening. He is referred by Dr. L because of persistent lower thoracic pain, following a motor vehicle accident, on October 4, 2000. Mr. Abc told Dr. R that he was the restrained passenger of a vehicle that was rear-ended at a moderate speed. He stated that he experienced immediate discomfort in his thoracic spine area without radiation. He further stated that thoracic spine x-rays were obtained at the Sunnyside Emergency Room and read as normal. It is noted that Mr. Abc was treated conservatively and then referred to physical therapy where he had a number of visits in late of 2002 and early 2003. No further chart entries were documented about the back problem until Mr. Abc complained to Dr. L that he still had ongoing thoracic spine pain during a visit the previous month. He obtained an MRI, out of pocket, at ABCD Hospital and stated that he paid $1100 for it. Dr. R asked to see the MRI and was told by Mr. Abc that he would have to reimburse or pay him $1100 first. He then told the doctor that the interpretation was that he had a T7 and T8 compression fracture. Mr. Abc reported his improvement at about 20%, compared to how he felt immediately after the accident. He described that his only symptoms are an aching pain that occurs after sitting for four to five hours. If he takes a break from sitting and walks around, his symptoms resolve. He is noted to be able to bike, ski, and be active in his garden without any symptoms at all. He denied upper extremity radicular symptoms. He denied lower extremity weakness or discoordination. He also denied bowel or bladder control or sensation issues. Dr. R noted that Mr. Abc was hostile about the Kaiser health plan and was quite uncommunicative, only reluctantly revealing his history. The physical examination revealed that he moved about the examination room without difficulty and exhibited normal lumbosacral range of motion. There was normal thoracic spine motion with good chest expansion. Neurovascular examination of the upper extremities was recorded as normal. There was no spasticity in the lower extremities. There was no tenderness to palpation or percussion up and down the thoracic spine. Dr. R reviewed the thoracic spine films and noted the presence of ""a little compression of what appears to be T7 and T8 on the lateral view."" Dr. R observed that this was not noted on the original x-ray interpretation. He further stated that the MRI, as noted above, was not available for review. Dr. R assessed that Mr. Abc was experiencing minimal thoracic spine complaints that probably related to the motor vehicle accident three years previously. The doctor further stated that ""the patient's symptoms are so mild as to almost not warrant intervention."" He discussed the need to make sure that Mr. Abc's workstation was ergonomic and that Mr. Abc could pursue core strengthening. He further recommended that Mr. Abc look into participation in a Pilates class. Mr. Abc was insistent, so Dr. R made plans to order a bone scan to further discriminate the etiology of his symptoms. He advised Mr. Abc that the bone scan results would probably not change treatment. As a result of this visit, Dr. R diagnosed thoracic spine pain (724.1) and ordered a bone scan study.",
 Insertion of a VVIR permanent pacemaker.  This is an 87-year-old Caucasian female with critical aortic stenosis with an aortic valve area of 0.5 cm square and recurrent congestive heart failure symptoms mostly refractory to tachybrady arrhythmias, Cardiovascular / Pulmonary, VVIR Permanent Pacemaker Insertion ,"PROCEDURE PERFORMED:,  Insertion of a VVIR permanent pacemaker.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , Minimal.,SITE:,  Left subclavian vein access.,INDICATION: , This is an 87-year-old Caucasian female with critical aortic stenosis with an aortic valve area of 0.5 cm square and recurrent congestive heart failure symptoms mostly refractory to tachybrady arrhythmias and therefore, this is indicated so that we can give better control of heart rate and to maintain beta-blocker therapy in the order of treatment.  It is overall a Class-II indication for permanent pacemaker insertion.,PROCEDURE:,  The risks, benefits, and alternative of the procedure were all discussed with the patient and the patient's family in detail at great length.  Overall options and precautions of the pacemaker and indications were all discussed.  They agreed to the pacemaker.  The consent was signed and placed in the chart.  The patient was taken to the Cardiac Catheterization Lab, where she was monitored throughout the whole procedure.  The patient was sterilely prepped and draped in the usual manner for permanent pacemaker insertion.  Myself and Dr. Wildes spoke for approximately 8 minutes before insertion for the procedure.  Using a lidocaine with epinephrine, the area of the left subclavian vein and left pectodeltoid region was anesthetized locally.,IV sedation, increments, and analgesics were given.  Using a #18 gauge needle, the left subclavian vein access was cannulated without difficulty.  A guidewire was then passed through the Cook needle and the Cook needle was then removed.  The wire was secured in place with the hemostat.  Using a #10 and #15 scalpel blade, a 5 cm horizontal incision was made in the left pectoral deltoid region where the skin was dissected and blunted down into the pectoris major muscle fascia.  The skin was then undermined used to make a pocket for the pacemaker.  The guidewire was then tunneled through the pacer pocket.  Cordis sheath was then inserted through the guidewire.  The guidewire and dilator were removed.  ___ cordis sheath was in placed within.  This was used for insertion of the ventricular screw and steroid diluted leads where under fluoroscopy.  It was placed into the apex.  Cordis sheath was then split apart and removed and after the ventricular lead was placed in its appropriate position and good thresholds were obtained, the lead was then sutured in place with #1-0 silk suture to the pectoris major muscle.  The lead was then connected on pulse generator.  The pocket was then irrigated and cleansed.  Pulse generator and the wire was then inserted into the ____ pocket.  The skin was then closed with gut suture.  The skin was then closed with #4-0 Poly___ sutures using a subcuticular uninterrupted technique.  The area was then cleansed and dried.  Steri-Strips and pressure dressing was then applied.  The patient tolerated the procedure well. there was no complications.,These are the settings on the pacemaker:,IMPLANT DEVICE: , Pulse Generator Model Name:  Sigma, model #:  12345, serial #:  123456.,VENTRICLE LEAD:,  Model #:  12345, the ventricular lead serial #:  123456.,Ventricle lead was a screw and steroid diluted lead placed into the right ventricle apex.,BRADY PARAMETER SETTINGS ARE AS FOLLOWS:,  Amplitude was set at 3.5 volts with a pulse of 0.4, sensitivity of 2.8.  The pacing mode was set at VVIR, lower rate of 60 and upper rate of 120.,STIMULATION THRESHOLDS:  ,The right ventricular lead and bipolar, threshold voltage is 0.6 volts, 1 milliapms current, 600 Ohms resistance, R-wave sensing 11 millivolts.,The patient tolerated the procedure well.  There was no complications.  The patient went to recovery in stable condition.  Chest x-ray will be ordered.  She will be placed on IV antibiotics and continue therapy for congestive heart failure and tachybrady arrhythmia.,Thank you for allowing me to participate in her care.  If you have any questions or concerns, please feel free to contact.","cardiovascular / pulmonary, aortic stenosis, vvir permanent pacemaker, permanent pacemaker insertion, congestive heart failure, tachybrady arrhythmias, subclavian vein, cordis sheath, ventricular lead, pulse generator, permanent pacemaker, insertion, ventricle, vvir, ventricular, permanent, pacemaker, leads, "
 Patient with worsening shortness of breath and cough., Cardiovascular / Pulmonary, Trouble breathing ,"CHIEF COMPLAINT:, ""Trouble breathing."",HISTORY OF PRESENT ILLNESS:, A 37-year-old German woman was brought to a Shock Room at the General Hospital with worsening shortness of breath and cough. Over the year preceding admission, the patient had begun to experience the insidious onset of shortness of breath. She had smoked one half pack of cigarettes per day for 20 years, but had quit smoking approximately 2 months prior to admission. Approximately 2 weeks prior to admission, she noted worsening shortness of breath and the development of a dry nonproductive cough. Approximately 1 week before admission, the shortness of breath became more severe and began to limit her activities. On the day of admission, her dyspnea had worsened to the point that she became markedly short of breath after walking a short distance, and she elected to seek medical attention. On arrival at the hospital, she was short of breath at rest and was having difficulty completing her sentences. She denied orthopnea, paroxysmal nocturnal dyspnea, swelling in her legs, chest pain, weight loss or gain, fever, chills, palpitations, and sick contacts. She denied any history of IVDA, tattoos, or high risk sexual behavior. She did report a distant history of pulmonary embolism in 1997 with recurrent venous thromboembolism in 1999 for which an IVC filter had been placed in Germany . She had been living in the United States for years, and had had no recent travel. She denied any occupational exposures. Before the onset of her shortness of breath she had been very active and had exercised regularly.,PAST MEDICAL HISTORY:,  Pulmonary embolism in 1997 which had been treated with thrombolysis in Germany. She reported that she had been on warfarin for 6 months after her diagnosis.  Recurrent venous thromboembolism in 1999 at which time an IVC filter had been placed.  Psoriasis.  She denied any history of miscarriage.,PAST SURGICAL HISTORY:,  IVC filter placement 1999.",
 Right and Left carotid ultrasound  , Cardiovascular / Pulmonary, Ultrasound - Carotid - 1 ,"RIGHT:,1.  Mild heterogeneous plaque seen in common carotid artery.,2.  Moderate heterogeneous plaque seen in the bulb and internal carotid artery.,3.  Severe heterogeneous plaque seen in external carotid artery with degree of stenosis around 70%.  ,4.  Peak systolic velocity is normal in common carotid, bulb, and internal carotid artery.,5.  Peak systolic velocity is 280 cm/sec in external carotid artery with moderate spectral broadening.,LEFT: , ,1.  Mild heterogeneous plaque seen in common carotid artery and external carotid artery.,2.  Moderate heterogeneous plaque seen in the bulb and internal carotid artery with degree of stenosis less than 50%.,3.  Peak systolic velocity is normal in common carotid artery and in the bulb.,4.  Peak systolic velocity is 128 cm/sec in internal carotid artery and 156 cm/sec in external carotid artery.,VERTEBRALS:,  Antegrade flow seen bilaterally.","cardiovascular / pulmonary, carotid ultrasound, antegrade flow, peak systolic velocity, bulb, carotid artery, homogeneous plaque, plaque, spectral broadening, bulb and internal carotid, velocity is normal, common carotid artery, internal carotid artery, external carotid artery, internal carotid, external carotid, peak systolic, systolic velocity, artery, carotid, ultrasound, velocity, heterogeneous,"
" Need for intravenous access.  Insertion of a right femoral triple lumen catheter.  he patient is also ventilator-dependent, respiratory failure with tracheostomy in place and dependent on parenteral nutrition secondary to dysphagia and also has history of protein-calorie malnutrition and the patient needs to receive total parenteral nutrition and therefore needs central venous access.", Cardiovascular / Pulmonary, Triple Lumen Catheter Insertion - 1 ,"PREOPERATIVE DIAGNOSIS: , Need for intravenous access.,POSTOPERATIVE DIAGNOSIS: , Need for intravenous access.,PROCEDURE PERFORMED:  ,Insertion of a right femoral triple lumen catheter.,ANESTHESIA: , Includes 4 cc of 1% lidocaine locally.,ESTIMATED BLOOD LOSS: , Minimum.,INDICATIONS:,  The patient is an 86-year-old Caucasian female who presented to ABCD General Hospital secondary to drainage of an old percutaneous endoscopic gastrostomy site.  The patient is also ventilator-dependent, respiratory failure with tracheostomy in place and dependent on parenteral nutrition secondary to dysphagia and also has history of protein-calorie malnutrition and the patient needs to receive total parenteral nutrition and therefore needs central venous access.,PROCEDURE:,  The patient's legal guardian was talked to.  All questions were answered and consent was obtained.  The patient was sterilely prepped and draped.  Approximately 4 cc of 1% lidocaine was injected into the inguinal site.  A strong femoral artery pulse was felt and triple lumen catheter Angiocath was inserted at 30-degree angle cephalad and aspirated until a dark venous blood was aspirated.  A guidewire was then placed through the needle.  The needle was then removed.  The skin was ________ at the base of the wire and a dilator was placed over the wire.  The triple lumen catheters were then flushed with bacteriostatic saline.  The dilator was then removed from the guidewire and a triple lumen catheter was then inserted over the guidewire with the guidewire held at all times.,The wire was then carefully removed.  Each port of the lumen catheter was aspirated with 10 cc syringe with normal saline till dark red blood was expressed and then flushed with bacteriostatic normal saline and repeated on the remaining two ports.  Each port was closed off and also kept off.  Straight needle suture was then used to suture the triple lumen catheter down to the skin.  Peristatic agent was then placed at the site of the lumen catheter insertion and a Tegaderm was then placed over the site.  The surgical site was then sterilely cleaned.  The patient tolerated the full procedure well.  There were no complications.  The nurse was then contacted to allow for access of the triple lumen catheter.","cardiovascular / pulmonary, intravenous access, catheter, femoral triple lumen catheter, triple lumen catheter, lumen, ventilator, respiratory, guidewire"
" Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc.", Chiropractic, Chiropractic Progress Note ,"CHIEF COMPLAINT:  ,Hip pain.,HISTORY OF PRESENTING ILLNESS:  ,The patient is a very pleasant 41-year-old white female that is known to me previously from our work at the Pain Management Clinic, as well as from my residency training program, San Francisco. We have worked collaboratively for many years at the Pain Management Clinic and with her departure there, she has asked to establish with me for clinic pain management at my office.  She reports moderate to severe pain related to a complicated past medical history.  In essence, she was seen at a very young age at the clinic for bilateral knee and hip pain and diagnosed with bursitis at age 23.  She was given nonsteroidals at that time, which did help with this discomfort.  With time, however, this became inadequate and she was seen later in San Francisco in her mid 30s by Dr. V, an orthopedist who diagnosed retroverted hips at Hospital.  She was referred for rehabilitation and strengthening.  Most of this was focused on her SI joints.  At that time, although she had complained of foot discomfort, she was not treated for it.  This was in 1993 after which she and her new husband moved to the Boston area, where she lived from 1995-1996.  She was seen at the Pain Center by Dr. R with similar complaints of hip and knee pain.  She was seen by rheumatologists there and diagnosed with osteoarthritis as well as osteophytosis of the back.  Medications at that time were salicylate and Ultram.,When she returned to Portland in 1996, she was then working for Dr. B.  She was referred to a podiatrist by her local doctor who found several fractured sesamoid bones in her both feet, but this was later found not to be the case.  Subsequently, nuclear bone scans revealed osteoarthritis.  Orthotics were provided.  She was given Paxil and Tramadol and subsequently developed an unfortunate side effect of grand mal seizure.  During this workup of her seizure, imaging studies revealed a pericardial fluid-filled cyst adhered to her ventricle.  She has been advised not to undergo any corrective or reparative surgery as well as to limit her activities since.  She currently does not have an established cardiologist having just changed insurance plans.  She is establishing care with Dr. S, of Rheumatology for her ongoing care.  Up until today, her pain medications were being written by Dr. Y prior to establishing with Dr. L.,Pain management in town had been first provided by the office of Dr. F. Under his care, followup MRIs were done which showed ongoing degenerative disc disease, joint disease, and facet arthropathy in addition to previously described sacroiliitis.  A number of medications were attempted there, including fentanyl patches with Flonase from 25 mcg titrated upwards to 50 mcg, but this caused oversedation.  She then transferred her care to Ab Cd, FNP under the direction of Dr. K.  Her care there was satisfactory, but because of her work schedule, the patient found this burdensome as well as the guidelines set forth in terms of monthly meetings and routine urine screens.  Because of a previous commitment, she was unable to make one unscheduled request to their office in order to produce a random urine screen and was therefore discharged.,PAST MEDICAL HISTORY:  ,1.  Attention deficit disorder.,2.  TMJ arthropathy.,3.  Migraines.,4.  Osteoarthritis as described above.,PAST SURGICAL HISTORY:,1.  Cystectomies.,2.  Sinuses.,3.  Left ganglia of the head and subdermally in various locations.,4.  TMJ and bruxism.,FAMILY HISTORY:  ,The patient's father also suffered from bilateral hip osteoarthritis.,MEDICATIONS:,1.  Methadone 2.5 mg p.o. t.i.d.,2.  Norco 10/325 mg p.o. q.i.d.,3.  Tenormin 50 mg q.a.m.,4.  Skelaxin 800 mg b.i.d. to t.i.d. p.r.n.,5.  Wellbutrin SR 100 mg q.d.,6.  Naprosyn 500 mg one to two pills q.d. p.r.n.,ALLERGIES: , IV morphine causes hives.  Sulfa caused blisters and rash.,PHYSICAL EXAMINATION: , A well-developed, well-nourished white female in no acute distress, sitting comfortably and answering questions appropriately, making good eye contact, and no evidence of pain behavior.,VITAL SIGNS:  Blood pressure 110/72 with a pulse of 68.,HEENT:  Normocephalic.  Atraumatic.  Pupils are equal and reactive to light and accommodation.  Extraocular motions are intact.  No scleral icterus.  No nystagmus.  Tongue is midline.  Mucous membranes are moist without exudate.,NECK:  Free range of motion without thyromegaly.,CHEST:  Clear to auscultation without wheeze or rhonchi.,HEART:  Regular rate and rhythm without murmur, gallop, or rub.,ABDOMEN:  Soft, nontender.,MUSCULOSKELETAL:  There is musculoskeletal soreness and tenderness found at the ankles, feet, as well as the low back, particularly above the SI joints bilaterally.  Passive hip motion also elicits bilateral hip pain referred to the ipsilateral side.  Toe-heel walking is performed without difficulty.  Straight leg raises are negative.  Romberg's are negative.,NEUROLOGIC:  Grossly intact.  Intact reflexes in all extremities tested.  Romberg is negative and downgoing.,ASSESSMENT:,1. Osteoarthritis.,2. Chronic sacroiliitis.,3. Lumbar spondylosis.,4. Migraine.,5. TMJ arthropathy secondary to bruxism.,6. Mood disorder secondary to chronic pain.,7. Attention deficit disorder, currently untreated and self diagnosed.,RECOMMENDATIONS:,1. Agree with Rheumatology referral and review.  I would particularly be interested in the patient pursuing a bone density scan as well as thyroid and parathyroid studies.,2. Given the patient's previous sulfa allergies, we would recommend decreasing her Naprosyn usage.",
 The patient was exercised according to standard Bruce protocol for 9 minutes., Cardiovascular / Pulmonary, Treadmill Test ,"REASON FOR EXAMINATION:,  Abnormal EKG.,FINDINGS: , The patient was exercised according to standard Bruce protocol for 9 minutes achieving maximal heart rate of 146 resulting in 85% of age-predicted maximal heart rate.  Peak blood pressure was 132/60.  The patient did not experience any chest discomfort during stress or recovery.  The test was terminated due to leg fatigue and achieving target heart rate.,Electrocardiogram during stress and recovery did not reveal an additional 1 mm of ST depression compared to the baseline electrocardiogram.  Technetium was injected at 5 minutes into stress.,IMPRESSION:,1.  Good exercise tolerance.,2.  Adequate heart rate and blood pressure response.,3.  This maximal treadmill test did not evoke significant and diagnostic clinical or electrocardiographic evidence for significant occlusive coronary artery disease.,","cardiovascular / pulmonary, ekg, st depression, maximal heart rate, treadmill test, bruce protocol, blood pressure, heart rate, treadmill, electrocardiogram, "
" Coronary artery bypass surgery and aortic stenosis.  Transthoracic echocardiogram was performed of technically limited quality.  Concentric hypertrophy of the left ventricle with left ventricular function.  Moderate mitral regurgitation.  Severe aortic stenosis, severe.", Cardiovascular / Pulmonary, Transthoracic Echocardiography ,"REASON FOR EXAM: , Coronary artery bypass surgery and aortic stenosis.,FINDINGS: , Transthoracic echocardiogram was performed of technically limited quality.  The left ventricle was normal in size and dimensions with normal LV function.  Ejection fraction was 50% to 55%.  Concentric hypertrophy noted with interventricular septum measuring 1.6 cm, posterior wall measuring 1.2 cm.  Left atrium is enlarged, measuring 4.42 cm.  Right-sided chambers are normal in size and dimensions.  Aortic root has normal diameter.,Mitral and tricuspid valve reveals annular calcification.  Fibrocalcific valve leaflets noted with adequate excursion.  Similar findings noted on the aortic valve as well with significantly adequate excursion of valve leaflets.  Atrial and ventricular septum are intact.  Pericardium is intact without any effusion.  No obvious intracardiac mass or thrombi noted.,Doppler study reveals mild-to-moderate mitral regurgitation.  Severe aortic stenosis with peak velocity of 2.76 with calculated ejection fraction 50% to 55% with severe aortic stenosis.  There is also mitral stenosis.,IMPRESSION:,1.  Concentric hypertrophy of the left ventricle with left ventricular function.,2.  Moderate mitral regurgitation.,3.  Severe aortic stenosis, severe.,RECOMMENDATIONS: , Transesophageal echocardiogram is clinically warranted to assess the aortic valve area.","cardiovascular / pulmonary, coronary artery bypass surgery, aortic stenosis, annular calcification, tricuspid, mitral, regurgitation, severe aortic stenosis, concentric hypertrophy, mitral regurgitation, transthoracic, echocardiogram, hypertrophy, ventricular, valve, stenosis, aortic"
 Bilateral carotid ultrasound to evaluate pain., Cardiovascular / Pulmonary, Ultrasound - Carotid - 2 ,"EXAM: , Ultrasound carotid, bilateral.,REASON FOR EXAMINATION: , Pain.,COMPARISON:,  None.,FINDINGS: , Bilateral common carotid arteries/branches demonstrate minimal, predominantly noncalcified plaquing with mild calcific plaquing in the left internal carotid artery.  There are no different colors or spectral Doppler waveform abnormalities.,PARAMETRIC DATA:,  Right CCA PSV 0.72 m/s.  Right ICA PSV is 0.595 m/s.  Right ICA EDV 0.188 m/s.  Right vertebral 0.517 m/s. Right IC/CC is 0.826. Left CCA PSV 0.571 m/s, left ICA PSV 0.598 m/s.  Left ICA EDV 0.192 m/s.  Left vertebral 0.551 m/s.  Left IC/CC is 1.047.,IMPRESSION:,1.  No evidence for clinically significant stenosis.,2.  Minimal, predominantly soft plaquing.,","cardiovascular / pulmonary, carotid, cca psv, doppler, ic/cc, ica edv, ica psv, ultrasound, arteries, calcific plaquing, common carotid, internal carotid artery, spectral, stenosis, waveform, ultrasound carotid bilateral, ultrasound carotid, plaquing,"
" Insertion of a right brachial artery arterial catheter and a right subclavian vein triple lumen catheter.  Hyperpyrexia/leukocytosis, ventilator-dependent respiratory failure, and acute pancreatitis.", Cardiovascular / Pulmonary, Triple Lumen Catheter Insertion ,"PREOPERATIVE DIAGNOSES:,1.  Hyperpyrexia/leukocytosis.,2.  Ventilator-dependent respiratory failure.,3.  Acute pancreatitis.,POSTOPERATIVE DIAGNOSES:,1.  Hyperpyrexia/leukocytosis.,2.  Ventilator-dependent respiratory failure.,3.  Acute pancreatitis.,PROCEDURE PERFORMED:,1.  Insertion of a right brachial artery arterial catheter.,2.  Insertion of a right subclavian vein triple lumen catheter.,ANESTHESIA: , Local, 1% lidocaine.,BLOOD LOSS:,  Less than 5 cc.,COMPLICATIONS: , None.,INDICATIONS: , The patient is a 46-year-old Caucasian female admitted with severe pancreatitis.  She was severely dehydrated and necessitated some fluid boluses.  The patient became hypotensive, required many fluid boluses, became very anasarcic and had difficulty with breathing and became hypoxic.  She required intubation and has been ventilator-dependent in the Intensive Care since that time.  The patient developed very high temperatures as well as leukocytosis.  Her lines required being changed.,PROCEDURE:,1.  RIGHT BRACHIAL ARTERIAL LINE:  ,The patient's right arm was prepped and draped in the usual sterile fashion.  There was a good brachial pulse palpated.  The artery was cannulated with the provided needle and the kit.  There was good arterial blood return noted immediately.  On the first stick, the Seldinger wire was inserted through the needle to cannulate the right brachial artery without difficulty.  The needle was removed and a catheter was inserted over the Seldinger wire to cannulate the brachial artery.  The femoral catheter was used in this case secondary to the patient's severe edema and anasarca.  We did not feel that the shorter catheter would provide enough length.  The catheter was connected to the system and flushed without difficulty.  A good waveform was noted.  The catheter was sutured into place with #3-0 silk suture and OpSite dressing was placed over this.,2.  RIGHT SUBCLAVIAN TRIPLE LUMEN CATHETER:  ,The patient was prepped and draped in the usual sterile fashion.  1% Xylocaine was used to anesthetize an area just inferior and lateral to the angle of the clavicle.  Using the anesthetic needle, we checked down to the soft tissues anesthetizing, as we proceeded to the angle of the clavicle, this was also anesthetized.  Next, a #18 gauge thin walled needle was used following the same track to the angle of clavicle.  We roughed the needle down off the clavicle and directed it towards the sternal notch.  There was good venous return noted immediately.  The syringe was removed and a Seldinger guidewire was inserted through the needle to cannulate the vein.  The needle was then removed.  A small skin nick was made with a #11 blade scalpel and the provided dilator was used to dilate the skin, soft tissue and vein.  Next, the triple lumen catheter was inserted over the guidewire without difficulty.  The guidewire was removed.  All the ports aspirated and flushed without difficulty.  The catheter was sutured into place with #3-0 silk suture and a sterile OpSite dressing was also applied.  The patient tolerated the above procedures well.  A chest x-ray has been ordered, however, it has not been completed at this time, this will be checked and documented in the progress notes.","cardiovascular / pulmonary, hyperpyrexia, leukocytosis, ventilator-dependen, respiratory failure, pancreatitis, brachial artery, arterial catheter, subclavian vein, triple lumen catheter, catheter, brachial, needle, "
 Urgent cardiac catheterization with coronary angiogram., Cardiovascular / Pulmonary, Urgent Cardiac Cath ,"PROCEDURE: , Urgent cardiac catheterization with coronary angiogram.,PROCEDURE IN DETAIL: , The patient was brought urgently to the cardiac cath lab from the emergency room with the patient being intubated with an abnormal EKG and a cardiac arrest.  The right groin was prepped and draped in usual manner.  Under 2% lidocaine anesthesia, the right femoral artery was entered.  A 6-French sheath was placed.  The patient was already on anticoagulation.  Selective coronary angiograms were then performed using a left and a 3DRC catheter.  The catheters were reviewed.  The catheters were then removed and an Angio-Seal was placed.  There was some hematoma at the cath site.,RESULTS,1.  The left main was free of disease.,2.  The left anterior descending and its branches were free of disease.,3.  The circumflex was free of disease.,4.  The right coronary artery was free of disease.  There was no gradient across the aortic valve.,IMPRESSION: , Normal coronary angiogram.,","cardiovascular / pulmonary, cardiac catheterization, coronary angiogram, angiogram"
 Transesophageal echocardiographic examination report.   Aortic valve replacement.  Assessment of stenotic valve.  Evaluation for thrombus on the valve., Cardiovascular / Pulmonary, Transesophageal Echocardiogram - 3 ,"REASON FOR EXAM: , Aortic valve replacement.  Assessment of stenotic valve.  Evaluation for thrombus on the valve.,PREOPERATIVE DIAGNOSIS:  ,Atrial valve replacement.,POSTOPERATIVE DIAGNOSES:,  Moderate stenosis of aortic valve replacement.  Mild mitral regurgitation.  Normal left ventricular function.,PROCEDURES IN DETAIL: , The procedure was explained to the patient with risks and benefits.  The patient agreed and signed the consent form.  The patient received a total of 3 mg of Versed and 50 mcg of fentanyl for conscious sedation and pain control.  The oropharynx anesthetized with benzocaine spray and lidocaine solution.,Esophageal intubation was done with no difficulty with the second attempt.  In a semi-Fowler position, the probe was passed to transthoracic views at about 40 to 42 cm.  Multiple pictures obtained.  Assessment of the peak velocity was done later.,The probe was pulled to the mid esophageal level.  Different pictures including short-axis views of the aortic valve was done.  Extubation done with no problems and no blood on the probe.  The patient tolerated the procedure well with no immediate postprocedure complications.,INTERPRETATION: , The left atrium was mildly dilated.  No masses or thrombi were seen.  The left atrial appendage was free of thrombus.  Pulse wave interrogation showed peak velocities of 60 cm per second.,The left ventricle was normal in size and contractility with mild LVH.  EF is normal and preserved.,The right atrium and right ventricle were both normal in size.,Mitral valve showed no vegetations or prolapse.  There was mild-to-moderate regurgitation on color flow interrogation.  Aortic valve was well-seated mechanical valve, bileaflet with acoustic shadowing beyond the valve noticed.  No perivalvular leak was noticed.  There was increased velocity across the valve with peak velocity of 3.2 m/sec with calculated aortic valve area by continuity equation at 1.2 cm2 indicative of moderate aortic valve stenosis based on criteria for native heart valves.,No AIC.,Pulmonic valve was somewhat difficult to see because of acoustic shadowing from the aortic valve.  Overall showed no abnormalities.  The tricuspid valve was structurally normal.,Interatrial septum appeared to be intact, confirmed by color flow interrogation as well as agitated saline contrast study.,The aorta and aortic arch were unremarkable.  No dissection.,IMPRESSION:,1.  Mildly dilated left atrium.,2.  Mild-to-moderate regurgitation.,3.  Well-seated mechanical aortic valve with peak velocity of 3.2 m/sec and calculated valve area of 1.2 cm2 consistent with moderate aortic stenosis.  Reevaluation in two to three years with transthoracic echocardiogram will be recommended.","cardiovascular / pulmonary, aortic valve replacement, stenotic valve, thrombus, stenosis, ventricular, esophageal, peak velocity, valve replacement, aortic valve, aortic, transesophageal, valve, oropharynx, atrium, interrogation, atrial, moderate, "
 Transesophageal Echocardiogram.  A woman admitted to the hospital with a large right MCA CVA causing a left-sided neurological deficit incidentally found to have atrial fibrillation on telemetry. , Cardiovascular / Pulmonary, Transesophageal Echocardiogram - 6 ,"HISTORY OF PRESENT ILLNESS: , I was kindly asked to see this patient for transesophageal echocardiogram performance by Dr. A and Neurology.  Please see also my cardiovascular consultation dictated separately.  But essentially, this is a pleasant 72-year-old woman admitted to the hospital with a large right MCA CVA causing a left-sided neurological deficit incidentally found to have atrial fibrillation on telemetry.  She has been recommended for a transesophageal echocardiogram for cardioembolic source of her CNS insult.,I discussed the procedure in detail with the patient as well as with her daughter, who was present at the patient's bedside with the patient's verbal consent.  I then performed a risk/benefit/alternative analysis with benefits being more definitive exclusion of intracardiac thrombus as well as assessment for intracardiac shunts; alternatives being transthoracic echo imaging, which she had already had, with an inherent false negativity for this indication as well as empiric medical management, which the patient was not interested in; risks including, but not limited to, and the patient was aware this was not an all-inclusive list, of oversedation from conscious sedation, risk of aspiration pneumonia from regurgitation of stomach contents, risk of oropharyngeal, esophageal, oral, tracheal, pulmonary and/or gastric perforation, hemorrhage, or tear.  The patient expressed understanding of this risk/benefit/alternative analysis, had the opportunity to ask questions, which I invited from her and her daughter, all of which were answered to their self-stated satisfaction.  The patient then stated in a clear competent and coherent fashion that she wished to go forward with the transesophageal echocardiogram.,PROCEDURE: , The appropriate time-out procedure was performed as per Medical Center protocol under my direct supervision with appropriate identification of the patient, position, physician, procedure documentation; there were no safety issues identified by staff nor myself.  She received 20 cc of viscous lidocaine for topical oral anesthetic effect.  She received a total of 4 mg of Versed and 100 micrograms of fentanyl utilizing titrated conscious sedation with continuous hemodynamic and oximetric monitoring with reasonable effect.  The multi-plane probe was passed using digital guidance for several passes, after an oral bite block had been put into place for protection of oral dentition.  This was placed into the posterior oropharynx and advanced into the esophagus, then advanced into the stomach and then rotated and withdrawn and removed with adequate imaging obtained throughout.  She was recovered as per the Medical Center conscious sedation protocol, and there were no apparent complications of the procedure.,FINDINGS: , Normal left ventricular size and systolic function.  LVEF of 60%.  Mild left atrial enlargement.  Normal right atrial size.  Normal right ventricular size and systolic function.  No left ventricular wall motion abnormalities identified.  The four pulmonary veins are identified.  The left atrial appendage is interrogated, including with Doppler and color flow, and while there is good to-and-fro motion seen, echo smoke is seen, and in fact, an intracardiac thrombus is identified and circumscribed at 1.83 cm in circumference at the base of the left atrial appendage.  No intracardiac vegetations nor endocarditis seen on any of the intracardiac valves.  The mitral valve is seen.  There is mild mitral regurgitation with two jets.  No mitral stenosis.  Four pulmonary veins were identified without reversible pulmonary venous flow.  There are three cusps of the aortic valve seen.  No aortic stenosis.  There is trace aortic insufficiency.  There is trace pulmonic insufficiency.  The pulmonary artery is seen and is within normal limits.  There is trace to mild tricuspid regurgitation.  Unable to estimate PA systolic pressure accurately; however, on the recent transthoracic echocardiogram (which I would direct the reader to) on January 5, 2010, RVSP was calculated at 40 mmHg on that study.  E wave velocity on average is 0.95 m/sec with a deceleration time of 232 milliseconds.  The proximal aorta is within normal limits, annulus 1.19 cm, sinuses of Valsalva 2.54 cm, ascending aorta 2.61 cm.  The intra-atrial septum is identified as are the SVC and IVC, and these are within normal limits.  The intra-atrial septum is interrogated with color flow as well as agitated D5W and there is no evidence of intracardiac shunting, including no atrial septal defect nor patent foramen ovale.  No pericardial effusion.  There is mild nonmobile descending aortic atherosclerosis seen.,IMPRESSION:,1.  Normal left ventricular size and systolic function.  Left ventricular ejection fraction visually estimated at 60% without regional wall motion abnormalities.,2.  Mild left atrial enlargement.,3.  Intracardiac thrombus identified at the base of the left atrial appendage.,4.  Mild mitral regurgitation with two jets.,5.  Mild nonmobile descending aortic atherosclerosis.,Compared to the transthoracic echocardiogram done previously, other than identification of the intracardiac thrombus, other findings appear quite similar.,These results have been discussed with Dr. A of inpatient Internal Medicine service as well as the patient, who was recovering from conscious sedation, and her daughter with the patient's verbal consent.","cardiovascular / pulmonary, echo, thrombus, intracardiac, cardiovascular, pulmonary veins, intracardiac thrombus, transesophageal echocardiogram, echocardiogram, atrial, mca, cva, transesophageal, pulmonary, ventricular, aortic"
 Transesophageal echocardiogram.   The transesophageal probe was introduced into the posterior pharynx and esophagus without difficulty., Cardiovascular / Pulmonary, Transesophageal Echocardiogram - 4 ,"PROCEDURE NOTE:,  The patient was brought to the transesophageal echo laboratory after informed consent was obtained.  The patient was seen by Anesthesia for MAC anesthesia.  The patient's posterior pharynx was anesthetized with local Cetacaine spray.  The transesophageal probe was introduced into the posterior pharynx and esophagus without difficulty.,FINDINGS: ,1.  Left ventricle is normal in size and function; ejection fraction approximately 60%.,2.  Right ventricle is normal in size and function.,3.  Left atrium and right atrium are normal in size.,4.  Mitral valve, aortic valve, tricuspid valve, and pulmonic valve with no evidence of vegetation.  Aortic valve is only minimally thickened.,5.  Mild mitral regurgitation and mild tricuspid regurgitation.,6.  No left ventricular thrombus.,7.  No pericardial effusion.,8.  There is evidence of patent foramen ovale by contrast study.,The patient tolerated the procedure well and is sent to recovery in stable condition.  He should be n.p.o. x4 hours, then liquid, then increase as tolerated.  Once his infection is cleared, he should follow up with us with regard to followup of patent foramen ovale.","cardiovascular / pulmonary, ventricle, atrium, mitral valve, aortic valve, tricuspid valve, pulmonic valve, regurgitation, transesophageal probe, transesophageal echocardiogram, posterior pharynx, transesophageal, valve"
" Transesophageal echocardiogram. MRSA bacteremia, rule out endocarditis.  The patient has aortic stenosis.", Cardiovascular / Pulmonary, Transesophageal Echocardiogram - 5 ,"CLINICAL INDICATIONS: , MRSA bacteremia, rule out endocarditis.  The patient has aortic stenosis.,DESCRIPTION OF PROCEDURE: , The transesophageal echocardiogram was performed after getting verbal and a written consent signed.  Then a multiplane TEE probe was introduced into the upper esophagus, mid esophagus, lower esophagus, and stomach and multiple views were obtained.  There were no complications.  The patient's throat was numbed with Cetacaine spray and IV sedation was achieved with Versed and fentanyl.,FINDINGS:,1.  Aortic valve is thick and calcified, a severely restricted end opening and there is 0.6 x 8 mm vegetation attached to the right coronary cusp.  The peak velocity across the aortic valve was 4.6 m/sec and mean gradient was 53 mmHg and peak gradient 84 mmHg with calculated aortic valve area of 0.6 sq cm by planimetry.,2.  Mitral valve is calcified and thick.  No vegetation seen.  There is mild-to-moderate MR present.  There is mild AI present also.,3.  Tricuspid valve and pulmonary valve are structurally normal.,4.  There is a mild TR present.,5.  There is no clot seen in the left atrial appendage.  The velocity in the left atrial appendage was 0.6 m/sec.,6.  Intraatrial septum was intact.  There is no clot or mass seen.,7.  Normal LV and RV systolic function.,8.  There is thick raised calcified plaque seen in the thoracic aorta and arch.,SUMMARY:,1.  There is a 0.6 x 0.8 cm vegetation present in the aortic valve with severe aortic stenosis.  Calculated aortic valve area was 0.6 sq. cm.,2.  Normal LV systolic function.,","cardiovascular / pulmonary, endocarditis, aortic stenosis, tee probe, mrsa bacteremia, transesophageal echocardiogram, aortic, echocardiogram, esophagus, vegetation, transesophageal"
 Transesophageal echocardiogram due to vegetation and bacteremia. Normal left ventricular size and function.  Echodensity involving the aortic valve suggestive of endocarditis and vegetation. Doppler study as above most pronounced being moderate-to-severe aortic insufficiency., Cardiovascular / Pulmonary, Transesophageal Echocardiogram - 2 ,"REASON FOR EXAM: , Vegetation and bacteremia.,PROCEDURE: , Transesophageal echocardiogram.,INTERPRETATION: , The procedure and its complications were explained to the patient in detail and formal consent was obtained.  The patient was brought to special procedure unit.  His throat was anesthetized with lidocaine spray.  Subsequently, 2 mg of IV Versed was given for sedation.  The patient was positioned.  Probe was introduced without any difficulty.  The patient tolerated the procedure very well.  Probe was taken out.  No complications were noted.  Findings are as mentioned below.,FINDINGS:,1.  Left ventricle has normal size and dimensions with normal function.  Ejection fraction of 60%.,2.  Left atrium and right-sided chambers were of normal size and dimensions.,3.  Left atrial appendage is clean without any clot or smoke effect.,4.  Atrial septum is intact.  Bubble study was negative.,5.  Mitral valve is structurally normal.,6.  Aortic valve reveals echodensity suggestive of vegetation.,7.  Tricuspid valve was structurally normal.,8.  Doppler reveals moderate mitral regurgitation and moderate-to-severe aortic regurgitation.,9.  Aorta is benign.,IMPRESSION:,1.  Normal left ventricular size and function.,2.  Echodensity involving the aortic valve suggestive of endocarditis and vegetation.,3.  Doppler study as above most pronounced being moderate-to-severe aortic insufficiency.","cardiovascular / pulmonary, ventricle, atrium, atrial, septum, mitral valv, aortic valve, tricuspid valve, doppler, ventricular size, transesophageal echocardiogram, severe aortic, bacteremia, transesophageal, echocardiogram, echodensity, vegetation, valve, aortic,"
 Insertion of transesophageal echocardiography probe and unsuccessful insertion of arterial venous lines., Cardiovascular / Pulmonary, Transesophageal Echocardiography Probe ,"INDICATIONS FOR PROCEDURE:,  Impending open heart surgery for closure of ventricular septal defect in a 4-month-old girl.,Procedures were done under general anesthesia.  The patient was already in the operating room under general anesthesia.  Antibiotic prophylaxis with cefazolin and gentamicin was already given prior to beginning the procedures.,PROCEDURE #1:,  Insertion of transesophageal echocardiography probe.,DESCRIPTION OF PROCEDURE #1: , The probe was well lubricated and with digital manipulation, was passed into the esophagus without resistance.  The probe was placed so that the larger diameter was in the anterior-posterior position during insertion.  The probe was used by the pediatric cardiologist for preoperative and postoperative diagnostic echocardiography.  At the end, it was removed without trauma and there was no blood tingeing.  It is to be noted that approximately 30 minutes after removing the cannula, I inserted a 14-French suction tube to empty the stomach and there were a few mL of blood secretions that were suctioned.  There was no overt bleeding.,PROCEDURE #2: , Attempted and unsuccessful insertion of arterial venous lines.,DESCRIPTION OF PROCEDURE #2:,  Both groins were prepped and draped.  The patient was placed at 10 degrees head-up position.  A Cook 4-French double-lumen 8-cm catheter kit was opened.  Using the 21-gauge needle that comes with the kit, several attempts were made to insert central venous and then an arterial line in the left groin.  There were several successful punctures of these vessels, but I was unable to advance Seldinger wire.  After removal of the needles, the area was compressed digitally for approximately 5 minutes.  There was a small hematoma that was not growing.  Initially, the left leg was mildly mottled with prolonged capillary refill of approximately 3 seconds.  Using 1% lidocaine, I infiltrated the vessels of the groin both medial and lateral to the vascular sheath.  Further observation, the capillary refill and circulation of the left leg became more than adequate.  The O2 saturation monitor that was on the left toe functioned well throughout the procedures, from the beginning to the end.  At the end of the procedure, the circulation of the leg was intact.,","cardiovascular / pulmonary, impending open heart surgery, ventricular septal defect, antibiotic prophylaxis, cefazolin, transesophageal echocardiography probe, arterial venous lines, groin, transesophageal echocardiography, echocardiography probe, insertion, transesophageal, arterial, venous, groins, echocardiography, probe"
 Tracheostomy change.  A #6 Shiley with proximal extension was changed to a #6 Shiley with proximal extension.  Ventilator-dependent respiratory failure and laryngeal edema., Cardiovascular / Pulmonary, Tracheostomy Change ,"PREOPERATIVE DIAGNOSES:,1.  Ventilator-dependent respiratory failure.,2.  Laryngeal edema.,POSTOPERATIVE DIAGNOSES:,1.  Ventilator-dependent respiratory failure.,2.  Laryngeal edema.,PROCEDURE PERFORMED: , Tracheostomy change.  A #6 Shiley with proximal extension was changed to a #6 Shiley with proximal extension.,INDICATIONS: , The patient is a 60-year-old Caucasian female who presented to ABCD General Hospital with exacerbation of COPD and CHF.  The patient had subsequently been taken to the operating room by Department of Otolaryngology and a direct laryngoscope was performed.  The patient was noted at that time to have transglottic edema.  Biopsies were taken.  At the time of surgery, it was decided that the patient required a tracheostomy for maintenance of continued ventilation and airway protection.  The patient is currently postop day #6 and appears to be unable to be weaned from ventilator at this time and may require prolonged ventricular support.  A decision was made to perform tracheostomy change.,DESCRIPTION OF PROCEDURE: , The patient was seen in the Intensive Care Unit.  The patient was placed in a supine position.  The neck was then extended.  The sutures that were previously in place in the #6 Shiley with proximal extension were removed.  The patient was preoxygenated to 100%.  After several minutes, the patient was noted to have a pulse oximetry of 100%.  The IV tubing that was supporting the patient's trache was then cut.  The tracheostomy tube was then suctioned.,The inner cannula was then removed from the tracheostomy and a nasogastric tube was placed down the lumen of the tracheostomy tube as a guidewire.  The tracheostomy tube was then removed over the nasogastric tube and the operative field was suctioned.  With the guidewire in place and with adequate visualization, a new #6 Shiley with proximal extension was then passed over the nasogastric tube guidewire and carefully inserted into the trachea.  The guidewire was then removed and the inner cannula was then placed into the tracheostomy.  The patient was then reconnected to the ventilator and was noted to have normal tidal volumes.  The patient had a tidal volume of 500 and was returning 500 cc to 510 cc.  The patient continued to saturate well with saturations 99%.  The patient appeared comfortable and her vital signs were stable.  A soft trache collar was then connected to the trachesotomy.  A drain sponge was then inserted underneath the new trache site.  The patient was observed for several minutes and was found to be in no distress and continued to maintain adequate saturations and continued to return normal tidal volumes.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well.  0.25% acetic acid soaks were ordered to the drain sponge every shift.","cardiovascular / pulmonary, shiley, proximal extension, ventilator-dependent, respiratory failure, laryngeal edema, tracheostomy, cannula, respiratory, laryngeal, nasogastric, edema, ventilator"
 Tracheostomy with skin flaps and SCOOP procedure FastTract.  Oxygen dependency of approximately 5 liters nasal cannula at home and chronic obstructive pulmonary disease. , Cardiovascular / Pulmonary, Tracheostomy & SCOOP Procedure ,"PREOPERATIVE DIAGNOSES:,1.  Oxygen dependency.,2.  Chronic obstructive pulmonary disease.,POSTOPERATIVE DIAGNOSES:,1.  Oxygen dependency.,2.  Chronic obstructive pulmonary disease.,PROCEDURES PERFORMED:,1.  Tracheostomy with skin flaps.,2.  SCOOP procedure FastTract.,ANESTHESIA: , Total IV anesthesia.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS:  ,None.,INDICATIONS FOR PROCEDURE: , The patient is a 55-year-old Caucasian male with a history of chronic obstructive pulmonary disease and O2 dependency of approximately 5 liters nasal cannula at home.  The patient with extensive smoking history who presents after risks, complications, and consequences of the SCOOP FastTract procedure were explained.,PROCEDURE:,  The patient was brought to operating suite by Anesthesia and placed on the operating table in the supine position.  After this, the patient was then placed under total IV anesthesia and the operating bed was then placed in reverse Trendelenburg.  The patient's sternal notch along with cricoid and thyroid cartilages were noted and palpated and a sternal marker was utilized to mark the cricoid cartilage in the sternal notch.  The midline was also marked and 1% lidocaine with epinephrine 1:100,000 at approximately 4 cc total was then utilized to localize the neck.  After this, the patient was then prepped and draped with Hibiclens.  A skin incision was then made in the midline with a #15 Bard-Parker in a vertical fashion.  After this, the skin was retracted laterally and a small anterior jugular branch was clamped and cross clamped and tied with #2-0 undyed Vicryl ties.  Further bleeding was controlled with monopolar cauterization and attention was then drawn down on to the strap muscles.  The patient's sternohyoid muscle was identified and grasped on either side and the midline raphe was identified.  Cauterization was then utilized to take down the midline raphe and further dissection was utilized with the skin hook and stat clamps.  The anterior aspect of the thyroid isthmus was identified and palpation on the cricoid cartilage was performed.  The cricoid cauterization over the cricoid cartilage was obtained with the monopolar cauterization and blunt dissection then was carried along the posterior aspect of the thyroid isthmus.  Stats were then placed on either side of the thyroid isthmus and the mid portion was bisected with the monopolar cauterization.  After this, the patient's anterior trachea was then identified and cleaned with pusher.  After this, the cricoid cartilage along the first and second tracheal rings was identified.  The cricoid hook was placed and the trachea was brought more anteriorly and superiorly.  After this, the patient's head incision was placed below the second tracheal ring with a #15 Bard-Parker.  After this, the patient had a tracheal punch with the SCOOP FastTract kit to create a small 4 mm punch within the tracheal cartilage.  After this, the patient then had a tracheal stent placed within the tracheal punched lumen and the patient was then had the tracheal stent secured to the neck with a Vicryl strap.  After this, the cricoid hook was removed and the patient then had FiO2 on the monitor noted with pulse oximetry of 100%.  The patient was then turned back to the anesthesia and transferred to the recovery room in stable condition.  The patient tolerated the procedure well and will stay in the hospital for approximately 23 hours.  The patient will have the stent guidewire removed with a scoop catheter 11 cm placed.","cardiovascular / pulmonary, oxygen dependency, chronic obstructive pulmonary disease, tracheostomy, scoop procedure, nasal cannula, scoop procedure fasttract, thyroid isthmus, cricoid cartilage, isthmus, oxygen, dependency, scoop, cartilages"
 Transesophageal echocardiogram and direct current cardioversion., Cardiovascular / Pulmonary, Transesophageal Echocardiogram ,"EXAM: , Transesophageal echocardiogram and direct current cardioversion.,REASON FOR EXAM:  ,1.  Atrial fibrillation with rapid ventricular rate.,2.  Shortness of breath.,PROCEDURE: , After informed consent was obtained, the patient was then sedated using a total of 4 mg of Versed and 50 mcg of fentanyl.  Following this, transesophageal probe was placed in the esophagus.  Transesophageal views of the heart were then obtained.,FINDINGS:,1.  Left ventricle is of normal size.  Overall LV systolic function is preserved.  Estimated ejection fraction is 60% to 65%.  No wall motion abnormalities are noted.,2.  Left atrium is dilated.,3.  Left atrial appendage is free of clots.,4.  Right atrium is of normal size.,5.  Right ventricle is of normal size.,6.  Mitral valve shows evidence of mild MAC.,7.  Aortic valve is sclerotic without significant restriction of leaflet motion.,8.  Tricuspid valve appears normal.,9.  Pulmonic valve appears normal.,10.  Pacer wires are noted in the right atrium and in the right ventricle.,11.  Doppler interrogation of moderate mitral regurgitation is present.,12.  Mild-to-moderate AI is seen.,13.  No significant TR is noted.,14.  No significant TI is noted.,15.  No pericardial disease seen.,IMPRESSION:,1.  Preserved left ventricular systolic function.,2.  Dilated left atrium.,3.  Moderate mitral regurgitation.,4.  Aortic valve sclerosis with mild-to-moderate aortic insufficiency.,5.  Left atrial appendage is free of clots.,Following these, direct current cardioversion was performed.  Three biphasic shock waves of 150 and two of 200 joules were then applied to the patient's chest in anteroposterior direction without success in conversion to sinus rhythm.  The patient remained in atrial fibrillation.,PLAN: , Plan will be to continue medical therapy.  We will consider using beta-blocker, calcium channel blockers for better ventricular rate control.",
 Tilt table test.  A patient with past medical history of syncope.  The patient is also complaining of dizziness., Cardiovascular / Pulmonary, Tilt Table Test - 1 ,"INDICATIONS: , The patient is a 22-year-old female with past medical history of syncope.  The patient is also complaining of dizziness.  She was referred here by Dr. X for tilt table.,TECHNIQUE: , Risks and benefits explained to the patient.  Consent obtained.  She was lying down on her back for 20 minutes and her blood pressure was 111/75 and heart rate 89.  She was standing up on the tilt tablet for 20 minutes and her heart rate went up to 127 and blood pressure was still in 120/80.  Then, the patient received sublingual nitroglycerin 0.4 mg.  The patient felt dizzy at that time and heart rate was in the 120 and blood pressure was 110/50.  The patient felt nauseous and felt hot at that time.  She did not pass out.,COMPLICATIONS:,  None.,Tilt table was then terminated.,SUMMARY:,  Positive tilt table for vasovagal syncope with significant increase of heart rate with minimal decrease of blood pressure.,RECOMMENDATIONS: , I recommend followup in the office in one week and she will need Toprol-XL 12.5 mg every day if symptoms persist.","cardiovascular / pulmonary, vasovagal syncope, tilt table test, blood pressure, heart rate, dizziness, "
 Patient referred for evaluation of tracheostomy tube placement and treatment recommendations., Cardiovascular / Pulmonary, Tracheostomy Tube Consult ,"HISTORY:  ,I had the pleasure of meeting and evaluating the patient today, referred for evaluation of tracheostomy tube placement and treatment recommendations.  As you are well aware, he is a pleasant 64-year-old gentleman who unfortunately is suffering from end-stage COPD, who required tracheostomy tube placement about three months ago when being treated for acute exacerbation of COPD and having difficulty coming off ventilatory support.  He now resides in an extended care facility with a capped tracheostomy tube, and he unfortunately states he has had not had to use the tracheostomy tube since his discharge and admission to the extended care facility.  He requires constant oxygen administration and has been having no problems with shortness of breath, worsening, requiring opening the tracheostomy tube site.  He states there has been some tenderness associated with the tracheostomy tube and difficulty with swallowing and he wishes to have it removed.  Apparently there is no history of any airway issues while sleeping or need for uncapping the tube and essentially the tube has just remained present for months capped in his neck.  No history of any previous tracheostomy tube insertion.,PAST MEDICAL HISTORY: , COPD, history of hypercarbic hypoxemia, history of coronary artery disease, history of previous myocardial infarction, and history of liver cirrhosis secondary to alcohol use.,PAST SURGICAL HISTORY:  ,Tonsillectomy, adenoidectomy, cholecystectomy, appendectomy, hernia repair, and tracheostomy.,FAMILY HISTORY:  ,Strong for heart disease, coronary artery disease, hypertension, diabetes mellitus, and cerebrovascular accident.,CURRENT MEDICATIONS:,  Prevacid, folic acid, aspirin, morphine sulfate, Pulmicort, Risperdal, Colace, clonazepam, Lotrisone, Roxanol, Ambien, Zolpidem tartrate, simethicone, Robitussin, and prednisone.,ALLERGIES: , Nitroglycerin.,SOCIAL HISTORY: , The patient has a 25-year-smoking history, which I believe is quite heavy and he has a significant alcohol use in the past.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Age 64, blood pressure is 110/78, pulse 96, and temperature is 98.6.,GENERAL:  The patient was examined in his wheelchair, resting comfortably, in no acute distress.,HEAD:  Normocephalic.  No masses or lesions noted.,FACE:  No facial tenderness or asymmetry noted.,EYES:  Pupils are equal, round and reactive to light and accommodation bilaterally.  Extraocular movements are intact bilaterally.,EARS:  The tympanic membranes are intact bilaterally with a good light reflex.  The external auditory canals are clear with no lesions or masses noted.  Weber and Rinne tests are within normal limits.,NOSE:  The nasal cavities are patent bilaterally.  The nasal septum is midline.  There are no nasal discharges.  No masses or lesions noted.,THROAT:  The oral mucosa appears healthy.  Dental hygiene is maintained well.  No oropharyngeal masses or lesions noted.  No postnasal drip noted.,NECK:  The patient has a stable-appearing tracheostomy tube site and the stoma appears to be without signs of infection.  The previous incision was vertical in nature and there is no hypertrophic scar formation.  No adenopathy noted.  No stridor noted.,NEUROLOGIC:  Cranial nerve VII intact bilaterally.  No signs of tremor.,LUNGS:  Diminished breath sounds in all four quadrants.  No wheezes noted.,HEART:  Regular rate and rhythm.,PROCEDURE: , Limited bronchoscopy and then fiberoptic laryngoscopy.,IMPRESSION:  ,1.  End-stage chronic obstructive pulmonary disease with a history of respiratory failure requiring mechanical ventilatory support with tracheostomy tube placement.,2.  Difficulty tolerating tracheostomy tubes secondary to swallow discomfort and neck irritation with no further need for tracheostomy tube over the past few months with the patient tolerating capped tracheostomy tube 24 hours a day.,3.  History of coronary artery disease.,4.  History of myocardial infarction.,5.  History of cirrhosis of liver.,RECOMMENDATIONS: , I discussed with the patient in detail after fiberoptic laryngoscopy and limited bronchoscopy was performed in the office whether or not to pull out the tracheostomy tube.  His vocal cords moved well, and I do not see any signs of granuloma or airway obstruction either in the supraglottic or subglottic region, and I felt he would tolerate the tube being removed with close monitoring by nursing at his extended care facility.  I did impress the fact that I believe he probably will have other events requiring airway support, which could include intubation, and if the intubation is prolonged a tracheostomy may be needed.  Creation of a long-term tracheostoma may be beneficial whereas the patient would not need such a long tracheostomy tube, and I informed the patient there are other options other than the tube he has at the present time.  The patient still wished to have the tube removed and he is aware he may need to have it replaced or he may have trouble with the area healing or scarring or he could end up having an emergent airway situation with the tube gone, but wishes to have it removed, and I did remove it today.  Dressing was applied and we will see him back next week to make sure everything is healing properly.",
 Tracheotomy for patient with respiratory failure., Cardiovascular / Pulmonary, Tracheotomy - 1 ,"PREOPERATIVE DIAGNOSIS: , Respiratory failure.,POSTOPERATIVE DIAGNOSIS:  ,Respiratory failure.,OPERATIVE PROCEDURE: , Tracheotomy.,ANESTHESIA:  ,General inhalational.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine on the operating table.  General inhalational anesthesia was administered through the patient's existing 4.0 endotracheal tube.  The neck was extended and secured with tape and incision in the midline of the neck approximately 2 fingerbreadths above the sternal notch was outlined.  The incision measured approximately 1 cm and was just below the palpable cricoid cartilage and first tracheal ring.  The incision area was infiltrated with 1% Xylocaine with epinephrine 1:100,000.  A #67 blade was used to perform the incision.  Electrocautery was used to remove excess fat tissue to expose the strap muscles.  The strap muscles were grasped and divided in the midline with a cutting electrocautery.  Sharp dissection was used to expose the anterior trachea and cricoid cartilage.  The thyroid isthmus was identified crossing just below the cricoid cartilage.  This was divided in the midline with electrocautery.  Blunt dissection was used to expose adequate cartilaginous rings.  A 4.0 silk was used for stay sutures to the midline of the cricoid.  Additional stay sutures were placed on each side of the third tracheal ring.  Thin DuoDerm was placed around the stoma.  The tracheal incision was performed with a #11 blade through the second, third, and fourth tracheal rings.  The cartilaginous edges were secured to the skin edges with interrupted #4-0 Monocryl.  A 4.5 PED tight-to-shaft cuffed Bivona tube was placed and secured with Velcro ties.  A flexible scope was passed through the tracheotomy tube.  The carina was visualized approximately 1.5 cm distal to the distal end of the tracheotomy tube.  Ventilation was confirmed.  There was good chest rise and no appreciable leak.  The procedure was terminated.  The patient was in stable condition.  Bleeding was negligible and she was transferred back to the Pediatric intensive care unit in stable condition.","cardiovascular / pulmonary, bivona tube, duoderm, tracheotomy tube, respiratory failure, cricoid cartilage, tracheotomy, tracheal, "
 Transesophageal echocardiogram for aortic stenosis.  Normal left ventricular size and function.  Benign Doppler flow pattern.   Doppler study essentially benign.  Aorta essentially benign.  Atrial septum intact.  Study was negative., Cardiovascular / Pulmonary, Transesophageal Echocardiogram - 1 ,"INDICATION: , Aortic stenosis.,PROCEDURE: , Transesophageal echocardiogram.,INTERPRETATION:  ,Procedure and complications explained to the patient in detail.  Informed consent was obtained.  The patient was anesthetized in the throat with lidocaine spray.  Subsequently, 3 mg of IV Versed was given for sedation.  The patient was positioned and transesophageal probe was introduced without any difficulty.  Images were taken.  The patient tolerated the procedure very well without any complications.  Findings as mentioned below.,FINDINGS:,1.  Left ventricle is in normal size and dimension.  Normal function.  Ejection fraction of 60%.,2.  Left atrium and right-sided chambers are of normal size and dimension.,3.  Mitral, tricuspid, and pulmonic valves are structurally normal.,4.  Aortic valve reveals annular calcification with fibrocalcific valve leaflets with decreased excursion.,5.  Left atrial appendage is clean without any clot or smoke effect.,6.  Atrial septum intact.  Study was negative.,7.  Doppler study essentially benign.,8.  Aorta essentially benign.,9.  Aortic valve planimetry valve area average about 1.3 cm2 consistent with moderate aortic stenosis.,SUMMARY:,1.  Normal left ventricular size and function.,2.  Benign Doppler flow pattern.,3.  Aortic valve area of 1.3 cm2 planimetry.,","cardiovascular / pulmonary, aortic valve, ejection fraction, planimetry, ventricular, transesophageal, echocardiogram, atrial septum, septum intact, transesophageal echocardiogram, aortic stenosis, doppler, aortic, valves"
" Aortic stenosis.   Insertion of a Toronto stentless porcine valve, cardiopulmonary bypass, and cold cardioplegia arrest of the heart.", Cardiovascular / Pulmonary, Toronto Porcine Valve Insertion ,"PREOPERATIVE DIAGNOSIS:,  Aortic stenosis.,POSTOPERATIVE DIAGNOSIS:  ,Aortic stenosis.,PROCEDURES PERFORMED,1.  Insertion of a **-mm Toronto stentless porcine valve.,2.  Cardiopulmonary bypass.,3.  Cold cardioplegia arrest of the heart.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS:  , 300 cc.,INTRAVENOUS FLUIDS:  , 1200 cc of crystalloid.,URINE OUTPUT:  , 250 cc.,AORTIC CROSS-CLAMP TIME: , **,CARDIOPULMONARY BYPASS TIME TOTAL: , **,PROCEDURE IN DETAIL:,  After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and general endotracheal anesthesia was administered.  Next the neck, chest and legs were prepped and draped in the standard surgical fashion.  We used a #10-blade scalpel to make a midline median sternotomy incision.  Dissection was carried down to the left of the sternum using Bovie electrocautery.  The sternum was opened with a sternal saw.  The chest retractor was positioned.  Next, full-dose heparin was given.  The pericardium was opened.  Pericardial stay sutures were positioned.  After obtaining adequate ACT, we prepared to place the patient on cardiopulmonary bypass.  A 2-0 double pursestring of Ethibond suture was placed in the ascending aorta.  Through this was passed an aortic cannula connected to the arterial side of the cardiopulmonary bypass machine.  Next a 3-0 Prolene pursestring was placed in the right atrial appendage.  Through this was passed our venous cannula connected to the venous portion of the cardiopulmonary bypass machine.  A 4-0 U-stitch was placed in the right atrium.  A retrograde cardioplegia catheter was positioned at this site.  Next, scissors were used to dissect out the right upper pulmonary vein.  A 4-0 Prolene pursestring was placed in the right upper pulmonary vein.  Next, a right-angle sump was placed at this position.  We then connected our retrograde cardioplegia catheter to the cardioplegia solution circuit.  Bovie electrocautery was used to dissect the interface between the aorta and pulmonary artery.  The aorta was completely encircled.  Next, an antegrade cardioplegia needle and associated sump were placed in the ascending aorta.  We then prepared to cross-clamp the aorta.  We went down on our flows and cross-clamped the aorta.  We backed up our flows.  We then gave antegrade and retrograde cold blood cardioplegia solution circuit so as to arrest the heart.  The patient had some aortic insufficiency so we elected, after initially arresting the heart, to open the aorta and transect it and then give direct ostial infusion of cardioplegia solution circuit.  Next, after obtaining complete diastolic arrest of the heart, we turned our attention to exposing the aortic valve, and 4-0 Tycron sutures were placed in the commissures.  In addition, a 2-0 Prolene suture was placed in the aortic wall so as to bring the aortic wall and root up into view.  Next, scissors were used to excise the diseased aortic valve leaflets.  Care was taken to remove all the calcium from the aortic annulus.  We then sized up the aortic annulus which came out to be a **-mm stentless porcine Toronto valve.  We prepared the valve.  Next, we placed our proximal suture line of interrupted 4-0 Tycron sutures for the annulus.  We started with our individual commissural stitches.  They were connected to our valve sewing ring.  Next, we placed 5 interrupted 4-0 Tycron sutures in a subannular fashion at each commissural position.  After doing so, we passed 1 end of the suture through the sewing portion of the Toronto stentless porcine valve.  The valve was lowered into place and all of the sutures were tied.  Next, we gave another round of cold blood antegrade and retrograde cardioplegia.  Next, we sewed our distal suture line.  We began with the left coronary cusp of the valve.  We ran a 5-0 RB needle up both sides of the valve.  Care was taken to avoid the left coronary ostia.  This procedure was repeated on the right cusp of the stentless porcine valve.  Again, care was taken to avoid any injury to the coronary ostia.  Lastly, we sewed our non-coronary cusp.  This was done without difficulty.  At this point we inspected our aortic valve.  There was good coaptation of the leaflets, and it was noted that both the left and the right coronary ostia were open.  We gave another round of cold blood antegrade and retrograde cardioplegia.  The antegrade portion was given in a direct ostial fashion once again.  We now turned our attention to closing the aorta.  A 4-0 Prolene double row of suture was used to close the aorta in a running fashion.  Just prior to closing, we de-aired the heart and gave a warm shot of antegrade and retrograde cardioplegia.  At this point, we removed our aortic cross-clamp.  The heart gradually regained its electromechanical activity.  We placed 2 atrial and 2 ventricular pacing wires.  We removed our aortic vent and oversewed that site with another 4-0 Prolene on an SH needle.  We removed our retrograde cardioplegia catheter.  We oversewed that site with a 5-0 Prolene.  By now, the heart was de-aired and resumed normal electromechanical activity.  We began to wean the patient from cardiopulmonary bypass.  We then removed our venous cannula and suture ligated that site with a #2 silk.  We then gave full-dose protamine.  After knowing that there was no evidence of a protamine reaction, we removed the aortic cannula.  We buttressed that site with a 4-0 Prolene on an SH needle.  We placed a mediastinal chest tube and brought it out through the skin.  We also placed 2 Blake drains, 1 in the left chest and 1 in the right chest, as the patient had some bilateral pleural effusions.  They were brought out through the skin.  The sternum was closed with #7 wires in an interrupted figure-of-eight fashion.  The fascia was closed with #1 Vicryl.  We closed the subcu tissue with 2-0 Vicryl and the skin with 4-0 PDS.","cardiovascular / pulmonary, cardioplegia, toronto stentless porcine valve, tycron sutures, coronary ostia, porcine valve, retrograde cardioplegia, cardiopulmonary bypass, sutures, valve, insertion, toronto, aortic, stentless, chest, coronary, porcine, cardiopulmonary, prolene, atrial, bypass, heart, aorta,"
" Thrombosed left forearm loop fistula graft, chronic renal failure, and hyperkalemia.  Thrombectomy of the left forearm loop graft.  The venous outflow was good.  There was stenosis in the mid-venous limb of the graft.", Cardiovascular / Pulmonary, Thrombectomy ,"PREOPERATIVE DIAGNOSES:,1.  Thrombosed left forearm loop fistula graft.,2.  Chronic renal failure.,3.  Hyperkalemia.,POSTOPERATIVE DIAGNOSES:,1.  Thrombosed left forearm loop fistula graft.,2.  Chronic renal failure.,3.  Hyperkalemia.,PROCEDURE PERFORMED: , Thrombectomy of the left forearm loop graft.,ANESTHESIA: , Local with sedation.,ESTIMATED BLOOD LOSS: , Less than 5 cc.,COMPLICATIONS:, None.,OPERATIVE FINDINGS:,  The venous outflow was good.  There was stenosis in the mid-venous limb of the graft.,INDICATIONS: , The patient is an 81-year-old African-American female who presents with an occluded left forearm loop graft.  She was not able to have her dialysis as routine.  Her potassium was dramatically elevated at 7 the initial evening of anticipated surgery.  Both Surgery and Anesthesia thought this would be too risky to do.  Thus, she was given medications to decrease her potassium and a temporary hemodialysis catheter was placed in the femoral vein noted for her to have dialysis that night as well as this morning.  This morning her predialysis potassium was 6, and thus she was scheduled for surgery after her dialysis.,PROCEDURE: , The patient was taken to the operative suite and prepped and draped in the usual sterile fashion.  A transverse incision was made at the region of the venous anastomosis of the graft.  Further dissection was carried down to the catheter.  The vein appeared to be soft and without thrombus.  This outflow did not appear to be significantly impaired.  A transverse incision was made with a #11 blade on the venous limb of the graft near the anastomosis.  Next, a thrombectomy was done using a #4 Fogarty catheter.  Some of the clot and thrombus was removed from the venous limb.  The balloon did hang up in the multiple places along the venous limb signifying some degree of stenosis.  Once removing most of the clots from the venous limb prior to removing the plug, dilators were passed down the venous limb also indicating the area of stenosis.  At this point, we felt the patient would benefit from a curettage of the venous limb of the graft.  This was done and subsequent passes with the dilator and the balloon were then very easy and smooth following the curettage.  The Fogarty balloon was then passed beyond the clot and the plug.  The plug was visualized and inspected.  This also gave a good brisk bleeding from the graft.  The patient was heparinized and hep saline solution was injected into the venous limb and the angle vascular clamp was applied to the venous limb.  Attention was directed up to its anastomosis and the vein.  Fogarty balloon and thrombectomy was also performed well enough into this way.  There was good venous back bleeding following this.  The area was checked for any stenosis with the dilators and none was present.  Next, a #6-0 Prolene suture was used in a running fashion to close the graft.  Just prior to tying the suture, the graft was allowed to flush to move any debris or air.  The suture was also checked at that point for augmentation, which was good.  The suture was tied down and the wound was irrigated with antibiotic solution.  Next, a #3-0 Vicryl was used to approximate the subcutaneous tissues and a #4-0 undyed Vicryl was used in a running subcuticular fashion to approximate the skin edges.  Steri-Strips were applied and the patient was taken to recovery in stable condition.  She tolerated the procedure well.  She will be discharged from recovery when stable.  She is to resume her regular dialysis schedule and present for dialysis tomorrow.","cardiovascular / pulmonary, thrombosed, hyperkalemia, thrombectomy, forearm loop graft, venous outflow, chronic renal failure, venous limb, loop graft, forearm loop, limb, forearm, graft, venous, anastomosis, stenosis,"
" Thromboendarterectomy of right common, external, and internal carotid artery utilizing internal shunt and Dacron patch angioplasty closure.  Coronary artery bypass grafting x3 utilizing left internal mammary artery to left anterior descending, and reverse autogenous saphenous vein graft to the obtuse marginal, posterior descending branch of the right coronary artery.", Cardiovascular / Pulmonary, Thromboendarterectomy ,"OPERATIVE PROCEDURE,1.  Thromboendarterectomy of right common, external, and internal carotid artery utilizing internal shunt and Dacron patch angioplasty closure.,2.  Coronary artery bypass grafting x3 utilizing left internal mammary artery to left anterior descending, and reverse autogenous saphenous vein graft to the obtuse marginal, posterior descending branch of the right coronary artery.  Total cardiopulmonary bypass,cold blood potassium cardioplegia, antegrade and retrograde, for myocardial protection, placement of temporary pacing wires.,DESCRIPTION:,  The patient was brought to the operating room, placed in supine position.  Adequate general endotracheal anesthesia was induced.  Appropriate monitoring lines were placed.  The chest, abdomen and legs were prepped and draped in a sterile fashion.  The greater saphenous vein was harvested from the right upper leg through interrupted skin incisions and was prepared by ligating all branches with 4-0 silk and flushing with vein solution.  The leg was closed with running 3-0 Dexon subcu, and running 4-0 Dexon subcuticular on the skin, and later wrapped.  A median sternotomy incision was made and the left internal mammary artery was dissected free from its takeoff at the subclavian to its bifurcation at the diaphragm and surrounded with papaverine-soaked gauze.  The sternum was closed.  A right carotid incision was made along the anterior border of the sternocleidomastoid muscle and carried down to and through the platysma.  The deep fascia was divided.  The facial vein was divided between clamps and tied with 2-0 silk.  The common carotid artery, takeoff of the external and internal carotid arteries were dissected free, with care taken to identify and preserve the hypoglossal and vagus nerves.  The common carotid artery was double-looped with umbilical tape, takeoff of the external was looped with a heavy silk, distal internal was double-looped with a heavy silk.  Shunts were prepared.  A patch was prepared.  Heparin 50 mg was given IV.  Clamp was placed on the beginning of the takeoff of the external and the proximal common carotid artery.  Distal internal was held with a forceps.  Internal carotid artery was opened with 11-blade.  Potts scissors were then used to extend the aortotomy through the lesion into good internal carotid artery beyond.  The shunt was placed and proximal and distal snares were tightened.  Endarterectomy was carried out under direct vision in the common carotid artery and the internal reaching a fine, feathery distal edge using eversion on the external.  All loose debris was removed and Dacron patch was then sutured in place with running 6-0 Prolene suture, removing the shunt just prior to completing the suture line.  Suture line was completed and the neck was packed.,The pericardium was opened.  A pericardial cradle was created.  The patient was heparinized for cardiopulmonary bypass, cannulated with a single aortic and single venous cannula.  A retrograde cardioplegia cannula was placed with a pursestring of 4-0 Prolene into the coronary sinus, and secured to a Rumel tourniquet.  An antegrade cardioplegia needle sump was placed in the ascending aorta and cardiopulmonary bypass was instituted.  The ascending aorta was cross-clamped and cold blood potassium cardioplegia was given antegrade, a total of 5 cc per kg.  This was followed sumping of the ascending aorta and retrograde cardioplegia, a total of 5 cc per kg to the coronary sinus.  The obtuse marginal 1 coronary was identified and opened, and an end-to-side anastomosis was then performed with running 7-0 Prolene suture.  The vein was cut to length.  Antegrade and retrograde cold blood potassium cardioplegia was given.  The obtuse marginal 2 was not felt to be suitable for bypass, therefore, the posterior descending of the right coronary was identified and opened, and an end-to-side anastomosis was then performed with running 7-0 Prolene suture to reverse autogenous saphenous vein.  The vein was cut to length.  The mammary was clipped distally, divided and spatulated for anastomosis.  Antegrade and retrograde cold blood potassium cardioplegia was given.  The anterior descending was identified and opened. the mammary was then sutured to this with running 8-0 Prolene suture.  Warm blood potassium cardioplegia was given, and the cross-clamp was removed.  A partial-occlusion clamp was placed.  Two aortotomies were made.  The veins were cut to fit these and sutured in place with running 5-0 Prolene suture.  The partial- occlusion clamp was removed.  All anastomoses were inspected and noted to be patent and dry.  Atrial and ventricular pacing wires were placed.  Ventilation was commenced.  The patient was fully warmed.  The patient was weaned from cardiopulmonary bypass and de-cannulated in a routine fashion.  Protamine was given.  Good hemostasis was noted.  A single mediastinal chest tube and bilateral pleural Blake drains were placed.  The sternum was closed with figure-of-eight stainless steel wire, the linea alba with figure-of-eight #1 Vicryl, the sternal fascia with running #1 Vicryl, the subcu with running 2-0 Dexon and the skin with a running 4-0 Dexon subcuticular stitch.","cardiovascular / pulmonary, cabg, thromboendarterectomy, carotid artery, coronary artery bypass, mammary, obtuse, papaverine-soaked, running prolene suture, cardiopulmonary bypass, internal carotid, running prolene, prolene suture, carotid, sutured, artery, prolene, coronary, bypass, veinNOTE"
" Thrombectomy AV shunt, left forearm and patch angioplasty of the venous anastomosis.  Thrombosed arteriovenous shunt, left forearm with venous anastomotic stenosis.", Cardiovascular / Pulmonary, Thrombectomy AV Shunt ,"PREOPERATIVE DIAGNOSIS: , Thrombosed arteriovenous shunt left forearm.,POSTOPERATIVE DIAGNOSIS:  ,Thrombosed arteriovenous shunt, left forearm with venous anastomotic stenosis.,PROCEDURE:  ,Thrombectomy AV shunt, left forearm and patch angioplasty of the venous anastomosis.,ANESTHESIA: , Local.,SKIN PREP: , Betadine.,DRAINS: , None.,PROCEDURE TECHNIQUE:  ,The left arm was prepped and draped.  Xylocaine 1% was administered and a transverse antecubital incision was made over the venous limb of the graft, which was dissected out and encircled with a vessel loop.  The runoff vein was dissected out and encircled with the vessel loop as well.  A longitudinal incision was made over the venous anastomosis.  There was a narrowing in the area and slightly the incision was extended more proximally.  There was good back bleeding from the vein as well as bleeding from the more distal vein.  These were occluded with noncrushing DeBakey clamps and the patient was given 5000 units of heparin intravenously.  A #4 Fogarty was used to extract thrombus from the graft systematically until the arterial plug was removed and excellent inflow was established.  There was a narrowing in the mid portion of the venous limb of the graft, which was dilated with a #5 coronary dilator.  The Fogarty catheter was then passed up the vein, but no clot was obtained.  A patch PTFE material was fashioned and was sutured over the graftotomy with running 6-0 Gore-Tex suture.  Clamps were removed and flow established.  A thrill was easily palpable.  Hemostasis was achieved and the wound was irrigated and closed with 3-0 Vicryl subcutaneous suture followed by 4-0 nylon on the skin.  A sterile dressing was applied.  The patient was taken to the recovery room in satisfactory condition having tolerated the procedure well.  Sponge, instrument and needle counts were reported as correct.","cardiovascular / pulmonary, angioplasty, venous, anastomosis, patch angioplasty, av shunt, venous anastomosis, av, thrombectomy, thrombosed, arteriovenous, vein, forearm, shunt,"
 Left muscle sparing mini thoracotomy with left upper lobectomy and mediastinal lymph node dissection.  Intercostal nerve block for postoperative pain relief at five levels., Cardiovascular / Pulmonary, Thoracotomy & Lobectomy ,"PREOPERATIVE DIAGNOSES:,1.  Non-small-cell carcinoma of the left upper lobe.,2.  History of lymphoma in remission.,POSTOPERATIVE DIAGNOSES:,1.  Non-small-cell carcinoma of the left upper lobe.,2.  History of lymphoma in remission.,PROCEDURE: , Left muscle sparing mini thoracotomy with left upper lobectomy and mediastinal lymph node dissection.  Intercostal nerve block for postoperative pain relief at five levels.,INDICATIONS FOR THE PROCEDURE: , This is an 84-year-old lady who was referred by Dr. A for treatment of her left upper lobe carcinoma.  The patient has a history of lymphoma and is in remission.  An enlarged right axillary lymph node was biopsied recently and was negative for lymphoma.  A mass in the left upper lobe was biopsied with fine-needle aspiration and shown to be a primary non-small-cell carcinoma of the lung.  PET scan was, otherwise, negative for spread and resection was advised.  All the risk and benefits were fully explained to the patient and she elected to proceed as planned.  She was transferred to rehab for couple of weeks to buildup strength before the surgery.,PROCEDURE IN DETAIL:,  In the operating room under anesthesia, she was prepped and draped suitably.  Dr. B was the staff anesthesiologist.  Left muscle sparing mini thoracotomy was made.  The serratus and latissimus muscles were not cut but moved out to the way.  Access to the chest was obtained through the fifth intercostal space.  Two Tuffier retractors of right angles provided adequate exposure.,The inferior pulmonary ligament was not dissected free and lymph nodes from the station 9 were now sent for pathology.  The parietal pleural reflexion around the hilum was now circumcised, and lymph nodes were taken from station 8 and station 5.,The branches of the pulmonary artery to the upper lobe were now individually stapled with a 30/2.5 staple gun or/and the smaller one were ligated with 2-0 silk.  The left superior pulmonary vein was transected using a TA30/2.5 staple gun, and the fissure was completed using firings of an endo-GIA 60/4.8 staple gun.  Finally, the left upper lobe bronchus was transected using a TA30/4.8 staple gun.  Please note, that this patient had been somewhat unusual variant of a small bronchus that was coming out posterior to the main trunk of the pulmonary artery and supplying a small section of the posterior portion of the left upper lobe.,The specimen was delivered and sent to pathology.  The mass was clearly palpable in the upper portion of the lingular portion of this left upper lobe.  Frozen section showed that the margin was negative.,The chest was irrigated with warm sterile water and when the left lower lobe inflated, there was no air leak.  A single 32-French chest tube was inserted, and intercostal block was done with Marcaine infiltrated two spaces above and two spaces below thus achieving a block at five levels 30 mL of Marcaine was used all together.  A #2 Vicryl pericostal sutures were now applied.  The serratus and latissimus muscles retracted back in place.  A #19 French Blake drain placed in the subcutaneous tissues and 2-0 Vicryl used for the fat followed by 4-0 Monocryl for the skin.  The patient was transferred to the ICU in a stable condition.","cardiovascular / pulmonary, upper lobe, intercostal nerve block, non-small-cell carcinoma, axillary lymph node, endo-gia, latissimus, lobectomy, lymph node dissection, lymphoma, pulmonary vein, serratus, thoracotomy, muscle sparing mini thoracotomy, upper lobectomy, staple gun, intercostal,"
" Left thoracotomy with total pulmonary decortication and parietal pleurectomy.  Empyema of the chest, left.", Cardiovascular / Pulmonary, Thoracotomy & Pleurectomy ,"PREOPERATIVE DIAGNOSIS: , Empyema of the chest, left.,POSTOPERATIVE DIAGNOSIS: , Empyema of the chest, left.,PROCEDURE: , Left thoracotomy with total pulmonary decortication and parietal pleurectomy.,PROCEDURE DETAIL: , After obtaining the informed consent, the patient was brought to the operating room, where he underwent a general endotracheal anesthetic using a double-lumen endotracheal tube.  A time-out process had been followed and preoperative antibiotics were given.,The patient was positioned with the left side up for a left thoracotomy.  The patient was prepped and draped in the usual fashion.  A posterolateral thoracotomy was performed.  It included the previous incision.  The chest was entered through the fifth intercostal space.  Actually, there was a very strong and hard parietal pleura, which initially did not allow us to obtain a good exposure, and actually the layer was so tough that the pin of the chest retractor broke.  Thanks to Dr. X's ingenuity, we were able to reuse the chest retractor and opened the chest after I incised the thickened parietal pleura resulting in an explosion of gas and pus from a cavity that was obviously welled off by the parietal pleura.  We aspirated an abundant amount of pus from this cavity.  The sample was taken for culture and sensitivity.,Then, at least half an hour was spent trying to excise the parietal pleura and finally we were able to accomplish that up to the apex and back to the aorta __________ towards the heart including his diaphragm.  Once we accomplished that, we proceeded to remove the solid exudate that was adhered to the lung.  Further samples for culture and sensitivity were sent.,Then, we were left with the trapped lung.  It was trapped by thickened visceral pleura.  This was the most difficult part of the operation and it was very difficult to remove the parietal pleura without injuring the lung extensively.  Finally, we were able to achieve this and after the corresponding lumen of the endotracheal tube was opened, we were able to inflate both the left upper and lower lobes of the lung satisfactorily.  There was only one area towards the mediastinum that apparently I was not able to fill.  This area, of course, was very rigid but any surgery in the direction __________ would have caused __________ injury, so I restrained from doing that.  Two large chest tubes were placed.  The cavity had been abundantly irrigated with warm saline.  Then, the thoracotomy was closed in layers using heavy stitches of Vicryl as pericostal sutures and then several figure-of-eight interrupted sutures to the muscle layers and a combination of nylon stitches and staples to the skin.,The chest tubes were affixed to the skin with heavy sutures of silk.  Dressings were applied and the patient was put back in the supine position and after a few minutes of observation and evaluation, he was able to be extubated in the operating room.,Estimated blood loss was about 500 mL.  The patient tolerated the procedure very well and was sent to the ICU in a satisfactory condition.","cardiovascular / pulmonary, total pulmonary decortication, pulmonary decortication, parietal pleurectomy, endotracheal tube, chest retractor, chest tubes, parietal pleura, pleurectomy, empyema, endotracheal, thoracotomy, pleura, chest "
" Tilt table test.  Tilt table test is negative for any evidence of vasovagal, orthostasis or vasodepressor syndrome.", Cardiovascular / Pulmonary, Tilt Table Test ,"FINDINGS:,1.  The patient's supine blood pressure was 153/88 with heart rate of 54 beats per minute.,2.  There was no significant change in heart rate or blood pressure on 80-degree tilt.,3.  No symptoms reported during the tilt study.,CONCLUSION: , Tilt table test is negative for any evidence of vasovagal, orthostasis or vasodepressor syndrome.","cardiovascular / pulmonary, blood pressure, tilt table test, vasovagal, vasodepressor, orthostasisNOTE"
" Empyema.  Right thoracotomy, total decortication and intraoperative bronchoscopy.  A thoracostomy tube was placed at the bedside with only partial resolution of the pleural effusion.  On CT scan evaluation, there is evidence of an entrapped right lower lobe with loculations.", Cardiovascular / Pulmonary, Thoracotomy & Bronchoscopy ,"PREOPERATIVE DIAGNOSIS:,  Empyema.,POSTOPERATIVE DIAGNOSIS: , Empyema.,PROCEDURE PERFORMED:,1.  Right thoracotomy, total decortication.,2.  Intraoperative bronchoscopy.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  300 cc.,FLUIDS: , 2600 cc IV crystalloid.,URINE: , 300 cc intraoperatively.,INDICATIONS FOR PROCEDURE:  ,The patient is a 46-year-old Caucasian male who was admitted to ABCD Hospital since 08/14/03 with acute diagnosis of right pleural effusion.  A thoracostomy tube was placed at the bedside with only partial resolution of the pleural effusion.  On CT scan evaluation, there is evidence of an entrapped right lower lobe with loculations.  Decision was made to proceed with surgical intervention for a complete decortication and the patient understands the need for surgery and signed the preoperative informed consent.,OPERATIVE PROCEDURE: , The patient was taken to the operative suite and placed in the supine position under general anesthesia per Anesthesia Department.  Intraoperative bronchoscopy was performed by Dr. Y and evaluation of carina, left upper and lower lobes with segmental evidence of diffuse mucous, thick secretions which were thoroughly lavaged with sterile saline lavage.  Samples were obtained from both the left and the right subbronchiole segments for Gram stain cultures and ASP evaluation.  The right bronchus lower, middle, and upper were also examined and subsegmental bronchiole areas were thoroughly examined with no evidence of masses, lesions, or suspicious extrinsic compressions on the bronchi.  At this point, all mucous secretions were thoroughly irrigated and aspirated until the airways were clear.  Bronchoscope was then removed.  Vital signs remained stable throughout this portion of the procedure.  The patient was re-intubated by Anesthesia with a double lumen endotracheal tube.  At this point, the patient was repositioned in the left lateral decubitus position with protection of all pressure points and the table was extended in customary fashion.  At this point, the right chest was prepped and draped in the usual sterile fashion.  The chest tube was removed before prepping the patient and the prior thoracostomy site was cleansed thoroughly with Betadine.  The first port was placed through this incision intrathoracically.  A bronchoscope was placed for inspection of the intrathoracic cavity.  Pictures were taken.  There is extensive fibrinous exudate noted under parietal and visceral pleura, encompassing the lung surface, diaphragm, and the posterolateral aspect of the right thorax.  At this point, a second port site anteriorly was placed under direct visualization.  With the aid of the thoracoscopic view, a Yankauer resection device was placed in the thorax and blunt decortication was performed and aspiration of reminder of the pleural fluid.  Due to the gelatinous nature of the fibrinous exudate, there were areas of right upper lobe that adhered to the chest wall and the middle and lower lobes appeared entrapped.  Due to the extensive nature of the disease, decision was made to open the chest in a formal right thoracotomy fashion.  Incision was made.  The subcutaneous tissues were then electrocauterized down to the level of the latissimus dorsi, which was separated with electrocautery down to the anterior 6th rib space.  The chest cavity was entered with the right lung deflated per Anesthesia at our request.  Once the intrathoracic cavity was accessed, a thorough decortication was performed in meticulous systematic fashion starting with the right upper lobe, middle, and the right lower lobe.  With the expansion of the lung and reduction of the pleural surface fibrinous extubate, warm irrigation was used and the lungs allowed to re-expand.  There was no evidence of gross leakage or bleeding at the conclusion of surgery.,Full lung re-expansion was noted upon re-inflation of the lung.  Two #32 French thoracostomy tubes were placed, one anteriorly straight and one posteriorly on the diaphragmatic sulcus.  The chest tubes were secured in place with #0-silk sutures and placed on Pneumovac suction.  Next, the ribs were reapproximated with five interrupted CTX sutures and latissimus dorsi was then reapproximated with a running #2-0 Vicryl suture.  Next, subcutaneous skin was closed sequentially with a cosmetic layered subcutaneous closure.  Steri-Strips were applied along with sterile occlusive dressings.  The patient was awakened from anesthesia without difficulty and extubated in the operating room.  The chest tubes were maintained on Pleur-Evac suction for full re-expansion of the lung.  The patient was transported to the recovery with vital signs stable.  Stat portable chest x-ray is pending.  The patient will be admitted to the Intensive Care Unit for close monitoring overnight.","cardiovascular / pulmonary, empyema, total decortication, intraoperative bronchoscopy, intrathoracic cavity, fibrinous exudate, latissimus dorsi, chest tubes, pleural effusion, bronchoscopy, thoracostomy, thoracotomy, decortication, anesthesia, pleural,"
" Left thoracotomy with drainage of pleural fluid collection, esophageal exploration and repair of esophageal perforation, diagnostic laparoscopy and gastrostomy, and radiographic gastrostomy tube study with gastric contrast, interpretation.", Cardiovascular / Pulmonary, Thoracotomy & Esophageal Exploration ,"PREOPERATIVE DIAGNOSIS:  ,Esophageal rupture.,POSTOPERATIVE DIAGNOSIS:,  Esophageal rupture.,OPERATION PERFORMED,1.  Left thoracotomy with drainage of pleural fluid collection.,2.  Esophageal exploration and repair of esophageal perforation.,3.  Diagnostic laparoscopy and gastrostomy.,4.  Radiographic gastrostomy tube study with gastric contrast, interpretation.,ANESTHESIA: , General anesthesia.,INDICATIONS OF THE PROCEDURE: , The patient is a 47-year-old male with a history of chronic esophageal stricture who is admitted with food sticking and retching.  He has esophageal rupture on CT scan and comes now for a thoracotomy and gastrostomy.,DETAILS OF THE PROCEDURE: , After an extensive informed consent discussion process, the patient was brought to the operating room.  He was placed in a supine position on the operating table.  After induction of general anesthesia and placement of a double lumen endotracheal tube, he was turned and placed in a right lateral decubitus position on a beanbag with appropriate padding and axillary roll.  Left chest was prepped and draped in a usual sterile fashion.  After administration of intravenous antibiotics, a left thoracotomy incision was made, dissection was carried down to the subcutaneous tissues, muscle layers down to the fifth interspace.  The left lung was deflated and the pleural cavity entered.  The Finochietto retractor was used to help provide exposure.  The sixth rib was shingled in the posterior position and a careful expiration of the left pleural cavity was performed.,Immediately encountered was left pleural fluid including some purulent fluid.  Cultures of this were sampled and sent for microbiology analysis.  The left pleural space was then copiously irrigated.  A careful expiration demonstrated that the rupture appeared to be sealed.  There was crepitus within the mediastinal cavity.  The mediastinum was opened and explored and the esophagus was explored.  The tissues of the esophagus appeared to show some friability and an area of the rupture in the distal esophagus.  It was not possible to place any stitches in this tissue and instead a small intercostal flap was developed and placed to cover the area.  The area was copiously irrigated, this provided nice coverage and repair.  After final irrigation and inspection, two chest tubes were placed including a #36 French right angled tube at the diaphragm and a posterior straight #36 French.  These were secured at the left axillary line region at the skin level with #0-silk.,The intercostal sutures were used to close the chest wall with a #2 Vicryl sutures.  Muscle layers were closed with running #1 Vicryl sutures.  The wound was irrigated and the skin was closed with skin staples.,The patient was then turned and placed in a supine position.  A laparoscopic gastrostomy was performed and then a diagnostic laparoscopy performed.  A Veress needle was carefully inserted into the abdomen, pneumoperitoneum was established in the usual fashion, a bladeless 5-mm separator trocar was introduced.  The laparoscope was introduced.  A single additional left-sided separator trocar was introduced.  It was not possible to safely pass a nasogastric or orogastric tube, pass the stricture and perforation and so the nasogastric tube was left right at the level where there was some stricture or narrowing or resistance.  The stomach however did have some air insufflation and we were able to place our T-fasteners through the anterior abdominal wall and through the anterior gastric wall safely.  The skin incision was made and the gastric lumen was then accessed with the Seldinger technique.  Guide wire was introduced into the stomach lumen and series of dilators was then passed over the guide wire.  #18 French Gastrostomy was then passed into the stomach lumen and the balloon was inflated.  We confirmed that we were in the gastric lumen and the balloon was pulled up, creating apposition of the gastric wall and the anterior abdominal wall.  The T-fasteners were all crimped and secured into position.  As was in the plan, the gastrostomy was secured to the skin and into the tube.  Sterile dressing was applied.  Aspiration demonstrated gastric content.,Gastrostomy tube study, with interpretation.  Radiographic gastrostomy tube study with gastric contrast, with","cardiovascular / pulmonary, esophageal rupture, thoracotomy, drainage of pleural fluid, esophageal perforation, esophageal exploration, laparoscopy, gastrostomy, pleural fluid, diagnostic laparoscopy, radiographic gastrostomy, gastric lumen, gastrostomy tube, gastric contrast, gastric, interpretation, abdominal, pleural, lumen, esophageal, tube, "
" Left thoracoscopy and left thoracotomy with declaudication and drainage of lung abscesses, and multiple biopsies of pleura and lung.", Cardiovascular / Pulmonary, Thoracoscopy/Thoracotomy ,"PREOPERATIVE DIAGNOSES:,  Empyema of the left chest and consolidation of the left lung.,POSTOPERATIVE DIAGNOSES:,  Empyema of the left chest, consolidation of the left lung, lung abscesses of the left upper lobe and left lower lobe.,OPERATIVE PROCEDURE: , Left thoracoscopy and left thoracotomy with declaudication and drainage of lung abscesses, and multiple biopsies of pleura and lung.,ANESTHESIA:,  General.,FINDINGS: , The patient has a complex history, which goes back about four months ago when she started having respiratory symptoms and one week ago she was admitted to another hospital with hemoptysis and on her evaluation there which included two CAT scans of chest she was found to have marked consolidation of the left lung with a questionable lung abscess or cavity with hydropneumothorax.  There was also noted to be some mild infiltrates of the right lung.  The patient had a 30-year history of cigarette smoking.  A chest tube was placed at the other hospital, which produced some brownish fluid that had foul odor, actually what was thought to be a fecal-like odor.  Then an abdominal CT scan was done, which did not suggest any communication of the bowel into the pleural cavity or any other significant abnormalities in the abdomen on the abdominal CT.  The patient was started on antibiotics and was then taken to the operating room, where there was to be a thoracoscopy performed.  The patient had a flexible fiberoptic bronchoscopy that showed no endobronchial lesions, but there was bloody mucous in the left main stem bronchus and this was suctioned out.  This was suctioned out with the addition of the use of saline ***** in the bronchus.  Following the bronchoscopy, a double lumen tube was placed, but it was not possible to secure the double lumen to the place so we did not proceed with the thoracoscopy on that day.,The patient was transferred for continued evaluation and treatment.  Today, the double lumen tube was placed and there was some erythema of the mucosa noted in the airways in the bronchi and also remarkably bloody secretions were also noted.  These were suctioned, but it was enough to produce a temporary obstruction of the left mainstem bronchus.  Eventually, the double lumen tube was secured and an attempt at a left thoracoscopy was performed after the chest tube was removed and digital dissection was carried out through that.  The chest tube tract, which was about in the sixth or seventh intercostal space, but it was not possible to dissect enough down to get a acceptable visualization through this tract.  A second incision for thoracoscopy was made about on the sixth intercostal space in the midaxillary line and again some digital dissection was carried out but it was not enough to be able to achieve an opening or space for satisfactory inspection of the pleural cavity.  Therefore the chest was opened and remarkable findings included a very dense consolidation of the entire lung such that it was very hard and firm throughout.  Remarkably, the surface of the lower lobe laterally was not completely covered with a fibrotic line, but it was more the line anterior and posterior and more of it over the left upper lobe.  There were many pockets of purulent material, which had a gray-white appearance to it.  There was quite a bit of whitish fibrotic fibrinous deposit on the parietal pleura of the lung especially the upper lobe.  The adhesions were taken down and they were quite bloody in some areas indicating that the process had been present for some time.  There seemed to be an abscess that was about 3 cm in dimension, all the lateral basilar segment of the lower lobe near the area where the chest tube was placed.  Many cultures were taken from several areas.  The most remarkable finding was a large cavity, which was probably about 11 cm in dimension, containing grayish pus and also caseous-like material, it was thought to be perhaps necrotic lung tissue, perhaps a deposit related to tuberculosis in the cavity.,The apex of the lung was quite densely adhered to the parietal pleura there and the adhesions were quite thickened and firm.,PROCEDURE AND TECHNIQUE:,  With the patient lying with the right side down on the operating table the left chest was prepped and draped in sterile manner.  The chest tube had been removed and initially a blunt dissection was carried out through the old chest tube tract, but then it was necessary to enlarge it slightly in order to get the Thoracoport in place and this was done and as mentioned above we could not achieve the satisfactory visualization through this.  Therefore, the next incision for Thoracoport and thoracoscopy insertion through the port was over the sixth intercostal space and a little bit better visualization was achieved, but it was clear that we would be unable to complete the procedure by thoracoscopy.  Therefore posterolateral thoracotomy incision was made, entering the pleural space and what is probably the sixth intercostal space.  Quite a bit of blunt and sharp and electrocautery dissection was performed to take down adhesions to the set of the fibrinous deposit on the pleural cavity.  Specimens for culture were taken and specimens for permanent histology were taken and a frozen section of one of the most quite dense.  Suture ligatures of Prolene were required.  When the cavity was encountered it was due to some compression and dissection of some of the fibrinous deposit in the upper lobe laterally and anterior and this became identified as a very thin layer in one area over this abscess and when it was opened it was quite large and we unroofed it completely and there was bleeding down in the depths of the cavity, which appeared to be from pulmonary veins and these were sutured with a ""tissue pledget"" of what was probably intercostal nozzle and endothoracic fascia with Prolene sutures.,Also as the upper lobe was retracted in caudal direction the tissue was quite dense and the superior branch of the pulmonary artery on the left side was torn and for hemostasis a 14-French Foley catheter was passed into the area of the tear and the balloon was inflated, which helped establish hemostasis and suturing was carried out again with utilizing a small pledget what was probably intercostal muscle and endothoracic fascia and this was sutured in place and the Foley catheter was removed.  The patch was sutured onto the pulmonary artery tear.  A similar maneuver was utilized on the pulmonary vein bleeding site down deep in the cavity.  Also on the pulmonary artery repair some ***** material was used and also thrombin, Gelfoam and Surgicel.  After reasonably good hemostasis was established pleural cavity was irrigated with saline.  As mentioned, biopsies were taken from multiple sites on the pleura and on the edge and on the lung.  Then two #24 Blake chest tubes were placed, one through a stab wound above the incision anteriorly and one below and one in the inferior pleural space and tubes were brought out through stab wounds necked into the skin with 0 silk.  One was positioned posteriorly and the other anteriorly and in the cephalad direction of the apex.  These were later connected to water-seal suction at 40 cm of water with negative pressure.,Good hemostasis was observed.  Sponge count was reported as being correct.  Intercostal nerve blocks at probably the fifth, sixth, and seventh intercostal nerves was carried out.  Then the sixth rib had been broken and with retraction the fractured ends were resected and rongeur used to smooth out the end fragments of this rib.  Metallic clip was passed through the rib to facilitate passage of an intracostal suture, but the bone was partially fractured inferiorly and it was very difficult to get the suture out through the inner cortical table, so that pericostal sutures were used with #1 Vicryl.  The chest wall was closed with running #1 Vicryl and then 2-0 Vicryl subcutaneous and staples on the skin.  The chest tubes were connected to water-seal drainage with 40 cm of water negative pressure.  Sterile dressings were applied.  The patient tolerated the procedure well and was turned in the supine position where the double lumen endotracheal tube was switched out with single lumen.  The patient tolerated the procedure well and was taken to the intensive care unit in satisfactory condition.","cardiovascular / pulmonary, empyema, biopsies, bronchus, declaudication, endothoracic, hydropneumothorax, left lower lobe, left lung, left upper lobe, mainstem, pleura, thoracoscopy, thoracotomy, thoracotomy with declaudication, declaudication and drainage, double lumen tube, sixth intercostal space, lung abscesses, pleural cavity, intercostal space, upper lobe, double lumen, chest tube, cavity, tube, chest, lung, pulmonary, pleural, intercostal,"
" A 26-mm Dacron graft replacement of type 4 thoracoabdominal aneurysm from T10 to the bifurcation of the aorta, re-implanting the celiac, superior mesenteric artery and right renal as an island and the left renal as a 8-mm interposition Dacron graft, utilizing left heart bypass and cerebrospinal fluid drainage.", Cardiovascular / Pulmonary, Thoracoabdominal Aneurysm ,"POSTOPERATIVE DIAGNOSIS: , Type 4 thoracoabdominal aneurysm.,OPERATION/PROCEDURE: , A 26-mm Dacron graft replacement of type 4 thoracoabdominal aneurysm from T10 to the bifurcation of the aorta, re-implanting the celiac, superior mesenteric artery and right renal as an island and the left renal as a 8-mm interposition Dacron graft, utilizing left heart bypass and cerebrospinal fluid drainage.,DESCRIPTION OF PROCEDURE IN DETAIL: , Patient was brought to the operating room and put in supine position, and general endotracheal anesthesia was induced through a double-lumen endotracheal tube.  Patient was placed in the thoracoabdominal position with the left chest up and the hips back to a 30-degree angle.  The left groin, abdominal and chest were prepped and draped in a sterile fashion.  A thoracoabdominal incision was made.  The 8th interspace was entered.  The costal margin was divided.  The retroperitoneal space was entered and bluntly dissected free to the psoas, bringing all the peritoneal contents to the midline, exposing the aorta.  The inferior pulmonary ligament was then taken down so the aorta could be dissected free at the T10 level just above the diaphragm.  It was dissected free circumferentially.  The aortic bifurcation was dissected free, dissecting free both iliac arteries.  The left inferior pulmonary vein was then dissected free, and a pursestring of 4-0 Prolene was placed on this.  The patient was heparinized.  Through a stab wound in the center of this, a right-angle venous cannula was then placed at the left atrium and secured to a Rumel tourniquet.  This was hooked to a venous inflow of left heart bypass machine.  A pursestring of 4-0 Prolene was placed on the aneurysm and through a stab wound in the center of this, an arterial cannula was placed and hooked to outflow.  Bypass was instituted.  The aneurysm was cross clamped just above T10 and also, cross clamped just below the diaphragm.  The area was divided at this point.  A 26-mm graft was then sutured in place with running 3-0 Prolene suture.  The graft was brought into the diaphragm.  Clamps were then placed on the iliacs, and the pump was shut off.  The aorta was opened longitudinally, going posterior between the left and right renal arteries, and it was completely transected at its bifurcation.  The SMA, celiac and right renal artery were then dissected free as a complete island, and the left renal was dissected free as a complete Carrell patch.  The island was laid in the graft for the visceral liner, and it was sutured in place with running 4-0 Prolene suture with pledgetted 4-0 Prolene sutures around the circumference.  The clamp was then moved below the visceral vessels, and the clamp on the chest was removed, re-establishing flow to the visceral vessels.  The graft was cut to fit the bifurcation and sutured in place with running 3-0 Prolene suture.  All clamps were removed, and flow was re-established.  An 8-mm graft was sutured end-to-end to the Carrell patch and to the left renal.  A partial-occlusion clamp was placed.  An area of graft was removed.  The end of the graft was cut to fit this and sutured in place with running Prolene suture.  The partial-occlusion clamp was removed.  Protamine was given.  Good hemostasis was noted.  The arterial cannula, of course, had been removed when that part of the aneurysm was removed.  The venous cannula was removed and oversewn with a 4-0 Prolene suture.  Good hemostasis was noted.  A 36 French posterior and a 32 French anterior chest tube were placed.  The ribs were closed with figure-of-eight #2 Vicryl.  The fascial layer was closed with running #1 Prolene, subcu with running 2-0 Dexon and the skin with running 4-0 Dexon subcuticular stitch.  Patient tolerated the procedure well.","cardiovascular / pulmonary, dacron graft, thoracoabdominal, cerebrospinal, thoracoabdominal aneurysm, running prolene, prolene suture, dissected free, graft, interposition, aneurysm, dacron, cannula, bifurcation, aorta, endotracheal, proleneNOTE"
" Left mesothelioma, focal.  Left anterior pleural-based nodule, which was on a thin pleural pedicle with no invasion into the chest wall.", Cardiovascular / Pulmonary, Thoracoscopy & Thoracotomy - Mesothelioma ,"PREOPERATIVE DIAGNOSIS: , Left mesothelioma, focal.,POSTOPERATIVE DIAGNOSIS: , Left pleural-based nodule.,PROCEDURES PERFORMED:,1.  Left thoracoscopy.,2.  Left mini thoracotomy with resection of left pleural-based mass.,FINDINGS:,  Left anterior pleural-based nodule, which was on a thin pleural pedicle with no invasion into the chest wall.,FLUIDS: , 800 mL of crystalloid.,ESTIMATED BLOOD LOSS: , Minimal.,DRAINS, TUBES, CATHETERS: , 24-French chest tube in the left thorax plus Foley catheter.,SPECIMENS: , Left pleural-based nodule.,INDICATION FOR OPERATION:  ,The patient is a 59-year-old female with previous history of follicular thyroid cancer, approximately 40 years ago, status post resection with recurrence in the 1980s, who had a left pleural-based mass identified on chest x-ray.  Preoperative evaluation included a CT scan, which showed focal mass.  CT and PET confirmed anterior lesion.  Therefore the patient was seen in our thoracic tumor board where it was recommended to have resection performed with chest wall reconstruction.  In the outpatient setting, the patient was willing to proceed.,PROCEDURE PERFORMED IN DETAIL: , After informed consent was obtained, the patient identified correctly.  She was taken to the operating room where an epidural catheter was placed by Anesthesia without difficulty.  She was sedated and intubated with double-lumen endotracheal tube without difficulty.  She was positioned with left side up.  Appropriate pressure points were padded.  The left chest was prepped and draped in the standard surgical fashion.  The skin incision was made in the posterior axillary line, approximately 7th intercostal space with #10 blade, taken down through tissues and Bovie electrocautery.,Pleura was entered.  There was good deflation of the left lung.  __________ port was placed, followed by the 0-degree 10-mm scope with appropriate patient positioning.  Posteriorly a pedunculated 2.5 x 3-cm pleural-based mass was identified on the anterior chest wall.  There were thin adhesions to the pleura, but no invasion of the chest wall that could be identified.  The tumor was very mobile and was on a pedunculated stalk, approximately 1.5 cm.  It was felt that this could be resected without the need of chest wall reconstruction because of the narrow stalk.,Therefore a 2nd port was placed in the anterior axillary line approximately 8th intercostal space in the usual fashion.  Camera was placed through this port.  Laparoscopic scissors were placed through the posterior port, but it was necessary to have another instrument to provide more tension than just gravity.  Therefore because of the need to bring the specimen through the chest wall, a small 3-cm thoracotomy was made, which incorporated the posterior port site.  This was taken down to the subcutaneous tissue with Bovie electrocautery.  Periosteal elevator was used to lift the intercostal muscle off.  The ribs were not spread.  Through this 3-cm incision, both the laparoscopic scissors as well as Prestige graspers could be placed.  Prestige graspers were used to pull the specimen from the chest wall.  Care was taken not to injure the capsule.  The laparoscopic scissors on cautery were used to resect the parietal pleural off of the chest wall.  Care was taken not to transect the stalk.  Specimen came off the chest wall very easily.  There was good hemostasis.,At this point, the EndoCatch bag was placed through the incision.  Specimen was placed in the bag and then removed from the field.  There was good hemostasis.  Camera was removed.  A 24-French chest tube was placed through the anterior port and secured with 2-0 silk suture.  The posterior port site was closed 1st with 2-0 Vicryl in a running fashion for the intercostal muscle layer, followed by 2-0 closure of the latissimus fascia as well as subdermal suture, 4-0 Monocryl was used for the skin, followed by Steri-Strips and sterile drapes.  The patient tolerated the procedure well, was extubated in the operating room and returned to the recovery room in stable condition.","cardiovascular / pulmonary, mini thoracotomy, pleural based mass, pleural based nodule, chest wall, mesothelioma focal, pleural, chest, thoracotomy, mesothelioma, laparoscopic, thoracoscopy, "
" The patient was originally hospitalized secondary to dizziness and disequilibrium.  Extensive workup during her first hospitalization was all negative, but a prominent feature was her very blunted affect and real anhedonia.", Cardiovascular / Pulmonary, Telemetry Monitoring ,"DIAGNOSES PROBLEMS:,1.  Orthostatic hypotension.,2.  Bradycardia.,3.  Diabetes.,4.  Status post renal transplant secondary polycystic kidney disease in 1995.,5.  Hypertension.,6.  History of basal cell ganglia cerebrovascular event in 2004 with left residual.,7.  History of renal osteodystrophy.,8.  Iron deficiency anemia.,9.  Cataract status post cataract surgery.,10.  Chronic left lower extremity pain.,11.  Hyperlipidemia.,12.  Status post hysterectomy secondary to uterine fibroids.,PROCEDURES:,  Telemetry monitoring.,HISTORY FINDINGS HOSPITAL COURSE: , The patient was originally hospitalized on 04/26/07, secondary to dizziness and disequilibrium.  Extensive workup during her first hospitalization was all negative, but a prominent feature was her very blunted affect and real anhedonia.  She was transferred briefly to Psychiatry, however, on the second day in Psychiatry, she became very orthostatic and was transferred acutely back to the medicine.  She briefly was on Cymbalta; however, this was discontinued when she was transferred back.  She was monitored back medicine for 24 hours and was given intravenous fluids and these were discontinued.  She was able to maintain her pressures then was able to ambulate without difficulty.  We had wanted to pursue workup for possible causes for autonomic dysfunction; however, the patient was not interested in remaining in the hospital anymore and left really against our recommendations.,DISCHARGE MEDICATIONS:,1.  CellCept - 500 mg twice a daily.,2.  Cyclosporine - 25 mg in the morning and 15 mg in the evening.,3.  Prednisone - 5 mg once daily.,4.  Hydralazine - 10 mg four times a day.,5.  Pantoprazole - 40 mg once daily.,6.  Glipizide - 5 mg every morning.,7.  Aspirin - 81 mg once daily.,FOLLOWUP CARE:  ,The patient is to follow up with Dr. X in about 1 week's time.","cardiovascular / pulmonary, orthostatic hypotension, bradycardia, basal cell ganglia cerebrovascular event, renal osteodystrophy, dizziness, disequilibrium, telemetry monitoring, "
 Insertion of right internal jugular Tessio catheter and placement of left wrist primary submental arteriovenous fistula., Cardiovascular / Pulmonary, Tessio Catheter Insertion ,"OPERATIONS/PROCEDURES,1.  Insertion of right internal jugular Tessio catheter.,2.  Placement of left wrist primary submental arteriovenous fistula.,PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed in the supine position.  Adequate general endotracheal anesthesia was induced.  Appropriate monitoring lines were placed.  The right neck, chest and left arm were prepped and draped in a sterile fashion.  A small incision was made at the top of the anterior jugular triangle in the right neck.  Through this small incision, the right internal jugular vein was punctured and a guidewire was placed.  It was punctured a 2nd time, and a 2nd guidewire was placed.  The Tessio catheters were assembled.  They were measured for length.  Counter-incisions were made on the right chest.  They were then tunneled through these lateral chest wall incisions to the neck incision, burying the Dacron cuffs.  They were flushed with saline.  A suture was placed through the guidewire, and the guidewire and dilator were removed.  The arterial catheter was then placed through this, and the tear-away introducer was removed.  The catheter aspirated and bled easily.  It was flushed with saline and capped.  This was repeated with the venous line.  It also aspirated easily and was flushed with saline and capped.  The neck incision was closed with a 4-0 Tycron, and the catheters were sutured at the exit sites with 4-0 nylon.  Dressings were applied.  An incision was then made at the left wrist.  The basilic vein was dissected free, as was the radial artery.  Heparin was given, 50 mg.  The radial artery was clamped proximally and distally with a bulldog.  It was opened with a #11 blade and Potts scissors, and stay sutures of 5-0 Prolene were placed.  The vein was clipped distally, divided and spatulated for anastomosis.  It was sutured to the radial artery with a running 7-0 Prolene suture.  The clamps were removed.  Good flow was noted through the artery.  Protamine was given, and the wound was closed with interrupted 3-0 Dexon subcutaneous and a running 4-0 Dexon subcuticular on the skin.  The patient tolerated the procedure well.","cardiovascular / pulmonary, internal jugular tessio catheter, arteriovenous, fistula, submental, tunneled, tessio catheter, internal jugular, radial artery, tessio, jugular, artery, catheterNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Thoracentesis.  Left pleural effusion.  Left hemothorax., Cardiovascular / Pulmonary, Thoracentesis ,"PREOPERATIVE DIAGNOSIS:,  Left pleural effusion.,POSTOPERATIVE DIAGNOSIS:,  Left hemothorax.,PROCEDURE: , Thoracentesis.,PROCEDURE IN DETAIL:,  After obtaining informed consent and having explained the procedure to the patient, he was sat at the side of a stretcher in the emergency department.  His left back was prepped and draped in the usual fashion.  Xylocaine 1% was used to infiltrate his chest wall and the chest entered upon the ninth intercostal space in the midscapular line and the thoracentesis catheter was used and placed, and then we proceed to draw by hand about 1200 mL blood.  This blood was nonclotting and it was tested twice.  Halfway during the procedure, the patient felt that he was getting dizzy and his pressure at that time had dropped to the 80s.  Therefore, we laid him off his right side while keeping the chest catheter in place.  At that time, I proceeded to continuously draw fluids slowly and then when the patient recovered we sat him up again and we proceed to complete the procedure.,Overall besides the described episode, the patient tolerated the procedure well and afterwards, we took another chest x-ray that showed much improvement in the pleural effusion and at that particular time, with all the history we proceeded to admit the patient for observation and with an idea to obtain a CT in the morning to see whether the patient would need an pigtail intrapleural catheter or not.","cardiovascular / pulmonary, pleural effusion, hemothorax, thoracentesis, chest,"
 Quick note on tachypnea., Cardiovascular / Pulmonary, Tachypnea ,,"cardiovascular / pulmonary, chest, cpr, breath sounds, tachypnea, epinephrine, rhythmNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Thoracentesis, left.   Malignant pleural effusion, left, with dyspnea.", Cardiovascular / Pulmonary, Thoracentesis - 1 ,"PREOPERATIVE DIAGNOSIS: , Malignant pleural effusion, left, with dyspnea.,POSTOPERATIVE DIAGNOSIS: , Malignant pleural effusion, left, with dyspnea.,PROCEDURE:  ,Thoracentesis, left.,DESCRIPTION OF PROCEDURE: , The patient was brought to the recovery area of the operating room.  After obtaining the informed consent, the patient's posterior left chest wall was prepped and draped in usual fashion.  Xylocaine 1% was infiltrated above the seventh intercostal space in the midscapular line.  Initially, I tried to use the thoracentesis set after 1% Xylocaine had been infiltrated, but the needle of the system was just too short to reach the pleural cavity due to the patient's very thick chest wall.  Therefore, I had to use a #18 spinal needle, which I had to use almost in its entire length to reach the fluid.  From then on, I proceeded manually to withdraw 2000 mL of a light milky fluid.,The patient tolerated the procedure fairly well, but almost at the end of it she said that she was feeling like fainting and therefore we carefully withdrew the needle.  At that time, it was getting difficult to withdraw fluid anyway and we allowed her to lie down and after a few minutes the patient was feeling fine.  At any rate, we gave her bolus of 250 mL of normal saline and the patient returned to her room for additional hours of observation.  We then thought that if she was doing fine, then we will send her home.,A chest x-ray was performed after the procedure which showed a dramatic reduction of the amount of pleural fluid and then there was no pneumothorax or no other obvious complications of her procedure.,","cardiovascular / pulmonary, malignant pleural effusion, chest wall, pleural effusion, dyspnea, thoracentesis, fluid, pleural, "
 Insertion of a left subclavian Tesio hemodialysis catheter and surgeon-interpreted fluoroscopy., Cardiovascular / Pulmonary, Tesio Hemodialysis Catheter Insertion ,"OPERATION,1.  Insertion of a left subclavian Tesio hemodialysis catheter.,2.  Surgeon-interpreted fluoroscopy.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and MAC anesthesia was administered.  Next, the patient's chest and neck were prepped and draped in the standard surgical fashion.  Lidocaine 1% was used to infiltrate the skin in the region of the procedure.  Next a #18-gauge finder needle was used to locate the left subclavian vein.  After aspiration of venous blood, Seldinger technique was used to thread a J wire through the needle.  This process was repeated.  The 2 J wires and their distal tips were confirmed to be in adequate position with surgeon-interpreted fluoroscopy.  Next, the subcutaneous tunnel was created.  The distal tips of the individual Tesio hemodialysis catheters were pulled through to the level of the cuff.  A dilator and sheath were passed over the individual J wires.  The dilator and wire were removed, and the distal tip of the Tesio hemodialysis catheter was threaded through the sheath, which was simultaneously withdrawn.  The process was repeated.  Both distal tips were noted to be in good position.  The Tesio hemodialysis catheters were flushed and aspirated without difficulty.  The catheters were secured at the cuff level with a 2-0 nylon.  The skin was closed with 4-0 Monocryl.  Sterile dressing was applied.  The patient tolerated the procedure well and was transferred to the PACU in good condition.","cardiovascular / pulmonary, needle, tesio hemodialysis catheter, hemodialysis catheter, fluoroscopy, catheters, catheter, tesio, hemodialysisNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 The patient was undergoing a routine physical examination and was found to have right supraclavicular lymphadenopathy.  She returned for followup examination and again was noted to have right supraclavicular lymphadenopathy.  She is now referred to the thoracic surgery clinic for evaluation., Cardiovascular / Pulmonary, Supraclavicular Lymphadenopathy ,"On review of systems, the patient admits to hypertension and occasional heartburn.  She undergoes mammograms every six months, which have been negative for malignancy.  She denies fevers, chills, weight loss, fatigue, diabetes mellitus, thyroid disease, upper extremity trauma, night sweats, DVT, pulmonary embolism, anorexia, bone pain, headaches, seizures, angina, peripheral edema, claudication, orthopnea, PND, coronary artery disease, rheumatoid arthritis, rashes, upper extremity edema, cat scratches, cough, hemoptysis, shortness of breath, dyspnea at two flights of stairs, hoarseness, GI bleeding, change in bowel habits, dysphagia, ulcers, hematuria, or history of TB exposure.  She has had negative PPD.,PAST MEDICAL HISTORY:,  Hypertension.,PAST SURGICAL HISTORY:,  Right breast biopsy - benign.,SOCIAL HISTORY: , She was born and raised in Baltimore.  She has not performed farming or kept birds or cats.,Tobacco: None.,Ethanol: ,Drug Use: ,Occupation:  She is a registered nurse at Spring Grove Hospital.,Exposure: Negative to asbestos.,FAMILY HISTORY:,  Mother with breast cancer.,ALLERGIES: , Percocet and morphine causing temporary hypotension.,MEDICATIONS: , Caduet 10 mg p.o. q.d., Coreg CR 40 mg p.o. q.d., and Micardis HCT 80 mg/12.5 mg p.o. q.d.,PHYSICAL EXAMINATION: ,BP:  133/72",
 The patient is a 4-month-old who presented with supraventricular tachycardia and persistent cyanosis., Cardiovascular / Pulmonary, Supraventricular Tachycardia - Consult ,"HISTORY: , The patient is a 4-month-old who presented today with supraventricular tachycardia and persistent cyanosis.  The patient is a product of a term pregnancy that was uncomplicated and no perinatal issues are raised.  Parents; however, did note the patient to be quite dusky since the time of her birth; however, were reassured by the pediatrician that this was normal.  The patient demonstrates good interval weight gain and only today presented to an outside hospital with significant duskiness, some irritability, and rapid heart rate.  Parents do state that she does appear to breathe rapidly, tires somewhat with the feeding with increased respiratory effort and diaphoresis.  The patient is exclusively breast fed and feeding approximately 2 hours.  Upon arrival at Children's Hospital, the patient was found to be in a narrow complex tachycardia with the rate in excess of 258 beats per minute with a successful cardioversion to sinus rhythm with adenosine.  The electrocardiogram following the cardioversion had demonstrated normal sinus rhythm with a right atrial enlargement, northwest axis, and poor R-wave progression, possible right ventricular hypertrophy.,FAMILY HISTORY:,  Family history is remarkable for an older sibling found to have a small ventricular septal defect that is spontaneously closed.,REVIEW OF SYSTEMS: , A complete review of systems including neurologic, respiratory, gastrointestinal, genitourinary are otherwise negative.,PHYSICAL EXAMINATION:,GENERAL:  Physical examination that showed a sedated, acyanotic infant who is in no acute distress.,VITAL SIGNS:  Heart rate of 170, respiratory rate of 65, saturation, it is nasal cannula oxygen of 74% with a prostaglandin infusion at 0.5 mcg/kg/minute.,HEENT:  Normocephalic with no bruit detected.  She had symmetric shallow breath sounds clear to auscultation.  She had full symmetrical pulses.,HEART:  There is normoactive precordium without a thrill.  There is normal S1, single loud S2, and a 2/6 continuous shunt type of murmur could be appreciated at the left upper sternal border.,ABDOMEN:  Soft.  Liver edge is palpated at 3 cm below the costal margin and no masses or bruits detected.,X-RAYS:,  Review of the chest x-ray demonstrated a normal situs, normal heart size, and adequate pulmonary vascular markings.  There is a prominent thymus.  An echocardiogram demonstrated significant cyanotic congenital heart disease consisting of normal situs, a left superior vena cava draining into the left atrium, a criss-cross heart with atrioventricular discordance of the right atrium draining through the mitral valve into the left-sided morphologic left ventricle.  The left atrium drained through the tricuspid valve into a right-sided morphologic right ventricle.  There is a large inlet ventricular septal defect as pulmonary atresia.  The aorta was malopposed arising from the right ventricle in the anterior position with the left aortic arch.  There was a small vertical ductus as a sole source of pulmonary artery blood flow.  The central pulmonary arteries appeared confluent although small measuring 3 mm in the diameter.  Biventricular function is well maintained.,FINAL IMPRESSION: , The patient has significant cyanotic congenital heart disease physiologically with a single ventricle physiology and ductal-dependent pulmonary blood flow and the incidental supraventricular tachycardia now in the sinus rhythm with adequate ventricular function.  The saturations are now also adequate on prostaglandin E1.,RECOMMENDATION: , My recommendation is that the patient be continued on prostaglandin E1.  The patient's case was presented to the cardiothoracic surgical consultant, Dr. X.  The patient will require further echocardiographic study in the morning to further delineate the pulmonary artery anatomy and confirm the central confluence.  A consideration will be made for diagnostic cardiac catheterization to fully delineate the pulmonary artery anatomy prior to surgical intervention.  The patient will require some form of systemic to pulmonary shunt, modified pelvic shunt or central shunt as a durable source of pulmonary blood flow.  Further surgical repair was continued on the size and location of the ventricular septal defect over the course of the time for consideration of possible Rastelli procedure.  The current recommendation is for proceeding with a central shunt and followed then by bilateral bidirectional Glenn shunt with then consideration for a septation when the patient is 1 to 2 years of age.  These findings and recommendations were reviewed with the parents via a Spanish interpreter.","cardiovascular / pulmonary, congenital heart disease, cyanotic, ductal-dependent, pulmonary blood flow, ventricular septal defect, blood flow, supraventricular tachycardia, tachycardia, ventricular, supraventricular, shunt, heart, pulmonary,"
" Subxiphoid pericardiotomy.  Symptomatic pericardial effusion.  The patient had the appropriate inflammatory workup for pericardial effusion, however, it was nondiagnostic.", Cardiovascular / Pulmonary, Subxiphoid Pericardiotomy ,"PREOPERATIVE DIAGNOSIS: , Symptomatic pericardial effusion.,POSTOPERATIVE DIAGNOSIS: , Symptomatic pericardial effusion.,PROCEDURE PERFORMED:,  Subxiphoid pericardiotomy.,ANESTHESIA:,  General via ET tube.,ESTIMATED BLOOD LOSS: , 50 cc.,FINDINGS:,  This is a 70-year-old black female who underwent a transhiatal esophagectomy in November of 2003.  She subsequently had repeat chest x-rays and CT scans and was found to have a moderate pericardial effusion.  She had the appropriate inflammatory workup for pericardial effusion, however, it was nondiagnostic.  Also, during that time, she had become significantly more short of breath.  A dobutamine stress echocardiogram was performed, which was negative with the exception of the pericardial effusions.  She had no tamponade physiology.,INDICATION FOR THE PROCEDURE: , For therapeutic and diagnostic management of this symptomatic pericardial effusion.  Risks, benefits, and alternative measures were discussed with the patient.  Consent was obtained for the above procedure.,PROCEDURE: , The patient was prepped and draped in the usual sterile fashion.  A 4 cm incision was created in the midline above the xiphoid.  Dissection was carried down through the fascia and the xiphoid was resected.  The sternum was retracted superiorly the pericardium was identified and pericardial fat was cleared off the pericardium.  An #0 silk suture was then placed into the pericardium with care taken not to enter the underlying heart.,This suture was used to retract the pericardium and the pericardium was nicked with #15 blade under direct visualization.  Serous fluid exited through the pericardium and was sent for culture, cytology, and cell count etc.  A section of pericardium was taken approximately 2 cm x 2 cm x 2 cm and was removed.  The heart was visualized and appeared to be contracting well with no evidence of injury to the heart.  The pericardium was then palpated.  There was no evidence of studding.  A right angle chest tube was then placed in the pericardium along the diaphragmatic of the pericardium and then brought out though a small skin incision in the epigastrium.  It was sewn into place with #0 silk suture.  There was some air leak of the left pleural cavity, so a right angle chest tube was placed in the left pleural cavity and brought out through a skin nick in the epigastrium.  It was sewn in the similar way to the other chest tube.  Once again, the area was inspected and found to be hemostatic and then closed with #0 Vicryl suture for fascial stitch, then #3-0 Vicryl suture in the subcutaneous fat, and then #4-0 undyed Vicryl in a running subcuticular fashion.  The patient tolerated the procedure well.  Chest tubes were placed on 20 cm of water suction.  The patient was taken to PACU in stable condition.","cardiovascular / pulmonary, subxiphoid pericardiotomy, symptomatic pericardial effusion, chest x-rays, echocardiogram, dobutamine, pleural cavity, chest tube, pericardial effusion, pericardium, inflammatory, subxiphoid, pericardiotomy, heart, chest, effusion, pericardial"
" Emergent subxiphoid pericardial window, transesophageal echocardiogram.", Cardiovascular / Pulmonary, Subxiphoid Pericardial Window ,"PREOPERATIVE DIAGNOSIS (ES):,1. Endocarditis.,2. Status post aortic valve replacement with St. Jude mechanical valve.,3. Pericardial tamponade.,POSTOPERATIVE DIAGNOSIS (ES):,1. Endocarditis.,2. Status post aortic valve replacement with St. Jude mechanical valve.,3. Pericardial tamponade.,PROCEDURE:,1. Emergent subxiphoid pericardial window.,2. Transesophageal echocardiogram.,ANESTHESIA:, General endotracheal.,FINDINGS:, The patient was noted to have 600 mL of dark bloody fluid around the pericardium. We could see the effusion resolve on echocardiogram. The aortic valve appeared to have good movement in the leaflets with no perivalvular leaks. There was no evidence of endocarditis. The mitral valve leaflets moved normally with some mild mitral insufficiency.,DESCRIPTION OF THE OPERATION:, The patient was brought to the operating room emergently. After adequate general endotracheal anesthesia, his chest was prepped and draped in the routine sterile fashion. A small incision was made at the bottom of the previous sternotomy incision. The subcutaneous sutures were removed. The dissection was carried down into the pericardial space. Blood was evacuated without any difficulty. Pericardial Blake drain was then placed. The fascia was then reclosed with interrupted Vicryl sutures. The subcutaneous tissues were closed with a running Monocryl suture. A subdermal PDS followed by a subcuticular Monocryl suture were all performed. The wound was closed with Dermabond dressing. The procedure was terminated at this point. The patient tolerated the procedure well and was returned back to the intensive care unit in stable condition.","cardiovascular / pulmonary, endocarditis, valve replacement, st. jude, echocardiogram, transesophageal, pericardium, blake drain, st jude mechanical valve, subxiphoid pericardial window, pericardial window, aortic valve, tamponade, subxiphoid, valve, pericardial, aortic"
" Chest pain,  Chest wall tenderness occurred with exercise.", Cardiovascular / Pulmonary, Stress Test Graded Exercise Treadmill ,"INDICATIONS:,  Chest pain.,PROCEDURE DONE:,  Graded exercise treadmill stress test.,STRESS ECG RESULTS:,  The patient was stressed by continuous graded treadmill testing for nine minutes of the standard Bruce protocol.  The heart rate increased from 68 beats per minute to 178 beats per minute, which is 100% of the maximum predicted target heart rate.  The blood pressure increased from 120/70 to 130/80.  The baseline resting electrocardiogram reveals a regular sinus rhythm.  The tracing is within normal limits.  Symptoms of chest pain occurred with exercise.  The pain persisted during the recovery process and was aggravated by deep inspiration.  Marked chest wall tenderness noted.  There were no ischemic ST segment changes seen during exercise or during the recovery process.,CONCLUSIONS,:,1.  Stress test is negative for ischemia.,2.  Chest wall tenderness occurred with exercise.,3.  Blood pressure response to exercise is normal.","cardiovascular / pulmonary, stress test, blood pressure, bruce protocol, chest pain, graded exercise, graded exercise treadmill, electrocardiogram, ischemia, sinus rhythm, treadmill, chest wall tenderness, chest wall, stress, chest, "
" Insertion of right subclavian central venous catheter.   Need for intravenous access, status post fall, and status post incision and drainage of left lower extremity.", Cardiovascular / Pulmonary, Subclavian Central Venous Catheter Insertion ,"PREOPERATIVE DIAGNOSES:,1.  Need for intravenous access.,2.  Status post fall.,3.  Status post incision and drainage of left lower extremity.,POSTOPERATIVE DIAGNOSES:,1.  Need for intravenous access.,2.  Status post fall.,3.  Status post incision and drainage of left lower extremity.,PROCEDURE PERFORMED: , Insertion of right subclavian central venous catheter.,SECOND ANESTHESIA: , Approximately 10 cc of 1% lidocaine.,ESTIMATED BLOOD LOSS: , Minimal.,INDICATIONS FOR PROCEDURE:  ,The patient is a 74-year-old white female who presents to ABCD General Hospital after falling down flight of eleven stairs and sustained numerous injuries.  The patient went to OR today for an I&D of left lower extremity degloving injury.  Orthopedics was planning on taking the patient back for serial debridements and need for reliable IV access is requested.,PROCEDURE: , Informed consent was obtained by the patient and her daughter.  All risks and benefits of the procedure were explained and all questions were answered.  The patient was prepped and draped in the normal sterile fashion.  After landmarks were identified, approximately 5 cc of 1% lidocaine were injected into the skin and subcuticular tissues and the right neck posterior head of the sternocleidomastoid.  Locator needle was used to correctly cannulate the right internal jugular vein.  Multiple attempts were made and the right internal jugular vein was unable to be cannulized.,Therefore, we prepared for a right subclavian approach.  The angle of the clavicle was found and a #22 gauge needle was used to anesthetize approximately 5 cc of 1% lidocaine in skin and subcuticular tissues along with the periosteum of the clavicle.  A Cook catheter needle was then placed and ________ the clavicle in the orientation aimed toward the sternal notch.  The right subclavian vein was then accessed.  A guidewire was placed with a Cook needle and then the needle was subsequently removed and a #11 blade scalpel was used to nick the skin.  A dilator sheath was placed over the guidewire and subsequently removed.  The triple lumen catheter was then placed over the guidewire and advanced to 14 cm.  All ports aspirated and flushed.  Good blood return was noted and all ports were flushed well.  The triple lumen catheter was then secured at 14 cm using #0 silk suture.  A sterile dressing was then applied.  A stat portable chest x-ray was ordered to check line placement.  The patient tolerated the procedure well and there were no complications.","cardiovascular / pulmonary, intravenous access, incision and drainage, subclavian central venous catheter, central venous catheter, lower extremity, venous, intravenous, lidocaine, subclavian, needle, catheter, insertion"
 Dobutrex stress test for abnormal EKG, Cardiovascular / Pulmonary, Stress Test Dobutrex ,"INDICATIONS:,","cardiovascular / pulmonary, dobutrex stress test, abnormal ekg, dobutrex, inferior abnormality, ischemic heart disease, ventricle, µg/kg/minute, stress test, stress,"
 Thallium stress test for chest pain., Cardiovascular / Pulmonary, Stress Test Thallium ,"INDICATIONS:  ,Chest pain.,STRESS TECHNIQUE:,","cardiovascular / pulmonary, chest pain, ecg stress, thallium stress test, aerobic capacity, ejection fraction, gated tomographic spect system, myocardial perfusion, thallous chloride, ventricle, wall motion, stress test, stress"
" Chest pain, hypertension.  Stress test negative for dobutamine-induced myocardial ischemia.  Normal left ventricular size, regional wall motion, and ejection fraction.", Cardiovascular / Pulmonary, Stress Test Dobutamine Myoview ,"INDICATIONS:  ,Chest pain, hypertension, type II diabetes mellitus.,PROCEDURE DONE:,  Dobutamine Myoview stress test.,STRESS ECG RESULTS:,  The patient was stressed by dobutamine infusion at a rate of 10 mcg/kg/minute for three minutes, 20 mcg/kg/minute for three minutes, and 30 mcg/kg/minute for three additional minutes.  Atropine 0.25 mg was given intravenously eight minutes into the dobutamine infusion.  The resting electrocardiogram reveals a regular sinus rhythm with heart rate of 86 beats per minute, QS pattern in leads V1 and V2, and diffuse nonspecific T wave abnormality.  The heart rate increased from 86 beats per minute to 155 beats per minute, which is about 90% of the maximum predicted target heart rate.  The blood pressure increased from 130/80 to 160/70.  A maximum of 1 mm J-junctional depression was seen with fast up sloping ST segments during dobutamine infusion.  No ischemic ST segment changes were seen during dobutamine infusion or during the recovery process.,MYOCARDIAL PERFUSION IMAGING:,  Resting myocardial perfusion SPECT imaging was carried out with 10.9 mCi of Tc-99m Myoview.  Dobutamine infusion myocardial perfusion imaging and gated scan were carried out with 29.2 mCi of Tc-99m Myoview.  The lung heart ratio is 0.36.  Myocardial perfusion images were normal both at rest and with stress.  Gated myocardial scan revealed normal regional wall motion and ejection fraction of 67%.,CONCLUSIONS:,1.  Stress test is negative for dobutamine-induced myocardial ischemia.,2.  Normal left ventricular size, regional wall motion, and ejection fraction.","cardiovascular / pulmonary, chest pain, dobutamine myoview, dobutamine myoview stress test, spect imaging, stress test, dobutamine infusion, ejection fraction, hypertension, myocardial ischemia, myocardial perfusion, ventricular size, wall motion, dobutamine, stress, myocardial, myoview, ischemia, ventricular, perfusion, "
 Subxiphoid pericardial window.   A #10-blade scalpel was used to make an incision in the area of the xiphoid process.  Dissection was carried down to the level of the fascia using Bovie electrocautery. , Cardiovascular / Pulmonary, Subxiphoid Pericardial Window - 1 ,"OPERATION: , Subxiphoid pericardial window.,ANESTHESIA: , General endotracheal anesthesia.,OPERATIVE PROCEDURE IN DETAIL:  ,After obtaining informed consent from the patient's family, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and general endotracheal anesthesia was administered.  Next, the neck and chest were prepped and draped in the standard surgical fashion.  A #10-blade scalpel was used to make an incision in the area of the xiphoid process.  Dissection was carried down to the level of the fascia using Bovie electrocautery.  The xiphoid process was elevated, and the diaphragmatic attachments to it were dissected free.  Next the pericardium was identified.,The pericardium was opened with Bovie electrocautery.  Upon entering the pericardium, serous fluid was expressed.  In total, ** cc of fluid was drained.  A pericardial biopsy was obtained.  The fluid was sent off for cytologic examination as well as for culture.  A #24 Blake chest drain was brought out through the skin and placed in the posterior pericardium.  The fascia was closed with #1 Vicryl followed by 2-0 Vicryl followed by 4-0 PDS in a running subcuticular fashion.  Sterile dressing was applied.","cardiovascular / pulmonary, xiphoid process, pericardium, subxiphoid pericardial window, endotracheal anesthesia, bovie electrocautery, subxiphoid pericardial, bovie, electrocautery, subxiphoid, window, pericardial,"
 Stress test - Adenosine Myoview.  Ischemic cardiomyopathy.  Inferoseptal and apical transmural scar., Cardiovascular / Pulmonary, Stress Test Adenosine Myoview ,"INDICATIONS:,  Ischemic cardiomyopathy, status post inferior wall myocardial infarction, status post left anterior descending PTCA and stenting.,PROCEDURE DONE:,  Adenosine Myoview stress test.,STRESS ECG RESULTS:,  The patient was stressed by intravenous adenosine, 140 mcg/kg/minute infused over four minutes.  The baseline resting electrocardiogram revealed an electronic pacemaker depolarizing the ventricles regularly at a rate of 70 beats per minute.  Underlying atrial fibrillation noted, very wide QRS complexes.  The heart rate remained unchanged at 70 beats per minute as the blood pressure decreased from 140/80 to 110/70 with adenosine infusion.","cardiovascular / pulmonary, stress test, adenosine, adenosine myoview stress test, ischemic cardiomyopathy, spect, cardiomyopathy, electrocardiogram, myocardial infarction, stress test adenosine myoview, adenosine myoview stress, myoview stress test, ptca and stenting, myoview stress, transmural scar, adenosine infusion, septal motion, adenosine myoview, myocardial perfusion, hypokinesis, inferoseptal, ischemic, myocardial, myoview, perfusion, scan"
 Dobutamine stress test for atrial fibrillation., Cardiovascular / Pulmonary, Stress Test Dobutamine ,"INDICATIONS:,  Atrial fibrillation, coronary disease.,STRESS TECHNIQUE:, The patient was infused with dobutamine to a maximum heart rate of 142.  ECG exhibits atrial fibrillation.,IMAGE TECHNIQUE:,  The patient was injected with 5.2 millicuries of thallous chloride and subsequently imaged on the gated tomographic SPECT system.,IMAGE ANALYSIS:,  It should be noted that the images are limited slightly by the patient's obesity with a weight of 263 pounds.  There is normal LV myocardial perfusion.  The LV systolic ejection fraction is normal at 65%.  There is normal global and regional wall motion.,CONCLUSIONS:,1.  Basic rhythm of atrial fibrillation with no change during dobutamine stress, maximum heart rate of 142.,2.  Normal LV myocardial perfusion.,3.  Normal LV systolic ejection fraction of 65%.,4.  Normal global and regional wall motion.","cardiovascular / pulmonary, dobutamine stress test, atrial fibrillation, lv myocardial perfusion, lv systolic ejection fraction, coronary disease, dobutamine, ejection fraction, gated tomographic spect system, thallous chloride, wall motion, stress, fibrillation, atrial "
 Stress test with Bruce protocol due to chest pain., Cardiovascular / Pulmonary, Stress Test Bruce Protocol ,"PROTOCOL:,  Bruce.,PERTINENT MEDICATION: , None.,REASON FOR TEST:,  Chest pain.,PROCEDURE AND INTERPRETATION: ,1.  Baseline heart rate:  67.,2.  Baseline blood pressure:  150/86.,3.  Total time:  6 minute 51 seconds.,4.  METs:  10.1.,5.  Peak heart rate:  140.,6.  Percent of maximum-predicted heart rate:  90.,7.  Peak blood pressure:  200/92.,8.  Reason test terminated:  Shortness of breath and fatigue.,9.  Estimated aerobic capacity:  Average.,10. Heart rate response:  Normal.,11. Blood pressure response:  Hypertensive.,12. ST segment response:  Normal.,13. Chest pain:  None.,14. Symptoms:  None.,15. Arrhythmia:  None.,CONCLUSION:,1.  Average aerobic capacity.,2.  Normal heart rate and blood pressure response to exercise.,3.  No symptomatic electrocardiographic evidence of ischemia.,CONDITION: , Stable with normal vital signs.,DISPOSITION:  ,The patient was discharged home and was asymptomatic.,",
" Sick sinus syndrome, atrial fibrillation, pacemaker dependent, mild cardiomyopathy with ejection fraction 40% and no significant decompensation, and dementia of Alzheimer's disease with short and long term memory dysfunction", Cardiovascular / Pulmonary, Sick Sinus Syndrome ,"HISTORY OF PRESENT ILLNESS: , The patient is an 85-year-old gentleman who has a history of sick sinus syndrome for which he has St. Jude permanent pacemaker.  Pacemaker battery has reached end of life and the patient is dependent on his pacemaker with 100% pacing in the right ventricle.  He also has a fairly advanced degree of Alzheimer's dementia and is living in an assisted care facility.  The patient is unable to make his own health care decision and his daughter ABC has medical power of attorney.  The patient's dementia has resulted in the patient's having sufficient and chronic anger and his daughter that he refuses to speak with her, refuses to be in a same room with her.  For this reason the Casa Grande Regional Medical Center would obtain surgical and anesthesia consent from the patient's daughter in the fashion keeps the patient and daughter separated.  Furthermore it is important to note that his degree of dementia has disabled the patient to adequately self monitor his status following surgery for significant changes and to seek appropriate medical care, hence he will be admitted after the pacemaker exchange.,PAST MEDICAL HISTORY:,1.  Sick sinus syndrome, pacemaker dependence with 100% with right ventricular pacing.,2.  Dementia of Alzheimer's disease.,3.  Gastroesophageal reflux disease.,4.  Multiple pacemaker implantation and exchanges.,FAMILY HISTORY: , Unobtainable.,SOCIAL HISTORY: , The patient resides full time at ABC supervised living facility.  He is nonsmoker, nondrinker.  He uses wheelchair and moves himself about with his feet.  He is independent of activities of daily living and dependent on independent activities of daily living.,ALLERGIES TO MEDICATIONS: , No known drug allergies.,MEDICATIONS:  ,Omeprazole 20 mg p.o. daily, furosemide 20 mg p.o. daily, citalopram 20 mg p.o. daily, loratadine 10 mg p.o. p.r.n.,REVIEW OF SYSTEMS: , A 10 systems review negative for chest pain, pressure, shortness of breath, paroxysmal nocturnal dyspnea, orthopnea, syncope, near-syncopal episodes.  Negative for recent falls.  Positive for significant memory loss.  All other review of systems is negative.,PHYSICAL EXAMINATION:,GENERAL:  The patient is an 85-year-old gentleman in no acute distress, sitting in the wheelchair.,VITAL SIGNS:  Blood pressure is 118/68, pulse is 80 and regular, respirations 16, weight is 200 pounds, oxygen saturation is 90% on room air.,HEENT:  Head atraumatic and normocephalic.  Eyes, pupils are equal and reactive to light and accommodate bilaterally, free from focal lesions.  Ears, nose, mouth, and throat.,NECK:  Supple.  No lymphadenopathy, thyromegaly, or thyroid masses appreciated.,CARDIOVASCULAR:  No JVD or no jugular venous distention.  No carotid bruits bilaterally.  Pacemaker pocket right upper thorax with healed surgical incisions.  S1 and S2 are normal.  No S3 or S4.  There are no murmurs.  No heaves or thrills, gout, or gallops.  Trace edema at dorsum of his feet and ankles.  Femoral pulses are present without bruits, posterior tibial pulses would be palpable bilaterally.,RESPIRATORY:  Breath sounds are clear but diminished throughout AP diameters expanded.  The patient speaks in full sentences.  No wheezing, no accessory muscles used for breathing.,GASTROINTESTINAL:  Abdomen is soft and nontender.  Bowel sounds are active in all 4 quadrants.  No palpable pulses.  No abdominal bruit is appreciated.  No hepatosplenomegaly.,GENITOURINARY:  Nonfocal.,MUSCULOSKELETAL:  Muscle strength in lower extremities is 4/5 bilaterally.  Upper extremities are 5/5 bilaterally with adequate range of motion.,SKIN:  Warm and dry.  No obvious rashes, lesions, or ulcerations. ,NEUROLOGIC:  Alert, not oriented to place and date.  His speech is clear.  There are no focal motor or sensory deficits.,PSYCHIATRIC:  Talkative, pleasant affect with limited impulse control, severe short-term memory loss.,LABORATORY DATA:,  Blood work dated 12/15/08, white count 4.7, hemoglobin 11.9, hematocrit 33.9, and platelets 115,000.  BUN 19, creatinine 1.15, glucose 94, potassium 4.5, sodium 140, and calcium 8.6.,DIAGNOSTIC DATA:,  St. Jude pacemaker interrogation dated 11/10/08 shows single chamber pacemaker and VVIR mode, implant date 08/2000, 100% paced in right ventricle, battery status is ERI.  A 12-lead ECG 12/15/08 shows 100% paced rhythm with rate of 80.  No Q waves at the baseline of atrial fibrillation.  Last measured ejection fraction 40% 12/08 with no significant decompensation.,IMPRESSION/PLAN:,1.  Sick sinus syndrome.,2.  Atrial fibrillation.,3.  Pacemaker dependent.,4.  Mild cardiomyopathy with ejection fraction 40% and no significant decompensation.,5.  Pacemaker battery end of life requiring exchange.,6.  Dementia of Alzheimer's disease with short and long term memory dysfunction.  The dementia disables the patient from recognizing changes in his health status in knowing if he needed to seek appropriate health care.  Dementia also renders the patient incapable informed consent, schedule the patient for pacemaker.  I explain the patient and reimplantation with any device in the surgical suite.  He will require anesthesia assistance for adequate sedation as the patient possesses behavioral risk secondary to his advanced dementia.,7.  Admit the patient after surgery for postoperative care and monitoring.",
" Successful stenting of the left anterior descending.  Angina pectoris, tight lesion in left anterior descending.", Cardiovascular / Pulmonary, Stenting ,"NAME OF PROCEDURE:,  Successful stenting of the left anterior descending.,DESCRIPTION OF PROCEDURE:,  Angina pectoris, tight lesion in left anterior descending.,TECHNIQUE OF PROCEDURE:,  Standard Judkins, right groin.,CATHETERS USED: , 6 French Judkins, right; wire, 14 BMW; balloon for predilatation, 25 x 15 CrossSail; stent 2.5 x 18 Cypher drug-eluting stent.,ANTICOAGULATION:  ,The patient was on aspirin and Plavix, received 3000 of heparin and was begun on Integrilin.,COMPLICATIONS: , None.,INFORMED CONSENT: , I reviewed with the patient the pros, cons, alternatives and risks of catheter and sedation exactly as I had done before during his diagnostic catheterization, plus I reviewed the risks of intervention including lack of success, need for emergency surgery, need for later restenosis and further procedures.,HEMODYNAMIC DATA: , The aortic pressure was in the physiologic range.,ANGIOGRAPHIC DATA: , Left coronary artery:  The left main coronary artery showed insignificant disease.  The left anterior descending showed fairly extensive calcification.  There was 90% stenosis in the proximal to midportion of the vessel.  Insignificant disease in the circumflex.,SUCCESSFUL STENTING: , A wire crossed the lesion.  We first predilated with a balloon, then advanced, deployed and post dilated the stent.  Final angiography showed 0% stenosis, no tears or thrombi, excellent intimal appearance.,PHYSICAL EXAMINATION,VITAL SIGNS:  Blood pressure 160/88, temperature 98.6, pulse 83, respirations 30.  He is saturating at 96% on 4 L nonrebreather.,GENERAL:  The patient is a 74 year-old white male who is cooperative with the examination and alert and oriented x3.  The patient cannot speak and communicates through writing.,HEENT:  Very small moles on face.  However, pupils equal, round and regular and reactive to light and accommodation.  Extraocular movements are intact.  Oropharynx is moist.,NECK:  Supple.  Tracheostomy site is clean without blood or discharge.,HEART:  Regular rate and rhythm.  No gallop, murmur or rub.,CHEST:  Respirations congested.  Mild crackles in the left lower quadrant and left lower base.,ABDOMEN:  Soft, nontender and nondistended.  Positive bowel sounds.,EXTREMITIES:  No clubbing, cyanosis or edema.,NEUROLOGIC:  Cranial nerves II-XII grossly intact.  No focal deficit.,GENITALIA:  The patient does have a right scrotal swelling, very much larger than the other side, not reproducible and mobile to touch.,CONCLUSIONS,1. Successful stenting of the left anterior descending.  Initially, there was 90% stenosis.  After stenting with a drug-eluting stent, there was 0% residual.,2. Insignificant disease in the other coronaries.,PLAN:,  The patient will be treated with aspirin, Plavix, Integrilin, beta blockers and statins.  I have discussed this with him, and I have answered his questions.",
" The patient is admitted for shortness of breath, continues to do fairly well.  The patient has chronic atrial fibrillation, on anticoagulation, INR of 1.72.  The patient did undergo echocardiogram, which shows aortic stenosis, severe.  The patient does have an outside cardiologist. ", Cardiovascular / Pulmonary, SOAP - Shortness of Breath ,"SUBJECTIVE: , The patient is admitted for shortness of breath, continues to do fairly well.  The patient has chronic atrial fibrillation, on anticoagulation, INR of 1.72.  The patient did undergo echocardiogram, which shows aortic stenosis, severe.  The patient does have an outside cardiologist.  I understand she was scheduled to undergo workup in this regard.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse of 78 and blood pressure 130/60.,LUNGS:  Clear.,HEART:  A soft systolic murmur in the aortic area.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema.,IMPRESSION:,1.  Status shortness of breath responding well to medical management.,2.  Atrial fibrillation, chronic, on anticoagulation.,3.  Aortic stenosis.,RECOMMENDATIONS:,1.  Continue medications as above.,2.  The patient would like to follow with her cardiologist regarding aortic stenosis.  She may need a surgical intervention in this regard, which I explained to her.  The patient will be discharged home on medical management and she has an appointment to see her cardiologist in the next few days.,In the interim, if she changes her mind or if she has any concerns, I have requested to call me back.","cardiovascular / pulmonary, shortness of breath, medical management, atrial fibrillation, aortic stenosis, atrial, fibrillation, breath, stenosis, cardiologist, aortic, anticoagulation, inr,"
" Chest, Single view post OP for ASD (Atrial Septal Defect).", Cardiovascular / Pulmonary, Single Frontal View of Chest ,"EXAM: , Single frontal view of the chest.,HISTORY: , Atelectasis.  Patient is status-post surgical correction for ASD.,TECHNIQUE: , A single frontal view of the chest was evaluated and correlated with the prior film dated mm/dd/yy.,FINDINGS:,  Current film reveals there is a right-sided central venous catheter, the distal tip appears to be in the superior vena cava.  Endotracheal tube with the distal tip appears to be in appropriate position, approximately 2 cm superior to the carina.  Sternotomy wires are noted.  They appear in appropriate placement.  There are no focal areas of consolidation to suggest pneumonia.  Once again seen is minimal amount of bilateral basilar atelectasis.  The cardiomediastinal silhouette appears to be within normal limits at this time.  No evidence of any pneumothoraces or pleural effusions.,IMPRESSION:,1.  There has been interval placement of a right-sided central venous catheter, endotracheal tube, and sternotomy wires secondary to patient's most recent surgical intervention.,2.  Minimal bilateral basilar atelectasis with no significant interval changes from the patient's most recent prior.,3.  Interval decrease in the patient's heart size which may be secondary to the surgery versus positional and technique.","cardiovascular / pulmonary, atrial septal defect, central venous catheter, bilateral basilar atelectasis, single frontal view, distal tip, endotracheal tube, sternotomy wires, basilar atelectasis, atrial, venous, catheter, endotracheal, tube, sternotomy, atelectasis, chest, asd"
" Pulmonary disorder with lung mass, pleural effusion, and chronic uncontrolled atrial fibrillation secondary to pulmonary disorder. The patient is admitted for lung mass and also pleural effusion.  The patient had a chest tube placement, which has been taken out.  The patient has chronic atrial fibrillation, on anticoagulation. ", Cardiovascular / Pulmonary, SOAP - Lung Mass ,"SUBJECTIVE:,  The patient is admitted for lung mass and also pleural effusion.  The patient had a chest tube placement, which has been taken out.  The patient has chronic atrial fibrillation, on anticoagulation.  The patient is doing fairly well.  This afternoon, she called me because heart rate was in the range of 120 to 140.  The patient is lying down.  She does have shortness of breath, but denies any other significant symptoms.,PAST MEDICAL HISTORY:,  History of mastectomy, chest tube placement, and atrial fibrillation; chronic.,MEDICATIONS:,1.  Cardizem, which is changed to 60 mg p.o. t.i.d.,2.  Digoxin 0.25 mg daily.,3.  Coumadin, adjusted dose.,4.  Clindamycin.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse 122 and blood pressure 102/68.,LUNGS:  Air entry decreased.,HEART:  PMI is displaced.  S1 and S2 are irregular.,ABDOMEN:  Soft and nontender.,IMPRESSION:,1.  Pulmonary disorder with lung mass.,2.  Pleural effusion.,3.  Chronic uncontrolled atrial fibrillation secondary to pulmonary disorder.,RECOMMENDATIONS:,1.  From cardiac standpoint, follow with pulmonary treatment.,2.  The patient has an INR of 2.09.  She is on anticoagulation.  Atrial fibrillation is chronic with the rate increased.,Adjust the medications accordingly as above.","cardiovascular / pulmonary, lung mass, pleural effusion, chest tube placement, chest tube, pulmonary disorder, atrial fibrillation, chest, anticoagulation, effusion, lung, pulmonary, atrial, fibrillation,"
  Insertion of a #8 Shiley tracheostomy tube.  A #10-blade scalpel was used to make an incision approximately 1 fingerbreadth above the sternal notch.  Dissection was carried down using Bovie electrocautery to the level of the trachea., Cardiovascular / Pulmonary, Shiley Tracheostomy Tube Insertion ,"OPERATION: , Insertion of a #8 Shiley tracheostomy tube.,ANESTHESIA: , General endotracheal anesthesia.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient's family, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered.,Next, a #10-blade scalpel was used to make an incision approximately 1 fingerbreadth above the sternal notch.  Dissection was carried down using Bovie electrocautery to the level of the trachea.  The 2nd tracheal ring was identified.  Next, a #11-blade scalpel was used to make a trap door in the trachea.  The endotracheal tube was backed out.  A #8 Shiley tracheostomy tube was inserted, and tidal CO2 was confirmed when it was connected to the circuit.  We then secured it in place using 0 silk suture.  A sterile dressing was applied.  The patient tolerated the procedure well.","cardiovascular / pulmonary, tracheostomy, shiley tracheostomy tube, sternal notch, bovie electrocautery, tracheostomy tube, electrocautery, endotracheal, shiley, tube,"
" Repair of total anomalous pulmonary venous connection, ligation of patent ductus arteriosus, repair secundum type atrial septal defect (autologous pericardial patch), subtotal thymectomy, and insertion of peritoneal dialysis catheter.", Cardiovascular / Pulmonary, Septal Defect Repair ,"TITLE OF OPERATION:,1.  Repair of total anomalous pulmonary venous connection.,2.  Ligation of patent ductus arteriosus.,3.  Repair secundum type atrial septal defect (autologous pericardial patch).,4.  Subtotal thymectomy.,5.  Insertion of peritoneal dialysis catheter.,INDICATION FOR SURGERY: , This neonatal was diagnosed postnatally with total anomalous pulmonary venous connection.  Following initial stabilization, she was transferred to the Hospital for complete correction.,PREOP DIAGNOSIS:  ,1.  Total anomalous pulmonary venous connection.,2.  Atrial septal defect.,3.  Patent ductus arteriosus.,4.  Operative weight less than 4 kilograms (3.2 kilograms).,COMPLICATIONS: , None.,CROSS-CLAMP TIME: , 63 minutes.,CARDIOPULMONARY BYPASS TIME MONITOR:,  35 minutes, profound hypothermic circulatory arrest time (4 plus 19) equals 23 minutes.  Low flow perfusion 32 minutes.,FINDINGS:,  Horizontal pulmonary venous confluence with right upper and middle with two veins entering the confluence on the right and multiple entry sites for left-sided veins.  Large patulous anastomosis between posterior aspect of the left atrium and anterior aspect of the pulmonary venous confluence.  Nonobstructed ascending vein ligated.  Patent ductus arteriosus diminutive left atrium with posterior atrial septal defect with deficient inferior margin.  At completion of the procedure, right ventricular pressure approximating one-half of systemic, normal sinus rhythm, good biventricular function by visual inspection.,PROCEDURE: , After the informed consent, the patient was brought to the operating room and placed on the operating room table in supine position.  Upon induction of general endotracheal anesthesia and placement of indwelling arterial and venous monitoring lines.  The patient was prepped and draped in the usual sterile fashion from chin to groins.  A median sternotomy incision was performed.  Dissection was carried through the deeper planes until the sternum was scored and divided with an oscillating saw.  A subtotal thymectomy was performed.  Systemic heparinization was achieved and the pericardium was entered and fashioned until cradle.  A small portion of the anterior pericardium was procured and fixed in glutaraldehyde for patch closure of segment of the atrial septal defect during the procedure.  Pursestrings were deployed on the ascending aorta on the right.  Atrial appendage.  The aorta was then cannulated with an 8-French aorta cannula and the right atrium with an 18-French Polystan right-angle cannula.  With an ACT greater than 400, greater pulmonary bypass was commenced with excellent cardiac decompression and the patent ductus arteriosus was ligated with a 2-0 silk tie.  Systemic cooling was started and the head was packed  and iced and systemic steroids were administered.  During cooling, traction suture was placed in the apex of the left ventricle.  After 25 minutes of cooling, the aorta was cross-clamped and the heart arrested by administration of 30 cubic centimeter/kilogram of cold-blood cardioplegia delivered directly within the aortic root following the aorta cross-clamping.  Following successful cardioplegic arrest, a period of low flow perfusion was started and a 10-French catheter was inserted into the right atrial appendage substituting the 18-French Polystan venous cannula.  The heart was then rotated to the right side and the venous confluence was exposed.  It was incised and enlarged and a corresponding incision in the dorsal and posterior aspect of the left atrium was performed.  The two openings were then anastomosed in an end-to-side fashion with several interlocking sutures to avoid pursestring effect with a running 7-0 PDS suture.  Following completion of the anastomosis, the heart was returned into the chest and the patient's blood volume was drained into the reservoir.  A right atriotomy was then performed during the period of circulatory arrest.  The atrial septal defect was very difficult to expose, but it was sealed with an autologous pericardial patch was secured in place with a running 6-0 Prolene suture.  The usual deairing maneuvers were carried out and lining was administered and the right atriotomy was closed in two layers with a running 6-0 Prolene sutures.  The venous cannula was reinserted.  Cardiopulmonary bypass restarted and the aorta cross-clamp was released.  The patient returned to normal sinus rhythm spontaneously and started regaining satisfactory hemodynamics which, following a prolonged period of rewarming, allow for us to wean her from cardiopulmonary bypass successfully and moderate inotropic support and sinus rhythm.  Modified ultrafiltration was carried out and two sets of atrial and ventricular pacing wires were placed as well as the peritoneal dialysis catheter and two 15-French Blake drains.  Venous decannulation was followed by aortic decannulation and administration of protamine sulfate.  All cannulation sites were oversewn with 6-0 Prolene sutures and the anastomotic sites noticed to be hemostatic.  With good hemodynamics and hemostasis, the sternum was then smeared with vancomycin, placing closure with stainless steel wires.  The subcutaneous tissues were closed in layers with the reabsorbable monofilament sutures.  Sponge and needle counts were correct times 2 at the end of the procedure.  The patient was transferred in very stable condition to the pediatric intensive care unit .,I was the surgical attending present in the operating room and in charge of the surgical procedure throughout the entire length of the case.  Given the magnitude of the operation, the unavailability of an appropriate level, cardiac surgical resident, Mrs. X (attending pediatric cardiac surgery at the Hospital) participated during the cross-clamp time of the procedure in quality of first assistant.","cardiovascular / pulmonary, total anomalous pulmonary venous connection, patent ductus arteriosus, ligation, secundum type atrial septal defect, atrial septal defect, subtotal thymectomy, peritoneal dialysis catheter, cross clamp, cardiopulmonary bypass, pulmonary venous, atrial septal, septal defect, anomalous, venous, atrial, arteriosus, patent, ductus, septal, aorta, pulmonary, "
 The patient was admitted approximately 3 days ago with increasing shortness of breath secondary to pneumonia.  Pulmonary Medicine Associates have been contacted to consult in light of the ICU admission. , Cardiovascular / Pulmonary, Shortness Of Breath - Progress Note ,"She was evaluated this a.m. and was without any significant clinical change.  Her white count has been improving and down to 12,000.  A chest x-ray obtained today showed some bilateral infiltrates, but no acute cardiopulmonary change.  There was a suggestion of a bilateral lower lobe pneumonitis or pneumonia.,She has been on Zosyn for the infection.,Throughout her hospitalization, we have been trying to adjust her pain medications.  She states that the methadone did not work for her.  She was ""immune"" to oxycodone.  She had been on tramadol before and was placed back on that.  There was some question that this may have been causing some dizziness.  She also was on clonazepam and alprazolam for the underlying bipolar disorder.,Apparently, her husband was in this afternoon.  He had a box of her pain medications.  It is unclear whether she took a bunch of these or precisely what happened.  I was contacted that she was less responsive.  She periodically has some difficulty to arouse due to pain medications, which she has been requesting repeatedly, though at times does not appear to have objective signs of ongoing pain.  The nurse found her and was unable to arouse her at this point.  There was a concern that she had taken some medications from home.  She was given Narcan and appeared to come around some.  Breathing remained somewhat labored and she had some diffuse scattered rhonchi, which certainly changed from this a.m.  Additional Narcan was given as well as some medications to reverse a possible benzodiazepine toxicity.  With O2 via mask, oxygenation was stable at 90% to 95% after initial hypoxia was noted.  A chest x-ray was obtained at this time.  An ECG was obtained, which shows a sinus tachycardia, noted to have ischemic abnormalities.,In light of the acute decompensation, she was then transferred to the ICU.  We will continue the IV Zosyn.  Respiratory protocol with respiratory management.  Continue alprazolam p.r.n., but avoid if she appears sedated.  We will attempt to avoid additional pain medications, but we will continue with the Dilaudid for time being.  I suspect she will need something to control her bipolar disorder.,Pulmonary Medicine Associates have been contacted to consult in light of the ICU admission.  At this juncture, she does not appear to need an intubation.  Pending chest x-ray, she may require additional IV furosemide.","cardiovascular / pulmonary, shortness of breath, pulmonary medicine, bipolar disorder, icuNOTE"
 Ligation and stripping of left greater saphenous vein to the level of the knee.  Stripping of multiple left lower extremity varicose veins.  Varicose veins., Cardiovascular / Pulmonary, Saphenous Vein - Ligation & Stripping ,"PREOPERATIVE DIAGNOSIS:,  Varicose veins.,POSTOPERATIVE DIAGNOSIS: , Varicose veins.,PROCEDURE PERFORMED:,1.  Ligation and stripping of left greater saphenous vein to the level of the knee.,2.  Stripping of multiple left lower extremity varicose veins.,ANESTHESIA:,  General endotracheal.,ESTIMATED BLOOD LOSS: , Approximately 150 mL.,SPECIMENS: , Multiple veins.,COMPLICATIONS:,  None.,BRIEF HISTORY:,  This is a 30-year-old Caucasian male who presented for elective evaluation from Dr. X's office for evaluation of intractable pain from the left lower extremity.  The patient has had painful varicose veins for number of years.  He has failed conservative measures and has felt more aggressive treatment to alleviate his pain secondary to his varicose veins.  It was recommended that the patient undergo a saphenous vein ligation and stripping.  He was explained the risks, benefits, and complications of the procedure including intractable pain.  He gave informed consent to proceed.,OPERATIVE FINDINGS:,  The left greater saphenous vein femoral junction was identified and multiple tributaries were ligated surrounding this region.,The vein was stripped from the saphenofemoral junction to the level of the knee.  Multiple tributaries of the greater saphenous vein and varicose veins from the left lower extremity were ligated and stripped accordingly.  Additionally, there were noted to be multiple regions within these veins that were friable and edematous consistent with acute and chronic inflammatory changes making stripping of these varicose veins extremely difficult.,OPERATIVE PROCEDURE:  ,The patient was marked preoperatively in the Preanesthesia Care Unit.  The patient was brought to the operating suite, placed in the supine position.  The patient underwent general endotracheal intubation.  After adequate anesthesia was obtained, the left lower extremity was prepped and draped circumferentially from the foot all the way to the distal section of the left lower quadrant and just right of midline.  A diagonal incision was created in the direction of the inguinal crease on the left.  A self-retaining retractor was placed and the incision was carried down through the subcutaneous tissues until the greater saphenous vein was identified.  The vein was isolated with a right angle.  The vein was followed proximally until a multiple tributary branches were identified.  These were ligated with #3-0 silk suture.  The dissection was then carried to the femorosaphenous vein junction.  This was identified and #0 silk suture was placed proximally and distally and ligated in between.  The proximal suture was tied down.  Distal suture was retracted and a vein stripping device was placed within the greater saphenous vein.  An incision was created at the level of the knee.  The distal segment of the greater saphenous vein was identified and the left foot was encircled with #0 silk suture and tied proximally and then ligated.  The distal end of the vein stripping device was then passed through at its most proximal location.  The device was attached to the vein stripping section and the greater saphenous vein was then stripped free from its canal within the left lower extremity.  Next, attention was made towards the multiple tributaries of the varicose vein within the left lower leg.  Multiple incisions were created with a #15 blade scalpel.  The incisions were carried down with electrocautery.  Next, utilizing sharp dissection with a hemostat, the tissue was spread until the vein was identified.  The vein was then followed to T3 and in all these locations intersecting segments of varicose veins were identified and removed.  Additionally, some segments were removed.  The stripping approach would be vein stripping device.  Multiple branches of the saphenous vein were then ligated and/or removed.  Occasionally, dissection was unable to be performed as the vein was too friable and would tear from the hemostat.  Bleeding was controlled with direct pressure.  All incisions were then closed with interrupted #3-0 Vicryl sutures and/or #4-0 Vicryl sutures.,The femoral incision was closed with interrupted multiple #3-0 Vicryl sutures and closed with a running #4-0 subcuticular suture.  The leg was then cleaned, dried, and then Steri-Strips were placed over the incisions.  The leg was then wrapped with a sterile Kerlix.  Once the Kerlix was achieved, an Ace wrap was placed over the left lower extremity for compression.  The patient tolerated the procedure well and was transferred to Postanesthesia Care Unit extubated in stable condition.  He will undergo evaluation postoperatively and will be seen shortly in the postanesthesia care unit.","cardiovascular / pulmonary, varicose veins, saphenous vein, stripping, ligation, vein stripping, lower extremity, saphenous, varicose, vein, ligated, "
 Complete heart block with pacemaker malfunction and  a history of Shone complex., Cardiovascular / Pulmonary, Shone complex ,"HISTORY AND PHYSICAL:  ,The patient is a 13-year-old, who has a history of Shone complex and has a complete heart block.  He is on the pacemaker.  He had a coarctation of the aorta and that was repaired when he was an infant.  He was followed in our Cardiology Clinic here and has been doing well.  However last night, he was sleeping, and he states he felt as if he has having a dream, and there was thunder in this dream, which woke him up.  He then felt that his defibrillator was going off and this has continued and feels like his heart rate is not normal.  Thus, his dad put him in the car and transported him here.  He has been evaluated here.  He had some scar tissue at one point when the internal pacemaker was not working properly and had to have that replaced.  It was 2 a.m. when he woke, and again, he was brought here by private vehicle.  He was well prior to going to bed.  No cough, cold, runny nose, fever.  No trauma has been noted.,PAST MEDICAL HISTORY:,  Shone complex, pacemaker dependent.,MEDICATIONS: , He is on no medications at this time.,ALLERGIES:,  He has no allergies.,IMMUNIZATIONS:,  Up to date.,SOCIAL HISTORY: , He lives with his parents.,FAMILY HISTORY: , Negative.,REVIEW OF SYSTEM: , Twelve asked, all negative, except as noted above.,PHYSICAL EXAMINATION:,GENERAL:  This is an awake, alert male, who appears to be in mild distress.,HEENT:  Pupils are equal, round, and reactive to light.  Extraocular movements are intact.  His TMs are clear.  His nares are clear.  The mucous membranes are pink and moist.  Throat is clear.,NECK:  Supple without lymphadenopathy or masses.  Trachea is midline.,LUNGS:  Clear.,HEART:  Shows bradycardia at 53.  He has good distal pulses.,ABDOMEN:  Soft, nontender.  Positive bowel sounds.  No guarding, no rebound.  No rashes are seen.,HOSPITAL COURSE:,  Initial blood pressure is 164/90.  He was moved in room 1.  He was placed on nasal cannula.  Pulse ox was 100%, which is normal.  We placed him on a monitor.  We did an EKG; it has not appear to be capturing his pacemaker at this time.  Shortly after the patient's arrival, the Medtronic technician came and worked out his pacemaker.  Medtronic representative informed me that the lead that he has in place has been recalled because it has been prone to microfractures, oversensing, and automatic defibrillation.  As noted, he was transferred to room 1, placed on a monitor, pulse ox.  An IV was placed.  A standard blood work was sent.  A chest x-ray was done showing normal heart size, lead appeared to be in placed.  There was no evidence of pulmonary edema.  His pacemaker did not appear to be capturing.  We placed him on transthoracic leads.  However, it is difficult to get good placement with these because of the area where his pacemaker was placed.  The Medtronic technician initially turned off his defibrillation mode and turned down his sensor.  However, we could not get our transthoracic pacer to capture his heart.  When the Medtronic representative turned off the pacemaker, the heart rate seemed to drop into the 40s.  The patient appeared to be in pain.  We placed it back on a rate of 60 at that time.  He has remained in sinus bradycardia, but no evidence of ectopic beats.  No widening of his QRS complex.  I spoke with Cardiology.  Cardiology service has come in, has evaluated him at bedside with me.  Again, we turned up the transthoracic pacer, but it is again not seem to be picking up, and his heart rate is still going with the Medtronic's internal pacemaker.  So with the ICU physician on call, Dr. X, he has agreed with taking this young man to the ICU.,An hour after presentation here, the ICU was ready for bed.  I accompanied the patient up to the ICU.  He remained awake and alert.  Initially, he was complaining of a lot of chest pain.  Once the defibrillator was turned off, he had no more pain.  He was transported to the Pediatrics PICU and delivered in stable condition.,LABORATORY DATA: , CBC was normal.  Chem-20 was normal as well.,IMPRESSION:  ,Complete heart block with pacemaker malfunction.,PLAN:  ,He is admitted to the ICU.,TIME SEEN: , Critical care time outside billable procedures was 45 minutes with this patient.  I should note that a 12-lead EKG was done here showing sinus bradycardia, normal intervals otherwise.",
" Selective coronary angiography, coronary angioplasty.  Acute non-ST-elevation MI.", Cardiovascular / Pulmonary, Selective Coronary Angiography & Angioplasty ,"PREOPERATIVE DIAGNOSIS AND INDICATIONS:,  Acute non-ST-elevation MI.,POSTOPERATIVE DIAGNOSIS AND SUMMARY:,  The patient presented with an acute non-ST-elevation MI.  Despite medical therapy, she continued to have intermittent angina.  Angiography demonstrated the severe LAD as the culprit lesion.  This was treated as noted above with angioplasty alone as the stent could not be safely advanced.  She has residual lesions of 75% in the proximal right coronary and 60% proximal circumflex, and the other residual LAD lesions as noted above.  She will be continued on her medical therapy.  At age 90, she is not a good candidate for aortic valve replacement and coronary bypass grafting.,PROCEDURE PERFORMED: , Selective coronary angiography, coronary angioplasty.,PROCEDURE IN DETAIL:,  After informed consent was obtained, the patient was taken to the cath lab, placed on the table in the supine position.  The area of the right femoral artery was prepped and draped in a sterile fashion.  Using the percutaneous technique, a 6-French sheath was placed in the right femoral artery under fluoroscopic guidance.  With the guidewire in place, a 5-French JL-4 catheter was used to selectively angiogram the left coronary system.  The catheter was removed.  The sheath flushed.  The 5-French 3DRC catheter was then used to selectively angiogram the right coronary artery.  The cath removed, the sheath flushed.,It was decided that intervention was needed in the severe lesions in the LAD, which appeared to be the culprit lesions for the non-ST elevation-MI.  The patient was given a bolus of heparin and an ACT of approximately 50 seconds was obtained, we rebolused and the ACT was slightly lower.  We repeated the level and it was slightly higher.  We administered 500 more units of heparin and then proceeded with an ACT of approximately 270 seconds prior to the 500 units of heparin IV.  Additionally, the patient had been given 300 mg of Plavix orally during the procedure and Integrilin IV bolus and then maintenance drip was started.,A 6-French CLS 3.5 left coronary guide catheter was used to cannulate the left main and HEW guidewire was positioned in the distal LAD and another HEW guidewire in the relatively large third diagonal.  An Apex 2.5 x 15 mm balloon was positioned in the distal portion of the mid LAD stenosis and inflated to 6 atmospheres for 15 seconds and then deflated.  Angiography was then performed, demonstrated marked improvement in the stenosis and this image was used for sizing the last of the needed stent.  The balloon was pulled more proximally and then inflated again at 6 atmospheres for approximately 20 seconds, with the proximal end of the balloon positioned distal to the origin of the third diagonal so as to not compromise the ostium.  The balloon was inflated and removed, repeat angiography performed.  We attempted to advance a Driver 2.5 x 24 mm bare metal stent, but I could not advance it beyond the proximal LAD, where there was significant calcification.  The stent was removed.  Attempts to advance the same 2.5 x 15 mm Apex balloon that was previously used were unsuccessful.  It was removed, a new Apex 2.5 x 15 mm balloon was then positioned in the proximal LAD and inflated to 6 atmospheres for 15 seconds and then deflated and advanced slightly with the distal tip of the balloon proximal to the third diagonal ostium and it was inflated to 6 atmospheres for 15 seconds and then deflated and removed.  Repeat angiography demonstrated no evidence of dissection.  One more attempt was made to advance the Driver 2.5 x 24 mm bare metal stent, but again I could not advance it beyond the calcified plaque in the proximal LAD and this was despite the presence of the buddy wire in the diagonal.  I felt that further attempts in this calcified vessel in a 90-year-old with severe aortic stenosis and severe aortic insufficiency would likely result in complications of dissection, so the stent was removed.  The guidewires and guide cath were removed.  The sheath flushed and sutured into position.  The patient moved to ICU in stable condition with no chest discomfort at all.,CONTRAST: , Isovue-370, 120 mL.,FLUORO TIME: , 9.4 minutes.,ESTIMATED BLOOD LOSS: , 30 mL.,HEMODYNAMICS:,  Aorta 185/54.,Left ventriculography was not performed.  I did not make an attempt to cross this severely stenotic aortic valve.,The left main is a large vessel, giving rise to LAD and circumflex vessels.  The left main has no significant disease other than calcification in the walls.,The LAD is a moderate-to-large vessel, giving rise to small diagonals and then a moderate-to-large third diagonal, and then a small fourth diagonal.  The LAD has significant calcification proximally.  There is a 50% stenosis between the first and second diagonals that we treated with angioplasty alone in an attempt to be able to advance the stent.  This resulted in a 30% residual, mostly eccentric calcified plaque.  Following this, there was a 50% stenosis in the LAD just after the takeoff of the third diagonal.  This was not ballooned.  Beyond this is an 80% stenosis prior to the fourth diagonal and then a 99% stenosis after the fourth diagonal.  These 2 lesions were dilated with 10% residual prior to the fourth diagonal and 25% residual distal to the fourth diagonal.  As noted above, this area was not stented because I could not safely advance the stent.  Note, there was also a 50% stenosis at the origin of the moderate-to-large third diagonal that did not change with angioplasty.,The circumflex is a large, nondominant vessel consisting of a large obtuse marginal with multiple branches.  The proximal circumflex has an eccentric 60% stenosis prior to the takeoff of the obtuse marginal.  The remainder of the vessel was without significant disease.,The right coronary was a large, dominant vessel giving rise to a large posterior descending artery and small-to-moderate first posterolateral, small second posterolateral, and a small-to-moderate third posterolateral branch.  The right coronary has an eccentric smooth 75% stenosis beginning about a centimeter after the origin of the vessel and prior to the acute marginal branch.  The remainder of the right coronary and its branches were without significant disease.","cardiovascular / pulmonary, non-st-elevation mi, selective coronary angiography, coronary angioplasty, calcified plaque, coronary angiography, st elevation, stenosis, lad, coronary, selective, angiography, angioplasty, balloon, vessel, stent, "
" Elevated cardiac enzymes, fullness in chest, abnormal EKG, and risk factors.  No evidence of exercise induced ischemia at a high myocardial workload.  This essentially excludes obstructive CAD as a cause of her elevated troponin.", Cardiovascular / Pulmonary, Radionuclide Stress Test ,"INDICATION FOR STUDY: , Elevated cardiac enzymes, fullness in chest, abnormal EKG, and risk factors.,MEDICATIONS:,  Femara, verapamil, Dyazide, Hyzaar, glyburide, and metformin.,BASELINE EKG: , Sinus rhythm at 84 beats per minute, poor anteroseptal R-wave progression, mild lateral ST abnormalities.,EXERCISE RESULTS:,1.  The patient exercised for 3 minutes stopping due to fatigue.  No chest pain.,2.  Heart rate increased from 84 to 138 or 93% of maximum predicted heart rate.  Blood pressure rose from 150/88 to 210/100.  There was a slight increase in her repolorization abnormalities in a non-specific pattern.,NUCLEAR PROTOCOL:  ,Same day rest/stress protocol was utilized with 11 mCi for the rest dose and 33 mCi for the stress test.,NUCLEAR RESULTS:,1.  Nuclear perfusion imaging, review of the raw projection data reveals adequate image acquisition.  The resting images showed decreased uptake in the anterior wall.  However the apex is spared of this defect.  There is no significant change between rest and stress images.  The sum score is 0.,2.  The Gated SPECT shows moderate LVH with slightly low EF of 48%.,IMPRESSION:,1.  No evidence of exercise induced ischemia at a high myocardial workload.  This essentially excludes obstructive CAD as a cause of her elevated troponin.,2.  Mild hypertensive cardiomyopathy with an EF of 48%.,3.  Poor exercise capacity due to cardiovascular deconditioning.,4.  Suboptimally controlled blood pressure on today's exam.","cardiovascular / pulmonary, sinus rhythm, cardiac enzymes, abnormal ekg, stress test, elevated troponin, heart rate, blood pressure, radionuclide, chest, ekg, stress, ischemia"
" A 23-month-old girl has a history of reactive airway disease, is being treated on an outpatient basis for pneumonia, presents with cough and fever.", Cardiovascular / Pulmonary, Reactive Airway Disease ,"CHIEF COMPLAINT AND IDENTIFICATION:,  A is a 23-month-old girl, who has a history of reactive airway disease who is being treated on an outpatient basis for pneumonia who presents with cough and fever.,HISTORY OF PRESENT ILLNESS: , The patient is to known to have reactive airway disease and uses Pulmicort daily and albuterol up to 4 times a day via nebulization.,She has no hospitalizations.,The patient has had a 1 week or so history of cough.  She was seen by the primary care provider and given amoxicillin for yellow nasal discharge according to mom.  She has been taking 1 teaspoon every 6 hours.  She originally was having some low-grade fever with a maximum of 100.4 degrees Fahrenheit; however, on the day prior to admission, she had a 104.4 degrees Fahrenheit temperature, and was having posttussive emesis.  She is using her nebulizer, but the child was in respiratory distress, and this was not alleviated by the nebulizer, so she was brought to Children's Hospital Central California.,At Children's Hospital, the patient was originally treated as an asthmatic and was receiving nebulized treatments; however, a chest x-ray did show right-sided pneumonia, and the patient was hypoxemic after resolution of her respiratory distress, so the Hospitalist Service was contacted regarding admission.  The patient was seen and admitted through the emergency room.,REVIEW OF SYSTEMS: , Negative except that indicated in the history of present illness.  All systems were checked.,PAST MEDICAL HISTORY: , As stated in the history of present illness, no hospitalizations, no surgeries.,IMMUNIZATIONS: , The patient is up-to-date on her shots.  She has a schedule for her 2-year-old shot soon.,ALLERGIES: , No known drug allergies.,DEVELOPMENT HISTORY: , Developmentally, she is within normal limits.,FAMILY HISTORY:,  Her maternal uncles have asthma.  There are multiple family members on the maternal side that have diabetes mellitus, otherwise the family history is negative for other chronic medical conditions.,SOCIAL HISTORY: , Her sister has a runny nose, but no other sick contacts.  The family lives in Delano.  She lives with her mom and sister.  The dad is involved, but the parents are separated.  There is no smoking exposure.,PHYSICAL EXAMINATION:,  ,GENERAL:  The child was in no acute distress.,VITAL SIGNS:  Temperature 99.8 degrees Fahrenheit, heart rate 144, respiratory rate 28.  Oxygen saturations 98% on continuous.  Off of oxygen shows 85% laying down on room air.  The T-max in the ER was 101.3 degrees Fahrenheit.,SKIN:  Clear.,HEENT:  Pupils were equal, round, react to light.  No conjunctival injection or discharge.  Tympanic membranes were clear.  No nasal discharge.  Oropharynx moist and clear.,NECK:  Supple without lymphadenopathy, thyromegaly, or masses.,CHEST:  Clear to auscultation bilaterally; no tachypnea, wheezing, or retractions.,CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs noted.  Well perfused peripherally.,ABDOMEN:  Bowel sounds are present.  The abdomen is soft.  There is no hepatosplenomegaly, no masses, nontender to palpation.,GENITOURINARY:  No inguinal lymphadenopathy.  Tanner stage I female.,EXTREMITIES:  Symmetric in length.  No joint effusions.  She moves all extremities well.,BACK:  Straight.  No spinous defects.,NEUROLOGIC:  The patient has a normal neurologic exam.  She is sitting up solo in bed, gets on her knees, stands up, is playful, smiles, is interactive.  She has no focal neurologic deficits.,LABORATORY DATA: , Chest x-ray by my reading shows a right lower lobe infiltrate.  Metabolic panel:  Sodium 139, potassium 3.5, chloride 106, total CO2 22, BUN and creatinine are 5 and 0.3 respectively, glucose 84, CRP 4.3.  White blood cell count 13.7, hemoglobin and hematocrit 9.6 and 29.9 respectively, and platelets 294,000.  Differential of the white count 34% lymphocytes, 55% neutrophils.,ASSESSMENT AND PLAN: , This is a 22-month-old girl, who has an infiltrate on the x-ray, hypoxemia, and presented in respiratory distress.  I believe, she has bacterial pneumonia, which is partially treated by her amoxicillin, which is a failure of her outpatient treatment.  She will be placed on the pneumonia pathway and started on cefuroxime to broaden her coverage.  She is being admitted for hypoxemia.  I hope that this will resolve overnight, and she will be discharged in the morning.  I will start her home medications of Pulmicort twice daily and albuterol on a p.r.n. basis; however, at this point, she has no wheezing, so no systemic steroids will be instituted.,Further interventions will depend on the clinical course.",
 Pulmonary function test.  Mild restrictive airflow limitation.  Clinical correlation is recommended., Cardiovascular / Pulmonary, Pulmonary Function Test - 5 ,"OBSERVATIONS: , FEV1 is 3.76, 103% predicted.  FVC is 4.98, 110% predicted.  Ratio is 75.  FEF 25-75 is 3.053, 82% predicted, postbronchodilator improves by 35%.  DLCO is 35, 121% predicted.  Residual volume is 3.04, 139% predicted.  Total lung capacity is 8.34, 120% predicted.,Flow volume loop reviewed.,INTERPRETATION:,  Mild restrictive airflow limitation.  Clinical correlation is recommended.","cardiovascular / pulmonary, fev1, fvc, fef, dlco, lung capacity, postbronchodilator, pulmonary function test, restrictive airflowNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 A 16-year-old male with Q-fever endocarditis., Cardiovascular / Pulmonary, Q-Fever Endocarditis ,"HISTORY OF PRESENT ILLNESS: , This is a follow-up visit on this 16-year-old male who is currently receiving doxycycline 150 mg by mouth twice daily as well as hydroxychloroquine 200 mg by mouth three times a day for Q-fever endocarditis.  He is also taking digoxin, aspirin, warfarin, and furosemide.  Mother reports that he does have problems with 2-3 loose stools per day since September, but tolerates this relatively well.  This has not increased in frequency recently.,Mark recently underwent surgery at Children's Hospital and had on 10/15/2007, replacement of pulmonary homograft valve, resection of a pulmonary artery pseudoaneurysm, and insertion of Gore-Tex membrane pericardial substitute.  He tolerated this procedure well.  He has been doing well at home since that time.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature is 98.5, pulse 84, respirations 19, blood pressure 101/57, weight 77.7 kg, and height 159.9 cm.,GENERAL APPEARANCE:  Well-developed, well-nourished, slightly obese, slightly dysmorphic male in no obvious distress.,HEENT:  Remarkable for the badly degenerated left lower molar.  Funduscopic exam is unremarkable.,NECK:  Supple without adenopathy.,CHEST:  Clear including the sternal wound.,CARDIOVASCULAR:  A 3/6 systolic murmur heard best over the upper left sternal border.,ABDOMEN:  Soft.  He does have an enlarged spleen, however, given his obesity, I cannot accurately measure its size.,GU:  Deferred.,EXTREMITIES:  Examination of extremities reveals no embolic phenomenon.,SKIN:  Free of lesions.,NEUROLOGIC:  Grossly within normal limits.,LABORATORY DATA: , Doxycycline level obtained on 10/05/2007 as an outpatient was less than 0.5.  Hydroxychloroquine level obtained at that time was undetectable.  Of note is that doxycycline level obtained while in the hospital on 10/21/2007 was 6.5 mcg/mL.  Q-fever serology obtained on 10/05/2007 was positive for phase I antibodies in 1/2/6 and phase II antibodies at 1/128, which is an improvement over previous elevated titers.  Studies on the pulmonary valve tissue removed at surgery are pending.,IMPRESSION: , Q-fever endocarditis.,PLAN:  ,1.  Continue doxycycline and hydroxychloroquine.  I carefully questioned mother about compliance and concomitant use of dairy products while taking these medications.  She assures me that he is compliant with his medications.  We will however repeat his hydroxychloroquine and doxycycline levels.,2.  Repeat Q-fever serology.,3.  Comprehensive metabolic panel and CBC.,4.  Return to clinic in 4 weeks.,5.  Clotting times are being followed by Dr. X.","cardiovascular / pulmonary, q-fever, q-fever endocarditis, endocarditis, doxycycline, fever, "
" Pulmonary valve stenosis, supple pulmonic narrowing, and static encephalopathy", Cardiovascular / Pulmonary, Pulmonary Valve Stenosis ,"HISTORY: , The patient is a 19-year-old boy with a membranous pulmonary atresia, underwent initial repair 12/04/1987 consisting of pulmonary valvotomy and placement of 4 mm Gore-Tex shunt between the ascending aorta and pulmonary artery with a snare.  This was complicated by shunt thrombosis __________ utilizing a 10-mm balloon.  Resulting in significant hypoxic brain injury where he has been left with static encephalopathy and cerebral palsy.  On 04/07/1988, he underwent heart catheterization and balloon pulmonary valvuloplasty utilizing a 10-mm balloon.  He has been followed conservatively since that time.  A recent echocardiogram demonstrated possibly a significant right ventricle outflow tract obstruction with tricuspid valve regurgitation velocity predicting a right ventricular systolic pressure in excess of 180 mmHg.  Right coronary artery to pulmonary artery fistula was also appreciated.  The patient underwent cardiac catheterization to assess hemodynamics associated with his current state of repair.,PROCEDURE:,  The patient was placed under general endotracheal anesthesia breathing on 30% oxygen throughout the case.  Cardiac catheterization was performed as outlined in the attached continuation sheets.  Vascular entry was by percutaneous technique, and the patient was heparinized.  Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a 7-French sheath, a 6-French wedge catheter was inserted.  The right femoral vein advanced through the right heart structures out to the branch pulmonary arteries.  This catheter was then exchanged over wire for a 5-French marker pigtail catheter, which was directed into the main pulmonary artery.,Using a 5-French sheath, a 5-French pigtail catheter was inserted in the right femoral artery and advanced retrograde to the descending aorta, ascending aorta, and left ventricle.  This catheter was then exchanged for a Judkins right coronary catheter for selective cannulation of the right coronary artery.,Flows were calculated by the Fick technique using a measured assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with injection of the main pulmonary artery and right coronary artery.,After angiography, two normal-appearing renal collecting systems were visualized.  The catheters and sheaths were removed and topical pressure applied for hemostasis.  The patient was returned to the recovery room in satisfactory condition.  There were no complications.,DISCUSSION:,  Oxygen consumption was assumed to be normal.  Mixed venous saturation was normal with no evidence of intracardiac shunt.  Left-sided heart was fully saturated.  Phasic right atrial pressures were normal with an A-wave similar to the normal right ventricular end-diastolic pressure.  Right ventricular systolic pressure was mildly elevated at 45% systemic level.  There was a 25 mmHg peak systolic gradient across the outflow tract to the main branch pulmonary arteries.  Phasic branch pulmonary artery pressures were normal.  Right-to-left pulmonary artery capillary wedge pressures were normal with an A-wave similar to the normal left ventricular end-diastolic pressure of 12 mmHg.  Left ventricular systolic pressure was systemic with no outflow obstruction to the ascending aorta.  Phasic ascending and descending pressures were similar and normal.  The calculated systemic and pulmonary flows were equal and normal.  Vascular resistances were normal.  Angiogram with contrast injection in the main pulmonary artery showed catheter induced pulmonary insufficiency.  The right ventricle appeared mildly hypoplastic with a good contractility and mild tricuspid valve regurgitation.  There is dynamic narrowing of the infundibulum with hypoplastic pulmonary annulus.  The pulmonary valve appeared to be thin and moved well.  The median branch pulmonary arteries were of good size with normal distal arborization.  Angiogram with contrast injection in the right coronary artery showed a non-dominant coronary with a small fistula arising from the proximal right coronary artery coursing over the infundibulum and entering the left facing sinus of the main pulmonary artery.,INITIAL DIAGNOSES:,1.  Membranous pulmonary atresia.,2.  Atrial septal defect.,3.  Right coronary artery to pulmonary artery fistula.,SURGERIES (INTERVENTIONS):  ,1.  Pulmonary valvotomy surgical.,2.  Aortopulmonary artery central shunt.,3.  Balloon pulmonary valvuloplasty.,CURRENT DIAGNOSES:  ,1.  Pulmonary valve stenosis supplemented to hypoplastic pulmonary annulus.,2.  Mild right ventricle outflow tract obstruction due to supple pulmonic narrowing.,3.  Small right coronary artery to main pulmonary fistula.,4.  Static encephalopathy.,5.  Cerebral palsy.,MANAGEMENT: , The case to be discussed with combined Cardiology/Cardiothoracic Surgery case conference.  Given the mild degree of outflow tract obstruction in this sedentary patient, aggressive intervention is not indicated.  Conservative outpatient management is to be recommended.  Further patient care will be directed by Dr. X.","cardiovascular / pulmonary, membranous pulmonary atresia, atrial septal defect, pulmonary artery fistula, pulmonary valvotomy, central shunt, pulmonary valvuloplasty, static encephalopathy, cerebral palsy, hypoplastic pulmonary annulus, pulmonary valve stenosis, outflow tract obstruction, ventricular systolic pressure, branch pulmonary arteries, systolic pressure, pulmonary arteries, pulmonary valve, branch pulmonary, coronary artery, catheterization, artery, pulmonary, pressures, coronary, "
 Increasing oxygen requirement.  Baby boy has significant pulmonary hypertension.  , Cardiovascular / Pulmonary, Pulmonary Hypertension - Pediatric Consult ,"INDICATION FOR CONSULTATION: , Increasing oxygen requirement.,HISTORY: , Baby boy, XYZ, is a 29-3/7-week gestation infant.  His mother had premature rupture of membranes on 12/20/08.  She then presented to the Labor and Delivery with symptoms of flu.  The baby was then induced and delivered.  The mother had a history of premature babies in the past.  This baby was doing well, and then, we had a significant increasing oxygen requirement from room air up to 85%.  He is now on 60% FiO2.,PHYSICAL FINDINGS,GENERAL:  He appears to be pink, well perfused, and slightly jaundiced.,VITAL SIGNS:  Pulse 156, 56 respiratory rate, 92% sat, and 59/28 mmHg blood pressure.,SKIN:  He was pink.,He was on the high-frequency ventilator with good wiggle.,His echocardiogram showed normal structural anatomy.  He has evidence for significant pulmonary hypertension.  A large ductus arteriosus was seen with bidirectional shunt.  A foramen ovale shunt was also noted with bidirectional shunt.  The shunting for both the ductus and the foramen ovale was equal left to right and right to left.,IMPRESSION: , My impression is that baby boy, XYZ, has significant pulmonary hypertension.  The best therapy for this is to continue oxygen.  If clinically worsens, he may require nitric oxide.  Certainly, Indocin should not be used at this time.  He needs to have lower pulmonary artery pressures for that to be considered.,Thank you very much for allowing me to be involved in baby XYZ's care.","cardiovascular / pulmonary, high-frequency ventilator, structural anatomy, foramen ovale, oxygen requirement, hypertension, pulmonary "
 Patient returns to Pulmonary Medicine Clinic for followup evaluation of COPD and emphysema., Cardiovascular / Pulmonary, Pulmonary Medicine Clinic Followup ,"SUBJECTIVE:,  The patient returns to the Pulmonary Medicine Clinic for followup evaluation of COPD and emphysema.  She was last seen in the clinic in March 2004.  Since that time, she has been hospitalized for psychiatric problems and now is in a nursing facility.  She is very frustrated with her living situation and would like to return to her own apartment, however, some believes she is to ill to care for herself.,At the present time, respiratory status is relatively stable.  She is still short of breath with activity, but all-in-all her pulmonary disease has not changed significantly since her last visit.  She does have occasional cough and a small amount of sputum production.  No fever or chills.  No chest pains.,CURRENT MEDICATIONS:,  The patient’s current medications are as outlined.,ALLERGIES TO MEDICATIONS:,  Erythromycin.,REVIEW OF SYSTEMS:,  Significant for problems with agitated depression.  Her respiratory status is unchanged as noted above.,EXAMINATION:,General:  The patient is in no acute distress.,Vital signs:  Blood pressure is 152/80, pulse 80 and respiratory rate 16.,HEENT:  Nasal mucosa was mild-to-moderately erythematous and edematous.  Oropharynx was clear.,Neck:  Supple without palpable lymphadenopathy.,Chest:  Chest demonstrates decreased breath sounds throughout all lung fields, coarse but relatively clear.,Cardiovascular:  Distant heart tones.  Regular rate and rhythm.,Abdomen:  Soft and nontender.,Extremities:  Without edema.,Oxygen saturation was checked today on room air, at rest it was 90%.,ASSESSMENT:,1.  Chronic obstructive pulmonary disease/emphysema, severe but stable.,2.  Mild hypoxemia, however, oxygen saturation at rest is stable without supplemental oxygen.,3.  History of depression and schizophrenia.,PLAN:,  At this point, I have recommended that she continue current respiratory medicine.  I did suggest that she would not use her oxygen when she is simply sitting, watching television or reading.  I have recommended that she use it with activity and at night.  I spoke with her about her living situation.  Encouraged her to speak with her family, as well as primary care physician about making efforts for her to return to her apartment.  Follow up evaluation is planned in Pulmonary Medicine Clinic in approximately three months or sooner if need be.","cardiovascular / pulmonary, respiratory, copd, chronic obstructive pulmonary disease, pulmonary medicine clinic, depression, emphysema, followup, hypoxemia, oxygen, schizophrenia, oxygen saturation, pulmonary medicine, medicine clinic, chest, medicine, pulmonary, "
 Sample of Pulmonary Function Test, Cardiovascular / Pulmonary, Pulmonary Function Test - 4 ,"SPIROMETRY:,  Spirometry reveals the FVC to be adequate.,FEV1 is also adequate 93% predicted.  FEV1/FVC ratio is 114% predicted which is normal and FEF25 75% is 126% predicted.,After the use of bronchodilator, there is no significant improvement of the abovementioned parameters.,MVV is also normal.,LUNG VOLUMES: , Reveal a TLC to be 80% predicted.  FRC is mildly decreased and RV is also mildly decreased.  RV/TLC ratio is also normal 97% predicted.,DIFFUSION CAPACITY:,  After correction for alveolar ventilation, is 112% predicted which is normal.,OXYGEN SATURATION ON ROOM AIR:,  98%.,FINAL INTERPRETATION: , Pulmonary function test shows mild restrictive pulmonary disease.  There is no significant obstructive disease present.  There is no improvement after the use of bronchodilator and diffusion capacity is normal.  Oxygen saturation on room air is also adequate.  Clinical correlation will be necessary in this case.,","cardiovascular / pulmonary, fev1, fev1/fvc, fvc, fef25, frc, lung volumes, saturation on room air, pulmonary function test, diffusion capacity, oxygen saturation, pulmonary function, function test, spirometry, fev, bronchodilator, diffusion, capacity, oxygen, saturation, pulmonary,"
" This 61-year-old retailer who presents with acute shortness of breath, hypertension, found to be in acute pulmonary edema.   No confirmed prior history of heart attack, myocardial infarction, heart failure. ", Cardiovascular / Pulmonary, Pulmonary Edema - Consult ,"HISTORY:  ,This 61-year-old retailer who presents with acute shortness of breath, hypertension, found to be in acute pulmonary edema.  No confirmed prior history of heart attack, myocardial infarction, heart failure.  History dates back to about six months of intermittent shortness of breath, intermittent very slight edema with shortness of breath.  The blood pressure was up transiently last summer when this seemed to start and she was asked not to take Claritin-D, which she was taking for what she presumed was allergies.  She never had treated hypertension.  She said the blood pressure came down.  She is obviously very hypertensive this evening.  She has some mid scapular chest discomfort.  She has not had chest pain, however, during any of the other previous symptoms and spells.,CARDIAC RISKS:,  Does not smoke, lipids unknown.  Again, no blood pressure elevation, and she is not diabetic.,FAMILY HISTORY:,  Negative for coronary disease.  Dad died of lung cancer.,DRUG SENSITIVITIES:,  Penicillin.,CURRENT MEDICATIONS: , None.,SURGICAL HISTORY:,  Cholecystectomy and mastectomy for breast cancer in 1992, no recurrence.,SYSTEMS REVIEW: , Did not get headaches or blurred vision.  Did not suffer from asthma, bronchitis, wheeze, cough but short of breath as described above.  No reflux, abdominal distress.  No other types of indigestion, GI bleed.  GU:  Negative.  She is unaware of any kidney disease.  Did not have arthritis or gout.  No back pain or surgical joint treatment.  Did not have claudication, carotid disease, TIA.  All other systems are negative.,PHYSICAL FINDINGS,VITAL SIGNS:  Presenting blood pressure was 170/120 and her pulse at that time was 137.  Temperature was normal at 97, and she was obviously in major respiratory distress and hypoxemic.  Saturation of 86%.  Currently, blood pressure 120/70, heart rate is down to 100.,EYES:  No icterus or arcus.,DENTAL:  Good repair.,NECK:  Neck veins, cannot see JVD, at this point, carotids, no bruits, carotid pulse brisk.,LUNGS:  Fine and coarse rales, lower two thirds of chest.,HEART:  Diffuse cardiomegaly without a sustained lift, first and second heart sounds present, second is split.  There is loud third heart sound.  No murmur.,ABDOMEN:  Overweight, guess you would say obese, nontender, no liver enlargement, no bruits.,SKELETAL:  No acute joints.,EXTREMITIES:  Good pulses.  No edema.,NEUROLOGICALLY:  No focal weakness.,MENTAL STATUS:  Clear.,DIAGNOSTIC DATA: , 12-lead ECG, left bundle-branch block.,LABORATORY DATA:,  All pending.,RADIOGRAPHIC DATA: , Chest x-ray, pulmonary edema, cardiomegaly.,IMPRESSION,1.  Acute pulmonary edema.,2.  Physical findings of dilated left ventricle.,3.  Left bundle-branch block.,4.  Breast cancer in 1992.,PLAN:  ,Admit.  Aggressive heart failure management.  Get echo.  Start ACE and Coreg.  Diuresis of course underway.",
" Patient felt dizzy, had some cold sweats, mild shortness of breath, no chest pain, no nausea or vomiting, but mild diarrhea, and sat down and lost consciousness for a few seconds.", Cardiovascular / Pulmonary, Pulmonary Embolism ,"REASON FOR CONSULTATION: , Pulmonary embolism.,HISTORY:,  The patient is a 78-year-old lady who was admitted to the hospital yesterday with a syncopal episode that happened for the first time in her life.  The patient was walking in a store when she felt dizzy, had some cold sweats, mild shortness of breath, no chest pain, no nausea or vomiting, but mild diarrhea, and sat down and lost consciousness for a few seconds.  At that time, her daughter was with her.  No tonic-clonic movements.  No cyanosis.  The patient woke up on her own.  The patient currently feels fine, has mild shortness of breath upon exertion, but this is her usual for the last several years.  She cannot get up one flight of stairs, but feels short of breath.  She gets exerted and thinks to take a shower.  She does not have any chest pain, no fever or syncopal episodes.,PAST MEDICAL HISTORY,1.  Pulmonary embolism diagnosed one year ago.  At that time, she has had an IVC filter placed due to massive GI bleed from diverticulosis and gastric ulcers.  Paroxysmal atrial fibrillation and no anticoagulation due to history of GI bleed.,2.  Coronary artery disease status post CABG at that time.  She has had to stay in the ICU according to the daughter for 3 weeks due to again lower GI bleed.,3.  Mitral regurgitation.,4.  Gastroesophageal reflux disease.,5.  Hypertension.,6.  Hyperlipidemia.,7.  History of aortic aneurysm.,8.  History of renal artery stenosis.,9.  Peripheral vascular disease.,10.  Hypothyroidism.,PAST SURGICAL HISTORY,1.  CABG.,2.  Hysterectomy.,3.  IVC filter.,4.  Tonsillectomy.,5.  Adenoidectomy.,6.  Cosmetic surgery.,7.  Renal stent.,8.  Right femoral stent.,HOME MEDICATIONS,1.  Aspirin.,2.  Potassium.,3.  Lasix.,4.  Levothyroxine.,5.  Lisinopril.,6.  Pacerone.,7.  Protonix.,8.  Toprol.,9.  Vitamin B.,10.  Zetia.,11.  Zyrtec.,ALLERGIES:,  SULFA,SOCIAL HISTORY: , She used to be a smoker, not anymore.  She drinks 2 to 3 glasses of wine per week.  She is retired.,REVIEW OF SYSTEMS: , She has a history of snoring, choking for breath at night, and dry mouth in the morning.,PHYSICAL EXAMINATION,GENERAL APPEARANCE:  In no acute distress.,VITAL SIGNS:  Temperature 98.6, respirations 18, pulse 61, blood pressure 155/57, and oxygen saturation 93-98% on room air.,HEENT:  No lymph nodes or masses.,NECK:  No jugular venous distension.,LUNGS:  Clear to auscultation bilaterally.",
 Pulmonary Function Test in a patient with smoking history., Cardiovascular / Pulmonary, Pulmonary Function Test - 1 ,"HISTORY: , Smoking history 50-pack years of smoking.,INDICATION: , Dyspnea.,PROCEDURE: , FVC was 59%.  FEV1 was 45%.  FEV1/FVC ratio was 52%. The predicted was 67%.  FEF 25/75% was 22%, improved about 400-cc, which represents 89% improvement with bronchodilator.  SVC was 91%. Inspiratory capacity was 70%.  Residual volume was 225% of its predicted.  Total lung capacity was 128%.  ,IMPRESSION:,1.  Moderate obstructive lung disease with some improvement with bronchodilator indicating bronchospastic element.,2.  Probably there is some restrictive element because of fibrosis.  The reason for that is that the inspiratory capacity was limited and the total lung capacity did not increase to the same extent as the residual volume and expiratory residual volume.,3.  Diffusion capacity was not measured.  The flow volume loop was consistent with the above.,","cardiovascular / pulmonary, pulmonary function test, diffusion capacity, dyspnea, fef, fev1, fev1/fvc ratio, fvc, pft, residual volume, svc, smoking history, bronchodilator, bronchospastic, fibrosis, inspiratory capacity, lung capacity, obstructive lung disease, pulmonary function, "
 Sample of Pulmonary Function Test, Cardiovascular / Pulmonary, Pulmonary Function Test - 3 ,"SPIROMETRY: , Spirometry reveals the FVC to be adequate.,FEV1 is also normal at 98% predicted and FVC is 90.5% predicted.  FEF25-75% is also within normal limits at 110% predicted.  FEV1/FVC ratio is within normal limits at 108% predicted.,After the use of bronchodilator, there is some improvement with 10%.  MVV is within normal limits.,LUNG VOLUMES:,  Shows total lung capacity to be normal.  RV as well as RV/TLC ratio they are within normal limits.,DIFFUSION CAPACITY:,  Shows that after correction for alveolar ventilation, is also normal.,Oxygen Saturation on Room Air:  98%.,FINAL INTERPRETATION:,  Pulmonary function test shows no evidence of obstructive or restrictive pulmonary disease.  There is some improvement after the use bronchodilator.  Diffusion capacity is within normal limits.  Oxygen saturation on room air is also normal.  Clinical correlation will be necessary in this case.","cardiovascular / pulmonary, fvc, fev1, fev1/fvc ratio, fef, lung volumes, saturation on room air, pulmonary function test, pulmonary function, oxygen saturation, spirometry, bronchodilator, lung, diffusion, oxygen, saturation, pulmonary, capacity, "
 Pulmonary function test.  Mild-to-moderate obstructive ventilatory impairment.  Some improvement in the airflows after bronchodilator therapy., Cardiovascular / Pulmonary, Pulmonary Function Test ,"OBSERVATIONS: , The forced vital capacity is 2.84 L and forced expiratory volume in 1 second is 1.93 L. The ratio between the two is 68%.  Small improvement is noted in the airflows after bronchodilator therapy.  Lung volumes are increased with a residual volume of 196% of predicted and total lung capacity of 142% of predicted.  Single-breath diffusing capacity is slightly reduced.,IMPRESSION: , Mild-to-moderate obstructive ventilatory impairment.  Some improvement in the airflows after bronchodilator therapy.","cardiovascular / pulmonary, lung volume, forced expiratory volume, forced vital capacity, airflows, total lung capacity, bronchodilator therapy, bronchodilatorNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 Obstructive sleep apnea syndrome.  Loud snoring.  Schedule an overnight sleep study., Cardiovascular / Pulmonary, Pulmonary Consultation - 1 ,"CHIEF COMPLAINT:,  Rule out obstructive sleep apnea syndrome.,Sample Patient is a pleasant, 61-year-old, obese, African-American male with a past medical history significant for hypertension, who presents to the Outpatient Clinic with complaints of loud snoring and witnessed apnea episodes by his wife for at least the past five years.  He denies any gasping, choking, or coughing episodes while asleep at night.  His bedtime is between 10 to 11 p.m., has no difficulty falling asleep, and is usually out of bed around 7 a.m. feeling refreshed.  He has two to three episodes of nocturia per night.  He denies any morning symptoms.  He has mild excess daytime sleepiness manifested by dozing off during boring activities.,PAST MEDICAL HISTORY:,  Hypertension, gastritis, and low back pain.,PAST SURGICAL HISTORY:,  TURP.,MEDICATIONS:,  Hytrin, Motrin, Lotensin, and Zantac.,ALLERGIES:,  None.,FAMILY HISTORY:,  Hypertension.,SOCIAL HISTORY:,  Significant for about a 20-pack-year tobacco use, quit in 1991.  No ethanol use or illicit drug use.  He is married.  He has one dog at home.  He used to be employed at Budd Automotors as a die setter for about 37 to 40 years.,REVIEW OF SYSTEMS:,  His weight has been steady over the years.  Neck collar size is 17½"".  He denies any chest pain, cough, or shortness of breath.  Last chest x-ray within the past year, per his report, was normal.,PHYSICAL EXAM:,  A pleasant, obese, African-American male in no apparent respiratory distress.  T:  98.  P:  90.  RR:  20.  BP:  156/90.  O2 saturation:  97% on room air.  Ht:  5' 5"".  Wt:  198 lb.  HEENT:  A short thick neck, low-hanging palate, enlarged scalloped tongue, narrow foreshortened pharynx, clear nares, and no JVD.  CARDIAC:  Regular rate and rhythm without any adventitious sounds.  CHEST:  Clear lungs bilaterally. ABDOMEN:  An obese abdomen with active bowel sounds.  EXTREMITIES:  No cyanosis, clubbing, or edema.  NEUROLOGIC:  Non-focal.,IMPRESSION:,1.  Probable obstructive sleep apnea syndrome.,2.  Hypertension.,3.  Obesity.,4.  History of tobacco use.,PLAN:,1.  We will schedule an overnight sleep study to evaluate obstructive sleep apnea syndrome.,2.  Encouraged weight loss.,3.  Check TSH.,4.  Asked not to drive and engage in any activity that could endanger himself or others while sleepy.,5.  Asked to return to the clinic one week after sleep the study is done.",
 Patient with complaints of significant coughing and wheezing., Cardiovascular / Pulmonary, Pulmonary Consultation - 2 ,"PAST MEDICAL HISTORY:,  Unremarkable, except for diabetes and atherosclerotic vascular disease.,ALLERGIES:,  PENICILLIN.,CURRENT MEDICATIONS:,  Include Glucovance, Seroquel, Flomax, and Nexium.,PAST SURGICAL HISTORY: , Appendectomy and exploratory laparotomy.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:  ,The patient is a non-smoker.  No alcohol abuse.  The patient is married with no children.,REVIEW OF SYSTEMS:,  Significant for an old CVA.,PHYSICAL EXAMINATION:,  The patient is an elderly male alert and cooperative.  Blood pressure 96/60 mmHg.  Respirations were 20.  Pulse 94.  Afebrile.  O2 was 94% on room air.  HEENT:  Normocephalic and atraumatic.  Pupils are reactive.  Oral mucosa is grossly normal.  Neck is supple.  Lungs:  Decreased breath sounds.  Disturbed breath sounds with poor exchange.  Heart:  Regular rhythm.  Abdomen:  Soft and nontender.  No organomegaly or masses.  Extremities:  No cyanosis, clubbing, or edema.,LABORATORY DATA: , Oropharyngeal evaluation done on 11/02/2006 revealed mild oropharyngeal dysphagia with no evidence of laryngeal penetration or aspiration with food or liquid.  Slight reduction in tongue retraction resulting in mild residual remaining in the palatal sinuses, which clear with liquid swallow and double-saliva swallow.,ASSESSMENT:,1.  Cough probably multifactorial combination of gastroesophageal reflux and recurrent aspiration.,2.  Old CVA with left hemiparesis.,3.  Oropharyngeal dysphagia.,4.  Diabetes.,PLAN:,  At the present time, the patient is recommended to continue on a regular diet, continue speech pathology evaluation as well as perform double-swallow during meals with bolus sensation.  He may use Italian lemon ice during meals to help clear sinuses as well.  The patient will follow up with you.  If you need any further assistance, do not hesitate to call me.","cardiovascular / pulmonary, pulmonary evaluation, cough, wheezing, congestion, coughing and wheezing, breath sounds, oropharyngeal dysphagia, pulmonary, breath, sounds, dysphagia, aspiration, sinuses, oropharyngeal, coughing, swallowing, "
 Pulmonary Function Test to evaluate dyspnea., Cardiovascular / Pulmonary, Pulmonary Function Test - 2 ,"HISTORY:,  Smoking history zero.,INDICATION: , Dyspnea with walking less than 100 yards.,PROCEDURE:,  FVC was 59%.  FEV1 was 61%.  FEV1/FVC ratio was 72%. The predicted was 70%.  The FEF 25/75% was 45%, improved from 1.41 to 2.04 with bronchodilator, which represents a 45% improvement.  SVC was 69%. Inspiratory capacity was 71%.  Expiratory residual volume was 61%.  The TGV was 94%.  Residual volume was 113% of its predicted.  Total lung capacity was 83%.  Diffusion capacity was diminished.,IMPRESSION:,1.  Moderate restrictive lung disease.,2.  Some reversible small airway obstruction with improvement with bronchodilator.,3.  Diffusion capacity is diminished, which might indicate extrapulmonary restrictive lung disease.,4.  Flow volume loop was consistent with the above and no upper airway obstruction.,","cardiovascular / pulmonary, pulmonary function test, diffusion capacity, dyspnea, fef, fev1, fev1/fvc ratio, fvc, flow volume loop, pft, svc, smoking history, airway obstruction, bronchodilator, extrapulmonary, residual volume, restrictive lung disease, walking, pulmonary function, lung disease, pulmonary, function, lung, capacity"
" The patient is a 9-year-old born with pulmonary atresia, intact ventricular septum with coronary sinusoids.", Cardiovascular / Pulmonary, Pulmonary Atresia ,"HISTORY: , The patient is a 9-year-old born with pulmonary atresia, intact ventricular septum with coronary sinusoids.  He also has VACTERL association with hydrocephalus.  As an infant, he underwent placement of a right modified central shunt.  On 05/26/1999, he underwent placement of a bidirectional Glenn shunt, pulmonary artery angioplasty, takedown of the central shunt, PDA ligation, and placement of a 4 mm left-sided central shunt.  On 08/01/2006, he underwent cardiac catheterization and coil embolization of the central shunt.  A repeat catheterization on 09/25/2001 demonstrated elevated Glenn pressures and significant collateral vessels for which he underwent embolization.  He then underwent repeat catheterization on 11/20/2003 and further embolization of residual collateral vessels.  Blood pressures were found to be 13 mmHg with the pulmonary vascular resistance of 2.6-3.1 Wood units.  On 03/22/2004, he returned to the operating room and underwent successful 20 mm extracardiac Fontan with placement of an 8-mm fenestration and main pulmonary artery ligation.  A repeat catheterization on 09/07/2006, demonstrated mildly elevated Fontan pressures in the context of a widely patent Fontan fenestration and intolerance of Fontan fenestration occlusion.  The patient then followed conservatively since that time.  The patient is undergoing a repeat evaluation to assess his candidacy for a Fontan fenestration occlusion, as well as consideration for a tricuspid valvuloplasty in attempt to relieve right ventricular hypertension and associated membranous ventricular aneurysm protruding into the left ventricular outflow tract.,PROCEDURE:,  After sedation and local Xylocaine anesthesia, the patient was placed under general endotracheal anesthesia, the patient was prepped and draped.  Cardiac catheterization was performed as outlined in the attached continuation sheets.  Vascular entry was by percutaneous technique, and the patient was heparinized.  Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a 7-French sheath, a 6-French wedge catheter was inserted in the right femoral vein and advanced from the inferior vena cava along the Fontan conduit into the main left pulmonary artery, as well as the superior vena cava.  This catheter was then exchanged for a 5-French VS catheter of a distal wire.  Apposition of the right pulmonary artery over, which the wedge catheter was advanced.  The wedge catheter could then be easily advanced across the Fontan fenestration into the right atrium and guidewire manipulation allowed access across the atrial septal defect to the pulmonary veins, left atrium, and left ventricle.,Using a 5-French sheath, a 5-French pigtail catheter was inserted into the right femoral artery and advanced retrograde to the descending aorta, ascending aorta, and left ventricle.  Attempt was then made to cross the tricuspid valve from the right atrium and guidewire persisted to prolapse through the membranous ventricular septum into the left ventricle.  The catheter distal wire position was finally achieved across what appeared to be the posterior aspect of the tricuspid valve, both angiographically as well as equal guidance.  Left ventricular pressure was found to be suprasystemic.  A balloon valvoplasty was performed using a Ranger 4 x 2 cm balloon catheter with no waste at minimal inflation pressure.  Echocardiogram, which showed no significant change in the appearance of a tricuspid valve and persistence of aneurysmal membranous ventricular septum.  Further angioplasty was then performed first utilizing a 6 mm cutting balloon directed through 7-French flexor sheath positioned within the right atrium.  There was a disappearance of a mild waist prior to spontaneous tear of the balloon.  The balloon catheter was then removed in its entirety.,Echocardiogram again demonstrated no change in the appearance of the tricuspid valve.  A final angioplasty was performed utilizing a 80 mm cutting balloon with the disappearance of a distinctive waste.  Echocardiogram; however, demonstrated no change and intact appearing tricuspid valve and no decompression of the right ventricle.  Further attempts to cross tricuspid valve were thus abandoned.  Attention was then directed to a Fontan fenestration.  A balloon occlusion then demonstrated minimal increase in Fontan pressures from 12 mmHg to 15 mmHg.  With less than 10% fall in calculated cardiac index.  The angiogram in the inferior vena cava demonstrated a large fenestration measuring 6.6 mm in diameter with a length of 8 mm.  A 7-French flexor sheath was again advanced cross the fenestration.  A 10-mm Amplatzer muscular ventricular septal defect occluder was loaded on delivery catheter and advanced through the sheath where the distal disk was allowed to be figured in the right atrium.  Entire system was then brought into the fenestration and withdrawal of the sheath allowed reconfiguration of the proximal disk.  Once the stable device configuration was confirmed, device was released from the delivery catheter.  Hemodynamic assessment and the angiograms were then repeated.,Flows were calculated by the Fick technique using an assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Angiograms with injection in the right coronary artery, left coronary artery, superior vena cava, inferior vena cava, and right ventricle.,After angiography, two normal-appearing renal collecting systems were visualized.  The catheters and sheaths were removed and topical pressure applied for hemostasis.  The patient was returned to the recovery room in satisfactory condition.  There were no complications.,DISCUSSION: , Oxygen consumption was assumed to be normal.  Mixed venous saturation was low due to systemic arterial desaturation.  There was modest increased saturation of the branch pulmonary arteries due to the presumed aortopulmonary collateral flow.  The right pulmonary veins were fully saturated.  Left pulmonary veins were not entered.  There was a fall in saturation within the left ventricle and descending aorta due to a right to left shunt across the Fontan fenestration.  Mean Fontan pressures were 12 mmHg with a 1 mmHg fall in mean pressure into the distal left pulmonary artery.  Right and left pulmonary capillary wedge pressures were similar to left atrial phasic pressure with an A-wave similar to the normal left ventricular end-diastolic pressure of 11 mmHg.  Left ventricular systolic pressure was normal with at most 5 mmHg systolic gradient pressure pull-back to the ascending aorta.  Phasic ascending and descending aortic pressures were similar and normal.  The calculated systemic flow was normal.  Pulmonary flow was reduced to the QT-QS ratio of 0.7621.  Pulmonary vascular resistance was normal at 1 Wood units.,Angiogram with injection in the right coronary artery demonstrated diminutive coronary with an extensive sinusoidal communication to the rudimentary right ventricle.  The left coronary angiogram showed a left dominant system with a brisk flow to the left anterior descending and left circumflex coronary arteries.  There was communication to the right-sided coronary sinusoidal communication to the rudimentary right ventricle.  Angiogram with injection in the superior vena cava showed patent right bidirectional Glenn shunt with mild narrowing of the proximal right pulmonary artery, as well as the central pulmonary artery, diameter of which was augmented by the Glenn anastomosis and the Fontan anastomosis.  There was symmetric contrast flow to both pulmonary arteries.  A large degree of contrast flowed retrograde into the Fontan and shunting into the right atrium across the fenestration.  There is competitive flow to the upper lobes presumably due to aortopulmonary collateral flow.  The branch pulmonaries appeared mildly hypoplastic.  Levo phase contrast returned into the heart, appeared unobstructed demonstrating good left ventricular contractility.  Angiogram with injection in the Fontan showed a widely patent anastomosis with the inferior vena cava.  Majority of the contrast flowing across the fenestration into the right atrium with a positive flow to the branch pulmonary arteries.,Following the device occlusion of Fontan fenestration, the Fontan and mean pressure increased to 15 mmHg with a 3 mmHg, a mean gradient in the distal left pulmonary artery and no gradient into the right pulmonary artery.  There was an increase in the systemic arterial pressures.  Mixed venous saturation increased from the resting state as with increase in systemic arterial saturation to 95%.  The calculated systemic flow increased slightly from the resting state and pulmonary flow was similar with a QT-QS ratio of 0.921.  Angiogram with injection in the inferior vena cava showed a stable device configuration with a good disk apposition to the anterior surface of the Fontan with no protrusion into the Fontan and no residual shunt and no obstruction to a Fontan flow.  An ascending aortogram that showed a left aortic arch with trace aortic insufficiency and multiple small residual aortopulmonary collateral vessels arising from the intercostal arteries.  A small degree of contrast returned to the heart.,INITIAL DIAGNOSES:  ,1.  Pulmonary atresia.,2.  VACTERL association.,3.  Persistent sinusoidal right ventricle to the coronary communications.,4.  Hydrocephalus.,PRIOR SURGERIES AND INTERVENTIONS:  ,1.  Systemic to pulmonary shunts.,2.  Right bidirectional Glenn shunt.,3.  Revision of the central shunt.,4.  Ligation and division of patent ductus arteriosus.,5.  Occlusion of venovenous and arterial aortopulmonary collateral vessels.,6.  Extracardiac Fontan with the fenestration.,CURRENT DIAGNOSES:  ,1.  Favorable Fontan hemodynamics.,2.  Hypertensive right ventricle.,3.  Aneurysm membranous ventricular septum with mild left ventricle outflow tract obstruction.,4.  Patent Fontan fenestration.,CURRENT INTERVENTION:  ,1.  Balloon dilation tricuspid valve attempted and failed.,2.  Occlusion of a Fontan fenestration.,MANAGEMENT:  ,He will be discussed at Combined Cardiology/Cardiothoracic Surgery case conference.  A careful monitoring of ventricle outflow tract will be instituted with consideration for a surgical repair.  Further cardiologic care will be directed by Dr. X.",
" Port-A-Cath insertion template.  Catheter was inserted after subcutaneous pocket was created, the sheath dilators were advanced, and the wire and dilator were removed.", Cardiovascular / Pulmonary, Port-A-Cath Insertion ,"PROCEDURE PERFORMED: , Port-A-Cath insertion.,ANESTHESIA: , MAC.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:  ,Minimal.,PROCEDURE IN DETAIL:  ,Patient was prepped and draped in sterile fashion.  The left subclavian vein was cannulated with a wire.  Fluoroscopic confirmation of the wire in appropriate position was performed.  Then catheter was inserted after subcutaneous pocket was created, the sheath dilators were advanced, and the wire and dilator were removed.  Once the catheter was advanced through the sheath, the sheath was peeled away.  Catheter was left in place, which was attached to hub, placed in the subcutaneous pocket, sewn in place with 2-0 silk sutures, and then all hemostasis was further reconfirmed.  No hemorrhage was identified.  The port was in appropriate position with fluoroscopic confirmation.  The wound was closed in 2 layers, the 1st layer being 3-0 Vicryl, the 2nd layer being 4-0 Monocryl subcuticular stitch.  Dressed with Steri-Strips and 4 x 4's.  Port was checked.  Had good blood return, flushed readily with heparinized saline.","cardiovascular / pulmonary, hemostasis, port a cath insertion, fluoroscopic confirmation, cath insertion, insertion, fluoroscopic, subcutaneous, catheter, sheath, dilators, wire, "
 Pulmonary Medicine Clinic for followup evaluation of interstitial disease secondary to lupus pneumonitis., Cardiovascular / Pulmonary, Pulmonary - Followup Note ,"SUBJECTIVE:,  The patient returns to the Pulmonary Medicine Clinic for followup evaluation of interstitial disease secondary to lupus pneumonitis.  She was last seen in the Pulmonary Medicine Clinic in January 2004.  Since that time, her respiratory status has been quite good.  She has had no major respiratory difficulties; however, starting yesterday she began with increasing back and joint pain and as a result a deep breath has caused some back discomfort.  She denies any problems with cough or sputum production.  No fevers or chills.  Recently, she has had a bit more problems with fatigue.  For the most part, she has had no pulmonary limitations to her activity.,CURRENT MEDICATIONS:,  Synthroid 0.112 mg daily; Prilosec 20 mg daily; prednisone, she was 2.5 mg daily, but discontinued this on 06/16/2004; Plaquenil 200 mg b.i.d.; Imuran 100 mg daily; Advair one puff b.i.d.; Premarin 0.3 mg daily; Lipitor 10 mg Monday through Friday; Actonel 35 mg weekly; and aspirin 81 mg daily.  She is also on calcium, vitamin D, vitamin E, vitamin C and a multivitamin.,ALLERGIES:,  Penicillin and also intolerance to shellfish.,REVIEW OF SYSTEMS:,  Noncontributory except as outlined above.,EXAMINATION:,General:  The patient was in no acute distress.,Vital signs:  Blood pressure 122/60, pulse 72 and respiratory rate 16.,HEENT:  Nasal mucosa was mild-to-moderately erythematous and edematous.  Oropharynx was clear.,Neck:  Supple without palpable lymphadenopathy.,Chest:  Chest demonstrates decreased breath sounds, but clear.,Cardiovascular:  Regular rate and rhythm.,Abdomen:  Soft and nontender.,Extremities:  Without edema.  No skin lesions.,O2 saturation was checked at rest.  On room air it was 96% and on ambulation it varied between 94% and 96%.  Chest x-ray obtained today showed mild increased interstitial markings consistent with a history of lupus pneumonitis.  She has not had the previous chest x-ray with which to compare; however, I did compare the markings was less prominent when compared with previous CT scan.,ASSESSMENT:,1.  Lupus with mild pneumonitis.,2.  Respiratory status is stable.,3.  Increasing back and joint pain, possibly related to patient’s lupus, however, in fact may be related to recent discontinuation of prednisone.,PLAN:,  At this time, I have recommended to continue her current medications.  We would like to see her back in approximately four to five months, at which time I would like to recheck her pulmonary function test as well as check CAT scan.  At that point, it may be reasonable to consider weaning her Imuran if her pulmonary status is stable and the lupus appears to be under control.","cardiovascular / pulmonary, pulmonary medicine clinic, cat scan, lupus, respiratory status, chest x-ray, interstitial disease, lupus pneumonitis, pneumonitis, pulmonary function test, pulmonary status, respiratory difficulties, chest x ray, interstitial, respiratory, chest, pulmonary, "
 Aspiration pneumonia and chronic obstructive pulmonary disease (COPD) exacerbation.  Acute respiratory on chronic respiratory failure secondary to chronic obstructive pulmonary disease exacerbation.  Systemic inflammatory response syndrome secondary to aspiration pneumonia.  No bacteria identified with blood cultures or sputum culture., Cardiovascular / Pulmonary, Pneumonia & COPD - Discharge Summary ,"ADMISSION DIAGNOSES:,1.  Pneumonia, likely secondary to aspiration.,2.  Chronic obstructive pulmonary disease (COPD) exacerbation.,3.  Systemic inflammatory response syndrome.,4.  Hyperglycemia.,DISCHARGE DIAGNOSES:,1.  Aspiration pneumonia.,2.  Aspiration disorder in setting of severe chronic obstructive pulmonary disease.,3.  Chronic obstructive pulmonary disease (COPD) exacerbation.,4.  Acute respiratory on chronic respiratory failure secondary to chronic obstructive pulmonary disease exacerbation.,5.  Hypercapnia on admission secondary to chronic obstructive pulmonary disease.,6.  Systemic inflammatory response syndrome secondary to aspiration pneumonia.  No bacteria identified with blood cultures or sputum culture.,7.  Atrial fibrillation with episodic rapid ventricular rate, now rate control.,8.  Hyperglycemia secondary to poorly controlled type ii diabetes mellitus, insulin requiring.,9.  Benign essential hypertension, poorly controlled on admission, now well controlled on discharge.,10.  Aspiration disorder exacerbated by chronic obstructive pulmonary disease and acute respiratory failure.,11.  Hyperlipidemia.,12.  Acute renal failure on chronic renal failure on admission, now resolved.,HISTORY OF PRESENT ILLNESS:,  Briefly, this is 73-year-old white male with history of multiple hospital admissions for COPD exacerbation and pneumonia who presented to the emergency room on 04/23/08, complaining of severe shortness of breath.  The patient received 3 nebulizers at home without much improvement.  He was subsequently treated successfully with supplemental oxygen provided by normal nasal cannula initially and subsequently changed to BiPAP.,HOSPITAL COURSE:  ,The patient was admitted to the hospitalist service, treated with frequent small volume nebulizers, treated with IV Solu-Medrol and BiPAP support for COPD exacerbation.  The patient also noted with poorly controlled atrial fibrillation with a rate in the low 100s to mid 100s.  The patient subsequently received diltiazem, also received p.o. digoxin.  The patient subsequently responded well as well received IV antibiotics including Levaquin and Zosyn.  The patient made slow, but steady improvement over the course of his hospitalization.  The patient subsequently was able to be weaned off BiPAP during the day, but continued BiPAP at night and will continue with BiPAP if needed.  The patient may require a sleep study after discharge, but by the third day prior to discharge he was no longer utilizing BiPAP, was simply using supplemental O2 at night and was able to maintain appropriate and satisfactory O2 saturations on one-liter per minute supplemental O2 per nasal cannula.  The patient was able to participate with physical therapy, able to ambulate from his bed to the bathroom, and was able to tolerate a dysphagia 2 diet.  Note that speech therapy did provide a consultation during this hospitalization and his modified barium swallow was thought to be unremarkable and really related only to the patient's severe shortness of breath during meal time.  The patient's chest x-ray on admission revealed some mild vascular congestion and bilateral pleural effusions that appeared to be unchanged.  There was also more pronounced patchy alveolar opacity, which appeared to be, ""mass like"" in the right suprahilar region.  This subsequently resolved and the patient's infiltrate slowly improved over the course of his hospitalization.  On the day prior to discharge, the patient had a chest x-ray 2 views, which allowing for differences in technique revealed little change in the bibasilar infiltrates and atelectatic changes at the bases bilaterally.  This was compared with an examination performed 3 days prior.  The patient also had minimal bilateral effusions.  The patient will continue with clindamycin for the next 2 weeks after discharge.  Home health has been ordered and the case has been discussed in detail with Shaun Eagan, physician assistant at Eureka Community Health Center.  The patient was discharged as well on a dysphagia 2 diet, thin liquids are okay.  The patient discharged on the following medications.,DISCHARGE MEDICATIONS:,1.  Home oxygen 1 to 2 liters to maintain O2 saturations at 89 to 91% at all times.,2.  Ativan 1 mg p.o. t.i.d.,3.  Metformin 1000 mg p.o. b.i.d.,4.  Glucotrol 5 mg p.o. daily.,5.  Spiriva 1 puff b.i.d.,6.  Lantus 25 units subcu q.a.m.,7.  Cardizem CD 180 mg p.o. q.a.m.,8.  Advair 250/50 mcg, 1 puff b.i.d.  The patient is instructed to rinse with mouthwash after each use.,9.  Iron 325 mg p.o. b.i.d.,10.  Aspirin 325 mg p.o. daily.,11.  Lipitor 10 mg p.o. bedtime.,12.  Digoxin 0.25 mg p.o. daily.,13.  Lisinopril 20 mg p.o. q.a.m.,14.  DuoNeb every 4 hours for the next several weeks, then q.6 h. thereafter, dispensed 180 DuoNeb ampule's with one refill.,15.  Prednisone 40 mg p.o. q.a.m. x3 days followed by 30 mg p.o. q.a.m. x3 days, then followed by 20 mg p.o. q.a.m. x5 days, then 10 mg p.o. q.a.m. x14 days, then discontinue, #30 days supply given.  No refills.,16.  Clindamycin 300 mg p.o. q.i.d. x2 weeks, dispensed #64 with one refill.,The patient's aspiration pneumonia was discussed in detail.  He is agreeable to obtaining a chest x-ray PA and lateral after 2 weeks of treatment.  Note that this patient did not have community-acquired pneumonia.  His discharge diagnosis is aspiration pneumonia.  The patient will continue with a dysphagia 2 diet with thin liquids after discharge.  The patient discharged with home health.  A dietary and speech therapy evaluation has been ordered.  Speech therapy to treat for chronic dysphagia and aspiration in the setting of severe chronic obstructive pulmonary disease.,Total discharge time was greater than 30 minutes.",
 Insertion of subclavian dual-port Port-A-Cath and surgeon-interpreted fluoroscopy., Cardiovascular / Pulmonary, Port-A-Cath Insertion - 5 ,"PROCEDURES PERFORMED,1.  Insertion of subclavian dual-port Port-A-Cath.,2.  Surgeon-interpreted fluoroscopy.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and general endotracheal anesthesia was administered.  Next, the chest was prepped and draped in a standard surgical fashion.  A #18-gauge spinal needle was used to aspirate blood from the subclavian vein.  After aspiration of venous blood, Seldinger technique was used to thread a J wire.  The distal tip of the J wire was confirmed to be in adequate position with surgeon-interpreted fluoroscopy.  Next a #15-blade scalpel was used to make an incision in the skin.  Dissection was carried down to the level of the pectoralis muscle.  A pocket was created.  A dual-port Port-A-Cath was lowered into the pocket and secured with #2-0 Prolene.  Both ports were flushed.  The distal tip was pulled through to the wire exit site with a Kelly clamp.  It was cut to the appropriate length.  Next a dilator and sheath were threaded over the J wire.  The J wire and dilator were removed, and the distal tip of the dual-port Port-A-Cath was threaded over the sheath, which was simultaneously withdrawn.  Both ports of the dual-port Port-A-Cath were flushed and aspirated without difficulty.  The distal tip was confirmed to be in adequate position with surgeon-interpreted fluoroscopy.  The wire access site was closed with a 4-0 Monocryl.  The port pocket was closed in 2 layers with 2-0 Vicryl followed by 4-0 Monocryl in a running subcuticular fashion.  Sterile dressing was applied.  The patient tolerated the procedure well and was transferred to the PACU in good condition","cardiovascular / pulmonary, surgeon-interpreted fluoroscopy, j wire, dual-port port-a-cath, port a cath, subclavian, fluoroscopy, cathNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Patient with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung. , Cardiovascular / Pulmonary, Pneumoconiosis ,"HISTORY OF PRESENT ILLNESS: , This is a 91-year-old male with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung.  The patient also has a positive history of smoking in the past.  At the present time, he is admitted for continued,management of respiratory depression with other medical complications.  The patient was treated for multiple problems at Jefferson Hospital prior to coming here including abdominal discomfort due to a ureteral stone with resultant hydronephrosis and hydroureter.  In addition, he also developed cardiac complications including atrial fibrillation.  The patient was evaluated by the cardiologist as well as the pulmonary service and Urology.  He had a cystoscopy performed and a left ureteral stone was removed as well as insertion of a left ureteral stent on 07/23/2008.  He subsequently underwent cardiac arrest and he was resuscitated at that time.  He was intubated and placed on mechanical ventilatory support.  Subsequent weaning was unsuccessful.  He then had a tracheostomy placed.,CURRENT MEDICATIONS:,1.  Albuterol.,2.  Pacerone.,3.  Theophylline,4.  Lovenox.,5.  Atrovent.,6.  Insulin.,7.  Lantus.,8.  Zestril.,9.  Magnesium oxide.,10.  Lopressor.,11.  Zegerid.,12.  Tylenol as needed.,ALLERGIES:,  PENICILLIN.,PAST MEDICAL HISTORY:,1.  History of coal miner's disease.,2.  History of COPD.,3.  History of atrial fibrillation.,4.  History of coronary artery disease.,5.  History of coronary artery stent placement.,6.  History of gastric obstruction.,7.  History of prostate cancer.,8.  History of chronic diarrhea.,9.  History of pernicious anemia.,10.  History of radiation proctitis.,11.  History of anxiety.,12.  History of ureteral stone.,13.  History of hydronephrosis.,SOCIAL HISTORY: , The patient had been previously a smoker.  No other could be obtained because of tracheostomy presently.,FAMILY HISTORY: , Noncontributory to the present condition and review of his previous charts.,SYSTEMS REVIEW: , The patient currently is agitated.  Rapidly moving his upper extremities.  No other history regarding his systems could be elicited from the patient.,PHYSICAL EXAM:,General:  The patient is currently agitated with some level of distress.  He has rapid respiratory rate.  He is responsive to verbal commands by looking at the eyes.,Vital Signs:  As per the monitors are stable.,Extremities:  Inspection of the upper extremities reveals extreme xerosis of the skin with multiple areas of ecchymosis and skin tears some of them to the level of stage II especially over the dorsum of the hands and forearm areas.  There is also edema of the forearm extending up to the mid upper arm area.  Palpation of the upper extremities reveals fibrosis more prominent on the right forearm area with the maximum edema in the elbow area on the ulnar aspect.  There is also scabbing of some of the possibly from earlier skin tears in the upper side forearm area.,IMPRESSION:,1.  Ulceration of bilateral upper extremities.,2.  Cellulitis of upper extremities.,3.  Lymphedema of upper extremities.,4.  Other noninfectious disorders of lymphatic channels.,5.  Ventilatory-dependent respiratory failure.",
" Preeclampsia, status post delivery with Cesarean section with uncontrolled blood pressure.  The patient is a 38-year-old female admitted following a delivery.  The patient had a cesarean section.  Following this, the patient was treated for her blood pressure.  She was sent home and she came back again apparently with uncontrolled blood pressure.", Cardiovascular / Pulmonary, Preeclampsia ,"REASON FOR CONSULTATION: , Management of blood pressure.,HISTORY OF PRESENT ILLNESS: , The patient is a 38-year-old female admitted following a delivery.  The patient had a cesarean section.  Following this, the patient was treated for her blood pressure.  She was sent home and she came back again apparently with uncontrolled blood pressure.  She is on multiple medications, unable to control the blood pressure.  From cardiac standpoint, the patient denies any symptoms of chest pain, or shortness of breath.  She complains of fatigue and tiredness.  The child had some congenital anomaly, was transferred to Hospital, where the child has had surgery.  The patient is in intensive care unit.,CORONARY RISK FACTORS:,  History of hypertension, history of gestational diabetes mellitus, nonsmoker, and cholesterol is normal.  No history of established coronary artery disease and family history noncontributory for coronary disease.,FAMILY HISTORY: , Nonsignificant.,SURGICAL HISTORY:  ,No major surgery except for C-section.,MEDICATIONS:,  Presently on Cardizem and metoprolol were discontinued.  Started on hydralazine 50 mg t.i.d., and labetalol 200 mg b.i.d., hydrochlorothiazide, and insulin supplementation.,ALLERGIES: , None.,PERSONAL HISTORY: , Nonsmoker.  Does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY:,  Hypertension, gestational diabetes mellitus, pre-eclampsia, this is her third child with one miscarriage.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No history of fever, rigors, or chills.,HEENT:  No history of cataract, blurry vision, or glaucoma.,CARDIOVASCULAR:  No congestive heart.  No arrhythmia.,RESPIRATORY:  No history of pneumonia or valley fever.,GASTROINTESTINAL:  No epigastric discomfort, hematemesis, or melena.,UROLOGIC:  No frequency or urgency.,MUSCULOSKELETAL:  No arthritis or muscle weakness.,SKIN:  Nonsignificant.,NEUROLOGICAL:  No TIA.  No CVA.  No seizure disorder.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 86, blood pressure 175/86, afebrile, and respiratory rate 16 per minute.,HEENT:  Atraumatic and normocephalic.,NECK:  Neck veins are flat.,LUNGS:  Clear.,HEART:  S1 and S2 regular.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema.  Pulses palpable.,LABORATORY DATA: , EKG shows sinus tachycardia with nonspecific ST-T changes.  Labs were noted.  BUN and creatinine within normal limits.,IMPRESSION:,1.  Preeclampsia, status post delivery with Cesarean section with uncontrolled blood pressure.,2.  No prior history of cardiac disease except for borderline gestational diabetes mellitus.,RECOMMENDATIONS:,1.  We will get an echocardiogram for assessment left ventricular function.,2.  The patient will start on labetalol and hydralazine to see how see fairs.,3.  Based on response to medication, we will make further adjustments.  Discussed with the patient regarding plan of care, fully understands and consents for the same.  All the questions answered in detail.",
" Atypical pneumonia, hypoxia, rheumatoid arthritis, and suspected mild stress-induced adrenal insufficiency.  This very independent 79-year old had struggled with cough, fevers, weakness, and chills for the week prior to admission.", Cardiovascular / Pulmonary, Pneumonia - Discharge Summary ,"ADMISSION DIAGNOSES:,1.  Pneumonia, failed outpatient treatment.,2.  Hypoxia.,3.  Rheumatoid arthritis.,DISCHARGE DIAGNOSES:,1.  Atypical pneumonia, suspected viral.,2.  Hypoxia.,3.  Rheumatoid arthritis.,4.  Suspected mild stress-induced adrenal insufficiency.,HOSPITAL COURSE: , This very independent 79-year old had struggled with cough, fevers, weakness, and chills for the week prior to admission.  She was seen on multiple occasions at Urgent Care and in her physician's office.  Initial x-ray showed some mild diffuse patchy infiltrates.  She was first started on Avelox, but had a reaction, switched to Augmentin, which caused loose stools, and then three days prior to admission was given daily 1 g Rocephin and started on azithromycin.  Her O2 saturations drifted downward.  They were less than 88% when active; at rest, varied between 88% and 92%.  Decision was made because of failed outpatient treatment of pneumonia.  Her medical history is significant for rheumatoid arthritis.  She is on 20 mg of methotrexate every week as well as Remicade every eight weeks.  Her last dose of Remicade was in the month of June.  Hospital course was relatively unremarkable.  CT scan was performed and no specific focal pathology was seen.  Dr. X, pulmonologist was consulted.  He also was uncertain as to the exact etiology, but viral etiology was most highly suspected.  Because of her loose stools, C. difficile toxin was ordered, although that is pending at the time of discharge.  She was continued on Rocephin IV and azithromycin.  Her fever broke 18 hours prior to discharge, and O2 saturations improved, as did her overall strength and clinical status.  She was instructed to finish azithromycin.  She has two pills left at home.  She is to follow up with Dr. X in two to three days.  Because she is on chronic prednisone therapy, it was suspected that she was mildly adrenal insufficient from the stress of her pneumonia.  She is to continue the increased dose of prednisone at 20 mg (up from 5 mg per day).  We will consult her rheumatologist as to whether to continue her methotrexate, which we held this past Friday.  Methotrexate is known on some occasions to cause pneumonitis.","cardiovascular / pulmonary, adrenal insufficiency, hypoxia, cough, fevers, weakness, chills, atypical pneumonia, loose stools, rheumatoid arthritis, azithromycin, arthritis, pneumonia, "
 Consult for subcutaneous emphysema and a small right-sided pneumothorax secondary to trauma., Cardiovascular / Pulmonary, Pneumothorax & Subcutaneous Emphysema ,"REASON FOR CONSULTATION:,  Pneumothorax and subcutaneous emphysema.,HISTORY OF PRESENT ILLNESS: , The patient is a 48-year-old male who was initially seen in the emergency room on Monday with complaints of scapular pain.  The patient presented the following day with subcutaneous emphysema and continued complaints of pain as well as change in his voice.  The patient was evaluated with a CT scan of the chest and neck which demonstrated significant subcutaneous emphysema, a small right-sided pneumothorax, but no other findings.  The patient was admitted for observation.,PAST SURGICAL HISTORY: , Hernia repair and tonsillectomy.,ALLERGIES: , Penicillin.,MEDICATIONS: , Please see chart.,REVIEW OF SYSTEMS:,  Not contributory.,PHYSICAL EXAMINATION:,GENERAL:  Well developed, well nourished, lying on hospital bed in minimal distress.,HEENT:  Normocephalic and atraumatic.  Pupils are equal, round, and reactive to light.  Extraocular muscles are intact.,NECK:  Supple.  Trachea is midline.,CHEST:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  Regular rate and rhythm.,ABDOMEN:  Soft, nontender, and nondistended.  Normoactive bowel sounds.,EXTREMITIES:  No clubbing, edema, or cyanosis.,SKIN:  The patient has significant subcutaneous emphysema of the upper chest and anterior neck area although he states that the subcutaneous emphysema has improved significantly since yesterday.,DIAGNOSTIC STUDIES:,  As above.,IMPRESSION: , The patient is a 48-year-old male with subcutaneous emphysema and a small right-sided pneumothorax secondary to trauma.  These are likely a result of either a parenchymal lung tear versus a small tracheobronchial tree rend.,RECOMMENDATIONS:,  At this time, the CT Surgery service has been consulted and has left recommendations.  The patient also is awaiting bronchoscopy per the Pulmonary Service.  At this time, there are no General Surgery issues.","cardiovascular / pulmonary, trauma, tracheobronchial, bronchoscopy, scapular pain, subcutaneous emphysema, pneumothorax, subcutaneous, emphysema, "
 Cardiology consultation regarding preoperative evaluation for right hip surgery.  Patient with a history of coronary artery disease status post bypass surgery, Cardiovascular / Pulmonary, Preop Cardiac Consult ,"HISTORY OF PRESENT ILLNESS: , I was kindly asked to see Ms. ABC by Dr. X for cardiology consultation regarding preoperative evaluation for right hip surgery.  She is a patient with a history of coronary artery disease status post bypass surgery in 1971 who tripped over her oxygen last p.m. she states and fell.  She suffered a right hip fracture and is being considered for right hip replacement.  The patient denies any recent angina, but has noted more prominent shortness of breath.,Past cardiac history is significant for coronary artery disease status post bypass surgery, she states in 1971, I believe it was single vessel.  She has had stress test done in our office on September 10, 2008, which shows evidence of a small apical infarct, no area of ischemia, and compared to study of December of 2005, there is no significant change.  She had a transthoracic echocardiogram done in our office on August 29, 2008, which showed normal left ventricular size and systolic function, dilated right ventricle with septal flattening of the left ventricle consistent with right ventricular pressure overload, left atrial enlargement, severe tricuspid regurgitation with estimated PA systolic pressure between 75-80 mmHg consistent with severe pulmonary hypertension, structurally normal aortic and mitral valve.  She also has had some presumed atrial arrhythmias that have not been sustained.  She follows with Dr. Y my partner at Cardiology Associates.,PAST MEDICAL HISTORY:  ,Other medical history includes severe COPD and she is oxygen dependent, severe pulmonary hypertension, diabetes, abdominal aortic aneurysm, hypertension, dyslipidemia.  Last ultrasound of her abdominal aorta done June 12, 2009 states that it was fusiform, infrarenal shaped aneurysm of the distal abdominal aorta measuring 3.4 cm unchanged from prior study on June 11, 2008.,MEDICATIONS:,  As an outpatient:,1.  Lanoxin 0.125 mg, 1/2 tablet once a day.,2.  Tramadol 50 mg p.o. q.i.d. as needed.,3.  Verapamil 240 mg once a day.,4.  Bumex 2 mg once a day.,5.  ProAir HFA.,6.  Atrovent nebs b.i.d.,7.  Pulmicort nebs b.i.d.,8.  Nasacort 55 mcg, 2 sprays daily.,9.  Quinine sulfate 325 mg p.o. q.h.s. p.r.n.,10.  Meclizine 12.5 mg p.o. t.i.d. p.r.n.,11.  Aldactone 25 mg p.o. daily.,12.  Theo-24 200 mg p.o., 2 in the morning.,13.  Zocor 40 mg once a day.,14.  Vitamin D 400 units twice daily.,15.  Levoxyl 125 mcg once a day.,16.  Trazodone 50 mg p.o. q.h.s. p.r.n.,17.  Janumet 50/500, 1 tablet p.o. b.i.d.,ALLERGIES: , To medications are listed as:,1.  LEVAQUIN.,2.  AZITHROMYCIN.,3.  ADHESIVE TAPE.,4.  BETA BLOCKERS.  When I talked to the patient about the BETA BLOCKER, she states that they made her more short of breath in the past.,She denies shrimp, seafood or dye allergy.,FAMILY HISTORY:  ,Significant for heart problems she states in her mother and father.,SOCIAL HISTORY:  ,She used to smoke cigarettes and smoked from the age of 14 to 43 and quit at the time of her bypass surgery.  She does not drink alcohol nor use illicit drugs.  She lives alone and is widowed.  She is a retired custodian at University.  Of note, she is accompanied with her verbal consent by her daughter and grandson at the bedside.,REVIEW OF SYSTEMS:  ,Unable to obtain as the patient is somnolent from her pain medication, but she is alert and able to answer my direct questions.,PHYSICAL EXAM: , Height 5'2"", weight 160 pounds, temperature is 99.5 degrees ranging up to 101.6, blood pressure 137/67 to 142/75, pulse 92, respiratory rate 16, O2 saturation 93-89%.  On general exam, she is an elderly, chronically ill appearing woman in no acute distress.  She is able to lie flat, she does have pain if she moves.  HEENT shows the cranium is normocephalic, atraumatic.  She has dry mucosal membranes.  Neck veins are not distended.  There are no carotid bruits.  Visible skin is warm and she appears pale.  Affect appropriate and she is somnolent from her pain medications, but arouses easily and answers my direct questions appropriately.  Lungs are clear to auscultation anteriorly, no wheezes.  Cardiac exam S1, S2 regular rate, soft holosystolic murmur heard over the tricuspid region.  No rub nor gallop.  PMI is nondisplaced, unable to appreciate RV heave.  Abdomen soft, mildly distended, appears benign.  Extremities with trivial peripheral edema.  Pulses grossly intact.  She has quite a bit of pain at the right hip fracture.,DIAGNOSTIC/LABORATORY DATA:  ,Sodium 135, potassium 4.7, chloride 99, bicarbonate 33, BUN 22, creatinine 1.3, glucose 149, troponin was 0.01 followed by 0.04.  Theophylline level 16.6 on January 23, 2009.  TSH 0.86 on March 10, 2009.  INR 1.06.  White blood cell count 9.5, hematocrit 35, platelet count 160.,EKG done July 16, 2009 at 7:31:15, shows sinus rhythm, which showed PR interval of about 118 milliseconds, nonspecific T wave changes.  When compared to EKG done July 15, 2009 at 1948, previously there more frequent PVCs seen.  This ECG appears similar to the ones she has had done previously in our office including on June 11, 2009, although the T wave changes are a bit more prominent, which is a nonspecific finding.,IMPRESSION: , She is an 81-year-old woman with severe O2 requiring chronic obstructive pulmonary disease with evidence of right heart overload, as well as known coronary artery disease status post single-valve bypass in 1971 suffering a right hip fracture for whom a right hip replacement is being considered.  I have had a long discussion with the patient, as well as her daughter and grandson at the bedside today.  There are no clear absolute cardiac contraindications that I can see.  Of note at the time of this dictation a chest x-ray report is pending.  With that being said, however, she is extremely high risk more from a pulmonary than cardiac standpoint.  We did also however review that untreated hip fractures themselves have very high morbidity and mortality incidences.  The patient is deciding on surgery and is clearly aware that she is very high risk for proposed surgery, as well as if she were to not pursue surgery.,PLAN/RECOMMENDATIONS:,1.  The patient is going to decide on surgery.  If she does have the right hip surgery, I would recommend overnight observation in the intensive care unit.,2.  Optimize pulmonary function and pursue aggressive DVT prophylaxis.,3.  Continue digoxin and verapamil.  Again, the patient describes clear INTOLERANCE TO BETA BLOCKERS by her history.",
" Left hemothorax, rule out empyema.  Insertion of a 12-French pigtail catheter in the left pleural space.", Cardiovascular / Pulmonary, Pigtail Catheter Insertion ,"PREOPERATIVE DIAGNOSIS:  ,Left hemothorax, rule out empyema.,POSTOPERATIVE DIAGNOSIS: , Left hemothorax rule out empyema.,PROCEDURE: , Insertion of a 12-French pigtail catheter in the left pleural space.,PROCEDURE DETAIL:  ,After obtaining informed consent, the patient was taken to the minor OR in the Same Day Surgery where his posterior left chest was prepped and draped in a usual fashion.  Xylocaine 1% was injected and then a 12-French pigtail catheter was inserted in the medial scapular line about the eighth intercostal space.  It was difficult to draw fluid by syringe, but we connected the system to a plastic bag and by gravity started draining at least 400 mL while we were in the minor OR.  Samples were sent for culture and sensitivity, aerobic and anaerobic.,The patient and I decided to admit him for a period of observation at least overnight.,He tolerated the procedure well and the postprocedure chest x-ray showed no complications.","cardiovascular / pulmonary, chest, pleural space, pigtail catheter, insertion, empyema, hemothorax, "
 Chest tube talc pleurodesis of the right chest., Cardiovascular / Pulmonary, Pleurodesis ,"PREOPERATIVE DIAGNOSIS:,  Large recurrent right pleural effusion.,POSTOPERATIVE DIAGNOSIS:,  Large recurrent right pleural effusion.,PROCEDURE:,1.  Conscious sedation.,2.  Chest tube talc pleurodesis of the right chest.,INDICATIONS: , The patient is a 65-year-old lady with a history of cirrhosis who has developed a recurrent large right pleural effusion.  Chest catheter had been placed previously, and she had been draining up to 1.5 liters of serous fluid a day.  Eventually, this has decreased and a talc pleurodesis is being done to see her pleural effusion does not recur.,SPECIMENS:,  None.,ESTIMATED BLOOD LOSS: , Zero.,NARRATIVE:,  After obtaining informed consent from the patient and her daughter, the patient was assessed and found to be in good condition and a good candidate for conscious sedation.  Vital signs were taken.  These were stable, so the patient was then given initially 0.5 mg of Versed and 2 mg of morphine IV.  After a couple of minutes, she was assessed and found to be awake but calm, so then the chest tube was clamped and then through the chest tube a solution of 120 mL of normal saline containing 5 g of talc and 40 mg of lidocaine were then put into her right chest taking care that no air would go in to create a pneumothorax.  She was then laid on her left lateral decubitus position for 5 minutes and then turned into the right lateral decubitus position for 5 minutes and then the chest tube was unclamped.  The patient was given additional 0.5 mg of Versed and 0.5 mg of Dilaudid IV achieving a state where the patient was comfortable but readily responsive.  The patient tolerated the procedure well.  She did complain of up to a 7/10 pain, but quickly this was brought under control.  The chest tube was unclamped.  Now, the patient will be left to rest and she will get a chest x-ray in the morning.","cardiovascular / pulmonary, chest tube talc pleurodesis, lateral decubitus position, decubitus position, talc pleurodesis, pleural effusion, chest tube, chest, pleurodesis, talc, recurrent, pleural, effusion, tube"
 Ultrasound-guided right pleurocentesis for right pleural effusion with respiratory failure and dyspnea., Cardiovascular / Pulmonary, Pleurocentesis ,"PREOPERATIVE DIAGNOSIS: , Right pleural effusion with respiratory failure and dyspnea.,POSTOPERATIVE DIAGNOSIS: , Right pleural effusion with respiratory failure and dyspnea.,PROCEDURE: , Ultrasound-guided right pleurocentesis.,ANESTHESIA: , Local with lidocaine.,TECHNIQUE IN DETAIL: , After informed consent was obtained from the patient and his mother, the chest was scanned with portable ultrasound.  Findings revealed a normal right hemidiaphragm, a moderate right pleural effusion without septation or debris, and no gliding sign of the lung on the right.  Using sterile technique and with ultrasound as a guide, a pleural catheter was inserted and serosanguinous fluid was withdrawn, a total of 1 L.  The patient tolerated the procedure well.  Portable x-ray is pending.","cardiovascular / pulmonary, pleural effusion, dyspnea, gliding sign, hemidiaphragm, pleural catheter, pleurocentesis, respiratory, serosanguinous fluid, ultrasound, pleural, "
" A middle-aged white female undergoing autologous stem cell transplant for multiple myeloma, now with paroxysmal atrial fibrillation.", Cardiovascular / Pulmonary, Paroxysmal Atrial Fibrillation ,"INDICATION: , Paroxysmal atrial fibrillation.,HISTORY OF PRESENT ILLNESS:  ,The patient is a pleasant 55-year-old white female with multiple myeloma.  She is status post chemotherapy and autologous stem cell transplant.  Latter occurred on 02/05/2007.  At that time, she was on telemetry monitor and noticed to be in normal sinus rhythm.,As part of study protocol for investigational drug for prophylaxis against mucositis, she had electrocardiogram performed on 02/06/2007.  This demonstrated underlying rhythm of atrial fibrillation with rapid ventricular response at 125 beats per minute.  She was subsequently transferred to telemetry for observation.  Cardiology consultation was requested.  Prior to formal consultation, the patient did have an echocardiogram performed on 02/06/2007, which showed a structurally normal heart with normal left ventricular (LV) systolic function, ejection fraction of 60%, aortic sclerosis without stenosis, a trivial pericardial effusion with no evidence for immunocompromise and mild tricuspid regurgitation with normal pulmonary atrial pressures.  Overall, essentially normal heart.,At the time of my evaluation, the patient felt somewhat jittery and nervous, but otherwise asymptomatic.,PAST MEDICAL HISTORY:,  Multiple myeloma, diagnosed in June of 2006, status post treatment with thalidomide and Coumadin.  Subsequently, with high-dose chemotherapy followed by autologous stem cell transplant.,PAST SURGICAL HISTORY: , Cosmetic surgery of the nose and forehead.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,CURRENT MEDICATIONS,1.  Acyclovir 400 mg p.o. b.i.d.,2.  Filgrastim 300 mcg subcutaneous daily.,3.  Fluconazole 200 mg daily.,4.  Levofloxacin 250 mg p.o. daily.,5.  Pantoprazole 40 mg daily.,6.  Ursodiol 300 mg p.o. b.i.d.,7.  Investigational drug is directed ondansetron 24 mg p.r.n.,FAMILY HISTORY: , Unremarkable.  Father and mother both alive in their mid 70s.  Father has an unspecified heart problem and diabetes.  Mother has no significant medical problems.  She has one sibling, a 53-year-old sister, who has a pacemaker implanted for unknown reasons.,SOCIAL HISTORY: , The patient is married.  Has four adult children.  Good health.  She is a lifetime nonsmoker, social alcohol drinker.,REVIEW OF SYSTEMS: , Prior to treatment for her multiple myeloma, she was able to walk four miles nonstop.  Currently, she has dyspnea on exertion on the order of one block.  She denies any orthopnea or paroxysmal nocturnal dyspnea.  She denies any lower extremity edema.  She has no symptomatic palpitations or tachycardia.  She has never had presyncope or syncope.  She denies any chest pain whatsoever.  She denies any history of coagulopathy or bleeding diathesis.  Her oncologic disorder is multiple myeloma.  Pulmonary review of systems is negative for recurrent pneumonias, bronchitis, reactive airway disease, exposure to asbestos or tuberculosis.  Gastrointestinal (GI) review of systems is negative for known gastroesophageal reflux disease, GI bleed, and hepatobiliary disease.  Genitourinary review of systems is negative for nephrolithiasis or hematuria.  Musculoskeletal review of systems is negative for significant arthralgias or myalgias.  Central nervous system (CNS) review of systems is negative for tic, tremor, transient ischemic attack (TIA), seizure, or stroke.  Psychiatric review of systems is negative for known affective or cognitive disorders.,PHYSICAL EXAMINATION,GENERAL:  This is a well-nourished, well-developed white female who appears her stated age and somewhat anxious.,VITAL SIGNS:  She is afebrile at 97.4 degrees Fahrenheit with a heart rate ranging from 115 to 150 beats per minute, irregularly irregular.  Respirations are 20 breaths per minute and blood pressure ranges from 90/59 to 107/68 mmHg.  Oxygen saturation on room air is 94%.,HEENT:  Benign being normocephalic and atraumatic.  Extraocular motions are intact.  Her sclerae are anicteric and conjunctivae are noninjected.  Oral mucosa is pink and moist.,NECK:  Jugular venous pulsations are normal.  Carotid upstrokes are palpable bilaterally.  There is no audible bruit.  There is no lymphadenopathy or thyromegaly at the base of the neck.,CHEST:  Cardiothoracic contour is normal.  Lungs, clear to auscultation in all lung fields.,CARDIAC:  Irregularly irregular rhythm and rate.  S1, S2 without a significant murmur, rub, or gallop appreciated.  Point of maximal impulse is normal, no right ventricular heave.,ABDOMEN:  Soft with active bowel sounds.  No organomegaly.  No audible bruit.  Nontender.,LOWER EXTREMITIES:  Nonedematous.  Femoral pulses were deferred.,LABORATORY DATA: , EKG, electrocardiogram showed underlying rhythm of atrial fibrillation with a rate of 125 beats per minute.  Nonspecific ST-T wave abnormality is seen in the inferior leads only.,White blood cell count is 9.8, hematocrit of 30 and platelets 395.  INR is 0.9.  Sodium 136, potassium 4.2, BUN 43 with a creatinine of 2.0, and magnesium 2.9.  AST and ALT 60 and 50.  Lipase 343 and amylase 109.  BNP 908.  Troponin was less than 0.02.,IMPRESSION: , A middle-aged white female undergoing autologous stem cell transplant for multiple myeloma, now with paroxysmal atrial fibrillation.,Currently enrolled in a blinded study, where she may receive a drug for prophylaxis against mucositis, which has at least one reported incident of acceleration of preexisting tachycardia.,RECOMMENDATIONS,1.  Atrial fibrillation.  The patient is currently hemodynamically stable, tolerating her dysrhythmia.  However, given the risk of thromboembolic complications, would like to convert to normal sinus rhythm if possible.  Given that she was in normal sinus rhythm approximately 24 hours ago, this is relatively acute onset within the last 24 hours.  We will initiate therapy with amiodarone 150 mg intravenous (IV) bolus followed by mg/minute at this juncture.  If she does not have spontaneous cardioversion, we will consider either electrical cardioversion or anticoagulation with heparin within 24 hours from initiation of amiodarone.,As part of amiodarone protocol, please check TSH.  Given her preexisting mild elevation of transaminases, we will follow LFTs closely, while on amiodarone.,2.  Thromboembolic risk prophylaxis, as discussed above.  No immediate indication for anticoagulation.  If however she does not have spontaneous conversion within the next 24 hours, we will need to initiate therapy.  This was discussed with Dr. X.  Preference would be to run intravenous heparin with PTT of 45 during her thrombocytopenic nadir and initiation of full-dose anticoagulation once nadir is resolved.,3.  Congestive heart failure.  The patient is clinically euvolemic.  Elevated BNP possibly secondary to infarct or renal insufficiency.  Follow volume status closely.  Follow serial BNPs.,4.  Followup.  The patient will be followed while in-house, recommendations made as clinically appropriate.",
 Coil embolization of patent ductus arteriosus., Cardiovascular / Pulmonary, Patent Ductus Arteriosus ,"HISTORY: , The patient is a 5-1/2-year-old, who recently presented with a cardiac murmur diagnosed due to a patent ductus arteriosus.  An echocardiogram from 09/13/2007 demonstrated a 3.8-mm patent ductus arteriosus with restrictive left-to-right shunt.  There is mild left atrial chamber enlargement with an LA/AO ratio of 1.821.  An electrocardiogram demonstrated normal sinus rhythm with possible left atrial enlargement and left ventricular hypertrophy.  The patient underwent cardiac catheterization for device closure of a ductus arteriosus.,PROCEDURE:  ,After sedation and local Xylocaine anesthesia, the patient was prepped and draped.  Cardiac catheterization was performed as outlined in the attached continuation sheets.  Vascular entry was by percutaneous technique, and the patient was heparinized.  Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a 5-French sheath, a 5-French wedge catheter was inserted into the right femoral vein and advanced through the right heart structures up to the branch pulmonary arteries.  The atrial septum was not probe patent.,Using a 4-French sheath, a 4-French marker pigtail catheter was inserted into the right femoral artery advanced retrograde to the descending aorta, ascending aorta, and left ventricle.  A descending aortogram demonstrated a small, type A patent ductus arteriosus with a small left-to-right angiographic shunt.  Minimal diameter was approximately 1.6 mm with ampulla diameter of 5.8 mm and length of 6.2 mm.  The wedge catheter could be directed from the main pulmonary artery across the ductus arteriosus to the descending aorta.  This catheter exchanged over wire for a 5-French nit-occlude delivery catheter through which a nit-occlude 6/5 flex coil that was advanced and allowed to reconfigure the descending aorta.  Entire system was then brought into the ductal ampulla or one loop of coil was delivered in the main pulmonary artery.  Once the stable device configuration was confirmed by fluoroscopy, device was released from the delivery catheter.  Hemodynamic measurements and angiogram in the descending aorta were then repeated approximately 10 minutes following device implantation.,Flows were calculated by the Fick technique using a measured assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with injection in the descending aorta.,After angiography, two normal-appearing renal collecting systems were visualized.  The catheters and sheaths were removed and topical pressure applied for hemostasis.  The patient was returned to the recovery room in satisfactory condition.  There were no complications.,DISCUSSION: , Oxygen consumption was assumed to be normal.  Mixed venous saturation was normal with a slight increased saturation of the branch pulmonary arteries due to left-to-right shunt through the ductus arteriosus.  The left-sided heart was fully saturated.  The phasic right-sided and left-sided pressures were normal.  The calculated systemic flow was normal and pulmonary flow was slightly increased with a QP:QS ratio of 1:1.  Vascular resistances were normal.  A cineangiogram with contrast injection in the descending aorta showed a small conical shaped ductus arteriosus with a small left-to-right angiographic shunt.  The branch pulmonary arteries appeared normal.  There is otherwise a normal left aortic arch.,Following coil embolization of the ductus arteriosus, there is no change in mixed venous saturation.  No evidence of residual left-to-right shunt.  There is no change in right-sided pressures.  There is a slight increase in the left-sided phasic pressures.  Calculated systemic flow was unchanged from the resting state and pulmonary flow was similar with a QP:QS ratio of 1:1.  Final angiogram with injection in the descending aorta showed a majority of coil mass to be within the ductal ampulla with minimal protrusion in the descending aorta as well as the coil in the main pulmonary artery.  There is a trace residual shunt through the center of coil mass.,INITIAL DIAGNOSES:, Patent ductus arteriosus.,SURGERIES (INTERVENTIONS):  ,Coil embolization of patent ductus arteriosus.,MANAGEMENT:  ,The case to be discussed at Combined Cardiology/Cardiothoracic Surgery case conference.  The patient will require a cardiologic followup in 6 months and 1 year's time including clinical evaluation and echocardiogram.  Further patient care be directed by Dr. X.,","cardiovascular / pulmonary, cardiac murmur, coil embolization, cineangiograms, patent ductus arteriosus, pulmonary artery, patent ductus, descending aorta, ductus, arteriosus, catheterization"
 Six-month follow-up visit for paroxysmal atrial fibrillation (PAF).  She reports that she is getting occasional chest pains with activity.  Sometimes she feels that at night when she is lying in bed and it concerns her., Cardiovascular / Pulmonary, PAF - 6-Month Followup ,"REASON FOR VISIT:,  Six-month follow-up visit for paroxysmal atrial fibrillation (PAF).,She reports that she is getting occasional chest pains with activity.  Sometimes she feels that at night when she is lying in bed and it concerns her.,She is frustrated by her inability to lose weight even though she is hyperthyroid.,MEDICATIONS: , Tapazole 10 mg b.i.d., atenolol/chlorthalidone 50/25 mg b.i.d., Micro-K 10 mEq q.d., Lanoxin 0.125 mg q.d., spironolactone 25 mg q.d., Crestor 10 mg q.h.s., famotidine 20 mg, Bayer Aspirin 81 mg q.d., Vicodin p.r.n., and Nexium 40 mg-given samples of this today.,REVIEW OF SYSTEMS:,  No palpitations.  No lightheadedness or presyncope.  She is having mild pedal edema, but she drinks a lot of fluid.,PEX: , BP:  112/74.  PR:  70.  WT:  223 pounds (up three pounds).  Cardiac:  Regular rate and rhythm with a 1/6 murmur at the upper sternal border.  Chest:  Nontender.  Lungs:  Clear.  Abdomen:  Moderately overweight.  Extremities:  Trace edema.,EKG: , Sinus bradycardia at 58 beats per minute, mild inferolateral ST abnormalities.,IMPRESSION:,1.  Chest pain-Mild.  Her EKG is mildly abnormal.  Her last stress echo was in 2001.  I am going to have her return for one just to make sure it is nothing serious.  I suspect; however, that is more likely due to her weight and acid reflux.  I gave her samples of Nexium.,2.  Mild pedal edema-Has to cut down on fluid intake, weight loss will help as well, continue with the chlorthalidone.,3.  PAF-Due to hypertension, hyperthyroidism and hypokalemia.  Staying in sinus rhythm.,4.  Hyperthyroidism-Last TSH was mildly suppressed, she had been out of her Tapazole for a while, now back on it.,5.  Dyslipidemia-Samples of Crestor given.,6.  LVH.,7.  Menometrorrhagia.,PLAN:,1.  Return for stress echo.,2.  Reduce the fluid intake to help with pedal edema.,3.  Nexium trial.","cardiovascular / pulmonary, atrial fibrillation, ekg, paroxysmal atrial fibrillation, chest pains, pedal edema, hyperthyroidism, paf, atrial, "
" The patient is an 84-year-old female presented to emergency room with shortness of breath, fatigue, and tiredness.  Low-grade fever was noted last few weeks.  The patient also has chest pain described as dull aching type in precordial region.  No relation to exertion or activity.  No aggravating or relieving factors. ", Cardiovascular / Pulmonary, Pericardial Effusion ,"REASON FOR CONSULTATION:,  Pericardial effusion.,HISTORY OF PRESENT ILLNESS: , The patient is an 84-year-old female presented to emergency room with shortness of breath, fatigue, and tiredness.  Low-grade fever was noted last few weeks.  The patient also has chest pain described as dull aching type in precordial region.  No relation to exertion or activity.  No aggravating or relieving factors.  A CT of the chest was done, which shows pericardial effusion.  This consultation is for the same.  The patient denies any lightheadedness or dizziness.  No presyncope or syncope.  Activity is fairly stable.,CORONARY RISK FACTORS: , History of borderline hypertension.  No history of diabetes mellitus.  Nonsmoker.  Cholesterol status is within normal limits.  No history of established coronary artery disease.  Family history noncontributory.,FAMILY HISTORY: , Nonsignificant.,PAST SURGICAL HISTORY:  ,Hysterectomy and bladder surgery.,MEDICATIONS AT HOME:  ,Aspirin and thyroid supplementation.,ALLERGIES:,  None.,PERSONAL HISTORY:,  She is a nonsmoker.  She does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY:,1.  Hypothyroidism.,2.  Borderline hypertension.,3.  Arthritis.,4.  Presentation at this time with chest pain and shortness of breath.,REVIEW OF SYSTEMS,CONSTITUTIONAL:  Weakness, fatigue, and tiredness.,HEENT:  No history of cataract, blurring of vision, or glaucoma.,CARDIOVASCULAR:  Chest pain.  No congestive heart failure.  No arrhythmia.,RESPIRATORY:  No history of pneumonia in the past, valley fever.,GASTROINTESTINAL:  Epigastric discomfort.  No hematemesis or melena.,UROLOGICAL:  Frequency.  No urgency.  No hematuria.,MUSCULOSKELETAL:  Arthritis and muscle weakness.,CNS:  No TIA.  No CVA.  No seizure disorder.,ENDOCRINE:  Nonsignificant.,HEMATOLOGICAL:  Nonsignificant.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse of 86, blood pressure 93/54, afebrile, respiratory rate 16 per minute.,HEENT:  Atraumatic and normocephalic.,NECK:  Supple.  Neck veins flat.  No significant carotid bruit.,LUNGS:  Air entry bilaterally fair.,HEART:  PMI displaced.  S1 and S2 regular.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema.  Pulses palpable.  No clubbing or cyanosis.,CNS:  Grossly intact.,LABORATORY DATA:  ,White count of 20 and H&H 13 and 39.  BUN and creatinine within normal limits.  Cardiac enzyme profile negative.,RADIOGRAPHIC STUDIES: , CT of the chest preliminary report, pericardial effusion.  Echocardiogram shows pericardial effusion, which appears to be chronic.  There is no evidence of hemodynamic compromise.,IMPRESSION:,1.  The patient is an 84-year-old female admitted with chest pain and shortness of breath, possibly secondary to pulmonary disorder.  She has elevated white count, possible infection.,2.  Pericardial effusion without any hemodynamic compromise, could be chronic.",
 Ligation (clip interruption) of patent ductus arteriosus.  This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch. , Cardiovascular / Pulmonary, Patent Ductus Arteriosus Ligation ,"TITLE OF OPERATION: , Ligation (clip interruption) of patent ductus arteriosus.,INDICATION FOR SURGERY: , This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch.  She has now been put forward for operative intervention.,PREOP DIAGNOSIS:  ,1.  Patent ductus arteriosus.,2.  Severe prematurity.,3.  Operative weight less than 4 kg (600 grams).,COMPLICATIONS: , None.,FINDINGS: , Large patent ductus arteriosus with evidence of pulmonary over circulation.  After completion of the procedure, left recurrent laryngeal nerve visualized and preserved.  Substantial rise in diastolic blood pressure.,DETAILS OF THE PROCEDURE: , After obtaining information consent, the patient was positioned in the neonatal intensive care unit, cribbed in the right lateral decubitus, and general endotracheal anesthesia was induced.  The left chest was then prepped and draped in the usual sterile fashion and a posterolateral thoracotomy incision was performed.  Dissection was carried through the deeper planes until the second intercostal space was entered freely with no damage to the underlying lung parenchyma.  The lung was quite edematous and was retracted anteriorly exposing the area of the isthmus.  The pleura overlying the ductus arteriosus was inside and the duct dissected in a nearly circumferential fashion.  It was then test occluded and then interrupted with a medium titanium clip.  There was preserved pulsatile flow in the descending aorta.  The left recurrent laryngeal nerve was identified and preserved.  With excellent hemostasis, the intercostal space was closed with 4-0 Vicryl sutures and the muscular planes were reapproximated with 5-0 Caprosyn running suture in two layers.  The skin was closed with a running 6-0 Caprosyn suture.  A sterile dressing was placed.  Sponge and needle counts were correct times 2 at the end of the procedure.  The patient was returned to the supine position in which palpable bilateral femoral pulses were noted.,I was the surgical attending present in the neonatal intensive care unit and in-charge of the surgical procedure throughout the entire length of the case.","cardiovascular / pulmonary, clip interruption, ligation, patent ductus arteriosus, premature baby, intercostal space, arteriosus, interruption, pulmonary, circulation"
 PICC line insertion, Cardiovascular / Pulmonary, PICC line insertion ,"PROCEDURE PERFORMED:,  PICC line insertion.,DESCRIPTION OF PROCEDURE:,  The patient was identified by myself on presentation to the angiography suite.  His right arm was prepped and draped in sterile fashion from the antecubital fossa up.  Under ultrasound guidance, a #21-gauge needle was placed into his right cephalic vein.  A guidewire was then threaded through the vein and advanced without difficulty.  An introducer was then placed over the guidewire.  We attempted to manipulate the guidewire to the superior vena cava; however, we could not pass the point of the subclavian vein and we tried several maneuvers and then opted to do a venogram.  What we did was we injected approximately 4 mL of Visipaque 320 contrast material through the introducer and did a mapping venogram and it turned out that the cephalic vein was joining into the subclavian vein.  It was very tortuous area.  We made several more attempts using the mapping system to pass the glide over that area, but we were unable to do that.  Decision was made at that point then to just do a midline catheter.  The catheter was cut to 20 cm, then we inserted back to the introducer.  The introducer was removed.  The catheter was secured by two #3-0 silk sutures.  Appropriate imaging was then taken.  Sterile dressing was applied.  The patient tolerated the procedure nicely and was discharged from Angiography in satisfactory condition back to the general floor.  We may make another attempt in the near future using a different approach.,","cardiovascular / pulmonary, picc, picc line, angiography, guidewire, superior vena cava, subclavian vein, venogramNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" Peripheral effusion on the CAT scan.  The patient is a 70-year-old Caucasian female with prior history of lung cancer, status post upper lobectomy.  She was recently diagnosed with recurrent pneumonia and does have a cancer on the CAT scan, lung cancer with metastasis. ", Cardiovascular / Pulmonary, Peripheral Effusion - Consult ,"REASON FOR CONSULT: , Peripheral effusion on the CAT scan.,HISTORY OF PRESENT ILLNESS: , The patient is a 70-year-old Caucasian female with prior history of lung cancer, status post upper lobectomy.  She was recently diagnosed with recurrent pneumonia and does have a cancer on the CAT scan, lung cancer with metastasis.  The patient had a visiting nurse for Christmas and started having abdominal pain, nausea and vomiting for which, she was admitted.  She had a CAT scan of the abdomen done, showed moderate pericardial effusion for which cardiology consult was requested.  She had an echo done, which shows moderate pericardial effusion with early tamponade.  The patient has underlying shortness of breath because of COPD, emphysema and chronic cough.  However, denies any dizziness, syncope, presyncope, palpitation.  Denies any prior history of coronary artery disease.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , At this time, she is on hydromorphone p.r.n., erythromycin, ceftriaxone, calcium carbonate, Ambien.  She is on oxygen and nebulizer.,PAST MEDICAL HISTORY: , History of COPD, emphysema, pneumonia, and lung cancer.,PAST SURGICAL HISTORY:  ,Hip surgery and resection of the lung cancer 10 years ago.,SOCIAL HISTORY:,  Still smokes, but less than before.  Drinks socially.,FAMILY HISTORY:,  Noncontributory.,REVIEW OF SYSTEMS: , Denies any syncope, presyncope, palpitations, shortness of breath, cough, nausea, vomiting, or diarrhea.,PHYSICAL EXAMINATION:,GENERAL:  The patient is comfortable not in any distress.,VITAL SIGNS:  Blood pressure 121/79, Pulse rate 94, respiratory rate 19, and temperature 97.6.,HEENT:  Atraumatic and normocephalic.,NECK:  Supple.  No JVD.  No carotid bruit.,CHEST:  Breath sounds vesicular.  Clear on auscultation.,HEART:  PMI could not be localized.  S2 and S2 regular.  No S3, no S4.  No murmur.,ABDOMEN:  Soft and nontender.  Positive bowel sounds.,EXTREMITIES:  No cyanosis, clubbing, or edema.  Pulse 2+.,CNS:  Alert, awake, and oriented x3.,EKG shows normal sinus rhythm, low voltage.,LABORATORY DATA: , White cell count 7.3, hemoglobin 12.9, hematocrit 38.1, and platelet at 322,000.  Sodium 135, potassium 5, BUN 6, creatinine 1.2, glucose 71, alkaline phosphatase 263, total protein 5.3, lipase 414, and amylase 57.,DIAGNOSTIC STUDIES:,  Chest x-ray shows left upper lobe airspace disease consistent with pneumonia _______.  CT abdomen showed diffuse replacement of the _______ metastasis, hepatomegaly, perihepatic ascites, moderate pericardial effusion, small left _______ sigmoid diverticulosis.,ASSESSMENT:,1.  Moderate peripheral effusion with early tamponade, probably secondary to lung cancer.,2.  Lung cancer with metastasis most likely.,3.  Pneumonia.,4.  COPD.,PLAN: , We will get CT surgery consult for pericardial window.  Continue present medication.",
" Sinus bradycardia, sick-sinus syndrome, poor threshold on the ventricular lead and chronic lead.  Right ventricular pacemaker lead placement and lead revision.", Cardiovascular / Pulmonary, Pacemaker Lead Placement & Rrevision. ,"PROCEDURE: , Right ventricular pacemaker lead placement and lead revision.,INDICATIONS:,  Sinus bradycardia, sick-sinus syndrome, poor threshold on the ventricular lead and chronic lead.,EQUIPMENT: , A new lead is a Medtronic model #12345, threshold sensing at 5.7, impedance of 1032, threshold of 0.3, atrial threshold is 0.3, 531, and sensing at 4.1.  The original chronic ventricular lead had a threshold of 3.5 and 6 on the can.,ESTIMATED BLOOD LOSS: , 5 mL.,PROCEDURE DESCRIPTION:  ,Conscious sedation with Versed and fentanyl over left subclavicular area with pacemaker pocket was anesthetized with local anesthetic with epinephrine.  The patient received a venogram documenting patency of the subclavian vein.  Skin incision with blunt and sharp dissection.  Electrocautery for hemostasis.  The pocket was opened and the pacemaker was removed from the pocket and disconnected from the leads.  The leads were sequentially checked.  Through the pocket a puncture of the vein with a thin wall needle was made and a long sheath was used to help carry it along the tortuosity of the proximal subclavian and innominate superior vena cava.  Ultimately, a ventricular lead was placed in apex of the right ventricle, secured to base pocket with 2-0 silk suture.  Pocket was irrigated with antibiotic solution.  The pocket was packed with bacitracin-soaked gauze.  This was removed during the case and then irrigated once again.  The generator was attached to the leads, placed in the pocket, secured with 2-0 silk suture and the pocket was closed with a three layer of 4-0 Monocryl.,CONCLUSION:  , Successful replacement of a right ventricular lead secondary to poor lead thresholds in a chronic lead and placement of the previous Vitatron pulse generator model # 12345.","cardiovascular / pulmonary, medtronic, atrial, subclavian, sick sinus syndrome, pacemaker lead placement, ventricular pacemaker, ventricular lead, lead, bradycardia, pacemaker, threshold, ventricular"
 Nuclear cardiac stress report.  Recurrent angina pectoris in a patient with documented ischemic heart disease and underlying ischemic cardiomyopathy., Cardiovascular / Pulmonary, Nuclear Cardiac Stress Report ,"NUCLEAR CARDIOLOGY/CARDIAC STRESS REPORT,INDICATION FOR STUDY: , Recurrent angina pectoris in a patient with documented ischemic heart disease and underlying ischemic cardiomyopathy.,PROCEDURE: , The patient was studied in the resting state following intravenous delivery of adenosine triphosphate at 140 mcg/kg/min delivered over a total of 4 minutes.  At completion of the second minute of infusion, the patient received technetium Cardiolite per protocol.  During this interval, the blood pressure 150/86 dropped to near 136/80 and returned to near 166/84 at completion.  No diagnostic electrocardiographic abnormalities were elaborated during this study.,REGIONAL MYOCARDIAL PERFUSION WITH ADENOSINE PROVOCATION: , Scintigraphic study reveals at this time multiple fixed defects in perfusion suggesting indeed multivessel coronary artery disease, yet no active ischemia at this time.  A fixed defect is seen in the high anterolateral segment.  A further fixed perfusion defect is seen in the inferoapical wall extending from close to the septum.  There is no evidence for active ischemia in either distribution.  Lateral wall moving towards the apex of the left ventricle is further involved from midway through the ventricle moving upward and into the high anterolateral vicinity.  When viewed from the vertical projection, the high septal wall is preserved with significant loss of the mid anteroapical wall moving to the apex and in a wraparound fashion in the inferoapical wall.  A limited segment of apical myocardium is still viable.,No gated wall motion study was obtained.,CONCLUSIONS:  ,Cardiolite perfusion findings support multivessel coronary artery disease and likely previous multivessel infarct as has been elaborated above.  There is no indication for active ischemia at this time.","cardiovascular / pulmonary, angina pectoris, ischemic cardiomyopathy, myocardial perfusion, adenosine provocation, cardiolite perfusion, nuclear cardiac stress report, coronary artery disease, active ischemia, ischemic, angina, "
 Implantation of a dual-chamber pacemaker and fluoroscopic guidance for implantation of a dual-chamber pacemaker., Cardiovascular / Pulmonary, Pacemaker (Dual Chamber) - 1 ,"PREPROCEDURE DIAGNOSIS: , Complete heart block.,POSTPROCEDURE DIAGNOSIS:  ,Complete heart block.,PROCEDURES PLANNED AND PERFORMED,1.  Implantation of a dual-chamber pacemaker.,2.  Fluoroscopic guidance for implantation of a dual-chamber pacemaker.,FLUOROSCOPY TIME: , 2.6 minutes.,MEDICATIONS AT THE TIME OF STUDY,1.  Versed 2.5 mg.,2.  Fentanyl 150 mcg.,3.  Benadryl 50 mg.,CLINICAL HISTORY: , the patient is a pleasant 80-year-old female who presented to the hospital with complete heart block.  She has been referred for a pacemaker implantation.,RISKS AND BENEFITS: , Risks, benefits, and alternatives to implantation of a dual-chamber pacemaker were discussed with the patient.  The patient agreed both verbally and via written consent.,DESCRIPTION OF PROCEDURE: , The patient was transported to the cardiac catheterization laboratory in the fasting state.  The region of the left deltopectoral groove was prepped and draped in the usual sterile manner.  Lidocaine 1% (20 mL) was administered to the area.  After achieving appropriate anesthesia, percutaneous access of the left axillary vein was then performed under fluoroscopy.  A guide wire was advanced into the vein.  Following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath.  Hemostasis was achieved with electrocautery.  Lidocaine 1% (10 mL) was then administered to the medial aspect of the incision.  A pocket was then fashioned in the medial direction.  Using the previously placed wire, a 7-French side-arm sheath was advanced over the wire into the left axillary vein.  The dilator was then removed over the wire.  A second wire was then advanced into the sheath into the left axillary vein.  The sheath was then removed over the top of the two wires.  One wire was then pinned to the drape.  Using the remaining wire, a 7 French side-arm sheath was advanced back into the left axillary vein.  The dilator and wire were removed.  A passive pacing lead was then advanced down into the right atrium.  The peel-away sheath was removed.  The lead was then passed across the tricuspid valve and positioned in the apical location.  Adequate pacing and sensing functions were established.  Suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue.  With the remaining wire, a 7-French side-arm sheath was advanced over the wire into the axillary vein.  The wire and dilating sheaths were removed.  An active pacing lead was then advanced down into the right atrium.  The peel-away sheath was removed.  Preformed J stylet was then advanced into the lead.  The lead was positioned in the appendage location.  Lead body was then turned, and the active fix screw was fixed to the tissue.  Adequate pacing and sensing function were established.  Suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue.  The pocket was then washed with antibiotic-impregnated saline.  Pulse generator was obtained and connected securely to the leads.  The leads were then carefully wrapped behind the pulse generator, and the entire system was placed in the pocket.  The pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using a running mattress stitch.  Sponge and needle counts were correct at the end of the procedure.  No acute complications were noted.,DEVICE DATA,1.  Pulse generator, manufacturer Boston Scientific, model # 12345, serial #1234.,2.  Right atrial lead, manufacturer Guidant, model #12345, serial #1234.,3.  Right ventricular lead, manufacturer Guidant, model #12345, serial #1234.,MEASURED INTRAOPERATIVE DATA,1.  Right atrial lead impedance 534 ohms.  P waves measured at 1.2 millivolts.  Pacing threshold 1.0 volt at 0.5 milliseconds.,2.  Right ventricular lead impedance 900 ohms.  R-waves measured 6.0 millivolts.  Pacing threshold 1.0 volt at 0.5 milliseconds.,DEVICE SETTINGS: , DDD 60 to 130.,CONCLUSIONS,1.  Successful implantation of a dual-chamber pacemaker with adequate pacing and sensing function.,2.  No acute complications.,PLAN,1.  The patient will be taken back to her room for continued observation.  She can be dismissed in 24 hours provided no acute complications at the discretion of the primary service.,2.  Chest x-ray to rule out pneumothorax and verified lead position.,3.  Completion of the course of antibiotics.,4.  Home dismissal instructions provided in written format.,5.  Device interrogation in the morning.,6.  Wound check in 7 to 10 days.,7.  Enrollment in device clinic.",
 Insertion of transvenous pacemaker for tachybrady syndrome, Cardiovascular / Pulmonary, Pacemaker Insertion ,"PREOPERATIVE DIAGNOSIS:, Tachybrady syndrome.,POSTOPERATIVE DIAGNOSIS:, Tachybrady syndrome.,OPERATIVE PROCEDURE:, Insertion of transvenous pacemaker.,ANESTHESIA:, Local,PROCEDURE AND GROSS FINDINGS:, The patient's chest was prepped with Betadine solution and a small amount of Lidocaine infiltrated.  In the left subclavian region, a subclavian stick was performed without difficulty, and a wire was inserted. Fluoroscopy confirmed the presence of the wire in the superior vena cava.  An introducer was then placed over the wire.  The wire was removed and replace by a ventricular lead that was seated under Fluoroscopy. Following calibration, the lead was attached to a pacemaker generator that was inserted in a subcutaneous pocket in the left subclavian area.  ,The subcutaneous tissues were irrigated and closed with Interrupted 4-O Vicryl, and the skin was closed with staples.  Sterile dressings were placed, and the patient was returned to the ICU in good condition.","cardiovascular / pulmonary, insertion of transvenous pacemaker, fluoroscopy, tachybrady, tachybrady syndrome, chest, pacemaker, subclavian, subcutaneous, superior vena cava, syndrome, transvenous pacemaker, wire, insertion, "
 DDDR permanent pacemaker.   Tachybrady syndrome.  A ventricular pacemaker lead was advanced through the sheath and into the vascular lumen and under fluoroscopic guidance guided down into the right atrium. , Cardiovascular / Pulmonary, Pacemaker - DDDR  ,"PROCEDURE PERFORMED:  ,DDDR permanent pacemaker.,INDICATION: , Tachybrady syndrome.,PROCEDURE:,  After all risks, benefits, and alternatives of the procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing.  The patient was taken to the Cardiac Catheterization Suite where the right subclavian region was prepped and draped in the usual sterile fashion.  1% lidocaine solution was used to infiltrate the skin overlying the left subclavian vein.  Once adequate anesthesia had been obtained, a thin-walled #18-gauze Argon needle was used to cannulate the left subclavian vein.  A steel guidewire was inserted through the needle into the vascular lumen without resistance.  The needle was then removed over the guidewire and the guidewire was secured to the field.  A second #18 gauze Argon needle was used to cannulate the left subclavian vein and once again a steel guidewire was inserted through the needle into the vascular lumen.  Likewise, the needle was removed over the guidewire and the guidewire was then secured to the field.  Next, a #15-knife blade was used to make a 1 to 1.5 inch linear incision over the area.  A #11-knife blade was used to make a deeper incision.  Hemostasis was made complete.  The edges of the incision were grasped and retracted.  Using Metzenbaum scissors, dissection was carried down to the pectoralis muscle fascial plane.  Digital blunt dissection was used to make a pacemaker pocket large enough to accommodate the pacemaker generator.  Metzenbaum scissors were then used to dissect cephalad to expose the guide wires.  The guidewires were then pulled through the pacemaker pocket.  One guidewire was secured to the field.,A bloodless introducer sheath was then advanced over a guidewire into the vascular lumen under fluoroscopic guidance.  The guidewire and dilator were then removed.  Next, a ventricular pacemaker lead was advanced through the sheath and into the vascular lumen and under fluoroscopic guidance guided down into the right atrium.  The pacemaker lead was then placed in the appropriate position in the right ventricle.  Pacing and sensing thresholds were obtained.  The lead was sewn at the pectoralis muscle plane using #2-0 silk suture in an interrupted stitch fashion around the ________.  Pacing and sensing threshold were then reconfirmed.  Next, a second bloodless introducer sheath was advanced over the second guidewire into the vascular lumen.  The guidewire and dilator were then removed.  Under fluoroscopic guidance, the atrial lead was passed into the right atrium.  The sheath was then turned away in standard fashion.  Using fluoroscopic guidance, the atrial lead was then placed in the appropriate position.  Pacing and sensing thresholds were obtained.  The lead was sewn to the pectoralis muscle facial plane utilizing #2-0 silk suture around the ________.  Sensing and pacing thresholds were then reconfirmed.  The leads were wiped free of blood and placed into the pacemaker generator.  The pacemaker generator leads were then placed into pocket with the leads posteriorly.  The deep tissues were closed utilizing #2-0 Chromic suture in an interrupted stitch fashion.  A #4-0 undyed Vicryl was then used to close the subcutaneous tissue in a continuous subcuticular stitch.  Steri-Strips overlaid.  A sterile gauge dressing was placed over the site.  The patient tolerated the procedure well and was transferred to the Cardiac Catheterization Room in stable and satisfactory condition.,PACEMAKER DATA (GENERATOR DATA):,Manufacturer:  Medtronics.,Model:  Sigma.,Model #:  1234.,Serial #:  123456789.,LEAD INFORMATION:,Right Atrial Lead:,Manufacturer:  Medtronics.,Model #:  1234.,Serial #:  123456789.,VENTRICULAR LEAD:,Manufacturer:  Medtronics.,Model #:  1234.,Serial #:  123456789.,PACING AND SENSING THRESHOLDS:,Right Atrial Bipolar Lead:  Pulse width 0.50 milliseconds, impedance 518 ohms, P-wave sensing 2.2 millivolts, polarity is bipolar.,Ventricular Bipolar Lead:  Pulse width 0.50 milliseconds, voltage 0.7 volts, current 1.5 milliamps, impedance 655 ohms, R-wave sensing 9.7 millivolts, polarity is bipolar.,PARAMETER SETTINGS:,  Pacing mode DDDR:  Mode switch is on, low rate 60, upper 120, ________ is 33.0 milliseconds.,IMPRESSION:,  Successful implantation of DDDR permanent pacemaker.,PLAN:,1.  The patient will be monitored on telemetry for 24 hours to ensure adequate pacemaker function.,2.  The patient will be placed on antibiotics for five days to avoid pacemaker infection.",
  Implantation of a single-chamber pacemaker.  Fluoroscopic guidance for implantation of single-chamber pacemaker., Cardiovascular / Pulmonary, Pacemaker (Single Chamber) - 1 ,"REFERRAL INDICATION,1.  Tachybrady syndrome.,2.  Chronic atrial fibrillation.,PROCEDURES PLANNED AND PERFORMED,1.  Implantation of a single-chamber pacemaker.,2.  Fluoroscopic guidance for implantation of single-chamber pacemaker.,FLUOROSCOPY TIME:  ,1.2 minutes.,MEDICATIONS AT THE TIME OF STUDY,1.  Ancef 1 g.,2.  Benadryl 50 mg.,3.  Versed 3 mg.,4.  Fentanyl 150 mcg.,CLINICAL HISTORY: , The patient is a pleasant 73-year-old female with chronic atrial fibrillation.  She has been found to have tachybrady syndrome, has been referred for pacemaker implantation.,RISKS AND BENEFITS: , Risks, benefits, and alternatives of implantation of a single-chamber pacemaker were discussed with the patient.  The patient agreed both verbally and via written consent.  Risks that were discussed included but were not limited to bleeding, infection, vascular injury, cardiac perforation, stroke, myocardial infarction, need for urgent cardiovascular surgery, and death were discussed with the patient.  The patient agreed both verbally and via written consent.,DESCRIPTION OF PROCEDURE: , The patient was transported to the cardiac catheterization laboratory in a fasting state.  The region of the left deltopectoral groove was prepped and draped in the usual sterile manner.  Lidocaine 1% (20 mL) was administered to the area.  Percutaneous access of the left axillary vein was then performed.  A wire was then advanced in the left axillary vein using fluoroscopy.  Following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath.  Lidocaine 1% (10 mL) was then administered to the medial aspect of the incision and a pocket was fashioned in the medial direction.  Using the previously placed guidewire, a 7-French sidearm sheath was advanced over the wire into the vein.  The dilator and wire were removed.  An active pacing lead was then advanced down in the right atrium.  The peel-away sheath was removed.  Lead was passed across the tricuspid valve and positioned in an apical septal location.  This was an active fixed lead and the screw was deployed.  Adequate pacing and sensing function were established.  The suture sleeve was then advanced to the entry point of the tissue and connected securely to the tissue.  The pocket was washed with antibiotic-impregnated saline.  A pulse generator was obtained and connected securely to the lead.  The lead was then carefully wrapped behind the pulse generator, and the entire system was placed in the pocket.  Pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using a running mattress stitch.  No acute complications were noted.,DEVICE DATA,1.  Pulse generator, manufacturer St. Jude model 12345, serial #123456.,2.  Right ventricular lead, manufacturer St. Jude model 12345, serial #ABCD123456.,MEASURED INTRAOPERATIVE DATA:,  Right ventricular lead impedance 630 ohms.  R wave measures 17.5 mV.  Pacing threshold of 0.8 V at 0.5 msec.,DEVICE SETTINGS: , VVI 70 to 120.,CONCLUSIONS,1.  Successful implantation of the single-chamber pacemaker with adequate pacing and sensing function.,2.  No acute complications.,PLAN,1.  The patient will be admitted for overnight observation and dismissed at the discretion of primary service.,2.  Chest x-ray to rule out pneumothorax and verify lead position.,3.  Completion of course of antibiotics.,4.  Device interrogation in the morning.,5.  Home dismissal instructions provided in a written format.,6.  Wound check in 7 to 10 days.,7.  Enrollment in Device Clinic.",
 Pacemaker ICD interrogation.  Severe nonischemic cardiomyopathy with prior ventricular tachycardia., Cardiovascular / Pulmonary, Pacemaker Interrogation ,"PROCEDURE NOTE: , Pacemaker ICD interrogation.,HISTORY OF PRESENT ILLNESS: , The patient is a 67-year-old gentleman who was admitted to the hospital.  He has had ICD pacemaker implantation.  This is a St. Jude Medical model current DRRS, 12345 pacemaker.,DIAGNOSIS: , Severe nonischemic cardiomyopathy with prior ventricular tachycardia.,FINDINGS: , The patient is a DDD mode base rate of 60, max tracking rate of 110 beats per minute, atrial lead is set at 2.5 volts with a pulse width of 0.5 msec, ventricular lead set at 2.5 volts with a pulse width of 0.5 msec.  Interrogation of the pacemaker shows that atrial capture is at 0.75 volts at 0.5 msec, ventricular capture 0.5 volts at 0.5 msec, sensing in the atrium is 5.34 to 5.8 millivolts, R sensing is 12-12.0 millivolts, atrial lead impendence 590 ohms, ventricular lead impendence 750 ohms.  The defibrillator portion is set at VT1 at 139 beats per minute with SVT discrimination on therapy is monitor only.  VT2 detection criteria is 169 beats per minute with SVT discrimination on therapy of ATP times 3 followed by 25 joules, followed by 36 joules, followed by 36 joules times 2.  VF detection criteria set at 187 beats per minute with therapy of 25 joules, followed by 36 joules times 5.  The patient is in normal sinus rhythm.,IMPRESSION:  ,Normally functioning pacemaker ICD post implant day number 1.","cardiovascular / pulmonary, cardiomyopathy, ventricular, tachycardia, pacemaker icd interrogation, millivolts, impendence, interrogation, pacemaker, "
 Single chamber pacemaker implantation.  Successful single-chamber pacemaker implantation with left subclavian approach and venogram to assess the subclavian access site and the right atrial or right ventricle with asystole that resolved spontaneously during the procedure., Cardiovascular / Pulmonary, Pacemaker (Single Chamber) ,"SINGLE CHAMBER PACEMAKER IMPLANTATION,PREOPERATIVE DIAGNOSIS: , Mobitz type II block with AV dissociation and syncope.,POSTOPERATIVE DIAGNOSIS: , Mobitz type II block, status post single chamber pacemaker implantation, Boston Scientific Altrua 60, serial number 123456.,PROCEDURES:,1.  Left subclavian access under fluoroscopic guidance.,2.  Left subclavian venogram under fluoroscopic evaluation.,3.  Insertion of ventricular lead through left subclavian approach and ventricular lead is Boston Scientific Dextrose model 12345, serial number 123456.,4.  Insertion of single-chamber pacemaker implantation, Altrua, serial number 123456.,5.  Closure of the pocket after formation of pocket for pacemaker.,PROCEDURE IN DETAIL:  ,The procedure was explained to the patient with risks and benefits.  The patient agreed and signed the consent form.  The patient was brought to the cath lab, draped and prepped in the usual sterile fashion, received 1.5 mg of versed and 25 mg of Benadryl for conscious sedation.,Access to the right subclavian was successful after the second attempt.  The first attempt accessed the left subclavian artery.  The needle was removed and manual compression applied for five minutes followed by re-accessing the subclavian vein successfully.  The J-wire was introduced into the left subclavian vein.,The anterior wall chest was anesthetized with lidocaine 2%, 2-inch incision using a #10 blade was used.,The pocket was formed using blunt dissection as he was using the Bovie cautery for hemostasis.  The patient went asystole during the procedure.  The transcutaneous pacer was used.  The patient was oxygenating well.  The patient had several compression applied by the nurse.  However, her own rhythm resolved spontaneously and the percutaneous pacer was kept on standby.,After that, the J-wire was tunneled into the pocket and then used to put the #7-French sheath into the left subclavian vein.  The lead from the Boston Scientific Dextrose model 12345, serial number 12345 was inserted through the left subclavian to the right atrium; however, it was difficult to really enter the right ventricle; and while the lead was in place, the side port of the sheath was used to inject 15 mL of contrast to assess the subclavian and the right atrium.  The findings were showing different anatomy, may be consistent with persistent left superior vena cava, and the angle to the right ventricle was different.  At that point, the lead stylet was reshaped and was able to cross the tricuspid valve in a position consistent with the mid septal place.,At that point, the lead was actively fixated.  The stylet was removed.  The R-wave measured at 40 millivolts.  The impedance was 580 and the threshold was 1.3 volt.  The numbers were accepted and because of the patient's fragility and the different anatomy noticed in the right atrium, concern about putting a second lead with re-access of the subclavian was high.  I decided to proceed with a single-chamber pacemaker as a backup system.,After that, the lead sleeve was used to actively fixate the lead in the anterior chest with two Ethibond sutures in the usual fashion.,The lead was attached to the pacemaker in the header.  The pacemaker was single-chamber pacemaker Altura 60, serial number 123456.  After that, the pacemaker was put in the pocket.  Pocket was irrigated with normal saline and was closed into two layers, deep interrupted #3-0 Vicryl and surface as continuous #4-0 Vicryl continuous.,The pacemaker was programmed as VVI 60, and with history is 10 to 50 beats per minute.  The lead position will be evaluated with chest x-ray.,No significant bleeding noticed.,CONCLUSION:  ,Successful single-chamber pacemaker implantation with left subclavian approach and venogram to assess the subclavian access site and the right atrial or right ventricle with asystole that resolved spontaneously during the procedure.  No significant bleed.","cardiovascular / pulmonary, mobitz, av dissociation, syncope, mobitz type ii block, boston scientific altrua, subclavian, venogram, ventricular, single chamber pacemaker implantation, single chamber pacemaker, pacemaker implantation, pacemaker, vein, chest, atrium, ventricle, atrial, implantation, chamber, "
 A patient with non-Q-wave myocardial infarction.  No definite chest pains.  The patient is breathing okay.  The patient denies orthopnea or PND., Cardiovascular / Pulmonary, Non-Q-wave Myocardial Infarction ,"REASON FOR CONSULT: , A patient with non-Q-wave myocardial infarction.,HISTORY OF PRESENT ILLNESS: , The patient is a pleasant 52-year-old gentleman with a history of diabetes mellitus, hypertension, and renal failure, on dialysis, who presented with emesis, dizziness, and nausea for the last few weeks.  The patient reports having worsening emesis and emesis a few times.  No definite chest pains.  The patient is breathing okay.  The patient denies orthopnea or PND.,PAST MEDICAL HISTORY:,1.  Diabetes mellitus.,2.  Hypertension.,3.  Renal failure, on dialysis.,MEDICATIONS:,  Aspirin, Coreg, doxazosin, insulin, metoclopramide, simvastatin, and Starlix.,ALLERGIES:  ,NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient denies tobacco, alcohol or drug use.,FAMILY HISTORY: , Negative for early atherosclerotic heart disease.,REVIEW OF SYSTEMS: , General:  The patient denies fever or chills.  Pulmonary:  The patient denies hemoptysis.  Cardiovascular:  Refer to HPI.  GI:  The patient denies hematemesis or melena.  The rest of systems review is negative.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse 71, blood pressure 120/70, and respiratory rate 18.,GENERAL:  A well-nourished, well-developed male in no acute distress.,HEENT:  Normocephalic, atraumatic.  Pupils seem to be equal, round, and reactive.  Extraocular muscles are full, but the patient has left eye ptosis.,NECK:  Supple without JVD or lymphadenopathy.,LUNGS:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  PMI is displaced 0.5 cm lateral to the midclavicular line.  Regular rate and rhythm, S1, S2.  No definite S3, 2/6 holosystolic murmur at the apex radiating to the axilla.,ABDOMEN:  Positive bowel sounds, nondistended and nontender.  No hepatosplenomegaly.,EXTREMITIES:  Trace pedal edema.,EKG shows atrial fibrillation with rapid ventricular response at 164 with old anteroseptal myocardial infarction and old inferior wall myocardial infarction.  Subsequent EKG in sinus rhythm shows sinus rhythm with old inferior wall myocardial infarction and probable anteroseptal myocardial infarction with Q-waves in V1, V2, and up to V3.,LABORATORY EXAM: , WBC 28,800, hemoglobin 13.6, hematocrit 40, and platelets 266,000.  PT 11.3, INR 1.1, and PTT 24.1.  Sodium 126, potassium 4.3, chloride 86, CO2 26, glucose 371, BUN 80, and creatinine 8.4.  CK was 261, then 315, and then 529 with CK-MB of 8.06, then 8.69, and then 24.6.  Troponin was 0.051, then 0.46, and then 19.8 this morning.,IMPRESSION:,1.  Paroxysmal atrial fibrillation.  The heart rate was slowed down with IV Cardizem, the patient converted to sinus rhythm.  The patient is currently in sinus rhythm.,2.  Emesis.  The etiology is unclear.  The patient reports that the emesis is better.  The patient is just having some nausea.,3.  Non-Q-wave myocardial infarction.  EKG shows atrial fibrillation with old anteroseptal myocardial infarction and old inferior wall myocardial infarction.,4.  Diabetes mellitus.,5.  Renal failure.,6.  Hypertension.,7.  Hypercholesterolemia.,PLAN:,1.  We will start amiodarone to keep from going back into atrial fibrillation.,2.  Echocardiogram.,3.  Aspirin and IV heparin.,4.  Serial CK-MB and troponin.,5.  Cardiac catheterization, possible percutaneous coronary intervention.  The risks, benefits, and alternatives were explained to the patient through a translator.  The patient understands and wishes to proceed.,6.  IV Integrilin.",
 Implantation of a dual chamber permanent pacemaker, Cardiovascular / Pulmonary, Pacemaker (Dual Chamber) ,"CLINICAL HISTORY: ,This 78-year-old black woman has a history of hypertension, but no other cardiac problems. She noted complaints of fatigue, lightheadedness, and severe dyspnea on exertion. She was evaluated by her PCP on January 31st and her ECG showed sinus bradycardia with a rate of 37 beats per minute. She has had intermittent severe sinus bradycardia alternating with a normal sinus rhythm, consistent with sinoatrial exit block, and she is on no medications known to cause bradycardia. An echocardiogram showed an ejection fraction of 70% without significant valvular heart disease.,PROCEDURE:, Implantation of a dual chamber permanent pacemaker.,APPROACH:, Left cephalic vein.,LEADS IMPLANTED: ,Medtronic model 12345 in the right atrium, serial number 12345. Medtronic 12345 in the right ventricle, serial number 12345.,DEVICE IMPLANTED: ,Medtronic EnRhythm model 12345, serial number 12345.,LEAD PERFORMANCE: ,Atrial threshold less than 1.3 volts at 0.5 milliseconds. P wave 3.3 millivolts. Impedance 572 ohms. Right ventricle threshold 0.9 volts at 0.5 milliseconds. R wave 10.3. Impedance 855.,ESTIMATED BLOOD LOSS:, 20 mL.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the electrophysiology laboratory in a fasting state and intravenous sedation was provided as needed with Versed and fentanyl. The left neck and chest were prepped and draped in the usual manner and the skin and subcutaneous tissues below the left clavicle were infiltrated with 1% lidocaine for local anesthesia. A 2-1/2-inch incision was made below the left clavicle and electrocautery was used for hemostasis. Dissection was carried out to the level of the pectoralis fascia and extended caudally to create a pocket for the pulse generator. The deltopectoral groove was explored and a medium-sized cephalic vein was identified. The distal end of the vein was ligated and a venotomy was performed. Two guide wires were advanced to the superior vena cava and peel-away introducer sheaths were used to insert the two pacing leads. The venous pressures were elevated and there was a fair amount of back-bleeding from the vein, so a 3-0 Monocryl figure-of-eight stitch was placed around the tissue surrounding the vein for hemostasis. The right ventricular lead was placed in the high RV septum and the right atrial lead was placed in the right atrial appendage. The leads were tested with a pacing systems analyzer and the results are noted above. The leads were then anchored in place with #0-silk around their suture sleeve and connected to the pulse generator. The pacemaker was noted to function appropriately. The pocket was then irrigated with antibiotic solution and the pacemaker system was placed in the pocket. The incision was closed with two layers of 3-0 Monocryl and a subcuticular closure of 4-0 Monocryl. The incision was dressed with Steri-Strips and a sterile bandage and the patient was returned to her room in good condition.,IMPRESSION: ,Successful implantation of a dual chamber permanent pacemaker via the left cephalic vein. The patient will be observed overnight and will go home in the morning.","cardiovascular / pulmonary, medtronic enrhythm, cephalic vein, dual chamber, dual chamber permanent pacemaker, dyspnea on exertion, echocardiogram, fatigue, hypertension, lightheadedness, normal sinus rhythm, pacemaker, permanent pacemaker, sinoatrial exit block, sinus bradycardia, valvular heart disease, bradycardia, medtronic, atrial,"
" Myocardial perfusion imaging - patient with history of MI, stents placement, and chest pain.", Cardiovascular / Pulmonary, Myocardial Perfusion Imaging - 1 ,"MEDICATIONS: , Plavix, atenolol, Lipitor, and folic acid.,CLINICAL HISTORY:  ,This is a 41-year-old male patient who comes in with chest pain, had had a previous MI in 07/2003 and stents placement in 2003, who comes in for a stress myocardial perfusion scan.,With the patient at rest, 10.3 mCi of Cardiolite technetium-99 m sestamibi was injected and myocardial perfusion imaging was obtained.,PROCEDURE AND INTERPRETATION:  ,The patient exercised for a total of 12 minutes on the standard Bruce protocol.  The peak workload was 12.8 METS.  The resting heart rate was 57 beats per minute and the peak heart rate was 123 beats per minute, which was 69% of the age-predicted maximum heart rate response.  The blood pressure response was normal with a resting blood pressure of 130/100 and a peak blood pressure of 158/90.  The test was stopped due to fatigue and leg pain.  EKG at rest showed normal sinus rhythm.  The peak stress EKG did not reveal any ischemic ST-T wave abnormalities.  There was ventricular bigeminy seen during exercise, but no sustained tachycardia was seen.  At peak, there was no chest pain noted.  The test was stopped due to fatigue and left pain.  At peak stress, the patient was injected with 30.3 mCi of Cardiolite technetium-99 m sestamibi and myocardial perfusion imaging was obtained, and was compared to resting myocardial perfusion imaging.,MYOCARDIAL PERFUSION IMAGING:,1.  The overall quality of the scan was good.,2.  There was no diagnostic abnormality on the rest and stress myocardial perfusion imaging.,3.  The left ventricular cavity appeared normal in size.,4.  Gated SPECT images revealed mild septal hypokinesis and mild apical hypokinesis.  Overall left ventricular systolic function was low normal with calculated ejection fraction of 46% at rest.,CONCLUSIONS:,1.  Good exercise tolerance.,2.  Less than adequate cardiac stress.  The patient was on beta-blocker therapy.,3.  No EKG evidence of stress induced ischemia.,4.  No chest pain with stress.,5.  Mild ventricular bigeminy with exercise.,6.  No diagnostic abnormality on the rest and stress myocardial perfusion imaging.,7.  Gated SPECT images revealed septal and apical hypokinesis with overall low normal left ventricular systolic function with calculated ejection fraction of 46% at rest.","cardiovascular / pulmonary, myocardial perfusion imaging, bruce protocol, cardiolite, ekg, mets, mi, spect, st-t, bigeminy, blood pressure, chest pain, exercise tolerance, myocardial perfusion, normal sinus rhythm, peak workload, sestamibi, stents, stress, tachycardia, ventricular, ventricular cavity, stress myocardial perfusion, perfusion imaging, myocardial, perfusion, mci, hypokinesis, imaging,"
 Myocardial perfusion imaging - patient had previous abnormal stress test.  Stress test with imaging for further classification of CAD and ischemia., Cardiovascular / Pulmonary, Myocardial Perfusion Imaging - 2 ,"CLINICAL HISTORY: , This is a 64-year-old male patient, who had a previous stress test, which was abnormal and hence has been referred for a stress test with imaging for further classification of coronary artery disease and ischemia.,PERTINENT MEDICATIONS:,  Include Tylenol, Robitussin, Colace, Fosamax, multivitamins, hydrochlorothiazide, Protonix and flaxseed oil.,With the patient at rest 10.5 mCi of Cardiolite technetium-99 m sestamibi was injected and myocardial perfusion imaging was obtained.,PROCEDURE AND INTERPRETATION: , The patient exercised for a total of 4 minutes and 41 seconds on the standard Bruce protocol.  The peak workload was 7 METs.  The resting heart rate was 61 beats per minute and the peak heart rate was 173 beats per minute, which was 85% of the age-predicted maximum heart rate response.  The blood pressure response was normal with the resting blood pressure 126/86, and the peak blood pressure of 134/90.  EKG at rest showed normal sinus rhythm with a right-bundle branch block.  The peak stress EKG was abnormal with 2 mm of ST segment depression in V3 to V6, which remained abnormal till about 6 to 8 minutes into recovery.  There were occasional PVCs, but no sustained arrhythmia.  The patient had an episode of supraventricular tachycardia at peak stress.  The ischemic threshold was at a heart rate of 118 beats per minute and at 4.6 METs.  At peak stress, the patient was injected with 30.3 mCi of Cardiolite technetium-99 m sestamibi and myocardial perfusion imaging was obtained, and was compared to resting images.,MYOCARDIAL PERFUSION IMAGING:,1.  The overall quality of the scan was fair in view of increased abdominal uptake, increased bowel uptake seen.,2.  There was a large area of moderate to reduced tracer concentration seen in the inferior wall and the inferior apex.  This appeared to be partially reversible in the resting images.,3.  The left ventricle appeared normal in size.,4.  Gated SPECT images revealed normal wall motion and normal left ventricular systolic function with normal wall thickening.  The calculated ejection fraction was 70% at rest.,CONCLUSIONS:,1.  Average exercise tolerance.,2.  Adequate cardiac stress.,3.  Abnormal EKG response to stress, consistent with ischemia.  No symptoms of chest pain at rest.,4.  Myocardial perfusion imaging was abnormal with a large-sized, moderate intensity partially reversible inferior wall and inferior apical defect, consistent with inferior wall ischemia and inferior apical ischemia.,5.  The patient had run of SVT at peak stress.,6.  Gated SPECT images revealed normal wall motion and normal left ventricular systolic function.","cardiovascular / pulmonary, stress test, arrhythmia, baseline heart rate, bruce, chest pain, mets, protocol, peak heart rate, spect, st segment response, svt, aerobic capacity, blood pressure, exercise, heart rate, ischemia, ventricular systolic function, myocardial perfusion imaging, cardiolite technetium, inferior apical, myocardial perfusion, perfusion imaging, stress, myocardial, imaging, perfusion"
" Myocardial perfusion study at rest and stress, gated SPECT wall motion study at stress and calculation of ejection fraction.", Cardiovascular / Pulmonary, Myocardial Perfusion Imaging - 3 ,"DIAGNOSIS:  ,Shortness of breath.  Fatigue and weakness.  Hypertension.  Hyperlipidemia.,INDICATION: , To evaluate for coronary artery disease.,","cardiovascular / pulmonary, myocardial perfusion imaging, spect wall motion study at stress, rest and stress, perfusion study at rest, calculation of ejection fraction, normal left ventricular wall, spect wall motion study, ventricular wall motion, myocardial perfusion study, perfusion imaging, blood pressure, nonspecific st, ventricular wall, gated spect, spect wall, motion study, stress test, heart rate, ejection fraction, myocardial perfusion, technetium, tetrofosmin, ischemia, ekg, imaging, spect, heart, ventricular, mci, resting, perfusion, stress, myocardial, "
 Multiple stent placements with Impella circulatory assist device., Cardiovascular / Pulmonary, Multiple Stent Placements ,"PROCEDURE PERFORMED:,1.  Left heart catheterization, left ventriculogram, aortogram, coronary angiogram.,2.  PCI of the LAD and left main coronary artery with Impella assist device.,INDICATIONS FOR PROCEDURE: , Unstable angina and congestive heart failure with impaired LV function.,TECHNIQUE OF PROCEDURE: , After obtaining informed consent, the patient was brought to the cardiac catheterization suite in postabsorptive and nonsedated state.  The right groin was prepped and draped in the usual sterile manner.  Lidocaine 2% was used for infiltration anesthesia.  Using modified Seldinger technique, a 7-French sheath was introduced into the right common femoral artery and a 6-French sheath was introduced into the right common femoral vein.  Through the arterial sheath, angiography of the right common femoral artery was obtained.  Thereafter, 6-French pigtail catheter was advanced to the level of the distal aorta where angiography of the distal aorta and the bifurcation of the right and left common iliac arteries was obtained.  Thereafter, a 4-French sheath was introduced into the left common femoral artery using modified Seldinger technique.  Thereafter, the pigtail catheter was advanced over an 0.035-inch J-wire into the left ventricle and LV-gram was performed in RAO view and after pullback, an aortogram was performed in the LAO view.  Therefore, a 6-French JL4 and JR4 guiding catheters were used to engage the left and right coronary arteries respectively and multiple orthogonal views of the coronary arteries were obtained.,ANGIOGRAPHIC FINDINGS:  ,1.  LV-gram:  LVEDP was 15 mmHg.  LV ejection fraction 10% to 15% with global hypokinesis.  Only anterior wall is contracting.  There was no mitral regurgitation.  There was no gradient across the aortic valve upon pullback, and on aortography, there was no evidence of aortic dissection or aortic regurgitation.,2.  The right coronary artery is a dominant vessels with a mid 50% to 70% stenosis which was not treated.  The left main coronary artery calcified vessel with disease.,2.  The left anterior descending artery had an 80% to 90% mid-stenosis.  First diagonal branch had a more than 90% stenosis.,3.  The circumflex coronary artery had a patent stent.,INTERVENTION: , After reviewing the angiographic images, we elected to proceed with intervention of the left anterior descending artery.  The 4-French sheath in the left common femoral artery was upsized to a 12-French Impella sheath through which an Amplatz wire and a 6-French multipurpose catheter were advanced into the left ventricle.  The Amplatz wire was exchanged for an Impella 0.018-inch stiff wire.  The multipurpose catheter was removed, and the Impella was advanced into the left ventricle and a performance level of 8 was achieved with a cardiac output of 2 to 2.5 l/min.  Thereafter, a 7-French JL4 guiding catheter was used to engage the left coronary artery and an Asahi soft 0.014-inch wire was advanced into the left anterior descending artery and a second 0.014-inch Asahi soft wire was advanced into the diagonal branch.  The diagonal branch was predilated with a 2.5 x 30-mm Sprinter balloon at nominal atmospheres and thereafter a 2.5 x 24 Endeavor stent was successfully deployed in the mid-LAD and a 3.0 x 15-mm Endeavor stent was deployed in the proximal LAD.  The stent delivery balloon was used to post-dilate the overlapping segment.  The LAD, the diagonal was rewires with an 0.014-inch Asahi soft wire and a 3.0 x 20-mm Maverick balloon was advanced into the LAD for post-dilatation and a 2.0 x 30-mm Sprinter balloon was advanced into the diagonal for kissing inflations which were performed at nominal atmospheres.  At this point, it was noted that the left main had a retrograde dissection.  A 3.5 x 18-mm Endeavor stent was successfully deployed in the left main coronary artery.  The Asahi soft wire in the diagonal was removed and placed into the circumflex coronary artery.  Kissing inflations of the LAD and the circumflex coronary artery were performed using 3.0 x 20 Maverick balloons x2 balloons, inflated at high atmospheres of 14.,RESULTS: , Lesion reduction in the LAD FROM 90% to 0% and TIMI 3 flow obtained.  Lesion reduction in the diagonal from 90% to less than 60% and TIMI 3 flow obtained.  Lesion reduction in the left maintained coronary artery from 50% to 0% and TIMI 3 flow obtained.,The patient tolerated the procedure well and the inflations well with no evidence of any hemodynamic instability.  The Impella device was gradually decreased from performance level of 8 to performance level of 1 at which point it was removed into the aorta and it was turned off and the Impella was removed from the body and the 2 Perclose sutures were tightened.  From the right common femoral artery, a 6-French IMA catheter was advanced and an 0.035-inch wire down into the left common femoral and superficial femoral artery, over which an 8 x 40 balloon was advanced and tamponade of the arteriotomy site of the left common femoral artery was performed from within the artery at 3 atmospheres for a total of 20 minutes.  The right common femoral artery and vein sheaths were both sutured in place for further observation.  Of note, the patient received Angiomax during the procedure and an ACT above 300 was maintained.,IMPRESSION:,1.  Left ventricular dysfunction with ejection fraction of 10% to 15%.,2.  High complex percutaneous coronary intervention of the left main coronary artery, left anterior descending artery, and diagonal with Impella circulatory support.,COMPLICATIONS: , None.,The patient tolerated the procedure well with no complications.  The estimated blood loss was 200 ml.  Estimated dye used was 200 ml of Visipaque.  The patient remained hemodynamically stable with no hypotension and no hematomas in the groins.,PLAN:  ,1.  Aspirin, Plavix, statins, beta blockers, ACE inhibitors as tolerated.,2.  Hydration.,3.  The patient will be observed over night for any hemodynamic instability or ischemia.  If she remains stable, the right common femoral artery and vein sheaths will be removed and manual pressure will be applied for hemostasis.","cardiovascular / pulmonary, impella circulatory assist device, impella assist device, unstable angina, congestive heart failure, heart catheterization, ventriculogram, aortogram, angiogram, ventricular dysfunction, pigtail catheter was advanced, femoral artery and vein, artery and vein, asahi soft wire, circumflex coronary artery, common femoral artery, modified seldinger technique, multiple stent placements, timi flow, multiple stent, impella circulatory, french sheath, femoral artery, endeavor stent, descending artery, coronary artery, common femoral, asahi soft, anterior descending, femoral, coronary, artery, impella, catheterization, "
 Resting Myoview perfusion scan and gated myocardial scan.  Findings consistent with an inferior non-transmural scar, Cardiovascular / Pulmonary, Myoview Perfusion Scan ,"INDICATIONS:,  Previously markedly abnormal dobutamine Myoview stress test and gated scan.,PROCEDURE DONE:,  Resting Myoview perfusion scan and gated myocardial scan.,MYOCARDIAL PERFUSION IMAGING:,  Resting myocardial perfusion SPECT imaging and gated scan were carried out with 32.6 mCi of Tc-99m Myoview.  Rest study was done and compared to previous dobutamine Myoview stress test done on Month DD, YYYY.  The lung heart ratio is 0.34.  There appears to be a moderate size inferoapical perfusion defect of moderate degree.  The gated myocardial scan revealed mild apical and distal inferoseptal hypokinesis with ejection fraction of 55%.,CONCLUSIONS:,  Study done at rest only revealed findings consistent with an inferior non-transmural scar of moderate size and moderate degree.  The left ventricular systolic function is markedly improved with much better regional wall motion of all left ventricular segments when compared to previous study done on Month DD, YYYY.  We cannot assess the presence of any reversible perfusion defects because no stress imaging was performed.","cardiovascular / pulmonary, myoview perfusion scan, rest study, spect imaging, dobutamine myoview stress test, ejection fraction, gated myocardial scan, hypokinesis, ventricular systolic function, resting myoview perfusion scan, myoview stress test, resting myoview, myocardial perfusion, myoview perfusion, perfusion scan, myocardial scan, myocardial, myoview, perfusion"
 MRI: Right parietal metastatic adenocarcinoma (LUNG) metastasis., Cardiovascular / Pulmonary, MRI of Lung - Adenocarcinoma ,"CC:, Found unresponsive.,HX: ,  39 y/o RHF complained of a severe HA at 2AM 11/4/92. It was unclear whether she had been having HA prior to this. She took an unknown analgesic, then vomited, then lay down in bed with her husband. When her husband awoke at 8AM he found her unresponsive with ""stiff straight arms"" and a ""strange breathing pattern."" A Brain CT scan revealed a large intracranial mass. She was intubated and hyperventilated to ABG (7.43/36/398). Other local lab values included: WBC 9.8, RBC 3.74, Hgb 13.8, Hct 40.7, Cr 0.5, BUN 8.5, Glucose 187, Na 140, K 4.0, Cl 107. She was given Mannitol 1gm/kg IV load, DPH 20mg/kg IV load, and transferred by helicopter to UIHC.,PMH:, 1)Myasthenia Gravis for 15 years, s/p Thymectomy,MEDS:, Imuran, Prednisone, Mestinon, Mannitol, DPH, IV NS,FHX/SHX:, Married. Tobacco 10 pack-year; quit nearly 10 years ago. ETOH/Substance Abuse unknown.,EXAM:, 35.8F, 99BPM, BP117/72, Mechanically ventilated at a rate of 22RPM on !00%FiO2. Unresponsive to verbal stimulation. CN: Pupils 7mm/5mm and unresponsive to light (fixed). No spontaneous eye movement or blink to threat. No papilledema or intraocular hemorrhage noted. Trace corneal reflexes bilaterally. No gag reflex. No oculocephalic reflex. MOTOR/SENSORY: No spontaneous movement. On noxious stimulation (Deep nail bed pressure) she either extended both upper extremities (RUE>LUE), or withdrew the stimulated extremity (right > left). Gait/Station/Coordination no tested. Reflexes: 1+ on right and 2+ on left with bilateral Babinski signs.,HCT 11/4/92: Large heterogeneous mass in the right temporal-parietal region causing significant parenchymal distortion and leftward subfalcine effect . There is low parenchymal density within the white matter. A hyperdense ring lies peripherally and may represent hemorrhage or calcification. The mass demonstrates inhomogeneous enhancement with contrast.,COURSE:, Head of bed elevated to 30 degrees, Mannitol and DPH were continued. MRI of Brain demonstrated a large right parietal mass with necrotic appearing center and leftward shift of midline structures. She underwent surgical resection of the tumor. Pathological analysis was consistent with adenocarcinoma. GYN exam, CT Abdomen and Pelvis, Bone scan were unremarkable. CXR revealed an right upper lobe lung nodule. She did not undergo thoracic biopsy due to poor condition. She received 3000 cGy cranial XRT in ten fractions and following this was discharged to a rehabilitation center.,In March, 1993 the patient exhibited right ptosis, poor adduction and abduction OD, 4/4 strength in the upper extremities and 5-/5- strength in the lower extremities. She was ambulatory with an ataxic gait.,She was admitted on 7/12/93 for lower cervical and upper thoracic pain, paraparesis and T8 sensory level. MRI brainstem/spine on that day revealed decreased T1 signal in the C2, C3, C6 vertebral bodies, increased T2 signal in the anterior medulla, and tectum, and spinal cord (C7-T3). Following injection of Gadolinium there was diffuse leptomeningeal enhancement from C7-T7 These findings were felt consistent with metastatic disease including possible leptomeningeal spread. Neurosurgery and Radiation Oncology agreed that the patients symptoms could be due to either radiation injury and/or metastasis. The patient was treated with Decadron and analgesics and discharged to a hospice center (her choice). She died a few months later.","cardiovascular / pulmonary, mri, lung, metastatic adenocarcinoma, parietal, breathing pattern, cranial xrt, t1 signal, sensory level, iv load, adenocarcinoma, metastatic, leptomeningeal"
" Seizure, hypoglycemia, anemia, dyspnea, edema. colon cancer status post right hemicolectomy, hospital-acquired pneumonia, 
and congestive heart failure.", Cardiovascular / Pulmonary, Multiple Medical Problems - Discharge Summary ,"ADMISSION DIAGNOSES:,1.  Seizure.,2.  Hypoglycemia.,3.  Anemia.,4.  Hypotension.,5.  Dyspnea.,6.  Edema.,DISCHARGE DIAGNOSES:,1.  Colon cancer, status post right hemicolectomy.,2.  Anemia.,3.  Hospital-acquired pneumonia.,4.  Hypertension.,5.  Congestive heart failure.,6.  Seizure disorder.,PROCEDURES PERFORMED:,1.  Colonoscopy.,2.  Right hemicolectomy.,HOSPITAL COURSE: , The patient is a 59-year-old female with multiple medical problems including diabetes mellitus requiring insulin for 26 years, previous MI and coronary artery disease, history of seizure disorder, GERD, bipolar disorder, and anemia.  She was admitted due to a seizure and myoclonic jerks as well as hypoglycemia and anemia.  Regarding the seizure disorder, Neurology was consulted.  Noncontrast CT of the head was negative.  Neurology felt that the only necessary intervention at that time would be to increase her Lamictal to 150 mg in the morning and 100 mg in the evening with gradual increase of the dosage until she was on 200 mg b.i.d.  Regarding the hypoglycemia, the patient has diabetic gastroparesis and was being fed on J-tube intermittent feedings throughout the night at the rate of 120 an hour.  Her insulin pump had a basal rate of roughly three at night during the feedings.  While in the hospital, the insulin pump rate was turned down to 1.5 and then subsequently decreased a few other times.  She seemed to tolerate the insulin pump rate well throughout her hospital course.  There were a few episodes of hypoglycemia as well as hyperglycemia, but the episode seem to be related to the patient's n.p.o. status and the changing rates of tube feedings throughout her hospital course.,At discharge, her endocrinologist was contacted.  It was decided to change her insulin pump rate to 3 units per hour from midnight till 6 a.m., from 0.8 units per hour from 6 a.m. until 8 a.m., and then at 0.2 units per hour from 8 a.m. until 6 p.m.  The insulin was to be NovoLog.  Regarding the anemia, the gastroenterologists were consulted regarding her positive Hemoccult stools.  A colonoscopy was performed, which found a mass at the right hepatic flexure.  General Surgery was then consulted and a right hemicolectomy was performed on the patient.  The patient tolerated the procedure well and tube feeds were slowly restarted following the procedure, and prior to discharge were back at her predischarge rates of 120 per hour.  Regarding the cancer itself, it was found that 1 out of 53 nodes were positive for cancer.  CT of the abdomen and pelvis revealed no metastasis, a CT of the chest revealed possible lung metastasis.  Later in hospital course, the patient developed a septic-like picture likely secondary to hospital-acquired pneumonia.  She was treated with Zosyn, Levaquin, and vancomycin, and tolerated the medications well.  Her symptoms decreased and serial chest x-rays were followed, which showed some resolution of the illness.  The patient was seen by the Infectious Disease specialist.  The Infectious Disease specialist recommended vancomycin to cover MRSA bacteria, which was found at the J-tube site.  At discharge, the patient was given three additional days of p.o. Levaquin 750 mg as well as three additional days of Bactrim DS every 12 hours.  The Bactrim was used to cover the MRSA at the J-tube site.  It was found that MRSA was sensitive to Bactrim.  Throughout her hospital course, the patient continued to receive Coreg 12.5 mg daily and Lasix 40 mg twice a day for her congestive heart failure, which remains stable.  She also received Lipitor for her high cholesterol.  Her seizure disorder remained stable and she was discharged on a dose of 100 mg in the morning and 150 mg at night.  The dosage increases can begin on an outpatient basis.,DISCHARGE INSTRUCTIONS/MEDICATIONS: , The patient was discharged to home.  She was told to shy away from strenuous activity.  Her discharge diet was to be her usual diet of isotonic fiber feeding through the J-tube at a rate of 120 per hour throughout the night.  The discharge medications were as follows:,1.  Coreg 12.5 mg p.o. b.i.d.,2.  Lipitor 10 mg p.o. at bedtime.,3.  Nitro-Dur patch 0.3 mg per hour one patch daily.,4.  Phenergan syrup 6.25 mg p.o. q.4h. p.r.n.,5.  Synthroid 0.175 mg p.o. daily.,6.  Zyrtec 10 mg p.o. daily.,7.  Lamictal 100 mg p.o. daily.,8.  Lamictal 150 mg p.o. at bedtime.,9.  Ferrous sulfate drops 325 mg, PEG tube b.i.d.,10.  Nexium 40 mg p.o. at breakfast.,11.  Neurontin 400 mg p.o. t.i.d.,12.  Lasix 40 mg p.o. b.i.d.,13.  Fentanyl 50 mcg patch transdermal q.72h.,14.  Calcium and vitamin D combination, calcium carbonate 500 mg/vitamin D 200 units one tab p.o. t.i.d.,15.  Bactrim DS 800mg/160 mg tablet one tablet q.12h. x3 days.,16.  Levaquin 750 mg one tablet p.o. x3 days.,The medications listed above, one listed as p.o. are to be administered via the J-tube.,FOLLOWUP:  ,The patient was instructed to see Dr. X in approximately five to seven days.  She was given a lab sheet to have a CBC with diff as well as a CMP to be drawn prior to her appointment with Dr. X.  She is instructed to follow up with Dr. Y if her condition changes regarding her colon cancer.  She was instructed to follow up with Dr. Z, her oncologist, regarding the positive lymph nodes.  We were unable to contact Dr. Z, but his telephone number was given to the patient and she was instructed to make a followup appointment.  She was also instructed to follow up with her endocrinologist, Dr. A, regarding any insulin pump adjustments, which were necessary and she was also instructed to follow up with Dr. B, her gastroenterologist, regarding any issues with her J-tube.,CONDITION ON DISCHARGE: , Stable.",
" A female admitted with jaundice and a pancreatic mass who was noted to have a new murmur, bacteremia, and fever. ", Cardiovascular / Pulmonary, Murmur & Bacteremia. ,"REASON FOR CONSULTATION: , New murmur with bacteremia.,HISTORY OF PRESENT ILLNESS:,  The patient is an 84-year-old female admitted with jaundice and a pancreatic mass who was noted to have a new murmur, bacteremia, and fever.  The patient states that apart from the fever, she was having no other symptoms and denies any previous cardiac history.  She denies any orthopnea or paroxysmal nocturnal dyspnea.  Denies any edema, chest pain, palpitations, or syncope.  She has had TIAs in the past, but none recently.,PAST MEDICAL HISTORY:,  Significant for diabetes, hypertension, and TIA.,MEDICATIONS: , Include:,1.  Acidophilus supplement.,2.  Cholestyramine.,3.  Creon 20 three times daily.,4.  Diovan 160 mg twice daily.,6.  Lantus 10 daily.,7.  Norvasc 5 mg daily.,8.  NovoLog 70/30, 10 units at 12 noon daily.,9.  Pamelor 15 mL every evening.,10.  Vitamin D3 one tablet weekly.,ALLERGIES: , THE PATIENT IS ALLERGIC TO CODEINE, COREG, AND VANCOMYCIN.,FAMILY HISTORY:  ,The patient's daughter apparently has history of a murmur, but no diagnosis of congenital heart disease.  The patient's father died in his 80s of CHF.,SOCIAL HISTORY: , The patient denies ever having smoked, denies any significant alcohol use, and lives with her daughter in Pasadena.,REVIEW OF SYSTEMS: , The patient has had fever and chills.  She has also had some jaundice.  Denies any nausea or vomiting.  Denies any chest pain or abdominal pain.  Denies orthopnea, paroxysmal nocturnal dyspnea or edema.  She has had TIAs in the past, but denies any recent neurological symptoms such as motor weakness or focal sensory deficits.  Denies melena or hematochezia.  All other systems were reviewed and were found to be negative.,PHYSICAL EXAMINATION,GENERAL:  An elderly Caucasian female, awake and alert, and in no distress.,VITAL SIGNS:  Temperature is 98.8, heart rate 96, sinus, blood pressure 138/55, respiratory rate 20, and oxygen saturation 92%.,HEAD AND NECK:  Her head is atraumatic.  She is normocephalic.  Her neck is supple.  There is no JVD.  No palpable adenopathy or thyromegaly.  There is some icterus of the sclerae bilaterally.  Oral mucosa is moist.,CHEST:  Symmetrical expansion with normal percussion note.  There are no inspiratory crackles or expiratory wheeze.,CARDIAC:  Heart sounds S1 and S2 are regular.  There is a 2/6 systolic murmur heard through the precordium.  There is no gallop or rub.  There is no palpable thrill or retrosternal lift.,ABDOMEN:  Soft, nondistended, and nontender with normal bowel sounds.  No audible bruits.,EXTREMITIES:  No pitting edema, no clubbing, no cyanosis, and peripheral pulses are 2+.,NEUROLOGIC:  She exhibits no focal motor or sensory findings.,LABORATORY DATA: , The patient's sodium was 133, potassium 2.8, chloride 99, bicarbonate 31, glucose 75, BUN 12, creatinine 0.8, calcium 8.6, total bilirubin 3.2, AST 63, and ALT 43.  White count 5.4, hemoglobin 9.1, hematocrit 26.6, and platelet count 128,000.  Lipase less than 10.,DIAGNOSTIC IMAGING: , The patient had a CT scan of the abdomen that demonstrated a pancreatic mass with biliary obstruction.  Previous biliary stent was present.,EKG shows normal sinus rhythm.  There are no acute ST-T changes.,ASSESSMENT: , This is an 84-year-old female with newly found murmur.  No previous history of heart disease.  This murmur has occurred in the setting of fever and bacteremia.  The patient also has a pancreatic mass with jaundice, history of hypertension, and now has hyponatremia and hypokalemia.,PLAN:  ,The patient should undergo an echocardiogram to assess for the possibility of endocarditis, which may be contributing to her symptoms.  Blood pressure control should be maintained with Diovan and Norvasc.  Potassium should be replaced, and hyponatremia should be on proactive.",
" Loculated left effusion, multilobar pneumonia.  Patient  had a diagnosis of multilobar pneumonia along with arrhythmia and heart failure as well as renal insufficiency. ", Cardiovascular / Pulmonary, Multilobar Pneumonia ,"REASON FOR CONSULTATION: , Loculated left effusion, multilobar pneumonia.","cardiovascular / pulmonary, neck bruits, nasal cannula, rhythm, pneumonia, chest tube, fluid collection, pleural effusion, multilobar pneumonia, pleural, loculations, multilobar,"
 Mitral valve repair using a quadrangular resection of the P2 segment of the posterior leaflet.  Mitral valve posterior annuloplasty using a Cosgrove Galloway Medtronic fuser band.  Posterior leaflet abscess resection., Cardiovascular / Pulmonary, Mitral Valve Repair & Annuloplasty ,"OPERATIONS,1.  Mitral valve repair using a quadrangular resection of the P2 segment of the posterior leaflet.,2.  Mitral valve posterior annuloplasty using a Cosgrove Galloway Medtronic fuser band.,3.  Posterior leaflet abscess resection.,ANESTHESIA:  ,General endotracheal anesthesia,TIMES:  ,Aortic cross-clamp time was ** minutes.  Cardiopulmonary bypass time total was ** minutes.,PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered.  Next, the patient's chest and legs were prepped and draped in standard surgical fashion.  A #10-blade scalpel was used to make a midline median sternotomy incision.  Dissection was carried down to the level of the sternum using Bovie electrocautery.  The sternum was opened with a sternal saw, and full-dose heparinization was given.  Next, the chest retractor was positioned.  The pericardium was opened with Bovie electrocautery and pericardial stay sutures were positioned.  We then prepared to place the patient on cardiopulmonary bypass.  A 2-0 Ethibond double pursestring was placed in the ascending aorta.  Through this was passed our aortic cannula and connected to the arterial side of the cardiopulmonary bypass machine.  Next, double cannulation with venous cannulas was instituted.  A 3-0 Prolene pursestring was placed in the right atrial appendage.  Through this was passed our SEC cannula.  This was connected to the venous portion of the cardiopulmonary bypass machine in a Y-shaped circuit.  Next, a 3-0 Prolene pursestring was placed in the lower border of the right atrium.  Through this was passed our inferior vena cava cannula.  This was likewise connected to the Y connection of our venous cannula portion.  We then used a 4-0 U-stitch in the right atrium for our retrograde cardioplegia catheter, which was inserted.  Cardiopulmonary bypass was instituted.  Metzenbaum scissors were used to dissect out the SVC and IVC, which were subsequently encircled with umbilical tape.  Sondergaard's groove was taken down.  Next, an antegrade cardioplegia needle and associated sump were placed in the ascending aorta.  This was connected appropriately as was the retrograde cardioplegia catheter.  Next, the aorta was cross-clamped, and antegrade and retrograde cardioplegia was infused so as to arrest the heart in diastole.  Next a #15-blade scalpel was used to open the left atrium.  The left atrium was decompressed with pump sucker.  Next, our self-retaining retractor was positioned so as to bring the mitral valve up into view.  Of note was the fact that the mitral valve P2 segment of the posterior leaflet had an abscess associated with it.  The borders of the P2 segment abscess were defined by using a right angle to define the chordae which were encircled with a 4-0 silk.  After doing so, the P2 segment of the posterior leaflet was excised with a #11-blade scalpel.  Given the laxity of the posterior leaflet, it was decided to reconstruct it with a 2-0 Ethibond pledgeted suture.  This was done so as to reconstruct the posterior annular portion.  Prior to doing so, care was taken to remove any debris and abscess-type material.  The pledgeted stitch was lowered into place and tied.  Next, the more anterior portion of the P2 segment was reconstructed by running a 4-0 Prolene stitch so as to reconstruct it.  This was done without difficulty.  The apposition of the anterior and posterior leaflet was confirmed by infusing solution into the left ventricle.  There was noted to be a small amount of central regurgitation.  It was felt that this would be corrected with our annuloplasty portion of the procedure.  Next, 2-0 non-pledgeted Ethibond sutures were placed in the posterior portion of the annulus from trigone to trigone in interrupted fashion.  Care was taken to go from trigone to trigone.  Prior to placing these sutures, the annulus was sized and noted to be a *** size for the Cosgrove-Galloway suture band ring from Medtronic.  After, as mentioned, we placed our interrupted sutures in the annulus, and they were passed through the CG suture band.  The suture band was lowered into position and tied in place.  We then tested our repair and noted that there was very mild regurgitation.  We subsequently removed our self-retaining retractor.  We closed our left atriotomy using 4-0 Prolene in a running fashion.  This was done without difficulty.  We de-aired the heart.  We then gave another round of antegrade and retrograde cardioplegia in warm fashion.  The aortic cross-clamp was removed, and the heart gradually resumed electromechanical activity.  We then removed our retrograde cardioplegia catheter from the coronary sinus and buttressed this site with a 5-0 Prolene.  We placed 2 ventricular and 2 atrial pacing leads which were brought out through the skin.  The patient was gradually weaned off cardiopulmonary bypass and our venous cannulas were removed.  We then gave full-dose protamine; and after noting that there was no evidence of a protamine reaction, we removed our aortic cannula.  This site was buttressed with a 4-0 Prolene on an SH needle.  The patient tolerated the procedure well.  We placed a mediastinal #32-French chest tube as well as a right chest Blake drain.  The mediastinum was inspected for any signs of bleeding.  There were none.  We closed the sternum with #7 sternal wires in interrupted figure-of-eight fashion.  The fascia was closed with a #1 Vicryl followed by a 2-0 Vicryl, followed by 3-0 Vicryl in a running subcuticular fashion.  The instrument and sponge count was correct at the end of the case.  The patient tolerated the procedure well and was transferred to the intensive care unit in good condition.","cardiovascular / pulmonary, mitral valve repair, mitral valve, abscess resection, leaflet abscess, cosgrove galloway medtronic, bovie electrocautery, cannulation, bypass, annuloplasty, cardioplegia, mitral, "
" Suspension microlaryngoscopy, rigid bronchoscopy, dilation of tracheal stenosis.", Cardiovascular / Pulmonary, Microlaryngoscopy ,"PREOPERATIVE DIAGNOSIS:,  Airway obstruction secondary to laryngeal subglottic stenosis.,POSTOPERATIVE DIAGNOSIS:  ,Airway obstruction secondary to laryngeal subglottic stenosis and tracheal stenosis.,OPERATION PERFORMED: , Suspension microlaryngoscopy, rigid bronchoscopy, dilation of tracheal stenosis.,INDICATIONS FOR SURGERY:  ,The patient is a 56-year-old white female with a history of relapsing polychondritis, which resulted in saddle nose deformity in glottic and subglottic stenosis for which she has undergone number of procedures in the past to the upper airway.  She currently is trach dependent for her airway because of glottic and subglottic stenosis, but she is having no significant problems breathing and talking around her trach tube and came for further evaluation.  Endoscopic reevaluation of her tube and nature of the proposed procedure done.  Risk and complications of bleeding, infection, alteration of with speech or swallowing, failure to improve her airway, and loss of voice.  Cardiorespiratory anesthetic results were discussed in length.  The patient states she understood and wished to proceed.,DESCRIPTION OF OPERATION:,  The patient was taken to the operating room and placed in the supine position.  Under adequate general endotracheal anesthesia, the patient's #5 metal tracheostomy tube was removed and a #5 laser-safe endotracheal tube was inserted.  The patient was then prepared for endoscopy.  The Kantor laryngoscope was then inserted.  Oral cavity, hypopharynx, larynx, and nasal cavity showed good dentition with good tongue, buccal cavity, and mucosa without lesions.  Larynx was then ***** short epiglottis.  Larynx was suspended with significant scarring beginning in the supraglottic area with loss of laryngeal contour beginning in the supraglottis with extensive scar tissue at the level of the false cord obliteration of ventricles and true cords.  This appeared to be stable, and airway was patent at the supraglottic and glottic level with some narrowing at the subglottic level with mild-to-moderate subglottic stenosis, otherwise this appeared to be stable.  However, distally, the level of the trach site examined with the microscope and 0 and 30-degree telescopes.  The patient noted to have marked narrowing with dense scarring posterolaterally on the left securing good visualization of the trach tube.  The laryngoscope was removed, and a 5 x 30 pediatric rigid bronchoscope was then passed.  The LP contact tip laser was utilized to vaporize the scar tissue and release the scar banding following which the scope was passed and further dilation carried out.  Mid and distal trachea were widely patent.  Trachea and mainstem bronchi were patent without obvious disease.  The patient did not appear to have any relapsing polychondritis with progressive scar tissue at the level of the trach site and the posterior trachea wall was significant.  This was further dilated and following which was removed and a new #5 metal tracheostomy tube inserted.  The patient tolerated the procedure well without complications and was taken to recovery room in satisfactory condition.","cardiovascular / pulmonary, airway obstruction, oral cavity, bronchoscopy, buccal cavity, hypopharynx, laryngeal, larynx, microlaryngoscopy, nasal cavity, polychondritis, subglottic, tracheal stenosis, tracheostomy tube, scar tissue, subglottic stenosis, tracheal, airway, cavity, tube, scarring, stenosis, "
 Right pleural effusion and suspected malignant mesothelioma., Cardiovascular / Pulmonary, Mesothelioma - Pleural Biopsy ,"PREOPERATIVE DIAGNOSIS: , Right pleural effusion and suspected malignant mesothelioma.,POSTOPERATIVE DIAGNOSIS:,  Right pleural effusion, suspected malignant mesothelioma.,PROCEDURE: , Right VATS pleurodesis and pleural biopsy.,ANESTHESIA:,  General double-lumen endotracheal.,DESCRIPTION OF FINDINGS: , Right pleural effusion, firm nodules, diffuse scattered throughout the right pleura and diaphragmatic surface.,SPECIMEN: , Pleural biopsies for pathology and microbiology.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid 1.2 L and 1.9 L of pleural effusion drained.,INDICATIONS: , Briefly, this is a 66-year-old gentleman who has been transferred from an outside hospital after a pleural effusion had been drained and biopsies taken from the right chest that were thought to be consistent with mesothelioma.  Upon transfer, he had a right pleural effusion demonstrated on x-ray as well as some shortness of breath and dyspnea on exertion.  The risks, benefits, and alternatives to right VATS pleurodesis and pleural biopsy were discussed with the patient and his family and they wished to proceed.,PROCEDURE IN DETAIL:  ,After informed consent was obtained, the patient was brought to the operating room and placed in supine position.  A double-lumen endotracheal tube was placed.  SCDs were also placed and he was given preoperative Kefzol.  The patient was then brought into the right side up, left decubitus position, and the area was prepped and draped in the usual fashion.  A needle was inserted in the axillary line to determine position of the effusion.  At this time, a 10-mm port was placed using the knife and Bovie cautery.  The effusion was drained by placing a sucker into this port site.  Upon feeling the surface of the pleura, there were multiple firm nodules.  An additional anterior port was then placed in similar fashion.  The effusion was then drained with a sucker.  Multiple pleural biopsies were taken with the biopsy device in all areas of the pleura.  Of note, feeling the diaphragmatic surface, it appeared that it was quite nodular, but these nodules felt as though they were on the other side of the diaphragm and not on the pleural surface of the diaphragm concerning for a possibly metastatic disease.  This will be worked up with further imaging study later in his hospitalization.  After the effusion had been drained, 2 cans of talc pleurodesis aerosol were used to cover the lung and pleural surface with talc.  The lungs were then inflated and noted to inflate well.  A 32 curved chest tube chest tube was placed and secured with nylon.  The other port site was closed at the level of the fascia with 2-0 Vicryl and then 4-0 Monocryl for the skin.  The patient was then brought in the supine position and extubated and brought to recovery room in stable condition.,Dr. X was present for the entire procedure which was right VATS pleurodesis and pleural biopsies.,The counts were correct x2 at the end of the case.","cardiovascular / pulmonary, double-lumen, endotracheal, pleural surface, chest tube, pleural biopsy, malignant mesothelioma, vats pleurodesis, pleural biopsies, pleural effusion, pleural, vats, pleurodesis, mesothelioma,"
" Mesothelioma versus primary lung carcinoma, Chronic obstructive pulmonary disease, paroxysmal atrial fibrillation, malignant pleural effusion, status post surgery as stated above, and anemia of chronic disease.", Cardiovascular / Pulmonary, Mesothelioma - Consult ,"REASON FOR CONSULTATION: , Mesothelioma.,HISTORY OF PRESENT ILLNESS: , The patient is a 73-year-old pleasant Caucasian male who is known to me from his previous hospitalization.  He has also been seen by me in the clinic in the last few weeks.  He was admitted on January 18, 2008, with recurrent malignant pleural effusion.  On the same day, he underwent VATS and thoracoscopic drainage of the pleural effusion with right pleural nodule biopsy, lysis of adhesions, and directed talc insufflation by Dr. X.  He was found to have 2.5L of bloody pleural effusions, some loculated pleural effusion, adhesions, and carcinomatosis in the parenchyma.  His hospital course here has been significant for dyspnea, requiring ICU stay.  He also had a chest tube, which was taken out few days ago.  He has also had paroxysmal atrial fibrillation, for which he has been on amiodarone by cardiologist.  The biopsy from the pleural nodule done on the right on January 18, 2008, shows malignant epithelioid neoplasm consistent with mesothelioma.  Immunohistochemical staining showed tumor cells positive for calretinin and focally positive for D2-40, MOC-31.  Tumor cells are negative for CDX-2, and monoclonal CEA.,The patient at this time reports that overall he has been feeling better with decrease in shortness of breath and cough over the last few days.  He does have edema in his lower extremities.  He is currently on 4L of oxygen.  He denies any nausea, vomiting, abdominal pain, recent change in bowel habit, melena, or hematochezia.  No neurological or musculoskeletal signs or symptoms.  He reports that he is able to ambulate to the bathroom, but gets short of breath on exertion.  He denies any other complaints.,PAST MEDICAL HISTORY:,  Left ventricular systolic dysfunction as per the previous echocardiogram done in December 2007, history of pneumonia in December 2007, admitted to XYZ Hospital.  History of recurrent pleural effusions, status post pleurodesis and locally advanced non-small cell lung cancer as per the biopsy that was done in XYZ Hospital.,ALLERGIES:,  No known drug allergies.,CURRENT MEDICATIONS:  ,In the hospital are amiodarone, diltiazem, enoxaparin, furosemide, methylprednisolone, pantoprazole, Zosyn, p.r.n. acetaminophen, and hydrocodone.,SOCIAL HISTORY: , The patient is married and lives with his spouse.  He has history of tobacco smoking and also reports history of alcohol abuse.  No history of illicit drug abuse.,FAMILY HISTORY:  ,Significant for history of ?cancer? in the mother and history of coronary artery disease in the father.,REVIEW OF SYSTEMS: , As stated above.  He denies any obvious asbestos exposure, as far as he can remember.,PHYSICAL EXAMINATION,GENERAL:  He is awake, alert, in no acute distress.  He is currently on 4L of oxygen by nasal cannula.,VITAL SIGNS:  Blood pressure 97/65 mmHg, respiration is 20 per minute, pulse is 72 per minute, and temperature 98.3 degrees Fahrenheit.,HEENT:  No icterus or sinus tenderness.  Oral mucosa is moist.,NECK:  Supple.  No lymphadenopathy.,LUNGS:  Clear to auscultation except few diffuse wheezing present bilaterally.,CARDIOVASCULAR:  S1 and S2 normal.,ABDOMEN:  Soft, nondistended, and nontender.  No hepatosplenomegaly.  Bowel sounds are present in all four quadrants.,EXTREMITIES:  Bilateral pedal edema is present in both the extremities.  No signs of DVT.,NEUROLOGICAL:  Grossly nonfocal.,INVESTIGATION:,  Labs done on January 28, 2008, showed BUN of 23 and creatinine of 0.9.  Liver enzymes checked on January 17, 2008, were unremarkable.  CBC done on January 26, 2008, showed WBC of 19.8, hemoglobin of 10.7, hematocrit of 30.8, and platelet count of 515,000.  Chest x-ray from yesterday shows right-sided Port-A-Cath, diffuse right lung parenchymal and pleural infiltration without change, mild pulmonary vascular congestion.,ASSESSMENT,1.  Mesothelioma versus primary lung carcinoma, two separate reports as for the two separate biopsies done several weeks apart.,2.  Chronic obstructive pulmonary disease.,3.  Paroxysmal atrial fibrillation.,4.  Malignant pleural effusion, status post surgery as stated above.,5.  Anemia of chronic disease.,RECOMMENDATIONS,1.  Compare the slides from the previous biopsy done in December at XYZ Hospital with recurrent pleural nodule biopsy slides.  I have discussed regarding this with Dr. Y in Pathology here at Methodist XYZ Hospital.  I will try to obtain the slides for comparison from XYZ Hospital for comparison and immunohistochemical staining.,2.  I will also discuss with Dr. X and also with intervention radiologist at XYZ Hospital regarding the exact sites of the two biopsies.,3.  Once the results of the above are available, I will make further recommendations regarding treatment.  The patient has significantly decreased performance status with dyspnea on exertion and is being planned for transfer to Triumph Hospital for rehab, which I agree with.,4.  Continue present care.,Discussed regarding the above in great details with the patient and his wife and daughter and answered the questions to their satisfaction.  They clearly understand the above.  They also understand his very poor performance status at this time, and the risks and benefits of delaying chemotherapy due to this.",
 Posterior mediastinal mass with possible neural foraminal involvement (benign nerve sheath tumor by frozen section).  Left thoracotomy with resection of posterior mediastinal mass., Cardiovascular / Pulmonary, Mediastinal Mass Resection ,"PREOPERATIVE DIAGNOSIS:,  Posterior mediastinal mass with possible neural foraminal involvement.,POSTOPERATIVE DIAGNOSIS: , Posterior mediastinal mass with possible neural foraminal involvement (benign nerve sheath tumor by frozen section).,OPERATION PERFORMED:,  Left thoracotomy with resection of posterior mediastinal mass.,INDICATIONS FOR PROCEDURE:  ,The patient is a 23-year-old woman who recently presented with a posterior mediastinal mass and on CT and MRI there were some evidence of potential widening of one of the neural foramina.  For this reason, Dr. X and I agreed to operate on this patient together.  Please note that two surgeons were required for this case due to the complexity of it.  The indications and risks of the procedure were explained and the patient gave her informed consent.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating suite and placed in the supine position.  General endotracheal anesthesia was given with a double lumen tube.  The patient was positioned for a left thoracotomy.  All pressure points were carefully padded.  The patient was prepped and draped in usual sterile fashion.  A muscle sparing incision was created several centimeters anterior to the tip of the scapula.  The serratus and latissimus muscles were retracted.  The intercostal space was opened.  We then created a thoracoscopy port inferiorly through which we placed a camera for lighting and for visualization.  Through our small anterior thoracotomy and with the video-assisted scope placed inferiorly we had good visualization of the posterior mediastinum mass.  This was in the upper portion of the mediastinum just posterior to the subclavian artery and aorta.  The lung was deflated and allowed to retract anteriorly.  With a combination of blunt and sharp dissection and with attention paid to hemostasis, we were able to completely resect the posterior mediastinal mass.  We began by opening the tumor and taking a very wide large biopsy.  This was sent for frozen section, which revealed a benign nerve sheath tumor.  Then, using the occluder device Dr. X was able to _____ the inferior portions of the mass.  This left the external surface of the mass much more malleable and easier to retract.  Using a bipolar cautery and endoscopic scissors we were then able to completely resect it.  Once the tumor was resected, it was then sent for permanent sections.  The entire hemithorax was copiously irrigated and hemostasis was complete.  In order to prevent any lymph leak, we used 2 cc of Evicel and sprayed this directly on to the raw surface of the pleural space.  A single chest tube was inserted through our thoracoscopy port and tunneled up one interspace.  The wounds were then closed in multiple layers.  A #2 Vicryl was used to approximate the ribs.  The muscles of the chest wall were allowed to return to their normal anatomic position.  A 19 Blake was placed in the subcutaneous tissues.  Subcutaneous tissues and skin were closed with running absorbable sutures.  The patient was then rolled in the supine position where she was awakened from general endotracheal anesthesia and taken to the recovery room in stable condition.","cardiovascular / pulmonary, posterior mediastinal mass, neural foraminal, nerve sheath tumor, frozen section, thoracotomy, mediastinal mass, foraminal, neural, sheath, mediastinal, "
" Myoview nuclear stress study.  Angina, coronary artery disease.  Large fixed defect, inferior and apical wall, related to old myocardial infarction.", Cardiovascular / Pulmonary, Mayoview - 1 ,"MYOVIEW NUCLEAR STRESS STUDY,REASON FOR THE TEST:,  Angina, coronary artery disease.,FINDINGS: , The patient exercised according to the Lexiscan nuclear stress study, received a total of 0.4 mg of Lexiscan.  At peak hyperemic effect, 25.8 mCi of Myoview injected for the stress imaging and earlier 8.1 mCi of Myoview injected for the resting and the usual SPECT and gated SPECT protocol was followed in the rest-stress sequence.,The data analyzed using Cedars-Sinai software.,The resting heart rate was 49 with the resting blood pressure of 149/86.  Maximum heart rate achieved was 69 with a maximum blood pressure achieved of 172/76.,EKG at rest showed to be abnormal with sinus rhythm, left atrial enlargement, and inverted T-wave in 1, 2, and aVL as well as from V4 to V6 with LVH.  Maximal stress test EKG showed no change from baseline.,IMPRESSION:  ,Maximal Lexiscan stress test with abnormal EKG at baseline maximal stress test, please refer to the Myoview interpretation.,MYOVIEW INTERPRETATIONS,FINDINGS: , The left ventricle appears to be dilated on both stress and rest with no significant change between stress and rest with left ventricular end-diastolic volume of 227, end-systolic volume of 154 with moderately to severely reduced LV function with akinesis of the inferior and inferoseptal wall.  EF was calculated at 32%, estimated 35% to 40%.,Cardiac perfusion reviewed, showed a large area of moderate-to-severe intensity in the inferior wall and small-to-medium area of severe intensity at the apex and inferoapical wall.  Both defects showed no change on the resting indicative of a fixed defect in the inferior and inferoapical wall consistent with old inferior inferoapical MI.  No reversible defects indicative of myocardium at risk.  The lateral walls as well as the septum and most of the anterior wall showed no reversibility and near-normal perfusion.,IMPRESSION:,1.  Large fixed defect, inferior and apical wall, related to old myocardial infarction.,2.  No reversible ischemia identified.,3.  Moderately reduced left ventricular function with ejection fraction of about 35% consistent with ischemic cardiomyopathy.","cardiovascular / pulmonary, myoview, myoview interpretations, spect, gated spect protocol, myoview nuclear stress study, nuclear stress study, stress study, stress test, stress, lexiscan, ekg, inferoapical, angina, wall, resting,"
 Left metastasectomy of metastatic renal cell carcinoma with additional mediastinal lymph node dissection and additional fiberoptic bronchoscopy., Cardiovascular / Pulmonary, Metastasectomy & Bronchoscopy ,"PREOPERATIVE DIAGNOSIS:  ,Metastatic renal cell carcinoma.,POSTOPERATIVE DIAGNOSIS:,  Metastatic renal cell carcinoma.,PROCEDURE PERFORMED:,  Left metastasectomy of metastatic renal cell carcinoma with additional mediastinal lymph node dissection and additional fiberoptic bronchoscopy used to confirm adequate placement of the double-lumen endotracheal tube with a tube thoracostomy, which was used to drain the left chest after the procedure.,ANESTHESIA:,  General endotracheal anesthesia with double-lumen endotracheal tube.,FINDINGS:,  Multiple pleural surface seeding, many sub-millimeter suspicious looking lesions.,DISPOSITION OF SPECIMENS:,To Pathology for permanent analysis as well as tissue banking.  The lesions sent for pathologic analysis were the following,,1.  Level 8 lymph node.,2.  Level 9 lymph node.,3.  Wedge, left upper lobe apex, which was also sent to the tissue bank and possible multiple lesions within this wedge.,4.  Wedge, left upper lobe posterior.,5.  Wedge, left upper lobe anterior.,6.  Wedge, left lower lobe superior segment.,7.  Wedge, left lower lobe diaphragmatic surface, anterolateral.,8.  Wedge, left lower lobe, anterolateral.,9.  Wedge, left lower lobe lateral adjacent to fissure.,10.  Wedge, left upper lobe, apex anterior.,11.  Lymph node package, additional level 8 lymph node.,ESTIMATED BLOOD LOSS:,  Less than 100 mL.,CONDITION OF THE PATIENT AFTER SURGERY: , Stable.,HISTORY OF PROCEDURE: , The patient was given preoperative informed consent for the procedure as well as for the clinical trial he was enrolled into.  The patient agreed based on the risks and the benefits of the procedure, which were presented to him and was taken to the operating room.  A correct time out procedure was performed.  The patient was placed into the supine position.  He was given general anesthesia, was endotracheally intubated without incident with a double-lumen endotracheal tube.  Fiberoptic bronchoscopy was used to perform confirmation of adequate placement of the double-lumen tube.  Following this, the decision was made to proceed with the surgery.  The patient was rolled into the right lateral decubitus position with the left side up.  All pressure points were padded.  The patient had a sterile DuraPrep preparation to the left chest.  A sterile drape around that was applied.  Also, the patient had Marcaine infused into the incision area.  Following this, the patient had a posterolateral thoracotomy incision, which was a muscle-sparing incision with a posterior approach just over the ausculatory triangle.  The incision was approximately 10 cm in size.  This was created with a 10-blade scalpel.  Bovie electrocautery was used to dissect the subcutaneous tissues.  The auscultatory triangle was opened.  The posterior aspect of the latissimus muscle was divided from the adjacent tissue and retracted anteriorly.  The muscle was not divided.  After the latissimus muscle was retracted anteriorly, the ribs were counted, and the sixth rib was identified.  The superior surface of the sixth rib was incised with Bovie electrocautery and the sixth rib was divided with rib shears.  Following this, the patient had the entire intercostal muscle separated from the superior aspect of the sixth rib on the left as far as the Bovie would reach.  The left lung was allowed to collapse and meticulous inspection of the left lung identified the lesions, which were taken out with stapled wedge resections via a TA30 green load stapler for all of the wedges.  The patient tolerated the procedure well without any complications.  The largest lesion was the left upper lobe apex lesion, which was possibly multiple lesions, which was taken in one large wedge segment, and this was also adjacent to another area of the wedges.  The patient had multiple pleural abnormalities, which were identified on the surface of the lung.  These were small white spotty looking lesions and were not confirmed to be tumor implants, but were suspicious to be multiple areas of tumor.  Based on this, the wedges of the tumors that were easily palpable were excised with complete excision of all palpable lesions.  Following this, the patient had a 32-French chest tube placed in the anteroapical position.  A 19-French Blake was placed in the posterior apical position.  The patient had the intercostal space reapproximated with #2-0 Vicryl suture, and the lung was allowed to be re-expanded under direct visualization.  Following this, the chest tubes were placed to Pleur-evac suction and the auscultatory triangle was closed with 2-0 Vicryl sutures.  The deeper tissue was closed with 3-0 Vicryl suture, and the skin was closed with running 4-0 Monocryl suture in a subcuticular fashion.  The patient tolerated the procedure well and had no complications.", 
 Resting Myoview and adenosine Myoview SPECT, Cardiovascular / Pulmonary, Mayoview ,"PROCEDURE DONE:  ,Resting Myoview and adenosine Myoview SPECT.,INDICATIONS:,  Chest pain.,PROCEDURE:,  13.3 mCi of Tc-99m tetrofosmin was injected and resting Myoview SPECT was obtained.  Pharmacologic stress testing was done using adenosine infusion.  Patient received 38 mg of adenosine infused at 140 mcg/kg/minute over a period of four minutes.  Two minutes during adenosine infusion, 31.6 mCi of Tc-99m tetrofosmin was injected.  Resting heart rate was 90 beats per minute.  Resting blood pressure was 130/70.  Peak heart rate obtained during adenosine infusion was 102 beats per minute.  Blood pressure obtained during adenosine infusion was 112/70.  During adenosine infusion, patient experienced dizziness and shortness of breath.  No significant ST segment, T wave changes, or arrhythmias were seen.,Resting Myoview and adenosine Myoview SPECT showed uniform uptake of isotope throughout myocardium without any perfusion defect.  Gated dynamic imaging showed normal wall motion and normal systolic thickening throughout left ventricular myocardium.  Left ventricular ejection fraction obtained during adenosine Myoview SPECT was 77%.  Lung heart ratio was 0.40.  TID ratio was 0.88.,IMPRESSION:,  Normal adenosine Myoview myocardial perfusion SPECT.  Normal left ventricular regional and global function with left ventricular ejection fraction of 77%.","cardiovascular / pulmonary, myoview, gated dynamic imaging, myoview spect, resting myoview, spect, tc-99m, adenosine myoview, adenosine infusion, ejection fraction, myocardium, systolic thickening, tetrofosmin, adenosine myoview spect, adenosine,"
" Patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI.  The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion.", Cardiovascular / Pulmonary, Lung Cancer & MI - Hospice Cosult ,"REASON FOR CONSULT: , I was asked to see this patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI.,HISTORY OF PRESENT ILLNESS: , The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion.  Her daughter who accompanies her is very attentive whom I had met previously during drainage of a malignant hemorrhagic pericardial effusion last month.  The patient has been feeling well for the last several weeks, per the daughter, but today per the personal aide, became agitated and uncomfortable at about 2:30 p.m.  At about 7 p.m., the patient began vomiting, was noted to be short of breath by her daughter with garbled speech, arms flopping, and irregular head movements.  Her daughter called 911 and her symptoms seemed to improve.  Then, she began vomiting.  When the patient's daughter asked her if she had chest pain, the patient said yes.,She came to the emergency room, an EKG showed inferior ST-elevation MI.  I was called immediately and knowing her history, especially, her hospice status with recent hemorrhagic pericardial effusion, I felt thrombolytic was contraindicated and she would not be a candidate for aggressive interventional therapy with PCI/CABG.  She was begun after discussion with the oncologist, on heparin drip and has received morphine, nitro, and beta-blocker, and currently states that she is pain free.  Repeat EKG shows normalization of her ST elevation in the inferior leads as well as normalization of prior reciprocal changes.,PAST MEDICAL HISTORY: , Significant for metastatic non-small-cell lung cancer.  In early-to-mid December, she had an admission and was found to have a malignant pericardial effusion with tamponade requiring urgent drainage.  We did repeat an echo several weeks later and that did not show any recurrence of the pericardial effusion.  She is on hospice from the medical history, atrial fibrillation, hypertension, history of multiple CVA.,MEDICATIONS: , Medications as an outpatient:,1.  Amiodarone 200 mg once a day.,2.  Roxanol concentrate 5 mg three hours p.r.n. pain.,ALLERGIES:  ,CODEINE.  NO SHRIMP, SEAFOOD, OR DYE ALLERGY.,FAMILY HISTORY: , Negative for cardiac disease.,SOCIAL HISTORY: , She does not smoke cigarettes.  She uses alcohol.  No use of illicit drugs.  She is divorced and lives with her daughter.  She is a retired medical librarian from Florida.,REVIEW OF SYSTEMS:  ,Unable to be obtained due to the patient's aphasia.,PHYSICAL EXAMINATION: , Height 5 feet 3, weight of 106 pounds, temperature 97.1 degrees, blood pressure ranges from 138/82 to 111/87, pulse 61, respiratory rate 22.  O2 saturation 100%.  On general exam, she is an elderly woman with now marked aphasia, which per her daughter waxes and wanes, was more pronounced and she nods her head up and down when she says the word, no, and conversely, she nods her head side-to-side when she uses the word yes with some discordance in her head gestures with vocalization.  HEENT shows the cranium is normocephalic and atraumatic.  She has dry mucosal membrane.  She now has a right facial droop, which per her daughter is new.  Neck veins are not distended.  No carotid bruits visible.  Skin:  Warm, well perfused.  Lungs are clear to auscultation anteriorly.  No wheezes.  Cardiac exam:  S1, S2, regular rate.  No significant murmurs.  PMI is nondisplaced.  Abdomen:  Soft, nondistended.  Extremities:  Without edema, on limited exam.  Neurological exam seems to show only the right facial droop.,DIAGNOSTIC/LABORATORY DATA: , EKGs as reviewed above.  Her last ECG shows normalization of prior ST elevation in the inferior leads with Q waves and first-degree AV block, PR interval 280 milliseconds.  Further lab shows sodium 135, potassium 4.2, chloride 98, bicarbonate 26, BUN 9, creatinine 0.8, glucose 162, troponin 0.17, INR 1.27, white blood cell count 1.3, hematocrit 31, platelet count of 179.,Chest x-ray, no significant pericardial effusion.,IMPRESSION: , The patient is a 69-year-old woman with metastatic non-small-cell lung cancer with a recent hemorrhagic pericardial effusion, now admitted with cerebrovascular accident and transient inferior myocardial infarction, which appears to be canalized.  I will discuss this in detail with the patient and her daughter, and clearly, her situation is quite guarded with likely poor prognosis, which they are understanding of.,RECOMMENDATIONS:,1.  I think it is reasonable to continue heparin, but clearly she would be at risk for hemorrhagic pericardial effusion recurrence.,2.  Morphine is appropriate, especially for preload reduction and other comfort measures as appropriate.,3.  Would avoid other blood thinners including Plavix, Integrilin, and certainly, she is not a candidate for a thrombolytic with which the patient and her daughter are in agreement with after a long discussion.,Other management as per the medical service.  I have discussed the case with Dr. X of the hospitalist service who will be admitting the patient.",
 Mediastinal exploration and delayed primary chest closure.  The patient is a 12-day-old infant who has undergone a modified stage I Norwood procedure with a Sano modification. , Cardiovascular / Pulmonary, Mediastinal Exploration ,"TITLE OF OPERATION:,  Mediastinal exploration and delayed primary chest closure.,INDICATION FOR SURGERY:,  The patient is a 12-day-old infant who has undergone a modified stage I Norwood procedure with a Sano modification.  The patient experienced an unexplained cardiac arrest at the completion of the procedure, which required institution of extracorporeal membrane oxygenation for more than two hours following discontinuation of cardiopulmonary bypass.  The patient has been successfully resuscitated with extracorporeal membrane oxygenation and was decannulated 48 hours ago.  She did not meet the criteria for delayed primary chest closure.,PREOP DIAGNOSIS: , Open chest status post modified stage I Norwood procedure.,POSTOP DIAGNOSIS: , Open chest status post modified stage I Norwood procedure.,ANESTHESIA:,  General endotracheal.,COMPLICATIONS:,  None.,FINDINGS: , No evidence of intramediastinal purulence or hematoma.  At completion of the procedure no major changes in hemodynamic performance.,DETAILS OF THE PROCEDURE: , After obtaining informed consent, the patient was brought to the room, placed on the operating room table in supine position.  Following the administration of general endotracheal anesthesia, the chest was prepped and draped in the usual sterile fashion and all the chest drains were removed.  The chest was then prepped and draped in the usual sterile fashion and previously placed segmental AlloDerm was removed.  The mediastinum was then thoroughly irrigated with diluted antibiotic irrigation and both pleural cavities suctioned.  Through a separate incision and another 15-French Blake drain was inserted and small titanium clips were utilized to mark the rightward aspect of the RV-PA connection as well as inferior most aspect of the ventriculotomy.  The pleural spaces were opened widely and the sternum was then spilled with vancomycin paste and closed the sternum with steel wires.  The subcutaneous tissue and skin were closed in layers.  There was no evidence of significant increase in central venous pressure or desaturation.  The patient tolerated the procedure well.  Sponge and needle counts were correct times 2 at the end of the procedure.  The patient was transferred to the Pediatric Intensive Care Unit shortly thereafter in critical but stable condition.,I was the surgical attending present in the operating room in charge of the surgical  procedure throughout the entire length of the case.","cardiovascular / pulmonary, mediastinal exploration, delayed primary chest closure, extracorporeal membrane oxygenation, stage i norwood procedure, sano modification, chest closure, infant, mediastinal, exploration, closure, endotracheal, chest"
 Lexiscan myoview stress study.  Chest discomfort.  Normal stress/rest cardiac perfusion with no indication of ischemia.  Normal LV function and low likelihood of significant epicardial coronary narrowing., Cardiovascular / Pulmonary, Mayoview - 2 ,"LEXISCAN MYOVIEW STRESS STUDY,REASON FOR THE EXAM: , Chest discomfort.,INTERPRETATION: , The patient exercised according to the Lexiscan study, received a total of 0.4 mg of Lexiscan IV injection.  At peak hyperemic effect, 24.9 mCi of Myoview were injected for the stress imaging and earlier 8.2 mCi were injected for the resting and the usual SPECT and gated SPECT protocol was followed and the data was analyzed using Cedars-Sinai software.  The patient did not walk because of prior history of inability to exercise long enough on treadmill.,The resting heart rate was 57 with the resting blood pressure 143/94.  Maximum heart rate achieved was 90 with a maximum blood pressure unchanged.,EKG at rest showed sinus rhythm with no significant ST-T wave changes of reversible ischemia or injury.  Subtle nonspecific in III and aVF were seen.  Maximum stress test EKG showed inverted T wave from V4 to V6.  Normal response to Lexiscan.,CONCLUSION:  ,Maximal Lexiscan perfusion with subtle abnormalities non-conclusive.  Please refer to the Myoview interpretation.,MYOVIEW INTERPRETATION: , The left ventricle appeared to be normal in size on both stress and rest with no change between the stress and rest with left ventricular end-diastolic volume of 115 and end-systolic of 51.  EF estimated and calculated at 56%.,Cardiac perfusion reviewed, showed no reversible defect indicative of myocardium risk and no fixed defect indicative of myocardial scarring.,IMPRESSION:,1.  Normal stress/rest cardiac perfusion with no indication of ischemia.,2.  Normal LV function and low likelihood of significant epicardial coronary narrowing.,","cardiovascular / pulmonary, chest discomfort, lexiscan myoview stress study, mci, spect, gated spect, myoview, lexiscan, stress test, ekg, lexiscan myoview, lv function, coronary narrowing, heart rate, blood pressure, myoview interpretation, cardiac perfusion, cardiac, ischemia, perfusion, stress,"
 The patient had undergone mitral valve repair about seven days ago. , Cardiovascular / Pulmonary, Mediastinal Exploration & Right Atrium Repair ,"PREOPERATIVE DIAGNOSES:,1.  Cardiac tamponade.,2.  Status post mitral valve repair.,POSTOPERATIVE DIAGNOSES:,1.  Cardiac tamponade.,2.  Status post mitral valve repair.,PROCEDURE PERFORMED: , Mediastinal exploration with repair of right atrium.,ANESTHESIA: , General endotracheal.,INDICATIONS: , The patient had undergone mitral valve repair about seven days ago.  He had epicardial pacing wires removed at the bedside.  Shortly afterwards, he began to feel lightheaded and became pale and diaphoretic.  He was immediately rushed to the operating room for cardiac tamponade following removal of epicardial pacing wires.  He was transported immediately and emergently and remained awake and alert throughout the time period inspite of hypotension with the systolic pressure in the 60s-70s.,DETAILS OF PROCEDURE:  ,The patient was taken emergently to the operating room and placed supine on the operating room table.  His chest was prepped and draped prior to induction under general anesthesia.  Incision was made through the previous median sternotomy chest incision.  Wires were removed in the usual manner and the sternum was retracted.  There were large amounts of dark blood filling the mediastinal chest cavity.  Large amounts of clot were also removed from the pericardial well and chest.  Systematic exploration of the mediastinum and pericardial well revealed bleeding from the right atrial appendix at the site of the previous cannulation.  This was repaired with two horizontal mattress pledgeted #5-0 Prolene sutures.  An additional #0 silk tie was also placed around the base of the atrial appendage for further hemostasis.  No other sites of bleeding were identified.  The mediastinum was then irrigated with copious amounts of antibiotic saline solution.  Two chest tubes were then placed including an angled chest tube into the pericardial well on the inferior border of the heart, as well as straight mediastinal chest tube.  The sternum was then reapproximated with stainless steel wires in the usual manner and the subcutaneous tissue was closed in multiple layers with running Vicryl sutures.  The skin was then closed with a running subcuticular stitch.  The patient was then taken to the Intensive Care Unit in a critical but stable condition.","cardiovascular / pulmonary, mitral valve repair, exploration, median sternotomy chest incision, pericardial, mediastinal exploration, pacing wires, cardiac tamponade, chest tubes, mitral valve, valve repair, mediastinal, mitral, wires, atrium, repair,"
" Lung, wedge biopsy right lower lobe and resection right upper lobe.  Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal.  PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.", Cardiovascular / Pulmonary, Lung Biopsy Pathology Report ,"CLINICAL HISTORY:,  A 48-year-old smoker found to have a right upper lobe mass on chest x-ray and is being evaluated for chest pain.  PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.  The lower lobe mass was approximately 1 cm in diameter and the upper lobe mass was 4 cm to 5 cm in diameter.  The patient was referred for surgical treatment.,SPECIMEN:,A.  Lung, wedge biopsy right lower lobe,B.  Lung, resection right upper lobe,C.  Lymph node, biopsy level 2 and 4,D.  Lymph node, biopsy level 7 subcarinal,FINAL DIAGNOSIS:,A.  Wedge biopsy of right lower lobe showing:  Adenocarcinoma, Grade 2, Measuring 1 cm in diameter with invasion of the overlying pleura and with free resection margin.,B.  Right upper lobe lung resection showing:  Adenocarcinoma, grade 2, measuring 4 cm in diameter with invasion of the overlying pleura and with free bronchial margin.  Two (2) hilar lymph nodes with no metastatic tumor.,C.  Lymph node biopsy at level 2 and 4 showing seven (7) lymph nodes with anthracosis and no metastatic tumor.,D.  Lymph node biopsy, level 7 subcarinal showing (5) lymph nodes with anthracosis and no metastatic tumor.,COMMENT:  ,The morphology of the tumor seen in both lobes is similar and we feel that the smaller tumor involving the right lower lobe is most likely secondary to transbronchial spread from the main tumor involving the right upper lobe.  This suggestion is supported by the fact that no obvious vascular or lymphatic invasion is demonstrated and adjacent to the smaller tumor, there is isolated nests of tumor cells within the air spaces.  Furthermore, immunoperoxidase stain for Ck-7, CK-20 and TTF are performed on both the right lower and right upper lobe nodule.  The immunohistochemical results confirm the lung origin of both tumors and we feel that the tumor involving the right lower lobe is due to transbronchial spread from the larger tumor nodule involving the right upper lobe.,","cardiovascular / pulmonary, pet scan, wedge biopsy, morphology, lung wedge biopsy, lymph node biopsy, lymph node, lower lobe, tumor, biopsy, lobe, lung, mass, lymph, node"
" Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, and pharmacologic thrombolysis following placement of a vena caval filter.", Cardiovascular / Pulmonary, Lymphoblastic Leukemia - Consult ,"CHIEF COMPLAINT: , Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, right iliac vein and inferior vena cava (IVC), status post balloon angioplasty, and mechanical and pharmacologic thrombolysis following placement of a vena caval filter.,HISTORY OF PRESENT ILLNESS: , The patient was transferred here the evening of 02/23/2007 from Hospital with a new diagnosis of high-risk acute lymphoblastic leukemia based on confirmation by flow cytometry of peripheral blood lymphoblasts that afternoon.  History related to this illness probably dates back to October of 2006 when he had onset of swelling and discomfort in the left testicle with what he described as a residual ""lump"" posteriorly.  The left testicle has continued to be painful off and on since.  In early November, he developed pain in the posterior part of his upper right leg, which he initially thought was related to skateboarding and muscle strain.  Physical therapy was prescribed and the discomfort temporarily improved.  In December, he noted onset of increasing fatigue.  He used to work out regularly, lifting lifts, doing abdominal exercises, and playing basketball and found he did not have energy to pursue these activities.  He has lost 10 pounds since December and feels his appetite has decreased.  Night sweats and cough began in December, for which he was treated with a course of Augmentin.  However, both of these problems have continued.  He also began taking Accutane for persistent acne in December (this agent was stopped on 02/19/2007).  Despite increasing fatigue and lethargy, he continues his studies at University of Denver, has a biology major (he aspires to be an ophthalmologist).,The morning of 02/19/2007, he awakened with severe right inguinal and right lower quadrant pain.  He was seen in Emergency Room where it was noted that he had an elevated WBC of 18,000.  CT scan of the abdomen was obtained to rule out possible appendicitis and on that CT, a large clot in the inferior vena cava extending to the right iliac and femoral veins was found.  He promptly underwent appropriate treatment in interventional radiology with the above-noted angioplasty and placement of a vena caval filter followed by mechanical and pharmacologic thrombolysis.  Repeat ultrasound there on 02/20/2007 showed no evidence of deep venous thrombosis (DVT).  Continuous intravenous unfractionated heparin infusion was continued.  Because there was no obvious cause of this extensive thrombosis, occult malignancy was suspected.  Appropriate blood studies were obtained and he underwent a PET/CT scan as part of his diagnostic evaluation.  This study showed moderately increased diffuse bone marrow metabolic activity.  Because the WBC continued to rise and showed a preponderance of lymphocytes, the smear was reviewed by pathologist, Sheryl Asplund, M.D., and flow cytometry was performed on the peripheral blood.  These studies became available the afternoon of 02/23/2007, and confirmed the diagnosis of precursor-B acute lymphoblastic leukemia.  The patient was transferred here after stopping of the continuous infusion heparin and receiving a dose of Lovenox 60 mg subcutaneously for further diagnostic evaluation and management of the acute lymphoblastic leukemia (ALL).,ALLERGIES: , NO KNOWN DRUG ALLERGIES.  HE DOES SEEM TO REACT TO CERTAIN ADHESIVES.,CURRENT MEDICATIONS:  ,1.  Lovenox 60 mg subcutaneously q.12h. initiated.,2.  Coumadin 5 mg p.o., was administered on 02/19/2007 and 02/22/2007.,3.  Protonix 40 mg intravenous (IV) daily.,4.  Vicodin p.r.n.,5.  Levaquin 750 mg IV on 02/23/2007.,IMMUNIZATIONS: , Up-to-date.,PAST SURGICAL HISTORY:  ,The treatment of the thrombosis as noted above on 02/19/2007 and 02/20/2007.,FAMILY HISTORY:  ,Two half-brothers, ages 26 and 28, both in good health.  Parents are in good health.  A maternal great-grandmother had a deep venous thrombosis (DVT) of leg in her 40s.  A maternal great-uncle developed leukemia around age 50.  A maternal great-grandfather had bone cancer around age 80.  His paternal grandfather died of colon cancer at age 73, which he had had since age 68.  Adult-onset diabetes is present in distant relatives on both sides.,SOCIAL HISTORY:  ,The patient is a student at the University majoring in biology.  He lives in a dorm there.  His parents live in Breckenridge.  He admits to having smoked marijuana off and on with friends and drinking beer off and on as well.,REVIEW OF SYSTEMS: , He has had emesis off and on related to Vicodin and constipation since 02/19/2007, also related to pain medication.  He has had acne for about two years, which he describes as mild to moderate.  He denied shortness of breath, chest pain, hemoptysis, dyspnea, headaches, joint pains, rashes, except where he has had dressings applied, and extremity pain except for the right leg pain noted above.,PHYSICAL EXAMINATION:  ,GENERAL:  Alert, cooperative, moderately ill-appearing young man.,VITAL SIGNS:  At the time of admission, pulse was 94, respirations 20, blood pressure 120/62, temperature 98.7, height 171.5 cm, weight 63.04 kg, and pulse oximetry on room air 95%.,HAIR AND SKIN:  Mild facial acne.,HEENT:  Extraocular muscles (EOMs) intact.  Pupils equal, round, and reactive to light and accommodation (PERRLA), fundi normal.,CARDIOVASCULAR:  A 2/6 systolic ejection murmur (SEM), regular sinus rhythm (RSR).,LUNGS:  Clear to auscultation with an occasional productive cough.,ABDOMEN:  Soft with mild lower quadrant tenderness, right more so than left; liver and spleen each decreased 4 cm below their respective costal margins.,MUSCULOSKELETAL:  Mild swelling of the dorsal aspect of the right foot and distal right leg.  Mild tenderness over the prior catheter entrance site in the right popliteal fossa and mild tenderness over the right medial upper thigh.,GENITOURINARY:  Testicle exam disclosed no firm swelling with mild nondiscrete fullness in the posterior left testicle.,NEUROLOGIC:  Exam showed him to be oriented x4.  Normal fundi, intact cranial nerves II through XII with downgoing toes, symmetric muscle strength, and decreased patellar deep tendon reflexes (DTRs).,LABORATORY DATA:  ,White count 25,500 (26 neutrophils, 1 band, 7 lymphocytes, 1 monocyte, 1 myelocyte, 64 blasts), hemoglobin 13.3, hematocrit 38.8, and 312,000 platelets.  Electrolytes, BUN, creatinine, phosphorus, uric acid, AST, ALT, alkaline phosphatase, and magnesium were all normal.  LDH was elevated to 1925 units/L (upper normal 670), and total protein and albumin were both low at 6.2 and 3.4 g/dL respectively.  Calcium was also slightly low at 8.8 mg/dL.  Low molecular weight heparin test was low at 0.27 units/mL.  PT was 11.8, INR 1.2, and fibrinogen 374.  Urinalysis was normal.,ASSESSMENT: , 1.  Newly diagnosed high-risk acute lymphoblastic leukemia.,2.  Deep vein thrombosis of the distal iliac and common femoral/right femoral and iliac veins, status post vena caval filter placement and mechanical and thrombolytic therapy, on continued anticoagulation.,3.  Probable chronic left epididymitis.,PLAN: , 1.  Proceed with diagnostic bone marrow aspirate/biopsy and lumbar puncture (using a #27-gauge pencil-tip needle for minimal trauma) as soon as these procedures can be safely done with regard to the anticoagulation status.,2.  Prompt reassessment of the status of the deep venous thrombosis with Doppler studies.,3.  Ultrasound/Doppler of the testicles.,4.  Maintain therapeutic anticoagulation as soon as the diagnostic procedures for ALL can be completed.,",
 The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy., Cardiovascular / Pulmonary, Lung Biopsy Pathology Report - 1 ,"GROSS DESCRIPTION:,A.  Received fresh labeled with patient's name, designated 'right upper lobe wedge', is an,8.0 x 3.5 x 3.0 cm wedge of lung which has an 11.5 cm staple line.  There is a 0.8 x,0.7 x 0.5 cm sessile tumor with surrounding pleural puckering.,B.  Received fresh, labeled with patient's name, designated ""lymph node', is a 1.7 cm possible lymph node with anthracotic pigment.,C.  Received fresh labeled with patient's name, designated 'right upper lobe', is a 16.0 x,14.5 x 6.0 cm lobe of lung.  The lung is inflated with formalin.  There is a 12.0 cm staple line on the lateral surface, inked blue.  There is a 1.3 x 1.1 x 0.8 cm subpleural firm ill-defined mass, 2.2 cm from the bronchial margin and 1.5 cm from the previously described staple line.  The overlying pleura is puckered.,D.  Received fresh, labeled with patient's name, designated '4 lymph nodes', is a 2.0 x 2.0 x 2.0 cm aggregate of lymphoid material with anthracotic pigment and adipose tissue.,E.  Received fresh, labeled with patient's name, designated 'subcarinal lymph node', is a,2.0 x 1.7 x 0.8 cm aggregate of lymphoid material with anthracotic pigment .,FINAL DIAGNOSIS:,A.  Right upper lobe wedge lung biopsy:  Poorly differentiated non-small cell carcinoma.  Tumor Size:  0.8 cm.  Arterial (large vessel) invasion:  Not seen.  Small vessel (lymphatic) invasion:  Not seen.  Pleural invasion:  Not identified.  Margins of excision:  Negative for malignancy.,B.  Biopsy, 10R lymph node:  Anthracotically pigmented lymphoid tissue, negative for malignancy.,C.  Right upper lobe, lung:  Moderately differentiated non-small cell carcinoma,(adenocarcinoma).  Tumor Size:  1.3 cm.  Arterial (large vessel) invasion:  Present.  Small vessel (lymphatic) invasion:  Not seen.  Pleural invasion:  Not identified.  Margins of excision:  Negative for malignancy.,D.  Biopsy, 4R lymph nodes:  Lymphoid tissue, negative for malignancy.,E.  Biopsy, subcarinal lymph node:  Lymphoid tissue, negative for malignancy.,COMMENTS:,  Pathologic examination reveals two separate tumors in the right upper lobe.  They appear histologically distinct, suggesting they are separate primary tumors (pT1).  The right upper lobe wedge biopsy (part A) shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.  The right upper lobe carcinoma identified in the resection (part C) is a moderately differentiated adenocarcinoma with obvious gland formation.","cardiovascular / pulmonary, lung biopsy, wedge, lobe, pathologic, lymph node', node', lymphoid, malignancy, lung, lymph, biopsy"
 Right upper lung lobectomy.  Mediastinal lymph node dissection, Cardiovascular / Pulmonary, Lobectomy & Lymph Node Dissection ,"OPERATION,1.  Right upper lung lobectomy.,2.  Mediastinal lymph node dissection.,ANESTHESIA,1.  General endotracheal anesthesia with dual-lumen tube.,2.  Thoracic epidural.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room, and general endotracheal anesthesia was administered with a dual-lumen tube.  Next, the patient was placed in the left lateral decubitus position, and his right chest was prepped and draped in the standard surgical fashion.  We used a #10-blade scalpel to make an incision in the skin approximately 1 fingerbreadth below the angle of the scapula.  Dissection was carried down in a muscle-sparing fashion using Bovie electrocautery.  The 5th rib was counted, and the 6th interspace was entered.  The lung was deflated.  We identified the major fissure.  We then began by freeing up the inferior pulmonary ligament, which was done with Bovie electrocautery.  Next, we used Bovie electrocautery to dissect the pleura off the lung.  The pulmonary artery branches to the right upper lobe of the lung were identified.  Of note was the fact that there was a visible, approximately 4 x 4-cm mass in the right upper lobe of the lung without any other metastatic disease palpable.  As mentioned, a combination of Bovie electrocautery and sharp dissection was used to identify the pulmonary artery branches to the right upper lobe of the lung.  Next, we began by ligating the pulmonary artery branches of the right upper lobe of the lung.  This was done with suture ligature in combination with clips.  After taking the pulmonary artery branches of the right upper lobe of the lung, we used a combination of blunt dissection and sharp dissection with Metzenbaum scissors to separate out the pulmonary vein branch of the right upper lobe of the lung.  This likewise was ligated with a 0 silk.  It was stick-tied with a 2-0 silk.  It was then divided.  Next we dissected out the bronchial branch to the right upper lobe of the lung.  A curved Glover was placed around the bronchus.  Next a TA-30 stapler was fired across the bronchus.  The bronchus was divided with a #10-blade scalpel.  The specimen was handed off.  We next performed a mediastinal lymph node dissection.  Clips were applied to the base of the feeding vessels to the lymph nodes.  We inspected for any signs of bleeding.  There was minimal bleeding.  We placed a #32-French anterior chest tube, and a #32-French posterior chest tube.  The rib space was closed with #2 Vicryl in an interrupted figure-of-eight fashion.  A flat Jackson-Pratt drain, #10 in size, was placed in the subcutaneous flap.  The muscle layer was closed with a combination of 2-0 Vicryl followed by 2-0 Vicryl, followed by 4-0 Monocryl in a running subcuticular fashion.  Sterile dressing was applied.  The instrument and sponge count was correct at the end of the case.  The patient tolerated the procedure well and was transferred to the PACU in good condition.","cardiovascular / pulmonary, mediastinal, thoracic, epidural, lymph node dissection, lymph node, artery branches, lobectomy, lung, anesthesia, bovie, electrocautery, lymph, pulmonary, branches"
" VATS right middle lobectomy, fiberoptic bronchoscopy, mediastinal lymph node sampling, tube thoracostomy x2, multiple chest wall biopsies and excision of margin on anterior chest wall adjacent to adherent tumor.", Cardiovascular / Pulmonary, Lobectomy - VATS ,"PREOPERATIVE DIAGNOSIS:,  Right middle lobe lung cancer.,POSTOPERATIVE DIAGNOSIS: , Right middle lobe lung cancer.,PROCEDURES PERFORMED:,1.  VATS right middle lobectomy.,2.  Fiberoptic bronchoscopy thus before and after the procedure.,3.  Mediastinal lymph node sampling including levels 4R and 7.,4.  Tube thoracostomy x2 including a 19-French Blake and a 32-French chest tube.,5.  Multiple chest wall biopsies and excision of margin on anterior chest wall adjacent to adherent tumor.,ANESTHESIA:  ,General endotracheal anesthesia with double-lumen endotracheal tube.,DISPOSITION OF SPECIMENS: , To pathology both for frozen and permanent analysis.,FINDINGS:,  The right middle lobe tumor was adherent to the anterior chest wall.  The adhesion was taken down, and the entire pleural surface along the edge of the adhesion was sent for pathologic analysis.  The final frozen pathology on this entire area returned as negative for tumor.  Additional chest wall abnormalities were biopsied and sent for pathologic analysis, and these all returned separately as negative for tumor and only fibrotic tissue.  Several other biopsies were taken and sent for permanent analysis of the chest wall.  All of the biopsy sites were additionally marked with Hemoclips.  The right middle lobe lesion was accompanied with distal pneumonitis and otherwise no direct involvement of the right upper lobe or right lower lobe.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,CONDITION OF THE PATIENT AFTER SURGERY: , Stable.,HISTORY OF PROCEDURE:,  This patient is well known to our service.  He was admitted the night before surgery and given hemodialysis and had close blood sugar monitoring in control.  The patient was subsequently taken to the operating room on April 4, 2007, was given general anesthesia and was endotracheally intubated without incident.  Although, he had markedly difficult airway, the patient had fiberoptic bronchoscopy performed all the way down to the level of the subsegmental bronchi.  No abnormalities were noted in the entire tracheobronchial tree, and based on this, the decision was made to proceed with the surgery.  The patient was kept in the supine position, and the single-lumen endotracheal tube was removed and a double-lumen tube was placed.  Following this, the patient was placed into the left lateral decubitus position with the right side up and all pressure points were padded.  Sterile DuraPrep preparation on the right chest was placed.  A sterile drape around that was also placed.  The table was flexed to open up the intercostal spaces.  A second bronchoscopy was performed to confirm placement of the double-lumen endotracheal tube.  Marcaine was infused into all incision areas prior to making an incision.  The incisions for the VATS right middle lobectomy included a small 1-cm incision for the auscultatory incision approximately 4 cm inferior to the inferior tip of the scapula.  The camera port was in the posterior axillary line in the eighth intercostal space through which a 5-mm 30-degree scope was used.  Third incision was an anterior port, which was approximately 2 cm inferior to the inframammary crease and the midclavicular line in the anterior sixth intercostal space, and the third incision was a utility port, which was a 4 cm long incision, which was approximately one rib space below the superior pulmonary vein.  All of these incisions were eventually created during the procedure.  The initial incision was the camera port through which, under direct visualization, an additional small 5-mm port was created just inferior to the anterior port.  These two ports were used to identify the chest wall lesions, which were initially thought to be metastatic lesions.  Multiple biopsies of the chest wall lesions were taken, and the decision was made to also insert the auscultatory incision port.  Through these three incisions, the initial working of the diagnostic portion of the chest wall lesion was performed.  Multiple biopsies were taken of the entire chest wall offers and specimens came back as negative.  The right middle lobe was noted to be adherent to the anterior chest wall.  This area was taken down and the entire pleural surface along this area was taken down and sent for frozen pathologic analysis.  This also returned as negative with only fibrotic tissue and a few lymphocytes within the fibrotic tissue, but no tumor cells.  Based on this, the decision was made to not proceed with chest wall resection and continue with right middle lobectomy.  Following this, the anterior port was increased in size and the utility port was made and meticulous dissection from an anterior to posterior direction was performed.  The middle lobe branch of the right superior pulmonary vein was initially dissected and stapled with vascular load 45-mm EndoGIA stapler.  Following division of the right superior pulmonary vein, the right middle lobe bronchus was easily identified.  Initially, this was thought to be the main right middle lobe bronchus, but in fact it was the medial branch of the right middle lobe bronchus.  This was encircled and divided with a blue load stapler with a 45-mm EndoGIA.  Following division of this, the pulmonary artery was easily identified.  Two branches of the pulmonary artery were noted to be going into the right middle lobe.  These were individually divided with a vascular load after encircling with a right angle clamp.  The vascular staple load completely divided these arterial branches successfully from the main pulmonary artery trunk, and following this, an additional branch of the bronchus was noted to be going to the right middle lobe.  A fiberoptic bronchoscopy was performed intraoperatively and confirmed that this was in fact the lateral branch of the right middle lobe bronchus.  This was divided with a blue load stapler 45 mm EndoGIA.  Following division of this, the minor and major fissures were completed along the edges of the right middle lobe separating the right upper lobe from the right middle lobe as well as the right middle lobe from the right lower lobe.  Following complete division of the fissure, the lobe was put into an EndoGIA bag and taken out through the utility port.  Following removal of the right middle lobe, a meticulous lymph node dissection sampling was performed excising the lymph node package in the 4R area as well as the 7 lymph node package.  Node station 8 or 9 nodes were easily identified, therefore none were taken.  The patient was allowed to ventilate under water on the right lung with no obvious air leaking noted.  A 19-French Blake was placed into the posterior apical position and a 32-French chest tube was placed in the anteroapical position.  Following this, the patient's lung was allowed to reexpand fully, and the patient was checked for air leaking once again.  Following this, all the ports were closed with 2-0 Vicryl suture used for the deeper tissue, and 3-0 Vicryl suture was used to reapproximate the subcutaneous tissue and 4-0 Monocryl suture was used to close the skin in a running subcuticular fashion.  The patient tolerated the procedure well, was extubated in the operating room and taken to the recovery room in stable condition.","cardiovascular / pulmonary, middle lobe, endogia, fiberoptic, mediastinal lymph node, vats, bronchoscopy, chest tube, chest wall, endotracheal tube, endotracheally, lobectomy, lung cancer, pneumonitis, sampling, thoracostomy, utility port, lumen endotracheal tube, superior pulmonary vein, chest wall lesions, anterior chest wall, middle lobectomy, fiberoptic bronchoscopy, anterior chest, lymph node, node, port, chest, bronchus, tumor, pulmonary, incision,"
" Probable right upper lobe lung adenocarcinoma.  Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".", Cardiovascular / Pulmonary, Lung adenocarcinoma Path Report ,"CLINICAL HISTORY:  ,Probable right upper lobe lung adenocarcinoma.,SPECIMEN: , Lung, right upper lobe resection.,GROSS DESCRIPTION:,  Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".  It consists of one lobectomy specimen measuring 16.1 x 10.6 x,4.5.cm.  The specimen is covered by a smooth, pink-tan and gray pleural surface which is largely unremarkable.  Sectioning reveals a round, ill-defined, firm, tan-gray mucoid mass.  This mass measures 3.6 x 3.3 x 2.7 cm and is located 3.7 cm from the closest surgical margin and 3.9 cm from the hilum.  There is no necrosis or hemorrhage evident.  The tumor grossly appears to abut, but not invade through, the visceral pleura, and the overlying pleura is puckered.,FINAL DIAGNOSIS:,  Right lung, upper lobe, lobectomy:  Bronchioloalveolar carcinoma, mucinous type,COMMENT:,  Right upper lobe, lobectomy.,Tumor type:  Bronchioloalveolar carcinoma, mucinous type.,Histologic grade:  Well differentiated.,Tumor size (greatest diameter):  3.6 cm.,Blood/lymphatic vessel invasion:  Absent.,Perineural invasion:  Absent.,Bronchial margin:  Negative.,Vascular margin:  Negative.,Inked surgical margin:  Negative.,Visceral pleura:  Not involved.,In situ carcinoma:  Absent.,Non-neoplastic lung:  Emphysema.,Hilar lymph nodes:  Number of positive lymph nodes:  0; Total number of lymph nodes:  1.,P53 immunohistochemical stain is negative in the tumor.","cardiovascular / pulmonary, bronchioloalveolar carcinoma, mucinous, mucoid mass, lymph nodes, upper lobe, visceral, bronchioloalveolar, carcinoma, lymph, pleural, margin, tumor, adenocarcinoma, specimen, lobe, lung, "
" Right lower lobectomy, right thoracotomy, extensive lysis of adhesions, mediastinal lymphadenectomy.", Cardiovascular / Pulmonary, Lobectomy & Lymphadenectomy ,"PREOPERATIVE DIAGNOSIS:  ,Right lower lobe mass, possible cancer.,POSTOPERATIVE DIAGNOSIS: , Non-small cell carcinoma of the right lower lobe.,PROCEDURES:,1.  Right thoracotomy.,2.  Extensive lysis of adhesions.,3.  Right lower lobectomy.,4.  Mediastinal lymphadenectomy.,ANESTHESIA: , General.,DESCRIPTION OF THE PROCEDURE: , The patient was taken to the operating room and placed on the operating table in the supine position.  After an adequate general anesthesia was given, she was placed in the left lateral decubitus and the right chest was prepped and draped in the sterile fashion.  Lateral thoracotomy was performed on the right side anterior to the tip of the scapula, and this was carried down through the subcutaneous tissue.  The latissimus dorsi muscle was partially transected and then the serratus was reflected anteriorly.  The chest was entered through the fifth intercostal space.  A retractor was placed and then extensive number of adhesions between the lung and the pleura were lysed carefully with sharp and blunt dissection.  The right lower lobe was identified.  There was a large mass in the superior segment of the lobe, which was very close to the right upper lobe, and because of the adhesions, it could not be told if the tumor was extending into the right upper lobe, but it appeared that it did not.  Dissection was then performed at the lower lobe of the fissure, and a GIA stapler was placed through here to separate the tumor from the upper lobe including a small segment of the upper lobe with the lower lobe.  Then, dissection of the hilum was performed, and the branches of the pulmonary artery to the lower lobe were ligated with #2-0 silk freehand ties proximally and distally and #3-0 silk transfixion stitches and then transected.  The inferior pulmonary vein was dissected after dividing the ligament, and it was stapled proximally and distally with a TA30 stapler and then transected.  Further dissection of the fissure allowed for its completion with a GIA stapler and then the bronchus was identified and dissected.  The bronchus was stapled with a TA30 bronchial stapler and then transected, and the specimen was removed and sent to the Pathology Department for frozen section diagnosis.  The frozen section diagnosis was that of non-small cell carcinoma, bronchial margins free and pleural margins free.  The mediastinum was then explored.  No nodes were identified around the pulmonary ligament or around the esophagus.  Subcarinal nodes were dissected, and hemostasis was obtained with clips.  The space below and above the osseous was opened, and the station R4 nodes were dissected.  Hemostasis was obtained with clips and with electrocautery.  All nodal tissue were sent to Pathology as permanent specimen.  Following this, the chest was thoroughly irrigated and aspirated.  Careful hemostasis was obtained and a couple of air leaks were controlled with #6-0 Prolene sutures.  Then, two #28 French chest tubes were placed in the chest, one posteriorly and one anteriorly, and secured to the skin with #2-0 nylon stitches.  The incision was then closed with interrupted #2-0 Vicryl pericostal stitches.  A running #1 PDS on the muscle layer, a running 2-0 PDS in the subcutaneous tissue, and staples on the skin.  A sterile dressing was applied, and the patient was then awakened and transferred to the following Intensive Care Unit in stable and satisfactory condition.,ESTIMATED BLOOD LOSS: , 100 mL.,TRANSFUSIONS:,  None.,COMPLICATIONS:,  None.,CONDITION: , Condition of the patient on arrival to the intensive care unit was satisfactory.","cardiovascular / pulmonary, right lower lobe, gia stapler, mediastinal, non-small cell carcinoma, cancer, frozen section, hilum, lobectomy, lymphadenectomy, lysis of adhesions, pleura, thoracotomy, upper lobe, lower lobectomy, adhesions, chest"
 Left lower extremity venous Doppler ultrasound, Cardiovascular / Pulmonary, Lower Extremity Venous Doppler ,"LEFT LOWER EXTREMITY VENOUS DOPPLER ULTRASOUND,REASON FOR EXAM: , Status post delivery five weeks ago presenting with left calf pain.,INTERPRETATIONS: , There was normal flow, compression and augmentation within the right common femoral, superficial femoral and popliteal veins.  Lymph nodes within the left inguinal region measure up to 1 cm in short-axis.,IMPRESSION: , Lymph nodes within the left inguinal region measure up to 1 cm in short-axis, otherwise no evidence for left lower extremity venous thrombosis.","cardiovascular / pulmonary, popliteal veins, superficial femoral, common femoral, inguinal region, lymph nodes, venous doppler, lower extremity, lymph, inguinal, axis, doppler, extremity, venous,"
 Lower Extremity Arterial Doppler, Cardiovascular / Pulmonary, Lower Extremity Arterial Doppler ,"RIGHT LOWER EXTREMITY:,  The arterial system was visualized showing triphasic waveform from the common femoral to popliteal and biphasic waveform at the posterior tibial artery with ankle brachial index of 0/8.,LEFT LOWER EXTREMITY:,  The arterial system was visualized with triphasic waveform from the common femoral to the popliteal artery, with biphasic waveform at the posterior tibial artery.  Ankle brachial index of 0.9.,IMPRESSION: , Mild bilateral lower extremity arterial obstructive disease.,","cardiovascular / pulmonary, lower extremity arterial doppler, posterior tibial artery, ankle brachial index, arterial doppler, triphasic waveform, common femoral, biphasic waveform, tibial artery, ankle brachial, brachial index, lower extremity, doppler, triphasic, femoral, popliteal, brachial, waveform, extremity, arterial,"
 Left lower lobectomy., Cardiovascular / Pulmonary, Lobectomy - Left Lower ,"OPERATION: , Left lower lobectomy.,OPERATIVE PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed in the supine position.  After general endotracheal anesthesia was induced, the appropriate monitoring devices were placed.  The patient was placed in the right lateral decubitus position.  The left chest and back were prepped and draped in a sterile fashion.  A right lateral thoracotomy incision was made.  Subcutaneous flaps were raised.  The anterior border of the latissimus dorsi was freed up, and the muscle was retracted posteriorly.  The posterior border of the pectoralis was freed up and it was retracted anteriorly.  The 5th intercostal space was entered.,The inferior pulmonary ligament was then taken down with electrocautery.  The major fissure was then taken down and arteries identified.  The artery was dissected free and it was divided with an Endo GIA stapler.  The vein was then dissected free and divided with an Endo GIA stapler.  The bronchus was then cleaned of all nodal tissue.  A TA-30 green loaded stapler was then placed across this, fired, and main bronchus divided distal to the stapler.,Then the lobe was removed and sent to pathology where margins were found to be free of tumor.  Level 9, level 13, level 11, and level 6 nodes were taken for permanent cell specimen.  Hemostasis noted.  Posterior 28-French and anterior 24-French chest tubes were placed.,The wounds were closed with #2 Vicryl.  A subcutaneous drain was placed.  Subcutaneous tissue was closed with running 3-0 Dexon, skin with running 4-0 Dexon subcuticular stitch.","cardiovascular / pulmonary, lower lobectomy, electrocautery, endo gia stapler, subcutaneous drain, endotracheal, subcutaneous, lobectomy,"
 Patient is here to discuss possible open lung biopsy., Cardiovascular / Pulmonary, Lung Biopsy Discussion ,"CHART NOTE:,  She is here to discuss possible open lung biopsy that she has actually scheduled for tomorrow.  Dr. XYZ had seen her because of her complaints of shortness of breath.  Then she had the pulmonary function test and CT scan and he felt that she probably had usual interstitial pneumonitis, but wanted her to have an open lung biopsy so he had her see Dr. XYZ Estep.  He had concurred with Dr. XYZ that an open lung biopsy was appropriate and she was actually scheduled for this but both Dr. XYZ and I were unavailable before the procedure was originally scheduled so he had it delayed so that she could talk with us prior to having the biopsy.  She was ready to go ahead with this and felt that it was important she find out why she is short of breath.  She is very concerned about the findings on her CAT scan and pulmonary function test.  She seemed alarmed to report that Dr. XYZ had found that her lung capacity was reduced to 60% of what should be normal.  However, I told her that two years ago Dr. XYZ did pulmonary function studies which showed the same change in function.  And that really her pulmonary function test, at least compared from two years ago, had not really changed over this period of time.  After discussing the serious nature of an open lung biopsy, the fact that her pulmonary function studies have not changed in two years, the fact that she likely has a number of other things that are contributing to her being out of breath, which is deconditioning and obesity, she seemed comfortable with the thought of simply monitoring this a little bit longer before undergoing something as risky as an open lung biopsy.  In fact when I called Dr. XYZ to talk to him about cancelling the procedure, he stated he would be very uncomfortable with doing an open lung biopsy on someone with pulmonary function studies which had not changed.  I also explained to patient that I did not think Dr. XYZ was aware that she had had pulmonary function studies two years previously and certainly did not know that there results of those.  And also I spoke with Dr. XYZ who agreed that although the two different tests may have some minor differences accounting for some of the similarity in results that may or may not be completely accurate, that generally a person with progressive interstitial lung disease without a fairly substantial change on pulmonary function tests even if they were done at different facilities.,I had a 30-minute discussion with patient about all of this and showed her the different test results and had a lengthy talk with her about the open lung biopsy and she ultimately felt very uncomfortable with going ahead and decided to cancel it.  I also told her we could continue to monitor her breathing problems and continue to monitor her CAT scan, x-ray, and pulmonary function tests.  And if there was some sign that this was a progressive problem, she could still go ahead with the lung biopsy.  But she needed to understand that the treatment and likely diagnosis found from an open lung biopsy were not highly likely to be of any great help to her.  She understands that the diagnoses made from open lung biopsy are not all that specific and that the treatment for the few specific things that can be detected are not often well tolerated or extremely helpful.,We are going to see her back in a month to see how her breathing is doing.  We will cancel her open lung biopsy for tomorrow and decide whether she should follow up with a pulmonologist at that time.  I told her I would try to talk to her sister sometime in the next day or two.","cardiovascular / pulmonary, discuss, interstitial pneumonitis, lung biopsy, lung capacity, pulmonary function test, shortness of breath, pulmonary function studies, pulmonary function, function, biopsy, lung, interstitial, pulmonaryNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
 The patient is a 65-year-old female who underwent left upper lobectomy for stage IA non-small cell lung cancer.  She returns for a routine surveillance visit.  The patient has no evidence of disease now status post left upper lobectomy for stage IA non-small cell lung cancer 13 months ago., Cardiovascular / Pulmonary, Lobectomy - Followup ,"HISTORY OF PRESENT ILLNESS: , The patient is a 65-year-old female who underwent left upper lobectomy for stage IA non-small cell lung cancer.  She returns for a routine surveillance visit.,She has undergone since her last visit an abdominopelvic CT, which shows an enlarging simple cyst of the left kidney.  She underwent barium swallow, which demonstrates a small sliding hiatal hernia with minimal reflux.  She has a minimal delayed emptying secondary tertiary contractions.  PA and lateral chest x-ray from the 11/23/09 was also reviewed, which demonstrates no lesions or infiltrates.  Review of systems, the patient continues to have periodic odynophagia and mid thoracic dysphagia.  This most likely is secondary to tertiary contractions with some delayed emptying.  She has also had increased size of the left calf without tenderness, which has not resolved over the past several months.  She has had a previous DVT in 1975 and 1985.  She denies weight loss, anorexia, fevers, chills, headaches, new aches or pains, cough, hemoptysis, shortness of breath at rest, or dyspnea on exertion.,MEDICATIONS: , Aspirin 81 mg p.o. q.d., Spiriva 10 mcg q.d., and albuterol p.r.n.,PHYSICAL EXAMINATION: , BP:  117/78.  RR:  18.  P:  93.,WT:  186 lbs.  RAS:  100%.,HEENT:  Mucous membranes are moist.  No cervical or supraclavicular lymphadenopathy.,LUNGS:  Clear to auscultation bilaterally.,CARDIAC:  Regular rate and rhythm without murmurs.,EXTREMITIES:  No cyanosis, clubbing or edema.,NEURO:  Alert and oriented x3.  Cranial nerves II through XII intact.,ASSESSMENT: , The patient has no evidence of disease now status post left upper lobectomy for stage IA non-small cell lung cancer 13 months ago.,PLAN:  ,She is to return to clinic in six months with a chest CT.  She was given a prescription for an ultrasound of the left lower extremity to rule out DVT.  She will be called with the results.  She was given a prescription for nifedipine 10 mg p.o. t.i.d. p.r.n. esophageal spasm.","cardiovascular / pulmonary, non-small cell lung cancer, lobectomy, lung cancer, non-small cell, lung, cancer"
" Lightheaded, dizziness, and palpitation.  This morning, the patient experienced symptoms of lightheaded, dizziness, felt like passing out; however, there was no actual syncope.  During the episode, the patient describes symptoms of palpitation and fluttering of chest.  She relates the heart was racing.  By the time when she came into the Emergency Room, her EKG revealed normal sinus rhythm.  No evidence of arrhythmia.", Cardiovascular / Pulmonary, Lightheaded & Dizziness ,"REASON FOR CONSULTATION: , Lightheaded, dizziness, and palpitation.,HISTORY OF PRESENT ILLNESS: , The patient is a 50-year-old female who came to the Emergency Room.  This morning, the patient experienced symptoms of lightheaded, dizziness, felt like passing out; however, there was no actual syncope.  During the episode, the patient describes symptoms of palpitation and fluttering of chest.  She relates the heart was racing.  By the time when she came into the Emergency Room, her EKG revealed normal sinus rhythm.  No evidence of arrhythmia.  The patient had some cardiac workup in the past, results are as mentioned below.  Denies any specific chest pain.  Activities fairly stable.  She is actively employed.  No other cardiac risk factor in terms of alcohol consumption or recreational drug use, caffeinated drink use or over-the-counter medication usage.,CORONARY RISK FACTORS: , No history of hypertension or diabetes mellitus.  Nonsmoker.  Cholesterol normal.  No history of established coronary artery disease and family history noncontributory.,FAMILY HISTORY: , Nonsignificant.,SURGICAL HISTORY: , Tubal ligation.,MEDICATIONS: , On pain medications, ibuprofen.,ALLERGIES:,  SULFA.,PERSONAL HISTORY: , She is a nonsmoker.  Does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY: , History of chest pain in the past.  Had workup done including nuclear myocardial perfusion scan, which was reportedly abnormal.  Subsequently, the patient underwent cardiac catheterization in 11/07, which was also normal.  An echocardiogram at that time was also normal.  At this time, presentation with lightheaded, dizziness, and palpitation.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No history of fever, rigors, or chills.,HEENT:  No history of cataract, blurry vision, or glaucoma.,CARDIOVASCULAR:  As above.,RESPIRATORY:  Shortness of breath.  No pneumonia or valley fever.,GASTROINTESTINAL:  No epigastric discomfort, hematemesis or melena.,UROLOGICAL:  No frequency or urgency.,MUSCULOSKELETAL:  Nonsignificant.,NEUROLOGICAL:  No TIA.  No CVA.  No seizure disorder.,ENDOCRINE/HEMATOLOGIC:  Nonsignificant.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 69, blood pressure 127/75, afebrile, and respiratory rate 16 per minute.,HEENT:  Atraumatic and normocephalic.,NECK:  Neck veins flat.  No carotid bruits.  No thyromegaly.  No lympyhadenopathy.,LUNGS:  Air entry bilaterally fair.,HEART:  PMI normal.  S1 and S2 regular.,ABDOMEN:  Soft and nontender.  Bowel sounds present.,EXTREMITIES:  No edema.  Pulses palpable.  No clubbing or cyanosis.,CNS:  Benign.,PSYCHOLOGICAL:  Normal.,MUSCULOSKELETAL:  Nonsignificant.,EKG: , Normal sinus rhythm, incomplete right bundle-branch block.,LABORATORY DATA:,  H&H stable.  BUN and creatinine within normal limits.  Cardiac enzyme profile negative.  Chest x-ray unremarkable.,IMPRESSION:,1.  Lightheaded, dizziness in a 50-year-old female.  No documented arrhythmia with the symptoms of palpitation.,2.  Normal cardiac structure by echocardiogram a year and half ago.,3.  Normal cardiac catheterization in 11/07.,4.  Negative workup so far for acute cardiac event in terms of EKG, cardiac enzyme profile.",
" Direct laryngoscopy, rigid bronchoscopy and dilation of subglottic upper tracheal stenosis.", Cardiovascular / Pulmonary, Laryngoscopy ,"PREOPERATIVE DIAGNOSIS,Subglottic upper tracheal stenosis.,POSTOPERATIVE DIAGNOSIS,Subglottic upper tracheal stenosis.,OPERATION PREFORMED,Direct laryngoscopy, rigid bronchoscopy and dilation of subglottic upper tracheal stenosis.,INDICATIONS FOR THE SURGERY,The patient is a 76-year-old white female with a history of subglottic upper tracheal stenosis.  She has had undergone multiple previous endoscopic procedures in the past; last procedure was in January 2007.  She returns with some increasing shortness of breath and dyspnea on exertion.  Endoscopic reevaluation is offered to her.  The patient has been considering laryngotracheal reconstruction; however, due to a recent death in the family, she has postponed this, but she has been having increasing symptoms.  An endoscopic treatment was offered to her.  Nature of the proposed procedure including risks and complications involving bleeding, infection, alteration of voice, speech, or swallowing, hoarseness changing permanently, recurrence of stenosis despite a surgical intervention, airway obstruction necessitating a tracheostomy now or in the future, cardiorespiratory, and anesthetic risks were all discussed in length.  The patient states she understood and wished to proceed.,DESCRIPTION OF THE OPERATION,The patient was taken to the operating room, placed on table in supine position.  Following adequate general anesthesia, the patient was prepared for endoscopy.  The top sliding laryngoscope was then inserted in the oral cavity, pharynx, and larynx examined. In the oral cavity, she had good dentition.  Tongue and buccal cavity mucosa were without ulcers, masses, or lesions.  The oropharynx was clear.  The larynx was then manually suspended.  Epiglottis area, epiglottic folds, false cords, true vocal folds with some mild edema, but otherwise, without ulcers, masses, or lesions, and the supraglottic and glottic airway were widely patent.  The larynx was manually suspended and a 5 x 30 pediatric rigid bronchoscope was passed through the vocal folds.  At the base of the subglottis, there was a narrowing and in the upper trachea, restenosis had occurred.  Moderate amount of mucoid secretions, these were suctioned, following which the area of stenosis was dilated.  Remainder of the bronchi was then examined.  The mid and distal trachea were widely patent.  Pale pink mucosa takeoff from mainstem bronchi were widely patent without ulcers, lesions, or evidence of scarring.  The scope was pulled back and removed and following this, a 6 x 30 pediatric rigid bronchoscope was passed through the larynx and further dilatation carried out.  Once this had been completed, dramatic improvement in the subglottic upper tracheal airway accomplished.  Instrumentation was removed and a #6 endotracheal tube, uncuffed, was placed to allow smooth emerge from anesthesia.  The patient tolerated the procedure well without complication.","cardiovascular / pulmonary, stenosis, epiglottis, subglottic, bronchoscope, bronchoscopy, endoscopic, laryngoscopy, laryngotracheal reconstruction, larynx, oral cavity, pharynx, tracheal, true vocal folds, vocal, upper tracheal stenosis, subglottic upper tracheal, subglottic upper, upper tracheal, airway, cavity, patent, "
" Laparoscopic lysis of adhesions and Laparoscopic left adrenalectomy.  Left adrenal mass, 5.5 cm and intraabdominal adhesions.", Cardiovascular / Pulmonary, Laparoscopic Adrenalectomy ,"PREOPERATIVE DIAGNOSIS: , Left adrenal mass, 5.5 cm.,POSTOPERATIVE DIAGNOSES:,1.  Left adrenal mass, 5.5 cm.,2.  Intraabdominal adhesions.,PROCEDURE PERFORMED:,1.  Laparoscopic lysis of adhesions.,2.  Laparoscopic left adrenalectomy.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS:,  Less than 100 cc.,FLUIDS: , 3500 cc crystalloids.,DRAINS:,  None.,DISPOSITION:,  The patient was taken to recovery room in stable condition.  Sponge, needle, and instrument counts were correct per OR staff.,HISTORY:,  This is a 57-year-old female who was found to have a large left adrenal mass, approximately 5.5 cm in size.  She had undergone workup previously with my associate, Dr. X as well as by Endocrinology, and showed this to be a nonfunctioning mass.  Due to the size, the patient was advised to undergo an adrenalectomy and she chose the laparoscopic approach due to her multiple pulmonary comorbidities.,INTRAOPERATIVE FINDINGS: , Showed multiple intraabdominal adhesions in the anterior abdominal wall.  The spleen and liver were unremarkable.  The gallbladder was surgically absent.,There was large amount of omentum and bowel in the pelvis, therefore the gynecological organs were not visualized.  There was no evidence of peritoneal studding or masses.  The stomach was well decompressed as well as the bladder.,PROCEDURE DETAILS: , After informed consent was obtained from the patient, she was taken to the operating room and given general anesthesia.  She was placed on a bean bag and secured to the table.  The table was rotated to the right to allow gravity to aid in our retraction of the bowel.,Prep was performed.  Sterile drapes were applied.  Using the Hassan technique, we placed a primary laparoscopy port approximately 3 cm lateral to the umbilicus on the left.  Laparoscopy was performed with ___________.  At this point, we had a second trocar, which was 10 mm to 11 mm port.  Using the non-cutting trocar in the anterior axillary line and using Harmonic scalpel, we did massive lysis of adhesions from the anterior abdominal wall from the length of the prior abdominal incision, the entire length of the abdominal incision from the xiphoid process to the umbilicus.  The adhesions were taken down off the entire anterior abdominal wall.,At this point, secondary and tertiary ports were placed.  We had one near the midline in the subcostal region and to the left midline and one at the midclavicular line, which were also 10 and 11 ports using a non-cutting blade.,At this point, using the Harmonic scalpel, we opened the white line of Toldt on the left and reflected the colon medially, off the anterior aspect of the Gerota's fascia.  Blunt and sharp dissection was used to isolate the upper pole of the kidney, taking down some adhesions from the spleen.  The colon was further mobilized medially again using gravity to aid in our retraction.  After isolating the upper pole of the kidney using blunt and sharp dissection as well as the Harmonic scalpel, we were able to dissect the plane between the upper pole of the kidney and lower aspect of the adrenal gland.  We were able to isolate the adrenal vein, dumping into the renal vein, this was doubly clipped and transected.  There was also noted to be vascular structure of the upper pole, which was also doubly clipped and transected.  Using the Harmonic scalpel, we were able to continue free the remainder of the adrenal glands from its attachments medially, posteriorly, cephalad, and laterally.,At this point, using the EndoCatch bag, we removed the adrenal gland through the primary port in the periumbilical region and sent the flap for analysis.  Repeat laparoscopy showed no additional findings.  The bowel was unremarkable, no evidence of bowel injury, no evidence of any bleeding from the operative site.,The operative site was irrigated copiously with saline and reinspected and again there was no evidence of bleeding.  The abdominal cavity was desufflated and was reinspected.  There was no evidence of bleeding.,At this point, the camera was switched to one of the subcostal ports and the primary port in the periumbilical region was closed under direct vision using #0 Vicryl suture.  At this point, each of the other ports were removed and then with palpation of each of these ports, this indicated that the non-cutting ports did close and there was no evidence of fascial defects.,At this point, the procedure was terminated.  The abdominal cavity was desufflated as stated.  The patient was sent to Recovery in stable condition.  Postoperative orders were written.  The procedure was discussed with the patient's family at length.",
 Patient with a history of ischemic cardiac disease and hypercholesterolemia., Cardiovascular / Pulmonary, Ischemic Cardiac Disease - Progress Note ,"HISTORY OF PRESENT ILLNESS:,  The patient is a 68-year-old man who returns for recheck.  He has a history of ischemic cardiac disease, he did see Dr. XYZ in February 2004 and had a thallium treadmill test.  He did walk for 8 minutes.  The scan showed some mild inferior wall scar and ejection fraction was well preserved.  He has not had difficulty with chest pain, palpitations, orthopnea, nocturnal dyspnea, or edema.,PAST MEDICAL HISTORY/SURGERIES/HOSPITALIZATIONS: , He had tonsillectomy at the age of 8.  He was hospitalized in 1996 with myocardial infarction and subsequently underwent cardiac catheterization and coronary artery bypass grafting procedure.  He did have LIMA to the LAD and had three saphenous vein grafts performed otherwise.,MEDICATIONS:,  Kerlone 10 mg 1/2 pill daily, gemfibrozil 600 mg twice daily, Crestor 80 mg 1/2 pill daily, aspirin 325 mg daily, vitamin E 400 units daily, and Citrucel one daily.,ALLERGIES: , None known.,FAMILY HISTORY:  ,Father died at the age of 84.  He had a prior history of cancer of the lung and ischemic cardiac disease.  Mother died in her 80s from congestive heart failure.  He has two brothers and six sisters living who remain in good health.,PERSONAL HISTORY:  ,Quit smoking in 1996.  He occasionally drinks alcoholic beverages.,REVIEW OF SYSTEMS:,Endocrine:  He has hypercholesterolemia treated with diet and medication.  He reports that he did lose 10 pounds this year.,Neurologic:  Denies any TIA symptoms.,Genitourinary:  He has occasional nocturia.  Denies any difficulty emptying his bladder.,Gastrointestinal:  He has a history of asymptomatic cholelithiasis.,PHYSICAL EXAMINATION:,Vital Signs:  Weight:  225 pounds.  Blood pressure:  130/82.  Pulse:  83.  Temperature:  96.4 degrees.,General Appearance:  He is a middle-aged man who is not in any acute distress.,HEENT:  Mouth:  The posterior pharynx is clear.,Neck:  Without adenopathy or thyromegaly.,Chest:  Lungs are resonant to percussion.  Auscultation reveals normal breath sounds.,Heart:  Normal S1, S2, without gallops or rubs.,Abdomen:  Without tenderness or masses.,Extremities:  Without edema.,IMPRESSION/PLAN:,1.  Ischemic cardiac disease.  This remains stable.  He will continue on the same medication.  He reports he has had some laboratory studies today.,2.  Hypercholesterolemia.  He will continue on the same medication.,3.  Facial tic.  We also discussed having difficulty with the facial tic at the left orbital region.  This occurs mainly when he is under stress.  He has apparently had numerous studies in the past and has seen several doctors in Wichita about this.  At one time was being considered for some type of operation.  His description, however, suggests that they were considering an operation for tic douloureux.  He does not have any pain with this tic and this is mainly a muscle spasm that causes his eye to close.  Repeat neurology evaluation was advised.  He will be scheduled to see Dr. XYZ in Newton on 09/15/2004.,4.  Immunization.  Addition of pneumococcal vaccination was discussed with him but had been decided by him at the end of the appointment.  We will have this discussed with him further when his laboratory results are back.",
" Specimen - Lung, left lower lobe resection.  Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma.  The tumor closely approaches the pleural surface but does not invade the pleura.", Cardiovascular / Pulmonary, Immunohistochemical Study ,"CLINICAL HISTORY: , Patient is a 37-year-old female with a history of colectomy for adenoma.  During her preop evaluation it was noted that she had a lesion on her chest x-ray.  CT scan of the chest confirmed a left lower mass.,SPECIMEN: , Lung, left lower lobe resection.,IMMUNOHISTOCHEMICAL STUDIES:,  Tumor cells show no reactivity with cytokeratin AE1/AE3.  No significant reactivity with CAM5.2 and no reactivity with cytokeratin-20 are seen.  Tumor cells show partial reactivity with cytokeratin-7.  PAS with diastase demonstrates no convincing intracytoplasmic mucin.  No neuroendocrine differentiation is demonstrated with synaptophysin and chromogranin stains.  Tumor cells show cytoplasmic and nuclear reactivity with S100 antibody.  No significant reactivity is demonstrated with melanoma marker HMB-45 or Melan-A.  Tumor cell nuclei (spindle cell and pleomorphic/giant cell carcinoma components) show nuclear reactivity with thyroid transcription factor marker (TTF-1).  The immunohistochemical studies are consistent with primary lung sarcomatoid carcinoma with pleomorphic/giant cell carcinoma and spindle cell carcinoma components.,FINAL DIAGNOSIS:,Histologic Tumor Type:  Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma.,Tumor Size:  2.7 x 2.0 x 1.4 cm.,Visceral Pleura Involvement:  The tumor closely approaches the pleural surface but does not invade the pleura.,Vascular Invasion:  Present.,Margins:  Bronchial resection margins and vascular margins are free of tumor.,Lymph Nodes:  Metastatic sarcomatoid carcinoma into one of four hilar lymph nodes.,Pathologic Stage:  pT1N1MX.","cardiovascular / pulmonary, cytokeratin-20, hmb-45, melanoma, spindle cell carcinoma, tumor cells, carcinoma, immunohistochemical, lung, cytokeratin, sarcomatoid, spindle, pleural, cell, tumor,"
 Comprehensive electrophysiology studies with attempted arrhythmia induction and IV Procainamide infusion for Brugada syndrome., Cardiovascular / Pulmonary, IV Procainamide Infusion ,"PREOPERATIVE DIAGNOSIS: , Syncopal episodes with injury.  See electrophysiology consultation.,POSTOPERATIVE DIAGNOSES:,1.  Normal electrophysiologic studies.,2.  No inducible arrhythmia.,3.  Procainamide infusion negative for Brugada syndrome.,PROCEDURES:,1.  Comprehensive electrophysiology studies with attempted arrhythmia induction.,2.  IV Procainamide infusion for Brugada syndrome.,DESCRIPTION OF PROCEDURE:, The patient gave informed consent for comprehensive electrophysiologic studies.  She received small amounts of intravenous fentanyl and Versed for conscious sedation.  Then 1% lidocaine local anesthesia was used.  Three catheters were placed via the right femoral vein; 5-French catheters to the right ventricular apex and right atrial appendage; and a 6-French catheter to the His bundle.  Later in the procedure, the RV apical catheter was moved to RV outflow tract.,ELECTROPHYSIOLOGICAL FINDINGS:,  Conduction intervals in sinus rhythm were normal.  Sinus cycle length 768 ms, PA interval 24 ms, AH interval 150 ms, HV interval 46 ms.  Sinus node recovery times were also normal at 1114 ms.  Corrected sinus node recovery time was normal at 330 ms.  One-to-one AV conduction was present to cycle length 480 ms, AH interval 240 ms, HV interval 54 ms.  AV nodal effective refractory period was normal, 440 ms at drive cycle length 600 ms.  RA-ERP was 250 ms.  With ventricular pacing, there was VA disassociation present.,Since there was no evidence for dual AV nodal pathways, and poor retrograde conduction, isoproterenol infusion was not performed to look for SVT.,Programmed ventricular stimulation was performed at both right ventricular apex and right ventricular outflow tracts.  Drive cycle length 600, 500, and 400 ms was used with triple extrastimuli down to troubling intervals of 180 ms, or refractoriness.  There was no inducible VT.  Longest run was 5 beats of polymorphic VT, which is a nonspecific finding.  From the apex 400-600 with 2 extrastimuli were delivered, again with no inducible VT.,Procainamide was then infused, 20 mg/kg over 10 minutes.  There were no ST segment changes.  HV interval after IV Procainamide remained normal at 50 ms.,ASSESSMENT: , Normal electrophysiologic studies.  No evidence for sinus node dysfunction or atrioventricular block.  No inducible supraventricular tachycardia or ventricular tachycardia, and no evidence for Brugada syndrome.,PLAN: , The patient will follow up with Dr. X.  She recently had an ambulatory EEG.  I will plan to see her again on a p.r.n. basis should she develop a recurrent syncopal episodes.  Reveal event monitor was considered, but not placed since she has only had one single episode.","cardiovascular / pulmonary, arrhythmia, attempted arrhythmia induction, conduction, sinus rhythm, electrophysiologic studies, sinus node, iv procainamide, brugada syndrome, electrophysiology, sinus, ventricular,"
 Lexiscan Nuclear Myocardial Perfusion Scan.  Chest pain.  Patient unable to walk on a treadmill.  Nondiagnostic Lexiscan.  Normal nuclear myocardial perfusion scan., Cardiovascular / Pulmonary, Lexiscan Nuclear Scan ,"EXAM:,  Lexiscan Nuclear Myocardial Perfusion Scan.,INDICATION:,  Chest pain.,TYPE OF TEST:  ,Lexiscan, unable to walk on a treadmill.,INTERPRETATION: , Resting heart rate of 96, blood pressure of 141/76.  EKG, normal sinus rhythm, nonspecific ST-T changes, left bundle branch block.  Post Lexiscan 0.4 mg injected intravenously by standard protocol.  Peak heart rate was 105, blood pressure of 135/72.  EKG remains the same.  No symptoms are noted.,SUMMARY:,1.  Nondiagnostic Lexiscan.,2.  Nuclear interpretation as below.,NUCLEAR MYOCARDIAL PERFUSION SCAN WITH STANDARD PROTOCOL:,  Resting and stress images were obtained with 10.4, 32.5 mCi of tetrofosmin injected intravenously by standard protocol.  Myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake.  There is no evidence of reversible or fixed defect.  Gated SPECT revealed mild global hypokinesis, more pronounced in the septal wall possibly secondary to prior surgery.  Ejection fraction calculated at 41%.  End-diastolic volume of 115, end-systolic volume of 68.,IMPRESSION:,1.  Normal nuclear myocardial perfusion scan.,2.  Ejection fraction 41% by gated SPECT.","cardiovascular / pulmonary, lexiscan nuclear myocardial perfusion scan, treadmill, bundle branch block, mci, tetrofosmin, nuclear myocardial perfusion scan, blood pressure, gated spect, ejection fraction, myocardial perfusion, ejection, fraction, myocardial, lexiscan, nuclear,"
" Nonischemic cardiomyopathy, branch vessel coronary artery disease, congestive heart failure - NYHA Class III, history of nonsustained ventricular tachycardia, hypertension, and hepatitis C.", Cardiovascular / Pulmonary, Hypertension & Cardiomyopathy ,"PROBLEMS LIST:,1.  Nonischemic cardiomyopathy.,2.  Branch vessel coronary artery disease.,3.  Congestive heart failure, NYHA Class III.,4.  History of nonsustained ventricular tachycardia.,5.  Hypertension.,6.  Hepatitis C.,INTERVAL HISTORY: , The patient was recently hospitalized for CHF exacerbation and was discharged with increased medications.  However, he did not fill his prescriptions and came back with persistent shortness of breath on exertion and on rest.  He has history of orthopnea and PND.  He has gained a few pounds of weight but denied to have any palpitation, presyncope, or syncope.,REVIEW OF SYSTEMS: , Positive for right upper quadrant pain.  He has occasional nausea, but no vomiting.  His appetite has decreased.  No joint pain, TIA, seizure or syncope.  Other review of systems is unremarkable.,I reviewed his past medical history, past surgical history, and family history.,SOCIAL HISTORY: , He has quit smoking, but unfortunately was positive for cocaine during last hospital stay in 01/08.,ALLERGIES: , He has no known drug allergies.,MEDICATIONS:,  I reviewed his medication list in the chart.  He states he is compliant, but he was not taking the revised dose of medications as per discharge orders and prescription.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse 91 per minute and regular, blood pressure 151/102 in the right arm and 152/104 in the left arm, weight 172 pounds, which is about 6 pounds more than last visit in 11/07.  HEENT:  Atraumatic and normocephalic.  No pallor, icterus or cyanosis.  NECK:  Supple.  Jugular venous distention 5 cm above the clavicle present.  No thyromegaly.  LUNGS:  Clear to auscultation.  No rales or rhonchi.  Pulse ox was 98% on room air.  CVS:  S1 and S2 present.  S3 and S4 present.  ABDOMEN:  Soft and nontender.  Liver is palpable 5 cm below the right subcostal margin.  EXTREMITIES:  No clubbing or cyanosis.  A 1+ edema present.,ASSESSMENT AND PLAN:,  The patient has hypertension, nonischemic cardiomyopathy, and branch vessel coronary artery disease.  Clinically, he is in NYHA Class III.  He has some volume overload and was not unfortunately taking Lasix as prescribed.  I have advised him to take Lasix 40 mg p.o. b.i.d.  I also increased the dose of hydralazine from 75 mg t.i.d. to 100 mg t.i.d.  I advised him to continue to take Toprol and lisinopril.  I have also added Aldactone 25 mg p.o. daily for survival advantage.  I reinforced the idea of not using cocaine.  He states that it was a mistake, may be somebody mixed in his drink, but he has not intentionally taken any cocaine.  I encouraged him to find a primary care provider.  He will come for a BMP check in one week.  I asked him to check his blood pressure and weight.  I discussed medication changes and gave him an updated list.  I have asked him to see a gastroenterologist for hepatitis C.  At this point, his Medicaid is pending.  He has no insurance and finds hard to find a primary care provider.  I will see him in one month.  He will have his fasting lipid profile, AST, and ALT checked in one week.","cardiovascular / pulmonary, congestive heart failure, hypertension, cardiomyopathy, coronary artery disease, ventricular tachycardia, nonischemic cardiomyopathy, branch vessel, nyha class, nonischemic, tachycardia, orthopnea,"
" An 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation.", Cardiovascular / Pulmonary, Hypertension - Consult ,"HISTORY OF PRESENT ILLNESS: , The patient is an 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation although not seen recently and I was asked to perform cardiology consultation for her because there was concern for atrial fibrillation after a fall.  Basically the patient states that yesterday she fell and she is not certain about the circumstances, on her driveway, and on her left side hit a rock.  When she came to the emergency room, she was found to have a rapid atrial tachyarrhythmia, and was put on Cardizem with reportedly heart rate in the 50s, so that was stopped.  Review of EKGs from that time shows what appears to be multifocal atrial tachycardia with followup EKG showing wandering atrial pacemaker.  An ECG this morning showing normal sinus rhythm with frequent APCs.  Her potassium at that time was 3.1.  She does recall having palpitations because of the pain after the fall, but she states she is not having them since and has not had them prior.  She denies any chest pain nor shortness of breath prior to or since the fall.  She states clearly she can walk and she would be able to climb 2 flights of stairs without problems.,PAST CARDIAC HISTORY: , She is followed by Dr. X in our office and has a history of severe tricuspid regurgitation with mild elevation and PA pressure.  On 05/12/08, preserved left and right ventricular systolic function, aortic sclerosis with apparent mild aortic stenosis, and bi-atrial enlargement.  She has previously had a Persantine Myoview nuclear rest-stress test scan completed at ABCD Medical Center in 07/06 that was negative.  She has had significant mitral valve regurgitation in the past being moderate, but on the most recent echocardiogram on 05/12/08, that was not felt to be significant.  She has a history of hypertension and EKGs in our office show normal sinus rhythm with frequent APCs versus wandering atrial pacemaker.  She does have a history of significant hypertension in the past.  She has had dizzy spells and denies clearly any true syncope.  She has had bradycardia in the past from beta-blocker therapy.,MEDICATIONS ON ADMISSION:,1.  Multivitamin p.o. daily.,2.  Aspirin 325 mg once a day.,3.  Lisinopril 40 mg once a day.,4.  Felodipine 10 mg once a day.,5.  Klor-Con 20 mEq p.o. b.i.d.,6.  Omeprazole 20 mg p.o. daily presumably for GERD.,7.  MiraLax 17 g p.o. daily.,8.  Lasix 20 mg p.o. daily.,ALLERGIES: , PENICILLIN.  IT IS LISTED THAT TOPROL HAS CAUSED SHORTNESS OF BREATH IN HER OFFICE CHART AND I BELIEVE SHE HAS HAD SIGNIFICANT BRADYCARDIA WITH THAT IN THE PAST.,FAMILY HISTORY:,  She states her brother died of an MI suddenly in his 50s.,SOCIAL HISTORY: , She does not smoke cigarettes, abuse alcohol, nor use any illicit drugs.  She is retired from Morse Chain and delivering newspapers.  She is widowed.  She lives alone but has family members who live either on her property or adjacent to it.,REVIEW OF SYSTEMS: , She denies a history of stroke, cancer, vomiting of blood, coughing up blood, bright red blood per rectum, bleeding, stomach ulcers.  She does not recall renal calculi, nor cholelithiasis, denies asthma, emphysema, pneumonia, tuberculosis, sleep apnea, home oxygen use.  She does note occasional peripheral edema.  She is not aware of prior history of MI.  She denies diabetes.  She does have a history of GERD.  She notes feeling depressed at times because of living alone.  She denies rheumatologic conditions including psoriasis or lupus.  Remainder of review of systems is negative times 15 except as described above.,PHYSICAL EXAM:  ,Height 5 feet 0 inches, weight 123 pounds, temperature 99.2 degrees Fahrenheit, blood pressure has ranged from 160/87 with pulses recorded at being 144, and currently ranges 101/53 to 147/71, pulse 64, respiratory rate 20, O2 saturation 97%.  On general exam, she is a pleasant elderly woman who is hard of hearing, but is alert and interactive.  HEENT:  Shows cranium is  normocephalic and atraumatic.  She has moist mucosal membranes.  Neck veins were not distended.  There are no carotid bruits.  Lungs:  Clear to auscultation anteriorly without wheezes.  She is relatively immobile because of her left hip fracture.  Cardiac Exam:  S1, S2, regular rate, frequent ectopic beats, 2/6 systolic ejection murmur, preserved aortic component of the second heart sound.  There is also a soft holosystolic murmur heard.  There is no rub or gallop.  PMI is nondisplaced.  Abdomen is soft and nondistended.  Bowel sounds present.  Extremities without significant clubbing, cyanosis, and there is trivial to 1+ peripheral edema.  Pulses appear grossly intact.  Affect is appropriate.  Visible skin warm and perfused.  She is not able to move because of left hip fracture easily in bed.,DIAGNOSTIC STUDIES/LAB DATA: , Pertinent labs include chest x-ray with radiology report pending but shows only a calcified aortic knob.  No clear pulmonary vascular congestion.  Sodium 140, potassium 3.7, it was 3.1 on admission, chloride 106, bicarbonate 27, BUN 17, creatinine 0.9, glucose 150, magnesium was 2 on 07/13/06.  Troponin was 0.03 followed by 0.18.  INR is 0.93, white blood cell count 10.2, hematocrit 36, platelet count 115,000.,EKGs are reviewed.  Initial EKG done on 08/19/08 at 1832 shows MAT, heart rate of 104 beats per minute, no ischemic changes.  She had a followup EKG done at 20:37 on 08/19/08, which shows wandering atrial pacemaker and some lateral T-wave changes, not significantly changed from prior.  Followup EKG done this morning shows normal sinus rhythm with frequent APCs.,IMPRESSION:  ,She is an 84-year-old female with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension and mild aortic stenosis admitted after a fall with left hip fracture and she will require surgery.  Telemetry now reviewed, shows predominantly normal sinus rhythm with frequent APCs _____ earlier yesterday evening showed burst of multifocal atrial tachycardia and I suspect that was exacerbated by prior hypokalemia, which has been corrected.  There has been no atrial fibrillation documented.  I do not feel these troponins are significant given the stress or fall in prior multifocal atrial tachycardia with increased rate especially in the absence of chest pain or shortness of breath.  She actually describes feeling good exercise capacity prior to this fall.  Given favorable risk to benefit ratio for needed left hip surgery, I feel she may proceed with needed left hip surgery from a cardiac standpoint with continued verapamil, which has been started, which should help control the multifocal atrial tachycardia, which she had and would watch for heart rate with that.  Continued optimization of electrolytes.  The patient cannot take beta-blockers as previously Toprol reportedly caused shortness of breath, although, there was some report that it caused bradycardia so we would watch her heart rate on the verapamil.  The patient is aware of the cardiac risks, certainly it is moderate, and wishes to proceed with needed surgery.  I do not feel any further cardiac evaluation is needed at this time and the patient may followup with Dr. X after discharge.  Regarding her mild thrombocytopenia, I would defer that to hospitalist and continue proton pump inhibitors for history of gastroesophageal reflux disease, management of left hip fracture as per orthopedist.","cardiovascular / pulmonary, hypokalemia, shortness of breath, atrial tachycardia, sinus rhythm, hip fracture, atrial, tachycardia, rhythm, apcs, cardiac, regurgitation, aortic, hypertension, pulmonary, "
" Patient with hypertension, syncope, and spinal stenosis - for recheck.", Cardiovascular / Pulmonary, Hypertension - Progress Note ,"SUBJECTIVE:,  The patient is a 78-year-old female who returns for recheck.  She has hypertension.  She denies difficulty with chest pain, palpations, orthopnea, nocturnal dyspnea, or edema.,PAST MEDICAL HISTORY / SURGERY / HOSPITALIZATIONS:,  Reviewed and unchanged from the dictation on 12/03/2003.,MEDICATIONS:  ,Atenolol 50 mg daily, Premarin 0.625 mg daily, calcium with vitamin D two to three pills daily, multivitamin daily, aspirin as needed, and TriViFlor 25 mg two pills daily.  She also has Elocon cream 0.1% and Synalar cream 0.01% that she uses as needed for rash.,ALLERGIES:  ,Benadryl, phenobarbitone, morphine, Lasix, and latex.,FAMILY HISTORY / PERSONAL HISTORY: , Reviewed.  Mother died from congestive heart failure.  Father died from myocardial infarction at the age of 56.  Family history is positive for ischemic cardiac disease.  Brother died from lymphoma.  She has one brother living who has had angioplasties x 2.  She has one brother with asthma.,PERSONAL HISTORY:,  Negative for use of alcohol or tobacco.,REVIEW OF SYSTEMS:,Bones and Joints:  She has had continued difficulty with lower back pain particularly with standing which usually radiates down her right leg.  She had been followed by Dr. Mills, but decided to see Dr. XYZ who referred to her Dr Isaac.  She underwent several tests.  She did have magnetic resonance angiography of the lower extremities and the aorta which were normal.  She had nerve conduction study that showed several peripheral polyneuropathy.  She reports that she has myelogram last week but has not got results of this.  She reports that the rest of her tests have been normal, but it seems that vertebrae shift when she stands and then pinches the nerve.  She is now seeing Dr. XYZ who comes to Hutchison from KU Medical Center, and she thinks that she probably will have surgery in the near future.,Genitourinary:  She has occasional nocturia.,PHYSICAL EXAMINATION:,Vital Signs:  Weight:  227.2 pounds.  Blood pressure:  144/72.  Pulse:  80.  Temperature:  97.5 degrees.,General Appearance:  She is an elderly female patient who is not in acute distress.,Mouth:  Posterior pharynx is clear.,Neck:  Without adenopathy or thyromegaly.,Chest:  Lungs are resonant to percussion.  Auscultation reveals normal breath sounds.,Heart:  Normal S1 and S2 without gallops or rubs.,Abdomen:  Without masses or tenderness to palpation.,Extremities:  Without edema.,IMPRESSION/PLAN:,1.  Hypertension.  She is advised to continue with the same medication.,2.  Syncope.  She previously had an episode of syncope around Thanksgiving.  She has not had a recurrence of this and her prior cardiac studies did not show arrhythmias.,3.  Spinal stenosis.  She still is being evaluated for this and possibly will have surgery in the near future.","cardiovascular / pulmonary, progress note, hypertension, spinal stenosis, syncope, spinal, stenosis, infarction, orthopnea, "
 Holter monitor report.   Predominant rhythm is sinus.  Triplet maximum rate of 178 beats per minute noted., Cardiovascular / Pulmonary, Holter Monitor Report - 1 ,"INDICATIONS: , Predominant rhythm is sinus.  Heart rate varied between 56-128 beats per minute, average heart rate of 75 beats per minute.  Minimum heart rate of 50 beats per minute.,640 ventricular ectopic isolated beats noted.  Rare isolated APCs and supraventricular couplets.,One supraventricular triplet reported.,Triplet maximum rate of 178 beats per minute noted.","cardiovascular / pulmonary, holter monitor, heart rate, supraventricular, triplet, heart, beatsNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Holter monitoring for syncope.  Analyzed for approximately 23 hours 57 minutes and artefact noted for approximately 23 seconds. , Cardiovascular / Pulmonary, Holter Monitor Report - 2 ,"INDICATION: , Syncope.,HOLTER MONITOR SUMMARY ANALYSIS: , Analyzed for approximately 23 hours 57 minutes and artefact noted for approximately 23 seconds.  Total beats of 108,489, heart rate minimum of approximately 54 beats per minutes at 7 a.m. and maximum of 106 beats per minute at approximately 4 p.m.  Average heart rate is approximately 75 beats per minute, total of 31 to bradycardia, longest being 225 beats at approximately 7 in the morning, minimum rate of 43 beats per minute at approximately 01:40 a.m.  Total ventricular events of 64, primarily premature ventricular contraction and supraventricular events total beats of 9 atrial premature contractions.  No significant ST elevation noted and ST depression noted only in one channel for approximately three minutes for a maximum of 2.7 mm.,IMPRESSION OF THE FINDINGS: , Predominant sinus rhythm with occasional premature ventricular contraction, occasional atrial premature contractions and Mobitz type 1 Wenckebach, several episodes, Mobitz type II, 3 to 2 AV conduction disease noted as well approximately two episodes and one episode of atrial bigeminy noted.  No significant pauses noted.","cardiovascular / pulmonary, artefact, ventricular contraction, holter monitor, premature contractions, mobitz type, holter, beatsNOTE"
 Placement of a subclavian single-lumen tunneled Hickman central venous catheter.  Surgeon-interpreted fluoroscopy., Cardiovascular / Pulmonary, Hickman Central Venous Catheter Placement ,"PROCEDURE PERFORMED,1.  Placement of a subclavian single-lumen tunneled Hickman central venous catheter.,2.  Surgeon-interpreted fluoroscopy.,OPERATION IN DETAIL:,  After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and anesthesia was administered.  Next, a #18-gauge needle was used to locate the subclavian vein.  After aspiration of venous blood, a J wire was inserted through the needle using Seldinger technique.  The needle was withdrawn.  The distal tip location of the J wire was confirmed to be in adequate position with surgeon-interpreted fluoroscopy.  Next, a separate stab incision was made approximately 3 fingerbreadths below the wire exit site.  A subcutaneous tunnel was created, and the distal tip of the Hickman catheter was pulled through the tunnel to the level of the cuff.  The catheter was cut to the appropriate length.  A dilator and sheath were passed over the J wire.  The dilator and J wire were removed, and the distal tip of the Hickman catheter was threaded through the sheath, which was simultaneously withdrawn.  The catheter was flushed and aspirated without difficulty.  The distal tip was confirmed to be in good location with surgeon-interpreted fluoroscopy.  A 2-0 nylon was used to secure the cuff down to the catheter at the skin level.  The skin stab site was closed with a 4-0 Monocryl.  The instrument and sponge count was correct at the end of the case.  The patient tolerated the procedure well and was transferred to the postanesthesia recovery area in good condition.","cardiovascular / pulmonary, j wire, distal tip, stab incision, tunneled, hickman central venous catheter, subclavian, venous, fluoroscopy, hickman, catheterNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 Holter monitoring - For bradycardia and dizziness., Cardiovascular / Pulmonary, Holter Monitoring ,"INDICATION: , Bradycardia and dizziness.,COMMENTS:,1.  The patient was monitored for 24 hours.,2.  The predominant rhythm was normal sinus rhythm with a minimum heart rate of 56 beats per minute and the maximum heart rate of 114 beats per minute and a mean heart rate of 86 beats per minute.,3.  There were occasional premature atrial contractions seen, no supraventricular tachycardia was seen.,4.  There was a frequent premature ventricular contraction seen.  Between 11:00 a.m. and 11:15 a.m. the patient was in ventricular bigemini and trigemini most of the time.  During rest of the monitoring period, there were just occasional premature ventricular contractions seen.  No ventricular tachycardia was seen.,5.  There were no pathological pauses noted.,6.  The longest RR interval was 1.1 second.,7.  There were no symptoms reported.","cardiovascular / pulmonary, holter monitoring, bradycardia, bigemini, dizziness, heart rate, interval, predominant, premature, premature ventricular contraction, rhythm, sinus, trigemini, ventricular, bradycardia and dizziness, premature ventricular, monitoring, "
 Holter Monitor Report, Cardiovascular / Pulmonary, Holter Monitor Report ,"INTERPRETATION:,1.  Predominant rhythm is normal sinus rhythm.,2.  No supraventricular arrhythmia.,3.  Frequent premature ventricular contractions.,4.  Trigemini and couplets.,5.  No high-grade atrial ventricular block was noted.,6.  Diary was not kept.,IMPRESSION:,  Frequent premature atrial contractions, couplets, and trigemini.,","cardiovascular / pulmonary, atrial ventricular block, holter monitor report, holter monitor, frequent premature, holter, monitor, rhythm, ventricular, contractions, trigemini, atrial, "
" Left heart catheterization, coronary angiography, and left ventriculogram.  No angiographic evidence of coronary artery disease.  Normal left ventricular systolic function.  Normal left ventricular end diastolic pressure.", Cardiovascular / Pulmonary," Heart Catheterization, Ventriculography, & Angiography - 8 ","PROCEDURES,1.  Left heart catheterization.,2.  Coronary angiography.,3.  Left ventriculogram.,PREPROCEDURE DIAGNOSIS:,  Atypical chest pain.,POSTPROCEDURE DIAGNOSES,1.  No angiographic evidence of coronary artery disease.,2.  Normal left ventricular systolic function.,3.  Normal left ventricular end diastolic pressure.,INDICATION:  ,The patient is a 58-year-old male with past medical history significant for polysubstance abuse, chronic tobacco abuse, chronic alcohol dependence with withdrawal, atrial flutter, history of ventricular tachycardia with AICD placement, and hepatitis C. The patient was admitted for atypical chest pain and scheduled for cardiac catheterization.,PROCEDURE IN DETAIL:,  After informed consent was signed by the patient, the patient was taken to the cardiac catheterization laboratory.  He was prepped and draped in the usual sterile manner.  The right inguinal area was anesthetized with 2% Xylocaine.  A 4-French sheath was inserted into the right femoral artery using the modified Seldinger technique.  JL4 and 3DRC catheters were used to cannulate the left and right coronary arteries respectively.  Coronary angiographies were performed.  These catheters were removed and exchanged for a 4-French pigtail catheter, which was positioned into the left ventricle.  Left ventriculography was performed.  The patient tolerated the procedure well.  At the end of the procedure, all catheters and sheaths were removed.  The patient was then transferred to telemetry in a stable condition.,HEMODYNAMIC DATA: , Hemodynamic data shows aortic pressures of 100/56 with mean of 70 mmHg and the LV 100/0 with LVEDP of 10 mmHg.,AORTIC VALVE:  ,There is no significant gradient across this valve noted.,LV GRAM: , A 10 mL of contrast were delivered for 3 seconds for a total of 30 mL.  Ejection fraction was calculated to be 69%.  There were no wall motion abnormalities noted.,ANGIOGRAM,LEFT MAIN CORONARY ARTERY: , Left main coronary artery is a moderate-caliber vessel free of disease and trifurcates.,LAD: , LAD is a long, tortuous vessel which wraps around the apex.  The LAD is small in caliber.  In addition, there is a long bifurcating small-caliber diagonal branch noted.  LAD and its branches are free of disease.,RAMUS INTERMEDIUS: , Ramus intermedius is a long small-caliber vessel free of disease.,LCX: , LCX is a nondominant small-caliber vessel with long bifurcating small-caliber distal OM branch.  LCX and its branches are free of disease.,RCA:,  RCA is a dominant small-caliber vessel with long small-caliber PDA branch.  RCA and its branches are free of disease.,IMPRESSION,1.  No angiographic evidence of coronary artery disease.,2.  Normal left ventricular systolic function.,3.  Normal left ventricular end diastolic pressure.,RECOMMENDATION: , Recommend to look for alternative causes of chest pain.",
" Left heart catheterization, coronary angiography, left ventriculography.  Severe complex left anterior descending and distal circumflex disease with borderline, probably moderate narrowing of a large obtuse marginal branch.", Cardiovascular / Pulmonary," Heart Catheterization, Ventriculography, & Angiography - 7 ","PROCEDURE: , Left heart catheterization, coronary angiography, left ventriculography.,COMPLICATIONS: , None.,PROCEDURE DETAIL: , The right femoral area was draped and prepped in the usual fashion after Xylocaine infiltration.  A 6-French arterial sheath was placed in the usual fashion.  Left and right coronary angiograms were then performed in various projections after heparin was given 2000 units intraaortic.  The right coronary artery was difficult to cannulate because of its high anterior takeoff.  This was nondominant.  Several catheters were used.  Ultimately, an AL1 diagnostic catheter was used.  A pigtail catheter was advanced across the aortic valve.  Left ventriculogram was then done in the RAO view using 30 mL of contrast.  Pullback gradient was obtained across the aortic valve.  Femoral angiogram was performed through the sheath which was above the bifurcation, was removed with a Perclose device with good results.  There were no complications.  He tolerated this procedure well and returned to his room in good condition.,FINDINGS,1.  Right coronary artery:  This has an unusual high anterior takeoff.  The vessel is nondominant, has diffuse mild-to-moderate disease.,2.  Left main trunk:  A 30% to 40% distal narrowing is present.,3.  Left anterior descending:  Just at the ostium of the vessel and up to and including the bifurcation of the first large diagonal branch, there is 80 to 90% narrowing.  The diagonal is a large vessel about 3 mm in size.,4.  Circumflex:  Dominant vessel, 50% narrowing at the origin of the obtuse marginal.  After this, there is 40% narrowing in the AV trunk.  The small posterior lateral branch has diffuse mild disease and then the vessel gives rise to a fairly large posterior ventricular branch, which has 70% ostial narrowing, and then after this the posterior descending has 80% narrowing at its origin.,5.  Left ventriculogram:  Normal volume in diastole and systole.  Normal systolic function is present.  There is no mitral insufficiency or left ventricular outflow obstruction.,DIAGNOSES,1.  Severe complex left anterior descending and distal circumflex disease with borderline, probably moderate narrowing of a large obtuse marginal branch.  Dominant circumflex system.  Severe disease of the posterior descending.  Mild left main trunk disease.,2.  Normal left ventricular systolic function.,Given the complex anatomy of the predominant problem which is the left anterior descending; given its ostial stenosis and involvement of the bifurcation of the diagonal, would recommend coronary bypass surgery.  The patient also has severe disease of the circumflex which is dominant.  This anatomy is not appropriate for percutaneous intervention.  The case will be reviewed with a cardiac surgeon.","cardiovascular / pulmonary, heart catheterization, coronary angiography, left ventriculography, arterial sheath, coronary artery, obtuse marginal branch, angiography, catheterization,"
" Very high PT-INR.  she came in with pneumonia and CHF.  She was noticed to be in atrial fibrillation, which is a chronic problem for her.", Cardiovascular / Pulmonary, High PT-INR - ER Visit ,"REASON FOR THE VISIT:,  Very high PT/INR.,HISTORY: , The patient is an 81-year-old lady whom I met last month when she came in with pneumonia and CHF.  She was noticed to be in atrial fibrillation, which is a chronic problem for her.  She did not want to have Coumadin started because she said that she has had it before and the INR has had been very difficult to regulate to the point that it was dangerous, but I convinced her to restart the Coumadin again.  I gave her the Coumadin as an outpatient and then the INR was found to be 12.  So, I told her to come to the emergency room to get vitamin K to reverse the anticoagulation.,PAST MEDICAL HISTORY:,1.  Congestive heart failure.,2.  Renal insufficiency.,3.  Coronary artery disease.,4.  Atrial fibrillation.,5.  COPD.,6.  Recent pneumonia.,7.  Bladder cancer.,8.  History of ruptured colon.,9.  Myocardial infarction.,10.  Hernia repair.,11.  Colon resection.,12.  Carpal tunnel repair.,13.  Knee surgery.,MEDICATIONS:,1.  Coumadin.,2.  Simvastatin.,3.  Nitrofurantoin.,4.  Celebrex.,5.  Digoxin.,6.  Levothyroxine.,7.  Vicodin.,8.  Triamterene and hydrochlorothiazide.,9.  Carvedilol.,SOCIAL HISTORY:  ,She does not smoke and she does not drink.,PHYSICAL EXAMINATION:,GENERAL:  Lady in no distress.,VITAL SIGNS:  Blood pressure 100/46, pulse of 75, respirations 12, and temperature 98.2.,HEENT:  Head is normal.,NECK:  Supple.,LUNGS:  Clear to auscultation and percussion.,HEART:  No S3, no S4, and no murmurs.,ABDOMEN:  Soft.,EXTREMITIES:  Lower extremities, no edema.,ASSESSMENT:,1.  Atrial fibrillation.,2.  Coagulopathy, induced by Coumadin.,PLAN: , Her INR at the office was 12.  I will repeat it, and if it is still elevated, I will give vitamin K 10 mg in 100 mL of D5W and then send her home and repeat the PT/INR next week.  I believe at this time that it is too risky to use Coumadin in her case because of her age and comorbidities, the multiple medications that she takes and it is very difficult to keep an adequate level of anticoagulation that is safe for her.  She is prone to a fall and this would be a big problem.  We will use one aspirin a day instead of the anticoagulation.  She is aware of the risk of stroke, but she is very scared of the anticoagulation with Coumadin and does not want to use the Coumadin at this time and I understand.  We will see her as an outpatient.",
 Left heart catheterization with left ventriculography and selective coronary angiography.  A 50% distal left main and two-vessel coronary artery disease with normal left ventricular systolic function.  Frequent PVCs.  Metabolic syndrome., Cardiovascular / Pulmonary," Heart Catheterization, Ventriculography, & Angiography - 6 ","PREOPERATIVE DIAGNOSES,1.  Dyspnea on exertion with abnormal stress echocardiography.,2.  Frequent PVCs.,3.  Metabolic syndrome.,POSTOPERATIVE DIAGNOSES,1.  A 50% distal left main and two-vessel coronary artery disease with normal left ventricular systolic function.,2.  Frequent PVCs.,3.  Metabolic syndrome.,PROCEDURES,1.  Left heart catheterization with left ventriculography.,2.  Selective coronary angiography.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained, the patient was brought to the Cardiac Catheterization Laboratory in fasting state.  Both groins were prepped and draped in the usual sterile fashion.  Xylocaine 1% was used as local anesthetic.  Versed and fentanyl were used for conscious sedation.  Next, a #6-French sheath was placed in the right femoral artery using modified Seldinger technique.  Next, selective angiography of the left coronary artery was performed in multiple views using #6-French JL4 catheter.  Next, selective angiography of the right coronary artery was performed in multiple views using #6-French 3DRC catheter.  Next, a #6-French angle pigtail catheter was advanced into the left ventricle.  The left ventricular pressure was then recorded.  Left ventriculography was the performed using 36 mL of contrast injected over 3 seconds.  The left heart pull back was then performed.  The catheter was then removed.,Angiography of the right femoral artery was performed.  Hemostasis was obtained by Angio-Seal closure device.  The patient left the Cardiac Catheterization Laboratory in stable condition.,HEMODYNAMICS,1.  LV pressure was 163/0 with end-diastolic pressure of 17.  There was no significant gradient across the aortic valve.,2.  Left ventriculography showed old inferior wall hypokinesis.  Global left ventricular systolic function is normal.  Estimated ejection fraction was 58%.  There is no significant mitral regurgitation.,3.  Significant coronary artery disease.,4.  The left main is approximately 7 or 8 mm proximally.  It trifurcates into left anterior descending artery, ramus intermedius artery, and left circumflex artery.  The distal portion of the left main has an ulcerated excentric plaque, up to about 50% in severity.,5.  The left anterior descending artery is around 4 mm proximally.  It extends slightly beyond the apex into the inferior wall.  It gives rises to several medium size diagonal branches as well as small to medium size multiple septal perforators.  At the ostium of the left anterior descending artery, there was an eccentric plaque up to 70% to 80%, best seen in the shallow LAO with caudal angulation.,There was no other flow-limiting disease noted in the rest of the left anterior descending artery or its major branches.,The ramus intermedius artery is around 3 mm proximally, but shortly after its origin, it bifurcates into two medium size branches.  There was no significant disease noted in the ramus intermedius artery however.,The left circumflex artery is around 2.5 mm proximally.  It gave off a recurrent atrial branch and a small AV groove branch prior to terminating into a bifurcating medium size obtuse marginal branch.  The mid to distal circumflex has a moderate disease, which is relatively diffuse up to about 40% to 50%.,The right coronary artery is around 4 mm in diameter.  It gives off conus branch, two medium size acute marginal branches, relatively large posterior descending artery and a posterior lateral branch.  In the mid portion of the right coronary artery at the origin of the first acute marginal branch, there is a relatively discrete stenosis of about 80% to 90%.  Proximally, there is an area of eccentric plaque, but seem to be non-flow limiting, at best around 20% to 30%.  Additionally, there is what appears to be like a shell-like lesion in the proximal segment of the right coronary artery as well.  The posterior descending artery has an eccentric plaque of about 40% to 50% in its mid segment.,PLAN:  ,Plan to consult cardiovascular surgery for consideration of coronary artery bypass surgery.  Continue risk factor modification, aspirin, and beta blocker.","cardiovascular / pulmonary, heart catheterization, ventriculography, coronary angiography, dyspnea, metabolic syndrome, two-vessel coronary artery disease, echocardiography, selective coronary angiography, anterior descending artery, branches, coronary, angiography, artery, catheterization, "
" Left heart catheterization, left ventriculography, selective coronary angiography.", Cardiovascular / Pulmonary," Heart Catheterization, Ventriculography, & Angiography - 9 ","PROCEDURE:,  Left heart catheterization, left ventriculography, selective coronary angiography.,INDICATION: , This lady with a previous left internal mammary graft to left anterior descending, saphenous vein graft to obtuse margin branch, saphenous vein graft to the diagonal branch, and saphenous vein graft to the right coronary artery presented with recurrent difficulties with breathing.  This was felt to be related largely to chronic obstructive lung disease.  She had dynamic T-wave changes in precordial leads.  Cardiac enzymes were indeterminate.  She was evaluated by Dr. X and given her previous history and multiple risk factors it was elected to proceed with cardiac catheterization and coronary angiography.,Risks of the procedure including risks of conscious sedation, death, cerebrovascular accident, dye reaction, need for emergency surgery, vascular access injury and/or infection, and risks of cath-based interventions were discussed in detail.  The patient understood and agreed to proceed.,DESCRIPTION OF THE PROCEDURE: , The patient was brought to the cardiac catheterization laboratory.  Under Versed and fentanyl sedation, the right groin was sterilely prepped and draped.  Local anesthesia was obtained with 2% Xylocaine.  The right femoral artery was entered using modified Seldinger technique and a 4-French introducer sheath placed in that vessel.  Through the indwelling femoral arterial sheath, a JL4 4-French catheter was advanced over the wire to the ascending aorta, appropriately aspirated and flushed.  Ascending aortic root pressures obtained.  This catheter was utilized in an attempt to cannulate the left coronary ostium.  This catheter was too small, was exchanged for a JL5 4-French catheter, which was advanced over the wire to the ascending aorta, the cath appropriately aspirated and flushed, and advanced to left coronary ostium and multiple views of left coronary artery obtained.,This catheter was then exchanged for a 4-French right coronary catheter, which was advanced over the wire to the ascending aorta.  The catheter appropriately aspirated and flushed.  The catheter was advanced in the right coronary artery.  Multiple views of that vessel were obtained.  The catheter was then sequentially advanced to the saphenous vein graft to the diagonal branch, saphenous vein graft to the obtuse marginal branch, and left internal mammary artery, left anterior descending coronary artery, and multiple views of those vessels were obtained.  This catheter was then exchanged for a 4-French pigtail catheter, which was advanced over the wire to the ascending aorta.  The catheter was appropriately aspirated and flushed and advanced to left ventricle, baseline left ventricular pressures obtained.,Following this, left ventriculography was performed in a 30-degree RAO projection using 30 mL of contrast injected over 3 seconds.  Post left ventriculography pressures were then obtained as was a pullback pressure across the aortic valve.  Videotapes were then reviewed.  It was elected to terminate the procedure at that point in time.,The vascular sheath was removed and manual compression carried out.  Excellent hemostasis was obtained.  The patient tolerated the procedure without complication.,RESULTS OF PROCEDURE,1.  ,HEMODYNAMICS:,  Left ventricular end-diastolic filling pressure was 24.  There was no gradient across the aortic valve.,2.  ,LEFT VENTRICULOGRAPHY: , Left ventriculography demonstrated well-preserved left ventricular systolic function.  Mild inferobasilar hypokinesis was noted.  No significant mitral regurgitation noted.  Ejection fraction was estimated at 60%.,3.  ,CORONARY ARTERIOGRAPHY,A.  ,LEFT MAIN CORONARY: , The left main coronary was patent.,B.  ,LEFT ANTERIOR DESCENDING CORONARY ARTERY:,  Left anterior descending coronary was occluded shortly after a very small first septal perforator was given.,C.  ,CIRCUMFLEX CORONARY ARTERY:,  Circumflex coronary artery was occluded at its origin.,D.  ,RIGHT CORONARY ARTERY,.  Right coronary artery was occluded in its mid portion.,4.  ,SAPHENOUS VEIN GRAFT ANGIOGRAPHY,A.  ,SAPHENOUS VEIN GRAFT TO THE DIAGONAL BRANCH: , The saphenous vein graft to diagonal branch was widely patent at its origin and insertion sites.  Excellent flow was noted in the diagonal system with some retrograde flow.,B.  There was retrograde flow as well in the left anterior descending system.,C.  ,SAPHENOUS VEIN GRAFT TO THE OBTUSE MARGINAL SYSTEM:,  Saphenous vein graft to the obtuse marginal system was widely patent at its origin and insertion sites.  There was no graft disease noted.  Excellent flow was noted in the bifurcating marginal system.,D.  ,SAPHENOUS VEIN GRAFT TO RIGHT CORONARY ARTERY:,  Saphenous vein graft to right coronary was widely patent with no graft disease.  Origin and insertion sites were free of disease.  Distal flow in the graft to the posterior descending was normal.,5.  ,LEFT INTERNAL MAMMARY ARTERY ANGIOGRAPHY: , Left internal mammary artery angiography demonstrated a widely patent left internal mammary at its origin and insertion sites.  There was no focal disease noted, inserted into the mid-to-distal LAD which was a small-caliber vessel.  Retrograde filling of a small septal system was noted.,SUMMARY OF RESULTS,1.  Elevated left ventricular end-diastolic filling pressure with normal left ventricular systolic function and mild hypokinesis of inferobasilar segment.",
" Left heart catheterization, selective bilateral coronary angiography and left ventriculography.  Revascularization of the left anterior descending with angioplasty and implantation of a drug-eluting stent.  Right heart catheterization and Swan-Ganz catheter placement for monitoring.", Cardiovascular / Pulmonary," Heart Catheterization, Ventriculography, & Angiography - 5 ","PREOPERATIVE DIAGNOSES,1.  Acute coronary artery syndrome with ST segment elevation in anterior wall distribution.,2.  Documented coronary artery disease with previous angioplasty and stent in the left anterior descending artery and circumflex artery, last procedure in 2005.,3.  Primary malignant ventricular arrhythmia and necessitated ventricular fibrillation.  He is intubated and ventilated.,POSTOPERATIVE DIAGNOSES:,  Acute coronary artery syndrome with ST segment elevation in anterior wall distribution.  Primary ventricular arrhythmia.  Occluded left anterior descending artery, successfully re-canalized with angioplasty and implantation of the drug-eluting stent.  Previously stented circumflex with mild stenosis and previously documented occlusion of the right coronary artery, well collateralized.,PROCEDURES:,  Left heart catheterization, selective bilateral coronary angiography and left ventriculography.  Revascularization of the left anterior descending with angioplasty and implantation of a drug-eluting stent.  Right heart catheterization and Swan-Ganz catheter placement for monitoring.,DESCRIPTION OF PROCEDURE:  ,The patient arrived from the emergency room intubated and ventilated.  He is hemodynamically stable on heparin and Integrilin bolus and infusion was initiated.  The right femoral area was prepped and draped in usual sterile fashion.  Lidocaine 2 mL was then filled locally.  The right femoral artery was cannulated with an 18-guage needle followed by a 6-French vascular sheath.  A guiding catheter XB 3.5 was advanced in manipulated to cannulate the left coronary artery and angiography was obtained.  A confirmed occlusion of the left anterior descending artery with minimal collaterals and also occlusion of the right coronary artery, which is well collateralized.  An angioplasty wire with present wire was advanced into the left anterior descending artery, and could cross the area of occlusion within the stent.  An angioplasty balloon measuring 2.0 x 15 was advanced and three inflations were obtained.  It successfully re-canalized the artery.  There is evidence of residual stenosis within the distal aspect of the previous stents.  A drug-eluting stent Xience 2.75 x 15 was advanced and positioned within the area of stenosis with its distal marker adjacent to bifurcation with a diagonal branch and was deployed at 12 and 18 atmospheres.  The intermittent result was improved.  An additional inflation was obtained more proximally.  His blood pressure fluctuated and dropped in the 70s, correlating with additional sedation.  There is patency of the left anterior descending artery and good antegrade flow.  The guiding catheter was replaced with a 5-French Judkins right catheter manipulated to cannulate the right coronary artery and selective angiography was obtained.  The catheter was then advanced into the left ventricle and pressure measurement was obtained including pullback across the aortic valve.  The right femoral vein was cannulated with an 18-guage needle followed by an 8-French vascular sheath.  A 8-French Swan-Ganz catheter was then advanced under fluoroscopic and hemodynamic control and pressure stenting was obtained from the right ventricle, pulmonary artery, and pulmonary capillary wedge position.  Cardiac catheter was determined by thermal dilution.  The procedure was then concluded, well tolerated and without complications.  The vascular sheath was in secured in place and the patient return to the coronary care unit for further monitoring.  Fluoroscopy time was 8.2 minutes.  Total amount of contrast was 113 mL.,HEMODYNAMICS:,  The patient remained in sinus rhythm with intermittent ventricular bigeminy post revascularization.  His initial blood pressure was 96/70 with a mean of 83 and the left ventricular pressure was 17 mmHg.  There was no gradient across the aortic valve.  Closing pressure was 97/68 with a mean of 82.,Right heart catheterization with right atrial pressure at 13, right ventricle 31/9, pulmonary artery 33/19 with a mean of 25, and capillary wedge pressure of 19.  Cardiac output was 5.87 by thermal dilution.,CORONARIES:,  On fluoroscopy, there was evidence of previous coronary stent in the left anterior descending artery and circumflex distribution.,A.  Left main coronary:  The left main coronary artery is of good caliber and has no evidence of obstructive lesions.,B.  Left anterior descending artery:  The left anterior descending artery was initially occluded within the previously stented proximal-to-mid segment.  There is minimal collateral flow.,C.  Circumflex:  Circumflex is a nondominant circulation.  It supplies a first obtuse marginal branch on good caliber.  There is an outline of the stent in the midportion, which has mild 30% stenosis.  The rest of the vessel has no significant obstructive lesions.  It also supplies significant collaterals supplying the occluded right coronary artery.,D.  Right coronary artery:  The right coronary artery is a weekly dominant circulation.  The vessel is occluded in intermittent portion and has a minimal collateral flow distally.,ANGIOPLASTY: , The left anterior descending artery was the site of re-canalization by angioplasty and implantation of a drug-eluting stent (Xience 15 mm length deployed at 2.9 mm) final result is good with patency of the left anterior descending artery, good antegrade flow and no evidence of dissection.  The stent was deployed proximal to the bifurcation with a second diagonal branch, which has remained patent.  There is a septal branch overlapped by the stent, which is also patent, although presenting a proximal stenosis.  The distal left anterior descending artery trifurcates with two diagonal branches and apical left anterior descending artery.  There is good antegrade flow and no evidence of distal embolization.,CONCLUSION: , Acute coronary artery syndrome with ST-segment elevation in anterior wall distribution, complicated with primary ventricular malignant arrhythmia and required defibrillation along intubation and ventilatory support.,Previously documented coronary artery disease with remote angioplasty and stents in the left anterior descending artery and circumflex artery.,Acute coronary artery syndrome with ST-segment elevation in anterior wall distribution related to in-stent thrombosis of the left anterior descending artery, successfully re-canalized with angioplasty and a drug-eluting stent.  There is mild-to-moderate disease of the previously stented circumflex and clinic occlusion of the right coronary artery, well collateralized.,Right femoral arterial and venous vascular access.,RECOMMENDATION:,  Integrilin infusion is maintained until tomorrow.  He received aspirin and Plavix per nasogastric tube.  Titrated doses of beta-blockers and ACE inhibitors are initiated.  Additional revascularization therapy will be adjusted according to the clinical evaluation.","cardiovascular / pulmonary, ventricular arrhythmia, coronary artery syndrome, st segment elevation, heart catheterization, selective bilateral coronary angiography, ventriculography, catheterization, swan-ganz catheter, anterior descending artery, drug eluting stent, coronary artery, angioplasty, stent, coronary, anterior, angiography, artery, heart, "
" Left heart catheterization, left ventriculography, selective coronary angiography, and right femoral artery approach.", Cardiovascular / Pulmonary," Heart Catheterization, Ventriculography, & Angiography - 12 ","PROCEDURE: , Cardiac catheterization by:,a.  Left heart catheterization.,b.  Left ventriculography.,c.  Selective coronary angiography.,d.  Right femoral artery approach.,COMPLICATIONS:,  None.,MEDICATIONS,1.  IV Versed.,2.  IV fentanyl.,3.  Intravenous fluid administration.,4.  Heparin 3000 units IV.,INDICATIONS: , This 70-year-old Asian-American presents with chest pain syndrome, abnormal EKG suggesting an acute ST elevation, anterior myocardial infarction, being taken urgently to cardiac catheterization laboratory with possible coronary intervention.,NARRATIVE: , After detailed informed consent had been obtained.  Usual benefits, alternatives, and risks of the procedure had been discussed with the patient, she was agreeable to proceed.  The patient was prepped, draped, and anesthetized in the usual manner.  Using modified Seldinger technique a 6 French introducer sheath inserted into the right femoral artery.  Next, 6 French 3D right coronary catheter was inserted and right coronary angiogram was obtained in various projections.  Next, a 6 French JL4.0 left coronary catheter was inserted and left coronary angiogram was obtained in various projections.  Next, 4 French pigtail catheter was inserted into left ventricle under fluoroscopic guidance.  Left ventricular angiogram was performed.  Pre and post angiogram LVEDP, LV, and aortic pressures were obtained.  At the end of the procedure catheters were removed and the introducer sheath was secured.  The patient was admitted to the TCU in stable condition.,FINDINGS,HEMODYNAMICS,LEFT HEART PRESSURES:,  LVEDP of 5, left ventricular systolic pressure of 81, central aortic pressure systolic 70, diastolic 20.,LEFT VENTRICULOGRAPHY: , Left ventricular chamber size is normal.  The distal half of the anterior wall of the entire apex and the distal half of the inferior wall are completely akinetic with hypercontractility of the basilar segments of the anterior and inferior wall.  Calculated ejection fraction of 51%, which probably overestimates the overall effective ejection fraction.  No LV thrombus or mitral regurgitation present.,CORONARY ARTERIOGRAPHY,1.  ,RIGHT CORONARY ARTERY: , The RCA gives rise to a posterior descending artery and a small posterolateral branch.  Angiographically the right coronary artery is normal.,2.  ,LEFT MAIN ARTERY:,  The left main vessel is angiographically normal, bifurcates into left anterior descending artery and circumflex system.,3.  ,LEFT ANTERIOR DESCENDING ARTERY: , The LAD gives rise to a normal complement of septal branches, diagonal branches, and extends around the apex.  Angiographically the mid left anterior descending artery and distal left anterior descending artery demonstrates systolic compression of the vessel lumen, consistent with myocardial bridging.  The degree of myocardial bridging appears moderate in the mid vessel and mild in the distal segment.  Otherwise, there is no evidence of atherosclerotic obstruction.,4.  ,CIRCUMFLEX ARTERY: , The circumflex gives rise to two large extremely tortuous marginal vessels that extend towards the apex.  Angiographically, the circumflex artery is normal.,CONCLUSION: , This is a 70-year-old female with above clinical and cardiovascular history, who has angiographic evidence of a large anterior apical and inferior apical wall motion abnormality with angiographically patent coronary arteries with two segments of myocardial bridging involving the mid and distal left anterior descending artery.  These angiographic findings are consistent with Takasubo syndrome, aka apical ballooning syndrome.  The patient will be treated medically.",
" Left heart catheterization with ventriculography, selective coronary angiography.  Standard Judkins, right groin.  Catheters used were a 6 French pigtail, 6 French JL4, 6 French JR4.", Cardiovascular / Pulmonary," Heart Catheterization, Ventriculography, & Angiography - 3 ","NAME OF PROCEDURE: , Left heart catheterization with ventriculography, selective coronary angiography.,INDICATIONS: , Acute coronary syndrome.,TECHNIQUE OF PROCEDURE: , Standard Judkins, right groin.  Catheters used were a 6 French pigtail, 6 French JL4, 6 French JR4.  ,ANTICOAGULATION:  ,The patient was on heparin at the time.,COMPLICATIONS: , None.,I reviewed with the patient the pros, cons, alternatives, risks of catheterization and sedation including myocardial infarction, stroke, death, damage to nerve, artery or vein in the leg, perforation of a cardiac chamber, dissection of an artery requiring countershock, infection, bleeding, ATN allergy, need for cardiac surgery.  All questions were answered, and the patient desired to proceed.,HEMODYNAMIC DATA:  ,Aortic pressure was in the physiologic range.  No significant gradient across the aortic valve.,ANGIOGRAPHIC DATA,1. Ventriculogram:  The left ventricle is of normal size and shape, normal wall motion, normal ejection fraction.,2. Right coronary artery:  Dominant.  There was insignificant disease in the system.,3. Left coronary:  Left main, left anterior descending and circumflex systems showed no significant disease.,CONCLUSIONS,1. Normal left ventricular systolic function.,2. Insignificant coronary disease.,PLAN: , Based upon this study, medical therapy is warranted.  Six-French Angio-Seal was used in the groin.","cardiovascular / pulmonary, standard judkins, french pigtail, selective coronary angiography, heart catheterization, ventriculography, catheterization, angiography,"
 Left heart catheterization with left ventriculography and selective coronary angiography.  Percutaneous transluminal coronary angioplasty and stent placement of the right coronary artery., Cardiovascular / Pulmonary," Heart Catheterization, Ventriculography, & Angiography - 4 ","NAME OF PROCEDURE,1.  Left heart catheterization with left ventriculography and selective coronary angiography.,2.  Percutaneous transluminal coronary angioplasty and stent placement of the right coronary artery.,HISTORY: , This is a 58-year-old male who presented with atypical chest discomfort.  The patient had elevated troponins which were suggestive of a myocardial infarction.  The patient is suspected of having significant obstructive coronary artery disease, therefore he is undergoing cardiac catheterization.,PROCEDURE DETAILS: , Informed consent was given prior to the patient was brought to the catheterization laboratory.  The patient was brought to the catheterization laboratory in postabsorptive state.  The patient was prepped and draped in the usual sterile fashion, 2% Xylocaine solution was used to anesthetize the right femoral region.  Using modified Seldinger technique, a 6-French arterial sheath was placed.  Then, the patient had already been on heparin.  Then, a Judkins left 4 catheter was intubated into the left main coronary artery.  Several projections were obtained and the catheter was removed.  A 3DRC catheter was intubated into the right coronary artery.  Several projections were obtained and the catheter was removed.  Then, a 3DRC guiding catheter was intubated into the right coronary artery.  Then, a universal wire was advanced across the lesion into the distal right coronary artery.  Integrilin was given.  Then, a 3.0 x 12 Voyager balloon was inflated at 13 atmospheres for 30 seconds.  Then, a projection was obtained.  Then, a 3.0 x 15 Vision stent was placed into the distal right coronary artery.  The stent was deployed at 15 atmospheres for 25 seconds.  Post stent, the patient was given intracoronary nitroglycerin after one projection.  Then, there was an attempt to place the intervention wire across the third posterolateral branch which was partially obstructed and this was not successful.  Then, a pilot 150 wire was advanced across the lesion.  Then, attempt to place the 2.0 x 8 power saver across the lesion was performed.  However, it was felt that there was adequate flow and no further intervention needed to be performed.  Then, the stent delivery system was removed.  A pigtail catheter was placed into the left ventricle.  Hemodynamics followed by left ventriculography was performed.  Then, a pullback gradient was performed and the catheter was removed.  Then, the right femoral artery was visualized and using angiography and then an Angio-Seal was applied.  The patient was transferred back to his room in good condition.,FINDINGS,1.  Hemodynamics:  The opening aortic pressure was 116/61 with a mean of 64.  The opening left ventricular pressure was 112 with end-diastolic pressure of 23.  LV pressure on pullback was 106 with end-diastolic pressure of 21.  Aortic pressure was 111/67 with a mean of 87.  The closing pressure was 110/67.,2.  Left ventriculography:  The left ventricle was of normal cavity, size, and wall thickness.  There is a mild anterolateral hypokinesis and moderate inferior and inferoapical hypokinesis.  The overall systolic function appeared to be mildly reduced with ejection fraction between 40% and 45%.  The mitral valve had no significant prolapse or regurgitation.  The aortic valve appeared to be trileaflet and moved normally.,3.  Coronary angiography:  The left main is a normal-caliber vessel.  This bifurcates into the left anterior descending and circumflex arteries.  The left main is free of any significant obstructive coronary artery disease.  The left anterior descending is a large vessel that extends to the apex.  It gives off approximately 10 septal perforators and 5 diagonal branches.  The first diagonal branch was large.  The left anterior descending had mild irregularities, but no high-grade disease.  The left circumflex is a nondominant vessel, which gives rise to two obtuse marginal branches.  The two obtuse marginal branches are large.  There is a relatively small left atrial branch.  The left circumflex had a 50% stenosis after the first obtuse marginal branch.  The rest of the vessel is moderately irregular, but no high-grade disease.  The right coronary artery appears to be a dominant vessel, which gives rise to three right ventricular branches, four posterior lateral branches, two right atrial branches, and two small conus branches.  The right coronary artery had moderate disease in its proximal segment with multiple areas of plaquing but no high-grade disease.  However, distal between the second and third posterolateral branch, there is a 90% stenosis.  The rest of the vessels had mild irregularities, but no high-grade disease.  Then percutaneous transluminal coronary angioplasty of the right coronary artery resulted in a 20% residual stenosis.  Then, after stent placement there was 0% residual stenosis; however, there was partial occlusion of the third posterolateral branch.  Then, a wire was advanced through this and there was improvement of flow.  There is improvement from TIMI grade 2 to TIMI grade 3 flow.,CLINICAL IMPRESSION,1.  Successful percutaneous transluminal angioplasty and stent placement of the right coronary artery.,2.  Two-vessel coronary artery disease.,3.  Elevated left ventricular end-diastolic pressure.,4.  Mild anterolateral and moderate inferoapical hypokinesis.,RECOMMENDATIONS,1.  Integrilin.,2.  Bed rest.,3.  Risk factor modification.,4.  Thallium scintigraphy in approximately six weeks.","cardiovascular / pulmonary, heart catheterization, ventriculography, selective coronary angiography., angioplasty, stent placement, transluminal, percutaneous, coronary artery, coronary angiography, coronary angioplasty, diastolic pressure, obtuse marginal, percutaneous transluminal, catheterization, artery, coronary, angiography"
" Left heart catheterization with ventriculography, selective coronary arteriographies, successful stenting of the left anterior descending diagonal.", Cardiovascular / Pulmonary," Heart Catheterization, Ventriculography, & Angiography - 2 ","NAME OF PROCEDURE: , Left heart catheterization with ventriculography, selective coronary arteriographies, successful stenting of the left anterior descending diagonal.,INDICATION:,  Recurrent angina.  History of coronary disease.,TECHNICAL PROCEDURE: , Standard Judkins, right groin.,CATHETERS USED:,  6-French pigtail, 6-French JL4, 6-French JR4.,ANTICOAGULATION: , 2000 of heparin, 300 of Plavix, was begun on Integrilin.,COMPLICATIONS: , None.,STENT: , For stenting we used a 6-French left Judkins guide.  Stent was a 275 x 13 Zeta.,DESCRIPTION OF PROCEDURE: , I reviewed with the patient the pros, cons, alternatives and risks of catheterization and sedation including myocardial infarction, stroke, death, damage to nerve, artery or vein in the leg, perforation of cardiac chamber, resection of an artery, arrhythmia requiring countershock, infection, bleeding, allergy, and need for vascular surgery.  All questions were answered and the patient decided to proceed.,HEMODYNAMIC DATA: , Aortic pressure was within physiologic range.  There was no significant gradient across the aortic valve.,ANGIOGRAPHIC DATA,1.  Ventriculogram:  Left ventricle was of normal size and shape with normal wall motion, normal ejection fraction.,2.  Right coronary artery:  Dominant.  There was a lesion in the proximal portion in the 60% range, insignificant disease distally.,3.  Left coronary artery:  The left main coronary artery showed insignificant disease.  The circumflex arose, showed about 30% proximally.  Left anterior descending arose and the previously placed stent was perfectly patent.  There was a large diagonal branch which showed 90% stenosis in its proximal portion.  There was a lesion in the 30% to 40% range even more proximal.,I reviewed with the patient the options of medical therapy, intervention on the culprit versus bypass surgery.  He desired that we intervene.,Successful stenting of the left anterior descending, diagonal.  The guide was placed in the left main.  We easily crossed the lesion in the diagonal branch of the left anterior descending.  We advanced, applied and post-dilated the 275 x 13 stent.  Final angiography showed 0% residual at the site of previous 90% stenosis.  The more proximal 30% to 40% lesion was unchanged.,CONCLUSION,1.  Successful stenting of the left anterior descending/diagonal.  Initially there was 90% in the diagonal after stenting.  There was 0% residual.  There was a lesion a bit more proximal in the 40% range.,2.  Left anterior descending stent remains patent.,3.  30% in the circumflex.,4.  60% in the right coronary.,5.  Ejection fraction and wall motion are normal.,PLAN: , We have stented the culprit lesion.  The patient will receive a course of aspirin, Plavix, Integrilin, and statin therapy.  We used 6-French Angio-Seal in the groin.  All questions have been answered.  I have discussed the possibility of restenosis, need for further procedures.",
" Selective coronary angiography, left heart catheterization, and left ventriculography.  Severe stenosis at the origin of the large diagonal artery and subtotal stenosis in the mid segment of this diagonal branch.", Cardiovascular / Pulmonary," Heart Catheterization, Ventriculography, & Angiography - 11 ","NAME OF PROCEDURES,1.  Selective coronary angiography.,2.  Left heart catheterization.,3.  Left ventriculography.,PROCEDURE IN DETAIL:  ,The right groin was sterilely prepped and draped in the usual fashion.  The area of the right coronary artery was anesthetized with 2% lidocaine and a 4-French sheath was placed.  Conscious sedation was obtained using a combination of Versed 1 mg and fentanyl 50 mcg.  A left #4, 4-French, Judkins catheter was placed and advanced through the ostium of the left main coronary artery.  Because of difficulty positioning the catheter, the catheter was removed and a 6-French sheath was placed and a 6-French #4 left Judkins catheter was placed.  This was advanced through the ostium of the left main coronary artery where selective angiograms were performed.  Following this, the 4-French right Judkins catheter was placed and angiograms of the right coronary were performed.  A pigtail catheter was placed and a left heart catheterization was performed, followed by a left ventriculogram.  The left heart pullback was performed.  The catheter was removed and a small injection of contrast was given to the sheath.  The sheath was removed over a wire and an Angio-Seal was placed.  There were no complications.  Total contrast media was 200 mL of Optiray 350.  Fluoroscopy time 5.3 minutes.  Total x-ray dose is 1783 mGy.,HEMODYNAMICS:  ,Rhythm is sinus throughout the procedure.  LV pressure of 155/22 mmHg, aortic pressure of 160/80 mmHg.  LV pullback demonstrates no gradient.,The right coronary artery is a nondominant vessel and free of disease.  This also gives rise to the conus branch and two RV free wall branches.  The left main has minor plaquing in the inferior aspect measuring no more than 10% to 15%.  This vessel then bifurcates into the LAD and circumflex.  The circumflex is a large caliber vessel and is dominant.  This vessel gives rise to a large first marginal artery, a moderate sized second marginal branch, and additionally gives rise to a large third marginal artery and the PDA.  There was a very eccentric and severe stenosis in the proximal circumflex measuring approximately 90% in severity.  The origin of the first marginal artery has a severe stenosis measuring approximately 90% in severity.  The distal circumflex has a 60% lesion just prior to the origin of the third marginal branch and PDA.,The proximal LAD is ectatic.  The LAD gives rise to a large first diagonal artery that has a 90% lesion in its origin and a subtotal occlusion midway down the diagonal.  Distal to the origin of this diagonal branch, there is another area of ectasia in the LAD, followed by an area of stenosis that in some views is approximately 50% in severity.,The left ventriculogram demonstrates hypokinesis of the distal half of the inferior wall.  The overall ejection fraction is preserved.  There is moderate dilatation of the aortic root.  The calculated ejection fraction is 63%.,IMPRESSION,1.  Left ventricular dysfunction as evidenced by increased left ventricular end diastolic pressure and hypokinesis of the distal inferior wall.,2.  Coronary artery disease with high-grade and complex lesion in the proximal portion of the dominant large circumflex coronary artery.  There is subtotal stenosis at the origin of the first obtuse marginal artery.,3.  A 60% stenosis in the distal circumflex.,4.  Ectasia of the proximal left anterior descending with 50% stenosis in the mid left anterior descending.,5.  Severe stenosis at the origin of the large diagonal artery and subtotal stenosis in the mid segment of this diagonal branch.","cardiovascular / pulmonary, coronary angiography, catheterization, ventriculography, heart catheterization, coronary artery, stenosis, artery, angiography"
" Left heart catheterization, left and right coronary angiography, left ventricular angiography, and intercoronary stenting of the right coronary artery.", Cardiovascular / Pulmonary," Heart Catheterization, Ventriculography, & Angiography - 10 ","PROCEDURE: , Left heart catheterization, left and right coronary angiography, left ventricular angiography, and intercoronary stenting of the right coronary artery.,PROCEDURE IN DETAIL:  ,The patient was brought to the Catheterization Laboratory.  After informed consent, he was medicated with Versed and fentanyl.  The right groin was prepped and draped, and infiltrated with 2% Xylocaine.  Percutaneously, #6-French arterial sheath was placed.  Selective native left and right coronary angiography was performed followed by left ventricular angiography.  The patient had a totally occluded right coronary.  We initially started with a JR4 guide.  We were able to a sport wire through the total occlusion and saw a very tight stenosis.  We were able to get a 30 x 13 mm power saver balloon into the stenosis and dilated.  We then attempted to put a 30 x 12 mm stent across the stenosis, but we had very little guide support, the guide kept coming out.  We then switched to an AL1 guide and that too did not enable us to get anything to cross this lesion.  We finally had to go an AL2 guide, we were concerned that this could cause some proximal dissection.  That guided seated, we did have initial difficulty getting the wire back across the stenosis, and we did see a little staining suggesting we did have some tearing from the guide tip.  The surgeons were put on notice in case we could not get this vessel open, but we were able to re-cross with a sport wire.  We then re-dilated the area of stenosis and with good guide support, we were able to get a 30 x 23 mm Vision stent, where the lesion was and post-dilated it to 18 atmospheres.  Routine angiography did show that the distal posterolateral branch seems to be occluded, whether this was from distal wire dissection or distal thrombosis was unclear, but we were able to re-wire that area and get a 25 x12 Vision balloon and dilate the area and re-establish flow to the small segment.  We then came back because of the residual dissection proximal to the first stent and put a 30 x15 mm Vision stent at 18 atmospheres.  Final angiography showed resolution of the dissection.  We could see a little staining extrinsic to the stent.  No perforation and excellent flow.  During the intervention, we did give a bolus and drip of Angiomax.  At the end of the procedure, we stopped the Angiomax and gave 600 mg of Plavix.  We did a right femoral angiogram; however, the Angio-Seal plug could not take, so we used manual pressure and a Femostop.  We transported the patient to his room in stable condition.,ANGIOGRAPHIC DATA:,  Left main coronary is normal.  Left anterior descending artery has a fair amount of wall disease proximally about 50 to 60% stenosis of the LAD before it bifurcates into diagonal.  The diagonal does appear to have about 50% osteal stenosis.  There is a lot of plaquing further down the diagonal, but good flow.  The rest of the LAD looked good pass the proximal 60% stenosis and after the diagonal branch.  Circumflex artery was nondominant vessel, consisting of an obtuse marginal vessel.  The first obtuse marginal had a long 50% narrowing and then the AV groove branch was free of any disease.  Some mild collaterals to the right were seen.  Right coronary angiography revealed a total occlusion of the right coronary, just about 0.5 cm after its origin.  After we got a wire across the area of occlusion, we could see some thrombosis and a 99% stenosis just at the curve.  Following the balloon angioplasty, we established good flow down the distal vessel.  We still had about residual 70% stenosis.  When we had to go back with the AL2 guide, we could see a little bit of staining in the proximal portion of the vessel that we did not notice previously and we felt that the tip of the guide caused a little bit of intimal dissection.  We re-dilated and then deployed.  Repeat angiography now did show some hang up off dye distally.  We never did have the wire that far down, so this was probably felt to be due to distal embolization of some thrombus.  After deploying the stent, we had total resolution of the original lesion.  We then directed our attention to the posterolateral branch, which the remainder of the vessel was patent giving off a large PDA.  The posterolateral branch appeared to be occluded in its mid portion.  We got a wire through and dilated this.  We then came back and put a second stent in the proximal area of the right coronary proximal and abutting to the previous stent.  Repeat angiography now showed no significant dissection, a little bit of contrast getting extrinsic to the stent probably in a little subintimal pouch, but this was excluded by the stent.  There were no filling defects in the stent and excellent flow.  The distal posterolateral branch did open up, although it was little under-filled and there may have been some mild residual disease there.,IMPRESSION: , Atherosclerotic heart disease with total occlusion of right coronary, successfully stented to zero residual with repair of a small proximal dissection.  Minor distal disease of the posterolateral branch and 60% proximal left anterior descending coronary artery stenosis and 50% diagonal stenosis along with 50% stenosis of the first obtuse marginal branch.","cardiovascular / pulmonary, heart catheterization, coronary angiography, ventricular angiography, intercoronary stenting, intercoronary, coronary, stenting, stenosis, angiography"
" Left heart cath, selective coronary angiography, LV gram, right femoral arteriogram, and Mynx closure device.  Normal stress test.", Cardiovascular / Pulmonary, Heart Catheterization & Angiography - 1 ,"CLINICAL INDICATION:  ,Normal stress test.,PROCEDURES PERFORMED:,1.  Left heart cath.,2.  Selective coronary angiography.,3.  LV gram.,4.  Right femoral arteriogram.,5.  Mynx closure device.,PROCEDURE IN DETAIL: , The patient was explained about all the risks, benefits, and alternatives of this procedure.  The patient agreed to proceed and informed consent was signed.,Both groins were prepped and draped in the usual sterile fashion.  After local anesthesia with 2% lidocaine, a 6-French sheath was inserted in the right femoral artery.  Left and right coronary angiography was performed using 6-French JL4 and 6-French 3DRC catheters.  Then, LV gram was performed using 6-French pigtail catheter.  Post LV gram, LV-to-aortic gradient was obtained.  Then, the right femoral arteriogram was performed.  Then, the Mynx closure device was used for hemostasis.  There were no complications.,HEMODYNAMICS: , LVEDP was 9.  There was no LV-to-aortic gradient.,CORONARY ANGIOGRAPHY:,1.  Left main is normal.  It bifurcates into LAD and left circumflex.,2.  Proximal LAD at the origin of big diagonal, there is 50% to 60% calcified lesion present.  Rest of the LAD free of disease.,3.  Left circumflex is a large vessel and with minor plaque.,4.  Right coronary is dominant and also has proximal 40% stenosis.,SUMMARY:,1.  Nonobstructive coronary artery disease, LAD proximal at the origin of big diagonal has 50% to 60% stenosis, which is calcified.,2.  RCA has 40% proximal stenosis.,3.  Normal LV systolic function with LV ejection fraction of 60%.,PLAN: , We will treat with medical therapy.  If the patient becomes symptomatic, we will repeat stress test.  If there is ischemic event, the patient will need surgery for the LAD lesion.  For the time being, we will continue with the medical therapy.,","cardiovascular / pulmonary, selective coronary angiography, lv gram, femoral, mynx, heart cath, mynx closure device, heart catheterization, femoral arteriogram, stress test, coronary angiography, heart, arteriogram, catheterization, lad, coronary, angiography, "
" Right and left heart catheterization, left ventriculogram, aortogram, and bilateral selective coronary angiography.  The patient is a 48-year-old female with severe mitral stenosis diagnosed by echocardiography, moderate aortic insufficiency and moderate to severe pulmonary hypertension who is being evaluated as a part of a preoperative workup for mitral and possible aortic valve repair or replacement. ", Cardiovascular / Pulmonary, Heart Catheterization & Ventriculogram ,"PROCEDURE PERFORMED:,1.  Right heart catheterization.,2.  Left heart catheterization.,3.  Left ventriculogram.,4.  Aortogram.,5.  Bilateral selective coronary angiography.,ANESTHESIA:,  1% lidocaine and IV sedation including Versed 1 mg.,INDICATION:,  The patient is a 48-year-old female with severe mitral stenosis diagnosed by echocardiography, moderate aortic insufficiency and moderate to severe pulmonary hypertension who is being evaluated as a part of a preoperative workup for mitral and possible aortic valve repair or replacement.  She has had atrial fibrillation and previous episodes of congestive heart failure.  She has dyspnea on exertion and occasionally orthopnea and paroxysmal nocturnal dyspnea.,PROCEDURE:,  After the risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient in detail, informed consent was obtained, both verbally and in writing.  The patient was taken to the Cardiac Catheterization Lab where the procedure was performed.  The right inguinal area was thoroughly cleansed with Betadine solution and the patient was draped in the usual manner.  1% lidocaine solution was used to anesthetize the right inguinal area.  Once adequate anesthesia had been attained, a thing wall Argon needle was used to cannulate the right femoral vein.  A guidewire was advanced into the lumen of the vein without resistance.  The needle was removed and the guidewire was secured to the sterile field.  The needle was flushed and then used to cannulate the right femoral artery.  A guidewire was advanced through the lumen of the needle without resistance.  A small nick was made in the skin and the needle was removed.  This pressure was held.  A #6 French arterial sheath was advanced over the guidewire without resistance.  The dilator and guidewire were removed.  FiO2 sample was obtained and the sheath was flushed.  An #8 French sheath was advanced over the guidewire into the femoral vein after which the dilator and guidewire were removed and the sheath was flushed.  A Swan-Ganz catheter was advanced through the venous sheath into a pulmonary capillary was positioned and the balloon was temporarily deflated.  An angulated pigtail catheter was advanced into the left ventricle under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to a manifold and flushed.  Left ventricular pressures were continuously measured and the balloon was re-inflated and pulmonary capillary wedge pressure was remeasured.  Using dual transducers together and the mitral valve radius was estimated.  The balloon was deflated and mixed venous sample was obtained.  Hemodynamics were measured.  The catheter was pulled back in to the pulmonary artery right ventricle and right atrium.  The right atrial sample was obtained and was negative for shunt.  The Swan-Ganz catheter was then removed and a left ventriculogram was performed in the RAO projection with a single power injection of non-ionic contrast material.  Pullback was then performed which revealed a minimal LV-AO gradient.  Since the patient had aortic insufficiency on her echocardiogram, an aortogram was performed in the LAO projection with a single power injection of non-ionic contrast material.  The pigtail catheter was then removed and a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  The ostium of the left main coronary artery was carefully engaged.  Using multiple hand injections of non-ionic contrast material, the left coronary system was evaluated in different views.  This catheter was then removed and a Judkins right #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  The ostium of the right coronary artery was then engaged and using hand injections of non-ionic contrast material, the right coronary system was evaluated in different views.  This catheter was removed.  The sheaths were flushed final time.  The patient was taken to the Postcatheterization Holding Area in stable condition.,FINDINGS:,HEMODYNAMICS: , Right atrial pressure 9 mmHg, right ventricular pressure is 53/14 mmHg, pulmonary artery pressure 62/33 mmHg with a mean of 46 mmHg.  Pulmonary capillary wedge pressure is 29 mmHg.  Left ventricular end diastolic pressure was 13 mmHg both pre and post left ventriculogram.  Cardiac index was 2.4 liters per minute/m2.  Cardiac output 4.0 liters per minute.  The mitral valve gradient was 24.5 and mitral valve area was calculated to be 0.67 cm2.  The aortic valve area is calculated to be 2.08 cm2.,LEFT VENTRICULOGRAM: , No segmental wall motion abnormalities were noted.  The left ventricle was somewhat hyperdynamic with an ejection fraction of 70%.  2+ to 3+ mitral regurgitation was noted.,AORTOGRAM: , There was 2+ to 3+ aortic insufficiency noted.  There was no evidence of aortic aneurysm or dissection.,LEFT MAIN CORONARY ARTERY: , This was a moderate caliber vessel and it is rather long.  It bifurcates into the LAD and left circumflex coronary artery.  No angiographically significant stenosis is noted.,LEFT ANTERIOR DESCENDING ARTERY:,  The LAD begins as a moderate caliber vessel ________ anteriorly in the intraventricular groove.  It tapers in its mid portion to become small caliber vessel.  Luminal irregularities are present, however, no angiographically significant stenosis is noted.,LEFT CIRCUMFLEX CORONARY ARTERY: , The left circumflex coronary artery begins as a moderate caliber vessel.  Small obtuse marginal branches are noted and this is the nondominant system.  Lumen irregularities are present throughout the circumflex system.  However no angiographically significant stenosis is noted.,RIGHT CORONARY ARTERY: , This is the moderate caliber vessel and it is the dominant system.  No angiographically significant stenosis is noted, however, mild luminal irregularities are noted throughout the vessel.,IMPRESSION:,1.  Nonobstructive coronary artery disease.,2.  Severe mitral stenosis.,3.  2+ to 3+ mitral regurgitation.,4.  2+ to 3+ aortic insufficiency.",
" Left heart catheterization, bilateral selective coronary angiography, saphenous vein graft angiography, left internal mammary artery angiography, and left ventriculography.", Cardiovascular / Pulmonary," Heart Catheterization, Ventriculography, & Angiography ","PROCEDURES PERFORMED:,1.  Left heart catheterization.,2.  Bilateral selective coronary angiography.,3.  Saphenous vein graft angiography.,4.  Left internal mammary artery angiography.,5.  Left ventriculography.,INDICATIONS: , Persistent chest pain on maximum medical therapy with known history of coronary artery disease, status post coronary artery bypass grafting in year 2000.,PROCEDURE: , After the risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient in detail, an informed consent was obtained both verbally and in writing.  The patient was taken to the Cardiac Catheterization Suite where the right femoral region was prepped and draped in the usual sterile fashion.  1% lidocaine solution was then used to infiltrate the skin overlying the right femoral artery.  Once adequate anesthesia had been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right femoral artery.  A steel guidewire was then inserted through the needle into the vascular lumen without resistance.  A small nick was then made in the skin and its pressure was held.  The needle was removed over the guidewire.  A #6 French sheath was then advanced over the guidewire into the vascular lumen without resistance.  The guidewire and dilator were then removed.  The sheath was then flushed.  Next, angulated pigtail catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of the guidewire.  The catheter was then advanced into the left ventricle.  The guidewire was then removed.  The catheter was connected to the manifold and flushed.  LVEDP was then measured and found to be favorable for a left ventriculogram.  The left ventriculogram was performed in the RAO position with a single power injection of non-ionic contrast material.  LVEDP was then remeasured.  Pullback was then performed, which failed to reveal an LVAO gradient.  The catheter was then removed.  Next, a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  Using hand injections of non-ionic contrast material, the left coronary system was evaluated in several different views.  Once adequate study has been performed, the catheter was removed.  Next, a Judkins right #4 catheter was then advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  The ostium of the saphenous vein graft was engaged using hand injections of non-ionic contrast material.  The saphenous vein graft was visualized in several different views.  The Judkins right catheter was then advanced and the native coronary artery was engaged using hand injections of non-ionic contrast material.  Right coronary system was evaluated in several different views.  Once adequate study has been performed, the catheter was retracted.  We were unable to engage the left subclavian artery thus the catheter was removed over an exchange wire.  Next, a multipurpose catheter was advanced over the exchange wire.  The wire was then easily passed into the left subclavian artery.  The multipurpose catheter was then removed.  LIMA catheter was then exchanged over the wire into the left subclavian artery.  The guidewire was removed and the catheter was connected to the manifold and flushed.  LIMA graft was then engaged using hand injections of non-ionic contrast material.  The LIMA graft was evaluated in several different views.  Once adequate study has been performed, the LIMA catheter was retracted under fluoroscopic guidance.  The sheath was flushed for the final time.  The patient was returned to the cardiac catheterization holding area in stable and satisfactory condition.,FINDINGS:,LEFT VENTRICULOGRAM: , There is no evidence of any wall motion abnormalities with an estimated ejection fraction of 60%.  Left ventricular end-diastolic pressure was 24 mmHg preinjection and 26 mmHg postinjection.  There is no mitral regurgitation.  There is no LVAO or pullback.,LEFT MAIN CORONARY ARTERY: , The left main is a moderate caliber vessel, which bifurcates into the left anterior descending and circumflex arteries.  There is no evidence of any hemodynamically significant stenosis.,LEFT ANTERIOR DESCENDING ARTERY: , The LAD is a small caliber vessel, which traverses through the intraventricular groove and wraps around the apex of the heart.  There are luminal irregularities from the mid to distal portion.  There is noted to be antegrade flow in the LIMA to LAD graft.  There are very small diagonal branches, which are diffusely diseased.,CIRCUMFLEX ARTERY: , The circumflex is a small caliber vessel, which traverses through the atrioventricular groove.  There are minor luminal irregularities throughout.  There are very small obtuse marginal branches, which are diffusely diseased.,RIGHT CORONARY ARTERY:,  The RCA is a small vessel with luminal irregularities throughout.  The RCA is the dominant coronary artery.,Left internal mammary artery graft to the left anterior descending artery failed to demonstrate any hemodynamically significant stenosis.  Saphenous vein graft to the obtuse marginal branches is a Y-graft, which bifurcates to the first obtuse marginal and the obtuse marginal branch.  The saphenous vein graft to the obtuse marginal branches is widely patent without any evidence of hemodynamically significant disease.,IMPRESSION:,1.  Diffusely diseased native vessels.,2.  Saphenous vein graft to the obtuse marginal branch is widely patent.,3.  Left internal mammary artery graft to the left anterior descending artery is patent.,4.  Normal left ventricular function with ejection fraction of 60%.,5.  Mildly elevated left-sided filling pressures.,PLAN:,1.  The patient is to continue on her current medical regimen, which includes beta-blocker, aspirin, statin, and Plavix.  The patient is unable to tolerate a long-acting nitrate, thus this will be discontinued.,2.  We will add Norvasc 5 mg daily as well as hydrochlorothiazide 25 mg daily.,3.  Risk factor modification was discussed with the patient including diet control as well as tobacco cessation.,4.  The patient will need to be monitored closely for close lipid control as well as blood pressure control.",
 Left heart catheterization and bilateral selective coronary angiography. Left ventriculogram was not performed., Cardiovascular / Pulmonary, Heart Catheterization & Angiography - 2 ,"PROCEDURES PERFORMED:,1.  Left heart catheterization.,2.  Bilateral selective coronary angiography.,3.  Left ventriculogram was not performed.,INDICATION: , Non-ST elevation MI.,PROCEDURE: , After risks, benefits, and alternatives of the above-mentioned procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing.  The patient was taken to cardiac catheterization suite where the right femoral region was prepped and draped in the usual sterile fashion.  1% lidocaine solution was used to infiltrate the skin overlying the right femoral artery.  Once adequate anesthesia had been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right femoral artery.  A steel guidewire was inserted through the needle into the vascular lumen without resistance.  A small nick was then made in the skin.  The pressure was held.  The needle was removed over the guidewire.  Next, a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  The ostium of the left main coronary artery was engaged.  Using hand injections of nonionic contrast material, the left coronary system was evaluated in several different views.  Once an adequate study had been performed, the catheter was removed from the ostium of the left main coronary artery and a steel guidewire was inserted through the catheter.  The catheter was then removed over the guidewire.,Next, a Judkins right #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to manifold and flushed.  The catheter did slip into the left ventricle.  During the rotation, the LVEDP was then measured.  The ostium of the right coronary artery was then engaged.  Using hand injections of nonionic contrast material, the right coronary system was evaluated in several different views.  Once adequate study has been performed, the catheter was then removed.  The sheath was lastly flushed for the final time.,FINDINGS:,LEFT MAIN CORONARY ARTERY: , The left main coronary artery is a moderate caliber vessel, which bifurcates into the left anterior descending and circumflex arteries.  There is no evidence of any hemodynamically significant stenosis.,LEFT ANTERIOR DESCENDING ARTERY: , The LAD is a moderate caliber vessel, which is subtotaled in its mid portion for approximately 1.5 cm to 1 cm with subsequent TIMI-I flow distally.  The distal portion was diffusely diseased.  The proximal portion otherwise shows minor luminal irregularities.  The first diagonal branch demonstrated minor luminal irregularities throughout.,CIRCUMFLEX ARTERY:  ,The circumflex is a moderate caliber vessel, which traverses through the atrioventricular groove.  There is a 60% proximal lesion and a 90% mid lesion prior to the takeoff of the first obtuse marginal branch.  The first obtuse marginal branch demonstrates minor luminal irregularities throughout.,RIGHT CORONARY ARTERY: , The RCA is a moderate caliber vessel, which demonstrates a 90% mid stenotic lesion.  The dominant coronary artery gives off the posterior descending artery and posterolateral artery.  The left ventricular end-diastolic pressure was approximately 22 mmHg.  It should be noted that during injection of the contrast agent that there was ST elevation in the inferior leads, which resolved after the injection was complete.,IMPRESSION:,1.  Three-vessel coronary artery disease involving a subtotaled left anterior descending artery with TIMI-I flow distally and 90% circumflex lesion and 90% right coronary artery lesion.,2.  Mildly elevated left-sided filling pressures.,PLAN:,1.  The patient will be transferred to Providence Hospital today for likely PCI of the mid LAD lesion with a surgical evaluation for a coronary artery bypass grafting.  These findings and plan were discussed in detail with the patient and the patient's family.  The patient is agreeable.,2.  The patient will be continued on aggressive medical therapy including beta-blocker, aspirin, ACE inhibitor, and statin therapy.  The patient will not be placed on Plavix secondary to the possibility for coronary bypass grafting.  In light of the patient's history of cranial aneurysmal bleed, the patient will be held off of Lovenox and Integrilin.","cardiovascular / pulmonary, non-st elevation, coronary angiography, ventriculogram, heart catheterization, bypass grafting, catheterization, coronary, artery, angiography, luminal, branch, descending, circumflex, vessel, guidewire, "
" Left heart catheterization, left ventriculography, coronary angiography, and successful stenting of tight lesion in the distal circumflex and moderately tight lesion in the mid right coronary artery.", Cardiovascular / Pulmonary," Heart Catheterization, Ventriculography, & Angiography - 1 ","PROCEDURE:,  Left heart catheterization, left ventriculography, coronary angiography, and successful stenting of tight lesion in the distal circumflex and moderately tight lesion in the mid right coronary artery.  This gentleman has had a non-Q-wave, troponin-positive myocardial infarction, complicated by ventricular fibrillation.,PROCEDURE DETAILS:,  The patient was brought to the catheterization lab, the chart was reviewed, and informed consent was obtained.  Right groin was prepped and draped sterilely and infiltrated 2% Xylocaine.  Using the Seldinger technique, a #6-French sheath was placed in the right femoral artery.  ACT was checked and was low.  Additional heparin was given.  A #6-French pigtail catheter was passed.  Left ventriculography was performed.  The catheter was exchanged for a #6-French JL4 catheter.  Nitroglycerin was given in the left main.  Left coronary angiography was performed.  The catheter was exchanged for a #6-French __________ coronary catheter.  Nitroglycerin was given in the right main, and right coronary angiography was performed.  Films were closely reviewed, and it was felt that he had a significant lesion in the RCA and the distal left circumflex is basically an OM.  Considering his age and his course, it was elected to stent both these lesions.  ReoPro was started, and the catheter was exchanged for a #6-French JR4 guide.  ReoPro was given in the RCA to prevent no reflow.  A 0.014 Universal wire was passed.  The lesion was measured.  A 4.5 x 18-mm stent was passed and deployed to moderate pressures with an excellent result.  The catheter was removed and exchanged for a #6-French JL4 guide.  The same wire was passed down the circumflex and the lesion measured.  A 2.75 x 15-mm stent was deployed to a moderate pressure with an excellent result.  Plavix was given.  The catheter was removed and sheath was in place.  The results were explained to the patient and his wife.,FINDINGS,1.  Hemodynamics.  Please  see attached sheet for details.  ED was 20.  There is no gradient across the aortic valve.,2.  Left ventriculography revealed septum upper limits of normal size with borderline normal LV systolic function with borderline normal wall motion, in which there is a question of  diffuse, very minimal global hypokinesis.  There is mild MR noted.,3.  Coronary angiography.,a.  Left main normal.,b.  LAD.  Some very minimal luminal irregularities.  There is a 1st diagonal which has a branch that is 1.5 mm with a proximal 50% narrowing.,c.  Left circumflex is basically a marginal branch, in which distally there was a long 98% lesion.,d.  The RCA is large dominant and has a mid somewhat long 70% lesion.,4.  Stenting.,a.  The RCA revealed a lesion that went from 70% to a -5%.,B.  The circumflex went from 95% to -5%.,CONCLUSION,1.  Decreased left ventricular compliance.,2.  Borderline normal overall ejection fraction with mild mitral regurgitation.,3.  Triple-vessel coronary artery disease with a borderline lesion in a very small branch of the 1st diagonal and significant lesions in the mid dominant right coronary artery and the distal circumflex, which is basically old.,4.  Successful stenting of the right coronary artery and the circumflex.,RECOMMENDATION: , ReoPro/stent protocol, Plavix for at least 9 months, aggressive control of risk factors.  I have ordered Zocor and a fasting lipid panel.,AICD will be considered, realizing when this gentleman becomes ischemic he is at high risk for fibrillating.","cardiovascular / pulmonary, heart catheterization, ventriculography, coronary angiography, stenting, distal circumflex, coronary artery, coronary, lesion, catheterization, cardiac, angiography, heart, rca, artery, circumflex, "
 Right heart catheterization.   Refractory CHF to maximum medical therapy., Cardiovascular / Pulmonary, Heart Catheterization - 2 ,"PROCEDURE PERFORMED:,  Right heart catheterization.,INDICATION: , Refractory CHF to maximum medical therapy.,PROCEDURE: , After risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient and the patient's family in detail, informed consent was obtained both verbally and in writing.  The patient was taken to Cardiac Catheterization Suite where the right internal jugular region was prepped and draped in the usual sterile fashion.  1% lidocaine solution was used to infiltrate the skin overlying the right internal jugular vein.  Once adequate anesthesia has been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right internal jugular vein.  A steel guidewire was then inserted through the needle into the vessel without resistance.  Small nick was then made in the skin and the needle was removed.  An #8.5 French venous sheath was then advanced over the guidewire into the vascular lumen without resistance.  The guidewire and dilator were then removed.  The sheath was then flushed.  A Swan-Ganz catheter was inserted to 20 cm and the balloon was inflated.  Under fluoroscopic guidance, the catheter was advanced into the right atrium through the right ventricle and into the pulmonary artery wedge position.  Hemodynamics were measured along the way.  Pulmonary artery saturation was obtained.  The Swan was then kept in place for the patient to be transferred to the ICU for further medical titration.  The patient tolerated the procedure well.  The patient returned to the cardiac catheterization holding area in stable and satisfactory condition.,FINDINGS:,  Body surface area equals 2.04, hemoglobin equals 9.3, O2 is at 2 liters nasal cannula.  Pulmonary artery saturation equals 37.8.  Pulse oximetry on 2 liters nasal cannula equals 93%.  Right atrial pressure is 8, right ventricular pressure equals 59/9, pulmonary artery pressure equals 61/31 with mean of 43, pulmonary artery wedge pressure equals 21, cardiac output equals 3.3 by the Fick method, cardiac index is 1.6 by the Fick method, systemic vascular resistance equals 1821, and transpulmonic gradient equals 22.,IMPRESSION:  ,Exam and Swan findings consistent with low perfusion given that the mixed venous O2 is only 38% on current medical therapy as well as elevated right-sided filling pressures and a high systemic vascular resistance.,PLAN: , Given that the patient is unable to tolerate vasodilator therapy secondary to significant orthostasis and the fact that the patient will not respond to oral titration at this point due to lack of cardiac reserve, the patient will need to be discharged home on Primacor.  The patient is unable to continue with his dobutamine therapy secondary to nonsustained ventricular tachycardia.  At this time, we will transfer the patient to the Intensive Care Unit for titration of the Primacor therapy.  We will also increase his Lasix to 80 mg IV q.d.  We will increase his amiodarone to 400 mg daily.  We will also continue with his Coumadin therapy.  As stated previously, we will discontinue vasodilator therapy starting with the Isordil.","cardiovascular / pulmonary, chf, cardiac, catheterization, swan-ganz, heart catheterization, internal jugular, pulmonary artery, heart, jugular, cannulate, vascular, needle, pulmonary, therapy"
 Left heart catheterization and bilateral selective coronary angiography.   The patient is a 65-year-old male with known moderate mitral regurgitation with partial flail of the P2 and P3 gallops who underwent outpatient evaluation for increasingly severed decreased functional capacity and retrosternal chest pain that was aggravated by exertion and decreased with rest., Cardiovascular / Pulmonary, Heart Cath & Coronary Angiography ,"PROCEDURE PERFORMED:,1.  Left heart catheterization.,2.  Bilateral selective coronary angiography.,ANESTHESIA: , 1% lidocaine and IV sedation, including fentanyl 25 mcg.,INDICATION: , The patient is a 65-year-old male with known moderate mitral regurgitation with partial flail of the P2 and P3 gallops who underwent outpatient evaluation for increasingly severed decreased functional capacity and retrosternal chest pain that was aggravated by exertion and decreased with rest.  It was accompanied by diaphoresis and shortness of breath.  The patient was felt to be a candidate for mitral valve repair versus mitral valve replacement and underwent a stress test as part of his evaluation for chest pain.  He underwent adenosine Cardiolite, which revealed 2 mm ST segment depression in leads II, III aVF, and V3, V4, and V5.  Stress images revealed left ventricular dilatations suggestive of multivessel disease.  He is undergoing evaluation today as a part of preoperative evaluation and because of the positive stress test.,PROCEDURE: , After risks, benefits, alternatives of the above mentioned procedure were explained to the patient in detail, informed consent was obtained both verbally and writing.  The patient was taken to the Cardiac Catheterization Laboratory where the procedure was performed.  The right inguinal area was sterilely cleansed with a Betadine solution and the patient was draped in the usual manner.  1% lidocaine solution was used to anesthetize the right inguinal area.  Once adequate anesthesia had been obtained, a thin-walled Argon needle was used to cannulate the right femoral artery.,The guidewire was then advanced through the lumen of the needle without resistance and a small nick was made in the skin.  The needle was removed and a pressure was held.  A #6 French arterial sheath was advanced over the guidewire without resistance.  The dilator and guidewire were removed and the sheath was flushed.  A Judkins left #4 catheter was advanced to the ascending aorta under direct fluoroscopic visualization with the use of the guidewire.  The guidewire was removed and the catheter was connected to the manifold and flushed.  The ostium of the left main coronary artery was carefully engaged and limited evaluation was performed after noticing that the patient had a significant left main coronary artery stenosis.  The catheter was withdrawn from the ostium of the left main coronary artery and the guidewire was inserted through the tip of the catheter.  The catheter was removed over guidewire and a Judkins right #4 catheter was advanced to the ascending aorta under direct fluoroscopic visualization with use of a guidewire.  The guidewire was removed and the catheter was connected to the manifold and flushed.  The ostium of the right coronary artery was carefully engaged and using hand injections of nonionic contrast material, the right coronary artery was evaluated in both diagonal views.  This catheter was removed.  The sheath was flushed the final time.  The patient was taken to the postcatheterization holding area in stable condition.,FINDINGS:,LEFT MAIN CORONARY ARTERY:,  This vessel is seen to be heavily calcified throughout its course.  Begins as a moderate caliber vessel.  There is a 60% stenosis in the distal portion with extension of the lesion to the ostium and proximal portions of the left anterior descending and left circumflex coronary artery.,LEFT ANTERIOR DESCENDING CORONARY ARTERY:,  This vessel is heavily calcified in its proximal portion.  It is of moderate caliber and seen post anteriorly in the intraventricular groove and wraps around the apex.  There is a 90% stenosis in the proximal portion and 90% ostial stenosis in the first and second anterolateral branches.  There is sequential 80% and 90% stenosis in the mid-portion of the vessel.  Otherwise, the LAD is seen to be diffusely diseased.,LEFT CIRCUMFLEX CORONARY ARTERY:  ,This vessel is also calcified in its proximal portion.  There is a greater than 90% ostial stenosis, which appears to be an extension of the lesion in the left main coronary artery.  There is a greater than 70% stenosis in the proximal portion of the first large obtuse marginal branch, otherwise, the circumflex system is seen to be diffusely diseased.,RIGHT CORONARY ARTERY: , This is a large caliber vessel and is the dominant system.  There is diffuse luminal irregularities throughout the vessel and a 80% to 90% stenosis at the bifurcation above the posterior descending artery and posterolateral branch.,IMPRESSION:,1.  Three-vessel coronary artery disease as described above.,2.  Moderate mitral regurgitation per TEE.,3.  Status post venous vein stripping of the left lower extremity and varicosities in both lower extremities.,4.  Long-standing history of phlebitis.,PLAN: , Consultation will be obtained with Cardiovascular and Thoracic Surgery for CABG and mitral valve repair versus replacement.","cardiovascular / pulmonary, left heart catheterization, bilateral selective coronary angiography, regurgitation, gallops, diaphoresis, shortness of breath, coronary angiography, proximal portions, catheterization, artery, coronary, bilateral, selective, angiography, mitral, stenosis, vessel, guidewire, "
 A female for a complete physical and follow up on asthma with allergic rhinitis., Cardiovascular / Pulmonary, Followup on Asthma ,"SUBJECTIVE: , This is a 42-year-old white female who comes in today for a complete physical and follow up on asthma.  She says her asthma has been worse over the last three months.  She has been using her inhaler daily.  Her allergies seem to be a little bit worse as well.  Her husband has been hauling corn and this seems to aggravate things.  She has not been taking Allegra daily but when she does take it, it seems to help somewhat.  She has not been taking her Flonase which has helped her in the past.  She also notes that in the past she was on Advair but she got some vaginal irritation with that.,She had been noticing increasing symptoms of irritability and PMS around her menstrual cycle.  She has been more impatient around that time.  Says otherwise her mood is normal during the rest of the month.  It usually is worse the week before her cycle and improves the day her menstrual cycle starts.  Menses have been regular but somewhat shorter than in the past.  Occasionally she will get some spotting after her cycles.  She denies any hot flashes or night sweats with this.  In reviewing the chart it is noted that she did have 3+ blood with what appeared to be a urinary tract infection previously.  Her urine has not been rechecked.  She recently had lab work and cholesterol drawn for a life insurance application and is going to send me those results when available.,REVIEW OF SYSTEMS: , As above.  No fevers, no headaches, no shortness of breath currently.  No chest pain or tightness.  No abdominal pain, no heartburn, no constipation, diarrhea or dysuria.  Occasional stress incontinence.  No muscle or joint pain.  No concerns about her skin.  No polyphagia, polydipsia or polyuria.,PAST MEDICAL HISTORY: , Significant for asthma, allergic rhinitis and cervical dysplasia.,SOCIAL HISTORY: , She is married.  She is a nonsmoker.,MEDICATIONS: , Proventil and Allegra.,ALLERGIES: , Sulfa.,OBJECTIVE:,Vital signs:  Her weight is 151 pounds.  Blood pressure is 110/60.  Pulse is 72.  Temperature is 97.1 degrees.  Respirations are 20.,General:  This is a well-developed, well-nourished 42-year-old white female, alert and oriented in no acute distress.  Affect is appropriate and is pleasant.,HEENT:  Normocephalic, atraumatic.  Tympanic membranes are clear.  Conjunctivae are clear.  Pupils are equal, round and reactive to light.  Nares without turbinate edema.  Oropharynx is nonerythematous.,Neck:  Supple without lymphadenopathy, thyromegaly, carotid bruit or JVD.,Chest:  Clear to auscultation bilaterally.,Cardiovascular:  Regular rate and rhythm without murmur.,Abdomen:  Soft, nontender, nondistended.  Normoactive bowel sounds.  No masses or organomegaly to palpation.,Extremities:  Without cyanosis or edema.,Skin:  Without abnormalities.,Breasts:  Normal symmetrical breasts without dimpling or retraction.  No nipple discharge.  No masses or lesions to palpation.  No axillary masses or lymphadenopathy.,Genitourinary:  Normal external genitalia.  The walls of the vaginal vault are visualized with normal pink rugae with no lesions noted.  Cervix is visualized without lesion.  She has a moderate amount of thick white/yellow vaginal discharge in the vaginal vault.  No cervical motion tenderness.  No adnexal tenderness or fullness.,ASSESSMENT/PLAN:,1.  Asthma.  Seems to be worse than in the past.  She is just using her Proventil inhaler but is using it daily.  We will add Flovent 44 mcg two puffs p.o. b.i.d.  May need to increase the dose.  She did get some vaginal irritation with Advair in the past but she is willing to retry that if it is necessary.  May also need to consider Singulair.  She is to call me if she is not improving.  If her shortness of breath worsens she is to call me or go into the emergency department.  We will plan on following up for reevaluation in one month.,2.  Allergic rhinitis.  We will plan on restarting Allegra and Flonase daily for the time being.,3.  Premenstrual dysphoric disorder.  She may have some perimenopausal symptoms.  We will start her on fluoxetine 20 mg one tablet p.o. q.d.,4.  Hematuria.  Likely this is secondary to urinary tract infection but we will repeat a UA to document clearing.  She does have some frequent dysuria but is not having it currently.,5.  Cervical dysplasia.  Pap smear is taken.  We will notify the patient of results.  If normal we will go back to yearly Pap smear.  She is scheduled for screening mammogram and instructed on monthly self-breast exam techniques.  Recommend she get 1200 mg of calcium and 400 U of vitamin D a day.",
" Left and right heart catheterization and selective coronary angiography.  Coronary artery disease, severe aortic stenosis by echo.", Cardiovascular / Pulmonary, Heart Catheterization & Angiography ,"INDICATION:,  Coronary artery disease, severe aortic stenosis by echo.,PROCEDURE PERFORMED:,1.  Left heart catheterization.,2.  Right heart catheterization.,3.  Selective coronary angiography.,PROCEDURE: , The patient was explained about all the risks, benefits and alternatives to the procedure.  The patient agreed to proceed and informed consent was signed.,Both groins were prepped and draped in usual sterile fashion.  After local anesthesia with 2% lidocaine, 6-French sheath was inserted in the right femoral artery and 7-French sheath was inserted in the right femoral vein.  Then right heart cath was performed using 7-French Swan-Ganz catheter.  Catheter was placed in the pulmonary capillary wedge position.  Pulmonary capillary wedge pressure, PA pressure was obtained, cardiac output was obtained, then RV, RA pressures were obtained.  The right heart catheter _______ pulled out.  Then selective coronary angiography was performed using 6-French JL4 and 6-French 3DRC catheter.  Then attempt was made to cross the aortic valve with 6-French pigtail catheter, but it was unsuccessful.  After the procedure, catheters were pulled out, sheath was pulled out and hemostasis was obtained by manual pressure.  The patient tolerated the procedure well.  There were no complications.,HEMODYNAMICS:,1.  Cardiac output was 4.9 per liter per minute.  Pulmonary capillary wedge pressure, mean was 7, PA pressure was 20/14, RV 26/5, RA mean pressure was 5.,2.  Coronary angiography, left main is calcified _______ dense complex.,3.  LAD proximal 70% calcified stenosis present and patent stent to the mid LAD and diagonal 1 is a moderate-size vessel, has 70% stenosis.  Left circumflex has diffuse luminal irregularities.  OM1 has 70% stenosis, is a moderate-size vessel.  Right coronary is dominant and has minimal luminal irregularities.,SUMMARY: , Three-vessel coronary artery disease with aortic stenosis by echo with normal pulmonary artery systolic pressure.,RECOMMENDATION: , Aortic valve replacement with coronary artery bypass surgery.","cardiovascular / pulmonary, lad proximal, femoral artery, sheath, catheter, selective coronary angiography, coronary artery disease, pulmonary capillary wedge, capillary wedge, coronary angiography, coronary artery, heart catheterization, catheterization, heart, artery, stenosis, angiography, pressure, coronary"
" Fogarty thrombectomy, left forearm arteriovenous Gore-Tex bridge fistula and revision of distal anastomosis with 7 mm interposition Gore-Tex graft.  Chronic renal failure and thrombosed left forearm arteriovenous Gore-Tex bridge fistula.", Cardiovascular / Pulmonary, Fogarty Thrombectomy ,"PREOPERATIVE DIAGNOSES:,1.  Chronic renal failure.,2.  Thrombosed left forearm arteriovenous Gore-Tex bridge fistula.,POSTOPERATIVE DIAGNOSIS:,1.  Chronic renal failure.,2.  Thrombosed left forearm arteriovenous Gore-Tex bridge fistula.,PROCEDURE PERFORMED:,1.  Fogarty thrombectomy, left forearm arteriovenous Gore-Tex bridge fistula.,2.  Revision of distal anastomosis with 7 mm interposition Gore-Tex graft.,ANESTHESIA:,  General with controlled ventillation.,GROSS FINDINGS: , The patient is a 58-year-old black male with chronic renal failure.  He undergoes dialysis through the left forearm bridge fistula and has small pseudoaneurysms at the needle puncture sites level.  There is narrowing at the distal anastomosis due to intimal hypoplasia and the vein beyond it was of good quality.,OPERATIVE PROCEDURE: , The patient was taken to the OR suite, placed in supine position.  General anesthetic was administered.  Left arm was prepped and draped in appropriate manner.  A Pfannenstiel skin incision was created just below the antecubital crease just deeper to the subcutaneous tissue.  Utilizing both blunt and sharp dissections segment of the fistula was isolated ________ vessel loop.  Transverse graftotomy was created.  A #4 Fogarty catheter passed proximally and distally restoring inflow and meager inflow.  A fistulogram was performed and the above findings were noted.  In a retrograde fashion, the proximal anastomosis was patent.  There was no narrowing within the forearm graft.  Both veins were flushed with heparinized saline and controlled with a vascular clamp.  A longitudinal incision was then created in the upper arm just deep into the subcutaneous tissue fascia.  Utilizing both blunt and sharp dissection, the brachial vein as well as distal anastomosis was isolated.  The distal anastomosis amputated off the fistula and oversewn with continuous running #6-0 Prolene suture tied upon itself.  The vein was controlled with vascular clamps.  Longitudinal venotomy created along the anteromedial wall.  A 7 mm graft was brought on to the field and this was cut to shape and size.  This was sewed to the graft in an end-to-side fashion with U-clips anchoring the graft at the heel and toe with interrupted #6-0 Prolene sutures.  Good backflow bleeding was confirmed.  The vein flushed with heparinized saline and graft was controlled with vascular clamp.  The end of the insertion graft was cut to shape in length and sutured to the graft in an end-to-end fashion with continuous running #6-0 Prolene suture.  Good backflow bleeding was confirmed.  The graftotomy was then closed with interrupted #6-0 Prolene suture.  Flow through the fistula was permitted, a good flow passed.  The wound was copiously irrigated with antibiotic solution.  Sponge, needles, instrument counts were correct.  All surgical sites were inspected.  Good hemostasis was noted.  The incision was closed in layers with absorbable sutures.  Sterile dressing was applied.  The patient tolerated the procedure well and returned to the recovery room in apparent stable condition.","cardiovascular / pulmonary, chronic renal failure, thrombosed, gore-tex bridge fistula, arteriovenous, fogarty, thrombectomy, anastomosis, gore tex bridge, fogarty thrombectomy, prolene suture, renal failure, distal anastomosis, bridge fistula, interposition, renal, prolene"
 H&P for a female with Angina pectoris., Cardiovascular / Pulmonary, H&P - Cardio (Angina) ,"CHIEF COMPLAINT (1/1):, This 62 year old female presents today for evaluation of angina.,Associated signs and symptoms: Associated signs and symptoms include chest pain, nausea, pain radiating to the arm and pain radiating to the jaw.,Context: The patient has had no previous treatments for this condition.,Duration: Condition has existed for 5 hours.,Quality: Quality of the pain is described by the patient as crushing.,Severity: Severity of condition is severe and unchanged.,Timing (onset/frequency): Onset was sudden and with exercise. Patient has the following coronary risk factors: smoking 1 packs/day for 40 years and elevated cholesterol for 5 years. Patient's elevated cholesterol is not being treated with medication. Menopause occurred at age 53.,ALLERGIES:, No known medical allergies.,MEDICATION HISTORY:, Patient is currently taking Estraderm 0.05 mg/day transdermal patch.,PMH:, Past medical history unremarkable.,PSH:, No previous surgeries.,SOCIAL HISTORY:, Patient admits tobacco use She relates a smoking history of 40 pack years.,FAMILY HISTORY:, Patient admits a family history of heart attack associated with father (deceased).,ROS:, Unremarkable with exception of chief complaint.,PHYSICAL EXAMINATION:,General: Patient is a 62 year old female who appears pleasant, her given age, well developed,,oriented, well nourished, alert and moderately overweight.,Vital Signs: BP Sitting: 174/92 Resp: 28 HR: 88 Temp: 98.6 Height: 5 ft. 2 in. Weight: 150 lbs.,HEENT: Inspection of head and face shows head that is normocephalic, atraumatic, without any gross or neck masses. Ocular motility exam reveals muscles are intact. Pupil exam reveals round and equally reactive to light and accommodation. There is no conjunctival inflammation nor icterus. Inspection of nose reveals no abnormalities. Inspection of oral mucosa and tongue reveals no pallor or cyanosis. Inspection of the tongue reveals normal color, good motility and midline position. Examination of oropharynx reveals the uvula rises in the midline. Inspection of lips, teeth, gums, and palate reveals healthy teeth, healthy gums, no gingival,hypertrophy, no pyorrhea and no abnormalities.,Neck: Neck exam reveals neck supple and trachea that is midline, without adenopathy or crepitance palpable.,Thyroid examination reveals smooth and symmetric gland with no enlargement, tenderness or masses noted.,Carotid pulses are palpated bilaterally, are symmetric and no bruits auscultated over the carotid and vertebral arteries. Jugular veins examination reveals no distention or abnormal waves were noted. Neck lymph nodes are not noted.,Back: Examination of the back reveals no vertebral or costovertebral angle tenderness and no kyphosis or scoliosis noted.,Chest: Chest inspection reveals intercostal interspaces are not widened, no splinting, chest contours are normal and normal expansion. Chest palpation reveals no abnormal tactile fremitus.,Lungs: Chest percussion reveals resonance. Assessment of respiratory effort reveals even respirations without use of accessory muscles and diaphragmatic movement normal. Auscultation of lungs reveal diminished breath sounds bibasilar.,Heart: The apical impulse on heart palpation is located in the left border of cardiac dullness in the midclavicular line, in the left fourth intercostal space in the midclavicular line and no thrill noted. Heart auscultation reveals rhythm is regular, normal S1 and S2, no murmurs, gallop, rubs or clicks and no abnormal splitting of the second heart sound which moves normally with respiration. Right leg and left leg shows evidence of edema +6.,Abdomen: Abdomen soft, nontender, bowel sounds present x 4 without palpable masses. Palpation of liver reveals no abnormalities with respect to size, tenderness or masses. Palpation of spleen reveals no abnormalities with respect to size, tenderness or masses. Examination of abdominal aorta shows normal size without presence of systolic bruit.,Extremities: Right thumb and left thumb reveals clubbing.,Pulses: The femoral, popliteal, dorsalis, pedis and posterior tibial pulses in the lower extremities are equal and normal. The brachial, radial and ulnar pulses in the upper extremities are equal and normal. Examination of peripheral vascular system reveals varicosities absent, extremities warm to touch, edema present - pitting and pulses are full to palpation. Femoral pulses are 2 /4, bilateral. Pedal pulses are 2 /4, bilateral.,Neurological: Testing of cranial nerves reveals nerves intact. Oriented to person, place and time. Mood and affect normal and appropriate to situation.Deep tendon reflexes normal. Touch, pin, vibratory and proprioception sensations are normal. Babinski reflex is absent. Coordination is normal. Speech is not aphasic. Musculoskeletal: Muscle strength is 5/5 for all groups tested. Gait and station examination reveals midposition without abnormalities.,Skin: No skin rash, subcutaneous nodules, lesions or ulcers observed. Skin is warm and dry with normal turgor and there is no icterus.,Lymphatics: No lymphadenopathy noted.,IMPRESSION:, Angina pectoris, other and unspecified.,PLAN:, ,DIAGNOSTIC & LAB ORDERS:, Ordered serum creatine kinase isoenzymes (CK isoenzymes). Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report. The following cardiac risk factor modifications are recommended: quit smoking and reduce LDL cholesterol to below 120 mg/dl.,PATIENT INSTRUCTIONS:",
" Chest pain and non-Q-wave MI with elevation of troponin I only.  Left heart catheterization, left ventriculography, and left and right coronary arteriography.", Cardiovascular / Pulmonary, Heart Catheterization - 1 ,"PROCEDURES: , Left heart catheterization, left ventriculography, and left and right coronary arteriography.,INDICATIONS: , Chest pain and non-Q-wave MI with elevation of troponin I only.,TECHNIQUE:  ,The patient was brought to the procedure room in satisfactory condition.  The right groin was prepped and draped in routine fashion.  An arterial sheath was inserted into the right femoral artery.,Left and right coronary arteries were studied with a 6FL4 and 6FR4 Judkins catheters respectively.  Cine coronary angiograms were done in multiple views.,Left heart catheterization was done using the 6-French pigtail catheter.  Appropriate pressures were obtained before and after the left ventriculogram, which was done in the RAO view.,At the end of the procedure, the femoral catheter was removed and Angio-Seal was applied without any complications.,FINDINGS:,1.  LV is normal in size and shape with good contractility, EF of 60%.,2.  LMCA normal.,3.  LAD has 20% to 30% stenosis at the origin.,4.  LCX is normal.,5.  RCA is dominant and normal.,RECOMMENDATIONS: , Medical management, diet, and exercise.  Aspirin 81 mg p.o. daily, p.r.n. nitroglycerin for chest pain.  Follow up in the clinic.","cardiovascular / pulmonary, arteriography, coronary arteriography, heart catheterization, ventriculography, angiograms"
 Flexible bronchoscopy  to evaluate the airway (chronic wheezing)., Cardiovascular / Pulmonary, Flexible Bronchoscopy ,"PROCEDURE:, Flexible bronchoscopy.,PREOPERATIVE DIAGNOSIS (ES):, Chronic wheezing.,INDICATIONS FOR PROCEDURE:, Evaluate the airway.,DESCRIPTION OF PROCEDURE: ,This was done in the pediatric endoscopy suite with the aid of Anesthesia. The patient was sedated with sevoflurane and propofol. One mL of 1% lidocaine was used for airway anesthesia. The 2.8-mm flexible pediatric bronchoscope was passed through the left naris. The upper airway was visualized. The epiglottis, arytenoids, and vocal cords were all normal. The scope was passed below the cords. The subglottic space was normal. The patient had normal tracheal rings and a normal membranous portion of the trachea. There was noted to be slight deviation of the trachea to the right. At the carina, the right and left mainstem were evaluated. The right upper lobe, right middle lobe, and right lower lobe were all anatomically normal. The scope was wedged in the right middle lobe, 10 mL of saline was infused, 10 was returned. This was sent for cell count, cytology, lipid index, and quantitative bacterial cultures. The left side was then evaluated and there was noted to be the normal cardiac pulsations on the left. There was also noted to be some dynamic collapse of the left mainstem during the respiratory cycle. The left upper lobe and left lower lobe were normal. The scope was withdrawn. The patient tolerated the procedure well.,ENDOSCOPIC DIAGNOSIS:, Left mainstem bronchomalacia.","cardiovascular / pulmonary, flexible bronchoscopy, airway, arytenoids, bronchomalacia, bronchoscopy, endoscopy suite, epiglottis, mainstem, subglottic, vocal cords, wheezing, chronic wheezing, tracheal, lobe, "
" Flexible fiberoptic bronchoscopy with right lower lobe bronchoalveolar lavage and right upper lobe endobronchial biopsy.  Severe tracheobronchitis, mild venous engorgement with question varicosities associated pulmonary hypertension, right upper lobe submucosal hemorrhage without frank mass underneath it status post biopsy.", Cardiovascular / Pulmonary, Flexible Fiberoptic Bronchoscopy ,"PREOPERATIVE/POSTOPERATIVE DIAGNOSES:,1.  Severe tracheobronchitis.,2.  Mild venous engorgement with question varicosities associated pulmonary hypertension.,3.  Right upper lobe submucosal hemorrhage without frank mass underneath it status post biopsy.,PROCEDURE PERFORMED: , Flexible fiberoptic bronchoscopy with:,a.  Right lower lobe bronchoalveolar lavage.,b.  Right upper lobe endobronchial biopsy.,SAMPLES: , Bronchoalveolar lavage for cytology and for microbiology of the right lower lobe endobronchial biopsy of the right upper lobe.,INDICATIONS: , The patient with persistent hemoptysis of unclear etiology.,PROCEDURE: , After obtaining informed consent, the patient was brought to Bronchoscopy Suite.  The patient had previously been on Coumadin and then heparin.  Heparin was discontinued approximately one-and-a-half hours prior to the procedure.  The patient underwent topical anesthesia with 10 cc of 4% Xylocaine spray to the left nares and nasopharynx.  Blood pressure, EKG, and oximetry monitoring were applied and monitored continuously throughout the procedure.  Oxygen at two liters via nasal cannula was delivered with saturations in the 90% to 100% throughout the procedure.  The patient was premedicated with 50 mg of Demerol and 2 mg of Versed.  After conscious sedation was achieved, the bronchoscope was advanced through the left nares into the nasopharynx and oropharynx.  There was minimal redundant oral soft tissue in the oropharynx.  There was mild erythema.  Clear secretions were suctioned.,Additional topical anesthesia was applied to the larynx and then throughout the tracheobronchial tree for the procedure, a total of 16 cc of 2% Xylocaine was applied.  Vocal cord motion was normal.  The bronchoscope was then advanced through the larynx into the trachea.  There was evidence of moderate inflammation with prominent vascular markings and edema.  No frank blood was visualized.  The area was suction clear of copious amounts of clear white secretions.  Additional topical anesthesia was applied and the bronchoscope was advanced into the left main stem.  The bronchoscope was then sequentially advanced into each segment and sub-segment of the left upper lobe and left lower lobe.  There was significant amount of inflammation, induration, and vascular tortuosity in these regions.  No frank blood was identified.  No masses or lesions were identified.  There was senile bronchiectasis with slight narrowing and collapse during the exhalation.  The air was suctioned clear.  The bronchoscope was withdrawn and advanced into the right main stem.  Bronchoscope was introduced into the right upper lobe and each sub-segment was visualized.  Again significant amounts of tracheobronchitis was noted with vascular infiltration.  In the sub-carina of the anterior segment of the right upper lobe, there was evidence of a submucosal hematoma without frank mass underneath this.  The bronchoscope was removed and advanced into the right middle and right lower lobe.  There was marked injection and inflammation in these regions.  In addition, there was marked vascular engorgement with near frank varicosities identified throughout the region.  Again, white clear secretions were identified.  No masses or other processes were noted.  The area was suctioned clear.  A bronchoalveolar lavage was subsequently performed in the anterior segment of the right lower lobe.  The bronchoscope was then withdrawn and readvanced into the right upper lobe.  Endobronchial biopsies of the carina of the sub-segment and anterior segment of the right upper lobe were obtained.  Minimal hemorrhage occurred after the biopsy, which stopped after 1 cc of 1:1000 epinephrine.  The area remained clear.  No further hemorrhage was identified.  The bronchoscope was subsequently withdrawn.  The patient tolerated the procedure well and was stable throughout the procedure.  No further hemoptysis was identified.  The patient was sent to Recovery in good condition.","cardiovascular / pulmonary, bronchoalveolar lavage, endobronchial biopsy, cytology, microbiology, tracheobronchitis, venous engorgement, varicosities, pulmonary hypertension, flexible fiberoptic bronchoscopy, fiberoptic bronchoscopy, lobe, bronchoalveolar, lavage, endobronchial, hemorrhage, oropharynx, vascular, bronchoscopy, biopsy, submucosal, bronchoscope"
" Right and left heart catheterization, coronary angiography, left ventriculography.", Cardiovascular / Pulmonary, Heart Catheterization ,"PROCEDURES:,1.  Right and left heart catheterization.,2.  Coronary angiography.,3.  Left ventriculography.,PROCEDURE IN DETAIL:,  After informed consent was obtained, the patient was taken to the cardiac catheterization laboratory.  Patient was prepped and draped in sterile fashion.  Via modified Seldinger technique, the right femoral vein was punctured and a 6-French sheath was placed over a guide wire.  Via modified Seldinger technique, right femoral artery was punctured and a 6-French sheath was placed over a guide wire.  The diagnostic procedure was performed using the JL-4, JR-4, and a 6-French pigtail catheter along with a Swan-Ganz catheter.  The patient tolerated the procedure well and there were immediate complications were noted.  Angio-Seal was used at the end of the procedure to obtain hemostasis.,CORONARY ARTERIES:,LEFT MAIN CORONARY ARTERY:  The left main coronary artery is of moderate size vessel with bifurcation into the left descending coronary artery and circumflex coronary artery.  No significant stenotic lesions were identified in the left main coronary artery.,LEFT ANTERIOR DESCENDING CORONARY ARTERY:  The left descending artery is a moderate sized vessel, which gives rise to multiple diagonals and perforating branches.  No significant stenotic lesions were identified in the left anterior descending coronary artery system.,CIRCUMFLEX ARTERY:  The circumflex artery is a moderate sized vessel.  The vessel is a stenotic lesion.  After the right coronary artery, the RCA is a moderate size vessel with no focal stenotic lesions.,HEMODYNAMIC DATA: , Capital wedge pressure was 22.  The aortic pressure was 52/24.  Right ventricular pressure was 58/14.  RA pressure was 14.  The aortic pressure was 127/73.  Left ventricular pressure was 127/15.  Cardiac output of 9.2.,LEFT VENTRICULOGRAM: , The left ventriculogram was performed in the RAO projection only.  In the RAO projection, the left ventriculogram revealed dilated left ventricle with mild global hypokinesis and estimated ejection fraction of 45 to 50%.  Severe mitral regurgitation was also noted.,IMPRESSION:,1.  Left ventricular dilatation with global hypokinesis and estimated ejection fraction of 45 to 50%.,2.  Severe mitral regurgitation.,3.  No significant coronary artery disease identified in the left main coronary artery, left anterior descending coronary artery, circumflex coronary artery or the right coronary artery.,","cardiovascular / pulmonary, ventriculography, catheterization, seldinger, hypokinesis, estimated ejection fraction, severe mitral regurgitation, descending coronary artery, coronary artery, aortic pressure, heart catheterization, stenotic lesions, coronary, artery, heart, angiography, anterior, ventricular, ventriculogram, lesions"
" Fiberoptic flexible bronchoscopy with lavage, brushings, and endobronchial mucosal biopsies of the right bronchus intermedius/right lower lobe.  Right hyoid mass, rule out carcinomatosis.  Chronic obstructive pulmonary disease.  Changes consistent with acute and chronic bronchitis.", Cardiovascular / Pulmonary, Fiberoptic Flexible Bronchoscopy ,"PREOPERATIVE DIAGNOSES:,1.  Right hyoid mass, rule out carcinomatosis.,2.  Weight loss.,3.  Chronic obstructive pulmonary disease.,POSTOPERATIVE DIAGNOSES:,1.  Right hyoid mass, rule out carcinomatosis.,2.  Weight loss.,3.  Chronic obstructive pulmonary disease.,4.  Changes consistent with acute and chronic bronchitis.,5.  Severe mucosal irregularity with endobronchial narrowing of the right middle and lower lobes.,6.  Left vocal cord irregularity.,PROCEDURE PERFORMED:  ,Fiberoptic flexible bronchoscopy with lavage, brushings, and endobronchial mucosal biopsies of the right bronchus intermedius/right lower lobe.,ANESTHESIA: , Demerol 50 mg with Versed 3 mg as well as topical cocaine and lidocaine solution.,LOCATION OF PROCEDURE: , Endoscopy suite #4.,After informed consent was obtained and following the review of the procedure including procedure as well as possible risks and complications were explained and consent was previously obtained, the patient was sedated with the above stated medication and the patient was continuously monitored on pulse oximetry, noninvasive blood pressure, and EKG monitoring.  Prior to starting the procedure, the patient was noted to have a baseline oxygen saturation of 86% on room air.  Subsequently, she was given a bronchodilator treatment with Atrovent and albuterol and subsequent saturation increased to approximately 90% to 91% on room air.,The patient was placed on a supplemental oxygen as the patient was sedated with above-stated medication.  As this occurred, the bronchoscope was inserted into the right naris with good visualization of the nasopharynx and oropharynx.  The cords were noted to oppose bilaterally on phonation.  There was some slight mucosal irregularity noted on the vocal cord on the left side.  Additional topical lidocaine was instilled on the vocal cords, at which point the bronchoscope was introduced into the trachea, which was midline in nature.  The bronchoscope was then advanced to the distal trachea and additional lidocaine was instilled.  At this time, the bronchoscope was further advanced through the main stem and additional lidocaine was instilled.  Bronchoscope was then further advanced into the right upper lobe, which revealed no evidence of any endobronchial lesion.  The mucosa was diffusely friable throughout.  Bronchoscope was then slowly withdrawn into the right main stem and additional lidocaine was instilled.  At this point, the bronchoscope was then advanced to the right bronchus intermedius.  At this time, it was noted that there was severe mucosal irregularities of nodular in appearance significantly narrowing the right lower lobe and right middle lobe opening.  The mucosal area throughout this region was severely friable.  Additional lidocaine was instilled as well as topical epinephrine.  At this time, bronchoscope was maintained in this region and endobronchial biopsies were performed.  At the initial attempt of inserting biopsy forceps, some resistance was noted within the proximal channel at this time making advancement of the biopsy forceps out of the proximal channel impossible.  So the biopsy forceps was withdrawn and the bronchoscope was completely withdrawn and new bronchoscope was then utilized.  At this time, bronchoscope was then reinserted into the right naris and subsequently advanced to the vocal cords into the right bronchus intermedius without difficulty.  At this time, the biopsy forceps were easily passed and visualized in the right bronchus intermedius.  At this time, multiple mucosal biopsies were performed with some mild oozing noted.  Several aliquots of normal saline lavage followed.  After completion of multiple biopsies there was good hemostasis.  Cytology flushing was also performed in this region and subsequently several aliquots of additional normal saline lavage was followed.  Bronchoscope was unable to be passed distally to the base of the segment of the right lower lobe or distal to the further visualized endobronchial anatomy of the right middle lobe subsegments.  The bronchoscope was then withdrawn to the distal trachea.,At this time, bronchoscope was then advanced to the left main stem.  Additional lidocaine was instilled.  The bronchoscope was advanced to the left upper and lower lobe subsegments.  There was no endobronchial lesion visualized.  There is mild diffuse erythema and fibromucosa was noted throughout.  No endobronchial lesion was visualized in the left bronchial system.  The bronchoscope was then subsequently further withdrawn to the distal trachea and readvanced into the right bronchial system.  At this time, bronchoscope was readvanced into the right bronchus intermedius and additional aliquots of normal saline lavage until cleared.  There is no gross bleeding evidenced at this time or diffuse mucosal erythema and edema present throughout.  The bronchoscope was subsequently withdrawn and the patient was sent to recovery room.  During the bronchoscopy, the patient noted ________ have desaturation and required increasing FiO2 with subsequent increased saturation to 93% to 94%.  The patient remained at this level of saturation or greater throughout the remaining of the procedure.,The patient postprocedure relates having some intermittent hemoptysis prior to the procedure as well as moderate exertional dyspnea.  This was confirmed by her daughter and mother who were also present at the bedside postprocedure.  The patient did receive a nebulizer bronchodilator treatment immediately prebronchoscopy and postprocedure as well.  The patient also admitted to continued smoking in spite of all of the above.  The patient was extensively counseled regarding the continued smoking especially with her present symptoms.  She was advised regarding smoking cessation.  The patient was also placed on a prescription of prednisone 2 mg tablets starting at 40 mg a day decreasing every three days to continue to wean off.  The patient was also administered Solu-Medrol 60 mg IV x1 in recovery room.  There was no significant bronchospastic component noted, although because of the severity of the mucosal edema, erythema, and her complaints, short course of steroids will be instituted.  The patient was also advised to refrain from using any aspirin or other nonsteroidal anti-inflammatory medication because of her hemoptysis.  At this time, the patient was also advised that if hemoptysis were to continue or worsen or develop progressive dyspnea, to either contact myself, , or return to ABCD Emergency Room for evaluation of possible admission.  However, the above was reviewed with the patient in great detail as well as with her daughter and mother who were at the bedsite at this time as well.","cardiovascular / pulmonary, carcinomatosis, chronic obstructive pulmonary disease, fiberoptic flexible bronchoscopy, lavage, brushings, endobronchial mucosal biopsies, mucosal, bronchoscope, atrovent, topical, fiberoptic, hemoptysis, bronchoscopy, endobronchial, oropharynx"
" Flexible fiberoptic bronchoscopy diagnostic with right middle and upper lobe lavage and lower lobe transbronchial biopsies.  Mild tracheobronchitis with history of granulomatous disease and TB, rule out active TB/miliary TB.", Cardiovascular / Pulmonary, Flexible Fiberoptic Bronchoscopy -1 ,"POSTOPERATIVE DIAGNOSIS:,  Mild tracheobronchitis with history of granulomatous disease and TB, rule out active TB/miliary TB.,PROCEDURE PERFORMED:,  Flexible fiberoptic bronchoscopy diagnostic with:,a.  Right middle lobe bronchoalveolar lavage.,b.  Right upper lobe bronchoalveolar lavage.,c.  Right lower lobe transbronchial biopsies.,COMPLICATIONS:,  None.,Samples include bronchoalveolar lavage of the right upper lobe and right middle lobe and transbronchial biopsies of the right lower lobe.,INDICATION:  ,The patient with a history of TB and caseating granulomata on open lung biopsy with evidence of interstitial lung disease and question tuberculosis.,PROCEDURE:,  After obtaining an informed consent, the patient was brought to the Bronchoscopy Suite with appropriate isolation related to ______ precautions.  The patient had appropriate oxygen, blood pressure, heart rate, and respiratory rate monitoring applied and monitored continuously throughout the procedure.  2 liters of oxygen via nasal cannula was applied to the nasopharynx with 100% saturations achieved.  Topical anesthesia with 10 cc of 4% Xylocaine was applied to the right nares and oropharynx.  Subsequent to this, the patient was premedicated with 50 mg of Demerol and then Versed 1 mg sequentially for a total of 2 mg.  With this, adequate consciousness sedation was achieved.  3 cc of 4% viscous Xylocaine was applied to the right nares.  The bronchoscope was then advanced through the right nares into the nasopharynx and oropharynx.,The oropharynx and larynx were well visualized and showed mild erythema, mild edema, otherwise negative.,There was normal vocal cord motion without masses or lesions.  Additional topical anesthesia with 2% Xylocaine was applied to the larynx and subsequently throughout the tracheobronchial tree for a total of 18 cc.  The bronchoscope was then advanced through the larynx into the trachea.  The trachea showed mild evidence of erythema and moderate amounts of clear frothy secretions.  These were suctioned clear.  The bronchoscope was then advanced through the carina, which was sharp.  Then advanced into the left main stem and each segment, subsegement in the left upper lingula and lower lobe was visualized.  There was mild tracheobronchitis with mild friability throughout.  There was modest amounts of white secretion.  There were no other findings including evidence of mass, anatomic distortions, or hemorrhage.  The bronchoscope was subsequently withdrawn and advanced into the right mainstem.  Again, each segment and subsegment was well visualized.  The right upper lobe anatomy showed some segmental distortion with dilation and irregularities both at the apical region as well as in the subsegments of the anteroapical and posterior segments.  No specific masses or other lesions were identified throughout the tracheobronchial tree on the right.  There was mild tracheal bronchitis with friability.  Upon coughing, there was punctate hemorrhage.  The bronchoscope was then advanced through the bronchus intermedius and the right middle lobe and right lower lobe.  These again had no other anatomic lesions identified.  The bronchoscope was then wedged in the right middle lobe and bronchoalveolar samples were obtained.  The bronchoscope was withdrawn and the area was suctioned clear.  The bronchoscope was then advanced into the apical segment of the right upper lobe and the bronchioalveolar lavage again performed.  Samples were taken and the bronchoscope was removed suctioned the area clear.  The bronchoscope was then re-advanced into the right lower lobe and multiple transbronchial biopsies were taken under fluoroscopic guidance in the posterior and lateral segments of the right lower lobe.  Minimal hemorrhage was identified and suctioned clear without difficulty.  The bronchoscope was then withdrawn to the mainstem.  The area was suctioned clear.  Fluoroscopy revealed no evidence of pneumothorax.  The bronchoscope was then withdrawn.  The patient tolerated the procedure well without evidence of desaturation or complications.","cardiovascular / pulmonary, bronchoalveolar, lavage, lobe, tracheobronchitis, granulomatous, miliary tb, tb, flexible fiberoptic bronchoscopy, bronchoscope, flexible, fiberoptic, transbronchial, biopsies, bronchoscopy, oropharynx,"
 Left arm fistulogram.  Percutaneous transluminal angioplasty of the proximal and distal cephalic vein.  Ultrasound-guided access of left upper arm brachiocephalic fistula., Cardiovascular / Pulmonary, Fistulogram & Angioplasty ,"PREPROCEDURE DIAGNOSIS: , End-stage renal disease.,POSTPROCEDURE DIAGNOSIS: , End-stage renal disease.,PROCEDURES PERFORMED,1.  Left arm fistulogram.,2.  Percutaneous transluminal angioplasty of the proximal and distal cephalic vein.,3.  Ultrasound-guided access of left upper arm brachiocephalic fistula.,ANESTHESIA:,  Sedation with local.,COMPLICATIONS:,  None.,CONDITION:,  Fair.,DISPOSITION:,  PACU.,ACCESS SITE:,  Left upper arm brachiocephalic fistula.,SHEATH SIZE: , 5 French.,CONTRAST TYPE: , JC PEG tube 70.,CONTRAST VOLUME: , 48 mL.,FLUOROSCOPY TIME: , 16 minutes.,INDICATION FOR PROCEDURE: , This is a 38-year-old female with a left upper arm brachiocephalic fistula which has been transposed.  The patient recently underwent a fistulogram with angioplasty at the proximal upper arm cephalic vein due to a stenosis detected on Duplex ultrasound.  The patient subsequently was noted to have poor flow to the fistula, and the fistula was difficult to palpate.  A repeat ultrasound was performed which demonstrated a high-grade stenosis involving the distal upper arm cephalic vein just distal to the brachial anastomosis.  The patient presents today for a left arm fistulogram with angioplasty.  The risks, benefits, and alternatives of the procedure were discussed with the patient and understands and in agreement to proceed.,PROCEDURE DETAILS:  ,The patient was brought to the angio suite and laid supine on the table.  After sedation was administered, the left arm was then prepped and draped in a standard surgical fashion.  Continuous pulse oximetry and cardiac monitoring were performed throughout the procedure.  The patient was given 1 g of IV Ancef prior to incision.,The left brachiocephalic fistula was visualized with bevel ultrasound.  The cephalic vein in the proximal upper arm region appeared to be of adequate caliber.  There was an area of stenosis at the proximal cephalic vein just distal to the brachial artery anastomosis.  The cephalic vein in the proximal forearm region was easily compressible.  The skin overlying the vessel was injected with 1% lidocaine solution.  A small incision was made with the #11 blade.  The cephalic vein then was cannulated with a 5 French micropuncture introducer sheath.  The sheath was advanced over the wire.  A fistulogram was performed which demonstrated a high-grade stenosis just distal to the brachial artery anastomosis.  The introducer sheath was then exchanged for a 5 French sheath over a 0.025 guide wire.  The sheath was aspirated and flushed with heparinized saline solution.  A 0.025 glidewire was then obtained and advanced, placed over the sheath and across the area of stenosis into the brachial artery.  A 5 French short Kumpe catheter was used to guide the wire into the distal brachial and radial artery.  After crossing the area of stenosis, a 5 x 20 mm standard angioplasty balloon was obtained and prepped from the back table.  This was placed over the glidewire into the area of stenosis and inflated to 14 mmHg pressure and then deflated.  The balloon was then removed over the wire and repeat fistulogram was performed which demonstrated significant improvement.  However, there is still a remainder of residual stenosis.  The 5-mm balloon was placed over the wire again and a repeat angioplasty was performed.  The balloon was then removed over the wire and a repeat angiogram was performed which demonstrated again an area of stenosis right at the anastomosis.  The glidewire was removed and a 0.014 guide wire was then obtained and placed through the sheath and across the brachial anastomosis and into the radial artery.  A 4 x 20 mm cutting balloon was obtained and prepped on the back table.  The 5 French sheath was then exchanged for a 6 French sheath.  The balloon was then placed over the 0.014 guide wire into the area of stenosis and then inflated to normal pressures at 8 mmHg.  The balloon was then deflated and removed over the wire.  A 5 mm x 20 mm balloon was obtained and prepped and placed over the wire into the area of stenosis and inflated to pressures of 14 mmHg.  A repeat fistulogram was performed after the removal of the balloon which demonstrated excellent results with no significant residual stenosis.  The patient actually had a nice palpable thrill at this point.  The fistulogram of the distal cephalic vein at the subclavian anastomosis was performed which demonstrated a mild area of stenosis.  The sheath was removed and blood pressure was held over the puncture site for approximately 10 minutes.,After hemostasis was achieved, the cephalic vein again was visualized with bevel ultrasound.  The proximal cephalic vein was then cannulated after injecting the skin overlying the vessel with a 1% lidocaine solution.  A 5 French micropuncture introducer sheath was then placed over the wire into the proximal cephalic vein.  A repeat fistulogram was performed which demonstrated an area of stenosis within the distal cephalic vein just prior to the subclavian vein confluence.  The 5 French introducer sheath was then exchanged for a 5 French sheath.  The 5 mm x 20 mm balloon was placed over a 0.035 glidewire across the area of stenosis.  The balloon was inflated to 14 mmHg.  The balloon was then deflated and a repeat fistulogram was performed through the sheath which demonstrated good results.  The sheath was then removed and blood pressure was held over the puncture site for approximately 10 minutes.  After adequate hemostasis was achieved, the area was cleansed in 2x2 and Tegaderm was applied.  The patient tolerated the procedure without any complications.  I was present for the entire case.  The sponge, instrument, and needle counts are correct at the end of the case.  The patient was subsequently taken to PACU in stable condition.,ANGIOGRAPHIC FINDINGS:,  The initial left arm brachiocephalic fistulogram demonstrated a stenosis at the brachial artery anastomosis and distally within the cephalic vein.  After standard balloon angioplasty, there was a mild improvement but some residual area of stenosis remained at the anastomosis.  Then postcutting balloon angioplasty, venogram demonstrated a significant improvement without any evidence of significant stenosis.,Fistulogram of the proximal cephalic vein demonstrated a stenosis just prior to the confluence with the left subclavian vein.  Postangioplasty demonstrated excellent results with the standard balloon.  There was no evidence of any contrast extravasation.,IMPRESSION,1.  High-grade stenosis involving the cephalic vein at the brachial artery anastomosis and distally.  Postcutting balloon and standard balloon angioplasty demonstrated excellent results without any evidence of contrast extravasation.,2.  A moderate grade stenosis within the distal cephalic vein just prior to the confluence to the left subclavian vein.  Poststandard balloon angioplasty demonstrated excellent results.  No evidence of contrast extravasation.",
 Emergent fiberoptic bronchoscopy with lavage.   Status post multiple trauma/motor vehicle accident.  Acute respiratory failure.  Acute respiratory distress/ventilator asynchrony.  Hypoxemia.  Complete atelectasis of left lung.  Clots partially obstructing the endotracheal tube and completely obstructing the entire left main stem and entire left bronchial system., Cardiovascular / Pulmonary, Fiberoptic Bronchoscopy with Lavage ,"PREOPERATIVE DIAGNOSES:,1.  Status post multiple trauma/motor vehicle accident.,2.  Acute respiratory failure.,3.  Acute respiratory distress/ventilator asynchrony.,4.  Hypoxemia.,5.  Complete atelectasis of left lung.,POSTOPERATIVE DIAGNOSES:,1.  Status post multiple trauma/motor vehicle accident.,2.  Acute respiratory failure.,3.  Acute respiratory distress/ventilator asynchrony.,4.  Hypoxemia.,5.  Complete atelectasis of left lung.,6.  Clots partially obstructing the endotracheal tube and completely obstructing the entire left main stem and entire left bronchial system.,PROCEDURE PERFORMED: ,Emergent fiberoptic plus bronchoscopy with lavage.,LOCATION OF PROCEDURE:  ,ICU.  Room #164.,ANESTHESIA/SEDATION:,  Propofol drip, Brevital 75 mg, morphine 5 mg, and Versed 8 mg.,HISTORY,:  The patient is a 44-year-old male who was admitted to ABCD Hospital on 09/04/03 status post MVA with multiple trauma and subsequently diagnosed with multiple spine fractures as well as bilateral pulmonary contusions, requiring ventilatory assistance.  The patient was noted with acute respiratory distress on ventilator support with both ventilator asynchrony and progressive desaturation.  Chest x-ray as noted above revealed complete atelectasis of the left lung.  The patient was subsequently sedated and received one dose of paralytic as noted above followed by emergent fiberoptic flexible bronchoscopy.,PROCEDURE DETAIL,:  A bronchoscope was inserted through the oroendotracheal tube, which was partially obstructed with blood clots.  These were lavaged with several aliquots of normal saline until cleared.  The bronchoscope required removal because the tissue/clots were obstructing the bronchoscope.  The bronchoscope was reinserted on several occasions until cleared and advanced to the main carina.  The endotracheal tube was noted to be in good position.  The bronchoscope was advanced through the distal trachea.  There was a white tissue completely obstructing the left main stem at the carina.  The bronchoscope was advanced to this region and several aliquots of normal saline lavage were instilled and suctioned.  Again this partially obstructed the bronchoscope requiring several times removing the bronchoscope to clear the lumen.  The bronchoscope subsequently was advanced into the left mainstem and subsequently left upper and lower lobes.  There was diffuse mucus impactions/tissue as well as intermittent clots.  There was no evidence of any active bleeding noted.  Bronchoscope was adjusted and the left lung lavaged until no evidence of any endobronchial obstruction is noted.  Bronchoscope was then withdrawn to the main carina and advanced into the right bronchial system.  There is no plugging or obstruction of the right bronchial system.  The bronchoscope was then withdrawn to the main carina and slowly withdrawn as the position of endotracheal tube was verified, approximately 4 cm above the main carina.  The bronchoscope was then completely withdrawn as the patient was maintained on ventilator support during and postprocedure.  Throughout the procedure, pulse oximetry was greater than 95% throughout.  There is no hemodynamic instability or variability noted during the procedure.  Postprocedure chest x-ray is pending at this time.","cardiovascular / pulmonary, multiple trauma, motor vehicle accident, acute respiratory failure, acute respiratory distress, ventilator asynchrony, hypoxemia, atelectasis, bronchoscopy, lavage, fiberoptic bronchoscopy, endotracheal tube, acute respiratory, asynchrony, bronchoscope, fiberoptic, endotracheal, bronchial, ventilatory, tube, respiratory, "
" Right common femoral artery cannulation, cnscious sedation using IV Versed and IV fentanyl, retrograde bilateral coronary angiography, abdominal aortogram with pelvic runoff, left external iliac angiogram with runoff to the patient's left foot, left external iliac angiogram with runoff to the patient's right leg, right common femoral artery angiogram runoff to the patient's right leg.", Cardiovascular / Pulmonary, Femoral Artery Cannulation & Aortogram ,"PREOPERATIVE DIAGNOSES: , Angina with severe claudication, coronary artery disease, hypertension, dyslipidemia, heavy tobacco abuse, and PAD.,POSTOPERATIVE DIAGNOSES: , Angina with severe claudication, coronary artery disease, hypertension, dyslipidemia, heavy tobacco abuse, and PAD.  Significant coronary artery disease, very severe PAD.,PROCEDURES PERFORMED:,1.  Right common femoral artery cannulation.,2.  Conscious sedation using IV Versed and IV fentanyl.,3.  Retrograde bilateral coronary angiography.,4.  Abdominal aortogram with pelvic runoff.,5.  Left external iliac angiogram with runoff to the patient's left foot.,6.  Left external iliac angiogram with runoff to the patient's right leg.,7.  Right common femoral artery angiogram runoff to the patient's right leg.,PROCEDURE IN DETAIL:,  The patient was taken to the cardiac catheterization laboratory after having a valid consent.  He was prepped and draped in the usual sterile fashion.,After local infiltration with 2% Xylocaine, the right common femoral artery was entered percutaneously and a 4-French sheath was placed over the artery.  The arterial sheath was flushed throughout the procedure.,Conscious sedation was obtained using IV Versed and IV fentanyl.,With the help of a Wholey wire, a 4-French 4-curve Judkins right coronary artery catheter was advanced into the ascending aorta.  The wire was removed, the catheter was flushed.  The catheter was engaged in the left main.  Injections were performed at the left main in different views.  The catheter was then exchanged for an RCA catheter, 4-French 4-curve which was advanced into the ascending aorta with the help of a J-wire.  The wire was removed, the catheter was flushed.  The catheter was engaged in the RCA.  Injections were performed at the RCA in different views.,The catheter was then exchanged for a 5-French Omniflush catheter, which was advanced into the abdominal aorta with the help of a regular J-wire.  The wire was removed.  The catheter was flushed.  Abdominal aortogram was then performed with runoff to the patient's pelvis.,The Omniflush catheter was then retracted into the aortic bifurcation.  Through the Omniflush catheter, a Glidewire was then advanced distally into the left SFA.  The Omniflush was then removed.  Through the wire, a Royal Flush catheter was then advanced into the left external iliac.  The wire was removed.  Left external iliac angiogram was performed with runoff to the patient's left foot _______ was then performed.  The catheter was then retracted into the left common iliac.  Angiograms were performed of the left common iliac with runoff to the patient's left groin.  The catheter was then positioned at the level of the right common iliac.  Angiogram of the right common iliac with runoff to the patient's right leg was then performed.  The catheter was then removed with the help of a J-wire.  The J-wire was left in the abdominal aorta.  Hand injection was performed of the right common femoral artery in 2 locations with runoff to the patient's right leg.,The wire was then removed.  The arterial sheath was then removed after being flushed.  Hemostasis was obtained using hand compression.,The patient tolerated the procedure well and had no complications.  At the end of the procedure, palpable right common femoral pulses were noted as well as 1+ right PT pulse.,Hemodynamic Findings:,  Aortic pressure 140/70.,ANGIOGRAPHIC FINDINGS: , Left main with calcification 25% to 40% lesion.,The left main is very short.,LAD with calcification 25% to 40% proximal lesion.,D1 has 25% lesion.  No in-stent restenosis was noted in D1.,D2 and D3 are very small with luminal irregularities.,Circumflex artery was diseased throughout the vessel.  The circumflex artery has an ostium of 60% to 75% lesion distally and the circumflex has a 75% lesion.,OM1 has 25% to 40% lesion.  These OMs are small with luminal irregularities.,RCA has 25% to 50% lesion, distally, the RCA has luminal irregularities.,Left ventriculography was not done.,ABDOMINAL AORTOGRAM:,  Right renal artery with luminal irregularities.  Left renal artery with luminal irregularities.  The abdominal aorta has 25% lesion.,Right common iliac has a 25% to 50% lesion as well as a distal 75% lesion.,The right external iliac has a proximal 75% lesion.,The distal part of the right external iliac as well as the right common femoral appears to be occlusive by the 5-French sheath.,The right SFA was visualized, although not very well.,Left common iliac with 25% to 50% lesion.  Left external iliac with 25% to 40% lesion.  Left common femoral with 25% to 40% lesion.  Left SFA with 25% lesion.  Left popliteal with wall luminal irregularities.,Three-vessel runoff is noted at the level of the left knee and at the level of the left ankle.,Conclusions:  Severe coronary artery disease.  Very severe peripheral arterial disease.,PLAN: , Because of the anatomic distribution of the coronary artery disease, for now we will continue medical treatment for CAD.  We will proceed with revascularization of the right external iliac as well as right common femoral.  Discontinue tobacco.",
" Reduced exercise capacity for age, no chest pain with exercise, no significant ST segment changes with exercise, symptoms of left anterior chest pain were not provoked with exercise, and hypertensive response noted with exercise.", Cardiovascular / Pulmonary, Exercise Stress Test - 2 ,"INDICATION: , This 69-year-old man is undergoing a preoperative evaluation for anticipated prostate surgery.  He is having a transurethral prostate resection performed by Dr. X for treatment of severely symptomatic prostatic hypertrophy.  He has recently completed radiation therapy to T11 for a plasmacytoma.  He has recently complained of left anterior chest pain, which radiates down the left upper arm towards the elbow.  This occurs during quiet periods such as in bed at night.  It may last all night and still be present in the morning.  It usually dissipates as the day progresses.  There are no obvious triggers and there are no obvious alleviating factors.  The patient has no known cardiac risk factors.  He is currently taking Avodart 0.5 mg daily, Wellbutrin 300 mg daily, Xanax 0.25 mg p.r.n., Uroxatral 10 mg daily, and omeprazole 20 mg daily.,PHYSICAL EXAMINATION: , On physical examination, the patient appears pale and fatigued.  He is 66 inches tall, 205 pounds for a body mass index of 32.  His resting heart rate is 80.  His resting blood pressure is 120/84.  His lungs are clear.  His heart exam reveals a regular rhythm and normal S1 and S2 without murmur, gallop, or rub appreciated.  The carotid upstroke is normal with no bruit identified.  The peripheral pulses are intact.  The resting electrocardiogram showed a sinus rhythm at 68 beats per minute and is normal.,DESCRIPTION: , The patient exercised according to the standard Bruce protocol stopping at 4 minutes and 39 seconds with fatigue.  He did not experience his left anterior chest pain with exercise.  He did achieve a maximal heart rate of 129 beats per minute, which is 85% of his maximal predicted heart rate.  His maximal blood pressure was 200/84, double product of 24,000 and achieving 7 METs.  As noted the resting electrocardiogram was normal.  With exercise, there were no significant deviations from baseline and no arrhythmias.,CONCLUSION:,1.  Reduced exercise capacity for age.,2.  No chest pain with exercise.,3.  No significant ST segment changes with exercise.,4.  Symptoms of left anterior chest pain were not provoked with exercise.,5.  Hypertensive response noted with exercise.","cardiovascular / pulmonary, regular rhythm, s1, s2, chest pain, hypertensive, bruce protocol, exercise stress test, blood pressure, resting electrocardiogram, anterior chest, heart rate, rhythm, electrocardiogram, stress, chest, heart"
 Chest pain.  Achieved optimum METs for the exercise done and this is a normal exercise treadmill stress test., Cardiovascular / Pulmonary, Exercise Stress Test - 4 ,"INDICATION: , Chest pain.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained from the patient, the patient was brought to the cardiology procedure room where he was hooked up to continuous hemodynamic monitoring.  The patient's baseline heart rate was 85 beats per minute and blood pressure was 124/90.  The patient was started on a Bruce protocol where he exercised for 11 minutes and 42 seconds achieving 12.8 METs.  The patient's maximum blood pressure during this stress part was 148/80 and the patient achieved heart rate of 152 with no EKG changes, no chest pain.,FINDINGS:,1.  Normal hemodynamic response to exercise.,2.  No EKG changes suggestive of ischemia.,3.  No chest pain during the stress test.,4.  Achieved optimum METs for the exercise done and this is a normal exercise treadmill stress test.","cardiovascular / pulmonary, treadmill stress test, heart rate, blood pressure, stress test, treadmill, hemodynamic, ekg, chest,"
" Fiberoptic bronchoscopy, diagnostic.  Hemoptysis and history of lung cancer.  Tumor occluding right middle lobe with friability.", Cardiovascular / Pulmonary, Fiberoptic Bronchoscopy - 1 ,"PREOPERATIVE DIAGNOSIS:,1.  Hemoptysis.,2.  History of lung cancer.,POSTOPERATIVE DIAGNOSIS:,  Tumor occluding right middle lobe with friability.,PROCEDURE PERFORMED:,  Fiberoptic bronchoscopy, diagnostic.,LOCATION: , Endoscopy suite #4.,ANESTHESIA:,  General per Anesthesia Service.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE: , The patient presented to ABCD Hospital with a known history of lung cancer and acute hemoptysis with associated chest pain.  Due to her prior history, it was felt that she would benefit from diagnostic fiberoptic bronchoscopy to help determine the etiology of the hemoptysis.  She was brought to endoscopy suite #4 and informed consent was obtained.  ,PROCEDURE DETAILS:  ,The patient was placed in the supine position and intubated by the Anesthesia Service.  Intravenous sedation was given as per Anesthesia.  The fiberoptic scope was passed through the #8 endotracheal tube into the main trachea.  The right mainstem bronchus was examined.  The right upper lobe and subsegments appeared grossly within normal limits with no endobronchial lesions noted.  Upon examining the right middle lobe, there was a tumor noted occluding the lateral segment of the right middle lobe and a clot appreciated over the medial segment of the right middle lobe.,The clot was lavaged with normal saline and there was noted to be tumor behind this clot.  Tumor completely occluded both segments of the right middle lobe.  Scope was then passed to the subsegments of the right lower lobe, which were individually examined and noted to be grossly free of endobronchial lesions.  Scope was pulled back to the level of the midtrachea, passed into the left mainstem bronchus.  Left upper lobe and its subsegments were examined and noted to be grossly free of endobronchial lesions.  The lingula and left lower subsegments were all each individually examined and noted to be grossly free of endobronchial lesions.  There were some secretions noted throughout the left lung.  The scope was retracted and passed again to the right mainstem bronchus.  The area of the right middle lobe was reexamined.  The tumor was noted to be grossly friable with oozing noted from the tumor with minimal manipulation.  It did not appear as if a scope or cannula could be passed distal to the tumor.  Due to continued oozing, 1 cc of epinephrine was applied topically with adequate hemostasis obtained.  The area was examined for approximately one minute for assurance of adequate hemostasis.  The scope was then retracted and the patient was sent to the recovery room in stable condition.  She will be extubated as per the Anesthesia Service.  Cytology and cultures were not sent due to the patient's known diagnosis.  Further recommendations are pending at this time.","cardiovascular / pulmonary, hemoptysis, lung cancer, tumor, fiberoptic, bronchoscopy, endoscopy suite, adequate hemostasis, fiberoptic bronchoscopy, endobronchial lesions, middle lobe, lobe,"
 No chest pain with exercise and no significant ECG changes with exercise. Poor exercise capacity 6 weeks following an aortic valve replacement and single-vessel bypass procedure., Cardiovascular / Pulmonary, Exercise Stress Test - 3 ,"INDICATIONS: , An 82-year-old man entering the cardiac rehabilitation program 6 weeks after a porcine aortic valve replacement and single-vessel coronary bypass graft procedure.  The patient has had a complicated postoperative course with rapid atrial fibrillation, pleural effusions, anemia and thrombocytopenia.  He is currently stabilized and improving in strength.  He is living in Nantucket with his daughter Debra Anderson while he recuperates and completes the cardiac rehabilitation program.  He has a few other significant medical problems.,MEDICATIONS:,1.  Toprol-XL 25 mg daily.,2.  Simvastatin 80 mg daily.,3.  Aspirin 81 mg daily.,4.  Synthroid 0.5 mg daily.,5.  Warfarin 1.5 mg daily.,PHYSICAL EXAMINATION: , The patient appears pale and fragile.  He is comfortable at rest.  His resting heart rate is 80.  His resting blood pressure is 112/70.  His conjunctivae are pale.  His lungs have decreased breath sounds throughout and dullness at the bases bilaterally.  Heart exam reveals a distant S1 and S2.  There is a short 2/6 systolic ejection murmur.  The extremities are normal without clubbing, cyanosis or edema.,The resting echocardiogram showed a sinus rhythm at 70 beats per minute.  There is poor R wave progression across the pericardium and Q waves inferiorly.,DESCRIPTION:  ,The patient exercised according to the modified Bruce protocol stopping at 3 minutes and 20 seconds with fatigue and shortness of breath.  He did not experience chest pain with exercise.  He did achieve a maximal heart rate of 100, which is 72% of his maximal predicted heart rate.  His maximal blood pressure was 190/70 resulting in a double product of 19,000 and achieving 2.3 METS.  As noted, the resting electrocardiogram had inferior Q waves and poor R wave progression.  There were no significant ST segment changes with exercise.  There were only rare ventricular premature beats with exercise.,CONCLUSION:,1.  Poor exercise capacity 6 weeks following an aortic valve replacement and single-vessel bypass procedure.,2.  No chest pain with exercise.,3.  No significant ECG changes with exercise.,4.  The patient is considered stable to enter our cardiac rehabilitation program.  I recommend the patient have a complete blood count, basic metabolic profile, and TSH obtained prior to entering the rehab program.","cardiovascular / pulmonary, bruce protocol, exercise stress test, cardiac rehabilitation program, blood pressure, cardiac rehabilitation, heart rate, stress, rehabilitation, heart, atrial,"
" Exercise stress test with nuclear scan for chest pain.  Chest pain resolved after termination of exercise. Good exercise duration, tolerance and double product.  Normal nuclear myocardial perfusion scan.", Cardiovascular / Pulmonary, Exercise Stress Test ,"INDICATION:  ,Chest pain.,INTERPRETATION: , Resting heart rate of 71, blood pressure 100/60.  EKG normal sinus rhythm.  The patient exercised on Bruce for 8 minutes on stage III.  Peak heart rate was 151, which is 87% of the target heart rate, blood pressure of 132/54.  Total METs was 10.1.  EKG revealed nonspecific ST depression in inferior and lateral leads.  The test was terminated because of fatigue.  The patient did have chest pain during exercise that resolved after termination of the exercise.,IN SUMMARY:,1.  Positive exercise ischemia with ST depression 0.5 mm.,2.  Chest pain resolved after termination of exercise.,3.  Good exercise duration, tolerance and double product.,NUCLEAR INTERPRETATION:,Resting and stress images were obtained with 10.1 mCi and 34.1 mCi of tetraphosphate injected intravenously by standard protocol.  Nuclear myocardial perfusion scan demonstrates homogenous and uniform distribution with tracer uptake without any evidence of reversible or fixed defect.  Gated SPECT revealed normal wall motion, ejection fraction of 68%.  End-diastolic volume of 77, end-systolic volume of 24.,IN SUMMARY:,1.  Normal nuclear myocardial perfusion scan.,2.  Ejection fraction of 68% by gated SPECT.","cardiovascular / pulmonary, chest pain, ekg, sinus, st depression, mci, gated spect, nuclear myocardial perfusion scan, ejection fraction, myocardial perfusion, perfusion scan, heart rate, spect, stress, nuclear, chest "
 Patient in ER complaining of shortness of breath (COPD), Cardiovascular / Pulmonary, ER Report - COPD ,"CHIEF COMPLAINT:,  The patient is a 49-year-old Caucasian male transported to the emergency room by his wife, complaining of shortness of breath.,HISTORY OF PRESENT ILLNESS:, The patient is known by the nursing staff here to have a long history of chronic obstructive pulmonary disease and emphysema. He has made multiple visits in the past. Today, the patient presents himself in severe respiratory distress. His wife states that since his recent admission of three weeks ago for treatment of pneumonia, he has not seemed to be able to recuperate, and has persistent complaints of shortness of breath.,Today, his symptoms worsened and she brought him to the emergency room. To the best of her knowledge, there has been no fever. He has persistent chronic cough, as always. More complete history cannot be taken because of the patient’s acute respiratory decompensation.,PAST MEDICAL HISTORY:,  Hypertension and emphysema.,MEDICATIONS:,  Lotensin and some water pill as well as, presumably, an Atrovent inhaler.,ALLERGIES:,  None are known.,HABITS:,  The patient is unable to cooperate with the history.,SOCIAL HISTORY:,  The patient lives in the local area with his wife.,REVIEW OF BODY SYSTEMS:,  Unable, secondary to the patient’s condition.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 96 degrees, axillary. Pulse 128. Respirations 48. Blood pressure 156/100. Initial oxygen saturations on room air are 80.,GENERAL: Reveals a very anxious, haggard and exhausted-appearing male, tripoding, with labored breathing.,HEENT: Head is normocephalic and atraumatic.,NECK: The neck is supple without obvious jugular venous distention.,LUNGS: Auscultation of the chest reveals very distant and faint breath sounds, bilaterally, without obvious rales.,HEART: Cardiac examination reveals sinus tachycardia, without pronounced murmur.,ABDOMEN: Soft to palpation.,Extremities: Without edema.,DIAGNOSTIC DATA:,  White blood count 25.5, hemoglobin 14, hematocrit 42.4, 89 polys, 1 band, 4 lymphocytes. Chemistry panel within normal limits, with the exception of sodium of 124, chloride 81, CO2 44, BUN 6, creatinine 0.7, glucose 182, albumin 3.3 and globulin 4.1. Troponin is 0.11. Urinalysis reveals yellow clear urine. Specific gravity greater than 1.030 with 2+ ketones, 1+ blood and 3+ protein. No white cells and 0-2 red cells.,Chest x-ray suboptimal in quality, but without obvious infiltrates, consolidation or pneumothorax.,CRITICAL CARE NOTE:,  Critical care one hour.,Shortly after the patient’s initial assessment, the patient apparently began to complain of chest pain and appeared to the nurse to have mounting exhaustion and respiratory distress. Although O2 had been placed, elevating his oxygen saturations to the mid to upper 90s, he continued to complain of symptoms, as noted above. He became progressively more rapidly obtunded. The patient did receive one gram of magnesium sulfate shortly after his arrival, and the BiPAP apparatus was being readied for his use. However, the patient, at this point, became unresponsive, unable to answer questions, and preparations were begun for intubation. The BiPAP apparatus was briefly placed while supplies and medications were assembled for intubation. It was noted that even with the BiPAP apparatus, in the duration of time which was required for transfer of oxygen tubing to the BiPAP mask, the patient’s O2 saturations rapidly dropped to the upper 60 range.,All preparations for intubation having been undertaken, Succinylcholine was ordered, but was apparently unavailable in the department. As the patient was quite obtunded, and while the Dacuronium was being sought, an initial trial of intubation was carried out using a straight blade and a cupped 7.9 endotracheal tube. However, the patient had enough residual muscle tension to make this impractical and further efforts were held pending administration of Dacuronium 10 mg. After approximately two minutes, another attempt at intubation was successful. The cords were noted to be covered with purulent exudates at the time of intubation.,The endotracheal tube, having been placed atraumatically, the patient was initially then nebulated on 100% oxygen, and his O2 saturations rapidly rose to the 90-100% range.,Chest x-ray demonstrated proper placement of the tube. The patient was given 1 mg of Versed, with decrease of his pulse from the 140-180 range to the 120 range, with satisfactory maintenance of his blood pressure.,Because of a complaint of chest pain, which I myself did not hear, during the patient’s initial triage elevation, a trial of Tridil was begun. As the patient’s pressures held in the slightly elevated range, it was possible to push this to 30 mcg per minute. However, after administration of the Dacuronium and Versed, the patient’s blood pressure fell somewhat, and this medication was discontinued when the systolic pressure briefly reached 98.,Because of concern regarding pneumonia or sepsis, the patient received one gram of Rocephin intravenously shortly after the intubation. A nasogastric and Foley were placed, and an arterial blood gas was drawn by respiratory therapy. Dr. X was contacted at this point regarding further orders as the patient was transferred to the Intensive Care Unit to be placed on the ventilator there. The doctor’s call was transferred to the Intensive Care Unit so he could leave appropriate orders for the patient in addition to my initial orders, which included Albuterol or Atrovent q. 2h. and Levaquin 500 mg IV, as well as Solu-Medrol.,Critical care note terminates at this time.,EMERGENCY DEPARTMENT COURSE:,  See the critical care note.,MEDICAL DECISION MAKING (DIFFERENTIAL DIAGNOSIS):,  This patient has an acute severe decompensation with respiratory failure. Given the patient’s white count and recent history of pneumonia, the possibility of recurrence of pneumonia is certainly there. Similarly, it would be difficult to rule out sepsis. Myocardial infarction cannot be excluded.,COORDINATION OF CARE:,  Dr. X was contacted from the emergency room and asked to assume the patient’s care in the Intensive Care Unit.,FINAL DIAGNOSIS:,  Respiratory failure secondary to severe chronic obstructive pulmonary disease.,DISCHARGE INSTRUCTIONS:, The patient is to be transferred to the Intensive Care Unit for further management.",
" Diagnostic fiberoptic bronchoscopy with biopsies and bronchoalveolar lavage.   Bilateral upper lobe cavitary lung masses.  Airway changes including narrowing of upper lobe segmental bronchi, apical and posterior on the right, and anterior on the left.  There are also changes of inflammation throughout.", Cardiovascular / Pulmonary, Fiberoptic Bronchoscopy ,"PREOPERATIVE DIAGNOSIS:,  Bilateral upper lobe cavitary lung masses.,POSTOPERATIVE DIAGNOSES:,1.  Bilateral upper lobe cavitary lung masses.,2.  Final pending pathology.,3.  Airway changes including narrowing of upper lobe segmental bronchi, apical and posterior on the right, and anterior on the left.  There are also changes of inflammation throughout.,PROCEDURE PERFORMED: , Diagnostic fiberoptic bronchoscopy with biopsies and bronchoalveolar lavage.,ANESTHESIA: , Conscious sedation was with Demerol 150 mg and Versed 4 mg IV.,OPERATIVE REPORT: , The patient is residing in the endoscopy suite.  After appropriate anesthesia and sedation, the bronchoscope was advanced transorally due to the patient's recent history of epistaxis.  Topical lidocaine was utilized for anesthesia.  Epiglottis and vocal cords demonstrated some mild asymmetry of the true cords with right true and false vocal cord appearing slightly more prominent.  This may be normal anatomic variant.  The scope was advanced into the trachea.  The main carina was sharp in appearance.  Right upper, middle, and lower segmental bronchi as well as left upper lobe and lower lobe segmental bronchi were serially visualized.  Immediately noted were some abnormalities including circumferential narrowing and probable edema involving the posterior and apical segmental bronchi on the right and to a lesser degree the anterior segmental bronchus on the left.  No specific intrinsic masses were noted.  Under direct visualization, the scope was utilized to lavage the posterior segmental bronchus in the right upper lobe.  Also cytologic brushings and protected bacteriologic brushing specimens were obtained.  Three biopsies were attempted within the cavitary lesion in the posterior segment of the right upper lobe.  During lavage, some caseous appearing debris appeared intermittently.  The specimens were collected and sent to the lab.  Procedure was terminated with hemostasis having been verified.  The patient tolerated the procedure well.,Throughout the procedure, the patient's vital signs and oximetry were monitored and remained within satisfactory limits.,The patient will be returned to her room with orders as per usual.","cardiovascular / pulmonary, inflammation, lung masses, lobe cavitary, bronchoalveolar, biopsies, segmental bronchi, fiberoptic, bronchoscopy, lavage, cavitary, segmental, lobe,"
 Patient complains of chest pain - possible esophageal reflux, Cardiovascular / Pulmonary, ER Report - Chest Pain ,"CHIEF COMPLAINT:, The patient complains of chest pain. ,HISTORY OF PRESENT ILLNESS: ,The patient is a 20-year-old male who states that he has had two previous myocardial infarctions related to his use of amphetamines. The patient has not used amphetamines for at least four to five months, according to the patient; however, he had onset of chest pain this evening. ,The patient describes the pain as midsternal pain, a burning type sensation that lasted several seconds. The patient took one of his own nitroglycerin tablets without any relief. The patient became concerned and came into the emergency department. ,Here in the emergency department, the patient states that his pain is a 1 on a scale of 1 to 10. He feels much more comfortable. He denies any shortness of breath or dizziness, and states that the pain feels unlike the pain of his myocardial infarction. The patient has no other complaints at this time. ,PAST MEDICAL HISTORY:, The patient's past medical history is significant for status post myocardial infarction in February of 1995 and again in late February of 1995. Both were related to illegal use of amphetamines. ,ALLERGIES:, None. ,CURRENT MEDICATIONS:, Include nitroglycerin p.r.n. ,PHYSICAL EXAMINATION: ,VITAL SIGNS: Blood pressure 131/76, pulse 50, respirations 18, temperature 96.5. ,GENERAL: The patient is a well-developed, well-nourished white male in no acute distress. The patient is alert and oriented x 3 and lying comfortably on the bed. ,HEENT: Atraumatic, normocephalic. The pupils are equal, round, and reactive. Extraocular movements are intact. ,NECK: Supple with full range of motion. No rigidity or meningismus. ,CHEST: Nontender. ,LUNGS: Clear to auscultation. ,HEART: Regular rate and rhythm. No murmur, S3, or S4. ,ABDOMEN: Soft, nondistended, nontender with active bowel sounds. No masses or organomegaly. No costovertebral angle tenderness. ,EXTREMITIES: Unremarkable. ,NEUROLOGIC: Unremarkable. ,EMERGENCY DEPARTMENT LABS:, The patient had a CBC, minor chemistry, and cardiac enzymes, all within normal limits. Chest x-ray, as read by me, was normal. Electrocardiogram, as read by me, showed normal sinus rhythm with no acute ST or T-wave segment changes. There were no acute changes seen on the electrocardiogram. O2 saturation, as interpreted by me, is 99%. ,EMERGENCY DEPARTMENT COURSE: ,The patient had a stable, uncomplicated emergency department course. The patient received 45 cc of Mylanta and 10 cc of viscous lidocaine with complete relief of his chest pain. The patient had no further complaints and stated that he felt much better shortly thereafter. ,AFTERCARE AND DISPOSITION: ,The patient was discharged from the emergency department in stable, ambulatory, good condition with instructions to use Mylanta for his abdominal pain and to follow up with his regular doctor in the next one to two days. Otherwise, return to the emergency department as needed for any problem. The patient was given a copy of his labs and his electrocardiogram. The patient was advised to decrease his level of activity until then. The patient left with final diagnosis of: ,FINAL DIAGNOSIS: ,1. Evaluation of chest pain. ,2. Possible esophageal reflux.",
 A 44-year-old woman with a history of rheumatoid arthritis admitted to the hospital with chest pain.  MI has been ruled out.  She has been referred for an exercise echocardiogram., Cardiovascular / Pulmonary, Exercise Stress Test - 1 ,"Informed written consent has been obtained from the patient.  I explained the procedure to her prior to initiation of such.  The appropriate time-out procedure as per Medical Center protocol was performed prior to the procedure being begun while the patient was actively participating with appropriate identification of the patient, procedure, physician, documentation, position.  There were no safety concerns noted by staff nor myself.,REST ECHO:,  EF 60%.  No wall motion abnormalities.  EKG shows normal sinus rhythm with mild ST depressions.  The patient exercised for 7 minutes 30 seconds on a standard Bruce protocol, exceeding target heart rate; no angina nor significant ECG changes seen.  Peak stress echo imaging shows EF of 75%, no regional wall motion abnormalities.  There was resting hypertension noted, systolic of approximately 152 mmHg with appropriate response of blood pressure to exercise.  No dysrhythmias noted.,IMPRESSION:,1.  Negative exercise ECG/echocardiogram stress evaluation for inducible ischemia in excess of target heart rate.,2.  Resting hypertension with appropriate response of blood pressure to exercise.,These results have been discussed with the patient.  Other management as per the hospital-based internal medicine service.,To be clear, there were no complications of this procedure.","cardiovascular / pulmonary, ecg/echocardiogram, exercise stress test, ecg, wall motion abnormalities, target heart rate, hypertension, echocardiogram"
" Ivor-Lewis esophagogastrectomy, feeding jejunostomy, placement of two right-sided 28 French chest tubes, and right thoracotomy.", Cardiovascular / Pulmonary," Esophagogastrectomy, Jejunostomy, & Chest Tubes ","OPERATION,1.  Ivor-Lewis esophagogastrectomy.,2.  Feeding jejunostomy.,3.  Placement of two right-sided #28-French chest tubes.,4.  Right thoracotomy.,ANESTHESIA:  ,General endotracheal anesthesia with a dual-lumen tube.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered.  Prior to administration of general anesthesia, the patient had an epidural anesthesia placed.  In addition, he had a dual-lumen endotracheal tube placed.  The patient was placed in the supine position to begin the procedure.  His abdomen and chest were prepped and draped in the standard surgical fashion.  After applying sterile dressings, a #10-blade scalpel was used to make an upper midline incision from the level of the xiphoid to just below the umbilicus.  Dissection was carried down through the linea using Bovie electrocautery.  The abdomen was opened.  Next, a Balfour retractor was positioned as well as a mechanical retractor.  Next, our attention was turned to freeing up the stomach.  In an attempt to do so, we identified the right gastroepiploic artery and arcade.  We incised the omentum and retracted it off the stomach and gastroepiploic arcade.  The omentum was divided using suture ligature with 2-0 silk.  We did this along the greater curvature and then moved to the lesser curvature where the short gastric arteries were taken down with ligation using 2-0 silk.  Next, we turned our attention to performing a Kocher maneuver.  This was done and the stomach was freed up.  We took down the falciform ligament as well as the caudate attachment to the diaphragm.  We enlarged the diaphragmatic hiatus so as to be able to place approximately 3 fingers into the chest.  We also did a portion of the esophageal dissection from the abdomen into the chest area.  The esophagus and the esophageal hiatus were identified in the abdomen.  We next turned our attention to the left gastric artery.  The left gastric artery was identified at the base of the stomach.  We first took the left gastric vein by ligating and dividing it using 0 silk ties.  The left gastric artery was next taken using suture ligature with silk ties followed by 2-0 stick tie reinforcement.  At this point the stomach was freely mobile.  We then turned our attention to performing our jejunostomy feeding tube.  A 2-0 Vicryl pursestring was placed in the jejunum approximately 20 cm distal to the ligament of Treitz.  We then used Bovie electrocautery to open the jejunum at this site.  We placed a 16-French red rubber catheter through this site.  We tied down in place.  We then used 3-0 silk sutures to perform a Witzel.  Next, the loop of jejunum was tacked up to the abdominal wall using 2-0 silk ties.  After doing so and pulling the feeding jejunostomy out through the skin and securing it appropriately, we turned our attention to closing the abdomen.  This was done with #1 Prolene.  We put in a 2nd layer of 2-0 Vicryl.  The skin was closed with 4-0 Monocryl.,Next, we turned our attention to performing the thoracic portion of the procedure.  The patient was placed in the left lateral decubitus position.  The right chest was prepped and draped appropriately.  We then used a #10 blade scalpel to make an incision in a posterolateral, non-muscle-sparing fashion.  Dissection was carried down to the level of the ribs with Bovie electrocautery.  Next, the ribs were counted and the 5th interspace was entered.  The lung was deflated.  We placed standard chest retractors.  Next, we incised the peritoneum over the esophagus.  We dissected the esophagus to just above the azygos vein.  The azygos vein, in fact, was taken with 0 silk ligatures and reinforced with 2-0 stick ties.  As mentioned, we dissected the esophagus both proximally and distally down to the level of the hiatus.  After doing this, we backed our NG tube out to above the level where we planned to perform our pursestring.  We used an automatic pursestring and applied.  We then transected the proximal portion of the stomach with Metzenbaum scissors.  We secured our pursestring and then placed a 28 anvil in the divided proximal portion of the esophagus.  The pursestring was then tied down without difficulty.  Next, we tabularized our stomach using a #80 GIA stapler.  After doing so, we chose a portion of the stomach more distally and opened it using Bovie electrocautery.  We placed our EEA stapler through it and then punched out through the gastric wall.  We connected our anvil to the EEA stapler.  This was then secured appropriately.  We checked to make sure that there was appropriate muscle apposition.  We then fired the stapler.  We obtained 2 complete rings, 1 of the esophagus and 1 of the stomach, which were sent for pathology.  We also sent the gastroesophageal specimen for pathology.  Of note was the fact that the frozen section showed no evidence of tumor and in the proximal distal margins.  We then turned our attention to closing the gastrostomy opening.  This was closed with 2-0 Vicryl in a running fashion.  We then buttressed this with serosal 3-0 Vicryl interrupted sutures.  We returned the newly constructed gastroesophageal anastomosis into the chest and covered it by covering the pleura over it.  Next, we placed two #28-French chest tubes, 1 anteriorly and 1 posteriorly, taking care not to place it near the anastomosis.  We then closed the chest with #2 Vicryl in an interrupted figure-of-eight fashion.  The lung was brought up.  We closed the muscle layers with #0 Vicryl followed by #0 Vicryl; then we closed the subcutaneous layer with 2-0 Vicryl and the skin with 4-0 Monocryl.  Sterile dressing was applied.  The instrument and sponge count was correct at the end of the case.  The patient tolerated the procedure well and was extubated in the operating room and transferred to the ICU in good condition.","cardiovascular / pulmonary, ivor-lewis, esophagogastrectomy, jejunostomy, thoracotomy, dual-lumen tube, chest tubes, bovie electrocautery, chest, endotracheal, electrocautery, abdomen, gastric, esophagus, tubes, vicryl, stomach, "
" Elevated BNP.  Diastolic heart failure, not contributing to his present problem. Chest x-ray and CAT scan shows possible pneumonia.  The patient denies any prior history of coronary artery disease but has a history of hypertension.", Cardiovascular / Pulmonary, Elevated BNP - Consult ,"REASON FOR REFERRAL: , Elevated BNP.,HISTORY OF PRESENT ILLNESS:,  The patient is a 95-year-old Caucasian male visiting from out of state, admitted because of the fall and could not get up and has a cough with dark color sputum, now admitted with pneumonia and a fall and the patient's BNP level was high, for which Cardiology consult was requested.  The patient denies any chest pain or shortness of breath.  Chest x-ray and CAT scan shows possible pneumonia.  The patient denies any prior history of coronary artery disease but has a history of hypertension.,ALLERGIES: , No known drug allergies.,MEDICATIONS:,  At this time, he is on:,1.  Atrovent and albuterol nebulizers.,2.  Azithromycin.,3.  Potassium chloride 10 mEq p.o. daily.,4.  Furosemide 20 mg IV daily.,5.  Enoxaparin 40 mg daily.,6.  Lisinopril 10 mg p.o. daily.,7.  Ceftriaxone.,PAST MEDICAL HISTORY: , History of hypertension.,PAST SURGICAL HISTORY:,  History of abdominal surgery.,SOCIAL HISTORY: , He does not smoke.  Drinks occasionally.,FAMILY HISTORY:  ,Noncontributory.,REVIEW OF SYSTEMS: , Denies chest pain, PND, or orthopnea.  He has cough.  No fever.  No abdominal pain.  No syncope, near-syncope, or palpitation.  All other systems were reviewed.,PHYSICAL EXAMINATION:,GENERAL:  The patient is comfortable, not in distress.,VITAL SIGNS:  His blood pressure is 118/50, pulse rate 76, respiratory rate 18, and temperature 98.1.,HEENT:  Atraumatic, normocephalic.  Eyes PERRLA.,NECK:  Supple.  No JVD.  No carotid bruit.,CHEST:  Clear.,HEART:  S1 and S2, regular.  No S3.  No S4.  No murmur.,ABDOMEN:  Soft, nontender.  Positive bowel sounds.,EXTREMITIES:  No cyanosis, clubbing, or edema.  Pulse 2+.,CNS:  Alert, awake, and oriented x3.,DIAGNOSTIC DATA:,  EKG shows sinus tachycardia, nonspecific ST-T changes, nonspecific intraventricular conduction delay.  CT chest shows bilateral pleural effusion, compressive atelectasis, pneumonic infiltrate noted in the right lower lobe.  Loculated pleural effusion in the left upper lobe.  No PE.  Chest x-ray shows bilateral lower lobe patchy opacities concerning for atelectasis or pneumonia.,LABORATORY DATA: , Sodium 139, potassium 4.1, BUN 26, creatinine 0.9, BNP 331, troponin less than 0.05.  White cell count 7.1, hemoglobin 11.5, hematocrit 35.2, platelet 195,000.,ASSESSMENT:,1.  Pneumonia.,2.  Diastolic heart failure, not contributing to his present problem.,3.  Hypertension, controlled.,4.  History of falls.,PLAN: , We will continue IV low-dose diuretics, continue lisinopril, continue IV antibiotics.  No further cardiac workup at this time.",
  Endotracheal intubation.  The patient was intubated secondary to respiratory distress and increased work of breathing and falling saturation on 15 liters nonrebreather.  PCO2 was 29 and pO2 was 66 on the 15 liters., Cardiovascular / Pulmonary, Endotracheal Intubation - 1 ,"PROCEDURE PERFORMED: , Endotracheal intubation.,INDICATION FOR PROCEDURE:  ,The patient was intubated secondary to respiratory distress and increased work of breathing and falling saturation on 15 liters nonrebreather.  PCO2 was 29 and pO2 was 66 on the 15 liters.,NARRATIVE OF PROCEDURE: , The patient was given a total of 5 mg of Versed, 20 mg of etomidate, and 10 mg of vecuronium.  He was intubated in a single attempt.  Cords were well visualized, and a #8 endotracheal tube was passed using a curved blade.  Fiberoptically, a bronchoscope was passed for lavage and the tube was found to be in good position 3 cm above the main carina where it was kept there and the right lower lobe was lavaged with trap A lavage with 100 mL of normal sterile saline for cytology, AFB, and fungal smear and culture.  A separate trap B was then lavaged for bacterial C&S and Gram stain and was sent for those purposes.  The patient tolerated the procedure well.","cardiovascular / pulmonary, nonrebreather, respiratory distress, falling saturation, endotracheal intubation, lavage, breathingNOTE"
 Exercise myocardial perfusion study.  The exercise myocardial perfusion study shows possibility of mild ischemia in the inferolateral wall and normal LV systolic function with LV ejection fraction of 59%, Cardiovascular / Pulmonary, Exercise Myocardial Perfusion Study ,"CLINICAL INDICATION:,  Chest pain.,INTERPRETATION: , The patient received 14.9 mCi of Cardiolite for the rest portion of the study and 11.5 mCi of Cardiolite for the stress portion of the study.,The patient's baseline EKG was normal sinus rhythm.  The patient was stressed according to Bruce protocol by Dr. X.  Exercise test was supervised and interpreted by Dr. X.  Please see the separate report for stress portion of the study.,The myocardial perfusion SPECT study shows there is mild anteroseptal fixed defect seen, which is most likely secondary to soft tissue attenuation artifact.  There is, however, mild partially reversible perfusion defect seen, which is more pronounced in the stress images and short-axis view suggestive of minimal ischemia in the inferolateral wall.,The gated SPECT study shows normal wall motion and wall thickening with calculated left ventricular ejection fraction of 59%.,CONCLUSION:,1.  The exercise myocardial perfusion study shows possibility of mild ischemia in the inferolateral wall.,2.  Normal LV systolic function with LV ejection fraction of 59%.","cardiovascular / pulmonary, chest pain, cardiolite, ekg, spect, lv systolic function, lv ejection fraction, myocardial perfusion study, spect study, ejection fraction, myocardial, perfusion, ischemia, "
" Echocardiographic examination.  Borderline left ventricular hypertrophy with normal ejection fraction at 60%, mitral annular calcification with structurally normal mitral valve, no intracavitary thrombi is seen, interatrial septum was somewhat difficult to assess, but appeared to be intact on the views obtained.", Cardiovascular / Pulmonary, Echocardiography ,"REASON FOR EXAM:,  CVA.,INDICATIONS: , CVA.,This is technically acceptable.  There is some limitation related to body habitus.,DIMENSIONS:  ,The interventricular septum 1.2, posterior wall 10.9, left ventricular end-diastolic 5.5, and end-systolic 4.5, the left atrium 3.9.,FINDINGS: , The left atrium was mildly dilated.  No masses or thrombi were seen.  The left ventricle showed borderline left ventricular hypertrophy with normal wall motion and wall thickening, EF of 60%.  The right atrium and right ventricle are normal in size.,Mitral valve showed mitral annular calcification in the posterior aspect of the valve.  The valve itself was structurally normal.  No vegetations seen.  No significant MR. Mitral inflow pattern was consistent with diastolic dysfunction grade 1.  The aortic valve showed minimal thickening with good exposure and coaptation.  Peak velocity is normal.  No AI.,Pulmonic and tricuspid valves were both structurally normal.,Interatrial septum was appeared to be intact in the views obtained.  A bubble study was not performed.,No pericardial effusion was seen.  Aortic arch was not assessed.,CONCLUSIONS:,1.  Borderline left ventricular hypertrophy with normal ejection fraction at 60%.,2.  Mitral annular calcification with structurally normal mitral valve.,3.  No intracavitary thrombi is seen.,4.  Interatrial septum was somewhat difficult to assess, but appeared to be intact on the views obtained.","cardiovascular / pulmonary, ventricular hypertrophy, normal wall motion, ventricle, atrium, annular calcification, mitral valve, interatrial septum, hypertrophy, annular, thrombi, ventricular, structurally, septum, valve, mitral,"
 Endovascular Brachytherapy (EBT), Cardiovascular / Pulmonary, Endovascular Brachytherapy ,"ENDOVASCULAR BRACHYTHERAPY (EBT),The patient is to undergo a course of angioplasty for in-stent restenosis.  The radiotherapy will be planned using simulation films when the Novoste system catheter markers are placed on either side of the coronary artery injury site.  After this, a calculation will take place to determine the length of time at which the strontium sources will be left in place to deliver an adequate dose given the reference vessel diameter.  The rationale for this treatment is based on radiobiological principles that make this type of therapy more effective than blade atherectomy or laser atherectomy.  The does per fraction is individualized for each patient according to radiobiological principles and reference vessel diameter.  Given that this is a very high dose rate source and the chances of severe acute toxicity such as cardiac ischemia and machine malfunction are present, it is imperative that the patient be followed closely by myself and monitored for ST segment elevation and correct machine function.","cardiovascular / pulmonary, endovascular brachytherapy, ebt, angioplasty, stent, vessel, atherectomy, endovascular, brachytherapyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Abnormal cardiac enzyme profile.  The patient is a 66-year-old gentleman, was brought into emergency room with obtundation.  The patient was mechanically ventilated originally.  His initial diagnosis was septic shock.  His labs showed elevated cardiac enzyme profile. ", Cardiovascular / Pulmonary, Elevated Cardiac Enzymes ,"REASON FOR CONSULTATION:,  Abnormal cardiac enzyme profile.,HISTORY OF PRESENT ILLNESS:,  The patient is a 66-year-old gentleman, was brought into emergency room with obtundation.  The patient was mechanically ventilated originally.  His initial diagnosis was septic shock.  His labs showed elevated cardiac enzyme profile.  This is a consultation for evaluation of the same.  The patient is unable to give history.  History obtained through the family members.  As per the patient's son, he does not have history of cardiac disease.  He lives in Utah, presently spending few months in Arizona.  As I understand, he has been followed by a physician back in Utah and believes that he had some workup done from cardiac standpoint which has been negative so far.  No prior history of chest pain, shortness of breath as per the family members.,CORONARY RISK FACTORS: , History of hypertension, no history of diabetes mellitus, ex-smoker, cholesterol status borderline elevated, no prior history of coronary artery disease, and family history noncontributory.,FAMILY HISTORY: , Nonsignificant.,SURGICAL HISTORY: , Foot surgery as per the family members.,MEDICATIONS:,1.  Vitamin supplementation.,2.  Prednisone.,3.  Cyclobenzaprine.,4.  Losartan 50 mg daily.,5.  Nifedipine 90 mg daily.,6.  Lasix.,7.  Potassium supplementation.,ALLERGIES:,  SULFA.,PERSONAL HISTORY:,  He is an ex-smoker.  Does not consume alcohol.,PAST MEDICAL HISTORY: , Pulmonary fibrosis, on prednisone, oxygen-dependent cellulitis status post foot surgery with infection recuperating from the same.  Presentation today with respiratory acidosis, septicemia and septic shock, presently on mechanical ventilation.  No prior cardiac history.  Elevated cardiac enzyme profile.,REVIEW OF SYSTEMS: , Limited.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 94, blood pressure 98/57, respiratory rate as per setting.,HEENT:  Atraumatic and normocephalic.,NECK:  Supple.  Neck veins flat.,LUNGS:  Air entry bilaterally clear, rales are scattered.,HEART:  PMI displaced.  S1, S2 regular.  Systolic murmur, grade 2/6.,ABDOMEN:  Soft, nontender.,EXTREMITIES:  Chronic skin changes, markings in the lower extremities noted.  Pulses found palpable.  Dressing also noted.,LABORATORY AND DIAGNOSTIC DATA: , EKG, normal sinus rhythm with wide complex.  Labs, white count of 20,000, H&H 10 and 33, platelets of 163, INR 1.36, BUN of 158, creatinine 8.7, potassium 7.3, of bicarbonate is 11.  Cardiac enzyme profile, troponin 0.05, total CK 312, myoglobin 1423.  Chest x-ray, no acute changes.,IMPRESSION:,1.  The patient is a 66-year-old gentleman with pulmonary fibrosis, on prednisone, oxygen dependent with respiratory acidosis.,2.  Septicemia, septic shock secondary to cellulitis of the leg.,3.  Acute renal shutdown.,4.  Elevated cardiac enzyme profile without prior cardiac history possibly due to sepsis and also acute renal failure.,RECOMMENDATIONS:,1.  Echocardiogram to assess LV function to rule out any cardiac valvular involvement.,2.  Aggressive medical management including dialysis.,3.  From cardiac standpoint, conservative treatment at this juncture.  His cardiac enzyme profile could be elevated secondary to sepsis and also underlying renal failure.,4.  Explained to patient's family in detail regarding condition which is critical which they are aware of.",
 Endotracheal intubation.  Respiratory failure.  The patient is a 52-year-old male with metastatic osteogenic sarcoma.  He was admitted two days ago with small bowel obstruction., Cardiovascular / Pulmonary, Endotracheal Intubation ,"PROCEDURE: , Endotracheal intubation.,INDICATION: , Respiratory failure.,BRIEF HISTORY: , The patient is a 52-year-old male with metastatic osteogenic sarcoma.  He was admitted two days ago with small bowel obstruction.  He has been on Coumadin for previous PE and currently on heparin drip.  He became altered and subsequently deteriorated quite rapidly to the point where he is no longer breathing on his own and has minimal responsiveness.  A code blue was called.  On my arrival, the patient's vital signs are stable.  His blood pressure is systolically in 140s and heart rate 80s.  He however has 0 respiratory effort and is unresponsive to even painful stimuli.  The patient was given etomidate 20 mg.,DESCRIPTION OF PROCEDURE:  ,The patient positioned appropriate equipment at the bedside, given 20 mg of etomidate and 100 mg of succinylcholine.  Mac-4 blade was used.  A 7.5 ET tube placed to 24th teeth.  There is good color change on the capnographer with bilateral breath sounds.  Following intubation, the patient's blood pressure began to drop.  He was given 2 L of bolus.  I started him on dopamine drip at 10 mcg.  Dr. X was at the bedside, who is the primary caregiver, he assumed the care of the patient, will be transferred to the ICU.  Chest x-ray will be reviewed and Pulmonary will be consulted.","cardiovascular / pulmonary, metastatic osteogenic sarcoma, respiratory failure, bowel obstruction, blood pressure, endotracheal intubation, endotracheal, sarcoma"
 Echocardiogram was performed including 2-D and M-mode imaging., Cardiovascular / Pulmonary, Echocardiogram - 1 ,"EXAM:,  Echocardiogram.,INTERPRETATION: , Echocardiogram was performed including 2-D and M-mode imaging, Doppler analysis continuous wave and pulse echo outflow velocity mapping was all seen in M-mode.  Cardiac chamber dimensions, left atrial enlargement 4.4 cm.  Left ventricle, right ventricle, and right atrium are grossly normal.  LV wall thickness and wall motion appeared normal.  LV ejection fraction is estimated at 65%.  Aortic root and cardiac valves appeared normal.  No evidence of pericardial effusion.  No evidence of intracardiac mass or thrombus.  Doppler analysis outflow velocity through the aortic valve normal, inflow velocities through the mitral valve are normal.  There is mild tricuspid regurgitation.  Calculated pulmonary systolic pressure 42 mmHg.,ECHOCARDIOGRAPHIC DIAGNOSES:,1.  LV Ejection fraction, estimated at 65%.,2.  Mild left atrial enlargement.,3.  Mild tricuspid regurgitation.,4.  Mildly elevated pulmonary systolic pressure.","cardiovascular / pulmonary, lv ejection fraction, ejection fraction, tricuspid regurgitation, systolic pressure, valves, atrial, echocardiogram,"
" Echocardiographic Examination Report.   Angina and coronary artery disease.  Mild biatrial enlargement, normal thickening of the left ventricle with mildly dilated ventricle and EF of 40%, mild mitral regurgitation, diastolic dysfunction grade 2, mild pulmonary hypertension.", Cardiovascular / Pulmonary, Echocardiogram - 3 ,"REASON FOR EXAM:,1.  Angina.,2.  Coronary artery disease.,INTERPRETATION:  ,This is a technically acceptable study.,DIMENSIONS:  ,Anterior septal wall 1.2, posterior wall 1.2, left ventricular end diastolic 6.0, end systolic 4.7.  The left atrium is 3.9.,FINDINGS:  ,  Left atrium was mildly to moderately dilated.  No masses or thrombi were seen.  The left ventricle was mildly dilated with mainly global hypokinesis, more prominent in the inferior septum and inferoposterior wall.  The EF was moderately reduced with estimated EF of 40% with near normal thickening.  The right atrium was mildly dilated.  The right ventricle was normal in size.,Mitral valve showed to be structurally normal with no prolapse or vegetation.  There was mild mitral regurgitation on color flow interrogation.  The mitral inflow pattern was consistent with pseudonormalization or grade 2 diastolic dysfunction.  The aortic valve appeared to be structurally normal.  Normal peak velocity.  No significant AI.  Pulmonic valve showed mild PI.  Tricuspid valve showed mild tricuspid regurgitation.  Based on which, the right ventricular systolic pressure was estimated to be mildly elevated at 40 to 45 mmHg.  Anterior septum appeared to be intact.  No pericardial effusion was seen.,CONCLUSION:,1.  Mild biatrial enlargement.,2.  Normal thickening of the left ventricle with mildly dilated ventricle and EF of 40%.,3.  Mild mitral regurgitation.,4.  Diastolic dysfunction grade 2.,5.  Mild pulmonary hypertension.","cardiovascular / pulmonary, angina, coronary artery disease, septal, ventricular, diastolic, systolic, pulmonary hypertension, mitral regurgitation, septum, tricuspid, thickening, dysfunction, wall, ef, regurgitation, atrium, valve, dilated, mitral, ventricle, mildly,"
" Echocardiogram for aortic stenosis.  Transthoracic echocardiogram was performed of adequate technical quality.  Concentric hypertrophy of the left ventricle with normal function.  Doppler study as above, most pronounced being moderate aortic stenosis, valve area of 1.1 sq. cm", Cardiovascular / Pulmonary, Echocardiogram - 2 ,"EXAM:,  Echocardiogram.,INDICATION: , Aortic stenosis.,INTERPRETATION: , Transthoracic echocardiogram was performed of adequate technical quality.  Left ventricle reveals concentric hypertrophy with normal size and dimensions and normal function.  Ejection fraction is 60% without any obvious wall motion abnormality.  Left atrium and right side chambers are of normal size and dimensions.  Aortic root has normal diameter.,Mitral and tricuspid valves are structurally normal except for minimal annular calcification.  Valvular leaflet excursion is adequate.  Aortic valve reveals annular calcification.  Fibrocalcific valve leaflets with decreased excursion.  Atrial and ventricular septum are intact.  Pericardium is intact without any effusion.  No obvious intracardiac mass or thrombi noted.,Doppler reveals mild mitral regurgitation, mild-to-moderate tricuspid regurgitation.  Estimated pulmonary pressure of 48.  Systolic consistent with mild-to-moderate pulmonary hypertension.  Peak velocity across the aortic valve is 3.0 with a peak gradient of 37, mean gradient of 19, valve area calculated at 1.1 sq. cm consistent with moderate aortic stenosis.,IN SUMMARY:,1. Concentric hypertrophy of the left ventricle with normal function.,2. Doppler study as above, most pronounced being moderate aortic stenosis, valve area of 1.1 sq. cm.","cardiovascular / pulmonary, moderate aortic stenosis, annular calcification, concentric hypertrophy, aortic stenosis, echocardiogram, stenosis, valve, aortic, "
 Duplex ultrasound of legs, Cardiovascular / Pulmonary, Duplex Ultrasound - Legs ,"DUPLEX ULTRASOUND OF LEGS,RIGHT LEG:,  Duplex imaging was carried out according to normal protocol with a 7.5 Mhz imaging probe using B-mode ultrasound.  Deep veins were imaged at the level of the common femoral and popliteal veins.  All deep veins demonstrated compressibility without evidence of intraluminal thrombus or increased echogenicity.,The long saphenous system displayed compressibility without evidence of thrombosis.  The long saphenous vein measured * cm at the proximal thigh with reflux of * seconds after release of distal compression and * cm at the knee with reflux of * seconds after release of distal compression.  The small saphenous system measured * cm at the proximal calf with reflux of * seconds after release of distal compression.,LEFT LEG:,  Duplex imaging was carried out according to normal protocol with a 7.5 Mhz imaging probe using B-mode ultrasound.  Deep veins were imaged at the level of the common femoral and popliteal veins.  All deep veins demonstrated compressibility without evidence of intraluminal thrombus or increased echogenicity.,The long saphenous system displayed compressibility without evidence of thrombosis.  The long saphenous vein measured * cm at the proximal thigh with reflux of * seconds after release of distal compression and * cm at the knee with reflux of * seconds after release of distal compression.  The small saphenous system measured * cm at the proximal calf with reflux of * seconds after release of distal compression.","cardiovascular / pulmonary, duplex ultrasound, b-mode ultrasound, duplex imaging, compression, echogenicity, femoral, intraluminal thrombus, popliteal, saphenous vein, thrombosis, release of distal compression, calf with reflux, distal compression, duplex, ultrasound, legs, saphenous, release, distal, veins,"
" Dobutamine Stress Echocardiogram.  Chest discomfort, evaluation for coronary artery disease.  Maximal dobutamine stress echocardiogram test achieving more than 85% of age-predicted heart rate.  Negative EKG criteria for ischemia.", Cardiovascular / Pulmonary, Dobutamine Stress Test - 1 ,"DOBUTAMINE STRESS ECHOCARDIOGRAM,REASON FOR EXAM: , Chest discomfort, evaluation for coronary artery disease.,PROCEDURE IN DETAIL: , The patient was brought to the cardiac center.  Cardiac images at rest were obtained in the parasternal long and short axis, apical four and apical two views followed by starting with a dobutamine drip in the usual fashion at 10 mcg/kg per minute for low dose, increased every 2 to 3 minutes by 10 mcg/kg per minute.  The patient maximized at 30 mcg/kg per minute.  Images were obtained at that level after adding 0.7 mg of atropine to reach maximal heart rate of 145.  Maximal images were obtained in the same windows of parasternal long and short axis, apical four and apical two windows.,Wall motion assessed at all levels as well as at recovery.,The patient got nauseated, had some mild shortness of breath.  No angina during the procedure and the maximal amount of dobutamine was 30 mcg/kg per minute.,The resting heart rate was 78 with the resting blood pressure 186/98.  Heart rate reduced by the vasodilator effects of dobutamine to 130/80.  Maximal heart rate achieved was 145, which is 85% of age-predicted heart rate.,The EKG at rest showed sinus rhythm with no ST-T wave depression suggestive of ischemia or injury.  Incomplete right bundle-branch block was seen.  The maximal stress test EKG showed sinus tachycardia.  There was subtle upsloping ST depression in III and aVF, which is a normal response to the tachycardia with dobutamine, but no significant depression suggestive of ischemia and no ST elevation seen.,No ventricular tachycardia or ventricular ectopy seen during the test.  The heart rate recovered in a normal fashion after using metoprolol 5 mg.,The heart images were somewhat suboptimal to evaluate because of obesity and some problems with the short axis windows mainly at peak exercise.,The EF at rest appeared to be normal at 55 to 60 with normal wall motion including anterior, anteroseptal, inferior, lateral, and septal walls at low dose.  All walls mentioned were augmented in a normal fashion.  At maximum dose, all walls were augmented on all views except for the short axis was foreshortened, was uncertain about the anterolateral wall at peak exercise; however, of the other views, the lateral wall was showing normal thickening and normal augmentation.  EF improved to about 70%.,The wall motion score was unchanged.,IMPRESSION:,1.  Maximal dobutamine stress echocardiogram test achieving more than 85% of age-predicted heart rate.,2.  Negative EKG criteria for ischemia.,3.  Normal augmentation at low and maximum stress test with some uncertainty about the anterolateral wall in peak exercise only on the short axis view.  This is considered the negative dobutamine stress echocardiogram test, medical management.","cardiovascular / pulmonary, chest discomfort, coronary artery disease, predicted heart rate, dobutamine stress echocardiogram, anterolateral wall, echocardiogram test, wall motion, stress echocardiogram, short axis, dobutamine stress, heart rate, dobutamine, stress, ekg, echocardiogram, artery, ischemia, heart"
 Echocardiogram with color flow and conventional Doppler interrogation., Cardiovascular / Pulmonary, Echocardiogram ,"REASON FOR EXAMINATION: , Cardiac arrhythmia.,INTERPRETATION: , No significant pericardial effusion was identified.,The aortic root dimensions are within normal limits.  The four cardiac chambers dimensions are within normal limits.  No discrete regional wall motion abnormalities are identified.  The left ventricular systolic function is preserved with an estimated ejection fraction of 60%.  The left ventricular wall thickness is within normal limits.,The aortic valve is trileaflet with adequate excursion of the leaflets.  The mitral valve and tricuspid valve motion is unremarkable.  The pulmonic valve is not well visualized.,Color flow and conventional Doppler interrogation of cardiac valvular structures revealed mild mitral regurgitation and mild tricuspid regurgitation with an RV systolic pressure calculated to be 28 mmHg.  Doppler interrogation of the mitral in-flow pattern is within normal limits for age.,IMPRESSION:,1.  Preserved left ventricular systolic function.,2.  Mild mitral regurgitation.,3.  Mild tricuspid regurgitation.","cardiovascular / pulmonary, arrhythmia, wall motion, ventricular systolic function, color flow, conventional doppler, systolic function, mitral regurgitation, mild tricuspid, tricuspid regurgitation, echocardiogram, doppler, cardiac, ventricular, systolic, tricuspid, valve, mitral, regurgitation, "
" Dual chamber generator replacement.  The patient is a pleasant patient who presented to the office, recently was found to be at ERI and she has been referred for generator replacement.", Cardiovascular / Pulmonary, Dual Chamber Generator Replacement ,"REFERRAL INDICATIONS,1.  Pacemaker at ERI.,2.  History AV block.,PROCEDURES PLANNED AND PERFORMED:,  Dual chamber generator replacement.,FLUOROSCOPY TIME: , 0 minutes.,MEDICATION AT THE TIME OF STUDY,1.  Ancef 1 g.,2.  Versed 2 mg.,3.  Fentanyl 50 mcg.,CLINICAL HISTORY:  ,The patient is a pleasant patient who presented to the office, recently was found to be at ERI and she has been referred for generator replacement.,RISKS AND BENEFITS: , Risks, benefits, and alternatives to generator replacement have been discussed with the patient.  Risks including but not limited to bleeding, infection, vascular injury, and the need for pacemaker upgrade were discussed with the patient.  The patient agreed both verbally and via written consent.,DESCRIPTION OF OPERATION: , The patient was transported to the cardiac catheterization laboratory in a fasting state.  The region of the left dorsal pectoral groove was prepped and draped in a usual sterile manner.  Lidocaine 1% (20 mL) was administered to the area of the previous incision.  A transverse incision was made through the skin and subcutaneous tissue.  Hemostasis was achieved with electrocautery.  Using blunt dissection, pacemaker, and leads were removed from the pocket.  Leads were disconnected from the pulse generator and interrogated.  The pocket was washed with antibiotic impregnated saline.  The new pulse generator was obtained and connected securely to the leads and placed back in the pocket.  The pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using running stitch.  Sponge and needle counts were correct at the end of the procedure.  No acute complications were noted.,DEVICE DATA,1.  Explanted pulse generator Medronic, product # KDR601, serial # ABCD1234.,2.  New pulse generator Medronic, product # ADDR01, serial # ABCD1234.,3.  Right atrial lead, product # 4068, serial # ABCD1234.,4.  Right atrial lead, product # 4068, serial # ABCD1234.,MEASURED INTRAOPERATIVE DATA,1.  Right atrial lead impedance 572 ohms.  P wave measure 3.7 mV, pacing threshold 1.5 volts at 0.5 msec.,2.  Right ventricular lead impedance 365 ohms.  No R waves to measure, pacing threshold 0.9 volts at 0.5 msec.,CONCLUSIONS,1.  Successful dual chamber generator replacement.,2.  No acute complications.,PLAN,1.  She will be monitored for 3 hours and then dismissed home.,2.  Resume all medications.  Ex-home dismissal instructions.,3.  Doxycycline 100 mg one p.o. twice daily for 7 days.,4.  Wound check in 7-10 days.,5.  Continue followup in device clinic.",
"  Dual Chamber ICD Implantation, fluoroscopy,  defibrillation threshold testing, venography.", Cardiovascular / Pulmonary, Dual Chamber ICD Implantation ,"PROCEDURE:,1.  Implantation, dual chamber ICD.,2.  Fluoroscopy.,3.  Defibrillation threshold testing.,4.  Venography.,PROCEDURE NOTE: , After informed consent was obtained, the patient was taken to the operating room.  The patient was prepped and draped in a sterile fashion.  Using modified Seldinger technique, the left subclavian vein was attempted to be punctured but unsuccessfully.  Approximately 10 cc of intravenous contrast was injected into the left upper extremity peripheral vein.  Venogram was then performed.  Under fluoroscopy via modified Seldinger technique, the left subclavian vein was punctured and a guidewire was passed through the vein into the superior vena cava, then the right atrium and then into the inferior vena cava.  A second guidewire was placed in a similar fashion.  Approximately a 5 cm incision was made in the left upper anterior chest.  The skin and subcutaneous tissue was dissected out of the prepectoral fascia.  Both guide wires were brought into the pocket area.  A sheath was placed over the lateral guidewire and fluoroscopically guided to the vena cava.  The dilator and guidewire were removed.  A Fixation ventricular lead, under fluoroscopic guidance, was placed through the sheath into the superior vena cava, right atrium and then right ventricle.  Using straight and curved stylettes, it was placed in position and screwed into the right ventricular apex.  After pacing and sensing parameters were established in the lead, the collar on the lead was sutured to the pectoral muscle with Ethibond suture.  A guide sheath was placed over the guidewire and fluoroscopically placed in the superior vena cava.  The dilator and guidewire were removed.  An Active Fixation atrial lead was fluoroscopically passed through the sheath, into the superior vena cava and then the right atrium.  Using straight and J-shaped stylettes, it was placed in the appropriate position and screwed in the right atrial appendage area.  After significant pacing parameters were established in the lead, the collar on the lead was sutured to the pectoral muscles with Ethibond suture.  The tract was flushed with saline solution.  A Medtronic pulse generator was attached to both the leads and fixed to the pectoral muscle with Ethibond suture.  Deep and superficial layers were closed with 3-0 Vicryl in a running fashion.  Steri-strips were placed over the incision.  Tegaderm was placed over the Steri-strips.  Pressure dressing was applied to the pocket area.","cardiovascular / pulmonary, venography, defibrillation threshold testing, venogram, dual chamber icd implantation, dual chamber icd, superior vena cava, seldinger technique, pectoral muscle, steri strips, dual chamber, ethibond suture, superior vena, vena cava, dual, chamber, icd, implantation, fluoroscopy, atrium, pectoral, vein, fluoroscopically, vena, cava, lead, guidewire,"
" Insertion of a double lumen port through the left femoral vein, radiological guidance.  Open exploration of the left subclavian and axillary vein.  Metastatic glossal carcinoma, needing chemotherapy and a port.", Cardiovascular / Pulmonary, Double Lumen Port Inserstion ,"PREOPERATIVE DIAGNOSIS:,  Metastatic glossal carcinoma, needing chemotherapy and a port.,POSTOPERATIVE DIAGNOSIS: , Metastatic glossal carcinoma, needing chemotherapy and a port.,PROCEDURES,1.  Open exploration of the left subclavian/axillary vein.,2.  Insertion of a double lumen port through the left femoral vein, radiological guidance.,DESCRIPTION OF PROCEDURE: , After obtaining the informed consent, the patient was electively taken to the operating room, where he underwent a general anesthetic through his tracheostomy.  The left deltopectoral and cervical areas were prepped and draped in the usual fashion.  Local anesthetic was infiltrated in the area.  There was some evidence that surgical procedure had happened in the area nearby and also there was collateral venous circulation under the skin, which made us suspicious that may be __________, but at any rate I tried to cannulate it subcutaneously and I was unsuccessful.  Therefore, I proceeded to make an incision and was able to isolate the vein, which would look very sclerotic.  I tried to cannulate it, but I could not advance the wire.,At that moment, I decided that there was no way we are going to put a port though that area.  I packed the incision and we prepped and redraped the patient including both groins.  Local anesthetic was infiltrated and then the left femoral vein was percutaneously cannulated without any difficulty.  The introducer was placed and then a wire and then the catheter of the double lumen port, which had been trimmed to position it near the heart.  It was done with radiological guidance.  Again, I was able to position the catheter in the junction of inferior vena cava and right atrium.  The catheter was looked upwards and the double lumen port was inserted subcutaneously towards the iliac area.  The port had been aspirated satisfactorily and irrigated with heparin solution.  The drain incision was closed in layers including subcuticular suture with Monocryl.  Then, we went up to the left shoulder and closed that incision in layers.  Dressings were applied.,The patient tolerated the procedure well and was sent back to recovery room in satisfactory condition.","cardiovascular / pulmonary, axillary, vein, subclavian, double lumen port, femoral vein, radiological guidance, glossal carcinoma, port, inserstion, femoral, radiological, metastatic, carcinoma, chemotherapy, anesthetic, catheter, "
 The patient was admitted after undergoing a drawn out process with a small bowel obstruction., Cardiovascular / Pulmonary, Discharge Summary - Respiratory Failure ,"DISCHARGE DIAGNOSIS:,1.  Respiratory failure improved.,2.  Hypotension resolved.,3.  Anemia of chronic disease stable.,4.  Anasarca improving.,5.  Protein malnourishment improving.,6.  End-stage liver disease.,HISTORY AND HOSPITAL COURSE:  ,The patient was admitted after undergoing a drawn out process with a small bowel obstruction.  His bowel function started to improve.  He was on TPN prior to coming to Hospital.  He has remained on TPN throughout his time here, but his appetite and his p.o. intake have improved some.  The patient had an episode while here where his blood pressure bottomed out requiring him to spend multiple days in the Intensive Care Unit on dopamine.  At one point, we were unsuccessful at weaning him off the dopamine, but after approximately 11 days, he finally started to tolerate weaning parameters, was successfully removed from dopamine, and has maintained his blood pressure without difficulty.  The patient also was requiring BiPAP to help with his oxygenation and it appeared that he developed a left-sided pneumonia.  This has been treated successfully with Zyvox and Levaquin and Diflucan.  He seems to be currently doing much better.  He is only using BiPAP in the evening.  As stated above, he is eating better.  He had some evidence of redness and exquisite swelling around his genital and lower abdominal region.  This may be mainly dependent edema versus anasarca.  The patient has been diuresed aggressively over the last 4 to 5 days, and this seems to have made some improvement in his swelling.  This morning, the patient denies any acute distress.  He states he is feeling good and understands that he is being discharged to another facility for continued care and rehabilitation.  He will be discharged to Garden Court skilled nursing facility.,DISCHARGE MEDICATIONS/INSTRUCTIONS:,  He is going to be going with Protonix 40 mg daily, metoclopramide 10 mg every 6 hours, Zyvox 600 mg daily for 5 days, Diflucan 150 mg p.o. daily for 3 days, Bumex 2 mg p.o. daily, Megace 400 mg p.o. b.i.d., Ensure 1 can t.i.d. with meals, and MiraLax 17 gm p.o. daily.  The patient is going to require physical therapy to help with assistance in strength training.  He is also going to need respiratory care to work with his BiPAP.  His initial settings are at a rate of 20, pressure support of 12, PEEP of 6, FIO2 of 40%.  The patient will need a sleep study, which the nursing home will be able to set up.,PHYSICAL EXAMINATION:,VITAL SIGNS:  On the day of discharge, heart rate 99, respiratory rate 20, blood pressure 102/59, temperature 98.2, O2 sat 97%.,GENERAL:  A well-developed white male who appears in no apparent distress.,HEENT:  Unremarkable.,CARDIOVASCULAR:  Positive S1, S2 without murmur, rubs, or gallops.,LUNGS:  Clear to auscultation bilaterally without wheezes or crackles.,ABDOMEN:  Positive for bowel sounds.  Soft, nondistended.  He does have some generalized redness around his abdominal region and groin.  This does appear improved compared to presentation last week.  The swelling in this area also appears improved.,EXTREMITIES:  Show no clubbing or cyanosis.  He does have some lower extremity edema, 2+ distal pedal pulses are present.,NEUROLOGIC:  The patient is alert and oriented to person and place.  He is alert and aware of surroundings.  We have not had any difficulties with confusion here lately.,MUSCULOSKELETAL:  The patient moves all extremities without difficulty.  He is just weak in general.,LABORATORY DATA: , Lab work done today shows the following:  White count 4.2, hemoglobin 10.2, hematocrit 30.6, and platelet count 184,000.  Electrolytes show sodium 139, potassium 4.1, chloride 98, CO2 26, glucose 79, BUN 56, and creatinine 1.4.  Calcium 8.8, phosphorus is a little high at 5.5, magnesium 2.2, albumin 3.9.,PLAN:  ,Discharge this gentleman from Hospital and admit him to Garden Court SNF where they can continue with his rehab and conditioning.  Hopefully, long-term planning will be discharge home.  He has a history of end-stage liver disease with cirrhosis, which may make him a candidate for hospice upon discharge.  The family initially wanted to bring the patient home, but he is too weak and requires too much assistance to adequately consider this option at this time.","cardiovascular / pulmonary, respiratory failure, hypotension, anemia, anasarca, end-stage liver disease, drawn out process, bowel obstruction, blood pressure, dopamine, discharge, "
" Dobutamine stress test for chest pain, as the patient was unable to walk on a treadmill, and allergic to adenosine.  Nondiagnostic dobutamine stress test.   Normal nuclear myocardial perfusion scan.", Cardiovascular / Pulmonary, Dobutamine Stress Test ,"EXAM: , Dobutamine Stress Test.,INDICATION: , Chest pain.,TYPE OF TEST: , Dobutamine stress test, as the patient was unable to walk on a treadmill, and allergic to adenosine.,INTERPRETATION: , Resting heart rate of 66 and blood pressure of 88/45.  EKG, normal sinus rhythm.  Post dobutamine increment dose, his peak heart rate achieved was 125, which is 87% of the target heart rate.  Blood pressure 120/42.  EKG remained the same.  No symptoms were noted.,IMPRESSION:,1. Nondiagnostic dobutamine stress test.,2. Nuclear interpretation as below.,NUCLEAR INTERPRETATION: , Resting and stress images were obtained with 10.8, 30.2 mCi of tetrofosmin injected intravenously by standard protocol.  Nuclear myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake without any evidence of reversible or fixed defect.  Gated and SPECT revealed normal wall motion and ejection fraction of 75%.  End-diastolic volume was 57 and end-systolic volume of 12.,IMPRESSION:,1. Normal nuclear myocardial perfusion scan.,2. Ejection fraction of 75% by gated SPECT.","cardiovascular / pulmonary, nuclear myocardial perfusion scan, dobutamine stress test, ejection fraction, myocardial perfusion, perfusion scan, dobutamine stress, stress test, myocardial, perfusion, nuclear, dobutamine, stress,"
" Patient had some cold symptoms, was treated as bronchitis with antibiotics.", Cardiovascular / Pulmonary, Discharge Summary ,"DISCHARGE DIAGNOSES:,1.  Acute respiratory failure, resolved.,2.  Severe bronchitis leading to acute respiratory failure, improving.,3.  Acute on chronic renal failure, improved.,4.  Severe hypertension, improved.,5.  Diastolic dysfunction.,X-ray on discharge did not show any congestion and pro-BNP is normal.,SECONDARY DIAGNOSES:,1.  Hyperlipidemia.,2.  Recent evaluation and treatment, including cardiac catheterization, which did not show any coronary artery disease.,3.  Remote history of carcinoma of the breast.,4.  Remote history of right nephrectomy.,5.  Allergic rhinitis.,HOSPITAL COURSE:, This 83-year-old patient had some cold symptoms, was treated as bronchitis with antibiotics.  Not long after the patient returned from Mexico, the patient started having progressive shortness of breath, came to the emergency room with severe bilateral wheezing and crepitations.  X-rays however did not show any congestion or infiltrates and pro-BNP was within normal limits.  The patient however was hypoxic and required 4L nasal cannula.  She was admitted to the Intensive Care Unit.  The patient improved remarkably over the night on IV steroids and empirical IV Lasix.  Initial swab was positive for MRSA colonization., ,Discussed with infectious disease, Dr. X and it was decided no treatment was required for de-colonization.  The patient's breathing has improved.  There is no wheezing or crepitations and O2 saturation is 91% on room air.  The patient is yet to go for exercise oximetry.  Her main complaint is nasal congestion and she is now on steroid nasal spray.  The patient was seen by Cardiology, Dr. Z, who advised continuation of beta blockers for diastolic dysfunction.  The patient has been weaned off IV steroids and is currently on oral steroids, which she will be on for seven days.,DISPOSITION: , The patient has been discharged home.,DISCHARGE MEDICATIONS:,1.  Metoprolol 25 mg p.o. b.i.d.,2.  Simvastatin 20 mg p.o. daily.,NEW MEDICATIONS:,1.  Prednisone 20 mg p.o. daily for seven days.,2.  Flonase nasal spray daily for 30 days.,Results for oximetry pending to evaluate the patient for need for home oxygen.,FOLLOW UP:,  The patient will follow up with Pulmonology, Dr. Y in one week's time and with cardiologist, Dr. X in two to three weeks' time.","cardiovascular / pulmonary, acute respiratory failure, bronchitis, acute on chronic renal failure, severe hypertension, diastolic dysfunction, cold symptoms, iv steroids, nasal spray, nasal, steroids, "
 A 3-year-old abrupt onset of cough and increased work of breathing., Cardiovascular / Pulmonary, Discharge Summary - Respiratory Distress ,"ADMITTING DIAGNOSES:,1.  Respiratory distress.,2.  Reactive airways disease.,DISCHARGE DIAGNOSES:,1.  Respiratory distress.,2.  Reactive airways disease.,3.  Pneumonia.,HISTORY OF PRESENT ILLNESS: , The patient is a 3-year-old boy previously healthy who has never had a history of asthma or reactive airways disease who presented with a 36-hour presentation of URI symptoms, then had an abrupt onset of cough and increased work of breathing.  Child was brought to Children's Hospital and received nebulized treatments in the ER and the Hospitalist Service was contacted regarding admission.  The patient was seen and admitted through the emergency room.,He was placed on the hospitalist system and was started on continuous nebulized albuterol secondary to his respiratory distress.  He also received inhaled as well as systemic corticosteroids.  An x-ray was without infiltrate on initial review by the hospitalist, but there was a right upper lobe infiltrate versus atelectasis per the official radiology reading.  The patient was not started on any antibiotics and his fever resolved.  However, the CRP was relatively elevated at 6.7.  The CBC was normal with a white count of 9.6; however, the bands were 84%.  Given these results, which she is to treat the pneumonia as bacterial and discharge the child with amoxicillin and Zithromax.,He was taken off of continuous and he was not on room air all night.  In the morning, he still had some bilateral wheezing, but no tachypnea.,DISCHARGE PHYSICAL EXAMINATION: , ,GENERAL:  No acute distress, running around the room.,HEENT:  Oropharynx moist and clear.,NECK:  Supple without lymphadenopathy, thyromegaly or masses.,CHEST:  Bilateral basilar wheezing.  No distress.,CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs noted.  Well perfused peripherally.,ABDOMEN:  Bowel sounds present.  The abdomen is soft.  There is no hepatosplenomegaly, no masses.  Nontender to palpation.,GENITOURINARY:  Deferred.,EXTREMITIES:  Warm and well perfused.,DISCHARGE INSTRUCTIONS:,  As follows:,1.  Activity, regular.,2.  Diet is regular.,3.  Follow up with Dr. X in 2 days.,DISCHARGE MEDICATIONS:,1.  Xopenex MDI 2 puffs every 4 hours for 2 days and then as needed for cough or wheeze.,2.  QVAR 40, 2 puffs twice daily until otherwise instructed by the primary care provider.,3.  Amoxicillin 550 mg p.o. twice daily for 10 days.,4.  Zithromax 150 mg p.o. on day 1, then 75 mg p.o. daily for 4 more days.,Total time for this discharge 37 minutes.",
" The patient is 14 months old, comes in with a chief complaint of difficulty breathing.  ", Cardiovascular / Pulmonary, Difficulty Breathing - ER Visit  ,"HISTORY:,  The patient is 14 months old, comes in with a chief complaint of difficulty breathing.  Difficulty breathing began last night.  He was taken to Emergency Department where he got some Xopenex, given a prescription for amoxicillin and discharged home.  They were home for about an hour when he began to get worse and they drove here to Children's Hospital.  He has a history of reactive airway disease.  He has been seen here twice in the last month on 10/04/2007 and 10/20/2007, both times with some wheezing.  He was diagnosed with pneumonia back on 06/12/2007 here in the Emergency Department but was not admitted at that time.  He has been on albuterol off and on over that period.  He has had fever overnight.  No vomiting, no diarrhea.  Increased work of breathing with retractions and audible wheezes noted and thus brought to the Emergency Department.  Normal urine output.  No rashes have been seen.,PAST MEDICAL HISTORY: , As noted above.  No hospitalizations, surgeries, allergies.,MEDICATIONS: , Xopenex.,IMMUNIZATIONS:,  Up-to-date.,BIRTH HISTORY:,  The child was full term, no complications, home with mom.  No surgeries.,FAMILY HISTORY: , Negative.,SOCIAL HISTORY: , No smokers or pets in the home.  No ill contacts, no travel, no change in living condition.,REVIEW OF SYSTEMS: , Ten are asked, all are negative, except as noted above.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temp 37.1, pulse 158, respiratory rate 48, 84% on room air indicating hypoxia.,GENERAL:  The child is awake, alert, in moderate respiratory distress.,HEENT:  Pupils equal, round, reactive to light.  Extraocular movements are intact.  The TMs are clear.  The nares show some dry secretions.  Audible congestion and wheezing is noted.  Mucous membranes are dry.  Throat is clear.  No oral lesions noted.,NECK:  Supple without lymphadenopathy or masses.  Trachea is midline.,LUNGS:  Show inspiratory and expiratory wheezes in all fields.  Audible wheezes are noted.  There are intercostal and subcostal retractions and suprasternal muscle use is noted.,HEART:  Shows tachycardia.  Regular rhythm.  Normal S1, S2.  No murmur.,ABDOMEN:  Soft, nontender.  Positive bowel sounds.  No guarding.  No rebound.  No hepatosplenomegaly.,EXTREMITIES:  Capillary refill is brisk.  Good distal pulses.,NEUROLOGIC:  Cranial nerves II through XII intact.  Moves all 4 extremities equally and normally.,HOSPITAL COURSE: , The child has an IV placed.  I felt the child was dehydrated on examination.  We gave 20 mL/kg bolus of normal saline over one hour.  The child was given Solu-Medrol 2 mg/kg IV.  He was initially started on unit dose albuterol and Atrovent but high-dose albuterol for continuous nebulization was ordered.,A portable chest x-ray was done showing significant peribronchial thickening bilaterally.  Normal heart size.  No evidence of pneumothorax.  No evidence of focal pneumonia.  After 3 unit dose of albuterol/Atrovent breathing treatments, there was much better air exchange bilaterally but still with inspiratory/expiratory wheezes and high-dose continuous albuterol was started at that time.  The child was monitored closely while on high-dose albuterol and slowly showed improvement resulting in only expiratory wheezes after one hour.  The child's pulse ox on breathing treatments with 100% oxygen was 100%.  Respiratory rate remained about 40 to 44 breaths per minute indicating tachypnea.  The child's color improved with oxygen therapy, and the capillary refill was always less than 2 seconds.,The child has failed outpatient therapy at this time.  After 90 minutes of continuous albuterol treatment, the child still has expiratory wheezes throughout.  After I removed the oxygen, the pulse ox was down at 91% indicating hypoxia.  The child has a normal level of alertness; however, has not had any vomiting here.  I spoke with Dr. X, on call for hospitalist service.  She has come down and evaluated the patient.  We both feel that since this child had two ER visits this last month, one previous ER visit within the last 5 hours, we should admit the child for continued albuterol treatments, IV steroids, and asthma teaching for the family.  The child is admitted in a stable condition.,DIFFERENTIAL DIAGNOSES:  ,Ruled out pneumothorax, pneumonia, bronchiolitis, croup.,TIME SPENT:  ,Critical care time outside billable procedures was 45 minutes with this patient.,IMPRESSION:  ,Status asthmaticus, hypoxia.,PLAN:  ,Admitted to Pediatrics.",
" DDDR permanent pacemaker, insertion of a steroid-eluting screw in right atrial lead, insertion of a steroid-eluting screw in right ventricular apical lead, pulse generator insertion, model Sigma,", Cardiovascular / Pulmonary, DDDR Permanent Pacemaker ,"PROCEDURES PERFORMED:,1.  DDDR permanent pacemaker.,2.  Insertion of a steroid-eluting screw in right atrial lead.,3.  Insertion of a steroid-eluting screw in right ventricular apical lead.,4.  Pulse generator insertion, model Sigma.,SITE: , Left subclavian vein access.,INDICATION: , The patient is a 73-year-old African-American female with symptomatic bradycardia and chronotropic incompetence with recurrent heart failure and symptoms of hypoperfusion, and for a Class 2a indication for a permanent pacemaker was ascertained.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , Minimal.,Risks, benefits, and alternatives of the procedure were all explained in detail to the patient and the patient's family at length.  They all consented for the procedure, and the consent was signed and placed on the chart.,PROCEDURE: , The patient was taken to cardiac cath lab where she was monitored throughout all procedure.  The area of the left pectoral deltoid and subclavian area was sterilely prepped and draped in the usual manner.  We also scrubbed for approximately eight minutes.  Using lidocaine with epinephrine, the area of the left pectoral deltoid region and subclavian area was then fully anesthetized.  Using an #18 gauge Cook needle, the left subclavian vein was cannulated at two separate sites without difficulty, where two separate guidewires were inserted into the left subclavian vein.  The Cook needles were removed.  Then the guidewires were secured in place with hemostat.  Using a #10 and #15 scalpel blade, a 5 cm horizontal incision was made in the left pectodeltoid groove, where the skin was dissected and blunted on to the pectoralis major muscle.  The skin was then undermined making a pocket for the generator.  The guidewires were then tunneled through the performed pocket.  Subsequently, the atrial and ventricular leads were inserted through each one of the Cordis separately and respectively.  Initially, the ventricular lead was inserted, where a Cordis sheath was placed and the guidewire was removed.  After the thresholds and appropriate position was obtained for the ventricular lead, the Cordis sheath was then inserted for the atrial lead.  After the atrial lead was inserted and appropriately placed and thresholds were obtained, the Cordis was removed and then both leads were sutured in place with pectoralis major muscle with #1-0 silk suture.  The leads were then connected to a pulse generator.  The pocket was then irrigated and cleansed, where then the leads and the generators were inserted into that pocket.  The subcutaneous tissue was then closed with gut sutures and the skin was then closed with #4-0 polychrome sutures using a subcuticular uninterrupted technique.  The area was then cleansed and dry.  Steri-Strips and pressure dressing were applied.  The patient tolerated the procedure well.  There were no complications.,Information on the pacemaker:,The implanted device are as follows:,PULSE GENERATOR,Model Name:  Sigma.,Model #:  SDR203.,Serial #:  123456.,ATRIAL LEAD,Model #:  4568-45 cm.,Serial #:  123456.,RIGHT VENTRICULAR APICAL STEROID-eluting SCREW IN LEAD:,Model #:  4068-52 cm.,Serial #:  123456.,STIMULATION THRESHOLDS ARE AS FOLLOWS:,The right atrial chamber polarity is bipolar, pulse width is 0.50 milliseconds, 1.5 volts of voltage, 3.7 milliamps of current, 557 ohms of impedance, and P-wave sensing of 3.3 millivolts.,The right ventricular polarity is bipolar, pulse width is 0.50 milliseconds, 0.7 volts of voltage, 1.4 milliamps of current, impedance of 700 ohms, and R-wave sensing of 14 millivolts.,The brady parameter settings were set as follows:,The atrial and ventricular appendages were set at 3.5 volts with 0.4 milliseconds of pulse width, atrial sensitivity of 0.5 with 180 milliseconds of blanking.  Ventricular sensitivity was set at 2.8 with 28 milliseconds of blanking.  The pacing mode was DDDR, mode switch was on lower rate of 70 and upper rate of 130.,The patient tolerated the procedure well.  There were no complications.  The patient went to Recovery in satisfactory condition.  Family was updated.  Orders are all in the chart.  Please see orders.,Again, thank you for allowing to participate in this care.",
" Chest x-ray on admission, no acute finding, no interval change.  CT angiography, negative for pulmonary arterial embolism.  Chronic obstructive pulmonary disease exacerbation improving, on steroids and bronchodilators.", Cardiovascular / Pulmonary, Discharge Summary - COPD ,"PROCEDURES:,1.  Chest x-ray on admission, no acute finding, no interval change.,2.  CT angiography, negative for pulmonary arterial embolism.,3.  Nuclear myocardial perfusion scan, abnormal.  Reversible defect suggestive of ischemia, ejection fraction of 55%.,DIAGNOSES ON DISCHARGE:,1.  Chronic obstructive pulmonary disease exacerbation improving, on steroids and bronchodilators.,2.  Coronary artery disease, abnormal nuclear scan, discussed with Cardiology Dr. X, who recommended to discharge the patient and follow up in the clinic.,3.  Diabetes mellitus type 2.,4.  Anemia, hemoglobin and hematocrit stable.,5.  Hypokalemia, replaced.,6.  History of coronary artery disease status post stent placement 2006-2008.,7.  Bronchitis.,HOSPITAL COURSE:  ,The patient is a 65-year-old American-native Indian male, past medical history of heavy tobacco use, history of diabetes mellitus type 2, chronic anemia, COPD, coronary artery disease status post stent placement, who presented in the emergency room with increasing shortness of breath, cough productive for sputum, and orthopnea.  The patient started on IV steroid, bronchodilator as well as antibiotics.,He also complained of chest pain that appears to be more pleuritic with history of coronary artery disease and orthopnea.  He was evaluated by Cardiology Dr. X, who proceeded with stress test.  Stress test reported positive for reversible ischemia, but Cardiology decided to follow up the patient in the clinic.  The patient's last cardiac cath was in 2008.,The patient clinically significantly improved and wants to go home.  His hemoglobin on admission was 8.8, and has remained stable.  He is afebrile, hemodynamically stable.,ALLERGIES: , LISINOPRIL AND PENICILLIN.,MEDICATIONS ON DISCHARGE:,1.  Prednisone tapering dose 40 mg p.o. daily for three days, then 30 mg p.o. daily for three days, then 20 mg p.o. daily for three days, then 10 mg p.o. daily for three days, and 5 mg p.o. daily for two days.,2.  Levaquin 750 mg p.o. daily for 5 more days.,3.  Protonix 40 mg p.o. daily.,4.  The patient can continue other current home medications at home.,FOLLOWUP APPOINTMENTS:,1.  Recommend to follow up with Cardiology Dr. X's office in a week.,2.  The patient is recommended to see Hematology Dr. Y in the office for workup of anemia.,3.  Follow up with primary care physician's office tomorrow.,SPECIAL INSTRUCTIONS:,1.  If increasing shortness of breath, chest pain, fever, any acute symptoms to return to emergency room.,2.  Discussed about discharge plan, instructions with the patient by bedside.  He understands and agreed.  Also discussed discharge plan instructions with the patient's nurse.",
 A 63-year-old man with a dilated cardiomyopathy presents with a chief complaint of heart failure.  He has noted shortness of breath with exertion and occasional shortness of breath at rest. , Cardiovascular / Pulmonary, Dilated Cardiomyopathy - Consult ,"REASON FOR VISIT: , I have been asked to see this 63-year-old man with a dilated cardiomyopathy by Dr. X at ABCD Hospital.  He presents with a chief complaint of heart failure.,HISTORY OF PRESENT ILLNESS: , In retrospect, he has had symptoms for the past year of heart failure.  He feels in general ""OK,"" but is stressed and fatigued.  He works hard running 3 companies.  He has noted shortness of breath with exertion and occasional shortness of breath at rest.  There has been some PND, but he sleeps on 1 pillow.  He has no edema now, but has had some mild leg swelling in the past.  There has never been any angina and he denies any palpitations, syncope or near syncope.  When he takes his pulse, he notes some irregularity.  He follows no special diet.  He gets no regular exercise, although he has recently started walking for half an hour a day.  Over the course of the past year, these symptoms have been slowly getting worse.  He gained about 20 pounds over the past year.,There is no prior history of either heart failure or other heart problems.,His past medical history is remarkable for a right inguinal hernia repair done in 1982.  He had trauma to his right thumb.  There is no history of high blood pressure, diabetes mellitus or heart murmur.,On social history, he lives in San Salvador with his wife.  He has a lot of stress in his life.  He does not smoke, but does drink.  He has high school education.,On family history, mother is alive at age 89.  Father died at 72 of heart attack.  He has 2 brothers and 1 sister all of whom are healthy, although the oldest suffered a myocardial infarction.  He has 3 healthy girls and 9 healthy grandchildren.,A complete review of systems was performed and is negative aside from what is mentioned in the history of present illness.,MEDICATIONS: , Aspirin 81 mg daily and chlordiazepoxide and clidinium - combination pill at 5 mg/2.5 mg 1 tablet daily for stress.,ALLERGIES: , Denied.,MAJOR FINDINGS:,  On my comprehensive cardiovascular examination, he is 5 feet 8 inches and weighs 231 pounds.  His blood pressure is 120/70 in each arm seated.  His pulse is 80 beats per minute and regular.  He is breathing 1two times per minute and that is unlabored.  Eyelids are normal.  Pupils are round and reactive to light.  Conjunctivae are clear and sclerae are anicteric.  There is no oral thrush or central cyanosis.  Neck is supple and symmetrical without adenopathy or thyromegaly.  Jugular venous pressure is normal.  Carotids are brisk without bruits.  Lungs are clear to auscultation and percussion.  The precordium is quiet.  The rhythm is regular.  The first and second heart sounds are normal.  He does have a fourth heart sound and a soft systolic murmur.  The precordial impulse is enlarged.  Abdomen is soft without hepatosplenomegaly or masses.  He has no clubbing, cyanosis or peripheral edema.  Distal pulses are normal throughout both arms and both legs.  On neurologic examination, his mentation is normal.  His mood and affect are normal.  He is oriented to person, place, and time.,DATA: , His EKG shows sinus rhythm with left ventricular hypertrophy.,A metabolic stress test shows that he was able to exercise for 5 minutes and 20 seconds to 90% of his maximum predicted heart rate.  His peak oxygen consumption was 19.7 mL/kg/min, which is consistent with mild cardiopulmonary disease.,Laboratory data shows his TSH to be 1.33.  His glucose is 97 and creatinine 0.9.  Potassium is 4.3.  He is not anemic.  Urinalysis was normal.,I reviewed his echocardiogram personally.  This shows a dilated cardiomyopathy with EF of 15%.  The left ventricular diastolic dimension is 6.8 cm.  There are no significant valvular abnormalities.,He had a stress thallium.  His heart rate response to stress was appropriate.  The thallium images showed no scintigraphic evidence of stress-induced myocardial ischemia at 91% of his maximum age predicted heart rate.  There is a fixed small sized mild-to-moderate intensity perfusion defect in the distal inferior wall and apex, which may be an old infarct, but certainly does not account for the degree of cardiomyopathy.  We got his post-stress EF to be 33% and the left ventricular cavity appeared to be enlarged.  The total calcium score will put him in the 56 percentile for subjects of the same age, gender, and race/ethnicity.,ASSESSMENTS: , This appears to be a newly diagnosed dilated cardiomyopathy, the etiology of which is uncertain.,PROBLEMS DIAGNOSES:  ,1.  Dilated cardiomyopathy.,2.  Dyslipidemia.,PROCEDURES AND IMMUNIZATIONS: , None today.,PLANS: , I started him on an ACE inhibitor, lisinopril 2.5 mg daily, and a beta-blocker, carvedilol 3.125 mg twice daily.  The dose of these drugs should be up-titrated every 2 weeks to a target dose of lisinopril of 20 mg daily and carvedilol 25 mg twice daily.  In addition, he could benefit from a loop diuretic such as furosemide.  I did not start this as he is planning to go back home to San Salvador tomorrow.  I will leave that up to his local physicians to up-titrate the medications and get him started on some furosemide.,In terms of the dilated cardiomyopathy, there is not much further that needs to be done, except for family screening.  All of his siblings and his children should have an EKG and an echocardiogram to make sure they have not developed the same thing.  There is a strong genetic component of this.,I will see him again in 3 to 6 months, whenever he can make it back here.  He does not need a defibrillator right now and my plan would be to get him on the right doses of the right medications and then recheck an echocardiogram 3 months later.  If his LV function has not improved, he does have New York Heart Association Class II symptoms and so he would benefit from a prophylactic ICD.,Thank you for asking me to participate in his care.,MEDICATION CHANGES:,  See the above.",
 Direct laryngoscopy and bronchoscopy., Cardiovascular / Pulmonary, Direct Laryngoscopy ,"PREOPERATIVE DIAGNOSIS:,  Subglottic stenosis.,POSTOPERATIVE DIAGNOSIS: , Subglottic stenosis.,OPERATIVE PROCEDURES: , Direct laryngoscopy and bronchoscopy.,ANESTHESIA:,  General inhalation.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and placed supine on the operative table.  General inhalational anesthesia was administered through the patient's tracheotomy tube.  The small Parsons laryngoscope was inserted and the 2.9-mm telescope was used to inspect the airway.  There was an estimated 60-70% circumferential mature subglottic stenosis that extended from just under the vocal folds to approximately 3 mm below the vocal folds.  The stoma showed some suprastomal fibroma.  The remaining tracheobronchial passages were clear.  The patient's 3.5 neonatal tracheostomy tube was repositioned and secured with Velcro ties.  Bleeding was negligible.  There were no untoward complications.  The patient tolerated the procedure well and was transferred to recovery room in stable condition.","cardiovascular / pulmonary, laryngoscopy and bronchoscopy, direct laryngoscopy, subglottic stenosis, bronchoscopy, laryngoscopy, subglottic, stenosis, "
 The patient is a 61-year-old female who was treated with CyberKnife therapy to a right upper lobe stage IA non-small cell lung cancer.  CyberKnife treatment was completed one month ago.  She is now being seen for her first post-CyberKnife treatment visit., Cardiovascular / Pulmonary, CyberKnife Treatment - Followup ,"HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old female who was treated with CyberKnife therapy to a right upper lobe stage IA non-small cell lung cancer.  CyberKnife treatment was completed one month ago.  She is now being seen for her first post-CyberKnife treatment visit.,Since undergoing CyberKnife treatment, she has had low-level nausea without vomiting.  She continues to have pain with deep inspiration and resolving dysphagia.  She has no heartburn, cough, hemoptysis, rash, or palpable rib pain.,MEDICATIONS: , Dilantin 100 mg four times a day, phenobarbital 30 mg three times per day, levothyroxine 0.025 mg p.o. q. day, Tylenol with Codeine b.i.d., prednisone 5 mg p.r.n., citalopram 10 mg p.o. q. day, Spiriva q. day, Combivent inhaler p.r.n., omeprazole 20 mg p.o. q. day, Lidoderm patch every 12 hours, Naprosyn 375 mg p.o. b.i.d., oxaprozin 600 mg p.o. b.i.d., Megace 40 mg p.o. b.i.d., and Asacol p.r.n.,PHYSICAL EXAMINATION: , BP:  122/86.  Temp:  96.8.  HR:  79.  RR:  26.  RAS:  100%.,HEENT:  Normocephalic.  Pupils are equal and reactive to light and accommodation.  EOMs intact.,NECK:  Supple without masses or lymphadenopathy.,LUNGS:  Clear to auscultation bilaterally,CARDIAC:  Regular rate and rhythm without rubs, murmurs, or gallops.,EXTREMITIES:  No cyanosis, clubbing or edema.,ASSESSMENT: , The patient has done well with CyberKnife treatment of a stage IA non-small cell lung cancer, right upper lobe, one month ago.,PLAN: , She is to return to clinic in three months with a PET CT.","cardiovascular / pulmonary, non-small cell lung cancer, cyberknife therapy, lung cancer, cell, lung, cancer, cyberknife,"
 A 10 years of age carries a diagnosis of cystic fibrosis, Cardiovascular / Pulmonary, Cystic Fibrosis ,"INTERVAL HISTORY:,  ABC who is 10 years of age and carries a diagnosis of cystic fibrosis, seen in the clinic today for routine follow-up visit.  He was accompanied by his adopted mother.  He is attending the fourth grade and has not missed significant days for illness.  He has a chronic cough that has been slightly increased for the prior 4 days.  Sputum is not produced.  Sinuses are described as clear.  He is an eager eater, eating a regular diet of increased calorie and protein.  He also was taking Resource just for kid juice boxes as well as chocolate milkmaid with half-and-half.  Belly complaints are denied.  He has 2 to 3 bowel movements per day.  He does need a flu vaccine.,MEDICATIONS: , Albuterol premix via nebulizer as needed, albuterol MDI 2 puffs b.i.d., therapy Vest daily, Creon 20 two with meals and snacks,  A-dec 2 tablets daily, Prevacid 15 mg daily, Advair 100/50 one inhalation twice daily, and MiraLax p.r.n.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Respiratory rate 20 and pulse 91.  Temperature is 100.0 per tympanic membrane.  Oximetry is 98% on room air.  Height is 128 cm, which is an increase of 1.0 cm from prior visit.  Weight is 24.5 kg, which is an increase of 500 grams from prior visit.,GENERAL:  He is a cooperative school-aged boy in no apparent distress.,HEENT:  Tympanic membranes clear, throat with minimal postnasal drip.,CHEST:  Significant for 1+ hyperinflation.  Lungs are auscultated with good air entry and clear breath sounds.,CARDIAC:  Regular sinus rhythm without murmur.,ABDOMEN:  Palpated as soft, without hepatosplenomegaly.,EXTREMITIES:  Not clubbed.,CHART REVIEW: , This chart was thoroughly reviewed prior to this conference by X, RN, BSN.  Review of chart indicates that mother has good adherence to treatment plan indicated by medications being refilled in a timely fashion as well as clinic contact documented with appropriate concerns.,DISCUSSION:  PHYSICIAN: , X did note that mother reported that the patient had discontinued the Pulmozyme due to CCS reasons.  He is not sure what this would be since CCS Pulmozyme is a covered benefit on CCS for children with cystic fibrosis.  This situation will be looked into with the hope of restarting soon.  Other than that the patient seems to be doing well.  A flu shot was given.,NURSE: , X, RN, BSN, did note that the patient was doing quite well.  Reinforcement of current medication regime was supplied.  No other needs identified at this time.,RESPIRATORY CARE: , X, RCP, did review appropriate sequencing of medications with the patient and family.  Once again, she was concerned the lack of Pulmozyme due to mom stating CCS issues.  At this time, they have increased the Vest use to twice daily and are doing 30-minute treatments.,DIETICIAN: , X, RD, CDE, notes that the patient is 89% of his ideal body weight, which is a nutritional failure per cystic fibrosis guidelines.  This is despite the fact that he has an excellent appetite.  Mom reports he is taking his enzymes consistently as well as vitamins.  He does have problems meeting his goal for resource drinks per day.  Since the patient has been struggling to gain weight this past year, we will need to monitor his nutritional status and weight trend very closely.  A variety of additional high calorie items were discussed with mom.,SOCIAL WORK: , X, LCSW, notes that mom has recently gradually from respiratory therapy school and has accepted a position here at Children's Hospital.  The patient is doing well in school.  With the exception of issues with CCS authorization, there appears to be no pressing social needs at this time.,IMPRESSION: , ,1.  Cystic fibrosis.,2.  Poor nutritional status.,PLAN:  ,1.  Give flu vaccine 0.5 mg IM now, this was done.,2.  Continue all other medications and treatment.,3.  Evaluate/investigate rationale for no authorization of Pulmozyme with CCS.,4.  Needs to augment current high-calorie diet to give more nutrition.  To follow advice by a dietician.,5.  Continue all the medication treatments before.,6.  To continue off and ongoing psychosocial nutritional counseling as necessary.",
 CT of chest with contrast.  Abnormal chest x-ray demonstrating a region of consolidation versus mass in the right upper lobe., Cardiovascular / Pulmonary, CT of Chest with Contrast ,"EXAM: , CT chest with contrast.,HISTORY: , Abnormal chest x-ray, which demonstrated a region of consolidation versus mass in the right upper lobe.,TECHNIQUE:  ,Post contrast-enhanced spiral images were obtained through the chest.,FINDINGS:  ,There are several, discrete, patchy air-space opacities in the right upper lobe, which have the appearance most compatible with infiltrates.  The remainder of the lung parenchyma is clear.  There is no pneumothorax or effusion.  The heart size and pulmonary vessels appear unremarkable.  There was no axillary, hilar or mediastinal lymphadenopathy.,Images of the upper abdomen are unremarkable.,Osseous windows are without acute pathology.,IMPRESSION: , Several discrete patchy air-space opacities in the right upper lobe, compatible with pneumonia.","cardiovascular / pulmonary, ct chest, air-space, axillary, chest x-ray, consolidation, contrast, contrast-enhanced, effusion, hilar, infiltrates, lung, lymphadenopathy, mass, mediastinal, parenchyma, patchy air-space, pneumonia, pneumothorax, right upper lobe, spiral images, with contrast, air space opacities, upper lobe, opacities, ct, lobe, chest"
" Cerebrovascular accident (CVA) with right arm weakness and MRI indicating acute/subacute infarct involving the left posterior parietal lobe without mass effect.  2.  Old coronary infarct, anterior aspect of the right external capsule.  Acute bronchitis with reactive airway disease.", Cardiovascular / Pulmonary, CVA - Discharge Summary ,"DIAGNOSES ON ADMISSION,1.  Cerebrovascular accident (CVA) with right arm weakness.,2.  Bronchitis.,3.  Atherosclerotic cardiovascular disease.,4.  Hyperlipidemia.,5.  Thrombocytopenia.,DIAGNOSES ON DISCHARGE,1.  Cerebrovascular accident with right arm weakness and MRI indicating acute/subacute infarct involving the left posterior parietal lobe without mass effect.,2.  Old coronary infarct, anterior aspect of the right external capsule.,3.  Acute bronchitis with reactive airway disease.,4.  Thrombocytopenia most likely due to old coronary infarct, anterior aspect of the right external capsule.,5.  Atherosclerotic cardiovascular disease.,6.  Hyperlipidemia.,HOSPITAL COURSE: , The patient was admitted to the emergency room.  Plavix was started  in addition to baby aspirin.  He was kept on oral Zithromax for his cough.  He was given Xopenex treatment, because of his respiratory distress.  Carotid ultrasound was reviewed and revealed a 50 to 69% obstruction of left internal carotid.  Dr. X saw him in consultation and recommended CT angiogram.  This showed no significant obstructive lesion other than what was known on the ultrasound.  Head MRI was done and revealed the above findings.  The patient was begun on PT and improved.  By discharge, he had much improved strength in his right arm.  He had no further progressions.  His cough improved with oral Zithromax and nebulizer treatments.  His platelets also improved as well.  By discharge, his platelets was up to 107,000.  His H&H was stable at 41.7 and 14.6 and his white count was 4300 with a normal differential.  Chest x-ray revealed a mild elevated right hemidiaphragm, but no infiltrate.  Last chemistry panel on December 5, 2003, sodium 137, potassium 4.0, chloride 106, CO2 23, glucose 88, BUN 17, creatinine 0.7, calcium was 9.1.  PT/INR on admission was 1.03, PTT 34.7.  At the time of discharge, the patient's cough was much improved.  His right arm weakness has much improved.  His lung examination has just occasional rhonchi.  He was changed to a metered dose inhaler with albuterol.  He is being discharged home.  An echocardiogram revealed mild concentric LVH with normal left ventricular function with an EF of 57%, moderate left atrial enlargement and diastolic dysfunction with mild mitral regurgitation.  He will follow up in my office in 1 week.  He is to start PT and OT as an outpatient.  He is to avoid driving his car.  He is to notify, if further symptoms.  He has 2 more doses of Zithromax at home, he will complete.  His prognosis is good.","cardiovascular / pulmonary, subacute infarct, atherosclerotic cardiovascular disease, cerebrovascular accident, coronary infarct, external capsule, cva, cerebrovascular, mri, bronchitis, cardiovascular, xopenex, atherosclerotic, accident"
 A 51-year-old male with chest pain and history of coronary artery disease., Cardiovascular / Pulmonary, Coronary CT Angiography (CCTA) - 4 ,"COMPARISON:, None.,MEDICATIONS:, Lopressor 5mg IV at 0920 hours.,HEART RATE: ,Recorded heart rate 55 to 57bpm.,EXAM:,Initial unenhanced axial CT imaging of the heart was obtained with ECG gating for the purpose of coronary artery calcium scoring (Agatston Method) and calcium volume determination.,18 gauge IV Intracath was inserted into the right antecubital vein.,A 20cc saline bolus was injected intravenously to confirm vein patency and adequacy of venous access.,Multi-detector CT imaging was performed with a 64 slice MDCT scanner with images obtained from the mid ascending aorta to the diaphragm at 0.5mm slice thickness during breath-holding.,95 cc of Isovue was administered followed by a 90cc saline “bolus chaser”. Image reconstruction was performed using retrospective cardiac gating. Calcium scoring analysis (Agatston Method and volume determination) was performed.,FINDINGS:,CALCIUM SCORE:  The patient's total Agatston calcium score is: 115. The Agatston score for the individual vessels are: LM: 49. RCA: 1. LAD: 2. CX: 2. Other: 62. The Agatston calcium score places the patient in the 90th percentile, which means 10 percent of the male population in this age group would have a higher calcium score.,QUALITY ASSESSMENT:,  Examination is of good quality with good bolus timing and good demonstration of coronary arteries.,LEFT MAIN CORONARY ARTERY:,  The left main coronary artery has a posteriorly positioned take-off from the valve cusp, with a patent ostium, and it has an extramural (non-malignant) course. The vessel is of moderate size. There is an apparent second ostium, in a more normal anatomic location, but quite small. This has an extramural (non-malignant) course. There is mixed calcific/atheromatous plaque within the distal vessel, as well as positive remodeling. There is no high grade stenosis but a flow-limiting lesion can not be excluded. The vessel trifurcates into a left anterior descending artery, a ramus intermedius and a left circumflex artery.,LEFT ANTERIOR DESCENDING CORONARY ARTERY:,  The left anterior descending artery is a moderate-size vessel, with ostial calcific plaque and soft plaque without a high-grade stenosis, but there may be a flow-limiting lesion here. There is a moderate size bifurcating first diagonal branch with ostial calcification, but no flow-limiting lesion. LAD continues as a moderate-size vessel to the posterior apex of the left ventricle.,Ramus intermedius branch is a moderate to large-size vessel with extensive calcific plaque, but no ostial stenosis. The dense calcific plaque limits evaluation of the vessel lumen, and a flow-limiting lesion within the proximal vessel cannot be excluded. The vessel continues as a small vessel on the left lateral ventricular wall.,LEFT CIRCUMFLEX CORONARY ARTERY:, The left circumflex artery is a moderate-size vessel with a normal ostium giving rise to a small OM1 branch and a large OM2 branch supplying much of the posterolateral wall of the left ventricular. The AV-groove branch tapers at the base of the heart. There is minimal calcific plaque within the mid vessel, but there is no flow-limiting stenosis.,RIGHT CORONARY ARTERY:, The right coronary artery is a large vessel with a normal ostium giving rise to a moderate-size acute marginal branch and continuing as a large vessel to the crux of the heart supplying a left posterior descending artery and small posterolateral ventricular branches. There is minimal calcific plaque within the mid vessel, but there is no flow-limiting lesion.,Coronary circulation is right dominant.,FUNCTIONAL ANALYSIS:, End diastolic volume: 106ml End systolic volume: 44ml Ejection fraction: 58 percent,ANATOMIC ANALYSIS:,Normal heart size with no demonstrated ventricular wall abnormalities. There are no demonstrated myocardial,bridges. Normal left atrial appendage with no evidence of thrombosis.,Cardiac valves are normal.,The aortic diameter measures 33mm just distal to the sino-tubular junction. The visualized thoracic aorta appears normal in size.,Normal pericardium without pericardial thickening or effusion.,There is no demonstrated mediastinal or hilar adenopathy. The visualized lung parenchyma is unremarkable.,There are two left and two right pulmonary veins.,IMPRESSION:,Ventricular function: Normal.,Single vessel coronary artery analysis:,LM: There is a posterior origin from the valve cusp. There is mixed calcific/atheromatous plaque and positive remodeling plaque within the LM, and although there is no high grade stenosis, a flow-limiting lesion can not be excluded. In addition, there is an apparent second ostium of indeterminate significance, but both ostia have extramural (non-malignant) courses.,LAD: Dense calcific plaque within the proximal vessel with ostial calcification and possible flow-limiting proximal lesion. There is a ramus branch with dense calcific plaque limiting evaluation of the vessel lumen, but a flow-limiting lesion cannot be excluded here.,CX: Minimal calcific plaque with no flow-limiting lesion.,RCA: Minimal calcific plaque with no flow-limiting lesion.,Coronary artery dominance: Right.",
" Chest pain, shortness of breath and cough, evaluate for pulmonary arterial embolism.   CT angiography chest with contrast.  Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.", Cardiovascular / Pulmonary, CT Angiography ,"CT ANGIOGRAPHY CHEST WITH CONTRAST,REASON FOR EXAM: , Chest pain, shortness of breath and cough, evaluate for pulmonary arterial embolism.,TECHNIQUE:  ,Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.,FINDINGS:  ,There is no evidence for pulmonary arterial embolism.,The lungs are clear of any abnormal airspace consolidation, pleural effusion, or pneumothorax.  No abnormal mediastinal or hilar lymphadenopathy is seen.,Limited images of the upper abdomen are unremarkable.  No destructive osseous lesion is detected.,IMPRESSION: , Negative for pulmonary arterial embolism.","cardiovascular / pulmonary, airspace consolidation, pleural effusion, pneumothorax, lymphadenopathy, hilar, ct angiography, pulmonary arterial, arterial embolism, angiography, ct, chest, arterial, pulmonary, embolism, isovue, "
 Shortness of breath for two weeks and a history of pneumonia.  CT angiography chest with contrast.  Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300., Cardiovascular / Pulmonary, CT Angiography - 1 ,"CT ANGIOGRAPHY CHEST WITH CONTRAST,REASON FOR EXAM:  ,Shortness of breath for two weeks and a history of pneumonia.  The patient also has a history of left lobectomy.,TECHNIQUE: , Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.,FINDINGS: , There is no evidence of any acute pulmonary arterial embolism.,The main pulmonary artery is enlarged showing a diameter of 4.7 cm.,Cardiomegaly is seen with mitral valvular calcifications.,Postsurgical changes of a left upper lobectomy are seen.  Left lower lobe atelectasis is noted.  A 7 mm and a 5 mm pulmonary nodule are seen within the left lower lobe (image #12).  A small left pleural effusion is noted.,Right lower lobe atelectasis is present.  There is a right pleural effusion, greater than as seen on the left side.  A right lower lobe pulmonary nodule measures 1.5 cm.  There is a calcified granuloma within the right lower lobe.,IMPRESSION:,1.  Negative for pulmonary arterial embolism.,2.  Enlargement of the main pulmonary artery as can be seen with pulmonary arterial hypertension.,3.  Cardiomegaly with mitral valvular calcifications.,4.  Postsurgical changes of a left upper lobectomy.,5.  Bilateral pleural effusions, right greater than left with bilateral lower lobe atelectasis.,6.  Bilateral lower lobe nodules, pulmonary nodules, and interval followup in three months to confirm stability versus further characterization with prior studies is advised.","cardiovascular / pulmonary, shortness of breath, pneumonia, pulmonary embolism, isovue-300, axial ct images, ct angiography, lower lobe, pulmonary, lobectomy, isovue, angiography, arterial, atelectasis, pleural, ct, embolism,"
 A 68-year-old white male with recently diagnosed adenocarcinoma by sputum cytology.  An abnormal chest radiograph shows right middle lobe infiltrate and collapse.  Patient needs staging CT of chest with contrast. , Cardiovascular / Pulmonary, CT Chest - 2 ,"CLINICAL HISTORY: , A 68-year-old white male with recently diagnosed adenocarcinoma by sputum cytology.  An abnormal chest radiograph shows right middle lobe infiltrate and collapse.  Patient needs staging CT of chest with contrast.  Right sided supraclavicular and lower anterior cervical adenopathy noted on physical exam.,TECHNIQUE: , Multiple transaxial images utilized in 10 mm sections were obtained through the chest.  Intravenous contrast was administered.,FINDINGS: , There is a large 3 x 4 cm lymph node seen in the right supraclavicular region.  There is a large right paratracheal lymph node best appreciated on image #16 which measures 3 x 2 cm.  A subcarinal lymph node is enlarged also.  It measures 6 x 2 cm.  Multiple pulmonary nodules are seen along the posterior border of the visceral as well as parietal pleura.  There is a pleural mass seen within the anterior sulcus of the right hemithorax as well as the right crus of the diaphragm.  There is also a soft tissue density best appreciated on image #36 adjacent to the inferior aspect of the right lobe of the liver which most likely also represents metastatic deposit.  The liver parenchyma is normal without evidence of any dominant masses.  The right kidney demonstrates a solitary cyst in the mid pole of the right kidney.,IMPRESSION:,1.  Greater than twenty pulmonary nodules demonstrated on the right side to include pulmonary nodules within the parietal as well as various visceral pleura with adjacent consolidation most likely representing pulmonary neoplasm.,2.  Extensive mediastinal adenopathy as described above.,3.  No lesion seen within the left lung at this time.,4.  Supraclavicular adenopathy.","cardiovascular / pulmonary, supraclavicular, cervical adenopathy, pulmonary nodules, lymph node, adenopathy, pulmonary, chest, "
 Coronary Artery CTA with Calcium Scoring and Cardiac Function, Cardiovascular / Pulmonary, Coronary CT Angiography (CCTA) - 3 ,"EXAM: , Coronary artery CTA with calcium scoring and cardiac function.,HISTORY: , Chest pain.,TECHNIQUE AND FINDINGS: , Coronary artery CTA was performed on a Siemens dual-source CT scanner.  Post-processing on a Vitrea workstation.  150 mL Ultravist 370 was utilized as the intravenous contrast agent.  Patient did receive nitroglycerin sublingually prior to the contrast.,HISTORY: , Significant for high cholesterol, overweight, chest pain, family history,Patient's total calcium score (Agatston) is 10. his places the patient just below the 75th percentile for age.,The LAD has a moderate area of stenosis in its midportion due to a focal calcified plaque.  The distal LAD was unreadable while the proximal was normal.  The mid and distal right coronary artery are not well delineated due to beam-hardening artifact.  The circumflex is diminutive in size along its proximal portion.  Distal is not readable.,Cardiac wall motion within normal limits.  No gross pulmonary artery abnormality however they are not well delineated.  A full report was placed on the patient's chart.  Report was saved to PACS.","cardiovascular / pulmonary, coronary artery cta, calcium scoring, cardiac function, coronary artery, ct, scoring, lad, midportion, cta, calcium, cardiac, coronary, artery, angiography, "
 CCTA with Cardiac Function/Calcium Scoring, Cardiovascular / Pulmonary, Coronary CT Angiography (CCTA) - 2 ,"CARDIAC CT INCLUDING CORONARY CT ANGIOGRAPHY,PROCEDURE: , Breath hold cardiac CT was performed using a 64-channel CT scanner with a 0.5-second rotation time.  Contrast injection was timed using a 10 mL bolus of Ultravist 370 IV.  Then the patient received 75 mL of Ultravist 370 at a rate of 5 mL/sec.,Retrospective ECG gating was performed.  The patient received 0.4 milligrams of sublingual nitroglycerin prior to the to the scan.  The average heart rate was 62 beats/min.,The patient had no adverse reaction to the contrast.  Multiphase retrospective reconstructions were performed.  Small field of view cardiac and coronary images were analyzed on a 3D work station.  Multiplanar reformatted images and 3D volume rendering was performed by the attending physician for the purpose of defining coronary anatomy and determining the extent of coronary artery disease.,CORONARY CTA:,1.  The technical quality of the scan is adequate.,2.  The coronary ostia are in their normal position.  The coronary anatomy is right dominant.,3.  LEFT MAIN:  The left main coronary artery is patent without angiographic stenosis.,4.  LEFT ANTERIOR DESCENDING ARTERY:  The proximal aspect of the left anterior descending artery demonstrates a mixed plaque consisting of both calcified and noncalcified lesion which is less than 30% in stenosis severity.  Diagonal 1 and diagonal 2 branches of the left anterior descending artery demonstrate mild irregularities.,5.  The ramus intermedius is a small vessel with minor irregularities.,6.  LEFT CIRCUMFLEX:  The left circumflex and obtuse marginal 1 and obtuse marginal 2 branches of the vessel are patent without significant stenosis.,7.  RIGHT CORONARY ARTERY:  The right coronary artery is a large and dominant vessel.  It demonstrates within its mid-segment calcified atherosclerosis, less than 50% stenosis severity.  Left ventricular ejection fraction is calculated to be 69%.  There are no wall motion abnormalities.,8.  Coronary calcium score was calculated to be 79, indicating at least mild atherosclerosis within the coronary vessels.,ANCILLARY FINDINGS: , None.,FINAL IMPRESSION:,1.  Mild coronary artery disease with a preserved left ventricular ejection fraction of 69%.,2.  Recommendation is aggressive medical management consisting of aggressive lifestyle modifications and statin therapy.,Thank you for referring this patient to us.","cardiovascular / pulmonary, coronary ct angiography, ventricular ejection fraction, anterior descending artery, coronary artery disease, coronary ct, ct angiography, cardiac ct, obtuse marginal, ventricular ejection, ejection fraction, coronary artery, artery, angiography, coronary, ccta, atherosclerosis, ventricular, beats/min, anterior, vessel, stenosis, ct, cardiac, disease,"
 CT chest with contrast., Cardiovascular / Pulmonary, CT Chest - 1 ,"EXAM: , CT chest with contrast.,REASON FOR EXAM: , Pneumonia, chest pain, short of breath, and coughing up blood.,TECHNIQUE: , Postcontrast CT chest 100 mL of Isovue-300 contrast.,FINDINGS: , This study demonstrates a small region of coalescent infiltrates/consolidation in the anterior right upper lobe.  There are linear fibrotic or atelectatic changes associated with this.  Recommend followup to ensure resolution.  There is left apical scarring.  There is no pleural effusion or pneumothorax.  There is lingular and right middle lobe mild atelectasis or fibrosis.,Examination of the mediastinal windows disclosed normal inferior thyroid.  Cardiac and aortic contours are unremarkable aside from mild atherosclerosis.  The heart is not enlarged.  There is no pathologic adenopathy identified in the chest including the bilateral axillary and hilar regions.,Very limited assessment of the upper abdomen demonstrates no definite abnormalities.,There are mild degenerative changes in the thoracic spine.,IMPRESSION:,1.Anterior small right upper lobe infiltrate/consolidation.  Recommend followup to ensure resolution given its consolidated appearance.,2.Bilateral atelectasis versus fibrosis.","cardiovascular / pulmonary, pneumonia, chest pain, short of breath, coughing up blood, upper lobe infiltrate, ct chest, ct, chest, isovue,"
" Selective coronary angiography, left heart catheterization with hemodynamics, LV gram with power injection, right femoral artery angiogram, closure of the right femoral artery using 6-French AngioSeal.", Cardiovascular / Pulmonary, Coronary Angiography ,"REASON FOR EXAM: , Dynamic ST-T changes with angina.,PROCEDURE:,1.  Selective coronary angiography.,2.  Left heart catheterization with hemodynamics.,3.  LV gram with power injection.,4.  Right femoral artery angiogram.,5.  Closure of the right femoral artery using 6-French AngioSeal.,Procedure explained to the patient, with risks and benefits.  The patient agreed and signed the consent form.,The patient received a total of 2 mg of Versed and 25 mcg of fentanyl for conscious sedation.  The patient was draped and dressed in the usual sterile fashion.  The right groin area infiltrated with lidocaine solution.  Access to the right femoral artery was successful, okayed with one attempt with anterior wall stick.  Over a J-wire, 6-French sheath was introduced using modified Seldinger technique.,Over the J-wire, a JL4 catheter was passed over the aortic arch.  The wire was removed.  Catheter was engaged into the left main.  Multiple pictures with RAO caudal, AP cranial, LAO cranial, shallow RAO, and LAO caudal views were all obtained.  Catheter disengaged and exchanged over J-wire into a JR4 catheter, the wire was removed.  Catheter with counter-clock was rotating to the RCA one shot with LAO, position was obtained.  The cath disengaged and exchanged over J-wire into a pigtail catheter.  Pigtail catheter across the aortic valve.  Hemodynamics obtained.  LV gram with power injection of 36 mL of contrast was obtained.,The LV gram assessed followed by pullback hemodynamics.,The catheter exchanged out and the right femoral artery angiogram completed to the end followed by the removal of the sheath and deployment of 6-French AngioSeal with no hematoma.  The patient tolerated the procedure well with no immediate postprocedure complication.,HEMODYNAMICS:  ,The aortic pressure was 117/61 with a mean pressure of 83.  The left ventricular pressure was 119/9 to 19 with left ventricular end-diastolic pressure of 17 to 19 mmHg.  The pullback across the aortic valve reveals zero gradient.,ANATOMY:  ,The left main showed minimal calcification as well as the proximal LAD.  No stenosis in the left main seen, the left main bifurcates in to the LAD and left circumflex.,The LAD was a large and a long vessel that wraps around the apex showed no focal stenosis or significant atheromatous plaque and the flow was TIMI 3 flow in the LAD.  The LAD gave off two early diagonal branches.  The second was the largest of the two and showed minimal lumen irregularities, but no focal stenosis.,Left circumflex was a dominant system supplying three obtuse marginal branches and distally supplying the PDA.  The left circumflex was large and patent, 6.0 mm in diameter.  All three obtuse marginal branches appeared to be with no significant stenosis.,The obtuse marginal branch, the third OM3 showed at the origin about 30 to 40% minimal narrowing, but no significant stenosis.  The PDA was wide, patent, with no focal stenosis.,The RCA was a small nondominant system with no focal stenosis and supplying the RV marginal.,LV gram showed that the LV EF is preserved with EF of 60%.  No mitral regurgitation identified.,IMPRESSION:,1.  Patent coronary arteries with normal left anterior descending, left circumflex, and dominant left circumflex system.,2.  Nondominant right, which is free of atheromatous plaque.,3.  Minimal plaque in the diagonal branch II, and the obtuse,marginal branch III, with no focal stenosis.,4.  Normal left ventricular function.,5.  Evaluation for noncardiac chest pain would be recommended.", 
" Acute on chronic COPD exacerbation and community acquired pneumonia both resolving.  However, she may need home O2 for a short period of time.", Cardiovascular / Pulmonary, COPD & Pneumonia - SOAP ,"SUBJECTIVE: , Review of the medical record shows that the patient is a 97-year-old female patient who has been admitted and has been treated for community acquired pneumonia along with COPD exacerbation.  The patient does have a longstanding history of COPD.  However, she does not use oxygen at her independent assisted living home.  Yesterday, she had made improvement since being here at the hospital.  She needed oxygen.  She was tested for home O2 and qualified for it yesterday also.  Her lungs were very tight.  She did have wheezes bilaterally and rhonchi on the right side mostly.  She appeared to be a bit weak and although she was requesting to be discharged home, she did not appear to be fit for it.,Overnight, the patient needed to use the rest room.  She stated that she needed to urinate.  She awoke, decided not to call for assistance.  She stated that she did have her nurse call light button next to her and she was unable to gain access to her walker.  She attempted to walk to the rest room on her own.  She sustained a fall.  She stated that she just felt weak.  She bumped her knee and her elbow.  She had femur x-rays, knee x-rays also.  There was possibility of subchondral fracture and some swelling of her suprapatellar bursa on the right side.  This morning, she denied any headache, back pain or neck pain.  She complained mostly of right anterior knee pain for which she had some bruising and swelling.,OBJECTIVE:,VITAL SIGNS:  The patient's max temperature over the past 24 hours was 36.5; her blood pressure is 148/77, her pulse is 87 to 106.  She is 95% on 2 L via nasal cannula.,HEART:  Regular rate and rhythm without murmur, gallop or rub.,LUNGS:  Reveal no expiratory wheezing throughout.  She does have some rhonchi on the right mid base.  She did have a productive cough this morning and she is coughing green purulent sputum finally.,ABDOMEN:  Soft and nontender.  Her bowel sounds x4 are normoactive.,NEUROLOGIC:  She is alert and oriented x3.  Her pupils are equal and reactive.  She has got a good head and facial muscle strength.  Her tongue is midline.  She has got clear speech.  Her extraocular motions are intact.  Her spine is nontender on palpation from neck to lumbar spine.  She has good range of motion with regard to her shoulders, elbows, wrists and fingers.  Her grip strengths are equal bilaterally.  Both elbows are strong from extension to flexion.  Her hip flexors and extenders are also strong and equal bilaterally.  Extension and flexion of the knee bilaterally and ankles also are strong.  Palpation of her right knee reveals no crepitus.  She does have suprapatellar inflammation with some ecchymosis and swelling.  She has got good joint range of motion however.,SKIN:  She did have a skin tear involving her right forearm lateral, which is approximately 2 to 2.5 inches in length and is at this time currently Steri-Stripped and wrapped with Coban and is not actively bleeding.,ASSESSMENT:,1.  Acute on chronic COPD exacerbation.,2.  Community acquired pneumonia both resolving.  However, she may need home O2 for a short period of time.,3.  Generalized weakness and deconditioning secondary to the above.  Also sustained a fall secondary to instability and not using her walker or calling for assistance.  The patient stated that she knew better and she should have called for assistance and she had been told repeatedly from her family members and staff to call for assistance if she needed to get out of bed.,PLAN:,1.  I will have PT and OT evaluate the patient and give recommendation to safety and appliance use at home i.e. walker.  Myself and one of her daughter's spoke today about the fact that she generally lives independently at the Brooke and she may need assisted living along with physical therapy and oxygen for a period of time rather than going back to independent living.,2.  We will obtain an orthopedic consult secondary to her fall to evaluate her x-rays and function.","cardiovascular / pulmonary, community acquired pneumonia, copd exacerbation, home o2, acute on chronic, pneumonia, exacerbation, copd"
 Common CT Chest template, Cardiovascular / Pulmonary, CT Chest ,"TECHNIQUE: , Sequential axial CT images were obtained from the base of the brain to the upper abdomen following the uneventful administration of 100cc Optiray 350 intravenous contrast.,FINDINGS: , The heart size is normal and there is no pericardial effusion.  The aorta and great vessels are normal in caliber.  The central pulmonary arteries are patent with no evidence of embolus.  There is no significant mediastinal, hilar, or axillary lymphadenopathy.  The trachea and mainstem bronchi are patent.  The esophagus is normal in course and caliber.  The lungs are clear with no infiltrates, effusions, or masses.  There is no pneumothorax.  Scans through the upper abdomen are unremarkable.  The osseous structures in the chest are intact.  ,IMPRESSION: , No acute abnormalities.","cardiovascular / pulmonary, sequential axial ct images, optiray, pericardial effusion, mediastinal, hilar, axillary, lymphadenopathy, ct chest, upper abdomenNOTE"
 A 62-year-old male with a history of ischemic cardiomyopathy and implanted defibrillator., Cardiovascular / Pulmonary, Coronary CT Angiography (CCTA) - 5 ,"COMPARISON STUDIES:, None.,MEDICATION: ,  Lopressor 5 mg IV.,HEART RATE AFTER MEDICATION:, 64bpm,EXAM:,TECHNIQUE: Tomographic images were obtained of the heart and chest with a 64 detector row scanner using slice thicknesses of less than 1 mm. 80cc’s of Isovue 370 was injected in the right arm.,TECHNICAL QUALITY:,Examination is limited secondary to extensive artifact from defibrillator wires.,There is good demonstration of the coronary arteries and there is good bolus timing.,FINDINGS:,LEFT MAIN CORONARY ARTERY:,The left main coronary artery is a moderate-sized vessel with a normal ostium. There is no calcific or non-calcific plaque. The vessel bifurcates into a left anterior descending artery and a left circumflex artery.,LEFT ANTERIOR DESCENDING ARTERY:,The left anterior descending artery is a moderate-sized vessel, with a small first diagonal branch and a large second diagonal branch. The vessel continues as a small vessel, tapering at the apex of the left ventricle. There is calcific plaque within the mid vessel, with dense calcific plaque at the bifurcation of the second diagonal branch. This limits evaluation of the vessel lumen, and although a flow-limiting lesion cannot be excluded, there is no evidence of a high-grade stenosis. There is ostial calcification within the second diagonal branch as well. The LAD distal to the second diagonal branch is small relative to the more proximal vessel, and this is worrisome for a proximal flow-limiting lesion.,In addition, there is marked tapering of the D2 branch distal to the proximal and ostial calcific plaque. This is worrisome for either occlusion or a high-grade stenosis. There is only minimal contrast that is identified in the distal vessel.,LEFT CIRCUMFLEX ARTERY:,The left circumflex artery is a moderate-sized vessel with a patent ostium. There is calcific plaque within the proximal vessel. There is dense calcific plaque at the bifurcation of the OM1, and the AV groove branch. The AV groove branch tapers as a small vessel at the base of the heart. The dense calcific plaque within the bifurcation of the OM1 and the AV groove branch limits evaluation of the vessel lumen. There is no demonstrated high-grade stenosis, but a flow-limiting lesion cannot be excluded here.,RIGHT CORONARY ARTERY:,The right coronary artery is a moderate-sized vessel with a patent ostium. There is proximal mixed calcific and non-calcific plaque, but there is no flow-limiting lesion. The vessel continues as a moderate-sized vessel to the crux of the heart, supplying a small posterior descending artery and moderate to large posterolateral ventricular branches.,There is scattered calcific plaque within the mid vessel and there is also calcific plaque within the distal vessel at the origin of the posterior descending artery. There is no flow-limited lesion demonstrated.,The right coronary artery is dominant.,NONCORONARY CARDIAC STRUCTURE:,CARDIAC CHAMBERS:, There is diffuse myocardial thinning within the left ventricle, particularly within the apex where there is subendocardial calcification, consistent with chronic infarction. There is ventricular enlargement. There is no demonstrated aneurysm or pseudoaneurysm.,CARDIAC VALVES: ,There is calcification within the left aortic valve cusp. The aortic valve is tri-leaflet. Normal mitral valve.,PERICARDIUM:, Normal.,GREAT VESSELS: ,There are atherosclerotic changes within the aorta.,VISUALIZED LUNG PARENCHYMA, MEDIASTINUM AND CHEST WALL: ,Normal.,IMPRESSION:,Limited examination secondary to extensive artifact from the pacemaker wires.,There is extensive calcific plaque within the left anterior descending artery as well as within the proximal second diagonal branch. There is marked tapering of the LAD distal to the bifurcation of the D1 and this is worrisome for a flow-limiting lesion, but there is no evidence of occlusion.,There is marked tapering of the D1 branch distal to the calcific plaque and occlusion cannot be excluded.,There is dense calcific plaque within the left circumflex artery, and although a flow-limiting lesion cannot be excluded here, there is no evidence of an occlusion or high-grade stenosis.,There is mixed soft and calcific plaque within the proximal RCA, but there is no flow limiting lesion demonstrated.,There is diffuse thinning of the left ventricular wall, most focal at the apex where there is also dense calcification, consistent with chronic infarction. There is no demonstrated aneurysm or pseudoaneurysm.",
 Chronic obstructive pulmonary disease (COPD) exacerbation and acute bronchitis., Cardiovascular / Pulmonary, COPD & Bronchitis - Discharge Summary ,"DIAGNOSIS AT ADMISSION:,  Chronic obstructive pulmonary disease (COPD) exacerbation and acute bronchitis.,DIAGNOSES AT DISCHARGE,1.  Chronic obstructive pulmonary disease exacerbation and acute bronchitis.,2.  Congestive heart failure.,3.  Atherosclerotic cardiovascular disease.,4.  Mild senile-type dementia.,5.  Hypothyroidism.,6.  Chronic oxygen dependent.,7.  Do not resuscitate/do not intubate.,HOSPITAL COURSE: , The patient was admitted from the office by Dr. X.  She was placed on the usual medications that included Synthroid 0.05 mg a day, enalapril 5 mg a day, Imdur 30 mg a day, Lanoxin 0.125 mg a day, aspirin 81 mg a day, albuterol and Atrovent nebulizers q.4 h., potassium chloride 10 mEq 2 tablets per day, Lasix 40 mg a day, Humibid L.A.  600 mg b.i.d.  She was placed on oral Levaquin after a load of 500 mg and 250 mg a day.  She was given oxygen, encouraged to eat, and suctioned as needed.,Laboratory data included a urinalysis that had 0-2 WBCs per high power field and urine culture was negative, blood cultures x2 were negative, TSH was 1.7, and chem-7, sodium 134, potassium 4.4, chloride 93, CO2 34, glucose 105, BUN 17, creatinine 0.9, and calcium 9.1.  Digoxin was 1.3.  White blood cell count was 6100 with a normal differential, H&H 37.4/12.1, platelets 335,000.  Chest x-ray was thought to have prominent interstitial lung changes without acute infiltrate.  There is a question if there is mild fluid overload.,The patient improved with the above regimen.  By discharge, her lungs fell back to her baseline.  She had no significant shortness of breath.  Her O2 saturations were stable.  Her vital signs were stable.,She is discharged home to follow up with me in a week and a half.,Her daughter has been spoken to by phone and she will notify me if she worsens or has problems.,PROGNOSIS:  ,Guarded.","cardiovascular / pulmonary, chronic obstructive pulmonary disease exacerbation, chronic obstructive pulmonary disease, pulmonary, copd, discharge, bronchitis,"
 Selective coronary angiography.  Placement of overlapping 3.0 x 18 and 3.0 x 8 mm Xience stents in the proximal right coronary artery.  Abdominal aortography., Cardiovascular / Pulmonary, Coronary Angiography & Abdominal Aortography ,"NAME OF PROCEDURE,1.  Selective coronary angiography.,2.  Placement of overlapping 3.0 x 18 and 3.0 x 8 mm Xience stents in the proximal right coronary artery.,3.  Abdominal aortography.,INDICATIONS:  ,The patient is a 65-year-old gentleman with a history of exertional dyspnea and a cramping-like chest pain.  Thallium scan has been negative.  He is undergoing angiography to determine if his symptoms are due to coronary artery disease.,NARRATIVE:  ,The right groin was sterilely prepped and draped in the usual fashion and the area of the right coronary artery anesthetized with 2% lidocaine.  Constant sedation was obtained using Versed 1 mg and fentanyl 50 mcg.  Received additional Versed and fentanyl during the procedure.  Please refer to the nurses' notes for dosages and timing.,The right femoral artery was entered and a 4-French sheath was placed.  Advancement of the guidewire demonstrated some obstruction at the level of abdominal aorta.  Via the right Judkins catheter, the guidewire was easily infiltrated to the thoracic aorta and over aortic arch.  The right Judkins catheter was advanced to the origin of the right coronary artery where selective angiograms were performed.  This revealed a very high-grade lesion at the proximal right coronary artery.  This catheter was exchanged for a left #4 Judkins catheter which was advanced to the ostium of the left main coronary artery where selective angiograms were performed.,The patient was found to have the above mentioned high-grade lesion in the right coronary artery and a coronary intervention was performed.  A 6-French sheath and a right Judkins guide was placed.  The patient was started on bivalarudin.  A BMW wire was easily placed across the lesion and into the distal right coronary artery.  A 3.0 x 15 mm Voyager balloon was placed and deployed at 10 atmospheres.  The intermediate result was improved with TIMI-3 flow to the terminus of the vessel.  Following this, a 3.0 x 18 mm Xience stent was placed across the lesion and deployed at 17 atmospheres.  This revealed excellent result however at the very distal of the stent there was an area of haziness but no definite dissection.  This was stented with a 3.0 x 8 mm Xience stent deployed again at 17 atmospheres.  Final angiograms revealed excellent result with TIMI-3 flow at the terminus of the right coronary artery and approximately 10% residual stenosis at the worst point of the narrowing.  The guiding catheter was withdrawn over wire and a pigtail was placed.  This was advanced to the abdominal aorta at the area of obstruction and small injection of contrast was given demonstrating that there was a small aneurysm versus a small retrograde dissection in that area with some dye hang up after injection.  The catheter was removed.  The bivalarudin was stopped at the termination of procedure.  A small injection of contrast given through arterial sheath and Angio-Seal was placed without incident.,It should also be noted that an 8-French sheath was placed in the right femoral vein.  This was placed initially as the patient was going to have a right heart catheterization as well because of the dyspnea.,Total contrast media, 205 mL, total fluoroscopy time was 7.5 minutes, X-ray dose, 2666 milligray.,HEMODYNAMICS: , Rhythm was sinus throughout the procedure.  Aortic pressure was 170/81 mmHg.,The right coronary artery is a dominant vessel.  This vessel gives rise to conus branch and two small RV free wall branches and PDA and a small left ventricular branch.  It should be noted that there was competitive flow in the posterior left ventricular branch and that the distal right coronary artery fills via left sided collaterals.  In the proximal right coronary artery, there is a large ulcerative plaque followed immediately by a severe stenosis that is subtotal in severity.  After intervention, there is TIMI-3 flow to the terminus of the right coronary with better fill into the distal right coronary artery and loss of competitive flow.  There was approximately 10% residual stenosis at the worst part of the previous stenosis.,The left main is without disease and trifurcates into a moderate-sized ramus intermedius, the LAD and the circumflex.  The ramus intermedius is free of disease.  The LAD terminates at the LV apex and has elongated area of mild stenosis at its mid segment.  This measures 25% to 30% at its worst point.  The circumflex is a large caliber vessel.  There is a proximal 15% to 20% stenosis and an area of ectasia in the proximal circumflex.  Distally, this circumflex gives rise to a large bifurcating marginal artery and beyond that point, the circumflex is a small vessel within the AV groove.,The aortogram demonstrates eccentric aneurysm formation.  This may represent a small retrograde dissection as well.  There was some dye hang up in the wall.,IMPRESSION,1.  Successful stenting of subtotal stenosis of the proximal coronary artery.,2.  Non-obstructive coronary artery disease in the mid left anterior descending as described above and ectasia of the proximal circumflex coronary artery.,3.  Left to right collateral filling noted prior to coronary intervention.,4.  Small area of eccentric aneurysm formation in the abdominal aorta.","cardiovascular / pulmonary, xience stents, thallium scan, coronary artery, coronary angiography, abdominal aortography, artery, coronary, angiography, stents, flow, vessel, abdominal, catheter, circumflex, stenosis, proximal,"
" A 67-year-old male with COPD and history of bronchospasm, who presents with a 3-day history of increased cough, respiratory secretions, wheezings, and shortness of breath.", Cardiovascular / Pulmonary, COPD - Discharge Summary ,"HISTORY OF PRESENT ILLNESS:  ,A 67-year-old male with COPD and history of bronchospasm, who presents with a 3-day history of increased cough, respiratory secretions, wheezings, and shortness of breath.  He was seen by me in the office on the day of admission and noted to be dyspneic with audible wheezing and he was admitted for acute asthmatic bronchitis, superimposed upon longstanding COPD.  Unfortunately over the past few months he has returned to pipe smoking.  At the time of admission, he denied fever, diaphoresis, nausea, chest pain or other systemic symptoms.,PAST MEDICAL HISTORY: , Status post artificial aortic valve implantation in summer of 2002 and is on chronic Coumadin therapy.  COPD as described above, history of hypertension, and history of elevated cholesterol.,PHYSICAL EXAMINATION: , Heart tones regular with an easily audible mechanical click.  Breath sounds are greatly diminished with rales and rhonchi over all lung fields.,LABORATORY STUDIES:  ,Sodium 139, potassium 4.5, BUN 42, and creatinine 1.7.  Hemoglobin 10.7 and hematocrit 31.7.,HOSPITAL COURSE: , He was started on intravenous antibiotics, vigorous respiratory therapy, intravenous Solu-Medrol.  The patient improved on this regimen.  Chest x-ray did not show any CHF.  The cortisone was tapered.  The patient's oxygenation improved and he was able to be discharged home.,DISCHARGE DIAGNOSES:  ,Chronic obstructive pulmonary disease and acute asthmatic bronchitis.,COMPLICATIONS: , None.,DISCHARGE CONDITION: , Guarded.,DISCHARGE PLAN: , Prednisone 20 mg 3 times a day for 2 days, 2 times a day for 5 days and then one daily, Keflex 500 mg 3 times a day and to resume his other preadmission medication, can be given a pneumococcal vaccination before discharge.  To follow up with me in the office in 4-5 days.","cardiovascular / pulmonary, increased cough, respiratory secretions, wheezings, shortness of breath, acute asthmatic bronchitis, asthmatic bronchitis, respiratory, breath, asthmatic, copd,"
 CCTA with cardiac function and calcium scoring., Cardiovascular / Pulmonary, Coronary CT Angiography (CCTA) - 1 ,"HISTORY: , Coronary artery disease.,TECHNIQUE AND FINDINGS:  ,Calcium scoring and coronary artery CTA with cardiac function was performed on Siemens dual-source CT scanner with postprocessing on Vitrea workstation.  Patient received oral Metoprolol 100 milligrams.  100 ml Ultravist 370 was utilized as the contrast agent.  0.4 milligrams of nitroglycerin was given.,Patient's calcium score 164, volume 205; this places the patient between the 75th and 90th percentile for age.  There is at least moderate atherosclerotic plaque with mild coronary artery disease and significant narrowings possible.,Cardiac wall motion was within normal limits.  Left ventricular ejection fraction calculated to be 82%.  End-diastolic volume 98 mL, end-systolic volume calculated to be 18 mL.,There is normal coronary artery origins.  There is codominance between the right coronary artery and the circumflex artery.  There is mild to moderate stenosis of the proximal LAD with mixed plaque.  Mild stenosis mid LAD with mixed plaque.  No stenosis.  Distal LAD with the distal vessel becoming diminutive in size.  Right coronary artery shows mild stenosis proximally and in the midportion due to calcified focal plaque.  Once again the distal vessel becomes diminutive in size.  Circumflex shows mild stenosis due to focal calcified plaque proximally.  No stenosis is seen involving the mid or distal circumflex.  The distal circumflex also becomes diminutive in size.  The left main shows small amount of focal calcified plaque without stenosis.  Myocardium, pericardium and wall motion was unremarkable as seen.,IMPRESSION:,1.  Atherosclerotic coronary artery disease with values as above.  There are areas of stenosis most pronounced in the LAD with mild to moderate change and mild stenosis involving the circumflex and right coronary artery.,2.  Consider cardiology consult and further evaluation if clinically indicated.,3.  Full report was sent to the PACS.  Report will be mailed to Dr. ABC.","cardiovascular / pulmonary, coronary ct angiography, vitrea workstation, cardiac wall motion, proximal lad, distal lad, focal calcified plaque, coronary artery disease, cardiac function, calcium scoring, wall motion, distal vessel, calcified plaque, distal circumflex, artery disease, mild stenosis, coronary artery, ccta, scoring, atherosclerotic, vessel, calcium, calcified, lad, circumflex, distal, plaque, coronary, artery, stenosis, "
 The patient admitted with palpitations and presyncope., Cardiovascular / Pulmonary, Consult - Palpitations & Presyncope ,"HISTORY OF PRESENT ILLNESS: , The patient is a charming and delightful 46-year-old woman admitted with palpitations and presyncope.,The patient is active and a previously healthy young woman, who has had nine years of occasional palpitations.  Symptoms occur three to four times per year and follow no identifiable pattern.  She has put thought and effort in trying to identify precipitating factors or circumstances but has been unable to do so.  Symptoms can last for an hour or more and she feels as if her heart is going very rapidly but has never measured her heart rate.  The last two episodes, the most recent of which was yesterday, were associated with feeling of darkness descending as if a shade was being pulled down in front of her vision.  On neither occasion did she lose consciousness.,Yesterday, she had a modestly active morning taking a walk with her dogs and performing her normal routines.  While working on a computer, she had a spell.  Palpitations persisted for a short time thereafter as outlined in the hospital's admission note prompting her to seek evaluation at the hospital.  She was in sinus rhythm on arrival and has been asymptomatic since.,No history of exogenous substance abuse, alcohol abuse, or caffeine abuse.  She does have a couple of sodas and at least one to two coffees daily.  She is a nonsmoker.  She is a mother of two.  There is no family history of congenital heart disease.  She has had no history of thoracic trauma.  No symptoms to suggest thyroid disease.,No known history of diabetes, hypertension, or dyslipidemia.  Family history is negative for ischemic heart disease.,Remote history is significant for an ACL repair, complicated by contact urticaria from a neoprene cast.,No regular medications prior to admission.,The only allergy is the neoprene reaction outlined above.,PHYSICAL EXAMINATION: , Vital signs as charted.  Pupils are reactive.  Sclerae nonicteric.  Mucous membranes are moist.  Neck veins not distended.  No bruits.  Lungs are clear.  Cardiac exam is regular without murmurs, gallops, or rubs.  Abdomen is soft without guarding, rebound masses, or bruits.  Extremities well perfused.  No edema.  Strong and symmetrical distal pulses.,A 12-lead EKG shows sinus rhythm with normal axis and intervals.  No evidence of preexcitation.,LABORATORY STUDIES: , Unremarkable.  No evidence of myocardial injury.  Thyroid function is pending.,Two-dimensional echocardiogram shows no evidence of clinically significant structural or functional heart disease.,IMPRESSION/PLAN: , Episodic palpitations over a nine-year period.  Outpatient workup would be appropriate.  Event recorder should be obtained and the patient can be seen again in the office upon completion of that study.  Suppressive medication (beta-blocker or Cardizem) was discussed with the patient for symptomatic improvement, though this would be unlikely to be a curative therapy.  The patient expresses a preference to avoid medical therapy if possible.,Thank you for this consultation.  We will be happy to follow her both during this hospitalization and following discharge.  Caffeine avoidance was discussed as well.,ADDENDUM: , During her initial evaluation, a D-dimer was mildly elevated to 5.  CT scan showed no evidence of pulmonary embolus.  Lower extremity venous ultrasound is pending; however, in the absence of embolization to the pulmonary vasculature, this would be an unlikely cause of palpitations.  In addition, no progression over the nine-year period that she has been symptomatic suggests that this is an unlikely cause.,","cardiovascular / pulmonary, presyncope, palpitations, episodic palpitations, beta-blocker, ultrasound, palpitations and presyncope, sinus rhythm, heart disease, heart"
" Atrial fibrillation and shortness of breath.  The patient is an 81-year-old gentleman with shortness of breath, progressively worsening, of recent onset. History of hypertension, no history of diabetes mellitus, ex-smoker, cholesterol status elevated, no history of established coronary artery disease, and family history positive.", Cardiovascular / Pulmonary, Consult - Atrial Fibrillation - 1 ,"REASON FOR CONSULTATION: , Atrial fibrillation and shortness of breath.,HISTORY OF PRESENTING ILLNESS: , The patient is an 81-year-old gentleman.  The patient had shortness of breath over the last few days, progressively worse.  Yesterday he had one episode and got concerned and came to the Emergency Room, also orthopnea and paroxysmal dyspnea.  Coronary artery disease workup many years ago.  He also has shortness of breath, weakness, and tiredness.,CORONARY RISK FACTORS: , History of hypertension, no history of diabetes mellitus, ex-smoker, cholesterol status elevated, no history of established coronary artery disease, and family history positive.,FAMILY HISTORY: , Positive for coronary artery disease.,SURGICAL HISTORY: , Knee surgery, hip surgery, shoulder surgery, cholecystectomy, and appendectomy.,MEDICATIONS: , Thyroid supplementation, atenolol 25 mg daily, Lasix, potassium supplementation, lovastatin 40 mg daily, and Coumadin adjusted dose.,ALLERGIES: , ASPIRIN.,PERSONAL HISTORY:,  Married, ex-smoker, and does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY: , Hypertension, hyperlipidemia, atrial fibrillation chronic, on anticoagulation.,SURGICAL HISTORY: , As above.,PRESENTATION HISTORY: , Shortness of breath, weakness, fatigue, and tiredness.  The patient also relates history of questionable TIA in 1994.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  Weakness, fatigue, tiredness.,HEENT:  No history of cataracts, blurry vision or glaucoma.,CARDIOVASCULAR:  Arrhythmia, congestive heart failure, no coronary artery disease.,RESPIRATORY:  Shortness of breath.  No pneumonia or valley fever.,GASTROINTESTINAL:  Nausea, no vomiting, hematemesis, or melena.,UROLOGICAL:  Some frequency, urgency, no hematuria.,MUSCULOSKELETAL:  Arthritis, muscle weakness.,SKIN:  Chronic skin changes.,CNS:  History of TIA.  No CVA, no seizure disorder.,ENDOCRINE:  Nonsignificant.,HEMATOLOGICAL:  Nonsignificant.,PSYCHOLOGICAL:  No anxiety or depression.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 67, blood pressure 159/49, afebrile, and respiratory rate 18 per minute.,HEENT:  Atraumatic and normocephalic.,NECK:  Neck veins flat.  No significant carotid bruits.,LUNGS:  Air entry bilaterally fair, decreased in basal areas.  No rales or wheezes.,HEART:  PMI displaced.  S1 and S2 regular.,ABDOMEN:  Soft and nontender.  Bowel sounds present.,EXTREMITIES:  Chronic skin changes.  Pulses are palpable.  No clubbing or cyanosis.,CNS:  Grossly intact.,LABORATORY DATA: , H&H stable 30 and 39, INR of 1.86, BUN and creatinine within normal limits, potassium normal limits.  First set of cardiac enzymes profile negative.  BNP 4810.,Chest x-ray confirms unremarkable findings.  EKG reveals atrial fibrillation, nonspecific ST-T changes.,IMPRESSION:",
 Patient with past medical history significant for coronary artery disease status post bypass grafting surgery and history of a stroke with residual left sided hemiplegia., Cardiovascular / Pulmonary, Consult - Atrial Fibrillation ,"REASON FOR CONSULTATION:,  Atrial fibrillation.,HISTORY OF PRESENT ILLNESS:,  The patient is a 78-year-old, Hispanic woman with past medical history significant for coronary artery disease status post bypass grafting surgery and history of a stroke with residual left sided hemiplegia.  Apparently, the patient is a resident of Lake Harris Port Square long-term facility after her stroke.  She was found to have confusion while in her facility.  She then came to the emergency room and found to have a right sided acute stroke.  12-lead EKG performed on August 10, 2009, found to have atrial fibrillation.  Telemetry also revealed atrial fibrillation with rapid ventricular response.  Currently, the telemetry is normal sinus rhythm.  Because of the finding of atrial fibrillation, cardiology was consulted.,The patient is a poor historian.  She did not recall why she is in the hospital, she said she had a stroke.  She reported no chest discomfort, no shortness of breath, no palpitations.,The following information was obtained from the patient's chart:,PAST MEDICAL HISTORY:,1.  Coronary artery disease status post bypass grafting surgery.  Unable to obtain the place, location, anatomy, and the year it was performed.,2.  Carotid artery stenosis status post right carotid artery stenting.  Again, the time was unknown.,3.  Diabetes.,4.  Hypertension.,5.  Hyperlipidemia.,6.  History of stroke with left side hemiplegia.,ALLERGIES: , No known drug allergies.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:,  The patient is a resident of Lake Harris Port Square.  She has no history of alcohol use.,CURRENT MEDICATIONS: , Please see attached list including hydralazine, Celebrex, Colace, metformin, aspirin, potassium, Lasix, Levaquin, Norvasc, insulin, Plavix, lisinopril, and Zocor.,REVIEW OF SYSTEMS: , Unable to obtain.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure 133/44, pulse 98, O2 saturation is 98% on room air.  Temperature 99, respiratory rate 16.,GENERAL:  The patient is sitting in the chair at bedside.  Appears comfortable.  Left facial droop.  Left side hemiplegia.,HEAD AND NECK:  No JVP seen.  Right side carotid bruit heard.,CHEST:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  PMI not displaced, regular rhythm.  Normal S1 and S2.  Positive S4.  There is a 2/6 systolic murmur best heard at the left lower sternal border.,ABDOMEN:  Soft.,EXTREMITIES:  Not edematous.,DATA:,  A 12-lead EKG performed on August 9, 2009, revealed atrial fibrillation with a ventricular rate of 96 beats per minute, nonspecific ST wave abnormality.,Review of telemetry done the last few days, currently the patient is in normal sinus rhythm at the rate of 60 beats per minute.  Atrial fibrillation was noted on admission noted August 8 and August 10; however, there was normal sinus rhythm on August 10.,LABORATORY DATA: , WBC 7.2, hemoglobin 11.7.  The patient's hemoglobin was 8.2 a few days ago before blood transfusion.  Chemistry-7 within normal limits.  Lipid profile:  Triglycerides 64, total cholesterol 106, HDL 26, LDL 17.  Liver function tests are within normal limits.  INR was 1.1.,A 2D echo was performed on August 11, 2009, and revealed left ventricle normal in size with EF of 50%.  Mild apical hypokinesis.  Mild dilated left atrium.  Mild aortic regurgitation, mitral regurgitation, and tricuspid regurgitation.  No intracardiac masses or thrombus were noted.  The aortic root was normal in size.,ASSESSMENT AND RECOMMENDATIONS:,1.  Paroxysmal atrial fibrillation.  It is unknown if this is a new onset versus a paroxysmal atrial fibrillation.  Given the patient has a recurrent stroke, anticoagulation with Coumadin to prevent further stroke is indicated.  However, given the patient's current neurologic status, the safety of falling is unclear.  We need to further discuss with the patient's primary care physician, probably rehab physician.  If the patient's risk of falling is low, then Coumadin is indicated.  However, if the patient's risk for falling is high, then a course using aspirin and Plavix will be recommended.  Transesophageal echocardiogram probably will delineate possible intracardiac thrombus better, however will not change our current management.  Therefore, I will not recommend transesophageal echocardiogram at this point.  Currently, the patient's heart rate is well controlled, antiarrhythmic agent is not recommended at this point.,2.  Carotid artery stenosis.  The patient underwent a carotid Doppler ultrasound on this admission and found to have a high-grade increased velocity of the right internal carotid artery.  It is difficult to assess the severity of the stenosis given the history of possible right carotid stenting.  If clinically indicated, CT angio of the carotid will be indicated to assess for stent patency.  However, given the patient's current acute stroke, revascularization is not indicated at this time.,3.  Coronary artery disease.  Clinically stable.  No further test is indicated at this time.",
" Congestive heart failure (CHF).  The patient is a 75-year-old gentleman presented through the emergency room.  Symptoms are of shortness of breath, fatigue, and tiredness.  Main complaints are right-sided and abdominal pain.  Initial blood test in the emergency room showed elevated BNP suggestive of congestive heart failure. ", Cardiovascular / Pulmonary, Consult - Congestive Heart Failure ,"REASON FOR CONSULTATION: , Congestive heart failure.,HISTORY OF PRESENT ILLNESS: , The patient is a 75-year-old gentleman presented through the emergency room.  Symptoms are of shortness of breath, fatigue, and tiredness.  Main complaints are right-sided and abdominal pain.  Initial blood test in the emergency room showed elevated BNP suggestive of congestive heart failure.  Given history and his multiple risk factors and workup recently, which has been as mentioned below, the patient was admitted for further evaluation.  Incidentally, his x-ray confirms pneumonia.,CORONARY RISK FACTORS: , History of hypertension, no history of diabetes mellitus, active smoker, cholesterol elevated, questionable history of coronary artery disease, and family history is positive.,FAMILY HISTORY: , Positive for coronary artery disease.,PAST SURGICAL HISTORY: , The patient denies any major surgeries.,MEDICATIONS:  ,Aspirin, Coumadin adjusted dose, digoxin, isosorbide mononitrate 120 mg daily, Lasix, potassium supplementation, gemfibrozil 600 mg b.i.d., and metoprolol 100 mg b.i.d.,ALLERGIES: , None reported.,PERSONAL HISTORY:,  Married, active smoker, does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY: , Hypertension, hyperlipidemia, smoking history, coronary artery disease, cardiomyopathy, COPD, and presentation as above.  The patient is on anticoagulation on Coumadin, the patient does not recall the reason.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  Weakness, fatigue, and tiredness.,HEENT:  History of blurry vision and hearing impaired.  No glaucoma.,CARDIOVASCULAR:  Shortness of breath, congestive heart failure, and arrhythmia.  Prior history of chest pain.,RESPIRATORY:  Bronchitis and pneumonia.  No valley fever.,GASTROINTESTINAL:  No nausea, vomiting, hematemesis, melena, or abdominal pain.,UROLOGICAL:  No frequency or urgency.,MUSCULOSKELETAL:  No arthritis or muscle weakness.,SKIN:  Non-significant.,NEUROLOGICAL:  No TIA.  No CVA or seizure disorder.,ENDOCRINE:  Non-significant.,HEMATOLOGICAL:  Non-significant.,PSYCHOLOGICAL:  Anxiety.  No depression.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 60, blood pressure of 129/73, afebrile, and respiratory rate 16 per minute.,HEENT:  Atraumatic and normocephalic.,NECK:  Supple.  Neck veins flat.,LUNGS:  Air entry bilaterally decreased in the basilar areas with scattered rales, especially right side greater than left lung.,HEART:  PMI displaced.  S1 and S2, regular.  Systolic murmur.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  Trace edema of the ankle.  Pulses are feebly palpable.  Clubbing plus.  No cyanosis.,CNS:  Grossly intact.,MUSCULOSKELETAL:  Arthritic changes.,PSYCHOLOGICAL:  Normal affect.,LABORATORY AND DIAGNOSTIC DATA: , EKG shows sinus bradycardia, intraventricular conduction defect.  Nonspecific ST-T changes.,Laboratories noted with H&H 10/32 and white count of 7.  INR 1.8.  BUN and creatinine within normal limits.  Cardiac enzyme profile first set 0.04, BNP of 10,000.,Nuclear myocardial perfusion scan with adenosine in the office done about a couple of weeks ago shows ejection fraction of 39% with inferior reversible defect.,IMPRESSION: , The patient is a 75-year-old gentleman admitted for:",
" A 10-1/2-year-old born with asplenia syndrome with a complex cyanotic congenital heart disease characterized by dextrocardia bilateral superior vena cava, complete atrioventricular septal defect, a total anomalous pulmonary venous return to the right-sided atrium, and double-outlet to the right ventricle with malposed great vessels, the aorta being anterior with a severe pulmonary stenosis. ", Cardiovascular / Pulmonary, Complex Cyanotic Congenital Heart Disease ,"HISTORY:,  The patient is a 10-1/2-year-old born with asplenia syndrome with a complex cyanotic congenital heart disease characterized by dextrocardia bilateral superior vena cava, complete atrioventricular septal defect, a total anomalous pulmonary venous return to the right-sided atrium, and double-outlet to the right ventricle with malposed great vessels, the aorta being anterior with a severe pulmonary stenosis.  He had undergone staged repair beginning on 04/21/1997 with a right modified Blalock-Taussig shunt followed on 09/02/1999 with a bilateral bidirectional Glenn shunt, and left pulmonary artery to main pulmonary artery pericardial patch augmentation.  These procedures were performed at Medical College Hospital.  Family states that they moved to the United States.  Evaluation at the Children's Hospital earlier this year demonstrated complete occlusion of the right bidirectional Glenn shunt as well as occlusion of the proximal right pulmonary artery.  He was also found to have elevated Glenn pressures at 22 mmHg, transpulmonary gradient axis of 14 mmHg.  The QP:QS ratio of 0.6:1.  A large decompressing venous collateral was also appreciated.  The patient was brought back to cardiac catheterization in an attempt to reconstitute the right caval pulmonary anastomosis and to occlude the venous collateral vessel.,DESCRIPTION OF PROCEDURE: , After sedation and local Xylocaine anesthesia, the patient was prepped and draped.  Cardiac catheterization was performed as outlined in the attached continuation sheets.  Vascular entry was by percutaneous technique, and the patient was heparinized.  Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a 6-French sheath, a 6-French wedge catheter was inserted in the right femoral vein and advanced from the inferior vena cava into the right-sided atrium pulmonary veins and the right ventricle.,Using a 6-French sheath, a 5-French pigtail catheter was inserted into the right femoral artery and advanced retrograde to the descending aorta and ascending aorta.  A separate port of arterial access was obtained in the left femoral artery utilizing a 5-French sheath.,Percutaneous access into the right jugular vein was attempted, but unsuccessful.  Ultrasound on the right neck demonstrated a complete thrombosis of the right internal jugular vein.  Using percutaneous technique and a 5-French sheath, 5-French wedge catheter was inserted into the left internal jugular vein and advanced along the left superior vena cava across the left caval-pulmonary anastomosis into the main pulmonary artery and left pulmonary artery with aid of guidewire.  This catheter then also advanced into the bridging innominate vein.  The catheter was then exchanged over wire for a 4-French Bernstein catheter, which was advanced to the blind end of the right superior vena cava.  A balloon wedge angiogram of the right lower pulmonary vein demonstrated back filling of a small right lower pulmonary artery.  There was no vascular continuity to the stump of the right Glenn.  The jugular venous catheter and sheaths were exchanged over a wire for a 6-French flexor sheath, which was advanced to the proximal right superior vena cava.  The Bernstein catheter was then reintroduced using a Terumo guidewire.  Probing of the superior vena cava facilitated access into the right lower pulmonary artery.  The angiogram in the right pulmonary artery showed a diminutive right lower pulmonary artery and severe long segment proximal stenosis.  The distal pulmonary measured approximately 5.5 to 60 mm in diameter with a long segment stenosis measuring approximately 31 mm in length.  The length of the obstruction was balloon dilated using ultra-thin SD 4 x 2 cm balloon catheter with complete disappearance of the waist.  This facilitated advancement of a flexor sheath into the proximal portion of the stenosis.  A PG 2960 BPX Genesis stent premounted on a 6 mm OptiProbe.  A balloon catheter was advanced across the area of narrowing and inflated with a near-complete disappearance of proximal waist.  Angiogram demonstrated a good stent apposition to the caval wall.  Further angioplasty was then performed utilizing an ultra-thin SDS 8 x 3 cm balloon catheter inflated to 19 atmospheres pressure with complete disappearance of a distinct proximal waist.  Angiogram demonstrated wide patency of reconstituted right caval pulmonary anastomosis though there was no flow seen to the right upper pulmonary artery.  The balloon wedge angiograms were then obtained in the right upper pulmonary veins suggesting the presence of right upper pulmonary artery and not contiguous with the right lower pulmonary artery.  Bernstein catheter was advanced into the main pulmonary artery where a wire probing of the stump of the proximal right pulmonary artery facilitated access to the right upper pulmonary artery.  Angiogram demonstrated severe long segment stenosis of the proximal right pulmonary artery.  Angioplasty of the right pulmonary was then performed using the OptiProbe 6-mm balloon catheter inflated to 16 atmospheres pressure with disappearance of a distinct waist.  Repeat angiogram showed improvement in caliber of right upper pulmonary artery with filling defect of the proximal right pulmonary artery.  The proximal right pulmonary artery was then dilated and stent implanted using a PG 2980 BPX Genesis stent premounted on 8-mm OptiProbe balloon catheter and implanted with complete disappearance of the waist.  Distal right upper pulmonary artery was then dilated and stent implanted utilizing a PG 1870 BPX Genesis stent premounted on 7-mm OptiProbe balloon catheter.  Repeat angiograms were then performed.  Attention was then directed to the large venous collateral vessel arising from the left superior vena cava with a contrast filling of a left-sided azygos vein.  A selective angiogram demonstrated a large azygos vein of the midsection measuring approximately 9.4 mm in diameter.  An Amplatzer 12 mm vascular plug was loaded on the delivery catheter and advanced through the flexor sheath into the azygos vein.  Once stable device was confirmed, the device was released from the delivery catheter.  The 4-French Bernstein catheter was then reintroduced and 5 inch empirical 0.038 inch, 10 cm x 8 mm detachable coils were then implanted above the vascular plug filling the proximal azygos vein.  A pigtail catheter was then introduced into the left superior vena cava for final angiogram.,Flows were calculated by the Fick technique using an assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with injection of the coronary sinus of pulmonary veins, the innominate vein, superior vena cava, the main pulmonary artery, and azygos vein.,After angiography, two normal-appearing renal collecting systems were visualized.  The catheters and sheaths were removed and topical pressure applied for hemostasis.  The patient was returned to the recovery room in satisfactory condition.  There were no complications.,DISCUSSION:,  Oxygen consumption was assumed to be normal mixed venous saturation, but was low due to systemic arterial desaturation of 79%.  The pulmonary veins were fully saturated with partial pressure of oxygen ranging between 120 and 169 mmHg in 30% oxygen.  Remaining saturations reflected complete admixture.  There was increased saturation in the left pulmonary artery due to aortopulmonary collateral flow.  Phasic right atrial pressures were normal with an A-wave somewhat to the normal right ventricular end-diastolic pressure of 9 mmHg.  Left ventricular systolic pressure was systemic with no outflow obstruction to the ascending aorta.  Phasic ascending, descending pressures were similar and normal.  Mean Glenn pressures at initiation of the case were slightly elevated at 14 mmHg with a transpulmonary gradient of 9 mmHg.  The calculated systemic flow was a normal pulmonary flows reduced with a QP:QS ratio of 0.6:1.  The pulmonary vascular resistance was elevated at 4.4 Woods units.  Following stent implantation in the right caval pulmonary anastomosis and right pulmonary artery, there was a slight increase in the Glenn venous pressures to 16 mmHg.  Following embolization of the azygos vein, there was increase in systemic arterial saturation to 84% and increase in mixed venous saturation.  There was similar increase in Glenn pressures to 28 mmHg with a transpulmonary gradient of 14 mmHg.  There was an increase in arterial pressure.  The calculated systemic flow increased from 3.1 liters /minute/meter squared to 4.3 liters/minute/meter squared.  Angiogram within the innominate vein following stent implantation demonstrated appropriate stent position without significant distortion of the innominate vein or proximal cava.  There appeared unobstructed contrast flow to the right lower pulmonary artery of a 1-mmHg mean pressure gradient.  There was absence of contrast filling of the right middle and right upper pulmonary artery.  Final angiogram with a contrast injection in the left superior vena cava showed a forward flow through the right Glenn, a good contrast filling of the right lower pulmonary artery, and a widely patent left Glenn negative contrast washout of the proximal right pulmonary artery and left pulmonary artery presumably due to aortopulmonary collateral flow.  Contrast injection within the right upper pulmonary artery following the stent implantation demonstrated widely patent proximal right pulmonary artery along the length of the implanted stents though with retrograde contrast flow.,INITIAL DIAGNOSES:  ,1.  Asplenia syndrome.,2.  Dextrocardia bilateral superior vena cava.,3.  Atrioventricular septal defect.,4.  Total anomalous pulmonary venous return to the right-sided atrium.,5.  Double outlet right ventricle with malposed great vessels.,6.  Severe pulmonary stenosis.,7.  Separate hepatic venous drainage into the atria.,PRIOR SURGERIES AND INTERVENTIONS:  ,1.  Right modified Blalock-Taussig shunt.,2.  Bilateral bidirectional Glenn shunt.,3.  Patch augmentation of the main pulmonary to left pulmonary artery.,CURRENT DIAGNOSES:  ,1.  Obstructed right caval pulmonary anastomosis.,2.  Obstructed right proximal pulmonary artery.,3.  Venovenous collateral vessel.,CURRENT INTERVENTION:  ,1.  Balloon dilation of the right superior vena cava and stent implantation.,2.  Balloon dilation of the proximal right pulmonary artery, stent implantation.,3.  Embolization of venovenous collateral vessel.,MANAGEMENT: , The case will be discussed in Combined Cardiology Cardiothoracic Surgery case conference.  A repeat catheterization is recommended in 3 months to assess for right pulmonary artery growth and to assess candidacy for Fontan completion.  The patient will be maintained on anticoagulant medications of aspirin and Plavix.  Further cardiology care will be directed by Dr. X.",
" Coronary artery disease, prior bypass surgery.  The patient has history of elevated PSA and BPH.  He had a prior prostate biopsy and he recently had some procedure done, subsequently developed urinary tract infection, and presently on antibiotic.  From cardiac standpoint, the patient denies any significant symptom except for fatigue and tiredness.", Cardiovascular / Pulmonary, Consult - Coronary Artery Disease ,"REASON FOR CONSULTATION:,  Coronary artery disease (CAD), prior bypass surgery.,HISTORY OF PRESENT ILLNESS: , The patient is a 70-year-old gentleman who was admitted for management of fever.  The patient has history of elevated PSA and BPH.  He had a prior prostate biopsy and he recently had some procedure done, subsequently developed urinary tract infection, and presently on antibiotic.  From cardiac standpoint, the patient denies any significant symptom except for fatigue and tiredness.  No symptoms of chest pain or shortness of breath.,His history from cardiac standpoint as mentioned below.,CORONARY RISK FACTORS: , History of hypertension, history of diabetes mellitus, nonsmoker.  Cholesterol elevated.  History of established coronary artery disease in the family and family history positive.,FAMILY HISTORY: , Positive for coronary artery disease.,SURGICAL HISTORY: , Coronary artery bypass surgery and a prior angioplasty and prostate biopsies.,MEDICATIONS:,1.  Metformin.,2.  Prilosec.,3.  Folic acid.,4.  Flomax.,5.  Metoprolol.,6.  Crestor.,7.  Claritin.,ALLERGIES:,  DEMEROL, SULFA.,PERSONAL HISTORY: , He is married, nonsmoker, does not consume alcohol, and no history of recreational drug use.,PAST MEDICAL HISTORY:,  Significant for multiple knee surgeries, back surgery, and coronary artery bypass surgery with angioplasty, hypertension, hyperlipidemia, elevated PSA level, BPH with questionable cancer.  Symptoms of shortness of breath, fatigue, and tiredness.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No history of fever, rigors, or chills except for recent fever and rigors.,HEENT:  No history of cataract or glaucoma.,CARDIOVASCULAR:  As above.,RESPIRATORY:  Shortness of breath.  No pneumonia or valley fever.,GASTROINTESTINAL:  Nausea and vomiting.  No hematemesis or melena.,UROLOGICAL:  Frequency, urgency.,MUSCULOSKELETAL:  No muscle weakness.,SKIN:  None significant.,NEUROLOGICAL:  No TIA or CVA.  No seizure disorder.,PSYCHOLOGICAL:  No anxiety or depression.,ENDOCRINE:  As above.,HEMATOLOGICAL:  None significant.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 75, blood pressure 130/68, afebrile, and respiratory rate 16 per minute.,HEENT:  Atraumatic, normocephalic.,NECK:  Veins flat.  No significant carotid bruits.,LUNGS:  Air entry bilaterally fair.,HEART:  PMI displaced.  S1 and S2 regular.,ABDOMEN:  Soft, nontender.  Bowel sounds present.,EXTREMITIES:  No edema.  Pulses are palpable.  No clubbing or cyanosis.,CNS:  Benign.,EKG: ",
" Left and right coronary system cineangiography.  Left ventriculogram.  PCI to the left circumflex with a 3.5 x 12 and a 3.5 x 8 mm Vision bare-metal stents postdilated with a 3.75-mm noncompliant balloon x2.
", Cardiovascular / Pulmonary, Cineangiography - 1 ,"REASON FOR CATHETERIZATION:,  ST-elevation myocardial infarction.,PROCEDURES UNDERTAKEN,1.  Left coronary system cineangiography.,2.  Right coronary system cineangiography.,3.  Left ventriculogram.,4.  PCI to the left circumflex with a 3.5 x 12 and a 3.5 x 8 mm Vision bare-metal stents postdilated with a 3.75-mm noncompliant balloon x2.,PROCEDURE: , After all risks and benefits were explained to the patient, informed consent was obtained.  The patient was brought to the cardiac cath suite.  Right groin was prepped in usual sterile fashion.  Right common femoral artery was cannulated with the modified Seldinger technique.  A 6-French sheath was introduced.  Next, Judkins right catheter was used to engage the right coronary artery and cineangiography was recorded in multiple views.  Next, an EBU 3.5 guide was used to engage the left coronary system.  Cineangiography was recorded in several views and it was noted to have a 99% proximal left circumflex stenosis.  Angiomax bolus and drip were started after checking an ACT, which was 180, and an Universal wire was advanced through the left circumflex beyond the lesion.  Next, a 3.0 x 12 mm balloon was used to pre-dilate the lesion.  Next a 3.5 x 12 mm Vision bare-metal stent was advanced to the area of stenosis and deployed at 12 atmospheres.  There was noted to be a plaque shift proximally at the edge of the stent.  Therefore, a 3.5 x 8 mm Vision bare-metal stent was advanced to cover the proximal margin of the first stent and deployed at 12 atmospheres.  Next, a 3.75 x 13 mm noncompliant balloon was advanced into the margin of the stent and two inflations at 20 atmospheres were done for 20 seconds.  Final images showed excellent results with initial 99% stenosis reduced to 0%.  The patient continues to have residual stenosis in the mid to distal in the OM branch.  At this point, wire was removed.  Final images confirmed initial stent results, no evidence of dissection, perforation, or complications.,Next, an angled pigtail catheter was advanced into the left ventricular cavity.  LV pressure was measured.  LV gram was done in both the LAO and RAO projections and a pullback gradient across the aortic valve was done and recorded.  Finally, all guides were removed.  Right femoral artery access site was imaged and Angio-Seal deployed to attain excellent hemostasis.  The patient tolerated the procedure very well without complications.,DIAGNOSTIC FINDINGS,1.  Left main:  Left main is a large-caliber vessel bifurcating in LAD and left circumflex with no significant disease.,2.  The LAD:  LAD is a large-caliber vessel, wraps around the apex, gives off multiple septal perforators, three small-to-medium caliber diagonal branches without any significant disease.,3.  Left circumflex:  Left circumflex is a large-caliber vessel, gives off a large distal PDA branch, has a 99% proximal lesion, 50% mid vessel lesion, and a 50% lesion in the OM, which is a distal branch.,4.  Right coronary artery:  Right coronary artery is a moderate-caliber vessel, dominant, bifurcates into PDA and PLV branches, has only mild disease.  Otherwise, no significant stenosis noted.,5.  LV:  The LVEF 50%.  Inferolateral wall hypokinesis.  No significant mitral regurgitation.  No gradient across the aortic valve on pullback.,ASSESSMENT AND PLAN: , ST-elevation myocardial infarction with a 99% stenosis of the proximal portion of the left circumflex treated with a 3.5 x 12 mm Vision bare-metal stent and a 3.5 x 8 mm Vision bare-metal stent.  Excellent results, 0% residual stenosis.  The patient continues to have some residual 50% stenosis in the left circumflex system, some mild disease throughout the other vessels.  Therefore, we will aggressively treat this patient medically with close followup as an outpatient.","cardiovascular / pulmonary, ventriculogram, circumflex, bare-metal stents, myocardial infarction, st-elevation, coronary system cineangiography, infarction, stents, cineangiography, stenosis,"
" Juxtaductal coarctation of the aorta, dilated cardiomyopathy, bicuspid aortic valve, patent foramen ovale.", Cardiovascular / Pulmonary, Coarctation of Aorta ,"HISTORY: , The patient is a 4-month-old who presented with respiratory distress and absent femoral pulses with subsequent evaluation including echocardiogram that demonstrated severe coarctation of the aorta with a peak gradient of 29 mmHg and associated dilated cardiomyopathy with fractional shortening of 16%.  A bicuspid aortic valve was also seen without insufficiency or stenosis.  The patient underwent cardiac catheterization for balloon angioplasty for coarctation of the aorta.,PROCEDURE:  ,After sedation and general endotracheal anesthesia, the patient was prepped and draped.  Cardiac catheterization was performed as outlined in the attached continuation sheets.  Vascular entry was by percutaneous technique, and the patient was heparinized.  Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a percutaneous technique a 4-French 8 cm long double lumen central venous catheter was inserted in the left femoral vein and sutured into place.  There was good blood return from both the ports.,Using a 4-French sheath a 4-French wedge catheter was inserted into the right femoral vein and advanced through the right heart structures out to the branch of pulmonary arteries.  The atrial septum was not probe patent.,Using a 4-French sheath a 4-French marker pigtail catheter was inserted into the left femoral artery and advanced retrograde to the descending aorta ,ascending aorta and left ventricle.  A descending aortogram demonstrated discrete coarctation of the aorta approximately 8 mm distal to the origin of the left subclavian artery.  The transverse arch measured 5 mm.  Isthmus measured 4.7 mm and coarctation measured 2.9 x 1.8 mm at the descending aorta level.  The diaphragm measured 5.6 mm.  The pigtail catheter was exchanged for a wedge catheter, which was then directed into the right innominate artery.  This catheter was exchanged over a wire for a Tyshak mini 6 x 2 cm balloon catheter which was advanced across the coarctation and inflated with complete disappearance of discrete waist.  Pressure pull-back following angioplasty, however, demonstrated a residual of 15-20 mmHg gradient.  Repeat angiogram showed mild improvement in degree of aortic narrowing.  The angioplasty was then performed using a Tyshak mini 7 x 2 cm balloon catheter with complete disappearance of mild waist.  The pigtail catheter was then reintroduced for a pressure pull-back measurement and final angiogram.,Flows were calculated by the Fick technique using an assumed oxygen consumption.,Cineangiograms were obtained with injection in the descending aorta.,After angiography, two normal-appearing renal collecting systems were visualized.  The catheters and sheaths were removed and topical pressure applied for hemostasis.  The patient was returned to the pediatric intensive care unit in satisfactory condition.  There were no complications.,DISCUSSION: , Oxygen consumption was assumed to be normal.  Mixed venous saturation was low due to mild systemic arterial desaturation and anemia.  There is no evidence of significant intracardiac shunt.  Further the heart was desaturated due to VQ mismatch.,Phasic right-sided pressures were normal as was the right pulmonary artery capillary wedge pressure with the A-wave similar to the normal left ventricular end-diastolic pressure of 12 mmHg.  Left ventricular systolic pressure was mildly increased with a 60 mmHg systolic gradient into the ascending aorta and a 29 mmHg systolic gradient on pressure pull-back to the descending aorta.  The calculated flows were mildly increased.  Vascular resistances were normal.  A cineangiogram with contrast injection in the descending aorta showed a normal left aortic arch with normal origins of the brachiocephalic vessels.  There is discrete juxtaductal coarctation of the aorta.  Flow within the intercostal arteries was retrograde.  Following balloon angioplasty of coarctation of the aorta, there was slight fall in the mixed venous saturation and an increase in systemic arterial saturation as the fall in left ventricular systolic pressure from 99 mmHg to 92 mmHg.  There remained a 4 mmHg systolic gradient into the ascending aorta and 9 mmHg systolic gradient pressure pull-back to the descending aorta.  The calculated systemic flow fell to normal values.  Final angiogram with injection in the descending aorta demonstrated improved caliber of coarctation of the aorta with mild intimal irregularity and a small left lateral filling defect consistent with a small intimal tear in the region of the ductus arteriosus.  There is brisk flow in the descending aorta and appropriate flow in the intercostal arteries.  The narrowest diameter of the aorta measured 4.9 x 4.2 mm.,DIAGNOSES:  ,1.  Juxtaductal coarctation of the aorta.,2.  Dilated cardiomyopathy.,3.  Bicuspid aortic valve.,4.  Patent foramen ovale.,INTERVENTION: , Balloon dilation of coarctation of the aorta.,MANAGEMENT: , The case will be discussed at combined Cardiology and Cardiothoracic Surgery Case Conference.  The patient will be allowed to recover from the current intervention with the hopes of complete left ventricular function recovery.  The patient will undoubtedly require formal coarctation of the aorta repair surgically in 4-6 months.  The further cardiologic care will be directed by Dr. X.","cardiovascular / pulmonary, coarctation, juxtaductal, dilated cardiomyopathy, bicuspid aortic valve, patent foramen ovale, catheter was inserted, mmhg systolic gradient, mmhg systolic, systolic gradient, descending aorta, catheterization, mmhg, ventricular, aorta, aortic, foramen,"
 Abnormal EKG and rapid heart rate.  The patient came to the emergency room.  Initially showed atrial fibrillation with rapid ventricular response.  It appears that the patient has chronic atrial fibrillation.  She denies any specific chest pain.  Her main complaint is shortness of breath and symptoms as above., Cardiovascular / Pulmonary, Consult - Abnormal EKG ,"REASON FOR CONSULTATION: , Abnormal EKG and rapid heart rate.,HISTORY OF PRESENT ILLNESS: , The patient is an 86-year-old female.  From the last few days, she is not feeling well, fatigue, tiredness, weakness, nausea, no vomiting, no hematemesis or melena.  The patient relates to have some low-grade fever.  The patient came to the emergency room.  Initially showed atrial fibrillation with rapid ventricular response.  It appears that the patient has chronic atrial fibrillation.  As per the medications, they are not very clear.  Husband has gone out to brief her medications.  She denies any specific chest pain.  Her main complaint is shortness of breath and symptoms as above.,CORONARY RISK FACTORS: , No hypertension or diabetes mellitus.  Nonsmoker.  Cholesterol status is normal.  Questionable history of coronary artery disease.  Family history noncontributory.,FAMILY HISTORY:,  Nonsignificant.,PAST SURGICAL HISTORY: , Questionable coronary artery bypass surgery versus valve replacement.,MEDICATIONS: , Unclear at this time, but she does take Coumadin.,ALLERGIES: , ASPIRIN.,PERSONAL HISTORY: , She is married, nonsmoker.  Does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY: , Symptoms as above, atrial fibrillation, history of open heart surgery, possible bypass surgery; however, after further query, husband relates that she may had just a valve surgery.,REVIEW OF SYSTEMS,CONSTITUTIONAL:  Weakness, fatigue, and tiredness.,HEENT:  No history of cataract, history of blurry vision and hearing impairment.,CARDIOVASCULAR:  Irregular heart rhythm with congestive heart failure, questionable coronary artery disease.,RESPIRATORY:  Shortness of breath, questionable pneumonia.  No valley fever.,GASTROINTESTINAL:  No nausea, no vomiting, hematemesis or melena.,UROLOGICAL:  No frequency or urgency.,MUSCULOSKELETAL:  Arthritis, muscle weakness.,CNS:  No TIA.  No CVA.  No seizure disorder.,SKIN:  Nonsignificant.,PSYCHOLOGIC:  Anxiety and depression.,ALLERGIES:  Nonsignificant except as mentioned above for medications.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse of 122, blood pressure 148/78, afebrile, and respiratory rate 18 per minute.,HEENT AND NECK:  Neck is supple.  Atraumatic and normocephalic.  Neck veins are flat.  No thyromegaly.,LUNGS:  Air entry bilaterally fair.  Decreased breath sounds especially in the right basilar areas.  Few crackles.,HEART:  Normal S1 and S2, irregular.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema.  Pulse is palpable.  No clubbing or cyanosis.,CNS:  Grossly intact.,MUSCULOSKELETAL:  Arthritic changes.,PSYCHOLOGICAL:  None significant.,DIAGNOSTIC DATA: , EKG, atrial fibrillation with rapid ventricular response, and nonspecific ST-T changes.  INR of 4.5, H and H 10 and 30.  BUN and creatinine are within normal limits.  Chest x-ray confirmed right lower lobe patchy infiltrate, and trace of pneumonia.,IMPRESSION:,1.  The patient is an 86-year-old female who has questionable bypass surgery, questionable valve surgery with a rapid atrial heart rate, chronic atrial fibrillation with rapid ventricular response, exacerbated by most likely underlying pneumonia by chest x-ray findings.,2.  Symptoms as above.,RECOMMENDATIONS:,1.  We will start her on a low dose of beta-blocker for rate control and antibiotic for pneumonia.  Once, if she is stable, we will consider further cardiac workup.,2.  We will also obtain an echocardiogram to assess valves such as whether she had a prior valve surgery versus coronary artery bypass surgery.",
" Left and right coronary system cineangiography, cineangiography of SVG to OM and LIMA to LAD.  Left ventriculogram and aortogram.  Percutaneous intervention of the left circumflex and obtuse marginal branch with plano balloon angioplasty unable to pass stent.", Cardiovascular / Pulmonary, Cineangiography ,"PROCEDURES UNDERTAKEN,1.  Left coronary system cineangiography.,2.  Right coronary system cineangiography.,3.  Cineangiography of SVG to OM.,4.  Cineangiography of LIMA to LAD.,5.  Left ventriculogram.,6.  Aortogram.,7.  Percutaneous intervention of the left circumflex and obtuse marginal branch with plano balloon angioplasty unable to pass stent.,NARRATIVE:,  After all risks and benefits were explained to the patient, informed consent was obtained.  The patient was brought to the cardiac catheterization suite.  The right groin was prepped in the usual sterile fashion.  Right common femoral artery was cannulated using a modified Seldinger technique and a long 6-French AO sheath was introduced secondary to tortuous aorta.  Next, Judkins left catheter was used to engage the left coronary system.  Cineangiography was recorded in multiple views.  Next, Judkins right catheter was used to engage the right coronary system.  Cineangiography was recorded in multiple views.  Next, the Judkins right catheter was used to engage the SVG to OM.  Cineangiography was recorded.  Next, the Judkins right was advanced into the left subclavian and exchanged over a long exchange length J-wire for a 4-French left internal mammary artery which was used to engage the LIMA graft to LAD and cineangiography was recorded in multiple views.  Next, an angled pigtail catheter was advanced into the left ventricular cavity.  LV pressures were measured.  LV gram was done and a pullback gradient across the aortic valve was done and recorded.  Next, an aortogram was done and recorded.  At this point, I decided to proceed with percutaneous intervention of the left circumflex.  Therefore, AVA 3.5 guide was used to engage the left coronary artery.  Angiomax bolus and drip was started.  Universal wire was advanced past the lesion and a 2.5-balloon was advanced first to the proximal lesions and predilations were done at 14 atmospheres and then to the distal lesion and predilatation was done at 12 atmospheres.  Next, we attempted to advance a 3.0 x 12 stent to the distal lesion; however, we were unable to pass the stent.  Next, second dilatations were done again with the 2.5 balloon at 18 atmospheres; however, we are unable to break the lesion.  We next attempted a cutting balloon.  Again, we are unable to cross the lesion, therefore a buddy wire technique was used with a PT choice support wire.  Again, we were unable to cross the lesion with the stent.  We then try to cross with a noncompliant balloon, which we were unsuccessful.  We also try to cutting balloon again, we were unsuccessful.  Despite multiple dilatations, we were unable to cross anything beyond the noncompliant balloon across the lesion; therefore, finally the procedure was aborted.  Final images showed no evidence of dissection, perforation, or further complication.  The right groin was filled after taking an image to confirm sheath placement above the bifurcation with excellent results.  The patient tolerated the procedure very well without complications, was taken off the operating table and transferred back to cardiac telemetry floor.,DIAGNOSTIC FINDINGS,1.  The LV.  LVEDP was 4.  LVES is approximately 50%-55% with inferobasal hypokinesis.  No significant MR. No gradient across the aortic valve.,2.  Aortogram.  The ascending aorta shows no significant dilatation or evidence of dissection.  The valve shows no significant aortic insufficiencies.  The abdominal aorta and distal aorta shows significant tortuosities.,3.  The left main.  The left main coronary artery is a large caliber vessel, bifurcating the LAD and left circumflex with some mild distal disease of about 10%-20%.,4.  Left circumflex.  The left circumflex vessel is a large caliber vessel gives off a distal branching obtuse marginal branch.  The upper pole of the OM shows retrograde filling of the distal graft and also at that point approximately a 70%-80% stenosis.  The mid left circumflex is a high-grade 80% diffuse tortuous stenosis.,5.  LAD.  The LAD is a totally 100% occluded vessel.  The LIMA to LAD is patent with only a small-to-moderate caliber LAD.  There is a large diagonal branch coming off the proximal portion of the LAD and that proximal LAD showed some diffuse disease upwards of 60%-70%.  The diagonal shows proximal 80% stenosis.,6.  The right coronary artery:  The right coronary artery is 100% occluded.  There are retrograde collaterals from left to right to the distal PDA and PLV branches.  The SVG to OM is 100% occluded at its take off.  The SVG to PDA is not found; however, presumed 100% occluded given that there is collateral flow to the distal right.,7.  LIMA to LAD is widely patent.,ASSESSMENT AND PLAN: , Attempted intervention to the left circumflex system, only able to perform plano balloon angioplasty, unable to pass stents, noncompliant balloons or cutting balloon.  Final images showed some improvement, however, continued residual stenosis.  At this point, the patient will be transferred back to telemetry floor and monitored.  We can attempt future intervention or continue aggressive medical management.  The patient continues to have residual stenosis in the diagonal; however, due to the length of this procedure, I did not attempt intervention to that diagonal branch.  Possible consideration would be a stress test as an outpatient depending on where patient shows ischemia, focus on treatment to that lesion.","cardiovascular / pulmonary, coronary system cineangiography, svg to om, lima to lad, ventriculogram, aortogram, percutaneous intervention, circumflex, obtuse marginal branch, balloon angioplasty, coronary artery, balloon, cineangiography, lad,"
" Left pleural effusion, parapneumonic, loculated.  Left chest tube placement.", Cardiovascular / Pulmonary, Chest Tube Placement ,"PREOPERATIVE DIAGNOSIS: , Left pleural effusion, parapneumonic, loculated.,POSTOPERATIVE DIAGNOSIS: , Left pleural effusion, parapneumonic, loculated.,OPERATION: , Left chest tube placement.,IV SEDATION: , 5 mg of Versed total given under pulse ox monitoring, 1% lidocaine local infiltration.,PROCEDURE: , With the patient semi recumbent and supine the left anterolateral chest was prepped and draped in the usual sterile fashion.  A 1% lidocaine was liberally infiltrated into the skin, subcutaneous tissue, deep fascia and the anterior axillary line just below the level of the nipple.  The incision was made and deepened through the different layers to reach the intercostal space.  The pleura was entered on top of the underlying rib and finger digital palpation was performed.  Multiple loculations were encountered.  Break up of loculations was performed posteriorly and a chest tube was directed posteriorly.  Only a small amount of fluid was noted to come out initially.  This was sent for various studies.  Soft adhesions were encountered.  The plan was to obtain a chest x-ray and start Activase installation.","cardiovascular / pulmonary, activase, chest tube placement, pleural effusion, chest tube, lidocaine, infiltration, parapneumonic, loculated, pleural, chest, "
 A routine return appointment for a 71-year-old woman with chronic atrial fibrillation.  Chief complaint today is shortness of breath., Cardiovascular / Pulmonary, Chronic Atrial Fibrillation ,"REASON FOR VISIT:,  This is a routine return appointment for this 71-year-old woman with chronic atrial fibrillation.  Her chief complaint today is shortness of breath.,HISTORY OF PRESENT ILLNESS:,  I last saw her in 09/2008.  Since then, she has been admitted to ABCD Hospital from 11/05/2008 through 11/08/2008 for a near syncopal episode.  She was found to have a fast heart rate in the atrial fibrillation.  She was also found to be in heart failure and so they diuresed her.  They wanted to send her home on furosemide 40 mg daily, but unfortunately they never gave her a prescription for this and so she now is not on any furosemide and since being discharged she has regained fluid to no one's great surprise.  My plan advent is to control her heart rate.  This has been a bit difficult with her retaining fluid.  We will try again to diurese her as an outpatient and go forward from there with rate control and anticoagulation.  She may need to have a pacemaker placed and her AV node ablated if this does not work.,She notes the shortness of breath and wheezing at nights.  I think these are manifestations of heart failure.  She has peripheral edema.  She is short of breath when she tries to walk a city block.  I believe she takes her medications as directed, but I am never sure she actually is taking them correctly.  In any case, she did not bring her medications with her today.,Today, she had an ECG which shows atrial fibrillation with a ventricular response of 117 beats per minute.  There is a nonspecific IVCD.  This is unchanged from her last visit except that her heart rate is faster.  In addition, I reviewed her echocardiogram done at XYZ.  Her ejection fraction is 50% and she has paradoxical septal motion.  Her right ventricular systolic pressure is normal.  There are no significant valvular abnormalities.,MEDICATIONS:  ,1.  Fosamax - 70 mg weekly.,2.  Lisinopril - 20 mg daily.,3.  Metformin - 850 mg daily.,4.  Amlodipine - 5 mg daily.,5.  Metoprolol - 150 mg twice daily.,6.  Warfarin - 5 mg daily.,7.  Furosemide - none.,8.  Potassium - none.,9.  Magnesium oxide - 200 mg daily.,ALLERGIES: , Denied.,MAJOR FINDINGS:,  On my comprehensive cardiovascular examination, she again looks the same which is in heart failure.  Her blood pressure today was 130/60 and her pulse 116 blood pressure and regular.  She is 5 feet 11 inches and her weight is 167 pounds, which is up from 158 pounds from when I saw her last visit.  She is breathing 1two times per minute and it is unlabored.  Eyelids are normal.  She has vitiligo.  Pupils are round and reactive to light.  Conjunctivae are clear and sclerae are anicteric.  There is no oral thrush or central cyanosis.  She has marked keloid formation on both sides of her neck, the left being worse than the right.  The jugular venous pressure is elevated.  Carotids are brisk are without bruits.  Lungs are clear to auscultation and percussion.  The precordium is quiet.  The rhythm is irregularly irregular.  She has a variable first and second heart sounds.  No murmurs today.  Abdomen is soft without hepatosplenomegaly or masses, although she does have hepatojugular reflux.  She has no clubbing or cyanosis, but does have 1+ peripheral edema.  Distal pulses are good.  On neurological examination, her mentation is normal.  Her mood and affect are normal.  She is oriented to person, place, and time.,ASSESSMENTS: , She has chronic atrial fibrillation and heart failure now.,PROBLEMS DIAGNOSES:  ,1.  Chronic atrial fibrillation, anticoagulated and the plan is rate control.,2.  Heart failure and she needs more diuretic.,3.  High blood pressure controlled.,4.  Hyperlipidemia.,5.  Diabetes mellitus type 2.,6.  Nonspecific intraventricular conduction delay.,7.  History of alcohol abuse.,8.  Osteoporosis.,9.  Normal left ventricular function.,PROCEDURES AND IMMUNIZATIONS: , None today.,PLANS: , I have restarted her Lasix at 80 mg daily and I have asked her to return in about 10 days to the heart failure clinic.  There, I would like them to recheck her heart rate and if still elevated, and she is truly on 150 mg of metoprolol twice a day, one could switch her amlodipine from 5 mg daily to diltiazem 120 mg daily.  If this does not work, in terms of controlling her heart rate, then she will need to have a pacemaker and her AV node ablated.,Thank you for asking me to participate in her care.,MEDICATION CHANGES: , See the above.",
" Resection of left chest wall tumor, partial resection of left diaphragm, left lower lobe lung wedge resection, left chest wall reconstruction with Gore-Tex mesh.", Cardiovascular / Pulmonary, Chest Wall Tumor Resection ,"PREOPERATIVE DIAGNOSIS: , Left chest wall tumor, spindle cell histology.,POSTOPERATIVE DIAGNOSIS: , Left chest wall tumor, spindle cell histology with pathology pending.,PROCEDURE:  ,Resection of left chest wall tumor, partial resection of left diaphragm, left lower lobe lung wedge resection, left chest wall reconstruction with Gore-Tex mesh.,ANESTHESIA: , General endotracheal.,SPECIMEN:,  Left chest wall with tumor and left lower lobe lung wedge resection to pathology.,INDICATIONS FOR PROCEDURE:,  The patient is a 79-year-old male who began to experience back pain approximately 2 years ago, which increased.  Chest x-ray and CT scan revealed a 3 cm x 4 cm mass abutting the left chest wall inferior to the left scapula with pleural thickening.  A biopsy was performed at an outside hospital (Kaiser) and pathology was consistent with mesothelioma.  The patient had a metastatic workup, which was negative including a brain MRI and bone scan.  The bone scan showed only signal positivity in the left 9th rib near the tumor.  The patient has a significant past medical history consisting of coronary artery disease, hypertension, non-insulin dependent diabetes, longstanding atrial fibrillation, anemia, and hypercholesterolemia.  He and his family were apprised of the high-risk nature of this surgery preoperatively and informed consent was obtained.,PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed in the supine position.  The patient was intubated with a double-lumen endotracheal tube.  Intravenous antibiotics were given.  A Foley catheter was placed.  The patient was placed in the right lateral decubitus position and the left chest was prepped and draped in the usual sterile fashion.  An incision approximately 8 inches long was made centered over the mass and extending slightly obliquely over the mass.  The skin and subcutaneous tissues were dissected sharply with the electrocautery.  Good hemostasis was obtained.  The tumor was easily palpable and clearly involving the 8th to 9th rib.  A thoracotomy was initially made above the mass in approximately the 7th intercostal space.  Inspection of the pleural cavity revealed multiple adhesions, which were taken down with a combination of blunt and sharp dissection.  The thoracotomy was extended anteriorly and posteriorly.  It was clear that in order to obtain an adequate resection of the tumor, approximately 4 rib segment of the chest wall would need to be resected.  The ribs of the chest wall were first cut at their anterior aspect.  The ribs 7, 8, 9, and 10 were serially transected after the interspaces were dissected with electrocautery.  Hemostasis was obtained with both electrocautery and clips.  The chest wall segment to be resected was retracted laterally and posteriorly.  It was clear that there were at least 2 areas where the tumor was invading the lung and a lengthy area of diaphragmatic involvement.  Inferiorly, the diaphragm was divided to provide a margin of at least 1 to 2 cm around the areas of tumor.  The spleen and the stomach were identified and were protected.  Inferiorly, the resection of the chest wall was continued in the 10th interspace.  The dissection was then carried posteriorly to the level of the spine.  The left lung at this point was further dissected out and multiple firings of the GIA 75 were used to perform a wedge resection of the left lower lobe, which provided a complete resection of all palpable and visible tumor in the lung.  A 2-0 silk tie was used to ligate the last remaining corner of lung parenchyma at the corner of the wedge resection.  Posteriorly, the chest wall segment was noted to have an area at the level of approximately T8 and T9, where the tumor involved the vertebral bodies.  The ribs were disarticulated, closed to or at their articulations with the spine.  Bleeding from the intercostal vessels was controlled with a combination of clips and electrocautery.  There was no disease grossly involving or encasing the aorta.,The posterior transection of the ribs was completed and the specimen was passed off of the field as a specimen to pathology for permanent section.  The specimen was oriented for the pathologist who came to the room.  Hemostasis was obtained.  The vent in the diaphragm was then closed primarily with a series of figure-of-8 #1 Ethibond sutures.  This produced a satisfactory diaphragmatic repair without undue tension.  A single 32-French chest tube was placed in the pleural cavity exiting the left hemithorax anteriorly.  This was secured with a #1 silk suture.  The Gore-Tex mesh was brought on to the field and was noted to be of adequate size to patch the resulting chest wall defect.  A series of #1 Prolene were placed in an interrupted horizontal mattress fashion circumferentially and tied down individually.  The resulting mesh closure was snug and deemed adequate.  The serratus muscle was reapproximated with figure-of-8 0 Vicryl.  The latissimus was reapproximated with a two #1 Vicryl placed in running fashion.  Of note, two #10 JP drains were placed over the mesh repair of the chest wall.  The subcutaneous tissues were closed with a running 3-0 Vicryl suture and the skin was closed with a 4-0 Monocryl.  The wounds were dressed.  The patient was brought from the operating room directly to the North ICU, intubated in stable condition.  All counts were correct.,","cardiovascular / pulmonary, chest wall tumor resection, diaphragm, left lower lobe, lung wedge resection, chest wall reconstruction, chest wall segment, gore tex mesh, chest wall tumor, chest wall, pleural cavity, lower lobe, wedge resection, resection, tumor, wall, chest, anesthesia, electrocautery, wedge, mesh, lung,"
 Bilateral pleural effusion.  Removal of bilateral #32 French chest tubes with closure of wound., Cardiovascular / Pulmonary, Chest Tube Removal ,"PREOPERATIVE DIAGNOSIS: , Bilateral pleural effusion.,POSTOPERATIVE DIAGNOSIS: , Bilateral pleural effusion.,PROCEDURE PERFORMED: ,Removal of bilateral #32-French chest tubes with closure of wound.,COMPLICATIONS:,  None.,INDICATIONS FOR PROCEDURE: , The patient is a 66-year-old African-American male who has been in the intensive care unit for over a month with bilateral chest tubes for chronic draining pleural effusions with serous drainage.  A decision was made to proceed with removal of these chest tubes and because of the fistulous tracts, this necessitated to close the wounds with sutures.  The patient was agreeable to proceed.,OPERATIVE PROCEDURE:  ,The patient was prepped and draped at the bedside over both chest tube sites.  The pressures applied over the sites and the skin was closed with interrupted #3-0 Ethilon sutures.  The skin was then cleansed and Vaseline occlusive dressing was applied over the sites.  The same procedure was performed on the other side.  The chest tubes were removed on full inspiration.  Vital signs remained stable throughout the procedure.  The patient will remain in the intensive care unit for continued monitoring.,","cardiovascular / pulmonary, serous drainage, bilateral pleural effusion, pleural effusion, chest tubes, effusion, pleural, chest "
" Postcontrast CT chest pulmonary embolism protocol, 100 mL of Isovue-300 contrast is utilized.", Cardiovascular / Pulmonary, Chest Pulmonary Angio ,"EXAM: , CTA chest pulmonary angio.,REASON FOR EXAM: , Evaluate for pulmonary embolism.,TECHNIQUE: , Postcontrast CT chest pulmonary embolism protocol, 100 mL of Isovue-300 contrast is utilized.,FINDINGS: , There are no filling defects in the main or main right or left pulmonary arteries.  No central embolism.  The proximal subsegmental pulmonary arteries are free of embolus, but the distal subsegmental and segmental arteries especially on the right are limited by extensive pulmonary parenchymal, findings would be discussed in more detail below.  There is no evidence of a central embolism.,As seen on the prior examination, there is a very large heterogeneous right chest wall mass, which measures at least 10 x 12 cm based on axial image #35.  Just superior to the mass is a second heterogeneous focus of neoplasm measuring about 5 x 3.3 cm.  Given the short interval time course from the prior exam, dated 01/23/09, this finding has not significantly changed.  However, there is considerable change in the appearance of the lung fields.  There are now bilateral pleural effusions, small on the right and moderate on the left with associated atelectasis.  There are also extensive right lung consolidations, all new or increased significantly from the prior examination.  Again identified is a somewhat spiculated region of increased density at the right lung apex, which may indicate fibrosis or scarring, but the possibility of primary or metastatic disease cannot be excluded.  There is no pneumothorax in the interval.,On the mediastinal windows, there is presumed subcarinal adenopathy, with one lymph node measuring roughly 12 mm suggestive of metastatic disease here.  There is aortic root and arch and descending thoracic aortic calcification.  There are scattered regions of soft plaque intermixed with this.  The heart is not enlarged.  The left axilla is intact in regards to adenopathy.  The inferior thyroid appears unremarkable.,Limited assessment of the upper abdomen discloses a region of lower density within the right hepatic lobe, this finding is indeterminate, and if there is need for additional imaging in regards to hepatic metastatic disease, follow up ultrasound.  Spleen, adrenal glands, and upper kidneys appear unremarkable.  Visualized portions of the pancreas are unremarkable.,There is extensive rib destruction in the region of the chest wall mass.  There are changes suggesting prior trauma to the right clavicle.,IMPRESSION:,1.  Again demonstrated is a large right chest wall mass.,2.  No central embolus, distal subsegmental and segmental pulmonary artery branches are in part obscured by the pulmonary parenchymal findings, are not well assessed.,3.  New bilateral pleural effusions and extensive increasing consolidations and infiltrates in the right lung.,4.  See above regarding other findings.","cardiovascular / pulmonary, chest pulmonary embolism, chest pulmonary embolism protocol, bilateral pleural effusions, chest wall mass, metastatic disease, pulmonary, isovue, subsegmental, metastatic, disease, mass, lung, embolism, chest, angio"
 A lady was admitted to the hospital with chest pain and respiratory insufficiency.  She has chronic lung disease with bronchospastic angina., Cardiovascular / Pulmonary, Chest Pain & Respiratory Insufficiency ,"We discovered new T-wave abnormalities on her EKG.  There was of course a four-vessel bypass surgery in 2001.  We did a coronary angiogram.  This demonstrated patent vein grafts and patent internal mammary vessel and so there was no obvious new disease.,She may continue in the future to have angina and she will have nitroglycerin available for that if needed.,Her blood pressure has been elevated and so instead of metoprolol, we have started her on Coreg 6.25 mg b.i.d.  This should be increased up to 25 mg b.i.d. as preferred antihypertensive in this lady's case.  She also is on an ACE inhibitor.,So her discharge meds are as follows:,1.  Coreg 6.25 mg b.i.d.,2.  Simvastatin 40 mg nightly.,3.  Lisinopril 5 mg b.i.d.,4.  Protonix 40 mg a.m.,5.  Aspirin 160 mg a day.,6.  Lasix 20 mg b.i.d.,7.  Spiriva puff daily.,8.  Albuterol p.r.n. q.i.d.,9.  Advair 500/50 puff b.i.d.,10.  Xopenex q.i.d. and p.r.n.,I will see her in a month to six weeks.  She is to follow up with Dr. X before that.","cardiovascular / pulmonary, chest pain, respiratory insufficiency, chronic lung disease, bronchospastic angina, insufficiency, chest, angina, respiratory, bronchospastic"
 Chest tube insertion done by two physicians in ER - spontaneous pneumothorax secondary to barometric trauma., Cardiovascular / Pulmonary, Chest Tube Insertion in ER ,"PREOPERATIVE DIAGNOSES:,1.  Right spontaneous pneumothorax secondary to barometric trauma.,2.  Respiratory failure.,3.  Pneumonia with sepsis.,POSTOPERATIVE DIAGNOSES:,1.  Right spontaneous pneumothorax secondary to barometric trauma.,2.  Respiratory failure.,3.  Pneumonia with sepsis.,INFORMED CONSENT: , Not obtained.  This patient is obtunded, intubated, and septic.  This is an emergent procedure with 2-physician emergency consent signed and on the chart.,PROCEDURE: , The patient's right chest was prepped and draped in sterile fashion.  The site of insertion was anesthetized with 1% Xylocaine, and an incision was made.  Blunt dissection was carried out 2 intercostal spaces above the initial incision site.  The chest wall was opened, and a 32-French chest tube was placed into the thoracic cavity, after examination with the finger, making sure that the thoracic cavity had been entered correctly.  The chest tube was placed.,A postoperative chest x-ray is pending at this time.,The patient tolerated the procedure well and was taken to the recovery room in stable condition.,ESTIMATED BLOOD LOSS:,  10 mL,COMPLICATIONS:,  None.,SPONGE COUNT: , Correct x2.","cardiovascular / pulmonary, spontaneous pneumothorax, barometric trauma, respiratory failure, sepsis, pneumonia, blunt dissection, chest wall, thoracic cavity, chest x-ray, chest tube insertion, chest tube, pneumothorax, tube, chest, insertion,"
 Chest PA & Lateral to evaluate shortness of breath and pneumothorax versus left-sided effusion., Cardiovascular / Pulmonary, Chest PA & Lateral ,"EXAM: , Chest PA & Lateral.,REASON FOR EXAM: , Shortness of breath, evaluate for pneumothorax versus left-sided effusion.,INTERPRETATION:  ,There has been interval development of a moderate left-sided pneumothorax with near complete collapse of the left upper lobe.  The lower lobe appears aerated.  There is stable, diffuse, bilateral interstitial thickening with no definite acute air space consolidation.  The heart and pulmonary vascularity are within normal limits.  Left-sided port is seen with Groshong tip at the SVC/RA junction.  No evidence for acute fracture, malalignment, or dislocation.,IMPRESSION:,1.  Interval development of moderate left-sided pneumothorax with corresponding left lung atelectasis.,2.  Rest of visualized exam nonacute/stable.,3.  Left central line appropriately situated and stable.,4.  Preliminary report was issued at time of dictation.  Dr. X was called for results.","cardiovascular / pulmonary, effusion, interstitial thickening, chest pa & lateral, shortness of breath, chest, pneumothorax, "
 Patient with a family history of premature coronary artery disease came in for evaluation of recurrent chest pain, Cardiovascular / Pulmonary, Chest Pain - Office Note ,"DISCHARGE DIAGNOSES:,1.  Chest pain.  The patient ruled out for myocardial infarction on serial troponins.  Result of nuclear stress test is pending.,2.  Elevated liver enzymes, etiology uncertain for an outpatient followup.,3.  Acid reflux disease.,TEST DONE: , Nuclear stress test, results of which are pending.,HOSPITAL COURSE: , This 32-year-old with family history of premature coronary artery disease came in for evaluation of recurrent chest pain, O2 saturation at 94% with both atypical and typical features of ischemia.  The patient ruled out for myocardial infarction with serial troponins.  Nuclear stress test has been done, results of which are pending.  The patient is stable to be discharged pending the results of nuclear stress test and cardiologist's recommendations.  He will follow up with cardiologist, Dr. X, in two weeks and with his primary physician in two to four weeks.  Discharge medications will depend on results of nuclear stress test.","cardiovascular / pulmonary, chest pain, serial troponins, premature coronary artery disease, coronary artery disease, nuclear stress test, stress test"
 Patient with palpitations and rcent worsening of chronic chest discomfort., Cardiovascular / Pulmonary, Chest discomfort & palpitations - Consult. ,"CHIEF COMPLAINT:, Palpitations.,CHEST PAIN / UNSPECIFIED ANGINA PECTORIS HISTORY:, The patient relates the recent worsening of chronic chest discomfort. The quality of the pain is sharp and the problem started 2 years ago. Pain radiates to the back and condition is best described as severe. Patient denies syncope. Beyond baseline at present time. Past work up has included 24 hour Holter monitoring and echocardiography. Holter showed PVCs.,PALPITATIONS HISTORY:, Palpitations - frequent, 2 x per week. No caffeine, no ETOH. + stress. No change with Inderal.,VALVULAR DISEASE HISTORY:, Patient has documented mitral valve prolapse on echocardiography in 1992.,PAST MEDICAL HISTORY:, No significant past medical problems. Mitral Valve Prolapse.,FAMILY MEDICAL HISTORY:, CAD.,OB-GYN HISTORY:, The patients last child birth was 1997. Para 3. Gravida 3.,SOCIAL HISTORY:, Denies using caffeinated beverages, alcohol or the use of any tobacco products.,ALLERGIES:, No known drug allergies/Intolerances.,CURRENT MEDICATIONS:, Inderal 20 prn.,REVIEW OF SYSTEMS:, Generally healthy. The patient is a good historian.,ROS Head and Eyes: Denies vision changes, light sensitivity, blurred vision, or double vision.,ROS Ear, Nose and Throat: The patient denies any ear, nose or throat symptoms.,ROS Respiratory: Patient denies any respiratory complaints, such as cough, shortness of breath, chest pain, wheezing, hemoptysis, etc.,ROS Gastrointestinal: Patient denies any gastrointestinal symptoms, such as anorexia, weight loss, dysphagia, nausea, vomiting, abdominal pain, abdominal distention, altered bowel movements, diarrhea, constipation, rectal bleeding, hematochezia.,ROS Genitourinary: Patient denies any genito-urinary complaints, such as hematuria, dysuria, frequency, urgency, hesitancy, nocturia, incontinence.,ROS Gynecological: Denies any gynecological complaints, such as vaginal bleeding, discharge, pain, etc.,ROS Musculoskeletal: The patient denies any past or present problems related to the musculoskeletal system.,ROS Extremities: The patient denies any extremities complaints.,ROS Cardiovascular: As per HPI.,EXAMINATION:,Exam Abdomen/Flank: The abdomen is soft without tenderness or palpable masses. No guarding, rigidity or rebound tenderness. The liver and spleen are not palpable. Bowel sounds are active and normal.,Exam Extremities: Lower extremities are normal in color, touch and temperature. No ischemic changes are noted.,Range of motion is normal. There is no cyanosis, clubbing or edema.,General: Healthy appearing, well developed,. The patient is in no acute distress.,Exam Skin Negative to inspection or palpation. There are no obvious lesions or new rashes noted. Non-diaphoretic.,Exam Ears Canals are clear. Throat is not injected. Tonsils are not swollen or injected.,Exam Neck: There is no thyromegaly, carotid bruits, lymphadenopathy, or JVD. Neck is supple.,Exam Respiratory: Normal breath sounds are heard bilaterally. There is no wheezing. There is no use of accessory muscles.,Exam Cardiovascular: Regular heart rate and rhythm, Normal S1 and S2 without murmur, gallops or rubs.,IMPRESSION / DIAGNOSIS:, Mitral Valve Prolapse. Palpitations.,TESTS ORDERED:, Cardiac tests: Echocardiogram.,MEDICATION PRESCRIBED:, ,Cardizem 30-60 qid prn.",
 Delayed primary chest closure.  Open chest status post modified stage 1 Norwood operation.  The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation., Cardiovascular / Pulmonary, Chest Closure ,"PROCEDURE:, Delayed primary chest closure.,INDICATIONS: , The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation.  Given the magnitude of the operation and the size of the patient (2.5 kg), we have elected to leave the chest open to facilitate postoperative management.  He is now taken back to the operative room for delayed primary chest closure.,PREOP DX: , Open chest status post modified stage 1 Norwood operation.,POSTOP DX:,  Open chest status post modified stage 1 Norwood operation.,ANESTHESIA: , General endotracheal.,COMPLICATIONS: , None.,FINDINGS:,  No evidence of intramediastinal purulence or hematoma.  He tolerated the procedure well.,DETAILS OF PROCEDURE: , The patient was brought to the operating room and placed on the operating table in the supine position.  Following general endotracheal anesthesia, the chest was prepped and draped in the usual sterile fashion.  The previously placed AlloDerm membrane was removed.  Mediastinal cultures were obtained, and the mediastinum was then profusely irrigated and suctioned.  Both cavities were also irrigated and suctioned.  The drains were flushed and repositioned.  Approximately 30 cubic centimeters of blood were drawn slowly from the right atrial line.  The sternum was then smeared with a vancomycin paste.  The proximal aspect of the 5 mm RV-PA conduit was marked with a small titanium clip at its inferior most aspect and with an additional one on its rightward inferior side.  The sternum was then closed with stainless steel wires followed by closure of subcutaneous tissues with interrupted monofilament stitches.  The skin was closed with interrupted nylon sutures and a sterile dressing was placed.  The peritoneal dialysis catheter, atrial and ventricular pacing wires were removed.  The patient was transferred to the pediatric intensive unit shortly thereafter in very stable condition.,I was the surgical attending present in the operating room and in charge of the surgical procedure throughout the entire length of the case.","cardiovascular / pulmonary, open chest, stage 1 norwood operation, hypoplastic left heart syndrome, delayed primary chest closure, chest closure, norwood operation"
 Right hemothorax.  Insertion of a #32 French chest tube on the right hemithorax.  This is a 54-year-old female with a newly diagnosed carcinoma of the cervix.  The patient is to have an Infuse-A-Port insertion., Cardiovascular / Pulmonary, Chest Tube Insertion ,"PREOPERATIVE DIAGNOSIS: , Right hemothorax.,POSTOPERATIVE DIAGNOSIS: , Right hemothorax.,PROCEDURE PERFORMED: , Insertion of a #32 French chest tube on the right hemithorax.,ANESTHESIA: , 1% Lidocaine and sedation.,INDICATIONS FOR PROCEDURE:,  This is a 54-year-old female with a newly diagnosed carcinoma of the cervix.  The patient is to have an Infuse-A-Port insertion today.  Postoperatively from that, she started having a blood tinged pink frothy sputum.  Chest x-ray was obtained and showed evidence of a hemothorax on the right hand side, opposite side of the Infuse-A-Port and a wider mediastinum.  The decision was made to place a chest tube in the right hemithorax to allow for the patient to be stable for transfer out of the operating room.,DESCRIPTION OF PROCEDURE: , The area was prepped and draped in the sterile fashion.  The area was anesthetized with 1% Lidocaine solution.  The patient was given sedation.  A #10 blade scalpel was used to make an incision approximately 1.5 cm long.  Then a curved scissor was used to dissect down to the level of the rib.  A blunt peon was then used to again enter into the right hemithorax.  Immediately a blood tinged effusion was released.  The chest tube was placed and directed in a posterior and superior direction.  The chest tube was hooked up to the Pleur-evac device which was ________ tip suction.  The chest tube was tied in with a #0 silk suture in a U-stitch fashion.  It was sutured in place with sterile dressing and silk tape.  The patient tolerated this procedure well.  We will obtain a chest x-ray in postop to ensure proper placement and continue to follow the patient very closely.","cardiovascular / pulmonary, hemothorax, hemithorax, pleur-evac device, infuse-a-port insertion, chest tube, carcinoma"
" Chest pain, possible syncopal spells.  She has been having multiple cardiovascular complaints including chest pains, which feel like cramps and sometimes like a dull ache, which will last all day long.", Cardiovascular / Pulmonary, Chest Pain - Cardiac Consult ,"REASON FOR REFERRAL:,  Chest pain, possible syncopal spells.,She is a very pleasant 31-year-old mother of two children with ADD.,She was doing okay until January of 2009 when she had a partial hysterectomy.  Since then she just says ""things have changed"".  She just does not want to go out anymore and just does not feel the same.  Also, at the same time, she is having a lot of household stressors with both of her children having ADD and ODD and she feels she does not get enough support from her husband.  Her 11-year-old is having a lot of trouble at school and she often has to go there to take care of problems.,In this setting, she has been having multiple cardiovascular complaints including chest pains, which feel ""like cramps"" and sometimes like a dull ache, which will last all day long.  She is also tender in the left breast area and gets numbness in her left hand.  She has also had three spells of ""falling"", she is not really clear on whether these are syncopal, but they sound like they could be as she sees spots before her eyes.  Twice it happened, when getting up quickly at night and another time in the grocery store.  She suffered no trauma.  She has no remote history of syncope.  Her weight has not changed in the past year.,MEDICATIONS: , Naprosyn, which she takes up to six a day.,ALLERGIES:,  Sulfa.,SOCIAL HISTORY: , She does not smoke or drink.  She is married with two children.,REVIEW OF SYSTEMS:,  Otherwise unremarkable.,PEX:,  BP:  130/70 without orthostatic changes.  PR:  72.  WT:  206 pounds.  She is a healthy young woman.  No JVD.  No carotid bruit.  No thyromegaly.  Cardiac:  Regular rate and rhythm.  There is no significant murmur, gallop, or rub.  Chest:  Mildly tender in the upper pectoral areas bilaterally (breast exam was not performed).  Lungs:  Clear.  Abdomen:  Soft.  Moderately overweight.  Extremities:  No edema and good distal pulses.,EKG: , Normal sinus rhythm, normal EKG.,ECHOCARDIOGRAM (FOR SYNCOPE): , Essentially normal study.,IMPRESSION:,1.  Syncopal spells - These do sound, in fact, to be syncopal.  I suspect it is simple orthostasis/vasovagal, as her EKG and echocardiogram looks good.  I have asked her to drink plenty of fluids and to not to get up suddenly at night.  I think this should take care of the problem.  I would not recommend further workup unless these spells continue, at which time I would recommend a tilt-table study.,2.  Chest pains - Atypical for cardiac etiology, undoubtedly due to musculoskeletal factors from her emotional stressors.  The Naprosyn is not helping that much, I gave her a prescription for Flexeril and instructed her in its use (not to drive after taking it).,RECOMMENDATIONS:,1.  Reassurance that her cardiac checkup looks excellent, which it does.,2.  Drink plenty of fluids and arise slowly from bed.,3.  Flexeril 10 mg q 6 p.r.n.,4.  I have asked her to return should the syncopal spells continue.","cardiovascular / pulmonary, chest pain, syncopal, echocardiogram, ekg, cardiac etiology, syncopal spells, rhythm, flexeril, cardiac, chest, "
 Carotid Ultrasonic & Color Flow Imaging, Cardiovascular / Pulmonary, Carotid Doppler Report ,"Grade II:  Atherosclerotic plaques are seen which appear to be causing 40-60% obstruction.,Grade III:  Atherosclerotic plaques are seen which appear to be causing greater than 60% obstruction.,Grade IV:  The vessel is not pulsating and the artery appears to be totally obstructed with no blood flow in it.,RIGHT CAROTID SYSTEM: , The common carotid artery and bulb area shows mild intimal thickening with no increase in velocity and no evidence for any obstructive disease.  The internal carotid artery shows intimal thickening with some mixed plaques, but no increase in velocity and no evidence for any significant obstructive disease.  The external carotid artery shows no disease.  The vertebral was present and was antegrade.,LEFT CAROTID SYSTEM: , The common carotid artery and bulb area shows mild intimal thickening, but no increase in velocity and no evidence for any significant obstructive disease. the internal carotid artery shows some intimal thickening with mixed plaques, but no increase in velocity and no evidence for any significant obstructive disease.  The external carotid artery shows no disease.  The vertebral was present and was antegrade.,IMPRESSION:,  Bilateral atherosclerotic changes with no evidence for any significant obstructive disease.","cardiovascular / pulmonary, atherosclerotic, atherosclerotic plaques, obstructive disease, carotid artery, carotid artery and bulb, common carotid artery, mild intimal thickening, external carotid artery, common carotid, internal carotid, external carotid, intimal thickening, carotid, intimal, plaques, artery,"
" Left carotid endarterectomy with endovascular patch angioplasty.  Critical left carotid stenosis.  The external carotid artery was occluded at its origin.  When the endarterectomy was performed, the external carotid artery back-bled nicely.  The internal carotid artery had good backflow bleeding noted.", Cardiovascular / Pulmonary, Carotid Endarterectomy & Angioplasty. ,"PREOPERATIVE DIAGNOSIS:,  Critical left carotid stenosis.,POSTOPERATIVE DIAGNOSIS: , Critical left carotid stenosis.,PROCEDURE PERFORMED:,  Left carotid endarterectomy with endovascular patch angioplasty.,ANESTHESIA:,  Cervical block.,GROSS FINDINGS:  ,The patient is a 57-year-old black female with chronic renal failure.  She does have known critical carotid artery stenosis.  She wishes to undergo bilateral carotid endarterectomy, however, it was felt necessary by Dr. X to perform cardiac catheterization.  She was admitted to the hospital yesterday with chest pain.  She has been considered for coronary artery bypass grafting.  I have been asked to address the carotid stenosis, left being more severe, this was addressed first.  Intraoperatively, an atherosclerotic plaque was noted in the common carotid artery extending into the internal carotid artery.  The internal carotid artery is quite torturous.  The external carotid artery was occluded at its origin.  When the endarterectomy was performed, the external carotid artery back-bled nicely.  The internal carotid artery had good backflow bleeding noted.,OPERATIVE PROCEDURE: , The patient was taken to the OR suite and placed in the supine position.  Then neck, shoulder, and chest wall were prepped and draped in appropriate manner.  Longitudinal incision was created along the anterior border of the left sternocleidal mastoid muscle and this was taken through the subcutaneous tissue and platysmal muscle utilizing electrocautery.,Utilizing both blunt and sharp dissections, the common carotid artery, the internal carotid artery beyond the atherosclerotic back, the external carotid artery, and the superior thyroid artery were isolated and encircled with a umbilical tape.  During the dissection, facial veins were ligated with #4-0 silk ligature prior to dividing them.  Also during the dissection, ansa cervicalis, hypoglossal, and vagus nerve identified and preserved.  There was some inflammation above the carotid bulb, but this was not problematic.,The patient had been administered 5000 units of aqueous heparin after allowing adequate circulating time.  The internal carotid artery is controlled with Heifitz clip followed by the external carotid artery and the superior thyroid artery being controlled with Heifitz clips.  The common carotid artery was controlled with profunda clamp.  The patient remained neurologically intact.  A longitudinal arteriotomy was created along the posterior lateral border of the common carotid artery.  This was extended across the lobe on to the internal carotid artery.  An endarterectomy was then performed.  The ________ intima was cleared of all debris and the ________ was flushed with copious amounts of heparinized saline.  As mentioned before, the internal carotid artery is quite torturous.  This was shortened by imbricating the internal carotid artery with horizontal mattress stitches of #7-0 Prolene suture.,The wound was copiously irrigated, rather an endovascular patch was then brought on to the field.  This was cut to shape and length.  This was sutured in place with continuous running #6-0 Prolene suture.  The suture line began at both sites.  The suture was tied in the center along the anterior and posterior walls.  Prior to completing the closure, the common carotid artery was flushed.  The internal carotid artery permitted to back bleed.  The clamp was placed after completing the closure.  The clamp was placed at the origin of the internal carotid artery.  Flow was first directed into the external carotid artery then into the internal carotid artery.  The patient remained neurologically intact.  Topical ________ Gelfoam was utilized.  Of note, during the endarterectomy, the patient did receive an additional 7000 units of aqueous heparin.  The wound was copiously irrigated with antibiotic solution.  Sponge, needle, and all counts were correct.  All surgical sites were inspected.  Good hemostasis noted.  The incision was closed in layers with absorbable suture.  Stainless steel staples approximated skin.  Sterile dressings were applied.  The patient tolerated the procedure well, grossly neurologically intact.","cardiovascular / pulmonary, carotid stenosis, carotid endarterectomy, endovascular patch angioplasty, cervical block, carotid artery, common carotid artery, external carotid artery, endovascular patch, common carotid, external carotid, angioplasty, artery, endovascular, neurologically, carotid, stenosis, endarterectomy"
 Right subclavian triple lumen central line placement, Cardiovascular / Pulmonary, Central Line Placement ,"PREOPERATIVE DIAGNOSIS:,1. Severe chronic obstructive coronary disease.,2. Respiratory failure.,POSTOPERATIVE DIAGNOSIS:,1. Severe chronic obstructive coronary disease.,2. Respiratory failure.,OPERATION:,  Right subclavian triple lumen central line placement.,ANESTHESIA: , Local Xylocaine.,INDICATIONS FOR OPERATION:  ,This 50-year-old gentleman with severe respiratory failure is mechanically ventilated. He is currently requiring multiple intravenous drips, and Dr. X has kindly requested central line placement.,INFORMED CONSENT:  ,The patient was unable to provide his own consent, secondary to mechanical ventilation and sedation. No available family to provide conservator ship was located either.,PROCEDURE:  ,With the patient in his Intensive Care Unit bed, mechanically ventilated in the Trendelenburg position. The right neck was prepped and draped with Betadine in a sterile fashion. Single needle stick aspiration of the right subclavian vein was accomplished without difficulty, and the guide wire was advanced. The dilator was advanced over the wire. The triple lumen catheter was cannulated over the wire, and the wire then removed. No PVCs were encountered during the procedure. All three ports to the catheter aspirated and flushed blood easily, and they were all flushed with normal saline. The catheter was anchored to the chest wall with butterfly phalange using 3-0 silk suture. Betadine ointment and a sterile Op-Site dressing were applied. Stat upright chest x-ray was obtained at the completion of the procedure, and final results are pending.,FINDINGS/SPECIMENS REMOVED:, None,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS:, Nil.","cardiovascular / pulmonary, respiratory failure, central line placement, chronic obstructive coronary disease, normal saline, subclavian, subclavian triple lumen central line placement, subclavian vein, triple lumen, triple lumen central line, lumen central line placement, central line, line placement, respiratory, xylocaine,"
 Carotid and cerebral arteriogram - abnormal carotid duplex studies demonstrating occlusion of the left internal carotid artery., Cardiovascular / Pulmonary, Carotid & Cerebral Arteriograms ,"EXAM: , Carotid and cerebral arteriograms.,INDICATION: , Abnormal carotid duplex studies demonstrating occlusion of the left internal carotid artery.,IMPRESSION:,1.  Complete occlusion of the left common carotid artery approximately 3 cm distal to its origin.,2.  Mild stenosis of the right internal carotid artery measured at 20%.,3.  Patent bilateral vertebral arteries.,4.  No significant disease was identified of the anterior cerebral vessels.,DISCUSSION:  ,Carotid and cerebral arteriograms were performed on Month DD, YYYY, previous studies are not available for comparison.,The right groin was sterilely cleansed and draped.  Lidocaine 1% buffered with sodium bicarbonate was used as local anesthetic.  A 19-French needle was then advanced into the common femoral artery and a wire was advanced.  Over the wire, a sheath was placed.  A wire was then advanced into the abdominal aorta and over the wire and the flushed catheter was then advanced to the arch of the aorta over a wire.  Flushed arteriogram was performed.  Arteriogram demonstrated no significant disease of the great vessels at their origins.  There is demonstration of complete occlusion of the left common carotid artery approximately 3 cm distal to its origin.  The vertebral arteries were widely patent.  Following this, the flushed catheter was exchanged for ***** catheter and selective catheterization of the common carotid artery on the right was performed.  Carotid and cerebral arteriograms were performed.  The carotid arteriograms on the right demonstrated the carotid bulb to be unremarkable.  The external carotid artery on the right is quite tortuous in its appearance.  The internal carotid artery demonstrates a mild plaque creating stenosis, which is measured approximately 20%.  Cerebral arteriogram on the right demonstrated the A1 and M1 segments bilaterally to be normal.  No significant stenosis identified.  There is complete cross-filling into the left brain via the right.  No significant stenosis was appreciated.,Following this, the catheter was parked at the origin of the left common carotid artery and ejection demonstrated complete occlusion.,The patient tolerated the procedure well.  No complications occurred during or immediately after the procedure.  Stasis was achieved of the puncture site using a VasoSeal.  The patient will be observed for at least 2-1/2 hours prior to being discharged to home.","cardiovascular / pulmonary, carotid, arteriogram, bulb, carotid duplex, catheter, cerebral, distal, femoral artery, internal carotid artery, needle, occlusion, sheath, stenosis, vertebral arteries, vessels, cerebral arteriograms, carotid artery, artery, arteriograms, wire,"
 Insertion of central venous line and arterial line and transesophageal echocardiography probe., Cardiovascular / Pulmonary, Central Venous & Arterial  Line ,"INDICATIONS FOR PROCEDURES: , Impending open-heart surgery for atrial septectomy and bilateral bidirectional Glenn procedure.,The patient was already under general anesthesia in the operating room.  Antibiotic prophylaxis with cephazolin and gentamicin were already given.  A strict aseptic technique was used including use of gowns, mask, and gloves, etc.  The skin was cleansed with alcohol and then prepped with ChloraPrep solution.,PROCEDURE #1:,  Insertion of central venous line.,DESCRIPTION OF PROCEDURE #1: , Attention was directed to the right groin.  A Cook 4-French double-lumen 12-cm long central venous heparin-coated catheter kit was opened.  Using the 21-gauge needle that comes with this kit, the needle was inserted approximately 2 cm below the right inguinal ligament just medial to the pulsations of the femoral artery.  There was good venous blood return on the first try.  Using the Seldinger technique, the soft J-end of the wire was inserted through the needle without resistance approximately 15 cm.  It was then exchanged for a 5-French dilator followed by the 4-French double-lumen catheter and the wire was removed intact.  There was good blood return from both lumens, which were flushed with heparinized saline.  The catheter was sutured to the skin at three points with #4-0 silk for stabilization.,PROCEDURE #2:,  Insertion of arterial line.,DESCRIPTION OF PROCEDURE #2:,  Attention was directed to the left wrist, which was placed on wrist rest.  The Allen test was normal.  A Cook 2.5-French 5 cm long arterial catheter kit was opened.  A 22-gauge IV cannula was used to enter the artery, which was done on the first try with good pulsatile blood return.  Using the Seldinger technique, the catheter was exchanged for a 2.5-French catheter and the wire was removed intact.  There was pulsatile blood return and the catheter was flushed with heparinized saline solution.  It was sutured to the skin with #4-0 silk at three points for stabilization.,Both catheters functioned well throughout the procedure.  The distal circulation of the leg and the hand was intact immediately after insertion, approximately 20 minutes later, and at the end of the procedure.  There were no complications.,PROCEDURE #3: , Insertion of transesophageal echocardiography probe.,DESCRIPTION OF PROCEDURE #3: , The probe was inserted under direct vision because initially there was some resistance to insertion.  Under direct vision, using the #2 Miller blade, the upper esophageal opening was visualized and the probe was passed easily without resistance.  There was good visualization of the heart.  The probe was used by the pediatric cardiologist for preoperative and postoperative diagnostic echocardiography.  The probe was removed at the end.  There was no trauma and there was no blood tingeing.,","cardiovascular / pulmonary, open-heart surgery, central venous line, arterial line, transesophageal echocardiography probe, glenn procedure, atrial septectomy, aseptic technique, pulsatile blood, central venous, blood return, arterial, central, probe, insertion, catheter"
 Central line insertion.  Empyema thoracis and need for intravenous antibiotics., Cardiovascular / Pulmonary, Central Line Insertion ,"PREOPERATIVE DIAGNOSES,1.  Empyema thoracis.,2.  Need for intravenous antibiotics.,POSTOPERATIVE DIAGNOSES,1.  Empyema thoracis.,2.  Need for intravenous antibiotics.,PROCEDURE:,  Central line insertion.,DESCRIPTION OF PROCEDURE: , With the patient in his room, after obtaining the informed consent, his left deltopectoral area was prepped and draped in the usual fashion.  Xylocaine 1% was infiltrated and with the patient in the Trendelenburg position, the left subclavian vein was subcutaneously cannulated without any difficulty.  The triple-lumen catheter was inserted and all ports were flushed out and were irrigated with normal saline.  The catheter was fixed to the skin with sutures.  The dressing was applied and then the chest x-ray was obtained which showed no complications of the procedure and good position of the catheter.","cardiovascular / pulmonary, thoracis, intravenous, central line insertion, empyema, catheter, "
" Right common carotid endarterectomy, internal carotid endarterectomy, external carotid endarterectomy, and Hemashield patch angioplasty of the right common, internal and external carotid arteries.", Cardiovascular / Pulmonary, Carotid Endarterectomy - 1 ,"PREOPERATIVE DIAGNOSIS:,  Right common, internal and external carotid artery stenosis.,POSTOPERATIVE DIAGNOSIS:,  Right common, internal and external carotid artery stenosis.,OPERATIONS,1.  Right common carotid endarterectomy.,2.  Right internal carotid endarterectomy.,3.  Right external carotid endarterectomy.,4.  Hemashield patch angioplasty of the right common, internal and external carotid arteries.,ANESTHESIA:,  General endotracheal anesthesia.,URINE OUTPUT: , Not recorded,OPERATION IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered.  Next the right neck was prepped and draped in the standard surgical fashion.  A #10-blade scalpel was used to make an incision at the anterior tip of the sternocleidomastoid muscle.  Dissection was carried down to the level of the carotid artery using Bovie electrocautery and sharp dissection with Metzenbaum scissors.  The common, internal and external carotid arteries were identified.  The facial vein was ligated with #3-0 silk.  The hypoglossal nerve was identified and preserved as it coursed across the carotid artery.  After dissecting out an adequate length of common, internal and external carotid artery, heparin was given.  Next, an umbilical tape was passed around the common carotid artery.  A #0 silk suture was passed around the internal and external carotid arteries.  The hypoglossal nerve was identified and preserved.  An appropriate sized Argyle shunt was chosen.  A Hemashield patch was cut to the appropriate size.  Next, vascular clamps were placed on the external carotid artery.  DeBakey pickups were used to control the internal carotid artery and common carotid artery.  A #11-blade scalpel was used to make an incision on the common carotid artery.  The arteriotomy was lengthened onto the internal carotid artery.  Next, the Argyle shunt was placed.  It was secured in place.  Next, an endarterectomy was performed; and this was done on the common, internal carotid and external carotid arteries.  An inversion technique was used on the external carotid artery.  The artery was irrigated and free debris was removed.  Next, we sewed the Hemashield patch onto the artery using #6-0 Prolene in a running fashion.  Prior to completion of our anastomosis, we removed our shunt.  We completed the anastomosis.  Next, we removed our clamp from the external carotid artery, followed by the common carotid artery, and lastly by the internal carotid artery.  There was no evidence of bleeding.  Full-dose protamine was given.  The incision was closed with #0 Vicryl, followed by #2-0 Vicryl, followed by #4-0 PDS in a running subcuticular fashion.  A sterile dressing was applied.","cardiovascular / pulmonary, angioplasty, common carotid artery, external carotid artery, hemashield patch, common carotid, carotid endarterectomy, external, artery, carotid, hemashield, endarterectomy"
 Right carotid stenosis and prior cerebrovascular accident. Right carotid endarterectomy with patch angioplasty., Cardiovascular / Pulmonary, Carotid Endarterectomy  ,"PREOPERATIVE DIAGNOSES:,1.  Right carotid stenosis.,2.  Prior cerebrovascular accident.,POSTOPERATIVE DIAGNOSES:,1.  Right carotid stenosis.,2.  Prior cerebrovascular accident.,PROCEDURE PERFORMED:  ,Right carotid endarterectomy with patch angioplasty.,ESTIMATED BLOOD LOSS:  ,250 cc.,OPERATIVE FINDINGS: , The common and internal carotid arteries were opened.  A high-grade narrowing was present at the proximal internal carotid and this tapered well to a slightly small diameter internal carotid.  This was repaired with a Dacron patch and the patient tolerated this well under regional anesthetic without need for shunting.,PROCEDURE:  ,The patient was taken to the operating room, placed in supine position, prepped and draped in the usual sterile manner with Betadine solution.  Longitudinal incisions were made along the anterior border of the sternocleidomastoid, carried down through subcutaneous fat and fascia.  Hemostasis was obtained with electrocautery.  The platysmal muscle was divided.  The carotid sheath was identified and opened.  The vagus nerve, ansa cervicalis, and hypoglossal nerves were identified and avoided.  The common internal and external carotids were then freed from the surrounding tissue.  At this point, 10,000 units of aqueous heparin were administered and allowed to take effect.  The external and common carotids were then clamped.  The patient's neurological status was evaluated and found to be unchanged from preoperative levels.,Once sufficient time had lapsed, we proceeded with the procedure.  The carotid bulb was opened with a #11 blade and extended with Potts scissors through the very tight lesion into normal internal carotid.  The plaque was then sharply excised proximally and an eversion endarterectomy was performed successfully at the external.  The plaque tapered nicely on the internal and no tacking sutures were necessary.  Heparinized saline was injected and no evidence of flapping or other debris was noted.  The remaining carotid was examined under magnification, which showed no debris of flaps present.  At this point, a Dacron patch was brought on to the field, cut to appropriate length and size, and anastomosed to the artery using #6-0 Prolene in a running fashion.  Prior to the time of last stitch, the internal carotid was back-bled through this.  The last stitch was tied.  Hemostasis was excellent.  The internal was again gently occluded while flow was restored to the common and external carotids for several moments and then flow was restored to the entire system.  At this point, a total of 50 mg of Protamine was administered and allowed to take effect.  Hemostasis was excellent.  The wound was irrigated with antibiotic solution and closed in layers using #3-0 Vicryl and #4-0 undyed Vicryl.  The patient was then taken to the recovery room in satisfactory condition after tolerating the procedure well.  Sponge, needles, and instrument count were correct.  Estimated blood loss was 250 cc.","cardiovascular / pulmonary, carotid stenosis, cerebrovascular, platysmal, dacron patch, carotid endarterectomy, cerebrovascular accident, internal carotid, carotid, stenosis, carotids, endarterectomy"
 Direct-current cardioversion.  This is a 53-year-old gentleman with history of paroxysmal atrial fibrillation for 3 years.  Successful DC cardioversion of atrial fibrillation., Cardiovascular / Pulmonary, Cardioversion - Direct Current - 1 ,"PROCEDURE:  ,Direct-current cardioversion.,BRIEF HISTORY:  ,This is a 53-year-old gentleman with history of paroxysmal atrial fibrillation for 3 years.  He had a wide area of circumferential ablation done on November 9th for atrial fibrillation.  He did develop recurrent atrial fibrillation the day before yesterday and this is persistent.  Therefore, he came in for cardioversion today.  He is still within the first 4 to 6 weeks post ablation where we would attempt early cardioversion.,The patient was in the SDI unit, attached to noninvasive monitoring devices.  After Brevital was brought by the anesthesia service a single 150 joule synchronized biphasic shock using AP paddles did restore him to sinus rhythm in the 80s.  He tolerated it well.  He will be observed for couple hours and discharged home later today.  He will continue on his current medications.  He will follow back up in two to three weeks in the Atrial Fibrillation Clinic and then again in a couple months with myself.,CONCLUSIONS / FINAL DIAGNOSES: , Successful DC cardioversion of atrial fibrillation.","cardiovascular / pulmonary, direct-current cardioversion, circumferential ablation, paroxysmal atrial, dc cardioversion, direct current, atrial fibrillation, ablation, cardioversion,"
 Direct current cardioversion.  Successful direct current cardioversion with restoration of sinus rhythm from atrial fibrillation with no immediate complication. , Cardiovascular / Pulmonary, Cardioversion - Direct Current ,"PROCEDURE: , Direct current cardioversion.,REASON FOR PROCEDURE: , Atrial fibrillation.,PROCEDURE IN DETAIL:  ,The procedure was explained to the patient with risks and benefits including risk of stroke.  The patient understands as well as her husband.  The patient had already a transesophageal echocardiogram showing no left atrial appendage thrombus or thrombus in the left atrium.  There was spontaneous echocardiogram contrast noticed.  The patient was on anticoagulation with Lovenox, received already 3 mg of Versed and 25 mcg of fentanyl for the TEE followed by next 2 mg of Versed for total of 5 mg of Versed.  The pads applied in the anterior and posterior approach.  With synchronized biphasic waveform at 150 J, one shock was successful in restoring sinus rhythm.  The patient had some occasional PACs noticed with occasional sinus tachycardia.  The patient had no immediate post-procedure complications.  The rhythm was maintained and 12-lead EKG was requested.,IMPRESSION:  ,Successful direct current cardioversion with restoration of sinus rhythm from atrial fibrillation with no immediate complication.","cardiovascular / pulmonary, thrombus, atrium, echocardiogram, transesophageal, direct current cardioversion, atrial fibrillation, sinus rhythm, sinus, rhythm, cardioversion"
" Cardiomyopathy and hypotension.  A lady with dementia, coronary artery disease, prior bypass, reduced LV function, and recurrent admissions for diarrhea and hypotension several times.", Cardiovascular / Pulmonary, Cardiomyopathy & Hypotension - Consult ,"REASON FOR CONSULTATION:,  Cardiomyopathy and hypotension.,HISTORY OF PRESENT ILLNESS:,  I am seeing the patient upon the request of Dr. X.  The patient is very well known to me, an 81-year-old lady with dementia, a native American with coronary artery disease with prior bypass, reduced LV function, recurrent admissions for diarrhea and hypotension several times in November and was admitted yesterday because of having diarrhea with hypotension and acute renal insufficiency secondary to that.  Because of her pre-existing coronary artery disease and cardiomyopathy with EF of about 30%, we were consulted to evaluate the patient.  The patient denies any chest pain or chest pressure.  Denies any palpitations.  No bleeding difficulty.  No dizzy spells.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No fever or chills.,EYES:  No visual disturbances.,ENT:  No difficulty swallowing.,CARDIOVASCULAR:  Basically, no angina or chest pressure.  No palpitations.,RESPIRATORY:  No wheezes.,GI:  No abdominal pain, although she had diarrhea.,GU:  No specific symptoms.,MUSCULOSKELETAL:  Have sores on the back.,NEUROLOGIC:  Have dementia.,All other systems are otherwise unremarkable as far as the patient can give me information.,PAST MEDICAL HISTORY:,1.  Positive for coronary artery disease for about two to three years.,2.  Hypertension.,3.  Anemia.,4.  Chronic renal insufficiency.,5.  Congestive heart failure with EF of 25% to 30%.,6.  Osteoporosis.,7.  Compression fractures.,8.  Diabetes mellitus.,9.  Hypothyroidism.,PAST SURGICAL HISTORY:,1.  Coronary artery bypass grafting x3 in 2008.,2.  Cholecystectomy.,3.  Amputation of the right second toe.,4.  ICD implantation.,CURRENT MEDICATIONS AT HOME:,1.  Amoxicillin.,2.  Clavulanic acid or Augmentin every 12 hours.,3.  Clopidogrel 75 mg daily.,4.  Simvastatin 20 mg daily.,5.  Sodium bicarbonate 650 mg twice daily.,6.  Gabapentin 300 mg.,7.  Levothyroxine once daily.,8.  Digoxin 125 mcg daily.,9.  Fenofibrate 145 mg daily.,10.  Aspirin 81 mg daily.,11.  Raloxifene once daily.,12.  Calcium carbonate and alendronate.,13.  Metoprolol 25 mg daily.,14.  Brimonidine ophthalmic once daily.,ALLERGIES: , She has no known allergies.,FAMILY HISTORY: ",
 Problem of essential hypertension.  Symptoms that suggested intracranial pathology., Cardiovascular / Pulmonary, Cardiology Progress Note ,"SUBJECTIVE:,  The patient is a 78-year-old female with the problem of essential hypertension.  She has symptoms that suggested intracranial pathology, but so far work-up has been negative.,She is taking hydrochlorothiazide 25-mg once a day and K-Dur 10-mEq once a day with adequate control of her blood pressure.  She denies any chest pain, shortness of breath, PND, ankle swelling, or dizziness.,OBJECTIVE:,  Heart rate is 80 and blood pressure is 130/70.  Head and neck are unremarkable.  Heart sounds are normal.  Abdomen is benign.  Extremities are without edema.,ASSESSMENT AND PLAN:,  The patient reports that she had an echocardiogram done in the office of Dr. Sample Doctor4 and was told that she had a massive heart attack in the past.  I have not had the opportunity to review any investigative data like chest x-ray, echocardiogram, EKG, etc.  So, I advised her to have a chest x-ray and an EKG done before her next appointment, and we will try to get hold of the echocardiogram on her from the office of Dr. Sample Doctor4.  In the meantime, she is doing quite well, and she was advised to continue her current medication and return to the office in three months for followup.","cardiovascular / pulmonary, cardiology, ekg, k-dur, progerss note, soap, ankle swelling, blood pressure, chest x-ray, echocardiogram, essential hypertension, heart attack, hydrochlorothiazide, hypertension, pathology, chest, heart, intracranial,"
 Cardioversion.  Unsuccessful direct current cardioversion with permanent atrial fibrillation., Cardiovascular / Pulmonary, Cardioversion - Unsuccessful ,"REASON FOR EXAM: , Atrial flutter/cardioversion.,PROCEDURE IN DETAIL: , The procedure was explained to the patient with risks and benefits.  The patient agreed and signed the consent form.  The patient received sedation prior to the cardioversion with a transesophageal echo as dictated earlier with a total of 50 mcg of fentanyl and 6 mg of Versed.  The pads were applied in the anterior-posterior approach.  The synchronized cardioversion with biphasic energy delivered at 150 J. First attempt was unsuccessful.  Second attempt at 200 J with anterior-posterior approach.  With biphasic synchronized energy delivered was also unsuccessful with degeneration of the atrial flutter into atrial fibrillation.,The patient was decided to be on wave control and amiodarone and reattempted cardioversion after anticoagulation for four to six weeks and because of the reduced LV function, the success of the rate without antiarrhythmic may be low.,IMPRESSION: , Unsuccessful direct current cardioversion with permanent atrial fibrillation.","cardiovascular / pulmonary, atrial flutter, cardioversion, anterior-posterior, transesophageal, atrial fibrillation, flutter/cardioversion, fibrillation, atrial,"
" Male with a history of therapy-controlled hypertension, borderline diabetes, and obesity.  Risk factors for coronary heart disease.", Cardiovascular / Pulmonary, Cardiovascular - Letter ,"Dear Sample Doctor:,Thank you for referring Mr. Sample Patient for cardiac evaluation.  This is a 67-year-old, obese male who has a history of therapy-controlled hypertension, borderline diabetes, and obesity.  He has a family history of coronary heart disease but denies any symptoms of angina pectoris or effort intolerance.  Specifically, no chest discomfort of any kind, no dyspnea on exertion unless extreme exertion is performed, no orthopnea or PND.  He is known to have a mother with coronary heart disease.  He has never been a smoker.  He has never had a syncopal episode, MI, or CVA.  He had his gallbladder removed.  No bleeding tendencies.  No history of DVT or pulmonary embolism.  The patient is retired, rarely consumes alcohol and consumes coffee moderately.  He apparently has a sleep disorder, according to his wife (not in the office), the patient snores and stops breathing during sleep.  He is allergic to codeine and aspirin (angioedema).,Physical exam revealed a middle-aged man weighing 283 pounds for a height of 5 feet 11 inches.  His heart rate was 98 beats per minute and regular.  His blood pressure was 140/80 mmHg in the right arm in a sitting position and 150/80 mmHg in a standing position.  He is in no distress.  Venous pressure is normal.  Carotid pulsations are normal without bruits.  The lungs are clear.  Cardiac exam was normal.  The abdomen was obese and organomegaly was not palpated.  There were no pulsatile masses or bruits.  The femoral pulses were 3+ in character with a symmetrical distribution and dorsalis pedis and posterior tibiales were 3+ in character.  There was no peripheral edema.  ,He had a chemistry profile, which suggests diabetes mellitus with a fasting blood sugar of 136 mg/dl.  Renal function was normal.  His lipid profile showed a slight increase in triglycerides with normal total cholesterol and HDL and an acceptable range of LDL.  His sodium was a little bit increased.  His A1c hemoglobin was increased.  He had a spirometry, which was reported as normal.  ,He had a resting electrocardiogram on December 20, 2002, which was also normal.  He had a treadmill Cardiolite, which was performed only to stage 2 and was terminated by the supervising physician when the patient achieved 90% of the predicted maximum heart rate.  There were no symptoms or ischemia by EKG.  There was some suggestion of inferior wall ischemia with normal wall motion by Cardiolite imaging.,In summary, we have a 67-year-old gentleman with risk factors for coronary heart disease.  I am concerned with possible diabetes and a likely metabolic syndrome of this gentleman with truncal obesity, hypertension, possible insulin resistance, and some degree of fasting hyperglycemia, as well as slight triglyceride elevation.  He denies any symptoms of coronary heart disease, but he probably has some degree of coronary atherosclerosis, possibly affecting the inferior wall by functional testings.  ,In view of the absence of symptoms, medical therapy is indicated at the present time, with very aggressive risk factor modification.  I explained and discussed extensively with the patient, the benefits of regular exercise and a walking program was given to the patient.  He also should start aggressively losing weight.  I have requested additional testing today, which will include an apolipoprotein B, LPa lipoprotein, as well as homocystine, and cardio CRP to further assess his risk of atherosclerosis.  ,In terms of medication, I have changed his verapamil for a long acting beta-blocker, he should continue on an ACE inhibitor and his Plavix.  The patient is allergic to aspirin.  I also will probably start him on a statin, if any of the studies that I have recommended come back abnormal and furthermore, if he is confirmed to have diabetes.  Along this line, perhaps, we should consider obtaining the advice of an endocrinologist to decide whether this gentleman needs treatment for diabetes, which I believe he should.  This, however, I will leave entirely up to you to decide.  If indeed, he is considered to be a diabetic, a much more aggressive program should be entertained for reducing the risks of atherosclerosis in general, and coronary artery disease in particular.,I do not find an indication at this point in time to proceed with any further testing, such as coronary angiography, in the absence of symptoms.,If you have any further questions, please do not hesitate to let me know.,Thank you once again for this kind referral.,Sincerely,,Sample Doctor, M.D.","cardiovascular / pulmonary, cardiovascular, letter, angioedema, beta-blocker, cardiac evaluation, chest discomfort, coronary heart disease, hypertension, metabolic syndrome, therapy-controlled hypertension, truncal obesity, controlled hypertension, borderline diabetes, risk factors, heart disease, intolerance, therapy, heart, atherosclerosis, diabetes, coronary, aspirin "
 Cardiology office visit sample note., Cardiovascular / Pulmonary, Cardiology Office Visit - 2 ,"HISTORY OF PRESENT ILLNESS:,  This 57-year-old black female was seen in my office on Month DD, YYYY for further evaluation and management of hypertension.  Patient has severe backache secondary to disc herniation.  Patient has seen an orthopedic doctor and is scheduled for surgery.  Patient also came to my office for surgical clearance.  Patient had cardiac cath approximately four years ago, which was essentially normal.  Patient is documented to have morbid obesity and obstructive sleep apnea syndrome.  Patient does not use a CPAP mask.  Her exercise tolerance is eight to ten feet for shortness of breath.  Patient also has two-pillow orthopnea.  She has intermittent pedal edema.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Blood pressure is 135/70.  Respirations 18 per minute.  Heart rate 70 beats per minute.  Weight 258 pounds.,HEENT:  Head normocephalic.  Eyes, no evidence of anemia or jaundice.  Oral hygiene is good. ,NECK:  Supple.  JVP is flat.  Carotid upstroke is good. ,LUNGS:  Clear. ,CARDIOVASCULAR:  There is no murmur or gallop heard over the precordium. ,ABDOMEN:  Soft.  There is no hepatosplenomegaly. ,EXTREMITIES:  The patient has no pedal edema.  ,MEDICATIONS:  ,1.  BuSpar 50 mg daily.,2.  Diovan 320/12.5 daily.,3.  Lotrel 10/20 daily.,4.  Zetia 10 mg daily.,5.  Ambien 10 mg at bedtime.,6.  Fosamax 70 mg weekly.,DIAGNOSES:,1.  Controlled hypertension.,2.  Morbid obesity.,3.  Osteoarthritis.,4.  Obstructive sleep apnea syndrome.,5.  Normal coronary arteriogram.,6.  Severe backache.,PLAN:,1.  Echocardiogram, stress test.,2  Routine blood tests.,3.  Sleep apnea study.,4.  Patient will be seen again in my office in two weeks.", 
  Congestive heart failure due to rapid atrial fibrillation and systolic dysfunction., Cardiovascular / Pulmonary, Cardiology Progress Note - 1 ,"SUBJECTIVE: , The patient is not in acute distress.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure of 121/63, pulse is 75, and O2 saturation is 94% on room air.,HEAD AND NECK:  Face is symmetrical.  Cranial nerves are intact.,CHEST:  There is prolonged expiration.,CARDIOVASCULAR:  First and second heart sounds are heard.  No murmur was appreciated.,ABDOMEN:  Soft and nontender.  Bowel sounds are positive.,EXTREMITIES:  He has 2+ pedal swelling.,NEUROLOGIC:  The patient is asleep, but easily arousable.,LABORATORY DATA:,  PTT is 49.  INR is pending.  BUN is improved to 20.6, creatinine is 0.7, sodium is 123, and potassium is 3.8.  AST is down to 45 and ALT to 99.,DIAGNOSTIC STUDIES: , Nuclear stress test showed moderate size, mostly fixed defect involving the inferior wall with a small area of peri-infarct ischemia.  Ejection fraction is 25%.,ASSESSMENT AND PLAN:,1.  Congestive heart failure due to rapid atrial fibrillation and systolic dysfunction.  Continue current treatment as per Cardiology.  We will consider adding ACE inhibitors as renal function improves.,2.  Acute pulmonary edema, resolved.,3.  Rapid atrial fibrillation, rate controlled.  The patient is on beta-blockers and digoxin.  Continue Coumadin.  Monitor INR.,4.  Coronary artery disease with ischemic cardiomyopathy.  Continue beta-blockers.,5.  Urinary tract infection.  Continue Rocephin.,6.  Bilateral perfusion secondary to congestive heart failure.  We will monitor.,7.  Chronic obstructive pulmonary disease, stable.,8.  Abnormal liver function due to congestive heart failure with liver congestion, improving.,9.  Rule out hypercholesterolemia.  We will check lipid profile.,10.  Tobacco smoking disorder.  The patient has been counseled.,11.  Hyponatremia, stable.  This is due to fluid overload.  Continue diuresis as per Nephrology.,12.  Deep venous thrombosis prophylaxis.  The patient is on heparin drip.","cardiovascular / pulmonary, atrial fibrillation, systolic dysfunction, ace inhibitors, coronary artery disease, rapid atrial fibrillation, congestive heart failure, beta blockers, heart failure, congestive, heart, asleep, "
 Cardioversion.  An 86-year-old woman with a history of aortic valve replacement in the past with paroxysmal atrial fibrillation , Cardiovascular / Pulmonary, Cardioversion ,"HISTORY: , The patient is an 86-year-old woman with a history of aortic valve replacement in the past with paroxysmal atrial fibrillation who was admitted yesterday with the recurrence of such in a setting of hypokalemia, incomplete compliance with obstructive sleep apnea therapy with CPAP, chocolate/caffeine ingestion and significant mental stress.  Despite repletion of her electrolytes and maintenance with Diltiazem IV she has maintained atrial fibrillation.  I have discussed in detail with the patient regarding risks, benefits, and alternatives of the procedure.  After an in depth discussion of the procedure (please see my initial consultation for further details) I asked the patient this morning if she would like me to repeat that as that discussion had happened yesterday.  The patient declined.  I invited questions for her which she stated she had none and wanted to go forward with the cardioversion which seemed appropriate.,PROCEDURE NOTE: , The appropriate time-out procedure was performed as per Medical Center protocol including proper identification of the patient, physician, procedure, documentation, and there were no safety issues identified by myself nor the staff.  The patient participated actively in this.  She received a total of 4 mg of Versed then and 50 micrograms of fentanyl with utilizing titrated conscious sedation with good effect.  She was placed in the supine position and hands free patches had previously been placed in the AP position and she received one synchronized cardioversion attempt after Diltiazem drip had been turned off with successful resumption of normal sinus rhythm.  This was confirmed on 12 lead EKG.,IMPRESSION/PLAN: , Successful resumption of normal sinus rhythm from recurrent atrial fibrillation.  The patient's electrolytes are now normal and that will need close watching to avoid hypokalemia in the future, as well as she has been previously counseled for strict adherence to sleep apnea therapy with CPAP and perhaps repeat sleep evaluation would be appropriate to titrate her settings, as well as avoidance of caffeine ingestion including chocolate and minimization of mental stress.  She will be discharged on her usual robust AV nodal antiarrhythmic therapy with sotalol 80 mg p.o. b.i.d., metoprolol 50 mg p.o. b.i.d., Diltiazem CD 240 mg p.o. daily and digoxin 0.125 mg p.o. daily and to be clear she does have a permanent pacemaker implanted.  She will follow-up with her regular cardiologist, Dr. X, for whom I am covering this weekend.,This was all discussed in detail with the patient, as well as her granddaughter with the patient's verbal consent at the bedside.","cardiovascular / pulmonary, atrial fibrillation, aortic valve, paroxysmal, normal sinus rhythm, sinus rhythm, cpap, cardioversion, fibrillation, atrial,"
" Patient with chest pains, CAD, and cardiomyopathy.", Cardiovascular / Pulmonary, Cardiac Radionuclide Stress Test ,"INDICATION FOR STUDY: , Chest pains, CAD, and cardiomyopathy.,MEDICATIONS:,  Humulin, lisinopril, furosemide, spironolactone, omeprazole, carvedilol, pravastatin, aspirin, hydrocodone, and diazepam.,BASELINE EKG: , Sinus rhythm at 71 beats per minute, left anterior fascicular block, LVBB.,PERSANTINE RESULTS: , Heart rate increased from 70 to 72.  Blood pressure decreased from 160/84 to 130/78.  The patient felt slightly dizziness, but there was no chest pain or EKG changes.,NUCLEAR PROTOCOL: , Same day rest/stress protocol was utilized with 12 mCi for the rest dose and 33 mCi for the stress test.  53 mg of Persantine were used, reversed with 125 mg of aminophylline.,NUCLEAR RESULTS:,1.  Nuclear perfusion imaging, review of the raw projection data reveals adequate image acquisition.  The resting images are normal.  The post Persantine images show mildly decreased uptake in the septum.  The sum score is 0.,2.  The Gated SPECT shows enlarged heart with a preserved EF of 52%.,IMPRESSION:,1.  Mild septal ischemia.  Likely due to the left bundle-branch block.,2.  Mild cardiomyopathy, EF of 52%.,3.  Mild hypertension at 160/84.,4.  Left bundle-branch block.,","cardiovascular / pulmonary, cardiac radionuclide, spect, sinus rhythm, cardiac radionuclide stress test, bundle branch block, stress test, bundle branch, chest pains, stress, test, cardiomyopathy, nuclear"
 Follow up update on patient with left carotid angioplasty and stent placement., Cardiovascular / Pulmonary, Cardiology - Letter ,"Please accept this letter of follow up on patient xxx xxx. He is now three months out from a left carotid angioplasty and stent placement. He was a part of a CapSure trial. He has done quite well, with no neurologic or cardiac event in the three months of follow up. He had a follow-up ultrasound performed today that shows the stent to be patent, with no evidence of significant recurrence.,Sincerely,,XYZ, MD,","cardiovascular / pulmonary, capsure, cardiac event, ultrasound, carotid angioplasty, stent placement, letter, angioplastyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Need for cardiac catheterization.  Coronary artery disease, chest pain, history of diabetes, history of hypertension, history of obesity,  a 1.1 cm lesion in the medial aspect of the right parietal lobe, and deconditioning.", Cardiovascular / Pulmonary, Cardiac Transfer Summary ,"REASON FOR TRANSFER:,  Need for cardiac catheterization done at ABCD.,TRANSFER DIAGNOSES:,1.  Coronary artery disease.,2.  Chest pain.,3.  History of diabetes.,4.  History of hypertension.,5.  History of obesity.,6.  A 1.1 cm lesion in the medial aspect of the right parietal lobe.,7.  Deconditioning.,CONSULTATIONS: , Cardiology.,PROCEDURES:,1.  Echocardiogram.,2.  MRI of the brain.,3.  Lower extremity Duplex ultrasound.,HOSPITAL COURSE: , Please refer to my H&P for full details.  In brief, the patient is a  64-year-old male with history of diabetes, who presented with 6 hours of chest pressure.  He was brought in by a friend.  The friend states that the patient deteriorated over the last few weeks to the point that he is very short of breath with exertion.  He apparently underwent a cardiac workup 6 months ago that the patient states he barely passed.  His vital signs were stable on admission.  He was ruled out for myocardial infarction with troponin x2.  An echocardiogram showed concentric LVH with an EF of 62%.  I had Cardiology come to see the patient, who reviewed the records from Fountain Valley.  Based on his stress test in the past, Dr. X felt the patient needed to undergo a cardiac cath during his inpatient stay.,The patient on initial presentation complained of, what sounded like, amaurosis fugax.  I performed an MRI, which showed a 1 cm lesion in the right parietal lobe.  I was going to call Neurology at XYZ for evaluation.  However, secondary to his indication for transfer, this could be followed up at ABCD with Dr. Y.,The patient is now stable for transfer for cardiac cath.,Discharged to ABCD.,DISCHARGE CONDITION:,  Stable.,DISCHARGE MEDICATIONS:,1.  Aspirin 325 mg p.o. daily.,2.  Lovenox 40 mg p.o. daily.,3.  Regular Insulin sliding scale.,4.  Novolin 70/30, 15 units b.i.d.,5.  Metformin 500 mg p.o. daily.,6.  Protonix 40 mg p.o. daily.,DISCHARGE FOLLOWUP: , Followup to be arranged at ABCD after cardiac cath.",
" A 49-year-old man with respiratory distress, history of coronary artery disease with prior myocardial infarctions, and recently admitted with pneumonia and respiratory failure.", Cardiovascular / Pulmonary, Cardio/Pulmo Discharge Summary ,"ADMISSION DIAGNOSIS:,1. Respiratory arrest.,2 . End-stage chronic obstructive pulmonary disease.,3. Coronary artery disease.,4. History of hypertension.,DISCHARGE DIAGNOSIS:,1. Status post-respiratory arrest.,2. Chronic obstructive pulmonary disease.,3. Congestive heart failure.,4. History of coronary artery disease.,5. History of hypertension.,SUMMARY:,  The patient is a 49-year-old man who was admitted to the hospital in respiratory distress, and had to be intubated shortly after admission to the emergency room. The patient’s past history is notable for a history of coronary artery disease with prior myocardial infarctions in 1995 and 1999. The patient has recently been admitted to the hospital with pneumonia and respiratory failure. The patient has been smoking up until three to four months previously. On the day of admission, the patient had the sudden onset of severe dyspnea and called an ambulance. The patient denied any gradual increase in wheezing, any increase in cough, any increase in chest pain, any increase in sputum prior to the onset of his sudden dyspnea.,ADMISSION PHYSICAL EXAMINATION:,GENERAL: Showed a well-developed, slightly obese man who was in extremis.,NECK: Supple, with no jugular venous distension.,HEART: Showed tachycardia without murmurs or gallops.,PULMONARY: Status showed decreased breath sounds, but no clear-cut rales or wheezes.,EXTREMITIES: Free of edema.,HOSPITAL COURSE:,  The patient was admitted to the Special Care Unit and intubated. He received intravenous antibiotic therapy with Levaquin. He received intravenous diuretic therapy. He received hand-held bronchodilator therapy. The patient also was given intravenous steroid therapy with Solu-Medrol. The patient’s course was one of gradual improvement, and after approximately three days, the patient was extubated. He continued to be quite dyspneic, with wheezes as well as basilar rales. After pulmonary consultation was obtained, the pulmonary consultant felt that the patient’s overall clinical picture suggested that he had a,significant element of congestive heart failure. With this, the patient was placed on increased doses of Lisinopril and Digoxin, with improvement of his respiratory status. On the day of discharge, the patient had minimal basilar rales; his chest also showed minimal expiratory wheezes; he had no edema; his heart rate was regular; his abdomen was soft; and his neck veins were not distended. It was, therefore, felt that the patient was stable for further management on an outpatient basis.,DIAGNOSTIC DATA:,  The patient’s admission laboratory data was notable for his initial blood gas, which showed a pH of 7.02 with a pCO2 of 118 and a pO2 of 103. The patient’s electrocardiogram showed nonspecific ST-T wave changes. The patent’s CBC showed a white count of 24,000, with 56% neutrophils and 3% bands.,DISPOSITION:,  The patient was discharged home.,DISCHARGE INSTRUCTIONS:,  His diet was to be a 2 grams sodium, 1800 calorie ADA diet. His medications were to be Prednisone 20 mg twice per day, Theo-24 400 mg per day, Furosemide 40 mg 1-1/2 tabs p.o. per day; Acetazolamide 250 mg one p.o. per day, Lisinopril 20 mg. one p.o. twice per day, Digoxin 0.125 mg one p.o. q.d., nitroglycerin paste 1 inch h.s., K-Dur 60 mEq p.o. b.i.d. He was also to use a Ventolin inhaler every four hours as needed, and Azmacort four puffs twice per day. He was asked to return for follow-up with Dr. X in one to two weeks. Arrangements have been made for the patient to have an echocardiogram for further evaluation of his congestive heart failure later on the day of discharge.","cardiovascular / pulmonary, discharge summary, ada diet, congestive heart failure, coronary artery disease, respiratory arrest, chest pain, chronic obstructive pulmonary disease, emergency room, hypertension, sputum, wheezing, respiratory distress, myocardial infarctions, respiratory failure, pulmonary disease, basilar rales, heart failure, infarctions, heart, wheezes, coronary, pulmonary, discharge, respiratory, "
 Cardiolite treadmill exercise stress test.  The patient was exercised on the treadmill to maximum tolerance achieving after 5 minutes a peak heart rate of 137 beats per minute with a workload of 2.3 METS., Cardiovascular / Pulmonary, Cardiolite Treadmill Stress Test ,"CARDIOLITE TREADMILL EXERCISE STRESS TEST,CLINICAL DATA:,  This is a 72-year-old female with history of diabetes mellitus, hypertension, and right bundle branch block.,PROCEDURE:,  The patient was exercised on the treadmill to maximum tolerance achieving after 5 minutes a peak heart rate of 137 beats per minute with a workload of 2.3 METS.  There was a normal blood pressure response.  The patient did not complain of any symptoms during the test and other than the right bundle branch block that was present at rest, no other significant electrographic abnormalities were observed.,Myocardial perfusion imaging was performed at rest following the injection of 10 mCi Tc-99 Cardiolite.  At peak pharmacological effect, the patient was injected with 30 mCi Tc-99 Cardiolite.,Gating poststress tomographic imaging was performed 30 minutes after the stress.,FINDINGS:,1.  The overall quality of the study is fair.,2.  The left ventricular cavity appears to be normal on the rest and stress studies.,3.  SPECT images demonstrate fairly homogeneous tracer distribution throughout the myocardium with no overt evidences of fixed and/or reperfusion defect.,4.  The left ventricular ejection fraction was normal and estimated to be 78%.,IMPRESSION: , Myocardial perfusion imaging is normal.  Result of this test suggests low probability for significant coronary artery disease.","cardiovascular / pulmonary, peak heart rate, bundle branch block, perfusion imaging, stress test, mci, ventricular, cardiolite, treadmill,"
 Sample cardiology office visit note., Cardiovascular / Pulmonary, Cardiology Office Visit - 1  ,"HISTORY OF PRESENT ILLNESS:,  This 66-year-old white male was seen in my office on Month DD, YYYY.  Patient was recently discharged from Doctors Hospital at Parkway after he was treated for pneumonia.  Patient continues to have severe orthopnea, paroxysmal nocturnal dyspnea, cough with greenish expectoration.  His exercise tolerance is about two to three yards for shortness of breath.  The patient stopped taking Coumadin for reasons not very clear to him.  He was documented to have recent atrial fibrillation.  Patient has longstanding history of ischemic heart disease, end-stage LV systolic dysfunction, and is status post ICD implantation.  Fasting blood sugar this morning is 130.,PHYSICAL EXAMINATION: , ,VITAL SIGNS:  Blood pressure is 120/60.  Respirations 18 per minute.  Heart rate 75-85 beats per minute, irregular.  Weight 207 pounds.,HEENT:  Head normocephalic.  Eyes, no evidence of anemia or jaundice.  Oral hygiene is good. ,NECK:  Supple.  JVP is flat.  Carotid upstroke is good. ,LUNGS:  Severe inspiratory and expiratory wheezing heard throughout the lung fields.  Fine crepitations heard at the base of the lungs on both sides. ,CARDIOVASCULAR:  PMI felt in fifth left intercostal space 0.5-inch lateral to midclavicular line. First and second heart sounds are normal in character.  There is a II/VI systolic murmur best heard at the apex.,ABDOMEN:  Soft.  There is no hepatosplenomegaly.,EXTREMITIES:  Patient has 1+ pedal edema.,MEDICATIONS: , ,1.  Ambien 10 mg at bedtime p.r.n.,2.  Coumadin 7.5 mg daily.,3.  Diovan 320 mg daily.,4.  Lantus insulin 50 units in the morning.,5.  Lasix 80 mg daily.,6.  Novolin R p.r.n.,7.  Toprol XL 100 mg daily.,8.  Flovent 100 mcg twice a day.,DIAGNOSES:,1.  Atherosclerotic coronary vascular disease with old myocardial infarction.,2.  Moderate to severe LV systolic dysfunction.,3.  Diabetes mellitus.,4.  Diabetic nephropathy and renal failure.,5.  Status post ICD implantation.,6.  New onset of atrial fibrillation.,7.  Chronic Coumadin therapy.,PLAN:,1.  Continue present therapy.,2.  Patient will be seen again in my office in four weeks.",
 Preoperative cardiac evaluation in the patient with chest pain in the setting of left hip fracture., Cardiovascular / Pulmonary, Cardiac Consultation - 6 ,"INDICATIONS: , Preoperative cardiac evaluation in the patient with chest pain in the setting of left hip fracture.,HISTORY OF PRESENT ILLNESS:,  The patient is a 78-year-old white female with no prior cardiac history.  She sustained a mechanical fall with a subsequent left femoral neck fracture.  She was transferred to XYZ Hospital for definitive care.  In the emergency department of XYZ, the patient described six to seven seconds of sharp chest pain without radiation, without associated symptoms.  Electrocardiogram was obtained, which showed nonspecific ST-segment flattening in the high lateral leads I, aVL.  She also had a left axis deviation.  Serial troponins were obtained.  She has had four negative troponins since admission.  Due to age and chest pain history, a cardiology consultation was requested preoperatively.,At the time of my evaluation, the patient complained of left hip pain, but no chest pain, dyspnea, or symptomatic dysrhythmia.,PAST MEDICAL HISTORY:,1.  Mesothelioma.,2.  Recurrent urinary tract infections.,3.  Gastroesophageal reflux disease/gastritis.,4.  Osteopenia.,5.  Right sciatica.,6.  Hypothyroidism.,7.  Peripheral neuropathy.,8.  Fibromyalgia.,9.  Chart review also suggests she has atherosclerotic heart disease and pneumothorax.  The patient denies either of these.,PAST SURGICAL HISTORY:,1.  Tonsillectomy.,2.  Hysterectomy.,3.  Appendectomy.,4.  Thyroidectomy.,5.  Coccygectomy.,6.  Cystoscopies times several.,7.  Bladder neck resuspension.,8.  Multiple breast biopsies.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,MEDICATIONS:,  At the time of evaluation include, 1.  Cefazolin 1 g intravenous (IV).  2.  Morphine sulfate.  3.  Ondansetron p.r.n.,OUTPATIENT MEDICATIONS: , 1.  Robaxin.  2.  Detrol 4 mg q.h.s.  3.  Neurontin 300 mg p.o. t.i.d.  4.  Armour Thyroid 90 mg p.o. daily.  5.  Temazepam, dose unknown p.r.n.  6.  Chloral hydrate, dose unknown p.r.n.,FAMILY HISTORY: , Mother had myocardial infarction in her 40s, died of heart disease in her 60s, specifics not known.  She knows nothing of her father's history.  She has no siblings.  There is no other history of premature atherosclerotic heart disease in the family.,SOCIAL HISTORY: , The patient is married, lives with her husband.  She is a lifetime nonsmoker, nondrinker.  She has not been getting regular exercise for approximately two years due to chronic sciatic pain.,REVIEW OF SYSTEMS: ,GENERAL:  The patient is able to walk one block or less prior to the onset of significant leg pain.  She ever denies any cardiac symptoms with this degree of exertion.  She denies any dyspnea on exertion or chest pain with activities of daily living.  She does sleep on two to three pillows, but denies orthopnea or paroxysmal nocturnal dyspnea.  She does have chronic lower extremity edema.  Her husband states that she has had prior chest pain in the past, but this has always been attributed to gastritis.  She denies any palpitations or tachycardia.  She has remote history of presyncope, no true syncope.,HEMATOLOGIC:  Negative for bleeding diathesis or coagulopathy.,ONCOLOGIC:  Remarkable for past medical history.,PULMONARY:  Remarkable for childhood pneumonia times several.  No recurrent pneumonias, bronchitis, reactive airway disease as an adult.,GASTROINTESTINAL:  Remarkable for past medical history.,GENITOURINARY:  Remarkable for past medical history.,MUSCULOSKELETAL:  Remarkable for past medical history.,CENTRAL NERVOUS SYSTEM:  Negative for tic, tremor, transient ischemic attack (TIA), seizure, or stroke.,PSYCHIATRIC:  Remarkable for history of depression as an adolescent, she was hospitalized at State Mental Institution as a young woman.  No recurrence.,PHYSICAL EXAMINATION:,GENERAL:  This is a well-nourished, well-groomed elderly white female who is appropriate and articulate at the time of evaluation.,VITAL SIGNS:  She has had a low-grade temperature of 100.4 degrees Fahrenheit on 11/20/2006, currently 99.6.  Pulse ranges from 123 to 86 beats per minute.  Blood pressure ranges from 124/65 to 152/67 mmHg.  Oxygen saturation on 2 L nasal cannula was 94%.,HEENT:  Exam is benign.  Normocephalic and atraumatic.  Extraocular motions are intact.  Sclerae anicteric.  Conjunctivae noninjected.  She does have bilateral arcus senilis.  Oral mucosa is pink and moist.",
" Patient with atrial fibrillation with slow ventricular response, partially due to medications.", Cardiovascular / Pulmonary, Cardiac Consultation - 3 ,"HISTORY OF PRESENT ILLNESS:, The patient is known to me secondary to atrial fibrillation with slow ventricular response, partially due to medications, at least when I first saw him in the office on 01/11/06. He is now 77 years old. He is being seen on the Seventh Floor. The patient is in Room 7607. The patient has a history of recent adenocarcinoma of the duodenum that was found to be inoperable, since it engulfed the porta hepatis. The workup began with GI bleeding. He was seen in my office on 01/11/06 for preop evaluation due to leg edema. A nonocclusive DVT was diagnosed in the proximal left superficial femoral vein. Both legs were edematous, and bilateral venous insufficiency was also present. An echocardiogram demonstrated an ejection fraction of 50%. The patient was admitted to the hospital and treated with a Greenfield filter since anticoagulant was contraindicated. Additional information on the echocardiogram, where a grossly dilated left atrium, moderately severely dilated right atrium. The rhythm was, as stated before, atrial fibrillation with slow atrioventricular conduction and an intraventricular conduction delay on the monitor strip. There was mild to moderate tricuspid regurgitation, mild pulmonic insufficiency. The ejection fraction was considered low normal, since it was estimated 50 to 54%. The patient received blood while in the hospital due to anemia. The leg edema improved while lying down, suggesting that the significant element of venous insufficiency was indeed present. The patient, who was diabetic, received consultation by Dr. R. He was also a chronic hypertensive and was treated for that with ACE inhibitors. The atrial fibrillation was slow, and no digitalis or beta blockers were recommended at the same time. As a matter of fact, they were discontinued. Now, the patient denied any shortness of breath or chest pain throughout this hospitalization, and cardiac nuclear studies performed earlier demonstrated no reversible ischemia.,ALLERGIES:, THE PATIENT HAS NO KNOWN DRUG ALLERGIES.,His diabetes was suspected to be complicated with neuropathy due to tingling in both feet. He received his immunizations with flu in 2005 but did not receive Pneumovax.,SOCIAL HISTORY:, The patient is married. He had 1 child who died at the age of 26 months of unknown etiology. He quit smoking 6 years ago but dips (smokeless) tobacco.,FAMILY HISTORY:, Mother had cancer, died at 70. Father died of unknown cause, and brother died of unknown cause.,FUNCTIONAL CAPACITY:, The patient is wheelchair bound at the time of his initial hospitalization. He is currently walking in the corridor with assistance. Nocturia twice to 3 times per night.,REVIEW OF SYSTEMS:,OPHTHALMOLOGIC: Uses glasses.,ENT: Complains of occasional sinusitis.,CARDIOVASCULAR: Hypertension and atrial fibrillation.,RESPIRATORY: Normal.,GI: Colon bleeding. The patient believes he had ulcers.,GENITOURINARY: Normal.,MUSCULOSKELETAL: Complains of arthritis and gout.,INTEGUMENTARY: Edema of ankles and joints.,NEUROLOGICAL: Tingling as per above. Denies any psychiatric problems.,ENDOCRINE: Diabetes, NIDDM.,HEMATOLOGIC AND LYMPHATIC: The patient does not use any aspirin or anticoagulants and is not of anemia.,LABORATORY:, Current EKG demonstrates atrial fibrillation with incomplete left bundle branch block pattern. Q waves are noticed in the inferior leads. Nonprogression of the R-wave from V1 to V4 with small R-waves in V5 and V6 are suggestive of an old anterior and inferior infarcts. Left ventilator hypertrophy and strain is suspected.,PHYSICAL EXAMINATION:,GENERAL: On exam, the patient is alert, oriented and cooperative. He is mildly pale. He is an elderly gentleman who is currently without diaphoresis, pallor, jaundice, plethora, or icterus.,VITAL SIGNS: Blood pressure is 159/69 with a respiratory rate of 20, pulse is 67 and irregularly irregular. Pulse oximetry is 100.,NECK: Without JVD, bruit, or thyromegaly. The neck is supple.,CHEST: Symmetric. There is no heave or retraction.,HEART: The heart sounds are irregular and no significant murmurs could be auscultated.,LUNGS: Clear to auscultation.,ABDOMEN: Exam was deferred.,LEGS: Without edema. Pulses: Dorsalis pedis pulse was palpated bilaterally.,MEDICATIONS:, Current medications include enalapril, low dose enoxaparin, Fentanyl patches. He is no longer on fluconazole. He is on a sliding scale as per Dr. Holden. He is on lansoprazole (Prevacid), Toradol, piperacillin/tazobactam, hydralazine p.r.n., Zofran, Dilaudid, Benadryl, and Lopressor p.r.n.,ASSESSMENT AND PLAN:, The patient is a very pleasant elderly gentleman with intractable/inoperable malignancy. His cardiac issues are chronic and most likely secondary to long term hypertension and diabetes. He has chronic atrial fibrillation. I do not envision a scenario whereby he will become a candidate for management of this arrhythmia beyond weight control. He is also not a candidate for anticoagulation, which is, in essence, a part and parcel of the weight control. Reason being is high likelihood for GI bleeding, especially given the diagnosis of invasive malignancy with involvement of multiple organs and lymph nodes. At this point, I agree with the notion of hospice care. If his atrioventricular conduction becomes excessive, occasional nondihydropyridine calcium channel blocker such as diltiazem or beta blockers would be appropriate; otherwise, I would keep him off those medications due to evidence of slow conduction in the presence of digitalis and beta blockers.",
" The patient has a previous history of aortic valve disease, status post aortic valve replacement, a previous history of paroxysmal atrial fibrillation, congestive heart failure, a previous history of transient ischemic attack with no residual neurologic deficits.", Cardiovascular / Pulmonary, Cardiac Consultation - 7 ,"HISTORY OF PRESENT ILLNESS: , The patient is a 41-year-old African-American male previously well known to me.  He has a previous history of aortic valve disease, status post aortic valve replacement on 10/15/2007, for which he has been on chronic anticoagulation.  There is a previous history of paroxysmal atrial fibrillation and congestive heart failure, both of which have been stable prior to this admission.  He has a previous history of transient ischemic attack with no residual neurologic deficits.,The patient has undergone surgery by Dr. X for attempted nephrolithotomy.  The patient has experienced significant postoperative bleeding, for which it has been necessary to discontinue all anticoagulation.  The patient is presently seen at the request of Dr. X for management of anticoagulation and his above heart disease.,PAST MEDICAL AND SURGICAL HISTORY:,1.  Type I diabetes mellitus.,2.  Hyperlipidemia.,3.  Hypertension.,4.  Morbid obesity.,5.  Sleep apnea syndrome.,6.  Status post thyroidectomy for thyroid carcinoma.,REVIEW OF SYSTEMS:,General:  Unremarkable.,Cardiopulmonary:  No chest pain, shortness of breath, palpitations, or dizziness.,Gastrointestinal:  Unremarkable.,Genitourinary:  See above.,Musculoskeletal:  Unremarkable.,Neurologic:  Unremarkable.,FAMILY HISTORY: , There are no family members with coronary artery disease.  His mother has congestive heart failure.,SOCIAL HISTORY:  ,The patient is married.  He lives with his wife.  He is employed as a barber.  He does not use alcohol, tobacco, or illicit drugs.,MEDICATIONS PRIOR TO ADMISSION:,1.  Clonidine 0.3 mg b.i.d.,2.  Atenolol 50 mg daily.,3.  Simvastatin 80 mg daily.,4.  Furosemide 40 mg daily.,5.  Metformin 1000 mg b.i.d.,6.  Hydralazine 25 mg t.i.d.,7.  Diovan 320 mg daily.,8.  Lisinopril 40 mg daily.,9.  Amlodipine 10 mg daily.,10.  Lantus insulin 50 units q.p.m.,11.  KCl 20 mEq daily.,12.  NovoLog sliding scale insulin coverage.,13.  Warfarin 7.5 mg daily.,14.  Levothyroxine 0.2 mg daily.,15.  Folic acid 1 mg daily.,ALLERGIES: , None.,PHYSICAL EXAMINATION:,General:  A well-appearing, obese black male.,Vital Signs:  BP 140/80, HR 88, respirations 16, and afebrile.,HEENT:  Grossly normal.,Neck:  Normal.  Thyroid, normal.  Carotid, normal upstroke, no bruits.,Chest:  Midline sternotomy scar.,Lungs:  Clear.,Heart:  PMI fifth intercostal space mid clavicular line.  Normal S1 and prosthetic S2.  No murmur, rub, gallop, or click.,Abdomen:  Soft and nontender.  No palpable mass or hepatosplenomegaly.",
" To evaluate recurrent episodes of uncomfortable feeling in arm at rest, as well as during exertion.", Cardiovascular / Pulmonary, Cardiac Consultation - 1 ,"CHIEF REASON FOR CONSULTATION:,  Evaluate recurrent episodes of uncomfortable feeling in the left upper arm at rest, as well as during exertion for the last one month.,HISTORY OF PRESENT ILLNESS:,  This 57-year-old black female complains of having pain and discomfort in the left upper arm, especially when she walks and after heavy meals.  This lasts anywhere from a few hours and is not associated with shortness of breath, palpitations, dizziness, or syncope.  Patient does not get any chest pain or choking in the neck or pain in the back.  Patient denies history of hypertension, diabetes mellitus, enlarged heart, heart murmur, history suggestive of previous myocardial infarction, or acute rheumatic polyarthritis during childhood.  Her exercise tolerance is one to two blocks for shortness of breath and easy fatigability.,MEDICATIONS:,  Patient does not take any specific medications.,PAST HISTORY:,  The patient underwent hysterectomy in 1986.,FAMILY HISTORY:,  The patient is married, has four children who are doing fine.  Family history is positive for hypertension, congestive heart failure, obesity, cancer, and cerebrovascular accident.,SOCIAL HISTORY:, The patient smokes one pack of cigarettes per day and takes drinks on social occasions.",
" To evaluate exercise-induced chest pain, palpitations, dizzy spells, shortness of breath, and abnormal EKG.", Cardiovascular / Pulmonary, Cardiac Consultation - 2 ,"CHIEF REASON FOR CONSULTATION:,  Evaluate exercise-induced chest pain, palpitations, dizzy spells, shortness of breath, and abnormal EKG.,HISTORY OF PRESENT ILLNESS:,  This 72-year-old female had a spell of palpitations that lasted for about five to ten minutes.  During this time, patient felt extremely short of breath and dizzy.  Palpitations lasted for about five to ten minutes without any recurrence.  Patient also gives history of having tightness in the chest after she walks briskly up to a block.  Chest tightness starts in the retrosternal area with radiation across the chest.  Chest tightness does not radiate to the root of the neck or to the shoulder, lasts anywhere from five to ten minutes, and is relieved with rest.  Patient gives history of having hypertension for the last two months.  Patient denies having diabetes mellitus, history suggestive of previous myocardial infarction, or cerebrovascular accident.,MEDICATIONS: , ,1.  Astelin nasal spray.,2.  Evista 60 mg daily.,3.  Lopressor 25 mg daily.,4.  Patient was given a sample of Diovan 80 mg daily for the control of hypertension from my office.,PAST HISTORY:,  The patient underwent right foot surgery and C-section.,FAMILY HISTORY:,  The patient is married, has six children who are doing fine.  Father died of a stroke many years ago.  Mother had arthritis.,SOCIAL HISTORY:, The patient does not smoke or take any drinks.  ,ALLERGIES:,  THE PATIENT IS NOT ALLERGIC TO ANY MEDICATIONS.,REVIEW OF SYSTEMS:,  Otherwise negative.  ,PHYSICAL EXAMINATION: , ,GENERAL:  Well-built, well-nourished white female in no acute distress. ,VITAL SIGNS:  Blood pressure is 160/80.  Respirations 18 per minute.  Heart rate 70 beats per minute.  Patient weighs 133 pounds, height 64 inches.  BMI is 22.,HEENT:  Head normocephalic.  Eyes, no evidence of anemia or jaundice.  Oral hygiene is good.,NECK:  Supple.  No cervical lymphadenopathy. Carotid upstroke is good. No bruit heard over the carotid or subclavian arteries.  Trachea in midline. Thyroid not enlarged.  JVP flat at 45°.,CHEST:  Chest is symmetrical on both sides, moves well with respirations.  Vesicular breath sounds heard over the lung fields.  No wheezing, crepitation, or pleural friction rub heard.  ,CARDIOVASCULAR SYSTEM:  PMI felt in fifth left intercostal space within midclavicular line. First and second heart sounds are normal in character.  There is a II/VI systolic murmur best heard at the apex.  There is no diastolic murmur or gallop heard.,ABDOMEN:  Soft.  There is no hepatosplenomegaly or ascites.  No bruit heard over the aorta or renal vessels.,EXTREMITIES:  No pedal edema.  Femoral arterial pulsations are 3+, popliteal 2+.  Dorsalis pedis and posterior tibialis are 1+ on both sides.,NEURO:  Normal.,EKG from Dr. Xyz's office shows normal sinus rhythm, ST and T wave changes.  Lipid profile, random blood sugar, BUN, creatinine, CBC, and LFTs are normal.,IMPRESSION:,",
" Patient with right-sided chest pain, borderline elevated high blood pressure, history of hyperlipidemia, and obesity.", Cardiovascular / Pulmonary, Cardiac Consultation - 4 ,"REASON FOR CONSULTATION:,  Cardiac evaluation.,HISTORY: , This is a 42-year old Caucasian male with no previous history of hypertension, diabetes mellitus, rheumatic fever, rheumatic heart disease, or gout.  Patient used to take medicine for hyperlipidemia and then that was stopped.  He used to live in Canada and he moved to Houston four months ago.  He started complaining of right-sided upper chest pain, starts at the right neck and goes down to the right side.  It lasts around 10-15 minutes at times.  It is 5/10 in quality.  It is not associated with shortness of breath, nausea, vomiting, or sweating.  It is not also associated with food.  He denies exertional chest pain, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, or pedal edema.  No palpitations, syncope or presyncope.  He said he has been having little cough at night and he went to see an allergy doctor who prescribed several medications for him and told him that he has asthma.  No fever, chills, cough, hemoptysis, hematemesis or hematochezia.  His EKG shows normal sinus rhythm, normal EKG.,PAST MEDICAL HISTORY:,  Unremarkable, except for hyperlipidemia.,SOCIAL HISTORY: , He said he quit smoking 20 years ago and does not drink alcohol.,FAMILY HISTORY: , Positive for high blood pressure and heart disease.  His father died in his 50s with an acute myocardial infarction.,MEDICATION:,  Ranitidine 300 mg daily, Flonase 50 mcg nasal spray as needed, Allegra 100 mg daily, Advair 500/50 bid.,ALLERGIES:,  No known allergies.,REVIEW OF SYSTEMS:,  As mentioned above,EXAMINATION:,  This is a 42-year old male awake, alert, and oriented x3 in no acute distress.,Wt:  238",
" Patient with a history of atrial fibrillation in the past, more recently who has had atrial flutter.  The patient has noted some lightheadedness as well as chest discomfort and shortness of breath when atrial flutter recurred.", Cardiovascular / Pulmonary, Cardiac Consult & Cardioversion ,"HISTORY OF PRESENT ILLNESS: , Mr. A is a 50-year-old gentleman with a history of atrial fibrillation in the past, more recently who has had atrial flutter, who estimates he has had six cardioversions since 10/09, and estimates that he has had 12 to 24 in his life beginning in 2006 when the atrial fibrillation first emerged.  He, since 10:17 p.m. on 01/17/10, noted recurrence of his atrial fibrillation, called our office this morning, that is despite being on flecainide, atenolol, and he is maintained on Coumadin.,The patient has noted some lightheadedness as well as chest discomfort and shortness of breath when atrial flutter recurred and we see that on his 12-lead EKG here.  Otherwise, no chest pain.,PAST MEDICAL HISTORY: , Significant for atrial fibrillation/atrial flutter and again he had atrial fibrillation more persistently in 2006, but more recently it has been atrial flutter and that is despite use of antiarrhythmics including flecainide.  He completed a stress test in my office within the past several weeks that was normal without evidence of ischemia.  Other medical history is significant for hyperlipidemia.,MEDICATIONS:,As outpatient,,1.  Atenolol 25 mg once a day.,2.  Altace 2.5 mg once a day.,3.  Zocor 20 mg once a day.,4.  Flecainide 200 in the morning and 100 in the evening.,5.  Coumadin as directed by our office.,ALLERGIES: , TO MEDICATIONS ARE NONE.  HE DENIES SHRIMP, SEA FOOD OR DYE ALLERGY.,FAMILY HISTORY: , He has a nephew who was his sister's son who passed away at age 22 reportedly from an MI, but was reported to have hypertrophic cardiomyopathy as well.  The patient has previously met with the electrophysiologist, Dr. X, at General Hospital and it sounds like he had a negative EP study.,SOCIAL HISTORY: , The patient does not smoke cigarettes, abuse alcohol nor drink any caffeine.  No use of illicit drugs.  He has been married for 22 years and he is actually accompanied throughout today's cardiology consultation by his wife.  He is not participating in regular exercises now because he states since starting flecainide, he has gotten sluggish.  He is employed as an attorney and while he states that overall his mental stress is better, he has noted more recent mental stress this past weekend when he was taking his daughter back to college.,REVIEW OF SYSTEMS: , He denies any history of stroke, cancer, vomiting of blood, coughing up blood, bright red blood per rectum, bleeding stomach ulcers, renal calculi.  There are some questions especially as his wife has told me that he may have obstructive sleep apnea and not had a formal sleep study.,PHYSICAL EXAM: , Blood pressure 156/93, pulse is 100, respiratory rate 18.  On general exam, he is a pleasant overweight gentleman, in no acute distress.  HEENT:  Shows cranium is normocephalic and atraumatic.  He has moist mucosal membranes.  Neck veins are not distended.  There are no carotid bruits.  Visible skin warm and perfused.  Affect appropriate.  He is quite oriented and pleasant.  No significant kyphoscoliosis on recumbent back exam.  Lungs are clear to auscultation anteriorly.  No wheezes.  No egophony.  Cardiac Exam:  S1, S2.  Regular rate, controlled.  No significant murmurs, rubs or gallops.  PMI is nondisplaced.  Abdomen is soft, nondistended, appears benign.  Extremities without significant edema.  Pulses grossly intact.,DIAGNOSTIC STUDIES/LAB DATA:,  Initial ECG shows atrial flutter.,IMPRESSION: , Mr. A is a 50-year-old gentleman with a history of paroxysmal atrial fibrillation in the past, more recently is having breakthrough atrial flutter despite flecainide and we had performed a transesophageal echocardiogram-guided cardioversion for him in late 12/20/09, who now has another recurrence within the past 41 hours or so.  I have reviewed again with him in detail regarding risks, benefits, and alternatives of proceeding with cardioversion, which the patient is in favor of.  After in depth explanation of the procedure with him that there would be more definitive resumption of normal sinus rhythm by using electrocardioversion with less long-term side effects, past the acute procedure, alternatives being continued atrial flutter with potential for electrophysiologic consultation for ablation and/or heart rate control with anticoagulation, which the patient was not interested nor was I primarily recommending as the next step, and risks including, but not limited to and the patient was aware and this was all done in the presence of his wife that this is not an all-inclusive list, but the risks include but not limited to oversedation from conscious sedation, risk of aspiration pneumonia from regurgitation of stomach contents, which would be less likely as I did confirm with the patient that he had been n.p.o. for greater than 15 hours, risk of induction of other arrhythmias including tachyarrhythmias requiring further management including cardioversion or risk of bradyarrhythmias, in the past when we had a cardioverter with 150 joules, he did have a 5.5-second pause especially while he is on antiarrhythmic therapy, statistically less significant risk of CVA, although we cannot really make that null.  The patient expressed understanding of this risk, benefit, and alternative analysis.  I invited questions from him and his wife and once their questions were answered to their self-stated satisfaction, we planned to go forward with the procedure.,PROCEDURE NOTE:  ,The patient received a total of 7 mg of Versed and 50 micrograms of fentanyl utilizing titrate-down sedation with good effect and this was after the appropriate time-out procedure had been done as per the Medical Center universal protocol with appropriate identification of the patient, position, procedure documentation, procedure indication, and there were no questions.  The patient did actively participate in this time-out procedure.  After the universal protocol was done, he then received the cardioversion attempt with 50 joules using ""lollipop posterior patch"" with hands-driven paddle on the side, which was 50 joules of synchronized biphasic energy.  There was successful resumption of normal sinus rhythm, in fact this time there was not a significant pause as compared to when he had this done previously in late 12/09 and this sinus rhythm was confirmed by a 12-lead EKG.,IMPRESSION: , Cardioversion shows successful resumption of normal sinus rhythm from atrial flutter and that is while the patient has been maintained on Coumadin and his INR is 3.22.  We are going to watch him and discharge him from the Medical Center area on his current flecainide of 200 mg in the morning and 100 mg in the evening, atenolol 25 mg once a day, Coumadin _____ as currently being diagnosed.  I had previously discussed with the patient and he was agreeable with meeting with his electrophysiologist again, Dr. X, at Electrophysiology Unit at General Hospital and I will be planning to place a call for Dr. X myself.  Again, he has no ischemia on this most recent stress test and I suppose in the future it may be reasonable to get obstructive sleep apnea evaluation and that may be one issue promulgating his symptoms.,I had previously discussed the case with Dr. Y who is the patient's general cardiologist as well as updated his wife at the patient's bedside regarding our findings.",
 Cardiac evaluation and treatment in a patient who came in the hospital with abdominal pain., Cardiovascular / Pulmonary, Cardiac Consultation - 5 ,"REASON FOR REFERRAL: , Cardiac evaluation and treatment in a patient who came in the hospital with abdominal pain.,HISTORY:,  This is a 77-year-old white female patient whom I have known for the last about a year or so who has underlying multiple medical problems including hypertension, hyperlipidemia, diabetes mellitus, coronary artery disease status post aortocoronary bypass surgery about eight years ago at Halifax Medical Center where she had triple vessel bypass surgery with left internal mammary artery to the left anterior descending artery, saphenous vein graft to the left circumflex and right coronary arteries.  Since then, she has generally done well.  She used to be seeing another cardiologist and apparently she had a stress test in September 2008 and she was otherwise cardiac catheterization and coronary angiography, but the patient declined to have one done and since then she has been on medical therapy.,The patient had been on medical therapy at home and generally doing well.  Recently, she had no leg swelling, undue exertional dyspnea, orthopnea, or paroxysmal nocturnal dyspnea.  She denies any rest or exertional chest discomfort.  Yesterday evening, she had her dinner and she was sitting around and she felt discomfort in the chest at about 7:00 p.m.  The discomfort was a crampy pain in the left lower quadrant area, which seemed to radiating to the center of the abdomen and to the right side and it was off and on lasting for a few minutes at a time and then subsiding.  Later on she was nauseous, but she did not have any vomiting.  She denied any diarrhea.  No history of fever or chills.  Since the pain seemed to persist, the patient came to the hospital emergency room at 11:35 p.m. where she was seen and admitted for the same.  She was given morphine, Zofran, Demerol, another Zofran, and Reglan as well as Demerol again and she was given intravenous fluids.  Subsequently, her pain finally went away and she does not have any pain since about 7:00 a.m. this morning.  The patient was admitted however for further workup and treatment.  At the time of my examination this afternoon, the patient is sitting, lying in bed and comfortable and has no abdominal pain of any kind.  She has not been fed any food, however.  The patient also had had pelvis and abdominal CT scan performed, which has been described to be partial small bowel obstruction, internal hernia, volvulus or adhesion most likely in the left flank area.  The patient has had left nephrectomy and splenectomy, which has been described.  A 1.5-mm solid mass is described to be in the lower pole of the kidney.  The patient also has been described to have diverticulosis without diverticulitis on this finding.,Currently however, the patient has no clinical symptoms according to her.,PAST MEDICAL HISTORY:,  She has had hypertension and hyperlipidemia for the last 15 years, diabetes mellitus for the last eight years, and coronary artery disease for last about eight years or so.  She had a chest and back pain about eight years ago for about two weeks and then subsequently she was reported to be evaluated.  She has a small myocardial infarction and then she was under the care of Dr. A and she had aortocoronary bypass surgery at Halifax Medical Center by Dr. B, which was a three-vessel bypass surgery with left internal mammary artery to the left descending artery and saphenous vein graft to the left circumflex and distal right coronary artery respectively.,She had had nuclear stress test with Dr. C on September 3, 2008, which was described to be abnormal with ischemic defects, but I do not think the patient had any further cardiac catheterization and coronary angiography after that.  She has been treated medically.,This patient also had an admission to this hospital in May 2008 also for partial small bowel obstruction and cholelithiasis and sigmoid diverticulosis.  She was described to have had a hemorrhagic cyst of the right kidney.  She has mild arthritis for the last 10 or 15 years.  She has a history of GERD for the last 20 years, and she also has a history of peptic ulcer disease in the duodenum, but never had any bleeding.  She has a history of diverticulosis as mentioned.  No history of TIA or CVA.  She has one kidney.  She was in a car accident in 1978 and afterwards she had to have left nephrectomy as well as splenectomy because of rupture.  The patient has a history of pulmonary embolism once about eight years ago after her aortocoronary bypass surgery.  She describes this to be a clot on left lung.  I am not sure if she had any long-term treatment, however.,In the past, the patient had aortocoronary bypass surgery in 2003 and incisional hernia surgery in 1979 as well as hysterectomy in 1979 and she had splenectomy and nephrectomy as described in 1978.,FAMILY HISTORY: , Her father died at age of 65 of massive heart attack and mother died at age of 62 of cancer.  She had a one brother who died of massive heart attack in his 50s, a brother died at the age of 47 of cancer, and another brother died in his 60s of possible rupture of appendix.,SOCIAL HISTORY: , The patient is a widow.  She lives alone.  She does have three daughters, two of them live in Georgia and one lives in Tennessee.  She did smoke in the past up to one to one and a half packs of cigarettes per day for about 10 years, but she quit long time ago.  She never drank any alcohol.  She likes to drink one or two cups of tea in a day.,ALLERGIES: , PAXIL.,MEDICATIONS:,  Her home medications prior to coming in include some of the following medications, although the exact list is not available in the chart at this stage, but they have been on glyburide, Januvia, lisinopril, metformin, metoprolol, simvastatin, ranitidine, meloxicam, and furosemide.,REVIEW OF SYSTEMS:,  Appetite is good.  She sleeps good at night.  She has no headaches and she has mild joint pains from arthritis.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse 90 per minute and regular, blood pressure 140/90 mmHg, respirations 18, and temperature of 98.5 degree Fahrenheit.  Moderate obesity is present.,CARDIAC:  Carotid upstroke is slightly diminished, but no clear bruit heard.,LUNGS:  Slightly decreased air entry at both bases.  No rales or rhonchi heard.,CARDIOVASCULAR:  PMI in the left fifth intercostal space in the midclavicular line.  Regular heart rhythm.  S1 and S2 normal.  S4 is present.  No S3 heard.  Short ejection systolic murmur grade I/VI is present at the left lower sternal border of the apex, peaking in LV systole, no diastolic murmur heard.,ABDOMEN:  Soft, obese, no tenderness, no masses felt.  Bowel sounds are present.,EXTREMITIES:  Bilateral trace edema.  The extremities are heavy.  There is no pitting at this stage.  No clubbing or cyanosis.  Distal pulses are fair.,CENTRAL NERVOUS SYSTEM:  Without any obvious focal deficits.,LABORATORY DATA: , Includes an electrocardiogram, which shows normal sinus rhythm, left atrial enlargement, and right bundle branch block.  This is overall unchanged compared to previous electrocardiogram, which also has the same present.  Nuclear stress test from 2008 was described to show ejection fraction of 49% and inferior and posterolateral ischemia.  Otherwise, laboratory data includes on this patient at this stage WBC 18.3, hemoglobin 15.5, hematocrit is 47.1, and platelet count is 326,000.  Electrolytes, sodium 137, potassium 5.2, chloride 101, CO2 27, BUN 34, creatinine 1.2, calcium 9.5, and magnesium 1.7.  AST and ALT are normal.  Albumin is 4.1.  Lipase and amylase are normal.  INR is 0.92.  Urinalysis is relatively unremarkable except for trace protein.  Chest x-ray has been described to show elevated left hemidiaphragm and median sternotomy sutures.  No infiltrates seen.  Abdomen and pelvis CAT scan findings are as described before with suggestion of partial small bowel obstruction and internal hernia.  Volvulus or adhesions have been considered.  Left nephrectomy and splenectomy demonstrated right kidney has a 1.5 cm solid mass at the lower pole suspicious for neoplasm according to the radiologist's description and there is diverticulosis.,IMPRESSION:,1.  Coronary artery disease and prior aortocoronary bypass surgery, currently clinically the patient without any angina.,2.  Possible small old myocardial infarction.,3.  Hypertension with hypertensive cardiovascular disease.,4.  Non-insulin-dependent diabetes mellitus.,5.  Moderate obesity.,6.  Hyperlipidemia.,7.  Chronic non-pitting leg edema.,8.  Arthritis.,9.  GERD and positive history of peptic ulcer disease.,CONCLUSION:,1.  Past left nephrectomy and splenectomy after an accident and injury and rupture of the spleen.,2.  Abnormal nuclear stress test in September 2008, but no further cardiac studies performed, such as cardiac catheterization.,3.  Lower left quadrant pain, which could be due to diverticulosis.,4.  Diverticulosis and partial bowel obstruction.,RECOMMENDATION:,1.  At this stage, the patient's cardiac medication should be continued if the patient is allowed p.o. intake.",
 Cardiac catheterization and coronary intervention report., Cardiovascular / Pulmonary, Cardiac Catheterization - 9 ,"EXAM: , Cardiac catheterization and coronary intervention report.,PROCEDURES:,1.  Left heart catheterization, coronary angiography, left ventriculography.,2.  PTCA/Endeavor stent, proximal LAD.,INDICATIONS: , Acute anterior ST-elevation MI.,ACCESS: , Right femoral artery 6-French.,MEDICATIONS:,1.  IV Valium.,2.  IV Benadryl.,3.  Subcutaneous lidocaine.,4.  IV heparin.,5.  IV ReoPro.,6.  Intracoronary nitroglycerin.,ESTIMATED BLOOD LOSS: , 10 mL.,CONTRAST:  ,185 mL.,COMPLICATIONS: , None.,PROCEDURE: , The patient was brought to the cardiac catheterization laboratory with acute ST-elevation MI and EKG.  She was prepped and draped in the usual sterile fashion.  The right femoral region was infiltrated with subcutaneous lidocaine, adequate anesthesia was obtained.  The right femoral artery was entered with _______ modified Seldinger technique and a J wire was passed.  The needle was exchanged for 6 French sheath.  The wire was removed.  The sheath was washed with sterile saline.  Following this, the left coronary was attempted to be cannulated with an XP catheter, however, the catheter folded on itself and could not reach the left main, this was removed.  A second 6-French JL4 guiding catheter was then used to cannulate the left main and initial guiding shots demonstrated occlusion of the proximal LAD.  The patient had an ACT check, received additional IV heparin and IV ReoPro.  The lesion was crossed with 0.014 BMW wire and redilated with a 2.5 x 20-mm balloon at nominal pressures.  The balloon was deflated and angiography demonstrated establishment of flow.  Following this, the lesion was stented with a 2.5 x 18-mm Endeavor stent at 10 atmospheres.  The balloon was deflated, reinflated at 12 atmospheres, deflated and removed.  Final angiography demonstrated excellent clinical result.  Additional angiography was performed with a wire out.  Following this, the wire and the catheter was removed.  Following this, the right coronary was selectively cannulated with diagnostic catheter and angiographic views were obtained in multiple views.  This catheter was removed.  The pigtail catheter was placed in the left ventricle and left ventriculography was performed with pullback pressures across the aortic valve.  At the end of procedure, wires and catheter were removed.  Right femoral angiography was performed and a right femoral Angio-Seal kit was deployed at the right femoral arteriotomy site.  There was no hematoma.  Peripheral pulses _______ procedure.  The patient tolerated the procedure well.  Symptoms of chest pain resolved at the end of the procedure with no complications.,RESULTS:,1.  Coronary angiography.,A.  Left main free of obstruction.,B.  LAD, subtotal proximal stenosis.,C.  Circumflex large vessel with three large obtuse marginal branches.  No high-grade obstruction, evidence of minimal plaquing.,D.  Right coronary 70% mid vessel stenosis and 50% mid to distal stenosis before giving rise to a right dominant posterior lateral and posterior descending artery.,2.  Left ventriculogram.  Left ventricular ejection fraction estimated at 45% to 50%.  There was an akinetic apical wall.,3.  Hemodynamics.  Aortic pressure 145/109, left ventricular pressure 147/13, left ventricular end-diastolic pressure 34 mmHg.,IMPRESSION:,1.  Acute ST-elevation myocardial infarction, culprit lesion, left anterior descending occlusion.,2.  Two-vessel coronary disease.,3.  Mild-to-moderate impaired LV systolic function.,4.  Successful stent left anterior descending, 100% occlusion, 0% residual stenosis.,PLAN:  ,Overnight observation in ICU.  Start aspirin, Plavix, beta-blocker and ACE inhibitor.  Check serial cardiac enzymes.  Further recommendations to follow.  Check fasting lipid panel, in addition add a statin.  Further recommendations to follow.",
" A woman with history of coronary artery disease, has had coronary artery bypass grafting x2 and percutaneous coronary intervention with stenting x1.  She also has a significant history of chronic renal insufficiency and severe COPD.  ", Cardiovascular / Pulmonary, Cardiac Consultation ,"HISTORY OF PRESENT ILLNESS: , The patient is a 71-year-old woman with history of coronary artery disease for which she has had coronary artery bypass grafting x2 and percutaneous coronary intervention with stenting x1.  She also has a significant history of chronic renal insufficiency and severe COPD.  The patient and her husband live in ABC but they have family in XYZ.  She came to our office today as she is in the area visiting her family.  She complains of having shortness of breath for the past month that has been increasingly getting worse.  She developed a frequent nonproductive cough about 2 weeks ago.  She has also had episodes of paroxysmal nocturnal dyspnea, awaking in the middle of the night, panicking from dyspnea and shortness of breath.  She has also gained about 15 pounds in the past few months and has significant peripheral edema.  In the office, she is obviously dyspnea and speaking in 2 to 3 word sentences.,PAST MEDICAL HISTORY: , Coronary artery disease, anemia secondary to chronic renal insufficiency, stage IV chronic kidney disease, diabetic nephropathy, hypertension, hyperlipidemia, COPD, insulin-dependent diabetes, mild mitral valve regurgitation, severe tricuspid valve regurgitation, sick sinus syndrome, gastritis, and heparin-induced thrombocytopenia.,PAST SURGICAL HISTORY: , Status post pacemaker implantation, status post CABG x4 in 1999 and status post CABG x2 in 2003, status post PCA stenting x1 to the left anterior descending artery, cholecystectomy, back surgery, bladder surgery, and colonic polypectomies.,SOCIAL HISTORY:  ,The patient is married.  Lives with her husband.  They are retired from ABC.,MEDICATIONS:,1.  Plavix 75 mg p.o. daily.,2.  Aspirin 81 mg p.o. daily.,3.  Isosorbide mononitrate 60 mg p.o. daily.,4.  Colace 100 mg p.o. b.i.d.,5.  Atenolol 50 mg p.o. daily.,6.  Lantus insulin 15 units subcutaneously every evening.,7.  Protonix 40 mg p.o. daily.,8.  Furosemide 40 mg p.o. daily.,9.  Norvasc 5 mg p.o. daily.,ALLERGIES: , SHE IS ALLERGIC TO HEPARIN AGENTS, WHICH CAUSE HEPARIN-INDUCED THROMBOCYTOPENIA.,REVIEW OF SYSTEMS,CONSTITUTIONAL:  Positive for generalized fatigue and malaise.,HEAD AND NECK:  Negative for diplopia, blurred vision, visual disturbances, hearing loss, tinnitus, epistaxis, vertigo, sinusitis, and gum or oral lesions.,CARDIOVASCULAR:  Positive for epigastric discomfort x2 weeks, negative for palpitations, syncope or near-syncopal episodes, chest pressure, and chest pain.,RESPIRATORY:  Positive for dyspnea at rest, paroxysmal nocturnal dyspnea, orthopnea, and frequent nonproductive cough.  Negative for wheezing.,ABDOMEN:  Negative for abdominal pain, bloating, nausea, vomiting, constipation, melena, or hematemesis.,GENITOURINARY:  Negative for dysuria, polyuria, hematuria, or incontinence.,MUSCULOSKELETAL:  Negative for recent trauma, stiffness, deformities, muscular weakness, or atrophy.,SKIN:  Negative for rashes, petechiae, and hair or nail changes.  Positive for easy bruising on forearms.,NEUROLOGIC:  Negative for paralysis, paresthesias, dysphagia, or dysarthria.,PSYCHIATRIC:  Negative for depression, anxiety, or mood swings.,All other systems reviewed are negative.,PHYSICAL EXAMINATION,VITAL SIGNS:  Her blood pressure in the office was 188/94, heart rate 70, respiratory rate 18 to 20, and saturations 99% on room air.  Her height is 63 inches.  She is weighs 195 pounds and her BMI is 34.6.,CONSTITUTIONAL:  A 71-year-old woman in significant distress from shortness of breath and dyspnea at rest.,HEENT:  Eyes:  Pupils are reactive.  Sclera is nonicteric.  Ears, nose, mouth, and throat.,NECK:  Supple.  No lymphadenopathy.  No thyromegaly.  Swallow is intact.,CARDIOVASCULAR:  Positive JVD at 45 degrees.  Heart tones are distant.  S1 and S2.  No murmurs.,EXTREMITIES:  Have 3+ edema in the feet and ankles bilaterally that extends up to her knees.  Femoral pulses are weakly palpable.  Posterior tibial pulses are not palpable.  Capillary refill is somewhat sluggish.,RESPIRATORY:  Breath sounds are clear with some bilateral basilar diminishment.  No rales and no wheezing.  Speaking in 2 to 3 word sentences.  Diaphragmatic excursions are limited.  AP diameter is expanded.,ABDOMEN:  Soft and nontender.  Active bowel sounds x4 quadrants.  No hepatosplenomegaly.  No masses are appreciated.,GENITOURINARY:  Deferred.,MUSCULOSKELETAL:  Adequate range of motion along with extremities.,SKIN:  Warm and dry.  No lesions or ulcerations are noted.,NEUROLOGIC:  Alert and oriented x3.  Head is normocephalic and atraumatic.  No focal, motor, or sensory deficits.,PSYCHIATRIC:  Normal affect.,IMPRESSION,1.  Coronary artery disease.",
 Left heart cardiac catheterization., Cardiovascular / Pulmonary, Cardiac Catheterization - 8 ,"PROCEDURE PERFORMED:,1.  Right femoral artery access.,2.  Selective right and left coronary angiogram.,3.  Left heart catheterization.,4.  Left ventriculogram.,INDICATIONS FOR PROCEDURE:,  A 50-year-old lady with known history of coronary artery disease with previous stenting to the left anterior descending artery presents with symptoms of shortness of breath.  The resting echocardiogram showed a severe decrease in her left ventricular systolic function with a reported LVEF of 20% to 25%.  This was a sharp decline from a previous LVEF of 50% to 55%.  We therefore, decided to proceed with coronary angiography.,TECHNIQUE: , After obtaining informed consent, the patient was brought to the cardiac catheterization suite in post-absorptive and non-sedated state.  The right groin was prepped and draped in the usual sterile manner.  2% Lidocaine was used for infiltration anesthesia.  Using modified Seldinger technique, a 6-French sheath was introduced into the right femoral artery.  6-French JL4 and JR4 diagnostic catheters were used to perform the left and right coronary angiogram.  A 6-French pigtail catheter was used to perform the LV-gram in the RAO projection.,HEMODYNAMIC DATA: , LVEDP of 11.  There was no gradient across the aortic valve upon pullback.,ANGIOGRAPHIC FINDINGS:,1.  The left main coronary artery is a very short vessel and immediately bifurcates into the left anterior descending artery and the left circumflex coronary artery.,2.  The left main coronary artery is free of any disease.,3.  The left circumflex coronary artery which is a nondominant vessel gives off 2 marginal branches.  The first marginal branch is very small in caliber and runs a fairly long course and is free of any disease.,4.  The second marginal branch which is actually a continuation of the left circumflex coronary artery gives off several secondary branches.  One of its secondary branches which is a small caliber has an ostial 70% stenosis.,5.  The left anterior descending artery has a patent stent in the proximal LAD.  The second stent which is overlapping the junction of the mid and distal left anterior descending artery has mild late luminal loss.  There appears to be 30% narrowing involving the distal cuff segment of the stent in the distal left anterior descending artery.  The diagonal branches are free of any disease.,6.  The right coronary artery is a dominant vessel and has mild luminal irregularities.  Its midsegment has a focal area of 30% narrowing as well.  The rest of the right coronary artery is free of any disease.,7.  The LV-gram performed in the RAO projection shows well preserved left ventricular systolic function with an estimated LVEF of 55%.,RECOMMENDATION: , Continue with optimum medical therapy.  Because of the discrepancy between the left ventriculogram EF assessment and the echocardiographic EF assessment, I have discussed this matter with Dr. XYZ and we have decided to proceed with a repeat 2D echocardiogram.  The mild disease in the distal left anterior descending artery with mild in-stent re-stenosis should be managed medically with optimum control of hypertension and hypercholesterolemia.","cardiovascular / pulmonary, heart catheterization, ventriculogram, femoral artery access, coronary angiogram, lvef, distal left anterior descending, circumflex coronary artery, anterior descending artery, femoral artery, systolic function, cardiac catheterization, circumflex coronary, anterior descending, coronary artery, coronary, artery, catheterization, descending"
" Right heart and left heart catheterization by way of right femoral artery, right femoral vein, and right internal jugular vein.", Cardiovascular / Pulmonary, Cardiac Catheterization - 6 ,"PRECATHETERIZATION DIAGNOSIS (ES):, Hypoplastic left heart, status post Norwood procedure and Glenn shunt.,POSTCATHETERIZATION DIAGNOSIS (ES):,1. Hypoplastic left heart.,A. Status post Norwood.,B. Status post Glenn.,2. Left pulmonary artery hypoplasia.,3. Diminished right ventricular systolic function.,4. Trivial neo-aortic stenosis.,5. Trivial coarctation.,6. Flow to right upper lobe more than left upper lobe from collaterals arising from branches of the aortic arch.,PROCEDURE (S):, Right heart and left heart catheterization by way of right femoral artery, right femoral vein, and right internal jugular vein.,I. PROCEDURES:, XXXXXX was brought to the catheterization lab and was anesthetized by anesthesia. He was intubated. His supplemental oxygen was weaned to 24%, on which all of his hemodynamics were obtained. The patient was prepped and draped in the routine sterile fashion, including both groins and the right neck. Xylocaine was administered in the right femoral area. A 6-French sheath was introduced into the right femoral vein percutaneously without complication. A 4-French sheath was introduced into the right femoral artery percutaneously without complication. A 4-French pigtail catheter was introduced and passed to the abdominal aorta.,Dr. Hayes, using the SiteRite device, introduced a 5-French sheath into the right internal jugular vein without complication.,A 5-French wedge catheter was introduced through the sheath in the right internal jugular vein and was passed to the left pulmonary artery and further to the left pulmonary capillary wedge position. This catheter would not pass to the right pulmonary artery. The wedge catheter was removed. A 5-French IMA catheter was then introduced and passed to the right pulmonary artery. After right pulmonary artery pressure was measured, this catheter was removed.,The 5 wedge catheter was advanced through the right femoral sheath and was passed to the following chambers or vessels: Inferior vena cava, right atrium, left atrium, and right ventricle.,The previously introduced 4 pigtail catheter was advanced to the ascending aorta. Simultaneous right ventricular and ascending aortic pressures were measured. A pullback from ascending aorta to descending aorta was then performed. Simultaneous measurements of right ventricular and descending aortic pressures were measured.,The wedge catheter was removed. A 5-French Berman catheter was advanced down the Glenn shunt to the right pulmonary artery, where a pullback from right pulmonary artery to Glenn shunt was performed. An injection was then performed using Omnipaque 16 mL at 8 mL per second with the Berman catheter positioned in the Glenn shunt. The 5-French Berman was removed.,A 6-French Berman was introduced through the right femoral vein sheath and was advanced to the right ventricle. A right ventriculogram was performed using Omnipaque 18 mL at 12 mL per second. The Berman catheter was pulled back to the inferior vena cava, where an inferior vena cavagram was performed using Omnipaque 10 mL at 8 mL per second.,The 4-French pigtail catheter was advanced to the ascending aorta and an ascending aortogram was performed using Omnipaque 16 mL at 12 mL per second.,Following the ascending angiograms, two kidneys and a bladder were noted. The catheters and sheaths were removed, and hemostasis was obtained by direct pressure. The estimated blood loss was less than 30 mL, and none was replaced. Heparin was administered following placement of all of the sheaths. Pulse oximetry saturation, pulse in the right foot, and EKG were monitored continuously.,II. PRESSURES:,A. Left pulmonary artery, mean of 11; left capillary wedge, mean of 9; main pulmonary artery, mean of 12; right pulmonary artery, mean of 10; descending aorta, 75/45, mean of 57; right atrium, A6 to 9, V6 to 8, mean 7; left atrium, mean 8; inferior vena cava, mean 7.,B. Ascending aorta, 65/35, with a simultaneous right ventricular pressure of 70/10; descending aorta, 60/35, with a right ventricular pressure of 72/10.,C. Pullbacks, left pulmonary artery to main pulmonary artery, mean of 11 to mean of 12; main pulmonary artery to Glenn, mean of 12 to mean of 13; right pulmonary artery to Glenn, mean of 12 to mean of 13; ascending aorta 68/35 to descending aorta 62/35.,INTERPRETATION:, Right and left pulmonary artery pressures are appropriate for this situation. There is a gradient of, at most, 2 mmHg on pullback from both the right and left pulmonary arteries to the Glenn shunt. The left atrial mean pressure is normal. Right ventricular end-diastolic pressure is, at most, slightly elevated. There is a trivial gradient between the right ventricle and ascending aorta consistent with trivial neo-aortic valve stenosis. There is a roughly 10-mm gradient between the right ventricle and descending aorta, consistent with additional coarctation of the aorta. On pullback from ascending to descending aorta, there is a 6-mmHg gradient between the two. Systemic blood pressure is normal.,III. OXIMETRY:, Superior vena cava 65, right pulmonary artery 67, left pulmonary artery 65, left atrium 96, right atrium 87, inferior vena cava 69, aorta 86, right ventricle 83.,INTERPRETATION:, Systemic arteriovenous oxygenation difference is normal, consistent with a normal cardiac output. Left atrial saturation is fairly normal, consistent with normal oxygenation in the lungs. The saturation falls passing from the left atrium to the right atrium and further to the right ventricle, consistent with mixing of pulmonary venous return and inferior vena cava return, as would be expected in this patient.,IV. SPECIAL PROCEDURE (S):, None done.,V. CALCULATIONS:,Please see the calculation sheet. Calculations were based upon an assumed oxygen consumption. The _____ saturation used was 67%, with a pulmonary artery saturation of 65%, a left atrial saturation of 96%, and an aortic saturation of 86%. Using the above information, the pulmonary to systemic flow ratio was 0.6. Systemic blood flow was 5.1 liters per minute per meter squared. Pulmonary blood flow was 3.2 liters per minute per meter squared. Systemic resistance was 9.8 Wood's units times meter squared, which is mildly diminished. Pulmonary resistance was 2.5 Wood's units times meter squared, which is in the normal range.,VI. ANGIOGRAPHY:, The injection to the Glenn shunt demonstrates a wide-open Glenn connection. The right pulmonary artery is widely patent, without stenosis. The proximal portion of the left pulmonary artery is significantly narrowed, but does open up near its branch point. The right pulmonary artery measures 6.5, the left pulmonary artery measures 3.0 mm. The aorta at the diaphragm on a later injection was 5.5 mm. There is a small collateral off the innominate vein passing to the left upper lobe. Flow to both upper lobes is diminished versus lower lung fields. There is normal return of the pulmonary veins from the right, with simultaneous filling of the left atrium and right atrium. There is normal return of the left lower pulmonary vein and left upper pulmonary vein. There is some reflux of dye into the inferior vena cava from the right atrium.,The right ventriculogram demonstrates a heavily pedunculated right ventricle with somewhat depressed right ventricular systolic function. The calculated ejection fraction from the LAO projection is only mildly diminished at 59%. There is no significant tricuspid regurgitation. The neo-aortic valve appears to open well with no stenosis. The ascending aorta is dilated. There is mild narrowing of the aorta at the isthmal area. On some projections, there appears to be a partial duplication of the aortic arch, probably secondary to this patient's style of Norwood reconstruction. There is some filling of the right upper and left upper lobes from collateral blood flow, with the left being more opacified than the right.,The inferior vena cavagram demonstrates normal return of the inferior vena cava to the right atrium.,The ascending aortogram demonstrates trivial aortic insufficiency, which is probably catheter-induced. The coronary arteries are poorly seen. Again, a portion of the aorta appears to be partially duplicated. There is faint opacification of the left upper lung from collateral blood flow. The above-mentioned narrowing of the aortic arch is again noted.",
" Left heart catheterization, left ventriculogram, selective coronary arteriography, aortic arch angiogram, right iliofemoral angiogram, #6 French Angio-Seal placement.", Cardiovascular / Pulmonary, Cardiac Catheterization - 7 ,"INDICATIONS FOR PROCEDURE:, The patient has presented with crushing-type substernal chest pain, even in the face of a normal nuclear medicine study. She is here for catheterization.,APPROACH:, Right common femoral artery.,ANESTHESIA:, IV sedation per cardiac catheterization protocol. Local sedation with 1% Xylocaine.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS:, Less than 10 mL.,ESTIMATED CONTRAST:, Less than 150 mL.,PROCEDURES PERFORMED:, Left heart catheterization, left ventriculogram, selective coronary arteriography, aortic arch angiogram, right iliofemoral angiogram, #6 French Angio-Seal placement.,OPERATIVE TECHNIQUE:, The patient was brought to the cardiac catheterization lab in the usual fasting state. She was placed supine on the cardiac catheterization table and the right groin was prepped and draped in the usual sterile fashion. One percent Xylocaine was infiltrated into the right femoral vessels. Next, a #6 French sheath was then placed in the right common femoral artery by the modified Seldinger technique.,SELECTIVE CORONARY ARTERIOGRAPHY:, Next, right and left Judkins diagnostic catheters were advanced through their respective ostia and injected in multiple views.,LEFT VENTRICULOGRAM:, Next, a pigtail catheter was advanced across the aortic valve and left ventricular pressure recorded. Next, an LV-gram was then performed with a hand injection of 50 mL of contrast. Next, pull-back pressure was measured across the aortic valve.,AORTA ARCH ANGIOGRAM:, Next, aortic arch angiogram was then performed with injection of 50 mL of contrast at a rate of 20 mL/second to maximum pressure of 750 PSI performed in the 40-degree LAO view.,Next, right iliofemoral angiogram was performed in the 20-degree RAO view. Next Angio-Seal was applied successfully.,The patient left the cath lab without problems or issues.,DIAGNOSES:, Left ventricular end-diastolic pressure was 18 mmHg. There was no gradient across the aortic valve. The central aortic pressure was 160 mmHg.,LEFT VENTRICULOGRAM:, The left ventriculogram demonstrated normal LV systolic function with estimated ejection fraction greater than 50%.,AORTIC ARCH ANGIOGRAM: ,The aortic arch angiogram demonstrated normal aortic arch. No aortic regurgitation was seen.,SELECTIVE CORONARY ARTERIOGRAPHY:, The right coronary artery is large and dominant.,The left main is patent.,The left anterior descending is patent.,The left circumflex is patent.,IMPRESSION:, This study demonstrates normal coronary arteries in the presence of normal left ventricular systolic function. In addition, the aortic root is normal.",
 Percutaneous intervention with drug-eluting stent placement to the ostium of the PDA., Cardiovascular / Pulmonary, Cardiac Catheterization - 4 ,"PROCEDURES PERFORMED:,1. Left heart catheterization with coronary angiography and left ventricular pressure measurement.,2. Left ventricular angiography was not performed.,3. Right posterior descending artery percutaneous transluminal coronary angioplasty followed by stenting.,4. Right femoral artery angiography.,5. Perclose to seal the right femoral arteriotomy.,INDICATIONS FOR PROCEDURE:, Patient presenting with a history of coronary artery disease in the past with coronary angiography in the early 1990s. The patient presented with what appeared to be a COPD exacerbation and had mildly positive cardiac enzyme markers suggestive of a non-ST elevation myocardial infarction. He was subsequently dispositioned to the cardiac catheterization lab for further evaluation.,DESCRIPTION OF PROCEDURE:, After informed consent was obtained, the patient was taken to the cardiac catheterization lab, where his procedure was performed. The patient was appropriately prepped and prepared on the table, after which his right groin was locally anesthetized with 1% lidocaine. Then, a 6-French sheath was inserted into the right femoral artery. Over a standard 0.035 guidewire, coronary angiography and left ventricular pressure measurements were performed using a 6-French JL4 diagnostic catheter to image the left coronary artery, a 6-French JR4 diagnostic catheter to image the right coronary artery, a 6-French angled pigtail catheter to measure left ventricular pressure. At the conclusion of the diagnostic study, the case was progressed to percutaneous coronary intervention, which will be described below. Subsequently, right femoral artery angiography was performed which showed right femoral artery which was free of significant atherosclerotic plaque, and an arteriotomy that was suitable for a closure device. Then, a Perclose was used to seal the right femoral arteriotomy.,HEMODYNAMIC DATA:, The opening aortic pressure was 91/63. The left ventricular pressure was 94/13 with an end-diastolic pressure of 24. Left ventricular ejection fraction was not assessed, as ventriculogram was not performed. The patient did have some elevated creatinine earlier in this hospital course which warranted limitation of contrast where possible.,CORONARY ANGIOGRAM:, The left main coronary artery was angiographically okay. The LAD had mild diffuse disease. There appeared to be distal tapering of the LAD. The left circumflex had mild diffuse disease. In the very distal aspect of the circumflex after OM-3 and OM-4 type branch, there was a long, severely diseased segment that appeared to be chronic and subtotal in one area. The runoff from this area appeared to be a very small PLOM type branch and continuation of a circ which did not appear to supply much territory, and there was not much to salvage by approaching this lesion. The right coronary artery had mild diffuse disease. The PLV branch was 100% occluded at its ostium at the crux. The PDA at the ostium had an 80% stenosis. The PDA was a fairly sizeable vessel with a long course. The right coronary is dominant.,CONCLUSION:, Mild diffuse coronary artery disease with severe distal left circumflex lesion with not much runoff beyond this lesion. This circumflex appears to be chronically diseased and has areas that appear to be subtotal. There is a 100% PLV branch which is also chronic and reported in his angiogram in the 1990s. There is an ostial 80% right PDA lesion. The plan is to proceed with percutaneous intervention to the right PDA.,The case was then progressed to percutaneous intervention of the right PDA. A 6-French JR4 guide catheter with side holes was selected and used to engage the right coronary artery ostium. The lesion was crossed with a long BMW 0.014 guidewire. Then, we ballooned the lesion with a 2.5 x 9 mm Maverick balloon. Subsequently, we stented the lesion with a 2.5 x 16 mm Taxus drug-eluting stent with a nice angiographic result. The patient tolerated the procedure very well, without complications.,ANGIOPLASTY CONCLUSION:, Successful percutaneous intervention with drug-eluting stent placement to the ostium of the PDA.,RECOMMENDATIONS:, Aspirin indefinitely, and Plavix 75 mg p.o. daily for no less than six months. The patient will be dispositioned back to telemetry for further monitoring.,TOTAL MEDICATIONS DURING PROCEDURE:, Versed 1 mg and fentanyl 25 mcg for conscious sedation. Heparin 8400 units IV was given for anticoagulation. Ancef 1 g IV was given for closure device prophylaxis.,CONTRAST ADMINISTERED:, 200 mL.,FLUOROSCOPY TIME:, 12.4 minutes.","cardiovascular / pulmonary, coronary angiography, ventricular pressure, coronary angioplasty, french, pda, drug-eluting stent, coronary artery disease, cardiac catheterization lab, plv branch, cardiac catheterization, femoral artery, coronary artery, artery, coronary, angioplasty, angiogram, angiographically, arteriotomy, angiography, cardiac, circumflex, ostium, ventricular, femoral, percutaneous, catheterization, "
" Left heart catheterization with coronary angiography, vein graft angiography and left ventricular pressure measurement and angiography.", Cardiovascular / Pulmonary, Cardiac Catheterization - 5 ,"PROCEDURE PERFORMED:,1. Left heart catheterization with coronary angiography, vein graft angiography and left ventricular pressure measurement and angiography.,2. Right femoral selective angiogram.,3. Closure device the seal the femoral arteriotomy using an Angio-Seal.,INDICATIONS FOR PROCEDURE: ,The patient with known coronary atherosclerotic heart disease and multiple risk factors of coronary disease, who had her last coronary arteriogram performed in 2004. She has had complaints of progressive chest discomfort, and has ongoing risks including current smoking, diabetes, hypertension, hyperlipidemia to name a few. The decision was made to proceed on with percutaneous evaluation and possible intervention given her known disease and the possibility of disease progression.,DESCRIPTION OF PROCEDURE:, After informed consent was obtained, The patient was taken to cardiac catheterization lab where her procedure was performed. She was prepped and prepared on the table; after which, her right groin was locally anesthetized with 1% lidocaine. Then, a 6-French sheath was inserted into the right femoral artery over a standard 0.035 guide wire. Coronary angiography and left ventricular measurement and angiography were performed using a 6-French JL4 diagnostic catheter to image the left coronary artery. A 6-French JR4 diagnostic catheter to image the right groin and her artery and the saphenous vein graft conduit. Subsequently, a 6-French angled pigtail catheter was used to measure left ventricular pressures and to perform a power injection, a left ventriculogram at 8 mL per second for a total of 30 mL. At the conclusion of the diagnostic evaluation, the patient had selective arteriography of her right femoral artery, which showed the right femoral artery to be free of significant atherosclerotic plaque. Did have a normal bifurcation into the superficial femoral and profunda femoris arteries and to have an arteriotomy that was in the common femoral artery away from the bifurcation. As such, an initial attempt to advance a Perclose device failed to allow the device descend to _____ tract and into the appropriate position within the artery. As such, the Perclose was never deployed and was removed intact over the wire from the system. We then replaced this with a 6-French Angio-Seal which was used to seal the femoral arteriotomy with achievement of hemostasis. The patient was subsequently dispositioned back to the MAC Unit where she will complete her bedrest prior to her disposition to home.,HEMODYNAMIC DATA:, Opening aortic pressure 125/60, left ventricular pressure 108/4 with an end-diastolic pressure of 16. There was no significant gradient across the aortic valve on pullback from the left ventricle. Left ventricular ejection fraction was 55%. Mitral regurgitation was less than or equal to 1+. There was normal wall motion in the RAO projection.,CORONARY ANGIOGRAM:, The left main coronary artery had mild atherosclerotic plaque. The proximal LAD was 100% occluded. The left circumflex had mild diffuse atherosclerotic plaque. The obtuse marginal branch which operates as an OM-2 had a mid approximately 80% stenosis at a kink in the artery. This appears to be the area of a prior anastomosis, the saphenous vein graft to the OM. This is a very small-caliber vessel and is 1.5-mm in diameter at best. The right coronary artery is dominant. The native right coronary artery had mild proximal and mid atherosclerotic plaque. The distal right coronary artery has an approximate 40% stenosis. The posterior left ventricular branch has a proximal 50 to 60% stenosis. The proximal PDA has a 40 to 50% stenosis. The saphenous vein graft to the right PDA is widely patent. There was competitive flow noted between the native right coronary artery and the saphenous vein graft to the PDA. The runoff from the PDA is nice with the native proximal PDA and PLV disease as noted above. There is also some retrograde filling of the right coronary artery from the runoff of this graft. The saphenous vein graft to the left anterior descending is widely patent. The LAD beyond the distal anastomosis is a relatively small-caliber vessel. There is some retrograde filling that allows some filling into a more proximal diagonal branch. The saphenous vein graft to the obtuse marginal was known to be occluded from the prior study in 2004. Overall, this study does not look markedly different than the procedure performed in 2004.,CONCLUSION:, 100% proximal LAD mild left circumflex disease with an OM that is a small-caliber vessel with an 80% lesion at a kink that is no amenable to percutaneous intervention. The native right coronary artery has mild to moderate distal disease with moderate PLV and PDA disease. The saphenous vein graft to the OM is known to be 100% occluded. The saphenous vein graft to the PDA and the saphenous vein graft to the LAD are open. Normal left ventricular systolic function.,PLAN:, The plan will be for continued medical therapy and risk factor modification. Aggressive antihyperlipidemic and antihypertensive control. The patient's goal LDL will be at or below 70 with triglyceride level at or below 150, and it is very imperative that the patient stop smoking.,After her bedrest is complete, she will be dispositioned to home, after which, she will be following up with me in the office within 1 month. We will also plan to perform a carotid duplex Doppler ultrasound to evaluate her carotid bruits.","cardiovascular / pulmonary, catheterization, vein graft, angiography, angiogram, angio-seal, closure device, coronary atherosclerotic heart disease, saphenous vein graft, ventricular pressure, coronary artery, saphenous vein, atherosclerotic, coronary, artery, bifurcation, pda, ventricular, saphenous"
 Cardiac catheterization.   Coronary artery disease plus intimal calcification in the mid abdominal aorta without significant stenosis., Cardiovascular / Pulmonary, Cardiac Catheterization - 12 ,"PREOPERATIVE DIAGNOSIS: , Coronary artery disease.,POSTOPERATIVE DIAGNOSIS: , Coronary artery disease plus intimal calcification in the mid abdominal aorta without significant stenosis.,DESCRIPTION OF PROCEDURE:,LEFT HEART CATHETERIZATION WITH ANGIOGRAPHY AND MID ABDOMINAL AORTOGRAPHY:,Under local anesthesia with 2% lidocaine with premedication, a right groin preparation was done.  Using the percutaneous Seldinger technique via the right femoral artery, a left heart catheterization was performed.  Coronary arteriography was performed with 6-French performed coronary catheters.  We used a 6-French JR4 and JL4 catheters to take multiple cineangiograms of the right and left coronary arteries.  After using the JR4 6-French catheter, nitroglycerin was administered because of the possibility of ostial spasm, and following that, we used a 5-French JR4 catheter for additional cineangiograms of the right coronary artery.  A pigtail catheter was placed in the mid abdominal aorta and abdominal aortic injection was performed to rule out abdominal aortic aneurysm, as there was dense calcification in the mid abdominal aorta.,ANALYSIS OF PRESSURE DATA: , Left ventricular end-diastolic pressure was 5 mmHg.  On continuous tracing from the left ventricle to the ascending aorta, there is no gradient across the aortic valve.  The aortic pressures were normal.  Contours of intracardiac pressure were normal.,ANALYSIS OF ANGIOGRAMS:,  Selective cineangiograms were obtained with injection of contrast to the left ventricle, coronary arteries, and mid abdominal aorta.  A pigtail catheter was introduced into the left ventricle and ventriculogram performed in right anterior oblique position.  The mitral valve is competent and demonstrates normal mobility.  The left ventricular cavity is normal in size with excellent contractility.  Aneurysmal dilatation and/or dyskinesia absent.  The aortic valve is tricuspid and normal mobility.  The ascending aorta appeared normal.,Pigtail catheter was introduced in the mid abdominal aorta and placed just above the renal arteries.  An abdominal aortic injection was performed.  Under fluoroscopy, we see heavy dense calcification of the mid abdominal aorta between the renal artery and the bifurcation.  There was some difficulty initially with maneuvering the wire pass that area and it was felt that might be a tight stenosis.  The abdominal aortogram reveals wide patency of that area with mild intimal irregularity.  There is a normal left renal artery, normal right renal artery.  The celiac seems to be normal, but what I believe is the splenic artery seen initially at its origin is normal.  The common left iliac and common right iliac arteries are essentially normal in this area.,CORONARY ANATOMY:,  One notes ostial coronary calcification of the right coronary artery.  Cineangiogram obtained with 6-French JR4 and 5-French JR4 catheters.  Prior to the introduction of the 5-French JR4 nitroglycerin was administered sublingually.  The 6-French JR4 catheters appeared to a show an ostial lesion of over 50%.  There was backwash of dye into the aorta, although there is a fine funneling of the ostium towards the proximal right coronary artery.  In the proximal portion of the right coronary artery just into the Shepherd turn, there is a 50% smooth tapering of the right coronary artery in the proximal third.  Then the artery seems to have a little bit more normal size and it divides into a large posterior descending artery posterolateral branch vessel.  The distal portion of the vessel is free of disease.  The conus branch is seen arising right at the beginning part of the right coronary artery.  We then removed the 6-French catheter and following nitroglycerin and sublingually we placed a 5-French catheter and again finding a stenosis, may be less than 50%.  At the ostium of the right coronary artery, calcification again is identified.  Backwash of dye noted at the proximal lesion, looked about the same 50% along the proximal turn of the Shepherd turn area.,The left coronary artery is normal, although there is a rim of ostial calcification, but there is no tapering or stenosis.  It forms the left anterior descending artery, the ramus branch, and the circumflex artery.,The left anterior descending artery is a very large vessel, very tortuous in its proximal segment, very tortuous in its mid and distal segment.  There appears to be some mild stenosis of 10% in the proximal segment.  It gives off a large diagonal branch in the proximal portion of the left anterior descending artery and it is free of disease.  The remaining portion of the left anterior descending artery is free of disease.  Upon injection of the left coronary artery, we see what I believe is the dye enters probably directly into the left ventricle, but via fistula excluding the coronary sinus, and we get a ventriculogram performed.  I could not identify an isolated area, but it seems to be from the interventricular septal collaterals that this is taking place.,The ramus branch is normal and free of disease.,The left circumflex artery is a tortuous vessel over the lateral wall and terminating in the inferoposterior wall that is free of disease.,The patient has a predominantly right coronary system.  There is no _______ circulation connecting the right and left coronary systems.,The patient tolerated the procedure well.  The catheter was removed.  Hemostasis was achieved.  The patient was transferred to the recovery room in a stable condition.,IMPRESSION:,1.  Excellent left ventricular contractility with normal left ventricular cavity size.,2.  Calcification of the mid abdominal aorta with wide patency of all vessels.  The left and right renal arteries are normal.  The external iliac arteries are normal.,3.  Essentially normal left coronary artery with some type of interventricular septal to left ventricular fistula.,4.  Ostial stenosis of the right coronary artery that appears to be about 50% or greater.  The proximal right coronary artery has 50% stenosis as well.,5.  Coronary calcification is seen under fluoroscopy at the ostia of the left and right coronary arteries.,RECOMMENDATIONS:  ,The patient has heavy calcification of the coronary arteries and continued risk factor management is needed.  The ostial lesion of the right coronary artery may be severe.  It is at least 50%, but it could be worse.  Therefore, she will be evaluated for the possibility of an IVUS and/or _______ analysis of the proximal right coronary artery.  We will reevaluate her stress nuclear study as well.  Continue aggressive medical therapy.","cardiovascular / pulmonary, intimal calcification, stenosis, coronary artery disease, mid abdominal aorta, coronary artery, cardiac catheterization, coronary arteries, descending artery, calcification, mid, proximal, aorta, catheterization, abdominal, cardiac, intimal, coronary, artery, "
" Left Heart Catheterization.  Chest pain, coronary artery disease, prior bypass surgery.  Left coronary artery disease native.  Patent vein graft with obtuse marginal vessel and also LIMA to LAD.  Native right coronary artery is patent, mild disease.", Cardiovascular / Pulmonary, Cardiac Catheterization - 10 ,"EXAM: , Left Heart Catheterization,REASON FOR EXAM:,  Chest pain, coronary artery disease, prior bypass surgery.,INTERPRETATION: , The procedure and complications were explained to the patient in detail and formal consent was obtained.  The patient was brought to the cath lab.  The right groin was draped in the usual sterile manner.  Using modified Seldinger technique, a 6-French arterial sheath was introduced in the right common femoral artery.  A JL4 catheter was used to cannulate the left coronary arteries.  A JR4 catheter was used to cannulate the right coronary artery and also bypass grafts.  The same catheter was used to cannulate the vein graft and also LIMA.  I tried to attempt to cannulate other graft with Williams posterior catheter and also bypass catheter was unsuccessful.  A 6-French pigtail catheter was used to perform left ventriculography and pullback was done.  No gradient was noted.  Arterial sheath was removed.  Hemostasis was obtained with manual compression.  The patient tolerated the procedure very well without any complications.,FINDINGS:,1.  Native coronary arteries.  The left main is patent.  The left anterior descending artery is not clearly visualized.  The circumflex artery appears to be patent.  The proximal segment gives rise to small caliber obtuse marginal vessel.,2.  Right coronary artery is patent with mild distal and mid segment.  No evidence of focal stenosis or dominant system.,3.  Bypass graft LIMA to the left anterior descending artery patent throughout the body as well the anastomotic site.  There appears to be possible _______ graft to the diagonal 1 vessel.  The distal LAD wraps around the apex.  No stenosis following the anastomotic site noted.,4.  Vein graft to what appears to be obtuse marginal vessel was patent with a small caliber obtuse marginal 1 vessel.,5.  No other bypass grafts are noted by left ventriculography and also aortic root shot.,6.  Left ventriculography with an ejection fraction of 60%.,IMPRESSION:,1.  Left coronary artery disease native.,2.  Patent vein graft with obtuse marginal vessel and also LIMA to LAD.  _______ graft to the diagonal 1 vessel.,3.  Native right coronary artery is patent, mild disease.,RECOMMENDATIONS: , Medical treatment.","cardiovascular / pulmonary, chest pain, coronary artery disease, bypass surgery, heart catheterization, lima, lad, obtuse marginal vessel, vein graft, obtuse marginal, marginal vessel, coronary artery, catheterization, coronary, artery, obtuse, marginal, bypass, vessel, graft"
" Left heart catheterization, LV cineangiography, selective coronary angiography, and right heart catheterization with cardiac output by thermodilution technique with dual transducer.", Cardiovascular / Pulmonary, Cardiac Catheterization ,"EXAMINATION: , Cardiac catheterization.,PROCEDURE PERFORMED: , Left heart catheterization, LV cineangiography, selective coronary angiography, and right heart catheterization with cardiac output by thermodilution technique with dual transducer.,INDICATION: , Syncope with severe aortic stenosis.,COMPLICATIONS:,  None.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained from the patient, the patient was brought to the cardiac catheterization laboratory in a post observed state.  The right groin was prepped and draped in the usual sterile fashion.  After adequate conscious sedation and local anesthesia was obtained, a 6-French sheath was placed in the right common femoral artery and a 8-French sheath was placed in the right common femoral vein.  Following this, a 7.5-French Swan-Ganz catheter was advanced into the right atrium where the right atrial pressure was 10/7 mmHg.  The catheter was then manipulated into the right ventricle where the right ventricular pressure was 37/10/4 mmHg.  The catheter was then manipulated into the wedge position where the wedge pressure was noted to be 22 mmHg.  The pulmonary arterial pressures were noted to be 31/14/21 mmHg.  Following this, the catheter was removed, the sheath was flushed and a 6-French JL4 diagnostic catheter was the advanced over the guidewire and the left main coronary artery was cannulated and selective angiogram was obtained in orthogonal views.  Following this, the catheter was exchanged over the guidewire for 6-French JR4 diagnostic catheter.  We were unable to cannulate the right coronary artery.  Therefore, we exchanged for a Williams posterior catheter and we were able to cannulate the right coronary artery and angiographs were performed in orthogonal views.  Following this, this catheter was exchanged over a guidewire for a 6-French Langston pigtail catheter and the left ventricle was entered and left ventriculography was performed.  Following this, the catheters were removed.  Sheath angiograms revealed the sheath to be in the right common femoral artery and the right common femoral arteriotomy was sealed using a 6-French Angio-Seal device.  The patient tolerated the procedure well.  There were no complications.,DESCRIPTION OF FINDINGS: , The left main coronary artery is a large vessel, which bifurcates into the left anterior descending artery and left circumflex artery and has moderate diffuse luminal irregularities with no critical lesions.  The left circumflex artery is a short vessel, which gives off one major obtuse marginal artery and has moderate diffuse luminal irregularities with no critical lesions.  The left anterior descending artery has moderate diffuse luminal irregularities and gives off two major diagonal branches.  There is a 70% ostial lesion in the first diagonal branch and the second diagonal branch has mild-to-moderate luminal irregularities.  The right coronary artery is a very large dominant vessel with a 60% to 70% lesion in its descending mid-portion.  The remainder of the vessel has moderate diffuse luminal irregularities with no critical lesions.  The left ventricle appears to be normal sized.  The aortic valve is heavily calcified.  The estimated ejection fraction is approximately 60%.  There was 4+ mitral regurgitation noted.  The mean gradient across the aortic valve was noted to be 33 mmHg yielding an aortic valve area of 0.89 cm2.,CONCLUSION:,1.  Moderate-to-severe coronary artery disease with a high-grade lesion seen at the ostium of the first diagonal artery as well as a 60% to 70% lesion seen at the mid portion of the right coronary artery.,2.  Moderate-to-severe aortic stenosis with an aortic valve area of 0.89 cm2.,3.  4+ mitral regurgitation.,PLAN: , The patient will most likely need a transesophageal echocardiogram to better evaluate the valvular architecture and the patient will be referred to Dr Kenneth Fang for possible aortic valve replacement as well as mitral valve repair/replacement and possible surgical revascularization.","cardiovascular / pulmonary, heart catheterization, cineangiography, selective coronary angiography, thermodilution technique, transducer, diffuse luminal irregularities, cardiac catheterization, luminal irregularities, aortic valve, coronary artery, artery, catheterization, regurgitation, angiography, thermodilution, coronary,"
" Left Cardiac Catheterization, Left Ventriculography, Coronary Angiography and Stent Placement.", Cardiovascular / Pulmonary, Cardiac Cath & Coronary Angiography ,"PROCEDURE:,  Left Cardiac Catheterization, Left Ventriculography, Coronary Angiography and Stent Placement.,INDICATIONS: , Atherosclerotic coronary artery disease.,PATIENT HISTORY: , This is a 55-year-old male.  He presented with 3 hours of unstable angina.,PAST CARDIAC HISTORY: , History of previous arteriosclerotic cardiovascular disease.  Previous ST elevation MI.,REVIEW OF SYSTEMS.,  The creatinine value is 1.3 mg/dL mg/dL.,PROCEDURE MEDICATIONS:,1.  Visipaque 361 mL total dose.,2.  Clopidogrel bisulphate (Plavix) 225 mg PO,3.  Promethazine (Phenergan) 12.5 mg total dose.,4.  Abciximab (Reopro) 10 mg IV bolus,5.  Abciximab (Reopro) 0.125 mcg/kg/minute, 4.5 mL/250 mL D5W x 17 mL,6.  Nitroglycerin 300 mcg IC total dose.,DESCRIPTION OF PROCEDURE:,APPROACH: , Left heart catheterization via right femoral artery approach.,ACCESS METHOD: , Percutaneous needle puncture.,DEVICES USED:,1.  Balloon catheter utilized:  Manufacturer:  Boston Sci Quantum Maverick RX 2.75mm x 20mm.,2.  Cordis Vista Brite Tip 6Fr JR 4.0,3.  ACS/Guidant Sport .014"" (190cm) Wire,4.  Stent utilized:  Boston Sci Taxus RX Stent 3.0mm x 32mm.,FINDINGS/INTERVENTIONS:,LEFT VENTRICULOGRAPHY:,  The overall left ventricular systolic function is mildly reduced.  Left ventricular ejection fraction is 40% by left ventriculogram.  Mild hypokinesis of the anterior wall of the left ventricle.  There was no transaortic gradient.  Mitral valve regurgitation is not seen.,LEFT MAIN CORONARY ARTERY:  ,  There were no obstructing lesions in the left main coronary artery.  Blood flow appeared normal.,LEFT ANTERIOR DESCENDING ARTERY: , There was a 95%, discrete stenosis in the mid left anterior descending artery.  A drug eluting, Boston Sci Taxus RX Stent 3.0mm x 32mm stent was placed in the mid left anterior descending artery and post-dilated to 3.5 mm.  Post-procedure stenosis was 0%.  There was no dissection and no perforation.,LEFT CIRCUMFLEX ARTERY: , There was a 50%, diffuse stenosis in the left circumflex artery.,RIGHT CORONARY ARTERY:,  The right coronary artery is dominant to the posterior circulation.  There were no obstructing lesions in the right coronary artery.  Blood flow appeared normal.,COMPLICATIONS:,There were no complications during the procedure., ,IMPRESSION:,1.  Severe two-vessel coronary artery disease.,2.  Severe left anterior descending coronary artery disease.  There was a 95% mid left anterior descending artery stenosis.  The lesion was successfully stented.,3.  Moderate left circumflex artery disease.  There was a 50% left circumflex artery stenosis.  Intervention not warranted.,4.  The overall left ventricular systolic function is mildly reduced with ejection fraction of 40%.  Mild hypokinesis of the anterior wall of the left ventricle.,RECOMMENDATION:,1.  Clopidogrel (Plavix) 75 mg PO daily for 1 year.",
 Left cardiac catheterization with selective right and left coronary angiography.   Post infarct angina., Cardiovascular / Pulmonary, Cardiac Cath & Selective Coronary Angiography ,"PREOPERATIVE DIAGNOSIS: , Post infarct angina.,TYPE OF PROCEDURE: , Left cardiac catheterization with selective right and left coronary angiography.,PROCEDURE: , After informed consent was obtained, the patient was brought to the Cardiac Catheterization Laboratory, and the groin was prepped in the usual fashion.  Using 1% lidocaine, the right groin was infiltrated, and using the Seldinger technique, the right femoral artery was cannulated.  Through this, a moveable guidewire was then advance to the level of the diaphragm, and through it, a 6 French pigtail catheter was advanced under hemodynamic monitoring to the ascending aorta and inserted into the left ventricle.  Pressure measurements were obtained and cineangiograms in the RAO and LAO positions were then obtained.  Catheter was then withdrawn and a #6 French non-bleed-back sidearm sheath was then introduced, and through this, a 6 French Judkins left coronary catheter was then advanced under hemodynamic monitoring to the left coronary ostium, engaged.  Cineangiograms were obtained of the left coronary system.  This catheter was then exchanged for a Judkins right 4 coronary catheter of similar dimension and under hemodynamic monitoring again was advanced to the right coronary ostium, engaged.  Cineangiograms were obtained, and the catheter and sheath were then withdrawn.  The patient tolerated the procedure well and left the Cardiac Catheterization Laboratory in stable condition.  No evidence of hematoma formation or active bleeding.  ,COMPLICATIONS: , None.  ,TOTAL CONTRAST: , 110 cc of Hexabrix.  ,TOTAL FLUOROSCOPY TIME:  ,1.8 minutes.  ,MEDICATIONS: , Reglan 10 mg p.o., 5 mg p.o.  Valium, Benadryl 50 mg p.o. and heparin 3,000 units IV push.","cardiovascular / pulmonary, selective, angiography, post infarct angina, engaged cineangiograms, coronary angiography, hemodynamic monitoring, cardiac catheterization, catheterization, cineangiograms, cardiac, coronary,"
" Orthostatic cardiac allograft transplantation utilizing total cardiopulmonary bypass, open sternotomy covered with Ioban, insertion of Mahurkar catheter for hemofiltration via the left common femoral vein.", Cardiovascular / Pulmonary, Cardiac Allograft Transplant ,"PREOPERATIVE DIAGNOSES:,1.  Ischemic cardiomyopathy.,2.  Status post redo coronary artery bypass.,3.  Status post insertion of intraaortic balloon.,POSTOPERATIVE DIAGNOSES:,1.  Ischemic cardiomyopathy.,2.  Status post redo coronary artery bypass.,3.  Status post insertion of intraaortic balloon.,4.  Postoperative coagulopathy.,OPERATIVE PROCEDURE:,1.  Orthostatic cardiac allograft transplantation utilizing total cardiopulmonary bypass.,2.  Open sternotomy covered with Ioban.,3.  Insertion of Mahurkar catheter for hemofiltration via the left common femoral vein.,ANESTHESIA: , General endotracheal.,OPERATIVE PROCEDURE: , With the patient in the supine position, he was prepped from shin to knees and draped in a sterile field.  A right common femoral artery vein were then exposed through a longitudinal incision in the right groin and prepared for cardiopulmonary bypass.  A sternotomy incision was then opened and the lesions from the previous operative procedures were lysed and they were very dense and firm, freeing up the right atrium and the ascending aorta and anterior right ventricle.  The patient was heparinized and then a pursestring suture was placed in the right atrium superior and inferior just above the superior and inferior vena cava.  A percutaneous catheter for arterial return was placed using Seldinger technique through exposed right femoral artery and then two 3-mm catheters were inserted with two pursestring sutures in the right atrium just superior to inferior vena cava.  After satisfactory heparinization has been obtained, the patient was placed on cardiopulmonary bypass and another pursestring suture was placed in the right superior pulmonary vein and a catheter was placed for suction in the left atrium.  After the heart was brought to the operating room and triggered, the patient had the ascending aorta clamped and tapes were placed around superior and inferior vena cava and were secured in place.  A cardiectomy was then performed by starting in the right atrium.  The wires from the pacemaker and defibrillator were transected coming from the superior vena cava and the Swan-Ganz catheter was brought out into the operative field.  Cardiectomy was then performed, first resecting the anterior portion of the right atrium and then transecting the aorta, the pulmonary artery, the septum between the right and left atriums, and then the heart was removed.  The right and left atrium, aorta, and pulmonary artery were prepared for the transplant.  First, we did a side-to-side anastomosis, continued to the left atrium and this was performed using 3-0 Prolene suture and a right atrial anastomosis side-to-side was performed using 3-0 Prolene suture.  The pulmonary artery was then anastomosed using 5-0 Prolene and the aorta was anastomosed with 4-0 Prolene.  The arterial anastomosis in the pulmonary artery and aorta were not completed until the heart was filled with blood.  Air was evacuated and the sutures were tied down.  The clamp on the ascending aorta was removed and the patient was gradually overtime weaned from cardiopulmonary bypass.  The patient had a postoperative coagulopathy which prolonged the period of time in the operating room after completion and weaning off of the cardiopulmonary bypass.  Blood factors and factor VII were given to try and correct the coagulopathy.  Because of excessive transfusions that were required, a Mahurkar catheter was inserted through the left common femoral vein, first placing a needle into the vein and then guidewire removed, and the needle dilators were then placed and then the Mahurkar catheter was then placed with 2-0 nylon suture.  Hemofiltration was started in the operating room at this time.  After he had satisfactory hemostasis, we decided to do the chest open and cover it with Ioban, which we did, and one chest tube was inserted into the mediastinum through a separate stab wound.  The patient also had an intraaortic balloon for counterpulsation which had been inserted into the left subclavian vein preoperatively.  This was left in place and the pulse generation, the pacemaker was in a right infraclavicular position, which was left in place because of the coagulopathy.  The patient received 11 units of packed red blood cells, 7 platelets, 23 fresh-frozen plasma, 20 cryoprecipitates, and factor VII.  Urine output for the procedure was 520 mL.  The preservation time of the heart is in the anesthesia sheet.  The estimated blood loss was at least 6 L.  The patient was taken to the intensive care unit in guarded condition.","cardiovascular / pulmonary, cardiomyopathy, ioban, ischemic, ischemic cardiomyopathy, mahurkar catheter, orthostatic, seldinger, swan-ganz, allograft, aorta, balloon, cardiac, cardiopulmonary bypass, catheter, coagulopathy, coronary artery bypass, femoral vein, hemofiltration, intraaortic, intraaortic balloon, sternotomy, transplantation, ventricle, inferior vena cava, cardiac allograft, common femoral, vena cava, pulmonary artery, atrium, insertion, cardiopulmonary, artery"
" Cardiac Catheterization - An obese female with a family history of coronary disease and history of chest radiation for Hodgkin disease, presents with an acute myocardial infarction with elevated enzymes.", Cardiovascular / Pulmonary, Cardiac Catheterization - 1 ,"INDICATIONS FOR PROCEDURE:, A 51-year-old, obese, white female with positive family history of coronary disease and history of chest radiation for Hodgkin disease 20 years ago with no other identifiable risk factors who presents with an acute myocardial infarction with elevated enzymes. The chest pain occurred early Tuesday morning. She was treated with Plavix, Lovenox, etc., and transferred for coronary angiography and possible PCI. The plan was discussed with the patient and all questions answered.,PROCEDURE NOTE:, Following sterile prep and drape, the right groin and instillation of 1% Xylocaine anesthesia, the right femoral artery was percutaneously entered with a single wall puncture. A 6-French sheath inserted. Selective left and right coronary injections performed using Judkins coronary catheters with a 6-French pigtail catheter used to obtain left ventricle pressures, and a left ventriculography. The left pullback pressure. The catheters withdrawn. Sheath injection. Hemostasis obtained with a 6-French Angio-Seal device. She tolerated the procedure well.,Left ventricular end-diastolic pressure equals 25 mmHg post A wave. No aortic valve or systolic gradient on pullback.,ANGIOGRAPHIC FINDINGS:,I. Left coronary artery: The left main coronary artery is,normal. The left anterior descending extends to the apex and has only minor luminal irregularities within the midportion of the vessel. Normal diagonal branches. Normal septal perforator branches. The left circumflex is a nondominant vessel with only minor irregularities with normal obtuse marginal branches.,II. Right coronary artery: The proximal right coronary artery has a focal calcification. There is minor plaque with luminal irregularity in the proximal and midportion of the vessel with no narrowing greater than 10 to 20% at most. The right coronary artery is a dominant system which gives off normal posterior,descending and posterior lateral branches. TIMI 3 flow is present.,III. Left ventriculogram: The left ventricle is slightly enlarged with normal contraction of the base, but, with wall motion abnormality involving the anteroapical and inferoapical left ventricle with hypokinesis within the apical portion. Ejection fraction estimated 40%, 1+ mitral regurgitation (echocardiogram ordered).,DISCUSSION:, Recent inferoapical mild myocardial infarction by left ventriculography and cardiac enzymes with elevated left ventricular end-diastolic pressure post A wave, but, only minor residual coronary artery plaque with calcification proximal right coronary artery.,PLAN:, Medical treatment is contemplated, including ACE inhibitor, a beta blocker, aspirin, Plavix, nitrates. An echocardiogram is ordered to exclude apical left ventricular thrombus and to further assess ejection fraction.","cardiovascular / pulmonary, cardiac catheterization, hodgkin disease, beta blocker, coronary angiography, coronary artery, coronary disease, elevated enzymes, inferoapical, myocardial infarction, ventriculogram, ventriculography, acute myocardial infarction, proximal right coronary, diastolic pressure, ejection fraction, coronary, echocardiogram, cardiac, catheterization, myocardial, enzymes, infarction, artery"
 The patient with atypical type right arm discomfort and neck discomfort., Cardiovascular / Pulmonary, Cardiac Catheterization - 2 ,"INDICATIONS FOR PROCEDURE:, The patient has presented with atypical type right arm discomfort and neck discomfort. She had noninvasive vascular imaging demonstrating suspected right subclavian stenosis. Of note, there was bidirectional flow in the right vertebral artery, as well as 250 cm per second velocities in the right subclavian. Duplex ultrasound showed at least a 50% stenosis.,APPROACH:, Right common femoral artery.,ANESTHESIA:, IV sedation with cardiac catheterization protocol. Local infiltration with 1% Xylocaine.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS:, Less than 10 ml.,ESTIMATED CONTRAST:, Less than 250 ml.,PROCEDURE PERFORMED:, Right brachiocephalic angiography, right subclavian angiography, selective catheterization of the right subclavian, selective aortic arch angiogram, right iliofemoral angiogram, 6 French Angio-Seal placement.,DESCRIPTION OF PROCEDURE:, The patient was brought to the cardiac catheterization lab in the usual fasting state. She was laid supine on the cardiac catheterization table, and the right groin was prepped and draped in the usual sterile fashion. 1% Xylocaine was infiltrated into the right femoral vessels. Next, a #6 French sheath was introduced into the right femoral artery via the modified Seldinger technique.,AORTIC ARCH ANGIOGRAM:, Next, a pigtail catheter was advanced to the aortic arch. Aortic arch angiogram was then performed with injection of 45 ml of contrast, rate of 20 ml per second, maximum pressure 750 PSI in the 4 degree LAO view.,SELECTIVE SUBCLAVIAN ANGIOGRAPHY:, Next, the right subclavian was selectively cannulated. It was injected in the standard AP, as well as the RAO view. Next pull back pressures were measured across the right subclavian stenosis. No significant gradient was measured.,ANGIOGRAPHIC DETAILS:, The right brachiocephalic artery was patent. The proximal portion of the right carotid was patent. The proximal portion of the right subclavian prior to the origin of the vertebral and the internal mammary showed 50% stenosis.,IMPRESSION:,1. Moderate grade stenosis in the right subclavian artery.,2. Patent proximal edge of the right carotid.","cardiovascular / pulmonary, discomfort, subclavian stenosis, artery, french angio-seal, lao view, rao view, aortic arch angiogram, arch angiogram, cardiac catheterization, aortic arch, brachiocephalic, cardiac, angiography, aortic, angiogram, stenosis, catheterization, atypical, subclavian, "
" White male with onset of chest pain, with history of on and off chest discomfort over the past several days.", Cardiovascular / Pulmonary, Cardiac Catheterization - 3 ,"INDICATIONS FOR PROCEDURE:, This is a 61-year-old, white male with onset of chest pain at 04: 30 this morning, with history of on and off chest discomfort over the past several days. CPK is already over 1000. There is ST elevation in leads II and aVF, as well as a Q wave. The chest pain is now gone, mild residual shortness of breath, no orthopnea. Cardiac monitor shows resolution of ST elevation lead III.,DESCRIPTION OF PROCEDURE:, Following sterile prep and drape of the right groin, installation of 1% Xylocaine anesthesia, the right common femoral artery was percutaneously entered and 6-French sheath inserted. ACT approximately 165 seconds on heparin. Borderline hypotension 250 mL fluid bolus given and nitroglycerin patch removed. Selective left and right coronary injections performed using Judkins coronary catheters with a 6-French pigtail catheter used to obtain left ventricular pressures and left ventriculography. Left pullback pressure. Sheath injection. Hemostasis obtained with a 6-French Angio-Seal device. He tolerated the procedure well and was transported to the Cardiac Step-Down Unit in stable condition.,HEMODYNAMIC DATA:, Left ventricular end diastolic pressure elevated post A-wave at 25 mm of Mercury with no aortic valve systolic gradient on pullback.,ANGIOGRAPHIC FINDINGS:,I. Left coronary artery: The left main coronary artery is unremarkable. The left anterior descending has 30 to 40% narrowing with tortuosity in its proximal portion, patent first septal perforator branch. The first diagonal branch is a 2 mm vessel with a 90% ostial stenosis. The second diagonal branch is unremarkable, as are the tiny distal diagonal branches. The intermediate branch is a small, normal vessel. The ostial non-dominant circumflex has some contrast thinning, but no stenosis, normal obtuse marginal branch, and small AV sulcus circumflex branch.,II. Right coronary artery: The right coronary artery is a large, dominant vessel which gives off large posterior descending and posterolateral left ventricular branches. There are luminal irregularities, less than 25%, within the proximal to mid vessel. Some contrast thinning is present in the distal RCA just before the bifurcation into posterior descending and posterolateral branches. A 25%, smooth narrowing at the origin of the posterior descending branch. Posterolateral branch is unremarkable and quite large, with secondary and tertiary branches.,III. Left ventriculogram: The left ventricle is normal in size. Ejection fraction estimated at 40 to 45%. No mitral regurgitation. Severe hypokinesis to akinesis is present in the posterobasal and posteromedial segments with normal anteroapical wall motion.,DISCUSSION:, Recent inferior myocardial infarction with only minor contrast thinning distal RCA remaining on coronary angiography with resolution of chest pain and ST segment elevation. Left coronary system has one hemodynamically significant stenosis (a 90% ostial stenosis at the first diagonal branch, which is a 2 mm vessel). Left ventricular function is reduced with ejection fraction 40 to 45% with inferior wall motion abnormality.,PLAN:, Medical treatment, including Plavix and nitrates, in addition to beta blocker, aspirin, and aggressive lipid reduction.","cardiovascular / pulmonary, cpk, q wave, st elevation, french angio-seal, pigtail catheter, st segment, ejection fraction, wall motion, diagonal branch, posterior descending, coronary artery, catheterization, circumflex, rca, cardiac, st, elevation, ventricular, stenosis, artery, coronary, branch,"
" Redo coronary bypass grafting x3, right and left internal mammary, left anterior descending, reverse autogenous saphenous vein graft to the obtuse marginal and posterior descending branch of the right coronary artery.  Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.  Placement of a right femoral intraaortic balloon pump.", Cardiovascular / Pulmonary, CABG - Redo ,"OPERATIVE PROCEDURE:,1.  Redo coronary bypass grafting x3, right and left internal mammary, left anterior descending, reverse autogenous saphenous vein graft to the obtuse marginal and posterior descending branch of the right coronary artery.  Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.,2.  Placement of a right femoral intraaortic balloon pump.,DESCRIPTION: , The patient was brought to the operating room and placed in the supine position.  After adequate endotracheal anesthesia was induced, appropriate monitoring lines were placed.  Chest, abdomen an legs were prepped and draped in sterile fashion.  The femoral artery on the right was punctured and a guidewire was placed.  The track was dilated and intraaortic balloon pump was placed in the appropriate position, sewn in place and ballooning started.,The left greater saphenous vein was harvested from the groin to the knee and prepared by ligating all branches with 4-0 silk and flushed with vein solution.  The leg was closed with running 3-0 Dexon subcu and running 4-0 Dexon on the skin.,The old mediastinal incision was opened.  The wires were cut and removed.  The sternum was divided in the midline.  Retrosternal attachments were taken down.  The left internal mammary was dissected free from its takeoff at the left subclavian bifurcation at the diaphragm and surrounded with papaverine-soaked gauze.  The heart was dissected free of its adhesions.  The patient was fully heparinized and cannulated with a single aorta and single venous cannula.  Retrograde cardioplegia cannula was attempted to be placed, but could not be fitted into the coronary sinus safely, therefore, it was banded and oversewn with 5-0 Prolene.  An antegrade cardioplegia needle sump was placed and secured to the ascending aorta.  Cardiopulmonary bypass ensued.  The ascending aorta was cross clamped.  Cold-blood potassium cardioplegia was given antegrade, a total of 10 cc/kg.  It was followed by sumping the ascending aorta.  The obtuse marginal was identified and opened and an end-to-side anastomosis was performed with a running 7-0 Prolene suture.  The vein was cut to length.  Antegrade cardioplegia was given, a total of 200 cc.  The posterior descending branch of the right coronary artery was identified, opened and end-to-side anastomosis then performed with a running 7-0 Prolene suture.  The vein was cut to length.  Antegrade cardioplegia was given.  The mammary was clipped distally, divided and spatulated for anastomosis.  The anterior descending was identified, opened and end-to-side anastomosis then performed with running 8-0 Prolene suture and warm blood potassium cardioplegia was given.  The cross clamp was removed.  A partial-occlusion clamp was placed.  Aortotomies were made.  The vein was cut to fit these and sutured in place with running 5-0 Prolene suture.  The partial-occlusion clamp was removed.  All anastomoses were inspected and noted to be patent and dry.  Atrial and ventricular pacing wires were placed.  The patient was fully warmed and ventilation was commenced.  The patient was weaned from cardiopulmonary bypass, ventricular balloon pumping and inotropic support and weaned from cardiopulmonary bypass.  The patient was decannulated in routine fashion.  Protamine was given.  Good hemostasis was noted.  A single mediastinal chest tube and bilateral pleural Blake drains were placed.  The sternum was closed with figure-of-eight stainless steel wire.  The linea alba was closed with figure-of-eight of #1 Vicryl, the sternal fascia closed with running #1 Vicryl, the subcu closed with running 2-0 Dexon, skin with running 4-0 Dexon subcuticular stitch.  The patient tolerated the procedure well.","cardiovascular / pulmonary, coronary bypass grafting, internal mammary, cardiopulmonary, intraaortic, femoral artery, cabg, running prolene suture, intraaortic balloon, balloon pump, ascending aorta, prolene suture, cardiopulmonary bypass, potassium, aorta, anastomosis, prolene, coronary, cardioplegia, bypass,"
" He is a 67-year-old man who suffers from chronic anxiety and coronary artery disease and DJD.  He has been having some chest pains, but overall he does not sound too concerning.  He does note some more shortness of breath than usual.  He has had no palpitations or lightheadedness.  No problems with edema.", Cardiovascular / Pulmonary, CAD - 6-Month Followup ,"REASON FOR VISIT:,  Six-month follow-up visit for CAD.,He is a 67-year-old man who suffers from chronic anxiety and coronary artery disease and DJD.,He has been having a lot of pain in his back and pain in his left knee.  He is also having trouble getting his nerves under control.  He is having stomach pains and occasional nausea.  His teeth are bad and need to be pulled.,He has been having some chest pains, but overall he does not sound too concerning.  He does note some more shortness of breath than usual.  He has had no palpitations or lightheadedness.  No problems with edema.,MEDICATIONS:,  Lipitor 40 mg q.d., metoprolol 25 mg b.i.d., Plavix 75 mg q.d-discontinued, enalapril 10 mg b.i.d., aspirin 325 mg-reduced to 81 mg, Lorcet 10/650-given a 60 pill prescription, and Xanax 0.5 mg b.i.d-given a 60 pill prescription.,REVIEW OF SYSTEMS: , Otherwise unremarkable.,PEX:,  BP:  140/78.  HR:  65.  WT:  260 pounds (which is up one pound).  There is no JVD.  No carotid bruit.  Cardiac:  Regular rate and rhythm and distant heart sounds with a 1/6 murmur at the upper sternal border.  Lungs:  Clear.  Abdomen:  Mildly tender throughout the epigastrium.,Extremities:  No edema.,EKG:,  Sinus rhythm, left axis deviation, otherwise unremarkable.,Echocardiogram (for dyspnea and CAD):  Normal systolic and diastolic function.  Moderate LVH.  Possible gallstones seen.,IMPRESSION:,1.  CAD-Status post anterior wall MI 07/07 and was found to a have multivessel CAD.  He has a stent in his LAD and his obtuse marginal.  Fairly stable.,2.  Dyspnea-Seems to be due to his weight and the disability from his knee.  His echocardiogram shows no systolic or diastolic function.,3.  Knee pain-We well refer to Scotland Orthopedics and we will refill his prescription for Lorcet 60 pills with no refills.,4.  Dyslipidemia-Excellent numbers today with cholesterol of 115, HDL 45, triglycerides 187, and LDL 33, samples of Lipitor given.,5.  Panic attacks and anxiety-Xanax 0.5 mg b.i.d., 60 pills with no refills given.,6.  Abdominal pain-Asked to restart his omeprazole and I am also going to reduce his aspirin to 81 mg q.d.,7.  Prevention-I do not think he needs to be on the Plavix any more as he has been relatively stable for two years.,PLAN:,1.  Discontinue Plavix.,2.  Aspirin reduced to 81 mg a day.,3.  Lorcet and Xanax prescriptions given.,4.  Refer over to Scotland Orthopedics.,5.  Peridex mouthwash given for his poor dentition and told he was cardiovascularly stable and have his teeth extracted.", 
" Coronary artery bypass grafting (CABG) x4.  Progressive exertional angina, three-vessel coronary artery disease, left main disease, preserved left ventricular function.", Cardiovascular / Pulmonary, CABG x4 ,"PREOPERATIVE DIAGNOSES: , Progressive exertional angina, three-vessel coronary artery disease, left main disease, preserved left ventricular function.,POSTOPERATIVE DIAGNOSES:,  Progressive exertional angina, three-vessel coronary artery disease, left main disease, preserved left ventricular function.,OPERATIVE PROCEDURE: , Coronary artery bypass grafting (CABG) x4.,GRAFTS PERFORMED: , LIMA to LAD, left radial artery from the aorta to the PDA, left saphenous vein graft from the aorta sequential to the diagonal to the obtuse marginal.,INDICATIONS FOR PROCEDURE: , The patient is a 74-year-old gentleman, who presented with six-month history of progressively worsening exertional angina.  He had a positive stress test and cardiac cath showed severe triple-vessel coronary artery disease including left main disease with preserved LV function.  He was advised surgical revascularization of his coronaries.,FINDINGS DURING THE PROCEDURE:  ,The aorta was free of any significant plaque in the ascending portion at the sites of cannulation and cross clamp.  Left internal mammary artery and saphenous vein grafts were good quality conduits.  Radial artery graft was a smaller sized conduit, otherwise good quality.  All distal targets showed heavy plaque involvement with calcification present.  The smallest target was the PDA, which was about 1.5 mm in size.  All the other targets were about 2 mm in size or greater.  The patient came off cardiopulmonary bypass without any problems.  He was transferred on Neo-Synephrine, nitroglycerin, Precedex drips.  Cross clamp time was 102 minutes, bypass time was 120 minutes.,DETAILS OF THE PROCEDURE:  ,The patient was brought into the operating room and laid supine on the table.  After he had been interfaced with the appropriate monitors, general endotracheal anesthesia was induced and invasive monitoring lines including right IJ triple-lumen catheter and Cordis catheter, right radial A-line, Foley catheter, TEE probes were placed and interfaced appropriately.  The patient was then prepped and draped from chin to bilateral ankles including the left forearm in the usual sterile fashion.  Preoperative checkup of the left forearm has revealed good collateral filling from the ulnar with the radial occluded thus indicating good common arch and thus left radial artery was suitable for harvest.,After prepping and draping the patient from the chin to bilateral ankles including left forearm in the usual sterile fashion, proper time-out was conducted and site identification was performed, and subsequently incision was made overlying the sternum and median sternotomy was performed.  Left internal mammary artery was taken down.  Simultaneously, left forearm radial artery was harvested using endoscopic harvesting techniques.  Simultaneously, endoscopic left leg saphenous vein was harvested using endoscopic minimally invasive techniques.  Subsequent to harvest, the incisions were closed in layers during the course of the procedure.,Heparin was given.  Pericardium was opened and suspended.  During the takedown of the left internal mammary artery, it was noted that the left pleural space was globally softened and left lung was adherent to the chest wall and mediastinum globally.  Only a limited dissection was performed to free up the lung from the mediastinal structures to accommodate the left internal mammary artery.,Pericardium was opened and suspended.  Pursestring sutures were placed.  Aortic and venous as well as antegrade and retrograde cardioplegia cannulation was performed and the patient was placed on cardiopulmonary bypass.  With satisfactory flow, the aorta was cross clamped and the heart was arrested using a combination of antegrade and retrograde cold blood cardioplegia.  An initial dose of about 1500 mL was given and this was followed by intermittent doses given both antegrade and retrograde throughout the procedure to maintain a good arrest and to protect the heart.,PDA was exposed first.  The right coronary artery was calcified along its course all the way to its terminal bifurcation.  Even in the PDA, calcification was noted in a spotty fashion.  Arteriotomy on the PDA was performed in a soft area and 1.5 probe was noted to be accommodated in both directions.  End radial to side PDA anastomosis was constructed using running 7-0 Prolene.  Next, the posterolateral obtuse marginal was exposed.  Arteriotomy was performed.  An end saphenous vein to side obtuse marginal anastomosis was constructed using running 7-0 Prolene.  This graft was then apposed to the diagonal and corresponding arteriotomy and venotomies were performed and a diamond shaped side-to-side anastomosis was constructed using running 7-0 Prolene.  Next, a slit was made in the left side of the pericardium and LIMA was accommodated in the slit on its way to the LAD.  LAD was exposed.  Arteriotomy was performed.  An end LIMA to side LAD anastomosis was constructed using running 7-0 Prolene.  LIMA was tacked down to the epicardium securely utilizing its fascial pedicle.,Two stab incisions were made in the ascending aorta and enlarged using 4-mm punch.  Two proximal anastomosis were constructed between the proximal end of the saphenous vein graft and the side of the aorta, and the proximal end of the radial artery graft and the side of the aorta separately using running 6-0 Prolene.  The patient was given terminal dose of warm retrograde followed by antegrade cardioplegia during which de-airing maneuvers were performed.  Following this, the aortic cross clamp was removed and the heart was noted to resume spontaneous coordinated contractile activity.  Temporary V-pacing wires were placed.  Blake drains were placed in the left chest, the right chest, as well as in the mediastinum.  Left chest Blake drain was placed just in the medial section where dissection had been performed.  After an adequate period of rewarming during which time, temporary V-pacing wires were also placed, the patient was successfully weaned off cardiopulmonary bypass without any problems.  With satisfactory hemodynamics, good LV function on TEE and baseline EKG, heparin was reversed using protamine.  Decannulation was performed after volume resuscitation.  Hemostasis was assured.  Mediastinal and pericardial fat and pericardium were loosely reapproximated in the midline and chest was closed in layers using interrupted stainless steel wires to reappose the two sternal halves, heavy Vicryl for musculofascial closure, and Monocryl for subcuticular skin closure.  Dressings were applied.  The patient was transferred to the ICU in stable condition.  He tolerated the procedure well.  All counts were correct at the termination of the procedure.  Cross clamp time was 102 minutes.  Bypass time was 120 minutes.  The patient was transferred on Neo-Synephrine, nitroglycerin, and Precedex drips.","cardiovascular / pulmonary, radial artery, lima, pda, obtuse marginal, exertional angina, coronary artery disease, triple-vessel, graft, conduit, ij triple-lumen catheter, cordis catheter, a-line, foley catheter, tee probes, coronary artery bypass grafting, cross clamp, mammary artery, saphenous vein, coronary artery, artery, cabg, coronary, grafting, aorta, angina, bypass"
 Patient with significant angina with moderate anteroapical ischemia on nuclear perfusion stress imaging only.  He has been referred for cardiac catheterization., Cardiovascular / Pulmonary, Cardiac Catheterization - 11 ,"The patient and his wife had the opportunity to ask questions, all of which were answered for them and the patient stated in a clear, competent and coherent fashion that he wished to go forward with cardiac catheterization which I felt was appropriate.,PROCEDURE NOTE:  ,The patient was brought to the Cardiac Catheterization Lab in a fasting state.  All appropriate labs had been reviewed.  Bilateral groins were prepped and draped in the usual fashion for sterile conditions.  The appropriate time-out procedure was performed with appropriate identification of the patient, procedure, physician, position and documentation all done under my direct supervision and there were no safety issues raised by the staff.  He received a total of 2 mg of Versed and 50 mcg of Fentanyl utilizing titrated concentration with good effect.  Bilateral groins had been prepped and draped in the usual fashion.  Right femoral inguinal fossa was anesthetized with 1% topical lidocaine and a 6-French vascular sheath was put into place percutaneously via guide-wire exchanger with a finder needle.  All catheters were passed using a J-tipped guide-wire.  Left heart catheterization and left ventriculography performed using a 6-French pigtail catheter.  Left system coronary angiography performed using a 6-French JL4 catheter.  Right system coronary angiography performed using a 6-French CDRC catheter.  Following the procedure, all catheters were removed.  Manual pressure was held with the Neptune pad and the patient was discharged back to his room.  I inspected the femoral arteriotomy site after the procedure was complete and it was benign without evidence of hematoma nor bruit with intact distal pulses.  There were no apparent complications.  A total of 77 cc of Isovue dye and 1.4 minutes of fluoroscopy time were utilized during the case.,FINDINGS:,HEMODYNAMICS: , LV pressure is 120, EDP is 20, aortic pressure 120/62, mean of 82.,LV function is normal, EF 60%, no wall motion abnormalities.,CORONARY ANATOMY:,1.  Left main demonstrates 30-40% distal left main lesion which is tapering, not felt significantly obstructive.,2.  The LAD demonstrates proximal moderate 50% lesion and a severe mid-LAD lesion immediately after the take-off of this large diagonal of 99% which is quite severe with TIMI-3 flow throughout the LAD and the left main.,3.  The left circumflex demonstrates mid-90% severe lesion with TIMI-3 flow.,4.  The right coronary artery was the dominant artery giving rise to right posterior descending artery demonstrates mild luminal irregularity.  There is a moderate distal PDA lesion of 60% seen.,IMPRESSION:,1.  Mild to moderate left main stenosis.,2.  Very severe mid-LAD stenosis with severe mid-left circumflex stenosis and moderate prox-LAD CAD.,We are going to continue the patient's aspirin, beta blocker as heart rate tolerates as he tends to run on the bradycardic side and add statin.  We will check a fasting lipid profile and ALT and titrate statin therapy to keep LDL of 70 mg/deciliter or less but in the past the patient's LDL had been higher or high.","cardiovascular / pulmonary, wall motion abnormalities, cardiac catheterization, mid lad, timi flow, femoral arteriotomy, catheterization, ischemia, angina, distal, stenosis, stress, artery, coronary, lad, cardiac,"
" Coronary artery bypass grafting (CABG) x2, left internal mammary artery to the left anterior descending and reverse saphenous vein graft to the circumflex, St. Jude proximal anastomosis used for vein graft.  Off-pump Medtronic technique for left internal mammary artery, and a BIVAD technique for the circumflex.", Cardiovascular / Pulmonary, CABG - 2 ,"PREOPERATIVE DIAGNOSIS: , Angina and coronary artery disease.,POSTOPERATIVE DIAGNOSIS: , Angina and coronary artery disease.,NAME OF OPERATION: , Coronary artery bypass grafting (CABG) x2, left internal mammary artery to the left anterior descending and reverse saphenous vein graft to the circumflex, St. Jude proximal anastomosis used for vein graft.  Off-pump Medtronic technique for left internal mammary artery, and a BIVAD technique for the circumflex.,ANESTHESIA: , General.,PROCEDURE DETAILS: , The patient was brought to the operating room and placed in the supine position upon the table.  After adequate general anesthesia, the patient was prepped with Betadine soap and solution in the usual sterile manner.  Elbows were protected to avoid ulnar neuropathy, chest wall expansion avoided to avoid ulnar neuropathy, phrenic nerve protectors used to protect the phrenic nerve and removed at the end of the case.,A midline sternal skin incision was made and carried down through the sternum which was divided with the saw.  Pericardial and thymus fat pad was divided.  The left internal mammary artery was harvested and spatulated for anastomosis.  Heparin was given.,Vein resected from the thigh, side branches secured using 4-0 silk and Hemoclips.  The thigh was closed multilayer Vicryl and Dexon technique.  A Pulsavac wash was done, drain was placed.,The left internal mammary artery is sewn to the left anterior descending using 7-0 running Prolene technique with the Medtronic off-pump retractors.  After this was done, the patient was fully heparinized, cannulated with a 6.5 atrial cannula and a 2-stage venous catheter and begun on cardiopulmonary bypass and maintained normothermia.  Medtronic retractors used to expose the circumflex.  Prior to going on pump, we stapled the vein graft in place to the aorta.,Then, on pump, we did the distal anastomosis with a 7-0 running Prolene technique.  The right side graft was brought to the posterior descending artery using running 7-0 Prolene technique.  Deairing procedure was carried out.  The bulldogs were removed.  The patient maintained good normal sinus rhythm with good mean perfusion.  The patient was weaned from cardiopulmonary bypass.  The arterial and venous lines were removed and doubly secured.  Protamine was delivered.  Meticulous hemostasis was present.  Platelets were given for coagulopathy.  Chest tube was placed and meticulous hemostasis was present.  The anatomy and the flow in the grafts was excellent.  Closure was begun.,The sternum was closed with wire, followed by linea alba and pectus fascia closure with running 0 Vicryl sutures in double-layer technique.  The skin was closed with subcuticular 4-0 Dexon suture technique.  The patient tolerated the procedure well and was transferred to the intensive care unit in stable condition.,We minimized the pump time to 16 minutes for just the distal anastomosis of the circumflex in order to lessen the insult to the kidneys as the patient already has kidney failure with a creatinine of 3.0.","cardiovascular / pulmonary, coronary artery disease, angina, coronary artery bypass grafting, internal mammary artery, coronary artery, vein graft, artery, bivad, cabg, medtronic, anastomosis, mammary, vein, circumflex,"
" Coronary artery bypass grafting times three utilizing the left internal mammary artery, left anterior descending and reversed autogenous saphenous vein graft to the posterior descending branch of the right coronary artery and obtuse marginal coronary artery, total cardiopulmonary bypass, cold blood potassium cardioplegia, antegrade and retrograde, for myocardial protection.", Cardiovascular / Pulmonary, CABG ,"TITLE OF PROCEDURE:  ,Coronary artery bypass grafting times three utilizing the left internal mammary artery, left anterior descending and reversed autogenous saphenous vein graft to the posterior descending branch of the right coronary artery and obtuse marginal coronary artery, total cardiopulmonary bypass, cold blood potassium cardioplegia, antegrade and retrograde, for myocardial protection.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room and placed in the supine position.  Adequate general endotracheal anesthesia was induced.  Appropriate monitoring devices were placed.  The chest, abdomen and legs were prepped and draped in the sterile fashion.  The right greater saphenous vein was harvested and prepared by ligating all branches with 4-0 Surgilon and flushed with heparinized blood.  Hemostasis was achieved in the legs and closed with running 2-0 Dexon in the subcutaneous tissue and running 3-0 Dexon subcuticular in the skin.  Median sternotomy incision was made and the left mammary artery was dissected free from its takeoff of the subclavian to its bifurcation at the diaphragm and surrounded with papaverine-soaked gauze.  The pericardium was opened.  The pericardial cradle was created.  The patient was fully heparinized and cannulated with a single aortic and single venous cannula and bypass was instituted.  A retrograde cardioplegic cannula was placed with a pursestring suture of 4-0 Prolene suture in the right atrial wall into the coronary sinus and tied to a Rumel tourniquet.  An antegrade cardioplegic needle sump combination was placed in the ascending aorta and tied in place with 4-0 Prolene.  The ascending aorta was crossclamped.  Cold blood potassium cardioplegia was given to the ascending aorta followed by sumping through the ascending aorta followed by cold retrograde potassium cardioplegia.  The obtuse marginal coronary artery was identified and opened and end-to-side anastomosis was performed to the reversed autogenous saphenous vein with running 7-0 Prolene suture and the vein was cut to length.  Cold antegrade and retrograde cardioplegia were given and the posterior descending branch of the right coronary artery was identified and opened.  End-to-side anastomosis was performed with a running 7-0 Prolene suture and the vein was cut to length.  Cold antegrade and retrograde potassium cardioplegia were given.  The mammary artery was clipped distally, divided and spatulated for anastomosis.  The anterior descending was identified and opened.  End-to-side anastomosis was performed through the left internal mammary artery with running 8-0 Prolene suture.  The mammary pedicle was sutured to the heart with interrupted 5-0 Prolene suture.  A warm antegrade and retrograde cardioplegia were given.  The aortic crossclamp was removed.  The partial occlusion clamp was placed.  Aortotomies were made.  The veins were cut to fit these and sutured in place with running 5-0 Prolene suture.  A partial occlusion clamp was removed.  All anastomoses were inspected and noted to be patent and dry.  Ventricular and atrial pacing wires were placed.  The patient was fully warmed and weaned from cardiopulmonary bypass.  The patient was decannulated in the routine fashion and Protamine was given.  Good hemostasis was noted.  A single mediastinal and left pleural chest tube were placed.  The sternum was closed with interrupted wire, linea alba with running 0 Prolene, the sternal fascia was closed with running 0 Prolene, the subcutaneous tissue with running 2-0 Dexon and the skin with running 3-0 Dexon subcuticular stitch.  The patient tolerated the procedure well.","cardiovascular / pulmonary, cabg, cardioplegia, potassium, cardiopulmonary, coronary artery, marginal, obtuse, myocardial, autogenous, coronary artery bypass grafting, running prolene suture, saphenous vein, ascending aorta, prolene suture, artery, coronary, bypassNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Coronary bypass graft x2 utilizing left internal mammary artery, the left anterior descending, reverse autogenous reverse autogenous saphenous vein graft to the obtuse marginal.  Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.", Cardiovascular / Pulmonary, CABG - 1 ,"PREOPERATIVE DIAGNOSIS: , Coronary occlusive disease.,POSTOPERATIVE DIAGNOSIS: , Coronary occlusive disease.,OPERATION PROCEDURE: , Coronary bypass graft x2 utilizing left internal mammary artery, the left anterior descending, reverse autogenous reverse autogenous saphenous vein graft to the obtuse marginal.  Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.,INDICATION FOR THE PROCEDURE:  ,The patient was a 71-year-old female transferred from an outside facility with the left main, proximal left anterior descending, and proximal circumflex severe coronary occlusive disease, ejection fraction about 40%.,FINDINGS: , The LAD was 2-mm vessel and good, mammary was good, and obtuse marginal was 2-mm vessel and good, and the main was good.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room and placed in the supine position.  Adequate general endotracheal anesthesia was induced.  Appropriate monitoring devices were placed.  The chest, abdomen and legs were prepped and draped in the sterile fashion.  The right greater saphenous vein was harvested and prepared by 2 interrupted skin incisions and by ligating all branches with 4-0 Surgilon and flushed with heparinized blood.  Hemostasis was achieved in the legs and closed with running 2-0 Dexon in the subcutaneous tissue and running 3-0 Dexon subcuticular in the skin.,Median sternotomy incision was made and the left mammary artery was dissected free from its takeoff of the subclavian to its bifurcation at the diaphragm and surrounded with papaverine-soaked gauze.  The pericardium was opened.  The pericardial cradle was created.  The patient was fully heparinized and cannulated with a single aortic and single venous cannula and bypass was instituted.  A retrograde cardioplegic cannula was placed with a pursestring suture of 4-0 Prolene suture in the right atrial wall into the coronary sinus and tied to a Rumel tourniquet.  An antegrade cardioplegic needle sump combination was placed in the ascending aorta and tied in place with 4-0 Prolene.  Cardiopulmonary bypass was instituted and the ascending aorta was crossclamped.  Antegrade cardioplegia was given at a total of 5 mL per kg through the aortic route.  This was followed by something in the aortic route and retrograde cardioplegia through the coronary sinus at a total of 5 mL per kg.  The obtuse marginal coronary was identified and opened.,End-to-side anastomosis was performed with a running 7-0 Prolene suture and the vein was cut to length.  Cold antegrade and retrograde potassium cardioplegia were given.  The mammary artery was clipped distally, divided and spatulated for anastomosis.  The anterior descending was identified and opened.  End-to-side anastomosis was performed with running 8-0 Prolene suture and the warm blood potassium cardioplegia was given antegrade and retrograde and the aortic cross-clamp was removed.  The partial occlusion clamp was placed.  Aortotomies were made.  The veins were cut to fit these and sutured in place with running 5-0 Prolene suture.  A partial occlusion clamp was removed.  All anastomoses were inspected and noted to be patent and dry.  Ventilation was commenced.  The patient was fully warm and the patient was then wean from cardiopulmonary bypass.  The patient was decannulated in routine fashion.  Protamine was given.  Good hemostasis was noted.  A single mediastinal chest tube and bilateral pleural Blake drains were placed.  The sternum was closed with figure-of-eight stainless steel wire plus two 5-mm Mersiline tapes.,The linea alba was closed with figure-of-eight of #1 Vicryl, the sternal fascia closed with running #1 Vicryl, the subcu closed with running 2-0 Dexon, skin with running 4-0 Dexon subcuticular stitch.  The patient tolerated the procedure well.","cardiovascular / pulmonary, coronary occlusive disease, coronary bypass graft, cabg, myocardial, mammary artery, obtuse marginal, cardiopulmonary bypass, potassium cardioplegia, prolene suture, bypass, artery, anastomosis, autogenous, obtuse, marginal, cardiopulmonary, potassium, retrograde, cardioplegia, antegrade, coronary"
 Lumbar osteomyelitis and need for durable central intravenous access.  Placement of left subclavian 4-French Broviac catheter., Cardiovascular / Pulmonary, Broviac Catheter Placement ,"PREOPERATIVE DIAGNOSES:,1.  Lumbar osteomyelitis.,2.  Need for durable central intravenous access.,POSTOPERATIVE DIAGNOSES:,1.  Lumbar osteomyelitis.,2.  Need for durable central intravenous access.,ANESTHESIA:,  General.,PROCEDURE:,  Placement of left subclavian 4-French Broviac catheter.,INDICATIONS:  ,The patient is a toddler admitted with a limp and back pain, who was eventually found on bone scan and septic workup to have probable osteomyelitis of the lumbar spine at disk areas.  The patient needs prolonged IV antibiotic therapy, but attempt at a PICC line failed.  She has exhausted most of her easy peripheral IV access routes and referral was made to the Pediatric Surgery Service for Broviac placement.  I met with the patient's mom.  With the help of a Spanish interpreter, I explained the technique for Broviac placement.  We discussed the surgical risks and alternatives, most of which have been exhausted.  All their questions have been answered, and the patient is fit for operation today.,DESCRIPTION OF OPERATION:  ,The patient came to the operating room and had an uneventful induction of general anesthesia.  We conducted a surgical time-out to reiterate all of the patient's important identifying information and to confirm that we were here to place the Broviac catheter.  Preparation and draping of her skin was performed with chlorhexidine based prep solution and then an infraclavicular approach to left subclavian vein was performed.  A flexible guidewire was inserted into the central location and then a 4-French Broviac catheter was tunneled through the subcutaneous tissues and exiting on the right anterolateral chest wall well below and lateral to the breast and pectoralis major margins.  The catheter was brought to the subclavian insertion site and trimmed so that the tip would lie at the junction of the superior vena cava and right atrium based on fluoroscopic guidelines.  The peel-away sheath was passed over the guidewire and then the 4-French catheter was deployed through the peel-away sheath.  There was easy blood return and fluoroscopic imaging showed initially the catheter had transited across the mediastinum up the opposite subclavian vein, then it was withdrawn and easily replaced in the superior vena cava.  The catheter insertion site was closed with one buried 5-0 Monocryl stitch and the same 5-0 Monocryl was used to tether the catheter at the exit site until fibrous ingrowth of the attached cuff has occurred.  Heparinized saline solution was used to flush the line.  A sterile occlusive dressing was applied, and the line was prepared for immediate use.  The patient was transported to the recovery room in good condition.  There were no intraoperative complications, and her blood loss was between 5 and 10 mL during the line placement portion of the procedure.","cardiovascular / pulmonary, lumbar osteomyelitis, central intravenous access, subclavian, osteomyelitis, broviac catheter, catheter, toddler, intravenous,"
 Flexible Bronchoscopy (pediatric), Cardiovascular / Pulmonary, Bronchoscopy - Pediatric ,"FLEXIBLE BRONCHOSCOPY,The flexible bronchoscopy is performed under conscious sedation in the Pediatric Intensive Care Unit.  I explained to the parents that the possible risks include:  irritation of the nasal mucosa, which can be associated with some bleeding; risk of contamination of the lower airways by passage of the scope in the nasopharynx; respiratory depression from sedation; and a very small risk of pneumothorax.  A bronchoalveolar lavage may be obtained by injecting normal saline in one of the bronchi and suctioning the fluid back.  The sample will then be sent for testing.  The flexible bronchoscopy is mainly diagnostic, any therapeutic intervention, if deemed necessary, will be planned and will require a separate procedure.,The parents seem to understand, had the opportunity to ask questions and were satisfied with the information.  A booklet containing the description of the procedure and other information was provided.","cardiovascular / pulmonary, flexible bronchoscopy, pediatric intensive care unit, bleeding, bronchi, bronchoalveolar lavage, bronchoscopy, conscious sedation, nasal mucosa, nasopharynx, pneumothorax, respiratory, pediatric flexible bronchoscopyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
" Bronchoscopy brushings, washings and biopsies.  Patient with a bilateral infiltrates, immunocompromised host, and pneumonia.", Cardiovascular / Pulmonary, Bronchoscopy Brushings ,"OPERATIVE PROCEDURE:,  Bronchoscopy brushings, washings and biopsies.,HISTORY: , This is a 41-year-old woman admitted to Medical Center with a bilateral pulmonary infiltrate, immunocompromise.,INDICATIONS FOR THE PROCEDURE:,  Bilateral infiltrates, immunocompromised host, and pneumonia.,Prior to procedure, the patient was intubated with 8-French ET tube orally by Anesthesia due to her profound hypoxemia and respiratory distress.,DESCRIPTION OF PROCEDURE: , Under MAC and fluoroscopy, fiberoptic bronchoscope was passed through the ET tube.,ET tube was visualized approximately 2 cm above the carina.  Fiberoptic bronchoscope subsequently was passed through the right lower lobe area and transbronchial biopsies under fluoroscopy were done from the right lower lobe x3 as well as the brushings were obtained and the washings.  The patient tolerated the procedure well.  Postprocedure, the patient is to be placed on a ventilator as well as postprocedure chest x-ray pending.  Specimens are sent for immunocompromise panel including PCP stains.,POSTPROCEDURE DIAGNOSIS:,  Pneumonia, infiltrates.","cardiovascular / pulmonary, mac, fluoroscopy, fiberoptic bronchoscope, bronchoscopy brushings, fiberoptic, bronchoscope, bronchoscopy, biopsies, pneumonia, immunocompromised"
" Bronchoscopy with bronchoalveolar lavage.  Refractory pneumonitis.  A 69-year-old man status post trauma, slightly prolonged respiratory failure status post tracheostomy, requires another bronchoscopy for further evaluation of refractory pneumonitis.", Cardiovascular / Pulmonary, Bronchoscopy & Bronchoalveolar Lavage ,"PREOPERATIVE DIAGNOSIS:,  Refractory pneumonitis.,POSTOPERATIVE DIAGNOSIS: , Refractory pneumonitis.,PROCEDURE PERFORMED: , Bronchoscopy with bronchoalveolar lavage.,ANESTHESIA: , 5 mg of Versed.,INDICATIONS: , A 69-year-old man status post trauma, slightly prolonged respiratory failure status post tracheostomy, requires another bronchoscopy for further evaluation of refractory pneumonitis.,PROCEDURE: , The patient was sedated with 5 mg of Versed that was placed on the endotracheal tube.  Bronchoscope was advanced.  Both right and left mainstem bronchioles and secondary and tertiary bronchioles were cannulated sequentially, lavaged out.  Relatively few tenacious secretions were noted.  These were lavaged out.  Specimen collected for culture.  No obvious other abnormalities were noted.  The patient tolerated the procedure well without complication.","cardiovascular / pulmonary, respiratory failure, bronchoalveolar lavage, refractory pneumonitis, tracheostomy, bronchoalveolar, bronchoscopy, pneumonitis"
" Diagnostic bronchoscopy and limited left thoracotomy with partial pulmonary decortication and insertion of chest tubes x2.  Bilateral bronchopneumonia and empyema of the chest, left.", Cardiovascular / Pulmonary, Bronchoscopy & Thoracotomy ,"PREOPERATIVE DIAGNOSES,1.  Bilateral bronchopneumonia.,2.  Empyema of the chest, left.,POSTOPERATIVE DIAGNOSES,1.  Bilateral bronchopneumonia.,2.  Empyema of the chest, left.,PROCEDURES,1.  Diagnostic bronchoscopy.,2.  Limited left thoracotomy with partial pulmonary decortication and insertion of chest tubes x2.,DESCRIPTION OF PROCEDURE:,  After obtaining an informed consent, the patient was taken to the operating room where a time-out process was followed.  Initially, the patient was intubated with a #6 French tube because of the presence of previous laryngectomy.  Because of this, I proceeded to use a pediatric bronchoscope, which provided limited visualization, but I was able to see the trachea and the carina and both left and right bronchial systems without significant pathology, although there was some mucus secretion that was aspirated.,Then, with the patient properly anesthetized and looking very stable, we decided to insert a larger endotracheal tube that allowed for the insertion of the regular adult bronchoscope.  Therefore, we were able to obtain a better visualization and see the trachea and the carina that were normal and also the left and right bronchial systems.  Some brownish secretions were obtained, particularly from the right side and were sent for culture and sensitivity, both aerobic and anaerobic fungi and acid fast.,Then, the patient was turned with left side up and prepped for a left thoracotomy.  He was properly draped.  I had recently re-inspected the CT of the chest and decided to make a limited thoracotomy of about 6 cm or so in the midaxillary line about the sixth intercostal space.  Immediately, it was evident that there was a large amount of pus in the left chest.  We proceeded to insert the suction catheters and we rapidly obtained about 1400 mL of frank pus.  Then, we proceeded to open the intercostal space a bit more with a Richardson retractor and it was immediately obvious that there was an abundant amount of solid exudate throughout the lung.  We spent several minutes trying to clean up this area.  Initially, I had planned only to drain the empyema because the patient was in a very poor condition, but at this particular moment, he was more stable and well oxygenated, and the situation was such that we were able to perform a partial pulmonary decortication where we broke up a number of loculations that were present and we were able to separate the lung from the diaphragm and also the pulmonary fissure.  On the upper part of the chest, we had limited access, but overall we obtained a large amount of solid exudate and we were able to break out loculations.  We followed by irrigation with 2000 cc of warm normal saline and then insertion of two #32 chest tubes, which are the largest one available in this institution; one we put over the diaphragm and the other one going up and down towards the apex.,The limited thoracotomy was closed with heavy intercostal sutures of Vicryl, then interrupted sutures of #0 Vicryl to the muscle layers, and I loosely approximately the skin with a few sutures of nylon because I am suspicious that the incision may become infected because he has been exposed to intrapleural pus.,The chest tubes were secured with sutures and then connected to Pleur-evac.  Then, the patient was transported.,Estimated blood loss was minimal and the patient tolerated the procedure well.  He was extubated in the operating room and he was transferred to the ICU to be admitted.  A chest x-ray was ordered stat.","cardiovascular / pulmonary, chest tubes, insertion, partial pulmonary decortication, thoracotomy, bronchoscopy, empyema, bronchopneumonia, diagnostic bronchoscopy, pulmonary decortication, bilateral bronchopneumonia, decortication, intercostal, pulmonary, tubes,"
  Plastic piece foreign body in the right main stem bronchus.  Rigid bronchoscopy with foreign body removal., Cardiovascular / Pulmonary, Bronchoscopy & Foreign Body Removal ,"PREOPERATIVE DIAGNOSIS: , Foreign body in airway.,POSTOPERATIVE DIAGNOSIS:,  Plastic piece foreign body in the right main stem bronchus.,PROCEDURE: , Rigid bronchoscopy with foreign body removal.,INDICATIONS FOR PROCEDURE: , This patient is 7-month-old baby boy who presented to emergency room today with increasing stridor and shortness of breath according to mom.  The patient had a chest x-ray and based on that there is concern by the Radiology it could be a foreign body in the right main stem.  The patient has been taken to the operating room for rigid bronchoscopy and foreign body removal.,DESCRIPTION OF PROCEDURE:  ,The patient was taken to the operating room, placed supine, put under general mask anesthesia.  Using a 3.5 rigid bronchoscope we visualized between the cords into the trachea.  There were some secretions but that looked okay.  Got down at the level of the carina to see a foreign body flapping in the right main stem.  I then used graspers to grasp to try to pull into the scope itself.  I could not do that, I thus had to pull the scope out along with the foreign body that was held on to with a grasper.  It appeared to be consisting of some type of plastic piece that had broke off some different object.  I took the scope and put it back down into the airway again.  Again, there was secretion in the trachea that we suctioned out.  We looked down into the right bronchus intermedius.  There was no other pathology noted, just some irritation in the right main stem area.  I looked down the left main stem as well and that looked okay as well.  I then withdrew the scope.  Trachea looked fine as well as the cords.  I put the patient back on mask oxygen to wake the patient up.  The patient tolerated the procedure well.","cardiovascular / pulmonary, main stem bronchus, bronchoscopy, airway, foreign body removal, rigid bronchoscopy, "
 Bronchoscopy for hypoxia and increasing pulmonary secretions, Cardiovascular / Pulmonary, Bronchoscopy - 6 ,"PREOPERATIVE DIAGNOSIS: , Hypoxia and increasing pulmonary secretions.,POSTOPERATIVE DIAGNOSIS: , Hypoxia and increasing pulmonary secretions.,OPERATION: , Bronchoscopy.,ANESTHESIA: , Moderate bedside sedation.,COMPLICATIONS:,  None.,FINDINGS:,  Abundant amount of clear thick secretions throughout the main airways.,INDICATIONS:,  The patient is a 43-year-old gentleman who has been in the ICU for several days following resection of small bowel for sequelae of SMV occlusion.  This morning, the patient developed worsening hypoxia with abundant sputum production requiring frequent suctioning from his ET tube.  The patient also had new-appearing atelectasis versus infiltrates in the right lower lobe of his lung on chest x-ray.  Given these findings, it was felt that bronchoscopy could further define source of secretions and send more appropriate specimen for culture if need be.,OPERATION:,  The patient was given additional fentanyl, Versed as well as paralytics for the procedure.  Small bronchoscope was inserted through the ET tube and to the trachea to the level of carina.  There was noted to be thick clear secretions adherent to the trachea walls as well as into the right mainstem bronchus.  Extensive secretions extended down into the secondary airways.  This was lavaged with saline and suctioned dry.  There is no overt specific occlusion of airways, nor was there any purulent-appearing sputum.  The bronchoscope was then advanced into the left mainstem bronchus, and there was noted to be a small amount of similar-appearing secretions which was likewise suctioned and cleaned.  The bronchoscope was removed, and the patient was increased to PEEP of 10 on the ventilator.  Please note that prior to starting bronchoscopy, he was pre oxygenated with 100% O2.  The patient tolerated the procedure well and lavage specimen was sent for gram stain as well as routine culture.","cardiovascular / pulmonary, pulmonary secretions, bronchoscopy, hypoxia, peep, smv occlusion, atelectasis, bedside sedation, bronchoscope, chest x-ray, mainstem, right lower lobe, mainstem bronchus,"
 Diagnostic fiberoptic bronchoscopy., Cardiovascular / Pulmonary, Bronchoscopy - 7 ,"PROCEDURE:,  Diagnostic fiberoptic bronchoscopy.,ANESTHESIA:  ,  Plain lidocaine 2% was given intrabronchially for local anesthesia.,PREOPERATIVE MEDICATIONS:,  ,1.  Lortab (10 mg) plus Phenergan (25 mg), p.o.  1 hour before the procedure.,2.  Versed a total of 5 mg given IV push during the procedure.,INDICATIONS: ,","cardiovascular / pulmonary, fiberoptic, intrabronchially, larynx, distal trachea, diagnostic fiberoptic bronchoscopy, bronchoscopy, bronchoscope,"
" Rigid bronchoscopy, removal of foreign body, excision of granulation tissue tumor, bronchial dilation , Argon plasma coagulation, placement of a tracheal and bilateral bronchial stents.", Cardiovascular / Pulmonary, Bronchoscopy - 5 ,"PREOPERATIVE DIAGNOSIS:,  Airway stenosis with self-expanding metallic stent complication.,POSTOPERATIVE DIAGNOSIS:,  Airway stenosis with self-expanding metallic stent complication.,PROCEDURES:,1.  Rigid bronchoscopy with removal of foreign body, prolonged procedure taking two hours to remove the stent piecemeal in a very difficult and trying situation.,2.  Excision of granulation tissue tumor.,3.  Bronchial dilation with a balloon bronchoplasty, right main bronchus.,4.  Argon plasma coagulation to control bleeding in the trachea.,5.  Placement of a tracheal and bilateral bronchial stents with a silicon wire stent.,ENDOSCOPIC FINDINGS:,1.  Normal true vocal cords.,2.  Proximal trachea with high-grade occlusion blocking approximately 90% of the trachea due to granulation tissue tumor and break down of metallic stent.,3.  Multiple stent fractures in the mid portion of the trachea with granulation tissue.,4.  High-grade obstruction of the right main bronchus by stent and granulation tissue.,5.  Left main bronchus was covered by the distal portion of the stent and was only being ventilated through the struts of the stent.,6.  All in all a high-grade terrible airway obstruction with involvement of the carina, left and right main stem bronchus, mid, distal, and proximal trachea.,TECHNIQUE IN DETAIL: , After informed consent was obtained from the patient, he was brought into the operating field.  A rapid sequence induction was done.  He was intubated with a rigid scope.  Jet ventilation technique was carried out using a rigid and flexible scope.  A thorough airway inspection was carried out with findings as described above.,Dr. D was present in the operating room and we conferred on operative strategy and agreed that the best of strategy would be to first dilate the right main bronchus, cauterize it to control bleeding and then piecemeal removed the stent from distal to proximal.  This is the technique that was carried out in a painstaking fashion removing bits of the stent piecemeal with finally getting all of the visible stent out of the airway.  It should be noted that Dr. Donovan and I felt that two of the metallic stents were probably in place but we cannot be sure because of the terrible anatomy and the fact that the stent pieces were coming out twisted metal in fragments.  Nevertheless, all the visible stent was removed, and the airway was much better after with the dilation of balloon and the rigid scope.  We took measurements and decided to place stents in the trachea, left and right main bronchus using a Dumon Y-stent.  It was measured 18 mm in tracheal diameter and 14 mm in bronchial diameter.  The right main stem stent was 2.25 cm in length, the left main stem stent was 3 cm in length and the tracheal portion was 9 cm in length.  After it was placed, excellent placement was achieved with the proximal end of the stent 3 cm below the true vocal cords.  The patient tolerated the procedure well and was brought to the recovery room extubated.","cardiovascular / pulmonary, airway, argon plasma coagulation, bronchial dilation, balloon bronchoplasty, bronchoscopy, bronchus, foreign body, granulation, metallic stent, stenosis, vocal cords, granulation tissue tumor, plasma coagulation, granulation tissue, tracheal, argon, stents, bronchial, metallic,"
 Bronchoscopy with aspiration and left upper lobectomy.  Carcinoma of the left upper lobe., Cardiovascular / Pulmonary, Bronchoscopy & Lobectomy ,"PREOPERATIVE DIAGNOSIS:  ,Carcinoma of the left upper lobe.,PROCEDURES PERFORMED:,1.  Bronchoscopy with aspiration.,2.  Left upper lobectomy.,PROCEDURE DETAILS:  ,With patient in supine position under general anesthesia with endotracheal tube in place, the flexible bronchoscope was then placed down through the endotracheal tube to examine the carina.  The carina was in the midline and sharp.  Moving directly to the right side, the right upper and middle lower lobes were examined and found to be free of obstructions.  Aspiration was carried out for backlog ________ examination.  We then moved to left side, left upper lobe.  There was a tumor mass located in the lingula of the left lobe and left lower lobe found free of obstruction.  No anatomic lesions were demonstrated.  The patient was prepared for left thoracotomy rotated to his right side with a double lumen endotracheal tube in place with an NG tube and a Foley catheter.  After proper position, utilizing Betadine solution, they were draped.  A posterolateral left thoracotomy incision was performed.  Hemostasis was secured with electrocoagulation.  The chest wall muscle was then divided over the sixth rib.  The periosteum of the sixth rib was then removed superiorly and the pleural cavity was entered carefully.  At this time, the mass was felt in the left upper lobe, which measures greater than 3 cm by palpation.  We examined the superior mediastinum.  No lymph nodes were demonstrated as well as in the anterior mediastinum.  Direction was then moved to the fascia where by utilizing sharp and blunt dissection, lingual artery was separated into the left upper lobe.  Casual dissection was carried out with superior segmental arteries and left lower lobe was examined.,Dissection was carried out around the pulmonary artery thus exposing the posterior artery to the left upper lobe.  Direction was carried out to the superior pulmonary vein and utilizing sharp and blunt dissection the entire superior pulmonary vein was separated from the surrounding tissue.  From the top side, the bronchus was then separated away from the pulmonary artery anteriorly, thus exposing the apical posterior artery, which was short.  Tumor mass was close to the artery at this time.  We then directed ourselves once again to the lingual artery which was doubly ligated and cut free.  The posterior artery of the superior branch was doubly ligated and cut free also.  At this time, the bronchus of the left upper lobe was encountered in the fissure on palpation to separate the upper lobe bronchus from lower lobe bronchus and the area was accomplished.  We then moved anteriorly to doubly ligate the pulmonary vein using #00 silk sutures for ligation and a transection #00 silk suture was used to fixate the vein.  Using sharp and blunt dissection, the bronchus through the left upper lobe was freed proximal.  Using the TA 50, the bronchus was then cut free allowing the lung to fall superiorly at which time direction was carried out to the pulmonary artery where the tumor was in close proximity at this time.  A Potts clamp arterial was then placed over the artery and shaving off the tumor and the apical posterior artery was then accomplished.  The anterior artery was seen in the clamp also and was separated and ligated and separated.  At this time, the entire tumor in the left upper lobe was then removed.  ,Direction was carried to the suture where #000 silk was used as a running suture over the pulmonary artery and was here doubly run and tied in place.  The clamp was then removed.  No bleeding was seen at this time.  Lymph nodes were then removed from the sump of the separation between the upper lobe and the lower lobe and sent for separate pathology.  We then carried out incision in the inferior pulmonary ligament up to the pulmonary vein allowing the lung to reexpand to its normal position.  At this time, two chest tubes #28 and #32 were placed anteriorly and posteriorly to fixate the skin using raw silk suture.  The chest cavity was then closed.  After reexamination, no bleeding was seen with three pericostal sutures of #1 chromic double strength.  A #2-0 Polydek was then used to close the chest wall muscle the anterior as well as latissimus dorsi #000 chromic subcutaneous tissue skin clips to the skin.  The chest tubes were attached to the Pleur-Evac drainage and placed on suction at this time.  The patient was extubated in the room without difficulty and sent to Recovery in satisfactory.","cardiovascular / pulmonary, ng tube, chest tubes, endotracheal tube, pulmonary vein, artery, aspiration, lobectomy, bronchoscopy, tumor, vein, bronchus, pulmonary,"
" Bronchoscopy with brush biopsies.  Persistent pneumonia, right upper lobe of the lung, possible mass.", Cardiovascular / Pulmonary, Bronchoscopy - 8 ,"PREOPERATIVE DIAGNOSIS: , Persistent pneumonia, right upper lobe of the lung, possible mass.,POSTOPERATIVE DIAGNOSIS: , Persistent pneumonia, right upper lobe of the lung, possible mass.,PROCEDURE:,  Bronchoscopy with brush biopsies.,DESCRIPTION OF PROCEDURE: , After obtaining an informed consent, the patient was taken to the operating room where he underwent a general endotracheal anesthesia.  A time-out process had been followed and then the flexible bronchoscope was inserted through the endotracheal tube after 2 cc of 4% lidocaine had been infused into the endotracheal tube.  First the trachea and the carina had normal appearance.  The scope was passed into the left side and the bronchial system was found to be normal.  There were scars and mucoid secretions.  Then the scope was passed into the right side where brown secretions were obtained and collected in a trap to be sent for culture and sensitivity of aerobic and anaerobic fungi and TB.  First, the basal lobes were explored and found to be normal.  Then, the right upper lobe was selectively cannulated and no abnormalities were found except some secretions were aspirated.  Then, the bronchi going to the three segments were visualized and no abnormalities or mass were found.  Brush biopsy was obtained from one of the segments and sent to Pathology.,The procedure had to be interrupted several times because of the patient's desaturation, but after a few minutes of Ambu bagging, he recovered satisfactorily.,At the end, the patient tolerated the procedure well and was sent to the recovery room in satisfactory condition.,","cardiovascular / pulmonary, persistent pneumonia, bronchoscopy, brush biopsies, endotracheal tube, biopsies, bronchial, abnormalities, pneumonia, secretions, endotracheal, "
 Bronchoscopy for persistent cough productive of sputum requiring repeated courses of oral antibiotics over the last six weeks in a patient who is a recipient of a bone marrow transplant with end-stage chemotherapy and radiation-induced pulmonary fibrosis., Cardiovascular / Pulmonary, Bronchoscopy - 2 ,"INDICATIONS FOR PROCEDURE:,  Persistent cough productive of sputum requiring repeated courses of oral antibiotics over the last six weeks in a patient who is a recipient of a bone marrow transplant with end-stage chemotherapy and radiation-induced pulmonary fibrosis.,PREMEDICATION:,1.  Demerol 50 mg.,2.  Phenergan 25 mg.,3.  Atropine 0.6 mg IM.,4.  Nebulized 4% lidocaine followed by nasal insufflation of lidocaine through the right naris and topical 4% lidocaine gel through the right naris, 4 mg of Versed was given at the start of the procedure and another 1 mg shortly after traversing the cords.,PROCEDURE DETAILS:,  With the patient breathing oxygen by nasal cannula, being monitored by noninvasive blood pressure cuff and continuous pulse oximetry, the Olympus bronchoscope was introduced through the right naris to the level of the cords.  The cords move normally with phonation and ventilation.  Two times 2 mL of 1% lidocaine were instilled on the cords and the cords were traversed.  Further 2 mL of 1% lidocaine was instilled in the trachea just distal to the cords, at mid trachea above the carina, and on the right, and on the left mainstem bronchus.  Scope was then introduced on to the left where immediately some hyperemia of the mucosa was noted.  Upper lobe and lingula were unremarkable.  There appeared to be some narrowing or tenting of the left lower lobe bronchus such that after inspection of the superior segment, one almost had to pop the bronchoscope around to go down the left mainstem.  This had been a change from the prior bronchoscopy of unclear significance.  Distal to this, there was no hyperemia or inspissated mucus or mucoid secretions or signs of infection.  The scope was wedged in the left lower lobe posterior basal segment and a BAL was done with good returns, which were faintly hemorrhagic.  The scope was then removed, re-introduced up to the right upper lobe, middle lobe, superior segment, right lower, anterior lateral, and posterior basal subsegments were all evaluated and unremarkable.  The scope was withdrawn.  The patient's saturation remained 93%-95% throughout the procedure.  Blood pressure was 103/62.  Heart rate at the end of the procedure was about 100.  The patient tolerated the procedure well.  Samples were sent as follows.  Washings for AFB, Gram-stain Nocardia, Aspergillus, and routine culture.  Lavage for AFB, Gram-stain Nocardia, Aspergillus, cell count with differential, cytology, viral mycoplasma, and Chlamydia culture, GMS staining, RSV by antigen, and Legionella and Chlamydia culture.","cardiovascular / pulmonary, cough, bronchoscopy, olympus, bronchoscope, nasal insufflation, oral antibiotics, pulse oximetry, sputum, ventilation, antibiotics, nocardia, aspergillus, chlamydia, atropine, lidocaine, cords, topical,"
" Fiberoptic bronchoscopy with endobronchial biopsies.  A CT scan done of the chest there which demonstrated bilateral hilar adenopathy with extension to the subcarinal space as well as a large 6-cm right hilar mass, consistent with a primary lung carcinoma.", Cardiovascular / Pulmonary, Bronchoscopy - Fiberoptic ,"HISTORY OF PRESENT ILLNESS:,  A 67-year-old gentleman who presented to the emergency room with chest pain, cough, hemoptysis, shortness of breath, and recent 30-pound weight loss.  He had a CT scan done of the chest there which demonstrated bilateral hilar adenopathy with extension to the subcarinal space as well as a large 6-cm right hilar mass, consistent with a primary lung carcinoma.  There was also a question of liver metastases at that time.,OPERATION PERFORMED:,  Fiberoptic bronchoscopy with endobronchial biopsies.,The bronchoscope was passed into the airway and it was noted that there was a large, friable tumor blocking the bronchus intermedius on the right.  The tumor extended into the carina, involving the lingula and the left upper lobe, appearing malignant.  Approximately 15 biopsies were taken of the tumor.,Attention was then directed at the left upper lobe and lingula.  Epinephrine had already been instilled and multiple biopsies were taken of the lingula and the left upper lobe and placed in a separate container for histologic review.  Approximately eight biopsies were taken of the left upper lobe.","cardiovascular / pulmonary, endobronchial, intermedius, fiberoptic bronchoscopy, lung carcinoma, bronchoscopy, fiberoptic, chest, tumor, lobeNOTE"
" Implantation of biventricular automatic implantable cardioverter defibrillator, fluoroscopic guidance for lead implantation for biventricular automatic implantable cardioverter defibrillator, coronary sinus venogram for left ventricular lead placement, and defibrillation threshold testing x2.", Cardiovascular / Pulmonary, Biventricular Cardioverter Defibrillator Implantation ,"REFERRAL INDICATION AND PREPROCEDURE DIAGNOSES,1.  Dilated cardiomyopathy.,2.  Ejection fraction less than 10%.,3.  Ventricular tachycardia.,4.  Bradycardia with likely high degree of pacing.,PROCEDURES PLANNED AND PERFORMED,1.  Implantation of biventricular automatic implantable cardioverter defibrillator.,2.  Fluoroscopic guidance for lead implantation for biventricular automatic implantable cardioverter defibrillator.,3.  Coronary sinus venogram for left ventricular lead placement.,4.  Defibrillation threshold testing x2.,FLUOROSCOPY TIME:  ,18.5 minutes.,MEDICATIONS AT THE TIME OF STUDY,1.  Vancomycin 1 g (the patient was allergic to penicillin).,2.  Versed 10 mg.,3.  Fentanyl 100 mcg.,4.  Benadryl 50 mg.,CLINICAL HISTORY: , The patient is a pleasant 57-year-old gentleman with a dilated cardiomyopathy, an ejection fraction of 10%, been referred for AICD implantation because of his low ejection fraction and a non-sustained ventricular tachycardia.  He has underlying sinus bradycardia.  Therefore, will likely be pacing much of the time and would benefit from a biventricular pacing device.,RISKS AND BENEFITS:,  Risks, benefits, and alternatives to implantation of biventricular AICD and defibrillation threshold testing were discussed with the patient.  Risks including but not limited to bleeding, infection, vascular injury, cardiac perforation, stroke, myocardial infarction, the need for urgent cardiovascular surgery, and death were discussed with the patient.  The patient agreed both verbally and via written consent.,DESCRIPTION OF PROCEDURE: , The patient was transported to the cardiac catheterization laboratory in the fasting state.  The region of the left deltopectoral groove was prepped and draped in the usual sterile manner.  Lidocaine 1% (20 mL) was administered to the area.  After achieving appropriate anesthesia, a percutaneous access of the left axillary vein was performed under fluoroscopy with two separate sticks.  Guidewires were advanced down into the left axillary vein.  Following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath.  Hemostasis was achieved with electrocautery.  Lidocaine 1% (10 mL) was administered to the medial aspect of the incision and a pocket was fashioned in the medial direction.  Using the more lateral of the guidewires, a 7-French side-arm sheath was advanced into the left axillary vein.  The dilator was removed and another wire was advanced down into the sheath.  The sheath was then backed up over the top of the two wires.  One wire was pinned to the drape and using the alternate wire, a 9-French side-arm sheath was advanced down into the left axillary vein.  The dilator and wire were removed.  A defibrillation lead was then advanced down into the atrium.  The peel-away sheath was removed.  The lead was then passed across the tricuspid valve and positioned in the apical septal location.  The active fix screw was deployed.  Adequate pacing and sensing functions were established.  A 10-volt pacing was used temporarily and there was no diaphragmatic stimulation.  The suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue.  Using the wire that had been pinned to the drape, a 7-French side-arm sheath was advanced over this wire into the axillary vein.  The wire and dilator were removed.  An active pacing lead was then advanced down to the right atrium and the peel-away sheath was removed.  The lead was parked until a later time.  Using the separate access point, a 9-French side-arm sheath was advanced into the left axillary vein.  The dilator and wire were removed.  A curved outer sheath catheter as well as an inner catheter were advanced down into the area of the coronary sinus.  The coronary sinus was cannulated.  Inner catheter was removed and a balloon-tipped catheter was advanced into the coronary sinus.  A coronary sinus venogram was then performed.  It was noted that the most suitable location for lead placement was the middle cardiac vein.  This was cannulated and a passive lead was advanced over a Whisper EDS wire into a distal position.  Adequate pacing and sensing functions were established.  A 10-volt pacing was used temporarily.  There was no diaphragmatic stimulation.  The outer sheath was peeled away.  The 9 French sheath was then peeled away.  Suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue.  At this point, the atrial lead was then positioned in the right atrial appendage using a preformed J-curved stylet.  The lead body was turned several times and the lead was affixed to the tissue.  Adequate pacing and sensing function were established.  A suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue.  The pocket was then washed with antibiotic-impregnated saline.  Pulse generator was obtained and connected securely to the leads.  The leads were carefully wrapped behind the pulse generator and the entire system was placed in the pocket.  The pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using a running mattress stitch.  Sponge and needle counts were correct at the end of the procedure and no acute complications were noted.,The patient was sedated further and shock on T was performed on two separate occasions.  The device was allowed to detect the charge and defibrillate, establishing the entire workings of the ICD system.,DEVICE DATA,1.  Pulse generator, manufacturer Boston Scientific, model # N119, serial #12345.,2.  Right atrial lead, manufacturer Guidant, model #4470, serial #12345.,3.  Right ventricular lead, manufacturer Guidant, model #0185, serial #12345.,4.  Left ventricular lead, manufacturer Guidant, model #4549, serial #12345.,MEASURED INTRAOPERATIVE DATA,1.  Right atrial lead impedance 705 ohms.  P-waves measured at 1.7 millivolts.  Pacing threshold 0.5 volt at 0.4 milliseconds.,2.  Right ventricular lead impedance 685 ohms.  R-waves measured 10.5 millivolts.  Pacing threshold 0.6 volt at 0.4 milliseconds.,3.  Left ventricular lead impedance 1098 ohms.  R-waves measured 5.2 millivolts.  Pacing threshold 1.4 volts at 0.4 milliseconds.,DEFIBRILLATION THRESHOLD TESTING,1.  Shock on T.  Charge time 2.9 seconds.  Energy delivered 17 joules, successful with lead impedance of 39 ohms.,2.  Shock on T.  Charge time 2.8 seconds.  Energy delivered 17 joules, successful with a type 2 break lead impedance of 38 ohms.,DEVICE SETTINGS,1.  A pacing DDD 60 to 120.,2.  VT-1 zone 165 beats per minute.  VT-2 zone 185 beats per minute.  VF zone 205 beats per minute.,CONCLUSIONS,1.  Successful implantation of a biventricular automatic implantable cardiovascular defibrillator,2.  Defibrillation threshold of less than or equal to 17.5 joules.,2.  No acute complications.,PLAN,1.  The patient will be taken back to his room for continued observation and dismissed to the discretion of the primary service.,2.  Chest x-ray to rule out pneumothorax and verified lead position.,3.  Device interrogation in the morning.,4.  Completion of the course of antibiotics.",
 Bronchoscopy.  Atelectasis and mucous plugging., Cardiovascular / Pulmonary, Bronchoscopy ,"PREOPERATIVE DIAGNOSIS: , Atelectasis.,POSTOPERATIVE DIAGNOSIS: , Mucous plugging.,PROCEDURE PERFORMED: , Bronchoscopy.,ANESTHESIA: , Lidocaine topical 2%, Versed 3 mg IV.  Conscious sedation.,PROCEDURE: , At bedside, a bronchoscope was passed down the tracheostomy tube under monitoring.  The main carina was visualized.  The trachea was free of any secretions.  The right upper lobe, middle and lower lobes appeared to have some mucoid secretions but minimal and with some erythema.  Left mainstem appeared patent.  Left lower lobe had slight plugging in the left base, but much better that previous bronchoscopy findings.  The area was lavaged with some saline and cleared.  The patient tolerated the procedure well.","cardiovascular / pulmonary, "
 Evaluation of airway for possible bacterial infection performed using bronchoalveolar lavage., Cardiovascular / Pulmonary, Bronchoalveolar lavage. ,"POSTOPERATIVE DIAGNOSIS:  Fever.,PROCEDURES:  Bronchoalveolar lavage.,INDICATIONS FOR PROCEDURE:  The patient is a 28-year-old male, status post abdominal trauma, splenic laceration, and splenectomy performed at the outside hospital, who was admitted to the Trauma Intensive Care Unit on the evening of August 4, 2008.  Greater than 24 hours postoperative, the patient began to run a fever in excess of 102.  Therefore, evaluation of his airway for possible bacterial infection was performed using bronchoalveolar lavage.,DESCRIPTION OF PROCEDURE:  The patient was preoxygenated with 100% FIO2 for approximately 5 to 10 minutes prior to the procedure.  The correct patient and procedure was identified by time out by all members of the team.  The patient was prepped and draped in a sterile fashion and sterile technique was used to connect the BAL lavage catheter to Lukens trap suction.  A catheter was introduced into the endotracheal tube through a T connector and five successive 20 mL aliquots of normal saline were flushed through the catheter, each time suctioning out the sample into the Lukens trap.  A total volume of 30 to 40 mL was collected in the trap and sent to the lab for quantitative bacteriology.  The patient tolerated the procedure well and had no episodes of desaturation, apnea, or cardiac arrhythmia.  A postoperative chest x-ray was obtained.","cardiovascular / pulmonary, abdominal trauma, bal lavage, lukens trap suction, splenectomy, splenic laceration, bronchoalveolar lavage, fever, catheter, bronchoalveolar, lavage, airwayNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
" Bronchiolitis, respiratory syncytial virus positive; improved and stable.  Innocent heart murmur, stable.", Cardiovascular / Pulmonary, Bronchiolitis - Discharge Summary ,"DIAGNOSES:,1.  Bronchiolitis, respiratory syncytial virus positive; improved and stable.,2.  Innocent heart murmur, stable.,HOSPITAL COURSE: , The patient was admitted for an acute onset of congestion.  She was checked for RSV, which was positive and admitted to the hospital for acute bronchiolitis.  She has always been stable on room air; however, because of her age and her early diagnosis, she was admitted for observation as RSV bronchiolitis typically worsens the third and fourth day of illness.  She was treated per pathway orders.  However, on the second day of admission, the patient was not quite eating well and parents live far away and she did have a little bit of trouble on first night of admission.  There was a heart murmur that was heard that sounded innocent, but yet there was no chest x-ray that was obtained.  We did obtain a chest x-ray, which did show a slight perihilar infiltrate in the right upper lobe.  However, the rest of the lungs were normal and the heart was also normal.  There were no complications during her hospitalization and she continued to be stable and eating better.  On day 2 of the admission, it was decided she was okay to go home.  Mother was advised regarding signs and symptoms of increased respiratory distress, which includes tachypnea, increased retractions, grunting, nasal flaring etc. and she was very comfortable looking for this.  During her hospitalization, albuterol MDI was given to the patient and more for mom to learn outpatient care.  The patient did receive a couple of doses, but she did not have any significant respiratory distress and she was discharged in improved condition.,DISCHARGE PHYSICAL EXAMINATION:,VITAL SIGNS:  She is afebrile.  Vital signs were stable within normal limits on room air.,GENERAL:  She is sleeping and in no acute distress.,HEENT:  Her anterior fontanelle was soft and flat.  She does have some upper airway congestion.,CARDIOVASCULAR:  Regular rate and rhythm with a 2-3/6 systolic murmur that radiates to bilateral axilla and the back.,EXTREMITIES:  Her femoral pulses were 2+ and her extremities were warm and well perfused with good capillary refill.,LUNGS:  Her lungs did show some slight coarseness, but good air movement with equal breath sounds.  She does not have any wheezes at this time, but she does have a few scattered crackles at bilateral bases.  She did not have any respiratory distress while she was asleep.,ABDOMEN:  Normal bowel sounds.  Soft and nondistended.,GENITOURINARY:  She is Tanner I female.,DISCHARGE WEIGHT:,  Her weight at discharge 3.346 kg, which is up 6 grams from admission.,DISCHARGE INSTRUCTIONS: , ,ACTIVITY:  No one should smoke near The patient.  She should also avoid all other exposures to smoke such as from fireplaces and barbecues.  She is to avoid contact with other infants since she is sick and they are to limit travel.  There should be frequent hand washings.,DIET:  Regular diet.  Continue breast-feeding as much as possible and encourage oral intake.,MEDICATIONS:  She will be sent home on albuterol MDI to be used as needed for cough, wheezes or dyspnea.,ADDITIONAL INSTRUCTIONS:,  Mom is quite comfortable with bulb suctioning the nose with saline and they know that they are to return immediately if she starts having difficulty breathing, if she stops breathing or she decides that she does not want to eat.,","cardiovascular / pulmonary, bronchiolitis, respiratory syncytial virus, bulb suctioning, innocent heart murmur, chest x ray, syncytial virus, heart murmur, respiratory distress, lungs, "
 Fiberoptic bronchoscopy for diagnosis of right lung atelectasis and extensive mucus plugging in right main stem bronchus., Cardiovascular / Pulmonary, Bronchoscopy - 3 ,"PROCEDURE: , Fiberoptic bronchoscopy.,PREOPERATIVE DIAGNOSIS:,  Right lung atelectasis.,POSTOPERATIVE DIAGNOSIS:,  Extensive mucus plugging in right main stem bronchus.,PROCEDURE IN DETAIL:,  Fiberoptic bronchoscopy was carried out at the bedside in the medical ICU after Versed 0.5 mg intravenously given in 2 aliquots.  The patient was breathing supplemental nasal and mask oxygen throughout the procedure.  Saturations and vital signs remained stable throughout.  A flexible fiberoptic bronchoscope was passed through the right naris.  The vocal cords were visualized.  Secretions in the larynx were as aspirated.  As before, he had a mucocele at the right anterior commissure that did not obstruct the glottic opening.  The ports were anesthetized and the trachea entered.  There was no cough reflex helping explain the propensity to aspiration and mucus plugging.  Tracheal secretions were aspirated.  The main carinae were sharp.  However, there were thick, sticky, grey secretions filling the right mainstem bronchus up to the level of the carina.  This was gradually lavaged clear.  Saline and Mucomyst solution were used to help dislodge remaining plugs.  The airways appeared slightly friable, but were patent after the airways were suctioned.  O2 saturations remained in the mid-to-high 90s.  The patient tolerated the procedure well.  Specimens were submitted for microbiologic examination.  Despite his frail status, he tolerated bronchoscopy quite well.","cardiovascular / pulmonary, bronchoscopy, fiberoptic, mucomyst, atelectasis, bronchoscope, bronchus, carinae, larynx, main stem, mucus, nasal, plugging, trachea, fiberoptic bronchoscopy, mucus plugging, secretionsNOTE"
" Rigid bronchoscopy with dilation, excision of granulation tissue tumor, application of mitomycin-C, endobronchial ultrasound.", Cardiovascular / Pulmonary, Bronchoscopy - 4 ,"PREOPERATIVE DIAGNOSIS:  ,Tracheal stenosis and metal stent complications.,POSTOPERATIVE DIAGNOSIS:  ,Tracheal stenosis and metal stent complications.,ANESTHESIA:  ,General endotracheal.,ENDOSCOPIC FINDINGS:,1.  Normal true vocal cords.,2.  Subglottic stenosis down to 5 mm with mature cicatrix.,3.  Tracheal granulation tissue growing through the stents at the midway point of the stents.,5.  Three metallic stents in place in the proximal trachea.,6.  Distance from the true vocal cords to the proximal stent, 2 cm.,7.  Distance from the proximal stent to the distal stent, 3.5 cm.,8.  Distance from the distal stent to the carina, 8 cm.,9.  Distal airway is clear.,PROCEDURES:,1.  Rigid bronchoscopy with dilation.,2.  Excision of granulation tissue tumor.,3.  Application of mitomycin-C.,4.  Endobronchial ultrasound.,TECHNIQUE IN DETAIL:  ,After informed consent was obtained from the patient and her husband, she was brought to the operating theater after sequence induction was done.  She had a Dedo laryngoscope placed.  Her airways were inspected thoroughly with findings as described above.  She was intermittently ventilated with an endotracheal tube placed through the Dedo scope.  Her granulation tissue was biopsied and then removed with a microdebrider.  Her proximal trachea was dilated with a combination of balloon, Bougie, and rigid scopes.  She tolerated the procedure well, was extubated, and brought to the PACU.","cardiovascular / pulmonary, tracheal stenosis, dedo scope, bronchoscopy, cicatrix, dilation, endotracheal, granulation, metal stent, mitomycin-c, proximal trachea, vocal cords, endobronchial ultrasound, granulation tissue, proximal, tracheal, stent,"
 Bilateral carotid cerebral angiogram and right femoral-popliteal angiogram., Cardiovascular / Pulmonary, Bilateral Carotid Cerebral Angiogram ,"PREOPERATIVE DIAGNOSES:,1.  Carotid artery occlusive disease.,2.  Peripheral vascular disease.,POSTOPERATIVE DIAGNOSES:,1.  Carotid artery occlusive disease.,2.  Peripheral vascular disease.,OPERATIONS PERFORMED:,1.  Bilateral carotid cerebral angiogram.,2.  Right femoral-popliteal angiogram.,FINDINGS: , The right carotid cerebral system was selectively catheterized and visualized.  The right internal carotid artery was found to be very tortuous with kinking in its cervical portions, but no focal stenosis was noted.  Likewise, the intracranial portion of the right internal carotid artery showed no significant disease nor did the right middle cerebral artery.,The left carotid cerebral system was selectively catheterized and visualized.  The cervical portion of the left internal carotid artery showed a 30 to 40% stenosis with small ulcer crater present.  The intracranial portion of the left internal carotid artery showed no significant disease nor did the left middle cerebral artery.,Visualization of the right lower extremity showed no significant disease.,PROCEDURE: , With the patient in supine position under local anesthesia plus intravenous sedation, the groin areas were prepped and draped in a sterile fashion.,The common femoral artery was punctured in a routine retrograde fashion and a 5-French introducer sheath was advanced under fluoroscopic guidance.  A catheter was then placed in the aortic arch and the right and left common carotid arteries were then selectively catheterized and visualized as described above.,Following completion of the above, the catheter and introducer sheath were removed.  Heparin had been initially given, which was reversed with protamine.  Firm pressure was held over the puncture site for 20 minutes, followed by application of a sterile Coverlet dressing and sandbag compression.,The patient tolerated the procedure well throughout.","cardiovascular / pulmonary, femoral-popliteal angiogram, carotid cerebral angiogram, internal carotid artery, carotid artery, angiogram, carotid, cerebral, artery,"
" Bronchoscopy, right upper lobe biopsies and right upper lobe bronchial washing as well as precarinal transbronchial needle aspiration.", Cardiovascular / Pulmonary, Bronchoscopy - 1 ,"PROCEDURE:,  Bronchoscopy, right upper lobe biopsies and right upper lobe bronchial washing as well as precarinal transbronchial needle aspiration.,DETAILS OF THE PROCEDURE: , The risks, alternatives, and benefits of the procedure were explained to the patient as well as conscious sedation and she agrees to proceed.  The patient received topical lidocaine by nebulization.  The flexible fiberoptic bronchoscope was introduced orally.  The patient had normal teeth, normal tongue, normal jaw, and her vocal cords moved symmetrically and were without lesions.  I proceeded to the right upper lobe where a mucous plug was noted in the subsegmental bronchus of the posterior segment of the right upper lobe.  I proceeded under fluoroscopic guidance to guide the biopsy wire in this area and took four biopsies.  Followup fluoroscopy was negative for pneumothorax.  I wedged the bronchoscope in the subsegmental bronchus and achieved good hemostasis after three minutes.,I then proceeded to inspect the rest of the tracheobronchial tree, which was without lesions.  I performed a bronchial washing after the biopsies in the right upper lobe.  I then performed two transbronchial needle aspirations with a Wang needle biopsy in the precarinal area.  All of these samples were sent for histology and cytology respectively.  Estimated blood loss was approximately 5 cc.  Good hemostasis was achieved.  The patient received a total of 12.5 mg of Demerol and 3 mg of Versed and tolerated the procedure well.  Her ASA score was 2.","cardiovascular / pulmonary, bronchoscopy, wang needle, biopsy, bronchial washing, bronchoscope, bronchus, fiberoptic, hemostasis, lidocaine, nebulization, right upper lobe, transbronchial, transbronchial needle aspiration, needle aspiration, transbronchial needle, upper lobe, bronchial, precarinal, biopsies, needle, lobeNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
 2-month-old female - increased work of breathing., Cardiovascular / Pulmonary, Bronchiolitis - 2-month-old ,"CHIEF COMPLAINT: , Increased work of breathing.,HISTORY OF PRESENT ILLNESS: , The patient is a 2-month-old female with a 9-day history of illness.  Per mom's report, the illness started 9 days ago with a dry cough.  The patient was eating normal up until approximately three days ago.  Mom was using a vaporizer at night, which she feels to have helped.  The patient's cough gradually worsened and three days ago, the patient had a significant increasing cough.  At that time, the patient also had significant increasing congestion.  Two days ago the patient was taken to the primary care physician's office and the patient was given Xopenex 2 puffs every 4 to 6 hours for home regimen, but this per mom's report, did not help the patient's symptoms.  On Wednesday evening, the patient's congestion and work of breathing increased and the patient was gagging after feedings.  The patient was brought to Children's Hospital Emergency Room at which time the patient was evaluated.  A chest x-ray was obtained and was noted to be normal.  The patient's saturations were noted to be normal and the patient was discharged home.  Last night, the patient was having multiple episodes of emesis after feedings with coughing and today was noted to have decreasing activity.  The patient had a 101 temperature on Wednesday evening, but has had no true fevers.  The patient has had a mild decrease in urine output today and secondary to the persistent increased work of breathing, coughing, and posttussive emesis, the patient was brought to Children's Hospital for reevaluation.,REVIEW OF SYSTEMS: , The remainder of the review of system is otherwise negative, all systems being reviewed, outside of pertinent positives as stated above.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,MEDICATIONS:  ,As above.,IMMUNIZATIONS:,  None.,PAST MEDICAL HISTORY:  ,No hospitalizations.  No surgeries.,BIRTH HISTORY: , The patient was born to a G8, P2, A6 mom via normal spontaneous vaginal delivery.  Birth weight 6 pounds 12 ounces.  Mom stated she had a uterine infection during her pregnancy and at the time of delivery, but the patient was only in the hospital for 24 hours with mom after delivery.  The patient was full term and mom was noted to have gestational diabetes controlled with diet during her pregnancy.,FAMILY HISTORY: , Brother, mother, and father all have asthma.  Mom was noted to have gestational diabetes.,SOCIAL HISTORY: , The patient lives with mother, father, and a brother.  There is one bird.  There are smokers in the household.  There are sick contacts.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature is 97.7 and pulse is 181, but the patient is fussy.  Respiratory rate ranged between 36 and 44.  The patient is saturating 100% on one-half liter and 89% on room air.,GENERAL APPEARANCE:  Nontoxic child, but with increased work of breathing.  No respiratory distress.,HEENT:  Head is normocephalic and atraumatic.  Anterior fontanelle flat.  Pupils are equal, round, and reactive to light bilaterally.  Tympanic membranes are clear bilaterally.  Nares are congested.  Mucous membranes are moist without erythema.,NECK:  Supple.  No lymphadenopathy.,CHEST:  Exhibits symmetric expansion and retractions.,LUNGS:  The patient has diffuse crackles bilaterally, but no wheezes, rales, or rhonchi.,CARDIOVASCULAR:  Heart has a 2/6 vibratory systolic ejection murmur, best heard over the left sternal boarder.,ABDOMEN:  Soft, nondistended, and nondistended.  Good bowel sounds noted in all 4 quadrants.,GU:  Normal female.  No discharge or erythema.,BACK:  Normal with a normal curvature.,EXTREMITIES:  A 2+ pulses in the bilateral upper lower extremities.  No evidence of clubbing, cyanosis, or edema.  Capillary refill less than 3 seconds.,LABORATORY DATA: , Labs in the emergency room include a CBC, which showed a white blood cell count of 20.8 with a hemoglobin of 10.7, hematocrit of 31.3 with platelet count of 715,000 with 40% neutrophils, 2 bands, and 70% monocytes.  A urinalysis obtained in the emergency room was noted to be negative.  CRP was noted to be 2.0.  The chest x-ray, reviewed by myself in the emergency room, showed no significant change from previous x-ray, but the patient does has some bronchial wall thickening.,ASSESSMENT AND PLAN: , This is a 2-month-old female who presents to Children's Hospital with examination consistent with bronchiolitis.  At this time, the patient will be placed on the bronchiolitis pathway providing this patient with aggressive suctioning and supplemental oxygen as needed.  Currently, at this time, I feel no respiratory treatments are indicated in this patient.  I hear no evidence of wheezing or reactive airway disease.  We will continue to monitor and reassess this patient closely for this as there is a strong family history of reactive airway disease; however, at this time, the patient will be monitored without any medications and the remainder of the clinical course will be determined by her presentation during the course of this illness.",
" The patient is a 5-1/2-year-old with Down syndrome, complex heart disease consisting of atrioventricular septal defect and tetralogy of Fallot with pulmonary atresia, discontinuous pulmonary arteries and bilateral superior vena cava with a left cava draining to the coronary sinus and a right aortic arch. ", Cardiovascular / Pulmonary, Atrioventricular Septal Defect ,"HISTORY:  ,The patient is a 5-1/2-year-old with Down syndrome, complex heart disease consisting of atrioventricular septal defect and tetralogy of Fallot with pulmonary atresia, discontinuous pulmonary arteries and bilateral superior vena cava with a left cava draining to the coronary sinus and a right aortic arch.  As an infant, he was initially palliated with the right and modified Blalock-Taussig shunt in October of 2002 and underwent atrioventricular septal defect and repair of pulmonary artery unifocalization and homograft placement between the right ventricle and unifocalized pulmonary arteries.  He developed a significant branch of pulmonary artery stenosis for which on 07/20/2004, he underwent a bilateral balloon pulmonary arterioplasty and stent implantation at the San Diego at Children's Hospital.  This was followed on 09/13/2007 with replacement of pulmonary valve utilizing a 16-mm Contegra valve.  A recent echocardiogram demonstrated a significant branch of pulmonary artery stenosis with the predicted gradient of 41 to 55 mmHg and a well-functioning Contegra valve.  The lung perfusion scan from 11/14/2007 demonstrated 47% flow to the left lung and 53% flow to the right lung.  The patient underwent a repeat catheterization in consideration for further balloon angioplasty of the branch pulmonary arteries.,PROCEDURE: , After sedation, the patient was placed under general endotracheal anesthesia breathing 50% oxygen throughout the case.  The patient was prepped and draped.  Cardiac catheterization was performed as outlined in the attached continuation sheets.  Vascular entry was by percutaneous technique, and the patient was heparinized.  Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures,Using a 7-French sheath, 6-French wedge catheter was inserted into the right femoral vein and advanced through the right heart structures out to the branch pulmonary arteries.  This catheter was exchanged over wire.  A 5-French marker pigtail catheter was directed into the main pulmonary artery.  A second site of venous access was achieved in and the left femoral vein with the placement of 5-French sheath.,Using a 4-French sheath, a 4-French pigtail catheter was inserted in the right femoral artery and advanced retrograde to the descending aorta, ascending aorta and left ventricle.  Angiogram with injection in the main pulmonary artery demonstrated stable stent configuration of the proximal branch pulmonary arteries with intimal ingrowth in the region of the proximal stents.  The distal right pulmonary measured approximately 10 mm in diameter with a mid stent section measuring 9.4 mm and the proximal stent near the origin of the right pulmonary artery of 5.80 mm.  The distal left pulmonary measured approximately 10 mm in diameter with a mid stent measuring 10.3 mm and the proximal stent near the origin of the left pulmonary artery is 6.8 mm diameter.  The left femoral venous sheath was exchanged over wire for a 7-French sheath.  Guidewires were then advanced through the respective venous sheath into the branch pulmonary arteries and simultaneous balloon pulmonary arterioplasty was performed using the two Z-Med 12 x 4 cm balloon catheter was advanced into the branch of pulmonary arteries and inflated maximally to 9 hemispheres of pressure on 5 occasions near complete disappearance of proximal waist.  The balloon catheter was then exchanged for a 5-French Mistique catheter for pressure pull-back and measurement in the angiogram.  The catheter's wires were then removed and final hemodynamic assessment was made with the wedge catheter.,Flows were calculated by the Fick technique using a measured assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with angiograph injection in the main pulmonary artery.,After angiography, two normal-appearing renal collecting systems were visualized.  The catheters and sheaths were removed and topical pressure applied for hemostasis.  The patient was returned to the recovery room in satisfactory condition.  There were no complications.,DISCUSSION:  ,Oxygen consumption was assumed to be in normal.  Mixed venous saturation that was not normal with no evidence of intracardiac shunt.  Left side of the heart was mildly desaturated following a part to parenchymal lung disease with the partial pressure of oxygen of only 82 mmHg.  Aphasic right atrial pressures were normal with an A-wave similar to the normal right ventricular end-diastolic pressure.  Left ventricular systolic pressure was moderately elevated at 70% of systemic level and there was no obstruction into the proximal main pulmonary artery.  There was a 20 mmHg of peak systolic gradient across the branch pulmonary artery stents to the distal artery.  Right and left pulmonary artery capillary wedge pressures were normal with an A-wave similar to the mildly elevated left ventricular end-diastolic pressure of 13 mmHg.  Left ventricular systolic pressure was systemic.  No outflow constriction to the ascending aorta.  Phasic ascending and descending pressures were similar and normal.  The calculated systemic and pulmonary flows were equal and normal.  Vascular resistances were normal.  Angiogram with injection in the main pulmonary artery showed catheter induced pulmonary insufficiency, well functioning Contegra valve with no appreciable calcification.  The proximal narrowing of the distal main pulmonary artery was appreciated.  Neointimal ingrowth within the proximal stents were appreciated.  There is good distal growth of the pulmonary arteries.  Arborization appeared normal.  Levophase contrast returned to the heart appeared normal with a well-functioning left ventricle and the right aortic arch.  Following the branch pulmonary artery angioplasty that was increased in the mixed venous saturation, as well as an increase in the systemic arterial saturation.  Right ventricular systolic pressure felt slightly to 40 mmHg with an increase in systemic arterial pressure with a systolic pressure ratio of 54%.  The main pulmonary pressures remained similar.  There was 10 mmHg systolic gradient into the branch of pulmonary arteries.  There is an increase in distal branch of pulmonary arteries with the mean pressure increased from 16 mmHg to 21 mmHg.  Final angiogram with injection in the main pulmonary artery showed a competent Contegra valve.  A brisk flow through the proximal branch stents with the improved caliber of the branch pulmonary artery lumens.  There was no evidence of intimal disruption.,DIAGNOSES: ,1.  Atrioventricular septal defect.,2.  Tetralogy of Fallot with the pulmonary atresia.,3.  Bilateral superior vena cava.  The left cava draining to the coronary sinus.,4.  The right aortic arch.,5.  Discontinuous pulmonary arteries.,6.  Down syndrome.,PRIOR SURGERIES AND INTERVENTIONS:  ,1.  Right modified Blalock-Taussig shunt.,2.  Repair of tetralogy of Fallot with external conduit.,3.  The atrioventricular septal defect repair.,4.  Unifocalization of branch pulmonary arteries.,5.  Bilateral balloon pulmonary angioplasty and stent implantation.,6.  Pulmonary valve replacement with 16-mm Contegra valve.,CURRENT DIAGNOSES:  ,1.  Mild-to-moderate proximal branch pulmonary stenosis.,2.  Well-functioning Contegra valve and current intervention.  A balloon dilation of the right pulmonary artery.,3.  Balloon dilation of left pulmonary artery.,MANAGEMENT: , The case will be discussed at Combined Cardiology and Cardiothoracic Surgery Case Conference and conservative outpatient management will be pursued.  Further cardiologic care be directed by Dr. X.",
 A critically ill 67-year-old with multiple medical problems probably still showing signs of volume depletion with hypotension and atrial flutter with difficult to control rate., Cardiovascular / Pulmonary, Atrial Flutter - Progress Note ,"HISTORY OF PRESENT ILLNESS: , Hospitalist followup is required for continuing issues with atrial flutter with rapid ventricular response, which was resistant to treatment with diltiazem and amiodarone, being followed by Dr. X of cardiology through most of the day.  This afternoon, when I am seeing the patient, nursing informs me that rate has finally been controlled with esmolol, but systolic blood pressures have dropped to the 70s with a MAP of 52.  Dr. X was again consulted from the bedside.  We agreed to try fluid boluses and then to consider Neo-Synephrine pressure support if this is not successful.  In addition, over the last 24 hours, extensive discussions have been held with the family and questions answered by nursing staff concerning the patient's possible move to Tahoe Pacific or a long-term acute care.  Other issues requiring following up today are elevated transaminases, continuing fever, pneumonia, resolving adult respiratory distress syndrome, ventilatory-dependent respiratory failure, hypokalemia, non-ST-elevation MI, hypernatremia, chronic obstructive pulmonary disease, BPH, atrial flutter, inferior vena cava filter, and diabetes.,PHYSICAL EXAMINATION,VITAL SIGNS:  T-max 103.2, blood pressure at this point is running in the 70s/mid 40s with a MAP of 52, heart rate is 100.,GENERAL:  The patient is much more alert appearing than my last examination of approximately 3 weeks ago.  He denies any pain, appears to have intact mentation, and is in no apparent distress.,EYES:  Pupils round, reactive to light, anicteric with external ocular motions intact.,CARDIOVASCULAR:  Reveals an irregularly irregular rhythm.,LUNGS:  Have diminished breath sounds but are clear anteriorly.,ABDOMEN:  Somewhat distended but with no guarding, rebound, or obvious tenderness to palpation.,EXTREMITIES:  Show trace edema with no clubbing or cyanosis.,NEUROLOGICAL:  The patient is moving all extremities without focal neurological deficits.,LABORATORY DATA: , Sodium 149; this is down from 151 yesterday.  Potassium 3.9, chloride 114, bicarb 25, BUN 35, creatinine 1.5 up from 1.2 yesterday, hemoglobin 12.4, hematocrit 36.3, WBC 16.5, platelets 231,000.  INR 1.4.  Transaminases are continuing to trend upwards of SGOT 546, SGPT 256.  Also noted is a scant amount of very concentrated appearing urine in the bag.,IMPRESSION: , Overall impressions continues to be critically ill 67-year-old with multiple medical problems probably still showing signs of volume depletion with hypotension and atrial flutter with difficult to control rate.,PLAN,1.  Hypotension.  I would aggressively try and fluid replete the patient giving him another liter of fluids.  If this does not work as discussed with Dr. X, we will start some Neo-Synephrine, but also continue with aggressive fluid repletion as I do think that indications are that with diminished and concentrated urine that he may still be down and fluids will still be required even if pressure support is started.,2.  Increased transaminases.  Presumably this is from increased congestion.  This is certainly concerning.  We will continue to follow this.  Ultrasound of the liver was apparently negative.,3.  Fever and elevated white count.  The patient does have a history of pneumonia and empyema.  We will continue current antibiotics per infectious disease and continue to follow the patient's white count.  He is not exceptionally toxic appearing at this time.  Indeed, he does look improved from my last examination.,4.  Ventilatory-dependent respiratory failure.  The patient has received a tracheostomy since my last examination.  Vent management per PMA.,5.  Hypokalemia.  This has resolved.  Continue supplementation.,6.  Hypernatremia.  This is improving somewhat.  I am hoping that with increased fluids this will continue to do so.,7.  Diabetes mellitus.  Fingerstick blood glucoses are reviewed and are at target.  We will continue current management.  This is a critically ill patient with multiorgan dysfunction and signs of worsening renal, hepatic, and cardiovascular function with extremely guarded prognosis.  Total critical care time spent today 37 minutes.","cardiovascular / pulmonary, rapid ventricular response, volume depletion, atrial flutter, atrial, hypotension, flutter, "
" The patient is a very pleasant 62-year-old African American female with a history of hypertension, hypercholesterolemia, and CVA, referred for evaluation and management of atrial fibrillation.", Cardiovascular / Pulmonary, Atrial Fibrillation Management ,"REASON FOR CONSULTATION: , Atrial fibrillation management.,HISTORY OF PRESENT ILLNESS: ,The patient is a very pleasant 62-year-old African American female with a history of hypertension, hypercholesterolemia, and CVA, referred by Dr. X for evaluation and management of atrial fibrillation.  The patient states that on Monday during routine Holt exam, it was detected by Dr. X that her heart was irregular on exam.  EKG obtained after that revealed atrial fibrillation, and subsequently the patient was started on Coumadin as well as having Toprol and referred for evaluation.  The patient states that for the last 3 years, she has had episodes of her heart racing.  It may last for minutes up to most 1 hour, and it will occasionally be related to eating a heavy meal or her caffeine or chocolate intake.  Denies dyspnea, diaphoresis, presyncope or syncope with the events, and she has had no episodes of chest pain.  They subsequently resolve on their own and do not limit her in anyway.  However, she states that for the last several years may be up to 7 years that she can recollect that she has been fatigued, and over the past couple of years, her symptoms have become more severe.  She said she can walk no more than 25 feet without becoming tired.  She states that she has to rest then her symptoms will go away, but she has been limited from that standpoint.  Denies peripheral edema, PND, orthopnea, abdominal pain, swelling, recent fever or chills.  She actually today has no complaints, and states that she has been compliant with her medications and has started taking her Coumadin as directed.,PAST MEDICAL HISTORY:,1.  Hypertension.,2.  Myocardial infarction in 2003.,3.  Left heart catheterization at University Hospital.,4.  Hypercholesterolemia.,5.  Arthritis.,6.  CVA in 2002 and in 2003 with right eye blindness.,PAST SURGICAL HISTORY:,1.  Left total knee replacement in 2002.,2.  Left lower quadrant abscess drainage in 12/07,FAMILY MEDICAL HISTORY: , Significant for lung and brain cancer.  There is no history that she is aware of cardiovascular disease in her family nor has any family member had sudden cardiac death.,SOCIAL HISTORY: , She is retired as a cook in a school cafeteria, where she worked for 34 years.  She retired 7 years ago because of low back pain.  She used to smoke 2-1/2 packs per day for 32 years, but quit in 1995.  Denies alcohol, and denies IV or illicit drug use.,ALLERGIES: , No known drug allergies.,MEDICATIONS:,1.  Coumadin 5 mg a day.,2.  Toprol-XL 50 mg a day.,3.  Aspirin 81 mg a day.,4.  Hydrochlorothiazide 25 mg a day.,5.  Plendil 10 mg daily.,6.  Lipitor 40 mg daily.,REVIEW OF SYSTEMS:  ,As above stating that following her stroke, she has right eye blindness, but she does have some minimal vision in her periphery.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure 138/66, pulse 96, and weight 229 pounds or 104 kg.  GENERAL:  A well-developed, well-nourished, middle-aged African American female in no acute distress.  NECK:  Supple.  No JVD.  No carotid bruits.  CARDIOVASCULAR:  Irregularly irregular rate and rhythm.  Normal S1 and S2.  No murmurs, gallops or rubs.  LUNGS:  Clear to auscultation bilaterally.  ABDOMEN:  Bowel sounds positive, soft, nontender, and nondistended.  No masses.  EXTREMITIES:  No clubbing, cyanosis or edema.  Pulses 2+ bilaterally.,LABORATORY DATA: , EKG today revealed atrial fibrillation with nonspecific lateral T-wave abnormalities and a rate of 94.,IMPRESSION:  ,The patient is a very pleasant 62-year-old African American female with atrial fibrillation of unknown duration with symptoms of paroxysmal episodes of palpitations, doing well today.,RECOMMENDATIONS:,1.  Her rate is suboptimally controlled, we will increase her Toprol-XL to 75 mg per day.,2.  We will obtain a transthoracic echocardiogram to evaluate her LV function as well as her valvular function.,3.  We will check a thyroid function panel.,4.  We will continue Coumadin as directed and to follow up with Dr. X for INR management.,5.  Given the patient's history of a stroke in her age and recurrent atrial fibrillation, the patient should be continued on Coumadin indefinitely.,6.  Depending upon the results of her transthoracic echocardiogram, the patient may benefit from repeat heart catheterization.  We will await results of transthoracic echocardiogram.,7.  We will arrange for the patient to wear a Holter monitor to monitor the rate controlled on a 24-hour period.  She will then return to the electrophysiology clinic in 1 month for followup visit with Dr. Y.,The patient was seen, discussed, and examined with Dr. Y in electrophysiology.",
" Ash split venous port insertion. The right anterior chest and supraclavicular fossa area, neck, and left side of chest were prepped with Betadine and draped in a sterile fashion.", Cardiovascular / Pulmonary, Ash Split Venous Port ,"ASH SPLIT VENOUS PORT,PROCEDURE DETAILS:  ,The patient was taken to the operating room and placed in supine position and monitored anesthesia care provided by the anesthetist.  The right anterior chest and supraclavicular fossa area, neck, and left side of chest were prepped with Betadine and draped in a sterile fashion.  Xylocaine 1% was infiltrated in the supraclavicular area and anterior chest along the planned course of the catheter.  The patient was placed into Trendelenburg position.,The right internal jugular vein was accessed by a supraclavicular 19-gauge, thin-walled needle as demonstrated by easy withdrawal of venous blood on the first pass of the needle.  Under fluoroscopic control, a J-wire was advanced into the right atrium.  The needle was removed and the skin puncture site enlarged to about 8 mm with the scalpel.  A second incision was made 5 cm inferior to the right midclavicular line, through which an Ash split catheter was advanced, using the tunneling rod, in a gently curving pass to exit the skin of the neck incision.  The tunneling needle was removed and the catheter split up to the marker as indicated in the recommended use of the catheter.,Sequential dilators were advanced over the J-wire under fluoroscopic control to dilate the subcutaneous tunnel followed by advancement of a dilator and sheath into the right superior vena cava under fluoroscopic control.  The dilator and wire were removed, leaving the sheath in position, through which a double-lumen catheter was advanced into the central venous system.  The sheath was peeled away, leaving the catheter into position.  Each port of the catheter was flushed with dilute heparinized saline.,The patient was returned to the flat position.  The catheter was secured to the skin of the anterior chest using 2-0 Ethilon suture placed through the suture ""wings."",The neck incision was closed with 3-0 Vicryl subcuticular closure and pressure dressing applied.  Fluoroscopic examination of the chest revealed no evidence of pneumothorax upon completion of the procedure and the catheter was in excellent position.,The patient was returned to the recovery room for postoperative care.","cardiovascular / pulmonary, ash split venous port, venous port, anterior chest, incision, dilators, sheath, port, supraclavicular, needle, fluoroscopic, venous, insertion, catheter"
 Carotid artery angiograms., Cardiovascular / Pulmonary, Bilateral Carotid Angiography ,"PROCEDURE PERFORMED:,1.  Selective ascending aortic arch angiogram.,2.  Selective left common carotid artery angiogram.,3.  Selective right common carotid artery angiogram.,4.  Selective left subclavian artery angiogram.,5.  Right iliac angio with runoff.,6.  Bilateral cerebral angiograms were performed as well via right and left common carotid artery injections.,INDICATIONS FOR PROCEDURE: , TIA, aortic stenosis, postoperative procedure.  Moderate carotid artery stenosis.,ESTIMATED BLOOD LOSS:,  400 ml.,SPECIMENS REMOVED:,  Not applicable.,TECHNIQUE OF PROCEDURE: , After obtaining informed consent, the patient was brought to the cardiac catheterization suite in postabsorptive and nonsedated state.  The right groin was prepped and draped in the usual sterile fashion.  Lidocaine 2% was used for infiltration anesthesia.  Using modified Seldinger technique, a 6-French sheath was placed into the right common femoral artery and vein without complication.  Using injection through the side port of the sheath, a right iliac angiogram with runoff was performed.  Following this, straight pigtail catheter was used to advance the aortic arch and aortic arch angiogram under digital subtraction was performed.  Following this, selective engagement in left common carotid artery, right common carotid artery, and left subclavian artery angiograms were performed with a V-Tech catheter over an 0.035-inch wire.,ANGIOGRAPHIC FINDINGS:,1.  Type 2 aortic arch.,2.  Left subclavian artery was patent.,3 Left vertebral artery was patent.,4.  Left internal carotid artery had a 40% to 50% lesion with ulceration, not treated and there was no cerebral cross over.,5.  Right common carotid artery had a 60% to 70% lesion which was heavily calcified and was not treated with the summed left-to-right cross over flow.,6.  Closure was with a 6-French Angio-Seal of the artery, and the venous sheath was sutured in.,PLAN:,  Continue aspirin, Plavix, and Coumadin to an INR of 2 with a carotid duplex followup.","cardiovascular / pulmonary, aortic arch angiogram, carotid artery angiogram, artery was patent, common carotid artery, arch angiogram, subclavian artery, aortic arch, carotid artery, carotid, angiography, artery, angiograms, subclavian, catheterization, aortic, angiogram, "
" Atrial fibrillation with rapid ventricular response, Wolff-Parkinson White Syndrome, recent aortic valve replacement with bioprosthetic Medtronic valve, and hyperlipidemia.", Cardiovascular / Pulmonary, Atrial Fibrillation - SOAP ,"SUBJECTIVE: , The patient states that she feels better.  She is on IV amiodarone, the dosage pattern is appropriate for ventricular tachycardia.  Researching the available records, I find only an EMS verbal statement that tachycardia of wide complex was seen.  There is no strip for me to review all available EKG tracings show a narrow complex atrial fibrillation pattern that is now converted to sinus rhythm.,The patient states that for a week, she has been home postoperative from aortic valve replacement on 12/01/08 at ABC Medical Center.  The aortic stenosis was secondary to a congenital bicuspid valve, by her description.  She states that her shortness of breath with exertion has been stable, but has yet to improve from its preoperative condition.  She has not had any decline in her postoperative period of her tolerance to exertion.,The patient had noted intermittent bursts of fast heart rate at home that had been increasing over the last several days.  Last night, she had a prolonged episode for which she contacted EMS.  Her medications at home had been uninterrupted and without change from those listed, being Toprol-XL 100 mg q.a.m., Dyazide 25/37.5 mg, Nexium 40 mg, all taken once a day.  She has been maintaining her Crestor and Zetia at 20 and 10 mg respectively.  She states that she has been taking her aspirin at 325 mg q.a.m.  She remains on Zyrtec 10 mg q.a.m.  Her only allergy is listed to latex.,OBJECTIVE:,VITAL SIGNS:  Temperature 36.1, heart rate 60, respirations 14, room air saturation 98%, and blood pressure 108/60.  The patient shows a normal sinus rhythm on the telemetry monitor with an occasional PAC.,GENERAL:  She is alert and in no apparent distress.,HEENT:  Eyes:  EOMI.  PERRLA.  Sclerae nonicteric.  No lesions of lids, lashes, brows, or conjunctivae noted.  Funduscopic examination unremarkable.  Ears:  Normal set, shape, TMs, canals and hearing.  Nose and Sinuses:  Negative.  Mouth, Tongue, Teeth, and Throat:  Negative except for dental work.,NECK:  Supple and pain free without bruit, JVD, adenopathy or thyroid abnormality.,CHEST:  Lungs are clear bilaterally to auscultation.  The incision is well healed and without evidence of significant cellulitis.,HEART:  Shows a regular rate and rhythm without murmur, gallop, heave, click, thrill or rub.  There is an occasional extra beat noted, which corresponds to a premature atrial contraction on the monitor.,ABDOMEN:  Soft and benign without hepatosplenomegaly, rebound, rigidity or guarding.,EXTREMITIES:  Show no evidence of DVT, acute arthritis, cellulitis or pedal edema.,NEUROLOGIC:  Nonfocal without lateralizing findings for cranial or peripheral nervous systems, strength, sensation, and cerebellar function.  Gait and station were not tested.,MENTAL STATUS:  Shows the patient to be alert, coherent with full capacity for decision making.,BACK:  Negative to inspection or percussion.,LABORATORY DATA: , Shows from 12/15/08 2100, hemoglobin 11.6, white count 12.9, and platelets 126,000.  INR 1.0.  Electrolytes are normal with exception potassium 3.3.  GFR is decreased at 50 with creatinine of 1.1.  Glucose was 119.  Magnesium was 2.3.  Phosphorus 3.8.  Calcium was slightly low at 7.8.  The patient has had ionized calcium checked at Munson that was normal at 4.5 prior to her discharge.  Troponin is negative x2 from 2100 and repeat at 07:32.  This morning, her BNP was 163 at admission.  Her admission chest x-ray was unremarkable and did not show evidence of cardiomegaly to suggest pericardial effusion.  Her current EKG tracing from 05:42 shows a sinus bradycardia with Wolff-Parkinson White Pattern, a rate of 58 beats per minute, and a corrected QT interval of 557 milliseconds.  Her PR interval was 0.12.,We received a call from Munson Medical Center that a bed had been arranged for the patient.  I contacted Dr. Varner and we reviewed the patient's managed to this point.  All combined impression is that the patient was likely to not have had actual ventricular tachycardia.  This is based on her EP study from October showing her to be non-inducible.  In addition, she had a cardiac catheterization that showed no evidence of coronary artery disease.  What is most likely that the patient has postoperative atrial fibrillation.  Her WPW may have degenerated into a ventricular tachycardia, but this is unlikely.  At this point, we will convert the patient from IV amiodarone to oral amiodarone and obtain an echocardiogram to verify that she does not have evidence of pericardial effusion in the postoperative period.  I will recheck her potassium, magnesium, calcium, and phosphorus at this point and make adjustments if indicated.  Dr. Varner will be making arrangements for an outpatient Holter monitor and further followup post-discharge.,IMPRESSION:,1.  Atrial fibrillation with rapid ventricular response.,2.  Wolff-Parkinson White Syndrome.,3.  Recent aortic valve replacement with bioprosthetic Medtronic valve.,4.  Hyperlipidemia.","cardiovascular / pulmonary, ventricular tachycardia, wolff-parkinson white syndrome., ventricular response, medtronic valve, wolff parkinson white syndrome, aortic valve replacement, atrial fibrillation, atrial, aortic, tachycardia, fibrillation, ventricular, valve, medtronic, "
" Aortogram with bilateral, segmental lower extremity run off.  Left leg claudication.  The patient presents with lower extremity claudication. ", Cardiovascular / Pulmonary, Aortogram - Leg claudication. ,"PREPROCEDURE DIAGNOSIS:,  Left leg claudication.,POSTPROCEDURE DIAGNOSIS: ,  Left leg claudication.,OPERATION PERFORMED: , Aortogram with bilateral, segmental lower extremity run off.,ANESTHESIA: , Conscious sedation.,INDICATION FOR PROCEDURE:  ,The patient presents with lower extremity claudication.  She is a 68-year-old woman, who is very fearful of the aforementioned procedures.  Risks and benefits of the procedure were explained to her to include bleeding, infection, arterial trauma requiring surgery, access issues and recurrence.  She appears to understand and agrees to proceed.,DESCRIPTION OF PROCEDURE: , The patient was taken to the Angio Suite, placed in a supine position.  After adequate conscious sedation, both groins were prepped with Chloraseptic prep.  Cloth towels and paper drapes were placed.  Local anesthesia was administered in the common femoral artery and using ultrasound guidance, the common femoral artery was accessed.  Guidewire was threaded followed by a ,4-French sheath.  Through the 4-French sheath a 4-French Omni flush catheter was placed.  The glidewire was removed and contrast administered to identify the level of the renal artery.  Using power injector an aortogram proceeded.,The catheter was then pulled down to the aortic bifurcation.  A timed run-off view of both legs was performed and due to a very abnormal and delayed run-off in the left, I opted to perform an angiogram of the left lower extremity with an isolated approach.  The catheter was pulled down to the aortic bifurcation and using a glidewire, I obtained access to the contralateral left external iliac artery.  The Omni flush catheter was advanced to the left distal external iliac artery.  The glidewire rather exchanged for an Amplatz stiff wire.  This was left in place and the 4-French sheath removed and replaced with a 6-French destination 45-cm sheath.  This was advanced into the proximal superficial femoral artery and an angiogram performed.  I identified a functionally occluded distal superficial femoral artery and after obtaining views of the run off made plans for angioplasty.,The patient was given 5000 units of heparin and this was allowed to circulate.  A glidewire was carefully advanced using Roadmapping techniques through the functionally occluded blood vessels.  A 4-mm x 4-cm angioplasty balloon was used to dilate the area in question.,Final views after dilatation revealed a dissection.  A search for a 5-mm stent was performed, but none of this was available.  For this reason, I used a 6-mm x 80-mm marked stent and placed this at the distal superficial femoral artery.  Post dilatation was performed with a 4-mm angioplasty balloon.  Further views of the left lower extremity showed irregular change in the popliteal artery.  No significant stenosis could be identified in the left popliteal artery and noninvasive scan.  For this reason, I chose not to treat any further areas in the left leg.,I then performed closure of the right femoral artery with a 6-French Angio-Seal device.  Attention was turned to the left femoral artery and local anesthesia administered.  Access was obtained with the ultrasound and the femoral artery identified.  Guidewire was threaded followed by a 4-French sheath.  This was immediately exchanged for the 6-French destination sheath after the glidewire was used to access the distal external iliac artery.  The glidewire was exchanged for the Amplatz stiff wire to place the destination sheath.  The destination was placed in the proximal superficial femoral artery and angiogram obtained.  Initial views had been obtained from the right femoral sheath before removal.,Views of the right superficial femoral artery demonstrated significant stenosis with accelerated velocities in the popliteal and superficial femoral artery.  For this reason, I performed the angioplasty of the superficial femoral artery using the 4-mm balloon.  A minimal dissection plane measuring less than 1 cm was identified at the proximal area of dilatation.  No further significant abnormality was identified.  To avoid placing a stent in the small vessel I left it alone and approached the popliteal artery.  A 3-mm balloon was chosen to dilate a 50 to 79% popliteal artery stenosis.  Reasonable use were obtained and possibly a 4-mm balloon could have been used.  However, due to her propensity for dissection I opted not to.  I then exchanged the glidewire for an O1 for Thruway guidewire using an exchange length.  This was placed into the left posterior tibial artery.  A 2-mm balloon was used to dilate the orifice of the posterior tibial artery.  I then moved the wire to the perineal artery and dilated the proximal aspect of this vessel.  Final images showed improved run-off to the right calf.  The destination sheath was pulled back into the left external iliac artery and an Angio-Seal deployed.,FINDINGS: , Aortogram demonstrates a dual right renal artery with the inferior renal artery supplying the lower one third of the right renal parenchyma.  No evidence of renal artery stenosis is noted bilaterally.  There is a single left renal artery.  The infrarenal aorta, both common iliac and the external iliac arteries are normal.  On the right, a superficial femoral artery is widely patent and normal proximally.  At the distal third of the thigh there is diffuse disease with moderate stenosis noted.  Moderate stenosis is also noted in the popliteal artery and single vessel run-off through the posterior tibial artery is noted.  The perineal artery is functionally occluded at the midcalf.  The dorsal pedal artery filled by collateral at the high ankle level.,On the left, the proximal superficial femoral artery is patent.  Again, at the distal third of the thigh, there is a functional occlusion of the superficial femoral artery with poor collateralization to the high popliteal artery.  This was successfully treated with angioplasty and a stent placement.  The popliteal artery is diffusely diseased without focal stenosis.  The tibioperoneal trunk is patent and the anterior tibial artery occluded at its orifice.,IMPRESSION,1.  Normal bilateral renal arteries with a small accessory right renal artery.,2.  Normal infrarenal aorta as well as normal bilateral common and external iliac arteries.,3.  The proximal right renal artery is normal with moderately severe stenosis in the superficial femoral popliteal and tibial arteries.  Successful angioplasty with reasonable results in the distal superficial femoral, popliteal and proximal posterior tibial artery as described.,4.  Normal proximal left superficial femoral artery with functional occlusion of the distal left superficial femoral artery successfully treated with angioplasty and stent placement.  Run-off to the left lower extremity is via a patent perineal and posterior tibial artery.","cardiovascular / pulmonary, claudication, extremity run off, angio suite, superficial femoral artery, popliteal, superficial, femoral, aortogram, artery, balloon, glidewire, angioplasty, stenosis, renal, "
 Aortic valve replacement using a mechanical valve and two-vessel coronary artery bypass grafting procedure using saphenous vein graft to the first obtuse marginal artery and left radial artery graft to the left anterior descending artery., Cardiovascular / Pulmonary, Aortic Valve Replacement ,"DIAGNOSIS: , Aortic valve stenosis with coronary artery disease associated with congestive heart failure.  The patient has diabetes and is morbidly obese.,PROCEDURES: , Aortic valve replacement using a mechanical valve and two-vessel coronary artery bypass grafting procedure using saphenous vein graft to the first obtuse marginal artery and left radial artery graft to the left anterior descending artery.,ANESTHESIA: , General endotracheal,INCISION: , Median sternotomy,INDICATIONS: , The patient presented with severe congestive heart failure associated with the patient's severe diabetes.  The patient was found to have moderately stenotic aortic valve.  In addition, The patient had significant coronary artery disease consisting of a chronically occluded right coronary artery but a very important large obtuse marginal artery coming off as the main circumflex system.  The patient also has a left anterior descending artery which has moderate disease and this supplies quite a bit of collateral to the patient's right system.  It was decided to perform a valve replacement as well as coronary artery bypass grafting procedure.,FINDINGS: , The left ventricle is certainly hypertrophied· The aortic valve leaflet is calcified and a severe restrictive leaflet motion.  It is a tricuspid type of valve.  The coronary artery consists of a large left anterior descending artery which is associated with 60% stenosis but a large obtuse marginal artery which has a tight proximal stenosis.,The radial artery was used for the left anterior descending artery.  Flow was excellent.  Looking at the targets in the posterior descending artery territory, there did not appear to be any large branches.  On the angiogram these vessels appeared to be quite small.  Because this is a chronically occluded vessel and the patient has limited conduit due to the patient's massive obesity, attempt to bypass to this area was not undertaken.  The patient was brought to the operating room,PROCEDURE: , The patient was brought to the operating room and placed in supine position.  A median sternotomy incision was carried out and conduits were taken from the left arm as well as the right thigh.  The patient weighs nearly three hundred pounds.  There was concern as to taking down the left internal mammary artery.  Because the radial artery appeared to be a good conduit The patient would have arterial graft to the left anterior descending artery territory.  The patient was cannulated after the aorta and atrium were exposed and full heparinization.,The patient went on cardiopulmonary bypass and the aortic cross-clamp was applied Cardioplegia was delivered through the coronary sinuses in a retrograde manner.  The patient was cooled to 32 degrees.  Iced slush was applied to the heart.  The aortic valve was then exposed through the aortic root by transverse incision.  The valve leaflets were removed and the #23 St. Jude mechanical valve was secured into position by circumferential pledgeted sutures.  At this point, aortotomy was closed.,The first obtuse marginal artery was a very large target and the vein graft to this target indeed produced an excellent amount of flow.  Proximal anastomosis was then carried out to the foot of the aorta.  The left anterior descending artery does not have severe disease but is also a very good target and the radial artery was anastomosed to this target in an end-to-side manner.  The two proximal anastomoses were then carried out to the root of the aorta.,The patient came off cardiopulmonary bypass after aortic cross-clamp was released.  The patient was adequately warmed.  Protamine was given without adverse effect.  Sternal closure was then done using wires.  The subcutaneous layers were closed using Vicryl suture.  The skin was approximated using staples.","cardiovascular / pulmonary, coronary artery bypass grafting, saphenous vein graft, radial artery graft, coronary artery disease, congestive heart failure, descending artery territory, aortic cross clamp, aortic valve replacement, coronary artery bypass, obtuse marginal artery, anterior descending artery, mechanical valve, artery bypass, bypass grafting, marginal artery, radial artery, aortic valve, coronary artery, anterior descending, descending artery, valve, artery, aortic, grafting,"
" Aortoiliac occlusive disease.  Aortobifemoral bypass.  The aorta was of normal size and consistency consistent with arteriosclerosis.  A 16x8 mm Gore-Tex graft was placed without difficulty.  The femoral vessels were small somewhat thin and there was posterior packing, but satisfactory bypass was performed.", Cardiovascular / Pulmonary, Aortobifemoral Bypass ,"PREOPERATIVE DIAGNOSIS:,  Aortoiliac occlusive disease.,POSTOPERATIVE DIAGNOSIS:, Aortoiliac occlusive disease.,PROCEDURE PERFORMED:, Aortobifemoral bypass.,OPERATIVE FINDINGS: , The patient was taken to the operating room.  The abdominal contents were within normal limits.  The aorta was of normal size and consistency consistent with arteriosclerosis.  A 16x8 mm Gore-Tex graft was placed without difficulty.  The femoral vessels were small somewhat thin and there was posterior packing, but satisfactory bypass was performed.,PROCEDURE: , The patient was taken to the operating room, placed in a supine position, and prepped and draped in the usual sterile manner with Betadine solution.  A longitudinal incision was made after a Betadine-coated drape was placed over the incisional area.  Longitudinal incision was made over each groin initially and carried down to the subcutaneous fat and fascia.  Hemostasis was obtained with electrocautery.  The common deep and superficial femoral arteries were exposed and then these incisions were covered with antibiotic soaked sponges.  Attention was then turned to the abdomen, where a longitudinal incision was made from the pubis xiphoid, carried down subcutaneous fat and fascia.  Hemostasis was obtained with electrocautery.  The abdomen was entered above the umbilicus and then this was extended with care inferiorly as the patient has undergone previous abdominal surgery.  Mild adhesions were lysed.  The omentum was freed.  The small and large intestine were run with no evidence of abnormalities.  The liver and gallbladder were within normal limits.  No abnormalities were noted.  At this point, the Bookwalter retractor was placed.  NG tube was placed in the stomach and placed on suction.  The intestines were gently packed intraabdominally and laterally.  The rest of the peritoneum was then opened.  The aorta was cleared, both proximally and distally.  The left iliac was completely occluded.  The right iliac was to be cleansed.  At this point, 5000 units of aqueous heparin was administered to allow take effect.  The aorta was then clamped below the renal arteries and opened in a longitudinal fashion.  A single lumbar was ligated with #3-0 Prolene.  The inferior mesenteric artery was occluded intraluminally and required no suture closure.  Care was taken to preserve collaterals.  The aorta was measured, and a 16 mm Gore-Tex graft was brought on the field and anastomosed to the proximal aorta using #3-0 Prolene in a running fashion.  Last stitch was tied.  Hemostasis was excellent.  The clamp was gradually removed and additional Prolene was placed in the right posterolateral aspect to obtain better hemostasis.  At this point, strong pulses were present within the graft.  The limbs were vented and irrigated.  Using bimanual technique, the retroperitoneal tunnels were developed immediately on top of the iliac arteries into the groin.  The grafts were then brought through these, care being taken to avoid twisting of the graft.  At this point, the right iliac was then ligated using #0 Vicryl and the clamp was removed.  Hemostasis was excellent.  The right common femoral artery was then clamped proximally and distally, opened with #11 blade extended with Potts scissors.  The graft was _____ and anastomosed to the artery using #5-0 Prolene in a continuous fashion with a stitch _______ running fashion.  Prior to tying the last stitch, the graft and artery were vented and the last stitch was tied.  Flow was initially restored proximally then distally with good results.  Attention was then turned to the left groin and the artery grafts were likewise exposed, cleared proximally and distally.  The artery was opened, extended with a Potts scissors and anastomosis was performed with #5-0 Prolene again with satisfactory hemostasis.  The last stitch was tied.  Strong pulses were present within the artery and graft itself.  At this point, 25 mg of protamine was administered.  The wounds were irrigated with antibiotic solution.  The groins were repacked.  Attention was then returned to the abdomen.  The retroperitoneal area and the anastomotic sites were checked for bleeding and none was present.  The shell of the aorta was closed over the proximal anastomosis and the retroperitoneum was then repaired over the remaining portions of the graft.  The intraabdominal contents were then allowed to resume their normal position.  There was no evidence of ischemia to the large or small bowel.  At this point, the omentum and stomach were repositioned.  The abdominal wall was closed in a running single layer fashion using #1 PDS.  The skin was closed with skin staples.  The groins were again irrigated, closed with #3-0 Vicryl and #4-0 undyed Vicryl and Steri-Strips.  The patient was then taken into the recovery room in satisfactory condition after tolerating the procedure well.  Sponges and instrument counts were correct.  Estimated blood loss 900 cc.","cardiovascular / pulmonary, aorta, bypass, arteriosclerosis, abdominal contents, aortoiliac occlusive disease, gore tex graft, aortobifemoral bypass, longitudinal incision, aortobifemoral, hemostasis, artery, graft, "
 Dementia and aortoiliac occlusive disease bilaterally.  Aortobifemoral bypass surgery utilizing a bifurcated Hemashield graft., Cardiovascular / Pulmonary, Aortobifemoral Bypass - 1 ,"PREOPERATIVE DIAGNOSIS,1.  Aortoiliac occlusive disease bilaterally.,2.  Dementia.,POSTOPERATIVE DIAGNOSIS,1.  Aortoiliac occlusive disease bilaterally.,2.  Dementia.,OPERATION: , Aortobifemoral bypass surgery utilizing a bifurcated Hemashield graft.,ANESTHESIA:,  General endotracheal,ESTIMATED BLOOD LOSS: , 300 cc,INTRAVENOUS FLUIDS: , 1200 cc of crystalloid,URINE OUTPUT: , 250 cc,OPERATION IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered.  Note that previously the patient was found to have some baseline dementia, although slight.  The patient was seen and evaluated by the neurology team, who cleared the patient for surgery.  The patient was taken to the operating room and general endotracheal anesthesia was administered.  The abdomen was prepped and draped in the standard surgical fashion.  We first began our dissection by using a #10-blade scalpel to incise the skin over the femoral artery in the groin bilaterally.  Dissection was carried down to the level of the femoral vessels using Bovie electrocautery.  The common femoral, superficial femoral, and profunda femoris arteries were encircled and dissected out peripherally.  Vessel loops were placed around the aforementioned arteries.  After doing so, we turned our attention to beginning our abdominal dissection.  We used a #10-blade scalpel to make a midline laparotomy incision.  Dissection was carried down to the level of the fascia using Bovie electrocautery.  The abdomen was opened and an Omni retractor was positioned.  The aorta was dissected out in the abdomen.  The left femoral vein was identified.  There was a nicely clampable portion of aorta visible.  We, as mentioned, placed our Omni retractor and then turned our attention to performing our anastomosis.  Full-dose heparin was given.  Next, vascular clamps were applied to the iliac vessels as well as to the proximal aorta just below the renal vessels.  A #11-blade scalpel was used to make an arteriotomy in the aorta, which was lengthened both proximally and distally using Potts scissors.  We then beveled our proximal graft and constructed an end graft-to-side artery anastomosis using 3-0 Prolene in a running fashion.  Upon completion of our anastomosis, we flushed our graft and noted there was no evidence of a leak from the newly constructed anastomosis.  We then created our tunnels over the iliac vessels.  We pulled the distal limbs over our ABF graft into the groin.  We then proceeded to perform our right anastomosis first.  We applied vascular clamps on the proximal common femoral, profunda, and superficial femoral arteries.  We incised the common femoral artery and lengthened our arteriotomy in the vessel both proximally and distally.  We then footed the graft down onto the common femoral artery to the level of the SFA and constructed our anastomosis using 6-0 Prolene in a running fashion.  Upon completion of our anastomosis, we flushed the common femoral, SFA, and profunda femoris arteries.  We then removed our clamp.  We opened the limb more proximally in the abdomen on the right side.  We then turned our attention to the left side and similarly placed our vascular clamps.  We used a #11-blade scalpel to make an arteriotomy in the vessel.  We then lengthened our arteriotomy both proximally and distally again onto the SFA.  We constructed a footed end graft-to-side artery anastomosis using 6-0 Prolene in a running fashion.  Upon completion of our anastomosis, we opened our clamps.  There was no noticeable leak from the newly constructed anastomosis.  We checked our proximal graft to aortic anastomosis, which was noted to be in good condition.  We then gave full-dose protamine.  We closed the peritoneum over the graft with 4-0 Vicryl in a running fashion.  The abdomen was closed with #1 nylon in a running fashion.  The skin was closed with subcuticular 4-0 Monocryl in a running subcuticular fashion.  The instrument and sponge count was correct at end of case.  Patient tolerated the procedure well and was transferred to the intensive care unit in good condition.","cardiovascular / pulmonary, bifurcated, hemashield graft, aortoiliac occlusive disease, aortobifemoral bypass, vascular clamps, common femoral, graft, femoral, anastomosis, aortobifemoral, aortoiliac, proximal, arteriotomy, bypass, artery, endotracheal, vessels,"
 A 74-year-old woman for Cardiology consultation regarding atrial fibrillation and anticoagulation after a fall.  The patient denies any chest pain nor clear shortness of breath., Cardiovascular / Pulmonary, Atrial Fibrillation - Consult ,"HISTORY OF PRESENT ILLNESS:,  I was kindly asked to see Ms. ABC who is a 74-year-old woman for cardiology consultation regarding atrial fibrillation and anticoagulation after a fall.,The patient is somnolent at this time, but does arouse, but is unable to provide much history.  By review of the chart, it appears that she fell, which is what she states when she got up out of a rocking chair and could not get herself off the floor.  She states that 1-1/2 hours later she was able to get herself off the floor.,The patient denies any chest pain nor clear shortness of breath.,PAST MEDICAL HISTORY: , Includes, end-stage renal disease from hypertension.  She follows up with Dr. X in her office and has been known to have a small-to-moderate sized pericardial effusion since 11/07 that has apparently been followed and it appears that the patient was not interested in having diagnostic pericardiocentesis done.  She had an echocardiogram today (please see also that report), which shows stable and small-to-moderate sized pericardial effusion without tamponade, normal left ventricular ejection fraction at 55% with mild concentric left ventricular hypertrophy, mildly dilated right ventricular size, normal right ventricular ejection fraction, moderate mitral regurgitation and severe tricuspid regurgitation with severe pulmonary hypertension, estimated PA systolic pressure of 71 mmHg when compared to the prior echocardiogram done 08/29/07, previously the mitral regurgitation was mild and previously the PA systolic pressure was estimated at 90 mmHg.  Other findings were not significantly changed including pericardial effusion description.  She has a history of longstanding hypertension.  She has been on hemodialysis since 1997 for renal failure, history of mini-strokes documented several years ago, history of seizure disorder, she has a history of right upper extremity edema and right breast enlargement from right subclavian vein occlusion.  She has a history of hypertension, depression, hyperlipidemia, on Sensipar for tertiary hyperparathyroidism.,PAST SURGICAL HISTORY: , Includes, cholecystectomy, post fistula in the left arm, which has failed, and right arm, which is being used including number of operative procedures to the fistula.  She follows up with Dr. Y regarding neurovascular surgery.,MEDICATIONS: , On admission:,1.  Norvasc 10 mg once a day.,2.  Aspirin 81 mg once a day.,3.  Colace 200 mg two at bedtime.,4.  Labetalol 100 mg p.o. b.i.d.,5.  Nephro-Vite one tablet p.o. q.a.m.,6.  Dilantin 100 mg p.o. t.i.d.,7.  Renagel 1600 mg p.o. t.i.d.,8.  Sensipar 120 mg p.o. every day.,9.  Sertraline 100 mg p.o. nightly.,10.  Zocor 20 mg p.o. nightly.,ALLERGIES: , TO MEDICATIONS PER CHART ARE NONE.,FAMILY HISTORY:  ,Unable to obtain as the patient becomes quite sleepy when I am talking.,SOCIAL HISTORY:  ,Unable to obtain as the patient becomes quite sleepy when I am talking.,REVIEW OF SYSTEMS: , Unable to obtain as the patient becomes quite sleepy when I am talking.,PHYSICAL EXAM:  ,Temperature 99.2, blood pressure ranges from 88/41 to 108/60, pulse 70, respiratory rate, 20, O2 saturation 98%.  Height is 5 feet 1 inch, weight 147 pounds.  On general exam, she is a pleasant elderly woman who does arouse to voice, but then becomes quite sleepy and apparently that is an improvement from when she was admitted.  HEENT shows the cranium is normocephalic and atraumatic.  She has moist mucosal membranes.  Neck veins are difficult to assess, but do not appear clinically distended.  No carotid bruits.  Lungs are clear to auscultation anteriorly.  No wheezes.  Cardiac exam:  S1, S2 regular rate, 3/6 holosystolic murmur heard with radiation from the left apex towards the left axilla.  No rub, no gallop.  PMI is nondisplaced.  Abdomen:  Soft, nondistended.  CVA is benign.  Extremities with no significant edema.  Pulses appear grossly intact.  She has evidence of right upper extremity edema, which is apparently chronic.,DIAGNOSTIC DATA/LAB DATA: , EKGs are reviewed including from 07/07/09 at 08:31 a.m., which shows atrial fibrillation with left anterior fascicular block, poor R-wave progression when compared to one done on 07/06/09 at 18:25, there is really no significant change.  The atrial fibrillation appears present since at least on EKG done on 11/02/07 and this EKG is not significantly changed from the most recent one.  Echocardiogram results as above.  Chest x-ray shows mild pulmonary vascular congestion.  BNP shows 3788.  Sodium 136, potassium 4.5, chloride 94, bicarbonate 23, BUN 49, creatinine 5.90.  Troponin was 0.40 followed by 0.34.  INR 1.03 on 05/18/07.  White blood cell count 9.4, hematocrit 42, platelet count 139.,IMPRESSION: , Ms. ABC is a 74-year-old woman admitted to the hospital with a fall and she has a history of vascular dementia, so her history is somewhat unreliable it seems and she is somnolent at that time.  She does have chronic atrial fibrillation again documented at least present since 2007 and I found an EKG report by Dr. X, which shows atrial fibrillation on 08/29/07 per her report.  One of the questions we were asked was whether the patient would be a candidate for Coumadin.  Clearly given her history of small mini-strokes, I think Coumadin would be appropriate given this chronic atrial fibrillation, but the main issue is the fall risk.  If not felt to be significant fall risk then I would strongly recommend Coumadin as the patient herself states that she has only fallen twice in the past year.  I would defer that decision to Dr. Z and Dr. XY who know the patient well and it may be that physical therapy consult is appropriate to help adjudicate.,RECOMMENDATIONS:,1.  Fall assessment as per Dr. Z and Dr. XY with possible PT consult if felt appropriate and if the patient is not felt to be at significant fall risk, would put her on Coumadin.  Given her history of small strokes as documented in the chart and her chronic atrial fibrillation, she does have reasonable heart rate control on current labetalol.,2.  The patient has elevated BNP and I suspect that is due to her severe pulmonary hypertension and renal failure and in the light of normal LV function, I would not make any further evaluation of that other than aggressive diuresis.,3.  Regarding this minimal troponin elevation, I do not feel this is a diagnosis especially in the setting of pulmonary hypertension and her small-to-moderate sized stable pericardial effusion again that has been longstanding since 2007 from what I can tell and there is no evidence of tamponade.  I would defer to her usual cardiologist Dr. X whether an outpatient stress evaluation is appropriate for risk stratification.  I did find that the patient had a prior cardiac stress test in 08/07 where they felt that there was some subtle reversibility of the anterior wall, but it was felt that it may be artifact rather than true ischemia with normal LV function seen on that study as well.,4.  Continue Norvasc for history of hypertension as well as labetalol.,5.  The patient is felt to be a significant fall risk and will at least continue her aspirin 81 mg once a day for secondary CVA, thromboprophylaxis (albeit understanding that it is inferior to Coumadin).,6.  Continue Dilantin for history of seizures.",
 Arterial imaging of bilateral lower extremities.  , Cardiovascular / Pulmonary, Arterial Imaging ,"INDICATIONS:,  Peripheral vascular disease with claudication.,RIGHT:,  ,1.  Normal arterial imaging of right lower extremity.,2.  Peak systolic velocity is normal.,3.  Arterial waveform is triphasic.,4.  Ankle brachial index is 0.96.,LEFT:,1.  Normal arterial imaging of left lower extremity.,2.  Peak systolic velocity is normal.,3.  Arterial waveform is triphasic throughout except in posterior tibial artery where it is biphasic.,4.  Ankle brachial index is 1.06.,IMPRESSION,:,Normal arterial imaging of both lower extremities.","cardiovascular / pulmonary, peripheral vascular disease, ankle brachial index, arterial waveform, peak systolic velocity, arterial imaging, biphasic, claudication, lower extremities, lower extremity, posterior tibial artery, triphasic, systolic velocity is normal, arterial waveform is triphasic, waveform is triphasic, normal arterial imaging, systolic velocity, brachial index, velocity, brachial, imaging, arterial,"
" Left heart cath, selective coronary angiogram, right common femoral angiogram, and StarClose closure of right common femoral artery.", Cardiovascular / Pulmonary, Angiogram & StarClose Closure ,"EXAM: , Left heart cath, selective coronary angiogram, right common femoral angiogram, and StarClose closure of right common femoral artery.,REASON FOR EXAM: , Abnormal stress test and episode of shortness of breath.,PROCEDURE: , Right common femoral artery, 6-French sheath, JL4, JR4, and pigtail catheters were used.,FINDINGS:,1.  Left main is a large-caliber vessel.  It is angiographically free of disease,,2.  LAD is a large-caliber vessel.  It gives rise to two diagonals and septal perforator.  It erupts around the apex.  LAD shows an area of 60% to 70% stenosis probably in its mid portion.  The lesion is a type A finishing before the takeoff of diagonal 1.  The rest of the vessel is angiographically free of disease.,3.  Diagonal 1 and diagonal 2 are angiographically free of disease.,4.  Left circumflex is a small-to-moderate caliber vessel, gives rise to 1 OM.  It is angiographically free of disease.,5.  OM-1 is angiographically free of disease.,6.  RCA is a large, dominant vessel, gives rise to conus, RV marginal, PDA and one PL.  RCA has a tortuous course and it has a 30% to 40% stenosis in its proximal portion.,7.  LVEDP is measured 40 mmHg.,8.  No gradient between LV and aorta is noted.,Due to contrast concern due to renal function, no LV gram was performed.,Following this, right common femoral angiogram was performed followed by StarClose closure of the right common femoral artery.,IMPRESSION:,1.  60% to 70% mid left anterior descending stenosis.,2.  Mild 30% to 40% stenosis of the proximal right coronary artery.,3.  Status post StarClose closure of the right common femoral artery.,PLAN:  ,Plan will be to perform elective PCI of the mid LAD.","cardiovascular / pulmonary, heart cath, selective coronary angiogram, common femoral angiogram, abnormal stress test, common femoral artery, starclose closure, femoral artery, angiogram, angiographically, artery, femoral, "
" Selective coronary angiography of the right coronary artery, left main LAD, left circumflex artery, left ventricular catheterization, left ventricular angiography, angioplasty of totally occluded mid RCA, arthrectomy using 6-French catheter, stenting of the mid RCA, stenting of the proximal RCA, femoral angiography and Perclose hemostasis.", Cardiovascular / Pulmonary, Angiography & Catheterization - 1 ,"INDICATION:,  Acute coronary syndrome.,CONSENT FORM: , The procedure of cardiac catheterization/PCI risks included but not restricted to death, myocardial infarction, cerebrovascular accident, emergent open heart surgery, bleeding, hematoma, limb loss, renal failure requiring dialysis, blood loss, infection had been explained to him.  He understands.  All questions answered and is willing to sign consent.,PROCEDURE PERFORMED:,  Selective coronary angiography of the right coronary artery, left main LAD, left circumflex artery, left ventricular catheterization, left ventricular angiography, angioplasty of totally occluded mid RCA, arthrectomy using 6-French catheter, stenting of the mid RCA, stenting of the proximal RCA, femoral angiography and Perclose hemostasis.,NARRATIVE: , The patient was brought to the cardiac catheterization laboratory in a fasting state.  Both groins were draped and sterilized in the usual fashion.  Local anesthesia was achieved with 2% lidocaine to the right groin area and a #6-French femoral sheath was inserted via modified Seldinger technique in the right common femoral artery.  Selective coronary angiography was performed with #6 French JL4 catheter for the left coronary system and a #6 French JR4 catheter of the right coronary artery.  Left ventricular catheterization and angiography was performed at the end of the procedure with a #6-French angle pigtail catheter.,FINDINGS,1.  Hemodynamics systemic blood pressure 140/70 mmHg.  LVEDP at the end of the procedure was 13 mmHg.,2.  The left main coronary artery is a large with mild diffuse disease in the distal third resulting in less than 20% angiographic stenosis at the take off of the left circumflex artery.  The left circumflex artery is a large caliber vessel with diffuse disease in the ostium of the proximal segment resulting in less than 30% angiographic stenosis.  The left circumflex artery gives rise to a high small obtuse marginal branch that has high moderate-to-severe ostium.  The rest of the left circumflex artery has mild diffuse disease and it gives rise to a second large obtuse marginal branch that bifurcates into an upper and lower trunk.,The LAD is calcified and diffusely disease in the proximal and mid portion.  There is mild nonobstructive disease in the proximal LAD resulting in less than 20% angiographic stenosis.,3.  The right coronary artery is dominant.  It is septal to be occluded in the mid portion.,The findings were discussed with the patient and she opted for PCI.  Angiomax bolus was started.  The ACT was checked.  It was higher in 300.  I have given the patient 600 mg of oral Plavix.,The right coronary artery was engaged using a #6-French JR4 guide catheter.  I was unable to cross through this lesion using a BMW wire and a 3.0x8 mm balloon support.  I was unable to cross with this lesion using a whisper wire.  I was unable to cross with this lesion using Cross-IT 100 wire.  I have also used second #6-French Amplatz right I guide catheter.  At one time, I have lost flow in the distal vessel.  The patient experienced severe chest pain, ST-segment elevation, bradycardia, and hypotension, which responded to intravenous fluids and atropine along with intravenous dopamine.,Dr. X was notified.,Eventually, an Asahi grand slam wire using the same 3.0 x 8 mm Voyager balloon support, I was able to cross into the distal vessel.  I have performed careful balloon angioplasty of the mid RCA.  I have given nitroglycerin under the nursing several times during the procedure.,I then performed arthrectomy using #5-French export catheter.,I performed more balloon predilation using a 3.0 x16 mm Voyager balloon.  I then deployed 4.0 x15 mm, excised, and across the mid RCA at 18 atmospheres with good angiographic result.  Proximal to the proximal edge of the stent, there was still some persistent haziness most likely just diseased artery/diffuse plaquing.  I decided to cover this segment using a second 4.0 x 15 mm, excised, and two stents were overlapped, the overlap was postdilated using the same stent delivery balloon at high pressure with excellent angiographic result.,Left ventricular catheterization was performed with #6-French angle pigtail catheter.  The left ventricle is rather smaller in size.  The mid inferior wall is minimally hypokinetic, ejection fraction is 70%.  There is no evidence of aortic wall stenosis or mitral regurgitation.,Femoral angiography revealed that the entry point was above the bifurcation of the right common femoral artery and I have performed this as Perclose hemostasis.,CONCLUSIONS,1.  Normal left ventricular size and function.  Ejection fraction is 65% to 70%.  No MR.,2.  Successful angioplasty and stenting of the subtotally closed mid RCA.  This was hard, organized thrombus, very difficult to penetrate.  I have deployed two overlapping 4.0 x15 mm excised and with excellent angiographic result.  The RCA is dominant.,3.  No moderate disease in the distal left main.  Moderate disease in the ostium of the left circumflex artery.  Mild disease in the proximal LAD.,PLAN: , Recommend smoking cessation.  Continue aspirin lifelong and continue Plavix for at least 12 months.","cardiovascular / pulmonary, acute coronary syndrome, circumflex artery, ventricular catheterization, ventricular angiography, angioplasty, coronary artery, coronary angiography, arthrectomy, femoral angiography, perclose hemostasis, selective coronary angiography, angiographic stenosis, rca, coronary, catheterization, artery, angiography, hemostasis, wire, lad, femoral, angiographic, stenting, proximal, "
" Left heart catheterization, bilateral selective coronary angiography, left ventriculography, and right heart catheterization.  Positive nuclear stress test involving reversible ischemia of the lateral wall and the anterior wall consistent with left anterior descending artery lesion.", Cardiovascular / Pulmonary, Angiography & Catheterization ,"PROCEDURES PERFORMED:,1.  Left heart catheterization.,2.  Bilateral selective coronary angiography.,3.  Left ventriculography.,4.  Right heart catheterization.,INDICATION: , Positive nuclear stress test involving reversible ischemia of the lateral wall and the anterior wall consistent with left anterior descending artery lesion.,PROCEDURE: , After risks, benefits, and alternatives of the above-mentioned procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing.  The patient was taken to cardiac catheterization suite where the right femoral region was prepped and draped in the usual sterile fashion.  1% lidocaine solution was used to infiltrate the skin overlying the right femoral artery and vein.  Once adequate anesthesia has been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right femoral artery.  A steel guidewire was inserted through the needle into the vascular lumen without resistance.  A small nick was then made in the skin.  The pressure was held.  The needle was removed over the guidewire.  Next, a #6 French arterial sheath was then advanced over the guidewire into the vascular lumen without resistance.  The guidewire and dilator were then removed.  The sheath was flushed.  Next, an angulated pigtail catheter was advanced to the level of the ascending aorta under the direct fluoroscopy visualization with the use of a guidewire.  The catheter was then guided into the left ventricle.  The guidewire and dilator were then removed.  The catheter was then flushed.  LVEDP was measured and found to be favorable for a left ventriculogram.  The left ventriculogram was performed in the RAO position with a single power injection of nonionic contrast material.  LVEDP was then remeasured.  Pullback was performed, which failed to reveal an LVAO gradient.  The catheter was then removed.  Next, a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  The ostium of the left main coronary was unable to be engaged with this catheter.  Thus it was removed over a guidewire.  Next, a Judkins left #5 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  Left main coronary artery was then engaged.  Using hand injections of nonionic contrast material, the left coronary system was evaluated in several different views.  The catheter was then removed from the ostium of the left main coronary artery and was removed over a guidewire.  Next, a Judkins right #4 catheter was then advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  Using hand injections of nonionic contrast material, the right coronary system was evaluated in several different views.  The catheter was then removed from the ostium of the right coronary artery and then removed.  The sheath was then flushed.  Because the patient did have high left ventricular end-diastolic pressures, it was determined that the patient wound need a right heart catheterization.  Thus an #18 gauge Argon needle was used to cannulate the right femoral vein.  A steel guidewire was inserted through the needle into the vascular lumen.  The needle was removed over the guidewire.  Next, an #8 French venous sheath was advanced over the guidewire into lumen without resistance.  The guidewire and dilator were then removed.  The sheath was then flushed.  Next, a Swan-Ganz catheter was advanced to the level of 20 cm.  The balloon was inflated.  Under fluoroscopic visualization, the catheter was guided into the right atrium, right ventricle, and into the pulmonary artery wedge position.  Hemodynamics were measured along the way.  PA saturation, right atrial saturation, femoral artery saturation were all obtained.  Once adequate study has been performed, the catheter was then removed.  Both sheaths were flushed and found fine.  The patient was returned to the cardiac catheterization holding area in stable satisfactory condition.,FINDINGS:,LEFT VENTRICULOGRAM:  ,There is no evidence of any wall motion abnormalities with estimated ejection fraction of 60%.  Left ventricular end-diastolic pressure was 38 mmHg preinjection and 40 mmHg postinjection.  There is no LVAO.  There is no mitral regurgitation.  There is a trileaflet aortic valve noted.,LEFT MAIN CORONARY ARTERY:  ,The left main is a moderate caliber vessel, which bifurcates into the left anterior descending and circumflex arteries.  There is no evidence of any hemodynamically significant stenosis.,LEFT ANTERIOR DESCENDING: , The LAD is a moderate caliber vessel, which traverses through the intraventricular groove and reaches the apex of the heart.  There is a proximal 60% to 70% stenotic lesion.  There was also a mid 70% to 80% stenotic lesion at the takeoff of the first and second diagonal branches.,CIRCUMFLEX ARTERY:  ,The circumflex is a moderate caliber vessel, which traverses through the atrioventricular groove.  There is a mid 60% to 70% stenotic lesion followed by a second mid 90% stenotic lesion.  The first obtuse marginal branch is small and the second obtuse marginal branch is large without any evidence of critical disease.  The third obtuse marginal branch is also small.,RIGHT CORONARY ARTERY:  ,The RCA is a moderate caliber vessel with minor luminal irregularities throughout.  There is no evidence of any critical disease.  The right coronary artery is the dominant right coronary vessel.,RIGHT HEART FINDINGS:  ,Pulmonary artery pressure equals 61/23 with a mean of 44.  Pulmonary artery wedge pressure equals 32.  Right ventricle pressure equals 65/24.  The right atrial pressure equals to 22.  Cardiac output by Fick is 4.9.  Cardiac index by Fick is 2.3.  Hand calculated cardiac output equals 7.8.  Hand calculated cardiac index equals 3.7.  On 2 liters nasal cannula, pulmonary artery saturation equals 77.8%.  Femoral artery saturation equals 99.1%.  Pulse oximetry is 99%.  Right atrial saturation is 76.3%.  Systemic blood pressure is 166/58.  Body surface area equals 2.12.  Hemoglobin equals 12.6.,IMPRESSION:,1.  Two-vessel coronary artery disease with a complex left anterior descending arterial lesion as well as circumflex disease.,2.  Normal left ventricular function with an estimated ejection fraction of 60%.,3.  Biventricular overload.,4.  Moderate pulmonary hypertension.,5.  There is no evidence of shunt.,PLAN:,1.  The patient will be admitted for IV diuresis in light of the biventricular overload.,2.  The findings of the heart catheterization were discussed in detail with the patient and the patient's family.  There is some concern with the patient's two-vessel coronary artery disease in light of the patient's diabetic history.  We will obtain a surgical evaluation for the possibility of a coronary artery bypass grafting.,3.  The patient will remain on aggressive medical regimen including ACE inhibitor, aspirin, Plavix, and nitrate.,4.  The patient will need to undergo aggressive risk factor modification including weight loss and diet control.,5.  The patient will have an Internal Medicine evaluation regarding the patient's diabetic history.",
" Lower extremity angiogram, superficial femoral artery laser atherectomy and percutaneous transluminal balloon angioplasty, external iliac artery angioplasty and stent placement, and completion angiogram.", Cardiovascular / Pulmonary, Angiogram & Angioplasty ,"PREOPERATIVE DIAGNOSES:,1.  Left superficial femoral artery subtotal stenosis.,2.  Arterial insufficiency, left lower extremity.,POSTOPERATIVE DIAGNOSES:,1.  Left superficial femoral artery subtotal stenosis.,2.  Arterial insufficiency, left lower extremity.,OPERATIONS PERFORMED:,1.  Left lower extremity angiogram.,2.  Left superficial femoral artery laser atherectomy.,3.  Left superficial femoral artery percutaneous transluminal balloon angioplasty.  ,4.  Left external iliac artery angioplasty.,5.  Left external iliac artery stent placement.,6.  Completion angiogram.,FINDINGS:  ,This patient was brought to the OR with a non-severe stenosis of the proximal left superficial femoral artery in the upper one-third of his thigh.  He is also known to have severe calcific disease involving the entire left external iliac system as well as the common femoral and deep femoral arteries.,Our initial plan today was to perform an atherectomy with angioplasty and stenting of the left superficial femoral artery as necessary.  However, whenever we started the procedure, it became clear that there was a severe stenosis of the left superficial femoral artery at its takeoff from the left common femoral artery.  The area was severely calcified including the external iliac artery extending up underneath the left inguinal ligament.  Indeed, this ultimately was dissected due to manipulation of sheath catheters and sheath through the area.  Ultimately, this wound up being a much more complex case than initially anticipated.,Because of the above, we ultimately performed a laser atherectomy of the left superficial femoral artery, which then had to be angioplastied to obtain a satisfactory result.  The completion angiogram showed that there was a dissection of the left external iliac artery, which precluded flow down into the left lower extremity.  We then had to come up and perform angioplasty and stenting of the left external iliac artery as well as aggressively dilating the takeoff of the less superficial femoral artery from the common femoral artery.,The left superficial femoral artery was dilated with a 6-mm balloon.,The left external iliac artery and common femoral arteries were dilated with an 8-mm balloon.,A 2.5-mm ClearPath laser probe was used to initially arthrectomize and debulk the superficial femoral artery starting at its takeoff from the common femoral artery and extending down to the tight stenotic area in the upper one-third of the thigh.  After the laser atherectomy was performed, the area still did not look good and so an angioplasty was then done, which looked good; however, as noted above, after we had dealt with the superficial femoral artery, we then had proximal inflow problems, which had to be dealt by angioplasty and stenting.,The patient had good dorsalis pedis pulses bilaterally upon completion.,The right common femoral artery was used for access in an up-and-over technique.,PROCEDURE: , With the patient in the supine position under general anesthesia, the abdomen and lower extremities were prepped and draped in the sterile fashion.,The right common femoral artery was punctured percutaneously, and a #5-French sheath was initially placed.  We used a pigtail catheter to go up and over the aortic bifurcation and placed a stiff Amplatz guidewire down into the left common femoral artery.  We then heparinized the patient and placed a #7-French Raby sheath over the Amplatz wire.  A selective left lower extremity angiogram was then done with the above-noted findings.,We then used a ClearPath 2.5-mm laser probe to laser the proximal superficial femoral artery.  Because of the findings as noted above, this became more involved than initially hoped for.  Once the laser atherectomy had been completed, the vessel still did not look good, so we used a 6-mm balloon to thoroughly dilate the area.  Once that had been done, it looked good and we performed what we felt would be a completion angiogram only to find out that we had a more proximal problem precluding flow down into the left femoral artery.,Once that was discovered, we then had to proceed with angioplasty and stenting of the left external iliac artery right down to the acetabular level.,Once we had dealt with our run-on problems, we then did another completion angiogram, which showed a good flow through the entire area and down into the left lower extremity.,Following completion of the above, all wires, sheaths, and catheters were removed from the right common femoral artery.  Firm pressure was held over the puncture site for 20 minutes followed by application of a sterile Coverlet dressing and a firm pressure dressing.,The patient tolerated the procedure well throughout.  He had good palpable dorsalis pedis pulses bilaterally on completion.  He was taken to the recovery room in satisfactory condition.  Protamine was given to partially reverse the heparin.",
 A sample note on Angina., Cardiovascular / Pulmonary, Angina ,"ANGINA, is chest pain due to a lack of oxygen to the heart most often occurring in men age 35 or older and postmenopausal women.  It is usually located right under the breast bone.  Physical and emotional stress, as well as eating heavy meals, can bring it on.  In a healthy person, these stresses are easily handled.  In a person with an underlying heart condition like coronary artery disease, heart valve problem, arrhythmias or high blood pressure, the heart doesn't get enough blood (i.e. not enough oxygen to the heart muscles).  Other causes could be due to a hyperactive thyroid disorder or anemia.  People more likely to have angina may also have diabetes mellitus, be overweight, smoke, have a poor diet with lots of salt and fat, fail to exercise, have a stressful workload or have a family history of coronary artery disease.,SIGNS AND SYMPTOMS:,*  Pain in chest described as tightness, heavy pressure, aching or squeezing.,*  The pain sometimes radiates to the jaw, left arm, teeth and/or outer ear.,*  Possibly a left-sided numbness, tingling, or pain in the arm, shoulder, elbow or chest.,*  Occasionally a sudden difficulty in breathing occurs.,*  Pain may be located between the shoulder blades.,TREATMENT:,*  Nitroglycerin relieves the immediate symptoms of angina in seconds.  Carry it with you at all times.,*  Other medications may be prescribed for the underlying heart problems.  It is important to take them as prescribed by your doctor.,*  Surgery may be necessary to open the blocked coronary arteries (balloon angioplasty) or to bypass them.,*  Correct the contributing factors you have control over.  Lose weight, don't smoke, eat a low-salt, low-fat diet and avoid physical and emotional stresses that cause angina.  Such stressors include anger, overworking, going between extremes in hot and cold, sudden physical exertion and high altitudes (pressurized airplanes aren't a risk).  Practice relaxation techniques.,*  Exercise! Discuss first what you are able to do with your doctor and then go do it.,*  Even with treatment, angina may result in a heart attack, congestive heart failure or a fatal abnormal heartbeat.  Treatment decreases the odds that these will occur.,*  Let your doctor know if your angina doesn't go away after 10 minutes, even when you have taken a nitroglycerin tablet.  Call if you have repeated chest pains that awaken you from sleep regardless if the nitroglycerin helps.  If your pain changes or feels different, call your doctor or call 911 if the pain is severe.","cardiovascular / pulmonary, lack of oxygen, heart valve, arrhythmias, blood pressure, heart, tightness, nitroglycerin, coronary artery disease, oxygen, angina, coronary, chest,"
 Adenosine with nuclear scan as the patient unable to walk on a treadmill.  Nondiagnostic adenosine stress test.  Normal nuclear myocardial perfusion scan., Cardiovascular / Pulmonary, Adenosine Nuclear Scan ,"INDICATION: , Chest pain.,TYPE OF TEST: , Adenosine with nuclear scan as the patient unable to walk on a treadmill.,INTERPRETATION:, Resting heart rate of 67, blood pressure of 129/86.  EKG, normal sinus rhythm.  Post-Lexiscan 0.4 mg, heart rate was 83, blood pressure 142/74.  EKG remained the same.  No symptoms were noted.,SUMMARY:,1.  Nondiagnostic adenosine stress test.,2.  Nuclear interpretation as below.,NUCLEAR INTERPRETATION:,  Resting and stress images were obtained with 10.4, 33.1 mCi of tetrofosmin injected intravenously by standard protocol.  Nuclear myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake without any evidence of reversible or fixed defect.  Gated SPECT revealed normal wall motion, ejection fraction of 58%.  End-diastolic volume of 74, end-systolic volume of 31.,IMPRESSION:,1.  Normal nuclear myocardial perfusion scan.,2.  Ejection fraction 58% by gated SPECT.","cardiovascular / pulmonary, adenosine nuclear myocardial perfusion scan, chest pain, adenosine stress test, nuclear myocardial perfusion scan, gated spect, spect, mci, myocardial perfusion scan, myocardial, perfusion, adenosine, nuclear,"
 Patient presents with a chief complaint of chest pain admitted to Coronary Care Unit due to acute inferior myocardial infarction., Cardiovascular / Pulmonary, Acute Inferior Myocardial Infarction ,"CHIEF COMPLAINT: , Chest pain.,HISTORY OF PRESENT ILLNESS:,  The patient is a 40-year-old white male who presents with a chief complaint of ""chest pain"".,The patient is diabetic and has a prior history of coronary artery disease.  The patient presents today stating that his chest pain started yesterday evening and has been somewhat intermittent.  The severity of the pain has progressively increased.  He describes the pain as a sharp and heavy pain which radiates to his neck & left arm.  He ranks the pain a 7 on a scale of 1-10.  He admits some shortness of breath & diaphoresis.  He states that he has had nausea & 3 episodes of vomiting tonight.  He denies any fever or chills.  He admits prior episodes of similar pain prior to his PTCA in 1995.  He states the pain is somewhat worse with walking and seems to be relieved with rest.  There is no change in pain with positioning.  He states that he took 3 nitroglycerin tablets sublingually over the past 1 hour, which he states has partially relieved his pain.  The patient ranks his present pain a 4 on a scale of 1-10.  The most recent episode of pain has lasted one-hour.,The patient denies any history of recent surgery, head trauma, recent stroke, abnormal bleeding such as blood in urine or stool or nosebleed.,REVIEW OF SYSTEMS:,  All other systems reviewed & are negative.,PAST MEDICAL HISTORY:,  Diabetes mellitus type II, hypertension, coronary artery disease, atrial fibrillation, status post PTCA in 1995 by Dr. ABC.,SOCIAL HISTORY: , Denies alcohol or drugs.  Smokes 2 packs of cigarettes per day.  Works as a banker.,FAMILY HISTORY: , Positive for coronary artery disease (father & brother).,MEDICATIONS: , Aspirin 81 milligrams QDay.  Humulin N. insulin 50 units in a.m.  HCTZ 50 mg QDay.  Nitroglycerin 1/150 sublingually PRN chest pain.,ALLERGIES: , Penicillin.,PHYSICAL EXAM: , The patient is a 40-year-old white male.,General:  The patient is moderately obese but he is otherwise well developed & well nourished.  He appears in moderate discomfort but there is no evidence of distress.  He is alert, and oriented to person place and circumstance.  There is no evidence of respiratory distress.  The patient ambulates",
" Patient had a recurrent left arm pain after her stent, three days ago, and this persisted after two sublingual nitroglycerin.", Cardiovascular / Pulmonary, Angina - Consult ,"HISTORY OF PRESENT ILLNESS: , The patient is a 68-year-old woman whom I have been following, who has had angina.  In any case today, she called me because she had a recurrent left arm pain after her stent, three days ago, and this persisted after two sublingual nitroglycerin when I spoke to her.  I advised her to call 911, which she did.  While waiting for 911, she was attended to by a physician who is her neighbor and he advised her to take the third nitroglycerin and that apparently relieved her pain.  By the time she presented here, she is currently pain-free and is feeling well.,PAST CARDIAC HISTORY: , The patient has been having arm pain for several months.  She underwent an exercise stress echocardiogram within the last several months with me, which was equivocal, but then she had a nuclear stress test which showed inferobasilar ischemia.  I had originally advised her for a heart catheterization but she wanted medical therapy, so we put her on a beta-blocker.  However, her arm pain symptoms accelerated and she had some jaw pain, so she presented to the emergency room.  On 08/16/08, she ended up having a cardiac catheterization and that showed normal left main 80%  mid LAD lesion, circumflex normal, and RCA totally occluded in the mid portion and there were collaterals from the left to the right, as well as right to right to that area.  The decision was made to transfer  her as she may be having collateral insufficiency from the LAD stenosis to the RCA vessel.  She underwent that with drug-eluting stents on 08/16/08, with I believe three or four total placed, and was discharged on 08/17/08.  She had some left arm discomfort on 08/18/08, but this was mild.  Yesterday, she felt very fatigued, but no arm pain, and today, she had arm pain after walking and again it resolved now completely after three sublingual nitroglycerin.  This is her usual angina.  She is being admitted with unstable angina post stent.,PAST MEDICAL HISTORY: , Longstanding hypertension, CAD as above, hyperlipidemia, and overactive bladder.,MEDICATIONS:,1.  Detrol LA 2 mg once a day.,2.  Prilosec for GERD 20 mg once a day.,3.  Glucosamine 500/400 mg once a day for arthritis.,4.  Multivitamin p.o. daily.,5.  Nitroglycerin sublingual as available to her.,6.  Toprol-XL 25 mg once a day which I started although she had been bradycardic, but she seems to be tolerating.,7.  Aspirin 325 mg once a day.,8.  Plavix 75 mg once a day.,9.  Diovan 160 mg once a day.,10.  Claritin 10 mg once a day for allergic rhinitis.,11.  Norvasc 5 mg once a day.,12.  Lipitor 5 mg once a day.,13.  Evista 60 mg once a day.,ALLERGIES: , ALLERGIES TO MEDICATIONS ARE NONE.  SHE DENIES ANY SHRIMP OR SEA FOOD ALLERGY.,FAMILY HISTORY: , Her father died of an MI in his 50s and a brother had his first MI and bypass surgery at 54.,SOCIAL HISTORY:  ,She does not smoke cigarettes, abuse alcohol, no use of illicit drugs.  She is divorced and lives alone and is a retired laboratory technician from Cornell Diagnostic Laboratory.,REVIEW OF SYSTEMS:,  She denies a history of stroke, cancer, vomiting up blood, coughing up blood, bright red blood per rectum, bleeding stomach ulcers, renal calculi, cholelithiasis, asthma, emphysema, pneumonia, tuberculosis, home oxygen use or sleep apnea, although she has been told in the past that she snores and there was some question of apnea in 05/08.  No morning headaches or fatigue.  No psychiatric diagnosis.  No psoriasis, no lupus.  Remainder of the review of systems is negative x14 systems except as described above.,PHYSICAL EXAMINATION:,GENERAL:  She is a pleasant elderly woman, currently in no acute distress.,VITAL SIGNS:  Height 4 feet 11 inches, weight 128 pounds, temperature 97.2 degrees Fahrenheit, blood pressure 142/70, pulse 47,  respiratory rate 16, and O2 saturation 100%,HEENT:  Cranium is normocephalic and atraumatic.  She has moist mucosal membranes.,NECK:  Veins are not distended.  There are no carotid bruits.,LUNGS:  Clear to auscultation and percussion without wheezes.,HEART:  S1 and S2, regular rate.  No significant murmurs, rubs or gallops.  PMI nondisplaced.,ABDOMEN:  Soft and nondistended.  Bowel sounds present.,EXTREMITIES:  Without significant clubbing, cyanosis or edema.  Pulses grossly intact.  Bilateral groins are inspected, status post as the right femoral artery was used for access for the diagnostic cardiac catheterization here and left femoral artery used for PCI and there is no evidence of hematoma or bruit and intact distal pulses.,LABORATORY DATA: , EKG reviewed which shows sinus bradycardia at the rate of 51 beats per minute and no acute disease.,Sodium 136, potassium 3.8, chloride 105, and bicarbonate 27.  BUN 16 and creatinine 0.9.  Glucose 110.  Magnesium 2.5.  ALT 107 and AST 65 and these were normal on 08/15/08.  INR is 0.89, PTT 20.9, white blood cell count 8.2, hematocrit 31 and it was 35 on 08/15/08, and platelet count 257,000.,IMPRESSION AND PLAN:  ,The patient is a 68-year-old woman with exertional angina, characterized with arm pain, who underwent recent left anterior descending percutaneous coronary intervention and has now had recurrence of that arm pain post stenting to the left anterior descending artery and it may be that she is continuing to have collateral insufficiency of the right coronary artery.  In any case, given this unstable presentation requiring three sublingual nitroglycerin before she was even pain free, I am going to admit her to the hospital and there is currently no evidence requiring acute reperfusion therapy.  We will continue her beta-blocker and I cannot increase the dose because she is bradycardic already.  Aspirin, Plavix, valsartan, Lipitor, and Norvasc.  I am going to add Imdur and watch headaches as she apparently had some on nitro paste before, and we will rule out MI, although there is a little suspicion.  I suppose it is possible that she has non-cardiac arm pain, but that seems less likely as it has been nitrate responsive and seems exertionally related and the other possibility may be that we end up needing to put in a pacemaker, so we can maximize beta-blocker use for anti-anginal effect.  My concern is that there is persistent right coronary artery ischemia, not helped by left anterior descending percutaneous coronary intervention, which was severely stenotic and she does have normal LV function.  She will continue the glucosamine for her arthritis, Claritin for allergies, and Detrol LA for urinary incontinence.,Total patient care time in the emergency department 75 minutes.  All this was discussed in detail with the patient and her daughter who expressed understanding and agreement.  The patient desires full resuscitation status.",
 Patient had a markedly abnormal stress test with severe chest pain after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only., Cardiovascular / Pulmonary, Abnormal Stress Test ,"HISTORY OF PRESENT ILLNESS: , Mr. ABC is a 60-year-old gentleman who had a markedly abnormal stress test earlier today in my office with severe chest pain after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only.  He required 3 sublingual nitroglycerin in total (please see also admission history and physical for full details).,The patient underwent cardiac catheterization with myself today which showed mild-to-moderate left main distal disease of 30%, moderate proximal LAD with a severe mid-LAD lesion of 99%, and a mid-left circumflex lesion of 80% with normal LV function and some mild luminal irregularities in the right coronary artery with some moderate stenosis seen in the mid to distal right PDA.,I discussed these results with the patient, and he had been relating to me that he was having rest anginal symptoms, as well as nocturnal anginal symptoms, and especially given the severity of the mid left anterior descending lesion, with a markedly abnormal stress test, I felt he was best suited for transfer for PCI.  I discussed the case with Dr. X at Medical Center who has kindly accepted the patient in transfer.,CONDITION ON TRANSFER: , Stable but guarded.  The patient is pain-free at this time.,MEDICATIONS ON TRANSFER:,1.  Aspirin 325 mg once a day.,2.  Metoprolol 50 mg once a day, but we have had to hold it because of relative bradycardia which he apparently has a history of.,3.  Nexium 40 mg once a day.,4.  Zocor 40 mg once a day, and there is a fasting lipid profile pending at the time of this dictation.  I see that his LDL was 136 on May 3, 2002.,5.  Plavix 600 mg p.o. x1 which I am giving him tonight.,Other medical history is inclusive for obstructive sleep apnea for which he is unable to tolerate positive pressure ventilation, GERD, arthritis,DISPOSITION:  ,The patient and his wife have requested and are agreeable with transfer to Medical Center, and we are enclosing the CD ROM of his images.","cardiovascular / pulmonary, standard bruce, nitroglycerin, abnormal stress test, st depressions, anginal symptoms, stress test, lad, anginal, stress"
" Abnormal echocardiogram findings and followup.  Shortness of breath, congestive heart failure, and valvular insufficiency.   The patient complains of shortness of breath, which is worsening.  The patient underwent an echocardiogram, which shows severe mitral regurgitation and also large pleural effusion.", Cardiovascular / Pulmonary, Abnormal Echocardiogram ,"REASON FOR CONSULTATION:  ,Abnormal echocardiogram findings and followup.  Shortness of breath, congestive heart failure, and valvular insufficiency.,HISTORY OF PRESENT ILLNESS:  ,The patient is an 86-year-old female admitted for evaluation of abdominal pain and bloody stools.  The patient has colitis and also diverticulitis, undergoing treatment.  During the hospitalization, the patient complains of shortness of breath, which is worsening.  The patient underwent an echocardiogram, which shows severe mitral regurgitation and also large pleural effusion.  This consultation is for further evaluation in this regard.  As per the patient, she is an 86-year-old female, has limited activity level.  She has been having shortness of breath for many years.  She also was told that she has a heart murmur, which was not followed through on a regular basis.,CORONARY RISK FACTORS: , History of hypertension, no history of diabetes mellitus, nonsmoker, cholesterol status unclear, no prior history of coronary artery disease, and family history noncontributory.,FAMILY HISTORY:  ,Nonsignificant.,PAST SURGICAL HISTORY: , No major surgery.,MEDICATIONS: , Presently on Lasix, potassium supplementation, Levaquin, hydralazine 10 mg b.i.d., antibiotic treatments, and thyroid supplementation.,ALLERGIES:  ,AMBIEN, CARDIZEM, AND IBUPROFEN.,PERSONAL HISTORY:,  She is a nonsmoker.  Does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY:  ,Basically GI pathology with diverticulitis, colitis, hypothyroidism, arthritis, questionable hypertension, no prior history of coronary artery disease, and heart murmur.,REVIEW OF SYSTEMS,CONSTITUTIONAL:  Weakness, fatigue, and tiredness.,HEENT:  History of cataract, blurred vision, and hearing impairment.,CARDIOVASCULAR:  Shortness of breath and heart murmur.  No coronary artery disease.,RESPIRATORY:  Shortness of breath.  No pneumonia or valley fever.,GASTROINTESTINAL:  No nausea, vomiting, hematemesis, or melena.,UROLOGICAL:  No frequency or urgency.,MUSCULOSKELETAL:  Arthritis and severe muscle weakness.,SKIN:  Nonsignificant.,NEUROLOGICAL:  No TIA or CVA.  No seizure disorder.,ENDOCRINE/HEMATOLOGICAL:  As above.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse of 84, blood pressure of 168/74, afebrile, and respiratory rate 16 per minute.,HEENT/NECK:  Head is atraumatic and normocephalic.  Neck veins flat.  No significant carotid bruits appreciated.,LUNGS:  Air entry bilaterally fair.  No obvious rales or wheezes.,HEART:  PMI displaced.  S1, S2 with systolic murmur at the precordium, grade 2/6.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  Chronic skin changes.  Feeble pulses distally.  No clubbing or cyanosis.,DIAGNOSTIC DATA: , EKG:  Normal sinus rhythm.  No acute ST-T changes.,Echocardiogram report was reviewed.,LABORATORY DATA:,  H&H 13 and 39.  BUN and creatinine within normal limits.  Potassium within normal limits.  BNP 9290.,IMPRESSION:,1.  The patient admitted for gastrointestinal pathology, under working treatment.,2.  History of prior heart murmur with echocardiogram findings as above.  Basically revealed normal left ventricular function with left atrial enlargement, large pleural effusion, and severe mitral regurgitation and tricuspid regurgitation.,RECOMMENDATIONS:,1.  From cardiac standpoint, conservative treatment.  Possibility of a transesophageal echocardiogram to assess valvular insufficiency adequately well discussed extensively.,2.  After extensive discussion, given her age 86, limited activity level, and no intention of undergoing any treatment in this regard from a surgical standpoint, the patient does not wish to proceed with a transesophageal echocardiogram.,3.  Based on the above findings, we will treat her medically with ACE inhibitors and diuretics and see how she fares.  She has a normal LV function.",
" Gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7", Bariatrics, Gastric Bypass Discussion - 1 ,"HISTORY OF PRESENT ILLNESS: , In short, the patient is a 55-year-old gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7 with comorbidities of hypertension, atrial fibrillation, hyperlipidemia, possible sleep apnea, and also osteoarthritis of the lower extremities.  He is also an ex-smoker.  He is currently smoking and he is planning to quit and at least he should do this six to eight days before for multiple reasons including decreasing the DVT, PE rates and marginal ulcer problems after surgery, which will be discussed later on. ,PHYSICAL EXAMINATION: , On physical examination today, he weighs 514.8 pounds, he has gained 21 pounds since the last visit with us.  His pulse is 78, temperature is 97.5, blood pressure is 132/74.  Lungs are clear.  He is a pleasant gentleman with stigmata of supermorbid obesity expected of his size.  Abdomen is soft, nontender.  No incisions.  No umbilical hernia, no groin hernia, has a large abdominal pannus.  No hepatosplenomegaly.  Lower extremities; no pedal edema.  No calf tenderness.  Deep tendon reflexes are normal.  Lungs are clear.  S1, S2 is heard.  Regular rate and rhythm. ,DISCUSSION:,  I had a long talk with the patient about laparoscopic gastric bypass possible open including risks, benefits, alternatives, need for long-term followup, need to adhere to dietary and exercise guidelines.  I also explained to him complications including rare cases of death secondary to DVT, PE, leak, peritonitis, sepsis shock, multisystem organ failure, need for reoperations, need for endoscopy for bleeding or leak, operations which could be diagnostic laparoscopy, exploratory laparotomy, drainage procedure, gastrostomy, jejunostomy for feeding, bleeding requiring blood transfusion, myocardial infarction, pneumonia, atelectasis, respiratory failure requiring mechanical ventilation, rarely tracheostomy, rare cases of renal failure requiring dialysis, etc., were all discussed. ,All these are going to be at high risk for this patient secondary to his supermorbid obese condition. ,I also explained to him specific gastric bypass related complications including gastrojejunal stricture requiring endoscopic dilatation, marginal ulcer secondary to smoking or antiinflammatory drug intake, which can progress on to perforation or bleeding, small bowel obstruction secondary to internal hernia or adhesions, signs and symptoms of which are described, so the patient could alert us for earlier intervention, symptomatic gallstone formation during rapid weight loss, how to avoid it by taking ursodiol, which will be prescribed in the postoperative period. ,Long-term complication of gastric bypass including hair loss, excess skin, multivitamin and mineral deficiencies, protein-calorie malnutrition, weight regain, weight plateauing, psychosocial and marital issues, addiction transfer, etc., were all discussed with the patient.  The patient is at higher risk than usual set of patients secondary to his supermorbid obesity of BMI nearing 70 and also major cardiopulmonary and metabolic comorbidities.  Smoking of course does not help and increase the risk for cardiopulmonary complications and is at increased risk for cardiac risk.  He will be seen by cardiologist, pulmonologist.  He will also undergo long Medifast dieting under our guidance, which is a very low-calorie diet to decrease the size of the liver and also to optimize his cardiopulmonary and metabolic comorbidities.  He will also see a psychologist, nutritionist, and exercise physiologist in preparation for surgery for a multidisciplinary approach for short and long-term success. ,Especially for him in view of his restricted mobility, supermorbid obesity status, and possibility of a pulmonary hypertension secondary to sleep apnea, he has been advised to have retrievable IVC filter and also will go home on Lovenox.  He also needs to start exercising to increase his flexibility and muscle tone before surgery and also to start getting the habit of doing so.  All these were discussed with the patient.  The patient understands.  He wants to go to surgery.  All questions were answered.  I will see him in few weeks before the planned date of surgery.","bariatrics, medifast, medifast dieting, hypertension, atrial fibrillation, hyperlipidemia, sleep apnea, morbid obesity, metabolic comorbidities, weight loss, supermorbid obesity, gastric bypass, bypass, "
 Preop evaluation regarding gastric bypass surgery., Bariatrics, Gastric Bypass - Preop Eval ,"REASON FOR VISIT:,  Preop evaluation regarding gastric bypass surgery.,The patient has gone through the evaluation process and has been cleared from psychological, nutritional, and cardiac standpoint, also had great success on the preop Medifast diet.,PHYSICAL EXAMINATION: , The patient is alert and oriented x3.  Temperature of 97.9, pulse of 76, blood pressure of 114/74, weight of 247.4 pounds.  Abdomen:  Soft, nontender, and nondistended.,ASSESSMENT AND PLAN:,  The patient is currently in stable condition with morbid obesity, scheduled for gastric bypass surgery in less than two weeks.  Risks and benefits of the procedure were reiterated with the patient and significant other and mother, which included but not limited to death, pulmonary embolism, anastomotic leak, reoperation, prolonged hospitalization, stricture, small bowel obstruction, bleeding, and infection.  Questions regarding hospital course and recovery were addressed.  We will continue on the Medifast diet until the time of surgery and cleared for surgery.","bariatrics, medifast, medifast diet, preop evaluation, gastric bypass surgery, bypass surgery, gastric bypass,"
 Patient scheduled for laparoscopic gastric bypass. , Bariatrics, Gastric Bypass Discussion - 2 ,"HISTORY: , The patient is scheduled for laparoscopic gastric bypass.  The patient has been earlier seen by Dr. X, her physician.  She has been referred to us from Family Practice.  In short, she is a 33-year-old lady with a BMI of 43, otherwise healthy with unsuccessful nonsurgical methods of weight loss. ,She was on laparoscopic gastric bypass for weight loss. ,She meets the National Institute of Health Criteria.  She is very well educated and motivated and has no major medical contraindications for the procedure.,PHYSICAL EXAMINATION:,  On physical examination today, she weighs 216 pounds with a BMI of 43.5, pulse is 96, temperature is 97.6, blood pressure is 122/80.  Lungs are clear.  Abdomen is soft, nontender.  There is stigmata for morbid obesity.  She has cesarean section scars in the lower abdomen with no herniation. ,DISCUSSION: , I had a long talk with the patient about laparoscopic gastric bypass, possible open including risks, benefits, alternatives, need for long-term followup, need to adhere to dietary and exercise guidelines.  I also explained to her complications including rare cases of death secondary to DVT, PE, leak , peritonitis, sepsis, shock, multisystem organ failure, need for re-operation including for leak or bleeding, gastrostomy or jejunostomy for feeding, rare case of respiratory failure requiring mechanical ventilation, etc., with myocardial infarction, pneumonia, atelectasis in the postoperative period were also discussed. ,Short-term complications of gastric bypass including gastrojejunal stricture requiring endoscopic dilatation, marginal ulcer secondary to smoking or anti-inflammatory drug intake which can progress on to perforation or bleeding, small bowel obstruction secondary to internal hernia or adhesions, signs and symptoms of which were discussed.  The patient would alert us for earlier intervention.  Symptomatic gallstone formation secondary to rapid weight loss were also discussed.  How to avoid it by taking ursodiol were also discussed.  Long-term complications of gastric bypass including hair loss, excess skin, multivitamin and mineral deficiencies, protein-calorie malnutrition, weight regain, weight plateauing, need for major lifestyle and exercise and habit changes, avoiding pregnancy in the first two years, etc., were all stressed.  The patient understands.  She wants to go to surgery. ,In preparation of surgery, she will undergo very low-calorie diet through Medifast to decrease the size of the liver to make laparoscopic approach more successful and also to optimize her cardiopulmonary and metabolic comorbidities.  She will also see a psychologist, nutritionist, and exercise physiologist for a multidisciplinary effort for short and long-term success for weight loss surgery.  I will see her two weeks before the plan of surgery for further discussion and any other questions at that point of time.","bariatrics, medifast, laparoscopic gastric bypass, short-term complications, long-term complications, gastric bypass, complications of gastric bypass, weight loss, "
 Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band., Bariatrics, Bariatric Consult - Surgical Weight Loss - 1 ,"PAST MEDICAL HISTORY: , She has a history of hypertension and shortness of breath.,PAST SURGICAL HISTORY: , Pertinent for cholecystectomy.,PSYCHOLOGICAL HISTORY: , Negative.,SOCIAL HISTORY: , She is single.  She drinks alcohol once a week.  She does not smoke.,FAMILY HISTORY: , Pertinent for obesity and hypertension.,MEDICATIONS: , Include Topamax 100 mg twice daily, Zoloft 100 mg twice daily, Abilify 5 mg daily, Motrin 800 mg daily, and a multivitamin.,ALLERGIES: , She has no known drug allergies.,REVIEW OF SYSTEMS: , Negative.,PHYSICAL EXAM:  ,This is a pleasant female in no acute distress.  Alert and oriented x 3.  HEENT:  Normocephalic, atraumatic.  Extraocular muscles intact, nonicteric sclerae.  Chest is clear to auscultation bilaterally.  Cardiovascular is normal sinus rhythm.  Abdomen is obese, soft, nontender and nondistended.  Extremities show no edema, clubbing or cyanosis.,ASSESSMENT/PLAN:  ,This is a 34-year-old female with a BMI of 43 who is interested in surgical weight via the gastric bypass as opposed to Lap-Band.  ABC will be asking for a letter of medical necessity from Dr. XYZ.  She will also see my nutritionist and social worker and have an upper endoscopy.  Once this is completed, we will submit her to her insurance company for approval.","bariatrics, elective surgical weight loss, surgical weight loss, weight loss, loss, weight, bmi, surgical, pounds,"
" The patient died of a pulmonary embolism, the underlying cause of which is currently undetermined.", Autopsy, Autopsy - 8 ,"SUMMARY OF CLINICAL HISTORY:,  The patient was a 35-year-old African-American male with no significant past medical history who called EMS with shortness of breath and chest pain.  Upon EMS arrival, patient was tachypneic at 40 breaths per minute with oxygen saturation of 90%.  At the scene, EMS administered breathing treatments and checked lung sounds that did not reveal any evidence of fluid in the lung fields.  EMS also reports patient was agitated upon their arrival at his residence.  Two minutes after arrival at UTMB at 1500, the patient became unresponsive, apneic, and had oxygen saturations from 80-90%.  The patient's heart rate decreased to asystole, was intubated with good breath sounds and air movement.  Patient then had wide complex bradycardia and ACLS protocol for pulseless electrical activity was followed for 45 minutes.  The patient was administered TPA with no improvement.  Bedside echocardiogram showed no pericardial effusion.  The patient was administered D5W, Narcan, and multiple rounds of epinephrine and atropine, calcium chloride, and sodium bicarbonate.  The patient had three episodes of ventricular tachycardia/fibrillation with cardioversion/defibrillation resulting in asystole.  The patient was pronounced dead at 1605 with fixed, dilated pupils, no heart sounds, no pulse and no spontaneous respirations.,DESCRIPTION OF GROSS LESIONS,EXTERNAL EXAMINATION:,  The body is that of a 35-year-old well-developed, well-nourished male.  There is no peripheral edema of the extremities.  There is an area of congestion/erythema on the upper chest and anterior neck.  There are multiple small areas of hemorrhage bilaterally in the conjunctiva.  A nasogastric tube and endotracheal tube are in place.  There is an intravenous line in the right hand and left femoral region.  The patient has multiple lead pads on the thorax.  The patient has no other major surgical scars.,INTERNAL EXAMINATION (BODY CAVITIES):,  The right and left pleural cavity contains 10 ml of clear fluid with no adhesions.  The pericardial sac is yellow, glistening without adhesions or fibrosis and contains 30 ml of a straw colored fluid.  There is minimal fluid in the peritoneal cavity.,HEART:,  The heart is large with a normal shape and a weight of 400 grams.  The pericardium is intact.  The epicardial fat is diffusely firm.  As patient was greater than 48 hours post mortem, no TTC staining was utilized.  Upon opening the heart was grossly normal without evidence of infarction.  There were slightly raised white plaques in the left ventricle wall lining.  The left ventricle measures 2.2 cm, the right ventricle measures 0.2 cm, the tricuspid ring measures 11 cm, the pulmonic right measures 8 cm, the mitral ring measures 10.2 cm, and the aortic ring measures 7 cm.  The foramen ovale is closed.  The circulation is left dominant.  Examination of the great vessels of the heart reveals minimal atherosclerosis with the area of greatest stenosis (20% stenosis) at the bifurcation of the LAD.,AORTA:,  There is minimal atherosclerosis with no measurable plaques along the full length of the ascending and descending aorta.,LUNGS: , The right lung weighed 630 grams, the left weighed 710 grams.  The lung parenchyma is pink without evidence of congestion of hemorrhage.  The bronchi are grossly normal.  In the right lung, there are two large organizing thrombo-emboli.  The first is located at the first branch of the pulmonary artery with an older, organizing area adherent to the vessel wall measuring 1.0 x 1.0 x 2.5 cm.  Surrounding this organizing area is a newer area of apparent thrombosis completely occluding the bifurcation.  The other large organizing, adherent embolus is located further in out in the vasculature measuring approximately 1.0 x 1.0 x 1.5 cm.  There are multiple other emboli located in smaller pulmonary vessels that show evidence of distending the vessels they are located inside.,GASTROINTESTINAL SYSTEM:,  The esophagus and stomach are normal in appearance without evidence of ulcers or varices.  The stomach contains approximately 800 ml, without evidence of any pills or other non-foodstuff material.  The pancreas shows a normal lobular cut surface with evidence of autolysis.  The duodenum, ileum, jejunum and colon are all grossly normal without evidence of abnormal vasculature or diverticula.  An appendix is present and is unremarkable.  The liver weighs 2850 grams and the cut surface reveals a normal liver with no fibrosis present grossly.  The gallbladder is in place with a probe patent bile duct through to the ampulla of Vater.,RETICULOENDOTHELIAL SYSTEM:,  The spleen is large weighing 340 grams, the cut surface reveals a normal appearing white and red pulp.  No abnormally large lymph nodes were noted.,GENITOURINARY SYSTEM:,  The right kidney weighs 200 grams, the left weighs 210 grams.  The left kidney contains a 1.0 x 1.0 x 1.0 simple cyst containing a clear fluid.  The cut surface reveals a normal appearing cortex and medulla with intact calyces.  The prostate and seminal vessels were cut revealing normal appearing prostate and seminal vesicle tissue without evidence of inflammation or embolus.,ENDOCRINE SYSTEM:,  The adrenal glands are in the normal position and weigh 8.0 grams on the right and 11.6 grams on the left.  The cut surface of the adrenal glands reveals a normal appearing cortex and medulla.  The thyroid gland weighs 12.4 grams and is grossly normal.,EXTREMITIES:,  Both legs and calves were measured and found to be very similar in circumference.  Both legs were also milked and produced no clots in the venous system.,CLINICOPATHOLOGIC CORRELATION,This patient died shortly after a previous pulmonary embolus completely occluded the right pulmonary artery vasculature., ,The most significant finding on autopsy was the presence of multiple old and new thromboemboli in the pulmonary vasculature of the right lung.  The autopsy revealed evidence of multiple emboli in the right lung that were at least a few days old because the emboli that were organizing were adherent to the vessel wall.  In order to be adherent to the vessel wall, the emboli must be in place long enough to evoke a fibroblast response, which takes at least a few days.  The fatal event was not the old emboli in the right lung, but rather the thrombosis on top of the large saddle thrombus residing in the pulmonary artery.  This created a high-pressure situation that the right ventricle could not handle resulting in cardiac dysfunction and ultimately the patient's demise.,Although this case is fairly straight forward in terms of what caused the terminal event, perhaps the more interesting question is why a relatively healthy 35-year-old man would develop a fatal pulmonary embolism.  Virchow's triad suggests we should investigate endothelial injury, stasis and a hypercoagulable state as possible etiologies.  The age of the patient probably precludes venous stasis as the sole reason for the embolus although it could have certainly contributed.  The autopsy revealed no evidence of endothelial damage in the pulmonary vasculature that would have caused the occlusion.  The next logical reason would be a hypercoagulable state.  Some possibilities include obesity, trauma, surgery, cancer, Factor V Leiden deficiency (as well as other inherited disorders-prothrombin gene mutation, deficiencies in protein C, protein S, or antithrombin III, and disorders of plasminogen), and Lupus anticoagulant.  Of these risks factors, obesity was the only risk factor the patient was known to have.  The patient had no evidence of trauma, surgery, cancer or the stigmata of SLE, therefore these are unlikely.  Perhaps the most fruitful search would be an examination of the genetic possibilities for a hypercoagulable state (Factor V Leiden being the most common).,In summary, this patient died of a pulmonary embolism, the underlying cause of which is currently undetermined.  A definitive diagnosis may be ascertained with either genetic or other laboratory tests and a more detailed history.,SUMMARY AND REFLECTION,WHAT I LEARNED FROM THIS AUTOPSY:,  I learned that although a cause of death may sometimes be obvious, the underlying mechanism for the death may still be elusive.  This patient was an otherwise completely healthy 35-year-old man with one known risk factor for a hypercoagulable state.,REMAINING UNANSWERED QUESTIONS:,  Basically the cause of the hypercoagulable state is undetermined.  Once that question is answered I believe this autopsy will have done a great service for the patient's family.",
 Evaluation for bariatric surgery., Bariatrics, Bariatric Consult - Surgical Weight Loss - 3 ,"PAST MEDICAL HISTORY: , Her medical conditions driving her toward surgery include hypercholesterolemia, hypertension, varicose veins, prior history of stroke.  She denies any history of cancer.  She does have a history of hepatitis which I will need to further investigate.  She complains of multiple joint pains, and heavy snoring.,PAST SURGICAL HISTORY: , Includes hysterectomy in 1995 for fibroids and varicose vein removal.  She had one ovary removed at the time of the hysterectomy as well.,SOCIAL HISTORY:,  She is a single mother of one adopted child.,FAMILY HISTORY:  ,There is a strong family history of heart disease and hypertension, as well as diabetes on both sides of her family.  Her mother is alive.  Her father is deceased from alcohol.  She has five siblings.,MEDICATIONS: , As you know she takes the following medications for her diabetes, insulin 70 units/6 units times four years, aspirin 81 mg a day, Actos 15 mg, Crestor 10 mg and CellCept 500 mg two times a day.,ALLERGIES: , She has no known drug allergies.,PHYSICAL EXAM: , She is a 54-year-old obese female.  She does not appear to have any significant residual deficits from her stroke.  There may be slight left arm weakness.,ASSESSMENT/PLAN:,  We will have her undergo routine nutritional and psychosocial assessment.  I suspect that we can significantly improve the situation with her insulin and oral hypoglycemia, as well as hypertension, with significant weight loss.  She is otherwise at increased risk for future complications given her history, and weight loss will be a good option.  We will see her back in the office once she completes her preliminary workup and submit her for approval to the insurance company.","bariatrics, evaluation for bariatric surgery, bariatric surgery, varicose veins, weight loss, varicose, veins, diabetes, bariatric, surgical, loss, surgery, hypertension, weight,"
 Autopsy - Homicide - evidence of exsanguination - multiple stab wounds., Autopsy, Autopsy - 5 ,"MANNER OF DEATH: , Homicide.,CAUSE OF DEATH:,",
 Patient suffered from morbid obesity for many years and made multiple attempts at nonsurgical weight loss without success. , Bariatrics, Discharge Summary - Gastric Bypass ,"ADMISSION DIAGNOSIS:,  Morbid obesity.  BMI is 51.,DISCHARGE DIAGNOSIS: , Morbid obesity.  BMI is 51.,PROCEDURE: , Laparoscopic gastric bypass.,SERVICE: , Surgery.,CONSULT: , Anesthesia and pain.,HISTORY OF PRESENT ILLNESS: , Ms. A is a 27-year-old woman, who suffered from morbid obesity for many years.  She has made multiple attempts at nonsurgical weight loss without success.  She underwent a preoperative workup and clearance for gastric bypass and was found to be an appropriate candidate.  She underwent her procedure.,HOSPITAL COURSE: , Ms. A underwent her procedure.  She tolerated without difficulty.  She was admitted to the floor post procedure.  Her postoperative course has been unremarkable.  On postoperative day 1, she was hemodynamically stable, afebrile, normal labs, and she was started on a clear liquid diet, which she has tolerated without difficulty.  She has ambulated and had no complaints.  Today, on postoperative day 2, the patient continues to do well.  Pain controlled with p.o. pain medicine, ambulating without difficulty, tolerating a liquid diet.  At this point, it is felt that she is stable for discharge.  Her drain was discontinued.,DISCHARGE INSTRUCTIONS:,  Liquid diet x1 week, then advance to pureed and soft as tolerated.  No heavy lifting, greater than 10 pounds x4 weeks.  The patient is instructed to not engage in any strenuous activity, but maintain mobility.  No driving for 1 to 2 weeks.  She must be able to stop in an emergency and be off narcotic pain medicine.  She may shower.  She needs to keep her wounds clean and dry.  She needs to follow up in my office in 1 week for postoperative evaluation.  She is instructed to call for any problems of shortness of breath, chest pain, calf pain, temperature greater than 101.5, any redness, swelling, or foul smelling drainage from her wounds, intractable nausea, vomiting, and abdominal pain.  She is instructed just to resume her discharge medications.,DISCHARGE MEDICATIONS:,  She was given a scripts for Lortab Elixir, Flexeril, ursodiol, and Colace.","bariatrics, laparoscopic gastric bypass, gastric bypass, morbid obesity, liquid diet, bmi, discharge,"
 Patient presented to the Bariatric Surgery Service for consideration of laparoscopic Roux-en-Y gastric bypass. , Bariatrics, Bariatric Consult - Surgical Weight Loss - 4 ,"HISTORY OF PRESENT ILLNESS:,  Ms. A is a 55-year-old female who presented to the Bariatric Surgery Service for consideration of laparoscopic Roux-en-Y gastric bypass.  The patient states that she has been overweight for approximately 35 years and has tried multiple weight loss modalities in the past including Weight Watchers, NutriSystem, Jenny Craig, TOPS, cabbage diet, grape fruit diet, Slim-Fast, Richard Simmons, as well as over-the-counter measures without any long-term sustainable weight loss.  At the time of presentation to the practice, she is 5 feet 6 inches tall with a weight of 285.4 pounds and a body mass index of 46.  She has obesity-related comorbidities, which includes hypertension and hypercholesterolemia.,PAST MEDICAL HISTORY:,  Significant for hypertension, for which the patient takes Norvasc and Lopressor for.  She also suffers from high cholesterol and is on lovastatin for this.  She has depression, for which she takes citalopram.  She also stated that she had a DVT in the past prior to her hysterectomy.  She also suffers from thyroid disease in the past though this is unclear, the nature of this.,PAST SURGICAL HISTORY: , Significant for cholecystectomy in 2008 for gallstones.  She also had a hysterectomy in 1994 secondary to hemorrhage.  The patient denies any other abdominal surgeries.,MEDICATIONS: , Norvasc 10 mg p.o. daily, Lopressor tartrate 50 mg p.o. b.i.d., lovastatin 10 mg p.o. at bedtime, citalopram 10 mg p.o. daily, aspirin 500 mg three times a day, which is currently stopped, vitamin D, Premarin 0.3 mg one tablet p.o. daily, currently stopped, omega-3 fatty acids, and vitamin D 50,000 units q. weekly.,ALLERGIES: , The patient denies allergies to medications and to latex.,SOCIAL HISTORY: , The patient is a homemaker.  She is married, with 2 children aged 22 and 28.  She is a lifelong nonsmoker and nondrinker.,FAMILY HISTORY:  ,Significant for high blood pressure and diabetes as well as cancer on her father side.  He did pass away from congestive heart failure.  Mother suffers from high blood pressure, cancer, and diabetes.  Her mother has passed away secondary to cancer.  She has two brothers one passed away from brain cancer.,REVIEW OF SYSTEMS: , Significant for ankle swelling.  The patient also wears glasses for vision and has dentures.  She does complain of shortness of breath with exertion.  She also suffers from hemorrhoids and frequent urination at night as well as weightbearing joint pain.  The patient denies ulcerative colitis, Crohn disease, bleeding diathesis, liver disease, or kidney disease.  She denies chest pain, cardiac disease, cancer, and stroke.,PHYSICAL EXAMINATION:  ,The patient is a well-nourished, well-developed female, in no distress.  Eye Exam:  Pupils equal and reactive to light.  Extraocular motions are intact.  Neck Exam:  No cervical lymphadenopathy.  Midline trachea.  No carotid bruits.  Nonpalpable thyroid.  Neuro Exam:  Gross motor strength in the upper and lower extremities, equal bilaterally with no focal neuro deficits noted.  Lung Exam:  Clear breath sounds without rhonchi or wheezes.  Cardiac Exam:  Regular rate and rhythm without murmur or bruits.  Abdominal Exam:  Positive bowel sounds.  Soft, nontender, obese, and nondistended abdomen.  Lap cholecystectomy scars noted.  No obvious hernias.  No organomegaly appreciated.  Lower extremity Exam:  Edema 1+.  Dorsalis pedis pulses 2+.,ASSESSMENT:  ,The patient is a 55-year-old female with a body mass index of 46, suffering from obesity-related comorbidities including hypertension and hypercholesterolemia, who presents to the practice for consideration of gastric bypass surgery.  The patient appears to be an excellent candidate for surgery and would benefit greatly from surgical weight loss in the management of her obesity-related comorbidities.,PLAN: , In preparation for surgery, we will obtain the usual baseline laboratory values including baseline vitamin levels.  I recommended the patient undergo an upper GI series prior to surgery due to find her upper GI anatomy.  Also the patient will meet with the dietitian and psychologist as per her usual routine.  I have recommended approximately six to eight weeks of Medifast for the patient to obtain a 10% preoperative weight loss in preparation for surgery.","bariatrics, jenny craig, medifast, nutrisystem, richard simmons, slim-fast, tops, weight watchers, cabbage diet, grape fruit diet, roux-en-y, laparoscopic roux-en-y gastric bypass, weight loss modalities, surgical weight loss, body mass index, weight loss,"
 Autopsy of a white female who died of acute combined drug intoxication., Autopsy, Autopsy - 2 ,"CLOTHING: , The body is clad in a light green hospital gown, which is intact, dry and clean. There is no jewelry present.,EXTERNAL EXAMINATION:,  The body is that of a well-developed, well-nourished white woman appearing the offered age of 39 years. The body measures 71 inches and weighs 178 pounds.,The unembalmed body is well preserved and cool to touch due to refrigeration. Rigor mortis is fully developed in the major muscle groups. Livor mortis is fixed and purple posteriorly except over pressure points. However, during initial examination in the emergency room, there was no rigor and lividity was at a minimum and unfixed. The skin is intact and shows no evidence of trauma except for medical intervention. The scalp hair is blond and measures up to 5 inches in length in the frontal area and up to 19 inches in length in the back and on top of the head. There are multiple blonde hair extensions including several pink strands attached to the natural hair, which shows light brown roots. The irides are hazel and the pupils are equal, each measuring 0.5 centimeter in diameter. The corneae are clear and the sclerae and conjunctivae are free of petechiae. The nasal bones are intact by palpation. The nares are patent and contain no foreign matter. There is a 3-millimeter raised nodule on the right side of the nose. The natural teeth are in good condition. The frenula are intact. The oral mucosa and tongue are free of injuries. The external ears have no injuries. There are bilateral earlobe piercings; no earring or jewelry were present. There are no earlobe creases.,The neck is symmetrical and shows no masses or injuries. The trachea is in the midline. The shoulders are symmetrical and are free of scars.,The chest is symmetrical and shows no evidence of injury. There were bilateral breasts with asymmetry of the left breast due to scarring. The flat abdomen has no injuries. There are piercings above and below the umbilicus. The back is symmetrical. The buttocks have inconspicuous small scars, bilaterally. There is a flat, round scar on the lower aspect of the left buttock approximately 1/2 inch in diameter.,The genitalia are those of a normally developed adult woman. There is no evidence of injury. The anus is unremarkable.,The upper extremities are symmetrical and have no injuries. The fingernails are long and clean. There is a linear 1/2 inch scar on the anterior right forearm. Two parallel linear scars measuring 1 inch and 2 inches are on the anterior surface of the left forearm.  The lower extremities are symmetrical. The toenails are short and clean. There is no edema of the legs or ankles.  There is no abnormal motion of the neck, the shoulders, the elbows, the wrists, the fingers, the hips and ankles. There is no bony crepitus or cutaneous crepitus present.,EVIDENCE OF INJURY: , A dissection of the posterior neck and upper back show a 2-1/4 x 2-3/4 inch reddish, recent contusion of the subcutaneous and superficial muscle layer of the left posterior shoulder. A recent, reddish, 1-3/4 x 1-1/2 inch reddish contusion is present on the right posterior shoulder involving the superficial muscular layer.,EVIDENCE OF RECENT MEDICAL TREATMENT: , A properly positioned size 8 endotracheal tube retained by a Thomas clamp is present at the mouth with the marker 22 at the anterior teeth.  ,Electrocardiogram pads are on the anterior chest in the following order: two on the right anterior shoulder, two on the left anterior shoulder, one on the upper anterior left arm, one each on the anterior side, one each on the anterior leg.,Two defibrillator pads are present: one to the right of the midline, above the right breast, and one to the left of the midline, below the left breast.,There is intravenous line placement at the right anterior neck with hemorrhage into the anterior strap muscles of the neck. One recent needle puncture mark is in the right antecubital fossa and two recent needle puncture marks are at the anterior left elbow with surrounding ecchymoses. There is one recent needle puncture into the medial one-third of the left anterior forearm with surrounding ecchymosis. A recent needle puncture mark is at the left anterior wrist with surrounding reddish ecchymosis, 1 inch in diameter.,OTHER IDENTIFYING FEATURES: , There are multiple scars and tattoos on the body.,SCARS:,  A 3/4 x 1/2 inch flat scar is on the upper inner aspect of the right breast quadrant. A 1/2 x 3/8-inch scar is on the medial aspect of the left nipple. There are circular scars adjacent to both areolae. The right inframammary skin has a linear transverse 3/4 inch remote ""chest tube"" scar. There were bilateral inframammary and transverse linear 3-3/4 inch scars compatible with left and right mammoplasty with breast implants. There are circular scars surrounding piercings above and below the umbilicus. A flat 3/8 inch in diameter scar is present on the middle third of the anterior surface of the right thigh. Lateral to this scar is a 1/2 inch in diameter flat scar. There are several scattered small inconspicuous scars on both buttocks. There is a cluster of multiple, parallel, linear, well-healed scars on the anterior and lateral aspects of the right leg covered by a tattoo.,TATTOOS: , There is a pair of red lips in the right lower abdominal quadrant.,Two red cherries are on the right mid pelvis.,A ""Playboy Bunny"" is on the left anterior mid pelvis.,The words ""Daniel"" and ""Papas"" are on the mid anterior pelvis region.,A mixed tattoo on the right lower leg and ankle represents: Christ's head; Our Lady of,Guadalupe; the Holy Bible; the naked torso of a woman; the smiling face of Marilyn Monroe; a,cross; a heart and shooting flames.,A mermaid on a flower bed with a pair of lips underneath it laying across the lower back.,INTERNAL EXAMINATION:  ,The body was opened with the usual Y incision. The breast tissues, when incised, revealed bilateral implants, each containing 700ml of clear fluid. The implants were surrounded by a thick connective tissue capsule with a thick yellow fluid. The content of each capsule was collected for bacteriological cultures.,BODY CAVITIES: , The muscles of the chest and abdominal wall are normal in color and consistency. The lungs are neither hyperinflated nor atelectatic when the pleural cavities are opened. The right lung shows adherence to the parietal pleura and to the diaphragm interiorly. The ribs, sternum and spine exhibit no fractures. The right and left pleural cavities have no free fluid. There are extensive right pleural fibrous adhesions. The mediastinum is in the midline. The pericardial sac has a normal amount of clear yellow fluid. The diaphragm has no abnormality. The subcutaneous abdominal fat measures 3 centimeters in thickness at the umbilicus. The abdominal cavity is lined with glistening serosa and has no collections of free fluid. The organs are normally situated. The mesentery and omentum are unremarkable.,NECK: , The soft tissues and the strap muscles of the neck, aside from the previously described focal hemorrhages, exhibit no abnormalities. The hyoid bone and the cartilages of the larynx and thyroid are intact and show no evidence of injury. The larynx and trachea are lined by smooth pink-tan mucosa, are patent and contain no foreign matter. There is a focal area of reddish hyperemia at the carina associated with the endotracheal tube. The epiglottis and vocal cords are unremarkable. The cervical vertebral column is intact. The carotid arteries and jugular veins are unremarkable.,CARDIOVASCULAR SYSTEM: , The heart and great vessels contain dark red liquid blood and little postmortem clots. The heart weighs 305 grams. The epicardial surface has a normal amount of glistening, yellow adipose tissue. The coronary arteries are free of atherosclerosis. The cut surfaces of the brown myocardium show no evidence of hemorrhage or necrosis.,The pulmonary trunk and arteries are opened in situ and there is no evidence of thromboemboli. The intimal surface of the aorta is smooth with a few scattered yellow atheromata. The ostia of the major branches are of normal distribution and dimension. The inferior vena cava and tributaries have no antemortem clots (See attached cardiopathology report for additional details).,RESPIRATORY SYSTEM:  ,The lungs weigh 550 grams and 500 grams, right and left, respectively. There is a small amount of subpleural anthracotic pigment within all the lobes. The pleural surfaces are free of exudates; right-sided pleural adhesions have been described above. The trachea and bronchi have smooth tan epithelium. The cut surfaces of the lungs are red-pink and have mild edema. The lung parenchyma is of the usual consistency and shows no evidence of neoplasm, consolidation, thromboemboli, fibrosis or calcification.,HEPATOBILIARY SYSTEM:  ,The liver weighs 2550 grams. The liver edge is somewhat blunted. The capsule is intact. The cut surfaces are red-brown and of normal consistency. There are no focal lesions. The gallbladder contains 15 milliliters of dark green bile. There are no stones. The mucosa is unremarkable. The large bile ducts are patent and non-dilated.,HEMOLYMPHATIC SYSTEM:  ,The thymus is not identified. The spleen weighs 310 grams. The capsule is shiny, smooth and intact. The cut surfaces are firm and moderately congested. The lymphoid tissue in the spleen is within a normal range. The lymph nodes throughout the body are not enlarged.,GASTROINTESTINAL SYSTEM:  ,The tongue shows a small focus of submucosal hemorrhage near the tip. The esophagus is empty and the mucosa is unremarkable. The stomach contains an estimated 30 milliliters of thick sanguinous fluid. The gastric mucosa shows no evidence or ulceration. There is a mild flattening of the rugal pattern within the antrum with intense hyperemia. The duodenum contains bile-stained thick tan fluid. The jejunum, ileum, and the colon contain yellowish fluid with a thick, cloudy, particulate matter. There is no major alteration to internal and external inspection and palpation except for a yellowish/white shiny discoloration of the mucosa. The vermiform appendix is identified. The pancreas is tan, lobulated and shows no neoplasia, calcification or hemorrhage.,There are no intraluminal masses or pseudomenbrane.,UROGENITAL SYSTEM:  ",
" Multiple sharp force injuries, involving chest and abdomen, multiple incised-stab wounds of the neck, and multiple incised or cutting wounds.", Autopsy, Autopsy - 6 ,"ANATOMICAL SUMMARY,1. Sharp force wound of neck, left side, with transection of left internal jugular vein.,2. Multiple stab wounds of chest, abdomen, and left thigh: Penetrating stab wounds of chest and abdomen with right hemothorax and hemoperitoneum.,3. Multiple incised wounds of scalp, face, neck, chest and left hand (defense wound).,4. Multiple abrasions upper extremities and hands (defense wounds).,NOTES AND PROCEDURES,1. The body is described in the Standard Anatomical Position. Reference is to this position only.,2. Where necessary, injuries are numbered for reference. This is arbitrary and does not correspond to any order in which they may have been incurred. All the injuries are antemortem, unless otherwise specified.,3. The term ""anatomic"" is used as a specification to indicate correspondence with the description as set forth in the textbooks of Gross Anatomy. It denotes freedom from significant, visible or morbid alteration.,EXTERNAL EXAMINATION:, The body is that of a well developed, well nourished Caucasian male stated to be 25 years old. The body weighs 171 pounds, measuring 69 inches from crown to sole. The hair on the scalp is brown and straight. The irides appear hazel with the pupils fixed and dilated.  The sclerae and conjunctive are unremarkable, with no evidence of petechial hemorrhages on either. Both upper and lower teeth are natural, and there are no injuries of the gums, cheeks, or lips.,There is a picture-type tattoo on the lateral aspect of the left upper arm. There are no deformities, old surgical scars or amputations.,Rigor mortis is fixed.,The body appears to the Examiner as stated above. Identification is by toe tag and  the autopsy is not material to identification. The body is not embalmed.,The head is normocephalic, and there is extensive evidence of external traumatic injury, to be described below. Otherwise, the eyes, nose and mouth are not remarkable. The neck shows sharp force injuries to be described below. The front of the chest and abdomen likewise show injuries to be described below. The genitalia are that of an adult male, with the penis circumcised, and no evidence of injury.,Examination of the posterior surface of the trunk reveals no antemortem traumatic injuries.,Refer to available photographs and diagrams and to the specific documentation of the autopsy protocol.,CLOTHING:,  The clothes were examined both before and after removal from the body.,The decedent was wearing a long-sleeved type of shirt/sweater; it was extensively bloodstained.,On the front, lower right side, there was a 1 1/2 inch long slit-like tear. Also on the lower right sleeve there was a 1 inch slit-like tear. On the back there was a 1/2 inch slit-like tear on the right lower side.,Decedent was wearing a pair of Levi jeans bloodstained.  On the outside of the left hip region there was a 1-1/2 inch long slit-like tear. The decedent also was wearing 2 canvas type boots and 2 sweat socks.,EVIDENCE OF THERAPEUTIC INTERVENTION:,  None.,EVIDENCE OF INJURY,SHARP FORCE INJURIES OF NECK,1.  Sharp force injury of neck, left side, transecting left internal jugular vein. This sharp force injury is complex, and appears to be a combination of a stabbing and cutting wound. It begins on the left side of the neck, at the level of the midlarynx, over the left sternocleidomastoid muscle; it is gaping, measuring 3 inches in length with smooth edges. It tapers superiorly to 1 inch in length cut skin. Dissection discloses that the wound path is through the skin, the subcutaneous tissue, and the sternocleidomastoid muscle with hemorrhage along the wound path and transection of the left internal jugular vein, with dark red-purple hemorrhage in the adjacent subcutaneous tissue and fascia. The direction of the pathway is upward and slightly front to back for a distance of approximately 4 inches where it exits, post-auricular, in a 2 inch in length gaping stab/incised wound which has undulating or wavy borders, but not serrated. Intersecting the wound at right angle superior inferior is a 2 inch in length interrupted superficial, linear incised wound involving only the skin. Also, intervening between the 2 gaping stab-incised wounds is a horizontally oriented 3-1/2 inch in length interrupted superficial, linear incised wound of the skin only.  In addition, there is a 1/2 inch long, linear-triangular in size wound of the inferior portion of the left earlobe.  The direction of the sharp force injury is upward (rostral), and slightly front to back with no significant angulation or deviation. The total length of the wound path is approximately 4 inches. However, there is a 3/4 inch in length, linear, cutting or incised wound of the top or superior aspect of the pinna of the left ear; a straight metallic probe placed through the major sharp force injury shows that the injury of the superior part of the ear can be aligned with the straight metallic rod, suggesting that the 3 injuries are related; in this instance the total length of the wound path is approximately 6 inches. Also, in the left postauricular region, transversely oriented, extending from the auricular attachment laterally to the scalp is a 1-1/8 inch in length linear superficial incised skin wound.,OPINION: , This sharp force injury of the neck is fatal, associated with transection of the left internal jugular vein.,2.  Sharp force wound of the right side of neck. This is a complex injury, appearing to be a combination stabbing and cutting wound. The initial wound is present on the right side of the neck, over the sternocleidomastoid muscle, 3 inches directly below the right external auditory canal. It is diagonally oriented, and after approximation of the edges measures 5/8 inch in length; there is a pointed or tapered end inferiorly and a split or forked end superiorly approximately 1/16 inch in maximal width. Subsequent autopsy shows that the wound path is through the skin and subcutaneous tissue, without penetration of injury of a major,artery or vein; the direction is front to back and upward for a total wound path length of 2 inches and the wound exits on the right side of the back of the neck, posterior to the right sternocleidomastoid muscle where a 2 inch long gaping incised/stab wound is evident on the skin; both ends are tapered; superiorly there is a 1 inch long superficial incised wounds extension on the skin to the back of the head; inferiorly there is a 2 inch long incised superficial skin extension, extending inferiorly towards the back of the neck. There is fresh hemorrhage and bruising along the wound path; the direction, as stated, is upward and slightly front to back.,OPINION: ,This is a nonfatal sharp force injury, with no injury or major artery or vein.,3.  At the level of the superior border of the larynx there is a transversely oriented, superficial incised wound of the neck, extending from 3 inches to the left of the anterior midline; it is 3 inches in length and involves the skin only; a small amount of cutaneous hemorrhage is evident.,OPINION:, This is a nonfatal superficial incised wound.,4.  ImmediateLY inferior and adjacent to incised wound #3 is a transversely oriented, superficial incised wound involving the skin and subcutaneous tissue; there is a small amount of dermal hemorrhage.,OPINION:, This is a nonfatal superficial incised wound.,SHARP FORCE INJURIES OF FACE,1.  There is a stab wound, involving the right earlobe; it is vertically oriented, and after approximation of the edges measures 1 inch in length with forked or split ends superiorly and inferiorly approximately 1/16 inch in total width both superior and inferior. Subsequent dissection discloses that the wound path is from right to left, in the horizontal plane for approximately 1-1/4 inches; there is fresh hemorrhage along the wound path; the wound path terminates in the left temporal bone and does not penetrate the cranial cavity.,OPINION:, This is a nonfatal stab wound.,2.  There is a group of 5 superficial incised or cutting wounds on the right side of the face, involving the right cheek and the right side of the jaw. They are varied in orientation both diagonal and horizontal; the smallest is 1/4 inch in length; the largest 5/8 inch in length. They are superficial, involving the skin only, associated with a small amount of cutaneous hemorrhage.,3.  On the back of the neck, right side, posterior to the ear and posterior border of the right sternocleidomastoid muscle there is vertically oriented superficial incised skin wound, measuring 3/4 inch in length.,4.  There are numerous superficial incised wounds or cuts, varied in orientation, involving the skin of the right cheek, intersection and mingled with the various superficial incised wounds described above. The longest is a 3 inch long diagonally oriented superficial incised wound extending from the right side of the forehead to the cheek; various other superficial wound vary from 1/2 to 1 inch.,5.  On the right side of the cheek, adjacent to the ramus of the mandible, right, there is a 1-1/2 x 3/4 inch superficial nonpatterned red-brown abrasion with irregular border, extending superiorly towards the angle of the jaw where there are poorly defined and circumscribed abrasions adjacent to the superficial cuts or abrasions described above. It should be noted that the 5th superficial incised wound of the right side of the mandible which measures 5/8 inch in length is tapered on the posterior aspect and forked on the anterior aspect where it has a width of 1/32 inch.,6.  On the left ear, there is a superficial incised wound measuring 1/4 inch, adjacent to the posterior border of the pinna. Just below this on the inferior pinna, extending to the earlobe, there is an interrupted superficial linear abrasion measuring 1 inch in length.",
 Autopsy - Homicide - Blunt force cranial trauma, Autopsy, Autopsy - 1 ,"EXTERNAL EXAMINATION - SUMMARY,The body is presented in a black body bag. At the time of examination, the body is clothed in a long-sleeved red cotton thermal shirt, khaki twill cargo pants, and one black shoe.,The body is that of a normally developed, well nourished Caucasian female measuring 63 inches in length, weighing 114 pounds, and appearing generally consistent with the stated age of thirty-five years. The body is cold and unembalmed with declining rigor. Pronounced unblanching lividity is present on the posterior of the body in the regions of the feet; the upper thighs, particularly on the right side; the lower back, particularly on the right side; the right arm; and the neck.,The scalp is covered by long (16 inches) brown hair. The body hair is female and average. The skull is symmetric and evidences extensive trauma in the occipital region. The eyes are open and the irises are blue. Pupils are asymmetrically dilated. The teeth are natural and well maintained. The anterior chest is of normal contour and is intact. The breasts are female and contain no palpable masses. The abdomen is flat and the pelvis is intact. The external genitalia are female and unremarkable. The back is symmetrical and intact. The upper and lower extremities are symmetric, normally developed and intact. The hands and nails are clean and evidence no injury.,There are no residual scars, markings or tattoos.,INTERNAL EXAMINATION - SUMMARY,CENTRAL NERVOUS SYSTEM: ,The brain weighs 1,303 grams and is within normal limits. ,SKELETAL SYSTEM:, Subdural hematoma and comminuted fractures of the occipital bone are observed. Numerous bone fragments from the fractures penetrated the brain tissue. ,RESPIRATORY SYSTEM--THROAT STRUCTURES: ,The oral cavity shows no lesions. The mucosa is intact and there are no injuries to the lips, teeth or gums. There is no obstruction of the airway. The mucosa of the epiglottis, glottis, piriform sinuses, trachea and major bronchi are anatomic. No injuries are seen and there are no mucosal lesions. The lungs weigh: right, 355 grams; left 362 grams. The lungs are unremarkable. ,CARDIOVASCULAR SYSTEM:, The heart weighs 253 grams, and has a normal size and configuration. No evidence of atherosclerosis is present. ,GASTROINTESTINAL SYSTEM: ,The mucosa and wall of the esophagus are intact and gray-pink, without lesions or injuries. The gastric mucosa is intact and pink without injury. Approximately 125 ml of partially digested semisolid food is found in the stomach. The mucosa of the duodenum, jejunum, ileum, colon and rectum are intact. ,URINARY SYSTEM:, The kidneys weigh: left, 115 grams; right, 113 grams. The kidneys are anatomic in size, shape and location and are without lesions. ,FEMALE GENITAL SYSTEM: ,The structures are within normal limits. Examination of the pelvic area indicates the victim had not given birth and was not pregnant at the time of death. Vaginal fluid samples are removed for analysis. ,DESCRIPTION OF INJURIES - SUMMARY,Blunt force traumatic injury with multiple cranial fractures resulting in craniocerebral injury. Wound measures approximately 4 inches high x 5 1/2 inches wide. Subdural hematoma and comminuted fractures of the occipital bone are observed. Numerous bone fragments from the fractures penetrated the brain tissue. Depths of penetration range from 1/2-inch to 3 inches. Injury appears to have resulted from a single blow administered to the posterior of the head, delivered at an approximate 90º angle to the occipital bone.,LABORATORY DATA,CEREBROSPINAL FLUID CULTURE AND SENSITIVITY:,Gram stain: Unremarkable,Culture: No growth after 72 hours,CEREBROSPINAL FLUID BACTERIAL ANTIGENS:,Hemophilus influenza B: Negative,Streptococcus pneumoniae: Negative,N. Meningitidis: Negative,Neiserria meningitidis B/E. Coli K1: Negative ,PRELIMINARY TOXICOLOGICAL RESULTS:,BLOOD  -  ETHANOL  -  NEG ,BLOOD  -  CANNABINOIDS-ETS  -  INC,BLOOD  -  COCAINE-ETS  -  INC,BLOOD  -  OPIATES-ETS  -  INC,BLOOD  -  AMPHETAMINE-ETS  -  INC,BLOOD  -  BARBITURATE -ETS  -  INC,BLOOD  -  BENZODIAZEPINE-ETS  -  INC,BLOOD  -  METHADONE-ETS  -  INC,BLOOD  -  PCP-ETS  -  INC,BLOOD  -  CARBON MONOXIDE  -  NEG,Urine Drugs: Initial test results inconclusive. Further tests pending. ,EVIDENCE COLLECTED,1. Samples of Blood (type O+), Urine, Bile, and Tissue (heart, lung, brain, kidney, liver, spleen). ,2. Thirteen autopsy photographs. ,3. Two postmortem x-rays. ,Clothing transferred to ABC Lab for further analysis. ",
 Evaluation for elective surgical weight loss via the Lap-Band as opposed to gastric bypass., Bariatrics, Bariatric Consult - Surgical Weight Loss - 2 ,"PAST MEDICAL HISTORY:  ,She had a negative stress test four to five years ago.  She gets short of breath in walking about 30 steps.  She has had non-insulin dependent diabetes for about eight years now.  She has a left knee arthritis and history of hemorrhoids.,PAST SURGICAL HISTORY: , Pertinent for laparoscopic cholecystectomy, tonsillectomy, left knee surgery, and right breast lumpectomy.,PSYCHOLOGICAL HISTORY: , Negative except that she was rehabilitated for alcohol addiction in 1990.,SOCIAL HISTORY: , The patient is married.  She is an office manager for a gravel company.  Her spouse is also overweight.  She drinks on a weekly basis and she smokes,about two packs of cigarettes over a week's period of time.  She is doing this for about 35 years.,FAMILY HISTORY: , Diabetes and hypertension.,MEDICATIONS:,  Include Colestid 1 g daily, Actos 30 mg daily, Amaryl 2 mg daily, Soma, and meloxicam for her back pain.,ALLERGIES:,  She has no allergies; however, she does get tachycardic with caffeine, Sudafed, or phenylpropanolamine.,REVIEW OF SYSTEMS: , Otherwise, negative.,PHYSICAL EXAM: , This is a pleasant female in no acute distress.  Alert and oriented x 3.  HEENT:  Normocephalic, atraumatic.  Extraocular muscles intact, nonicteric sclerae.  Chest is clear.  Abdomen is obese, soft, nontender and nondistended.  Extremities show no edema, clubbing or cyanosis.,ASSESSMENT/PLAN: , This is a 51-year-old female with a BMI of 43 who is interested in the Lap-Band as opposed to gastric bypass.  ABC will be asking for a letter of medical necessity from XYZ.  She will also need an EKG and clearance for surgery.  She will also see my nutritionist and social worker and once this is completed, we will submit her to her insurance company for approval.","bariatrics, elective surgical weight loss, surgical weight loss, weight loss, lap band, gastric bypass, loss, weight, lap, band, lost, gained, diabetes, gastric, bypass, overweight, surgical"
 Cause of death - Anoxic Encephalopathy, Autopsy, Autopsy - 7 ,"EXTERNAL EXAMINATION: , The body is that of a 62-inch, 112-pound white female who appears the recorded age of 41 years.  The body is clad in a pink and white gown.  Three pillows and a blanket are also received with the body.  The scalp is covered in thick brown hair with flecks of gray.  The irides are brown.  There is bilateral tache noire.  The eyelids are yellow and dry.  The eyes have a sunken appearance.  The ears and nose are normally developed.  The mouth has partial natural dentition.  The left upper first bicuspid through the molars are absent.  The left lower bicuspid is absent.  The right upper second molar is capped.  The left lower first molar appears decayed.  The teeth are otherwise in good repair.  The lips and buccal mucosa have no trauma.  The neck is unremarkable except for a 2.5 cm tracheostomy scar just above the suprasternal notch.  The posterior portion of the neck is unremarkable and free of scars.  An obliquely oriented 6 cm surgical scar is on the anterior left chest with an underlying, implanted, medical device.  The breasts are pendulous and otherwise unremarkable.  There is white powder underneath the breasts.  A round, 8 mm scar is on the upper central abdomen.  A horizontally oriented 2.5 cm linear scar is on the central upper abdomen.  A faint, approximately 1 cm scar is on the right mid lateral abdomen.  There are a few striae on the hips and lower abdomen.  The external genitalia are normally developed and white powder covers the perineum.  The labia are dry.  The urethral meatus is visible and 3.5 mm in diameter.  No objects or substances are in the vagina other than a slight amount of yellow-white discharge.  The anus is patent and unremarkable.  Faint, pink-white, flat, 1-2 cm scars are just above the superior portion of the gluteal cleft.  A 2.5 cm, somewhat square shaped, brown macule is on the left buttock.  There are no open and active decubitus ulcers.  The upper extremities have flexion contractures with striae on the medial portions of the upper arms.  The muscles of the extremities are atrophic.  The lower extremities are partially shaved.  The left fifth toe is absent.  The skin on the back is intact.  The spine has accentuated thoracic kyphosis and lumbar lordosis.  The skin demonstrates tenting,RADIOGRAPHS: , Postmortem radiographs show radiopaque shadows extending from the periosteum of the femurs, left tibia, and right ischial tuberosity.  Diffuse, severe osteoporosis is present.  The 11th thoracic vertebral body has an endplate fracture.  Degenerative joint changes are noted in the acromioclavicular joints, hips, right knee, left foot, and pelvis.  The left fifth toe is amputated along with the distal portion of the left fifth metatarsal.  Radiographs of anterior neck structures and iliac wings are not remarkable.  Calculi are seen in the urinary tract.  Staples are in the gallbladder bed.,INTERNAL EXAMINATION: , The muscles of the chest and abdominal wall are normally developed.  The subcutaneous tissues are dry.  The panniculus is 2.5-3 cm.  In the left chest wall is an implanted medical device with a wire extending through subcutaneous tissues of the left neck and into the left scalp.  A flat, four-prong electrical device is in the subgaleal area of the left scalp.  A wire then further extends into the cranial cavity.  The peritoneal cavity is unremarkable and dry.  There are no intraperitoneal adhesions except for an adhesion of the anterior portion of the stomach to the anterior abdominal wall in the area of the previously described round abdominal scar.  The organs are in the usual anatomic relations.  The pleural cavities are dry.  The lungs are well aerated.  The pericardial sac is remarkable for a 1 cm focal area of anterior pericardial adhesion to the anterior portion of the right ventricle.  There is some lateral adhesion of the right ventricle to the right lateral portion of the pericardial sac.  No other adhesions are noted.  The pericardial sac is dry.  The diaphragm is intact.  The sternum is unremarkable.  The ribs have no trauma and are normally developed with somewhat prominent costochondral junctions.,CARDIOVASCULAR SYSTEM: , The pericardial sac is remarkable as previously described.  The epicardial fat of the 255 gram heart is otherwise unremarkable.  The root of the aorta has no atherosclerosis.  The arch and descending aorta have minimal atherosclerosis (see attached CV pathology report).,RESPIRATORY SYSTEM: , The right and left lungs are 260 and 245 grams, respectively.  The lungs have a normal number of lobes and have light pink-red outer surfaces.  The bronchi are unobstructed.  The well-aerated lung parenchyma is pink-red.  There are no anthracosis, tumors, cysts, or infarcts.  The upper lobe bronchi contain a scant amount pearlescent fluid.  The proximal bronchi contain yellow pearlescent fluid.  The lower lobe distal bronchi contain some scattered areas of yellow pearlescent fluid.  The alveoli otherwise contain foamy, reddish-white fluid.  The pulmonary arteries contain no emboli.  The lower lobes have firm areas of partial consolidation with yellow-green pearlescent fluid.  The firm area of the left lower lobe is ,4 x 4 x 3 cm.  The right lung has scattered firm areas (<lcm).,HEMOLYMPHATIC SYSTEM: , The 215 gram spleen is covered in an intact, gray, somewhat wrinkled capsule.  There are two hilar accessory spleens (1.4 and 1 cm in diameter).  The splenic parenchyma is dark red-maroon and unremarkable.  There is no interstitial fibrosis, tumors, cysts or infarcts.  No enlarged lymph nodes are noted.  The bone marrow of the lumbar vertebral bodies is red and soft.,GENITOURINARY SYSTEM:,  The right and left kidneys are 100 and 130 grams, respectively.  The right kidney has a central, 2-2.5 cm, obliquely oriented cleft/scar extending from the central renal pelvis to the upper lateral cortex.  The brown-tan outer surfaces are otherwise slightly lobular and granular.  The pelvis of the right kidney is mildly dilated.  A 1 x 0.6 x 0.7 cm, green-brown stone is in the pelvis of the right kidney.  The left renal pelvis has an approximately 0.5 x 0.6 x 1 cm, green-brown stone.  The corticomedullary ratios are reduced.  The pelvic fat is increased.  The left ureter contains pearlescent fluid.  The urinary bladder contains ,6 cc of brown-yellow fluid.  A 3.8 x 1.2 x 1 cm, white-yellow, somewhat crescent shaped stone is within the lumen of the bladder.  The uterus is present and has a normal shape.  The cervix is normally developed.  The cervical os is large (coned) and contains mucoid fluid.  There are a few minute nabothian cysts (<2 mm).  A 2 cm, spherical leiomyoma is in the posterior portion of the uterine corpus.  The endometrial cavity contains 3 to 4 mm thick, tan endometrium.  The ovaries are present, firm and otherwise grossly unremarkable.  The fallopian tubes are unremarkable except for a few adhesions of the fimbriated ends.,GASTROINTESTINAL SYSTEM:,  The stomach contains 60 cc of green-brown fluid without any solid food fragments.  The gastric mucosa is flat, congested, and green-gray.  The gastric mucosa is congested.  No ulcerations are noted.  There are a few congested vessels with minute petechiae around the previously healed ostomy site.  An 8 mm blood clot is on the gastric mucosa near the healed/healing gastrostomy site.  The wall of the stomach is thin (<3mm).  No perforations are noted.  The esophagus is not remarkable with gray/pink mucosa.  The bowel contains progressively formed feces with the rectum containing hard stool.  The appendix is present, but is atrophic/small.  The bowel has no perforations.  An abundant amount of greenish liquid is in the duodenum.  No foreign objects are noted.,HEPATOBILIARY SYSTEM:,  The outer surface of the 965 gram liver is covered in a transparent intact capsule.  There are very few inferior hepatic adhesions associated with an absent gallbladder.  Surgical staples are imbedded in the area of the cystic duct.  The hepatic parenchyma is brown-green with a slight pattern of congestion.  The bile ducts and portal veins appear grossly unremarkable.  No fibrosis, cysts or infarcts are noted.  A yellow-white, round, 2 mm nodule is in the anterior portion of the right lobe of the liver.,ENDOCRINE SYSTEM: , The adrenals and pancreas are present and grossly unremarkable.  The thyroid is mildly atrophic without nodules.,MUSCULOSKELETAL SYSTEM: , The upper and lower extremities are atrophic as previously described.  The trunk musculature is atrophic.  A 1 x 1.5 x ,1 cm area of induration/calcification extends from the anterior surface of the right femur.  The anterior/lateral cortical surface of the distal right femur metaphysis is rough and irregular.  The cortical bone of the lumbar and thoracic vertebral bodies is thin and soft.  The iliac wings have no trauma or deformity.,NECK: , The strap muscles of the anterior neck have intact musculature with atrophy of the musculature on the right side.  The right sternocleidomastoid is moderately atrophic.  There are no hemorrhages.  The larynx and piriform recesses contain yellow-tan, mucoid fluid.  There is yellow-green, mucoid fluid on the base of the tongue and epiglottis.  The larynx contains a scant amount of fluid.  The thyroid and cricoid cartilages are intact.  The hyoid bone is intact.  The tongue is atrophic.  There is a yellow-green dry crusted material on the surface of the tongue.  The posterior pharyngeal musculature appears atrophic.  There are no hemorrhages.  A healed tracheostomy site is on the anterior trachea.  The carotid arteries and jugular veins are not remarkable.  The muscles and cervical vertebral bodies of the posterior neck are not remarkable.  The spinal cord and column have no trauma.  The posterior laminae are soft.,CENTRAL NERVOUS SYSTEM: , See neuropathology report,MICROSCOPIC EXAMINATION: , (Also see neuropathology and cardiovascular pathology reports),LUNGS, LOWER LOBES:  Widespread bronchopneumonia.  Intraalveolar debris and bacteria.,Intraalveolar foamy macrophages.  Congestion.  Edema.,UTERUS:  Late proliferative endometrium leiomyoma.,ACCESSORY SPLEEN:  Not remarkable.,COLON:  Autolysis.  Melanosis.,URINARY BLADDER:  Chronic inflammation.,OVARIES:  Corpora albicantia.  Follicular cyst.,FALLOPIAN TUBES:  Paratubal cyst.  Congestion.,VAGINA:  Vascular congestion.,ADRENAL GLANDS:  Mild congestion.,STOMACH, GASTROSTOMY:  Clotted blood.,LIVER:  Focal nodular hyperplasia (single focus).  Centrilobular congestion with steatosis,KIDNEYS:  Tubular necrosis.  Mild vascular congestion.,THYROID:  Not remarkable.,PANCREAS:  Early autolysis.  Mild interstitial fibrosis.,EPIGLOTTIS:  Focal ulceration with acute inflammation.,LARYNX, RIGHT ARYEPIGLOTTIC FOLD:  Not remarkable.",
 Autopsy - Asphyxia due to ligature strangulation., Autopsy, Autopsy - 3 ,"EXTERNAL EXAMINATION: , The autopsy is begun at 8:30 A.M. on May 24, 2004. The body is presented in a black body bag. The victim is wearing a white sleeveless turtleneck shirt and navy blue sweatpants. Jewelry included two smooth-textured silver hoop pierced earrings, 1-inch diameter, one in each ear, and one 1-inch wide silver expandable wristband on left wrist. A 1.5-inch wide tan belt with green stripes is cinched around the upper neck using the buckle. The opposite end of the belt is tied in a half-hitch knot, which was used to affix it to the crossbar in the closet where the body was found. ,The body is that of a normally developed white female measuring 67 inches and weighing 118 pounds, and appearing generally consistent with the stated age of twenty-six years. The body is cold and unembalmed. Lividity is fixed in the distal portions of the limbs. The eyes are open. The irises are brown and corneas are cloudy. Petechial hemorrhaging is present in the conjunctival surfaces of the eyes. The pupils measure 0.3 cm. The hair is dark blonde with lighter blonde highlights, wavy, layered and approximately 11 inches in length at the longest point. ,Removal of the belt revealed a ligature mark (known throughout this report as Ligature A) on the neck below the mandible. Ligature A is approximately 1.5 inches wide and encircles the neck in the form of a ""V"" on the anterior of the neck and an inverted ""V"" on the posterior of the neck, consistent with hanging. Minor abrasions are present in the area of Ligature A. Lack of hemorrhage surrounding Ligature A indicates this injury to be post-mortem. ,Upon removal of the victim's clothing, an odor of bleach was detected. Areas of the body were swabbed and submitted for detection of hypochlorite. Following removal of the shirt, a second ligature mark (known throughout this report as Ligature B) was observed on the victim's neck. The mark is dark red ligature and encircles the neck, crossing the anterior midline of the neck just below the laryngeal prominence. The width of the mark varies between 0.8 and 1cm and is horizontal in orientation. The skin of the anterior neck above and below the ligature mark shows petechial hemorrhaging. Ligature B is not consistent with the belt that caused Ligature A. The absence of abrasions associated with Ligature B, along with the variations in the width of the ligature mark, are consistent with a soft ligature, such as a length of fabric. No trace evidence was recovered from Ligature B that might assist in identification of the ligature used. ,The genitalia are that of an adult female and there is no evidence of injury. Pubic hair has been shaved in its entirety within six hours of death. Limbs are equal, symmetrically developed and show no evidence of injury. The fingernails are medium length and fingernail beds are blue. There are no residual scars, markings or tattoos.,INTERNAL EXAMINATION:  ,HEAD--CENTRAL NERVOUS SYSTEM: ,Subsequent autopsy shows a broken hyoid bone. Hemorrhaging from Ligature B penetrates the skin and subdermal tissues of the neck. The brain weighs 1,303 grams and within normal limits. ,SKELETAL SYSTEM:, The hyoid bone is fractured. ,RESPIRATORY SYSTEM--THROAT STRUCTURES: ,The oral cavity shows no lesions. Petechial hemorrhaging is present in the mucosa of the lips and the interior of the mouth. Otherwise, the mucosa is intact and there are no injuries to the lips, teeth or gums. ,There is no obstruction of the airway. The mucosa of the epiglottis, glottis, piriform sinuses, trachea and major bronchi are anatomic. No injuries are seen and there are no mucosal lesions. The hyoid bone, the thyroid, and the cricoid cartilages are fractured. ,The lungs weigh: right, 355 grams; left 362 grams. The lungs are unremarkable. ,CARDIOVASCULAR SYSTEM: ,The heart weighs 253 grams, and has a normal size and configuration. No evidence of atherosclerosis is present. ,GASTROINTESTINAL SYSTEM: ,The mucosa and wall of the esophagus are intact and gray-pink, without lesions or injuries. The gastric mucosa is intact and pink without injury. Approximately 125 ml of partially digested semisolid food is found in the stomach. The mucosa of the duodenum, jejunum, ileum, colon and rectum are intact. ,URINARY SYSTEM: ,The kidneys weigh: left, 115 grams; right, 113 grams. The kidneys are anatomic in size, shape and location and are without lesions. ,FEMALE GENITAL SYSTEM: ,The structures are within normal limits. Examination of the pelvic area indicates the victim had not given birth and was not pregnant at the time of death. There is evidence of recent sexual activity but no indications that the sexual contact was forcible. Vaginal fluid samples are removed for analysis. ,TOXICOLOGY: ,Sample of right pleural blood and bile are submitted for toxicologic analysis. Stomach contents are saved. ,SEROLOGY:, A sample of right pleural blood is submitted in the EDTA tube. Routine toxicologic studies were ordered.,LABORATORY DATA,CEREBROSPINAL FLUID CULTURE AND SENSITIVITY:,Gram stain: Unremarkable,Culture: No growth after 72 hours,CEREBROSPINAL FLUID BACTERIAL ANTIGENS:,Hemophilus influenza B: Negative,Streptococcus pneumoniae: Negative,N. Meningitidis: Negative,Neiserria meningitidis B/E. Coli K1: Negative ,Drug Screen Results:,URINE SCREEN {IMMUNOASSAY} WAS NEGATIVE. ,Ethanol: 0 gm/dl, Blood (Heart),Ethanol: 0 gm/dl, Vitreous ,EVIDENCE COLLECTED:,1. One (1) white turtleneck sleeveless shirt, size Small. ,2. One (1) pair navy blue sweatpants, size Small.,3. Two (2) silver hoop earrings. ,4. One (1) silver bracelet.,5. Samples of Blood (type O+), Bile, and Tissue (heart, lung, brain, kidney, liver, spleen). ,6. Fifteen (15) swabs from various body locations, to be tested for presence of hypochlorite.,7. Eleven (11) autopsy photographs. ",
 Autopsy - Ligature strangulation and craniocerebral injuries., Autopsy, Autopsy - 4 ,"FINAL DIAGNOSIS: ,I. Ligature strangulation.,A. Circumferential ligature with associated ligature furrow of neck.,B. Abrasions and petechial hemorrhages, neck.,C. Petechial hemorrhages, conjunctival surfaces of eyes and skin of face.,II. Craniocerebral injuries.,A. Scalp contusion.,B. Linear, comminuted fracture of right side of skull.,C. Linear pattern of contusions of right cerebral hemisphere.,D. subarachnoid and subdural hemorrhage.,E. Small contusions, tips of temporal lobes.,III. Abrasion of right cheek.,IV. Abrasion/contusion, posterior right shoulder.,V. Abrasions of left lower back and posterior left lower leg.,VI. Abrasion and vancular congestion of vaginal mucosa.,VII. Ligature of right wrist.,TOXICOLOGIC STUDIES ,Blood ethanol - none detected.,Blood drug screen - no drugs detected.,CLINOCOPATHOLIGICAL CORRELATION:, Cause of death of this six year old female is asphyxia by strangulation associated with craniocerebral trauma. ,The body of this six year old female was first seen by me after I was called to an address XYZ, on 12/26/96. I arrived at the scene approximately 8 PM on 12/26 and entered the house where the decedent's body was located at approximately 8:20 PM. ,A brief examination of the body disclosed a ligature around the neck and a ligature around the right wrist. Also noted was a small area of abrasion or contusion below the right ear on the lateral aspect of the right cheek. A prominent dried abrasion was present on the lower left neck. After examining the body, I left the residence at approximately 8:30 PM. ,EXTERNAL EVIDENCE OF INJURY:, Located just below the right ear at the right angle of the mandible, 1.5 inches below the right external auditory canal is a 3/8 x 1/4 inch area of rust colored abrasion. In the lateral aspect of the left lower eyelid on the inner conjunctival surface is a 1 mm in maximum dimension petechial hemorrhage. Very fine, less than 1 mm petechial hemorrhages are present on the skin of the upper eyelids bilaterally as well as on the lateral left cheek. On everything the left upper eyelid there are much smaller, less than 1 mm petechial hemorrhages located on the conjunctival surface. Possible petechial hemorrhages are also seen on the conjunctival surfaces of the right upper and lower eyelids, but liver mortis on this side of the face makes definite identification difficult. ,A deep ligature furrow encircles the entire neck. The width of the furrow varies from one- eight of an inch to five/sixteenths of an inch and is horizontal in orientation, with little upward deviation. The skin of the anterior neck above and below the ligature furrow contains areas of petechial hemorrhage and abrasion encompassing an area measuring approximately 3 x 2 inches. The ligature furrow crosses the anterior midline of the neck just below the laryngeal prominence, approximately at the level of the cricoid cartilage. It is almost completely horizontal with slight upward deviation from the horizontal towards the back of the neck. The midline of the furrow mark on the anterior neck is 8 inches below the top of the head. The midline of the furrow mark on the posterior neck is 6.75 inches below the top of the head. ,The area of abrasion and petechial hemorrhage of the skin of the anterior neck includes on the lower left neck, just to the left of the midline, a roughly triangular, parchment-like rust colored abrasion which measures 1.5 inches in length with a maximum width of 0.75 inches. This roughly triangular shaped abrasion is obliquely oriented with the apex superior and lateral. The remainder of the abrasions and petechial hemorrhages of the skin above and below the anterior projection of the ligature furrow are nonpatterned, purple to rust colored, and present in the midline, right, and left areas of the anterior neck. The skin just above the ligature furrow along the right side of the neck contains petechial hemorrhage composed of multiple confluent very small petechial hemorrhages as well as several larger petechial hemorrhages measuring up to one-sixteenth and one-eight of an inch in maximum dimension. Similar smaller petechial hemorrhages are present on the skin below the ligature furrow on the left lateral aspect of the neck. Located on the right side of the chin is a three-sixteenths by one-eight of an inch area of superficial abrasion. On the posterior aspect of the right shoulder is a poorly demarcated, very superficial focus of abrasion/contusion which is pale purple in color and measures up to three-quarters by one-half inch in maximum dimension. Several linear aggregates of petechial hemorrhages are present in the anterior left shoulder just above deltopectoral groove. These measure up to one inch in length by one-sixteenth to one-eight of an inch in width. On the left lateral aspect of the lower back, approximately sixteen and one-quarter inches and seventeen and one-half inches below the level of the top of the head are two dried rust colored to slightly purple abrasions. The more superior of the two measures one-eight by one-sixteenth of an inch and the more inferior measures three-sixteenths by one-eight of an inch. There is no surrounding contusion identified. On the posterior aspect of the left lower leg, almost in the midline, approximately 4 inches above the level of the heel are two small scratch-like abrasions which are dried and rust colored. They measure one-sixteenth by less than one- sixteenth of an inch and one-eight by less than one-sixteenth of an inch respectively. ,On the anterior aspect of the perineum, along the edges of closure of the labia majora, is a small amount of dried blood. A similar small amount of dried and semifluid blood is present on the skin of the fourchette and in the vestibule. Inside the vestibule of the vagina and along the distal vaginal wall is reddish hyperemia. This hyperemia is circumferential and perhaps more noticeable on the right side and posteriorly. The hyperemia also appears to extend just inside the vaginal orifice. A 1 cm red-purple area of abrasion is located on the right posterolateral area of the 1 x 1 cm hymeneal orifice. The hymen itself is represented by a rim of mucosal tissue extending clockwise between the 2 and 10:00 positions. The area of abrasion is present at approximately the 7:00 position and appears to involve the hymen and distal right lateral vaginal wall and possibly the area anterior to the hymen. On the right labia majora is a very faint area of violent discoloration measuring approximately one inch by three-eighths of an inch. Incision into the underlying subcutaneous tissue discloses no hemorrhage. A minimal amount of semiliquid thin watery red fluid is present in the vaginal vault. No recent or remote anal or other perineal trauma is identified. ,REMAINDER OF EXTERNAL EXAMINATION:, The unembalmed, well developed and well nourished Caucasian female body measures 47 inches in length and weighs an estimated 45 pounds. ,No scalp trauma is identified. The external auditory canals are patent and free of blood. The eyes are green and the pupils equally dilated. The sclerae are white. The nostrils are both patent and contain a small amount of tan mucous material. The teeth are native and in good repair. The tongue is smooth, pink-tan and granular. No buccal mucosal trauma is seen. The frenulum is intact. There is slight drying artifact of the tip of the tongue. On the right cheek is a pattern of dried saliva and mucous material which does not appear to be hemorrhagic. The neck contains no palpable adenopathy or masses and the trachea and larynx are midline. The chest is symmetrical. Breasts are prepubescent. The abdomen is flat and contains no scars. No palpable organomegaly or masses are identified. The external genitalia are that of a prepubescent female. No pubic hair is present. The anus is patent. Examination of the extremities is unremarkable. ,The fingernails of both hands are of sufficient length for clipping. Examination of the back is unremarkable. There is dorsal 3+ to 4+ livor mortis which is nonblanching. Livor mortis is also present on the right side of the face. At the time of the initiation of the autopsy there is mild 1 to 2+ rigor mortis of the elbows and shoulders with more advanced 2 to 3+ rigor mortis of the joints of the lower extremities. ,INTERNAL EXAM:, The anterior chest musculature is well developed. No sternal or rib fractures are identified. ,MEDIASTINUM: ,The mediastinal contents are normally distributed. The 21 gm thymus gland has a normal external appearance. The cut sections are finely lobular and pink-tan. No petechial hemorrhages are seen. The aorta and remainder of the mediastinal structures are unremarkable. ,BODY CAVITIES: ,The right and left thoracic cavities contain approximately 5 cc of straw colored fluid. The pleural surfaces are smooth and glistening. The pericardial sac contains 3-4 cc of straw colored fluid and the epicardium and pericardium are unremarkable. The abdominal contents are normally distributed and covered by a smooth glistening serosa. No intra-abdominal accumulation of fluid or blood is seen. ,LUNGS: ,The 200 gm right lung and 175 gm let lung have a normal lobar configuration. An occasional scattered subpleural petechial hemorrhage is seen on the surface of each lung. The cut sections of the lungs disclose an intact alveolar architecture with a small amount of watery fluid exuding from the cut surfaces with mild pressure. The intrapulmonary bronchi and vasculature are unremarkable. No evidence of consolidation is seen. ,HEART: ,The 100 gm heart has a normal external configuration. There are scattered subepicardial petechial hemorrhages over the anterior surface of the heart. The coronary arteries are normal in their distribution and contain no evidence of atherosclerosis. The tan- pink myocardium is homogeneous and contains no areas of fibrosis or infarction. The endocardium is unremarkable. The valve cusps are thin, delicate and pliable and contain no vegetation or thrombosis. The major vessels enter and leave the heart in the normal fashion. The foramen ovale is closed. ,AORTA AND VENA CAVA: ,The aorta is patent throughout its course as are its major branches. No atherosclerosis is seen. The Vena Cava is unremarkable. ,SPLEEN: ,The 61 gm spleen has a finely wrinkled purple capsule. Cut sections are homogeneous and disclose readily identifiable red and white pulp. No intrinsic abnormalities are identified. ,ADRENALS: ,The adrenal glands are of normal size and shape. A golden yellow cortex surmounts a thin brown-tan medullary area. No intrinsic abnormalities are identified. ",
" Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.", Allergy / Immunology, Evaluation of Allergies ,"HISTORY:,  A 55-year-old female presents self-referred for the possibility of evaluation and treatment of allergies, diminished taste, xerostomia, gastroesophageal reflux disease, possible food allergies, chronic GI irritability, asthma, and environmental inhalant allergies.  Please refer to chart for history and physical and review of systems and detailed medical history.,IMPRESSION:  ,1.  Chronic glossitis/xerostomia/probable environmental inhalant allergies/probable food allergies/history of asthma.,2.  History of fibromyalgia.,3.  History of peptic ulcer disease, history of gastritis, history of gastroesophageal disease.,4.  History of chronic fatigue.,5.  History of hypothyroidism.,6.  History of depression.,7.  History of dysphagia.,RECOMMENDATIONS: , RAST allergy testing was ordered for food allergy evaluation.  The patient had previous allergy testing done less than one year ago iby Dr. X, which was requested.  The patient will follow up after RAST allergy testing for further treatment recommendations.  At this point, no changes in her medication were prescribed until her followup visit.","allergy / immunology, chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, environmental inhalant allergies, rast allergy testing, rast, inhalant, food, allergy"
" Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.", Allergy / Immunology, Chronic Sinusitis ,"HISTORY:,  I had the pleasure of meeting and evaluating the patient referred today for evaluation and treatment of chronic sinusitis.  As you are well aware, she is a pleasant 50-year-old female who states she started having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.  She states she really has sinus problems, but this infection has been rather severe and she notes she has not had much improvement with antibiotics.  She had a CT of her paranasal sinuses identifying mild mucosal thickening of right paranasal sinuses with occlusion of the ostiomeatal complex on the right and turbinate hypertrophy was also noted when I reviewed the films and there is some minimal nasal septum deviation to the left.  She currently is not taking any medication for her sinuses.  She also has noted that she is having some problems with her balance and possible hearing loss or at least ear popping and fullness.  Her audiogram today demonstrated mild high frequency sensorineural hearing loss, normal tympanometry, and normal speech discrimination.  She has tried topical nasal corticosteroid therapy without much improvement.  She tried Allegra without much improvement and she believes the Allegra may have caused problems with balance to worsen.  She notes her dizziness to be much worse if she does quick positional changes such as head turning or sudden movements, no ear fullness, pressure, humming, buzzing or roaring noted in her ears.  She denies any previous history of sinus surgery or nasal injury.  She believes she has some degree of allergy symptoms.,PAST MEDICAL HISTORY:  ,Seasonal allergies, possible food allergies, chronic sinusitis, hypertension and history of weight change.  She is currently 180 pounds.,PAST SURGICAL HISTORY:,  Lower extremity vein stripping, tonsillectomy and adenoidectomy.,FAMILY HISTORY: , Strong for heart disease and alcoholism.,CURRENT MEDICATIONS: , DynaCirc.,ALLERGIES: , Egg-based products cause hives.,SOCIAL HISTORY:  ,The patient used to smoke cigarettes for about 20 years, one-half pack a day.  She currently does not, which was encouraged to continue.  She rarely drinks any alcohol-containing beverages.,PHYSICAL EXAMINATION: ,VITAL SIGNS:  Age 50, blood pressure is 136/74, pulse 84, temperature is 98.4, weight is 180 pounds, and height is 5 feet 3 inches.,GENERAL:  The patient is healthy appearing; alert and oriented to person, place and time; responds appropriately; in no acute distress.,HEAD:  Normocephalic.  No masses or lesions noted.,FACE:  No facial tenderness or asymmetry noted.,EYES:  Pupils are equal, round and reactive to light and accommodation bilaterally.  Extraocular movements are intact bilaterally.  No nystagmus.,EARS:  During Hallpike examination, the patient did not become dizzy until she would be placed back into sitting in the upright position.  No nystagmus was appreciated; however, the patient did subjectively report dizziness, which was repeated twice.  No evidence of any orthostatic hypotension was noted during the exam.  Tympanic membranes were noted to be intact.  No signs of middle ear effusion or ear canal inflammation.,NOSE:  The patient appears congested.  Turbinate hypertrophy is noted.  There are no signs of any acute sinusitis.  Septum is midline, slightly deviated to the left.,THROAT:  There is clear postnasal drip.  Oral hygiene is good.  No masses or lesions noted.  Both vocal cords move well to midline.,NECK:  The neck is supple with no adenopathy or masses palpated.  The trachea is midline.  The thyroid gland is of normal size with no nodules.,LUNGS:  Clear to auscultation bilaterally.  No wheeze noted.,HEART:  Regular rate and rhythm.  No murmur noted.,NEUROLOGIC:  Facial nerve is intact bilaterally.  The remaining cranial nerves are intact without focal deficit.,PROCEDURE: , Fiberoptic nasopharyngoscopy identifying turbinate hypertrophy and nasal septum deviation to the left, more significant posteriorly.,IMPRESSION:  ,1.  Probable increasing problems with allergic rhinitis and chronic sinusitis, both contributing to the patient's symptoms.,2.  Subjective dizziness, etiology uncertain; however, consider positional vertigo versus vestibular neuronitis as possible ear causes of dizziness, cannot rule out systemic, central or medication or causes at this time.,3.  Inferior turbinate hypertrophy.,4.  Nasal septum deformity.,RECOMMENDATIONS:,  An ENG was ordered to evaluate vestibular function.  She was placed on Veramyst nasal spray two sprays each nostril daily and even twice daily if symptoms are worsening.  A Medrol Dosepak was prescribed as directed.  The patient was given instruction on use of nasal saline irrigation to be used twice daily and Clarinex 5 mg daily was recommended.  After the patients' ENG examination, we will see the patient back for further evaluation and treatment recommendations.  In light of the patient's atypical dizziness symptoms, I cannot rule out other pathology at this time, and I informed her if there are any acute changes or problems with regards to her balance or any other acute changes, which she attributes associated with her dizziness, she most likely should pursue an emergent visit to the emergency room.,Thank you for allowing me to participate with the care of your patient.",
" This is a 14-month-old baby boy Caucasian who came in with presumptive diagnosis of Kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated neutrophils and thrombocytosis, elevated CRP and ESR. ", Allergy / Immunology, Kawasaki Disease - Discharge Summary ,"ADMITTING DIAGNOSIS: , Kawasaki disease.,DISCHARGE DIAGNOSIS:,  Kawasaki disease, resolving.,HOSPITAL COURSE:,  This is a 14-month-old baby boy Caucasian who came in with presumptive diagnosis of Kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated neutrophils and thrombocytosis, elevated CRP and ESR.  When he was sent to the hospital, he had a fever of 102.  Subsequently, the patient was evaluated and based on the criteria, he was started on high dose of aspirin and IVIG.  Echocardiogram was also done, which was negative.  IVIG was done x1, and between 12 hours of IVIG, he spiked fever again; it was repeated twice, and then after second IVIG, he did not spike any more fever.  Today, his fever and his rash have completely resolved.  He does not have any conjunctivitis and no redness of mucous membranes.  He is more calm and quite and taking good p.o.; so with a very close followup and a cardiac followup, he will be sent home.,DISCHARGE ACTIVITIES:,  Ad-lib.,DISCHARGE DIET: , PO ad-lib.,DISCHARGE MEDICATIONS: , Aspirin high dose 340 mg q.6h. for 1 day and then aspirin low dose 40 mg q.d. for 14 days and then Prevacid also to prevent his GI from aspirin 15 mg p.o. once a day.  He will be followed by his primary doctor in 2 to 3 days.  Cardiology for echo followup in 4 to 6 weeks and instructed not to give any vaccine in less than 11 months because of IVIG, all the live virus vaccine, and if he gets any rashes, any fevers, should go to primary care doctor as soon as possible.","allergy / immunology, mucous membranes, conjunctivitis, ad lib, kawasaki disease, vaccine, fever, aspirin"
 A female for a complete physical and follow up on asthma with allergic rhinitis., Allergy / Immunology, Followup on Asthma ,"SUBJECTIVE: , This is a 42-year-old white female who comes in today for a complete physical and follow up on asthma.  She says her asthma has been worse over the last three months.  She has been using her inhaler daily.  Her allergies seem to be a little bit worse as well.  Her husband has been hauling corn and this seems to aggravate things.  She has not been taking Allegra daily but when she does take it, it seems to help somewhat.  She has not been taking her Flonase which has helped her in the past.  She also notes that in the past she was on Advair but she got some vaginal irritation with that.,She had been noticing increasing symptoms of irritability and PMS around her menstrual cycle.  She has been more impatient around that time.  Says otherwise her mood is normal during the rest of the month.  It usually is worse the week before her cycle and improves the day her menstrual cycle starts.  Menses have been regular but somewhat shorter than in the past.  Occasionally she will get some spotting after her cycles.  She denies any hot flashes or night sweats with this.  In reviewing the chart it is noted that she did have 3+ blood with what appeared to be a urinary tract infection previously.  Her urine has not been rechecked.  She recently had lab work and cholesterol drawn for a life insurance application and is going to send me those results when available.,REVIEW OF SYSTEMS: , As above.  No fevers, no headaches, no shortness of breath currently.  No chest pain or tightness.  No abdominal pain, no heartburn, no constipation, diarrhea or dysuria.  Occasional stress incontinence.  No muscle or joint pain.  No concerns about her skin.  No polyphagia, polydipsia or polyuria.,PAST MEDICAL HISTORY: , Significant for asthma, allergic rhinitis and cervical dysplasia.,SOCIAL HISTORY: , She is married.  She is a nonsmoker.,MEDICATIONS: , Proventil and Allegra.,ALLERGIES: , Sulfa.,OBJECTIVE:,Vital signs:  Her weight is 151 pounds.  Blood pressure is 110/60.  Pulse is 72.  Temperature is 97.1 degrees.  Respirations are 20.,General:  This is a well-developed, well-nourished 42-year-old white female, alert and oriented in no acute distress.  Affect is appropriate and is pleasant.,HEENT:  Normocephalic, atraumatic.  Tympanic membranes are clear.  Conjunctivae are clear.  Pupils are equal, round and reactive to light.  Nares without turbinate edema.  Oropharynx is nonerythematous.,Neck:  Supple without lymphadenopathy, thyromegaly, carotid bruit or JVD.,Chest:  Clear to auscultation bilaterally.,Cardiovascular:  Regular rate and rhythm without murmur.,Abdomen:  Soft, nontender, nondistended.  Normoactive bowel sounds.  No masses or organomegaly to palpation.,Extremities:  Without cyanosis or edema.,Skin:  Without abnormalities.,Breasts:  Normal symmetrical breasts without dimpling or retraction.  No nipple discharge.  No masses or lesions to palpation.  No axillary masses or lymphadenopathy.,Genitourinary:  Normal external genitalia.  The walls of the vaginal vault are visualized with normal pink rugae with no lesions noted.  Cervix is visualized without lesion.  She has a moderate amount of thick white/yellow vaginal discharge in the vaginal vault.  No cervical motion tenderness.  No adnexal tenderness or fullness.,ASSESSMENT/PLAN:,1.  Asthma.  Seems to be worse than in the past.  She is just using her Proventil inhaler but is using it daily.  We will add Flovent 44 mcg two puffs p.o. b.i.d.  May need to increase the dose.  She did get some vaginal irritation with Advair in the past but she is willing to retry that if it is necessary.  May also need to consider Singulair.  She is to call me if she is not improving.  If her shortness of breath worsens she is to call me or go into the emergency department.  We will plan on following up for reevaluation in one month.,2.  Allergic rhinitis.  We will plan on restarting Allegra and Flonase daily for the time being.,3.  Premenstrual dysphoric disorder.  She may have some perimenopausal symptoms.  We will start her on fluoxetine 20 mg one tablet p.o. q.d.,4.  Hematuria.  Likely this is secondary to urinary tract infection but we will repeat a UA to document clearing.  She does have some frequent dysuria but is not having it currently.,5.  Cervical dysplasia.  Pap smear is taken.  We will notify the patient of results.  If normal we will go back to yearly Pap smear.  She is scheduled for screening mammogram and instructed on monthly self-breast exam techniques.  Recommend she get 1200 mg of calcium and 400 U of vitamin D a day.",
 Mother states he has been wheezing and coughing., Allergy / Immunology, Asthma in a 5-year-old ,"CHIEF COMPLAINT: , This 5-year-old male presents to Children's Hospital Emergency Department by the mother with ""have asthma.""  Mother states he has been wheezing and coughing.  They saw their primary medical doctor.  He was evaluated at the clinic, given the breathing treatment and discharged home, was not having asthma, prescribed prednisone and an antibiotic.  They told to go to the ER if he got worse.  He has had some vomiting and some abdominal pain.  His peak flows on the morning are normal at 150, but in the morning, they were down to 100 and subsequently decreased to 75 over the course of the day.,PAST MEDICAL HISTORY:,  Asthma with his last admission in 07/2007.  Also inclusive of frequent pneumonia by report.,IMMUNIZATIONS: , Up-to-date.,ALLERGIES: , Denied.,MEDICATIONS:  ,Advair, Nasonex, Xopenex, Zicam, Zithromax, prednisone, and albuterol.,PAST SURGICAL HISTORY: , Denied.,SOCIAL HISTORY: , Lives at home, here in the ED with the mother and there is no smoking in the home.,FAMILY HISTORY: , No noted exposures.,REVIEW OF SYSTEMS:  ,Documented on the template.  Systems reviewed on the template.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 98.7, pulse 105, respiration is 28, blood pressure 112/65, and weight of 16.5 kg.  Oxygen saturation low at 91% on room air.,GENERAL:  This is a well-developed male who is cooperative, alert, active with oxygen by facemask.,HEENT:  Head is atraumatic and normocephalic.  Pupils are equal, round, and reactive to light.  Extraocular motions are intact and conjugate.  Clear TMs, nose, and oropharynx.,NECK:  Supple.  Full painless nontender range of motion.,CHEST:  Tight wheezing and retractions heard bilaterally.,HEART:  Regular without rubs or murmurs.,ABDOMEN:  Soft, nontender.  No masses.  No hepatosplenomegaly.,GENITALIA:  Male genitalia is present on a visual examination.,SKIN:  No significant bruising, lesions or rash.,EXTREMITIES:  Moves all extremities without difficulty, nontender.  No deformity.,NEUROLOGIC:  Symmetric face, cooperative, and age appropriate.,MEDICAL DECISION MAKING:,  The differential entertained on this patient includes reactive airways disease, viral syndrome, and foreign body pneumonia.  He is evaluated in the emergency department with continuous high-dose albuterol, Decadron by mouth, pulse oximetry, and close observation.  Chest x-ray reveals bronchial thickening, otherwise no definite infiltrate.  She is further treated in the emergency department with continued breathing treatments.  At 0048 hours, he has continued tight wheezes with saturations 99%, but ED sats are 92% with coughing spells.  Based on the above, the hospitalist was consulted and accepts this patient for admission to the hospital with the working diagnosis of respiratory distress and asthma.",
" Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.", Allergy / Immunology, Allergy Evaluation Consult ,"HISTORY: , A 34-year-old male presents today self-referred at the recommendation of Emergency Room physicians and his nephrologist to pursue further allergy evaluation and treatment.  Please refer to chart for history and physical, as well as the medical records regarding his allergic reaction treatment at ABC Medical Center for further details and studies.  In summary, the patient had an acute event of perioral swelling, etiology uncertain, occurring on 05/03/2008 requiring transfer from ABC Medical Center to XYZ Medical Center due to a history of renal failure requiring dialysis and he was admitted and treated and felt that his allergy reaction was to Keflex, which was being used to treat a skin cellulitis dialysis shunt infection.  In summary, the patient states he has some problems with tolerating grass allergies, environmental and inhalant allergies occasionally, but has never had anaphylactic or angioedema reactions.  He currently is not taking any medication for allergies.  He is taking atenolol for blood pressure control.  No further problems have been noted upon his discharge and treatment, which included corticosteroid therapy and antihistamine therapy and monitoring.,PAST MEDICAL HISTORY:,  History of urticaria, history of renal failure with hypertension possible source of renal failure, history of dialysis times 2 years and a history of hypertension.,PAST SURGICAL HISTORY:,  PermCath insertion times 3 and peritoneal dialysis.,FAMILY HISTORY: , Strong for heart disease, carcinoma, and a history of food allergies, and there is also a history of hypertension.,CURRENT MEDICATIONS: , Atenolol, sodium bicarbonate, Lovaza, and Dialyvite.,ALLERGIES: , Heparin causing thrombocytopenia.,SOCIAL HISTORY: , Denies tobacco or alcohol use.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Age 34, blood pressure 128/78, pulse 70, temperature is 97.8, weight is 207 pounds, and height is 5 feet 7 inches.,GENERAL:  The patient is healthy appearing; alert and oriented to person, place and time; responds appropriately; in no acute distress.,HEAD:  Normocephalic.  No masses or lesions noted.,FACE:  No facial tenderness or asymmetry noted.,EYES:  Pupils are equal, round and reactive to light and accommodation bilaterally.  Extraocular movements are intact bilaterally.,EARS:  The tympanic membranes are intact bilaterally with a good light reflex.  The external auditory canals are clear with no lesions or masses noted.  Weber and Rinne tests are within normal limits.,NOSE:  The nasal cavities are patent bilaterally.  The nasal septum is midline.  There are no nasal discharges.  No masses or lesions noted.,THROAT:  The oral mucosa appears healthy.  Dental hygiene is maintained well.  No oropharyngeal masses or lesions noted.  No postnasal drip noted.,NECK:  The neck is supple with no adenopathy or masses palpated.  The trachea is midline.  The thyroid gland is of normal size with no nodules.,NEUROLOGIC:  Facial nerve is intact bilaterally.  The remaining cranial nerves are intact without focal deficit.,LUNGS:  Clear to auscultation bilaterally.  No wheeze noted.,HEART:  Regular rate and rhythm.  No murmur noted.,IMPRESSION:  ,1.  Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.,2.  Renal failure requiring dialysis.,3.  Hypertension.,RECOMMENDATIONS:  ,RAST allergy testing for both food and environmental allergies was performed, and we will get the results back to the patient with further recommendations to follow.  If there is any specific food or inhalant allergen that is found to be quite high on the sensitivity scale, we would probably recommend the patient to avoid the offending agent to hold off on any further reactions.  At this point, I would recommend the patient stopping any further use of cephalosporin antibiotics, which may be the cause of his allergic reaction, and I would consider this an allergy.  Being on atenolol, the patient has a more difficult time treating acute anaphylaxis, but I do think this is medically necessary at this time and hopefully we can find specific causes for his allergic reactions.  An EpiPen was also prescribed in the event of acute angioedema or allergic reaction or sensation of impending allergic reaction and he is aware he needs to proceed directly to the emergency room for further evaluation and treatment recommendations after administration of an EpiPen.",